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Ultrasound Obstet Gynecol 2009; 34: 503–509

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.7348

Reference intervals of gestational sac, yolk sac
and embryo volumes using three-dimensional ultrasound
J. S. BAGRATEE*, L. REGAN†, V. KHULLAR†, C. CONNOLLY‡ and J. MOODLEY*
*Department of Obstetrics and Gynaecology, Nelson R Mandela School of Medicine, University of Kwa-Zulu Natal and ‡Medical Research
Council, Durban, South Africa and †Imperial College Academic Health Sciences Centre at St Mary’s Hospital, London, UK

K E Y W O R D S: crown–rump length; embryo volume; first trimester; gestational sac diameter; gestational sac volume; reference
intervals; three-dimensional ultrasound; yolk sac volume

ABSTRACT INTRODUCTION
The ability to accurately determine the volumes of
Objectives To create reference intervals of gestational sac the gestational sac, yolk sac and the embryo enables
volume (GSV), yolk sac volume (YSV), embryo volume the creation of gestational age-related centiles that
(EV), crown–rump length (CRL) and gestational sac may be used as the basis for predicting adverse
diameter (GSD) in the first trimester of pregnancy using pregnancy outcome. The use of three-dimensional
three-dimensional ultrasound. (3D) ultrasonography has facilitated accurate volume
estimation that has been confirmed in many organ
Methods Women in the first trimester of pregnancy
systems, either in vitro or in vivo1,2 , and it has also been
were invited to participate in the study. Inclusion cri-
found to be superior to two-dimensional (2D) ultrasound
teria were well-established dates, and that the women
volumetry3 . However, some researchers still use incorrect
were non-smokers and healthy, without any medi-
methodology to estimate gestational age-specific reference
cal disorders. Three-dimensional ultrasound volumetric
intervals for embryo measurements4 . It is recommended
data (GSV, YSV, EV) were collected together with
that data from each pregnancy are included once only,
standard two-dimensional measurements of CRL and
as cross-sectional data, in the development of reference
GSD. For each measurement separate regression mod-
intervals for fetal size5 . This has not been the case with
els were fitted to estimate the mean and SD at published reference intervals for first-trimester volumetric
each gestational age. The 5th , 50th and 95th centiles measurements6 – 8 . Longitudinal studies may be used to
were derived using a combination of these regression produce reference intervals for fetal size and fetal growth9 ,
models. however, appropriate methodology has not always
Results One hundred and sixty-six women at between 6 been employed8 . Figueras et al.10 stated that they used
and 12 weeks’ gestation were scanned once. The mean appropriate methodology in constructing centile curves
(± SD) maternal age was 29.4 (± 5) years. There were for yolk sac volume (YSV) and gestational sac volume
no miscarriages and no congenital abnormalities were (GSV), but these centiles were not presented in their paper.
noted. Mean gestational age at delivery was 39.3 (± 1.4) We therefore aimed to produce valid reference
weeks and mean birth weight was 3.3 (± 0.4) kg. The intervals for first-trimester GSV, YSV and embryo
CRL centiles fitted a cubic model and the GSD centiles volume (EV) using 3D transvaginal ultrasonography. In
fitted a linear model. The centiles for YSV fitted a addition, centiles of gestational sac diameter (GSD) and
quadratic model on the modified log-transformed data. crown–rump length (CRL) were constructed for the same
The centiles for GSV and EV were modeled using quantile reference population. The centiles of CRL were compared
regression. with previously published centiles11 , and the relationships
between CRL and EV, and CRL and GSV were analyzed.
Conclusion Reference intervals and centile charts for
first-trimester GSV, YSV and EV have been created in
METHODS
addition to CRL and GSD using rigorous methodology.
