Diabetes

iolaus — Tue, 24 Aug 2010 20:22:06 GMT

Diabetes

Diabetes or Diabetes Mellitus is a condition in which the amount of glucose in the blood is too high because the body cannot use it properly due to a lack of insulin. Insulin is a hormone produced by beta cells, a subset of the cells in the islets of Langerhans in the pancreas (approx. 1-2% of the mass of the pancreas), that helps the glucose to enter the cells where it is used as fuel.

The St Vincent Statement to try and reduce the risks to pregnant diabetic woman and their children to that of non-diabetics has not yet been met.

Types of Diabetes

Type 1 diabetes is where the body makes NO insulin as the beta cells have been destroyed. The reason the cells are destroyed is unknown but the most likely cause is an abnormal reaction of the body to the cells. A viral or other infection may trigger this. Type 1 usually occurs below the age of 40 (so more likely to be of childbearing age). This type accounts for between 5 – 15% of all people with diabetes. Insulin injections and diet treat the diabetes, and regular exercise is recommended. Insulin cannot be taken by mouth because the digestive juices in the stomach destroy it.

Type 2 diabetes develops when the body can still make some insulin, but not enough, or when the insulin that is produced does not work properly (known as insulin resistance). This type of diabetes usually appears in obese people (or if the waist is 31.5 inches or over for women; 35 inches or over for Asian men and 37 inches or over for white and black men.) and those over the age of 40, though in South Asian and African-Caribbean people often appears after the age of 25. However, recently, more children are being diagnosed with the condition. Those with high blood pressure, or have had a heart attack or a stroke, polycystic ovary syndrome or those with a first degree relative has any type of diabetes. Type 2 may be controlled by diet alone or with supplements. There are several kinds of tablets for people with Type 2 diabetes. Some kinds help the pancreas to produce more insulin. Other kinds help the body to make better use of the insulin that the pancreas does produce. Another type of tablet slows down the speed at which the body absorbs glucose from the intestine. Type 2 diabetes is progressive and may need to be treated by insulin injections.
Gestational Diabetes (GDM) occurs in pregnancy (occasionally women with type 2 diabetes (rarely type 1) are mistaken diagnosed with gestational diabetes as it is discovered for the first time in pregnancy. This is why it is recommended that a woman with GDM has a fasting glucose tolerance test 6 weeks after giving birth. This test is then carried out yearly for the next three years and then 3 yearly after that, as half of women with GDM will go on to develop Type 2 Diabetes.

Signs and Symptoms

• Increased thirst
• Urinating frequently – especially at night
• Extreme tiredness
• Weight loss
• Blurred vision
• Genital itching or regular episodes of thrush
• Slow healing of wounds

Type 1 Diabetics develop these symptoms rapidly, over days or weeks. Type 2 Diabetics may not notice these symptoms, or they come on so slowly that the person doesn’t really notice. If this coincides with pregnancy then many symptoms may be associated with the pregnancy.

Complications

Not everyone with diabetes will develop all or any of these complications, however anyone may develop any of them. Good control of blood sugar levels reduces the chance of developing any of the complications.

Short term complications of diabetes
Hypoglycaemia (Hypos) occurs when the level of glucose in the blood falls too low, usually under 4 mmol/l. People with diabetes who take insulin and/or certain diabetes tablets are at risk of having a hypo. A hypo may occur if too much diabetes medication has been taken, by delaying or missing a meal or snack, not eating enough carbohydrate, taking part in unplanned or more strenuous exercise than usual, or drinking alcohol without food. Sometimes there is no obvious cause.
When a hypo happens the person often experiences ‘warning signs’, which occur as the body tries to raise the blood glucose level. These ‘warning signs’ vary from person to person but often include feeling shaky, sweating, tingling in the lips, going pale, heart pounding, confusion and irritability. During pregnancy this warning is often absent, even if prior to pregnancy the woman could recognise the signs.
Treatment is usually very simple and requires taking some fast acting carbohydrate, such as a sugary drink or some glucose tablets, and following this up with some longer acting carbohydrate, such as a cereal bar, a sandwich, piece of fruit, biscuits and milk or the next meal if it is due. If left untreated the person will, eventually, become unconscious and will need to be treated with an injection of glucagon.
Hypos are not normally dangerous in themselves. In the vast majority of cases the body will release its own stores of glucose and raise the blood glucose level to normal, though this may take several hours. Many people have hypos while they are asleep and come to no harm. However, being unconscious is always dangerous – for example especially if you are driving and because of the risk of choking. An ambulance should be called immediately if someone with diabetes is found unconscious. Hypos can be particularly dangerous following alcohol. If a hypo occurs after drinking, the body is less able to release stored glucose and the blood glucose level may fall dangerously low. It is recommended that people on insulin should not drink more than three units of alcohol for a man or two units for a woman per day. Food should always be taken when drinking alcohol.

