Large For Gestational Age

Definition
An infant is LGA (also termed macrosomia) if the birth weight is above the
90th percentile on an intrauterine growth chart for that gestational age. Such a baby
appears deceptively healthy at birth because of the weight, but a gestational age
examination often reveals immature development. It is important that LGA infants be
identified immediately so they can be given care appropriate to their gestational age
rather than being treated as term newborns (Ouzounian & Goodwin, 2010).

Etiology
Infants who are LGA have been subjected to an overproduction of nutrients
and growth hormone in utero. This happens most often to infants of women who are
obese or who have diabetes mellitus (Miller & Morris, 2011). Multiparous women
may also have large babies because with each succeeding pregnancy, babies tend
to grow larger. Beckwith– Wiedemann Syndrome, a rare condition characterized by
general body overgrowth and congenital anomalies such as omphalocele, may also
be a cause.

Pathophysiology
An interplay of physiologic and endocrine changes occurs in pregnancy,
aiming at adequate nurturing of the developing fetus. The primary underlying
pathophysiology of macrosomia could be broadly divided into maternal and fetal risk
factors. However, maternal hyperglycemia appears to be the most significant factor
in the pathogenesis of macrosomia. In the second trimester of pregnancy, an
increase in the levels of the stress hormones such as cortisone, human placenta
lactogen (HPL), and prolactin leads to modest degrees of maternal insulin
resistance. This, however, is countered by physiologic postprandial
hyperinsulinemia. Patients with metabolic syndrome or other existing risk factors
may be unable to mount an adequate hyperinsulinemic response leading to the
development of hyperglycemia. Glucose transfer through the placenta occurs
through facilitated diffusion that results in fetal hyperglycemia. This, in turn, brings
about the hyperplasia of the beta islet cells of the fetal pancreas leading to
overutilization of glucose by the fetus and hence an abnormal increase in fetal
growth.

Clinical Manifestations

Babies may be called large for gestational age if they weigh more than 9 in 10
babies or 97 of 100 babies of the same gestational age. In the U.S., this means
babies born at 40 weeks' gestation who weigh more than 8 pounds 13 ounces (4,000
grams) or 9 pounds, 11 ounces (4,400 grams) at birth.

Appearance.
 At birth, LGA infants may show immature reflexes and low scores on
gestational age examinations in relation to their size. They may have
extensive bruising or a birth injury such as a broken clavicle or Erb–Duchenne
paralysis from trauma to the cervical nerves if they were stressed in order for
the wide shoulders to be born vaginally. Because the head is large, it may
have been exposed to more than the usual amount of pressure during
birth, causing a prominent caput succedaneum, cephalohematoma, or
molding.
Because LGA newborn are large, but often immature, they require the
same cautious care necessary for a preterm infant.

Cardiovascular Dysfunction.
Polycythemia may occur in an LGA fetus as the fetus attempts to fully
oxygenate more than the average amount of body tissue. Following birth,
observe LGA infants closely for signs of hyperbilirubinemia that may result
from absorption of blood from bruising and breakdown of the extra red blood
cells created by polycythemia. Assess the infant’s heart rate also. If cyanosis
is present, it may be a sign of poor heart function, but it could also be from
transposition of the great vessels, a serious heart anomaly associated with
macrosomia.

Hypoglycemia.
LGA infants also need to be carefully assessed for hypoglycemia in the
early hours of life because large infants require large amounts of nutritional
stores to sustain their weight. If the mother had diabetes that was poorly
controlled (the cause of the large size), the infant would have had an
increased blood glucose level in utero to match the mother’s glucose level;
this caused the infant to produce elevated levels of insulin. After birth, these
increased insulin levels will continue for up to 24 hours of life, possibly
causing rebound hypoglycemia.

Incidence
Fetal macrosomia occurs in 0.5–15% of all pregnancies. There is no
international consensus on the definition of macrosomia but the most common is
birth weight ≥ 4000 g.
In the United States vital statistics report of 2015, it was indicated that 7% of
infants had a birth weight greater that 4000 grams, while 1% had a birth weight
greater than 4500 grams.

