Maternal and neonatal complications of fetal macrosomia: systematic review and meta-analysis

Second-trimester anthropometric estimators of cesarean section: the agreement between body roundness index, body mass index, body fat percentage, and waist circumference

PURPOSE

To explore the relationships between second-trimester anthropometric obesity indicators and cesarean section (CS).

METHODS

A retrospective study was conducted at West China Second University Hospital, utilizing electronic health records from 15,304 pregnant women who received routine prenatal care and delivered between January 2021 and June 2022. Second-trimester anthropometric indicators, including body roundness index (BRI), body mass index (BMI), body fat percentage (BFP), and waist circumference (WC), were measured using bioelectrical impedance analysis (BIA). Logistic regression models were employed to assess the associations between these indicators and CS risk, with additional subgroup analyses based on maternal age and fetal sex.

RESULTS

The mean maternal age was 30.13 years. After adjusting for covariates, BRI (OR 1.22, 95%CI 1.15-1.30), BMI (OR 1.07, 95%CI 1.05-1.08), BFP (OR 1.03, 95%CI 1.02-1.04), and WC (OR 1.02, 95%CI 1.01-1.03) were all significantly associated with CS. Stratified analyses based on maternal age and fetal sex further confirmed these independent associations.

CONCLUSION

Second-trimester BRI, BMI, BFP, and WC were all significantly associated with CS risk, with BRI potentially demonstrating the strongest independent correlation. An integrated approach incorporating BMI and WC is recommended for CS risk, particularly in time-sensitive or resource-limited settings. The effect of anthropometric changes during pregnancy on CS may be explored in the future.

Integrating SHAP analysis with machine learning to predict postpartum hemorrhage in vaginal births

OBJECTIVE

This study aimed to develop a machine learning (ML) model integrated with SHapley Additive exPlanations (SHAP) analysis to predict postpartum hemorrhage (PPH) following vaginal deliveries, offering a potential tool for personalized risk assessment and prevention in clinical settings.

METHODS

We conducted a retrospective multicenter cohort study in Northeast China, including women who had vaginal deliveries at three tertiary hospitals from September 2018 to December 2023. Data were extracted from electronic medical records. The dataset was split into a training set (70%) and an internal validation set (30%) to prevent overfitting. External validation was performed on a separate dataset. Several evaluation metrics, including the area under the receiver operating characteristic curve (AUC), were used to compare prediction performance. Features were ranked using SHAP, and the final model was explained.

RESULTS

The XGBoost model demonstrated superior predictive accuracy for PPH, with an AUC of 0.997 in the training set. SHAP value-based feature selection identified 15 key features contributing to the model's predictive power. SHAP dependence and summary plots provided intuitive insights into each feature's contribution, enabling the identification of anomalies. The final model maintained high predictive power, with an AUC of 0.894 in internal validation and 0.880 in external validation.

CONCLUSION

This study successfully developed an interpretable ML model that predicts PPH with high accuracy. Future studies with larger and more diverse datasets are necessary to further validate and refine the model, particularly to assess its generalizability across different populations and healthcare settings.

Association of birthweight with all-cause and cause-specific premature mortality in the UK: A prospective cohort study

PURPOSE

We investigated the association between birthweight and all-cause and cause-specific premature mortality, and evaluated the effect modification by lifestyle factors.

METHODS

This prospective cohort study used data of participants aged 39-71 years from the UK Biobank in 2006-2010 and followed up till the end of 2022. Birthweight was classified into < 1.0 kg, 1.0-<1.5 kg, 1.5-<2.5 kg, 2.5-<4.0 kg, and ≥ 4.0 kg. Cox proportional-hazards models were used to estimate adjusted hazard ratios (aHR) and 95 % confidence intervals (CI) for premature mortality.

RESULTS

Of 221 848 participants, there were 6336 premature deaths (2148 cardiovascular, 624 respiratory, 3040 cancers, 524 other causes). Birthweight was nonlinearly associated with risks of all-cause, cardiovascular, and cancer-related mortality but the association was linear for respiratory and other-cause mortality. Compared to birthweight of 2.5-<4.0 kg, birthweight< 1.0 kg (aHR 1.36, 95 %CI 1.00-1.85) and ≥ 4.0 kg (1.10, 1.02-1.17) were associated with increased risks of all-cause mortality. A similar pattern was observed for cardiovascular mortality, with corresponding aHRs of 1.54 (1.02-2.49) and 1.16 (1.03-1.31) for birthweight of 2.5-<4.0 kg, and ≥ 4.0 kg, respectively. Birthweight≥ 4.0 kg was associated with increased risk of cancer-related mortality (1.11, 1.00-1.22). The mortality risks did not differ significantly across lifestyle scores (all P-interaction>0.05).

CONCLUSIONS

Both lower and higher birthweight were associated with increased risks of premature mortality from all causes and cardiovascular diseases, and higher birthweight was associated with increased risk of cancer-related mortality.

The Impact of Overweight and Obesity on Pregnancy: A Narrative Review of Physiological Consequences, Risks and Challenges in Prenatal Care, and Early Intervention Strategies

BACKGROUND

While substantial literature exists on the intersection of overweight/obesity (OWO) and pregnancy, much of it focuses on specific aspects, making it difficult to maintain an overview of clinically relevant factors for optimal care of OWO women throughout pregnancy.

OBJECTIVES

To provide a comprehensive synthesis of the existing literature, covering the full spectrum of clinically relevant information needed to manage OWO women from preconception to birth.

METHODS

For this narrative review a literature search was conducted on PubMed in January 2025. Eligible studies included full-text English articles with data from human subjects, with no restrictions on publication date.

FINDINGS

The impact of OWO on pregnancy is multifaceted, encompassing four interrelated themes: physiological consequences, emerging risks, challenges in prenatal care, and intervention strategies. OWO women exhibit differences in metabolic and inflammatory pathways compared to normal-weight women, reflected in altered laboratory tests. When managing gestational diabetes and preeclampsia, obesity-related characteristics must be considered. Clinicians need to be alert of obesity-mediated fetal complications, including overgrowth, malformations, stillbirth, and preterm birth, while navigating challenges in ultrasound measurements. Interventions during the preconception and prenatal periods provide key opportunities to optimize maternal weight and reduce the risk of long-term disease development.

CONCLUSION

The review's insights enhance clinical practice and call on researchers and policymakers to prioritize strategies that offer early counseling for obese pregnant women. These initiatives aim to optimize outcomes for both mother and child and contribute to combating the global obesity crisis.

Early Pregnancy Waist Circumference for Prediction of Fetal Macrosomia

Fetal macrosomia is associated with adverse short- and long-term outcomes for the mother and the child. Present models to predict fetal macrosomia cannot be used in all settings, and their precision could be improved. We assessed if waist circumference could replace or outperform weight for early pregnancy prediction of macrosomia. We included 5827 women in this population-based cohort study and assessed the influence of early pregnancy waist circumference and weight on the prediction of macrosomia with logistic regression analysis. We generated receiver operating characteristic (ROC) curves and calculated the area under the curve (AUC) to compare models, including waist circumference, weight, or neither of them. The odds of macrosomia increased with a larger waist circumference (adjusted odds ratio (AOR) 1.03 (95% Confidence Interval (CI) 1.02, 1.04)). For women with waist circumference between 80 and 88 cm the AOR was 1.41 (95% CI 1.09, 1.82) and women with waist circumference ≥ 88 cm had AOR 1.98 (95% CI 1.56, 2.53) for macrosomia. There was no difference in predictive capacity between waist circumference and weight in the macrosomia prediction model. The AUC was 0.75 (95% CI 0.72, 0.77) for waist circumference and 0.74 (95% CI 0.72, 0.77) for weight. The model that excluded waist circumference and weight had an AUC of 0.72 (95% CI 0.70, 0.75). The predictive capacity of the model including waist circumference was, however, higher than that of the model without waist circumference or weight (p < 0.001). In conclusion, waist circumference can replace weight in an early pregnancy macrosomia prediction model.

Fetal Birth Weight Prediction in the Third Trimester: Retrospective Cohort Study and Development of an Ensemble Model

Background

Accurate third-trimester birth weight prediction is vital for reducing adverse outcomes, and machine learning (ML) offers superior precision over traditional ultrasound methods.

Objective

This study aims to develop an ML model on the basis of clinical big data for accurate prediction of birth weight in the third trimester of pregnancy, which can help reduce adverse maternal and fetal outcomes.

Methods

From January 1, 2018 to December 31, 2019, a retrospective cohort study involving 16,655 singleton live births without congenital anomalies (>28 weeks of gestation) was conducted in a tertiary first-class hospital in Shanghai. The initial set of data was divided into a train set for algorithm development and a test set on which the algorithm was divided in a ratio of 4:1. We extracted maternal and neonatal delivery outcomes, as well as parental demographics, obstetric clinical data, and sonographic fetal biometry, from electronic medical records. A total of 5 basic ML algorithms, including Ridge, SVM, Random Forest, extreme gradient boosting (XGBoost), and Multi-Layer Perceptron, were used to develop the prediction model, which was then averaged into an ensemble learning model. The models were compared using accuracy, mean squared error, root mean squared error, and mean absolute error. International Peace Maternity and Child Health Hospital's Research Ethics Committee granted ethical approval for the usage of patient information (GKLW2021-20).

Results

Train and test sets contained a total of 13,324 and 3331 cases, respectively. From a total of 59 variables, we selected 17 variables that were readily available for the "few feature model," which achieved high predictive power with an accuracy of 81% and significantly exceeded ultrasound formula methods. In addition, our model maintained superior performance for low birth weight and macrosomic fetal populations.

Conclusions

Our research investigated an innovative artificial intelligence model for predicting fetal birth weight and maximizing health care resource use. In the era of big data, our model improves maternal and fetal outcomes and promotes precision medicine.

Characterization of the association between birth weight and severe postpartum hemorrhage in women with delivery at term

BACKGROUND

Macrosomia, classically defined by an arbitrary birthweight threshold, is associated with an increased risk of postpartum hemorrhage. However, some preliminary evidence suggests that lower birthweights may also be at increased risk. We hypothesized that birthweight, analyzed as a continuous variable, is significantly associated with the risk of severe postpartum hemorrhage, with the risk increasing not only at higher birthweights traditionally associated with macrosomia but also potentially at lower birthweights. This association was hypothesized to persist independently of confounding factors and may provide new insights into risk stratification and prevention strategies for severe postpartum hemorrhage.

OBJECTIVE

We tested and quantified the independent association between birthweight and severe postpartum hemorrhage in a nationwide contemporary population of women with singleton birth at term.

STUDY DESIGN

The data source was the French Enquête Nationale Périnatale (2021), a nationally representative population of all women who gave birth during 1 week in March 2021 in all maternity units in France (n=12,809). For this analysis, we included women with a live singleton birth ≥37 gestational weeks. Exposure was birthweight analyzed as a continuous variable. The primary outcome was severe postpartum hemorrhage, defined as a binary variable based on the presence of at least one of the following criteria: blood loss ≥1000 mL, embolization, surgical intervention, or blood transfusion. The association between birthweight and severe postpartum hemorrhage was tested by multivariate Poisson regression with stratification by parity because of significant interaction. Secondary analyses tested the association between macrosomia defined by thresholds of 3900 g (90th percentile of our study population) and 4000 g (the macrosomia threshold commonly used in the literature) and severe postpartum hemorrhage.

