GENETIC SYNDROMES ASSOCIATED WITH ISOLATED FETAL GROWTH RESTRICTION

Running head
Early onset fetal growth restriction and genetic abnormalities

Authors and affiliations

Eva Meler1, Silvina Sisterna2, Antoni Borrell1
1
BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and
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Hospital Sant Joan de Deu), Institut Clinic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS,
University of Barcelona, Fetal i+D Fetal Medicine Research, and Centre for Biomedical
Research on Rare Diseases (CIBER-ER), Barcelona, Catalonia, Spain.
2
Clinical Genetics and Prenatal Diagnosis, Hospital Privado de Comunidad – Maternal Fetal
Medicine, Clínica Colon – Reproduction and human genetics center CRECER. Mar del Plata,
Buenos Aires, Argentina.

Corresponding author
Eva Meler Barrabés
Hospital Clínic Maternitat
Sabino Arana 1, 08028 Barcelona
Phone Number 0034 932 275 600
Email: emeler@clinic.cat

Conflict of interest
None declared

Funding support
No funding has supported this review

Bulleted Statements
What is already known about this subject?
Early isolated fetal growth restriction (FGR) can be part of different genetic syndromes.
What does this study add?
This review article describes the most common genetic diagnoses associated with a
prenatal finding of an early isolated FGR and provides a suggested diagnostic process.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analyzed in this
study.

Abstract
Early onset fetal growth restriction (FGR) may be due to impaired placentation, environmental
or toxic exposure, congenital infections or genetic abnormalities.
Remarkable research, mainly based on retrospective series, has been published on the diverse
genetic causes. Those have become more and more relevant with the improvement in the
accuracy of the analysis techniques and the rising of breakthrough genomewide methods such
as the whole genome sequencing.

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been through the copyediting, typesetting, pagination and proofreading process, which
may lead to differences between this version and the Version of Record. Please cite
this article as doi: 10.1111/pd.5635

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 However, no publication has presented an integrated view of management of those fetuses
with an early and severe affection.
In this review, we explored to which extent genetic syndromes can cause FGR fetuses without
structural defects. The most common chromosomal abnormalities (Triploidies and Trisomy 18),
submicroscopic chromosomal anomalies (22q11.2 microduplication syndrome ) and single
gene disorders (often associated with mild ultrasound findings) related to early and severe FGR
had been analysed. Finally, we addressed the impact of epigenetic marks on fetal growth, a
matter of growing importance.
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At the end of this review, we should be able to provide an adequate counseling to parents in
terms of diagnosis, prognosis and management of those pregnancies.

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 1. Introduction

Fetal Growth Restriction (FGR), also known as Intra-uterine Growth Restriction (IUGR), is a
condition that classically was defined as an inappropriate fetal weight gain for a specific
gestational age, or synonymously, as the impossibility to reach the fetal biological growth
potential. Practically, FGR is demonstrated by the statistical deviation of an estimated fetal
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weight (EFW) or an abdominal circumference (AC) from a population-based reference, with a

typical threshold at the 10th, 5th or 3rd centile1. However, according to a recent expert
consensus, this condition should be redefined and be restricted to the smallest fetuses, those
with an EFW or an AC below the third centile, or impaired growth velocity, or alternatively to
fetuses with an EFW below the 10th centile and a concomitant abnormal fetal or uterine
Doppler2. Those are the fetuses at higher risk for perinatal morbidity and mortality, but also at
higher risk for cardiovascular and endocrine diseases in adulthood.

The terms of FGR and Small for Gestational Age (SGA), that sometimes have been used
indistinctively, are in fact not synonym. SGA encompasses all fetuses with an EFW below the
10th centile for gestational age but not abnormally small. Among fetuses below the 10th
centile for growth, only approximately 40% are at increased risk of potentially preventable
perinatal demise, whereas 40% of them are constitutionally small and the remaining 20% are
intrinsically small secondary to a chromosomal or environmental etiology 3. Interestingly
enough, not all fetuses that have not met their genetic growth potential have an EFW below
the 10th centile4,5.

Isolated FGR has been defined as FGR with no associated structural anomalies. Although
several reasons have been reported, the most recognized factor is impaired placental function,
most commonly due to abnormal placentation 6. Congenital infections7,8, with CMV the most
relevant one and maternal factors such as extreme maternal ages or maternal toxic exposures
or substance abuse9-13have also been recognized as causes of FGR. The third etiology group of
FGR would be genetic abnormalities14 including chromosomal15, submicroscopic16,17 or single
gene disorders18,19. As several studies have demonstrated, these anomalies would be more
prevalent in early gestational ages and severe FGR. Etiologies of FGR are summarized in Figure
1.

According to several national guidelines, including the American College of Obstetricians and
Gynecologists (ACOG) and the Royal College of Obstetricians and Gynecologists (RCOG),

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 prenatal genetic diagnostic testing should be recommended in cases of midtrimester onset
FGR or in FGR associated with structural anomalies20,21. However, in some countries invasive
prenatal testing is advised in any pregnancy with FGR, regardless of gestational age at onset
and presence of sonographic anomalies.

In this review, we explored to which extent genetic syndromes can cause FGR in the absence
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of associated structural defects, mainly at early gestational ages. This information is desirable
to provide an adequate counseling to parents in terms of diagnosis, prognosis and
management of those pregnancies. To conduct this review, a non-systematic targeted search
was performed using Pubmed/Medline. Keywords used were [fetal growth restriction],
[intrauterine growth restriction], [chromosomal abnormalities], [epigenetic]. Relevant articles
regarding fetal growth restriction and genetic abnormalities were reviewed. Articles searching
progressed as the paper was being completed, including additional studies identified by
handsearching the references of included articles. Although there were no timing restrictions,
most recent publications were prioritized. The review was organized by sections, each one
corresponding to one of the main genetic abnormalities. Each section aims to give an overview
of the evidence in relation to specific genetic abnormalities and FGR. We have defined severe
FGR when estimated fetal weight is below the 3rd centile. Early FGR has been defined as
gestational age at diagnosis below 32 weeks.

