A systematic review of outcomes of maternal weight gain according to the Institute of Medicine recommendations: birthweight, fetal growth, and postpartum weight retention

This systematic review focuses on outcomes of gestational weight gain, specifically birthweight, fetal growth, and postpartum weight retention, for singleton pregnancies with respect to the 1990 Institute of Medicine weight gain recommendations. A total of 35 studies met the inclusion criteria and were reviewed. There was strong evidence to support associations between excessive gestational weight gain and increased birthweight and fetal growth (large for gestational age) as well as inadequate gestational weight gain and decreased birthweight and fetal growth (small for gestational age). There was moderate evidence to support the association between excessive gestational weight gain and postpartum weight retention. Clear clinical recommendations based on this review are challenging because of several limitations in the literature. Improvements in future research include the use of consistent definitions of gestational weight gain and outcomes of interest, assessment of confounders, and better collection of weight and weight gain data.

Macrosomia and hyperinsulinaemic hypoglycaemia in patients with heterozygous mutations in the HNF4A gene

BACKGROUND

Macrosomia is associated with considerable neonatal and maternal morbidity. Factors that predict macrosomia are poorly understood. The increased rate of macrosomia in the offspring of pregnant women with diabetes and in congenital hyperinsulinaemia is mediated by increased foetal insulin secretion. We assessed the in utero and neonatal role of two key regulators of pancreatic insulin secretion by studying birthweight and the incidence of neonatal hypoglycaemia in patients with heterozygous mutations in the maturity-onset diabetes of the young (MODY) genes HNF4A (encoding HNF-4alpha) and HNF1A/TCF1 (encoding HNF-1alpha), and the effect of pancreatic deletion of Hnf4a on foetal and neonatal insulin secretion in mice.

METHODS AND FINDINGS

We examined birthweight and hypoglycaemia in 108 patients from families with diabetes due to HNF4A mutations, and 134 patients from families with HNF1A mutations. Birthweight was increased by a median of 790 g in HNF4A-mutation carriers compared to non-mutation family members (p < 0.001); 56% (30/54) of HNF4A-mutation carriers were macrosomic compared with 13% (7/54) of non-mutation family members (p < 0.001). Transient hypoglycaemia was reported in 8/54 infants with heterozygous HNF4A mutations, but was reported in none of 54 non-mutation carriers (p = 0.003). There was documented hyperinsulinaemia in three cases. Birthweight and prevalence of neonatal hypoglycaemia were not increased in HNF1A-mutation carriers. Mice with pancreatic beta-cell deletion of Hnf4a had hyperinsulinaemia in utero and hyperinsulinaemic hypoglycaemia at birth.

CONCLUSIONS

HNF4A mutations are associated with a considerable increase in birthweight and macrosomia, and are a novel cause of neonatal hypoglycaemia. This study establishes a key role for HNF4A in determining foetal birthweight, and uncovers an unanticipated feature of the natural history of HNF4A-deficient diabetes, with hyperinsulinaemia at birth evolving to decreased insulin secretion and diabetes later in life.

Maternal obesity and occurrence of fetal macrosomia: a systematic review and meta-analysis

OBJECTIVE

To determine a precise estimate for the contribution of maternal obesity to macrosomia.

DATA SOURCES

The search strategy included database searches in 2011 of PubMed, Medline (In-Process & Other Non-Indexed Citations and Ovid Medline, 1950-2011), and EMBASE Classic + EMBASE. Appropriate search terms were used for each database. Reference lists of retrieved articles and review articles were cross-referenced.

METHODS OF STUDY SELECTION

All studies that examined the relationship between maternal obesity (BMI ≥30 kg/m(2)) (pregravid or at 1st prenatal visit) and fetal macrosomia (birth weight ≥4000 g, ≥4500 g, or ≥90th percentile) were considered for inclusion.

TABULATION, INTEGRATION, AND RESULTS

Data regarding the outcomes of interest and study quality were independently extracted by two reviewers. Results from the meta-analysis showed that maternal obesity is associated with fetal overgrowth, defined as birth weight ≥ 4000 g (OR 2.17, 95% CI 1.92, 2.45), birth weight ≥4500 g (OR 2.77,95% CI 2.22, 3.45), and birth weight ≥90% ile for gestational age (OR 2.42, 95% CI 2.16, 2.72).

