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Diagnosis and Management of Fetal Growth Restriction

By Jacqueline E. A. K. Bamfo and Anthony O. Odibo


Fetal growth restriction (FGR) remains a leading contributor to perinatal mortality and morbidity and metabolic syndrome in later life. Recent advances in ultrasound and Doppler have elucidated several mechanisms in the evolution of the disease. However, consistent classification and characterization regarding the severity of FGR is lacking. There is no cure, and management is reliant on a structured antenatal surveillance program with timely intervention. Hitherto, the time to deliver is an enigma. In this paper, the challenges in the diagnosis and management of FGR are discussed. The biophysical profile, Doppler, biochemical and molecular technologies that may refine management are reviewed. Finally, a model pathway for the clinical management of pregnancies complicated by FGR is presented

Topics: Review Article
Publisher: Hindawi Publishing Corporation
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Provided by: PubMed Central

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  1. (1987). A .M .V i n t z i l e o s
  2. (1992). A comparison between computerised (mean range) and clinical visual cardiotocographic assessment,”
  3. (2002). A computer system for the numerical analysis of nonstress tests,”
  4. (2001). A critical appraisal of the use of umbilical artery Doppler ultrasound in high-risk pregnancies: use of meta-analyses in evidence-based obstetrics,”
  5. (1975). A critical evaluation of sonar ”crown-rump length” measurements,”
  6. (1983). a m p b e l l ,J .D i a zR e c a s e n s ,a n dD .R .G r i ffen, “New Doppler technique for assessing uteroplacental blood flow,”
  7. A prospective multi-institutional study of antepartum fetal heart rate monitoring. I. Risk of perinatal mortality and morbidity according to antepartum fetal heart rate test results,”
  8. (2003). A randomised trial of timed delivery for the compromised preterm fetus: short term outcomes and bayesian interpretation,”
  9. (2001). Abnormal fetal cerebral and umbilical doppler measurements in fetuses with intrauterine growth restriction predicts the severity of perinatal morbidity,”
  10. (2003). Accuracy of ultrasound dating formulae in the late second-trimester in pregnancies conceived with in-vitro fertilization,”
  11. (1993). Alpha-fetoprotein: a biomarker for pregnancy outcome,”
  12. (1992). Amniotic fluid volume assessment: comparison of ultrasonographic estimates versus direct measurements with a dye-dilution technique in human pregnancy,”
  13. An evaluation of two equations for predicting fetal weight by ultrasound,”
  14. (2004). Applications of proteomic methodologies to human pregnancy research: a growing gestation approaching delivery?”
  15. (1995). Are babies of normal birth weight who fail to reach their growth potential as diagnosed by ultrasound at increased risk?”
  16. (2000). athology of the Human Placenta,
  17. (2007). Bilardo et al., “Predictors of neonatal outcome in early-onset placental dysfunction,”
  18. (2000). Biophysical profile for fetal assessment in high risk pregnancies,” Cochrane Database
  19. (1999). Birth weight in relation to morbidity and mortality among newborn infants,” The New England
  20. (2000). Cardiotocography for antepartum fetal assessment,”
  21. (2008). Cerebral palsy and restricted growth status at birth: population-based case-control study,”
  22. (2005). Cerebroplacental Doppler ratio and adverse perinatal outcomes in intrauterine growth restriction: evaluating the impact of using gestational age-specific reference values,”
  23. (1990). Chronic renal disease and pregnancy outcome,”AmericanJournalofObstetricsandGynecology,vol.
  24. (1992). Color Doppler imaging of the uterine artery in pregnancy: normal ranges of impedance to blood flow, mean velocity and volume of flow,” ltrasound
  25. (2010). Combining biochemical and ultrasonographic markers in predicting preeclampsia: a systematic review,”
  26. (2008). Comparison of fetal and neonatal growth curves in detecting growth restriction,”
  27. (1989). Conceptional age, menstrual age, and ultrasound age: a second-trimester comparison of pregnancies of known conception date with pregnancies dated from the last menstrual period,”
  28. (1998). Confined placental mosaicism and intrauterine fetal growth,”
  29. (1999). Controlled trial of fundal height measurement plotted on customised antenatal growth charts,”
  30. (1992). Customised antenatal growth charts,”
  31. (2008). Customised birthweight percentiles: does adjusting for maternal characteristics matter?”
