Gestational age is a measure of the age of a pregnancy which is taken from the woman's last menstrual period (LMP), or the corresponding age of the gestation as estimated by a more accurate method if available. Such methods include adding 14 days to a known duration since fertilization (as is possible in in vitro fertilization), or by obstetric ultrasonography. The popularity of using such a definition of gestational age is that menstrual periods are essentially always noticed, while there is usually a lack of a convenient way to discern when fertilization occurred.
The initiation of pregnancy for the calculation of gestational age can be different from definitions of initiation of pregnancy in context of the abortion debate or beginning of human personhood.
According to American Congress of Obstetricians and Gynecologists, the main methods to calculate gestational age are:
A more complete listing of methods is given in following table:
|Method of estimating gestational age||Variability (2 standard deviations)|
|Days from oocyte retrieval or co-incubation in in vitro fertilisation + 14 days||±1 day|
|Days from estimated ovulation in Ovulation induction + 14 days||±3 days|
|Days from artificial insemination + 14 days||±3 days|
|Days from known single sexual intercourse + 14 days||±3 days|
|Days from estimated ovulation by basal body temperature record + 14 days||±4 days|
|First-trimester physical examination||±2 weeks|
|Second-trimester physical examination||±4 weeks|
|Third-trimester physical examination||±6 weeks|
|First-trimester obstetric ultrasonography (crown-rump length)||±8% of the estimate|
|Second-trimester obstetric ultrasonography (head circumference, femur length)||±8% of the estimate|
|Third-trimester obstetric ultrasonography (head circumference, femur length)||±8% of the estimate|
As a general rule, the official gestational age should be based on the actual beginning of the last menstrual period, unless any of the above methods gives an estimated date that differs more than the variability for the method, in which case the difference cannot probably be explained by that variability alone. For example, if there is a gestational age based on the beginning of the last menstrual period of 9.0 weeks, and a first-trimester obstetric ultrasonography gives an estimated gestational age of 10.0 weeks (with a 2 SD variability of ±8% of the estimate thereby giving a variability of ±0.8 weeks), the difference of 1.0 weeks between the tests is larger than the 2 SD variability of the ultrasonography estimate, indicating that the gestational age estimated by ultrasonography should be used as the official gestational age.
Once the estimated due date (EDD) is established, it should rarely be changed, as the determination of gestational age is most accurate earlier in the pregnancy.
Following are diagrams for estimating gestational age from obstetric ultrasound, by various target parameters:
The fertilization age (also called embryonic age and later fetal age) is the time from the fertilization. It usually occurs within a day of ovulation, which, in turn, occurs on average 14.6 days after the beginning of the preceding menstruation (LMP). There is also considerable variability in this interval, with a 95% prediction interval of the ovulation of 9 to 20 days after menstruation even for an average woman who has a mean LMP-to-ovulation time of 14.6. In a reference group representing all women, the 95% prediction interval of the LMP-to-ovulation is 8.2 to 20.5 days. The actual variability between gestational age as estimated from the beginning of the last menstrual period (without the use of any additional method mentioned in previous section) is substantially larger because of uncertainty which menstrual cycle gave rise to the pregnancy. For example, the menstruation may be scarce enough to give the false appearance that an earlier menstruation gave rise to the pregnancy, potentially giving an estimated gestational age that is approximately one month too large. Also, vaginal bleeding occurs during 15-25% of first trimester pregnancies, and may be mistaken as menstruation, potentially giving an estimated gestational age that is too low.
Gestational age is used for example for:
The mean pregnancy length has been estimated to be 283.4 days of gestational age as timed from the first day of the last menstrual period and 280.6 days when retrospectively estimated by obstetric ultrasound measurement of the fetal biparietal diameter (BPD) in the second trimester. Other algorithms take into account other variables, such as whether this is the first or subsequent child, the mother's race, age, length of menstrual cycle, and menstrual regularity. In order to have a standard reference point, the normal pregnancy duration is assumed by medical professionals to be 280 days (or 40 weeks) of gestational age. Furthermore, actual childbirth has only a certain probability of occurring within the limits of the estimated due date. A study of singleton live births came to the result that childbirth has a standard deviation of 14 days when gestational age is estimated by first trimester ultrasound, and 16 days when estimated directly by last menstrual period.
The most common system used among healthcare professionals is Naegele's rule, which estimates the expected date of delivery (EDD) by adding a year, subtracting three months, and adding seven days to the first day of a woman's last menstrual period (LMP) or corresponding date as estimated from other means.
