83

Estimating Fetal Age:

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. Effect of
Head Shape on BPD

Frank P. Hadlock1 Several recent obstetrical sonographic examinations in this department demon-
R. L. Deter2 strated that variations in the shape of the fetal skull (e.g., dolichocephaly, brachyce-
R. J. Carpenter2 phaly) may adversely affect the accuracy of the biparletal diameter (BPD) measurement
in estimating fetal age. In each case the cephalic index of the fetal skull (short axis/
S. K. Park1
long axis x 100) was in either the dolichocephalic or brachycephalic range based on
established postnatal criteria. Consequently, normal values were determined (mean,
78.3) for the cephalic index in utero based on 31 6 obstetrical sonographic studies
performed at 14-40 weeks. Preliminary experience indicates that a cephalic index
greater than I SD from the mean (<74, >83) may be associated with a significant
alteration in the BPD measurement expected for a given gestational age, and that the
head circumference can be used effectively as an alternative means of establishing
gestational age.

The bipanietal diameter(BPD) has proven to be a reliable indicator of fetal

gestational (menstrual) [1 -3].
age In the second trimester of pregnancy, it is
accurate to within 1 -1 .5 weeks (2 SD) [2-3], but in the third trimester the
reported accuracy is considerably less; a BPD obtained after 28 weeks is
accurate only to within 3 weeks (2 SD), even if the image meets the criteria
for a good BPD [3-4]. The observed variation in the third trimester is undoubtedly
multifactonial in etiology, related only in part to technical errors in imaging.
If we assume a technically adequate BPD image, and an accurate measure-
ment, and if we eliminate pathologic causes of variation in fetal head size (e.g.,
microcephaly, hydrocephaly, growth retardation), there remain two obvious
reasons why women with the same last menstrual period may have fetuses with
different BPD measurements: (1 ) genetic variations in head size in fetuses of the
same conceptual age and (2) differences in time of ovulation and fertilization with
respect to the first day of the last menstrual period.
Our recent experience has suggested that variations in the shape of the fetal
skull such as dolichocephaly and brachycephaly may also have a significant
effect on BPD measurements. An investigation was therefore undertaken to
determine the normal relation between the short and long axis of the fetal skull
at the BPD plane, in the hope that it would produce a simple method for detecting
variations in the shape of the fetal skull, which may adversely affect the accuracy
Received October 21, 1980: accepted after
revision February 12, 1981. of the BPD measurement in predicting fetal gestational age.
Department of Radiology, Baylor College of
Medicine, Houston, TX 77019, and Jefferson
Davis Hospital, 1801 AlIen Parkway, Houston, TX Subjects and Methods
77019. Address reprint requests to F. P. Hadlock.
2Department of Obstetrics and Gynecology, We examined 31 6 consecutive patients using a commercially available dynamic image
Baylor College of Medicine, Houston, TX 77030. scanner (Toshiba Medical Systems, Carson, Cal.). The gestational age, based on the BPD
measurement, was 1 4-40 weeks. The widest transverse and longitudinal dimensions of
AJR I 37:83-85, July 1981
0361 -803X/81 /1371-0083 $00.00 the skull at the level of the BPD [3, 4] were measured from outer margin to outer margin
American Roentgen Ray Society (fig. 1), and the cephalic index [5, 6] (short axis/long axis x 100) was calculated.
 84 HADLOCK ET AL. AJR:137, July 1981

Representative Case Reports

Case 1

A 24-year-old woman, gravida 3, para 2, Ab 0, was examined

sonographically at 35 menstrual weeks. A single viable fetus was
identified. The bipanietal diameter was 7.9 cm (32 weeks), which
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suggested that the fetus was growth retarded or that the menstrual
dates were 3 weeks in error. However, the head was noted to be
rather elongated (fig. 3) and this was confirmed by a cephalic index
[5-6] measurement of 68, which is by definition dolichocephaly
[7]. Measurements of the head circumference [8] (32 cm) and
abdominal circumference at the level of the umbilical vein (31 .8 cm)
[9] were both consistent with the patients menstrual history of 35
weeks amenorrhea. The patient delivered spontaneously
7 weeks
later, and the head circumference [8] (36 cm), length [8] (50 cm),
Fig. 1.-Real-time sonognaphic image of fetal skull at level of bipanietal weight [8] (3,300 g), and Dubowitz score [10] were all consistent
diameter. Cephalic index is A/B x 100. with a 42 week fetus.

