Research

JAMA Pediatrics | Original Investigation

Association of Maternal Obesity With Longitudinal

Ultrasonographic Measures of Fetal Growth
Findings From the NICHD Fetal Growth Studies–Singletons
Cuilin Zhang, MD, MPH, PhD; Mary L. Hediger, PhD; Paul S. Albert, PhD; Jagteshwar Grewal, PhD, MPH; Anthony Sciscione, DO;
William A. Grobman, MD, MBA; Deborah A. Wing, MD, MBA; Roger B. Newman, MD; Ronald Wapner, MD; Mary E. D’Alton, MD;
Daniel Skupski, MD; Michael P. Nageotte, MD; Angela C. Ranzini, MD; John Owen, MD, MSPH; Edward K. Chien, MD;
Sabrina Craigo, MD; Sungduk Kim, PhD; Katherine L. Grantz, MD, MS; Germaine M. Buck Louis, PhD, MS

Supplemental content
IMPORTANCE Despite the increasing prevalence of pregravid obesity, systematic evaluation of
the association of maternal obesity with fetal growth trajectories is lacking.

OBJECTIVE To characterize differences in fetal growth trajectories between obese and

nonobese pregnant women, and to identify the timing of any observed differences.

DESIGN, SETTING, AND PARTICIPANTS The Eunice Kennedy Shriver National Institute of Child
Health and Human Development Fetal Growth Studies–Singletons study enrolled cohorts of
pregnant women at 12 US health care institutions. Obese women (with prepregnancy body
mass index > 30) and nonobese women (prepregnancy body mass indexes, 19-29.9) without
major chronic diseases were recruited between 8 weeks and 0 days’ gestation and 13 weeks
and 6 days’ gestation. A mixed longitudinal randomization scheme randomized participants
into 1 of 4 schedules for 2-dimensional and 3-dimensional ultrasonograms to capture weekly
fetal growth data throughout the remainder of their pregnancies.

MAIN OUTCOMES AND MEASURES On each ultrasonogram, fetal humerus length, femur
length, biparietal diameter, head circumference, and abdominal circumference were
measured. Fetal growth curves were estimated using linear mixed models with cubic splines.
Median differences in the fetal measures at each gestational week of the obese and nonobese
participants were examined using the likelihood ratio and Wald tests after adjustment for
maternal characteristics.

RESULTS The study enrolled 468 obese and 2334 nonobese women between 8 weeks and
0 days’ gestation and 13 weeks and 6 days’ gestation. After a priori exclusion criteria, 443 obese
and 2320 nonobese women composed the final cohort. Commencing at 21 weeks’ gestation,
femur length and humerus length were significantly longer for fetuses of obese woman than
those of nonobese women. Differences persisted in obese and nonobese groups through 38
weeks’ gestation (median femur length, 71.0 vs 70.2 mm; P = .01; median humerus length, 62.2
vs 61.6 mm; P = .03). Averaged across gestation, head circumference was significantly larger in
fetuses of obese women than those of nonobese women (P = .02). Fetal abdominal
circumference was not greater in the obese cohort than in the nonobese cohort but was
significantly larger than in fetuses of normal-weight women (with body mass indexes between
19.0-24.9) commencing at 32 weeks (median, 282.1 vs 280.2 mm; P = .04). Starting from 30
weeks’ gestation, estimated fetal weight was significantly larger for the fetuses of obese women
(median, 1512 g [95% CI, 1494-1530 g] vs 1492 g [95% CI, 1484-1499 g]) and the difference
Author Affiliations: Author
grew as gestational age increased. Birth weight was higher by almost 100 g in neonates born to
affiliations are listed at the end of this
obese women than to nonobese women (mean, 3373.2 vs 3279.5 g). article.
Corresponding Author: Cuilin
CONCLUSIONS AND RELEVANCE As early as 32 weeks’ gestation, fetuses of obese women had Zhang, MD, MPH, PhD, Epidemiology
higher weights than fetuses of nonobese women. The mechanisms and long-term health Branch, Division of Intramural
Population Health Research, Eunice
implications of these findings are not yet established.
Kennedy Shriver National Institute of
Child Health and Human
Development, 6710B Rockledge Dr,
JAMA Pediatr. 2018;172(1):24-31. doi:10.1001/jamapediatrics.2017.3785 MSC 7004, Bethesda, MD 20817
Published online November 13, 2017. (zhangcu@mail.nih.gov).

24 (Reprinted) jamapediatrics.com

© 2017 American Medical Association. All rights reserved.