There is no sharp limit of development, gestational age, or weight at which a human fetus automatically becomes viable. According to studies between 2003 and 2005, 20 to 35 percent of babies born at 23 weeks of gestation survive, while 50 to 70 percent of babies born at 24 to 25 weeks, and more than 90 percent born at 26 to 27 weeks, survive. It is rare for a baby weighing less than 500 g (17.6 ounces) to survive. A baby's chances for survival increases 3-4% per day between 23 and 24 weeks of gestation and about 2-3% per day between 24 and 26 weeks of gestation. After 26 weeks the rate of survival increases at a much slower rate because survival is high already. Prognosis depends also on medical protocols on whether to resuscitate and aggressively treat a very premature newborn, or whether to provide only palliative care, in view of the high risk of severe disability of very preterm babies.
|Completed weeks of gestation at birth||21 and less||22||23||24||25||26||27||30||34|
|Chance of survival||0%||0-10%||10-35%||40-70%||50-80%||80-90%||>90%||>95%||>98%|
Using gestational age, births can be classified into broad categories:
|Gestational Age in Weeks||Classification|
|< 37 0/7||Preterm|
|34 0/7 - 36 6/7||Late preterm|
|37 0/7 - 38 6/7||Early Term|
|39 0/7 - 40 6/7||Full Term|
|41 0/7 - 41 6/7||Late Term|
|> 42 0/7||Postterm|
Using the LMP (last menstrual period) method, a full-term human pregnancy is considered to be 40 weeks (280 days), though pregnancy lengths between 38 and 42 weeks are considered normal. A fetus born prior to the 37th week of gestation is considered to be preterm. A preterm baby is likely to be premature and consequently faces increased risk of morbidity and mortality. An estimated due date is given by Naegele's rule.
According to the WHO, a preterm birth is defined as "babies born alive before 37 weeks of pregnancy are completed." According to this classification, there are three sub-categories of preterm birth, based on gestational age: extremely preterm (less than 28 weeks), very preterm (28 to 32 weeks), moderate to late preterm (32 to 37 weeks). Various jurisdictions may use different classifications.
For most of the 20th Century, official definitions of a live birth and infant death in the Soviet Union and Russia differed from common international standards, such as those established by the World Health Organization in the latter part of the century. Babies who were less than 28 weeks of gestational age, or weighed less than 1000 grams, or less than 35 cm in length – even if they showed some sign of life (breathing, heartbeat, voluntary muscle movement) – were classified as "live fetuses" rather than "live births." Only if such newborns survived seven days (168 hours) were they then classified as live births. If, however, they died within that interval, they were classified as stillbirths. If they survived that interval but died within the first 365 days they were classified as infant deaths.
More recently, thresholds for "fetal death" continue to vary widely internationally, sometimes incorporating weight as well as gestational age. The gestational age for statistical recording of fetal deaths ranges from 16 weeks in Norway, to 20 weeks in the US and Australia, 24 weeks in the UK, and 26 weeks in Italy and Spain.
The WHO defines the perinatal period as "The perinatal period commences at 22 completed weeks (154 days) of gestation and ends seven completed days after birth." Perinatal mortality is the death of fetuses or neonates during the perinatal period. A 2013 study found that "While only a small proportion of births occur before 24 completed weeks of gestation (about 1 per 1000), survival is rare and most of them are either fetal deaths or live births followed by a neonatal death."
Gestational age (as well as fertilization age) is sometimes used postnatally (after birth) to estimate various risk factors. For example, it is a better predictor than postnatal age for risk of intraventricular hemorrhage in premature babies treated with extracorporeal membrane oxygenation.
Child's gestational age at birth (pregnancy length) is associated with various likely causal maternal non-genetic factors: stress during pregnancy, age, parity, smoking, infection and inflammation, BMI. Also, preexisting maternal medical conditions with genetic component, e.g., diabetes mellitus type 1, systemic lupus erythematosus, anaemia. Parental ancestral background (race) also plays a role in pregnancy duration. Gestational age at birth is on average shortened by various pregnancy aspects: twin pregnancy, prelabor rupture of (fetal) membranes, pre-eclampsia, eclampsia, intrauterine growth restriction. The ratio between fetal growth rate and uterine size (reflecting uterine distension) is suspected to partially determine the pregnancy length.
Family-based studies showed that gestational age at birth is partially (from 25% to 40%) determined by genetic factors.
