Мacrosomia

DIFINITIONS
 Macrosomia, also known as big baby
syndrome, is sometimes used synonymously
with LGA, or is otherwise defined as a fetus or
infant that weighs above 4000 grams or 4500
grams regardless of gestational age
 Large for gestational age (LGA) is an indication
of high prenatal growth rate, often defined as a
weight (or length, or head circumference) that
lies above the 90th percentile for that
gestational age
 DIAGNOSIS
 GRAVIDOGRAMM- (size og the utery) upper
than 90 percent.
 ultrasound( fetal head, femur, and abdomen)
 calculation of estimated fetal weight with
formules
 Pathophysiology

Numerous endocrinologic changes occur during pregnancy to

ensure an adequate fetal glucose supply. In the second half of
pregnancy, increased concentrations of human placental
lactogen, free and total cortisol, and prolactin combine to
produce modest maternal insulin resistance, which is countered
by postprandial hyperinsulinemia. In those who are unable to
mount this hyperinsulinemic response, relative hyperglycemia
may develop (ie, gestational diabetes). Because glucose
crosses the placenta by facilitated diffusion, fetal hyperglycemia
ensues. This in turn produces fetal hyperinsulinemia with
resultant intracellular transfer of glucose, leading to fetal
macrosomia.
 Maternal Diabetes
Maternal diabetes, whether gestational, chemical, or insulin dependent, is the condition
classically associated with fetal macrosomia.
The "Pedersen hypothesis" was long assumed to account for fetal macrosomia, that is,
the condition was the result of inadequate management of diabetes during pregnancy.
Initial reports suggested that careful control of blood glucose level in insulin-dependent
diabetic women would prevent fetal macrosomia, but recent studies have suggested
that the problem is not so simple and that the incidence may correlate better with cord
blood concentrations of maternally acquired anti-insulin IgG antibodies and/or
increased serum levels of free fatty acids, triglycerides, and the amino acids alanine,
serine, and isoleucine.
Cord serum epidermal growth factor concentrations also have been found to be higher
than normal in pregnancies complicated by prepregnancy diabetes and gestational
diabetes.

A significant correlation exists between plasma leptin levels and neonatal birthweight,
which suggests that leptin levels are directly related to the quantity of body fat tissue in
fetal macrosomia.
 Maternal Obesity

Maternal obesity is associated with a 3- to 4-fold

increased likelihood of fetal macrosomia. This situation
may result in part from associated gestational or
chemical diabetes, although these disorders are not
present in most obese women who deliver macrosomic
babies. One study showed a significantly higher rate of
cesarean delivery for obese mothers, even after
comorbidities such as diabetes were excluded.
 Postdatism

