Neonatal chemical hypoglycemia in newborns from pregnancies complicated by type 2 and gestational diabetes mellitus – the importance of neonatal ponderal index

Remote patient monitoring for management of diabetes mellitus in pregnancy is associated with improved maternal and neonatal outcomes

BACKGROUND

Diabetes mellitus is a common medical complication of pregnancy, and its treatment is complex. Recent years have seen an increase in the application of mobile health tools and advanced technologies, such as remote patient monitoring, with the aim of improving care for diabetes mellitus in pregnancy. Previous studies of these technologies for the treatment of diabetes in pregnancy have been small and have not clearly shown clinical benefit with implementation.

OBJECTIVE

Remote patient monitoring allows clinicians to monitor patients' health data (such as glucose values) in near real-time, between office visits, to make timely adjustments to care. Our objective was to determine if using remote patient monitoring for the management of diabetes in pregnancy leads to an improvement in maternal and neonatal outcomes.

STUDY DESIGN

This was a retrospective cohort study of pregnant patients with diabetes mellitus managed by the maternal-fetal medicine practice at one academic institution between October 2019 and April 2021. This practice transitioned from paper-based blood glucose logs to remote patient monitoring in February 2020. Remote patient monitoring options included (1) device integration with Bluetooth glucometers that automatically uploaded measured glucose values to the patient's Epic MyChart application or (2) manual entry in which patients manually logged their glucose readings into their MyChart application. Values in the MyChart application directly transferred to the patient's electronic health record for review and management by clinicians. In total, 533 patients were studied. We compared 173 patients managed with paper logs to 360 patients managed with remote patient monitoring (176 device integration and 184 manual entry). Our primary outcomes were composite maternal morbidity (which included third- and fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage requiring transfusion, postpartum hysterectomy, wound infection or separation, venous thromboembolism, and maternal admission to the intensive care unit) and composite neonatal morbidity (which included umbilical cord pH <7.00, 5 minute Apgar score <7, respiratory morbidity, hyperbilirubinemia, meconium aspiration, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, pneumonia, seizures, hypoxic ischemic encephalopathy, shoulder dystocia, trauma, brain or body cooling, and neonatal intensive care unit admission). Secondary outcomes were measures of glycemic control and the individual components of the primary composite outcomes. We also performed a secondary analysis in which the patients who used the two different remote patient monitoring options (device integration vs manual entry) were compared. Chi-square, Fisher's exact, 2-sample t, and Mann-Whitney tests were used to compare the groups. A result was considered statistically significant at P<.05.

RESULTS

Maternal baseline characteristics were not significantly different between the remote patient monitoring and paper groups aside from a slightly higher baseline rate of chronic hypertension in the remote patient monitoring group (6.1% vs 1.2%; P=.011). The primary outcomes of composite maternal and composite neonatal morbidity were not significantly different between the groups. However, remote patient monitoring patients submitted more glucose values (177 vs 146; P=.008), were more likely to achieve glycemic control in target range (79.2% vs 52.0%; P<.0001), and achieved the target range sooner (median, 3.3 vs 4.1 weeks; P=.025) than patients managed with paper logs. This was achieved without increasing in-person visits. Remote patient monitoring patients had lower rates of preeclampsia (5.8% vs 15.0%; P=.0006) and their infants had lower rates of neonatal hypoglycemia in the first 24 hours of life (29.8% vs 51.7%; P<.0001).

CONCLUSION

Remote patient monitoring for the management of diabetes mellitus in pregnancy is superior to a traditional paper-based approach in achieving glycemic control and is associated with improved maternal and neonatal outcomes.

Risk of hypoglycemia by anthropometric measurements in neonates of mothers with diabetes

