fetal growth assessment amongst primary care...

SHORT PAPER

FETAL GROWTH ASSESSMENT AMONGST PRIMARY

CARE PHYSICIANS

ALMEIDA, A.; ALMEIDA, C.; ALVES, M.; ANDRADE, A.; BARBOSA, M.; BERNARDO, J.;

CHOUPINA, B.; COSTA, A.; COSTA, C.; GUIMARÃES, J.1; MACHADO, N.; MARQUES, A.;

MORAIS, A.; SÁ, A.; SANTOS, R, MD

June 2012

Faculty of Medicine – University of Oporto

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Fetal Growth Assessment amongst Primary Care Physicians

ALMEIDA, A. 1; ALMEIDA, C. 1; ALVES, M. 1; ANDRADE, A. 1; BARBOSA, M. 1; BERNARDO, J. 1; CHOUPINA,

B. 1; COSTA, A. 1; COSTA, C. 1; GUIMARÃES, J. 1; MACHADO, N. 1; MARQUES, A. 1; MORAIS, A. 1; SÁ, A. 1;

SANTOS, R, MD 2

1Class 2, Introdução à Medicina, Faculdade de Medicina da Universidade do Porto

(contact: [email protected])

2Adviser, Introdução à Medicina, Faculdade de Medicina da Universidade do Porto

ABSTRACT

BACKGROUND: In Portugal the quality of the prenatal assistance provided has been largely

improved in the last two decades as a result of the implementation of several specific health

programs. This prenatal assistance is provided by the primary care physicians and the surveillance

aims to identify and solve risk situations both to the mother and fetus, and is performed according to

pre-established protocols. These evaluations must be performed in key moments, so that the

collected data may be correctly interpreted. One of the aspects of this evaluation refers to fetal

growth. A correct screening of fetal growth complications such as macrosomia or fetal growth

restriction (FGR) is essential to fetal health. Fetal growth complications are still difficult to diagnose,

and the search for a more adequate protocol for fetal growth assessment continues.

AIM: To understand how fetal growth assessment is performed by primary care physicians from

primary care facilities in Porto and Vila Nova de Gaia.

METHODS: We performed an observational and cross-sectional study in which the analysis unit is

the individual. The participants in this study were part of a convenience sample of General

Practitioners, residents and specialists in general and family medicine who work in primary health

care centers in Porto and Vila Nova de Gaia and have monitored pregnant women in 2011. An

anonymous enquiry, with questions relating to the evaluation of fetal growth performed by the

doctors, was applied face-to-face by the investigators in each health care facility. The date collected

was carefully organized ad analyzed statistically in IBM SPSS Statistics 19 TM.

RESULTS: From a total number of 71 potential respondents, 56 answers to the inquiry were

obtained, which corresponds to a response rate of 78,8%. Most respondents were primary care

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physicians (60,7%) and had less than 5 (33,9%) or more than 25 (32,1%) years of service. A vast

majority (58,9%) follows between 5 and 9 pregnancies annually. Concerning fetal growth

assessment, the median value of ultrasounds performed per pregnant woman was 3. Most of the

participants considers crown-rump length (CRL) as the best method to determine gestational age

(GA); only 23,2% of the respondents were able to correctly select the best way to calculate and

correct GA; concerning the correction of GA from the last menstrual period (LMP), answers fluctuate.

Approximately 60% of the respondents don’t know the error associated with ultrasound fetal weight

estimation and almost 73% know the meaning of GA on a 3rd trimester ultrasound. Regarding the use

of fetal growth reference tables, approximately 91% of the respondents stated that they do not use

these resources. A large number of respondents (50%) with more than 25 years of experience were

not able to correctly identify the best method to determine GA.

DISCUSSION: This study reveals that the assessment of fetal growth by primary care physicians is

mainly performed according to the imposed guidelines and consensual procedures. However

improvement areas were identified such as knowledge on the conditions in which GA must be

corrected, the pondered value of different data, the integration of the available data, the use of

reference tables, and the best method for GA calculations.

