Combine Meeting

Infants of Diabetic Mother

PGY 劉上琪
VS 王曉萍 醫師
 Case Report

Basic informations

• 蔡 OO ， 18021200
• Justborn male infant ( 2020/09/02 9:10 )

Chief Complaint

Tachypnea was noted after birth.

Birth history
1. GA : 39+1 weeks
2. BBW : 4058 gm(90-97 percentile), BH: 53cm(75-90th percentile)
3. Apgar score : 7- ＞ 9 , C/S due to macrosomia and cephalopelvic
disproportion

Maternal history
• G2P1A1
• GBS (not checked) , preeclampsia(-) , (-), HbsAg: (-), HbeAg: (-)
VDRL / HIV (-) , Rubella vaccination(+)
• GDM (+) , under metformin 1# QN

Present illness
1. No DOIC , no bradycardia
2. Tachypnea with chest wall retractions , s/p neopuff for 5 mins
3. NOT jittery, tremulous, hyperexcitable , hypotonia
 Physical Examinations
Physical examinations
Consciousness alert but lethargy

Skin Rash(-), Jaundice(-), Petechiae(-), Vesicles(-), Skin turgor: Normal

ant. fontanelle (2 fb width, flat) , cephalohematoma(-)

HEENT Sclera (anicteric) , conjunctiva (not pale)
eardrum (no congestion) , Oral ulcers(-) , tonsil (normal size)

Chest Symmetric expansion, BS : Coarse, intercostal retraction(+)

Heart RHB w/o murmur

Abdomen soft and flat. No distension. No palpable mass. Nosplenomegaly.

extremities Freely movable(+), Edema(-)

Genital organ Male, Anomaly (-)

Plasma
Lab DataSugar after admission
after admission

9/2 9:10 born

9/2 9:50 PS: 96mg/dl
9/4 10:58 PS: 79mg/dl
 Lab
LabData after
Data after admission
admission
BUN Crea. Na K Ca Mg eGFR
mg/dl mg/dl mmol/L mmol/L mg/dl mg/dl
10 0.63 137 5.0 8.7 1.8 34.7

WBC Hgb HCT MCV RDW PLT IgM

K/ul g/fl pg fl % K/UL mg/dl
14.77 16.7 47.1 99.4 15.1 307 5.23

SEG LYM MONO EOSINO BASO MYELO META CRP

% % % % % % % mg/dl
56 29 9 3 1 1 1 0.13

pH pCO2 pO2 HCO3- ABEc SatO2

mmHg mmHg mmol/L mmol/L %
7.2 66 32 25.8 -3.9 22.5
 Lab
LabData after
Data after admission
admission
BUN Crea. Na K Ca Mg eGFR
mg/dl mg/dl mmol/L mmol/L mg/dl mg/dl
10 0.63 137 5.0 8.7 1.8 34.7

WBC Hgb HCT MCV RDW PLT IgM

K/ul g/fl pg fl % K/UL mg/dl
14.77 16.7 47.1 99.4 15.1 307 5.23

SEG LYM MONO EOSINO BASO MYELO META CRP

% % % % % % % mg/dl
56 29 9 3 1 1 1 0.13

pH pCO2 pO2 HCO3- ABEc SatO2

mmHg mmHg mmol/L mmol/L %
7.2 66 32 25.8 -3.9 98
 Lab
LabData after
Data after admission
admission
BUN Crea. Na K Ca Mg eGFR
mg/dl mg/dl mmol/L mmol/L mg/dl mg/dl
10 0.63 137 5.0 8.7 1.8 34.7

WBC Hgb HCT MCV RDW PLT IgM

K/ul g/fl pg fl % K/UL mg/dl
14.77 16.7 47.1 99.4 15.1 307 5.23

SEG LYM MONO EOSINO BASO MYELO META CRP

% % % % % % % mg/dl
56 29 9 3 1 1 1 0.13

pH pCO2 pO2 HCO3- ABEc SatO2

mmHg mmHg mmol/L mmol/L %
7.2 66 32 25.8 -3.9 98
 Lab
LabData after
Data after admission
admission
BUN Crea. Na K Ca Mg eGFR PS
mg/dl mg/dl mmol/L mmol/L mg/dl mg/dl mg/dl
10 0.63 137 5.0 8.7 1.8 34.7 96

