Growth charts for individual biometric indices Vasilica Stratulat

Growth charts for individual biometric indices Vasilica Stratulat, U/S, Sunnybrook Nir Melamed, MFM, Sunnybrook Nov-12, 2019

Questions of interest

Questions of interest 8 equations… Dating (Index weeks) Index centiles GA = 8. 8+0. 55 x. HCMean HC = -10. 34+1. 48 x. GA • Present charts (Vasi) Contents 3 0. 0028*HC 0. 000226*GA 3 • Compare charts using (1) 1 st trimester dating (CRL, BPD) SB/MSH data (Nir) (2) 2 nd & 3 rd trimester dating (HC, BPD, AC, FL) (3) Growth percentiles (indices percentiles) (4) Best way to calculate AUA (5) How to expresses indices in the report?

(1) st 1 trimester dating – CRL & BPD

Characteristics of selected charts Reference Design N Population Methodology Comments CRL Robinson 75’ Prosp. 334 “Reasonably intelligent LMP” Cross sectional 6 -14 weeks TA Hadlock 92’ Prosp 416 Cross Sectional Daya 93’ Retro. 94 IG-21 Prosp 4265 White LMP IVF Canada Multiethnic LMP 5 -18 weeks TA/TV 6 -14 weeks TA/TV 6 -16 weeks TA Verburg 08’ Prosp 3760 Spontaneous Pregnancy LMP Cross Sectional 6 -14 weeks TA/TV Hadlock 82’ Prosp 533 White Cross sectional 12 -40 weeks Hadlock 84’ Prosp 361 White Cross Sectional 14 -42 weeks Cross Sectional Longitudinal BPD

What is being used in SOON? Center CRL Sunnybrook Daya 93 Ants Toi, CEOU Daya 93 Hani Akouri, St Jose Daya 93 Howard Berger, SMH Hadlock 92 True North Imaging Hadlock 92 Pat Mohide, St Joseph’s Daya 93 MUMC Byron De. France Daya 93 Elad Mei-Dan, NYGH Hadlock 92 Rose Rahmani, RRI Robinson 75 Port Perry Daya 93 Fetal unit, MSH Robinson 75 Credit Valley ?

CRL Weeks Gestational Age (Weeks) 16 14 12 10 Hadlock 92' Daya 93' Robinson 75' IG 21 Verburg 08' 8 6 4 0 1 2 3 4 CRL (cm) 5 6 7 8

BPD weeks 40 35 GA (weeks) 30 25 Hadlock 82 Hadlock 84 20 15 10 5 0 2 4 6 BPD (cm) 8 10 12

Deviation from actual GA – (Sunnybrook data , NT scan, N=1, 136) D P B L R C 92

Proportion within 2 -5 days – (Sunnybrook data , NT scan, N=1, 136) 100% 90% 80% 70% 60% 50% 40% options: Best • CRL 30% - Daya – most accurate, Canadian • BPD - Hadlock 82 20% 10% 0% ± 2 days ± 3 days ± 4 days ± 5 days CRL Hadlock 92' CRL Daya 93' CRL Robinson 75' CRL IG 21 CRL Verburg 08' BPD Hadlock 82' BPD Hadlock 84'

Summary of Best Charts Dating (Index weeks) Hadlock 82 CRL Daya 93 Contents (1) 1 st trimester dating (CRL, BPD) (2) 2 nd & 3 rd trimester dating (HC, BPD, AC, FL) (3) Growth percentiles (indices percentiles) (4) How to calculate AUA (5) How to expresses indices in the report?

nd (2) 2 rd and 3 trimester dating (Index weeks)

Evolution of sonographic dating 1982 - Hadlock –HC, BPD-April, AC- May, FL- August 1984 -Hadlock—Fetal age by multiple parameters 1984 -January Jeanty-Gestational Age from long bones 1990 -January-Hadlock- Fetal age and growth 1997 –June-Chitty- New charts for ultrasound dating of pregnancy 2008 -March-Verburg New charts for U/S dating of pregnancy 2014 -IG 21 st-One size Fits All 2017 -WHO—International charts, but need local adjustments

Characteristics of selected charts Reference Design N Population Methodology Hadlock 82’ Longitudinal 338 -533 Caucasian Prospective Hadlock 84’ Cross Sectional 316 Caucasian Prospective Nicolaides 94’ Cross sectional 1040 Caucasian Retrospective Jeanty 84’ Longitudinal 250 Caucasian Prospective Cervenak 17’ Cross Sectional 27, 679 Mixed Retrospective IG-21 Longitudinal 4321 Multiethnic Prospective WHO Longitudinal 1387 Multiethnic Prospective Chitty 94’ Cross Sectional 663 Caucasian/Af Prospective ro-Caribbean

