The American College of

Obstetricians and Gynecologists

WOMEN’S HEALTH CARE PHYSICIANS

P RACTICE BULLET IN
CLINICAL MANAGEMENT GUIDELINES FOR OBSTETRICIAN – GYNECOLOGISTS

NUMBER 175, DECEMBER 2016 (Replaces Practice Bulletin 101, February 2009,
(Reaffirmed 2018) and Committee Opinion 297, August 2004)

Ultrasound in Pregnancy
Obstetric ultrasonography is an important and common part of obstetric care in the United States. The purpose of this
document is to present information and evidence regarding the methodology of, indications for, benefits of, and risks
associated with obstetric ultrasonography in specific clinical situations. Portions of this Practice Bulletin were devel-
oped from collaborative documents with the American College of Radiology and the American Institute of Ultrasound
in Medicine (1, 2).

Background for later review. To ensure that the ultrasound equipment

is operating at a safe and optimal level, regular service
Instrumentation should be performed as recommended by the manufacturer.
Obstetric ultrasound examinations are performed with a Types of Examinations
transabdominal, transvaginal, or transperineal approach.
Real-time ultrasonography is necessary to confirm fetal The American College of Obstetricians and Gynecologists,
viability through observation of cardiac activity and the American College of Radiology, the American
active fetal movement. The choice of transducer fre- Institute of Ultrasound in Medicine, the National
quency is a trade-off between beam penetration and Institute of Child Health and Human Development, the
resolution. Lower frequencies provide better penetration Society for Maternal–Fetal Medicine, and the Society of
but at the expense of resolution. Selection of the proper Radiologists in Ultrasound have adopted the following
transducer is based on the clinical situation; however, uniform terminology for the performance of ultrasonog-
with modern equipment, abdominal transducers gener- raphy in the second trimester and the third trimester:
ally allow sufficient penetration in most patients while standard, limited, and specialized (1–3).
providing adequate resolution. During early pregnancy,
an abdominal transducer with a frequency of 5 MHz or Standard Examination
a transvaginal transducer with a frequency of 5–10 MHz A standard obstetric ultrasound examination includes an
or higher generally provides very good resolution while evaluation of fetal presentation and number, amniotic
allowing adequate penetration. A lower-frequency trans- fluid volume, cardiac activity, placental position, fetal
ducer may be needed to provide adequate penetration biometry, and an anatomic survey. The maternal cervix
for abdominal imaging later in pregnancy or in an obese and adnexa should be examined as clinically appropriate
patient. Images should be archived and easily accessible and when technically feasible.

Committee on Practice Bulletins—Obstetrics and American Institute of Ultrasound in Medicine. This Practice Bulletin was developed by the
American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Obstetrics and the American Institute of Ultrasound in Medicine
in collaboration with Lynn L. Simpson, MD.
The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These guidelines should not be
construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient,
resources, and limitations unique to the institution or type of practice.
 The necessary components of fetal anatomy in a Limited Examination
standard examination are listed in Box 1 and commonly
A limited examination is performed when a specific
can be obtained after approximately 18 weeks of gesta-
question requires investigation. It does not replace a
tion, although it may be possible to document normal
standard examination. For example, a limited examina-
structures before this time. Sometimes structures can
tion in the second trimester or the third trimester could
be difficult to visualize because of fetal size, position,
be performed to confirm fetal heart activity in a patient
and movement; maternal abdominal scars; increased
experiencing vaginal bleeding or confirm placental loca-
maternal abdominal wall thickness; and reduced amni-
tion or to establish fetal presentation in a laboring
otic fluid volume. When technical limitations result in
patient. A limited examination also may be performed in
suboptimal images, the nature of the limitations should
any trimester to estimate amniotic fluid volume, evaluate
be documented in the report; a follow-up examination
the cervix, or assess embryonic or fetal viability.
should be considered.
Specialized Examination
Box 1. Essential Elements of The components of the specialized examination are
Standard Examination of Fetal Anatomy ^ more extensive than for a standard ultrasound examina-
tion and are determined on a case-by-case basis. Also
Head, Face, and Neck* referred to as a “detailed,” “targeted,” or “76811” ultra-
Lateral cerebral ventricles sound examination, the specialized anatomic examina-
Choroid plexus tion is performed when there is an increased risk of an
Midline falx anomaly based on the history, laboratory abnormalities,
or the results of the limited examination or the standard
Cavum septum pellucidi examination (4). Other specialized examinations include
Cerebellum fetal Doppler ultrasonography, biophysical profile, fetal
Cisterna magna echocardiography, or additional biometric measure-
Upper lip ments. Specialized examinations are performed by an
operator with formal training in this area (4). Indications
Chest for specialized examinations also include the possibility
Heart of fetal growth restriction and multifetal gestation (5, 6).
Four-chamber view
Left and right ventricular outflow tracts First-Trimester Ultrasound Examination
Indications. A first-trimester ultrasound examination
Abdomen
is performed before 14 0/7 weeks of gestation. Some
Stomach (presence, size, and situs) indications for performing first-trimester ultrasound
Kidneys examinations are listed in Box 2.
Urinary bladder Imaging Parameters. An ultrasound examination may
Umbilical cord insertion site into the fetal abdomen be performed either transabdominally or transvaginally.
Umbilical cord vessel number If a transabdominal examination is inconclusive, a
transvaginal scan or transperineal scan is recommended.
Spine
The following factors should be considered during the
Cervical, thoracic, lumbar, and sacral spine examination.
Extremities The uterus, including the cervix, and the adnexa
Legs and arms should be evaluated for the presence of a gestational sac
Fetal Sex and any adnexal pathology. If a gestational sac is seen,
its location should be documented. The gestational sac
In multiple gestations and when medically indicated
should be evaluated for the presence or absence of a
*A measurement of the nuchal fold may be helpful during a specific yolk sac or embryo, and the crown–rump length of the
gestational age interval to assess the risk of aneuploidy. embryo should be documented. The crown–rump length
Data from the American College of Radiology. ACR-ACOG- is a more accurate indicator of gestational (menstrual)
AIUM-SRU Practice parameter for the performance of obstetrical
ultrasound. ACR, Diagnostic Radiology: Ultrasonography Practice age than the mean gestational sac diameter. Mean sac
Parameters and Technical Standards, 2013. Amended 2014. diameter measurements are not recommended for esti-
mating the due date (7). However, the mean gestational

2 Practice Bulletin No. 175

sac diameter may be recorded when an embryo is not Second- and Third-Trimester Ultrasound
identified. Caution should be used in presumptively Examination
diagnosing a gestational sac in the absence of a definite
embryo or yolk sac. Without these findings, an intrauter- Indications. Ultrasonography can be beneficial in many
ine fluid collection could represent a pseudogestational situations in the second and third trimesters. Indications
sac associated with an ectopic pregnancy. for second- and third-trimester ultrasonography are
Presence or absence of cardiac activity should be listed in Box 3.
reported. The criteria for diagnosing nonviability in early Imaging Parameters for a Standard Fetal Examination.
pregnancy have been revised to reduce false positive Transabdominal ultrasonography generally is used to
results (8). An embryo should be visible by transvaginal assess the second- and third-trimester pregnancy, with
ultrasonography with a mean gestational sac diameter of transvaginal ultrasonography added as needed. If a trans-
25 mm or greater. With transvaginal ultrasound exami- abdominal examination is inconclusive, a transvaginal
nations, cardiac motion should be observed when the scan or transperineal scan is recommended. This may
embryo is 7 mm or greater in length. If an embryo less be especially useful in imaging the fetal brain structures
than 7 mm in length is seen without cardiac activity, a
when the head lies deep within the maternal pelvis or
subsequent ultrasound examination at a later time may
when a low-lying placenta is obscured by shadowing.
be needed to assess the presence or absence of cardiac
Fetal cardiac activity, fetal number, and fetal presenta-
activity. Fetal number should be reported. Amnionicity
tion should be reported. Any abnormal heart rates or
and chorionicity should be documented, to the extent
rhythms should be reported. An abnormal finding on
possible, for all multiple gestations. Embryonic or fetal
second-trimester ultrasonography that identifies a major
anatomy should be assessed as appropriate for the ges-
congenital anomaly significantly increases the risk of
tational age.
genetic abnormality and warrants further counseling,
including the discussion of various prenatal testing
strategies. Multiple gestations require the documentation
Box 2. Indications for First-Trimester of this additional information: chorionicity, amnionic-
Ultrasonography ^ ity, comparison of fetal sizes, fetal sex (when pos-
Indications for first-trimester ultrasonography include, sible to visualize), estimation of amniotic fluid volume
but are not limited to the following: (increased, decreased, or normal) in each sac, and, if
• To confirm the presence of an intrauterine monochorionic or of uncertain chorionicity, findings that
pregnancy may suggest twin–twin transfusion syndrome.
• To evaluate a suspected ectopic pregnancy Ultrasonography can detect abnormalities in amni-
• To evaluate vaginal bleeding otic fluid volume. An estimate of amniotic fluid volume
should be reported. Although it is acceptable for expe-
• To evaluate pelvic pain
rienced examiners to qualitatively estimate amniotic
• To estimate gestational age fluid volume, semiquantitative methods also have been
• To diagnose or evaluate multiple gestations described for this purpose (eg, amniotic fluid index
• To confirm cardiac activity [AFI] and single deepest pocket) and are preferred
because of their reproducibility.
• As adjunct to chorionic villus sampling, embryo
transfer, or localization and removal of an intra- The placental location, appearance, and relationship
uterine device to the internal cervical os should be recorded. It is recog-
nized that apparent placental position early in pregnancy
• To assess for certain fetal anomalies, such as
may not correlate with its location at the time of deliv-
anencephaly, in patients at high risk
ery. Therefore, if a low-lying placenta or placenta previa
• To evaluate maternal pelvic or adnexal masses or is suspected early in gestation, verification in the third
uterine abnormalities trimester by repeat ultrasonography is indicated. If an
• To screen for fetal aneuploidy anterior placenta previa or low-lying placenta is found
• To evaluate suspected hydatidiform mole in a patient with a prior cesarean delivery, the possibil-
ity of abnormal implantation, including placenta accreta,
Data from the American College of Radiology. ACR-ACOG-
AIUM-SRU Practice parameter for the performance of obstetrical
should be considered.
ultrasound. ACR, Diagnostic Radiology: Ultrasonography Practice Transabdominal, transvaginal, or transperineal
Parameters and Technical Standards, 2013. Amended 2014. views may be helpful in assessing cervical length or
visualizing the internal cervical os and its relationship

