Large for gestational age

Last updated
Large for gestational age
Other namesMacrosomia
New-baby-boy-weight-11-pounds.jpg
LGA: A healthy 11-pound (5.0 kg) newborn child, delivered vaginally without complications (41 weeks; fourth child; no gestational diabetes)
Specialty Obstetrics, pediatrics

Large for gestational age (LGA) is a term used to describe infants that are born with an abnormally high weight, specifically in the 90th percentile or above, compared to other babies of the same developmental age. [1] [2] [3] Macrosomia is a similar term that describes excessive birth weight, but refers to an absolute measurement, regardless of gestational age. [4] Typically the threshold for diagnosing macrosomia is a body weight between 4,000 and 4,500 grams (8 lb 13 oz and 9 lb 15 oz), or more, measured at birth, but there are difficulties reaching a universal agreement of this definition. [4]

Contents

Evaluating an infant for macrosomia or LGA can help identify risks associated with their birth, including labor complications of both the parent and the child, potential long-term health complications of the child, and infant mortality. [5]

Signs and symptoms

Fetal macrosomia and LGA often do not present with noticeable patient symptoms. Important signs include large fundal height (uterus size) and excessive amniotic fluid (polyhydramnios). [6] Fundal height can be measured from the top of the uterus to the pubic bone and indicates that the newborn is likely large in volume. Excessive amniotic fluid indicates that the fetus’ urine output is larger than expected, indicating a larger baby than normal; some symptoms of excessive amniotic fluid include

Complications

LGA or macrosomic births can lead to complications for both the mother and the infant. [7]

Infant complications

Common risks in LGA babies include shoulder dystocia, [5] hypoglycemia, [5] brachial plexus injuries, [8] metatarsus adductus, hip subluxation [9] and talipes calcaneovalgus, due to intrauterine deformation. [9]

Shoulder dystocia occurs when the infant's shoulder becomes impacted on the mother's pubic symphysis during birth. [10] Newborns with shoulder dystocia are at risk of temporary or permanent nerve damage to the baby's arm, or other injuries such as fracture. [11] Both increased birth weight and diabetes in the gestational parent are independent risk factors seen to increase risk of shoulder dystocia. [11] In non-diabetic women, shoulder dystocia happens 0.65% of the time in babies that weigh less than 8 pounds 13 ounces (4,000 g), 6.7% of the time in babies that weigh 8 pounds (3,600 g) to 9 pounds 15 ounces (4,500 g), and 14.5% of the time in babies that weigh more than 9 pounds 15 ounces (4,500 g). [12] In diabetic women, shoulder dystocia happens 2.2% of the time in babies that weigh less than 8 pounds 13 ounces (4,000 g), 13.9% of the time in babies that weigh 8 pounds (3,600 g) to 9 pounds 15 ounces (4,500 g), and 52.5% of the time in babies that weigh more than 9 pounds 15 ounces (4,500 g). [12] Although larger babies are at higher risk for shoulder dystocia, most cases of shoulder dystocia happen in smaller babies because there are many more small and normal-size babies being born than large babies. [13]

LGA babies are at higher risk of hypoglycemia in the neonatal period, independent of whether the mother has diabetes. [14] Hypoglycemia, as well as hyperbilirubinemia and polycythemia, occurs as a result of hyperinsulinemia in the fetus. [15]

High birth weight may also impact the baby in the long term as studies have shown associations with increased risk of overweight, obesity, and type 2 diabetes mellitus. [4] [16] [17] Studies have shown that the long-term overweight risk is doubled when the birth weight is greater than 4,000 g. The risk of type 2 diabetes mellitus as an adult is 19% higher in babies weighing more than 4,500 g at birth compared to those with birth weights between 4,000 g and 4,500 g. [18]

Pregnant mother complications

Complications of the pregnant mother include: emergency cesarean section, postpartum hemorrhage, and obstetric anal sphincter injury. [7] Compared to pregnancies without macrosomia, pregnant women giving birth to newborns weighing between 4,000 grams and 4,500 grams are at two times greater risk of complications, and those giving birth to infants over 4,500 grams are at three times greater risk. [7]

Schematic representation of macrosomia/LGA risk factors and related complications. Schematic representation of maternal, gestational and fetal risk factors of macrosomia, related complications and parameters used in the diagnostic process.png
Schematic representation of macrosomia/LGA risk factors and related complications.

