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Fetal macrosomia: Diagnosis

Authors Jacques S Abramowicz, MD Jennifer T Ahn, MD Section Editors Charles J Lockwood, MD Deborah Levine, MD Deputy Editor Vanessa A Barss, MD

Last literature review version 17.3: September 2009 | This topic last updated: April 2, 2009 (More)

INTRODUCTION The worldwide prevalence of the birth of infants 4000 g is approximately 9 percent, with wide variations between countries *1+ . About 0.1 percent of newborns weigh 5000 g. Despite major progress in obstetrics over the last 100 years, the delivery of large fetuses remains a source of anxiety among caregivers because these pregnancies are at increased risk of several perinatal complications [2-6] :

Maternal risks [2] : Protracted labor Operative delivery Genital tract lacerations Uterine rupture Postpartum hemorrhage

Fetal risks: Shoulder dystocia leading to birth trauma (brachial plexus injury, fracture) or asphyxia [3]

Neonatal and childhood risks: Development of impaired glucose tolerance and obesity [4] Development of metabolic syndrome [5] Increase in aorta intima-media thickness, left ventricular mass, and abnormal lipid profile [6]

Accurate estimation of fetal weight, and particularly detection of fetuses with growth deviation (excessive or restricted), is important so that appropriate interventions can be undertaken, when possible, to minimize these adverse outcomes.

The diagnosis of macrosomia will be reviewed here. Risk factors for and obstetrical management of pregnancies complicated by macrosomia, as well as pediatric care of macrosomic infants, are discussed separately. (See "Diagnosis and management of pregnancies at risk for shoulder dystocia" and see "Large for gestational age newborn").

DEFINITION Macrosomia refers to growth beyond a specific threshold [7] . The most common thresholds that have been proposed are weight above 4000 g, 4500 g, or 4536 g (ie,10 pounds) [811] . 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 [12] . The American College of Obstetricians and Gynecologists supports use of the 4500 g threshold for diagnosis of macrosomia because morbidity increases sharply beyond this weight, but acknowledges there is some increased risk of morbidity at weights >4000 g [7] .

These thresholds are not based upon population statistics, in which normal weight is typically defined as between the 10th and 90th percentile for gestational age (assuming a normal population distribution) (show table 1). Using a statistical approach, any fetus/infant weighing >90th percentile for gestational age would be considered large for gestational age (LGA). However, the 95th and 97.75th percentiles have also been used as thresholds. The 95th percentile corresponds to 1.96 standard deviations (SD) above the mean and defines 90 percent of the population as normal weight (not too large or small), while the 97.75th percentile corresponds to 2.00 SD above the mean and defines the weight of 95 percent of the population as normal. Weight percentile for gestational age is the best means for identifying the preterm (or term) macrosomic fetus/infant.

There are additional complicating factors that should be considered when interpreting fetal/infant weight: At birth, male infants weigh slightly more than females. Racial and ethnic differences influence birth weight. Infant weights have increased over the past few decades, thus making older tables obsolete [13] . One of the most widely used growth curves excluded, by choice, AfricanAmerican, Asian, and Native American infants and was published decades ago, when infant weights were lower [14] .

RISK FACTORS The etiology of accelerated growth is also an important consideration since the consequences of increased weight in the fetus of the diabetic mother are very different from those of the constitutionally large fetus or the fetus with genetic macrosomia (eg, Beckwith-Wiedemann,

Weaver, and Sotos syndromes) [15,16] . Risk factors for macrosomia are listed in the table (show table 2). Of interest, 70 percent of infants with birthweight over 4500 grams are male [17] .

DIAGNOSIS The estimation of fetal weight is not precise. Difficulties exist in identifying clinically important deviations of fetal growth, whether excessively large or excessively small. (See "Diagnosis of fetal growth restriction").

The three major methods employed are: maternal estimation, clinical assessment, and sonographic measurement of one or more fetal parts integrated into a weight formula, generally computergenerated (biometry). These methods have been used alone and in combination [7,18-32] . Comparison of 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).

