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Fetal macrosomia (birthweight equal to or in excess of 4500 g) in a study of 110 affected infants was associated with excessive maternal weight, prolonged gestation, white race, multiparity, maternal diabetes, male fetus, and a previous macrosomic infant. The two most common obstetric complications associated with fetal macrosomia were postpartum hemorrhage and shoulder dystocia. One-minute Apgar score was less than 7 in 10.9% of the macrosomic infants, in contrast to 6.3% for the smaller infants studied as controls. The low fetal mortality rate (1.8%) was attributed to a 22.5% cesarean rate for the macrosomia group. Even more frequent use of abdominal delivery might further reduce obstetric and neonatal complications for macrosomic infants.
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PMID:Macrosomia. A proposed indication for primary cesarean section. 30 70

Shoulder dystocia is an infrequently encountered obstetric emergency varying in incidence from 0.15 to 0.60% of all deliveries. Previously identified risk factors include maternal obesity, previous infants weighing greater than 4 kg, maternal diabetes, and fetal macrosomia (greater than 4 kg). To evaluate the role of prolonged second stage of labor (PSS) as a warning sign for shoulder dystocia, 9864 deliveries at LAC-USC Women's Hospital were retrospectively reviewed. Ninety percent delivered vaginally and 4.89% had PSS with midpelvic delivery. Shoulder dystocia occurred in 0.37% of all vertex vaginal deliveries. In the absence of PSS and midpelvic delivery, the incidence of shoulder dystocia was 0.16%. However, with PSS and midpelvic delivery, the incidence of shoulder dystocia was 4.57% (P less than 0.01). Infants weighing in excess of 4 kg were at increased risk of shoulder dystocia compared with infants weighing less than 4 kg. When PSS occurred and midpelvic delivery was attempted, the incidence of shoulder dystocia was 21% in infants weighing in excess of 4 kg; 8% had had failed vaginal delivery. All shoulder dystocias and failed vaginal deliveries occurred after use of the vacuum extractor. Immediate neonatal injury was apparent in 47% of infants with shoulder dystocia after PSS with midpelvic delivery. There were no maternal or fetal deaths related to shoulder dystocia during the study period.
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PMID:Shoulder dystocia. A complication of fetal macrosomia and prolonged second stage of labor with midpelvic delivery. 72 69

Infants of insulin-dependent diabetic mothers are considered to be at high risk for birth trauma, presumably due to macrosomia. With current management of diabetes in pregnancy, including strict glycemic control, the rate and the severity of macrosomia should be decreased. The frequent use of ultrasound to assess fetal growth and weight and the use of cesarean delivery in case of fetal macrosomia should further decrease the risk for birth trauma in these infants. We therefore undertook this study to test the null hypothesis that with current management, insulin-dependent diabetic mothers have a rate of birth trauma similar to that of infants of nondiabetic mothers (normal glucose challenge test at 28 weeks' gestation) matched for gestational age at birth, presence or absence of labor, delivery method (vaginal versus cesarean), and race. We studied 118 insulin-dependent diabetic mothers (White classes B-RT) and 354 control subjects (three matches for each insulin-dependent diabetic mother). The rate of birth trauma was 3.4% in insulin-dependent diabetic mothers, not significantly different from controls (2.5%). Logistic regression analysis in which birth trauma was the dependent variable and diabetes, race, presence or absence of labor, mode of delivery (vaginal versus cesarean), infant weight, and infant head circumference were independent variables revealed that only vaginal delivery was a significant risk factor for birth trauma in infants in both groups (p = 0.01). Most frequently observed birth traumas were brachial plexus injury, facial nerve injury, and cephalohematoma. Of the three infants with brachial plexus injury (insulin-dependent diabetic mothers, two; controls, one), two were delivered with use of midforceps.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Birth trauma in insulin-dependent diabetic pregnancies. 157 44

