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Diagnosis and management of fetal growth restriction: the ISUOG guideline and comparison with the SMFM guideline.

The recent international guidelines by the Society for Maternal-Fetal Medicine (SMFM) and the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) differ in their definitions of fetal growth restriction (FGR). Our aim was to compare the performance of the two definitions in predicting neonatal small-for-gestational age (SGA) and composite adverse neonatal outcome (ANO). This was a secondary analysis of data from a prospective study of women referred for fetal growth ultrasound examination between 26 + 0 and 36 + 6 weeks' gestation. The SMFM and ISUOG guidelines were used to define pregnancies with FGR. The SMFM definition of FGR is estimated fetal weight (EFW) or abdominal circumference (AC) < 10th percentile. The ISUOG-FGR definition follows the Delphi consensus criteria and includes either EFW or AC < 3rd percentile or EFW or AC < 10th percentile combined with abnormal Doppler findings or a decrease in growth centiles. The primary outcome was the prediction of neonatal SGA, defined as birth weight < 10th percentile, and a composite of ANO, which was defined as one or more of: Grade-III or -IV intraventricular hemorrhage, respiratory distress syndrome, neonatal death, cord blood pH < 7.1, seizures and admission to the neonatal intensive care unit. Test characteristics (sensitivity, specificity, positive predictive value (PPV), negative predictive value and positive (LR+) and negative likelihood ratios) and area under the receiver-operating-characteristics curve were determined. The association between FGR detected by each definition and selected adverse outcomes was assessed using logistic regression analysis. Of the 1054 pregnancies that met the inclusion criteria, 137 (13.0%) and 55 (5.2%) were defined as having FGR by the SMFM and ISUOG definitions, respectively. Composite ANO and SGA neonate each occurred in 139 (13.2%) pregnancies. For the prediction of neonatal SGA, the SMFM-FGR definition had a higher sensitivity (54.7%) than did the ISUOG definition (28.8%). The ISUOG-FGR definition had higher specificity (98.4% vs 93.3%), LR+ (18.0 vs 8.2) and PPV (72.7% vs 55.5%) than did the SMFM definition for the prediction of a SGA neonate. The SMFM- and ISUOG-FGR definitions had similarly poor performance in predicting composite ANO, with sensitivities of 15.1% and 10.1%, respectively. The SMFM definition of FGR is associated with a higher detection rate for SGA neonates but at the cost of some reduction in specificity. The ISUOG-FGR definition has a higher specificity, LR+ and PPV for the prediction of neonatal SGA. Both definitions of FGR performed poorly in predicting a composite ANO. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Objective: To evaluate the utility of a chromosomal microarray (CMA) in fetuses with isolated fetal growth restriction (FGR) and explore risk factors for the prediction of chromosomal aberration and perinatal adverse outcomes. Method: This study included 271 fetuses of estimated fetal weight less than the 3rd percentile without other structural malformation. Early-onset and late-onset FGR were defined as gestational weeks less than 32 weeks and more than 32 weeks respectively. These patients underwent quantitative fluorescent polymerase chain reaction (QF-PCR) and CMA as the first-line genetic detection strategy. Chromosomal anomalies were compared after stratified analysis by the early-onset and the late-onset FGR, including the absence or presence of ultrasound soft markers, abnormal amniotic fluid, abnormal umbilical Doppler, and gestational disorders. The follow-up time was within 1 year after birth. Logistic regression was used to seek risk predictors of chromosomal aberration and perinatal adverse outcomes for isolated FGR. Results: The CMA identified clinically significant variants in 18/271 (6.6%) fetuses, and variants of unknown significance (VOUS) in 15/271 (5.5%) fetuses. Stratified analysis showed that there was a higher incidence of clinically significant variants in fetuses with the early-onset FGR compared with late-onset FGR (8.7%, 17/195 vs. 1.3%, 1/76, p < 0.05). Regression analysis showed that early gestational age (GA) at diagnosis of FGR was the major risk factor for chromosomal aberration (OR = 0.846). By variable regression analysis, early GA at diagnosis and decreased estimated fetal weight (EFW) percentile of suspicion of FGR, asymmetrical FGR, abnormal amniotic fluid, and severe preeclampsia could all increase the risk of adverse outcomes of isolated FGR including intra-uterine fetal death (IUFD), termination of pregnancy (TOP), and preterm birth in pregnancies with FGR. Conclusion: This study emphasized the value of microarrays for unbalanced genomic variants in fetuses with isolated FGR, especially since the gestational age of nullipara was less than 32 weeks. Perinatal adverse outcomes of isolated FGR were influenced by multiple factors including GA and estimated fetal weight (EFW) percentile of suspicion of FGR, asymmetrical FGR, abnormal amniotic fluid, and severe preeclampsia.

