Evidence-based national guidelines for the management of suspected fetal growth restriction: comparison, consensus, and controversy
Open accessAbstract
Small for gestational age is usually defined as an infant with a birthweight <10th centile for a population or customized standard. Fetal growth restriction refers to a fetus that has failed to reach its biological growth potential because of placental dysfunction. Small-for-gestational-age babies make up 28-45% of nonanomalous stillbirths, and have a higher chance of neurodevelopmental delay, childhood and adult obesity, and metabolic disease. The majority of small-for-gestational-age babies are not recognized before birth. Improved identification, accompanied by surveillance and timely delivery, is associated with reduction in small-for-gestational-age stillbirths. Internationally and regionally, detection of small for gestational age and management of fetal growth problems vary considerably. The aim of this review is to: summarize areas of consensus and controversy between recently published national guidelines on small for gestational age or fetal growth restriction; highlight any recent evidence that should be incorporated into existing guidelines; and identify future research priorities in this field. A search of MEDLINE, Google, and the International Guideline Library identified 6 national guidelines on management of pregnancies complicated by fetal growth restriction/small for gestational age published from 2010 onwards. There is general consensus between guidelines (at least 4 of 6 guidelines in agreement) in early pregnancy risk selection, and use of low-dose aspirin for women with major risk factors for placental insufficiency. All highlight the importance of smoking cessation to prevent small for gestational age. While there is consensus in recommending fundal height measurement in the third trimester, 3 specify the use of a customized growth chart, while 2 recommend McDonald rule. Routine third-trimester scanning is not recommended for small-for-gestational-age screening, while women with major risk factors should have serial scanning in the third trimester. Umbilical artery Doppler studies in suspected small-for-gestational-age pregnancies are universally advised, however there is inconsistency in the recommended frequency for growth scans after diagnosis of small for gestational age/fetal growth restriction (2-4 weekly). In late-onset fetal growth restriction (≥32 weeks) general consensus is to use cerebral Doppler studies to influence surveillance and/or delivery timing. Fetal surveillance methods (most recommend cardiotocography) and recommended timing of delivery vary. There is universal agreement on the use of corticosteroids before birth at <34 weeks, and general consensus on the use of magnesium sulfate for neuroprotection in early-onset fetal growth restriction (<32 weeks). Most guidelines advise using cardiotocography surveillance to plan delivery in fetal growth restriction <32 weeks. The recommended gestation at delivery for fetal growth restriction with absent and reversed end-diastolic velocity varies from 32 to ≥34 weeks and 30 to ≥34 weeks, respectively. Overall, where there is high-quality evidence from randomized controlled trials and meta-analyses, eg, use of umbilical artery Doppler and corticosteroids for delivery <34 weeks, there is a high degree of consistency between national small-for-gestational-age guidelines. This review discusses areas where there is potential for convergence between small-for-gestational-age guidelines based on existing randomized controlled trials of management of small-for-gestational-age pregnancies, and areas of controversy. Research priorities include assessing the utility of late third-trimester scanning to prevent major morbidity and mortality and to investigate the optimum timing of delivery in fetuses with late-onset fetal growth restriction and abnormal Doppler parameters. Prospective studies are needed to compare new international population ultrasound standards with those in current use.
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Of fetuses diagnosed with fetal growth restriction, approximately 18%-22% will be constitutionally small but healthy at birth with a normal outcome.
“Of fetuses diagnosed with FGR, approximately 18%e22% will be constitutionally small but healthy at birth with a normal outcome.24”
From Society for Maternal-Fetal Medicine Consult Series #52: Diagnosis and management of fetal growth restriction (2020) · cites this paper as [24]
The Introduction says 18–22% of babies classified as small for gestational age (SGA) are constitutionally small but healthy. The Expert Reviews section says reclassified babies have perinatal mortality similar to normally grown babies. The figure applies to SGA infants, not fetuses diagnosed with FGR, and similar mortality does not establish a normal outcome in every respect. (LLM, conf=0.88)
Experimental — accuracy not yet measuredProtocols for umbilical artery Doppler in FGR surveillance vary from weekly to a 2-to 4-week interval.
