Large For Gestational Age Fetuses Research Articles

Third-Trimester Ultrasound Diagnosis of Large for Gestational Age and Risk of Cesarean Delivery.

Determine if knowledge of a third-trimester ultrasound diagnosis of large for gestational age (LGA) independently increases the risk of cesarean delivery (CD). Historical cohort comparing CD rate among patients diagnosed with an LGA fetus on a clinically indicated ultrasound from January 2017 to July 2021 with those without an LGA diagnosis at 34 weeks or later. LGA was defined as an ultrasound-estimated fetal weight greater than or equal to the 90th percentile for the gestational age. Univariate analysis was performed to identify significant confounding variables and was utilized as covariates for binary regression with CD rate as the primary outcome, and adjusted odds ratios (AOR) with 95% confidence intervals (CI) were calculated. Nulliparous term singleton vertex (NTSV) and multiparous CD rates were also compared. There were 447 patients diagnosed with an LGA fetus and 1971 patients without an LGA diagnosis on third-trimester ultrasound. The positive predictive value of LGA diagnosis was 50.1% and the false positive rate was 10.6%. Patients with a diagnosis of LGA had higher AOR of CD (OR 2.11, 95% CI 1.56-2.83), and higher AOR of NTSV CD (OR 1.88, 95% CI 1.14-3.13) compared with those without an LGA diagnosis. There was no difference in the rates of non-medically indicated CD, multiparous primary CD, and attempted and successful TOLAC. Our results suggest third-trimester ultrasound diagnosis of LGA independently increases odds of CD, specifically among nulliparous patients, and the potential bias may be one factor contributing to excessive CDs and NTSV CDs.

Identifying First-Trimester Risk Factors for SGA-LGA Using Weighted Inheritance Voting Ensemble Learning.

The classification of fetuses as Small for Gestational Age (SGA) and Large for Gestational Age (LGA) is a critical aspect of neonatal health assessment. SGA and LGA, terms used to describe fetal weights that fall below or above the expected weights for Appropriate for Gestational Age (AGA) fetuses, indicate intrauterine growth restriction and excessive fetal growth, respectively. Early prediction and assessment of latent risk factors associated with these classifications can facilitate timely medical interventions, thereby optimizing the health outcomes for both the infant and the mother. This study aims to leverage first-trimester data to achieve these objectives. This study analyzed data from 7943 pregnant women, including 424 SGA, 928 LGA, and 6591 AGA cases, collected from 2015 to 2021 at the Third Affiliated Hospital of Sun Yat-sen University in Guangzhou, China. We propose a novel algorithm, named the Weighted Inheritance Voting Ensemble Learning Algorithm (WIVELA), to predict the classification of fetuses into SGA, LGA, and AGA categories based on biochemical parameters, maternal factors, and morbidity during pregnancy. Additionally, we proposed algorithms for relevance determination based on the classifier to ascertain the importance of features associated with SGA and LGA. The proposed classification solution demonstrated a notable average accuracy rate of 92.12% on 10-fold cross-validation over 100 loops, outperforming five state-of-the-art machine learning algorithms. Furthermore, we identified significant latent maternal risk factors directly associated with SGA and LGA conditions, such as weight change during the first trimester, prepregnancy weight, height, age, and obstetric factors like fetal growth restriction and birthing LGA baby. This study also underscored the importance of biomarker features at the end of the first trimester, including HDL, TG, OGTT-1h, OGTT-0h, OGTT-2h, TC, FPG, and LDL, which reflect the status of SGA or LGA fetuses. This study presents innovative solutions for classifying and identifying relevant attributes, offering valuable tools for medical teams in the clinical monitoring of fetuses predisposed to SGA and LGA conditions during the initial stage of pregnancy. These proposed solutions facilitate early intervention in nutritional care and prenatal healthcare, thereby contributing to enhanced strategies for managing the health and well-being of both the fetus and the expectant mother.

Comparison Between Fetal Abdominal Subcutaneous Tissue Thickness and Abdominal Circumference to Predict Large for Gestational Age Neonate in Gestational Diabetes.

Increased subcutaneous fat deposition in abdomen in large for gestational age (LGA) fetuses of mothers with gestational diabetes mellitus can be measured by fetal abdominal subcutaneous tissue thickness (FASTT) using ultrasound. The current study aimed to evaluate the correlation between FASTT and birth weight and compare FASTT and abdominal circumference (AC) for prediction of LGA babies in gestational diabetes. 150 term GDM women were enrolled into the study. FASTT was measured weekly. Birth weight was measured immediately after delivery and categorized into SGA, AGA and LGA according to International growth charts. The last FASTT and AC values were recorded for analysis. Correlation statistics was used to determine the relation between FASTT with birth weight and ROC curves were used to compare FASTT and AC for prediction of LGA fetuses. There was weak positive correlation between FASTT and birth weight with Pearson's co-efficient (r) of 0.375. The cut-off value for FASTT to predict LGA fetuses obtained by ROC curve was ≥8.05 mm with sensitivity and specificity of 68.8% and 68.7%. The mean values of FASTT for small for gestational age (SGA), appropriate for gestational age (AGA) and LGA fetuses were significantly different. AUC for FASTT was 0.692 and for AC was 0.755. FASTT had a positive but weak correlation with birth weight. The utility of FASTT as a screening tool may not be impressive. FASTT can discriminate between SGA, AGA and LGA fetuses. AC is a better predictor than FASTT for LGA neonates.

