FIGO initiative on fetal growth

Fetal growth restriction (FGR) is described as the failure of the fetus to fulfil its growth potential because of a pathological factor-like placental dysfunction. 

It is the greatest cause of stillbirth, neonatal mortality, and short‐ and long‐term morbidity, globally. The agreements depending on current research in the diagnosis and management of FGR are described in a recent article, which delivers a comprehensive summary of available evidence and the practical recommendations regarding the care of pregnancies at risk of or complicated by FGR, to reduce the risk of stillbirth and neonatal mortality and morbidity associated with this condition. 

The main recommendations for monitoring, timing and mode of delivery in cases with suspected fetal growth restriction are as follows-

1. In small for gestational age (SGA) (EFW at 3rd–9th percentile, normal fluid and Doppler studies), the Risk of stillbirth is Low. Suggested to monitor Doppler (UA, MCA) every 1–2 weeks, Growth every 2 weeks, At ≥37 weeks consider BPP(biophysical profile)/NST(nonstress test) 1–2 times per week. Time and mode of delivery should be 37–39 weeks and induction respectively.
2. In Uncomplicated FGR at <3rd percentile (normal fluid and Doppler studies), the Risk of stillbirth is Low. Suggested to monitor Doppler (UA, MCA) 1–2 times per week; Growth every 2 weeks and at ≥37 weeks consider BPP/NST 1–2 times per week. Time and mode of delivery should be 36–38 weeks and induction respectively.
3. In FGR with mild abnormalities, and 

• Early Doppler changes:

a. UA PI(pulsatility index) >95th percentile, or

b. MCA PI <5th percentile, or

c. CPR(cerebroplacental ratio) <5th percentile, or

d. UtA( uterine artery) PI >95th percentile

• Oligohydramnios
• Suboptimal interval growth
• Suspected pre‐eclampsia
• The risk of stillbirth is Low. Consider inpatient monitoring, Consider steroids for fetal lung maturation, BPP/NST 1–2 times per week, Doppler [UA (umbilical artery), MCA(middle cerebral artery), DV(ductus venosus)] 1–2 times per week, monitor Growth every 2 weeks. Time and mode of delivery should be 34–37 weeks and cesarean section or induction respectively.

4. In FGR with umbilical artery AEDV/REDV (absent or reversed diastolic velocity), 

• The overall risk of stillbirth is

a. AEDV: 6.8%, OR(odds ratio) 3.6 [2.3–5.6]

b. REDV: 19%, OR 7.3 [4.6–11.4]

• Risk of stillbirth with strict monitoring protocol with a safety net:

a. AEDV: 0%–1%

b. REDV: 1%–2%

• The median time for deterioration is:

a. AEDV: 5 days

b. REDV: 2 days

Inpatient monitoring is suggested along with Steroids for fetal lung maturation, BPP/NST 1–2 times per day, Doppler (UA, MCA, DV) every 1–2 days, and Growth monitoring every 2 weeks. The timing of delivery should be AEDV: 32–34 weeks, REDV: 30–32 weeks; which should be done by a cesarean section.

5. In FGR with abnormal ductus venosus Doppler,

• The overall risk of stillbirth is: 20%, OR 11.6 (6.3–19.7)
• Risk of stillbirth with strict monitoring protocol with a safety net:

a. Elevated DV PIV(pulsatility index for veins): 2%

b. Absent‐reverse a‐wave in DV: 4%

• Inpatient monitoring is suggested along with Steroids for fetal lung maturation, BPP/NST twice per day, and Daily Doppler. The time of delivery should be 26–30 weeks; which should be done by a cesarean section.

SOURCE-. Int J Gynaecol Obstet. 2021;152Suppl 1(Suppl 1):3-57. doi:10.1002/ijgo.13522