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ORIGINAL RESEARCH
Increasing Maternal Body Mass Index
and the Accuracy of Sonographic
Estimation of Fetal Weight Near Delivery
Sara Kritzer, MD, Kristin Magner, MD, Carri R. Warshak, MD
Received October 7, 2013, from the Department of
Obstetrics and Gynecology, Division of Maternal-
Fetal Medicine, University of Cincinnati College
of Medicine, Cincinnati, Ohio USA (S.K., K.M.,
C.R.W.); and Department of Obstetrics and
Gynecology, The Christ Hospital, Cincinnati,
Ohio USA (S.K., K.M.). Revision requested
November 19, 2013. Revised manuscript accepted
for publication March 29, 2014.
We thank the Center for Clinical and
Translational Science and Training for assistance
with development of the RedCap database.
Address correspondence to Carri R. Warshak,
MD, Department of Obstetrics and Gynecology,
Division of Maternal-Fetal Medicine, University
of Cincinnati College of Medicine, 231 Albert
Sabin Way, Cincinnati, OH 45267-0526 USA.
E-mail: eaglercr@ucmail.uc.edu
Abbreviations
BMI, body mass index; EFW, estimated fetal
weight
doi:10.7863/ultra.33.12.2173
2014 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2014; 33:21732179 | 0278-4297 | www.aium.org
ObjectivesTo evaluate whether an increasing body mass index (BMI) influences the
accuracy of sonographic estimation of fetal weight.
MethodsWe performed a retrospective cohort study of singleton deliveries over a
2-year period in a single institution. Patients were included if they had a fetal weight
estimation within 2 weeks of delivery. The estimated fetal weight (EFW) was calcu-
lated by subtracting the sonographic EFW from the birth weight and compared among
our study groups, which were based on the maternal BMI class. We also compared the
absolute percentage error of estimation, rate of substantial error greater than 20%, rate
of underestimation, and ability to predict fetal weight greater than 4000 g. Post hoc
power analysis determined that our study group of 1200 patients allowed for an of .05
and of .90.
ResultsWe included 1177 women in our analysis. The median EFW varied between
study groups: 137, 202, 157, 200, and 189 g, respectively, in normal-weight, overweight,
and obese classes 1, 2, and 3 (P = .01). The median percentage error of estimation
between study groups varied between 5.0% in normal-weight women and 7.1% in class
2 obese women (P = .05). The rate of substantial error was similar between study groups
and varied between 2.7% in class 1 obese women and 4.3% in normal-weight and class
2 obese women. Linear regression analysis showed a weak association between mater-
nal BMI and EFW (R2 = 0.005; r = 0.069).
ConclusionsThe absolute EFW was lower in normal-weight women; however, the
percentage error of the EFW was similar between women of varying BMI classifica-
tions, as was the rate of substantial error and the rate of underestimation of the EFW.
Key Wordsestimated fetal weight; macrosomia; obesity; obstetric ultrasound;
sonography
T he shifting demographic of the maternal body mass index
(BMI) in pregnancy over the last decades is well documented.
In a review from 1956, the rate of obesity in pregnancy was
3.6% (defined as weight >190 lb).1 In a cohort study from 1980,
the rate of obesity was 10.1% (defined as weight >198 lb [90 kg]).2
A recent American College of Obstetricians and Gynecologists
committee opinion, published in 2013, estimated that at least one-
third of pregnant women are obese, and 8% are extremely obese.3
The increased incidence of overweight and obesity complicating
pregnancy has immediate and far-reaching effects on the health of
the mother and fetus, with increased risks of diabetes, preeclampsia,
preterm delivery, thromboembolic disease, macrosomia, and still-
birth being well documented.415 Advances in our understanding
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Kritzer et alIncreasing Maternal BMI and Estimation of Fetal Weight Near Delivery
of the fetal origins of disease have demonstrated associa-
tions between maternal obesity and childhood diseases
such as obesity and metabolic syndrome.1618 Maternal
obesity has also been found to be associated with abnormal
labor1924 and fetal macrosomia.7,25,26 The prepregnancy
BMI and gestational weight gain have been associated with
an increased risk of surgical delivery.7,2729
The detrimental impact maternal obesity has on the
accuracy of sonography for detection of anomalies has
been reported.3032 However, analogous studies evaluat-
ing the influence of maternal obesity on accurate estima-
tion of fetal weight are lacking. Historically, the error rate
of sonography for estimation of fetal weight has been found
to be as high as 25% in all-weight women.33 More recently,
Goetzinger et al34 examined the sensitivity and specificity
for extremes of abnormal fetal growth and found no associ-
ation with the maternal BMI class. Whether an increasing
maternal BMI affects the accuracy of the estimated fetal
weight (EFW) is unreported, and given the added diffi-
culty with imaging in this population, increased error is bio-
logically feasible. Understanding whether maternal obesity
decreases the accuracy of sonographic EFW is vital given
known associations between an increasing maternal BMI
and macrosomia, abnormal labor, and increasing surgical
delivery rates. We performed this study to quantitate the
impact, if any, an increasing maternal BMI has on the accu-
racy of sonographic EFW obtained within 2 weeks of
delivery.
