Original Research

Accuracy of estimated fetal weight assessment in

fetuses with congenital diaphragmatic hernia
Lisa C. Zuckerwise, MD; Laura C. Ha, MD; Sarah S. Osmundson, MD; Emily W. Taylor, WHNP-BC; J Newton, MD, PhD

BACKGROUND: Congenital diaphragmatic hernia is a congenital
anomaly in which fetal abdominal organs herniate into the thoracic cavity
through a diaphragmatic defect, which can impede fetal lung develop-
ment. Standard formulas for estimated fetal weight include measurement
of fetal abdominal circumference, which may be inaccurate in fetuses with
congenital diaphragmatic hernia because of displacement of abdominal
contents into the thorax.
OBJECTIVES: This study aimed to assess the accuracy of standard
estimated fetal weight assessment in fetuses with congenital diaphrag-
matic hernia by comparing prenatal assessment of fetal weight with actual
birthweight.
STUDY DESIGN: A retrospective cohort study of fetuses diagnosed
with congenital diaphragmatic hernia was performed at a single center
from 2012 to 2018. Fetuses with multiple anomalies or confirmed chro-
mosome abnormalities were excluded. Estimated fetal weight was
calculated using the Hadlock formula. Published estimates of fetal growth
rate were used to establish a projected estimated fetal weight at birth from
the final growth ultrasound, and the percentage difference between pro-
jected estimated fetal weight at birth and actual birthweight was calcu-
lated. A Wilcoxan rank-sum test was used to examine the difference
between projected estimated fetal weight and birthweight.
RESULTS: We had complete data for 77 fetuses with congenital dia-
phragmatic hernia. The majority (76.6%, 55 of 77) had left-sided
congenital diaphragmatic hernia. The median [interquartile range] pro-
jected estimated fetal weight was similar to median birthweight, at 3177 g
[2691e3568] and 3180 g [2630e3500], respectively, which did not
represent a statistically significant difference between projected estimated
fetal weight and birthweight (P ¼ .66). The median absolute percentage
difference between projected birthweight and actual birthweight was 6.3%
[3.2e7.0]. Estimated fetal weight was overall underestimated in a minority
of cases (44.2%, 34 of 77).
CONCLUSION: In fetuses with a congenital diaphragmatic
hernia, standard measurements of fetal estimated fetal weight show
accuracy that is at least comparable with previously established
margins of error for ultrasound assessment of fetal weight. Standard
estimated fetal weight assessment remains an appropriate method
of estimating fetal weight in fetuses with congenital diaphragmatic
hernia.
Key words: abdominal circumference, congenital diaphragmatic her-
nia, estimated fetal weight, fetal anomalies, ultrasound

C ongenital diaphragmatic hernia

(CDH) is a congenital anomaly in
which fetal abdominal organs herniate
into the thoracic cavity through a dia-
phragmatic defect. Displaced organs
impede normal lung development and
can result in neonatal respiratory failure
and pulmonary hypertension because of
pulmonary hypoplasia and immaturity.1
Accurate ultrasound assessment of
estimated fetal weight (EFW) is crucial
to antenatal surveillance in obstetrics
because it has an impact on the recom-
mendations for delivery timing and
mode of delivery. For fetuses with CDH,
EFW is also used as a prognosticator for
neonatal morbidity and mortality, which
are increased in neonates with CDH and
a birthweight below 2000 g. This
Cite this article as: Zuckerwise LC, Ha LC, Osmundson
SS, et al. Accuracy of estimated fetal weight assessment
in fetuses with congenital diaphragmatic hernia. Am J
Obstet Gynecol MFM 2020;2:100064.
2589-9333/$36.00
ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajogmf.2019.100064
information can be used to predict
whether a neonate is a candidate for
extracorporeal membrane oxygenation.2
Estimated fetal weight is commonly
determined by the Hadlock formula,
which includes measurements of fetal
abdominal circumference, femur length,
biparietal diameter, and head circum-
ference.3,4 With the Hadlock formula,
there is an accepted range of error up to
20% in either direction for accuracy of
EFW.5e7 However, in fetuses with CDH,
this degree of error may be even higher
because of a decreased abdominal
circumference because the fetal abdom-
inal organs, such as bowel, stomach, and
liver, are displaced into the fetal thorax
(Figures 1e3).
Currently there is no universally
accepted method for assessing EFW in
fetuses with prenatally diagnosed
CDH, and there are limited and mixed
results in the literature regarding the
accuracy of EFW in this population.8,9
Therefore, we sought to assess the ac-
curacy of standard EFW measurement in
fetuses with CDH. We hypothesized that
the standard EFW assessment would
underestimate the EFW of fetuses with
CDH because of decreased fetal
abdominal circumference.
Materials and Methods
This was a retrospective cohort of fetuses
diagnosed with CDH at our institution
from Jan. 1, 2012, to Dec. 31, 2018. This
study was approved for exempt review by
the Vanderbilt University Institutional
Review Board. All patients older than 18
years of age signed a written informed
consent to have their data and outcomes
tracked in our database.
Inclusion criteria were women at least
18 years old with prenatally diagnosed
CDH, complete prenatal information
with dating established by last menstrual
period and/or ultrasound prior to 22
weeks, estimated fetal weight by ultra-
sound, and neonatal birthweight infor-
mation. We excluded fetuses with known
chromosomal abnormalities or addi-
tional major structural anomalies
because these may have an impact on
growth velocities in pregnancy.

