Fetal Growth Restriction (FGR · Doppler)

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Early vs late onset + Doppler (Delphi)
   Early vs late onset + Doppler (Delphi)? (FGR is not SGA (constitutionally small); it is placental insufficiency, accounting for 5–10%. Delphi divides early-onset (<32 weeks) vs late-onset (≥32 weeks). Must check anatomy + infection + chromosomes (especially early-onset) to exclude non-placental causes.)
   • Early-onset (<32 weeks): AC/EFW <3rd percentile or UA-PI >95/UtA-PI >95 with AC/EFW <10 → Early-onset FGR · Doppler-graded monitoring
   • Late-onset (≥32 weeks): AC/EFW <3 or ≥2 of (<10, crossing 2 quartiles, CPR <5 or UA-PI >95) → Late-onset FGR · CPR/CTG monitoring
   • UA absent/reversed end-diastolic flow (AEDV/REDV) or DV a-wave reversed or abnormal CTG → Critical Doppler · admit for close monitoring
2. [End] Early-onset FGR · Doppler-graded monitoring
   Early-onset FGR (<32 weeks): mostly placental, strongly associated with preeclampsia; serial growth (2–3 weeks) + Doppler (UA/MCA/CPR/DV) + UtA + maternal preeclampsia assessment (BP/PlGF) + exclude infection/chromosomes; monitor by Doppler grade, time delivery by TRUFFLE (DV/CTG-STV guided).
3. [End] Late-onset FGR · CPR/CTG monitoring
   Late-onset FGR (≥32 weeks): relies on brain-sparing (MCA-PI down → CPR down), UA/DV often normal, prone to sudden decompensation; close monitoring of CPR/UA + growth + CTG; abnormal CPR/UA → deliver around 37 weeks, isolated SGA → 38–39 weeks; harder to diagnose than to manage.
4. [End] Critical Doppler · admit for close monitoring
   Critical Doppler (UA absent/reversed end-diastolic AEDV/REDV, DV a-wave reversed, abnormal CTG): fetal decompensation, high stillbirth risk (DV a-wave reversed → stillbirth ~46%); admit for close monitoring + steroids (<34 weeks) + magnesium sulfate neuroprotection (<32 weeks); individualize delivery timing by GA and Doppler/CTG; multidisciplinary.

Source guidelines & references

• Fetal growth restriction definition and management (Delphi consensus; SMFM Consult #52; FIGO 2021)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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