RESULTS

Among the 11,041 women included, the median birth weight was 3340 g and the 90th percentile was 3920 g. The overall incidence of severe postpartum hemorrhage was 2.7% (293/11,041; 95% confidence interval [2.4-3.0]) and increased from 1.5% for birth weights ≤2600 g to 10.3% for birth weights ≥4600 g. The association between birth weight and severe postpartum hemorrhage was linear, with an adjusted relative risk of severe postpartum hemorrhage of 1.29 (95% confidence interval 1.18-1.41) for each 200-g increase in birth weight for primiparous women and adjusted relative risk 1.09 (1.00-1.18, P value .043) for multiparous women. Birth weights >3900 g and 4000 g were associated with increased risk of severe postpartum hemorrhage for primiparous women (adjusted relative risk 2.62, 1.68-4.08; and 3.27, 2.02-5.32) and multiparous women (adjusted relative risk 1.70, 1.15-2.51; and 1.60, 1.03-2.51).

CONCLUSION

In women with singleton birth at term, the risk of severe postpartum hemorrhage increased linearly with birth weight, and more notably for primiparous women: 29% per each 200-g increase in birth weight vs 9% for multiparous women. This result underlines the limitations of macrosomia definitions and suggests that birth weight, and the associated maternal risks, should be considered along the entire weight distribution, rather than systematically dichotomized above an arbitrary threshold, in both research and clinical practice.

The Role of Accurate Estimations of Blood Loss and Identification of Risk Factors in the Management of Early Postpartum Hemorrhage in Women Undergoing a Cesarean Section

Objective: This study aimed to analyze and compare three different methods of estimated blood loss (EBL) assessment in conjunction with the exploration of risk factors associated with early postpartum hemorrhage (PPH) among women undergoing a cesarean section (CS). Methods: Women with a singleton pregnancy who underwent an elective/emergency CS were recruited for this prospective cross-sectional study. Early PPH was defined as a cumulative blood loss ≥1000 mL within the 24 h period following the delivery. Methods of EBL assessment included the following: (1) visual estimation by the surgeon (sEBL), (2) the evaluation of blood-soaked dressings (dEBL), and (3) implementation of a mathematical formula (fEBL). Results: In the study period, 21 cases of early PPH were identified and compared with 452 controls. Among the patients with a PPH, a significant increase in the surgery time (60 min. vs. 46 min., p = 0.001), fetal birthweight (3780 g vs. 3417.5 g, p < 0.01), the occurrence of uterine atony (61.9% vs. 2.2%, p < 0.001), and myomas (9.5% vs. 1.1%, p < 0.05) was noted. In both groups, dEBL and sEBL provided the highest and the lowest EBL values, respectively (PPH dEBL: 1230 mL vs. fEBL: 1173.3 mL vs. sEBL 1000 mL, p < 0.001; control dEBL: 652 mL vs. fEBL 604 mL vs. sEBL 600 mL, p < 0.001). A patient age of 31-34 years (OR 1.71; 95%CI: 1.19-2.44), overweight (OR 2.65; 95%CI: 1.87-3.76), obesity (OR 2.68; 95%CI: 1.71-4.21), emergency mode of CS (OR 4.06; 95%CI: 2.94-5.62), surgeon experience (resident OR 1.86; 95%CI: 1.27-2.7; assistant specialist OR 3.13; 95%CI: 2.15-4.55) and fetal macrosomia (OR 3.19; 95%CI: 2.14-4.74) were selected as significant risk factors of the PPH. Conclusions: In women with early PPH following a CS, both dEBL and fEBL provide comparable estimations of blood loss. An emergency-mode CS and fetal macrosomia are the strongest contributors to PPH among women undergoing a CS. A combination of different methods of EBL with the proper identification of risk factors of a PPH can lead to improvement in the clinical management of obstetric hemorrhage following the CS.

Concordance Between Estimated Fetal Weight by Ultrasound and Birth Weight and Its Association with Adverse Perinatal Outcomes

Objective: The aim of this study was to analyze the concordance between estimated fetal weight (EFW) and birth weight among ultrasound examinations with fetal biometry considered adequate and inadequate according to the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guidelines, and its association with adverse perinatal outcomes. Methods: This was a retrospective and cross-sectional study carried out in two centers, involving parturients who delivered between 37 and 41 weeks. The following parameters were evaluated: biparietal (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) measurement; EFW; the interval between the ultrasound and delivery; and the discrepancy between EFW and birth weight. A minimum of 140 participants were required to assess the association between EFW and birth weight. Results: A total of 305 ultrasound examinations were selected and divided into two groups: adequate (Group I n = 115) and inadequate (Group II n = 190) fetal biometry. The measurements of the cephalic pole (BPD + HC), AC, and FL were inadequate in 69.5% (132/190), 91.6% (175/190), and 72.1% (137/190) of participants, respectively. Group I had a lower gestational age at ultrasound examination (38.4 vs. 39.9 weeks, p < 0.001), a larger BPD measurement (93.9 vs. 91.6 mm, p = 0.001), a longer interval between ultrasound examination and delivery (3.8 vs. 2.0 days, p < 0.001), and a smaller discrepancy between EFW and birth weight (7.2 vs. 9.5%, p = 0.002) than Group II. In Group I, EFW was a strong significant predictor (AUC:0.94, 95%CI 0.85-0.99, p = 0.032) for identifying birth weight >4000 g. An EFW cut-off value of 4019.0 g was found to be a correct identifier for 85.7% of newborns with a birth weight >4000 g, with a false-positive rate of 13.7%. Group I had a lower risk of postpartum hemorrhage (7.0% vs. 15.8%, OR:0.39, 95%CI 0.17-0.90, p = 0.024) and composite adverse perinatal outcomes (13.0 vs. 23.3%, OR:0.49, 95%CI 0.26-0.94, p = 0.030) than Group II. In Group I patients, undergoing an ultrasound 7 days before delivery was an independent predictor of composite adverse perinatal outcomes [x2(1) = 4.9, OR:0.49, 95%CI: 0.26-0.94, R2 Nagelkerke:0.026, p = 0.030]. Conclusions: We observed a high rate of inadequate fetal biometry. There was poor concordance between EFW and birth weight. EFW was a strong significant predictor for identifying macrosomia. Ultrasound examination performed 7 days before delivery was an independent predictor of adverse perinatal outcomes.

Application Value of Two-Dimensional Ultrasound Combined With Three-Dimensional Power Doppler in the Prediction of Macrosomia in Early Pregnancy

OBJECTIVE

To investigate the value of two-dimensional (2D) ultrasound combined with three-dimensional power Doppler (3D-PD) in the prediction of macrosomia in early pregnancy.

METHODS

A total of 171 singleton pregnant women who underwent prenatal ultrasound examination at 11+0-13+6 weeks of gestation in the First Affiliated Hospital of Shihezi University from October 2021 to October 2022 were selected as the research subjects. They were followed up until delivery. Their general data and Doppler ultrasound parameters were recorded and analyzed. The differences in ultrasound data between the two groups were compared, and the receiver operating characteristic (ROC) curve was drawn to evaluate the parameters.

RESULTS

Compared with the normal group, the macrosomia group had significantly higher biparietal diameter, placental volume, and placental microvascular index (p < 0.05).

CONCLUSIONS

Increased placental vascular perfusion occurs in macrosomia during early pregnancy. The vascularization-flow index (VFI) had a high predictive value for macrosomia (AUC = 0.826), and 2D ultrasound combined with 3D-PD had the best predictive efficiency for macrosomia in early pregnancy (AUC = 0.926). Future studies should also consider combining maternal and fetal factors to predict macrosomia, to reduce the occurrence of adverse pregnancy outcomes.

Trends of Large for Gestational Age and Macrosomia and Their Mediating Effect on the Association Between Diabetes Mellitus and Obstetric Hemorrhage

This study aimed to determine the prevalence of large for gestational age (LGA) and macrosomia in China from 2012 to 2021 and explore if LGA and macrosomia mediate the relationship between diabetes mellitus in pregnancy (DIP) and obstetric haemorrhage. The overall annual change rate (ACR) was calculated, and stratification analysis was performed. Mediation analysis assessed the influence of LGA and macrosomia in the association between DIP and obstetric haemorrhage. The nationwide prevalence of LGA and macrosomia was 15.8% and 6.8%, respectively. The ACR for LGA was 0.71% (95% CI, 0.66%-0.76%); pre-2016, -0.44% (95% CI, -0.63% to -0.25%); post-2016, -0.29% (95% CI, -0.39% to -0.19%). The ACR for macrosomia was -1.17% (95% CI, -1.24% to -1.09%); pre-2016, -0.73% (95% CI, -1.03% to -0.43%); post-2016, -2.42% (95% CI, -2.59% to -2.26%). In western and rural area, the ACR for LGA was 1.94% (95% CI, 1.84%-2.05%) and 1.81% (95% CI, 1.73%-1.89%), and LGA was increasing among these women in the post-2016 period. About 7.0% of pregnant women had DIP, and the LGA and macrosomia prevalences among women with DIP were 23.7% and 10.0%, respectively. In the mediation analysis, the total excess risk associated with DIP on obstetric haemorrhage was approximately 0.21 and the proportion mediated by LGA and macrosomia was 12.10% and 11.81%, respectively. In rural areas, the proportion mediated by LGA and macrosomia was amplified to 18.34% and 16.40%. Macrosomia rates declined steadily, but LGA rates increased slightly in disadvantaged areas. LGA and macrosomia mediated the association between DIP and obstetric haemorrhage, and the mediating effect intensified in rural regions. Addressing LGA warrants management for at-risk fetuses.

Machine learning approaches for predicting fetal macrosomia at different stages of pregnancy: a retrospective study in China

BACKGROUND

Macrosomia presents significant risks to both maternal and neonatal health, however, accurate antenatal prediction remains a major challenge. This study aimed to develop machine learning approaches to enhance the prediction of fetal macrosomia at different stages of pregnancy.

METHODS

This retrospective study involved 500 pregnant women who delivered singleton infants at Beijing Tsinghua Changgung Hospital between December 2019 and July 2024. The training set comprised 208 cases of macrosomia and 208 non-macrosomia cases, with 84 additional cases used for external validation. A total of 23 candidate variables, including maternal characteristics, physical measurements, and laboratory tests were collected for feature selection. Seven algorithms were applied in combination with three sets of selected features, resulting in 21 fitted models. Model performance was evaluated via the area under the receiver operating characteristic curve (AUC), accuracy, precision, sensitivity, specificity, and F1-score.

RESULTS

Maternal height, pre-pregnancy weight, first-trimester weight, pre-labor weight, gestational age at birth, gestational weight gain, and the proportion of male neonates were significantly greater in the macrosomia group compared to non-macrosomia group in the training set (p < 0.05). The top five predictors for macrosomia were pre-labor weight, gestational weight gain, the Pre-labor Hb/First-trimester Hb ratio, first-trimester Hb, and maternal height. Logistic regression yielded the highest AUC values in the pre-pregnancy (0.790) and first-trimester (0.815) periods in the validation set, whereas the ensemble model achieved the highest AUC value of 0.930 before labor. SHapley Additive exPlanations (SHAP) analysis highlighted pre-labor weight, gestational age, gestational weight gain, first-trimester Hb, and neonatal sex as important factors for the prediction of macrosomia.

CONCLUSION

This is the first study to utilize machine learning with data from the pre-pregnancy, first-trimester, and pre-labor periods to predict macrosomia. The logistic regression model and the final ensemble model demonstrated strong predictive performance, offering valuable insights to improve pre-pregnancy counseling, antenatal assessment, and intrapartum decision-making.

Gestational diabetes mellitus in previous pregnancy associated with the risk of large for gestational age and macrosomia in the second pregnancy

Background

Since the implementation of China's new birth policy, the incidence of large for gestational age (LGA) and macrosomia associated with gestational diabetes mellitus (GDM) has increased. It remains unclear whether a history of GDM in a previous pregnancy raises the risk of LGA or macrosomia in Chinese women planning two or more pregnancies.