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 2. Chromosomal abnormalities

Chromosomal anomalies were reported to account for up to 19% of fetuses with FGR 15, with
triploidies being the most common anomaly in fetuses below 26 weeks, and trisomy 18 above
26 weeks (Table 1). In apparently isolated FGR fetuses at any gestational age (10 to 39 weeks),
a recent systematic review by Sagi-Dain et al.22 (2017) including 14 studies, found a 6.4%
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(47/874) chromosomal abnormality rate. Nevertheless, all the included studies were
retrospective and the quality of evidence of these selected manuscripts was defined as low in
all except one study. The numeric chromosomal abnormalities reported in this systematic
review are listed in Table 2.

The chromosomal abnormality rate in FGR fetuses decreases with advancing gestational age. A
retrospective study by Anandakumar et al. (1996)23 found a 5.8% overall fetal aneuploidy rate
among 71 singleton pregnancies with asymmetrical isolated FGR, that decreased from 20% in
FGR detected before 23 weeks to 0% after 23 weeks. Since then, several studies have
confirmed an increased risk of chromosomal abnormalities with at an earlier gestational age at
diagnosis of FGR. For instance, Drummond et al. (2003)24 did not find any chromosomal
abnormality in fetuses with isolated FGR after 28 weeks. In a recent retrospective study among
128 fetuses with an EFW below the 10th centile, Peng et al. (2017)25 confirmed the inverse
correlation between the gestational age at diagnosis and the chromosomal anomaly rate: 7 %
in the early onset group defined as onset below 32 weeks and 1.8% after 32 weeks. This study
also demonstrated an association between the chromosomal abnormality rate and FGR
severity: the rate increased from 7.8% in fetuses with EFW below the 10th centile, to 10% in
those with EFW below the 5th centile, and to 18% for EFW below the 3rd centile.

Sometimes the chromosomal anomaly can be confined to the placenta and cause growth
restriction in a fetus chromosomally normal. Mosaicism is defined as the presence of two or
more different chromosomal complements in the fetoplacental unit developed from a single
zygote. It is caused by a viable somatic post-mitotic error occurring in an initially normal
conceptus, or a meiotic error resulting in trisomy with subsequent post-zygotic trisomic
rescue26. Placental mosaicism is observed in 1-2% of chorionic villi samples (CVS). Amniotic
fluid sampling is considered the standard procedure to differentiate true fetal mosaicism from
confined placenta mosaicism (CPM), two conditions with a different prognosis27,28. Grati et al.
(2017) 28 reviewed 1497 mosaics found in chorionic villi, with true fetal mosaicism accounting
for 13.5% of the studied samples. Most chromosomal mosaicisms identified at chorionic villi

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 sampling do not presage an abnormal fetus, although it has been described in association with
FGR, pregnancy loss, or perinatal demise in some cases,29-33.

The exact mechanism by which chromosomally abnormal cells in the placenta alter its function
is unknown, but the effect seems to be restricted to specific chromosomes. Chromosomes 2,
7–10, 13–18, 21–22 have been shown to be related to poor perinatal outcomes, presumably
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because they carry imprinted growth-related or placental function genes. The ratio of
placental infarcts and decidual vasculopathy nearly doubled in cases of CPM compared to
chromosomally normal placentas from growth-restricted newborns34-36. In addition to the
specific chromosome involved, the fraction of placenta carrying trisomic tissue (usually above
10%) also matters. The distribution of the normal and the abnormal cell lines in the fetus and
the placenta depends upon the time and the place of the mitotic errors.37-38.

A special mention should be made for trisomy 16. This aneuploidy is estimated to complicate
more than 1% of all clinically recognized pregnancies, including miscarriages, stillbirths and live
births. When trisomy 16 is assumed to be confined to the placenta (CPM16) in an ongoing
pregnancy, counseling of the expectant parents is challenging, as CPM16 has been associated
with a normal outcome in 20-36% of the cases while the frequency of SGA is 43-58%,
fetal/child malformations 20-22%, preeclampsia 16-24% and prematurity 32-37%39-40.
Moreover, several imprinted genes have been described on chromosome 16 and maternal
uniparental disomy may be associated with FGR and other obstetric complications (even
though not all publications support this hypothesis- see below in Epigenetic changes section).

The overall risk of developing FGR when a CPM is detected remains controversial. It seems that
the risk is 6.5–25% in pregnancies with CPM compared to 5-8.3% in those without CPM 33,34,41.
42
Among FGR cases, the CPM rate ranges between 9 and 16%. Robinson et al. observed
placental autosomal trisomy (trisomies 2, 7 and 13) in 9.3% (4/43) of pregnancies complicated
by FGR, but in none of 84 placentas from uncomplicated pregnancies. Wilkins-Haug et al.
(2006)29 compared the placental karyotypes of 70 newborns with birth weight <10th percentile
to an equal number of infants of normal size. CPM occurred significantly more often in the
placentas from SGA newborns (16%: 11/70) compared to controls (1.4%: 1/70). In a postnatal
study, Kiyonori Miura et al. (2006)43 performed cytogenetic and molecular studies of the
placenta and cord blood in 50 infants born with FGR (defined as EFW <2 SD) and they found a
16% rate of CPM, including five single trisomy (CPM 2, 7, 13, 21 and 22), one double trisomy
(CPM 7/13), one quadruple trisomy (CPM 2/7/15/20), and one partial monosomy [del(2)(p16)].

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 While there is scarce evidence on long-term follow-up of newborns associated with CPM, data
on trisomy 16 mosaicism suggests that postnatal catch-up growth may be common and
outcomes are generally good when multiple malformations at birth are lacking.44 Nonetheless,
the risk of low level of trisomy in the fetus and the long-term impact of placental insufficiency
on adult health are relevant issues to be evaluated in CPM cases. Diagnosis of CPM at term
would allow long-term outcome studies of FGR babies that are better phenotyped based on
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etiology42.

