Extreme macrosomia - Obstetric outcomes and complications in birthweights >5000 g

Association between Diabetes in Pregnancy and Shoulder Dystocia by Infant Birth Weight in an Era of Cesarean Delivery for Suspected Macrosomia

OBJECTIVE

 We estimated the association between diabetes and shoulder dystocia by infant birth weight subgroups (<4,000, 4,000-4,500, and >4,500 g) in an era of prophylactic cesarean delivery for suspected macrosomia.

STUDY DESIGN

 A secondary analysis from the National Institute of Child Health and Human Development U.S. Consortium for Safe Labor of deliveries at ≥24 weeks with a nonanomalous, singleton fetus with vertex presentation undergoing a trial of labor. The exposure was either pregestational or gestational diabetes compared with no diabetes. The primary outcome was shoulder dystocia and secondarily, birth trauma with a shoulder dystocia. We calculated adjusted risk ratios (aRRs) with modified Poison's regression between diabetes and shoulder dystocia and the number needed to treat (NNT) to prevent a shoulder dystocia with cesarean delivery.

RESULTS

 Among 167,589 assessed deliveries (6% with diabetes), pregnant individuals with diabetes had a higher risk of shoulder dystocia at birth weight <4,000 g (aRR: 1.95; 95% confidence interval [CI]: 1.66-2.31) and 4,000 to 4,500 g (aRR: 1.57; 95% CI: 1.24-1.99), albeit not significantly at birth weight >4,500 g (aRR: 1.26; 95% CI: 0.87-1.82) versus those without diabetes. The risk of birth trauma with shoulder dystocia was higher with diabetes (aRR: 2.29; 95% CI: 1.54-3.45). The NNT to prevent a shoulder dystocia with diabetes was 11 and 6 at ≥4,000 and >4,500 g, versus without diabetes, 17 and 8 at ≥4,000 and >4,500 g, respectively.

CONCLUSION

 Diabetes increased the risk of shoulder dystocia, even at lower birth weight thresholds than at which cesarean delivery is currently offered. Guidelines providing the option of cesarean delivery for suspected macrosomia may have decreased the risk of shoulder dystocia at higher birth weights.

KEY POINTS

· >Diabetes increased the risk of shoulder dystocia, even at lower birth weight thresholds than at which cesarean delivery is currently offered.. · Cesarean delivery for suspected macrosomia may have decreased the risk of shoulder dystocia at higher birth weights.. · These findings can inform delivery planning for providers and pregnant individuals with diabetes..

Antenatal prediction of fetal macrosomia in pregnancies affected by maternal pre-gestational diabetes

AIMS

Higher rates of fetal macrosomia may occur in infants of women with pre-gestational diabetes compared with non-diabetic controls. Antenatal predication of fetal macrosomia remains challenging. Ultrasound over-estimated fetal weight could result in over-classification of fetuses as macrosomic with corresponding inappropriate clinical interventions. Previously we had studied a measurement - the anterior abdominal wall measurement (AAW) - to predict fetal macrosomia in fetal estimation of weight. The purpose of the study was to study whether specific third trimester ultrasound measurements with measures of glycaemic control (HbA1c) predicted macrosomia in babies born to women with pre-gestational diabetes. In particular, a new variant of this measurement (fetal anterior abdominal wall thickness (AAW), abdominal circumference (AC) ratio: AAW:AC) was investigated.

METHODS

This was a prospective cohort study in a tertiary referral maternity hospital. Serial growth scans including measurement of AAW and AC: AAW ratio was performed at 30, 33- and 36-weeks' gestation. Birth-weight data was collected, and macrosomia was defined as >90th centile based on gestational age and gender of the baby. Serial HbA1c as measured at the first antenatal visit, 14, 20- and 36-weeks' gestation were reported for this study.

RESULTS

Of the 416 pregnancies analyzed, mean maternal age was 33.3 years. One in five women were primigravida's. The mean birthweight was 3548 g (+/- 581 g), of which 142 (34%) babies were classified as macrosomic. The median gestational age at delivery was 38³ weeks (31⁴ - 40² weeks). There were 37 (9%) babies born preterm at <37 weeks' gestation. Mean AC measurements in fetuses that would be born with macrosomia compared with those with a non-macrosomic birth weight were 282 mm vs. 266 mm at 30 weeks, 318.3 mm vs. 297 mm at 33 weeks and 350 mm vs. 325 mm at 36 weeks' gestation (all p < .001). Mean AAW measurements in macrosomic fetuses compared with normal size fetuses were 3.7 mm vs. 3.3 mm at 30 weeks, 4.9 mm vs 4.3 mm at 33 weeks and 5.9 mm vs. 5.3 mm at 36 weeks' gestation (all p < .001). The mean AC: AAW was 0.01 for both normal and macrosomic fetuses at 30 weeks. There was no clinical or statistical difference in AC:AAW ratios between non-macrosomic and macrosomic infants. Binary logistic regression showed that AC at 36 weeks was most predictive of macrosomia (76.5%), followed by AAW at 30 weeks (68.5%). Using a combination of HbA1c booking, 14, 20, 36 weeks and AAW 30, 33, 36 weeks and AC 30, 33, 36 weeks predicted macrosomia in 80.9%. The ratio of AC: AAW did not act as a useful antenatal clinical predictor of macrosomia at birth.

