Population Covered By The Guidance
This pathway provides guidance on the imaging investigation of a fetus with suspected intra-uterine growth retardation (IUGR), and the role of imaging in the management of confirmed IUGR.
Lead Researcher: Sian Chin
Experts & Contributors: Ravinder Dhillon, Emmeline Lee
Editorial Panel: Core Membership
Date reviewed: September 2018
Date Published: April 2019
Intrauterine Growth Restriction
Intrauterine Growth Restriction
Intrauterine Growth Restriction
Intrauterine Growth Restriction
- Small for gestational age (SGA) is defined as an estimated fetal weight (EFW) on a customised growth chart less than the 10th centile for gestation. Most SGA fetuses are small but healthy, however a proportion will be considered to have intrauterine growth restriction (IUGR). IUGR occurs when the fetus fails to reach its genetic growth potential due to a pathological reason or an event in utero causing placental dysfunction
- The abdominal circumference is usually the first measurement to become reduced. A growth restricted fetus may have a discrepancy between head and abdominal circumference but may not meet the criteria for SGA
- Several risk factors for IUGR have been identified, and screening with growth scans at 24-28 weeks may be considered in high-risk pregnancies
- Fundal symphysis height (FSH) should be measured and plotted regularly in all pregnancies from 24 weeks. Ultrasound examination is required to confirm SGA/IUGR suspected from abnormal measurements. If FSH is unreliable, e.g. due to obesity or large fibroids, then serial growth ultrasounds are recommended for monitoring
- Conventional and Doppler ultrasonography are used to assess fetal wellbeing in conjunction with clinical examination. Depending on gestation cardiotocography (CTG) monitoring may also be used
- Recommendations on timing of fetal surveillance intervals and delivery vary
- Delivery is indicated when risk of fetal death or morbidity is greater than the risk of prematurity
Date of literature search: August-September 2018
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Blue NR, Beddow ME, Savabi M, Katukuri VR, Mozurkewich EL, Chao CR. A comparison of methods for the diagnosis of fetal growth restriction between the Royal College of Obstetricians and Gynaecologists and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2018;131(5):835-41. (Level II-III evidence) View the reference
- Alberry M, Soothill P. Management of fetal growth restriction. Arch Dis Child Fetal Neonatal Ed. 2007;92(1):F62-F7. (Review article) View the reference
- Beune IM, Pels A, Gordijn SJ, Ganzevoort W. Definitions of fetal growth restriction in existing literature over time. Ultrasound Obstet Gynecol. 2018. (Review article) View the reference
- Gardosi J, Clausson B, Francis A. The value of customised centiles in assessing perinatal mortality risk associated with parity and maternal size. BJOG. 2009;116(10):1356-63. BJOG. 2009;116(10):1356-63. View the reference
- McCowan LM, Harding JE, Stewart AW. Customized birthweight centiles predict SGA pregnancies with perinatal morbidity. BJOG. 2005;112(8):1026-33. (Level II evidence) View the reference
- Chiossi G, Pedroza C, Costantine MM, Truong VTT, Gargano G, Saade GR. Customized vs population-based growth charts to identify neonates at risk of adverse outcome: systematic review and Bayesian meta-analysis of observational studies. Ultrasound Obstet Gynecol. 2017;50(2):156-66. (Level I evidence) View the reference
- Gardosi J, Madurasinghe V, Williams M, Malik A, Francis A. Maternal and fetal risk factors for stillbirth: population based study. BMJ. 2013;346:f108. (Level II evidence) View the reference
- Nyberg DA, Abuhamad A, Ville Y. Ultrasound assessment of abnormal fetal growth. Semin Perinatol. 2004;28(1):3-22. (Review article) View the reference
- Smith-Bindman R, Chu PW, Ecker JL, Feldstein VA, Filly RA, Bacchetti P. US evaluation of fetal growth: prediction of neonatal outcomes. Radiology. 2002;223(1):153-61. (Review article) View the reference
