SGA management
Authors: Ahmet Baschat, Francesc Figueras, Gerry Visser, Kypros Nicolaides
References: click here
Notes: click here
The estimated fetal weight from the measurements of HC, AC and FL is derived from the formula reported by: Hadlock FP, Harrist RB, Martinez-Poyer J. In utero analysis of fetal growth: a sonographic weight standard. Radiology 1991; 181: 129-133
The estimated fetal weight is plotted on the reference range for gestational age derived from the formula reported by: Nicolaides KH, Wright D, Syngelaki A, Wright A, Akolekar R. Fetal Medicine Foundation fetal and neonatal population weight charts. Ultrasound Obstet Gynecol 2018; doi:10.1002/uog.19073 
Baschat AA, Galan HL, Bhide A, Berg C, Kush ML, et al. Doppler and biophysical assessment in growth restricted fetuses: distribution of test results. Ultrasound Obstet Gynecol 2006;27:41-7.
Baschat AA, Gembruch U, Harman CR. The sequence of changes in Doppler and biophysical parameters as severe fetal growth restriction worsens. Ultrasound Obstet Gynecol 2001;18:571-7.
Bilardo CM, Hecher K, Visser GHA, Papageorghiou AT, Marlow N, et al. Severe fetal growth restriction at 26-32 weeks: key messages from the TRUFFLE study. Ultrasound Obstet Gynecol 2017;50:285-290.
Bilardo CM, Wolf H, Stigter RH, Ville Y, Baez E, Visser GH, Hecher K. Relationship between monitoring parameters and perinatal outcome in severe, early intrauterine growth restriction. Ultrasound Obstet Gynecol 2004;23:119-25.
Boers KE, van Wyk L, van der Post JA, Kwee A, van Pampus MG, et al. Neonatal morbidity after induction vs expectant monitoring in intrauterine growth restriction at term: a subanalysis of the DIGITAT RCT. Am J Obstet Gynecol 2012;206:344.e1-7.
Boers KE, Vijgen SM, Bijlenga D, van der Post JA, Bekedam DJ, et al. Induction versus expectant monitoring for intrauterine growth restriction at term: randomised equivalence trial (DIGITAT). BMJ 2010;341:c7087.
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 2019;218:S774–S782.e21
Crimmins S, Desai A, Block-Abraham D, Berg C, Gembruch U, Baschat AA. A comparison of Doppler and biophysical findings between liveborn and stillborn growth-restricted fetuses. Am J Obstet Gynecol 2014;211:669.e1-10.
Figueras F, Caradeux J, Crispi F, Eixarch E, Peguero A, Gratacos E. Diagnosis and surveillance of late-onset fetal growth restriction. Am J Obstet Gynecol 2018;218:S790-S802.e1
Figueras F, Gratacós E. Update on the diagnosis and classification of fetal growth restriction and proposal of a stage-based management protocol. Fetal Diagn Ther 2014;36:86-98.
Ganzevoort W, Mensing Van Charante N, Thilaganathan B, Prefumo F, 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;49:769-777.
Hecher K, Bilardo CM, Stigter RH, Ville Y, Hackelöer BJ, Kok HJ, Senat MV, Visser GH. Monitoring of fetuses with intrauterine growth restriction: a longitudinal study. Ultrasound Obstet Gynecol 2001;18:564-70.
Lees CC, Marlow N, van Wassenaer-Leemhuis A, Arabin B, Bilardo CM, et al. 2 year neurodevelopmental and intermediate perinatal outcomes in infants with very preterm fetal growth restriction (TRUFFLE): a randomised trial. Lancet 2015;385:2162-72.
Manning FA, Snijders R, Harman CR, Nicolaides K, Menticoglou S, Morrison I. Fetal biophysical profile score. VI. Correlation with antepartum umbilical venous fetal pH. Am J Obstet Gynecol 1993;169:755-63.
McCowan LM, Figueras F, Anderson NH. Evidence-based national guidelines for the management of suspected fetal growth restriction: comparison, consensus, and controversy. Am J Obstet Gynecol 2018;218:S855-S868
Thornton JG, Hornbuckle J, Vail A, Spiegelhalter DJ, Levene M; GRIT study group. Infant wellbeing at 2 years of age in the Growth Restriction Intervention Trial (GRIT): multicentred randomised controlled trial. Lancet 2004;364:513-20.
