Macrosomia Clinical Presentation

  • Author: Allahyar Jazayeri, MD, PhD, FACOG, DACOG, FSMFM; Chief Editor: David Chelmow, MD   more...
 
Updated: Feb 14, 2012
 

History

Fetal macrosomia has been defined in several ways. The definitions include birth weight greater than 4000-4500 g or greater than 90% for the newborn adjusted for race, sex, and gestational age. Based on these definitions, macrosomia occurs in 1-10% of all deliveries. Macrosomia may place the mother and fetus or neonate at risk for adverse outcomes. Antenatal risk factors reportedly predict macrosomia at birth. Identification of these at-risk pregnancies may allow intervention to reduce the risk, to provide appropriate counseling, and to implement appropriate plans for monitoring and follow-up care during pregnancy and after delivery.

  • Maternal diabetes is one of the strongest risk factors associated with giving birth to an infant that is considered large for gestational age. Pregestational and gestational diabetes result in fetal macrosomia in as many as 50% of pregnancies complicated by gestational diabetes and in 40% of those complicated by type 1 diabetes mellitus. Studies of macrosomic infants of diabetic mothers reveal a greater amount of total body fat, thicker upper-extremity skin fold measurements, and smaller ratios of head to abdominal circumference than macrosomic infants of nondiabetic mothers.[3]
  • Maternal weight prior to pregnancy can affect the weight of the fetus. Women who are obese are more likely to have larger infants.[7]
  • Excessive weight gain in pregnancy is a risk factor for macrosomia. The risk is greater for women with obesity than for women without obesity.[7]
  • Gestational age is associated with macrosomia. Birth weight increases as gestational age increases. Prolonged pregnancies (>41 wk) are associated with an increased incidence of macrosomia. Macrosomic infants account for about 1% of term deliveries and 3-10% of postterm deliveries.[3]
  • Multiparity and grand multiparity increase the risk of macrosomia.[8] Parity has been reported to be associated with 100-150 grams of weight gain at birth.[9]
  • A history of macrosomia can influence future pregnancies. Women who previously delivered a macrosomic fetus are 5-10 times more likely than women without such a history to deliver a baby considered large for gestational age the next time they become pregnant.
  • Fetal sex influences macrosomic potential. Male infants weigh more than female infants at any gestational age. Recent studies have confirmed this association.[10]
  • Excessive amniotic fluid defined as greater than or equal to 60th percentile for gestational age has recently been associated with macrosomia.[11]
  • Despite these so-called risk factors for macrosomia, much of the variation in birth weights remains unexplained. Most infants who weigh more than 4500 g have no identifiable risk factors.
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Physical

Many physical examination findings help identify a pregnancy at risk for macrosomia.

  • Maternal obesity is associated with fetal macrosomia. Maternal body mass index (BMI) is a good way of diagnosing obesity prior to pregnancy. Calculated based on height in meters and weight in kilograms, BMI is determined using the following formula:
  • BMI = (weight [kg])/(height [m])2
    • Body fat percentage can be estimated using the following Deurenberg equation:
    • Body fat percentage = 1.2(BMI) + 0.23(age [y]) – 10.8(sex) – 5.4
    • Males are coded as 1 and females are coded as 0. This formula has a standard error of 4% and explains approximately 80% of the variation in body fat.
    • The most widely accepted definition for obesity is that based on the World Health Organization criteria, which uses the BMI. Under this convention for adults, grade 1 overweight (commonly and simply called overweight) is a BMI of 25-29.9 kg/m2. Grade 2 overweight (commonly called obesity) is a BMI of 30-39.9 kg/m2. Grade 3 overweight (commonly called severe or morbid obesity) is a BMI greater than or equal to 40 kg/m2.
    • A BMI greater than 30 kg/m2 is associated with larger infants at delivery.
  • The recommendations for weight gain in pregnancy have been based on the Institute of Medicine (IOM) guidelines published in 1990. The suggested weight gain is 11.2–15.9 kg (25–35 lb) for women with a normal BMI, 6.8 –11.2 kg (15–25 lb) for women who are overweight, and 6.8 kg (15 lb) for women who are obese.[12] Excessive weight gain in pregnancy, especially in women who are already obese, is a risk factor for macrosomia.
  • Fundal height measurements are an inaccurate way of estimating fetal size. They are influenced by maternal size, the amount of amniotic fluid, the status of the bladder, the presence of pelvic masses (eg, fibroids), fetal position, and many other factors. However, in general, a fundal height that is 3-4 cm larger than the gestational age of the pregnancy in the third trimester necessitates further testing to determine the cause. Excessive fetal growth can be one reason for the discrepancy between the fundal height and the gestational age of the pregnancy.
  • Leopold maneuvers are techniques developed to determine fetal presentation, lie, and size. They are also limited by many factors, as mentioned previously for fundal height measurements. However, these maneuvers provide the clinician with a general appreciation of fetal size and other important information. Prospective studies designed to evaluate Leopold maneuvers with fundal height measurement for the prenatal diagnosis of possible macrosomia report sensitivities of 10-43%, specificities of 99-99.8%, and positive predictive values of 28-53%.[13, 14]
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Causes

Causes for macrosomia include factors that contribute to excessive fetal growth and weight gain.