Maternal Obesity and Longitudinal Ultrasonographic Measures of Fetal Growth
O
besity, including in women of reproductive age, has
become a global epidemic. Data from the 2011/2012
National Health and Nutrition Examination Survey
(NHANES)1 reported that 32% of reproductive-aged US women
have a body mass index (BMI; calculated as weight in kilo-
grams divided by height in meters squared) of 30 or higher and
are considered obese. Moreover, approximately 45% of US
women were either overweight or obese (BMI 25 or higher)
when becoming pregnant.2 Obese pregnant women are at
higher risk for several common pregnancy complications, such
as gestational diabetes, gestational hypertension, and pre-
eclampsia. In addition, their fetuses are exposed to an unfa-
vorable in utero metabolic environment. 3 Emerging evi-
dence from both animal and human experimental studies has
demonstrated that increased levels of chronic inflammation,
oxidative stress, insulin resistance, and glucose related to ma-
ternal obesity create an environment that can lead to altered
fetal growth.4-8 Additional data from human epidemiologic
studies corroborate that fetuses born to obese women are at
greater risk for overgrowth, which may predispose them to obe-
sity and cardiometabolic disorders later in life.9
Most previous studies on maternal obesity and fetal growth
were based on birth size and did not assess the longitudinal
pattern of in utero fetal growth. Longitudinal and systematic
evaluation of differences in growth trajectories across gesta-
tion by maternal obesity status, as measured by serial ultra-
sonography, is lacking. Moreover, it is unknown when differ-
ences in fetal growth might arise or persist. This information
is particularly relevant in designing gestation-specific inter-
ventions that might reduce the effect of maternal obesity on
fetal growth. Further, because obese women often experi-
ence coexisting morbidities such as diabetes and hyperten-
sion, it is important to determine whether the association of
maternal obesity with fetal growth is independent of these co-
morbid conditions. In response to these critical data gaps, we
sought to determine whether fetal growth differs by mater-
nal prepregnancy obesity status by analyzing 2-dimensional
serial ultrasonogramss taken throughout pregnancy from the
cohort of women enrolled in the National Institute of Child
Health and Human Development (NICHD) Fetal Growth
Studies–Singletons. Moreover, we sought to identify the tim-
ing and duration of observed differences.
Methods
Study Design
The NICHD Fetal Growth Studies–Singletons comprised 2 co-
horts of pregnant women: those with singleton pregnancies10
and dichorionic twin pregnancies.11 Women in the singleton
cohort (n = 2802) were aged 18 to 40 years, had a viable single-
ton pregnancy, and planned to deliver at participating hospi-
tals; the group included 468 obese women (ie, those with a
prepregnancy BMI of 30.0 to 44.9) and 2334 nonobese women
(ie, those with a prepregnancy BMI of 19.0 to 29.9). Women
were recruited from 12 US clinical sites between July 2009 and
January 2013 and were followed up through delivery. After
enrollment, 2585 women (92%) completed the protocol.
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© 2017 American Medical Association. All rights reserved.
Original Investigation Research
Key Points
Question What are the associations of maternal obesity with fetal
growth, and when do these associations start emerging?
Findings In a longitudinal cohort study that included 468 obese
and 2334 nonobese pregnant women, the femur length, humerus
length, head circumference, and estimated weight of fetuses were
significantly greater in the fetuses of obese women compared with
fetuses of nonobese women. Differences commenced as early as
21 weeks’ gestation.
Meaning Fetal growth differs in obese and nonobese pregnant
women; the mechanisms of these findings and their long-term
implications for child and adult health remain to be established.
Both obese and nonobese pregnant women were ex-
cluded if they reported having major chronic conditions be-
fore pregnancy (autoimmune diseases, cancer, diabetes,
chronic hypertension requiring 2 or more medications, renal
disease requiring medical supervision, HIV/AIDS, or psychi-
atric disorders). In addition, nonobese women were excluded
if they had epilepsy or seizures requiring medication, hema-
tologic disorders, asthma, or thyroid disease. Both obese and
nonobese women were excluded if they became pregnant with
the use of ovulation stimulation drugs or assisted reproduc-
tive technology, or if they reported having smoked tobacco in
the prior 6 months, having used illicit drugs in the past year,
or having consumed 1 or more alcoholic drinks per day at the
time of enrollment. In these analyses, 14 nonobese women and
25 obese women were identified as ineligible after enroll-
ment and excluded from the final analytical population. There-
fore, the final analytic study population included 443 obese
and 2320 nonobese women.
Approval for human subjects research was obtained from
the institutional review boards at all participating sites, and
women gave informed consent before enrollment. Further de-
tails have been previously reported.10
Exposure
Participants completed a screening and enrollment visit be-
tween 8 weeks and 0 days’ gestation and 13 weeks and 6 days’
gestation. During this visit, prepregnancy BMI was calcu-
lated based on self-reported weight and height. Self-reported
weights and heights were highly correlated with the weights
and heights subsequently measured by study personnel dur-
ing the enrollment visit (correlation coefficient r = 0.97 for
weight; r = 0.95 for height). Women were classified as obese,
overweight, or normal weight if their prepregnancy BMI
was 30.0 or greater, 25 to 29.99, or 18.5 to 24.9, respectively;
both overweight and normal-weight women were consid-
ered nonobese.
Covariates
During the enrollment visit, research nurses interviewed
women about diet and lifestyle; sociodemographic character-
istics; and medical, reproductive, and pregnancy histories. In
follow-up study visits, women were also interviewed about any
(Reprinted) JAMA Pediatrics January 2018 Volume 172, Number 1 25
 Research Original Investigation
changes in diet, lifestyle, and medical conditions. Maternal
weight was measured at every postenrollment study visit via
a standardized protocol.
Outcomes
Following the baseline enrollment visit and ultrasonography,
women were randomized to 1 of the following 4 schedules for
additional ultrasonographies: 16, 20, 24, 28, 32, and 35 weeks
(schedule A); 18, 22, 26, 30, 34, and 36 weeks (schedule B); 20,
28, 32, 36, and 40 weeks (schedule C); and 22, 29, 33, 37, and
41 weeks (schedule D). By design, this mixed longitudinal ran-
domization scheme captured fetal growth data for each week
of pregnancy without exposing women to weekly ultrasono-
graphic examinations. Study visits were scheduled within
1 week of the targeted gestational age to accommodate wom-
en’s availability.
At each ultrasonographic examination, fetal biometric
measurements were performed following standard operating
procedures and using identical equipment (Voluson E8; GE
Healthcare). All measurements and images were captured in
ViewPoint (GE Healthcare) and electronically transferred to
the study’s imaging data coordination center. Longitudinal
measurements were taken for humerus length, femur length,
and biparietal diameter from the outer to the inner edge of
the calvarial wall using the linear function and for head cir-
cumference and abdominal circumference using the ellipse
function. The study’s central ultrasonographic unit creden-
tialed all participating ultrasound technicians throughout the
study.12 Furthermore, intraobserver correlations for all fetal
growth ultrasonographic measurements were greater than
0.99 in both obese and nonobese women; no differences in
the quality of data were found by maternal obesity.
Within 24 hours of delivery, neonatal anthropometric mea-
surements, including birth weight and length, were com-
pleted. Newborns were classified as large for gestational
age (LGA) if birth weight was greater than or equal to the 90th
percentile for birth weight; small for gestational age if birth
weight was less than the 10th percentile for birth weight,13 and
macrosomic if birth weight was equal or greater than 4000 g.
Estimated fetal weight (EFW) was calculated using the
Hadlock formula,14 which incorporates head circumference,
abdominal circumference, and femur length. Newborns were
classified as having idiopathic fetal growth restriction if their
EFW was less than 10% the EFW of the standard (nonobese)
cohort in this study. The ratio of head circumference to ab-
dominal circumference and femur length to abdominal cir-
cumference were calculated for examination of trends in
growth patterns and body proportions over time.
Statistical Analysis
Characteristics of study participants were presented with
means with standard deviation (SD) for continuous variables
and as percentages for categorical variables. Differences in char-
acteristics between obese and nonobese women were as-
sessed by t test for continuous variables and by χ2 test for cat-
egorical variables. All serial ultrasonographic data were used
to estimate individual fetal parameters, ratios of head circum-
ference to abdominal circumference, ratios of femur length to
26 JAMA Pediatrics January 2018 Volume 172, Number 1 (Reprinted)
© 2017 American Medical Association. All rights reserved.
Maternal Obesity and Longitudinal Ultrasonographic Measures of Fetal Growth
abdominal circumference, and EFW by gestational age. Ultra-
sonographic measurements (biparietal diameter, head circum-
ference, abdominal circumference, humerus length, and fe-
mur length), ratio of head circumference to abdominal
circumference, ratio of femur length to abdominal circumfer-
ence, and EFW were log-transformed to stabilize variances
across gestational age and to improve normal approxima-
tions for the error structures used in statistical analysis.
The primary analysis compared fetal growth trajectories by
maternal obesity status regardless of pregnancy complica-
tions or neonatal conditions. For modeling growth trajectories
among obese women, we used linear mixed models with a
cubic spline mean structure and a random-effects structure that
included linear, quadratic, and cubic random effects and an in-
tercept term for the individual fetus.15 A polynomial random-
effects structure was chosen to provide flexibility in modeling
between variation in the fetal growth trajectories of individual
participants. Linear mixed models were also used to test be-
tween obese and nonobese groups for overall differences in
fetal growth trajectories in EFW and other anthropometric vari-
ables. These used likelihood ratio tests of interaction terms
between spline mean structure terms and obese-nonobese
indicator variables. For the cubic spline mean structure, 3-knot
points (25th, 50th, and 75th percentiles) were chosen at gesta-
tional ages that evenly split the distributions.
For an overall comparison of fetal growth trajectories be-
tween obese and nonobese women, the nonobese women were
weighted to have the same distribution of race/ethnicity as in
the obese cohort. For anthropometric parameters that were sig-
nificantly different between obese and nonobese cohorts, we
further tested for week-specific differences using Wald tests
computed at each gestational age. These tests were con-
ducted on the estimated curves with and without adjust-
ments for the following maternal characteristics: age, race/
ethnicity, parity, full-time employment/student status (yes/
no), marital status (married/cohabitating vs single), health
insurance (private/managed care vs Medicaid/other), annual
income (less than $29 999, $30 000-$49 999, $50 000-
$74 999, $75 000-$99 999, and more than $100 000), educa-
tion (less than high school, high school, some college, under-
graduate degree, and postgraduate degree) and infant sex (male
or female). When performing covariate-adjusted tests for week-
specific differences in fetal growth curves, we used a proce-
dure of multiple imputation (with 20 imputations) to ac-
count for missing covariate data.16 Similar analysis methods
were applied in the secondary analyses, which tested the dif-
ference in fetal growth measures between obese and normal-
weight women (ie, those with BMIs between 18.5 and 24.9).
To assess the robustness of the findings, we performed a
sensitivity analysis limited to fetuses from women without ma-
jor obstetric complications associated with abnormal fetal
growth, such as gestational diabetes, gestational hyperten-
sion, preeclampsia, and preterm delivery. By design, non-
obese women were excluded post hoc from the analysis if they
had additional chronic medical conditions (epilepsy or sei-
zures requiring medication, hematologic disorders, asthma, or
thyroid disease); the exclusion was not applied to obese
women. We conducted a sensitivity analysis by excluding 16
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Maternal Obesity and Longitudinal Ultrasonographic Measures of Fetal Growth Original Investigation Research

Table 1. Characteristics of Study Participants by Prepregnancy Obesity Status

No. (%)
Characteristic Obese Womena Nonobese Womenb P Value
Maternal
Sample size, No. 443 2320 .11
Age, mean (SD), y 27.8 (5.6) 28.2 (5.5) <.001
Race/ethnicity
Non-Hispanic white 123 (37.8) 610 (26.3)
Non-Hispanic black 165 (36.3) 605 (26.1)
Hispanic 150 (33.9) 646 (27.8)
Asian/Pacific Islander 5 (1.1) 459 (19.8)
Prepregnancy weight, mean (SD), kg 91.5 (13.0) 62.5 (9.6) <.001
Height, mean (SD), cm 162.8 (6.9) 162.5 (7.1) .46
Prepregnancy BMI, mean (SD)a 34.5 (3.9) 23.6 (3.1) <.001
Parity <.001
0 158 (35.6) 1143 (49.3)
1 145 (32.4) 788 (34.0)
2 79 (18.1) 277 (11.9)
≥3 81 (13.8) 62 (4.8)
Never married 125 (28.2) 498 (21.5) <.001
Education <.001
<High school 70 (15.8) 252 (10.9)
High school/GED 107 (24.2) 401 (17.3)
Some college/associate degree 154 (35.8) 677 (29.2)
College undergraduate degree 77 (17.7) 562 (24.2)
Postgraduate degree 35 (8.2) 427 (18.4)
Private health insurance 209 (51.0) 1239 (57.6) .03
Pregnancy complications <.001
Preeclampsia 33 (7.4) 78 (3.4) <.001
Gestational hypertension 50 (11.3) 70 (3.0) <.001
Abbreviations: BMI, body mass index
Gestational diabetes 37 (8.4) 85 (3.7) <.001 (calculated as weight in kilograms
Placenta abruption 5 (1.1) 29 (1.3) .83 divided by height in meters squared);
Cesarean delivery 151 (34.1) 585 (25.2) <.001 GED, General Educational
Development; IUGR, idiopathic
Neonatal intrauterine growth restriction:
Gestational age at delivery, mean (SD), wk 39.0 (2.3) 39.2 (1.8) .29 estimated fetal weight <10% of
Birth weight, mean (SD), g 3373.2 (484.4) 3279.5 (466.7) <.001 normal.
a
As estimated from self-reported
Male 204 (47.7) 1104 (51.9) .13
pregravid weight and height at
b
Macrosomia 35 (7.9) 118 (5.1) .04 enrollment; obese women have BMI
Large for gestational age 47 (11.7) 176 (8.3) .03 of 30 or more; nonobese women
have BMIs of 19 to 29.99.
Small for gestational age 26 (6.5) 190 (9.0) .10
b
Macrosomia: birth weight
IUGR 5 (1.1) 38 (1.8) .43
ⱖ4000 g.

obese women with the medical conditions that had been ex-
clusion criteria for the nonobese cohort.
All analyses were implemented using SAS, version 9.4 (SAS
Institute Inc) or R, version 3.1.2 (R Development Core Team).
A 2-tailed P value less than .05 defined significance.
Results
In general, obese women had lower educational attainment and
were more likely to be single, unemployed, and residing in
households in lower income brackets than nonobese women
(Table 1). The height of obese women was similar to that of
nonobese women (mean, 162.8 cm vs 162.5 cm). Moreover,
obese women were more likely to develop gravid diseases, such
as gestational diabetes (8.4% vs 3.7%; P < .001), gestational hy-
pertension (11.3% vs 3.0%; P < .001), and preeclampsia (7.4%
vs 3.4%; P < .001), and to have a cesarean delivery than non-
obese women (34.1% vs 25.2%; P < .001). Although the mean
gestational age at delivery for obese women was similar to that
of nonobese women (39.0 weeks vs 39.2 weeks; P = .29),
infants born to obese women had heavier birth weights by al-
most 100 g (mean, 3373 vs 3279 g; P < .001) and were more
likely to be LGA (11.7% vs 8.3%, P = .03). No significant differ-
ences were observed based on obese status for male sex, fetal
growth restriction, or small-for-gestational age status.

