Umbilical Cord Biometry and Fetal Abdominal Skinfold Assessment as Potential Biomarkers for Fetal Macrosomia in a Gestational Diabetes Romanian Cohort

Backgroundand Objectives: Gestational diabetes mellitus (GDM) is a pregnancy-associated pathology commonly resulting in macrosomic fetuses, a known culprit of obstetric complications. We aimed to evaluate the potential of umbilical cord biometry and fetal abdominal skinfold assessment as screening tools for fetal macrosomia in gestational diabetes mellitus pregnant women. Materials and methods: This was a prospective case−control study conducted on pregnant patients presenting at 24−28 weeks of gestation in a tertiary-level maternity hospital in Northern Romania. Fetal biometry, fetal weight estimation, umbilical cord area and circumference, areas of the umbilical vein and arteries, Wharton jelly (WJ) area and abdominal fold thickness measurements were performed. Results: A total of 51 patients were enrolled in the study, 26 patients in the GDM group and 25 patients in the non-GDM group. There was no evidence in favor of umbilical cord area and WJ amount assessments as predictors of fetal macrosomia (p > 0.05). However, there was a statistically significant difference in the abdominal skinfold measurement during the second trimester between macrosomic and normal-weight newborns in the GDM patient group (p = 0.016). The second-trimester abdominal circumference was statistically significantly correlated with fetal macrosomia at term in the GDM patient group with a p value of 0.003, as well as when considering the global prevalence of macrosomia in the studied populations, 0.001, when considering both populations. Conclusions: The measurements of cord and WJ could not be established as predictors of fetal macrosomia in our study populations, nor differentiate between pregnancies with and without GDM. Abdominal skinfold measurement and abdominal circumference measured during the second trimester may be important markers of fetal metabolic status in pregnancies complicated by GDM.

Independent effect of gestational weight gain and prepregnancy obesity on pregnancy outcomes among Saudi women: A sub-cohort analysis from Riyadh mother and baby cohort study (RAHMA)

Background

Gestational weight gain (GWG) and prepregnancy obesity are garnering more attention as determining factors of pregnancy outcomes when it comes to the wellbeing of both the mother and her baby. This study was conducted to describe the pattern of GWG among participants of Riyadh Mother and Baby Multicenter Cohort Study (RAHMA) and to investigate the detrimental effects of excessive GWG and prepregnancy obesity on pregnancy outcomes.

Methods

RAHMA is a multicentre cohort study conducted in three hospitals in Riyadh, Saudi Arabia. Participants were categorized according to the Institute of Medicine into inadequate, adequate, and excessive GWG, and stratified by body mass index (BMI) into under/normal weight, overweight, and obese. To examine the independent effect of maternal prepregnancy obesity and GWG, a multivariate regression model was used and adjusted odds ratio (AOR) and 95% Confidence Interval (CI) for each outcome were calculated.

Results

A total of 7029 participants were included in this study; 31.8% had adequate GWG, 25.9% had excessive GWG and 42.3% had inadequate GWG, while 29.7% had normal BMI, 33.3% were overweight, 34.8% were obese, and 2.2% were underweight. Excessive GWG was independently associated with increased risk of hypertensive events, (AOR = 1.77, 95% CI 1.20–2.63). Obesity was associated with higher risk of gestational diabetes (AOR 2.11, 95% CI 1.76–2.53), hypertensive events (AOR 2.06, 95% CI 1.48–3.01), and delivery by emergency caesarean section (AOR = 1.63, 95% CI 1.35–1.97). Infants of obese women had increased odds of macrosomia (AOR 3.11, 95% CI 1.94–4.99) and lower odds of low birth weight (AOR = 0.68, 95% CI 0.53–0.88).

Conclusion

In comparison to excessive GWG, which increases the risk of hypertensive events during pregnancy, prepregnancy obesity is associated with more adverse outcomes including GDM, hypertensive events in pregnancy and emergency CS.

Epidemiology of Macrosomia in Korea: Growth and Development

BACKGROUND

Macrosomia, as an infant with birth weight over 4 kg, can have several perinatal, and neonatal complications. This study aimed to estimate the incidence of macrosomia in Korea and to identify the growth and developmental outcomes and other neonatal complications.

METHODS

In total, 397,203 infants who were born in 2013 with birth weight ≥ 2.5 kg and who underwent infant health check-up between their 1^st and 7^th visit were included from the National Health Insurance Service database. The information was obtained by the International Classification of Diseases-10 codes or self-reported questionnaires in the National Health Screening Program.

RESULTS

The distribution of infants by birth weight was as follows: 384,181 (97%) infants in the 2.5-3.99 kg (reference) group, 12,016 (3%) infants in the 4.0-4.49 kg group, 772 (0.2%) infants in the 4.5-4.99 kg group, and 78 (0.02%) infants in the ≥ 5 kg group. Macrosomia showed significantly higher incidence of sepsis, male sex, and mothers with GDM and birth injury. There was a significant difference in weight, height, and head circumference according to age, birth weight group, and combination of age and birth weight, respectively (P < 0.001). The number of infants with the weight above the 90^th percentile in macrosomia at each health check-up showed higher incidence than in reference group. The mean body mass index significantly differed among the groups, as 50.6 in infants with 2.5-3.99 kg of birth weight, 63.5 with 4.0-4.49 kg, 71.0 with 4.5-4.99 kg, and 73.1 with ≥ 5 kg. There was a significant difference in the incidence of poor developmental results between infants with macrosomia and the reference group at 24, 36 and 48 month of age.

CONCLUSION

Macrosomia was significantly associated with the risk of sepsis, birth injury, obesity and developmental problem especially in a boy born from mothers with gestational diabetes mellitus. Careful monitoring and proper strategies for monitoring growth and development are needed.

The role of cardiovascular risk factors in maternal cardiovascular disease according to offspring birth characteristics in the HUNT study

A history of preterm or small (SGA) or large (LGA) for gestational age offspring is associated with smoking and unfavorable levels of BMI, blood pressure, glucose and lipids. Whether and to what extent the excess cardiovascular risk observed in women with these pregnancy complications is explained by conventional cardiovascular risk factors (CVRFs) is not known. We examined the association between a history of SGA, LGA or preterm birth and cardiovascular disease among 23,284 parous women and quantified the contribution of individual CVRFs to the excess cardiovascular risk using an inverse odds weighting approach. The hazard ratios (HR) between SGA and LGA offspring and CVD were 1.30 (95% confidence interval (CI) 1.15, 1.48) and 0.89 (95% CI 0.76, 1.03), respectively. Smoking explained 49% and blood pressure may have explained ≈12% of the excess cardiovascular risk in women with SGA offspring. Women with preterm birth had a 24% increased risk of CVD (HR 1.24, 95% CI 1.06, 1.45), but we found no evidence for CVRFs explaining any of this excess cardiovascular risk. While smoking explains a substantial proportion of excess cardiovascular risk in women with SGA offspring and blood pressure may explain a small proportion in these women, we found no evidence that conventional CVRFs explain any of the excess cardiovascular risk in women with preterm birth.

Perinatal outcomes associated with the diagnosis of gestational diabetes: Systematic review and meta-analysis

OBJECTIVE

To compare perinatal outcomes in pregnant women diagnosed with gestational diabetes using the one-step and the two-step test.

METHODS

Meta-analysis of observational studies pregnancies women with gestational diabetes from January 2014 to February 2019. The outcomes studied were induction of labor and delivery, preterm delivery, fetal macrosomia, neonatal hypoglycemia, hyperbilirubinemia, low birth weight, and admission to the neonatal intensive care unit.

RESULTS

Eight studies were included with a population of 108,609 pregnancies. Statistical differences were obtained for fetal macrosomia RR0.9 (95%CI0.85-0.97; I²0%) and neonatal hypoglycemia RR1.1 (95%CI1.01-1.40; I²48.5%).

CONCLUSION

Neonatal macrosomia appears to be less present when the one-step diagnostic test is used and neonatal hypoglycemia was lower with the two-step test. Register PROSPERO CRD42020215062.