Causes

Multiple factors have been shown to increase likelihood of infant macrosomia, including preexisting obesity, diabetes, or dyslipidemia of the mother, gestational diabetes, post-term pregnancy, prior history of a macrosomic birth, genetics, and other factors. [4]

Risk factors

Diabetes of the mother

One of the primary risk factors of LGA births and macrosomia is poorly-controlled maternal diabetes, particularly gestational diabetes (GD), as well as preexisting type 2 diabetes mellitus (DM). [19] The risk of having a macrosomic fetus is three times greater in mothers with diabetes than those without diabetes. [20]

Obesity in the mother

Obesity prior to pregnancy and maternal weight gain above recommended guidelines during pregnancy are another key risk factor for macrosomia or LGA infants. [21] [22] [23]   It has been demonstrated that while maternal obesity and gestational diabetes are independent risk factors for LGA and macrosomia, they can act synergistically, with even higher risk of macrosomia when both are present. [4] [20]

Genetics

Genetics can also play a role in having an LGA baby and it is seen that taller, heavier parents tend to have larger babies. [24] Genetic disorders of overgrowth (e.g. Beckwith–Wiedemann syndrome, Sotos syndrome, Perlman syndrome, Simpson-Golabi-Behmel syndrome) are often characterized by macrosomia. [25] [26]

Other risk factors

  • Gestational age: pregnancies that go beyond 40 weeks increase incidence of an LGA infant [20]
  • Fetal sex: male infants tend to weigh more than female infants [8]
  • Multiparity: giving birth to previous LGA infants vs. non-LGA infants [8]
  • Frozen embryo transfer as fertility treatment, as compared with fresh embryo transfer or no artificial assistance [27] [28]

Mechanism

How each of these factors leads to excess fetal growth is complex and not completely understood. [4] [29]

Traditionally, the Pedersen hypothesis has been used to explain the mechanism in which uncontrolled gestational diabetes can lead to macrosomia, and many aspects of it have been confirmed with further studies. [20] This explanation proposes that impaired glucose control in the mother leads to a hyperglycemic state for the fetus, which leads to a hyperinsulinemia response, in turn causing increased glucose metabolism, fat deposition, and excess growth. [20] [29] [30]

It has also been shown that different patterns of excess fetal growth are seen in diabetic associated macrosomia compared to other predisposing factors, suggesting different underlying mechanisms. [4] [29] Specifically, macrosomic infants associated with glucose abnormalities are seen to have increased body fat, larger shoulders and abdominal circumference. [4] [29]

Diagnosis

Weight vs gestational Age.jpg

Diagnosing fetal macrosomia cannot be performed until after birth, as evaluating a baby's weight in the womb may be inaccurate. [20] While ultrasound has been the primary method for diagnosing LGA, this form of fetal weight assessment remains imprecise, as the fetus is a highly variable structure in regards to density and weight— no matter the gestational age. [20] Ultrasonography involves an algorithm that incorporates biometric measurements of the fetus, such as biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL), to calculate the estimated fetal weight (EFW). [31] Variability of fetal weight estimations has been linked to differences due to sensitivity and specificity of ultrasound algorithms as well as to the individual performing the ultrasound examination. [32]

