Fetal Growth Restriction (FGR)

Approach

1. Confirm gestational age with first trimester CRL (7–60 mm; earliest scan with CRL ≥10 mm on multiple scans); Biometry before 22+0 weeks is acceptable; If the date is uncertain, perform serial USG at least 2 weeks apart.
2. Measure SFH at every visit starting from 24+0 weeks in low-risk pregnant women; perform USG biometry if threshold is exceeded (thresholds: Guide difference).
3. Monitor with USG instead of SFH in cases of high BMI (especially >35 kg/m²), polyhydramnios or large myoma.
4. Plan serial growth USG in pregnant women with risk factors; The starting week and interval vary depending on the risk level (Guideline difference).
5. Perform serial SFH and selective USG instead of routine 3rd trimester USG in low risk cases.
6. If >2 quartile percentile decrease is observed in the growth curve, perform Doppler evaluation with suspicion of FGR.

Note

• Do not repeat biometric measurements more frequently than every 2 weeks.
• Do not routinely order UA Doppler (including CPR) in a low-risk pregnancy.

Approach

1. Confirm gestational age with first trimester CRL.
2. Confirm growth decline by repeated measurement at least 2 weeks apart.
3. At ≥32+0 weeks: evaluate with UA PI and CPR; the Delphi criterion for late FGR is met if a decline of >2 quartile bands is accompanied by CPR <5th percentile or UA PI >95th percentile.
4. Apply the early FGR criteria at <32+0 weeks: when size is ≥10th percentile, declining growth or an isolated UA PI/CPR abnormality is not sufficient on its own; UA AEDF is a stand-alone criterion (growth velocity threshold: Guideline difference).
5. If FGR criteria are met, monitor as early FGR if the gestational age at diagnosis is <32+0 weeks, and late as FGR if it is ≥32+0 weeks; Make your follow-up and birth plan according to the Doppler level.

Note

• Do not repeat biometric measurements more frequently than every 2 weeks.

Approach

1. Provide genetic counseling; Recommend invasive prenatal diagnostic testing including CMA regardless of week.
2. Request maternal serology at signs of infection (brain or liver echogenicity or calcification, ventriculomegaly, echogenic bowel, hydrops); Add CMV PCR in amniocentesis, plan sampling time according to gestational week and estimated maternal infection date (Guideline difference).
3. Individualize management according to the nature of the disorder, prognosis, gestational age, and family wishes; Explain that changing the timing may not improve the outcome.
4. Co-manage with center with expertise in fetal medicine and MFM.

Note

• Do not use NIPT as a substitute for an invasive diagnostic test.
• Note that AC measurement has limited diagnostic value in omphalocele or gastroschisis.

Approach

1. Perform detailed anatomy USG.
2. Provide genetic counseling; recommend invasive prenatal diagnostic testing with CMA in unexplained early FGR; in late-onset cases (≥32+0 weeks) with EFW <3rd percentile, recommendations differ by guideline (Guideline difference).
3. If amniocentesis is performed, request CMV PCR in amniotic fluid; Plan the sampling time according to the week of gestation and estimated date of maternal infection, there is a risk of false negatives in early sampling (Guideline difference).
4. Make the decision for maternal infection serology based on marker and history; coverage varies by guide (Guide difference).
5. Record findings supporting a placental cause with UtA Doppler and placental appearance.
6. Assess blood pressure and proteinuria at each check-up; Hypertensive disease is common in early FGR.
7. Individualize management according to the identified cause, prognosis, gestational age, and family wishes; Explain that changing the timing may not improve the outcome.
8. Manage early FGR (<32+0 weeks) at a tertiary center together with MFM and neonatology.

Note

• Do not use NIPT as a substitute for an invasive diagnostic test; a normal NIPT result does not exclude a genetic cause.
• Do not order hereditary thrombophilia testing.
• Do not routinely order antiphospholipid antibody testing; test only in selected patients based on their history.

Approach

1. If detailed anatomy USG has not been performed, perform it.
2. Do not routinely recommend fetal genetic diagnostic testing; evaluate regardless of gestational age if there is a malformation, polyhydramnios or another genetic concern.
3. Make maternal infection serology decision based on marker and history (Guideline difference).
4. Record findings supporting a placental cause with UtA Doppler and placental appearance.
5. Assess blood pressure and proteinuria.

