Establishing Estimated Date of Delivery (EDD)

Megan N. Beatty MD
Basics
Definition
Duration of pregnancy is 40 weeks (280 days) from LMP or 266 days from
fertilization.
Establishing the fetus' GA is critical in managing pregnancy.

Term pregnancy is 3842 weeks from LMP.

Pregnancy dating is based on the timing of earliest detection of:

o

-Subunit of hCG, produced by the trophoblast and detectable in urine

and serum after implantation, ~810 days after fertilization:

Current urine pregnancy tests are sensitive to 25 mIU/mL hCG.

Serum tests may detect 5 mIU/mL -hCG.

TVUS reveals IUP with -hCG ~1,500 mIU at ~5 wks from LMP.

Epidemiology
>6 million women are diagnosed with pregnancy each year.
Millions more seek diagnostic testing for pregnancy.
Risk Factors
Unprotected intercourse
Inconsistent/Incorrect use of contraception
Diagnosis
Signs and Symptoms
History
Complete menstrual, sexual, contraception history
Menstrual history:
o

LMP (NORMAL menstrual periodLNMP):

Bleeding in early pregnancy or implantation bleeding occurs in

up to 20% of pregnancies.

Regularity of menstrual cycles

Sexual history:
o

Number of partners

Recent episodes/dates of unprotected intercourse

Awareness of ovulation

Contraception use:
o

Recent use of birth control or EC

Regularity of usage

Review of Systems
Earliest signs and symptoms:
o General:

Alterations in menstrual cycle:

Amenorrhea

Intermenstrual bleeding/spotting

Bleeding suddenly heavier/lighter than normal

GI system:

Nausea/Vomiting (especially 612 weeks' gestation)

Food cravings/aversions

Bloating/Constipation

Weight gain

GU system:

Urinary frequency/nocturia (secondary to enlarging uterus

resting on the bladder)

Uterine cramping/pain

Musculoskeletal:

Fatigue

Low back pain

Breasts:

Tenderness

Enlargement/Heaviness

Darkening of skin around areola; 1st trimester

More prominent veins over surface

Physical Exam
Presence of signs increases likelihood of pregnancy, but absence does not rule
it out.
Abdominal exam:
o

Uterus palpable above symphysis 12 weeks

At umbilicus 20 weeks

Vulva/Vagina:
o

Increased blood supply leads to blue-violet color of cervix (Chadwick

sign) ~810 weeks.

Uterus:
o

Softens (Hegar sign) ~6 weeks' gestation

Enlarged/Globular after 8 weeks' gestation

Increases by ~1 cm/wk after 4 weeks' gestation

Increased blood supply; uterine artery pulsation may be felt in lateral

fornices on bimanual exam.

Cervix:
o

~1 cm/week of gestation (e.g., 28 cm at 28 weeks)

Softens (Goodell sign) at 6 weeks' gestation

Breasts:
o

Fullness

Tenderness

Darkening areolas

Increased venous patterns

Tests

Urine -hCG:
o Most common method used to confirm pregnancy
o

Identifies the -subunit of hCG

Qualitative test (positive or negative)

Most home kits can detect hCG 2550 mIU/mL

Depending on the brand, can detect 1695% of pregnancies near the

1st day of the unexpected/missed menses

Serum -hCG:
o

Quantitative test (can be used to determine approximate GA in very

early pregnancies)

Can detect as low as 5 mIU/mL

Sensitivity and specificity for pregnancy is between 97 and 100%.

False-positive occasionally seen with serum can be confirmed with

urine testing.

Steep rise starts ~5 weeks' gestation, peaking by ~10 weeks' gestation

Audible Doppler:
o

Can detect fetal cardiac activity audibly at 1012 weeks' gestation

Imaging
TVUS:

Can detect fetal cardiac activity as early as 5 weeks' gestation

Should see a gestational sac with -hCG between 1,000 and 2,000
mIU/mL

TAUS:
o

May detect a gestational sac by 45 weeks' gestation

Can detect fetal cardiac activity as early as 6 weeks' gestation

Up to 12 weeks' gestation, the crown-rump length is predictive of GA

within 4 days.

Differential Diagnosis
Many pregnancy symptoms are nonspecific and may be associated with a wide
variety of other medical conditions.
Amenorrhea (See Amenorrhea: Absence of Bleeding.)

Nausea/Vomiting

Breast symptoms (See Breast Signs and Symptoms: Breast Pain.)

Fatigue

Urinary frequency

Weight gain

Infection
Nausea/Vomiting:
o Gastroenteritis

Urinary frequency:
o

UTI

Metabolic/Endocrine
Amenorrhea:
o PCOS (See Polycystic Ovarian Syndrome.)
o

POF (See Ovarian Insufficiency (Premature Ovarian Failure).)

Hypo/Hyperthyroidism (See Thyroid Disease.)

Immunologic

Amenorrhea (See Amenorrhea: Absence of Bleeding.)

POF (See Ovarian Insufficiency (Premature Ovarian Failure).):
o

Hashimoto thyroiditis

Tumor/Malignancy
Gestational trophoblastic disease (molar pregnancy)
Fibroids:
o

Can be mistaken for enlarged pregnant uterus

Ovarian mass

Drugs

Amenorrhea (See Amenorrhea: Absence of Bleeding.):

o Depo-Provera
o

Busulfan

Chlorambucil

Cyclophosphamide

Phenothiazines

Trauma
Asherman's syndrome (see topic)
P.341
Other/Miscellaneous
Fatigue:
o Thyroid disorders (See Thyroid Disease.)

