Large size of the fetus leading to disproportion. Childbirth with a large fetus. What worries doctors? Reasons for having large children

It is customary to speak of a large fetus if at birth the child has a body weight from 4000 to 5000 g; a giant (giant) fetus is considered if its weight exceeds 5000 g. Both large and giant fetuses usually differ from other fruits not only large weight - an increase in body weight is accompanied by an increase in body length and other indicators.

Fetal development is determined by the state of health of the pregnant woman and depends on the state of the placenta, which performs complex functions in the system of maternal-fetal relations. In the absence of damaging effects of external and internal factors, the fetus grows according to certain patterns. When the course of pregnancy is complicated and the function of the placenta is impaired, the growth processes of the fetus are disrupted - the rate of its growth slows down or accelerates, as, for example, in women with diabetes mellitus.

In the last decade, the number of births of large fetuses has increased: it is 8-18.5%. The birth of giant children is much less common.

Why are babies born big?

There are many reasons for the development of large fruits, and they are not fully understood. The highest risk factors include nutritional-metabolic obesity (obesity due to increased food consumption) and heredity.

Excessive nutrition of a pregnant woman. Nutrition must meet the needs of the mother’s body and the growing fetus. Improving social and living conditions, excessive high-calorie nutrition - on the one hand, and physical inactivity, on the other, reducing the use of physical labor, and therefore reducing energy consumption - all this negatively affects the health of a pregnant woman. Eating spicy and aromatic substances, significantly degree of increase in appetite, excessive consumption of carbohydrates (baked goods and confectionery products) and fats, fast food intake leads to the intake of excess calories and, due to the inability of their adequate absorption, adversely affects metabolic processes: an increase in sugar, lipids, cholesterol is noted in the blood of a pregnant woman, This leads to maternal obesity and increases the risk of developing a large fetus.

The main test for assessing a woman’s rational nutrition in the second half of pregnancy is an increase in body weight. It is the excess weight gain of a woman in the second half of pregnancy that affects the rate of weight gain of the fetus, since at the beginning of pregnancy the formation of organs and systems occurs, and in the second half (especially in the third trimester) growth and gain of muscle mass occur. A pregnant woman's weight gain of more than 0.5 kg per week and its increase during pregnancy by more than 15 kg indicates either an increase in edema or fat deposition.

Hereditary factors. The development of a large fetus in harmoniously developed, tall, healthy parents can be considered a physiological hereditary phenomenon. Large children in such cases are characterized by a proportional increase in body size and do not have any pathological manifestations. Children at birth have both greater body weight and length. The ratio of the length of the femur to the circumference of the abdomen, determined by ultrasound, remains within the limits of normal individual fluctuations.

There is an increased risk of having large children among parents who were themselves born large (over 4000 g).

The risk of having a large child is high in women who have given birth to a large fetus in the past. Probably, the repeated birth of large fetuses in the same woman is not random and is probably due to the individual characteristics of blood circulation in the uteroplacental system.

Endocrine metabolic diseases(diabetes mellitus, obesity). In the presence of diabetes mellitus - a disease in which the process of glucose absorption is disrupted, all types of metabolism are changed - or when it develops during pregnancy, a disturbance in carbohydrate metabolism is observed in the direction of its acceleration. This leads to excessive glucose levels in the mother’s blood and the fetus’s umbilical cord blood, contributes to an increase in fetal weight, often accompanied by changes in lipid metabolism with the accumulation of fat reserves. The fetus grows unevenly, its growth either accelerates or slows down, which is due to periods of increased or decreased content mother's blood sugar.

With diabetes mellitus, large children can be born with the following signs: a moon-shaped, puffy face, a short neck, a wide shoulder girdle, a large body due to an enlarged liver, spleen, and subcutaneous fat layer. There is an increase not only in body weight, but also in its length, but the child is disproportionately built. The size of the head and the length of the femur are at the upper limit of normal, the abdominal circumference exceeds it, and the ratio of the length of the femur to the abdominal circumference is below individual normal fluctuations. There is a relationship between fetal weight and the duration of diabetes (fetal weight increases as the duration of the mother's disease increases up to 6 years).