KEY-WORDS: Pregnancy; Neonatology; Perinatal Mortality; Physicians, primary care; Fetal Development; Fetal Growth Retardation; Fetal Macrosomia; Birth Weight.

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INTRODUCTION

Perinatal mortality is considered an indicator of the life conditions of a population, reflecting the

quality of the provided treatment to the pregnant woman during the pregnant-puerperal cycle 1. One

of the aspects of this treatment is prenatal assistance, which is linked to a decrease in risk of low

weight birth, premature birth and neonatal and child mortality 2.

Around the world, the number of women receiving prenatal care has increased over 20% since

1990. The improvement of this number is still contemplated in the Millennium Development Goals

established by the United Nations and World Health Organization (WHO), in order to reduce both

mother and child mortality 3.

In Portugal, maternal, perinatal and child mortality have suffered a significant reduction over

the years, as a consequence of a great investment in specific health programs, meant to improve the

quality of the assistance provided during the pregnant-puerperal cycle 4.

The monitoring is performed by the primary care physician as long as it can be considered a

low-risk pregnancy (pregnancy that has no identified additional factor of maternal, fetal and/or

neonatal morbidity, after clinical evaluation) 5. This surveillance aims to identify and solve risk

situations both to the mother and fetus, and is performed according to pre-established protocols.

These evaluations must be performed in key moments, so that the collected data may be correctly

interpreted 6.

Given the imposed (and needed) rationalization in the health care system, it is of great

importance to extract all the available information from the recommended medical exams, and to

interpret that data correctly.

According to the Circular Rule Nº5 of 06/08/2007 by the Health Care System Administration,

Portuguese Ministry of Health (ACSS), the first step of prenatal assistance is the prenatal medical

appointment, in which the pregnancy is confirmed and gestational age is calculated 7, one of the

essential estimations to the assessment of obstetric risk concerning fetal growth.

The evaluation of the obstetric risk is also performed by the primary care physician, using the

information collected in the contact with the pregnant woman, as well as performed ultrasounds and

blood tests.

One of the aspects of this evaluation refers to fetal growth, using biometric evaluation during

an ultrasound and auxiliary methods such as the uterine fundal height and fetal growth percentiles as

instruments.

Ultrasound is a main part of pregnancy monitoring. Amongst others, it serves the purpose of

verifying the adequacy of fetal growth. However, some of the data relied through the ultrasound

report may be ambiguous or susceptible of wrong interpretation. Conflicting data provided from the

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ultrasounds, evaluations or gestational age calculations create additional difficulties to a correct

assessment of fetal growth and possible diagnosis.

A correct screening of fetal growth complications such as macrosomia or fetal growth

restriction (FGR) is essential to fetal health 8. FGR affects 10-15% of population and increases late

fetal mortality (ten times higher) and perinatal mortality (relative risk= 2.77). Studies have shown that

early detection and adequate surveillance of FGR cases decreases significantly perinatal morbidity

and mortality (about 20%) 9.

Being a relatively uncommon problem, fetal growth complications are still difficult to diagnose,

and the search for a more adequate protocol for fetal growth assessment continues.10,11,12,13 As such,

it is important to establish risk groups (in which the pre-diagnose risk is higher) and to closely monitor

them. Recent studies show that integrated approaches that consider an extensive number of

parameters and adequate diagnostic criteria to the characteristics of the pregnancy make it easier to

detect anomalies on fetal growth and diagnose pathological conditions such as Fetal Growth

Restriction (FGR) and Macrosomia that influence the perinatal outcome and the long-term health of

the offspring negatively 14, 15, 16, 17, 18.

A new guideline, concerning ultrasound exams reporting during pregnancy, was proposed by

the division of reproductive health from the department of health care quality of DGS, and is currently

under discussion. It addresses primary care physicians, and aims to improve the monitoring of

pregnant women, proving that information concerning this topic is greatly needed and will aid the

improving of pre natal care19.

Given that, the question we aim to answer is: How is the monitoring of fetal growth performed

in primary care facilities?

