Morbidities and Mortalities Among Infant of Diabetic Mother in a Newly Established SCANU of a Tertiary Care Hospital , Bangladesh

Address for correspondence: Dr. Md. Nazrul Islam, MBBS, MCPS (Paed), FCPS (Paed), MD (Neonatology) Assistant Professor, Department of Neonatology Mymensingh Medical College, Mymensingh, Bangladesh E-mail: mnislamdr1@yahoo.com Tel: +88-01711-247222 1Dr. Md. Nazrul Islam*, MBBS, MCPS, FCPS, MD, Assistant Professor, Department of Neonatology, Mymensingh Medical College, Mymensingh, Bangladesh, 2Dr. Tanha Tazmin, MBBS, MD Resident, Dept. of Neonatology. Mymensingh Medical College, Mymensingh, Bangladesh, 3Dr. Mohosina Siddika, MBBS, DGO, Assistant Professor, Dept. of Gynae and OBS, Community Based Medical College, Mymensingh, Bangladesh. 4Mohammod Kamruj Jaman Bhuiyan, B.Sc. (Hon’s), M.Sc. (Statistics), Associate Professor, Dept. of Agricultural Statistics, Bangladesh Agricultural University, Mymensingh, Bangladesh. Abstract


Introduction
D iabetes mellitus is characterized by hyperglycaemia, disturbance of carbohydrate, fat, and protein metabolism that are associated with absolute and rela ve defi ciencies in insulin ac on and/or insulin secre on 1 .An infant of a diabe c mother (IDM) is a baby who is born to a mother with diabetes.
In pregnancy, there is an inevitable sharing of maternal nutrients through transport via placenta to the fetus, thus any changes in the maternal systems aff ect the fetal plasma composi on and organogenesis.Maternal diabetes is one of the compromising environment for the fetus which complicates 2% to 3% of all pregnancies; 90% of these cases present with gesta onal diabetes mellitus 2 .In our popula on Gesta onal diabetes mellitus develops among 6.7% of all pregnancies 3 .Diabetes mellitus has long been associated with perinatal morbidity and mortality.Among all complica ons hypoglycaemia is the most commonest and most dangerous problem 4 .IDM has 47% risk of having signifi cant hypoglycaemia 5 .Lethergy, apathy, limpness, apnoea, tremors, ji eriness, irritability are the symptoms of hypoglycaemia.Macrosomia (28%), hypocalcaemia (22%), hyperbillirubinaemia (19%), polycythemia (34%), perinatal asphyxia, birth injury and congenital anomaly (6-9%) are the other complica ons of IDM 5 .This newly established Special Care Neonatal Unit (SCANU) at our hospital is serving about 30 million popula on of greater Mymensingh.It caters for sick inborn neonate as well as serves as a referral centre for sick newborn from the six districts under greater Mymensingh.Daily about 30 pa ents were admi ed in our neonatal ward; among them 2.4% pa ents were infant of diabe c mother.So, IDM is not so uncommon in our unit who need prompt and proper management.
In view of the high morbidity and mortality associated with infant of diabe c mother, our study was aimed at to determine the prevalence of the common morbidi es and to fi nd out the causes of mortality among IDM and thus improving our services and facili es to save the ny life as well as to serve a healthy newborn for future.

