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Am J Perinatol 2024; 41(S 01): e2625-e2635
DOI: 10.1055/a-2135-6838
Original Article

Selection of Standards for Sonographic Fetal Head Circumference by Use of z-Scores

C. Andrew Combs
1   Pediatrix Center for Research, Education, Quality and Safety, Pediatrix Medical Group, Sunrise, Florida
2   Obstetrix of San Jose, Campbell, California
,
Amber del Rosario
2   Obstetrix of San Jose, Campbell, California
,
Olaide Ashimi Balogun
3   Obstetrix Maternal-Fetal Medicine Specialists, Houston, Texas
,
Zachary S. Bowman
4   Perinatal Associates of Sacramento, Sacramento, California
,
Sushma Amara
5   Eastside Maternal-Fetal Medicine Specialists, Bellevue, Washington
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Abstract

Objective This study aimed to evaluate which of five established norms should be used for sonographic assessment of fetal head circumference (HC).

Study Design Cross-sectional study using pooled data from four maternal–fetal medicine practices. Inclusion criteria were singleton fetus, gestational age 220/7 to 396/7 weeks, biometry measured, and fetal cardiac activity present. Five norms of HC were studied: Jeanty et al, Hadlock et al, the INTERGROWTH-21st Project (IG-21st), the World Health Organization Fetal Growth Curves (WHO), and the National Institutes of Child Health and Human Development Fetal Growth Studies unified standard (NICHD-U). The fit of our HC measurements to each norm was assessed by these criteria: mean z-score close to 0, standard deviation (SD) of z close to 1, low Kolmogorov–Smirnov D-statistic, high Youden J-statistic, close to 10% of exams >90th percentile, close to 10% of exams <10th percentile, and close to 2.28% of exams >2 SD below the mean.

Results In 23,565 ultrasound exams, our HC measurements had the best fit to the WHO standard (mean z-score 0.10, SD of z = 1.01, D-statistic <0.01, J-statistic 0.83–0.94). The SD of the Jeanty reference was much larger than all the other norms and our measurements, resulting in underdiagnosis of abnormal HC. The means of the IG-21st and NICHD-U standards were smaller than the other norms and our measurements, resulting in underdiagnosis of small HC. The means of the Hadlock reference were larger than all the other norms and our measurements, resulting in overdiagnosis of small HC. Restricting the analysis to a low-risk subgroup of 4,423 exams without risk factors for large- or small-for-gestational age produced similar results.

Conclusion The WHO standard is likely best for diagnosis of abnormal HC. The Jeanty (Chervenak) reference suggested by the Society for Maternal-Fetal Medicine had poor sensitivity for microcephaly screening.

Key Points

  • There are >30 norms for fetal HC.

  • It is unknown which norm should be used.

  • The WHO standard fits our data best.

  • The Chervenak reference is not sensitive for microcephaly.

Keywords

fetal biometry - fetal microcephaly - growth references - growth standards - large-for-gestational age - small-for-gestational age