High-level tetraploid mosaicism has a unique predominance among the fetal growth-restricted
placentas. Historically, low levels of tetraploidy have been routinely identified in both
amniocytes as well as chorionic villi and were considered likely to reflect in vitro artifacts45.
However, growing evidence now supports a clinically significant role when higher levels of
tetraploidy are identified46. Tetraploidy of greater than 10/50 (20%) of cells from a long-term
chorionic villus culture warrants further investigation46, given that the occurrence of such
levels of tetraploidy from more than one sample argues strongly for an in vivo presence, rather
than a culture artifact. These findings support an increased occurrence of tetraploidy among
fetal growth-restricted placentas although the underlying mechanism, whether a primary
causation or a secondary effect, remains to be established29.
A special mention regarding CPM should be done about non-invasive prenatal testing (NIPT)
with the use of cell-free DNA (cfDNA) in maternal plasma. This is a test that is being
incrementally used to screen for common aneuploidies since 2011 and CPM has been
recognized as one important cause of false positive results. Grati et al. (2017)28 reported that
the following risks of finding a mosaicism in CVS after a positive cfDNA result: 2% for T21, 4%
for T18 and 22% for T13. While cfDNA testing is highly sensitive and specific, false positive
results can occur and therefore positive results should be confirmed with invasive testing 47-49.

In conclusion, with CPM occurring in 9-16% of placentas from growth-restricted newborns,

investigation of the placental karyotype to identify CPM may provide a useful marker for
underlying placental abnormalities in the evaluation of the isolated growth-restricted infant.
Although among placentas from pregnancies complicated by FGR, the finding of infarct is
associated with underlying CPM almost a third of the time 29, an ultrasound placental pattern
has not been described yet.

Discordant feto-placental findings in FGR with chromosomal abnormalities

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 Growth dysfunction in trisomic fetuses can be primarily fetal in origin, but might also be the
consequence of an impaired placentation. Abnormal umbilical artery Doppler findings have
been associated with disturbance in placental function of fetuses affected by autosomal
trisomies irrespective of the presence of fetal growth restriction50-53. Trisomy 21 fetuses have a
progressively higher incidence of abnormal umbilical artery impedance indices throughout
pregnancy. This alteration, that likely begins around the mid second trimester and increases
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with gestational age54, has been strongly correlated with placental findings such as disturbance
of syncytiotrophoblast formation, as in preeclampsia and FGR, and a large irregular
hypovascular villi and abnormalities of the trophoblastic layer55-57. In the third trimester, the
placenta of trisomic (18, 13 and 21) fetuses exhibit a significant reduction in small muscular
artery count and a small muscular artery to villous ratio51 .
Although there is more evidence in trisomy 21, other chromosomal abnormalities were also
found to be associated with increased umbilical artery impedance to blood flow: triploidy,
trisomy 18, trisomy 13 and CPM2258-60

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 3. Submicroscopic chromosomal anomalies

Since its commercial explosion, several studies have supported the use of CMA in high-risk
pregnancies with a normal karyotype. However, isolated FGR has rarely been specified as a
referral indication for this analysis and scarce reports have assessed the potential value of
CMA in FGR fetuses with normal karyotype and its additional value to conventional
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chromosomal analysis. In a recent retrospective study of 107 growth-restricted fetuses (2016)

17
using a SNP-array, a 5.7% rate of pathogenic CNVs was detected among FGR cases with
normal karyotype. Among the 53 isolated growth-restricted fetuses, 3 (5.6%) had pathogenic
CNV not detected by karyotyping, and 2 had a VOUS. CMA can identify more abnormalities
than karyotyping among FGR cases diagnosed in the second trimester, whereas no differences
have been found in third trimester FGR fetuses between the two techniques.17

Schaeffer et al. in 201261, and Borrell et al. in 201716, published the most representative
studies, especially because of the number of cases recruited. Schaeffer et al. (2012)61
evaluated, in a retrospective study, the utility of a CMA in pregnancies with abnormal
ultrasound findings including 259 fetuses with FGR. There were 76 isolated FGR, 46 FGR in
association with other nonstructural anomalies and 137 FGR with structural anomalies.
Significant CNVs were found in 2.6%, 2.2% and 10.2% of cases respectively. However, not all
those fetuses had a previous normal karyotype done and all findings below 10 Mb were
included. Gestational age at diagnosis and resolution of CMA were not reported.
62
Vanlieferinghen et al. (2014) strengthened these results in the largest cohort including 135
isolated FGR. The chromosomal anomaly rate was 9.6% (5/52) in very early onset FGR (below
24 weeks) and 9.3% (7/75) in late FGR, and CMA showed a 5.5% incremental yield compared
with karyotyping.

Borrell et al. (2017)16, in a multicenter prospective study, focused in a subgroup of well-

identified and followed-up early FGR fetuses diagnosed before 32 weeks, with a normal
karyotype. All of them were considered severe FGR, as EFW was below the 3rd centile. Three
groups were categorized: isolated FGR (n=84), FGR with nonstructural anomalies but
ultrasound signs such as abnormal amniotic fluid anomalies or soft markers (n=30) and FGR
with structural anomalies (n= 19). The overall pooled data revealed a 6.8% incremental yield of
CMA over karyotyping, and when analyzing 3 groups, the incremental yield was 4.8% (95% CI:
0.2-11.0), 10% (95% CI: 0-20.7) and 10.5% (95% CI: 0-24.3), respectively. The resolution of the
array-CGH was 100 kb and no VOUS were found in this study.

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 Following this study, Borrell et al.63 published in 2018 a systematic review and a metanalysis
inclusive of 10 articles. Nine out of 10 included non-malformed FGR and among them, the
incremental yield of CMA ranged from 0 to 21%. After the overall analysis, the additional value
of CMA over karyotyping was 4% (95% CI: 1-6) in this subgroup of fetuses and 10% in the
group of malformed ones. 22q11.1 duplication, Xp22.3 deletion and 7q11.23 deletion were the
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more frequent CNVs findings (Table 3), accounting for 64% of the nonmalformed fetuses and
only 18% of the malformed.

Mosaicism of submicroscopic CNV has also been described. CMA is frequently performed on
intact chorionic villi tissue that includes analysis of the cytotrophoblast layer. This technique
can detect mosaicism at levels as low as 9%. Incidence seems to be similar to conventional
karyotyping (3%). When a mosaic is found at CMA, the finding should be reassessed in
chorionic villi after a long-term culture or amniotic fluid64.

4- Monogenic disorders

FGR and particularly extreme FGR (EFW below the 1st centile), may also be a sign of a
syndrome caused by a single-gene mutation although the overall incidence is not known. Some
genes have been described to be involved specifically with fetal growth, some with postnatal
short stature and others with additional anomalies such as skeletal dysplasias. Most of these
syndromes will result in FGR with no postnatal catch-up growth and progressive postnatal
growth failure ending up in a short adult height. Half of them are associated with intellectual
disability18-19.