Laboratory and Diagnostic

1. Before birth, the mother can undergo ultrasonography. Although
ultrasonography remains imprecise, it can still be used to confirm the LGA
diagnosis.
 - A fetus is suspected of being LGA when a woman’s uterus is unusually
large for the date of pregnancy. If a fetus seem to be growing at an
abnormally rapid rate, a sonogram can confirm the suspicion.
Nursing Responsibility during Ultrasonography:
BEFORE Procedure:
1. Explain procedure and its purpose
2. To ensure that the mother has a full bladder at the time of the procedure, she
should drink a full glass of water every 15 minutes beginning an hour and a
half before the procedure.
3. Instruct the mother not to void before the procedure.

DURING Procedure:
1. The ultrasound technician may apply a clear gel to the skin in order to help
the transducer more freely over the body.
2. Ask the patient to relax while the procedure is going on.

AFTER Procedure:
1. Allow mother to void.
2. Allow the mother to take home a photograph of the sonogram image which
can enhance bonding because it is a proof that the pregnancy exists and that
the fetus appears well.

2. Pregnancy-assosciated plasma protein A (PAPP-A) Test

- A high PAPP-A level may predict a large for gestational age (LGA)
baby. Routinely tested first-trimester PAPP-A is a novel biomarker for
maternal diabetes and LGA. PAPP-A decreased with increasing
severity of maternal diabetes. Although this cannot infer causality, low
PAPP-A may help identify women at risk of GDM, and high PAPP-A
may help identify pregnancies at risk of LGA (Wells et al., 2015).
3. Antenatal testing. If your health care provider suspects fetal macrosomia, they
might perform antenatal testing, such as a nonstress test or a fetal biophysical
profile, to monitor your baby's well-being.
a. A nonstress test measures the baby's heart rate in response to his or
her own movements.
b. A fetal biophysical profile combines nonstress testing with ultrasound to
monitor your baby's movement, tone, breathing and volume of amniotic
fluid.
4. During pregnancy, doctors measure the sdistance on the woman's abdomen
from the top of the pubic bone to the top of the uterus (fundus).
- If the measurement is high for the number of weeks, the fetus may be
larger than expected.
5. After birth, LGA is diagnosed by assessing the gestational age and the weight
of the baby.
LGA newborns are assessed for any complications. Blood sugar is measured to
detect hypoglycemia, and doctors do a thorough examination to look for birth injuries
and structural or genetic abnormalities.

Medical Management
Induction of labor (IOL), which was widely recommended until recently, has
been discouraged due to the lack of clear evidence on its significance in the
management of macrosomia. Pregnancies complicated by fetal macrosomia in
patients with pre-existing or gestational diabetes and improved glycemic control via
recommended pharmacologic and other interventions will lead to a reduction in the
risk of perinatal complications. Pregnancies with macrosomia and no underlying
diabetes pose a different challenge to the obstetric provider and other health care
providers when appropriate treatment and intervention are needed. The American
College of Obstetrics and Gynecology (ACOG) recommends an elective caesarian
delivery to women with pregnancies complicated by macrosomia if the estimated
fetal weight is above 5000 g and no underlying glucose intolerance or 4500 g with
underlying glucose intolerance. Assisted vaginal delivery, such as forceps or
vacuum-assisted deliveries, should be performed with significant caution in women
with macrosomic pregnancies.
Nursing Management
● If IDM, observe for potential complications
● Monitor for, and manage, birth injuries and complications of birth injuries.
a) Clavicle fracture
- Confirm by x-ray.
- Assess the infant for crepitus, hematoma, or deformity over the
clavicle; decreased movement of arm on the affected side; and
asymmetrical or absent. Moro reflex.
- Limit arm motion by pinning the infant’s sleeve to the shirt.
- Manage the pain
b) Facial nerve injury
- Assess for symmetry of mouth while crying.
- Wrinkles are deeper on the unaffected side.
- The paralyzed side is smooth with a swollen appearance.
- The nasiolabial fold is absent.
- If the eye is affected, protect it with patches and artificial tears.
c) Erb-Duchenne palsy and Klumpke paralysis
- Erb-Duchenne palsy. Assess for adduction of the affected arm
with internal rotation and elbow extension. The Moro reflex is
absent on the affected side. The grasp reflex is intact.
- Klumpke paralysis. Assess for absent grasp on the affected
side. The hand appears claw-shaped.
- Management includes:
 - 1. X-ray studies of the shoulder and upper arm to rule out bony
injury
- 2.Examination of the chest to rule out phrenic nerve injury
- 3.Delay of passive movement to maintain range of motion of the
affected joints until the nerve edema resolves (7 to 10 days)
- 4.Splints may be useful to prevent wrist and digit contractures
on the affected side
d) Phrenic nerve palsy
- Assess for respiratory distress with diminished breath sounds.
- X-ray usually shows elevation of the diaphragm on the affected
side.
- Provide pulmonary toilet to avoid pneumonia during the recovery
phase (1 to 3 months).
e) Skull fracture
- Assess for soft-tissue swelling over fracture site, visible
indentation in scalp, cephalhematoma, positive skull x-ray, and
CNS signs with intracranial hemorrhage (e.g., lethargy,seizures,
apnea, and hypotonia).