Note

• Do not order hereditary thrombophilia testing.
• Do not routinely order antiphospholipid antibody testing.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Repeat biometrics every 2–4 weeks (no more often than 2 weeks).
4. Perform UA Doppler every 1–2 weeks; If it remains normal, extend the interval according to the guide (Guide difference).
5. Perform fetal well-being testing (NST/cCTG or BPP) weekly; Question about decreased fetal movement.
6. If there are no additional maternal or fetal findings requiring hospitalization, monitor on an outpatient basis.
7. If Doppler is broken, go to the relevant step.
8. Plan birth within the guideline range after 37+0 weeks. [If there is no oligohydramnios and hypertensive disease (gestational HT, preeclampsia, chronic HT)]

Treatment

• Based on viability and active neonatal care decision (lower limit: Guideline difference), if birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Before 34+0 weeks, instead of betamethasone — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• Consider a case at 34+0–36+6 weeks, who has not previously received antenatal corticosteroids in this pregnancy, who does not have pregestational diabetes, and who has a high risk of birth within 7 days, before 37+0 weeks — Betamethasone: 12 mg IM, 2 doses (single course) with an interval of 24 hours.
• If birth is expected within 24 hours before 32+0 weeks, based on viability and active neonatal care decision (lower limit: Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not rely on amniotic fluid alone as the basis for management decisions.
• Do not recommend activity restriction or bed rest.
• If steroids are given after 34+0 weeks, monitor for hypoglycemia in the newborn.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Plan the birth between 37+0–39+6 weeks, according to the guide; do not go beyond the expected due date (range and guidelines: Guideline difference). [If there is no oligohydramnios and hypertensive disease (gestational HT, preeclampsia, chronic HT)]
4. Continue UA Doppler and fetal well-being test monitoring until birth.
5. Plan the delivery route according to the mode of delivery and the normal Doppler branch in the intrapartum section.

Note

• Do not rely on amniotic fluid alone as the basis for management decisions.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Delphi FGR criteria are met even if Doppler is normal (smallness at diagnosis at ≥32+0 weeks and >2 quartile percentile drop; smallness at diagnosis at <32+0 weeks and UtA PI >95th percentile); Do not use the SGA pathway.
4. Repeat biometrics at least 2 weeks apart.
5. Perform fetal well-being testing with UA and MCA/CPR Doppler at least weekly (Guideline difference).
6. If UA PI increases, CPR/MCA is impaired, or AEDF/REDF develops, proceed to the relevant step.
7. Plan the birth within the guideline range of 37+0–39+0 weeks (Guideline difference). [If there is no oligohydramnios and hypertensive disease (gestational HT, preeclampsia, chronic HT)]

Treatment

• Based on viability and active neonatal care decision (lower limit: Guideline difference), if birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Before 34+0 weeks, instead of betamethasone — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• Consider a case at 34+0–36+6 weeks, who has not previously received antenatal corticosteroids in this pregnancy, who does not have pregestational diabetes, and who has a high risk of birth within 7 days, before 37+0 weeks — Betamethasone: 12 mg IM, 2 doses (single course) with an interval of 24 hours.
• If birth is expected within 24 hours before 32+0 weeks, based on viability and active neonatal care decision (lower limit: Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.
• At 32+0–33+6 weeks, if birth is expected within 24 hours, it may be considered according to the guideline (Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not rely on amniotic fluid alone as the basis for management decisions.
• Do not recommend activity restriction or bed rest.
• If steroids are given after 34+0 weeks, monitor for hypoglycemia in the newborn.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Delphi FGR criteria are met even if Doppler is normal (smallness at diagnosis at ≥32+0 weeks and >2 quartile percentile drop; smallness at diagnosis at <32+0 weeks and UtA PI >95th percentile); Do not use the SGA pathway.
4. Plan your birth without delaying it.
5. Plan the birth within the guideline range of 37+0–39+0 weeks (Guideline difference). [If there is no oligohydramnios and hypertensive disease (gestational HT, preeclampsia, chronic HT)]
6. Continue UA Doppler and fetal well-being test monitoring until birth.
7. Plan the delivery route according to the mode of delivery and the normal Doppler branch in the intrapartum section.

