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Diabetes Mellitus: Pregnancy/Delivery


Management in Suspected Fetal
Macrosomia

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Title: Diabetes Mellitus: Pregnancy/Delivery Management in Suspected Fetal Macrosomia By:


Caple C, Schub T, Pravikoff D, CINAHL Nursing Guide, November 20, 2015Database: Nursing
Reference Center

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Diabetes Mellitus: Pregnancy/Delivery Management in
Suspected Fetal Macrosomia

Contents

1. What We Know
2. What We Can Do
3. References
4. Reviewer(s)
Evidence-Based Care Sheet
By: Carita Caple, RN, BSN, MSHS

Cinahl Information Systems, Glendale, CA

Tanja Schub, BS

Cinahl Information Systems, Glendale, CA

Edited by: Diane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA


What We Know
Pregnancy is considered high-risk in a woman who has pre-existing diabetes
mellitus (DM) or who develops gestational diabetes mellitus (GDM; i.e., onset of glucose
intolerance after conception) because either of these diabetic states poses maternal and
fetal health risks.(3,4) (For more information, see Quick Lesson About Diabetes Mellitus:
Pregnancy in Patients with Preexisting Diabetes and Quick Lesson About Diabetes
Mellitus, Gestational)
Strict blood glucose control through dietary modification, exercise,
blood-glucose monitoring, and pharmacotherapy is essential to reduce maternal
and fetal complications(3)
Poor blood glucose control during pregnancyparticularly during the
third trimesterincreases the risk of complications, including fetal
macrosomia (i.e., an abnormally large fetus weighing at least 4,000 g [8.8
lbs])(3,4,6,8 )
Macrosomia is considered to be the most common unfavorable
outcome of pregnancy that is complicated by GDM(3)
Maternal diabetes and fetal macrosomia are thought to be
linked by maternal hyperglycemia, which causes fetal
hyperinsulinemia(3,4)
The risk of fetal macrosomia increases in direct proportion to
increasing maternal glucose levels; excessive maternal weight gain
further increases the risk of fetal macrosomia(1,3,11)
Researchers in a study of 12,109 pregnant women in Italy
reported that maternal obesity associates risk of fetal
macrosomia by a factor of 1.7, excessive gestational weight gain
increases risk by a factor of 1.9, and DM increases risk by a
factor of 2.1(1)
Receiving treatment for DM or GDM reduces the risk of fetal
macrosomia by more than 50%(6)
Fetal macrosomia is associated with a variety of risks for the mother
and fetus/newborn(4,8 ,9)
Potential maternal complications include prolonged labor, third-
and fourth-degree perineal lacerations, infection, postpartum
hemorrhage, pudendal nerve damage, longer duration of maternal
hospital stay, and an increased likelihood that cesarean delivery will be
necessary. Cesarean delivery is associated with surgical complications
and with slower recovery than vaginal delivery(4,6,7,8,9)
Potential complications for the fetus/newborn include perinatal
mortality, meconium aspiration, asphyxia, shoulder dystocia, brachial
plexus injury, humeral and clavicular fractures, respiratory distress,
hypoglycemia, polycythemia, hyperbilirubinemia, depressed 5-minute
Apgar score (i.e., an evaluation system of 5 criteriaskin color, pulse
rate, reflex irritability, muscle tone, and breathingfor assessing the
newborns physical condition immediately after delivery), longer
duration of neonatal hospital stay, and admission to the neonatal
intensive care unit (NICU)(3,4,7,8,9 )
Fetal macrosomia is associated with increased risk of
obesity and DM later in life(4,12)
Researchers who conducted a study of 10,468
children in several European countries reported that
macrosomia was associated with a 70% increased risk of
overweight in boys born to mothers who did not have
diabetes, a 60% increased risk of overweight in girls born
to mothers who did not have diabetes, and a 260%
increased risk of overweight in girls born to mothers who