There are two main groups of monogenic syndromes according to the body symmetry of
smallness. We can differentiate a first group of fetuses with all fetal biometries (head and
abdominal circumference and long bones) corresponding roughly to the same gestational age,
and those fetuses often associate specific additional ultrasound findings such as genital
abnormalities (hypospadias or cryptorchidism), hand abnormalities (syndactyly and
clynodactily of the 5th finger), or even more specific signs related to each syndrome. In those
cases, the measurement of the head circumference and other key minor ultrasound findings
can help in the differential diagnosis (Figure 2A). Most frequent syndromes are summarized in
Table 4. Some of these syndromes derive from an impairment in DNA repair, causing
chromosome instability syndromes65. They include Fanconi anemia, Seckel, Bloom and

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 Nijmegen Breakage Syndromes, all with an autosomal recessive inheritance pattern. Identified
gene and impaired function are also summarized in Table 4.

The second group includes those fetuses with roughly normal head and abdominal
circumferences and extremely short long bones, commonly below 3 SD, together with some
additional ultrasound anomalies (Table 5). This group includes several skeletal dysplasias66,
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many caused by dysfunction of the SHOX gene, and syndromes due to an impaired GH/IGF-1
axis. Findings in the characteristics of the long bones may help in the differential diagnosis
(Figure 2B). Several dysfunctions in the SHOX locus, located in the pseudoautosomal region of
the X and Y chromosomes, have been identified due to mutations located at Xp22.33 and
Yp11. These dysplasias have classic features such as mesomelia and Madelung deformity of
the forearm (shortened and bowed radii and long ulnae leading to dorsal dislocation of the
distal ulna and limited mobility of the wrist and elbow), and include Microcephalic Primordial
Dwarfism disorders with a closely overlapping phenotype with Hypochondroplasia caused
by FGFR3 mutations. Although not typically classified as a skeletal dysplasia, Turner syndrome
is a relatively common cause of short stature, with some of the short stature likely attributable
to SHOX haploinsufficiency67.

A second subgroup of FGR fetuses with extremely short long bones is related to a dysfunction
in the Growth Hormone/Insulin Growing Factor-1 (GH/IGF-1) axis68. It is well established that
GH plays a critical role in human growth, primarily through its regulation of IGF-1 production.
Therefore, any dysfunction in the GH/IGF-1 axis will lead to a fetus with short long bones.
Several genetic defects resulting in GH deficiency and potentially in multiple pituitary hormone
deficiency have been described19. Isolated GHD is familial is 3-30% of the cases, mutations of
relevant candidate genes have been identified in 11% of the patients and in 34% of familial
cases. Most mutations involve genes for GH (GH1) or the GHRH receptor (GHRHR), with AR, AD
and X-linked inheritance. This entity is usually associated with postnatal growth failure. In
particular, defects involving IGF1 or IGF1R result in prenatal more severe FGR. Because IGF-1
also appears to be involved in central nervous system development in utero, the latter defects
are often characterized by some degree of microcephaly and, postnatally, developmental
delay and/or hearing deficiency. All of these molecular defects are, generally, transmitted in an
autosomal recessive manner19. Genetic defects resulting in primary IGF deficiency and IGF
resistance can be found in a comprehensive database at www.growthgenetics.com.

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 Few gene panels have been used in the investigation of FGR, and the existing ones are mainly
focused in the postnatal assessment of “Short Stature Syndrome”. This strategy that assesses
about 44 relevant genes, minimizes both the risk of identifying incidental findings and the
incomplete coverage of those genes. However, the selection of relevant genes has to be
accurate and updated, otherwise an incomplete gene selection might result in an important
limitation of the panels69. A commercial gene panel including 24 genes is available to confirm
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the clinical suspicion of primordial dwarfism disorders, such as the 3-M syndrome, MOPD2 and
Seckel syndrome.

Whole exome sequencing (WES) allows assessment of all the protein coding regions of the
genome (harboring around 80% of known disease-causing variants) in a single test. Fetal WES
is now possible owing to advances in next generation sequencing (NGS)70. The British PAGE
study performed a prospective cohort study of 596 fetus-parental trios with an incremental
yield of prenatal WES to CMA of 8.5% in fetal structural anomalies cases, but no FGR cases
were included.71 Similarly, in the United States, Petrovski et al72, included 234 trios in a
prospective cohort study of fetuses showing fetal structural anomalies and they identified
diagnostic genetic variants in 24 (10%) families. Twenty-nine FGR cases with other structural
anomalies where analyzed. Three (10%) of these had diagnostic genetic variants. To our
knowledge, nowadays it is unknown which is the diagnostic yield of WES in isolated FGR
fetuses. A compromise option between gene panels, that include less than 200 causative
genes associated to a specific disease or group of diseases, and WES, that assesses the overall
23,000 genes described in the human genome, may be represented by clinical exome
sequencing (CES), which evaluates studies only the OMIM genes, i.e. those that have already
been reported to be causative of an specific phenotype73.

To sum-up, we can affirm that currently, there is no good evidence to support definitive
selection criteria for patients who would benefit from genetic testing. Following a negative
CMA analysis in isolated FGR, additional genetic testing is controversial because of its
unknown and probably low diagnostic yield. Sequencing of single genes associated with known
conditions, gene panels, CES or WES could be offered with an appropriate pre and post-test
counselling in those cases with high suspicion. In case of an invasive testing, DNA should
always be stored. (FIGURE 3)

In recent years, noninvasive prenatal diagnosis (NIPD) for identifying paternally inherited or de
novo alleles appears to be an alternative to invasive tests in fetuses with suspicion of specific

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 skeletal dysplasias74. The detection of the mutation in maternal plasma provides definitive
diagnosis of an affected fetus. Chitty et al (2015)75 developed a panel for NIPD of skeletal
dysplasias, including 29 known disease-causing different mutations in the FGFR3 gene76.
Theoretically it can be performed as soon as the fetal fraction of cfDNA is sufficient, usually
from 7-9 weeks of gestation77 and it may offer a definitive diagnosis at an earlier stage in the
pregnancy than an invasive test. However, since many mutations causing skeletal dysplasias
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appear the novo, the diagnosis is usually carried out prompted by ultrasound findings.