There is a direct relationship between the degree of obesity of the pregnant woman and the average weight of the newborn, because there is a violation of lipid metabolism: high mobilization of free fatty acids from the blood of the pregnant woman to the fetus contributes to its rapid growth.

Obesity of the child's father is also regarded as one of the risk factors for large fetuses.

Not all women with obesity develop a large fetus, since obesity can create conditions that are unfavorable for the blood supply to the fetus - inferiority of the uteroplacental system, complications of pregnancy.

The mechanism for the formation of a large fetus in obese women is as follows: in such women, the blood sugar level in the second and third trimesters of pregnancy is slightly increased, which indicates a possible deterioration in the absorption of glucose when it is supplied in excess from food and is caused by relative insulin deficiency, i.e. e. there is latent diabetes mellitus. The penetration of a large amount of glucose into the fetal body leads to the fact that the pancreas begins to function with increased load, which ultimately leads to the formation of a large fetus. Thus, the birth of a large fetus is one of the risk factors for diabetes mellitus in the mother.

Post-maturity. Increasing the duration of pregnancy can lead to the birth of large children. It is possible to both physiologically prolong (extend) pregnancy by 2 weeks (pregnancy lasts longer than 40 weeks, while the condition of the fetus does not suffer), and biological true post-maturity, in which there are signs of overmaturity of the newborn and placenta: fetal weight of 4000 g or more, it is noted increasing its length and head volume. With true postmaturity, the skull bones of a large fetus are more massive and denser, the sutures and fontanelles are less wide and stretchable, as a result of which the mobility of the skull bones in relation to each other (configuration) is reduced, which can complicate the course of labor.

Features of the placenta. The morphofunctional characteristics of the placenta also contribute to the development of a large fetus. In the case of the birth of a large fetus, large size and volume of the placenta are noted. Large thickness (more than 5 cm), area and volume of the placenta lead to more intense metabolism and accelerated development of the fetus. The hormonal function of the fetal-placental system in a pregnant woman with a large fetus is characterized by instability; changes in the level of placental hormones in the blood indirectly affect metabolic processes in the mother’s body and thus affect the growth and development of the fetus.

An increase in the volume of circulating blood with intensive blood supply also contributes to the development of a large fetus: in such conditions, the fetus receives more nutrients. The location of the placenta along the posterior wall of the uterus promotes the development of a large fetus: probably, with this location of the fetus, more favorable conditions are created for the blood supply to the fetus.

Larger children with repeated pregnancies are born due to better conditions of intrauterine nutrition associated with the development of a network of blood vessels in the uterine wall. Better conditions for fetal development play a certain role due to greater extensibility of the uterus and less resistance of the abdominal press. More often, an increase in fetal weight occurs between the third and fifth births.

Uncontrolled long-term use of drugs that improve uteroplacental circulation also promotes fetal growth.

Other factors. Large sizes are more common in male fetuses. Women of young (before 20 years) and older (after 34 years) also often experience the birth of large children. The presence of inflammatory diseases of the female genital organs and menstrual irregularities in the past can also affect the development of a large fetus.

How do they find out about a large fruit?

The basis for diagnosing a large fetus during pregnancy and childbirth is:

• The use of traditional methods - such as measuring the height of the fundus of the uterus above the womb and the circumference of the abdomen, which is carried out by the doctor at each visit to the pregnant woman. In a woman carrying a large fetus, already from the 24th week, a significant excess in the height of the uterine fundus and abdominal circumference is 3-3.5 cm or more from the norm for a given period of pregnancy, and this trend continues until childbirth. A large fetus during childbirth is indicated by the volume of the abdomen (at the level of the navel) over 100 cm, the height of the fundus of the uterus above the womb is more than 42 cm. Ultrasound diagnostics provides the most accurate data, with its help the size of the biparietal size of the head is determined (this is the size determined between the temporal regions ), abdominal circumference, fetal femur length.
• In large fetuses, fetal measurements are usually 2 weeks longer than normal for a given stage of pregnancy. The ratio of the length of the femur to the circumference of the abdomen is also important.

