Ultrasound Obstet Gynecol 2005; 26: 500–503
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.1989
Ultrasound diagnosis of fetal macrosomia: a comparison of
weight prediction models using computer simulation
M. MONGELLI* and R. BENZIE†
*Division of Women and Children’s Health, Western Clinical School, University of Sydney, Nepean Hospital, and †Department of Perinatal
Ultrasound, Nepean Hospital, Penrith NSW, Australia
K E Y W O R D S: birth-weight prediction; computer modeling; gestational age; macrosomia
ABSTRACT
Objective To assess the frequency of the diagnosis of
macrosomia in relation to differing weight estimation
formulae in unselected pregnancies.
Methods Computer modeling techniques were employed.
Computer modeling software generated correlated fetal
biometry measurements according to published British
standards, from 37 to 41 weeks’ gestation. For each set of
measurements, estimated fetal weights were obtained by
a panel of 18 ultrasound weight formulae. The diagnosis
of macrosomia was made if the fetal weight estimate was
greater than 4500 g. Cohorts of 5000 pregnancies for
each week of gestation were studied.
Results The frequency of diagnosis of macrosomia
increased progressively with advancing gestational age,
with large increases between 40 and 41 weeks. The type
of weight estimation formula had a profound influence
on the frequency of diagnosis of macrosomia. Five of the
formulae tested almost never returned a weight estimate
greater than 4500 g. Three formulae yielded false positive
rates in excess of 15%. The Hadlock group of formulae
yielded frequencies of 0.3% to 14.6%.
Conclusions Most formulae tend to over-diagnose
macrosomia at term. Intervention rates for suspected
fetal macrosomia may be influenced by gestational age
at the time of scan and the type of fetal weight estimation
formula in use. Copyright  2005 ISUOG. Published by
John Wiley & Sons, Ltd.
INTRODUCTION
The temporal trend towards higher birth weights is
leading to increased rates of fetal macrosomia, a
Correspondence to: Prof. M. Mongelli, Division of Women and Children’s Health, Western Clinical School, University of Sydney, Nepean
Hospital, Penrith NSW, Australia (e-mail: max mongelli@yahoo.com)
Accepted: 27 June 2005
Copyright  2005 ISUOG. Published by John Wiley & Sons, Ltd.
condition associated with increased neonatal and mater-
nal morbidity1,2 . This excess morbidity is significantly
higher in pregnancies complicated by gestational diabetes
and maternal obesity. In most units the antenatal diagno-
sis of fetal macrosomia is based on ultrasound-estimated
fetal weight, and some clinicians may regard this an indi-
cation for intervention, such as induction of labor or
elective Cesarean section3 .
Ultrasound biometry used to detect macrosomia is
characterized by low sensitivity, low positive predictive
value and high negative predictive value4 . A particular
concern is the prevention of shoulder dystocia, but the
correlation with birth weight is rather poor5 . Hence it is
likely that most elective deliveries for this indication are
unnecessary. It is important therefore to determine the
effect of differing fetal weight estimation formulae on the
frequency of diagnosis of macrosomia.
The aim of this study was to estimate the frequency
of the ultrasound diagnosis of macrosomia in relation to
ultrasound weight formulae and gestational age at the time
of ultrasound scan using computer modeling techniques.
METHODS
The computer model simulates ultrasound screening of
unselected populations of singleton pregnancies between
37 and 41 weeks’ gestation. Macrosomia was defined
as an estimated fetal weight greater than 4500 g6 . The
simulation was based on a modification of a previously
published model of fetal growth screening7 , which has
been independently validated by field studies8 . The
software generated random numbers, which were then
transformed to normally-distributed z-scores. Since the z-
scores for head measurements, abdominal circumference
(AC) and femur length (FL) are correlated, the Cholesky
matrix decomposition method was used to generate inter-
correlated data sets9 . This is a computerized mathematical
ORIGINAL PAPER
Ultrasound diagnosis of fetal macrosomia 501

algorithm that uses matrix algebra to generate data 4500

sets with desired correlation coefficients. The correlation 4000
coefficients for biometric variables were derived from 3500
a UK database of fetal ultrasound measurements in a 3000
low-risk population10 . For each week of gestational age