5- Epigenetic changes
In epigenetics, a core consideration is that a phenotype may differ according to whether a DNA
sequence is active, or inactive, but with the DNA sequence itself remaining unchanged26.
Epigenetic mechanisms are crucial for a healthy development. They regulate all gene
expression by determining the accessibility of DNA to drivers of gene activation. As they are
not part of the genome, epigenetic marks are plastic and responsive to the environment, and,
in contrast to genetic mechanisms, they are also cell type and developmental stage
specific78,79. This phenomenon starts during gametogenesis and the early prenatal phase.
Imprinted genes, which are exclusively expressed from the maternal or paternal allele in the
offspring, are epigenetically marked during gametogenesis80.

Uniparental disomy is rare and its prevalence is unknown. UPD has been observed for every
chromosome except 1981; however, for most chromosomes there is no apparent phenotypic
consequence. CPM may be a marker for UPD in the fetus. In such cases, an initial meiotic non-
disjunction leads to a trisomic conceptus, with two chromosomes originated from one parent,
and one chromosome from the other parent. In the process of meiotic rescue, there is a
theoretical 1 in 3 chance the final pair will be from only one parent, leading to UPD. If the UPD
involves imprinted gene regions, this can have clinical consequences. If CVS establishes CPM
for chromosomes 6, 7, 11, 14, 15, 16 or 20, a diagnosis of UPD should be considered48,81-82. In
table 6 UPD syndromes associated with FGR are highlighted. The frequency of UPD in CPM of
imprinted chromosomes is reported to be 2%48. Furthermore, there is an increased risk of
recessive disorders occurring due to homozygosity of some segments along the UPD
homologues.

Silver-Russell syndrome is one of the better known FGR-related syndromes. It has multiple
etiologies including epigenetic changes that modify expression of genes in

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 the imprinted region of chromosome 11p15.5, maternal UPD7, and (infrequently) autosomal
dominant or autosomal recessive inheritance. Characteristics are summarized in table 7.

Uniparental disomy of chromosome 16 is one of the more commonly seen UPDs, and it is
almost always due to correction of trisomy 16 of maternal meiotic origin. It has been difficult
to separate out the effects of UPD and those of placental insufficiency due to CPM for trisomy
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1626. Opinions differ. Yong et al. (2003)83 showed in a large series of mosaic trisomy 16
discovered at prenatal diagnosis that the degree of FGR, and probably the malformation rate,
was greater in those with upd(16)mat than in those with biparental inheritance, thus
suggesting a role of the UPD per se. Imprinting of the FOXF1 locus at 16q24.1 has been
proposed as a mechanism underpinning some phenotypic features of upd(16)mat84. In
contrast, Scheuvens et al. (2017)85 suggest that upd(16)mat is, of itself, without phenotype and
may serve merely as a biomarker for an underlying trisomy 16 mosaicism. Madsen et al
(2018)86 published that 3/13 pregnancies identified with upd(16)mat had adverse outcomes.
However, these three pregnancies also had high levels of trisomic cells (≥ 97 %). As for
paternal UPD16, it seems probable that it has no clinical consequences87. The utility of UPD
testing in the setting of CPM16 remains uncertain88-90.

There are epigenetic published studies related with FGR performed in newborns and in the
placenta. Stalman et al (2018)91 studied a prospective cohort of 21 growth restricted newborns
with a birthweight below the 1st centile, and identified one systematically disturbed
methylation pattern in 11p15.5 region and a sequence variant explaining smallness. Additional
methylation disturbances were present in all except one of the patients, with
hypermethylation being much more frequent than hypomethylation92-93. Maternal cigarette
smoking and air pollution exposure in pregnancy is associated with lower birth weight for
gestational age. Several studies in adults have demonstrated that cigarette smoking results in
reproducible DNA methylation differences in blood, specifically demethylation in the promoter
of AHRR, a gene involved in regulating detoxification processes. Maternal smoking in
pregnancy also affects the DNA methylation of AHRR gene in offspring cord blood94. Whether
less potent but more ubiquitous exposures, such as air pollution, affect DNA methylation or
other epigenetic processes in utero is less well established, but plausible95.

Being the primary interface between the mother and fetus, the placenta is susceptible to
various environmental exposures that have the capacity to alter placental function and fetal
development. In recent years, numerous studies have established a strong link between

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 epigenetic regulation and placental development by demonstrating the critical role of
epigenetic regulators, and the associated transcription factors, in maintaining a healthy
pregnancy96.

Even though epigenetic variation in the placenta is now emerging as a candidate mediator of
environmental influence on placental functioning and a key regulator of pregnancy outcome,
Accepted Article

replication of findings is generally lacking, most likely due to small sample sizes and a lack of
standardization of analytical approaches. Defining DNA methylation “signatures” in the
placenta associated with maternal and fetal outcomes offers tremendous potential to improve
pregnancy outcomes97, but care must be taken in interpretation of findings98. At present, no
strong evidence exists for a role of placental epigenetic disruption as a driver of FGR and/or
preeclampsia phenotypes in human beings99.

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 4. Conclusions

Fetal or neonatal genetic testing appears to be crucial in early onset FGR, given that it may
provide information of utmost importance for an optimal counseling regarding outcome of the
current pregnancy and risks future pregnancies. Whereas most of the genetic disorders are
caused by a “de novo” variant, some may be inherited. The main categories of genetic
Accepted Article

disorders in early isolated FGR, their prevalence, and their possible diagnosis are summarized
in Table 8.

