Die Schwangere über 25 (BMI) – Herausforderung in der antenatalen und peripartalen Überwachung

Zusammenfassung

Die weltweite Zunahme von Übergewicht und Adipositas sowohl in den westlichen Industrienationen als auch in den Entwicklungsländern ist unumstritten. Der Trend dieses von der WHO als globale Epidemie eingestuften Phänomens zeigt sich bereits bei jungen Erwachsenen und insbesondere auch bei Frauen im fertilen Alter. Den neuesten Daten der Centers of Disease Control and Prevention (CDC) zufolge wird die Prävalenz der Adipositas bei Frauen mit 30,2 % und die der übergewichtigen Frauen mit 56,7 % angegeben. In Deutschland sind nach Angaben des Statistischen Bundesamts 42 % der Frauen übergewichtig und davon 13 % sogar (stark) adipös [1]. Maternales Übergewicht ist mit einer Reihe von relevanten Risiken für die Schwangere und den Fetus vergesellschaftet und stellt für den Geburtshelfer eine besondere Herausforderung in der Betreuung dieser Schwangeren dar. Generell sind die diagnostischen Möglichkeiten (z. B. im Rahmen der pränatalen Diagnostik) aufgrund z. T. drastisch eingeschränkter Sichtbedingungen limitiert. Die Folge ist eine potenziell verminderte Detektionsrate kongenitaler Auffälligkeiten des Fetus. In aktuellen Metaanalysen konnte darüber hinaus gezeigt werden, dass gerade bei adipösen Frauen die Rate an feto-maternalen Komplikationen vorgeburtlich als auch peri- und postpartal deutlich erhöht ist. Im Rahmen dieser Übersichtsarbeit sollen zum einen sowohl klinische als auch technische Schwierigkeiten im Zuge der vorgeburtlichen Überwachung und zum anderen die Auswirkungen maternaler Adipositas auf das geburtshilflich-peripartale Vorgehen diskutiert werden.

Abstract

Pandemic obesity is a global public health concern as the incidence of obesity has increased substantially over the past decades even among adolescents and women of childbearing age. Recent data from the Centers of Disease Control and Prevention (CDC) revealed a prevalence of obesity among women of 30.2 %, with 56.7 % of women classified as overweight. In the German female population 42 % were found to be overweight, and 13 % fulfilled the criteria for morbid adiposity [1]. This prevalence of overweight and obesity is a major challenge in obstetrical practice, because increased maternal weight is associated with a number of pregnancy complications affecting both the mother and the developing fetus. Diagnostic modalities, such as obstetrical ultrasound imaging are adversely affected by obesity with a negative impact on the detection rate of congenital anomalies. It is known and has been previously confirmed by several meta-analyses that maternal obesity poses an elevated risk for feto-maternal complications both antenatally, peri- and postnatally. This review aims to present relevant data on the prenatal surveillance of obese pregnant women and to discuss clinical and technical issues affecting the obstetrical management of the obese gravida.

Schlüsselwörter

Schwangerschaft - Fettleibigkeit - pränatal - Ultraschall - Überwachung

Key words

pregnancy - obesity - prenatal - ultrasound - surveillance

Literatur

• 1 Statistisches Bundesamt .Pressemitteilung Nr. 227. Immer mehr Übergewichtige. 2006. http://www.destatis.de/jetspeed/portal/cms/Sites/destatis/Internet/DE/Presse/pm/2006/06/PD06__227__23.psml
• 2 World Health Organization .Obesity and overweight. http://www.who.int/media-centre/factsheets/fs311/en/index.html
• 3 World Health Organization . Obesity: preventing and managing a global epidemic.  World Health Organ Tech Rep Ser. 2000;  894 1-4
• 4 Centers of Disease Control and Prevention Obesity and overweight .http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_glance.html
