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Fetal growth restriction: Screening and diagnosis

Author: Michael Y Divon, MD
Section Editor: Deborah Levine, MD
Deputy Editor: Vanessa A Barss, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2021. | This topic last updated: Jun 18, 2021.
INTRODUCTION
Fetal growth restriction (FGR, also called intrauterine growth restriction [IUGR]) is the term
used to describe a fetus that has not reached its growth potential because of environmental
factors. The origin of the problem may be fetal, placental, or maternal, with significant
overlap among these entities.
A major focus of prenatal care is to determine whether a fetus is at risk for growth restriction
and to identify the growth-restricted fetus. This is important because these fetuses are at
increased risk of adverse perinatal outcome. In addition, FGR appears to be an antecedent to
some adult-onset disorders, including hypertension, hyperlipidemia, coronary heart disease,
and diabetes mellitus (Barker hypothesis [1]). (See "Infants with fetal (intrauterine) growth
restriction" and "Possible role of low birth weight in the pathogenesis of primary (essential)
hypertension".)
The most common obstetric definition of FGR is based on sonography: an estimated fetal
weight below the 10th percentile for gestational age; however, other definitions using a
variety of criteria have been proposed. An abdominal circumference <10th percentile for
gestational age is another common definition. When a small fetus is detected, it can be
difficult to distinguish between the fetus that is constitutionally small versus growth
restricted. It is also difficult to identify the fetus that is not small but growth restricted
relative to its genetic potential. Making the correct diagnosis is not always possible
prenatally, but is important prognostically and for estimating the risk for recurrence.
This topic will describe normal fetal growth and discuss the definition, classification, and
diagnosis of FGR, as well as screening for the disorder. The etiology, management, and
prognosis of FGR are reviewed separately.
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● (See "Fetal growth restriction: Evaluation and management".)

● (See "Infants with fetal (intrauterine) growth restriction".)
NORMAL FETAL GROWTH
Fetal growth reflects the interaction of the fetus's predetermined growth potential and its
modulation by the health of the fetus, placenta, and mother. Population-based
intergenerational studies of birth weight have concluded that genetic factors account for 30
to 50 percent of the variation in birth weight, with the remainder due to environmental
factors [2-5]. Maternal genes influence birth weight more than paternal genes, but both have
an effect.
Fetal growth velocity is defined as the rate of fetal growth over a given time interval. In terms
of individual biometric measurements, the rate of change in biparietal diameter (BPD), head
circumference (HC), femur length (FL), and abdominal circumference (AC) initially peaks at 13,
14, 15, and 16 weeks of gestation, respectively [6]. BPD, HC, and AC then have a second
acceleration in growth at 19 to 22, 19 to 21, and 27 to 31 weeks, respectively.
Estimated fetal weight growth velocity peaks at around 35 weeks. In general, normal growth
in singletons increases from approximately 5 g/day at 14 to 15 weeks of gestation to 10
g/day at 20 weeks and 30 to 35 g/day at 32 to 34 weeks, after which the daily increase in
weight decreases [7].
DEFINITION AND CLASSIFICATION OF FGR
Definition — The most common obstetric definition of FGR is an estimated weight below the
10th percentile for gestational age in the second half of pregnancy [8], although other
definitions employing a variety of criteria have been advocated (eg, <5th percentile, <3rd
percentile) [9,10]. An abdominal circumference (AC) <10th percentile for gestational age is
another common definition [11,12].
Accurate assessment of gestational age is critical to the diagnosis of FGR, given that normal
and abnormal fetal size are defined, in part, by comparing the fetal weight of the index fetus
with that of other fetuses of the same gestational age. A detailed discussion of
determination of gestational age can be found separately. (See "Prenatal assessment of
gestational age, date of delivery, and fetal weight".)
Limitations — The use of a percentile to define FGR is problematic because it does not

distinguish among fetuses who are constitutionally small versus small because of a
pathologic process that has kept them from achieving their genetic growth potential versus
not small but kept from achieving their genetic growth potential by a pathologic process. As
many as 70 percent of fetuses estimated to weigh below the 10th percentile for gestational
age are small simply due to constitutional factors (eg, maternal ethnicity, parity, or body
mass index) and are not at high risk of perinatal mortality and morbidity [13]. There is a real
possibility of misclassifying these normally nourished, healthy, but constitutionally small,
fetuses as growth restricted. By comparison, a malnourished fetus whose estimated weight
is slightly greater than the 10th percentile may be misclassified as appropriately grown and at
low risk of adverse perinatal outcome, even though its weight may be far below its genetic
potential. A similar argument can be made when the AC is <10th percentile for the gestational
age.
An additional problem is that use of percentiles requires an appropriate reference, but there
is little consensus on which reference should be used. Available references have been based
on birth weights across gestation in a low-risk population (standard reference curve) or in an
unselected population (population reference curve), on ultrasound-estimated fetal weights
(EFW) across gestation, and on a customized standard [14,15]. The major flaw of birth weight
reference standards is that infants who are born preterm are born early because of a
pathologic process that often results in growth restriction. Ultrasound-based standards avoid
this bias but are limited by the inaccuracy and imprecision of ultrasound-EFW.
Classification — Regardless of the FGR definition used, FGR may be classified as early or late
and as symmetric or asymmetric:
● Early FGR refers to diagnosis before 32 weeks of gestation, in the absence of

congenital anomalies.
● Late FGR refers to diagnosis at ≥32 weeks of gestation, in the absence of congenital
anomalies.
● Symmetric FGR comprises 20 to 30 percent of FGR and refers to a growth pattern in

which all fetal organs are decreased proportionally due to global impairment of cellular
hyperplasia early in gestation.
Symmetric FGR is thought to result from a pathologic process manifesting early in

gestation.
● Asymmetric FGR comprises the remaining 70 to 80 percent of the FGR population and
is characterized by a relatively greater decrease in abdominal size (eg, liver volume and
subcutaneous fat tissue) than in head circumference.
Asymmetric fetal growth is thought to result from the capacity of the fetus to adapt to a
pathologic environment late in gestation by redistributing blood flow in favor of vital
organs (eg, brain, heart, placenta) at the expense of nonvital fetal organs (eg,
abdominal viscera, lungs, skin, kidneys) [16,17].
Undoubtedly, some overlap exists between these two entities.
SCREENING
Rationale — Ideally, prenatal detection of FGR will provide an opportunity to employ

