idm: it’s not just about sugar - children's mercy · pdf fileidm: it’s not...

© The Children’s Mercy Hospital, 2017

Lindsey Churchman, MSN, RN, NNP-BC

IDM: It’s not just about Sugar

Types of Diabetes

• Pregestational Diabetes:

• Type 1 or Type II Diabetes

– 1.8 percent prevalence

– Usually diagnosed if fasting

glucose ≥92 or random

glucose ≥200.

– Hgb A1C ≥6.5%

Gestational Diabetes:

• Diabetes first diagnosed during

pregnancy.

– 2-25% prevalence

Gestational Diabetes Classifications

• The White Classification system is used to differentiate between

gestational diabetes and diabetes that existed prior to pregnancy.

Gestational diabetes is class A with the following

subclassifications:

– A1GDM: diet controlled

– A2GDM: medication controlled- most common medications used to treat

mom’s are glyburide, metformin, and insulin

Who is at Risk:Gestational diabetes is more likely to occur in women who:

• Are >25 years of age

• Are overweight

• Have had a very large baby

• Have a close relative with diabetes

• Have had a stillbirth in a previous pregnancy

• Are African American, American Indian, Asian American, Hispanic,

Latina, or Pacific Islander

Screening For Gestational Diabetes

– All pregnant women should be screened for gestational diabetes using

history, clinical risk factors, and glucose screening tests

– Screening usually occurs some time between 24 and 28 weeks of

gestation

• 1 hour GTT

• 3 hour GTT

• Early screening is recommended in women with risk factors

Maternal and neonatal

Adverse Outcomes

Maternal

• Preeclampsia

• Macrosomia

• Birth trauma

• Increased need for C/S

• Stillbirth

• 10% chance of developing overt diabetes

immediately after pregnancy

• As high as 40% chance within 20 years

Neonatal

• Macrosomia

• Birth Trauma

• Fetal organomegaly(hepatomegaly, cardiomegaly)

• Increased perinatal mortality

• Respiratory distress syndrome

• Hypoglycemia

• Hyperbilirubinemia

• Hypocalcemia

• Polycythemia

• Congenital anomalies

• Increased risk of developing diabetes later in life

• Renal Vein Thrombosis

Neonatal Complications cont• Congenital Anomalies: Cardiac

• Heart defects are present in 3-9% of all

IDM’s

– Most common heart defects seen

are:

» Transposition of the Great

Vessels

» Double Outlet Right Ventricle

» VSD

» Truncus Arteriosus

» Tricuspid Atresia

» PDA

• Congenital Anomalies: CNS

– Anencephaly

– Spina Bifida

Other Congenital Anomalies

(less common)

– Flexion contracture of the limbs

– Vertebral anomalies

– Small left colon syndrome

– Caudal regression Syndrome

Case Study• 38 week infant born via C/S to a G1, P1 27 year old. Mother is obese, early

screening was positive for gestational diabetes. Initially given glyburide,

however insulin was added at 22 weeks gestation. All other serologies were

negative, including GBS.

• scheduled C/S for macrosomia, estimated fetal weight was 4.4kg.

• No complications with C/S, apgars 8,9. Birthweight was 4.6kg.

• Infant developed increased WOB shortly after delivery, oxygen saturations in

room air were in the mid 80’s. Infant brought to the NICU and placed in

head hood with 80% Fio2. Saturations improved to >95%.

macrosomia

• Definition: Infant with a

birthweight of >4kg, or

BW greater than the 90th

percentile on a

population appropriate

growth chart

macrosomia

• Can occur in all diabetic

pregnancies, but has a greater

incidence in pregestational diabetic

mothers

– One particular study using the

Swedish Medical Birth Registry

found that of the 3705 infants

born to mothers with type 1

diabetes between 1998-2007,

47% of the infant’s were LGA

macrosomia

• Associated with disproportionate

growth which results in increased fat

accumulation in the abdominal and

scapular regions of the body

• Increased risk for birth injury,

including brachial plexus injury,

clavicular or humeral fractures

• Increased risk for perinatal asphyxia

• Shoulder dystocia

What could be the cause of the Respiratory

distress and oxygen need?

• A. Respiratory Distress Syndrome

• B. C/S without labor

• C. Pulmonary Hypertension

• D. All of the above

Respiratory Distress in IDM’s

• Respiratory Distress Syndrome occurs more frequently in

IDM’s because:

– More likely to be delivered prematurely than infant’s born to nondiabetic mother

– Maternal hyperglycemia delays surfactant synthesis- proposed mechanism is

neonatal hyperinsulinemia is though to interfere with the induction of lung

maturation by glucocorticoids

– Other causes of respiratory distress in addition to RDS, include TTNB and

Cardiomypathy

Case Study Cont.

• Upon admission to NICU, CBC, ABG, and

glucose levels are drawn on the infant

• CBC: WBC 12, H&H are 23/70, platelet

count of 207k, normal diff

Which Value in the CBC is concerning?

• A. WBC of 12

• B. Platelet count of 207k

• C. H&H of 23/70

• D. Everything is fine….send the baby home!