Consensus and controversies of international guidelines for the diagnosis, surveillance, and management of fetal growth restriction: an updated comparison.

217: Validation of the Delphi Procedure Consensus criteria for defining Fetal Growth Restriction (FGR)

ABSTRACTObjectiveTo identify foetal growth restriction (FGR) based on estimated foetal weight (EFW) &lt; 10th percentile, abdominal circumference (AC) &lt; 10th percentile or both EFW and AC &lt; 10th percentile. To determine which group(s) is associated with a higher risk for adverse neonatal outcomes in singleton FGR pregnancies.Study DesignRetrospective cohort study of singleton deliveries with prenatal FGR diagnosis at a single tertiary hospital system 1/1/2021–12/31/2021. FGR was defined as: EFW &lt; 10th percentile only (EFW group), AC &lt; 10th percentile only (AC group), or both EFW/AC &lt; 10th percentile at initial diagnosis (EFW/AC group). The primary composite neonatal outcome includes urgent caesarean section delivery, APGAR &lt; 6 at 1 or 5 min, NICU admission, stillbirth, or neonatal death.ResultsA total of 647 patients met inclusion criteria (EFW: 168, AC: 139, EFW/AC: 340) and no differences were observed in maternal demographics between groups. The composite neonatal outcome occurred at a higher frequency in EFW (36.3%) and EFW/AC (37.8%) groups compared to AC group alone (22.3%) (p = 0.004). Gestational age at delivery in days was earlier in EFW/AC group (264 [258, 273]) compared to EFW (267 [259, 273]) and AC (269 [264, 274]) groups (p &lt; 0.001). Although not reaching statistical significance, there was higher rate of preeclampsia with severe features in the EFW/AC group (20%) compared to the EFW (13.1%) or AC groups (13.7%) (p = 0.078).ConclusionsEFW and EFW/AC groups were associated with a higher risk of adverse neonatal outcomes compared to the AC group. Delivery occurred earlier in pregnancies diagnosed with FGR based on EFW and EFW/AC compared to the AC group. These findings can inform risk counselling in pregnancies diagnosed with FGR.

Planning management and delivery of the growth-restricted fetus

We thank Dr Shen for his comments on the ISUOG Practice Guideline on fetal biometry and growth1 and regret that some of our recommendations may appear to require more clarity. Concerning how fetal biometric measurements should be carried out, it is understandable that these should be obtained in accordance with the way in which the reference standard was established. This was particularly true a few years ago, when many references were available, often technically different. In recent years, there has been a relative consensus to use the ellipse method for abdominal circumference (AC) and head circumference (HC) measurement and to place the calipers on the outer border of the anatomical landmarks. It is this consensus that is reflected in our recommendations. With regard to the definition of fetal growth restriction (FGR), ‘AC/EFW’ below a given centile stands for AC or estimated fetal weight (EFW), and not the division of AC by EFW. This format is the same as that in the original table from which it was derived (table 6 of Gordijn et al.2). We hope that this is clear to the majority of readers. Regarding the definition of early FGR, absent end-diastolic flow in the umbilical artery was chosen as a standalone criterion by the experts in the Delphi consensus definition2 that is cited in the guideline. To this end, the Doppler indication goes beyond the objective of our guideline. Finally, although it may be difficult to visualize the cavum septi pellucidi in a proportion of cases at the extremes of gestational age, this anatomical structure remains a preferred landmark for determining the optimal measurement plane for HC. Guidelines are developed to be applied as a first-line tier in the vast majority of cases. For this reason, we do not discuss the measurement of HC in cases of non-visualization of the cavum septi pellucidi, nor the measurement of AC or femur length in cases of their corresponding abnormalities. We appreciate Dr Shen's interest in this work and hope that we have addressed the ambiguities he identified.

