ASSESSMENT OF GESTATIONAL AGE by Ultrasound

DR.AKRAM ABD ELGHANY

MD,ALAZHAR UNIVERSITY
CONSULTANT OBS.&GYN.
PORTSAID G.HOSPITAL

EGYPT

Accurate determination of gestational age is fundamental to obstetric care and is important in a variety of situations: antenatal test(AFP,BHCG,NT) i when dates are inaccurate, test results will be incorrect and misleading.1

Fetal growth assessment, either clinically or by ultrasound evaluation, relies on accurate assessment of gestational age. Fetal growth retardation or macrosomia may be missed owing to errors in gestational age assignment. Interpretation of antenatal biophysical testing subjected to variation with gestational age as well.

Obstetric management is dependent on gestational age

Proper decisions regarding presumed preterm labor or postdate pregnancies are only possible when gestational age is accurately estimated. Timing of repeat cesarean section requires accurate dates.4,5

METHODS OF GESTATIONAL AGE ASSESSMENT

The historical information and the physical examination. The maternal sensation of fetal movement (quickening). Assessment of uterine size by bimanual examination in the first trimester.

 Detection of fetal heart tones by Doppler (1012 weeks). Auscultation (1921 weeks). Fundal height measurement.

Both the history and the physical examination are fraught with error, even in the best circumstances.

Menstrual history was considered reliable in only 18% of women.

Even among women with known LMP, neonatal age assessment differed markedly from that assigned by certain menstrual dates in 15% .

20% to 40% of women cannot relate the LMP with certainty.6,

7 due to: oligomenorrhea,metrorrhagia. bleeding in the first trimester of pregnancy. pregnancy following use of oral contraceptives or intrauterine devices. pregnancy in the postpartum period.

1.Physical examination inaccurate, especially with advancing gestational age. 2. Bimanual examination in the first trimester may be accurate within 2 weeks. 3. fundal height measurement is only accurate within 4 to 6 weeks. 4. the inaccuracies of history and physical examination may limit their usefulness in assessment of gestational age.

 Timed ovulation,either by basal body temperature recording or semiquantitative assessment of LH surge, predicts gestational age within 4 to 6 days. Ovulation induction with agents such as clomiphene citrate and Pergonal,accurately predicts gestational age. In vitro fertilization the most accurate means of predicting gestational age (1 day). in most pregnancies, the date of ovulation or conception cannot be accurately predicted and gestational age must be established by other methods.

Clinical Predictors of Gestational Age

Estimated Range for Parameter In vitro fertilization Ovulation induction LH surge indicator Basal body temperature Certain menstrual history 95% of Cases 1 day 46 days 46 days 46 days 2 weeks

Bimanual examination (first trimester) 2 weeks First fetal heart tones by Doppler Quickening First fetal heart tones by auscultation Fundal height measurement between 18 and 32 weeks' gestation Fundal height measurement after 32 weeks' gestation 46 weeks 2 weeks 24 weeks 24 weeks 4 weeks

Ulrasound assessment of gestational age is feasible in a majority of pregnancies with greater accuracy than physical examination. In the first trimester, gestational sac mean diameter and crown-rump length measurements have become the primary means of evaluating gestational age.15,16,17,18,19

In the second and third trimesters, fetal head, body, and extremity measurements have been commonly used to assess gestational age. Those parameters most commonly measured include biparietal diameter,head circumference ,abdominal circumference and femur length.

First Trimester Assessment

the gestational sac mean diameter and crown-rump length are used to establish fetal age. Both parameters are useful because each measures a different aspect of the firsttrimester pregnancy and may be used at different times during the first trimester.

GESTATIONAL SAC MEAN DIAMETER

The gestational sac is the first identifiable structure imaged in the first trimester. transabdominal ultrasound as early as 5 weeks' , as early as 4 weeks' gestation by transvaginal ultrasound.15,16,47 The gestational sac is an echo-free space containing the fluid, embryo, and extraembryonic structures.

