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Keywords:

  • gestation;
  • ultrasound estimate;
  • LMP estimate;
  • perterm rate;
  • post-term rate

Summary

Although early ultrasound (<20 weeks' gestation) systematically underestimates the gestational age of smaller fetuses by approximately 1–2 days, this bias is relatively small compared with the large error introduced by last menstrual period (LMP) estimates of gestation, as evidenced by the number of implausible birthweight-for-gestational age. To characterise this misclassification, we compared gestational age estimates based on LMP from California birth certificates with those based on early ultrasound from a California linked Statewide Expanded Alpha-fetoprotein Screening Program (XAFP). The final sample comprised 165 908 women. Birthweight distributions were plotted by gestational age; sensitivity and positive predictive value for preterm rates according to LMP were calculated using ultrasound as the ‘gold standard’.

For gestational ages 20–27 and 28–31 weeks, the LMP-based birthweight distributions were bimodal, whereas the ultrasound-based distributions were unimodal, but had long right tails. At 32–36 weeks, the LMP distribution was wider, flatter, and shifted to the right, compared with the ultrasound distribution. LMP vs. ultrasound estimates were, respectively, 8.7% vs. 7.9% preterm (<37 weeks), 81.2% vs. 91.0% term (37–41 weeks), and 10.1% vs. 1.1% post-term (≥42 weeks). The sensitivity of the LMP-based preterm birth estimate was 64.3%, and the positive predictive value was 58.7%. Overall, 17.2% of the records had estimates with an absolute difference of >14 days. The groups most likely to have inconsistent gestational age estimates included African American and Hispanic women, younger and less-educated women, and those who entered prenatal care after the second month of pregnancy. In conclusion, we found substantial misclassification of LMP-based gestational age.

The 2003 revised US Standard Certificate of Live Birth includes a new gestational age item, the obstetric estimate. It will be important to assess whether this estimate addresses the problems presented by LMP-based gestational age.