[Risk groups of newborn infants of diabetic mothers in relation to their somatic outcome and maternal diabetic metabolic status in pregnancy]. / Risikogruppen Neugeborener diabetischer Mütter in Abhängigkeit von ihrem somatischen Outcome und der mütterlichen diabetischen Stoffwechsellage in der Schwangerschaft.

In a prospective study, neonatal morbidity of newborn children of diabetic mothers and its association with the maternal metabolism was determined. Particular attention was directed on the somatic outcome of the children and their frequent metabolic imbalances. In addition, we determined the influence of maternal biological and somatometrical variables on the somatic outcome of newborns. Dependent upon the mothers' and children' variables, risk groups of newborns (fetopathy groups) were defined to optimize clinical care and surveillance of newborns. A total of 810 children were included born to mothers with primary insulin dependent diabetes mellitus (IDDM), non insulin dependent diabetes (NIDDM), or gestational diabetes (GDM). Among the study population, 41.7% of children had macrosomia, 27.2% had a weight-length index > 1.2, 17.9% developed hypoglycemia and 19.5% hyperbilirubinemia within the initial 72 hours after birth. The somatic outcome of the children was significantly associated with pregnancy duration, maternal age, weight, height, and HbA1. Increasing maternal HbA1 prior to delivery (categorized in < 8.5%, 8.6-10%, > 10%) was associated with increased relative risk of incidence of neonatal morbidity. Finally, risk groups (fetopathy groups I-III) were defined according to maternal HbA1 value and somatic outcome of the newborns. The importance of these fetopathy groups for criteria of neonatal morbidity is demonstrated. Based upon categorization of newborn children into fetopathy groups, children should be allocated to specific concepts of appropriate surveillance and clinical care. The fetopathy classification may also serve as an independent tool for retrospective quality control of diabetic pregnancy.

[Diabetic retinopathy and nephropathy--complications in pregnancy and labor]. / Diabetische Retinopathie und Nephropathie--Komplikationen während Schwangerschaft und Geburt.

The purpose of this retrospective study was to determine the risk factors for the morbidity of the mothers and their fetus in patients with diabetic retinopathy and/or nephropathy with an open family planning. We compared the course of pregnancies, complications as well as the maternal and neonatal morbidity in 76 patients with diabetic retinopathy or nephropathy (White R F) with 85 patients without severe microangiopathy (White C D). We found a correlation between retinopathy progression and hyperglycaemia during the first trimester (p < 0.05). There was an increase in the deterioration of visual acuity up to blindness due to the progression of this microangiopathy in cases of proliferative retinopathy. There was a significant increase of the mean diastolic blood pressure (mdp) and preeclamptic symptoms occurred in 71% of the cases with severe microangiopathy (p < 0.05). Deterioration of the diabetic nephropathy with excessive proteinuria (> 10 g/d) and unmanageable hypertension or a progression of the retinopathy led to an earlier delivery in 80% of the patients (p < 0.05). A high rate of preterm deliveries (39%) and a frequent occurrence of intrauterine growth retardation's (9%) characterised the fetal outcome. The following examinations for a patient with an open family planning, if diabetes is diagnosed during childhood or the course of the disease is between 10 and 15 years, should be done: Ophthalmological evaluation, control of the renal function, contraceptive advice and an improvement of the metabolic situation. In case of a diabetic nephropathy in combination with hypertonus the patients shoud be warned against pregnancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Offspring of diabetic mothers. Problems of morbidity.

In the past decade, malformation rates and life-threatening neonatal disorders of infants of diabetic mothers have been lowered to a marked degree. However, the remaining neonatal morbidity (metabolic and functional abnormalities and macrosomia) is still rather high. The meaning of these signs and symptoms for the further somatic development is unclear. A study comprising 443 neonatal infants of diabetic mothers was performed in order to quantify the morbidity. In 340 of the mothers, insulin treatment during pregnancy was based on HbA1c and blood glucose values; in the remaining 103 women, it was additionally controlled by measurement of insulin concentration in the amniotic fluid. A new classification of fetopathy at four different stages was established as a basis for further follow-up. In preparation of the latter, a pilot study including 160 infants in their fourth year of life was conducted to test the hypothesis that the further somatic growth is related to neonatal findings. The results demonstrate that the neonatal morbidity profile has changed with therapy. Metabolic control based additionally on insulin concentration in the amniotic fluid has resulted (1) in less infants with macrosomia and/or with striking phenotype but (2) also in a increase of small-for-gestational-age infants and of the frequency of hypoglycaemia. Only purely macrosomatic infants showed a tendency towards obesity and length acceleration in their fourth year of life.

The feedback between monitoring and improvement of quality of diabetes care.

