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The mother was suffering from GDM since 26 wks of gestation and was on regular antenatal check up. The baby was large, plethoric without any respiratory distress or apparent congenital anomaly. His HR 140 / min, RR - 40 / min, temp - 99F with good primitive reflexes, birth weight - 4.2 kg, length - 54 cm and OFC - 35 cm.
Capillary blood glucose level recorded at 1st hour of age was 2.2 mmol/L, 2.4 mmol/L at 3rd hour and 2.9 mmol/L at 5th hour.
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Definition:
Infant of Diabetic mother is a baby born to a mother who has diabetes.
Pathophysiology of GDM
Hormones produced by placenta like estrogen, progesterone, cortisol & human placental lactogen Contra insulin effect Additional insulin requirement to overcome the effect
Glucose & amino acid, but not insulin traverse placental membrane Increased blood sugar in fetus Fetal pancreatic cell hyperplasia
Physiology of Glucose Control in IDM (continued) Increased insulin & pro insulin level
Glycogen deposition protein synthesis fat deposition
Hypoglycemia
RDS
How to diagnose?
History: H/O diabetes or GDM in mother. Poor glucose control during pregnancy. Mother may have previous LGA infant. Antenatal records: RBS > 11.8 mmol/L USG in last trimester: LGA baby
Clinical Feature
Large baby. Poor feeding, lethargy and weak cry. Convulsion. Respiratory distress. Plethoric with puffy face. Jaundice. Tachycardia, tachypnea (in HF). Hepatomegaly. Cardiomegaly.
Still born Neonatal death Premature labour Perinatal asphyxia Birth injury Shoulder dystocia Fracture of clavicle and humerus Brachial plexus injury
After birth:
LGA SGA Hypoglycemia Hypocalcaemia Hypomagnesaemia Respiratory Distress Syndrome Transient Tachypnea of Newborn Polycythemia Hyperbilirubinaemia
Congenital malformations: Cardiac Hypertrophic cardiomyopathy, VSD, TGA, ASD. Lumbosacral agenesis Renal agenesis. GIT - small left colon syndrome. Nervous system anencephaly, meningocele. Skeletal hemivertebrae, caudal regression syndrome.
Investigations
S Glucose level: At delivery, 2 , 4, 6, 8, 12, 18, 24, 36, 48, 60, 72 hours of age. S Calcium level: At 6 , 24 , 48 hrs of age. S Magnesium level: Done if hypocalcemia present. Haematocrit. S Bilirubin.
Investigations (continued)
CBC, Hb%, Blood grouping ABG Radiological studies: CXR P/A view X - ray of involved joints associated with birth injury or congenital anomalies.
Echocardiogram
Barium enema
Treatment
Frequent
risk. Fetal evaluation Delivery planning Periconceptual glucose control Control during labor
Hypoglycemia
Asymptomatic:
Blood glucose levels : within 1st hr, then hourly for 6-8 hrs. If normoglycemic start feeding ( oral or NG) If feeding unsuccessful: IV glucose 4-8 mg/kg/min Hypertonic glucose should be avoided.
Symptomatic:
IV bolus of 2cc/kg of DW 10%, if seizures 4cc/kg to be given. IV infusion at rate of 8mg/kg/min If inadequate concentration can go up to 20% .
Hydrocortisone:
5mg/kg/day
Glucagon
Diazoxide Octreotide Measure
glucose hourly then Q 4-6 hrs Never abruptly stop IV glucose infusion: reactive hypoglycemia
Hypoglycemia
hrs Persistent hypoglycemia : persistent hyperinsulinemia If more than 7 days consider other causes.
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Maui Sunset