Susan Campbell Westerway 1, Rob Heard 2 and Jonathan Morris 1 University of Sydney, Department of...
1
Susan Campbell Westerway 1 , Rob Heard 2 and Jonathan Morris 1 University of Sydney, Department of Obstetrics & Gynaecology, Royal North Shore Hospital 1 School of Behavioural & Community Health Sciences 2 ASUM image planes for measuring the BPD, OFD, head circumference, abdominal circumference and long bones. Images are actual third trimester pregnancies reflecting the difficulty of perfect image planes. • No statistically significant difference was seen for the BPD, OFD, HC & long bones between the study group & the general population based on the ASUM graphs. •In 3/4 of the cases of macrosomic births to Caucasian women with GDM, both the head & abdominal circumference was greater than 1 standard deviation above the ASUM mean by 35 weeks gestation. There was no correlation between AC, HC and birth-weight. • 8/9 babies of Chinese immigrant women (both with and without GDM) with AC > ASUM AC mean from 34 weeks had birth-weights > 3,600g. The Fisher exact probability that Chinese AC > ASUM mean from 34 weeks is unrelated to birth weight > 3600g was < 0.0000001. This suggests that AC > ASUM mean from 34 weeks predicts excess birth weight for Chinese. • An increased AC prior to 34 weeks was non specific as 22% of Chinese had a raised AC which normalised after 34 weeks. Conclusion • The mean birth weights of the groups in the study did not differ statistically from each other - Chinese (3312g) < Chinese GDM (3405g) < Caucasian (3435g) < Caucasian GDM (3486g). • For Chinese fetuses an AC > ASUM mean beyond 34 weeks predicts birth weight above 3600g (p < 0.0000005). This was not true for Caucasians. • Ultrasound of the abdominal circumference after 34 weeks helped identify those fetuses of both Caucasian & Chinese women that were potentially larger than average and therefore at a greater risk of birth complications. • Measurements prior to 34weeks gestation gave a high rate of false positives for predicting increased birth-weight. Literature 1. Hoffman L, Nolan C, Wilson J>D, Oats JN, Simmons D. Gestational diabetes mellitus –management guidelines.The Australasian Diabetes in Pregnancy Society. MJA 169;July 1998. 2. Bochner CJ, Medearis AL, Williams J, Castro L, Hobel C. Early third trimester ultrasound screening in Gestational Diabetes to S ingleton Birthweights,1992 and 99-00 0 10 20 30 40 50 Percentage of Births C auc 92 % 21.6 38.1 29.4 10.9 C auc 99-00 % 18.3 33.1 34.9 13.6 Chinese 92 % 26.3 46.4 23.5 3.9 Chinese 99-00 % 23.9 36.5 29.8 9.8 <3000gm s 3000-3500gms 3501-4000gms >4000gm s Results 3568 ultrasonic fetal measurements were performed. A one-way ANOVA showed no statistically significant difference in birth- weights between the groups. The abdominal circumference showed no statistically significant difference between the ASUM AC mean and Caucasian women with GDM. Fetuses of both Chinese GDM and normal Chinese women were below the ASUM AC mean but not statistically different Mary Abdominal Circumference. AS U M /Caucasian & C hinese GestationalDiabetics / Chinese Non GD BPD 60 70 80 90 100 110 120 26 28 30 32 34 36 38 40 42 W eeks Gestation B PD (mm) Ch NBPD Ch GDBPD CGD BPD C aucasian & Chinese GestationalD iabetics C hinese N on G D /ASUM Fem urLength 40 50 60 70 80 90 26 28 30 32 34 36 38 40 42 W eeks Gestation FemurLength (mm) C h N GD F CGD FL C h GD FL ASUM /C aucasian & Chinese Gestational Diabetics C hinese Non GD Head Circum ference 200 220 240 260 280 300 320 340 360 380 26 28 30 32 34 36 38 40 42 W eeks G estation H ead C ircum ference (m m) C h N H C C h GD HC C GD HC ASUM /Queen Mary /C aucasian & Chinese GestationalD iabetics C hinese N on G D A bdom inalC ircum ference 200 250 300 350 400 450 26 28 30 32 34 36 38 40 42 W eeks Gestation Abdom inal Circum ference (m m ) C h N A C C GD AC C h GD AC Q ueen Mary Appendix Three The Effect of Gestational Diabetes Mellitus on Fetal Size Northern Sydney Mean GDM GDM & Total Births with Health Statistics