CASE-BASED LEARNING
Fetal macrosomia
Kirsten Allen
Suzanne V F Wallace
Abstract
Clinical palpation, ultrasound biometry and maternal perception can all
lead to the suspicion of a large for gestational age fetus and fetal macro-
somia. Although maternal diabetes and rare genetic syndromes may be
the cause of large fetal size, most of these pregnancies will in fact be
normal. Nevertheless, maternal and perinatal risks do increase with
increasing fetal size. Antenatal prediction, however, is imprecise and
the evidence to date does not support intervention in non-diabetic preg-
nancies where there is a suspicion of fetal macrosomia.
Keywords BeckwitheWiedemann syndrome; diabetes; Erb’s palsy; fetal
macrosomia; gestational diabetes; shoulder dystocia
Introduction
Fetal macrosomia is becoming an increasingly common manage-
ment problem in modern obstetrics. Incidence is increasing and is
likely to continue to do so as levels of maternal obesity rise. The long-
term implications of fetal macrosomia are now recognized to include
increased risk of childhood obesity, with subsequent increased risks
of obesity in adulthood, diabetes and cardiovascular disease.
The difficulties in management stem from a difficulty in making
the diagnosis of macrosomia and the lack of good quality evidence
for what should be done once it is suspected. In the literature, birth
weights of 4 kg, 4.5 kg and 5 kg are variously used to describe
macrosomia. A birth weight of 4 kg at 40 weeks corresponds to the
90th centile, and thus is consistent with a definition of large for
gestational age (LGA). Macrosomia as defined by birth weight,
correlates most closely with clinical outcome, and so is used in
research to assess the effect of interventions on maternal and fetal
morbidity. However, birth weight is a retrospective diagnosis; the
available antenatal measure, to plan further investigations and
management, is a diagnosis of ‘large for gestational age’, based on
estimated fetal weights. Current UK guidelines define macrosomia
as a birth weight over 4 kg, and this is what will be used throughout
this article, unless otherwise stated.
Risk factors
Case 1
A 30-year-old woman is referred for consultant-led care in her
second pregnancy. In her first pregnancy she had a ventouse
Kirsten Allen BMed Sci BMBS MRCOG is a Clinical Lecturer in the Department
of Obstetrics and Gynaecology, Nottingham University Hospitals,
Nottingham, UK. Conflicts of interest: none declared.
Suzanne V F Wallace BM BCh MA MRCOG is a Consultant Obstetrician in the
Department of Obstetrics and Gynaecology, Nottingham University
Hospitals, Nottingham, UK. Conflicts of interest: none declared.
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delivery at 41 weeks of a male infant weighing 4.2 kg. Her BMI at
booking is 35. She is worried about the risks of having another
‘big baby’.
Risk factors for fetal macrosomia can be divided into those
which can be modified during the pregnancy in order to reduce
the risk of macrosomia and non-modifiable factors. Both should
be considered when determining management of the current
pregnancy.
Non-modifiable risk factors include increased maternal weight
and height at booking, Caucasian ethnicity and a male fetus.
Increased pre-pregnancy body mass index is a risk factor for the
development of fetal macrosomia, independent of its influence
on maternal glucose metabolism. There is increasing evidence
for a genetic contribution to fetal macrosomia in the expression
of a gene for insulin-like growth factor; this may be further
influenced by maternal glucose metabolism. Another important
risk factor is a previous baby with macrosomia, as is the case for
this patient. This should be interpreted in the context of a
customized fetal growth chart if possible, as a birth weight of 4.2
kg for this patient may be within normal range for her build and
ethnicity.
One of the most common modifiable risk factors seen in
pregnancy is diabetes, whether this is pre-existing (type 1 or 2
diabetes) or gestational. Although diabetes cannot easily be
prevented, close management and good glycaemic control (using
insulin if necessary) will reduce the rate of complications asso-
ciated with diabetes, including macrosomia. Post-prandial blood
glucose readings are recognized to be a particularly important
tool in reducing fetal macrosomia. It is important to recognize the
women at high risk of developing gestational diabetes so that the
appropriate screening can be done. In the UK, guidelines pro-
duced by the National Institute of Clinical Excellence (NICE)
recommend an oral glucose tolerance test (OGTT) be performed
at 24e28 weeks in any woman meeting the following criteria: a
BMI >30, a previous baby weighing >4.5 kg, a first degree
relative with diabetes or family origin from a high risk group
(South Asian, black Caribbean, Middle Eastern). In addition, an
early OGTT at 16e18 weeks should be offered to any woman
who has had previous gestational diabetes, or those with a BMI
>40, as the incidence of gestational diabetes is known to be
higher in these groups.
