What is the recommended management for fetal growth restriction (FGR)?

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Management of Fetal Growth Restriction

The management of FGR requires a structured, gestational age-based approach centered on serial umbilical artery Doppler surveillance with delivery timing determined by the severity of Doppler abnormalities and gestational age to optimize perinatal outcomes. 1, 2

Initial Diagnostic Workup

Ultrasound Assessment

  • Perform a comprehensive transabdominal ultrasound within 24-48 hours including fetal biometry, amniotic fluid volume, umbilical artery Doppler, detailed anatomic survey, and placental evaluation 3
  • A detailed obstetrical ultrasound examination (CPT code 76811) is mandatory for early-onset FGR (<32 weeks) since up to 20% of cases have associated fetal or chromosomal abnormalities 1, 2

Genetic Testing

  • Offer chromosomal microarray analysis when FGR occurs with fetal malformation, polyhydramnios, or both—regardless of gestational age 1, 2
  • Offer chromosomal microarray analysis for unexplained isolated FGR diagnosed before 32 weeks, as it provides 4-10% incremental yield over standard karyotype 1, 3

Infectious Workup

  • Do NOT routinely screen for toxoplasmosis, rubella, or herpes unless other risk factors exist 1
  • Perform PCR for cytomegalovirus only in women with unexplained FGR who elect amniocentesis 1, 2

Surveillance Protocol

Umbilical Artery Doppler Monitoring

  • Initiate serial umbilical artery Doppler assessment immediately after FGR diagnosis to detect deterioration 1, 2
  • Weekly umbilical artery Doppler for decreased end-diastolic velocity (flow ratios >95th percentile) or severe FGR (EFW <3rd percentile) 1, 2
  • 2-3 times per week Doppler when absent end-diastolic velocity (AEDV) is detected 1, 2

Cardiotocography (NST)

  • Weekly cardiotocography after viability for FGR without AEDV/reversed end-diastolic velocity (REDV) 1, 2
  • Increase frequency when AEDV/REDV develops or other comorbidities are present 2
  • 1-2 times daily cardiotocography when REDV is detected 1, 2

Additional Doppler Parameters

  • Do NOT use ductus venosus, middle cerebral artery, or uterine artery Doppler for routine clinical management decisions, as evidence does not support their use over umbilical artery Doppler (GRADE 2B) 1, 4
  • Do NOT rely on cerebroplacental ratio alone to guide delivery timing despite its indication of brain-sparing physiology 4

Delivery Timing Based on Doppler Findings

This is the critical decision algorithm:

Normal Umbilical Artery Doppler (EFW 3rd-10th percentile)

  • Deliver at 38-39 weeks gestation 1, 2, 4

Decreased Diastolic Flow (without AEDV/REDV) OR Severe FGR (EFW <3rd percentile)

  • Deliver at 37 weeks gestation 1, 2, 4
  • This applies even with normal Doppler if severe growth restriction is present 2, 3

Absent End-Diastolic Velocity (AEDV)

  • Deliver at 33-34 weeks gestation 1, 2, 4
  • Increase Doppler monitoring to 2-3 times per week immediately 1, 2

Reversed End-Diastolic Velocity (REDV)

  • Deliver at 30-32 weeks gestation 1, 2, 4
  • Hospitalize immediately 1, 2
  • Administer antenatal corticosteroids 1, 2
  • Perform cardiotocography at least 1-2 times daily 1, 2
  • Consider delivery based on the entire clinical picture and additional fetal well-being assessments 1

Antenatal Interventions

Corticosteroids

  • Administer antenatal corticosteroids if delivery is anticipated before 33 6/7 weeks 2, 3
  • Consider for pregnancies between 34 0/7 and 36 6/7 weeks in women at risk of preterm delivery within 7 days 2

Magnesium Sulfate

  • Administer intrapartum magnesium sulfate for fetal neuroprotection when delivery is anticipated at <32 weeks 2

Ineffective Interventions

  • Do NOT use low-molecular-weight heparin solely for prevention of recurrent FGR 1
  • Do NOT use sildenafil or activity restriction for in utero treatment of FGR 1

Mode of Delivery

Cesarean Delivery Considerations

  • Strongly consider cesarean delivery for FGR complicated by AEDV or REDV based on the entire clinical scenario 2, 4
  • Cesarean delivery is NOT routinely indicated for FGR alone unless other obstetric indications arise or fetal intolerance of labor occurs 4

Vaginal Delivery

  • Vaginal delivery with continuous electronic fetal monitoring is appropriate if umbilical artery end-diastolic flow remains present 4
  • Continuous fetal monitoring in labor is mandatory for all FGR cases 2

Critical Pitfalls to Avoid

  • Do NOT delay delivery beyond the recommended gestational age even with reassuring testing, as stillbirth risk increases significantly 2, 4
  • Do NOT miss deterioration to AEDV or REDV, which requires immediate change in surveillance frequency and earlier delivery 2, 4
  • Do NOT rely solely on cerebroplacental ratio to guide delivery timing, as current guidelines do not support this practice (GRADE 2B) 4
  • Do NOT use middle cerebral artery or ductus venosus Doppler for routine management decisions 1

Special Considerations

Maternal Hypertension

  • Monitor closely for hypertensive disorders of pregnancy, as maternal hypertension is present in 50-70% of early-onset FGR cases and significantly worsens outcomes 2, 3
  • Maternal hypertension is associated with earlier delivery and lower birthweights 2, 3

Prognostic Factors

  • Gestational age at delivery is the single most important prognostic factor in preterm FGR, with 1-2% increase in intact survival for every additional day in utero up to 32 weeks 2
  • Severe FGR (EFW <3rd percentile) carries a 3-7 fold increased stillbirth risk compared to fetuses at 5th-10th percentile 3

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Fetal Growth Restriction Management Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Fetal Growth Restriction Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Guideline

Management of Fetal Growth Restriction at 36 Weeks Gestation

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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