Note

• Do not rely on amniotic fluid alone as the basis for management decisions.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Repeat biometrics every 2–3 weeks.
4. Perform UA Doppler once a week (1–2 times a week according to the guidelines).
5. Perform fetal well-being testing (NST/cCTG or BPP) at least weekly (Guideline difference).
6. If there are no additional maternal or fetal findings requiring hospitalization, monitor on an outpatient basis.
7. Complete etiological evaluation (anatomy, genetic counseling).
8. If Doppler is broken, go to the relevant step.
9. Plan birth within the guideline range of 36+0–38+0 weeks. [If there is no oligohydramnios and hypertensive disease (gestational HT, preeclampsia, chronic HT)]
10. If oligohydramnios or hypertensive disease is accompanied, plan the birth individually between 34+0–37+6 weeks; Apply indication for earlier maternal or fetal delivery (Guideline difference). [only if Oligohydramnios or Hypertensive disease (gestational hypertension, preeclampsia, chronic hypertension) is selected]

Treatment

• Based on viability and active neonatal care decision (lower limit: Guideline difference), if birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Before 34+0 weeks, instead of betamethasone — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• Consider a case at 34+0–36+6 weeks, who has not previously received antenatal corticosteroids in this pregnancy, who does not have pregestational diabetes, and who has a high risk of birth within 7 days, before 37+0 weeks — Betamethasone: 12 mg IM, 2 doses (single course) with an interval of 24 hours.
• If birth is expected within 24 hours before 32+0 weeks, based on viability and active neonatal care decision (lower limit: Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.
• At 32+0–33+6 weeks, if birth is expected within 24 hours, it may be considered according to the guideline (Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• If steroids are given after 34+0 weeks, monitor for hypoglycemia in the newborn.
• Do not recommend activity restriction or bed rest.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Plan the birth between 36+0–38+0 weeks, according to the guide; If diagnosed after this interval, deliver at diagnosis (range and guidelines: Guideline difference). [If there is no oligohydramnios and hypertensive disease (gestational HT, preeclampsia, chronic HT)]
4. If oligohydramnios or hypertensive disease is accompanied, plan the birth individually between 34+0–37+6 weeks; Apply indication for earlier maternal or fetal delivery (Guideline difference). [only if Oligohydramnios or Hypertensive disease (gestational hypertension, preeclampsia, chronic hypertension) is selected]
5. Monitor with weekly UA Doppler and fetal well-being test until birth.
6. Plan the delivery route according to the mode of delivery and the normal Doppler branch in the intrapartum section.

Treatment

• Consider a case at 34+0–36+6 weeks, who has not previously received antenatal corticosteroids in this pregnancy, who does not have pregestational diabetes, and who has a high risk of birth within 7 days, before 37+0 weeks — Betamethasone: 12 mg IM, 2 doses (single course) with an interval of 24 hours.

Note

• If steroids are given after 34+0 weeks, monitor for hypoglycemia in the newborn.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Perform UA Doppler 1–2 times per week; Addition of MCA and DV varies by guideline (Guideline difference).
4. Perform fetal well-being testing (NST/cCTG or BPP) 1–2 times a week.
5. Repeat the abnormal MCA/CPR value within 24 hours; If there is an indication for urgent labor, do not delay delivery for repeat measurement. [CPR only <5. p or MCA PI <5. if p is selected]
6. Repeat biometrics every 2 weeks.
7. Inpatient evaluation for oligohydramnios, PE or other comorbidity; If monitoring is required more than 3 times a week, consider hospitalization.
8. Manage early FGR at a tertiary center with MFM and neonatology; If birth is expected before 34 weeks, plan it in a NICU center.
9. If DV/STV deteriorates or AEDF/REDF develops, proceed to the relevant step; If the finding does not progress, plan the birth within the guideline range starting from 34+0 weeks at the earliest (34+0–37+6 weeks; Guideline difference).