Another modifiable risk factor is excessive weight gain during
pregnancy. This can be minimized by giving women advice on
healthy diet and safe lifestyle interventions to increase physical
activity during the pregnancy. Ideally, population interventions
should be introduced to tackle obesity in the non-pregnant
population and thus reduce the number of women who book
with a raised BMI.
Suspected fetal macrosomia
Case 2
A 28-year-old primigravida is referred to the antenatal clinic by
her community midwife at 34 weeks as her symphysis-fundal
height is measured at 37 cm. Her BMI at booking was 27.
For those women in whom fetal macrosomia is suspected, the
history should be reviewed for the presence of any risk factors,
particularly modifiable ones. A careful examination should be
performed to assess the fetal size clinically using both palpation
185 Ó 2013 Published by Elsevier Ltd.
 CASE-BASED LEARNING
and repeat symphysis-fundal height (SFH) measurement. The
patient should be weighed to determine the extent of weight gain
during pregnancy. Once these basic assessments have been car-
ried out, an ultrasound is commonly performed to assess fetal
size and amniotic fluid volume. This certainly has some benefit
in those cases where polyhydramnios is suspected clinically,
however, ultrasound has not been shown to give a more accurate
prediction of macrosomia than clinical assessment. Several
studies have demonstrated the probability of an ultrasound
correctly estimating fetal weight in cases where birth weight is
greater than 4 kg to be anything between 15 and 79%, although
most have shown this to be less than 50%. The abdominal
circumference is known to be the most valuable routine mea-
surement when assessing the LGA fetus, as these babies have an
increased growth of insulin-sensitive tissues such as abdominal
fat. More specific markers of fetal adiposity may provide a more
accurate way to predict macrosomia, particularly the subcu-
taneous tissue thickness in the fetal anterior abdominal wall, and
formulae incorporating this are being developed. In the future,
biochemical markers for fetal adiposity or MRI scanning may aid
the diagnosis of macrosomia, but these methods have not yet
been validated. Interestingly, in multiparous patients, maternal
perception of fetal size has been shown to be as accurate as
clinical or ultrasound assessments.
Once a fetus is identified as large for gestational age, an un-
derlying cause should be ruled out. A scan may show features
suggestive of a genetic cause for fetal macrosomia. The com-
monest of these is BeckwitheWiedemann syndrome, in which
fetal macrosomia is associated with macroglossia, cardiomegaly,
exomphalos and increased incidence of Wilms tumour. Other
genetic syndromes are listed in Table 1; not all are recognizable
antenatally and therefore a decision on performing a repeat
anomaly scan should be an individualized one recognizing any
patient-specific risk factors. In addition, an OGTT would usually
be performed in suspected macrosomia to exclude gestational
diabetes, particularly if polyhydramnios is present on ultrasound
scan. After this, optimal ongoing management is not clear. Serial
SFH measurements have been shown to be more reliable than
individual ones, particularly if performed by the same practi-
tioner. In diabetic pregnancies serial ultrasound scans have value
in identifying accelerated growth, which could be an indication
to deliver or start hypoglycaemic drugs. However, if diabetes is
absent, acceleration of growth is unlikely. Serial ultrasound
Syndromic causes of fetal macrosomia
Syndrome Genetics
BeckwitheWiedemann Autosomal dominant
syndrome
Marfan’s syndrome Autosomal dominant
WeavereSmith syndrome Autosomal dominant
Perimans Autosomal recessive
SimpsoneGolabieBehmel X-linked recessive
syndrome
Table 1
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measurements will therefore not alter the management and
may lead to increased anxiety, particularly as the due date
approaches.
Management
Case 3
A 30-year-old primigravida is seen in antenatal clinic at 39/40.
She had a growth scan at 30 weeks due to a large SFH mea-
surement which showed an AC over the 90th centile. An OGTT
performed at that point was normal, but serial SFH measure-
ments have been consistently over the 90th centile for gestation.
She attends requesting induction of labour due to her big baby.
The risks of macrosomia at term are well recognized.
Maternal risks include increased length of first and second stage
of labour, increased rate of operative delivery, genital tract
trauma and postpartum haemorrhage. This is particularly the
case for birth weights greater than 4.5 kg. For the fetus, there are
increased risks of hypoxia during labour, increased rates of
shoulder dystocia and brachial plexus injury, and a risk of
neonatal hypoglycaemia. Fetal macrosomia increases the risk of
brachial plexus injury by 2e3 times. Diabetes, which has been
excluded in this patient, is known to increase the risk of shoulder
dystocia and brachial plexus injury at all birth weights (Table 2).
