DETECTION OF MACROSOMIA · 2019-11-27 · Ultrasound Detection of Macrosomia. GREGGORY R. DEVORE,...

UltrasoundDetectionofMacrosomia

GREGGORYR.DEVORE,M.D.,FACOG,FAIUM

ClinicalProfessorDepartmentofObstetricsandGynecologyDavidGeffenSchoolofMedicineatUCLA

LosAngeles,CA

DirectorFetalDiagnosticCenters

Pasadena,Tarzana,andLancaster,CA

DETECTIONOFMACROSOMIA

NormalTermBirthWeightDistribution

BirthWeight(grams)

GestationalAge

5othPercentile

90thPercentile

95thPercentile

37 3,117 3,755 3.959

38 3,263 3,867 4,027

39 3,400 3,980 4,107

40 3,495 4,060 4,185

41 3,527 4,094 4,217

42 3,522 4,098 4,213

Grams

3,000

3,250

3,500

3,750

4,000

4,250

4,500

4,750

5,000

5,250

5,500

WeeksGestation

37 38 39 40 41 42

PercentilesforBirthWeightforGestationalAge:U.S.1991SingleLiveBirthstoResidentMothers37–42CompletedWeeks(ACOGPracticeBulletin,Number22,November2000)

ObstetGynecol1996:87:163-168

95th

90th

50th


ACOGDefinitionofMacrosomia

Grams

3,000

3,250

3,500

3,750

4,000

4,250

4,500

4,750

5,000

5,250

5,500

WeeksGestation

37 38 39 40 41 42

NODIABETES ACOG:5,000grams(NoDiabetes)

DIABETES ACOG:4,500grams(Diabetes)


AccuracyofUltrasoundToPredictWeight%Differen

ceBetwee

nUSan

dBirth

Weigh

t

0

2.3

4.5

6.8

9

All <2000g 2000-4000g >4000g

8.6

4.34.9

5.9

Hadlock

UltrasoundObstetGynecol2013;41:198–203


AccuracyofUltrasoundToPredictWeight

%Differen

ceBetwee

nUSan

dBirth

Weigh

t

0

2.8

5.5

8.3

11

HadlockII HadlockII HadlockIIIHadlockIV Hart

3.7

10.4

8.5

10.3

9

PercentageError


ESTIMATINGFETALWEIGHT

-SoftTissueAnalysis-


ThighVolumeEquationforEFW

BiparietalDiameter

AbdominalCircumference

ThighVolume

lnBW=−0.8297+(4.0344xlnBPD)–(0.7820x(lnBPD)2)+(0.7853xlnAC)+(0.0528x(lnTVol)2)



%Differen

ceBetwee

nUSan

dBirth

Weigh

t

0

2.3

4.5

6.8

9

All <2000g 2000-4000g >4000g

4.3

1.5

0.4

1.9

8.6

4.34.9

5.9

Hadlock3DLegVolume


AccuracyofUltrasoundToPredictWeightDETECTIONOFMACROSOMIA

ESTIMATINGDELIVERY

WEIGHTREMOTEFROMTERM


PredictingBirthWeightAtTermFromEFWObtainedBetween34and37Weeks

Acta Obstet Gynecol Scand. 1996 Jan;75(1):28-31. Gestation-adjusted projection of estimated fetal weight. Mongelli M1, Gardosi J.

Obstet Gynecol. 2002 May;99(5 Pt 1):740-4. Ultrasonographic prediction of birth weight in diabetic pregnancies. Best G1, Pressman EK.

ForwardExtrapolationofSonographicEstimatesofFetalWeighttotheTimeofDelivery

PROBLEM:DIFFICULTTOMEASUREFETALHEADANDABDOMENATTERMTOACCURATELYPREDICTFETALWEIGHT


RatiooftheEstimatedFetaltotheMedianFetalWeightForGestationalAgeRemainsConstantintheThirdTrimester

UsingGestation-AdjustedProjectionMethod-Hypothesis-

PredictingBirthWeightAtTerm

Am J Obstet Gynecol. 1976 Nov 1;126(5):555-64.

A standard of fetal growth for the United States of America. Brenner WE, Edelman DA, Hendricks CH.

STEP1:IDENTIFYMEDIANWEIGHT



STEP2:ULTRASOUNDESTIMATEDWEIGHTDETERMINEDBETWEEN34-36.9WEEKSUSINGHADLOCKFORMULA

Obstet Gynecol. 2002 May;99(5 Pt 1):740-4. Ultrasonographic prediction of birth weight in diabetic pregnancies. Best G1, Pressman EK.