The need for permanent, population-wide, improvement in metabolic care of diabetic patients is generally accepted. This paper highlights some related aspects which must be considered by any health care provider: (1) Monitoring metabolic or other variables in diabetic patients is an essential tool in routine metabolic care, where a "short feedback" between monitored data and medical or behavioral measures is permanently established by the patients themselves, the physicians, the nurses etc. (2) Quality insurance requires the closure of a "long feedback" between informations and interventions, such as conditions, tools, methods, used at the different levels of the care system, from the individual patient to a population scale. (3) Appropriate epidemiological studies are required to program and evaluate the effect of any activity aimed at insuring and maybe improving the quality of care of diabetic patients, especially if one considers the time required to reach "hard end-points" such as the evaluation of patient mortality or the outcome of children from diabetic mothers. (4) The knowledge of incidence and prevalence rates of diabetes and its complications, and of risk factors may stimulate the political and economical recognition of the importance of the disease by health care officials. (5) In this way, the medical recognition is also stimulated within the professional team responsible for the establishment of the "long feedback" of quality insurance at the level of a given method, of an individual patient or of a health care unit, and for the actual implementation of generally accepted knowledge, everywhere in routine care.

[Somatic and psychomotor development of children of diabetic mothers in the 4th year in relation to neonatal findings]. / Somatische und psychomotorische Entwicklung von Kindern diabetischer Mütter im vierten Lebensjahr in Beziehung zu Neonatalbefunden.

340 infants of mothers with type I diabetes (IDM) were examined during the neonatal period for gestational age, somatic data and clinical symptoms of diabetogenic foetopathy and assigned to one of three groups: group I--those whose weight development was delayed or appropriate for gestational age and without symptoms of foetopathy; group II--neonates who were overweight or of appropriate weight for their gestational age and who showed clear symptoms of foetopathy; group III--macrosomic infants (weight and length in advance of gestational age) without any major symptoms of foetopathy. In a pilot study preparing for more comprehensive follow up, 20 children from each group were examined in their fourth year to check their psychomotor and somatic development. To evaluate their growth additional data obtained on IDMs by correspondence were included. Although the group as whole showed a normal weight development for the fourth year with a low obesity rate (8.4%), the distribution among the three groups proved non-homogenous. 11.4% of the macrosomic children were overweight; this comprises 57% of all the obese children registered. There was a still clearer trend towards macrosomia among the children in groups II and III where the average age: length percentiles amounted to 57 and 67%. The psychological test showed an IQ of less than 95 in 16.7% of the cases distributed homogeneously among the different groups. With reference to their psychomotoric and language development the children examined were normal, some slight deviations in group II in walking and concentration ability need to be checked further. Our studies show that in children of diabetic mothers there are links between neonatal findings and later psychomotor and somatic development. A classification of newborns which goes beyond the usual establishment of percentiles for weight and gestational age seems appropriate in order to identify risk cases (macrosomia, obesity). A follow up study is required on a larger representative group and should be conducted at a more advanced age and not before the sixth year.

[Problems of perinatal transmission of hepatitis B]. / Probleme der perinatalen Ubertragung von Hepatitis B.

This review of recent publications and of the results of our own research brings our insights into the perinatal transmission of hepatitis B up to date. It includes facts concerning epidemiology, means of transmission, serological detection and problems of infection specific to newborns. The detailed discussion of the issue of prevention is intended to serve the basic objective of counteracting the further spread of the hepatitis B virus by a systematic screening of all pregnants followed by immunoprophylaxis for the newborns.

[Birth weight of newborn infants in relation to body height and body weight of parents with special reference to duration of pregnancy]. / Gewicht Neugeborener in Abhängigkeit von Körperlänge und -gewicht der Eltern unter besonderer Berücksichtigung der Schwangerschaftsdauer.

Using the data of the 1985 GDR somatogram standards (birthweight percentiles calculated from 51,570 liveborn singletons) the impact of parental weight and length on the birthweight were calculated. Peristatic factors in combination with the genetic 'anlage' act first of all via maternal weight. Body height and/or length of mother and father are more representative for the genetic constitution. Their impact on neonatal weight seems to be less significant, however statistically calculable. The paternal 'anlage' is relatively modified by the intrauterine environment (maternal constitution).

Neonatal jaundice in infants of diabetic mothers.

357 IDMs and 20 healthy newborns of non-diabetic mothers were examined at term for body measurements, red blood cell count, serum bilirubin, cord blood insulin and blood glucose during the first postnatal week. The stage of maternal diabetes did not influence the course of neonatal bilirubin levels, but the IDMs had prolonged and higher bilirubinaemia compared with the controls. Hyperbilirubinaemia was found to be most prominent in newborns with an increased birthweight/length ratio and was not simply related to macrosomia (LGA). These infants had significantly lower blood glucose concentrations immediately after birth, whereas cord blood insulin was found to be identical between the IDM sub-groups. Bilirubinaemia in heavy for length infants was slightly correlated to haematocrit. For the pathogenesis of hyperbilirubinaemia in IDMs induction of heme oxygenase (due to a lack of energy provision following a phosphorylation disorder) is discussed. Nutritional support (early feeding, glucose infusions) does not affect the course of bilirubinaemia.