Comparisons of the Rates of Large-for-Gestational-Age Newborns between Women with Diet-Controlled Gestational Diabetes Mellitus and Those with Non-Gestational Diabetes Mellitus.

(1) Objectives: The primary objective is to compare the rate of large-for-gestational-age (LGA) between women with diet-controlled gestational diabetes mellitus (GDM) and those with non-GDM, and to assess whether or not diet-controlled GDM is an independent factor of LGA fetuses. The secondary objectives are to compare the rates of other common adverse pregnancy outcomes, such as preeclampsia, cesarean section rate, preterm birth, and low Apgar score, between pregnancies with diet-controlled GDM and non-GDM pregnancies. (2) Methods: A retrospective cohort study was conducted on singleton pregnancies, diagnosed with GDM and non-GDM between 24 and 28 weeks of gestation, based on a two-step screening test. The prospective database of the obstetric department was accessed to retrieve the records meeting the inclusion criteria, and full medical records were comprehensively reviewed. The patients were categorized into two groups, GDM (study group) and non-GDM (control group). The main outcome was the rate of LGA newborns, and the secondary outcomes included pregnancy-induced hypertension, preterm birth, cesarean rate, low Apgar scores, etc. (3) Results: Of 1364 recruited women, 1342 met the inclusion criteria, including 1177 cases in the non-GDM group and 165 (12.3%) in the GDM group. Maternal age and pre-pregnancy BMI were significantly higher in the GDM group. The rates of LGA newborns, PIH, and cesarean section were significantly higher in the GDM group (15.1% vs. 7.1%, p-value < 0.001; 7.8% vs. 2.6%, p-value = 0.004; and 54.5% vs. 41.5%, p-value = 0.002; respectively). On logistic regression analysis, GDM was not significantly associated with LGA (odds ratio 1.64, 95% CI: 0.97-2.77), while BMI and gender were still significantly associated with LGA. Likewise, GDM was not significantly associated with the rate of PIH (odds ratio: 1.7, 95% CI: 0.825-3.504), while BMI and maternal age were significantly associated with PIH, after controlling confounding factors. (4) Conclusions: The rates of LGA newborns, PIH, and cesarean section are significantly higher in women with diet-controlled GDM than those with non-GDM. Nevertheless, the rates of LGA newborns and PIH are not directly caused by GDM but mainly caused high pre-pregnancy BMI and advanced maternal age, which are more commonly encountered among women with GDM.

Association between extrapolated time in range and large for gestational age infants in pregnant women with type 1 diabetes

AimsTo evaluate the association between extrapolated time in range (eTIR), measured by self-monitoring of blood glucose (SMBG), and large-for-gestational-age (LGA) infants in pregnancies with type 1 diabetes (T1D). MethodsRetrospective cohort analysis including singleton pregnancies with T1D who started antenatal care before 20 gestational weeks and delivered live newborns at a Brazilian hospital between 2010 and 2019, with LGA fetuses as the main outcome. Glycemic records acquired using SMBG were categorized as eTIR, extrapolated time below range (eTBR), and extrapolated time above range (eTAR). Women were divided into two groups (LGA and adequate for gestational age [AGA]) and compared regarding clinical characteristics, obstetric outcomes, and frequencies of eTIR, eTBR, and eTAR. Logistic regression analysis verified the independent predictive variables for LGA infants. ResultsData from 125 pregnancies were analyzed. For the first, second and third trimesters, each 1 % increase in eTIR was associated with a decreased risk of LGA by 2.9 % (OR: 0.971; 95%CI: 0.945–0.998), 2.5 % (OR: 0.975; 95%CI: 0.951–0.999) and 2.3 % (OR: 0.977; 95%CI: 0.955–0.998) and each 1 % increase in eTAR was associated with an increased risk of LGA by 2.7 % (OR: 1.027; 95%CI: 1.005–1.050), 3.9 % (OR: 1.039; 95%CI: 1.014–1.063) and 4.6 % (OR: 1.046; 95%CI: 1.018–1.075), respectively. ConclusionThe concept of TIR can be extrapolated to patients undergoing SMBG to assess the risk of LGA infants in pregnant women with T1D.

Timing of induction of labor in suspected macrosomia: retrospective cohort study, systematic review and meta-analysis.