Practice Bulletin No. 175 3

to the placenta. Transvaginal or transperineal ultraso- Gestational age is most accurately determined in
nography should be considered if the cervix appears the first half of pregnancy. First-trimester crown–rump
shortened. measurement is the most accurate means for ultrasound
dating of pregnancy. Beginning at 14 weeks, a variety
of ultrasound parameters, such as biparietal diameter,
abdominal circumference, and femoral diaphysis length,
Box 3. Indications for Second- and
can be used to estimate gestational age. However, the
Third-Trimester Ultrasonography ^
variability of gestational age estimation increases with
Indications for second- and third-trimester ultrasonog- advancing pregnancy. Standards for acceptable variation
raphy include, but are not limited to the following: in ultrasonographic gestational age have been previ-
• Screening for fetal anomalies ously published (7). Significant discrepancies between
• Evaluation of fetal anatomy gestational age and fetal measurements, especially later
• Estimation of gestational age in pregnancy, may suggest a fetal growth abnormality
such as intrauterine growth restriction or macrosomia.
• Evaluation of fetal growth
The gestational age should not be revised after a date
• Evaluation of vaginal bleeding has been calculated from an accurate earlier scan that is
• Evaluation of abdominal or pelvic pain available for comparison.
• Evaluation of cervical insufficiency Biparietal diameter is measured at the level of
• Determination of fetal presentation the thalamus and cavum septi pellucidi. The cerebel-
lar hemispheres should not be visible in this scanning
• Evaluation of suspected multiple gestation plane. The measurement is taken from the outer edge of
• Adjunct to amniocentesis or other procedure the proximal skull to the inner edge of the distal skull.
• Evaluation of a significant discrepancy between The head shape may be flattened (dolichocephalic) or
uterine size and clinical dates rounded (brachycephalic) as a normal variant. Under
• Evaluation of a pelvic mass these circumstances, measurement of the head circum-
• Evaluation of a suspected hydatidiform mole ference may be more reliable than measurement of the
biparietal diameter for estimating gestational age. Head
• Adjunct to cervical cerclage placement
circumference is measured at the same level as the bipa-
• Suspected ectopic pregnancy rietal diameter, around the outer perimeter of the calvar-
• Suspected fetal death ium. The accuracy of head circumference measurement
• Suspected uterine abnormalities is not affected by head shape.
Femoral diaphysis length can be used for dating
• Evaluation of fetal well-being
after 14 weeks of gestation. The long axis of the femo-
• Suspected amniotic fluid abnormalities ral shaft is most accurately measured with the beam of
• Suspected placental abruption insonation perpendicular to the shaft, excluding the dis-
• Adjunct to external cephalic version tal femoral epiphysis.
• Evaluation of prelabor rupture of membranes or Abdominal circumference or average abdominal
premature labor diameter should be determined at the skin line on a
• Evaluation of abnormal biochemical markers true transverse view at the level of the umbilical vein,
portal sinus, and fetal stomach when visible. Abdominal
• Follow-up evaluation of a fetal anomaly circumference or average abdominal diameter measure-
• Follow-up evaluation of placental location for ment is used with other biometric parameters to estimate
suspected placenta previa fetal weight and may allow detection of intrauterine
• History of previous congenital anomaly growth restriction or macrosomia.
• Evaluation of the fetal condition in late registrants Fetal weight can be estimated by obtaining mea-
for prenatal care surements such as the biparietal diameter, head circum-
• Assessment for findings that may increase the risk of ference, abdominal circumference or average abdominal
aneuploidy diameter, and femoral diaphysis length. Results from
various prediction models can be compared with fetal
Data from the American College of Radiology. ACR-ACOG- weight percentiles from published nomograms. If pre-
AIUM-SRU Practice parameter for the performance of obstetrical
ultrasound. ACR, Diagnostic Radiology: Ultrasonography Practice vious ultrasound studies have been performed during
Parameters and Technical Standards, 2013. Amended 2014. the pregnancy, appropriateness of growth also should
be reported. Scans for growth evaluation typically are

4 Practice Bulletin No. 175

performed at least 3–4 weeks apart. In rare cases, a with published standards and guidelines for the perfor-
2-week interval may be chosen, but a shorter scan mance of obstetric ultrasound examinations (10).
interval may result in confusion as to whether size dif- Physicians who perform, evaluate, and interpret
ferences are caused by growth or by variations in the diagnostic obstetric ultrasound examinations should be
measurement technique itself. Currently, even the best licensed medical practitioners with an understanding of
fetal weight prediction methods can yield errors as high the indications for such imaging studies, the expected
as plus or minus 20%. This variability can be influenced content of a complete obstetric ultrasound examination,
by factors such as the nature of the patient population, and a familiarity with the limitations of ultrasound imag-
the number and types of anatomic parameters being ing. They should be familiar with ultrasound safety and
measured, technical factors that affect the resolution of the anatomy, physiology, and pathophysiology of the
ultrasound images, and the weight range being studied. pelvis, pregnant uterus, and fetus. All physicians who per-
Evaluation of the uterus, adnexal structures, and form or supervise the performance of obstetric ultrasonog-
cervix should be performed when feasible. The presence, raphy should have received specific training in obstetric
location, size, and characteristics of adnexal masses ultrasonography; this is especially necessary in perform-
should be documented, as well as the presence of any ing specialized obstetric ultrasound examinations (4).
leiomyomas with potential clinical significance. It may Physicians are responsible for the quality and
not be possible to image normal maternal ovaries during accuracy of ultrasound examinations performed in their
the second and third trimesters. names, regardless of whether they personally produced
the images. Physicians also are responsible for the qual-
Three-Dimensional Ultrasonography ity of the documentation of examinations and the quality
Three-dimensional ultrasonography represents an control and safety of the environments, the ultrasonog-
advance in imaging technology. With three-dimensional raphy, and the procedures performed.
ultrasonography, the volume of a target anatomic region
can be calculated. The defined volume then can be dis- Documentation and Quality Assurance
played in three orthogonal two-dimensional planes rep- Adequate documentation is essential for high-quality
resenting the sagittal, transverse, and coronal planes of patient care and communication of medical information.
a reference two-dimensional image within the volume. There should be a report of each ultrasound examination,
The volume also can be displayed in its rendered format, which includes all findings and an interpretation. Quality
which depicts the topographic anatomy of the volume. control should be accomplished through careful docu-
The technical advantages of three-dimensional ultraso- mentation of obstetric ultrasound examination results,
nography include its ability to acquire and manipulate a organized and reliable archiving of reports and images
large number of planes and to display ultrasound planes and, ideally, correlation with clinical outcomes. Quality
traditionally inaccessible by two-dimensional ultra- review and education regarding nuchal translucency
sonography. Despite these technical advantages, proof measurement, first-trimester nasal bone assessment, and
of a clinical advantage of three-dimensional ultrasonog- cervical length measurement are available from organi-
raphy in prenatal diagnosis in general still is lacking. zations such as the Perinatal Quality Foundation and the
Potential areas of promise include fetal facial anomalies, Fetal Medicine Foundation. Quality assurance is an inte-
neural tube defects, fetal tumors, and skeletal malforma- gral part of clinical care and obstetric ultrasonography is
tions for which three-dimensional ultrasonography may no exception. Practices that perform obstetric imaging as
be helpful in diagnosis as an adjunct to but not a replace- part of their clinical services should continually correlate
ment for two-dimensional ultrasonography (9). their imaging results to clinical outcomes.

