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Fetal growth restriction: Evaluation and management

Author
Robert Resnik, MD
Section Editors
Charles J Lockwood, MD, MHCM
Deborah Levine, MD
Deputy Editor
Vanessa A Barss, MD, FACOG

INTRODUCTION

When ultrasound examination suggests fetal growth restriction (FGR), prenatal care involves confirming the suspected diagnosis, determining the cause and severity of FGR, counseling the parents, closely monitoring fetal growth and well-being, and determining the optimal time for and route of delivery. FGR resulting from intrinsic fetal factors such as aneuploidy, congenital malformations, or infection carries a guarded prognosis that often cannot be improved by any intervention. FGR related to uteroplacental insufficiency has a better prognosis, but the risk for adverse outcome remains increased.

This topic will discuss the evaluation and management of pregnancies complicated by FGR. The diagnosis of FGR and outcome of affected infants are reviewed separately. (See "Fetal growth restriction: Diagnosis" and "Infants with fetal (intrauterine) growth restriction".)

INITIAL APPROACH

Confirm the diagnosis — The diagnosis of FGR is based on discrepancies between actual and expected sonographic biometric measurements for a given gestational age. Traditionally, it has been defined as <10th percentile weight for gestational age and this establishes the diagnosis as being small for gestational age (SGA). In our practice, when a fetus <10th percentile weight for gestational age is identified, we monitor fetal growth and fetal physiology over time. A normal growth trajectory, normal Doppler velocimetry of the umbilical artery, and normal amniotic fluid volume suggest a constitutionally small fetus or minimal fetal impact from uteroplacental insufficiency. (See 'Pregnancy management' below.)

A weight <10th percentile definition is clinically practical, but it alone does not distinguish the constitutionally small fetus that achieves its normal growth potential and is not at increased risk of adverse outcome from the similarly small fetus whose growth potential is restricted and is at increased risk of perinatal morbidity and mortality. This definition also does not account for the fetus who is not small, but not achieving its growth potential because of intrinsic or environmental restrictions to normal growth. Distinguishing the constitutionally small fetus from the fetus with pathologic growth restriction can help the clinician avoid unnecessary interventions for pregnancies with a constitutionally small fetus and appropriately monitor and time delivery, which may be preterm, of the growth restricted fetus. However, this distinction is difficult to make prenatally. Characteristics that support a diagnosis of a constitutionally small fetus include modest smallness (ie, estimated weight between the 5th and 10th percentiles), normal growth velocity across gestation, normal physiology (ie, normal amniotic fluid volume and umbilical artery Doppler), abdominal circumference growth velocity above the lowest decile, and appropriate size in terms of maternal characteristics (height, weight, race/ethnicity). For example, when race/ethnicity was taken into account, the 5th percentiles for white, Hispanic, black, and Asian women were 2790, 2633, 2622, and 2621 grams, respectively, in a prospective study of 2334 healthy women with low-risk, singleton pregnancies from 12 medical centers in the United States. Using biometric standards derived solely from the group of white fetuses, as many as 15 percent of the non-white fetuses would have been classified as growth-restricted (<5th percentile) [1]. It is also important to distinguish normal from aberrant growth when considering dichorionic twin gestations. Growth is similar to that of singleton pregnancies until 32 weeks of gestation, at which point growth velocity patterns differ: abdominal circumference growth velocity in twins slows [2]. (See "Twin pregnancy: Prenatal issues", section on 'Evaluation of fetal growth and growth discordance'.)

Customized growth curves account for nonpathological maternal factors that affect birth weight. This allows interpretation of estimated fetal weight in the context of the individual fetus' growth potential, rather than against a population-based birthweight distribution. Estimated fetal weight is plotted on a customized growth curve that reflects the specific fetus' growth potential based on the mother's height, prepregnancy weight, parity, and ethnicity, all strong contributors to birth weight [3,4]. This approach may more reliably distinguish those fetuses who are truly growth restricted and at increased risk of morbidity and mortality from those who are small but normal [5]. However, routine clinical use of customized growth curves remains controversial as clear evidence of benefit has not been demonstrated and its use has implications on resource allocation. (See "Fetal growth restriction: Diagnosis", section on 'Customized growth curves'.)

                           

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