Diabetic ketoacidosis (DKA) occurs when there is consistent high blood glucose levels. This happens because of a lack of glucose entering the cells where it can be used as energy. The body begins to use stores of fat as an alternative source of energy, and this in turn produces an acidic by-product known as ketones.
Ketones are very harmful and the body will immediately try to get rid of them by excreting them in urine. Consequently, when ketones are present and blood glucose levels are rising, people often become increasingly thirsty as the body tries to flush them out. If the level of ketones in the body continues to rise, ketoacidosis develops (ketoacidosis means acidity of the blood, due to an excess of ketones in the body). Their harmful effect becomes more apparent, and nausea or vomiting may start. In addition, the skin may become dry, eyesight blurred and breathing deep and rapid. Unfortunately, because of vomiting, the body becomes even more dehydrated and less efficient at flushing out the ketones, allowing levels to rise even faster. As the level of ketones rise, it may be possible to smell them on the breath – often described as smelling like pear drops or nail varnish.
If untreated, the level of ketones will continue to rise and, combined with high blood glucose levels, a coma will develop which can be fatal. However, at any of these intermediate stages, ketoacidosis can be treated and damage usually limited.
DKA more often occurs if a person relies upon insulin injections, but rarely occurs with a diet or tablet controlled diabetic if they are severely ill and unable to control their blood sugars. The high-risk time for developing ketoacidosis is when a person is unwell, as part of the body’s response to illness and infection is to release more glucose into the bloodstream, and to stop insulin from working properly. This happens even if the person loses their appetite or goes off food altogether. During periods of illness, even if they are not eating, insulin is still needed and diabetics need to test their blood sugars more frequently. Ketones are easily detected by a simple urine test, using strips available on prescription. People with diabetes should test their urine for ketones if their blood glucose is high (usually over 15mmol/l) or if they have any symptoms of ketoacidosis.

Hyperosmolar non-ketotic acidosis (HONK) occurs in people with Type 2 diabetes, who may be experiencing very high blood glucose levels (often over 40mmol/l). It can develop over a course of weeks and symptoms can include frequent urination and great thirst, nausea, dry skin, disorientation and, in later stages, drowsiness and a gradual loss of consciousness.
Its name refers to the fact that it does not usually lead to the presence of ketones in the urine, as occurs in ketoacidosis. Ketones develop when the blood glucose level is high and a lack of insulin is available to the body, which would normally allow glucose to enter the cells for energy. Because people with Type 2 diabetes may still be producing some insulin, these acidic by-products may not be created.
Hospital treatment for HONK involves replacing the lost fluid caused by high glucose levels and the administration of insulin through a vein, to bring the blood glucose down to an acceptable level.

Long term complications of diabetes

Cardiovascular disease (CVD) includes heart disease, stroke and all other diseases of the heart and circulation, such as hardening and narrowing of the arteries supplying blood to the legs, which is known as peripheral vascular disease (PVD). However, heart disease and stroke are the two most common forms of CVD.
People with diabetes have an up to fivefold increased risk of CVD compared with those without diabetes. The reasons are prolonged, poorly controlled blood glucose levels, which affect the lining of the body’s arterial walls. This increases the likelihood of furring up of the vessels, forming a narrowing (atherosclerosis). People with Type 2 diabetes also often have low HDL cholesterol and raised triglyceride levels, which both increase the risk of atherosclerosis. High blood pressure, smoking, obesity and physical inactivity are also risk factors for CVD.

Retinopathy affects the blood vessels supplying the retina – the seeing part of the eye. Blood vessels in the retina of the eye can become blocked, leaky or grow haphazardly. This damage gets in the way of the light passing through to the retina and if left untreated can damage vision. Keeping blood glucose and blood pressure under control will help to reduce the risk of developing retinopathy. Eye examinations should be carried out when diabetes is first diagnosed then annually.
Laser can treat retinopathy, which is very successful, if the condition is caught early and is generally pain free. In 80 percent of cases it can prevent any further loss of sight. Tiny laser beams are used to destroy damaged parts of the retina, stopping the growth of new abnormal blood vessels and preventing any further damage to vision. Laser therapy cannot restore any vision that has already been lost.