Receiver-operator characteristic (ROC) curves are plots of the sensitivity or true positive rate against the false positive rate (1-specificity) for the possible cutoff points of a diagnostic test. The area under the ROC curve measures test accuracy: 1.0 represents a perfect test, 0.9 to 1.0 an excellent test, 0.8 to 0.9 a good test, while an area of 0.5 to 0.6 suggests a worthless test (show figure 1). ROC curves display the tradeoff between sensitivity and specificity since an increase in sensitivity will be accompanied by a decrease in specificity. For diagnosing macrosomia, the accuracy of the testing method depends upon how well the test distinguishes macrosomic fetuses from those with weight within the normal range. Thus, an ROC curve is the ideal way to compare methods of fetal weight estimation. Unfortunately, it has not been used consistently in diagnostic studies.

Maternal estimation In several studies, a mother's estimate of her own baby's weight has been shown to be as or more accurate than clinical or sonographic estimates (show table 3A-3B) [18,3336] . 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 [12,37] . Maternal estimation has been used primarily to predict macrosomia during labor in women without a recent ultrasound examination.

Clinical assessment 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 [38] , fetal position, amount of amniotic fluid, and, most importantly, the examiner's experience [39] . 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 (show table 3A-3B) [7,40] . 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 posttest probability of macrosomia after a positive test was similar to positive predictive values reported by others [1] . As would be expected, clinical diagnosis was more accurate (posttest probability of macrosomia after a positive test 61 to 86 percent) in populations with a higher prevalence of macrosomia, such as postterm 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.

Sonography Because ultrasound can measure fetal body parameters more precisely than the clinician's hands, it seems reasonable to assume that sonographic estimation of fetal weight and detection of macrosomia would be more accurate than clinical methods. The problem is that fetal weight is not a parameter that can be measured directly, but must be calculated by integrating biometric measurements into a formula. Since the fetus is an irregular, three dimensional structure of varying density, the ability of formulas to predict fetal weight has been limited. In addition, sonographic measurement does not permit differentiation between pathologically large and large but healthy infants [41] . (See "Prenatal assessment of fetal weight").

Approximately three dozen formulas for sonographic estimation of fetal weight have been proposed, attesting to the inadequacy of all methods [20] . These formulas use measurements of fetal body parts with regression analysis of the dimension of one or multiple fetal biometric parameters against gestational age (GA) and actual birth weight (BW) [42] . Serial measurements can be taken over time to create individual growth curves, which enhance diagnostic accuracy. The introduction of threedimensional (3-D) ultrasound examination is likely to improve sonographic estimates of fetal weight by providing more accurate assessment of fetal volume.

Formulas for estimating fetal weight perform better for small and normal sized fetuses than for macrosomic ones [1,24,39,43-46] . As an example, in one study, the mean absolute percent error was 12.6 percent in infants weighing above 4500 g versus 8.4 percent for those below 4500 g [44] . In another series, 74 percent of all fetuses examined had BW within 10 percent of the

ultrasonographic estimate; however, only 50 percent of infants with BW over 4500 g weighed within 10 percent of the ultrasound estimate [24] .

A review of 14 studies on the sonographic detection of macrosomia ( 4000 g) in general obstetric populations reported widely varying results: sensitivity 12 to 75 percent, specificity 68 to 99 percent, and posttest 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 [1] .These studies used a variety of methods for sonographic estimate of fetal weight and illustrate the difficulty in accurately diagnosing macrosomia. The diagnosis of macrosomia defined as 4500 was even less accurate, and there were no data on the ability to identify fetuses >5000 g [1] .

A computer simulation study found that with advancing gestational age estimated fetal weight was less accurate (eg, less accurate after 37 weeks than from 34 to 37 weeks) and the diagnosis of macrosomia (defined as estimated fetal weight above 4500 g) was more frequent, particularly between 40 and 41 weeks [47] . Most of the formulas that were tested tended to overdiagnose macrosomia, sometimes as many as 15 percent of fetuses were classified as macrosomic. This gestational age-related finding was thought to be an aberration since the actual incidence of birth weight above 4500 g was 1.3 percent at 40 weeks and 2.9 percent at 41 weeks while frequencies by several of the tested formulas were 3 percent at 40 weeks and 10 percent at 41 weeks.

Important areas of investigation include whether any test performed early in pregnancy will be able to predict macrosomia late in pregnancy or at birth, and determining when overgrowth starts and whether its course can be altered if diagnosed early [48] . It is possible that macrosomia is genetically "pre-programmed" and cannot be altered by antepartum interventions.

Data regarding specific methods are reviewed below.