- Haram K, Softeland E, Bukowski R. Intrauterine growth restriction. Int J Gynaecol Obstet. 2006;93(1):5-12. (Review article) View the reference
- Australian Health Ministers' Advisory Council. Clinical practice guidelines: Preganancy care. Canberra: Australian Governement Department of Health; 2018. (Guideline) View the reference
- Sovio U, White IR, Dacey A, Pasupathy D, Smith GCS. Screening for fetal growth restriction with universal third trimester ultrasonography in nulliparous women in the Pregnancy Outcome Prediction (POP) study: a prospective cohort study. Lancet (London, England). 2015;386(10008):2089-97. (Level II evidence) View the reference
- Bricker L, Medley N, Pratt JJ. Routine ultrasound in late pregnancy (after 24 weeks' gestation). Cochrane Database Syst Rev. 2015(6):Cd001451. (Level I evidence) View the reference
- Royal College of Obstetricians and Gynaecologists. Green-top guideline no. 31. The investigation and management of the small-for-gestational-age fetus. 2014. (Guideline) View the reference
- King Edward Memorial Hospital. Clinical practice guidelines. Small for gestational age and intrauterine growth restriction: management of. Government of Western Australia. Women and Newborn Health Service; 2016. (Guideline) View the reference
- McCowan L, Bloomfield F. Guideline for the management of suspected small for gestational age singleton pregnancies after 34 weeks gestation. New Zealand Maternal Fetal Medicine Network; 2013. (Guideline) View the reference
- Odibo AO, Nelson D, Stamilio DM, Sehdev HM, Macones GA. Advanced maternal age is an independent risk factor for intrauterine growth restriction. Am J Perinatol. 2006;23(5):325-8. (Level III evidence) View the reference
- Shah PS, Shah V. Influence of the maternal birth status on offspring: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2009;88(12):1307-18. (Level I-II evidence) View the reference
- Shah PS. Paternal factors and low birthweight, preterm, and small for gestational age births: a systematic review. Am J Obstet Gynecol. 2010;202(2):103-23. (Review article) View the reference
- Jaquet D, Swaminathan S, Alexander GR, Czernichow P, Collin D, Salihu HM, et al. Significant paternal contribution to the risk of small for gestational age. BJOG. 2005;112(2):153-9. (Level II-III evidence) View the reference
- Kramer MS, Platt R, Yang H, McNamara H, Usher RH. Are all growth-restricted newborns created equal(ly)? Pediatrics. 1999;103(3):599-602. (Level II-III evidence) View the reference
- Gouin K, Murphy K, Shah PS. Effects of cocaine use during pregnancy on low birthweight and preterm birth: systematic review and metaanalyses. Am J Obstet Gynecol. 2011;204(4):340.e1-12. (Level I-II evidence) View the reference
- Howarth C, Gazis A, James D. Associations of Type 1 diabetes mellitus, maternal vascular disease and complications of pregnancy. Diabet Med. 2007;24(11):1229-34. (Level II-III evidence) View the reference
- Allen VM, Joseph KS, Murphy KE, Magee LA, Ohlsson A. The effect of hypertensive disorders in pregnancy on small for gestational age and stillbirth: a population based study. BMC Pregnancy and Childbirth. 2004;4:17. (Level II-III evidence) View the reference
- Fink JC, Schwartz SM, Benedetti TJ, Stehman-Breen CO. Increased risk of adverse maternal and infant outcomes among women with renal disease. Paediatr Perinat Epidemiol. 1998;12(3):277-87. (Level III evidence) View the reference
- Yasuda M, Takakuwa K, Tokunaga A, Tanaka K. Prospective studies of the association between anticardiolipin antibody and outcome of pregnancy. Obstet Gynecol. 1995;86(4 Pt 1):555-9. (Level II-III evidence) View the reference
- Ananth CV, Peltier MR, Chavez MR, Kirby RS, Getahun D, Vintzileos AM. Recurrence of ischemic placental disease. Obstet Gynecol. 2007;110(1):128-33. (Level III evidence) View the reference
- Lang JM, Lieberman E, Cohen A. A comparison of risk factors for preterm labor and term small-for-gestational-age birth. Epidemiology. 1996;7(4):369-76. (Level II-III evidence) View the reference
