Fetal macrosomia

Authors:
Jacques S Abramowicz, MD, FACOG, FAIUM
Jennifer T Ahn, MD, FACOG
Section Editor:
Deborah Levine, MD
Deputy Editor:
Vanessa A Barss, MD, FACOG
All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Mar 2017. | This topic last updated: Feb 02,
2017.

INTRODUCTION Fetal macrosomia is associated with an increased risk of several

maternal and newborn complications. This topic will review the definition, prevalence,
significance, risk factors, etiology, and diagnosis of macrosomia. Obstetric and
pediatric management are discussed separately. (See "Shoulder dystocia: Risk factors
and planning delivery of at risk pregnancies" and "Large for gestational age newborn".)

DEFINITION Macrosomia refers to growth beyond a specific threshold, regardless of

gestational age. In developed countries, the most commonly used threshold is weight
above 4500 g (9 lb 15 oz), but weight above 4000 g (8 lb 13 oz) or 10 lb (4536 g) are
also commonly used [1-4]. A grading system has also been suggested: grade 1 for
infants 4000 to 4499 g, grade 2 for 4500 to 4999 g, and grade 3 for over 5000 g [5].
This system is useful at term for decision-making regarding operative delivery.

These thresholds are not based upon population statistics, where normal weight is
typically defined as between the 10th and 90th percentile for gestational age (assuming a
normal population distribution), and are not useful for identifying the preterm
macrosomic fetus. Using a statistical approach, any fetus/infant weighing
>90th percentile for gestational age is considered large for gestational age. The
following table shows the 5th, 10th, 50th, 90th, and 95th percentile birth weights for
gestational ages 24 to 42 weeks in the United States (table 1). Some researchers
prefer to use the 95th percentile as the threshold for macrosomia as it corresponds to
1.90 standard deviations (SD) above the mean and defines 90 percent of the
population as normal weight. Others use the 97.75th percentile, which corresponds to
1.96 SD above the mean and defines 95 percent of the population as normal weight.

The use of contemporary country-specific percentile tables is advisable when

interpreting estimated fetal and newborn weight, particularly in the developing world.
Newborn weights have increased over the past few decades, thus making older tables
obsolete [6,7]. In addition, some older tables (eg, Lubchenco) excluded, by choice,
African-American, Asian, and Native American infants [8]. Racial and ethnic differences
influence birth weight and also should be considered when interpreting estimated fetal
and newborn weight [9-11].
PREVALENCE The worldwide prevalence of birth of infants 4000 g is
approximately 9 percent and approximately 0.1 percent for weight 5000 g, with wide
variations among countries [12].

In the United States, 8 percent of live born infants weigh 4000 g and 1.1 percent
weigh more >4500 g [13]. The prevalence of birth weight 4000 g in developing
countries is typically 1 to 5 percent but ranges from 0.5 to 14.9 percent [14].

SIGNIFICANCE The risk of adverse outcome increases along a continuum based

on the degree of macrosomia: At birth weights of 4000 to 4499 g, labor abnormalities
and newborn complications begin to increase [15]. At birth weights of 4500 to 4999 g,
maternal and newborn morbidity further increases. At birth weights 5000 g, the risk of
stillbirth and neonatal mortality increases. For this reason, the presence of macrosomia
is an important factor to consider in decision-making during delivery (eg, whether to
use forceps or vacuum, whether to proceed to cesarean delivery). (See "Operative
vaginal delivery" and "Shoulder dystocia: Risk factors and planning delivery of at risk
pregnancies".)

Specific risks include [16-23]:

Maternal:
Protracted or arrested labor
Operative vaginal delivery
Cesarean delivery
Genital tract lacerations (vaginal, third-degree and fourth-degree perineal)
Postpartum hemorrhage
Uterine rupture
Macrosomia may be a greater obstetric hazard for women in developing countries
where undernutrition during youth can inhibit complete pelvic growth, pregnancy
before the pelvis is fully developed is common, and facilities for operative delivery
of women with obstructed labor are not consistently available [24].
Fetal:
Shoulder dystocia leading to birth trauma (brachial plexus injury, fracture) or
asphyxia. This is the most common serious intrapartum concern, and is
discussed in detail separately. (See "Shoulder dystocia: Risk factors and
planning delivery of at risk pregnancies" and "Shoulder dystocia: Intrapartum
diagnosis, management, and outcome".)
Neonatal (see "Large for gestational age newborn", section on 'Neonatal
complications'):
Hypoglycemia
Respiratory problems
Polycythemia
Minor congenital anomalies
Increased frequency of admission and prolonged admission (greater than
three days) to a neonatal intensive care unit
 Childhood and beyond:
Obesity
Impaired glucose tolerance
Metabolic syndrome
Cardiac remodeling (increase in aorta intima-media thickness and left
ventricular mass)