Through this study we intend to gain knowledge about the current reality concerning this topic

and obtain information that will aid to further improve the quality of treatment of pregnant women in

Portugal, using the resources currently available. It may also help to identify intervention areas, which

may provide to primary care physicians strategies to improve the diagnosis of potentially dangerous

situations during pregnancy, both for mothers and fetuses.

RESEARCH QUESTIONS AND AIMS

The main research question of this project is: “Do primary care physicians from primary care

facilities of Porto and Vila Nova de Gaia have an adequate knowledge on fetal growth assessment?”

We intend to understand how fetal growth assessment is performed by primary care physicians:

i. Analyze the action taken by primary care physicians during fetal growth assessment;

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ii. Understand if the training provided to these doctors, as well as their years of experience,

have an influence on their performance to complete an accurate diagnosis towards fetal

growth assessment.

PARTICIPANTS AND METHODS

STUDY PARTICIPANTS

A convenience sample of general practitioners, residents and primary care physicians who

work in primary care facilities in Porto and Vila Nova de Gaia with clinical autonomy (registered within

the Medical Order with no limitations), that have monitored pregnant women in the year of 2011.

STUDY DESIGN

Our study is analytical and cross-sectional.

DATA COLLECTION METHODS

The method that was used to collect data was an enquiry (presented in paper), to be filled out

anonymously and to be handed in sealed and not identified. The doctors’ identification and respective

work places were preserved; therefore, a comparative analysis between units isn’t going to be

performed, to ensure the confidentiality of the enquired participants.

Answers were collected about the participants’ attitudes towards data referring to fetal growth

and development namely on the clinical integration of data referring to fetal ultrasound.

The enquiry was developed in cooperation with an obstetrics resident, given the lack of

published instruments on this subject.

A pilot survey was applied to 5 doctors: 3 from Centro de Saúde de Viana do Castelo and 2

from USF Gil Eanes, in order to assess its clarity and optimize its comprehension. The enquiry turned

out to reveal itself adequate to the purpose as no alterations had to be done posteriorly.

In order to apply the enquiry, we contacted the Regional Health Administration – North (ARS

Norte) in order to assess their availability to participate in this study. An answer was not obtained in

time. Following this action, the ACES corresponding to the aforementioned health units were

contacted. Given that the waiting period to obtain an answer was too long, the coordinators from

each health unit were contacted via telephone in order to fasten the process. A total number of 22

enquiries were obtained in this phase. Posteriorly, we obtained a positive result from some of the

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already contacted ACES and 36 more enquiries were obtained at this stage. Therefore, we were able

to obtain a total number of 56 enquiries. These enquiries were applied face-to-face by the

researchers in the health units of Porto and Vila Nova de Gaia.

VARIABLES’ DESCRIPTION

The questionnaire included 2 main groups of questions regarding:

A. Knowledge on fetal growth:

a. number of pregnancies followed;

b. number of ultra-sounds;

c. calculation and correction of gestational age (GA);

d. hypothetical cases;

e. best method to determine GA;

f. correction of GA based on ecography;

g. errors associated to ultra-sound fetal weight estimation;

h. fetal growth reference tables;

i. mean of GA on a 3 trimester ultra-sound.

B. Inquireds’:

a. age;

b. years of service;

c. habilitations.

RESULTS

CHARACTERIZATION OF POPULATION SAMPLE

Based on a total number of 71 possible respondents belonging to different primary health care

centers that accepted to participate in this study, 56 answers were obtained, which translated in a

response rate of 78,8%.

Referring to the training, 60,7% of the inquired participants are primary care physicians while

the remaining 39,3% are residents (Table 1). The majority of them have less than 5 years of

experience (33,9%) or more than 25 years of experience (32,1%), given that the remaining

percentage is distributed amongst the years of experience group between 5 and 15 years and

between 16 and 25 years (Graph 1).

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On the other side, a vast majority of the participants (58,9%) have monitored 5 to pregnant

women annually and only one participant stated that he monitors more than 25 pregnant women per

year (Graph 2).

Table 1. Participants’ habilitations, n=56 (%).

Primary Care Physician

Resident

Total

34 (60,7)

22 (39,3)

56 (100)

Table 2. Participants’ years of service, n=56 (%).