Treatment

• Based on viability and active neonatal care decision (lower limit: Guideline difference), if birth is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Alternative corticosteroid — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• If birth has not occurred after the first course and rescue-course criteria are met — Betamethasone (rescue course): 12 mg IM single dose (2 doses of 12 mg given 24 hours apart are also acceptable); Only before the 34th week, maximum one rescue dose/course throughout pregnancy.
• If birth is expected within 24 hours before 32+0 weeks, based on viability and active neonatal care decision (lower limit: Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.
• At 32+0–33+6 weeks, if birth is expected within 24 hours, it may be considered according to the guideline (Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Do not consider abnormal UA Doppler as an obstacle to steroids; do not change the plan on the basis of temporary UA improvement after steroids.
• Do not use sildenafil, LMWH, progesterone, or routine nutritional supplementation as treatment for diagnosed FGR; do not recommend bed rest. Maternal oxygen and aspirin initiated after diagnosis also lack evidence.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Plan the birth between 34+0–37+6 weeks, according to the guide; do not automatically choose the lower end of the range if findings are stable (range and guides: Guide difference).
4. Perform UA Doppler and fetal well-being testing 1–2 times a week.
5. Repeat biometrics every 2 weeks.
6. Repeat the abnormal MCA/CPR value within 24 hours; If there is an indication for urgent labor, do not delay delivery for repeat measurement. [CPR only <5. p or MCA PI <5. if p is selected]
7. Evaluate inpatient for comorbidity.
8. If DV/STV deteriorates or AEDF/REDF develops, proceed to the relevant step.
9. Plan the delivery route according to the mode of delivery and normal Doppler / UA PI branch in the intrapartum section.

Treatment

• Consider in patients who have not previously received antenatal corticosteroids during this pregnancy, do not have pregestational diabetes, and are at high risk of delivery within the next 7 days and before 37+0 weeks — Betamethasone: 12 mg IM, 2 doses 24 hours apart (single course).

Note

• If steroids are given after 34+0 weeks, monitor for hypoglycemia in the newborn.
• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Do not recommend activity restriction or bed rest.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Plan birth without delay; Most guidelines recommend delivery at 37+0 weeks, at diagnosis later than this week, at 37+6 weeks at the latest (Guideline difference).
4. Plan the delivery route according to the mode of delivery and normal Doppler / UA PI branch in the intrapartum section.

Note

• Do not rely on amniotic fluid alone as the basis for management decisions.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Repeat the abnormal MCA/CPR value in 24 hours.
4. Increase monitoring frequency: Perform Doppler and fetal well-being test 1–2 times a week (Guideline difference).
5. Repeat biometrics every 2 weeks.
6. If UA PI increases, AEDF/REDF develops or DV/STV deteriorates, proceed to the relevant step.
7. If EFW or AC <3rd percentile coexists with low CPR/MCA, plan delivery within the guideline range of 34+0–37+6 weeks (Guideline difference). [only if EFW or AC <3rd percentile is selected]
8. Base the decision on delivery before 37+0 weeks on surveillance and accompanying findings; most guidelines do not recommend delivery before 37+0 weeks for low CPR/MCA alone (Guideline difference). [If neither EFW nor AC is <3rd percentile]

Treatment

• Based on viability and active neonatal care decision (lower limit: Guideline difference), if birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Before 34+0 weeks, instead of betamethasone — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• Consider a case at 34+0–36+6 weeks, who has not previously received antenatal corticosteroids in this pregnancy, who does not have pregestational diabetes, and who has a high risk of birth within 7 days, before 37+0 weeks — Betamethasone: 12 mg IM, 2 doses (single course) with an interval of 24 hours.
• If birth is expected within 24 hours before 32+0 weeks, based on viability and active neonatal care decision (lower limit: Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.
• At 32+0–33+6 weeks, if birth is expected within 24 hours, it may be considered according to the guideline (Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• If steroids are given after 34+0 weeks, monitor for hypoglycemia in the newborn.
• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Do not recommend activity restriction or bed rest.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Plan birth within the guideline range: 37+0–39+0 weeks; guides diverge (Guide difference). [EFW or AC <3. p and if there is no Oligohydramnios and Hypertensive disease (gestational HT, preeclampsia, chronic HT)]
4. With EFW or AC <3rd percentile or a concomitant condition: do not delay delivery; do not go beyond 37+6 weeks (Guideline difference). [Only if EFW or AC <3rd percentile, oligohydramnios, or hypertensive disease (gestational hypertension, preeclampsia, chronic hypertension) is selected]
5. With Delphi FGR: plan delivery without delay (Guideline difference). [if only 'EFW or AC <10th percentile and a fall of >2 quartile bands at ≥32+0 weeks, or UtA PI >95th percentile at diagnosis before 32+0 weeks' is selected]
6. Plan the delivery route according to the mode of delivery and the normal Doppler / CPR branch in the intrapartum section.

