UHS PBL – Infant of a Diabetic Mother
Learning Objectives
Be able to take history in a perinatal clinical case.
Demographics
Present obstetric history
Past obstetric history:
o Previous large babies?
o Is this the 1st or 2nd C-section?
o Hypertension?
Past history (family & mother): hemolytic disorders (G6PD; thalassemia; sickle cell
disease, etc.)
Birth & delivery:
o NVD / C-section
o Assisted with forceps / vacuum
o APGAR score
o Need for resuscitation / NICU
o Growth parameters
o Medications
Chief complaint
Be able to recognize complications of IDM.
Congenital anomalies:
o Cardiovascular: transposition of the great arteries / double outlet right
ventricle / VSD / truncus arteriosus / tricuspid atresia / PDA
o CNS: anencephaly / spina bifida
o Others: sacral agenesis / flexion contraction of the limbs / vertebral
anomalies / cleft palate / intestinal anomalies / short left colon
Prematurity (spontaneous / medically-indicated)
KETONES AND GLUCOSE ARE TOXIC FOR BABY
Perinatal asphyxia (increased risk due to macrosomia and cardiomyopathy)
Macrosomia ( increased risk of difficult labor & birth injury especially shoulder
dystocia)
Respiratory distress:
o Respiratory distress syndrome
o Transient Tachypnea of newborn (30% of cases)
o Cerebral edema due to trauma or asphyxia
o Hypoglycemia
o Polycythemia: HYPOXIA BC OF THE GLYCOSYLATED hemoglobin
o Heart failure
Metabolic:
o Hypoglycemia: maternal hyperglycemia fetal hyperglycemia increased
insulin production after birth there is no more maternal glucose, but the
insulin is still high hypoglycemia
o Hypocalcemia: due to transient hypoparathyroidism
o Hypomagnesemia: due to maternal hypomagnesemia which is due to
increased urinary loss secondary to diabetes)
Hematological complications: glycosylated haemoglobin causes low oxygen
kidney increases erythropoietin polycythemia hyperviscosity risk of
ischemia / infarction (especially renal vein thrombosis)
o Note: if Hb is high do a partial exchange (draw 10-15 mL of blood &
replace with NS)
Low iron stores
Hyperbilirubinemia (due to polycythemia + inhibition of conjugation in the liver due
to insulin
Cardiomyopathy (transient hypertrophic cardiomyopathy)
High fetal mortality (especially in poorly-controlled diabetes with ketoacidosis)
Convulsions (due to hypoglycemia / hypocalcemia / birth trauma)
Be able to list the treatment of hypoglycemia.
Initial treatment: glucose 10% 2-4mL/kg IV
Maintenance: glucose 10% continuous IV infusion at a rate of 8 mg/kg/min
Monitor blood glucose every 2 hours:
o If glucose level is controlled: gradually withdraw IV fluids & advance oral
feeding
o If poorly controlled: hydrocortisone & glucagon
o If no hypoglycemia for 24-48 hours with no complications: discharge
Be able to council mothers to decrease the incidence of IDM complications
Explain all the risk factors of uncontrolled diabetes
Be able to recognize the measures to be taken to prevent hypoglycemia after birth
Counselling of the mother
Immediate feeding of the baby
Case Scenario
Amina is a 35-year-old known diabetic lady, treated with insulin. Her mean blood
sugar during this pregnancy was ranging between 12 and 15 mmol/L. Her blood group is B+.
Serology for HIV and hepatitis were negative. Her baby was delivered by caesarean section
at 38 weeks of gestation; G3 P3.
The baby was born with APGAR scores of 8 and 9 at 1 and 5 minutes. Birth weight
was 4,500 g. Initially, the baby was transferred to the maternity ward with the mother. After
3 hours, the midwife called the paediatrician because she noticed abnormal movements.
Discussion Questions:
1. What other information do you want to obtain from the history?
Demographics
Presenting compliant: abnormal movements
o Duration
o Description (up-rolling of the eyes? Jerking of the limbs? Tonic / tonic-clonic/
atonic; unilateral or bilateral; Generalized or focal)
o Drowsiness or loss of consciousness?
o Stopped when touched? (yes = tremors; no = convulsions)
o Last feeding + RAPID GLUCOSE TEST
Past obstetric history:
o Past pregnancies: births / abortions or miscarriages
o Previous neonatal / child death
o Complications: congenital anomalies; prolonged rupture of the membrane
o Illnesses: diabetes (gestational?); pre-eclampsia
o Infections: Group B streptococci status; TORCH
o Control of diabetes during pregnancy: diet, medications, regular follow-up
o Pre-natal visits: polyhydramnios; abnormalities on US
Natal history:
o Type of delivery: caesarean (emergent or elective – b/c microsomal baby may
be an indication) / normal vaginal delivery
o APGAR score
o Growth parameters (macrosomia)
o Complications: trauma; jaundice; plethora
2. In your clinical examination, which points would you want to focus on?
CHECK HIS GLUCOSE FIRST.
Vital signs
Anthropometric measurements
Check alertness
Neurological examination + check fontanelle
Look for any dysmorphic features
3. What is your impression?
Infant of a diabetic mother:
3 hours age
Large for gestational age
Abnormal movements (most likely due to hypoglycemia b/c hyperinsulinemia)
4. What is your differential diagnosis?
Metabolic:
o Hypoglycemia
o Hyponatremia / hypernatremia
o Hypocalcemia: if persistent and not corrected by calcium supplements, check
magnesium levels as hypomagnesemia can cause hypocalcemia [PTH levels
increase only if magnesium levels are normal]
o encephalopathy
o NOT HYPOKALEMIA
o Inborn errors of metabolism
Infections: meningitis / encephalitis / sepsis
Trauma (birth injury): brain haemorrhage or contusion
Asphyxia / hypoxia
5. What are the most important investigations?
Blood glucose
Electrolytes
CBC (check for polycythaemia)
Renal function tests uremia encephalopathy
Arterial blood gases
Cardiac ultrasound for anomalies
Brain US & EEG
6. What is your management?
Acute & symptomatic: glucose IV
i. <25mg / 1.3mmol give IV glucose
Prophylactic: immediate feeding & monitor blood sugar; counsel the mother &
follow-up with a diabetologist (HbA1c). Check within 0.5 hours & give another
feeding.
Intervention depends on degree:
o <1.3 mmol/L (25 mg/dL): IV glucose
Asymptomatic: 2mL/kg
Symptomatic: 4mL/kg
o >1.3 mmol/L: oral glucose monitor if not improving then IV
7. What would your advice be for preventing this situation?
Prenatal visits & screening
Control the mother’s diabetes
Monitor the baby’s glucose (hourly for the first 4 hours every 6 hours till 24 hours)
Immediate feeding
Notes:
- To convert glucose levels from mmol/L to mg/dL: multiply by 18
- Infants of mothers with uncontrolled DM are at higher risk of complications than those
of mothers with gestational diabetes because high sugar & ketones are toxic to
embryogenesis, whereas GD occurs in 2nd and 3rd trimesters after embryogenesis.
Hypoglycemia:
- <2.5 mmol/L [equivalent to 45 mg/dL]
- It can cause brain damage (b/c glucose is the only source of energy in the brain)
convulsions = 90% damage
- Risk of hypoglycemia in an IODM lasts for the first 24 hours (4% persist for > 24 hours)
IODM:
- Macrosomal (above 90th %): due to hyperinsulinemia
- Microsomal (below 10th %): pre-gestational diabetes + hypertensive mother placental
insufficiency (microvascular disease)
