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Gestational Age Assessment

Authors

Krelin Naidu1; Katherine L. Fredlund2.

Affiliations
1 Southeast Regional Medical Center
2 Campbell University

Last Update: August 2, 2021.

Continuing Education Activity

Gestational age is a key piece of data used by healthcare providers to determine when to perform various screening
tests and assessments of the fetus and mother throughout pregnancy. Gestational age may be assessed at any time
during pregnancy, and several modes of assessment exist, each requiring diverse equipment or skills and associated
with varying degrees of accuracy. Obtaining more accurate estimates of gestational age through better diagnostic
approaches may initiate more prompt medical management of a pregnant patient. This activity describes the many
modalities used to correctly estimate gestational age and highlights the role of the interprofessional team in caring for
pregnant patients.

Objectives:

Explain how to assess gestational age with an ultrasound.

Describe the non-sonographic methods for estimating gestational age.

Explain the clinical significance of correctly estimating gestational age using ultrasound.

Explain the importance of enhancing care coordination amongst the interprofessional team to optimize the use
of ultrasound for estimation of gestational age.

Access free multiple choice questions on this topic.

Introduction
Gestational age is a key piece of data used by healthcare providers to determine the timing of various screening tests
and assessments of the fetus and mother throughout pregnancy. Gestational age may be assessed at any time during
pregnancy, and several modes of assessment exist, each requiring different equipment or skills and with varying
degrees of accuracy. Obtaining more accurate estimates of gestational age through better diagnostic approaches may
initiate more prompt medical management of a pregnant patient.

There are numerous approaches to assess gestational age. Before sonography, practitioners had to rely on detailed
histories and physical exam findings. In particular, determining the date of the last known menstrual period was of
significance. Inputting the date of the last menstrual period into various formulas can give both an estimated
gestational age and an estimated delivery date. Physical exam findings such as determining uterine fundal height is
also a method for estimating gestational age.[1][2]

Ultrasound has emerged as the more accurate method of assessing fetal gestational age, especially in the first
trimester. Both transvaginal and transabdominal probe assessments are used to obtain a more accurate measurement of
gestational age. Transvaginal is more helpful in first trimester pregnancies. Multiple parameters have been described
using ultrasound to aid in calculating gestational age and will be described here. Additionally, postnatal scoring
systems involving focused physical and neurologic exams may also provide insight into gestational age.[3][4]
Anatomy and Physiology
The uterus is a pelvic organ that will nurture the developing fetus. Approximately 4 weeks after conception, the uterus
will increase about 1 cm in size every week. Between 4.5 to 5 weeks of gestation, a gestational sac or intrauterine
fluid collection will form. The next remarkable finding occurs between 5 to 6 weeks with the development of the yolk
sac. This structure may remain present until 10 weeks. A fetal pole with cardiac activity can be detected between 5.5
to 6 weeks. After this period, the embryo further develops with more discernable organs and anatomical features.
When using ultrasound to visualize anatomy, pelvic landmarks include the bladder, uterine wall, vaginal stripe, and
rectum. The bladder is typically anterior and inferior to the uterus. The bladder wall will be circular with an anechoic
(black) fluid-filled center. The bladder will range in size based on the amount of urine being retained. The uterus will
have a thick muscular isoechoic (gray) wall with an anechoic (black) center where an intrauterine pregnancy at
varying stages can be identified. Differentiating the bladder from the uterus can be done easily by looking at the
thickness of the wall. The uterine wall is significantly thicker than the bladder wall. The vaginal stripe is posterior to
the bladder. The rectum will be the most posterior circular structure, on pelvic ultrasound, with either an anechoic
(black) or isoechoic (gray) center on the exam.[5]

Indications
All pregnant patients should have a gestational age calculated for safe prenatal evaluation throughout the remainder of
the pregnancy for both mother and fetus.

Contraindications
There are no specific contraindications to assessing a pregnant patient's gestational age. However, the modality
utilized to assess gestational age may not be appropriate for certain patients. A transvaginal ultrasound exam should
not be performed in a pregnant patient with vaginal bleeding and known placenta previa, a pregnant patient with
premature rupture of membranes, and a patient who refuses exam despite informed discussion. There are no specific
contraindications to transabdominal ultrasound; however, scanning over an open wound would be suboptimal for
patient care and image acquisition.

Equipment
Ultrasound machine with a phased array or curvilinear probe for the transabdominal approach. Endocavitary probe for
the transvaginal approach.[6]

Personnel
An experienced ultrasonographer should evaluate gestational age in a pregnant patient. Experience can include
specific bedside hands-on training with an ultrasound-credentialed instructor, continuous medical education courses
or seminars, or other ultrasound education. The healthcare provider performing the bedside ultrasound evaluation
should have specific training for estimating gestational age and feel comfortable making a gestational age estimate
based on their previous experience and own-assessment of their capabilities and skill level. For a more accurate
assessment of gestational age, a pregnant patient should undergo an evaluation by a certified ultrasound technician.

