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Intrauterine growth restriction

Key sources
The following summarized guidelines for the evaluation and management of intrauterine growth restriction are prepared by our editorial team based on guidelines from the International Consensus Group on Small for Gestational Age (ICG-SGA 2023), the International Federation of Gynecology and Obstetrics (FIGO 2021), the American College of Obstetricians and Gynecologists (ACOG 2021), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG 2020), the Royal College of Obstetricians and Gynaecologists (RCOG 2013), and the Society of Obstetricians and Gynaecologists of Canada (SOGC 2013).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per FIGO 2021 guidelines, obtain risk stratification for FGR (and other placenta-mediated complications) at the time of the first-trimester antenatal visit using history-based (medical and obstetric) risk factors.
B
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  • Diagnostic criteria

2.Diagnostic investigations

History and physical examination: as per FIGO 2021 guidelines, elicit detailed history in patients with suspected FGR.
A

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  • Fetal ultrasound

  • Uterine artery Doppler ultrasound

  • Umbilical artery Doppler ultrasound

  • Fetal cardiotocography

  • Screening for infections

  • Screening for aneuploidy

3.Diagnostic procedures

Placental histopathology: perform histopathological examination of the placenta where available to provide useful information for counseling regarding future pregnancies.
B

4.Medical management

Setting of care: as per FIGO 2021 guidelines, deliver fetuses with FGR ideally at centers with the appropriate level of neonatal care for the gestational age and with the ability to perform an urgent C-section if needed.
A

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  • Specific treatment

  • Antenatal corticosteroids

  • Magnesium sulfate

5.Nonpharmacologic interventions

Smoking cessation
As per FIGO 2021 guidelines:
Advise females that smoking cessation and elimination of alcohol and illicit drugs can decrease the risk of FGR.
B
Advise smoking cessation as a preventive intervention in females with a history of placenta-mediated FGR and females at risk of preeclampsia.
B

6.Therapeutic procedures

Indications for delivery: as per FIGO 2021 guidelines, initiate delivery irrespective of gestational age in case of biophysical profile or cardiotocography/nonstress test abnormalities (reduced variability and/or repetitive late decelerations), or severe preeclampsia with uncontrolled hypertension, HELLP syndrome, or other types of end-organ damage.
A
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7.Patient education

General counseling: as per FIGO 2021 guidelines, advise females on the association of insufficient gestational weight gain with FGR, and inform them regarding their target weight gain range.
B

8.Preventative measures

Antiplatelet therapy
As per FIGO 2021 guidelines:
Insufficient evidence to recommend routine treatment with aspirin in all females at high risk of FGR.
I
Initiate aspirin (100-150 mg taken in the evening) starting at 12-16 weeks as a preventive intervention in females with a history of placenta-mediated FGR or at risk of preeclampsia.
B

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  • Anticoagulant therapy

  • Nutrition

  • Other measures

9.Follow-up and surveillance

Serial clinical assessment: as per FIGO 2021 guidelines, consider using fetal movement counting to decrease the risk of stillbirth in pregnancies with FGR in both high- and low-resource settings.
B

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  • Serial ultrasound assessment

  • Postnatal maternal surveillance

  • Postnatal infant surveillance (general principles)

  • Postnatal infant surveillance (evaluation of short stature)

  • Postnatal infant surveillance (evaluation of bone maturation and mineral density)

  • Postnatal infant surveillance (evaluation of neurocognitive impairment)

  • Postnatal infant surveillance (genetic testing)

  • Postnatal infant surveillance (nutrition)

  • Postnatal infant surveillance (GH therapy)

  • Postnatal infant surveillance (laboratory monitoring)