Neuropathy causes damage to the nerves that transmit impulses to and from the brain and spinal cord, to the muscles, skin, blood vessels and other organs. This includes erectile disfunction. Despite research, there is still no conclusive proof as to the cause of diabetic neuropathy. However there are factors which are thought to contribute to the condition. Hyperglycaemia (high blood glucose) causes chemical changes in nerves that can impair their ability to transmit signals. Hyperglycaemia can also harm the blood vessels that carry oxygen and nutrients to the nerves. But neuropathy can also be caused by factors not necessarily associated with diabetes. These include disorders of the immune system, infectious diseases and deficiencies in certain nutrients.

Nephropathy (Kidney Disease) is much more common in people with diabetes and people with high blood pressure. Kidney disease in diabetes develops very slowly, over many years. It is most common in people who have had the condition for over 20 years. About one in four people with diabetes might go on to develop kidney disease, though as treatments improve, fewer people are affected. As with many of the other complications of diabetes, kidney disease is caused by damage to small blood vessels. This damage can cause the vessels to become leaky or, in some cases, to stop working, making the kidneys work less efficiently. It is now known that keeping blood glucose levels as near normal as possible (between 4 and 6 mmol/l before meals, and less than 10 mmol/l two hours after food) can greatly reduce the risk of kidney disease developing as well as other diabetes complications. It is also very important to keep blood pressure controlled (130/80mmHg or less). This can be detected by testing for proteinuria, although other conditions such as urine infections may give similar reading.

Necrobiosis Lipoidica Diabeticorum (A skin disorder) is usually known as necrobiosis and is often associated with diabetes, although not exclusively so. Although necrobiosis is well known, it is a very uncommon condition and many healthcare professionals may never have seen it before. It may develop before or at the time of diagnosis of diabetes, but usually will appear some years after diagnosis. It occurs most commonly in young women treated with insulin. The cause is unknown and it can happen no matter how well the diabetes is controlled.
It usually appears as small oval dark red or browny yellow patches (lesions) with a thick shiny surface. The patches may be raised above the surrounding skin and the edges are usually sharply defined. In a small percentage of cases, a part of the patch may break down and form ulcers. The patches may be single or multiple and are most commonly found on the legs, particularly over the shins. However, the arms, hands and body may also be affected.
Necrobiosis usually progresses slowly and it may remain very slight but rarely will it clear up completely. There are no symptoms and it is not painful unless it ulcerates usually following injury or knocking the skin, especially on the shins. It does not lead to gangrene. Although the patches may be unsightly, they will not lead to any serious harm. Treatment is disappointing. Creams, dressings or injections of steroids into the patches may be tried and can help in some cases.

Diabetic mastopathy is a rare condition (fibrous (tough) breast tissue which presents as single or multiple hard, non tender, lump(s), in one or both breasts). It is usually seen in women who are pre-menopausal, and who have had Type 1 diabetes for many years, although very rarely it can be seen in men with diabetes as well. Often diabetic mastopathy is associated with micro-vascular complications (damage to the eyes, kidneys and heart), and some people will also have other disorders such as thyroid problems.
The cause is unknown but it appears to be due to material that is deposited in the breast due to the high blood glucose levels. If there is only one lesion, it is often removed. These lesions commonly appear in both breasts however and re-occur after removal. They may in this case be allowed to develop. When several lesions develop they can become uncomfortable and in this situation the lesions may be removed.
Lesions due to diabetic mastopathy do not become malignant, but the number and size of the lesions tends to increase as women get older. Women who have developed diabetic mastopathy should be examined annually using mammography and ultrasound.