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 Research Original Investigation
Figure 1. Distribution of Estimated Fetal Weight by Gestational Age
and Prepregnancy Obesity Status
Estimated fetal weight
5000
Nonobese
4000 Obese
10th Percentile
Estimated Fetal Weight, g
50th Percentile
90th Percentile
3000
2000
1000
0 longer in fetuses of obese women compared with nonobese
10 20
Gestational Age, wk
Estimated fetal weight for singletons by prepregnancy obesity status,
as estimated from linear mixed models with log-transformed outcomes
and cubic splines.
Fetal growth curves for EFW for obese and nonobese
women, including the 10th, 50th, and 90th percentiles, are pre-
sented in Figure 1 and illustrate important differences. Corre-
sponding EFWs by maternal adiposity status (ie, obese, all non-
obese women, overweight women, and normal-weight women)
are provided in Table 2. Starting from 30 weeks’ gestation
through 38 weeks’ gestation (at which point a large percent-
age of the women had delivered), the EFW of fetuses born to
obese women were significantly and progressively larger than
those of nonobese women. Specifically, at 30 weeks, the me-
dian EFW for fetuses of obese women was 20 g heavier than
for fetuses of all nonobese women (1512 vs 1492 g; P = .04) and
28 g heavier than the fetuses of normal-weight women (1512
vs 1484 g; P = .05). At 38 weeks’ gestation, this difference be-
tween obese and nonobese cohorts increased to 71 g (3217 vs
3146 g; P = .01) at the median and to 98 g (3217 vs 3119 g;
P < .001) between obese and normal-weight women.
The curves for individual fetal anthropometric measure-
ments are presented in Figure 2. Corresponding results are pro-
vided in eTables 1-7 in the Supplement. The fetuses of obese
women had longer femur and humerus lengths, larger head
circumferences, and larger femur length to abdominal circum-
ference ratios than the fetuses of nonobese women (P < .05).
More specifically, commencing at 21 weeks’ gestation, both fe-
mur and humerus lengths were longer in the fetuses of obese
women than in those of nonobese women, even after covari-
ate adjustment. Such differences persisted through 38 weeks’
gestation (median, 71.3 vs 70.2 mm for femur length and 62.2
vs 61.6 mm for humerus length). Head circumference was also
larger in the fetuses of obese woman than the fetuses of non-
obese women, most significantly between 33 and 35 weeks.
The fetuses of obese women had greater femur length to ab-
dominal circumference ratios than did fetuses of nonobese
women, although significant differences were restricted to time
spans in early pregnancy (at 11 weeks), midpregnancy (19 to
26 weeks) and late pregnancy (31 to 35 weeks). Overall, mean
28 JAMA Pediatrics January 2018 Volume 172, Number 1 (Reprinted)
© 2017 American Medical Association. All rights reserved.
Maternal Obesity and Longitudinal Ultrasonographic Measures of Fetal Growth
abdominal circumference did not differ significantly be-
tween obese and nonobese cohorts. However, when being com-
pared with normal-weight women, average fetal abdominal cir-
cumference was significantly larger for obese women, starting
from 32 weeks’ gestation (median, 282.1 vs 280.2 mm) through
38 weeks’ gestation (median, 341.9 vs 338.3 mm). Overall fe-
tal biparietal diameter was not statistically different in fe-
tuses of obese women compared with those of either non-
obese or normal-weight women.
To evaluate whether the association of obesity with fetal
growth was independent of gravid complications particu-
larly related to fetal growth (gestational diabetes, gestational
hypertension, and preeclampsia), we restricted our analyses
to women without these conditions. The results observed were
similar. For instance, humerus length remained significantly
30 40
women commencing at 20 weeks’ gestation even after covar-
iate adjustment. Such differences persisted through 40 weeks’
gestation (median, 64.7 vs 64.2 mm for humerus length; ad-
justed global test P = .003). Similarly, from 24 weeks’ gesta-
tion through 39 weeks’ gestation, femur length was signifi-
cantly longer in fetuses of obese women compared with
nonobese women (median, 72.5 vs 71.9 mm for femur length
at 39 weeks’ gestation; adjusted global test P = .04).
We also investigated whether there was a sex-specific
association between maternal obesity and fetal growth by
stratifying the cohort by fetal sex and performing tests of in-
teraction by model fitting. No statistically significant interac-
tion was observed.
Discussion
In this prospective longitudinal study, we observed signifi-
cant differences in fetal growth between obese and nonobese
pregnant women without preexisting major chronic condi-
tions. To our knowledge, our study is the first to demonstrate
that femur and humerus lengths in the fetuses of obese women
were significantly longer than in the fetuses of nonobese
women, starting from 21 weeks’ gestation, extending through
the rest of pregnancy, and persisting even after adjustments
for sociodemographic differences between obese and non-
obese cohorts. Furthermore, the differences in femur and hu-
merus lengths were not accounted for by an increased risk of
common obesity-associated gravid diseases. Overall, head cir-
cumference was also greater in fetuses of obese women, with
the difference being significant between 33 and 35 weeks. Ab-
dominal circumference of the fetuses of obese women didn’t
differ significantly from those of nonobese women, but this
measurement was significantly greater than normal-weight
women starting from 32 weeks’ gestation onward. Overall, EFW
among obese women was significantly and progressively
larger starting at 30 weeks’ gestation, and the difference be-
came larger with increasing gestational age. At delivery, neo-
nates of obese women were significantly heavier and more
likely to be LGA.
Our findings of significantly larger EFWs for fetuses of
obese women compared with nonobese women are gener-
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Maternal Obesity and Longitudinal Ultrasonographic Measures of Fetal Growth Original Investigation Research

Table 2. Geometric Mean and 95% Confidence Intervals for Estimated Fetal Weight (Grams) by Gestational Age
and Maternal Prepregnancy Adiposity Status

