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Fetal growth restriction: Evaluation and management

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


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".)


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 is the first challenge for the clinician; it can help to 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.

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), which have a major influence on fetal growth potential. 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'.)


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Literature review current through: Jul 2017. | This topic last updated: Jul 19, 2017.
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