• 5 Reece E A. Perspectives on obesity, pregnancy and birth outcomes in the United States: the scope of the problem.  Am J Obstet Gynecol. 2008;  198 23-27
• 6 Blissing S, Roloff R, Rehn M et al. Prevalence of overweight or adiposity among pregnant women at the university gynecology clinic of Würzburg and resultant perinatal outcomes – a comparison between 1980 and 2005.  Geburtsh Frauenheilk. 2008;  68 159-164
• 7 Villena-Heinsen C, Hendrik J, Hahn H et al. Impact of massive obesity on obstetrics.  Geburtsh Frauenheilk. 2008;  57 675-680
• 8 Chu S Y, Bachman D J, Callaghan W M et al. Association between obesity during pregnancy and increased use of health care.  N Engl J Med. 2008;  358 1444-1453
• 9 Galtier-Dereure F, Boegner C, Bringer J. Obesity and pregnancy: complications and cost.  Am J Clin Nutr. 2000;  71 1242S-1248S
• 10 American College of Obstetricians and Gynecologists . ACOG Committee Opinion number 315, September 2005. Obesity in pregnancy.  Obstet Gynecol. 2005;  106 671-675
• 11 Ramsay J E, Greer I, Sattar N. ABC of obesity. Obesity and reproduction.  BMJ. 2006;  333 1159-1162
• 12 Institute of Medicine of The National Academies .Committee on nutritional status during pregnancy and lactation, Institute of Medicine. Nutrition during pregnancy: part I: weight gain, part II: nutrient supplements. Washington (DC); The National Academies Press 1990
• 13 Committee on the impact of pregnancy weight on maternal and child health .Influence of pregnancy weight on maternal and child health: workshop report. Washington (DC); The National Academies Press 2007
• 14 Voigt M, Briese V, Fusch C et al. Analysis of subgroup of pregnant women in Germany – 15th communication. Relationship between overweight status or obesity and pregnancy-related maternal diseases.  Geburtsh Frauenheilk. 2008;  68 152-158
• 15 Sebire N J, Jolly M, Harris J P et al. Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London.  Int J Obes Relat Metab Disord. 2001;  25 1175-1182
• 16 Cnattingius S, Bergström R, Lipworth L et al. Prepregnancy weight and the risk of adverse pregnancy outcomes.  N Engl J Med. 1998;  338 147-152
• 17 Nohr E A, Bech B H, Vaeth M et al. Obesity, gestational weight gain and preterm birth: a study within the Danish National Birth Cohort.  Paediatr Perinat Epidemiol. 2007;  21 5-14
• 18 Queisser-Luft A, Kieninger-Baum D, Menger H et al. Does maternal obesity increase the risk of fetal abnormalities? Analysis of 20,248 newborn infants of the Mainz Birth Register for detecting congenital abnormalities.  Ultrasch in Med. 1998;  19 40-44
• 19 Cedergren M I, Källén B A. Maternal obesity and infant heart defects.  Obes Res. 2003;  11 1065-1071
• 20 Waller D K, Shaw G M, Rasmussen S A et al. National birth defects prevention study. Prepregnancy obesity as a risk factor for structural birth defects.  Arch Pediatr Adolesc Med. 2007;  161 745-750
• 21 Watkins M L, Rasmussen S A, Honein M A et al. Maternal obesity and risk for birth defects.  Pediatrics. 2003;  111 1152-1158
• 22 Stothard K J, Tennant P W, Bell R et al. Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis.  JAMA. 2009;  301 636-650
• 23 Rasmussen S A, Chu S Y, Kim S Y et al. Maternal obesity and risk of neural tube defects: a metaanalysis.  Am J Obstet Gynecol. 2008;  198 611-619
• 24 Chu S Y, Kim S Y, Lau J et al. Maternal obesity and risk of stillbirth: a metaanalysis.  Am J Obstet Gynecol. 2007;  197 223-228
• 25 Andreasen K R, Andersen M L, Schantz A L. Obesity and pregnancy.  Acta Obstet Gynecol Scand. 2004;  83 1022-1029