Aim

To analyze the association between previous GDM and the risk of LGA and macrosomia in second pregnancy.

Method

A retrospective study was conducted on a cohort of 3,131 women who had experienced two consecutive singleton births. The incidences of LGA and macrosomia in the second pregnancy were compared between women with and without previous GDM. The relationship between previous GDM and the occurrence of LGA and macrosomia was analyzed using multivariate logistic regression and stratified analysis.

Results

The incidence of LGA and macrosomia during the second pregnancy was significantly higher in women with previous GDM (22.67% and 10.25%, respectively) compared to those without prior GDM (15.34% and 5.06%, respectively) (P < 0.05). After adjusting for potential confounders, previous GDM was significantly associated with LGA (aOR: 1.511, 95% CI: 1.066-2.143) and macrosomia (aOR: 1.854, 95% CI: 1.118-3.076) in the second pregnancy. Stratified analysis revealed that these associations were present only in women without previous LGA, those with GDM, appropriate gestational weight gain (AGWG), non-advanced maternal age, and male newborns during the second pregnancy (P < 0.05). Compared to excessive GWG (EGWG), AGWG correlated with lower risks for LGA and macrosomia during the second pregnancy in women without prior GDM, an association not observed in those with previous GDM. Among women without previous GDM, if the pre-pregnancy BMI is normal, the risk of LGA and macrosomia is significant lower in AGWG compared with EGWG (P< 0.001), while this difference was no significant among women with prior GDM (P>0.05).

Conclusion

Previous GDM is strongly linked to LGA and macrosomia in subsequent pregnancies. However, this relationship is influenced by GWG, prior LGA history, fetal sex, and maternal age. Managing weight alone may not sufficiently reduce the risk of LGA or macrosomia for women with a history of GDM.

Mapping neonatal vulnerability using the Small Vulnerable Newborn (SVN) framework-secondary analysis of PRISMA Pakistan study

Background

Despite progress in global neonatal mortality, South Asia continues to lag behind in reducing neonatal deaths. The Small Vulnerable Newborn (SVN) framework has been proposed to integrate preterm birth (PT), small for gestational age (SGA), and low birth weight. However, there is lack of data on the burden and risk factors of SVN in Pakistan, a country which has one of the highest neonatal deaths globally. This study aimed to estimate the incidence of SVN, and identify risk factors among pregnant women in Pakistan.

Methods

This secondary analysis leverages data from PRISMA (Pregnancy Risk Infant Surveillance, and Measurement Alliance)-Pakistan. Women presenting ≤20 weeks gestation and, with birth weights recorded within 72 h post-delivery were analysed. Newborns were classified into categories of SVN. Multinomial and binomial regression models were used to examine associations between maternal characteristics and SVN categories, as well as neonatal mortality.

Findings

The overall incidence of SVN was 46% (n = 771) with Term + SGA being the most common category (n = 461, 27.5%), followed by PT + AGA (n = 210, 12.5%) and PT + SGA (n = 41, 2.5%). Maternal undernutrition (MUAC <23 cm) increased the risk of SVN by 17% (aRR 1.17, 95% CI 1.05-1.31). SVN also emerged as a significant predictor of neonatal mortality, quadrupling the risk (aRR 4.52, 95% CI 2.42-8.46).

Interpretation

This study adds to the growing body of evidence on Pakistan's alarming burden of SVN, with every second newborn at risk. Identification and targeted interventions are imperative to mitigate adverse birth outcomes and optimize child growth and development.

Funding

No funding was received for this secondary data analysis.

The Link Between Newborn SNP Polymorphism rs266729, Adiponectin, and Newborn Macrosomia in a Cohort of Pregnant Women with Gestational Diabetes Mellitus: A Case-Control Pilot Study

BACKGROUND

Gestational diabetes mellitus (GDM) is linked to higher newborn weight and an increased risk of macrosomia. The newborn single-nucleotide polymorphism (SNP) of the ADIPOQ gene rs266729 is linked to a higher birth weight of the offspring of healthy pregnant women.

OBJECTIVES

This study aims to evaluate the relationship between newborn ADIPOQ rs266729 polymorphism, cord blood adiponectin, maternal glycemic and lipid metabolism, and maternal adiponectin levels at 24 to 28 weeks of gestation (WG) and at birth and its impact on newborn weight in a cohort of GDM mothers.

MATERIALS AND METHODS

This study involved 71 women diagnosed with GDM and 142 control pregnant women. The ADIPOQ (rs266729) gene polymorphisms were genotyped using TaqMan real-time PCR analysis. Maternal and cord blood adiponectin levels were measured using human total adiponectin ELISA kits. We performed a Pearson correlation analysis to identify significant correlations between maternal metabolic parameters and adiponectin levels at 24-28 WG and birth and the weight of newborns. A logistic regression analysis was also conducted to identify potential macrosomia predictors.

RESULTS

We found no significant differences in the distribution of the allele (C, G) (p = 0.82) and genotype (CC, CG, GG) (p = 0.46) of APIPOQ rs266729 among normoponderal and macrosomic newborns from the GDM mothers group. Maternal fasting glucose at 24-28 WG was higher in the GDM mothers who gave birth to macrosomic newborns (106 ± 17 vs. 93 ± 10 mg/dL, p < 0.0001). Adiponectin levels in the cord blood of newborns from mothers with GDM were lower than those in newborns from control mothers (p < 0.0001). In correlation analysis, we identified a weak positive correlation between the newborn weight of GDM mothers and cord blood adiponectin (r = 0.262), maternal fasting glucose level at 24-28 WG (r = 0.288), and maternal adiponectin level at birth (0.334). Multivariate logistic regression, after adjusting for confounders, revealed that maternal fasting glucose levels at 24-28 WG had an OR of 11.59, and cord blood adiponectin levels had an OR of 30.31 for macrosomia.

CONCLUSIONS

The preliminary findings of our pilot study suggest that in the gestational diabetes mellitus group, the ADIPOQ rs266729 polymorphism in newborns is not associated with a higher birth weight, maternal fasting glucose levels between 24 and 28 WG were a predictor for macrosomia, and cord blood adiponectin levels were lower than those from control mothers. Further large-scale studies are needed to confirm our findings.

Vaginal versus caesarean delivery in fetal macrosomia-a retrospective cohort study

OBJECTIVE

The aims of this study were to determine the incidence of macrosomic births over a 5-year period and to examine the childbirth complications for both mother and newborn.

PATIENTS AND METHODS

During the study period there were a total of 16,126 deliveries, of which 1905 were macrosomic fetuses (defined as those with a birthweight of 4000 g or more). Data on the course of pregnancy and childbirth were collected from existing maternal and peripartum medical records. Patients were divided into two groups: those who delivered vaginally and those who delivered by caesarean section. The groups were compared in terms of obstetric, fetal, and neonatal data as well as perinatal outcomes.

RESULTS

We included 1905 women in the study, 1286 (67.5%) with vaginal delivery and 619 (32.4%) with caesarean section. Primiparous women more frequently delivered by caesarean section, whereas multiparous women more commonly delivered vaginally (p < 0.00001). Male fetuses were significantly more prevalent in both examined groups. Risk factors for fetal macrosomia, such as gestational diabetes, maternal obesity, pregnancy-induced hypertension, polyhydramnios, and multiparity, were significantly more prevalent in the group with caesarean section (p < 0.00001). Delivery complications such as dorsoposterior presentation of the fetal head; fetal asphyxia, dystocia, and cephalopelvic disproportion; and uterine rupture were statistically significantly more frequent with caesarean section CONCLUSION: Our data show that caesarean deliveries for fetal macrosomia were associated with more maternal and neonatal complications than vaginal deliveries.

Gestational Diabetes Mellitus Affects the Risk of Obstetric Anal Sphincter Injury: A Systematic Review and Meta-Analysis of Cohort Studies

INTRODUCTION AND HYPOTHESIS

High birth weight increases the risk of obstetric anal sphincter injury. Macrosomia is a well-known complication in pregnancies complicated by gestational diabetes mellitus. The aim of this study was to investigate whether gestational diabetes is a risk factor for obstetric anal sphincter injury. We hypothesized that women with gestational diabetes have an increased risk of obstetric anal sphincter injury.

METHODS

We performed a systematic review and meta-analysis using the PubMed and Embase databases. Studies including numbers on women with and without gestational diabetes and with and without obstetric anal sphincter injury were included. Studies were assessed using the SIGN-methodology checklist to evaluate the quality and risk of bias. Extracted data was analyzed using RevMan 5.4 and the statistical software R.

RESULTS

Twelve cohort studies were included for the meta-analyses. Overall, we found a slightly increased prevalence of obstetric anal sphincter injury among the women with gestational diabetes of 2.40% (95% CI; 2.37-2.43) compared to 2.31% (95% CI; 2.30-2.32) in women without diabetes. The meta-analysis revealed increased risk of obstetric anal sphincter injury in the gestational diabetes-group (RR 1.24 [95% CI; 1.12-1.37]) with a high level of heterogeneity (I2 = 94%). Primiparous women with gestational diabetes had an increased risk of obstetric anal sphincter injury 6.65% (95% CI; 6.18-7.14) compared to 4.98% (95% CI; 4.89-5.08) in the control group, whereas the risk was not significantly increased in multiparous women.

CONCLUSIONS

The risk of obstetric anal sphincter injury is increased in primiparous women with gestational diabetes mellitus compared to women without gestational diabetes.

Fetal size monitoring in women with gestational diabetes and normal glucose tolerance

AIMS

To monitor fetal size and identify predictors for birthweight in women with gestational diabetes (GDM) and normal glucose tolerance (NGT).

METHODS

Cohort study of 1843 women universally screened for GDM, with routine ultrasounds each trimester. Women with GDM and NGT were categorized in subgroups by birthweight centile.

RESULTS

Of the total cohort, 231 (12.5%) women were diagnosed with GDM. Fetal size, incidence of large-for-gestational age (LGA: 12.3% of GDM vs. 12.9% of NGT, p = 0.822) and small-for-gestational age (SGA) neonates (4.8% of GDM vs. 5.1% of NGT, p = 0.886) were similar between GDM and NGT. GDM women with LGA neonates were more insulin resistant at baseline and had more often estimated fetal weight (EFW) ≥ P90 on the 28-33 weeks ultrasound (p = 0.033) than those with AGA (appropriate-for-gestational age) neonates. Compared to NGT women with AGA neonates, those with LGA neonates were more often obese and multiparous, had higher fasting glycemia, a worse lipid profile, and higher insulin resistance between 24 -28 weeks, with more often excessive gestational weight gain. On the 28-33 weeks ultrasound, abdominal circumference ≥ P95 had a high positive predictive value for LGA neonates in GDM (100%), whereas, in both GDM and NGT, EFW ≥ P90 and ≤ P10 had a high negative predictive value for LGA and SGA neonates (> 88%), respectively.

CONCLUSIONS

There were no differences in fetal size throughout pregnancy nor in LGA incidence between GDM and NGT women. EFW centile at 28-33 weeks correlated well with birthweight. This indicates that GDM treatment is effective and targeted ultrasound follow-up is useful. TRIAL REGISTRATION CLINICALTRIALS.GOV: NCT02036619. Registration date: January 15, 2014. https://clinicaltrials.gov/ct2/show/NCT02036619 .

Epidemiology of Macrosomia in Saudi Arabia: An Analysis of 12,045 Pregnancies from the Riyadh Mother and Baby Multicenter Cohort Study (RAHMA) Database

OBJECTIVE

To investigate the prevalence, risk factors, and complications associated with delivering macrosomic babies.

