IDM: It’s not just about Sugar - Children's Mercy · PDF fileIDM: It’s not just...
Transcript of IDM: It’s not just about Sugar - Children's Mercy · PDF fileIDM: It’s not just...
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© The Children’s Mercy Hospital, 2017
Lindsey Churchman, MSN, RN, NNP-BC
IDM: It’s not just about Sugar
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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
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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
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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
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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
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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
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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
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Other Congenital Anomalies
(less common)
– Flexion contracture of the limbs
– Vertebral anomalies
– Small left colon syndrome
– Caudal regression Syndrome
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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%.
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macrosomia
• Definition: Infant with a
birthweight of >4kg, or
BW greater than the 90th
percentile on a
population appropriate
growth chart
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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
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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
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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
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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
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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
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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!
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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*
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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%.
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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
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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.
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What is the most likely cause of this
baby’s poor perfusion?• A. Septal Hypertrophy
• B. VSD
• C. Respiratory Distress Syndrome
• D. Hypoglycemia
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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.
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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.
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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
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Which lab value is
worrisome?
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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
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• 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.
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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.
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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
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Any
Questions??
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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.