Aim

- Summarize areas of consensus and controversy between recently published national guidelines on Small for
Gestational Age or Fetal Growth Restriction
- Highlight any recent evidence that should be incorporated into existing guidelines
- Identify future research priorities in this field
Small for gestational age (SGA)  infant with a birthweight for gestational age <10 th centile for a population or
customized standard
- Include proportion (18 – 22%) who are constitutionally small but healthy
- Fetal growth restriction (FGR)  fetus that has failed to reach its biological growth potential because of
placental dysfunction
o Considerable with SGA
o More difficult to define in practice, as not all FGR infants have a birthweight <10th centile
- Major contributor  placental insufficiency
- Infants born SGA  higher rates of neurodevelopmental delay, poor school performance, childhood and
adult obesity, as well as metabolic disease
- Limitation of antenatal care  majority of SGA pregnancies are not identified before birth
o SGA infants recognized before birth  surveillance and timely delivery  4 – 5 fold reduction in
mortality and/or severe morbidity.
- SGA stillbirth  preventable if detection is improved and management optimized
- Detection and management of SGA  vary internationally and regionally
- Chauhan et al
o Obsolete 200 American Congress of Obstetricians and Gynecologist (ACOG) guidelines vs 2002 Royal
College of Obstetricians and Gynecologists (RCOG) United Kingdome Guidelines
 Considerable variations in content, references cited, and recommendations
o Unterscheider et al
 Compraing 4 national guideline but did not include New Zealand or the French guideline.
 Summarize areas of consensus and controversy between recently published national
guidelines on SGA or FGR
 Highlight any recent evidence that should be incorporated into existing guidelines
 Identity future research priorities in this field.

