Large For Gestational Age Fetuses Research Articles

2074928 Determining Fetal Adiposity in Utero Based on Sonographic Measurements of Fetal Buoyancy (Rate of Fetal Rise, RFR)

Accurate identification of pathologically large for gestational age (LGA) or small for gestational age (SGA) fetuses is clinically challenging; sonographic measurements tend to overestimate and underestimate the weights of suspected LGA and SGA fetuses, respectively. We sought to validate a new method for evaluating fetal weight in three groups of gravidae: those with an uncomplicated pregnancy, and those with suspected LGA or SGA. 34 gravidae with gestational age over 34 weeks were prosepectively enrolled. Routine biometry was performed and two sets of subcutaneous skin thickness were sonographically measured, alongside AFI and placental location and thickness. The fetus was then manually depressed downward and its ascent (rate of fetal rise (RFR)) was recorded in a clip. The rate of fetal rise was then calculated as a measure of frames, distance, and time. Postnatal anthropometry was completed, including PeaPod DEXA scanning in a subset of infants (n 10). Robustness of sonographic measurements to postnatal anthropometric measures were assessed by Pearson's, with linear regression for covariates. As shown in the table, there was no correlation between the RFR and infant birthweight. However, there were significant correlations between RFR and the neonate's BMI, Ponderal Index, and body fat percentage. Only 95% of sonographic measurements are within 20% of birthweight. Fetal buoyancy, as measured by the RFR, is a potentially promising new modality for predicting not only birthweight but also clinically relevant adiposity in the neonate.Tabled 1Pearson's correlation coefficients for rate of fetal rise against measures of neonatal adiposityMeasure of adiposityPearson's correlationSignificanceBody mass index0.3560.049Ponderal index0.3630.045Birth weight0.2820.124Fat mass0.3070.099Lean mass0.3380.067Body fat (%)0.3690.041 Open table in a new tab

Examination of the Impact of Maternal Weight Gain on Abnormalities of Fetal Growth in Women of Varying Body Mass Indices

Objective: To analyze the association between maternal weight gain and abnormalities of fetal growth. Methods: We calculated mean weight gain in pregnancies resultingin small for gestational age (SGA) or large for gestational age (LGA) fetuses, with normal growth as the referent. We classified pregnancies as to whether they had met, gained under or exceeded 2009 Institute of Medicine recommendations (IOMR) and evaluated the rate of SGA and LGA. Multivariateand linear regression analyses were performed. Results: We found similar weight gains in women with normal versus SGA fetuses, 10.5 versus 9.6 kg respectively, LGA fetuses had a significantly higher weight gain, 13.8 kg (p<0.01). We found higher rates of SGA in NW women who gained under versus met IOMR (17.5 versus 11.6%), but not in OW women (10 versus 12 %, p=0.58).Obese women had a higher rate of SGA when women gained under versus met IOMR (10.7 vs 5.0%, p=0.02), however once controlled for confounders, this association was no longer significant, aOR 1.23 (0.82-1.86).The rate of SGA in obese women who gained under IOMR, 10.7%, was less than the baseline risk of SGA in NW women, 11.6%,indicating loss of a protective effect in obese women. Conclusion: Weight gain in women who deliver normal weight fetuses and SGA fetuses is clinically similar, however in NW women there is a greater rate of SGA when weight gain is insufficient. This increase in SGA is not found in OW women, nor is it found in obese women, when adjusted for confounding variables. Any increase in SGA in obese women when they gain under IOMR appears to be secondary to a loss of a protective effect.

281: Large for gestational age and stillbirth: is there a role for antenatal testing?

Antenatal testing is a standard component in the management of the fetus with suspected growth restriction, but is not currently recommended for the large for gestational age (LGA) fetus. Our aim was to investigate the association between LGA and stillbirth (SB) to determine if the LGA fetus may benefit from antenatal testing.

