Suspected large for gestational age fetus and suspected

polyhydramnios

Full Title of Guideline: Guideline for the investigation of ‘large for gestational age’
(Symphysial- fundal height >90th centile) and management of
the large for gestational age fetus and polyhydramnios in
women with a singleton pregnancy
Author (include email and role): Gemma Malin Consultant Obstetrician
Division & Speciality: Family health, obstetrics
Scope (Target audience, state if Trust Midwives and Obstetricians
wide):
Review date (when this version goes out August 2022 (Amended October 2017)
of date):
Explicit definition of patient group
to which it applies (e.g. inclusion and All pregnant women
exclusion criteria, diagnosis):
Changes from previous version (not New guideline version 1
applicable if this is a new guideline, enter
below if extensive):
Summary of evidence base this
guideline has been created from:
This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert.
Caution is advised when using guidelines after the review date or outside of the Trust.

1
MACROSOMIA

Macrosomia is associated with an increased risk of shoulder dystocia

and birth trauma, with associated adverse maternal and neonatal
outcomes. These include maternal post-partum haemorrhage, third and
fourth degree tears, and fractures, Erb’s palsy and hypoxic injury to the
infant. (King JR, Miller DA, Ouzounian 2012)

Definitions

For the purposes of this guideline, macrosomia at birth will be defined as

birth weight  4500g. As the definition of macrosomia relates to
birthweight, a fetus cannot technically be described as macrosomic until
it is born. The term ‘large for gestational age’ (LGA) refers to suspected
macrosomia in pregnancy and will be used instead. The thresholds used
to define LGA antenatally will be:
 symphisio-fundal height (SFH) > 90th centile for gestation
 Abdominal circumference (AC) > 95th centile for gestation
 Estimated fetal weight (EFW) > 95th centile for gestation

Management of women with suspected LGA fetus

Detected at 18-21 weeks gestation

At this gestation, accelerated fetal growth is unlikely to be related to

maternal glycaemic status

Recommendation:
 If the AC is > 95th centile at the routine anomaly scan, a glucose
tolerance test (GTT) is not indicated.
 A follow up antenatal clinic appointment with repeat ultrasound
scan for biometry scheduled for 36-38 weeks.

Detected at 24-36 weeks gestation

Recommendations:

 If the symphysial-fundal height (SFH) is > 90th centile on routine

measurements, an ultrasound scan for fetal biometry should be
arranged for the next available routine appointment if the woman is
not already scheduled for an ultrasound scan

2
  If the EFW and AC are  95th centile, return to routine care. If the
growth trajectory on SFH remains the same, even If this is above
the 90th centile, a repeat scan is not needed.
o These women will only require a further growth scan if the
growth trajectory on SFH changes (rises or falls)
 If the EFW or AC on ultrasound scan are >95th centile:
o a GTT should be arranged as soon as possible
o If a GTT has already been performed at an earlier gestation
with a negative result, consideration should be given to
repeating this. Late development of gestational diabetes may
occur. The decision should be made by a senior registrar or
consultant, taking into account any other evidence of
development of diabetes, for example glycosuria
o Arrange repeat ultrasound scan and antenatal clinic
appointment at 36-38 weeks gestation (If the initial USS is ≥
34 weeks, consider if a repeat scan is necessary, clinical
assessment may be adequate)

Detected at 36- 40 weeks gestation

Recommendations:

 If the symphysial-fundal height (SFH) is > 90th centile on routine

measurements, an ultrasound scan for fetal biometry should be
arranged for the next available routine appointment
 If the EFW and AC on ultrasound scan are  95th centile, return to
routine care
 If the EFW or AC on ultrasound scan are >95th centile:
o Perform a GTT as soon as possible
o If a GTT has already been performed at an earlier gestation,
consideration should be made regarding whether a repeat
test is necessary, The decision should be made by a senior
registrar or consultant, taking into account any other
evidence of development of diabetes, for example glycosuria
 If the GTT is positive (use same thresholds as earlier gestation)
refer to specialist diabetic midwife and dietician clinic, but remain
under original consultant for delivery planning
 Care in labour and postnatally as per gestational diabetes
diagnosed at earlier gestation
  In women who have other risk factors in addition to a LGA fetus,
for example previous caesarean section, care should be
individualised regarding the timing and mode of delivery

Planning delivery for a fetus with EFW/ AC >95th centile at 36-40

weeks
 Advise women of the risks of shoulder dystocia
 Inform women that there is evidence from a randomized control
trial (RCT) (Boulvain et al 2015) that induction of labour at 37-38+6
weeks gestation reduces the risks of shoulder dystocia and
associated morbidity with no increase in the risk of caesarean
section (Relative risk 0.32, 95% CI 0.15 to 0.71; p=0.004). This
should be balanced with evidence from the American college of
Obstetricians and Gynecologists that neonatal outcomes are
optimised, and morbidity reduced, if birth occurs between 39+0
and 40+6 weeks gestation (ACOG 2013)
 Induction of labour may therefore be offered between 37 and 40
weeks, depending on the degree of macrosomia and the
preferences of the woman
 Elective caesarean section may be considered for suspected fetal
macrosomia of at least 5000g in women without diabetes and at
least 4500g in women with diabetes (ACOG 2016)