CONCLUSION

Maternal obesity appears to play a significant role in the development of fetal overgrowth. There is a critical need for effective personal and public health initiatives designed to decrease prepregnancy weight and optimize gestational weight gain.

Fetal growth: a review of terms, concepts and issues relevant to obstetrics

The perinatal literature includes several potentially confusing and controversial terms and concepts related to fetal size and growth. This article discusses fetal growth from an obstetric perspective and addresses various issues including the physiologic mechanisms that determine fetal growth trajectories, known risk factors for abnormal fetal growth, diagnostic and prognostic issues related to restricted and excessive growth and temporal trends in fetal growth. Also addressed are distinctions between fetal growth 'standards' and fetal growth 'references', and between fetal growth charts based on estimated fetal weight vs those based on birth weight. Other concepts discussed include the incidence of fetal growth restriction in pregnancy (does the frequency of fetal growth restriction increase or decrease with increasing gestation?), the obstetric implications of studies showing associations between fetal growth and adult chronic illnesses (such as coronary heart disease) and the need for customizing fetal growth standards.

Animal evidence for the transgenerational development of diabetes mellitus

The mammalian fetus develops inside the uterus of its mother and is completely dependent on the nutrients supplied by its mother. Disturbances in the maternal metabolism that alter this nutrient supply from mother to fetus can induce structural and functional adaptations during fetal development, with lasting consequences for growth and metabolism of the offspring throughout life. This effect has been investigated, by several research groups, in different experimental models where the maternal metabolism during pregnancy was experimentally manipulated (maternal diabetes and maternal malnutrition) and the effect on the offspring was investigated. The altered maternal/fetal metabolism appears to be associated with a diabetogenic effect in the adult offspring, including gestational diabetes. This diabetic pregnancy in the offspring again induces a diabetogenic effect into the next generation, via adaptations during fetal development. These experimental data in laboratory animals are confirmed by epidemiological studies on infants of mothers suffering from diabetes or malnutrition during pregnancy. It can be concluded that fetal development in an abnormal intra-uterine milieu can induce alterations in the fetal metabolism, with lasting consequences for the glucose tolerance of the offspring in adult life. The most marked effect is the development of gestational diabetes, thereby transmitting the diabetogenic tendency to the next generation again. The concept of fetal origin of adult diabetes therefore is of major significance for public health in the immediate and the far future.

Incidence of persistent birth injury in macrosomic infants: association with mode of delivery

OBJECTIVE

Our purpose was to determine the incidence of birth injury in a cohort of macrosomic infants (birth weight >4000 gm) and analyze the association between persistent injury and delivery method.

STUDY DESIGN

Deliveries of 2924 macrosomic infants were reviewed. Outcomes were compared with those of 16,711 infants with birth weights between 3000 and 3999 gm.

RESULTS

Macrosomic infants had a sixfold increase in significant injury relative to controls (relative risk 6.7,95% confidence interval 6.5 to 6.9). Risk of trauma correlated with delivery mode: forceps were associated with a fourfold risk of clinically persistent findings compared with spontaneous vaginal delivery or cesarean section. However, the overall incidence of persistent cases remained low (0.3%); a policy of elective cesarean section for macrosomia would necessitate 148 to 258 cesarean sections to prevent a single persistent injury. Avoidance of operative vaginal delivery would require 50 to 99 cesarean sections per injury prevented.

CONCLUSIONS

These findings support a trial of labor and judicious operative vaginal delivery for macrosomic infants.

The outcome of macrosomic infants weighing at least 4500 grams: Los Angeles County + University of Southern California experience

OBJECTIVE

To describe the maternal and neonatal outcome of macrosomic infants weighing at least 4500 g.

METHODS

Maternal and neonatal records of infants with birth weights of at least 4500 g were identified during 1991. Outcome variables included the mode of delivery and incidence of maternal and perinatal complications.