What is being used in SOON? Center Which charts are you using to express biometric indices as weeks? BPD HC AC FL Sunnybrook Hadlock 82/84 Hadlock 84 Ants Toi, CEOU Hadlock 82 Jeanty 84 Hani Akouri, St Jose Hadlock 82 Howard Berger SMH Hadlock 84 True North Imaging Hadlock 82 Pat Mohide, SJH Hadlock 82 Byron De. France, MUMC Hadlock 82 Elad Mei-Dan, NYGH Hadlock 84 Rose Rahmani RRI Hadlock 82 Hadlock 84 Jeanty 84 Port Perry Hadlock 82 Jeanty Fetal unit, MSH Chitty 94 Verburg 08? Credit Valley Hadlock 82

Deviation from expected GA – (SB + MSH data , 17 -40 w, N=1, 984) FL C A D P B C H

Proportion within 1 week – (SB + MSH data , 17 -40 w, N=1, 984) HC 100% BPD AC FL 90% 80% 70% 60% 50% 40% Within 1 week 30% 20% 10% ty 4 an _J e FL lo c ad k 8 FL _H lo c ad k 8 2 4 k 8 FL _H lo c k 8 AC _H ad lo c dl D_ Ha AC _H ad oc k 8 2 4 2 k 8 oc dl BP BP D_ Ha oc k_ 84 dl HC _H a HC _ Ha d lo ck 8 2 0%

Deviation from expected GA – (SB + MSH data , 17 -40 w, N=1, 984) FL

Summary of Best Charts Index weeks Index centiles Hadlock 82 Hadlock 84 CRL Daya 93 Contents (1) 1 st trimester dating (CRL, BPD) (2) 2 nd & 3 rd trimester dating (HC, BPD, AC, FL) (3) Growth percentiles (indices percentiles) (4) How to calculate AUA (5) How to expresses indices in the report?

(3) Growth percentiles (Index percentiles)

What is being used in SOON? Center Which charts are you using to express biometric indices as percentiles? BPD HC AC FL Sunnybrook Hadlock 82/84 Hadlock 84 Ants Toi, CEOU Hadlock 82 Jeanty 84 Hani Akouri, St Jose Hadlock 82 Jeanty 84 Howard Berger, SMH Hadlock 84 True North Imaging Hadlock 82 Pat Mohide, St Joseph’s Hadlock 82 MUMC Byron De. France Hadlock 82 Jeanty 84 Elad Mei-Dan, NYGH Hadlock 84 Rose Rahmani RRI Hadlock 84 Jeanty 84 Port Perry Hadlock 82 Fetal unit, MSH Chitty 94 Verburg 08 Credit Valley Hadlock 82

HC

HC - Mean 35 Chitty IG-21 30 HC (cm) 25 Hadlock 82' Hadlock 84' Jeanty 1984' Chervenak 2017 IG 21 WHO Chitty 20 15 10 5 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 GA (weeks)

HC – 5 th percentile 35 Chitty 30 IG-21 HC (cm) 25 20 Jeanty 15 10 Hadlock 82' Hadlock 84' Jeanty 1984' Chervenak 2017 IG 21 WHO Chitty 5 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 GA (weeks)

HC – 95 th percentile 40 Chitty 35 IG-21 HC (cm) 30 Hadlock 82' Hadlock 84' Jeanty 1984' Chervenak 2017 IG 21 WHO Chitty 25 20 15 Jeanty 10 5 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 GA (weeks)

Distribution of HC percentile – (SB + MSH data , 17 -40 w, N=1, 984) Hadlock 82’ Hadlock 84’ Jeanty Chitty IG-21

Proportion of abnormal HC– (SB + MSH data , 17 -40 w, N=1, 984) 25% Proportion of cases 20% Best options (17 -40 w): • Hadlock 84’ Less 5 p 15% 10% 5% 0% Hadlock 82' Hadlock 84' Jeanty 1984' IG 21 WHO Chitty

Proportion of abnormal HC by GA – (SB + MSH data , N=1, 984) Proportion of cases 25% 20% 15% Best options (17 -22 w): • Hadlock 84’ 17 -22 w Less 5 p Over 95 p 10% 5% 0% Hadlock 82' Hadlock 84' Proportion of cases 25% Jeanty 1984' IG 21 WHO Best options (27 -40 w) : • Hadlock 84’ 20% Less 5 p 15% Over 95 p Chitty 27 -40 w 10% 5% 0% Hadlock 82' Hadlock 84' Jeanty 1984' IG 21 WHO Chitty

