Ulrmsound m Med. & B~ol.. Vol. 3. pp. 47-51.

Per~amon Press. 1977.

Pnntcd m Great Britain

CLINICAL NOTE
ASSESSMENT OF GESTATIONAL AGE IN THE
FIRST TRIMESTER OF PREGNANCY
BY MAXIMUM FETAL DIAMETER
J. HIGGINBOQOM,
J. SLATERand G. PORTER
University Hospital of South Manchester, Departments of Radiology. and of Obstetrics and Gynaecology. West
Didsbury, Manchester M20 8LR, England
(First received

25 November 1976; and

in final

form 2 February

1977)

Abstract-Amethodusingultrasoundto estimatefetal$estationalagebetweenthe sixthandfourteenthweekof

pregnancyis described. The maximum fetal diameter is measured by a modification of the technique developed by
Robinson (1973. 1975) to determine crown-rump length. Correlation of values for maximum fetal diameter with
subsequent estimation of gestational age by ultrasound at adjudged 24 weeks, by X-ray at adjudged 37 weeks and also
with the actual date of delivery. contirmed the accuracy for clinical purposes of this simplified method.
Key words: Acoustics, Ultrasonics. Pregnancy, Gestational age, Fetus.

INTRODXTIOIQ
With the frequent use of induction of labour in
modern obstetrics, accurate knowledge of the
gestational age has become increasingly important,
especially in relation to the dysmature fetus, but
clinical methods are not always reliable particularly
with an uncertain menstrual history (Beazley and
Underhill, 1970).
Ultrasound provides the most satisfactory way
of measuring the fetus in ufero. Although the
biparietal diameter provides a reasonably accurate
method of estimating gestation age after the
fourteenth week of pregnancy (Campbell and
Newman, 1971), an earlier estimation is often very
useful; for the latter purpose, the most reliable
method so far described is that of Robinson (1973),
in which the so called crown-rump length of the
fetus is measured direct from a Polaroid photograph of the fetus as displayed on the oscilloscope. In patients with a reliable menstrual
history, Robinson achieved accuracy to within half
a week, but his technique is complex and time
consuming. In modifying it, we have established a
quicker and simpler procedure which is only
marginally less accurate.
It should be appreciated that this method can
only be used to estimate fetal age in the first
trimester of pregnancy and is different from our
technique to estimate fetal weight later in
pregnancy which is described elsewhere in Ulrrasound in Medicine and Biology (1977) (this issue,
p. 59). It is not possible to use the latter technique in
fetuses of less than 20 weeks.
hElEOD
The maximum fetal diameter is measured by B
mode sonar, using a Kretz L.M. 4100 M.G.S.

apparatus. As emphasized by Donald (1963) care is

taken to ensure that the patients bladder is full to
make the fetal echoes more easily recognized. The
presence of fetal movements or detection of the
fetal heart can help identification of the fetus. Its
diameter is measured in as many longitudinal,
transverse and oblique positions as possible using
electronic calipers until the maximum fetal
diameter is obtained. This term is preferred to
crown-rump length partly to distinguish it from
Robinsons method but also to emphasize that a
linear diameter is being determined rather than a
surface measurement (Figs 1 and 2). The main
difference between this procedure and Robinsons
method is that in the latter, having calculated the
exact position of the fetus, the crown-rump length
is measured only when it lies parallel to the
ultrasonic beam, whereas the maximum fetal
diameter is the greatest measurement obtained with
multiple scans along different planes. The maximum fetal diameter is the same as the crown-rump
length if it is measured along the correct alignment,
but if the alignment is not exactly correct then it

Fig. 2.

J. HIGGINBOTTOM
et al.

48

will be slightly smaller. In practice, this error is

extremely
small and makes little difference
especially if the result is calculated to the nearest
week: for instance, an error in angulation of 12can
be shown by trigonometry to produce an error of
about 2%, which is equivalent to about one day in
terms of gestational age, and this error should
rarely be exceeded.
Using Robinsons data (Table 1) the value for the
maximum fetal diameter was measured
in 65
normal patients. The gestational age equivalents of
these values were determined and subsequently
compared with three criteria of gestational age
later in the pregnancy. The first was an ultrasound
biparietal
diameter
(Campbell,
1969) taken at
predicted 24 weeks. The second criterion was
estimated from a radiograph taken at predicted 37
weeks. The maturity from the X-ray was assessed
by the appearance of the secondary ossification
centres at the knee joint (Russell, 1971), and the
measurement
of the femoral shaft length (Martin
and Higginbottom, 1971). Finally, the actual date of
delivery was compared with the original assessment.