Single parameter method Abdominal circumference (AC) is the most common and reliable single parameter used to assess risk of macrosomia (show table 3A-3B). The AC is measured on a defined plane incorporating the liver (See "Prenatal assessment of gestational age" section on Abdominal circumference). Growth abnormalities are often reflected by changes in liver size; thus, these abnormalities can be detected by measurement of AC [42] .

The AC measurement is equally accurate whether determined in two-dimensions (show ultrasound 1) or by an elliptical estimate (show ultrasound 2). Tracing the circumference (show ultrasound 3), however, is less accurate and should be avoided [49] . The value of AC measurement depends upon the cut-off chosen, definition of macrosomia, and timing of examination, as illustrated by the

following examples: In a retrospective study, an AC >35 cm had a 93 percent predictive value for BW >4000 g when measured within two weeks of delivery [50] . When measured within one week of delivery in singleton pregnancies over 36 weeks of gestation, an AC >38 cm was associated with a >50 percent risk of macrosomia, while an AC <35 cm was associated with <1 percent risk of BW >4500 g [21] . A prospective study designed to identify BW >4000 g in term infants reported the ROC curve for AC >35 cm had a likelihood ratio of 2.9 [32] . An intrapartum study found that an AC measurement >37 cm had sensitivity, specificity, and positive predictive value of 77, 75, and 91 percent, respectively, for detecting macrosomic infants [22] . The positive likelihood ratio was 3.1. The AC threshold was determined using an ROC curve.

Finally, a study involving 170 patients at the beginning of labor reported AC>35 cm was 100 percent sensitive for predicting birth weight of 4250 g or more [51] .

Multiple parameter method Ultrasound examination typically involves measurement of multiple biometric parameters that are incorporated into a formula for calculating EFW. Most commonly, a combination of biparietal diameter (BPD), head circumference (HC), AC, and femur length (FL) is used. The most popular formulas are Warsof's [52] with Shepard's modification [53] and Hadlock's [54,55] . These formulas are included in most ultrasound equipment packages: Shepard formula:

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

A comparison of these formulas found that the formula using BPD and FL and AC (second Hadlock formula) demonstrated the best estimate of fetal weight with a mean absolute percentage error of 8.6 percent, while formula using BPD and AC (Shepard formula) had the least accurate estimate [23] and was prone to underestimation [56] .

The sensitivity and specificity of single and multiple parameter derived EFWs for prediction of macrosomia are shown in the table (show table 3A-3B). When the effects of adjusting EFW to the date of delivery and dependency on maternal weight, height, and presence of diabetes were evaluated, results were better than when using traditional formulas, particularly in fetuses weighing above 3900 g (sensitivity 86 percent, specificity 95 percent) [25] .

One systematic review compared the accuracy of sonographic EFW (computed from 16 different formulas with various combinations of BPD, HC, AC, and FL) and AC in the prediction of macrosomia [57] . Sixty-three accuracy studies (51 for EFW and 12 for AC) including 19,117 women were analyzed. The pooled likelihood ratio (LR) for EFW over 4000 g to predict an actual weight over 4000 g was 5.7 (4.3 to 7.6) and for AC above 36 cm to have the same prediction, 6.9 (5.2 to 9.0). For AC above the 90th percentile for gestational age, the LR was 4.2 (2.3 to 7.7). The LR of values below the chosen threshold to predict actual weights below 4000 g (negative likelihood ratio or LR-) were 0.48 (0.38 to 0.60), 0.37 (0.30 to 0.45) and 0.33 (0.21 to 0.54) for sonographic EFW below 4000, AC below 36 cm and AC below the 90th percentile, respectively. Therefore, the AC positive predictive value (BW >4000 g) is much more useful than its negative predictive value. The results were pooled in ROC curves and there were no significant differences in the areas under the curves, indicating similar accuracies for EFW and AC.

However, performing a single estimation at 29 to 34 weeks of gestation has very poor predictive value for actual birth weight. EFW at this time can significantly underestimate birth weight, probably because of accelerated growth in the later part of the third trimester [58,59] .

The HC/AC ratio is of no proven value in predicting macrosomia since the constitutionally large fetus maintains a normal HC/AC ratio.

Serial measurements The rationale for determining individualized growth curves is that fetal measurements obtained at intervals allow construction of a growth curve specific to an individual fetus. This makes it possible to extrapolate from multiple points to predict BW [26-28] . In one study, serial averaging of AC had sensitivity and specificity of 84 and 100 percent, respectively, for predicting BW >90th percentile [29] . This was better than a single AC measurement or single and serial EFW's (show table 3A-3B).

