Patient Presentation
A 26-year-old female with Type I diabetes for 11 years, is referred to you by her obstetrician for a general prenatal appointment to specifically discuss what will happen to her child after delivery.
This is the first pregnancy for the mother. She has had pre-conception and prenatal care from her obstetrician and endocrinologist and has been in good glycemic control using frequent daily testing and insulin. There have been no other complications to the pregnancy.
Obstetrical ultrasound has identified no obvious abnormalities.
The diagnosis of a fetus at risk for a variable constellation of problems was made. These mainly include metabolic problems, respiratory distress syndrome, polycythemia and congenital anomalies. In addition to regular prenatal information, the mother was counseled about the additional monitoring and testing that would be needed especially for potential respiratory, glucose, and calcium problems and polycythemia. She was also told that additional testing and treatment may be needed if congenital abnormalities were identified.
Discussion
Although, infants of diabetic mothers (IDM) generally are healthy and do well with today’s obstetrical and neonatal care, they are at risk for complications. The risk has been associated with the duration, severity and control of the mother’s diabetes.
Important maternal historical information includes:
- Gestational age of the infant
- Obstetrical diabetes class (i.e. White’s Classes)
- Maternal therapy (i.e. diet, oral hypoglycemic drugs, insulin, etc.)
- Degree of chronic glucose control
- Delivery – time of last maternal insulin injection, amount and type of IV fluids in labor and delivery
Learning Point
There are many potential complications for IDMs which include:
Prenatal/Natal risks
- Sudden fetal death in third trimester
- Premature birth with or without cesarean delivery
- Intrapartum asphyxia
- Birth trauma secondary to macrosomia
Perinatal risks
- Cardiac – restrictive cardiomyopathy
- Congenital – overall incidence is increased 2-4 times
- Congenital heart disease – ventricular septal defect
- Central nervous system – anencephaly, spina bifida, microcephaly
- Gastrointestinal atresia
- Sacral agensis and/or caudal regression syndrome
- Small left colon syndrome – is transient and may mimic Hirschsprung disease
- Urinary tract abnormalities
- Growth- macrosomia or intrauterine growth retardation
- Hematologic – hyperviscosity or polycythemia. A screening capillary hematocrit should be obtained at 4-6 hours and if > 65% then immediately recheck by peripheral venous sample.
- Metabolic
- Hypoglycemia – occurs in as high as 50% of IDMs. Cord blood can be sent to the laboratory immediately for analysis. The higher the cord blood glucose value, the greater the risk for hypoglycemia in the next few hours.
Hypoglycemia has the highest incidence at 1-4 hours of age. Plasma glucose values should be monitored at 1, 2, 4, 6, 9, 12 and 24 hours of life in asymptomatic infants. Chemstrips® are not recommended because of their inaccuracy. Hypoglycemia is usually transient and easily treated with oral or IV glucose. - Hypocalcemia – often occurs in the first 12- 24 hours of life and should be checked and treated appropriately depending on if clinically symptomatic.
- Hypermagnesemia – evaluate similar to hypocalcemia
- Hyperbilirubinemia – up to 30% of IDMs have hyperbilirubinemia in the first 3 days
- Hypoglycemia – occurs in as high as 50% of IDMs. Cord blood can be sent to the laboratory immediately for analysis. The higher the cord blood glucose value, the greater the risk for hypoglycemia in the next few hours.
- Respiratory – surfactant deficiency or Respiratory Distress Syndrome
Postnatal Risks (increased throughout life)
- Diabetes
- Obesity
Questions for Further Discussion
1. What are the obstetrical diabetes classes (i.e. White’s Classes)?
2. How is hyperviscosity treated?
Related Cases
- Symptom/Presentation
- Specialty
- Age
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused case is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Birth Defects.
To view current news articles on this topic check Google News.
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:124-127.
Widness JA. Metabolic Problems in Infants of Diabetic Mothers (IDM’S). Iowa Neonatology Handbook
Available from the Internet at http://www.vh.org/pediatric/provider/pediatrics/iowaneonatologyhandbook/metabolic/diabeticmoms.html (rev. 6/2005, cited 9/29/05).
Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
November 28, 2005
Pediatric Education 