|Year : 2014 | Volume
| Issue : 3 | Page : 151-156
Infants of diabetic mothers: 4 years analysis of neonatal care unit in a teaching hospital, Saudi Arabia
Mohammad H Al-Qahtani
Department of Pediatrics, King Fahd Hospital of the University, University of Dammam, Al-Khobar, Saudi Arabia
|Date of Web Publication||11-Oct-2014|
Mohammad H Al-Qahtani
Department of Pediatrics, King Fahd Hospital of the University, University of Dammam, P.O. Box 2208, Al-Khobar 31952
Background: Diabetes mellitus (DM) in pregnant ladies has consequences during the perinatal period, affecting the mothers' gestation and their mode of delivery. The infants of diabetic mothers (IDM) are also prone to spectrum of morbidity. This study aimed to evaluate the outcome of diabetic mothers, of both types; pregestational and gestational, and to determine the spectrum of morbidity pattern among their infants.
Materials and Methods: This study is a retrospective analysis of 4 years period May 2008 to April 2012 at King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia. All the diabetic pregnant mothers admitted to the hospital and their babies within that period were included into the study.
Results: The diabetic mothers constitute 2.9% of all the pregnant ladies. Multiparity was found in the majority of our diabetic mothers regardless of their type of diabetes. Around 70% of the IDM were born to mothers with gestational diabetes mellitus (GDM), while 26% were born to mothers with type 2 DM, and only 4.5% type 1 DM. Full term babies were 163 (92.0%), preterm were only 14 (8.0%). The most common IDM morbidities were Hypomagnesaemia, followed by macrosomia, which was found higher in infant of GDM. The least common complications were polycythemia and acute respiratory distress syndrome. A low percentage of asymptomatic hypoglycemia and hypocalcemia were found. There was no mortality among the IDM during the study period.
Conclusions: As proven in this study Gestational DM continues as health care problem with risks for both the mothers and their offspring. It is recommended to follow the international guidelines for early detection, proper diagnosis and management of the gestational diabetic mothers to improve the outcome and limit the complications.
ملخص البحث :
تهدف هذه الدارسة لتقييم محصلة تأثير مرض السكري قبل الحمل وأثناءه وتحديد نمط الأمراض الناتجة على المواليد. شملت هذه الدراسة الاسترجاعية الأمهات الحوامل خلال 4 سنوات بمستشفى الملك فهد الجامعي - الخبر. وخلصت إلى أن سكر الحمل يظل مشكلة لمقدمي الرعاية الصحية بما يحمل من مخاطر للام والمواليد . يوصي الباحث بإتباع الإرشادات الدولية للاكتشاف المبكر والتشخيص الصحيح والمعالجة الفاعلة لسكر الحمل ولتقليل مضاعفاته.
Keywords: Diabetes mellitus, gestation, infants of diabetic mothers
|How to cite this article:|
Al-Qahtani MH. Infants of diabetic mothers: 4 years analysis of neonatal care unit in a teaching hospital, Saudi Arabia. Saudi J Med Med Sci 2014;2:151-6
|How to cite this URL:|
Al-Qahtani MH. Infants of diabetic mothers: 4 years analysis of neonatal care unit in a teaching hospital, Saudi Arabia. Saudi J Med Med Sci [serial online] 2014 [cited 2020 Jun 2];2:151-6. Available from: http://www.sjmms.net/text.asp?2014/2/3/151/142499
| Introduction|| |
Diabetes mellitus (DM) in pregnant ladies is either pregestational DM, which includes type 1 and type 2 diabetes mellitus (type 1 DM, type 2 DM), or the most common form of DM, which is pregnancy induced glucose intolerance and ends at the birth time or immediately after and it is called gestational diabetes mellitus (GDM). 
Diabetes mellitus affects about 3-10% of all pregnant ladies and most of them (80%) have GDM. 
In Saudi Arabia unfortunately, we do not have national registry for all the cases; however, the different regional studies showed that DM during pregnancy affects 8.9-12.5% of the Saudi pregnant ladies. 
Although mortality of mothers with gestational diabetes during their perinatal period has declined , yet their infants continued to have progressive morbidity and mortality. ,
The infants of diabetic mothers (IDM) have a special concern and constitute one of the common health problems in the neonatal care unit. There is more than 100,000 IDM born yearly in the United States. 
