8/8/23 mt/njm

FETAL GROWTH RESTRICTION

1. DEFINITION

Fetal growth restriction (FGR) is a leading cause of perinatal morbidity and mortality.
FGR is defined as an ultrasound estimated fetal weight (EFW) of less than the 10th
percentile or abdominal circumference <10% for gestational age. Adverse
consequences of FGR usually do not develop until growth is less than the 3rd
percentile, but sonographic weight estimates are variable enough that management
decisions should be made when the EFW is reported as <10th percentile or the
abdominal circumference <10%.

Some constitutionally small fetuses are growing normally when consideration is

given to the size of their parents, or their ethnic group. Small fetuses should be treated
as if they have FGR. The term “growth retardation” should not be used. The term
“small for gestational age (SGA)” refers to infants, not fetuses, and should not be
used.

Fetal surveillance is an important part of Monitoring and includes Doppler analysis

and cardiotocography (CTG).

2. DIAGNOSIS

a) A lag of more than 3 cm between fundal height and gestational age may identify
patients at risk of FGR, who should then have an ultrasound performed.

b) When FGR is suspected pregnancy dating should be confirmed for accuracy. If

LMP was used to establish the Estimated Date of Confinement ensure it was a
certain, normal period. Follow ACOG/SMFM pregnancy dating criteria.
(See addendum- Table 1 Guidelines for Redating Based on Ultrasonography.
Methods for Estimating the due date. Committee Opinion # 700 May 2017)

c) The ultrasound diagnosis of FGR is defined as an estimated fetal weight less than
the 10th percentile or abdominal circumference <10% for gestational age. If the
weight percentile is not reported, it should be sought from the radiologist or the
worksheet on the PACS system, or a standard fetal weight curve can be consulted.
Our current ultrasound machines use the Hadlock curve. Customized growth curves,
which correct for maternal height, weight, and ethnicity, are not currently in
widespread use in the United States.

d) Since fetal weight may vary by as much as +20% in the third trimester, please err
on the side of caution for borderline cases.

e) An additional ultrasound parameter that may suggest the diagnosis of FGR

is oligohydramnios (low amniotic fluid volume).
 f) If late care, and unsure if the pregnancy is misdated (less farther along than
dates), if time allows, repeat the growth ultrasound in 3 weeks to see if the fetus
follows the same curve, suggesting misdating, or flattens out, suggesting FGR.
Monitor as below, as if FGR, until the situation is clarified.

g) Early onset FGR is before 32 weeks

a. This tends to be more severe, associated with hypertensive disease and
placental dysfunction
b. Up to 20% are associated with fetal or chromosomal abnormalities. The
risk for chromosomal abnormalities is further increased in the presence of
polyhydramnios or fetal malformation.
c. early onset FGR complicated by EFW < 3 %centile, oligohydramnios,
abnormal cord doppler studies, or fetal anomalies should be considered in
a higher risk cohort.

f) Late onset FGR is after 32 weeks

d. This tends to be less severe with less placental dysfunction

3. ANTEPARTUM MANAGEMENT

1) Fetuses diagnosed as having FGR should have an anatomic survey performed.

2) Fetuses with an EFW <10th percentile or abdominal circumference <10% should
have reflex Doppler studies done. The clinically relevant Doppler parameters for
this disorder include:
a. systolic to diastolic ratio of the umbilical artery (S/D-UA)
b. pulsatility index of the umbilical artery (PI-UA)

Nomograms are available for the interpretation of these values (see attached).
Abnormal Doppler indices include:
a. elevated S/D and/or PI of the UA
b. absent or reversed flow in the UA

3) Maternal Fetal Medicine consult should be considered when the diagnosis is

made, especially in the setting of early onset FGR before 32 weeks.

4) Early onset FGR complicated by any higher risk factors (EFW < 3 %centile,
oligohydramnios, abnormal cord doppler studies, or fetal anomalies) should have
weekly evaluation in MFM that is likely to include amniotic fluid assessment,
cord doppler studies, and fetal heart rate monitoring looking for late decelerations
if the fetus is considered viable and the patient has provided informed consent to
the plan of care. Fetal heart rate monitoring for early onset FGR is looking for
persistent late decelerations and may not be focused on a reactive tracing.

5) Manage according to SMFM Algorithm Figure 1 (below) for the diagnosis and
management of fetal growth restriction. Early onset FGR that does not have any
 listed higher risk factors (EFW < 3 %centile, oligohydramnios, abnormal cord
doppler studies, or fetal anomalies) will start surveillance starting at 32 weeks
unless otherwise specified.

5) Surveillance will include Doppler assessment, cardiotocography, amniotic fluid

assessment and nonstress test/biophysical profile when appropriate.

6) Discuss the need for patient to relocate to Anchorage (if they live out of town) for
more careful monitoring once they have reached a gestational age of fetal viability
and patient approval.

7) Smoking cessation has been shown to be beneficial for the growth restricted
fetus. No other interventions (hospitalization for bedrest, oxygen therapy,
nutritional supplements, aspirin, heparin, antihypertensive medication, etc.) have
been demonstrated to have a favorable effect in established FGR.

4. DELIVERY

1. The evidence is controversial as to the risks vs benefits of early delivery in fetuses

with growth restriction. Early delivery may prevent intrauterine fetal demise or future
neurodevelopmental problems. Very early preterm delivery of the growth restricted
fetus is associated with the worst prognosis.

2. If delivery is anticipated within 7 days, then administration of antenatal

corticosteroids for fetal lung maturation is indicated in fetuses diagnosed with
growth restriction prior to < 33 6/7 weeks.

3. If delivery prior to 32 0/7 is anticipated, then consider neuroprotection with

magnesium sulfate.

4. Growth restricted fetuses with abnormal Doppler velocimetry at less than 32

weeks should be discussed with Maternal Fetal Medicine.

4. Delivery
-EFW <3%-ile or abnormal UA Dopplers (S/D or PI >95%ile) at ≤ 37 wks
-EFW > 3 - <10%-ile with normal UA Doppler at 38-39 wks

5. Continuous electronic fetal monitoring should be instituted in active labor.

Summary of antenatal testing and delivery

For FGR 3rd% - 9th%:

‐ Fetal heart rate monitoring once per week
‐ Doppler q 1 – 2 weeks, then if normal, q 2 – 4 weeks
‐ Fetal growth q 3 – 4 weeks
‐ Delivery at 38 – 39 weeks
For FGR < 3rd%:
‐ Fetal heart rate monitoring once per week
‐ Doppler q week
‐ Fetal growth every 2 weeks (although we will likely perform growth at 3 – 4
weeks)
‐ Delivery at 37 weeks or less

Revised 8/8/23 mt/njm

Revised 9/29/21 njm
Revised 4/16/21 njm
Revised 10/23/20 njm
Revised 10/17/18 njm
Reviewed 10/23/16 njm
Reviewed 11/17/14 njm
Reviewed 11/28/12 njm
Approved 10/16/10gg

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