MACROSOMIA & IUGR

POLYHDRAMINOS AND
OLIGOHYDRAMINOS

DR.SHAIMA ABOZEID
 MACROSOMIA
Large for gestational age (LGA) is an indication
of high prenatal growth rate, often defined as a
weight (or length, or head circumference) that lies
above the 90th percentile for that gestational age.
Macrosomia, also known as big baby syndrome,
is sometimes used synonymously with LGA, or is
otherwise defined as a fetus or infant that weighs
above 4000 grams (8 lb. 13 oz.) or 4500 grams (9
lb. 15 oz.) regardless of gestational age.
incidence is 10% in usa.
 diagnosis
• LGA is generally not diagnosed until after the birth, as
the size and weight of the child is rarely checked during
the latter stages of pregnancy.
• Babies that are large for gestational age throughout the
pregnancy can sometimes be seen during a routine
ultrasound, although fetal weight estimations late in
pregnancy are quite imprecise.
• There are believed to be links with polyhydramnios
(excessive amniotic sac fluid).
• One of the primary risk factors is poorly-controlled diabetes,
Predetermining
particularly gestational factors
diabetes (GD),as well as preexisting
diabetes mellitus (DM) (preexisting type 2 is associated more
with Macrosomia, while preexisting type 1 can be associated
with Macrosomia).
• This increases maternal plasma glucose levels as well as
insulin, stimulating fetal growth.
• The LGA newborn exposed to maternal DM usually has an
increase only in weight. LGA newborns that have
complications other than exposure to maternal DM present
with universal measurements >90th percentile.
Other determining factors include:
Gestational age; pregnancies that go beyond 40 weeks increase incidence
Fetal sex; male infants tend to weigh more than female infants
Genetic factors; taller, heavier parents tend to have larger babies, with an
obese mother greatly increasing the chances
Excessive maternal weight gain
Multiparty (have 2-3x the number of LGA infants vs. primaparas)
Congenital anomalies (transposition of great vessels) - Hydrops Fetalis
Erythroblastosis Fetalis - Hydrops Fetalis
Use of some antibiotics (amoxicillin, pivampicillin) during pregnancy -
Hydrops Fetalis
Genetic disorders of overgrowth (e.g. Beckwith- Wiedemann syndrome,
Sotos syndrome)
The condition is most common in mothers of African origin, partly due to
the higher incidence of diabetes
 Risk factors
Maternal diabetes Excessive weight gain

Maternal impaired glucose Male fetus

intolerance

Multiparty Parental stature

Previous macrosomic infant Need for labor augmentation

Prolonged gestation Prolonged second stage

Maternal obesity
 PREDICTION
CLINICIAN ESTIMATION OF FETAL WEIGHT
The volume of amniotic fluid, the size and configuration of the uterus and maternal
body habitus complicate estimation of the size of the fetus by palpation through the
abdominal wall. Several studies have documented mean errors of about 300 g
ULTRASONOGRAPHY
Ultrasonography has been proposed as a more accurate method of estimation of
fetal weight.
Unfortunately, the typical mean error ranges from 300 to 550 g A study comparing
fetal weight estimates of clinicians, multiparous patients and ultrasonography found
that ultrasound was the least accurate of the three methods.
Limitations in the sensitivity and specificity of ultrasound have been observed in
other studies. Despite these limitations, clinicians continue to incorrectly believe
that ultrasound is an accurate way of predicting Macrosomia.
Treatment
•Depending upon the relative size of the head of the
baby and the pelvic diameter of the mother vaginal
birth may become complicated. One of the most
common complications is shoulder dystocia.
•Such pregnancies often end in caesarean sections in
order to safely deliver the baby and to avoid birth
canal lacerations. Upon birth, early feeding is
essential to prevent fetal hypoglycemia.
•Early diagnosis of individual problems is required.
FETAL CONSEQUENCES
•The delivery of a macrosomic infant has potentially serious consequences
for the infant and the mother. The most feared result of macrosomia is
shoulder dystocia, and up to one fourth of infants with shoulder dystocia
experience brachial plexus or facial nerve injuries, or fractures of the
humerus or clavicle. Brachial plexus injuries, such as Erb-Duchenne palsy,
are ordinarily attributed to delivery complicated by shoulder dystocia;
however, approximately one third of these injuries are not associated with a
clinical diagnosis of shoulder dystocia. The most feared complication
secondary to shoulder dystocia is asphyxia, which is rare.
MATERNAL CONSEQUENCES OF FETAL MACROSOMIA
•The mother is at increased risk for cesarean section, which occurs more
commonly in pregnancies complicated by macrosomia.
• Vaginal delivery of a macrosomic infant increases the risk of third- or
fourth-degree lacerations fivefold.
Interventions for Suspected Macrosomia