Reduced glucose-stimulated insulin secretion following a 1-wk IGF-1 infusion in late gestation fetal sheep is due to an intrinsic islet defect

Insulin and insulin-like growth factor-1 (IGF-1) are fetal hormones critical to establishing normal fetal growth. Experimentally elevated IGF-1 concentrations during late gestation increase fetal weight but lower fetal plasma insulin concentrations. We therefore hypothesized that infusion of an IGF-1 analog for 1 wk into late gestation fetal sheep would attenuate fetal glucose-stimulated insulin secretion (GSIS) and insulin secretion in islets isolated from these fetuses. Late gestation fetal sheep received infusions with IGF-1 LR3 (IGF-1, n = 8), an analog of IGF-1 with low affinity for the IGF binding proteins and high affinity for the IGF-1 receptor, or vehicle control (CON, n = 9). Fetal GSIS was measured with a hyperglycemic clamp (IGF-1, n = 8; CON, n = 7). Fetal islets were isolated, and insulin secretion was assayed in static incubations (IGF-1, n = 8; CON, n = 7). Plasma insulin and glucose concentrations in IGF-1 fetuses were lower compared with CON (P = 0.0135 and P = 0.0012, respectively). During the GSIS study, IGF-1 fetuses had lower insulin secretion compared with CON (P = 0.0453). In vitro, glucose-stimulated insulin secretion remained lower in islets isolated from IGF-1 fetuses (P = 0.0447). In summary, IGF-1 LR3 infusion for 1 wk into fetal sheep lowers insulin concentrations and reduces fetal GSIS. Impaired insulin secretion persists in isolated fetal islets indicating an intrinsic islet defect in insulin release when exposed to IGF-1 LR3 infusion for 1 wk. We speculate this alteration in the insulin/IGF-1 axis contributes to the long-term reduction in β-cell function in neonates born with elevated IGF-1 concentrations following pregnancies complicated by diabetes or other conditions associated with fetal overgrowth.NEW & NOTEWORTHY After a 1-wk infusion of IGF-1 LR3, late gestation fetal sheep had lower plasma insulin and glucose concentrations, reduced fetal glucose-stimulated insulin secretion, and decreased fractional insulin secretion from isolated fetal islets without differences in pancreatic insulin content.

The factors affecting the physical development of neonates in pregnant women with or without gestational diabetes mellitus

OBJECTIVES

To explore the factors affecting neonatal physical development in pregnant women with or without gestational diabetes mellitus (GDM).

METHODS

The subjects were selected from the pregnant woman giving birth in 2nd Affiliated Hospital of Zhengzhou University, from November 2015 to May 2016. The age, occupation, education level, gestational age, body weight before pregnancy, body weight at delivery, body height, delivery pattern, GDM status of pregnant women and neonatal gender, birth weight (BW), chest circumference (CC), head circumference (HC) and birth length (BL) were collected through medical records and questionnaires. The clinical data were retrospectively analyzed and studied.

RESULTS

The significant differences were found between women with GDM and without GDM in following neonatal variables (P<0.05): BW, CC, and HC. GDM status increased the incidence of macrosomia (OR = 2.241, 95% CI: 1.406-3.573), large CC (OR = 2.470, 95% CI: 1.687-3.6153). Gestational weight gain (GWG) above IOM guideline was risk factor for macrosomia (OR = 1.763, 95% CI:1.098-2.833), large HC (OR = 1,584, 95% CI: 1.093-2.296) and large CC (OR = 1.707, 95% CI:1.163-2.506). Underweight was risk factor for short BL (OR = 2.543, 95% CI:1.161-5.571) and small CC (OR = 1.901, 95% CI:1.064-3.394). Female neonate was prone to appear short BL(OR = 2.831, 95% CI: 1.478-5.422) and small HC (OR = 2.750, 95% CI: 1.413-5.350), and not likely to macrosomia (OR = 0.538, 95% CI: 0.343-0.843), longer BL (OR = 0.584, 95% CI: 0.401-0.850), large HC (OR = 0.501, 95% CI: 0.352-0.713), and (OR = 0.640, 95% CI: 0.446-0.917). For women with GDM, gestational age was an risk factor of neonatal BW (low BW: OR = 0.207, 95% CI: 0.085-0.503; macrosomia: OR = 1.637, 95% CI: 1.177-2.276), BL (short BL: OR = 0.376, 95% CI: 0.241-0.585; long BL: OR = 1.422, 95% CI: 1.054-1.919), HC (small HC: OR = 0.343, 95% CI: 0.202-0.583; large HC: OR = 1.399, 95% CI: 1.063-1.842) and CC (small CC: OR = 0.524, 95% CI: 0.374-0.733; large CC: OR = 1.485, 95% CI: 1.138-1.936).

CONCLUSIONS

In our study, gestational age, GDM status, neonatal gender, GWG and pre-pregnancy body mass index (BMI) are associated the abnormal physical development of neonates. In women with GDM, gestational age was correlate with neonatal abnormal physical developments.

Observations of the Effects of Maternal Fasting Plasma Glucose Changes in Early Pregnancy on Fetal Growth Profiles and Birth Outcomes

INTRODUCTION

Although the role of maternal hyperglycemia on birth outcomes is clear, literature regarding fetal growth is scarce. We examined the possible associations between maternal fasting plasma glucose (FPG) and fetal growth.

MATERIALS AND METHODS

A total of 35,981 singleton-pregnant women with FPG in the first trimester were included. Fetal growth parameters were measured during pregnancy by ultrasound at mid and late pregnancy. Information on birth characteristics was retrieved from medical records. We used multivariable linear and logistic regression to determine the associations between FPG and z-scores of fetal parameters and risks of birth outcomes and to assess effect modification by maternal characteristics.

RESULTS

A per-unit increase in FPG levels was negatively associated with fetal parameters in mid pregnancy but positively correlated with those in late pregnancy and with birth characteristics. The effect estimates in late pregnancy were attenuated by maternal pre-pregnancy body mass index (BMI). A significant relationship between FPG and abdominal circumference (AC), an indicator of fetal adiposity, was sustained in subgroups of women with advanced age, positive family history of diabetes, and multiparity in fully adjusted models. After stratification by BMI, high FPG was associated with accelerated AC only in normal controls (0.044 SD; 95% CI: 0.010, 0.079) and overweight/obese women (0.069 SD; 95% CI: -0.002, 0.140) but not in underweight women. High FPG was an independent risk factor for large-for-gestational age in the whole group and stratified subgroups.

CONCLUSIONS

Increased FPG in early pregnancy is closely related to fetal growth. Maternal characteristics may modify the associations between FPG and fetal adiposity in late pregnancy.

The effect of vascular complications of diabetes mellitus on human umbilical cord tissue and the number of Wharton Jelly's mesenchymal stem cells

The current study investigated the change in umbilical cord tissue and the number of markers of Wharton's jelly mesenchymal stem cells (WJ-MSC) in pregnant women with gestational diabetes (GDM), with chronic diabetes who developed nephropathy as vascular complication (VC-PGDM), and healthy pregnant women as the control. The umbilical cords (UC) were investigated by the histomorphological method and the number of WJ-MSC were detected by flow-cytometry using the CD90, CD44, CD105, and CD73 markers in Wharton's jelly (WJ) isolated from fresh umbilical cords. The number of positive cells for CD 90, CD44, CD105, and CD73 were found to be elevated in the GDM group, whereas it was significantly diminished in the VC-PGDM group (p = 0.001, p = 0.001, p = 0.001, and p = 0.001). The only histopathological sign in the GDM group were an increased number of pores in the Wharton jelly. Artery wall thickness/cord diamater ratio was increased, which indicates an increase of the artery wall thickness in the VC- PGDM group (p = 0.039 and p = 0.048). The increase in umbilical cord diameter and number of Wharton jelly mesenchymal stem cells in babies of gestational diabetic mothers was considered as an effect of macrosomia seen in babies of mothers with gestational diabetes. Vasculopathy, a long-term complication of diabetes, is known to affect all tissues by causing marked lower perfusion and hypoxia, as well as a decrease in the MSC number in our study.

The triad macrosomia, obesity, and hypertriglyceridemia in gestational diabetes

AIMS

Offspring of women with gestational diabetes (GD) have more macrosomia than newborns of normal mothers. We studied macrosomia frequency, possible pathogenesis, and main predictors of its appearance at different gestational ages.

