Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 83e96

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Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Macrosomia
Edward Araujo Jnior, PhD a, *, Alberto Borges Peixoto, MD a,
Ana Cristina Perez Zamarian, MD a, Jlio Elito Jnior, PhD a,
Gabriele Tonni, PhD b
a ~o Paulo (EPM-UNIFESP),
Department of Obstetrics, Paulista School of Medicine - Federal University of Sa
Sa~o Paulo-SP, Brazil
b
Department of Obstetrics and Gynecology, Guastalla Civil Hospital, AUSL Reggio Emilia, Italy

Fetal macrosomia is dened as birth weight >4000 g and is asso-

Key words:
ciated with several maternal and fetal complications such as
fetal macrosomia
gestational diabetes mellitus maternal birth canal trauma, shoulder dystocia, and perinatal
birth weight asphyxia. Early identication of risk factors could allow preventive
two-dimensional ultrasound measures to be taken to avoid adverse perinatal outcomes. Pre-
three-dimensional ultrasound natal diagnosis is based on two-dimensional ultrasound formulae,
induction of labor but accuracy is low, particularly at advanced gestation. Three-
shoulder dystocia dimensional ultrasound could be an alternative to soft tissue
monitoring, allowing better prediction of birth weight than two-
dimensional ultrasound. In this article, we describe the deni-
tion, risk factors, diagnosis, prevention, ultrasound monitoring,
prenatal care, and delivery in fetal macrosomia cases.
2016 Published by Elsevier Ltd.

Introduction and denition

Fetal macrosomia may be arbitrarily dened as a birth weight >4000 g and occurs as a complication
in more than 10% of all pregnancies in the United States of America [1]. It is associated with increased
risks of cesarean section and trauma to the birth canal and fetus. Prediction of fetal macrosomia may be
performed using clinical and ultrasonographic evaluation. Clinical evaluation is based on maternal
fundal height assessment. When fundal height assessment is performed on an individual basis using a
customized chart, greater accuracy can potentially be obtained. Similarly, ultrasound estimation of fetal

~o PauloeSP, CEP 05089-030, Brazil. Tel.:/Fax:

* Corresponding author. Rua Belchior de Azevedo, 156 apto. 111 Torre Vitoria, Sa
55 11 37965944.
E-mail address: araujojred@terra.com.br (E. Araujo Jnior).

http://dx.doi.org/10.1016/j.bpobgyn.2016.08.003
1521-6934/ 2016 Published by Elsevier Ltd.
84 E. Araujo Jnior et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 83e96

weight (EFW) may not be accurate, resulting in an increased rate of false positive tests. Inaccurate
prediction of fetal macrosomia has resulted in a high number of unnecessary procedures, since early
induction of labor to limit fetal growth may result in a substantial increase in the cesarean section rate
because of failed inductions [2] or respiratory complications in newborns. Hence, it is suggested that
pregnancies complicated by fetal macrosomia might be best managed expectantly [1].
Generally, fetal macrosomia may be dened by a birth weight >4000 g or higher cutoffs [3]. Since a
clear-cut denition of fetal macrosomia has not yet been established, a clinical value independent of
gestational age, such as large for gestational age (LGA), is preferable. LGA fetuses are usually dened as
those with a birth weight >90th percentile for gestational age. One of the reasons for induction of labor
in case of suspected macrosomia is to reduce the likelihood of cesarean section and of difcult oper-
ative delivery, possibly resulting in maternal or perinatal morbidity [4]. Observational studies have
raised concerns on the effectiveness of this management [5,6].
A direct correlation has been observed between maternal weight gain and the incidence of sec-
ondary cesarean section when vaginal delivery was initially planned; in addition, a direct correlation