RISK FACTORS Risk factors for macrosomia are listed in the table (table 2).
Macrosomia may be related to constitutional factors (eg, familial trait, male sex,
ethnicity), environmental factors (maternal diabetes, gestational weight gain, maternal
obesity, prepregnancy body mass index >30 kg/m2 [25]), post-term gestation, or genetic
abnormalities. The long-term consequences vary for the different factors [26].

It has been proposed that a common characteristic of these conditions is intermittent

maternal, and thus fetal, hyperglycemia. The consequent release of insulin, insulin-like
growth factors, and growth hormone, among others, leads to increased fetal glycogen
and fat deposition and, in turn, amplified fetal growth [27]. Others have reported that
increased size of the placenta early in pregnancy is associated with macrosomia [28].

In a correctly dated pregnancy, macrosomia is usually related to constitutional factors,

maternal diabetes (gestational or
pregestational), and/or maternal obesity/excessive gestational weight gain. With the
increasing prevalence of overweight and obese pregnant women, maternal obesity
may have a greater impact on the prevalence of macrosomia than maternal diabetes
[29]. In a retrospective study of the relative contribution of prepregnancy weight and
gestational diabetes to the prevalence of large for gestational age (LGA) infants, the
prevalence of LGA among normal weight and obese women without gestational
diabetes was 7.7 and 12.7 percent, respectively [30]. For women with gestational
diabetes, the prevalence of LGA for normal weight and obese women was almost
twofold higher: 13.6 and 22.3 percent, respectively. These differences were statistically
significant.

PATHOLOGIC ETIOLOGIES If constitutional factors, maternal

diabetes, and/or maternal obesity/excessive gestational weight gain have been
excluded or seem unlikely, then the possibility of one of the rare syndromes associated
with accelerated fetal growth should be considered, particularly in the presence of one
or more fetal structural anomalies [31]. Consultation with a geneticist can be useful to
help with differential diagnosis, prenatal diagnostic evaluation (eg, selection and
interpretation of molecular testing), and patient counseling. Syndromes associated with
fetal overgrowth include:

Pallister-Killian
Beckwith-Wiedemann (see "Beckwith-Wiedemann syndrome")
Sotos
Perlman
Simpson-Golabi-Behmel
 Costello
Weaver
Macrocephaly Cutis Marmorata Telangiectasia Congenita (M-CMTC)

DIAGNOSIS Two-dimensional ultrasound examination is the standard modality used

for diagnosis of fetal macrosomia and large for gestational age. In the general
obstetrical population, Hadlock's formula (encompassing head circumference,
abdominal circumference, and femur length measurements) is more informative than
other methods. (See 'Estimating fetal weight' below.)

Macrosomia is best identified by an ultrasound scan at the gestational-age when a

decision regarding the clinical management of the patient needs to be made.
Performing a single estimation at 29 to 34 weeks of gestation has very poor predictive
value for birth weight at term; estimated fetal weight at this time can significantly
underestimate birth weight, probably because of accelerated growth in the later part of
the third trimester [32,33]. As discussed below, the estimation of fetal weight is not
precise at any gestational age, and accurately identifying clinically important deviations
of fetal growth, whether excessively large or excessively small, is particularly difficult.
(See 'Diagnostic performance' below.)

SONOGRAPHY

Diagnostic performance Fetal weight is calculated by integrating biometric

measurements into a formula, given that weight cannot be measured directly. Since the
fetus is an irregular, three-dimensional structure of varying density, the ability of any
formula to predict fetal density or weight is limited. Approximately three dozen formulas
for sonographic estimation of fetal weight have been proposed, attesting to the
inadequacy of all methods (table 3) [34]. These formulas use measurements of fetal
body parts with regression analysis of the dimension of one or multiple fetal biometric
parameters against gestational age and actual birth weight [35]. Available formulas
perform better for normal sized fetuses than for macrosomic ones [12,36-42] and no
formula is clearly superior [43].