Controlling the weight of a pregnant woman. An increase in weekly weight gain of more than about 5 kg, as well as a total increase in body weight of the pregnant woman of more than 15 kg in the absence of symptoms of gestosis - edema, increased blood pressure, and the appearance of protein in the urine, allows us to assume a large fetus.

Possible complications during childbirth

Childbirth with a large fetus usually begins in a timely manner. However, in case of postmaturity, they can be late, and in case of diabetes mellitus, they can be premature.

• In tall women with normal height and weight indicators, the incidence of complications during pregnancy and childbirth is insignificant. Features of the course of labor are the following complications (their frequency increases in direct proportion with increasing fetal weight):- before the onset of labor (premature) or before the opening of the cervix (early) - is associated with the high position of the fetal head, the lack of differentiation of the waters into anterior and posterior, as well as, apparently, with the characteristics of the fetal bladder and often the accompanying polyhydramnios. With the flow of water, a loop of the umbilical cord may fall out, which poses a threat to the life of the fetus.
• Anomalies of labor- weakness, incoordination. Discoordinated contractions of the uterus are characterized by painful contractions of irregular intensity and duration, and weakness of labor is characterized by short contractions of low strength or rare contractions of normal strength and duration, which leads to slow dilatation of the cervix. The high frequency of weakness of labor forces is explained by overstretching of the muscles of the uterus, especially its lower segment, the large area of ​​the placenta and the need for significant effort to move a large fetus along the birth canal.
• Acute fetal hypoxia(insufficient oxygen supply) develops as a result of prolongation of labor, fatigue of the woman in labor, infection against the background of an increase in the anhydrous interval.
• The situation of a clinically narrow pelvis develops as a result of the discrepancy between the large head of a large fetus and even the normal size of the mother’s pelvis. Such births, in the absence of complications and good labor activity, often end through the natural birth canal.
• Shoulder dystocia is a form of clinically narrow pelvis, since there is a discrepancy between the size of the woman’s small pelvis and the size of the fetal shoulder girdle. In this case, the fetal head, due to its rounded shape, gradually moves forward, stretching the birth canal, while the fetal shoulders, having a rectangular shape, seem to get stuck after birth. Such critical situations require certain professional skills in providing assistance (a number of techniques) to free the shoulder girdle and may be accompanied by a fracture of the collarbone, shoulder, or injury to the cervical spine of a newborn. Shoulder dystocia is more often observed in large fetuses with diabetic fetopathy, that is, size features characteristic of women suffering from diabetes (we discussed them above).
• Increase in the number of surgical interventions associated with complications encountered during childbirth. There is an increase in the frequency of delivery by cesarean section with pronounced signs of a clinically narrow pelvis, weakness of labor, not amenable to drug correction. When a large fetus is combined with a breech presentation (the pelvic part, not the fetal head, is facing the exit from the uterus), a scar on the uterus, post-maturity in an older first-time mother, the presence of various diseases, unfavorable course of previous pregnancies and births, a cesarean section is performed as planned.
• There are more and more births with amniotomy (artificial opening of the amniotic sac), using medicinal methods to induce labor.

Labor induction can be planned from 38-39 weeks of pregnancy in the presence of a large fetal mass in combination with extragenital pathology, as well as when pregnancy lasts more than 41 weeks (in the absence of signs of intrauterine fetal hypoxia).

Postpartum problems Complications in the mother.

