Infant of a Diabetic Mother

00:06 So here’s an infant of a diabetic mother, what we worried about is any infant whose mother has had persistently high blood sugars during the pregnancy.

00:17 This is about 3-10% of infants in the United States.

00:21 About 1/3 are type 1 diabetes, but 2/3 are type 2 diabetes and the rate is on the rise because of our worsening obesity epidemic in the U.S.

00:34 So the pathology of infants of diabetic mothers is as follows.

00:38 Mom has a high blood sugar, that’s running unchecked.

00:42 This, in turn, results in a high fetal blood sugar.

00:47 The problem is, is that high sugars have direct effects on a variety of tissues throughout the fetus.

00:56 So we need to look at what are all the various problems that can happen as a result of developing inside the uterus where there is a high sugar environment.

01:06 So the first is size alone.

01:08 Because sugar is such a great growing substrate, these infants are usually large for gestational age.

01:15 They are too big.

01:16 About 30% of infants of diabetic mothers are going to be large for gestational age.

01:22 This can lead to problems.

01:24 For example, they may develop failure to progress.

01:27 I’m talking about the delivery now.

01:29 As the baby starts coming out, baby stops, baby can’t go any further.

01:34 This can result in fetal distress, difficulty with breathing, difficulty with blood perfusion.

01:41 Infants can get strokes, all kinds of problems can happen.

01:45 Another one for example is shoulder dystocia and that’s the classic one you read about.

01:49 Where because the child is having a hard time getting out of the vagina, that shoulder gets injured.

01:56 Okay.

01:58 Infants can also be small for gestational age.

02:02 This happens in 20% of infants of diabetic mothers.

02:06 It doesn’t seem to make sense but it’s true.

02:09 This stems from basically a poor uterine growth environment.

02:13 This can lead to poor outcomes after birth.

02:18 So, here’s our graph where we would see what is the appropriate weight of an infant based on how premature they are or what week they're born on.

02:29 So you could plot an infant on a graph such as this.

02:33 So let’s do it together.

02:34 If an infant is 1,000 grams and they’re born at 28 weeks, they’re about appropriate.

02:42 But if they are above the line, they are large or if they are below line, they are small.

02:49 Infants of diabetic mothers are at increased risk for other problems such as respiratory distress syndrome.

02:57 This is more common in these babies, but I talked a little bit about that in another lecture.

03:03 They can also get polycythemia.

03:06 Basically that sugar substrate is so good that they have too many red blood cells.

03:11 That, in turn, can result in a hypertension in the lung of the infant, which is called persistent pulmonary hypertension of the newborn.

03:20 Infants with PPHN can be at grave distress when they’re born because basically the blood is having a hard time getting through their lungs.

03:31 Additionally, infants may become hypoglycemic at birth.

03:36 Think about as simply this way, that infant has been exposed to high amounts of sugar while they were in utero, so their pancreas is really ramped up.

03:45 They are born, they are not getting that sugar from their mom anymore and there is a transient period of time when suddenly they get too low.

03:52 And the problem is that low sugar can cause seizure or even frank brain damage.

03:59 So we have to watch these kids carefully after birth to make sure they don’t have a rebound hypoglycemia.

04:06 They may get plethora.

04:08 This is a red color to the skin and this is because of those increasing red blood cells.

04:13 That in itself can cause not only problems in the lungs but can cause problems elsewhere.

04:18 In fact, they can get strokes.

04:21 So infants of diabetic mothers because of too many red blood cells and sludging of the blood can actually have an ischemic stroke of the brain.

04:30 Because those red cells then breakdown, they can also get hyperbilirubinemia and bad hyperbilirubinemia can lead to brain damage through kernicterus.

04:42 Lastly, they can get thrombocytopenia.

04:45 That’s because of inhibited thrombopoiesis in utero from chronic hypoxia.

04:52 So these infants may have low platelet counts.

04:56 Additionally, infants may have structural organ disease.

05:00 A common one is cardiomyopathy.

05:03 This can even happen so significantly they have ventricular hypertrophy and thus an outflow tract obstruction.

05:10 This is really common.

05:11 It happens in about a third of babies with exposure to diabetic mothers while in utero.

05:18 Also, these infants can be at risk for ventricular septal defects, transposition of the great vessels and a variety of other problems.

05:27 So the heart can structurally be wrong as a result of being in a high sugar environment in utero.

05:34 Also, these infants are at increased risk for significant CNS malformations.

05:39 So they are 16 times more likely than regular infants of diabetic mothers and especially the one we think of is anencephaly.

05:49 This is when the infant is actually born without a brain.

05:53 This is not consistent with life.

05:57 Also, they may have renal malformation of a variety of types and they may have gastrointestinal complications.

06:05 The classic gastrointestinal complication that you will see is an atresia or a poor growth of an intestine.

06:14 This may happen in duodenal atresia.

06:17 For duodenal atresia, we can expect to see the double bubble sign which you can see in this x-ray here.

06:22 They may have anorectal atresia which is an inability to form the anus and the rectum. That’s a surgical emergency.

06:30 Or they may have small left colon syndrome.

06:34 So just remember that the intestine may be atretic as a result of exposure to high sugar in utero.

06:41 So that’s my review of the basic problems of infants born to diabetic mothers.

06:48 Thanks for your time.