Polycythemia

Neonatal polycythemia in a term infant is defined by a peripheral venous hemoglobin and hematocrit more than 2 standard deviations above the mean; this translates to a hemoglobin greater than 22 g/dl and a hematocrit greater than 65%.

*More likely to occur in IDMs than in infants born to nondiabetic mothers*

*Underlying pathogenesis is due to increased erythropoietin concentrations*

* Can lead to hyperviscosity syndrome, which may then contribute to the increase incidence of renal vein thrombosis seen in IDMs*

Treatment of polycythemia1. Treatment should be based on presence of clinical signs and symptoms, not

just on laboratory values alone

2. Peripheral hematocrits >65% should be confirmed with a central sample

3. Asymptomatic infants with Hct of 60-70% may be monitored closely with

adequate hydration and glucose levels

4. Some institutions choose to treat (partial exchange transfusion) infants

regardless of symptoms if repeated Hct levels are above 70% or in patients who

are symptomatic (ie cardiopulmonary or neurologic symptoms) with a Hct >65%.

Maternal Hyperglycemia

Fetal

Hyperglycemia

Fetal

Hyperinsulinemia

Fetal substrate

uptake increased

Decreased

lung surfactant

Resp Distress

Synrome

Macrosomia

Oxygen uptake

increases

Hypoxemia

?stillbirth

Erythropoietin

increased

Polycythemia

From Schwartz R, et al: Infant of

the diabetic mother, J. Pediatric

Endocrin. 5:197, 1992

Case Study Cont.

The infant is closely monitored over the next 24 hours and develops

delayed cap refill of 4-5seconds, decreased pulses in all extremities,

and becomes tachypneic.

Vital signs are otherwise normal, and repeat CBC continues to have

no shift.

What is the most likely cause of this

baby’s poor perfusion?• A. Septal Hypertrophy

• B. VSD

• C. Respiratory Distress Syndrome

• D. Hypoglycemia

Cardiomyopathy– Increased risk of transient cardiomyopathy thought to be caused by fetal hyperinsulinemia

increasing the synthesis and deposition of fat and glycogen in myocardial cells, ie septal hypertrophy

– Septal hypertrophy decreases size of ventricles, possibly obstructing outflow of the left ventricle

– Cardiac output is significantly reduced

– The severity of IDM cardiomyopathy can vary from an incidental finding on echocardiograph, to an infant with severe symptoms of congestive heart failure

– Diagnosis is made by echocardiography, chest radiograph may show cardiomegaly.

Treatment of Cardiomyopathy• Treatment for Cardiomyopathy from septal hypertrophy is supportive care

• Supportive care includes, IV fluid administration, oxygen support as needed,

diuretics as needed, and/or beta blockers.

• Digoxin and inotropes which are often used in heart failure associated with

structural heart defects, are contraindicated if hypertrophic cardiomyopathy

is present as they increase LVOT obstruction.

• Resolution of symptoms usually occurs within 2-4 weeks, and resolution of

septal hypertrophy occurs during the first 2-12 months of life.

Case Study Cont.• The baby is currently receiving D15W @ 70ml/kg/day. The baby has a BMP

drawn at 36 hours of age with the following results:

• Na 139

• K 3.5

• Cl 102

• CO2 20

• BUN 12

• Cr 0.8

• Ca 6.7

Which lab value is

worrisome?

Alterations in Calcium and magnesium homeostasis

• IDM’s demonstrate an exaggerated drop in circulating calcium

levels compared to infants of non-diabetic mothers

• Occurs in about 50% of infant’s born to insulin dependent

diabetic mothers

• Usually is most apparent at 24-72 hours of age, and is related to

the severity and duration of maternal diabetes

• Mechanism of hypocalcemia is most likely the failure of the IDM

to mount an appropriate parathyroid hormone response,

persistently high calcitonin, and possibly alterations in vitamin D

metabolism

• In most infant’s hypocalcemia and hypomagnesemia are

transient events that improve spontaneously, but serum levels

should be monitored in infant’s with jitteriness, lethargy, apnea,

tachypnea, or seizures.

Treatment of hypocalcemia

• Treatment for hypocalcemia is

administration of calcium salts

• Treatment may be given orally

after the initial correction has

been given and the infant can

tolerate oral solution

• Complications of IV calcium

therapy include extravasation

into soft tissues and bradycardia.

Long Term effects/Summary

• Morbidity and mortality lessen with adequate glucose control

during pregnancy, especially during the early part of gestation

when organogenesis is occurring

• May also negatively effect neurodevelopmental outcomes as well

• Long term outcome data suggest that exposure to hyperglycemia

increases the risk of postnatal metabolic complications, including

diabetes, increased BMI, and impaired glucose metabolism

Any

Questions??

References:• Fanaroff, A., Martin, R., & Walsh, M. (2011). Neonatal-Perinatal

Medicine: Diseases of the Fetus and Infant. St. Louis, MO:

Elsevier.

• Riskin, A., Garcia-Prats, J., Infant of a Diabetic Mother [PDF

document]. Retrieved from Online Web site:

http://www.uptodate.com

• Gardner, S., Carter, B., Hines, M., & Hernandez, J. (2016).

Neonatal Intensive Care. St. Louis, MO: Elsevier.