Gestational diabetes mellitus can negatively affect the pregnancy and result in adverse perinatal outcome such as macrosomia, birth trauma, shoulder dystocia, and higher rates of cesarean section ,
Some authors have recommended that serious perinatal morbidity can be reduced with treatment of the mothers with GDM. ,
Our target of this study is to analyze the incidence of DM during pregnancy and the IDM, and to assess the possible differences in the outcome according to the type of diabetes; type 1 DM, type 2 DM, and those with GDM, in a teaching hospital.
| Materials and Methods|| |
Retrospectively we reviewed all the medical records and the electronic database of the diabetic ladies diagnosed, followed and gave birth at King Fahd Hospital of the University, Khobar Saudi Arabia, as well as their infants admitted to the neonatal care unit between May 2008 and April 2012.
Mothers with pregestational DM (type 1 and type 2) as well as GDM were studied.
Ladies with any medical or surgical complications related directly or indirectly to DM(since they have higher risks of fetal complications and it will affect the results of the study that targeted uncomplicated diabetic mothers and their offsprings), those with multiple gestations since this will affect all the parameters of their babies which will be biased to compare with those with singletons. Also we excluded those who gave birth outside the hospital.
Maternal data are; Nationality, Age, parity, type and duration of diabetes, treatment of diabetes, and mode of delivery.
Gestational diabetes mellitus was confirmed if a pregnant lady between 20 and 24 weeks tested after oral 50 g-glucose bolus and had two or more values more than the following cut-off points: fasting blood sugar 100 mg/dl; 1-h sugar 190 mg/dl; 2-h sugar 165 mg/dl; and 3-h sugar 145 mg/dl. 
The second set of data was a list of characteristics of their babies, and included the following; gestational age (GA), birth weight (BWT) in relation to their GA; (appropriate for gestational age (AGA) defined as the baby's weight between 10 th and 90 th percentile of the gestational-age weight), small for gestational age, defined as baby's weight less than the 10 th percentile for gestational-age weight and macrosomia; defined as BWT ≥4000 g). ,
Congenital heart diseases (CHD), acute respiratory distress syndrome (ARDS), and transient tachypnea of newborn were also included. The variables also included the biochemical laboratory results; namely random blood sugar readings as per hospital protocol, serum total calcium level, serum total and direct bilirubin level, magnesium level and hematocrit to check for polycythemia.
Hypoglycemia was defined as random blood glucose level <2.6 mmol/L, and polycythemia as a peripheral venous hematocrit >0.65, and hyperbilirubinemia as serum levels of indirect bilirubin >204 μmol/l (12 mg/dl). Hypocalcaemia was defined by total serum calcium values ≤1.50 mmol/l (7 mg/dl), hypomagnesaemia defined as serum magnesium level of less than 1.6 mg/dl (0.65 mmol/L).
Echocardiography was done in suspected cases of CHD. Data were entered in computer using SPSS for windows version 20.0 (SPSS Inc., Chicago, IL). Frequency tables were performed as descriptive statistics for categorical variables. For a continuous data means and standard deviation were calculated as descriptive values.
| Results|| |
During the study period, total delivery number was 6000 and out of them there were 177 ladies with pregestational and gestational diabetes with a prevalence of 2.95%.
[Table 1] presents the baseline characteristics of the mothers having DM in that period.
|Table 1: The demographic as well as the clinical data|
of the diabetic ladies
Click here to view
The mean age of those diabetic ladies was 35 years, majority of them were 20-40 years of age and almost 15% of ladies were above 40 years of age, and very few were less than 20 years of age, majority were Saudis (82.5%).
As multiparity is so common in our society we got 91.5% of them were multiparous and only 8.5% were primigravida ladies. 
While more than two-third of the diabetic ladies (70%) have GDM, yet good percentage of the ladies were having type 2 DM (26%) and only eight ladies were having type 1 DM (4.5%).
One-third of the ladies were managed by diet only, while the remaining two thirds of the ladies including all type 1 DM, type 2 DM, were treated with subcutaneous insulin injections as single daily dose, two doses per day and few of them treated as three doses per day.
The mode of delivery was by caesarian section (CS) done for 47% of all the diabetic ladies almost equal to those delivered by spontaneous vaginal mode. Out of 84 ladies who had CS, most of them were GDM 69% (58), while 26% (22) were having type 2 DM, and only 4.76% (4) were type 1 DM.