Publication History

Received: 10 June 2023

Accepted: 21 July 2023

Accepted Manuscript online:
24 July 2023

Article published online:
24 August 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 AIUM-ACR-ACOG-SMFM-SRU practice parameter for the performance of standard diagnostic obstetric ultrasound examinations. J Ultrasound Med 2018; 37 (11) E13-E24
    CrossrefPubMedGoogle Scholar
  • 2 Society for Maternal-Fetal Medicine (SMFM) Publications Committee. Ultrasound screening for fetal microcephaly following Zika virus exposure. Am J Obstet Gynecol 2016; 214 (06) B2-B4
    CrossrefPubMedGoogle Scholar
  • 3 Chervenak FA, Jeanty P, Cantraine F. et al. The diagnosis of fetal microcephaly. Am J Obstet Gynecol 1984; 149 (05) 512-517
    CrossrefPubMedGoogle Scholar
  • 4 Jeanty P, Cousaert E, Hobbins JC, Tack B, Bracken M, Cantraine F. A longitudinal study of fetal head biometry. Am J Perinatol 1984; 1 (02) 118-128
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Hadlock FP, Deter RL, Harrist RB, Park SK. Estimating fetal age: computer-assisted analysis of multiple fetal growth parameters. Radiology 1984; 152 (02) 497-501
    CrossrefPubMedGoogle Scholar
  • 6 Papageorghiou AT, Ohuma EO, Altman DG. et al; International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st). International standards for fetal growth based on serial ultrasound measurements: the Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project. Lancet 2014; 384 (9946) 869-879
    CrossrefPubMedGoogle Scholar
  • 7 Kiserud T, Piaggio G, Carroli G. et al. The World Health Organization Fetal Growth Charts: a multinational longitudinal study of ultrasound biometric measurements and estimated fetal weight. PLoS Med 2017; 14 (01) e1002220
    CrossrefPubMedGoogle Scholar
  • 8 Grantz KL, Grewal J, Kim S. et al. Unified standard for fetal growth: the NICHD fetal growth studies. Am J Obstet Gynecol 2022; 226: 576-587
    CrossrefPubMedGoogle Scholar
  • 9 Hadlock FP, Deter RL, Harrist RB, Park SK. Fetal head circumference: relation to menstrual age. AJR Am J Roentgenol 1982; 138 (04) 649-653
    CrossrefPubMedGoogle Scholar
  • 10 Hansmann M, Hackelöer BJ, Staudach A. Ultrasound Diagnosis in Obstetrics and Gynecology. Springer: Berlin, Heidelberg, New York, Tokyo, 1986
    CrossrefGoogle Scholar
  • 11 Nicolini U, Todros T, Ferrazzi E. et al. Curve trasversali dell'accrescimento fetale. Studio multicentrico. Minerva Ginecol 1986; 38 (11) 873-887
    PubMedGoogle Scholar
  • 12 Chitty LS, Altman DG, Henderson A, Campbell S. Charts of fetal size: 2. Head measurements. Br J Obstet Gynaecol 1994; 101 (01) 35-43
    CrossrefPubMedGoogle Scholar
  • 13 Snijders RJ, Nicolaides KH. Fetal biometry at 14-40 weeks' gestation. Ultrasound Obstet Gynecol 1994; 4 (01) 34-48
    CrossrefPubMedGoogle Scholar
  • 14 Kurmanavicius J, Wright EM, Royston P. et al. Fetal ultrasound biometry: 1. Head reference values. Br J Obstet Gynaecol 1999; 106 (02) 126-135
    CrossrefPubMedGoogle Scholar
  • 15 Lai FM, Yeo GSH. Reference charts of foetal biometry in Asians. Singapore Med J 1995; 36 (06) 628-636
    PubMedGoogle Scholar
  • 16 Merz E, Wellek S. Das normale fetale Wachstumsprofil–ein einheitliches Modell zur Berechnung von Normkurven für die gängigen Kopf- und Abdomen-parameter sowie die grossen Extremitätenknochen. Ultraschall Med 1996; 17 (04) 153-162
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Lessoway VA, Schulzer M, Wittmann BK, Gagnon FA, Wilson RD. Ultrasound fetal biometry charts for a North American Caucasian population. J Clin Ultrasound 1998; 26 (09) 433-453
    CrossrefPubMedGoogle Scholar
  • 18 Guihard-Costa AM, Thiebaugeorges O, Droullé P. Biométrie foetale: standards de croissance et croissance individuelle. Encyclopédie Médico-Chirurgicale. Elsevier: Paris, 1999
    Google Scholar
  • 19 Sutanthavibul A, Sunsaneevithayakul P, Boriboonhirunsarn D, Titapant V, Siwadune T. Charts of Thai fetal biometry: head circumference. Siriraj Hosp Gaz 2000; 52: 445-451
    PubMedGoogle Scholar
  • 20 Créquat J, Duyme M, Brodaty G. Biométrie 2000. Tables de croissance foetale par le Collège français d'échographie foetale (CFEF) et l'Inserm U 155. Gynécol Obstét Fertil 2000; 28 (06) 435-445
    PubMedGoogle Scholar
  • 21 Johnsen SL, Rasmussen S, Sollien R, Kiserud T. Fetal age assessment based on ultrasound head biometry and the effect of maternal and fetal factors. Acta Obstet Gynecol Scand 2004; 83 (08) 716-723
    CrossrefPubMedGoogle Scholar
  • 22 Schluter PJ, Pritchard G, Gill MA. Ultrasonic fetal size measurements in Brisbane, Australia. Australas Radiol 2004; 48 (04) 480-486
    CrossrefPubMedGoogle Scholar
  • 23 Paladini D, Rustico M, Viora E. et al. Fetal size charts for the Italian population. Normative curves of head, abdomen and long bones. Prenat Diagn 2005; 25 (06) 456-464
    CrossrefPubMedGoogle Scholar