FEBRUARY 2020 AJOG MFM 1

Original Research

by gestational age: projected EFW ¼ final

AJOG MFM at a Glance EFW þ (grams per week)*(days/7).
Why was this study conducted? The percentage discrepancy between
Current data are scarce and conflicting regarding the accuracy of standard ul- the projected EFWat the time of birth and
trasound assessment of estimated fetal weight in fetuses with congenital dia- the actual birthweight was then calculated
phragmatic hernia (CDH), in which abdominal content herniation into the fetal for each fetus. To assess the accuracy of
thorax may lead to smaller abdominal circumference measurements. We sought standard EFWassessment in this cohort of
to determine the accuracy of standard measurements for fetuses with prenatally fetuses with CDH, we determined the
diagnosed CDH, as compared with actual neonatal birthweight and accepted median and interquartile ranges for the
ranges of error. projected EFW at birth, the actual birth-
weights, and the absolute percentage dif-
Key findings ferences between these values, within our
Using the Hadlock formula for calculating estimated fetal weight (EFW), in population. A Wilcoxan rank-sum test
addition to established fetal growth rates, we found no significant difference was used to examine the difference be-
between projected EFW at birth and actual birthweight. tween projected EFW and birthweight.
What does this study add to what is known? Results
Standard EFW assessment, including fetal abdominal circumference measurement, Complete data were available for 77
remains an appropriate method of estimating fetal weight in fetuses with CDH. fetuses with CDH that met inclusion
criteria. The median (interquartile range
Gestational age was calculated from ultrasounds perfomed, the final growth [IQR]) maternal body mass index was
the last menstrual period and was ultrasound measurements were used. 31.4 kg/m2 (25.2e37.1). The majority of
confirmed by, or recalculated with, bio- To account for the time interval be- fetuses (n ¼ 59, 76.6%) had left-sided
metric measurements from the first ul- tween final growth ultrasound and CDH. The median gestational age at
trasound performed during the actual date of delivery, we used published delivery was 38 weeks 4 days (37 weeks 1
pregnancy.10 The EFW was calculated estimates of fetal growth of 220 g/wk day to 39 weeks 1 day), with a median of
using the Hadlock formula with stan- from 24 to 35 weeks and then 185 g/wk 13 (7e20) days between final EFW
dard measurements of the fetal head from 35 to 40 weeks11,12 to establish a assessment and delivery. Thirteen de-
circumference, biparietal diameter, projected EFW at birth using the liveries (16.9%) occurred prior to 37
abdominal circumference, and femur following formula, where grams per weeks’ gestation (Table 1).
length.4 If fetuses had multiple growth week represents the average growth rate The median projected EFW was 3177 g
(IQR, 2691e3568], and median actual
birthweight was 3180 g (IQR,
FIGURE 1 2630e3500), which were not statistically
Growth ultrasound images from a fetus with CDH different (P ¼ .66). Overall, the median
absolute percentage difference between
projected EFW at birth and actual birth-
weight was 6.3% (IQR 3.2-11.6%). The
signed percentage difference between
projected and actual birthweight was
e0.9% (IQR e9.0% to 3.4%), suggesting
slight birthweight underestimation.
Our study sample contained 17 fetuses
with right-sided CDH. Within this group,
the median absolute percentage difference
between projected EFWat birth and actual
birthweight was 5.9% (IQR, 4.3e5.0),
similar to that of those with left-sided
CDH of 6.3% (IQR, 2.9e7.0). Our study
sample had 6 fetuses with birthweights
below 2000 g (Table 2). Within this group,
the median absolute percentage difference
Left-sided CDH with stomach, bowel, and liver displaced into fetal thorax. between projected EFWat birth and actual
CDH, congenital diaphragmatic hernia. birthweight was 8.9% [IQR, 4.1e13.5].
Zuckerwise et al. Estimating fetal weight with diaphragmatic hernia. AJOG MFM 2020. Contrary to our original hypothesis, we
found that, overall, the EFW was