WBC Hgb HCT MCV RDW PLT IgM

K/ul g/fl pg fl % K/UL mg/dl
14.77 16.7 47.1 99.4 15.1 307 5.23

SEG LYM MONO EOSINO BASO MYELO META CRP

% % % % % % % mg/dl
56 29 9 3 1 1 1 0.13
IT ratio : 5%

pH pCO2 pO2 HCO3- ABEc SatO2

mmHg mmHg mmol/L mmol/L %
7.2 66 32 25.8 -3.9 98
 Lab
LabData after
Data after admission
admission
BUN Crea. Na K Ca Mg eGFR PS
mg/dl mg/dl mmol/L mmol/L mg/dl mg/dl mg/dl
10 0.63 137 5.0 8.7 1.8 34.7 96

WBC Hgb HCT MCV RDW PLT IgM

K/ul g/fl pg fl % K/UL mg/dl
14.77 16.7 47.1 99.4 15.1 307 5.23

SEG LYM MONO EOSINO BASO MYELO META CRP

% % % % % % % mg/dl
56 29 9 3 1 1 1 0.13

pH pCO2 pO2 HCO3- ABEc SatO2

mmHg mmHg mmol/L mmol/L %
7.2 66 32 25.8 -3.9 98
1. bilateral lung : increased infiltration
2. thymus shadow over RUL
Problem List

1. Respiratory distress, r/o transient tachypnea of newborn

2. Infant of GDM mother and LGA, BBW : 4058gm

Hospital Course

09/02
• Admission to NBCU
• nCPAP ( 9/2 – 9/3 )

09/03
• wean nCPAP
• monitor :
• intermittent tachyarrhythmia with HR up to 175bpm.
• Occational PAC and PVC was noted.
• CV sono : no structural abnormality
Hospital Course

09/04
add propranolol 1mg Q12H

09/05 B/C : negative

09/06 Transfer to SBR
09/07 MBD

10/05 CV OPD :
- no murmur , EKG : sinus rhythm , sono : WNL.
- Keep propranolol 1mg Q12H for 1 month
Diagnosis at Discharge

1. Neonatal respiratory distress, favor transient tachypnea of

newborn, s/p nCPAP on 9/2~9/3

2. Neonate of GDM mother and LGA, BBW 4058gm

3. Intermittent PAC and PVC, under inderal control

 Review :
Infants of Diabetic Mother

Ref : Nelson ( 21thED ) , UPTODATE , 實用新生兒科醫療手冊 ( 第二版 )

1. pathophysiology

2. clinical manifestations

3. Risk Factors

4. neonatal management

5. long-term outcome
Pathophisiology
Mother placenta Fetal

glucose glucose

insulin
Pathophisiology
Fetal Period
 GDM mother

1st trimester 2nd + 3rd trimester

embryopathy Diabetic Fetopathy

decreased early growth

fetal hyperglycemia
GA < 20wk

fetal hyperinsulinemia
Organ anomalies
GA > 20wk
 GDM mother

1st trimester 2nd + 3rd trimester

embryopathy Diabetic Fetopathy

decreased early growth

fetal hyperglycemia
GA < 20wk

Organ anomalies fetal hyperinsulinemia

CNS 和 CV defect 最常見 GA > 20wk
 Hepatic glucose uptake
Glycogen synthesis
Lipogenesis
hyperglycemia Protein synthesis

hyperinsulinemia
B cell hypertrophy
GA > 20wk
hyperglycemia

hyperinsulinemia
GA > 20wk
 extramedullary
hyperglycemia hematopoiesis

myocardial
hyperinsulinemia
hypertrophy
GA > 20wk
 extramedullary
hyperglycemia hematopoiesis
Macrosomia
GA > 20 wkmyocardial
hyperinsulinemia
hypertrophy
GA > 20wk
 Metabolic rate↑
O2 consumption↑

