Clinical Opinion

TY - JOUR

T1 - Clinical Opinion

T2 - The diagnosis and management of suspected fetal growth restriction: an evidence-based approach

AU - Lees, Christoph C

AU - Romero, Roberto

AU - Stampalija, Tamara

AU - Dall'Asta, Andrea

AU - DeVore, Greggory A

AU - Prefumo, Federico

AU - Frusca, Tiziana

AU - Visser, Gerard H A

AU - Hobbins, John C

AU - Baschat, Ahmet A

AU - Bilardo, Caterina M

AU - Galan, Henry L

AU - Campbell, Stuart

AU - Maulik, Dev

AU - Figueras, Francesc

AU - Lee, Wesley

AU - Unterscheider, Julia

AU - Valensise, Herbert

AU - Da Silva Costa, Fabricio

AU - Salomon, Laurent J

AU - Poon, Liona C

AU - Ferrazzi, Enrico

AU - Mari, Giancarlo

AU - Rizzo, Giuseppe

AU - Kingdom, John C

AU - Kiserud, Torvid

AU - Hecher, Kurt

N1 - Copyright © 2022. Published by Elsevier Inc.

PY - 2022/3

Y1 - 2022/3

N2 - 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.

AB - 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.

KW - Female

KW - Fetal Growth Retardation/diagnostic imaging

KW - Fetal Weight

KW - Gestational Age

KW - Humans

KW - Infant

KW - Placenta

KW - Pregnancy

KW - Randomized Controlled Trials as Topic

KW - Ultrasonography, Doppler

KW - Ultrasonography, Prenatal

KW - Umbilical Arteries/diagnostic imaging

U2 - 10.1016/j.ajog.2021.11.1357

DO - 10.1016/j.ajog.2021.11.1357

M3 - SCORING: Review article

C2 - 35026129

VL - 226

SP - 366

EP - 378

JO - AM J OBSTET GYNECOL

JF - AM J OBSTET GYNECOL

SN - 0002-9378

IS - 3

ER -