CONCLUSIONS

Abdominal circumference at 36 weeks was the single best predictor of fetal macrosomia. A combined model of HbA1c, AC and AAW was the best antenatal predictor of macrosomia, with intriguing clinical possibilities in the possible prevention of maternal and fetal complications of macrosomia.

Do you pay to go private?: a single centre comparison of induction of labour and caesarean section rates in private versus public patients

Background

The aim of this study was to compare rates of induction and subsequent caesarean delivery among nulliparous women with private versus publicly funded health care at a single institution. This is a retrospective cohort study using the electronic booking and delivery records of nulliparous women with singleton pregnancies who delivered between 2010 and 2015 in an Irish Tertiary Maternity Hospital (approx. 9000 deliveries per annum).

Methods

Data were extracted from the National Maternity Hospital (NMH), Dublin, Patient Administration System (PAS) on all nulliparous women who delivered a liveborn infant at ≥37 weeks gestation during the 6-year period. At NMH, all women in spontaneous labour are managed according to a standardised intrapartum protocol. Twenty-two thousand two hundred thirty-two women met the inclusion criteria. Of these, 2520 (12.8%) were private patients; the remainder (19,712; 87.2%) were public. Mode of and gestational age at delivery, rates of and indications for induction of labour, rates of pre-labour caesarean section, and maternal and neonatal outcomes were examined. Rates of labour intervention and subsequent maternal and neonatal outcomes were compared between those with and without private health cover.

Results

Women attending privately were more than twice as likely to have a pre-labour caesarean section (12.7% vs. 6.5%, RR = 2.0, [CI 1.8–2.2])); this finding persisted following adjustment for differences in maternal age and body mass index (BMI) (adjusted relative risk 1.74, [CI 1.5–2.0]). Women with private cover were also more likely to have induction of labour and significantly less likely to labour spontaneously. Women who attended privately were significantly more likely to have an operative vaginal delivery, whether labour commenced spontaneously or was induced.

Conclusions

These findings demonstrate significant differences in rates of obstetric intervention between those with private and public health cover. This division is unlikely to be explained by differences in clinical risk factors as no significant difference in outcomes following spontaneous onset of labour were noted. Further research is required to determine the roots of the disparity between private and public decision-making. This should focus on the relative contributions of both mothers and maternity care professionals in clinical decision making, and the potential implications of these choices.

Antenatal awareness and obstetric outcomes in large fetuses: A retrospective evaluation

INTRODUCTION

There is currently no consensus on the management of large fetuses in order to minimize fetal complications. The aim of this study was to assess whether antenatal recognition of large-for-gestational age (LGA) reduced poor obstetric newborn outcomes in a hospital where expectant management was used.

MATERIAL AND METHODS

A retrospective cohort study was made of two delivery units at Karolinska University Hospital, Stockholm, Sweden, using expectant management of LGA. All deliveries > 37⁺⁰ weeks of gestation during an 8-year period (2002-2009) were included. The main outcome was severe adverse outcome, a composite variable including neonatal trauma (brachial plexus birth palsy [BPBP] and fractures) and asphyxic sequelae (severe asphyxia, cerebral damage, and fetal/infant death).

RESULTS

The study population consisted of 63,542 appropriate-for-gestational age (AGA) and 3,343 LGA pregnancies (of which 21 % were identified before delivery). Compared to AGA, LGA pregnancies showed a five-fold increased risk of neonatal trauma (OR 5.1, 95 % CI 4.0 - 6.4), but no differences were seen regarding asphyxic sequelae. LGA fetuses identified antenatally had adverse outcomes in 3.7 % of all cases, compared to 3.5 % where LGA was not identified (OR 1.07 95 % CI 0.7 - 1.7). When adjusted for newborn weight deviation, the OR was 0.96, 95 % CI 0.6 - 1.5. There was a three-fold higher risk (OR 3.0, 95 % CI 1.2 - 7.4) of neonatal trauma among non-identified LGA cases > 41⁺⁰ gestational weeks. A total of 81 % of those with LGA were identified after a week 41 routine ultrasound. Out of 68 cases with planned vaginal delivery and expected birth weight > 5000 g, 7.4 % suffered BPBP, representing a 31-fold increase in risk, compared to 0% BPBP among those delivered by elective caesarean section.

CONCLUSION

Antenatal awareness of LGA did not lower the risk of severe adverse outcomes in a unit using expectant management, but those identified postdate were at a lower risk of neonatal trauma. For every 14 fetuses with an expected birth weight > 5000 g delivered by cesarean section, one case of BPBP could be avoided.

Sonographic markers of fetal adiposity and risk of Cesarean delivery

OBJECTIVE

Increased fetal size is associated with shoulder dystocia during labor and subsequent need for assisted delivery. We sought to investigate if increased fetal adiposity diagnosed sonographically in late pregnancy is associated with increased risk of operative delivery.