 The sac is measured inside the hyperechoic rim, including only the echo-free space. The gestational sac is imaged first in the longitudinal plane, obtaining long axis and anteroposterior measurements perpendicular to each other. Then, in the transverse plane at the level of the anteroposterior measurement, the width measurement is obtained. The three measurements are averaged to obtain the gestational sac mean diameter. The accuracy was found to be 1 week.16

CROWN RUMP LENGTH(CRL)

The embryo is measured along its longest axis to obtain the CRL measurement accurately date pregnancy between 7 and 13 weeks' gestation. measurement of the fetal length from the tip of the cephalic pole to the tip of the caudal pole. The fetus should be at rest and assuming its natural curvature.

 At 5 to 6 weeks' distinct landmarks cannot be identified but heart motion can be detected centrally. As the pregnancy continues, the head can be easily identified from the rest of the body. After 12 weeks' gestation excessive curvature of the fetus leads to erroneous shortening of CRL measurement.

 Gestational age assessment by CRL was extremely accurate, approaching 3 to 4 days. Subsequent studies have suggested that the CRL is somewhat less accurate; however, the accuracy is still within 5 to 7 days.49,50,51,52 Variations in the measurement of CRL can be attributed to differences in fetal growth patterns. Such differences are related to factors similar to those that influence birth weight curves, including maternal age and parity, prepregnancy maternal weight, geographic location, and population characteristics

Technical factors can lead to errors in CRL measurements. incorporation of the yolk sac or lower limbs in the CRL measurement, excessive curling or extension of the fetus, tangential section of the trunk.17

The crown-rump length is measured along the longest axis of the fetus

Second and Third Trimester Assessment

fetal head (BPD and HC), body (AC), extremity (FL) measurements.

BIPARIETAL DIAMETER (BPD)

The BPD is imaged in the transaxial plane of the fetal head at the level of thalami in the midline, equidistant from the temporoparietal bones and usually the cavum septum pellucidum anteriorly.58, 59 the most commonly accepted method is measurement from leading edge to leading edge (outer-to-inner) .

 Between 12 and 26 weeks' the BPD is accurate 10 to 11 days. After 26 weeks' the accuracy of BPD measurement progressively decreases and is 3 weeks near term. Biologic variation, occur because of differences in maternal age, parity, prepregnancy weight, geographic location, and specific population characteristics contribute to inaccuracy in the BPD measurement.

Technical factors
interobserver error, different techniques of measurements, and single versus multiple measurements influence the accuracy.60,61,62 BPD measurement is most accurate in assessing gestational age when the head shape is appropriately ovoid. If the head is rounded (brachycephalic) or elongated (dolicocephalic), BPD measurements would overestimate or underestimate gestational age, respectively.

 To determine whether head shape is appropriate, the BPD and the frontooccipital diameter ratio( the cephalic index) (CI) Is calculated with a mean value of 0.78 (2 SD) of 0.70 to 0.86.. In the fetus with an abnormal cephalic index (noted in <2% of fetuses prior to 26 weeks' gestation), dates may be estimated more accurately using head circumference.

HEAD CIRCUMFERENCE(HC)
Although tracing of the outer perimeter of the head is the most reliable means of measuring HC, the following formula using biparietal and fronto-occipital diameters may be used to calculate HC with a maximum error of 6%:63,65

D1 + D2 / 2 x3.13
The accuracy of HC measurement is comparable with that of BPD measurement.30 in fetuses with abnormal head shape, either brachycephaly or dolicocephaly, HC may be a more accurate predictor of fetal age than BPD.30,65

Transaxial image of the fetal head for biparietal diameter and head circumference measurements

ABDOMINAL CIRCUMFERENCE (AC)

AC is obtained in the transaxial view of the fetal abdomen,at the level of the fetal liver, using the umbilical portion of the left portal vein as a landmark,The fetal stomach is at the same level, which is slightly caudad to the fetal heart and cephalad to the kidneys. The AC measurement is taken from the outermost aspects of the fetal soft tissues. (1) tracing the outer perimeter of the AC by the trackball on the ultrasonic equipment (2) the same equation as for HC using transverse and anteroposterior diameters of the fetal abdomen.