Estimated Fetal Weight, mean (95% CI), g

Gestation
Week Obesea Nonobese (All)b Normal Weightc Overweightd
11 43.9 (43.0-44.7) 43.9 (43.6-44.2) 43.9 (43.5-44.3) 43.8 (43.2-44.5)
12 54.8 (54.1-55.5) 55.0 (54.7-55.3) 55.1 (54.7-55.4) 54.8 (54.3-55.4)
13 68.9 (68.1-69.7) 69.3 (68.9-69.6) 69.4 (69.0-69.8) 69.0 (68.4-69.6)
14 87.0 (85.9-88.1) 87.5 (87.1-88.0) 87.7 (87.1-88.2) 87.2 (86.4-88.1)
15 110.1 (108.7-111.5) 110.6 (110.0-111.2) 110.7 (110.0-111.5) 110.3 (109.3-111.4)
16 139.0 (137.2-140.7) 139.4 (138.7-140.2) 139.6 (138.7-140.5) 139.2 (137.9-140.5)
17 174.6 (172.5-176.7) 174.9 (174.0-175.8) 175.0 (173.9-176.1) 174.7 (173.1-176.2)
18 217.6 (215.0-220.3) 217.6 (216.5-218.7) 217.7 (216.4-219.1) 217.4 (215.5-219.3)
19 268.3 (265.1-271.6) 268.0 (266.6-269.4) 268.2 (266.5-269.9) 267.7 (265.3-270.1)
20 327.1 (323.1-331.1) 326.4 (324.8-328.1) 326.7 (324.6-328.7) 326.0 (323.1-328.9)
21 394.4 (389.7-399.2) 393.5 (391.5-395.5) 393.7 (391.2-396.1) 393.0 (389.6-396.5)
22 471.1 (465.5-476.7) 469.7 (467.3-472.1) 469.8 (467.0-472.7) 469.4 (465.4-473.5)
23 557.6 (551.1-564.2) 555.7 (552.9-558.5) 555.7 (552.3-559.1) 555.8 (551.0-560.6)
24 654.7 (647.1-662.5) 652.0 (648.8-655.3) 651.7 (647.8-655.7) 652.8 (647.2-658.4)
25 763.1 (754.1-772.3) 759.5 (755.6-763.3) 758.6 (754.0-763.3) 761.2 (754.6-767.9)
26 883.7 (873.0-894.5) 878.6 (874.1-883.2) 877.1 (871.6-882.6) 882.0 (874.1-889.9)
27 1017.6 (1005.2-1030.2) 1010.5 (1005.2-1015.9) 1007.9 (1001.5-1014.3) 1016.1 (1006.9-1025.4)
28 1166.1 (1151.9-1180.6) 1156.2 (1150.1-1162.3) 1152.0 (1144.7-1159.3) 1164.8 (1154.3-1175.4)
29 1330.8 (1314.8-1347.1) 1316.7 (1309.9-1323.6) 1310.6 (1302.3-1318.9) 1329.3 (1317.5-1341.3)
30 1511.7 (1493.6-1530.0)e 1492.1 (1484.4-1499.9) 1483.7 (1474.4-1493.1) 1509.4 (1496.0-1523.0)
31 1707.3 (1686.4-1728.4)e 1681.2 (1672.3-1690.2) 1670.4 (1659.7-1681.1) 1703.8 (1688.2-1719.5)
32 1915.0 (1890.7-1939.7)e 1882.1 (1871.8-1892.5) 1868.7 (1856.4-1881.1) 1910.1 (1892.1-1928.3)
33 2131.1 (2103.2-2159.4)e 2091.8 (2080.0-2103.6) 2075.9 (2061.9-2090.0) 2125.2 (2104.5-2146.0)
34 2350.3 (2319.2-2381.7)e 2306.3 (2293.2-2319.5) 2288.3 (2272.7-2304.0) 2344.5 (2321.4-2367.7)
35 2566.9 (2532.7-2601.6)e 2521.2 (2506.7-2535.8) 2501.5 (2484.3-2518.8) 2562.9 (2537.4-2588.6)
36 2780.9 (2741.9-2820.5)e 2733.7 (2717.3-2750.1) 2712.4 (2693.0-2731.9) 2778.4 (2749.4-2807.6)
37 2995.9 (2951.3-3041.2)e 2942.2 (2923.7-2960.8) 2918.9 (2897.0-2941.0) 2990.9 (2958.0-3024.2)
38 3217.4 (3168.0-3267.6)e 3145.7 (3125.4-3166.2) 3119.2 (3095.1-3143.4) 3201.4 (3165.0-3238.1)
d
Abbreviation: BMI, body mass index (calculated as weight in kilograms divided Overweight women: BMI, 25-29.9.
by height in meters squared). e
Indicates a statistically significant mean difference in estimated fetal weight
a
Obese women: BMI, 30 or more. values between obese vs nonobese groups and between obese vs normal
b
Nonobese women: BMI, 19-29.9. weight groups (P < .05).
c
Normal-weight women: BMI, less than 25.

ally consistent with findings from the Generation R Study.17
In this study conducted in the Netherlands, prepregnancy
BMI was significantly and positively related to estimated
fetal weight from midpregnancy onward.17 Our finding that a
significant elevated risk of LGA is associated with maternal
obesity is generally in line with findings from additional pre-
vious studies.18-21 However, previous research on maternal
obesity and fetal growth has relied mainly on birth weight.
Data on the relation between other fetus anthropometric
measures and maternal adiposity were not reported in the
Generation R study,17 and studies with longitudinal ultraso-
nographic measures of fetal growth are scant.
In addition, major chronic conditions, such as diabetes,
that disproportionately affect obese women have not been
fully considered in previous studies, making it hard to deter-
mine whether the elevated risks of LGA are related to these
complications or to the excess maternal BMI per se. Because
our cohort of obese women was free of many preexisting
major chronic conditions, we were able to assess the associa-
tions specifically with obesity.
A potential mechanism for fetal growth might be related
to the greater insulin resistance and fetal glucose exposure that
is found in obese women. However, the precise underlying
mechanisms remain unclear. The development of insulin re-
sistance is a physiologic goal of pregnancy, because it pro-
vides nutrients to a growing fetus.21 Women who are obese at
conception are more insulin resistant, which may lead to over-
nutrition of the fetus and overgrowth at birth. Maternal
prepregnancy obesity not only reflects maternal insulin
resistance but also other maternal characteristics, including
maternal overnutrition, fat accumulation, and low-grade sys-
temic inflammation.22 All these conditions either indepen-
dently or in combination may lead to adverse programming
effects in the fetuses.

jamapediatrics.com (Reprinted) JAMA Pediatrics January 2018 Volume 172, Number 1 29

© 2017 American Medical Association. All rights reserved.

 Research Original Investigation Maternal Obesity and Longitudinal Ultrasonographic Measures of Fetal Growth

Figure 2. Distribution of Fetal Anthropometric Measurements by Gestational Age and Obesity Status

A Biparietal diameter B Head circumference C Abdominal circumference D Femur length

100 400 400 80

Abdominal Circumference, mm
Head Circumference, mm
Biparietal Diameter, mm

Femur Length, mm
75 300 300 60

50 200 200 40

25 100 100 20

0 0 0 0
10 20 30 40 10 20 30 40 10 20 30 40 10 20 30 40
Gestational Age, wk Gestational Age, wk Gestational Age, wk Gestational Age, wk

E Humerus length F Ratio of head circumference to abdominal G Ratio of femur length to abdominal
Nonobese
circumference circumference
Obese
80 1.4 0.25
Ratio of Head Circumference to
Abdominal Circumference

Abdominal Circumference
10th Percentile

Ratio of Femur Length to

Humerus Length, mm

60 0.20 50th Percentile

1.2 90th Percentile

40 0.15

1.0
20 0.10

0 0.8 0.05
10 20 30 40 10 20 30 40 10 20 30 40
Gestational Age, wk Gestational Age, wk Gestational Age, wk

Estimated fetal anthropometric parameters for obese and nonobese women, as estimated from linear mixed models with log-transformed outcomes and cubic splines.

The prospective longitudinal measurement of fetal growth lated with measured maternal weight (r = 0.97) in this and in
and implementation of a standardized ultrasonography pro- other US populations.23 Lastly, there were some differences in
tocol to ensure high-quality measurements are major strengths the exclusion criteria pertaining to maternal preexisting chronic
of this study. Furthermore, the quality of ultrasonographic data conditions between the 2 cohorts, to ensure a sufficient num-
was excellent and did not vary by maternal obesity status, be- ber of obese women were included. This underscores the need
cause intraobserver correlations for all fetal growth mea- for careful interpretation of the results. However, in sensitiv-
sures were greater than 0.99 in both obese and nonobese ity analyses that excluded obese women with chronic condi-
women. Other strengths include weekly measurement of tions, our findings remained the same.
fetal growth across pregnancy, the a priori credentialing of
ultrasonography technicians, and attention to covariate ad-
justment. In addition, this prospective cohort study was con-
ducted in a multiracial cohort from across the United States
Conclusions
who lacked major chronic conditions such as hypertension, dia- In this prospective longitudinal study among US pregnant
betes, and cardiovascular disease. This aspect is essential to women, we observed that fetuses born to obese women had
help tease apart the effect of these obesity-related chronic longer bone lengths and head circumference than those born
conditions from the impact of prepregnancy obesity alone. to nonobese women. Such differences commenced as early
as 21 weeks’ gestation and remained through delivery. More-
Limitations over, starting from 32 weeks’ gestation, fetuses had greater
Some potential limitations of the present study merit discus- abdominal circumference than those of normal-weight
sions. The study methods may limit the generalizability of these women. The mechanisms for and long-term health implica-
findings to pregnant women without chronic conditions. As tions of these differences remain unknown. Future work
in other observational studies, measurement errors or re- integrating measurements of neonatal body composition
sidual confounding cannot be entirely eliminated. While with long-term follow-up are warranted. Such data will also
prepregnancy obesity (BMI) was our primary exposure for be relevant in informing the design of gestation-specific
analysis, it was self-reported by women on recruitment into interventions for obese women to optimize fetal growth and
the cohort; however, self-reported weight was highly corre- health outcomes.

ARTICLE INFORMATION Published Online: November 13, 2017. Author Affiliations: Division of Intramural
Accepted for Publication: August 13, 2017. doi:10.1001/jamapediatrics.2017.3785 Population Health Research, Eunice Kennedy
Shriver National Institute of Child Health and

30 JAMA Pediatrics January 2018 Volume 172, Number 1 (Reprinted) jamapediatrics.com

© 2017 American Medical Association. All rights reserved.