Turan OM, Turan S, Berg C, Gembruch U, Nicolaides KH, Harman CR, Baschat AA. Duration of persistent abnormal ductus venosus flow and its impact on perinatal outcome in fetal growth restriction. Ultrasound Obstet Gynecol 2011;38:295-302.
Turan OM, Turan S, Gungor S, Berg C, Moyano D, Gembruch U, Nicolaides KH, Harman CR, Baschat AA. Progression of Doppler abnormalities in intrauterine growth restriction. Ultrasound Obstet Gynecol 2008;32:160-7.
Turan S, Turan OM, Berg C, Moyano D, Bhide A, et al. Computerized fetal heart rate analysis, Doppler ultrasound and biophysical profile score in the prediction of acid-base status of growth-restricted fetuses. Ultrasound Obstet Gynecol 2007;30:750-6.
Visser GHA, Bilardo CM, Derks JB, Ferrazzi E, Fratelli N, et al. Fetal monitoring indications for delivery and 2-year outcome in 310 infants with fetal growth restriction delivered before 32 weeks' gestation in the TRUFFLE study. Ultrasound Obstet Gynecol 2017;50:347-352.
Wolf H, Arabin B, Lees CC, Oepkes D, Prefumo F, et al. Longitudinal study of computerized cardiotocography in early fetal growth restriction. Ultrasound Obstet Gynecol 2017;50:71-78.
WHO recommendations on interventions to improve preterm birth outcomes, 2015; www.who.int
Timing of delivery
| Surveillance finding | Gestational age (weeks) | ||||||||
| ≥24 | ≥26 | ≥29 | ≥30 | ≥32 | ≥34 | ≥36 | ≥37 | ≥38 | |
| Severe preeclampsia with systemic dysfunction | |||||||||
| Ductus venosus absent/reversed a-wave | |||||||||
| Repetitive FHR decelerations | |||||||||
| Biophysical profile <6 | |||||||||
| Computerized FHR short-term variation <3.5 ms | |||||||||
| Computerized FHR short-term variation <4.0 ms | |||||||||
| Umbilical artery reversed end diastolic flow | |||||||||
| Umbilical artery absent end diastolic flow | |||||||||
| Computerized FHR short-term variation <4.5 ms | |||||||||
| Oligohydramnios (maximum vertical pocket <2 cm) | |||||||||
| EFW <3rd and umbilical artery PI >95th or CPR <5th | |||||||||
| EFW 3rd to 10th, umbilical artery PI >95th and CPR <5th | |||||||||
| Computerized FHR short-term variation <5.0 ms | |||||||||
| Preeclampsia | |||||||||
| EFW <3rd, normal Doppler and biophysical profile | |||||||||
| EFW 3rd to 10th, uterine or umbilical artery PI >95th or MCA PI or CPR <5th |
|||||||||
| EFW 3rd to 10th, normal Doppler and biophysical profile | |||||||||
FHR = fetal heart rate; EFW = estimated fetal weight; CPR = cerebroplacental ratio; MCA = middle cerebral artery; ms = milliseconds; PI = pulsatility index
Notes on gestational thresholds for delivery
The delivery thresholds are based on expected neonatal survival and morbidity for gestational age. Below 26 weeks, delivery thresholds need to be individualized based on local survival rates for gestational age, EFW and fetal sex.