When delivering a large fetus, bleeding is observed in the placenta and early postpartum period due to reduced contractility of the uterus and the presence of a large wound surface at the placenta insertion site. In this regard, the number of manual examinations of the uterine cavity is increasing; During this procedure, the unseparated parts of the placenta are removed, as well as a massage of the uterus, which helps to contract the muscles of the uterus and stop bleeding. In women giving birth with a large fetus, perineal ruptures and deep vaginal lacerations more often occur, therefore, in order to prevent trauma to the mother and fetus, perineal dissection is widely used,

In the postpartum period, there is a slow involution (reverse development) of the uterus, anemia (decrease in the amount of hemoglobin), hypogalactia (insufficient milk production). Women with excess body weight more often develop thromboembolic complications - the occurrence of blood clots, more often in the vessels of the lower extremities, purulent-septic complications: endometritis - inflammation of the mucous membrane of the uterine cavity, symphysitis - inflammation of the pubic symphysis (place of articulation of the pubic bones), mastitis - inflammation of the mammary gland. Adverse neonatal outcomes.

Often, large newborns experience neurological disorders (restlessness, tremors - muscle twitching, changes in muscle tone and reflexes), which is a manifestation of cerebrovascular accident, and quite serious birth injuries also occur.

The high frequency of purulent-septic complications (for example, inflammation of the umbilical wound, etc.) in large children is due to primary immunodeficiency (decreased number of immunoglobulins).

These children cause concern not only for neonatologists and pediatricians, but also for neurologists and endocrinologists, because they are predisposed to diabetes mellitus, obesity, more often have abnormalities in their neuropsychic status, and have an increased allergic background.

Prevention

Childbirth with a large fetus can be placed on the line between normality and pathology. Therefore, the main goal pursued when managing pregnancy and childbirth with a large fetus is to prevent possible complications.

For women at risk, prenatal hospitalization is required to prepare for childbirth and choose the method of optimal delivery. Childbirth is carried out with constant monitoring of the condition of the fetus and contractile activity of the uterus. Careful monitoring of the progress of labor is carried out (the rate of dilatation of the cervix, insertion of the head and its advancement along the birth canal) in order to timely diagnose weakness of labor or a clinically narrow pelvis.

If the size of the fetus exceeds the norm, constant monitoring of the woman in labor, widespread use of a vitamin-energy complex, antispasmodics, analgesia, timely administration of birth-stimulating therapy, and prevention of fetal hypoxia are necessary (for this, the administration of medications is used).

When deviations from the normal course of labor are detected, the choice is often made in favor of a cesarean section.

To prevent bleeding at the time of eruption of the head or immediately after childbirth, the woman is given a drug that promotes contraction of the uterus; After childbirth, an IV with contracting drugs is placed. Even with the successful completion of labor and the birth of a child in satisfactory condition, careful monitoring of the newborn is necessary. With proper and careful care, large children and giant children develop normally in the future.

Prevention of macrosomia (large size) of the fetus is carried out primarily in women with identified metabolic disorders, in pregnant women with obesity, overnutrition, and diabetes mellitus.

Diet - and more...

To prevent a large fetus, the doctor gives the woman the following dietary recommendations:

• It is necessary to eat rationally and balancedly, reducing the amount of pasta, bakery, and confectionery products in the diet, reducing fat consumption while maintaining a sufficient amount of protein, including a large amount of fruits and berries in the diet. The energy value of the diet should be in the range of 2000-2200 kcal (proteins - 120 g, carbohydrates - 250 g, fats -65 g), and if fat metabolism is impaired, up to 1200 kcal.
• You should eat slowly.
• It is advisable to eat often (5-6 times a day), in small portions.
• Pregnant women at risk for developing a large fetus are prescribed a predominantly vegetable diet (salads, greens, green beans, tomatoes, cabbage, and vegetable oils from fats). Such women are advised to completely exclude easily digestible carbohydrates (sweets, baked goods, confectionery) from their diet.
• Be sure to combine the diet with a daily set of physical exercises for 20-30 minutes (in the absence of contraindications).
• Insulin-dependent diabetes requires strict correction, that is, control of blood sugar.