Note

• Do not rely on amniotic fluid alone as the basis for management decisions.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Make an individual decision by discussing the prognosis and options with the family, obstetrics and neonatology team; Provide comprehensive support throughout the decision process.
4. If active neonatal care is not planned, clearly discuss the option of avoiding birth with a fetal indication.
5. If active care is decided, plan follow-up and delivery at a tertiary center with MFM and neonatology.
6. Complete etiological assessment (anatomy, genetics, infection); The result may change the decision.
7. If the finding progresses, re-evaluate according to the birth criteria in the relevant week.

Treatment

• If active neonatal care is decided and birth is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• If active neonatal care is decided, instead of betamethasone — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• If active neonatal care has been decided, delivery has not occurred after the initial course, and rescue criteria are met — Betamethasone (rescue course): 12 mg IM single dose (2 × 12 mg 24 hours apart is also acceptable); only before 34 weeks, maximum one rescue dose/course per pregnancy.
• If active neonatal care is decided and birth is expected within 24 hours — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Do not use sildenafil, LMWH, progesterone, or routine nutritional supplementation as treatment for diagnosed FGR; do not recommend bed rest. Maternal oxygen and aspirin initiated after diagnosis also lack evidence.
• Do not consider abnormal UA Doppler as an obstacle to steroids; do not change the plan on the basis of temporary UA improvement after steroids.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Consider inpatient monitoring (Guideline difference).
4. Perform UA Doppler 2–3 times a week (every 2–3 days); Adding DV varies depending on the guide (Guide difference).
5. Perform fetal well-being testing frequently: 1–2 times a day to every 2–3 days according to the guideline (Guideline difference).
6. If DV a wave loss or reversal, low STV, or an indication independent of the week develops, deliver; Otherwise, aim to reach the guideline range for AEDF (32+0–34+0 weeks).
7. Plan follow-up and delivery at a tertiary center with MFM and neonatology.

Treatment

• If birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Alternative corticosteroid — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• If birth has not occurred after the first course and rescue-course criteria are met — Betamethasone (rescue course): 12 mg IM single dose (2 doses of 12 mg given 24 hours apart are also acceptable); Only before the 34th week, maximum one rescue dose/course throughout pregnancy.
• If birth before 32+0 weeks is expected within 24 hours — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Do not consider abnormal UA Doppler as an obstacle to steroids; do not change the plan on the basis of temporary UA improvement after steroids.
• Do not use sildenafil, LMWH, progesterone, or routine nutritional supplementation as treatment for diagnosed FGR; do not recommend bed rest. Maternal oxygen and aspirin initiated after diagnosis also lack evidence.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Plan birth within the guideline range: 32+0–34+0 weeks; latest limit of guidelines 34+0 weeks (interval and guidelines: Guideline difference); Time of birth when AEDF is detected in late-onset FGR (diagnosis ≥32+0 weeks): Guideline difference.
4. Monitor as an inpatient until delivery with frequent Doppler and fetal well-being testing.
5. Plan the birth in a NICU center with MFM and neonatology.
6. Plan the delivery route according to the AEDF/REDF/DV branch in the Delivery mode and intrapartum section.

Treatment

• If birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Alternative corticosteroid — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• If birth has not occurred after the first course and rescue-course criteria are met — Betamethasone (rescue course): 12 mg IM single dose (2 doses of 12 mg given 24 hours apart are also acceptable); Only before the 34th week, maximum one rescue dose/course throughout pregnancy.
• At 32+0–33+6 weeks, if birth is expected within 24 hours, it may be considered according to the guideline (Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Do not consider abnormal UA Doppler as an obstacle to steroids; do not change the plan on the basis of temporary UA improvement after steroids.
• Do not use sildenafil, LMWH, progesterone, or routine nutritional supplementation as treatment for diagnosed FGR; do not recommend bed rest. Maternal oxygen and aspirin initiated after diagnosis also lack evidence.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Do the birth without delaying it; The latest limit of guidelines in AEDF is 34+0 weeks (Guide difference).
4. Plan the birth in a NICU center.
5. Plan the delivery route according to the AEDF/REDF/DV branch in the Delivery mode and intrapartum section.