Caloric restriction during pregnancy is contraindicated for women with a normal body mass index (BMI) of 19.8-26 kg/m2. Reduction of caloric intake in obese pregnant normal and diabetic women has been a controversial topic for many years. This paper reviews several clinical studies initiated in 1978 at the University of California, San Diego. One focus of this review concerns modest caloric reduction in obese women with gestational diabetes mellitus (GDM). Metabolic observations of diabetes during pregnancy in the past decade include extensive use of a 400 kcal isocaloric breakfast meal tolerance test to assess maternal glucose:insulin relationships and the degree of insulin resistance in obese pregnant subjects. We have previously reported that maternal hyperinsulinemia with or without maternal hyperglycemia is an important factor in fetal macrosomia. We suggest for obese pregnant diabetic women implementation of nutritional recommendations of the 1990 Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board, Institute of Medicine, National Academy of Sciences that advise a lower caloric intake for obese normal pregnant women with BMIs greater than 26. In obese noninsulin-dependent diabetic women and those with GDM, we urge that a large prospective epidemiologic study be undertaken to assess the respective roles of modest maternal caloric restriction and maternal glucose:insulin relationships on neonatal and long-term longitudinal measurements of growth and development of children of diabetic mothers.
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PMID:Caloric restriction in pregnant diabetic women: a review of maternal obesity, glucose and insulin relationships as investigated at the University of California, San Diego. 161 75

To understand mechanisms at the cellular level that may lead to the selective organomegaly seen in fetuses of diabetic mothers, we examined the role of insulin and autocrine-paracrine growth factors in the regulation of hepatic growth in the fetal rat. Analyses of fetal liver from the last one-third of gestation demonstrated the presence of specific mRNAs for the transforming growth factors (TGFs) TGF-alpha and TGF-beta. TGF-alpha, a homologue of epidermal growth factor (EGF), acts through EGF receptors. Levels of mRNA for TGF-alpha increased dramatically postnatally, whereas EGF receptor number increased just before term. In contrast, levels of mRNA for TGF-beta, an inhibitor of epithelial cell growth, were greater in fetal liver than in adult liver, as was TGF-beta-receptor binding. Other analyses demonstrated increases in tyrosine kinase activities of the insulin receptor, EGF receptor, and insulinlike growth factor I receptor as term approached. Proliferation of fetal rat hepatocytes in primary culture did not require mitogens or serum, consistent with production and activity of autocrine-paracrine growth factors. TGF-beta was a potent inhibitor of fetal hepatocyte proliferation in culture, whereas insulin potentiated fetal hepatocyte growth above "mitogen-independent" levels. The regulatory mechanisms controlling fetal hepatic growth involve a complex interaction between stimulatory and inhibitory factors. Growth factor expression, receptor expression, receptor tyrosine kinase activity, and postreceptor signal transmission represent potential loci for insulin action that might be involved in the pathogenesis of fetal macrosomia seen in diabetic pregnancies.
Diabetes 1991 Dec
PMID:Fetal growth factors as determinants of intrauterine hepatic growth. 166 Aug 27

Several maternal plasma fuel abnormalities have been described in gestational diabetes mellitus (GDM), and all may contribute to the development of fetal macrosomia, generally because of the surfeit of calories they provide. Elevated maternal plasma glucose and amino acid concentrations represent key disturbances, because they are also well-known fetal pancreatic beta-cell secretagogues. Fetal hyperinsulinemia contributes to macrosomia in a special way by selectively accelerating fuel utilization and storage in insulin-sensitive fetal tissues. Maternal obesity intensifies the insulin resistance already present in late pregnancy and probably exaggerates the metabolic abnormalities attending GDM that impact on fetal growth and development. However, the means by which maternal obesity per se promotes the development of heavy babies in nondiabetic pregnancies remains poorly defined. Significant correlations exist between newborn birth weight and the levels of maternal plasma glucose, amino acids, free fatty acids, and triglycerides in diabetic pregnancies. However, the relative influence of each disturbance on fetal birth weight remains controversial and requires more detailed investigation.
Diabetes 1991 Dec
PMID:Impact of maternal fuels and nutritional state on fetal growth. 174 67

