M.SC. Obstetrics , Academic Staff , Nasibeh Faculty Of Nursing And Midwifery , Sari,Mazandran University, Iran
Abstract
Background and aim : In case of appearing macrosomia , the amount of maternal - infant complications will increase .The aim of this research is evaluating these complications and their relationship with fetal macrosomia , which was carried out in Imam khomeini hospital of sari in 1997 .
Materials and methods : In this cohort research , 5440 child- birth files ( 4400 cases of normal vaginal delivery and 1040 cesarian ) were studied . The case group was consisting term infant weighing 4000 grams and more as well as control group consisting of term infants weighing 2500- 3999 grams. The factors like age , parity and delivery between two groups were similarized . Moreover , repeated cases of cesarian in both groups were laid aside .
Results : The results of this study show that total amount cesarian in case group was 15.5% in contrary to 11.5% in control group ( p < 0.037 ) . The most important reason for cesarian in macrosomia group was fetal distress and lack of progress . Shoulder dystocia and meconium defication are those complications related to macrosomic infants which shows meaningful statistical difference if compared with control group . ( P < 0.002 ) . Postnatal bleeding and more usage of oxytocin for acceleration of labor in case group shows meaningful statistical difference in control group ( P < 0.001 ) .
Analysis : Studying the results show that despite the high amount of vaginal delivery in those mothers having macrosomic infants , dose not show any meaningful increase of maternal – infant complication except shoulder dystocia , meconium defication and , postnatal bleeding . At the same time , follow up studies on long term result of complicated macrosomic infant are recommended.
Key words : macrosomia , management of delivery , maternal complications and infant complications .
Introduction
Today , as it is emphasized on improvement of result of pregnancy and decreasing maternal as well as infants complications and damages , studying those obstetrics problems which lead to increase these damages are necessary .
One of these problems is increase of fetal size or macrosomia . Macrosomia is called to those infants weighing at least 4000 grams or more ( 1 , 2 ) . The amount of macrosomia incidence is variable from 3.67% in Bangal , 6% in Iran to 10% in Canada and 15% in Denmark ( 2 , 3 , 4 , 5 ) . In case of appearing the macrosomia , the amount of Maternal - infant complications and damages would be increased . ( 6 , 7 , 8 )
Those risks threatening mother are : delivery disorders , intenatal damages , uterus tearing and increased manipulation of delivery passage . ( 6 , 9 ) Fetal distress , shousder dystocia and intenatal damages may also be increased . ( 10 , 11 )
So the reason for the study is to evaluating child - birth complications in macrosomic neonates and their mothers in comparing with neonates having normal weight . The research is carried out
on child - birth of Imam Khomeini Hospital of Sari in 1997 .
Materials and methods
In this cohort research all 1997 child - birth files of Imam Khomeini Hospital of Sari , the sole governmental maternity hospital affiliated to Mazandaran Medical Science University , were studied which consisting of 5440 cases of delivery ( 4400 cases of vaginal and 1040 cases of cesarian delivery ) . All files of mother and macrosomic infant were studied . By similarization of parity , age and presentation , 347 cases of women having term infant weighted 2500 - 3999 grams were selected as control group . Meanwhile , all below 37 weeks delivery and repeated cesarian were laid aside .
The factors studied were as follows :
1 ) Particulars of mothers and infants like : age and parity age of pregnancy , infant weight and congenital abnormality .
2 ) Maternal complications such as : postnatal bleeding , death of mother , vaginal tearing and induction and acceleration of labor .
3 ) Fetal complications such as : shoulder dystocia , fetal distress , asphyxia , apgar classification , death of infant , clavicular fracture , meconium defication and brachial plexus paralysis .
For quantity variable T test and for quality variable x2test were used .
Results
Macrosomia infants were 232 cases ( 4.3% ) among which 162 cases ( 70% ) were male infants . The average weight of infants was 4257±209 grams in macrosomic group and 3264 ±331 grams in control group . The mothers age was 27.1 ±5 in macrosomic group in contrary to 27.3 ±4 years in control group ( NS ) .The average number of parity also resulted to 2.6 ±1.2 in macrosomic group in contrary to 2.5 ±1.3 in control group ( NS ) .
The average of pregnancy age ( based on weeks ) resulted to 39.4 ± 4 in macrosomic group in contrary to 38.7±3 weeks in control group . Since both macrosomia and control groups were term , but the comparison between both groups showed meaningful difference ( P < 0.05 ) .
Studying method of delivery showed that cesarian carried out for 33 persons ( 15.5% ) in macrosomic group in contrary to 40 persons ( 11.5% ) in control group ( P < 0.037 ) . Vaginal delivery carried out for 180 persons ( 84.5% ) in macrosomic group in contrary to 303 persons ( 87.3% ) in control group . The amount of by equipment delivery was 4 persons ( 1.2 % ) in control group . No by equipment delivery carried out in macrosomic group . Comparing the method of delivery showed meaningful difference in both groups ( p < 0.03 ) . The reason for cesarian is showed in table 1 . Concerning the reason for cesarian , lack of progress and thick meconium showed meaningful difference in both groups ( p < 0.03 ) .
Studying infant complications showed that among 6 cases of shoulder dystocia , 2 cases were accompanied by brachial plexus paralysis . Appearing shoulder dystocia and meconium defication in macrosomic group were the most important complications which had meaningful difference in control group ( P < 0.002 ) .
The amount of relative risk calculated for shoulder dystocia was also 9.78 ( 28.7 and 3.3 CI 95% ) . In macrosomia 1 case and in control group 2 cases of abnormal congenital were observed ( NS ) .
Just one case ( 4% ) of asphyxia has happened in macrosomic group . No infant death was observed in macrosomia group , but there were 9 cases of infant death in control group ( NS ) . Other complications were compared in table 2 .
