Elective delivery of infants with macrosomia in diabetic women: reduced shoulder dystocia versus increased cesarean deliveries

Prominent themes in shoulder dystocia research: A bibliometric and document-based analysis

BACKGROUND

This study aims to comprehensively examine the academic development of shoulder dystocia (SD) through bibliometric and document analysis and to identify topics that can guide future research.

METHODS

In this study, performance, co-citation, co-word, and document analyses were used as bibliometric analysis techniques.

RESULTS

The study identified 3 main themes in terms of the intellectual structure of Shoulder Dystocia (SD): "Management of SD, Risk Factors and Associated Complications," "Clinical Practices, Birth Abnormalities and Effects of Complications," and "Impact of Education, Clinical Maneuvers and Fetal Health Outcomes." Co-occurrence analysis identified 4 significant themes: "Management and Clinical Practice of SD," "Fetal Macrosomia and Risk Factors," "Obstetric Maneuvers and Brachial Plexus Injury," and "Clinical Trends and Risks in SD." Additionally, ten consolidated themes were identified as a result of thematic coding analysis.

CONCLUSION

Shoulder dystocia remains a critical component of obstetric practice. Themes such as training and simulation, risk factors, and technical and management approaches are consistently emphasized. Technological advances and studies on how machine learning techniques can be used effectively in this field reflect innovative approaches in the scientific literature. This analysis confirms that shoulder dystocia is a complex topic requiring a multidisciplinary approach and that research in this field is constantly evolving.

Shoulder dystocia in babies born to Aboriginal mothers with diabetes: a population-based cohort study, 1998-2015

BACKGROUND

Australian Aboriginal and Torres Strait Islander women with diabetes in pregnancy (DIP) are more likely to have glycaemic levels above the target range, and their babies are thus at higher risk of excessive fetal growth. Shoulder dystocia, defined by failure of spontaneous birth of fetal shoulder after birth of the head requiring obstetric maneuvers, is an obstetric emergency that is strongly associated with DIP and fetal size. The aim of this study was to investigate the epidemiology of shoulder dystocia in Aboriginal babies born to mothers with DIP.

METHODS

Stratifying by Aboriginal status, characteristics of births complicated by shoulder dystocia in women with and without DIP were compared and incidence and time-trends of shoulder dystocia were described. Compliance with guidelines aiming at preventing shoulder dystocia in women with DIP were compared. Post-logistic regression estimation was used to calculate the population attributable fractions (PAFs) for shoulder dystocia associated with DIP and to estimate probabilities of shoulder dystocia in babies born to mothers with DIP at birthweights > 3 kg.

RESULTS

Rates of shoulder dystocia from vaginal births in Aboriginal babies born to mothers with DIP were double that of their non-Aboriginal counterparts (6.3% vs 3.2%, p < 0.001), with no improvement over time. Aboriginal mothers with diabetes whose pregnancies were complicated by shoulder dystocia were more likely to have a history of shoulder dystocia (13.1% vs 6.3%, p = 0.032). Rates of guideline-recommended elective caesarean section in pregnancies with diabetes and birthweight > 4.5 kg were lower in the Aboriginal women (28.6% vs 43.1%, p = 0.004). PAFs indicated that 13.4% (95% CI: 9.7%-16.9%) of shoulder dystocia cases in Aboriginal (2.7% (95% CI: 2.1%-3.4%) in non-Aboriginal) women were attributable to DIP. Probability of shoulder dystocia among babies born to Aboriginal mothers with DIP was higher at birthweights > 3 kg.

CONCLUSIONS

Aboriginal mothers with DIP had a higher risk of shoulder dystocia and a stronger association between birthweight and shoulder dystocia. Many cases were recurrent. These factors should be considered in clinical practice and when counselling women.

Comparison of adverse maternal and perinatal outcomes between induction and expectant management among women with gestational diabetes mellitus at term pregnancy: a systematic review and meta-analysis

BACKGROUND

Induction at 38-40 weeks of gestation has been broadly suggested for women with gestational diabetes mellitus (GDM), yet its benefits and risks remain unclear. This study aimed to systematically review and meta-analyze existing evidence on the effect of induction at term gestation among women with GDM.

METHODS

We searched MEDLINE, EMBASE, Cochrane Libraries, and Web of Science from inception to June 2021. We included randomized controlled trials (RCTs) and observational studies comparing induction with expectant management among GDM term pregnancies. Primary outcomes included caesarean section (CS) and macrosomia. All screening and extraction were conducted independently and in duplicates. Meta-analyses with random-effects models were conducted to generate the pooled odds ratios (ORs) and 95% confidence intervals (CIs) using the Mantel-Haenszel method. Methodological quality was assessed independently by two reviewers using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale for observational studies.

RESULTS

Of the 4,791 citations, 11 studies were included (3 RCTs and 8 observational studies). Compared to expectant management, GDM women with induction had a significantly lower odds for macrosomia (RCTs 0.49 [0.30-0.81]); observational studies 0.64 [0.54-0.77]), but not for CS (RCTs 0.95 [0.64-1.43]); observational studies 1.03 [0.79-1.34]). Induction was associated with a lower odds of severe perineal lacerations in observational studies (0.59 [0.39-0.88]). No significant difference was observed for other maternal or neonatal morbidities, or perinatal mortality between groups.

CONCLUSIONS

For GDM women, induction may reduce the risk of macrosomia and severe perineal lacerations compared to expectant management. Further rigorous studies with large sample sizes are warranted to better inform clinical implications.

The association between an oral glucose tolerance test performed at term pregnancy and obstetric outcomes

Aims

Assessing the value of oral glucose tolerance test performed at term pregnancy in identifying obstetric complications.

Methods

Retrospective cohort study of women with a normal 50 g glucose challenge test who also had an oral glucose tolerance test at term (defined as at or after 37 weeks of gestation). Comparison between the pathological and normal oral glucose tolerance test groups was performed.

Results

The mean glucose in the glucose challenge test of women in the normal oral glucose tolerance test (n = 256) group was lower than that in the pathological oral glucose tolerance test (N = 16) group (105 ± 17 mg/dl (5.8 ± 0.9 mmol/l) vs 117 ± 13 mg/dl (6.5 ± 0.7 mmol/l), p = 0.007). Relevant obstetrical complications did not differ significantly between the groups. Of note, in the pathological oral glucose tolerance test group only one woman delivered a macrosomic infant.

Conclusions

A pathological oral glucose tolerance test performed at term was unable to identify women at risk for impaired glucose metabolism-related obstetric complications and is therefore of limited clinical value and seems to be unjustified.

