Consensus and controversies of international guidelines for the diagnosis, surveillance and management of fetal growth restriction: an updated comparison.

Abstract

<h4>Objective</h4>To compare areas of consensus and disagreements across contemporary international and national guidelines on the diagnosis, surveillance, and management of fetal growth restriction (FGR).<h4>Data sources</h4>Electronic searches of MEDLINE from database inception up to March 2026 using MeSH terms and keywords related to FGR and guidelines.<h4>Study eligibility criteria</h4>Critical, structured comparison of national or international guidelines on FGR published since 2010. Final inclusion required unanimous agreement from all authors.<h4>Study appraisal and synthesis methods</h4>Pre-specified extraction across domains: definition; prediction/prevention; surveillance tools and frequency; delivery timing and mode; and labor induction methods. Dual data checking with consensus resolution. We focused mainly on areas of cross-guideline agreement and divergence in (1) definitions (FGR vs small-for-gestational age [SGA]; early vs late), (2) diagnostic/surveillance tools (biometry, Doppler, cardiotocography CTG (conventional or computerized), biophysical profile, biomarkers), and (3) management (aspirin/low-molecular weight heparin [LMWH], steroids, magnesium sulfate, induction methods, delivery timing/mode).<h4>Results</h4>Six guidelines, three national (Canada, United Kingdom, France), one US society guideline (SMFM) and two international societies (ISUOG, FIGO) published predominantly between 2015 and 2024 were included. Broad agreement exists on the central role of Doppler-especially umbilical artery and, in early-onset cases, ductus venosus (except for SMFM) -for risk stratification and delivery timing. Other consensus points include antenatal corticosteroids, magnesium sulfate for anticipated preterm birth, early aspirin in high-risk pregnancies, and access to genetic counseling/testing in severe or early-onset FGR with structural anomalies. Universal third-trimester ultrasound is not recommended in low-risk pregnancies. Controversies remain on the definition of FGR versus SGA (SMFM biometric threshold vs Delphi criteria), routine use of angiogenic biomarkers, LMWH for prevention, choice of growth charts, the role of the biophysical profile, computerized CTG, and induction methods (mechanical generally favored but with limited evidence).<h4>Conclusions</h4>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 and DV), clarifying growth-chart selection, and rigorously testing the added value of angiogenic biomarkers and induction strategies to improve FGR outcomes.