•Management strategies for suspected fetal macrosomia

include elective cesarean section and early induction of
labor
 IUGR
Intrauterine growth restriction (IUGR) is a common diagnosis in
obstetrics and carries an increased risk of perinatal mortality and
morbidity. Identification of IUGR is crucial because proper
evaluation and management can result in a favorable outcome.
Certain pregnancies are at high risk for growth restriction,
although a substantial percentage of cases occur in the general
obstetric population.
Accurate dating early in pregnancy is essential for a diagnosis of
IUGR.
Ultrasound biometry is the gold standard for assessment of fetal
size and the amount of amniotic fluid.
Growth restriction is classified as symmetric and asymmetric.
• A lag in fundal height of 4 cm or more suggests IUGR.
• Serial ultra sonograms are important for monitoring growth
restriction, and management must be individualized.
• General management measures include treatment of
maternal disease, good nutrition and institution of bed rest.
• Preterm delivery is indicated if the fetus shows evidence of
abnormal function on biophysical profile testing.
• The fetus should be monitored continuously during labor to
minimize fetal hypoxia.
• Fetal growth is dependent on genetic, placental and
maternal factors.
• The fetus is thought to have an inherent growth potential
that, under normal circumstances, yields a healthy
newborn of appropriate size.
• The maternal-placental-fetal units act in harmony to
provide the needs of the fetus while supporting the
physiologic changes of the mother.
• Limitation of growth potential in the fetus is analogous to
failure to thrive in the infant. The causes of both can be
intrinsic or environmental
• Fetal growth restriction is the second leading cause of
perinatal morbidity and mortality, followed only by
prematurity.
• The incidence of intrauterine growth restriction (IUGR)
is estimated to be approximately percent in the general
obstetric population.
• However, the incidence varies depending on the
population under examination (including its geographic
location) and the standard growth curves used as
reference.
• In assessing perinatal outcome by weight, infants who
weigh less than 2,500 g at term have a perinatal
mortality rate that is five to 30 times greater than that of
infants whose birth weights are at the 50th percentile.
• The mortality rate is 70 to 100 times higher in infants
who weigh less than 1,500 g Perinatal asphyxia
involving multiple organ systems is one of the most
significant problems in growth-restricted infants.
• Timely diagnosis and management of IUGR is one of the
major achievements in contemporary obstetrics. If the
growth-restricted fetus is identified and appropriate
management instituted, perinatal mortality can be reduced,
underscoring the need for assessment of fetal growth at
each prenatal visit.
Classification and Etiology
• IUGR is the pathologic counterpart of small-for-
gestational-age. The latter includes fetuses that are small
but have reached their appropriate growth potential.
• Many babies are simply genetically small and are otherwise
normal. Some women have a tendency to have
constitutionally small babies.
• Although both parents' genes affect childhood
growth and final adult size, maternal genes mainly
influence birth weight.
• Parity, age and socioeconomic status are
intercorrelated and may also influence the pregnancy
and the infant's birth weight.