Copyright  2009 ISUOG. Published by John Wiley & This cross-sectional observational study was performed
Sons, Ltd. in the Early Pregnancy Assessment Unit at St Mary’s

Correspondence to: Prof. J. S. Bagratee, Department of Obstetrics and Gynaecology, Nelson R Mandela School of Medicine, Private Bag 7,
Congella, 4013, South Africa (e-mail: bagrateej1@ukzn.ac.za)
Accepted: 3 June 2009

Copyright  2009 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER

without any medical disorders. Least-squares compared with ultrasound-derived gestational age using regression analysis was used to determine the mean CRL12 and if there was a marked discrepancy of 2 weeks curves as polynomial functions of exact gestational age or more then the woman was excluded from the study. London. The 2D the model were dropped in favor of simpler models. The selection of the final nancy loss were also excluded from the study. During this procedure the gestational sac was repeated using a cubic polynomial of a logarithmic magnified on the screen as much as possible to minimize transformation of the measurement. The patient was then asked to hold her breath SD curves was checked by examining the scatter patterns and. sagittal and coronal) after volume by substituting the expressions for the mean and SD into acquisition. The CRL was recorded as an average a quadratic polynomial was used and the quadratic of three measurements. clinic and the antenatal and labor data were recorded YSV and EV. Each tee approved the study.645.5-MHz transvaginal Another important criterion was the simplicity of the probe using a Combison 530D ultrasound machine (Kret.) performed two measurements practitioners inviting women with a positive pregnancy of GSV. of the measurement (log(x) + m). YSV and EV was performed by sequentially centiles and a scatter plot with reference intervals was viewing and tracing each structure in one of the three generated. The volume scans were stored on 540 MB–1. College Station.). the model-fitting process was mode. a polynomial or linear model measurements was recorded as the GSD. non-smokers. pregnancies of between 6 and 12 weeks’ gestation. If the 2D transvaginal ultrasound imaging. 50th and 95th centiles were calculated planes (transverse. 0.645. were each recorded. Austria). K. +1. S. UK. was selected depending on the most appropriate fit for The gestational sac was visualized again in the sagittal the scaled absolute residuals plotted against gestational plane and the region of interest was selected using the age. When all refinements of the model failed to produce Copyright  2009 ISUOG. B.3 GB Philips or Sony hard discs with an integrated magneto-optical where K = −1. model. the volume of points (SD scores) relative to ±1. goodness of fit. The ges. regular menses without hormonal contracep- Statistical analysis tion for at least three cycles before conception and a precise date of their last menstrual period or known date Statistical analysis was performed using STATA version of embryo transfer in assisted reproduction. involved an ultrasound examination for confirmation of All the women were referred to the St Mary’s antenatal their pregnancy and 3D ultrasound to record the GSV. Ultrasound Obstet Gynecol 2009. A number of different models were addition. with the vaginal probe held stationary. particularly at the tails of the distribution. YSV and EV on separate occasions using the test to participate in this study in the first trimester of stored volume and were unaware of each other’s results pregnancy. Once the final model had been region was displayed on the screen in the three orthogonal determined. drive for later measurement and analysis. explored for each measurement. a singleton pregnancy. This process was repeated until all arate printed images to prevent the examiner seeing the the coefficients in the model were significantly different results of the previous measurement and preventing the from zero. centile = mean + (K × SD). a ztechnik AG. 34: 503–509. coefficient assessed. The local research ethics commit. YSV and EV was tested on a random selection of 15 of m. Letters were sent to local general observer (J. Similarly. In measured in days. Determination Tables were then prepared for the 5th . As recommended by Royston and Wright4 . The appearance of the model with its mean and volume box. The scanned W-test and a normal plot. Inclusion criteria were: healthy women postdelivery. which were obtained from sep. Zipf. Initially. B. and V. TX. and the examiner confirmed that the entire the equation: gestational sac was contained in the acquired volume scan. using conventional cubic polynomial was initially fitted to the data. The women were informed that the study until completion of the study. The average of the three the curves for the SD. the 5th . S. the same process was repeated calculated the volume from the measured circumferences using a modified (shifted) logarithmic transformation and distances between them. Last menstrual period-derived gestational age was recommendations of Royston and Wright4 .504 Bagratee et al. Fitted measurements of the gestational sac included the maxi. in determining (D2 and D3) in the sagittal plane. The Shapiro–Wilk Intra. 50th and 95th of GSV. The study was performed with a 7.and interobserver reliability of measurement of W-test was used to determine the most appropriate value GSV. those women with uncertain dates or early preg. The normality data were generated by the automatic rotation of the of the SD score was assessed using the Shapiro–Wilk transducer crystal through 180◦ for 5–20 s. Published by John Wiley & Sons. . The computer software automatically met the required criteria. USA). If none of the models measurement error. The gestational tational age was calculated by the modified Naegele’s age-related reference intervals were obtained using the rule. Hospital. 9 (StataCorp. All scans were performed by a single examiner (J. values from the most appropriate polynomial regression mum transverse diameter (D1) in the transverse plane and curve of the desired measurement were used to predict the the maximum anteroposterior and longitudinal diameters mean for each gestational age. Informed model depended on the appearance of the curve and its consent was obtained from all participants. Where negative centile values were obtained orthogonal planes at 1–2 mm intervals using the contour for early gestational age. the CRL and GSD cubic coefficient was not significantly different from zero. Very small coefficients that contributed little to introduction of bias in subsequent measurements. Ltd.645.

