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Three Part Question

In [a pregnant patient] is [the measurement of fundal height effective] at [determining gestational age]?

Clinical Scenario

A pregnant trauma patient involved in a domestic incident has been brought in by ambulance you have been told that she is pregnant but no one is certain by how many weeks, you wonder if measuring fundal height will give you a good estimate.

Search Strategy

Medline 1950 to 06/2008 using Ovid Interface
EMBASE 1980-2008 Week 1
The Cochrane Library
[{fundal height.mp} AND {gestation.mp.}] LIMIT to human and English language

Search Outcome

32 papers were found of which 10 were suitable for answering the question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Jimenez JM et al, 1983 USA	83 pregnant patients over a 3 year period	Case study	Fundal height reached umbilicus between 15-19 weeks (16.9 + 0.9 weeks)	Fundal-Symphysis height (FSH) is more accurate in assessing gestation than when the fundus reaches the umbilicus	Study is over 25years old Patients predominantly young primigravid and Mexican-American Small sample size Not directly addressing the question
Traisathit P et al, 2006 Thailand	1398 women enrolled in an HIV prevention trial where gestational age was compared using ultrasound, last menstrual period and fundal height	Case	The first value of fundal height measure after 24 weeks is an efficient estimate of gestation	Fundal height is efficient after 24 weeks	Study done on one ethnic group The comparable measurements using US, LMP and FSH were not all measured at the same time Not directly addressing the question
Stuart JM et al, 1989 UK	1379 pregnant women from 50 GP antenatal clinics and the hospital clinics of 2 obstetricians over 12 months from 1985-86	Prospective study to assess the value of the symphysis fundal height	Sensitivity of SFH decreases with increase in maternal BMI. Specificity increases with increase in maternal BMI. Attention needs to be paid to the technique use in order to ensure accurate measurements	SFH is a reasonably accurate means of estimating gestational age as long as the mother does not have a high BMI.	The GPs having been taught via lecture how to measure correctly taught the midwives. No information how the random allocation of the checked results was carried out. The study focuses on indentifying small for term babies. Possible bias as there was a lack of consistency between measurers. The study was just carried out in Gloucestershire Not directly addressing the question 3. Stuart JM, Healy TJ, Sutton M, Swingler GR.
Crosby Me, Engstrom JL, 1989 USA	22 pregnant women at a prenatal clinic in an urban area of Southern USA	Preliminary study to evaluate inter-examiner reliability of fundal height measurements	Inter-examiner reliability is low when measuring fundal height, but improvement could be achieved by training.	Reliability of measurements are low	No balanced design. No random allocation of patients. Small sample size. No details of ethnicity Not directly addressing the question
Engstrom JL, 1987 USA	Pregnant women	Narrative review	Several factors can alter the accuracy of fundal height measurement. Variability in anatomical landmarks, finger breadths are not accurate, comparison of the uterus with fruits is not accurate as fruits vary in size. Bladder fullness and maternal position can influence fundal height.	Fundal height should not be measured by comparing the fundus with anatomical landmarks, it should be obtained by use of a tape measure of pelvimetry callipers and done when the maternal bladder is empty.	No search strategy
Geirsson RT, Agustsson P, 1987 Scotland	74 pregnant women in Dundee, Scotland	Prospective study to correlate fundal height and intra-uterine volume	A total of 81measurements found that advancing gestation increases the correlation between intra-uterine volume and symphysis fundal height although it was not clear why.	Individual measurements of fundal height are not that accurate, serial measurements over time are a better indicator of small babies.	Small sample size 2 observers no information of whether measurements were checked. Measurements of fundal height were only made at 32 and 36 weeks but only 26 and 20 measurements were made
Taylor et al 1984 Australia	Pregnant women over a 1 year period. Total of 3788 measurements taken.	Consecutive study symphysis-fundal height	A graph of symphysial-height when used in conjunction with standing charts showing centiles of birth-weight for gestational age an estimate of foetal weight may be simply made	On average the fundus reached the umbilicus at 18-19 weeks	Not directly addressing the question
Quaranta P, et al, 1981 UK	241 pregnant women either measured at each antenatal visit or as an inpatient	Retrospective study	Prediction of normal birth weight from fundal height measurements was correct in 75 to 96% of patients.	If the pregnancy is progressing normally the fundal height above the symphysis pubis is roughly equal to each week of pregnancy. Measurements of fundal height are most accurate between 32 to 33 weeks.	Study is looking at predictions for small for dates infants. No information how they got the patients. No checker so possibility of observer error.
Mathai M et al, 1987 India	250 consecutive pregnant patients attending an antenatal clinic in India between Sep 83 –Apr 85	Case Study	Fundal height has high sensitivity and satisfactory specificity for detecting light for gestational age infants	Fundal height does correspond with gestational age	The study was intended to address the issue of light for gestational age infants. The study was intended to address the issue of light for gestational age infants. Inter observer error as measurements do not appear to be checked.
Lockwood CJ & Weiner S 1986 USA	Pregnant women	Narrative review	If the fundal height is measured from the symphysis pubis to the superior aspect of the uterine fundus is 4 cm less than the corresponding gestational age IUGR can be ruled out	Fundal height if measured accurately may estimate gestational age	No search strategy

