History

Fact Explanation
History of maternal diabetes [4] Macrosomia is defined as birth-weight over 4,000 g irrespective of gestational age. [1] Maternal diabetes is the strongest risk factor for the macrosomia. Gestational diabetes mellitus (GDM) which is defined as any degree of glucose intolerance which is first recognized during the pregnancy. [3] Macrosomic infants of diabetic mothers are at a greater risk of shoulder dystocia of mothers nondiabetic mothers.
History of fetal macrosomia [1] Increases the chance of having macrosomic babies in the future pregnancies. [2]
Maternal age [4] If the mother is older than 35 years, baby is more likely to become macrosomic. [1]
Multiparity Multiparity is recognized as a main risk factor for macrosomia. [1]
Weight gain during pregnancy [1] If mother had excess weight gain during pregnancy, that is associated with macrosomia of the fetus. [1]
Shoulder dystocia [1] Shoulder dystocia is a dangerous complication occurring due to the macrosomia. Studies have shown that half of the shoulder dystocia happen to macrosomic infants [3] and recurrence of shoulder dystocia in subsequent deliveries.
History of poor progression of labour This is a maternal complication of macrosomia. Labour may get obstructed result in prolonged labor, and may need to augment the labor with oxytocin. [1]
History caesarian section for delivery of the baby [1] Vaginal delivery may be failed in macrosomic infants and it also increases the risk of perineal tears and cevical lacerations. [6,7] Therefore CS may be needed for the delivery on some occasions. .
Fetal death [1] Can be due to birth asphyxia, cardiorespiratory arrest and cardiac failure.
Exess bleeding after delicery of the baby and maternal pyrexia [5] Postpartum hemorrhage and infection are maternal complications due to the macrosomia. [1] Postpartum uterine atony is more common in mothers with gestational diabetes mellitus. [5]
Future risk of co-morbidities for the baby [5] Macrosomic infants have greater chance of getting type 2 diabetes mellitus, hypertension, and obesity in their adulthood. [1]
References
  1. MOHAMMADBEIGI A, FARHADIFAR F, SOUFI ZADEH N, MOHAMMADSALEHI N, REZAIEE M, AGHAEI M. Fetal Macrosomia: Risk Factors, Maternal, and Perinatal Outcome Ann Med Health Sci Res [online] 2013, 3(4):546-550 [viewed 26 July 2014] Available from: doi:10.4103/2141-9248.122098
  2. ALBERICO S, MONTICO M, BARRESI V, MONASTA L, BUSINELLI C, SOINI V, ERENBOURG A, RONFANI L, MASO G. The role of gestational diabetes, pre-pregnancy body mass index and gestational weight gain on the risk of newborn macrosomia: results from a prospective multicentre study BMC Pregnancy Childbirth [online] :23 [viewed 26 July 2014] Available from: doi:10.1186/1471-2393-14-23
  3. CAPULA C, CHIEFARI E, VERO A, ARCIDIACONO B, IIRITANO S, PUCCIO L, PULLANO V, FOTI DP, BRUNETTI A, VERO R. Gestational Diabetes Mellitus: Screening and Outcomes in Southern Italian Pregnant Women ISRN Endocrinol [online] :387495 [viewed 26 July 2014] Available from: doi:10.1155/2013/387495
  4. BALAJI V, BALAJI M, ANJALAKSHI C, CYNTHIA A, ARTHI T, SESHIAH V. Diagnosis of gestational diabetes mellitus in Asian-Indian women Indian J Endocrinol Metab [online] 2011, 15(3):187-190 [viewed 10 September 2014] Available from: doi:10.4103/2230-8210.83403
  5. GILMARTIN A“, URAL SH, REPKE JT. Gestational Diabetes Mellitus Rev Obstet Gynecol [online] 2008, 1(3):129-134 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582643
  6. ALSAMMANI MA, AHMED SR. Fetal and Maternal Outcomes in Pregnancies Complicated with Fetal Macrosomia N Am J Med Sci [online] 2012 Jun, 4(6):283-286 [viewed 12 September 2014] Available from: doi:10.4103/1947-2714.97212
  7. FUCHS FLORENT, BOUYER JEAN, ROZENBERG PATRICK, SENAT MARIE-VICTOIRE. Adverse maternal outcomes associated with fetal macrosomia: what are the risk factors beyond birthweight?. Array [online] 2013 December [viewed 12 September 2014] Available from: doi:10.1186/1471-2393-13-90