Immunohistochemical localization of bilirubin oxidation in human placenta

Immunohistochemical localization of bilirubin oxidation in human placenta

Soluble Fas and Fas-ligand levels in mid-trimester amniotic fluid and their associations with severe small for gestational age fetuses: a prospective observational study

We aimed to determine the second-trimester amniotic fluid (AF) levels of soluble Fas (sFas) and Fas-ligand (FasL) and investigate their association with fetal growth. Therefore, sFas and FasL levels were measured by enzyme immunoassay in the AF of 21 small for gestational age (SGA), 13 large for gestational age (LGA), and 44 appropriate for gestational age (AGA) fetuses of pregnant women who underwent amniocentesis at between 15 and 22 weeks gestation. Our study results showed that sFas and FasL levels were detectable in AF. sFAS median (25th–75th centile) levels were 3.8 (2.8–4.6)ng/ml in SGA, 3.6 (3.1–4.5)ng/ml in AGA, and 4.0 (3.1–4.4)ng/ml in LGA. FasL median (25th–75th centile) levels were 26.0 (20.3–32.7)pg/ml in SGA, 22.7 (18.4–28.5)pg/ml in AGA, and 21.5 (15.8–30.9)pg/ml in LGA. The differences were not statistically significant. Nevertheless, statistically significant differentiation of FasL levels existed when SGA fetuses in the extremes of distribution (≤5th, ≤2.5th centile) were considered. This is the first study presenting sFas and FasL concentrations in early second-trimester amniotic fluid in AGA, SGA, and LGA fetuses. We found indications that severe and very severe SGA fetuses (≤5th and ≤2.5th centile) have high levels of FasL in the amniotic fluid. This finding probably reflects the increased rate of apoptosis that is assumed to exist in cases of extreme growth restriction.

Early Prediction of Macrosomia Based On an Analysis of Second Trimester Amniotic Fluid by Capillary Electrophoresis

To identify, using capillary electrophoresis and chemometrics, early biomarkers in human amniotic fluid of large-for-gestational-age (LGA) infants. Second trimester amniotic fluid samples, obtained from mothers undergoing age-related amniocentesis, were analyzed by capillary electrophoresis. Electropherogram data were aligned using correlation-optimized warping. A genetic algorithm using a Bayesian evaluation function and a leave-one-out cross-validation strategy for two birth outcomes: appropriate-for-gestational-age (AGA) versus LGA infants. LGA (n = 23) was differentiated from AGA (n = 86) with a sensitivity of 100% and a specificity of 98% using only two wavelets. The first wavelet is associated with albumin and the second wavelet with an unknown small molecule. The approach developed herein allows LGA fetuses to be metabolically distinguished from AGA fetuses early in pregnancy and indicates that the birth of a LGA infant is already associated with an altered biochemical profile by the second trimester.

Wisconsin Stillbirth Service Program: Analysis of large for gestational age cases

Since its inception in 1983, the Wisconsin Stillbirth Service Program (WiSSP) has reviewed over 2,600 referrals. Among 2,451 with fetal weight and gestational age recorded, 186 (7.6%) were large for gestational age (LGA), which is more than expected. We reviewed these cases to identify factors causing or contributing to fetal death as well as increased fetal size. LGA losses tended to occur later in pregnancy than non-LGA losses. The most common cause of death in LGA fetuses was fetal (43.5%), followed by placental (22.6%), and maternal (11.2%), which contrasts with previous studies involving the same database, but unselected for fetal weight, in which 21.5%, 40.0%, and 12.7% had fetal, placental, and maternal causes, respectively. The most common fetal cause was hydrops (60 cases/32.4%), which was most frequently idiopathic (16/26.6%), followed by cardiac (11/18.3%), Turner syndrome (8/13.3%), and twin-twin transfusions (6/10.0%). Placental causes, most commonly abruption and infarct, were more frequent in diabetic mothers, accounting for 33% versus only 18% in the entire LGA group. In the LGA group overall, 21% of mothers were diabetic, and most stillbirths in diabetic mothers occurred after 28 weeks. Despite large placentas (>95th centile) in 71.8% of the LGA cohort compared to 11% previously reported in the entire database, the most extreme LGA cases had a high fetoplacental ratio. We recommend pathologic evaluation of placentas from all stillbirths, close follow-up of pregnancies complicated by diabetes, and continued research into causes and pathophysiology of hydrops.

