Article

Risk Factors for macrosomia and its clinical consequences: A study of 350,311 pregnancies

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Abstract

To identify demographic risk factors for either birthweight >4kg or over the 90th centile and to quantify the obstetric risks. Data from 350,311 completed singleton pregnancies in the North West Thames Region between 1988 and 1997 were analysed using logistic regression. Predisposing factors and pregnancy outcome were compared by birthweight 2.5-4kg (n=259,902) and >4kg (n=36,462) and 10th-90th centile (n=279,780) and >90th centile (n=34,937). Macrosomia defined as birthweight >90th centile was more likely in women whose BMI >30 (kg/m(2)) (odds ratio (OR) 2.08; confidence intervals (CI) 1.99, 2.17), parity >4 (OR 2.20; CI 2.02, 2.40), age >40 (OR 1.22; CI 1.11, 1.35) and in women with pre-existing diabetes (OR 6.97; CI 5.36, 8.16) or who developed gestational diabetes (OR 2.77; CI 2.51, 3.07). Macrosomia defined by birthweight >4kg was better than birthweight >90th centile at predicting morbidity and was associated with a prolonged first and second stage of labour (OR 1.57; CI 1.51, 1.63) and (OR 2.03; CI 1.88, 2.19), respectively, an increased risk of instrumental vaginal delivery (OR 1.76; CI 1.68, 1.85), third degree perineal trauma (OR 2.73; CI 2.30, 3.23), emergency caesarean section (OR 1.84; CI 1.75, 1.93), postpartum haemorrhage (OR 2.01; CI 1.93, 2.10), Apgar score <4 (OR 1.35; CI 1.03, 1.76), and admission to the special care baby unit (OR 1.51; CI 21.38, 1.68). Macrosomia is more common in mothers who are obese, older or diabetic and is associated with significant obstetric morbidity.

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... Both conditions are associated with numerous maternalfetal complications during the pregnancy period, as well as due to the adverse effect of the intrauterine environment lead to an increased morbidity in adulthood (Araujo J unior, Peixoto, Zamarian, Elito J unior, & Tonni, 2017;Suhag & Berghella, 2013). With regard to excessive fetal growth, researchers have identified maternal obesity and diabetes as the key risk factors (Boulet et al., 2003;Jolly, Sebire, Harris, Regan, & Robinson, 2003;Li et al., 2014). During the perinatal period, fetal macrosomia is responsible for an increased rate of Cesarean sections and birth trauma, as well as e based on the results of cohort studies e constitutes a significant risk factor for the development of metabolic syndrome in childhood and adult life (Boney, Verma, Tucker, & Vohr, 2005;Boulet et al., 2003;Jolly et al., 2003). ...
... With regard to excessive fetal growth, researchers have identified maternal obesity and diabetes as the key risk factors (Boulet et al., 2003;Jolly, Sebire, Harris, Regan, & Robinson, 2003;Li et al., 2014). During the perinatal period, fetal macrosomia is responsible for an increased rate of Cesarean sections and birth trauma, as well as e based on the results of cohort studies e constitutes a significant risk factor for the development of metabolic syndrome in childhood and adult life (Boney, Verma, Tucker, & Vohr, 2005;Boulet et al., 2003;Jolly et al., 2003). The etiology of FGR is more complex and multifactorial. ...
... As mentioned in the introduction, both obesity and diabetes are known risk factors of fetal macrosomia (Boulet et al., 2003;Jolly et al., 2003;Li et al., 2014). Previous studies in obese patients who delivered macrosomic fetuses demonstrated a significant reduction or increase of GLUT-1 Table 2 Placental expression of glucose transporter proteins in human pregnancies complicated by fetal growth disorders. ...
Chapter
During pregnancy fetal growth disorders, including fetal macrosomia and fetal growth restriction (FGR) are associated with numerous maternal-fetal complications, as well as due to the adverse effect of the intrauterine environment lead to an increased morbidity in adult life. Accumulating evidence suggests that occurrence of fetal macrosomia or FGR, may be associated with alterations in the transfer of nutrients across the placenta, in particular of glucose. The placental expression and activity of specific GLUT transporters are the main regulatory factors in the process of maternal-fetal glucose exchange.This review article summarizes the results of previous studies on the expression of GLUT transporters in the placenta, concentrating on human pregnancies complicated by intrauterine fetal growth disorders. Characteristics of each transporter proteinfound in the placenta is presented, alterations in the location and expression of GLUT isoforms observed in individual placental compartments are described, and the factors regulating the expression of selected GLUT proteins are examined. Based on the above data, the potential function of each GLUT isoform in the maternal-fetal glucose transfer is determined. Further on, a detailed analysis of changes in the expression of glucose transporters in pregnancies complicated by fetal growth disorders is given, and significance of these modifications for the pathogenesis of fetal macrosomia and FGR is discussed. In the final part novel interventional approaches that might reduce the risk associated with abnormalities of intrauterine fetal growth through modifications of placental GLUT-mediated glucose transfer are explored.
... Low-birth weight (LBW, <2500 g) and macrosomia (>4000 g) increase the risk of morbidity and mortality [2,3]. LBW babies are at greater risk for chronic lung disease, cerebral palsy, deafness, epilepsy, learning disabilities and attention deficit disorders [4][5][6], while macrosomic babies are at greater risk for shoulder dystocia, clavicular fracture, instrumented vaginal delivery, emergency caesarean section and neonatal hypoglycemia [7][8][9]. Birthweight has been linked to different pregnancy-related variables, such as excessive maternal weight gain during pregnancy and gestational diabetes (GDM) both of which trigger increased fetal growth [8]. Also, pre-existing maternal conditions, such as a pre-pregnancy body mass index (BMI) >30, parity >4 and advanced age (>40) contribute to higher infant birthweight [8,10,11]. ...
... LBW babies are at greater risk for chronic lung disease, cerebral palsy, deafness, epilepsy, learning disabilities and attention deficit disorders [4][5][6], while macrosomic babies are at greater risk for shoulder dystocia, clavicular fracture, instrumented vaginal delivery, emergency caesarean section and neonatal hypoglycemia [7][8][9]. Birthweight has been linked to different pregnancy-related variables, such as excessive maternal weight gain during pregnancy and gestational diabetes (GDM) both of which trigger increased fetal growth [8]. Also, pre-existing maternal conditions, such as a pre-pregnancy body mass index (BMI) >30, parity >4 and advanced age (>40) contribute to higher infant birthweight [8,10,11]. ...
... Birthweight has been linked to different pregnancy-related variables, such as excessive maternal weight gain during pregnancy and gestational diabetes (GDM) both of which trigger increased fetal growth [8]. Also, pre-existing maternal conditions, such as a pre-pregnancy body mass index (BMI) >30, parity >4 and advanced age (>40) contribute to higher infant birthweight [8,10,11]. In contrast, LBW is more common in infants from low socioeconomic backgrounds, as well as when mothers present chronic hypertension or nephropathy, or tobacco, alcohol or drug consumption [12]. ...
Article
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Birthweight is an important predictor of newborn health and has been linked to maternal psychological stress during pregnancy. However, it is unclear whether prenatal stress affects birthweight similarly for both male and female infants. We used a well-established pregnancy cohort to investigate the impact of high maternal psychological stress during pregnancy on birthweight as a function of infant sex. Overall, 5702 mother-newborn pairs were analysed. Of these, 198 mothers reported high levels of stress using the Psychological Stress Measure (nine-items version; PSM-9). Maternal psychological stress was assessed between the 24 th and 28 th week of gestation and analyses were performed jointly and independently as a function of neonatal sex (separate analyses for male and female infants). Newborns exposed to high maternal psychological stress during pregnancy (a score above 26 measured using the PSM-9 questionnaire, corresponding to >97.5 th percentile) were compared to newborns of mothers who reported lower stress. ANCOVAs revealed that high levels of maternal stress during pregnancy were linked to infant birthweight as a function of infant sex. Male infants of mothers who reported high levels of stress had a greater birthweight whereas female infants had a lower birthweight under the same conditions, in comparison to mothers who did not report greater levels of stress. Although the effect size is small, these results underline the possibility that male and female fetuses may use different strategies when adapting to maternal adversity and highlight the need to consider infant sex as a moderator of the association between maternal psychological stress during pregnancy and infant birthweight.
... Macrosomia is associated with adverse perinatal outcomes (e.g., shoulder dystocia, brachial plexus injury and low APGAR scores) and maternal morbidity (e.g., post-partum haemorrhage, caesarean section and obstetric anal sphincter injury) (Beta et al., 2019;Boulet et al., 2003;Jolly et al., 2003). Definitions of macrosomia vary between ≥4000 g and ≥4500 g, based on thresholds associated with increased maternal and neonatal complications (Boulet et al., 2003). ...
... However, breastfeeding is not routinely reported as a perinatal health outcome for macrosomic infants. Limited evidence available for the association between macrosomia and breastfeeding (exclusivity and duration) is complex and contradictory with studies suggesting positive (Jolly et al., 2003;Leonard & Rasmussen, 2011), negative (Lande et al., 2005) and no associations (Oddy et al., 2006). To the best of our knowledge, no studies to date have systematically examined whether macrosomic infants are at increased odds of not receiving breast milk or early breastfeeding cessation within 6 months of birth. ...
... Evidence suggests macrosomia is associated with increased risk of diabetes, cardiovascular disease and obesity in childhood and later life (Monasta et al., 2010;Whincup et al., 2008). Sustained, exclusive breastfeeding is recognised to attenuate the risk of such morbidities (Horta et al., 2015;Horta & Victora, 2013;Victora et al., 2016). For macrosomic infants, the risk of obesity and associated morbidities may be attenuated by optimal feeding practices early on. ...
Article
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The health benefits of breastfeeding are well recognised, but breastfeeding rates worldwide remain suboptimal. Breastfeeding outcomes have yet to be explored among women who give birth to macrosomic (birthweight ≥4000 g) infants, a cohort for whom the benefits of breastfeeding may be particularly valuable, offering protection against later‐life morbidity associated with macrosomia. This longitudinal prospective cohort study aimed to identify whether women who give birth to macrosomic infants are at greater risk of breastfeeding non‐initiation or exclusive breastfeeding (EBF) cessation. A total of 328 women in their third trimester were recruited from hospital and community settings and followed to 4 months post‐partum. Women gave birth to 104 macrosomic and 224 non‐macrosomic (<4000 g) infants between 2018 and 2020. Longitudinal logistic regression models calculated odds ratios (ORs) and 95% confidence intervals (CIs) to assess likelihood of EBF at four timepoints post‐partum (birth, 2 weeks, 8 weeks, and 4 months) between women who gave birth to macrosomic and non‐macrosomic infants, adjusted for maternal risk (obesity and/or diabetes), ethnicity and mode of birth. Macrosomic infants were more likely to be exclusively breastfed at birth and 2 weeks post‐partum than non‐macrosomic infants with adjusted OR = 1.94 (95% CI: 0.90, 4.18; p = 0.089) and 2.13 (95% CI: 1.11, 4.06; p = 0.022), respectively. There were no statistically significant associations between macrosomia and EBF at 8 weeks or 4 months post‐partum. Macrosomia may act as a protective factor against early formula‐milk supplementation, increasing the likelihood of EBF in the early post‐partum period, but rates of exclusive breastfeeding continued to decline over the first 4 months post‐partum.
... Fetal growth disorders are major risk factors for adverse pregnancy and later life outcomes [1][2][3][4]. Proxy outcomes for disorders of fetal growth include small for gestational age (SGA, �10th percentile) and large for gestational age (LGA, �90th percentile) birth weight. Risk factors for SGA include maternal obstetrical complications, fetal genetic factors, infection, and various medical conditions [5]. ...
... LGA is a less studied outcome despite its increasing incidence in the United States and globally [6,7]. Major risk factors for LGA include maternal obesity, older age, hyperglycemia, and preexisting or gestational diabetes [4]. A large proportion of both SGA and LGA cases have unknown causes [5,8]. ...
Article
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Background: Inflammation during pregnancy is hypothesized to influence fetal growth. Eicosanoids, an important class of lipid mediators derived from polyunsaturated fatty acids, can act as both direct influences and biomarkers of inflammation through a variety of biological pathways. However, quantifying these distinct inflammatory pathways has proven difficult. We aimed to characterize a comprehensive panel of plasma eicosanoids longitudinally across gestation in pregnant women and to determine whether levels differed by infant size at delivery. Methods and findings: Our data come from a case-control study of 90 pregnant women nested within the LIFECODES prospective birth cohort study conducted at Brigham and Women's Hospital in Boston, Massachusetts. This study included 31 women who delivered small for gestational age (SGA) babies (SGA, ≤10th percentile), 28 who delivered large for gestational age (LGA) babies (≥90th percentile), and 31 who delivered appropriate for gestational age (AGA) babies (controls, >10th to <90th percentile). All deliveries occurred between 2010 and 2017. Most participants were in their early 30s (median age: 33 years), of white (60%) or black (20%) race/ethnicity, and of normal pre-pregnancy BMI (median BMI: 23.5 kg/m2). Women provided non-fasting plasma samples during 3 prenatal study visits (at median 11, 25, and 35 weeks gestation) and were analyzed for a panel of eicosanoids. Eicosanoids were grouped by biosynthetic pathway, defined by (1) the fatty acid precursor, including linoleic acid (LA), arachidonic acid (AA), docosahexaenoic acid (DHA), or eicosapentaenoic acid (EPA), and (2) the enzyme group, including cyclooxygenase (COX), lipoxygenase (LOX), or cytochrome P450 (CYP). Additionally, the concentrations of the 4 fatty acids (LA, AA, DHA, and EPA) were measured in maternal plasma. Analytes represent lipids from non-esterified plasma. We examined correlations among eicosanoids and trajectories across pregnancy. Differences in longitudinal concentrations between case groups were examined using Bayesian linear mixed effects models, which included participant-specific random intercepts and penalized splines on gestational age. Results showed maternal plasma levels of eicosanoids and fatty acids generally followed U-shaped curve patterns across gestation. Bayesian models showed that associations between eicosanoids and case status varied by biosynthetic pathway. Eicosanoids derived from AA via the CYP and LOX biosynthetic pathways were positively associated with SGA. The adjusted mean concentration of 12-HETE, a LOX pathway product, was 56.2% higher (95% credible interval 6.6%, 119.1%) among SGA cases compared to AGA controls. Eicosanoid associations with LGA were mostly null, but negative associations were observed with eicosanoids derived from AA by LOX enzymes. The fatty acid precursors had estimated mean concentrations 41%-97% higher among SGA cases and 33%-39% lower among LGA cases compared to controls. Primary limitations of the study included the inability to explore the potential periods of susceptibility of eicosanoids on infant size due to limited sample size, along with the use of infant size at delivery instead of longitudinal ultrasound measures to estimate fetal growth. Conclusions: In this nested case-control study, we found that eicosanoids and fatty acids systematically change in maternal plasma over pregnancy. Eicosanoids from specific inflammation-related pathways were higher in mothers of SGA cases and mostly similar in mothers of LGA cases compared to controls. These findings can provide deeper insight into etiologic mechanisms of abnormal fetal growth outcomes.