METHODS

Singleton term pregnancies (12,045) were studied. Macrosomia was categorized using the following two definitions: birthweight > 4 kg and birthweight ≥ 90th percentile (3.7 kg). Regression models were developed to identify significant risk factors for macrosomia such as maternal age, parity, pre-pregnancy body mass index, gestational weight gain, and hyperglycemia. Other models were constructed to identify the independent effect of macrosomia on outcomes such as shoulder dystocia, emergency cesarean section, stillbirth, and low APGAR scores.

RESULTS

The 50th centile birth weight of Saudi term infants is 3.18 kg; the 90th and 95th centiles were 3.70 and 3.91 kg, respectively. The prevalence of macrosomia (>4 kg) was 3.4%. The likelihood of macrosomia was associated with maternal age >40 years for newborns >4 kg, OR = 1.88, 95% CI (1.02-3.48), and maternal age < 18 for newborns ≥90th centile, OR = 5.23, 95% CI, (1.05-26.06). Regardless of the classification of macrosomia, it was associated with gestational age ≥41 weeks, parity > 4, pre-pregnancy BMI > 30, and maternal hyperglycemia. Macrosomia, using either definition, was associated with increased risk of shoulder dystocia, OR = 11.45, 95% CI (4.12-31.82) and OR = 9.65, 95% CI (3.89-23.94), and emergency CS, OR = 2.03, 95% CI (1.36-3.08) and OR = 1.77, 95% CI (1.34-1.52), for birthweight > 4 kg and ≥90th centile, respectively. Furthermore, newborns whose weights >4 kg were at greater risk to be stillborn, OR = 4.24, 95% CI (1.18-15.20), and to have low APGAR scores at birth, OR = 3.69, 95% CI (1.25-10.98).

CONCLUSION

The risk of macrosomia among Saudi women significantly increases with maternal age, parity, gestational age, hyperglycemia, and pre-pregnancy obesity. Regardless of the definition used, delivering a macrosomic baby was associated with risks of shoulder dystocia and emergency cesarean section. Newborns (>4 kg) were at greater risk of stillbirth and low APGAR scores.

Triglyceride-glycaemic index: Insights into predicting fetal macrosomia and its interaction with gestational diabetes mellitus: A cohort study of Chinese pregnant women

OBJECTIVE

This study investigates the association between a new insulin resistance indicator, the triglyceride-glucose (TyG) index, and the risk of macrosomia.

DESIGN

This is a prospective cohort study.

METHODS

This study included 1332 women who delivered at Peking University International Hospital between October 2017 and August 2019. Participants were divided equally into three groups based on the TyG index. Logistic regression and restricted cubic spline (RCS) analyses were used to evaluate the relationship between the TyG index and macrosomia and conducted subgroup analyses. The TyG index's ability to predict macrosomia was assessed using the receiver operating characteristic (ROC) curve.

RESULTS

Multivariable logistic regression analysis revealed that the TyG index is an independent risk factor for macrosomia (Odds ratio [OR] 1.84, 95% confidence interval [CI] 1.02-3.30, p < .05). RCS analysis indicates that the risk of macrosomia increases with the rise of the TyG index (p for nonlinearity <.001) when the TyG index is >6.53. Subgroup analysis showed a synergistic additive interaction between the TyG index and gestational diabetes mellitus (GDM) of macrosomia. The area under the ROC curve for the predictive model was 0.733 (95% CI 0.684, 0.781), with a sensitivity of 76.4% and specificity of 66.9%. Incorporating the TyG index alongside traditional risk factors notably enhances macrosomia prediction (p < .05).

CONCLUSIONS

The TyG index independently predicts macrosomia, and exhibits an additive interaction with GDM in its occurrence. Integrating the TyG index with traditional risk factors improves the prediction of macrosomia.

TRIAL REGISTRY

Clinical trials. gov [NCT02966405].

The Impact on Birth Outcomes of Sonographic Fetal Weight Estimation in Neonatal Macrosomia

OBJECTIVE

 Our objective was to examine the association between sonographic estimated fetal weight (EFW) and obstetrical and neonatal outcomes in women with neonatal macrosomia.

STUDY DESIGN

 This study, conducted at a tertiary university-affiliated hospital from 2017 to 2021, compared obstetrical and neonatal outcomes between two groups of women who delivered macrosomic newborns (actual birth weight ≥ 4,000 g): (1) those with EFW ≥ 3,800 g (suspected impending macrosomia) and (2) those with EFW < 3,800 g (unsuspected impending macrosomia).

RESULTS

 During the study period, 854 women with neonatal macrosomia attempted vaginal delivery. Only 9.2% had a sonographic EFW ≥ 4,000 g. Among women with EFW ≥3,800 g (n = 317) compared with EFW < 3,800 g (n = 537), the cesarean delivery (CD) rate was higher (17.0 vs. 10.5%, p = 0.004) and the operative delivery rate was lower (3.2 vs. 0.6%, p = 0.015). Among primiparous women, the CD rate was higher among those with EFW ≥ 3,800 versus <3,800 g (37.3 vs. 23.2%, p = 0.033). EFW ≥3,800 g was associated with CD, regardless of predelivery body mass index, parity, diabetes mellitus, maximal fetal weight at previous deliveries, actual birth weight, and labor induction (p = 0.014). EFW ≥3,800 g and diabetes mellitus were independent predictors of CD. Among women with EFW ≥3,800 g and diabetes mellitus, the risk of CD was double that of those without diabetes and with EFW ≥ 3,800 g (31.4% vs. 15.2%, p = 0.02), although their actual birth weights were similar. Obstetrical and neonatal outcomes were similar between those with sonographic EFW ≥3,800 and < 3,800 g.

CONCLUSION

 Larger EFW increased CD risk among pregnancies with actual neonatal macrosomia. Antenatally suspected macrosomia might alter labor management due to concerns for potential complications, especially when associated with primiparity, diabetes mellitus, or maternal obesity. The increase in the CD rate did not show an association with improved maternal and neonatal outcomes.

KEY POINTS

· Antenatally suspected macrosomia might alter labor management due to concerns about complications.. · Larger EFW increased cesarean delivery risk among pregnancies with actual neonatal macrosomia.. · The increase in the cesarean delivery rate was not associated with improved outcomes..

Untargeted Lipidomic Profiling of Amniotic Fluid Reveals Dysregulated Lipid Metabolism in Healthy Normal-Weight Mothers with Fetal Macrosomia

BACKGROUND

Alterations in maternal lipid metabolism have been elucidated by several studies in relation to macrosomia. However, the lipidome of the intrauterine compartment associated with macrosomia, particularly in early pregnancy, remains largely unknown.

OBJECTIVES

(1) To compare the lipidomic profile of early 2nd trimester amniotic fluid (AF) of healthy mothers with normal body mass index who gave birth to large-for-gestational age (LGA) versus appropriate-for-gestational age (AGA) infants; and (2) to examine if insulin and glucose concentrations in AF were associated with the AF lipidomic profile.

METHODS

In this nested case-control study, bio-banked AF samples were collected from pregnant women undergoing routine amniocentesis at 12-22 weeks of gestation. A subsample of 15 LGA infants (cases) were contrasted with 15 AGA infants (controls). An untargeted lipidomics analysis using liquid chromatography quadrupole time-of-flight mass spectrometry was conducted. Univariate and multivariate statistical analyses (principal component analysis and partial least-squares discriminant analysis) were used to extract differentially abundant (DA) features with high variable importance in projection (VIP) scores.

RESULTS

LGA AF was characterized by elevations of 30 phosphatidic acid species. Among other DA features, sphingomyelin (SM 14:0;O2/20:1) had the highest VIP score and was markedly elevated in LGA AF. Neither insulin nor glucose was associated with 2nd trimester AF lipidomic profiles in these healthy, normal-weight mothers.

CONCLUSION

These findings provide evidence of early dysregulated lipid metabolism in healthy, normal-weight mothers with LGA infants.

Confluence of newborn's sex and their mother's characteristics resulting in fetal macrosomia among Indian neonates

BACKGROUND

A newborn's birth weight ≥4000 g is defined as fetal macrosomia, which is recognized as a reproductive and serious child health concern.

OBJECTIVES

Our study aims to reveal existence of any connection between maternal factors and newborn sex in giving birth to newborn ≥4000 g in an Indian context.

METHODS

Data were drawn from the fifth round of National Family Health Survey (NFHS-5). A cross-sectional observational study was carried out with a total of 152,827 children born to women in reproductive age group (15-49) who had most recent live birth in the five years preceding the survey. Descriptive analyses, cross-tabulation, test of association and multivariate logistic regression analyses were performed.

RESULTS

In India, the prevalence of macrosomia was found in 3.8% of the total study participants. Considering newborn characteristics, fetal macrosomia was more prevalent among male neonates than female (AOR: 0.730; 95% CI: 0.687-0.775). Regarding maternal characteristics, overweight (AOR: 1.468; 95% CI: 2.042-2.559) and obese (AOR: 2.764; 95% CI: 2.394-3.192) motherswith gestational diabetes (AOR: 1.731, 95% CI: 1.385-2.164) and hypertension (AOR: 1.288, 95% CI: 1.116-1.488) were more likely to giving birth of macrosomic babies. Multiparous mothers (AOR: 1.207, 95% CI: 1.128-1.293) and women who did not undergo proper antenatal care (ANC) follow up had also greater risk of developing fetal macrosomia. Muslim women (AOR: 1.223, 95% CI: 1.119-1.338), and women belonging to a tribe (AOR: 1.476, 95% CI: 0.922-2.361) were significantly associated with the risk of having newborn ≥4000 g.

CONCLUSION

Emphasis should be given on counseling for mothers for desired weight management before and during pregnancy, gestational diabetes and hypertension screening, physical activity during pregnancy, adequate ANC follow up and balanced dietary intake among pregnant women.

Is vaginal birth after cesarean section a risk factor for obstetric anal sphincter injury?

OBJECTIVE

To investigate whether women undergoing their first vaginal delivery after a previous cesarean section (secundiparous) are at increased risk for obstetric anal sphincter injury (OASI) compared with primiparous women.

METHODS

A retrospective cohort study of 85 428 women who delivered vaginally over a 10-year period in a single tertiary medical center. Incidence of OASI, risk factors, and clinical characteristics were compared between primiparous women who delivered vaginally and secundiparous women who underwent their first vaginal birth after cesarean section (VBAC). A multivariable logistic regression analysis was used to study the association between VBAC and OASI.

RESULTS

Overall, 36 250 primiparous and 1602 secundiparous women were enrolled, 309 of whom had OASI. The rates of OASI were similar among secundiparous women who had VBAC and primiparous women who underwent vaginal delivery (15 [0.94%] vs 294 [0.81%], P = 0.58). The proportions of third- and fourth-degree tears were also similar among secundiparous and primiparous women who experienced OASI (87% vs 91.5%, and 13% vs 8.5%, respectively, P = 0.68). Furthermore, the rates of OASI were similar in both study groups, although secundiparous women who underwent VBAC had higher rates of birth weights exceeding 3500 g (414 [25.8%] vs 8284 [22.8%], P = 0.016), and higher rates of vacuum-assisted deliveries (338 [21%] vs 6224 [17.2%], P < 0.001). A multivariate logistic regression analysis failed to establish a statistically significant association between VBAC and OASI (odds ratio 0.672, 95% confidence interval 0.281-1.61, P = 0.37).

CONCLUSIONS

No increased risk for OASI was found in secundiparous women who underwent VBAC compared with primiparous women at their first vaginal birth.

Gestational diabetes mellitus management according to ultrasound fetal growth versus strict glycemic treatment in singleton pregnancies: A systematic review and meta-analysis of clinical trials

AIM

The objective of this meta-analysis was to evaluate obstetric outcomes in gestational diabetes mellitus (GDM) patients treated with flexible management based on intrauterine ultrasound fetal growth (FMIUFG) or strict maternal glycemic adjustment (SMGA).