• Table 1 summarizes clinical situations in which

IUGR may occur.
Placental insufficiency
Unexplained elevated maternal alpha-fetoprotein level

Idiopathic
Preeclampsia
Chronic maternal disease
Cardiovascular disease
Diabetes
Hypertension
Abnormal placentation
Abruptio placentae
Placenta previa
Infarction
Circumvallate placenta
Placenta accretia
Hemangioma
Genetic disorders
Family history
Trisomy 13, 18 and 21
Triploidy
Turner's syndrome (some cases)
Malformations
Immunologic
Antiphospholipid syndrome
Infections
Cytomegalovirus
Rubella
Herpes
Toxoplasmosis
Metabolic
Phenylketonuria
Poor maternal nutrition
Substance abuse (smoking, alcohol, drugs)
Multiple gestation
Low socioeconomic status
Definition of IUGR

•The most widely used definition of IUGR is a fetus whose

estimated weight is below the 10th percentile for its
gestational age and whose abdominal circumference is below
the 2.5th percentile. At term, the cutoff birth weight for IUGR
is 2,500 g Growth percentiles for fetal weight versus
gestational age are shown in Figure 1.
•Approximately 70 percent of fetuses with a birth weight
below the 10th percentile for gestational age are
constitutionally small ; in the remaining 30 percent, the cause
of IUGR is pathologic.
Importance of Accurate Dating
•Accurate dating in early pregnancy is essential for making the
diagnosis of IUGR. The usual qualifier for reliable dating and
establishment of an accurate gestational age is a certain date for the
last menstrual period in a woman with regular cycles or assessment
of gestational age by an ultrasound examination performed no later
than the 20th gestational week, when the margin of error is seven to
10 days.
•Early ultrasound examination, ideally at eight to 13 weeks of
gestation, is more accurate for estimating gestational age than
ultrasound assessment later in pregnancy.
•An error that is commonly made is to change a patient's due date
on the basis of a third-trimester ultra sonogram.
•Doing so can result in failure to recognize IUGR.
Symmetric and Asymmetric IUGR

IUGR is usually classified as symmetric and asymmetric.