Materials and Methods
We conducted a retrospective cohort study of all women
who delivered a singleton live birth at the University of
Cincinnati in 2008 and 2009. The study was approved by
the Institutional Human Subjects Review Committee; the
need for informed consent was waived given the retro-
spective nature of the study. We included all women with
a known BMI who had obtained a sonographic EFW
within 14 days of the date of delivery. We chose a 2-week
period considering the known plateau in fetal growth in
later pregnancy,35 although realizing there would be some
fetal growth between the sonographic examination and
delivery; by using a 2 week period later in pregnancy, this
factor would be minimal. In addition, this time frame paral-
lels clinical practice in that physicians are likely to schedule
final growth scans near delivery but not necessarily simul-
taneous with delivery. Women were excluded if they deliv-
ered before 32 weeks or if they had a severe anomaly that
could interfere with the ability to accurately estimate the
fetal weight, such as an abdominal wall defect or skeletal
2174
dysplasia (Figure 1). We also excluded underweight women
(BMI <18.5 kg/m2), given that there were a very small
number of patients in this category (n = 2). After all criteria
were considered, 1177 women were available for analysis.
Our power analysis was calculated on the basis of the pri-
mary outcome of interest: EFW. We determined that
with 1200 patients, assuming a 10% EFW and setting
at .05, would be .90.
Women were categorized according to their last
recorded BMI according to the National Institutes of Health
BMI classification system36: normal weight, 18.5 to 24.9
kg/m2; overweight, 25.0 to 29.9 kg/m2; class 1 obese, 30.0
to 34.9 kg/m2; class 2 obese, 35.0 to 39.9 kg/m2; and class
3 obese, greater than 40.0 kg/m2. As this study was designed
to determine whether the maternal body habitus affected
the accuracy of the EFW, the BMI nearest delivery (and
therefore the BMI at the time of sonographic evaluation)
was used to determine study groups. All sonographic
examinations were performed by certified sonographers in
an exclusive obstetric imaging center. Estimated fetal
weights were obtained by measurement of the head cir-
cumference, biparietal diameter, abdominal circumference,
and femur length, and an estimation of the fetal weight was
derived from these measurements by using the 1985 bio-
metric equations of Hadlock et al.37
Our primary outcome measurement was the absolute
EFW. The absolute EFW was determined by calcu-
lating the absolute value of the difference between the
sonographic EFW and the actual birth weight of the fetus.
We used the absolute value of this difference so that the
magnitude of the error could be compared, without posi-
tive and negative values regressing to 0. We performed a
subanalysis comparing other outcome variables such as the
percentage error of estimation, the rate of underestimation/
overestimation, and the ability to predict birth weight
greater than 4000 g.38 The percentage error of estimation
was calculated by dividing the calculated EFW by the
actual birth weight to measure the absolute percentage
error of the sonographic EFW. In addition, we categorized
those with an elevated error, which we defined as a per-
centage error of estimation greater than 20%, and com-
pared study groups as to the rate of substantial error.
We also evaluated the rate of underestimation and, given
there were comparatively few exact measurements, the
rate of overestimation. Positive and negative predictive
values for prediction of fetal weight greater than 4000 g
were calculated.
Study data were collected and managed by RedCap
electronic data capture tools posted at the University of
Cincinnati. Categorical variables were analyzed by a 2 test.
J Ultrasound Med 2014; 33:21732179
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Kritzer et alIncreasing Maternal BMI and Estimation of Fetal Weight Near Delivery
Continuous variables were analyzed by analysis of variance.