... Central adiposity during pregnancy is associated with macrosomic and large for gestational age (LGA) infants, independent of the mother's body mass index (BMI) 12-18 . A macrosomic or LGA infant has a higher risk of complicated delivery 19 , fetal asphyxia 20 , shoulder dystocia 21 , plexus brachialis injury 22 , hypoglycemia 23 , and admission to neonatal intensive care unit 19,24,25 . Being born LGA may also have far-reaching consequences. ...
... The authors describe that this "assumed agreement to contribute personal data to research is part of the informal contract between the individual and the state (…), given that health care is traditionally virtually free of charge (…), and registrybased data are maintained for the purpose of health care quality improvement" 34 . Eligible participants were women undergoing a second-trimester anomaly scan at [16][17][18][19] weeks of gestation at this hospital from January 2015 to December 2017 (n = 12,744), who had their scan performed by a midwife trained in VF and SCF measurements (n = 3027). It was a coincident which pregnant woman who was undergoing a scan that included fat depth measurements, since the personnel booking the second-trimester anomaly scan appointments was not involved in this study. ...
Article
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We sought to investigate whether early mid pregnancy visceral and subcutaneous fat depths measured by ultrasound were associated with infant birth size, independent of early pregnancy BMI. A cohort study was performed at Uppsala University Hospital, Sweden, between 2015–2018. Visceral and subcutaneous fat depths were measured at the early second-trimester anomaly scan in 2498 women, giving birth to singleton, term infants. Primary outcomes were birthweight and LGA (birthweight standard deviation score > 90th percentile in the cohort). Linear and logistic regression models were used, adjusted for BMI, age, smoking, parity, maternal country of birth, gestational age and infant sex. A 5-mm increase in visceral fat depth was associated with an increase in birthweight of 8.3 g [95% confidence interval (CI) 2.5 − 14.1 g], after adjustments, and a 6% increase in the adjusted odds of having an infant born LGA (OR 1.06, CI 1.02–1.11). There was no association between subcutaneous fat depth and birthweight or LGA after covariate adjustments. Hence, visceral fat depth measured by ultrasound in early mid pregnancy was associated with excessive fetal growth, independent of early pregnancy BMI, and may be useful in models for predicting LGA infants.
... Significant selection pressure in recent human evolution is mediated by the spread of infectious diseases due to an increase in the population density, the addition of grain and dairy products to the diet, and changes in the level of oxygen and ultraviolet radiation during human settlement, but these selective factors could have had a more serious effect during pregnancy. This assumption is based on the greater vulnerability of the body of a pregnant woman to the action of various environmental factors due to the extraordinary energy, physical, and immunological costs to meet the needs of the fetus [33][34][35][36][37][38][39][40]. ...
... It is known that the incidence of GDM for modern populations is inversely proportional to the amount of consumed high glycemic carbohydrates and dairy products that are a part of a traditional diet [33,[59][60][61][62][63][64]. Since this pathology contributes to the development of macrosomia in the case of a discrepancy between an oversized fetus and the size of the mother's small pelvis, GDM was one of the causes of perinatal morbidity and mortality before the appearance of cesarean section, and it also often led to massive bleeding during the delivery [39,65]. In this regard, the reduced glycemic response of Europeans to food intake, in comparison with other populations, may be the result of targeted selection to change the metabolism of the maternal organism in accordance with a special diet [33,[62][63][64][65][66][67]. ...
Article
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The review discusses the data on the significant role of pregnancy in adaptive evolution of modern humans. In the aspect of evolutionary medicine, the main attention is paid to preeclampsia (PE), a severe hypertensive pathology of pregnancy. The current evolutionary hypotheses about the origin and causes of racial and ethnic variability in the incidence of this pathology in human populations are summarized. Studies that suggest the contribution of adaptive evolution to the formation of a hereditary predisposition to the development of PE are presented. Our results which first showed the significant role of negative selection in the formation of the genetic architecture of PE via the regulatory single nucleotide polymorphisms of new candidate genes for this pathology are demonstrated.
... Short-term adverse fetal outcomes in infants of obese mothers include increased risk of fetal overgrowth, still birth [40] and neonatal hypoglycemia [41]. Fetal overgrowth is a major contributor to the increased rates of caesarian delivery as well as complications during delivery such as shoulder dystocia [42,43]. Severe neonatal hypoglycemia affects 10-15% of newborns and has been associated with neurodevelopmental sequelae [41]. ...
... Maternal obesity increases the risk of fetal overgrowth, which is associated with poor maternal outcomes including emergency Cesarean section, obstetrical trauma, postpartum hemorrhage and diabetes as well as risks for the infants, such as shoulder dystocia, brachial plexus injury, skeletal injuries, meconium aspiration, perinatal asphyxia, hypoglycemia and fetal death [42,226]. Infants of obese mothers also tend to have increased adiposity [24,227] and/or insulin resistance at birth [73]. ...
Article
Maternal obesity is associated with pregnancy complications and increases the risk for the infant to develop obesity, diabetes and cardiovascular disease later in life. However, the mechanisms linking the maternal obesogenic environment to adverse short- and long-term outcomes remain poorly understood. As compared with pregnant women with normal BMI, women entering pregnancy obese have more pronounced insulin resistance, higher circulating plasma insulin, leptin, IGF-1, lipids and possibly proinflammatory cytokines and lower plasma adiponectin. Importantly, the changes in maternal levels of nutrients, growth factors and hormones in maternal obesity modulate placental function. For example, high insulin, leptin, IGF-1 and low adiponectin in obese pregnant women activate mTOR signaling in the placenta, promoting protein synthesis, mitochondrial function and nutrient transport. These changes are believed to increase fetal nutrient supply and contribute to fetal overgrowth and/or adiposity in offspring, which increases the risk to develop disease later in life. However, the majority of obese women give birth to normal weight infants and these pregnancies are also associated with activation of inflammatory signaling pathways, oxidative stress, decreased oxidative phosphorylation and lipid accumulation in the placenta. Recent bioinformatics approaches have expanded our understanding of how maternal obesity affects the placenta; however, the link between changes in placental function and adverse outcomes in obese women giving birth to normal sized infants is unclear. Interventions that specifically target placental function, such as activation of placental adiponectin receptors, may prevent the transmission of metabolic disease from obese women to the next generation.
... The association between high glucose levels and macrosomia has been widely documented. 1,[13][14][15][16] There is evidence that a direct relationship between maternal blood glucose levels during pregnancy and fetal growth and size at birth exists, even when maternal blood glucose levels are within a normal range. 4 In addition, there is the paradoxic hypothesis proposing that elevated maternal glycemic levels may lead to both macrosomia and intrauterine growth restriction and, consequently, decreased birth weight. ...
... It is well established that high blood glucose levels during pregnancy may lead to an increase in birth weight. 1,14,15,18,25 There is evidence that there is a direct relationship between maternal blood glucose levels during pregnancy and fetal growth and size at birth, even when maternal blood glucose levels are within a normal range. 4 In this context, the results of the present study suggest that a normal glycemic level (<5.6%) in pregnancy does not interfere in the association between periodontitis and LBW. ...
Article
Background: Maternal hyperglycemia, periodontitis, and adverse gestational outcomes are important health problems. The present study investigated the hypothesis that periodontitis and the glycemic level of mothers may have opposing influences on birth weight (BW). This study evaluated the effect of high glycemic levels, albeit within the normal range, on the association between periodontitis and low birth weight (LBW). Methods: 732 women took part in this case-control study; 172 were mothers of children with LBW <2,500g, and 560 were mothers of children with BW ≥2,500g. The BW of newborns was obtained from medical records, and information on socioeconomic-demographic, lifestyle behavior were obtained through interviews. Glycated hemoglobin (HbA1c) levels were evaluated, and full-mouth periodontal examination was carried out within seven days postpartum. Hierarchical and logistic regression analysis evaluated the effect of glycemic levels on the association between periodontitis and LBW by subgroups, estimating Odds Ratios (OR) with 95% confidence intervals (95%CI). Results: In the group with HbA1c levels <5.6%, a statistically significant relationship existed between periodontitis and LBW. Using the Centre for Disease Control/American Academy of Periodontics criteria, the ORadjusted was 1.55; 95%CI: 1.04-2.31; using the Gomes-Filho et al. criteria the ORadjusted was 1.91; 95%CI: 1.06-3.45. In the group with higher HbA1c levels but still within the normal range (≥5.6% and <6.5%), the findings showed no association between periodontitis and LBW. Conclusion: Higher maternal glycemic levels within the normal range, inferior to those indicative of gestational diabetes, diabetes mellitus, or hyperglycemia, and periodontitis have opposing effects on BW, altering the association magnitude. This article is protected by copyright. All rights reserved.
... É esta hiperinsulinemia fetal que leva a maioria dos problemas fetais observados na gravidez diabética, sendo esses coletivamente conhecidos como fetopatia diabética (22). A macrossomia fetal, definida como recém-nascido (RN) com peso superior a 4.000 g, é um dos problemas mais proeminentes da DM na gestação (23). Algumas das suas consequências incluem trauma do nascimento, distorcia de ombro, lacerações perineais e morbidade materna de parto cesáreo (23,24 (27). ...
... A macrossomia fetal, definida como recém-nascido (RN) com peso superior a 4.000 g, é um dos problemas mais proeminentes da DM na gestação (23). Algumas das suas consequências incluem trauma do nascimento, distorcia de ombro, lacerações perineais e morbidade materna de parto cesáreo (23,24 (27). Relatos indicam que o excesso de peso da mulher está relacionado ao parto pré-termo, ao peso do concepto e ao aumento do risco de macrossomia fetal, predispondo a cesariana (28). ...
Article
Sabe-se que o diabetes mellitus durante a gestação está relacionado ao aumento decomplicações materno-fetais e que apesar de ter tido uma redução significativa da suamorbimortalidade materno-infantil nos últimos tempos, ainda há muitas dificuldades comrelação à assistência prestada para este público. Este estudo tem como objetivo avaliar o perfildas gestantes com diabetes mellitus gestacional e com diabetes mellitus tipo 1 e tipo 2, quetiveram o parto realizado em 2018 no Hospital Regional de Sobradinho-DF (HRS-DF), ecorrelacioná-lo com as complicações materno-fetais ocorridas. Trata-se de uma pesquisaretrospectiva e transversal de caráter descritivo. Foram analisados 2142 prontuários degestantes que fizeram o parto no HRS-DF durante o ano de 2018, sendo selecionados 93gestantes que tinham diabetes mellitus prévio ou tiveram diagnóstico de diabetes mellitusgestacional. Também foram avaliados os prontuários do recém-nascidos das 93 gestantesrespectivamente. As complicações maternas aconteceram em 72,4% das gestantes, commaior prevalência nas com diabetes mellitus tipo 1, destacando-se infecção do trato urinário(26,9%) e doença hipertensiva específica da gravidez (25,8%). As complicações fetais eperinatais acometeram 74,7% das gestações, principalmente nas pacientes com diabetesmellitus tipo 1 e naquelas que necessitaram de insulina, sendo as principais complicações:macrossomia (6,8%), prematuridade (20,4%), recém-nascido grande para a idade gestacional(26,9%), icterícia (17,8%), hipoglicemia (11,6%) e sepse (11,6%). Os achados do estudo estão em consonância com a literatura, visto a alta morbidade materna, fetal e perinatal ligadas ao diabetes mellitus durante a gestação, mostrando-se ser de extrema importância orastreamento precoce e o seguimento adequado das gestantes e dos recém-nascidos para aredução da morbimortalidade materna-infantil.
... Factors that could contribute to intrapartum complications among women with overweight and obesity include ineffective uterine contractility 38,39 and fetal macrosomia 7 . Macrosomic infants are at increased risk of a complicated delivery 40 , shoulder dystocia 41 , fetal asphyxia 42 , and subsequent NICU admission 40,43,44 . ...
... Factors that could contribute to intrapartum complications among women with overweight and obesity include ineffective uterine contractility 38,39 and fetal macrosomia 7 . Macrosomic infants are at increased risk of a complicated delivery 40 , shoulder dystocia 41 , fetal asphyxia 42 , and subsequent NICU admission 40,43,44 . ...
Article
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This study investigated whether maternal central adiposity and body mass index (BMI) were associated with neonatal hypoglycemia and adverse neonatal outcomes. A cohort study was performed at Uppsala University Hospital, Sweden, between 2015 and 2018. Visceral and subcutaneous fat depths were measured by ultrasound at the early second-trimester anomaly scan in 2771 women giving birth to singleton infants. Body mass index was assessed in early pregnancy. Logistic regression models were performed. Adjustments were made for age, BMI (not in model with BMI as exposure), smoking, maternal country of birth, and parity. Outcomes were neonatal hypoglycemia (blood glucose concentration < 2.6 mmol/l), a composite of adverse neonatal outcomes (Apgar < 7 at 5 min of age, or umbilical artery pH ≤ 7.0, or admission to neonatal intensive care unit), and the components of the composite outcome. Visceral and subcutaneous fat depths measured by ultrasound in early mid pregnancy were not associated with any of the outcomes in adjusted analyses. For every unit increase in BMI, the likelihood of neonatal hypoglycemia increased by 5% (aOR 1.05, 95% CI 1.01–1.10), the composite outcome by 5% (aOR 1.05, 95% CI 1.01–1.08), and admission to neonatal intensive care unit by 6% (aOR 1.06, 95% CI 1.02–1.10).