DIABETICN=133

CONTROLN=1690

Theratiobetweentheestimatedfetalweight and the median fetal weightforthegestationalage(Brenner)wascalculated

CALCULATION1

The ratio was multiplied by themed i an b i r t h we i gh t a t t h egestationalageofdeliverytogivethepredictedbirthweight

CALCULATION2

BirthWeightErrorsweredeterminedby the difference between thepredicted birth weighted the actualbirthweight.

CALCULATION3


Birth Weight

Birth

Wei

ght (

Gra

ms)

1000

1500

2000

2500

3000

3500

4000

4500

5000

Weeks Gestation

34 35 36 37 38 39 40 41 42

3,700

502510

7590

1. 37 wk US EFW: 3,700

Computing Birth Weight

ABSOLUTEERROR:CONTROL10.1%ABSOLUTEERROR:DIABETIC68%


Birth Weight

Birth

Wei

ght (

Gra

ms)

1000

1500

2000

2500

3000

3500

4000

4500

5000

Weeks Gestation

34 35 36 37 38 39 40 41 42

2,870

3,700

502510

7590

1. 37 wk US EFW: 3,700 2. 37 wk Median Wt: 2,870




Birth Weight

Birth

Wei

ght (

Gra

ms)

1000

1500

2000

2500

3000

3500

4000

4500

5000

Weeks Gestation

34 35 36 37 38 39 40 41 42

2,870

3,700

502510

7590

1. 37 wk US EFW: 3,700 2. 37 wk Median Wt: 2,870 3. 3,700/2,870=1.29




Birth Weight

Birth

Wei

ght (

Gra

ms)

1000

1500

2000

2500

3000

3500

4000

4500

5000

Weeks Gestation

34 35 36 37 38 39 40 41 42

2,8703,280

3,700

502510

7590

1. 37 wk US EFW: 3,700 2. 37 wk Median Wt: 2,870 3. 3,700/2,870=1.29 4. 40 wk Median Wt:3,280




Birth Weight

Birth

Wei

ght (

Gra

ms)

1000

1500

2000

2500

3000

3500

4000

4500

5000

Weeks Gestation

34 35 36 37 38 39 40 41 42

2,8703,280

3,700

4,231

502510

7590

1. 37 wk US EFW: 3,700 2. 37 wk Median Wt: 2,870 3. 3,700/2,870=1.29 4. 40 wk Median Wt:3,280 5. Est Wt 40 wk: 3,280*1.29=4,231




Birth Weight

Birth

Wei

ght (

Gra

ms)

1000

1500

2000

2500

3000

3500

4000

4500

5000

Weeks Gestation

34 35 36 37 38 39 40 41 42

2,870

3,280

3,700

4,231

502510

7590





FINDINGS:PREDICTINGMACROSOMIA

Obstet Gynecol. 2002 May;99(5 Pt 1):740-4.

Ultrasonographic prediction of birth weight in diabetic pregnancies. Best G1, Pressman EK.

DIABETICN=31

CONTROLN=155

SENSITIVITY:68%SPECIFICITY:96%POSITIVEPREDICTIVEVALUE:97%NEGATIVEPREDICTIVEVALUE:87%

SENSITIVITY:52%SPECIFICITY:95%POSITIVEPREDICTIVEVALUE:52%NEGATIVEPREDICTIVEVALUE:95%


Cheek-to-CheekDiameter

PREDICTINGADVERSEOUTCOME

-FAILURETOPROGRESSINLABORREQUIRINGC/S-

IDENTIFICATIONOFTHEFETUSATRISKFORADVERSEOUTCOME

Cheek-to-CheekDiameter

The cheek-to-cheek diameter in the ultrasonographic assessment of fetal growth. Abramowicz JS, Sherer DM, Bar-Tov E, Woods JR Jr. Am J Obstet Gynecol. 1991 Oct;165(4 Pt 1):846-52.