MATERIALS AND METHODS

A total of 1870 pregnant women with GD were recruited in primary care centres and maternity hospitals in the Argentine provinces of Corrientes, Chaco, Buenos Aires, and in Buenos Aires City; 1088 completed gestation and delivered an infant. We collected clinical and metabolic data, personal and obstetric history, and gestational and delivery characteristics. Presence of macrosomia was analysed in the whole population, the entire pregnancy, and in each trimester of gestation. Data were statistically analysed and values were expressed as mean ± SD and percentages. The study protocol was approved by the Ethics Committee and all participants signed informed consent.

RESULTS

Macrosomia was found in 12.9% of newborns and obesity in all mothers with no significant differences between mothers with/without macrosomic offspring. In early pregnancy, the main significant indicators of macrosomia were: history of dyslipidaemia (5.6% vs 1.2%, respectively) and macrosomia in previous pregnancies (27% vs 13%, respectively). However, the third trimester showed a significant combination of higher BMI, FBG, and triglycerides.

CONCLUSIONS

Offspring of women with GD presented macrosomia in 12.9% of cases, maternal history of dyslipidaemia and macrosomia in previous pregnancies being early predictors. The combination of maternal obesity, FBG, and hypertriglyceridemia became significant during the last trimester of pregnancy.

Disadvantages of a weight estimation formula for macrosomic fetuses: the Hart formula from a clinical perspective

Purpose

Sonographic fetal weight (FW) estimation to detect macrosomic fetuses is an essential part of everyday routine work in obstetrics departments. Most of the commonly used weight estimation formulas underestimate FW when the actual birth weight (BW) exceeds 4000 g. One of the best-established weight estimation formulas is the Hadlock formula. In an effort to improve the detection rates of macrosomic infants, Hart et al. published a specially designed formula including maternal weight at booking. The usefulness of the Hart formula was tested.

Methods

Retrospective study of 3304 singleton pregnancies, birth weight ≥ 3500 g. The accuracy of the Hadlock and Hart formula were tested. A subgroup analysis examined the influence of the maternal weight. The Chi-squared test and one-way analysis of variation were carried out. For all analyses, p < 0.05 was considered statistically significant.

Results

The overall percentages of births falling within ± 5% and ± 10% of the BW using the Hadlock formula were 27% and 53%, respectively. Using the Hart formula, 24% and 54% were identified within these levels. With the Hart formula, 94% of all weight estimations fall within 4200 g ± 5% and nearly 100% fall within 4200 g ± 10%.

Conclusions

Applying the Hart formula results in an overestimation of fetal weight in neonates with a birth weight < 4000 g and fails to identify high-risk fetuses. We, therefore, do not consider Hart’s formula to be of clinical relevance.

Adipose Tissue Inflammation and Adrenomedullin Overexpression Contribute to Lipid Dysregulation in Diabetic Pregnancies

CONTEXT

Impaired maternal lipid metabolism in gestational diabetes mellitus (GDM) has detrimental effects on maternal health and fetal growth. We previously reported the excessive expression of adrenomedullin (ADM) and its receptors in GDM adipose tissues compared with normal glucose-tolerant pregnancies. In the present study, we determined the mechanisms underlying enhanced expression of ADM and its receptors.

DESIGN

Omental adipose tissue (OAT) samples were collected from women during cesarian section of term pregnancy with nonoverweight (NOW; n = 9), overweight (OW; n = 8), obese (OBS; n = 10), and GDM (n = 10) status.

RESULTS

The expression of ADM and its receptors was greater in OATs from GDM than from women who were NOW, OW, and OBS. The expression of adipokines, leptin, and resistin were significantly increased, but adiponectin was decreased in OATs from patients with GDM compared with those without GDM. Macrophage infiltration and TNF-α expression were greater in OAT from pregnant women with GDM than in pregnant women without GDM. Furthermore, TNF-α dose dependently increased mRNA for ADM and its receptor components calcitonin receptor-like receptor and receptor activity-modifying proteins 2 and 3 in OAT explants from women who were NOW. Human adipocytes treated with ADM significantly increased glycerol release in culture medium, and the increases of glycerol in culture medium of OAT from women with GDM were attenuated by ADM antagonists, ADM22-52.

CONCLUSIONS

Increased macrophage infiltration and TNF-α expression in adipose tissue from GDM, but not from OBS, tissues stimulate ADM and its receptor overexpression, leading to enhanced lipolysis and hyperlipidemia. This might contribute to fetal macrosomia and adiposity in diabetic pregnancies.

Ethnic differences in antepartum glucose values that predict postpartum dysglycemia and neonatal macrosomia

BACKGROUND AND OBJECTIVE

Gestational diabetes (GDM) occurs more often in women from certain ethnic groups and is also associated with fetal macrosomia. In this study, we investigated the ability of a gestational diabetes screening test (GDS), the 2 h 75 g-Oral Glucose Tolerance Test (OGTT), and glycated hemoglobin (HbA1c) in predicting postpartum dysglycemia and fetal macrosomia in women of Caucasian, Filipino, Chinese and South-Asian descent.

METHODS

848 women diagnosed with carbohydrate intolerance in pregnancy who completed a 2 h 75 g- OGTT within 6 months postpartum, were included in the study. Receiver Operating Characteristic curve analysis was used to test the ability of antepartum GDS, HbA1c and OGTT in predicting postpartum hyperglycemia, type 2 diabetes (T2D) and neonatal macrosomia (birth weight >4000 g).

RESULTS

20.2% had postpartum hyperglycemia while 3.8% had T2D. Those with postpartum dysglycemia were more likely to be non-Caucasian (South-Asian > Filipino > Chinese), have higher antepartum glucose values, require insulin during pregnancy and have cesarean births. Of HbA1c and the antepartum glucose values, a fasting glucose of ≥5.25 mmol/L was predictive of fetal macrosomia in Caucasians. 1 h glucose of ≥11.05 mmol/L was predictive of postpartum hyperglycemia, while 2 h glucose of ≥9.75 mmol/L was predictive of T2D; ethnicity influenced the predictive ability of these tests.

CONCLUSIONS

Ethnicity influences the ability of antepartum glucose and HbA1c to predict the risk of macrosomia and postpartum dysglycemia. This information will help detect those most at risk of T2D.

Immunohistochemical detection of vimentin in pancreatic islet β- and α-cells of macrosomic infants of diabetic and nondiabetic mothers

BACKGROUND

Expression of the intermediate filament protein vimentin has been recently observed in the pancreatic islet β- and α-cells of humans with type 2 diabetes mellitus. It was suggested that the presence of vimentin in endocrine cells may indicate islet tissue renewal, or potentially represent the dedifferentiation of endocrine cells, which could contribute to the onset of type 2 diabetes or islet cell dysfunction.

AIM

To analyze the expression of vimentin in pancreatic β- and α-cells of macrosomic infants of diabetic and nondiabetic mothers.

SUBJECTS

Pancreatic samples of five macrosomic infants (gestational age 34-40weeks) from three diabetic and two nondiabetic mothers were compared to six control infants (32-40weeks, weight appropriate for gestational age) from normoglycemic mothers.

METHODS

Pancreatic autopsy samples were examined by double immunofluorescent labeling with antibodies against vimentin and either insulin or glucagon. Alterations in the endocrine pancreas were measured using morphometric methods, then data were statistically analyzed.

RESULTS

In the pancreatic islets of macrosomic infants from diabetic and nondiabetic mothers, we observed vimentin-positive cells, some of which simultaneously contained insulin or glucagon. We also quantitatively showed that the presence of such cells was associated with hypertrophy and hyperplasia of the islets, and with an increase in β- and α-cell density.

CONCLUSIONS

We speculate that the appearance of vimentin-positive islet cells may reflect induction of differentiation in response to the increased insulin demand, and vimentin may serve as an early marker of endocrine pancreas disorders.

Alteration in Expression and Methylation of IGF2/H19 in Placenta and Umbilical Cord Blood Are Associated with Macrosomia Exposed to Intrauterine Hyperglycemia

Objective

Macrosomia is one of the most common complications in gestational diabetes mellitus. Insulin-like growth factor 2 and H19 are two of the imprinted candidate genes that are involved in fetal growth and development. Change in methylation at differentially methylated region of the insulin-like growth factor 2 and H19 has been proved to be an early event related to the programming of metabolic profile, including macrosomia and small for gestational age in offspring. Here we hypothesize that alteration in methylation at differentially methylated region of the insulin-like growth factor 2 and H19 is associated with macrosomia induced by intrauterine hyperglycemia.