Musculoskeletal conditions can affect anyone, but people with diabetes can be at an increased risk of developing them. The reasons for this are not fully understood, but it is thought that raised blood glucose levels may, overtime, cause changes to the naturally occurring protein collagen. Collagen is the main constituent of connective tissue and is present in the skin, cartilage, tendons and ligaments (see definitions below). Glucose can bind to strands of collagen in a process known as glycosylation, and lead to the formation of cross-links with adjacent collagen strands. As a result the whole structure of the skin, or a tendon or ligament, can become thicker and less flexible, and this may lead to, or aggravate, a range of musculoskeletal conditions.
If musculoskeletal conditions do develop then treatment options include resting the affected joint, physiotherapy, anti-inflammatory painkillers, steroid injections (to help reduce any inflammation) and, in extreme cases, surgery. Ultrasound may also sometimes be beneficial – the reasons for this are not fully understood, but it is thought to help reduce inflammation.
Steroid injections can increase blood glucose levels for approximately 24 hours and therefore blood glucose tests may need to be carried out more frequently following an injection.
Limited joint mobility is a type of rheumatism that causes the joints to lose their normal flexibility. It is thought that about a third of people with diabetes have some degrees of limited joint mobility.
Although most common in the hands (where it is also known as diabetic cheiroarthropathy), limited joint mobility can also affect the wrists, elbows, shoulders, knees, ankles and, in some cases, the neck and lower back. A classic sign of cheiroarthropathy is not being able to press the fingers together tightly in a palm to palm ‘prayer sign’. The affected fingers stay permanently bent.
Dupuytren’s contracture is a disorder of the hand that is more common amongst people with diabetes. The first sign is often a tender nodule (a small bump) in the palm, near the base of the fingers. It progresses slowly and usually painlessly to cause the fingers to bend inwards towards the palm, so you can no longer fully open your hand.
Scar tissue is thought to accumulate under the skin on the palm (the fascia), thickening and shortening the tissue. This restricts the movement of the tendons, the cord like structures that connect muscle to bone. Like limited joint mobility, Dupuytren’s contracture can be a marker of microvascular complications (kidney and eye disease).
The symptoms of carpal tunnel syndrome can include pain or numbness in the hand and wrist, and weakness of the muscles in the fingers and thumb. These symptoms are caused by compression of the median nerve (the nerve that supplies the palm and fingers) as it passes through the carpal tunnel in the wrist. The pain (often described as a tingling or burning sensation) is often worse at night and can extend into the whole hand, and even sometimes up the arm into the elbow, shoulder and neck. Sometimes just one hand is affected, sometimes both are.
Tenosynovitis is where the tendons, the cord like structures connecting muscle to bone, swell. This causes pain and swelling in the affected area of the body, and stiffness in the joint moved by the tendon. Tenosynovitis occurs most commonly in the wrist and hand, and in this case the tendons that swell are those connecting the muscles in the forearm to the bones in the fingers and thumb. These tendons run through a tunnel or sheath. When they swell they sometimes becomes too thick for this tunnel and ‘catch’ on it as you try and move the connected finger or thumb.
Adhesive capsulitis (frozen shoulder), is a condition that can cause pain and stiffness in the shoulder. There is an increased incidence of frozen shoulder in people with diabetes – it is thought to affect 20 per cent of people with diabetes at some stage in their life, compared to just five per cent of people without diabetes. Frozen shoulder often develops after an injury to the shoulder, although sometimes there is no obvious case
Charcot joint is often known as Charcot foot, as the foot is the part of the body most likely to be affected, but it can also affect joints in the ankle, knee and, more occasionally, the wrist and hand. Charcot joint usually affects people who have had diabetes some 15 to 20 years and who are over the age of 50. High blood glucose levels over a long period of time can lead to neuropathy (nerve damage), and this can lead to a loss of sensation in the foot. The motor nerves, responsible for movement, can also become damaged, and as a result the muscles may no longer be able to support the joint properly. Due to the lack of pain perception, minor injuries or traumas, such as a sprain, can go unnoticed and untreated. This can rapidly progress to a state where the joint becomes dislocated and deformed.

Pregnancy and Diabetes

Diabetes occurs in 2-4% of all pregnancies (75% of which are gestational diabetes). Pregnancy has an effect on diabetes, and diabetes also has effects on pregnancy, so both angles must be considered. For this reason multidisciplinary care is needed.

Maternal risks
� Hypertension
� Pre-Eclampsia
� Polyhydramnios (although the levels need standardising)
� Increased risk of caesarean section

Effects on Baby
� 3.5 times the rate of congenital abnormalities – neural tube defects, caudal regression, cardiac and renal anomalies (not GDM)
� IUGR (worse outcomes than macrosomic infants)
� IUD/Stillbirth/Miscarriage
� Macrosomia (often accompanied with chronic hypoxia)
� Hypoglycaemia
� Perinatal morbidity levels are 3.8times higher than babies born to non diabetic mothers.

Gestational Diabetes

Gestational Diabetes occurs in up to 2% of all pregnancies. It is thought that the hormones produced during pregnancy may block the action of insulin. Gestational diabetes can happen if the mother's body can't produce enough extra insulin to counteract this blocking effect.