  32. (2007). Customised birthweight standards accurately predict perinatal morbidity,”
  33. (2000). D a s h e ,D .D .M c I n t i r e ,M .J .L u c a s ,a n dK .J .L e v e n o , “Effects of symmetric and asymmetric fetal growth on pregnancy outcomes,” Obstetrics and Gynecology,
  34. (1992). Detection of intrauterine growth retardation in twins using individualized growth assessment: I. Evaluation of growth outcome at birth,”
  35. (1992). Detection of intrauterine growth retardation in twins usingJournal of Pregnancy 11 individualized growth assessment.
  36. (1998). Dilatation of the ductus venosus in human fetuses: ultrasonographic evidence and mathematical modeling,”
  37. (2006). Doppler and biophysical assessment in growth restricted fetuses: distribution of test results,”
  38. (2001). Doppler assessment of umbilical artery, thoracic aorta and middle cerebral artery in the management of pregnancies with growth restriction,”
  39. (1995). Doppler ultrasonography in high-riskpregnancies:systematicreviewwithmeta-analysis,”
  40. (1996). Doppler ultrasound of the uterine arteries: the importance of bilateral notching in the prediction of preeclampsia, placental abruption or delivery of a small-forgestational-age baby,”
  41. (2006). Ductus venosus shunting in growth-restricted fetuses and the effect of umbilical circulatory compromise,”
  42. (2002). Early pregnancy levels of pregnancy-associated plasma protein A and the risk of intrauterine growth restriction, premature birth, preeclampsia, and stillbirth,”
  43. Effectiveness of interventions to prevent or treat impaired fetal growth,”
  44. (1990). Effects of fetal intravenous glucose challenge
  45. (2001). Elective caesarean section versus expectant management for delivery of the small baby,” Cochrane Database of Systematic Reviews,n o .2 ,A r t i c l eI D CD000078,
  46. (2003). Energy and protein intake in pregnancy,”
  47. (1988). Erickson,J .F .Cordero ,andB.J .M cCarth y , “Congenital malformations and intrauterine growth retardation: a population study,”
  48. (1985). Estimation of fetal weight with the use of head, body, and femur measurements—a prospective study,”
  49. (1990). Fetal assessment based on fetal biophysical profile scoring. IV. An analysis of perinatal morbidity and mortality,”
  50. (1987). Fetal biophysical profile scoring: selective use of the nonstress test,”
  51. Fetal biparietal diameter: a critical re-evaluation of the relation to menstrual age by means of real-time ultrasound,”
  52. (2004). Fetal responses to placental insufficiency: an update,”
  53. (2008). Fetalgrowthbetweenthefirstandsecondtrimestersandthe risk of adverse pregnancy outcome,”
  54. (2008). First trimester maternal serum PAPP-A, β-hCG and ADAM12 in prediction of small-for-gestational-age fetuses,”
  55. (2007). First-trimester ADAM12 and PAPP-A as markers for intrauterine fetal growth restriction through their roles in the insulin-like growth factor system,”
  56. (1998). First-trimester growth and the risk of low birth weight,” The New England
  57. (2007). Firsttrimester placental protein 13 screening for preeclampsia and intrauterine growth restriction,”
  58. (1983). Further experience with the fetal biophysical profile,”
  59. (1996). G u z m a n ,A .M .V i n t z i l e o s ,M .M a r t i n s ,C .B e n i t o
  60. (1989). Glycemic control in gestational diabetes mellitus—how tight is tight enough: small for gestational age versus large for gestational age?”
  61. Gratac´ os, “Sequence of changes in myocardial performance index in relation with aortic isthmus and ductus venosus Doppler in fetuses with early-onset intrauterine growth restriction,” Ultrasound in Obstetrics & Gynecology.
