Republic of the Philippines

Bicol University
POLANGUI CAMPUS
NURSING DEPARTMENT
Polangui, Albay
www.bupolangui.com
Email: bupc.nursing@gmail.com
====================================================================

Case
Analysis
Submitted by:
Trixia U. Almendral
Nicole Jarri I. Capellan
Earl Queen Durante
Carl Angelo T. Sadueste
Armand James C. Villamil
Case Scenario
Sheena, 37-year Primigravida reported in opd at regional, Imphal, as a case of
primigravida, 39 weeks pog with breech in labour with fetopelvic (big baby) on 28
august 2015. By per abdomen examination baby was big and there was fetopelvic
disproportion by pv examination. She delivered a single live male, 6.1kg baby by
emergency lower segment caesarean section. Baby did not cry immediately. Neonatal
resuscitation done and baby admitted in NICU. Baby’s, temperature, spo2 and blood
glucose monitoring results were within normal limit except tachypnea. Neonatal
resuscitation done to the baby. During ANC checkup mother’s blood sugar was
elevated, fetus weight was 3.7kg at 38wks and result of GTT shows impaired glucose
tolerance/diabetes. Mother’s thyroid profile antenately and after delivery was not
favouring for any hypothyroidism. There was a history of diabetes of first degree
relatives in family. Parents were overweight and as well as the mother of the baby.
Glucose tolerance test and thyroid profile were elevated after delivery. Pt was followed
up and advise for genetic counseling and further examination for higher centre as
chances of macrosomia in future pregnancy are there.
Definition
The term macrosomia is used to describe a newborn with an excessive birth weight. An
accurate diagnosis of fetal macrosomia can be made only by measuring birth weight
after delivery; therefore, the condition is confirmed only retrospectively, ie, after delivery
of the neonate. Fetal macrosomia has been defined in several different ways, including
birth weight greater than 4000 g or 4500 g (8 lb 13 oz or 9 lb 15 oz) or greater than 90%
for gestational age.  According to National Vital Statistics Report for U.S. Births in 2017,
approximately 7.8% of infants had birth weight >4000 g, 1% had birth weight greater
than 4500 g, and 0.1% had birth weight greater than 5000 g.

PATHOPHYSIOLOGY

Precipitating Factors
Predisposing Factors
- Maternal Glucose Metabolism/
- Previous Macrosomic Delivery
Diabetes
- Parental Height
- Maternal Obesity
- Maternal Age
- Gestational Age at delivery
-Fetal sex (Male)

Exaggerated Insulin Resistance

Reduced Insulin Effect

 Increased absorption of maternal
fat stores
Maternal Hyperglycemia

Dyslipidemia

Increased nutrients to Fetus

Fetal Hyperinsulinemia

Fetal Macrosomia

Maternal Short-term (Fetal)

Long-term (Fetal)
- Perineal Injury - Prolonged Labor
- Overweight/Obesity
- Instrumental Delivery or - Fetal Hypoxia
- Diabetes (T1/T2 DM)
Caesarean Section - Shoulder Dystocia
- Metabolic Syndrome
- Postpartum Hemorrhage - Low APGAR Score

Pharmacologic Management
Name of Action Adverse Contraindications Nursing
Drug Reaction and Cautions Considerations
Generic Lowers blood CV: Peripheral -During the -Monitor blood
name: Insulin glucose level by edema episodes of glucose level and
Regular stimulation hypoglycemia adjust insulin
peripheral glucose Metabolic: -Hypersensitivity dosage as
Brand name: uptake by binding Hypoglycemia -Use cautiously in needed
Humulin R to insulin receptors older patients -Monitor patient
Regular on fat cells Skin: Injection carefully for sign
– Site and symptoms of
Reactions hypoglycemia
-Increase
Other: Allergic frequency of
reactions glucose
monitoring
 Patient Teaching
-Teach patient to
eat within 30
mins of injecting
short-acting
insulin
-Advise patient
that allergic
reaction can
occur
-Warn patient
that insulin
requirements
may vary due to
illness.
Generic Metformin works Metabolic: -should not use -This product
name: by helping to Lactic Acidosis metformin if you may contain
Metformin restore your body's have severe kidney inactive
proper response to Other: Allergic disease, metabolic ingredients,
Brand name: the insulin you reaction acidosis, or diabetic which can cause
Fortamet, naturally produce. ketoacidosis allergic reactions
Glucophage, It also decreases -If you need to or other
Glucophage the amount of have any type of x- problems.
XR, sugar that your ray or CT scan -Before using this
Glumetza. liver makes and using a dye that is medication, tell
Riomet that your injected into your doctor or
stomach/intestines veins, you may pharmacist of
absorb need to temporarily the patient’s
stop taking medical history,
metformin especially of:
severe breathing
problems (such
as obstructive
lung disease,
severe asthma),
blood problems
(such as anemia,
vitamin B12
deficiency),
kidney disease,
liver disease.
-During
pregnancy, this
medication
should be used
only when clearly
needed.
-Metformin can
cause changes in
the menstrual