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.

Body fat accounts for 14 percent of the BW in neonates, but 46 percent of BW variance [60] . Adipose tissue is subject to major changes when conditions associated with accelerated or decreased growth are present. As an example, diabetic mothers with poor glycemic control are at increased risk of having a macrosomic infant with a large volume of subcutaneous fat (see "Diabetic mother" below). Ultrasound has been used to assess subcutaneous fat and thus provide better evaluation of normal and disturbed growth [60] .

Subcutaneous fat has been measured at the midhumerus [61,62] , shoulder [63] , abdominal wall [30,64,65] , thigh [64-68] , and peribuccal area [69,70] . Prenatal sonographic evaluation of adipose tissue appears to have good correlation with postnatal skin fold measurements, although data are limited [71] . The utility of soft tissue measurement for screening for macrosomia is illustrated by the following examples: A study that compared humeral soft tissue thickness (muscle and fat) and EFW in 95 fetuses at risk for macrosomia (BW >4,000 g) found that the relative risk of macrosomia was 5.1 at a midhumeral soft tissue thickness cutoff of 13 mm [61] . Midhumeral soft tissue thickness detected more macrosomic infants than EFW (sensitivity 88 versus 71 percent), but was less specific (75 versus 91 percent) [61] . Measurement of subcutaneous tissue thickness at the shoulder had a good overall predictive value for macrosomia in pregnancies complicated by diabetes [63] . At a cutoff of 12 mm, the sensitivity and specificity were 83 and 90 percent, respectively, for detecting BW >90th percentile. Abdominal wall thickness was measured in 133 fetuses at term who delivered within 72 hours of the study [30] . Mean wall thickness was significantly higher in macrosomic fetuses, 12.4 mm compared to 7 mm in appropriately grown fetuses. The best cut-off for macrosomia was 11 mm (sensitivity and specificity 70 and 96 percent, respectively). Negative predictive values ranged from 84.3 to 100 percent, depending upon the thickness cut-off, but positive predictive values were generally low (less than 50 percent). The screening efficacy of the subcutaneous tissue width/femur length (SCT/FL) ratio for the intrapartum detection of fetal macrosomia in a nondiabetic population at term was evaluated and compared to other screening methods using ROC curves [72] . AC had the best sensitivity-specificity trade-off, followed by EFW, while subcutaneous tissue thickness alone and the SCT/FL ratio performed poorly. However, in another series, the SCT/FL ratio was a better predictor of macrosomia than other modalities [68] . In a third series studying midcalf, midthigh and abdominal thickness, <25 percent of macrosomic fetuses had midthigh subcutaneous thickness more than 2 SD above the mean [65] . The discordant results may be because these measurements usually include muscles as well as fat, so standardization is difficult. Furthermore, the number of study subjects was small. The cheeks are a logical area to study subcutaneous tissue because they are formed mainly of white fat, which is very sensitive to changes in nutritional status. The cheek-to-cheek diameter (CCD) is significantly greater in the macrosomic than the appropriately grown fetus [69] and performs better for diagnosis of macrosomia than upper arm and femur measurements (area under the ROC curve 0.67, 0.52, and 0.58, respectively) [73] .

Despite these promising findings, a study comparing measurement of soft tissues (CCD, thigh, ratio of thigh to FL, humerus) to traditional EFW obtained from HC, AC and FL found that no subcutaneous tissue measurement performed better than EFW using multiple parameters for detection of macrosomia [73] . However, incorporating CCD into the weight formula may improve its accuracy [74] . When CCD was used to calculate weight (EFW [g] = 1065 + 84.5 BPD [cm] + 41.29 AC [cm] + 111.0 CCD [cm]) the mean percent error in EFW was lower than with traditional formulas in fetuses with EFW >4000 g (4.14 versus 7.97 percent). In addition, while EFW alone has weak correlation with cesarean delivery at term, abnormal CCD (more than 2SD above normal) is closely associated with cesarean delivery, regardless of EFW [75] .

Another study reported that sonographic measurement of the umbilical cord cross section thickness was a very good predictor of macrosomia, particularly when combined with AC measurement [76] .

A different approach using a combination of the amniotic fluid index (AFI) with the traditional EFW has also been proposed. An AFI at or over the 60th percentile and an EFW at or over the 70th percentile were strongly correlated with severe macrosomia at birth [77] .