96.0 Case 2

A 27-year-old woman, gravida 5, para 4, Ab 0, was referred for

sonography at 30 menstrual weeks to rule out placenta previa. The
x 88.0 . . .
bipanietal diameter of 7.6 cm (30 weeks) was consistent with the
LIJ . . 3.
0 . 3 . 2. 224.
. . . 2 2
menstrual history. A posterior marginal placenta previa was ob-
2 . 34..3.3. . . . 2 served, and for this reason a repeat examination was suggested.
80.0 . . . 2. #{149}
3 3425 534.. 3 5. 2#{149}
The second examination was 6 weeks later (36 menstrual weeks),
_J . 2 #{149}222 4 62#{149}2 4. . 3#{149}22..
< . . . #{149}22
2 62 . . 2.3. 62.
. . 5 22 24 2 2 3.3 . . .2.
and the placenta was posterior with no evidence of a marginal
(Li 2. .. .3.3 .5. 2 . 23 4.2 placenta previa. The BPD on this examination was 8.2 cm (33
0 72.0 ...4 . weeks), and this was initially believed to represent evidence of
growth retardation. However, on reviewing the sonograms (fig. 4) it
was obvious that the head shape on the second examination was
640 I I I
_J considerably more elongated than on the first. Additional measure-
7.0 14.0 21.0 28.0 35.0
42.0 ments of the head from the first study demonstrated a cephalic
GESTATIONAL AGE (wks) index of 76, which is within the normal range [5-7]; the head
Fig. 2.-Distribution of cephalic index measurements in 31 6 fetuses at circumference was 28 cm, which is at the mean at 30.5 weeks [8].
14-40 weeks. Additional measurements of the second study demonstrated a ce-
phalic index of 70, which by definition represents dolichocephaly
[7], and the head circumference was 32.5 cm, which approximates
Results the mean at 36 weeks [8]. At 3 weeks later the patient sponta-
neously delivered a 3,630 g boy, which was judged to be a term
The distribution of cephalic index measurements demon- infant by neonatal examination. The head circumference at delivery
stnated no significant change with increasing gestational was 35 cm, which is appropriate for a term infant [8].
age (mean, 78.3; SD, 4.4) (fig. 2). Preliminary use of these
values has resulted in the detection of 1 0 fetuses in which
Discussion
the BPD was significantly affected by head shape; eight of
these were dolichocephalic and two were brachycephalic. Previous investigators have established normal values for
The range of error in predicting the gestational age by the the cephalic index measured postnatally. In a study of skull
BPD varied from 1 .5 weeks in the second trimester to 5.5 nadiognaphs, Haas [5] found a mean value of 81 .7 in 52
weeks in the late third trimester. Our earliest observation of infants aged 4 weeks to 1 2 months, with an observed range
this finding was in an 1 8 week dolichocephalic fetus whose of 73.5-90.4. He noted that these values might be slightly
true gestational age had been established by an early higher than actual values because the distortion by pnojec-
crown-rump length measurement and by documentation of tion of breadth was greaten in his series than that of length.
the time of ovulation by measurement of the basal body Jordaan [6] measured the cephalic index directly in 50
temperature. However, most of our cases (eight of 1 0) have neonates delivered by cesanean section; he found a mean
been observed in the third trimester. Interestingly, in two value of 80.6, with a normal range of 76-85 (2 SD). Our
cases the BPD and cephalic index changed from normal data, based on a large sample oven a wide range of gesta-
values to abnormal values oven a 6 week period in the third tional ages (1 4-40 weeks), demonstrated no significant
trimester (see case 2 below). Our experience to date sug- change in the cephalic index with gestational age. Our mean
gests that a cephalic index greaten than 1 SD from the mean value of 78.3 is slightly lower than the values observed
(<74, >83), may be associated with a significant change in postnatally. This may be related in part to the greater
the BPD measurement expected for any given gestational distortion of the frontal and occipital bones resulting from
age. the sonognaphic beam passing parallel to these structures
 AJR:137, July 1981 ESTIMATING FETAL AGE 85
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Fig. 3.-Case 1 . Real-time sonognaphic image Fig. 4.-Case 2. Real-time sonographic images. A, BPD of 7.6 cm (30 weeks) in 30 week
shows dolichocephalic shaped fetal skull in 35 week normocephalic fetus. B, 6 weeks later. More elongated (dolichocephalic) fetal skull; BPD (8.2 cm)
fetus. BPD (7.9 cm) suggested gestational age of 32 suggested gestational age of 33 weeks: however, head circumference (32.5 cm) was appropriate for 36
weeks, while head circumference (32 cm) was ap- weeks.
propriate for 35 weeks.

rather than perpendicular. The range of normal (2 SD) in age, and we hope that the presentation of this data will
our series was rather large (70-86), which is very similar to encourage others to examine the same problem.
values reported by Haas [5] in a study of 705 adults oven
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