Maternal Obesity and Longitudinal Ultrasonographic Measures of Fetal Growth
Human Development, National Institutes of Health,
Bethesda, Maryland (Zhang, Hediger, Grewal,
Grantz, Louis); Division of Cancer Epidemiology and
Genetics, National Cancer Institute, National
Institutes of Health, Bethesda, Maryland (Albert,
Kim); Christiana Care Health System, Newark,
Delaware (Sciscione); Department of Obstetrics
and Gynecology, Feinberg School of Medicine,
Northwestern University, Chicago, Illinois
(Grobman); Division of Maternal-Fetal Medicine,
Department of Obstetrics-Gynecology, University
of California School of Medicine, Irvine (Wing);
Fountain Valley Regional Hospital and Medical
Center, Fountain Valley, California (Wing);
Department of Obstetrics and Gynecology, Medical
University of South Carolina, Charleston (Newman);
Department of Obstetrics and Gynecology,
Columbia University Medical Center, New York,
New York (Wapner, D’Alton); Department of
Obstetrics and Gynecology, New York-Presbyterian
Hospital/Queens, Queens (Skupski); Department of
Obstetrics and Gynecology, Miller Children’s
Hospital/Long Beach Memorial Medical Center,
Long Beach, California (Nageotte); Division of
Maternal and Fetal Medicine, Department of
Obstetrics and Gynecology, St Peter’s University
Hospital, New Brunswick, New Jersey (Ranzini);
Division of Maternal-Fetal Medicine, Department of
Obstetrics and Gynecology University of Alabama
School of Medicine, Birmingham (Owen); Division
of Maternal Fetal Medicine, Department of
Obstetrics and Gynecology, Women and Infants
Hospital of Rhode Island, Providence (Chien);
Department of Obstetrics and Gynecology, Tufts
Medical Center, Boston, Massachusetts (Craigo).
Author Contributions: Dr Zhang had full access to
all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Zhang, Hediger, Albert,
Sciscione, Grobman, Wing, Newman, Wapner,
Skupski, Buck Louis.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Zhang, Albert, Kim,
Buck Louis.
Critical revision of the manuscript for important
intellectual content: Zhang, Hediger, Albert, Grewal,
Sciscione, Grobman, Wing, Newman, Wapner,
D'Alton, Skupski, Nageotte, Ranzini, Owen, Chien,
Craigo, Grantz, Buck Louis.
Statistical analysis: Albert, Kim.
Obtained funding: Sciscione, Grobman, Wing,
Newman, Wapner, D'Alton, Owen, Chien,
Buck Louis.
Administrative, technical, or material support:
Zhang, Hediger, Grewal, Sciscione, Wing, Newman,
Wapner, Skupski, Nageotte, Chien, Grantz,
Buck Louis.
Study supervision: Zhang, Sciscione, Wing, Wapner,
D'Alton, Ranzini, Owen, Chien.
Other scientific expertise and input: Wapner.
Conflict of Interest Disclosures: None reported.
Funding/Support: This research was supported by
the Eunice Kennedy Shriver National Institute of
jamapediatrics.com
© 2017 American Medical Association. All rights reserved.
Child Health and Human Development intramural
funding and included American Recovery and
Reinvestment Act funding via contract numbers
HHSN275200800013C, HHSN275200800002I,
HHSN27500006, HHSN275200800003IC,
HHSN275200800014C, HHSN275200800012C,
HHSN275200800028C, and
HHSN275201000009C.
Additional Contributions: We thank Jun Zhang,
MD, PhD, and Roberto Romero, MD, for their earlier
efforts in helping to develop the study protocol; Dr
Karin Fuchs, MD, for her assistance with the
credentialing of sonographers and the research
teams at all participating clinical centers (which
include Christina Care Health Systems, Columbia
University, Northwestern University, University of
Alabama at Birmingham, University of California-
Irvine, Medical University of South Carolina, and
Women and Infants Hospital of Rhode Island);
Clinical Trials and Surveys Corporation and the
EMMES Corporation for providing data and imaging
support for this multisite study; Hanyun Li for her
programming support and the assistance of GE
Healthcare Women’s Health Ultrasound and their
support and training on the Voluson and Viewpoint
products over the course of this study.
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31
 Supplementary Online Content

Zhang C, Hediger ML, Albert PS, et al. Association of maternal obesity with longitudinal
ultrasonographic measures of fetal growth: findings from the NICHD Fetal Growth Studies–
Singletons. JAMA Pediatr. Published online November 13, 2017.
doi:10.1001/jamapediatrics.2017.3785

eTable 1. Geometric mean and 95% confidence intervals for Biparietal diameters (mm)
by gestational age and maternal pre-pregnancy adiposity status, NICHD Fetal Growth
Studies–Singletons.

eTable 2. Geometric mean and 95% confidence intervals for head circumference (mm)
by gestational age and maternal pre-pregnancy adiposity status, NICHD Fetal Growth
Studies–Singletons.

eTable 3. Geometric mean and 95% confidence intervals for abdominal circumference
(mm) by gestational age and maternal pre-pregnancy adiposity status, NICHD Fetal
Growth Studies–Singletons.

eTable 4. Geometric mean and 95% confidence intervals for Fumer length (mm) by
gestational age and maternal pre-pregnancy adiposity status, NICHD Fetal Growth
Studies–Singletons.

eTable 5. Geometric mean and 95% confidence intervals for Humerus length (mm) by
gestational age and maternal pre-pregnancy adiposity status, NICHD Fetal Growth
Studies–Singletons.

eTable 6. Geometric mean and 95% confidence intervals for Ratio: Head
circumference/abdominal circumference by gestational age and maternal pre-pregnancy
adiposity status, NICHD Fetal Growth Studies–Singletons.

eTable 7. Geometric mean and 95% confidence intervals for Ratio: Femur
length/abdominal circumference by gestational age and maternal pre-pregnancy
adiposity status, NICHD Fetal Growth Studies–Singletons.

This supplementary material has been provided by the authors to give readers additional
information about their work.

© 2017 American Medical Association. All rights reserved.

 eTable 1. Geometric mean and 95% confidence intervals for estimated biparietal
diameters (mm) by gestational age and maternal pre-pregnancy adiposity status,
NICHD Fetal Growth Studies: Singletons.
Biparietal diameters, mean, (95%CI), mm, by Maternal Pre-Pregnancy Adiposity
Status
Gestation Obese Non-obese (All) Normal weight Overweight
weeks
11 15.4 (15.2-15.6) 15.4 (15.3-15.5) 15.4 (15.3-15.5) 15.5 (15.4-15.6)
12 18.9 (18.7-19.1) 19.0 (19.0-19.1) 19.1 (19.0-19.1) 19.0 (18.9-19.1)
13 22.5 (22.3-22.7) 22.8 (22.7-22.8) 22.9 (22.8-23.0) 22.6 (22.5-22.8)
14 26.1 (25.9-26.3) 26.5 (26.4-26.6) 26.6 (26.5-26.7) 26.2 (26.1-26.4)
15 29.6 (29.4-29.9) 30.1 (30.0-30.2) 30.2 (30.1-30.4) 29.8 (29.6-29.9)
16 33.1 (32.8-33.3) 33.5 (33.4-33.6) 33.7 (33.5-33.8) 33.2 (33.0-33.4)
17 36.4 (36.1-36.6) 36.8 (36.6-36.9) 36.9 (36.8-37.0) 36.4 (36.2-36.6)
18 39.6 (39.3-39.8) 39.9 (39.8-40.0) 40.0 (39.9-40.2) 39.6 (39.4-39.8)
19 42.8 (42.5-43.1) 43.0 (42.9-43.1) 43.1 (42.9-43.2) 42.8 (42.6-43.1)
20 46.0 (45.7-46.3) 46.2 (46.0-46.3) 46.2 (46.1-46.4) 46.0 (45.8-46.3)
21 49.1 (48.8-49.4) 49.3 (49.2-49.4) 49.4 (49.2-49.5) 49.2 (49.0-49.5)
22 52.2 (51.9-52.5) 52.4 (52.3-52.6) 52.5 (52.3-52.7) 52.4 (52.1-52.6)
23 55.3 (55.0-55.6) 55.6 (55.4-55.7) 55.6 (55.4-55.8) 55.5 (55.3-55.8)
24 58.3 (58.0-58.6) 58.7 (58.5-58.8) 58.7 (58.5-58.9) 58.6 (58.3-58.9)
25 61.2 (60.9-61.5) 61.7 (61.6-61.9) 61.8 (61.6-61.9) 61.6 (61.3-61.9)
26 64.1 (63.7-64.4) 64.7 (64.5-64.8) 64.7 (64.6-64.9) 64.6 (64.3-64.8)
27 66.9 (66.6-67.2) 67.6 (67.4-67.8) 67.7 (67.5-67.9) 67.5 (67.2-67.7)
28 69.7 (69.3-70.0) 70.4 (70.3-70.6) 70.5 (70.3-70.7) 70.3 (70.0-70.6)
29 72.4 (72.1-72.8) 73.2 (73.0-73.4) 73.3 (73.1-73.5) 73.0 (72.7-73.3)
30 75.2 (74.8-75.5) 75.8 (75.7-76.0) 75.9 (75.7-76.1) 75.7 (75.4-76.0)
31 77.8 (77.4-78.1) 78.4 (78.2-78.5) 78.4 (78.2-78.6) 78.2 (77.9-78.6)
32 80.2 (79.9-80.6) 80.7 (80.5-80.9) 80.8 (80.5-81.0) 80.6 (80.3-80.9)
33 82.5 (82.2-82.9) 82.9 (82.7-83.1) 82.9 (82.7-83.1) 82.8 (82.5-83.1)
34 84.6 (84.2-84.9) 84.8 (84.6-85.0) 84.8 (84.6-85.1) 84.7 (84.4-85.1)
35 86.3 (85.9-86.7) 86.5 (86.3-86.7) 86.5 (86.3-86.8) 86.4 (86.1-86.7)
36 87.7 (87.3-88.1) 88.0 (87.8-88.1) 88.0 (87.8-88.2) 87.8 (87.5-88.2)
37 89.0 (88.6-89.4) 89.2 (89.0-89.5) 89.3 (89.1-89.6) 89.1 (88.7-89.5)
38 90.1 (89.7-90.6) 90.4 (90.2-90.6) 90.5 (90.2-90.7) 90.3 (89.9-90.7)
Non-obese women: BMI 19-29.99 kg/m².
Normal women: BMI <25 kg/m²
Overweight women 25≤BMI<30 kg/m²
Obese women: BMI 30-45 kg/m².