Less than 5

Between 5 and 15

Between 16 and 25

More than 25

Total

19 (33,9)

12 (21,4)

7 (12,5)

18 (32,1)

56 (100)

Graph 1. Respondents’ years of service, n=56.

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Table 3. Average number of pregnancies followed, n=56 (%).

Less than 5

Between 5 and 9

Between 10 and 20

More than 25

Total

8 (14,3)

33 (58,9)

14 (25,0)

1 (1,8)

56 (100)

Graph 2. Average number of pregnancies followed, n=56.

CHARACTERIZATION OF SOME PARAMETERS OF FETAL GROWTH ASSESSMENT

AMONGST PRIMARY CARE PHYSICIANS

On the topic of the evaluation of fetal growth to primary care physicians, the results stated that

the median value of the ultrasounds performed per pregnant woman is 3 (Graph 3).

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Ilustração 1 - Median number of ultrasounds by pregnant women followed (pregnant woman without pathologies or complications) (n=55): 3

The results also stated that 83,0% of the participants considered the crown-rump length (CRL)

determined based on and ultrasound performed between the 8th and 10th week, as the best method

to calculate the gestational age (GA).

It must also be mentioned that there was one participant who did not know the best method to

calculate the GA (Table 4).

Table 4. Best method to determine GA, n=53 (%).

CRL determined from ultrasound between 8 and 10

weeks

Biometric determinations from 20 to 22 weeks

Don’t know

Total

44 (83,0)

8 (15,1)

1 (1,9)

53 (100)

Referring to the calculation and correction of the GA, only 23,2% of the inquired participants

considered the set of the three considered options as the most indicated (calculate or correct GA on

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the first appointment based on last menstrual period (LMP) & based on early ultrasound & based on

1º trimester ultrasound), while the remaining 76,8% considered other possibilities while answering

(Table 5).

Table 5. GA’s calculation and correction, n=56 (%).

Calculate or correct GA on the first appointment

based on LMP & based on early ultrasound &

based on 1º trimester ultrasound

Others

Total

13 (23,2)

43 (76,8)

56 (100)

Likewise, the results also stated that 48,1% of the inquired participants corrects the GA based

on the first trimester ultrasound and no participant does it based on the last ultrasound performed. To

also be accentuated is the fact that one of the inquired participants never corrects the GA based on

ultrasounds (Table 6).

Table 6. Ultrasound used to correct GA, n=54 (%).

Never correct

Ultrasound from 1º trimester

Ultrasound from 2º trimester

Ultrasound from 1º trimester, if there is significant

discrepancy

Always correct based on last ultrasound

Total

1 (1,9)

26 (48,1)

2 (3,7)

25 (46,3)

0 (0)

54 (100)

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Concerning the correction of the GA based one the Last Menstrual Period (LMP), the answers

vary: 26,9% of the inquired participants state that they do it if the ultrasound determines a difference

of 6 or more days counting from the day of the last menstrual period (LMP); 21,2% defends the

existence of an 8 or more days difference to the LMP while 23,1% always does it based on the date

of birth already foreseen, calculated based on the CRL (Table 7).

Table 7. Correct GA from LMP, n=52 (%).

Never correct

Always correct based on predicted delivery

day calculated from CRL

Correct if ultrasound determines 2 or more

days of difference from LMP







Don’t know

Total

1 (1,9)

12 (23,1)

7 (13,5)

6 (11,5)

14 (26,9)

11 (21,2)

1 (1,9)

52 (100)

Another main point consists on the error associated to the ultrasound estimation of fetal

weight, where only 11,5% of the inquired participants chose the correct answer (+/- 15% of the

estimated weight). The fact that more than half of the inquired participants stated that they did not

know the answer to the question is to be accentuated (Table 8).

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Table 8. Error associated with ultrasound fetal weight estimation, n=52 (%).

