First Trimester

What are the first symptoms of pregnancy?

Missing a period is usually the first signal of a new pregnancy, although women with irregular periods
may not initially recognize a missed period as pregnancy. During this time, many women experience a
need to urinate frequently, extreme fatigue, nausea and/or vomiting, and increased breast tenderness.
All of these symptoms can be normal. Most overthecounter pregnancy tests are sensitive !"# days
after conception, and they are readily available at most drug stores. $erforming these tests early
helps to allay confusion and guesswor%. A serum pregnancy test &performed in a provider's office or
laboratory facility( can detect pregnancy )"" days after conception.
How long after conception does the fertilized egg implant?
*he fertilized conceptus enters the uterus as a # to )cell embryo and freely floats in the endometrial
cavity about !+",+ hours, roughly -. days after conception. Most embryos implant by the morula
stage, when the embryo consists of many cells. *his happens, on average, / days after conception.
*he new embryo then induces the lining changes of the endometrium, which is called decidualization.
0t then rapidly begins to develop the physiologic changes that establish maternalplacental exchange.
$rior to this time, medications ingested by the mother typically do not affect a pregnancy.
What is the most accurate pregnancy test to use?
1erum beta2human chorionic gonadotropin &h34( is the hormone produced by the
syncytiotrophoblast beginning on the day of implantation, and it rises in both the maternal blood
stream and the maternal urine fairly quic%ly. *he serum h34 test is the most sensitive and specific,
and the hormone can be detected in both blood and urine by about )! days after conception. *his
test can be performed quantitatively or qualitatively. 5rine pregnancy tests differ in their sensitivity and
specificity, which are based on the h34 units set as the cutoff for a positive test result, usually #,
m05/m6.
5rine pregnancy tests can produce positive results at the level of #+ m05/m6, which is #7 days before
most women expect the next menstrual period. *he %its are very accurate and widely available. *he
test can be completed in about 7, minutes. *he %its all use the same technique8recognition by an
antibody of the beta subunit of h34. 9alsely high readings of the h34 hormone can occur in cases
of hydatidiform molar pregnancy or other placental abnormalities. Also, test results can remain
positive for pregnancy wee%s after a pregnancy termination, miscarriage, or birth. :n the other hand,
falsenegative test results can occur from incorrect test preparation, urine that is too dilute, or
interference by several medications.
1erum pregnancy tests can be performed by a variety of methods. *he enzymelin%ed
immunosorbent assay &;601A( is the most popular in many clinical laboratories. *his test is a
determination of total betah34 levels. 0t is performed using a monoclonal antibody to bind to the
h34< a second antibody is added that also interacts with h34 and emits color when doing so. *his
form of ;601A is commonly called a =sandwich= of the sample h34. >adioimmunoassay &>0A( is still
used by some laboratories. *his test adds radiolabeled antih34 antibody to nonlabeled h34 of the
blood sample. *he count is then essentially determined by the amount of displacement of the
radiolabeled sample.
*he h34 level doubles approximately every # days in early pregnancy. ?owever, it should be noted
that even increases of only 77@ can be consistent with healthy pregnancies. *hese values increase
until about /+.+ days and then decrease to very low levels by about "++"7+ days and never
decrease any further until the pregnancy is over.
Is cramping during pregnancy normal?
;arly in pregnancy, uterine cramping can indicate normal changes of pregnancy initiated by hormonal
changes< later in pregnancy, it can indicate a growing uterus. 3ramping that is different from previous
pregnancies, worsening cramping, or cramping associated with any vaginal bleeding may be a sign
of ectopic pregnancy, threatened abortion, or missed abortion.
:ther physical effects that are normal during pregnancy, and not necessarily signs of disease, include
nausea, vomiting, increase in abdominal girth, changes in bowel habits, increased urinary frequency,
palpitations or more rapid heartbeat, upheaving of the chest &particularly with breathing(, heart
murmurs, swelling of the an%les, and shortness of breath.
Why do pregnant women feel tired?
9atigue in early pregnancy is very normal. Many changes are occurring as the new pregnancy
develops, and women experience this as fatigue and an increased need for sleep. 6ower blood
pressure level, lower blood sugar levels, hormonal changes due to the soporific effects of
progesterone, metabolic changes, and the physiologic anemia of pregnancy all contribute to fatigue.
Aomen should chec% with their health care provider to determine if an additional wor% up, prenatal
vitamin changes, and/or supplemental iron would be beneficial.
Second Trimester
When do the postural changes of pregnancy occur?
Aomen experience a progressive increase in the anterior convex shape of the lumbar spine during
pregnancy. *his change, termed lordosis, helps %eep the center of gravity stable and over the legs as
the uterus enlarges &see below(. 6ate in pregnancy, aching, wea%ness, and numbness of the arms
may occur secondary to compensatory anterior positioning of the nec% and hunching of the shoulders
in positional response to exaggerated lordosis. *hese positional responses put traction on the ulnar
and median nerves, resulting in the previously mentioned symptoms.
6umbar lordosis of pregnancy.
>elaxin in pregnancy is secreted by the corpus luteum, the placenta, and part of the decidual lining of
the uterus. 0t is thought to cause remodeling of the connective tissue of the reproductive tract,
especially inducing biochemical changes of the cervix. Although relaxin levels are more than "+fold
higher than nonpregnant levels, it is not currently thought that this hormone has a direct effect on
actual ligamentous loosening. Boint laxity and shifting center of gravity can contribute to an increase in
gait unsteadiness. *hese changes are most exaggerated in later pregnancy. More than ,+@ of gravid
females complain of bac% pain during pregnancy, which may also be due to sacroiliac Coint
dysfunction or paraspinous muscle spasm.
About -/ per "+++ women will have scoliosis. *his is not accompanied by any functional
osteoporosis, although pregnancy is a very high bone turnover state, approximately equivalent to
double the bone loss rates of a menopausal female, reversibly losing about #@ of bone during the first
#+ wee%s of gestation. 1pinal changes are usually not severe enough to affect the pregnancy or the
lung's functional capacity. Also, the pregnancy rarely affects the degree of lateral curvature in these
cases of scoliosis. 0f a pregnant patient has had correction with prior ?arrington distraction rod
insertion, the pregnancy, labor, and delivery are not typically affected. *he epidural space may be
distorted, and some anesthesiologists may refuse to place epidural anesthetics in these patients.
When do changes in the pelvic contour occur?
*he pelvis continues to grow until about 7 years after menarche, which is why it is more common for
younger women, and women sooner after menarche to have greater ris% for obstructed labor due to
the relative size discrepancy between the fetal head and the maternal pelvis. >elaxin was also
thought to loosen pelvic ligaments when secreted from the ovaries, contributing to enlargement of the
pelvis, but this is not proven in human pregnancies. *he symphysis pubis can enlarge from about 7-
mm in nulliparas to about -., mm &or as much as ) mm( in multiparas, but during gestation itself the
average separation is about .) mm.
When is fetal movement usually felt?
Most women feel the beginnings of fetal movement before #+ wee%s' gestation. 0n a first pregnancy,
this can occur around ") wee%s' gestation, and in following pregnancies it can occur as early as ","/
wee%s' gestation. ;arly fetal movement is felt most commonly when the woman is sitting or lying
quietly and concentrating on her body. 0t is usually described as a tic%le or feathery feeling below the
umbilical area. As the fetus grows in size, these feelings become stronger, regular, and easier to feel.
*he medical term for the point at which a woman feels the baby move is quic%ening. Dabies should
move at least - times an hour as they get larger, and some clinicians advise patients to count fetal
movement to follow the baby's wellbeing.
What kind of breast changes are normal during pregnancy?
Dumps that appear to enlarge around the areola are called Montgomery tubercles, and they normally
appear during mid pregnancy.
Third Trimester
How much does the uterus grow during pregnancy?
*he uterus grows from an organ that weighs .+ g with a cavity space of about " m6 to an organ that
weighs more than "+++ g that can accumulate a fluid area of almost #+ 6. *he shape also evolves
during pregnancy from the original pearli%e shape to a more round form, and it is almost a sphere by
the early third trimester. Dy full term, the uterus becomes ovoid. *he uterus is completely palpable in
the abdomen &not Cust by pelvic examination( at about "#"- wee%s' gestation. After #+ wee%s'
gestation, most women begin to appear pregnant upon visual examination.
1ee below.
5terine fundal size and relative position on abdomen throughout gestation.
Is it normal to secrete milk from the breast prior to delivery?
4alactorrhea &mil% secretion from the nipple( is the product of the combined effects of prolactin,
glucocorticoids, progesterone, and human placental lactogen. 4alactorrhea is not uncommon in the
first trimester, although it usually does not occur until mil% letdown soon after delivery. At that time,
the high levels of progesterone, which bloc% mil% excretion, drop with the delivery of the placenta. 0n
mid pregnancy a woman reaches lactogenesis stage 0 and she is able to secrete colostrum.
;arly galactorrhea does not mean that a woman will produce less mil% after delivery. 1ome women
notice secretions beginning before the fifth month of pregnancy. Many women find they
spontaneously lea% or express some fluid by the ninth month.
*he mil% secretion is %nown as colostrum and is watery and pale. 3olostrum has more protein and
lower fat than mature mil%.
6actogenesis stages 00 and 000 occur postpartum and form more mature mil%.
hysiological !daptations to regnancy
Why do women undergo skin pigmentation changes during pregnancy?
$igmentation changes are directly related to melanocytestimulating hormone &M1?( elevations
during pregnancy. 1ome evidence suggests that elevated estrogen and progesterone levels cause
hyperpigmentation in women. *his is typically evident in the nipples, umbilicus, axillae, perineum, and
linea alba, which dar%ens enough to be considered a linea nigra. More than !+@ of patients have s%in
dar%ening. 9acial dar%ening, called melasma, is a diffuse macular facial hyperpigmentation. Ahen
melasma occurs as a result of pregnancy, it is %nown as chloasma. *his is due to the pigment being
deposited in the epidermis itself. *he distribution is usually malar but can be central or mandibular.
5ltraviolet light exposure intensifies melasma and appropriate sunscreen decreases the effect.
Decause it is related to the hormones of pregnancy, it lessens with delivery.
:ther pigmentation changes, such as palmar erythema, pseudoacanthosis nigricans, vulvar or dermal
melanocytosis, or postinflammatory hyperpigmentation secondary to specific dermatologic conditions
of pregnancy, are fairly common as well.
"o ocular changes occur in pregnancy?
$regnant women report dry eyes, and some transient visual acuity changes have been reported as
well. During pregnancy, the shift seems to be toward more far sightedness, and some corneal
thic%ening can disturb contact wearers.
Why does acne increase during pregnancy?
1tudies show a variable effect of acne in pregnancy. 0f treatment regimens that were wor%ing prior to
pregnancy were abandoned, the patient can have initial flares that are not directly related to the
pregnancy. 1ome studies show that as many as a third of cases actually improve in pregnancy, but
most women will report some worsening. $rogesterone, which has some androgenic components, is
increased during pregnancy, resulting in more secretions from the s%in glands.
$ostpartum, some women will get acne for the first time &called postgestational acne(. Maintaining
hydration should help. Aomen should consult their doctor if a topical medication is needed. Azelaic
acid, topical erythromycin or clindamycin, and oral erythromycin are all safe. Although topical tretinoin
has not been reported to cause ris%, no studies have established it's safety and it should be avoided.
*etracyclines are contraindicated during pregnancy. Appropriate cleansing with mild abrasion aids
has been found to be helpful.
Will changes in headache patterns occur during pregnancy?
9or most women, headaches remain unchanged during pregnancy. 1ome women improve, but some
may worsen. Decause migraines have a hormonal component, many women's migraines improve with
increasing estrogen levels, such as those that occur during pregnancy. 9or women whose conditions
remain unchanged or worsen, treatment options are limited, especially in the first trimester. 1ome
clinicians suggest acetaminophen, narcotics, and antiemetics. Eonpharmacologic treatments include
relaxation strategies, eliminating stressors, and a good exercise program. *hese should first be
attempted before pharmacologic therapy.
F", #G
Is feeling the heart racing a common occurrence during pregnancy?
A significant number of cardiovascular changes occur during pregnancy, which may be accompanied
by dyspnea and a reduced tolerance for endurance exercise. During pregnancy, women expand their
blood volume by approximately 7+,+@. *his is accompanied by an increase in cardiac output. *he
heart rate may also increase by "+#+ beats per minute. *he changes pea% during wee%s #+#- and
usually resolve completely within / wee%s of childbirth.
*he blood pressure in the upper extremities should change very little during pregnancy, but pressure
in the lower extremities increases. *his is accompanied by pedal edema. Decause of extra blood flow,
variances in the auscultated heart sounds may occur, such as murmurs, a wider split between the first
and second heart sounds, or an 17 gallop. 1ome nonspecific 1*segment changes may occur, and
some changes to the cardiac outline may appear on chest radiographs. *he following is a summary of
cardiovascular changesH
1ystolic blood pressure level decreases -/ mm ?g.
Diastolic blood pressure level decreases )", mm ?g.
Mean blood pressure level decreases /"+ mm ?g.
?eart rate increases "#") beats per minute.
1tro%e volume increases "+7+@.
3ardiac output increases 77-,@.
What are common respiratory system changes during pregnancy?
$regnant women experience nasal stuffiness due to estrogeninduced hypersecretion of mucus.
;pistaxis is also common. *he safest treatment of these symptoms is a saline nasal spray. *he
following is a summary of respiratory changesH
>espiratory rate does not change.
*idal volume increases +."+.# 6.
;xpiratory reserve volume &;>I( decreases ",@.
>esidual volume decreases.
Iital capacity does not change.
0nspiratory capacity increases ,@.
9unctional reserve capacity decreases ")@.
Minute volume increases -+@.
Is gallbladder disease more common during pregnancy?
4allbladder disease may be more common during pregnancy. ;strogen is an important ris% factor for
gallstone formation< it increases the concentration of cholesterol in the bile leading to an increased
ris% of forming gallstones.
Is liver disease more common during pregnancy?
$regnant women can experience spider angiomata and palmar erythema. About two thirds of white
women and only "+@ of blac% women experience these symptoms. 0n addition, women may have
reduced serum albumin concentration, elevated serum al%aline phosphate activity, and elevated
cholesterol levels. *hese are common symptoms of liver disease, but they are not evidence of liver
disease if they occur during pregnancy.
What hair changes are common during pregnancy?
?air changes in pregnancy are very common, and body hair changes are common as well. Many
women develop mild hirsutism that may be due to levels of male hormone production by the ovary
and adrenal gland.
0n nonpregnant patients, hair grows in the anagen phase and rests in the telogen phase. About ",
#+@ of all hairs are in the telogen phase at any given time. During pregnancy, however, more scalp
hairs are in the anagen phase, so more growth is documented. During the telogen resting phase, it is
normal for hair to fall out so new hair can regrow. During late pregnancy, fewer hairs are in the
telogen phase< immediately postpartum, more hairs are in the telogen phase. *his often results in a
dramatic loss of hair immediately postpartum< this is termed telogen effluvium. Although this may be
disturbing, it is normal.
Eormal hair loss is probably in the range of /+"++ hairs a day and most patients do not notice a
dramatic loss unless -+@ of all hair is lost. *his process spontaneously resolves in about ", months,
but has been reported to last more than a year. *he frontal and parietal areas are usually most
affected. Eo effective treatment is %nown.
How do sleep patterns change in pregnancy?
Aomen do have functional changes in their sleep, and while a pregnancyrelated sleep disorder is not
a specific diagnosis, it has been proposed as a new categorization by the American 1leep Disorder
Association. Disruptions such as positional discomfort, contractions, leg cramps, gastric reflux, and
more frequent urination may lead to disordered sleep patterns. 3hanges in the amount of total sleep
required is not uncommon. *ypically the amount of sleep needed is increased in the first and second
trimester and actually decreased in the third trimester. *his may have to do with the patterns of sleep.
*he amount of >;M and deeper staged sleep also changes in pregnancy.
#utrition in regnancy
What are the most common dietary complaints during pregnancy?
During early pregnancy, most women experience an increased appetite, with extra caloric needs of
approximately #++ %cal/d. 1tomach motility does decrease, probably due to reduced production of
motilin. >educed peptic ulcer disease is due to reduced gastric acid secretion. $rolonged transit times
through the colon are also reported, with transit from the stomach to the cecum occurring in about ,)
hours instead of ,#.
*he common myths surrounding food desires are individually and culturally determined. Among rural
1outhern American women, the most common food cravings include clay, laundry starch, or pica,
while Dritish women commonly crave coal. Aomen experiencing nausea or hyperemesis may develop
ptyalism &spitting(. >eported fluid losses of "# 6/d can occur in these women.
1ee also $renatal Eutrition.
Should certain foods be avoided during pregnancy?
9ood concerns during pregnancy include raw vegetables, unpasteurized Cuices, liver, and
undercoo%ed meat, poultry, or eggs. De aware of food poisoning. >aw vegetables, unpasteurized
Cuices, and undercoo%ed meat, poultry, or eggs have been lin%ed with Salmonella species
and Escherichia coli &including the dangerous E coli +",.(.
3oo%ing properly %ills bacteria< the proper temperature can be determined by a meat thermometer,
although coo%ing until well done is safe for most meat. 4round beef should be coo%ed to at least
"/+J9, roasts and stea%s to "-,J9, and whole poultry to ")+J9. ;ggs should have a firm yol% and
white after coo%ing. ;ggnog and hollandaise sauce have raw or partially coo%ed eggs and are not
considered safe. 6iver can contain extremely high levels of vitamin A and is probably safe, but it
should be eaten in moderation.
0n #++., the 9DA warned that Salmonella can be found on the outer s%in and shell surfaces of small
pet turtles and cautioned those handling turtles without properly washing their hands after handling
the animals.
Mad cow disease, Dovine spongiform encephalopathy, has become a growing concern. *he disease
can be transmitted to humans who eat infected meat, causing 3reutzfeldtBa%ob disease. *he
chances of contracting this disease in the 5nited 1tates is relatively small, but chances can be
reduced even further by choosing cuts of meat that are li%ely to be free of nervous system tissue such
as boneless stea%s, chops, and roasts. 4rassfed and organic cattle should not have been exposed to
any animal products in their feed and are considered to have no %nown ris%. *he ris% of mad cow
disease cannot be lowered by coo%ing beef more thoroughly because the prions that cause mad cow
disease are not destroyed by heat.
$an women safely eat fish while pregnant?
*he American 3ollege of :bstetricians and 4ynecologists &A3:4( issued a warning regarding eating
fish in response to the 51 9DA's consumer advisory about the dangers of eating fish for nursing
mothers and women who are or who may become pregnant. *he fish themselves are not harmful, but
extensive fish consumption increases exposure to the naturally occurring compound methylmercury,
levels of which have been increasing in the waters because of industrial pollution. Mercury is very
toxic and can cause danger to the fetus and to the newborn nursing infant. Mercury exposure can
actually occur via inhalation and/or s%in absorption, and all fish contain trace amounts. ?owever,
longerlived and larger fish, such as shar%, swordfish, %ing mac%erel, and tilefish, have increased
mercury levels and cause the most concern for consumption by pregnant women.
*he 9DA, as of March of #++-, therefore advises that pregnant or nursing women should not eat
shar%, swordfish, %ing mac%erel, or tilefish. ?owever, these women can safely eat "# ounces per
wee% of varieties of fish thought to be low in mercury if they eat a variety of coo%ed, smaller fish. *he
safest fish that are low in mercury are shrimp, canned light tuna, salmon, $olloc%, and catfish.
1pecifically, the 9DA states that albacore &white( tuna has more mercury than light tuna. 1o, pregnant
women should eat only up to / ounces &one average meal( of albacore tuna per wee%. 0n addition, the
;nvironmental $rotection Agency &;$A( also recommends that pregnant women and young children
limit their consumption of freshwater fish caught by family and friends to no more than one meal per
wee% and to follow all local advisories as to fish safety. *he ;$A specifies no more than ) ounces of
uncoo%ed fish per wee% for adults.