Large-for-gestational-age (LGA) is associated with several adverse maternal and neonatal outcomes. Although many studies have found that early induction of labor (eIOL) in LGA reduces the incidence of shoulder dystocia (SD), no current guidelines recommend this particular strategy, due to concerns about increased rates of cesarean delivery (CD) and neonatal complications. The purpose of this study was to assess whether the timing of IOL in LGA fetuses affects maternal and neonatal outcomes in a single center; and to combine these results with the evidence reported in the literature. This study comprised two parts. The first was a retrospective cohort study that included: consecutive patients with singleton pregnancy, an estimated fetal weight (EFW) ≥90th percentile on ultrasound (US) between 35+0 and 39+0 weeks of gestation (WG), who were eligible for normal vaginal delivery. The second part was a systematic review of literature and meta-analysis that included the results of the first part as well as all previously reported studies that have compared IOL to expectant management in patients with LGA. The perinatal outcomes were CD, operative vaginal delivery (OVD), SD, brachial plexus palsy, anal sphincter injury, postpartum hemorrhage (PPH), APGAR score, umbilical arterial pH, neonatal intensive care unit (NICU) admission, use of continuous positive airway pressure (CPAP), intracranial hemorrhage (ICH), phototherapy, and bone fracture. Retrospective cohort: of the 547 patients, 329 (60.1%) were induced and 218 (39.9%) entered spontaneous labor. Following covariate balancing, CD was significantly higher in the IOL group in comparison to the spontaneous labor group. This difference only became apparent beyond 40WG (hazard ratio: 1.9, p=0.030). The difference between both groups for shoulder dystocia was not statistically significant. Systematic review and metanalysis: 17 studies were included in addition to our own results giving a total sample size of 111,300 participants. When IOL was performed <40+0WG, the risk for SD was significantly lower in the IOL group (OR: 0.64, 95%CI: 0.42-0.98, I2 =19%). There was no significant difference in CD rate between IOL and expectant management after pooling the results of these 17 studies. However, when removing the studies in which IOL was done exclusively before 40+0WG, the risk for CD in the remaining studies (IOL not exclusively <40+0WG) was significantly higher in the IOL group (odds ratio [OR]: 1.46, 95% confidence interval [95%CI]: 1.02-2.09, I2 =56%). There were no statistically significant differences between IOL and expectant management for the remaining perinatal outcomes. Nulliparity, history of CD, and low Bishop score but not methods of induction were independent risk factors for intrapartum CD in patients who were induced for LGA. Timing of IOL in patients with suspected macrosomia significantly impacts perinatal adverse outcomes. IOL has no impact on rates of SD but does increase CD when considered irrespective of gestational age, but it may decrease the risk of SD without increasing the risk of other adverse maternal outcomes, in particular cesarean section when performed before 40+0 WG. (GRADE: Low/Very low). This article is protected by copyright. All rights reserved.

Measurement of Calprotectin and PTH in the Amniotic Fluid of Early Second Trimester Pregnancies and Their Impact on Fetuses with Growth Disorders: Are Their Levels Related to Oxidative Stress?

Background: During the early stages of human fetal development, the fetal skeleton system is chiefly made up of cartilage, which is gradually replaced by bone. Fetal bone development is mainly regulated by the parathyroid hormone parathormone (PTH) and PTH-related protein, with specific calprotectin playing a substantial role in cell adhesion and chemotaxis while exhibiting antimicrobial activity during the inflammatory osteogenesis process. The aim of our study was to measure the levels of PTH and calprotectin in early second trimester amniotic fluid and to carry out a comparison between the levels observed among normal full-term pregnancies (control group) and those of the groups of embryos exhibiting impaired or enhanced growth. Methods: For the present prospective study, we collected amniotic fluid samples from pregnancies that underwent amniocentesis at 15 to 22 weeks of gestational age during the period 2021–2023. Subsequently, we followed up on all pregnancies closely until delivery. Having recorded fetal birthweights, we then divided the neonates into three groups: small for gestational age (SGA), appropriate for gestational age (AGA), and large for gestational age (LGA). Results: In total, 64 pregnancies, including 14 SGA, 10 LGA, and 40 AGA fetuses, were included in our study. Both substances were detected in early second trimester amniotic fluid in both groups. Concentrations of calprotectin differed significantly among the three groups (p = 0.033). AGA fetuses had a lower mean value of 4.195 (2.415–6.425) IU/mL, whereas LGA fetuses had a higher mean value of 6.055 (4.887–13.950) IU/mL, while SGA fetuses had a mean value of 5.475 (3.400–9.177) IU/mL. Further analysis revealed that only LGA fetuses had significantly higher calprotectin concentrations compared to AGA fetuses (p = 0.018). PTH concentration was similar between the groups, with LGA fetuses having a mean value of 13.18 (9.51–15.52) IU/mL, while SGA fetuses had a mean value of 14.18 (9.02–16.00) IU/mL, and AGA fetuses had similar concentrations of 13.35 (9.05–15.81) IU/mL. The differences in PTH concentration among the three groups were not statistically significant (p = 0.513). Conclusions: Calprotectin values in the amniotic fluid in the early second trimester were higher in LGA fetuses compared to those in the SGA and AGA categories. LGA fetuses can possibly be in a state of low-grade chronic inflammation due to excessive fat deposition, causing oxidative stress in LGA fetuses and, eventually, the release of calprotectin. Moreover, PTH concentrations in the amniotic fluid of early second trimester pregnancies were not found to be statistically correlated with fetal growth abnormalities in either LGA or SGA fetuses. However, the early time of collection and the small number of patients in our study should be taken into account.