Material and Methods
This prospec ve observa onal study was done in the SCANU of Mymensingh Medical College Hospital (MMCH) from January 2015 to March 2015.A total 50 IDM pa ents who admi ed during this period were recruited in the study irrespec ve of their gesta onal age, birth weight, pa ern and dura on of maternal diabetes.
The study protocol was approved by ethical review commi ee of MMCH.A er taking informed wri en consent from the mother or caregiver details history regarding mother and the infant were taken.Maternal history was taken about parity, type and dura on of diabetes, treatment received for diabetes, mode of delivery and maternal outcome.Regarding infant's history me and place of delivery, history of convulsion, respiratory distress, cyanosis etc were taken.
A er resuscita on (if needed) thorough physical examina on was done with special a en on to asses gesta onal age, birth weight, signs of hypoglycaemia and hypocalcaemia and also to seek any congenital anomaly.Infants having birth weight equal or more than 4000gm referred as macrosomic and less than 2500gm referred as low birth weight baby.Some relevant inves ga ons were done where applicable like complete blood count, sep c screening, serum electrolytes, serum bilirubin, chest radiographs.But in all cases blood glucose level was measured.Hypoglycaemia was defi ned as blood glucose concentra on <2.6mmol/l, hypocalcaemia was defi ned as total serum calcium <7mg/dl, when peripheral venous haematocrit level was greater than 0.65 then it was defi ned as polycythemia.Rou ne echocardiogram could not be done due to cost but it was done in suspected infants of cardiac symptoms who had symptoms like cardiac murmur, persistent cyanosis, signs of heart failure etc.All the infants were treated accordingly in line with the hospital management protocol.Babies were discharged when presen ng complaints were improved, feeding was well established, bowel and bladder were moved normally and inves ga on reports became normal.

Results
Among all 50 pa ents, twenty nine (58%) were male and twenty one (42%) were female.Forty three pa ents were delivered by caesarian sec on and seven pa ents were delivered by vaginal delivery.Gesta onal age ranged from 35weeks to 41weeks, among them >37weeks were 47 pa ents (94%) and <37weeks were three pa ents (6%).35 infants had mother who had gesta onal diabetes (70%) and15 pa ents had mother who had pregesta onal diabetes (30%).Maximum pa ents were admi ed before the age of 24 hours and residence of maximum parents were in urban area.
Most of the pa ents presented with the complaints of apparently large baby, respiratory distress, delayed cry a er birth, convulsion, cyanosis, reluctant to feed and yellow colora on of body.
The commonest morbidi es were perinatal asphyxia, macrosomia, neonatal jaundice, hypoglycaemia, neonatal sepsis, polycythemia and congenital heart disease.Among all IDM congenital heart disease was present in 10 pa ents (20%), RDS was present in three pa ents (6%) and TTN was present in three pa ents (6%).Mortality was recorded in 3 pa ents.Among them one was severely asphyxiated and two had complex congenital heart disease with heart failure.All of them died within 48hours of life.

Discussion
IDM has already been recognized as one of the important causes of neonatal morbidity and mortality.
In our study prevalence of IDM is 24/1000 live birth which is a bit higher than any other study.The facili es and manpower available at our hospital are broadly not equivalent to those envisaged in a referral neonatal unit of Bangladesh.The paper therefore provides a case study of neonatal outcomes of infant of diabe c mother at a well func oning neonatal unit in a ter ary level hospital.
In this study, it has been iden fi ed that the maximum IDM had gesta onal diabe c mother (70%) and remaining had pregesta onal diabe c mother (30%).This fi ndings is almost similar to the fi ndings of another study 6,7,8 .But our study diff ers from Begum A et.al 9 .
Out of 50 infants most of the infants about 94% were term baby and most of them were delivered by caesarian sec on (86%).This correlates with the fi ndings of other studies 8,9,10,11 .Reports of Ranade et.al showed a bit lower prevalence of term IDM which was dissimilar with our study 12 .This diff erence in observa on might be due to that in his study the IDM were delivered by elec ve caesarian sec on to prevent the complica on of large baby but as a country of dense popula on our pregnant women were deprived of proper antenatal check up and thereby most of them were not aware about their glycaemic condi on and there was no proper planning for the delivery of the baby.
Out of 50 pa ents three were died (6%).One of them were severely asphyxiated and remaining two had complex congenital heart disease with heart failure.This fi ndings correlates with other study 8,9 .

Conclusion
Our observa ons show the high prevalence of IDM (24/1000 live birth) and their various complica ons.The mortality and morbidity is a bit higher in IDM.So, life style modifi ca on, proper planning for pregnancy, regular antenatal check up and to conduct delivery at a hospital where the facili es for neonatal care is available are mandatory.Our health policy makers should give adequate emphasis on above measures.

Table 3 :
Morbidi es and mortali es associated with IDM.

Table 1 :
Demographic characteris cs at the me of admission, (n=50).