RESULTS

The study sample consisted of 227 infant and mother pairs. Mean (+/- standard deviation) birth weight was 4706 +/- 219 g. A trial of labor was allowed in 192 women, and elective cesarean delivery was performed in 35 patients. The overall cesarean rate, including elective cesarean delivery and failed trial of labor, was 30.8% (70 of 227). Of those undergoing a trial of labor, 82% (157) delivered vaginally. Shoulder dystocia occurred 29 times, for an incidence of 18.5% in vaginal deliveries for macrosomia. There were seven cases each of Erb palsy and clavicular fracture, and one humeral fracture. By 2 months of age, all affected infants were without permanent sequelae. There was no birth asphyxia or perinatal mortality related to delivery for macrosomia. Maternal complications included increased risk of lacerations requiring repair (especially third- or fourth-degree lacerations) when vaginal delivery was complicated by shoulder dystocia (relative risk [RR] 5.4, 95% confidence interval [CI] 3.1-9.4). There was no statistically significant difference with respect to hemorrhage or hospital stay for women who had a vaginal delivery (with or without shoulder dystocia) compared with women who had a cesarean delivery. However, infectious morbidity increased significantly in those patients who underwent a cesarean after a trial of labor compared with women who had a vaginal delivery (RR 7.1, 95% CI 3.9-13.1) or elective cesarean birth (RR 5.4, 95% CI 3.1-9.4). Ninety-one percent of patients undergoing elective cesarean delivery had no complications.

CONCLUSION

Vaginal delivery is a reasonable alternative to elective cesarean for infants with estimated birth weights of at least 4500 g, and a trial of labor can be offered.

Gestational diabetes and subsequent growth patterns of offspring: the National Collaborative Perinatal Project

Our objective was to test the hypothesis that intrauterine exposure to gestational diabetes [GDM] predicts childhood growth independent of the effect on infant birthweight. We conducted a prospective analysis of 28,358 mother-infant pairs who enrolled in the National Collaborative Perinatal Project between 1959 and 1965. The offspring were followed until age 7. Four hundred and eighty-four mothers (1.7%) had GDM. The mean birthweight was 3.2 kg (range 1.1-5.6 kg). Maternal characteristics (age, education, race, family income, pre-pregnancy body mass index and pregnancy weight gain) and measures of childhood growth (birthweight, weight at ages 4, and 7) differed significantly by GDM status (all P < 0.05). As expected, compared to their non-diabetic counterparts, mothers with GDM gave birth to offspring that had higher weights at birth. The offspring of mothers with GDM were larger at age 7 as indicated by greater weight, BMI and BMI z-score compared to the offspring of mothers without GDM at that age (all P < 0.05). These differences at age 7 persisted even after adjustment for infant birthweight. Furthermore, the offspring of mothers with GDM had a 61% higher odds of being overweight at age 7 compared to the offspring of mothers without GDM after adjustment for maternal BMI, pregnancy weight gain, family income, race and birthweight [OR = 1.61 (95%CI:1.07, 1.28)]. Our results indicate that maternal GDM status is associated with offspring overweight status during childhood. This relationship is only partially mediated by effects on birthweight.

Abnormal fetal growth: intrauterine growth retardation, small for gestational age, large for gestational age

The two extremes of abnormal fetal growth are restricted growth and excessive growth, both of which originate from alterations in the uterine metabolic milieu. The fetus must adapt to these conditions to survive. In both instances, however, the inciting insult and the subsequent adaptation of the fetus carry long-term health consequences. In some instances, these changes may have generational implications. Counseling and care by pediatricians should be directed at the continuum of age ranges, including the expectant mother, the newborn, the child and adolescent, and future generations.

Determinants of fetal growth at different periods of pregnancies complicated by gestational diabetes mellitus or impaired glucose tolerance

OBJECTIVE

To determine maternal parameters with the strongest influence on fetal growth in different periods of pregnancies complicated by an abnormal glucose tolerance test (GTT).

RESEARCH DESIGN AND METHODS

Retrospective study of 368 women with gestational diabetes mellitus (GDM; > or = 2 abnormal GTT values, n = 280) and impaired glucose tolerance (IGT; one abnormal value, n = 88) with 869 ultrasound examinations at entry to and during diabetic care. Both groups were managed comparably. Abdominal circumference (AC) > or = 90th percentile defined fetal macrosomia. Maternal historical and clinical parameters, and diagnostic and glycemic values of glucose profiles divided into five categories of 4 weeks of gestational age (GA; <24 weeks, 24 weeks/0 days to 27 weeks/6 days, 28/0-31/6, 32/0-35/6, and 36/0-40/0 [referred to as <24 GA, 24 GA, 28 GA, 32 GA, and 36 GA categories, respectively]) were tested by univariate and multiple logistic regression analysis for their ability to predict an AC > or = 90th percentile at each GA group and large-for-gestational-age (LGA) newborn. Data obtained at entry were also analyzed separately irrespective of the GA.