• 26 Hendler I, Blackwell S C, Treadwell M C et al. Does advanced ultrasound equipment improve the adequacy of ultrasound visualization of fetal cardiac structures in the obese gravid woman?.  Am J Obstet Gynecol. 2004;  190 1616-1619
• 27 Siva S, McLennan A. The impact of obesity on obstetrical and gynaecological ultrasound.  OGMagazine. 2008;  10 26-28
• 28 National Institutes of Health .Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Bethesda; NIH publication No. 98 – 4083 1998 http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf
• 29 Neovius M, Linné Y, Rossner S. BMI, waist-circumference and waist-hip-ratio as diagnostic tests for fatness in adolescents.  Int J Obes (Lond). 2005;  29 163-169
• 30 Molarius A, Seidell J C, Sans S et al. Waist and hip circumferences, and waist-hip ratio in 19 populations of the WHO MONICA Project.  Int J Obes Relat Metab Disord. 1999;  23 116-125
• 31 Welborn T A, Dhaliwal S S. Preferred clinical measures of central obesity for predicting mortality.  Eur J Clin Nutr. 2007;  61 1373-1379
• 32 Brown J E, Potter J D, Jacobs Jr. D R et al. Maternal waist-to-hip ratio as a predictor of newborn size: Results of the Diana Project.  Epidemiology. 1996;  7 62-66
• 33 Bergman R N, Kim S P, Hsu I R et al. Abdominal obesity: role in the pathophysiology of metabolic disease and cardiovascular risk.  Am J Med. 2007;  120 (2 Suppl. 1) S3-S8
• 34 Noori N, Hosseinpanah F, Nasiri A A et al. Comparison of overall obesity and abdominal adiposity in predicting chronic kidney disease incidence among adults.  J Ren Nutr. 2009;  19 228-237
• 35 Ochs-Balcom H M, Grant B J, Muti P et al. Pulmonary function and abdominal adiposity in the general population.  Chest. 2006;  129 853-862
• 36 Yamamoto S, Douchi T, Yoshimitsu N et al. Waist to hip circumference ratio as a significant predictor of preeclampsia, irrespective of overall adiposity.  J Obstet Gynaecol Res. 2001;  27 27-31
• 37 Sattar N, Clark P, Holmes A et al. Antenatal waist circumference and hypertension risk.  Obstet Gynecol. 2001;  97 268-271
• 38 Bartha J L, Marín-Segura P, González-González N L et al. Ultrasound evaluation of visceral fat and metabolic risk factors during early pregnancy.  Obesity (Silver Spring). 2007;  15 2233-2239
• 39 Sibai B M, Ewell M, Levine R J et al. Risk factors associated with preeclampsia in healthy nulliparous women.  Am J Obstet Gynecol. 1997;  177 1003-1010
• 40 Weiss J L, Malone F D, Emig D FASTER Research Consortium et al. Obesity, obstetric complications and cesarean delivery rate – a population-based screening study.  Am J Obstet Gynecol. 2004;  190 1091-1097
• 41 http://www.deutsche-diabetes-gesellschaft.de/redaktion/mitteilungen/Leitlinien/PL_DDG2009_Schwangerschaft
• 42 http://www.dggg.de/fileadmin/public_docs/Dokumente/Leitlinien/g_03_03_04_diagnostik_therapie_gestationsdiabetes.pdf
• 43 Wald N, Cuckle H, Boreham J et al. The effect of maternal weight on maternal serum alpha-fetoprotein levels.  Br J Obstet Gynaecol. 1981;  88 1094-1096
• 44 Phillips J, Henderson J. For the obese gravida, try strong counselling and close follow-up.  OBG Management. 2009;  21 42-50
• 45 Zador I E, Bottoms S F, Tse G M et al. Nomograms for ultrasound visualization of fetal organs.  J Ultrasound Med. 1988;  7 197-201
• 46 Wolfe H M, Zador I E, Bottoms S F et al. Trends in sonographic fetal organ visualization.  Ultrasound Obstet Gynecol. 1993;  3 97-99
• 47 Wolfe H M, Sokol R J, Martier S M et al. Maternal obesity: a potential source of error in sonographic prenatal diagnosis.  Obstet Gynecol. 1990;  76 339-342
• 48 Hendler I, Blackwell S C, Bujold E et al. The impact of maternal obesity on midtrimester sonographic visualization of fetal cardiac and craniospinal structures.  Int J Obes Relat Metab Disord. 2004;  28 1607-1611
