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Newborn Nursery Curriculum Julee Waldrop, MS,PNP

Diabetes in Pregnancy
Diabetes in pregnancy 4% Pre-gestational diabetes 12% Gestational diabetes 88%

Classification of Severity
Whites Classification for diabetes

A A1

Abnormal GTT treated with diet Medication controlled GDM

A2 B C D
R-T

Insulin-treated GDM Onset at age >/=20 and duration of < 10 yr Onset at 10-19 years or duration > 10-19 years Onset before 10 yrs, duration > 20 yrs, some macrovascular to microvascular disease Various complications have already occurred

Pathophysiology
Reduced insulin activity in the mom leads to a hyperglycemic environment for the baby
In the first trimester this can cause embryopathy (birth defects and spontaneous abortions)
Highest risk are women with type 1 DM

In the 2nd & 3rd trimesters can cause fetopathy


Macrosomia Neonatal hypoglycemia

Pathophysiology
Intermittent maternal hyperglycemia leads to to premature maturation of fetal pancreatic islets and hypertrophy of the beta cells which produce more insulin causing hyperinsulinemia. Hyperinsulinemia stimulates storage of glycogen in the liver, increased activity of hepatic enzymes in lipid synthesis and accumulation of fat in adipose tissue. All this leads to increased fetal growth especially in insulin sensitive tissues, muscle and fat.

Pathophysiology
These increased metabolic needs require more O2

and leads to relative hypoxemia in the fetus


It also promotes catecholamine production which can

lead to HTN and cardiac hypertrophy which may be involved in the 20-30% rate of stillbirth seen in poor control

Congenital Anomalies
Type 1 DM RR was ~8 times greater Account for about 50% of the perinatal deaths Systems most frequently affected: CV and CNS
Anencephaly and Spina bifida- 13-20 x more likely

DM during pregnancy accounts for most of infants born with caudal regression syndrome (defects of the caudal region of the spinal cord)
200 x more likely
Spinal cord injury results in significant sequelae like

incontinence to paraplegia

Prematurity
Related consequences
Perinatal aspyxia can be related to many things Examples: Maternal vascular compromise Macrosomia Prematurity

Macrosomia
Increased growth occurs after the 24th week of

pregnancy.
There is a linear relationship between elevated blood

glucose and birth weight.

Disproportionate growth
Excessive fat in the abdomen and scapular areas.

Increased risk for:


Hyperbilirubinemia Hypoglycemia Acidosis

Complications of Macrosomia
Birth injury
Shoulder dystocia (1/3rd of infants > 4000gms) 1.7 times more likely to occur Brachial plexus injury Clavicular or humoral fracture Perinatal asphyxis Facial palsy

cephalohematomas

IUGR
If hypertension is significant enough with

vasculopathy then growth restriction may occur

Respiratory Distress
More common in IDMs when delivered prematurely Delayed maturation of surfactant synthesis caused by hyperinsulinemia TTNB 2-3 x more likely Decreased fluid clearance in diabetic fetal lung Cesarean delivery

Metabolic Disorders
Hypoglycemia Definition: BGL < 40 mg/dL Incidence: 14-21% Most common in macrosomic infants Can also occur in IUGR Persistent hyperinsulinemia in the newborn Depressed counter response to hypoglycemia

Glucagon catecholamines

Metabolic Disorders
Hypocalcemia Infrequent in term infants Routine evaluation not recommended but may contribute to persistent hypoglycemia Hypomagnesemia Infrequent in term infants If hypocalcemia occurs is more likely

Polycythemia
Definition: HCT > 65%
Incidence: 13-33% Fetal hypoxemia stimulates synthesis of erythropoietin which leads to polycythemia Puts infants at risk for renal vein thrombosis (more common in IDMs) Recommend measurement within 12 hours of birth

Hyperbilirubinemia
Incidence: 11-29%
Risk factors Prematurity Polycythemia Macrosomia

Cardiomyopathy
Hypertrophic cardiomyopathy
30-50% of IDMs Increased thickening of the interventricular septum

Hyperinsulinemia leads to increased deposition of fat in myocardial cells


Symptomatic in only 15-20% Resolves on its own as insulin levels decrease Echo normalizes in 6-12 months