Ultrasound Obstet Gynecol 2002; 19: 467– 470
Fetal gastric size in normal and abnormal pregnancies
Blackwell Science, Ltd
M. SASE*, H. ASADA*, M. OKUDA† and H. KATO*
Departments of *Reproductive, Pediatric and Infection Science and †Human Environment and Preventive Medicine, Yamaguchi University School
of Medicine, Ube, Japan
KEYWORDS: Congenital digestive tract obstruction, Human fetal stomach, Ultrasound index of fetal gastric size
ABSTRACT
Objective The aim of this observational study was to con-
struct an ultrasound index of fetal gastric size for the prenatal
detection of congenital digestive tract obstruction.
Subjects A total of 386 fetal measurements were performed
in routine ultrasonographic examinations of women with
normal singleton pregnancies between 18 and 39 weeks of
gestation. Gastric measurements were also performed in 13
fetuses with digestive tract obstruction.
Methods The ultrasound plane which included the pylorus
and which provided the largest stomach area was used for
definition and measurement of gastric area and maximal
longitudinal dimension. The transverse section at the center of
the gastric corpus was used for transverse and anteroposterior
dimensions. Gastric volumes were calculated as a prolate
ellipsoid. The gastric area ratio was defined as the gastric area
divided by the transverse abdominal area. Biparietal diameter
(BPD) and abdominal transverse area were also measured.
Results The fetal gastric area was significantly correlated
with fetal gastric volume (r = 0.91) and gestational age
(r = 0.74). However, the correlation coefficient for gastric
area with gestational age was smaller than those of the BPD
(r = 0.97) with gestational age and abdominal transverse area
with gestational age (r = 0.97). Gastric area ratio decreased
slightly towards term. The gastric area ratio was below the
95% confidence intervals for the predicted values in all five
fetuses with esophageal atresia, and exceeded the 95% con-
fidence intervals in seven of the eight fetuses with duodenal
atresia or intestinal tract obstruction.
Conclusion Fetal gastric area correlates with ultrasound-
determined gastric volume measurements and appears to be
useful in the assessment of digestive tract anomalies.
INTRODUCTION
Fetal swallowing and absorption in the fetal digestive tract
are the major routes of amniotic fluid resorption, and upper
Correspondence: Dr M. Sase, Department of Reproductive, Pediatric and Infection Science, Yamaguchi University School of Medicine, Ube,
Yamaguchi, 755-8505, Japan (e-mail: sase@po.cc.yamaguchi-u.ac.jp)
Accepted 17-2-02
ORIGINAL PAPER
digestive tract obstruction often results in polyhydramnios1.
Amniotic fluid which is swallowed by the fetus initially enters
the stomach. Therefore, abnormal conditions of the fetal digest-
ive tract may alter both amniotic fluid volume and gastric
volume. The developmental profile of the human fetal stomach
has been investigated at advanced stages of gestation using
real-time ultrasonography. Growth charts for fetal stomach
dimension have been documented throughout pregnancy2–4.
Previous studies have reported on the prognostic significance
of non-visualization of the fetal stomach by ultrasonography5–8.
However, there has been no accepted standard of fetal gastric size
to evaluate congenital abnormalities of the digestive tract.
We sought to construct a growth chart for a standardized
fetal stomach dimension throughout pregnancy and evaluate
the usefulness of the standard to assess the fetal gastric size
in cases of gastrointestinal tract obstruction.
MATERIALS AND METHODS
A total of 386 fetal measurements were collected from routine
ultrasonographic examinations of women with normal singleton
pregnancies between 18 and 39 weeks of gestation. One
measurement only from each fetus was taken. None of the
fetuses had significant oligohydramnios, polyhydramnios,
macrosomia, growth restriction or detectable fetal malforma-
tions. The mothers had no medical or obstetric complications
and the pregnancies were uneventful. In addition, 13 cases of
fetuses with digestive tract obstruction (esophageal atresia in
five cases, duodenal atresia in four cases, intestinal obstruction
in four cases) were studied. The gestational age was estimated
from the last menstrual period and by serial ultrasonographic
measurements of the crown–rump length before 12 weeks.
The ultrasonographic equipment used included an Aloka
SSD-650 scanner (Aloka, Tokyo, Japan) and a Yokogawa
RT-2600 scanner (Yokogawa, Tokyo, Japan) with a linear
and convex array transducer of 3.5 MHz. When the fetal
stomach was not detected, a repeat examination was performed
15–30 min later.