interventions to reduce the morbidity and mortality associated with this problem. Adverse
outcomes include fetal demise, preterm birth, perinatal asphyxia, poor thermoregulation,
hypoglycemia, polycythemia/hyperviscosity, impaired immune function, neonatal death,
neurodevelopmental delay, and some adult-onset disorders. (See "Fetal growth restriction:
Evaluation and management", section on 'Prognosis' and "Infants with fetal (intrauterine)
growth restriction".)
As discussed below, the ability of screening and appropriate intervention to reduce the
frequency of any of these outcomes has not been proven. Harms of screening include
overdiagnosis of FGR, leading to parental anxiety and unnecessary, costly, and/or potentially
harmful interventions (eg, antenatal fetal testing, induction of labor, iatrogenic preterm
delivery).
Screening tests
Symphysis-fundal height measurement with selective

ultrasonography — Measurement of the distance between the upper edge of the pubic
symphysis and the top of the uterine fundus using a tape measure is a simple, inexpensive,
and widespread technique performed during antenatal care to detect FGR, as well as other
disorders that result in size/date discrepancy. The first suspicion of FGR often arises when
this length is noted to be discordant with the expected size for dates. Discordancy has been
defined in various ways; the most common criterion is a fundal height in centimeters that is
at least 3 centimeters less than the gestational age in weeks (eg, fundal height 32 cm at 36
weeks of gestation) [18]. Alternatively, a fundal height measurement below the 3rd or 10th
percentile for gestational age can be used: The INTERGROWTH-21st Project International
published printable symphysis-fundal height measurement standards for the 3rd, 10th, 50th,
90th, and 97th percentiles using eight urban populations of healthy, well-nourished women
[19].
The performance of fundal height measurements for screening for FGR is controversial. A
systematic review concluded evidence was inadequate (one randomized trial) to evaluate the
effectiveness of this technique versus abdominal palpation for detecting abnormal fetal
growth [20]. Observational studies using symphysis pubis-fundal height measurements have
reported a wide range of sensitivities: 13 to 86 percent of small fetuses were detected [18,21-
28]. Factors that may affect sensitivity include maternal body mass index, bladder volume,
parity, and ethnic group [26,27,29,30].

This technique appears to perform best when all of the measurements are obtained by the
same clinician using the unmarked side of the tape (to reduce bias [31]) and plotted to reflect
fetal growth for the individual patient ("customized"), rather than against a standardized
norm [32,33].
Universal ultrasonography — Routine universal performance of ultrasound examination is

an alternative method of screening for FGR. There is no consensus on the timing or number
of screening examinations. In general, if two screening examinations are performed after the
18- to 22-week fetal anatomic survey, they are obtained at approximately 32 and 36 weeks of
gestation [34]. If one examination is obtained, it is obtained between 32 and 36 weeks of
gestation, and the predictive performance is higher nearer to 36 weeks [35].
Individualized growth assessment is an investigational screening approach that requires at

least three ultrasound examinations. It establishes sonographic standards for multiple
biometric parameters in a specific fetus during at least two time points in the second
trimester, when fetal growth is linear [36]. Third-trimester measurements are then compared
with those predicted by the second-trimester measurements for the specific fetus, not with a
population standard, thus using the fetus as its own control. The Individualized Growth
Assessment Program software is used to interpret the data. If a fetal growth disorder has
already occurred during the second trimester, the estimate of growth potential will be
compromised, but this can be detected by the software [37]. No data are available on the
clinical use of this tool to characterize abnormal growth and its relationship to physiologic
changes, perinatal complications, and long-term disabilities.
Our approach to screening — Our approach to screening for FGR is described in the

algorithm ( algorithm 1). This approach is generally consistent with pregnancy guidelines
from many countries, including the United Kingdom, Canada, France, and the United States,
which recommend screening for FGR using risk assessment for impaired fetal growth (
table 1) and serial fundal height measurements at each prenatal visit. In addition:
● For women at high risk for FGR, an ultrasound examination is performed to estimate
fetal weight and provide a detailed sonographic assessment of the fetus, placenta, and
amniotic fluid at least once or twice in the third trimester (and as often as every three to
four weeks), as well as when a lag in fundal height is detected. The frequency of
ultrasound examination within this range depends on the clinician’s assessment of the
patient’s level of risk for FGR. The information from ultrasound examination is used to
support or exclude the diagnosis of FGR.
● For women who are not at high risk for FGR, an ultrasound examination is performed
when a lag in fundal height is detected, the fundal height cannot be palpated (eg,
patient with obesity), or the fundal height is not reliable (eg, large or multiple fibroids)
[38,39].
Evidence — Universal ultrasonography in late pregnancy (after 24 weeks) is not generally

recommended because the test has low sensitivity and a clear outcome benefit has not been
proven:
● In a 2019 meta-analysis of 21 cohort studies of screening ultrasound at ≥32 weeks of

gestation in low-risk or nonselected singleton pregnancies, pooled sensitivities for
abdominal circumference (AC) and estimated fetal weight (EFW) <10th percentile for
birth weight <10th percentile were similar and poor (AC 35 percent, 95% CI 20-52; EFW
38 percent, 95% CI 31-46) [40]. Pooled specificity for AC was 97 percent (95% CI 95-98)
and for EFW was 95 percent (95% CI 93-97). Modeled sensitivities of AC and EFW <10th
percentile at a 10 percent false-positive rate were 78 and 54 percent, respectively.
Perinatal outcome was not assessed.
● In a previous meta-analysis of 13 controlled trials including nearly 35,000 women,

perinatal mortality was similar for patients undergoing routine versus
no/concealed/selective ultrasonography (risk ratio 1.01, 95% CI 0.67-1.54); none of the
trials reported on neurodevelopmental outcomes at age 2 [34]. The absence of benefit
may be due to the poor diagnostic performance of the screening test, lack of an
effective intervention when FGR is diagnosed, and deficiencies in study design. A
subsequent prospective study reported sensitivity for detection of small for gestational
age infants was higher with universal than with selective ultrasound screening, but this
did not lead to a significant reduction in composite severe adverse perinatal outcome
[41].
DIAGNOSIS
Sonographic estimation of either fetal weight <10th percentile for gestational age or
abdominal circumference (AC) <10th percentile for gestational age is the best finding on
which to base the diagnosis of FGR. A population-based fetal growth reference should be
used; we prefer the Hadlock formula to the INTERGROWTH-21st, the Eunice Kennedy Shriver
National Institute of Child Health and Human Development (NICHD), and the World Health
Organization (WHO) standards [42-44].
The following findings should also be considered to increase confidence in the diagnosis:
● The lower the percentile, the more likely the diagnosis is FGR rather than a
constitutionally small fetus. (See 'Estimated fetal weight' below.)
● Some findings on imaging, such as body proportion ratios (discussed below), can
support the diagnosis of asymmetric FGR but are likely to overlook fetuses with
symmetric FGR. As discussed above, asymmetric FGR occurs in 70 to 80 percent of the