• 49 Catanzarite V, Delaney K, Wolfe S et al. Targeted mid-trimester ultrasound examination: how does fetal anatomic visualization depend upon the duration of the scan?.  Ultrasound Obstet Gynecol. 2005;  26 521-526
• 50 Hendler I, Blackwell S C, Treadwell M C et al. Does sonographer's experience impact the rate of suboptimal visualization in the obese gravida?.  Am J Obstet Gynecol. 2004;  189 S239
• 51 Troya-Nutt M, Hendler I, Blackwell S C et al. The accuracy of prenatal diagnosis of fetal heart anomalies in the obese gravida.  Am J Obstet Gynecol. 2004;  189 S239
• 52 Lantz M E, Chisholm C A. The preferred timing of second-trimester obstetric sonography based on maternal body mass index.  J Ultrasound Med. 2004;  23 1019-1022
• 53 Schwärzler P, Senat M V, Holden D et al. Feasibility of the second-trimester fetal ultrasound examination in an unselected population at 18, 20 or 22 weeks of pregnancy: a randomized trial.  Ultrasound Obstet Gynecol. 1999;  14 92-97
• 54 Thornburg L L, Miles K, Ho M et al. Fetal anatomic evaluation in the overweight and obese gravida.  Ultrasound Obstet Gynecol. 2009;  33 670-675
• 55 Hendler I, Blackwell S C, Wolfe H et al. The effect of maternal obesity on midtrimester sonographic visualization of the fetal heart.  Am J Obstet Gynecol. 2004;  187 S209
• 56 Khoury F R, Ehrenberg H M, Mercer B M. The impact of maternal obesity on satisfactory detailed anatomic ultrasound image acquisition.  J Matern Fetal Neonatal Med. 2009;  22 337-341
• 57 Gandhi M, Fox N, Pozharny Y et al. The effect of increased body mass index on the 1st trimester ultrasound for aneuploidy risk assessment.  Am J Obstet Gynecol. 2008;  199 (Suppl. 1) S130
• 58 Thornburg L L, Mulconry M, Post A et al. Fetal nuchal translucency thickness evaluation in the overweight and obese gravida.  Ultrasound Obstet Gynecol. 2009;  33 665-669
• 59 Davidoff A, Reuter K, Karellas A et al. Maternal umbilicus: ultrasound window to the gravid uterus.  J Clin Ultrasound. 1994;  22 263-267
• 60 Rosenberg J C, Guzman E R, Vintzileos A M et al. Transumbilical placement of the vaginal probe in obese pregnant women.  Obstet Gynecol. 1995;  85 132-134
• 61 McCoy M C, Watson W J, Chescheir N C et al. Transumbilical use of the endovaginal probe.  Am J Perinatol. 1996;  13 395-397
• 62 Paladini D. Sonography in obese and overweight pregnant women: clinical, medicolegal and technical issues.  Ultrasound Obstet Gynecol. 2009;  33 720-729
• 63 Sohan K, Woodward B, Ramsewak S S. Successful use of transrectal ultrasound for embryo transfer in obese women.  J Obstet Gynaecol. 2004;  24 839-840
• 64 Hedrick W R, Metzger L. Tissue harmonic imaging: a review.  J Diagn Med Sonogr. 2005;  21 183-189
• 65 Tranquart F, Grenier N, Eder V et al. Clinical use of ultrasound tissue harmonic imaging.  Ultrasound Med Biol. 1999;  25 889-894
• 66 Choudhry S, Gorman B, Charboneau J W et al. Comparison of tissue harmonic imaging with conventional US in abdominal disease.  Radiographics. 2000;  20 1127-1135
• 67 Treadwell M C, Seubert D E, Zador I et al. Benefits associated with harmonic tissue imaging in the obstetric patient.  Am J Obstet Gynecol. 2000;  182 1620-1623
• 68 Kovalchin J P, Lewin M B, Bezold L I et al. Harmonic imaging in fetal echocardiography.  J Am Soc Echocardiogr. 2001;  14 1025-1029
• 69 Zhao B W, Tang F G, Shou J D et al. Comparison study of harmonic imaging (HI) and fundamental imaging (FI) in fetal echocardiography.  J Zhejiang Univ Sci. 2003;  4 374-377
• 70 Paladini D, Vassallo M, Tartaglione A et al. The role of tissue harmonic imaging in fetal echocardiography.  Ultrasound Obstet Gynecol. 2004;  23 159-164