•Symmetric growth restriction implies a fetus whose entire
body is proportionally small.
•Asymmetric growth restriction implies a fetus who is
undernourished and is directing most of its energy to
maintaining growth of vital organs, such as the brain and
heart, at the expense of the liver, muscle and fat.
This type of growth restriction is usually the result of
placental insufficiency.
A fetus with asymmetric IUGR has a normal head dimension
but a small abdominal circumference (due to decreased liver
size), scrawny limbs (because of decreased muscle mass) and
thinned skin (because of decreased fat).
If the insult causing asymmetric growth restriction is
sustained long enough or is severe enough, the fetus may lose
the ability to compensate and will become symmetrically
growth-restricted.
Arrested head growth is of great concern to the developmental
potential of the fetus
Ultrasound Biometry
•Ultrasound biometry of the fetus is now the gold standard for
assessing fetal growth (Figure 2). The measurements most
commonly used are the biparietal diameter, head circumference,
abdominal circumference and femur length. Percentiles have
been established for each of these parameters, and fetal weight
can be calculated. The most sensitive indicator of symmetric and
asymmetric IUGR is the abdominal circumference, which has a
sensitivity of over 95 percent if the measurement is below the
2.5th percentile.
• Accurate dating of the pregnancy is essential in the use of any
parameter.
• Also useful is the ratio of the head circumference to the abdominal
circumference (HC/AC). Between 20 and 36 weeks of gestation, the
HC/AC ratio normally drops almost linearly from 1.2 to 1.0. The ratio is
normal in the fetus with symmetric growth restriction and elevated in the
infant with asymmetric growth restriction.
• Another important use of ultrasound is estimating the amount of amniotic
fluid.
• A decreased volume of amniotic fluid is closely associated with IUGR.
Significant morbidity has been found to exist in pregnancies with an
amniotic fluid index value of less than 5 cm. The amniotic fluid index is
obtained by summing the largest cord-free vertical pocket in each of the
four quadrants of an equally divided uterus.
• The combination of oligohydramnios and IUGR portends a less favorable
outcome, and early delivery should be considered
• The management of IUGR must be individualized for each
patient. In addition to managing any maternal illness, a detailed
sonogram should be performed to search for fetal anomalies, and
karyotyping should be considered to rule out aneuploidy.
• Symmetric restriction may be due to a fetal chromosomal
disorder or infection. This possibility should be discussed with
the patient, who may decide to undergo a diagnostic procedure
such as amniocentesis.
• It should be remembered, however, that many infants with
evidence of growth restriction are constitutionally small.
• Serial ultrasound examinations are important to determine the
severity and progression of IUGR.
• A controversy involves the timing of delivery to prevent
intrauterine demise because of chronic oxygen deprivation.
• Preterm delivery is indicated if the growth-restricted fetus
demonstrates abnormal fetal function tests, and it is often
advisable in the absence of demonstrable fetal growth. The
risks of prematurity must be weighed against the
complications unique to IUGR.
• General management measures include treatment of
maternal disease, cessation of substance abuse, good
nutrition and institution of bed rest.
• Although not of proven benefit, bed rest may maximize
uterine blood flow. In any case, antenatal testing should be
instituted.
• Options include the nonstress test, the biophysical profile
and an oxytocin (Pitocin) challenge test.
• The biophysical profile involves assessment of fetal well-
being with a combination of the nonstress test and four
ultrasonographic parameters (amniotic fluid volume,
respiratory movements, body movements and muscle tone).
• The use of Doppler flow velocimetry, usually of the
umbilical artery, identifies the growth-restricted fetus at
greatest risk for neonatal morbidity and mortality. In
controlled trials, Doppler analysis has been associated with
improved outcome.
• Combination testing is thought to more accurately predict
the status of the fetus .
• For this reason, close antenatal surveillance is
encouraged, with a well-timed delivery.
• A proposed management approach for IUGR is shown in
the following figure:
• This approach is based on outstanding advances in
neonatal care and improved outcome for the low-birth-
weight infant
Labor and Delivery
•Because of the increased risk of intrapartum asphyxia, the
fetus should be monitored carefully and continuously during
labor. Delivery should be in a hospital capable of dealing with
the various neonatal morbidities associated with growth
restriction, including asphyxia, meconium aspiration, sepsis,
hypoglycemia and malformations.
•Preterm induction of labor is often required.
•Amnioinfusion may be of benefit in the presence of a
nonreassuring fetal response during labor and a low amniotic
fluid index or oligohydramnios.
•In the face of deteriorating fetal status, a cesarean section
should be performed
Outcome
•Most infants who had growth restriction in utero have normal rates of
growth in infancy and childhood, although studies have demonstrated that at
least one third of them never achieve normal height.
• Many of these infants also are born prematurely, with its similar,
independent, morbidities.
•The lower the birth weight and the earlier the gestational age, the less the
child's chance of catching up. Neurologic development is also related to the