FGR population, while symmetric FGR comprises the remaining 20 to 30 percent of

growth-restricted fetuses.
● Information from the maternal history ( table 1) and from a customized growth curve
and assessment of amniotic fluid volume may improve diagnostic performance by
helping to distinguish between the constitutionally small fetus, the growth-restricted
fetus, and the fetus that is not small but not achieving its growth potential. (See
'Customized growth curve' below and 'Amniotic fluid volume' below.)
● Findings on Doppler velocimetry of the umbilical artery are insensitive diagnostically

[45-47], but can still be useful as they are predictive of need for intervention and
outcome. Overall, it is reasonable to assume that a fetus <10th percentile with a normal
growth curve over three weeks, normal amniotic fluid volume, absence of risk factors
for FGR, and normal Doppler velocimetry is at low risk of the adverse outcomes related
to FGR, even if affected. By comparison, the fetus <10th percentile with a lagging growth
curve, oligohydramnios, and risk factors for FGR is probably affected and at high risk of
complications if Doppler velocimetry is abnormal. (See 'Doppler velocimetry' below.)
A meta-analysis comparing estimated fetal weight (EFW) versus AC for diagnosis of FGR
concluded that both have theoretical disadvantages and advantages [40]. AC may be more
susceptible to expected value bias because measurement can be technically challenging, but
it reflects liver size and abdominal subcutaneous fat storage and is strongly related to fetal
nutritional status. Because EFW combines multiple biometric measurements (AC, biparietal
diameter, head circumference, and femur length), it is susceptible to the inherent
measurement errors of each variable, thus potentially resulting in an overall worse predictive
performance. However, EFW is more consistent with the newborn standards used to define
small for gestational age since pediatricians do not typically measure AC. Based on these and
other data, the Society for Maternal-Fetal Medicine and the American College of
Obstetricians and Gynecologists consider either sonographic EFW or AC below the 10th
percentile for gestational age an acceptable threshold for suspecting FGR [12].
POTENTIAL SONOGRAPHIC FINDINGS IN FGR
A variety of sonographic parameters have been used to diagnose FGR. The technique for
measuring these parameters and calculating fetal weight can be found separately. (See
"Prenatal assessment of gestational age, date of delivery, and fetal weight", section on
'Sonographic assessment of fetal weight'.)
A major limitation in interpreting the predictive value of sonographic findings for diagnosing
FGR and comparing predictive values derived from different studies is that these values, like
all laboratory values, depend upon the prevalence of FGR in the population studied. Thus,

the post-test risk of FGR needs to take into account whether the study population was at low,
moderate, or high risk of a fetal growth abnormality [48-50].
Estimated fetal weight — Estimated fetal weight (EFW) is the most common method of
identifying the growth-restricted fetus since pediatricians use birth weight as their primary
variable for defining growth restriction in the infant. The sensitivity of EFW for predicting FGR
and adverse outcomes associated with FGR is highest when performed within one to two
weeks of delivery and when the infant's birth weight is <3rd percentile [51-55].
The sensitivity, specificity, positive, and negative predictive values of EFW for FGR <10th
percentile are approximately 90, 85, 80, and 90 percent, respectively [51-54]. By comparison,
in one study, all infants with birth weight <3rd percentile were identified prenatally [51]. In
another study including 1116 consecutive fetuses with EFW <10th percentile, all 8 mortalities
occurred among the 826 fetuses with EFW <3rd percentile, and EFW <3rd percentile was the
only sonographic weight-related definition consistently associated with adverse outcome
[56].
Reference tables — Examples of fetal weight distribution standards by gestational age in

the United States population are provided in the tables ( table 2 and table 3); several
such tables exist and are slightly different depending on the population studied and
methods used. Investigators involved in the Eunice Kennedy Shriver National Institute of
Child Health and Human Development (NICHD) fetal growth studies have published
comprehensive tables of the 5th, 10th, 50th, 90th, and 95th percentiles for EFW and individual
biometric parameters by race and ethnicity [6].
Worldwide standards have also been proposed:
● The Fetal Growth Longitudinal Study developed an international growth and size
standard by prospectively assessing fetal growth in over 4000 healthy, well-nourished
women in eight countries with well-dated pregnancies at low risk of FGR who had no
major pregnancy complications and delivered live, nonanomalous singletons [57].
Ultrasound examinations were obtained every 5 weeks from 14 to 42 weeks of
gestation, and biometric measurements were used to derive the best fitting curves for
the 3rd, 50th, and 97th percentiles. They also provide a calculator that will compare an
individual patient's biometric values with the international standard. Standards for
newborn birth weight were also developed ( table 4) [58].
● The World Health Organization has published charts for fetal growth and common
ultrasound biometric measurements based on longitudinal data derived from 10
countries [59].
The validity of a worldwide standard has been challenged by the argument that adopting a
universal standard for fetal growth "may lead to over diagnosing of both large- and small-for-
gestational-age fetuses in terms of what is appropriate for a particular population, with a

corresponding detrimental impact on clinical care" [60].
Customized growth curve — EFW is typically interpreted using population-based birth

weight centiles, such as those provided above for the United States ( table 2 and table 3
); however, fetal weight is affected by multiple nonpathologic factors, including fetal sex and
maternal parity, ethnicity, height, weight, and age [61-64]. Maternal characteristics have
greater fetal effects than paternal characteristics.
A potentially better approach to interpretation of EFW is to utilize large population-based

