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Risk Factors and Outcomes of Fetal Macrosomia in a Tertiary Centre in Tanzania: a Case-Control Study Aisha Salim Said1* and Karim Premji Manji2

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Risk Factors and Outcomes of Fetal Macrosomia in a Tertiary Centre in Tanzania: a Case-Control Study Aisha Salim Said1* and Karim Premji Manji2 Said and Manji BMC Pregnancy and Childbirth (2016) 16:243 DOI 10.1186/s12884-016-1044-3 RESEARCH ARTICLE Open Access Risk factors and outcomes of fetal macrosomia in a tertiary centre in Tanzania: a case-control study Aisha Salim Said1* and Karim Premji Manji2 Abstract Background: Fetal macrosomia is defined as birth weight ≥4000 g. Several risk factors have been shown to be associated with fetal macrosomia. There has been an increased incidence of macrosomic babies delivered and the antecedent complications. This study assessed the risk factors, maternal and neonatal complications of fetal macrosomia in comparison with normal birth weight neonates. Methods: A case-control study was conducted at the Muhimbili National Hospital (MNH) maternity and neonatal wards. Cases comprised of neonates with birth weight ≥4000 g; controls were matched for sex and included neonates weighing 2500–3999 g. Detailed clinical and demographic information and laboratory investigations which included blood glucose, hematocrit and plasma calcium were collected. The child was followed up to discharge/death. Results: The prevalence of macrosomic babies was 2.3 % (103 out of 4528 deliveries). Mean birth weight of macrosomic babies was 4.2 ± 0.31 kg whereas in the controls it was 3.2 ± 0.35 kg. Maternal weight ≥80 kg, maternal age ranging between 30 and 39 years, multiparity, presence of diabetes mellitus, and gestational age ≥40 years, previous history of fetal macrosomia and delivery weight ≥80 kg were significantly associated with fetal macrosomia. Macrosomic infants were more likely to have birth asphyxia, shoulder dystocia, hypoglycemia, respiratory distress and perinatal trauma and increased risk of death compared to controls. Maternal complications such as postpartum hemorrhage, second degree perineal tears and prolonged labor occurred more frequently in the macrosomia group compared to controls (p-value <0.05), while shoulder dystocia, uterine rupture and maternal death were recorded only among the cases and none occurred in the controls. Conclusion: Fetal macrosomia was an important cause of maternal and neonatal morbidity at Muhimbili National Hospital. Presence of risk factors should alert the obstetrician to closely monitor these pregnancies and plan on appropriate mode of delivery. Macrosomic neonates should be routinely screened and appropriately managed for hypoglycemia. Abbreviations: ABD, Assisted breech delivery; BMI, Body mass index; C/S, Caesarean section; GDM, Gestational diabetes mellitus; IOM, Institute of Medicine; LCVE, Low cavity vacuum extraction; MNH, Muhimbili National Hospital; MUHAS, Muhimbili University of Health and Allied Sciences; SVD, Spontaneous vertex delivery * Correspondence: [email protected] 1London Health Centre, PO Box 2562, Dar-es-Salaam, Tanzania Full list of author information is available at the end of the article © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Said and Manji BMC Pregnancy and Childbirth (2016) 16:243 Page 2 of 8 Background medical characteristics of mother and baby were obtained Fetal macrosomia is common in obstetrics with prob- from antenatal charts and clinical notes. Infants weight, lems to both the mother and the newborn. It has been length, and occipito-frontal circumference was measured associated with significant risk of morbidity and mortal- and entered in a standardized form. ity. Over the years, the trend in fetal macrosomia has At recruitment, a drop of capillary blood was obtained been shown to be increasing worldwide [1–3]. by heel prick of the baby for random blood sugar es- Several risk factors have been identified in the caus- timation. This screening was repeated during the sec- ation of macrosomia. These include maternal diabetes, ond, fourth and sixth hour after delivery. Results were high pre-pregnancy Body Mass Index (BMI), excessive confirmed by checking plasma glucose levels. Blood weight gain during pregnancy, multiparity, male sex, par- was drawn for hematocrit, plasma calcium and glu- ental height, and prolonged gestation [3–18]. cose estimation. Infants suspected to have a fracture During labour, cephalo-pelvic disproportion can result underwent X-ray examination for confirmation. They in fetal distress and difficult deliveries are frequent in this were reported by an experienced radiologist. Manage- group of infants. Maternal complications include in- ment was based on the standard treatment guidelines creased risk of Caesarian section, postpartum hemorrhage of the unit and all recruited babies were followed-up and perineal lacerations [3, 8, 19]. The risk increases with while in the ward until recovery and discharge or a higher birth weight of the infant [20]. death. Discharge was sub-classified as discharge with/ Neonatal complications include birth asphyxia, birth without disability. trauma, and hypoglycemia [8, 19, 21–25]. Polycythemia Analysis was done using SPSS (Statistical Package for and hypocalcemia are most often noted in infants born Social Science) software version 15. Means were com- to diabetic mothers. Furthermore, these infants may be at pared by using Wilcoxon signed ranks test. Univariate a higher risk of obesity and diabetes later in life [26, 27]. analysis of risk factors was carried out using conditional The few studies on macrosomia have mainly focused logistic regression in order to determine strength of as- on the risk factors and maternal outcome. Little atten- sociation with the outcome. Multivariate conditional lo- tion has been given to the macrosomic infant even gistic regression analysis was carried out on variables though they have high perinatal mortality and morbidity that were significant in the univariate analysis. Indica- rates, particularly in our setting. Hence a need was felt tions for caesarean section (C/S) and maternal and neo- to conduct this study on fetal macrosomia so as to aid in natal complications of fetal macrosomia were analyzed future identification of these pregnancies, anticipate using binary logistic regression. Odds ratio with 95 % their complications and plan on appropriate mode of confidence intervals (CIs) were calculated for risk factors management. and complications. A p-value of less than 0.05 was con- sidered as statistically significant. Methods This was a prospective matched case-control study con- Results ducted at MNH maternity and neonatal wards in Dar es During the study period October 2009 to March 2010, Salaam, Tanzania. All infants with birth weight of 4000 g there were a total of 4528 deliveries of which 103 had a or greater delivered at the labor ward during the study weight greater than or equal to 4000 g. The prevalence period were selected as cases. The next infant of the of fetal macrosomia was 2.3 %. same sex delivered with birth weight ranging from 2500 to 3999 g was selected and served as control. Cases and Maternal and fetal characteristics controls were matched for sex. In the macrosomia group, mean maternal age was Three trained nurse midwives at the labor ward (one 29.9 years and was not significantly higher than the con- nurse per shift) were selected and assisted in recruit- trol group (p-value 0.05). Mean parity was significantly ment of study participants. Babies were recruited within greater in the macrosomia group compared to the con- the first hour after delivery and after written informed trols (2.4 vs. 1.2, p-value <0.001). Other parameters in- consent. Recruitment of patients and sample collection cluding weight at delivery, mean height and gestational was done at any time of the day. On average two to age at delivery were also significantly higher among the three cases and controls were enrolled daily. cases compared to the controls. Mean birth weight in Assuming the percentage of exposure (BMI > 28 kg/m2) the macrosomia group was similar among male and fe- of 13.6 % in controls [8], a confidence interval of 95 %, a male macrosomic neonates (p-value 0.3). Infants deliv- power of 90 %, an assumed odds ratio of 2.5 and coeffi- ered by caesarean section had a greater mean birth cient of correlation between cases and controls of 0.2, the weight compared to those delivered vaginally (4800 vs. sample size was estimated using the Epi-Info version 6, 4200 kg). However this was not statistically significant being 163 controls and 163 cases. Demographic and (p-value 0.4). There were more males than females in Said and Manji BMC Pregnancy and Childbirth (2016) 16:243 Page 3 of 8 the study population and the overall male to female ratio that were significantly associated with increased odds for was 1.5:1 (Table 1). macrosomic births (OR - 2.8 [1.1–7.2] and 2.5 [1.1–5.9], respectively (Table 2). Maternal risk factors for fetal macrosomia More than half of the mothers who delivered macroso- Mode of delivery mic infants had weight greater than 80 kg at delivery. In The overall rate of C/S was 55.3 %. Other modes of de- comparison, 73.6 % of women who delivered normal livery included spontaneous vaginal delivery (SVD), birth weight infants had a delivery weight less than assisted breech delivery (ABD) and low cavity vacuum 80 kg. Women with delivery weight greater than or extraction (LCVE). There was no significant difference equal to 80 kg were four times more likely to deliver in these modes of deliveries between the two groups. macrosomic babies compared to controls (95 % CI Majority of the macrosomic infants were delivered by [2.2–9.1]). C/S was (61.1 %) followed by SVD (34.0 %).
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