Less than 50g

Less than 100g

Less than 200g

+/- 5% of the estimated weight

+/- 15% of the estimated weight

Don’t know

Total

0 (0)

1 (1,9)

1 (1,9)

17 (32,7)

6 (11,5)

27 (51,9)

52 (100)

Another important point concerning the evaluation of fetal growth consists on the use of

reference tables. Only 5 of the inquired participants (9,3%) stated that they use a reference table,

given that the remaining 90,7% do not use this type of resource (Table 9).

Table 9. Uses any fetal growth reference table, n=54 (%).

Yes

No

Total

5 (9,3)

49 (90,7)

54 (100)

Concerning the interpretation of ultrasound data, the majority of the inquired participants

(72,2%) was able to interpret the meaning of the GA based on the third trimester ultrasound. On the

other side, only a small percentage (3,7%) does not know the meaning of this type of data (Table

10).

Table 10. Meaning of GA on a 3º trimester ultrasound n=54 (%).

Fetus has that number of weeks

Fetuses with the same IG from report have, on average,

13 (24,1)

39 (72,2)

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those parameters found on the fetus observed

Don’t know

Total

2 (3,7)

54 (100)

STATISTICALLY SIGNIFICANT RESULTS BETWEEN VARIABLES

In order to verify possible differences between the respondents according to the years of

experience, habilitations and average number of pregnant women followed, we used Fisher’s Exact

Test. We considered statistically significant results if p<0,05.

This analysis showed only one statistically significant difference in “Best method to determine

GA” within “Inquireds’ years of service”. In this case, it was verified that all (100%) inquired

participants between 5 and 25 years of service were able to recognize correctly the best method to

determine GA (CRL determined from ultrasound between 8 and 10 weeks). On the other hand, only

50% of the inquired participants with more than 25 years of experience gave the same answer; the

other half considered biometric determinations from 20 to 22 weeks (43,8%). One participant (6,3)

stated not knowing the best method to determine GA (Table 11).

Table 11. Relation between “best method to determine GA” and “inquireds’ years of service”,

using Fisher’s Exact Test. Statistically significant, considering p<0,05.

Years of service

p

Less than 5

n=18

Between 5

and 15

n=12

Between 16

and 25

n=7

More than 25

n=16

Best method to

determine GA: n=53(%)

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CRL determined from

ultrasound between 8

and 10 weeks

Biometric determinations

from 20 to 22 weeks

Don’t know

17 (94,4)

1 (5,6)

0 (0)

12 (100)

0 (0)

0 (0)

7 (100)

0 (0)

0 (0)

8 (50)

7 (43,8)

1 (6,3)

0,002*

*statistically significant, considering p<0,05

DISCUSSION

The results of the enquiry performed are congruent with those expected, revealing that most

primary care physicians are prepared to correctly perform screening and diagnostics concerning fetal

growth. Most the courses of action chosen when beholding the hypothetical situations posed by the

inquiry are according to the established guidelines.

As expected most primary care physicians stated that perform three ultrasounds during the

monitoring of low risk pregnancies as supported by research and current guidelines 20.

Most consider CRL determined from ultrasound between 8 and 10 weeks the best method to

determine GA as recommended by in agreement with the established guidelines

Only 13% of the participants Calculate or correct GA on the first appointment based on LMP &

based on early ultrasound & based on 1º trimester ultrasound, pointing the calculation and correction

of GA as an intervention area, specifically the timing and the data used to support these estimations,

which accuracy is of great importance to a reliable screening of fetal growth complications21.

As expected, and according to prenatal care guidelines 96,3% of participants do not correct GI

after the first trimester ultrasound, since the purpose of second trimester ultrasound is mainly to

identify fetal malformations and to provide additional information. However, only 46.3% of primary

care physicians take into consideration the discrepancy between a previous calculation of GI, based

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on the date of the last menstruation, showing that most participants base their estimations solely onto

the ultrasound data and do not consider additional data relevant to GA determination22.

As regarding the correction of GA when comparing the data provided by the first trimester

ultrasound with the previous estimation based on LMP, the discrepancy considered relevant is not

consensual, and results fluctuate, making this a possible topic of intervention concerning the creation

of new guidelines on ultrasound reports and GA calculations.