Summary of Best Charts Index weeks Index centiles Hadlock 82 Hadlock 84 CRL Daya 93 Hadlock 84

BPD

BPD - Mean 10 9 8 BPD (cm) 7 6 Hadlock 82' 5 Hadlock 84' 4 Jeanty 1984' 3 WHO 2 Chitty 1 0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 GA (weeks)

BPD – 5 th percentile 10 9 8 BPD (cm) 7 6 Hadlock 82' 5 Hadlock 84' 4 Jeanty 1984' 3 WHO 2 Chitty 1 Hadlock 84 0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 GA (weeks)

BPD – 95 th percentile 12 10 BPD (cm) 8 Hadlock 82' 6 Hadlock 84' Jeanty 1984' 4 WHO Chitty 2 0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 GA (weeks)

Proportion of abnormal BPD (SB + MSH data , 17 -40 w, N=1, 984) 14% Best options 17 -40 w: • Hadlock 82’? Jeanty? Less 5 p 12% Over 95 p Proportion of cases 10% 8% 6% 4% 2% 0% Hadlock 82' Hadlock 84' Jeanty 1984' WHO Chitty

Proportion of abnormal BPD by GA (SB + MSH data , N=1, 984) Proportion of cases 14% 12% 10% Less 5 p Over 95 p Best options (17 -22 w): • None ideal • Hadlock 82? Jeanty? 17 -22 w 8% 6% 4% 2% 0% Proportion of cases Hadlock 82' 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Hadlock 84' WHO Best options (27 -40 w): • None ideal • Hadlock 82? WHO? Less 5 p Over 95 p Hadlock 82' Jeanty 1984' Hadlock 84' Jeanty 1984' WHO Chitty 27 -40 w Chitty

Summary of Best Charts Index weeks Hadlock 82 Hadlock 84 CRL Index centiles Daya 93

AC

AC- Mean 40 35 30 AC (cm) 25 Hadlock 82' 20 Hadlock 84' 15 IG 21 10 WHO 5 Chitty Hadlock 84 0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 GA (weeks)

AC– 5 th percentile 40 35 30 IG-21 AC (cm) 25 Hadlock 82' Hadlock 84' IG 21 WHO Chitty 20 15 10 5 Hadlock 84 0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 GA (weeks)

AC– 95 th percentile 45 WHO 40 35 AC (cm) 30 Hadlock 82' Hadlock 84' IG 21 WHO Chitty 25 20 15 10 5 0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 GA (weeks)

Distribution of AC percentile – (SB + MSH data , 17 -40 w, N=1, 984) Hadlock 82’ Hadlock 84’ IG-21 Chitty

Proportion of abnormal AC (SB + MSH data , 17 -40 w, N=1, 984) Best options (17 -40 w): • Hadlock 82 25% Less 5 p Proportion of cases 20% Over 95 p 15% 10% 5% 0% Hadlock 82' Hadlock 84' IG 21 WHO Chitty

Proportion of abnormal AC by GA (SB + MSH data , N=1, 984) Proportion of cases 30% 25% 20% 15% Best options (17 -22 w): • Hadlock 82? 84? Less 5 p Over 95 p 17 -22 w 10% 5% 0% Hadlock 82' Proportion of cases 25% 20% Hadlock 84' IG 21 WHO Chitty Best options (27 -40 w): • Hadlock 82? Chitty? Less 5 p Over 95 p 15% 27 -40 w 10% 5% 0% Hadlock 82' Hadlock 84' IG 21 WHO Chitty

Summary of Best Charts Index weeks Hadlock 82 Hadlock 84 CRL Index centiles Daya 93

FL

FL- Mean 9 8 7 IG-21 FL (cm) 6 Hadlock 82' Hadlock 84' Jeanty 1984' IG 21 WHO Chitty 5 4 3 2 1 0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 GA (weeks)

FL– 5 th percentile 8 7 IG-21 6 FL (cm) 5 Hadlock 82' Hadlock 84' Jeanty 1984' IG 21 WHO Chitty 4 3 2 1 0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 GA (weeks)

FL– 95 th percentile 9 8 IG-21 7 FL (cm) 6 Hadlock 82' Hadlock 84' Jeanty 1984' IG 21 WHO Chitty 5 4 3 2 1 0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 GA (weeks)

Distribution of AC percentile – (SB + MSH data , 17 -40 w, N=1, 984) Hadlock 82’ Hadlock 84’ Jeanty IG-21 Chitty