Table 2. Maximum fetal diameter assessed against ultrasound

biparietal estimation at 24 weeks
Assessment by biparietal
diameter at predicted
24 weeks by maximum
fetal diameter

Number of
cases

22
224
:33t

1
7
11
5

1.5
10.8
17.0
7.7

24
244
25
254
26
26!
27

19
8
6
3
2
1
z
65

29.2
12.3
9.2
4.6
3.1
1.5
3.1
100.0%

Table 3. Maximum fetal diameter assessed against a radiograph at

37 weeks
X-Ray at calculated
37 weeks from previous
estimation of maximum
fetal diameter

Number of
cases

34I
Table 1. The mean value for maximum
fetal diameter/crown-rump length
Gestation (weeks)

M.F.D. (cm)

RESULTS

Table 2 shows the results at predicted 24 weeks

using ultrasound biparietal diameter. The arithmetical mean was 24.03 weeks with one standard
deviation of 1.06 weeks. 75.4% of estimations were
within one week of the predicted 24 weeks.
Table 3 shows the results at predicted 37 weeks
using radiology. The arithmetical mean was 37.02
weeks with one standard deviation of 1.02 weeks.
80% were within 1 week of the predicted 37
weeks.
The dates of delivery are shown in Table 4. Four
cases were undelivered by predicted 41 weeks and
labour was induced to avoid the risks of presumed
post maturity. Excluding these four cases then the
arithmetical
mean was 39.9 weeks with one
standard deviation 0.76 weeks. If the four excluded
cases had been allowed to go into spontaneous
labour, the arithmetical
mean and the standard

::t

2
41

3.1
6.2
1.5

13.8

15
10
9
3
2
-

23.1
15.4
13.8
4.6
3.1

37
374
38
384
39
34
40

0.7
1.0
1.5
2.2
3.0
4.2
5.5
6.5

6
7
8
9
10
11
12
13

L 15
100%

65

Table 4. Predicted gestational age by maximum

fetal diameter at time of spontaneous onset oi
labour to the nearest half week
Weeks

Number of cases

37$
38
38t
39
3%

1
2
2
6
11

1.5
3.1
3.1
9.2
16.9

z
41

15
17
7

23.1
26.2
10.8

Total

61

93.8

Total number of patients was 65. Four patients

were undelivered at 41 weeks gestation.

deviation
including

would have been slightly higher;

but
these four, 86.1% went into labour within

one week of the predicted

40 weeks,

Assessment of gestational age in the first trimester of pregnancy by maximum fetal dieter

Fig. I.

49

Assessment

of gestational

age in the first trimester of pregnancy

DlSCUMON

As can be seen from these results, at least 75% of

predictions were within one week when assessed
by later criteria, some biological variation beyond
this was to be expected; less than 5% showed a
difference greater than 2 weeks. It is, therefore,
concluded that maximum fetal diameter is a
satisfactory method of estimating fetal gestational
age in early pregnancy.
The most suitable stage for this technique is
between the sixth and thirteenth week of
pregnancy; before 6 weeks the fetus is difficult to
identify with certainty and after 14 weeks it
becomes harder to visualize all of the fetus
simultaneously with the B-scan and by this time the
biparietal diameter provides a satisfactory alternative.
The time taken for each estimation is rarely more
than 10 min so it can easily be performed as a
routine procedure at the antenatal booking clinic. It
is particularly valuable as a base-line estimation of
gestational age in any case where there is considered to be a risk of fetal growth retardation
occurring later in pregnancy.
A recent paper by Kurjak et al. (1976) has further
confirmed the use of crown-rump length for
estimating gestational age in the first trimester. Our
simplified technique should prove useful in the
majority of obstetric ultrasound departments.

U.M.BYol 3. No 1-D

by maximum fetal diameter

51

Acknowledgements-We
would like to thank Professor C. R.
Whitfield, Dr G. Hartley and Dr D. L. Asbury for encouragement
and advice; and Dr R. W. Burslem and Mr J. B. Jones whose
patients were included in this study.

rlmmRENcl?s

Beazley. J. M. and Underhill, R. A. (1970) Fallacy of fundal height.

Br. Med. 3. 4, 4Q4-406.
Campbell, S. (1%9) Prediction of fetal maturity by measurement
of biparietal diameter. J. Obstet. Gynaec. Br. Commonw. 76,
603-609.
Campbell. S. and Newman, G. B. (1971) Growth of fetal biparietal
diameter during normal pregnancy. 1. Obstet. Gynaec. Br.
Commonw. 78, 513-519.
Donald, I. (1%3) Use of ultrasonics in abdominal diagnosis. Br.
Med. J. 2. 1154-1155.
Higginbottom. J. (1977) Estimation of Fetal Weight. Ultrasound
Med. Biol. 3. 59.
Kurjak, A.. Cecuck, S. and Brayer, B. (1976) Prediction of
maturity in the first trimester of pregnancy by ultrasonic
measurement of fetal crown-rump length. 1. clin. Uitrasound. 4,
83-87.
Martin, R. H. and Higginbottom, I. (1971) A clinical and radiological assessment of fetal age. J. Obstet. Gynaec. Br. Commonw. 78,
155-162.
Robinson, H. P. (1973) Sonar measurement of fetal crown-rump
length as a means of assessing fetal maturity in the first
trimester of pregnancy. Br. Med. 1. 4, 28.
Robinson, H. P. (1974) A Critical Eoaluation of Ukrasonic
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Robinson, H. P. (1975) A clinical evaluation of sonar crown-rump
length measurements. J. Obstet. Gynaec. Br. Commonw, 82,
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