© 2017 American Medical Association. All rights reserved.

eTable 2. Geometric mean and 95% confidence intervals for head circumference
(mm) by gestational age and maternal pre-pregnancy adiposity status, NICHD
Fetal Growth Studies–Singletons.
Head circumference, mean, (95%CI), mm, by Maternal Pre-Pregnancy Adiposity Status

Gestatio Obese Non-obese (All) Normal weight Overweight

n weeks
11 58.4 (57.9-59.0) 58.5 (58.2-58.7) 58.5 (58.2-58.8) 58.5 (58.1-58.9)
12 71.0 (70.5-71.5) 71.3 (71.1-71.5) 71.4 (71.1-71.7) 71.2 (70.9-71.6)
13 84.1 (83.5-84.6) 84.6 (84.3-84.8) 84.7 (84.4-85.0) 84.3 (83.9-84.7)
14 97.2 (96.5-97.8) 97.9 (97.6-98.2) 98.1 (97.7-98.4) 97.5 (97.1-98.0)
15 110.1 (109.4-110.9) 110.9 (110.6-111.3) 111.2 (110.8-111.6) 110.5 (110.0-111.0)
16 122.8 (122.0-123.5) 123.6 (123.3-123.9) 123.9 (123.4-124.3) 123.1 (122.6-123.6)
17 135.1 (134.3-135.8) 135.8 (135.5-136.1) 136.1 (135.6-136.5) 135.3 (134.8-135.9)
18 147.2 (146.4-147.9) 147.7 (147.4-148.1) 148.0 (147.5-148.4) 147.3 (146.8-147.9)
19 159.2 (158.4-160.0) 159.6 (159.3-160.0) 159.8 (159.3-160.2) 159.3 (158.7-159.9)
20 171.2 (170.4-172.1) 171.5 (171.2-171.9) 171.6 (171.2-172.1) 171.3 (170.7-171.9)
21 183.1 (182.3-184.0) 183.4 (183.1-183.8) 183.5 (183.0-184.0) 183.2 (182.6-183.8)
22 194.8 (194.0-195.7) 195.2 (194.8-195.6) 195.3 (194.8-195.8) 195.0 (194.4-195.6)
23 206.3 (205.5-207.2) 206.8 (206.4-207.2) 206.9 (206.4-207.4) 206.6 (206.0-207.2)
24 217.5 (216.7-218.4) 218.2 (217.8-218.6) 218.3 (217.8-218.8) 217.9 (217.3-218.5)
25 228.5 (227.6-229.4) 229.3 (228.9-229.6) 229.4 (228.9-229.9) 228.9 (228.3-229.6)
26 239.1 (238.1-240.0) 240.0 (239.6-240.4) 240.2 (239.7-240.7) 239.6 (238.9-240.3)
27 249.4 (248.5-250.4) 250.4 (250.0-250.8) 250.6 (250.0-251.1) 250.0 (249.3-250.7)
28 259.5 (258.5-260.5) 260.4 (259.9-260.8) 260.6 (260.0-261.1) 260.1 (259.3-260.8)
29 269.4 (268.4-270.3) 270.0 (269.6-270.4) 270.1 (269.6-270.6) 269.8 (269.0-270.5)
30 278.9 (278.0-279.9) 279.1 (278.7-279.5) 279.2 (278.7-279.7) 279.0 (278.3-279.8)
31 288.0 (287.0-289.0) 287.7 (287.3-288.2) 287.7 (287.2-288.2) 287.8 (287.0-288.6)
32 296.4 (295.3-297.5) 295.7 (295.2-296.2) 295.6 (295.0-296.2) 295.9 (295.1-296.8)
33 304.0 (302.9-305.2) 303.0 (302.5-303.5) 302.8 (302.2-303.4) 303.3 (302.4-304.2)
34 310.7 (309.5-311.9) 309.4 (308.9-309.9) 309.2 (308.6-309.8) 309.8 (308.9-310.7)
35 316.2 (315.0-317.4) 315.1 (314.6-315.6) 314.9 (314.3-315.5) 315.4 (314.5-316.3)
36 320.8 (319.5-322.1) 319.9 (319.4-320.5) 319.8 (319.1-320.5) 320.2 (319.2-321.2)
37 324.7 (323.2-326.2) 324.1 (323.5-324.7) 324.0 (323.2-324.7) 324.4 (323.3-325.5)
38 328.2 (326.7-329.8) 327.8 (327.1-328.4) 327.6 (326.8-328.4) 328.2 (327.0-329.3)
Non-obese women: BMI 19-29.99 kg/m²;
Normal women: BMI <25 kg/m²;
Overweight women 25≤BMI<30 kg/m²;
Obese women: BMI 30-45 kg/m².

© 2017 American Medical Association. All rights reserved.

eTable 3. Geometric mean and 95% confidence intervals for abdominal
circumference (mm) by gestational age and maternal pre-pregnancy adiposity
status, NICHD Fetal Growth Studies–Singletons

Abdominal circumference, mean, (95%CI), mm, by Maternal Pre-Pregnancy Adiposity

Status
Gestation Obese Non-obese (All) Normal weight Overweight
weeks
11 45.4 (44.8-45.9) 45.4 (45.1-45.6) 45.4 (45.1-45.7) 45.3 (44.9-45.8)
12 55.5 (55.0-55.9) 55.7 (55.5-55.9) 55.8 (55.6-56.1) 55.5 (55.2-55.9)
13 66.4 (65.9-66.9) 66.8 (66.6-67.1) 67.0 (66.7-67.2) 66.5 (66.1-66.9)
14 77.8 (77.2-78.4) 78.4 (78.2-78.7) 78.7 (78.3-79.0) 78.0 (77.5-78.5)
15 89.6 (88.9-90.3) 90.3 (90.0-90.6) 90.6 (90.2-91.0) 89.8 (89.3-90.3)
16 101.5 (100.7-102.2) 102.3 (102.0-102.6) 102.6 (102.2-103.0) 101.8 (101.2-102.3)
17 113.4 (112.7-114.2) 114.3 (113.9-114.6) 114.5 (114.1-114.9) 113.8 (113.2-114.4)
18 125.4 (124.6-126.2) 126.1 (125.8-126.5) 126.4 (125.9-126.8) 125.7 (125.1-126.4)
19 137.3 (136.4-138.2) 138 (137.6-138.4) 138.1 (137.7-138.6) 137.7 (137.0-138.4)
20 149.1 (148.2-150.0) 149.7 (149.3-150.1) 149.8 (149.3-150.3) 149.5 (148.8-150.3)
21 160.8 (159.8-161.7) 161.3 (160.9-161.7) 161.3 (160.9-161.8) 161.2 (160.5-162.0)
22 172.2 (171.3-173.2) 172.7 (172.2-173.1) 172.7 (172.2-173.2) 172.7 (171.9-173.4)
23 183.4 (182.4-184.4) 183.8 (183.4-184.3) 183.8 (183.3-184.3) 183.9 (183.1-184.7)
24 194.4 (193.3-195.4) 194.7 (194.2-195.2) 194.7 (194.1-195.2) 194.9 (194.0-195.7)
25 205.1 (204.0-206.3) 205.4 (204.9-205.9) 205.3 (204.8-205.9) 205.6 (204.8-206.5)
26 215.8 (214.6-217.0) 216.0 (215.5-216.5) 215.8 (215.2-216.5) 216.3 (215.4-217.3)
27 226.4 (225.2-227.7) 226.5 (226.0-227.1) 226.3 (225.7-226.9) 227.0 (226.0-228.0)
28 237.2 (235.9-238.5) 237.1 (236.6-237.7) 236.8 (236.2-237.5) 237.8 (236.8-238.8)
29 248.2 (246.9-249.5) 248.0 (247.4-248.5) 247.5 (246.8-248.2) 248.9 (247.9-250.0)
30 259.5 (258.1-260.8) 259.0 (258.4-259.6) 258.4 (257.7-259.0) 260.2 (259.2-261.3)
31 270.8 (269.3-272.3) 270.0 (269.4-270.7) 269.3 (268.5-270.0) 271.6 (270.5-272.7)
32 282.1 (280.4-283.7) 281.1 (280.4-281.7) 280.2 (279.4-281.0) 282.9 (281.7-284.1)
33 293.1 (291.3-294.8) 291.9 (291.1-292.6) 290.9 (290.0-291.8) 293.9 (292.6-295.3)
34 303.7 (301.9-305.5) 302.4 (301.6-303.1) 301.3 (300.4-302.2) 304.5 (303.2-305.9)
35 313.7 (311.8-315.6) 312.3 (311.6-313.1) 311.3 (310.4-312.2) 314.5 (313.1-315.9)
36 323.3 (321.2-325.3) 321.8 (321.0-322.7) 320.8 (319.8-321.8) 323.9 (322.4-325.5)
37 332.6 (330.3-334.9) 330.8 (329.9-331.8) 329.8 (328.6-330.9) 333.0 (331.3-334.7)
38 341.9 (339.5-344.4) 339.4 (338.4-340.4) 338.3 (337.1-339.5) 341.9 (340.1-343.7)
Non-obese women: BMI 19-29.99 kg/m²;
Normal women: BMI <25 kg/m²;
Overweight women 25≤BMI<30 kg/m²;
Obese women: BMI 30-45 kg/m².