Macrosomia in neonates of diabetic women is a risk factor for neonatal hypoglycemia, with an over-risk for asymmetric macrosomia. This study aimed to study the association between anthropometric measurements and hypoglycemia in neonates of mothers treated for gestational diabetes. This is a secondary analysis of the INDAO trial study conducted between May 2012 and November 2016 in 13 French tertiary care university hospitals in 890 pregnant women with gestational diabetes treated with either insulin or glyburide. Neonatal anthropometric measurements were birthweight and weight-length ratio (WLR, defined as birth weight/length). Neonatal hypoglycemia was defined as capillary blood glucose below 36 mg/dL (2 mmol/L) or below 45 mg/dL (2.5 mmol/L) associated with clinical signs after 2 h of life. Their relationships were modeled with logistic regressions using fractional polynomials. Extreme categories of birthweight or WLR adjusted for gestational age at birth and sex were defined as Z-score <  -1.28 or > 1.28. These categories were compared to Z-score between -1.28 and 1.28 by estimating odds ratios and confidence intervals for neonatal hypoglycemia. Neonatal hypoglycemia occurred in 9.1% of cases. The relationship between birthweight and WLR Z-scores and neonatal risk of hypoglycemia adjusted for maternal treatment was a U-shaped curve. Adjusted odds ratios for the risk of hypoglycemia were 9.6 (95% CI 3.5, 26.8) and 2.3 (95% CI 1.1, 4.9) for WLR Z-score below -1.28 and above 1.28, respectively, compared with WLR Z-score between -1.28 and 1.28.    Conclusion: Birthweight Z-score was associated with the risk of neonatal hypoglycemia in neonates from mothers treated for gestational diabetes. The risk of neonatal hypoglycemia was increased for both extreme birthweight Z-scores, regardless of maternal treatment. Small for gestational age neonates of diabetic mothers require special attention for the risk of neonatal hypoglycemia. What is Known: • Macrosomia in neonates of diabetic women is a risk factor for neonatal hypoglycemia, with an over-risk for asymmetric macrosomia. Few retrospective studies have assessed the risk for neonatal hypoglycemia among small for gestational age neonates born to diabetic mothers. What is New: • The risk of neonatal hypoglycemia among neonates of diabetic mothers increased for both low and high weight-length ratio, regardless of maternal medicinal treatment, gestational age at birth, and sex of the newborn.

Predicting resolution of hypoglycemia with and without dextrose infusion in newborn infant of gestational diabetic mothers

INTRODUCTION

Neonatal hypoglycemia (NH) may lead to significant neurological impairment if left untreated. Infants of gestational diabetic mothers (IGDM) are at increased risk of early NH and need to be screened. However, it is challenging to predict management with or without intravenous dextrose once hypoglycemia is identified. We evaluated the association between hypoglycemia risk scores at 1-hour of life and the need for intravenous dextrose for hypoglycemia resolution in IGDM.

METHODS

This was a retrospective cohort study of IGDM born at a gestational age ≥35 weeks from January 2015 to December 2017. NH was the disease of interest. The outcomes were the association of hypoglycemia risk score (HRS) with and without intravenous dextrose for hypoglycemia resolution. Each infant's hypoglycemia risk score (HRS) was calculated using data extracted from the maternal and neonatal electronic medical records. Resolution of hypoglycemia with and without intravenous dextrose was compared between the low HRS (0-1) group and the high HRS (2-5) group.

RESULTS

Sixty-five infants were included in the study with a mean gestational age of 38.2 ± 1 weeks for low HRS and 38.0 ± 2 weeks for high HRS. While more children with high HRS were delivered by cesarean section (p = 0.04), hypoglycemia resolved more frequently without intravenous dextrose in infants with low HRS (p = 0.03).

CONCLUSION

IGDM is at increased risk of NH. The resolution of hypoglycemia without dextrose infusion is frequently associated with low HRS at 1-hour of life. Early identification using HRS of IGDM whose hypoglycemia will resolve with or without intravenous dextrose may help clinicians triage newborns to either stay in the nursery or transfer for more invasive care.

Barriers and benefits to breastfeeding with gestational diabetes

Gestational diabetes mellitus (GDM) is a disease of glucose intolerance during pregnancy and is associated with infant macrosomia, infant hypoglycemia, and increased risk of type 2 diabetes development for both mother and infant. Although breastfeeding potentially mitigates metabolic sequelae for both mother and her offspring, women with GDM are more likely to introduce formula and, therefore, are less likely to exclusively breastfeed, and some studies show less initiation and shorter breastfeeding duration as well. Therefore, women with GDM and their infants warrant investigation of methods by which to increase breastfeeding exclusivity and duration. Exploration of the barriers to breastfeeding for women with GDM demonstrate not only biologic complications such as maternal obesity, increased prevalence of cesarean section, and infant hypoglycemia, but also maternal report of less provider support of breastfeeding and reduced breastfeeding self-efficacy. Consequently, interventions designed to optimize breastfeeding outcomes in this high-risk population should not only focus on the biology but also on provider behavior and maternal social factors.

Proposing a new approach to measuring birth size asymmetry

BACKGROUND

Existing methods of measuring birth size asymmetry based on ratios of growth parameters are clinically useful but simplistic, and as such may have limited usefulness in studies of aetiology.

OBJECTIVES

We aimed to develop a novel method of measuring asymmetric fetal growth at birth and demonstrate its utility in characterising the perturbed growth associated with a number of prenatal exposures and neonatal outcomes.