Information sharing and communication in management of large for gestational age babies in non‐diabetic mothers

Key content There is no specific UK guideline on how to identify or manage large for gestational age (LGA) fetuses in non‐diabetic mothers. There is conflicting evidence with regard to the optimal mode and timing of delivery in such women and babies in order to minimise the possible risks. Pre‐delivery patient–clinician discussion on management and mode of delivery in LGA babies can be challenging due to the lack of conclusive evidence and guidance for both screening and interventions, but it is crucial in order to facilitate information sharing, counselling and collaborative decision making. Decision‐making tools could help to facilitate these discussions and ensure ‘material risks’ are discussed. Learning objectives To be aware of the limitations of available methods for screening for LGA fetuses, specifically symphyseal fundal height and ultrasound estimation of fetal weight. To understand the lack of robust evidence for obstetric interventions, which makes it difficult to convey clear information in a practical and useful way. To consider the use of decision‐making tools (such as BRAIN and iDECIDE), which can provide a framework for shared decision making, particularly when the evidence is limited or conflicting. These tools offer a structure which empowers patients to weigh up information as well as assist clinicians in determining what is considered ‘material risk’ when counselling in line with the Montgomery ruling. Ethical issues The Montgomery ruling advises that doctors must discuss any ‘material risks’ involved in a proposed treatment and offer other reasonable alternatives. Clinicians, therefore, have a duty to be transparent about the lack of strong evidence to recommend one mode of birth over another but at the same time acknowledge that individual preference and perceptions need to be explored to enable personalised decision making.

Detection and Quantification of Neurotrophin-3 (NT-3) and Nerve Growth Factor (NGF) Levels in Early Second Trimester Amniotic Fluid: Investigation into a Possible Correlation with Abnormal Fetal Growth Velocity Patterns.

Abnormal fetal growth is associated with adverse perinatal and long-term outcomes. The pathophysiological mechanisms underlying these conditions are still to be clarified. Nerve growth factor (NGF) and neurotrophin-3 (NT-3) are two neurotrophins that are mainly involved in the neuroprotection process, namely promotion of growth and differentiation, maintenance, and survival of neurons. During pregnancy, they have been correlated with placental development and fetal growth. In this study, we aimed to determine the early 2nd trimester amniotic fluid levels of NGF and NT-3 and to investigate their association with fetal growth. This is a prospective observational study. A total of 51 amniotic fluid samples were collected from women undergoing amniocentesis early in the second trimester and were stored at -80 °C. Pregnancies were followed up until delivery and birth weight was recorded. Based on birth weight, the amniotic fluid samples were divided into three groups: appropriate for gestational age (AGA), small for gestational age (SGA), and large for gestational age (LGA). NGF and NT-3 levels were determined by using Elisa kits. NGF concentrations were similar between the studied groups; median values were 10.15 pg/mL, 10.15 pg/mL, and 9.14 pg/mL in SGA, LGA, and AGA fetuses, respectively. Regarding NT-3, a trend was observed towards increased NT-3 levels as fetal growth velocity decreased; median concentrations were 11.87 pg/mL, 15.9 pg/mL, and 23.5 pg/mL in SGA, AGA, and LGA fetuses, respectively, although the differences among the three groups were not statistically significant. Our findings suggest that fetal growth disturbances do not induce increased or decreased production of NGF and NT-3 in early second trimester amniotic fluid. The trend observed towards increased NT-3 levels as fetal growth velocity decreased shows that there may be a compensatory mechanism in place that operates in conjunction with the brain-sparing effect. Further associations between these two neurotrophins and fetal growth disturbances are discussed.

Risk of Stillbirth in Pregnancies Complicated by Diabetes, Stratified by Fetal Growth.