... Außerdem drohen den zu schweren Neugeborenen Atemstörungen oder Asphyxie, eine Hyperbilirubinämie oder eine Mekoniumaspiration. Die Mütter müssen vermehrt mit verzögerten Geburten, operativen vaginalen Entbindungen, einer Uterusatonie und postpartalen Blutungen rechnen (18). Ihr Verletzungsrisiko ist deutlich höher, bei Kindern über 4 000 g ist 5-mal häufiger mit schwerwiegenden Verletzungen des Dammes zu rechnen. ...
Article
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Many experts advocate for lower caesarean section rates. Yet, the cohort of pregnant women has changed and this might be a misleading theoretical goal. Women are older and have havier babies (due to the rising rate of obesity and gestational Diabetes), which make them face more difficulties during delivery. Also, many women with chronic conditions (inborn heart failure, mucoviszidosis, Typ 1 Diabetes, Multiple Slerosis, … ) may wish to have children now, thanks to better treatment. The growing number of assisted reproduction also hightens the rate of perinatal risks. The article also mentions the Morecambe Desaster, where midwives imposed their natural birth-ideology on mothers and Babys - at any costs and whatever it took.
... 7,9,12,19,[21][22][23][24][25][26][27][28][29] Factors such as pregestational body mass index (BMI), weight gain during pregnancy, and pre-existing diabetes mellitus (DM) and gestational diabetes (GDM) are recognized as independent factors for macrosomia. 7,26,[30][31][32] Macrosomia is a growing public health problem in most developing countries and it directly or indirectly contributes to maternal and neonatal morbidity and mortality. 6,7 This is due to the higher prevalence of diabetes and obesity in reproductive-aged women in developing countries. ...
Article
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Background: Macrosomia is defined as a birth weight of newborns ≥4000 grams irrespective of gestational age. It is becoming a burning public health issue in most developing countries and contributes to maternal and newborn complications. Though macrosomia has been increasing in Ethiopia, evidence about its magnitude and associated factors is limited yet. Therefore, this study aimed to assess the prevalence and associated factors of macrosomia among newborns delivered at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. Methods: An institution-based cross-sectional study was carried out from February 23rd to April 23rd, 2020. A total of 491 mothers and their newborns were included in the study. The data were collected by interviewing the mothers and reviewing their charts using a structured questionnaire. The outcome variable was newborn birth weight. Data were entered using Epi-data version 4.6 and analyzed using STATA version 14 software. Bivariable and multivariable binary logistic regression were used to identify the factors associated with macrosomia. Results: The prevalence of macrosomia was 7.54%. Gestational age ≥40 weeks (adjusted odds ratio (AOR) = 4.1 (95% CI = 1.7-9.7)), diabetes mellitus (AOR=5.5 (95% CI = 1.2-25)), previous history of macrosomia (AOR = 3.7 (95% CI = 1.4-10)), and male sex (AOR = 3.4 (95% CI = 1.3-8.7)) were significantly associated with macrosomia. Conclusion: In the current study, the prevalence of macrosomia was relatively high. The study revealed that maternal diabetes mellitus, higher gestational age, history of macrosomia, and male newborns were the predictors of macrosomia. Thus, obstetric caregivers should give attention to early detection and management of mothers with diabetes mellitus, history of macrosomia, and gestational age of ≥40 weeks during pregnancy to prevent macrosomia and its complications.
... Several factors are known to contribute to LBW and macrosomia. LBW is more common in women with lower socioeconomic status (SES), chronic hypertension or nephropathy, and tobacco, alcohol, or drug consumption (Valero de Bernabé et al., 2004), whereas risk factors for macrosomia include mothers with a prepregnancy body mass index (BMI) Ͼ 30, parity Ͼ 4, age Ͼ 40, and preexisting diabetes or gestational diabetes mellitus (Jolly et al., 2003). ...
Article
Objective: The study aimed to evaluate the impact of prenatal maternal stress on birth weight using a large cohort of predominantly White women living in an urban area. Method: Women were recruited between 2005 and 2010. Data collection took place between the 24th and the 28th week of gestation. The Measure of Psychological Stress (MSP-9), a validated tool to assess stress symptoms, was used to collect data on prenatal maternal stress (independent variable). Birth weight (dependent variable) was classified as low birth weight (<2,500 g), normal birth weight (2,500-4,000 g), and macrosomia (>4,000 g). Adjusted odds ratios (aOR) were obtained after performing multivariate logistic regressions adjusted for potential cofounders. At the final stage, 5,721 women were included in analysis. Results: When compared with women experiencing low stress, participants with high stress scores were at increased risk of delivering a newborn with low birth weight before adjustment (OR = 2.06, 95% CI [1.04, 4.09]), but after adjustment, only a nonsignificant trend remained. However, women experiencing intermediate and high levels of stress were at increased risk of delivering a newborn with macrosomia, even after adjustment (aOR = 1.23, [1.02, 1.49]) and (aOR = 1.76, [1.11, 2.77]) compared to those who scored low on the psychological stress scale. Conclusion: Women exposed to high psychological stress during the second trimester (24th to 28th weeks) of pregnancy have a 1.8-fold increased risk for delivering a newborn with macrosomia when compared to women exposed to low psychological stress. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
... We did not find an association between older maternal age and macrosomia. However, we did not consider gestational age at delivery as older maternal women may have delivered at an earlier gestation age decreasing the probability of attaining a >4 kg neonate (77). ...
Article
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Objective: To evaluate the risk of macrosomia in newborns from women with gestational diabetes, pregestational diabetes, overweight, and obesity in Uruguay in 2012, as well as its association with prolonged pregnancy, maternal age, multiparity, and excessive gestational weight gain (EGWG). Methods: We performed a cross-sectional study of 42,663 pregnant women. The risk of macrosomia was studied using logistic regression. Results: Mean maternal age was 26.7 ± 6.8 years. Pregestational overweight and obesity was present in 20.9% and 10.7% of women, respectively. There were 28.1% and 19.8% of women overweight and obese at the end of the pregnancy, respectively. Furthermore, 0.5% had pregestational diabetes and 8.5% were multiparous. Twenty two percent developed gestational diabetes and 44.9% had EGWG. The prevalence of macrosomia was 7.9%, significantly more prevalent in males (10.0% vs. 5.5%, p<0.005). Univariate analysis showed that obesity and overweight pre-pregnancy, obesity and overweight at the end of pregnancy, EGWG, pregestational diabetes, gestational diabetes, multiparity, prolonged pregnancy, and male newborn were strongly associated with macrosomia (p<0.0001). Maternal age >35 years did not increase the risk of macrosomia. After multiple logistic regression macrosomia was more likely in pre-gestational obese women (OR 1.24; CI 1.07-1.44), overweight women at the end of pregnancy (OR 1.66; CI 1.46-1.87), obese women at the end of pregnancy (OR 2.21; CI 1.90-2.58), women with EGWG (OR 1.78; CI 1.59-1.98), pregestational diabetes (OR 1.75; CI 1.15-2.69), gestational diabetes (OR 1.39; CI 1.25-1.53), prolonged pregnancy (OR 2.67; CI 2.28-3.12), multiparity (OR 1.24; CI 1.04-1.48), and male newborn (OR 1.89; CI 1.72-2.08). Conclusion: Maternal overweight, obesity, EGWG, and gestational diabetes are prevalent in Uruguay, increasing the risk of macrosomia. Efforts to implement strategies to decrease the prevalence of overweight and obesity among women of reproductive age are essential to improve maternal and neonatal outcomes.
... Previous studies have shown that prepregnancy BMI, excessive weight gain during pregnancy, and preexisting GDM/DM are independent risk factors for macrosomia. GDM/DM, overweight/obesity and excess gestational weight gain have more metabolic characteristics such as increased insulin resistance, hyperglycemia, and hyperinsulinemia, which play important roles in macrosomia [20][21][22][23] This study found that prepregnancy BMI, weight gain during pregnancy, the proportion of preexisting GDM/DM in the macrosomia group were significantly higher than those in the non-macrosomia group (P < 0.05). The result of multivariate logistic regression showed the risk of macrosomia were significantly and independently associated with prepregnancy overweight /obesity, the history of GDM/DM and weight gain during pregnancy, which was consistent with the above findings. ...
Article
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Background Macrosomia is closely associated with poor maternal and fetal outcome. But there is short of studies on the risk of macrosomia in early pregnancy. The purpose of this study is to establish a nomogram for predicting macrosomia in the first trimester. Methods A case-control study involving 1549 pregnant women was performed. According to the birth weight of newborn, the subjects were divided into macrosomia group and non-macrosomia group. The risk factors for macrosomia in early pregnancy were analyzed by multivariate logistic regression. A nomogram was used to predict the risk of macrosomia. Results The prevalence of macrosomia was 6.13% (95/1549) in our hospital. Multivariate logistic regression analysis showed that prepregnancy overweight (OR: 2.13 95% CI: 1.18–3.83)/obesity (OR: 3.54, 95% CI: 1.56–8.04), multiparity (OR:1.88, 95% CI: 1.16–3.04), the history of macrosomia (OR: 36.97, 95% CI: 19.90–68.67), the history of GDM/DM (OR: 2.29, 95% CI: 1.31–3.98), the high levels of HbA1c (OR: 1.76, 95% CI: 1.00–3.10) and TC (OR: 1.36, 95% CI: 1.00–1.84) in the first trimester were the risk factors of macrosomia. The area under ROC (the receiver operating characteristic) curve of the nomogram model was 0.807 (95% CI: 0.755–0.859). The sensitivity and specificity of the model were 0.716 and 0.777, respectively. Conclusion The nomogram model provides an effective mothed for clinicians to predict macrosomia in the first trimester.
... Maternal obesity, independent of gestational diabetes mellitus (GDM), is associated with excessive fetal growth [3,4]. Fetal macrosomia and large for gestational age (LGA) at birth increase risk of delivery complications and also serve as predictors of childhood overweight and obesity later in life [5][6][7]. ...
Article
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One potential mechanism by which maternal obesity impacts fetal growth is through hyperglycemia below the threshold for gestational diabetes. Data regarding which measures of maternal glucose metabolism mediate this association is sparse. The objectives of this study were to (i) quantify the associations of maternal pre-pregnancy body mass index (BMI) with neonatal size and adiposity and (ii) examine the role of markers of maternal glucose metabolism as mediators in these associations. This is a secondary analysis of 6,379 mother-infant dyads from the Hyperglycemia and Adverse Pregnancy Outcome cohort. Markers of glucose metabolism, including plasma glucose and c-peptide values, Stumvoll first-phase estimate, modified Matsuda index, and oral disposition index were measured and calculated from an oral glucose tolerance test (OGTT) between 24- and 32-weeks’ gestation. We calculated the direct effect of maternal BMI category, measured at the time of the OGTT and regressed to estimate pre-pregnancy BMI, on neonatal (1) birth weight (BW), (2) fat mass (FM), (3) % body fat (BF%), and (4) sum of skinfold thickness (sSFT). We then calculated the indirect effect of BMI category on these measures through markers of glucose metabolism. Maternal BMI category was positively associated with neonatal BW, FM, BF%, and sSFT. Additionally, mothers who were overweight or obese had higher odds of delivering an infant with BW, FM, BF%, or sSFT >90th percentile. Fasting glucose and c-peptide values were the strongest mediators in the linear associations between maternal BMI category and neonatal size and adiposity. Maternal overweight and obesity were associated with higher odds of neonatal BW and adiposity >90th percentile. Fasting measures of glucose metabolism were the strongest mediators of these associations, suggesting that future studies should investigate whether incorporation of these markers in pregnant women with obesity may improve prediction of neonatal size and adiposity.
... Additionally, various risk factors in pregnancy are related to fetal growth. These factors include maternal smoking, maternal body mass index (BMI), gestational diabetes, gestational weight gain, parity, infectious diseases, and fetal diseases [12,13]. The extent to which birthweight charts take these risk factors into account differs substantially. ...
Article
Objective: To assess the association between maternal height and birthweight in a healthy population and to study the effect of maternal height on the classification of birthweight as small for gestational age (SGA) and large for gestational age (LGA). Methods: A descriptive, observational retrospective study was conducted in a low risk population in the Netherlands. The study included term singleton healthy nonsmoking pregnant women with normal body mass index (n = 9291). We calculated the impact of maternal height on birthweight using multiple linear regression analyses with adjustment for gestational age, gender, and parity. We calculated the number of newborns classified as SGA and LGA using the cutoff point of the Dutch Birthweight chart, which does not customize for maternal height. Subsequently, we calculated the changes in classification from SGA and LGA to appropriate for gestational age (AGA) in case of customization for maternal height. Results: A significant association was found between maternal height and birthweight; 15.0 g higher birthweight per extra cm maternal height (95% confidence interval 13.8-16.1; p<.001; R2 model = 0.28). The incidence of SGA was 7.1% (range 17.4-2.0% form shortest to tallest maternal height category) and of LGA 8.4% (range 1.9-21.5% from shortest to tallest maternal height category). We calculated a shift in classification: 114 newborns (17.3%) in shorter (<167 cm) women previously SGA and 165 newborns (21.1%) in taller (>173 cm) women previously LGA were classified as AGA when controlling for maternal height. Conclusions: Maternal height is significantly associated with birthweight. Birthweight charts customized for maternal height change classification in one out of six SGA or LGA newborns at term.
... The unborn child has a higher risk of complications, inluding premature delivery, miscarriage, macrosomia and intrauterine growth retardation. 46 The adverse intrauterine environment caused by GDM may result in epigenetic changes, making future generations more prone to metabolic diseases in later life. That is, children born to women with GDM have a higher risk of developing type 2 diabetes, obesity, cardiovascular disease, and metabolic syndrome in late childhood and adulthood. ...
