I.

INTRODUCTION

What is large for gestational age (LGA)?

Large for gestational age (LGA) is a term used to describe babies who are born weighing more
than the usual amount for the number of weeks of pregnancy. LGA babies have birthweights
greater than the 90th percentile for their gestational age, meaning that they weigh more than 90
percent of all babies of the same gestational age.

The average baby weighs about 7 pounds at birth. About 10 percent of all babies weigh more
than 4,000 grams (8 pounds, 13 ounces). Rarely do babies weigh over 10 pounds.

Although most LGA babies are born at term (37 to 41 weeks of pregnancy), a few premature
babies may be LGA.

What causes large for gestational age (LGA)?

Some babies are large because their parents are large; genetics does play a part. Birthweight may
also be related to the amount of a mother's weight gain in pregnancy. Excessive weight gain can
translate to increased fetal weight.

By far, maternal diabetes is the most common cause of LGA babies. Diabetes during pregnancy
causes the mother's increased blood glucose (sugar) to circulate to the baby. In response, the
baby's body makes insulin. All the extra sugar and the extra insulin production can lead to
excessive growth and deposits of fat, thus, a larger baby.

Symptoms and Complications

Symptoms depend on which complications occur. Common complications include the following:

 Excess amount of red blood cells (polycythemia): Large-for-gestational-age newborns

may have a ruddy complexion because too many red blood cells are produced. As the
excess red blood cells are broken down, bilirubin is formed, which, along with poor
feeding, results in jaundice.
 Low blood sugar levels (hypoglycemia): In newborns of mothers with diabetes, the
oversupply of glucose from the placenta stops abruptly at delivery when the umbilical
cord is cut and the continuing rapid production of insulin by the newborn's pancreas leads
to low levels of sugar in the blood (hypoglycemia). Often hypoglycemia causes no
symptoms. Sometimes, newborns are listless, limp, or jittery. Despite their large size,
newborns of mothers with diabetes often do not feed well for the first few days.
 Lung problems: Lung development is delayed in newborns whose mothers have
diabetes. When these newborns are delivered by cesarean, they are at risk of developing
lung problems. Newborns born prematurely are more likely to have immature diabetes
are more likely to have immature lungs and to develop respiratory distress syndrome),
even when born only a few weeks before full term.
  Increased risk of birth injuries: Newborns who are large for gestational age are at
increased risk of birth injuries such as stretching of the nerves in the shoulder (brachial
plexus injuries) and collarbone (clavicle) fractures. Vaginal delivery, especially breech
deliveries, may be difficult when the fetus's head is large in comparison with the mother's
pelvic measurements, which increases the risk of birth injury. Therefore, such a fetus may
have to be delivered by caesarean.

Infants whose mother has diabetes also have a higher rate of birth defects than other newborns.
Large-for-gestational-age newborns born to mothers with diabetes are likely to be significantly
overweight later in childhood and as adults, which, along with their genetic predisposition, puts
them at risk of developing type 2 diabetes.

Why is large for gestational age (LGA) a concern?

Because LGA babies are so large, delivery can be difficult. Delivery problems may include the
following:

 prolonged vaginal delivery time

 difficult birth
 increase in cesarean delivery

Because many large babies are born to diabetic mothers, many problems of LGA babies are
related to problems with glucose regulation. These may include the following:

 hypoglycemia (low blood sugar) of baby after delivery

 increased incidence of birth defects
 respiratory distress (difficulty breathing)

Many babies with LGA also have hyperbilirubinemia (jaundice - yellowing of the skin, eyes, and
mucous membranes).
 II: PATIENT’S DATA

Name: Patient MDO

Age: Newborn

Address: Muntinlupa City

Diagnosis: NBFT, NSD, Non-institutionalized delivery, 39 weeks AOG, LGA

Wt: 4.2 kgs

Attending Physician: Dr. Tatad/ Dra. Aliwalas

Date of Admission: Jan 6, 2011

Time of Admission: 5:20 am

Admitted at: NICU From ER

 III: ANATOMY AND PHYSIOLOGY

Every cell in the human body needs energy in order to function. The body’s primary energy
source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates
(sugars and starches). Glucose from the digested food circulates in the blood as a ready energy
source for any cells that need it. Insulin is a hormone or chemical produced by cells in the
pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of
cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of
the glucose can be converted to concentrated energy sources like glycogen or fatty acids and
saved for later use. When there is not enough insulin produced or when the doorway no longer
recognizes the insulin key, glucose stays in the blood rather entering the cells.
Diabetes has long been associated with maternal and perinatal morbidity and mortality. Before
the discovery of insulin in 1921, women with diabetes rarely reached reproductive age or
survived pregnancy. In fact, pregnancy termination was routinely recommended for women with
diabetes because of high mortality rates.

