ASPECTS REGARDING THE BIRTH OF MACROSOM FETUS
Received for publication: 10th of February, 2006
Revised: 14th of March, 2006
SUMMARY: (Hide the summary)
The fetus macrosomy is considered a high risk for both the moment of birth and the evolution of the fetus in the perinatal period. By definition the fetus macrosomy has over 90 percent of the weight distribution according to the gestational age. The diagnosis is set after birth when the weight of the fetus is over 4000 gr. When the weight of the fetus at birth is situated between 4000-5000 gr, we are talking about "big fetus" and when the weight is over 5000 gr, we can say that the fetus is huge. This study is referring to the birth of macrosom fetus within the time interval 2002-2003, considering the way of giving birth, the pathology associated to the pregnancy and the evolution during the perinatal period. At 3514 births, we registered 930 caesarian sections (the caesarian index: 26, 46%). In 47 cases (5, 05%) out of the total, the fetuses were macrosom and three of them (1, 84%) were "giant fetuses," which weighed over 5000gr. 163 cases (4, 63%) from the total number of births were fetuses which weighed over 4000 gr. From these 163 macrosom fetuses, 47 (28, 83%) were born through caesarian section, and 116 (71, 17%) through the natural way. Analyzing the observation records, we noticed that only in one case (0, 61%) the pregnant woman had gestational diabetes. From the total numbers of caesarian sections that extracted macrosom fetuses, in 16 cases (34, 04%) the main indication was the negative test of labour, the feto-pelvin disproportion. In the rest of 31 cases (65, 96%), the caesarian section had other main indications like HTA inducted by the pregnancy, the cicatriceal uterus, the over term pregnancy and the pregnancy obtained after the treatment of sterility. From all the cases of macrosom fetuses, 115 (70, 55%) had an Apgar index of 9-10 and only 11 (6, 74%) had the index situated within the interval 5-7. From these 11, only 4 (36, 36%) were born through caesarian section. The mother and the fetus death rates were zero. Choosing the right moment to proceed to do the caesarian section in the labor of a pregnant woman with a macrosom fetus in order to obtain a positive prognosis for both the mother and the child, is important..
fetal macrosomy, caesarian section, pregnancy
The fetus macrosomy is considered a high risk for both the moment of birth and for the evolution of the fetus in the perinatal period.
The fetus macrosomy is defined as the surpassing of 90 percent of the weight distribution according to the gestational age.
The diagnosis is set after the birth when the weight of the fetus is over 4000 gr. When the weight of the fetus at birth is situated between 4000-5000 gr, we are talking about “big fetus” and when the weight is over 5000 gr, we can say that the fetus is huge.
The fetus macrosomy may be due to the genetic remittance or it can be the result of a pathology associated to the pregnancy: prediabetes, diabetes, over term pregnancy, multiple births, obesity.
In the etiology of the pregnancy with a macrosom fetus, one needs to consider the nutrition of the pregnant woman during the pregnancy.
The macrosom fetus may be an etiological factor of some birth complications as the uterine rupture, dynamics distocies, and obstetrical traumatism.
Material and methods
During a two-year period 2002-2003, we conducted a retrospective study by analyzing the observations records, the birth registers, and the caesarian sections registers of births from which macrosom fetus resulted.
From 3514 births through caesarian section, resulted 163 (4, 63%) macrosom fetus. From these, 142 (87, 11%) had the weight situated between 4000-4500 gr, 18 (11, 04%) had the weight situated between 4500-5000 gr and three (1, 85%) had a weight over 5000 gr.
Considering the total number of births, the percentage of the macrosom fetus is 4,04% for those with weight situated between 4000-4500 gr, 0,5% for those with weight situated between 4500-5000 gr and 0,08% for those fetus with weight over 5000 gr.
Considering the age of mothers who gave birth to macrosom fetus, we mention that 4, 29% were under 20, 1, 84% over 40 and 5, 52% were36-40. The rest is situated in the age group 20-35.
Concerning the parity, in 83 cases (50, 29%) of pregnant woman, the birth of macrosom fetus was the first birth, in 26 (15, 95%) were mothers with multiple births and the rest of the women gave birth two or third times.
Concerning the gestational age, we noticed that 21, 47% cases were over term pregnancies and the majority of the cases (76, 68%) were at term pregnancies (38-40 weeks of gestation). Only in three cases (1, 85%) the gestational age was situated under 38 weeks.
In 19, 64% of cases the women had premature broken diaphragms. The premature broken diaphragms syndrome can be a factor of labour distocies. Concerning the macrosom fetus posture at birth, in 1, 22 cases there was a pelvine presentation, in 0, 68% cases there was a transversal posture and in the rest of cases, the posture of the fetus was cephalic.
From 163 cases of macrosom fetus, 47 (28,83%) were born through caesarian section, the rest of 116 (71,17%) were born in a natural way.
Analyzing the observation records, we noticed that only in one case (0, 61%) the pregnant woman had gestational diabetes.
Consulting the surgical records, we noticed that in 16 cases (34, 04%) the main indication was the negative test of labour, the feto-pelvine disproportion. In the rest of 31 cases (65, 96%) the caesarian section has been done for other main indications like HTA inducted by the pregnancy, the cicatricial uterus, over term pregnancy and the pregnancy obtained after the treatment of sterility.
115 (70, 55%) out of the total number of newborn macrosoms had an Apgar index ranged from 9 to10 and only 11 (6, 74%) had the Apgar index ranged from 5 to7.
Only 4 (36, 36%) out of these 11 with poor Apgar index were born through caesarean section.
We can appreciate that in 70% of cases the birth of macrosom fetus can be done through natural way even though sometimes, the labour is long and the prenatal consult must appreciate the possibility of the natural birth.
The macrosom fetus pregnancy determines important mechanic and dynamic events during the labour. There is a correlation between the prolongation of the labour and the period of dilatation of the cervix and even the prolongation of the expulsion, due to the premature break of diaphragms or to the lean uterine contraction.
This fact is due to a high level of the basal uterine tonus because of a big extension of the uterus fiber. The bigger the weight of fetus is, the more frequent the mechanic distocy is, and the expulsion of the fetus skull can lead to cervix ruptures and to large vaginal and perineal ruptures.
In addition, an important problem is expulsion of the macrosom fetus shoulder. This may require performing special maneuvers.
The expulsion can present risks because of the placentar retention and bleeding due to the uterine atony.
Only 34.04% out of the resolved cases through caesarean section are due to the feto-pelvine disproportion and to the negative test labour. In over 65% of cases, the caesarian section is performed for other main obstetrical indications.
We consider that in the case of secondary obstetrical indications for a pregnancy that evolves with a macrosom fetus, performing the caesarean section is the most appropriate way of giving birth.
We totally agree with performing the caesarean section in case of macrosom fetus placed in a transversal, pelvine and cephalic presentation.
The rate of newborn macrosom fetus in our Clinic was 4.63%. This percentage can be found in the medical literature.
It is very important to investigate the pregnant woman during the evolution of a macrosom fetus pregnancy. The investigations, using the glucose tolerance test, must identify the gestational diabetes. An important aspect is the close collaboration with the nutritional physician. The ecographic estimation of macrosom weight near to the delivery term can help the obstetrician choose the most appropriate obstetrical conduct.
It is not important to reduce the index of caesarean sections. We prefer performing “an extra caesarean section” in order to avoid obtaining a traumatized child. It is mandatory to investigate both the mother and the child in order to distinguish the etiological factors of the fetal macrosomy.
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