Preparation
Preparation for assessment of gestational age by ultrasound includes describing the procedure to the patient and the
risks and benefits of using ultrasound to evaluate their pregnancy. Consent should be obtained from your patient
before beginning. When performing a transvaginal ultrasound exam, an appropriate chaperone should be present.
Patient comfort should be considered throughout the evaluation.

Technique
Prenatal Techniques
Non-Sonographic Methods for Determining Gestational Age

Naegele’s Rule: Establish the date of the last menstrual period by obtaining a history from the patient. From this
date, add 1 year and 7 days, then subtract 3 months. This will approximate the estimated delivery date. The date
of the last known menstrual period will give the approximate start date for age of the fetus.[7]

Uterine Size: The uterus has been described as a soft and globular pelvic organ. In pregnancy, the uterus
increases in size to accommodate the developing fetus. At approximately 12 weeks gestation the uterus
becomes large enough to be palpable just above the pubic symphysis. At 16 weeks gestation, the fundus of the
uterus can be palpated at the midpoint between the umbilicus and the pubic symphysis. At 20 weeks gestation,
the fundus can be palpable at the level of the umbilicus. After 20 weeks of gestation, the pubic symphysis to
fundal height in centimeters should correlate with the week of gestation.

Sonographic Methods for Determining Gestational Age

First Trimester Dating: Sonographic assessment within the first 13 weeks and 6 days will provide the most
accurate estimate of gestational age. Both transvaginal and transabdominal approaches may be used. However,
the transvaginal approach may provide a more clear and accurate view of early embryonic structures. Although
the gestational sac and yolk sac are the first measurable markers visible on ultrasound, these poorly correlate
with gestational age.

The crown-rump length (CRL) is the most accurate measurement correlating with gestational age. Using
the mean of three measurements, CRL can be determined by using the calipers on the ultrasound
machine, measuring a straight line from the outer margin of the cephalic pole to the rump of the embryo.
This measurement can be plugged into numerous validated tables and formulas that correlate well with
gestational age.[8]

Second Trimester Dating: If gestational age is not determined within the first trimester, alternate sonographic
techniques may be used to estimate gestational age. These techniques are generally not recommended as first-
line options for dating but are more helpful in determining if fetal size is within normal range. These
measurements should not change the gestational age or delivery date if a previous CRL has been calculated
within the first trimester.

Biparietal Diameter (BPD): This biometric parameter is recommended as a strong modality for dating
because it has been extensively studied and is well reproduced. The technique involves a transabdominal
approach by positioning the phased array or curvilinear transducer perpendicular to the fetal parietal
bones. The calvarium should appear as a hyperechoic (bright white) structure that is smooth and
symmetric. The BPD is measured along a plane that intersects the third ventricle and the thalami. Using
the caliper function, cursors are placed on the outer edge of the proximal skull and the inner edge of the
distal skull. This value will give the biparietal diameter.[9]

Head Circumference (HC): This biometric parameter has been regarded as a good estimator of
gestational age with some studies suggesting superiority to the biparietal diameter. This parameter may
also be useful clinically in assessing for growth disorders. A similar sonographic approach as the BPD is
used here. A phased array or curvilinear transducer is used to visualize a plane that intersects the third
ventricle and thalami. However, to achieve the greatest anterior-posterior diameter, the cavum septum
pellucidum must be visualized anteriorly, and the tentorial hiatus must be visualized posteriorly. The
cerebellum and lateral ventricles should not be visualized in a standard HC view. Using the calipers, mark
the cursors on the outer margins of the calvarium bilaterally. The ultrasound should have an elliptical
measuring tool that will generate a measurement of the perimeter of the calvarium.[10]

Femur Length (FL): The femur can be visualized as early as 10 weeks gestation due to its size and
density on ultrasound. Using a phased array or curvilinear transducer, align along the long axis of the
closest femur. Proximally, visualize either the femoral head or greater trochanter and distally, visualize
 the femoral condyle. Using the calipers, measure the length of the diaphysis, at the junction of bone and
cartilage, taking care not to include the femoral head, greater trochanter, or femoral condyle.[10]

Abdominal Circumference (AC): The biometric parameter is more difficult to measure and is less able to
predict gestational age than the other described techniques accurately. However, it may be useful in
fetuses with cranial or limb abnormalities and to estimate a fetal weight and note interval growth. Using
the phased array or curvilinear transducer, position the transducer perpendicular to the fetal abdominal
wall and visualize the symmetric appearance of the lower ribs. This view should be at the largest
diameter of the fetal liver. Note, the fetal stomach is often visualized at this level. The umbilical portion
of the left portal vein in its shortest view is another hallmark of appropriate positioning. Using the
calipers, obtain four calibration points around the abdomen on the skin edge making sure not to include
the rib cage. The elliptical tool may also be used to calculate circumference.[10]