Copyright  2009 ISUOG.3 (±0. quantile regression For the SD. The Shapiro–Wilk gestational age range. at between 6 and 12 weeks’ gestation responded to our letter of invitation for a first-trimester ultrasound scan For the SD. thus the assump- were used to calculate the 5th . Gestational sac diameter A linear model provided the best fit to the GSD data in RESULTS relation to GA: One hundred and seventy-five healthy pregnant women GSD = −31. 34: 503–509.4 (±5) years. Details of the reference equations derived are given below. In addition.6%) function provided a good fit to the transformed values: were nulliparous and 67 women (40. Ninety-nine women (59.114 + (0. A linear weight was 3. model for the reference intervals of CRL in relation to The model fitted satisfactorily as 17 observations gestational age (GA): (10. The intra. we obtained a negative value of in Table 1.2%) fell below the 10th centile and 18 (10. In this case 13 One hundred and sixty-six women at between 6 and (7. The mean difference in CRL estimate the ICC for consistency. Quantile regression gestational age.8%) fell above the 90th percentile. Centiles by days of gestation are provided in Table ence and SD are reported. A normal probability plot of the Z-scores showed the and that these values were scattered randomly across the scores lying close to a straight line. mean measurement for each observer.670 × GA).4) weeks and the mean birth transformation of the form log (GSV + 9).3 (±1. None of these women sustained a miscarriage or stillbirth and no infants had any congenital abnormalities. . are presented was then used to estimate more appropriate centiles. fit: The quantile regression model was assessed using three SDCRL = −1.997 + (0. 11 + 1 (14 + 1). A random effects model was used to Robinson and Fleming11 . Z-scores were randomly scattered around zero. enrolled and completed the study. The num- Intraobserver variation was calculated as the differ.171 − (0. two SDGSD = 0.882 + (0. 13 (7. Figure 2 and Table S2 present a comparison of our variation were also expressed as the intraclass correlation reference curve for median CRL with that published by coefficient (ICC). the Z-scores (14 + 5) weeks.115 + (0.0%) were above it. thus the assumption of (12 + 1). In addition. agreement were assessed following the methods described −1. bers observed above the 90th centile.4) kg.170 + (0. were randomly scattered around zero.24 to 3. para 1 to para 4).and interobserver S1.and intraobserver across the gestational age range studied was −0. mean gestational age The best model for GSV was a modified logarithmic at delivery was 39. The menstrual dates (ultrasound CRL dates in scores lying close to a straight line.362 × GA). Ultrasound Obstet Gynecol 2009. The in Figure 1.411 × GA). a linear model also showed the most at the Early Pregnancy Assessment Unit. quantile regression models that best fit the data are: 5th Centile : log (GSV) = −4.8%) points were below the 10th centile and 15 points 12 weeks’ gestation who met the eligibility criteria were (9. The data points lying outside CRL = −3. 11 + 2 (13 + 2) and 12 + 2 normality could not be rejected. Interobserver variation was calculated using the expected value of 10%.074 + (0.183 + (7.033 × GA3 ).4%) were parous (range. Medians and 5th and 95th centiles for each When the predicted values were back-transformed to measurement by weeks of gestational age are shown calculate the centiles. The mean differ.First-trimester reference intervals using three-dimensional ultrasound 505 centiles meeting the required criteria. had early embryonic demise and five women had incorrect A normal probability plot of the Z-scores showed the dates. 50th and 95th centiles and tion of normality could not be rejected. Nine women appropriate fit: were excluded from the study following their ultrasound examination: two had an anembryonic pregnancy. a linear model showed the most appropriate was used to determine more appropriate centiles13 . log (GSV + 9) = 0. were close to the observer.385 × GA). Scatter plots of each measurement against −0. Crown–rump length 50th Centile : log (GSV) = −2.06). the a scatter plot with reference intervals was constructed.675 × GA).84). that 10% of observed values lay above the 90th centile and below the 10th centile. the reference interval were spread throughout the range.545 × GA). th A least squares cubic model was shown to be the best 95 Centile : log (GSV) = −0. with the modeled centiles. by Bland and Altman14 .05). Inter. and ence between the first and second measurements by one below the 10th centile. 8 + 4 test was not significant (P = 0. The mean age (± SD) of Gestational sac volume the women was 29.6 for the 5th centile at 6 weeks. Ltd. criteria13 : no negative values.14 (range. 15 (9. The quantile regression equations W-test was not significant (P = 0.537 × GA).0%).8%). The Shapiro–Wilk W- brackets) of these five women were: 7 + 1 (9 + 0). Published by John Wiley & Sons.

