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The son of a diabetic mother

  1. Gastroepato
  2. Diabetology
  3. The son of a diabetic mother
  4. Pregnancy and risk od diabetes
  5. Recommendations for screening
    and diagnosis of gestational diabetes
  6. Type 1 or type 2 diabetes mellitus
  7. Diabetes. What are we talking about?
  8. The checks to be performed

If you are a pregnant mother and you have these characteristics:
- Age over 35 years.
- Positive diabetic familiarity in the first degree (parents or siblings who are diabetic).
- Obesity.
- Previous pregnancy with diagnosis of gestational diabetes.
- Previous childbirth with birth weight greater than or equal to 4 kg (fetal macrosomia).
- Previous / childbirth of a stillborn baby.
- Presence of glycosuria, ie glucose response in the urine.
- Occasional finding of a fasting plasma glucose greater than 92 mg / dL

You must immediately contact your obstetrician or diabetologist to perform a:

Screening test for diabetes during pregnancy that must be performed between the 16th and 24th week

The "giant with feet of clay", macrosomic child

We begin to dispel the common opinion that if a child is born macrosomic, that is, its weight is noticeable at birth, it means that it enjoys excellent health, indeed! Example in both the born of a diabetic mother, if she was not followed adequately by her obstetrician. In fact, the son of a diabetic mother is the most common example of neonatal mortality and morbidity from a mother's metabolic disease. There is a correlation between the bad control of diabetes at the beginning of gestation and the incidence of congenital malformations

- HbA1c <9.3 risk of miscarriage 12.4% malformations 3%
- HbA1c> 14.3 risk of abortion 37.5% malformations 40%

With the advent of insulin therapy today, with a strict and rigorous diet that does not increase the weight of diabetic weight, the woman not only reaches the fertile age, but also is able to carry out her pregnancies well, with all the associated and related risks. In the 60s, fetal and neonatal mortality was still around 65%, but today, in most cases even if the perinatal course is normal, the fact remains that the mother born with diabetes remains a newborn at risk of even serious complications.
The prognosis depends, as well as on the disease, on how the gynecologist and the pediatrician know how to manage this condition.
It is not uncommon to come across a child born of a diabetic mother, because this event varies from 10% of the US to 4% of other populations.
The incidence increases with:
-the age,
-overweight at the beginning of pregnancy,
-the familiarity for diabetes
-previous pregnancies with gestational diabetes
These newborns present a risk:
-triple for mortality and congenital malformations
-double for birth trauma,
-quadruple for hospitalization in TIN.

Pathophysiology

Why should a child born of a diabetic mother have suffering?

Have you not seen, perhaps, these beautiful little girls, with their chubby cheeks, that the mothers admire, not knowing the suffering of these creatures called "the giants with their feet of clay"? This is not a question of discouraging a diabetic mother from having a pregnancy like all the other mothers of the world, but it is a matter of warning her to be followed well by her obstetrician, without taking weight and with very rigorous nutrition. In fact, a maternal hyperglycemia means that even the product of conception will go into distress for the same hyperglycemia, if the compensation of gestational diabetes has not been adequate, and the fetal hyperglycemia will ultimately stimulate the fetal pancreatic beta cell leading to a fetal hyperinsulinemia.

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There will be the formation of macrosomal fetuses, with huge organs, liver and pancreas of increased volume, where there will be the risk of generating polyglobulary infants, due to the increased needs of the organism with extramedullary hematopoiesis. The hepatic uptake of glucose by the liver is increased in these fetuses, as is the synthesis of glycogen which even accumulates even in the interventricular septum of the heart, making it hypertrophic and the lithogenesis with protein synthesis are increased.

So, within the first twenty weeks, when tissues and organs are in formation, the child will be affected by congenital anomalies and a reduction in the speed of growth. Neonatal hypoglycemia, surfactant deficiency and immaturity of the hepatic metabolism may be present, the conspicuous consequence of which is jaundice. Then from the twentieth week onwards there will be macrosomia and at birth these children will show asphyxia due to the changed metabolic needs, hypocalcaemia and respiratory distress syndrome with severe hypoxemia. The polycythemia that occurs may still be responsible for stroke, with the corpuscular elements of the blood appearing stacked. The child with stroke and with hypoglycemic crisis taking place, will eventually have results, if the neurological damage that has been established in the meantime has not been understood and treated as it should (cf. PEDERSEN, 1997)

Not always, however, the child is macrosomic; sometimes if the diabetic patient has micro and macrovascular complications, then the fetus increases badly, for example if the uterine vessels are calcified and at the time of birth may appear undernourished. It is established, that is, a picture of malnutrition with reduction of fat and protein mass. Macrosomic children are about 26% of those born to diabetic mothers; they are newborn chubby, with weight> 4000 gr or> 90C ° but disharmonic, weight disproportionate to the length and to the c. cranial, with organomegaly (increase in volume but also in cell number).

Hyperinsulinemia

They present these critical points:

- Asparticular intrapartum, brachial paralysis, etc.
- Hypoglycemia
- Cardiomyopathy
- Respiratory distress
- Neurological outcomes

The neurological outcomes of children born to untreated diabetic mothers.