had diabetes; macrosomia was not significantly associated
childhood overweight in boys born to mothers who had
diabetes(12)
Prenatal diagnosis of fetal macrosomia is difficult and there is no single, accurate
method for determining potential fetal size. Clinicians should closely monitor women who
are assessed to be at high risk of delivering a baby with macrosomia(3,4,7,8,9)
Methods to predict birth weight include assessment of maternal risk factors,
clinical examination, and ultrasound evaluation(3,4,5,9)
Macrosomia in a previous pregnancy, prepregnancy body mass index
(BMI) that is over 30 kg/m2, excessive weight gain during pregnancy, poorly
controlled maternal blood glucose levels, advanced maternal age, and a
family history of DM are associated with increased risk of fetal
macrosomia(1,4,9,1 1,1 3)
Although measurement of fundal height, Leopold maneuvers (e.g.,
abdominal palpation), and ultrasound are typically performed, information
obtained from these assessments is not considered definitive. Sonographic
fetal weight estimation is not considered reliable in macrosomia and is
associated with positive predictive values of only 3867%(4,5,9)
Levels of maternal serum adiponectina molecule released by
adipose tissue that is found to be low in women with GDMhas been
effectively used as a biomarker to identify neonatal macrosomy at 1113
weeks of gestation(10)
Management of a high-risk pregnancy involving increased risk of fetal macrosomia
is controversial among obstetric clinicians. Some clinicians employ expectant
management (i.e., surveillance with no specific intervention) and others opt to induce
labor(2,3,7,9)
Suspected fetal macrosomia is not an indication for induction of labor.
Compared with labor induction, expectant management is associated with fewer
cesarean deliveries and there are similar perinatal outcomes (e.g., the incidence of
infant birth trauma is not increased; Apgar scores are not decreased)(2,7)
According to the American College of Obstetricians and
Gynecologists, women with diabetes should be counseled regarding the
possibility of a scheduled cesarean delivery when the estimated fetal weight
is 4,500 g( 2)
What We Can Do
Learn about pregnancy and delivery management in cases of suspected fetal
macrosomia so you can accurately assess your patients personal characteristics and
health education needs; share this information with your colleagues
Educate your pregnant patients who have diabetes about management and
potential complications of a high-risk pregnancy, including fetal macrosomia and birth
trauma and maternal morbidity resulting from cesarean delivery(3,7)
Educate regarding the risks and benefits of treatment with expectant
management and with labor induction, and encourage your patients to ask their
obstetric clinician how their personal risk factors affect the choice of a treatment
strategy
Emphasize the importance of maintaining strict glycemic control to promote
optimal maternal and fetal health
Collaborate with your hospitals continuing medical education department to
provide education to clinicians of all specialties about treatment of suspected fetal
macrosomia in pregnant women with diabetes
References
1. Alberico, S., Montico, M., Barresi, V., Monasta, L., Businelli, C., Soini, V., ... Maso, G. (2014).
The role of gestational diabetes, pre-pregnancy body mass index and gestational weight gain on
the risk of newborn macrosomia: Results from a prospective multicenter study. B MC Pregnancy
& Childbirth, 14(1), 23. doi:10.1186/1471-2393-14-23 (R)
2. American College of Obstetricians and Gynecologists Committee on Practice
Bulletins--Obstetrics. (2013). Practice Bulletin No. 137: Gestational diabetes mellitus. O bstetrics
and Gynecology, 122(2 Pt 1), 406-416. doi:10.1097/01.AOG.0000433006.09219.f1 (G )
3. Cunningham, F. G., Levano, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., ...
Sheffield, J. S. (2014). Diabetes. In Williams obstetrics (24th ed., pp. 1125-1143). New York,