Volume measurement The sonographic measurements described above estimate weight using 2dimensional principles on a 3-dimensional subject. Improvements in imaging technologies have helped alleviate this problem, leading to better weight estimation. Two-dimensional ultrasound Volumetric measurement by 2-D ultrasound can be calculated using the following formula [20] : EFW = (0.23718 X AC2 X FL) + (0.03312 X HC3). When compared to the traditional calculation of EFW using Shepard or Hadlock formulas (see above), this method had fewer systematic and absolute errors (mean percent error was 6.2). Three-dimensional ultrasound The availability of 3-D ultrasound has heightened interest in using volumetric estimates to predict fetal macrosomia. Validation studies using 3-D ultrasound for BW prediction showed similarities between 3-D and 2-D measures in systemic error measurements of fetal thigh, AC, and estimated weight precision [78] . Most predictions were within 10 percent of true BW. Subsequent studies incorporated measurement of single parameters, such as the fetal upper arm [79] and thigh [80] , which also correlated well to BW. Better qualitative analysis of fetal soft tissue may be possible with 3-D ultrasound, allowing for improved estimation of actual birth weight [81] .

The best ability to predict macrosomia comes from combining 3-D volumetric measurements (volume of upper arms, thigh, and abdomen) with 2-D 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) [82,83] . With combined measurements, the mean absolute percentage of error was 6 + 5 percent versus 10 to 15 percent with 2-D alone.

Neural network This is a computerized model of a biologic neural system which 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.

Two studies have been performed analyzing the value of artificial neural networks in the estimation of fetal weight [84,85] . 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 [84] . 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 [85] . The absolute percent error was 6.15 percent and the

absolute error 179.91 g, both better than traditional methods [85] . However, the method was less accurate at <2500 g or >4000 g and therefore would not offer an advantage in diagnosis of macrosomia.

Other methods Magnetic resonance imaging (MRI) [86-88] , endocrine evaluation, and combinations of methods have also been used to estimate fetal weight and detect macrosomia.

Magnetic resonance imaging In theory, MRI should be a superior technique for evaluation of macrosomia because it evaluates fat better than ultrasound does [89] . Some results have been encouraging; in one study the median difference between MRI-derived EFW and actual BW was 3 percent, as opposed to 6.5 percent for ultrasound-derived EFW [87] . In addition, a small, but well designed, study demonstrated a significant correlation between MRI prediction of fetal shoulder measurements of fetuses with suspected macrosomia and the actual shoulder width [88] . This could be useful for prediction of shoulder dystocia in infants of diabetic mothers. However, MRI is expensive and not as readily available as sonography, nor has its safety been evaluated as thoroughly. (See "Diagnostic imaging procedures during pregnancy").

Endocrine evaluation Sonographic EFW has been combined with results of the glucose challenge test to better predict macrosomia. When sonographic EFW was >4000 g, the presence of a glucose challenge test (GCT) 120 mg/dL had a positive predictive value of 71 percent for macrosomia compared to 60 percent with GCT 120 mg/dL *90+ . Sensitivity, specificity, positive and negative predictive values were similar for both the high and low GCT groups (63,91,71,86 percent, respectively, versus 65, 89, 60, 91 percent, respectively).

Combined methods Some investigators have combined ultrasonography with pregnancy-specific data (eg, parity; ethnicity; BMI; maternal height, weight, and weight gain) to create nomograms for detecting fetal macrosomia, but these methods have not performed well consistently [113-115] .

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 [40] . Overestimations and underestimations are more common in estimating weight in infants of diabetic mothers, multiple gestations, and breech fetuses.

Diabetic mother Since infants of diabetic mothers are at greatest relative risk of shoulder dystocia, this population has been targeted for prenatal diagnosis of macrosomia. The growth pattern of these fetuses is different from that in large fetuses of nondiabetic mothers [41,91,92] .

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 [15,93] . Furthermore, an abnormal growth pattern is often not detected in fetuses of diabetic mothers by routinely employed EFW formulas. As an example, the EFW of a particular fetus may be at a "normal" percentile, for instance 70th, but this may represent macrosomia if the genetic weight predetermination is only the 20th percentile [94] .