Article
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Wenshu Yu,1 Na Wu,1 Ling Li,1 Hong OuYang,1 Meichen Qian,1 Haitao Shen2 1Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang, People’ s Republic of China; 2Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang, People’s Republic of ChinaCorrespondence: Na WuDepartment of Endocrinology, Shengjing Hospital of China Medical University, 36 Sanhao Road, Heping District, Shenyang, Liaoning Province 110004, People’ s Republic of ChinaTel +86 18940258445Email 3441535223@qq.comAbstract: Gestational diabetes mellitus (GDM) is associated with many adverse obstetric outcomes and neonatal outcomes, including preeclampsia, Cesarean section, and macrosomia. Active screening and early diabetes control can reduce the occurrence of adverse outcomes. Glycosylated hemoglobin (HbA1c) only reflects average blood glucose levels, but not glycemic variability (GV). Studies have shown that GV can cause a series of adverse reactions, and good control of GV can reduce the incidence of adverse pregnancy outcomes in patients with GDM. In order to provide clinicians with a better basis for diagnosis and treatment, this study reviewed the measurement, evaluation, and control of GV, the importance of GV for patients with GDM, and correlations between GV and maternal and neonatal outcomes.Keywords: gestational diabetes mellitus, glycemic variability, outcomes, self-monitoring of blood glucose, continuous glucose monitoring
... In China, it was reported that the prevalence of macrosomia increased from 6.0% in 1994 to 7.8% in 2005 [9]. A variety of factors have been reported to be associated with an increased risk of macrosomia, such as gestational diabetes mellitus (GDM), older maternal age, excessive gestational weight gain, and male fetal sex [10][11][12], and the prevalence of diabetes and obesity in women of reproductive age has been thought to be more important factors [13,14]. ...
Article
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Objective: To investigate the associations between late-gestational dyslipidemia, expressed as the ratio between triglycerides (TGs) and high-density lipoprotein cholesterol (HDL), and the risk of macrosomia among nondiabetic pregnant women. Methods: In this case-control study, 171 pregnant women who delivered macrosomia newborns were recruited from a total of 1856 nondiabetic pregnant women who delivered a singleton, nonanomalous newborn. A total of 684 normal controls were one-to-four matched by age. Logistic regression analysis was used to analyze the association between the TG/HDL ratio and the neonatal body weight as well as the risk of macrosomia. Results: The maternal serum TG and TG/HDL levels were much higher in the macrosomia group, while the maternal serum HDL-C levels were much lower in the macrosomia group than those in the control group. However, the serum total cholesterol (TC) and LDL-C levels were not significantly different between the two groups. Furthermore, maternal TG/HDL levels were positively associated with neonatal body weight. The confounding factors including maternal age, maternal height, gestational age, maternal body mass index (BMI), FPG, SBP, and neonatal sex were adjusted. A positive association between TG/HDL and neonatal body weight was still found. Moreover, the prevalence of macrosomia increased markedly in a dose-dependent manner as with maternal TG/HDL levels increased. Conclusions: Maternal serum TG/HDL levels at late gestation are positively associated with neonatal body weight and the risk of macrosomia in women without DM. Maintaining maternal lipid levels in an appropriate range is important in the context of fetal overgrowth and primary prevention of macrosomia.
... This study showed a significant association of other factors with macrosomia such as aging, increased parity, obesity, previous history of macrosomia, and family history of DM. Agreement was noticed with a number of studies as (19,20) when they showed that the mean age of mothers who delivered macrosomic babies was significantly higher than that in mothers who delivered normal babies. The higher growth velocity may be because of age-related changes in maternal metabolism. ...
Article
Background: A mother who had abnormal glucose tolerance during pregnancy may lead to delivery of a large baby. Glycosylated hemoglobin concentration might be expected to identify women who had high blood glucose concentration before delivery. The aim of current study was to identify retrospectively gestational diabetes in mothers of large babies. Methods:A prospective case-control study that was conducted in the Department of Obstetrics and Gynecology at Al-Imamine Al-Kadhimein Medical City, Baghdad, Iraq for a period of one year and included 100 women who recently delivered newborns and divided into two groups; Macrosomia group included 50 women who delivered babies weighed 4000gm or more and control group included 50 women who delivered babies weighed less than 4000gm.Women who were known cases of diabetes, blood disorders, delivered a preterm baby, delivered a baby with any congenital malformations, or still birth delivery were excluded from this study. Blood was obtained from all women within 72 hours after delivery to investigate for HbA1c level. A questionnaire was applied to all women to collect the needed information. Results: The prevalence of macrosomia was significantly increased with increasing age, and parity of mothers, gestational age ≥40 weeks, increasing body mass index level, positive history of macrosomia, and positive family history of diabetes. Mean HbA1c was significantly higher in women who delivered macrosomic babies than those who delivered babies with birth weights<4000gm. The cut-off point of HbA1c level was 5.8%, so HbA1c level >5.8% was predictive for macrosomia.Conclusion:HbA1c is a good indicator of unscreened or unobserved glucose intolerance in mothers who delivered a macrosomic baby. Other possible risk factors for macrosomia included aging, increased parity, obesity, previous history of macrosomia, and family history of diabetes. © 2020 Wolters Kluwer Medknow Publications. All rights reserved.
... Fetal macrosomia is a well-documented complication of pregnancy occurring in approximately 9 in 100 births, both in the United States and globally [1,2]. While commonly defined as birth weight greater than 4000 grams, a cut-off of 4500 g may also be observed throughout the literature [3][4][5][6]. Irrespective of this variation, a grading scale has been established to further delineate among macrosomic phenotypes. Infants weighing between 4000g and 4499g are defined as type I, 4500g -4999g are type II, and ≥ 5000g are designated type III [7]. ...
Article
Objective An examination of the synergistic effects of maternal obesity and macrosomia on the risk of stillbirth is lacking. The purpose of this study was to determine the association between fetal macrosomia, maternal obesity, and the risk of stillbirth. Methods This retrospective cross-sectional study used the CDC’s Birth Data and Fetal Death Data files for 2014-2017 [n = 10,043,398‬ total births; including 48,799 stillbirths]. The exposure was fetal macrosomia stratified by obesity subtypes (I-III). The outcome was the risk of stillbirth. We also controlled for potential and known confounding factors in adjusted models. Adjusted Relative Risks (ARR) were estimated with log-binomial regression models. Results The rate of stillbirth was higher among macrosomic infants born to mothers with obesity compared to those without (6.55 vs. 0.54 per 1000 total births). After controlling for confounding, women with obesity types II and III were at increased risk for stillbirth [Obesity II ARR = 2.37 (2.07-2.72); Obesity III ARR = 9.06 (7.61-10.78)] Conclusions for Practice Obesity-related fetal overgrowth is a significant risk factor for stillbirth, especially among women with type II and type III obesity. This finding highlights the need for more effective clinical and public health strategies to address pre-pregnancy obesity and to optimize gestational weight gain.
... [4][5][6] LGA increases the risk of shoulder dystocia and neonatal intensive care unit admission, and maternal risks include higher caesarean section rates, postpartum haemorrhage and third-degree and fourth-degree tears. [7][8][9] Several studies have suggested that prenatal identification of LGA and appropriate management of delivery in suspected LGA infants are effective preventive measures to prevent delivery-related perinatal morbidity. 7 10 Therefore, identifying the causes of LGA and defining strategies to improve the early detection of LGA are important. ...
Article
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Objectives There is no consensus regarding a possible relation between false positive glucose challenge test (GCT) results and large-for-gestational-age (LGA) infants. This study aimed to clarify the association between false positive GCT results and LGA, after adjusting for potential confounding factors, using a large clinical dataset. Design Retrospective cohort study. Setting National Hospital Organisation Kofu National Hospital, which is a community hospital, between January 2012 and August 2019. Participants Japanese women who underwent GCT between 24 and 28 weeks of gestation at the hospital were included. After excluding those with gestational diabetes mellitus, diabetes in pregnancy and multiple pregnancies, subjects were divided into a false positive GCT group (≥140 mg/dL) and a GCT negative group (<140 mg/dL). Methods Obstetric records of patients were examined. The χ ² -test and multivariable logistic regression analysis were used to investigate the association between false positive GCT results and LGA. Primary and secondary outcome measures Incidence of LGA and the association between false positive GCT results and LGA. Results The mean subject age was 31.4±5.5 years, with 43.3% nulliparity (n=974) and 2160 (96.1%) term deliveries. The incidence of LGA was 9.4% (211/2248) and 11.4% (257/2248) of the women had false positive GCT results. False positive GCT results were significantly associated with an increased risk of LGA (OR, 1.51; 95% CI, 1.02 to 2.23), after controlling for maternal age, prepregnancy maternal weight, maternal weight gain during pregnancy and parity. Conclusions It appears that there is a significant association between false positive GCT results and LGA. Additional research is required to confirm these results and to investigate appropriate interventions for women with abnormal screens for gestational diabetes mellitus.
... Fetal macrosomia > 4000 g constitutes frequent complication in pregnancies with concomitant GDM/T1DM and is associated with numerous adverse perinatal outcomes including prolonged labor, cephalopelvic dysproportion, shoulder dystocia, increased risk of Cesarean section, birth injuries, post-partum hemorrhage, low Apgar scores as well as increased neonatal mortality [45,46]. As a consequence preventive measures aimed at the most accurate estimation of the FBW are of particular importance for clinicians deciding on the mode of delivery. ...
Article
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Background: The aim of the study was to evaluate the ultrasound-derived measurements of the fetal soft-tissue, heart, liver and umbilical cord in pregnancies complicated by gestational (GDM) and type 1 diabetes mellitus (T1DM), and further to assess their applicability in the estimation of the fetal birth-weight and prediction of fetal macrosomia. Methods: Measurements were obtained from diet-controlled GDM (GDMG1) (n = 40), insulin-controlled GDM (GDMG2) (n = 40), T1DM (n = 24) and healthy control (n = 40) patients. The following parameters were selected for analysis: fetal sub-scapular fat mass (SSFM), abdominal fat mass (AFM), mid-thigh fat/lean mass (MTFM/MTLM) and inter-ventricular septum (IVS) thicknesses, heart and thorax circumference and area (HeC/HeA; ThC/ThA), liver length (LL), umbilical cord/vein/arteries circumference and area (UmC/UmA; UvC/UvA; UaC/UaA) together with total umbilical vessels (UveA) and Wharton’s jelly area (WjA). Regression models were created in order to assess the contribution of selected parameters to fetal birth-weight (FBW) and risk of fetal macrosomia. Results: Measurements of the fetal SSFM, AFM, MTFM, MTFM/MTLM ratio, HeC, HeA, IVS, LL, UmC, UmA, UaC, UaA, UveA and WjA were significantly increased among patients with GDMG2/T1DM as compared to GDMG1 and/or control groups (p < .05). The regression analysis revealed that maternal height as well as fetal biparietal diameter, abdominal circumference (AC), AFM and LL measurements were independent predictors of the FBW (p < .05). In addition, increase in the fetal AFM, AC and femur length (FL) was associated with a significant risk of fetal macrosomia occurrence (p < .05). The equation developed for the FBW estimation [FBW(g) = − 2254,942 + 17,204 * FL (mm) + 105,531 * AC (cm) + 131,347 * AFM (mm)] provided significantly lower mean absolute percent error than standard formula in the sub-group of women with T1DM (5.7% vs 9.4%, p < .05). Moreover, new equation including AC, FL and AFM parameters yielded sensitivity of 93.8%, specificity 77.7%, positive predictive value 54.5% and negative predictive value of 97.8% in the prediction of fetal macrosomia. Conclusions: Ultrasound measurements of the fetal soft tissue, heart, liver and umbilical cord are significantly increased among women with GDM treated with insulin and T1DM. In addition to standard biometric measurements, parameters, such as AFM, may find application in the management of diabetes‑complicated pregnancies.
... Exceeding the term was observed in 32% of mothers with emacrosomes, which is consistent with most studies. This can be explained by: lack of an early ultrasound for dating the pregnancy, imprecision of the date of the last period and the irregular nature of prenatal consultations [1,5,6]. As for the 25% rate of obesity cases found in our series, it is similar to that observed in the literature [7]. ...
... Constitutional factors of pregnant women like prepregnancy BMI, excessive weight gain during pregnancy, and preexisting GDM/DM, are recognized as independent risk factors for macrosomia. GDM/DM, overweight/obesity and excess gestational weight gain have common metabolic characteristics such as increased insulin resistance, hyperglycemia, and hyperinsulinemia, which play an important role in macrosomia [17][18][19][20] Our study found that prepregnancy BMI, weight gain during pregnancy, the proportion of preexisting GDM/DM in the macrosomia group were signi cantly higher than those in the non-macrosomia group (P < 0.05). The result of multivariate logistic regression showed the risk of macrosomia were signi cantly associated with prepregnancy overweight /obesity, the history of GDM/DM and weight gain during pregnancy, which was consistent with the above ndings. ...
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Objective: This study aimed to establish a nomogram for predicting the risk of macrosomia in early pregnancy. Methods: We performed a prospective cohort study involving 1,549 pregnant women. According to the birth weight of newborn, the subjects were divided into two groups: macrosomia group and non-macrosomia group. Multivariate logistic regression was used to analyze the risk factors for macrosomia. Results: The prevalence of macrosomia was 6.13% (95/1549) in our hospital. Multivariate logistic regression analysis showed the risk factors of macrosomia were prepregnancy overweight (OR: 2.126, 95% CI: 1.181-3.826)/obesity (OR: 3.536, 95% CI: 1.555-8.036), multiparity (OR:1.877, 95% CI: 1.160-3.039), the history of macrosomia (OR: 36.971, 95% CI: 19.903-68.674), the history of GDM/DM (OR: 2.285, 95% CI: 1.314-3.976), the higher levels of HbA1c (OR: 1.763, 95% CI: 1.004-3.097) and TC (OR: 1.360, 95% CI: 1.004-1.842). A nomogram was developed for predicting macrosomia based on maternal factors related to the risk of macrosomia in early pregnancy. The area under the receiver operating characteristic (ROC) curve of the nomogram was 0.807 (95% CI: 0.755–0.859), the sensitivity and specificity of the model were 0.716 and 0.777, respectively. Conclusion: The nomogram model provides an accurate mothed for clinicians to early predict macrosomia.
... Furthermore, studies performed over the past few decades consistently demonstrate an upward trend in the prevalence of both disease entities worldwide 2,4 . One of the main complications of diabetes in pregnancy is fetal macrosomia, occurring in 15-20% and 40-45% of women with GDM and PGDM, respectively, and is associated with an increased risk of birth trauma, asphyxia and emergency cesarean section 3,5 . Available data suggest that one of the factors responsible for the occurrence of diabetic fetal overgrowth might be the alterations in the placental transfer of nutrients including glucose, amino acids and lipids 6 . ...