Amniotic fluid index (AFI) is a quantitative estimate of amniotic fluid and an indicator of fetal well-being. It is a part of the biophysical profile.
AFI is the score (expressed in cm) given to the amount of amniotic fluid seen on ultrasonography of a pregnant uterus. To determine the AFI, doctors may use a four-quadrant technique, when the deepest, unobstructed, vertical length of each pocket of fluid is measured in each quadrant and then added up to the others, or the so-called "Single Deepest Pocket" technique.
An AFI between 8-18 is considered normal. Median AFI level is approximately 14 from week 20 to week 35, when the amniotic fluid begins to reduce in preparation for birth.
An AFI < 5-6 is considered as oligohydramnios. The exact number can vary by gestational age. The fifth percentile for gestational age is sometimes used as a cutoff value.
An AFI > 24-25 is considered as polyhydramnios.Ballard Maturational Assessment
The Ballard Maturational Assessment, Ballard Score, or Ballard Scale is a commonly used technique of gestational age assessment. It assigns a score to various criteria, the sum of all of which is then extrapolated to the gestational age of the fetus. These criteria are divided into physical and neurological criteria. This scoring allows for the estimation of age in the range of 26 weeks-44 weeks. The New Ballard Score is an extension of the above to include extremely pre-term babies i.e. up to 20 weeks.
The scoring relies on the intra-uterine changes that the fetus undergoes during its maturation. Whereas the neurological criteria depend mainly upon muscle tone, the physical ones rely on anatomical changes. The neonate (less than 37 weeks of age) is in a state of physiological hypotonia. This tone increases throughout the fetal growth period, meaning a more premature baby would have lesser muscle tone.
It was developed in 1979.Crown-rump length
Crown-rump length (CRL) is the measurement of the length of human embryos and fetuses from the top of the head (crown) to the bottom of the buttocks (rump). It is typically determined from ultrasound imagery and can be used to estimate gestational age.Embryo
An embryo is an early stage of development of a multicellular diploid eukaryotic organism. In general, in organisms that reproduce sexually, an embryo develops from a zygote, the single cell resulting from the fertilization of the female egg cell by the male sperm cell. The zygote possesses half the DNA from each of its two parents. In plants, animals, and some protists, the zygote will begin to divide by mitosis to produce a multicellular organism. The result of this process is an embryo.
In human pregnancy, a developing fetus is considered as an embryo until the ninth week, fertilization age, or eleventh-week gestational age. After this time the embryo is referred to as a fetus.Estimated date of delivery
The estimated date of delivery (EDD), also known as expected date of confinement, and estimated due date or simply due date, is a term describing the estimated delivery date for a pregnant woman. Normal pregnancies last between 37 and 42 weeks.Fetus
A fetus or foetus (; plural fetuses, feti, foetuses or foeti) is the unborn offspring of an animal that develops from an embryo. Following embryonic development the fetal stage of development takes place. In human prenatal development, fetal development begins from the ninth week after fertilisation (or eleventh week gestational age) and continues until birth. Prenatal development is a continuum, with no clear defining feature distinguishing an embryo from a fetus. However, a fetus is characterized by the presence of all the major body organs, though they will not yet be fully developed and functional and some not yet situated in their final anatomical location.Fundal height
Fundal height, or McDonald's rule, is a measure of the size of the uterus used to assess fetal growth and development during pregnancy. It is measured from the top of the mother's uterus to the top of the mother's pubic symphysis. Fundal height, when expressed in centimeters, roughly corresponds to gestational age in weeks between 16 and 36 weeks for a vertex fetus. When a tape measure is unavailable, finger widths are used to estimate centimeter (week) distances from a corresponding anatomical landmark. However, landmark distances from the pubic symphysis are highly variable depending on body type. In clinical practice, recording the actual fundal height measurement from the palpable top of the uterus to the superior edge of the pubic symphysis is standard practice beginning around 20 weeks gestation.
Most caregivers will record their patient's fundal height on every prenatal visit. Measuring the fundal height can be an indicator of proper fetal growth and amniotic fluid development.
Knowledge of gestational age may impact how the height is measured.Gestation
Gestation is the period of development during the carrying of an embryo or fetus inside viviparous animals. It is typical for mammals, but also occurs for some non-mammals. Mammals during pregnancy can have one or more gestations at the same time for example in a multiple birth.
