. 2021 Mar 19;152(Suppl 1):3–57. doi: 10.1002/ijgo.13522

TABLE 1.

Recommendations for monitoring, timing, and mode of delivery in cases with suspected fetal growth restriction.

Findings	Risk of stillbirth	Suggested monitoring ^a	Timing and mode of delivery ^b
SGA (EFW at 3rd–9th percentile, normal fluid and Doppler studies)	Low	Doppler (UA, MCA) every 1–2 weeks Growth every 2 weeks At ≥37 weeks consider BPP/NST 1–2 times per week ^c	37–39 weeks Mode of delivery: induction
Uncomplicated FGR at <3rd percentile (normal fluid and Doppler studies)	Low	Doppler (UA, MCA) 1–2 times per week Growth every 2 weeks At ≥37 weeks consider BPP/NST 1–2 times per week ^c	36–38 weeks Mode of delivery: induction
FGR with mild abnormalities: Early Doppler changes: UA PI >95th percentile, or MCA PI <5th percentile, or CPR <5th percentile, or UtA PI >95th percentile Oligohydramnios Suboptimal interval growth Suspected pre‐eclampsia	Low	Consider inpatient monitoring Consider steroids for fetal lung maturation BPP/NST 1–2 times per week Doppler (UA, MCA, DV) 1–2 times per week Growth every 2 weeks	34–37 weeks Mode of delivery: cesarean section or induction
FGR with umbilical artery AEDV/REDV	Overall risk of stillbirth ³³² : AEDV: 6.8%, OR 3.6 [2.3–5.6] REDV: 19%, OR 7.3 [4.6–11.4] Risk of stillbirth with strict monitoring protocol with a safety net ³⁴³ : AEDV: 0%–1% REDV: 1%–2% Median time for deterioration: AEDV: 5 days REDV: 2 days	Inpatient monitoring Steroids for fetal lung maturation BPP/NST 1–2 times per day Doppler (UA, MCA, DV) every 1–2 days Growth every 2 weeks	AEDV: 32–34 weeks ^d REDV: 30–32 weeks ^d Mode of delivery: cesarean section
FGR with abnormal ductus venosus Doppler	Overall risk of stillbirth ³³² : 20%, OR 11.6 (6.3–19.7) Risk of stillbirth with strict monitoring protocol with a safety net ³⁴³ : Elevated DV PIV: 2% Absent‐reverse a‐wave in DV: 4%	Inpatient monitoring Steroids for fetal lung maturation BPP/NST twice per day Daily Doppler	26–30 weeks ^d Mode of delivery: cesarean delivery

Abbreviations: AEDV/REDV, absent or reversed diastolic velocity in the umbilical artery; BPP, biophysical profile; CPR, cerebroplacental ratio; DV, ductus venosus; FGR, fetal growth restriction; MCA, middle cerebral artery; NST, nonstress test; OR, odds ratio; PI, pulsatility index; PIV, pulsatility index for veins; SGA, small for gestational age; UA, umbilical artery; UtA, uterine artery.

^{^a}

Monitoring should be based on integration of multiple modalities (Doppler, BPP, NST).

^{^b}

Absolute indications for delivery at any gestational age and birth weight combination that are considered to be viable include: BPP or NST abnormalities or severe pre‐eclampsia with uncontrolled hypertension or end‐organ damage (section 8.2.3). In addition, timing of delivery should be individualized based on factors such as parental decision regarding threshold for intervention.

^{^c}

There is lack of evidence on the appropriate test to predict the risk of fetal deterioration and on the optimal monitoring strategy in cases of uncomplicated SGA fetuses, especially at term. Given this, there are differences in practice in various regions of the world regarding use of BPP/NST for fetal monitoring in this context, and some of the authors of these guidelines do not use BPP or NST for monitoring of fetuses with uncomplicated SGA as long as Doppler studies are normal. We suggest that the decision regarding use of BPP/NST should be based on local practices, the risk profile of the local population, and the available resources in each particular setting.

^{^d}

Timing should be individualized based on local neonatal outcomes. Before 26 weeks, careful and shared decision making with the parents and neonatology team is recommended.