[Use of the new East German percentiles in the classification of newborn infants]. / Zur Anwendung der neuen DDR-Perzentilen bei der Klassifizierung von Neugeborenen.

Re-classifying the newborns treated in the NICU of the University of Greifswald between 1983 and 1987, according to the percentiles (birthweight and length) of Lubchenco and the new standards recommended for the GDR after a data sampling in 1985, identic results could be found for the number of LGA using the 90th percentile. Certainly until the 34th week of gestation (but probably also thereafter), using the 10th percentile of the GDR standard, a to high rate (greater than 20%) of SGA infants could be found, whereas the range of birthweights of our own patients fitted exactly the distribution found by Lubchenco. The reason might be an underrepresentation of lifeborn VLBW infants in the GDR sample due to differences of the definitions used for the assessment of lifeborns and stillborns/fetal loss. Therefore, for practical use of the new standards as criterion for classifying AGA/SGA newborns until the 34th week of gestation the 5th percentile is recommended. A reevaluation of the distribution of birthweight in the GDR population is proposed including even-dead newborns in the data sampling.

Bilirubin binding and acid-base equilibrium in newborn infants with low birthweight.

Acidosis is known as a risk factor for the development of bilirubin encephalopathy in neonatal jaundice. However, few attempts have been made to evaluate the influence of acid-base state on bilirubin-albumin binding state in blood of newborn infants. Therefore, in 171 appropriate and 83 small for gestational age newborns (birthweight less than 2,500 g) the acid-base state in blood and bilirubin (BR) binding state in serum was measured at the ages of 3, 4, 5, and 8 days. There is a weak but significant correlation between standard base deficit and the ratio BR/reserve albumin as well as the toxic potential of serum BR. The results suggest that the higher risk in acidosis is not only caused by increased tissue binding of BR but also--at least partially--attributable to decreased BR binding in serum.

[Quality assessment in neonatology]. / Qualitätsbeurteilung in der Neonatologie.

After discussing some general factors influencing the result of medical care at all (socio-economic conditions, biological factors), the difficulties of neonatal quality control compared with the assessment of quality in obstetric care are pointed out (greater variability of the data, evaluation of long-term effects). In addition to the obstetric system of data collection a similar evaluation of neonatal data is recommended to be introduced and definitions for general use are given. The recommendations are based on own investigations of the predictive value of some data gained within the perinatal period (history, physical examination, laboratory tests etc.). The high expenditures of personnel and equipment, at present, don't allow a nationwide introduction of such records. But in future perinatal centers should collect their data in an unique way according to this recommendations for comparing the efficiency of perinatal care in voluntary programs of quality control. The experiences collected by those analyses will be of great value concerning planning the design of a nationwide data recording system in perinatal medicine.

[Breast milk jaundice--a harmless symptom or a reason for stopping breast feeding?]. / Brustmilchikterus--harmloses Symptom oder Grund zum Abstillen?

Increased interest in breast-feeding focuses attention on an undesirable side effect--the breast milk jaundice of the newborn. In this review a complication is given on contemporary knowledge with respect to types of breast milk jaundice, etiology, diagnostic and preventive strategies. Especially the early and late onset types of breast milk jaundice are distinguished. Though of the jaundice-aggravating effect of some human milks, there is no reason to avoid breast-feeding. Improved hospital nursing policies and careful information may help to encourage the mothers to continue in breast-feeding successfully.

[Hepatitis B screening in pregnant patients and their children--a Greifswald perinatal-pediatric study]. / Hepatitis-B-Screening bei Schwangeren und ihren Kindern--Eine Greifswalder perinatologisch-pädiatrische Studie. 1. Befunde bei Schwangeren und stillenden Fauen.

During a period of one year with systematic screening performed in 1,401 pregnant women 8 cases positive for HBs-antigen could be detected. For the investigation we used a counter electrophoresis method. In 500 serial specimens an additional examination was performed by aid of a RIA as well. With an incidence of 0.57% the number of HBs antigen positive pregnancies in the territory of Greifswald was found to be significantly higher than reported previously from other regions of the GDR. Our results claim for a mass screening for hepatitis B during pregnancy. Because of the possibility of virus excretion with human milk, HBs positive mothers should not be used as milk donors. Other results related to our investigations give evidence for the significance of obtaining specific hygienic regulations when medical care is given to asymptomatic HBsAg carriers. They also underline the necessity of interdisciplinary cooperation for teaching medical staff in health care centers and giving correct advice to those detected as hepatitis B carriers.