RESULTS

Maternal weight, glycemia after therapy, rates of fetal macrosomia, and LGA were not significantly different between GDM and IGT; thus, both groups were analyzed together. LGA in a previous pregnancy, (odds ratio [OR] 3.6; 95% CI 1.8-7.3) and prepregnancy obesity (BMI > or = 30 kg/m(2); 2.1; 1.2-3.7) independently predicted AC > or = 90th percentile at entry. When data for each GA category were analyzed, no predictors were found for <24 GA. Independent predictors for each subsequent GA category were as follows: at 24 GA, LGA history (OR 9.8); at 28 GA, LGA history (OR 4.2), and obesity (OR 3.3); at 32 GA, fasting glucose of 32 GA (OR 1.6 per 5-mg/dl increase); at 36 GA, fasting glucose of 32 GA (OR 1.6); and for LGA at birth, LGA history (OR 2.7), and obesity (OR 2.4).

CONCLUSIONS

In the late second and early third trimester, maternal BMI and LGA in a previous pregnancy appear to have the strongest influence on fetal growth, while later in the third trimester coincident with the period of maximum growth described in diabetic pregnancies, maternal glycemia predominates.

Gestational diabetes: weight gain during pregnancy and its relationship to pregnancy outcomes

BACKGROUND

Weight gain during pregnancy reflects the mother's nutritional status. However, it may be affected by nutritional therapy and exercise interventions used to control blood sugar in gestational diabetes mellitus (GDM). This study aimed to evaluate weight gain during gestation and pregnancy outcomes among women with GDM.

METHODS

A retrospective study involving 1523 women with GDM was conducted between July 2013 and July 2016. Demographic data, gestational weight gain (GWG), blood glucose, glycated-hemoglobin level, and maternal and fetal outcomes were extracted from medical records. Relationships between GWG and pregnancy outcomes were investigated using multivariate logistic regression.

RESULTS

In total, 451 (29.6%) women showed insufficient GWG and 484 (31.8%) showed excessive GWG. Excessive GWG was independently associated with macrosomia (adjusted odds ratio [aOR] 2.20, 95% confidence interval [CI] 1.50-3.52, P < 0.001), large for gestational age (aOR 2.06, 95% CI 1.44-2.93, P < 0.001), small for gestational age (aOR 0.49, 95% CI 0.25-0.97, P = 0.040), neonatal hypoglycemia (aOR 3.80, 95% CI 1.20-12.00, P = 0.023), preterm birth (aOR 0.45, 95% CI 0.21-0.96, P = 0.040), and cesarean delivery (aOR 1.45, 95% CI 1.13-1.87, P = 0.004). Insufficient GWG increased the incidence of preterm birth (aOR 3.53, 95% CI 1.96-6.37, P < 0.001).

CONCLUSIONS

Both excessive and insufficient weight gain require attention in women with GDM. Nutritional therapy and exercise interventions to control blood glucose should also be used to control reasonable weight gain during pregnancy to decrease adverse pregnancy outcomes.

Gestational diabetes and its impact on the neonate

Gestational diabetes mellitus is a relatively common medical condition that was described as early as the nineteenth century. This article discusses the maternal and fetal pathophysiology and the impact of the maternal condition on the neonate. Fetal macrosomia and infant respiratory distress syndrome, cardiomyopathy, hypoglycemia, hypocalcemia, hypomagnesemia, polycythemia, and hyperviscosity all can occur as a result of maternal hyperglycemia and are discussed in detail. Therapeutic approaches and treatment options for the mother, manifestations and diagnosis of the infant, and current research related to this condition are also included.

Hyperinsulinemia in macrosomic infants of nondiabetic mothers

OBJECTIVE

We tested the hypothesis that macrosomic infants of nondiabetic mothers are more likely to have hyperinsulinemia and increased subcutaneous fat.

RESEARCH DESIGN AND METHODS

Plasma insulin concentrations were measured in cord blood from 50 macrosomic infants and 32 normal-sized (control), term infants. All mothers had had a normal 50-g 1-h GCT. Skin-fold measurements of the triceps and subscapular area were done on 44 macrosomic infants with a Halpern caliper.