hyperglycemia
Fetal Hypoxemia
GA > 30 wk
hyperinsulinemia
GA > 20wk
• Acidosis
• Catecholamine↑
• EPO↑
• HTN → cardiac remodeling
20-30 %
Stillbirth

neurodeficit cardiomyopathy
Crosstalk between catecholamines and erythropoiesis , 2017
 Macrosomia
GA > 20 wk
fetal asphyxia , cardiomyopathy , TTN
hyperglycemia

hyperinsulinemia
GA > 20wk Fetal Hypoxemia
GA > 30 wk
• Acidosis
• Catecholamine↑
• EPO↑ / polycythemia
• HTN → cardiac remodeling
• neurodeficit
• cardiomyopathy
 Pathophisiology
Neonatal Period
 Macrosomia
GA > 20 wk

Fetal Hypoxemia
fetal hyperglycemia GA > 30 wk

fetal hyperinsulinemia
GA > 20wk
 Macrosomia
GA > 20 wk

Fetal Hypoxemia
fetal hyperglycemia GA > 30 wk

fetal hyperinsulinemia Neonatal hypoglycemia

GA > 20wk 0-7 days

RDS
 Macrosomia
GA > 20 wk

Fetal Hypoxemia
fetal hyperglycemia GA > 30 wk

fetal hyperinsulinemia Neonatal hypoglycemia

GA > 20wk 0-7 days

RDS
 Macrosomia
GA > 20 wk

Fetal Hypoxemia
fetal hyperglycemia GA > 30 wk

fetal hyperinsulinemia Neonatal hypoglycemia

GA > 20wk 0-7 days

RDS

→ insulin 抑制 cortisol 合成 surfactant

→ lung maturation 慢
Clinical Manifestations
11 events YOU should know
 Especially at T1DM mother

Preterm / SGA

• jaundice
• LUNG : RDS
• abnormal HR → cardiomyopathy
• injury
- shoulder dystocia / Erb’s palsy
Macrosomic - perinatal asphyxia
LGA
 • CV (3-9%)
TGA / DORV / VSD / TS / PDA / ASD / HLHS / AS / CoA

• CNS : 比一般人高 15 倍機率

congenital neural tube closure 出問題 ( encephalocele,meningomyelocele, anencephaly )
caudal regression syndrome (sacrum/lumbar 發育不良 ) 是一般人的 200 倍
anomalies

• 30-50%
• Intraventricular septum(IVS) hypertrophy
Transient Hypertrophic • ventricle size↓ LVOT obstruction
Cardiomyopathy

• 少見。
• 機轉： maternal + fetal glucose fluctuation
intestinal motility impair
Small Left Colon Syndrome • Detect : Prenatal ultrasound
 24 小時內血糖 <40mg/dl
Glu↓ 3HR 後出現；血管病變之 DM 母親 delay 到 6-12HR

25% macrosomia 者更嚴重

Ca<7mg/dl 或 free Ca<1mmol/L(BW<1500gm 則 free

Ca↓ Ca<0.8)

機轉： delayed parathyroid response

5-30%
通常無症狀

Mg < 1.5mg/dl ( 0.75mmol/L )

Mg↓ 機轉： maternal urine loss
40% HypoMg 會抑制 PTH 分泌

出生頭三天可能出現神經學症狀
jittery, tremulous, hyperexcitable , hypotonia, lethargy, poor sucking
 • 低血鈣 低血鎂 低血糖 周產期窒息
Acute
neuro-abnormalities

• HCT > 65%

• Fe ↓ (shunt inside RBC) ，但不建議補鐵
• jaundice (10-30%)
• hyperviscosity : 各種 infarction (renal vein thrombosis)
polycythemia • 建議出生 12 小時內驗 HCT

3%

RDS
Risk Factors
 • pregestational 比 GDM 差
• insulin control 比 diet control 差
Mortality • 血糖控制越差， mortality 越高
Infant Outcomes

