ESTIMATION OF GESTATIONAL AGE

By: Anushya Jayendran

OBJECTIVES
Definitions of important terminology Methods of determination of gestational age Importance of determination of gestational age

TERMINOLOGY
Gestational Age
Refers to the length of pregnancy after the first day of the last menstrual period (LMP) and is usually expressed in weeks and days.

Conceptional Age
Refers to the true fetal age and refers to the length of pregnancy from the time of conception.

DETERMINATION OF GESTATIONAL AGE

DETERMINATION OF GESTATIONAL AGE History Taking Physical Examination

Investigation

DETERMINATION OF GESTATIONAL AGE

HISTORY TAKING Date of Fruitful Coitus Date of Quickening

Date of Last Normal Menstrual Period (Naegele s Formula)

HISTORY TAKING
Date of Fruitful Coitus
266 days are to be added to the date of single fruitful coitus Accuracy is up to 50% within 7 days on either side Advantages: Useful and extremely accurate when used in cases of assisted reproduction, particularly in IVF Disadvantages: Not practicable except when pregnancy occurs in instances of sudden death or absence of the husband or rape

HISTORY TAKING
Date of Last Normal Menstrual Period
This follows Naegele s Rule: EDD is 280 days from the LNMP in a patient with a regular cycle of 28 days and where ovulation occurs in midcycle Accuracy is up to 50% within 7 days on either side If the interval of cycles is longer, the extra days are to be added and if the interval is shorter, the lesser days are to be subtracted to get the EDD Advantages: Easy to calculate in a patient who is certain of LNMP Disadvantages: Inaccurate in patients in the following circumstances: Oligomenorrhoea or polymenorrhagia (irregular cycles) Bleeding in the first trimester of pregnancy (implantation bleeding) Pregnancy following the use of oral contraceptives or intrauterine devices Pregnancy in the postpartum period (lactational amenorrhoea)

HISTORY TAKING
Date of Quickening
A rough idea about the probable date of delivery can be deduced by adding 22 weeks in primigravidae and 24 weeks in multiparae to the date of quickening Advantage: Can be used as an estimation in the absence of other more reliable methods Disadvantages: Inaccurate as every patient is different and values used are based on an average

DETERMINATION OF GESTATIONAL AGE

Size of Uterus Uterus Height of the Uterus From Vaginal Examination Palpation of Fetal Parts Auscultation of Fetal Heart Rate Fetus Lightening

Cervix PHYSICAL EXAMINATION

Size of Fetus

PHYSICAL EXAMINATION
Uterus
Size of Uterus
Can be assessed by vaginal examination Is most accurate prior to 12 weeks Corresponds with the Period of Amenorrhoea Disadvantages: Size can be misleading in the presence of multiple pregnancy, uterine fibroids, or a full bladder

Height of the Uterus

Refers to the Symphysial-Fundal-Height (SFH) Corresponds with the Period of Gestation (POG) Advantages: Accurate in cases of normal pregnancy Disadvantages: Inaccurate in cases of fetus which are small for gestational age or pregnancies with inadequate liquor

PHYSICAL EXAMINATION
Cervix
From Vaginal Examination
If the cervix becomes shorter and dilated, the labour is fairly not far off More accurately assessed using the Bishop s score Advantages: Extremely accurate when used to monitor the progress of labour Disadvantages: Can only be used to assess pregnancy in the later part. Labour may start even with long and closed cervix

BISHOP SCORE
Scoring
Cervical Dilation
Cervix dilated < 1 cm: 0 Cervix dilated 1-2 cm: 1 Cervix dilated 2-4 cm: 2 Cervix dilated > 4 cm: 3 Cervical Length > 4 cm (0% effaced): 0 Cervical Length 2-4 cm (0 to 50% effaced): 1 Cervical Length 1-2 cm (50 to 75% effaced): 2 Cervical Length < 1 cm (>75% effaced): 3

Cervical Length (Effacement)

BISHOP SCORE
Scoring (Cont.)
Cervical Consistency
Firm cervical consistency: 0 Average cervical consistency: 1 Soft cervical consistency: 2

