The American College of

Obstetricians and Gynecologists
WOMEN’S HEALTH CARE PHYSICIANS Society for
Maternal-Fetal Medicine

P RACTICE BULLET IN
CLINICAL MANAGEMENT GUIDELINES FOR OBSTETRICIAN – GYNECOLOGISTS

NUMBER 134, MAY 2013 (Replaces Practice Bulletin Number 12, January 2000)

Fetal Growth Restriction
Fetal growth restriction, also known as intrauterine growth restriction, is a common complication of pregnancy that
has been associated with a variety of adverse perinatal outcomes. There is a lack of consensus regarding terminol-
ogy, etiology, and diagnostic criteria for fetal growth restriction, with uncertainty surrounding the optimal manage-
ment and timing of delivery for the growth-restricted fetus. An additional challenge is the difficulty in differentiating
between the fetus that is constitutionally small and fulfilling its growth potential and the small fetus that is not fulfilling
its growth potential because of an underlying pathologic condition. The purpose of this document is to review the topic
of fetal growth restriction with a focus on terminology, etiology, diagnostic and surveillance tools, and guidance for
management and timing of delivery.

Background definition of fetal growth restriction in the United States
is an estimated fetal weight that is less than the 10th
Terminology percentile for gestational age (5). However, this defini-
The terminology for classifying fetuses and newborns tion does not take into account the individualized growth
who have failed to achieve normal weight is inconsistent. potential of each fetus, and its use may fail to identify
Communication between obstetric and newborn practi- larger fetuses that have not achieved their growth poten-
tioners is facilitated by the use of clearly defined terms tial and may be at risk of adverse outcomes. Conversely,
that characterize fetal and newborn weight according to this definition will result in the misdiagnosis of fetal
either the absolute weight or the weight percentile for a growth restriction for some constitutionally small fetuses
given gestational age (1–4). In this document, the term (6–9). In an attempt to assess more accurately whether
fetal growth restriction will be used to describe fetuses newborns and fetuses are of appropriate growth, investi-
with an estimated fetal weight that is less than the 10th gators have devised formulas for individualized growth
percentile for gestational age, whereas the term small standards (10, 11). However, use of such formulas has
for gestational age (SGA) will be used exclusively to not been shown to improve outcomes.
describe newborns whose birth weight is less than the
10th percentile for gestational age. Etiology
The etiology of fetal growth restriction can be broadly
Prevalence categorized into maternal, fetal, and placental (see Box
The prevalence of fetal growth restriction depends on the 1). Although the primary pathophysiologic mechanisms
definition used. As noted previously, the most widely used underlying these conditions are different, they often (but

Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the American College of Obstetricians and Gynecologists
Committee on Practice Bulletins—Obstetrics and the Society for Maternal-Fetal Medicine Publications Committee with the assistance of Henry Galan, MD,
and William Grobman, MD. The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These
guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs
of the individual patient, resources, and limitations unique to the institution or type of practice.