Materials and Methods

- Searches through MEDLINE and GOOGLE
o MEDLINE
 “Fetal Growth Retardation / Fetal Growth Restriction”
 “Small for Gestational Age”
 “Clinical Practice Guidline”
 Article from 2010 and published in English
 Last search  7th of August 2017
 Four relevant national guidelines
o Google
 National guidelines on diagnosis and management of FGR or SFA
 Three additional guidelines
o The International Guideline Library
 Fetal growth guidelines
 No additional guidelines
- Guideline published before 2010 were not eligible for inclusion as they did not incorporate recently
published evidence
- Each guideline was read by all authors
- Producing summary tables  Early-onset SGA (<32 weeks) and Late-onset SGA considered separately
o Definitions
o Screening
o Prevention of SGA
o Ultrasound surveillance
o Surveillance after diagnosis of SGA
o Timing of delivery
Results
- National Guidelines from 6 countries met the above criteria
o United States (ACOG and Society for Maternal-Fetal Medicine)
o United Kingdom (RCOG)
o Canada (Society of Obstetricians and Gynecologists of Canada)
o New Zealand (New Zealand Maternal Fetal Medicine Network)
o Ireland (Health Service Execcutive)
o France (French College of Gynecologists and Obstetricians)
- All Guideline:
o Importance of an accurate assessment of gestational age to determine whether the pregnancy is
complicated by FGR or is possibly midated
o Broad consensus on definitions of SGA and FGR
 Birthweight or Estimated Fetal Weight (EFW) <10th centile
 4 of 6 guidelines (67%) recommend using a customized for EFW
 The other 2 (33%) recommend using a population reference for EFW
 Some require other evidence of severity such as abnormal Doppler studies or an EFW <3rd
centile to confirm pathological FGR
o Comment on the need for early pregnancy risk selection
o 5 of 6 (83%) guidelines recommend low-dose aspirin treatment for women with major risk factors
for placental insufficiency
o Importance of smoking cessation to prevent SGA
o Use of Growth Chart
 3 of 6 (50%) recommend using customized growth charts
 2 of 6 (33%) recommend use of McDonald rule
 1 does not specify a reference
o Third-trimested ultrasound in low- and high- risk women are compared
 5 of 6 (83%) agree that there is no current evidence to support routine third-trimester
scanning
 4 of 6 (67%) specify that women with major risk factors should have serial scans in the third
trimester
o Unanonimous agreement about the importance of undertaking umbilical artery (UA) Doppler studies
in suspected SGA pregnancies as this has been shown to reduce perinatal mortality and not guideline
currently incorporates recommendations on utility of third-trimester biomarkers
o Surveillance and timing of birth in late-onset SGA/FGR (≥32 weeks)
 4 of 6 (83%) recommend undertaking cerebral Doppler studies and using that information to
influence the management
 There is considerably inconsistency in term of recommended frequency for ongoing growth
scans after the diagnosis of SGA/FGR (2-4 weekly), fetal surveillance methods (most
recommend undertaking cardiotocography (CTG)), and timing of delivery.
 Recommend delivery at 37 – 38 weeks (5 of 6 (83%) guidelines)
 Abnormal Doppler studies
o Raised UA
o Uterine artery
o Reduced Cerebral Doppler
 EFW <3rd centile
o Management approach in early-onset SGA/FGR (<32 weeks)
 Universal agreement of corticosteroid use before birth that is likely to occur at <34 weeks 0
days
 RCOG alone recommends corticosteroid up to 35 weeks 6 days
 4 of 6 (67%) recommend use of Magnesium Sulfate for neuroprotection before very preterm
delivery, with gestation of administration varying from <30 to 32 – 33 weeks.
 Regarding timing of delivery for preterm FGR with absent or reversed end-diastolic velocity
the recommendation for timing of delivery vary from 32 – 34 weeks and 30 – 34 weeks
(respectively, majority 4 of 6, 67%)
 Cesarean delivery should be undertaken with this severe Doppler abnormality
  The commonest criterion for deciding when to deliver, based on fetal grounds 
computerized antenatal CTG (3 of 6, 50%) which includes a real-time automated assessment
of short-term fetal heart rate variability
- Comment
o Areas where there is potential for improved convergence between SGA Guidelines
 Definitions of FGR
 All guideline recommended that EFW <10th centile is an appropriate definition of
FGR
o Some require additional parameters to confirm pathological growth
restriction
 Incorporation of a measure of reduced growth velocity was inconsistent (4 of 6;
67%) but often without a specific definition
 Early – onset FGR  <32 weeks
o 3 solitary parameters (Abdominal Circumference (AC) <3rd centile, Estimated
Fetal Weight (EFW) <3rd centile, and absent end-diastolic velocity)
o 4 contributory parameter (AC or EFW <10th centile with a PI >95th in either
UA or uterine artery)
 Late – onset FGR  ≥32 weeks
o 2 solitary parameters (AC or EFW <3rd centile)
o 4 contributory parameter (AC or EFW <10th centile, AC or EFW crossing
centiles by >2 quartile on growth charts, cerebroplacental ratio >5th centile
or UA pulsality index (PI))
 Recent publication
o Fetuses with a >30% reduction in EFW with a birthweight in the normal
range are more likely to be acidotic at birth, have abnormal
cerebroplacental ratio, and have lower percentage body fat
 Further support for adding reduced growth velocity to definitions of
FGR in future guidelines
o Low-dose Aspirin
 Recommended for women at increased risk of preeclampsia
 Recent publications
 Marked reduction in risk of early-onset preeclampsia in women who are identified
high – risk during 1st trimester screening (maternal history, uterine artery Doppler,
blood pressure, serum pregnancy-associated plasma protein plasma protein (PAPP)-
A, and placental growth factor and treated with low-dose aspirin 150 mg in the
evening
 Reduction in SGA has also been demonstrated especially in high-risk women
 Aspirin more effective in preventing preeclampsia and FGR when started at <16
weeks and in a dose of 100 mg compared with 60 mg
 5 of 6 guidelines (83%)
o Recommend low-dose aspirin for prevention of SGA with 3 specifying that
low-dose aspirin should be started by 16 weeks
o The other journal recommended up to 20weeks (New Zealand Maternal
Fetal Medicine Network guideline)
 The French guideline specifies that the aspirin should be taken in the evening to
maximize efficacy which is based on Randomized Controlled Trial (RCT) evidence
o Should be incorporated into the other guidelines
o Role of Heparin in preventing SGA
 Meta analysis data
 Not effective in preventing FGR in women with previous severe or early – onset FGR,
or in those with thrombophilia, and can therefore not be recommended.
o Uterine artery Doppler Velocimetry screening