Results

The expression of insulin-like growth factor 2 is significant higher in gestational diabetes mellitus group (GDM group) compared to normal glucose tolerance group (NGT group) both in umbilical cord blood and placenta, while the expression of H19 is significant lower in GDM group in umbilical cord blood. The expression of insulin-like growth factor 2 is significant higher in normal glucose tolerance with macrosomia group (NGT-M) compared to normal glucose tolerance with normal birthweight group (NGT-NBW group) both in placenta and umbilical cord blood. A model with interaction term of gene expression of IGF2 and H19 found that IGF2 and the joint action of IGF2 and H19 in placenta showed significantly relationship with GDM/NGT and GDM-NBW/NGT-NBW. A borderline significant association was seen among IGF2 and H19 in cord blood and GDM-M/NGT-M. The methylation level at different CpG sites of insulin-like growth factor 2 and H19 in umbilical cord blood was also significantly different among groups. Based on the multivariable linear regression analysis, the methylation of the insulin-like growth factor 2 / H19 is closely related to birth weight and intrauterine hyperglycemia.

Conclusions

We confirmed the existence of alteration in DNA methylation in umbilical cord blood exposed to intrauterine hyperglycemia and reported a functional role in regulating gene associated with insulin-like growth factor 2/H19. Both of these might be the underlying pathogenesis of macrosomia. We also provided the evidence of strong associations between methylation of insulin-like growth factor 2/H19 and macrosomia induced by intrauterine hyperglycemia.

Congenital hyperinsulinism in a newborn with a novel homozygous mutation (p.Q392H) in the ABCC8 gene

Congenital hyperinsulinism is the most frequent cause of persistent hypoglycemia in infancy. We present the case of a preterm, large-for-gestation-age infant with congenital hyperinsulinism who was found to have a novel p.Q392H homozygous mutation in the ABCC8 gene. The patient had severe brain damage, despite early diagnosis and appropriate management. The new mutations may provide an understanding of the prognosis and treatment of the disease. In addition, the data will help the family make informed decisions about future pregnancies.

Searching for the definition of macrosomia through an outcome-based approach

Background

Macrosomia has been defined in various ways by obstetricians and researchers. The purpose of the present study was to search for a definition of macrosomia through an outcome-based approach.

Methods

In a study of 30,831,694 singleton term live births and 38,053 stillbirths in the U.S. Linked Birth-Infant Death Cohort datasets (1995–2004), we compared the occurrence of stillbirth, neonatal death, and 5-min Apgar score less than four in subgroups of birthweight (4000–4099 g, 4100–4199 g, 4200–4299 g, 4300–4399 g, 4400–4499 g, 4500–4999 g vs. reference group 3500–4000 g) and birthweight percentile for gestational age (90^th–94^th percentile, 95^th-96^th, and ≥97^th percentile, vs. reference group 75^th–90^th percentile).

Results

There was no significant increase in adverse perinatal outcomes until birthweight exceeded the 97^th percentile. Weight-specific odds ratios (ORs) elevated substantially to 2 when birthweight exceeded 4500 g in Whites. In Blacks and Hispanics, the aORs exceeded 2 for 5-min Apgar less than four when birthweight exceeded 4300 g. For vaginal deliveries, the aORs of perinatal morbidity and mortality were larger for most of the subgroups, but the patterns remained the same.

Conclusions

A birthweight greater than 4500 g in Whites, or 4300 g in Blacks and Hispanics regardless of gestational age is the optimal threshold to define macrosomia. A birthweight greater than the 97^th percentile for a given gestational age, irrespective of race is also reasonable to define macrosomia. The former may be more clinically useful and simpler to apply.

A new case of holoprosencephaly-polydactyly syndrome with alobar holoprosencephaly, preaxial polydactyly and congenital glaucoma

We report a case of a female baby born at 34 weeks of gestation. Birth weight was 1760 g (10th-25th centile), length 41cm (10th-25th centile) and head circumference 27cm (< 10th centile). Clinical examination revealed microcephaly, hypotelorism, micrognathia, a flat rudimentary nose, high palate, thick dysplastic low-set ears, a short neck, preaxial polydactyly of the right hand, and overriding toes. Investigations showed bilateral congenital glaucoma, alobar holoprosencephaly, severe ventriculomegaly and absence midline structures of the brain, a large atrial septal defect. The karyotype was 46,XX. The case was also diagnosed as having holoprosencephaly-polydactyly syndrome (pseudotrisomy 13) because she had alobar holoprosencephaly, preaxial polydactyly, facial dysmorfism (hypotelorism, micrognathia, a flat rudimentary nose, high palate, thick dysplastic low-set ears) and normal karyotype.

Perinatal nutrition programs the hypothalamic melanocortin system in offspring

Epidemiological studies initially suggested that maternal undernutrition leading to low birth weight may predispose for long-lasting energy balance disorders. High birth weight due to maternal obesity or diabetes, inappropriate early postnatal nutrition, and rapid catch-up growth, may also sensitize to increased risk of obesity. As stated by the Developmental Origin of Health and Disease concept, the perinatal perturbation of fetus/neonate nutrient supply might be a crucial determinant of individual programming of body weight set-point. The hypothalamic melanocortin system composed of the melanocortin receptor 4, its agonist α-melanin-stimulating hormone (α-MSH), and its antagonist agouti-related protein (AgRP) is considered as the main central anorexigenic pathway controlling energy homeostasis. Studies in numerous animal models demonstrated that this system is a prime target of developmental programming by maternal nutritional manipulation. In rodents, the perinatal period of life corresponds largely to the period of brain maturation (i. e., melanocortin neuronal differentiation and development of their neural projections). In contrast, these phenomena essentially take place before birth in bigger mammals. Despite these different developmental time windows, altricial and precocial species share several common offspring programming mechanisms. Offspring from malnourished dams present a hypothalamic melanocortin system with a series of alterations: impaired neurogenesis and neuronal functionality, disorganization of feeding pathways, modified glucose sensing, and leptin/insulin resistance. Overall, these alterations may account for the long-lasting dysregulation of energy balance and obesity. Following maternal malnutrition, hormonal and epigenetic mechanisms might be responsible for melanocortin system programming in offspring.

Relationship between sonographically estimated fetal subcutaneous adipose tissue measurements and neonatal skinfold measurements

OBJECTIVE

Increased subcutaneous adipose tissue is a well known characteristic of diabetic fetopathy. Prenatal estimation of adipose tissue can be performed by ultrasound, while postnatally skinfold measurements are performed using a Holtain caliper. The aim of this study was to compare these methods in the same patients.

METHODS

This was a prospective study of 172 pregnant patients (142 controls and 30 with gestational diabetes) at ≥ 37 gestational weeks. In addition to fetal weight estimation, fetal subcutaneous tissue was measured at the anterior abdomen lateral to the umbilicus (SonoSfAbd) and at the middle of the femur (SonoSfFem). Within 72 h after delivery, a Holtain caliper was used to measure neonatal skinfold thickness at the left anterior iliac spine (SfAbd), at the lower angle of the left scapula (SfSca), at the middle of the femur, above the left quadriceps femoris (SfFem) and at the middle of the left triceps (SfHum). Ultrasound and mechanical measurements were correlated.

RESULTS

The sonographic and mechanical methods showed good correlation with each other. Linear regression analysis gave the following equations: SfAbd (mm) = SonoSfAbd (mm) × 0.489 + 1.988 (r(2) = 0.34, P < 0.001); SfSca (mm) = SonoSfAbd (mm) 0.457 + 2.043 (r(2) = 0.40, P < 0.001); SfFem (mm) = SonoSfFem (mm) × 0.714 + 1.763 (r(2) = 0.41, P < 0.001); SfHum (mm) = SonoSfFem (mm) 0.564 + 2.09 (r(2) = 0.39, P < 0.001).

CONCLUSIONS

Ultrasound examination is a reliable method for non-invasive intrauterine measurement of fetal subcutaneous tissue and can be used to predict mechanical neonatal skinfold thickness measurements.