50% of those born to a diabetic mother have hypoglycemia already at 30 min. from birth (75% if the mother is insulin dependent); it is unipoglycemia is more frequent in macrosomes and malnourished due to the poor metabolic control of the 2nd and 3rd trimester of pregnancy. The likelihood of a newborn developing hypoglycaemia increases the higher levels of glucose in the umbilical cord or fasting maternal blood. The neuro-behavioral performances of those born to a diabetic mother appear to be related to the mother's glycemic balance. The presence of "minimal brain dysfunction" in children with asymptomatic hypoglycemia will be assessed at the age of 8, when the child becomes a "difficult" child at school, who learns poorly to read and write.

Generally the risk of hypoglycemia should be far from the child at birth because glucose is a very important brain energy substrate for a brain of the newborn that grows rapidly using more than 80% of the metabolized glucose, and it is necessary to promptly release glucose endogenous glucose is mobilized greatly, already within a few minutes of birth, the release of catecholamines which increases 3-5 times the concentration of glucagon and suppresses the release of insulin, which remains at baseline levels and does not show the usual response to glucose. Glycogenolysis and neoglucogenesis are activated (cf. carbohydrates), but also lipolysis with increased fatty acids and ketone bodies (the brain of the newborn is able to oxidise ketone bodies 5 times more than adults. malnutrition, that is, in the young with growth failure, which has experienced a state of chronic malnutrition, hypoglycemia is particularly severe and manifests itself with dangerous neonatal seizures.Generally, but it is not a rule, glycemia is symptomatic if:

- Glycaemia <40 mg / dl in term newborns (45 mg / dl after the first 24 hours)
- Blood sugar <30mg / dl in preterm births
- sometimes even hypoglycemia better than 60 mg / dl were symptomatic and the newborn presented
- Tremors
- Sweating
- Cry
- Apnee
- Convulsions
- Sequelae

Treatment of the hypoglycemic crisis of the newborn

In these cases the readiness in the neonatologist is essential to overcome the symptomatic hypoglycemic crisis (<45 mg / dl) by implementing these therapeutic measures:
- Glucose 10% 2-4 ml / kg e.v. in bolus followed by glucose infusion at 6-8 mg/kg / m.
- Blood glucose control after 30-60 min.
- Increase the glucose concentration until the patient is euglycemic and stable but continue the checks every 4-6 hours.
- Start feeding as soon as possible

To increase the glucose rate above 6mg / Kg / min it is necessary to gradually increase the glucose concentration from 10% up to 18-20%, therefore a central vessel is required!
Subsequently the newborn must be fed as soon as possible. Or by tube or by natural means if it is able to do it. A diabetic mother can and must necessarily breastfeed her baby, to prevent them from growing up in obesity (see proper nutrition). Another problem with this type of newborn is the crisis of hypocalcaemia and hypomagnesemia. Hypocalcaemia and hypomagnesemia occur in up to 50% of the births of MD and the incidence is correlated with severity and duration of diabetes. They appear in 2 ° -3 ° day of life with symptoms similar to that from hypoglycemia. Further risk factors are respiratory distress and asphyxia at birth. The reason lies in the fact that there is a delay in the postnatal response of parathormone which increases physiologically in the 24 following birth and high values ​​of calcitonin (which is inversely related to gestational age), with low levels of Mg (which suppress the release of PTH). Mothers with severe diabetes have a greater urinary loss of Mg, followed by fetal hypomagnesemia and therefore reduced secretion of PTH. Hypocalcaemia crises are similar to hypoglycaemia: tremors, sweating, tachypnea, irritability, convulsions. The therapy includes:
- Treat only symptomatic patients
- Calcium gluconate 10% e.v. 2ml-4ml / Kg very slowly
- Magnesium sulphate: 0.1-0.2 ml / kg of MgSO4 at 50% e.v. in 1 hour
- Monitor ECG
These children will still have the risk of developing polyglobulia, ie the blood will be very rich in red blood cells, and the reason for this depends on the fact that the fetal hyperglycemia and hyperinsulinemia increase the consumption of tissue oxygen stimulating the production of erythropoietin with secondary erythropoiesis. The symptomatology is consequent to the hyperviscosity of the blood. The baby will be hyporeactive, lethargic, plethoric, irritable, quivering, shrill weeping. It will be able to address central neurological and hypercoagulability problems: cerebral infarction, convulsions, necrotizing enterocolitis, renal vein thrombosis, venous sinus thrombosis, pulmonary hypertension
Finally, fetal malformations of the child born of a diabetic mother come:
- Complex cardiopathies
- Neural tube defects
- Palatoschisis, micrognathia
- Vertebral abnormalities
- Hypoplasia of the femur
- Renal malformations
Caudal regression syndrome (developmental deficit of vertebral, urogenital and intestinal structures up to sirenomyelia).

Think about it, if you suffer from diabetes or suspected of being it or just by chance you have checked your blood sugar after the meal and these were high, above the value of 140-180 mg / dl, talk to your doctor immediately and talk about it.

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