Macrosomia Treatment & Management

  • Author: Allahyar Jazayeri, MD, PhD, FACOG, DACOG, FSMFM; Chief Editor: David Chelmow, MD   more...
 
Updated: Feb 4, 2010
 

Medical Care

  • Risks associated with macrosomia can be divided into 3 groups: maternal risks, fetal risks, and neonatal risks.
    • Maternal risks include risks associated with the passage of a large fetus through the birth canal. Macrosomic fetuses place the mother at increased risk of birth canal (eg, perineal, vaginal, cervical) lacerations. In addition, the risk of cesarean delivery is higher in pregnancies complicated by macrosomia.[3] Cesarean delivery places the mother at risk for problems associated with major abdominal surgery, which include infections, bleeding, and damage to adjacent organs (eg, bladder, uterus, fallopian tubes, ovaries, intestines, ureter). It also places the mother at risk for complications associated with regional and general anesthesia.
    • Fetal risks associated with macrosomia include birth trauma (3-7%), including shoulder dystocia (9.2-24%); brachial plexus injuries (1-4%); and death (0.4%).[5]
    • Neonatal risks associated with macrosomia include hypoglycemia (50%), hematological disturbances (ie, polycythemia), and electrolyte disturbances (up to 50%).
  • A consensus has not been reached regarding management strategies to reduce the risk of macrosomia. Cesarean delivery to reduce the risk associated with macrosomia places the mother at risk, and subsequent pregnancies are at risk of uterine dehiscence before or during the onset of labor. Not all cases of nerve injuries can be prevented by cesarean delivery because some occur in utero. Estimates indicate that as many as 3700 cesarean deliveries must be performed to prevent a single permanent nerve injury in macrosomic infants.[21]
  • Induction of labor for probable macrosomia has not been shown to significantly change outcomes. Some studies have shown increased rates of cesarean delivery when labor induction was attempted because of macrosomia.[22]
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Surgical Care

  • The obstetrician involved in the care of a macrosomic infant must be familiar with procedures that release a shoulder dystocia at delivery.
  • Because macrosomic infants are more likely to be born by cesarean delivery because of cephalopelvic disproportion, the obstetrician caring for a mother with risk factors must be capable of performing a cesarean delivery or must have backup help available in case cesarean delivery is necessary.
  • Operative vaginal deliveries (eg, forceps, vacuum) must be performed with caution in infants with risk factors for macrosomia. Midpelvic procedures are associated with a much greater risk of significant shoulder dystocia (50%) in macrosomic infants than nonmacrosomic infants.[23] Other than in absolute emergencies, do not perform these types of procedures in a possibly macrosomic infant. Instead, proceed to cesarean delivery.
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Consultations

  • In patients with poorly controlled diabetes resulting in macrosomia, consultation with a maternal fetal medicine specialist to obtain better control may be useful.
  • In cases of significant macrosomia (estimated fetal weight >99th percentile), a careful evaluation of the dates and a sonographic evaluation of fetal anatomy can be helpful to investigate potential causes of the macrosomia. Incorrect gestational age is frequently encountered and may result in estimated fetal weights that are greater than the 90th percentile but usually should not result in estimations greater than 4000 or 4500 grams. Intra-abdominal and intracranial masses may result in larger abdomen and head measurements resulting in a large estimated fetal weight. Such causes should be diagnosed prior to delivery if at all possible.
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Diet

  • Maternal obesity and maternal weight gain in pregnancy are 2 of the strongest predictors of macrosomia at birth; therefore, a reasonable belief is that appropriate dietary education in pregnancy may help prevent prepregnancy obesity and excessive maternal weight gain in pregnancy. Intuitively, this type of intervention, if successful, may reduce the risks of macrosomia in those women who are obese prior to pregnancy or who may gain excessive weight in pregnancy. However, this has not been tested in clinical trials.
  • No studies have been performed on maternal dietary intervention and the risk of macrosomia in pregnancy in nondiabetic women. In diabetic patients, maternal diet alone, without the use of insulin, did not alter rates of macrosomia.[24, 25]
  • Excessive maternal weight gain can double the risk of macrosomia; thus, a reasonable suggestion is careful weight control for women who exceed the recommended weight gain in pregnancy.[26, 27, 28]
  • In diabetic patients, diet control and the addition of insulin therapy has been shown to significantly reduce the incidence of birth weight greater than the 90th percentile for gestational age.
  • Because maternal obesity in pregnancy is associated with fetal macrosomia, gestational diabetes, increased risk of ces arean deliveries, and preeclampsia, appropriate dietary education in pregnancy and preconception should be provided to all patients who are at risk of obesity and excessive weight gain in pregnancy. Such intervention may potentially reduce maternal and neonatal risks. At the present time, clinical trials are lacking support of the effectiveness of such intervention.[29]
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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, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, 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, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making

Disclosure: Nothing to disclose.

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Photograph of a macrosomic newborn soon after birth.
 
 
 
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