between increasing birth weight and a higher incidence of secondary cesarean section and assisted
vaginal delivery has been reported.
Gestational diabetes mellitus (GDM) is a known clinical risk factor associated with fetal macrosomia
and represents 90% of all types of diabetes occurring in pregnancy. In women diagnosed with GDM, the
main complication is fetal macrosomia. The rationale for performing an elective cesarean section in-
cludes a potential reduction in perinatal complications, especially those related to macrosomia. Using
multiple logistic regression models in 181,479 deliveries for comparing birth outcome of women with
and without familial history of DM, it has been shown that women with a familial history of DM
(n 13,813) had a higher rate of fetal macrosomia, dened as a birth weight >4000 g, compared with
controls (p < 0.001) and a 1.3-fold increase in the risk for cesarean section (p < 0.001) [7].
According to the National Vital Statistics in the United States, the prevalence of newborns weighing
at least 4000 g has decreased by 10% in seven years (10.2% in 1996 and 9.2% in 2002) and 19% for
newborns weighing >5000 g (0.16% and 0.13%, respectively). Bayesian calculations indicate that the
post-test probability of detecting a macrosomic fetus in an uncomplicated pregnancy is variable,
ranging from 15% to 79% with ultrasound estimation of birth weight, and 40% to 52% with clinical
estimates. Among diabetic patients, the post-test probability of identifying a newborn weighing
>4000 g clinically and by ultrasound is over 60%. Among uncomplicated pregnancies, there is sufcient
evidence that suspected fetal macrosomia is not an indication for induction of labor or for elective
cesarean section. For pregnancies complicated by diabetes, with a prior cesarean section or shoulder
dystocia, delivery of a macrosomic fetus increases the risk of complications, but there is insufcient
evidence on the threshold of EFW to prompt cesarean section [8].
The accuracy of 31 published formulae for EFW in predicting macrosomia (birth weight >4000 g) in
infants of diabetic mothers has been reported in 165 women with GDM or pre-GDM who had ultra-
sound for EFW > 36 weeks of gestation and within 2 weeks of delivery. Formulae were ranked ac-
cording to a scoring system based on three different outcome measurements. Furthermore, each rank
score was summed up to give an overall score. The formula with the lowest total score was considered
the best to predict diabetic fetal macrosomia. Fetal macrosomia occurred in 49 cases (30%). Areas under
the receiver operator characteristics (ROC) curves ranged from 0.8361 to 0.8978. Using this best
formula, an EFW of 4000 g had a sensitivity of 45% to predict macrosomia and a positive predictive
value (PPV) of 81%. This study concluded that all 31 formulae for EFW had comparably poor accuracy
for the prediction of macrosomia and that delivery decisions based on EFW will often result in an
error [9].
Coomarasamy et al. [10] have calculated the likelihood ratios for positive (LR) and negative (LR-)
test results for an ultrasound EFW of >4000 g and an abdominal circumference (AC) of 36 cm for
predicting birth weight >4000 g. The authors reported that the area under the ROC curves for ultra-
sonographically determined EFW was no different from the area under the ROC curve for fetal AC in
19,117 pregnant women. Moreover, for predicting a birth weight >4000 g, the summary LRs were 5.7
(95% CI: 4.3 to 7.6) for a positive test and 0.48 (95% CI: 0.38 to 0.60) for a negative test by using
Hadlock's formula. When fetal AC 36 cm was considered, the LRs for predicting a birth weight
>4000 g were 6.9 (95% CI: 5.2 to 9.0) and 0.37 (0.30e0.45), respectively. The authors' conclusion was
 E. Araujo Jnior et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 83e96 85