Theoretical basis of perinatology therapy in pregnant women with diabetes mellitus

Diabetes mellitus is a metabolic disorder that can occur before pregnancy, be detected during pregnancy, or develop during pregnancy. Therapeutic modalities available today significantly facilitate glycoregulation during pregnancy and childbirth. This review presents different insulin regimens, as well as the advantages and disadvantages of oral antidiabetic agents use with a special focus on hypoglycemia. The importance of maintaining optimal glycemic levels and educating patients in blood glucose self-measurement is explained.

Maternal and Fetal Outcomes in Women with Diabetes in Pregnancy Treated before and after the Introduction of a Standardized Multidisciplinary Management Protocol

BACKGROUND

Diabetes in pregnancy is associated with an increased risk to the woman and to the developing fetus. Currently, there is no consensus on the optimal management strategies for the follow-up and the timing of delivery of pregnancies affected by gestational and pregestational diabetes, with different international guidelines suggesting different management options.

MATERIALS AND METHODS

We conducted a retrospective cohort study from January 2017 to January 2021, to compare maternal and neonatal outcomes of pregnancies complicated by gestational and pregestational diabetes, followed-up and delivered in a third level referral center before and after the introduction of a standardized multidisciplinary management protocol including diagnostic, screening, and management criteria.

RESULTS

Of the 131 women included, 55 were managed before the introduction of the multidisciplinary management protocol and included in group 1 (preprotocol), while 76 were managed according to the newly introduced multidisciplinary protocol and included in group 2 (after protocol). We observed an increase in the rates of vaginal delivery, rising from 32.7% to 64.5% (<0.001), and the rate of successful induction of labor improved from 28.6% to 86.2% (P < 0.001). No differences were found in neonatal outcomes, and the only significant difference was demonstrated for the rates of fetal macrosomia (20% versus 5.3%, P: 0.012). Therefore, the improvements observed in the maternal outcomes did not impact negatively on fetal and neonatal outcomes.

CONCLUSION

The introduction of a standardized multidisciplinary management protocol led to an improvement in the rates of vaginal delivery and in the rate of successful induction of labor in our center. A strong cooperation between obstetricians, diabetologists, and neonatologists is crucial to obtain a successful outcome in women with diabetes in pregnancy.

Fetal Doppler Parameters at Term in Pregnancies Affected by Gestational Diabetes: Role in the Prediction of Perinatal Outcomes

OBJECTIVE

 The timing of delivery for women affected by gestational diabetes (GDM) is still controversial. Good clinical practice often suggests offering induction of labor at term in order to reduce the complications associated with this condition, while recent evidence supports expectant management. Fetal Doppler parameters represent a validated tool for testing fetal well-being at term and can select pregnancies that need increased surveillance. The aim of the present study was to evaluate the role of fetal Doppler parameters at term for the prediction of pregnancy outcomes in patients affected by GDM.

METHODS

 Prospective cohort study in a single center. Evaluation of umbilical artery (UA) PI, middle cerebral artery (MCA) PI, cerebroplacental ratio (CPR) and umbilical-to-cerebral ratio (UCR) at > 37 weeks of gestation in singleton, morphologically normal pregnancies affected by GDM, was performed in order to estimate the association between ultrasound measurements at term and perinatal outcome. Regression linear analysis was used to estimate the association between fetal Doppler parameters and neonatal pH, neonatal Apgar score, neonatal weight and a composite adverse outcome. The receiver operating characteristic (ROC) curve was used to estimate the possible predictive value of the above association.

RESULTS

 Our results on 130 women showed MCA PI to be the best predictor of perinatal outcomes in terms of low Apgar score at the 1st minute (p = 0.00), pH (p = 0.02) and composite adverse outcome (p = 0.05). UCR showed a significant correlation with neonatal pH (p = 0.02). No significant correlations for UA PI and CPR MoMs have been demonstrated in our population. However, the small sample size is a limitation of the study.

CONCLUSION

 Evaluation of MCA Doppler and eventually UCR at term can be a useful tool to discriminate pregnancies affected by GDM that can benefit from IOL before 41 weeks in order to reduce complications related to this condition.

Effects of gestational diabetes mellitus on risk of adverse maternal outcomes: a prospective cohort study in Northwest Ethiopia

Background

Gestational diabetes mellitus is a leading medical condition woman encounter during pregnancy with serious short- and long-term consequences for maternal morbidity. However, limited evidence was available on potential impacts of gestational diabetes mellitus using updated international diagnostic criteria on adverse maternal outcomes. Therefore, this study aimed to assess the effects of gestational diabetes mellitus on the risk of adverse maternal outcomes in Northwest Ethiopia.

Methods

A prospective cohort study was conducted among pregnant women followed from pregnancy to delivery. Gestational diabetes mellitus status was determined by using a two-hour 75 g oral glucose tolerance test and based on updated international diagnostic criteria. Multivariable log-binomial model was used to examine the effects of gestational diabetes mellitus on the risk of adverse maternal outcomes.

Results

A total of 694 women completed the follow-up and included in the analysis. Women with gestational diabetes mellitus had a higher risk of composite adverse maternal outcome (ARR=1.58, 95% CI: 1.22, 2.04), caesarean delivery (ARR=1.67; 95%: 1.15, 2.44), pregnancy induced hypertension (ARR= 3.32; 95%: 1.55, 7.11), premature rupture of membranes (ARR= 1.83; 95%: 1.02, 3.27), antepartum hemorrhage (ARR= 2.10; 95%: 1.11, 3.98) and postpartum hemorrhage (ARR= 4.85; 95%:2.28, 10.30) compared to women without gestational diabetes mellitus.

Conclusions

Gestational diabetes mellitus increased the risk of adverse maternal outcomes. This implies that maternal care and intervention strategies relating to women with gestational diabetes mellitus should be strengthened.

Pregestational Diabetes in Pregnancy

Diabetes is a common chronic condition in women of reproductive age. Preconception care is crucial to reducing the risk of adverse maternal and fetal outcomes, such as hypertensive disorders, abnormal fetal growth, traumatic delivery and stillbirth, associated with poor glycemic control. Insulin is the preferred medication to optimize glucose control in women with pregestational diabetes. Frequent dose adjustments are needed during pregnancy to achieve glycemic goals, and team-based multidisciplinary care may help. Postpartum care should include lactation support, counseling on contraceptive options, and transition to primary care.

The impact of first trimester fasting glucose level on adverse perinatal outcome

OBJECTIVE

To evaluate the impact of first trimester fasting glucose (FTFG) level on perinatal outcome.

STUDY DESIGN

A retrospective cohort study of singleton deliveries. Maternal and neonatal outcome were compared between two groups-women with FTFG < 95 mg/dl and FTFG ≥ 95 mg/dl. Women with pre-gestational diabetes were excluded.