datasets that account for these variables and exclude the effects of pathologic variables such
as maternal smoking, hypertension, diabetes, and preterm birth. This allows interpretation
of EFW in the context of the individual fetus's growth potential, rather than against a
population-based birth weight distribution. The optimal weight and range of normal around
this weight for a specific fetus can be estimated for each gestational age to create an
ultrasound-based, customized, optimal growth curve. The actual EFW is then plotted on this
optimized, customized curve to create the individual fetus's growth curve across gestation.
Free software for calculating customized fetal weight percentiles can be downloaded from
www.gestation.net.
Although no randomized trials of this approach have been performed [65], several studies
have compared the use of population-based birth weight centiles with customized
percentiles for prediction of growth restriction and perinatal morbidity. Although many of
these studies have concluded that using a customized birth weight standard improves the
identification of fetuses at risk of perinatal death and neonatal morbidity [66-75], others have
not, and this conclusion remains controversial [10,42,76-78].
The reported improvement in prediction of perinatal outcome with use of customized growth
curves may be related to better identification of the constitutionally small fetus through
adjustment for maternal characteristics, or to use of an intrauterine (ultrasound) growth
standard rather than a birth weight standard for classification of FGR. Since fetuses who are
born preterm tend to have lower birth weights than fetuses of the same gestational age who
remain in utero, using an intrauterine weight standard increases identification of FGR remote
from term [79]. The higher perinatal mortality among infants classified as FGR by the
customized reference is largely due to the inclusion of more preterm births in this group
[71,80,81]. When adjusted for preterm birth, the use of customized fetal growth curves
rather than population-based growth curves does not clearly improve identification of
pregnancies at increased risk of neonatal morbidity and mortality [81].
Biometry

Abdominal circumference — When fetal growth is compromised, the fetal abdominal

circumference (AC) is smaller than expected because of depletion of abdominal adipose
tissue and a reduction in hepatic size from depletion of glycogen. Most studies report that
reduced AC is the most sensitive single biometric indicator of FGR [82-87]. Small AC also
correlates with morbidity associated with FGR: biochemical markers of hypoxia and acidemia
are more common when the AC is below the 5th percentile for gestational age [88].
● In a study of over 3600 pregnancies >25 weeks of gestation that had a single
ultrasound examination performed within two weeks of delivery, AC measurement
predicted a birth weight <10th percentile for gestational age with sensitivity, specificity,
positive, and negative predictive values of 61, 95, 86, and 83 percent, respectively [86].
Measurement of AC was more predictive of FGR than measurement of either head
circumference (HC) or biparietal diameter (BPD) or the combination of AC with either
one of these two variables.
AC is most sensitive for detection of FGR when it is asymmetric (sensitivity in asymmetric and
symmetric FGR: 73 and 59 percent, respectively [48]) and when measured near term
(sensitivity at 29 to 31 weeks and at term: 41 and 88 percent, respectively [89]), although the
above study concluded that the optimal time to screen for FGR with AC was at approximately
34 weeks of gestation [86].
Biometric ratios — The HC/AC and femur length (FL)/AC ratios have been used to identify
FGR and are most sensitive in asymmetric FGR. Since FGR related to uteroplacental
insufficiency is often asymmetric, biometric ratios are generally better for predicting FGR
related to uteroplacental insufficiency than for FGR from other etiologies, when FGR is often
symmetric.
HC/AC ratio — In asymmetric FGR, the size of the liver tends to be disproportionately
small compared with the HC and length of the femur, which are initially spared from the
effects of nutritional deficiency [90].
The HC/AC ratio decreases linearly throughout pregnancy; a ratio >2 standard deviations (SD)
above the mean for gestational age is considered abnormal. One prospective study of the
HC/AC ratio for detecting asymmetric FGR due to uteroplacental insufficiency reported
normal ratios in 79 percent of fetuses, none of whom were FGR at birth; the remaining 21
percent had abnormal ratios and were diagnosed correctly as FGR [91]. By contrast, the
sensitivity, specificity, positive, and negative predictive values of an abnormal HC/AC in a
population with FGR of mixed etiologies were 36, 90, 67, and 72 percent, respectively [52].
Not all fetuses with an elevated HC/AC ratio have asymmetric FGR. Macrocephaly from an
increase in the size of any of the components of the cranium (brain, cerebrospinal fluid,
blood, or bone) or increased intracranial pressure could also be associated with an increased
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HC/AC ratio and should be excluded. (See "Macrocephaly in infants and children: Etiology and
evaluation".)
FL/AC ratio — The FL/AC ratio uses biometric parameters that relate to both weight
and length in the prediction of FGR and is independent of gestational age in normally grown
fetuses in the last half of pregnancy. An FL/AC ratio >23.5 percent has been reported to have
sensitivity of 56 to 64 percent and specificity of 74 to 90 percent for identification of
asymmetric FGR [92,93] but does not detect symmetric FGR. The sensitivity, specificity,
positive, and negative predictive values of the 90th percentile of FL/AC ratio in a mixed
population of FGR fetuses were 30, 91, 14, and 96 percent, respectively [94-96].
Amniotic fluid volume — Oligohydramnios is one of the sequelae of FGR. The proposed

mechanism is diminished fetal urination due to hypoxia-induced redistribution of blood flow
to vital organs at the expense of less vital organs, such as the kidney [97,98]. (See
"Oligohydramnios: Etiology, diagnosis, and management".)
In general, pregnancies with the most severe oligohydramnios have the highest perinatal
mortality rate, incidence of congenital anomalies (especially of the urinary tract), and
incidence of FGR [99]. Oligohydramnios combined with EFW <3rd percentile is highly
predictive of adverse outcome [56].
Oligohydramnios is difficult to assess accurately (ie, as determined by dye-dilution studies)

and commonly occurs with complications of pregnancy other than FGR. In addition, a
significant proportion (approximately 15 to 80 percent) of fetuses with FGR do not have
decreased amniotic fluid volume. Although generally an insensitive marker for FGR [100,101],
if oligohydramnios is present in the absence of ruptured membranes, congenital
genitourinary anomalies, or prolonged pregnancy, FGR is the most likely etiology.
Doppler velocimetry — FGR may be associated with abnormal Doppler wave forms in

maternal vessels (uterine arteries) and fetal vessels (umbilical arteries, middle cerebral
arteries, ductus venosus) when the etiology is placental dysfunction related to progressive
obliteration of the villus vasculature. Assessment of Doppler flow with appropriate
intervention can reduce perinatal mortality in these pregnancies. Doppler findings in FGR
and management of FGR based on these findings are reviewed in detail separately and
briefly summarized below. (See "Fetal growth restriction: Evaluation and management",
section on 'Doppler velocimetry'.)
● Umbilical artery – When 30 percent of the villous vasculature ceases to function, an