Treatment

• Consider a case at 34+0–36+6 weeks, who has not previously received antenatal corticosteroids in this pregnancy, who does not have pregestational diabetes, and who has a high risk of birth within 7 days, before 37+0 weeks — Betamethasone: 12 mg IM, 2 doses (single course) with an interval of 24 hours.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• If steroids are given after 34+0 weeks, monitor for hypoglycemia in the newborn.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Make an individual decision by discussing the prognosis and options with the family, obstetrics and neonatology team; Provide comprehensive support throughout the decision process.
4. If active neonatal care is not planned, clearly discuss the option of avoiding birth with a fetal indication.
5. If active care is decided, plan follow-up and delivery at a tertiary center with MFM and neonatology.
6. Complete etiological assessment (anatomy, genetics, infection); The result may change the decision.
7. If the finding progresses, re-evaluate according to the birth criteria in the relevant week.

Treatment

• If active neonatal care is decided and birth is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• If active neonatal care is decided, instead of betamethasone — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• If active neonatal care has been decided, delivery has not occurred after the initial course, and rescue criteria are met — Betamethasone (rescue course): 12 mg IM single dose (2 × 12 mg 24 hours apart is also acceptable); only before 34 weeks, maximum one rescue dose/course per pregnancy.
• If active neonatal care is decided and birth is expected within 24 hours — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Do not use sildenafil, LMWH, progesterone, or routine nutritional supplementation as treatment for diagnosed FGR; do not recommend bed rest. Maternal oxygen and aspirin initiated after diagnosis also lack evidence.
• Do not consider abnormal UA Doppler as an obstacle to steroids; do not change the plan on the basis of temporary UA improvement after steroids.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Admit for inpatient monitoring.
4. Perform fetal well-being testing 1–2 times a day; If you have cCTG, watch STV (Guideline difference).
5. Perform UA and DV Doppler daily to every 2–3 days (Guideline difference).
6. If DV a wave loss or reversal, low STV, or an indication independent of the week develops, deliver; Otherwise, aim to reach the guideline range for REDF (30+0–32+0 weeks).
7. Plan follow-up and delivery at a tertiary center with MFM and neonatology.

Treatment

• If birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Alternative corticosteroid — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• If birth has not occurred after the first course and rescue-course criteria are met — Betamethasone (rescue course): 12 mg IM single dose (2 doses of 12 mg given 24 hours apart are also acceptable); Only before the 34th week, maximum one rescue dose/course throughout pregnancy.
• If birth before 32+0 weeks is expected within 24 hours — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Do not consider abnormal UA Doppler as an obstacle to steroids; do not change the plan on the basis of temporary UA improvement after steroids.
• Do not use sildenafil, LMWH, progesterone, or routine nutritional supplementation as treatment for diagnosed FGR; do not recommend bed rest. Maternal oxygen and aspirin initiated after diagnosis also lack evidence.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Plan birth within guideline range: 30+0–32+0 weeks (range and guidelines: Guideline difference).
4. Monitor as an inpatient until delivery, with fetal well-being testing 1–2 times daily.
5. Plan the birth in a NICU center with MFM and neonatology.
6. Plan the delivery route according to the AEDF/REDF/DV branch in the Delivery mode and intrapartum section.

Treatment

• If birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Alternative corticosteroid — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• If birth has not occurred after the first course and rescue-course criteria are met — Betamethasone (rescue course): 12 mg IM single dose (2 doses of 12 mg given 24 hours apart are also acceptable); Only before the 34th week, maximum one rescue dose/course throughout pregnancy.
• If birth before 32+0 weeks is expected within 24 hours — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Do not consider abnormal UA Doppler as an obstacle to steroids; do not change the plan on the basis of temporary UA improvement after steroids.
• Do not use sildenafil, LMWH, progesterone, or routine nutritional supplementation as treatment for diagnosed FGR; do not recommend bed rest. Maternal oxygen and aspirin initiated after diagnosis also lack evidence.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Do the birth without delaying it; In REDF, the latest limit of guidelines is 32+0 weeks (Guide difference).
4. Plan the birth in a NICU center.
5. Plan the delivery route according to the AEDF/REDF/DV branch in the Delivery mode and intrapartum section.

