Clinical Opinion: The diagnosis and management of suspected fetal growth restriction: an evidence-based approach

Christoph C. Lees, Roberto Romero, Tamara Stampalija, Andrea Dall'Asta, Greggory A. DeVore, Federico Prefumo, Tiziana Frusca, Gerard H.A. Visser, John C. Hobbins, Ahmet A. Baschat, Caterina M. Bilardo, Henry L. Galan, Stuart Campbell, Dev Maulik, Francesc Figueras, Wesley Lee, Julia Unterscheider, Herbert Valensise, Fabricio Da Silva Costa, Laurent J. SalomonLiona C. Poon, Enrico Ferrazzi, Giancarlo Mari, Giuseppe Rizzo, John C. Kingdom, Torvid Kiserud, Kurt Hecher

Research output: Contribution to journalArticleOtherpeer-review

58 Citations (Scopus)


This study reviewed the literature about the diagnosis, antepartum surveillance, and time of delivery of fetuses suspected to be small for gestational age or growth restricted. Several guidelines have been issued by major professional organizations, including the International Society of Ultrasound in Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine. The differences in recommendations, in particular about Doppler velocimetry of the ductus venosus and middle cerebral artery, have created confusion among clinicians, and this review has intended to clarify and highlight the available evidence that is pertinent to clinical management. A fetus who is small for gestational age is frequently defined as one with an estimated fetal weight of <10th percentile. This condition has been considered syndromic and has been frequently attributed to fetal growth restriction, a constitutionally small fetus, congenital infections, chromosomal abnormalities, or genetic conditions. Small for gestational age is not synonymous with fetal growth restriction, which is defined by deceleration of fetal growth determined by a change in fetal growth velocity. An abnormal umbilical artery Doppler pulsatility index reflects an increased impedance to flow in the umbilical circulation and is considered to be an indicator of placental disease. The combined finding of an estimated fetal weight of <10th percentile and abnormal umbilical artery Doppler velocimetry has been widely accepted as indicative of fetal growth restriction. Clinical studies have shown that the gestational age at diagnosis can be used to subclassify suspected fetal growth restriction into early and late, depending on whether the condition is diagnosed before or after 32 weeks of gestation. The early type is associated with umbilical artery Doppler abnormalities, whereas the late type is often associated with a low pulsatility index in the middle cerebral artery. A large randomized clinical trial indicated that in the context of early suspected fetal growth restriction, the combination of computerized cardiotocography and fetal ductus venosus Doppler improves outcomes, such that 95% of surviving infants have a normal neurodevelopmental outcome at 2 years of age. A low middle cerebral artery pulsatility index is associated with an adverse perinatal outcome in late fetal growth restriction; however, there is no evidence supporting its use to determine the time of delivery. Nonetheless, an abnormality in middle cerebral artery Doppler could be valuable to increase the surveillance of the fetus at risk. We propose that fetal size, growth rate, uteroplacental Doppler indices, cardiotocography, and maternal conditions (ie, hypertension) according to gestational age are important factors in optimizing the outcome of suspected fetal growth restriction.

Original languageEnglish
Pages (from-to)366-378
Number of pages13
JournalAmerican Journal of Obstetrics and Gynecology
Issue number3
Publication statusPublished - Mar 2022
Externally publishedYes


  • abdominal circumference
  • cardiotocography
  • cesarean delivery
  • Disproportionate Intrauterine Growth Intervention Trial at Term
  • Doppler velocimetry
  • ductus venosus
  • fetal biometry
  • fetal death
  • fetal distress
  • fetal growth
  • longitudinal
  • middle cerebral artery
  • neurodevelopmental outcome
  • Prospective Observational Trial to Optimize Pediatric Health
  • randomized controlled trial
  • short-term variation
  • small for gestational age
  • systematic review
  • Trial of Umbilical and Fetal Flow in Europe
  • umbilical artery Doppler
  • umbilical artery pH
  • uterine artery

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