A 2005 review of 14 studies on the sonographic detection of macrosomia (4000) in

general obstetrical populations reported widely varying results: sensitivity 12 to 75
percent, specificity 68 to 99 percent, and post-test probability after a positive test 17 to
79 percent; results for populations with a high prevalence of macrosomia were at the
upper end of these ranges [12]. The studies used a variety of methods for sonographic
estimation of fetal weight and illustrate the difficulty in accurately diagnosing or
excluding macrosomia.

The diagnosis of macrosomia defined as 4500 g is even less accurate; the mean
absolute percent error for infants weighing above 4500 g was 12.6 percent versus 8.4
percent if below 4500 g in one study, regardless of diabetic status [40]. In another
study, only 50 percent of fetuses weighed within 10 percent of the sonographic
estimate when infant birth weight was >4500 g [37]. There are minimal data on the
ability of ultrasound to identify fetuses >5000 g [12].
Comparison of diagnostic methods is complicated because investigators have used
different methodologies to obtain and analyze their data (eg, mean error, mean percent
error, standard deviation, and proportion of estimate fetal weight within 10 percent of
actual birth weight). For diagnosing macrosomia, the accuracy of the testing method
depends upon how well the test distinguishes macrosomic fetuses from those with a
weight within the normal range. Thus, a receiver-operator characteristic curve is the
ideal way to compare methods of fetal weight estimation, but it has not been used
consistently in diagnostic studies. (See "Evaluating diagnostic tests", section on
'Receiver operating characteristic curves'.)

Another consideration is that sonographic measurement does not permit accurate

differentiation between fetuses who are large because of intrinsic fetal (genetic) versus
extrinsic environmental factors [44], similar to the scenario with the "constitutionally
small" versus "growth restricted" fetus.

Adding to the confusion, the American College of Obstetricians and Gynecologists

concluded that ultrasound is better at ruling out macrosomia than ruling it in, since
ultrasound tends to overestimate fetal weight [15], while others have concluded that a
positive ultrasound result is more accurate for ruling in macrosomia than a negative
result for ruling it out [45].

Estimating fetal weight Ultrasound examination typically involves measurement of

multiple biometric parameters that are incorporated into a formula for calculating
estimated fetal weight (EFW). Most commonly, a combination of biparietal diameter
(BPD), head circumference (HC), abdominal circumference (AC), and femur length
(FL) is used. The most popular formulas are Hadlock's [46,47] and Warsof's [48] with
Shepard's modification [49]. These formulas are included in most ultrasound equipment
packages:

Hadlock formulas:

Log10 BW = 1.3598 + 0.051 (AC) + 0.1844 (FL) 0.0037 (AC X FL), or

Log10 BW = 1.4787 + 0.001837 (BPD)2 + 0.0458 (AC) + 0.158 (FL) 0.003343 (AC X
FL)

Shepard formula:

Log10 BW = -1.7492 + 0.166 (BPD) + 0.046 (AC) -(2.646 [AC X BPD] /100)

Comparisons of these formulas concluded that the formula using BPD, FL and AC
(second Hadlock formula) resulted in the best estimate of fetal weight, while the
formula using only BPD and AC (Shepard formula) had the least accurate estimate
[50,51].

The AC is the most important parameter for assessment of risk of macrosomia [52,53]:
An AC of 35 to 38 cm alone is predictive of macrosomia [45]. AC is measured on a
defined plane incorporating the liver since growth abnormalities are often reflected by
changes in liver size [35]. The AC measurement is equally accurate whether
determined in two dimensions (image 1) or by an elliptical estimate (image 2). Manually
tracing the abdominal circumference, however, is less accurate and should be avoided
[54] (see "Prenatal assessment of gestational age and estimated date of delivery",
section on 'Abdominal circumference').

An AC >90th percentile or two to three weeks ahead of gestational age may be an early
marker for development of macrosomia despite normal EFW. Assessment of an
enlarged AC on ultrasound should prompt fetal re-evaluation in three to four weeks,
especially in patients with diabetes. Predictions for absence or presence of
macrosomia can generally be made after two successive scans that show an increased
AC. If the AC remains <90th percentile, then performing more ultrasound examinations
does not increase predictive value [55].