Concerning more specific knowledge on the implications of fetal growth assessment, the error

associated with ultrasound fetal weight estimation is stated as unknown by 51,9% of the participants,

and only 11,5% are aware of the specific value, that would help weight the value of ultrasound data

when assessing fetal growth23.

On the subject of reference tables for fetal growth, a majority of 90,7% of participants declared

that they did not use reference tables in order to compare the weight estimation stated in the

ultrasound report to the calculated GA. Though not included in the existing guidelines, the use of

reference tables increases the accuracy of the GA calculation, becoming a simple way to capitalize

the data available. As such, and given the reduced application of this tables, this topic can be

identified as an intervention field and focus topic in the formulation of new guidelines23.

When assessing the meaning of GA on a third trimester ultrasound, 72,2% of the physicians

acknowledged that Fetuses with the same GA from report have, on average, those parameters found

on the fetus observed, and not the exact same GA, since the increasing fetal weight accumulation

associated with late pregnancy is coincident with decreasing precision in estimating gestational

length20.

Concerning the best method o GA calculation, statistically significant differences were found

between the respondents, according to the years of experience. Where nearly all physicians under

25 years of experience consider CRL the best method to calculate GA, only 50% participants over

that interval chose the same option. CRL is currently considered the most adequate method of GA

calculation, but the method used to perform these estimations is still not clearly described in current

guidelines. This is clearly an intervention field in order to even the treatment provided and to the

formulation of up to date more specific guidelines.

The number of followed pregnancies was also considered as a differentiating factor, and

statistically significant differences were found when concerning the correction of GA when comparing

the data provided by the first trimester ultrasound with the previous estimation based on LMP though

not revealing a direct relation between more pregnancies followed and more accurate assessment of

the need to correct GA based on discrepancies between CRL and LMP calculations.

Overall this study reveals that the assessment of fetal growth by primary care physicians is

mainly performed according to the imposed guidelines and consensual procedures. However

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improvement areas were identified such as knowledge on the conditions in which GA must be

corrected, the pondered value of different data, the integration of the available data, the use of

reference tables, and the best method for GA calculations. These subjects should be the focus of

improved guidelines and divulgation.

AKNOWLEDGMENTS

We gratefully thank our Professor Ricardo Santos and Alfredo Castro for their generous

support throughout the whole year, allowing us to meet the proposals that we have been assigned

for.

Moreover, we feel our acknowledgements should also be directed to Professor Altamiro

Pereira, PhD, whose in-depth reviews provided us invaluable guidance for our tasks.

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ATTACHMENT A: Enquiry to be applied to the previously selected primary care physicians

QUESTIONÁRIO

AVALIAÇÃO DO CRESCIMENTO FETAL

Obrigado pela sua preciosa colaboração neste estudo.

Este questionário pretende recolher dados sobre as atitudes dos clínicos gerais, internos e especialistas de Medicina Geral e Familiar em relação a dados referentes ao crescimento e desenvolvimento fetal, nomeadamente na integração clínica de dados ecográficos na gravidez.

Vão-lhe ser apresentadas perguntas acerca de atitudes no sua prática clínica habitual e questões mais técnicas e/ou específicas, sobre crescimento fetal.

As questões poderão corresponder a aspetos cuja natureza técnica considere fora do seu âmbito de atuação, mas as respostas tornam-se importantes para ajudar a definir estratégias, nomeadamente em relação aos relatórios de ecografia.

A informação aqui recolhida é completamente anónima, em relação à sua identificação ou da sua instituição (Unidade

de Saúde)

COMO PREENCHER ESTE QUESTIONÁRIO?

A si pedimos-lhe que colabore no estudo preenchendo o questionário, através da colocação de uma cruz (X) no

quadrado correspondente à sua resposta ou resposta por extenso sempre que lhe for pedido.

O inquérito é anónimo, por isso não escreva o seu nome no inquérito ou envelope.

Muito obrigado, desde já, pela sua colaboração.

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A1. Quantas gestantes acompanha, em média, por ano?