1122 VOL. 121, NO. 5, MAY 2013 OBSTETRICS & GYNECOLOGY

Although twin pregnancies account for only 2–3% of live births in the United States. The effect of s -ATERNALMEDICALCONDITIONS any particular medication is dependent on the inherent ˆ0REGESTATIONALDIABETESMELLITUS teratogenicity of the drug. Etiology of Fetal Growth Restriction A associated with fetal growth restriction. The risk of SGA in multiple gestations has factor (12. hereditary of true maternal malnutrition increases fetal weight or thrombophilias. Other substances that have been associ. has been associated with suggest that additional nutrient intake in the absence fetal growth restriction (15). In (20–25). is a modifiable risk (29–31). Use of certain antineoplastic ˆ!UTOIMMUNEDISEASEEG. reductase gene mutations have not been found consis- tently to be associated with fetal growth restriction or Multiple Gestation SGA (16–18). 26 weeks of gestation was associated with SGA. 19). cocaine.5-fold increased risk of SGA. been reported to be as high as 25% for twin pregnancies ated with SGA include alcohol. improves the outcome in cases of suspected fetal growth the prothrombin mutation. Longitudinal studies of women who conceived and gave birth during famine periods have shown an associa- Maternal Disorders tion between SGA and maternal malnutrition (26. The risk of SGA associated with alcohol con. the timing and duration of exposure. including the factor V Leiden mutation. Maternal medical conditions that may result in fetal In these studies. In contrast. However. monochorionic twin pregnancies are at risk of sumption is increased even with the intake of only one SGA because of unequal placental sharing and twin– to two drinks daily (21). addition. extremely poor protein intake before growth restriction or SGA include any chronic disor. severe caloric restriction (ie. Teratogen Exposure Exposure to certain maternal medications has been Box 1. weight. twin transfusion syndrome (33).not always) have the same final common pathway: sub. there is no high-quality evidence to meditated thrombophilic state. the dosage. an acquired immune. and narcotics and 60% for triplet and quadruplet pregnancies (32). daily) was associated with modest reductions in birth Antiphospholipid syndrome. 27). Maternal Nutrition optimal uterine–placental perfusion and fetal nutrition. and der that is associated with vascular disease (12–14). which is associated with increased frequency of preterm births and SGA births a 3. they account for 10–15% Substance Use and Abuse of adverse neonatal outcomes and are associated with an Tobacco use during pregnancy. or methylenetetrahydrofolate restriction (28). and individual genetic predisposi- ˆ2ENALINSUFFICIENCY tion for drug metabolism. intake of 600–900 kcal such as pregnancy-related hypertensive diseases (12).

warfa- ˆ#YANOTICCARDIACDISEASE rin). cyclophosphamide). medications (eg.SYSTEMICLUPUSERYTHEMA. valproic acid). and antithrombotic drugs (eg. antiepileptic drugs TOSUS (eg. NANCYEG. has been associated with an increased risk of fetal ˆ0REGNANCY RELATEDHYPERTENSIVEDISEASESOFPREG growth restriction (34–38).

CHRONICHYPERTENSION.

GESTATIONALHYPER- TENSION.

ORPREECLAMPSIA Infectious Diseases ˆ!NTIPHOSPHOLIPIDANTIBODYSYNDROME It has been estimated that intrauterine infection may s 3UBSTANCEUSEANDABUSEEG.

TOBACCO.

ALCOHOL.

be the primary etiology underlying approximately COCAINE.

ORNARCOTICS 5–10% of cases of fetal growth restriction (39). Malaria s -ULTIPLEGESTATION accounts for most cases of infection-related fetal growth s 4ERATOGENEXPOSUREEG.

CYCLOPHOSPHAMIDE.

Other infections implicated ACID.VALPROIC restriction worldwide (40).

toxoplasmosis. rubella.ORANTITHROMBOTICDRUGS as causes of fetal growth restriction include cytomega- lovirus. and syphilis s )NFECTIOUSDISEASESEG. varicella.

MALARIA.

CYTOMEGALOVIRUS.

RUBELLA. (39. 41–44).

TOXOPLASMOSIS.

ORSYPHILIS s 'ENETICANDSTRUCTURALDISORDERSEG.

TRISOMY.

Genetic and Structural Disorders TRISOMY.

CONGENITALHEARTDISEASE.

NO.ORGASTROSCHISIS Fetal growth restriction is associated with certain chro- s 0LACENTALDISORDERSANDUMBILICALCORDABNORMALITIES mosomal abnormalities: at least 50% of fetuses with tri- somy 13 or trisomy 18 have fetal growth restriction (45). 5. 121. VOL. MAY 2013 Practice Bulletin Fetal Growth Restriction 1123 .