that no differences could be observed in accuracy between ultrasound EFW and AC in the prediction of
a macrosomic baby at birth.
Vaginal delivery of a macrosomic fetus requires considered attention by an experienced clinical
obstetrician to manage operative delivery, counteract shoulder dystocia, and prevent neonatal com-
plications [11].

Risk Factors

Macrosomia dened as a fetal weight exceeding the 95th centile or > 2 standard deviations (SD)
above the mean for expected gestational age has multifactorial causes [12,13]. Genetic, environmental,
and constitutional factors as well as metabolic disorders, e.g. diabetes mellitus, have a signicant
impact on the occurrence of fetal macrosomia. Constitutional factors like pre-gestational body mass
index (BMI), excessive weight gain during pregnancy, and pre-gestational diabetes mellitus as well as
GDM are recognized as independent risk factors for fetal macrosomia [14e18].
It has been demonstrated that fasting plasma glucose (FPG) in late pregnancy (30e32 weeks of
gestation) but not fasting plasma insulin or insulin resistance, is a determinant of newborn macro-
somia. Moreover, if an increase in FPG is observed from early to late pregnancy, these women had a 4.5-
fold increase in risk of newborn macrosomia [19]. Among women with GDM, maternal FPG concen-
trations during pregnancy were signicantly and positively associated with offspring birth size and
overweight/obesity risk at 7 years, adjusting for maternal pre-pregnancy BMI [20].
In a population-based observational analysis performed on routinely collected data in Central
China, more than 60% of overweight and obese women have excessive weight gain above the IOM
(Institute of Medicine, 2009) limit (7e11.5 kg) [21] while the overall incidence of macrosomia was
similar to that observed in a national survey in the East of China (6.5 and 8.2 %, respectively) [22]. The
study by Shi et al. [23] conrmed that maternal overweight, gestational weight gain, and elevated FPG
were signicantly associated with fetal macrosomia after adjusting for maternal age and gestational
weeks at delivery.
Primary prevention should aim to control nutritional behavior, physical activity, and BMI. Family
and patient history should also be investigated for diabetes mellitus and/or previous GDM. Epidemi-
ological studies have shown that females are more prone to develop overweight and become obese
than males. This has a great impact on maternal complications such as preeclampsia, GDM, fetal
macrosomia, operative delivery, and/or need for elective cesarean section [24].
A recent meta-analysis by He et al. [25] demonstrated that GDM is independently associated with
macrosomia with an adjusted odds ratio (aOR) of 1.71 (95% CI: 1.52e1.94). Clinical risk factors for
macrosomia are delivery of a previous macrosomic baby (OR 13.1), maternal weight gain (OR 10.2),
parity (OR 4.8), father's BMI (OR 3.7), male sex (OR 2.2), and post-term pregnancy (OR 1.9) [26]. Pre-
pregnancy overweight (adjusted aOR 1.27; 95% CI: 1.01e1.59), obesity (adjusted aOR 1.63; 95 % CI:
1.29e2.07), and excessive gestational weight gain (adjusted aOR 1.16; 95% CI: 1.13e1.20) were clinical
risk factors associated with fetal macrosomia. There is evidence that pre-pregnancy BMI may have a
greater inuence on fetal macrosomia than on gestational weight gain [27].
Increased placental levels of insulin growth factor (IGF) I, IGF-II, IGF-IR, and IGF-IIR mRNA are
positively associated with fetal macrosomia as well as increased placental levels of apo-M, a high-
density apoliproprotein that inuences pre-beta 1 HDL formation and is thus an important regulator
of HDL metabolism [28].
Consensus agreement of the diagnostic threshold for fetal macrosomia is not well established
although the ACOG (American College of Obstetricians and Gynecologists) recommends a birth
weight>4500 g as there are increased postnatal complications beyond this value [29]. LGA is variously
dened as above the 90th or the 95e97th centile for gestational age, although centile has the
advantage of being independent of gestational age. However, birth weight is also inuenced by gender
and other factors such as ethnicity; in addition, specic nation-based reference ranges are not currently
available in many cases or reference values need to be updated. A large number of formulae have been
produced to calculate the EFW, either by using conventional two-dimensional (2D) or three-
dimensional (3D) ultrasound equipment [30].
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To increase ultrasound accuracy of EFW, standardization of the measurement technique and EFW
calculated on average measurements should be encouraged to reduce intra- and inter-observer vari-
ability as well as maintaining a measurement auditing system [31]. Mongelli and Benzie [32] tested 18
formulae for fetal macrosomia and found that some formulae did not enable a diagnosis of macrosomia
while others showed high false positive rates. Interestingly, Poon et al. [33] have demonstrated a
diagnostic accuracy for fetal macrosomia in 34% women with a false positive rate of 10% using the rst
trimester combined test to screen for common trisomies since nuchal translucency, serum b-hCG, and
PAPP-A were signicantly higher in macrosomic than in non-macrosomic newborns.
Although the mode of delivery is still under discussion and women with GDM now generally un-
dergo induction of labor at 39e40 weeks of gestation (depending on glucose metabolic assessment,
ultrasound ndings, and absence/presence of comorbidities), the most dangerous obstetric compli-
cation associated with fetal macrosomia is shoulder dystocia and its related delivery consequences
[34]. The OR for shoulder dystocia is 21 for birth weight>4500 g versus normal birth weight and the
perinatal mortality rate had an OR of 2.3 in case the birth weight exceeded the 97th percentile [35]. In
addition, the risk of postpartum hemorrhage and fourth-degree perineal tears are increased [36].
Table 1 shows the clinical risk factors, pregnancy outcome, and ORs.

Ultrasound monitoring

Despite fetal macrosomia being associated with a 2e3 times increase in fetal death risk and an
increase in the risk of neonatal and long-term maternal complications [11], there are not enough
studies in literature on how prenatal ultrasound monitoring should be performed in pregnancies with
suspected fetal macrosomia, especially in non-diabetic patients. The difculty of monitoring a fetus
with macrosomia comes from the complexity of making a diagnosis as well as from the lack of quality
evidence on the next steps if it is suspected [37].
2D ultrasound is the most widely used method for the diagnosis and monitoring of macrosomia,
despite studies showing a lower accuracy in the prediction of LGA than in normal weight fetus [38].
Some studies show that performing serial ultrasound could provide more accurate data on the EFW
[39,40] in addition to the creation of an individual growth curve for that fetus, increasing accuracy in
the detection of macrosomia [38]. A new reassessment should be performed every 3e4 weeks
following suspicion of LGA on ultrasound examination. Most often, macrosomia can be predicted after
two successive scans with an EFW or AC above the 90th percentile, respectively. Moreover, if after two
successive assessments the EFW weight or AC is below the 90th percentile, it is not necessary to
perform further ultrasound examinations because the predictive value does not increase [38].
Regarding the optimal time for ultrasound examination for better prediction of macrosomia at birth,
Souka et al. [41] showed that examination carried out late in the third trimester (between 34e37
weeks) has better accuracy than at the beginning of the third trimester (between 30e33 6/7). Another

Table 1
Clinical risk factors, pregnancy outcome, and odds ratios (OR).