• 71 Lee Y M, Simpson L L. Major fetal structural malformations: the role of new imaging modalities.  Am J Med Genet C Semin Med Genet. 2007;  145 C 33-44
• 72 Timor-Tritsch I E, Monteagudo A. Three- and four-dimensional ultrasound in obstetrics and gynecology.  Curr Opin Obstet Gynecol. 2007;  19 157-175
• 73 Gonçalves L F, Nien J K, Espinoza J et al. What does 2-dimensional imaging add to 3- and 4-dimensional obstetric ultrasonography?.  J Ultrasound Med. 2006;  25 691-699
• 74 Gonçalves L F, Lee W, Espinoza J et al. Three- and 4-dimensional ultrasound in obstetric practice: does it help?.  J Ultrasound Med. 2005;  24 1599-1624
• 75 Wang P H, Chen G D, Lin L Y. Imaging comparison of basic cardiac views between two- and three-dimensional ultrasound in normal fetuses in anterior spine positions.  Int J Cardiovasc Imaging. 2002;  18 17-23
• 76 Laifer-Narin S, Budorick N E, Simpson L L et al. Fetal magnetic resonance imaging: a review.  Curr Opin Obstet Gynecol. 2007;  19 151-156
• 77 Behairy N H, Talaat S, Saleem S N et al. Magnetic resonance imaging in fetal anomalies: What does it add to 3D and 4D US?.  Eur J Radiol. 2010;  74 250-255
• 78 Frates M C, Kumar A J, Benson C B et al. Fetal anomalies: comparison of MR imaging and US for diagnosis.  Radiology. 2004;  232 398-404
• 79 Whitby E, Paley M N, Davies N et al. Ultrafast magnetic resonance imaging of central nervous system abnormalities in utero in the second and third trimester of pregnancy: comparison with ultrasound.  BJOG. 2001;  108 519-526
• 80 Hubbard A M. Ultrafast fetal MRI and prenatal diagnosis.  Semin Pediatr Surg. 2003;  12 143-153
• 81 Garel C. Imaging the fetus: when does MRI really help?.  Pediatr Radiol. 2008;  38 (Suppl. 3) S467-S470
• 82 EUROCAT Working Group .Appendix 7 & appendix 8 in report 8: surveillance of congenital anomalies in Europe 1980–99. EUROCAT Central Registry, University of Ulster. http://www.eurocat.ulster.ac.uk
• 83 Ewigman B G, Crane J P, Frigoletto F D RADIUS Study Group et al. Effect of prenatal ultrasound screening on perinatal outcome.  N Engl J Med. 1993;  329 821-827
• 84 Grandjean H, Larroque D, Levi S. Sensitivity of routine ultrasound screening of pregnancies in the Eurofetus database. The Eurofetus Team.  Ann N Y Acad Sci. 1998;  847 118-124
• 85 Grandjean H, Larroque D, Levi S. The performance of routine ultrasonographic screening of pregnancies in the Eurofetus Study.  Am J Obstet Gynecol. 1999;  181 446-454
• 86 Levi S. Ultrasound in prenatal diagnosis: polemics around routine ultrasound screening for second trimester fetal malformations.  Prenat Diagn. 2002;  22 285-295
• 87 Wiesel A, Queisser-Luft A, Clementi M EUROSCAN Study Group et al. Prenatal detection of congenital renal malformations by fetal ultrasonographic examination: an analysis of 709,030 births in 12 European countries.  Eur J Med Genet. 2005;  48 131-144
• 88 Garne E, Loane M, Dolk H et al. Prenatal diagnosis of severe structural congenital malformations in Europe.  Ultrasound Obstet Gynecol. 2005;  25 6-11
• 89 Levi S. Mass screening for fetal malformations: the Eurofetus study.  Ultrasound Obstet Gynecol. 2003;  22 555-558
• 90 Wong S F, Chan F Y, Cincotta R B et al. Factors influencing the prenatal detection of structural congenital heart diseases.  Ultrasound Obstet Gynecol. 2003;  21 19-25
• 91 Wong S F, Chan F Y, Cincotta R B et al. Routine ultrasound screening in diabetic pregnancies.  Ultrasound Obstet Gynecol. 2002;  19 171-176
• 92 Ehrenberg H M, Fischer R L, Hediger M L et al. Are maternal and sonographic factors associated with the detection of a fetal echogenic cardiac focus?.  J Ultrasound Med. 2001;  20 1047-1052