Comment(s)

There are 2 main measurements of fundal height that of the symphysis pubis to fundal height measurement measured in centimetres and the fundal height in relation to anatomical landmarks such as the umbilicus and xiphisternum. Both are assessed in obstetrical exams as a tool to assess that foetal growth is progressing correctly. Obviously in an emergency setting the fundal height in relation to anatomical landmarks is probably the most useful as it is a quick and easy assessment to make. Its use as a marker of gestation could be highly informative in the emergency setting if a pregnant woman is admitted who is unable to inform us of the gestational age of the foetus. This is important as there are a few areas of management of a pregnant trauma patient that may have to be altered depending on the gestational age. However fundal height can only ever be a guide as gestational age in a foetus who is growth restricted will obviously not be an accurate indicator. The FSH measurement is equal to the gestation in weeks plus or minus 3 centimetres [Douglas G, Nicol F, Robertson C.]. It is important to note that all the studies looked at the measurements in terms of screening for low birth weight etc as opposed to can they be used as an indicator of gestational age, however it could be argued that if the use of fundal height measurements result in a high sensitivity for detecting small for dates infants then using the measurements as a means of estimating gestational age are not that unreasonable.

Clinical Bottom Line

The FSH can be used as an estimate of gestational age but it should not be used as more than a guide and additional means of determining gestation should be sought.

References

1. Jimenez JM et al. Clinical measures of gestational age in normal pregnancies. Obstetrics and Gynecology. 61(4):1983:438-443
2. Traisathit P et al. Gestational age determination and prevention of HIV perinatal transmission. International journal of gynaecology & obstetrics. 92(2): 2006;176-180
3. Stuart JM, Healy TJ, Sutton M, Swingler GR. Symphysis-fundus measurements in screening for small-for-dates infants: a community based study in Gloucestershire. Journal of the Royal College of General Practitioners. 39(319):1989;45-8
4. Crosby Me, Engstrom JL. Inter-examiner reliability in fundal height measurement. Midwives Chronicle. 102(1219):1989:254-6
5. Engstrom JL. Measurement of fundal height. Journal of Obstetric , Gynecologic & Neonatal Nursing. 17(3):1988;172-8
6. Geirsson RT, Augustsson P. Total intra-uterine volume and symphysis fundus height. Is there a relation? Acta Obstetrica et Gynecologica Scandinavica. 66(4):1987;345-8
7. Taylor P, Coulthard Ac, Robinson JS. Symphysial-fundal height from 12 weeks gestation. Australian & New Zealand Journal of Obstetrics and Gynaecology. 24(3):1984;189-91
8. Quaranta P, et al. Prediction of small for dates infants by measurement of symphysial-fundal height. British journal of obstetrics and gynaecology. 1981:88;115-119
9. Mathai M, Jairaj P, Muthurathnam S. Screening for light for gestational age infants: a comparison of 3 simple measurements. British Journal of Obstetrics & Gynaecology. 1987:94(3);217-21
10. Lockwood CJ, Weiner S. Assessment of foetal growth. Clinics in Perinatology 1986:13(1);3-35
11. Douglas G, Nicol F, Robertson C. Macleod’s Clinical Examination. Elsevier. 2006:11;215