© 2017 American Medical Association. All rights reserved.

eTable 4. Geometric mean and 95% confidence intervals for Fumer length (mm)
by gestational age and maternal pre-pregnancy adiposity status, NICHD Fetal
Growth Studies–Singletons.

Femur length, mean, (95%CI), mm, by Maternal Pre-Pregnancy Adiposity Status

Gestation Obese Non-obese (All) Normal weight Overweight
weeks
11 4.2 (4.1-4.3) 4.1 (4.0-4.1) 4.1 (4.0-4.1) 4.1 (4.0-4.1)
12 6.4 (6.3-6.6) 6.4 (6.3-6.4) 6.4 (6.3-6.4) 6.4 (6.3-6.5)
13 9.2 (9.1-9.4) 9.3 (9.2-9.3) 9.2 (9.2-9.3) 9.3 (9.2-9.4)
14 12.4 (12.2-12.6) 12.5 (12.4-12.6) 12.5 (12.4-12.6) 12.5 (12.4-12.7)
15 15.7 (15.5-16.0) 15.9 (15.8-16.0) 15.9 (15.8-16.1) 15.9 (15.8-16.1)
16 19.1 (18.8-19.4) 19.3 (19.2-19.5) 19.3 (19.2-19.5) 19.3 (19.1-19.6)
17 22.4 (22.1-22.7) 22.6 (22.4-22.7) 22.6 (22.4-22.7) 22.6 (22.4-22.8)
18 25.6 (25.3-26.0) 25.7 (25.5-25.8) 25.6 (25.5-25.8) 25.7 (25.5-26.0)
19 28.8 (28.5-29.2) 28.6 (28.5-28.8) 28.6 (28.4-28.8) 28.8 (28.5-29.0)
20 31.9 (31.5-32.3) 31.6 (31.4-31.8) 31.5 (31.3-31.7) 31.8 (31.5-32.1)
21 34.9 (34.5-35.3) 34.5 (34.3-34.7) 34.4 (34.2-34.6) 34.7 (34.4-35.0)
22 37.8 (37.4-38.2) 37.3 (37.1-37.5) 37.2 (37.0-37.4) 37.5 (37.2-37.8)
23 40.5 (40.1-40.9) 40.0 (39.8-40.2) 39.9 (39.7-40.1) 40.2 (39.9-40.5)
24 43.1 (42.7-43.5) 42.6 (42.4-42.7) 42.5 (42.3-42.7) 42.7 (42.4-43.0)
25 45.5 (45.1-45.9) 45.0 (44.8-45.2) 44.9 (44.7-45.1) 45.1 (44.8-45.4)
26 47.8 (47.4-48.2) 47.3 (47.2-47.5) 47.3 (47.1-47.5) 47.4 (47.1-47.7)
27 50.0 (49.6-50.4) 49.6 (49.4-49.7) 49.5 (49.3-49.7) 49.6 (49.3-49.9)
28 52.1 (51.7-52.6) 51.8 (51.6-51.9) 51.7 (51.5-51.9) 51.8 (51.5-52.1)
29 54.3 (54.0-54.7) 53.9 (53.8-54.1) 53.9 (53.7-54.1) 54.0 (53.8-54.3)
30 56.6 (56.2-56.9) 56.1 (55.9-56.2) 56.0 (55.8-56.2) 56.3 (56.0-56.5)
31 58.8 (58.4-59.1) 58.2 (58.1-58.4) 58.1 (57.9-58.2) 58.5 (58.2-58.7)
32 60.9 (60.5-61.3) 60.3 (60.1-60.4) 60.1 (59.9-60.3) 60.6 (60.3-60.9)
33 63.0 (62.6-63.4) 62.2 (62.1-62.4) 62.1 (61.8-62.3) 62.7 (62.3-63.0)
34 64.9 (64.5-65.3) 64.1 (64.0-64.3) 63.9 (63.7-64.1) 64.5 (64.2-64.9)
35 66.6 (66.3-67.0) 65.9 (65.7-66.0) 65.7 (65.5-65.9) 66.3 (66.0-66.5)
36 68.2 (67.8-68.6) 67.5 (67.3-67.6) 67.3 (67.1-67.5) 67.8 (67.5-68.1)
37 69.6 (69.1-70.1) 68.9 (68.7-69.1) 68.8 (68.5-69.0) 69.2 (68.8-69.6)
38 71.0 (70.5-71.5) 70.2 (70.0-70.4) 70.0 (69.8-70.3) 70.6 (70.2-71.0)
Non-obese women: BMI 19-29.99 kg/m²;
Normal women: BMI <25 kg/m²;
Overweight women 25≤BMI<30 kg/m²;
Obese women: BMI 30-45 kg/m².

© 2017 American Medical Association. All rights reserved.

eTable 5. Geometric mean and 95% confidence intervals for Humerus length (mm)
by gestational age and maternal pre-pregnancy adiposity status, NICHD Fetal
Growth Studies–Singletons.

Humerus length, mean, (95%CI), mm, by Maternal Pre-Pregnancy Adiposity

Status
Gestation Obese Non-obese (All) Normal weight Overweight
weeks
11 4.4 (4.3-4.5) 4.3 (4.3-4.3) 4.3 (4.2-4.3) 4.3 (4.2-4.4)
12 6.8 (6.7-6.9) 6.7 (6.7-6.8) 6.7 (6.7-6.8) 6.8 (6.7-6.8)
13 9.7 (9.6-9.9) 9.7 (9.7-9.8) 9.7 (9.7-9.8) 9.7 (9.6-9.8)
14 13.0 (12.8-13.2) 13.0 (13.0-13.1) 13.1 (13.0-13.2) 13.0 (12.9-13.2)
15 16.3 (16.1-16.6) 16.4 (16.3-16.5) 16.5 (16.3-16.6) 16.4 (16.2-16.5)
16 19.6 (19.3-19.9) 19.7 (19.6-19.8) 19.8 (19.6-19.9) 19.6 (19.4-19.8)
17 22.6 (22.3-23.0) 22.7 (22.6-22.8) 22.8 (22.6-22.9) 22.6 (22.4-22.8)
18 25.5 (25.2-25.8) 25.5 (25.3-25.6) 25.5 (25.3-25.7) 25.4 (25.2-25.7)
19 28.3 (27.9-28.6) 28.1 (28.0-28.2) 28.1 (27.9-28.3) 28.2 (27.9-28.4)
20 31.0 (30.6-31.4) 30.7 (30.5-30.8) 30.6 (30.4-30.8) 30.8 (30.5-31.1)
21 33.5 (33.2-33.9) 33.2 (33.0-33.3) 33.1 (32.9-33.3) 33.3 (33.1-33.6)
22 36.0 (35.6-36.3) 35.6 (35.4-35.7) 35.5 (35.3-35.6) 35.7 (35.5-36.0)
23 38.2 (37.8-38.6) 37.8 (37.7-38.0) 37.7 (37.5-37.9) 38.0 (37.8-38.3)
24 40.3 (39.9-40.7) 39.9 (39.8-40.1) 39.8 (39.7-40.0) 40.1 (39.9-40.4)
25 42.3 (41.9-42.7) 41.9 (41.8-42.1) 41.9 (41.7-42.0) 42.1 (41.8-42.4)
26 44.1 (43.7-44.5) 43.8 (43.7-44.0) 43.8 (43.6-43.9) 44.0 (43.7-44.3)
27 45.9 (45.5-46.3) 45.6 (45.5-45.8) 45.6 (45.4-45.8) 45.8 (45.5-46.0)
28 47.6 (47.3-48.0) 47.4 (47.2-47.5) 47.3 (47.1-47.5) 47.5 (47.2-47.8)
29 49.4 (49.0-49.7) 49.0 (48.9-49.2) 49.0 (48.8-49.1) 49.2 (49.0-49.5)
30 51.2 (50.8-51.5) 50.7 (50.6-50.8) 50.6 (50.4-50.8) 50.9 (50.7-51.1)
31 52.9 (52.6-53.2) 52.3 (52.2-52.5) 52.2 (52.0-52.4) 52.6 (52.3-52.8)
32 54.6 (54.2-54.9) 53.9 (53.8-54.0) 53.8 (53.6-53.9) 54.2 (53.9-54.5)
33 56.2 (55.8-56.6) 55.4 (55.3-55.6) 55.2 (55.1-55.4) 55.7 (55.5-56.0)
34 57.6 (57.3-58.0) 56.8 (56.7-57.0) 56.7 (56.5-56.9) 57.2 (56.9-57.5)
35 58.9 (58.6-59.3) 58.2 (58.1-58.4) 58.0 (57.9-58.2) 58.5 (58.3-58.8)
36 60.1 (59.7-60.5) 59.5 (59.3-59.6) 59.3 (59.1-59.5) 59.7 (59.5-60.0)
37 61.1 (60.7-61.6) 60.6 (60.4-60.8) 60.5 (60.3-60.7) 60.9 (60.6-61.2)
38 62.2 (61.7-62.7) 61.6 (61.4-61.8) 61.5 (61.2-61.7) 62.0 (61.6-62.3)
Non-obese women: BMI 19-29.99 kg/m²;
Normal women: BMI <25 kg/m²;
Overweight women 25≤BMI<30 kg/m²;
Obese women: BMI 30-45 kg/m².