Adjusting EFW for maternal weight, maternal height, date of delivery, and presence of
diabetes yields better sensitivity and specificity than traditional unadjusted formulas,
particularly in macrosomic fetuses [56,57]. Some investigators have combined
ultrasonography with pregnancy-specific data (eg, parity, ethnicity, body mass index,
maternal height, weight, and weight gain) to create nomograms for detecting fetal
macrosomia, but these methods have not performed well consistently [58-60].

Adjunctive techniques

Serial measurements Serial measurements can be taken over time to create

an individual growth curve specific to an individual fetus. This makes it possible to
extrapolate from multiple points to predict birth weight, theoretically enhancing
diagnostic accuracy. However, the superiority and cost-effectiveness of this
approach have not been proven [61-63].
Soft tissue measurements The majority of sonographic EFW formulas do not
take body composition into account. Because body composition can vary greatly,
even in the fetus, significant variation in birth weight can occur among fetuses with
similar biometric parameters.
Ultrasound measurement of subcutaneous fat may improve assessment of normal
versus accelerated growth [64,65]. Body fat accounts for 14 percent of the birth
weight in neonates, but 46 percent of birth weight variance [64], and is subject to
major changes when conditions associated with accelerated growth are present.
As an example, women with poorly controlled diabetes are at increased risk of
having a macrosomic infant with a large volume of subcutaneous fat (see 'Women
with diabetes' below).
Subcutaneous fat has been measured at the midhumerus [66,67], shoulder [68],
abdominal wall [69-71], thigh [70-74], and peribuccal area [75-79]. Prenatal
sonographic evaluation of adipose tissue appears to have good correlation with
postnatal skin fold measurements, although data are limited [77,80]. An analysis
of three studies with a total of 287 fetuses reported a high degree of accuracy in
predicting macrosomia, based on measurements of the abdominal or thigh fetal
soft tissue, with a pooled detection rate of 80 percent [81].
However, a study comparing measurement of various soft tissues to traditional
estimated fetal weight obtained from HC, AC, and FL found that no subcutaneous
tissue measurement performed better than estimated fetal weight for detection of
macrosomia [77]. Combinations of soft tissue measurements or other parameters
(umbilical cord cross section, amniotic fluid volume) with estimated fetal weight
may be more useful for predicting macrosomia than any method alone
[78,79,82,83].
Fetal volume measurement The sonographic measurements described
above estimate weight using two-dimensional principles on a three-dimensional
subject. Improvements in imaging technologies have helped alleviate this problem,
leading to better weight estimation.
Volumetric measurement by two-dimensional ultrasound can be calculated using
the following formula [34]: EFW = (0.23718 X AC2 X FL) + (0.03312 X HC3). When
compared with the traditional calculation of EFW using Shepard or Hadlock
formulas described above, this method had fewer systematic and absolute errors
(mean percent error was 6.2).
Three-dimensional (3D) ultrasound examination can improve sonographic
estimates of fetal weight by providing more accurate assessment of fetal volume.
In addition, better qualitative analysis of fetal soft tissue may be possible with 3D
ultrasound, allowing for improved estimation of actual birth weight [84]. Studies
using 3D ultrasound for birth weight prediction have validated the technique, with
most predictions within 10 percent of birth weight [85-88].
The best approach for predicting macrosomia may be to combine 3D volumetric
measurements (volume of upper arms, thigh, and abdomen) with two-dimensional
(2D) measurements (formula = -1478.557 + 7.242 X thigh vol +13.309 X upper
arm vol + 852.998 X log10 AC vol + 0.526 X BPD3) [89,90]. With combined
measurements, the mean absolute percentage of error was 6.5 percent versus 10
to 15 percent with 2D ultrasound alone.
Neural network This is a computerized model of a biologic neural system that
can be "trained" by establishing connections between basic data (input: BPD,
occipitofrontal diameter, AC, FL, gestational age, fetal position) and results
(output: EFW) and constantly rectifying the relations. It is still investigational.
Only two studies have been performed analyzing the value of artificial neural
networks in the estimation of fetal weight [91,92].
In one study, assuming a 10 percent error in macrosomia, the neural
network method was applied to 100 presumed macrosomic fetuses and
yielded an error of 4.7 percent, significantly better than conventional methods
[91].
In the other analysis, 991 singleton fetuses within three days of delivery
were used to train the system, and then 362 additional fetuses were
examined to validate the method [92]. The absolute percent error was 6.15
percent and the absolute error was 179.91 g, both better than traditional
methods [92]. However, the method was less accurate at <2500 g or >4000 g
and therefore would not offer an advantage in diagnosis of macrosomia.
HC/AC The HC/AC ratio is of no proven value in predicting macrosomia since
the constitutionally large fetus maintains a normal HC/AC ratio. However, in one
 study, a difference in HC/AC 50mm predicted shoulder dystocia regardless of
EFW, with an odds ratio of 7.3, 95% CI 1.6-33.3 [93].