Birth-weight Macrosomia Macrosomia ------------------------------------------------------------------------- ------------------------------------------------- Caucasian Births 2002 3435.5g 2.3% 11.1% 15.3% ------------------------------------------------------------------------- ------------------------------------------------- Chinese Births 2002 3343.9g 12% 6.7% 10% ------------------------------------------------------------------------- ------------------------------------------------- THIS STUDY Mean Gestation/ Macrosomia NSH GDM & mean weight Macrosomia ------------------------------------------------------------------------- ------------------------------------------------- Caucasians 39w 4d 20% 11.1% With GDM 3486g ------------------------------------------------------------------------- ------------------------------------------------- Weeks Queen Mary ASUM Gestation AC (mm) AC (mm) _________________________________ __ 34 296 mm 305 mm 35 304 315 36 311 325 37 318 333 38 324 342 39 331 356 40 335 362 41 341 367 _________________________________ _ Introduction Gestational diabetes mellitus (GDM) is defined as glucose intolerance of any degree with onset or first recognition during pregnancy. 1 In Australia around 5% of Caucasian pregnancies are affected by GDM compared with 15% in Asians. 1 GDM may cause excessive fetal growth, particularly of the fetal abdomen 2 , and an increased incidence of macrosomia (birth-weight > 4000g) and birth complications. Ultrasound is frequently required to assess fetal well being in pregnancies complicated by GDM. Chinese women have babies of lower birth- weight (Graph 1) and macrosomia in this group is considered to be a weight > 3,500g. 3 The fetal measurement charts used in Hong Kong and Beijing (The Queen Mary Charts) show no statistical difference to the ASUM charts for all fetal parameters except the abdominal circumference (Table 1), where a term baby is equivalent to 37 weeks on the ASUM AC chart. If these abdominal circumference differences are translated to our Chinese immigrant population then, when applied to a fetal weight formula, this may explain the difference in birth-weight between Caucasian and Chinese babies. Graph 1 Table 1. dology: Northern Sydney Health Study 0201-003 en were examined serially throughout the last 12 weeks of pregnancy. were 3 groups: aucasian women with diet controlled GDM. hinese women with diet controlled GDM. Partners also Chinese. hinese without GDM. Partners also Chinese. leton pregnancy with known dates confirmed by ultrasound. asound at each Antenatal Clinic visit from 28 weeks gestation to sure BPD, OFD, head & abdominal circumference and long bones. lts plotted onto scatter graphs using Microsoft Excel. istical analysis performed with SPSS for Windows. Aims a. To determine if the mean fetal size in Caucasian & Chinese pregnancies affected by GDM varies from normal Caucasian or Chinese pregnancies. b. To determine if any ultrasonically measured fetal parameter helps predict excessive birth-weight of Chinese or Caucasian babies. Results Abdom inalC ircum ference C om parison ASUM (+/-2SD ),Q ueen M ary,C aucasian G DM , Chinese G DM C hinese N on G M 180 200 220 240 260 280 300 320 340 360 380 400 420 28 29 30 31 32 33 34 35 36 37 38 39 40 41 W eeks Gestation Abdom inalC ircum ference (mm) Graph 4 – BPD Graph 5 - Head Circumference Graph 6 – Femur Length Graph 2 – Scatter Plot. Graph 3 – Mean Abdominal Cir 229
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Transcript of Susan Campbell Westerway 1, Rob Heard 2 and Jonathan Morris 1 University of Sydney, Department of...
Susan Campbell Westerway1, Rob Heard2 and Jonathan Morris1
University of Sydney, Department of Obstetrics & Gynaecology, Royal North Shore Hospital1
School of Behavioural & Community Health Sciences2
ASUM image planes for measuring the BPD, OFD, head circumference, abdominal circumference and long bones. Images are actual third trimester pregnancies reflecting the difficulty of perfect image planes.