METHODS

Data were drawn from the Queensland (QLD) Perinatal Data Collection, which included all livebirths in the Australian state of QLD between July 2010 and December 2015, with analyses restricted to babies born between 32 and 42 weeks of gestation (n = 280 084). Novel measures of asymmetric birthweight, length, and head circumference were developed using a weighted average, representing "how far" an individual's given birth size measure deviated from the sample average and their other birth size measures. Associations among prenatal exposures and neonatal outcomes with the new asymmetry measures and traditional ratio measures (ie ponderal index, brain-to-body weight ratio, and birth length divided by head circumference) were then compared using log-binomial and multinomial regressions.

RESULTS

The new asymmetry measures clearly indicated that prenatal smoking was linked to a disproportionate decrease in all birth size measures and that low birthweight asymmetry and low birth head circumference asymmetry were specifically associated with neonatal respiratory distress and chromosomal abnormalities, respectively. When these same associations were tested using the traditional ratios, the estimates were weak, imprecise, and non-specific.

CONCLUSIONS

We developed a new approach to measuring fetal growth asymmetry which provides complimentary insights against the existing ratios approach. Associations with the new asymmetry measures were more precise and easier to interpret than the associations obtained using the ratios, and may better reflect the underlying pathological processes, providing an advantage when investigating the aetiologies of perturbed fetal growth.

Care of Infants Born to Women with Diabetes

PURPOSE OF REVIEW

Infants of women with diabetes are at risk for specific morbidities including congenital anomalies, abnormalities of fetal growth, neonatal hypoglycemia, electrolyte abnormalities, polycythemia, hyperbilirubinemia, and respiratory distress syndrome. Recent studies have shed light on long-term outcomes of these infants and presented advances in treatment. The purpose of this review is to outline the most common neonatal morbidities affecting infants of women with diabetes, the pathophysiology and prevalence of these conditions, and contemporary approaches to treatment.

RECENT FINDINGS

Recent investigative findings have led to advances in treatment approaches for these infants, particularly regarding risks of neonatal hypoglycemia. Optimizing maternal glycemic control during pregnancy is imperative to improving infant outcomes. However, on a population level, maternal diabetes still poses significant risks to the infant. Timely and appropriate treatment of infants of women with diabetes is imperative to decrease short- and long-term morbidity.

Swedish national guideline for prevention and treatment of neonatal hypoglycaemia in newborn infants with gestational age ≥35 weeks

AIM

Postnatal hypoglycaemia in newborn infants remains an important clinical problem where prolonged periods of hypoglycaemia are associated with poor neurodevelopmental outcome. The aim was to develop an evidence-based national guideline with the purpose to optimise prevention, diagnosis and treatment of hypoglycaemia in newborn infants with a gestational age ≥35 + 0 weeks.

METHODS

A PubMed search-based literature review was used to find actual and applicable evidence for all incorporated recommendations. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used for grading the evidence of the recommendations.

RESULTS

Recommendations for the prevention of neonatal hypoglycaemia were extended and updated, focusing on promotion of breastfeeding as one prevention strategy. Oral dextrose gel as a novel supplemental therapy was incorporated in the treatment protocol. A new threshold-based screening and treatment protocol presented as a flow chart was developed.

CONCLUSION

An updated and evidence-based national guideline for screening and treatment of neonatal hypoglycaemia will support standardised regimes, which may prevent hypoglycaemia and the risk for hypoglycaemia-related long-term sequelae.

Follow-up study of neurodevelopment in 2-year-old infants who had suffered from neonatal hypoglycemia

BACKGROUND

Neonatal hypoglycemia is tightly related to adverse neurodevelopmental and brain injury outcomes.

METHODS

A total of 195 infants who were born from diabetic mothers with a low blood glucose level (< 2.6 mM) within 0.5 h after birth were enrolled in this prospective cohort study. Of these, 157 infants who had neonatal hypoglycemia (group A) were followed up, and this group was further divided into A1 [blood glucose concentration (BGC) < 2.6 mM at < 2 h after birth], A2 (BGC < 2.6 mM at 2-24 h after birth), and A3 (BGC < 2.6 mM at > 24 h after birth). A total of 144 infants whose mothers had no high risk for gestational diabetes mellitus were followed up as the control group during the same period. The neurodevelopment of the infants was evaluated by the Gesell scoring method.

RESULTS

The adaptability in the A2 and A3 subgroups was significantly lower than that in the control group (73.9 ± 6.6 vs. 87.9 ± 11.2; 71.5 ± 8.9 vs. 87.9 ± 11.2, respectively). There were significantly more mothers who used insulin during the perinatal period in A3 than in A1 and A2 (31% vs. 2%; 31% vs. 7.9%, respectively). The mothers of babies in subgroups A2 and A3 gained more weight than those of the control group (15.3 ± 1.9 kg vs. 11.1 ± 2.2 kg; 14.8 ± 2.6 kg vs. 11.1 ± 2.2 kg, respectively).