Background This study aimed to investigate fetal cardiac functions by spectral tissue Doppler imaging (s-TDI) in pregnancies complicated with late-onset fetal growth restriction (LO-FGR) and small-for-gestational age (SGA). Methods Forty pregnancies complicated with late-onset FGR and 40 pregnancies complicated with SGA between the 34th and 37th weeks of gestation were enrolled in this study. Forty gestational age-matched pregnant women with no obstetrics complication were randomly selected as a control group. Small fetuses were classified as fetal growth restriction or SGA according to estimated fetal weight (EFW), umbilical artery pulsatility index (PI), cerebroplacental ratio (CPR) and uterine artery PI. s-TDI measurements were obtained at the right atrioventricular valve annulus. Results SGA and LO-FGR fetuses had significantly lower A' and S' values, and higher E'/A' ratio than the control group (P < 0.001). In comparison to controls, significantly prolonged isovolumetric contraction time (ICT') and isovolumetric relaxation time (IRT') and, significantly shortened ejection time (ET') were observed in fetuses with SGA and LO-FGR. Increased myocardial performance index (MPI') values were also found in fetuses with SGA and LO-FGR compared to controls. Conclusion The signs of cardiac dysfunction were observed both in fetuses with SGA and LO-FGR. The fetal cardiac function assessment with s-TDI could be a valuable method in the diagnosis of true growth restricted fetuses and in the management of these fetuses.

To evaluate amniotic fluid volume with Doppler parameters and its association with composite adverse perinatal outcomes (CAPOs) in fetal growth restriction (FGR). This study was conducted prospectively in a tertiary referral center between 2023 and 2024 on pregnant women diagnosed with early- and late-onset FGR. Fetal ultrasonographic measurements, including deepest vertical pocket (DVP) for amniotic fluid, and Doppler parameters including uterine artery (UtA) systolic/diastolic (S/D) and pulsatility index (PI), middle cerebral artery (MCA) S/D and PI, and umbilical artery (UA) S/D and PI, were conducted following fetal biometry. The cerebroplacental ratio (CPR), cerebral ratio, cerebro-placental-uterine ratio (CPUR), and amniotic-umbilical-to-cerebral ratio (AUCR) were all calculated. Pregnant women diagnosed with FGR were planned to give birth after 37 weeks' gestation, unless a pregnancy complication requiring earlier delivery occurred. We assessed perinatal outcomes subsequent to delivery, with CAPOs defined as the presence of at least one adverse outcome: 5th minute APGAR score <7, respiratory distress syndrome (RDS), umbilical cord blood pH <7.2, and neonatal intensive care unit (NICU) admission. The study included 132 participants, divided into early- (n = 32) and late-onset FGR (n = 100) groups. AUCR was significantly lower in fetuses with late-onset FGR who experienced CAPOs. Multivariate analysis showed gestational age at birth and birth weight were significant predictors of CAPOs in early-onset FGR, while gestational age, birth weight, and AUCR were significant predictors in late-onset FGR. CPR, UCR, and CPUR did not show significance in predicting CAPOs in both early- and late-onset FGR on multivariate analysis. AUCR is a potential reliable marker for predicting adverse perinatal outcomes in late-onset FGR.

This study aimed to evaluate if an estimated fetal weight (EFW) between 10 and 15th percentiles at the time of anatomy ultrasound, referred to as borderline fetal growth, is associated with progression to fetal growth restriction (FGR) on subsequent ultrasound, delivery of a small for gestational age (SGA) neonate, or neonatal intensive care (NICU) admission.We performed a secondary analysis using the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMom2b) data. The exposures were normotensive pregnancies with non-anomalous singleton gestations with normal growth, defined as EFW >15th percentile at the anatomy scan compared to borderline fetal growth fetuses defined as those with an EFW in the 10 to 15th percentiles. The primary outcome was FGR at subsequent ultrasound, defined as EFW or AC <10%. The secondary outcomes were NICU admission and SGA neonate. Univariable analyses were performed comparing maternal baseline demographic and clinical characteristics. Multivariable analysis was performed for the primary outcome with variables adjusted a priori for body mass index, smoking status, race/ethnicity, insurance status, and drug use.In total, 4,883 patients met inclusion criteria with 114 in the borderline fetal growth group and 4,769 in the normal growth group. There were no significant differences in maternal demographic or medical characteristics. In adjusted multivariable analysis, patients with borderline growth had significantly higher odds of being diagnosed with FGR at their subsequent scan (adjusted odds ratio [aOR] = 6.68, confidence interval [CI]: 3.98-11.20) compared to those with normal growth. For secondary outcomes, patients with borderline fetal growth were significantly more likely to have SGA neonates (6.14 vs. 2.67%, p = 0.025). There was no difference in admissions to the NICU between groups.Diagnosis of borderline fetal growth at the time of the anatomy scan was associated with significantly increased odds of progression to FGR at subsequent scans and delivery of an SGA neonate. · Patients with EFWs between the 10th and 15th percentiles, referred to as borderline fetal growth, are at an increased risk of progression to FGR compared to those with EFWs >15th percentile.. · Patients with borderline fetal growth are more likely to deliver SGA neonates compared to those with EFWs >15th percentile.. · Providers should consider follow-up antenatal growth assessment in patients with borderline fetal growth..