%ther &uestions 'elated to regnancy
What is the recommended weight gain in pregnancy?
Eearly #+ years have passed since guidelines for pregnancy weight gain have been reissued from the
0nstitute of Medicine &0:M(. 0n that time, more research has been completed to better understand the
effects of weight gain during pregnancy on the health of both the mother and the infant. 0mportant
variables to ta%e into consideration regarding recommended weight gain include twin or triplet
pregnancies, the motherKs age, and the motherKs prepregnancy weight.
*hese variables can add to the burden of chronic disease for the mother and baby< excessive weight
gain is associated with an increased ris% for gestational diabetes, pregnancyassociated hypertension,
and delivery of largeforgestationalage infants. Decause of these ris%s, the 0nstitute of Medicine has
developed new guidelines for weight gain during pregnancy.
F7G
4uidelines for weight gain during pregnancyL are as followsH
5nderweight women &DM0 M ").,( should gain #)-+ pounds.
Eormalweight women &DM0, ").,#-.!( should gain #,7, pounds.
:verweight women &DM0, #,#!.!( should gain ",#, pounds.
:bese women &DM0, 7+ or higher( should gain ""#+ pounds.
LAeight gain guidelines are for singleton pregnancy< weight gain should be higher for multiple
pregnancies.
3linicians are urged to supplement these guidelines with individualized counseling about diet and
exercise, and preconception counseling should emphasize the importance of conceiving when the
mother is at a normal body mass index &DM0(.
Dietz et al found that prepregnancy body mass index &DM0( modifies the relationship between
pregnancy weight gain and newborn weight for gestational age. 0n a populationbased cohort study of
"+-,!)+ singleton, term births from #+++#++,, women who gained 7/ lb or more during pregnancy
were more li%ely to bear an infant who was large for gestational age &birthweight N!+
th
percentile( if the
mother was lean before pregnancy than if she was overweight or obese. 3ompared with women who
gained ",#, lb, the adCusted odds ratio &a:>( for a gain of #/7, lb was "., &!,@ confidence interval
F30G, ".#".!(< for a gain of 7/-, lb, the a:> was #." &!,@ 30, "..#..(< and for a gain of -/ lb or
more, the a:> was 7.! &!,@ 30, 7.+,.+(. *he ris% of macrosomia &birthweight -,++ g or more( was
not modified by prepregnancy DM0.
F-G
"o older fathers have an increased risk of fathering children with birth defects?
Eo medical information exists to support the hypothesis that increased paternal age causes increased
numerical chromosomal abnormalities as increased maternal age does. As males age, however,
structural spermatozoa abnormalities are increased and these sperm usually cannot fertilize an egg.
*he literature suggests that older fathers have a #+@ higher ris% of transmitting autosomal dominant
diseases as a result of abnormal cell division.
F,G
Autosomal dominant disorders
include neurofibromatosis, Marfan syndrome, achondroplasia, and polycystic %idney disease. *he
American 1ociety of >eproductive Medicine recommends an age limit of ,+ years for semen donors.
Any family with a history of birth defects should see% individual genetic counseling. *o determine
whether an individual has a family history of ris%, patients should inform their clinician or genetic
counselor about any birth defects that have occurred in the past 7 generations.
Should women wear seatbelts during pregnancy?
1eatbelts should absolutely be worn during pregnancy.
F/G
*rauma to the mother is more devastating to
the child than any potential entrapment of the pregnant abdomen in the seatbelt. *he seatbelt should
be placed low, across the hip bones and under the pregnant abdomen. *he shoulder strap should be
placed to the side of the abdomen, between the breasts, and over the midportion of the clavicle. Eo
information indicates that air bags are unsafe during pregnancy. $regnant women should try to %eep
their abdomen "+ inches from the airbag.
F.G
1ee the image below.
3orrect use of seat belts in pregnancy.
Should travel be restricted during pregnancy?
Most of the newest guidelines revolve around the patientKs individual ris%s and the li%elihood of acute
problems during the travel segment.
F)G
*he second trimester is considered the safest time to travel.
$rolonged sitting in pregnancy is more restrictive because the gravid uterus contributes to ris% of
thrombosis and can cause lower extremity venous stasis and ambulation, particularly at #hour
intervals. Air travel can additionally increase travel ris% because of low oxygen tension, low humidity,
and recirculated air, which contribute to dehydration.
Deing pregnant has been estimated to increase the ris% of thrombosis about "+ times, to a rate of
about "+H"++,+++< air travel further increases this rate between #- times. Most planes are
pressurized to around )+++ feet, so altitude is not an issue.
Aith respect to radiation exposure, the A3:4 has estimated that overall radiation levels of ,+ m1v
are safe. Daily radiation is about #.# m1v per year cumulative dose and travel is about +.+, m1v.
Maternal adaptions to altitude itself vary but could include elevated blood pressure, increased
maternal heart rate, and lower oxygen saturation. A fetus can physiologically adapt to these
conditions and is typically protected during these flights.
Drin%ing water and avoiding alcohol and caffeine is important to avoid dehydration. Additional ris%s
may be due to communicable diseases, but those typically depend on to the destination. *ravelers
diarrhea is common< pregnant women have an increased ris% because of slower gastric and intestinal
transit times. $regnant women should be informed of travel ris%s and told to wear compression
stoc%ings.
$an pregnant women go to the dentist?
Dental care during pregnancy is an important part of overall healthcare.
F!G
During pregnancy, the gums
naturally become more edematous and may bleed after brushing. ;pulis gravidarum, a type of
gingivitis with violaceous pedunculated lesions, can occur. 0f treatment of cavities, surgery, or infection
care is required, be sure the dentist is aware of the pregnancy. Most antibiotics and local anesthetics
are safe to use during pregnancy. >adiographs can be obtained with abdominal shielding but are best
avoided during pregnancy because a small, but statistically significant, increase in childhood
malignancies exists in children exposed to inutero radiographic irradiation.
1ee also $sychosocial and ;nvironmental $regnancy >is%s.
Why is heartburn more common during pregnancy?
1tomach emptying was thought to be retarded during pregnancy, but hormonal influences of
increased progesterone and/or decreased levels of motilin may be more responsible for pyrosis
&heartburn( than the actual mechanical obstruction in the third trimester. 1ome studies have also
shown decreased lower esophageal sphincter tone, which can lead to an excess of gastric acid in the
esophagus.
Why is back pain prevalent during pregnancy and can it be treated?
?alf of women report having bac% pain at some point during pregnancy. *he pain can be lumbar or
sacroiliac. *he pain may also be present only at night. Dac% pain is thought to be due to multiple
factors, which include shifting of the center of gravity caused by the enlarging uterus, increased Coint
laxity due to an increase in relaxin, stretching of the ligaments &which are painsensitive structures(,
and pregnancyrelated circulatory changes.
*reatment is heat and ice, acetaminophen, massage, proper posturing, good support shoes, and a
good exercise program for strength and conditioning. $regnant women may also relieve bac% pain by
placing one foot on a stool when standing for long periods of time and placing a pillow between the
legs when lying down.
0n a randomized, placebocontrolled trial, 6acciardone et al studied the effect of osteopathic
manipulative treatment of bac% pain during pregnancy. Eo statistically significant differences were
achieved between treatment and control groups< however, bac% pain decreased in the usual obstetric
care and osteopathic manipulative treatment group, remained unchanged in the usual obstetric care
and sham ultrasound treatment group, and increased in the usual obstetric care only group.
F"+G
Is se(ual intercourse safe during pregnancy?
>esearch indicates that sexual intercourse is safe in the absence of ruptured membranes, bleeding,
or placenta previa, but pregnant women engage in sex less often as their pregnancy progresses. Eo
studies have suggested that any particular position is unsafe, although a "!!7 study demonstrated a
#fold increased incidence of preterm membrane rupture with the malesuperior position compared to
other positions.
F""G
A3:4 states that sexual activity during pregnancy is safe for most women right up
until labor, unless there is a specific contraindication.
A3:4 specifically cautions that a women should limit or avoid sex if she has had preterm labor or
birth, more than one miscarriage, placenta previa, infection, bleeding, and/or brea%ing of the amniotic
sac or lea%ing amniotic fluid. A3:4 discusses that, as part of natural sexuality, couples may need to
try different positions as the woman's stomach grows. Iaginal penetration by the male is not as deep
with the male facing the woman's bac%, and this may be more comfortable for the pregnant woman.
Why do women get varicose veins during pregnancy?
Iaricose veins are more common as women age< weight gain, the pressure on maCor venous return
from the legs, and familial predisposition increase the ris% of developing varicose veins during
pregnancy. *hese can occur in the vulvar area and be fairly painful. >est, leg elevation,
acetaminophen, topical heat, and support stoc%ings are typically all that is necessary. Determining
that the varicosities are not complicated by superficial thrombophlebitis is important. ?aving a venous
thromboembolism in association with superficial thrombophlebitis is rare. ?emorrhoids, essentially
varicosities of the anorectal veins, may first appear during pregnancy for the same reasons and are
aggravated by constipation during pregnancy.
Why are urinary tract infections more common during pregnancy?
$regnancy predisposes women with bacteruria, which in the nonpregnant state is usually selflimiting.
Eormal pregnancyrelated physiologic changes contribute to 5*0s and include dilatation of the upper
collecting systems, increased urinary tract dead space, increased vesicoureteral reflux, hypotonic
renal pelvises, decrease in the natural antibacterial activity in the urine, and a decrease in the
phagocytic activity of leu%ocytes at the mucosal surfaces. 5*0s in pregnant women usually do not
present with typical symptoms and may be asymptomatic. $yelonephritis is a serious complication of
5*0s.
How can stretch marks be prevented?
5nfortunately, striae &stretch mar%s( cannot be prevented. *he degree to which a woman experiences
stretch mar%s is determined genetically. 1tretch mar%s usually occur when weight is lost or gained
quic%ly. 5sing creams and gels rarely ma%e a difference. 9ortunately, stria fades with time and mar%s
become silvery white, but they do not tan. 1tria managed early can be reduced and with new medical
laser technology.
Work and )(ercise "uring regnancy
What kind of e(ercise can women engage in during pregnancy?
Maintaining an active lifestyle during pregnancy adds to a woman's overall health and may reduce
complications. 1ome research shows that women who exercise have shorter easier labors, better
newborn health, and higher newborn 0Os. ?owever, these same women are %nown to be more li%ely
to have had routine prenatal care, overall better health prior to conception, and compliance with
prenatal vitamin instructions &see below(. *herefore, designing studies to discern specifically if
exercise alone provides an increased benefit to these basically healthy mothers is difficult. ?ence,
specific benefit has yet to be demonstrated.
6umbar lordosis of pregnancy.
0n studies that have loo%ed at exercise during pregnancy, pulse rates did not exceed "-+ beats per
minute during exercise. *hese studies, therefore, do not advise women to perform extreme levels of
exercise, such as competitive running, during pregnancy. 1ome consider swimming to be the ideal
exercise for pregnant women because exercise is not affected by Coint changes, balance alterations,
or weight gain.
0f a woman is already participating in an exercise program, she may continue with minor alterations.
Aomen should as% their healthcare providers for specific restrictions, especially if they experience
bleeding, are at ris% for premature labor, or have other highris% concerns. $regnancy is not an
appropriate time to begin aerobics classes, weightlifting, or a new sport. Aal%ing is good for the heart
and may be performed by most women. $regnant women should avoid contact sports and activities
that could result in inCury. $regnancy can ma%e recovery from inCury prolonged or more complicated.
Should women restrict work during pregnancy?
Maintaining an active and productive lifestyle helps ma%e time pass faster and adds to a feeling of
accomplishment. Aor%ing during pregnancy is usually not a problem unless a woman has ris% factors
or a complicated pregnancy. Aomen should chec% with their healthcare providers for specific
restrictions. Aith an uncomplicated pregnancy, wor%ing close to or near the due date should not be a
problem. $regnant women should wear comfortable clothing, move around frequently if sedentary,
drin% plenty of fluids, and have time to rest and ta%e brea%s. Aomen with strenuous Cobs, those who
wor% with heavy machinery, or those who wor% with toxic chemicals should consult their healthcare
providers and their Cob's occupational department for restrictions or concerns.
*abor and "elivery
Which form of psychoprophyla(is is the best and what are their differences?
Appropriate childbirth preparation varies with each birthing woman. Aomen are recommended to
learn a variety of coping techniques because one philosophy may not be what is needed during the
wor% of labor. 1ome of the most popular methods include 6amaze, Dradley, ?ypnoDirthing, and
Dirthing from Aithin.
6amazeH 4enerally regarded as breathing focused. 0nvolves focal points, relaxation, and partner
coaching. *oday the 6amaze 0nternational organization focuses on education to empower women to
ma%e informed choices in their healthcare. *hey support birth as a normal, natural experience that is
guided by a woman's innate wisdom and ability to birth.
DradleyH 6argely focused on =husbandcoached childbirth.= Dradley teaches coaching and coping
techniques aimed at supporting unmedicated childbirth. *he Dradley method supports deep
abdominal breathing, body awareness, and relaxation techniques.
?ypnoDirthingH ?ypnoDirthing teaches that labor does not have to involve severe pain. *hrough
techniques of relaxation and environment modification, ?ypnoDirthing aims at eliminating fear and
tension during labor. *he fear of pain is believed to be what causes the pain itself.
Dirthing from AithinH Birthing from Within is a boo% and approach to childbirth education that sees
birth as a rite of passage. *he lessons, artwor% exercises, and reflections are aimed at celebrating the
spiritual, psychological, and emotional growth that comes with birth and motherhood. 0t provides a
variety of coping techniques for labor aimed at reducing fear and anxieties surrounding childbirth.
What is the !$%+,s position on home births?
*he A3:4 ac%nowledges that both labor and delivery, =while a physiologic process, clearly presents
potential hazards to both mother and fetus before and after birth.= *he A3:4's statement continues
to specifically state that =these hazards require standards of safety that are provided in the hospital
setting and cannot be matched in the home situation.= *he A3:4 supports those actions that improve
the experience of the family while continuing to provide the mother and her infant with accepted
standards of safety available only in hospitals. *hese safety standards are outlined by the American
Academy of $ediatrics and A3:4. Aomen considering home births should investigate the standards
of the midwifery or birthing organization to which the birth attendant belongs.
*he American 3ollege of Eurse Midwifery is more flexible, supporting home births within certain
defined parameters. *hey refer to this as a =planned home birth.= *hey support the provision of
protocols by hospitals, physicians, and insurers which define strict parameters for the care of patients
at home.
What are the benefits of water birth?
A3:4's 3ommittee on :bstetric $ractice addressed the issue of warmwater immersion for laboring
women and for delivery of infants. *he 3ommittee felt that there are =insufficient data, especially
concerning rates of infection, to render an opinion on whether warmwater immersion is a safe and
appropriate birthing alternative.= *he 3ommittee also felt that =this procedure should be performed
only if the facility can be compliant with :1?A F:ccupational 1afety and ?ealth ActG standards
regarding infection.= *his would include the specific tub and water recirculation systems used. Also,
warm water exposure over time can cause hypotension, and careful attendance by an assistant is
necessary to prevent drowning. *he American 3ollege of EurseMidwives has no current position on
either hydrotherapy or water births.
What is the !$%+,s position on -role of allied personnel-?
3ontinuous support during labor from caregivers, including nurses, midwives, or lay individuals, has a
number of benefits for women and their newborns, with no apparent harmful effects. *he continuous
presence of a support person may reduce the li%elihood of the use of medication for pain relief,
operative delivery, and patient dissatisfaction.
F"#G
ostpartum
When will the uterus return to normal size?
*he uterus returns to prepregnancy size after approximately / wee%s. *his is accomplished through a
process called involution. During this process, the uterus has contractions that women may be able to
feel, especially with breastfeeding.
When can women resume se(ual intercourse after pregnancy?
Aomen usually can resume their sex lives when they feel ready, typically this is -/ wee%s after
delivery and when bleeding has substantially decreased. Medically, this will be when the cervix has
closed, which should occur at - wee%s' postpartum, and uterine bleeding is minimal. Dreastfeeding
may cause increased vaginal dryness due to slightly decreased estrogen levels. Aomen who have
had an episiotomy need at least #7 wee%s to heal before intercourse. A3:4 has pointed out in a
recent bulletin that some women may find that they do not have much interest in sex after giving birth
because of fatigue, stress, fear of pain, lac% of opportunity, and/or lac% of desire. *his is usually
temporary.
regnancy Information Sources
A wealth of pregnancy information is available in boo%s, boo%lets, and on the 0nternet. *he American
3ollege of :bstetricians and 4ynecologists textPlanning Your Pregnancy and Birth and the popular
press boo% What to Expect When You're Expecting are probably the # most popular and complete
guides for pregnant women.
Importance of !ntenatal Fetal Weight )stimation
Doth low birth weight and excessive fetal weight at delivery are associated with an increased ris% of
newborn complications during labor and the puerperium.
F", #, 7, -, ,, /, ., ), !, "+, "", "#, "7, "-, ",, "/, ".G
*he perinatal complications associated with low birth weight are most often attributable to fetal
prematurity, but may sometimes also arise as the result of intrauterine growth restriction.
F#, 7, "), ,G
9or
macrosomic fetuses &see the image below(, potential complications associated with delivery include
shoulder dystocia, brachial plexus inCuries, bony inCuries, and intrapartum asphyxia, as well as
maternal ris%s that include birth canal inCuries, pelvic floor inCuries damage, and postpartum
hemorrhage &see *able "(.
F", /, ., ), !, "+, "", "#, "7, "-, ",, "/, ".G
*he occurrence of cephalopelvic disproportion is more prevalent with increasing fetal size and
contributes to an increased rate of both operative vaginal delivery and cesarean delivery for
macrosomic fetuses compared with fetuses of normal weight.
F", "", "#, "7, "-, ",, "/, "., "!G
0n a study comparing the prevalence of perinatal complications for fetuses weighing N-,+++ g at birth
&n P 7/,-/#( to those who weighed #,,++-,+++ g &n P #!7,)##( in the northwest *hames region of
;ngland &"!))"!!)(, there was a statistically significantly increased rate for macrosomic newborns of
prolonged labor &:> P ".,. for the first stage N"+ hours and :> P #.+7 for the second stage N#
hours(, perineal trauma &:> P ".-- for a second degree laceration and :> P #..7 for a third degree
laceration(, instrumented vaginal delivery &:> P "../(, emergency 3esarean section &:> P ".)-(,
postpartum hemorrhage &:> P #.+"(, Apgar score M - &:> P ".7,(, and neonatal special care nursery
admission &:> P ".,"(.
F"G
0n another recent study that examined the relationship between increasing birth weight and perinatal
mortality among ,,+-!,"+- liveborns in the 5nited 1tates between "!!,#+++, a nadir was observed
at approximately 7,!++ g and a sharp rise occurred for newborns with higher weights &see the image
below(.
F#+G
*hus, depending on many factors, the optimal birthweight range to minimize the ris% of fetal
and maternal morbidity and mortality is between 7+++-+++ g.
F7, "), ,, #+G
*able ". Eewborn and Maternal 3omplications Associated Aith a Dirth Aeight N-+++ g
F"#, "7, ., #", ##, ), !, #7, "+,
/, "-, ",, ""G


&:pen *able in a new window(
Complication Relative Risk Attributable Risk, %
Shoulder dystocia 2-38 2-18
Brachial plexus palsy 16-216 0.2-8
Bony injuries/fracture 1.4-! 0.2-6
"rolon#ed la$or 2.2-3.2 2-!
Birth asphyxia/lo% &p#ar scores 1.!-'.6 0.6-6
(orceps/)acuu* extraction 1.'-3.6 8-14
Birth canal/perineal lacerations 1.6-'.1 3-!