NONSONOGRAPHIC METHODS

Maternal estimation In several studies, a mother's estimate of her baby's weight

has been reported to be as or more accurate than clinical or sonographic estimates
(table 3) [94-99]. Most of these studies have been in parous women, in whom an
increased risk of repeat macrosomic birth in subsequent pregnancies has been well
documented [5,100]. Maternal estimation has been used primarily to predict
macrosomia during labor in women without a recent ultrasound examination.

Physical examination Fetal weight can be estimated clinically by simple palpation

of the fetus through the maternal abdomen (eg, Leopold maneuvers) and/or by
measurement of fundal height (the distance between the superior aspect of the
symphysis pubis and the upper border of the uterine fundus). These assessments are
performed with the woman supine and her bladder empty.

Major factors that affect estimation of fetal weight by palpation include maternal habitus
[101], fetal position, amount of amniotic fluid, and, most importantly, the examiner's
experience [38]. For fundal height measurement, the fundal endpoint is more a matter
of judgment than a well-defined point. Some clinicians prefer starting the measurement
at the fundus, which tends to prevent "adjustments" to selection of a specific endpoint,
which may occur when measuring from the symphysis.

Although inexpensive, convenient, and easy to learn, prospective studies of symphysis-

fundal measurements combined with Leopold maneuvers showed sensitivities of only
10 to 43 percent and positive predictive values of 28 to 53 percent for detecting
macrosomia (table 3) [102]. A review of a variety of clinical methodologies used to
diagnose macrosomia reported that these methods detected 34 to 68 percent of infants
4000 g, and the post-test probability of macrosomia after a positive test was similar to
positive predictive values reported by others [12]. As would be expected, clinical
diagnosis was more accurate (post-test probability of macrosomia after a positive test:
61 to 86 percent) in populations with a higher prevalence of macrosomia, such as post-
term and diabetic pregnancies. Thus, the capacity for antepartum diagnosis of fetal
macrosomia in the general obstetrical population by clinical means is limited, but is
somewhat better in patients at higher risk.

Magnetic resonance imaging In theory, magnetic resonance imaging (MRI) should

be a superior technique for evaluation of macrosomia because it evaluates fat better
than ultrasound [103]. A meta-analysis of studies comparing MRI versus two-
dimensional ultrasound for predicting birth weight >4000 g or >90th percentile found that
MRI estimated fetal weight (EFW) had higher sensitivity that two-dimensional (2D)
ultrasound EFW (93 versus 56 percent), but MRI EFW was not significantly more
sensitive than 2D ultrasound abdominal circumference >35 cm (93 versus 80 percent)
[104]. Its use should be confined to research studies. MRI is expensive and not as
readily available as sonography. (See "Diagnostic imaging procedures during
pregnancy".)
DIAGNOSIS IN SPECIAL SITUATIONS The methods for detection of macrosomia
described above are standardized for singleton, cephalic presenting, nondiabetic
pregnancies. When special situations prevail, limitations in these formulas should be
recognized [102]. Overestimations and underestimations are more common in
estimating weight in infants of diabetic mothers, multiple gestations, and breech
fetuses.

Women with diabetes The growth pattern of fetuses of women with diabetes,
especially when glycemic control has been poor, is different from that in fetuses of
women without diabetes [44,105,106]. Macrosomic infants of diabetic mothers have
larger shoulders and greater amounts of body fat, decreased head-to-shoulder ratio,
and increased skin folds in the upper extremities [107,108]. Several studies have used
this information in an attempt to predict the risk of shoulder dystocia in pregnancies
complicated by diabetes, but no method has proven to be reliable [109-113].