Ultrasound Facility Accreditation Patient Safety

The American Institute of Ultrasound in Medicine and Ultrasonography is safe for the fetus when used appro-
the American College of Radiology offer ultrasound priately and should be used when medical information
facility accreditation. This process involves a review of about a pregnancy is needed; however, ultrasound
ultrasound case studies, equipment use and maintenance, energy delivered to the fetus cannot be assumed to be
report generation, image storage, and ultrasonographer completely innocuous, and the possibility exists that
and physician qualifications. Practices, not individuals, such biological effects may be identified in the future
may be accredited in ultrasonography for obstetrics, (11). Thus, ultrasonography should be performed only
gynecology, or both. Practices that receive ultrasound when there is a valid medical indication and, in all cases,
accreditation have been shown to improve compliance the lowest possible ultrasound exposure settings that

Practice Bulletin No. 175 5

obtain adequate image quality and gain the necessary that tertiary-level centers have higher detection rates
diagnostic information should be used, following the as- for detecting fetal anomalies, but when an ultrasound
low-as-reasonably-achievable (ALARA) principle (12). examination is performed, patients should be counseled
Aligned with the ALARA principle, spectral or “flow” about the limitations of ultrasonography regardless of
Doppler should not routinely be used to “auscultate” the the site, skill of the examiner, or the sophistication of
fetal heart rate in the first trimester because of its higher the equipment.
energy delivery; instead, adequate documentation of
viability can be obtained with use of M-mode scanning What is the sensitivity of ultrasonography for
or conventional two-dimensional real-time ultrasonogra- detecting fetal anomalies?
phy with video archiving (1). Ultrasonography can be used to diagnose many major
fetal anomalies. However, significant variability in the
Cleaning and Sterilization sensitivity of routine ultrasonography for detection of
Use of ultrasound transducers, like any instrument used fetal anomalies has been reported (18–20). In a review
on a patient, presents the possibility of microbial of 36 studies that included more than 900,000 fetuses, an
transmission if not properly cleaned after each use. overall sensitivity of approximately 40% for detecting
Transabdominal ultrasonography is not completely free fetal anomalies was noted, with a range from less than
of this risk, although the risk is substantially lower than 15% to higher than 80% (21). In general, studies per-
it is for transvaginal and transperineal ultrasonography. formed at tertiary centers showed a higher detection rate
Transabdominal ultrasound transducers may be ade- for fetal anomalies (19, 22). Also, studies on this subject
quately cleansed between patients with soap and water have varied with regard to the definition of major versus
or a disposable disinfectant spray or wipe. Transvaginal minor fetal anomalies, the level of background risk of
ultrasound transducers always should be covered with anomalies in the study population, the level of training
a single-use disposable cover when used. However, and expertise of the operators, and the completeness of
disposable protective covers are not without risk of rup- anomaly confirmation. The detection rate tends to be
ture or defect, and it is recommended that transvaginal higher for defects of the central nervous system and
ultrasound transducers undergo high-level disinfection urinary tract than for the heart and great vessels (23).
between each use. Steps involved in cleaning transvagi- Obesity also lowers detection rates of fetal anomalies
nal ultrasound transducers include using running water during prenatal ultrasonography (24, 25).
followed by a damp soft cloth with mild soap, and a Although detection of some anomalies is possible
small brush if needed, to thoroughly cleanse the probe, as early as 11–14 weeks, the use of ultrasonography to
followed by high-level disinfection with chemical agents screen for major fetal anomalies in the first trimester
(13, 14). The U.S. Food and Drug Administration has should not replace the more appropriate screening of
published a list of approved high-level disinfectants for fetal anatomy in the second trimester (26). The benefits
use in processing reusable medical devices (15). For and limitations of ultrasonography should be discussed
all chemical disinfectants, precautions must be taken with all patients.
to protect workers and patients from the toxicity of the
disinfectant. Practitioners should consult the labels of What is the role of nonmedical use of ultra-
proprietary products for specific instructions as well as sonography in pregnancy?
instrument manufacturers regarding the compatibility of
these agents with probes. Although there is no reliable evidence of physical harm
to human fetuses from diagnostic ultrasound imaging
using current technology, casual use of ultrasonography,
Clinical Considerations and especially during pregnancy, should be avoided. The
use of two-dimensional or three-dimensional ultraso-
Recommendations nography without a medical indication and only to view
the fetus, obtain a “keepsake” picture, or determine the
Should all patients be offered ultrasonography?
fetal sex is inappropriate and contrary to responsible
At various gestational ages, an ultrasound examination medical practice. Viewed in this light, exposing the
is an accurate method of determining gestational age, fetus to ultrasound energy with no anticipation of medi-
fetal number, viability, and placental location, and it is cal benefit is not justified (27–29). The U.S. Food and
recommended for all pregnant patients (16, 17) An ultra- Drug Administration views the promotion, sale, or lease
sound examination in the second trimester also should of ultrasound equipment for making “keepsake” fetal
include screening for structural abnormalities. It appears videos as an unapproved use of a medical device. Use

6 Practice Bulletin No. 175

of ultrasonography without a physician’s order may be a fetal aneuploidy screening), use of dating by a reliable
violation of state or local laws or regulations regarding last menstrual period is acceptable. When performed,
the use of a prescription medical device (30). ultrasound measurement of the embryo or fetus in the
In addition, nonmedical ultrasonography may first trimester is the most precise method to confirm or
falsely reassure pregnant women who may incorrectly establish gestational age. Measurements of the crown–
believe that the ultrasound imaging is diagnostic. If rump length are more precise the earlier in the first
abnormalities are detected in this setting, patients may trimester that ultrasonography is performed and are
not receive the necessary support, information, and fol- more precise than mean sac diameter measurements (7).
low-up. Obstetric ultrasonography is most appropriately Before 14 0/7 weeks of gestation, gestational age assess-
obtained as part of delivery of prenatal care and should ment based on measurement of the crown–rump length
be performed only with the intention of providing medi- has a precision of 5–7 days (7, 34, 35). If the embryonic
cal benefit to the patient (31). morphology is normal and if ultrasound dating before
9 0/7 weeks of gestation differs by more than 5 days
What is the optimal gestational age at from menstrual dating, or if ultrasound dating between
which to perform an obstetric ultrasound 9 0/7 weeks of gestation and 13 6/7 weeks of gestation
examination? differs by more than 7 days from menstrual dating, the
estimated due date should be changed to correspond with
The best gestational age for obstetric ultrasonography
the ultrasound dating. Dating changes for smaller dis-
will depend on the clinical indication for the examina-
crepancies may be appropriate depending on how early
tion. For patients with uncertain or unreliable menstrual
in the first trimester the ultrasound examination was per-
dating or with an indication to confirm viability, first-
formed, the reliability of the last menstrual period date,
trimester ultrasonography is most accurate (7). In these
and other relevant information (Table 1).
instances, a dating ultrasound examination should be
At measurements greater than 84 mm (correspond-
obtained at the first prenatal visit.
ing to 14 0/7 weeks of gestation), the precision of the
When used as part of combined first-trimester
crown–rump length to estimate gestational age decreases,
screening or integrated screening for aneuploidy, an
and in these cases, multiple second-trimester biometric
ultrasound examination with nuchal translucency mea-
parameters should be used for dating. Ultrasound dating
surement before 14 0/7 weeks of gestation provides
in the second trimester typically is based on calculations
accurate dating of pregnancy and an effective screening
that incorporate the biparietal diameter, head circumfer-
test for trisomy 13, trisomy 18, and trisomy 21 when
ence, femur length, and abdominal circumference. Of
combined with maternal age and serum markers (32,
the different measurements, the head circumference is
33). However, a complete anatomic assessment is not
the single most-predictive parameter of gestational age
possible before at least 14 weeks of gestation.
between 14–22 weeks of gestation, although combining
In the absence of other specific indications, the
various parameters improves the precision of gestational
optimal time for a single ultrasound examination is
age over the use of head circumference measurement
at 18–22 weeks of gestation. This timing allows for a
alone (16, 36). Formulas derived from singleton data
survey of fetal anatomy in most women and an accurate
can be used to determine gestational age in twins and
estimation of gestational age. At 18–22 weeks of gesta-
triplets (37).
tion, anatomically complex organs such as the fetal heart
The third trimester (28 0/7 weeks of gestation and
and brain can be imaged with sufficient clarity to allow
beyond) is the least accurate period for gestational age
detection of many major malformations, compared with
assessment by ultrasonography, with a precision range
visualization earlier in pregnancy when the anatomy
of plus or minus 21–30 days (7). As in the second tri-
is not as well developed. This timing also allows for
mester, measurement of the four biometric parameters
management options to be available, including fetal
usually is used to calculate a mean ultrasonographic ges-
monitoring and treatment and, for those who desire it,
tational age in the third trimester. Among the four, the
pregnancy termination. In the obese patient, expecta-
best single measurement of gestational age in the third
tions regarding visualization of fetal anatomy should be
trimester is the femur length. However, reported preci-
tempered.
sion of femur length ranges from 3–4 weeks at term (38,
39). Reassigning gestational age in the third trimester
How and when is ultrasonography used to
should be done with caution because of this wide mar-
adjust gestational age? gin of precision and, therefore, early ultrasound dating
In clinical situations for which first-trimester ultraso- is preferred. Repeat ultrasound examinations to ensure
nography is not performed for other indications (such as appropriate interval growth may be necessary to guide

