TOPLINE:

Six major international and national guidelines on fetal growth restriction (FGR) converge on Doppler-based surveillance and standard preterm interventions but diverge substantially on how FGR is defined and how fetal deterioration is monitored. Major discrepancies include the use of biometric thresholds vs Delphi consensus criteria, the role of ductus venosus and computerized cardiotocography, and the application of angiogenic biomarkers.

METHODOLOGY:

• Researchers conducted a systematic search of MEDLINE from database inception to March 2026 using MeSH terms and keywords related to FGR and guidelines, supplemented by manual screening of reference lists.
• A total of six guidelines were included: three national (Canada, UK, France), one US society guideline (Society for Maternal-Fetal Medicine [SMFM]), and two international societies (International Society of Ultrasound in Obstetrics and Gynecology [ISUOG], International Federation of Gynecology and Obstetrics [FIGO]), published predominantly between 2015 and 2024.
• Inclusion criteria required national or international clinical practice guidelines published from 2010 onward and available in English, with unanimous agreement from all authors for final inclusion.
• Data extraction focused on predefined domains including definition, differentiation between small for gestational age and FGR, prediction and prevention strategies, surveillance tools and frequency, delivery timing and mode, and labor induction methods.
• Dual data checking with consensus resolution was performed, and extracted data were cross-checked against original guideline documents by all coauthors to ensure accuracy.

TAKEAWAY:

• Four of six guidelines adopt the Delphi consensus criteria for FGR definition, while SMFM uses only estimated fetal weight or abdominal circumference below the 10th centile, and the French guideline uses a nuanced distinction based on longitudinal growth trends and Doppler findings.
• All guidelines except SMFM recommend ductus venosus Doppler for surveillance of early-onset FGR before 32 weeks and to guide timing of delivery, with abnormal ductus venosus associated with a 40%-70% increased risk for stillbirth and neonatal mortality.
• Four guidelines (Royal College of Obstetricians and Gynaecologists, FIGO, ISUOG, French College of Gynecologists and Obstetricians) support computerized cardiotocography use in early-onset FGR with defined short-term variability thresholds, while Society of Obstetricians and Gynaecologists of Canada and SMFM do not recommend its routine use.
• All guidelines recommend antenatal corticosteroids from 24+0 to 34+6 weeks and magnesium sulfate for fetal neuroprotection between 24+0 and 33+6 weeks in pregnancies complicated by FGR, following the same protocols as for non-FGR pregnancies at high risk for preterm birth.

IN PRACTICE:

“Current guidelines converge on Doppler-based surveillance and standard preterm interventions, but substantial heterogeneity persists in definitions and several management domains, reflecting variable evidence and resource contexts. Priorities include harmonizing definitions, validating surveillance algorithms (notably computerized CTG [cardiotocography] and DV [ductus venosus]), clarifying growth-chart selection, and rigorously testing the added value of angiogenic biomarkers and induction strategies to improve FGR outcomes,” wrote the authors of the study.

SOURCE:

The study was led by Daniele Di Mascio, MD, Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy. It was published online on April 10 in the American Journal of Obstetrics and Gynecology.

LIMITATIONS:

This is a descriptive review that does not assess clinical outcomes associated with adherence to specific guidelines. Only guidelines available in English were included, which may have limited representation of recommendations from regions where national guidelines are published in other languages. Recommendations are dynamic and may evolve as new evidence emerges, and differences across guidelines may reflect the timing of publication and availability of emerging evidence. Some divergences might reflect variability in resource availability and feasibility across healthcare systems.

DISCLOSURES:

No funding was received for this study. The authors reported having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.