"ostpartu* he*orrha#e 1.6-'.2 2-'
+ephalopel)ic disproportion 1.-2.2 4-'
+esarean deli)ery 1.2-2. 4-14
,ote--ata co*piled fro* 13 studies of the relati)e and attri$uta$le ris. of co*plications associated %ith the $irth
of *acroso*ic fetuses. /eported ran#es reflect the differences a*on# studies in the patient populations and
differences in the criteria used for the dia#nosis of each co*plication. /elati)e and attri$uta$le ris.s are for
fetuses %ei#hin# 4000 # or *ore at deli)ery co*pared %ith control su$jects %ei#hin# 0 4000 #. P )alues
associated %ith each relati)e ris. are 0 .001 in all cases1 except for $irth canal/perineal lacerations1 for %hich P is
0 .0'.
0n a study that examined shoulder dystociarelated permanent fetal inCury as a function of birth weight,
the absolute ris% of fetal damage increased suddenly and dramatically at a threshold of -,+++ g from "
in ",7/) deliveries to " in #., deliveries &,fold increase in ris%( &see *able #(
F#-G
*able #. AdCusted >is% of 1houlder Dystociarelated $ermanent 9etal 0nCury as a 9unction of
0ncreasing Dirth Aeight &:pen *able in a new window(
Birth
Weight (g)
% of Total Births
in the U (in !""#)
% of Cases $ith
%ermanent &etal
'n(uries
Absolute Risk of
&etal )amage
"*% Confi+ence 'nterval for
&etal )amage(Upper Boun+)
0 3000 24 2 12 121000 12 61000
3000-324 1! 2 12 81'00 12 411'0
32'0-34 20 4.' 12 41444 12 21!40
3'00-3!4 16 12 12 11333 12 4
3!'0-3 13 .' 12 11368 12 !!
4000-424 '.' 20 12 2!' 12 222
42'0-44 3 14 12 214 12 16'
4'00-4!4 0.8 14 12 '! 12 43
4!'0-4 0.3 8 12 3! 12 2'
'000-'24 0.2 8 12 2' 12 18
3'2'0 0.2 6 12 33 12 23
Source-&dapted fro* 4ffy1 2008
5246
6imiting the potential complications associated with the birth of both small and excessively large
fetuses requires an accurate estimation of fetal weight before delivery. *his article reviews the factors
that influence fetal growth and the methods that can be used to accurately estimate fetal weight.
Standard Fetal +rowth $urves
Mean birth weight can be described as a function of gestational age.
F#, 7, "), ,, #,, #/, #., #), #!, -, 7+, 7", 7#, 77, 7-, 7,, 7/, 7., 7),
7!G
1everal reports subdivide such results into those that apply to women of different races,
F#,, #/, #., #), #!,
-G
to male versus female fetuses,
F#,, #/, #., #), #!, -, 7+, 7#, 7-, 7., -+G
and to primiparous versus multiparous status.
F#/, #.,
-+G
1ome have further stratified the data, creating specific curves and tables for women of different
heights and weights.
1tandard fetal growth curves are useful for estimating the range of expected fetal weight for
populations of women at any particular gestational age. ?owever, these curves are applicable only to
populations of gravidas and not to individuals. Although population estimates of fetal weight as a
function of gestational age can be made for groups of individuals that are demographically similar to
the reference population from which the original data was obtained &eg, the median weight as a
function of gestational age, as well as the standard deviation and !,@ confidence interval for each
gestational agedependent point estimate(, this information cannot be applied successfully to any
particular gravida. 0n addition, all such tables presuppose that the gestational age of the fetus is
adequately established< without proper gestational dating, fetal growth curves cannot be appropriately
applied even to groups of gravidas.
*he principal limitations of standard fetalgrowth curves that are derived from populationbased
studies are the followingH
". *hey apply only to fetuses of normal size for their gestational age and not to those with
clinically significant &and potentially pathologic( growth abnormalities.
#. *he data from which they are derived are highly population dependent.
3. *he standard deviation &1D( associated with the estimated mean birth weight for any
particular gestational age is wide, typically exceeding -,+,++ g.
F#,, #!, -, 7", 7#G
4. *he !,@ confidence interval &30( for fetalweight estimates are N"/++ g at term &ie, Q)++ g
FQ" lb "# ozG, or Q#7@(.
F#), 7+, 7", 7.G
,. *he gestational age of the fetus must be %nown with a high degree of accuracy to reliably use
the growth curves.
0n general, standard fetalgrowth curves can be expected to apply to large populations of pregnant
women who have welldated pregnancies, but the limits of their predictive accuracy ma%e them less
thanideal tools for estimating fetal weight in individual patients. 0n addition, fetalgrowth curves are
the most inaccurate at the extremes of fetal weight, which are the most clinically relevant situations in
which they are used &eg, in fetuses that are either growth restricted or macrosomic(. *he accurate
estimation of fetal weight is most necessary for fetuses with suspected significant deviations of
intrauterine growth. 5nfortunately, standard fetal growth curves are of little value in assessing maCor
deviations in fetal weight for these women in advance of delivery.
A study by Mi%olaCczy% et al created a generic reference for fetal weight and birthweight percentiles.
*he study used the fetal weight reference developed by ?adloc% and colleagues and the notion of
proportionality proposed by 4ardosi and colleagues. 0t also made the weight reference easily
adCustable according to the mean birthweight at -+ wee%sK gestation for any local population. *he
generic reference created showed better ability to predict adverse perinatal outcomes than
noncustomized fetal weight references.
F-"G
What is the #ormal 'ange for Human .irth Weight?
"eviations in fetal weight
*he diagnosis of clinically significant deviations in fetal weight is based on the presupposition that the
reference range for fetal weight at each gestational age is established. Defore a reference range for a
human birth weight can be properly determined, the gestational age of the pregnancy must first be
defined because fetal weight increases rapidly after the second trimester of pregnancy.
F#.G
/ariations in fetal weight
*he normal gestational age for the spontaneous delivery of human pregnancies is well accepted as
#)+ days &-+ w%( from the first day of the last normal menstrual period &#// d after ovulation(.
F-#G
Decause fewer than 7@ of births occur at precisely -+ wee%s' gestation and because the 1D for
term pregnancies is " wee%, the normal range of term birth weight is typically referenced to the mean
birth weight for pregnancies delivered at 7)-# wee%s' gestation &ie, mean term gestational age Q #
1Ds(.
During this -wee% interval, the typical fetus gains approximately "#.. Q ".- g/day, with a difference of
Q +.7 g/day depending on the sex of the fetus &male fetuses gain weight more rapidly than female
fetuses.(
F-7G
*he average birth weight during this period varies substantially and depends on many
factors, including maternal race, size, parity, pregnancy weight gain, glucose tolerance, hematocrit,
and ambient elevation.
F#,, #/, #., #), #!, -, --, -,, -/, -., -), -!, ,+, ,", ,#, ,7, ,-, ,,, ,/, ,.G
0n the 5nited 1tates, a study of ,/,.#) singleton births from "!.,"!!# showed that the mean birth
weight at 7)-# completed wee%s' gestation was 7+/+7,#+ g &range, -/+ g F" lbG(.
F#!G
0n 4reat Dritain,
a similar study of -",.") newborns showed that the average was 7#+"7.,7 g &range, ,," g F" lb 7
ozG(.
F-G
0n 1ingapore, a study of "",+#/ neonates showed that the average was #))+7#!+ g &range,
-"+ g F"- ozG(.
F7,G
Decause birthweight data from population studies are often nonnormally distributed, the median birth
weight at each gestational age is reported. 0n 3anada, for live births recorded in "!)/"!)), the
median term birth weight at 7)-# wee%s' gestation for ,,.,7,! male singleton births was 7#!+7)++
g &range, ,"+ g F" lb # ozG(.
F7+G
0n the 5nited 1tates, for 7),)") term male births in "!)-"!!", the
median birth weight was 7+#+7,.# g &range, ,,# g F" lb 7 ozG(.
F#,G
0n 1weden, for 7#,+). term male
births in "!,/"!,., the median birth weight was 77++7.!+ g &range, -!+ g F" lb " ozG(.
F7.G
.irth weights of women from different racial groups
Median term birth weights of neonates born to women from different racial groups differ substantially.
Median birth weights were compared in ".,7-. newborns of 3aucasian and African American women
of low socioeconomic status in the 5nited 1tates from "!,!"!//. At -+ wee%s' gestation, liveborn
3aucasian male singleton fetuses had a median weight of 77,+ g compared with 7#"+ g for African
American male neonates &difference of "-+ g(. A similar difference in median birth weight was also
evident among female offspring. 3aucasian female newborns at -+ wee%s' gestation had a median
birth weight of 7#"+ g, and African American female neonates had a median birth weight of 7"++ g
&difference of ""+ g(.
F#)G
.est method to determine the reference range for term birth weight
$erhaps the best method for defining the reference range of term birth weight is to examine fetal
weights at the # extremes of the range &ie, below the ,
th
"+
th
percentile and above the !+
th

!,
th
percentile(. 0n the 5nited 1tates, a comprehensive study of 7,"7-,).! live births in "!!" showed
that, at 7)-# wee%s' gestation, the ,
th
percentile of birth weight was #,-7#./- g, the "+
th
percentile
was #."-#!7, g, the !+
th
percentile was 7)/.-+!) g, and the !,
th
percentile was -+#.-#"7 g.
F77G
1everal studies from the last half of the #+
th
century demonstrated consistent results, showing that the
"+
th
percentile of birth weight over the range of gestational ages listed above was #-7+7",# g,
whereas the !+
th
percentile was 7/++-7/+ g.
F#,, #., #!, -, 7"G
*he most consistent feature of all these studies
was the wide range of birth weights in the ,
th
!,
th
percentile. *his range is equivalent to defining the
empirical !+@ 30 for normal birth weight and, in the case of the most recent largescale American
study from "!!", this range is N"-++ g &7 lb " oz(.
F77G
Dy using an )+@ 30 as an alternate measure, this
range narrows to approximately ""++ g &# lb . oz(. *hese findings suggest that the reference range of
birth weight at term might be defined as 7-,+ Q .++ g &#.,+-",+ g, or / lb " oz to ! lb # oz(.
*able 7 shows specific birth weights associated with the different percentile ran%s from "" large
studies.
*able 7. *erm DirthAeight $ercentiles for 1ingleton 6ive Dirths at -+ Aee%s' 4estation &:pen *able
in a new window(
Author ,ocation -o. of -e$borns *
th
%ercentile !/
th
%ercentile */
th
%ercentile "/
th
%ercentile "*
th
%ercentile 0aternal Race
&lexander et al1 16 7nited States 3113418! 2!61 22 34' 4060 418' ,&
&*ini et al1 14 8hio '61!28 ,& 2!8' 3320 310 ,& '39 :hite1 449 Blac.1 39 8ther
:ilcox et al1 13; <reat Britain 411!18 ,& 3000 3'20 4100 ,& 39 :hite1 39 Blac.1 49 8ther
8tt et al1 13; St =ouis1 >o '!'! ,& 288 3638 4216 ,& ,&
-o*$ro%s.i et al1 12 -etroit1 >ich 3310!3 ,& 2820 334' 33' ,& 19 :hite1 819 Blac.
-a)id et al1 183 ,orth +arolina 101830 ,& 2830 3380 360 ,& !69 :hite1 239 Blac.1 19 8ther
Brenner et al1 1!6 8hio 301!!2 ,& 2!'0 3280 38!0 ,& '39 :hite1 469 Blac.1 19 8ther
+hen# et al1 1!2 Sin#apore 261000 ,& 2660 3180 3!10 ,& 1009 +hinese
Ba$son et al1 1!0 "ortland1 8r 318' 2!20 2880 3448 404' 4246 '9 :hite1 '9 8ther
<ruen%ald et al1 166 Balti*ore1 >d 13132! 2'80 2!20 3260 38'0 4060 ,&
=u$chenco et al1 163 -en)er1 +o '63' ,& 2630 3230 381' ,& 1009 :hite
,ote - ?he ran#e of $irth %ei#hts in the '
th
-'
th
percentiles at 40 %ee.s@ #estation %as consistent and $et%een 1421 # A3 l$ 2 oBC and 1'26 # A3 l$ 6 oBC.
,& D not applica$le
;7ltrasono#raphically dated
$erhaps the best method for establishing the reference range of term birth weight is to define the
point at which newborns begin to substantially vary from the mean with respect to their prevalence of
perinatal complications and perinatal death. ;ven within neonatal groupings that are well matched for
gestational age, poor perinatal outcomes occur most frequently in fetuses who are born with weights
at the extreme ends of the range &ie, M "+
th
percentile and N!+
th
percentile for each gestational age(.
F#, 7,
")G
Dy using this approach to establish a criterion, the reference range of term birth weight can be
defined somewhat narrowly as about 7#,+-#,+, or 7.,+ Q ,++ g &. lb 7 oz to ! lb / oz(.
F7, "), ,G
Data from a Dritish cohort study of 7,!! neonates born in "!-/ suggested that increasing term birth
weight is positively correlated with cognitive ability in later life.
F,)G
*his result persisted even after
neonates of low birth weight &M #,++ g( were excluded from analysis, so that all of the remaining
neonates weighed #,++,+++ g.
"efinitions of "eviations in Fetal +rowth
$ategories of fetal weight
9etal weight may be characterized as falling into " of 7 categoriesH &"( reference range &generally
defined as the "+
th
!+
th
percentile for gestational age(, &#( small for gestational age &M "+
th
percentile(,
or &7( large for gestational age &N!+
th
percentile(.
5ntil a fetus is delivered, only methods that help in evaluating fetal size in utero are of any value in
assigning the fetus to these categories. Depending on the patient population that was evaluated to
establish the percentiles, the standards may be misleading if they are applied to other sets of
pregnant women. 9or instance, if standard birthweight curves for 3aucasian women are
inappropriately applied to African American women, the proportion of newborns who appear to have
birth weights below the "+
th
percentile is higher for African American neonates than for an
appropriately matched group of 3aucasian neonates.
$omplications
Iarious authors in different eras have used the term low birth weight to refer to different ranges of
fetal weight. Although excessive neonatal morbidity and mortality was once associated with newborns
weighing #+++#,++ g,
F,G
advances in neonatal care during the last quarter century have improved
adverse neonatal outcomes attributable to low birth weight.
:ne modern classification scheme for underweight newborns is based on fetal weight alone. Dy using
this schema, newborns can be categorized by weight to assess their ris% for neonatal complications,
as followsH &"( low birth weight &",+"#,++ g(, &#( very low birth weight &"++"",++ g(, or &7( extremely
low birth weight &,++"+++ g(.
1ubclassifications in these weight groups are possible according to the incidence of neonatal
morbidity and mortality in each group and the gestational age of the newborns &especially those with
very low or extremely low birth weight(.
F7G
1uccessfully and accurately classifying fetuses in each of
these three broad categories before delivery can help in predicting and possibly avoiding neonatal
complications in underweight newborns.
Fetal macrosomia
*he term fetal macrosomia denotes a fetus that is too large &see the image below(.
0n ideal usage, this designation should be referenced to the mean fetal and maternal dimensions in a
given population< however, it has been arbitrarily and variously defined as a birth weight N-+++ g &) lb
"7 oz(, N-"++ g &! lb(, N-,++ g, or N-,7/ g &"+ lb( for all pregnant women, depending on the author
and era.
F!, "", "#, "7, "-, ",, "/, ".G
Ahen fetal macrosomia is considered a birth weight of N-+++ g, it affects #
",@ of all pregnant women, depending on the racial, ethnic, and socioeconomic composition of the
population under study.
F!, "", "#, "7, "-G
What we would like to know before delivery
*wo issues concerning the size of a fetus before delivery are of interest to cliniciansH the absolute size
and relative size of the fetus.
*he first issue is absolute fetal size &ie, actual fetal dimensions and/or fetal weight(. *his information is
important in estimating the ris% of perinatal morbidity and mortality, but it is difficult to assess
accurately before delivery.
*he second is the relative size of the fetus &relative fetal dimensions and/or fetal weight( compared
with data from some reference group. *his is important for determining whether there is either
intrauterine growth restriction or fetal macrosomia relative to a standard that has previously been
established for a particular group of women &both of which are also predictors of perinatal morbidity
and mortality(. *hese determinations are difficult to establish accurately before delivery because they
depend not only on the accurate estimation of absolute fetal size and/or weight, but also on the choice
of an appropriate reference group for comparison. *hus, the accurate determination of relative fetal
size and/or weight is a particularly challenging but necessary prerequisite for allowing the absolute
fetal size and/or weight to be interpreted within the context of a clinically meaningful framewor%.
Factors $ontributing to "ifferences in Fetal Weight
Many factors, both endogenous and extrinsic, can influence fetal weight. *hese encompass maternal
factors &eg, race, stature, genetics(,
F#,, #/, #., #), #!, -, 7,, 7/, -+, --, ,!, -/, /+G
paternal factors &eg, paternal height(,
F/", /#, /7,
/-, /,, //, /., /), /!G
environmental influences &eg, altitude, availability of adequate nutrition, degree of physical
activity(,
F--, -,, -., -), -!, ,+, ,", ,#, .+, ."G
physiologic factors &eg, altered glucose metabolism, hemoglobin
concentration, microvascular integrity(,
F.#, .7, .-, .,, ./G
pathologic factors &eg, hypertension, uterine
malformations(,
F.., .), .!G
and complications of pregnancy &eg, gestational diabetes mellitus,
preeclampsia(.
F"", .!, )+, )", ./, )#, )7G
0n a systematic review of 7/ studies, 1hah found that, in addition to paternal height, characteristics
associated with low birth weight include extreme paternal age and paternal lower birth weight.
$ossible associations with low birth weight were paternal occupational exposure and low levels of
education.
F)-G
+estational age at delivery
4estational age at delivery is the most significant determinant of newborn weight.
F,!, ,.G
$reterm delivery
is the leading cause of low birth weight newborns in the 5nited 1tates. :ther potential causes for low
birth weight can collectively be attributed to 054> &previously termed intrauterine growth retardation(.
3auses of 054> include intrauterine infections, congenital syndromes, genetic abnormalities, and
chronic uteroplacental insufficiency.
F),G
0n the case of postdate gestations, the rate of fetal macrosomia is ".#!@, as compared with #",@
for the general population delivering term pregnancies. *he rate of fetal macrosomia increases
steadily with advancing gestational age beyond 7. wee%s of pregnancy &see *able -(. 3onsistent with
this observation, !!@ of fetuses that weigh N-+++ g are delivered at N7. wee%s' gestation.
*able -. >ates of 9etal Macrosomia &N-+++ g( as a 9unction of 4estational Age &:pen *able in a new
window(
Complete+ 1estational Week &etal 0acrosomia, %
3! 2.1
38 4.8
3 8.2
40 12.3
41 1'.8
42 21
Source-&dapted fro* Boyd1 183
5126
0aternal race
A systematic difference is observed in the mean birth weight of babies born to mothers of different
races and ethnicities. Depending on the mother's race, mean birth weights differ by as much as "-"
7!, g at term. Although some of this difference may be attributed to systematic differences in the
mean gestational age of fetuses at delivery, systematic racial differences in maternal characteristics
&eg, maternal height, weight, glucose tolerance, etc(
F)/G
, and differences in the prevalence of various
diseases and complications of pregnancy that occur in different populations, an additional disparity in
birth weight is attributable to racial differences per se.
*he precise cause of this effect is un%nown, but it may be related to genetic or metabolic differences
in fetalgrowth potential for women of different races. Decause of this effect, properly characterizing
the race of mothers is important to accurately predict birth weights.
As an example, African American and Asian women have fetuses that are smaller than those of
3aucasian women when appropriately matched for gestational age.
F#,, #), -, 7,, 7/, --, -/, )., ))G
0f a single birth
weight standard is used, 3aucasian women have a significantly higher prevalence of fetal
macrosomia compared with that of African American and Asian women,
F"7, "-, 7/, -/G
and women from
these latter groups have a significantly higher prevalence of smallforgestationalage newborns
compared with that of 3aucasian women.