Since infants of women with diabetes are at greatest relative risk of shoulder dystocia,
this population has been targeted for prenatal diagnosis of macrosomia. Ultrasound
prediction of estimated fetal weight in fetuses of diabetic mothers tends to overestimate
fetal weight since the formula is very sensitive to measurement of abdominal
circumference (AC), and AC in particular is increased in these fetuses [114-119]. As an
example, approximately 50 percent of infants of diabetic mothers delivered by
scheduled cesarean for sonographic estimated fetal weight 4250 g had a birth weight
<4000 g in one study [120]. Customized formulas for use in diabetic mothers have
generally not been proven to be beneficial.

A study comparing three estimated fetal weight formulas using multiple parameters
versus prediction of birth weight by formulas using AC alone concluded that
measurement of AC was quicker and similarly accurate; all of the formulas were
associated with an error of +/- 20 to 25 percent [121]. Another study reported that AC
>70th percentile is predictive of poor glycemic control and increased risk of macrosomia
[122]. Based on these findings, the American Diabetes Association recommended the
use of AC >75th percentile as a measure of glycemic control and risk for macrosomia in
diabetic gravidas, as discussed at the Fifth International Workshop-Conference on
Gestational Diabetes [123]. They suggested less intensified management (eg, less
frequent self-blood glucose monitoring, medical nutritional therapy alone [without
insulin]) was reasonable in pregnancies with normal fetal growth (defined as fetal AC
<75th percentile for gestational age).

Breech presentation The mean biparietal diameter measurement in breech fetuses

measured at 33, 35, and 38 weeks is 2 to 3 mm less than that of cephalic fetuses of the
same gestational age. This disparity has been attributed to the dolichocephalic (long
and narrow) head shape of the breech fetus. Nevertheless, ultrasound weight
estimations of breech fetuses are reasonably consistent with actual birth weight since
AC and femur length have greater impact in the formula; therefore, the usual formulas
may be used. Furthermore, the risk for macrosomia is lower in the breech fetus; infants
delivered from breech presentation are 4.9 percent lighter than cephalic infants,
suggesting a true deviation in growth [124].
Multiple gestation Singleton estimated fetal weight formulas used with multiple
gestations tend to overestimate estimated fetal weight, particularly at weights less than
2500 g [125], possibly due to distortion of the AC from overcrowding [35]. This is not
clinically important for macrosomia screening since macrosomia is rare in multiple
gestations.

MANAGEMENT Obstetrical and pediatric management are discussed separately.

(See "Shoulder dystocia: Risk factors and planning delivery of at risk
pregnancies" and "Operative vaginal delivery" and "Large for gestational age
newborn".)

PREVENTION For women with diabetes mellitus, avoiding hyperglycemia is a

proven means of reducing the frequency of macrosomia. In two large randomized trials,
treatment of gestational diabetes reduced the incidence of macrosomia by 50 to 60
percent (from 21 to 10 percent [126] and from 14.3 to 5.9 percent [127]). In women with
pregestational diabetes, studies have noted that mean blood glucose levels need to be
less than about 100 mg/dL (5.6 mmol/L) to achieve a macrosomia rate comparable to
the nondiabetic pregnant population [128,129] (See "Pregestational diabetes mellitus:
Glycemic control during pregnancy" and "Gestational diabetes mellitus: Glycemic
control and maternal prognosis".)

For obese women, prepregnancy weight loss can reduce the risk of delivering a
macrosomic infant (see "Obesity in pregnancy: Complications and maternal
management", section on 'Prepregnancy weight loss'). Prepregnancy intervention is
important because substantial weight loss is not safe during pregnancy and fetal
growth acceleration is sometimes noted as early as the first or early- to mid-second
trimester [130].

For women of normal weight, avoidance of excessive gestational weight gain can
reduce the risk of macrosomia. (See "Weight gain and loss in pregnancy", section on
'Pregnancy outcomes in women who meet, exceed, or do not achieve IOM
recommendations for gestational weight gain'.)

