Clinical profile and pattern of congenital heart disease in infants of diabetic mother and infants of non-diabetic mother at a tertiary care hospital

Abstract

OBJECTIVES:

To assess the clinical manifestations and pattern of congenital heart diseases (CHD) in infants of diabetic mothers (IDMs) and infants of non-diabetic mothers.

METHODS:

A prospective cross sectional study was carried out at tertiary care center over a period of thirty months. All neonates were included in this study if CHD were identified by echocardiography within this study period. Chi-square test and Fisher’s exact test were used to compare between groups.

RESULT:

Out of 62 neonates, IDMs and non-IDMs were equal in number, male and female ratio was 3 : 2, and majority were delivered by cesarean section (85.5%). Mean gestational age was 35 weeks, 62.3% were preterm, and 37.7% were term. Common clinical presentations were cardiac murmur (61%), and respiratory distress (43.5%). Less common presentations were low SaO₂ (27.4%), tachycardia (24.2%), and cyanosis (24.2%). Common combination of presentations were murmur and tachypnea (38.7%); cyanosis and low SaO₂ (24.19%); and low SaO₂ and tachypnea 15(24.19). The common echocardiographic findings were atrial septal defect (ASD; 72.6%), patent ductus arteriosus (PDA; 45.2%), and ventricular septal defect (VSD; 25.8%). ASD (77.4% vs 67.7%) and VSD (35.5% vs 16.1%) were more in IDMs, and PDA (48.4% vs 41.9%) was more in non-IDMs. These differences were not significant between groups.

CONCLUSION:

Clinical presentation and echocardiographic findings of CHD were similar in IDMs and non-IDMs.

Keywords

Congenital heart disease infant of diabetic mother (IDMs)echocardiography

1 Introduction

Congenital heart disease is defined as a gross structural abnormality of the heart or intra-thoracic great vessels that is actually or potentially of functional significance [1]. The prevalence of CHD at birth has been relatively variable at 4.05 to 10.4 cases per 1000 live births in different surveys [2, 3] CHD is the most common congenital problem in children accounting for nearly 25% of all congenital malformations [4] CHDs are one of the significant causes of infant morbidity and mortality.

Approximately one third of neonates with CHD requiring intervention in the first month of life [5] Clinical manifestation of CHD varies according to the type of lesion. Neonates with respiratory distress, cyanosis, feeding difficulties, and low cardiac output are common presentations of CHD [6]. Clinical manifestations of CHD are similar features of other non-cardiac causes in the early neonatal period like perinatal asphyxia, RDS, transient tachypnea, congenital pneumonia, sepsis etc. So diagnosis of CHD at the earliest possible time is very important as early referral and appropriate intervention in some of these cases are lifesaving.

2 Methods

A prospective cross sectional study was carried out in the Special Care Baby Unit (SCABU), in BIRDEM from January 2008 to June 2010. All neonates age up to 28 days were included in this study if congenital heart disease were identified by echocardiography in clinically suspected cases. Echocardiography was done by VIVID 7GE Color Doppler Machine. Neonates were categorized as infants of diabetic mothers (IDMs) if infant‘s mother was diagnosed as diabetes mellitus during or before pregnancy and infants of non-diabetic mothers (INDMs) were the neonates whose mother was non-diabetic. Diabetes mellitus in mother was diagnosed by OGTT. OGTT was done in mother by obstetrician in all pregnancy at 24–28 weeks and in high risk groups at presentation of pregnant woman, if not at 28 weeks and if not at 32 weeks of gestational period. Detailed history and clinical examination were performed. Baby’s birth weight, age, sex, gestational age, place of delivery, and mode of delivery were recorded. Echocardiography was done in the suspected cases, those had heart murmur, respiratory distress, tachycardia, and cyanosis. Echocardiographs were performed by a pediatrician working in pediatric cardiology unit and having training in echocardiography. Neonate who was suspected clinically but later found to have normal echocardiography findings were excluded from study. Approval has taken from the ethical committee of institute.

2.1 Statistical analysis

Chi-square test and Fisher’s exact test were used for compare the variables. The value P < 0.05 was considered statistically significant. Statistical analysis was done using EpiInfo 7.