Polyhydramnios

Polyhydramnios is defined as the excessive accumulation of amniotic

fluid, occurring in 0.2-3.9% of pregnancies. This may occur due to a
variety of maternal and fetal reasons, and in 50% of cases is
unexplained. (Karkhanis 2014) The volume of amniotic fluid varies
according to gestation, but amniotic fluid index (AFI) >25cm constituted
a diagnosis of polyhydramnios regardless of gestation. (Karkhanis 2014)
The severity of polyhydramnios can be sub-classified as
follows(Karkhanis 2014):
 Mild (AFI 25.0-29.9cm)
 Moderate (AFI 30-34.9cm)
 Severe (AFI 35cm)

Unexplained polyhydramnios is a diagnosis of exclusion. The causes

which should be considered are as follows:
Maternal
 Diabetes (gestational or pre-existing)
 Isoimmunisation leading to fetal hydrops
 Drug exposure (e.g.lithium)

Fetal
 Structural or chromosomal abnormalities
 Congenital infections (e.g. toxoplasmosis, parvovirus,
cytomegalovirus, rubella)
 Macrosomia
 Tumours (e.g. teratomas, haemangiomas)

Placental
 Tumours (e.g. chorioangiomas)

Diagnosis and Management of Polyhydramnios

Recommendations for diagnosis and investigation:

 If the symphysial- fundal height measurement is > 90th centile, the

next available routine ultrasound appointment should be booked
for biometry and liquor volume.

 If the fetus is found to be large for gestational age with mild

polyhydramnios (AFI <30cm), manage as per the large for
gestational age guidance. Further investigations for
polyhydramnios alone are not indicated.

 Where the fetus has normal biometry and AFI >95th centile or 
25cm, the following investigations should be performed.
o Next available GTT (if previously normal, consider repeat if
other suspicion of late development of gestational diabetes
e.g. acute increase in AFI, glycosuria)
o Infection screen: cytomegalovirus, parvovirus,
toxoplasmosis, rubella
o Review anomaly scan report and antibody screening tests

 Where the fetus is found to be small for gestational age with an

AC<5th centile or an EFW<5th centile in the presence of an AFI
>95th centile or 25cm liaise with fetal medicine regarding
management
  If the infection screen is positive, an anomaly is present, or AFI 
35cm, then refer to a fetal medicine specialist for review

 If AFI is 25-35cm and no cause for polyhydramnios found:

o Inform woman of risks of preterm labour, cord prolapse and
unstable lie
o Complete paediatric alert form and document the presence
of polyhydramnios in the part 1 maternity record pregnancy
summary and on Medway
o repeat ultrasound and biometry in 4 weeks time
 If AFI is >95th centile but < 25cm, adverse outcome is unlikely.
Arrange repeat ultrasound in 4 weeks time. If AFI remains <25cm
do not offer induction of labour for this indication alone

Follow up in mild- moderate polyhydramnios:

Mild polyhydramnios (AFI <30cm), in association with a large for

gestational age fetus, is likely to be as a result of macrosomia. A glucose
tolerance test should be performed, but further investigation of the
polyhydramnios is not indicated. Mild to moderate polyhydramnios (AFI
<35cm) is less likely to be associated with fetal anomaly or require
interventions such as therapeutic amniocentesis, so referral to a fetal
medicine specialist under this threshold is only indicated if an anomaly
or infectious cause is identified. A systematic review (Morris et al, 2014)
did not show any association between polyhydramnios and adverse
neonatal outcomes (threshold AFI > 24cm or >25cm). Routine induction
of labour prior to 40 weeks has not shown to be of benefit, (Karkhanis
2014) and care should be individualised depending on the severity of the
polyhydramnios, any underlying cause identified and the preferences of
the pregnant woman. A paediatric check to confirm oesophageal
patency through passing a nasogastric tube is recommended in
unexplained polyhydramnios, therefore a paediatric alert should be
completed for this reason.

