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The American College of Obstetricians and Gynecologists The College , a c 3 organization, is the nation's leading group of physicians providing health care for women. Accurate determination of gestational age can positively affect pregnancy outcomes.
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- Methods for Estimating the Due Date - ACOG!
For instance, one study found a reduction in the need for postterm inductions in a group of women randomized to receive routine first-trimester ultrasonography compared with women who received only second-trimester ultrasonography 5. A Cochrane review concluded that ultrasonography can reduce the need for postterm induction and lead to earlier detection of multiple gestations 6.
Because decisions to change the EDD significantly affect pregnancy management, their implications should be discussed with patients and recorded in the medical record. Measurements of the CRL are more accurate the earlier in the first trimester that ultrasonography is performed 11, 15— The measurement used for dating should be the mean of three discrete CRL measurements when possible and should be obtained in a true midsagittal plane, with the genital tubercle and fetal spine longitudinally in view and the maximum length from cranium to caudal rump measured as a straight line 8, Mean sac diameter measurements are not recommended for estimating the due date.
Dating changes for smaller discrepancies are appropriate based on how early in the first trimester the ultrasound examination was performed and clinical assessment of the reliability of the LMP date Table 1. For instance, the EDD for a pregnancy that resulted from in vitro fertilization should be assigned using the age of the embryo and the date of transfer.
Committee opinion no 611: method for estimating due date.
For example, for a day-5 embryo, the EDD would be days from the embryo replacement date. Likewise, the EDD for a day-3 embryo would be days from the embryo replacement date. Using a single ultrasound examination in the second trimester to assist in determining the gestational age enables simultaneous fetal anatomic evaluation. With rare exception, if a first-trimester ultrasound examination was performed, especially one consistent with LMP dating, gestational age should not be adjusted based on a second-trimester ultrasound examination.
Ultrasonography dating in the second trimester typically is based on regression formulas that incorporate variables such as. Other biometric variables, such as additional long bones and the transverse cerebellar diameter, also can play a role. Date changes for smaller discrepancies 10—14 days are appropriate based on how early in this second-trimester range the ultrasound examination was performed and on clinician assessment of LMP reliability.
Because of the risk of redating a small fetus that may be growth restricted, management decisions based on third-trimester ultrasonography alone are especially problematic; therefore, decisions need to be guided by careful consideration of the entire clinical picture and may require close surveillance, including repeat ultrasonography, to ensure appropriate interval growth.
The best available data support adjusting the EDD of a pregnancy if the first ultrasonography in the pregnancy is performed in the third trimester and suggests a discrepancy in gestational dating of more than 21 days. As soon as data from the LMP, the first accurate ultrasound examination, or both are obtained, the gestational age and the EDD should be determined, discussed with the patient, and documented clearly in the medical record.
ACOG Reinvents the Pregnancy Wheel
For the purposes of research and surveillance, the best obstetric estimate, rather than estimates based on the LMP alone, should be used as the measure for gestational age. The American College of Obstetricians and Gynecologists, the American Institute of Ultrasound in Medicine, and the Society for Maternal—Fetal Medicine recognize the advantages of a single dating paradigm being used within and between institutions that provide obstetric care.
Table 1 provides guidelines for estimating the due date based on ultrasonography and the LMP in pregnancy, and provides single-point cutoffs and ranges based on available evidence and expert opinion. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.
Methods for estimating the due date. American College of Obstetricians and Gynecologists.
ACOG Reinvents the Pregnancy Wheel - ACOG
Women's Health Care Physicians. Recommendations The American College of Obstetricians and Gynecologists, the American Institute of Ultrasound in Medicine, and the Society for Maternal—Fetal Medicine make the following recommendations regarding the method for estimating gestational age and due date: Indicated preterm deliveries in women with suboptimally dated pregnancies should be based on the best clinical estimate of gestational age. Although guidelines for indicated late-preterm and early-term deliveries depend on accurate determination of gestational age, women with suboptimally dated pregnancies should be managed according to these same guidelines because of the lack of a superior alternative 8 , 9.
Antenatal corticosteroid administration generally is recommended before anticipated delivery between 24 weeks and 34 weeks of gestation There is insufficient data to support a policy for antenatal corticosteroid exposure in the setting of a woman with a suboptimally dated pregnancy undergoing presumed term delivery. Historically, amniocentesis has been used to assess fetal lung maturity before the planned delivery of a fetus lacking an accurate gestational age determination in order to mitigate the risks of unintentionally delivering a fetus at an earlier-than-expected gestational age However, late-preterm and early-term newborns with mature fetal lung profiles remain at increased risk of adverse respiratory and nonrespiratory morbidities when compared with newborns born at or beyond 39 weeks of gestation 1, 8, 13 , Given the lack of reliability for predicting newborn pulmonary outcomes and an inability to predict nonrespiratory outcomes, amniocentesis for fetal lung maturity is not recommended as a routine component of decision making when considering delivery in a woman with a suboptimally dated pregnancy.
Management of a presumably late-term pregnancy that lacks accurate gestational age determination warrants different consideration because the greater risk for these ongoing gestations is unrecognized advanced postmaturity and related increases in perinatal morbidity and mortality Given concern that a full-term or late-term suboptimally dated pregnancy could actually be weeks further along than it is believed to be 16 , late-term delivery is indicated at 41 weeks of gestation when gestational age is uncertain, using the best clinical estimate of gestational age.
For similar reasons, initiation of antepartum fetal surveillance at 39—40 weeks of gestation may be considered for suboptimally dated pregnancies. Delivery management of a pregnancy in a woman with a prior cesarean delivery also can be complicated by suboptimal pregnancy dating. In suitable candidates who favor a trial of labor after cesarean delivery but lack accurate gestational age determination, decisions about delivery timing and mode of delivery should be based on the best clinical estimate of gestational age In a patient with a suboptimally dated pregnancy and a prior low-transverse cesarean delivery who requests a repeat cesarean delivery, delivery is advised at 39 weeks of gestation using best clinical estimate of gestational age.
Although this follow-up examination is intended to support the working gestational age, interval fetal growth assessment potentially may detect cases of fetal growth restriction. For cases in which fetal growth restriction is suspected upon follow-up ultrasonography, fetal surveillance with umbilical artery Doppler velocimetry study is indicated and delivery timing should be reconsidered When planning a delivery in a woman with a suboptimally dated pregnancy, the patient should be informed that limitations in determining an accurate gestational age introduce a greater risk of neonatal morbidity if the pregnancy is dated incorrectly and is actually earlier in gestation than it is believed to be.
However, the patient should be informed that the rationale supporting delivery is that the risks of an ongoing pregnancy in the setting of a specific indication are believed to outweigh the risks associated with inaccurate gestational age assignment.
No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Management of suboptimally dated pregnancies. American College of Obstetricians and Gynecologists. Women's Health Care Physicians.