Fetal growth restriction: aetiology, screening, diagnosis and management

Valsa Chathampadathil Augusthy


Foetal growth restriction (FGR) is a pathological condition that refers to a foetus that fails to reach his/her genetically predetermined growth potential. FGR remains a leading contributor to perinatal mortality and morbidity and metabolic syndrome in later life. The purpose of this review is to provide the summary statements of the aetiology of FGR and to establish a framework for screening, diagnosis, and management of pregnancies affected with foetal growth restriction. For this study, published literature was retrieved through searches of PubMed (Medline), Highwire, Google Scholar, Scopus, Cochrane Database of Systematic Reviews. Conference/Seminar proceedings, textbooks, previously published systematic reviews, controlled clinical trials, high quality prospective and retrospective observational studies, research articles and unpublished studies were also used for this study. The identification of FGR begins with assessment of maternal, foetal, placental and environmental risk factors and the diagnosis is made by Ultrasound biometry examination. Functional assessment of placental and foetal circulation by Doppler velocimetry and blood flow volume, together with computerized assessment of foetal heart rate variability, are key examinations in early and late FGR to assess severity of the disease and monitor foetal wellbeing. Appropriate timing of delivery in early FGR might change the outcome, and appropriate monitoring in late and term FGR might avoid unnecessary interventions.


Foetal growth restriction, Foetal abdominal circumference, Doppler velocimetry, Screening, Diagnosis, Management

Full Text:



Lees C, Baumgartner H. Perinatal morbidity and mortality in early-onset fetal growth restriction: cohort outcomes of the trial of randomized umbilical and fetal flow in Europe. Ultrasound Obstet Gynecol. 2013;42:400-8.

Unterscheider J, Daly S, Geary MP, Kennelly MM, McAuliffe FM, O'Donoghue K, et al. Optimizing the Definition of Intrauterine Growth Restriction– Results of the Multicenter Prospective PORTO Study. Am J Obstet Gynecol. 2013;208(4):290-6.

Barker ED, McAuliffe FM, Alderdice F, Unterscheider J, Daly S, Geary MP, et al. The Role of Growth Trajectories to Identify Fetal Growth Restriction. Obstet Gynecol. 2013;122:248-54.

Manning E, Corcoran P, Meaney S, Greene RA. On behalf of the Perinatal Mortality Group: Perinatal Mortality in Ireland Annual Report 2011. NPEC, Cork, 2013.

Bernstein I, Gabbe SG, Reed KL. In: Gabbe SG et al., editors. Intrauterine growth restriction. in Obstetrics: Normal and Problem Pregnacies. New York: Churchill Livingston, 2002.

Hernandez-Andrade E, Stampalija T, Figueras F. Cerebral blood flow studies in the diagnosis and management of intrauterine growth restriction. Curr Opin Obstet Gynecol. 2013;25(2):138-44.

Villar J, de Onis M, Kestler E, Bolanos F, Cerezo R, Bernedes H. The differential neonatal morbidity of the intrauterine growth retardation syndrome. Am J Obstet Gynecol. 1990;163:151-7.

Varvarigou AA. Intrauterine growth restriction as a potential risk factor for disease onset in adulthood. J Pediatr Endocrinol Metab. 2010;23:215-24.

Verburg BO, Steegers EA, De RM, Snijders RJ, Smith E, Hofman A et al. New charts for ultrasound dating of pregnancy and assessment of fetal growth: longitudinal data from a population-based cohort study. Ultrasound Obstet Gynecol. 2008;31(4):388-96.

Dashe JS, McIntire DD, Lucas MJ, Leveno KJ. Effects of symmetric and asymmetric fetal growth on pregnancy outcomes. Obstet Gynecol. 2000;96(3):321-27.

Lee KS, Ferguson RM, Corpuz M, Gartner LM. Maternal age and incidence of low birth weight at term: a population study. Am J Obstet Gynecol. 1988;158(1):84-9.

Strobino DM, Ensminger ME, Kim YJ, Nanda J. Mechanisms for maternal age differences in birth weight. Am J Epidemiol. 1995;142(5):504-14.

Wen SW, Goldenberg RL, Cutter GR, et al. Intrauterine growth retardation and preterm delivery: prenatal risk factors in an indigent population. Am J Obstet Gynecol. 1990;162:213-8.

Berghella V. Prevention of recurrent fetal growth restriction. Obstet Gynecol. 2007;110(4):904-12.

Lieberman E, Gremy I, Lang JM, Cohen AP. Low birth weight at term and the timing of fetal exposure to maternal smoking. Am J Public Health. 1994;84(7):1127-31.

Wen SW, Goldenberg RL, Cutter GR, Hoffman HJ, Cliver SP, Davis RO, et al. Smoking, maternal age, fetal growth and gestational age at delivery. Am J Obstet Gynecol. 1990;162:213-53.