Fetal and neonatal mortality rates were as high as 65% before the development of specialized
maternal, fetal, and neonatal care. Since then, infants of diabetic mothers (IDMs) have
experienced a nearly 30-fold decrease in morbidity and mortality rates. Today, 3-10% of
pregnancies are affected by abnormal glucose regulation and control. Of these cases, 80-88% are
related to abnormal glucose control of pregnancy or gestational diabetes mellitus. Of mothers
with preexisting diabetes, 35% had type 1 diabetes mellitus, and 65% had type 2 diabetes
mellitus.

Infants born to mothers with glucose intolerance are at an increased risk of morbidity and
mortality related to the following:

 Growth abnormalities (large for gestational age [LGA], small for gestational age [SGA])
 Hyperviscosity secondary to polycythemia
 Hypoglycemia
 Congenital malformations
 Hypocalcemia, hypomagnesemia, and iron abnormalities

These infants are likely to be born by cesarean delivery for many reasons, among which are such
complications as shoulder dystocia with potential brachial plexus injury related to the infant's
large size. These mothers must be closely monitored throughout pregnancy. If optimal care is
provided, the perinatal mortality rate, excluding congenital malformations, is nearly equivalent to
that observed in normal pregnancies.
 IV. PATHOPHYSIOLOGY

Increased levels of both estrogen and progesterone affect glucose homeostasis as counter-
regulatory hormones in the mother early in pregnancy. As a result, beta-cell hyperplasia occurs
in the pancreas, stimulating an increased release of insulin.

Increased insulin levels stimulate glycogen deposition and decrease hepatic glucose production.
A decreased need for insulin in women with diabetes is not unusual in early pregnancy.
Furthermore, amino acids decrease, and fatty acid triglycerides and ketones both increase with
increased fatty acid deposition. As a result, increased protein catabolism and accelerated renal
gluconeogenesis occurs.

As pregnancy progresses, human placental lactogen is released by the syncytiotrophoblast,

leading to lipolysis in the mother. The subsequent release of glycerol and fatty acids reduces
maternal use of glucose and amino acid, thus preserving these substrates for the fetus.

The release of increasing amounts of contrainsulin factors as placental growth continues causes
up to a 30% increase in maternal insulin needs as pregnancy progresses. Mothers with previous
borderline glucose control, obesity, or frank diabetes may require initiation of or increase in their
insulin requirements to maintain glucose homeostasis.

Glucose and amino acids traverse the placental membrane. On the other hand, insulin is unable
to cross from maternal to fetal circulations. Using a carrier-mediated facilitated diffusion
mechanism, fetal glucose levels are maintained at a level that is 20-30 mg/dL lower than those of
the mother.

The fetus is subjected to high levels of glucose during times of maternal hyperglycemia. Before
20 weeks' gestation, fetal islet cells are incapable of responding, subjecting the fetus to
unchecked hyperglycemia and decreased fetal growth. Poor growth is especially noted in
mothers with diabetic vascular disease. After 20 weeks' gestation, the fetus responds to
hyperglycemia with pancreatic beta-cell hyperplasia and increased insulin levels.

Chronic fetal hyperglycemia and hyperinsulinemia increase the fetal basal metabolic rate and
oxygen consumption, leading to a relative hypoxic state. The fetus responds by increasing
oxygen-carrying capacity through increased erythropoietin production, potentially leading to
polycythemia. The fetus redistributes iron from developing organs, including the heart and brain,
to support this expanded blood mass, leaving these organs iron deficient and with possible long-
term functional consequences.

Prior to birth, elevated insulin levels may inhibit the maturational effect of cortisol on the lung,
including the production of surfactant from type 2 pneumocytes. This puts the fetus at risk for
developing respiratory distress syndrome after birth at a gestational age normal lung function is
expected.
 V. TREATMENT

Treatment for large for gestational age (LGA): Specific treatment for large for gestational
age will be determined by your baby's physician based on:

 Your baby's gestational age, overall health and medical history.

 Extent of the condition.
 Your baby's tolerance for specific medications, procedures or therapies.
 Expectations for the course of the condition.
 Your opinion or preference.

If ultrasound examinations during pregnancy show a fetus is quite large, some physicians
may recommend early delivery before the baby grows much bigger. A mother may need
induction of labor, or a planned cesarean delivery if the baby is estimated to be very
large.

After delivery, a LGA baby will be carefully examined for any birth injuries. Blood
glucose testing is also performed to check for hypoglycemia. Early feeding with a
glucose/water solution is sometimes needed to counter the low blood sugar.
intravenous glucose or frequent feedings by mouth or by tube into the stomach are often
needed. Treatment of respiratory distress syndrome may require supplemental oxygen
through a tube placed in the nose or intense intervention, such as respiratory support with
a ventilator.
 Global City Innovative College
3/F Bonifacio technology Center
Bonifacio Global City, Taguig City
Transforming lives. Innovative Education
College of Nursing and allied health education

In partial fulfillment of the requirements

On the Related Learning Experience (RLE)

CASE STUDY

Submittted By:

Jude Lawrence S. Jacalan

N-411 Group B Cluster 2

Submitted to:

Mr. Ben De Paz, R.N, MAN

Clinical Instructor

Ospital Ng Muntinlupa

NICU/ PICU

Febuary 3-5, 10-12, 2011