Fetal Medicine Foundation fetal and neonatal population weight charts

Objective: To develop fetal and neonatal population weight charts. The rationale for this objective is that while reference ranges of estimated fetal weight (EFW) are representative of the whole population, the traditional approach of deriving birth-weight (BW) charts is misleading because a high proportion of babies born preterm arises from pathological pregnancies. We propose that the reference population for BW charts, as in the case of EFW charts, should be all babies at a given gestational age including those still in utero.

Patients: Two sources of data were used for this study and in both the inclusion criteria were singleton pregnancy, dating by fetal crown-rump length at 11+0 to 13+6 weeks’ gestation, ultrasonographic measurements of fetal head circumference (HC), abdominal circumference (AC) and femur length (FL), and livebirth of phenotypically normal neonate. Dataset 1, comprised a sample of 5,163 paired measurements of EFW and BW; the ultrasound scans were carried out at 22-43 weeks’ gestation and birth occurred within 2 days of the ultrasound examination. The EFW was derived from the measurements of HC, AC and FL using the formula reported by Hadlock et al. in 1985. Dataset 2, comprised a sample of 95,579 pregnancies with EFW obtained by routine ultrasonographic fetal biometry at 20+0 to 23+6 weeks’ gestation (n=45,034), or at 31+0 to 33+6 weeks (n=19,224) or at 35+0 to 36+6 weeks (n=31,321); for the purpose of this study we included data for only one of the three visits.

Methods: In the development of reference ranges of EFW and BW with gestational age the following assumptions were made: first, the EFW and BW have a common median, dependent on gestational age and second, deviations from the median occur in both EFW and BW and these deviations are correlated with different levels of spread for EFW and BW, dependent on gestational age. We adopted a Bayesian approach to inference combining information from the two datasets using Markov Chain Monte–Carlo sampling (MCMC). The fitted model assumed that the mean log transformed measurements of EFW and BW are
related to gestational age according to a cubic equation and that deviations about the mean follow a bivariate Gaussian distribution.

Results: In the case of EFW in dataset 2 there was a good distribution of values <3rd, <5th, <10th, >90th, >95th and >97th percentiles of the reference range of EFW with gestational age throughout the gestational age range of 20+0- 36+6 weeks. In the case of BW there was a good distribution of values only for the cases born at >39 weeks’ gestation. For preterm births, particularly at 27-36 weeks, the BW was below the 3rd, 5th and 10th percentiles in a very high proportion of cases and this was particularly marked for cases of iatrogenic birth. The incidence of SGA fetuses and neonates in the respective EFW and BW charts was higher in women of Black than White racial origin.

Conclusion: We established a BW chart for the population of all babies at a given gestational age, including those still in utero, which overcomes the problem of underestimation of growth restriction in preterm births. The BW and EFW charts have a common median but they differ in the levels of spread from the median.