19911/2CheekDistancex2

Cheek-to-Cheek Diameter

Che

ek-to

-Che

ek D

iam

eter

(mm

)

0123456789

10

Weeks Gestation

20 22 24 26 28 30 32 34 36 38 40

+2SD

-2SD

PREDICTINGADVERSEOUTCOME:C/SFORFAILURETOPROGRESSINLABOR

Cheek-to-Cheek Diameter/Biparietal Diameter

CC

D/B

PD

0

0.125

0.25

0.375

0.5

0.625

0.75

0.875

1

Weeks Gestation

20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

+2SD

-2SD


1991


Cheek-to-CheekDiameter/BPD

CCD/BPD

Perce

ntile

0

15

30

45

60

75

90

Prediction

6372

90

LGADiabeticLGA-Non-DiabeticAGADiabetic


1991


ReferenceRanges


1991


Percent of Complicated Deliveries

Perc

ent

0

8

16

24

32

Retrospective Prospective

24

32

59/1869/39

> 38 Weeks of Gestation

Fetal cheek-to-cheek diameter in the prediction of mode of delivery. Abramowicz JS1, Rana S, Abramowicz S. Am J Obstet Gynecol. 2005 Apr;192(4):1205-11

2005


Prediction of Need for Cesaran Section For Failure to Progress in

Labor

Perc

ent

0

25

50

75

100

Increased Cheak-to-Cheak Diameter (>7.9 mm)

97

40Sensitivity

Specificity

>7.9 cm

Fetal cheek-to-cheek diameter in the prediction of mode of delivery. Abramowicz JS1, Rana S, Abramowicz S. Am J Obstet Gynecol. 2005 Apr;192(4):1205-11

2005

Abnormal CCD (>2SD a b o v e p r e v i o u s l y published norms for each G A ) w a s c l o s e l y associated with cesarean delivery, regardless of EFW. At term, risk of C/S with a CCD >7.9 cm was 94%


COMPLICATIONSOFMACROSOMIA

-SHOULDERDYSTOCIA-


ACOGPRACTICEBULLETIN

29

“Shoulder dystocia ismostoftenanunpredictableandunpreventable obstetricemergency. Failure of thes hou l d e r s t o d e l i v e rspontaneously places boththe pregnant woman andfetusatriskforinjury”

RateofShoulderDystocia

RateofShoulderDystocia

31

0

0.006

0.011

0.017

0.022

1979 2003

2.11%

0.2%

277,974VaginalDeliveries1979-200310XIncrease

JMaternFetalNeonatalMed.2005Nov;18(5):305-10.Trendsintherateofshoulderdystociaovertwodecades.DandoluV1,LawrenceL,GaughanJP,GrotegutC,HarmanliOH,Jaspan

Maryland

RateofShoulderDystociaManagementofShoulderDystocia:TrendsinIncidenceandMaternalandNeonatalMorbidity.MacKenzie,IZ.;Shah,Mutayyab;Lean,Katie;Dutton,Susan;Newdick,Helen;Tucker,DannyEObstetrics&Gynecology.110(5):1059-1068,November2007.

1991-2005

1991-2005

(79,781VaginalDeliveries)

RiskFactorsAssociatedWithShoulderDystocia

ManagementofShoulderDystocia:TrendsinIncidenceandMaternalandNeonatalMorbidity

MacKenzie,IZ.etalObstetrics&Gynecology

110(5):1059-1068,November2007

(79,781VaginalDeliveries)

RiskforShoulderDystocia

34

BMI>30

Percen

t

0

5

10

15

20

25


19

12

NoSD

SDRelativeRisk1.64

p<0.001

ManagementofShoulderDystocia:TrendsinIncidenceandMaternalandNeonatalMorbidity.MacKenzie,IZ.;Shah,Mutayyab;Lean,Katie;Dutton,Susan;Newdick,Helen;Tucker,DannyEObstetrics&Gynecology.110(5):1059-1068,November2007.

IncreaseinAdultObesity

35


36

BirthWeight>4kg

Percen

t

0

15

30

45

60

75


62

11NoSD

SD

RelativeRisk5.42p<0.001



37

BirthWeight>4.5kg

Percen

t

0

6

12

18

24

30


23

1NoSD

SD

RelativeRisk15.8p<0.001


OtherClinicalFactors

38

ClinicalFindings RelativeRisk PValue

Multiparas1stStage8hoursormore 1.64 <0.001

Nulliparas2ndStage4hoursormore 2.30 <0.001

Multiparas2ndStage2hoursormore 2.30 <0.001

AssistedDelivery 2.11<0.001

NeonatalAcidosis 2.17 <0.001

Management of shoulder dystocia: trends in incidence and maternal and neonatal morbidity. MacKenzie IZ, Shah M, Lean K, Dutton S, Newdick H, Tucker DE. Obstet Gynecol. 2007 Nov;110(5):1059-68.