Although these risks are known, there are no clear recom-
mendations on management to reduce these risks Management
decisions are based on estimated fetal weight with the inaccur-
acies described above. Many patients will request early delivery
in the hope of reducing the risks of a big baby. In reality, the rate
of fetal growth is slower after 39 weeks, so earlier delivery may
not have much influence on fetal size. A recent Cochrane review
identified 3 randomized controlled trials which compared a
policy of induction of labour at term with expectant management
in cases of fetal macrosomia. Overall, early induction of labour
did not reduce the Caesarean section or instrumental delivery
rates, and no difference was seen in rates of shoulder dystocia.
There were fewer cases of neonatal injury in the control group
(expectant management), but the numbers were small and the
studies not powered sufficiently to detect a statistically signifi-
cant difference. Therefore it concluded that induction of labour
does not reduce the risks of macrosomia for mother or baby.
Elective lower segment Caesarean section (LSCS) has been
proposed for suspected fetal macrosomia, particularly to reduce
the risks of shoulder dystocia and neonatal brachial plexus
Features
Macroglossia, cardiomegaly, exomphalos, Wilms tumour
Micrognathia, enophthalmos, predominant features after birth
Mainly developmental features
Visceromegaly, ascites, polyhydramnios, bilateral renal
harmartomas/Wilms tumour
Macrocephaly, hypertelorism, cleft palate, cardiac defects,
postaxial polydactyly, syndactyly of 2nd/3rd fingers amongst others
186 Ó 2013 Published by Elsevier Ltd.
 CASE-BASED LEARNING
Risk of shoulder dystocia and brachial plexus injury (adapted from Rouse et al, 1996)
Birth weight No maternal diabetes:
incidence of shoulder
dystocia (95% CI)
<4000 g 0.7% (0.3e1.1%)
4000e4499 g 6.7% (3.4e10%)
>4500 g 14.5% (9.8e22%)
Table 2
injury. However brachial plexus injuries have been reported after
elective LSCS. One American study in 2000 looked at the rate of
brachial plexus injury following the introduction of a policy to
offer LSCS to all women with an estimated fetal weight >4.5 kg.
The sensitivity of their diagnosis of macrosomia was only 18%
(based on clinical examination and ultrasound). Even in those
infants weighing >4.5 kg the incidence of BPI was low, and the
authors estimated that approximately 740 LSCS would be
required to prevent one permanent brachial plexus injury. Other
authors have provided even higher estimates, of up to 28,000
LSCS to prevent one brachial plexus injury.
In light of the increased risks of macrosomia in the presence of
diabetes, the RCOG guideline on shoulder dystocia suggests of-
fering elective LSCS to diabetic women with an estimated fetal
weight >4.5 kg. For non-diabetic women there is a paucity of
evidence, but the ACOG recommends considering LSCS if the
estimated weight is >5 kg.
Case 4
A 33-year-old para 1 is seen in antenatal clinic at 36 weeks. In her
first pregnancy she had a normal delivery with shoulder dystocia
which required McRoberts and suprapubic pressure to deliver.
The baby weighed 4.3 kg and was born in good condition with no
sequelae. In this pregnancy ultrasound scan has shown the AC to
be above the 90th centile. GTT was normal. She wants to know
what the risks are for this pregnancy.
Most studies which have looked at delivery after previous
shoulder dystocia are observational, and therefore caution
should be used when interpreting their results. The RCOG
shoulder dystocia guideline quotes a recurrence risk of
shoulder dystocia of up to 25%, which is around 10 times the
risk in the general population. Other studies have suggested if
macrosomia is present in the current pregnancy the recurrence
rate may be as high as 50%. Although almost 50% of cases of
shoulder dystocia occur in babies weighing <4 kg, if it does
occur then larger babies are more likely to suffer severe
brachial plexus injury. Management needs to be individual-
ized to the patient. This should take into account the cir-
cumstances around the previous birth, including the severity
of shoulder dystocia, diabetes and birth weight, but also risk
factors present in the current pregnancy and the wishes of the
patient.
Case 5
A 32-year-old para 1 is seen in antenatal clinic at 36 weeks. In her
first pregnancy she had an elective LSCS for breech presentation
of a baby weighing 4 kg. In this pregnancy an ultrasound has
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Maternal diabetes: incidence Incidence of brachial plexus
of shoulder dystocia (95% CI) injury with shoulder dystocia
(95% CI)
2.2% (0.6e3.7%) 9% (6e12%)
13.9% (4.8e23%) 18% (12e24%)
52.5% (37.5e83.3%) 26% (17e35%)
shown the AC to be above the 90th centile at 36 weeks. She
comes to clinic to discuss a vaginal birth after Caesarean section
(VBAC).