METHODS

This secondary analysis of the Genesis Study recruited 2392 nulliparous women with singleton pregnancy in cephalic presentation, in a prospective, multicenter study, to examine prenatal and intrapartum predictors of Cesarean delivery. Participants underwent ultrasound and clinical evaluation between 39 + 0 and 40 + 6 weeks' gestation. Data on fetal biometry were not revealed to patients or to their managing clinicians. A fetal adiposity composite of fetal thigh adiposity and fetal abdominal wall thickness was compiled for each infant in order to determine whether fetal adiposity > 90^th centile was associated with an increased risk of Cesarean or operative vaginal delivery.

RESULTS

After exclusions, data were available for 2330 patients. Patients with a fetal adiposity composite > 90^th centile had a higher maternal body mass index (BMI) (25 ± 5 kg/m² vs 24 ± 4 kg/m² ; P = 0.005), birth weight (3872 ± 417 g vs 3585 ± 401 g; P < 0.0001) and rate of induction of labor (47% (108/232) vs 40% (834/2098); P = 0.048) than did those with an adiposity composite ≤ 90^th centile. Fetuses with adiposity composite > 90^th centile were more likely to require Cesarean delivery than were those with adiposity composite ≤ 90^th centile (P < 0.0001). After adjusting for birth weight, maternal BMI and need for induction of labor, fetal adiposity > 90^th centile remained a risk factor for Cesarean delivery (P < 0.0001). A fetal adiposity composite > 90^th centile was more predictive of the need for unplanned Cesarean delivery than was an estimated fetal weight > 90^th centile (odds ratio, 2.20 (95% CI, 1.65-2.94; P < 0.001) vs 1.74 (95% CI, 1.29-2.35; P < 0.001). Having an adiposity composite > 90^th centile was not associated with an increased likelihood of operative vaginal delivery when compared with having an adiposity composite ≤ 90^th centile (P = 0.37).

CONCLUSIONS

Fetuses with increased adipose deposition are more likely to require Cesarean delivery than are those without increased adiposity. Consideration should, therefore, be given to adding fetal thigh adiposity and abdominal wall thickness to fetal sonographic assessment in late pregnancy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Prevalence and predisposing factors of brachial plexus birth palsy in a regional hospital in Ghana: a five year retrospective study

Introduction

Brachial plexus birth injury is one of the challenges associated with maternal delivery, with varying prevalence between countries. Brachial plexus birth injury poses negative health implications to children and also has socio-economic implications on families and the community as a whole. To treat brachial plexus birth injury, a multi-disciplinary treatment approach is recommended. Brachial plexus birth palsy (BPBP) is categorised into two-upper plexus injury (Erb's palsy) and lower plexus injury (Klumpke's palsy). These categories present with various degrees of injuries, with less severe injuries responding well to treatment and in most instances may resolve on their own, but serious and complicated injuries will require a multi-disciplinary treatment approach to treat and/or manage. Effective treatment and management depends on adequate knowledge of the disease condition. These include the risk factors and prevalence of brachial plexus birth palsy within a particular population at a specific period in time. The aim of this study was to determine the risk factors and the prevalence of a hospital based brachial plexus birth palsy within a five-year period (2013-2017).

Methods

A five-year retrospective study design was used. The study involved selection of all clients' diagnosed with brachial plexus birth palsy, where their gender, birth weight, complications at birth, type of brachial plexus suffered, mothers' diabetes status, mother's age, birth attendant, side of affectation, presentation at birth and mode of delivery were recorded.

Results

The prevalence rate of brachial plexus birth palsy was 14.7% out of a total of three hundred and twenty (320) cases reviewed over the study period in the Volta Regional Hospital. Erb's palsy was found to be the modal type of BPBP in this population (93.6%).

Conclusion

There is the need to provide a nationwide education on the risk factors that predispose babies to brachial plexus birth palsy. There is also the need for frequent antenatal visit by pregnant women; this will help in the provision of best antenatal history, diagnostic investigation in determining the birth weight and safe mode of delivery.

A Study of the Diagnostic Accuracy of an Existing Multivariable Test to Predict Shoulder Dystocia

Objectives  To evaluate the diagnostic accuracy of a multivariable prediction model, the Shoulder Screen (Perigen, Inc.), and compare it with the American College of Obstetricians and Gynecologists (ACOG) guidelines to prevent harm from shoulder dystocia. Study Design  The model was applied to two groups of 199 patients each who delivered during a 4-year period. One group experienced shoulder dystocia and the other group delivered without shoulder dystocia. The model's accuracy was analyzed. The performance of the model was compared with the ACOG guideline. Results  The sensitivity, specificity, positive, and negative predictive values of the model were 23.1, 99.5, 97.9, and 56.4%, respectively. The sensitivity of the ACOG guideline was 10.1%. The false-positive rate of the model was 0.5%. The accuracy of the model was 61.3%. Conclusion  A multivariable prediction model can predict shoulder dystocia and is more accurate than ACOG guidelines.