METHODS

We performed a comprehensive systematic review of electronic databases for randomized clinical trials (RCTs) comparing obstetrics outcomes of singleton GDM patients managed according to FMIUFG or SMGA. The review protocol was registered in PROSPERO (CRD497888). Searches were conducted in PubMed, Embase, Cochrane, and LILACS. Primary outcomes were gestational age at delivery and birth weight. Random-effect model meta-analyses were used to minimize the effects of uncertainty associated with inter-study variability. Results are reported as standardized mean differences (SMDs) or as odds ratios (ORs) and their 95% confidence interval (CI). Heterogeneity between studies was estimated using the I2 statistic. The Cochrane Risk of Bias Scale was used to assess the quality of studies. There were five RCTs with low to moderate risk of bias, including 450 patients managed according to the FMIUFSG and 381 according to the SMGA.

RESULTS

The macrosomia (birthweight >4000 g) rate was lower in pregnancies managed according to FMIUFG than SMGA adjustments (OR: 0.34; 95%CI: 0.16, 0.71). There were no significant differences in hypertensive disorder, cesarean section, neonatal intensive care unit admission, and large newborn for gestational age rates.

CONCLUSIONS

The macrosomia rate was lower in women managed with the FMIUFG. There were no significant differences in other obstetric and neonate outcomes.

Peripartum Prediction of Fetal Weight in Gravidas With Obesity

OBJECTIVES

Estimated fetal weight (EFW) is an important metric at delivery as neonates with abnormal birthweight and their mothers are at higher risk of birth complications. Data regarding optimal EFW assessment in gravidas with obesity is inconsistent, and with the increasing incidence of obesity, clarification of this question is crucial. We aimed to compare accuracy of ultrasound (US)-derived EFW and clinical assessments of EFW in predicting neonatal birthweight among gravidas with obesity.

METHODS

This prospective cohort study enrolled gravidas with obesity and a singleton pregnancy admitted for delivery at term. EFW was determined using either US biometry or clinical assessment (Leopold's maneuvers, Johnson's formula, and Insler's formula) at time of admission. Our primary outcome was accurate EFW, defined as EFW within 500 g of birthweight. Secondary outcomes included ability to predict small-for-gestational age (SGA) and large-for-gestational age (LGA) birthweights. These outcomes were compared between all EFW methods.

RESULTS

A total of 250 gravidas with a median body mass index of 36.4 kg/m2 were enrolled. Admission US outperformed Leopold's maneuvers in obtaining accurate EFW (81.6% versus 74.5%, P = .03). When comparing all methods, Johnson's and Insler's formulae performed the worst, accurately predicting EFW in only 27.4% and 14.3% of cases, respectively. Likewise, US-derived EFW outperformed Leopold's maneuvers and fundal height in the prediction of SGA and LGA neonates.

CONCLUSIONS

US is more accurate than clinical assessment of EFW in gravidas with obesity both for estimation of actual birthweight and prediction of abnormal birthweight. Universal late third-trimester or peripartum US for EFW should be considered in gravidas with obesity.

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

OBJECTIVES

Large-for-gestational age (LGA) is associated with several adverse maternal and neonatal outcomes. Although many studies have found that early induction of labor (IOL) in case of a LGA fetus reduces the incidence of shoulder dystocia, no current guidelines recommend this particular clinical strategy, owing 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 affected maternal and neonatal outcomes in a single center, and to combine these results with evidence reported in the literature.

METHODS

This study comprised two parts. The first part was a retrospective cohort study that included consecutive patients with a singleton pregnancy and an estimated fetal weight ≥ 90th percentile on ultrasound between 35 + 0 and 39 + 0 weeks' gestation, who were eligible for normal vaginal delivery. The second part of the study was a systematic review of the literature and meta-analysis, including the results of our cohort study as well as those of previous studies that compared IOL with expectant management in patients with a LGA fetus. The perinatal outcomes of the study were CD, operative vaginal delivery, shoulder dystocia, brachial plexus palsy, anal sphincter injury, postpartum hemorrhage, Apgar score, umbilical artery pH, admission to the neonatal intensive care unit, use of continuous positive airway pressure, intracranial hemorrhage, need for phototherapy and bone fracture.

RESULTS

Of the 547 patients included in this retrospective cohort study, 329 (60.1%) underwent IOL and 218 (39.9%) experienced spontaneous labor. Following covariate balancing, the odds of CD were significantly higher in the IOL group compared with the spontaneous-labor group. This difference only became apparent beyond 40 weeks' gestation (hazard ratio, 1.90; P = 0.030). The difference between the IOL and spontaneous-labor groups for the rate of shoulder dystocia was not statistically significant (hazard ratio, 1.57; P = 0.200). Seventeen studies, in addition to our own results, were included in the systematic review and meta-analysis, giving a total population of 111 300 participants. Although there was no significant difference in the rate of CD between IOL and expectant management after pooling the results of included studies, the risk for shoulder dystocia was significantly lower in the IOL group (odds ratio (OR), 0.64 (95% CI, 0.42-0.98); I2 = 19% from 12 studies) when considering only IOL performed before 40 + 0 weeks. When the studies in which IOL was carried out exclusively before 40 + 0 weeks were removed from the analysis, the risk for CD in the remaining studies was significantly higher in the IOL group (OR, 1.46 (95% CI, 1.02-2.09); I2 = 56%). There were no statistically significant differences between the IOL and expectant-management groups for the remaining perinatal outcomes. Nulliparity, history of CD and low Bishop score, but not method of induction, were independent risk factors for intrapartum CD in patients that underwent IOL for LGA.

CONCLUSIONS

The timing of IOL in patients with suspected macrosomia significantly impacts on perinatal adverse outcomes. IOL has no impact on rates of shoulder dystocia but increases the odds of CD when considered irrespective of gestational age; in contrast, IOL may decrease the risk of shoulder dystocia without increasing the risk of other adverse maternal outcomes, in particular CD, when performed before 40 + 0 weeks (GRADE: low/very low). © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

To know or not to know: Effect of third-trimester sonographic fetal weight estimation on outcomes of large-for-gestational age neonates

OBJECTIVE

The aim of the present study was to evaluate the impact of late third-trimester sonographic estimation of large for gestational age fetuses on pregnancy management and selected fetal and maternal adverse outcomes.

METHODS

A retrospective cohort study was conducted in a tertiary, university-affiliated medical center between 2015 and 2019. All singleton large-for-gestational-age neonates born during this period were included. The cohort was divided into two groups: neonates for whom fetal weight was estimated on late third trimester (<14 days before delivery) sonography and neonates with no recent fetal weight estimation. The groups were compared for pregnancy management strategies, rates of labor induction, cesarean deliveries, and maternal and neonatal outcomes.

RESULTS

A total of 1712 neonates were included in the study, among whom 791 (46.2%) had a late third-trimester fetal weight estimation (study group) and 921 (53.8%) did not (control group). Compared to the control group, the study group was characterized by higher rates of maternal primiparity (24.20% vs 19.20%, P = 0.013), higher maternal body mass index (26.0 ± 6.2 kg/m2 vs 24.7 ± 4.5 kg/m2, P = 0.002), more inductions of labor (29.84% vs 16.40%, P < 0.001) and cesarean deliveries (31.0% vs 19.97%, P < 0.001). There were no clinical differences in neonatal birth weight (4041 ± 256 g vs 3984 264 g, P < 0.001) and no significant differences between other neonatal outcomes, as rates of admission to the neonatal intensive care unit, jaundice, hypoglycemia, and shoulder dystocia.

CONCLUSION

Late third-trimester sonographic fetal weight estimation is associated with a higher rate of labor induction and planned and intrapartum cesarean deliveries. In this retrospective cohort study, those interventions did not lead to reduction in maternal or neonatal adverse outcomes.

Predictors of low birthweight and comparisons of newborn birthweights among different groups of maternal factors at Rev. John Chilembwe Hospital in Phalombe district, Malawi: A retrospective record review

BACKGROUND

Birthweight has an impact on newborn's future health outcomes. Maternal factors, including age, delivery mode, HIV status, gestational age, parity and obstetric complications (preeclampsia or eclampsia [PE], antepartum hemorrhage [APH] and sepsis), however, have been shown as risk factors of low birthweight (LBW) elsewhere. For data-guided interventions, we aimed to identify predictors of LBW and compare newborn birthweights between different groups of maternal factors at Rev. John Chilembwe Hospital in Phalombe district, Malawi.

METHODS

Using a retrospective record review study design, we extracted data from maternity registers of 1244 women and their newborns from October, 2022 to March, 2023. Data were skewed. Median test was used to compare median birthweights. Chi-square or Fisher's exact tests were used to compare proportions of LBW among different groups of maternal factors. Multivariable logistic regression with stepwise, forward likelihood method was performed to identify predictors of LBW.

RESULTS

Median birthweight was 2900.00g (interquartile range [IQR]: 2600.00g to 3200.00g). Prevalence of LBW was 16.7% (n = 208). Proportions of LBW infants were higher in women with PE, APH, including women with sepsis than controls (10 [47.6%] of 21 vs 7 [58.3%] of 12 vs 191 [15.8%] of 1211, p < .001). Lower in term and postterm than preterm (46 [5.5%] of 835 vs 2 [3.7%] of 54 vs 160 [45.1%] of 355, p < .001). The odds of LBW infants were higher in preterm than term (AOR = 13.76, 95%CI: 9.54 to 19.84, p < .001), women with PE (AOR = 3.88, 95%CI: 1.35 to 11.18, p = .012), APH, including women with sepsis (AOR = 6.25, 95%CI: 1.50 to 26.11, p = .012) than controls.

CONCLUSION

Prevalence of LBW was high. Its predictors were prematurity, PE, APH and sepsis. Interventions aimed to prevent these risk factors should be prioritized to improve birthweight outcomes.

Prominent themes in shoulder dystocia research: A bibliometric and document-based analysis

BACKGROUND

This study aims to comprehensively examine the academic development of shoulder dystocia (SD) through bibliometric and document analysis and to identify topics that can guide future research.

METHODS

In this study, performance, co-citation, co-word, and document analyses were used as bibliometric analysis techniques.

RESULTS

The study identified 3 main themes in terms of the intellectual structure of Shoulder Dystocia (SD): "Management of SD, Risk Factors and Associated Complications," "Clinical Practices, Birth Abnormalities and Effects of Complications," and "Impact of Education, Clinical Maneuvers and Fetal Health Outcomes." Co-occurrence analysis identified 4 significant themes: "Management and Clinical Practice of SD," "Fetal Macrosomia and Risk Factors," "Obstetric Maneuvers and Brachial Plexus Injury," and "Clinical Trends and Risks in SD." Additionally, ten consolidated themes were identified as a result of thematic coding analysis.

CONCLUSION

Shoulder dystocia remains a critical component of obstetric practice. Themes such as training and simulation, risk factors, and technical and management approaches are consistently emphasized. Technological advances and studies on how machine learning techniques can be used effectively in this field reflect innovative approaches in the scientific literature. This analysis confirms that shoulder dystocia is a complex topic requiring a multidisciplinary approach and that research in this field is constantly evolving.

Study of triglyceride changes during pregnancy and neonatal birth weight and adverse outcomes

BACKGROUND

Changes of maternal triglyceride concentrations are closely associated with intrauterine fetal growth and development, but the effect of mid- to late-term triglyceride changes on birth weight is uncertain. This study investigated the association between changes in triglycerides in mid to late in pregnant women gestational age ≥ 35 weeks on neonatal birth weight and adverse outcomes.

METHODS

This cohort study was based on 931 pregnant women with a singleton delivery at gestational age ≥ 35 weeks from January 1, 2022 to December 31, 2022 at Nanjing Lishui People's Hospital (NJLSPH) in China, with all maternal triglyceride concentrations measured at mid-term and late-term before delivery. The primary outcomes were neonatal birth weight and the risk of macrosomia.