RESULTS

No difference was observed in GCT between mothers of macrosomic (5.8 +/- 1.0 mM) and normal (5.7 mM) infants. The insulin level in macrosomic infants (18.75 +/- 19.08 microU/ml) was significantly higher than in control infants (8.67 +/- 6.64 microU/ml). Macrosomia was a predictor of hyperinsulinemia and vice versa (R2 = 0.26). Maternal height, prepregnancy weight, and weight gain were predictors for macrosomia (R2 = 0.26). No differences were noted in anthropometric measurements between hyperinsulinemic and normoinsulinemic infants.

CONCLUSIONS

A subset of macrosomic infants have hyperinsulinemia. Maternal anthropometric factors as well as hyperinsulinemia are correlated with macrosomia. The macrosomia may be causally related to the high insulin levels.

Estimators of birth weight in pregnant women requiring insulin: a comparison of seven sonographic models

OBJECTIVE

To determine if the relative accuracy of the sonographic estimate of birth weight among diabetic gravidas requiring insulin improves significantly as more fetal measurements are used.

METHODS

We studied 172 diabetic women requiring insulin who had sonographic measurements of fetal parts within 7 days of delivery. Friedman nonparametric analysis of variance followed by Dunn multiple comparison and chi 2 were used to assess the relative accuracy of the seven models. Prediction limits were calculated to determine the estimate of fetal weight that would ensure (with 90% accuracy) that the newborn was macrosomic (at least 4 kg).

RESULTS

The mean (+/- standard deviation [SD]) birth weight was 3388 +/- 727 g, and the frequency of macrosomia at term gestation was 19.4% (29 of 149). The mean standardized absolute error (g/kg) based on abdominal circumference (AC) and femur length (FL) (86 +/- 72 g/kg) was not significantly different from the other models (range 84 +/- 72 to 116 +/- 99 g/kg, P > .05). The percent of estimate within 10% of actual birth weight using AC and FL (65%) was similar to the other models (53.4-66.2%). Regardless of the White classification, the estimation of fetal weight using AC and FL had an accuracy similar to the other six regression equations. To ensure that the birth weight is at most 3999 g, the estimated fetal weight should be 3200 g, and, conversely, if the predicted weight is 4700 g, then the newborn is macrosomic.

CONCLUSION

Among patients requiring insulin, estimation of birth weight using AC and FL is as accurate as more complicated models. The ability to detect macrosomia by ultrasound is limited.

Trends in maternal BMI, glycaemic control and perinatal outcome among type 1 diabetic pregnant women in 1989-2008

AIMS/HYPOTHESIS

Our objective was to examine the trends in prepregnancy BMI and glycaemic control among Finnish type 1 diabetic patients and their relation to delivery mode and perinatal outcome.

METHODS

We analysed the obstetric records of 881 type 1 diabetic women with a singleton childbirth during 1989-2008. Maternal prepregnancy weight and height were obtained from the maternity cards, where they are recorded as reported by the mother.

RESULTS

Maternal BMI increased significantly during 1989-2008 (p < 0.001). The mean HbA(1c) in the first trimester remained unchanged, but the midpregnancy and the last HbA(1c) before delivery increased (p = 0.009 and 0.005, respectively). Elective Caesarean sections (CS) decreased (p for trend <0.001), while emergency CS increased (p for trend <0.001). The mean umbilical artery (UA) pH decreased in vaginal deliveries (p for trend <0.001). The frequency of UA pH <7.15 and <7.05 increased (p for trend <0.001 and 0.008, respectively). The macrosomia rate remained at 32-40%. Neonatal intensive care unit (NICU) admissions increased (p for trend 0.03) and neonatal hypoglycaemia frequency decreased (p for trend 0.001). In multiple logistic regression analysis, maternal BMI was associated with macrosomia and NICU admission. The last HbA(1c) value before delivery was associated with delivery before 37 weeks' gestation, UA pH <7.15, 1 min Apgar score <7, macrosomia, NICU admission and neonatal hypoglycaemia.

CONCLUSIONS/INTERPRETATION

Self-reported pregestational BMI has increased and glycaemic control during the second half of pregnancy has deteriorated. Poor glycaemic control seems to be associated with the observed increases in adverse obstetric and perinatal outcomes.