Table 1 : studying the reason for cesarian delivery in macrosomia and control group of Imam Khomeini Hospital in 1997 .
Reason for cesarian delivery |
C.P.D |
fetal distress |
Abnormal presentation |
lack of progress * |
Thick meconium |
total |
Control |
9 ( 22.5% ) |
18 ( 45% ) |
4 ( 10% ) |
5 ( 12.5% ) |
4 ( 10% ) |
40 ( 100% ) |
Case |
6 ( 18.2% ) |
14 (42.4% ) |
3 ( 9% ) |
9 ( 27.3% ) |
1 ( 3% ) |
33 ( 100% ) |
* It is meaningful between both groups ( P < 0.03 ) .
Table 2 : the comparison of fetal - infant complications in both macrosomia and control group of Imam Khomeini Hospital of Sari , 1997 .
complication |
Shoulder dystocia |
Meconium defication |
apgar score below 7 |
Aspiration Meconium |
brachial plexusus paralysis |
Clavicular fracture |
fetal distress |
total | |
|
Minute-1 |
Minute-5 |
|||||||
Control group |
1(0.2%) |
25 ( 7.4%) |
9 |
9 |
4 ( 1.1% ) |
- |
- |
19 |
66 |
case group (based on number ) |
6 (2.8%) |
28 (12.1%) |
8 |
1 |
2 (0.9%) |
2 (0.9%) |
1 (0.5%) |
19 (8.3%) |
67 (29.4%) |
P |
< 0.0025 |
<0.0538 |
< 0.027 |
NS |
NS |
NS |
NS |
- | |
Studying maternal complications shows that no maternal death was observed in macrosomia group , except 1 case in control group ( NS ) . As it is observed , postnatal bleeding and acceleration of labor was more in macrosomia group which shows meaningful difference in both group .
Table 3 : the comparison of maternal complications in macrosomia and control group of Imam Khomeini Hospital of Sari , 1997 .
Complication |
Expedition in delivery |
Induction of delivery |
postantal |
Vagina |
Total |
Control |
100(28.8%) |
24 ( 6.9% ) |
5 ( 1.4% ) |
33 ( 9.5% ) |
162(46.6%) |
Case |
76 ( 35% ) |
2 ( 0.9% ) |
7 ( 3.3% ) |
26 ( 12.2% ) |
111(15.4%) |
P |
< 0.001 |
< 0.01 |
< 0.01 |
NS |
- |
Discussion
In general , the results of present study show that among those infant complications just 2.8% of shoulder dystocia and 12.1% of meconium defication in macrosomic group is more than in control group , but other complications are similar between both groups , even some other complications like apgar score below 7 in minute 5 in control group was more than macrosomias .
These findings are similar to the reports of other researchers who believe that intenatal infant complications are not limited to macrosomic infant and may happen similarly for those infant having normal weight as well ( 8 , 10 , 14 ) .
Rodriguez and Gonen have mentioned 2% for shoulder dystocia ( 6, 17 ) . Moreover , Gabbe and Benedetti stated it 0.3- 0.13% . The reason for such a low amount of shoulder dystocia is increase of cesarian ( 18 ) . In the contrary , Blickstein and kimberly have mentioned it 11.2% and 11% ( 8 , 14 ) . As Meshari and Majalbert indicated the reason for increasing shoulder dystocia in these studies is using forceps , specially mid forceps . Another reason is more high risk mothers with diabetes mellitus in these studies ( 4 , 5 ) .
Despite the high amount of meconium defication ( 12.1% ) in macrosomic group , the amount of aspiration meconium ( 0.9% ) was similar to control group . Meshari and Berard have approved this finding as well ( 5 , 11 ) . In the contrary , Boyd found the asphyxia as well as aspiration meconium in macrosomia more than control groupand reported the asphyxia 9.1% . One reason for such increase is more application of midforceps in recent study moreover , those macrosomia mothers who had diabetics or were postterm , were higher in comparison with other studies .
The amount of macrosomia incidence in the research was 4.3% . The amount of incidence is mentioned 3.67% by Mitra , 8.2% by Meshari and 13% by kimberly . The amount of macrosomia incidence are generaly reported differently according to climate and racial conditions and presence of talent factors in different regions ( 1 , 2 , 5 ) .
Concerning maternal complications , the results generally showed that , like other studies , despite low increase of some complications , no death or complication was observed in this group ( 10, 13 ) . In this research , postnatal bleeding was 3 times mere in macrosomic group in contrary to control group . The amount of P . P . H is mentioned 5% by kimbcrly and 4.2% by Meshari ( 5 ) . Low amount of bleeding in the research may be due to unproper estimate or postnatal routine use of oxytocin .
In this research ,amount of induction of labor in macrosomic group is almost 9 times lower than control group . Most studies also show that induction of labor of macrosomic infants is not only accompanied with the decrease of cesarian and infant damages ( 15 ) , but also will increase amount of cesarean in some case ( 19 ) .
Induction of labor in macrosomic group was more than control group which may show high amount of protraction of labor and lack of progress in macrosomic group .
Houchang and Bahar observed more use of oxytocin in macrosomic group than control group ( 13,20) . So , we can conclude that shoulder dystocia is the most important complication in macrosomic infants . Mothers having macrosomic infants are more in danger due to post natal bleeding , more use of oxytocin and vaginal tearing .
In general , we can conclude that despite high amount of vaginal delivery in macrosomic group ( 84.5% ) , other maternal - infant complications in macrosomic infants and their mothers will not be increased except shoulder dystocia , meconium defication and postnatal bleeding .
At the same time , follow - up studies on long term result of complicated macrosomic infant are recommended . This research may be effective for logical selection of child - birth method in macrosomic infants .
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