Examination

Fact Explanation
Greater fundal height and polyhydramnios [3] Fundal height is more than corresponding height for period of gestation. Polyhydramnios is associated with gestational diabetes mellitus. [3] Abdomen will be shiny, fetal parts may not be clearly palpable, fetal heart sounds may diminished in intensity.
Birth weight more than 4kg [1] Macrosomia is birth weight greater than either 4kg. [1]
Dyspnoea, tachypnea and cyanosis of the baby [1] Cardiorespiratory problems [1] can be frequently seen among macrosomic babies. As the fetus gets hyperglycaemia due to the transfer of glucose from the diabetic mother, pancrea gets stimulated and there is oversecretion of insulin in the baby. Insulin is an anabolic hormone that results in cardiac hypertrophy and failure of the cardiac function.Birth asphyxia [1] can occur due to the shoulder dystocia.
Nerve palsies of the baby [1] Can be occurred during the delivery of large baby. Damaged to the lower roots of brachial plexus [1] causes Klumpke's paralysis with paralysis of intrinsic muscles of the hand. Erb's palsy [7] causes Facial nerve palsy is another complication.
Bone fractures [1] Clavicle, humerus are the frequent bones to be fractured [7] during the delivery.
Jaundice (yellowish discolouration of eyes and mucous membrane) As there is state of chronic fetal hypoxia due to the placental insufficiency for the large fetus in the fetus and placental vasculopathy result in from diabetes, erythropoietin level of the fetus is increased with increased number of red cells. These red cells get destroyed after birth causing excess bilirubin and jaundice. [6]
Low 5-minute Apgar scores [3] Strength and regularity of heart rate, lung maturity, muscle tone, skin colour and reflex response to irritable stimuli are the 5 components measured in the apgar score. Apgar score of 7 or above is normal, below 7 indicate some fetal distress and need for resuscitation.
Pre-gestational maternal obesity [5] Is a risk factor for fetal macrosomia. Obesity, is defined as Body Mass Index (BMI) equal or over 30 Kg/m2. [2] High Body mass index of the mother is an indication for the risk of large baby. [1]
Maternal perineal tears [1] Third and fourth degree tears are seen after delivery of large fetus in certain occasions. [1]
References
  1. MOHAMMADBEIGI A, FARHADIFAR F, SOUFI ZADEH N, MOHAMMADSALEHI N, REZAIEE M, AGHAEI M. Fetal Macrosomia: Risk Factors, Maternal, and Perinatal Outcome Ann Med Health Sci Res [online] 2013, 3(4):546-550 [viewed 26 July 2014] Available from: doi:10.4103/2141-9248.122098
  2. ALBERICO S, MONTICO M, BARRESI V, MONASTA L, BUSINELLI C, SOINI V, ERENBOURG A, RONFANI L, MASO G. The role of gestational diabetes, pre-pregnancy body mass index and gestational weight gain on the risk of newborn macrosomia: results from a prospective multicentre study BMC Pregnancy Childbirth [online] :23 [viewed 26 July 2014] Available from: doi:10.1186/1471-2393-14-23
  3. CAPULA C, CHIEFARI E, VERO A, ARCIDIACONO B, IIRITANO S, PUCCIO L, PULLANO V, FOTI DP, BRUNETTI A, VERO R. Gestational Diabetes Mellitus: Screening and Outcomes in Southern Italian Pregnant Women ISRN Endocrinol [online] :387495 [viewed 26 July 2014] Available from: doi:10.1155/2013/387495
  4. CHENG Y, SPARKS T, LAROS R JR, NICHOLSON J, CAUGHEY A. Impending macrosomia: will induction of labour modify the risk of caesarean delivery? BJOG [online] 2012 Mar, 119(4):402-409 [viewed 26 July 2014] Available from: doi:10.1111/j.1471-0528.2011.03248.x
  5. BALAJI V, BALAJI M, ANJALAKSHI C, CYNTHIA A, ARTHI T, SESHIAH V. Diagnosis of gestational diabetes mellitus in Asian-Indian women Indian J Endocrinol Metab [online] 2011, 15(3):187-190 [viewed 10 September 2014] Available from: doi:10.4103/2230-8210.83403
  6. GILMARTIN A“, URAL SH, REPKE JT. Gestational Diabetes Mellitus Rev Obstet Gynecol [online] 2008, 1(3):129-134 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582643
  7. ALSAMMANI MA, AHMED SR. Fetal and Maternal Outcomes in Pregnancies Complicated with Fetal Macrosomia N Am J Med Sci [online] 2012 Jun, 4(6):283-286 [viewed 12 September 2014] Available from: doi:10.4103/1947-2714.97212