Growth patterns of large-for-gestational-age and appropriate-for-gestational-age infants of gestational diabetic mothers and control mothers at age 1 year

OBJECTIVE

The purpose of this study was to explore the development of adiposity in macrosomic and normosomic infants of mothers with gestational diabetes mellitus (GDM) and control subjects between birth and age 1 year, and assess its relation to maternal prenatal factors and neonatal factors.

RESEARCH DESIGN AND METHODS

This was a prospective observational study of 192 infants, including 47 large-for-gestational-age (LGA) infants of GDM mothers, 47 appropriate-for-gestational-age (AGA) infants of GDM mothers, 55 LGA control infants, and 44 AGA control infants who were evaluated at birth and age 1 year. Maternal prenatal and pregnancy anthropometric measurements were recorded. Multiple infant anthropometric measurements, including skinfold thicknesses, were obtained at birth and age 1 year. Regression models were run to detect the independent effects of various maternal and infant factors on 1-year child adiposity, adjusting for their effects at birth.

RESULTS

LGA infants of GDM mothers had a higher BMI, waist circumference, and abdominal skinfold at age 1 year compared with all other study groups. Among infants of GDM mothers, the mean 2-h postprandial glucose value for the second and third trimester correlated with waist circumference (r = 0.28, P < 0.04) and subscapular skinfold (r = 0.37, P < 0.007), and correlated marginally with 1-year sum of four skinfolds. Among infants of GDM mothers, a regression of 1-year sum of four skinfolds was significantly related to maternal prepregnancy weight after controlling for sum of skinfolds at birth. For control infants, the maternal glucose screen value was significantly associated with 1-year sum of skinfolds adjusted for the birth sum of skinfolds.

CONCLUSIONS

We concluded that macrosomic infants of GDM mothers have unique patterns of adiposity that are present at birth and persist at age 1 year. Further, we concluded that maternal factors, including adiposity and intrauterine fuel environment, influence the presence and distribution of adiposity for both infants of GDM mothers and control infants.

Biphasic effects of maternal metabolism on fetal growth. Quintessential expression of fuel-mediated teratogenesis

More than a decade ago, Norbert Freinkel postulated that alterations in the maternal metabolic milieu at any time during gestation can influence intrauterine development and also may have long-term consequences for certain tissues such as adipocytes, myocytes, pancreatic beta-cells, and neurons. This review illustrates that metabolic alterations early in gestation, such as those that occur in diabetes mellitus, may impair growth of the embryo and increase the risk of dysmorphogenesis. Such delayed growth of the embryo may in turn influence size at birth. In midgestation, metabolic perturbations may accelerate functional maturation of fetal pancreatic beta-cells. Fetal beta-cell development is very sensitive to alterations in the nutrient milieu and may be enhanced in gestational diabetes mellitus (GDM) with only minimal elevations of plasma glucose and minor alterations in other nutrient fuels, including insulinogenic amino acids. Data are reviewed that suggest that the ensuing fetal hyperinsulinemia may promote the development of macrosomia even if metabolic control is satisfactory during late gestation. The overall potential influences of metabolic alterations on intrauterine growth are different in pregnancies complicated by diabetes mellitus throughout gestation (pregestational) and GDM. However, the implications in an individual pregnancy may be defined by the degree of metabolic control at the specific stages of gestation when growth of the embryo, development of fetal beta-cell function, and growth of insulin-sensitive tissues are most critically influenced by the metabolic milieu.

Lipid profile, glucose homeostasis, blood pressure, and obesity-anthropometric markers in macrosomic offspring of nondiabetic mothers

OBJECTIVE

The study was to determine whether being the macrosomic offspring of a mother without detected glucose intolerance during pregnancy has an impact on lipid profile, glucose homeostasis, and blood pressure during childhood.

RESEARCH DESIGN AND METHODS

Plasma total, HDL, and LDL cholesterol; triglycerides; apolipoprotein (Apo) A-1, -B, and -E; lipoprotein (a); fasting glucose and insulin; homeostasis model assessment of insulin resistance (HOMA-IR) index; blood pressure; BMI; and detailed anthropometry were evaluated in 85 children aged 3-10 years old, born appropriate for gestational age (AGA; n = 48) and large for gestational age (LGA; n = 37) of healthy mothers.