Women are more at risk if they:

have a 1st degree family history of type II (adult-onset) diabetes
are over the age of 35
are obese
have previously given birth to a macrosomic baby
have previously given birth to a baby born with an abnormality
have previously had a stillbirth late in pregnancy
have persistent glycosuria

For these women a oral glucose tolerance test is conducted at 28 weeks gestation (earlier if more than two occasions of glycosuria – if this is normal it should be repeated at 28 weeks). This consists of 75g of glucose being taken orally, and blood glucose levels being taken before and afterwards. The first reading (prior to which the woman should have fasted for several hours – the exact figure varies from trust to trust) should be below 6 mmol/l and two hours later less than 7.8mmol/ls. If the figures are above this gestational diabetes is diagnosed.

These women are then taught about the diet advice for diabetics and how to try and control their blood glucose levels with their diet. They are also taught to check their own levels and how to administer insulin if this treatment is needed.

They would need to go under consultant care, with joint care of a diabetologist at this point.

Pre-pregnancy care

Diabetic women of child bearing age should be offered pre-conceptual care. It is important that their blood glucose levels are well under control before embarking upon a pregnancy. Only 38% of pregnant type 1 diabetics and 25% of pregnant type 2 diabetic accessed any pre-conception care.

High Blood Glucose levels are toxic to the fetus, if these occur in the first trimester (particularly prior to 7 weeks gestation) then there is 3.5 times the rate of congenital abnormalities, namely neural tube defects, caudal regression, cardiac and renal anomalies.

If the woman’s HbA1c level is less than 8% there is a 5% chance of a fetal abnormality, if it is above 10% there is a 25% of an abnormality. (In the blood stream are the red blood cells, which are made of a molecule, haemoglobin. Glucose sticks to the haemoglobin to make a 'glycosylated haemoglobin' molecule, called haemoglobin A1C or HbA1C. The more glucose in the blood, the more haemoglobin A1C or HbA1C will be present in the blood. Red cells live for 8 -12 weeks before they are replaced. By measuring the HbA1C it can tell you how high your blood glucose has been on average over the last 8-12 weeks. A normal non-diabetic HbA1C is 3.5-5.5%. In diabetes about 6.5% is good. )

A high dose of folic acid (5mg) should be taken daily to avoid neural tube defects.

Drugs taken to help with diabetes or the complications thereof may need to be changed. ACE inhibitors increase the risk of renal and cardiac problems in pregnancy and the ‘statin’ group of drugs is teratogenic to the fetus and should be avoided in pregnancy.

Pregnancy

Good antenatal care is essential, with close monitoring of blood glucose levels, frequent blood pressure checks, with treatment if required, the eyes and kidneys should be screened. Frequent fetal surveillance should be carried out.

Blood Glucose Levels limits are individually set but are usually around 6mmol/ls pre meal and 8mmol/ls at 2 hours post meal. Hyperglycaemia and ketoacidosis increases the risk of miscarriage and stillbirth, the fetus is more tolerant of hypoglycaemia. Levels should be checked at least 3 – 4 times a day.

It is recommended that pregnant diabetics are seen fortnightly until 30 weeks and then weekly. CTGs are less predictive of problems with diabetic women, the variability is often reduced with no problems occurring to the fetus as a result. However with the mediolegal climate CTGs are still recommended. Serial growth scans, amniotic fluid index scans and particularly umbilical artery doppler scans will give a better idea as to fetal well being.

If a pregnant woman is on insulin it is generally accepted that delivery is induced around the 38-39 week gestation and pregnancy does not go past 40 weeks. For this reason accurate dating is essential, however at the 10-12 week mark, when dating scans often occur, a diabetic mother often has a larger fetus, even at this stage, than a non-diabetic woman. This can lead to discrepancies in dating.

Macrosomia occurs in 25% of diabetic pregnancies, this is because the high glucose levels cross the placenta, these levels stimulate the fetus make extra insulin, which results in growth being stimulated. The extra sugar is also laid down as fat, usually around the abdomen. This often occurs most rapidly round the 28-30 week gestation.

Pregnancy does increase the chances of hypoglycaemia occurring, and pregnant diabetics often loose their warning signs of an impending hypo. The insulin requirements are increased during pregnancy, particularly in the 2nd and 3rd trimesters. Retinopathy and nephropathy often worsen in pregnancy.

Labour/Birth

Blood Glucose levels should be checked hourly in established labour and the dose of insulin (which is administered IV on a ‘sliding scale’) adjusted according. IV Glucose and potassium is also administered throughout labour to ensure that there is no hypoglycaemia.