 The AC may be used to estimate gestational age but is less accurate than head measurements (BPD or HC).33 the accuracy of AC in estimating gestational age is greatest in the second trimester, with decreasing accuracy near term. Biologic and technical factors may contribute to the inaccuracy of AC measurements.

 AC is the growth parameter most commonly affected in pregnancies complicated by abnormal fetal growth patterns.33 A macrosomic fetus will have increased AC relative to gestational age, A growth-retarded fetus will have diminished AC measurements. Estimation of gestational age by AC will lead to inaccuracies in fetuses displaying either of these growth patterns.

HC/AC ratio
a predictor of head-toabdomen symmetry or asymmetry in order to identify the type of abnormal growth.

Transaxial image of the upper fetal abdomen

 the largest of the long bones, least moveable, and easiest to image. It is measured along the long axis of the bone; a straight measurement of the osseous portion is taken from one end to the other, disregarding bone curvature. The ultrasound beam shoud be perpendicular To the shaft. the measured ends shoud be blunt in appearance and the distal femoral epiphysis should not be included.

FEMUR LENGTH(FL)

 FL accurately predict gestational age between 14 weeks' and term.39 The accuracy of the FL and BPD is similar in the third trimester. Although there is controversy regarding the accuracy of the FL prior to 26 weeks' gestation.38,39 the accuracy of FL is greatest in the second trimester and least near term.

Biologic and technical factors may lead to inaccuracies of FL measurements. ultrasound imaging may lead to overestimation of FL, particularly when the femur is in the far field or lateral margins of the image.

Tangential section of the

femur, failing to visualize the entire length of the shaft, leads to underestimation of FL.

 Artifactual bowing of the femur may also occur on ultrasound imaging and lead to a shortened FL measurement. The distal femoral epiphysis becomes echogenic in the third trimester, Inclusion of the distal epiphysis will falsely overestimate FL.67,68 FL is useful when head measurement is difficult to obtain due to fetal position.

 The FL/BPD ratio (normal values 79 6%) is useful as an internal verification of the measurements obtained. Abnormal ratio is an indicator of pathologic entities, microcephaly (FL/BPD abnormally high) hydrocephalus or short-limb dysplasia (FL/BPD abnormally low).

FL/BPD ratio

 femur length and abdominal circumference (FL/AC) have been compared in order to diagnose fetal growth abnormalities (macrosomia and fetal growth retardation),34 there is much overlap between normal and abnormal values of this ratio.75,76,77,78

The femur length is measured between the arrows

ASSESSMENT OF GESTATIONAL AGE

The accuracy of a single parameter is dependent on the gestational age at the time of ultrasound examination. To improve the accuracy of gestational age assessment growthadjusted sonographic age79 and averaging multiple parameters are used.80,81

Ultrasound Predictors of Gestational Age

Estimated Range for Parameter* Gestational sac mean diameter Crown-rump length BPD, 1226 weeks HC, 1226 weeks AC, 1226 weeks FL, 1226 weeks BPD, 2742 weeks HC, 2742 weeks AC, 2742 weeks FL, 2742 weeks 95% of Cases week 57 days 1011 days 1014 days 1014 days 1020 days 23 weeks 23 weeks 23 weeks 23 weeks

Growth-Adjusted Sonographic Age

Gestational age estimation using a single BPD is accurate 10 to 11 days in the second trimester. Gestational age can be more accurately predicted by obtaining paired BPD measurements (the first from 20 to 26 weeks' gestation and the second from 31 to 33 weeks' gestation) and assigning gestational age by a method 79 known as growth-adjusted sonographic age (GASA).

 In approximately 90% of fetuses, BPD growth from 20 to 33 weeks' gestation tends to progress within narrow percentile ranks.21,25 BPD growth patterns can be subdivided into three types: large ( 90th percentile); average (10th to 90th percentile); and small ( 10th percentile). Paired BPD measurements obtained at different gestational ages allows categorization of the specific cephalic growth pattern. The first measurement should be obtained between 20 and 26 weeks' gestation, and the second measurement should be obtained between 30 and 33 weeks' gestation.