Differential Diagnoses

Fact Explanation
Diabetes Mellitus [2] Gestational diabetes mellitus (GDM) is any degree of glucose intolerance which is first recognized during the pregnancy. [1] Risk factors for the development of GDM are age more than 35 years, pregestational maternal obesity, past history of GDM, family history of diabetes mellitus previous stillbirths.
Post-term Pregnancy [4] Postterm delivery is where pregnancy is continuing beyond 42 weeks of period of gestation. [2] Postterm delivery is associated with increased risk of complications, [5] such as perinatal mortality, birth injury, low Apgar scores, macrosomia, meconium aspiration syndrome and cesarean delivery.
Other causes for fundus larger than for dates Wrong dates may be a reason. Therefore accurate last menstrual period is important to know. Dating scan should be done at around 11-14 weeks of gestation when it is more accurate. Occasionally pelvic tumours or any pelvic lumps [3] can give larger fundal height.
References
  1. CAPULA C, CHIEFARI E, VERO A, ARCIDIACONO B, IIRITANO S, PUCCIO L, PULLANO V, FOTI DP, BRUNETTI A, VERO R. Gestational Diabetes Mellitus: Screening and Outcomes in Southern Italian Pregnant Women ISRN Endocrinol [online] :387495 [viewed 26 July 2014] Available from: doi:10.1155/2013/387495
  2. GILMARTIN A“, URAL SH, REPKE JT. Gestational Diabetes Mellitus Rev Obstet Gynecol [online] 2008, 1(3):129-134 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582643
  3. ANAND M, DESHMUKH SD. Massive Abdominal Wall Endometriosis Masquerading as Desmoid Tumour J Cutan Aesthet Surg [online] 2011, 4(2):141-143 [viewed 10 September 2014] Available from: doi:10.4103/0974-2077.85043
  4. FARQUHARSON DF. Management of post-Date Pregnancy Can Fam Physician [online] 1986 Oct:2171-2176 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2328217
  5. BROWNE FJ. Foetal Post-maturity and Prolongation of Pregnancy Br Med J [online] 1957 Apr 13, 1(5023):851-855 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1973588

Investigations - for Diagnosis

Fact Explanation
Ultrasound scan [1] This is an accurate method of estimation of fetal weight in utero. Abdominal circumference(AC), Bi parietal diameter (BPD), femur length (FL) and estimated fetal weight can be estimated by ultrasound scan. Out of these measures AC is the single most important factor in predicting the macrosomia. [1]
Oral glucose tolerance test [3] Gestational diabetes is a well known contributory factor for the macrosomia. Mothers are screened during the antenatal period at around 16-18 weeks of period of gestation for the gestational diabetes mellitus and even earlier in mothers with risk factors for the diabetes like past history of gestational or chronic diabetes, family history of diabetes, obesity and past history of macrosomic babies. Oral glucose tolerance test is the diagnostic method for gestational diabetes. Blood glucose is checked after period of fasting and then after 75 mg of glucose load. Fasting should be less than 92 mg/dl and 1 hour and 2 hour glucose concentration should be less than 180 and 153 mg/dl respectively. [2]
References
  1. CHAABANE K, TRIGUI K, LOUATI D, KEBAILI S, GASSARA H, DAMMAK A, AMOURI H, GUERMAZI M. Antenatal macrosomia prediction using sonographic fetal abdominal circumference in South Tunisia Pan Afr Med J [online] :111 [viewed 26 July 2014] Available from: doi:10.11604/pamj.2013.14.111.1979
  2. KARAGIANNIS T, BEKIARI E, MANOLOPOULOS K, PALETAS K, TSAPAS A. Gestational diabetes mellitus: why screen and how to diagnose Hippokratia [online] 2010, 14(3):151-154 [viewed 26 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943351
  3. BALAJI V, BALAJI M, ANJALAKSHI C, CYNTHIA A, ARTHI T, SESHIAH V. Diagnosis of gestational diabetes mellitus in Asian-Indian women Indian J Endocrinol Metab [online] 2011, 15(3):187-190 [viewed 10 September 2014] Available from: doi:10.4103/2230-8210.83403

