Information sharing and communication in management of large for gestational age babies in non-diabetic mothers ;7JUNE 2023

 

Large for Gestational Age (LGA)

Introduction: Large for Gestational Age (LGA) 🌟

• Definition of LGA: Refers to fetal size above the 90th centile nomogram for gestational age. 📏

• Prevalence: More common among women with obesity or gestational diabetes. ⚖️

• Associated Adverse Outcomes:

  • Maternal complications include:
    • Emergency caesarean birth 🚑
    • Postpartum hemorrhage (PPH) 🩸
    • Severe perineal trauma 💔
  • Neonatal complications include:
    • Shoulder dystocia 🤱
    • Neonatal hypoglycemia 🍼

• Critical Period: Most maternal and neonatal morbidity occurs during labor or attempted vaginal birth. ⏳

• Antenatal Discussions:

  • Essential for sharing information, counseling, and collaborative decision-making regarding mode and timing of birth. 🗣️

• Lack of Guidelines:

  • Absence of specific guidelines for managing LGA in non-diabetic mothers creates uncertainty for obstetricians. 🤔
  • HSIB (2020) National Learning Report highlighted poor information sharing and collaborative decision-making in cases of suspected LGA. 📉

• Key Challenges in Care:

  • Appropriateness of screening methods and accurate diagnosis of LGA 🩺
  • Counseling on benefits, risks, and alternatives of obstetric interventions ⚖️
  • Collaborating with parents to decide on timing and mode of delivery 🤝

• Objective of the Article:

  • Evaluate limitations of ultrasound in fetal weight estimation 📡
  • Present evidence on obstetric interventions and risks/benefits of early delivery 🔍
  • Highlight the importance of shared decision-making for individualized care 🛠️
  • Introduce decision-making tools like BRAIN and IDECIDE to empower patients. 📋

• Understanding the Term ‘Big Baby’:

  • Terms like macrosomia and LGA are often used interchangeably. 🔄
  • Definitions vary across sources:
    • RCOG: Macrosomia as birth weight >4500 g. 📏
    • NICE: LGA as weight >95th centile for gestational age. 📊
    • Cochrane Review: Macrosomia as >4000 g or LGA as >90th centile. 📈

• Tools for Tracking Fetal Growth:

  • Centile-based growth charts are available for tracking fetal size:
    • Descriptive Reference Charts: Birth weight distribution in a general population. 🌍
    • Prescriptive Standard Charts: Based on an optimal population (e.g., WHO and INTERGROWTH-21st). 📊
  • The Growth Assessment Protocol (GAP) using GROW charts is widely adopted but has not shown improved detection of LGA. 📉

• Counseling Challenges:

  • Lack of standardized definitions and inconsistent chart use adds complexity to patient counseling. 🩺

• Consequences of LGA:

  • About 10% of babies born in England weigh >4000 g. ⚖️
  • Maternal risks include:
    • Postpartum hemorrhage 🩸
    • Perineal trauma 💔
    • Instrumental or caesarean birth risks ⚕️
  • Neonatal risks include:
    • Bone fractures, shoulder dystocia, brachial plexus injury, hypoxic brain injury, and neonatal unit admission. 👶
  • Statistics:
    • 52% of shoulder dystocia cases occur in babies >4000 g. 🤱
    • HSIB (2019–2020): 71% of grade III hypoxic brain ischemia cases involved babies >4000 g. 🩸

• Potential for Gestational Diabetes Diagnosis:

  • Suspected LGA on ultrasound may lead to detection of late-onset gestational diabetes, enabling care adjustments. 🩺
  • NICE Diabetes Guidelines do not specify LGA as an indication for screening. 📋

• Screening for LGA:

  • SFH measurement is commonly used to screen for small-for-gestational-age (SGA) babies but is not routinely recommended for LGA in non-diabetic mothers. 📏
  • SFH Limitations:
    • Low sensitivity and specificity for LGA/macrosomia detection. 🔍
  • NICE recommends ultrasound if SFH exceeds expectations by >2 cm. 📡

• Ultrasound Accuracy:

  • Evidence does not fully support routine ultrasound for LGA screening in low-risk populations. 📉
  • Studies indicate:
    • Overestimation of fetal weight in ~43.9% of cases. ⚖️
    • Better predictive value when performed within 10 days of delivery. ⏳
  • Alternatives like fetal MRI are expensive and lack proven superiority. 💰

• Decision-Making Tools:

  • BRAIN: Helps patients structure decision-making by considering Benefits, Risks, Alternatives, Intuition, and Nothing (doing nothing). 🧠
  • IDECIDE: A digital tool guiding shared decision-making during intrapartum care. 💻

• Importance of Shared Decision-Making:

  • Empowers patients to make informed choices. 🤝
  • Reduces anxiety by fostering two-way communication and transparency. 🌈

• Legal and Ethical Considerations:

  • The GMC mandates meaningful information exchange for decision-making. ⚖️
  • Montgomery Ruling: Clinicians must disclose risks significant to the patient’s perspective. 🏛️

• Conclusion:

  • Managing LGA in non-diabetic mothers is challenging due to:
    • Limitations of ultrasound-based EFW 📡
    • Weak evidence for routine obstetric interventions 🔬
  • Shared decision-making is essential for personalized care and patient satisfaction. 🤝
  • Decision-making tools like BRAIN and IDECIDE provide structured, patient-centered frameworks. 🛠️