Background Fetal Growth Restriction (FGR) is the one of largest contributing factor to perinatal morbidity in non-anomalous fetuses and is associated with an increased risk of stillbirth, neonatal death and short and long-term complications. Fetal growth restriction (FGR) is defined as an estimated fetal weight and/or abdominal circumference (AC) is less than the10th percentile. In order to avoid these adverse outcomes, the management of pregnancies with FGR involves close monitoring of fetal well-being and early delivery when necessary. Screening for FGR during pregnancy is thus a central component of prenatal care, as highlighted in recent national guidelines, first-line tools include risk factor assessment at the beginning and during pregnancy. Hence, in this study we evaluated the maternal risk factors and diagnosis-delivery intervals and perinatal outcomes in FGR. Aim To determine the effect of specific antenatal FGR risk factors on fetal growth trajectory and the outcomes using threshold of estimated fetal weight (EFW) and abdominal circumference (AC) &amp;lt;10th percentile. Methods Prospective observational analytical study was conducted in a tertiary care hospital in Cairo, Egypt on 100 pregnant women with documented fetal growth restriction attended Ain Shams University hospital over a period of 1 year and eight months. All fetuses considered as growth restrictions. Fetuses with multiple pregnancy, congenital malformation, chromosomal abnormality, and premature rupture of membrane were. Socio-demographic, maternal risk, Diagnosis- delivery interval in FGR and neonatal morbidities were studied. Results This study included 100 pregnant women with documented FGR fetuses, the mean maternal age at diagnosis was 28.6±2.7 years, the mean pregnant women weight at diagnosis was 72.7±5.1 (kg) with BMI range 25.6–29.8 (kg/m2) and their pregnancy weight gain was 12.0–25.0 (kg), 50 women used to consume caffeine more than 200 mg/day, and the percentage of nicotine exposure was 22% of total studied pregnants, 19 % were passive smokers and 3% of them were active. 73% were multigravida and the rest were primi-gravida, the mean inter-pregnancy interval was 17.3±4.7 months. Obstetric history of Previous placental mediated diseases included (prior FGR, previous intrauterine fetal death (IUFD), Pre-eclampsia and un-explained antepartum hemorrhage) were distributed as follows 16.0%, 6.0%, 12.0% and 2.0% respectively. Also we found 2.0% had an in vitro fertilization (IVF) and 26 women got regular antenatal care (ANC). At the end of our study 45% of fetuses were delivered at completed 37 weeks and 55% showed pre-term delivery (before 37 weeks). 95% of total were delivered by caesarean section. The indications for caesarean section were different. So, among 100 FGR fetuses, 35 fetus had abnormal Doppler pattern which considered the main indication for termination of pregnancy, the most frequent one was absent/reversed ductus venosus Doppler which was the cause of preterm immediate caesarean section in 4 of fetuses. We also found 2 fetuses with also absent/reversed EDV but with abnormal CTG, we found 20 fetuses with PI &amp;gt; 2SD with preserved EDV and completed 37 weeks, 13% had non-reactive non-stress test (NST) necessitating imminent delivery, also 3 fetuses with absent EDV &amp;gt; 34 weeks while only one fetus with reversed EDV &amp;gt;32 weeks. We found 1 fetus with static growth over 3 weeks during our follow up, also we discovered 1 pregnant women who developed accidental hemorrhage with placental separation and other 3 women developed sever pre-eclampsia who underwent emergency caesarean section after controlling their condition. Conclusion FGR is associated with sociodemographic status and various medical conditions. Analysis of various maternal and familial risk factors is an integral part of in-utero fetal surveillance to identify impending fetal hypoxia. Appropriate management should be offered to these FGR fetuses, is optimizing the timing of delivery to improve perinatal health in FGR.