degree of growth restriction and prematurity. Decreased intrauterine growth
may possibly have a negative effect on brain growth and mental
developmental potential. At baseline, children with a history of IUGR have
been found to demonstrate attention and performance deficits.
• Minimizing hypoxic episodes during labor and delivery, as well as
optimizing neonatal care for these infants, will likely produce the healthiest
outcome
 Polyhydramnios
& oligohydramnios
Definition
•Polyhydramnios is a high level and
oligohydramnios is low level of amniotic fluid, and
ahydraminos is no amniotic fluid.
•Polyhydramnios in the second trimester is found in
about 1 per 200 pregnancies.
• Amniotic fluid is the liquid that surrounds the developing fetus
during pregnancy. It is contained within the amniotic membrane
that forms the amniotic sac (bag of waters).
• During the first three months after conception (first trimester),
amniotic fluid is mainly derived from the blood plasma that
diffuses through the thin tissues of the fetus into the
surrounding space.
• After the fetal kidneys form and become functional at about 10-
11 weeks, fetal urine becomes the main source of amniotic fluid
and remains so for the rest of the pregnancy. In addition, the
lungs also produce liquid that becomes part of the amniotic
fluid.
• Other contributions come from fetal oral and nasal
secretions and from the fetal surface of the placenta.
• Amniotic fluid removal is largely due to fetal swallowing
and absorption into the fetal blood. Uptake also occurs
across the placental surface. The volume of amniotic fluid
normally increases throughout pregnancy, reaching a peak
at about 32-33 weeks and remaining fairly constant or
decreasing slightly thereafter.
• There is a wide range of normal fluid volumes with an
average of 700-800 ml at 32-33 weeks. Through the
processes of swallowing and urination, a fetus can recycle
the entire volume in less than 24 hours.
• Because the normal values for amniotic fluid volume
increase during pregnancy, the actual volume that
constitutes polyhydramnios is dependent on the
gestational age of the fetus.
• During the last two months of pregnancy, polyhydramnios
usually refers to amniotic fluid volumes greater than 1,700-
1,900 ml.
• Severe cases are associated with much greater fluid volume
excesses.
• The range of fluid values diagnostic of oligohydramnios is
not as wide as that for polyhydramnios.
• Less than 300 ml, or lower than the 5% percentile for
gestational age, is usually considered the upper threshold.
• Diagnosis:
• The diagnosis of polyhydramnios is usually made
subjectively. Quantitatively, polyhydramnios is defined an
amniotic fluid index (the sum of the vertical measurements
of the largest pockets of amniotic fluid in the four
quadrants of the uterus) of 20 cm or more.
• Alternatively, the vertical measurement of the largest single
pocket of amniotic fluid free of fetal parts is used to
classify polyhydramnios into mild (8-11 cm), moderate
(12-15 cm) and severe (16 cm or more).
Causes and symptoms
•Polyhydramnios, also referred to as hydramnios, can have any one of a
number of causes related either to an underlying maternal or fetal
condition. Maternal diabetes, which is associated with a macrosomic
(enlarged) fetus, is a common cause. The medication lithium, used to treat
depression, can also increase amniotic fluid levels. Twin gestations are
prone to polyhydramnios. Infections passed from mother to fetus such as
rubella, cytomegalovirus, and toxoplasmosis, can also result in damage to
the fetus and elevated amniotic fluid levels.
•Fetal abnormalities, including many that are life-threatening or lead to a
significant impairment in the quality of life, are found in up to a quarter of
all patients. For this reason, the initial finding of excess amniotic fluid
should be followed by thorough diagnostic studies to determine the cause
and the prognosis.
• Because fetal swallowing is a major factor in amniotic fluid removal, fetal
abnormalities that prevent fluid uptake should be investigated. These
include gastrointestinal obstructions such as esophageal atresia and
duodenal atresia, as well as neurological conditions that affect swallowing
including anencephaly. Certain cardiac abnormalities, kidney disorders,
and genetic conditions such as myotonic dystrophy and alpha-
thalassemia can also cause polyhydramnios.
• Fetal chromosome abnormalities are frequently associated with elevated
amniotic fluid levels. The more severe the polyhydramnios the more
likely it is that fetal abnormalities will be present. In addition, there are
other, infrequent causes, and in
• a number of cases, no cause can be found. Polyhydramnios can lead to
maternal abdominal discomfort and respiratory difficulties as well as
preterm labor.
• When polyhydramnios is associated with fetal abnormalities, perinatal
mortality is significantly increased.
• Oligohydramnios is most commonly associated with
abnormalities of the fetal kidneys. Since fetal urine is the
main source of amniotic fluid in the latter two-thirds of
pregnancy, any condition that interferes with fetal urine
production can lead to oligohydramnios.
• Oligohydramnios in the second trimester is found in about 1
per 500 pregnancies
• Renal agenesis, cystic kidneys, and bladder outlet
obstructions are common. Meckel -Gruber syndrome, a
lethal autosomal recessive genetic disorder featuring brain
and kidney abnormalities and extra digits is one specific
cause.
• Placental insufficiency and fetal growh retardation can also
result in oligohydramnios
The diagnosis of oligohydramnios is usually made
subjectively.

