Controversies in the management of fetal growth restriction: a state-of-the-art review

Abstract

Fetal growth restriction (FGR) affects 5%-10% of pregnancies and remains a major contributor to stillbirth, neonatal morbidity, and long-term adverse outcomes. Despite its clinical importance, substantial controversy persists regarding its definition, diagnostic criteria, surveillance modalities, and optimal timing of delivery. Divergence among major professional societies reflects gaps in outcome-based evidence and differing philosophical approaches to physiologic staging. This review examines current controversies and proposes a pragmatic approach to harmonize practice. We propose incorporating fetal growth velocity (>2 quartile drop) into the diagnostic criteria for FGR in conjunction with estimated fetal weight and abdominal circumference. In addition, we recommend assessment of the ductus venosus in pregnancies complicated by early-onset FGR and abnormal umbilical artery Doppler findings. We also support offering amniocentesis for genetic testing in all cases of unexplained FGR and propose delivery thresholds based on both biometric parameters and Doppler abnormalities to better guide clinical management.