 The first BPD measurement will not distinguish the fetus with large, average, or small BPD growth, and, therefore, the fetus is assigned a mean gestational age based on an assumed average BPD growth pattern. The second BPD measurement identifies the specific type of growth pattern. For example, in the fetus with average growth the second BPD measurement will fall between the 10th and 90th percentiles, confirming the gestational age assignment from the first BPD measurement.

 BPD growth in the small-for-gestational age fetus will follow a slow growth pattern and the second BPD measurement will be less than or equal to the 10th percentile for the gestational age assigned by the first BPD. Since the first BPD measurement failed to recognize the small growth pattern and, therefore, underestimated gestational age, the second

measurement allows the gestational age assessment to be adjusted based on the BPD growth pattern. Such a fetus with a

slowed growth pattern would have the gestational age advanced by 1 week at the time of the second BPD measurement.

 Dates in the large-for-gestational age fetus may be adjusted by GASA at the time of the second BPD measurement, decreasing gestational age assignment by 1 week if the BPD measurement is greater than or equal to the 90th percentile.

Use of GASA increases the accuracy of gestation by BPD measurement to within 3 to 5 days.
79

Multiple Fetal Growth Parameters

when two or more parameters predict the same end point, the probability of correctly predicting that end point is increased. The BPD, HC, AC, and FL measurements were obtained and the mean gestational ages of combinations of these parameters were averaged to obtain a mean gestational age. The use of multiple parameters improved the accuracy of gestational age assessment compared with any single parameter.80

 If the gestational age estimates derived from all of the parameters are similar, assignment of gestational age from the average of all the parameters will improve accuracy. If gestational age estimates of the various parameters are quite different, averaging multiple parameters will decrease the accuracy of the best predictor(s).

Averaging of fetal growth parameters should be avoided when certain conditions are suspected, fetal macrosomia, intrauterine growth retardation (both symmetric and asymmetric), congenital anomalies (skeletal dysplasias, hydrocephalus, and others).

Multiple Gestations
During the last 10 weeks of pregnancy there is a decrease in the growth rate for twin fetuses compared with singleton fetuses. The femur continues to grow normally throughout pregnancy in twin gestations, while the head (BPD and HC) and abdominal (AC) growth rates decrease in the last 10 weeks of pregnancy. FL measurement may be a more reliable parameter to use for gestational age assessment in twin gestations during the third trimest.

Guidelines recommended for the assessment of gestational age When menstrual dates fall within the confidence limits of the ultrasound assessment, the role of ultrasound is to

confirm menstrual dates.

 When menstrual dates fall outside the confidence limits of ultrasound assessment, assignment of dates should be based on ultrasound assessment of gestational age.

When menstrual dates are unknown, assignment of dates should be based on ultrasound assessment of gestational age.

Obstetric management must appreciate this potential for error. A patient presenting in spontaneous labor at 33 3 weeks' gestation should be managed as if the pregnancy may be as little as 30 weeks' gestation, rather than as advanced at 36 weeks' gestation. The patient presenting for prenatal care at 39 3 weeks' gestation, should be managed for the potential of postdates pregnancy.

 Use of the multiple parameters method of assessing gestational age is valid when the gestational age estimates of the various ultrasound parameters are

similar.

If the gestational age estimates of one or several parameters is greater than 2 weeks different than the estimates of the other parameters, either the abnormal ultrasound parameters should be excluded or a different method should be used to estimate gestational age.

When the various ultrasound parameters predict different gestational ages the fetus should be further evaluated to explain these differences,
an abnormally small FL measurement may suggest short-limb defects. A large BPD may be secondary to hydrocephalus. an abnormally small or large AC measurement may suggest asymmetric intrauterine growth retardation or macrosomia.

 the different ultrasound ratios (CI, HC/AC, and FL/BPD) may be used to identify abnormally small or large parameters. In the instance of an abnormal cephalic index, the HC should be used to estimate gestational age, rather than the BPD measurement.

CONCLUSIONS
Assessment of gestational age is fundamental to obstetric care and should be a carefully thought-out process. Assessment should depend on history and physical examination, as well as ultrasound evaluation.
Ultrasound is a reliable method for establishing the length of pregnancy and in this way can improve obstetric care.

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