%ther parental1 environmental1 and pregnancy2specific determinants
After gestational age and maternal race, several other maCor parental, environmental, and pregnancy
specific determinants of birth weight are relevant for mothers with otherwise uncomplicated
pregnancies &see *able ,(. *hese include the followingH &"( maternal height, &#( maternal obesity, &7(
maternal pregnancy weight gain, &-( parity, &,( fetal sex, &/( ambient altitude, &.( maternal hemoglobin
concentration, &)( paternal height, &!( cigarette smo%ing, and &"+( glucose tolerance.
F"#, "7, "-, ",, --, -/, -., ,#, ,7,
/!, ,-, ,,, ,/, ,., -7G
*a%en together, these measurable factors can explain more than two fifths of the variance in term
birth weight.
F,., )!G
0n addition, several other maCor environmental factors can adversely affect fetal
weight. Malnutrition is chief among these. 0n thirdworld countries where poverty among reproductive
aged women is prevalent, malnutrition is a common factor that can substantially affect the size of
neonates at all gestational ages.
*able ,. >outinely Measurable $arental and $regnancy1pecific Demographic 9actors that 0nfluence
9etal Aeight
F,#, ,7, /!, ,-, ,.G


&:pen *able in a new window(
%arental or %regnanc23pecific &actor &irst34r+er Correlation With Birth Weight5
<estational a#e at deli)ery 0.2!-0.41
>aternal %ei#ht at 26 %ee.s 0.30-0.3
>aternal %ei#ht at ter* 0.36-0.3!
>aternal prepre#nancy %ei#ht 0.23-0.2!
>aternal pre#nancy %ei#ht #ain 0.1'-0.31
>aternal hei#ht 0.22-0.26
>aternal $ody *ass index AB>4C 0.16-0.2!
>aternal a#e 0.01-0.14
"arity 0.01-0.1
>aternal he*o#lo$in concentration -0.1' to -0.1!
"aternal hei#ht 0.14-0.23
(etal sex 0.13-0.1
1-h '0-# #lucose screenin# result 0.04-0.0
; /an#es represent findin#s fro* ' peer-re)ie%ed studies. &ll first-order correlations %ith ter* $irth %ei#ht %ere
statistically si#nificant at the P 0 .0' le)el1 except for the 1-h '0-# #lucose result. "atients %ith dia$etes *ellitus
%ere excluded fro* all analyses.
0aternal height
Maternal height is an easily measurable physical characteristic that is positively correlated with term
fetal weight.
F!+, ,7, ,-, ,,, ,/, ,., -7G
Although lifestyle choices can potentially modify other maternal physical
features &eg, maternal weight and DM0(, maternal height is arguably the single best measure of native
humansize potential.
Darring special circumstances &eg, malnutrition in childhood, scoliosis, intrinsic bone disease( adult
height is a trait that has genetic underpinnings that are generationally transmissible. 9amily pedigree
studies have shown that, on average, =big people have big babies and small people have small ones.=
:ne would be intuitively challenged to argue with this line of reasoning, and data from numerous
studies have independently confirmed the direct relationship of maternal height to the birth weight of
offspring.
0aternal obesity
*he level of maternal obesity independently influences fetal weight such that the more a mother
weighs, the larger her fetus is li%ely to be. *his occurs because maternal weight and fetal weight are
directly related, and women with high DM0s are at increased ris% for developing diabetes during
pregnancy &see Diabetes mellitus below(.
F!+G
0aternal pregnancy weight gain
Maternal pregnancy weight gain is important with regard to fetal growth, such that the greater the
weight gain is, the larger the fetus is li%ely to be. Aeight gain during pregnancy is generally
proportional to the caloric inta%e of a mother and, the greater the number of calories consumed, the
more is available for incorporation into the developing tissues of the fetus. 0n addition, increased
pregnancy weight gain is associated with an increased ris% of developing gestational diabetes &see
Diabetes Mellitus below(.
arity
$arity is directly and independently associated with fetal size. *he greater the maternal parity, the
larger the fetus is li%ely to be. Maternal parity is closely lin%ed to maternal age, but once maternal
parity is specified, maternal age is not an independent predictor of fetal weight. At term, a fetus
typically gains +.#+., g/day for each increase of " in maternal parity.
Fetal se(
9emale fetuses are systematically smaller than males when appropriately matched for gestational age
and other factors, although the precise cause for this difference is un%nown.
F"#, "7, "-, ",, "/, "!, .#, -/, -., .,, )+, ./,
!"G
9etal sex is associated significantly with birth weight and independently accounts for approximately
#@ of the variance.
F,.G
9emale fetuses are smaller than male fetuses when matched for gestational age
and for all other %nown factors that influence fetal weight. :n average, male fetuses weigh more than
females by "7/ g &, oz( at term.
!mbient altitude
Ambient altitude predictably influences fetal weight such that, when controlled for all other variables,
an increase in altitude of "+++ m accounts for a reduction in term birth weight of "+#"-, g.
F-., -), -!, ,+,
,#G
0n addition, adult hemoglobin concentrations increase by ".,# g/d6 for every "+++m increase in
ambient altitude.
F,#G
*he dependence of fetal weight on ambient altitude is independent of all other
factors that can influence fetal weight. *he magnitude of the effect of altitude on fetal weight is 7+ to
-7 g per "+++ feet above sea level at term.
1everal potential explanations have been proposed for the inverse relationship between increasing
altitude and fetal weight< they include &"( the decrease in oxygen tension with increasing altitude, &#(
the increase in maternal hemoglobin concentration with increasing altitude, and/or &7( the decrease in
maternal plasma volume with increasing altitude.
0aternal hemoglobin concentration
Maternal hemoglobin concentration at constant altitude independently explains #./@ of the variance
in birth weight, apart from all other %nown predictive variables. *he relationship between birth weight
and circulating maternal hemoglobin concentration is inverse, such that for each ".+g/d6 increase in
maternal hemoglobin concentration, term birth weight is reduced by )! g &see the image below(.
F,#G
*his effect may be as the result of changes in blood viscosity. Dlood is a highly nonEewtonian fluid
that has a rapid nonlinear rise in viscosity with increasing hematocrit. 0ncreasing viscosity tends to
retard the rate of blood flow through small vessels, including those in the placental bed, raising
extraction ratios and lowering solute gradients. *his effect may partly explain why increasing altitude
&which increases circulating hematocrit and hemoglobin concentrations( results in progressively lower
mean birth weights.
aternal height
$aternal height is the only routinely measured paternal demographic variable that has significant
influence on fetal weight,
F/", /#G
but it accounts independently for less than #@ of the variance &"+ g/cm
of fetal weight at term(.
F/!G
:ffspring of fathers with heights # 1Ds above or below the mean have a
term birth weight that is increased or decreased by "#, g, respectively. Eormal variability in paternal
height explains an independent portion of the variance in term birth weight of up to #,+ g that other
maternal, environmental, or pregnancyspecific factors do not account for.
F/!G
$aternal weight and DM0,
which are acquired traits and which depend on lifestyle choices and behaviors, do not independently
influence fetal weight. $aternal age also has no effect on birth weight up to at least the age of /+
years.
$igarette smoking
3igarette smo%ing during pregnancy both increases maternal hemoglobin concentrations and
systematically lowers term birth weight by "#") g per cigarette smo%ed per day.
F-, /+, -., !#, !7, !-, !,G
*hat is,
a mother who smo%es " pac% per day will li%ely have a baby with a mean birth weight reduction of
#-+7/+ g at term.
hysical activity during pregnancy
*he effect of aerobic physical activity during pregnancy on term birth weight was recently assessed in
," healthy, nonsmo%ing women who completed uncomplicated pregnancies &mean gestational age at
delivery 7!.-Q".#" wee%s Frange 7/-# w%G, mean birth weight 7,/!,Q,". g Frange #,.-7-,!-7 gG(.
F."G
*he degree of aerobic physical activity &as assessed by accelerometry at #+ and 7# w%( was
strongly and inversely correlated with fetal growth &r +.-#< P M .++#(.
0nfants born to women in the highest quartile of physical activity weighed a mean of /+) g less than
infants born to women in the lowest physical activity quartile. Maternal weight gain did not modify the
association of physical activity with fetal growth. Dased on this, the study's authors concluded that
=aerobic physical activity during midtolate pregnancy accounted for ")@ of the variance in fetal
growth.= ?owever, the independence of this effect from other factors that can influence fetal growth
was not established.
"iabetes mellitus
5ncontrolled maternal diabetes mellitus is commonly associated with excessive fetal weight.
F"", )#,
)7G
4lucose is the primary substrate fetuses require for growth.
F)#G
Ahen maternal glucose levels are
excessive, abnormally high rates of fetal growth can be expected. 3ompared with the baseline rate of
fetal macrosomia of #",@ in the general population &depending on the group studied(, the rate
among mothers with poorly controlled gestational diabetes is elevated &#+77@(. Decause of routine
glucose screening during pregnancy and the stringent glucose criteria now used to monitor and treat
women who have diabetes during pregnancy, undiagnosed and poorly controlled gestational diabetes
mellitus are now unusual, and the rate of macrosomia among women with fran% gestational diabetes
has recently diminished.
F./, /"G
;ven in women without diabetes mellitus, elevated glucose levels in pregnancy predispose their
fetuses to increased birth weight.
F.7, .-, .,G
*he subgroups of women at highest ris% for fetal macrosomia
are those who are unmonitored and untreated, those who have an abnormal "hour glucose result
during pregnancy and a subsequent normal 7hour glucose tolerance test, and those who have a
single abnormal value indicative of only mild glucose intolerance.
F.-, .,G
%ther maternal illnesses and complications of pregnancy
1everal maternal illnesses and complications of pregnancy are associated with decreased birth
weight. *he most common are chronic maternal hypertension and preeclampsia.
F.), .!, )+, )"G
3hronic
maternal hypertension is associated with a mean decrement in birth weight of "/" g at term. 9or mild
preeclampsia, the mean reduction is at least "+, g. Ahen severe preeclampsia or ?;66$ syndrome
is a complication, an additional and generally less predictable downward adCustment in fetal weight
must be made.
1ome maternal connectivetissue diseases, intrauterine infections &eg, viral, parasitic, bacterial(,
chromosomal abnormalities, and congenital syndromes are also associated with smallforgestational
age fetuses.
F),G
"iagnosis of "eviations in Fetal Weight
Techni3ues for estimating fetal weight
All of the currently available methods for assessing fetal weight in utero are subCect to substantial
predictive errors. *hese errors are most clinically relevant at the # extremes of fetal weight &eg, M
#,++ g, li%ely the product of premature deliveries, and N-+++ g, at ris% for the complications
associated with fetal macrosomia(.
Tactile assessment of fetal size
*actile assessment of fetal size is the oldest technique for assessing fetal weight and is also referred
to as clinical palpation or 6eopold maneuvers. 0t involves manual assessment of fetal size by the
obstetrical practitioner. Aorldwide, this method is used extensively because it is both convenient and
virtually costless< however, it is a subCective method associated with notable predictive errors.
F!/, !7, !,, !.,
!), !!G
$linical risk factor assessment
Ouantitative assessment of clinical ris% factors can be valuable in predicting deviations in fetal weight.
F"#G
*able / shows the odds ratio &:>s( for fetal macrosomia associated with "" clinical ris% factors.
*able /. 3linical >is% 9actors and :>s for 9etal Aeight N-+++ g
F"#, "7, ., #", ##, ), "-, "", .7, .-, .,, "++, .#, "+"G


&:pen
*able in a new window(
Risk &actor
%ercent of %atients With 0acrosomic
&etuses With %resence of Risk
&actors
4++s Ratio for %resence of Risk &actor
Compare+ With Controls 1reater Than
6/// g
>aternal dia$etes *ellitus; 2-30 1.6-3
&$nor*al 1-h '0-# oral
#lucose-screenin# result
1'-2! 1.8-2.1
%ithout #estational dia$etes
*ellitus
&$nor*al sin#le 3-h 100-#
oral #lucose-tolerance result
8-34 1.-2.4
"rolon#ed #estation1 E41 %. 1-3' '.'-'.
>aternal o$esity 16-3! 1.!-4.4
"re#nancy %ei#ht #ain E3'
l$
21-'6 1.'-2.2
>aternal hei#ht E' ft 3 in 20-24 1.'-2
>aternal a#e E3' y 12-21 1.3-2.3
>ultiparity 64-3 1.2-1.3
>ale fetal sex 62-6 1.2-1.4
+aucasian *aternal race 4'-4 1.1-2.'
,ote--ata co*piled fro* 14 studies of the pre)alence of ris. factors for fetal *acroso*ia a*on# %o*en
deli)erin# fetuses %ei#hin# 4000 # or *ore and control su$jects %ith $irth %ei#hts of 0 4000 #.
; &ll classes1 includin# #estational dia$etes *ellitus. ?he %ide ran#e of )alues reflects differences a*on# studies
in criteria for screenin# and dia#nosis1 pre)alence of disease in the populations under study1 and the #enerally
#ood A$ut )aria$leC success of #lucose control durin# pre#nancy.
Source-,ahu* 2000
5''1 '66
0aternal self2estimation
A third method for estimating fetal weight is maternal selfestimation. $erhaps a surprise, in some
studies, selfestimates of fetal weight in multiparous women were comparably accurate to findings on
clinical palpation in predicting fetal weight and abnormally large fetuses at term &see *able .(.
F"+#, "+7, "+-,
"+,G
*able .. 3omparison of the Accuracy of DirthAeight $rediction for $regnancies at N7. Aee%s'
4estationL &:pen *able in a new window(
Author Clinical %alpation onographic &etal Biometr25 elf37stimates
0ean Absolute 7rror, % %re+ictions
Within !/% of Actual Weight, %
0ean Absolute 7rror, % %re+ictions Within !/% of Actual Weight, % 0ean Absolute
7rror, %
%re+ictions Within !/% of Actual Weight, %
:atson et al1 188 !. 6! 8.2 66 ,& ,&
+hauhan et al1 12 .0 66 1'.6 42 8.! !0
+hauhan et al1 13 .1 6' 10.! '6 ,& ,&
+hauhan et al1 14 .1 !0 12.1 48 ,& ,&
+hauhan et al1 1' !.' 6' ,& ,& .2 6!
+hauhan et al1 1' . '4 11.4 '1 ,& ,&
Sher*an et al1 18 !.2 !3 8.1 6 ,& ,&
+hauhan et al1 18 10.3 61 10 60 ,& ,&
Ferrero et al1 1 .' 61 ,& ,& .' 62
Fendrix et al1 2000 10.6 '8 16.' 32 ,& ,&
-ar et al1 2000 8.' 61 '. 83 ,& ,&
,ahu* et al1 2002 . '1 8.3 !1 11.' ''
?otal !.2-10.6 '1-!3 '.-16.' 32-83 8.!-11.' ''-!0
; Sono#raphic prediction al#orith*s used to esti*ate fetal %ei#ht %ere those of Shepard
51066
1 Fadloc.
510!1 1086
1 Sa$$a#ha
5106
1 and :arsof
51101 1116
1 in addition to the $est of 8 al#orith*s $ased on )arious co*$inations of a$do*inal circu*ference A&+C1
fe*oral len#th A(=C1 $iparietal dia*eter AB"-C1 and head circu*ference AF+C1 $oth sin#ly and in co*$ination.
%bstetric ultrasonography
*he most modern method for assessing fetal weight in utero involves the use of fetal measurements
obtained during obstetrical ultrasonography. *he advantage of this technique is that it relies on linear
and/or planar measurements of in utero fetal dimensions that are obCectively definable and generally
reproducible. 9indings from multiple studies have shown that ultrasonographic estimates of fetal
weight are no better than clinical palpation in predicting fetal weight<
F""#, /+, !), "+#, ""7, ""-, "",, ""/, ""., ""), ""!, "#+, "+,,
"#"G
these observations have undermined early expectations that this method might provide an obCective
standard for identifying fetuses of abnormal size for gestational age &see *able .(.
*a%en together, these findings suggest that the prediction of fetal weight is not an exact science and
that it requires additional refinement.
!ccuracy of Fetal Weight rediction by 4sing "ifferent 0ethods
! standard against which to measure all methods of fetal weight prediction5 The accuracy
of birth weight prediction by simply applying the gestation2specific mean value
9or any particular set of newborns, the single bestfitting estimate of birth weight for each individual
fetus is the average weight for that particular cohort. 3onsequently, the simplest approach to birth
weight prediction is to apply the mean gestationalage specific birth weight as the prediction criterion
for any particular population of women in each case. *his involves merely identifying the mean birth
weight associated with each gestational age for the given population.
Eot surprisingly, this method results in fairly accurate estimations of mean fetal weight for new and
demographically wellmatched populations of patients, but it is a much poorer tool for estimating the
actual birth weight for any particular fetus. ?owever, the accuracy of this method can be used as a
benchmar% against which other techniques can be assessed for their intrinsic value beyond merely
%nowing the average birth weight for a particular class of patients. Any other method of prediction that
purports to predict birth weight more accurately in individual cases must be able to improve upon the
application of such =mean value= estimates in order to have added value. 0f growth curves can be
found that are specific to a particular population of pregnant women &eg, specific for the maternal
race, parity, fetal gender, altitude of residence, etc. of a particular class of patients(, then the accuracy
of this =meanbirthweight= prediction method can be improved significantly.
*o assess the accuracy of this method, the populationspecific mean birth weight for a group of
3aucasian women with uncomplicated singleton term pregnancies was calculated and applied bac% to
the same group. *he mean absolute prediction error for estimating birth weight by simply =guessing=
the populationspecific mean value in each case was Q --! g and the mean absolute percentage
prediction error was Q "7./@.
F"##G
4iven that in this study, the mean birth weight was derived from the same group to which it was
applied, these results would seem to be the optimal that can be obtained using this approach for
normal singleton liveborns that are delivered to healthy mothers without maCor complications of
pregnancy &eg, without gestational diabetes mellitus, hypertension, or preeclampsia(. Although the
accuracy of these results is far from optimal, they rival the accuracy of other more traditional methods
of term birth weight prediction &such as clinical palpation(.
!ccuracy of clinical palpation for estimating fetal weight
1everal investigations have shown that the accuracy of clinical palpation for estimating fetal weight is
Q #.),!! g &Q ..,"!.)@(, depending on fetal weight and gestational age.
F!), !!, "+#, "+7, "+-, ""-, ""/, ""), ""., ""7G
*he
technique is best for estimating fetal weight in the reference range of #,++-+++ g.
1everal studies demonstrate that the accuracy of clinical palpation for estimating fetal weight M #,++ g
deteriorates mar%edly, with a mean absolute percentage error of Q "7.."!.)@. :nly -+-!@ of birth
weights below the #,++g threshold are properly estimated by means of clinical palpation to within Q
"+@ of the actual birth weight. Ahen fetuses weigh M ")++ g, the accuracy of such clinical estimates
is reduced even further, with more than half of these predictions in error by N-,+ g &Q #,@(.
:ne study showed that the sensitivity of clinical palpation for identifying a birth weight of M #,++ g was
only ".@, with an associated positive predictive value of 7.@. At the upper limit of term fetal weights,
# studies have shown that the positive predictive value of clinical palpation for predicting birth weight
N-+++ g was /+/7@, with an associated sensitivity of 7-,-@.
9urthermore, findings from # studies have suggested that the accuracy of clinical palpation for
predicting fetal weight does not depend on the level of training of the operator, whereas data from
another study suggests that resident physicians in obstetrics and gynecology are systematically better
than medical students at estimating term birth weight by using this technique &see *able )(.
F"+,, "#7G
0n a study by Eoumi et al that assessed the accuracy of clinical and sonographic estimations of fetal
weight performed during the active phase of labor by resident physicians, the correlation between the
clinical and sonographic estimates and actual birth weight was +.,! &$ M .+++"( and +./, &$ M .+++"(,
respectively. 3linical estimates were correct to within Q "+@ in .#@ of cases, with sonographic
estimates correct in .-@. ?owever, the sensitivity of predicting birth weight of -,+++ g or more was
only ,+@ for both methods, with !,@ and !.@ specificity, respectively. *he authors concluded that
both clinical and sonographic estimates of fetal weight by resident physicians had poor sensitivity for
detecting macrosomic fetuses, and that the sonographic estimates offered no advantage over clinical
ones.