Fundal height measured in centimeters (between 24–38 weeks of gestation) approximates the gestational age and Placental Disorders and Umbilical Cord is used to screen for fetal growth less than or greater than Abnormalities the 10th percentile (74). At fetal reviewed extensively in cases of fetal growth restric- weights less than the 10th percentile for gestational age. 2) cated by the presence of a single umbilical artery (59). measures are commonly used: 1) biparietal diameter. neonatal morbidity. The has been associated with fetal growth restriction in some estimate may deviate from the birth weight by up to 20% studies but not in others (60. If the Perinatal Morbidity and Mortality ultrasonographically estimated fetal weight is below the Fetal growth restriction increases the risks of intrauterine 10th percentile for gestational age. in 95% of cases. syndrome. coro. respiratory distress disease are at an increased risk of fetal growth restric. To assess for fetal growth restriction. cantly increased risk of stillbirth. The utility of Doppler velocimetry evaluation. and neonatal death (69–73). If the accuracy of fundal height is com- and umbilical cord abnormalities (eg. Maternal (52). or reversed end-diastolic flow of the umbilical artery are Flow in the ductus venosus also has been measured in 1124 Practice Bulletin Fetal Growth Restriction OBSTETRICS & GYNECOLOGY . An association between fetal growth restriction obesity and uterine leiomyomas are factors that may and certain placental disorders (eg. with the most severely especially of the umbilical artery. tion and SGA. should be considered. 53–57). Because growth-restricted fetuses have a high opment of cognitive delay in childhood and diseases in incidence of structural and genetic abnormalities. 47). recommended if not performed already. 90). ultrasonographic examination of fetal anatomy also is nary artery disease. in the absence 4) femur length. ultrasonography may marginal cord insertion) also has been suggested (34. such as amniotic fluid assess- Furthermore. type 2 diabetes mellitus. 67). Growth-restricted fetuses with absent testing in the setting of fetal growth restriction (89. abruption. which is umbilical artery is associated with an increased risk of twice the background rate of fetuses of normal growth. four biometric Approximately 1% of all pregnancies are compli. placental insufficiency) is the most com. obesity. at particular increased risk of adverse outcomes and have rionic villus sampling also has been associated with fetal an increased frequency of neonatal mortality and mor- growth restriction (46. 3) abdominal circumference. respectively. including hypoglycemia. limit the accuracy of fundal height measurement as a circumvallate shape. artery. the deviation is even greater than 20% (78. hemangioma. Doppler velocimetry is added to standard antepartum tional age (66. Screening for Fetal Growth Restriction schisis is another malformation commonly associated with fetal growth restriction. However. Fetal growth restriction is associated with a signifi. an adulthood (eg. combined to generate an estimated fetal weight (80). tion (84). and for the remaining 5% of cases. have not been Ultrasonographic Diagnosis and Evaluation associated consistently with fetal growth restriction (58). and stroke) (63. nec- For example. infarction.5% is reduced by as much as 29% when umbilical artery at fetal weights less than the 5th percentile for gesta. hyperbiliru- have an increased risk of fetal growth restriction (48). epidemiologic studies have revealed that ment and Doppler blood flow studies of the umbilical growth-restricted fetuses are predisposed to the devel. the risk of fetal death increases to 2. seizures. compared with fetuses and newborns without these malformations (49. 64). be a better screening modality. The biometric measurements can be of additional anatomical or chromosomal abnormalities. and chorioangioma) screening tool. hypothermia. and neonatal death (62). Absent or reversed end-diastolic flow in the the risk of fetal death is approximately 1. 61). further evaluation demise. such as placenta accreta and placenta previa. sepsis. which is present in up to Physical Examination or History 25% of cases of gastroschisis (51). Fetuses with many types of structural malformations Small-for-gestational-age newborns are predisposed (but without chromosomal or genetic abnormalities) also to complications. 81–83).Confined placental mosaicism that is identified by cho. perinatal mortality (85–88). The rate of perinatal death Comparatively. other placental disorders. velamentous or promised because of such factors. and Identification of a single umbilical artery. be approximately 65–85% sensitive and 96% specific for mon pathology associated with fetal growth restriction detecting the growth-restricted fetus (75–79). bidity (68). Gastro. binemia. intraventricular hemorrhage. has been studied and affected fetuses being at greatest risk (65). A single fundal height measure- Abnormal placentation that results in poor placental ment at 32–34 weeks of gestation has been reported to perfusion (ie. 50).5%. head circumference. fetuses and newborns with congenital heart rotizing enterocolitis.

