INFANT OF A DIABETIC MOTHER
Globally, the number of people living with diabetes mellitus is expected to rise to 592 million by 2035 (Guariguata et al., 2014). Many mothers and infants will be impacted because every pregnancy complicated by maternal diabetes is a pregnancy at risk. Despite a benign history, insulin deficiency or resistance develops during pregnancy in some women. The prevalence of this condition, called gestational diabetes, is approximately 2% to 6% globally and as high as 9.2% in the United States (DeSisto, Kim, & Sharma, 2014; Mitanchez, Burguet, & Simeoni, 2014). In both diabetes mellitus and gestational diabetes, unstable and often excessive glucose levels are a defining characteristic and may be linked to adverse fetal and neonatal outcomes.
The infant of a diabetic mother (IDM) is at risk for numerous complications and requires careful monitoring during the early neonatal period. Two distinct clinical pictures present: the first is associated with overnutrition and the second with teratogenesis.
Gestational diabetes is a frequent clinical presentation in the pregnant woman and occurs when maternal glucose intolerance develops. The mother lacks sufficient functioning insulin and develops a persistent excess of her own serum glucose. The glucose-rich serum is perfused to the fetus, which results in fetal hyperglycemia. The fetus adapts by producing higher-than-normal levels of insulin in order to maintain fetal glucose levels within normal range. The fetus then converts and stores excess glucose as fat. The result is an overnourished, hyperinsulinemic, macrosomic infant. Complications associated with overnutrition and macrosomia include difficult labor, cephalo-pelvic disproportion, possible cesarean section, shoulder dystocia, birth trauma, hemorrhage, glucose instability, temperature instability, and respiratory distress in the first few days of life. For these neonates, unstable maternal insulin and glucose levels are associated with increased rates of perinatal asphyxia (Riskin & Garcia-Prats, 2016).
The second clinical presentation occurs when unrecognized or poorly controlled diabetes precedes pregnancy or complicates the early weeks of pregnancy. High serum glucose levels can be teratogenic during early fetal development and result in cardiovascular and neural malformations. These defects can lead to first-trimester loss, fetal demise, or serious congenital anomalies. Referred to as diabetic embryopathy, these complications are the direct result of pregestational diabetes (Hay, 2012; Riskin & Garcia-Prats, 2016). Pregnancy complicated by diabetes can lead to intrapartum complications, preterm birth, altered glucose metabolism, respiratory problems, and difficulty transitioning to extrauterine life (Mitanchez et al., 2015).
A careful history, including family history of diabetes, mother’s health before and during this pregnancy as well as previous pregnancies (including birthweight of infants), are key to interpreting the clinical picture, evaluating risks, stabilizing glucose levels, and preventing complications.
Head-to-toe assessment by the bedside nurse will aid in identifying risks for complications in the IDM. Any infant with a birth weight greater than 90% on the growth chart for gestational age or greater than 4,000 g birth weight is classified as macrosomic and at risk for potential complications as an IDM (Hay, 2012; Riskin & Garcia-Prats, 2016).
NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS
IDMs who present as macrosomic, overnourished, or hyperinsulinemic face many challenges requiring careful monitoring and support by nursing. Chief among these are low serum glucose concentrations; respiratory distress; electrolyte imbalances; polycythemia, cardiomegaly, and hyperbilirubinemia; temperature instability; feeding difficulties; and poor state regulation (Mitanchez et al., 2014; Riskin & Garcia-Prats, 2016).
Low blood glucose levels are an issue in the IDM. Accustomed to high-circulating serum glucose levels provided by the mother through the placenta, the IDM has become efficient in producing insulin to normalize blood glucose. After cutting the umbilical cord, the glucose supply from the mother is terminated resulting in glucose levels in the newborn to fall precipitously. As a result, the formerly adaptive elevated insulin levels also cause glucose levels to drop. Frequent glucose monitoring starting between 1 and 3 hours of life is necessary until levels stabilize. Serum glucose levels below 47 mg/dL are considered hypoglycemic and require intervention. However, thresholds vary by institutions (Sweet, Grayson, & Polak, 2013).
Early feedings help prevent or attenuate low serum glucose levels. Breastfeeding can be initiated in the delivery room and sustained through the early neonatal period. However, robust research to support this practice is not available (East, Dolan, & Forster, 2014