Treatment

• If birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Before 34+0 weeks, instead of betamethasone — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• Before 34+0 weeks, if delivery has not occurred after the first course and rescue-course criteria are met — Betamethasone (rescue course): 12 mg IM single dose (2 × 12 mg given 24 hours apart is also acceptable); only before week 34, with at most one rescue dose/course during pregnancy.
• Consider a case at 34+0–36+6 weeks, who has not previously received antenatal corticosteroids in this pregnancy, who does not have pregestational diabetes, and who has a high risk of birth within 7 days, before 37+0 weeks — Betamethasone: 12 mg IM, 2 doses (single course) with an interval of 24 hours.
• At 32+0–33+6 weeks, if birth is expected within 24 hours, it may be considered according to the guideline (Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• If steroids are given after 34+0 weeks, monitor for hypoglycemia in the newborn.
• Do not consider abnormal UA Doppler as an obstacle to steroids; do not change the plan on the basis of temporary UA improvement after steroids.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Make an individual decision by discussing the prognosis and options with the family, obstetrics and neonatology team; Provide comprehensive support throughout the decision process.
4. If active neonatal care is not planned, clearly discuss the option of avoiding birth with a fetal indication.
5. If active care is decided, plan follow-up and delivery at a tertiary center with MFM and neonatology.
6. Complete etiological assessment (anatomy, genetics, infection); The result may change the decision.
7. If the finding progresses, re-evaluate according to the birth criteria in the relevant week.

Treatment

• If active neonatal care is decided and birth is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• If active neonatal care is decided, instead of betamethasone — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• If active neonatal care has been decided, delivery has not occurred after the initial course, and rescue criteria are met — Betamethasone (rescue course): 12 mg IM single dose (2 × 12 mg 24 hours apart is also acceptable); only before 34 weeks, maximum one rescue dose/course per pregnancy.
• If active neonatal care is decided and birth is expected within 24 hours — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Do not use sildenafil, LMWH, progesterone, or routine nutritional supplementation as treatment for diagnosed FGR; do not recommend bed rest. Maternal oxygen and aspirin initiated after diagnosis also lack evidence.
• Do not consider abnormal UA Doppler as an obstacle to steroids; do not change the plan on the basis of temporary UA improvement after steroids. [only if UA AEDF, UA REDF or UA PI >95th percentile (with diastolic flow present) is selected]
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Consider birth: in this slice, DV a wave at/below baseline or STV <2.6 ms is the criterion for birth (Guideline difference).
4. UA with AEDF or REDF: According to the guidelines that do not consider DV/STV as a birth criterion, the latest limit is 34+0 weeks in AEDF and 32+0 weeks in REDF (Guideline difference). [only if UA AEDF or UA REDF is selected]
5. Admit for inpatient monitoring with daily Doppler and cCTG (or conventional CTG/BPP if unavailable).
6. Provide neonatology consultation before delivery decision; Plan your birth at a tertiary centre.
7. Plan the delivery route according to the AEDF/REDF/DV branch in the Delivery mode and intrapartum section.

Treatment

• If birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Alternative corticosteroid — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• If birth has not occurred after the first course and rescue-course criteria are met — Betamethasone (rescue course): 12 mg IM single dose (2 doses of 12 mg given 24 hours apart are also acceptable); Only before the 34th week, maximum one rescue dose/course throughout pregnancy.
• If birth before 32+0 weeks is expected within 24 hours — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Do not consider abnormal UA Doppler as an obstacle to steroids; do not change the plan on the basis of temporary UA improvement after steroids.
• Do not use sildenafil, LMWH, progesterone, or routine nutritional supplementation as treatment for diagnosed FGR; do not recommend bed rest. Maternal oxygen and aspirin initiated after diagnosis also lack evidence.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Consider labor: in this slice, DV a wave at/below baseline or STV <3.0 ms is the criterion for labor (Guideline difference).
4. UA with AEDF or REDF: According to the guidelines that do not consider DV/STV as a birth criterion, the latest limit is 34+0 weeks in AEDF and 32+0 weeks in REDF (Guideline difference). [only if UA AEDF or UA REDF is selected]
5. Admit for inpatient monitoring with daily Doppler and cCTG (or conventional CTG/BPP if unavailable).
6. Provide neonatology consultation before delivery decision; Plan your birth at a tertiary centre.
7. Plan the delivery route according to the AEDF/REDF/DV branch in the Delivery mode and intrapartum section.