The time interval of a gestation is called the gestation period. In human obstetrics, gestational age refers to the embryonic or fetal age plus two weeks. This is approximately the duration since the woman's last menstrual period (LMP) began.Gestational sac
The gestational sac is the large cavity of fluid surrounding the embryo. During early embryogenesis it consists of the extraembryonic coelom, also called the chorionic cavity. The gestational sac is normally contained within the uterus. It is the only available structure that can be used to determine if an intrauterine pregnancy exists until the embryo is identified.
On obstetric ultrasound, the gestational sac is a dark ("anechoic") space surrounded by a white ("hyperechoic") rim.Gravidity and parity
In biology and human medicine, gravidity and parity are the number of times a female is or has been pregnant (gravidity) and carried the pregnancies to a viable gestational age (parity). These terms are usually coupled, sometimes with additional terms, to indicate more details of the woman's obstetric history. When using these terms:
Gravida indicates the number of times a woman is or has been pregnant, regardless of the pregnancy outcome. A current pregnancy, if any, is included in this count. Twin pregnancy is counted as 1.
Parity, or "para" indicates the number of pregnancies reaching viable gestational age (including live births and stillbirths). The number of fetuses does not determine the parity. Twin pregnancy carried to viable gestational age is counted as 1.
Abortus is the number of pregnancies that were lost for any reason, including induced abortions or miscarriages. The abortus term is sometimes dropped when no pregnancies have been lost. Stillbirths are not included.In utero
In utero is a Latin term literally meaning "in the womb" or "in the uterus". In biology, the phrase describes the state of an embryo or fetus. In legal contexts, the phrase is used to referred to an unborn child, i.e., gestational age until birth. Under common law, unborn children are still considered to exist for property transfer purposes.Intrauterine growth restriction
Intrauterine growth restriction (IUGR) refers to poor growth of a fetus while in the mother's womb during pregnancy. The causes can be many, but most often involve poor maternal nutrition or lack of adequate oxygen supply to the fetus.
At least 60% of the 4 million neonatal deaths that occur worldwide every year are associated with low birth weight (LBW), caused by intrauterine growth restriction (IUGR), preterm delivery, and genetic abnormalities, demonstrating that under-nutrition is already a leading health problem at birth.
Intrauterine growth restriction can result in a baby being small for gestational age (SGA), which is most commonly defined as a weight below the 10th percentile for the gestational age. At the end of pregnancy, it can result in a low birth weight.Large for gestational age
Large for gestational age (LGA) is an indication of high prenatal growth rate.
LGA is often defined as a weight, length, or head circumference that lies above the 90th percentile for that gestational age. However, it has been suggested that the definition be restricted to infants with birth weights greater than the 97th percentile (2 standard deviations above the mean) as this more accurately describes infants who are at greatest risk for perinatal morbidity and mortality.Macrosomia, which literally means "long body", is sometimes used for LGA. Some experts consider a baby to be big when it weighs more than 8 pounds 13 ounces (4,000 g) at birth, and others say a baby is big if it weighs more than 9 pounds 15 ounces (4,500 g). A baby is also called “large for gestational age” if its weight is greater than the 90th percentile at birth.Late termination of pregnancy
Late termination of pregnancy (TOP), also known as postviability abortion, or simply abortion is a termination of pregnancy that is performed during a later stage of pregnancy. Late termination of pregnancy is more controversial than abortion in general because it results in the death of a fetus that is more developed and sometimes able to survive independently. Given the complex, gradual nature of human fetal development, the definition of "late" in this context is not precise, and different medical publications have discussed the varying gestational age points that can be involved.Low birth weight
Low birth weight (LBW) is defined by the World Health Organization as a birth weight of a
infant of 2,499 g or less, regardless of gestational age. Subcategories include very low birth weight (VLBW), which is less than 1500 g (3 pounds 5 ounces), and extremely low birth weight (ELBW), which is less than 1000 g (2 pounds 3 ounces). Normal weight at term delivery is 2500–4200 g (5 pounds 8 ounces – 9 pounds 4 ounces).Obstetric ultrasonography
Obstetric ultrasonography is the use of medical ultrasonography in pregnancy, in which sound waves are used to create real-time visual images of the developing embryo or fetus in its mother's uterus (womb). The procedure is a standard part of prenatal care in many countries, as it can provide a variety of information about the health of the mother, the timing and progress of the pregnancy, and the health and development of the embryo or fetus.