Prolonged pregnancy is more likely to result in a

macrosomic fetus, presumably because of continued
delivery of nutrients and oxygen to the fetus. Placental
sulfatase deficiency or congenital adrenal hypoplasia
are rare causes of postdatism.
 Genetic and Congenital Disorders
Several genetic and congenital syndromes are
associated with an increased incidence of macrosomia.
Beckwith-Wiedemann syndrome is frequently
associated with fetal macrosomia, usually because of
pancreatic islet cell hyperplasia (nesidioblastosis).
Affected infants usually have hypoglycemia,
macroglossia, and omphalocele. They also may have
intestinal malrotation or visceromegaly. Although
usually a sporadic event, other inheritance patterns
have been suggested in a few families. Other rare
syndromes include Weaver's syndrome, Sotos'
syndrome, Nevo's syndrome, Ruvalcaba-Myhre
syndrome, and Marshall's syndrome. Carpenter's
syndrome and the fragile X syndrome may be
associated with an increased incidence of LGA infants.
 Constitutionally Large Fetus
Fetuses who are suspected of being large for gestational
age may simply be large secondary to constitutional
factors. Large maternal stature should be considered
as contributing to macrosomia because birthweight
tends to correlate more closely with maternal height
than maternal weight.
Male gender fetuses are more likely to be considered
LGA because male fetuses are an average of 150 g
heavier than appropriately matched female fetuses at
each gestational week during late pregnancy. Series
addressing fetal macrosomia generally report an
increased incidence of male fetuses, usually
approximately 60–65%. One recent study showed that
male fetuses were twice as likely to be diagnosed with
macrosomia as compared with female fetuses.
 138.Complications of LGA
Pregnancy.
Maternal Complications
 Cesarean section, postpartum hemorrhage, shoulder
dystocia, perineal trauma, operative vaginal delivery, CPD
Fetal Complications
Stillbirth, anomalies, shoulder dystocia
Neonatal Complications
Low Apgar score, hypoglycemia, birth injury, hypocalcemia,
polycythemia, jaundice, feeding difficulties
 Long-Term Complications
Obesity, type 2 diabetes, neurologic or behavioral problems
 Prevention
Prevention of macrosomia and ensuing complications
requires early detection of risk factors.
Risk factors for having a macrosomic infant include
multiparity, advanced maternal age, and previous
delivery of a macrosomic infant. When controlled for
gestational age and fetal gender, the average birthweight
with successive pregnancies increases by 80–120 g up
to the fifth pregnancy.
Multiparity is also associated with other risk factors (eg,
obesity, diabetes) and therefore may be a confounding
variable.
Advanced maternal age also contributes to increased
birthweight. However, as with multiparity, it is also
associated with obesity and diabetes.
Patients with the risk factors should be evaluated for possible
fetal macrosomia with an ultrasound estimate of fetal size
and weight.
EFW by ultrasound is not very accurate. More than 30
different formulas for EFW calculation have been proposed,
attesting to the inadequacy of each individual method.
No single formula has been consistently better than the
others. Even in skillful hands, the error of fetal weight
estimates by ultrasound is 10–20%.
One review of ultrasonographic diagnosis of macrosomia
shows sensitivity ranging from 24–88% and specificity from
60–98%. The margin of error in estimating fetal weight
means that the EFW by ultrasound must be at least 4750 g
in order to predict a birthweight of 4000 g with a confidence
interval of 90%.
The best single measurement in evaluating macrosomia in diabetic mothers is
abdominal circumference. An initial abdominal circumference above the
70th percentile is significantly associated with subsequent delivery of an
LGA infant. Fetal body composition and fetal shoulder width cannot be
accurately assessed by ultrasound.
Adequate control of maternal glucose levels is thought to prevent the
development of macrosomia in gestational diabetics, although neonatal
complications despite excellent metabolic control have been reported.
Prepregnancy weight and degree of weight gain are strong indicators for
macrosomia regardless of glycemic control. However, the rates of
macrosomia and complications are reduced overall when postprandial
levels are monitored. Studies have shown that the risk of macrosomia is
reduced to near normal in diabetic women who monitor 1-hour postprandial
glucose levels and that 1-hour postprandial glucose levels are directly
related to fetal abdominal circumference values.
One study showed that when postprandial glucose levels were kept below 104
mg/dL, macrosomia rates of diabetic women were similar to those of
nondiabetics.
High carbohydrate intake is associated with a decreased incidence of newborn
macrosomia. Essential management principles in known diabetics includes
nutrition and exercise counseling beginning in the preconception period.
 Treatment
Although widely recommended, labor induction in at-risk
pregnancy for reducing the incidence of fetal macrosomia and
intrapartum complications remains an unproven hypothesis.
Several published reviews of fetal macrosomia suggest routine
cesarean delivery for fetuses with estimated weights of 5000 g
or more (or estimated weights 4500 g in diabetic pregnancies).
This suggestion is based in part on the data that very macrosomic
fetuses have bisacromial circumferences in excess of HCs.
Because of current limitations in the sensitivity and specificity of ultrasound-derived fetal weight
calculations, decisions regarding scheduled abdominal delivery must be partially based on
clinical grounds.
Such considerations are particularly warranted in women who are obese or are diabetic or in
postdate pregnancies.
Maternal age and maternal preference also should be considered when deciding on delivery
method.
Vacuum-assisted vaginal delivery increases the risk of shoulder dystocia. If the estimate
of fetal weight is greater than 4000 g, the vacuum should be avoided if the second stage is
prolonged, and in general the vacuum should be used with caution.
Some physicians have adopted the practice of discussing the option of vaginal delivery versus
cesarean delivery if the EFW is greater than 4500 g in nondiabetic women or greater than
4000–4250 g in diabetic women.
No firm data indicate that this practice offers greater benefit in preventing complications such as
shoulder dystocia than risks associated with many unnecessary cesarean births.
Because of these factors, women at risk for macrosomic or LGA babies should deliver in
facilities where adequate obstetric care, pediatric care, and anesthesia are available. Large-
bore intravenous access must be established, and blood must be available.
Delivery should occur in a setting where immediate operation can be accomplished. In many
situations, delivery should occur in a delivery room.
 Prognosis
Any woman who delivers an LGA baby should be informed that the risk of her
having another LGA baby is increased by 2.5- to 4-fold. Such women should
be screened for previously undiagnosed chemical or insulin-dependent
diabetes and, even if screening is negative, should be followed carefully in
any subsequent pregnancy to rule out gestational diabetes.

Obese women should be strongly encouraged to lose weight prior to becoming

pregnant. Any woman who has delivered an LGA infant should be
encouraged to seek early care for any subsequent pregnancy, if for no other
reason than early confirmation of the EDC, which can minimize the likelihood
of subsequent postdatism. Women who deliver an LGA infant with an
underlying genetic or congenital disorder should receive genetic counseling
regarding recurrence risks and the feasibility of antepartum diagnosis.

In addition to the many neonatal complications previously noted, infants of

mothers with gestational or chemical diabetes are at increased risk for
subsequent obesity, type 2 diabetes, or both. Infants who suffer from
neonatal complications are at increased risk for subsequent neurologic or
behavioral problems.