Additional measures
- Delivery before 32 weeks: administer MgSO4 for neuroprotection
- Delivery before 34 weeks: administer steroids
Notes on monitoring
- Repetitive decelerations: based on conventional FHR monitoring
- Short-term variation: based on 1 hour recording of computerized FHR monitoring
- Biophysical profile score: based on a ≥30 minute observation period; prolonged sleep episode can result in a score of 4 or 6, if this is suspected the observation period can be extended to 1 hour
- Women presenting with reduced fetal movements may be at increased risk of stillbirth and they should therefore have fetal Doppler and biophysical profile assessment within a few hours of presentation
- Please note that sinusoidal FHR pattern, especially near term, may indicate feto-maternal hemorrhage
Criteria for monitoring
| GA | Findings | Monitoring |
|---|---|---|
| ≥24 | The mother has non-severe preeclampsia | Fetal growth in 2 weeks Fetal Doppler twice per week BP, creatinine, liver enzymes, platelets 3 times per week |
| Normal fetal condition | Fetal growth in 2 weeks Fetal Doppler in 2 weeks |
|
| Umbilical artery absent (reversed) EDF or PI ≥90th | Fetal growth in 2 weeks Fetal Doppler in 2 weeks |
|
| Ductus venosus PI ≥90th | Fetal growth in 1 week Fetal Doppler in 1 week |
|
| Oligohydramnios | ||
| Umbilical artery absent (reversed) EDF or PI ≥90th and oligohydramnios |
Fetal growth in 1 week Fetal Doppler twice per week |
|
| Ductus venosus PI ≥90th and oligohydramnios | ||
| Umbilical artery absent (reversed) EDF or PI ≥90th and ductus venosus PI ≥90th |
||
| ≥26 | The mother has non-severe preeclampsia | Fetal growth in 2 weeks Fetal Doppler twice per week Fetal heart rate pattern (and/or BPS) 3 times per week BP, creatinine, liver enzymes, platelets 3 times per week |
| Biophysical profile score equal to 6 | Reassess fetal condition within 24 hours | |
| Biophysical profile score equal to 6 and oligohydramnios | Reassess fetal condition within 12 hours | |
| Umbilical artery PI ≥90th | Fetal growth in 1 week Fetal Doppler in 1 week Fetal heart rate pattern (and/or BPS) in 1 week |
|
| Ductus venosus PI ≥90th | Fetal growth in 1 week Fetal Doppler in 1 week Fetal heart rate pattern (and/or BPS) twice per week |
|
| Umbilical artery PI ≥90th and ductus venosus PI ≥90th | Fetal growth in 1 week Fetal Doppler twice per week Fetal heart rate pattern (and/or BPS) 3 times per week |
|
| Umbilical artery absent (reversed) EDF | ||
| Oligohydramnios | Fetal growth in 1 week Fetal Doppler twice per week Fetal heart rate pattern (and/or BPS) daily |
|
| Umbilical artery absent (reversed) EDF and ductus venosus PI ≥90th |
Fetal growth in 1 week Fetal Doppler daily Fetal heart rate pattern (and/or BPS) daily |
|
| ≥30 | Umbilical artery PI ≥90th | Fetal growth in 1 week Fetal Doppler in 1 week Fetal heart rate pattern (and/or BPS) twice per week |
| Ductus venosus PI ≥90th | Fetal growth in 1 week Fetal Doppler twice per week Fetal heart rate pattern (and/or BPS) twice per week |
|
| Umbilical artery absent EDF | Fetal growth in 1 week Fetal Doppler twice per week Fetal heart rate pattern (and/or BPS) 3 times per week |
|
| Umbilical artery absent EDF and oligohydramnios | Fetal growth in 1 week Fetal Doppler 3 times per week Fetal heart rate pattern (and/or BPS) daily |
|
| Umbilical artery absent EDF and ductus venosus PI ≥90th | Fetal growth in 1 week Fetal Doppler 3 times per week Fetal heart rate pattern (and/or BPS) daily |
|
| Umbilical artery absent EDF, ductus venosus PI ≥90th and oligohydramnios |
Fetal growth in 1 week Fetal Doppler daily Fetal heart rate pattern (and/or BPS) daily |
|
| ≥32 | Umbilical artery PI ≥90th | Fetal growth in 2 weeks Fetal Doppler twice per week Fetal heart rate pattern (and/or BPS) twice per week |
| Middle cerebral artery PI ≤10th | ||
| Cerebroplacental ratio ≤10th | Fetal growth in 2 weeks Fetal Doppler in 1 week Fetal heart rate pattern (and/or BPS) in 1 week |
This calculator provides guidance for the management of pregnancies with small for gestational age fetuses and is meant to support rather than replace good clinical judgement. It is assumed that all the provided information is reliable. Neither the FMF nor any other party involved in the research and development of this software shall be held liable for adverse pregnancy outcomes.