- Weiss JL, Malone FD, Vidaver J, Ball RH, Nyberg DA, Comstock CH, et al. Threatened abortion: A risk factor for poor pregnancy outcome, a population-based screening study. Am J Obstet Gynecol. 2004;190(3):745-50. (Level II evidence) View the reference
- Goetzinger KR, Cahill AG, Macones GA, Odibo AO. Echogenic bowel on second-trimester ultrasound: evaluating the risk of adverse pregnancy outcome. Obstet Gynecol. 2011;117(6):1341-8. (Level II-III evidence) View the reference
- Khan NA, Kazzi SN. Yield and costs of screening growth-retarded infants for torch infections. Am J Perinatol. 2000;17(3):131-5. (Level II-III evidence) View the reference
- Espiritu MM, Bailey S, Wachtel EV, Mally PV. Utility of routine urine CMV PCR and total serum IgM testing of small for gestational age infants: a single center review. J Perinat Med. 2018;46(1):81-6. (Level III evidence) View the reference
- Chung MH, Shin CO, Lee J. TORCH (toxoplasmosis, rubella, cytomegalovirus, and herpes simplex virus) screening of small for gestational age and intrauterine growth restricted neonates: efficacy study in a single institute in Korea. Korean Journal of Pediatrics. 2018;61(4):114-20. (Level III evidence) View the reference
- Mongelli M, Ek S, Tambyrajia R. Screening for fetal growth restriction: a mathematical model of the effect of time interval and ultrasound error. Obstet Gynecol. 1998;92(6):908-12. (Level III evidence) View the reference
- Morris RK, Malin G, Robson SC, Kleijnen J, Zamora J, Khan KS. Fetal umbilical artery Doppler to predict compromise of fetal/neonatal wellbeing in a high-risk population: systematic review and bivariate meta-analysis. Ultrasound Obstet Gynecol. 2011;37(2):135-42. (Level I-II evidence) View the reference
- Alfirevic Z, Stampalija T, Dowswell T. Fetal and umbilical Doppler ultrasound in high-risk pregnancies. Cochrane Database Syst Rev. 2017;6:Cd007529. (Level I evidence) View the reference
- Berkley E, Chauhan SP, Abuhamad A. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol. 2012;206(4):300-8. (Guideline) View the reference
- Unterscheider J, Daly S, Geary MP, Kennelly MM, McAuliffe FM, O'Donoghue K, et al. Optimizing the definition of intrauterine growth restriction: the multicenter prospective PORTO Study. Am J Obstet Gynecol. 2013;208(4):290.e1-6. (Level II evidence) View the reference
- Alfirevic Z, Stampalija T, Gyte GM. Fetal and umbilical Doppler ultrasound in high-risk pregnancies. Cochrane Database Syst Rev. 2010(1):Cd007529. (Level I evidence) View the reference
- Vollgraff Heidweiller‐Schreurs CA, De Boer MA, Heymans MW, Schoonmade LJ, Bossuyt PMM, Mol BWJ, et al. Prognostic accuracy of cerebroplacental ratio and middle cerebral artery Doppler for adverse perinatal outcome: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2018;51(3):313-22. (Level I evidence) View the reference
- Morris RK, Say R, Robson SC, Kleijnen J, Khan KS. Systematic review and meta-analysis of middle cerebral artery Doppler to predict perinatal wellbeing. Eur J Obstet Gynecol Reprod Biol. 2012;165(2):141-55. (Level I evidence) View the reference
- Conde-Agudelo A, Villar J, Kennedy SH, Papageorghiou AT. Predictive accuracy of cerebroplacental ratio for adverse perinatal and neurodevelopmental outcomes in suspected fetal growth restriction: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2018. (Level I evidence) View the reference
- Caradeux J, Martinez-Portilla RJ, Basuki TR, Kiserud T, Figueras F. Risk of fetal death in growth-restricted fetuses with umbilical and/or ductus venosus absent or reversed end-diastolic velocities before 34 weeks of gestation: a systematic review and meta-analysis. Am J Obstet Gynecol. 2018;218(2s):S774-S82.e21. (Level I evidence) View the reference
- Morris RK, Selman TJ, Verma M, Robson SC, Kleijnen J, Khan KS. Systematic review and meta-analysis of the test accuracy of ductus venosus Doppler to predict compromise of fetal/neonatal wellbeing in high risk pregnancies with placental insufficiency. Eur J Obstet Gynecol Reprod Biol. 2010;152(1):3-12. (Level I evidence) View the reference