Dietary polyunsaturated fatty acid prevents hyperlipidemia and hepatic oxidant status in pregnant diabetic rats and their macrosomic offspring

A considerable amount of clinical and experimental evidence now exists and suggests the involvement of fatty acids and free radical-mediated oxidative processes in the pathogenesis of diabetic complications. Fetuses from diabetic mothers are at increased risk of developing neonatal macrosomia and oxidative stress. We investigated the modulation of antioxidant status and liver biochemical parameters in normal and diabetic pregnant rats and their offspring. Animals were randomly allocated into three groups of six rats each: a control group, a diabetic group and diabetic rats fed with flax and sesame seeds mixture group. The time course of changes in lipid metabolism and antioxidant status by dietary rich in ω3- and ω6-polyunsaturated fatty acids in alloxan-induced diabetic pregnant rats and their macrosomic offspring was studied. Glucose and insulin levels were also assessed in order to characterize the diabetic state of dams and their offspring. The diabetic rats presented a significant increase in glycemia, plasma and liver lipid parameters compared with those of control group. In addition, liver malonaldialdehyde levels significantly increased. Antioxidant enzyme activities such as catalase and superoxide dismutase and reduced glutathione levels significantly decreased in the liver of diabetic rats when compared with controls. Diet supplemented with flax and sesame seeds mixture in pregnant diabetic rats ameliorated lipid parameters, antioxidant enzyme activities, level of reduced glutathione and significantly decreased malonaldialdehyde levels. These ameliorations were also observed in pups whose pregnant diabetic mothers were fed seeds mixture. Our results suggested that flax and sesame seeds mixture supplemented to diet of pregnant diabetic rats might be helpful in preventing diabetic complications in adult dams and their offspring.

[Insulin-like growth factor 2 imprinting status and promoter usage in the placenta of macrosomia]

OBJECTIVE

To study the mechanism of marcosomia by investigating insulin-like growth factor 2 (IGF(2))imprinting status, expression level and the promoter usage in the placenta of macrosomia.

METHODS

We selected heterozygous cases for Apa I polymorphism in exon 9 of IGF(2) gene and then analyzed its imprinting status in 168 placentas of macrosomia and normal pregnancies. IGF(2) transcription levels and promoter usages in macrosomic and normal placenta were evaluated by using semi-quantitative RT-PCR assay.

RESULTS

Thirty specimens of macrosomic placenta and 30 of normal placenta were identified as heterozygous for IGF(2). All of the heterozygous specimens showed maintenance of imprinting. The expression of placental IGF(2) mRNA (2.2 +/- 1.2) was significantly higher in macrosomia than that of normal weight group (1.6 +/- 0.6, P < 0.05). Of four promoters, P4 was the most powerful, P3 was the second, and P2 was weakest. Transcripts from P1 were the fewest, and they were only detected in two specimens. The value of P4 was 2.06 +/- 1.26, P3 0.99 +/- 0.72, P2 0.20 +/- 0.20 in macrosomia group and P4 2.05 +/- 1.27, P3 0.98 +/- 0.80, P2 0.19 +/- 0.17 in normal group. There were no significant differences between two groups (P > 0.05).

CONCLUSION

It is possible that over expression of IGF(2) in placenta contributes to macrosomia while the promoter usage and imprinting status are not associated with macrosomia.

Aortic intima-media thickness and lipid profile in macrosomic newborns

Macrosomia is associated with alterations in lipoprotein composition and concentration at birth. Exposure to diabetes in utero has been established as a significant risk factor for some of the components of metabolic syndrome. The aim of this study was to investigate the effect of macrosomia on lipid metabolism, aortic intima-media thickness (aIMT) and subsequent atherogenic risk in newborn infants. Aortic intima-media thickness was measured in 40 macrosomic neonates of diabetic mothers (group A), 30 macrosomic neonates of healthy mothers (group B) and 30 healthy neonates (group C). Lipid profile was determined in all infants and their mothers. Mean aIMT was significantly higher in macrosomic neonates of diabetic and healthy mothers (0.56+/-0.06 and 0.49+/-0.03 mm respectively) than in controls (0.39+/-0.03 mm). Weight-adjusted aIMT in macrosomic neonates of diabetic mothers (0.129+/-0.013 mm/kg) was significantly higher than in groups B and C (0.114+/-0.008 and 0.113+/-0.011 mm/kg respectively). There were significant alterations of total serum, high-density lipoprotein (HDL), very low-density lipoprotein (VLDL) cholesterols and triglyceride levels in the macrosomic neonates of diabetic mothers compared with controls. Macrosomia was associated with increased lipid concentrations. Macrosomic neonates of diabetic mothers have significantly higher aIMT with lipid alterations. This may play a role in the pathogenesis of atherosclerosis in adult life.

Serum insulin-like growth factor-I (IGF-I) IGF binding protein-3 (IGFBP-3) and leptin levels are related to abdominal aortic intima-media thickness in macrosomic newborns

OBJECTIVE

Exposure to diabetes in utero has been established as a significant risk factor for some of the components of metabolic syndrome, and was associated with increased levels of maternal, placental, and fetal insulin-like growth factors and leptin. The atherogenic effects of leptin and insulin-like growth factor-I (IGF-I) have been extensively described. The present study was therefore designed to investigate relationships between abdominal aortic intima-media thickness (aIMT), serum IGF-I, IGF binding protein-3 (IGFBP-3) and leptin levels in macrosomic newborns.

DESIGN

Neonates whose birth weights exceed 90th percentile for gestational age and gender are termed macrosomic. Abdominal aortic intima-media thickness was measured in 30 macrosomic neonates of diabetic mothers (group A), 30 macrosomic neonates of healthy mothers (group B) and 30 healthy neonates (group C). Serum IGF-I, IGFBP-3 and leptin levels were determined in all infants and their mothers. Stepwise logistic regression analysis was used to determine independent risk factors for aortic intima-media thickness.

RESULTS

Mean aortic intima-media thickness was significantly higher in groups A and B (0.489+/-0.015,0.466+/-0.019 mm, respectively) than in controls (0.375+/-0.024 mm, p<0.0001). Weight-adjusted aortic intima-media thickness was significantly higher in-group A than in groups B (p=0.004) and C (p=0.048). Serum leptin concentration in-group B (37.4+/-10.7 ng/ml) was significantly greater than in-group C (23.5+/-7.1 ng/ml, p<0.0001), but significantly lower than in-group A (46.6+/-14.1 ng/ml, p<0.0001). Serum IGF-I levels of the infants were significantly lower in-group C (113.2+/-33.1 ng/ml) than in groups A and B (205.2+/-60.1 and 179.3+/-55.1 ng/ml respectively, p<0.0001). Serum IGF-I, IGFBP-3 and leptin levels of the infants were positively correlated with mean (p<0.0001) and weight-adjusted aortic intima-media thickness measurements (p=0.003, p=0.006 and p=0.001, respectively).

CONCLUSIONS

Macrosomic neonates of diabetic mothers have significantly increased aortic intima-media thickness with higher serum IGF-I, IGFBP-3 and leptin concentrations than those of controls. It might be speculated that these changes may exaggerate the atherosclerotic process later in life.

Macrosomic newborns of diabetic mothers are associated with increased aortic intima-media thickness and lipid concentrations

BACKGROUND/AIMS

Exposure to diabetes in utero has been established as a significant risk factor for some of components of metabolic syndrome. A few studies have examined relationship between the metabolic syndrome and echocardiographic left ventricular (LV) mass. We aimed to investigate relationship between abdominal aortic intima-media thickness (aIMT), LV mass and lipid profile in macrosomic newborns.

METHODS

Abdominal aIMT was measured in 30 macrosomic neonates of diabetic mothers (group A), 30 macrosomic neonates of healthy mothers (group B) and 30 healthy neonates (group C). Lipid profile and LV mass were determined.

RESULT

Mean aIMT was significantly higher in groups A and B (0.489 +/- 0.015, 0.466 +/- 0.019 mm, respectively) than in controls (0.375 +/- 0.024 mm). Weight-adjusted aIMT in group A was significantly higher than in groups B and C. Macrosomia was associated with increased lipid concentrations. Both LV mass indexed for BSA (body surface area) and birth weight measurements were significantly increased in group A compared with control.

CONCLUSIONS

Macrosomic neonates of diabetic mothers have significant aIMT and LV mass indexed for BSA and birth weight with lipid alterations. It might play a role in the pathogenesis of atherosclerosis in adult life.