Several studies have used this information to predict the risk of shoulder dystocia in diabetic pregnancies [95-99] : An increased risk for shoulder dystocia occurred in infants in whom the difference between the AC and BPD measurements was 0.32 cm *95+ . One-third of these infants experienced shoulder dystocia versus <10 percent when the difference was less than 0.32 cm. An AC greater than the 90 percentile at 30 to 33 weeks of gestation was associated with an increased risk for shoulder dystocia, birth trauma, and cesarean delivery in diet-controlled diabetic mothers [96] . Comparing chest diameter and BPD was shown to potentially reduce the incidence of birth trauma in large infants of diabetic mothers [97] . Cesarean delivery for all fetuses with a chest- biparietal diameter difference of 1.4 cm or greater would reduce the incidence of traumatic morbidity from 27 to 9 percent. A fetal abdominal fat layer >5 mm had the best positive likelihood ratio (9.75) for macrosomia (BW >4000), but sensitivity was only 41 percent as opposed to 76 percent for AC >90th percentile [98] .

Ultrasound prediction of EFW in fetuses of diabetic mothers can overestimate fetal weight due to the asymmetry that exists in the fetus with increased AC due to excess adipose tissue. In many, but not all, studies standard formulas have been shown to be less accurate in these patients [100-105] . The mean absolute percent error is greater in infants weighing above 4500 g (12.6 versus 8.4 percent if below 4500 g), regardless of diabetic status [44] . Customized formulas for use in diabetic mothers have generally not been proven to be beneficial, although the FL/AC ratio (X100) appears to be useful for prediction of macrosomic infants in diabetic mothers [55] .

A report comparing four EFW formulas with multiple parameters, versus prediction of birth weight by AC alone, concluded that measurement of the AC is quick and more effective, with multiple parameter formulas being associated with error of +/- 20 to 25 percent [106] . Another study reported that AC >70 percentile is predictive of poor glycemic control and increased macrosomia [107] . Based on these findings, the American Diabetes Association recommended the use of AC >75 percentile as a measure of glycemic control and risk for macrosomia in diabetic gravidas as discussed at the 5th International Workshop-Conference on Gestational Diabetes [108] . Future studies assessing volumetric measures and fat content may improve potential predictive parameters.

Breech presentation The mean BPD 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 consistent with actual BW; therefore, the usual formulas may be used. Furthermore, the risk for macrosomia is lower in the breech fetus; in fact, infants delivered from breech presentation are 4.9 percent lighter than cephalic infants, suggesting a true deviation in growth [109] .

Multiple gestation Singleton EFW formulas used with multiple gestations tend to overestimate EFW, particularly at weights less than 2500 g [110] , possibly due to distortion of the AC from overcrowding [42] . This is not clinically important for macrosomia screening since macrosomia is rare in multiple gestations.

Poor prenatal care Poor prenatal care is a well-known risk factor for poor pregnancy outcome. In particular, it appears to be a risk factor for perinatal mortality in newborns with macrosomia [111] .

SUMMARY AND RECOMMENDATIONS Fetal macrosomia is an important risk factor for poor delivery outcomes, such as maternal and infant traumatic injury. Although measures to prevent fetal growth acceleration have not prevailed, multiple diagnostic techniques are available. Numerous sonographic formulae have shown good positive predictive value, but varying degrees of sensitivity (show table 3A-3B). While advances in imaging quality with 3-D ultrasound, MRI, and unique softtissue measurements address the 3-dimensional character of the fetus and create more avenues toward improved prediction and volumetric measurements, maternal prediction and good clinical acumen remain the practitioner's greatest diagnostic allies. Sonographic detection of fetal macrosomia has not been proven to be superior to clinical methods in the laboring patient. Using ROC curve analysis to compare various models of prediction of BW >4000 g; the area under the curve was 0.84 for clinical estimates versus 0.83 for the best sonographic method (HC, AC and FL) [112] .

When macrosomia is suspected clinically, 2-D ultrasound examination remains the most studied and standard diagnostic modality available for diagnosis. Hadlock's formula (encompassing HC, AC and FL measurements) has the best predictive value in the non-diabetic population.

Measurement of the AC alone merits close attention, as this sonographic method is also useful in the diabetic population. Additional measurement of fetal soft tissue (in particular the CCD) may provide more precise correlation with birth weight, but the clinical significance is yet unknown. These recommendations are perhaps the "gold standard" tools for diagnosing fetal macrosomia until more studies in 3-D ultrasound, MRI, and other diagnostic modalities become available.

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