Third Trimester Dating: If gestational age has not been determined by the third trimester multiple parameters
are correlated with estimated age and fetal maturity. For example, femoral epiphyseal ossification centers are
often noted at 32 weeks. Proximal tibial ossification centers are visualized at 35 weeks. The proximal humeral
ossification centers appear in the late trimester and have been correlated with fetal lung maturity.[11]

Postnatal Techniques

Dubowitz Method: This was the historically standard method of determining postnatal gestational age based on
34 physical and neurologic assessments. These assessments are divided into 6 categories: tone, tone patterns,
reflexes, movements, abnormal signs, and behaviors. Scores are assigned based on a detailed illustration sheet.
Higher scores correlate with greater maturity. The total score can be plotted on a graph that also correlates with
gestational age.[12]

New Ballard Score: This improved scoring system is used to determine postnatal gestational age in infants as
preterm as 20 weeks. The system is divided into 6 physical maturity components and six neuromuscular
components. The physical maturity components include skin, lanugo, plantar creases, breast, ear/eye, and
genitals. The neuromuscular components include posture, square window/wrist, arm recoil, popliteal angle,
scarf sign, and heel to ear. Detailed illustrations have been created to assist the examiner in determining
appropriate scores which correlate with gestational age. This exam is quicker to perform and may be more
tolerable for sicker infants.[13]

Complications
Prenatal Techniques

Non-Sonographic Methods for Determining Gestational Age

Naegele’s Rule: This rule assumes a standardized 28-day menstrual cycle with fertilization occurring on day 14.
However, many women have irregular cycles with variability in the length of the follicular phase affecting
ovulation. History of last menstrual period may be confounded by early pregnancy bleeding, hormonal
contraceptive use, or incorrect recall of last menstrual period date.[7]

Uterine Size: This finding primarily relies on the provider’s physical examination. This may be confounded by
maternal factors including but not limited to obesity, multiple gestation, leiomyoma, and fibroids. The mother
may also have a retroverted uterus which will alter normal progressive landmarks. Individual practitioner skill
and experience make findings less reliable and reproducible.

Sonographic Methods for Determining Gestational Age

Crown-rump length (CRL): This parameter becomes less accurate for predicting gestational age and delivery
date with the advancement of gestation due to normal embryonic development and variability in anatomic
positioning. Once the CRL exceeds 84 mm, the BDP serves as a better indicator for gestational age.[8]
 Biparietal Diameter (BPD): This parameter becomes limited after 22 weeks gestation due to normal biologic
development with variations in fetal size and shape. If there is a physiologic or pathologic cause for the skull
size and shape to be altered, the BPD may produce false measurements.[9]

Head Circumference (HC): This parameter is useful for obtaining gestation age, but multiple landmarks need to
be identified before taking measurements. After 22 weeks, there is significant variation due to normal
development affecting size and shape.[10]

Femur Length (FC): Multiple errors may occur when obtaining this parameter including but not limited to, non-
ossified portions of the femur and not visualizing the full femur. This can lead to incorrect gestational age
calculations. Average femur lengths may differ among certain ethnic groups or can be indicative of pathology.
Again, this parameter does have variability after 22 weeks due to normal biologic development.[10]

Abdominal Circumference (AC): This parameter has a wide margin of error for determining gestational age due
to multiple factors including asymmetry of the abdomen, changes with respiration and movement, and user
skills. Like the other parameters, significant variability is seen after 22 weeks.[10]

Ossification Centers: These parameters do not directly correlate with exact gestational age. Presence of these
ossified centers are rather markers of fetal maturity which is seen later in pregnancy.[11]

Postnatal Techniques

Dubowitz Method: Due to a large number of criteria needed to perform the exam, this method may be more
difficult to perform on sick and preterm infants. Also, it can take up to 20 minutes to perform this exam. Studies
have shown that this method tends to overestimate the gestational age.[12]

New Ballard Score: Although this exam is quicker to perform, studies have shown that this system can
overestimate gestational age in preterm infants.[13]

Clinical Significance
Early sonography has been a useful adjunct to the history and physical exam findings in establishing gestational age.
Although sonography can visualize the pregnancy at various stages, this tool must be applied appropriately, and the
tool's specific limitations must be considered. Determining the most accurate gestational age as early as possible
generally allows for the best medical care for both mother and fetus throughout the remainder of the pregnancy.

Enhancing Healthcare Team Outcomes

It is important to obtain a gestational age in all pregnancies to provide the standard of care medical management for
both mother and fetus. A combination of history, physical exam, early sonography in the first trimester, and prenatal
assessments are all essential to obtaining a more accurate gestational age. Different techniques may be more useful
depending on how far along the pregnancy has progressed. Early sonography has been shown to be the most useful
predictor of gestational age; however, other late modalities are available to help determine age.

Review Questions
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Comment on this article.

References
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Figures

Timeline of pregnancy by weeks and months of gestational age. Contributed by Wikimedia Commons,"Medical
gallery of Mikael Häggström 2014" (Public Domain)
 Chart showing birth weights for gestational ages. Contributed by Wikimedia Commons (Public Domain)

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