Those continuous variables not found to be normally dis-
tributed by a Kolmovorov-Smirnov test for normality were
evaluated by nonparametric Kruskal-Wallis 1-way analysis
of variance on ranks, and medians and 25th- and 75th-
percentile interquartile ranges are reported. Two-sided
P < .05 was considered statistically significant. Logistic
regression was performed to determine the impact of other
potentially significant covariates, including fetal sex, mater-
nal race, gestational diabetes, pregestational diabetes, and
chronic hypertension. Linear regression was performed to
evaluate the correlation between the EFW and the
maternal BMI. The r and R2 values for this linear regres-
sion were calculated. All data analyses were performed
with NCSS version 8 statistical software (NCSS, LLC,
Kaysville, UT).
Results
Of 4569 total deliveries, 4395 were singleton, live-born,
nonanomalous fetuses born after 32 weeks gestation
(Figure 1). We excluded 2788 patients because they did
not undergo sonographic evaluation of the fetal weight
within the last 14 days before delivery. An additional 158
patients were excluded because they lacked either BMI or
birth weight information. Our analysis included the
remaining 1177 women. The characteristics of our study
groups are outlined in Table 1. The women classified as
obese tended to be older and of higher parity. A higher rate
Figure 1. Flowchart of patients included and excluded from analysis.
IUFD indicates intrauterine fetal demise.
J Ultrasound Med 2014; 33:21732179
of overweight was seen in white and Hispanic women, and
a higher rate of class 3 obesity was seen in black women
(P < .01). The mean gestational age at which the last sono-
gram was obtained was similar (P = .19), as was the inter-
val between the last sonogram and the date of the delivery
(P = .14). As expected, obese women had significantly
higher rates of pregestational diabetes, gestational dia-
betes, chronic hypertension, and preeclampsia (P < .01
for all). Obese women also had considerably higher rates
of induction and cesarean delivery (P = .05; P < .01,
respectively). The rate of tobacco use was similar between
groups (P = .21). Also, as expected, we found a trend
toward larger fetuses with an increasing maternal BMI
(P < .01; Table 2).
The EFW was clinically similar among the study
groups (Figure 2), only varying by 70 g from the smallest
to the largest EFW. The median EFW varied from 137 g
(interquartile range, 72296 g) in normal-weight women
to 202 g (100325 g) in overweight women (P = .01;
Table 2). However, there was not a clear trend seen in rela-
tion to the EFW by maternal BMI classification. Logistic
regression analysis revealed that the following covariants
did not significantly affect the EFW: fetal sex (P = .09),
race (P = .13), gestational diabetes (P = .22), pregestational
diabetes (P = .16), and chronic hypertension (P = .20).
The median error of estimation varied between 5.0%
in normal-weight women and 7.1% in class 2 obese
women, which approached statistical significance (P = .05)
and also did not show a trend with increasing BMI classi-
fication (Figure 3). Clinically, this variance in the percentage
error of estimation of the EFW is unlikely to be impactful.
The rate of substantial error was very similar among study
groups (Table 2). There were similar rates of underesti-
mation between study groups (P = .39). The positive pre-
dictive value for the sonographic prediction of fetal weight
greater than 4000 g was low (Table 2). However, the neg-
ative predictive value was high and consistently greater
than 92%.
Linear regression comparing the quantitative EFW
and maternal BMI showed a very weak correlation coeffi-
cient (r = 0.069; Figure 4). The R2 value for this linear
regression was found to be 0.005, meaning that 0.5% of the
variation in EFW could be attributed to the variation in
the maternal BMI.