NY: McGraw-Hill Medical. (GI)
4. Dixon, A. (2009). Macrosomia: Effective management of the newborn. B ritish Journal of
Midwifery, 17(6), 363-366. (RV)
5. Gonzalez Gonzalez, N. L., Plasencia, W., Gonzalez Davila, E., Padron, E., di Renzo, G. C., &
Bartha, J. L. (2013). First and second trimester screening for large for gestational age infants.
Journal of Maternal-Fetal & Neonatal Medicine, 2(16), 1635-1640.
doi:10.3109/14767058.2013.794779 (R)
6. Hillier, T. A., Pedula, K. L., Vesco, K. K., Schmidt, M. M., Mullen, J. A., LeBlanc, E. S., &
Pettitt, D. J. (2008). Excess gestational weight gain: Modifying fetal macrosomia risk associated
with maternal glucose. Obstetrics and Gynecology, 112(5), 1007-1014. (R)
7. Ju, H., Chadha, Y., Donovan, T., & O'Rourke, P. (2009). Fetal macrosomia and pregnancy
outcomes. Australian and New Zealand Journal of Obstetrics and Gynaecology, 49(5), 504-509.
doi:10.1111/j.1479-828X.2009.01052.x (R)
8. King, J. R., Korst, L. M., Miller, D. A., & Ouzounian, J. G. (2012). Increased composite
maternal and neonatal morbidity associated with ultrasonographically suspected fetal
macrosomia. Journal of Maternal-Fetal & Neonatal Medicine, 25(10), 1953-1959.
doi:10.3109/14767058.2012.674990 (R)
9. Luo, G., & Copel, J. A. (2009). Using U/S to assess macrosomia: Are we there yet?
Contemporary OB/GYN, 54(1), 26-30, 32-34. (G I)
10. Nanda, S., Akolekar, R., Sarquis, R., Mosconi, A. P., & Nicolaides, K. H. (2011). Maternal
serum adiponectin at 11 to 13 weeks of gestation in the prediction of macrosomia. P renatal
Diagnosis, 31(5), 479-483. (R)
11. Shi, P., Yang, W., Yu, Q., Zhao, Q., Li, C., Ma, X., ... Yan, W. (2014). Overweight,
gestational weight gain and elevated fasting plasma glucose and their association with
macrosomia in Chinese pregnant women. Maternal & Child Health Journal, 18(1), 10-15.
doi:10.1007/s10995-013-1253-6 (R)
12. Sparano, S., Ahrens, W., Henauw, S., Marild, S., Molnar, D., Moreno, L., ... Russo, P.
(2013). Being macrosomic at birth is an independent predictor of overweight in children: Results
from the IDEFICS Study. Maternal & Child Health Journal, 17(8), 1373-1381.
doi:10.1007/s10995-012-1136-2 (R)
13. Yadav, H., & Lee, N. (2014). Factors influencing macrosomia in pregnant women in a
tertiary care hospital in Malaysia. Journal of Obstetrics & Gynaecology Research, 40(2),
439-444. doi:10.1111/jog.12209 (R)
Reviewer(s)
Darlene Strayer, RN, MBA, Cinahl Information Systems, Glendale, CA
Nursing Executive Practice Council, Glendale Adventist Medical Center, Glendale, CA
Original document: 2007 Feb 27
Latest revision: 2015 Nov 20

Coding Matrix

References are rated using the following codes,

listed in order of strength:


CodeDescriptionMPublished meta-analysisSRPublished systematic or integrative literature
reviewRCTPublished research (randomized controlled trial)RPublished research (not
randomized controlled trial)CCase histories, case studiesGPublished guidelinesRVPublished
review of the literatureRUPublished research utilization reportQIPublished quality improvement
report LLegislationPGRPublished government reportPFRPublished funded reportPPPolicies,
procedures, protocolsXPractice exemplars, stories, opinionsGIGeneral or background
information/texts/reportsUUnpublished research, reviews, poster presentations or other such
materialsCPConference proceedings, abstracts, presentation

Published by EBSCO Information Services. Copyright 2015, EBSCO Information Services. All
rights reserved. No part of this may be reproduced or utilized in any form or by any means,
electronic or mechanical, including photocopying, recording, or by any information storage and
retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or
errors/omissions in the text. It is merely intended as a general informational overview of the
subject for the healthcare professional.

Source: EBSCO Publishing (Ipswich, Massachusetts). 2015 Nov 20

Item Number: T703412

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