In addition to sonography, fetal weight can also be assessed using clinical and maternal methods. Clinical methods for estimating fetal weight involves measuring the mother's symphysis-fundal height and performing Leopold's maneuvers, which can help with determining the fetus position in utero in addition to size. [32] However, as this method relies heavily on practitioner experience and technique, it does not provide an accurate and definite diagnosis of an LGA infant and would only serve as a potential indication of suspected macrosomia. [32] Fetal weight can also be estimated through a mother's subjective assessment of the fetus size, but this method is dependent on a mother's experience with past pregnancies and may not be clinically useful. [32] There are new methods being studied for their accuracy in predicting fetal weight, such as measuring fetal soft tissue, but more research needs to be done to find a consistent, reliable method. [33]

Prevention

LGA and fetal macrosomia associated with poor glycemic control can be prevented by effective blood glucose management below a mean blood glucose level of 100 mg/dl before and during pregnancy; additionally, closely monitoring weight gain and diet during pregnancy can help to prevent LGA and fetal macrosomia. [34] [35] Women with obesity that undergo weight loss can greatly decrease their chances of having a macrosomic or LGA infant. [35] Additionally, regular prenatal care and routine check-ups with one's physician are important in planning pregnancy, especially if one has obesity, diabetes, hypertension, or other conditions before conception. [34]

Screening

Most screening for LGA and macrosomia occurs during prenatal check-ups, where both fundal height and ultrasound scans can give an approximate measurement of the baby's proportions. [36] Two-dimensional ultrasound can be used to screen for macrosomia and LGA but estimations are generally not precise at any gestational age until birth. [35]

Management

An approach that is sometimes suggested is to induce labor close to the estimated due date (at term) or near that date. The rationale is that by the baby being born with a lower birth weight, there would be a lower risk of long labors, cesarean section, bone fractures, and shoulder dystocia. [10] However, this method could increase the number of women with perineal tears, and failed inductions can prompt the need for emergency cesarean sections. [10] There is not strong evidence that an induced birth increases the risk of the person requiring a cesarean section. Another consideration is that since there may be inaccuracies in estimating or predicting the neonates weight in utero, there is a risk of inducing labor unnecessarily. [10] Doctors disagree whether women should be induced for suspected macrosomia and more research is needed to find out what is best for women and their babies. [10]

Elective cesarean section has also been presented as a potential delivery method for infants of suspected macrosomia, as it can serve to prevent possible birth trauma. However, the American College of Obstetricians and Gynecologists recommends that cesarean delivery should only be considered if the fetus is an estimated weight of at least 5,000 grams in non-diabetic mothers and at least 4,500 grams in diabetic mothers. [37] A number needed to treat analysis determined that approximately 3,700 women with suspected fetal macrosomia would have to undergo an unnecessary cesarean section in order to prevent one incident of brachial plexus injuries secondary to shoulder dystocia. [8]

Management of gestational diabetes through dietary modifications and anti-diabetic medications has been shown to decrease the incidence of LGA. [38] The use of metformin to control maternal blood glucose levels has shown to be more effective than using insulin alone in reducing the likelihood of fetal macrosomia. [39] There is a 20% lower chance of having an LGA baby when using metformin to manage diabetes compared to using insulin. [40]

Modifiable risk factors that increase the incidence of LGA births, such as gestational weight gain above recommended BMI guidelines, can be managed with lifestyle modifications, including maintaining a balanced diet and exercising. [41] [42] Such interventions can help mothers achieve the recommended gestational weight and lower the incidence of fetal macrosomia in obese and overweight women. [41] [42] The World Health Organization also recommends that mothers aim for their recommended BMI prior to conception. [23] In general, obese mothers or women with excessive gestational weight gain may have higher risk of pregnancy complications (ranging from LGA, shoulder dystocia, etc.). [43]