© 2017 American Medical Association. All rights reserved.

eTable 6. Geometric mean and 95% confidence intervals for Ratio: Head
circumference/abdominal circumference by gestational age and maternal pre-pregnancy
adiposity status, NICHD Fetal Growth Studies–Singletons.

Ratio: Head circumference/abdominal circumference, mean, (95%CI), by Maternal

Pre-Pregnancy Adiposity Status
Gestation Obese
weeks
11 1.293 (1.281-1.304)
12 1.281 (1.274-1.287)
13 1.265 (1.259-1.271)
14 1.247 (1.240-1.253)
15 1.227 (1.221-1.234)
16 1.208 (1.202-1.214)
17 1.189 (1.184-1.195)
18 1.173 (1.167-1.179)
19 1.159 (1.154-1.165)
20 1.148 (1.143-1.154)
21 1.139 (1.134-1.144)
22 1.131 (1.126-1.137)
23 1.125 (1.120-1.130)
24 1.119 (1.114-1.124)
25 1.113 (1.108-1.118)
26 1.107 (1.102-1.113)
27 1.101 (1.095-1.106)
28 1.093 (1.088-1.099)
29 1.085 (1.079-1.090)
30 1.074 (1.070-1.079)
31 1.063 (1.058-1.068)
32 1.051 (1.045-1.056)
33 1.037 (1.032-1.043)
34 1.023 (1.018-1.029)
35 1.008 (1.003-1.014)
36 0.992 (0.987-0.998)
37 0.977 (0.970-0.983)
38 0.960 (0.954-0.967)
Non-obese women: BMI 19-29.99 kg/m²;
Normal women: BMI <25 kg/m²;
Overweight women 25≤BMI<30 kg/m²;
Obese women: BMI 30-45 kg/m².
Non-obese (All) Normal weight Overweight
1.292 (1.287-1.298) 1.293 (1.286-1.299) 1.292 (1.283-1.300)
1.281 (1.278-1.284) 1.280 (1.276-1.284) 1.282 (1.277-1.287)
1.265 (1.262-1.267) 1.264 (1.260-1.267) 1.267 (1.263-1.271)
1.246 (1.244-1.249) 1.245 (1.241-1.249) 1.249 (1.244-1.254)
1.226 (1.224-1.229) 1.225 (1.222-1.229) 1.229 (1.224-1.234)
1.206 (1.204-1.209) 1.206 (1.202-1.209) 1.209 (1.204-1.213)
1.188 (1.185-1.190) 1.187 (1.184-1.190) 1.189 (1.185-1.193)
1.171 (1.168-1.173) 1.170 (1.167-1.173) 1.172 (1.168-1.176)
1.157 (1.154-1.159) 1.157 (1.154-1.160) 1.158 (1.153-1.162)
1.146 (1.144-1.148) 1.146 (1.143-1.149) 1.146 (1.142-1.150)
1.138 (1.135-1.140) 1.138 (1.135-1.141) 1.137 (1.133-1.141)
1.131 (1.129-1.133) 1.131 (1.129-1.134) 1.130 (1.126-1.134)
1.126 (1.123-1.128) 1.126 (1.124-1.129) 1.124 (1.120-1.128)
1.121 (1.119-1.123) 1.122 (1.119-1.124) 1.119 (1.115-1.122)
1.116 (1.114-1.118) 1.117 (1.115-1.120) 1.113 (1.110-1.117)
1.111 (1.109-1.113) 1.113 (1.110-1.115) 1.108 (1.104-1.112)
1.105 (1.103-1.107) 1.107 (1.104-1.110) 1.101 (1.097-1.105)
1.098 (1.095-1.100) 1.100 (1.097-1.103) 1.093 (1.089-1.097)
1.088 (1.086-1.091) 1.091 (1.088-1.094) 1.083 (1.079-1.087)
1.078 (1.075-1.080) 1.080 (1.078-1.083) 1.072 (1.068-1.076)
1.065 (1.063-1.067) 1.068 (1.066-1.071) 1.059 (1.056-1.063)
1.052 (1.050-1.054) 1.055 (1.052-1.058) 1.046 (1.042-1.050)
1.038 (1.035-1.040) 1.041 (1.038-1.044) 1.032 (1.028-1.036)
1.023 (1.021-1.026) 1.026 (1.023-1.029) 1.017 (1.013-1.021)
1.009 (1.006-1.011) 1.011 (1.008-1.014) 1.003 (0.999-1.007)
0.994 (0.991-0.996) 0.996 (0.993-0.999) 0.988 (0.984-0.993)
0.979 (0.977-0.982) 0.982 (0.979-0.985) 0.974 (0.970-0.979)
0.966 (0.963-0.968) 0.968 (0.965-0.972) 0.960 (0.956-0.965)

© 2017 American Medical Association. All rights reserved.

eTable 7. Geometric mean and 95% confidence intervals for Ratio: Femur
length/abdominal circumference by gestational age and maternal pre-pregnancy
adiposity status, NICHD Fetal Growth Studies–Singletons.

Ratio: Femur length/abdominal circumference, mean, (95%CI), by Maternal Pre-

Pregnancy Adiposity Status
Gestation Obese Non-obese (All)
weeks
11 0.092 (0.090-0.094)
12 0.116 (0.114-0.117)
13 0.138 (0.137-0.140)
14 0.158 (0.156-0.160)
15 0.175 (0.173-0.177)
16 0.188 (0.186-0.190)
17 0.197 (0.195-0.200)
18 0.204 (0.202-0.207)
19 0.210 (0.208-0.212)
20 0.214 (0.212-0.216)
21 0.217 (0.215-0.219)
22 0.220 (0.218-0.222)
23 0.221 (0.219-0.223)
24 0.222 (0.220-0.223)
25 0.222 (0.220-0.223)
26 0.221 (0.219-0.223)
27 0.220 (0.219-0.222)
28 0.220 (0.218-0.221)
29 0.219 (0.217-0.220)
30 0.218 (0.217-0.219)
31 0.217 (0.216-0.219)
32 0.216 (0.215-0.218)
33 0.215 (0.214-0.217)
34 0.214 (0.212-0.215)
35 0.212 (0.211-0.214)
36 0.211 (0.209-0.212)
37 0.209 (0.207-0.211)
38 0.208 (0.206-0.209)
Non-obese women: BMI 19-29.99 kg/m²;
Normal women: BMI <25 kg/m²;
Overweight women 25≤BMI<30 kg/m²;
Obese women: BMI 30-45 kg/m².
Normal weight Overweight
0.090 (0.089-0.091) 0.090 (0.089-0.091) 0.090 (0.089-0.092)
0.115 (0.114-0.115) 0.114 (0.114-0.115) 0.115 (0.114-0.116)
0.138 (0.138-0.139) 0.138 (0.137-0.139) 0.139 (0.138-0.141)
0.159 (0.158-0.160) 0.159 (0.158-0.160) 0.160 (0.159-0.162)
0.176 (0.175-0.177) 0.176 (0.175-0.177) 0.177 (0.176-0.179)
0.189 (0.188-0.190) 0.188 (0.187-0.189) 0.190 (0.188-0.191)
0.197 (0.197-0.198) 0.197 (0.196-0.198) 0.198 (0.197-0.200)
0.203 (0.202-0.204) 0.203 (0.202-0.204) 0.204 (0.203-0.206)
0.208 (0.207-0.209) 0.207 (0.206-0.208) 0.209 (0.207-0.211)
0.211 (0.210-0.212) 0.211 (0.210-0.212) 0.213 (0.211-0.214)
0.214 (0.213-0.215) 0.213 (0.212-0.214) 0.215 (0.214-0.217)
0.216 (0.215-0.217) 0.216 (0.215-0.217) 0.217 (0.216-0.219)
0.218 (0.217-0.218) 0.217 (0.216-0.218) 0.219 (0.217-0.220)
0.219 (0.218-0.219) 0.218 (0.217-0.219) 0.219 (0.218-0.221)
0.219 (0.218-0.220) 0.219 (0.218-0.220) 0.219 (0.218-0.221)
0.219 (0.218-0.220) 0.219 (0.218-0.220) 0.219 (0.218-0.220)
0.219 (0.218-0.219) 0.219 (0.218-0.220) 0.219 (0.217-0.220)
0.218 (0.217-0.219) 0.218 (0.217-0.219) 0.218 (0.217-0.219)
0.217 (0.217-0.218) 0.218 (0.217-0.218) 0.217 (0.216-0.218)
0.217 (0.216-0.217) 0.217 (0.216-0.217) 0.216 (0.215-0.217)
0.215 (0.215-0.216) 0.216 (0.215-0.216) 0.215 (0.214-0.216)
0.214 (0.214-0.215) 0.215 (0.214-0.215) 0.214 (0.213-0.215)
0.213 (0.213-0.214) 0.213 (0.213-0.214) 0.213 (0.212-0.214)
0.212 (0.211-0.213) 0.212 (0.211-0.213) 0.212 (0.211-0.213)
0.211 (0.210-0.211) 0.211 (0.210-0.212) 0.210 (0.209-0.212)
0.209 (0.209-0.210) 0.210 (0.209-0.210) 0.209 (0.208-0.210)
0.208 (0.207-0.209) 0.208 (0.207-0.209) 0.208 (0.206-0.209)
0.207 (0.206-0.208) 0.207 (0.206-0.208) 0.206 (0.205-0.208)

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