To compare stillbirth rates per week of expectant management stratified by birth weight in pregnancies complicated by gestational diabetes mellitus (GDM) or pregestational diabetes mellitus. A national population-based retrospective cohort study of singleton, nonanomalous pregnancies complicated by pregestational diabetes or GDM was performed using national birth and death certificate data from 2014 to 2017. Stillbirth rates per 10,000 patients (stillbirth incidence at gestational age week/ongoing pregnancies-[0.5×live births at gestational age week]) were determined for each week of pregnancy from 34 to 39 completed weeks of gestation. Pregnancies were stratified by birth weight, categorized as having small-for-gestational-age (SGA), appropriate-for-gestational-age (AGA), or large-for-gestational-age (LGA) fetuses, assigned by sex-based Fenton criteria. Relative risk (RR) and 95% CI for stillbirth were calculated for each gestational age week compared with the GDM-related AGA group. We included 834,631 pregnancies complicated by either GDM (86.9%) or pregestational diabetes (13.1%) in the analysis, with a total of 3,033 stillbirths. Stillbirth rates increased with advancing gestational age for pregnancies complicated by both GDM and pregestational diabetes regardless of birth weight. Compared with pregnancies with AGA fetuses, those with both SGA and LGA fetuses were significantly associated with an increased risk of stillbirth at all gestational ages. Ongoing pregnancies at 37 weeks of gestation complicated by pregestational diabetes with LGA or SGA fetuses had respective stillbirth rates of 64.9 and 40.1 per 10,000 patients. Pregnancies complicated by pregestational diabetes had an RR of stillbirth of 21.8 (95% CI 17.4-27.2) for LGA fetuses and 13.5 (95% CI 8.5-21.2) for SGA fetuses compared with GDM-related AGA at 37 weeks of gestation. The greatest absolute risk of stillbirth was in pregnancies complicated by pregestational diabetes at 39 weeks of gestation with LGA fetuses (97/10,000). Pregnancies complicated by both GDM and pregestational diabetes affected by pathologic fetal growth have an increased risk of stillbirth with advancing gestational age. This risk is significantly higher with pregestational diabetes, especially pregestational diabetes with LGA fetuses.

Bigger babies: what happens in real practice in a non-academic UK center? Detection accuracy and outcomes with induction.

There is emerging evidence of improved outcomes with induction of labour for pregnancies in which the baby is thought to be large. This trial identifies scan accuracy and the effect of intervention for pregnancies complicated by suspected large for gestational age (LGA) on customized chart outside an academic center. This is a retrospective cohort study of 3 groups of induced pregnancies; women with a suspected LGA fetus, women with diabetes (DM) and a control group (C) of women that underwent induction of labour on or after 280 days gestation. Data collection and analysis were prespecified. Scan accuracy and outcomes between the cohorts were compared. Over 1 year there were 845 cases: LGA (128), DM (116) and control cases (601). Mean birthweights differed significantly. PPV of EFW for birthweight >90th centile on GROW chart, WHO chart, and >4 kg was 0.35-0.40. Projected birthweight of >4 kg significantly better predicted itself (AUROC 0.70, 0.74 and 0.80). Mean scan error was -5.2% and +15.6% for DM and LGA. Shoulder dystocia and neonatal morbidity were not increased in LGA despite the significant increase in AVD 28/128, 21.9% vs. 99/601, 16.5%, aOR 2.20 (1.07-4.5). SVD was significantly less likely LGA vs. C at 69/128, 53.9% vs. 413/601, 68.7% aOR 0.38 (95% CI: 0.21-0.70). Third trimester EFW for bigger babies was poorly predictive of macrosomia. Fetal outcomes were good but women selected and induced as LGA had higher rates of hemorrhage and intervention.

The Presence of a Single Nuchal Cord in the Third Trimester May Not Affect Tei Index in LGA Fetuses

(1) Background: The aim of this study was to assess the RV (right ventricle) and LV (left ventricle) Tei index in large for gestational age (LGA) fetuses with a single 360-degree umbilical coil of the umbilical cord around the fetal neck identified by ultrasound in the third trimester of gestation. (2) Methods: The RV and LV Tei index for the cardiac function were measured in 297 singleton pregnancies, and we identified 25 LGA fetuses. There were 48% of LGA fetuses with a nuchal umbilical cord-LGA/NC-larger for gestational age fetuses with a nuchal cord. NC was detected with a color Doppler during a transverse scan of the fetal neck, when the umbilical cord formed a U shape. All fetuses had normal anatomy and normal uterine, placental, umbilical, intracardiac and cerebral Doppler waveforms values for their gestational age. (3) Results: The RV Tei index was significantly higher in the LGA subgroup vs. AGA (0.6 ± 0.2 vs. 0.50 ± 0.2; p value = 0.01), but in LGA fetuses with a single coil of the nuchal cord, there were not any significant changes in the Tei indexes. (4) Conclusions: The Tei index might not be impacted by the presence of the nuchal cord in LGA fetuses.

Does detection of a large for gestational age (LGA) fetus in fetal anomaly scan (FAS) require an early oral glucose screening test (OGTT) and can LGA fetus be detected at birth?