RESULTS

Five thousand and thirty women met inclusion criteria. Of whom, 4644 (92.3%) had FTFG < 95 mg/dl and 386 (7.7%) had FTFG ≥ 95 mg/dl. Women with FTFG ≥ 95 mg/dl had higher rates of gestational hypertension (2.33 vs. 0.7%) and gestational diabetes (9.07 vs. 2.86%), p < 0.05 for both. Moreover, they had higher rates of cesarean delivery and arrest of descent, p < 0.05. Composite diabetes outcome was significantly higher among women with FTFG ≥ 95 mg/dl (8 vs. 3%, p = 0.002). After adjusting for potential confounders, composite diabetes outcome (aOR = 1.942 95% CI 1.265-2.981, p = 0.002) and gestational hypertension (aOR = 2.827 95% CI 1.295-6.175, p = 0.009) remained significantly higher in the FTFG ≥ 95 mg/dl group.

CONCLUSION

FTFG ≥ 95 mg/dl is an independent risk factor for adverse perinatal outcome including gestational hypertension and diabetes-related complications.

Practice Bulletin No. 173: Fetal Macrosomia

Suspected fetal macrosomia is encountered commonly in obstetric practice. As birth weight increases, the likelihood of labor abnormalities, shoulder dystocia, birth trauma, and permanent injury to the neonate increases. The purpose of this document is to quantify those risks, address the accuracy and limitations of methods for estimating fetal weight, and suggest clinical management for a pregnancy with suspected fetal macrosomia.

Timing of delivery and pregnancy outcomes in women with gestational diabetes

BACKGROUND

Women with gestational diabetes mellitus (GDM) commonly undergo induction of labor (IOL) at term, but the risks and benefits of IOL are incompletely understood.

OBJECTIVE

We examined the relationship among gestational age, IOL, and the rate of cesarean delivery (CD) in women with GDM.

STUDY DESIGN

We identified 863 women with GDM who underwent either IOL or spontaneous labor ≥37 0/7 weeks. Demographic, cervical favorability, and outcome data were abstracted from the medical record. We compared the CD rate in women undergoing IOL at each week of gestation with expectant management to a later gestational age.

RESULTS

When compared to women who were expectantly managed, IOL at 37 weeks (adjusted odds ratio [aOR], 1.53; 95% confidence interval [CI], 0.76-3.06; P = .23), 38 weeks (aOR, 2.07; 95% CI, 0.89-4.80; P = .09), and 39 weeks (aOR, 0.79; 95% CI, 0.44-1.42; P = .43)) was associated with similar risk for CD as expectant management after adjustment for nulliparity, body mass index, baseline simplified Bishop score, and maternal age. CD rates were higher in nulliparous women, but did not differ significantly in those undergoing IOL or expectant management. In multiparous women, IOL was significantly associated with an increased risk for CD at 38 weeks (aOR, 7.47; 95% CI, 1.6-34.8; P = .01) and rates of CD (17.39% vs 2.2%, P = .001) were significantly higher in multiparous women with an unfavorable Bishop score induced <39 weeks. Neonatal morbidity was similar across gestational ages after adjustment for maternal body mass index and maternal glycemic control.

CONCLUSION

IOL results in similar risk for CD as expectant management between 37-40 weeks of gestation. Rates of CD differed based on cervical exam and parity. These findings suggest that gestational age alone does not significantly impact maternal and neonatal outcomes, but that decisions regarding delivery in women with GDM should take into account cervical exam and parity.

Pregnancy outcome in pregnancies complicated with gestational diabetes mellitus and late preterm birth

AIM

To assess pregnancy outcome among women with gestational diabetes mellitus (GDM) delivering at the late preterm period.

METHODS

Retrospective observational cohort of all women with GDM who delivered a singleton fetus at the late preterm birth period (34+0/7 to 36+6/7 weeks of gestation). The study group included all women diagnosed with GDM and were compared to a control group of women delivering at the same gestational age period but without known GDM.

RESULTS

1849 women were included in the study, of whom 132 (7.1%) were diagnosed with GDM and 1717 (92.9%) were not. Women with GDM had a lower rate of spontaneous vaginal delivery (45.5% vs. 62.9%, p<0.001) and a higher rate of cesarean delivery (50.8% vs. 31.8%, p<0.001). GDM diagnosis incurs an adjusted ratio of 1.82 for cesarean delivery (95% CI 1.24-2.66, p=0.002). Neonates of mothers with GDM had significant higher mean birth weight and birth weight percentile, including higher rate of large-for-gestational age newborns. There were no differences in mortality or other parameters for neonatal morbidity.

CONCLUSION

according to our data, late preterm occurring in women with GDM does not confer an increased risk for neonatal complications.

Induction of labor before 40 weeks is associated with lower rate of cesarean delivery in women with gestational diabetes mellitus

BACKGROUND

In women with gestational diabetes mellitus, it is not clear whether routine induction of labor at <40 weeks of gestation is beneficial to mother and newborn infant.

OBJECTIVE

The purpose of this study was to compare outcomes among women with gestational diabetes mellitus who had induction of labor at either 38 or 39 weeks with those whose pregnancy was managed expectantly.

STUDY DESIGN

We included all women in Ontario, Canada, with diagnosed gestational diabetes mellitus who had a singleton hospital birth at ≥38 + 0 weeks of gestation between April 2012 and March 2014. Data were obtained from the Better Outcomes Registry & Network Ontario, which is a province-wide registry of all births in Ontario, Canada. Women who underwent induction of labor at 38 + 0 to 38 + 6 weeks of gestation (38-IOL; n = 1188) were compared with those who remained undelivered until 39 + 0 weeks of gestation (38-Expectant; n = 5229). Separately, those women who underwent induction of labor at 39 + 0 to 39 + 6 weeks of gestation (39-IOL; n = 1036) were compared with women who remained undelivered until 40 + 0 weeks of gestation (39-Expectant; n = 2162). Odds ratios and 95% confidence intervals were adjusted for maternal age, parity, insulin treatment, and prepregnancy body mass index.

RESULTS

Of 281,480 women who gave birth during the study period, 14,600 women (5.2%) had gestational diabetes mellitus; of these, 8392 women (57.5%) met all inclusion criteria. Compared with the 38-Expectant group, those women in the 38-IOL group had lower odds for cesarean delivery (adjusted odds ratio, 0.73; 95% confidence interval, 0.52-0.90), higher odds for neonatal intensive care unit admission (adjusted odds ratio, 1.36; 95% confidence interval, 1.09-1.69), and no difference in other maternal-newborn infant outcomes. Compared with the 39-Expectant group, women in the 39-IOL group likewise had lower odds for cesarean delivery (adjusted odds ratio, 0.73; 95% confidence interval, 0.58-0.93) but no difference in neonatal intensive care unit admission (adjusted odds ratio, 0.83; 95% confidence interval, 0.61-1.11).

CONCLUSION

In women with gestational diabetes mellitus, the routine induction of labor at 38 or 39 weeks is associated with a lower risk of cesarean delivery compared with expectant management but may increase the risk of neonatal intensive care unit admission when done at <39 weeks of gestation.