The fetal stomach, which was detected as the largest area
including the pyloric site on a transverse or oblique section,
467
Human fetal gastric size
Figure 1 Diagram representing the method of measurement of the fetal
gastric area ratio. Gastric area ratio = gastric area /abdominal transverse
area.
Figure 2 Correlation between fetal gastric area and fetal gastric volume
throughout pregnancy (r = 0.91).
was observed by real-time imaging during routine ultrasound
screening. Gastric area and the longitudinal dimension of the
stomach were measured. Transverse and anteroposterior
dimensions were measured in the transverse section at the
center of the gastric corpus. The gastric area ratio was defined
as the gastric area divided by the transverse abdominal area
(Figure 1). Biparietal diameter (BPD) and fetal abdominal
transverse area were also measured. Volumes were calculated
according to the formula of a prolate ellipsoid:
4/3π (a/2)(b/2)(c/2),
where a, b and c are longitudinal, transverse and anteropos-
terior dimensions, respectively, of the fetal stomach. All
examinations were performed by one observer (MS).
Statistical analysis was performed using regression ana-
lysis. Correlations and differences were considered significant
when P < 0.05.
468
Sase et al.
RESULTS
The fetal gastric area was significantly correlated with
ultrasound-determined fetal gastric volume (r = 0.91) (Figure 2).
The fetal gastric area was also significantly correlated with
gestational age (r = 0.74) (Figure 3a). However, the correla-
tion coefficient of gastric area with gestational age was
smaller than those of the BPD with gestational age (r = 0.97)
(Figure 3b) or transverse abdominal area with gestational age
(r = 0.97) (Figure 3c). The gastric area ratio decreased slightly
toward term and the distribution of the values of gastric area
ratio was constant at each gestational age (Figure 4).
The gastric area ratio was below the 95% confidence inter-
vals for the predicted values in all five fetuses with esophageal
atresia, and exceeded the 95% confidence intervals for the
predicted values in seven of the eight fetuses with duodenal
atresia or intestinal tract obstruction (Figure 5). All cases
with esophageal atresia or duodenal atresia demonstrated
polyhydramnios.
D ISCU SSIO N
The fetal digestive tract plays a major role in amniotic fluid
circulation. Amniotic fluid swallowed by the fetus enters the
stomach and is subsequently absorbed or transferred to the
intestine. Filled with amniotic fluid, the stomach appears as
an echolucent organ on ultrasonography in the left upper
quadrant of the fetal abdomen. Sonographic visualization of
the fetal stomach is possible at 9 weeks of gestation, and
measurements of stomach area are possible after 10 weeks of
gestation. The characteristic anatomy of the stomach, includ-
ing the greater curvature, the lesser curvature, the fundus, the
body, and the pylorus, may be identified at about 14 weeks
of gestation2.
Abnormal configurations of the fetal stomach may be asso-
ciated with congenital malformations. Gastric size has been
found to be influenced by abnormalities of the fetal digestive
tract. For example, duodenal atresia is associated with a dilated
stomach, proximal duodenum, and polyhydramnios9. In
cases of esophageal atresia, the stomach may be absent or
diminished in size, depending on whether communication
between the trachea and esophagus distal to the obstruc-
tion is present10. Other studies have reported prognostic
significance of non-visualization of the fetal stomach by
ultrasonography5–8. Some studies have reported that the
fetal stomach is an index, reflecting the physical and patho-
logical condition in the digestive tracts3,11,12. Consequently,
gastric size was identified as a potential marker to diagnose
congenital malformations of the fetal digestive tract and evalu-
ate the motility of the fetal gastrointestinal tract.
Several studies have investigated the developmental profile
of the stomach in the human fetus at advanced stages of
gestation and have constructed ultrasound-derived growth
charts for fetal stomach dimensions throughout pregnancy2–4.
However, the standard deviation of the normal gastric meas-
urements increases markedly with advancing gestational age.
Therefore, these measurements limit the ability to diagnose
abnormalities of stomach size in cases of congenital digestive
tract obstruction, particularly in mid to late gestation.
Ultrasound in Obstetrics and Gynecology
Human fetal gastric size
Figure 3 Gastric area (a), biparietal diameter (b) and abdominal
transverse area (c) correlated with gestational age. Correlation
coefficients (r) were 0.74, 0.97, and 0.97, respectively.
Ultrasound in Obstetrics and Gynecology
Sase et al.