RESULTS

Late term triglyceride levels were positively associated with birth weight (β = 126.40, 95% CI: 61.95, 190.84, p < .001) and risk of macrosomia (OR = 2.11, 95% CI: 1.12, 3.98, p = .022). Late mid-term triglyceride was positively associated with birth weight (β = 27.58, 95% CI: 9.67, 45.50, p = .003), and no correlation with risk of macrosomia (OR = 1.12, 95% CI: 0.95, 1.31, p = .178). Mid-term triglyceride was not associated with birth weight (β = 45.79, 95% CI: -28.73, 120.30, p = .229) and risk of macrosomia (OR = 1.83, 95% CI: 0.89, 3.78, p = .101).

CONCLUSION

Late triglyceride levels were associated with birth weight and risk of macrosomia, while late to mid-term triglyceride were associated with birth weight but not with risk of macrosomia. This suggests that maternal triglyceride changes may affect fetal growth and development, and more studies focusing on the effects of gestational triglyceride profiles are warranted.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Value of foetal umbilical vein standardised blood flow volume in predicting weight gain in the third trimester: a prospective case-cohort study

Objective

This study aims to establish a prediction model of foetal umbilical vein standardised blood flow volume (sQuv) on estimated foetal weight (EFW) in the third trimester.

Methods

A case-cohort study involving 200 eligible normal foetuses was conducted at the Ultrasound Department of Longquanyi District of Maternity and Child Healthcare Hospital between June 1, 2020 and December 31, 2021. Ultrasound measurements were taken at two separate intervals to assess EFW and the rate of EFW (rEFW) [first: between 28 w and 33 w6d of gestational age (GA); second: after 4-6 weeks]. Umbilical vein blood flow volume (Quv) and sQuv (normalised with EFW) were calculated only during the initial measurement. Using general linear regression, a prediction model for EFW based on GA and sQuv was developed, with the gestational week employed as a calibration scalar and validated using linear regression cross-validation.

Results

In the third trimester, EFW exhibited significant correlations with GA, abdominal circumference (AC), head circumference (HC) and Quv (all ρ > 0.6, P < 0.001). Furthermore, the rEFW showed significant correlations with Quv and sQuv (all ρ > 0.6, P < 0.001). A linear regression equation was established using a general linear regression model: rEFW = 0.32689 × sQuv. Additionally, a foetal weight prediction model (EFW = -2,554.6770 + 0.9655 × sQuv + 129.6916 × GA) was established using sQuv. The above two formulas were cross-validated by intra-group linear regression and proved to be of good efficacy.

Conclusions

In the third trimester, EFW displayed significant correlations with GA, AC, HC and Quv. Additionally, the rEFW exhibited significant correlations with Quv and sQuv. The sQuv during the third trimester has predictive value for foetal weight, serving as an early warning indicator.

A prediction tool for mode of delivery in twin pregnancies-a secondary analysis of the Twin Birth Study

BACKGROUND

One of the controversies regarding the management of twin gestations relates to the mode of delivery. Currently, counseling regarding the mode of delivery and the chance of successful vaginal twin delivery is based on the average risk for intrapartum cesarean delivery in the general population of twin pregnancies. Decision support tools that provide an individualized risk for intrapartum cesarean delivery based on the unique characteristics of each patient can improve counseling and decision-making regarding the choice of mode of delivery in twin pregnancies.

OBJECTIVE

This study aimed to develop and validate a prediction model to determine the risk for intrapartum cesarean delivery in twin pregnancies.

STUDY DESIGN

In this secondary analysis of the Twin Birth Study, a multicenter randomized controlled trial, we considered the subgroup of individuals who underwent a trial of vaginal delivery. Candidate predictors included maternal age, parity, previous cesarean delivery, conception method, chorionicity, diabetes and hypertension in pregnancy, gestational age at birth, the onset of labor, presentation of the second twin, sonographic fetal weight estimation, and fetal sex. The co-primary outcomes were overall intrapartum cesarean delivery and cesarean delivery of the second twin. Multivariable logistic regression models were used to estimate the probability of the study outcomes. Model performance was evaluated using measures of discrimination (the area under the receiver operating characteristic curve), calibration, and predictive accuracy. Internal validation was performed using the bootstrap resampling technique.

RESULTS

A total of 1221 individuals met the study criteria. The rate of overall intrapartum cesarean delivery and cesarean delivery for the second twin was 25.4% and 5.7%, respectively. The most contributory predictor variables were nulliparity, term birth (≥37 weeks), a noncephalic presentation of the second twin, previous cesarean delivery, and labor induction. The models for overall intrapartum cesarean delivery and cesarean delivery of the second twin had good overall discriminatory accuracy (area under the receiver operating characteristic curve, 0.720; 95% confidence interval, 0.688-0.752 and 0.736; 95% confidence interval, 0.669-0.803, respectively) and calibration (as illustrated by the calibration plot and Brier scores of 0.168; 95% confidence interval, 0.156-0.180 and 0.051; 95% confidence interval, 0.040-0.061, respectively). The models achieved good specificity (66.7% and 81.6%, respectively), high negative predictive value (86.0% and 96.9%, respectively), and moderate sensitivity (68.1% and 57.1%, respectively).

CONCLUSION

The prediction models developed in this study may assist care providers in counseling individuals regarding the optimal timing and mode of delivery in twin pregnancies by providing individualized estimates of the risk for intrapartum cesarean delivery.

Prevalence of autism spectrum disorder diagnosis by birth weight, gestational age, and size for gestational age: a systematic review, meta-analysis, and meta-regression

We aimed to comprehensively pool the prevalence of autism spectrum disorder (ASD) diagnosis by birth weight, gestational age, and size for gestational age. PubMed, EMBASE, Web of Science, Ovid PsycINFO, and Cochrane Library were searched up to December 22, 2021. We pooled data using the random-effects model and quantified heterogeneity using the I2 statistic. Of 66 643 records initially identified, 75 studies were included in the meta-analysis. The pooled prevalence estimates of ASD diagnosis are as follows: very-low-birth weight, 3.1% (912 ASD/66,445 individuals); low-birth weight, 2.3% (5672 ASD/593,927 individuals); normal-birth weight, 0.5% (17,361 ASD/2,378,933 individuals); high-birth weight, 0.6% (4505 ASD/430,699 individuals); very preterm, 2.8% (2113 ASD/128,513 individuals); preterm, 2.1% (19 672 ASD/1 725 244 individuals); term, 0.6% (113,261 ASD/15,297,259 individuals); postterm, 0.6% (9419 ASD/1,138,215 individuals); small-for-gestational-age, 1.9% (6314 ASD/796,550 individuals); appropriate-for-gestational-age, 0.7% (21,026 ASD/5,936,704 individuals); and large-for-gestational-age, 0.6% (2607 ASD/635,666 individuals). Compared with the reference prevalence (those in normal-birth weight, term, and appropriate-for-gestational-age individuals), the prevalence estimates of ASD diagnosis in very-low-birth weight, low-birth weight, very preterm, preterm, and small-for-gestational-age individuals increased significantly, while those in high-birth weight, postterm, and large-for-gestational-age individuals did not change significantly. There were geographical differences in the prevalence estimates. This meta-analysis provided reliable estimates of the prevalence of ASD diagnosis by birth weight, gestational age, and size for gestational age, and suggested that low-birth weight (especially very-low-birth weight), preterm (especially very preterm), and small-for-gestational-age births, rather than high-birth weight, postterm, and large-for-gestational-age births, were associated with increased risk of ASD diagnosis. However, in view of marked between-study heterogeneity in most conditions, unknown effects of certain important confounders associated with ASD due to limited information in original articles, and included studies from a relatively small number of countries, the findings of this study should be interpreted with caution.

Mortality of neonates born to mothers of extreme reproductive age in Ethiopia; multilevel mixed effect analysis of Ethiopian demographic and health survey data of 2016

Introduction

Neonatal mortality is still a major public health problem in middle- and low-income countries like Ethiopia. Despite strategies and efforts made to reduce neonatal death, the mortality rate declines at a slower pace in the country. Though there are studies conducted on neonatal mortality and its determinants, our searches of the literature have found no study on the extent of mortality of neonates born to mothers of extreme reproductive age in the study area. Therefore, this study aimed to assess the magnitude and factors associated with the mortality of neonates born to mothers of extreme reproductive age in Ethiopia.

Methods

Secondary data analysis was conducted using 2016 Ethiopian Demographic and Health Survey data. The final study contained an overall weighted sample of 2,269 live births. To determine the significant factors in newborn deaths, a multilevel binary logistic regression was fitted. For measuring the clustering impact, the intra-cluster correlation coefficient, median odds ratio, proportional change in variance, and deviation were employed for model comparison. The adjusted odds ratio with a 95% confidence interval was presented in the multivariable multilevel logistic regression analysis to identify statistically significant factors in neonatal mortality. A P-value of less than 0.05 was declared statistically significant.

Results

The neonatal mortality rate of babies born to extreme aged reproductive women in Ethiopia was 34 (95% Cl, 22.2%-42.23%) per 1,000 live birth. Being twin pregnancy (AOR = 10; 95% Cl: 8.61-20.21), being from pastoralist region (AOR = 3.9; 95% Cl: 1.71-8.09), having larger baby size (AOR = 2.93; 95% Cl: 1.4-9.12) increase the odds of neonatal mortality. On the other hand, individual level media exposure (AOR = 0.3; 95% Cl: 0.09-0.91) and community level media exposure (AOR = 0.24; 95% Cl: 0.07-0.83), being term gestation (AOR = 0.14; 95% Cl: 0.01-0.81) decreases the odds of neonatal mortality born to mothers of extreme reproductive age.

Conclusion

Ethiopia had a greater rate of neonatal death among babies born at the extremes of reproductive age than overall reproductive life. Multiple pregnancies, larger baby sizes, emerging regions, term gestation, and media exposure were found to be significant factors associated with the mortality of neonates born to mothers of extreme reproductive age. Therefore, the concerned bodies should give emphasis to mothers giving birth before the age of 20 and above 35, access to media, healthy pregnancy, and special attention to pastoralists to reduce the burden of neonatal mortality.

Developing and validating a predictive model of delivering large-for-gestational-age infants among women with gestational diabetes mellitus

BACKGROUND

The birth of large-for-gestational-age (LGA) infants is associated with many short-term adverse pregnancy outcomes. It has been observed that the proportion of LGA infants born to pregnant women with gestational diabetes mellitus (GDM) is significantly higher than that born to healthy pregnant women. However, traditional methods for the diagnosis of LGA have limitations. Therefore, this study aims to establish a predictive model that can effectively identify women with GDM who are at risk of delivering LGA infants.

AIM

To develop and validate a nomogram prediction model of delivering LGA infants among pregnant women with GDM, and provide strategies for the effective prevention and timely intervention of LGA.

METHODS

The multivariable prediction model was developed by carrying out the following steps. First, the variables that were associated with LGA risk in pregnant women with GDM were screened by univariate analyses, for which the P value was < 0.10. Subsequently, Least Absolute Shrinkage and Selection Operator regression was fit using ten cross-validations, and the optimal combination factors were selected by choosing lambda 1se as the criterion. The final predictors were determined by multiple backward stepwise logistic regression analysis, in which only the independent variables were associated with LGA risk, with a P value < 0.05. Finally, a risk prediction model was established and subsequently evaluated by using area under the receiver operating characteristic curve, calibration curve and decision curve analyses.