Investigations - Fitness for Management

Fact Explanation
Ultrasound scan with doppler studies [1] Blood flow velocity waveforms are recorded from the umbilical arteries, the middle cerebral artery, and the descending thoracic aorta. Resistance index and pulsatility index is also measured. Absent or reverse end-diastolic flow in the umbilical artery is an indicator of fetal compromise. [1] Doppler studies are repeated at intervals not less than 2 weeks.
Cardiactocography (CTG) [3] Is done when there it is suspicious about fetus with deteriorating status (e.g. ongoing fetal hypoxia). [2] Absence of accelerations, presence of decelerations, and reduced variability are found in fetal distress.
References
  1. HECHER K., CAMPBELL S., DOYLE P., HARRINGTON K., NICOLAIDES K.. Assessment of Fetal Compromise by Doppler Ultrasound Investigation of the Fetal Circulation : Arterial, Intracardiac, and Venous Blood Flow Velocity Studies. Circulation [online] 1995 January, 91(1):129-138 [viewed 26 July 2014] Available from: doi:10.1161/​01.CIR.91.1.129
  2. CHUDáčEK V, SPILKA J, BURšA M, JANKů P, HRUBAN L, HUPTYCH M, LHOTSKá L. Open access intrapartum CTG database BMC Pregnancy Childbirth [online] :16 [viewed 10 September 2014] Available from: doi:10.1186/1471-2393-14-16
  3. HEINTZ E, BRODTKORB TH, NELSON N, LEVIN LÅ. The long-term cost-effectiveness of fetal monitoring during labour: a comparison of cardiotocography complemented with ST analysis versus cardiotocography alone BJOG [online] 2008 Dec, 115(13):1676-1687 [viewed 10 September 2014] Available from: doi:10.1111/j.1471-0528.2008.01935.x

Investigations - Followup

Fact Explanation
Ultrasound scan [2] Abdominal circumference needs to be monitored by plotting on a chart in suspected macrosomic fetus. [2]
Random blood sugar monitoring of the baby of a diabetic mother [3] Infants of diabetic mothers are shot of glucose supply after delivery and due to the hyperinsulinemia they can develop hypoglycaemia. [1] They need frequent monitoring of blood glucose level after delivery in order to avoid complications such as convulsions and neuroglycopenia with brain damage.
References
  1. KARAGIANNIS T, BEKIARI E, MANOLOPOULOS K, PALETAS K, TSAPAS A. Gestational diabetes mellitus: why screen and how to diagnose Hippokratia [online] 2010, 14(3):151-154 [viewed 26 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943351
  2. CHAABANE K, TRIGUI K, LOUATI D, KEBAILI S, GASSARA H, DAMMAK A, AMOURI H, GUERMAZI M. Antenatal macrosomia prediction using sonographic fetal abdominal circumference in South Tunisia Pan Afr Med J [online] :111 [viewed 26 July 2014] Available from: doi:10.11604/pamj.2013.14.111.1979
  3. GILMARTIN A“, URAL SH, REPKE JT. Gestational Diabetes Mellitus Rev Obstet Gynecol [online] 2008, 1(3):129-134 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582643