 If AFI remains > 95th centile and 25-35cm:

o Consider induction of labour at 40 weeks
 If AFI normalises:
o Back to routine care
 ANTENATAL PATHWAY FOR THE DIAGNOSIS AND MANAGEMENT OF THE LARGE FOR GESTATIONAL
AGE (LGA) FETUS IN PREGNANT WOMEN (WITHOUT KNOWN DIABETES)
Arrange:
18-21 WEEKS Abdominal circumference (AC) >  Repeat ultrasound scan and antenatal clinic appointment at 36-38
GESTATION 95th centile at detailed scan? Y
weeks gestation (GTT not indicated)

24-36 WEEKS Symphysial-fundal height (SFH) > Arrange next available routine ultrasound scan (USS) for biometry
Y
GESTATION 90th centile? and liquor volume.
If polyhydramnios present, see polyhydramnios pathway

AC or estimated fetal weight Back to routine care

(EFW) > 95th centile on scan N Repeat scan only indicated if
biometry? growth trajectory on SFH
changes
Y
Arrange:
 GTT next available. Consider repeat if previously normal
 Repeat ultrasound scan and antenatal clinic appointment at 36-38
weeks gestation (If the initial USS is ≥ 34 weeks, consider if a repeat
scan is necessary, clinical assessment may be adequate)
o If the fetus remains LGA consider the offer of IOL at 37-40 or
caesarean if EFW>5000g


36-40 WEEKS Symphysial-fundal height (SFH) > Y Arrange next available
GESTATION 90th centile? routine ultrasound scan (USS)
for biometry
Offer: 7 Y
 Induction of labour at 37-40 weeks gestation
 For GTT as soon as possible if not previously tested Back to routine care
Y AC or EFW> 95th centile on N
 Consider caesarean if EFW >5000g scan biometry?
 ANTENATAL PATHWAY FOR THE DIAGNOSIS AND MANAGEMENT OF POLYHYDRAMNIOS IN WOMEN WITH A
SINGLETON PREGNANCY
AC<5th centile or an EFW<5th with Liaise with fetal medicine
Symphysial-fundal height (SFH) AFI >95th centile or 25cm? Y
specialist
>90th centile for gestation?
AC or estimated fetal weight
Y (EFW) > 95th centile on scan with
normal liquor volume or mild
Book next available routine scan polyhydramnios (AFI <30cm)? Y Follow large for gestational age
for biometry and liquor volume (LGA) pathway
N

Normal biometry and AFI? Back to routine care. Repeat scan

only indicated if SFH trajectory
Y changes

N Investigate:
 Glucose tolerance test (GTT) next available
(unless > 28 weeks and already performed)
Normal biometry and AFI > 95th
 Infection screen- parvovirus, toxoplasmosis,
centile for gestation or  25cm?
Y CMV, rubella
 Check anomaly scan and antibody screen result

 See 4 weekly with ultrasound scan for biometry and liquor volume.
 Inform woman of risks of preterm labour/ unstable lie
 Complete paediatric alert form & document on pregnancy plan Infection screen Refer to fetal
 Refer to fetal medicine specialist if AFI  35cm N positive, anomaly Y medicine
 Consider induction of labour at 40 weeks if polyhydramnios persists present or AFI  specialist
35cm?
8
References

ACOG Committee Opinion No 579: Definition of term pregnancy. Obstet

Gynecol, 2013. 122(5): p. 1139-40.

ACOG Practice Bulletin No 173: Fetal macrosomia. Obstet Gynecol

2016; 128: e195-209.

Allen KW, Wallace SVF. Fetal Macrosomia. Obstet Gynecol Reprod Biol
2013. 6: p. 185-8.

Boulvain M et al., Induction of labour versus expectant management for

large-for-date fetuses: a randomised controlled trial. Lancet, 2015.
385(9987): p. 2600-5.

Karkhanis PPS. Polyhydramnios in singleton pregnancies: perinatal

outcomes and management. The Obstetrician and Gynaecologist, 2014.
16(3): p. 207-213.

King JR, Miller DA, Ouzounian JG. Increased composite maternal and
neonatal morbidity associated with ultrasonographically suspected fetal
macrosomia. J Matern Fetal Neonatal Med 2012. 25(10): p. 1953-1959.

Kramer MS, M.I., Yang H, Platt RW, Usher R, McNamara H, et al. Why
are babies getting bigger? Temporal trends in fetal growth and its
determinants. . J Pediatr., 2002. 141(4): p. 538-42.

Liao P, Park AL, Berger H, Ray JG. Using estimated fetal weight from
ultrasonography at 18 to 22 weeks to predict gestational diabetes
mellitus and newborn macrosomia. J Obstet Gynaecol Can 2014; 36 (8):
688-91

Lowe LPM, Dyer AR. Hyperglycaemia and adverse pregnancy outcome

(HAPO) study. Associations of maternal A1C and glucose with
pregnancy outcomes. Diabetes Care, 2012. 35: p. 574-80.

Morris RK, Meller CH, Tamblyn J, Malin G, Riley RD, Kilby MD, Robson
SC, Khan KS. Association and prediction of amniotic fluid
measurements for adverse pregnancy outcome: systematic review and
meta-analysis. BJOG 2014; 121: 686-699

9
Office of National Statistics. Birth Characteristics in England and Wales,
2014. 2015. www.ons.gov.uk

Schaefer-Graf UM et al. Determinants of fetal growth at different periods

of pregnancies complicated by gestational diabetes mellitus or impaired
glucose tolerance. Diabetes Care, 2003. 26(1): p. 193-8.