F""#G
*he mean absolute percentage error in birth weight prediction by using clinical palpation for term
fetuses at N7. wee%s' gestation is ..#"+./@ &see *able .(. 9or a fetus predicted to weigh N-+++ g,
the average error in birthweight estimation routinely exceeds 7++-++ g. 0n " study, N/@ of fetal
weights were wrongly assessed by N"7.+ g &7 lb(.
F"/G
*able ). Accuracy of 3linical $alpation for $redicting *erm Dirth Aeight by *ype of 3linician &:pen
*able in a new window(
Accurac2 4bstetric312necologic Resi+ents 0e+ical tu+ents % 8alue
>ean a$solute error1 # 261 388 .06
>ean a$solute error1 9 !.6 11.' .0'
:ithin 109 of actual %ei#ht1 9 !1 38 .0'
Source-,ahu*1 2002
510'6
!ccuracy of obstetric ultrasonography for estimating fetal weight
:bstetric sonographic assessment for the purpose of obtaining fetal biometric measurements to
predict fetal weight has been integrated into the mainstream of obstetric practice in the past quarter
century. 9rom its inception, this method has been presumed to be more accurate than clinical
methods for estimating fetal weight. *he reasons for this assumption vary, but the fundamental
underlying presumption is that sonographic measurements of multiple linear and planar dimensions of
the fetus provide sufficient parametric information to allow for accurate algorithmic reconstruction of
the 7dimensional fetal volume of varying tissue density. 3onsistent with these beliefs, much effort
has generated bestfit fetal biometric algorithms to ma%e birth weight predictions based on obstetric
ultrasonographic measurements. As such, the ultrasonographic technique represents the newest and
most technologically sophisticated method of estimating fetal weight.
Modern algorithms that incorporate standardly defined fetal measurements &eg, some combination of
fetal A3, 96, D$D, and ?3( are generally comparable in their overall accuracy in predicting fetal
weight. *able ! shows a categorization of #. ultrasonographic algorithms according to the type of fetal
biometric information that they incorporate.
*he formulas can be arranged into ) groups according to the type of fetal biometric information that
they rely on to ma%e their fetal weight predictions, as followsH
". A3
#. 96
7. A3 R 96
-. A3 R D$D
,. A3 R ?3
/. A3 R D$D R 96
.. A3 R ?3 R 96
). A3 R ?3 R D$D R 96
*able !. Algorithms for 5ltrasonographic 9etal Diometric $rediction of ;stimated 9etal AeightL &:pen
*able in a new window(
T2pe of 79uation ource 79uation
&+ +a*p$ell and :il.in1 1!'; =n B: D -4.'64 G 0.0282
A&+C - 0.00331A&+C
2
Fi##in$otto* et al1 1!' B: D 0.0816A&+C
3
:arsof et al1 1!!; =o#10 B: D -1.836! G 0.02
A&+C - 0.00001A&+C
3
Fadloc. et al1 184 =n B: D 2.6' G 0.2'3
A&+C - 0.002!'A&+C
2
Hordaan1 183 =o#10 B: D 0.6328 G 0.1881
A&+C - 0.0043A&+C
2
G
0.00003623A&+C
3
(= :arsof et al1 186 =n B: D 4.614 G 0.001'1
A(=C
2
- 0.000011A(=C
3
&+ and (= Fadloc. et al1 18' =o#10 B: D 1.304 G 0.0'281
A&+C G 0.138A(=C - 0.004
A&+CA(=C
:oo et al1 18' =o#10 B: D 0.' G 0.08A&+C
G 0.28A(=C - 0.00!16
A&+CA(=C
:arsof et al1 186 =n B: D 2.!2 G 0.108A(=C G
0.0036A&+C
2
- 0.002!A(=C
A&+C
&+ and F+ :arsof et al1 1!!; =o#10 B: D -1.' G
0.144AB"-C G 0.032A&+C -
0.000111AB"-C
2
A&+C
Shepard et al1 182; =o#10 B: D -1.!42 G 0.166
AB"-C G 0.046A&+C -
0.002'46A&+CAB"-C
Hordaan1 183 =o#10 B: D -1.1683 G
0.03!!A&+C G 0.0'0AB"-C -
0.001'AB"-CA&+C
Fadloc. et al1 184 =o#10 B: D 1.1134 G
0.0'84'A&+C - 0.000604A&+C
2
- 0.00!36'AB"-C
2
G
0.000''AB"-CA&+C G 0.164
AB"-C
:oo et al1 18' =o#10 B: D 1.63 G 0.16AB"-C
G 0.00111A&+C
2
- 0.00008'
AB"-CA&+C
2
IintBileos et al1 18! =o#10 B: D 1.8! G 0.084
AB"-C G 0.026A&+C
Fsieh et al1 18! =o#10 B: D 2.131' G
0.00'6'41A&+CAB"-C -
0.0001''1'AB"-CA&+C
2
G
0.00001!82A&+C
3
G 0.0'2'4AB"-C
&+ and F+ Hordaan1 183 =o#10 B: D 0.11 G 0.0488
AF+C G 0.0824A&+C -
0.001'AF+CA&+C
Fadloc. et al1 184 =o#10 B: D 1.182 G 0.02!3
AF+C G 0.0!0'!A&+C -
0.00063A&+C
2
- 0.0002184
AF+CA&+C
&+1 B"-1 and (= Fadloc. et al1 18' =o#10 B: D 1.33' - 0.0034
A&+CA(=C G 0.0316AB"-C G
0.04'!A&+C G 0.1623A(=C
:oo et al1 18' =o#10 B: D 1.'4 G 0.1'AB"-C
G 0.00111A&+C
2
- 0.0000!64
AB"-CA&+C
2
G 0.0'A(=C -
0.0002A(=CA&+C
ShinoBu.a et al1 18! J B: D 0.2366A&+C
2
A(=C G
1.6230AB"-C
3
Fsieh et al1 18! =o#10 B: D 2.!13 G
0.00462A&+CAB"-C -
0.1432A(=C - 0.000!6!42A&+C
AB"-C
2
G 0.001!4'A(=CAB"-C
2
&+1 F+1 and (= Fadloc. et al1 18' =o#10 B: D 1.326 - 0.00326
A&+CA(=C G 0.010!AF+C G
0.0438A&+C G 0.1'8A(=C
8tt et al1 186; =o#10 B: D -2.0661 G
0.043''AF+C G 0.0'34A&+C
- 0.0008'82AF+CA&+C G
1.2'4A(=/&+C
+o*$s et al1 13 B: D 0.23!18A&+C
2
A(=C G
0.03312AF+C
3
&+1 F+1 B"-1 and (= Hordaan1 183 =o#10 B: D 2.3231 G
0.0204A&+C G 0.00!AF+C -
0.00'8AB"-C
Fadloc. et al1 18' =o#10 B: D 1.3'6 G 0.0064
AF+C G 0.0424A&+C G 0.1!4
A(=C G 0.00061AB"-CA&+C -
0.00386A&+CA(=C
Source-,ahu* 2003
51226
,ote-B: D $irth %ei#htK =n D natural lo#arith*. B"-1 F+1 &+1 and (= in centi*eters Aexcept in the :arsof
eLuations1 %here the (= is expressed in *illi*etersC
;B: expressed in .ilo#ra*s Afor other eLuations1 results are expressed in #ra*sC.
J ?he ShinoBu.a eLuation has $een *odified fro* its ori#inal pu$lished for* $y su$stitutin# the fetal &+
*easure*ent for the a$do*inal trans)erse and anteroposterior dia*eters in the ori#inal eLuationK +o*$s et al
ha)e recalculated its coefficients.
51241 12'6
:f note is that higherorder terms appear in "/ of the #. ultrasound prediction equations that are
listed in *able !. *he value of each of the - standard ultrasonographic fetal biometric parameters for
predicting fetal weight has been evaluated to determine whether their correlation with fetal weight
increases with increasing order. *able "+ shows these results.
*able "+. 3orrelations of 5ltrasonographic 9etal Measurements Aith *erm 9etal Aeight &:pen *able
in a new window(
Correlation With Birth Weight B%) :C AC &,
(irst order 0.64 0.6! 0.!' 0.'6
Second order 0.64 0.6! 0.!' 0.''
?hird order 0.64 0.6! 0.!4 0.''
Source-&dapted fro* ,ahu* 2003
51226
*he predictive value of the standard ultrasonographic fetal biometric measurements for estimating
fetal weight did not increase with increasing order for any of the - parameters. 3onsistent with these
findings, data evaluated from an unrelated set of patients found that the correlations of these -
ultrasonographic measurements at firstorder with fetal weight were as followsH D$D P +.,), ?3 P
+./,, A3 P +..), and 96 P +.,#.
F"#/G
Again, the correlation did not increase with increasing order for any
of the - parameters.
*hese results suggest that the fetal A3 is the single best ultrasonographic predictor of fetal weight
and that the predictive value of none of the measurements increase with increasing order.
F"#.G
*he
additional implication is that the incorporation of higherorder terms into ultrasonographic prediction
algorithms is not theoretically or empirically Custified.
Ahen other sonographic fetal measurements are used to estimate fetal weight &eg, humeral soft
tissue thic%ness, ratio of subcutaneous tissue to 96, chee%tochee% diameter(, these nonstandard
measurements do not significantly improve the usefulness of obstetric ultrasonography in predicting
fetal weight, except in special patient groups &eg, mothers with diabetes(.
F"#), "#!, "7+G
6imiting factors associated with the ultrasonographic prediction of fetal weight are &"( imprecise
imaging of fetal structures &due to limitations such as patient obesity, placentation, oligohydramnios,
and/or fetal position(, &#( the limited number of linear and/or planar measurements that can be ta%en
of the complex 7dimensional fetal conformation, &7( fetal tissues of similar dimensions with varying
densities &eg, bone N muscle N adipose tissue density(, &-( unavoidable operator and equipment
related measurement errors and approximations
F"".G
, and &,( inappropriate algorithmic compounding of
measurement errors and approximations by the incorporation of highorder terms.
0n a recent study by Anderson et al, the contributions of different types of errors in attaining
ultrasonographic fetal weight estimates for "# published formulae were evaluated in "!!" and #+++.
F"7"G
*heir findings were as followsH &"( ultrasound is a relatively inaccurate method for the purpose of
estimating fetal weight &!,@ agreement limits between predicted and actual fetal weights is
approximately Q #"@(, &#( errors are due to the ultrasoundbased equations and not image resolution,
&7( observer inaccuracies are only a minor component of prediction errors &agreement between and
within observers range from -@ to R7@(, &-( most prediction errors are due to equation bias, lac% of
precision, and inconsistencies among the different published ultrasonographic formulae, and &,( fetal
weight predictions using ultrasoundalone equations did not improve from "!!"#+++.
F"7#G
*his study concluded that !,@ limits of agreement ranged from -.-@ to R7.7@ for interobserver and
intraobserver fetal biometric measurement estimates, but that the limits were ").+@ to R#-.+@ for
the correspondence between equationestimated and actual birth weights. 9urthermore, in #+++, out
of the "# published formulas, only / had an overall bias within .@ and precision within ",@ and this
was not an improvement in accuracy from "!!". 9inally, the authors concluded that ultrasonographic
prediction equation error in estimating fetal weight is the largest source of the inaccuracy, whereas
observer error is relatively minor. *herefore, it is not surprising that fetal weight estimates are no more
accurate following improvements in ultrasonographic technology.
0n a study of "+7- patients, the mean absolute percentage error associated with the calculation of
estimated fetal weights based on D$D, A3, and 96 &according to a widely used ?adloc% equation(
was up to "".7@, depending on the gestational age of the fetus &ie, after crude stratification of fetal
size(.
F"")G
Ahen the mean absolute percentage error of the method is assessed for the 7 clinically
significant ranges of fetal weight &M #,++, #,++-+++, N-+++ g(, the mean absolute percentage error
of the technique is typically lowest &Q ..""+.,@( for the mid and high ranges and slightly greater for
the lowest range &Q )""@(.
Ahen another commonly used measure of accuracy is used &percentage of fetuses with weight
accurately estimated to within Q "+@ of actual birth weight(, weight was accurately predicted to within
these limits for ,/@ of fetuses weighing M #,++ g, for ,)@ of fetuses weighing #,++-+++ g, and for
/#@ of fetuses weighing N-+++ g.
Ahen the accuracy of detecting clinically relevant deviations in term birth weight &M #,++, N-+++, and
N-,++ g( is determined for the sonographic technique of fetal weight estimation, the positive
predictive value ranges from --,,@, with corresponding sensitivities of ,)."@. As expected, for
preterm fetuses delivered at M 7. wee%s' gestation that have a decreased mean birth weight, the "
way accuracy of sonographic fetal biometric classifications of clinically significant deviations &ie, low
birth weight( improved. *he positive predictive value of a sonographic estimate of fetal weight of M
#,++ g is ).@ for preterm fetuses, with a sensitivity of !+@, and the positive predictive value for a
sonographic estimate of fetal weight M ",++ g is )/@, with a sensitivity of !7@.
*wo studies have investigated the relative accuracy of the different classes of ultrasonographic fetal
biometric algorithms for predicting fetal weight. 0n the first study, .- patients with normal, term,
singleton pregnancies underwent complete sonographic examinations within ".- wee%s of delivery.
*he mean absolute predictive accuracy of #. algorithms ranged from Q #!, g for the Aarsof equation
&based on fetal A3 alone( to Q ,#+ g for the Aoo equation &based on both A3 and D$D( &see *able
""(. *he accuracy of the algorithms to within Q ",@ of actual birth weight ranged from ,-@ for the
?igginbottom equation &based on A3 alone( to ),@ for the modified 1hinozu%a equation &based on
A3, D$D, and 96(.
Aith regard to the prediction of fetal weight within Q "+@ of actual birth weight, accuracy ranged from
7"@ for the Aoo equation &based on A3 and D$D( to .+@ for the ?adloc% equation &based on A3,
D$D, ?3, and 96(.
F"##G
*hirteen &-)@( of the #. equations did not predict fetal weight to within Q ",@ of actual weight better
than guessing the mean birth weight. 9or fetalweight predictions to within Q "+@ of actual weight, #+
&.-@( of the ultrasonographic algorithms performed better than guessing.
1eventeen &/7@( of the #. ultrasonic algorithms generated substantially lower mean absolute
prediction errors and mean absolute percentage errors than guessing. 9or these equations, the
improvement in the mean absolute prediction error and the absolute percentage prediction error was
!/",- g &7.#,.+@( depending on the algorithm used. *he "+ remaining equations resulted in
estimates no better than simple guesses of 7-,, g for each newborn.
:verall, the 7 algorithms that were most accurate were those of :tt et al &based on A3, ?3, and 96(,
1hinozu%a et al &based on A3, D$D, and 96, as 3ombs et al modified it(, and Aarsof et al &based on
A3 alone(. >esults in any category of analysis for these equations were not significantly different.
*able "". Accuracy of #. 5ltrasonographic Algorithms for $redicting 9etal Aeight at 7. Aee%sK
4estation or 6ater &n P .-(
*able "". Accuracy of #. 5ltrasonographic Algorithms for $redicting 9etal Aeight at 7. Aee%sK
4estation or 6ater &n P .-(
0etho+ ource Correlation
With Actual
Birth Weight5
0ean
Absolute
7rror, g
0ean
Absolute
%ercent
7rror, %
&raction of Birth
Weight 7stimates
Within ; !*% of
Birth Weight, %
&raction of Birth
Weight 7stimates
Within ; !/% of
Birth Weight, %
&+ :arsof et al1
1!!
0.!' 2' J 8.8 J 82 J 6 J
+a*p$ell et al1
1!'
0.!' 33! J .8 J 82 J 62 J
Fadloc. et al1
184
0.!' 334 J . J !! '8 J
Hordaan1 183 0.!4 46' 13.1 !2 3
Fi##in$otto*
et al1 1!'
0.!3 48 14.! '4 38
(= :arsof et al1
186
0.'2 30 11.1 !0 4
&+ and
(=
:arsof et al1
186
0.!3 33 J .8 J 80 J 6' J
Fadloc. et al1
18'
0.!' 3'' J 10.4 J !4 '!
:oo et al1
18'
0.!' 42! 12.3 !3 '4
&+ and
B"-
Fadloc. et al1
184
0.!6 324 J .' J 82 J 62 J
Hordaan1 183 0.!6 332 J .! J 80 J 62 J
Shepard et al1
182
0.!6 338 J .8 J !8 J 6' J
Fsieh et al1
18!
0.!6 36 10.! 80 J '8 J
IintBileos et al1
18!
0.!' 33 11.3 !3 '8 J
:arsof et al1
1!!
0.!6 432 12.6 6 4'
:oo et al1
18'
0.!! '20 1'.0 '! 31
&+ and
F+
Hordaan1 183 0.!1 323 J .4 J !! 66
Fadloc. et al1
184
0.! 32! J .' J !! 66
&+1 B"-1
and (=
ShinoBu.a et al1
18! M
0.!! 312 J .0 J 8' J 68 J
Fadloc. et al1
18'
0.!6 33 J . J 80 J 64 J
:oo et al1
18'
0.!! 3'3 J 10.3 J 80 '8
Fsieh et al1
18!
0.!! 363 10.6 !! ' J
&+1 F+1
and (=
8tt et al1 186 0.!8 2! J 8.6 J 819 669
+o*$s et al1
13
0.!8 31! J .1 J 84 J 66 J
Fadloc. et al1
18'
0.!8 333 J .! J !8 J 64 J
&+1 B"-1
F+1 and
(=
Fadloc. et al1
18'
0.!! 334 J .! J 80 J !0 J
Hordaan1 183 0.!' 364 10.' !! ';
Si*ply
#uessin#
,& ,& 44 13.6 64 42
Source-,ahu* 2003
51226
; &ll co*parisons %ith actual $irth %ei#ht %ere calculated $y addin# to the predicted ultrasono#raphic $irth-
%ei#ht rate of 12.4 #/day Afor fe*alesC or 13.0 #/day Afor *alesC for the ti*e elapsed $et%een the date of
ultrasono#raphic fetal $io*etric assess*ent and the actual date of deli)ery.
5436
J /esults for the ultrasono#raphic prediction eLuation %ere statistically superior to those o$tained $y #uessin# the
*ean ter* $irth %ei#ht atP 0 .0'. +o*parisons %ere *ade $y usin# the Student t test for *ean a$solute errors
and *ean a$solute percenta#e errors and $y *eans of x2 analysis for the percenta#e of $irth %ei#ht predictions
%ithin N 109 and N 1'9 of actual $irth %ei#ht.
M ?he ShinoBu.a eLuation has $een *odified fro* its ori#inal pu$lished for* $y su$stitutin# the fetal &+
*easure*ent for the a$do*inal trans)erse and anteroposterior dia*eters in the ori#inal eLuationK +o*$s et al
ha)e recalculated its coefficients.
51241 12'6
Ahen used to ma%e predictions concerning the occurrence of fetal macrosomia, the "7 best
performing ultrasonographic equations had #,.,@ sensitivity for fetal macrosomia N-+++ g with a
positive predictive value of -"/7@ &see *able "#(. *he - most accurate algorithms that possessed
superior combinations of a sensitivity of N-+@, a positive predictive value of N,+@, and a li%elihood
ratio of N,.+ for the prediction of fetal macrosomia were the equations of :tt et al, 1hinozu%a et al &as
3ombs et al modified it(, Bordaan &based on A3 and D$D(, and Aarsof et al &based on A3 alone(.