Mode of delivery and the survival of macrosomic infants in the United States, 1995-1999

BACKGROUND

Although increases in perinatal mortality risk associated with fetal macrosomia are well documented, the optimal route of delivery for fetuses with suspected macrosomia remains controversial. The objective of this investigation was to assess the risk of neonatal death among macrosomic infants delivered vaginally compared with those delivered by cesarean section.

METHODS

Data were derived from the U.S. 1995-1999 Linked Live Birth-Infant Death Cohort files and term (37-44 wk), single live births to United States resident mothers selected. A proportional hazards model was used to analyze the risk of neonatal death associated with cesarean delivery among 3 categories of macrosomic infants (infants weighing 4,000-4,499 g; 4,500-4,999 g; and 5,000+ g).

RESULTS

After controlling for maternal characteristics and complications, the adjusted hazard ratio for neonatal death associated with cesarean delivery among the 3 categories of macrosomic infants was 1.40, 1.30, and 0.85.

CONCLUSIONS

Although cesarean delivery may reduce the risk of death for the heaviest infants (5,000+ g), the relative benefit of this intervention for macrosomic infants weighing 4,000-4,999 g remains debatable. Thus, policies in support of prophylactic cesarean delivery for suspected fetal macrosomia may need to be reevaluated.

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.

Maternal morbidity associated with obstetrical maneuvers in shoulder dystocia

OBJECTIVES

To determine whether shoulder dystocia and obstetrical maneuvers used for its relief have detrimental effects on perineum or immediate postpartum outcome.

DESIGN

Case-control study.

SETTING

Tertiary maternity ward in Marseille, France.

POPULATION

A total 140 cases with shoulder dystocia and 280 controls without shoulder dystocia were enrolled by reviewing charts for the period between January 1999 and December 2004.

METHODS

Demographic data including obstetrical history, age, height, weight before pregnancy and at the time of delivery, and respective body mass index (BMI) and obstetrical data including analgesic technique, duration of first and second stage of labor were compared in function of outcome and of the type and number of maneuvers used to relieve shoulder dystocia.

RESULTS

Resolving shoulder dystocia required one obstetrical maneuver in 41 cases (29.3%) and two obstetrical maneuvers in 48 cases (34.3%). Third-degree tears occurred in one patient in the case group versus five in the control group. No correlation was found between the number of obstetrical maneuvers needed to relieve shoulder dystocia and risk for third-degree tear (OR: 0.8; 95% CI: 0.1-7.6). Mean hemoglobin values were 96.1 g/l in the case group and 96.0 g/l in the control group (p=0.95). There was no difference between the two groups regarding duration of postpartum hospitalization. The incidence of urinary incontinence was similar in the group that underwent obstetrical maneuvers: 4.7% (6/127) and in the control group: 3.7% (13/352). Only two patients reported de novo anal symptoms, both in the control group.

CONCLUSION

Shoulder dystocia and obstetrical techniques used for its relief did not result in adverse maternal outcome.

Villous histomorphometry and placental bed biopsy investigation in Type I diabetic pregnancies

Insulin-dependent diabetes mellitus (Type I) is associated with disregulation of the glucose and oxygen metabolic pathways during pregnancy, both of which affect placental villous development. Term complete placentas and placental bed biopsies, between 37 and 40 weeks, from 12 singleton pregnancies complicated by Type I diabetes were collected following delivery by elective Caesarean section. The controls consisted of 10 term placentas from uncomplicated pregnancies delivered by elective Caesarean section. Villous morphology was investigated using unbiased histomorphometric techniques, in relation to the degree of transformation of the spiral arteries and the presence of fetal macrosomia. A significant increase in fetal and placental weights, placental volume, volumes of the intervillous space and the trophoblast was found in the diabetic group compared to the controls. A significant reduction in the villous membrane specific diffusing capacity was observed between the diabetic and control groups (1.32 vs 1.72 cm3 min(-1)mmHg(-1)kg(-1), P=0.032). A significant increase in the volume of the intermediate and terminal villi, the surface area of the villi and of the fetal capillaries, and the harmonic thickness of the villous membrane was found in the macrosomic subgroup compared to the controls. There were no differences between the hypertensive subgroup with histological evidence of partial transformation of the spiral arteries and the controls. These data indicate that placental development in insulin-dependent diabetic pregnancies is affected differentially when pregnancies complicated by fetal macrosomia are separated from those complicated by maternal hypertensive disorders with partial transformation of the spiral arteries. The reduction in the specific diffusing capacity of the villous membrane may contribute to the fetal hypoxia and increased fetal and neonatal morbidity associated with diabetes.

Fetal hemangiopericytoma with an associated cerebral anomaly

We report the first case of infantile hemangiopericytoma explored prenatally by fetal ultrasonography and magnetic resonance imaging (MRI). It was associated with a developmental cerebral anomaly identified on MRI. The largest lesions of the multifocal hemangiopericytoma were located in the soft tissue adjacent to the left temporal bone, and smaller lesions were found in the lumbar area and in the retroperitoneum. MRI showed no connection between the tumor and the fetal brain but there was anomalous cerebral gyration in the region and the Sylvian fissure beneath the tumor was enlarged. The pregnancy was terminated because of the severe brain anomalies and postmortem examination confirmed the prenatal findings. Microscopic analysis of the tumor tissue showed branching vessels which are typical of hemangiopericytoma. The lesions in our case occurred in association with macrosomia with visceromegaly detected at autopsy, suggesting a possible role of tumor suppressor genes.

A provisionally unique syndrome of macrosomia, bone overgrowth, macrocephaly, and tall stature

We report a young man with intrauterine macrosomia, macrocephaly, and bony abnormalities. Excessive growth continued throughout infancy and childhood. Bone age was advanced. He developed contractures of the large joints and was confined to a wheelchair. Extensive laboratory studies, repeated on multiple occasions were all normal. Intellectually, he was normal. His near final height was 234 cm. The constellation of findings in this patient is at variance with previously described syndromes of tall stature. We postulate that excessive size and bone overgrowth in this young man is caused by a receptor/post-receptor abnormality involving a growth on/off mechanism at the cellular level.

Evaluation of the measurement of the fetal fat layer, interventricular septum and abdominal circumference percentile in the prediction of macrosomia in pregnancies affected by gestational diabetes

OBJECTIVES

To evaluate the measurement of the fetal abdominal fat layer (FFL), cardiac interventricular septum (IVS) and abdominal circumference (AC) percentile in the early third trimester as predictors of macrosomia at birth in the fetuses of women with gestational diabetes.

METHODS

Ninety patients attending the hospital's special diabetic clinic were recruited prospectively. FFL and IVS were measured in addition to the routine biometry in the early third trimester. AC was measured routinely and AC percentile was determined from established antenatal charts. These measurements were then assessed as predictors of macrosomia.

RESULTS

A fetal fat layer of >/=5 mm was the most useful predictor of macrosomia at term as assessed using the likelihood ratio. An AC >/=90th percentile, however, had a better sensitivity.

CONCLUSION

The usefulness of routine FFL measurement in the early third trimester in the management of diabetic pregnancies is worthy of further evaluation.

Macrosomic births in the united states: determinants, outcomes, and proposed grades of risk

OBJECTIVE

We describe maternal risk factors for macrosomia and assess birth weight categories to determine predictive thresholds of adverse outcomes.

STUDY DESIGN

We analyzed linked live birth and infant death cohort files from 1995 to 1997 for the United States with the use of selected term (37-44 weeks of gestation) single live births to mothers who were US residents. We compared macrosomic infants (4000-4499 g, 4500-4999 g, and >5000 g infants) with a normosomic control group of infants who weighed 3000 to 3999 g.

RESULTS

Maternal risk factors for macrosomia included nonsmoking, advanced age, married, diabetes mellitus, hypertension, and previous macrosomic infant or pregnancy loss. The risks of labor complications, birth injuries, and newborn morbidity rose with each gradation of macrosomic birth weight. Infant mortality rates increased significantly among infants weighing >5000 g.

CONCLUSION

Although a definition of macrosomia as >4000 g (grade 1) may be useful for the identification of increased risks of labor and newborn complications, >4500 g (grade 2) may be more predictive of neonatal morbidity, and >5000 g (grade 3) may be a better indicator of infant mortality risk.