Investigations - Screening/Staging

Fact Explanation
Ultrasound scan-anomaly scan [2] Fetus of the diabetic mother is vulnerable congenital anomalies such as cardiac lesions(ventricular and atrial septal defects), sacral agenesis, micro colon, GUT atresia etc. Therefore anomaly scan is of great importance in suspected macrosomic fetus. [2]
Bilirubin levels of the baby [1] Due to the hyperbilirubinemia due to the break down of excess red blood cells. [1]
Screen for diabetes [3] :HbA1c Maternal HbA1c greater than 7% is associated with increased risk of fetal malformations. [2]
References
  1. KARAGIANNIS T, BEKIARI E, MANOLOPOULOS K, PALETAS K, TSAPAS A. Gestational diabetes mellitus: why screen and how to diagnose Hippokratia [online] 2010, 14(3):151-154 [viewed 26 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943351
  2. ZECK W, SCHLEMBACH D, PANZITT T, LANG U, MCINTYRE D. Management of Diabetes in Pregnancy: Comparison of Guidelines with Current Practice at Austrian and Australian Obstetric Center Croat Med J [online] 2007 Dec, 48(6):831-841 [viewed 26 July 2014] Available from: doi:10.3325/cmj.2007.6.831
  3. GILMARTIN A“, URAL SH, REPKE JT. Gestational Diabetes Mellitus Rev Obstet Gynecol [online] 2008, 1(3):129-134 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582643

Management - General Measures

Fact Explanation
Management of gestational diabetes [4] Dietary modifications and physical exercise in recommended amounts are important. [1]
Antenatal follow up [3] During the antenatal period, monthly follow up is adequate if there are no complications. Antenatal determination of fetal weight [5] is one important method to suspect the featal macrosomia and improve the outcome during the labour. If there is uncontrolled diabetes more frequent visits are needed.
Insulin treatment [4] Insulin is started in gestational diabetes where capillary blood glucose levels exceed 105 mg per dL (5.8 mmol per L) in the fasting state and 120 mg per dL (6.7 mmol per L) two hours after meals. Oral hypoglycemics are usually not used except metformin. Metformin acts by by suppressing hepatic glucose output, increasing insulin sensitivity and enhancing peripheral glucose uptake. [4]
Postpartum follow up [2] Women with GDM are at a greater risk of risk for subsequent type 2 diabetes, [1] and they need to be checked their sugar levels at least upto 12 weeks and then at regular intervals. If the postpartum test is normal, they should be advised for get checked every three years and at first prenatal visit in subsequent pregnancy.
References
  1. GABBE SG, LANDON M, WARREN-BOULTON E, FRADKIN J. Promoting Health After Gestational Diabetes: A National Diabetes Education Program Call to Action Obstet Gynecol [online] 2012 Jan, 119(1):171-176 [viewed 26 July 2014] Available from: doi:10.1097/AOG.0b013e3182393208
  2. MOHAMMADBEIGI A, FARHADIFAR F, SOUFI ZADEH N, MOHAMMADSALEHI N, REZAIEE M, AGHAEI M. Fetal Macrosomia: Risk Factors, Maternal, and Perinatal Outcome Ann Med Health Sci Res [online] 2013, 3(4):546-550 [viewed 26 July 2014] Available from: doi:10.4103/2141-9248.122098
  3. CHAABANE K, TRIGUI K, LOUATI D, KEBAILI S, GASSARA H, DAMMAK A, AMOURI H, GUERMAZI M. Antenatal macrosomia prediction using sonographic fetal abdominal circumference in South Tunisia Pan Afr Med J [online] :111 [viewed 26 July 2014] Available from: doi:10.11604/pamj.2013.14.111.1979
  4. GUI J, LIU Q, FENG L. Metformin vs Insulin in the Management of Gestational Diabetes: A Meta-Analysis PLoS One [online] , 8(5):e64585 [viewed 10 September 2014] Available from: doi:10.1371/journal.pone.0064585
  5. ALSAMMANI MA, AHMED SR. Fetal and Maternal Outcomes in Pregnancies Complicated with Fetal Macrosomia N Am J Med Sci [online] 2012 Jun, 4(6):283-286 [viewed 12 September 2014] Available from: doi:10.4103/1947-2714.97212