Neonatal demographic data as well as their medical outcome analysis are shown in [Table 2]. The total number of infants born during that period was 177. Males and females were almost comparable 52% and 48% were respectively. Most babies were full term 92% and only 8% of them were preterm, females were 3.5 times more than the males.
The weight of the majority of babies 115 (65%) was in the AGA class. Macrosomia in our sample affected 37 babies (21%), with equal gender distribution, majority of their mothers had GDM constituting about73%, however 7 babies (19%) their mothers had type 2 DM, and only 3 (8%) had type 1 DM. SGA constituted only 14% of the babies.
Apgar score means were 7.84 and 9.257 at 1 st and 5 th min respectively, with equal gender distribution 14% of the babies were having CHD the most common one was patent ductus arteriosus in two-thirds of the babies.
Only 26 babies (14.7%) had hypoglycemia in their 1 st day of life affecting males almost 2 times more than females.
Transient hypocalcemia defined as total serum calcium equal or less than 7.0 mg/dL within the first 48 h of life was found in 17.5% all of them were asymptomatic. Hyperbilirubinemia was found in a percentage of 17.5% all of them were indirect type of hyperbilirubinemia with equal gender affection.
Hypomagnesaemia, was the commonest biochemical abnormality in our sample and it affected more than 54% of all the babies, while polycythemia was least common affecting only around 3%.
Out of all the IDM, ARDS affected only; 10% majority of them were transient tachypnea of newborns almost 3 times commoner in males, while those who had hyaline membrane disease were only four patients two of them were preterm.
There was no birth trauma reported although there was good percentage of macrosomia.
| Discussion|| |
This retrospective study shows that the prevalence of GDM in our sample is 2.9% which is comparable to the previous recent national studies, one of them was in our hospital 5 years back. , Also it is comparable to the other the national and international ranges, however it is less than few other studies which might be explained by the lower delivery rate in our sample. ,
Majority of the diabetic ladies 123 (69.5%) were having only GDM. The literature showed GDM is about 80% of all the diabetes in pregnant ladies. 
Type 2 DM was found in 46 (26%) of all the diabetic ladies, majority of them were Saudis (83%) which is comparable to the hospital percentage of Saudi pregnant ladies admission rate of 82-88%. This is well explained as type 2 DM is common metabolic disorder all over the world and has high prevalence in Saudi Arabia.  The remaining 8 ladies (4.5%) were having type 1 DM.
One third was primigravida. Multiparity in our sample is huge (91.5%) and comparable to the previous Saudi studies. ,
As the mother age gets higher the prevalence of GDM gets increased. In our sample the average maternal age is 35 years and 15% of them were above 40 years of age, similar to other studies findings. ,
The CS rate in this study was very high compared to national studies , although we do not know the different indications in this sample, yet it is much less than other studies. ,
Fortunately in the IDM cases; there was no mortality reported in our samples over the 4 years period which was similarly found in many studies as the perinatal mortality was declining. ,,,
The preterm deliveries in our sample were only 8% and most of these babies were females, although the literature mentions that the rate of prematurity in IDM is 5 times that of the general population and reaching up to one third of all cases IDM. 
Macrosomia although is affected by many maternal, placental and fetal factors,  yet the DM during pregnancy is one of the major causing factors, and macrosomia is thought to be a leading cause for traumatic birth injury, obesity, and metabolic diseases in later life of the offspring. In our study, it was found in about 21% of the sample, which is almost double the percentage found in the previous study in our hospital  but much lower than another Saudi study.  In our sample macrosomia was so prevalent in GDM compared with the infants of pregestational DM both type 1 and type 2 DM, which is contradictive to another UK study.  However macrosomia in our study was not associated with birth trauma, which might be explained by the high percentage of CS delivery, in addition to the small size of the sample.
Hypoglycemia was found only in 26 babies (14.7%) affecting males almost 2 times more than females, and it is similar to another national study;  however, it is much less than an older national study  and other recent international study's results.  It depends on timing of glucose testing, which should avoid at least the first 2-3 h of life since it is the physiological response of the high maternal glucose status  yet it is considered one of the potentially serious outcomes of IDM.  Strict peri-conceptional glycemic control was found very effective in controlling the outcome on IDM  and the implementation of gestational diabetes protocols had decreased the prevalence of some complications. 