 Very early onset severe isolated FGR, defined as an EFW below 3rd centile apparent
before 24 weeks of gestation with no additional ultrasound findings, may be a sign of a
chromosomal syndrome that can be detected in a karyotype or by CMA. The diagnosis
of a monogenic disorder is hampered by the lack of availability of a genomewide
method, because gene panels for FGR are rare. The prenatal use of clinical exome
sequencing (all the exons from OMIM genes) or whole exome sequencing (all the
exons) is now transitioning from research to its clinical use. We recommend offering
CMA in those cases, and consideration should be given to storing DNA when feasible.
Serial detailed ultrasound scans should be performed to assess new findings that can
help in the diagnosis of monogenic disorders (Figure 3).
 In early onset severe isolated FGR cases, defined an EFW <3rd centile below 32 weeks,
CMA should be offered when minor (e.g. genital hypoplasia) fetal anomalies are
observed at ultrasound or minor findings (e.g. polyhydramnios) (Figure 3).
 In FGR with extreme short long bones, a genetic panel for skeletal dysplasias should be
offered.
 The possibility of CPM and UPD should be considered in fetuses with normal CMA.
However at present pertinent diagnostic tests would not seem to be recommended.
 In the presence of placental dysfunction by means of uterine artery Doppler, with a
normal fetal morphologic ultrasound examination, the yield from CMA testing is
probably low and as such it may be reasonable not to recommend genetic testing in
this setting, although no evidence has been published about. Postpartum counseling
should take into account histologic placenta findings and modifiable maternal risk
factors, and can assist in planning future pregnancy. Underlying pathologies associated
with FGR of a non-genetic origin have a wide range of recurrence risks.

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  In liveborn growth restricted infants, a thorough physical examination should be
performed to identify mild phenotypic findings. A clinical genetic assessment should
be offered to rule out any known compatible syndrome.
 Post-mortem studies are of paramount importance in growth-restricted fetuses
resulting in perinatal demise or termination of pregnancy. The macroscopic
assessment should be carried out to exclude dysmorphic features and congenital
Accepted Article

anomalies that may have been missed at the prenatal ultrasound assessment. These
findings can dictate further genetic studies. Although autopsy is nowadays considered
the gold standard, in those cases in which parents deny it, magnetic resonance
imaging should be offered and DNA should be always stored for further genetic
testing.

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 TABLE 1. The most common chromosomal abnormalities associated with FGR

Abnormality Frequency US findings Other findings Prognostic Recurrence risk

Triploidy (3n = 69)
-1-2% of recognized conceptions. 1/10,000 livebirths.
-10-20% of recognized miscarriages.
Accepted Article
- Diandric (2n >90% of cases -Symmetric FGR with High maternal Almost 100% result in Diandric triploidy
from the of partial structural anomalies (82%). serum hCG (80%). fetal demise during the with a partial mole:
fater) moles. - Large placenta, hydropic first or early second ~1%
changes, hyperechoic trimester.
appearance, multiple small or Increased risk of pre-
a single large cyst. eclampsia.
-Oligohydramnios
-Abnormal placental Doppler
studies.

- Digynic (2n - Nonmolar - Almost 100% result in Extremely low

from the -Severe FGR. fetal demise. (recurrence has
mother) Disproportionately large More likely than diandric been described only
head. May have to survive to the second in a few families)
holoprosencephaly. trimester.
-Oligohydramnios.
-Abnormally small placenta
and abnormal placental
Doppler studies

Trisomy 18 1/3000-7000 Most frequent: FGR, cardiac
livebirths structural anomalies,
chroroid plexus cysts, central
nervous system anomalies,
and overlapping
fingers/clenched hands.
Low maternal High risk of 64% of in Full trisomy 18: 1%
serum PAPP-A, utero demise. Median or the age-related
hCG, estriol and postnatal survival for maternal risk.
alfa-fetoprotein. males is 1-2 months and
females, 9-10 months.

TABLE 2 - Chromosomal abnormalities reported in apparently isolated FGR24

Numeric chromosomal abnormalities

Trisomy 21, Trisomy 18, Trisomy 13, Trisomy 16, Trisomy 7
69,XXX or 69,XXY
47,XXX and 47,XXY
45,X
Mosaic trisomy 21
Trisomy 16 confined to the placenta
Structural chromosomal abnormalities
47,XY,4p-

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 46,XY,+16q
46,XX,-14,+rob(14;21)
46,XY,del(12)(p12)
46,XY,t(2;14)(q23:q32)

TABLE3. Most common pathogenic copy number variants in FGR fetuses 19

Accepted Article

Abnormality Frequency US findings Other findings Prognostic Mode of

inheritance and
recurrence risk
22q11.2 1:320 in -FGR Multiple defects to mild learning Highly variable Autosomal
microduplication individuals -Polyhydramnios. difficulties with some individuals dominant.
syndrome with -Similar features as 22q11.2 being normal. Phenotype is not Mostly inherited
developmental deletion syndrome: heart sufficiently distinct to be from a parent.
problems defects, urogenital specifically suspected on clinical
abnormalities, cleft palate grounds alone.

Xp22.3 deletion 1/2000-6000 -FGR Variable association of ichthyosis, Highly X-link recessive.
syndrome livebirths -Short long bones chondrodysplasia punctata, variable. Depends on
-Polyhydramnios hypogonadotropic hypogonadism, Phenotype parent’s test.
-Hypoplastic nose with anosmia, ocular albinism, short depends on
depressed nasal bridge stature and mental retardation. length of
-Contractures of wrists and deletion and
fingers genes
-Central nervous system involved.
anomalies

7q11.23 1/7500-10000 -FGR Multisystem disorder: facial Phenotypic Autosomal

microdeletion livebirths -Congenital heart defects: dysmorphia, psychomotor features are dominant.
(Williams- valvular stenosis retardation, specific cognitive and variable but De novo in most
Beuren -Polyhydramnios behavioral profile. penetrance is cases with a
syndrome) -Exomphalos 100%. recurrence risk
less than 1%.

TABLE4. Monogenic disorders associated with FGR with concordant biometries

Abnormality Frequency Gene, loci and US findings Other postnatal findings Prognosis Mode of inheritance
dysfunction and recurrence risk
Cornelia de 1:10.000- NIPBL (60%) -FGR may be detected in -Hirsutism, synophrys, highly Moderate to severe Autosomal
Lange 100.000 live SMC1A (5%) third trimester arched eyebrows, long intellectual dominant: NIPBL
syndrome births HDAC8 (4%) -Upper-limb reduction eyelashes, short nose with disability. (99% de novo,
SMC3 (1-2%) defects anteverted nares, small Modest increase in recurrence risk 1.5%
RAD21 (<1%) -Microcephaly widely spaced teeth. mortality. because of germline
-Cardiac septal defects -Autistic and self-destructive mosaicism), RAD21,
-Hypoplastic genitalia tendencies. SMC3
-Gastrointestinal X-linked: HDAC8,
dysfunction, hearing loss, SMC1A (recurrence
myopia, and cryptorchidism. risk depends on
mother status).