The diagnosis of “large fetus” is made at the birth of a child weighing more than 4000 g. According to scientific research, the frequency of births of large children has increased significantly in the last decade and ranges from 10% to 16% of all births. Also, sometimes children are born weighing more than 5000g, then the mother’s medical record says: “giant birth.” But this is rare - 1 case in 2000 - 3000 births. Many believe that the heroic size of a baby is a sure sign of health and strength. However, this is not always the case. Let's look at the reasons for the birth of large babies and possible complications during childbirth for the mother and her child.

Information The intrauterine development and growth of the baby is genetically predetermined, but directly depends on the state of the mother’s body, nutritional characteristics and the image of the pregnant woman.

Reasons for having large children:

• Errors in nutrition, that is, excessive consumption of easily digestible carbohydrates (bakery products, pasta) and high-calorie foods in combination with low activity and low physical activity.
• Obesity - a disorder of lipid metabolism leads to a high level of fatty acids in the blood of a pregnant woman, which, penetrating to the fetus, significantly accelerates its growth rate. Obesity of the child's father is considered a risk factor for the birth of a large fetus. However, a pronounced disorder of fat metabolism can lead to narrowing of the placental vessels and, as a consequence, retardation of intrauterine development of the fetus.
• Heredity - tall, physically developed parents most often give birth to large children, all their sizes are proportionally increased.
• Features of the structure of the placenta - with an increase in the thickness and area of ​​the placenta, the intensity of blood circulation increases, and the fetus receives more stimulating hormones and nutrients.
• Features of the blood supply to the uterus - the likelihood of having a large child increases during the second or third pregnancy, since the vascular network of the uterus is better developed and better conditions are created for the development of the fetus.
• With diabetes mellitus, the level of glucose in the blood of a pregnant woman is significantly increased, which can easily penetrate to the fetus, unlike insulin, which promotes its entry into cells.

  information In this case, disproportionate growth of the fetus occurs (the shoulders significantly exceed the size of the head), the liver enlarges, and subcutaneous fat is deposited.

• Uncontrolled use of drugs that activate metabolic processes, especially.
• When pregnancy is carried beyond term, if the placenta is functioning normally, further uniform growth of the fetus occurs. As the placenta ages, signs of fetal hypoxia (oxygen starvation) are observed and its condition gradually worsens.
• With hemolytic disease of the fetus, which occurs when the blood of the mother and child is incompatible by group or Rh, tissue swelling occurs and the size of the fetus increases.

You can expect the possibility of having a large baby at the end of the third trimester of pregnancy. in several ways:

• Measuring the abdominal circumference (AC) at the level of the navel and the height of the uterine fundus (FH) with a centimeter tape. Coolant>100 cm, and VDM>40 cm. You can calculate the estimated weight of the fetus by multiplying these indicators. This method gives more reliable results if the thickness of the subcutaneous fat fold at the navel level does not exceed 2.5 - 3 cm.
• Measuring the main dimensions of the fruit A and determining its estimated mass. The method is more accurate than the previous one and allows you to calculate the ratio of the length of the femur to the circumference of the abdomen and the biparietal size of the head to determine whether the baby is developing evenly.
• An increase of more than 500g per week in the absence of edema and other signs of gestosis.

Pregnancy, as a rule, proceeds without complications if the increase in fetal weight is not associated with endocrine diseases of the mother. Only at the end of pregnancy can difficulty breathing and shortness of breath on exertion be more common; this is due to the high position of the uterine fundus, which complicates the movement of the diaphragm and prevents the lungs from fully opening.

Features of the course of labor with a large fetus:

In tall, healthy women, childbirth usually proceeds without complications, because the fetus and the mother's pelvis are completely consistent with each other.