Article
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Aim The aim of the present study was to evaluate the placental expression of glucose transporters GLUT-1, GLUT-3, GLUT-8 and GLUT-12 in term pregnancies complicated by well-controlled gestational (GDM) and type 1 pregestational diabetes mellitus (PGDM). Materials and Methods A total of 103 placental samples were obtained from patients diagnosed with GDM (n=60), PGDM (n=20) and a non-diabetic control group (n=23). Computer-assisted quantitative morphometry of stained placental sections was performed to determine the expression of selected GLUT proteins. Results Immunohistochemical techniques used for the identification of GLUT-1, GLUT-3, GLUT-8 and GLUT-12 revealed the presence of all glucose transporters in the placental tissue. Morphometric evaluation performed for the vascular density-matched placental samples demonstrated a significant increase in the expression of GLUT-1 protein in patients with PGDM as compared to GDM and control groups (p<.05). With regard to the expression of the other GLUT isoforms, no statistically significant differences were observed between patients from the diabetic and control populations. Positive correlations between fetal birth-weight and the expression of GLUT-1 protein in the PGDM group (rho=.463, p<.05) and GLUT-12 in the control group (rho=.481, p<.05) were noted. Conclusions In term pregnancies complicated by well-controlled GDM/PGDM expression of transporters GLUT-3, GLUT-8 and GLUT-12 in the placenta remains unaffected. Increased expression of GLUT-1 among women with type 1 PGDM may contribute to higher rate of macrosomic fetuses in this population.
... Some foreign studies [16]. A population in the UK showed that the incidence of macrosomia in women between 35 and 39 years increased by 40% relative to women under 35 years old [25]. Our research also showed that the compared with those in the second pregnancy group, the mothers in the first pregnancy group were older and received higher education. ...
Article
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Background After the implementation of the universal two-child policy in China, the increase in parity has led to an increase in adverse pregnancy outcomes. The impact of one and two fetuses on the incidence of fetal macrosomia has not been fully confirmed in China. This study aimed to explore the differences in the incidence of fetal macrosomia in first and second pregnancies in Western China after the implementation of the universal two-child policy. Methods A total of 1598 pregnant women from three hospitals were investigated by means of a cross-sectional study from August 2017 to January 2018. Participants were recruited by convenience and divided into first and second pregnancy groups. These groups included 1094 primiparas and 504 women giving birth to their second child. Univariate and multivariate logistic regression analyses were performed to discuss the differences in the incidence of fetal macrosomia in first and second pregnancies. Results No significant difference was found in the incidence of macrosomia in the first pregnancy group (7.2%) and the second pregnancy group (7.1%). In the second-time pregnant mothers, no significant association was found between the macrosomia of the second child (5.5%) and that of the first child (4.7%). The multivariate logistic regression model showed that mothers older than 30 years are not likely to give birth to children with macrosomia (odds ratio (OR) 0.6, 95% confidence interval (CI) 0.4,0.9). Conclusions The incidence of macrosomia in Western China is might not be affected by the birth of the second child and is not increased by low parity.
... 3 In fact, excessive and low weights of the baby are associated with increased risk of newborn complications during labour, delivery and postpartum. 4,5 In obstetric practice, the decision on the route of delivery of a baby is markedly influenced by the estimated foetal weight in some clinical conditions like intra-partum management of a breech presenting foetus, vaginal birth after Caesarean section and diabetic pregnancy. This emphasises the significance of estimation of foetal weight to the obstetrician. ...
Article
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Background: The weight of the foetus is an important factor to consider when determining the outcome of pregnancy. The birth weight is reliable in predicting perinatal outcome. Excessive and low weights of the baby are associated with increased risk of newborn complications during labour, delivery and postpartum. The objective of the study was to determine the relationship between estimated foetal weight and maternal renal dimensions and volume in normal pregnant women in Bayelsa State, Nigeria. Methods: This prospective, descriptive, cross-sectional study was conducted at the Obstetrics and Gynaecology, and Radiology Departments of the two tertiary hospitals in Bayelsa State, Nigeria, from July to December, 2021. Sonographic assessments of estimated foetal weight and the maternal renal dimensions and volume in 400 consecutive normal pregnant women in both tertiary institutions were done, after obtaining written informed consent from them. Data were entered into a pre-designed proforma, and analysed using Statistical Product and Service Solutions for windows® version 25, (SPSS Inc.; Chicago, USA). Results were presented in frequencies and percentages for categorical variables and mean and standard deviation for continuous variables. Results: A total of 400 pregnant women were scanned. There was a valid relationship between right renal antero- posterior diameter (ɼ = 0.32; p – 0.010), right renal width (ɼ = 0.32; p – 0.007), right renal volume (ɼ = 0.32; p – 0.007) and estimated foetal weight. The left renal width and renal volume showed the same trend as the right parameters with slight differences in values. Conclusions: This study revealed that estimated foetal weight increased with increase in maternal renal volume and dimensions. Keywords : Foetal weight, Renal dimensions, Renal volume, Complications.
... 10 Pregnant people with obesity are at increased risk for gestational hypertension, 11 preeclampsia, 12 gestational diabetes, 11,13 maternal mortality, 14 and are more likely to have caesarean births. 15,16 There are also serious implications for the fetus including risk of stillbirth, 17 macrosomia, 18 and congenital abnormalities. 19 Infants born to people with obesity more often demonstrate fetal distress in labor, meconium aspiration, and low Apgar's scores, 20 and, in future, life as adults with an increased risk of premature death. ...
Article
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Objective This study aimed to identify cardiovascular differences between pregnant people with and without obesity for trimester-specific changes in hemodynamic parameters using noninvasive cardiac output monitoring (NICOM). Study Design This study is a pilot prospective comparative cohort between pregnant people with and without obesity. Hemodynamic assessment was performed with NICOM (12–14, 21–23, and 34–36 weeks) during pregnancy. Results In first trimester, pregnant people with obesity had higher blood pressure, stroke volume (SV), total peripheral resistance index (TPRI), and cardiac output (CO). Pregnant people with obesity continued to have higher SV and cardiac index (second and third trimesters). During the first trimester, body mass index (BMI) positively correlated with SV, TPRI, and CO. Fat mass showed a strong correlation with TPRI. BMI positively correlated with CO during the second trimester and fat mass was positively associated with CO. During the third trimester, TPR negatively correlated with BMI and fat mass. Conclusion Fat mass gain in the period between the first and second trimesters in addition to the hemodynamic changes due to obesity and pregnancy contribute to some degree of left ventricular diastolic dysfunction which was manifested by lower SVs. Future work should investigate the possible causative role of obesity in the cardiovascular changes identified in people with obesity.
... Fetal macrosomia may increase postpartum blood loss via multiple pathways. The most direct mechanism is the distension of uterus due to large fetal size, which causes uterine atony after birth [56]. Studies also showed that fetal macrosomia increased the risk of instrumental delivery and third-degree tear of an episiotomy wound [8,57,58]. ...
Article
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Postpartum hemorrhage (PPH) is a common complication of pregnancy and a global public health concern. Even though PPH risk factors were extensively studied and reported in literature, almost all studies were conducted in non-Asian countries or tertiary care centers. Our study aimed to explore relevant risk factors for PPH among pregnant women who underwent transvaginal delivery at a Thai–Myanmar border community hospital in Northern Thailand. An exploratory nested case-control study was conducted to explore risk factors for PPH. Women who delivered transvaginal births at Maesai hospital from 2014 to 2018 were included. Two PPH definitions were used, which were ≥ 500 mL and 1000 mL of estimated blood loss within 24 h after delivery. Multivariable conditional logistic regression was used to identify significant risk factors for PPH and severe PPH. Of 4774 women with vaginal births, there were 265 (5.55%) PPH cases. Eight factors were identified as independent predictors for PPH and severe PPH: elderly pregnancy, minority groups, nulliparous, previous PPH history, BMI ≥ 35 kg/m2, requiring manual removal of placenta, labor augmentation, and fetal weight > 4000 gm. Apart from clinical factors, particular attention should be given to pregnant women who were minority groups as PPH risk significantly increased in this population.
... Complications that occur and that are widely studied in pregnancies complicated by diabetes include spontaneous abortions/miscarriage, congenital anomalies, and pathological fetal growth [2][3][4][5], as well as maternal outcomes, such as preeclampsia and hypoglycaemia [6]. Large for gestational age (LGA) and/or macrosomic outcomes are one of the most common complications of diabetic pregnancy, which can result in further complications during delivery, such as the requirement for a *Address correspondence to this author at Leeds Institute of Cardiovascular and Metabolic Medicine, LIGHT Laboratories, University of Leeds, LS2 9JT, UK; E-mail: bs14ab@leeds.ac.uk caesarean section and instrumental delivery as well as perinatal complications, including neonatal hypoglycaemia, shoulder dystocia and stillbirth [7,8]. In addition to this, LGA infants are also at increased risk of developing obesity, cardiovascular disease, and diabetes in the future [9][10][11][12][13]. ...
Article
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Background Maternal diabetes mellitus during pregnancy is associated with an increased risk of pregnancy complications for both the mother and the fetus. One of the most prevalent complications is pathological fetal growth, and particularly infants are born large for gestational age (LGA), which leads to problematic deliveries, including the need for caesarean section, instrumental delivery and further perinatal complications. Glucose monitoring during pregnancy is essential for ensuring appropriate glycaemic control and to reduce these associated risks. The current methods of glucose monitoring include measuring glycosylated haemoglobin (HbA1c), self-monitoring of capillary blood glucose (SMBG), and more recently, continuous glucose monitoring (CGM). Observational studies and randomised controlled trials (RCTs) have assessed the appropriate glycaemic targets for HbA1c, SMBG, and CGM in relation to pregnancy outcomes. Objective In this review we identify current international guidelines on glycaemic targets and review the supporting evidence. Method We performed an extensive literature search on glycaemic targets in pregnancies affected by diabetes and we researched international guidelines from recognised societies. Results and Conclusion The majority of studies used to define the glucose targets associated with the best pregnancy outcomes, across all modalities, were in women with type 1 diabetes. There were limited studies in women with type 2 diabetes and gestational diabetes. We therefore suggest that further research needs to be conducted on glucose targets and clinical outcomes specifically in these populations where CGM technology offers the greatest potential for monitoring glucose and improving pregnancy outcomes.
... Importantes investigações apontam para existência de associação causal entre excesso de ganho de peso gestacional e macrossomia, condição em que o peso ao nascer é superior a 4000g (ALVES et al., 2020;JOLLY et al., 2003;MORAIS et al., 2018 ...
... Recently, a meta-analysis involving 350,311 pregnancies revealed that fetal macrosomia was associated with a higher risk of prolonged first and second stage of labor ( 30-3.23), and emergency cesarean section (OR 1.84; 95% CI 1.75-1.93), and these factors were also risk factors for PPH (34). Maternal pre-pregnancy obesity has been found to be positively correlated with large for gestational age (1.88, 95% CI 1.67-2.11) ...
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Background: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide but the incidence and its risk factors in China is limited. The objective of this study is to investigate the incidence and the risk factors of PPH in Chinese women. Methods: A multi-center retrospective study of pregnant women at ≥28 weeks of gestation was conducted. Logistic regression was used to identify potential risk factors of PPH and receiver operating characteristic curve was used to evaluate the predictive performance of the identified risk factors. Subgroup analysis focusing on the number of fetus and the mode of delivery was conducted. Results: A total of 99,253 pregnant women were enrolled and 804 (0.81%) experienced PPH. The subgroup analysis revealed that the incidence of PPH was 0.75, 2.65, 1.40, and 0.31% in singletons, twin pregnancies, cesarean sections, and vaginal deliveries, respectively. Placenta previa and placenta accreta were the predominant risk factors of PPH in the overall population and all subgroups. A twin pregnancy was a risk factor for PPH regardless of the mode of delivery. Obesity, and multiparity were risk factors for PPH in both singletons and cesarean section cases, but the latter predicted a reduced probability of PPH in vaginal deliveries. Macrosomia was associated with increased risk of PPH in singletons or vaginal deliveries. In women who delivered vaginally, preeclampsia was associated with a higher risk of PPH. The areas under the curve for the overall cohort, singletons, twin pregnancies, cesarean section cases, and vaginal deliveries were 0.832 (95% confidence interval [CI] 0.813–0.851), 0.824 (95% CI 0.803–0.845), 0.686 (95% CI 0.617–0.755), 0.854 (95% CI 0.834–0.874), and 0.690 (95% CI 0.646–0.735), respectively. Conclusions: The risk factors of PPH varied slightly based on the number of fetuses and the mode of delivery, while placenta previa and placenta accreta were the two major risk factors. A combination of the identified risk factors yielded a satisfactory predictive performance in determining PPH in the overall cohort, singletons pregnancies, and women who delivered by cesarean section, whereas the performance was moderate in twin pregnancies and in women delivering vaginally.
... [10,11]; high birth weight (LGA-large for gestational age) OR 2.08, 95% CI 1.97-2.17) [12]; perinatal complications (cephalopelvic disproportion, hypoxia/asphyxia, shoulder dystocia, impacted fetus at cesarean section, neonatal injury and neonatal/postneonatal death) [7,[13][14][15][16][17]. For the offspring of obese mothers Whitaker additionally enumerated the relative risk of childhood obesity to be increased by 2.0 (95% CI 1.7-2.3) ...
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Background/objective To investigate the longitudinal development of maternal body weight and analyze the influence of obesity on obstetrics during more than two decades in Germany. Subjects/methods Data collected from the Federal state of Schleswig-Holstein (German Perinatal Survey) were analyzed with regard to the dynamics of maternal anthropometric variables (body weight, BMI) between 1995–7 and 2004–17. In total 335,511 mothers substantiated the presented study-collective. The statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY. Results Maternal BMI advanced significantly over the study period. Among a rise in mean periconceptional body weight (67.6–72.0 kg), the segment of obese women increased disproportionately (in average 9.4–19.2%). Despite the observed trend to late giving birth (mean maternal age 1995: 29.3 vs. 30.7 years in 2017), it was not advanced maternal age but parity that influenced the continuous increase in maternal weight (mean maternal body weight 1995–7: primi- bi-, multiparae 67.4, 68.3 and 69.0 kg vs. 2004–17: primi- bi-, multiparae 70.0, 71.5 and 73.2 kg respectively). Conclusion Obesity is a major problem on health issues in obstetrics. Advancing maternal BMI, increasing mother’s age and derived prenatal risks considerably complicate pregnancy and delivery. It has to be emphasized that its consequences do not end with delivery or childbed, but represent a livelong burden to the mother and their offspring. Hence, multimodal strategies to reduce/control periconceptional body weight are mandatory.