the z-scores were converted to sets of measurements
for head circumference (HC), biparietal diameter (BPD),
AC and FL, according to the medians and standard
deviations of British ultrasound reference standards11 – 13 .
These variables were then converted to a fetal weight
estimate (EFW) using a total of 18 weight estimation
formulae14 – 28 retrieved from a literature search. The
population characteristics of the original formulae and
their ultrasound variables are listed in Table 1.
Simulations were run on cohorts of 5000 pregnancies
for each week of gestation, using a Pentium III PC and
Turbo Pascal programming software (Borland Software
Corporation, Scotts Valley, CA, USA). The statistical
distributions of the output of the computer model
were tested to check for conformity with the published
input data. The frequency of weight estimates greater
than 4500 g was converted to a percentage using the
weekly cohort as denominator. The output of Campbell’s
and Wilkin’s formula as a function of the abdominal
circumference is shown in Figure 1.
Differences in proportions were tested using the Pearson
Chi-square test, at the 0.05 significance level. Statistical
analyses were performed with SPSS for Windows (Systat
Software Inc., Richmond, CA, USA)29 .
RESULTS
The results of the model validation exercise are shown in
Table 2; we used medians in order to compare the output
with the original published studies. In most instances the
computer-generated fetal biometry medians were within
10% of the reference standard, with very similar standard
deviations.
EFW (g)
2500
2000
1500
1000
500
0
20 25 30 35 40 45 50
AC (cm)
Figure 1 Estimated fetal weight (EFW) from Campbell’s and
Wilkin’s formula (on y-axis) as a function of the fetal abdominal
circumference (AC) (x-axis).
The percentage of cases diagnosed with macrosomia
according to the week of gestation and the fetal
weight estimation formula is shown in Table 3. For
most formulae the frequency of ultrasound diagnoses
of macrosomia increased progressively with advancing
gestational age. It was generally very low at 37–38 weeks,
with large increases occurring between 40 and 41 weeks.
It ranged from nearly zero in the case of the formulae of
Campbell and Wilkin14 , Scott et al.22 , Thurnau et al.24 ,
Weinberger et al.27 and Woo and Wan (b)28 , to a
maximum of 55% for the formula of Vintzileos et al25 .
Nine of the formulae yielded diagnoses of macrosomia for
more than 10% of the population at 41 weeks’ gestation.
This was even higher for the formulae of Jordaan19
and Higginbottom et al.18 – as well as that of Vintzileos
et al.25 – with rates in excess of 15% at 41 weeks.
DISCUSSION
The advantages of computer modeling in this area include
the avoidance of biases due to differences between centers
and operators, selection bias, avoidance of errors related

Table 1 Characteristics of fetal populations used to derive original weight estimation formulae

Sample Birth weight; Weight Gestational age;

Authors Reference size range (g) > 4000 g (%) range (weeks)

Campbell & Wilkin 14 140 790–5460 7 N/A

Combs et al. 15 380 500–4600* N/A N/A
Dudley et al. 16 779 1300–5200 10 N/A
Hadlock et al. 17 109 < 1500 to > 4000 17 N/A
Higginbottom et al. 18 50 1200–4300* N/A N/A
Jordaan 19 98 1000 to > 3500 N/A 26–41
Ott et al. 20 464 < 1500 to > 3999 N/A N/A
Persson & Weldner 21 89 330–5070 N/A N/A
Scott et al. 22 142 400–1000 N/A N/A
Shepard et al. 23 73 710–4125 N/A N/A
Thurnau et al. 24 62 500–2500 N/A 25.5–35.5
Vintzileos et al. 25 89 570–4678 N/A 24–42
Warsof et al. 26 85 400–4800* 6 17–41
Weinberger et al. 27 41 510–1999 N/A N/A
Woo & Wan 28 125 850–4350 N/A 25–42

*, data estimated from published graphs. N/A, not available.

Copyright  2005 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2005; 26: 500–503.
502 Mongelli and Benzie

Table 2 Model validation: comparison of output with reference standard at different gestational ages; median (SD) in cm

Gestational age (weeks)

37 38 39 40 41

Generated BPD 9.26 (0.37) 9.43 (0.37) 9.59 (0.37) 9.74 (0.37) 9.87 (0.36)
BPD reference standard 9.29 (0.42) 9.47 (0.42) 9.48 (0.38) 9.78 (0.45) 9.86 (0.33)
Generated HC 33.04 (1.36) 33.48 (1.44) 33.85 (1.52) 34.17 (1.61) 34.42 (1.71)
HC reference standard 32.93 (1.15) 33.31 (1.81) 33.51 (1.18) 34.19 (1.86) 34.98 (1.58)
Generated AC 32.5 (1.81) 33.6 (1.86) 34.6 (1.91) 35.65 (1.98) 36.67 (2.01)
AC reference standard 32.64 (1.74) 33.5 (1.79) 34.4 (1.83) 35.25 (1.88) 36.08 (1.93)
Generated FL 6.94 (0.32) 7.09 (0.32) 7.23 (0.33) 7.37 (0.33) 7.48 (0.33)
FL reference standard 6.97 (0.32) 7.11 (0.33) 7.24 (0.33) 7.36 (0.34) 7.46 (0.35)

AC, abdominal circumference; BPD, biparietal diameter; FL, femur length; HC, head circumference.