increase in umbilical artery resistance leading to reduced end-diastolic flow is
consistently seen and is a weak predictor of adverse outcome in FGR. When 60 to 70
percent of the villous vasculature is obliterated, umbilical artery diastolic flow is absent
or reversed, and fetal prognosis is poor. Reversed diastolic flow is associated with

poorer neonatal outcomes than absent diastolic flow. (See "Fetal growth restriction:
Evaluation and management", section on 'Umbilical artery'.)
● Uterine artery – The systolic/diastolic (S/D) ratio of the uterine artery in normal
pregnancies should be <2.7 after the 26th week of gestation. If the end-diastolic flow
does not increase throughout pregnancy or a small uterine artery notch is detected at
the end of systole, the fetus is at high risk for developing FGR [102]. Diastolic blood flow
may be absent or even reversed with extreme degrees of placental dysfunction. Such
findings are ominous and may precede fetal death or signal a high risk of abnormal
fetal neurologic outcome [103].
● Fetal descending aorta – An elevated pulsatility index in the fetal descending aorta is
associated with both FGR and adverse outcomes, such as severe FGR, necrotizing
enterocolitis, nonreassuring fetal heart rate patterns, and perinatal mortality [104-112].
In one group of 30 fetuses with absent end-diastolic flow in the descending aorta,
abnormal wave forms were detected at a mean of 80 days prior to the onset of fetal
heart rate (FHR) abnormalities [108]. All of the neonates were growth restricted, and 66
percent had abnormal placentas with villous fibrosis and microfibrinous deposits.
The sensitivity and specificity of absent end-diastolic flow in the descending aorta for
prediction of FGR with FHR abnormalities are approximately 85 and 80 percent,
respectively [110-112]. These pregnancies are also characterized by higher rates of
cesarean delivery, right ventricular failure, and perinatal mortality.
● Fetal middle cerebral artery – In the normally developing fetus, the brain is an area of
low vascular impedance and the recipient of continuous forward flow throughout the
cardiac cycle. Asymmetric FGR is likely caused by redistribution of fetal blood flow to the
fetal brain at the expense of less essential areas, such as subcutaneous tissue, kidneys,
and liver. Since the already low middle cerebral resistance has to drop even further to
enhance cerebral blood flow, FGR may be associated with increased end-diastolic
velocities and decreased S/D ratios in the middle cerebral arteries. (See "Fetal growth
restriction: Evaluation and management", section on 'Middle cerebral artery'.)
● Cerebroplacental ratio – The cerebroplacental Doppler ratio (CPR) is the middle

cerebral artery pulsatility index (or resistance index) divided by the umbilical artery
pulsatility index (or resistance index). A low CPR indicates fetal blood flow redistribution
(brain sparing) and is predictive of adverse neonatal outcome. (See "Fetal growth
restriction: Evaluation and management", section on 'Cerebroplacental ratio'.)
● Fetal venous Doppler – Venous Doppler abnormalities are late, ominous circulatory
findings in FGR. (See "Fetal growth restriction: Evaluation and management", section on
'Ductus venosus'.)

Other
Three-dimensional ultrasonography — Three-dimensional ultrasound appears to be

highly promising in the clinical setting of FGR because it appears to provide more precise
information regarding structural abnormality, organ volumetry, EFW, and oligohydramnios
than standard two-dimensional techniques [113-123]. However, this modality is not widely
available and has not been adequately assessed in large or controlled studies.
One study used this technique in 100 fetuses to compare birth weight predicted by
calculating thigh volume with birth weight predicted by two-dimensional ultrasound using
BPD, AC, and FL [119]. All infants were delivered within 48 hours of ultrasound examination.
The best-fit formula for thigh volume in the prediction of birth weight was linear and was
superior to commonly used two-dimensional formulas. The errors in birth weight prediction
by three-dimensional ultrasound, Warsof's formula, Hadlock's formula, and Thurnau's
formula were 0.7, 6.2, 6.7, and 20.8 percent respectively. In addition, three-dimensional
ultrasound thigh volumetry was not influenced by oligohydramnios, fetal head engagement,
or inaccurate AC measurement.
These results were confirmed in other studies that found three-dimensional thigh, femur, or
humerus volume measurement was simple and more accurate than two-dimensional
ultrasound methods in the prediction of fetal weight [120-123].
Soft tissue — FGR results in a decrease in both adipose tissue and muscle mass. Although
measurement of fetal soft tissue is probably predictive of FGR, there are inadequate data for
defining the best site for measurement or the sensitivity and specificity of soft tissue
parameters.
Measurement of the fetal thigh circumference incorporates the contributions of both

adipose and muscle. In one study, a thigh circumference measuring 2 SD below the mean
had a sensitivity of 78 percent and a positive predictive value of 85 percent in the prediction
of FGR [124].
Other potential soft tissue measurements include subcutaneous tissue thickness at the level
of the fetal midcalf, midthigh, or abdominal wall, and cheek-to-cheek diameter [125,126]. A
prospective study of 137 unselected pregnancies that underwent serial sonographic
measurement of fetal subcutaneous abdominal fat found fetuses with subcutaneous fat <5
mm at 38 weeks of gestation were approximately fivefold more likely to be FGR [127]. The
sensitivity and specificity for diagnosis of FGR were 76 and 67 percent, respectively. In
addition, the frequency of neonatal morbidity (eg, meconium aspiration, hypoglycemia,
hypothermia, poor feeding, and jaundice) was significantly higher in infants with adipose
tissue depletion.

SPECIAL POPULATIONS
Suboptimally dated pregnancies — Biometric findings used to diagnose FGR are

interpreted in the context of gestational age. When the gestational age is not known with
reasonable certainty, a single ultrasound examination may not be able to distinguish a small
for gestational age fetus from an appropriately grown fetus that is less far along in gestation
than expected from menstrual dates.
Serial sonographic examinations at two-week intervals can be useful when pregnancy dating
is suboptimal. Irrespective of gestational age, FGR is associated with a significantly smaller
rate of change over time in estimated fetal weight and other biometric parameters than
observed in fetuses who are appropriate for gestational age [101,128,129]. The presence of
risk factors for FGR, oligohydramnios, and abnormal Doppler velocimetry support the
diagnosis of FGR, whereas the absence of these findings suggests that the fetus is at the
gestational age calculated from biometry.
Multiple gestation — Growth in multiple gestations diverges from that in singletons in the