Clinical Risk Factors Outcome OR (Odd Ratio)

Familial DM [7] Risk of CS 1.2

GDM [25] Macrosomia 1.71
Previous macrosomia [26] Macrosomia 13.1
Maternal weight gain [26] Macrosomia 10.2
Parity [26] Macrosomia 4.8
Father BMI [26] Macrosomia 3.7
Male sex [26] Macrosomia 2.2
Post-term pregnancy [26] Macrosomia 1.9
LGA [35] Preterm delivery 1.9
BW >97th centile [35] Perinatal mortality 2.3
Fetal macrosomia [98] Shoulder dystocia 16.1

(Legend: BMI, body mass index; BW, birth weight; CS, cesarean section; GDM, gestational diabetes mellitus; LGA, large for
gestational age).
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study found that ultrasound examinations performed up to 7 days before delivery had the best results
in predicting birth weight [7]. Rigorous vitality monitoring should be performed in cases of suspected
macrosomia and post-term pregnancy due to the increased risk of perinatal morbidity and mortality
[37].
Diabetes mellitus is a leading cause of fetal macrosomia and shows a few peculiarities in prenatal
monitoring. Fetal macrosomia in diabetic mothers is characterized by asymmetric growth of the AC,
with an excess of muscle and fat accumulation in the fetal abdomen and the scapular area of the fetus,
increasing the risk of shoulder dystocia compared to the macrosomic fetus of pregnant women without
diabetes [42]. In addition to the increased risk of neonatal birth trauma, the fetuses of diabetic mothers
have an increased risk of metabolic disorders (anaerobic metabolism with lactate accumulation) and
fetal death; therefore, these fetuses need more careful ultrasound monitoring [43]. Importantly, the
NICE guidelines [44] consider the option of initiating hypoglycemic therapy if ultrasound examination
documents sign of impending fetal macrosomia dened as an abdominal fetal circumference > 70th
centile for expected gestational age. A meta-analysis and systematic review of RCT compared con-
ventional management to assess fetal growth versus metabolic and ultrasound-based management
prior to delivery in women with a wide range of GDM severity. A total of 417 women were enrolled
from two studies, 242 in the ultrasound-based group and 175 in the conventional group. Metabolic
management was based on FPG and HbA1c [43]. This RCT [43] concluded that ultrasound-based
management was associated with reductions of 42% in LGA, 36% in abnormal birth weight, and 68%
in macrosomia although 58% more women would be treated with insulin.
In patients with pre-gestational diabetes, ultrasound evaluation of amniotic uid volume and fetal
growth is recommended every 4 weeks, starting in the 20th week, and every 2 weeks after the 28th
week. In patients with gestational diabetes, ultrasound monitoring is similar to that for patients with
pre-gestational diabetes; however, fetal monitoring may be less rigorous in patients treated only with
diet who are maintaining normal blood glucose levels [43].
Ultrasound can be used to measure soft tissue in the shoulder, abdomen, thigh, and perioral region
of the fetus. It is based on the fact that the adipose tissue undergoes the greatest change in growth
disorders. Although some studies have shown good correlation of this assessment with the evaluation
of post-natal skin folds, a study comparing soft tissue evaluation with the EFW (head circumference -
HC, AC, and femur length - FL) has not demonstrated any advantage of such a technique in the detection
of macrosomia. The combined use of soft tissue measurements with the EFW could possibly improve
the prediction of macrosomia compared with any isolated method [38]. 3D ultrasound provides a
better assessment of fetal soft tissues. Studies to validate 3D ultrasound in predicting birth weight
showed similarity to the estimated weight using the 2D ultrasound method [45,46]. In a study that
assessed the accuracy of 3D ultrasound fractional limb volume compared with conventional 2D ul-
trasound in GDM pregnant women, the 3D ultrasound method showed better sensitivity for the
prediction of macrosomia than 2D ultrasound (84% vs. 63%) [47] (Figure 1).
Magnetic resonance imaging (MRI) provides a better evaluation of fetal fat. A systematic review and
meta-analysis showed that MRI is a more specic method than 2D ultrasound and is apparently also
more sensitive despite the limited number of studies and cases [48]. In addition, an MRI study was
conducted and showed good correlation of fetal shoulder measurement with shoulder width at birth;
this may help in the prediction of shoulder dystocia in macrosomic fetuses [38]. However, MRI is an
expensive test and is not as accessible as ultrasound examination; therefore, further studies are
required before it can be recommended in clinical practice [48]. The monitoring of fetal growth is an
important part of prenatal care. Abnormal fetal growth has short- and long-term consequences.
Despite the lack of accuracy, ultrasound improves the monitoring of fetuses with abnormal growth and
assists decisions around the timing of delivery [49].