Beta-cell hyperplasia in macrosomic infants and fetuses of nondiabetic mothers

The objective of this study was to test the hypothesis that macrosomic infants of nondiabetic mothers have beta-cell hyperplasia in their pancreases. Pancreatic tissues were examined from 10 macrosomic fetuses and liveborn infants and from 10 comparison cases matched for gestational age and gender. None of the mothers had a history of diabetes and all had normal glucose screening during pregnancy. Tissues were stained with hematoxylin and eosin and a monoclonal antibody against beta cells and were analyzed using an image analysis program to evaluate the size and surface area of beta-cell clusters. Brain/liver weight ratios were calculated and compared. The total surface area and cluster size of beta cells in the pancreases of macrosomic subjects were significantly larger than in the comparison pancreases. The study subjects lacked macroscopic and histopathologic findings expected in infants of diabetic mothers. We conclude that some macrosomic fetuses and infants of nondiabetic mothers manifest beta-cell hyperplasia. This corresponds to the higher insulin levels in macrosomic infants of nondiabetic mothers described in previous clinical studies. In macrosomic fetuses the stimulus for beta-cell hyperplasia may not involve aberrant maternal glucose levels.

Weaver syndrome: autosomal dominant inheritance of the disorder

Weaver syndrome (WS), a condition first described in 1974 by Weaver et al., consists of macrosomia, advanced skeletal age, characteristic pattern of facial and radiographic anomalies, and contractures. Although there have been three reports of close relatives (sibs or both parent and offspring) affected with this condition, the syndrome generally occurs sporadically, and the recurrence risk in sporadic cases appears to be low. We report here on a family in which the propositus and his sister were born with the facial phenotype, club feet, and macrosomia characteristic of WS. Their father had macrosomia and macrocephaly as an adult, and childhood photos show clearly that he has WS. Two sisters of the propositus have had normal growth and development. The syndrome in this family appears to be inherited in an autosomal dominant fashion.

The syndromes of Sotos and Weaver: reports and review

The syndromes of Sotos and Weaver are paradigmatic of the daily nosologic difficulties faced by clinical geneticists attempting to diagnose and counsel, and to give accurate prognoses in cases of extensive phenotypic overlap between molecularly undefined entities. Vertebrate development is constrained into only very few final or common developmental paths; therefore, no developmental anomaly seen in humans is unique to ("pathognomonic" of) one syndrome. Thus, it is not surprising that prenatal overgrowth occurs in several syndromes, including the Sotos and Weaver syndromes. Are they sufficiently different in other respects to allow the postulation of locus (rather than allele) heterogeneity? Phenotypic data in both conditions are biased because of ascertainment of propositi, and the apparent differences between them may be entirely artificial as they were between the G and BBB syndromes. On the other hand, the Sotos syndrome may be a cancer syndrome, the Weaver syndrome not (though a neuroblastoma was reported in the latter); in the former there is also remarkably advanced dental maturation rarely commented on in the latter. In Weaver syndrome there are more conspicuous contractures and a facial appearance that experts find convincingly different from that of Sotos individuals. Nevertheless, the hypothesis of locus heterogeneity is testable; at the moment we are inclined to favor the hypothesis of allele heterogeneity. An international effort is required to map, isolate, and sequence the causal gene or genes.

Limited usefulness of fetal weight in predicting neonatal brachial plexus injury

OBJECTIVE

The objectives were to determine the neonatal morbidity rate from vaginal birth and examine fetal weight-based injury-prevention strategies.

STUDY DESIGN

Selected neonatal morbidities were categorized by birth weight for all vertex vaginal deliveries occurring during a 12-year period. Sensitivity, specificity, and predictive values for brachial palsy were calculated at increasing birth weight cutoff levels. A policy of cesarean delivery for macrosomic infants was evaluated.

RESULTS

There were 80 cases of brachial palsy among 63,761 infants (0.13%). In mothers without diabetes, rates in the 4500- to 4999-g and >5000-g groups were 3.0% and 6.7%, respectively. A threshold of 3700 g had a sensitivity of 71% and a specificity of 86%; the positive predictive value was 0.56%. To prevent a single case of permanent injury, 155 to 588 cesarean deliveries are required at the currently recommended cutoff weight of 4500 g.

CONCLUSIONS

The rates of lasting morbidity do not justify routine cesarean delivery for infants without diabetic complications weighing <5000 g.

Gestational diabetes mellitus (GDM) and macrosomia: a controversial story

Increased perinatal morbidity-mortality are associated with gestational diabetes mellitus (GDM). We studied 69 non-diabetic pregnancies (age 30 +/- 5 years) by repeating oral glucose tolerance test (OGTT, 100 g; area under glycemic, AUGC as g min/dl, and insulinemic, AUIC as mU min/ml, curves were calculated) and HbA1c measurement at 14, 24 and 33 weeks. In the 3rd trimester, 7 women had abnormal OGTT, but none of the 12 mothers of large babies (> 3.9 kg) had GDM. Among 15 pregnants with basal body mass index (BMI) > 25 kg/m2, 2 developed GDM, 5 had babies > 3.9 kg, 8 had normal birthweight babies. Those pregnants who showed after-load hyperglycemia despite normal insulin secretory response (insulin resistance) developed GDM, but delivered normal birthweight babies. Large neonates were delivered from women with the greatest both gestational weight gain and insulin sensitivity, but normal glucose tolerance. The heaviest pregnants with normal both glucose tolerance and insulin sensitivity had normal weight gain and normal birthweight infants. Neonatal body weight was correlated with maternal gestational weight gain, placental weight, 3rd trimester AUIC/AUGC ratio and 1st-2nd trimester HbA1c.

Gestational diabetes: clinical characteristics and birth weight

This retrospective study investigates the clinical characteristics of gestational diabetes mellitus (GDM) (time of diagnosis, different treatment, metabolic parameters, etc.) in relation to prepregnancy body mass index (BMI) and the influence of BMI on neonatal outcome. 93 GDM women and 110 control subjects were divided into three groups in relation to their prepregnancy BMI: normalweight (Nw), overweight (Ow) and obese (Ob). GDM was diagnosed significantly (p < 0.01) earlier in Ow and Ob than in Nw. Preterm deliveries and cesarean sections resulted significantly (p < 0.01) increased in all BMI categories of GDM respect to matched controls. Prevalence of neonatal macrosomia was higher in GDM patients (44.6%) compared with normal controls (15.4%) and correlated (p < 0.01) with prepregnancy BMI in both groups. Nevertheless in each BMI category the prevalence of macrosomia was significantly higher in GDM patients. The body weight increase during pregnancy was not associated with neonatal macrosomia. This study shows that prepregnancy BMI is an important risk factor for GDM and is predictive for macrosomia specially in women suffering from GDM.

Lipid metabolism alterations in patients with gestational diabetes mellitus associated fetal macrosomia

Fetal macrosomia is commonly associated with gestational diabetes mellitus (GDM) which may lead to various complications. It has been suggested that some other metabolites apart from maternal hyperglycemia are responsible for the genesis of macrosomia. Lipid metabolism changes in GDM patients having macrosomic fetuses were studied. A lipid tolerance test (10% Lipovenous solution) was performed in 14 GDM. Pre- and post-infusion plasma lipid levels and their elimination rates were measured and compared to the ones of 8 non diabetic control pregnant women. HbA1c, basal glucose and triglyceride levels were found to be higher in GDM group and significantly higher levels of triglycerides persisted throughout the infusion. FFA, glycerol and phospholipid levels increased following infusion in both groups without significant differences. Glucose, C-peptide and insulin levels remained unchanged after the infusion. Increased basal triglycerides with slowed triglyceride metabolism may be responsible for the fetal macrosomia in mild GDM patients whose fasting blood glucose are below 105 mg/dl. A better metabolic control that provides plasma lipid regulation as well as glucose control may forestall the occurrence of fetal macrosomia.

