Fetal macrosomia (FM) is an impairment of fetal growth in excess mainly due to hyperinsulinemia. It is defined by a birth weight (BW) above 4000 g or 4500 g irrespective of gestational age or a BW above 90 or 95^th percentile on growth charts according to the term at delivery. These babies are described as large for gestational age (LGA) in comparison to those appropriate or small for gestational age [1] [2] . The main causes of fetal macrosomia are grouped into 3 main categories which are diabetes during pregnancy, excess weight gain during pregnancy and obesity [1] [2] [3] . Fetal macrosomia can lead to life-threatening complications for both mothers and babies. Among mothers, it is common to identify a high rate of caesarean delivery, obstetrical maneuvers, tearing of the perineum, postpartum haemorrhage and the dreaded shoulder dystocia. Among babies, traumatic deliveries can result in brachial plexus palsy, fractures, neonatal asphyxia, and many metabolic complications such as hypoglycemia, hypocalcemia, hyperbilirubinemia [4] [5] . Overall FM can affect 20% of live births worldwide, regarding the threshold retained for its definition. In Cameroun, this prevalence rates has been reported from 5% - 31% notably when included the prevalence of diabetes mellitus in pregnancy [5] [6] . Beyond the perinatal period, neonatal macrosomia is a determinant of diseases in adolescence and adulthood, notably obesity, hypertension and metabolic syndrome [7] . To improve the prevention of FM, several interventions are carried out among others: improving timely screening of gestational diabetes, adopting local guidelines for management of delivery of macrosomic babies and prenatal education [8] [9] . Within a context of resource-limited settings, we conducted this institutional facility based study to analyze risk factors associated to complications amongst macrosomic babies. The results of the study can be used to update local guidelines on prevention of FM including management of delivery of babies LGA in our particular setting.

POPULATION STUDY AND CHARACTERISTICS OF CASES AND CONTROLS

A total of 362 macrosomic babies and their mothers were included, consisting of 186 cases and 176 controls.

Descriptive analyzes showed that the mothers in the case group were older (31.3 ± 5.3 years vs 29.1 ± 5.3 years; p = 0.012) for controls (Table 1). Compliance with the eight CPN model was found more in the controls (47.7% vs 19.4%; p = 0.002). Non-screening for gestational diabetes was more common in cases (26.9% vs 4.3%; p < 0.001). Weight gain during pregnancy was lower in controls (16.02 ± 4.01 kg vs 18.75 ± 3.25; p < 0.001). The case group had more mothers with a history of caesarean section for fetal macrosomia (8.1% vs 0.6%; p = 0.007). Fetal birth weight ≥4500 g was found more in the case group (17.7% vs 1.7%; p < 0.001). The mean birth height of the cases was greater than that of the controls (52.7 cm ± 1.7 cm vs 51.8 cm ± 1.5 cm) (see Table 2 and Table 3).

OR: Odd Ratio; CI: Confidence Interval.

OR: Odd Ratio; SD: Standard deviation; CI: Confidence Interval.

Bold: Significant associated covariates (p < 0.05); OR: Odd Ratio; SD: Standard Deviation.

One of the particularities of this study is that it compares the factors associated with complications in babies weighting 4000 g or above. This is contrary to previous studies comparing babies with macrosomia to those weighting less than 4000 g [10] [11] [12] . Our work seems to document that within our population, complications are more frequent in case of poor prenatal follow-up and as such reinforces the recommendations for good antenatal follow-up advocated by the World Health Organization [13] . This good prenatal follow-up includes, among other things, screening for gestational diabetes, the absence of which increases the risk of macrosomia, thus confirming data from previous studies. However, in our context, the timing of this remains worrying and the consensus of experts seems to recommend a blood glucose test for all women from the first prenatal consultation and a new measurement between 24 and 28 weeks for those at risk and even earlier [14] [15] . Unsurprisingly, our study confirms the deleterious effect of excessive weight gain on the risk of macrosomia as well as the existence of obesity prior pregnancy. In our study, excessive weight gain beyond 16 kg requires sustained attention. However, this result must be tempered, as it was not correlated with pre-pregnancy weight [16] [17] . The risk of complications seems to increase with the age of the mothers as well as with the existence of a past story of caesarean section. These data are consistent with those found in similar populations of sub-Saharan Africa [12] [18] [19] [20] .

What is striking in this study is the high rate of emergency and non-elective caesarean section testifying of the late detection of macrosomia, probably during labor. This reinforces the need for good clinical follow-up by regular measurement of symphysis fundal height associated to abdominal circumference [21] . In addition, the absence of influence of third term ultrasonography to predict macrosomia in our study is consistent with previous reports in the literature and emphasizes the need to use a multiparametric ultrasound model including umbilical vein flow for optimal performance and accuracy to diagnose macrosomia [22] [23] . Finally, in newborns, the parameters most associated with complications

Bold: Significant associated covariates (p < 0.05); OR: Odd Ratio.

within this population of over 4000 g were those with over 4500 g and over 52.7 cm of height. Such thresholds have previously been described for weight [24] , but data on height are wandering thus require more attention [25] . At last, the HIV factor found in this study should without doubt be linked to the therapies taken by HIV infected women; some of those drugs may induce metabolic effects, in particular disturbing the metabolism of carbohydrates and lipids. This could therefore suggest to reinforce metabolic monitoring of HIV infected pregnant women under antiretroviral therapy [26] .

In conclusion, this study has identified the main risks associated with the complications of fetal macrosomia in our context. In terms of prevention, the data observed suggest strengthening prenatal monitoring of all pregnancies but also setting up a gestational screening program for diabetes; any excessive weight gain, especially over 16 kg, requires special attention. Although 3rd trimester ultrasound is not predictive of complications, the importance of fundal height measurement remains crucial. In short, it would be urgent, taking into account the data of this work, to revisit the recommendations for the management of childbirth in case of suspected fetal macrosomia, around the questions of induction of labor, elective caesarean section versus vaginal delivery, particularly at the threshold of 4500 g of presumed weight and an estimated fetal size of more than 52.7 cm.

The authors wish to express their gratitude to all the working team of Essos Hospital Centre.

The authors declare no conflicts of interest regarding the publication of this paper.

Nlend, A.E.N., Gwodog, J. and Sandie, A.B. (2023) Outcomes of Fetal Macrosomia and Associated Factors: A Case-Control Facility Based Study. Open Journal of Pediatrics, 13, 196-206. https://doi.org/10.4236/ojped.2023.132025