• No statistically significant difference was seen for the BPD, OFD, HC & long bones between the study group & the general population based on the ASUM graphs. •In 3/4 of the cases of macrosomic births to Caucasian women with GDM, both the head & abdominal circumference was greater than 1 standard deviation above the ASUM mean by 35 weeks gestation. There was no correlation between AC, HC and birth-weight.• 8/9 babies of Chinese immigrant women (both with and without GDM) with AC > ASUM AC mean from 34 weeks had birth-weights > 3,600g. The Fisher exact probability that Chinese AC > ASUM mean from 34 weeks is unrelated to birth weight > 3600g was < 0.0000001. This suggests that AC > ASUM mean from 34 weeks predicts excess birth weight for Chinese. • An increased AC prior to 34 weeks was non specific as 22% of Chinese had a raised AC which normalised after 34 weeks.
Conclusion• The mean birth weights of the groups in the study did not differ statistically from each other - Chinese (3312g) < Chinese GDM (3405g) < Caucasian (3435g) < Caucasian GDM (3486g).• For Chinese fetuses an AC > ASUM mean beyond 34 weeks predicts birth weight above 3600g (p < 0.0000005). This was not true for Caucasians.• Ultrasound of the abdominal circumference after 34 weeks helped identify those fetuses of both Caucasian & Chinese women that were potentially larger than average and therefore at a greater risk of birth complications.• Measurements prior to 34weeks gestation gave a high rate of false positives for predicting increased birth-weight.
Literature1. Hoffman L, Nolan C, Wilson J>D, Oats JN, Simmons D. Gestational diabetes mellitus –management guidelines.The Australasian Diabetes in Pregnancy Society. MJA 169;July 1998.2. Bochner CJ, Medearis AL, Williams J, Castro L, Hobel C. Early third trimester ultrasound screening in Gestational Diabetes to determine the risk of macrosomia & labour dystocia at term. Am J Obstet Gynecol 1987;157:703-08.3. Westerway SL, Keogh J, Heard R, Morris J. The incidence of fetal macrosomia & birth complications in Chinese immigrant women. Aust NZ J Obstet & Gynae 43;1:2003. 4. Buchanan TA, Kjos SI, Montoro MN, et al. The use of foetal ultrasound to select metabolic therapy for pregnancies complicated by mild gestational diabetes. Diabetes Care 1994;17:275.
AcknowledgementsCatriona Andronicos – Data Manager – OBSTET Data Base – NSAHS. Rosemary Hitchman and staff at Royal North Shore & Hornsby Ku-Ring-Gai Hospital Antenatal Clinics
Singleton Birthweights, 1992 and 99-00
0
10
20
30
40
50
Perc
enta
ge o
f Birt
hs
Cauc 92 % 21.6 38.1 29.4 10.9
Cauc 99-00 % 18.3 33.1 34.9 13.6
Chinese 92 % 26.3 46.4 23.5 3.9
Chinese 99-00 % 23.9 36.5 29.8 9.8
<3000gms 3000-3500gms 3501-4000gms >4000gms
Results3568 ultrasonic fetal measurements were performed. A one-way ANOVA showed no statistically significant difference in birth-weights between the groups. The abdominal circumference showed no statistically significant difference between the ASUM AC mean and Caucasian women with GDM. Fetuses of both Chinese GDM and normal Chinese women were below the ASUM AC mean but not statistically significantly different to the Queen Mary Abdominal Circumference.