SUMMARY AND RECOMMENDATIONS

Using a statistical approach, any fetus/infant weighing >90th percentile for

gestational age can be considered large for gestational age (LGA). An estimated
weight of 4500 g (9 lb 15 oz) is a widely used threshold for diagnosis of
macrosomia, but formulae for deriving this number have a significant error rate.
Other thresholds for macrosomia are weight above 4000 g (8 lb 13 oz) or 10 lb
(4536 g). (See 'Definition' above.)
The risk of adverse outcome increases along a continuum based on the degree
of macrosomia (eg, 4000 to 4499 g, 4500 to 4999 g, 5000 g). Fetal macrosomia
is an important risk factor for operative delivery, as well as poor delivery
outcomes, particularly maternal and infant traumatic injury. For this reason, it is an
important factor in decision-making during delivery. (See 'Significance' above.)
 Macrosomia may be related to constitutional factors (eg, familial trait, male sex,
ethnicity), environmental factors (maternal diabetes, maternal weight gain,
maternal obesity, post-term gestation), or genetic abnormalities (syndromes such
as Pallister-Killian, Beckwith-Wiedemann, etc). (See 'Risk factors' above
and 'Pathologic etiologies' above.)
Two-dimensional ultrasound examination is the standard modality used for
diagnosis of macrosomia and LGA. Hadlock's formula (encompassing head
circumference, abdominal circumference, and femur length measurements) has
the highest predictive value in the nondiabetic population. An abdominal
circumference >35 cm is also predictive of macrosomia, but no test is highly
sensitive and specific (table 3). (See 'Sonography' above.)
For women with diabetes mellitus, avoiding hyperglycemia is a proven means of
reducing the frequency of macrosomia. For obese women, prepregnancy weight
loss can reduce the risk of delivering a macrosomic infant. For women of normal
weight, avoidance of excessive gestational weight gain can reduce the risk of
macrosomia. (See 'Prevention' above.)
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Topic 4443 Version 20.0

GRAPHICS
Birth weight percentiles by gestational age

Week of
5th percentil 10th percenti 50th percenti 90th percenti 95th percenti
gestatio
e le le le le
n

24 539 567 680 850 988

25 540 584 765 938 997

26 580 637 872 1080 1180

27 650 719 997 1260 1467

28 740 822 1138 1462 1787

29 841 939 1290 1672 2070

30 952 1068 1455 1883 2294

31 1080 1214 1635 2101 2483

32 1232 1380 1833 2331 2664

33 1414 1573 2053 2579 2861

34 1632 1793 2296 2846 3093

35 1871 2030 2549 3119 3345

 36 2117 2270 2797 3380 3594

37 2353 2500 3025 3612 3818

38 2564 2706 3219 3799 3995

39 2737 2877 3374 3941 4125

40 2863 3005 3499 4057 4232

41 2934 3082 3600 4167 4340

42 2941 3099 3686 4290 4474

Table constructed using United States National Center for Health Statistics data from 2011

for live-born singleton neonates between 500 and 6000 grams without malformations.

Gestational age was based on the obstetric estimate of gestational age included in the

revised 2003 United States birth certificate, which, when available, incorporates ultrasound

dating information.

From: Duryea EL, Hawkins JS, McIntire DD, et al. A revised birth weight reference for the United

States. Obstet Gynecol 2014; 124:16. DOI: 10.1097/AOG.0000000000000345. Copyright 2014

American College of Obstetricians and Gynecologists. Reproduced with permission from Lippincott

Williams & Wilkins. Unauthorized reproduction of this material is prohibited.

Graphic 56847 Version 7.0

Maternal risk factors for having a macrosomic infant

Sensitivity, Specificity, PPV, NPV,

Method
percent percent percent percent

Maternal estimate: parous women estimate of weight >4000 g[1] 56 94 77 86

Clinician's estimate of weight >4000 g[2,15] 10 to 43 99.0 to 99.8 28 to 53 -

Sonographic estimates for weight >4000 g unless otherwise specified [1-16]

1. AC

for weight >4000 g 77 75 91 50

for weight >4500 g 89 94 93 89

2. Serial ACs 84 94 93 89

3. FL and AC 63 - 68 -

4. AC and BPD 65 90 - -

5. BPD and AC and FL

 for weight >4000 g 71 92 55 96

for weight >4500 g 22 to 44 99 30 to 44 97 to 99

6. BPD and AC and FL adjusted by maternal characteristics 86 95 - -

7. Abdominal wall thickness >11 mm

70 96 Less than 50 -

eight gain

Hispanic or African-American ethnicity

Graphic 79202 Version 2.0

Methods for assessment of macrosomia

PPV: positive predictive value; NPV: negative predictive value; AC: abdominal circumference; FL:

femur length; BPD: biparietal diameter.