Obstetric complications recorded prospectively were assessed retrospectively in 150 women with gestational diabetes mellitus (GDM) and 305 control subjects matched for age, parity, and ethnicity. Intensive diet therapy and self-monitoring of capillary blood glucose were used to obtain postprandial euglycemia; 22% of GDM subjects required insulin. GDM and control subjects were grouped by body mass index to detect any influence of maternal prepregnancy weight on outcome. Polyhydramnios, preterm labor, and pyelonephritis were not more frequent in GDM, but hypertension without proteinuria (7.3 vs. 3.3%) and preeclampsia (8 vs. 3.9%) were more frequent in GDM. The frequency of hypertensive complications in GDM was not totally attributable to being overweight. Abnormalities of labor, birth trauma, and fetal macrosomia were not more common in GDM; 6.7% of the infants of mothers with GDM weighed greater than 4200 g at birth compared with 3.6% of control infants (NS), and 10% were large for gestational age and sex compared with 6.6% of control infants (NS). Despite this, cesarean delivery was more common in GDM (35.3 vs. 22%, P less than 0.01), mostly due to significantly more cesarean births without labor.
Diabetes 1991 Dec
PMID:Obstetric complications with GDM. Effects of maternal weight. 174 71

Strict clinical management of a diabetic mother who is pregnant reduces the risk of neonatal complications. It also reduces the frequency of fetal macrosomia. Diabetic mothers have a heavier placenta than mothers who are not diabetic. Light microscopic placental changes associated with diabetes include villous immaturity and dysmaturity. We have examined the placentas of 27 diabetic mothers whose maternal hemoglobin A1c (HbA1C) levels were measured throughout pregnancy. None of these placentas had a trimmed weight in excess of 600 grams. Eighteen of 27 specimens had immature villi. Four had dysmature villi. Three placentas had fibromuscular sclerosis within the villi. Five had cholangiosis and there was one cholangioma. Villous immaturity was present in 16 of 18 mothers whose HbA1C was more than 5.6% of the total hemoglobin. We found villous immaturity in 2 of 5, within 5.1-5.5% HbA1C. There was no villous immaturity in four cases whose HbA1C was less than 5.0% total hemoglobin. Our findings indicate that maternal hyperglycemia during pregnancy is associated with placental immaturity and dysmaturity.
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PMID:[Correlation of placental villous immaturity and dysmaturity with clinical control of maternal diabetes]. 185 19

The purpose of this paper is to determine the incidence of fetal macrosomia, analyze risk factors, and review maternal and fetal outcome. Macrosomia occurred in 15.1% of deliveries, with very macrosomic fetuses comprising 4.1% of these pregnancies; 61.3% were male. Diabetes mellitus, post-term pregnancy, and excessive weight gain were identified as maternal risk factors. The incidence of shoulder dystocia, birth injury, and low Apgar scores was significantly higher than in controls. In addition, cesarean section rates were higher for the macrosomic groups. Fetuses delivered vaginally had more frequent birth injury than those delivered by cesarean section. Women at risk for fetal macrosomia should be screened, and liberal use of cesarean section is recommended.
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PMID:Fetal macrosomia in a military hospital: incidence, risk factors, and outcome. 190 May 88

Gestational diabetes is the most common complication of pregnancy. If maternal hyperglycemia is not well controlled, excess glucose is transmitted to the fetus, which can lead to fetal macrosomia and maternal and fetal complications. Dietary treatment for gestational diabetes varies among practitioners. A case review is presented of a 32-year-old white woman with gestational diabetes whose condition was complicated by her blood glucose intolerance to lactose in milk. By following a carefully monitored regimen using specific dietary manipulation to maintain normoglycemia, the woman was able to deliver a normal, healthy baby by spontaneous vaginal delivery.
Diabetes Educ
PMID:Euglycemic control of gestational diabetes mellitus by specific dietary manipulation: a case study presentation. 193 53


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