Guidelines on Fetal Growth Restriction: A Comparison of Recent National Publications

Abstract

Objective This study aims to compare recommendations from recently published national clinical guidelines for pregnancies complicated by fetal growth restriction (FGR).

Materials and Methods Clinical guidelines informing best practice management of pregnancies with FGR issued by the American Congress of Obstetricians and Gynecologists, the Society of Obstetricians and Gynaecologists of Canada and the Royal College of Obstetricians and Gynaecologists in the United Kingdom are reviewed together with the published literature on this topic.

Results Each of the guidelines uses different terminology to describe pregnancies affected by suboptimal fetal growth; all of them agree that an estimated fetal weight < 10th centile should alert clinicians to small fetal size. All guidelines describe risk factor screening for improved detection of FGR and acknowledge the limited accuracy achieved with fundal height measurement. No agreement is reached over the value of fetal weight customization. All colleges have varied opinions regarding methods of Doppler surveillance, however agree that umbilical artery Doppler is beneficial as primary surveillance tool.

Conclusions The results of this review relay significant inconsistencies and call for an urgent and practical international consensus on this important and common clinical topic. Current data were used to develop a clinical practice guideline for Ireland, which will be presented in context with this review.

Keywords

fetal growth restriction - IUGR - SGA - clinical practice guidelines - practice bulletin

• References

• 1 Al-Niaimi A, Chauhan SP, Gupta LM, Bailet JW. Factors influencing the evolving practice of obstetricians in eastern Wisconsin: a survey. Am J Perinatol 2008; 25 (6) 321-324
• 2 Gardosi J, Madurasinghe V, Williams M, Malik A, Francis A. Maternal and fetal risk factors for stillbirth: population based study. BMJ 2013; 346: f108
• 3 McCowan LM, Roberts CT, Dekker GA , et al; SCOPE consortium. Risk factors for small-for-gestational-age infants by customised birthweight centiles: data from an international prospective cohort study. BJOG 2010; 117 (13) 1599-1607
• 4 Chauhan SP, Beydoun H, Chang E , et al. Prenatal detection of fetal growth restriction in newborns classified as small for gestational age: correlates and risk of neonatal morbidity. Am J Perinatol 2014; 31 (3) 187-194
• 5 Gardosi J, Chang A, Kalyan B, Sahota D, Symonds EM. Customised antenatal growth charts. Lancet 1992; 339 (8788) 283-287
• 6 Unterscheider J, Daly S, Geary MP , et al. Optimizing the definition of intrauterine growth restriction: the multicenter prospective PORTO Study. Am J Obstet Gynecol 2013; 208 (4) e1-e6
• 7 Lees C, Marlow N, Arabin B , et al; TRUFFLE Group. Perinatal morbidity and mortality in early-onset fetal growth restriction: cohort outcomes of the trial of randomized umbilical and fetal flow in Europe (TRUFFLE). Ultrasound Obstet Gynecol 2013; 42 (4) 400-408
• 8 GRIT Study Group. A randomised trial of timed delivery for the compromised preterm fetus: short term outcomes and Bayesian interpretation. BJOG 2003; 110 (1) 27-32
• 9 Barker ED, McAuliffe FM, Alderdice F , et al. The role of growth trajectories in classifying fetal growth restriction. Obstet Gynecol 2013; 122 (2 Pt 1) 248-254
• 10 Groom KM, Poppe KK, North RA, McCowan LM. Small-for-gestational-age infants classified by customized or population birthweight centiles: impact of gestational age at delivery. Am J Obstet Gynecol 2007; 197 (3) e1-e5
• 11 Grivell RM, Wong L, Bhatia V. Regimens of fetal surveillance for impaired fetal growth. Cochrane Database Syst Rev 2012; 6: CD007113
• 12 Alfirevic Z, Stampalija T, Gyte GM. Fetal and umbilical Doppler ultrasound in high-risk pregnancies. Cochrane Database Syst Rev 2010; (1) CD007529
• 13 Boers KE, Bijlenga D, Mol BW , et al. Disproportionate Intrauterine Growth Intervention Trial At Term: DIGITAT. BMC Pregnancy Childbirth 2007; 7: 12
• 14 Boers KE, van Wyk L, van der Post JA , et al; DIGITAT Study Group. Neonatal morbidity after induction vs expectant monitoring in intrauterine growth restriction at term: a subanalysis of the DIGITAT RCT. Am J Obstet Gynecol 2012; 206 (4) e1-e7
• 15 Boers KE, Vijgen SM, Bijlenga D , et al; DIGITAT study group. Induction versus expectant monitoring for intrauterine growth restriction at term: randomised equivalence trial (DIGITAT). BMJ 2010; 341: c7087
• 16 Baschat AA, Cosmi E, Bilardo CM , et al. Predictors of neonatal outcome in early-onset placental dysfunction. Obstet Gynecol 2007; 109 (2 Pt 1) 253-261
• 17 RCOG Green-top Guideline No 31. The Investigation and Management of the Small-for-Gestational-Age Fetus. London: Royal College of Obstetricians and Gynaecologists; 2013
• 18 American College of Obstetricians and Gynecologists. ACOG Practice bulletin no. 134: fetal growth restriction. Obstet Gynecol 2013; 121 (5) 1122-1133
• 19 Lausman A, Kingdom J, Gagnon R , et al; Maternal Fetal Medicine Committee. Intrauterine growth restriction: screening, diagnosis, and management. J Obstet Gynaecol Can 2013; 35 (8) 741-757
• 20 Lausman A, McCarthy FP, Walker M, Kingdom J. Screening, diagnosis, and management of intrauterine growth restriction. J Obstet Gynaecol Can 2012; 34 (1) 17-28
• 21 Chauhan SP, Hendrix NW, Berghella V, Siddiqui D. Comparison of two national guidelines in obstetrics: American versus royal college of obstetricians and gynecologists. Am J Perinatol 2010; 27 (10) 763-770
• 22 Chauhan SP, Gupta LM, Hendrix NW, Berghella V ; American College of Obstetricians and Gynecologists. Intrauterine growth restriction: comparison of American College of Obstetricians and Gynecologists practice bulletin with other national guidelines. Am J Obstet Gynecol 2009; 200 (4) e1-e6
• 23 Bricker L, Neilson JP, Dowswell T. Routine ultrasound in late pregnancy (after 24 weeks' gestation). Cochrane Database Syst Rev 2008; (4) CD001451
• 24 RCOG Green-top Guideline No. 7. Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality. London: Royal College of Obstetricians and Gynaecologists; 2010
• 25 Unterscheider J, O'Donoghue K, Daly S , et al. Fetal growth restriction and the risk of perinatal mortality-case studies from the multicentre PORTO study. BMC Pregnancy Childbirth 2014; 14 (1) 63
• 26 Unterscheider J, Daly S, Geary MP , et al. Predictable progressive Doppler deterioration in IUGR: does it really exist?. Am J Obstet Gynecol 2013; 209 (6) e1-e7