Table 3 Diagnosis of macrosomia (% of cases) in relation to gestational age and fetal weight formula

Gestational age (weeks)

Ultrasound
Authors Reference variables 37 38 39 40 41 P

Campbell & Wilkin 14 AC only 0 0 0 0 0 —

Combs et al. 15 HC, AC, FL 0 0 0 0.26 2.1 < 0.001
Dudley et al. 16 HC, BPD, AC, FL 0 0 0.06 1.56 7.3 < 0.001
Hadlock et al. (a) 17 AC, FL 0 0 0.3 3.2 13.8 < 0.001
Hadlock et al. (b) 17 BPD, AC, FL 0 0 0.5 3.4 14.6 < 0.001
Hadlock et al. (c) 17 HC, BPD, AC, FL 0 0 0.40 2.72 11.4 < 0.001
Higginbottom et al. 18 AC only 0.1 0.8 3.3 11 24.9 < 0.001
Jordaan 19 HC, AC 0.1 0.6 2.6 7.2 15.4 < 0.001
Ott et al. 20 HC, AC, FL 0 0 0.1 1.5 8.1 < 0.001
Persson & Weldner 21 BPD, AC, FL 0 0 0.02 0.96 5.0 < 0.001
Scott et al. 22 HC, AC, FL 0 0 0 0 0 —
Shepard et al. 23 BPD, AC 0 0.02 0.7 3.5 13.8 < 0.001
Thurnau et al. 24 BPD, AC 0 0 0 0 0 —
Vintzileos et al. 25 BPD, AC 0.4 2.6 12.1 31.3 55.2 < 0.001
Warsof et al. 26 BPD, AC 0 0 0.64 3.2 13.4 < 0.001
Weinberger et al. 27 BPD, AC 0 0 0 0 0 —
Woo & Wan (a) 28 BPD, AC, FL 0 0 0.5 3.1 13.3 < 0.001
Woo & Wan (b) 28 BPD, AC, FL 0 0 0 0 0.2 < 0.001

AC, abdominal circumference; BPD, biparietal diameter; FL, femur length; HC, head circumference.

to time intervals from scanning to delivery, and large
sample sizes. However a model requires validation in
order for its results to be acceptable. The output of our
model in terms of the biometric variables is close to the
input reference standard, and well within range of similar
biometric standards for Western populations. The results
of a very similar model were validated by independent
field studies8 . Hence it is likely that it would approximate
results from a prospective clinical study of similar design.
We noted increasing rates in the diagnosis of macro-
somia with advancing gestational age. The large increase
found between 40 and 41 weeks for most formulae could
be an artifact arising from the intrinsic properties of the
formulae, or possibly related to an overestimate of the
fetal growth kinetics in the post-term period in the ref-
erence standards of Chitty et al.11 – 13 . It is very unlikely
to reflect a true biological phenomenon, since in the East
Midlands Obstetric Database the frequency of macro-
somia was approximately 1.3% at 40 weeks and 2.9%
at 41 weeks30 , whereas many of the formulae we tested
gave frequencies higher than 3% at 40 weeks and 10%
at 41 weeks. At the other extreme in performance, with
zero rates of macrosomia, diagnosis is due either to the
characteristics of the original populations from which the
formulae were derived, or to the intrinsic properties of
the formulae. The equations by Scott et al.22 , Thurnau
et al.24 and Weinberger et al.27 were targeted at small-
for-dates fetuses, and thus the zero rates of diagnosis of
macrosomia are expected.
The mathematical properties of the formula can have a
major influence on the accuracy of the weight estimates.
The example of Campbell’s and Wilkin’s formula is shown
in Figure 1, which shows the weight estimate of this for-
mula as a function of the fetal abdominal circumference.
It is grossly non-linear in that the estimate is never higher
than about 4100 g irrespective of the input fetal AC.
In general, these findings are consistent with previous
work, suggesting that ultrasound weight estimation is less
accurate at term than at 34–37 weeks’ gestation31 , and
that it becomes less accurate for larger fetuses4 . They also
show that formulae perform best in populations similar
to those from which they were originally derived. The

Copyright  2005 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2005; 26: 500–503.
Ultrasound diagnosis of fetal macrosomia
great variation in performance between different formu-
lae suggests that choice of fetal weight estimation formula
may significantly affect intervention rates for macroso-
mia. The formulae of Campbell and Wilkin14 , Thurnau
et al.24 , Scott et al.22 , Weinberger et al.27 and Woo and
Wan (b)28 will almost never yield a diagnosis of macro-
somia, and hence should not be used for this purpose.
On the other hand, the formulae of Jordaan19 , Vintzileos
et al.25 and Higginbottom et al.18 will yield high false
positive rates and are thus likely to be of limited clinical
utility. The equations of Ott et al.20 , Dudley et al.16 and
Persson and Weldner21 yield macrosomia frequencies that
are somewhat closer to the UK birth-weight distribution
and with lower false positive rates.
Our computer model cannot estimate the sensitivities
of differing ultrasound weight formulae; field data would
be required to address this issue. Previous work and
our studies suggest that the diagnosis of macrosomia is
most accurate if the ultrasound examination is performed
before 40 weeks’ gestation. This estimate can then be pro-
jected forwards to more advanced gestational ages using
the gestation-adjusted (GAP) method32 . This is a simple
mathematical technique that allows extrapolation of a
fetal weight estimate to any gestational age by using fetal
growth formulae.
CONCLUSIONS
The detection of a large fetus depends on ultrasound fetal
weight estimation, and the way this technique is applied
will have a significant impact on clinical intervention rates.
Hence sonographers should be aware of the ultrasound
formula that has been programmed in their machines
when assessing cases of suspected macrosomia.
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