  • Diabetes that is poorly controlled in pregnancy is the greatest risk factor for fetal macrosomia. This is believed to be partially explained by excessive growth due to elevated maternal plasma glucose levels and resulting elevated insulin and insulinlike growth factor levels, which stimulate glycogen synthesis, fat deposition, and fetal growth.
  • Excessive maternal weight gain and/or prepregnancy weight also play the some role in macrosomia by providing excessive growth in selected cases. Whether this is also due to undiagnosed glucose intolerance in these individuals remains to be studied.
  • Genetic factors also contribute to fetal size. Taller and heavier parents typically produce larger offspring.
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Contributor Information and Disclosures
Author

Allahyar Jazayeri, MD, PhD, FACOG, DACOG, FSMFM  Medical Director of Perinatal Services, Bellin Health Hospital Center; Consulting Staff, Women's Specialty Care of Green Bay, WI

Allahyar Jazayeri, MD, PhD, FACOG, DACOG, FSMFM is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Society for Gynecologic Investigation, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David Chelmow, MD  Leo J Dunn Distinguished Professor and Chair, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, American Society for Colposcopy and Cervical Pathology, Association of Professors of Gynecology and Obstetrics, Council of University Chairs of Obstetrics and Gynecology, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

David Chelmow, MD  Leo J Dunn Distinguished Professor and Chair, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, American Society for Colposcopy and Cervical Pathology, Association of Professors of Gynecology and Obstetrics, Council of University Chairs of Obstetrics and Gynecology, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making

Disclosure: Nothing to disclose.

References

  1. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S. Births: final data for 2004. Natl Vital Stat Rep. Sep 29 2006;55(1):1-101. [Medline].

  2. Okun N, Verma A, Mitchell BF, Flowerdew G. Relative importance of maternal constitutional factors and glucose intolerance of pregnancy in the development of newborn macrosomia. J Matern Fetal Med. Sep-Oct 1997;6(5):285-90. [Medline].

  3. Spellacy WN, Miller S, Winegar A, Peterson PQ. Macrosomia--maternal characteristics and infant complications. Obstet Gynecol. Aug 1985;66(2):158-61. [Medline].

  4. McFarland LV, Raskin M, Daling JR, Benedetti TJ. Erb/Duchenne's palsy: a consequence of fetal macrosomia and method of delivery. Obstet Gynecol. Dec 1986;68(6):784-8. [Medline].

  5. Mondestin MA, Ananth CV, Smulian JC, Vintzileos AM. Birth weight and fetal death in the United States: the effect of maternal diabetes during pregnancy. Am J Obstet Gynecol. Oct 2002;187(4):922-6. [Medline].

  6. Mulik V, Usha Kiran TS, Bethal J, Bhal PS. The outcome of macrosomic fetuses in a low risk primigravid population. Int J Gynaecol Obstet. Jan 2003;80(1):15-22. [Medline].

  7. Catalano PM. Management of obesity in pregnancy. Obstet Gynecol. Feb 2007;109(2 Pt 1):419-33. [Medline].

  8. GIBSON JR, McKEOWN T. Observations on all births (23, 970) in Birmingham, 1947. VII. Effect of changing family size on infant mortality. Br J Soc Med. Jul 1952;6(3):183-7. [Medline].

  9. Thomson AM, Billewicz WZ, Hytten FE. The assessment of fetal growth. J Obstet Gynaecol Br Commonw. Sep 1968;75(9):903-16. [Medline].

  10. Di Renzo GC, Rosati A, Sarti RD, Cruciani L, Cutuli AM. Does fetal sex affect pregnancy outcome?. Gend Med. Mar 2007;4(1):19-30. [Medline].

  11. Hackmon R, Bornstein E, Ferber A, Horani J, O'Reilly Green CP, Divon MY. Combined analysis with amniotic fluid index and estimated fetal weight for prediction of severe macrosomia at birth. Am J Obstet Gynecol. Apr 2007;196(4):333.e1-4. [Medline].