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 Smith Lemli 1:20.000- DHCR7 (96%) -Microcephaly -Narrow forehead, -Increased Autosomal recessive:
Opitz 40.000 live -Midline and para- epicanthal folds, ptosis, short incidence of 25% recurrence risk if
syndrome births Dysfunction in midline structures mandible with preservation intrauterine fetal parents are carriers.
cholesterol anomalies of the brain. of jaw width, short nose, demise or neonatal
production -Cleft palate anteverted nares, and low- death in severely
-Cardiac defects set ears. affected individuals.
-Hypospadias - Serum concentration of -Moderate to severe
-Postaxial polydactyly, 2- cholesterol is usually low. intellectual disability
3 (Y-shaped) syndactyly
of the toes.
Accepted Article

Seckel <1:1.000.000 ATR, NIN, ATRIP -Severe FGR -Craniosynostosis Usually mild to Autosomal recessive:
syndrome -Microcephaly usually moderate intellectu 25% of recurrence
DNA damage detected during 2nd al disability risk if parents are
response trimester carriers.
dysfunction

3M 100 cases CUL7 (65%) -Severe FGR Final height 5-6SD below the Intelligence usually Autosomal recessive:
described OBSL1 (30%) -Hypospadias, mean, triangular-shaped and unaffected. 25% of recurrence
worldwide. CCDC8 (5%) hypogonadism hypoplastic midline face, T risk if parents are
-Macrocephaly skeletal abnormalities. carriers.
Defect on
ubiquitization

Meier- Prevalence ORC1, ORC4, OR -Severe FGR -Microtia Intellect is Autosomal recessive:
unknown C6, CDT1, -Microcephaly -Aplasia or hypoplasia of preserved. 25% of recurrence
Gorlin
and CDC6 the patellae risk if parents are
syndrome -High forehead, micrognathia carriers.
with full lips and small
mouth, and accentuated
nasolabial folds.

Fanconi Most BRCA2 (3%), -Severe FGR -Short stature, abnormal skin -Developmental Predominantly an
common BRIP1 (2%), -Microcephaly pigmentation, ophthalmic delay: 10% autosomal recessive
anemia
genetic FANCA (70%), -Skeletal malformations and genitourinary tract -Bone marrow disease (19 genes), it
syndrome cause of FANCB (2%), of the upper and lower anomalies. failure can also be
aplastic FANCC (14%), limbs -Increased chromosome -Increased autosomal dominant
anemia and FANCD2 (3%), breakage and radial forms susceptibility to (RAD51) or X-linked
hematologic FANCE (3%), on cytogenetic testing of cancer. (FANCB).
malignancy. FANCF (2%), lymphocytes with
FANCG (10%), diepoxybutane (DEB) and
FANC1 (1%) mitomycin C (MMC).

DNA repair
dysfunction
Bloom Fewer than BLM -Severe FGR -Immune abnormalities, Usually normal Autosomal recessive:
syndrome 300 cases sensitivity to sunlight, insulin intellectual ability 25% of recurrence
reported DNA repair resistance, and a high risk for risk if parents are
dysfunction many cancers that occur at carriers.
an early age.
-Early menopause, infertility.

Nijmegen 1:100,000 NBN -FGR Short stature, recurrent -Moderate Autosomal recessive:
Breakage live births -Progressive sinopulmonary infections, intellectual 25% of recurrence
syndrome DNA repair microcephaly increased risk for cancer, disability. risk if parents are
dysfunction premature ovarian failure in -Recurrent carriers.
females. pneumonia and
bronchitis may
result in respiratory
failure and early
death.

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 TABLE 5. Monogenic disorders associated to FGR with extremely short long bones

Abnormality Frequency Gene, loci and US findings Other postnatal Prognosis Mode of inheritance
dysfunction findings and recurrence risk
Noonan syndrome 1/1000- PTPN11 (50%), -Increased NT -Distinctive facial Variable degree of Autosomal
2000 SOS1 (13%), RAF1 -Congenital heart features. neurocognitive delay dominant.
newborns (5%),RIT1 (5%), KR defects (50%- -Short stature Recurrence depends
AS (<5%) 80%): pulmonary valve - Variable clinical on parental status.
BRAF, LZTR1, MAP stenosis the most phenotype.
2K1, and NRAS in frequent.
<1%.

Achondroplasia 1:26,000- FGFR3: 98% will -Short limbs and -Hypotonia -Developmental Autosomal
28,000 live have c.1138G>A rhyzomelic -Obstructive sleep motor milestones is dominant.
births and 1%, disproportion. apnea, middle ear often delayed. 80% de novo; very
c.1138G>C - Macrocephaly dysfunction, kyphosis, -Intelligence usually low recurrence risk.
Accepted Article
mutation. -Midfacial retrusion and spinal stenosis. near normal
-Small chest -Craniocervical
- Often diagnosed at junction
3th trimester compression
increases the risk of
death in infancy.

1:15,000 - FGFR3: 70% will -Skeletal features are -Clinically significant sequelae are less Autosomal
Hypochondroplasia 40,000 live have c.1620C>A very similar to those frequent and less severe in hypochondroplasia dominant.
births and 30%, seen in achondroplasia than achondroplasia. Vast majority are de
c.1620C>G. but tend to be milder -Intellectual disability and epilepsy may be novo; very low
more prevalent recurrence risk.

Mulibrey Nanism 1: 37,000 TRIM37 gene -Relative macrocephaly -Feeding and Normal Autosomal recessive
-Thin extremities and respiratory problems- neurocognitive
Peroxisomal typical craniofacial Yellowish dots in the development
dysfunction features retinal mid peripheral
region
-Perimyocardial heart
disease
-Insulin Resistance

Microcephalic 150 cases PCNT -Broad and elevated Central nervous Autosomal recessive:
Osteodysplastic described -Marked microcephaly nasal root, wide system vascular 25% of recurrence
Primordial Dwarfism, worldwide Centrosomal bridge, dysplastic anomalies are a risk if parents are
Type II (MOPD2) dysfunction pinnae with attached significant cause of carriers
lobes. morbidity and
- Skeletal dysplasia mortality.