Gestational diabetes mellitus (GDM) complications increase with late diagnosis and late treatment, so early diagnosis and treatment is one of the most important factors in preventing complications. We tried to find an answer to the question of whether the detection of large for gestational age (LGA) fetus in fetal anomaly scan (FAS) requires earlier oral glucose screening test (OGTT) and predicts LGA fetus at birth. Pregnant women who underwent fetal anomaly scan and gestational diabetes screening at the Department of Obstetrics and Gynecology, University of Health Sciences, Tepecik Training and Research Hospital between 2018 and 2020 were included in this large retrospective cohort study. FAS was routinely performed between 18-22 weeks in our hospital. 75 grams of OGTT was used for gestational diabetes screening and it was performed between 24-28 weeks. This large retrospective cohort study was performed on 3,180 fetuses, 2,904 appropriate for gestational age (AGA) and 276 LGA, in the second trimester. The prevalence of GDM was significantly higher in the LGA group (OR 2.44, 95% CI 1.66-3.58; p < 0.001). Insulin requirement for blood glucose regulation was significantly higher in the LGA group (OR 3.6, 95% CI 1.68-7.7; p = 0.001). Fasting and 1st hour OGTT values were similar between the groups, but 2nd hour OGTT values were significantly higher in the second trimester LGA group (p = 0.041). The prevalence of LGA newborns at birth was higher in second trimester LGA fetuses than in fetuses with AGA (21.1% vs. 7.1%, p < 0.001). The fact that the estimated fetal weight (EFW) measured in the second trimester FAS is LGA may be related to GDM in the future and LGA fetus at birth. A more detailed GDM risk questioning should be performed to these mothers and OGTT should be considered when additional risk factors are detected. In addition to all these, glucose regulation may not be possible with diet alone in mothers who have LGA in the second trimester ultrasound and who may have GDM in the future. These mothers should be monitored more closely and more carefully.

Additional single third trimester ultrasound scan in detection of large for gestational age fetuses

To evaluate the accuracy of growth scans in the third trimester. To evaluate the accuracy of universal third trimester ultrasound scans in the detection of large for gestational age (LGA) fetuses. To investigate how universal ultrasound scans affect the delivery and outcomes. Universal third trimester screening for LGA recorded a 22% positive predictive value (PPV), and 96% negative predicted value (NPV). The sensitivity in most studies reaches around 70% or more, of all the LGA fetuses delivered, there are different studies for and against universal ultrasonic screening of LGA. Estimated fetal weight (>4 kg/90th centile) and abdominal circumference are the best predictors of LGA with nearly 70% sensitivity. One study reported that an antenatal ultrasonic diagnosis of LGA in a low risk population has a weak association with the incidence of shoulder dystocia or poor neonatal outcomes. Universal screening in the third trimester for LGAs is not cost effective. Low risk pregnancies constitute the majority of the pregnancy population. All low risk pregnancy women will only receive two routine scans throughout the whole pregnancy. There is no evidence at present that conclusively demonstrates that an additional scan at 36 weeks improves maternal and neonatal outcomes and is cost effective.

Obstetric ultrasonography as a screening tool for the diagnosis of GDM: Detection of raised AFI and large for gestational age fetus

Objective: To establish the role of determining increased amniotic fluid index (AFI) and large for gestational age (LGA) fetus on ultrasound for the screening of gestational diabetes mellitus (GDM). Study Design: Descriptive Observational study. Place and Duration: Department of Gynaecology and Obstetrics, Pakistan Railway Hospital, Rawalpindi from 1st September 2021 till 28th February 2022. Methodology: The pregnant women, between 20-30 weeks of gestation, suspected of having excessive AFI or LGA fetuses on routine clinical examination, were advised to have an obstetric ultrasound scan. AFI &gt; 20 cm or LGA on ultrasound (&gt;90th percentile for that gestation) were considered abnormal. These participants were then subjected to 75-gram Oral Glucose Tolerance test (OGTT). Based on OGTT, the sample population was divided into two groups at the post-stratification stage: with and without Gestational Diabetes Mellitus (GDM). Chi-square test was applied to compare the frequency of increased AFI and LGA between patients having GDM or not having GDM. Results: The study population (n=75) showed the frequency of LGA as 37.3 % and increased AFI as 65.3%. Women with increased AFI were at a significantly greater risk of GDM (65%), as compared to those with normal AFI (27%) with p-value of 0.002. Also, patients having LGA fetuses (60.7%) were at a greater risk of having GDM, as compared to those with normal weight fetuses (34%) with p-value of 0.024. Conclusion: Women with Increased AFI and LGA fetuses between 20-30 weeks of gestation are at a greater risk to develop GDM. Hence these ultrasound parameters can be used as reliable screening tools for the detection of GDM. Keywords: Adverse pregnancy outcome, Fetal macrosomia, Gestational diabetes mellitus, Increased Fetal weight, Polyhydramnios

Maternal diabetes independent of BMI is associated with altered accretion of adipose tissue in large for gestational age fetuses.