• Premature(before the onset of labor) or earlier(up to 5 - 6 cm) occurs due to the lack of contact between the fetal head and the pelvic bones, since the large head cannot be inserted into the pelvis and the waters are not divided into anterior and posterior.
• Anomalies of labor– primary and secondary weakness, discoordinated labor, as well as weakness of pushing in the second stage of labor. These complications develop due to overstretching of the muscle fibers of the uterus.
• Clinically, there is a discrepancy between the sizes of the fetal head and the mother’s pelvis. Natural childbirth in such a situation is impossible and an emergency caesarean section is indicated.
• Shoulder dystocia– with diabetic fetopathy, the fetal shoulder girdle is much larger than the head and gets stuck between the sacrum and the pubic symphysis. This situation requires the immediate use of special aids and often results in fractures of the collarbone, shoulder or cervical spine. Therefore, if the mother has diabetes mellitus, a planned caesarean section is prescribed.
• With a prolonged course of labor and various anomalies of labor, it often develops fetal hypoxia(lack of oxygen), which subsequently leads to disruption of the processes of adaptation to independent life.
• In the third stage of labor, due to overstretching of the uterus, disturbances in the separation of the placenta and hypotonic bleeding often occur, requiring the use of surgical aids to stop the bleeding.

Important When a large fetus is combined with additional indications, a planned cesarean section is prescribed to prevent all sorts of complications of natural childbirth.

Classification according to ICD – 10 O33
Large size of the fetus, leading to the appearance
imbalances that require provision
mothers' medical care.
A fruit is large if its weight
above 4.0 kg, or 4000 g. Giant fruit is accepted
counted if its mass is higher than 5.0 kg, or 5000 g.

- a child with a fetal weight of more than 4 kg. Children weighing over 5 kg at birth are called giant. Pregnancy with a large fetus is manifested by a significant increase in the abdominal circumference and weight of the pregnant woman, and a high position of the uterine fundus. To make a diagnosis, fetometry is used, which, if indicated, is supplemented by determining blood sugar levels, a glucose tolerance test, and invasive methods of prenatal diagnosis. During pregnancy, monitoring of the condition of the woman and the fetus is provided. A natural or surgical option for delivery is selected taking into account the data obtained during the examination.

General information

A large fetus (baby macrosomia) is said to occur when its weight is greater than the 90th percentile, which corresponds to gestational age. The height of large and giant children is increased to more than 54 cm, their body proportions are normal, there are no signs of genetic abnormalities and intrauterine damage to organs and systems. Today, the frequency of carrying heavy children is 8.8-10.5%. Giant babies are born in every 3,000 births. Macrosomia of newborns is more often observed in women over 30 years of age who have given birth repeatedly, and in patients with signs of obesity and diabetes mellitus. According to statistics, 28.5% of pregnant women with 1st degree obesity give birth to a large baby. With the 2nd degree, this figure reaches 32.9%, and with the 3rd - 35.5%. Since the birth of a large fetus increases the likelihood of complications, such children require more careful medical supervision.

Causes of a large fetus

The height and weight of the intrauterine child increase proportionally in the presence of one or a combination of several provoking factors associated with the state of health, the eating behavior of the expectant mother, and the characteristics of the current and past pregnancies. According to research in the field of obstetrics and gynecology, the most common reasons for the birth of large children are:

• Metabolic disorders in pregnant women. Fetal macrosomia is more often detected in women with non-insulin-dependent, insulin-dependent, gestational diabetes, and obesity. Disruption of carbohydrate and fat metabolism contributes to the acceleration of plastic processes in the child’s body due to the anabolic effect of insulin.
• Irrational diet. A rapid increase in fetal weight is observed with a high average daily calorie intake and an imbalanced ratio between the main nutritional ingredients. The risk of macrosomia increases with excess consumption of fats and carbohydrates, lack of calcium, phosphorus, copper, vitamins B1, B2, C, PP.
• Post-term pregnancy. The lengthening of the gestational age is accompanied by the continuation of intrauterine development of the fetus, a further increase in its weight and height. This factor is of particular importance for women who have given birth multiple times, since each subsequent pregnancy is often longer than the previous one.
• Genetic predisposition. The role of hereditary mechanisms in the occurrence of macrosomia is still being studied. The genetic theory is supported by the frequent birth of large children to strongly built, tall parents. Experts reasonably include women with a height of 1.70 m and a body weight of 70 kg or more in the risk group.
• Large newborn in a previous pregnancy. According to statistics, the weight of the second fetus is often 20-30% greater than the first. Most likely, this is due to the higher readiness of the woman’s body for gestation and better functioning of the placental system. In addition, endocrinopathies and somatic diseases worsen with age.
• Use of drugs with anabolic effect. More intensive growth of the child's tissue occurs when taking certain medications that enhance anabolism. Hormonal drugs (glucocorticoids, gestagens), inosine, glucose, orotic acid and a number of other substances have a similar effect.