2 AJOG MFM FEBRUARY 2020

 Original Research

underestimated in a minority of cases

FIGURE 2
(n ¼ 34, 44.2%).
Growth ultrasound images from a fetus with CDH
Comment
Principal findings
In our study of 77 fetuses with CDH, we
did not find a statistically significant
difference between medians of projected
EFW and actual birthweight, with a
median percent difference of 6.3%. This
degree of error is within the accepted
range of error (up to 20%) for standard
EFW assessment in pregnancies without
structural anomalies.

Results
Available literature is extremely limited
regarding the accuracy of EFW assess-
ment in fetuses with CDH. Additionally,
the 2 main studies that have previously
examined this question present con-
flicting conclusions. A 2002 multicenter
study by Rode et al8 looked at 53 patients
with recorded birthweight and sono-
graphically derived EFW within 3 weeks
of delivery, compared with 66 normal
pregnancies, and found that the corre-
lation coefficient between EFW and
birthweight between the 2 groups was
similar. These authors concluded that
EFW accuracy was not significantly
affected by fetal CDH; however, they did
not report the formula used for calcu-
lating EFW in their population. Addi-
tionally, sonographic EFW within 3
weeks of delivery was used, allowing for a
large margin of error because of the time
interval between measurement and de-
livery, without calculating a projected
EFW to account for fetal growth during
that time interval.
In contrast, a 2012 multicenter study
by Faschingbauer et al9 examined the
accuracy of 8 different formulas for
determining EFW in 172 fetuses with
CDH. They included fetuses that had
EFW assessment within 7 days of de-
livery and found that all formulas eval-
uated except the Siemer equation had
smaller proportions of estimates within
10% of actual birthweight compared
with the control group (172 normal fe-
tuses). Using the Hadlock I formula, they
found a statistically significant difference
in percentage error, absolute percentage
error, and proportion of fetuses with
Transverse measurement at the proper level for abdominal circumference without evident landmarks
because of displaced abdominal contents.
CDH, congenital diaphragmatic hernia.
Zuckerwise et al. Estimating fetal weight with diaphragmatic hernia. AJOG MFM 2020.
EFW within 10% of birthweight in fe-
tuses with CDH vs control fetuses. Thus,
they concluded that standard formulas
for EFW assessment are less accurate for
fetuses with CDH as compared with
structurally normal controls.9
Our study contributes to the existing
literature because we demonstrate, by
calculating a projected EFW to account
for fetal growth in the interval between
final ultrasound and delivery, that
standard EFW assessment by the Had-
lock formula is acceptably accurate for
use in fetuses with CDH. In fact, we
found that our median percentage dif-
ference between the projected EFW at
birth and the actual birthweight was
well below 10%.
Clinical implications
Our study supports the continued use
of the Hadlock formula to estimate
fetal weight in pregnancies complicated
by CDH, despite potential concerns
related to the impact of this specific
anomaly on fetal abdominal circum-
ference measurement. This has several
important implications for the man-
agement of fetuses with CDH. Because
lower birthweight is associated with
higher rates of neonatal morbidity and
mortality for neonates with CDH,2 an
accurate EFW informs delivery timing
recommendations as well as appro-
priate antenatal counseling on neonatal
prognosis.
Additionally, pregnancies with CDH
are associated with a higher risk of fetal
growth restriction.13 Fetal growth re-
striction is defined as EFW less than the
10th percentile and is a strong risk factor
for fetal demise; consequently, growth
restriction often leads to increased
antenatal surveillance and earlier de-
livery.14 This strategy is beneficial only if
accurate and appropriate methods are

FEBRUARY 2020 AJOG MFM 3

Original Research

External validation with a separate

FIGURE 3
sample of fetuses with CDH comparing
Growth ultrasound images from a fetus with CDH
the accuracy of the Hadlock formula
with the new proposed formula by
Faschingbauer et al in calculating EFW
would contribute significantly to the
existing literature on this topic.