Practice Bulletin No. 175 7

management decisions late in pregnancy but should not fluid pocket with either method, the width of the pocket
be used to change a gestational age or estimated date must be at least 1 cm.
of delivery established by an earlier reliable ultrasound The term oligohydramnios refers to decreased
examination. In general, gestational age established by amniotic fluid volume relative to gestational age.
ultrasound examination should take preference over Oligohydramnios is associated with genitourinary abnor-
estimates based on the last menstrual period when the malities in the fetus, premature rupture of membranes,
discrepancy between the estimated ages is greater than uteroplacental insufficiency, and postterm pregnancy.
the precision of ultrasonography as noted in Table 1 (7). Oligohydramnios has been linked to increased rates of
perinatal morbidity and mortality (42). Oligohydramnios
How is amniotic fluid volume evaluated is described in various ways, including absence of
using ultrasonography? a vertical pocket of at least 2 cm and an AFI of less than
5 cm. However, best available evidence supports using
Several techniques have been proposed for the estima- the deepest vertical pocket method of measurement
tion of amniotic fluid during the ultrasound examination, because it leads to fewer interventions with no increase
including a subjective assessment, measurement of the in poor perinatal outcomes compared with use of the
single deepest vertical pocket, and the AFI. Objective AFI (3, 43, 44). Only the deepest vertical pocket method
measurement to detect amniotic fluid abnormalities has should be used with multiple pregnancies.
many advantages over subjective assessment, includ- The term polyhydramnios refers to increased
ing reproducibility, easily communicated levels of fluid amniotic fluid volume relative to gestational age.
volume, and the ability to follow trends in amniotic fluid Polyhydramnios most often is idiopathic but can be asso-
measurement. It is recommended that objective, rather ciated with gestational and pregestational diabetes, fetal
than subjective, measurements of amniotic fluid volume structural abnormalities and chromosomal abnormali-
be used, especially in the third trimester. ties, fetal infections, multiple gestations with twin–twin
The single deepest pocket technique involves find- transfusion syndrome, or fetal anemia due to isoim-
ing the deepest pocket of amniotic fluid that is free munization or fetal–maternal hemorrhage. Idiopathic
of cord and fetal parts with the ultrasound transducer polyhydramnios, which represents 50–60% of cases of
oriented perpendicular to the floor, then measuring polyhydramnios, has been linked to fetal macrosomia
the pocket’s greatest vertical dimension (40). The AFI and an increase in adverse pregnancy outcome (45),
technique is based on the division of the uterus into four including stillbirth (46). Polyhydramnios commonly is
quadrants and measuring the deepest vertical pocket of described by an AFI greater than or equal to 24 cm or a
fluid in each quadrant and then adding the four measure- maximum deepest vertical pocket of equal to or greater
ments together (41). To qualify as a measurable amniotic than 8 cm.

Table 1. Guidelines for Redating Based on Ultrasonography ^

Gestational Age Range* Method of Measurement Discrepancy Between Ultrasound Dating

and LMP Dating That Supports Redating
8 6/7 wk or less CRL More than 5 d
9 0/7 wk to 13 6/7 wk CRL More than 7 d
14 0/7 wk to 15 6/7 wk BPD, HC, AC, FL More than 7 d
16 0/7 wk to 21 6/7 wk BPD, HC, AC, FL More than 10 d
22 0/7 wk to 27 6/7 wk BPD, HC, AC, FL More than 14 d
28 0/7 wk and beyond †
BPD, HC, AC, FL More than 21 d
Abbreviations: AC, abdominal circumference; BPD, biparietal diameter; CRL, crown–rump length; FL, femur length; HC, head circumference;
LMP, last menstrual period.
*Based on LMP.
†
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 and need to be guided by careful consideration of the entire clinical picture and close surveillance.
Method for estimating due date. Committee Opinion No. 611. American College of Obstetricians and Gynecologists. Obstet Gynecol
2014;124:863–6.

8 Practice Bulletin No. 175

 Can ultrasonography alone be used to modify high-risk populations have reported detection rates of
the risk of fetal chromosome abnormalities approximately 50–75% in the second trimester, albeit
in the first and second trimesters? with high false-positive rates ranging from 5% to greater
than 15% (52).
Although ultrasonography cannot be used to confirm The significance of ultrasonographic markers iden-
or exclude a diagnosis of chromosomal anomalies such tified by a second-trimester ultrasound examination in a
as aneuploidy, ultrasonography can be used to further patient who has had a negative first-trimester screening
modify the risk that already exists by age or serum test result is unknown (33). Subtle second-trimester
screening. In the first trimester, an increased nuchal ultrasound markers should be interpreted in the context
translucency is an early presenting feature of a broad of a background risk based on the patient’s age, his-
range of fetal chromosomal, genetic, and structural tory, genetic screening, and serum screening results. In
abnormalities. When nuchal translucency measurements women who have undergone invasive fetal genetic test-
are used to modify the maternal age-related trisomy 21 ing or who have had cell-free DNA testing, the associa-
risk, the detection rate for trisomy 21 is approximately tion between isolated soft markers and aneuploidy risk
70% in a high-risk population (47). Nuchal translucency generally is not relevant (3).
measurements may be particularly useful in the evalua- If no abnormal markers are identified after care-
tion of multifetal gestations, for which serum screening fully performed ultrasonography, the pretest risk of
is not as accurate (twins) or is unavailable (triplets or trisomy 21 in a patient at high risk may be reduced (49,
higher), compared with a singleton gestation. Nuchal 53). This approach is not reliable in women at low risk.
translucency screening during the first trimester for At this time, risk adjustment based on second-trimester
trisomy 21 is feasible in twin or triplet gestation but has ultrasound markers should be limited to individuals with
lower sensitivity than first-trimester integrated screen- expertise in this area. Although ultrasonography can
ing in singleton pregnancies. However, measurement help identify fetuses with trisomy 21, it is most effective
of nuchal translucency alone is less effective for first- in detecting trisomy 21 and other aneuploidies when
trimester screening of the singleton pregnancy than is combined with other modalities.
combined testing (nuchal translucency measurement
and biochemical markers) (33). Among first-trimester How and when is ultrasonography used to
fetuses with increased nuchal translucency measure- assess for fetal anemia?
ment, approximately one third will have chromosome
defects, and trisomy 21 accounts for approximately Doppler ultrasonography is a noninvasive method that
50% of these chromosomal disorders (47). Other first- can be used to assess the degree of fetal anemia asso-
trimester ultrasonographic markers such as nonvisual- ciated with a variety of conditions such as red cell
ization of the nasal bone, tricuspid regurgitation, and alloimmunization, fetal infection, and fetal hydrops. A
abnormal ductus venosus waveforms have been associ- peak systolic velocity in the fetal middle cerebral artery
ated with trisomy 21, but their clinical usefulness in the greater than 1.5 multiples of the median for gestational
general population remains uncertain. age is a good predictor of severe anemia in the second
A second-trimester specialized ultrasound exami- trimester and early third trimester, with an overall sensi-
nation may be targeted to detect fetal aneuploidy. tivity of approximately 75% (54, 55). Also, there is good
Individual second-trimester ultrasound markers for correlation between the peak systolic velocity in the
aneuploidy, such as echogenic bowel, short femur or fetal middle cerebral artery and hemoglobin in fetuses
humerus, and dilated renal pelvis, have a low sensitivity that have undergone multiple transfusions, expanding
and specificity for trisomy 21, particularly when used to the clinical use of this Doppler test (56). However, its
screen a low-risk population (48), and a meta-analysis of accuracy in monitoring fetuses at risk of anemia after
48 studies confirms that most isolated ultrasound mark- 34–35 weeks of gestation is less clear because of a
ers have only a small effect on modifying the pretest higher false-positive rate (57). Correct technique is a
risk of trisomy 21 (49). Isolated markers that have little critical factor when determining peak systolic velocity
significance in the absence of an elevated pretest risk of in the fetal middle cerebral artery and should be per-
fetal aneuploidy are choroid plexus cyst and echogenic formed only at an appropriate gestational age by those
intracardiac foci (3). Studies indicate that the highest with adequate training and clinical experience (58–60).
detection rate for aneuploidy is achieved with the use of In a center with trained personnel, Doppler measure-
a systematic combination of markers and gross anoma- ment of peak systolic velocity in the fetal middle
lies, such as thickened nuchal fold, absent or hypoplastic cerebral artery is an appropriate noninvasive means to
nasal bone, or cardiac defects (50, 51). Studies done in monitor pregnancies at risk of fetal anemia.