  12. Institute of Medicine. Nutritional status and weight gain. In: Nutrition During Pregnancy. National Academies Press; 27-233.

  13. Smith GC, Smith MF, McNay MB, Fleming JE. The relation between fetal abdominal circumference and birthweight: findings in 3512 pregnancies. Br J Obstet Gynaecol. Feb 1997;104(2):186-90. [Medline].

  14. Chauhan SP, Hendrix NW, Magann EF, Morrison JC, Kenney SP, Devoe LD. Limitations of clinical and sonographic estimates of birth weight: experience with 1034 parturients. Obstet Gynecol. Jan 1998;91(1):72-7. [Medline].

  15. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 60, March 2005. Pregestational diabetes mellitus. Obstet Gynecol. Mar 2005;105(3):675-85. [Medline].

  16. Jazayeri A, Heffron JA, Phillips R, Spellacy WN. Macrosomia prediction using ultrasound fetal abdominal circumference of 35 centimeters or more. Obstet Gynecol. Apr 1999;93(4):523-6. [Medline].

  17. Ben-Haroush A, Yogev Y, Bar J, et al. Accuracy of sonographically estimated fetal weight in 840 women with different pregnancy complications prior to induction of labor. Ultrasound Obstet Gynecol. Feb 2004;23(2):172-6. [Medline].

  18. De Reu PA, Smits LJ, Oosterbaan HP, Nijhuis JG. Value of a single early third trimester fetal biometry for the prediction of birth weight deviations in a low risk population. J Perinat Med. 2008;36(4):324-9. [Medline].

  19. Coomarasamy A, Connock J, Thornton J, Khan KS. Accuracy of ultrasound biometry in the prediction of macrosomia: a systematic quantitative review. BJOG. 2005;112:1461-66.

  20. Loetworawanit R, Chittacharoen A, Sututvoravut, S. Intrapartum fetal abdominal circumference by ultrasonography for predicting fetal macrosomia. J Med Assoc Thai. 2006;Suppl 4:S60-4.

  21. Rouse DJ, Owen J, Goldenberg RL, Cliver SP. The effectiveness and costs of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound. JAMA. Nov 13 1996;276(18):1480-6. [Medline].

  22. Combs CA, Singh NB, Khoury JC. Elective induction versus spontaneous labor after sonographic diagnosis of fetal macrosomia. Obstet Gynecol. Apr 1993;81(4):492-6. [Medline].

  23. Cheng Y, Sparks T, Laros R Jr, Nicholson J, Caughey A. Impending macrosomia: will induction of labour modify the risk of caesarean delivery?. BJOG. Mar 2012;119(4):402-9. [Medline].

  24. Acker DB, Gregory KD, Sachs BP, Friedman EA. Risk factors for Erb-Duchenne palsy. Obstet Gynecol. Mar 1988;71(3 Pt 1):389-92. [Medline].

  25. Buchanan TA, Kjos SL, Montoro MN, et al. Use of fetal ultrasound to select metabolic therapy for pregnancies complicated by mild gestational diabetes. Diabetes Care. Apr 1994;17(4):275-83. [Medline].

  26. Walkinshaw SA. Dietary regulation for 'gestational diabetes'. Cochrane Database Syst Rev. 2000;(2):CD000070. [Medline].

  27. Parker JD, Abrams B. Prenatal weight gain advice: an examination of the recent prenatal weight gain recommendations of the Institute of Medicine. Obstet Gynecol. May 1992;79(5 (Pt 1)):664-9. [Medline].

  28. Cogswell ME, Serdula MK, Hungerford DW, Yip R. Gestational weight gain among average-weight and overweight women--what is excessive?. Am J Obstet Gynecol. Feb 1995;172(2 Pt 1):705-12. [Medline].

  29. Bianco AT, Smilen SW, Davis Y, et al. Pregnancy outcome and weight gain recommendations for the morbidly obese woman. Obstet Gynecol. Jan 1998;91(1):97-102. [Medline].

  30. ACOG Committee Opinion number 315, September 2005. Obesity in pregnancy. Obstet Gynecol. Sep 2005;106(3):671-5. [Medline].

  31. Boney CM, Verma A, Tucker R, Vohr BR. Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus. Pediatrics. Mar 2005;115(3):e290-6. [Medline].

  32. Jovanovic-Peterson L, Peterson CM, Reed GF, Metzger BE, Mills JL, Knopp RH. Maternal postprandial glucose levels and infant birth weight: the Diabetes in Early Pregnancy Study. The National Institute of Child Health and Human Development--Diabetes in Early Pregnancy Study. Am J Obstet Gynecol. Jan 1991;164(1 Pt 1):103-11. [Medline].