*able "#. 3omparison of the Most Accurate 5ltrasonographic Algorithms *hat 0ncorporate Different
5ltrasonographic $arameters to $redict *erm 9etal Aeight &n P .-( &:pen *able in a new window(
*able "#. 3omparison of the Most Accurate 5ltrasonographic Algorithms *hat 0ncorporate Different
5ltrasonographic $arameters to $redict *erm 9etal Aeight &n P .-(
79uation
ource
%aram3
eters in
79uation
0ean
Absolute
7rror, g
0ean
Absolute
%ercent3age
7rror, %
7stimates
Within ; !/%
of Birth
Weight, %
7stimates
Within ; !*%
of Birth
Weight, %
ensi tivit2
for &etal
Weight
<6/// g,
%5
%ositive
%re+ictive
8alue for &etal
Weight <6///
g, %5
:arsof et
al1 1!!
&+ 2' 8.8 6 82 6! '3
+a*p$ell et
al1 1!'
&+ 33! .8 62 82 2' 60
:arsof et
al1 186
&+1 (= 33 .8 6' 80 '8 41
Fadloc. et
al1 184
&+1 B"- 324 .' 62 82 42 4'
Hordaan1
183
&+1 B"- 332 .! 62 80 42 ''
Shepard et
al1 182
&+1 B"- 338 .8 6' !8 !' 43
ShinoBu.a
et al1 18! J
&+1 B"-1
(=
312 .0 68 8' 42 '6
Fadloc. et
al1 18'
&+1 B"-1
(=
33 . 64 80 42 '0
:oo et al1
18'
&+1 B"-1
(=
3'3 10.3 '8 80 42 '6
8tt et al1
186
&+1 F+1 (= 28 8.6 66 81 42 63
+o*$s et
al1 13
&+1 F+1 (= 31! .1 66 84 2' 60
Fadloc. et
al1 18'
&+1 F+1 (= 333 .! 64 !8 42 63
Fadloc. et
al1 18'
&+1 B"-1
F+1 (=
334 .! !0 80 42 '0
Source-,ahu* 2003
51266
;+alculations %ere *ade $y addin# to the predicted ultrasono#raphic $irth %ei#ht 12.4 #/day Afor fe*alesC or
13.0 #/day Afor *alesC for the ti*e elapsed $et%een the date of ultrasono#raphic fetal $io*etric assess*ent and
the actual date of deli)ery.
5436
J ?he ShinoBu.a eLuation has $een *odified fro* its ori#inal pu$lished for* $y su$stitutin# the fetal &+
*easure*ent for the a$do*inal trans)erse and anteroposterior dia*eters in the ori#inal eLuationK +o*$s et al
ha)e recalculated its coefficients.
51241 12'6
Normal Labor and Delivery
"efinition
6abor is a physiologic process during which the products of conception &ie, the fetus, membranes,
umbilical cord, and placenta( are expelled outside of the uterus. 6abor is achieved with changes in the
biochemical connective tissue and with gradual effacement and dilatation of the uterine cervix as a
result of rhythmic uterine contractions of sufficient frequency, intensity, and duration.
F", #G
6abor is a clinical diagnosis. *he onset of labor is defined as regular, painful uterine contractions
resulting in progressive cervical effacement and dilatation. 3ervical dilatation in the absence of uterine
contraction suggests cervical insufficiency, whereas uterine contraction without cervical change does
not meet the definition of labor.
Stages of *abor and )pidemiology
Stages of *abor
:bstetricians have divided labor into 7 stages that delineate milestones in a continuous process.
First stage of labor
*he first stage begins with regular uterine contractions and ends with complete cervical dilatation at
"+ cm. 0n 9riedmanKs landmar% studies of ,++ nulliparas
F7G
, he subdivided the first stage into an early
latent phase and an ensuing active phase. *he latent phase begins with mild, irregular uterine
contractions that soften and shorten the cervix. *he contractions become progressively more rhythmic
and stronger. *his is followed by the active phase of labor, which usually begins at about 7- cm of
cervical dilation and is characterized by rapid cervical dilation and descent of the presenting fetal part.
*he first stage of labor ends with complete cervical dilation at "+ cm. According to 9riedman, the
active phase is further divided into an acceleration phase, a phase of maximum slope, and a
deceleration phase.
3haracteristics of the average cervical dilatation curve is %nown as the 9riedman labor curve, and a
series of definitions of labor protraction and arrest were subsequently established.
F-, ,G
?owever,
subsequent data of modern obstetric population suggest that the rate of cervical dilatation is slower
and the progression of labor may be significantly different from that suggested by the 9riedman labor
curve.
F/, ., )G
Second stage of labor
*he second stage begins with complete cervical dilatation and ends with the delivery of the fetus. *he
American 3ollege of :bstetricians and 4ynecologists &A3:4( has suggested that a prolonged
second stage of labor should be considered when the second stage of labor exceeds 7 hours if
regional anesthesia is administered or # hours in the absence of regional anesthesia for nulliparas. 0n
multiparous women, such a diagnosis can be made if the second stage of labor exceeds # hours with
regional anesthesia or " hour without it.
F"G
1tudies performed to examine perinatal outcomes associated with a prolonged second stage of labor
revealed increased ris%s of operative deliveries and maternal morbidities but no differences in
neonatal outcomes.
F!, "+, "", "#G
Maternal ris% factors associated with a prolonged second stage include
nulliparity, increasing maternal weight and/or weight gain, use of regional anesthesia, induction of
labor, fetal occiput in a posterior or transverse position, and increased birthweight.
F"", "#, "7, "-G
Third stage of labor
*he third stage of labor is defined by the time period between the delivery of the fetus and the delivery
of the placenta and fetal membranes. During this period, uterine contraction decreases basal blood
flow, which results in thic%ening and reduction in the surface area of the myometrium underlying the
placenta with subsequent detachment of the placenta.
F",G
Although delivery of the placenta often
requires less than "+ minutes, the duration of the third stage of labor may last as long as 7+ minutes.
;xpectant management of the third stage of labor involves spontaneous delivery of the placenta.
Active management often involves prophylactic administration of oxytocin or other uterotonics
&prostaglandins or ergot al%aloids(, early cord clamping/cutting, and controlled cord traction of the
umbilical cord. A systematic review of the literature that included , randomized controlled trials
comparing active and expectant management of the third stage reports that active management
shortens the duration of the third stage and is superior to expectant management with respect to
blood loss/ris% of postpartum hemorrhage< however, active management is associated with an
increased ris% of unpleasant side effects.
F"/G
*he third stage of labor is considered prolonged after 7+ minutes, and active intervention, such as
manual extraction of the placenta, is commonly considered.
F#G
)pidemiology
As the childbearing population in the 5nited 1tates has changed, the clinical obstetric management of
labor also has evolved since 9riedman's studies. Data from number a studies have suggested that
normal labor can progress at a rate much slower than that 9riedman and 1achtleben
F-, ,G
had described.
Shang et al examined the labor progression of ","/# nulliparas who presented in spontaneous labor
and constructed a labor curve that was mar%edly different from 9riedman'sH *he average interval to
progress from -"+ cm of cervical dilatation was ,., hours compared with #., hours of 9riedman's
labor curve.
F".G
Tilpatric% et al
F/G
and Albers et al
F.G
also reported that the median lengths of first and
second stages of labor were longer than those 9riedman suggested.
A number of investigators have identified several maternal characteristics obstetric factors that are
associated with the length of labor. :ne group reported that increasing maternal age was associated
with a prolonged second stage but not first stage of labor.
F")G
Ahile nulliparity is associated with a longer labor compared to multiparas, increasing parity does not
further shorten the duration of labor.
F"!G
1ome authors have observed that the length of labor differs
among racial/ethnic groups. :ne group reported that Asian women have the longest first and second
stages of labor compared with 3aucasian or African American women
F#+G
, and American 0ndian women
had second stages shorter than those of non?ispanic 3aucasian women.
F.G
?owever, others report
conflicting findings.
F#", ##G
Differences in the results may have been due to variations in study designs,
study populations, labor management, or statistical power.
0n one large retrospective study of the length of labor, specifically with respect to race and/or ethnicity,
the authors observed no significant differences in the length of the first stage of labor among different
racial/ethnic groups. ?owever, the second stage was shorter in African American women than in
3aucasian women for both nulliparas &## min( and multiparas &.., min(. ?ispanic nulliparas,
compared with their 3aucasian counterparts, also had a shortened second stage, whereas no
differences were seen for multiparas. 0n contrast, Asian nulliparas had a significantly prolonged
second stage compared with their 3aucasian counterparts, and no differences were seen for
multiparas.
F#7G
0echanism of *abor
*he ability of the fetus to successfully negotiate the pelvis during labor involves changes in position of
its head during its passage in labor. *he mechanisms of labor, also %nown as the cardinal
movements, are described in relation to a vertex presentation, as is the case in !,@ of all
pregnancies. Although labor and delivery occurs in a continuous fashion, the cardinal movements are
described as . discrete sequences, as discussed below.
F#G
)ngagement
*he widest diameter of the presenting part &with a wellflexed head, where the largest transverse
diameter of the fetal occiput is the biparietal diameter( enters the maternal pelvis to a level below the
plane of the pelvic inlet. :n the pelvic examination, the presenting part is at + station, or at the level of
the maternal ischial spines.
"escent
*he downward passage of the presenting part through the pelvis. *his occurs intermittently with
contractions. *he rate is greatest during the second stage of labor.
Fle(ion
As the fetal vertex descents, it encounters resistance from the bony pelvis or the soft tissues of the
pelvic floor, resulting in passive flexion of the fetal occiput. *he chin is brought into contact with the
fetal thorax, and the presenting diameter changes from occipitofrontal &"".+ cm( to
suboccipitobregmatic &!., cm( for optimal passage through the pelvis.
Internal rotation
As the head descends, the presenting part, usually in the transverse position, is rotated about -,J to
anteroposterior &A$( position under the symphysis. 0nternal rotation brings the A$ diameter of the
head in line with the A$ diameter of the pelvic outlet.
)(tension
Aith further descent and full flexion of the head, the base of the occiput comes in contact with the
inferior margin of the pubic symphysis. 5pward resistance from the pelvic floor and the downward
forces from the uterine contractions cause the occiput to extend and rotate around the symphysis.
*his is followed by the delivery of the fetus' head.
'estitution and e(ternal rotation
Ahen the fetus' head is free of resistance, it untwists about -,J left or right, returning to its original
anatomic position in relation to the body.
)(pulsion
After the fetus' head is delivered, further descent brings the anterior shoulder to the level of the pubic
symphysis. *he anterior shoulder is then rotated under the symphysis, followed by the posterior
shoulder and the rest of the fetus.
$linical History and hysical )(amination
History
*he initial assessment of labor should include a review of the patient's prenatal care, including
confirmation of the estimated date of delivery. 9ocused history ta%ing should be conducted to include
information, such as the frequency and time of onset of contractions, the status of the amniotic
membranes &whether spontaneous rupture of the membranes has occurred, and if so, whether the
amniotic fluid is clear or meconium stained(, the fetus' movements, and the presence or absence of
vaginal bleeding.
Draxton?ic%s contractions, which are often irregular and do not increase in frequency with increasing
intensity, must be differentiated from true contractions. Draxton?ic%s contractions often resolve with
ambulation or a change in activity. ?owever, contractions that lead to labor tend to last longer and are
more intense, leading to cervical change. *rue labor is defined as uterine contractions leading to
cervical changes. 0f contractions occur without cervical changes, it is not labor. :ther causes for the
cramping should be diagnosed. 4estational age is not a part of the definition of labor.
0n addition, Draxton?ic%s contractions occur occasionally, usually no more than "# per hour, and
they often occur Cust a few times per day. 6abor contractions are persistent, they may start as
infrequently as every "+", minutes, but they usually accelerate over time, increasing to contractions
that occur every #7 minutes.
$atients may also describe what has been called lightening, ie, physical changes felt because the
fetus' head is advancing into the pelvis. *he mother may feel that her baby has become light. As the
presenting fetal part starts to drop, the shape of the mother's abdomen may change to reflect descent
of the fetus. ?er breathing may be relieved because tension on the diaphragm is reduced, whereas
urination may become more frequent due to the added pressure on the urinary bladder.
hysical e(amination
$hysical examination should include documentation of the patient's vital signs, the fetus' presentation,
and assessment of the fetal wellbeing. *he frequency, duration, and intensity of uterine contractions
should be assessed, particularly the abdominal and pelvic examinations in patients who present in
possible labor.
Abdominal examination begins with the 6eopold maneuvers described below
F#G
H
*he initial maneuver involves the examiner placing both of his or her hands on each upper
quadrant of the patient's abdomen and gently palpating the fundus with the tips of the fingers to
define which fetal pole is present in the fundus. 0f it is the fetus' head, it should feel hard and round.
0n a breech presentation, a large, nodular body is felt.
*he second maneuver involves palpation in the paraumbilical regions with both hands by
applying gentle but deep pressure. *he purpose is to differentiate the fetal spine &a hard, resistant
structure( from its limbs &irregular, mobile small parts( to determinate the fetus' position.
*he third maneuver is suprapubic palpation by using the thumb and fingers of the dominant
hand. As with the first maneuver, the examiner ascertains the fetus' presentation and estimates its
station. 0f the presenting part is not engaged, a movable body &usually the fetal occiput( can be felt.
*his maneuver also allows for an assessment of the fetal weight and of the volume of amniotic fluid.
*he fourth maneuver involves palpation of bilateral lower quadrants with the aim of
determining if the presenting part of the fetus is engaged in the mother's pelvis. *he examiner
stands facing the mother's feet. Aith the tips of the first 7 fingers of both hands, the examiner exerts
deep pressure in the direction of the axis of the pelvic inlet. 0n a cephalic presentation, the fetus'
head is considered engaged if the examiner's hands diverge as they trace the fetus' head into the
pelvis.
$elvic examination is often performed using sterile gloves to decrease the ris% of infection. 0f
membrane rupture is suspected, examination with a sterile speculum is performed to visually confirm
pooling of amniotic fluid in the posterior fornix. *he examiner also loo%s for fern on a dried sample of
the vaginal fluid under a microscope and chec%s the p? of the fluid by using a nitrazine stic% or litmus
paper, which turns blue if the amniotic fluid is al%alotic. 0f fran% bleeding is present, pelvic examination
should be deferred until placenta previa is excluded with ultrasonography. 9urthermore, the pattern of
contraction and the patient's presenting history may provide clues about placental abruption.
Digital examination of the vagina allows the clinician to determine the followingH &"( the degree of
cervical dilatation, which ranges from + cm &closed or fingertip( to "+ cm &complete or fully dilated(, &#(
the effacement &assessment of the cervical length, which is can be reported as a percentage of the
normal 7 to -cmlong cervix or described as the actual cervical length(< actual reporting of cervical
length may decrease potential ambiguity in percenteffacement reporting, &7( the position, ie, anterior
or posterior, and &-( the consistency, ie, soft or firm. $alpation of the presenting part of the fetus
allows the examiner to establish its station, by quantifying the distance of the body &, to R, cm( that
is presenting relative to the maternal ischial spines, where + station is in line with the plane of the
maternal ischial spines(.
F#G
*he pelvis can also be assessed either by clinical examination &clinical pelvimetry( or radiographically
&3* or M>0(. *he pelvic planes include the followingH
$elvic inletH *he obstetrical conCugate is the distance between the sacral promontory and the
inner pubic arch< it should measure ""., cm or more. *he diagonal conCugate is the distance from
the undersurface of the pubic arch to sacral promontory< it is # cm longer than the obstetrical
conCugate. *he transverse diameter of the pelvic inlet measures "7., cm.
MidpelvisH *he midpelvis is the distance between the bony points of ischial spines, and it
typically exceeds "# cm.
$elvic outletH *he pelvic outlet is the distance between the ischial tuberosities and the pubic
arch. 0t usually exceeds "+ cm.
*he shape of the mother's pelvis can also be assessed and classified into - broad categories based
on the descriptions of 3aldwell and MoloyH gynecoid, anthropoid, android, and platypelloid.
F#-G
Although
the gynecoid and anthropoid pelvic shapes are thought to be most favorable for vaginal delivery,
many women can be classified into " or more pelvic types, and such distinctions can be arbitrary.
F#G
Workup
?ighris% pregnancies can account for up to )+@ of all perinatal morbidity and mortality. *he
remaining perinatal complications arise in pregnancies without identifiable ris% factors for adverse
outcomes.
F#,G
*herefore, all pregnancies require a thorough evaluation of ris%s and close surveillance.
As soon as the mother arrives at the 6abor and Delivery suite, external tocometric monitoring for the
onset and duration of uterine contractions and use of a Doppler device to detect fetal heart tones and
rate should be started.
0n the presence of labor progression, monitoring of uterine contractions by external tocodynamometry
is often adequate. ?owever, if a laboring mother is confirmed to have rupture of the membranes and if
the intensity/duration of the contractions cannot be adequately assessed, an intrauterine pressure
catheter can be inserted into the uterine cavity past the fetus to determine the onset, duration, and
intensity of the contractions. Decause the external tocometer records only the timing of contractions,
an intrauterine pressure catheter can be used to measure the intrauterine pressure generated during
uterine contractions if their strength is a concern. Ahile it is considered safe, placental abruption has
been reported as a rare complication of an intrauterine pressure catheter placed
extramembraneously.
F#/G
:ften, fetal monitoring is achieved using cardiotography, or electronic fetal monitoring.
3ardiotography as a form of fetal assessment in labor was reviewed using randomized and
quasirandomized controlled trials involving a comparison of continuous cardiotocography with no
monitoring, intermittent auscultation, or intermittent cardiotocography. *his review concluded that
continuous cardiotocography during labor is associated with a reduction in neonatal seizures but not
cerebral palsy or infant mortality< however, continuous monitoring is associated with increased
cesarean and operative vaginal deliveries.
F#.G
0f nonreassuring fetal heart rate tracings by cardiotography &eg, late decelerations( are noted, a fetal
scalp electrode may be applied to generate sensitive readings of beattobeat variability. ?owever, a
fetal scalp electrode should be avoided if the mother has ?0I, hepatitis D or hepatitis 3 infections, or if
fetal thrombocytopenia is suspected. >ecently, a framewor% has been suggested to classify and
standardize the interpretation of a fetal heart rate monitoring pattern according to the ris% of fetal
acidemia with the intention of minimizing neonatal acidemia without excessive obstetric intervention.
F#)G
*he question of whether fetal pulse oximetry may be useful for fetal surveillance in labor was
examined in a review of , published trials comparing fetal pulse oximetry and cardiotography with
cardiotography alone. 0t concluded that existing data provide limited support for the use of fetal pulse
oximetry when used in the presence of a nonreassuring fetal heart rate tracing to reduce caesarean
delivery for nonreassuring fetal status. *he addition of fetal pulse oximetry does not reduce overall
caesarean deliveries.
F#!G
9urther evaluation of a fetus at ris% for labor intolerance or distress can be accomplished with blood
sampling from fetal scalp capillaries. *his procedure allows for a direct assessment of fetal
oxygenation and blood p?. A p? of M ..#+ warrants further investigation for the fetus' wellbeing and
for possible resuscitation or surgical intervention.
>outine laboratory studies of the parturient, such as 3D3 analysis, blood typing and screening, and
urinalysis, are usually performed. 0ntravenous &0I( access is established.
Intrapartum 0anagement of *abor
First stage of labor
3ervical change occurs at a slow, gradual pace during the latent phase of the first stage of labor.
6atent phase of labor is complex and not wellstudied since determination of onset is subCective and
may be challenging as women present for assessment at different time duration and cervical dilation
during labor. 0n a cohort of women undergoing induction of labor, the median duration of latent labor
was 7)-min with an interquartile range of #-+/+- min. *he authors report that cervical status at
admission for labor induction, but not other ris% factors typically associated with cesarean delivery, is
associated with length of the latent phase.
F7+G
Most women experience onset of labor without premature rupture of the membranes &$>:M(<
however, approximately )@ of term pregnancies is complicated by $>:M. 1pontaneous onset of
labor usually follows $>:M such that ,+@ of women with $>:M who were expectantly managed
delivered within , hours, and !,@ gave birth within #) hours of $>:M.
