A weighty issue: The implications of an ultrasound prediction of a large baby in pregnancy

Introduction: The assessment of fetal growth in Aotearoa New Zealand is governed by a largely medical model of care which highly values the purported objectivity of sonographic assessment. Ultrasound scans are an increasingly normalised part of pregnancy care, and expectant parents may advocate strongly for access to them. It could be questioned whether the increasing number of scans is aligned with clinical need. This paper presents a literature review that explores the implications of an ultrasound diagnosis of a large baby during pregnancy. Method: Databases searched were CINAHL, PubMed, Proquest, and Google Scholar. Search terms used were “macrosomia”, “large for dates” and “large for gestational age”. This search was first undertaken in May 2019, and then repeated in November 2020. Findings: Sonographic assessment of fetal size can be inaccurate and the existence of a predicted fetal weight on scan increases the likelihood of birth interventions, regardless of the baby’s actual size. While there are potentially negative outcomes associated with a larger baby, it is unclear whether birth interventions will significantly reduce the occurrence of these outcomes. There is limited research that focuses on the parents’ experience of having a predicted large baby, offering contradictory insights, which suggests the influence of conflicting meanings applied to large babies and ignoring the experiences of women whose babies were predicted to be large but were born “normal” sized. Discussion: Midwives are encouraged to openly discuss with women the limitations in available evidence in this area. Midwives can consider the context of the woman and whānau (wider family), and how they may assess risk uniquely. Finally, midwives can honour the woman and whānau as the decision-makers in their own experience. There are further opportunities for research to provide a counter-narrative to medicalising discourses about large babies, grounded in a midwifery belief in normal birth. Conclusion: Midwives and women are drawn into a risk-centric paradigm that pathologises large babies for questionable benefit. To support informed decision-making within the midwifery partnership, midwives need to critically evaluate existing research and communicate its limitations and risk-centric orientation.

Hypermobility of ulnar nerve does not affect throwing performance (122)

Objectives: Ulnar nerve neuropathy around the elbow is a common pathology in throwing athletes, and occurs due to many factors including valgus elbow, and ulnar nerve hypermobility. For patients with ulnar nerve neuropathy, anterior transposition of the ulnar nerve is common procedures. Meanwhile, Ulnar nerve hypermobility has been reported to be present in 2% to 47% of asymptomatic individuals. However, no studies have investigated the rate of ulnar nerve hypermobility in throwing athletes, and the relationship between ulnar nerve mobility, and clinical symptom and throwing performance. This study was designed to classify the sonographic assessment for the mobility of the ulnar nerve compared to physical evaluation, and to determine whether ulnar nerve hypermobility is associated with clinical symptoms and throwing performance in baseball players. We investigated ulnar nerve hypermobility using ultrasound to evaluate the relationship between the ulnar nerve hypermobility and clinical sign including throwing performance in college baseball players. Methods: 138 elbows in 69 college baseball players were examined. Each participant was queried regarding symptoms attributable to the ulnar nerve. In addition, structural measurements consisting of the tinel test and elbow flexion compression testing were examined. Sonographic examiners were, unaware of reported symptoms, independently performed a standardized examination of both elbows to assess ulnar nerve hypermobility. For sonographic assessment, the ultrasound probe was located at the medial condyle of the humerus to visualize the ulnar nerve in short-axis view in the extended elbow position. During extension to flexion of the elbow, the mobility of ulnar nerves was assessed, and categorized as stable, or hypermobile, which was further subclassified as subluxation, or dislocation (Figure 1A, 1B, 1C). Pared t-test was used to compare the mobility of the ulnar nerve between throwing and non-throwing sides. Fisher’s exact test was used to assess the relationship between physical exams and the mobility of the ulnar nerve. Values of p<0.05 were considered statistically significant. Results: Ulnar nerve hypermobility was identified in 54 (78.3%) of the 69 elbows in throwing side. Meanwhile, hypermobility was 53 (76.8%) in non-throwing side without significant difference, compared to non-throwing side. Elbows with nerve hypermobility did not experience a higher prevalence of subjective symptoms (snapping, pain, and tingling) than did elbows with stable nerves. Provocative physical examination testing for ulnar nerve irritability, however, showed consistent trends toward heightened irritability in hypermobile nerves (p = 0.04 to 0.16). Demographic data and anatomic measurements were similar between the subjects with stable nerves and those with hypermobile nerves. Additionally, all participants did not show decrease of throwing performance. Conclusions: Ulnar nerve hypermobility occurs in over half of the baseball players in throwing and non-throwing sides. Utilizing a standardized sonographic examination, a diagnosis of ulnar nerve hypermobility can be established with substantial interobserver reliability. In baseball players, ulnar nerve hypermobility does not appear to be associated with an increased symptomatology attributable to the ulnar nerve and throwing performance. Anterior transplantation of ulnar nerve may not be needed for baseball players with ulnar nerve neuropathy.