Shu XO, Hatch MC, Mills J. Maternal smoking, alcohol drinking, caffeine consumption, and fetal growth: results from a prospective study. Epidemiology. 1995;6:115-20.

Mills JL, Graubard BI, Harley EE. Maternal alcohol consumption and birth weight: How much drinking during pregnancy is safe? JAMA 1984;252:1875.

Naeye RL, Blanc W, Leblanc W, Khatamee MA. Fetal complications of maternal heroin addiction: abnormal growth, infections and episodes of stress. J Pediatr. 1973;83:1055-61.

Fulroth R, Phillips B, Durand DJ. Perinatal outcome of infants exposed to cocaine and/or heroin in utero. Am J Dis Child. 1989;143:905-10.

Little BB, Snell LM. Brain growth among fetuses exposed to cocaine in utero: Asymmetrical growth retardation. Obstet Gynecol. 1991;77:361.

Hendrix N, Berghella V. Non-placental causes of intrauterine growth restriction. Semin Perinatol. 2008;32(3):161-5.

American College of Obstetricians and Gynecologists. Intrauterine growth restriction. Practice Bulletin no. 12, 2000, Washington DC. Accessed 28 December 2014.

Reeves S, Galan HL. Fetal growth restriction. In: Berghella V, editor. Maternal-fetal evidence based guidelines. 2nd ed. London: Informa Health Care. 2012:329-44.

Baschat AA, Galan HL, Gabbe SG. Intrauterine growth restriction. In: Gabbe SG, Neibyl JR, Simpson JL, editors. Obstetrics normal and problem pregnancies. Philadelphia: Elsevier. 2012:706-41.

Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol. 2008;198:357-66.

Cooney MJ, Benson CB, Doubilet PM. Outcome of pregnancies in women with uterine duplication anomalies. J Clin Ultrasound. 1998;26(1):3-6.

Khader YS, Ta’ani Q. Periodontal diseases and the risk of preterm birth and low birth weight: a meta-analysis. J Periodontol. 2005;76(2):161-5.

Baschat AA, Galan HL, Gabbe SG. Intrauterine growth restriction. In: Gabbe SG, Neibyl JR, Simpson JL, editors. Obstetrics normal and problem pregnancies. Philadelphia: Elsevier. 2012:706-41.

Hendrix N, Berghella V. Non-placental causes of intrauterine growth restriction. Semin Perinatol. 2008;32(3):161-5.

Lin CC, Santolaya-Forgas J. Current concepts of fetal growth restriction: part I. Causes, classification, and pathophysiology. Obstet Gynecol. 1998;92(6):1044-55.

Khoury MJ, Erickson JD, Cordero JF, McCarthy BJ. Congenital malformations and intrauterine growth retardation: a population study. Pediatrics. 1988;82(1):83-90.

Hendrix N, Berghella V. Non-placental causes of intrauterine growth restriction. Semin Perinatol. 2008;32(3):161-5.

Divon MY, Ferber A. Overview of causes and risk factors for fetal growth restriction In: Lockwood CJ, Barss VA (eds) UpToDate Accessed 28 December 2014.

Divon MY, Weiner Z. Ultrasound in twin pregnancy. Semin Perinatol. 1995;19:404-12.

D’Alton ME, Simpson LL. Syndromes in twins. Semin Perinatol. 1995;19:375-86.

Miller J, Chauhan SP, Abuhamad AZ. Discordant twins: diagnosis, evaluation and management. Am J Obstet Gynecol. 2012;206(1):10-20.

Khong TY, De Wolf F, Robertson WB, Brosens I. Inadequate maternal vascular response to placentation in pregnancies complicated by pre-eclampsia and by small for- gestational age infants. Br J Obstet Gynaecol. 1986;93(10):1049-59.

Pijnenborg R, Vercruysse L, Hanssens M. The uterine spiral arteries in human pregnancy: facts and controversies. Placenta. 2006;27(9):939-58.

Baschat AA, Galan HL, Gabbe SG. Intrauterine growth restriction. In: Gabbe SG, Neibyl JR, Simpson JL, editors. Obstetrics normal and problem pregnancies. Philadelphia: Elsevier. 2012:706-41.

Laurini R, Laurin J, Marsal K. Placental histology and fetal blood flow in intrauterine growth retardation. Acta Obstet Gynecol Scand. 1994;73:529-34.

Wilkins-Haug L, Roberts DJ, Morton CC. Confined placental mosaicism and intrauterine growth retardation: a case control analysis of placentas at delivery. Am J Obstet Gynecol. 1995;172:44-50.

Galan HL, Rigano S, Radaelli T, et al. Reduction of subcutaneous mass, but not lean mass, in normal fetuses in Denver, Colorado. Am J Obstet Gynecol. 2001;185:839-44.

Kametas NA, McAuliffe F, Krampl E, et al. Maternal cardiac function during pregnancy at high altitude. BJOG. 2004;111:1051-8.