late second or early third trimester. Smallness of one or both fetuses of a multiple gestation
can be related to any of the disorders that cause FGR in singleton pregnancies, as well as
disorders unique to multiple gestations, such as unequal placental sharing or twin-twin
transfusion. FGR in multiple gestations is reviewed separately. (See "Selective fetal growth
restriction in monochorionic twin pregnancies" and "Twin pregnancy: Routine prenatal care",
section on 'Screening for fetal growth restriction and discordance'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Fetal growth
restriction".)
SUMMARY AND RECOMMENDATIONS
● The two most common definitions of suspected fetal growth restriction (FGR) are an
estimated fetal weight below the 10th percentile for gestational age and an abdominal
circumference below the 10th percentile for gestational age. The use of the 10th
percentile to define FGR is problematic because it does not distinguish among fetuses
who are constitutionally small versus small because of a pathologic process that has
kept them from achieving their growth potential versus not small but kept from
achieving their growth potential by a pathologic process. However, the lower the

percentile, the more likely the diagnosis of FGR rather than a constitutionally small
fetus. (See 'Definition and classification of FGR' above and 'Diagnosis' above.)
● Symmetric FGR comprises 20 to 30 percent of FGR and refers to a growth pattern in

which all fetal organs are decreased proportionally. Asymmetric FGR comprises the
remaining 70 to 80 percent of the FGR population and is characterized by a relatively
greater decrease in abdominal size than head circumference. (See 'Definition and
classification of FGR' above.)
● Ideally, prenatal detection of FGR will provide an opportunity to employ interventions to

reduce the morbidity and mortality associated with this problem; however, the benefit
of screening for FGR has not been clearly established. (See 'Rationale' above.)
● We agree with pregnancy guidelines from many countries, including the United
Kingdom, Canada, France, and the United States, which recommend risk assessment
for impaired fetal growth ( table 1) and serial fundal height measurements at each
prenatal visit ( algorithm 1).
In women at high risk for FGR, detailed sonographic assessment of the fetus, placenta,
and amniotic fluid is performed once or twice in the third trimester and when a lag in
fundal height is detected. In the general/low-risk obstetric population, ultrasound
examination is recommended only when a lag in fundal height is detected. (See 'Our
approach to screening' above and 'Screening tests' above.)
● Information from the maternal history ( table 1) and from a customized growth curve
and assessment of amniotic fluid volume may improve diagnostic performance by
helping to distinguish between the constitutionally small fetus, the growth-restricted
fetus, and the fetus that is not small but not achieving its growth potential (see
'Customized growth curve' above and 'Amniotic fluid volume' above). Findings on
Doppler velocimetry of the umbilical artery are insensitive diagnostically but predictive
of outcome (see 'Doppler velocimetry' above). Overall, it is reasonable to assume that a
small fetus with a normal growth curve over three weeks, normal amniotic fluid volume,
and normal Doppler velocimetry is at low risk of FGR and complications associated with
FGR, especially in the absence of risk factors for FGR, whereas the small fetus with a
lagging growth curve, oligohydramnios, and maternal risk factors for FGR is probably
affected and at high risk of complications if Doppler velocimetry is abnormal. (See
'Diagnosis' above.)
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ultrasonographic assessment of fetal growth. Am J Obstet Gynecol 1991; 165:846.
126. Hill LM, Guzick D, Boyles D, et al. Subcutaneous tissue thickness cannot be used to
distinguish abnormalities of fetal growth. Obstet Gynecol 1992; 80:268.
127. Gardeil F, Greene R, Stuart B, Turner MJ. Subcutaneous fat in the fetal abdomen as a
predictor of growth restriction. Obstet Gynecol 1999; 94:209.
128. de Jong CL, Francis A, van Geijn HP, Gardosi J. Fetal growth rate and adverse perinatal
events. Ultrasound Obstet Gynecol 1999; 13:86.
129. Deter RL, Lee W, Kingdom JCP, Romero R. Fetal growth pathology score: a novel
ultrasound parameter for individualized assessment of third trimester growth
abnormalities. J Matern Fetal Neonatal Med 2018; 31:866.
Topic 6752 Version 55.0

GRAPHICS
Approach to screening for fetal growth restriction in singleton pregnancies

in the third trimester
FGR: fetal growth restriction; EFW: estimated fetal weight; AC: abdominal circumference; NST:
nonstress test; AFV: amniotic fluid volume; BPP: biophysical profile.
* To assess FGR risk, refer to UpToDate content on causes and risk factors for FGR. Patients with
multiple gestations or large or multiple leiomyomas and some patients with obesity are not
appropriate candidates for measurement of the symphysis to top of the fundus distance alone
because it does not correlate well with fetal size in these settings.
¶ The most common criterion for discordancy is a fundal height in centimeters that is at least 3
centimeters less than the gestational age in weeks. Alternatively, a fundal height measurement
below the 10th percentile for gestational age can be used: The INTERGROWTH-21st Project
International published printable symphysis-fundal height measurement standards for the 3rd,
10th, 50th, 90th, and 97th percentiles.
Δ EFW or AC <10th percentile or oligohydramnios.
◊ The frequency of monitoring and use of additional types of monitoring (eg, ductus venosus) need
to be individualized. The timing of delivery is based on a combination of factors, including
gestational age, umbilical artery Doppler findings, BPP score, ductus venosus Doppler, and the
presence or absence of risk factors for, or signs of, uteroplacental insufficiency. The goal is to
maximize fetal maturity and growth while minimizing the risks of fetal or neonatal mortality and
short-term and long-term morbidity. Refer to UpToDate content on evaluation and management of
FGR.
Graphic 131353 Version 1.0