3 Results

Congenital heart disease was identified in 62 neonates by echocardiography. Out of 62 neonates, IDMs and INDMs were equal in number; male and female ratio was 3 : 2, and majority were delivered by cesarean section (85.5%). Thirty seven (59.7%) babies were inborn, 25(40.3%) were out born, and 83.9% inborn were IDMs whereas 64.5% INDMs were out born. Gestational age were almost equal in both groups which was 35.77±2.43 weeks in IDMs and 35.29±2.91 weeks in INDMs; 62.3% were preterm, and 37.7% were term but statistically not significant. Birth weight was 2447.61±526.47 gm. in IDMs, 2373.03±746.09 gm. in INDMs, and 57.8% were LBW (Table 1).

Table 1
Demographic characteristics of neonate with CHD (N = 62)

n (%) IDMs n (%) 31 (50) INDMs n (%) 31 (50) P value

Sex Male 36 (59.7) 19 (61.3) 17 (54.8) 0.23

Female 26 (40.3) 12 (38.7) 14 (45.2) 0.31

Mode of delivery CS 53 (85.5) 29 (93.5) 24 (77.4) 0.04

Normal delivery 2 (6.2) 7 (22.6) 0.07

9 (14.5)

Place of delivery Inborn 37 (59.7) 26 (83.9) 11 (35.5) <0.0001

Outborn 25 (40.3) 5 (16.1) 20 (64.5) <0.0001

Gestational age (wks) 35.5±2.67 wks 35.77±2.43 35.29±2.91 0.71

Birth wt (grams) 2447.61±526.47 2373.03±746.09 0.71

Preterm 38 (62.3%) 17 (56.7) 21 (67.7) 0.23

Term 24 (37.7%) 14 (45.2) 10 (32.3)

Normal wt 28 (45.2%) 12 (38.7) 16 (51.6) 0.23

LBW 34 (54.8%) 19 (61.3) 15 (48.4)

	n (%)	IDMs n (%) 31 (50)	INDMs n (%) 31 (50)	P value
Sex	Male 36 (59.7)	19 (61.3)	17 (54.8)	0.23
	Female 26 (40.3)	12 (38.7)	14 (45.2)	0.31
Mode of delivery	CS 53 (85.5)	29 (93.5)	24 (77.4)	0.04
	Normal delivery	2 (6.2)	7 (22.6)	0.07
	9 (14.5)
Place of delivery	Inborn 37 (59.7)	26 (83.9)	11 (35.5)	<0.0001
	Outborn 25 (40.3)	5 (16.1)	20 (64.5)	<0.0001
Gestational age (wks)	35.5±2.67 wks	35.77±2.43	35.29±2.91	0.71
Birth wt (grams)		2447.61±526.47	2373.03±746.09	0.71
Preterm 38 (62.3%)		17 (56.7)	21 (67.7)	0.23
Term 24 (37.7%)		14 (45.2)	10 (32.3)
Normal wt 28 (45.2%)		12 (38.7)	16 (51.6)	0.23
LBW 34 (54.8%)		19 (61.3)	15 (48.4)

CHD: congenital heart disease, IDMs: infant of diabetic mothers, INDMs: infant of non-diabetic mothers, LBW: low birth weight.