Fetal well-being

Literature does not include many studies regarding fetal well-being in macrosomic fetuses not
associated with diabetes. Most papers focus on the timing and type of delivery for preventing birth
trauma and dystocia. In addition to ultrasound monitoring for the assessment of fetal growth described
above, fetal well-being can be assessed through the evaluation of amniotic uid volume, fetal
88 E. Araujo Jnior et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 83e96

Fig. 1. Fractional fetal humerus volume by three-dimensional ultrasound. The fetal limb is automatically divided into ve similar
cross-sectional areas, and its areas are manually delineated.

movement counting by the pregnant woman, fetal biophysical prole (BPP), electronic fetal monitoring
(EFM), and Doppler ultrasound.
A study reports that the assessment of amniotic uid volume together with the EFW increases the
accuracy of prediction of macrosomia at birth [50]. The evaluation of amniotic uid volume should also
be included in all ultrasound examinations, as polyhydramnios may be indicative of poor glycemic
control [42].
The counting of fetal movements is a no-cost method for assessing fetal well-being in the third
trimester. There is no consensus on how to instruct the woman to perform this assessment and there
are not enough randomized studies to evaluate the various existing protocols; however, maternal
perception of 10 fetal movements in two hours is considered reassuring [51]. If the woman perceives a
decrease in fetal movements, another test such as EFM or BPP should be performed. Some authors
suggest this monitoring method can be carried out by the 26th to 28th week in pregnancies compli-
cated by diabetes. Studies have demonstrated an increase in fetal activity associated with increased
glucose levels in maternal blood [52].
The BPP examination is usually used as a good predictor of fetal vitality, especially in pregnancies
that, in addition to macrosomia, have GDM or pre-gestational diabetes. The BPP has a high PPV for an
Apgar score> 7 at 5 minute; however, when the test is abnormal, it is not a good predictor of fetal
acidemia [53]. Kjos et al. [54] concluded that a fetal BPP evaluation carried out twice a week can
prevent fetal death in diabetic pregnant women.
Despite the lack of large randomized clinical trials, most protocols recommend that pregnant
women with pre-gestational diabetes perform an antepartum evaluation, including EFM. Researchers
from USA have recommended that women affected by pre-gestational diabetes should undergo EFM
weekly from the 32nd week and twice a week from the 36th week onward [55]. However, EFM does not
provide fetal well-being reassurance for no longer than 24 hours, and this protocol does not represent a
guideline in Europe or in many other countries. EFM can be combined with other non-invasive tests
such as fetal biophysical prole. Normal results provide greater condence for doctors and patients
that pregnancy can continue for another week [51]. EFM can be classied into reassuring, non-
reassuring, or abnormal, according to NICE classication [56]. When it is classied as non-
reassuring, it has a low predictive value for fetal distress (<50%) and should be supplemented with
BPP [57]. In diabetic pregnant women, loss of fetal heart rate variability at electronic tracing has a
higher correlation with impending fetal risk than has decelerations with maintained baseline vari-
ability [58]. When computerized EFM was analyzed, an increase in the baseline and short-term vari-
ability in diabetic patients was observed [59]. In these patients, the short-term variability may not be
able to predict hypoxia [60].
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Some studies have been conducted to demonstrate changes in patterns of arterial and venous ow
in macrosomic fetuses. Ebbing et al. [61] evaluated fetuses with isolated macrosomia and showed
increased umbilical vein ow, increased venous perfusion of the fetal liver, greater distribution of blood
to the right liver lobe, and decreased pulsatility index (PI) of the umbilical artery. This increased blood
ow to the fetal liver occurs by the end of pregnancy in macrosomic fetuses, unlike that which occurs in
fetuses of the appropriate weight for the gestational age. Therefore, a correlation between fetal size and
hepatic venous perfusion can be established [62]. It has been shown that newborns with birth weight
either >4000 g or > 90th centile have a lower mean umbilical artery PI than non-macrosomic fetuses
[63]. Doppler study of the umbilical artery and the middle cerebral artery provides adequate moni-
toring of placental insufciency in non-diabetic pregnancies. However, most authors believe that we
cannot use the same Doppler criteria of placental insufciency to evaluate the fetuses of diabetic
mothers, since the mechanism leading to fetal death in these patients is of different etiology [64].
No randomized clinical trials have been published on the use of the umbilical artery Doppler in
evaluating fetal well-being in diabetic patients. Current evidence recommends pregnancies compli-
cated by preexisting diabetes should be monitored closely (twice a week) using EFM or BPP or a
combination of both. Moreover, Doppler ultrasound investigation should be carried out in women with
diabetic vasculopathy or with complications of placental insufciency such as pregnancy-induced
hypertension or intrauterine growth restriction (IUGR) [51]. Despite being a difcult vessel to assess
and requiring training for insonation, the ductus venosus seems to have potential in the evaluation of a
jeopardized fetus. This is because hypoxia releases catecholamines and diverts more ow from the liver
to the fetal heart, thus dilating the ductus venosus. The hepatic artery is another vessel that is worthy of
further studies in the evaluation of the well-being of the fetus of a diabetic mother because of the large
metabolic role of the liver in intrauterine life [64].

