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.
The lecture Infant of a Diabetic Mother by Brian Alverson, MD is from the course Neonatology (Newborn Medicine). It contains the following chapters:
Which of the following is NOT a finding in an infant of a diabetic mother?
What percentage of infants of diabetic mothers are large for gestational age?
What percentage of infants of diabetic mothers are small for gestational age?
Persistent pulmonary hypertension of the newborn (PPHN) can occur in infants of diabetic mothers due to which of the following reasons?
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I learned a lot regarding the complications of gestational diabetes. Before this lecture I only knew that it would make a big baby and that they were at risk for hypoglycaemia. Thanks a lot!