Causes of and risk factors for fetal growth restriction
Causes of and risk

Comments
factors for FGR
Fetal genetic abnormalities Account for 5 to 20% of FGR. Genetic abnormalities include: aneuploidy
(including triploidy), uniparental disomy, single gene mutations (eg,
IGF1, IGF2, IGF1R), partial deletions or duplications, ring chromosome,
and aberrant genomic imprinting. At least 50 percent of fetuses with
trisomy 13 or 18 are restricted. The finding of symmetric FGR prior to
20 weeks of gestation suggests aneuploidy as the cause, most
commonly trisomy 18. Syndromes to consider include Russell-Silver,
which is characterized by asymmetric growth impairment (normal
head size circumference); Smith-Lemli-Opitz, which is characterized by
asymmetric growth impairment (small head circumference) and
multiple extracranial anomalies; and Prader-Willi, which is characterized
by asymmetric growth impairment (small head circumference),
polyhydramnios, genital abnormalities, and decreased fetal movement.
Fetal infection Accounts for 5 to 10% of FGR. Cytomegalovirus and toxoplasmosis are
the most common infectious etiologies of FGR in developed countries.
Other viruses and parasites that may cause FGR include rubella,
varicella-zoster, malaria, syphilis, and herpes simplex. Malaria is a
common infectious cause of FGR where the infection is endemic.
Fetal structural anomaly Fetuses with congenital anomalies can have impaired growth, which is
often related to coexistent cytogenetic disorders. The frequency of FGR
is related to both the type and number of anomalies.
Multiple gestation Fetal growth in multiple gestations is directly related to the number of
fetuses. The lower weight of fetuses from multiple gestations is
thought to be due to an inability of the environment to meet the
nutritional needs of multiple fetuses and to pregnancy complications
more common in multiple gestations (eg, preeclampsia, twin-twin
transfusion). Placental and umbilical cord anomalies potentially
associated with underperfusion are also more common in multiple
gestations (eg, velamentous cord insertion). Loss of one fetus of a twin
gestation increases the risk for FGR in the surviving twin.
CPM CPM refers to chromosomal mosaicism in the placenta but not in the
fetus. It usually involves a trisomy and is strongly associated with FGR.
CPM has been identified after birth in approximately 10% of otherwise
idiopathic FGR and in one-third of FGR associated with placental
infarction and decidual vasculopathy. By comparison, the rate of CPM in
placentas of women undergoing chorionic villus sampling is
approximately 1%.
The severity of FGR associated with CPM depends upon the

chromosomes involved, the proportion of mosaic cells, and the
presence of uniparental disomy.
Ischemic placental disease Ischemic placental disease can manifest clinically as FGR, preeclampsia,

placental abruption, stillbirth, growth restriction, or a combination of

these disorders, and is often recurrent.
Gross cord and placental Gross cord and placental structural anomalies possibly associated with
abnormalities FGR include single umbilical artery, velamentous umbilical cord
insertion, marginal cord insertion, bilobate placenta, circumvallate
placenta, and placental hemangioma. If an association between these
entities and FGR exists, it is at most weak.
Placental mesenchymal dysplasia is a rare placental abnormality characterized by

placentomegaly and grape-like vesicles resembling a partial mole. The euploid
fetus is at increased risk for intrauterine growth restriction, perinatal death, and
Beckwith-Wiedemann syndrome.
Maternal genetic factors In epidemiologic studies, women who were growth-restricted at birth
have a twofold increase in risk of FGR in their offspring. In addition,
women who give birth to a growth-restricted fetus are at high risk of
recurrence, and the risk increases with increasing numbers of FGR
deliveries.
Maternal medical and Maternal conditions that can be associated with diminished utero-
obstetric conditions placental-fetal blood flow and/or oxygen delivery have been associated
with FGR. These conditions include, but are not limited to:
Preeclampsia
Placental abruption
Chronic hypertension
Chronic kidney disease
Pregestational diabetes mellitus
Systemic lupus erythematosus and antiphospholipid syndrome
Cyanotic heart disease
Chronic pulmonary disease
Severe chronic anemia
Sickle cell disease
Uterine malformations
Misuse of alcohol, cigarettes, and/or drugs (eg, heroin, cocaine)
Prepregnancy radiation therapy to the pelvis
Heavy first trimester antepartum bleeding
Previous small for gestational age newborn
Previous stillbirth (unless placental insufficiency was excluded)
Teratogens and other Exposures to various teratogens, including medications such as

environmental factors warfarin, anticonvulsants (eg, valproic acid), antineoplastic agents, and
folic acid antagonists, can cause FGR with specific dysmorphic
features. Exposure to alcohol, tobacco, marijuana, and air pollution can
also impair fetal growth. Exposure to therapeutic, but not diagnostic,
doses of radiation can cause permanent restriction of growth.
Assisted reproductive Singleton pregnancies conceived via assisted reproductive technologies

technologies have a higher prevalence of small for gestational age infants compared
with naturally conceived pregnancies.

Low prepregnancy weight, Maternal weight at birth, prepregnancy weight, and gestational weight
poor gestational weight gain can affect the risk of FGR as these factors are responsible for
gain, malabsorption, poor approximately 10% of the variance in fetal weight. Macro- and
nutritional status micronutrients in the maternal diet also appear to play a role.
Residing at high altitude A direct relationship between increasing altitude and lower birth weight
has been demonstrated in studies performed in Denver and Leadville,
Colorado (altitude 1600 and 3100 m, respectively), Tibet (altitude 3658
m), and Peru. Birth weight data from 15 areas in Peru located between
sea level and 4575 m showed birth weight declined an average of 65 g
for every additional 500 m in altitude above 2000 m.
Short interpregnancy
interval
Extremes of maternal age
Abnormal maternal Examples include: Low pregnancy-associated plasma protein A (PAPP-

biochemical markers for A), low beta-human chorionic gonadotropin (hCG), high alpha-
Down syndrome screening fetoprotein (AFP)
Discrepancy between crown-

rump length measurements
and accurate menstrual
history by 2 to 6 days
FGR: fetal growth restriction; CPM: confined placental mosaicism.

Birth weight percentiles by gestational age based on 2011 United States

National Center for Health Statistics data
Week of 5th 10th 50th 90th 95th

gestation percentile percentile percentile percentile percentile
24 539 567 680 850 988
25 540 584 765 938 997
26 580 637 872 1080 1180
27 650 719 997 1260 1467
28 740 822 1138 1462 1787
29 841 939 1290 1672 2070
30 952 1068 1455 1883 2294
31 1080 1214 1635 2101 2483
32 1232 1380 1833 2331 2664
33 1414 1573 2053 2579 2861
34 1632 1793 2296 2846 3093
35 1871 2030 2549 3119 3345
36 2117 2270 2797 3380 3594
37 2353 2500 3025 3612 3818
38 2564 2706 3219 3799 3995
39 2737 2877 3374 3941 4125
40 2863 3005 3499 4057 4232
41 2934 3082 3600 4167 4340
42 2941 3099 3686 4290 4474
Table constructed using United States National Center for Health Statistics data from 2011 for live
born singleton neonates between 500 and 6000 grams without malformations. Gestational age was
based on the obstetric estimate of gestational age included in the revised 2003 United States birth
certificate, which, when available, incorporates ultrasound dating information.
From: Duryea EL, Hawkins JS, McIntire DD, et al. A revised birth weight reference for the United States. Obstet Gynecol 2014;
124:16. DOI: 10.1097/AOG.0000000000000345. Copyright © 2014 American College of Obstetricians and Gynecologists.
Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.