F7"G
3urrently, the American
3ollege of :bstetricians and 4ynecologists &A3:4( recommends that fetal heart rate monitoring
should be used to assess fetal status and dating criteria reviewed, and group D streptococcal
prophylaxis be given based on prior culture results or ris% factors of cultures not available.
Additionally, randomized controlled trials to date suggest that for women with $>:M at term, labor
induction, usually with oxytocin infusion, at time of presentation can reduce the ris% of
chorioamnionitis.
F7#G
According to 9riedman and colleagues,
F-G
the rate of cervical dilation should be at least " cm/h in a
nulliparous woman and ".# cm/h in a multiparous woman during the active phase of labor. ?owever,
labor management has changed substantially during the last quarter century. $articularly, obstetric
interventions such as induction of labor, augmentation of labor with oxytocin administration, use of
regional anesthesia for pain control, and continuous fetal heart rate monitoring are increasingly
common practice in the management of labor in todayKs obstetric population.
F77, 7-, ".G
Iaginal breechand
mid or highforceps deliveries are now rarely performed.
F7,, 7/, 7.G
*herefore, subsequent authors have
suggested normal labor may precede at a rate less rapid than those previously described.
F/, ., ".G
Data collected from the 3onsortium on 1afe 6abor suggests that allowing labor to continue longer
before /cm dilation may reduce the rate of intrapartum and subsequent cesarean deliveries in the
5nited 1tates.
F7)G
0n the study, the authors noted that the !,
th
percentile for advancing from -cm
dilation to ,cm dilation was longer than / hours< and the !,
th
percentile for advancing from ,cm
dilation to /cm dilation was longer than 7 hours, regardless of the patientKs parity.
:n admission to the 6abor and Delivery suite, a woman having normal labor should be encouraged to
assume the position that she finds most comfortable. $ossibilities including wal%ing, lying supine,
sitting, or resting in a left lateral decubitus position. :f note, ambulating during labor did not change
the progression of labor in a large randomized controlled study of N"+++ women in active labor.
F7!G
*he patient and her family or support team should be consulted regarding the ris%s and benefits of
various interventions, such as the augmentation of labor using oxytocin, artificial rupture of the
membranes, methods and pharmacologic agents for pain control, and operative vaginal delivery
&including forceps or vacuumassisted vaginal deliveries( or cesarean delivery. *hey should be
actively involved, and their preferences should be considered in the management decisions made
during labor and delivery.
F#G
*he frequency and strength of uterine contractions and changes in cervix and in the fetus' station and
position should be assessed periodically to evaluate the progression of labor. Although progression
must be monitored, vaginal examinations should be performed only when necessary to minimize the
ris% of chorioamnionitis, particularly in women whose amniotic membrane has ruptured. During the
first stage of labor, fetal wellbeing can be assessed by monitoring the fetal heart rate at least every
", minutes, particularly during and immediately after uterine contractions. 0n most labor and delivery
units, the fetal heart rate is assessed continuously.
F-+G
*wo methods of augmenting labor have been established. *he traditional method involves the use of
low doses of oxytocin with long intervals between dose increments. 9or example, lowdose infusion of
oxytocin is started at " mili 05/min and increased by "# mili 05/min every #+7+ minutes until
adequate uterine contraction is obtained.
F#G
*he second method, or active management of labor, involves a protocol of clinical management that
aims to optimize uterine contractions and shorten labor. *his protocol includes strict criteria for
admission to the labor and delivery unit, early amniotomy, hourly cervical examinations, early
diagnosis of inefficient uterine activity &if the cervical dilation rate is M ".+ cm/h(, and highdose
oxytocin infusion if uterine activity is inefficient. :xytocin infusion starts at - mili 05/min &or even / mili
05/min( and increases by - mili 05/min &or / mili 05/min( every ", minutes until a rate of . contractions
per ", minutes is achieved or until the maximum infusion rate of 7/ mili 05/min is reached.
F-", #G
Although active management of labor was originally intended to shorten the length of labor in
nulliparous women, its application at the Eational Maternity ?ospital in Dublin produced a primary
cesarean delivery rate of ,/@ in nulliparas.
F-#G
Data from randomized controlled trials confirmed that
active management of labor shortens the first stage of labor and reduces the li%elihood of maternal
febrile morbidity, but it does not consistently decrease the probability of cesarean delivery.
F-7, --, -,G
Although the active management protocol li%ely leads to early diagnosis and interventions for labor
dystocia, a number of ris% factors are associated with a failure of labor to progress during the first
stage. *hese ris% factors include premature rupture of the membranes &$>:M(, nulliparity, induction
of labor, increasing maternal age, and or other complications &eg, previous perinatal death,
pregestational or gestational diabetes mellitus, hypertension, infertility treatment(.
F-/, -.G
Ahile the A3:4 defines labor dystocia as abnormal labor that results form abnormalities of the power
&uterine contractions or maternal expulsive forces(, the passenger &position, size, or presentation of
the fetus(, or the passage &pelvis or soft tissues(, labor dystocia can rarely be diagnosed with
certainty.
F"G
:ften, a =failure to progress= in the first stage is diagnosed if uterine contraction pattern
exceeds #++ Montevideo units for # hours without cervical change during the active phase of labor is
encountered.
F"G
*hus, the traditional criteria to diagnose activephase arrest are cervical dilatation of at
least - cm, cervical changes of M " cm in # hours, and a uterine contraction pattern of N#++
Montevideo units. *hese findings are also a common indication for cesarean delivery.
$roceeding to cesarean delivery in this setting, or the =#hour rule,= was challenged in a clinical trial of
,-# women with active phase arrest.
F-)G
0n this cohort of women diagnosed with active phase arrest,
oxytocin was started, and cesarean delivery was not performed for labor arrest until adequate uterine
contraction lasted at least - hours &N#++ Montevideo units( or until oxytocin augmentation was given
for / hours if this contraction pattern could not be achieved. *his protocol achieved vaginal delivery
rates of ,//"@ in nulliparas and ))@ in multiparas without severe adverse maternal or neonatal
outcomes. *herefore, extending the criteria for activephase labor arrest from # to at least - hours
appears to be effective in achieving vaginal birth.
F-), "G
Second stage of labor
Ahen the woman enters the second stage of labor with complete cervical dilatation, the fetal heart
rate should be monitored or auscultated at least every , minutes and after each contractions during
the second stage.
F-+G
Although the parturient may be encouraged to actively push in concordance with
the contractions during the second stage, many women with epidural anesthesia who do not feel the
urge to push may allow the fetus to descend passively, with a period of rest before active pushing
begins.
A number of randomized controlled trials have shown that, in nulliparous women, delayed pushing, or
passive descend, is not associated with adverse perinatal outcomes or an increased ris% for operative
deliveries despite an often prolonged second stage of labor.
F-!, ,+, 7"G
9urthermore, investigators who
recently compared obstetric outcomes associated with coached versus uncoached pushing during the
second stage reported a slightly shortened second stage &"7 min( in the coached group, with no
differences in the immediate maternal or neonatal outcomes.
F,"G
Ahen a prolonged second stage of labor is encountered, clinical assessment of the parturient, the
fetus, and the expulsive forces is warranted. A randomized controlled trial performed by Api et al
determined that application of fundal pressure on the uterus does not shorten the second stage of
labor.
F,#G
Although the #++7 A3:4 practice guidelines state that the duration of the second stage alone
does not mandate intervention by operative vaginal delivery or cesarean delivery if progress is being
made, the clinician has several management options &continuing observation/expectant management,
operative vaginal delivery by forceps or vacuumassisted vaginal delivery, or cesarean delivery( when
secondstage arrest is diagnosed.
*he association between a prolonged second stage of labor and adverse maternal or neonatal
outcome has been examined. Ahile a prolonged second stage is not associated with adverse
neonatal outcomes in nulliparas, possibly because of close fetal surveillance during labor, but it is
associated with increased maternal morbidity, including higher li%elihood of operative vaginal delivery
and cesarean delivery, postpartum hemorrhage, third or fourthdegree perineal lacerations, and
peripartum infection.
F!, "+, "", "#G
*herefore, it is crucial to weigh the ris%s of operative delivery against the
potential benefits of continuing labor in hopes to achieve vaginal delivery. *he question of when to
intervene should involve a thorough evaluation of the ongoing ris%s of further expectant management
versus the ris%s of intervention with vaginal or cesarean delivery, as well as the patients' preferences.
"elivery of the fetus
Ahen delivery is imminent, the mother is usually positioned supine with her %nees bent &ie, dorsal
lithotomy position(, though delivery can occur with the mother in any position, including the lateral
&1ims( position, the partial sitting or squatting position, or on her hands and %nees.
F#G
Although an
episiotomy &an incision continuous with the vaginal introitus( used to be routinely performed at this
time, the A3:4 recommended in #++/ that its use be restricted to maternal or fetal indications.
1tudies have also shown that routine episiotomy does not decrease the ris% of severe perineal
lacerations during forceps or vacuumassisted vaginal deliveries.
F,7, ,-G
3rowning is the word used to describe when the fetal head forcibly extends the vaginal outlet. A
modified >itgen maneuver can be performed to deliver the head. Draped with a sterile towel, the heel
of the clinician's hand is placed over the posterior perineum overlying the fetal chin, and pressure is
applied upward to extend the fetus' head. *he other hand is placed over the fetus' occiput, with
pressure applied downward to flex its head. *hus, the head is held in mid position until it is delivered,
followed by suctioning of the oropharynx and nares. 3hec% the fetus' nec% for a wrapped umbilical
cord, and promptly reduce it if possible. 0f the cord is wrapped too tightly to be removed, the cord can
be double clamped and cut. :f note, some providers, in an attempt to avoid shoulder dystocia, deliver
the anterior shoulder prior to restitution of the fetal head.
Eext, the fetus' anterior shoulder is delivered with gentle downward traction on its head and chin.
1ubsequent upward pressure in the opposite direction facilitates delivery of the posterior shoulder.
*he rest of the fetus should now be easily delivered with gentle traction away from the mother. 0f not
done previously, the cord is clamped and cut. *he baby is vigorously stimulated and dried and then
transferred to the care of the waiting attendants or placed on the mother's abdomen.
Third stage of labor 2 "elivery of the placenta and the fetal membranes
*he labor process has now entered the third stage, ie, delivery of the placenta. *hree classic signs
indicate that the placenta has separated from the uterusH &"( *he uterus contracts and rises, &#( the
cord suddenly lengthens, and &7( a gush of blood occurs.
F#G
Delivery of the placenta usually happens within ,"+ minutes after delivery of the fetus, but it is
considered normal up to 7+ minutes after delivery of the fetus. ;xcessive traction should not be
applied to the cord to avoid inverting the uterus, which can cause severe postpartum hemorrhage and
is an obstetric emergency. *he placenta can also be manually separated by passing a hand between
the placenta and uterine wall. After the placenta is delivered, inspect it for completeness and for the
presence of " umbilical vein and # umbilical arteries. :xytocin can be administered throughout the
third stage to facilitate placental separation by inducing uterine contractions and to decrease bleeding.
;xpectant management of the third stage involves allowing the placenta to deliver spontaneously,
whereas active management involves administration of uterotonic agent &usually oxytocin, an ergot
al%aloid, or prostaglandins( before the placenta is delivered. *his is done with early clamping and
cutting of the cord and with controlled traction on the cord while placental separation and delivery are
awaited.
A review of , randomized trials comparing active versus expectant management of the third stage
demonstrated that active management was associated with lowered ris%s of maternal blood loss,
postpartum hemorrhage, and prolongation of the third stage, but it increased maternal nausea,
vomiting, and blood pressure &when ergometrine was used(. ?owever, given the reduced ris% of
complications, this review recommends that active management is superior to expectant management
and should be the routine management of choice.
F"/G
A multicenter, randomized, controlled trial of the
efficacy of misoprostol &prostaglandin ;" analog( compared with oxytocin showed that oxytocin "+ 05
0I or given intramuscularly &0M( was preferable to oral misoprostol /++ mcg for active management of
the third stage of labor in hospital settings.
F,,G
*herefore, if the ris%s and benefits are balanced, active
management with oxytocin may be considered a part of routine management of the third stage.
After the placenta is delivered, the labor and delivery period is complete. $alpate the patient's
abdomen to confirm reduction in the size of the uterus and its firmness. :ngoing blood loss and a
boggy uterus suggest uterine atony. A thorough examination of the birth canal, including the cervix
and the vagina, the perineum, and the distal rectum, is warranted, and repair of episiotomy or
perineal/vaginal lacerations should be carried out.
9ranchi et al found that topically applied lidocaineprilocaine &;M6A( cream was an effective and
satisfactory alternative to mepivacaine infiltration for pain relief during perineal repair. 0n a randomized
trial of /" women with either an episiotomy or a perineal laceration after vaginal delivery, women in
the ;M6A group had lower pain scores than those in the mepivacaine group &".. R/ #.- vs 7.! R/ #.-<
$ P .+++#(, and a significantly higher proportion of women expressed satisfaction with anesthesia
method in the ;M6A group than in the mepivacaine group &)7.)@ vs ,7.7@< $ P .+"(.
F,/G
ain $ontrol
6aboring women often experience intense pain. 5terine contractions result in visceral pain, which is
innervated by *"+6". Ahile in descent, the fetus' head exerts pressure on the mother's pelvic floor,
vagina, and perineum, causing somatic pain transmitted by the pudendal nerve &innervated by 1#-(.
F,.G
*herefore, optimal pain control during labor should relieve both sources of pain.
A number of opioid agonists and opioid agonistantagonists can be given in intermittent doses for
systemic pain control. *hese include meperidine #,,+ mg 0I every "# hours or ,+"++ mg 0M every
#- hours, fentanyl ,+"++ mcg 0I every hour, nalbuphine "+ mg 0I or 0M every 7 hours, butorphanol
"# mg 0I or 0M every - hours, and morphine #, mg 0I or "+ mg 0M every - hours.
F,.G
As an
alternative, regional anesthesia may be given. :ptions are epidural, spinal, or combined spinal
epidural anesthesia. *hese provide partial to complete bloc%age of pain sensation below *)"+, with
various degree of motor bloc%ade. *hese bloc%s can be used during labor and for surgical deliveries.
1tudies performed to compare the analgesic effect of regional anesthesia and parenteral agents
showed that regional anesthesia provides superior pain relief.
F,), 7/, ,!G
Although some researchers
reported that epidural anesthesia is associated with a slight increase in the duration of labor and in the
rate of operative vaginal delivery,
F/+, /"G
large randomized controlled studies did not reveal a difference in
frequency of cesarean delivery between women who received parenteral analgesics compared with
women who received epidural anesthesia
F,), ,!, /"G
given during earlystage or later in labor.
F/#G
Although
regional anesthesia is effective as a method of pain control, common adverse effects include maternal
hypotension, maternal temperature N"++.-J9, postdural puncture headache, transient fetal heart
deceleration, and pruritus &with added opioids(.
F,.G
Despite the many methods available for analgesia and anesthesia to manage labor pain, some
women may not wish to use conventional pain medications during labor, opting instead for a natural
childbirth. Although these women may use breathing and mental exercises to help alleviate labor pain,
they should be assured that pain relief can be administered at any time during labor.
:f note, use of nonsteroidal antiinflammatory drugs &E1A0Ds( are relatively contraindicated in the
third trimester of pregnancy. *he repeated use of E1A0Ds has been associated with early closure of
the fetal ductus arteriosus in utero and with decreasing fetal renal function leading to oligohydramnios.
Early Pregnancy Loss
.ackground
An abortion is the spontaneous or induced loss of an early pregnancy. *he period of pregnancy prior
to fetal viability outside of the uterus is considered early pregnancy. Most consider early pregnancy to
end at #+ wee%s' gestation or when the fetus weighs ,++ grams. *he term miscarriage is used often
in the lay language and refers to spontaneous abortion.
athophysiology
A spontaneous abortion is a process that can be divided into - stages8threatened, inevitable,
incomplete, and complete. *he - stages of abortion form a continuum. Most studies do not
differentiate separately between the epidemiology and pathophysiology of each entity.
Threatened abortion
Abortus imminens meliputi perdarahan dari vagina selama masa %ehamilan awal tanpa ada dilatasi
servi%s atau perubahan pada %onsistensi servi%s. Diasanya tida% ada rasa nyeri yang signifi%an,
mes%ipun nyeri ringan dapat terCadi. Eyeri yang lebih berat mung%in mengindi%asi%an telah terCadinya
abortus insipien.
Abortus iminens umum terCadi pada trimester pertama %ehamilan, #,7+@ %ehamilan mengalami
sedi%it perdarahan selama %ehamilan. 6ebih dari setengahnya berlanCut menCadi abortus %omplit.
$ada pemeri%saan fisi%, darah atau cairan %eco%latan dapat terlihat di vagina. 1ervi%s tida% luna%,
dan os servi%al tertutup. *ida% ada Caringan atau membran Canin yang %eluar. 514 menunCu%%an
%ehamilan intra uterin yang masih berlanCut. Bi%a 514 belum dila%u%an sebelumnya, ma%a 514
harus segera dila%u%an untu% menying%ir%an %emung%inan %ehamilan e%topi%, yang geCala %linisnya
mirip. Bi%a %antung uterin %osong pada pemeri%saan 514, perlu dila%u%an pemeri%saan %adar h34
untu% menentu%an apa%ah ada %ehamilan atau tida%.
!bortus Insipien
Abortus insipien terCadi pada awal %ehamilan dengan perdarahan dari vagina dan terdapat dilatasi
servi%s. Diasanya perdarahan per vaginam lebih banya% daripada perdarahan pada abortus iminens,
dan nyeri perut yang dirasa%an lebih berat. *ida% ada pengeluaran Caringan Canin. $ada 514, hasil
%onsepsi terlihat pada segmen bawah uterus atau pada %analis servi%s.
!bortus Inkomplit
Abortus in%omplit terCadi dengan perdarahan pervaginam, dilatasi %analis servi%s, dan pengeluaran
dari hasil %onsepsi. Diasanya nyeri yang terCadi lebih intens dan perdarahan banya%. *erdapat
pengeluaran Caringan Canin dari vagina. 514 menunCu%%an sebagian hasil %onsepsi masih tinggal di
dalam uterus.
!bortus 6omplit
Abortus %omplit adalah abortus yang telah terCadi secara %omplit/%eseluruhan. *erdapat riwayat
perdarahan per vaginam, nyeri perut, dan pengeluaran Caringan per vaginam. 1etelah terCadi
pengeluaran Caringan Canin, pasien umumnya merasa%an nyeri perut ber%urang dan perdarahan per
vaginam ber%urang secara signifi%an.
0issed abortion
Missed abortion adalah %ehamilan intrauterin yang sudah tida% hidup lagi namun bertahan di dalam
uterus tanpa terCadi abortus spontan. Diasanya, tida% ada geCala yang terlihat %ecuali amenorea dan
pasien menyadari %ehamilan berhenti ber%embang Ci%a deta% Cantung Canin tida% diobservasi atau
terdengar pada wa%tu pemeri%saan. 514 dapat meng%onfirmasi diagnosis. *ida% ada perdarahan
pervaginam, nyeri perut, pengeluaran Caringan Canin, atau perubahan servi%s.
)pidemiologi
Insiden
$revalensi abortus secara %eseluruhan di Ameri%a 1eri%at yaitu ",#+@. 1e%itar )+@ abortus terCadi
pada trimester pertama %ehamilan. 9re%uensi terCadinya abortus menurun seiring dengan
mening%atnya usia gestasional. Abortus re%uren, yang dinyata%an Ci%a terCadi abortus dari %ehamilan
yang terCadi sebanya% #7 %ali berturutturut, terCadi pada "@ %ehamilan.
Faktor risiko
fa%tor risi%o abortus spontan termasu% hamil pada usia terlalu muda atau terlalu tua, stress, dan usia
paternal lanCut. 4eCala perdarahan pervaginam diasosiasi%an dengan pening%atan risi%o abortus,
tetapi nyeri perut tida%. 1alah satu penelitian menyata%an abortus spontan terCadi pada ,+@ pasien
dengan abortus iminens.