Lactate production as a response to intrapartum hypoxia in the growth‐restricted fetus

To analyse whether the increase in lactate in response to intrapartum hypoxia differs between small- (SGA), appropriate- (AGA) and large-for-gestational-age (LGA) fetuses. Observational cohort study. Ten obstetric units in Sweden. A cohort of 1496 women. A secondary analysis of a randomised controlled trial, in which 1496 women with fetal heart rate abnormalities, indicating fetal scalp blood sampling, were randomised to lactate analyses. After delivery, the neonates were divided according to birthweight for gestational age into SGA, AGA and LGA groups. Lactate concentration in fetal scalp blood. Acid-base balance in cord artery blood and Apgar score <7 at 5 minutes. Median lactate concentrations in the SGA, AGA and LGA groups were 3.8, 3.0 and 2.2 mmol/l, respectively (SGA versus AGA, P = 0.017; LGA versus AGA, P = 0.009). In the subgroups with scalp lactate >4.8 mmol/l (lactacidaemia), the corresponding median (range) values were 6.2 (4.9-14.6), 5.9 (4.9-15.9) and 5.7 mmol/l (5.0-7.9 mmol/l), respectively (no significant differences between the groups). The proportions of neonates with cord artery pH < 7.00, metabolic acidaemia or Apgar score <7 at 5 minutes were similar in all weight groups. SGA fetuses with fetal heart rate abnormalities have the same ability to produce lactate as a response to intrapartum hypoxia as AGA and LGA fetuses. The risk of a poor outcome associated with high lactate concentration is the same in SGA, AGA and LGA fetuses. Scalp blood lactate analysis is therefore a reliable method for intrapartum fetal surveillance of suspected growth-restricted fetuses scheduled for vaginal delivery at ≥ 34 weeks of gestation.

Can we really turn a blind eye to signs of diabetes in pregnancy?

IntroductionTo screen for gestational diabetes mellitus (GDM) NICE recommends a 75g oral glucose tolerance test (OGTT) at 24-28 weeks gestation only for non-diabetic women with specific risk factors. This excludes...

OP30.03: The Tei index in fetuses of diabetic mothers

Objectives: The Tei index is a useful Doppler index of combined systolic and diastolic function, calculated as isovolumic relaxation time plus isovolumic contraction time divided by ejection time. This study was focused on comparing the Tei index between normal fetus and fetuses of diabetic mothers (DMs). Methods: A prospective study was performed in a total of 68 fetuses. The study group underwent 2-dimensional/Doppler echocardiographic measurement of their Tei index. They included total 28 fetuses of diabetic mothers (DMs) (32–38 weeks of gestation). In this group, 18 fetuses were appropriate for gestational age (AGA), 6 fetuses were large for gestational age (LGA) and 4 fetuses were small for gestational age (SGA). Control group included total 40 fetuses (22–38 weeks of gestation). Results: In the control group, the mean Tei indices of left and right ventricles were 0.29 (0.10–0.56) and 0.31 (0.15–0.48), respectively. In the fetuses with DMs, the Tei indices of the left ventricles in AGA, and SGA fetuses were 0.310 (0.17–0.42) and 0.330 (0.28–0.38). Those of the right ventricle were 0.250 (0.10–0.44) and 0.35 (0.31–0.39). The left ventricular Tei indices in LGA fetuses with DMs were 0.490 (0.47–0.52). Those for the right ventricle were 0.530 (0.50–0.57). These values were significantly higher than the control (P < 0.001 for both ventricles). Conclusions: LGA fetuses from DMs who have an increased value of the Tei index may have abnormal myocardial performance. Tei index is a simple and useful parameter for the assessment of fetal both ventricular myocardial performance and is able to reflect fetal cardiac function.

Is the use of symphysis-fundal height measurement and ultrasound examination effective in detecting small or large fetuses?