Practice Bulletin No. 175 9

 How is ultrasonography used to detect distur- increased surveillance. Serial ultrasound measurements
bances in fetal growth? are of considerable clinical value in confirming or
excluding disturbances in fetal growth. These cases are
Serial assessment of fetal size by clinical methods such complex and should be managed in consultation with a
as fundal height is a low-cost, relatively reliable, and specialist, especially when growth restriction is detected
easy way to screen for fetal growth disturbances in before 34 weeks (5).
most pregnant women (5, 61). However, when a growth If the ultrasonographically determined estimated
disturbance is suspected clinically or there is a medical fetal weight is below the 10th percentile for gestational
or obstetric condition that increases the risk of a growth age, further evaluation should be considered, such as
disturbance, ultrasonography is the modality of choice to amniotic fluid assessment and Doppler blood flow stud-
identify abnormal fetal growth. ies of the umbilical artery. Because growth-restricted
Four standard fetal measurements generally are fetuses have a high incidence of structural abnormali-
obtained as part of a complete obstetric ultrasound ties and genetic abnormalities, a specialized ultrasound
examination after the first trimester: 1) fetal abdominal examination of fetal anatomy also is recommended if not
circumference, 2) head circumference, 3) biparietal performed previously.
diameter, and 4) femur length (62). Fetal morphologic
parameters can be converted to fetal weight estimates How should the fetus with intrauterine
using published formulas and tables (63). Contemporary growth restriction be assessed?
ultrasound equipment calculates and displays an esti-
mate of fetal weight on the basis of these formulas. Monitoring the growth-restricted fetus should involve
Although all of the published formulas for estimating serial ultrasound measurements of fetal biometry and
fetal weight show a good correlation with birth weight, amniotic fluid volume, antenatal surveillance with fetal
the variability of the estimate is up to 20% with most of heart rate or biophysical heart rate testing, and Doppler
the formulas (62). flow assessment of the umbilical artery. Antenatal sur-
Because calculations of estimated fetal weight in veillance of the growth-restricted fetus should not begin
the past have not been based on prospective ultrasound before a gestational age when delivery would be consid-
data, and because multiple reports have shown cus- ered for perinatal benefit (5).
tomization of fetal weight standards for maternal race The optimal interval to assess growth in the fetus
and weight can improve the accuracy of ultrasound- with growth restriction has not been established (67). In
estimated fetal growth, the National Institute of Child most cases, growth can be routinely evaluated with serial
Health and Human Development performed a prospec- ultrasound examinations every 3–4 weeks. Although
tive study to determine new standards for fetal growth interval growth in the growth-restricted fetus is some-
(63–65). This study showed that maternal race or ethnic- times done as frequently as every 2 weeks, ultrasound
ity significantly affects fetal growth, and adjusting for assessment of growth should not be performed more
this maternal factor likely decreases the misdiagnosis frequently because of the inherent error associated with
of intrauterine growth restriction and macrosomia by ultrasound measurements (68, 69).
ultrasonography. Regardless, it is unclear whether use Umbilical artery Doppler velocimetry used in con-
of customized growth calculations improves outcomes, junction with standard fetal surveillance, such as non-
and their use is not yet widely accepted. Standard growth stress tests, biophysical profiles, or both, is associated
tables continue to be acceptable for clinical use. with improved outcomes in fetuses with fetal growth
If the estimated fetal weight is below the restriction. Absent or reversed end-diastolic flow in the
10th percentile, further evaluation for intrauterine growth umbilical artery is associated with an increased risk of
restriction should be considered (5). Similarly, if the perinatal mortality (70–73). The rate of perinatal death
estimated fetal weight is more than the 90th percentile, is reduced by as much as 29% when umbilical artery
evaluation should be considered for fetal macrosomia Doppler velocimetry is added to standard antepartum
(66). For multifetal pregnancies, a 20% discordance in testing in the setting of fetal growth restriction (74, 75).
estimated fetal weight between the larger fetus and the Other Doppler studies have been investigated to deter-
smaller fetus warrants further evaluation for discordant mine whether normal physiologic adaptation is failing
growth (6). Monochorionic multiple pregnancies are at and fetal death is imminent, including the evaluation of
increased risk of complications such as unequal placen- flow in the middle cerebral artery, aortic isthmus, and
tal sharing with discordant growth or intrauterine growth ductus venosus, but it is unclear, at this time, if addition
restriction and for twin–twin transfusion syndrome of these tests to standard clinical surveillance improves
with resultant fetal growth restriction, and they require neonatal outcomes (76–79). Currently, there is a lack of

10 Practice Bulletin No. 175

data to support the use of Doppler studies of fetal vessels are employed to assess fetal growth. For dichorionic
other than the umbilical artery in monitoring the growth- twin gestations, there are no evidence-based recom-
restricted fetus (5, 80). mendations on the frequency of fetal growth scans after
There are no large clinical trials to guide the 20 weeks of gestation; however, it seems reasonable to
frequency of antepartum testing; thus, the optimal fre- perform serial ultrasound surveillance every 4–6 weeks
quency remains unknown (44). Antepartum testing of in the absence of evidence of fetal growth restriction or
the growth-restricted fetus should be repeated peri- other pregnancy complications (6). For monochorionic
odically to monitor for continued fetal well-being until twins, who carry a risk of twin–twin transfusion begin-
delivery; tests of fetal well-being (eg, nonstress tests, ning in the second trimester, serial ultrasound evalua-
biophysical profiles, umbilical artery Doppler velocim- tion approximately every 2 weeks beginning at around
etry) are typically repeated once or twice weekly. An 16 weeks of gestation should be considered (6).
abnormal test result requires further evaluation, which
may include more frequent testing or delivery (44).

How should twin gestations be monitored

Summary of Conclusions
with ultrasonography? and Recommendations
Because clinical criteria alone are unreliable to diagnose The following conclusions are based on good and
and assess multifetal gestations, the use of ultrasound consistent evidence (Level A):
assessment is recommended (6). Ultrasonography can
be used to determine fetal number, estimated gestational At various gestational ages, ultrasound examination
age, chorionicity, and amnionicity. Assessment of chori- is an accurate method of determining gestational
onicity is most accurate early in pregnancy and, because age, fetal number, viability, and placental location,
of the increased rate of complications associated with and it is recommended for all pregnant patients.
monochorionicity, determination of chorionicity by the Gestational age is most accurately determined in the
late first trimester or early second trimester is important first half of pregnancy.
for counseling and caring for women with multifetal
pregnancies. The determination of chorionicity guides Measurement of nuchal translucency alone is less
pregnancy management, including decisions and techni- effective for first-trimester screening of the single-
cal considerations for multifetal reduction or selective ton pregnancy than is combined testing (nuchal trans-
fetal termination, the initiation and frequency of fetal lucency measurement and biochemical markers).
surveillance, and the timing and route of delivery (6). In a center with trained personnel, Doppler mea-
Because of the increased rate of complications surement of peak systolic velocity in the fetal middle
associated with monochorionicity, a specialized exami- cerebral artery is an appropriate noninvasive means
nation, if available, is recommended (81). Importantly, to monitor pregnancies at risk of fetal anemia.
monochorionic twins have a higher frequency of fetal
and neonatal death compared with dichorionic twins, as Umbilical artery Doppler velocimetry used in con-
well as morbidities such as fetal anomalies and congeni- junction with standard fetal surveillance, such as
tal anomalies, twin–twin transfusion syndrome, prema- nonstress tests, biophysical profiles, or both, is asso-
turity, and fetal growth restriction (82, 83). This trend ciated with improved outcomes in fetuses with fetal
also is seen in higher-order multifetal pregnancies with growth restriction.
monochorionic placentation; for example, a triplet gesta-
tion that is fully monochorionic or has a monochorionic The following conclusions are based on limited or
pair is at higher risk of complications than a triplet gesta- inconsistent evidence (Level B):
tion that is trichorionic (84, 85). Recent reports suggest
Nuchal translucency screening during the first tri-
an increased risk of congenital heart defects in fetuses of
mester for trisomy 21 is feasible in twin or triplet
monochorionic pregnancies, and a fetal echocardiogram
gestation but has lower sensitivity than first-trimester
should be considered, especially if cardiac anatomy is
integrated screening in singleton pregnancies.
not clearly seen and normal on a specialized ultrasound
examination. Assessment of chorionicity is most accurate early
Because of the increased incidence of growth dis- in pregnancy and, because of the increased rate
turbance and the difficulty in assessing fetal growth with of complications associated with monochorion-
clinical criteria, serial ultrasound examinations usually icity, determination of chorionicity by the late first