Cervical Position
Posterior cervical position: 0 Middle or anterior cervical position: 1

Zero Station Notation (presenting part level)

Presenting part at ischial spines -3 cm: 0 Presenting part at ischial spines -1 cm: 1 Presenting part at ischial spines +1 cm: 2 Presenting part at ischial spines +2 cm: 3

BISHOP SCORE
Modifiers
Add 1 point to score for:
Preeclampsia Each prior Vaginal Delivery

Subtract 1 point from score for:

Postdates Pregnancy Nulliparity Premature or prolonged Rupture of Membranes

Interpretation
Indications for Cervical Ripening with prostaglandins
Bishop Score <5 Membranes intact No regular contractions

Indications for Labor Induction with Pitocin

Bishop Score >= 5 Rupture of Membranes

PHYSICAL EXAMINATION
Fetus (Cont.)
Palpation of Fetal Parts
Fetal parts are felt earliest by 20 weeks of gestation Disadvantages: Extremely subjective and subject to the skill of examiner

Auscultation of Fetal Heart Rate

Heard earliest by 18-20 weeks of gestation using ordinary Pinard Stethescope Heard earliest by 10 weeks of gestation using Doppler Ultrasound Disadvantages: Extremely subjective and subject to the skill of examiner

PHYSICAL EXAMINATION
Fetus (Cont.)
Lightening
Labour is likely to commence within 3 weeks of appearance of symptoms of lightening Disadvantages: Extremely subjective and can only be used to assess pregnancy in its later part

Size of the Fetus

Change in uterine shape, volume of liquor amnii, hardening of the skull and girth of the abdomen are of value in assessing he maturity of the fetus specially if the examinations are done by the same person at intervals Disadvantages: Extremely subjective and inaccurate in cases of Intrauterine Growth Restriction and fetuses which are Small for Gestational Age

DETERMINATION OF GESTATIONAL AGE

INVESTIGATIONS

Recording of Positive Pregnancy Test

Ultrasonography

Radiography

INVESTIGATIONS
Recording of Positive Pregnancy Test
The date of the first positive pregnancy test result allows the calculation of a minimum GA. This depends on the sensitivity of the test. For example, if the test was performed 4 weeks ago and the test is known to return positive results as early as 1 week after conception, then the minimum conceptional age (CA) would be 5 weeks (GA, 5 + 2 = 7 wk of amenorrhea)

Radiography
Based on x-ray findings Corresponds to the appearance and density of ossification centres in the upper end of the tibia (38-40 weeks) and lower end of femur (36-37 weeks)

INVESTIGATIONS
Ultrasonography
First Trimester: Crown-Rump Length (CRL) is most accurate (Variation: 5 days) Second Trimester: Biparietal Diameter (BPD), Head Circumference (HC), (AC) and Femur Length (FL) is more accurate. This is best done between week 12 and 20. (Variation: 8 days) Third Trimester: Less reliable. (Variation: 16 days) In clinical practice, when the difference between the gestational age determined by sonographic measurement and the menstrual age is less than 10 days, the EDD is derived from the LNMP is confirmed. When the difference is more than 10 days, the EDD should be based on ultrasonographic fetal biometry

IMPORTANCE OF DETERMINATION OF GESTATIONAL AGE

Accurate determination of gestational age is fundamental to obstetric care and is important in a variety of situations:
Antenatal test results will be inaccurate and misleading when the dates are inaccurate Fetal growth assessment, either clinically or by ultrasound evaluation, relies on accurate assessment of gestational age.
Fetal growth retardation or macrosomia may be missed owing to errors in gestational age assignment.

Interpretation of antenatal biophysical testing subjected to variation with gestational age as well.

REFERENCE
Konar H, D.C. Dutta s Textbook of Obstetrics, 7th Edition, New Central Book Agency, 2010 Mongelli M and Gardosi J, Update 19 April 2010, Evaluation of Gestation, Emedicine.medscape.com, Extracted from: http://emedicine.medscape.com/article/2592 69-overview

THE END
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