SHORT syndrome Fewer than PIK3R1 Short Intelligence usually Autosomal

50 cases Mild FGR stature, Hyperextensi unaffected. dominant. Unknown
described Cell proliferation bility, Ocular Limited proportion of de
worldwide. and growth depression (deeply understanding novo pathogenic
dysfunction set eyes), Rieger regarding phenotype variant cases but
anomaly or related spectrum and appears to be
ocular anterior natural history. significant. Each child
chamber dysgenesis, of an individual with
and Teething delay SHORT syndrome has
Insulin resistance a 50% chance of
and/or diabetes inheriting the
mellitus in early pathogenic variant.
adulthood; and
sensorineural hearing
loss

TABLE6. Uniparental disomy syndromes

UPD type Syndrome/Disease Phenotype

Paternal UPD6 Transient neonatal diabetes mellitus FGR, neonatal diabetes

Maternal UPD7 and Maternal Silver-Russell FGR/PNGR, dysmorphisms

UPD11
Paternal UPD11 Beckwith-Wiedemann Overgrowth, dysmorphisms, tumors (or
isolated hemihyperplasia)

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 Maternal UPD14 Temple syndrome FGR, dysmorphisms

Known prevalence in FGR Common anomalies Testing type Tissue

CHROMOSOMAL ABNORMALITIES
Accepted Article
Pure (all cells affected)
In: Triploidy, Trisomy 18 Karyotype, CVS, AF, cord blood
- FGR: 19% CMA, FISH,
- Isolated FGR: 6.4% QF-PCR

Abnormality Frequency Etiology US findings Other Prognosis Mode of inheritance

findings and recurrence risk

Silver-Russell 1/100,000 Epigenetic changes in -FGR with limb- -Triangular Usually Most are in a single
50% (loss of paternal length asymmetry facies with developmental family member, so
syndrome
methylation at the H19- that may result from broad delay (both recurrence risk usually
(SRS) IGF2 ICI), uniparental hemihypotrophy forehead and motor and low.
disomies in 10% with reduced narrow chin cognitive) and
(maternal UPD7) and less growth of the learning
often, autosomal affected side. disabilities
dominant or autosomal -Fifth finger
recessive inheritance clinodactyly

Paternal UPD14 Bell-shaped thorax, developmental retardation Dwarfisms, dysmorphisms

Maternal UPD15 Prader-Willi Obesity, dysmorphisms, intellectual

disability
Paternal UPD15 Angelman Intellectual disability, dysmorphisms

Maternal UPD16 FGR FGR, malformations

Maternal UPD20 Growth failure, hyperactivity FGR

Paternal UPD20 Pseudohypoparathyroidism Pseudohypoparathyroidism

In red, those disomies associated with FGR

TABLE7. Silver-Russell Syndrome

Table8. Summary of the main categories of genetic disorders associated with isolated FGR

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 - Early FGR (<3rd centile): 18%

Confined placental mosaicism

In FGR: 9-16% (unknown rate in CPM16, Tetraploidy Karyotype, CVS, placental biopsy
isolated FGR) CMA, FISH

SUBMICROSCOPIC CHROMOSOMAL ABNORMALITIES

Accepted Article
In: dup22q11.1, delXp22.3, CMA, FISH CVS, AF, cord blood
- Isolated FGR with normal del7q11.23
karyotype: 4.8-5.6%
- Isolated FGR with
nonstructural anomalies and
normal karyotype: 10%
MONOGENIC DISORDERS
Unknown rate Noonan syndrome, Gene panels, CVS, placental
achondroplasia, Seckel, WES, WGS biopsy, AF, cord
3M, Meier Gorlin, blood
Bloom syndromes.
EPIGENETIC CHANGES
In: Silver Russell SNP-CMA, CVS, placental
- Unknown rate syndrome, UPD16 methylation biopsy, AF, cord
- CPM: 2% studies blood

Figure 1. Etiological factors leading to FGR

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 PLACENTAL DISEASE
•Isolated
•Associated: CPM,
epigenetics
Accepted Article

FETAL DISEASE ISOLATED

•GENETIC
•Chromosomal
FGR MATERNAL
•CNVs FACTORS
•Single gene disorders
•EPIGENETICS •Extreme maternal
•Aberrant methylation and age
other mecanisms •Toxic exposures
•UPD
•INFECTIONS: Toxoplasmosis,
•Maternal diseases
Rubeolla, CMV, HSV, VZV,
Treponema pallidum

FGR: Fetal growth restriction. CPM: confined placental mosaicism. CNVs: copy number
variants. UPD: uniparental disomy. CMV: citomegalovirus. HSV: herpes simplex virus. VZV:
varicela zoster virus.

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 FETAL GROWTH RESTRICTION with
Long bones and AC corresponding to same GA
Accepted Article

Genital and/or hands/limbs and/or

facial specific findings

Head circumference

Relative Relative
Relative Microchephaly
Macrochephaly Normochephaly

Floating and Cornelia de Smith-Lemli- Chromosom

Silver Russell 3M Lange Seckel Meier Gorlin Others
Syndrome Harbor Opitz e instability
Syndrome syndrome Syndrome (Dubowitz)
Syndromes (several loci) (11q13.4) syndromes

Nijmegen
Fanconi Bloom
Breakage
Anemia Syndrome
Syndrome

FIGURE 2B. Suggested algorythm for early severe FGR with extremely short long bones

ASYMMETRIC GROWTH RESTRICTION

Long bones <3SD, independently of AC
Skeletal Dysplasias

Head Circumference

Macrocephaly Normocephaly Microcephaly

Hypochondroplasia Dysfunction in
Noonan
Mulibrey Nanism Short Syndrome SHOX and IGF-1 MOPD2
Achondroplasia Syndrome
genes

FIGURE 3. PRENATAL ALGORYTHM STUDY for Severe Early FGR (based on the most frequent
associated syndromes)

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 Early severe FGR

CMA study
(DNA stored) and detailed US
Accepted Article
Genital, hands or Extreme short
No US findings facial long bones
abnormalities (<3SD)

Targeted genetic testing for

Serial US Microcephaly Macrocephaly Achondroplasia/Hypoachond
roplasia

Smith-Lemli Cornelia de Silver Rusell

Others
Opitz Lange Syndrome

When high suspicion of Syndrome and previous genetic testing negative,

WES can be considered.

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