Am J Perinatol
DOI: 10.1055/a-2135-6838
Original Article

Selection of Standards for Sonographic Fetal Head Circumference by Use of z-Scores

C. Andrew Combs
1   Pediatrix Center for Research, Education, Quality and Safety, Pediatrix Medical Group, Sunrise, Florida
2   Obstetrix of San Jose, Campbell, California
Amber del Rosario
2   Obstetrix of San Jose, Campbell, California
Olaide Ashimi Balogun
3   Obstetrix Maternal-Fetal Medicine Specialists, Houston, Texas
Zachary S. Bowman
4   Perinatal Associates of Sacramento, Sacramento, California
Sushma Amara
5   Eastside Maternal-Fetal Medicine Specialists, Bellevue, Washington
› Author Affiliations


Objective This study aimed to evaluate which of five established norms should be used for sonographic assessment of fetal head circumference (HC).

Study Design Cross-sectional study using pooled data from four maternal–fetal medicine practices. Inclusion criteria were singleton fetus, gestational age 220/7 to 396/7 weeks, biometry measured, and fetal cardiac activity present. Five norms of HC were studied: Jeanty et al, Hadlock et al, the INTERGROWTH-21st Project (IG-21st), the World Health Organization Fetal Growth Curves (WHO), and the National Institutes of Child Health and Human Development Fetal Growth Studies unified standard (NICHD-U). The fit of our HC measurements to each norm was assessed by these criteria: mean z-score close to 0, standard deviation (SD) of z close to 1, low Kolmogorov–Smirnov D-statistic, high Youden J-statistic, close to 10% of exams >90th percentile, close to 10% of exams <10th percentile, and close to 2.28% of exams >2 SD below the mean.

Results In 23,565 ultrasound exams, our HC measurements had the best fit to the WHO standard (mean z-score 0.10, SD of z = 1.01, D-statistic <0.01, J-statistic 0.83–0.94). The SD of the Jeanty reference was much larger than all the other norms and our measurements, resulting in underdiagnosis of abnormal HC. The means of the IG-21st and NICHD-U standards were smaller than the other norms and our measurements, resulting in underdiagnosis of small HC. The means of the Hadlock reference were larger than all the other norms and our measurements, resulting in overdiagnosis of small HC. Restricting the analysis to a low-risk subgroup of 4,423 exams without risk factors for large- or small-for-gestational age produced similar results.

Conclusion The WHO standard is likely best for diagnosis of abnormal HC. The Jeanty (Chervenak) reference suggested by the Society for Maternal-Fetal Medicine had poor sensitivity for microcephaly screening.

Key Points

  • There are >30 norms for fetal HC.

  • It is unknown which norm should be used.

  • The WHO standard fits our data best.

  • The Chervenak reference is not sensitive for microcephaly.

Publication History

Received: 10 June 2023

Accepted: 21 July 2023

Accepted Manuscript online:
24 July 2023

Article published online:
24 August 2023

© 2023. Thieme. All rights reserved.

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