... It is well recognized that large for gestational age infants (LGA), defined as a babies born with a birthweight above the 90th centile for gestational age and gender, have increased risks of adverse short-term perinatal outcomes i.e., induction of labor, instrumental vaginal delivery, caesarean section, shoulder dystocia, and perinatal asphyxia [1][2][3][4]. These neonates also face long-term increased risks of death, hospitalization as well as increased occurrence of obesity, hypertension and type 2 diabetes later in life [5,6]. ...
Article
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Background Large for gestational age infants (LGA) have increased risk of adverse short-term perinatal outcomes. This study aims to develop a multivariable prediction model for the risk of giving birth to a LGA baby, by using biochemical, biophysical, anamnestic, and clinical maternal characteristics available at first trimester. Methods Prospective study that included all singleton pregnancies attending the first trimester aneuploidy screening at the Obstetric Unit of the University Hospital of Modena, in Northern Italy, between June 2018 and December 2019. Results A total of 503 consecutive women were included in the analysis. The final prediction model for LGA, included multiparity (OR = 2.8, 95% CI: 1.6–4.9, p = 0.001), pre-pregnancy BMI (OR = 1.08, 95% CI: 1.03–1.14, p = 0.002) and PAPP-A MoM (OR = 1.43, 95% CI: 1.08–1.90, p = 0.013). The area under the ROC curve was 70.5%, indicating a satisfactory predictive accuracy. The best predictive cut-off for this score was equal to − 1.378, which corresponds to a 20.1% probability of having a LGA infant. By using such a cut-off, the risk of LGA can be predicted in our sample with sensitivity of 55.2% and specificity of 79.0%. Conclusion At first trimester, a model including multiparity, pre-pregnancy BMI and PAPP-A satisfactorily predicted the risk of giving birth to a LGA infant. This promising tool, once applied early in pregnancy, would identify women deserving targeted interventions. Trial registration ClinicalTrials.gov NCT04838431, 09/04/2021.
Article
Objective We aimed to compare pregnancy outcomes in association with placental pathology in pregnancies complicated by macrosomia in diabetic vs. non-diabetic women. Study design Pregnancies complicated by macrosomia (≥4000gr) were included. Pregnancy and delivery characteristics, neonatal outcomes and placental histopathology reports were compared between macrosomia in diabetic [pre-gestational or Gestational Diabetes Mellitus (GDM)] women (diabetic-macrosomia group) vs. non-diabetic women (non-diabetic macrosomia group). Adverse neonatal outcome was defined as ≥1 neonatal complications. Multivariate analysis was used to identify independent associations with adverse neonatal outcome Results The diabetic macrosomia group (n = 160) was characterized by higher maternal age (p = 0.002), Body Mass Index (BMI) (p < 0.001), and smoking (p = 0.03), and lower gestational age at delivery (p = 0.001). The diabetic-macrosomia group had higher rates of scheduled Cesarean deliveries (CDs) (58.9% vs23.7%,p < 0.001) while the non-diabetic macrosomia group (n = 214) had higher rates of emergent CDs (76.3% vs.40.7%,p < 0.001), perineal tears (p = 0.027) and Post Partum Hemorrhage (PPH) (p = 0.006). Placentas from the non-diabetic macrosomia group were characterized by higher rates of maternal and fetal inflammatory response lesions (p < 0.001). Except for higher jaundice rate in the diabetic macrosomia group (p < 0.001), none of the other neonatal outcomes including shoulder dystocia differed between the groups. In multivariate analysis GA < 37 weeks (aOR = 1.4,95%,CI-1.2-3.9), and emergent CDs (aOR = 1.7,95%,CI-1.4-4.1) but not diabetes (aOR = 1.1,95%,CI-0.7-3.9) were associated with adverse neonatal outcome. Conclusions Despite major differences in maternal demographics, mode of delivery, maternal morbidity, and placental characteristics- adverse neonatal outcome did not differ between macrosomia in diabetic vs. non-diabetic women and was high in both groups. Clinicians should be aware of the high rate of adverse neonatal outcome in macrosomic fetuses, even in the absence of diabetes mellitus.
Chapter
Diabetes mellitus during pregnancy may be pregestational (type 1 diabetes mellitus or type 2 diabetes mellitus) or gestational. Obesity and type 2 diabetes mellitus have become escalating global health problems. Obesity is a major risk factor for gestational diabetes mellitus and pregestational type 2 diabetes mellitus. Both diabetes and obesity during pregnancy can lead to adverse maternal and neonatal outcomes and epigenetic changes in the baby that lead to increased disease risk later in life. While the placentas from pregnancies complicated by diabetes and obesity have been extensively studied, currently there are no signature pathological changes reported. The changes described are largely morphological adaptions or alterations to the known hormonal, metabolic, and inflammatory profiles associated with diabetes and obesity.
Article
OBJETIVO: Describir los desenlaces maternos y perinatales en embarazadas de edad avanzada. MATERIALES Y MÉTODOS: Estudio de dos cohortes, prospectivo y retrospectivo efectuado con base en la información de expedientes clínicos de pacientes atendidas en el Complexo Hospitalario Universitario de Ourense entre 2017 y 2018. Se establecieron dos cohortes: la cohorte A con edad mayor o igual a 40 años y la cohorte B con edad menor de 40 años. Se realizaron pruebas paramétricas y no paramétricas para determinar la asociación potencial entre las variables de estudio (χ², t de Student, U de Mann-Whitney). RESULTADOS: Las pacientes de la cohorte A (n = 207) tuvieron significación estadística: índice de masa corporal mayor al inicio del embarazo (p = 0.028), mayor cantidad de embarazos previos (p = 0.001), a expensas de mayor cantidad de abortos (p < 0.001), estados hipertensivos del embarazo (p = 0.03), prematurez (p = 0.009), retraso en el crecimiento intrauterino (p = 0.006), macrosomía fetal (p = 0.04), inducciones (p < 0.001), cesáreas programadas o intraparto y hemorragia posparto (p = 0.001). No se encontraron diferencias en la paridad, amenorrea al parto, diabetes pregestacional-gestacional, peso fetal medio, Apgar, pH de la arteria umbilical y cantidad de recién nacidos con requerimiento de ingreso a la unidad de Neonatología. CONCLUSIONES: La edad materna avanzada es un factor de riesgo importante de morbilidad materna y perinatal. La mayor tasa de complicaciones descritas refleja la importancia del control exhaustivo del embarazo y vigilancia periparto minuciosa.
Article
Resumen Introducción La macrosomía fetal es definida como un peso al nacer igual o mayor de 4.000 g, con una incidencia aproximadamente del 10%. Se ha asociado con múltiples factores de riesgo como la masa corporal previa, diabetes, multiparidad, sexo fetal varón, etcétera. Es una causa importante de morbimortalidad neonatal y materna, y supone un aumento en la tasa de cesáreas. Objetivo Identificar la prevalencia de macrosomía fetal en nuestra área, detectar sus principales factores de riesgo y resultados perinatales. Métodos Se incluyeron 6.221 recién nacidos a término, nacidos en el Hospital Juan Ramón Jiménez, en el curso de los años 2018 y 2019. Se realizó un estudio observacional retrospectivo, tipo caso control. Resultados La incidencia de macrosomía fue de 5,9%. Los principales factores de riesgo asociados con la macrosomía fueron la edad gestacional, el sexo masculino, la multiparidad y la diabetes pregestacional, con resultados estadísticamente significativos. En cuanto a los resultados perinatales; encontramos asociación entre la macrosomía y la vía del parto, el riesgo de cesárea en los macrosomas es mayor (OR 1,62, IC 95% 1,3-2.1; p < 0,0001). Si el inicio del parto es inducido, el riesgo de cesárea se duplica (RR 2,32; IC 95% 1,56-3,38; p < 0,0001). Como complicaciones neonatales se registró un aumento del riesgo de distocia de hombros (OR 11,45; IC 95% 7,1-18,5; p < 0,0001), fractura de clavícula (OR 6,87, IC 95% 1,3-37,4; p = 0,0258), y parálisis braquial (OR 13,74; IC 95% 2,8-67,87; p = 0,0013). Conclusiones Es importante conocer los factores de riesgo de macrosomía para poder identificar a estas gestantes y prevenir las complicaciones asociadas. Actualmente no hay consenso sobre cómo y cuándo finalizar la gestación, la inducción del parto o realizar una cesárea son estrategias parciales, que producen un aumento de cesáreas sin disminución de las complicaciones.
Chapter
The role of early microsurgical reconstruction in total birth palsies cannot be disputed. Surgery inevitably involves comprehensive exploration of the injured area and re-establishment of the brain’s control of the paralysed upper limb by bridging viable proximal stumps of the broken roots to the suitable distal targets. The extent of functional recovery depends largely on the strategy employed during the nerve operation. With increasing confidence in the quality of motor and sensory outcomes and the consistent results obtained with extra-plexal nerve transfers, we can, now, aim at restoring functions of the shoulder, elbow and the hand with the main objective being to maximize hand function. Since the upper limb continues to evolve over 6–8 years, diligent and relentless physical therapy is necessary to help incorporate the regained motor abilities in bimanual activities. The children have to be observed closely to prevent appearance and progression of deformities at the shoulder and elbow. Secondary operations are necessary to augment the range of shoulder motion, to correct forearm deformities and to correct residual deficits of wrist and finger extension. This extended and aggressive approach offers us the possibility of restoring full upper limb function in total palsies instead of merely creating a helping hand.
Chapter
Although the frequency varies widely, the International Diabetes Federation has estimated that diabetes affects one in six births worldwide, with the majority being women who develop gestational diabetes (GDM). This affects especially women with predisposing factors such as polycystic ovary syndrome or a family history of type 2 diabetes. The diagnosis of GDM has consequences for the newborn (e.g., macrosomia and its sequelae), the young child (e.g., obesity and insulin resistance), and the mother (e.g., development of type 2 diabetes and nonalcoholic liver disease in later life). In normal pregnancy, an early period of heightened insulin sensitivity in the mother is followed by insulin resistance in the late second and third trimesters. This insulin resistance ensures an adequate supply of nutrients for fetal growth and development, but GDM ensues if maternal insulin secretion cannot increase to compensate. Endocrine changes increase insulin resistance or reduce insulin secretion through altered secretion and/or action of hormones such as growth hormone, prolactin and placental lactogen, progesterone, cortisol, and kisspeptin. Pregnancy itself creates a mild anti-inflammatory environment which contributes further to insulin insensitivity through alterations in the activity of inflammatory mediators such as leptin, adiponectin, and tumor necrosis factor-α (TNFα). Adaptations in the innate and adaptive immune systems may also contribute. Once GDM develops, this leads to increased availability of glucose and fat, especially triglyceride, for transfer from mother to fetus, which is facilitated by placental adaptations in transporter proteins and through other mechanisms. This nutrient excess coupled with an adaptive insulin response in the fetus typically leads to macrosomia. Similar mechanisms are thought to operate during pregnancy in women with pregestational diabetes, both type 1 and type 2, where an additional hazard in the form of congenital malformations is greatest. Pregnancy in women with pregestational type 2 diabetes has become increasingly common and is now the dominant form in some more prosperous societies. A concerted effort is needed to achieve good control of diabetes during the pre-conception phase to avoid pregnancy complications, proving a major challenge in patient care.
Conference Paper
Modern development of education requires a clear understanding of the most important global changes that directly affect the methods, content, management of education-the formation of the global economy, the global community, the development of intellectual technology. In the context of globalization, the new mission of the education system is to create conditions for achieving greater justice and social stability in society by ensuring equal rights for all citizens, including persons with disabilities, to receive education and access to knowledge. It should be noted that inclusive education in the Republic of Kazakhstan and abroad is developing at different levels: political, scientific, organizational and practical.
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Introduction: Increasing of obesity become endemic problem in childbearing age of women. Therefore, this morbidity frequently found in pregnancy with all of the obesity consequences. Some problems in developing country like Indonesia, especially in our tertiary hospital also experienced burden situation of obesity in pregnancy cases. Aims:To describe obesity in pregnancy cases and analyze obesity status before pregnancy on obstetric outcome of this morbidity Material and methods:Retrospective case control study using medical record on singleton pregnancy complicated with obesity in major East Java tertiary referral hospital in one year. Results:of 1144 deliveries, we revealed 337 cases (29%) of obesity. 246 cases were included and analyzed in this study. Majority of cases were multiparity (72.8%), with age of 31.5±5.6 y.o, BMI of 35.6±4.9 kg/m 2 with 19.5% had morbidly obese status.48% of cases had obesity status before pregnancy. Pre pregnancy obesity status not related to Cesarean Section delivery (P=0.07), the occurrence of preeclampsia (P=0.35), gestational diabetes (P=0.97) and fetal macrosomia (P=0.97). Pre pregnancy obesity status related to higher BMI status at delivery (P<0.001) and morbidly obesity condition (P<0.001; OR 5.96; CI 2.58-13.77) Conclusion:Our study revealed high incidence of obesity during pregnancy. While obesity correlated well with obstetric morbidity, pre pregnancy body mass index status did not associated with obstetric complication in pregnant obesity cases. Higher BMI and morbidly obese pregnancy cases due to pre pregnancy obesity status may contribute to non-significant increase of cesarean section.
Article
Macrosomia results from abnormal fetal growth and can lead to serious consequences for the mother and fetus. In cases of suspected macrosomia, patients must be counseled carefully regarding a delivery plan, and Cesarean section should be considered when indicated. Techniques to assess for suspected macrosomia include clinical measurements, ultrasound, and MRI.