RESULTS

After using a multistep screening method, we establish a predictive model. Several risk factors for delivering an LGA infant were identified (P < 0.01), including weight gain during pregnancy, parity, triglyceride-glucose index, free tetraiodothyronine level, abdominal circumference, alanine transaminase-aspartate aminotransferase ratio and weight at 24 gestational weeks. The nomogram's prediction ability was supported by the area under the curve (0.703, 0.709, and 0.699 for the training cohort, validation cohort, and test cohort, respectively). The calibration curves of the three cohorts displayed good agreement. The decision curve showed that the use of the 10%-60% threshold for identifying pregnant women with GDM who are at risk of delivering an LGA infant would result in a positive net benefit.

CONCLUSION

Our nomogram incorporated easily accessible risk factors, facilitating individualized prediction of pregnant women with GDM who are likely to deliver an LGA infant.

A simulation study to assess the potential benefits of MRI-based fetal weight estimation as a second-line test for suspected macrosomia

OBJECTIVE

To simulate the outcomes of Boulvain's trial by using magnetic resonance imaging (MRI) for estimated fetal weight (EFW) as a second-line confirmatory imaging.

STUDY DESIGN

Data derived from the Boulvain's trial and the study PREMACRO (PREdict MACROsomia) were used to simulate a 1000-patient trial. Boulvain's trial compared induction of labor (IOL) to expectant management in suspected macrosomia, whereas PREMACRO study compared the performance of ultrasound-EFW (US-EFW) and MRI-EFW in the prediction of birthweight. The primary outcome was the incidence of significant shoulder dystocia (SD). Cesarean delivery (CD), hyperbilirubinemia (HB), and IOL at < 39 weeks of gestation (WG) were selected as secondary outcomes. A subgroup analysis of the Boulvain's trial was performed to estimate the incidence of the primary and secondary outcomes in the true positive and false positive groups for the two study arms. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) for the prediction of macrosomia by MRI-EFW at 36 WG were calculated, and a decision tree was constructed for each outcome.

RESULTS

The PPV of US-EFW for the prediction of macrosomia in the PREMACRO trial was 56.3 %. MRI-EFW was superior to US-EFW as a predictive tool resulting in lower rates of induction for false-positive cases. Repeating Boulvain's trial using MRI-EFW as a second-line test would result in similar rates of SD (relative risk [RR]:0.36), CD (RR:0.84), and neonatal HB (RR:2.6), as in the original trial. Increasing the sensitivity and specificity of MRI-EFW resulted in a similar relative risk for SD as in Boulvain's trial, but with reduced rates of IOL < 39 WG, and improved the RR of CD in favor of IOL. We found an inverse relationship between IOL rate and incidence of SD for both US-EFW and MRI-EFW, although overall rates of IOL, CD, and neonatal HB would be lower with MRI-derived estimates of fetal weight.

CONCLUSION

The superior accuracy of MRI-EFW over US-EFW for the diagnosis of macrosomia could result in lower rates of IOL without compromising the relative advantages of the intervention but fails to demonstrate a significant benefit to justify a replication of the original trial using MRI-EFW as a second-line test.

Mediating effect of gestational weight gain on the preventive effect of exercise during pregnancy on macrosomia: a randomized clinical trial

OBJECTIVE

We sought to investigate the impact of individualized exercise guidance during pregnancy on the incidence of macrosomia and the mediating effect of gestational weight gain (GWG).

DESIGN

A prospective randomized clinical trial.

SETTING

A Hospital in Xingtai District, Hebei Province.

POPULATION

Older than 20 years of age, mid-pregnancy, and singleton pregnant women without contraindications to exercise during pregnancy.

METHODS

A randomized clinical trial was conducted from December 2021 to September 2022 to compare the effects of standard prenatal care with individualized exercise guidance on the incidence of macrosomia.

MAIN OUTCOME MEASURE

Incidence of macrosomia.

RESULTS

In all, 312 singleton women were randomized into an intervention group (N = 162) or a control group (N = 150). Participants who received individualized exercise guidance had a significantly lower incidence of macrosomia (3.73% vs. 13.61%, P = 0.002) and infants large for gestational age (9.94% vs. 19.73%, P = 0.015). However, no differences were observed in the rate of preterm birth (1.86% vs. 3.40%, P = 0.397) or the average gestational age at birth (39.14 ± 1.51 vs. 38.69 ± 1.85, P = 0.258). Mediation analysis revealed that GWG mediated the effect of exercise on reducing the incidence of macrosomia.

CONCLUSION

Individualized exercise guidance may be a preventive tool for macrosomia, and GWG mediates the effect of exercise on reducing the incidence of macrosomia. However, evidence does not show that exercise increases the rate of preterm birth or affects the average gestational age at birth.

TRIAL REGISTRATION

The trial is registered at www.clinicaltrails.gov [registration number: NCT05760768; registration date: 08/03/2023 (retrospectively registered)].

Reducing macrosomia-related birth complications in primigravid women: ultrasound- and magnetic resonance imaging-based models

BACKGROUND

Many complications increase with macrosomia, which is defined as birthweight of ≥4000 g. The ability to estimate when the fetus would exceed 4000 g could help to guide decisions surrounding the optimal timing of delivery. To the best of our knowledge, there is no available tool to perform this estimation independent of the currently available growth charts.

OBJECTIVE

This study aimed to develop ultrasound- and magnetic resonance imaging-based models to estimate at which gestational age the birthweight would exceed 4000 g, evaluate their predictive performance, and assess the effect of each model in reducing adverse outcomes in a prospectively collected cohort.

STUDY DESIGN

This study was a subgroup analysis of women who were recruited for the estimation of fetal weight by ultrasound and magnetic resonance imaging at 36 0/7 to 36 6/7 weeks of gestation. Primigravid women who were eligible for normal vaginal delivery were selected. Multiparous patients, patients with preeclampsia spectrum, patients with elective cesarean delivery, and patients with contraindications for normal vaginal delivery were excluded. Of note, 2 linear models were built for the magnetic resonance imaging- and ultrasound-based models to predict a birthweight of ≥4000 g. Moreover, 2 formulas were created to predict the gestational age at which birthweight will reach 4000 g (predicted gestational age); one was based on the magnetic resonance imaging model, and the second one was based on the ultrasound model. This study compared the adverse birth outcomes, such as intrapartum cesarean delivery, operative vaginal delivery, anal sphincter injury, postpartum hemorrhage, shoulder dystocia, brachial plexus injury, Apgar score of <7 at 5 minutes of life, neonatal intensive care unit admission, and intracranial hemorrhage in the group of patients who delivered after the predicted gestational age according to the magnetic resonance imaging-based or the ultrasound-based models with those who delivered before the predicted gestational age by each model, respectively.

RESULTS

Of 2378 patients, 732 (30.8%) were eligible for inclusion in the current study. The median gestational age at birth was 39.86 weeks of gestation (interquartile range, 39.00-40.57), the median birthweight was 3340 g (interquartile range, 3080-3650), and 63 patients (8.6%) had a birthweight of ≥4000 g. Prepregnancy body mass index, geographic origin, gestational age at birth, and fetal body volume were retained for the optimal magnetic resonance imaging-based model, whereas maternal age, gestational diabetes mellitus, diabetes mellitus type 1 or 2, geographic origin, fetal gender, gestational age at birth, and estimated fetal weight were retained for the optimal ultrasound-based model. The performance of the first model was significantly better than the second model (area under the curve: 0.98 vs 0.89, respectively; P<.001). The group of patients who delivered after the predicted gestational age by the first model (n=40) had a higher risk of cesarean delivery, postpartum hemorrhage, and shoulder dystocia (adjusted odds ratio: 3.15, 4.50, and 9.67, respectively) than the group who delivered before this limit. Similarly, the group who delivered after the predicted gestational age by the second model (n=25) had a higher risk of cesarean delivery and postpartum hemorrhage (adjusted odds ratio: 5.27 and 6.74, respectively) than the group who delivered before this limit.

CONCLUSION

The clinical use of magnetic resonance imaging- and ultrasound-based models, which predict a gestational age at which birthweight will exceed 4000 g, may reduce macrosomia-related adverse outcomes in a primigravid population. The magnetic resonance imaging-based model is better for the identification of the highest-risk patients.

RNA-seq analysis-based study on the effects of gestational diabetes mellitus on macrosomia

Background

Both the mother and the infant are negatively impacted by macrosomia. Macrosomia is three times as common in hyperglycemic mothers as in normal mothers. This study sought to determine why hyperglycemic mothers experienced higher macrosomia. Methods: Hematoxylin and Eosin staining was used to detect the placental structure of normal mother(NN), mothers who gave birth to macrosomia(NM), and mothers who gave birth to macrosomia and had hyperglycemia (DM). The gene expressions of different groups were detected by RNA-seq. The differentially expressed genes (DEGs) were screened with DESeq2 R software and verified by qRT-PCR. The STRING database was used to build protein-protein interaction networks of DEGs. The Cytoscape was used to screen the Hub genes of the different group.

Results

The NN group's placental weight differed significantly from that of the other groups. The structure of NN group's placenta is different from that of the other group, too. 614 and 3207 DEGs of NM and DM, respectively, were examined in comparison to the NN group. Additionally, 394 DEGs of DM were examined in comparison to NM. qRT-PCR verified the results of RNA-seq. Nucleolar stress appears to be an important factor in macrosomia, according on the results of KEGG and GO analyses. The results revealed 74 overlapped DEGs that acted as links between hyperglycemia and macrosomia, and 10 of these, known as Hub genes, were key players in this process. Additionally, this analysis believes that due of their close connections, non-overlapping Hubs shouldn't be discounted.

Conclusion

In diabetic mother, ten Hub genes (RPL36, RPS29, RPL8 and so on) are key factors in the increased macrosomia in hyperglycemia. Hyperglycemia and macrosomia are linked by 74 overlapping DEGs. Additionally, this approach contends that non-overlapping Hubs shouldn't be ignored because of their tight relationships.

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.

A retrospective cohort study on the influencing factors for macrosomia in singleton pregnancies

To explore the influencing factors of singletons with macrosomia, and to develop interventions for the prevention of macrosomia. A retrospective cohort study was conducted on 26,379 pregnant women who established the Maternal and Child Health Record and gave birth from January 1, 2019 to December 31, 2019 in a community health service center in Haidian district, Beijing. The study analyzed factors such as maternal age, ethnicity, education level, prepregnancy body mass index (BMI), parity, folic acid supplementation, gestational diabetes mellitus, gestational hyper, hypothyroidism in pregnancy (including subhypothyroidism), hyperthyroidism in pregnancy, and infant gender. Univariate analysis was performed using the χ2 test, and multivariate analysis was performed using non-conditional multivariate logistic regression analysis. Out of 26,379 live births, 5.8% (1522/26,379) were macrosomia and 94.2% (24,857/26,379) were non-macrosomia. Univariate analysis revealed that maternal age, prepregnancy BMI, education level, parity, hypothyroidism during pregnancy, and infant gender were identified as influencing factors for macrosomia (P < .05). Multivariate analysis showed that maternal age ≥ 35 years, education level of high school or below, pre-pregnancy BMI, hypothyroidism, male infant, and parity were all influencing factors for macrosomia (P < .05). Prepregnancy overweight or obesity, male infants, multiparity, and low education level are risk factors for macrosomia. Multiple factors can contribute to macrosomia, and therefore, maternal health care should be strengthened, and early interventions should be taken for the above-mentioned factors in the local area.

Paternal and maternal birthweight and offspring risk of macrosomia at term gestations: A nationwide population study

BACKGROUND

There is a paucity of data on whether parents' macrosomia (birthweight ≥4500 g) status influences the risk of macrosomia in the offspring. The role of maternal overweight in the generational effect of macrosomia is not known.

OBJECTIVE

To estimate the risk of macrosomia by parental birthweight at term and evaluate if this risk varied with maternal body mass index (BMI, kg/m2) early in pregnancy.