Pathogenesis

The main mechanism leading to the development of a large fetus is the acceleration of plastic processes. Typically, significant weight gain is associated with the passage of more nutrients through the placenta during a high-calorie diet and exposure to high concentrations of insulin produced in response to excess glucose in the blood of the pregnant woman. The intensification of anabolic processes is manifested by increased formation of fetal tissues and an increase in its size. The ability for rapid growth and development due to the active absorption of nutrients can also be constitutionally determined. Prolongation of gestation aggravates the situation, since the capabilities of the aging placenta no longer satisfy the needs of a large fetus for nutrition and oxygen.

Symptoms of a large fetus

Typically, the course of pregnancy when carrying a large child is practically no different from the physiological one. Possible signs of a large fetus at the time of birth are a woman’s weight gain of more than 15 kg, an abdominal circumference of 100 cm or more, a height of the uterine fundus of more than 42 cm. 7-10% of women have complaints characteristic of compression of the inferior vena cava by an enlarged uterus. When lying on their backs, they note a significant deterioration in their health - dizziness, weakness, nausea, ringing in the ears, chest heaviness, darkening in the eyes. Closer to childbirth, the severity of such disorders can reach the depths of a fainting state. Characteristic disorders of the gastrointestinal tract are a feeling of heartburn after eating and constipation.

Complications

A large fetus, which puts increased pressure on the isthmic-cervical region, is one of the factors in the formation of a short cervix and a high risk of early termination of pregnancy. By the end of gestation, fetoplacental insufficiency and hypoxia may occur due to a discrepancy between the functional capabilities of the placenta and the needs of the child. Childbirth is complicated by premature rupture of amniotic fluid, protracted course, weakness of labor, and fetal asphyxia. The risk of maternal trauma is higher - ruptures of the perineum, vagina, cervix and body of the uterus, divergence of the pubic symphysis. Possible birth injuries to the newborn - fractures of the bones of the arm, collarbone, formation of cephalohematoma, damage to the brachial plexus, hemorrhages in the brain. After childbirth, hypotonic uterine bleeding occurs more often.

In large children carried by women with diabetes, immediately after birth, polycythemia, respiratory distress syndrome and metabolic disorders - hypoglycemia, neonatal hypocalcemia, hypomagnesemia, hyperbilirubinemia are likely. The long-term consequences of complicated childbirth with a large fetus are the formation of rectovaginal and genitourinary fistulas as a result of prolonged compression of the soft tissues of the birth canal with a clinically narrow pelvis, paresis of the leg muscles with lameness. Children who have suffered birth injuries may have neurological disorders and lag behind in psychomotor development. According to the results of observations, in women who give birth to a child weighing 3740 g or more, the risk of breast cancer in the future increases by 2.5 times, which is associated with specific hormonal changes in the body - an increase in the concentration of estrogen, a decrease in the level of antiestrogens and the release of significant amounts of insulin-like growth factor.