AimTo analyse the effects of maternal diabetes mellitus (DM) and body mass Index (BMI) on central and peripheral fat accretion of large for gestational age (LGA) offspring.MethodsThis retrospective study included LGA fetuses (n = 595) with ultrasound scans at early (19.23 ± 0.68 weeks), mid (28.98 ± 1.62 weeks) and late (36.20 ± 1.59 weeks) stages of adipogenesis and measured abdominal (AFT) and mid-thigh (TFT) fat as surrogates for central and peripheral adiposity. Women were categorised according to BMI and DM status [pre-gestational (P-DM; n = 59), insulin managed (I-GDM; n = 132) and diet managed gestational diabetes (D-GDM; n = 29)]. Analysis of variance and linear regressions were applied.ResultsAFT and TFT did not differ significantly between BMI categories (normal, overweight and obese). In contrast, AFT was significantly higher in pregnancies affected by D-GDM compared to non-DM pregnancies from mid stage (0.44 mm difference, p = 0.002) and for all DM categories in late stage of adipogenesis (≥ 0.49 mm difference, p < 0.008). Late stage TFT accretion was higher than controls for P-DM and I-GDM but not for D-GDM (0.67 mm difference, p < 0.001; 0.49 mm difference, p = 0.001, 0.56 mm difference, p = 0.22 respectively). In comparison to the early non-DM group with an AFT to TFT ratio of 1.07, the I-GDM group ratio was 1.25 (p < 0.001), which normalised by 28 weeks becoming similar to control ratios.ConclusionsDM, independent of BMI, was associated with higher abdominal and mid-thigh fat accretion in fetuses. Use of insulin improved central to peripheral fat ratios in fetuses of GDM mothers.

Obstetric consequences of a false‐positive diagnosis of large‐for‐gestational‐age fetus

ObjectiveTo compare delivery outcomes between true‐positive (TP) and false‐positive (FP) large‐for‐gestational‐age (LGA) fetuses, appropriate‐for‐gestational‐age (AGA) fetuses, and false‐negative (FN) LGA fetuses.MethodsRetrospective cohort study of singleton pregnancies at risk for macrosomia without contraindication to vaginal delivery, receiving an ultrasound scan at 34–37 weeks of pregnancy.ResultsIn all, 430 pregnancies were included: 155 TP LGA, 87 FP LGA, 177 AGA and 11 FN LGA newborns. Cesarean section rate during labor was significantly higher in FP LGA than in AGA (19% vs. 8.7%) but not significantly different between FP LGA and TP LGA (19% vs. 32.4%). Median birth weight z score was significantly higher in TP LGA (1.9) compared with the FP LGA and AGA (0.91 and 0.84, respectively), whereas no significant differences were found between FP LGA and AGA. Admission to a neonatal intensive care unit was significantly more frequent in TP LGA than AGA, whereas shoulder dystocia, postpartum hemorrhage, and third‐ to fourth‐degree perineal tears were similar between the different groups.ConclusionA false‐positive diagnosis of LGA fetus is associated with a significant increase of cesarean section during labor. Therefore, a suspicious ultrasound may result in reduction of the clinical threshold for the diagnosis of abnormal labor.

Maternal and fetal serum leptin levels and their association with maternal and fetal variables and labor: A cross-sectional study

BackgroundLeptin is a polypeptide hormone that may be implicated in the pathogenesis of various disorders during pregnancy. We sought to determine serum leptin levels among pregnant women and their fetuses and to investigate their association with fetal and maternal variables. Method452 pregnant women who attended to labor ward between January 2020 and August 2020 were included in the study. Serum leptin concentrations were measured using enzyme-linked immunosorbent assay method. Mann-Whitney U test and Spearman's correlation test were used for statistical analysis. A multivariate linear regression analysis was then performed. Significance level was considered at alpha <0.05. ResultsThe median maternal and fetal serum leptin levels were 6.42 [4.16–8.51] ng/mL and 2.9 [1.03–5.36] ng/mL respectively. There was no significant correlation between maternal and fetal serum leptin levels (p = 0.064). Maternal serum leptin levels correlated positively with maternal body mass index (BMI) (r = 0.117, p = 0.005). Besides, maternal serum leptin levels were significantly higher in nulliparous women (7.57 [4.45–9.30] ng/mL vs. 6.22 [4.02–8.30] ng/mL, p = 0.037) and in women who were in active labor (6.83 [4.39–8.92] ng/mL vs. 6.25 [4.04–8.30] ng/mL, p = 0.047). Fetal serum leptin levels were significantly higher in large for gestational age (LGA) fetuses (4.81 [2.13–7.22] ng/mL vs. 2.80 [0.96–5.16] ng/mL, p = 0.003) and in fetuses with preterm premature ruptures of membranes (PPROM) (5.23 [2.42–8.07] ng/mL vs. 2.86 [1.00–5.23] ng/mL, p = 0.021). ConclusionMaternal serum leptin levels were influenced by maternal BMI, parity and labor. Fetal serum leptin levels were higher among LGA fetuses and in fetuses with PPROM.