Prediction

Ultrasound is a practical method for screening pregnant women for fetal macrosomia. The almost
universal practice is to add the measurements of biparietal diameter (BPD), HC, AC, and FL into a
regression model that calculates EFW [65]. The main components contributing to inaccuracy in ul-
trasound predictions are the following: (a) the inaccuracy of prediction formulae and (b) inaccuracies
of technical measurements, which can be reduced by taking repeated and multiple fetal measurements
and ensuring that the sections of fetal anatomy have been obtained accurately [66]. Other factors that
increase random error are maternal obesity, oligohydramnios, poor-quality equipment, and inexpe-
rienced operators [65].
Fetal AC has the greatest impact on weight estimation. The maximum random error for weight
prediction by ultrasound is 100 g/Kg (10%) [65]. Measurements should be performed in a standardized
manner on the basis of strict quality criteria to decrease variability [67]. For correct AC representation,
an axial cross-sectional view must be obtained. The kidneys should not be visible, and only one pair of
ribs and the three ossication points of the vertebrae should be visible. Furthermore, according to
Campbell and Wilkin [68] the correct transverse section includes the stomach, and Hansmann [69]
stated that the umbilical vein should be visualized at the level of the portal sinus and should not be
present at any stage. The AC is measured at the outer surface of the skin line, either directly with ellipse
calipers or calculated from linear measurements made perpendicular to each other, usually the
anteroposterior abdominal diameter (APAD) and transverse abdominal diameter (TAD) (Figure 2). To
measure the APAD, the calipers are placed on the outer borders of the body outline, from the posterior
aspect (skin covering the spine) to the anterior abdominal wall. To measure the TAD, the calipers are
placed on the outer borders of the body outline, across the abdomen at the widest point. The AC is then
calculated using the formula: AC p (APAD TAD)/2 1.57 (APAD TAD) [70].
Estimation of fetal weight has a substantial impact on the further obstetric management as both
fetal and maternal risks increase with increasing fetal weight. The risk of shoulder dystocia is about
0.2% in average-sized fetuses. With a birth weight of 4000e4500 g, this risk increases to about 5% and is
about 30% above 4500 g [71]. This makes it important to have other sonographic approaches, including
a targeted formula for fetuses over 4500 g, to reduce systematic errors to a minimum [72]. The majority
of sonographic EFW formulae do not consider body composition. Because body composition can vary
90 E. Araujo Jnior et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 83e96

Fig. 2. Standard axial view for fetal abdominal circumference measurement. S: spine; St: stomach; UV: umbilical vein.

greatly, even in the fetus, there may be signicant variation in birth weight among fetuses with similar
biometric parameters. On average, body fat accounts for 14% of the birth weight, but 46% of birth
weight variance [73]. The adipose tissue is subject to major changes when conditions associated with
accelerated or decreased growth are present. For example, diabetic mothers with poor glycemic control
are at increased risk of having a macrosomic infant with a large volume of subcutaneous fat. Ultrasound
has been used to assess subcutaneous fat to provide better evaluation of normal and disturbed growth
[74,75]. Scioscia et al. [76] proposed a linear measurement of the soft tissue above the external side of
the fetal femur as a straightforward method for assessing the amount of fat and muscular mass of the
fetal thigh, and a new algorithm was calculated to predict birth weight. This method has two main
advantages as follows: rst, it has good reproducibility and, second, it is based on linear 2D mea-
surements that can be adequately obtained by non-expert sonographers (less experienced physicians/
midwives).

Prevention

Obesity, maternal weight gain, and poor glycemic control are the main risk factors for macrosomia
[77]. The prevalence of obesity is increasing both in developed countries and developing countries. An
estimated one-fth of pregnant women in the United Kingdom and one-third of those in the United
States are obese [78,79]. Obesity during pregnancy is associated with an increased risk of adverse
short-term and long-term consequences for both mother and baby [80]. Hyperglycemia and increased
insulin resistance occurring with obesity may explain the association between obesity and fetal
macrosomia as well as other pregnancy complications [81].
Because metformin is associated with less gestational weight gain [82] and because birth weight is
related to both BMI and gestational weight gain [83], metformin appears to be an alternative strategy
for reducing insulin resistance and then reducing the risk of macrosomia. However, two clinical trials
performed recently, with pregnant women without diabetes and BMI > 30 and 35kg/m2, showed that
daily administration of metformin from 12 to 18 weeks of gestation until delivery did not reduce the
median neonatal birth weight z-score or the incidence of LGA neonates [84]. The use of metformin in
women with GDM is an effective and safe treatment, and it is not associated with increased composite
neonatal complications. Severe neonatal hypoglycemia is less frequent in newborns whose mothers
were treated with insulin, although 46.3% of women receiving metformin required supplemental in-
sulin. A higher rate of spontaneous preterm birth, however, occurred in women with GDM treated with
metformin, suggesting a possible active role of metformin in the process of labor [82]. Pre-pregnancy
counseling and public health initiatives should stress the importance of attaining a healthy weight
prior to pregnancy and avoiding excessive gestational weight gain following conception [77].
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However, the UK-UPBEAT (Pregnancies Better Eating and Activity Trial) multicenter RCT has failed
to demonstrate that lifestyle changes during pregnancy may be associated with signicant effects on
the incidence of LGA/macrosomia in women with obesity [85].