METHODS

We used data from the Medical Birth Registry of Norway on all singleton term births (37-42 gestational weeks) during 1967-2017. The primary exposure was parental macrosomia, and the outcome was macrosomia in the second generation. The secondary exposure was maternal BMI. We used binomial regression to calculate relative risk (RR) with a 95% confidence interval. We assessed potential unmeasured confounding and selection bias using a probabilistic bias analysis and performed analyses with and without imputation for variables with missing values.

RESULTS

The data included 647,957 singleton parent-offspring trios born at term. The prevalence of macrosomia was 3.2% (n = 41,396) in the parental generation and 4.0% (n = 25,673) in the offspring generation. Macrosomia in parents was associated with an increased risk of macrosomia in offspring, with the RR for both parents were born macrosomic being 6.53 (95% confidence interval [CI] 5.31, 8.05), only mother macrosomic 3.37 (95% CI 3.17, 3.57) and only father macrosomic RR 2.22 (95% CI 2.12, 2.33). These risks increased by maternal BMI in early pregnancy: if both parents were born macrosomic, 17% of infants were macrosomic among mothers with normal BMI. If both parents were macrosomic and the mothers were obese, 31% of offspring were macrosomic. Macrosomia-related adverse outcomes did not differ with parental macrosomia status.

CONCLUSIONS

Parents' weight at birth and maternal BMI appear to be strongly associated with macrosomia in the offspring delivered at term gestations.

Pre- and Perinatal Risk Factors for Youth with Autism Spectrum Disorder Versus Youth with Other Mental Health Disorders

Research has linked pre- and perinatal complications (PPCs) with increased risk for autism spectrum disorder (ASD). However, PPCs are also known risk factors for other mental health disorders. This study explored which PPCs are specific risk factors for ASD, as opposed to other forms of psychopathology, among a large sample of clinically-referred youth. Archival data were used from 1177 youth who were evaluated at a hospital-based autism clinic. Results from logistic regressions indicated that use of tobacco, alcohol, or drugs, or experiencing amniocentesis predicted inclusion in the non-ASD group, while physical difficulties with delivery predicted inclusion in the ASD group. Possible explanations and implications for these findings are discussed.

Partitioning genetic effects on birthweight at classical human leukocyte antigen loci into maternal and fetal components, using structural equation modelling

BACKGROUND

Single nucleotide polymorphisms in the human leukocyte antigen (HLA) region in both maternal and fetal genomes have been robustly associated with birthweight (BW) in previous genetic association studies. However, no study to date has partitioned the association between BW and classical HLA alleles into maternal and fetal components.

METHODS

We used structural equation modelling (SEM) to estimate the maternal and fetal effects of classical HLA alleles on BW. Our SEM leverages the data structure of the UK Biobank (UKB), which includes ∼270 000 participants' own BW and/or the BW of their firstborn child.

RESULTS

We show via simulation that our model yields asymptotically unbiased estimates of the maternal and fetal allelic effects on BW and appropriate type I error rates, in contrast to simple regression models. Asymptotic power calculations show that we have sufficient power to detect moderate-sized maternal or fetal allelic effects of common HLA alleles on BW in the UKB. Applying our SEM to imputed classical HLA alleles and own and offspring BW from the UKB replicated the previously reported association at the HLA-C locus and revealed strong evidence for maternal (HLA-A*03:01, B*35:01, B*39:06, P <0.001) and fetal allelic effects (HLA-B*39:06, P <0.001) of non-HLA-C alleles on BW.

CONCLUSIONS

Our model yields asymptotically unbiased estimates, appropriate type I error rates and appreciable power to estimate maternal and fetal effects on BW. These novel allelic associations between BW and classical HLA alleles provide insight into the immunogenetics of fetal growth in utero.

A systematic review and a meta-analysis on the incidence of obstetric anal sphincter injuries during vaginal delivery

AIM

The incidence of obstetric anal sphincter injuries (OASIS) has increased in the past two decades despite improved awareness of the risk factors. This study aimed to define the incidence of OASIS in women with different features (instrumental delivery or other variables).

METHODS

A systematic review was conducted on articles reporting the incidence of OASIS. This review aims to examine the association of instrumentation and OASIS by performing a formal systematic review of the published literature. Databases used for the research were MEDLINE, Embase, CINAHL and 'Maternity and infant care' databases.

RESULTS

Two independent reviewers screened the selected articles. 2326 duplicates were removed from the total of 4907 articles. The remaining 2581 articles were screened for title and abstract. 1913 articles were excluded due to irrelevance. The remaining 300 were screened as full text. Primiparity associated with the use of forceps were the features associated with the highest incidence of OASIS in the selected articles (19.4%). OASIS in all women had an overall incidence of 3.8%. The incidence of OASIS in all women by geographical region was the highest (6.5%) in North America.

CONCLUSIONS

There are various factors that impact on the incidence of OASIS and the combination of some of these, such as the use of forceps in primiparas, resulted in the highest incidence of OASIS. The lack of international consensus is limiting the improvements that can be done to reduce OASIS rates and improve best clinical practice.

Neonatal Birthweight Spectrum: Maternal Risk Factors and Pregnancy Outcomes in Saudi Arabia

Background and Objectives: Low-birth-weight (LBW) neonates are at increased risk of morbidity and mortality which are inversely proportional to birth weight, while macrosomic babies are at risk of birth injuries and other related complications. Many maternal risk factors were associated with the extremes of birthweight. The objectives of this study are to investigate maternal risk factors for low and high birthweight and to report on the neonatal complications associated with abnormal birth weights. Materials and Methods: We conducted a retrospective analysis of medical records of deliveries ≥ 23 weeks. We classified the included participants according to birth weight into normal birth weight (NBW), LBW, very LBW (VLBW), and macrosomia. The following maternal risk factors were included, mother's age, parity, maternal body mass index (BMI), maternal diabetes, and hypertension. The neonatal outcomes were APGAR scores < 7, admission to neonatal intensive care unit (NICU), respiratory distress (RD), and hyperbilirubinemia. Data were analyzed using SAS Studio, multivariable logistic regression analyses were used to investigate the independent effect of maternal risk factors on birthweight categories and results were reported as an adjusted odds ratio (aOR) and 95% Confidence Interval (CI). Results: A total of 1855 were included in the study. There were 1638 neonates (88.3%) with NBW, 153 (8.2%) with LBW, 27 (1.5%) with VLBW, and 37 (2.0%) with macrosomia. LBW was associated with maternal hypertension (aOR = 3.5, 95% CI = 1.62-7.63), while increasing gestational age was less likely associated with LBW (aOR = 0.51, 95% CI = 0.46-0.57). Macrosomia was associated with maternal diabetes (aOR = 3.75, 95% CI = 1.67-8.41), in addition to maternal obesity (aOR = 3.18, 95% CI = 1.24-8.14). The odds of VLBW were reduced significantly with increasing gestational age (aOR = 0.41, 95% CI = 0.32-0.53). In total, 81.5% of VLBW neonates were admitted to the NICU, compared to 47.7% of LBW and 21.6% of those with macrosomia. RD was diagnosed in 59.3% of VLBW neonates, in 23% of LBW, in 2.7% of macrosomic and in 3% of normal-weight neonates. Hyperbilirubinemia was reported in 37.04%, 34.21%, 22.26%, and 18.92% of VLBW, LBW, NBW, and macrosomic newborns, respectively. Conclusions: Most neonates in this study had normal birthweights. Maternal hypertension and lower gestational age were associated with increased risk of LBW. Additionally, maternal obesity and diabetes increased the risk of macrosomia. Neonatal complications were predominantly concentrated in the LBW and VLBW, with a rising gradient as birthweight decreased. The main complications included respiratory distress and NICU admissions.

Combined maternal central adiposity measures in relation to infant birth size

Improvement of prenatal identification of large-for-gestational-age (LGA) infants could lower the risk for adverse outcomes. Therefore, we sought to evaluate the association of a combination of maternal waist circumference (WC) and abdominal fat depths with infant birth size. A cohort study including 1240 women was performed between 2015 and 2018 at Uppsala University Hospital, Sweden. Maternal WC was measured at the first antenatal visit, and visceral (VF) and subcutaneous (SCF) fat depths by ultrasound at the second-trimester anomaly scan. Waist circumference, VF, and SCF were categorized as low or high (cut-offs WC ≥ 88 cm, VF ≥ 54 mm, SCF ≥ 21 mm). Outcomes were birth weight standard deviation score (BWSDS) and LGA (BWSDS > 90th and > 97th percentile). Secondary outcome was small-for-gestational-age (SGA, BWSDS < 10th and < 3rd percentile). Univariate analysis of variance and logistic regression analyses were performed adjusted for maternal weight, height, parity, smoking, country of birth, pregestational diabetes, and chronic hypertension. For both high and low WC, high VF was positively associated with BWSDS and LGA. There was no association with SGA. The results did not demonstrate any value of the combination of WC and fat depth measures in predicting infant birth size but suggested VF as a marker for large infants.

Perinatal outcome of fetuses predicted to be large-for-gestational age on universal third-trimester ultrasound in non-diabetic pregnancy

OBJECTIVE

To describe the perinatal outcome of fetuses predicted to be large-for-gestational age (LGA) on universal third-trimester ultrasound in non-diabetic pregnancies of women attempting vaginal delivery.

METHODS

This was a prospective population-based cohort study of patients from a single tertiary maternity unit in the UK offering universal third-trimester ultrasound and practicing expectant management of suspected LGA until 41-42 weeks. All women with a singleton pregnancy and an estimated due date between January 2014 and September 2019 were included. Women delivering before 37 weeks, those having a planned Cesarean delivery, those with pre-existing or gestational diabetes, those with fetal abnormalities and those who did not undergo a third-trimester scan were excluded from the assessment of perinatal outcome of cases with LGA predicted on ultrasound after implementation of the universal scan period. Association of LGA on universal third-trimester ultrasound screening and perinatal adverse outcome was assessed, with the exposures of interest being estimated fetal weight (EFW) at the 90th -95th , > 95th and > 99th percentile. The reference group was composed of fetuses with EFW at the 30th -70th percentile. Analysis was performed using multivariate logistic regression. The evaluated adverse perinatal outcomes included a composite outcome of admission to neonatal intensive care unit, Apgar score < 7 at 5 min and arterial cord pH < 7.1 (CAO1) and a composite outcome of stillbirth, neonatal death and hypoxic ischemic encephalopathy (CAO2). Secondary maternal outcomes were induction of labor, mode of delivery, postpartum hemorrhage, shoulder dystocia and obstetric anal sphincter injury.

RESULTS

Cases with EFW > 95th percentile on universal third-trimester scan were at increased risk of CAO1 (adjusted odds ratio (aOR), 2.18 (95% CI, 1.69-2.80)) and CAO2 (aOR, 2.58 (95% CI, 1.05-6.34)). Cases with EFW at the 90th -95th percentile had a less pronounced increase in the risk of CAO1 (aOR, 1.35 (95% CI, 1.02-1.78)) and were not at increased risk of CAO2. All pregnancies with a fetus predicted to be LGA were at increased risk of all of the evaluated secondary maternal outcomes except for obstetric anal sphincter injury. The risk of adverse maternal outcome was typically higher with increasing EFW. Post-hoc exploration of data suggested that shoulder dystocia had a limited contribution to composite adverse perinatal outcomes in LGA cases (population attributable fraction of 10.8% for CAO1 and 29.1% for CAO2).

CONCLUSIONS

Cases with EFW > 95th percentile are at increased risk of severe adverse perinatal outcome, such as death and hypoxic ischemic encephalopathy. These findings should aid antenatal counseling regarding the associated risk and delivery options. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.