Figure 4 The 95% confidence intervals on an individual predicted y for
a given value of x. y = 0.11456 − 0.00094729x.
Figure 5 The cases with obstructed gastrointestinal tracts are indicated
in the figure. Measurements of the same case are connected. The closed
circles represent cases of esophageal atresia. The open circles represent
cases of duodenal atresia. The open squares represent cases of intestinal
obstruction.
A three-dimensional measurement may be more appropri-
ate for the evaluation of gastric size because of the complex
form of the stomach. However, a three-dimensional meas-
urement is complicated and time-consuming compared with
two-dimensional measurements2–4. We have reported the
usefulness of the measurement of the fetal gastric area with
ultrasound to assess fetal gastric emptying12. In the present
study, fetal gastric size with a two-dimensional method
closely correlates with that of a three-dimensional method.
This indicates that it is appropriate to evaluate fetal gastric
size with the two-dimensional gastric area. However, the
standard deviation of gastric area measurements also increased
469
Human fetal gastric size
markedly with advancing gestational age, compared with BPD
and transverse abdominal area. Therefore, gastric area alone
is insufficient as the standard for diagnosis of normal or abnormal
size in cases of the congenital digestive tract anomalies.
The gastric area ratio, defined as the ratio of the fetal gas-
tric area divided by the area of the fetal abdominal transverse
section, is a preferable method to evaluate the gastric size of
the fetus12. We reported that the value of the gastric area ratio
was stable during pregnancy. The values of gastric area ratio
in the fetuses with esophageal atresia were below the 95%
confidence intervals for the prediction and the values of all
fetuses with duodenal atresia and most of the fetuses with the
intestinal tract obstruction exceeded the 95% confidence
intervals for the prediction.
In conclusion, fetal gastric area can be measured easily
with ultrasound and correlates closely with ultrasound-
determined gastric volume measurements. Fetal gastric area
ratio is useful in the assessment of digestive tract anomalies.
REFERENCES
1 Murray SR. Hydramnios. A study of 846 cases. Am J Obstet Gynecol
1964; 88: 65–7
2 Goldstein I, Reece JB, Yarkoni S, Wan M, Green JLJ, Hobbins JC.
Growth of the fetal stomach in normal pregnancy. Obstet Gynecol
1987; 70: 641– 4
470
Sase et al.
3 Vandenberg K, De Wolf F. Ultrasonic assessment of fetal stomach
function. Physiology and clinic. In Kurjak A, ed. Recent Advances in
Ultrasound Diagnosis 2. Amsterdam: Excerpta Medica, 1980: 275 –
82
4 Nagata S, Koyanagi T, Horimoto N, Satoh S, Nakano H. Chrono-
logical development of the fetal stomach assessed using real-time
ultrasound. Early Hum Dev 1990; 22: 15– 22
5 Brumfield CG, Davis RO, Owen J, Wenstrom K, Kynerd P.
Pregnancy outcomes following sonographic nonvisualization of fetal
stomach. Obstet Gynecol 1998; 91: 905– 8
6 McKenna KM, Goldstein RB, Stringer MD. Small or absent fetal
stomach prognostic significance. Radiology 1995; 197: 729–33
7 Millener PB, Anderson NG, Chisholm RJ. Prognostic significance of
nonvisualization of the fetal stomach by sonography. AJR Am J
Roentgenol 1993; 160: 827– 30
8 Pretorius DH, Gosink BB, Clautice-Engle T, Leopold GR, Minnick CM.
Sonographic evaluation of the fetal stomach: significance of non-
visualization AJR Am J Roentgenol 1988; 151: 987– 9
9 Gross H, Filly A. Potential for a normal stomach to simulate the
sonographic ‘double bubble’ sign. J Can Assoc Radiol 1982; 33: 39 –
40
10 Andrassy RJ, Mahour H. Gastrointestinal anomalies associated with
esophageal atresia or trachesophageal fistula. Arch Surg 1979; 114:
1125– 8
11 Yoshizato T, Koyanagi T, Nagata S, Takashima T, Fukushima S,
Nakano H. Three-dimensional image of the fetal stomach: congen-
ital duodenal obstruction in utero. Early Hum Dev 1995; 22: 15 –
22
12 Sase M, Nakata M, Tashima L, Kato H. Development of gastric
emptying in the human fetus. Ultrasound Obstet Gynecol 2000; 16:
56– 9
Ultrasound in Obstetrics and Gynecology