Strengths and limitations

Our study has several limitations. As a
retrospective study, we are limited by
available data for the included fetuses
such as timing of ultrasounds and their
proximity to delivery. Another limita-
tion is our lack of control group;
rather, we compare our median per-
centage difference to the previously
established margin of error (up to
20%) with use of the Hadlock formula.
However, internal quality reviews
within our ultrasound unit have proven
our overall EFW accuracy to remain
within published ranges of error.
Additionally, our sample size is limited
Transverse fetal thorax with displaced abdominal contents. by the rarity of this diagnosis and our
B, bowel; CDH, congenital diaphragmatic hernia; H, heart; L, liver; S, stomach.
exclusion of fetuses with additional
Zuckerwise et al. Estimating fetal weight with diaphragmatic hernia. AJOG MFM 2020.
anomalies, which occur in up to
30e50% of fetuses with CDH.16e18
Of note, the majority of our study
available to estimate fetal weight. Based nonanomalous fetuses would be a sample had left-sided CDH, so our
on our results, we recommend using the worthwhile addition to the literature, conclusions may not be generalizable to
standard EFW assessment for fetuses although this would likely require patients with right-sided CDH. Howev-
with CDH to appropriately inform multicenter subject enrollment to ach- er, left-sided CDH accounts for approx-
neonatal prognosis as well as diagnose ieve a larger population. Additionally, a imately 80e85% of all CDH, and the 2
and manage fetal growth restriction. 2015 study by Faschingbauer et al15 previously mentioned studies examining
suggests a new formula for calculating accuracy of standard EFW measure-
Research implications EFW in fetuses with CDH, which they ments in CDH similarly had a majority
In the future, a prospective study with a conclude is more accurate than the of fetuses with left-sided CDH.18,19
larger sample size and a control group of Hadlock formula in this population. Furthermore, within our group of pa-
tients with-right sided CDH, the median
absolute percentage difference between
TABLE 1 projected EFW and birthweight was
Patient demographics similar to that of left-sided CDH and still
within the accepted range of error of the
Category Median (IQR)
Hadlock formula.
BMI 31.9 (25.2e37.1) Finally, we acknowledge that our use
Gestational age at delivery 38 wks 3 d (37 wks 1 d to 39 wks 1 d) of an established fetal growth rate in
Days between last growth ultrasound and delivery 13 (7e20) determining a projected EFW at birth
assumes that fetuses with CDH grow at
CDH parameters, n, %
similar rates to nonanomalous fetuses.
L sided 59 (76.6)
R sided 17 (22.1) Conclusions
Bilateral 1 (1.3) In summary, based on our results,
standard measurements of EFW in fe-
BMI, body mass index; CDH, congenital diaphragmatic hernia; IQR, interquartile range; L, left; R, right.
Zuckerwise et al. Estimating fetal weight with diaphragmatic hernia. AJOG MFM 2020. tuses with CDH demonstrate accuracy
that is at least comparable with

4 AJOG MFM FEBRUARY 2020


TABLE 2
Infant data
Category
Projected EFW at birth, g
Birthweight, g
Difference in EFW and birthweight, %
EFW, estimated fetal weight; IQR, interquartile range.
Zuckerwise et al. Estimating fetal weight with diaphragmatic hernia. AJOG MFM 2020.
previously established margins of error
for ultrasound assessment of fetal
weight. Our data refute our initial hy-
pothesis that EFW in these fetuses is
underestimated because of the distor-
tion of the fetal abdominal circumfer-
ence. To our knowledge, ours is the
first study to calculate a projected EFW
at birth to better compare EFW accu-
racy and birthweight in this population
of fetuses with CDH. Based on our
results, we conclude that standard EFW
assessment utilizing the Hadlock for-
mula remains an appropriate method
for estimating fetal weight in fetuses
with CDH. n et al. Sonographic weight estimation in fetuses
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Original Research
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Author and article information
From the Department of Obstetrics and Gynecology,
Vanderbilt University Medical Center, Nashville, TN.
Received July 17, 2019; revised Oct. 22, 2019;
accepted Oct. 24, 2019.
The authors report no conflict of interest.
Presented as an abstract at the 39th annual preg-
nancy meeting of the Society for Maternal-Fetal Medi-
cine, Las Vegas, NV, Feb. 11e16, 2019.
Corresponding author: Lisa Zuckerwise, MD. lisa.
zuckerwise@vumc.org
FEBRUARY 2020 AJOG MFM 5