increased consumption of fish. some experts tion screening have been studied (including universal have advocated for the use of aspirin to prevent placen- third-trimester ultrasonography. restriction or reduces the incidence of SGA births (114). such as preg. Also. magnesium (112). Heterozygosity for the inherited thrombo- Recommendations philias (eg. Ultrasonographic screening also may be Similarly.an attempt to assess fetal status. fruits. Thus. because fetal growth restriction may be reasonable to perform serial ultrasonography for detected earlier in gestation is more commonly associ- growth assessment. Monitoring the VOL. multiple pregnancy. 121. although none has been effec- of gestational age and fundal height measurement of tive. Ultrasonography remains the best method for eval- pholipid syndrome includes a prior pregnancy affected uating the growth-restricted fetus. current pregnancy is not an indication for antenatal fetal heart rate testing. and vitamin D (113). although the optimal surveillance ated with aneuploidy (119). Maternal history of growth restriction is an indication to offer genetic coun- a prior SGA newborn with normal fetal growth in the seling and prenatal diagnostic testing. about the type of anomaly and consideration of prenatal particularly modifiable risk factors. protein (111). However. and vegetables (106). consumption of a should keep in mind the potential limitation of assess. an ultrasound examination is preferred as a restriction are not effective and are not recommended. screening tool. or umbili. for such therapy to be routinely indicated for fetal nancy-associated plasma protein A) there is no evidence growth restriction prevention (115–118). zinc ing fundal height in the presence of maternal obesity. calcium (110). growth restriction be evaluated and managed? Other maternal risk factors for SGA have been evaluated. that required delivery before 34 weeks of gestation. there is insufficient evidence that screening and treatment in a subsequent pregnancy improves out- Clinical Considerations and come (104). 5. the risk of aneuploidy is The risk of recurrence of an SGA birth is approximately increased if fetal structural abnormalities also are pres- 20% (9). but its use has not been by a morphologically normal growth-restricted fetus shown to improve outcomes (91–94). The practitioner grains. nutritional and dietary tiple gestations or in cases where the fundus cannot be supplemental strategies for the prevention of fetal growth palpated. and how is screening bophilias is not indicated (17. and maternal testing for these throm- fetal growth restriction. there is insufficient evidence velocimetry. 104). Many nutritional and dietary should be performed at each prenatal care visit after supplemental strategies to prevent fetal growth restric- 24 weeks of gestation. In women with a history of an SGA birth. MAY 2013 Practice Bulletin Fetal Growth Restriction 1125 . In these women. NO. Fundal height measurements fetal growth restriction. low-salt diet (107). in mul. however. or a history of leiomyomas. Any patient with a prior birth of an SGA new. A discrepancy between weeks tion have been studied. accomplished? Can fetal growth restriction be prevented? All pregnant patients should be screened for risk factors for fetal growth restriction through a review of medi. One criterion for the diagnosis of antiphos. A variety of approaches have been undertaken to prevent cal and obstetric history. uterine artery Doppler tal insufficiency. Therefore. that these fetal growth restriction screening methods improve outcomes (95–102). midtrimester onset of fetal regimen has not been determined. Although other approaches to fetal growth restric. ent. low-fat meats. These include individualized nutritional counseling greater than 3 has been proposed for identifying a fetus (105). and measurement of analytes. that may be growth restricted (74). it diagnostic testing. factor V Leiden mutation and prothrombin mutation) has not consistently been associated with fetal How should pregnancies be screened for growth restriction. (109). How should a pregnancy complicated by fetal cal artery Doppler velocimetry (103). supplementation with iron (108). When should genetic counseling and prena- tal diagnostic testing be offered in the case of How should women with a prior birth of fetal growth restriction? a small for gestational age newborn be evaluated? Although fetal growth restriction alone may be associ- ated with an aneuploid fetus. biophysical profile testing. the combination of fetal growth restriction born should have her medical and obstetric histories and a structural defect should prompt patient counseling reviewed to help identify any additional risk factors. there is no consistent evidence that either used in the presence of maternal factors that increase the inpatient or outpatient bed rest prevents fetal growth risk of fetal growth restriction.

