Fetal Growth Restriction: Contemporary Evidence to Guide Delivery Timing and Intrapartum Management

TL;DR

This paper reviews recent evidence on managing pregnancies with fetal growth restriction, focusing on when and how to deliver to improve outcomes.

Contribution

The paper provides updated management flowcharts for fetal growth restriction based on the latest evidence and fetal surveillance findings.

Findings

There is limited high-quality evidence for managing fetal growth restriction, with few randomized clinical trials.

Delivery timing depends on gestational age and fetal surveillance abnormalities.

Management flowcharts were developed to guide clinicians based on available evidence.

Abstract

Fetal growth restriction (FGR), a condition in which the fetus fails to achieve its growth and developmental potential, affects 5% to 10% of pregnancies and is associated with high rates of perinatal morbidity and mortality. There is currently insufficient high-quality evidence to define the optimal approach for diagnosing fetal growth restriction. In 2016, with the aim of standardizing clinical practice and enabling comparability across scientific studies, an expert opinion-based consensus was published. This document proposed unified terminology and clear diagnostic criteria for early- and late-onset fetal growth restriction (FGR). Because no effective treatment is available, careful assessment of fetal well-being and appropriate timing of delivery are the main tools for managing these fetuses. This decision should be based on gestational age and the severity of abnormalities identified on fetal surveillance tests, balancing the risks of prematurity against the risks of severe permanent sequelae or fetal death. The objective of this update is to analyze the most recent evidence on when and how to deliver pregnancies complicated by fetal growth restriction, emphasizing that specific abnormalities on fetal surveillance examinations warrant delivery at different gestational ages. To this end, a literature search of the PubMed/Medline and Latin America and the Caribbean Literature on Health Sciences (LILACS) databases was conducted using the terms fetal growth restriction, management, and delivery over the past ten years. Results were grouped into gestational age at delivery, mode of delivery, and methods of labor induction. The main fetal surveillance abnormalities prompting delivery in each gestational-age range were discussed, leading to the development of management flowcharts. Despite the lack of consensus in the literature and the limited number of randomized clinical trials guiding clinical decisions in FGR, the available evidence was summarized to assist clinicians in managing pregnancies complicated by FGR. It should be emphasized that there are few randomized clinical trials to guide management decisions in FGR.

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