Intrapartum Fetal Electrocardiogram in Small- and Large-for-Gestational Age Fetuses.

This study aimed to evaluate whether intrapartum fetal electrocardiogram (ECG) tracings with ST-elevation or depression occur more frequently in each stage of labor in small-for-gestational age (SGA) or large-for-gestational age (LGA), as compared with appropriate-for-gestational age (AGA) fetuses. We conducted a secondary analysis of a large, multicenter trial in which laboring patients underwent fetal ECG waveform-analysis. We excluded participants with diabetes mellitus and major fetal anomalies. Birth weight was categorized as SGA (<10th percentile), LGA (>90th percentile), or AGA (10-90th percentile) by using a gender and race/ethnicity specific nomogram. In adjusted analyses, the frequency of ECG tracings with ST-depression or ST-elevation without depression was compared according to birthweight categories and labor stage. Our study included 4,971 laboring patients in the first stage and 4,074 in the second stage. During the first stage of labor, there were no differences in the frequency of ST-depression in SGA fetuses compared with AGA fetuses (6.7 vs. 5.5%; adjusted odds ratio [aOR]: 1.41, 95% confidence interval [CI]: 0.93-2.13), or in ST-elevation without depression (35.8 vs. 34.1%; aOR: 1.17, 95% CI: 0.94-1.46). During the second stage, there were no differences in the frequency of ST-depression in SGA fetuses compared with AGA fetuses (1.6 vs. 2.0%; aOR: 0.69, 95% CI: 0.27-1.73), or in ST-elevation without depression (16.2 vs. 18.1%; aOR: 0.90, 95% CI: 0.67-1.22). During the first stage of labor, there were no differences in the frequency of ST-depression in LGA fetuses compared with AGA fetuses (6.3 vs. 5.5%; aOR: 0.97, 95% CI: 0.60-1.57), or in ST-elevation without depression (33.1 vs. 34.1%; aOR: 0.80, 95% CI: 0.62-1.03); during the second stage of labor, the frequency of ST-depression in LGA compared with AGA fetuses (2.5 vs. 2.0%, aOR: 1.36, 95% CI: 0.61-3.03), and in ST-elevation without depression (15.5 vs. 18.1%; aOR: 0.83, 95% CI: 0.58-1.18) were similar as well. The frequency of intrapartum fetal ECG tracings with ST-events is similar among SGA, AGA, and LGA fetuses. · SGA and LGA neonates are at increased risk of cardiac dysfunction.. · Fetal ECG has been used to evaluate fetal response to hypoxia.. · Fetal ST-elevation and ST-depression occur during hypoxia.. · Frequency of intrapartum ST-events is similar among SGA, AGA and LGA fetuses..

Novel metabolic marker Afamin: A predictive factor for Large-for-Gestational-Age (LGA) fetus estimation in pregnancies with gestational diabetes mellitus?

Gestational diabetes mellitus (GDM) affects both maternal and fetal/infant outcomes during and after pregnancy. The reason for the high incidence of large-for-gestational-age (LGA) infants in GDM patients despite close monitorization of glucose levels with early detection of the disease remains unclear to date. Our study aims to investigate the levels of the third-trimester novel marker afamin in GDM versus non-GDM pregnancies in terms of glycemic control status and their utility in the prediction of LGA fetuses. This prospective case-control study analysis involved 49 pregnant women with GDM diagnosed using the 75-g oral glucose tolerance test (75-g OGTT) and 40 randomly selected women with a similar body mass index (BMI) and gestational age (GA). Blood samples were collected in the third trimester of pregnancy. The afamin level was determined using a human afamin ELISA kit according to the manufacturer's procedure. There was no significant difference found in BMI or GA of patients. Third-trimester afamin levels were 93.91 mg/L and 83.87 mg/L in the GDM and non-GDM groups, respectively (p=0.625). Afamin values of patients were not correlated with age, BMI, GA, HgA1c, 75-g OGTT fasting and 75-g OGTT 1-hour, or 75-g OGTT 2-hour values (p>0.05). GDM patients with LGA fetuses had significantly higher afamin values than patients with appropriate-for-gestational-age (AGA) fetuses (120.8 mg/L versus 91.26 mg/L, respectively). Between GDM patients with either LGA or AGA fetuses, there was no statistically significant difference found for age, BMI, GAs, insulin dose, 75-g OGTT results, or HgA1c values. Our findings conclude that novel marker afamin levels could predict the risk of LGA infants independently of glycemic control status and provide insight into the pathogenesis of LGA fetuses, thus helping to reduce the risk of associated complications.