SummaryWe investigated the accuracy of using symphysis pubis-fundal height measurement and ultrasonically derived estimation of fetal weight for identifying small-for-gestational-age (SGA) and large-for-gestational-age (LGA) fetuses. A retrospective cohort study was performed using computerised records of all non-diabetic women referred for an ultrasound growth scan (US) with clinically suspected SGA or LGA singleton fetuses from 35 weeks’ gestation between October 2008 and March 2009 (n = 185). Birth weight data were also collected for all births over the study period (n = 3200). One-third (34%) of ultrasound estimated fetal weights were inaccurate by >10%. However, an inaccurate ultrasound estimation did not significantly increase the likelihood of spontaneous or induced onset of labour or delivery by caesarean section. Most (79%) growth scans were performed on well-grown fetuses. The majority (80%) of SGA and LGA babies in our cohort were not identified by clinicians during routine antenatal care. From 3,200 live births, there were a total of 59 infants weighing <2,500 g or >5,000 g. Of these, only 12 had been referred for an ultrasound growth scan, indicating that abdominal palpation and fundal height measurement has a 20% sensitivity in detecting SGA or LGA fetuses. Of the 12, four were detected using ultrasound, indicating a 33% detection rate. Although ultrasound has a slightly higher sensitivity, neither clinical examination using fundal height measurements nor 3rd trimester ultrasound examinations are effective at detecting SGA or LGA fetuses.

Size matters – but how good are clinicians at identifying SFGA and LFGA fetuses?

Detection of the small for gestational age (SFGA) or large for gestational age (LFGA) fetus is important because they are associated with poor perinatal outcome. Ultrasound can be used to...

Ultrasonographic weight estimation in large for gestational age fetuses: A comparison of 17 sonographic formulas and four models algorithms

Objective. To evaluate the accuracy of different formulas and role of fetal parameters (cephalic, abdominal, femur) used for estimation fetal weight (EFW) in large for gestational age (LGA) fetus in diabetic and non-diabetic mothers.Methods. Seventeen formulas were assessed individually and clustered in four algorithms (X, Y, Z, W) on the basis of fetal biometric parameters using the mean absolute % error, standard deviation (SD), prediction within ±5%, ±10%, ±15% of error and introducing new variable hypotenuse test (HPT) that can sum up precision and accuracy of formulas employed. For predicting fetal macrosomia (BW ≥ 4200 g) a receiver-operating characteristic curve was constructed.Results. Warsof2 formula showed the lowest mean % error, SD and HPT (p < 0.01) with overall prediction ±5, ±10%, ±15% of birth weight in 68, 94 and 98%. The formulas that were only based on abdominal measurement (Warsof2, Hadlock1, Campbell) showed the best ability to identify fetal macrosomia. The X algorithm confirming primary role of abdominal circumference for EFW in diabetic mothers.Conclusions. Accuracy of EFW in LGA fetuses is attributable to the biometric parameters used. Our findings show that the best formulas for EFW are those which only consider the abdominal measurements, especially in diabetic mothers. The new variable that we propose (HPT) confirms this result.

Maternal Glycemia and Risk of Large-for-Gestational-Age Babies in a Population-Based Screening

OBJECTIVEGestational diabetes is a risk factor for large-for-gestational-age (LGA) newborns, but many LGA babies are born to mothers with normal glucose tolerance. We aimed to clarify the association of maternal glycemia across the whole distribution with birth weight and risk of LGA births in mothers with normal glucose tolerance.RESEARCH DESIGN AND METHODSWe undertook a population-based gestational diabetes screening in an urban area of Hungary in 2002–2005. All singleton pregnancies of mothers ≥18 years of age, without known diabetes or gestational diabetes (World Health Organization criteria) and data on a 75-g oral glucose tolerance test at 22–30 weeks of gestation, were included (n = 3,787, 78.9% of the target population). LGA was determined as birth weight greater than the 90th percentile using national sex- and gestational age–specific charts.RESULTSMean ± SD maternal age was 30 ± 4 years, BMI was 22.6 ± 4.0 kg/m2, fasting blood glucose was 4.5 ± 0.5 mmol/l, and postload glucose was 5.5 ± 1.0 mmol/l. The mean birth weight was 3,450 ± 476 g at 39.2 ± 1.2 weeks of gestation. There was a U-shaped association of maternal fasting glucose with birth weight (Pcurve = 0.004) and risk of having an LGA baby (lowest values between 4 and 4.5 mmol/l, Pcurve = 0.0004) with little change after adjustments for clinical characteristics. The association of postload glucose with birth weight (P = 0.03) and the risk of an LGA baby (P = 0.09) was weaker and linear.CONCLUSIONSBoth low and high fasting glucose values at 22–30 weeks of gestation are associated with increased risk of an LGA newborn. We suggest that the excess risk related to low glucose reflects the increased use of nutrients by LGA fetuses that also affects the mothers' fasting glucose.