*Menos que 5 □

*Entre 5 e 9 □

*Entre 10 e 20 □

*Mais que 20 □

Numa grávida sem patologia ou complicações, e durante toda a gravidez, quantas ecografias fazem as suas grávidas

habitualmente?

Número:____

A2. Calcula ou corrige a idade gestacional em que altura(s) para cada grávida?

Assuma que recebe todas estas informações, na forma consecutiva apresentada.

É POSSÍVEL MAIS QUE UMA OPÇÃO.

*Nunca o faço □

*Na primeira consulta, com base no primeiro dia da última menstruação □

*Com base numa ecografia precoce (até às 10 semanas) □

*Com base na ecografia do primeiro trimestre (entre as 11 e as 13 semanas) □

*Com base na ecografia do segundo trimestre (entre as 19 e as 23 semanas)□

*Com base na ecografia do terceiro trimestre (entre as 28 e as 32 semanas) □

*Não sei □

A3. Qual das seguintes considera a forma mais fidedigna de determinar ou corrigir a idade gestacional por ecografia

numa gravidez?

ESCOLHA APENAS UMA OPÇÃO

*Comprimento Crânio-Caudal (CCC ou CRL) em ecografia entre as 8 e as 10 semanas □

*Média das determinações biométricas ecográficas entre as 20 e as 22 semanas □

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*Média das determinações biométricas ecográficas entre as 28 e as 32 semanas □

*Nunca determino ou altero a idade gestacional com base na informação ecográfica □

*Não sei □

A4.Numa grávida com períodos menstruais prévios regulares e data da última menstruação conhecida:


*Nunca altero a idade gestacional □

*Corrijo a idade gestacional com base na ecografia do primeiro trimestre □

*Corrijo a idade gestacional com base na ecografia do segundo trimestre □

*Corrijo a idade gestacional com base na ecografia do primeiro trimestre, mas apenas se tiver uma diferença

significativa □

*Atualizo sempre a IG com base na última ecografia (1º, 2º e 3º trimestre) realizada □

A5. Numa mulher com menstruação regular, com data de última menstruação (DUM) conhecida, e na posse de uma

ecografia realizada às 12 semanas (por CRL), em que circunstâncias corrige a idade gestacional (IG) calculada a partir da

DUM?


*Nunca corrijo a IG calculada a partir da DUM □

*Corrijo sempre a IG com base na data provável de parto calculada a partir do CRL (ecografia) □

*Corrijo a IG apenas quando a ecografia determina uma idade gestacional com 2 ou mais dias de diferença em relação à

DUM □


DUM □


DUM □


DUM□

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*Não sei □

A6. A estimativa ecográfica do peso fetal (a partir do segundo trimestre) tem um erro associado que é, em cerca de 95%

dos casos:


*Inferior a 50g □

*Inferior a 100g □

*Inferior a 200g □

*±5% do peso estimado □

*±15% do peso estimado □

*Não sei □

A7.Usa alguma tabela de valores de referência do crescimento fetal para verificar o crescimento fetal? (ou seja,

compara habitualmente o valor da estimativa peso de ecografia com a idade gestacional com base numa tabela ou

gráfico?)

*Sim

*Não

Se sim, qual? _____________________________________________

A8. A idade gestacional (IG) ecográfica (calculada com base nos parâmetros biométricos) presente no relatório de uma

ecografia do 3º trimestre significa:


*Que o feto observado tem aquele número de semanas (ou aquela data provável de parto) □

*Que os fetos com a idade gestacional presente no relatório, têm, em média, aqueles parâmetros encontrados no feto

em questão □

*Não sei □

F

F

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B.CARACTERIZAÇÃO PESSOAL

B1. Idade

*Menos que 30 □

*Entre 30 e 40 □

*Entre 40 e 50 □

*Mais que 50 □

B2. Anos de Serviço

*Menos que 5 □

*Entre 5 e 15 □

*Entre 16 e 25 □

*Mais que 25 □

B3. Formação:

Especialista em Medicina Geral e Familiar

Interno em Medicina Geral e Familiar Clinico Geral

Obrigado pela sua colaboração