Estimation of gestational age by the length of the dorsal spine

Gestational age assessed by dorsal spine length (DSL) was compared with that based on date of the last menstrual period (LMP). This study was performed in 70 newborn infants admitted to a neonatal intensive care unit requiring chest radiography, by which dorsal spine length was measured (figure 1). Gestational age ranged from 23 to 42 weeks. Regression analysis were performed on DSL and gestational age. Estimation error was evaluated based on the percentage of agreement in weeks (validity) and the difference in averages between both methods (accuracy) (table I and figure 2). Variations during the first week of life were also studied and no significant differences were found. For infants born at 31 weeks or less, DSL overestimated gestational age in one week. There was no differences between 32 and 36 weeks, and over 37 weeks, underestimation was one week (figure 3). With this correction a table was built estimating gestational age for different DSL; percentage of agreement was 91.4% for +/- 3 weeks (table III). This methodology assists the clinician to evaluate gestational age by an objective method, that does not vary during the first week of life and that can be obtained retrospectively.

The evaluation of accelerated fetal growth

The timely recognition of fetal macrosomia may reduce the complications associated with vaginal delivery of a macrosomic fetus. Today, the most frequently used tool for identification of fetal macrosomia is ultrasound. Although many different calculations have been applied, the most commonly used is the estimation of fetal weight. Generally, the detection rate of fetal macrosomia is 33-82%, with a specificity of 70-100%, a positive predictive value of 40-83%, and negative predictive value of 66-92%. Adding amniotic fluid volume, cheek-to-cheek diameter or fetal subcutaneous tissue: femur length ratio may improve the accuracy of the diagnosis. Other promising diagnostic tools include the echo-planar imaging and the neural network. Despite the progress that has been achieved since the use of Nagele's rule, our ability to fetal macrosomia remains limited.

Relation of amniotic fluid C-peptide levels to neonatal body composition

OBJECTIVE

To compare the correlation between fetal insulin production (as estimated by amniotic fluid [AF] C-peptide concentration) and neonatal body fat (as estimated by both anthropometrics and total body electrical conductivity) with that between fetal insulin production and birth weight or fat-free mass.

METHODS

Amniotic fluid C-peptide concentration measured within 1 week of delivery was correlated with birth weight and neonatal body composition, estimated by both anthropometric measures and total body electrical conductivity within 24 hours of birth. Eighteen term neonates were studied: 13 from pregnancies complicated by diabetes and five from mothers with normal glucose tolerance.

RESULTS

Six infants were large for gestational age and 12 were appropriate for gestational age. There was a significant correlation between AF C-peptide level and neonatal fat mass, estimated by either anthropometric measures (r = 0.72, P = .0008) or total body electrical conductivity (r = 0.61, P = .008) methodology. The correlation was weaker between AF C-peptide level and either ponderal index (r = 0.44, P = .064) or total weight (r = 0.39, P = .11). The correlation with fat-free mass estimated by either method was not statistically significant.

CONCLUSION

Our results suggest that fetal insulin production, as estimated by AF C-peptide concentration, influences fetal growth primarily through increasing fetal fat deposition rather than lean body mass.

Ratios between the abdominal circumference, head circumference, or femur length and the transverse cerebellar diameter of the growth-retarded and macrosomic fetus

The purpose of our investigation was twofold: to provide normative data for the ratios between head circumference and cerebellum, abdominal circumference and cerebellum, and femur length and cerebellum; and to evaluate the predictive accuracy of an abnormal ratio in the detection of growth retardation and macrosomia. Data on 675 women with normal gestations between 14 and 42 weeks were used to estimate reference curves for the three ratios to be evaluated. We then compared the ratios of 34 fetuses with intrauterine growth retardation and 28 macrosomic fetuses to the control group. Of the three ratios that we investigated, abdominal circumference to transverse cerebellar diameter was the most efficacious. However, the sensitivity of this ratio for the detection of intrauterine growth retardation and macrosomia was only 52.9% and 46.6%, respectively. A ratio between head circumference, abdominal circumference, or femur length and the transverse cerebellar diameter cannot reliably distinguish between normally growing fetuses and those that are growth retarded or macrosomic.

Fetal heart circumference as a predictor of menstrual age in fetuses affected by disturbances in growth

OBJECTIVE

The purpose of this study was twofold: (1) to evaluate the relationship between fetal heart circumference and gestational age and (2) to determine the effect, if any, of disturbances in fetal growth on heart circumference.

STUDY DESIGN

Heart circumference was measured in 262 women with normal gestations (control group) and in two study groups consisting of 52 large-for-gestational age 32 small-for-gestational age fetuses. Standardized, gestational age-adjusted values in the two study groups were compared with normative data provided by the control group.

RESULTS

There was a close correlation (R2 = 0.94) between heart circumference and gestational age in normally growing fetuses. Disturbances of fetal growth (i.e., macrosomia and growth retardation) were found to have an inconsistent effect on heart circumference.

CONCLUSION

Heart circumference cannot be used as an independent parameter for gestational age evaluation in fetuses with disturbances of growth.

[The newborn infant of a diabetic mother]

The authors present a case of a newborn of a diabetic mother with fatal outcome in the 6th day postnatally. The principal troubles in newborn were: fetal macrosomy, hypoglycemia and a lot of congenital malformations. They discuss the relationship between the maternal alteration of hydrocarbonate metabolism and the troubles in fetus and newborn.

Acardiac acephalic monster extremely larger than its co-twin. A case report

The acardiac monster represents a rare but one of the severest congenital anomalies which occur only in multiple pregnancy. The affected fetus is sustained by a parasitic anastomosis to the umbilical blood vessels of the normal fetus. We report an interesting case of a macrosomic acardiac acephalic fetus weighing 4.5-fold of another variable donor fetus (approximately 6 kg) in a twin pregnancy.

The transverse cerebellar diameter in estimating gestational age in the large for gestational age fetus

The transverse cerebellar diameter was measured in 62 nondiabetic and 30 diabetic women with large for gestational age fetuses. Using reference curves from 675 women with normal gestations between 14-42 weeks, head circumference and abdominal circumference overestimated gestational age significantly in both study groups, whereas the transverse cerebellar diameter did not.

Ultrasonographic measurement of fetal femur length in growth disturbances

Ultrasonographic measurement of fetal femur length is a recognized technique for determination of gestational age and fetal growth. A total of 280 pregnant women were studied, each of whom had pathologies with the potential to either accelerate or delay fetal growth. There were 1000 measurements of the fetal femur length performed on these 280 fetuses. A total of 125 fetuses were found to have a growth disturbance-91 with asymmetrical intrauterine growth retardation and 34 with macrosomia. Comparison of fetuses with either intrauterine growth retardation or macrosomia with appropriate-for-gestational-age fetuses showed that the femur length is not statistically affected by intrauterine growth abnormalities.

Delayed lung maturation in the macrosomic offspring of genetically determined diabetic (db/+) mice

We studied a genetically determined diabetes in pregnancy, the heterozygous diabetes (db/+) mouse. We found that fetal mice from these pregnancies are macrosomic with increased body, lung, and placenta wt, have altered organ protein, DNA and phospholipid content, and exhibit abnormal carbohydrate metabolism with increased liver and glycogen content. We further studied the effect of increased substrate availability and utilization on lung growth and maturation in (db/+) fetal mice, by measuring lung phospholipid synthesis as represented by the incorporation of the radiolabeled precursors, [3H]choline and [14C]glycerol, in fetal lung at 18 days' gestation (term = 19). Diabetic fetuses incorporated significantly more [3H]choline into disaturated phosphatidylcholine than controls (1.32 +/- 0.10 X 10(-2) versus 0.78 +/- 0.05 X 10(-2) nmol/g protein/min, mean +/- SE; p less than 0.001), but significantly less [14C]glycerol into phosphatidylglycerol than controls (3.18 +/- 0.38 versus 4.91 +/- 0.53 nmol/g protein/min, mean +/- SE; p less than 0.002), and their phosphatidylglycerol/phosphatidylinositol synthesis ratios were decreased (1.81 +/- 0.18 versus 3.17 +/- 0.14; mean +/- SE; p less than 0.001). Diabetic fetal lungs appeared morphologically less mature than controls at 18 days' gestation, as shown by a significantly decreased air space density (0.27 +/- 0.01 versus 0.43 +/- 0.02, mean +/- SE; p less than 0.001) and alveolar epithelial cell/total tissue ratio (0.54 +/- 0.02 versus 0.66 +/- 0.03, mean +/- SE; p less than 0.01). The increased synthesis of lung disaturated phosphatidylcholine in diabetic fetal mice may reflect the enhancement of body and lung growth in these macrosomic fetuses.(ABSTRACT TRUNCATED AT 250 WORDS)