- Ganzevoort W, Mensing Van Charante N, Thilaganathan B, Prefumo F, Arabin B, Bilardo CM, et al. How to monitor pregnancies complicated by fetal growth restriction and delivery before 32 weeks: post-hoc analysis of TRUFFLE study. Ultrasound Obstet Gynecol. 2017;49(6):769-77. (Level II evidence) View the reference
- Turan OM, Turan S, Berg C, Gembruch U, Nicolaides KH, Harman CR, et al. Duration of persistent abnormal ductus venosus flow and its impact on perinatal outcome in fetal growth restriction. Ultrasound Obstet Gynecol. 2011;38(3):295-302. (Level II-III evidence) View the reference
- Alfirevic Z, Stampalija T, Medley N. Fetal and umbilical Doppler ultrasound in normal pregnancy. Cochrane Database Syst Rev. 2015(4):Cd001450. (Level I evidence) View the reference
- Thornton JG, Hornbuckle J, Vail A, Spiegelhalter DJ, Levene M. Infant wellbeing at 2 years of age in the Growth Restriction Intervention Trial (GRIT): multicentred randomised controlled trial. Lancet. 2004;364(9433):513-20. (Level II evidence) View the reference
- Walker DM, Marlow N, Upstone L, Gross H, Hornbuckle J, Vail A, et al. The Growth Restriction Intervention Trial: long-term outcomes in a randomized trial of timing of delivery in fetal growth restriction. Am J Obstet Gynecol. 2011;204(1):34.e1-9. (Level II evidence) View the reference
Pathway User Guide
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Ultrasound
Ultrasound and umbilical artery Doppler studies
The assessment of growth requires at least 2 measurements, at least two weeks apart. Umbilical artery Doppler studies in high risk populations can help reduce perinatal mortality. Consider results in conjunction with ultrasound and other Doppler studies of the MCA and ductus venosus
- Where SGA or IUGR are suspected, ultrasound examination should be undertaken to assess:
- Fetal anatomy and biometry: including estimated fetal weight (EFW), abdominal circumference (AC), head circumference, femur length and assessment of the placenta and umbilical cord. The assessment of growth requires at least two measurements, two weeks apart. Measurements three weeks apart reduces the false positive rate ,
- Biophysical profile (BPP): fetal heart rate, breathing, movements, tone and amniotic fluid volume
- Umbilical artery Doppler
- In women where measuring fundal-symphysis height is unreliable, e.g. in obesity or large uterine fibroids, serial growth ultrasounds are recommended for monitoring instead
- In high risk populations, umbilical artery Doppler can predict mortality and risk of fetal compromise and help guide management and timing of delivery. Use of fetal and umbilical artery Doppler ultrasound surveillance reduces the risk of perinatal death and obstetric intervention
- Maternal or placental conditions that obliterate small arteries in the placental villi result in a progressive decrease in the end-diastolic flow in the umbilical artery waveform until it is absent and then reversed
- Absent or reversed end-diastolic flow is a late change and is associated with adverse perinatal outcomes
- Doppler studies of the middle cerebral artery (MCA) and ductus venosus are also useful to monitor fetal well-being and guide management
- In IUGR, there is preferential flow to the brain (“brain sparing effect”), heart and adrenal glands, with increased cerebral diastolic flow and cerebral vasodilation leading to decreased MCA Doppler indices, while aortic blood flow resistance increases
- Studies of MCA Doppler are conflicting. Meta-analyses have found MCA Doppler to have a limited predictive accuracy for perinatal wellbeing. It may be useful after 32 weeks gestation where umbilical artery Doppler is normal
- The cerebroplacental ratio (CPR) may also be useful in monitoring. It is calculated by dividing the MCA pulsatility index by the umbilical artery pulsatility index. Abnormal CPR is associated with perinatal death, and may be a better predictor than MCA Doppler alone. Further trials are needed to assess whether the use of CPR reduces adverse perinatal outcomes
- Ductus venosus Doppler showed moderate predictive accuracy for perinatal mortality in high risk fetuses IUGR and with placental insufficiency. It is also useful in the monitoring of very premature pregnancies with IUGR 45