Large-for-Gestational-Age Ultrasound Diagnosis and Risk for Cesarean Delivery in Women With Gestational Diabetes Mellitus

OBJECTIVE

To assess the accuracy of a large-for-gestational-age (LGA) ultrasound diagnosis and the subsequent risk for cesarean delivery associated with ultrasound diagnosis of LGA among women with gestational diabetes mellitus.

METHODS

This was a retrospective cohort study of 903 women with GDM who delivered after 36 weeks of gestation with an ultrasound-estimated fetal weight within 31 days of delivery. Delivery outcomes were compared between women with an ultrasound diagnosis of LGA and a non-LGA ultrasound diagnosis.

RESULTS

Based on ultrasound assessments, we identified 248 women with an LGA fetus and 655 women with a non-LGA fetus. Among women with an LGA ultrasound diagnosis, 56 of 248 (22.6%) delivered an LGA neonate, whereas, of women with a non-LGA ultrasound diagnosis, 18 of 655 (2.8%) delivered an LGA neonate. Ultrasound diagnosis of LGA was associated with increased risk for cesarean delivery (adjusted odds ratio [OR] 3.13, 95% confidence interval [CI] 2.10-4.67, P<.001) after adjusting for relevant covariates. Stratified analyses demonstrated that ultrasound diagnosis of LGA was associated with an increased risk for cesarean delivery whether the birth weight was between 2,500 and 3,499 g (OR 2.82, 95% CI 1.62-4.84, P<.001) or between 3,500 and 4,500 g (OR 3.47, 95% CI 2.06-5.88, P<.001).

CONCLUSION

Ultrasonography significantly overestimates the prevalence of LGA in women with gestational diabetes mellitus, and an ultrasound diagnosis of LGA is associated with an increased risk for cesarean delivery independent of birth weight.

LEVEL OF EVIDENCE

II.

Labor and neonatal outcomes after term induction of labor in gestational diabetes

OBJECTIVE

To identify the optimal gestational age (GA) for induction of labor (IOL) at term among patients with gestational diabetes (GDMA) according to perinatal outcomes.

STUDY DESIGN

The US Natality Database from 2007 to 2010 was reviewed. Inclusion criteria were singleton delivery, IOL at 37 to 42 weeks and GDMA. Exclusion criteria included congenital anomalies, pre-gestational diabetes, hypertensive disorders, previous cesarean, breech presentation and rupture of membranes. Controls were non-GDMA cases delivered in geographic and temporal proximity. Delivery mode, macrosomia and perinatal complications were analyzed. Logistic regression adjusted for confounders was used to calculate odds ratios by GA using 39 weeks non-GDMA as reference.

RESULTS

In all, 96,964 cases and 176,079 controls were included. Increased risk for all adverse outcomes among GDMA cases was found. The nadir for intrapartum and neonatal complications was 38 and 40 weeks, respectively, whereas for cesarean and macrosomia was 39 weeks.

CONCLUSION

The optimal timing for IOL at term in GDMA appears to be 39 to 40 weeks.

Gestational diabetes mellitus and macrosomia: a literature review

BACKGROUND

Fetal macrosomia, defined as a birth weight ≥ 4,000 g, may affect 12% of newborns of normal women and 15-45% of newborns of women with gestational diabetes mellitus (GDM). The increased risk of macrosomia in GDM is mainly due to the increased insulin resistance of the mother. In GDM, a higher amount of blood glucose passes through the placenta into the fetal circulation. As a result, extra glucose in the fetus is stored as body fat causing macrosomia, which is also called 'large for gestational age'. This paper reviews studies that explored the impact of GDM and fetal macrosomia as well as macrosomia-related complications on birth outcomes and offers an evaluation of maternal and fetal health.

SUMMARY

Fetal macrosomia is a common adverse infant outcome of GDM if unrecognized and untreated in time. For the infant, macrosomia increases the risk of shoulder dystocia, clavicle fractures and brachial plexus injury and increases the rate of admissions to the neonatal intensive care unit. For the mother, the risks associated with macrosomia are cesarean delivery, postpartum hemorrhage and vaginal lacerations. Infants of women with GDM are at an increased risk of becoming overweight or obese at a young age (during adolescence) and are more likely to develop type II diabetes later in life. Besides, the findings of several studies that epigenetic alterations of different genes of the fetus of a GDM mother in utero could result in the transgenerational transmission of GDM and type II diabetes are of concern.

The impact of abnormal glucose tolerance and obesity on fetal growth

OBJECTIVE

Factors linked with insulin resistance were examined for their association with large-for-gestational-age (LGA) infant birth weight and gestational diabetes.

STUDY DESIGN

Data came from a longitudinal cohort study of 2,305 subjects without overt diabetes, analyzed using multinomial logistic and linear regression.

RESULTS

High maternal BMI (OR = 1.53 (1.11, 2.12)), height (1.98 (1.62, 2.42)), antidepressant use (1.71 (1.20, 2.44)), pregnancy weight-gain exceeding 40 pounds (1.79 (1.25, 2.57)), and high blood sugar (2.68, (1.53, 5.27)) were all positively associated with LGA birth. Strikingly, the difference in risk from diagnosed and treated gestational diabetes compared to women with a single abnormal glucose tolerance test (but no diagnosis of gestational diabetes) was significant (OR = 0.65, p = 0.12 versus OR = 2.84, p < 0.01). When weight/length ratio was used instead, different factors were found to be significant. BMI and pregnancy weight-gain were found to influence the development of gestational diabetes, through an additive interaction.

CONCLUSIONS

High prepregnancy BM, height, antidepressant use, pregnancy weight-gain exceeding 40 pounds, and high blood sugar were associated with LGA birth, but not necessarily infant weight/length ratio. An additive interaction between BMI and pregnancy weight-gain influenced gestational diabetes development.

Obesity or diabetes: which is more hazardous to the health of the offspring?

OBJECTIVE

To examine impact on perinatal outcome of untreated gestational diabetes (GDM) and non-diabetics stratified by body mass index (BMI).

RESEARCH DESIGN AND METHODS

This is a secondary analysis of our investigation of the consequences of not treating GDM. We evaluated 555 untreated GDMs matched to 1100 non-diabetics. BMI was determined using subjects' recalled pre-pregnancy weight. A primary composite variable consisted of stillbirth, neonatal macrosomia/large-for-gestational-age (LGA), neonatal hypoglycemia, erythrocytosis and hyperbilirubinemia. Secondary outcomes included shoulder dystocia, respiratory complications, cesarean delivery and pregnancy-related hypertension.