NURSING MANAGEMENT
Nursing Management
Ask client about her medical history and past
pregnancies.
(Fetal macrosomia can't be diagnosed until
after the baby is born and weighed)
Measuring the height of the fundus.
Advise for Ultrasound
Check the amniotic fluid level. Too much
amniotic fluid is a sign that the baby is
producing excess urine.
Explain what is fetal macrosomia and potential
harm to the baby. Then provide client and
family teaching.
 Proper nutrition. Foods that are high in
fat and highly refined sugars should be
avoided.
 Blood sugar monitoring
 Regular Exercise. Everyday activities
such as walking and doing household
chores are also beneficial.
 Insulin Administration.
cycle (promote
ovulation) and
increase the risk
of becoming
pregnant.
-Metformin
passes into
breast milk in
small amounts.
Rationale
If client had diabetes before pregnancy or
develop gestational diabetes it could result to
fetal macrosomia, and C-section might be the
safest way to deliver the baby.
The fundus is the length from the top of the
mother’s uterus to her pubic bone. A larger
than normal fundal height could be a sign of
macrosomia.
This test uses sound waves to view an image
of the baby in the uterus. Although it’s not
completely accurate at predicting the birth
weight, it can estimate whether the baby is too
large in the womb.
Larger babies produce more urine.
Helps the client to make informed decisions
about managing regimen and may increase
cooperation.
 It is important to get the daily nutrition
by consuming foods that are high in
nutrients such as fruits, vegetables,
whole grains and lean protein. A meal
plan based on one’s preference and
food habits can be of great help.
 Mother’s food choices and daily
activities can improved or negatively
blood sugar. So it is important to set a
pregnancy weight gain goal with
dietician.
 Exercise not only relieves pregnancy
discomfort but also helps a lot in
lowering blood sugar.
 If the lifestyle modifications are

Recommend elective caesarean section
After baby is born, he or she will likely be
examined for signs of birth injuries, abnormally
low blood sugar (hypoglycemia) and a blood
disorder.
inadequate then insulin injections may
be incorporated in the management.
Fetal macrosomia may complicate vaginal
delivery and can put the baby at risk of injury
during birth.
Baby might be at risk of childhood obesity and
insulin resistance and should be monitored for
these conditions.

PREVENTION

Promotion of healthy pregnancy:

 Schedule a preconception appointment. If you're considering pregnancy, talk with your

health care provider. If you're obese, you might also be referred to another health care
provider — such as a registered dietitian or an obesity specialist — who can help you
reach a healthy weight before pregnancy.
 Monitor your weight. Gaining a healthy amount of weight during pregnancy —
often 25 to 35 pounds (about 11 to 16 kilograms) if you have a normal pre-pregnancy
weight — supports your baby's growth and development. Women who weigh more when
they get pregnant will have lower recommended pregnancy weight gain. Work with your
health care provider to determine what's right for you.
 Manage diabetes. If you had diabetes before pregnancy or if you develop gestational
diabetes, work with your health care provider to manage the condition. Controlling
your blood sugar level is the best way to prevent complications, including fetal
macrosomia.

Be active. Follow your health care provider's recommendations for physical activity.
References:
Mayo Clinic (n.d). Fetal Macrosomia. Retrieved August 31, 2021 from
https://www.mayoclinic.org/diseases-conditions/fetal-macrosomia/symptoms-
causes/syc-20372579#:~:text=Prevention,reduce%20the%20risk%20of
%20macrosomia.
Kumar, D. (2016). A RARE CASE OF FETAL MACROSOMIA: WITHOUT MATERANAL
DIABETES OR HYPOTHYROIDISM. International Journal of Current Research.
Retrieved from http://www.journalcra.com/sites/default/files/issue-pdf/13724.pdf