Article
Background and aim Macrosomia is used to describe an infant born with excessively high weight, and it brings lots of unexpected risks in clinical work. Macrosomia causes considerable challenges for both physicians and pregnant women. Our objectives were to identify factors in gravida to be associated with the risk of macrosomia, to guide clinical prevention and treatment. Methods The study assessed risk factors of macrosomia by comparison with normal birth weight neonates, and a case-control study was conducted at Shandong Provincial Maternity and Child Healthcare Hospital. We followed and selected the relevant indicators of gravida who gave birth to macrosomia or normal infants, and applied statistical analysis to identify clinical indicators related to macrosomia. Results Maternal blood glucose (OR 3.88 (1.07, 14.15)), history of abnormal conception (OR 18.44 (1.05, 322.89)), situation of menarche (OR 13.53 (1.28, 142.66)), and menstrual cycle of gravida (OR 13.24 (1.17, 150.24)) were significant influencing factors of macrosomia, but did not appear in the univariate analysis. Adding gestational age at delivery (OR 4.00 (1.45, 11.09)), triglyceride (OR 0.01 (<0.01, 0.40)), and MBI (OR 46.35 (2.08, >99.99)) of pregnant women, the area under the curve (AUC) curve was drawn for forecasting the risk of macrosomia, and the value of AUC was 0.9174. The triglyceride blood index of pregnant women was the only one that was inversely proportional to the probability of giving birth to macrosomic infants. The low-density lipoprotein (LDL) (OR 0.29 (0.12, 0.72)) and total cholesterol (OR 0.39 (0.20, 0.75)) were important factors in univariate analysis, and both of them were negative correlation factors of macrosomia. All influencing factors in multivariate analysis were selected for drawing a receiver operating characteristic (ROC) curve, and the value of the AUC was 0.9174. Conclusions This analysis could therefore accurately predict the risk of pregnant women who would deliver macrosomic infants.
Article
The worldwide rates of obesity have increased significantly in recent decades. In the United States, more than 50% of pregnant women are overweight or obese. Obese gravid women are more prone to adverse pregnancy outcomes, including gestational diabetes, hypertensive disorders, and cardiovascular diseases. The adverse outcomes extend beyond the pregnant obese woman; offspring of obese women are themselves at increased risk of prematurity, fetal death, injury during birth, and transient respiratory problems and metabolic effects (ie, neonatal hypoglycemia). Furthermore, maternal obesity can predispose their offspring to long-term health problems, potentially generating an intergenerational cycle of obesity and insulin resistance.
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Background: Large for gestational age infants (LGA) have increased risks of adverse short-term perinatal outcomes. This study aims to develop a multivariable prediction model for the risk of giving birth to a LGA baby, by using biochemical, biophysical, anamnestic, and clinical maternal characteristics available at first trimester. Methods: Prospective study that included all singleton pregnancies attending the first trimester aneuploidy screening at the Obstetric Unit of the University Hospital of Modena, in Northern Italy, between June 2018 and December 2019. Results: A total of 503 consecutive women were included in the analysis. The final prediction model for LGA, included multiparity (OR = 2.8, 95%; CI: 1.6 - 4.9, p=0.001), pre-pregnancy BMI (OR = 1.08. 95% CI 1.03 – 1.14, p=0,002) and PAPP-A MoM (OR = 1.43 95% CI 1.08 – 1.90, p=0.013). The area under the ROC curve was 70.5%, indicating a satisfactory predictive accuracy. The best predictive cut-off for this score was equal to -1.378, which corresponds to a 20.1% probability of having a LGA infant. By using such a cut-off, the risk of LGA can be predicted in our sample with sensitivity of 55.2% and specificity of 79.0%. Conclusion: At first trimester, a model including multiparity, pre-pregnancy BMI and PAPP-A satisfactory predicted the risk of giving birth to a LGA infant. This promising tool, once applied early in pregnancy, would identify women for targeted interventions. Trial registration: NCT04838431
Article
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Obezite dünyada hızla yayılan ve gebeleri de ciddi şekilde etkileyen önemli bir halk sağlığı problemidir. Obezite ve fazla kilolu olmak özellikle doğurganlık çağındaki (15-49 yaş) kadınlarda daha yaygın görülmektedir. Obez gebeliklerde gestasyonel problemler, obstetrik komplikasyonlar ve neonatal olumsuz sonuçlar daha fazla görülmektedir. Obezite anne adayında gestasyonel diyabet, hipertansiyon, preeklampsi, tromboemboli, uzamış doğum eylemi, sezaryen doğuma, postpartum dönemde ise yara enfeksiyonu, emzirme problemlerine neden olabilmektedir. Fetüs için ise makrazomik bebek, omuz distosisi, prematürite, doğum anomalisi, ölü doğuma neden olabilmekte ve çocukluk ve adölesan dönemde obezite riskini artırmaktadır. Hemşireler obez kadınlarda gebelik öncesi, gebelik dönemi ve sonrasında kilo kontrolünü sağlamalı, maternal ve fetal komplikasyonlara karşı önlemler almalı, hastayı bütüncül bir şekilde değerlendirmeli, prenatal, intrapartum ve postpartum dönemde etkili bakım sunmalıdır. Bu derlemenin amacı obezitenin maternal ve fetal sağlık üzerine etkilerini ve obstetride obezitenin yönetimine yönelik hemşirelik yaklaşımlarını ele almaktır. ABSTRACT Obesity is an important public health problem that is rapidly spreading in the world and affecting pregnant women. Obesity and overweight are more common in women of childbearing age (15-49 years). Gestational problems, obstetric complications and neonatal adverse outcomes are more common in obese pregnancies. Obesity may cause gestational diabetes, hypertension, preeclampsia, thromboembolism, prolonged labor, caesarean delivery and postpartum wound infection and breastfeeding problems in the mothers. For the fetus, macrazomic infant can cause shoulder dystocia, premature birth, birth anomaly, stillbirth and increase the risk of obesity in childhood and adolescence. Nurses should provide weight control in obese women before, during and after pregnancy, should take precautions against maternal and fetal complications, evaluate the patient holistically, and provide effective care during prenatal, intrapartum and postaprtum periods. The aim of this review is to discuss the effects of obesity on maternal and fetal health and nursing approaches to the management of obesity in obstetrics.
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To examine the relation between maternal body fat and fetal metabolism. In this observational study, cord blood samples were collected from 60 infants of healthy women for the measurement of insulin and C peptide concentrations. Maternal weight, height, body mass index (BMI) and body composition (skinfold thickness measurements and bioelectrical impedance) were assessed at 13-15 weeks of gestation. Twenty five of the volunteers agreed to have a 75 g oral glucose tolerance test at 28-31 weeks of gestation. Positive correlations were observed with both cord insulin or C peptide concentrations and maternal early pregnancy BMI (r=0.44, p=0.002 and r=0.33, p=0.008, respectively). There was no significant correlation between cord insulin or C peptide concentrations and birthweight or birth weight centiles. Maternal BMI could be a predictor of fetal cord insulin concentration.
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Background: Women with a suspected large-for-dates fetus or a fetus with suspected macrosomia (birthweight greater than 4000 g) are at risk of operative birth or caesarean section. The baby is also at increased risk of shoulder dystocia and trauma, in particular fractures and brachial plexus injury. Induction of labour may reduce these risks by decreasing the birthweight, but may also lead to longer labours and an increased risk of caesarean section. Objectives: To assess the effects of a policy of labour induction at or shortly before term (37 to 40 weeks) for suspected fetal macrosomia on the way of giving birth and maternal or perinatal morbidity. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), contacted trial authors and searched reference lists of retrieved studies. Selection criteria: Randomised trials of induction of labour for suspected fetal macrosomia. Data collection and analysis: Review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We contacted study authors for additional information. For key outcomes the quality of the evidence was assessed using the GRADE approach. Main results: We included four trials, involving 1190 women. It was not possible to blind women and staff to the intervention, but for other 'Risk of bias' domains these studies were assessed as being at low or unclear risk of bias.Compared to expectant management, there was no clear effect of induction of labour for suspected macrosomia on the risk of caesarean section (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.76 to 1.09; 1190 women; four trials, moderate-quality evidence) or instrumental delivery (RR 0.86, 95% CI 0.65 to 1.13; 1190 women; four trials, low-quality evidence). Shoulder dystocia (RR 0.60, 95% CI 0.37 to 0.98; 1190 women; four trials, moderate-quality evidence), and fracture (any) (RR 0.20, 95% CI 0.05 to 0.79; 1190 women; four studies, high-quality evidence) were reduced in the induction of labour group. There were no clear differences between groups for brachial plexus injury (two events were reported in the control group in one trial, low-quality evidence). There was no strong evidence of any difference between groups for measures of neonatal asphyxia; low five-minute infant Apgar scores (less than seven) or low arterial cord blood pH (RR 1.51, 95% CI 0.25 to 9.02; 858 infants; two trials, low-quality evidence; and, RR 1.01, 95% CI 0.46 to 2.22; 818 infants; one trial, moderate-quality evidence, respectively). Mean birthweight was lower in the induction group, but there was considerable heterogeneity between studies for this outcome (mean difference (MD) -178.03 g, 95% CI -315.26 to -40.81; 1190 infants; four studies; I(2) = 89%). In one study with data for 818 women, third- and fourth-degree perineal tears were increased in the induction group (RR 3.70, 95% CI 1.04 to 13.17).For outcomes assessed using GRADE, we based our downgrading decisions on high risk of bias from lack of blinding and imprecision of effect estimates. Authors' conclusions: Induction of labour for suspected fetal macrosomia has not been shown to alter the risk of brachial plexus injury, but the power of the included studies to show a difference for such a rare event is limited. Also antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed. Nevertheless, induction of labour for suspected fetal macrosomia results in a lower mean birthweight, and fewer birth fractures and shoulder dystocia. The unexpected observation in the induction group of increased perineal damage, and the plausible, but of uncertain significance, observation of increased use of phototherapy, both in the largest trial, should also be kept in mind.Findings from trials included in the review suggest that to prevent one fracture it would be necessary to induce labour in 60 women. Since induction of labour does not appear to alter the rate of caesarean delivery or instrumental delivery, it is likely to be popular with many women. In settings where obstetricians can be reasonably confident about their scan assessment of fetal weight, the advantages and disadvantages of induction at or near term for fetuses suspected of being macrosomic should be discussed with parents.Although some parents and doctors may feel the evidence already justifies induction, others may justifiably disagree. Further trials of induction shortly before term for suspected fetal macrosomia are needed. Such trials should concentrate on refining the optimum gestation of induction, and improving the accuracy of the diagnosis of macrosomia.
Article
Objective: To study prospectively the prediction power, at different gestations, of clinical and ultrasound measurements for fetal size in diabetic pregnancy. Setting: A large combined obstetric diabetic clinic in a teaching hospital. Participants: One hundred and eighty-one pregnancies in which women had scans at least two of three specific time points and who were delivered of singletons after 34 weeks: 73% were pre-gestational insulin-dependent diabetics, the others were pre-gestational White class A or gestational diabetics. Interventions: Clinical estimates of fundal height and fetal size and ultrasound estimates of abdominal circumference and head circumference were routinely carried out at gestational ages of 28, 34 and 38 weeks or before delivery. Main outcome measures: Standardised birthweight, corrected for gestation and parity. The relation with clinical and ultrasound measurements was investigated using multiple linear regression and the capability of the measurements to predict macrosomic births (> 95th centile of normals) using receiver-operator characteristic curves. Results: All measurements are poor predictors of eventual standardised birthweight. Prediction improves with closeness to delivery. Prediction is significantly improved by adding ultrasound to clinical information, but at 34 weeks or later this only contributes 8% of the variance. There is no difference in the prediction power for macrosomia between clinical and ultrasound measurements. Conclusions: Even regular serial scanning and clinical examination will not always diagnose the macrosomic fetus in diabetic pregnancy. In our hands, clinical examination is as predictive as ultrasound measurements. Ultrasound does add to clinical prediction power but only to a small extent. Ultrasound should be used in a selected way, as defined by clinical findings, and with recognition and understanding of the errors and biases involved.
Article
Gestational DiabetesThe Role of Fetal InsulinImplications For Cell BiologyAcknowledgementsReferencesDiscussionReferences
Article
Charts for fetal growth do not take physiological variables into account. We have therefore designed a computer-generated antenatal chart that can be easily "customised" for each individual pregnancy, taking the mother's characteristics and birthweights from previous pregnancies into consideration. The adjusted birthweight range expected at 40 weeks' gestation is combined with a standard, longitudinal ultrasound-derived curve for intrauterine weight gain. Review at the Queen's Medical Centre, Nottingham, UK, of 4179 pregnancies with ultrasound-confirmed dates showed that, in addition to gestation and sex, maternal weight at first antenatal-clinic visit, height, ethnic group, and parity were significant determinants of birthweight in our population. Correction factors were calculated for each of these variables and entered into a computer program to adjust the normal birthweight centile limits. With adjusted centiles we found that 28% of babies conventionally designated small for gestational age (less than 10th centile) and 22% of those designated large (greater than 90th centile) were in fact within normal limits for the pregnancy. Conversely, 24% and 26% of babies identified as small or large, respectively, with adjusted centiles were "missed" by conventional unadjusted centile assessment. Adjustment for physiological variables will make assessment of fetal growth more precise and reduce unnecessary investigations, interventions, and parental anxiety.
Article
Two hundred thirteen women with abnormal glucose tolerance tests (GTTs) were diagnosed over 9 years by a screening program involving the total antenatal population. Each subject was matched for age, parity, and ethnic group with a control. The gestational diabetics were subdivided into classes A1 or A2 based on the fasting plasma glucose value of their GTT: A1 when below 6.0 mmol/L (108 mg/dL) and A2 when 6.0 mmol/L (108 mg/dL) or higher. All received treatment with dietary advice and some with insulin. Birth weight was not related to maternal age or severity of diabetes, but was related to maternal obesity. However, neonatal morbidity indices such as admission to the special care baby unit for longer than 48 hours and polycythemia (hematocrit above 65%) were related significantly to the severity of the diabetes and not to maternal age or obesity.
Article
The placental transfer of non-esterified fatty acids, predominantly in the direction of mother to fetus, is regulated on a gross scale by the transplacental non-esterified fatty acid gradient. This is maintained by fetal liver lipid uptake and by enhanced lipolysis of circulating triacylglycerol in the pregnant mother. It is also dependent upon maternal placental blood flow, which is reduced in diabetes, upon the fetal umbilical blood flow, upon maternal and fetal albumin concentrations and upon intratrophoblastic fatty acid binding protein, which appears to be altered in diabetes. Circulating maternal triacylglycerols also directly contribute non-esterified fatty acids to the fetus by intraplacental hydrolysis and the hypertriglyceridaemia associated with maternal diabetes, in concert with changes in lipase levels will enhance maternal to fetal lipid flux.
Article
The outcome of delivery of infants weighing more than 4000 g born during two time periods 15 years apart was studied retrospectively. The increased use of cesarean section and other obstetric advances did not reduce the risk of fetal asphyxia and trauma associated with large fetal size. Maternal factors were identified for risk categorization of fetal macrosomia during pregnancy. Macrosomia was rare at 37 weeks and increasingly common thereafter. Fetal size assessment by ultrasound at 36 to 38 weeks' gestation would permit induction of labor for the macrosomic infant before the size became excessive or would make the accoucheur aware of the dangers that may arise during delivery.