Tenth percentile of birth weight (g) for gestational age by gender: United
States, 1991, single live births to resident mothers
Gestational age, weeks Male Female

20 270 256
21 328 310
22 388 368
23 446 426
24 504 480
25 570 535
26 644 592
27 728 662
28 828 760
29 956 889
30 1117 1047
31 1308 1234
32 1521 1447
33 1751 1675
34 1985 1901
35 2205 2109
36 2407 2300
37 2596 2484
38 2769 2657
39 2908 2796
40 2986 2872
41 3007 2891
42 2998 2884
43 2977 2868
44 2963 2853
Reprinted with permission from the American College of Obstetricians and Gynecologists (Obstetrics and Gynecology, 1996;
87:163).

International birth weight centiles
Boys Girls
Number of Centiles for birth weight (kg) Number of Centiles fo

observations 3rd 10th 50th 90th 97th observations 3rd 10th
33 34 1.18 1.43 1.95 2.52 2.82 33 17 1.20 1.41

weeks weeks
34 48 1.45 1.71 2.22 2.79 3.08 34 65 1.47 1.68

weeks weeks
35 128 1.70 1.95 2.47 3.03 3.32 35 114 1.71 1.92

weeks weeks
36 323 1.93 2.18 2.69 3.25 3.54 36 293 1.92 2.14

weeks weeks
37 857 2.13 2.38 2.89 3.45 3.74 37 803 2.11 2.33

weeks weeks
38 2045 2.32 2.57 3.07 3.63 3.92 38 1802 2.28 2.50

weeks weeks
39 3009 2.49 2.73 3.24 3.79 4.08 39 2869 2.42 2.65

weeks weeks
40 2568 2.63 2.88 3.38 3.94 4.22 40 2523 2.55 2.78

weeks weeks
41 1179 2.76 3.01 3.51 4.06 4.35 41 1195 2.65 2.89

weeks weeks
42 206 2.88 3.12 3.62 4.17 4.46 42 224 2.74 2.98

weeks weeks
Total 10397 .. .. .. .. .. Total 9905 .. ..
International standards for newborn weight by gestational age and sex from the Newborn Cross-
Sectional Study of the INTERGROWTH-21st Project. Table shows smoothed centiles for birth weight of
boys and girls according to exact gestational age.
kg: kilogram.
Reproduced from: Villar J, Cheikh Ismail L, Victoria CG, et al. International standards for newborn weight, length, and head
circumference by gestational age and sex: the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project. Lancet 2014;
384:857. Table used with the permission of Elsevier Inc. All rights reserved.

Contributor Disclosures
Michael Y Divon, MD No relevant financial relationship(s) with ineligible companies to
disclose. Deborah Levine, MD No relevant financial relationship(s) with ineligible companies to
disclose. Vanessa A Barss, MD, FACOG No relevant financial relationship(s) with ineligible companies
to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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11/26/21, 3:15 PM Fetal growth restriction: Screening and diagnosis - UpToDate

Official reprint from UpToDate®

Fetal growth restriction: Screening and diagnosis

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● (See "Fetal growth restriction: Evaluation and management".)

NORMAL FETAL GROWTH

DEFINITION AND CLASSIFICATION OF FGR

Limitations — The use of a percentile to define FGR is problematic because it does not

● Early FGR refers to diagnosis before 32 weeks of gestation, in the absence of

● Symmetric FGR comprises 20 to 30 percent of FGR and refers to a growth pattern in

Symmetric FGR is thought to result from a pathologic process manifesting early in

Undoubtedly, some overlap exists between these two entities.

Rationale — Ideally, prenatal detection of FGR will provide an opportunity to employ

Symphysis-fundal height measurement with selective

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Universal ultrasonography — Routine universal performance of ultrasound examination is

Individualized growth assessment is an investigational screening approach that requires at

Our approach to screening — Our approach to screening for FGR is described in the

Evidence — Universal ultrasonography in late pregnancy (after 24 weeks) is not generally

● In a 2019 meta-analysis of 21 cohort studies of screening ultrasound at ≥32 weeks of

● In a previous meta-analysis of 13 controlled trials including nearly 35,000 women,

https://www.uptodate.com/contents/fetal-growth-restriction-screening-and-diagnosis/print?search=fetal growth restriction&source=search_result&selectedTitle… 6/32

FGR population, while symmetric FGR comprises the remaining 20 to 30 percent of

● Findings on Doppler velocimetry of the umbilical artery are insensitive diagnostically

POTENTIAL SONOGRAPHIC FINDINGS IN FGR

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Reference tables — Examples of fetal weight distribution standards by gestational age in

Worldwide standards have also been proposed:

gestational-age fetuses in terms of what is appropriate for a particular population, with a

Customized growth curve — EFW is typically interpreted using population-based birth

A potentially better approach to interpretation of EFW is to utilize large population-based

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Abdominal circumference — When fetal growth is compromised, the fetal abdominal

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Amniotic fluid volume — Oligohydramnios is one of the sequelae of FGR. The proposed

Oligohydramnios is difficult to assess accurately (ie, as determined by dye-dilution studies)

Doppler velocimetry — FGR may be associated with abnormal Doppler wave forms in

● Umbilical artery – When 30 percent of the villous vasculature ceases to function, an

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● Cerebroplacental ratio – The cerebroplacental Doppler ratio (CPR) is the middle

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Three-dimensional ultrasonography — Three-dimensional ultrasound appears to be

Measurement of the fetal thigh circumference incorporates the contributions of both

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Suboptimally dated pregnancies — Biometric findings used to diagnose FGR are

Multiple gestation — Growth in multiple gestations diverges from that in singletons in the

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

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● Symmetric FGR comprises 20 to 30 percent of FGR and refers to a growth pattern in

● Ideally, prenatal detection of FGR will provide an opportunity to employ interventions to

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11. Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org,

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39. Committee on Practice Bulletins—Obstetrics and the American Institute of Ultrasound in

40. Caradeux J, Martinez-Portilla RJ, Peguero A, et al. Diagnostic performance of third-

Obstet Gynecol 2012; 206:300.

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