Epidemiology

In healthy pregnancies without pre-term or post-term health complications, fetal macrosomia has been observed to affect around 12% of newborns. [10] By comparison, women with gestational diabetes are at an increased risk of giving birth to LGA babies, where ~15-45% of neonates may be affected. [10] In 2017, the National Center of Health Statistics found that 7.8% of live-born infants born in the United States meet the definition of macrosomia, where their birth weight surpasses the threshold of 4000 grams (about 8.8 pounds). [10] Women in Europe and the United States tend to have higher pre-term body weight and have increased gestational weight during pregnancy compared to women in east Asia. [44] Thus, women in Europe and the United States, with higher gestational weight gain, tend to have higher associated risk of LGA infants, macrosomia and cesarean. [44] In European countries, the prevalence of births of newborns weighing between 4,000 g and 4,499 g is 8% to 21%, and in Asian countries the prevalence is between 1% and 8%. [45] In general, rates of LGA infants have increased 15-25% in many countries including the United States, Canada, Germany, Denmark, Scotland and more in the past 20–30 years, suggesting an increase in LGA births worldwide. [46]

Related Research Articles

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.

<span class="mw-page-title-main">Stillbirth</span> Death of a fetus before or during delivery, resulting in delivery of a dead baby

Stillbirth is typically defined as fetal death at or after 20 or 28 weeks of pregnancy, depending on the source. It results in a baby born without signs of life. A stillbirth can often result in the feeling of guilt or grief in the mother. The term is in contrast to miscarriage, which is an early pregnancy loss, and Sudden Infant Death Syndrome, where the baby dies a short time after being born alive.

Fetal distress, also known as non-reassuring fetal status, is a condition during pregnancy or labor in which the fetus shows signs of inadequate oxygenation. Due to its imprecision, the term "fetal distress" has fallen out of use in American obstetrics. The term "non-reassuring fetal status" has largely replaced it. It is characterized by changes in fetal movement, growth, heart rate, and presence of meconium stained fluid.

<span class="mw-page-title-main">Gestational diabetes</span> Medical condition

Gestational diabetes is a condition in which a woman without diabetes develops high blood sugar levels during pregnancy. Gestational diabetes generally results in few symptoms; however, it increases the risk of pre-eclampsia, depression, and of needing a Caesarean section. Babies born to mothers with poorly treated gestational diabetes are at increased risk of macrosomia, of having hypoglycemia after birth, and of jaundice. If untreated, diabetes can also result in stillbirth. Long term, children are at higher risk of being overweight and of developing type 2 diabetes.

In obstetrics, gestational age is a measure of the age of a pregnancy taken from the beginning of the woman's last menstrual period (LMP), or the corresponding age of the gestation as estimated by a more accurate method, if available. Such methods include adding 14 days to a known duration since fertilization, or by obstetric ultrasonography. The popularity of using this measure of pregnancy is largely due to convenience: menstruation is usually noticed, while there is generally no convenient way to discern when fertilization or implantation occurred.

<span class="mw-page-title-main">Pregnancy</span> Time of offspring development in mothers body

Pregnancy is the time during which one or more offspring develops (gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.

<span class="mw-page-title-main">Shoulder dystocia</span> Birthing obstruction complication

Shoulder dystocia is when, after vaginal delivery of the head, the baby's anterior shoulder gets caught above the mother's pubic bone. Signs include retraction of the baby's head back into the vagina, known as "turtle sign". Complications for the baby may include brachial plexus injury, or clavicle fracture. Complications for the mother may include vaginal or perineal tears, postpartum bleeding, or uterine rupture.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

<span class="mw-page-title-main">Diabetes and pregnancy</span> Effects of pre-existing diabetes upon pregnancy

For pregnant women with diabetes, some particular challenges exist for both mother and fetus. If the pregnant woman has diabetes as a pre-existing disorder, it can cause early labor, birth defects, and larger than average infants. Therefore, experts advise diabetics to maintain blood sugar level close to normal range about 3 months before planning for pregnancy.