Prenatal care

The diagnosis of fetal macrosomia during pregnancy is a challenge, because prenatal diagnostic
methods based on clinical examination and ultrasound are imprecise for the estimation of fetal weight.
A high index of suspicion of macrosomia should be maintained in women with risk factors such as a
history of macrosomia, high maternal pre-pregnancy weight, increased weight gain during pregnancy,
multiparity, male fetus, gestational age over 40 weeks, high maternal birth weight, maternal age under
17 years, pre-gestational diabetes, and GDM. Over and above these risk factors, fetal macrosomia may
be suspected following clinical examination that can estimate fetal weight based on fundal height that
is higher than expected for gestational age and abdominal palpation (Leopold's maneuvers). Clinical
examination is not accurate; several factors may affect its accuracy such as obesity, uterine broids,
multiple pregnancy, and the amount of amniotic uid [86].
The obstetrician should rule out or conrm diabetes. If diabetes is conrmed, the goal of antepartum
management is good glycemic control throughout gestation with diet, exercise, and additional treat-
ment (insulin or oral hypoglycemic agents), if necessary [87]. Several reports addressed an association
between pre-gestational BMI, high maternal weight gain during pregnancy, and fetal macrosomia
[14e18,23,28]. However, there is no evidence supporting clinical interventions for the treatment of
suspected macrosomia in cases without diabetes. Once the diagnosis of macrosomia is suspected,
concerns about birth trauma arise. Fetal macrosomia is a signicant risk for shoulder dystocia and its
sequalae such as fracture of the clavicle, brachial plexus injury, and perinatal asphyxia [88]. During
prenatal care, the obstetrician should discuss the risks and strategies for preventing birth trauma.

Delivery

The mode of delivery e cesarean section, induction of labor, or expectant management e in women
with suspected fetal macrosomia is very controversial in the medical literature. The value of elective
cesarean section in suspected fetal macrosomia is questionable [89]. Some authors demonstrated that the
number of elective needed to prevent one permanent brachial plexus injury was 3695 at a cost of 8.7
million dollars [90]. The ACOG recommends prophylactic cesarean section for suspected fetal macro-
somia with an EFW >5000g in pregnant women without diabetes and >4500g in those with GDM [91].
Induction of labor was proposed to prevent ongoing fetal growth, since the fetus gains approxi-
mately 280 g per week at the end of gestation. This procedure theoretically reduces the risks of
shoulder dystocia, perinatal trauma, and cesarean section. Sanchez-Ramos et al. [92] performed a
systematic review and meta-analysis based on two RCTs and in 9 observational studies comparing
expectant management versus induction of labor for suspected fetal macrosomia and concluded that
induction of labor resulted in an increased cesarean section rate without improving perinatal out-
comes. The criticisms of this study are the small sample size and the fact that induction of labor started
at 40 weeks of gestation or more.
Boulvain et al. [86] did a multicenter RCT in 19 tertiary University hospitals in France, Switzerland, and
Belgium comparing induction of labor with expectant management for LGA fetuses. The authors included
women if the EFW was above the 95th percentile using Hadlock's formula. They allocated 407 women to
induction of labor and 411 women to expectant management. Labor was induced between 37 and 38 6/7
weeks within 3 days of randomization. The primary outcome of the study was shoulder dystocia, fracture
of the clavicle or a long bone, brachial plexus injury, intracranial hemorrhage, or death. The authors
demonstrated that induction of labor for women with suspected fetal macrosomia reduces the risk of
shoulder dystocia and bone fracture, and increases the likelihood of vaginal delivery. However, this RCT
demonstrated that induction of labor increased the risk of cesarean section. Despite some critics of the
study by Boulvain et al. [86], such as the inclusion of women with diabetes and the induction of labor in
the early term of gestation (37e39 weeks), the results of this work could change the management and
mode of delivery of fetal macrosomia and could serve as a basis for new guidelines.
92 E. Araujo Jnior et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 83e96