Diagnostics

A significant increase in the weight and volume of a pregnant woman’s abdomen is the basis for prescribing examination methods to determine the large size of the fetus. The objectives of the diagnostic search are to assess the fetometric indicators and vital functions of the child, to exclude other disorders in which similar clinical manifestations are noted. If a large fetus is suspected, the following are recommended:

• Fetal fetometry. Based on data on the biparietal size of the head, the circumference of the child’s abdomen, the length of the femur and its relationship with the abdominal girth, it is possible to accurately calculate the estimated body weight. Using ultrasound, they also obtain information about the amount of amniotic fluid, identify multiple pregnancies and possible anatomical defects.
• Determination of blood sugar levels. Since large children are often born to pregnant women with hyperglycemia, analysis of glucose levels makes it possible to clarify the cause of fetal hypertrophy. The indicator is a marker for proper management of pregnancy. To diagnose latent diabetes mellitus, the examination is supplemented with a glucose tolerance test.
• Invasive diagnostic methods. Indicated for suspected genetic defects and developmental anomalies, which are manifested by pathological macrosomia of the fetus. To confirm chromosomal pathology, taking into account the period, ultrasound-guided amniocentesis, placentocentesis, and cordocentesis are used. The latter method is also effective for determining Rh conflict.

After the 30th week of pregnancy, to assess the condition of the child and timely detect fetoplacental insufficiency, if indicated, cardiotocography or phonocardiography of the fetus and Dopplerography of the uterine-placental blood flow are performed. If signs of a threatened miscarriage appear, cervicometry is performed to exclude isthmic-cervical insufficiency. The condition is differentiated from multiple pregnancy, polyhydramnios, hereditary macrosomia (Beckwith-Wiedemann, Marshall, Sotos, Weaver syndromes), edematous form of hemolytic disease, other fetal diseases (hydrocephalus, teratoma, erythroblastosis, etc.), submucosal and subserous uterine fibroids. If necessary, the patient is consulted by an endocrinologist, geneticist, or immunologist.

Management of pregnancy and childbirth with a large fetus

Tactics for managing pregnancy with a large baby include regular monitoring of the condition of the mother and fetus. Drug therapy with the prescription of antispasmodics and tocolytics is indicated only if there is a risk of preterm birth. If the disorder is combined with a shortening of the cervix, it is possible to install an obstetric pessary or place sutures around the cervical canal. The patient was recommended therapeutic exercises and diet correction with a limited amount of carbohydrates and fats. When treating concomitant diseases and complications of pregnancy, it is necessary to exclude drugs with anabolic effects.

Usually a large fetus can be born on its own, but in some cases a caesarean section is preferable. The optimal method of delivery is chosen taking into account data on past pregnancies and births, information on the clinical correspondence of the size of the fetus and the woman’s pelvis, the presence of extragenital and genital pathology, the duration and characteristics of the gestational period:

• Surgical delivery. Caesarean section is indicated for post-term pregnancy, breech presentation, anatomical narrowing of the pelvis, the presence of myomatous nodes or abnormalities of the uterus. Surgical intervention is also performed for women in labor under the age of 18 and over 30 years with diseases in which it is necessary to reduce or eliminate the period of pushing, stillbirth and recurrent miscarriage in the past, conception using ART.
• Natural childbirth. Recommended for uncomplicated pregnancy, favorable obstetric history and sufficient pelvic size for the passage of the child through the birth canal. During childbirth, the contractile activity of the uterus and the condition of the fetus are necessarily monitored, and the compliance of the head with the size of the pelvis is monitored. If necessary, analgesics, antispasmodics, and uterotonics are administered. In the afterbirth and early postpartum period, measures are taken to prevent postpartum hemorrhage.

If weakness and other anomalies of labor are observed during natural childbirth, signs of fetal hypoxia appear, diagnostic criteria for functional narrowing of the pelvis are determined, and delivery is completed with an emergency cesarean section for health reasons. Intrapartum fetal death during complicated labor is an indication for craniotomy.

Prognosis and prevention

Timely diagnosis and the correct choice of method of delivery minimize possible complications and negative consequences of carrying a large fetus. For preventive purposes, women suffering from obesity and diabetes are recommended to plan pregnancy with weight loss and treatment of the underlying disease. Pregnant patients at risk are advised to undergo early registration with a consultation, regular examinations by an obstetrician-gynecologist, undergoing routine ultrasound screening, sufficient physical activity, a rational diet with a high protein content, and limiting foods rich in carbohydrates and fats.