49 5.71 SD When the predicted values were back-transformed to 12 weeks. The model fitted 0. 2.4). There 6 7 8 9 Copyright  2009 ISUOG.59 38.32 75.074 0. The data points lying outside the reference interval were 12.17 71.480 × GA) − (0. was used to model the data.94 22.44 28.54 1.97 46.95 63.24 5th log (EV + 0.52 38. A modified log transformation.29 95.050 satisfactorily as 18 observations (12.71 according to gestational age (GA) 50th above the 90th centile.20 32. Table 2 presents the intra. log (YSV EV (mm3 ) 0.68 17.83 6.82 24.116 0.50 10. yolk sac volume (YSV) and embryo volume (EV) Measurements were available in 145 of the 166 n represents the number of pregnancies included in the study at each week of GA. The volume measure- ments of GSV.84 19.50 144.74 61.18 0.78 2. A linear function provided a good fit to the transformed values: 1.119 was not significant (P = 0.15) = −6.123 + (2. .042 0.005 0.94 35. 13 at 11 weeks and 9 at pregnancies.08 spread throughout the range. calculate the centiles.36 7.165 0.45 50th Centile : log (EV) = −18.74 2.58 60.01 57.67 7.884 + (3.15 3.0%) were 5.54 73.488 + (2.80 41.506 Bagratee et al.047 0. gestational sac diameter (GSD).82 4.52 26. Ultrasound Obstet Gynecol 2009. 95th GSV (mm3 ) Embryo volume 4.94 19. with 25 at 10 weeks.063 0.063 For the SD. Ltd.71 46. A quadratic model 0.00 50. In addition.93 15.039 + 0.054 0. 4.16 5.74 49.874 + (0.243 0.67 16.1095 × GA2 ).47 40.43 27.47 3.234 95th YSV (mm3 ) A normal probability plot of the Z-scores showed them lying close to a straight line.44 41.19 0.749 × GA) 0.0%) were below the 10th centile and 15 (9.64 7.94 48.05). 34: 503–509.49 5.23 37. a linear model showed the most appropriate 0.28 66.90 34. There was no difference in gestational age (weeks) between the males and females (P = 0.29 50th provided the best fit: log (YSV + 0.049 for the 5th centile at 6 weeks.52 12.61 114.36 53.68 18.37 9. Yolk sac volume 0.022 − (0.034 × GA2 ).23 32.146 0.05) = −5.032 0.95 24.130 0.078 + (0.20 31.12 28.129 0.3%) lay above the 90th centile. YSV and EV showed high levels of intra- and interobserver agreement.07 SD fit: SDYSV = 0.21 18.03 5.13 50th 5th Centile : log (EV) = −20.58 5.4%) fell below the 5th 10th centile and 15 (10.81 95th −0.07 0.034 0.86 10.0842 × GA2 ).119 0.019 × GA). thus the assumption of 50th normality could not be rejected.61 66.66 4. 0.19 56.79 5.31 5. The data points lying outside the reference interval were spread throughout the range.06 9. Therefore GA* 10 11 12 overall measurement means and SDs are reported.50 SD 95th Centile : log (EV) = −14.97 22. *Centile and SD values are given for the midpoint of each gestational week.28 43.059 0.93 50th The best model for EV was a modified logarithmic transformation of the form log (EV + 0.095 0.039 0. 50th and 95th centiles for crown–rump length (CRL).84 23.38 38.856 + (0.and interobserver variation 1.11 14. Quantile regression GSD (mm) was then used to estimate more appropriate centiles: 16. Measurements of YSV were not obtained for all pregnancies.068 0.28 5th 0.17 7.460 × GA) − (0.68 95th Table 1 Calculated 5th . we obtained a negative value of 24.014 0.02 5th of the 3D volume measurements. 9. 9. 26 26 24 22 26 20 22 n Table 3 shows the CRL and EV in relation to fetal gender.805 × GA).060 0.10 6. Published by John Wiley & Sons. The Shapiro–Wilk W-test 0.14). the Z-scores were randomly scattered around zero.84 11.31 2. gestational sac volume (GSV).39 95th CRL (mm) The model fitted satisfactorily as 15 observations (9.233 0.0041 × GA3 ).116 × GA) 5th − (0.15).031 0. 0.205 0.44 15.56 6.