RESULTS

Untreated subjects in the normal weight category had an ∼2-fold increase for composite outcome and LGA and a 7-fold increase in metabolic complications. The overweight untreated group showed composite outcome, LGA and metabolic complications 2-3-fold higher and induction of labor 5-fold higher. For obese untreated GDMs, significantly higher rates of composite outcome, LGA and metabolic complications, induction of labor and cesarean delivery were 10-, 3-, 5-, 4- and 9-fold, respectively. Perinatal outcome for normal weight untreated GDM was similar to obese non-diabetics.

CONCLUSIONS

Maternal obesity and GDM independently affect adverse pregnancy outcome. The combination has a greater impact than each one alone. However, glycemic level contributes a greater portion to the adverse pregnancy equation.

Diabetes in pregnancy: timing and mode of delivery

Diabetes in pregnancy represents a risk condition for adverse maternal and feto-neonatal outcomes and many of these complications might occur during labor and delivery. In this context, the obstetrician managing women with pre-existing and gestational diabetes should consider (1) how these conditions might affect labor and delivery outcomes; (2) what are the current recommendations on management; and (3) which other factors should be considered to decide about the timing and mode of delivery. The analysis of the studies considered in this review leads to the conclusion that the decision to deliver should be primarily intended to reduce the risk of stillbirth, macrosomia, and shoulder dystocia. In this context, this review provides useful information for managing specific subgroups of diabetic women that may present overlapping risk factors, such as women with insulin-requiring diabetes and/or obesity and/or prenatal suspicion of macrosomic fetus. To date, the lack of definitive evidences and the complexity of the problem suggest that the "appropriate" clinical management should be customized according with the clinical condition, the type and mode of intervention, its consequences on outcomes, and considering the woman's consent and informed decisions.

Elective induction of labor in women with gestational diabetes mellitus: an intervention that modifies the risk of cesarean section

AIM

To evaluate the effect of elective induction at term for women with gestational diabetes mellitus (GDM) on the risk for cesarean delivery.

STUDY DESIGN

This is a retrospective case-control matched study, based on a single-center computerized database, 2005-2011. The medical records were reviewed for GDM management and glycemic control. For the study, two groups were defined: Group 1, women diagnosed with GDM with an estimated fetal weight <4,000 g, electively induced at term; Group 2, women induced due to Term-PROM, an indication for term induction in normoglycemic women with uncomplicated pregnancies, matched for age and parity (ratio 1:2). The primary outcome was cesarean delivery and secondary outcomes included other maternal and neonatal events. Descriptive analyses and multivariate analyses models were fitted.

RESULTS

GDM was diagnosed in 1,873 (2.6 %) women of 72,374 births; 227 (12.1 %) were eligible for inclusion in Group 1 and matched with 454 women in Group 2. GDM management included diet in 103 (45.4 %), insulin in 81 (35.7 %), and oral hypoglycemic agents in 43 (18.9 %).The cesarean delivery rate was significantly higher in Group 1, 17.1 vs. 11.2 % (p = 0.02). Three out of four births complicated by shoulder dystocia and BW <4,000 g, occurred in Group 1 (p = 0.076) and were associated with no glycemic control. Other obstetrical-related outcomes such as instrumental birth, severe perineal tears, early postpartum hemorrhage and peripartum transfusion were similar between groups.

CONCLUSION

Elective induction at term for women with GDM is associated with an increased risk for cesarean delivery as compared to other elective induction of labor.

Timing of delivery in women with diabetes in pregnancy

The incidence of both gestational and pre-gestational diabetes is increasing worldwide. The main cause of this increase is likely the concomitant increase in the incidence of global obesity, but in the case of gestational diabetes, changes in the diagnostic criteria are also a contributing factor. The adverse outcomes associated with pre-gestational diabetes are well known and have led clinicians to implement various strategies that include increased fetal surveillance and induction of labour at various gestational ages. In many cases these same strategies have been applied in clinical practice also to women with gestational diabetes despite there being differences in the type and magnitude of perinatal complications associated with this diagnosis. Despite the widespread application of these clinical practices, there is a paucity of quality data in the medical literature to guide the clinician in choosing a strategy for fetal surveillance and timing of delivery in both gestational diabetes and pre-gestational diabetes pregnancies. In the following review, we will discuss the rationale and consequences of planned delivery in gestational diabetes and pre-gestational diabetes, the evidence supporting different strategies for delivery and finally highlight future targets for research in this area.

Pre-existing diabetes mellitus and adverse pregnancy outcomes

Background

Pregnancies complicated by pre-existing diabetes mellitus (PDM) are associated with a high rate of adverse outcomes, including an increased miscarriage rate, preterm delivery, preeclampsia, perinatal mortality and congenital malformations; compared to the background population. The objectives of this study are to determine the prevalence of PDM and to investigate the maternal and the neonatal outcomes of women with PDM.

Methods

This is a retrospective cohort study for women who delivered in King Khalid University Hospital (KKUH) during the period of January 1^st to the 31^st of December 2008. The pregnancy outcomes of the women with PDM were compared to the outcomes of all non-diabetic women who delivered during the same study period.

Results

A total of 3157 deliveries met the inclusion criteria. Out of the study population 116 (3.7%) women had PDM. There were 66 (57%) women with type 1 diabetes mellitus (T1DM) and 50 (43%) women with type 2 diabetes mellitus (T2DM). Compared to non-diabetic women those with PDM were significantly older, of higher parity, and they had more previous miscarriages. Women with PDM were more likely to be delivered by emergency cesarean section (C/S), OR 2.67, 95% confidence intervals (CI) (1.63-4.32), P < 0.001, or elective C/S, OR 6.73, 95% CI (3.99-11.31), P < 0.001. The neonates of the mothers with PDM were significantly heavier, P < 0.001; and more frequently macrosomic; OR 3.97, 95% CI (2.03-7.65), P = 0.002. They more frequently have APGAR scores <7 in 5 minutes, OR 2.61, 95% CI (0.89-7.05), P 0.057 and more likely to be delivered at <37 gestation weeks, OR 2.24, 95% CI (1.37- 3.67), P 0.003. The stillbirth rate was 2.6 times more among the women with PDM; however the difference did not reach statistical significance, P 0.084.

Conclusion

PDM is associated with increased risk for C/S delivery, macrosomia, stillbirth, preterm delivery and low APGAR scores at 5 min.

Is prenatal identification of fetal macrosomia useful?

OBJECTIVES

To determine whether prenatal identification of macrosomia (≥4000g) reduces neonatal complications and maternal perineal lesions during delivery.

STUDY DESIGN

This historical cohort study (n=14,684 from the National perinatal database of the Audipog Association, France) included women with cephalic singleton term pregnancies. Among the babies born with macrosomia, we compared those who had been identified as such in utero (n=1211) with those who were not (n=13,473). The principal outcome was a composite variable defined as resuscitation in the delivery room, death in the delivery room or the immediate postpartum period, or transfer to a neonatal intensive care unit (NICU). The secondary outcome measures were neonatal trauma, 5-min Apgar score (≤4 and <7), and maternal perineal lesions. Results are expressed as crude relative risks and adjusted odds ratios.