$revalensi abortus iminens berdasar%an usia adalahH ",@ pada ibu M 7, tahun, #+#,@ pada ibu 7,
7! tahun, 7,@ pada ibu -+-# tahun, dan ,+@ pada ibu N -# tahun.
History
$atients with spontaneous complete abortion usually present with a history of vaginal bleeding,
abdominal pain, and passage of tissue. After the tissue passes, the vaginal bleeding and abdominal
pain subsides.
Iaginal bleeding is usually heavy.
o Ouantification of the amount of bleeding is very important because lifethreatening
hemorrhage may occur. *he patient may be able to quantify the number of pads or tampons used
over a specified time and qualify the amount that each pad is soa%ed. *his is Cust an estimate< yet,
soa%ing a pad or more an hour suggests significant and worrisome amounts of bleeding that
require prompt attention. *hese patients should be sent to the emergency department.
o *he presence of blood clots suggests heavy bleeding. *he presence of blood clots
also may be confused with passage of tissue.
o ;xamining the passed material helps clarify whether the material is clot or tissue. 0f
the material is tissue, then the type of abortion may be identified. 0f the tissue is evaluated and
appears complete, then a complete abortion is confirmed.
Abdominal pain is associated with concurrent abortion and resolves with the completion of the
abortion.
o *he pain usually is in the suprapubic area, but reports of pain in one or both lower
quadrants are not uncommon.
o *he pain may radiate to the lower bac%, buttoc%s, genitalia, and perineum.
o 0f the pain is occurring only on one side, consider an ectopic pregnancy or a ruptured
ovarian cyst as possible causes.
3onsider any reproductiveaged woman presenting with vaginal bleeding to be pregnant until
proven otherwise.
:ther symptoms, such as fever or chills, are more characteristic of infection, such as in a
septic abortion. 1eptic abortions need to be treated immediately, otherwise they may be life
threatening.
"ifferentials
Abortion
Adnexal *umors
Amenorrhea, 1econdary
3ervical 3ancer
3ervicitis
?ematologic Disease and $regnancy
:varian 3ysts
*hreatened Abortion
von Aillebrand Disease
*aboratory Studies
3omplete blood count &3D3( with differential, betah34, blood type and screen &possible
crossmatch(, possible D03 profile, and urinalysis
3D3 will help document the amount of blood loss and whether anemia is present. 0f
the hemoglobin and hematocrit are very low and the patient is symptomatic then transfusions would
be warranted. *he 3D3 also will provide evidence regarding an infection, which, in the case of
infection, would yield an elevated white blood cell count and a left shift on differential.
Detah34 is important to confirm the pregnancy and distinguish it from dysfunctional
uterine bleeding or bleeding from another etiology. *he h34 level is also important to help
distinguish a complete abortion from a threatened abortion or ectopic pregnancy.
0f the h34 level is above ",++#+++ m05/m6, then transvaginal
ultrasonography should detect a viable intrauterine pregnancy. A level over 7+++ m05/m6 should
enable one to visualize a viable intrauterine pregnancy by transabdominal ultrasonography. 0f the
values are so elevated, the cervical canal is closed, and the patient's history is consistent with
passing tissue &which a physician has confirmed(, then an empty uterus on ultrasonography is
consistent with a completed abortion. ?owever, if the h34 level is elevated, no history of passing
tissue is present, and the ultrasonography demonstrates an empty uterus, one must assume that
an ectopic pregnancy is present until proven otherwise.
6ow h34 levels &ie, M #++ m05/m6( may ma%e the diagnosis more difficult.
:bservation and monitoring the h34 levels every few days may be an option if the patient is
stable and not complaining of pain. 0f these low h34 levels plateau and fall, the patient will li%ely
miscarry or have a tubal abortion on her own. ?owever, if the values rise, then followup
ultrasonography is necessary to determine whether an intrauterine pregnancy or an ectopic
pregnancy is present and subsequent appropriate management is necessary. *he h34 level
should rise at least ,7@ every # days during the early first trimester.
F!G
Dlood type and screen &possible crossmatch( is important to determine whether
treatment with >ho4AM is appropriate. An >hnegative woman should receive >ho4AM within .#
hours of miscarriage or ectopic pregnancy to avoid the possibility that the pregnancy has exposed
the patient to a positive antigen. 0f the father of the baby is also >h negative then the patient can
forego the immunoglobulin therapy. 0t is also important in cases where transfusions are necessary.
D03 profile is necessary only in those cases with significant bleeding. *he D03 profile
usually consists of a platelet count, fibrinogen level, prothrombin time &$*(, and activated partial
prothrombin time &a$**(. Ahen significant bleeding occurs and the patient is consuming these
factors faster then she can ma%e them, then the initiating event needs to be treated &ie, DU3,
hysterectomy( and platelets, coagulation factors &usually administered in the form of fresh frozen
plasma or cryoprecipitate(, or fibrinogen in addition to pac%ed red blood cells may need to be
replaced when transfusing a patient. Ahole blood may be transfused as another alternative.
5rinalysis is important to rule out a urinary tract infection. $regnant women are prone
to urinary tract infections due to the progesterone effect on the smooth muscle of the ureters, which
causes mild physiologic hydroureters. A cystitis or renal stone also could be present with bleeding
but from a urinary source.
Imaging Studies
5ltrasonography of the pelvis using a vaginal probe should be performed to rule out an ectopic
pregnancy, retained products of conception, hematometra, or other etiologies. :nce the
discriminatory level is passed, the ultrasound is fairly reliable as long as it is ta%en within the clinical
scenario.
rocedures
0f the diagnosis truly is a complete abortion, then no further procedures are needed.
0f the diagnosis is unclear and there is fluid in the cul de sac, then a culdocentesis can be
performed. *his procedure is one where a needle with "+#+ m6 syringe attached is placed into the
posterior cul de sac through the vagina and the fluid is aspirated. 0f the fluid consists of nonclotting
blood, then a ruptured ectopic pregnancy must be considered. *his technique is not used often.
Alternatively, if the diagnosis is unclear, but normal early pregnancy has been excluded, a
diagnostic DU3 may be performed. 0n this situation, the specimen is sent for pathologic evaluation
and, if chorionic villi are found, then an intrauterine pregnancy demise is confirmed. Eo further
treatment is needed beyond the suction DU3. ?owever, if no chorionic villi are found, then one needs
to presume that an ectopic pregnancy is present and initiate appropriate treatment.
Histologic Findings
$athology results from specimen sent from an early pregnancy &either from DU3 for incomplete
abortion or from ectopic pregnancy( should reveal chorionic villi.
0edical $are
A complete abortion usually needs no further treatment, medically or surgically.
Aith missed, incomplete, or inevitable abortion present before "7 wee%s' gestation, the standard
therapy has been suction DU3. ?owever, at least # randomized controlled trials show that misoprostol
is an effective alternative medical therapy. 0n one study of incomplete abortion, the patients were
randomized between oral misoprostol &/++ mcg( or suction DU3, with success rates at !/.7@ and
!".,@, respectively. *he complication rate is low &+.!@ for misoprostol(.
F"+G
*he other study was a randomized controlled trial with a 7H" randomization to medical therapy versus
DU3. 0t included subCects with the following diagnosesH missed abortion &with or without a fetal pole<
no fetal heart motion when the fetal pole was present(, incomplete abortion, or inevitable abortion. 0n
this study, the initial dose of misoprostol was )++ mcg &- tab #++ mcg placed vaginally(, and the
subCect was reevaluated on day 7. 0f the expulsion had not occurred, then a second dose of )++ mcg
of misoprostol was placed vaginally. *he study showed that ."@ had completed abortion after the first
dose by day 7, and )-@ had success with misoprostol by day ) &!,@ confidence interval, )").@(.
*he ris%s for bleeding and infection were similar to those of surgical management.
F""G
Medical therapy using misoprostol is an acceptable alternative to surgical therapy for most women
based upon these early data. *he patient should be counseled regarding the ris%s and benefits of
both. *he advantages of medical therapy is that no surgical procedures are needed if it is successful.
$assage of tissue should happen within a few days of receiving medical therapy. 0f it is not successful,
then a surgical approach may follow. *he ris%s for medical therapy include bleeding, infection,
possible incomplete abortion, and possible failure of the medication to wor%. *he advantage of a
suction DU3 is that the procedure is scheduled and occurs at a %nown time. *he ris%s of a DU3
include bleeding, infection, possible perforation of the uterus &as noted in 1urgical 3are(, and possible
Asherman syndrome after the procedure.
0n the situation in which a considerable amount of blood loss has occurred, aggressive
hydration, iron therapy or transfusions may be indicated.
0f the diagnosis in not correct, the patient is li%ely to continue to bleed and cramp for an
incomplete or inevitable abortion. 0n these situations, a suction DU3 is indicated. 0f the patient has
any signs of infection, start antibiotics prior to the DU3, if possible, without significantly delaying the
suction DU3.
An ectopic pregnancy may be treated medically or surgically, depending on the clinical
scenario. *reatment guidelines for ectopic pregnancy are available from the American 3ollege of
:bstetricians and 4ynecologists.
F"#G
&1ee eMedicine article ;ctopic $regnancy for further
information.(
o Medical therapy consists of methotrexate, which is usually administered in a dose of
,+ mg/m
#
. *he maximum dose is "++ mg. *he effectiveness of medical therapy depends on only
applying it to patients who are appropriate candidates based on gestational age, h34 level,
ectopic size, patient reliability and compliance, proximity to the office or hospital, and health.
o $rior to administering the methotrexate, renal and liver function tests are measured
and results should be normal. A 3D3 is warranted, and, if significant anemia exists, then medical
therapy is not warranted.
o *he absolute limits for gestational age, h34 level, ectopic size, and the presence or
absence of an embryonic heartbeat are debated in the literature. Despite the debate, the factors
that decrease the li%elihood of success are older gestational age, higher h34, larger ectopic size,
and the presence of a fetal heartbeat.
o *he author li%es to use a rule of 7's because it is easy to remember. A patient who is
less than 7 wee%s from expected menses &. w% from last menstrual period F6M$G(, has an h34
level less than 7+++ m05/m6, and has an ectopic size less than 7 cm has a !,@ chance of
success with methotrexate. An increase beyond these parameters for gestational age, h34 level,
or ectopic size, or presence of a fetal heart motion on ultrasound significantly decreases the
success of this medical approach. *he patient should not have pelvic pain and should have only
minimal vaginal bleeding for medical therapy to be considered.
o :n the day of methotrexate inCection and on days - and . after the inCection, the h34
level is monitored. A ",@ drop in the h34 level is expected between day - and day ..
F"#G
9rom day
" to day -, a rise in the h34 level may occur. 0f a ",@ or more drop in the h34 level occurs from
day - to day ., then the patient is monitored with wee%ly h34 levels until the level is less than ,
m05/m6.
o $atients may have some cramping or discomfort on the side of the ectopic pregnancy
as the h34 declines, but these symptoms should be mild. *ypically, patients do not experience
bleeding until the h34 level is low.
o *he authors encourage increased fluid inta%e to avoid some of the adverse effects of
methotrexate &eg, mouth sores, renal impairment(. ?owever, this dose of methotrexate is much
smaller than that used to treat trophoblastic disease, and most patients have very little problems
with ta%ing it.
After methotrexate therapy for an ectopic pregnancy, any plateau or rising of h34 requires
evaluation. 0n some situations, considering a second dose of methotrexate is possible. ?owever,
surgery should be considered as well.
Any symptoms suggesting ectopic rupture &eg, acute pain, rebound tenderness( should
immediately direct the physician to the operating room.
o 6aparoscopy can still be considered if the patient is stable.
o A linear salpingostomy with excision of the ectopic pregnancy or partial
salpingectomy are the possible procedures.
o 0f the patient is unstable, the same procedures are performed using a laparotomy.
9or a complete abortion, the medical care is to treat any remaining anemia and to evaluate
the blood type and treat the patient with >ho4AM when indicated.
$rehospital careH Monitor vital signs and provide fluid resuscitation if the patient is
hemodynamically stable.
;mergency department careH 0f they %now what to expect, most patients with complete
abortions are not treated in the emergency department. :nly those with significant blood loss go to
the emergency department.
$atients with threatened, inevitable, incomplete, and ectopic pregnancies may go to the
emergency department.
o $atients with threatened abortions need an ultrasound to confirm the diagnosis and
for reassurance. 5sually, no other medical therapy is needed. *hese patients often are counseled
to increase fluid inta%e, remain at bedrest, or add progesterone supplements. ?owever, none of
these treatments have been proven effective in a prospective randomized trial.
o Abortion, 0nevitable , Abortion, 0ncomplete, and ;ctopic $regnancyare discussed
above and in separate articles.
Surgical $are
Eo surgical care is used for complete abortion.
0nevitable and incomplete abortions are typically treated surgically with suction DU3.
A septic abortion requires broad spectrum antibiotic therapy prior to a suction DU3, if possible
without delaying the DU3.
0f a boggy uterus is noted with active bleeding during a DU3, then methylergonovine maleate
&Methergine( &+.# mg 0M( may be given to contract the uterus. *his will also decrease the li%elihood
that clots will be retained in the uterus.
An ectopic pregnancy may be treated medically for the appropriate candidates. *he rest
require surgery. 1urgery for an ectopic pregnancy may consist of either linear salpingostomy or partial
or complete salpingectomy via laparoscopy or laparotomy. Although most ectopic pregnancies occur
in the fallopian tube, rarely they are located in the ovary and the ovary may need to be removed. An
ectopic pregnancy may be found in the abdomen after a tubal abortion has occurred. 0n this case, the
ectopic gestation is removed. 0f it is adherent to the bowel, then the ectopic gestation is removed as
much as possible and followup treatment with methotrexate is warranted. 0n this latter case, the h34
levels need to be monitored until they are less than , m05/m6. 9or more information, see eMedicine
article ;ctopic $regnancy.
Ahenever the diagnosis is uncertain, a diagnostic suction DU3 with a diagnostic laparoscopy
may be appropriate.
$onsultations
3onsult an obstetrician/gynecologist any time uncertainty about the diagnosis exists and to administer
treatment.
"iet
*he patient's diet should be regular if the diagnosis truly is a complete abortion.
0f any uncertainty about the diagnosis exists, restrict oral inta%e until certain that surgical
treatment is not necessary.
!ctivity
*he patient should rest for a few days to # wee%s for a complete abortion. *he rest schedule needs to
be adCusted if one of the other diagnoses is correct.
0edication Summary
9or a complete abortion, no medication is li%ely to be needed. 5sually, the uterus contracts well after
expelling the entire contents and the cervix is closed. *he ris% for infection is minimal.
Immune globulins
$lass Summary
5sed to suppress the immune system when the mother is >h negative.
Iiew full drug information
'ho 7"8 immune globulin 7'ho+!08

1uppresses immune response of mother who is nonsensitized >h : &D( negative exposed to >h :
&D( positive blood from the fetus as a result of a fetomaternal hemorrhage, abdominal trauma,
amniocentesis, abortion, fullterm delivery, or transfusion accident.
)rgot alkaloid and derivatives
$lass Summary
:ccasionally, the uterus does not contract well, and a clot may form in the uterine cavity. 0f the
physician notes a boggy uterus after expulsion of the products of conception, the physician may
consider methylergonovine in the appropriate candidate. 0n most cases in which a clot forms within
the uterus, a surgical DU3 finally is warranted.
Iiew full drug information
0ethylergonovine 70ethergine8

Acts directly on uterine smooth muscle, causing a sustained tetanic uterotonic effect that reduces
uterine bleeding and shortens the third stage of labor.
Administer 0M after a DU3, during puerperium, after delivery of placenta, or after delivering anterior
shoulder. Also may be administered 0I over no less than /+ sec, but should not be administered
routinely because it may provo%e hypertension or a stro%e. Monitor blood pressure closely when
administering 0I.
!ntineoplastic !gent1 !ntimetabolite
$lass Summary
*hese agents inhibit cell growth and proliferation.
Iiew full drug information
0ethotre(ate 7'heumatre(1 Tre(all8

Antimetabolite that inhibits dihydrofolate reductase, thereby hindering DEA synthesis and embryonic
cell reproduction.
rostaglandins
$lass Summary
Misoprostol, a prostaglandin agent, has been recently reported as safe and effective medical
treatment for missed abortion, inevitable abortion, or incomplete abortion. 0t is used as offlabeled
indication and is not 9DA approved for this indication.
Iiew full drug information
0isoprostol 7$ytotec8

$rostaglandin agent also categorized as an antiulcer &protective( and endocrine metabolic agent. As
a prostaglandin agent, misoprostol will increase uterine smooth muscle contractions and soften the
cervix to allow passage of products of conception from missed abortion, inevitable abortion, or
incomplete abortion. Eot 9DA approved for medical treatment of these types of abortions< yet, recent
literature suggests is that it is safe and effective. Administered orally or vaginally. 3omes in #++ mcg
tablets.
Further Inpatient $are
$atients do not need to remain in the hospital when a diagnosis of complete abortion is made.
*hese patients are usually sent home.
0f there are concerns about significant blood loss, then the patient may need to stay for #-
hour observation and receive blood transfusions.
0f there are concerns regarding significant infection, 0I antibiotic therapy may be needed for a
short time until fever/symptoms resolve.
Further %utpatient $are
Aith a complete abortion, measure the h34 level wee%ly until it is less than , m05/m6 in
situations in which the products of conception were not evaluated by a physician &eg, the products
were flushed down the toilet(.
0f the expelled products of conception are evaluated by a physician and confirmed to be intact
and truly products of conception &not a clot(, performing any further followup tests is not necessary.
$roviding reassurance and routine gynecologic care is recommended.
9or ectopic pregnancies, the h34 levels should be monitored as noted above, particularly if
medical therapy is performed. 0f surgical therapy is performed and it is a linear salpingostomy, then
the h34 levels should be monitored until they are less than , m05/m6. 0f a complete salpingectomy is
performed and the pathology confirms the ectopic pregnancy, then one may forgo the followup for
h34 levels.
"eterrence9revention
3ontraceptive counseling is warranted. $atients should avoid intercourse or use
contraception until the h34 levels have become negative. $atients may wish to continue
contraception until they are emotionally ready to try again to become pregnant.
$sychological counseling or grief counseling should be offered for those with early pregnancy
loss. 1upport groups can also be helpful.
$omplications
3omplete abortions may be complicated by infection or accumulation of clot in the uterine
cavity without expulsion due to uterine atony. Doth of these complications are rare.
:ccasionally, a decidual cast is passed and is mista%en for products of conception. 0n these
cases, an ectopic pregnancy is li%ely.
rognosis
*he prognosis for early pregnancy loss is excellent. After one complete abortion, no increased ris%
exists for another one. $atients need reassurance. =*ender loving care= with subsequent pregnancies
is proven effective therapy in some studies.
F"7, "-, ",G
*his approach includes early quantitative h34 levels
and ultrasounds wee%ly, after the h34 threshold is reached, with more frequent visits available if
needed for reassurance.
atient )ducation
*he patient needs to hear that one miscarriage does not put her at increased ris% for another
miscarriage. ?er next pregnancy is li%ely to last to term if she is young and has no other ris% factors.
Advise the patient to return to the emergency department if any of the following symptoms
occurH
$rofuse vaginal bleeding
1evere pelvic pain
*emperature greater than "++J9
$atients may experience intermittent menstrualli%e flow and cramps during the following
wee%. *he next menstrual period usually occurs in -, wee%s.
$atients may resume regular activities when able, but they should refrain from intercourse
and douching for approximately # wee%s.
9or excellent patient education resources, visit eMedicine's $regnancy and >eproduction
3enter. Also, see eMedicine's patient education articlesMiscarriage, Abortion, ;ctopic $regnancy,
and Dilation and 3urettage &DU3(.