This is another circumstance where the management should
be individualized to the patient. Cohort studies have not shown
any difference in VBAC success rate or scar rupture when the
baby weighs >4 kg. Other factors predicting the likelihood of
successful VBAC also need to be taken into account. For
instance, a raised BMI or previous LSCS for labour dystocia will
both reduce the chances of successful vaginal birth.
Case 6
A 26-year-old para 1 is seen in spontaneous labour at 41 weeks.
She had a previous ventouse delivery at 39 weeks of a baby
weighing 3.7 kg. On arrival to the labour ward, the symphysis-
fundal height (SFH) is measured at 45 cm. Progress in the first
stage of labour is slow, but she eventually reaches full dilatation
using entonox for pain relief. The midwife asks for review after
she has been pushing an hour as the presenting part is not visible.
When making an assessment of a patient for delay in second
stage, clinical estimation of fetal weight must be taken into ac-
count. In this case the SFH is well above the 90th centile for
gestation, which suggests fetal macrosomia. Before undertaking
instrumental delivery, contraction strength and frequency should
be assessed, and signs of obstructed labour should be sought.
This should include abdominal palpation to assess engagement
and vaginal assessment to include the station, position and
presence of caput or moulding. Fetal wellbeing should be
confirmed prior to attempting instrumental delivery by car-
diotocograph (CTG) as macrosomic babies are more prone to
hypoxia in labour due to increased oxygen demands. If there are
signs of obstructed labour or concerns regarding fetal wellbeing,
consideration should be made to proceeding straight for a
Caesarean section rather than attempting an instrumental de-
livery consequent on the risks of shoulder dystocia and neonatal
injury.
Summary
Fetal macrosomia is increasing in incidence yet there remains a
paucity of evidence to guide optimal diagnosis and management.
Investigation should include screening for diabetes, but the role
of ultrasound is less clear. Many decisions on management,
particularly delivery, should be individualized to the patient
taking account their wishes. However, there is no evidence that
induction of labour or planned Caesarean section reduce the
complications associated with fetal macrosomia. A
187 Ó 2013 Published by Elsevier Ltd.
 CASE-BASED LEARNING

FURTHER READING Royal College of Obstetricians and Gynaecologists. Shoulder dystocia

Chauhan SP, Grobman WA, Gherman RA, et al. Suspicion and treatment of the
macrosomic fetus: a review. Am J Obstet Gynecol 2005; 193: 332e46.
Gardosi J, Chang A, Kalyan B, Sahota D, Symonds EM. Customised ante-
natal growth charts. Lancet 1992; 339: 283e7.
Henriksen T. The macrosomic fetus: a challenge in current obstetrics. Acta
Obstet Gynecol Scand 2008; 87: 134e45.
Irion O, Boulvain M. Induction of labour for suspected fetal macrosomia
(review). Cochrane Database Syst Rev 1998. Issue 4 updated 2009.
Johnstone FD, Prescott RJ, Steel JM, et al. Clinical and ultrasound prediction
of macrosomia in diabetic pregnancy. BJOG 1996; 103: 747e54.
Jolly MC, Sebire NJ, Harris JP, Regan L, Robinson S. Risk factors for mac-
rosomia and its clinical consequences: a study of 350,311 pregnan-
cies. Eur J Obstet Gynecol Reprod Biol 2003; 111: 9e14.
National Collaborating Centre for Women’s and Children’s Health. Diabetes
pregnancy (clinical guideline). London: RCOG Press, 2008.
Rouse DJ, Owen J, Goldenburg RL, Oliver SP. The effectiveness and costs
of elective cesarean delivery for fetal macrosomia diagnosed by ul-
trasound. JAMA 1996; 276: 1480e6.
(green top guideline no.42) 2012.
Walsh JM, McAuliffe FM. Prediction and prevention of the macrosomic
fetus. Eur J Obstet Gynecol Reprod Biol 2012; 162: 125e30.
Practice points
C The diagnosis of fetal macrosomia antenatally is imprecise,
clinical estimation from palpation is as accurate as ultrasound
measurement
C There are significant fetal and maternal risks associated with
fetal macrosomia
C Current evidence does not suggest an advantage to elective
induction of labour or Caesarean section in reducing these
risks

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