timing of delivery as well as expert consensus. language. women with singleton gesta- growth restriction because increased impedance in the tions at or beyond 36 weeks with suspected fetal growth umbilical artery suggests that the pregnancy is compli- restriction (defined as an estimated fetal weight less cated by underlying placental insufficiency. weeks of gestation) growth-restricted fetus. Most growth-restricted fetuses ery and the route of delivery should be based on other can be adequately evaluated with serial ultrasonography clinical circumstances. altering the timing of delivery at 38 0/7–39 6/7 weeks of gestation in cases of for fetuses with aneuploidy or congenital infection may isolated fetal growth restriction and 2) delivery at not improve the outcome. Furthermore. these flow measurements have not performed to determine the optimal time for delivery been shown to improve perinatal outcome. has been explored in the setting of fetal growth No adequately powered randomized trials have been restriction. absent than the 10th percentile) were randomized to undergo or reversed end-diastolic flow in the umbilical artery delivery or expectant management with delivery only if is associated with an increased frequency of perinatal some other indication arose (134). women with growth-restricted fetuses whose obstetri- cians were uncertain whether delivery would be ben- What is the role of Doppler velocimetry in eficial. Fetal growth growth assessment and the optimal surveillance regimen restriction alone is not an indication for cesarean deliv- have not been established. In this trial. In the Disproportionate Intrauterine Growth assessment may provide insight into the etiology of fetal Intervention Trial at Term. a joint conference of the Eunice Kennedy Shriver National When should a growth-restricted fetus be Institute of Child Health and Human Development. ultrasound assessment of growth should The Growth Restriction Intervention Trial is cur- not be performed more frequently than every 2 weeks rently the only published randomized trial to assess the because the inherent error associated with ultrasono. 31. or both. behavior. in and at the 6–12-year follow-up there were no differ- conjunction with standard fetal surveillance. were randomized to either the early delivery evaluating a pregnancy complicated by fetal group (delivery within 48 hours) or to the expectant growth restriction? management group (with antepartum surveillance until it was felt that delivery should not be delayed any lon- Umbilical artery Doppler velocimetry plays an impor- ger). fetal growth restriction has been diagnosed: 1) delivery tional age.growth-restricted fetus includes serial ultrasonographic women may choose to forgo delivery of a severely measurements of fetal biometry and amniotic fluid vol. some growth restriction with additional risk factors for adverse 1126 Practice Bulletin Fetal Growth Restriction OBSTETRICS & GYNECOLOGY . timing of delivery of the early preterm (less than 34 graphic measurements can preclude an accurate assess. Doppler (131–133). When intervention for perinatal ben- age when delivery would be considered for perinatal efit is the preferred option. including assessments natal death. 128–130). For example. growth-restricted fetus at 25 weeks of gestation even ume. 120–124). Antenatal surveillance with umbilical artery Doppler if there is an increased risk of fetal death. and the role of the growth-restricted fetus between 34 weeks and of these measures in clinical practice remains uncertain 36 weeks of gestation. The rates of betamethasone administration were tant role in the management of a pregnancy complicated the same in both groups. 127) and can affect decisions regard- ences in composite neonatal outcome between these two ing timing of delivery in the context of fetal growth groups. every 3–4 weeks. although the study cohort was not large enough restriction (84). Also. There were no differ- mortality (86–88. were affected by the different management of the middle cerebral artery and the precordial venous approaches. system. For example. Perinatal survival was similar. nonstress tests or may be enhanced by an individualized and multidisci- biophysical profiles) should not begin before a gestational plinary approach. Management velocimetry and antepartum testing (eg. 92. Its use. delivered? the Society for Maternal-Fetal Medicine. or motor abili- nonstress tests. such as ences in cognitive. Based on existing data regarding (91. such as peri- sels with Doppler velocimetry. in some cases 34 0/7–37 6/7 weeks of gestation in cases of fetal patients may elect nonintervention. is associ- ties of the children born to women in the early-delivery ated with improved outcomes in fetuses in which fetal group versus those in the expectant management group growth restriction has been diagnosed (90). and the The optimal timing of delivery of the growth-restricted American College of Obstetricians and Gynecologists fetus depends on the underlying etiology of the growth suggested the following two timing strategies when restriction (if known) as well as the estimated gesta. Investigation of other fetal blood ves- to determine whether individual outcomes. by a diagnosis of fetal growth restriction. antenatal fetal surveillance benefit (30. ment of interval growth (125. biophysical profiles. However. The optimal interval for fetal may help guide the timing of delivery. 127. 126).