Calvert JP, Crean EE, Newcombe RG, Pearson JF. Antenatal screening by measurement of symphysis-fundus height. Br Med J 1982;285:846-9.

Persson B, Stangenberg M, Lunell NO, Brodin U, Holmberg NG, Vaclavinkova V. Prediction of size of infants at birth by measurement of symphysis fundus height. Br J Obstet Gynaecol. 1986;93:206-11.

Campbell S, Thoms A. Ultrasound measurement of the fetal head to abdomen circumference ratio in the assessment of growth retardation. Br J Obstet Gynaecol. 1977;84:165-74.

Figueras F, Gardosi J. Should we customize fetal growth standards? Fetal Diagn Ther. 2009;25(3):297-303.

Shepard MJ, Richards VA, Berkowitz RL, Warsof SL, Hobbins JC. An evaluation of two equations for predicting fetal weight by ultrasound. Am J Obstet Gynecol. 1982;142(1):47-54.

Hadlock FP, Harrist RB, Sharman RS, Deter RL, Park SK. Estimation of fetalweightwith the use of head, body, and femur measurements - a prospective study. Am J Obstet Gynecol. 1985;151(3):333-7.

Gardosi J. Customized fetal growth standards: rationale and clinical application. Semin Perinatol. 2004;28:33-40.

Ego A, Subtil D, Grange G, et al. Customized versus population-based birth weight standards for identifying growth restricted infants: a French multicenter study. Am J Obstet Gynecol. 2006;194:1042-9.

Gardosi J, Chang A, Kalyan B, Sahota D, Symonds EM. Customized antenatal growth charts. Lancet. 1992;339:283-7.

Clausson B, Gardosi J, Francis A, Cnattingius S. Perinatal outcome in SGA births defined by customized versus population-based birth weight standards. BJOG 2001;108:830-4.

Gardosi J, Francis A. Controlled trial of fundal height measurement plotted on customized antenatal growth charts. Br J Obstet Gynaecol. 1999;106:309-17.

Clausson B, Gardosi J, Francis A, Cnattingius S. Perinatal outcome in SGA births defined by customised versus population-based birthweight standards. BJOG. 2001;108:830-4.

Sciscione AC, Gorman R, Callan NA. Adjustment of birth weight standards for maternal and infant characteristics improves the prediction of outcome in the small-for-gestational-age infant. Am J Obstet Gynecol. 1996;175:544-7.

De Jong CL, Gardosi J, Dekker GA, Colenbrander GJ, van Geijn HP. Application of a customized birth weight standard in the assessment of perinatal outcome in a high risk population. Br J Obstet Gynaecol. 1998;105:531-5.

Alkazaleh F, Chaddha V, Viero S. Second-trimester prediction of severe placental complications in women with combined elevations in alpha-fetoprotein and human chorionic gonadotrophin. Am J Obstet Gynecol. 2006;194:821-7.

Toal M, Chaddha V, Windrim R, Kingdom J. Ultrasound detection of placental insufficiency in women with elevated second trimester serum alpha-fetoprotein or human chorionic gonadotropin. J Obstet Gynaecol Can. 2008;30:198-206.

Proctor LK, Toal M, Keating S, Chitayat D, Okun N, Windrim RC, et al. Placental size and the prediction of severe early-onset intrauterine growth restriction in women with low pregnancy-associated plasma protein-A. Ultrasound Obstet Gynecol. 2009;34:274-82.

Toal M, Chan C, Fallah S, Alkazaleh F, Chaddha V, Windrim RC, et al. Usefulness of a placental profile in high-risk pregnancies. Am J Obstet Gynecol. 2007;196:363-7.

Franco C, Walker M, Robertson J, Fitzgerald B, Keating S, McLeod A, et al. Placental infarction and thrombophilia. Obstet Gynecol. 2011;117:929-34.

Mitani M, Matsuda Y, Makino Y, Akizawa Y, Ohta H. Clinical features of fetal growth restriction complicated later by preeclampsia. J Obstet Gynaecol Res. 2009;35:882-7.

The Society of Obstetricians and Gynaecologists of Canada. Clinical practice guidelines. The use of fetal Doppler in obstetrics. J Obstet Gynecol Can. 2003;25:601-7.

American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Utility of antepartum umbilical artery Doppler velocimetry in intrauterine growth restriction. ACOG committee opinion no. 188, October 1997. Int J Gynaecol Obstet. 1997;59:269-70.

Baschat AA, Cosmi E, Bilardo CM, Wolf H, Berg C, Rigano S, et al. Predictors of neonatal outcome in early-onset placental dysfunction. Obstet Gynecol 2007;109:253-61.

Royal College of Obstetricians and Gynaecologists. Green-top guideline No. 31: The investigation and management of the small for gestational age fetus. 2nd ed. UK: RCOG, 2013.

Lausman A, Kingdom J. Intrauterine growth restriction: screening, diagnosis, and management. J Obstet Gynaecol Can. 2013;35(8):741-8.