Practice Bulletin No. 175 11

 trimester or early second trimester is important for organization's website, or the content of the resource.
counseling and caring for women with multifetal These resources may change without notice.
pregnancies.
An abnormal finding on second-trimester ultraso-
nography that identifies a major congenital anomaly
References
significantly increases the risk of genetic abnormal- 1. American College of Radiology. ACR–ACOG–AIUM–
SRU practice parameter for the performance of obstet-
ity and warrants further counseling, including the rical ultrasound. Reston (VA): ACR; 2013. Available
discussion of various prenatal testing strategies. at: http://www.acr.org/~/media/ACR/Documents/PGTS/
guidelines/US_Obstetrical.pdf. Retrieved July 25, 2016.
When a growth disturbance is suspected clinically
(Level III) ^
or there is a medical or obstetric condition that
2. American Institute of Ultrasound in Medicine. AIUM
increases the risk of a growth disturbance, ultraso- practice guideline for the performance of obstetric ultra-
nography is the modality of choice to identify sound examinations. J Ultrasound Med 2013;32:1083–101.
abnormal fetal growth. (Level III) [PubMed] [Full Text] ^
Objective measurement to detect amniotic fluid 3. Reddy UM, Abuhamad AZ, Levine D, Saade GR. Fetal
imaging: executive summary of a joint Eunice Kennedy
abnormalities has many advantages over subjective
Shriver National Institute of Child Health and Human
assessment, including reproducibility, easily com- Development, Society for Maternal–Fetal Medicine,
municated levels of fluid volume, and the ability to American Institute of Ultrasound in Medicine, American
follow trends in amniotic fluid measurement. It is College of Obstetricians and Gynecologists, American
recommended that objective, rather than subjective, College of Radiology, Society for Pediatric Radiology,
and Society of Radiologists in Ultrasound Fetal Imaging
measurements of amniotic fluid volume be used, workshop. Fetal Imaging Workshop Invited Participants.
especially in the third trimester. Obstet Gynecol 2014;123:1070–82. (Level III) [PubMed]
[Obstetrics & Gynecology] ^
The following conclusions and recommendations 4. Wax JR, Benacerraf BR, Copel J, O’Keeffe D, Riley L,
are based primarily on consensus and expert opin- Minkoff H, et al. Consensus report on the 76811 scan:
ion (Level C): modification [letter]. J Ultrasound Med 2015;34:1915.
(Level III) [PubMed] [Full Text] ^
In the absence of other specific indications, the opti- 5. Fetal growth restriction. Practice Bulletin No. 134.
mal time for a single ultrasound examination is at American College of Obstetricians and Gynecologists.
18–22 weeks of gestation. Obstet Gynecol 2013;121:1122–33. (Level III) [PubMed]
[Obstetrics & Gynecology] ^
In the obese patient, expectations regarding visual- 6. Multifetal gestations: twin, triplet, and higher-order mul-
ization of fetal anatomy should be tempered. tifetal pregnancies. Practice Bulletin No. 169. American
College of Obstetricians and Gynecologists. Obstet
Subtle second-trimester ultrasound markers should Gynecol 2016;128:e131–46. (Level III) [PubMed]
be interpreted in the context of a background risk [Obstetrics & Gynecology] ^
based on the patient’s age, history, genetic screen- 7. Method for estimating due date. Committee Opinion
ing, and serum screening results. No. 611. American College of Obstetricians and Gyne-
cologists. Obstet Gynecol 2014;124:863–6. (Level III)
The benefits and limitations of ultrasonography [PubMed] [Obstetrics & Gynecology] ^
should be discussed with all patients.
8. Doubilet PM, Benson CB, Bourne T, Blaivas M, Barnhart
KT, Benacerraf BR, et al. Diagnostic criteria for nonvi-
able pregnancy early in the first trimester.  Society of
For More Information Radiologists in Ultrasound Multispecialty Panel on Early
First Trimester Diagnosis of Miscarriage and Exclusion
The American College of Obstetricians and Gynecol- of a Viable Intrauterine Pregnancy. N Engl J Med
ogists has identified additional resources on topics 2013;369:1443–51. (Level III) [PubMed] [Full Text] ^
related to this document that may be helpful for ob- 9. Goncalves LF, Lee W, Espinoza J, Romero R. Three- and
gyns, other health care providers, and patients. You 4-dimensional ultrasound in obstetric practice: does it
may view these resources at www.acog.org/More-Info/ help? J Ultrasound Med 2005;24:1599–624. (Level III)
[PubMed] [Full Text] ^
UltrasoundinPregnancy.
These resources are for information only and are not 10. Abuhamad AZ, Benacerraf BR, Woletz P, Burke BL. The
accreditation of ultrasound practices: impact on compli-
meant to be comprehensive. Referral to these resources ance with minimum performance guidelines. J Ultrasound
does not imply the American College of Obstetricians Med 2004;23:1023–9. (Level II-3) [PubMed] [Full Text]
and Gynecologists' endorsement of the organization, the ^

12 Practice Bulletin No. 175

11. Abramowicz JS, Fowlkes JB, Skelly AC, Stratmeyer Study Group. Am J Obstet Gynecol 1994;171:392–9.
ME, Ziskin MC. Conclusions regarding epidemiology for (Level I) [PubMed] ^
obstetric ultrasound. J Ultrasound Med 2008;27:637–44. 23. Grandjean H, Larroque D, Levi S. The performance of
(Level III) [PubMed] [Full Text] ^ routine ultrasonographic screening of pregnancies in the
12. American Institute of Ultrasound in Medicine. Prudent Eurofetus Study. Am J Obstet Gynecol 1999;181:446–54.
use and clinical safety. Laurel (MD): AIUM; 2012. (Level II-2) [PubMed] [Full Text] ^
Available at: http://www.aium.org/officialStatements/34. 24. Dashe JS, McIntire DD, Twickler DM. Effect of maternal
Retrieved July 25, 2016. (Level III) ^ obesity on the ultrasound detection of anomalous fetuses.
13. American Institute of Ultrasound in Medicine. Guidelines Obstet Gynecol 2009;113:1001–7. (Level II-3) [PubMed]
for cleaning and preparing external- and internal-use ultra- [Obstetrics & Gynecology] ^
sound probes between patients. Laurel (MD): AIUM; 2014. 25. Obesity in pregnancy. Practice Bulletin No. 156.
Available at: http://www.aium.org/officialStatements/57. American College of Obstetricians and Gynecologists.
Retrieved July 25, 2016. (Level III) ^ Obstet Gynecol 2015;126:e112–26. (Level III) [PubMed]
14. Centers for Disease Control and Prevention. Sterilization [Obstetrics & Gynecology] ^
or disinfection of medical devices. Atlanta (GA): CDC; 26. Rossi AC, Prefumo F. Accuracy of ultrasonography at
1998. Available at: http://www.cdc.gov/HAI/prevent/sd_ 11–14 weeks of gestation for detection of fetal struc-
medicalDevices.html. Retrieved July 25, 2016. (Level III) tural anomalies: a systematic review. Obstet Gynecol
^ 2013;122:1160–7. (Level I) [PubMed] [Obstetrics &
Gynecology] ^
15. U.S. Food and Drug Administration. FDA-cleared steril-
ants and high level disinfectants with general claims for 27. Stark CR, Orleans M, Haverkamp AD, Murphy J. Short-
processing reusable medical and dental devices—March and long-term risks after exposure to diagnostic ultra-
2015. Silver Spring (MD): FDA; 2015. Available at: sound in utero. Obstet Gynecol 1984;63:194–200. (Level
http://www.fda.gov/MedicalDevices/DeviceRegulation II-2) [PubMed] [Obstetrics & Gynecology] ^
andGuidance/ReprocessingofReusableMedicalDevices/ 28. Lyons EA, Dyke C, Toms M, Cheang M. In utero
ucm437347.htm. Retrieved July 25, 2016. (Level III) ^ exposure to diagnostic ultrasound: a 6-year follow-up.
Radiology 1988;166:687–90. (Level II-2) [PubMed] ^
16. Salomon LJ, Alfirevic Z, Berghella V, Bilardo C,
Hernandez-Andrade E, Johnsen SL, et al. Practice guide- 29. American Institute of Ultrasound in Medicine. Prudent
lines for performance of the routine mid-trimester fetal use in pregnancy. Laurel (MD): AIUM; 2012. Available
ultrasound scan. ISUOG Clinical Standards Committee. at: http://www.aium.org/officialStatements/33. Retrieved
Ultrasound Obstet Gynecol 2011;37:116–26. (Level III) July 25, 2016. (Level III) ^
[PubMed] [Full Text] ^ 30. Rados C. FDA cautions against ultrasounds “keep-
17. Cargill Y, Morin L, Bly S, Butt K, Denis N, Gagnon R, sake” images. FDA Consum 2004;38:12–6. (Level III)
et al. Content of a complete routine second trimester [PubMed] [Full Text] ^
obstetrical ultrasound examination and report. J Obstet 31. Salvesen K, Lees C, Abramowicz J, Brezinka C, Ter
Gynaecol Can 2009;31:272–5, 276–80. (Level III) Haar G, Marsal K. ISUOG-WFUMB statement on the
[PubMed] ^ non-medical use of ultrasound, 2011. Board of the
18. Saari-Kemppainen A, Karjalainen O, Ylostalo P, International Society of Ultrasound in Obstetrics and
Heinonen OP. Fetal anomalies in a controlled one-stage Gynecology (ISUOG), Bioeffects and Safety Committee.
Ultrasound Obstet Gynecol 2011;38:608. (Level III)
ultrasound screening trial. A report from the Helsinki
[PubMed] [Full Text] ^
Ultrasound Trial. J Perinat Med 1994;22:279–89. (Level I)
[PubMed] ^ 32. Malone FD, Canick JA, Ball RH, Nyberg DA, Comstock
CH, Bukowski R, et al. First-trimester or second-
19. Grandjean H, Larroque D, Levi S. Sensitivity of routine trimester screening, or both, for Down’s syndrome. First-
ultrasound screening of pregnancies in the Eurofetus and Second-Trimester Evaluation of Risk (FASTER)
database. The Eurofetus Team. Ann N Y Acad Sci 1998; Research Consortium. N Engl J Med 2005;353:2001–11.
847:118–24. (Level II-3) [PubMed] ^ (Level II-1) [PubMed] [Full Text] ^
20. Ewigman BG, Crane JP, Frigoletto FD, LeFevre ML, 33. Screening for fetal aneuploidy. Practice Bulletin No. 163.
Bain RP, McNellis D. Effect of prenatal ultrasound American College of Obstetricians and Gynecologists.
screening on perinatal outcome. RADIUS Study Group. Obstet Gynecol 2016;127:e123–37. (Level III) [PubMed]
N Engl J Med 1993;329:821–7. (Level I) [PubMed] [Full [Obstetrics & Gynecology] ^
Text] ^
34. Tunon K, Eik-Nes SH, Grottum P, Von During V, Kahn
21. Levi S. Ultrasound in prenatal diagnosis: polemics around JA. Gestational age in pregnancies conceived after in
routine ultrasound screening for second trimester fetal vitro fertilization: a comparison between age assessed
malformations. Prenat Diagn 2002;22:285–95. (Level III) from oocyte retrieval, crown–rump length and bipari-
[PubMed] ^ etal diameter. Ultrasound Obstet Gynecol 2000;15:41–6.
22. Crane JP, LeFevre ML, Winborn RC, Evans JK, Ewigman (Level II-3) [PubMed] [Full Text] ^
BG, Bain RP, et al. A randomized trial of prenatal ultra- 35. Sladkevicius P, Saltvedt S, Almstrom H, Kublickas M,
sonographic screening: impact on the detection, manage- Grunewald C, Valentin L. Ultrasound dating at 12–14
ment, and outcome of anomalous fetuses. The RADIUS weeks of gestation. A prospective cross-validation of