RESULTS

The mean birthweight in the cohort was 4229g±219. The adjusted OR for the principal outcome defined above was 1.15 (95% CI: 0.89-1.50) in the group identified prenatally as macrosomic compared with the others (10.8% vs. 8.5%). The risk of neonatal trauma was higher in prenatally identified babies (adjusted OR: 1.80; 95% CI: 1.34-2.42). The 5-min Apgar score and the perineal lesion rate did not differ significantly between the groups. The a posteriori study power according to our results with α=0.05 was 84% (one-sided test).

CONCLUSIONS

Among babies born with macrosomia, in utero identification did not improve neonatal or maternal outcomes.

Diabetes gestacional: um algoritmo de tratamento multidisciplinar

O tratamento do diabetes gestacional é importante para evitar a morbimortalidade materno-fetal. O objetivo deste artigo é descrever o tratamento atualmente disponível para o manejo otimizado da hiperglicemia na gestação e sugerir um algoritmo de tratamento multidisciplinar. A terapia nutricional é a primeira opção de tratamento para as gestantes, e a prática de exercício físico leve a moderado deve ser estimulada na ausência de contraindicações obstétricas. O tratamento medicamentoso está recomendado quando os alvos glicêmicos não são atingidos ou na presença de crescimento fetal excessivo à ultrassonografia. O tratamento tradicional do diabetes gestacional é a insulinoterapia, embora mais recentemente a metformina venha sendo considerada uma opção segura e eficaz. A monitorização do tratamento é realizada com aferição da glicemia capilar e com avaliação da circunferência abdominal fetal por meio de ultrassonografia obstétrica a partir da 28ª semana de gestação.

Perinatal brachial plexus palsy

BACKGROUND

Perinatal brachial plexus palsy (PBPP) is a flaccid paralysis of the arm at birth that affects different nerves of the brachial plexus supplied by C5 to T1 in 0.42 to 5.1 infants per 1000 live births.

OBJECTIVES

To identify antenatal factors associated with PBPP and possible preventive measures, and to review the natural history as compared with the outcome after primary or secondary surgical interventions.

METHODS

A literature search on randomized controlled trials, systematic reviews and meta-analyses on the prevention and treatment of PBPP was performed. EMBASE, Medline, CINAHL and the Cochrane Library were searched until June 2005. Key words for searches included 'brachial plexus', 'brachial plexus neuropathy', 'brachial plexus injury', 'birth injury' and 'paralysis, obstetric'.

RESULTS

There were no prospective studies on the cause or prevention of PBPP. Whereas birth trauma is said to be the most common cause, there is some evidence that PBPP may occur before delivery. Shoulder dystocia and PBPP are largely unpredictable, although associations of PBPP with shoulder dystocia, infants who are large for gestational age, maternal diabetes and instrumental delivery have been reported. The various forms of PBPP, clinical findings and diagnostic measures are described. Recent evidence suggests that the natural history of PBPP is not all favourable, and residual deficits are estimated at 20% to 30%, in contrast with the previous optimistic view of full recovery in greater than 90% of affected children. There were no randomized controlled trials on nonoperative management. There was no conclusive evidence that primary surgical exploration of the brachial plexus supercedes conservative management for improved outcome. However, results from nonrandomized studies indicated that children with severe injuries do better with surgical repair. Secondary surgical reconstructions were inferior to primary intervention, but could still improve arm function in children with serious impairments.

CONCLUSIONS

It is not possible to predict which infants are at risk for PBPP, and therefore amenable to preventive measures. Twenty-five per cent of affected infants will experience permanent impairment and injury. If recovery is incomplete by the end of the first month, referral to a multidisciplinary team is necessary. Further research into prediction, prevention and best mode of treatment needs to be done.

A customized standard of large size for gestational age to predict intrapartum morbidity

OBJECTIVE

The purpose of this study was to determine whether a customized standard of large-for-gestational age (LGA) identifies pregnancies with increased perinatal risk.

STUDY DESIGN

We evaluated 7510 estimates of fetal weight to generate a fetal growth curve. Next, we analyzed the gestational age at delivery, physiologic and pathological variables from 5072 pregnancies to predict birthweight, and calculated a customized ideal birthweight and cutoff for LGA. In a separate analysis of 32,271 pregnancies, rates of macrosomia-related adverse outcomes were compared in pregnancies that had been identified as LGA by a customized standard (LGA(cust)) and those pregnancies that had been identified as LGA or macrosomic by conventional standards.

RESULTS

LGA(cust) pregnancies carried increased risk of shoulder dystocia, third- or fourth-degree laceration, and cephalopelvic disproportion. LGA(cust) pregnancies that did not meet conventional criteria for LGA/macrosomia were at increased risk of all measured outcomes.

CONCLUSION

A customized standard of LGA identifies a previously unrecognized population that is at increased risk of perinatal morbidity.

"GINEXMAL RCT: Induction of labour versus expectant management in gestational diabetes pregnancies"

BACKGROUND

Gestational diabetes (GDM) is one of the most common complications of pregnancies affecting around 7% of women. This clinical condition is associated with an increased risk of developing fetal macrosomia and is related to a higher incidence of caesarean section in comparison to the general population. Strong evidence indicating the best management between induction of labour at term and expectant monitoring are missing.

METHODS/DESIGN

Pregnant women with singleton pregnancy in vertex presentation previously diagnosed with gestational diabetes will be asked to participate in a multicenter open-label randomized controlled trial between 38+0 and 39+0 gestational weeks. Women will be recruited in the third trimester in the outpatient clinic or in the Day Assessment Unit according to local protocols. Women who opt to take part will be randomized according to induction of labour or expectant management for spontaneous delivery. Patients allocated to the induction group will be admitted to the obstetric ward and offered induction of labour via use of prostaglandins, Foley catheter or oxytocin (depending on clinical conditions). Women assigned to the expectant arm will be sent to their domicile where they will be followed up until delivery, through maternal and fetal wellbeing monitoring twice weekly. The primary study outcome is the Caesarean section (C-section) rate, whilst secondary measurements are maternal and neonatal outcomes. A total sample of 1760 women (880 each arm) will be recruited to identify a relative difference between the two arms equal to 20% in favour of induction, with concerns to C-section rate. Data will be collected until mothers and newborns discharge from the hospital. Analysis of the outcome measures will be carried out by intention to treat.

DISCUSSION

The present trial will provide evidence as to whether or not, in women affected by gestational diabetes, induction of labour between 38+0 and 39+0 weeks is an effective management to ameliorate maternal and neonatal outcomes. The primary objective is to determine whether caesarean section rate could be reduced among women undergoing induction of labour, in comparison to patients allocated to expectant monitoring. The secondary objective consists of the assessment and comparison of maternal and neonatal outcomes in the two study arms. .