“Protocols vary from weekly umbilical artery Doppler to a 2-to 4-week interval.24,108”
From Society for Maternal-Fetal Medicine Consult Series #52: Diagnosis and management of fetal growth restriction (2020) · cites this paper as [24]
Table 4 (Conclusions; page not supplied) shows that recommended umbilical artery Doppler intervals vary, including weekly and every two weeks, depending on the guideline and Doppler findings. The Results section gives a 2–4-week interval for ongoing growth scans, not umbilical artery Doppler, so the claimed four-week Doppler interval is unsupported. (LLM, conf=0.88)
Experimental — accuracy not yet measuredA review of national guidelines from 6 countries reveals broad consensus that fetal growth restriction is defined as an ultrasonographic estimated fetal weight below the 10th percentile for gestational age.
“A review of national guidelines for the diagnostic criteria for FGR from 6 countries (United States, United Kingdom, France, Ireland, Canada, and New Zealand) reveals a broad consensus on this definition of FGR.24”
From Society for Maternal-Fetal Medicine Consult Series #52: Diagnosis and management of fetal growth restriction (2020) · cites this paper as [24]
National guidelines from 4 countries recommend cesarean delivery when FGR is complicated by AEDV/REDV of the umbilical artery.
“National guidelines from 4 countries recommend cesarean delivery when FGR is complicated by AEDV/REDV of the umbilical artery.24”
From Society for Maternal-Fetal Medicine Consult Series #52: Diagnosis and management of fetal growth restriction (2020) · cites this paper as [24]
A prospective observational study suggests that rapid progression of Doppler abnormalities in FGR, if it occurs, is typically noted within the first 2 weeks after diagnosis.
“A prospective observational study of the progression of Doppler abnormalities in FGR suggests that rapid progression, if it is going to occur, is typically noted within the first 2 weeks after diagnosis.24,108”
From Society for Maternal-Fetal Medicine Consult Series #52: Diagnosis and management of fetal growth restriction (2020) · cites this paper as [24]
The Results discuss surveillance after FGR diagnosis, and the Conclusions table lists Doppler monitoring intervals. Neither reports a prospective observational study finding that rapid Doppler deterioration typically appears within the first two weeks after diagnosis. Searches for that study and the two-week progression claim found no supporting passage in our copy. (LLM, conf=0.73)
Experimental — accuracy not yet measured
Estimated fetal weight or abdominal circumference can be used as a baseline parameter for the detection of subsequent growth problems.
“Estimated fetal weight (EFW) or AC can be used as a baseline parameter for the detection of subsequent growth problems 26 .”
From <scp>ISUOG</scp> Practice Guidelines (updated): performance of the routine mid‐trimester fetal ultrasound scan (2022) · cites this paper as [26]
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- Authors
- McCowan, L. M., Figueras, F., & Anderson, N. H.
- Affiliations
- University of Auckland (NZ)
- Hospital Sant Joan de Déu Barcelona (ES)
- Corresponding author
- McCowan, Lesley M.
- Venue
- American Journal of Obstetrics and Gynecology
- Publisher
- Elsevier BV
- Published
- 2018-02
- Volume
- 218
- Issue
- 2
- Pages
- S855-S868
- ISSN
- 0002-9378 (ISSN-L)
- OpenAlex
- W2793911400
- Semantic Scholar
- 182b7560972c73212bd51d97de31d3142334f4f2
- Cited by
- 451
- References
- 93
- Citations by year
- 2026: 37 · 2025: 49 · 2024: 34 · 2023: 55 · 2022: 93 · 2021: 78 · 2020: 53 · 2019: 42 · 2018: 8 · 2016: 1 · 2013: 1
- FWCI
- 50.96
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- American Journal of Obstetrics and Gynecology (publishedVersion)
- PubMed (publishedVersion)
- ResearchSpace (University of Auckland) (submittedVersion)
- Topics
- Health Sciences › Medicine › Obstetrics and Gynecology › Pregnancy and preeclampsia studies
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Birth, Development, and Health
- Keywords
- fetal growth restriction, small for gestational age, placental insufficiency, low-dose aspirin, smoking cessation, fundal height measurement, umbilical artery Doppler, cardiotocography, corticosteroids, magnesium sulfate, delivery timing, stillbirth prevention
- MeSH terms
- Aspirin, Canada, Female, Fetal Growth Retardation, France, United Kingdom, Humans, Infant, Newborn, Infant, Small for Gestational Age, Ireland, New Zealand, Placental Insufficiency, Platelet Aggregation Inhibitors, Pregnancy, Prenatal Care, Umbilical Arteries, United States, Biomarkers, Ultrasonography, Prenatal, Smoking Cessation, Practice Guidelines as Topic, Risk Assessment, Ultrasonography, Doppler, Evidence-Based Medicine, Consensus, Growth Charts
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