A1C 控制越差，越容易先天異常

congenital anomalies
Neonatal Management
孕期
嚴格控制血糖，目標至少 A1C<6.5%
控制方法： diet 、 insulin 、 glyburide( 不會穿過胎盤 )
1. PC glu > 120mg/dl→20% macrosomia
2. PC glu > 160mg/dl→50% macrosomia

生產前
評估 resuscitation 的必要
出生後
須小心 hypoglycemia 和 polycythemia
1. Saturation
2. Plasma Sugar
• 不論有無症狀， 3 小時內評估空腹血糖，監測 24 小時
• 24 小時後： glu<45mg/dl ，繼續監測
• 建議 1HR 內餵食或 dextrose gel
3. HCT ：出生前 12 小時內驗
Plasma Sugar Target
4. Ca /Mg •: 有症狀再監測
uptodate
5. hypertropic cardiomyopathy
• 24 小時內 GLU>40: propranolol 0.5-2 mg/lkg/day
• 48 小時內 GLU>50
• Nelson : 48 小時內 GLU>40
 吊 D10W 的時機：
• <4 小時，血糖 <25
• 4-24 小時，血糖
<35
Nelson / 臺大醫院處置建議
D10W 2 cc/kg (=0.2 gm/kg)
slow IV push 接 continuous infusion
出生後
須小心 hypoglycemia 和 polycythemia
1. Saturation
2. glucose
• 不論有無症狀， 3 小時內評估空腹血糖，監測 24 小時
• 24 小時後： glu<45mg/dl ，繼續監測
• 建議 1HR 內餵食或 dextrose gel
3. HCT ：出生前 12 小時內驗
4. Ca /Mg : 有症狀再監測
5. hypertropic cardiomyopathy : propranolol 0.5-2 mg/lkg/day
出生後
須小心 hypoglycemia 和 polycythemia
1. Saturation
2. glucose
• 不論有無症狀， 3 小時內評估空腹血糖，監測 24 小時
• 24 小時後： glu<45mg/dl ，繼續監測
• 建議 1HR 內餵食或 dextrose gel
3. HCT ：出生 12 小時內驗
出生後
須小心 hypoglycemia 和 polycythemia
1. Saturation
2. glucose
• 不論有無症狀， 3 小時內評估空腹血糖，監測 24 小時
• 24 小時後： glu<45mg/dl ，繼續監測
• 建議 1HR 內餵食或 dextrose gel
3. HCT ：出生 12 小時內驗
4. Ca /Mg : 有症狀再監測
出生後
須小心 hypoglycemia 和 polycythemia
1. Saturation
2. glucose
• 不論有無症狀， 3 小時內評估空腹血糖，監測 24 小時
• 24 小時後： glu<45mg/dl ，繼續監測
• 建議 1HR 內餵食或 dextrose gel
3. HCT ：出生 12 小時內驗
4. Ca /Mg : 有症狀再監測
5. Transient hypertropic cardiomyopathy :
• propranolol 0.5-2 mg/kg/day ，禁用 inotropics
• reversible within 1 year
Hypocalcemia 補法
• Astmptomatic : feeding 優先，必要時 Ca 50-150mg/kg/day
• Symptomatic :
• acute ： calglon IV 100mg/kg/dose run 10 分鐘，需監測 HR
• maintain : IV 75mg/kg 或 30-50mg/kg/day QID 吃
• complications
• bradyarrhythmias
• extravasation / necrosis / calcification
• umbilical v : hepatic necrosis if tips at portal v. branch.
• unbilical a. : not suggest
Long-term Outcome
 代謝疾病
DM
• 研究們： > 2/3 IDM 在 34 歲前發展出 T2DM
• 結論： intrauterine environment 可能提高 DM 的發生

Obesity
→intrauterine hyperglycemia+hyperinsulinemia
→adipose 和 beta cell 壞掉
→ 影響 glucose 代謝和 BMI→Obesity

神經發展
研究不多，也沒有共識
有些研究認為 poor controlled 血糖直接影響寶寶 outcome
Thanks
For Listening