Management - Specific Treatments

Fact Explanation
Normal vaginal delivery [1] Special attention is needed in macrosomic babies as there are risks of birth trauma, shoulder dystosia, brachial plexus injuries and even fetal death. [1] Experienced persons should attend the delivery. First stage and second stage has to be monitored to detect complications such as poor progression of labour. Partogram has to be carefully maintained to detect poor progression. Vaginal birth after cesarean section (VBAC) is less likely to succeed if the baby is macrosomic. [1,3]
Induction of labour [1] Induction of labour at a given gestational age will reduce the risk of caesarean delivery compared with expectant management. During the expectant management, there can be 200 g fetal weight gain per week of gestation which is unable to handle with the poor placental supply. Induction is associated with decreased risk of caesarean delivery. [1] If there are no complications induction can be aimed at 40 weeks of period of gestation.
Elective cesarean section [3] Elective cesarean section can be used for the suspected cases of macrosomia, where there is a risk of poor progression. Specially if there is a past obstetric history of repeated cesarean section, the chance of getting successful vaginal birth after cesarean section is less if the baby is macrosomic. [5] One study has shown that more than 70% of the shoulder dystocia are preventable if the rate of CS is increased by 2.6%. [4]
Neonatal care [2] Neonate of a diabetic mother is particularly vulnerable for complications such as neonatal hypoglycaemia, [2] seizures, jaundice etc. If needed baby has to be admitted to special care baby unit for further management.
Management of neonatal hypoglycaemia [2] During fetal life, glucose passively diffuses across the placenta, by a concentration gradient, but not the insulin. After delivery though there is no glucose transfer baby tends to secrete insulin independently. This insulin may lower the blood sugar in the baby. Repeated blood sugar monitoring should be done inorder to detect hypoglycaemia at an early stage. Prevention of poor neurodevelopmental outcomes and to encourage normal feeding behaviors are the aims of management. [2] Serum glucose less than 50 mg/dL is defined as hypoglycaemia. 2 mL/kg to 3 mL/kg (200−300 mg/kg) intravenous bolus of 10% dextrose is given to correct the low bood glucose and glucose infusion rates for full-term infants are 4 to 6 mg/kg/min, for premature infants may be 6 to 8 mg/kg/min. [2] Glucagon and glucocorticoids, octreotide which is a long-acting somatostatin analogue and diazoxide are the other modes of treatment.
References
  1. CHENG Y, SPARKS T, LAROS R JR, NICHOLSON J, CAUGHEY A. Impending macrosomia: will induction of labour modify the risk of caesarean delivery? BJOG [online] 2012 Mar, 119(4):402-409 [viewed 26 July 2014] Available from: doi:10.1111/j.1471-0528.2011.03248.x
  2. MOHAMMADBEIGI A, FARHADIFAR F, SOUFI ZADEH N, MOHAMMADSALEHI N, REZAIEE M, AGHAEI M. Fetal Macrosomia: Risk Factors, Maternal, and Perinatal Outcome Ann Med Health Sci Res [online] 2013, 3(4):546-550 [viewed 26 July 2014] Available from: doi:10.4103/2141-9248.122098
  3. PATEL RM, JAIN L. Delivery after previous cesarean: Short-term perinatal outcomes Semin Perinatol [online] 2010 Aug, 34(4):272-280 [viewed 10 September 2014] Available from: doi:10.1053/j.semperi.2010.03.007
  4. ALSAMMANI MA, AHMED SR. Fetal and Maternal Outcomes in Pregnancies Complicated with Fetal Macrosomia N Am J Med Sci [online] 2012 Jun, 4(6):283-286 [viewed 12 September 2014] Available from: doi:10.4103/1947-2714.97212
  5. BALACHANDRAN L, VASWANI PR, MOGOTLANE R. Pregnancy Outcome in Women with Previous One Cesarean Section J Clin Diagn Res [online] 2014 Feb, 8(2):99-102 [viewed 12 September 2014] Available from: doi:10.7860/JCDR/2014/7774.4019