The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) recommends that pregnant women have routine obstetric ultrasounds between 18 weeks' and 22 weeks' gestational age (the anatomy scan) in order to confirm pregnancy timing, to measure the fetus so that growth abnormalities can be recognized quickly later in pregnancy, and to assess for congenital malformations and multiple pregnancies (i.e. twins). Additionally, the ISUOG recommends that pregnant women have obstetric ultrasounds between 11 weeks' and 13 weeks 6 days' gestational age in countries with resources to perform them (the nucal scan). Performing an ultrasound at this early stage of pregnancy can more accurately confirm the timing of the pregnancy and can also assess for multiple fetuses and major congenital abnormalities at an earlier stage. Research shows that routine obstetric ultrasound before 24 weeks' gestational age can significantly reduce the risk of failing to recognize multiple gestations and can improve pregnancy dating to reduce the risk of labor induction for post-dates pregnancy. There is no difference, however, in perinatal death or poor outcomes for babies.Pregnancy
Pregnancy, also known as gestation, is the time during which one or more offspring develops inside a woman. A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy can occur by sexual intercourse or assisted reproductive technology. Childbirth typically occurs around 40 weeks from the last menstrual period (LMP). This is just over nine months, where each month averages 31 days. When measured from fertilization it is about 38 weeks. An embryo is the developing offspring during the first eight weeks following fertilization, after which, the term fetus is used until birth. Symptoms of early pregnancy may include missed periods, tender breasts, nausea and vomiting, hunger, and frequent urination. Pregnancy may be confirmed with a pregnancy test.Pregnancy is typically divided into three trimesters. The first trimester is from week one through 12 and includes conception, which is when the sperm fertilizes the egg. The fertilized egg then travels down the fallopian tube and attaches to the inside of the uterus, where it begins to form the embryo and placenta. During the first trimester, the possibility of miscarriage (natural death of embryo or fetus) is at its highest. The second trimester is from week 13 through 28. Around the middle of the second trimester, movement of the fetus may be felt. At 28 weeks, more than 90% of babies can survive outside of the uterus if provided with high-quality medical care. The third trimester is from 29 weeks through 40 weeks.Prenatal care improves pregnancy outcomes. Prenatal care may include taking extra folic acid, avoiding drugs and alcohol, regular exercise, blood tests, and regular physical examinations. Complications of pregnancy may include disorders of high blood pressure, gestational diabetes, iron-deficiency anemia, and severe nausea and vomiting among others. In the ideal childbirth labor begins on its own when a woman is "at term". Pregnancy is considered at full term when gestation has lasted 39 to 41 weeks. After 41 weeks, it is known as late term and after 42 weeks post term. Babies born before 39 weeks are considered early term while those before 37 weeks are preterm. Preterm babies are at higher risk of health problems such as cerebral palsy. Delivery before 39 weeks by labor induction or caesarean section is not recommended unless required for other medical reasons.About 213 million pregnancies occurred in 2012, of which, 190 million (89%) were in the developing world and 23 million (11%) were in the developed world. The number of pregnancies in women ages 15 to 44 is 133 per 1,000 women. About 10% to 15% of recognized pregnancies end in miscarriage. In 2016, complications of pregnancy resulted in 230,600 deaths, down from 377,000 deaths in 1990. Common causes include bleeding, infections, hypertensive diseases of pregnancy, obstructed labor, and complications associated with miscarriage, ectopic pregnancy, or elective abortion. Globally, 44% of pregnancies are unplanned. Over half (56%) of unplanned pregnancies are aborted. Among unintended pregnancies in the United States, 60% of the women used birth control to some extent during the month pregnancy occurred.Prenatal development
Prenatal development (from Latin natalis, meaning 'relating to birth') includes the development of the embryo and of the fetus during a viviparous animal's gestation. Prenatal development starts with fertilization, in the germinal stage of embryonic development, and continues in fetal development until birth.
In human pregnancy, prenatal development is also called antenatal development. The development of the human embryo follows fertilization, and continues as fetal development. By the end of the tenth week of gestational age the embryo has acquired its basic form and is referred to as a fetus. The next period is that of fetal development where many organs become fully developed. This fetal period is described both topically (by organ) and chronologically (by time) with major occurrences being listed by gestational age.
The very early stages of embryonic development are the same in all mammals. Later stages of development across all taxa of animals and the length of gestation vary.Small for gestational age
Small for gestational age (SGA) newborns are those who are smaller in size than normal for the gestational age, most commonly defined as a weight below the 10th percentile for the gestational age.