Prognosis
A baby that is LGA has a higher risk for birth injury. There is also a risk for
complications of low blood sugar after delivery if the mother has diabetes.
Children born large for gestational age are prone to induce neonatal
complications and develop insulin resistance, obesity, diabetes and early
cardiovascular disease later in life. High birth weight has also been associated with
increased future risk of cancer such as leukemia, breast, prostate and colon cancer.

Ruiz, Patricia Dianne V.- Definition, Etiology, Medical Management

Rasalan, Jasmine Melle Laika A. - Incidence, Laboratory and Diagnostics,
Prognosis
Pagdilao, Shainna Meire P. - Pathophysiology, Clinical Manifestations, Nursing
Management
References:

 Large-for-Gestational age (LGA) newborn nursing care plan & management.

(2018, August 29). RNpedia.
https://www.rnpedia.com/nursing-notes/maternal-and-child-nursing-notes/
large-gestational-age-lga-newborn/?
fbclid=IwAR1iwk_NPkIGA3ZZSHr6hn9_ephsnLM7NaT1z517rcsH0zlpgONBfl
sEOa

 Default. (n.d.). Stanford Children's Health - Lucile Packard Children's Hospital

Stanford. https://www.stanfordchildrens.org/en/topic/default?id=large-for-
gestational-age-90-P02383&fbclid=IwAR3wJKJ51slMpe-
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 Nursestudynet@gmail.com. (2020, December 5). Dystocia nursing care plans

and diagnosis interventions. NurseStudy.Net. https://nursestudy.net/dystocia-
nursing-care-plans/

 Macrosomia: Determination of EFW and recommendations for delivery. (2022,

January 20). The ObG Project.
https://www.obgproject.com/2017/02/07/macrosomia-role-early-delivery/

 Content. (2020, November 27). St. Clair Health.

https://www.stclair.org/services/mayo-clinic-health-information/diseases-and-
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 Ng, S. K., Olog, A., Spinks, A. B., Cameron, C. M., Searle, J., & McClure, R.
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Nursing Care Plan (Large for Gestational Age)

Nursing Diagnosis
Ineffective breathing pattern related to possible birth trauma in the LGA newborn as
evidenced by tachypnea (RR of 65 bpm)

Inference
Some LGA infants experience birth trauma such as increased intracranial pressure
from birth of the larger than usual head causing pressure on the respiratory center,
or a diaphragmatic paralysis or broken clavicle preventing effective lung function,
therefore causing ineffective breathing pattern.

Nursing Goal
After 1 to 2 hours of appropriate nursing interventions, the client will have a normal
newborn respiratory rate of 30 to 60 breaths/min.

Nursing Interventions

Intervention Rationale

Administer oxygen therapy and respiratory To improve oxygenation in the

medications as prescribed. body and manage respiratory
distress.

Maintain head of bed elevated. To promote proper lung

expansion and reduce
pressure in the abdomen.

Keep a cool, calm, and relaxing environment. To limit level of anxiety.

Monitor respirations, including the rate, depth and To have a baseline data in
effort. evaluating the respiratory
function.

Monitor pulse oximetry, as indicated. To verify maintenance/

 improvement in oxygen
saturation

Nursing Evaluation
After 1 hour of appropriate nursing interventions, the client was able to have a
normal newborn respiratory rate of 40 breaths/min.