ASUM / Caucasian & Chinese Gestational Diabetics / Chinese Non GD BPD
60
70
80
90
100
110
120
26 28 30 32 34 36 38 40 42
Weeks Gestation
BP
D (
mm
)
Ch NBPD
Ch GDBPD
CGD BPD
Caucasian & Chinese Gestational Diabetics Chinese Non GD / ASUM Femur Length
40
50
60
70
80
90
26 28 30 32 34 36 38 40 42
Weeks Gestation
Fe
mu
r L
en
gth
(m
m) Ch NGD F
CGD FL
Ch GDFL
ASUM / Caucasian & Chinese Gestational Diabetics Chinese Non GD Head Circumference
200
220
240
260
280
300
320
340
360
380
26 28 30 32 34 36 38 40 42
Weeks Gestation
Hea
d C
ircu
mfe
ren
ce (m
m) Ch NHC
Ch GD HC
C GD HC
ASUM / Queen Mary / Caucasian & Chinese Gestational Diabetics Chinese Non GD Abdominal Circumference
200
250
300
350
400
450
26 28 30 32 34 36 38 40 42
Weeks Gestation
Abdo
min
al C
ircu
mfe
renc
e (m
m)
Ch NAC
C GD AC
Ch GD AC
Queen Mary
Appendix ThreeThe Effect of Gestational Diabetes Mellitus on Fetal Size
Northern Sydney Mean GDM GDM & Total Births withHealth Statistics Birth-weight Macrosomia Macrosomia--------------------------------------------------------------------------------------------------------------------------CaucasianBirths 2002 3435.5g 2.3% 11.1% 15.3%--------------------------------------------------------------------------------------------------------------------------Chinese Births 2002 3343.9g 12% 6.7% 10%--------------------------------------------------------------------------------------------------------------------------THIS STUDY Mean Gestation/ Macrosomia NSH GDM & mean weight Macrosomia-------------------------------------------------------------------------------------------------------------------------- Caucasians 39w 4d 20% 11.1%With GDM 3486g--------------------------------------------------------------------------------------------------------------------------Chinese 39w 1d 5% 6.7%With GDM 3405g --------------------------------------------------------------------------------------------------------------------------Chinese 39w 3d 5% Non-GDM 3312g---------------------------------------------------------------------------------------------------
Weeks Queen Mary ASUMGestation AC (mm) AC (mm)___________________________________34 296 mm 305 mm35 304
31536 311
32537 318
33338 324
34239 331
35640 335
36241 341
367__________________________________
Introduction Gestational diabetes mellitus (GDM) is defined as glucose intolerance of any degree with onset or first recognition during pregnancy. 1 In Australia around 5% of Caucasian pregnancies are affected by GDM compared with 15% in Asians.1 GDM may cause excessive fetal growth, particularly of the fetal abdomen2, and an increased incidence of macrosomia (birth-weight > 4000g) and birth complications. Ultrasound is frequently required to assess fetal well being in pregnancies complicated by GDM. Chinese women have babies of lower birth-weight (Graph 1) and macrosomia in this group is considered to be a weight > 3,500g. 3 The fetal measurement charts used in Hong Kong and Beijing (The Queen Mary Charts) show no statistical difference to the ASUM charts for all fetal parameters except the abdominal circumference (Table 1), where a term baby is equivalent to 37 weeks on the ASUM AC chart. If these abdominal circumference differences are translated to our Chinese immigrant population then, when applied to a fetal weight formula, this may explain the difference in birth-weight between Caucasian and Chinese babies. Graph 1 Table 1.
Methodology: Northern Sydney Health Study 0201-00375 women were examined serially throughout the last 12 weeks of pregnancy.There were 3 groups:• 25 Caucasian women with diet controlled GDM.• 25 Chinese women with diet controlled GDM. Partners also Chinese.• 25 Chinese without GDM. Partners also Chinese.• Singleton pregnancy with known dates confirmed by ultrasound.• Ultrasound at each Antenatal Clinic visit from 28 weeks gestation to measure BPD, OFD, head & abdominal circumference and long bones.• Results plotted onto scatter graphs using Microsoft Excel.• Statistical analysis performed with SPSS for Windows.
Aimsa. To determine if the mean fetal size in Caucasian & Chinese pregnancies affected by GDM varies from normal Caucasian or Chinese pregnancies. b. To determine if any ultrasonically measured fetal parameter helps predict excessive birth-weight of Chinese or Caucasian babies.
Results
Abdominal Circumference ComparisonASUM (+/- 2SD), Queen Mary, Caucasian GDM,
Chinese GDM Chinese Non GM
180
200
220240
260
280
300
320
340360
380
400
420
28 29 30 31 32 33 34 35 36 37 38 39 40 41
Weeks Gestation
Ab
do
min
al
Cir
cu
mfe
ren
ce
(m
m)
Graph 4 – BPD Graph 5 - Head Circumference Graph 6 – Femur Length
Graph 2 – Scatter Plot. Graph 3 – Mean Abdominal Circumference
229