Postterm pregnancy is when a woman has not yet delivered her baby after 42 weeks of gestation, two weeks beyond the typical 40-week duration of pregnancy. Postmature births carry risks for both the mother and the baby, including fetal malnutrition, meconium aspiration syndrome, and stillbirths. After the 42nd week of gestation, the placenta, which supplies the baby with nutrients and oxygen from the mother, starts aging and will eventually fail. Postterm pregnancy is a reason to induce labor.

An asynclitic birth or asynclitism are terms used in obstetrics to refer to childbirth in which there is malposition of the head of the fetus in the uterus, relative to the birth canal. Asynclitic presentation is different from a shoulder presentation, in which the shoulder is presenting first. Many babies enter the pelvis in an asynclitic presentation, and most asynclitism corrects spontaneously as part of the normal birthing process.

Maternal obesity refers to obesity of a woman during pregnancy. Parental obesity refers to obesity of either parent during pregnancy.

An obstetric labor complication is a difficulty or abnormality that arises during the process of labor or delivery.

Post-maturity syndrome develops in about 20% of human pregnancies continuing past the expected dates. Ten years ago it was generally held that the postmature fetus ran some risk of dying in the uterus before the onset of labour because of degeneration and calcification of the placenta. Features of post-maturity syndrome include oligohydramnios, meconium aspiration, macrosomia and fetal problems such as dry peeling skin, overgrown nails, abundant scalp hair, visible creases on palms and soles, minimal fat deposition and skin colour become green or yellow due to meconium staining. Post-maturity refers to any baby born after 42 weeks gestation or 294 days past the first day of the mother's last menstrual period. Less than 6 percent of all babies are born at 42 weeks or later. In most cases, continued fetal growth between 39 and 43 wk gestation results in a macrosomic infant. However, sometimes the placenta involutes, and multiple infarcts and villous degeneration cause placental insufficiency syndrome. In this syndrome, the fetus receives inadequate nutrients and oxygen from the mother, resulting in a thin, small-for-gestational-age, undernourished infant with depleted glycogen stores. Post term, the amniotic fluid volume eventually decreases, leading to oligohydramnios. Although pregnancy is said to last nine months, health care providers track pregnancy by weeks and days. The estimated delivery date, also called the estimated due date or EDD, is calculated as 40 weeks or 280 days from the first day of the last menstrual period. Only 4 percent women will deliver on their due date. The terms Post-maturity or "Post-term" are both words used to describe babies born after 42 weeks. The terms "post-maturity" and "post-term" are interchangeable. As there are many definitions for prolonged pregnancy the incidence varies from 2 to 10%. When incidence is taken as delivery beyond 42 weeks it is 10%, if it is taken according to the delivered baby's weight and length it is 2%. The baby may have birth weight of 4 kg and length of 54 cm but these findings are variable, even the baby may have underweight. Post-maturity is more likely to happen when a mother has had a post-term pregnancy before. After one post-term pregnancy, the risk of a second post-term birth increases by 2 to 3 times. Other, minor risk factors include an older or obese mother, a white mother, male baby, or a family history of post-maturity. Maternal risks include obstructed labor, perennial damage, instrumental vaginal delivery, a Cesarean section, infection, and post postpartum hemorrhage. Accurate pregnancy due dates can help identify babies at risk for post-maturity. Ultrasound examinations early in pregnancy help establish more accurate dating by measurements taken of the fetus. Pregnancies complicated by gestational diabetes, hypertension, or other high-risk conditions should be managed according to guidelines for those conditions.

<span class="mw-page-title-main">Prenatal nutrition</span>

Prenatal nutrition addresses nutrient recommendations before and during pregnancy. Nutrition and weight management before and during pregnancy has a profound effect on the development of infants. This is a rather critical time for healthy development since infants rely heavily on maternal stores and nutrient for optimal growth and health outcome later in life.