Shoulder dystocia and associated risk factors with macrosomic infants born in California. Nesbitt TS, Gilbert WM, Herrchen B.

Am J Obstet Gynecol. 1998 Aug;179(2):476-80.


(175,886VaginalDeliveriesofInfants>3,500g)


• 175,886WomenDeliveredBabies>3,500grams• 6,238CasesofShoulderDystocia• INCIDENCE:3%

AmJObstetGynecol1998;179:476-80



RELATIVERISKFORSHOULDERDYSTOCIA

RateofShoulderDystocia:SUMMARY


Percen

tofS

houlde

rDys

tocia

0

10

20

30

40

BirthWeightinGrams

4000-4250 4250-4500 4500-4750 4750-5000

12.2

16.7

27.3

34.8

8.4

12.3

19.9

23.5

8.6

12.9

23

29

5.2

9.1

14.3

21.1

UnassistedBirth:NoDiabetesVacuumorForcepts:NoDiabetesUnassistedBirth:DiabetesVacuumorForceps:Diabetes

AssistedDelivery(Diabetes)

AssistedDelivery(NoDiabetes)

UnassistedDelivery(Diabetes)

UnassistedBirth(NoDiabetes)

RiskScale

VacuumorForcepsandDiabetes

VacuumorForceps

NoDiabetes

UnassistedBirthandDiabetes

UnassistedBirthNoDiabetes

AbdominalDiameter-BiparietalDiameter


-PREDICTINGSHOULDERDYSTOCIA-

IDENTIFICATIONOFTHEFETUSATRISKFORSHOULDERDYSTOCIA


PREDICTINGADVERSEOUTCOME:SHOULDERDYSTOCIA

J Ultrasound Med. 2007 Nov;26(11):1523-8. Sonographic fetal asymmetry predicts shoulder dystocia. Miller RS1, Devine PC, Johnson EB.

HYPOTHESIS

Asymmetric distribution of fetalweight may predispose to fetalshoulderdystocia



STUDYPOPULATION

322patients23of322(6.9%)hadshoulderdystocia


AbdominalDiameter(Circumference/3.14)

BiparietalDiameter

Minus


J Ultrasound Med. 2007 Nov;26(11):1523-8.

Sonographic fetal asymmetry predicts shoulder dystocia. Miller RS1, Devine PC, Johnson EB.

REQUIREMENTSFORPOSITIVESCREENRESULTS

AbdominalDiameter-BiparietalDiameterEFW>97thPercentileAbdominalcircumference>95thpercentile




RiskFactors

Percen

t

0

10

20

30

40

SHOULDERDYSTOCIA NOSHOULDERDYSTOCIA

17.5

39.1

PercentWhoHadDiabetes

p<0.05



RiskFactors

Percen

t

2500

2875

3250

3625

4000


3,7143,880

BirthWeight

p<0.05




RiskFactorsPe

rcen

t

0

0.75

1.5

2.25

3


1.97

2.39

MeanAbdominalDiameter-BiparietalDiameter

p<0.0002




UltrasoundFindings

Parameter Sensitivity Specificity OddsRatio(95%CL)

AD-BPD>2.6cm 44% 90% 7.15(2.9-17.7)

AC>95% 36% 79% 1.95(0.6-6.1)

EFW>97% 13% 95% 1.95(0.5-6.1)

EFW>4000g 17% 85% 1.15(0.4-3.5)



UltrasoundFindings

ParameterLikelihood

Ratio

PositivePredictiveValue

NegativePredictiveValue

AD-BPD>2.6cm 4.44 25% 96%

AC>95% 1.67 10% 95%

EFW>97% 1.67 17% 93%

EFW>4000g 1.12 8% 94%

ClinicalProtocols

52

High-RiskPatient

PredictingBirthWeight

HadlockEquation

Limb-VolumeEquation

PeriCalmShoulderScreentoPredictRiskforPermanent

Erb’sPalsy

Cheek-to-CheekDiameter(>2SD)

IncreasedRiskofCesareanSection

forFailuretoProgressinLabor

AD-BPD(>2.6cm)

IncreasedRiskforShoulderDystocia

AtTerm34w-37w

Gestation-AdjustedProjectionMethod

Macrosomia

DETECTION OF MACROSOMIA · 2019-11-27 · Ultrasound Detection of Macrosomia. GREGGORY R. DEVORE,...

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