RESULTS

At the time of the assessment, body weight, height, skinfold thickness, BMI, waist circumference, and blood pressure did not differ between the LGA and AGA groups with the exception of head circumference (P < 0.01). There were no significant differences in plasma total or LDL cholesterol; triglycerides; Apo A-1, -B, or -E; lipoprotein (a); Apo B-to-Apo A-1 ratio; or glucose levels between the groups. The LGA group had significantly higher HDL cholesterol levels (P < 0.01), fasting insulin levels (P < 0.01), and HOMA-IR index (P < 0.01) but lower values of the glucose-to-insulin ratio (P < 0.01) as compared with the AGA group.

CONCLUSIONS

Children born LGA of mothers without confirmed impaired glucose tolerance during pregnancy show higher insulin concentrations than AGAs.

Modulation of lipid metabolism by n-3 polyunsaturated fatty acids in gestational diabetic rats and their macrosomic offspring

The time course of changes in lipid metabolism by dietary n-3 PUFAs (polyunsaturated fatty acids) in streptozotocin-induced diabetic rats during pregnancy (days 12 and 21) and their macrosomic offspring at birth (day 0) and through adulthood (days 60 and 90) was studied with respect to adipose tissue, liver and serum lipid concentrations, and fatty acid composition. Glucose and insulin levels were also assessed in order to characterize the diabetic state of macrosomic offspring. Pregnant diabetic and control rats were fed either an Isio-4 or EPAX diet (enriched with n-3 PUFA). The same diets were also consumed by pups at weaning. Compared with control rats, during pregnancy diabetic rats had a significant elevation in liver and serum triacylglycerol (triglyceride) and cholesterol concentrations. At birth, macrosomic pups had higher serum insulin and glucose levels than control pups. The macrosomic rats maintained accelerated postnatal growth combined with high adipose tissue weight and lipid content through the first 12 weeks of age. The macrosomic pups from diabetic rats fed the Isio-4 diet also showed a significant enhancement in liver and serum triacylglycerol and cholesterol levels at birth and during adulthood. Feeding the EPAX diet to diabetic mothers as well as their macrosomic pups increased serum and liver levels of EPA (eicospentaenoic acid) and DHA (docosahexaenoic acid) with a reduction in arachidonic acid. The EPAX diet induced a significant decrease in liver and serum triacylglycerol and cholesterol concentrations in mothers during pregnancy and in their macrosomic pups during adulthood. Since the EPAX diet improves lipid anomalies considerably in diabetic mothers and their macrosomic offspring, it may prevent long-term metabolic abnormalities associated with macrosomia.

Diabetic fetal macrosomia: significance of disproportionate growth

Fetal hyperinsulinism in infants of diabetic mothers (IDMs) produces increased fetal growth leading to macrosomia, which may or may not be proportionate. Disproportionate macrosomia refers to excessive weight characterized by a high weight/length ratio. We tested the hypotheses that (1) macrosomia in IDMs would be characterized by a high ponderal index (defined as weight/length ratio) and (2) infants with macrosomia who have a high ponderal index would have increased neonatal morbidity--specifically, hyperbilirubinemia, hypoglycemia, polycythemia, and acidosis. We studied 170 IDMs and 510 non-IDMs matched 1:3 for gestational age, race, and year of delivery. Forty-five percent of IDMs had macrosomia compared with 8% of control infants (p = 0.001), and 19% of IDMs had disproportionate macrosomia compared with 1% of control infants (p = 0.001). The rates of hyperbilirubinemia (p = 0.02), hypoglycemia (p = 0.01), and acidosis (p = 0.01) were greatest in infants with disproportionate macrosomia and least in nonmacrosomic infants. The incidence of polycythemia was not significantly different between the groups. We suggest that disproportionate macrosomia in the IDM is associated with an increased likelihood of neonatal complications.

Macrosomia revisited: ponderal index and leptin delineate subtypes of fetal overgrowth

OBJECTIVES

We sought to reanalyze the concept of fetal macrosomia with regard to the ponderal index and to investigate the role of insulin, insulinlike growth factor I, leptin, and maternal factors on birth size in a population of infants with nondiabetic mothers.

STUDY DESIGN

Venous cord blood levels of insulin, insulinlike growth factor I, insulinlike growth factor binding protein 3, and leptin were measured in 28 large-for-gestational-age and 21 appropriate-for-gestational-age newborns.