Discussion
We found the EFW between the sonographic EFW and
the actual birth weight to be lowest in women who were
normal weight and somewhat higher in those who were over-
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Kritzer et alIncreasing Maternal BMI and Estimation of Fetal Weight Near Delivery

weight and obese. In obese women, there was not a clear
pattern of an increasing BMI contributing to an increased
EFW. There was a similar pattern in the percentage error
of estimation. There were similar rates of underestimation
and rates of substantial error in women of varying BMI
classifications. The percentage error of estimation found
in this study (5.0%7.1%) was considerably below that
previously reported (16%20%).39 The sonographic
examinations in this study were all conducted by a small
group of highly trained sonographers who exclusively per-
form obstetric sonography in low- and high-risk pregnan-
cies. This factor may have contributed to the increased

Table 1. Maternal Demographic Information, Medical Complications, and Obstetric Outcome Information

Normal Overweight Class 1 Class 2 Class 3

Parameter (n = 161) (n = 289) (n = 297) (n = 210) (n = 220) P
Demographic
Age, y 23.8 5.5 24.8 6.0 26.6 6.2 26.3 5.6 26.6 5.4 <.01
Parity 1 (02) 1 (02) 1 (03) 1 (02) 2 (13) <.01
Race, n (%) <.01
White 59 (14.8) 99 (24.8) 97 (24.3) 79 (19.8) 65 (16.3)
Black 72 (12.0) 124 (20.7) 149 (24.9) 108 (18.1) 145 (24.2)
Hispanic 24 (15.9) 56 (37.1) 41 (27.2) 22 (14.6) 8 (5.3)
Asian 6 (31.6) 5 (26.3) 7 (2.4) 1 (5.3) 0 (0)
Other 0 (0) 5 (50.0) 3 (30.0) 0 (0) 2 (20.0)
GA at last sonogram, wk 36 (3438) 37 (3639) 37 (3639) 37 (3639) 38 (3638) .19
GA at delivery, wk 37 (3539) 38 (3739) 38 (3740) 39 (3840) 39 (3739) <.01
Sonography-delivery interval, d 54 54 54 65 64 .14
Birth weight, g 2687 542 3004 564 3163 659 3224 580 3268 665 <.01
Birth weight >4000 g, n (%) 0 (0) 7 (2.4) 30 (10.1) 17 (8.1) 31 (14.1) <.01
Medical complications, n (%)
Pregestational diabetes 1 (0.6) 6 (2.2) 13 (5.1) 17 (9.5) 33 (18.5) <.01
Chronic hypertension 1 (0.6) 7 (2.4) 17 (5.7) 22 (10.5) 54 (24.5) <.01
Tobacco 45 (28.0) 53 (18.4) 50 (16.8) 47 (22.4) 48 (21.8) .21
Obstetric complications, n (%)
Gestational diabetes 7 (4.4) 20 (7.1) 41 (14.4) 31 (16.1) 43 (23.0) <.01
Preeclampsia 13 (8.1) 24 (8.3) 30 (10.1) 19 (9.0) 48 (21.8) <.01
Fetal growth restrictiona 15 (9.3) 17 (5.9) 16 (5.4) 6 (2.9) 1 (0.5) <.01
Induction 53 (32.9) 112 (38.8) 120 (40.4) 97 (46.2) 101 (45.9) .05
Cesarean delivery 37 (23.3) 94 (32.8) 113 (38.2) 90 (43.1) 104 (47.9) <.01
Data are presented as mean SD and median (interquartile range) where applicable. GA indicates gestational age.
aDefined as an EFW below the 10th percentile, a fetal abdominal circumference below the 5th percentile, or both.

Table 2. Comparison of EFW Between BMI Classifications

Normal Overweight Class 1 Class 2 Class 3

Parameter (n = 161) (n = 289) (n = 297) (n = 210) (n = 220) P
EFW, g 2598 552 2924 606 3061 672 3149 623 3174 667 <.01
Birth weight, g 2687 542 3004 564 3163 659 3224 580 3268 665 <.01
EFW, ga 137 (72296) 202 (100325) 157 (86282) 200 (85330) 189 (103337) .01
Underestimation, n (%) 88 (54.7) 151 (52.2) 165 (55.7) 114 (54.5) 126 (57.3) .39
Error of estimation, %a 5.0 (2.610.6) 6.8 (3.310.7) 5.1 (2.7 8.7) 7.1 (2.810.3) 5.9 (3.5 9.9) .05
Rate of substantial error, n (%)b 7 (4.3) 12 (4.2) 8 (2.7) 9 (4.3) 8 (3.6) .84
Range of error, % 0.0237.7 029.4 0.13 35.2 028.3 030.3
PPV fetal size >4000 g, % NA 12.5 72.7 58.8 80.0
NPV fetal size >4000 g, % 100 97.8 95.0 96.4 92.5
Data are presented as mean SD and median (interquartile range) where applicable. NA indicates not applicable; NPV, negative predictive value;
and PPV, positive predictive value.
aCalculated from absolute values.
bError of estimation greater than 20%.

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Kritzer et alIncreasing Maternal BMI and Estimation of Fetal Weight Near Delivery
accuracy demonstrated in this study. In addition, prior
studies have used varying research designs, including
longer/shorter intervals to delivery and calculations of pro-
jected growth, which may have also led to the differences
seen in our study. We chose a sonography-to-delivery
interval of 2 weeks to limit influences of fetal growth while
simultaneously being most applicable to clinical practice
patterns.
