OBSTETRIC AND GYNEACOLOGY

Year 5, MBBS 08/09

CASE WRITE-UP
MACROSOMIA

Name: Mohamad Aizuddin bin Ahmad Matric No.: 0808-0811 Group/ Rotation: 01/5 Supervisor: Assoc.

Prof. Dr. Mohd Haizal Mohd Nor

PATIENTS HISTORY History Madam NH, 34 year old malay lady from Putrajaya G4P3 at 38 period of gestation was admitted yesterday for elective lower segment caeserian section secondary to macrosomic baby. Her LNMP was 3/4/12 and her EDD is 10/1/13. Patient detect the pregnancy when she missed period for 2 months. Then she confirmed the pregnancy in private clinic by urine pregnancy test. Booking was done at 12 week of pregnancy in KK Putrajaya. During booking fasting blood glucose is 5.6, BP 92/72, weight is 123kg, height 140cm, HB 12.5, blood test for infectious disease was non reactive, and maternal blood group is O+. 3 scans was done throughout the pregnancy, 1st scan at 16 weeks which reveal normal size fetus and normal amount of liquor, but during 2nd scan which at 28 weeks, fetus was detected to be larger than dates and the latest scan which at 36 weeks of pregnancy show a big fetus estimated weight of 4.4kg. Throughout the pregnancy maternal blood was well controlled which 1 set of blood sugar profile was done at 28 week and the result was normal which the reading is 6, 4.7, 4.3, 4. Throughout the pregnancy maternal weight gain is 13kg besides of maternal is obese with BMI of 35. Previous pregnancy patient was blessed with 3 children which all of them are boys, delivered in 2001, 2004 and 2010 and was delivered uneventful via spontaneous vaginal delivery and was breastfeed up to 6 month. The weight of the baby is 3.7kg, 3.4kg and 3.1kg. During the 3rd or previous pregnancy patient was diagnosed with gestational diabetes mellitus on insulin and was induced at 38 weeks. Both patients parent has type 2 diabetes mellitus. Beside that, no other significant history.

PHYSICAL EXAMINATION On inspection, patient lying supine, alert but uncomfortable with overdistended abdomen, pulse rate 78 beats per minute, with regular rhythm and good volume, bp 114/75, patient is not pale, no sign of dehydration. Her abdomen was distended with gravid uterus as evidence by linea nigra and striae gravidarum. Umbilical is everted, no skin changes, no dilated but there are visible vein. On palpation, abdomen was soft and non tender. Symphysis fundal height was 40 cm which is larger than dates, baby singleton, with fetal back on the right side of maternal, oblique lie with head at left iliac fossa.

PROVISIONAL DIAGNOSIS

Elective lower segment caeserian section secondary to macrosomic baby.

DISCUSSION Risk of macrosomic baby in this patient Fetal macrosomia is defined when the fetal weight is more than 4kg or greater than 90% of gestational age. The delivery of a macrosomic fetus (defined as a birth weight of at least 4000 g) is associated with prolonged labor, an increased likelihood of operative delivery. The pathophysiology of macrosomic baby is, poorly controlled macrosomia and have intermittent periods of hyperglycemia in common. Hyperglycemia in the fetus results in the stimulation of insulin, insulinlike growth factors, growth hormone, and other growth factors, which, in turn, stimulate fetal growth and deposition of fat and glycogen. It is very important to anticipate macrosomic fetus for proper and safe delivery. It is very important to know patient that at risk to develop macrosomic baby. If we can prevent maternal to develop macrosomic baby, then we can prevent more co-morbid to maternal and especially to fetus in this case. Although the causes of high birthweight include both genetic and environmental factors, the rapid increase in the maternal overweight and associated metabolic changes, including type 2 and gestational diabetes, play a central role. Other study stated that, Fasting plasma glucose at week 3032, but not fasting plasma insulin or insulin resistance, is a determinant of newborn macrosomia. Overweight women with high increase in fasting plasma glucose from early to late pregnancy had a 4.5-fold increase in risk of newborn macrosomia compared to the remaining group with high BMI. Among the risk factors to develop macrosomic baby that is related to this patient is maternal overweight, patient gestational diabetes, type 2 diabetes mellitus, and previous macrosomic baby. Neonatal birth weight and the incidence of macrosomia were similar in comparison of pregnancies with and without GDM. In the population of Caucasian women the strongest single predictors for macrosomia were prior macrosomia, BMI>23kg/m(2) and prior GDM. According to this study, the three most important predictor of macrosomic baby is prior macrosomia, maternal BMI more than 23 and prior gestational diabetes mellitus. Even the latest study state that they can predict the sex depending on oral glucose tolerance test. There is sexual dimorphism in the risk of abnormal birth weight attributed to maternal glucose tolerance status. A closer surveillance of foetal growth might be warranted in pregnant women with abnormal glucose tolerance carrying a male fetus. There are many study done show the risk of future macrosomic baby according to certain features and certain investigation. Given the complications that are associated with delivering large babies, overweight women may benefit from not gaining excess weight gain in pregnancy, The corrected weight gain is a better estimate of true accretion of maternal weight. Our results suggest that recommendations for weight gain during pregnancy should take this index into account, There is no difference in accuracy