  62. (1988). H.S.BrarandS.E.Rutherford,“Classificationofintrauterine growth retardation,” Seminars in Perinatology,
  63. (2000). High prevalence of the prothrombin gene mutation in women with intrauterine growth retardation, abruptio placentae and second trimester loss,”
  64. (2002). How strong is the association between maternal thrombophilia and adverse pregnancy outcome? A systematic review,”
  65. (2000). I.Caniggia,J.Winter,S.J.Lye,andM.Post,“Oxygenandplacental development during the first trimester: implications for the pathophysiology of pre-eclampsia,”
  66. (2004). Identification of macrosomic, normal and intrauterine growth retarded neonates using the modified neonatal growth assessment score,”
  67. (1991). In utero analysis of fetal growth: a sonographic weight standard,”
  68. (1986). Inadequate maternal vascular response to placentation in pregnancies complicated by pre-eclampsia and by smallfor-gestational age infants,”
  69. (2004). Individualized growth assessment: evaluation of growth using each fetus as its own control,”
  70. (2008). Individualized norms of optimal fetal growth: fetal growth potential,”
  71. (2004). Infant wellbeing at 2 years of age in the Growth Restriction Intervention Trial (GRIT): multicentred randomised controlled trial,”
  72. (2000). Intrauterine growth restriction and doppler ultrasonography,”
  73. (2003). Intrauterine growth restriction, preeclampsia, and intrauterine mortality at high altitude in
  74. (2002). Intrauterine growth restriction,”
  75. (1990). Intrauterine growth retardation and preterm delivery: prenatal risk factors in an indigent population,”
  76. (2002). Investigation and management of the small-for-gestational-age fetus,” Guidelines and Audit Committee of the Royal College of Obstetricians and Gynaecologists (RCOG),
  77. (2004). J.Gardosi,“Customizedfetalgrowthstandards:rationaleand clinical application,” Seminars in Perinatology,
  78. (2005). L.Dugoff,A.M.L ynch,D .Cioffi-Raganetal.,“Firsttrimester uterine artery Doppler abnormalities predict subsequent intrauterine growth restriction,”
  79. (2000). Longitudinal changes in the ductus venosus, cerebral transverse sinus and cardiotocogram
  80. (2000). Longitudinal changes in the ductus venosus, cerebral transverse sinus and cardiotocogram in f e t a lg r o w t hr e s t r i c t i o n ,
  81. (2011). Longitudinal changes in uterine, umbilical and fetal cerebral Doppler indices in late-onset small-for-gestational age fetuses,”
  82. (2010). M o o k - K a n a m o r i
  83. (1985). M.Ounsted,V.A.Moar,andA.Scott,“Riskfactorsassociated with small-for-dates and large-for-dates infants,”
  84. (2007). Management of fetal growth restriction,”
  85. (2006). Management of fetal growth restriction: an evidence-based approach,”
  86. (1987). Maternal oxygen therapy for intrauterine growth retardation,”
  87. (1984). Mathematical modeling of fetal growth: I. Basic principles,”
  88. (1995). Meta-analysis of randomized controlled trials of antenatal corticosteroid for the prevention of respiratory distresssyndrome:discussion,”AmericanJournalofObstetrics and Gynecology,
  89. (2005). Microarray-based identification of differentially expressed genes in hypoxic term human trophoblasts and in placental villi of pregnancies with growth restricted fetuses,”
  90. (2007). Middle cerebral artery peak systolic velocity: a new Doppler parameter in the assessment of growth-restricted fetuses,”
  91. (2001). Monitoring of fetuses with intrauterine growth restriction: a longitudinal study,”
  92. (2001). Multicenter screening for pre-eclampsia and fetal growth restriction by transvaginal uterine artery Doppler at 23 weeks of gestation,”
  93. (1987). N ybe r g,L .A .M ac k ,F .C .L a i n g,a n dR .M .P a t t e n ,“ Di s -tinguishing normal from abnormal gestational sac growth in early pregnancy,”
  94. (2000). One-stage screening for pregnancy complications by color Doppler assessment of the uterine arteries at 23 weeks’ gestation,”
  95. (1992). Organization, International Statistical Classifi-cation of Diseases and Related Health Problems, World Health Organization,
  96. (1997). Oxygen and placental villous development: origins of fetal hypoxia,”
  97. (1990). P .B a r k e r ,A .R .B u l l ,C .O s m o n d ,a n dS .J .S i m m o n d s , “Fetal and placental size and risk of hypertension in adult life,”
  98. (2008). p e n c e r ,N .J .C o w a n s ,K .A v g i d o u ,F .M o l i n a ,a n d