Depression

Anemia

Alterations in menstrual cycle:

o

PCOS

Thyroid/Pituitary abnormalities

Weight disorders (anorexia, obesity)

Outflow obstruction (cervical stenosis)

Excessive exercise

Psychiatric disorders:
o

Pseudocyesis: Patient believes she is pregnant when she is not.

Anxiety can cause amenorrhea.

Depression can cause changes in appetite, fatigue, musculoskeletal

pain.

Treatment
Pregnancy-Specific Issues
Pregnancy dating is important for many reasons, including avoiding iatrogenic
prematurity and appropriate management of pregnancy-related complications
and conditions.
Pregnancy dating should be based on a combination of factors from LMP and
menstrual/sexual history, to physical exam, to correlation of quantitative hCG.

Size > dates suggests:

o

Incorrect dating

Multiple pregnancy (see topic)

Molar pregnancy (see topic)

Hydramnios (see topic)

Size < dates suggests:

o

Incorrect dating

IUGR (See Intrauterine Growth Restriction.)

Oligohydramnios (See Oligohydramnios.)

Intrauterine fetal demise (See Intrauterine Fetal Demise.)

By Trimester
1st trimester pregnancy dating is important:
o The earlier the assessment of GA, the more accurate.

1st trimester issues include:

o

Ectopic pregnancy vs. spontaneous abortion

Risks for Mother

Ectopic pregnancy is the most common cause of maternal mortality in the 1st
trimester. It is imperative to diagnose as quickly as possible. Discrepancies in
expected rise of serum quantitative -hCG over 48 hours aid in diagnosis (see
Pregnancy-Related Conditions: Ectopic Pregnancy).
Risks for Fetus
Spontaneous abortion/miscarriage (See Pregnancy-Related Conditions: Spontaneous
Abortion.)
Medication (Drugs)
Vitamins:
Prenatal vitamins with 400 g folic acid for all women of reproductive age

Women with risk factors for NTDs (on seizure medications, history of
precious pregnancy with NTDs) should take 4 mg/d folic acid.

Iron sulfate supplementation for anemia

Surgery
Planned cesarean delivery on maternal request:
Requires accuracy of estimated GA and the calculated EDD:
o Calculated EDD impacts the risk/benefit ratio of cesarean delivery on
maternal request, as respiratory morbidity decreases in increasing GA.
Followup
Disposition
Issues for Referral
At the time of pregnancy diagnosis:
Patients desiring to continue with their pregnancy should be counseled to seek
prenatal care as soon as possible.
Patients desiring to terminate their pregnancy should be referred to the proper
center and counseled to seek this service as soon as possible, as the risks of
abortion increase with increasing GA (see Unplanned Pregnancy and Options
Counseling).
Patient Monitoring
Prenatal care
Initial evaluation:

Define the health status of the mother and fetus.

Estimate the GA of the fetus.

Initiate a plan for continuing obstetric care.

See topic on routine prenatal labs (see Prenatal Laboratory Testing,

Routine).

Measurement of fundal height with each prenatal visit correlates with

appropriate fetal growth, and inappropriate growth should trigger fetal
assessment.

Bibliography
Bastion L, et al. Is this patient pregnant?: Can you reliably rule in or rule out early
pregnancy by clinical examination? JAMA. 1997;278(7):586591.
Cole L, et al. Accuracy of home pregnancy tests at the time of missed menses. Am J
Obstet Gynecol. 2004;190(1):100105.
Cole LA, et al. Sensitivity of over-the counter pregnancy tests: Comparison of utility
and marketing messages. J Am Pharm Assoc. 2005;45(5):608615.
Cunningham F, et al, eds. Williams Obstetrics, 22nd ed. 2005.
Gardosi J, et al. Controlled trial of fundal height measurement plotted on customised
antenatal growth charts. Br J Obstet Gynaecol. 1999;106(4):309317.
Kriebs J, et al. Ectopic pregnancy. J Midwifery Womens Health. 2006;51(6):431439.

Patel M. Rule out ectopic: Asking the right questions, getting the right answers.
Ultrasound. 2006;22(2):87100.
Ramoska E, et al. Reliability of patient history in determining the possibility of
pregnancy. Ann Emerg Med. 1989;18:4850.
Wilcox A, et al. Natural limits of pregnancy testing in relation to the expected
menstrual period. JAMA. 2001;286(14):17591761.
Miscellaneous
Synonym(s)
Due date
Estimated date of confinement (EDC)
Clinical Pearls
Growth of fundal height measured from symphysis to fundus should be ~1 cm/wk of
GA.
Abbreviations
ECEmergency contraception
EDDEstimated date of delivery
GAGestational age
hCGHuman chorionic gonadotropin
IUPIntrauterine pregnancy
LMPLast menstrual period
NTDNeural tube defect
PCOSPolycystic ovary syndrome
POFPremature ovarian failure
TAUSTransabdominal ultrasound
TVUSTransvaginal ultrasound
UTIUrinary tract infection
Codes
ICD9-CM
V22 Normal Pregnancy
V22.0 Supervision of normal 1st pregnancy
V22.1 Supervision of other normal pregnancy
V72.40 Pregnancy exam or test, pregnancy unconfirmed
Patient Teaching
Encourage women to record dates of menses.
Prevention
Prevention of unintended pregnancy and family planning:
See topics on contraception in Section III, Women's Health and Primary Care.
Patients should be informed that they can become pregnant during the menopausal
transition, as ovulation can still occur.