perinatal medicine that results from impaired placental function and has poor perinatal outcomes.However, there is a lack of consensus on diagnostic criteria and management strategies worldwide.While some clinicians consider only fetal size in the diagnosis, others disagree and recommend adding fetal growth velocity Doppler indices to the diagnostic criteria.Different strategies are followed for pregnancy follow-up and delivery decision-making.There are different opinions on which Doppler measurements of vessels such as the umbilical artery, middle cerebral artery, and ductus venosus should be performed during follow-up.To assess fetal well-being and to decide on delivery, methods such as cardiotocography, computed cardiotocography, biophysical profile scoring, and biophysical profile scoring are used or not used.The Society of Maternal-Fetal Medicine (SFMF) and the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) published guidelines in the same year.However, their perspectives on fetal growth restriction were quite different.We basically analyzed the differences between these two guidelines and the reasons for the differences.As a result, we presented our own practice.

The aim of the study was to prospectively evaluate in over 1000 patients, a protocol for late fetal growth restriction (FGR) management classifying pregnancies at high or low risk of adverse perinatal outcome using ultrasound parameters. This was a prospective study of women with a non-anomalous singleton pregnancy from 32 weeks, at University College London Hospital, UK, between 2018 and 2022. Women were included if any of the following was present: estimated fetal weight (EFW) ≤10th centile (c.), abdominal circumference (AC) decrease ≥50 c. compared with a previous scan, umbilical artery (UmbA) Doppler pulsatility index (PI) >95th c. or cerebroplacental ratio (CPR) < 5th c. High-risk cases were delivered at 37-38 weeks if there EFW <10th c. plus any of the following: EFW<3rd c. or AC >50 c. drop, or UmbA PI >95th c. or CPR <5th c. Otherwise late FGR was considered as Low-risk and managed conservatively until 40-41 weeks. The primary outcome was a composite of severe adverse perinatal outcomes including any of the following: stillbirth, neonatal or infant death, advanced resuscitation, 5 min APGAR<7, UmbA pH<7, sepsis, cerebral, respiratory and circulatory morbidity. Multiple logistic regression analysis was performed. Sample size was powered to explore differences in severe adverse neonatal outcome. 408 and 594 of 1002 patients were classified as High- and Low-risk FGR respectively. Neonates from the High-risk group were twice as likely to have severe adverse perinatal outcomes [8.3 Vs 3.2%, aOR 2.1 (95% CI 1.2-3.9), P = 0.02]. There was no extended perinatal mortality in the Low-risk group. Our study demonstrated that appropriate risk stratification of late FGR allows pregnancies at low risk of adverse perinatal outcomes to be managed conservatively at term up to 40-41 weeks with improved perinatal outcomes compared with the High-risk group, and no increase in perinatal mortality.

To determine the magnitude of fetal growth restriction (FGR) using fetal Doppler integrated with antenatal ultrasound in third-trimester screened pregnant women at Agra in northern India. Screened participants underwent routine third-trimester ultrasound assessments integrating fetal Doppler studies. Any one or more of mean uterine artery (UtA) or umbilical artery (UA) pulsatility index > 95th centile, middle cerebral artery (MCA) or cerebroplacental ratio (CPR) PI < 5th centile, absent or reversed end-diastolic velocity, or ductus venosus PI > 95th centile was considered abnormal Doppler studies. Fetuses with estimated fetal weight (EFW) < 3rd percentile or EFW 3rd to 10th percentile with abnormal Doppler were categorised as FGR. Fetuses with EFW 3rd to 10th percentile and normal Doppler were classified as small for gestational age (SGA) and EFW 10th to 50th percentile and abnormal Doppler were classified as appropriate for gestational age (AGA) fetuses with adapted growth restriction. Among 1065 screened participants, 142 fetuses (13.33%) had an EFW < 10th centile and 139 (13.05%) fetuses had both EFW and fetal AC < 10th centile. Stage 1 FGR was identified in 58 (5.45%) fetuses, 75 fetuses (7.04%) were classified as SGA and 77 (7.23%) were adapted growth-restricted AGA fetuses. Reclassifying FGR after integrating Doppler assessments reduced magnitude by 52.13, 51.11, and 76.82% from the estimates of FGR derived based on EFW < 10th centile alone, both EFW and fetal AC < 10th centile and either EFW or fetal AC < 10th centile respectively. Integrating fetal Doppler studies with routine third-trimester ultrasound assessment significantly reclassifies FGR with a huge reduction in the proportion of fetuses that need more intense surveillance in the third trimester.