.004 0. resulting in substandard To the best of our knowledge. of appropriate methodology is crucial.23 (−0.2 a very strong correlation (r = 0.99 Figure 2 Comparison of the reference curve for median ICC.40 5.024 to 0. There was also CRL (mm) 84 28. the recommend that each fetus be included once only in currently available reference intervals for these parameters the study.08 82 24.2) or in EV (P = 0.05 (−3.36) 0.91 0.325 0.8 (−2. Published by John Wiley & Sons. Table 3 Crown–rump length (CRL) and embryo volume (EV) according to fetal gender were no statistical differences between males and females Male Female in CRL (P = 0.99 6 7 8 9 10 11 12 YSV (mm3 ) 0.94) between Parameter n Mean SD n Mean SD P CRL and EV (Figure 3a).80) 0.17) 0.2 10 0.009 to 0.13 (−0. intraclass correlation coefficient. gestational sac volume (GSV) (c).12 to 0. Ultrasound Obstet Gynecol 2009.95) between CRL and GSV (Figure 3b).90 82 4.075 0.08 19. 50th and 95th centiles of crown–rump length (CRL) (a). Altman and Chitty5 GSV.99 Intraobserver difference 0 GSV (mm3 ) 0.12 to 0.03) 0.86 7.1 0 0 6 8 10 12 14 6 8 10 12 14 Gestational age (weeks) Gestational age (weeks) Figure 1 Scatter plots with 5th .021 0. study in the literature that has used 3D transvaginal In the collection of data specifically for the purpose ultrasound to derive reference intervals of first-trimester of developing centiles for size. 34: 503–509.2 EV (mm3 ) 84 5. this is the first clinical care15 .3 YSV (mm3) EV (mm3) 20 0. gestational sac diameter (GSD) (b). as inaccurate DISCUSSION centiles may lead to incorrect decisions regarding embryonic/fetal development.First-trimester reference intervals using three-dimensional ultrasound 507 (a) (b) (c) 80 80 150 60 60 CRL (mm) GSV (mm3) GSD (mm) 100 40 40 50 20 20 0 0 0 6 8 10 12 14 6 8 10 12 14 6 8 10 12 14 Gestational age (weeks) Gestational age (weeks) Gestational age (weeks) (d) 0.and interobserver variation of three-dimensional volume measurements of gestational sac volume (GSV).285 1. yolk sac 60 volume (YSV) and embryo volume (EV) 50 Parameter Mean SD Range ICC CRL (mm) 40 30 Interobserver difference GSV (mm3 ) 0. crown–rump length (CRL) against gestational age obtained in the present study ( ) with that published by Robinson and Fleming11 ( ).99 20 YSV (mm3 ) 0.4 (e) 30 0.01 (−0. YSV and EV using accepted methodology. There was a very strong correlation (r = 0.63) 0. The use lished reference intervals of first-trimester volumetric Copyright  2009 ISUOG. 70 Table 2 Intra.015) 0.98 Gestational age (weeks) EV (mm3 ) 0.6 to 1.56 17. yolk sac volume (YSV) (d) and embryo volume (EV) (e) against gestational age.2).97 10 EV (mm3 ) 0.002 0.62 0. Ltd.01 (−0. For CRL measurements between 20 and 70 mm the relationship was linear.6 to 0. This was not the case with recently pub- are based on incorrect methodology6 – 8 .

