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)