• 93 Queisser-Luft A, Stolz G, Wiesel A et al. Malformations in newborn: results based on 30,940 infants and fetuses from the Mainz congenital birth defect monitoring system (1990–1998).  Arch Gynecol Obstet. 2002;  266 163-167
• 94 Werler M M, Louik C, Shapiro S et al. Prepregnant weight in relation to risk of neural tube defects.  JAMA. 1996;  275 1089-1092
• 95 Siega-Riz A M, Herring A H, Olshan A F National Birth Defects Prevention Study et al. The joint effects of maternal prepregnancy body mass index and age on the risk of gastroschisis.  Paediatr Perinat Epidemiol. 2009;  23 51-57
• 96 Dashe J S, McIntire D D, Twickler D M. Effect of maternal obesity on the ultrasound detection of anomalous fetuses.  Obstet Gynecol. 2009;  113 1001-1007
• 97 Hendler I, Blackwell S C, Bujold E et al. Suboptimal second-trimester ultrasonographic visualization of the fetal heart in obese women: should we repeat the examination?.  J Ultrasound Med. 2005;  24 1205-1209
• 98 Kabiru W, Raynor B D. Obstetric outcomes associated with increase in BMI category during pregnancy.  Am J Obstet Gynecol. 2004;  191 928-932
• 99 Phillips J, Henderson J. Delivery and postpartum concerns in the obese gravida.  OBG Management. 2009;  21 51-54
• 100 Mazouni C, Porcu G, Cohen-Solal E et al. Maternal and anthropomorphic risk factors for shoulder dystocia.  Acta Obstet Gynecol Scand. 2006;  8 567-570
• 101 Hänseroth K, Distler W, Kamin G et al. Pregnancy course, delivery and post-partum period in adipose women.  Geburtsh Frauenheilk. 2007;  67 33-37
• 102 Voigt M, Zygmunt M, Henrich W et al. Analysis of subgroup of pregnant women in Germany – 16th communication: Morbid obesity: Pregnancy risks, birth risks and status of the newborn.  Geburtsh Frauenheilk. 2008;  68 794-800
• 103 Juhasz G, Gyamfi C, Gyamfi P et al. Effect of body mass index and excessive weight gain on success of vaginal birth after cesarean delivery.  Obstet Gynecol. 2005;  106 741-746
• 104 Perlow J H, Morgan M A. Massive maternal obesity and perioperative cesarean morbidity.  Am J Obstet Gynecol. 1994;  170 560-565
• 105 Alexander C I, Liston W A. Operating on the obese woman – A review.  BJOG. 2006;  113 1167-1172
• 106 Wall P D, Deucy E E, Glantz J C et al. Vertical skin incisions and wound complications in the obese parturient.  Obstet Gynecol. 2003;  102 952-956
• 107 Ramsey P S, White A M, Guinn D A et al. Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing cesarean delivery.  Obstet Gynecol. 2005;  105 967-973
• 108 Myles T D, Gooch J, Santolaya J. Obesity as an independent risk factor for infectious morbidity in patients who undergo cesarean delivery.  Obstet Gynecol. 2002;  100 959-964
• 109 Katz S. Anaesthesia for the obese parturient.  OGMagazine. 2008;  10 29-31
• 110 Roofthooft E. Anesthesia for the morbidly obese parturient.  Curr Opin Anaesthesiol. 2009;  22 341-346
• 111 Juvin P, Lavaut E, Dupont H et al. Difficult tracheal intubation is more common in obese than in lean patients.  Anesth Analg. 2003;  97 595-600
• 112 Dietz P M, Callaghan W M, Cogswell M E et al. Combined effects of prepregnancy body mass index and weight gain during pregnancy on the risk of preterm delivery.  Epidemiology. 2006;  17 170-177
• 113 Nohr E A, Vaeth M, Bech B H et al. Maternal obesity and neonatal mortality according to subtypes of preterm birth.  Obstet Gynecol. 2007;  110 1083-1090
• 114 Catalano P M. Obesity and pregnancy – the propagation of a viscous cycle?.  J Clin Endocrinol Metab. 2003;  88 3505-3506
• 115 Combs C A, Rosenn B, Miodovnik M et al. Sonographic EFW and macrosomia: is there an optimum formula to predict diabetic fetal macrosomia?.  J Matern Fetal Med. 2000;  9 55-61
• 116 Pates J A, McIntire D D, Casey B M et al. Predicting macrosomia.  J Ultrasound Med. 2008;  27 39-43