Age of diagnosis of CHD by echocardiography at 5–15 days. About 61% neonate with CHD were presented with murmur, 59.3% with respiratory distress, 27.4% was presented with low SaO₂, 24.2% with tachycardia, and 24.2% with cyanosis in this study (Table 2). About 89% neonate presented with combined clinical features, in which common combined presentations were murmur and tachypnea (38.7%); cyanosis and low SaO₂ (24.19%); low SaO₂ and tachypnea (24.19%); tachycardia and tachypnea (17.74%); and Low SaO₂ and murmur (17.74%). Less common combination of presentations were cyanosis and murmur; cyanosis, murmur and tachypnea; and cyanosis, murmur and low SaO₂; in which 14.52% were each combination. Other less common combined presentations were cyanosis and tachycardia (11.29%); cyanosis, low SaO₂ and tachycardia (11.29%); cyanosis, low SaO₂, tachypnea and tachycardia (9.67%); murmur, low SaO₂ and tachycardia (9.67%); and murmur, low SaO₂, tachypnea and tachycardia (8.06%) (Table 3). Clinical presentations were similar in IDMs and INDMs. It was observed that ASD in 45(72.6%), PDA in 28(45.2%), VSD in 16(25.8%) cases, PS was in 9(14.5%) cases, IVS hypertrophy was in 7(11.3%) cases, PHTN was in 7(11.3%) cases, and coarctation of aorta in 5(8.1%) cases. Hypertrophy cardiomyopathy and TR were equal in number (4.8% each), AV canal defect and TOF were 2 (3.2%) of each. Bicuspid aortic valve, common atrium, ebstien anomaly, single ventricle, TAPVD, and truncus arteriosus were observed one of each (Table 4). Type of CHD was almost similar in both groups. But ASD(77.4% vs 67.7%), VSD(35.5% vs 16.1%), IVS hypertrophy(16.1% vs 6.5%), PHTN (19.4% vs 3.2%), coarctation of aorta (12.9% vs 3.2%), hypertrophy cardiomyopathy (6.5% vs 3.2%), and TOF(6.5% vs 0%) were more in IDMs whereas PDA(48.4% vs 41.9%), and TR (6.5% vs 3.2%) were more in NIDMs but statistically not significant. Rare CHDs were AV canal defect, bicuspid aortic valve, common atrium, single ventricle, TAPVD, and truncus arteriosus reported one in each in IDMs; AV canal defect and ebstien anamoly were 1 (1.6%) in each INDMs (Table 5).

Table 2

Clinical features of CHD in IDMs and INDMs

Clinical feature n (%)	IDMs n (%)	INDMs n (%)	P value
Murmur 38 (61.3)	19 (61.3)	19 (61.3)	0.5
Tachypnea 37 (59.7)	9 (29.0)	18 (58.1)	0.4
Low SaO2 17 (27.4)	9 (29.0)	8 (25.6)	0.32
Tachycardia 15 (24.2)	8 (25.8)	7 (22.6)	0.36
Cyanosis 15 (24.2)	7 (22.6)	8 (25.8)	0.36

CHD: congenital heart disease, IDMs: infant of diabetic mothers, INDMs: infant of non-diabetic mothers.

Table 3

Combination of clinical features of CHD in IDMs and INDMs

Clinical features n (%)	IDM n (%)	Non-IDM n (%)	P value
Murmur and tachypnea 24 (38.7)	13 (41.9)	11 (35.5)	0.26
Cyanosis and low SaO₂ 15 (24.19)	8 (25.8)	7 (22.6)	0.42
Low SaO₂ and tachypnea 15 (24.19)	8 (25.8)	7 (22.6)	0.42
Tachycardia and tachypnea 11 (17.74)	7 (22.6)	4 (12.9)	0.27
Low SaO₂ and murmur11 (17.74)	7 (22.6)	4 (12.9)	0.27
Cyanosis and murmur 9 (14.52)	6 (19.4)	3 (9.6)	0.16
Murmur, cyanosis and tachypnea 9 (14.52)	6 (19.4)	3 (9.6)	0.16
Murmur, low SaO₂ and cyanosis 9 (14.52)	6 (19.4)	3 (9.6)	0.16
Cyanosis and tachycardia 7 (11.29)	3 (9.6)	4 (12.9)	0.25
Cyanosis, low SaO₂ and tachycardia 7 (11.29)	4 (12.9)	3 (9.6)	0.59
Cyanosis, low SaO₂, tachypnea and tachycardia 6 (9.67)	3 (9.6)	3 (9.6)	0.50
Murmur, low SaO₂ and tachycardia 6 (9.67)	3 (9.6)	3 (9.6)	0.50
Murmur, low SaO₂, tachypnea and tachycardia 5 (8.06)	2 (6.4)	3 (9.6)	0.62

CHD: congenital heart disease, IDMs: infant of diabetic mothers, INDMs: infant of non-diabetic mothers.