Environmental rather than genetic fetal overgrowth: defining the difference and hints for diagnosis and management

Environmental rather than genetic fetal overgrowth: defining the difference and hints for diagnosis and management

Validation study of the capacity of the reference curves of ultrasonographic measurements of the umbilical cord to identify deviations in estimated fetal weight

The objective of this study was to evaluate the capacity of the cross-sectional area and diameter of the umbilical cord, and the area of Wharton's jelly (WJ), to predict abnormalities in estimated fetal weight (EFW) in 20-40 week, low-risk pregnancies. A validation study was performed in 1,828 pregnant women. Fetal weight was estimated by ultrasonography and classified as: small for gestational age (SGA), appropriate for gestational age (AGA) or large for gestational age (LGA) according to the 10th and 90th percentiles of the reference curve. Measurements of the parameters of the cord were used to classify it as thin, normal or thick using the 10th and 90th percentiles of the reference curves as limits. The capacity of the diameter and total area of the cord and the area of WJ to predict abnormal EFW was calculated for different gestational ages. The capacity of the diameter of thin cords to predict SGA fetuses (S =8.3%, PPV =16.5%) or thick cords to predict LGA fetuses (S =5.5%, PPV =30.1) was weak, similar to the capacity of the area of the umbilical cord to predict SGA (S =8.3%; PPV =16.3%) or LGA fetuses (S =5.5%; PPV =27.8%). The capacity of the area of WJ to predict SGA fetuses (S =5.7%, PPV =11.7%) was similar to its capacity to predict LGA fetuses (S =4%, PPV =27.1%). Despite the correlation between the diameter and cross-sectional area of the cord and EFW, these measurements were not found to be useful in predicting alterations in EFW and should not be used for this purpose.

Stillbirths and neonatal deaths in appropriate, small and large birthweight for gestational age fetuses

To compare the risk of stillbirth and neonatal death in small-for-gestational-age (SGA), appropriate-for-gestational-age (AGA) and large-for-gestational-age (LGA) fetuses and neonates. Retrospective analysis of 662 043 births and outcomes recorded in the Victorian Perinatal Data Collection Unit (1992-2002). Births in Victoria in 1992-2002. Multiple pregnancy and congenital birth defects. Births, stillbirths and neonatal deaths at each week of gestation after 23 weeks were stratified by birthweight into appropriate, small and large for gestational age. Stillbirth risk per 1000 ongoing pregnancies and neonatal death rate per 1000 live births were calculated. For the AGA group, the overall stillbirth risk was 2.88 per 1000 and neonatal death rate was 1.35 per 1000. In the LGA group, these were 2.62 and 1.83 per 1000, respectively. The slight increase in neonatal death rate among LGA fetuses was confined to those delivered after 28 weeks gestation. In the SGA group, the stillbirth risk and neonatal death rate were 15.1 and 3.99 per 1000, respectively. The risk of stillbirth per week of gestational age and neonatal death rates do not differ significantly between AGA and LGA fetuses and neonates. The SGA fetus is at significantly greater risk of both stillbirth and neonatal death, particularly with advancing gestational age.

Resultados preliminares do uso de anti-hiperglicemiantes orais no diabete melito gestacional