RESULTS

Large-for-gestational-age newborns can be divided into symmetric and asymmetric subtypes according to the ponderal index. Mean leptin concentrations in cord blood were significantly higher in asymmetric than in symmetric large-for-gestational-age newborns (P =.01). A positive correlation was observed between leptin and the ponderal index (r = 0.53, P =.001) and between leptin and insulin concentrations in cord blood (r = 0.53, P =.008).

CONCLUSION

Our results strongly suggest that macrosomia should not be classified on the basis of birth weight and gestational age alone. We also show that asymmetric macrosomic infants with nondiabetic mothers have abnormal leptin and insulin concentrations.

Gestational Diabetes Impairs Human Fetal Postprandial Brain Activity

CONTEXT

Gestational diabetes (GDM) influences the fetal phenotype.

OBJECTIVE

In the present study, our aim was to determine the effect of GDM specifically on fetal brain activity.

DESIGN

Pregnant participants underwent an oral glucose tolerance test (OGTT, 75 g). At 0, 60, and 120 minutes, maternal metabolism was determined, and fetal auditory evoked fields were recorded with a fetal magnetoencephalographic device.

SETTING

All measurements were performed at the fMEG Center in Tübingen.

PARTICIPANTS

Twelve women with GDM and 28 normal glucose-tolerant (NGT) pregnant women participated on a voluntary basis.

INTERVENTIONS

OGTT (75 g, 120 minutes) was used in this study.

MAIN OUTCOMES AND MEASURES

Fetal auditory evoked response latencies were determined for this study.

RESULTS

In the fetuses of NGT women, latencies decreased between 0 and 60 minutes from 260 ± 90 to 206 ± 74 ms (P = .008) and remained stable until 120 minutes (206 ± 74 vs 230 ± 79, P =.129). In fetuses of women with GDM, there was no change in response latencies during OGTT (P = .11). Sixty minutes after glucose ingestion, fetal latencies in the GDM group were longer than in the NGT group (296 ± 82 vs 206 ± 74 ms, P = .001). Linear regression revealed a significant effect of maternal glucose, insulin levels, and insulin sensitivity on response latencies after 60 minutes.

CONCLUSIONS

Fetal postprandial brain responses were slower in the offspring of women with GDM. This might indicate that gestational diabetes directly affects fetal brain development and may lead to central nervous insulin resistance in the fetus.

Fetal Macrosomia – A Continuing Obstetric Challenge

BACKGROUND

Macrosomic fetuses represent a continuing challenge in obstetrics.

OBJECTIVES

We studied maternal risk factors of fetal macrosomia and maternal and infant outcome in such cases.

METHODS

A retrospective cohort study was carried out with a total of 26,961 singleton pregnancies between 1989 and 2001. Records of 886 mothers who gave birth to live born infants weighing > or =4,500 g were compared to those of 26,075 mothers with normal weight (<4,500 g) infants. Multiple regression analysis was used to identify independent reproductive risk factors. Perinatal complications were also assessed.

RESULTS

The incidence of fetal macrosomia was 3.4%. Diabetes, previous macrosomic birth, postdatism (>42 weeks of gestation), obesity (BMI > 25 before pregnancy), male infant, gestational diabetes mellitus, and non-smoking were independent risk factors of fetal macrosomia, with adjusted risks of 4.6, 3.1, 3.1, 2.0, 1.9, 1.6, 1.4, respectively. In the macrosomic group, birth and maternal traumas occurred significantly more often than in the control group. However, records of subsequent pregnancies (n = 250) after the study period showed that a previous uncomplicated birth appeared to decrease complication risks.

CONCLUSIONS

Most cases of fetal macrosomia occur in low-risk pregnancies and evaluation of maternal risks cannot accurately predict which women will eventually give birth to an overweight newborn. After an uncomplicated birth of a macrosomic infant, vaginal delivery may be a safe option for the infant and mother.

Benign extra-axial collections of infancy

The clinical histories, physical examinations and results of head computed tomography and head ultrasound scans were reviewed in a group of 15 infants who had macrocrania, excessive extra-axial fluid and normal development. Diagnostic evaluations demonstrated mild ventriculomegaly and extra-axial fluid collections. No treatment was undertaken. All infants continued to exhibit normal development during a period of extended follow-up. In this select group of infants exhibiting these findings, treatment appears to be unnecessary and the prognosis for continued normal development is excellent.