Maternal outcome of gestational diabetes mellitus

OBJECTIVE

To estimate maternal outcome of treated or untreated gestational diabetes mellitus (GDM).

METHODS

French and English publications were searched using PubMed and the Cochrane library.

RESULTS

The diagnosis of GDM includes a high risk population for preeclampsia and Caesarean sections (EL3). The risks are positively correlated with the level of hyperglycaemia in a linear way (EL2). Intensive treatment of mild GDM compared with routine care reduces the risk of pregnancy-induced hypertension (preeclampsia, gestational hypertension). Moreover, it does not increase the risk of operative vaginal delivery, Caesarean section and postpartum haemorrhage (EL1). Being overweight, obesity and maternal hyperglycaemia are independent risk factors for preeclampsia (EL2). Their association with GDM increases the risk of preeclampsia and Caesarean section compared to diabetic women with a normal body mass index (EL3). The association of several risk factors (such as advanced maternal age, pre-existing chronic hypertension, pre-existing nephropathy, obesity, suboptimal glycaemic control) increases the risk of preeclampsia. In that case, the classic follow-up (blood pressure measurement, proteinuria) should be more frequent than monthly (professional consensus). The risk of Caesarean section is increased by macrosomia, whether suspected prenatally or not, but this increased risk remains whatever the birth weight (EL3). Diagnosis and treatment of GDM do not reduce the risk of severe perineal lesions, operative vaginal delivery and postpartum haemorrhage (EL2). Some psychological symptoms, such as anxiety and alteration of self-perception, can occur upon diagnosis of GDM (EL3). The treatment of GDM appears to reduce the risk of postpartum depression symptoms (EL2).

CONCLUSION

Most of the information published on GDM covers the risks of preeclampsia and Caesarean section; intensive care of GDM reduces these risks. Pregnancy care should be adjusted to the risk factors.

Shoulder Dystocia: Etiology, Common Risk Factors, and Management

Shoulder dystocia and brachial plexus injury occur in 0.5% to 1.5% of all births. Risk factors for both include maternal obesity, excessive prenatal weight gain, maternal diabetes, protracted labor, and fetal macrosomia. These factors are involved in only about 50% of births complicated by shoulder dystocia or brachial plexus injury. Shoulder dystocia has a low recurrence rate (9.8%-16.7%), although history of previous shoulder dystocia is the most reliable predictor of occurrence. Brachial plexus injury is the most common morbidity associated with shoulder dystocia, but 50% of newborns who present with this injury were not subject to shoulder dystocia at birth. Most brachial plexus injuries are transient, although 5% to 22% become permanent. Shoulder dystocia followed by permanent brachial plexus injury or mental impairment is one of the leading causes of malpractice allegations. Prompt assessment and management of shoulder dystocia and preparation to maximize the efficiency of shoulder dystocia maneuvers are critical. Documentation of the appropriate use of maneuvers to relieve shoulder dystocia demonstrates standard of care practice, thereby decreasing the potential for successful malpractice allegations.

Gestational diabetes: risks, management, and treatment options

Gestational diabetes mellitus (GDM) is commonly defined as glucose intolerance first recognized during pregnancy. Diagnostic criteria for GDM have changed over the decades, and several definitions are currently used; recent recommendations may increase the prevalence of GDM to as high as one of five pregnancies. Perinatal complications associated with GDM include hypertensive disorders, preterm delivery, shoulder dystocia, stillbirths, clinical neonatal hypoglycemia, hyperbilirubinemia, and cesarean deliveries. Postpartum complications include obesity and impaired glucose tolerance in the offspring and diabetes and cardiovascular disease in the mothers. Management strategies increasingly emphasize optimal management of fetal growth and weight. Monitoring of glucose, fetal stress, and fetal weight through ultrasound combined with maternal weight management, medical nutritional therapy, physical activity, and pharmacotherapy can decrease comorbidities associated with GDM. Consensus is lacking on ideal glucose targets, degree of caloric restriction and content, algorithms for pharmacotherapy, and in particular, the use of oral medications and insulin analogs in lieu of human insulin. Postpartum glucose screening and initiation of healthy lifestyle behaviors, including exercise, adequate fruit and vegetable intake, breastfeeding, and contraception, are encouraged to decrease rates of future glucose intolerance in mothers and offspring.

A scoring system for detection of macrosomia and prediction of shoulder dystocia: A disappointment

OBJECTIVE

To develop a scoring system for the detection of a macrosomic fetus (birth weight (BW) >or= 4000 g) and predict shoulder dystocia among large for gestational age fetuses.

STUDY DESIGN

We retrospectively identified all singletons with accurate gestational age (GA) that were large for GA (abdominal circumference (AC) or estimated fetal weight (EFW) >or= 90% for GA) at >or=37 weeks with delivery within three weeks. The scoring system was: 2 points for biparietal diameter, head circumference, AC, or femur length >or=90% for GA, or if the amniotic fluid index (AFI) was >or=24 cm; for biometric parameters <90% or with AFI <24 cm, 0 points. The predictive values for detection of shoulder dystocia were calculated.

RESULTS

Of the 225 cohorts that met the inclusion criteria the rate of macrosomia was 39% and among vaginal deliveries (n = 120) shoulder dystocia occurred in 12% (15/120; 95% confidence interval (CI) 7-20%). The sensitivity of EFW >or=4500 g to identify a newborn with shoulder dystocia was 0% (95% CI 0-21%), positive predictive values 0% (95% CI 0-46%), and likelihood ratio of 0. For a macrosomia score >6, the corresponding values were 20% (4-48%), 25% (5-57%) and 2.3.

CONCLUSION

Though the scoring system can identify macrosomia, it offers no advantage over EFW. The scoring system and EFW are poor predictors of shoulder dystocia.

Independent predictors of Cesarean delivery in women with diabetes

OBJECTIVES

To identify independent risk factors for Cesarean delivery in women with pregnancy complicated by diabetes.

METHODS

Retrospective analysis of pregnancies from 5735 diabetic women delivering liveborn infants. Maternal demographic, medical, obstetric historical factors and index pregnancy obstetric, glycemic and neonatal outcome parameters were evaluated for association with Cesarean delivery after a trial of labor. Individual risk factors were analyzed for association by chi2 and ANOVA. Independent predictors of Cesarean delivery and adjusted relative risk (RR) were identified by stepwise logistic regression.