Proportion of abnormal FL (SB + MSH data , 17 -40 w, N=1, 984) 30% Best options (17 -40 w): • Hadlock 82/84’ Less 5 p Proportion of cases 25% Over 95 p 20% 15% 10% 5% 0% Hadlock 82' Hadlock 84' Jeanty 1984' IG 21 WHO Chitty

Proportion of abnormal FL by GA (SB + MSH data , N=1, 984) Proportion of cases 25% 20% 15% 17 -22 w Best options (17 -22 w): • Hadlock 84’ best distribution Less 5 p Over 95 p 10% 5% 0% Hadlock 82' Hadlock 84' Proportion of cases 30% Jeanty 1984' IG 21 WHO 27 -40 w Best options (27 -40 w): • Hadlock 82/84’ best 25% Less 5 p 20% Over 95 p Chitty 15% 10% 5% 0% Hadlock 82' Hadlock 84' Jeanty 1984' IG 21 WHO Chitty

Summary of Best Charts e pl m Si m n ea Index weeks Index centiles Models CRL Hadlock 82 Hadlock 84 Daya 93 Contents (1) 1 st trimester dating (CRL, BPD) (2) 2 nd & 3 rd trimester dating (HC, BPD, AC, FL) (3) Growth percentiles (indices percentiles) (4) How to calculate AUA (5) How to expresses indices in the report?

(4) How to determine Average Ultrasound Age (AUA)

What is being used in SOON? Center How is the mean (overall, AUA) gestational age is determined in your u/s reports: SHSC Simple average BDP+HC+AC+FL Ants Toi, CEOU Hani Akouri, SJH Howard Berger, SMH True North Imaging Simple average c. BDP+AC+FL Multiparameter Hadlock equation Simple average HC, AC, FL Multiparameter Hadlock equation Pat Mohide, SJH Multiparameter Hadlock equation (after CRL>84 mm and up to 22 -24 weeks, for EDC estimation only) Byron De. France, MUMC Other: SOGC recommendation Feb 2014 Elad Mei-Dan, NYGH Rose Rahmani, RRI Karolyn Zarestsky, Port Perry Imaging) Multiparameter Hadlock equation BPD is no longer used to calculate EFW (as per 2019 SOON consensus meeting) FMU, MSH Credit Valley Multiparameter Hadlock equation Simple average BDP+HC+AC+FL

Deviation of AUA from actual GA (SB + MSH data , 17 -40 w, N=1, 984) Model based on HC-AC-FL (Hadlock, 1990) Model based on all indices (Hadlock, 1990) Simple mean of HC-AC-FL Simple mean of all indices

Deviation of AUA from actual GA by GA (SB+MSH , 17 -40 w, N=1, 984)

Summary of Best Charts Sim HC ple -A m C- ean FL o f Index weeks CRL Index centiles Hadlock 82 Hadlock 84 Daya 93 Contents (1) 1 st trimester dating (CRL, BPD) (2) 2 nd & 3 rd trimester dating (HC, BPD, AC, FL) (3) Growth percentiles (indices percentiles) (4) How to calculate AUA (5) How to expresses indices in the report?

(5) How to express indices in report?

What is being used in SOON? Center How are biometric indices expressed in your u/s reports: SHSC Weeks (+centile when abnormal) Ants Toi, CEOU Weeks Hani Akouri, SJH Weeks Howard Berger, SMH Weeks + centile True North Imaging Weeks (+centile when abnormal) Pat Mohide, SJH (a) Centile after 22 weeks and dates and EDC confirmed (b) weeks prior to 20 weeks Byron De. France, MUMC Centile Elad Mei-Dan, NYGH Weeks + centile Rose Rahmani, RRI Weeks + centile Karolyn Zarestsky, Port Perry Imaging) Weeks FMU, MSH Centile (weeks for T 1) Credit Valley Weeks

How to express indices in report? Using both WEEKS + PERCENTILES? • Pros • Percentiles - more precise, GA independent more likely to capture attention • Weeks – easier in early gestation, compare serial exams • Some care providers may be used to percentiles/weeks • Cons • Potential discrepancy between the two (at early GA) Index weeks Index centiles

Summary

Summary • Large amount of data • 4 indices • 9 equations • performance vary by GA

Sim HC ple -A m C- ean FL o Summary of Best Charts f Include both weeks + centiles Index weeks CRL Index centiles Hadlock 82 Hadlock 84 Daya 93 Open for Discussion

Thank You Vasilica Stratulat, U/S, Sunnybrook Nir Melamed, MFM, Sunnybrook Nov-12, 2019