<span class="mw-page-title-main">High-risk pregnancy</span> Medical condition

A high-risk pregnancy is one where the mother or the fetus has an increased risk of adverse outcomes compared to uncomplicated pregnancies. No concrete guidelines currently exist for distinguishing “high-risk” pregnancies from “low-risk” pregnancies; however, there are certain studied conditions that have been shown to put the mother or fetus at a higher risk of poor outcomes. These conditions can be classified into three main categories: health problems in the mother that occur before she becomes pregnant, health problems in the mother that occur during pregnancy, and certain health conditions with the fetus.

Obstetric medicine, similar to maternal medicine, is a sub-specialty of general internal medicine and obstetrics that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant women. It is closely related to the specialty of maternal-fetal medicine, although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech.

<span class="mw-page-title-main">Emergency childbirth</span>

Emergency childbirth is the precipitous birth of an infant in an unexpected setting. In planned childbirth, mothers choose the location and obstetric team ahead of time. Options range from delivering at home, at a hospital, a medical facility or a birthing center. Sometimes, birth can occur on the way to these facilities, without a healthcare team. The rates of unplanned childbirth are low. If the birth is imminent, emergency measures may be needed. Emergency services can be contacted for help in some countries.

<span class="mw-page-title-main">Diabetic embryopathy</span> Medical condition

Diabetic embryopathy refers to congenital maldevelopments that are linked to maternal diabetes. Prenatal exposure to hyperglycemia can result in spontaneous abortions, perinatal mortality, and malformations. Type 1 and Type 2 diabetic pregnancies both increase the risk of diabetes induced teratogenicity. The rate of congenital malformations is similar in Type 1 and 2 mothers because of increased adiposity and the age of women with type 2 diabetes. Genetic predisposition and different environmental factors both play a significant role in the development of diabetic embryopathy. Metabolic dysfunction in pregnant mothers also increases the risk of fetal malformations.

<span class="mw-page-title-main">Pregnancy Outcome Prediction study</span>

The Pregnancy Outcome Prediction (POP) Study is a prospective cohort study of 4,512 women who have never given birth, recruited at the Rosie Hospital between January 2008 and July 2012.

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  31. ↑ Coomarasamy A, Connock M, Thornton J, Khan KS (November 2005). "Accuracy of ultrasound biometry in the prediction of macrosomia: a systematic quantitative review". BJOG. 112 (11): 1461–6. doi: 10.1111/j.1471-0528.2005.00702.x . PMID   16225563. S2CID   34330598.
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  35. 1 2 3 "UpToDate". www.uptodate.com. Retrieved 2021-09-15.
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  38. ↑ Hartling L, Dryden DM, Guthrie A, Muise M, Vandermeer B, Donovan L (July 2013). "Benefits and harms of treating gestational diabetes mellitus: a systematic review and meta-analysis for the U.S. Preventive Services Task Force and the National Institutes of Health Office of Medical Applications of Research". Annals of Internal Medicine. 159 (2): 123–9. doi:10.7326/0003-4819-159-2-201307160-00661. PMID   23712381. S2CID   21881403.
  39. ↑ Guo L, Ma J, Tang J, Hu D, Zhang W, Zhao X (2019). "Comparative Efficacy and Safety of Metformin, Glyburide, and Insulin in Treating Gestational Diabetes Mellitus: A Meta-Analysis". Journal of Diabetes Research. 2019: 9804708. doi: 10.1155/2019/9804708 . PMC   6875019 . PMID   31781670.
  40. ↑ Butalia S, Gutierrez L, Lodha A, Aitken E, Zakariasen A, Donovan L (January 2017). "Short- and long-term outcomes of metformin compared with insulin alone in pregnancy: a systematic review and meta-analysis". Diabetic Medicine. 34 (1): 27–36. doi:10.1111/dme.13150. PMID   27150509. S2CID   3418227.
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  46. ↑ Miller V, Saxena S, Farhan M (2010). "Management of large-for-gestational-age pregnancy in non-diabetic women". The Obstetrician & Gynaecologist. 12 (4): 250–256. doi: 10.1576/toag.12.4.250.27617 .
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