S. Bland and Altman have CRL (mm) argued that averaging repeated measurements for each subject may lead to narrower centiles at any given ges- Figure 3 Embryo volume (EV) (a) and gestational sac volume tational age than had they been constructed from single (GSV) (b) plotted against crown–rump length (CRL). we developed reference intervals for CRL for this 100 group of healthy women with a normal pregnancy out- GSV (mm3) come.508 Bagratee et al. In our study GSV increased in an they studied between 10 and 14 fetuses per week from 6 exponential manner between 6 and 12 weeks’ gestation. the impact is probably minimal in clinical prac- between the 25th and 65th days post-ovulation. It has been reported previously that a sex difference in they recorded values from 4 + 2 weeks of gestational age. prediction of gestational age of no better than ±9 days. the gestational age was recorded from 4.5-MHz probe. and were therefore of lesser value than CRL in measur- The volumetric assessment by Aviram et al. did not take this into account and presented their 6 weeks to 31 mm3 at 10 weeks and then in a more linear data rounded to each gestational week in the development manner to 100 mm3 at 13 weeks. or will call the practice nurse during their 5th week of amenorrhea.16 . we were able to recruit EV (mm3) an adequate number of women between the 6th and 12th gestational weeks. Published by John Wiley & Sons. confirmed by the plot 0 of Z-scores against gestational age. which were performed in smooth reference interval curves. 50 whereas an average of three different measurements may reduce the SD to ±2. with male they developed their reference intervals from 5 + 4 weeks embryos having an average measurement 2 mm greater to 9 + 2 weeks6 . He expect on a biological basis4 . This impacts on the creation erence intervals in the literature20 . measurements18 . resulting in the mean and SD measurements using 2D ultrasound imaging and used the not changing smoothly with gestational age as one would mathematical formula of a sphere to calculate volumes. resulting in contrast to our measurements. He also found that the of their centile charts. In our study the mean and also used transabdominal ultrasound with a full bladder. Babinski et al.7 days11 . CRL was demonstrated from 8 weeks onward. Ltd. their reference intervals were not obtained from a pregnant population with normal fetal outcome.) to have a pregnancy confir- (b) 150 mation scan and additionally to determine the volume of the early pregnancy structures. In our study. Robinson20 performed of the reference intervals. Reference intervals derived from single CRL measurements may give widened centiles because measurements6 – 8 . Our precisely to the day. In the present study.8 is limited as ing gestational age. We averaged the CRL obtained from three different satisfactory measurements because a single measurement may estimate gestational age with an SD of ±4. using 73 measurements obtained from 49 pregnancies However. rather than rounding it off to the estimation of the GSV differs from the first reported ref- number of completed weeks. Our values for CRL fitted a standard Gaussian distribution. In addi- 30 tion. How- Gadelha et al. and were similar to 0 20 40 60 80 the reported normal values11 . (a) to 11 weeks and only three fetuses at 12 weeks. two-SDs limits increased considerably with gestational age In the construction of reference intervals requiring a and concluded that volume measurements would allow a 90% range between the 5th and 95th centiles of the distri. . using transvaginally using a 7. and Weissman et al. Prior to the construction of the volume reference inter- vals. It would have 0 0 20 40 60 80 been only then that their general practitioner or practice CRL (mm) nurse would have offered them the opportunity to contact one of the authors (J. SD were modeled using the exact gestational age. Ultrasound Obstet Gynecol 2009. as all 72 women recruited to their study underwent a termination 20 of pregnancy. however. possibly owing to the fact 10 that many women have a home pregnancy test when their menses are delayed by a week and only see their doctor in most instances after the 5th week. Gadelha et al.7 days. Although tice. we found no difference in CRL or in EV between longitudinal prospective study and measured each fetus on male and female embryos. during the 8th . B. that the mean GSV increased exponentially from 1 mm3 at sound. Robinson20 found 3D ultrasound.4 mm3 at 6 weeks to 114.7 . 10th and 11th weeks of Our formula for median GSV gives values that increase pregnancy.7 only studied a total of 25 fetuses in a ever.9 mm3 at 12 weeks.6 created nomograms they include a greater amount of measurement error. Copyright  2009 ISUOG. a sample size of 20 per week is recommended17 . using 2D ultra. than female embryos at the same gestational age19 . 9th . not possible for the fifth week of pregnancy. bution. 34: 503–509. This was. four occasions.