  33. Schrauwers C, Dekker G. Maternal and perinatal outcome in obese pregnant patients. J Matern Fetal Neonatal Med. Mar 2009;22(3):218-26. [Medline].

  34. Maggard MA, Yermilov I, Maglione M, et al. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA. 2008;300(19):2286-96.

  35. Karmon A, Sheiner E. Pregnancy after bariatric surgery: a comprehensive review. Arch Gynecol Obstet. May 2008;277(5):381-8. [Medline].

  36. Raio L, Ghezzi F, Di Naro E, et al. Perinatal outcome of fetuses with a birth weight greater than 4500 g: an analysis of 3356 cases. Eur J Obstet Gynecol Reprod Biol. Aug 15 2003;109(2):160-5. [Medline].

  37. Alexander GR, Himes JH, Kaufman RB, et al. A United States national reference for fetal growth. Obstet Gynecol. Feb 1996;87(2):163-8. [Medline].

  38. Babinszki A, Kerenyi T, Torok O, et al. Perinatal outcome in grand and great-grand multiparity: effects of parity on obstetric risk factors. Am J Obstet Gynecol. Sep 1999;181(3):669-74. [Medline].

  39. Benedetti TJ, Gabbe SG. Shoulder dystocia. A complication of fetal macrosomia and prolonged second stage of labor with midpelvic delivery. Obstet Gynecol. Nov 1978;52(5):526-9. [Medline].

  40. Deter RL, Hadlock FP. Use of ultrasound in the detection of macrosomia: a review. J Clin Ultrasound. Oct 1985;13(8):519-24. [Medline].

  41. Dooley SL, Metzger BE, Cho NH. Gestational diabetes mellitus. Influence of race on disease prevalence and perinatal outcome in a U.S. population. Diabetes. Dec 1991;40 Suppl 2:25-9. [Medline].

  42. Ecker JL, Greenberg JA, Norwitz ER, et al. Birth weight as a predictor of brachial plexus injury. Obstet Gynecol. May 1997;89(5 Pt 1):643-7. [Medline].

  43. Flamm BL, Goings JR. Vaginal birth after cesarean section: is suspected fetal macrosomia a contraindication?. Obstet Gynecol. Nov 1989;74(5):694-7. [Medline].

  44. Gonen O, Rosen DJ, Dolfin Z, et al. Induction of labor versus expectant management in macrosomia: a randomized study. Obstet Gynecol. Jun 1997;89(6):913-7. [Medline].

  45. Homko CJ, Sivan E, Nyirjesy P, Reece EA. The interrelationship between ethnicity and gestational diabetes in fetal macrosomia. Diabetes Care. Nov 1995;18(11):1442-5. [Medline].

  46. Juntunen K, Kirkinen P, Kauppila A. The clinical outcome in pregnancies of grand grand multiparous women. Acta Obstet Gynecol Scand. Sep 1997;76(8):755-9. [Medline].

  47. Klebanoff MA, Mills JL, Berendes HW. Mother's birth weight as a predictor of macrosomia. Am J Obstet Gynecol. Oct 1 1985;153(3):253-7. [Medline].

  48. Larsen CE, Serdula MK, Sullivan KM. Macrosomia: influence of maternal overweight among a low-income population. Am J Obstet Gynecol. Feb 1990;162(2):490-4. [Medline].

  49. Little RE, Sing CF. Genetic and environmental influences on human birth weight. Am J Hum Genet. Jun 1987;40(6):512-26. [Medline].

  50. McFarland MB, Trylovich CG, Langer O. Anthropometric differences in macrosomic infants of diabetic and nondiabetic mothers. J Matern Fetal Med. Nov-Dec 1998;7(6):292-5. [Medline].

  51. Sermer M, Naylor CD, Gare DJ, et al. Impact of increasing carbohydrate intolerance on maternal-fetal outcomes in 3637 women without gestational diabetes. The Toronto Tri-Hospital Gestational Diabetes Project. Am J Obstet Gynecol. Jul 1995;173(1):146-56. [Medline].

  52. Spellacy WN. Shoulder dystocia risks. Am J Obstet Gynecol. Apr 1999;180(4):1047. [Medline].

  53. Toohey JS, Keegan KA, Morgan MA, et al. The "dangerous multipara": fact or fiction?. Am J Obstet Gynecol. Feb 1995;172(2 Pt 1):683-6. [Medline].

 
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Photograph of a macrosomic newborn soon after birth.
 
 
 
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