Table 4

Type of CHD in neonate (n = 62)

Type	N	%
ASD	45	72.6
PDA	28	45.2
VSD	16	25.8
Pulmonary stenosis	9	14.5
IVS hypertrophy	7	11.3
PHTN	7	11.3
Coarctation of aorta	5	8.1
Hypertrophy cardiomyopathy	3	4.8
TR	3	4.8
AV canal defect	2	3.2
TOF	2	3.2
Bicuspid aortic valve	1	1.6
Common atrium	1	1.6
Ebstien anamoly	1	1.6
Single ventricle	1	1.6
TAPVD	1	1.6
Truncus arteriosus	1	1.6

CHD: congenital heart disease, IDM: infant of diabetic mothers, INDM: infant of non-diabetic mothers, ASD: atrial septal defect, PDA: patent ductus arteriosus, VSD: ventricular septal defect, IVS: inter-ventricular septum, PHTN: pulmonary hypertension, TR: tricuspid regurgitation, AV: atrio-ventricular, TOF: tetrology of Fellot, TAPVD: total anomalous pulmonary venous drainage.

Table 5

Type of CHD in IDMs (n = 31) and INDMs (n = 31)

Type n (%)	IDMs n (%)	INDMs n (%)	P value
ASD 45 (72.6)	24 (77.4)	21 (67.7)	0.21
PDA 28 (45.2)	13 (41.9)	15 (48.4)	0.31
VSD 16 (25.8)	11 (35.5)	5 (16.1)	0.05
Pulmonary stenosis 9 (14.5)	3 (9.7)	6 (19.4)	0.24
IVS hypertrophy 7 (11.3)	5 (16.1)	2 (6.4)	0.21
PHTN 7 (11.3)	6 (19.4)	1 (3.2)	0.05
Coarctation of aorta 5 (8.1)	4 (12.9)	1 (3.2)	0.18
Hypertrophy cardiomyopathy 3 (4.8)	2 (6.5)	1 (3.2)	0.50
TR 3 (4.8)	1 (3.2)	2 (6.4)	0.50
AV canal defect 2 (3.2)	1 (3.2)	1 (3.2)	0.75
TOF 2 (3.2)	2 (6.4)	0 (0)	0.24
Bicuspid aortic valve 1 (1.6)	1 (3.2)	0 (0)	0.50
Common atrium 1 (1.6)	1 (3.2)	0 (0)	0.50
Ebstein anomaly 1 (1.6)	0 (0)	1 (3.2)	0.50
Single ventricle 1 (1.6)	1 (3.2)	0 (0)	0.50
TAPVD 1 (1.6)	1 (3.2)	0 (0)	0.50
Truncus arteriosus 1 (1.6)	1 (3.2)	0 (0)	0.50

IDM: infants of diabetic mother, INDM: infants of non-diabetic mother, ASD: atrial septal defect, PDA: patent ductus arteriosus, VSD: ventricular septal defect, IVS: inter-ventricular septum, PHTN: pulmonary hypertension, TR: tricuspid regurgitation, AV: atrio-ventricular, TOF: tetrology of Fellot, TAPVD: total anomalous pulmonary venous drainage.

4 Discussion

Congenital heart disease is due to defect in the structure of the heart and great vessels that is present at birth [7]. CHD are one of the serious problems of perinatology. We found that CHD was more common in male births (60%) which was consistent with other study done by Wanee KA [8]. This finding is not similar to the study reported in Iceland, where the frequency was the same for males and females while in Nigeria CHD was found to be more common in female births [9, 10].

About 85% babies were delivered by cesarean section, which was more in diabetic mothers than non-diabetic mothers (93.7% vs 77.4%, p < 0.05). Elective as well as emergency cesarean section was done more in diabetic mothers than non-diabetic mothers as chance of complications both in mothers and babies were more in this group. Majority of IDMs were inborn (83.9%) in this study because most of the mothers admitted in this hospital were diabetic while most of the INDMs were out born (64.5%).