between ultrasonographically EFW and AC in the prediction of a macrosomic baby at birth. A positive test result is more accurate for ruling in macrosomia than a negative test result for ruling it out, There is a significant correlation between mid-third-trimester AFI and BW. AFI > or = 60th percentile and EFW > or = 71st percentile during the mid third trimester are useful predictors of severe macrosomia at birth

Complication in macrosomic baby.

When we encounter patient that has high risk or patient that alredy diagnose as macrosomic baby must take precaution especially in the rule of choosing methods of delivery. There are many complication of macrosomic baby. Gestational diabetes, maternal obesity, increasing age and parity were the main risk factors for fetal macrosomia. The incidence of shoulder dystocia, birth injuries and neonatal morbidity increased in this group. The larger the baby or fetus the higher complication might occur. Birth weight greater than 4500 g, and especially greater than 5000 g, is associated with increased risks of perinatal and infant mortality and morbidity. With multiple complication, patient also can encounter these dangerous condition in the next pregnancy. Women with a history of one macrosomic infant are at significantly increased risk of another macrosomic infant in a subsequent pregnancy. We know that that there are many complication especially to the fetus if the development of macrosomic baby occur. Therefore, proper evaluation and monitoring need to be done in this patient and the fetus. Macrosomia was associated with an increased risk of adverse maternal and neonatal health outcomes. Optimal management strategies of macrosomic pregnancies need evaluation. Lastly, patient need to go into delivery if the already reach the exact time. Before choosing the types of delivery we need to assess maternal and fetus condition if they fit for vaginal delivery. Macrosomia was associated with increased rates of instrumental delivery and anal sphincter injury regardless of parity, and additionally with increased rates of caesarean delivery and shoulder dystocia among nulliparas. Overall, 88% of women who laboured with a macrosomic infant achieved vaginal delivery.

References

BMJ Bestpractice Acta Obstetricia et Gynecologica Scandinavi, Volume 87, Issue 2, pages 134 145, February 2008 Suneet P. Chauhan, MD,Suspicion and treatment of the macrosomic fetus: A review, American Journal of Obstetrics and Gynecology (2005) 193, 33246 Nanna voldner et.al, Increased risk of macrosomia among overweight women with high gestational rise in fasting glucose, January 2010, Vol. 23, No. 1 Ogonowski J, Factors influencing risk of macrosomia in women with gestational diabetes mellitus undergoing intensive diabetic care, Diabetes Res Clin Pract. 2008 Jun;80(3):405-10. doi: 10.1016/j.diabres.2008.01.017. Epub 2008 Mar 14.

W. Ricart, Maternal glucose tolerance status influences the risk of macrosomia in male but not in female foetuses, J Epidemiol Community Health 2009;63:64-68 doi:10.1136/jech.2008.074542

PREPREGNANT BODY MASS INDEX, WEIGHT GAIN AND THE RISK OF DELIVERING LARGE BABIES AMONG NON-DIABETIC MOTHERS, Int J Gynaecol Obstet. 2007 May; 97 100104.

Fetal macrosomia and maternal weight gain during pregnancy Doi : DM-092002-28-4-1262-3636-101019-ART9

Accuracy of ultrasound biometry in the prediction of macrosomia: a systematic quantitative review, BJOG: An International Journal of Obstetrics & Gynaecology Volume 112, Issue 11 pages 14611466, November 2005 How big is too big? The perinatal consequences of fetal macrosomia, American Journal of Obstetrics & Gynecology Volume 198, Issue 5, Pages 517.e1-517.e6, May 2008 Fetal macrosomia. Risk factor and outcome. Saudi Medical Journal [2005, 26(1):96-100]