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No part of this publica- tion may be reproduced. Level C—Recommendations are based primarily on con- sensus and expert opinion. (Level III) [PubMed] [Obstetrics & own internal resources and documents were used to con- Gynecology] A duct a literature search to locate relevant articles published between January 1990–January 2013. Committee Opinion No. recording. The search was restricted to articles published in the English language.115:669–71. although review articles and commentaries also were consulted. or otherwise. Magnesium sulfate before anticipated preterm birth for neuroprotection. 134. MAY 2013 Practice Bulletin Fetal Growth Restriction 1133 . American College of Obstetricians and Gynecologists. expert opinions from obstetrician–gynecologists were used. Level B—Recommendations are based on limited or incon- sistent scientific evidence. and additional studies were located by reviewing bibliographies of identified articles. Obstet Gyne. electronic. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed. All rights reserved. PO Box 96920. Washington. SW. American The MEDLINE database. Dramatic results in uncon- trolled experiments also could be regarded as this type of evidence. or reports of expert committees. Based on the highest level of evidence found in the data. III Opinions of respected authorities. recommendations are provided and graded according to the following categories: Level A—Recommendations are based on good and con- sistent scientific evidence. (978) 750-8400. mechanical. Preventive Services Task Force: I Evidence obtained from at least one properly designed randomized controlled trial. posted on the Internet. Studies were reviewed and evaluated for quality according to the method outlined by the U. or transmitted. photocopying. the Cochrane Library. Practice Bulletin No. Copyright May 2013 by the American College of Obstetricians and Gynecologists.121:1122–33. descriptive studies. Requests for authorization to make photocopies should be directed to Copyright Clearance Center.S. stored in a retrieval system. II-2 Evidence obtained from well-designed cohort or case–control analytic studies. American College of Obstetricians and Gynecologists’ col 2010. 455. II-3 Evidence obtained from multiple time series with or without the intervention.142. Danvers. 222 Rosewood Drive. 5. The American College of Obstetricians and Gynecologists 409 12th Street. VOL. When reliable research was not available. preferably from more than one center or research group. without prior written permission from the publisher. DC 20090-6920 Fetal growth restriction. MA 01923. based on clinical experience. Abstracts of research presented at sympo- sia and scientific conferences were not considered adequate for inclusion in this document. NO. II-1 Evidence obtained from well-designed controlled trials without randomization. 121. Priority was given to articles reporting results of original research. and the College of Obstetricians and Gynecologists. Obstet Gynecol 2013. in any form or by any means.