Practice Bulletin No. 175 13

 established dating formulae in in-vitro fertilized pregnan- 48. Smith-Bindman R, Hosmer W, Feldstein VA, Deeks
cies. Ultrasound Obstet Gynecol 2005;26:504–11. (Level JJ, Goldberg JD. Second-trimester ultrasound to detect
II-3) [PubMed] [Full Text] ^ fetuses with Down syndrome: a meta-analysis. JAMA
36. Hadlock FP, Harrist RB, Shah YP, King DE, Park SK, 2001;285:1044–55. (Level III) [PubMed] [Full Text] ^
Sharman RS. Estimating fetal age using multiple param- 49. Agathokleous M, Chaveeva P, Poon LC, Kosinski P,
eters: a prospective evaluation in a racially mixed popula- Nicolaides KH. Meta-analysis of second-trimester
tion. Am J Obstet Gynecol 1987;156:955–7. (Level II-2) markers for trisomy 21. Ultrasound Obstet Gynecol
[PubMed] ^ 2013;41:247–61. (Level III) [PubMed] [Full Text] ^
37. Chervenak FA, Skupski DW, Romero R, Myers MK, 50. Vintzileos AM, Campbell WA, Rodis JF, Guzman
Smith-Levitin M, Rosenwaks Z, et al. How accurate is ER, Smulian JC, Knuppel RA. The use of second-
fetal biometry in the assessment of fetal age? Am J Obstet trimester genetic sonogram in guiding clinical manage-
Gynecol 1998;178:678–87. (Level II-3) [PubMed] ^ ment of patients at increased risk for fetal trisomy 21.
38. Reece EA, Gabrielli S, Degennaro N, Hobbins JC. Dating Obstet Gynecol 1996;87:948–52. (Level III) [PubMed]
through pregnancy: a measure of growing up. Obstet [Obstetrics & Gynecology] ^
Gynecol Surv 1989;44:544–55. (Level III) [PubMed] ^ 51. Bromley B, Benacerraf BR. The genetic sonogram scor-
39. Pierce BT, Hancock EG, Kovac CM, Napolitano PG, ing index. Semin Perinatol 2003;27:124–9. (Level III)
Hume RF Jr, Calhoun BC. Influence of gestational age [PubMed] ^
and maternal height on fetal femur length calculations. 52. Bahado-Singh RO, Oz UA, Mendilcioglu I, Mahoney MJ.
Obstet Gynecol 2001;97:742–6. (Level II-3) [PubMed] The mid-trimester genetic sonogram. Semin Perinatol
[Obstetrics & Gynecology] ^ 2005;29:209–14. (Level III) [PubMed] [Full Text] ^
40. Chamberlain PF, Manning FA, Morrison I, Harman CR, 53. Yeo L, Vintzileos AM. The use of genetic sonography to
Lange IR. Ultrasound evaluation of amniotic fluid vol- reduce the need for amniocentesis in women at high-risk
ume. I. The relationship of marginal and decreased for Down syndrome. Semin Perinatol 2003;27:152–9.
amniotic fluid volumes to perinatal outcome. Am J Obstet (Level III) [PubMed] ^
Gynecol 1984;150:245–9. (Level II-3) [PubMed] ^ 54. Mari G, Deter RL, Carpenter RL, Rahman F, Zimmerman
41. Rutherford SE, Phelan JP, Smith CV, Jacobs N. The four- R, Moise KJ Jr, et al. Noninvasive diagnosis by Doppler
quadrant assessment of amniotic fluid volume: an adjunct ultrasonography of fetal anemia due to maternal red-
to antepartum fetal heart rate testing. Obstet Gynecol cell alloimmunization. Collaborative Group for Doppler
1987;70:353–6. (Level II-3) [PubMed] ^ Assessment of the Blood Velocity in Anemic Fetuses.
N Engl J Med 2000;342:9–14. (Level II-3) [PubMed]
42. Baron C, Morgan MA, Garite TJ. The impact of amniotic
[Full Text] ^
fluid volume assessed intrapartum on perinatal outcome.
Am J Obstet Gynecol 1995;173:167–74. (Level II-3) 55. Pretlove SJ, Fox CE, Khan KS, Kilby MD. Noninvasive
[PubMed] [Full Text] ^ methods of detecting fetal anaemia: a systematic review
and meta-analysis. BJOG 2009;116:1558–67. (Level I)
43. Nabhan AF, Abdelmoula YA. Amniotic fluid index
[PubMed] [Full Text] ^
versus single deepest vertical pocket as a screening test
for preventing adverse pregnancy outcome.  Cochrane 56. Hermann M, Poissonnier MH, Grange G. Cerebral
Database of Systematic Reviews. 2008, Issue 3. Art. No.: Doppler velocimetry to predict fetal anemia after more
CD006593. DOI: 10.1002/14651858.CD006593.pub2. than three intravenous fetal exchange transfusions. Trans-
(Level I) [PubMed] [Full Text] ^ fusion 2014;54:2968–73. (Level III) [PubMed] ^
44. Antepartum fetal surveillance. Practice Bulletin No. 145. 57. Moise KJ Jr. Management of rhesus alloimmunization in
American College of Obstetricians and Gynecologists. pregnancy [published erratum appears in Obstet Gyne-
Obstet Gynecol 2014;124:182–92. (Level III) [PubMed] col 2002;100:833]. Obstet Gynecol 2002;100:600–11.
[Obstetrics & Gynecology] ^ (Level III) [PubMed] [Obstetrics & Gynecology] ^
45. Magann EF, Chauhan SP, Doherty DA, Lutgendorf 58. Management of alloimmunization during pregnancy.
MA, Magann MI, Morrison JC. A review of idiopathic ACOG Practice Bulletin No. 75. American College of
hydramnios and pregnancy outcomes. Obstet Gynecol Obstetricians and Gynecologists. Obstet Gynecol 2006;
Surv 2007;62:795–802. (Level III) [PubMed] ^ 108:457–64. (Level III) [PubMed] [Obstetrics &
Gynecology] ^
46. Pilliod RA, Page JM, Burwick RM, Kaimal AJ, Cheng
YW, Caughey AB. The risk of fetal death in non- 59. Mari G, Norton ME, Stone J, Berghella V, Sciscione
anomalous pregnancies affected by polyhydramnios. AC, Tate D, et al. Society for Maternal–Fetal Medicine
Am J Obstet Gynecol 2015;213:410.e1–6. (Level II-2) (SMFM) Clinical Guideline #8: the fetus at risk for
[PubMed] [Full Text] ^ anemia—diagnosis and management.  Society for
47. Snijders RJ, Noble P, Sebire N, Souka A, Nicolaides Maternal–Fetal Medicine (SMFM). Am J Obstet Gynecol
KH. UK multicentre project on assessment of risk of 2015;212:697–710. (Level III) [PubMed] [Full Text] ^
trisomy 21 by maternal age and fetal nuchal-translucency 60. Clark EA, Lacoursiere DY, Byrne JL, Ponder R, Silver
thickness at 10–14 weeks of gestation. Fetal Medicine RM, Esplin MS. Reliability of fetal middle cerebral
Foundation First Trimester Screening Group. Lancet artery velocity measurements: a randomized controlled
1998;352:343–6. (Level III) [PubMed] [Full Text] ^ trial of sonographer training [published erratum appears