OBJETIVO: comparar a eficacia da glibenclamida e da acarbose com insulina no tratamento do diabete melito gestacional (DMG) em relacao ao controle glicemico materno, peso do recem-nascido (RN) e hipoglicemia neonatal. METODOS: trata-se de ensaio clinico randomizado, prospectivo e aberto. Foram incluidas 57 pacientes com diagnostico de DMG, que necessitaram de terapeutica complementar a dietoterapia e a atividade fisica. As gestantes foram aleatoriamente alocadas em um de tres grupos com terapeuticas diferentes: um grupo controle conduzido com insulinoterapia, outro com glibenclamida e outro com acarbose. O periodo do estudo foi de sete meses (1o de outubro de 2003 a 1o de maio de 2004). Os desfechos primarios avaliados foram o nivel glicemico materno apos o inicio do tratamento, a necessidade de troca de terapeutica para controle glicemico, peso do RN e presenca de hipoglicemia neonatal. A analise estatistica foi realizada pelo teste estatistico ANOVA, com nivel de significância de 5%. RESULTADOS: as caracteristicas maternas foram semelhantes nos tres grupos estudados. O controle glicemico nao foi obtido em tres pacientes que utilizaram glibenclamida (15%) e em sete das usuarias de acarbose (38,8%). Nao houve diferenca quanto a glicemia em jejum e pos-prandial e no peso medio do RN entre os tres grupos. A incidencia de fetos grandes para a idade gestacional foi de 5,2, 31,5 e 11,1% nos grupos tratados com insulina, glibenclamida e acarbose, respectivamente. A hipoglicemia neonatal ocorreu em seis RN, sendo quatro deles do grupo glibenclamida (21,0%). CONCLUSOES: a glibenclamida foi mais eficiente para o controle glicemico que a acarbose, mas ambos foram menos eficientes que a insulina. Os RN de pacientes alocadas no grupo glibenclamida apresentaram maior incidencia de macrossomia e de hipoglicemia neonatal quando comparados com os RN cujas maes receberam outros tratamentos.

Relationship between cerebroplacental Doppler ratio and birth weight in postdates pregnancies

To explore the relationship between cerebroplacental Doppler impedance index and birth weight in postdates pregnancies, and to evaluate the use of a combination of Doppler parameters and ultrasound biometry in the prediction of large-for-gestational age (LGA) fetuses at 41 weeks of gestation. The pulsatility indices of the umbilical (UA-PI) and middle cerebral (MCA-PI) arteries, the cerebroplacental pulsatility index ratio (CPR) and the estimated fetal weight (EFW) were obtained in a cohort of 181 ultrasound-dated pregnancies at 41 weeks' gestation, 2 days before induction of delivery. A regression equation was established and the correlation between umbilical artery impedance and different birth-weight centile groups was determined. A receiver-operating characteristics (ROC) curve was used to compare prediction of LGA fetuses using biometry alone with that using biometry and UA-PI. UA-PI was inversely related to EFW (Spearson's correlation coefficient rho = -0.28, P < 0.001). Logistic regression showed an independent contribution of UA-PI to the birth-weight estimation (birth weight = 1356.8 - 232.0 x UA-PI + 0.65 x EFW). On ROC curve analysis, the prediction of LGA with the regression equation was comparable to that using ultrasound biometry alone. UA-PI was inversely correlated to EFW, but the combination of ultrasound biometry and UA-PI compared with biometry alone showed similar prediction of LGA fetuses in postdates pregnancies. Further prospective trials on larger populations or groups with a higher prevalence of LGA fetuses would be needed to validate the use of the new formula.

The Tei index for evaluation of fetal myocardial performance in sick fetuses

Objective The Tei index is a useful, new, noninvasive Doppler index of combined systolic and diastolic function calculated by isovolumic relaxation time plus isovolumic contraction time divided by ejection time. Sick fetuses were evaluated with the Tei index. Methods The study group underwent two-dimensional/Doppler echocardiographic measurement of their Tei index and included 10 monochorionic diamniotic (MD) twin pairs with non-twin to twin transfusion syndrome (TTTS), 4 twin pairs with TTTS, 12 fetuses with intrauterine growth retardation (IUGR), 14 fetuses of diabetic mothers, 3 hydrops fetalis fetuses, 8 fetuses of mothers treated with a tocolytic agent, and 40 normal fetuses (control group). Results The Tei indices in the following groups were significantly higher than the control: recipient fetuses in TTTS, large for gestational age (LGA) fetuses of diabetic mothers, and fetuses with hydrops fetalis. Conclusion The Tei index may be a useful tool for the assessment of fetal cardiac status in a variety of sick fetuses. Recipient fetuses in TTTS, LGA fetuses of diabetic mothers, and hydrops fetalis fetuses may have abnormal myocardial performance. The Tei index readily provides early detection of diminished myocardial function, particularly ventricular dysfunction.