Article
To assess the validity of clinical information held on a regional maternity database, the St Mary's Maternity Information System (SMMIS). A retrospective review of 892 maternity case notes and matched SMMIS records, by a midwife trained in clinical coding techniques. Three maternity units in the North West Thames Region. Percentage agreement for 17 directly recorded SMMIS data items and equivalent data abstracted from the notes. Frequencies of diagnosis codes abstracted from case notes, as compared with those generated by SMMIS on the basis of directly recorded data. A generally high level of agreement was observed between the abstracts of the notes and the SMMIS records. Of the 17 data items examined, 10 showed 95% agreement or better, and all but two exceeded 80% agreement. Little difference was found between the levels of agreement observed at the three sites. A greater number and range of diagnosis codes were abstracted from the notes than were generated by SMMIS. The directly recorded clinical data held on the SMMIS regional database is largely accurate and consistently recorded across a variety of units. The database can therefore be considered a valuable resource for the comparative audit of maternity practice. The SMMIS technique for deriving, on a semi-automatic basis, diagnosis codes from the directly recorded fields, appears to work moderately well. We suggest that the direct method of data collection used in SMMIS could provide a model for other specialties in the National Health Service.
Article
To determine (i) risk factors in the development of third degree obstetric tears and (ii) the success of primary sphincter repair. (i) Retrospective analysis of obstetric variables in 50 women who had sustained a third degree tear, compared with the remaining 8553 vaginal deliveries during the same period. (ii) Women who had sustained a third degree tear and had primary sphincter repair and control subjects were interviewed and investigated with anal endosonography, anal manometry, and pudendal nerve terminal motor latency measurements. Antenatal clinic in teaching hospital in inner London. (i) All women (n = 8603) who delivered vaginally over a 31 month period. (ii) 34 women who sustained a third degree tear and 88 matched controls. Obstetric risk factors, defecatory symptoms, sonographic sphincter defects, and pudendal nerve damage. (i) Factors significantly associated with development of a third degree tear were: forceps delivery (50% v 7% in controls; P = 0.00001), primiparous delivery (85% v 43%; P = 0.00001), birth weight > 4 kg (P = 0.00002), and occipito-posterior position at delivery (P = 0.003). No third degree tear occurred during 351 vacuum extractions. Eleven of 25 (44%) women who were delivered without instruments and had a third degree tear did so despite a posterolateral episiotomy. (ii) Anal incontinence or faecal urgency was present in 16 women with tears and 11 controls (47% v 13%; P = 0.00001). Sonographic sphincter defects were identified in 29 with tears and 29 controls (85% v 33%; P = 0.00001). Every symptomatic patient had persistent combined internal and external sphincter defects, and these were associated with significantly lower anal pressures. Pudendal nerve terminal motor latency measurements were not significantly different. Vacuum extraction is associated with fewer third degree tears than forceps delivery. An episiotomy does not always prevent a third degree tear. Primary repair is inadequate in most women who sustain third degree tears, most having residual sphincter defects and about half experiencing anal incontinence, which is caused by persistent mechanical sphincter disruption rather than pudendal nerve damage. Attention should be directed towards preventive obstetric practice and surgical techniques of repair.
Article
Insulin sensitivity and postprandial thermogenesis were investigated at various stages of pregnancy to assess if changes in insulin sensitivity contribute to energy conservation during pregnancy. Cross-sectional and longitudinal studies were undertaken. Sixteen control non-pregnant women were compared with 10 women in the second trimester (2nd) and thirteen women in the third trimester (3rd) of uncomplicated pregnancy. Six women were studied at all three time points. The slope of plasma glucose decline following a bolus of intravenous insulin was used as an index of insulin sensitivity. Resting energy expenditure was measured with continuous indirect calorimetry. Postprandial thermogenesis was measured as the change in energy expenditure for the 2 h after a mixed meal. Results are expressed as mean +/- SEM or median (interquartile range). Insulin sensitivity was lower as pregnancy progressed (non-pregnant control 181 (177-205) vs 2nd 111 (100-112) vs 3rd 96 (80-109) mumol l-1 min-1, p < 0.001). Fasting insulin levels were significantly higher in the third trimester but not in the second trimester (non-pregnant control 1.9 (1.5-6.0) vs 2nd 3.1 (2.8-5.2) vs 3rd 8.6 (4.8-9.7) mU l-1, p < 0.05). Meal stimulated insulin levels were higher in the second and third trimesters compared to non-pregnant women (insulin area over 2 h, postmeal, non-pregnant control 78 +/- 10 vs 2nd 92 +/- 14 vs 3rd 145 +/- 14 mU l-1 h-1, p < 0.005). Postprandial thermogenesis was lowest in the third trimester (non-pregnant control 103 +/- 5 vs 2nd 74 +/- 8 vs 3rd 48 +/- 8 kJ, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Article
To assess our ability to detect macrosomic fetuses, and to examine the relationship between prenatal diagnosis of macrosomia and the incidence of shoulder dystocia and birth trauma. We instituted a protocol for routine detection of macrosomic fetuses, defined as weight estimated to be at least 4500 g. Fetal weight was estimated by ultrasonography when there was clinical suspicion of macrosomia. We collected data on these pregnancies as well as on deliveries of macrosomic infants, shoulder dystocia, and birth trauma. During the 14-month study period, there were 4480 deliveries. There were 23 macrosomic newborns (0.5%), of whom 17 were born vaginally. Six of these 17 (35%) vaginal deliveries were complicated by shoulder dystocia, and one infant sustained brachial plexus injury. The overall frequency of shoulder dystocia was 2%, the majority (93%) occurring in infants weighing less than 4500 g. Eleven newborns sustained brachial plexus injury (0.2%), and 39 had isolated clavicular fracture. Six of nine cephalic deliveries that resulted in brachial plexus injury were associated with shoulder dystocia. The sensitivity and predictive value of the study protocol were 17% (four of 23) and 36% (four of 11), respectively. Surprisingly, clinical estimation alone had a sensitivity of 43% (ten of 23) and a positive predictive value of 53% (ten of 19). The ability to predict macrosomia is limited. The predictive value of clinical estimation of fetal weight alone may be slightly higher than when it is combined with ultrasonography. Because most cases of shoulder dystocia and birth trauma occur in nonmacrosomic infants, these conditions are practically impossible to prevent.
Article
Over the past decade the weights of babies born in the United Kingdom have been increasing,1 which may have implications for the pattern of adult disease.2 From 1980 to 1992 the mean birth weight of live singleton births in Scotland increased steadily from 3326 g to 3382 g. We investigated factors that may explain this trend. The distribution of gestational age has changed noticeably over the past decade because of the gradual introduction of its assessment by ultrasonography.3 In 1980 around 42% of all live births occurred at 40 weeks' gestation; by 1992 this had fallen to 32%. Thus trends in birth weights adjusted for gestation may be misleading and are not considered here. We assessed data on live, singleton births in …
Article
The purpose of this study was to examine the 1-year incidence statewide in California of shoulder dystocia and its associated risk factors. With a data set that contains computer-linked records from the birth certificate and hospital discharge records of both mother and baby, all births of infants >3500 g in >300 civilian acute care hospitals in California in 1992 were analyzed. All cases of shoulder dystocia were identified from discharge records, birth certificates, or both and were analyzed with both bivariate and multivariate techniques to identify specific risk factors. A total of 175,886 vaginal births of infants >3500 g were included in our database, of which 6238 infants (3%) had shoulder dystocia. The percentages of births complicated by shoulder dystocia for unassisted births not complicated by diabetes were 5.2% for infants 4000 to 4250 g, 9.1% for those 4250 to 4500 g, 14.3% for 4500 to 4750, and 21.1% for those 4750 to 5000 g. Shoulder dystocia increased by approximately 35% to 45% in vacuum- or forceps-assisted births to nondiabetic mothers. Similar increases were seen in unassisted births to diabetic mothers. The risk of shoulder dystocia for assisted births to diabetic mothers was even more dramatic: 12.2% for infants 4000 to 4250 g, 16.7% for those 4250 to 4500 g, 27.3% for those 4500 to 4750 g, and 34.8% for those 4750 to 5000 g. After controlling for other parameters, there was an increased risk of shoulder dystocia associated with diabetes (odds ratio 1.7), assisted delivery (odds ratio 1.9), and induction of labor (odds ratio 1.3). Rates of birth trauma, asphyxia, and length of stay were all increased among births complicated by shoulder dystocia. This information on the incidence of shoulder dystocia and associated risk factors for a large statewide population may assist providers of obstetric care in counseling patients when macrosomia is suspected. The inaccuracy of estimating fetal weight is a severe limitation in attempting to establish guidelines designed to prevent shoulder dystocia.
Article
Both our previously performed decision analysis and more recent clinical data considered in the context of our decision analytic framework support the claim that in the pregnancies of women without diabetes the level of intervention and the economic costs of prophylactic cesarean delivery for fetal macrosomia diagnosed by means of ultrasonography are predicted to be excessive. Under the most plausible assumptions, a prophylactic cesarean policy with either a 4000- or 4500-g macrosomia threshold would require more than 1000 cesarean deliveries and millions of dollars to avert a single permanent brachial plexus injury. In the pregnancies of diabetic women, although such policies would be expected to perform appreciably better, their use would nevertheless entail considerable intervention for any benefit achieved. Under most assumptions, hundreds of cesarean deliveries and hundreds of thousands of dollars would be required to avert a single permanent brachial plexus injury. In light of the available data, optimizing the management of shoulder dystocia seems at present to be the most immediate and tenable approach to the prevention of birth-related brachial plexus injury.
Article
To compare the accuracy of 31 published formulas for estimated fetal weight (EFW) in predicting macrosomia (birthweight 4,000 gm or more) in infants of diabetic mothers. The study population comprised 165 women with gestational or pregestational diabetes who had sonograms to estimate fetal weight after 36 weeks of gestation and within 2 weeks of delivery. Three measures of accuracy were compared: 1) area under the receiver operating characteristic (ROC) curve relating EFW to macrosomia, 2) systematic error, and 3) absolute error. For each measure, the 31 formulas were rank-ordered from 1 (best) to 31 (worst). For each formula, the three rank scores were summed to give a total score. The formula with the lowest total score was considered the "best" formula. Macrosomia occurred in 49 cases (30%). Areas under the ROC curves ranged from 0.8361-0.8978. Differences in areas were not significantly different between the 31 formulas. The 1986 formula of Ott et al. had the lowest total score. Using this "best" formula, an EFW of 4,000 gm or more had a sensitivity of 45% to predict macrosomia and a positive predictive value of 81%. To achieve 90% sensitivity with this formula would have required diagnosis of macrosomia with an EFW of 3,535 gm or more, but this would have comprised 46% of the population with a 42% false-positive rate. All 31 formulas were better at predicting macrosomia than predictions based on gestational age alone, and 28 were better than predictions based on abdominal circumference alone. All 31 formulas for EFW had comparably poor accuracy for prediction of macrosomia. Delivery decisions based on EFW will often be in error. Future studies should determine whether specific sonographic measurements, ratios, or differences are better than EFW or birthweight as predictors of birth trauma.
Article
Suspected macrosomic fetuses are usually induced in order to reduce the risk of difficult operative delivery. The objective of this review was to assess the effects of a policy of labour induction for suspected fetal macrosomia on method of delivery and maternal or perinatal morbidity. We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Randomised trials of induction of labour for suspected fetal macrosomia in non-diabetic women. Trial quality assessment and data extraction were done independently by two reviewers. Study authors were contacted for additional information. Two trials involving 313 women were included. Compared to expectant management, induction of labour for suspected macrosomia did not reduce the risk of caesarean section (odds ratio 0.85, 95% confidence interval 0.50 to 1.46) or instrumental delivery (odds ratio 0.98, 95% confidence interval 0.48 to 1.98). Perinatal morbidity was similar between groups. Induction of labour for suspected fetal macrosomia in non-diabetic women did not appear to alter the risk of maternal or neonatal morbidity.
Article
To analyse by parity the obstetric and neonatal outcome of babies delivered weighing more than 4.5 kg. All deliveries resulting in a baby weighing more than 4.5 kg, in the 5 years from 1991 to 1995, were identified using a computerised database. The following variables confined to singleton, cephalic pregnancies were recorded: mode of delivery, duration of labour, incidence of shoulder dystocia and admission to the neonatal centre. Outcome measures in primigravidae and multigravidae were compared using the Epi Info package (WHO, Version 6.0b January 1997). There were 32,834 deliveries over the study period and 828 (2.5%) weighed more than 4.5 kg. Birthweight more than 4.5 kg occurred in 1.6% (n=198) of primigravidae and 3.1% (n=630) of multigravidae (P<0.05). Primigravidae had a higher risk of prolonged labour (27.7% vs. 4.9%), operative vaginal delivery (32% vs.9%) and emergency caesarean section (24.2% vs. 5.7%) compared to multigravidae. When delivering a macrosomic baby, primigravidae had a higher incidence of prolonged labour (27% vs. 7.9%), operative vaginal delivery (32% vs.25%) and emergency caesarean section (24.2% vs. 5.7%) compared to normal weight babies. The incidence of shoulder dystocia and elective caesarean section were similar in both primigravidae and multigravidae. Macrosomic infants have an increased incidence of prolonged labour, operative vaginal delivery and emergency caesarean section compared with normal weight babies and these complications are more pronounced in primigravidae compared to multigravidae. Shoulder dystocia occurs with equal frequency in primigravidae and multigravidae. The poor antenatal predictability of macrosomia, the high rate of vaginal delivery and the low incidence of shoulder dystocia would not support the use of elective caesarean section for delivery of the macrosomic infant either in primigravidae or multigravidae.
Development of adipose tissue in vivo and in vitro
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Leucine flux is increased whilst glucose turnover is normal in pregnancy complicated by gestational diabetes
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Clinical and ultrasound prediction of macrosomia in diabetic pregnancy (see comments)
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The Adipocyte and Obesity: Cellular and Molecular Mechanisms
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Leucine flux is increased whilst glucose turnover is normal in pregnancy complicated by gestational diabetes
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Clinical and ultrasound prediction of macrosomia in diabetic pregnancy (see comments)
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