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![ It is reasonable to offer elective induction of labor to
women:
Women without diabetes:
4000 and 4500 g -> at 39 weeks of gestation
Reduced the risk of neonatal fractures (relative risk [RR] 0.20, 95% CI 0.05-0.79)
Reduced the risk of shoulder dystocia (RR 0.60, 95% CI 0.37-0.98)
HashemYaseen, MBBS 2018](https://image.slidesharecdn.com/lgaseminarhashem2018-180314082032/85/LGA-seminar-hashem-2018-24-320.jpg)
Uploaded byHashem Yaseen
LGA seminar hashem 2018
This document discusses macrosomia, which refers to infants with high birth weights, usually over 4000g or 9 pounds. Risks of macrosomia include difficult delivery and injuries. It reviews methods of predicting macrosomia like ultrasound measurements and maternal estimates. For infants over 4000g or 4500g, induction of labor at 39 weeks is recommended to reduce risks. For infants over 4500g born to diabetic mothers, cesarean delivery may help prevent injuries. The document provides details on evaluating and managing pregnancies at risk for a macrosomic infant.
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LGA seminar hashem 2018
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- 9. large-for-gestational-age: hasmainly been used for fetuses or newborns with an (estimated) weight 90th percentile or 2 standard deviations from the mean for the gestational age Macrosomia: refers to growth beyond a specific threshold, regardless of gestational age A grading system has been suggested: 1. grade 1 for infants 4000 to 4499 g 2. grade 2 for 4500 to 4999 g 3. grade 3 for over 5000 g HashemYaseen, MBBS 2018
- 10. The worldwideprevalence of birth of infants ≥4000 g is approximately 9 percent and approximately 0.1 percent for weight ≥5000 g,HashemYaseen, MBBS 2018
- 11. Maternal: Protractedor arrested labor Operative vaginal delivery Cesarean delivery Genital tract lacerations (vaginal, anal sphincter, rectum) Postpartum hemorrhage Uterine rupture Fetal: Shoulder dystocia leading to birth trauma (brachial plexus injury, fracture) or asphyxia. HashemYaseen, MBBS 2018
- 12. At birth weights≥5000 g, the risk of stillbirth and neonatal mortality increases. For this reason, the presence of macrosomia is an important factor to consider in decision-making during delivery (eg, whether to use forceps or vacuum, whether to proceed to cesarean delivery). HashemYaseen, MBBS 2018
- 13. It has beenproposed that a common pathway to macrosomia is intermittent maternal, and thus fetal, hyperglycemia. The consequent release of insulin, insulin-like growth factors, and growth hormone, among others, leads to increased fetal glycogen and fat deposition and, in turn, amplified fetal growth HashemYaseen, MBBS 2018
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- 15. Comparisons ofthese formulas concluded that the formula using BPD, FL and AC (second Hadlock formula) resulted in the best estimate of fetal weight, while the formula using only BPD and AC (Shepard formula) had the least accurate estimate The diagnosis of macrosomia defined as ≥4500 g is even less accurate; the mean absolute percent error for infants weighing above 4500 g was 12.6 percent versus 8.4 percent if below 4500 The majority of sonographic EFW formulas do not take body composition into account. Because body composition can vary greatly, even in the fetus, significant variation in birth weight can occur among fetuses with similar biometric parametersHashemYaseen, MBBS 2018
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- 18. The HC/AC ratiois of no proven value in predicting macrosomia since the constitutionally large fetus maintains a normal HC/AC ratio. HashemYaseen, MBBS 2018
- 19. The ACis the most important parameter for assessment of risk of macrosomia An AC of 35 to 38 cm alone is predictive of macrosomia An AC >90th percentile or two to three weeks ahead of gestational age may be an early marker for development of macrosomia despite normal EFW. HashemYaseen, MBBS 2018
- 20. Maternal estimation— In several studies, a mother's estimate of her baby's weight has been reported to be as, or more, accurate than clinical or sonographic estimates Maternal estimation has been used primarily to predict macrosomia during labor in women without a recent ultrasound examination. Physical examination — Fetal weight can be estimated clinically by simple palpation of the fetus through the maternal abdomen (eg, Leopold maneuvers) and/or by measurement of fundal height (the distance between the superior aspect of the symphysis pubis and the upper border of the uterine fundus).These assessments are performed with the woman supine and her bladder empty. HashemYaseen, MBBS 2018
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- 22. Macrosomic infantsof diabetic mothers have larger shoulders and greater amounts of body fat, decreased head-to-shoulder ratio, and increased skin folds in the upper extremities. Ultrasound prediction of estimated fetal weight in fetuses of diabetic mothers tends to overestimate fetal weight since the formula is very sensitive to measurement of abdominal circumference (AC), and AC in particular is increased in these fetuses HashemYaseen, MBBS 2018
- 23. Fundal height measurements(FHM) from 26 – 28 weeks 1st plot above 90th Centile Arrange GTT Abnormal GTT Refer to diabetes team Ultrasound biometry, including AFI EFW >90th centile and increased AFI Normal GTT HashemYaseen, MBBS 2018
- 24. It isreasonable to offer elective induction of labor to women: Women without diabetes: 4000 and 4500 g -> at 39 weeks of gestation Reduced the risk of neonatal fractures (relative risk [RR] 0.20, 95% CI 0.05-0.79) Reduced the risk of shoulder dystocia (RR 0.60, 95% CI 0.37-0.98) HashemYaseen, MBBS 2018
- 25. The AmericanCollege of Obstetricians and Gynecologists practice bulletin on operative delivery suggests that judicious use of forceps or vacuum extraction is not contraindicated for most fetuses suspected to be macrosomic, if the maternal pelvis and progress of labor are adequate HashemYaseen, MBBS 2018
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- 27. It isreasonable to offer prophylactic cesarean delivery to women: Women with diabetes: to prevent brachial plexus injury when the estimated fetal weight is greater than 4500 g. HashemYaseen, MBBS 2018
- 28. Neonatal: Hypoglycemia Respiratory problems Polycythemia Minor congenital anomalies Increased frequency of admission and prolonged admission (greater than three days) to a neonatal intensive care unit Childhood and beyond: Obesity Impaired glucose tolerance Metabolic syndrome Cardiac remodeling (increase in aorta intima-media thickness and left ventricular mass) HashemYaseen, MBBS 2018
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Editor's Notes
- #11 These thresholds are not useful for identifying the preterm macrosomic fetus since they are not based upon population statistics, where normal weight is typically defined as between the 10th and 90th percentile for gestational age (assuming a normal population distribution). Using a statistical approach, any fetus/infant weighing >90th percentile for gestational age is considered large for gestational age
- #14 Risk factors for macrosomia are listed in the table (table 2) and include constitutional factors (eg, familial trait, male sex, ethnicity), environmental factors (maternal diabetes, gestational weight gain, maternal obesity, post-term gestation, multiparity, large placenta in early pregnancy), or heritable genetic abnormalities [28,29]. The long-term consequences vary depending on the etiology [30].
- #15 then the possibility of one of the rare syndromes associated with accelerated fetal growth should be considered, particularly in the presence of one or more fetal structural anomalies
- #23 Women with diabetes — The growth pattern of fetuses of women with diabetes, especially when glycemic control has been poor, is different from that in fetuses of women without diabetes [50,113,114]. Macrosomic infants of diabetic mothers have larger shoulders and greater amounts of body fat, decreased head-to-shoulder ratio, and increased skin folds in the upper extremities [115,116]. Several studies have used this information in an attempt to predict the risk of shoulder dystocia in pregnancies complicated by diabetes, but no method has proven to be reliable [117-121].