Hypocalcemia as asymptomatic transient biochemical complication of diabetes during pregnancy is caused by maternal loss of calcium in urine and transient unresponsiveness of the fetal parathyroid gland to this hypocalcaemia. In our study, it was found in 17% with equal gender affection, which is not far from other studies;  however, it is much less than another study since they consider the cut-off point is less than 6.0 mg/dl and they got half of their patients asymptomatic. 
Hypomagnesaemia is explained by the maternal excessive urinary loss of magnesium accompanying the glycosuria during the period of poor control. Deficiency of this electrolyte affects the secretion and peripheral action of parathyroid hormone. Hypomagnesaemia was the major metabolic abnormality detected in our sample; almost 55% of babies and female:male ratio is 1.3:1; however, one author reported only in 10.6%. 
Hyperbilirubinemia as one of the consequences of diabetes during pregnancy and its pathogenesis is due to increased production of bilirubin, prolonged red blood cell life span as result of glycated cell membrane, and immature hepatic conjugation.  It was found in 31 babies (17.5%) with equal gender distribution; all of them were nonpathological indirect hyperbilirubinemia and this is much less than what was found in another national study  where it was a major cause for nursery intensive care unit admission. However, the international range is 20-25%. ,
Polycythemia leads to hyperviscosity and considered as a risk factor for renal vein thrombosis in IDM and it is due to hypoxic stimulus of placental insufficiency caused by glycated hemoglobin.  It was found only in 5 babies (2.8%) which resolved spontaneously. This result is within the lower published range of 5-29%. 
Acute respiratory distress syndrome is thought to be due to hyperinsulinism in IDM which inhibits the synthesis of the phospholipid component of the surfactant in the fetal lungs.  Only four babies (2.23%) had ARDS and two of them were preterm, which is similar to results of strictly controlled diabetic mothers studies.  It was found to be higher in those poorly controlled ladies.  In the literature ARDS is getting less and less compared to the studies done in the last decade. 
Furthermore some authors found ARDS in a comparable ratio among IDM and babies of nondiabetic mothers. 
Over all, there was no difference in complications in babies of women with type 1 compared to type 2 diabetic mothers, the most important factor is the maternal blood glucose concentration. Studies have shown that improvement in outcome for IDM can be achieved through active management of the mother's diabetes; aiming to keep the blood sugar as controlled as possible in the early stage of pregnancy as well as the late stages. 
The limitation in this study is being retrospective, in addition to the lack of correlating the maternal glycemic control with the outcomes in both the mothers and their babies which was due to missing data of the glycemic control in the medical records. The other limitation is the lack of control group.
| Conclusion|| |
It can be concluded that the commonest consequences of GDM were asymptomatic hypomagnesimia and hypocalcemia. The outcomes of gestational and pregestational DM were similar in those mothers as well as their offsprings.
It is suggested to conduct a prospective study assessing all diabetic ladies from their initial visits to the time of delivery, which will correlate precisely the glycemic control level with the outcome in the mothers and their offsprings.
| References|| |
American Diabetes Association. Gestational diabetes mellitus. Diabetes Care 2000;23 Suppl 1:S77-9.
King H. Epidemiology of glucose intolerance and gestational diabetes in women of childbearing age. Diabetes Care 1998;21 Suppl 2:B9-13.
Al-Khalifah R, Al-Subaihin A, Al-Kharfi T, Al-Alaiyan S, Alfaleh KM. Neonatal short-term outcomes of gestational diabetes mellitus in Saudi mothers: A retrospective cohort study. J Clin Neonatol 2012;1:29-33.
Landon MB, Gabbe SG, Piana R, Mennuti MT, Main EK. Neonatal morbidity in pregnancy complicated by diabetes mellitus: Predictive value of maternal glycemic profiles. Am J Obstet Gynecol 1987;156:1089-95.
Gregory R, Scott AR, Mohajer M, Tattersall RB. Diabetic pregnancy 1977-1990: Have we reached a plateau? J R Coll Physicians Lond 1992;26:162-6.
Cordero L, Landon MB. Infant of the diabetic mother. Clin Perinatol 1993;20:635-48.
