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Intra- and interobserver variability in fetal ultrasound measurements


To assess intra- and interobserver variability of fetal biometry measurements throughout pregnancy.


A total of 175 scans (of 140 fetuses) were prospectively performed at 14–41 weeks of gestation ensuring an even distribution throughout gestation. From among three experienced sonographers, a pair of observers independently acquired a duplicate set of seven standard measurements for each fetus. Differences between and within observers were expressed in measurement units (mm), as a percentage of fetal dimensions and as gestational age-specific Z-scores. For all comparisons, Bland–Altman plots were used to quantify limits of agreement.


When using measurement units (mm) to express differences, both intra- and interobserver variability increased with gestational age. However, when measurement of variability took into account the increasing fetal size and was expressed as a percentage or Z-score, it remained constant throughout gestation. When expressed as a percentage or Z-score, the 95% limits of agreement for intraobserver difference for head circumference (HC) were ± 3.0% or 0.67; they were ± 5.3% or 0.90 and ± 6.6% or 0.94 for abdominal circumference (AC) and femur length (FL), respectively. The corresponding values for interobserver differences were ± 4.9% or 0.99 for HC, ± 8.8% or 1.35 for AC and ± 11.1% or 1.43 for FL.


Although intra- and interobserver variability increases with advancing gestation when expressed in millimeters, both are constant as a percentage of the fetal dimensions or when reported as a Z-score. Thus, measurement variability should be considered when interpreting fetal growth rates.

UOG: Sarris I, Ioannou C, Chamberlain P, Ohuma E, Roseman F, Hoch L, Altman DG and Papageorghiou AT, for the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st). Intra- and interobserver variability in fetal ultrasound measurements. Ultrasound Obstet Gynecol 2012; 39: 266-73