14 Practice Bulletin No. 175

 in J Ultrasound Med 2009;28:706]. J Ultrasound Med 73. Kingdom JC, Burrell SJ, Kaufmann P. Pathology and
2009;28:19–25. (Level I) [PubMed] [Full Text] ^ clinical implications of abnormal umbilical artery Doppler
61. Lindhard A, Nielsen PV, Mouritsen LA, Zachariassen A, waveforms. Ultrasound Obstet Gynecol 1997;9:271–86.
Sorensen HU, Roseno H. The implications of introducing (Level III) [PubMed] [Full Text] ^
the symphyseal-fundal height-measurement. A prospec- 74. Giles W, Bisits A. Clinical use of Doppler ultrasound in
tive randomized controlled trial. Br J Obstet Gynaecol pregnancy: information from six randomised trials. Fetal
1990;97:675–80. (Level I) [PubMed] ^ Diagn Ther 1993;8:247–55. (Level III) [PubMed] ^
62. Hadlock FP, Deter RL, Harrist RB, Park SK. Estimating 75. Alfirevic Z, Stampalija T, Medley N. Fetal and umbili-
fetal age: computer-assisted analysis of multiple fetal cal Doppler ultrasound in normal pregnancy. Cochrane
growth parameters. Radiology 1984;152:497–501. (Level Database of Systematic Reviews 2015, Issue 4. Art. No.:
II-3) [PubMed] ^ CD001450. DOI: 10.1002/14651858.CD001450.pub4.
(Level I) [PubMed] [Full Text] ^
63. Anderson NG, Jolley IJ, Wells JE. Sonographic estima-
tion of fetal weight: comparison of bias, precision and 76. Hecher K, Snijders R, Campbell S, Nicolaides K. Fetal
consistency using 12 different formulae. Ultrasound venous, intracardiac, and arterial blood flow measure-
Obstet Gynecol 2007;30:173–9. (Level II-2) [PubMed] ments in intrauterine growth retardation: relationship with
[Full Text] ^ fetal blood gases. Am J Obstet Gynecol 1995;173:10–5.
(Level III) [PubMed] [Full Text] ^
64. Mongelli M, Gardosi J. Reduction of false-positive
diagnosis of fetal growth restriction by application of 77. Rizzo G, Capponi A, Arduini D, Romanini C. The value
customized fetal growth standards. Obstet Gynecol of fetal arterial, cardiac and venous flows in predicting
1996;88:844–8. (Level II-2) [PubMed] [Obstetrics & pH and blood gases measured in umbilical blood at cordo-
Gynecology] ^ centesis in growth retarded fetuses. Br J Obstet Gynaecol
1995;102:963–9. (Level III) [PubMed] ^
65. Buck Louis GM, Grewal J, Albert PS, Sciscione A, Wing
DA, Grobman WA, et al. Racial/ethnic standards for fetal 78. Baschat AA. Doppler application in the delivery timing
growth: the NICHD Fetal Growth Studies. Am J Obstet of the preterm growth-restricted fetus: another step in
Gynecol 2015;213:449.e1–41. (Level II-3) [PubMed] the right direction. Ultrasound Obstet Gynecol 2004;23:
[Full Text] ^ 111–8. (Level III) [PubMed] [Full Text] ^
66. Fetal macrosomia. Practice Bulletin No. 173. American 79. Ghidini A. Doppler of the ductus venosus in severe pre-
College of Obstetricians and Gynecologists. Obstet term fetal growth restriction: a test in search of a purpose?
Gynecol 2016;128:e195–209. (Level III) [PubMed] Obstet Gynecol 2007;109:250–2. (Level III) [PubMed]
[Obstetrics & Gynecology] ^ [Obstetrics & Gynecology] ^
67. Grivell RM, Wong L, Bhatia V. Regimens of fetal surveil- 80. Doppler assessment of the fetus with intrauterine
lance for impaired fetal growth. Cochrane Database of growth restriction.  Society for Maternal–Fetal Medicine
Systematic Reviews 2012, Issue 6. Art. No.: CD007113. [published erratum appears in Am J Obstet Gynecol
DOI: 10.1002/14651858.CD007113.pub3. (Level I) 2012;206:508]. Am J Obstet Gynecol 2012;206:300–8.
[PubMed] [Full Text] ^ (Level III) [PubMed] [Full Text] ^
68. Divon MY, Chamberlain PF, Sipos L, Manning FA, Platt 81. Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel
LD. Identification of the small for gestational age fetus JA, Sklansky MS, Abuhamad A, et al. Diagnosis and
with the use of gestational age-independent indices of treatment of fetal cardiac disease: a scientific statement
fetal growth. Am J Obstet Gynecol 1986;155:1197–201. from the American Heart Association. American Heart
(Level II-3) [PubMed] ^ Association Adults with Congenital Heart Disease Joint
Committee of the Council on Cardiovascular Disease in
69. Mongelli M, Ek S, Tambyrajia R. Screening for fetal the Young and Council on Clinical Cardiology, Council
growth restriction: a mathematical model of the effect on Cardiovascular Surgery and Anesthesia, and Council
of time interval and ultrasound error. Obstet Gynecol on Cardiovascular and Stroke Nursing [published erra-
1998;92:908–12. (Level II-3) [PubMed] [Obstetrics & tum appears in  Circulation 2014;129:e512]. Circulation
Gynecology] ^ 2014;129:2183–242. (Level III) [PubMed] [Full Text] ^
70. Nicolaides KH, Bilardo CM, Soothill PW, Campbell S. 82. Geipel A, Berg C, Katalinic A, Plath H, Hansmann
Absence of end diastolic frequencies in umbilical artery: M, Germer U, et al. Prenatal diagnosis and obstetric
a sign of fetal hypoxia and acidosis. BMJ 1988;297: outcomes in triplet pregnancies in relation to chorionic-
1026–7. (Level III) [PubMed] [Full Text] ^ ity. BJOG 2005;112:554–8. (Level II-3) [PubMed] [Full
71. Bilardo CM, Nicolaides KH, Campbell S. Doppler mea- Text] ^
surements of fetal and uteroplacental circulations: rela- 83. Glinianaia SV, Obeysekera MA, Sturgiss S, Bell R.
tionship with umbilical venous blood gases measured at Stillbirth and neonatal mortality in monochorionic and
cordocentesis. Am J Obstet Gynecol 1990;162:115–20. dichorionic twins: a population-based study. Hum Reprod
(Level III) [PubMed] ^ 2011;26:2549–57. (Level II-3) [PubMed] [Full Text] ^
72. Pardi G, Cetin I, Marconi AM, Lanfranchi A, Bozzetti P, 84. Bajoria R, Ward SB, Adegbite AL. Comparative study
Ferrazzi E, et al. Diagnostic value of blood sampling of perinatal outcome of dichorionic and trichorionic iat-
in fetuses with growth retardation. N Engl J Med 1993; rogenic triplets. Am J Obstet Gynecol 2006;194:415–24.
328:692–6. (Level III) [PubMed] [Full Text] ^ (Level II-3) [PubMed] [Full Text] ^

Practice Bulletin No. 175 15

85. Kawaguchi H, Ishii K, Yamamoto R, Hayashi S, Mitsuda
N. Perinatal death of triplet pregnancies by chorionic- The MEDLINE database, the Cochrane Library, and
ity.  Perinatal Research Network Group in Japan. Am J ACOG’s own internal resources and documents were
Obstet Gynecol 2013;209:36.e1–7. (Level II-3) [PubMed] used to conduct a literature search to locate relevant
[Full Text] ^ articles published between January 1985 and November
2014. The search was restricted to articles published in the
English language. Priority was given to articles reporting
results of original research, although review articles and
commentaries also were consulted. Abstracts of research
presented at symposia and scientific conferences were not
considered adequate for inclusion in this document. Guide-
lines published by organizations or institutions such as the
National Institutes of Health and the American College of
Obstetricians and Gynecologists were reviewed, and addi-
tional studies were located by reviewing bibliographies of
identified articles. When reliable research was not available,
expert opinions from obstetrician–gynecologists were used.
Studies were reviewed and evaluated for quality according
to the method outlined by the U.S. Preventive Services
Task Force:
I Evidence obtained from at least one properly
designed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled
trials without randomization.
II-2 Evidence obtained from well-designed cohort or
case–control analytic studies, preferably from more
than one center or research group.
II-3 Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncon-
trolled experiments also could be regarded as this
type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to the
following categories:
Level A—Recommendations are based on good and con-
sistent scientific evidence.
Level B—Recommendations are based on limited or incon-
sistent scientific evidence.
Level C—Recommendations are based primarily on con-
sensus and expert opinion.

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Ultrasound in pregnancy. Practice Bulletin No. 175. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:
e241–56.

16 Practice Bulletin No. 175