39% of pregnant diabetics are induced and 67% end up with a caesarean section (CEMACH report 2007).

If prophylactic steroids are given due to the chance of a premature birth it is essential that the woman is monitored closely for 24 hours afterwards as they can cause hyperglycaemia and she may require IV insulin.

If CTG monitoring is used, then remember that reduced variability may be due to the diabetes – so check fetal distress by FBS etc before jumping to any conclusions.

Each woman should have a plan of care regarding her insulin regime for the birth, this should also cover a planned caesarean section.

Postnatal Care

GDM should stop any insulin as soon as the placenta is delivered and they should return to their pre-pregnant state. it is recommended that a woman with GDM has a fasting glucose tolerance test 6 weeks after giving birth. This test is then carried out yearly for the next three years and then 3 yearly after that, as half of women with GDM will go on to develop Type 2 Diabetes.

Type 1 and Type 2 diabetics can go back to their pre-pregnancy regimes. It should be explained that they are likely to need less insulin and more calories if they are breastfeeding.

If a type 2 diabetic which is controlled by oral agents such as metformin is breastfeeding then she needs to remain on insulin (her diabetes specialist will work out rates) as these agents are contraindicated when breastfeeding)

When giving contraceptive advice it is important to discuss pre-conceptual advice for a subsequent pregnancy.

Maternal hyperglycaemia in pregnancy results in fetal hyperglycaemia and the fetus producing excess insulin. This excess production continues after the birth, however the neonate no longer has the high glucose levels. Within two hours of birth most will have hypoglycaemia however this is not a problem unless it is not resolved. For the first few days of life the neonate uses lactate, not glucose, to fuel any brain activity, to allow them to transition to life outside the uterus.

When caring for the baby of a diabetic woman it is important to :-
� Keep baby warm
� Feed frequently (first feed to be offered immediately post birth)
� A term baby need 60mls per kilo per day, so if the baby is bottle fed then this can be monitored (if breastfeeding then just ensure frequent feeds as it cannot be monitored)
� Blood Glucose Levels to be monitored – first 2-3hours after birth and the first feed, then 3 hourly PRE-FEED. When 3 normal readings in a row have been achieved then monitoring can be discontinued, the baby has successfully transitioned.

Neonatal Blood Glucose Levels (check with local policies first)

READING ACTION TO BE TAKEN

<1.4mmol/ls Admit baby to NICU immediately
Send Lab Sugar Test
1.4 – 2.6mmol/ls Retest 1 hour later post feed
If still less than 2.6 then NICU
>2.6mmol/ls This is normal range
Repeat before next feed, unless this is the 3rd normal reading – when discontinue

Potential Neonatal Complications

� Macrosomia Where the baby is above the 90th %ile. If the diabetes causes this then the excess weight is often due to extra fatty tissue, especially around the abdomen. Due to the potential of complications during the birth be aware of an increased risk of erb’s palsy. The infant will tend to keep the fractured arm straight to prevent further damage, often only being distressed if handled roughly. The injured arm will hang limp.
� IUGR This often results in neurological delays later in life.

� Transient Tachypnea of the Newborn (TTN) there is extra fluid in the lungs or the fluid in the lungs is absorbed too slowly. As a result, it is more difficult for the baby to take in oxygen properly, and the baby breathes faster and harder to compensate. This usually resolves in the first 24 hours of life. Symptoms of TTN include:

rapid, laboured breathing (tachypnea) of more than 60 breaths a minute
grunting or moaning sounds when the baby exhales
flaring nostrils or head bobbing
retractions (when the skin pulls in between the ribs or under the ribcage during rapid or laboured breathing)
cyanosis around the mouth and nose

� Respiratory Distress (RDS) is manifest by tachypnea and chest wall retractions during breathing efforts. In addition, grunting on expiration, flaring of the nostrils and cyanosis are common. This is due to a lack of surfactant in the lungs. This worsens over the first 24 hours of life and lasts at least 3-5days.
� Hypoglycaemia as the fetus was used to large amounts of glucose and produced high levels of insulin to cope. Often baby will show no symptoms, however if blood glucose levels are very low then they may be jittery, floppy, irritable or even fitting in extreme cases. This may also present with hypocalcaemia or hypomagnesaemia.
� Cranial Haemorrhage This is often linked either with an instrumental birth (often due to macrosomia) or to RDS.
� Polycythemia (more than 60% of the blood is red blood cells), these babies look ‘ruddy’, have excessive jaundice and often have RDS.

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