CONCLUSIONS

Long and repeated neonatal hypoglycemia caused poor adaptability. The babies of mothers who used insulin or had a high weight gain during pregnancy were associated with severe or persistent neonatal hypoglycemia.

Neonatal endocrine emergencies: a primer for the emergency physician

The resuscitation principles of securing the airway and stabilizing hemodynamics remain the same in any neonatal emergency. However, stabilizing endocrine disorders may prove especially challenging. Several organ systems are affected simultaneously and the clinical presentation can be subtle. Although not all-inclusive, the implementation of newborn screening tests has significantly reduced morbidity and mortality in neonates. Implementing routine screening tests worldwide and improving the accuracy of present tests remains the challenge for healthcare providers. With further study of these disorders and best treatment practices we can provide neonates presenting to the emergency department with the best possible outcomes.

Update on neonatal hypoglycemia

PURPOSE OF REVIEW

Neonatal hypoglycemia is one of the most common biochemical abnormalities encountered in the newborn. However, controversy remains surrounding its definition and management especially in asymptomatic patients.

RECENT FINDINGS

New information has been published that describes the incidence and timing of low glucose concentrations in the groups most at risk for asymptomatic neonatal hypoglycemia. Furthermore, one large prospective study failed to find an association between repetitive low glucose concentrations and poor neurodevelopmental outcomes in preterm infants. But hypoglycemia due to hyperinsulinism, especially genetic causes, continued to be associated with brain injury. New advances were made in the diagnosis and management of hyperinsulinism, including acquired hyperinsulinism in small for gestational age infants and others. Continuous glucose monitoring remains an attractive strategy for future research in this area.

SUMMARY

The fundamental question of how best to manage asymptomatic newborns with low glucose concentrations remains unanswered. Balancing the risks of overtreating newborns with low glucose concentrations who are undergoing a normal transition following birth against the risks of undertreating those in whom low glucose concentrations are pathological, dangerous, and/or a harbinger of serious metabolic disease remains a challenge.

Association between neonatal hypoglycaemia and prediabetes in postpartum women with a history of gestational diabetes

AIMS AND OBJECTIVES

To determine the association between hypoglycaemia among neonates born to mothers with gestational diabetes mellitus and their postpartum prediabetes.

BACKGROUND

Infants born to mothers with diabetes who experienced hyperglycaemia are more likely to develop hypoglycaemia.

DESIGN

A prospective-descriptive research was conducted in three tertiary hospitals in southern Thailand.

METHODS

One hundred and fifty matched pairs of mothers and their newborns were included in the study. Data were analysed using descriptive statistic, odds ratio, Spearman's rho correlation and binary logistic regression.

RESULTS

The incidence of neonatal hypoglycaemia was 42·37% and odds ratio was 0·30. The findings showed the significant association between neonatal hypoglycaemia and postpartum blood sugar levels of women with a history of gestational diabetes mellitus.

CONCLUSIONS

Neonatal hypoglycaemia was associated with maternal hyperglycaemia and prediabetes.

RELEVANCE TO CLINICAL PRACTICE

Neonatal hypoglycaemia might be used to predict prediabetes of postpartum women with a history of gestational diabetes mellitus.

Maternal and neonatal circulating markers of metabolic and cardiovascular risk in the metformin in gestational diabetes (MiG) trial: responses to maternal metformin versus insulin treatment

OBJECTIVE

This study was designed to compare glucose, lipids, and C-reactive protein (CRP) in women with gestational diabetes mellitus treated with metformin or insulin and in cord plasma of their offspring and to examine how these markers relate to infant size at birth.

RESEARCH DESIGN AND METHODS

Women with gestational diabetes mellitus were randomly assigned to metformin or insulin in the Metformin in Gestational Diabetes trial. Fasting maternal plasma glucose, lipids, and CRP were measured at randomization, 36 weeks' gestation, and 6-8 weeks postpartum as well as in cord plasma. Women with available cord blood samples (metformin n = 236, insulin n = 242) were included.

RESULTS

Maternal plasma triglycerides increased more from randomization to 36 weeks' gestation in women treated with metformin (21.93%) versus insulin (9.69%, P < 0.001). Maternal and cord plasma lipids, CRP, and neonatal anthropometry did not differ between treatments. In logistic regression analyses adjusted for confounders, the strongest associations with birth weight >90th centile were maternal triglycerides and measures of glucose control at 36 weeks.

CONCLUSIONS

There were few differences in circulating maternal and neonatal markers of metabolic status and no differences in measures of anthropometry between the offspring of women treated with metformin and the offspring of women treated with insulin. There may be subtle effects of metformin on maternal lipid function, but the findings suggest that treating gestational diabetes mellitus with metformin does not adversely affect lipids or CRP in cord plasma or neonatal anthropometric measures.