Gannoun A. 27: J Obstet Gynaecol 1994. 11: 12–21. Saracco J. Shao MYC. Mukherjee T. In conclusion. A prospective study of prognostic value. Cole TJ. Stat St Mary’s Hospital. Gadelha PS. Agreement between methods of mea- surement with multiple observations per individual. Kamar Shpan D. El Beitune P. staff of the Early Pregnancy Assessment Unit at 17. we included the amniotic fluid. 18: 203–211. similar to the findings of Kupesic age (5–18 weeks) with high-resolution real-time US. Statistical methods for constructing gestational age-related reference intervals and centile charts for fetal size. Royston P. Hustin J. Ltd. Babinski A. J vascularity of the yolk sac at the time of its maximum Reprod Med 2003. 2. volume is proposed as the cause of its degeneration and 11. Fishman A. Müller T. Br sound and color Doppler. Charts of fetal size: 1. Silverwood RJ. Markovitch O. 17: 571–582. Radiology et al. 15: 771–774. sac and embryo in the first trimester of pregnancy using 14. Ultrasound Obstet Gynecol 2007. Fleming JEE. then maintained a plateau until 11 weeks and crown–rump length: Reevaluation of relation to menstrual decreased thereafter. The decreased tational sac volume. Jakobi P. A critical evaluation of sonar disappearance23 . Carrera JM.23 . at 6 weeks and 16. Sütterlin M. 10. 29: 6–13. Design and analysis of longitudinal our study. Shah YP. Sonographic measure- ment of amniotic fluid volume in the first trimester of pregnancy. Guinot C. Three dimensional 21. Three-dimensional measurement of gestational and yolk sac volumes as predictors of pregnancy outcome in the first We found that the embryo occupied 0. Tep- per R. methodology as prescribed by previous authors4. Ultrasound Obstet Gynecol 2009. Da Costa AG. King DL. 281: 1253. 82: 100–107. Bree RL. Three-dimensional first trimester fetal volumetry: com- of 95 pregnancies they therefore ignored the estimated EV parison with crown rump length. 48: 252–256. 1975.8% at 12 weeks. 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Antolin E. 6: 5 weeks’ gestation onwards. using 2D ultrasound fluid volumetry by three-dimensional ultrasonography during measurements and the formula of an ellipsoid (V = 4/3 π the first trimester of pregnancy. 16% of the sac volume. Early Hum Dev 2004. we have presented new reference 13. Chitty LS.15 . Three-dimensional yolk and ges- size up to 11 weeks and then decreases22 . Kurjak A. Ultrasound evidence of sexual difference in fetal size in first trimester. J Biopharm Stat 2007. Altman DG. Measurement agreement in method 3D ultrasound. Fetal 10 weeks. Ultrasound CT MR 1990. Correlation of with three-dimensional ultrasound. 10: 675–690. We would like to thank the nursing and medical J Ultrasound Med 1996. Robinson HP. and in their subsequent analysis 8. Aviram R. Weissman A. ACKNOWLEDGMENTS 16. the reference intervals for ‘‘crown-rump length’’ measurements. Transvaginal volumetry 22. Nasseri A. 1. when the gestational sac 307–312. as did Robinson20 . Statist Med 2002. Jordan S. Am J Perinat 2001. How to construct ‘normal ranges’ for 23.5. Reference curves intervals for the volumes of the gestational sac. Jauniaux E. Methodology. Volume and vascu- fetal variables. Dietl J. 18. Torrents M. Robinson HP. 32: r1 r2 r3 ). 182: 501–505. Nyari T. Wright EM. Transvaginal sonography in the first ultrasound: accuracy of distance and volume measurements. 12. Riccabona M. Ultrasound Obstet Gynecol 1998. the 6. King DL Jr. We obtained YSV in 145 of the 166 pregnancies in 9. 91–96. Its diameter increases in Echevarria M. trimester: embryology. Bland JM. J Perinat Med 1999. 1–5. Altman DG. Royston P. Stat Meth Med Res 1999. Bland JM. Hadlock FP. UK for their co-operation Med 1991. Figueras F. Pedersen JF. Pöhls U. yolk based on non-parametric quantile regression.9% of the GSV trimester. Ultrasound Obstet Gynecol 1995. Evaluation of in vitro 20. 15. In our study. Hum Reprod 1991. 7: 429–434. 1992. and assistance during the study. Comas C. 101: 29–34. perman AB.