References:

1. Chauhan SP, Sullivan CA, Lutton TC, et al. Parous patients' estimate of birth weight in postterm

pregnancy. J Perinatol 1995; 15:192.

2. Chauhan SP, Hendrix NW, Magann EF, et al. Limitations of clinical and sonographic estimates of

birth weight: experience with 1034 parturients. Obstet Gynecol 1998; 91:72.

3. Combs CA, Rosenn B, Miodovnik M, Siddiqi TA. Sonographic EFW and macrosomia: is there an

optimum formula to predict diabetic fetal macrosomia? J Matern Fetal Med 2000; 9:55.

4. Gilby JR, Williams MC, Spellacy WN. Fetal abdominal circumference measurements of 35 and 38

cm as predictors of macrosomia. A risk factor for shoulder dystocia. J Reprod Med 2000;

45:936.

5. Al-Inany H, Alaa N, Momtaz M, Abdel Badii M. Intrapartum prediction of macrosomia: accuracy

of abdominal circumference estimation. Gynecol Obstet Invest 2001; 51:116.

6. Pinette MG, Pan Y, Pinette SG, et al. Estimation of fetal weight: mean value from multiple

formulas. J Ultrasound Med 1999; 18:813.

7. Benacerraf BE, Gelman R, Frigoletto FD. Sonographically estimated fetal weights: accuracy and

limitation. Am J Obstet Gynecol 1988; 159:1118.

8. Sokol RJ, Chik L, Dombrowski MP, Zador IE. Correctly identifying the macrosomic fetus:

improving ultrasonography-based prediction. Am J Obstet Gynecol 2000; 182:1489.

9. Hirata GI, Medearis AL, Horenstein J, et al. Ultrasonographic estimation of fetal weight in the

clinically macrosomic fetus. Am J Obstet Gynecol 1990; 162:238.

10. Owen P, Ogston S. Conditional centiles for the quantification of fetal growth. Ultrasound Obstet

Gynecol 1998; 11:110.

11. Shields LE, Huff RW, Jackson GM, et al. Fetal growth: a comparison of growth curves with

mathematical modeling. J Ultrasound Med 1993; 12:271.

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and management. Obstet Gynecol 1977; 50:205.

13. Hedriana HL, Moore TR. A comparison of single versus multiple growth ultrasonographic

examinations in predicting birth weight. Am J Obstet Gynecol 1994; 170:1600.

14. Petrikovsky BM, Oleschuk C, Lesser M, et al. Prediction of fetal macrosomia using

sonographically measured abdominal subcutaneous tissue thickness. J Clin Ultrasound 1997;

25:378.

15. Gonen R, Spiegel D, Abend M. Is macrosomia predictable, and are shoulder dystocia and birth

trauma preventable? Obstet Gynecol 1996; 88:526.

16. Henrichs C, Magann EF, Brantley KL, et al. Detecting fetal macrosomia with abdominal

circumference alone. J Reprod Med 2003; 48:339.

Graphic 61014 Version 5.0

Two-dimensional method for calculating abdominal circumference

The abdominal circumference measurement is calculated by the ultrasound machine by

placing four calipers (+) around the abdomen on the skin edge, not the rib cage.

Courtesy of Jennifer T Ahn, MD.

Graphic 65319 Version 4.0

Elliptical method for calculating abdominal circumference

AC: abdominal circumference.

Courtesy of Jennifer T Ahn, MD.

Graphic 66648 Version 4.0

Contributor Disclosures
Jacques S Abramowicz, MD, FACOG, FAIUMConsultant/Advisory Boards: Philips
Healthcare [Ultrasound (Ultrasound equipment)].Jennifer T Ahn, MD, FACOGNothing
to discloseDeborah Levine, MDNothing to discloseVanessa A Barss, MD,
FACOGNothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group.
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