However, there was a considerable range of error in
all BMI classes. We were intrigued by many of the outliers
and reviewed imaging from these patients. A consistent
characteristic of these outliers was biometric measure-
ments being performed when the fetal head was deeply
engaged in the pelvis, with smaller head measurements
obtained and therefore more substantial underestimations
of the fetal weight. For this reason, we would exercise cau-
tion when interpreting biometric measurements in this
clinical context.
A recent editorial by Caughey40 summarized the
impact the EFW can have on the mode of delivery. A study
by Little et al41 found that patients who underwent a recent
sonographic examination were 50% more likely to undergo
a cesarean delivery, with an even greater impact if the EFW
was greater than 3500 g. This finding lends credence to the
conclusion that clinicians rely on the EFW in their man-
Figure 2. EFW distribution by maternal BMI class. The boxes repre-
sent the median, 25th, and 75th percentiles, and the whiskers extend to
the 10th and 90th percentiles.
J Ultrasound Med 2014; 33:21732179
agement of labor and decision making regarding the mode
of delivery. The extent to which physician confidence in the
EFW is altered by the maternal body habitus is unknown.
Although we found statistical differences in the EFW and
the percentage error of estimation, the absolute EFW
only varied by 70 g from the smallest to the largest values,
and there was not a clear pattern, with higher error being
seen in the overweight, not obese, women. This finding is
quite different from findings in studies that looked at detec-
tion rates of anomalies in the obese3032 and should
increase physician confidence in the EFW, even in obese
woman, which may lead to a more aggressive pursuit of
labor as opposed to opting for cesarean delivery in this pop-
ulation. Importantly, we found the negative predictive val-
ues for predicting the largest fetuses to be consistently above
90% across categories of BMI classifications.
Strengths of our study include the large sample size and
the high level of training of the sonographers performing
the sonographic fetal weight estimations. In addition, our
population has a high rate of overweight and obesity, allow-
ing us to perform a comprehensive analysis comparing all
BMI classes. Weaknesses of this study include the possible
limitations in applicability to other centers that may not
have a dedicated obstetric ultrasound center. In addition,
our lack of normal-weight patients who had both a sono-
Figure 3. Percentage error of EFW by maternal BMI class (P = .06). The
boxes represent the median, 25th, and 75th percentiles, and the whiskers
extend to the 10th and 90th percentiles. A density plot is also shown,
with a line across categories depicting the mean percentage error of
estimation.
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Kritzer et alIncreasing Maternal BMI and Estimation of Fetal Weight Near Delivery
graphic examination within 2 weeks of delivery and a fetus
weighing greater than 4000 g limited our ability to evalu-
ate this subset of the population. The gestational age at
delivery was earlier in normal-weight women than the
other BMI classes (Table 1). We suspect that this finding
was due to the fact that normal-weight women were less
likely to have had the fetal weight reexamined unless they
had other obstetric complications that may have led to ear-
lier delivery, and we would not expect an, at most, 8-day
difference to have substantially impacted our findings.
Finally, our power analysis was based on a mean 10% error
rate in the EFW from prior studies, but our actual error
rate was lower, therefore increasing our likelihood of falsely
accepting the null hypothesis. It should be noted that
although it is likely that there are differences in the rates of
growth of fetuses in women of varying BMI classes, it is not
likely that this factor influenced our results, given that
patients were only included if there was a very short interval
between sonography and delivery (<2 weeks), the actual
interval was similar in our study groups, and the expected
tapering of the growth rate near delivery. In addition, this
association would be expected to exaggerate an effect, not
reduce it.
In summary, although prior studies have demon-
strated decreased accuracy for detection of anomalies in
obese women, estimation of the EFW near delivery does
not appear to be similarly affected by the maternal body
habitus. Sonography performed in a dedicated obstetric
ultrasound unit within 2 weeks of delivery had a relatively
Figure 4. Linear regression analysis comparing EFW to maternal BMI
at the time of sonography nearest delivery (r = 0.069; R 2 = 0.005).
2178
low percentage error for estimation of fetal weight, and
this error rate did not vary substantially by maternal BMI
classification. These data should reassure clinicians that an
EFW obtained near delivery will have similar accuracy even
in women of varying BMI classifications. Although our values
were statistically different, there was not a class-dependent
trend in the effect of the maternal BMI on the EFW.
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