RESULTS

Trial of labor was permitted in 90.8% and 59.4% of women without (n = 4643) and with prior Cesarean delivery (n = 1092) and was successful in 85.2% and 56.9%, respectively. Eleven independent predictors were found. Five were related to obstetric history and maternal age: prior Cesarean delivery (RR 5.34, 95% CI 3.94-7.25), no prior live birth (RR 3.17, 95% CI 1.98-5.07), no prior vaginal delivery (RR 2.28, 95% CI 1.50-3.44), prior stillbirth (RR 1.71, 95% CI 1.09-2.68%) and maternal age > or = 35 years (RR 1.53, 95% CI 1.20-1.93). Two were related to the severity of diabetes at entry to diabetes care: requiring insulin (RR 1.53, 95% CI 1.20-1.93) and highest fasting plasma glucose level (RR 1.04, 95% CI 1.01-1.07). Two were related to obstetric factors: pre-eclampsia/hypertension (RR 2.56, 95% CI 2.00-3.27) and labor induction (RR 3.32, 95% CI 2.70-4.10). The remaining two were birth weight (per 250 g, RR 1.12, 95% CI 1.09-1.17) and pre-delivery body mass index (RR, 1.03, 95% CI 1.00-1.05).

CONCLUSION

The majority of predictors were not modifiable, relating to obstetric history, maternal age and diabetes severity. Possible modifiable interventions to avoid/improve labor induction, and decrease birth weight and maternal weight gain might decrease risk of Cesarean delivery. Future studies must address these multiple predictors.

Mode of delivery and birth outcomes of macrosomic infants

This review examines and summarises the literature regarding the mode of delivery of macrosomic infants and subsequent perinatal outcomes. A search of electronic databases was conducted and supplemented with investigation of the references cited in the original articles. Although the rates of obstetric complications differ among high birth weight infants delivered by caesarean section compared to those delivered vaginally, there is currently little evidence that perinatal mortality differs significantly by delivery method. Shoulder dystocia and birth injury occur with greater frequency among macrosomic infants, yet the relative inaccuracy of clinical and ultrasonographic estimates of birth weight among high birth weight infants indicates that a trial of labour may be warranted among non-diabetic mothers with a suspected macrosomic fetus. The majority of studies identified in this review utilised small sample sizes and observational design, thereby hindering valid assessments of the impact of delivery method on the mortality of this population. Consequently, an optimal management strategy has yet to be defined.

Active compared with expectant delivery management in women with gestational diabetes: a systematic review

OBJECTIVE

We conducted a systematic review to estimate benefits and harms of the choice of timing of induction or elective cesarean delivery based on estimated fetal weight or gestational age in women with gestational diabetes mellitus (GDM).

DATA SOURCES

An electronic literature search was performed using MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, and The Cochrane Central Register of Controlled Trials from inception to January 2007.

METHODS OF STUDY SELECTION

Two investigators independently reviewed titles and abstracts, assessed article quality, and abstracted data. Maternal outcomes included cesarean delivery and operative vaginal delivery. Neonatal outcomes included birth weight, macrosomia, large for gestational age, shoulder dystocia, birth trauma, neonatal intensive care admissions, and perinatal mortality.

TABULATION, INTEGRATION, AND RESULTS

Five studies met our inclusion criteria: one randomized controlled trial (RCT) and four observational studies. The RCT (n=200) compared the effect of labor induction at term with expectant management. The proportion of newborns with birth weight greater than the 90th percentile was significantly greater in the expectant-management group (23% compared with 10% with active induction, P=.02); there were no significant differences in rates of cesarean delivery, shoulder dystocia, neonatal hypoglycemia, or perinatal deaths. The four observational studies suggest a potential reduction in macrosomia and shoulder dystocia with labor induction and cesarean delivery for estimated fetal weight indications, but there was insufficient evidence to assess other clinical outcomes.

CONCLUSION

Active rather than expectant management of labor at term for women with GDM may reduce rates of macrosomia and related complications. Further RCTs and observational studies with a broader range of outcomes are needed for sufficient evidence to inform clinical practice.

Is severe macrosomia manifested at 11-14 weeks of gestation?

OBJECTIVE

To determine the association between fetal biometry in the first or early second trimester and severe macrosomia at delivery.

METHODS

This case-control study included 30 term severely macrosomic neonates; 90 appropriate-for-gestational age (AGA) neonates served as controls. All pregnancies underwent nuchal translucency (NT) screening at 11-14 weeks' gestation. Pregnancies were dated by accurate last menstrual period consistent with crown-rump length (CRL) measurements at the time of screening, early pregnancy CRL or date of fertilization. The association between birth weight and the difference between the measured and the expected CRL at the time of NT screening was analyzed.

RESULTS

The difference between measured and expected CRL, expressed both in mm and in days of gestation, was statistically greater in the severely macrosomic neonates compared with controls (mean, 6.66 +/- 4.78 mm vs. 1.17 +/- 4.6 mm, P < 0.0001 and 3 +/- 2.2 days vs. 0.5 +/- 2.3 days, P < 0.0001, respectively). Furthermore, there were significant correlations between the extent of macrosomia and the discrepancy between expected and measured fetal size at the time of NT screening (r = 0.47, P < 0.01 and r = 0.48, P < 0.01, respectively).

CONCLUSION

Severe macrosomia apparently manifests as early as 11-14 weeks' gestation.

[Severe shoulder dystocia: study of 14 cases treated by Jacquemier's maneuver]

OBJECTIVE

Shoulder dystocia is a dreadful complication of vaginal deliveries since it can be responsible of brachial plexus palsies and even neonatal deaths. Unlike most studies, we defined shoulder dystocia as the enclosing of fetal shoulders above the superior strait (cavity station of 1cm) and situations being resolved only by delivery of the posterior arm (Jacquemier's maneuver). The purpose of this study was to analyze cases of shoulder dystocia in terms of maternal and neonatal complications and to compare risk factors with those identified in the literature.

MATERIAL AND METHODS

We conducted a retrospective study of 14 cases of severe shoulder dystocia (SSD) which occurred at our hospital between January 1995 and January 2007. TSD was diagnosed in the absence of engagement of both fetal shoulders requiring recourse to Jacquemier's maneuver for delivery. Any gestational diabetes, abnormal progression of labour, suspicion or existence of fetal macrosomia, instrumental delivery, and neonatal complications were noted.

RESULTS

The incidence of SSD was around 1 per thousand. Multiparity, weight gain greater than 15kg and gestational diabetes were moderately present in our study group. Only 20% of neonates were macrosomic and 50% had a birth-weight of less than 4000g. In 80% of cases, an instrumental extraction was practised. Brachial plexus injuries affected 20% of neonates, no fracture was observed, one child died following an unresolved SSD.

CONCLUSION

This series shows that the incidence of SSD is rare and difficultly predictable even though identified risk factors exist. However, an instrumental extraction seems frequently associated with SSD and any extraction should take into account the presence of known risk factors. In spite of the severity of our cases of shoulder dystocia, complications found seemed to be similar to those observed in the literature.