  99. (1997). Pathology and clinical implications of abnormal umbilical artery
  100. (2002). Physiological functions of imprinted genes,”
  101. (2005). Prediction of pregnancy complications by firsttrimester maternal serum PAPP-A and free β-hCG and with second-trimester uterine artery Doppler,” Prenatal Diagnosis,
  102. (1983). Pregnancy outcome in 211 patients with mild chronic hypertension,”
  103. (2006). Pregnancyassociated plasma protein A and alpha-fetoprotein and prediction of adverse perinatal outcome,”
  104. (1987). Prenatal asphyxia, hyperlacticaemia, hypoglycaemia, and erythroblastosis in growth retarded fetuses,”
  105. (1986). Qualitative assessment of uteroplacental blood flow: early screening test
  106. (2002). R.C.o.O.a.Gynaecologists,“investigationandManagement of the Small for Gestational ” RCOG,
  107. (2010). Rauh-Hain et al., “Early-pregnancy soluble Fas levels in idiopathic small-for-gestational-age pregnancies,”
  108. (1991). Relation of fetal blood gases and data from computer-assisted analysis of fetal heart rate patterns in small for gestation fetuses,”
  109. (2001). Relationship between the sonographic pattern of intrauterine growth restriction and acid-base status at the time of cordocentesis,”
  110. (2009). Rheological and Physiological Consequences of Conversion oftheMaternalSpiralArteriesforUteroplacentalBloodFlow during
  111. (1998). Routine screening for intrauterine growth retardation in Germany: low sensitivity and questionable benefit for diagnosed cases,”
  112. (1993). S n i j d e r s ,C .S h e r r o d ,C .M .G o s d e n ,a n dK .H . Nicolaides, “Fetal growth retardation: associated malformations and chromosomal abnormalities,”
  113. (1977). S.CampbellandA.Thoms,“Ultrasoundmeasurementofthe fetal head to abdomen circumference ratio in the assessment of growth retardation,”
  114. (1989). S.M.Bailey,P.Sarmandal,andJ.M.Grant,“Acomparisonof three methods of assessing inter-observer variation applied to measurement of the symphysis-fundal height,”
  115. (1998). Schr¨ oder, “Doppler ultrasound evaluation of ductus venosus blood flow during acute hypoxemia in fetal lambs,”
  116. (2007). Screening for pre-eclampsia and fetal growth restriction by uterine artery
  117. (2001). Screening for pre-eclampsia and fetal growth restriction by uterine artery Doppler at 11-14 weeks of gestation,”
  118. (2004). Simultaneous measurements of umbilical venous, fetal hepatic, and ductus venosus blood flow in growth-restricted human fetuses,”
  119. (1991). Sonographic prediction of gestational age: accuracy of second- and third-trimester fetal measurements,”
  120. (1990). Standardized measurement of amniotic fluid volume by correlation of sonography with dye dilution technique,”
  121. (2002). Temporal sequence of abnormal Doppler changes in the peripheral and central circulatory systems of the severely growth-restricted fetus,”
  122. (1990). The abnormal fetal biophysical profile score. V. Predictive accuracy according to score composition,”
  123. (1990). The amniotic fluid index in normal human pregnancy,”
  124. (2011). The case against customised birthweight
  125. (2011). The customised growth potential: an international research tool to study the epidemiology of fetal growth,” Paediatric and Perinatal Epidemiology,
  126. (1992). The outcome of congenital cytomegalovirus infection in relation to maternal antibody status,” The New England
  127. (1990). The relationship between the umbilical artery systolic/diastolic ratio and umbilical blood gas measurements in specimens obtained by cordocentesis,”
  128. (2001). The sequence of changes in Doppler and biophysical parameters as severe fetal growth restriction worsens,”
  129. (1993). The use of vibroacoustic stimulation during the abnormal14
  130. (2006). The uterine spiral arteries in human pregnancy: facts and controversies,”
  131. (1997). Ultrasonographic assessment of amniotic fluid does not reflect actual amniotic fluid volume,”
  132. (2000). Ultrasound evaluation of fetal growth,”
  133. (2005). Uterine artery Doppler at 11-14 weeks of gestation to screen for hypertensive disorders and associated complications in an unselected
  134. (2007). Vitamins and perinatal outcomes among HIV-negative women
  135. Weight in infancy and death from ischaemic heartdisease,”TheLancet,vol.2,no.8663,pp.577–580,1989.
  136. (2004). What antepartum fetal test should guide the timing of delivery of the preterm growthrestricted fetus? a decision-analysis,”