Our observation showed that number of CHD was higher in the low birth weight group (54.8%) and preterm babies (62.3%) although statistically not significant. Seon Young Cho et al., found similar result as our study [11]. Tanner et al., reported that preterm infants have more than twice cardiovascular malformations than infants born at term [12]. Godfrey et al., reported increased incidence of CHD in very low birth weight infants, as compared with the general population [13]. Cardiac murmur is one of the most important finding of identify CHD, though the presence or absence of a murmur does not assure either the presence or absence of congenital heart disease. In our study cardiac murmur was observed in 61.3% cases and murmur reported equally both in IDMs and INDMs. Rein et al. found that 86% of asymptomatic neonates presenting with a murmur in the first days of life have structural heart disease [14]. In another study showed that neonatal examination detects 44% of cardiac malformation in infancy, if a murmur is heard there is 54% chance of there being an underlying cardiac malformation [15].

In this study, the second common clinical feature was respiratory distress (59.6%) which was more common in INDMs (58.1% vs 29%), tachycardia and cyanosis were in 24.2% in each, and 27.4% was presented with low SaO_2 ; these clinical features were similar in both IDMs and INDMs. Akbar Molaei reported Respiratory distress was the most common complaint (70.7%) and cyanosis was the second most common complaint (24.4%) in his study [16]. Islam MN found Respiratory distress was the commonest symptom (71%) followed by cyanosis (26%), similar observation was found by another study [17, 18]. In our study combination of presentations were observed in 89% cases and there was no significant difference of combined features in both groups.

ASD (72.6%) accounted for the highest percentage, followed by PDA (45.2%) and VSD (25.8%) in present study. Bagher Nikyar et al., and Rahim et al. reported ASD was the most common CHD in their study [19, 20]. While in other studies the most frequent type of CHD was VSD [21, 22]. Kecskes et al., studied 47 infants with congenital heart disease; VSD and coarctation of aorta were the most common diagnoses in their study [23]. Moreover, in a study by Sawanta and colleagues VSD (42.86%) and ASD (25.71%) were the most common CHD [24]. Rein et al., found VSD was most common cardiac lesion (37%) followed by PDA (23%) [25]. Pulmonary valve stenosis was the fourth most common congenital heart lesion (14.5%) in our study. It was also consistent with the report mentioned by other authors [26, 27].

In our study, ASD (77.4% vs 67.7%), VSD (35.5% vs 16.1%), and IVS hypertrophy (16.1% vs 6.5%) were more in IDMs than INDMs whereas PDA (48.4% vs 41.9%), and TR (6.5% vs 3.2%) were more in NIDMs but statistically not significant. Bejati M. showed in his study that PDA was in 54.7% cases, HCMP in 24% cases, VSD, ASD, PDA, and Coarctation of aorta was in 4%, 2.7%, 1.3% and 1.3% cases respectively in IDMs [28]. Korraa A. found that more common echocardiographic findings in IDMs were asymmetrical septal hypertrophy (80%), PFO (37.5%), and PDA (27.5%) [29]. Pattern of CHD in IDMs was different in a study done by Ferdouse SA. They found PFO, PDA, and HCMP were more common and ASD and VSD were less common findings [30]. These findings were not consistent with our study.

4.1 Study limitations

Data was not true presentation of CHD as number of patients were less. Data was collected from single tertiary care hospital settings provide service mainly diabetic patients. It only included patients who did reach this tertiary care facility.

5 Conclusion

High index of suspicion, detailed history, clinical examination, and echocardiography help us to diagnose the CHD in neonates. Murmur and tachypnea were the most common clinical features. Combination of clinical presentations were observed in majority of cases. ASD, PDA, and VSD were common CHD in both IDMs and INDMs in a tertiary care hospital in this study. There was no different in the clinical presentation and pattern of CHD in IDMs and INDMs.

Disclosure statements

Financial support and sponsorship: Nil.

Conflicts of interest

There are no conflicts of interest.

Footnotes

Acknowledgments

We would like to thank parents, doctors, and nurses of special care baby unit. We also grateful to doctors and technicians of pediatric cardiology department, for their contribution.

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