The incidence of shoulder dystocia ranges from 0.2% to 3.0% of all vaginal deliveries [93]. It is dened
as birth with an interval of 60 seconds or more between delivery of the head and the body [94].
Therefore, it is of great importance to reduce the time between delivery of the head and the body. The
risk of shoulder dystocia seems to increase with increasing birth weight; however, 40% to 60% of
shoulder dystocia occurs in births with infants who weigh less than 4000 g [95].
Many maneuvers for the management of shoulder dystocia alleviation have been described. The
majority of physicians employ the McRobert's maneuver as their rst step. The McRobert's maneuver is
performed by removing the legs from the bed/stirrups and sharply exing the maternal thighs up onto
her abdomen. This procedure results in a straightening of the woman sacrum relative to the lumbar
vertebrae with consequent cephalic rotation of the symphysis pubis [96]. Suprapubic pressure,
commonly administered by an assistant, is given immediately before or in direct conjunction with the
McRobert's maneuver. This pressure is usually directed posteriorly, in an attempt to force the anterior
shoulder under the symphysis pubis while downward traction is applied to the fetal head [97]. In the
Wood's corkscrew maneuver, the physician attempts to rotate the posterior shoulder through 180
degrees in a corkscrew fashion with the aim of delivering the posterior shoulder, and then the
impacted anterior shoulder can be released. In the Rubin's maneuver, pressure is applied to the most
accessible part of the fetal shoulder, which is then pushed toward the anterior surface of the chest.
These rotational maneuvers, however, may be difcult to perform when the anterior shoulder is tightly
wedged underneath the symphysis pubis. It may therefore be necessary to push the fetus upward
slightly in order to facilitate the rotation [98].
Delivery of the posterior fetal arm consists of sweeping out the posterior arm of the fetus across the
chest, followed by delivery of the arm. Rotation of the fetal trunk to one of the oblique diameters of the
pelvis helps with the subsequent delivery of the anterior shoulder [99]. Intentional fracture of the
clavicle can be achieved by pressing the anterior clavicle against the ramus of the pubis freeing the
impacted shoulder. Usually, this can occur naturally when applying force to remove the anterior
shoulder. The consequences of this type of fracture are less signicant than those associated with
brachial nerve injury [100]. The Zavanelli maneuver is considered the last resort. This procedure
consists of manual replacement of the fetal head into the vagina followed by cesarean section. Other
heroic techniques are symphysiotomy, hysterotomy, and cleidotomy [101] (Figure 3).
There is a clear association between shoulder dystocia and fetal macrosomia. Tsur et al. [102], in a
review of 240,189 deliveries, stated that fetal macrosomia is an important risk factor for shoulder

Fig. 3. Flowchart for obstetrical maneuvers in shoulder dystocia cases.

 E. Araujo Jnior et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 83e96 93

dystocia (OR: 16.1). Fetal brachial plexus injury is the most frequent fetal complication. The incidence
ranges from 4% to 40% in literature. Fortunately, only 10% or less cases of brachial plexus injury result in
permanent injury. Fractures of the clavicle and humerus occur in approximately 10.6% of cases of
shoulder dystocia and usually recover without sequelae.
Hypoxic-ischemic brain injury can occur in 0.5e23% of cases of shoulder dystocia. The duration of
head-to-body delivery is a critical point and the risk increases if the duration is over 5 minutes [103].
Perinatal mortality is not frequent and is reported in 0.4% of cases, usually when all the maneuvers
applied to release the shoulder fail. Neonates with macrosomia have a high oxygen demand and
subsequently have increased erythropoiesis and polycythemia. Therefore, when these cells break
down, bilirubin increases resulting in neonatal jaundice [104].

Summary

Fetal macrosomia is an obstetric complication that affects 10% of all pregnancies and is associated
with severe maternalefetal complications such as maternal birth canal trauma, fracture of the clavicle,
brachial plexus injury, and perinatal asphyxia. Early identication of risk factors such as pre-gestational
BMI, excessive weight gain during pregnancy, pre-gestational and GDM can allow the early application
of measures to prevent adverse perinatal outcomes. The diagnosis of fetal macrosomia is based on 2D
ultrasound formulae in which the EFW is >4000 g. Furthermore, 3D ultrasound could monitor the soft
tissue allowing better prediction of birth weight than 2D ultrasound. Elective cesarean section does not
improve the perinatal outcomes in fetal macrosomia cases and induction of labor seems to be better
than expectant management for the risk of shoulder dystocia.

Practice points

 Fetal macrosomia may be defined as a birth weight >4000 g.

 Fetal macrosomia is a clinical risk factor for shoulder dystocia and is associated with
increased risks of cesarean section, trauma to the birth canal, and adverse perinatal out-
comes such as fracture of the clavicle, brachial plexus injury, and perinatal asphyxia.
 Fetal macrosomia may be predicted using clinical and ultrasonographic data.
 Pre-gestational body mass index, excessive weight gain during pregnancy, and pre-
gestational diabetes mellitus are recognized as independent risk factors for fetal
macrosomia.
 Biophysical profile examination is usually the best test of fetal well-being in assessing
pregnant women with a high risk of macrosomia in pregnancies with gestational or pre-
gestational diabetes.
 Three-dimensional ultrasound could monitor the fetal soft tissues and predict macrosomia
with better sensitivity than two-dimensional ultrasound.
 Metformin is an effective and safe treatment, and it is not associated with increased com-
posite neonatal complications.

Research agenda

 Two- and three-dimensional ultrasound formulae for the prediction of birth weight with more
accuracy in cases at high risk of fetal macrosomia.
 Maternal biochemical markers for prediction of fetal macrosomia.
 Fetal well-being tests for monitoring pregnant women at high risk of fetal macrosomia.
 Induction of labor versus expectant management in pregnant women with a suspicion of
fetal macrosomia.
 Prediction of shoulder dystocia in pregnant women with fetal macrosomia.
94 E. Araujo Jnior et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 83e96

Conict of Interest Statement

The authors declare no conict of interest.

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