Nasrat HA, Salleh M, Ardawi M, Ghafouri H. Outcome of pregnancy in diabetic mothers. Int J Gynaecol Obstet 1993;43:29-34.
Sendag F, Terek MC, Itil IM, Oztekin K, Bilgin O. Maternal and perinatal outcomes in women with gestational diabetes mellitus as compared to nondiabetic controls. J Reprod Med 2001;46:1057-62.
Reece EA. The fetal and maternal consequences of gestational diabetes mellitus. J Matern Fetal Neonatal Med 2010;23:199-203.
Johns K, Olynik C, Mase R, Kreisman S, Tildesley H. Gestational diabetes mellitus outcome in 394 patients. J Obstet Gynaecol Can 2006;28:122-7.
Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS, et al
. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005;352:2477-86.
Gasim T. Gestational diabetes mellitus: Maternal and perinatal outcomes in 220 saudi women. Oman Med J 2012;27:140-4.
Battaglia FC, Lubchenco LO. A practical classification of newborn infants by weight and gestational age. J Pediatr 1967;71:159-63.
Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard Score, expanded to include extremely premature infants. J Pediatr 1991;119:417-23.
Al-Rowaily MA, Abolfotouh MA. Predictors of gestational diabetes mellitus in a high-parity community in Saudi Arabia. East Mediterr Health J 2010;16:636-41.
Nold JL, Georgieff MK. Infants of diabetic mothers. Pediatr Clin North Am 2004;51:619-37, viii.
Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al-Harthi SS, Arafah MR, Khalil MZ, et al
. Diabetes mellitus in Saudi Arabia. Saudi Med J 2004;25:1603-10.
Engelgau MM, Herman WH, Smith PJ, German RR, Aubert RE. The epidemiology of diabetes and pregnancy in the U.S., 1988. Diabetes Care 1995;18:1029-33.
Al-Hakeem MM. Pregnancy outcome of gestational diabetic mothers: Experience in a tertiary center. J Family Community Med 2006;13:55-9.
Alam M, Raza SJ, Sherali AR, Akhtar AS. Neonatal complications in infants born to diabetic mothers. J Coll Physicians Surg Pak 2006;16:212-5.
Anonymous. Confidential enquiry into maternal and child health: Maternity services in 2002 for women with type 1 and type 2 diabetes. England, Wales and Northern Ireland, London: CEMACH; 2005.
Michael Weindling A. Offspring of diabetic pregnancy: Short-term outcomes. Semin Fetal Neonatal Med 2009;14:111-8.
Cordero L, Treuer SH, Landon MB, Gabbe SG. Management of infants of diabetic mothers. Arch Pediatr Adolesc Med 1998;152:249-54.
al-Dabbous IA, Owa JA, Nasserallah ZA, al-Qurash IS. Perinatal morbidity and mortality in offspring of diabetic mothers in Qatif, Saudi Arabia. Eur J Obstet Gynecol Reprod Biol 1996;65: 165-9.
Hod M, Merlob P, Friedman S, Schoenfeld A, Ovadia J. Gestational diabetes mellitus. A survey of perinatal complications in the 1980s. Diabetes 1991;40 Suppl 2:74-8.
Opara PI, Jaja T, Onubogu UC. Morbidity and mortality amongst infants of diabetic mothers admitted into a special care baby unit in Port Harcourt, Nigeria. Ital J Pediatr 2010;36:77.
Ward Platt M, Deshpande S. Metabolic adaptation at birth. Semin Fetal Neonatal Med 2005;10:341-50.
Leipold H, Kautzky-Willer A, Ozbal A, Bancher-Todesca D, Worda C. Fetal hyperinsulinism and maternal one-hour postload plasma glucose level. Obstet Gynecol 2004;104:1301-6.
Murthy EK, Renar IP, Metelko Z. Diabetes and pregnancy. Diabetol Croat 2002;31-3.
Bourbon JR, Farrell PM. Fetal lung development in the diabetic pregnancy. Pediatr Res 1985;19:253-67.
Merlob P, Hod M. Short-term implications: The neonate. In: Hod M, Jovanovic L, Di Renzo GC, De Leiva A, Langer O, editors. Textbook of Diabetes and Pregnancy. 2 nd
ed. London: Informa; 2008.
[Table 1], [Table 2]