- Increase in the resistance of venous blood flow in the ductus venosus and inferior vena cava are late changes associated with impending acidaemia or perinatal death
- Systematic reviews of conventional or Doppler ultrasound use have not yet demonstrated a benefit in the routine screening of low-risk or unselected patients
- If IUGR is diagnosed and there are no indications for immediate delivery, fetal monitoring is appropriate, particularly if the fetus is < 31 weeks gestation. This usually consists of serial ultrasound (biophysical profile, Doppler studies, and assessment of fetal growth) and cardiotocography (CTG)
Ultrasound
Fetal monitoring
Close monitoring involves ultrasound surveillance including Doppler studies, amniotic fluid volume and fetal biometry. CTG monitoring may also be indicated after 32-34 weeks
- Where SGA or IUGR are suspected, ultrasound examination should be undertaken to assess:
- Fetal anatomy and biometry: including estimated fetal weight (EFW), abdominal circumference (AC), head circumference, femur length and assessment of the placenta and umbilical cord. The assessment of growth requires at least two measurements, two weeks apart. Measurements three weeks apart reduces the false positive rate ,
- Biophysical profile (BPP): fetal heart rate, breathing, movements, tone and amniotic fluid volume
- Umbilical artery Doppler
- In women where measuring fundal-symphysis height is unreliable, e.g. in obesity or large uterine fibroids, serial growth ultrasounds are recommended for monitoring instead
- In high risk populations, umbilical artery Doppler can predict mortality and risk of fetal compromise and help guide management and timing of delivery. Use of fetal and umbilical artery Doppler ultrasound surveillance reduces the risk of perinatal death and obstetric intervention
- Maternal or placental conditions that obliterate small arteries in the placental villi result in a progressive decrease in the end-diastolic flow in the umbilical artery waveform until it is absent and then reversed
- Absent or reversed end-diastolic flow is a late change and is associated with adverse perinatal outcomes
- Doppler studies of the middle cerebral artery (MCA) and ductus venosus are also useful to monitor fetal well-being and guide management
- In IUGR, there is preferential flow to the brain (“brain sparing effect”), heart and adrenal glands, with increased cerebral diastolic flow and cerebral vasodilation leading to decreased MCA Doppler indices, while aortic blood flow resistance increases
- Studies of MCA Doppler are conflicting. Meta-analyses have found MCA Doppler to have a limited predictive accuracy for perinatal wellbeing. It may be useful after 32 weeks gestation where umbilical artery Doppler is normal
- The cerebroplacental ratio (CPR) may also be useful in monitoring. It is calculated by dividing the MCA pulsatility index by the umbilical artery pulsatility index. Abnormal CPR is associated with perinatal death, and may be a better predictor than MCA Doppler alone. Further trials are needed to assess whether the use of CPR reduces adverse perinatal outcomes
- Ductus venosus Doppler showed moderate predictive accuracy for perinatal mortality in high risk fetuses IUGR and with placental insufficiency. It is also useful in the monitoring of very premature pregnancies with IUGR 45
- Increase in the resistance of venous blood flow in the ductus venosus and inferior vena cava are late changes associated with impending acidaemia or perinatal death
- Systematic reviews of conventional or Doppler ultrasound use have not yet demonstrated a benefit in the routine screening of low-risk or unselected patients
- If IUGR is diagnosed and there are no indications for immediate delivery, fetal monitoring is appropriate, particularly if the fetus is < 31 weeks gestation. This usually consists of serial ultrasound (biophysical profile, Doppler studies, and assessment of fetal growth) and cardiotocography (CTG)