  • 24 Johnsen SL, Wilsgaard T, Rasmussen S, Sollien R, Kiserud T. Longitudinal reference charts for growth of the fetal head, abdomen and femur. Eur J Obstet Gynecol Reprod Biol 2006; 127 (02) 172-185
    CrossrefPubMedGoogle Scholar
  • 25 Salomon LJ, Duyme M, Créquat J. et al. French fetal biometry: reference equations and comparison with other charts. Ultrasound Obstet Gynecol 2006; 28 (02) 193-198
    CrossrefPubMedGoogle Scholar
  • 26 Leung TN, Pang MW, Daljit SS. et al. Fetal biometry in ethnic Chinese: biparietal diameter, head circumference, abdominal circumference and femur length. Ultrasound Obstet Gynecol 2008; 31 (03) 321-327
    CrossrefPubMedGoogle Scholar
  • 27 Verburg BO, Steegers EAP, De Ridder M. et al. New charts for ultrasound dating of pregnancy and assessment of fetal growth: longitudinal data from a population-based cohort study. Ultrasound Obstet Gynecol 2008; 31 (04) 388-396
    CrossrefPubMedGoogle Scholar
  • 28 Daniel-Spiegel E, Weiner E, Yarom I. et al. Establishment of fetal biometric charts using quantile regression analysis. J Ultrasound Med 2013; 32 (01) 23-33
    CrossrefPubMedGoogle Scholar
  • 29 Buck Louis GM, Grewal J, Albert PS. et al. Racial/ethnic standards for fetal growth: the NICHD Fetal Growth Studies. Am J Obstet Gynecol 2015; 213 (04) 449.e1-449.e41
    CrossrefPubMedGoogle Scholar
  • 30 Stirrup OT, Khalil A, D'Antonio F, Thilaganathan B. Southwest Thames Obstetric Research Collaborative (STORK). Fetal growth reference ranges in twin pregnancy: analysis of the Southwest Thames Obstetric Research Collaborative (STORK) multiple pregnancy cohort. Ultrasound Obstet Gynecol 2015; 45 (03) 301-307
    CrossrefPubMedGoogle Scholar
  • 31 Gelber SE, Grünebaum A, Chervenak FA. Prenatal screening for microcephaly: an update after three decades. J Perinat Med 2017; 45 (02) 167-170
    CrossrefPubMedGoogle Scholar
  • 32 Hutcheon JA, Liauw J. Should fetal growth charts be references or standards?. Epidemiology 2021; 32 (01) 14-17
    CrossrefPubMedGoogle Scholar
  • 33 Salomon LJ, Bernard JP, Duyme M, Buvat I, Ville Y. The impact of choice of reference charts and equations on the assessment of fetal biometry. Ultrasound Obstet Gynecol 2005; 25 (06) 559-565
    CrossrefPubMedGoogle Scholar
  • 34 ACOG Committee Opinion 700: methods for estimating the due date. Obstet Gynecol 2017; 129 (05) e150-e154
    CrossrefPubMedGoogle Scholar
  • 35 Combs CA, Castillo R, Webb GW, Del Rosario A. Impact of adding abdominal circumference to the definition of fetal growth restriction. Am J Obstet Gynecol MFM 2021; 3 (04) 100382
    CrossrefPubMedGoogle Scholar
  • 36 Combs CA, Castillo R, Kline C. et al. Choice of standards for sonographic fetal abdominal circumference percentile. Am J Obstet Gynecol MFM 2022; 4 (06) 100732
    CrossrefPubMedGoogle Scholar
  • 37 Sananes N, Guigue V, Kohler M. et al. Use of Z-scores to select a fetal biometric reference curve. Ultrasound Obstet Gynecol 2009; 34 (04) 404-409
    CrossrefPubMedGoogle Scholar
  • 38 Bihoun B, Zango SH, Traoré-Coulibaly M. et al. Fetal biometry assessment with INTERGROWTH 21st's and Salomon's equations in rural Burkina Faso. BMC Pregnancy Childbirth 2020; 20 (01) 492
    CrossrefPubMedGoogle Scholar
  • 39 Melamed N, Yogev Y, Danon D, Mashiach R, Meizner I, Ben-Haroush A. Sonographic estimation of fetal head circumference: how accurate are we?. Ultrasound Obstet Gynecol 2011; 37 (01) 65-71
    CrossrefPubMedGoogle Scholar
  • 40 Poojari VG, Jose A, Pai MV. Sonographic estimation of the fetal head circumference: accuracy and factors affecting the error. J Obstet Gynaecol India 2022; 72 (Suppl. 01) 134-138
    CrossrefPubMedGoogle Scholar
  • 41 Leibovitz Z, Daniel-Spiegel E, Malinger G. et al. Prediction of microcephaly at birth using three reference ranges for fetal head circumference: can we improve prenatal diagnosis?. Ultrasound Obstet Gynecol 2016; 47 (05) 586-592
    CrossrefPubMedGoogle Scholar
  • 42 Opitz JM, Holt MC. Microcephaly: general considerations and aids to nosology. J Craniofac Genet Dev Biol 1990; 10 (02) 175-204
    PubMedGoogle Scholar
  • 43 Leviton A, Holmes LB, Allred EN, Vargas J. Methodologic issues in epidemiologic studies of congenital microcephaly. Early Hum Dev 2002; 69 (1-2): 91-105
    CrossrefPubMedGoogle Scholar
  • 44 Passemard S, Kaindl AM, Verloes A. Microcephaly. Handb Clin Neurol 2013; 111: 129-141
    CrossrefPubMedGoogle Scholar
  • 45 Dolk H. The predictive value of microcephaly during the first year of life for mental retardation at seven years. Dev Med Child Neurol 1991; 33 (11) 974-983
    CrossrefPubMedGoogle Scholar
  • 46 International Society of Ultrasound in Obstetrics and Gynecology. Sonographic examination of the fetal central nervous system: guidelines for performing the ‘basic examination’ and the ‘fetal neurosonogram’. Ultrasound Obstet Gynecol 2007; 29 (01) 109-116
    CrossrefPubMedGoogle Scholar