Quantitative criteria include:

(a) the largest single pocket of amniotic fluid being 1

cm or less, or

(b) amniotic fluid index (the sum of the vertical

measurements of the largest pockets of amniotic
fluid in the four quadrants of the uterus) of 5 cm.
• Premature rupture of membranes, especially between 16
and 24 weeks is another cause and, because amniotic fluid
is important in lung growth, it can lead to
underdevelopment of the lungs (pulmonary hypoplasia).
• In general, regardless of the cause, oligohydramnios that
arises early in a pregnancy, can cause hypoplastic lungs.
• It can also result in space limitations within the amniotic sac
that cause fetal compression and orthopedic abnormalities
such as clubbed feet in the newborn.
In general, oligohydramnios that begins near the time of
delivery is associated with a better outcome than cases than
have an onset earlier in pregnancy
Diagnosis

•In current obstetrical practice, polyhydramnios and

oligohydramnios are usually detected during a routine
prenatal ultrasound.
• If the ultrasonographer suspects that excess or reduced fluid
is present, it is customary to take measurements of pockets of
fluid visualized around the fetus, calculate the amniotic fluid
index (AFI), and compare it to AFI values found in standard
tables.
•Subsequent ultrasound measurements can then be used to
track the increase or decrease in fluid
• It is extremely important that the cause of an abnormal AFI
be sought. Because of the high risk of fetal abnormalities,
detailed ultrasound exams (targeted exams) should then be
performed.
• The mother should be counseled about the possible
complications and offered additional testing as necessary.
For example, an amniocentesis for prenatal chromosome
analysis may be important because of the high risk of fetal
chromosome abnormalities.
• This test is usually indicated if fetal abnormalities are
suspected on the basis of the ultrasound exam. An
amniocentesis can also be used to check for fetal infections
and some rare single gene defects
Treatment
•Effective treatments for polyhydramnios and oligohydramnios are
limited. To relieve maternal discomfort, an excess fluid level can
be reduced by inserting a needle into the amniotic sac and using a
syringe to withdraw excess fluid. This can be done repeatedly, if
necessary.
• In oligohydramnios, the opposite approach of adding fluid either
by increasing oral intake in the mother or by directly infusing
saline into the amniotic sac has been tried in select cases. If the
cause of oligohydramnios is a fetal bladder obstruction, it may be
possible to place a small tube in the bladder to shunt the fluid into
the amniotic sac.
• Alternative treatment

• In select cases where polyhydramnios is thought to

be due to an increased output of fetal urine, the drug
indomethicin has been used with some success, but
there is concern about side effects, particularly on the
fetus.

• Another similar drug, sulindac, is currently being

investigated.
• If oligohydramnios is due to premature rupture of
the membranes, a protocol to manage complications
should be instituted.
 Prognosis
•The prognosis for both polyhydramnios and oligohydramnios depends on
the cause. If excess or reduced amniotic fluid is the result of an underlying
fetal abnormality, the nature of that abnormality will determine the
prognosis. This is one reason why it is important to perform the necessary
follow-up studies. A woman who has been diagnosed with polyhydramnios
or oligohydramnios needs to be made fully aware of the types of testing
available and carefully counseled about the diagnosis and its impact on the
chance for a successful pregnancy out-come and a healthy infant.
Prevention
•In order to prevent polyhydramnios or oligohydramnios, it would be
necessary to prevent the underlying cause. Good control of maternal
diabetes and the prevention of infections transmittable from mother to fetus
are two approaches for a subset of cases, but, in general, prevention is not
possible.