Treatment

• If birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Alternative corticosteroid — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• If birth has not occurred after the first course and rescue-course criteria are met — Betamethasone (rescue course): 12 mg IM single dose (2 doses of 12 mg given 24 hours apart are also acceptable); Only before the 34th week, maximum one rescue dose/course throughout pregnancy.
• If birth before 32+0 weeks is expected within 24 hours — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Do not consider abnormal UA Doppler as an obstacle to steroids; do not change the plan on the basis of temporary UA improvement after steroids.
• Do not use sildenafil, LMWH, progesterone, or routine nutritional supplementation as treatment for diagnosed FGR; do not recommend bed rest. Maternal oxygen and aspirin initiated after diagnosis also lack evidence.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. If cCTG STV is below the threshold, consider delivery; the threshold varies by guideline (Guideline difference).
4. If DV a wave is absent or reversed, plan delivery (Guide difference).
5. Monitor as an inpatient until delivery with daily Doppler and cCTG; If cCTG is not available, use conventional CTG/BPP (monitoring frequency: Guideline difference).
6. UA With AEDF or REDF: deliver without delay; The latest limit of the guidelines is 34+0 weeks in AEDF and 32+0 weeks in REDF (Guideline difference). [only if UA AEDF or UA REDF is selected]
7. With UA PI >95th percentile, EFW or AC <3rd percentile, or an accompanying condition: plan delivery no later than 37+6 weeks; do not delay at 37+0 weeks or beyond (Guideline difference). [only if UA PI >95th percentile (diastolic flow present), EFW or AC <3rd percentile, Oligohydramnios, or Hypertensive disease (gestational HT, preeclampsia, chronic HT) is selected · and UA AEDF and UA REDF are absent]
8. CPR or MCA PI <5. With p, if there are no accompanying findings requiring earlier delivery, complete the birth at 39+0 weeks at the latest (Guideline difference). [CPR only <5. p or MCA PI <5. If p is selected · UA AEDF and UA REDF and UA PI >95. p (diastolic flow present) and EFW or AC <3. p and if there is no Oligohydramnios and Hypertensive disease (gestational HT, preeclampsia, chronic HT)]
9. With Delphi FGR: do not delay delivery beyond 37+0 weeks (Guideline difference). [only if EFW or AC <10th percentile is present together with either a fall of >2 quartile bands at ≥32+0 weeks or UtA PI >95th percentile at diagnosis before 32+0 weeks]
10. Plan the birth in a NICU center; Choose the birth path according to the AEDF/REDF/DV branch in the Birth type and intrapartum section.

Treatment

• If birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses (single course) 24 hours apart.
• Before 34+0 weeks, instead of betamethasone — Dexamethasone sodium phosphate: 6 mg IM, 4 doses 12 hours apart.
• Before 34+0 weeks, if delivery has not occurred after the first course and rescue-course criteria are met — Betamethasone (rescue course): 12 mg IM single dose (2 × 12 mg given 24 hours apart is also acceptable); only before week 34, with at most one rescue dose/course during pregnancy.
• Consider a case at 34+0–36+6 weeks, who has not previously received antenatal corticosteroids in this pregnancy, who does not have pregestational diabetes, and who has a high risk of birth within 7 days, before 37+0 weeks — Betamethasone: 12 mg IM, 2 doses (single course) with an interval of 24 hours.
• At 32+0–33+6 weeks, if birth is expected within 24 hours, it may be considered according to the guideline (Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV, loading over 20 minutes; followed by 1 g/h infusion. Stop at birth or no later than 24 hours after starting the infusion; If birth does not occur, restarting is not recommended. In planned cesarean section, if the clinical situation allows, 6-12 hours of maintenance is aimed before birth.

Note

• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• If steroids are given after 34+0 weeks, monitor for hypoglycemia in the newborn.
• Do not consider abnormal UA Doppler as an obstacle to steroids; do not change the plan on the basis of temporary UA improvement after steroids. [only if UA AEDF, UA REDF or UA PI >95th percentile (with diastolic flow present) is selected]
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Plan the delivery route as cesarean section (Guide difference).
4. Plan the birth in a NICU center with the neonatology team ready.
5. If labor has started or vaginal delivery is selected, perform continuous FHR monitoring.

Treatment

• Planned caesarean section.
• If birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses 24 hours apart (a single course). [Only if NONE of the following conditions is selected: DV a-wave absent/reversed or low cCTG STV; UA REDF; UA AEDF; UA PI >95th percentile (diastolic flow present); CPR <5th percentile or MCA PI <5th percentile; EFW or AC <3rd percentile; EFW or AC <10th percentile and a fall of >2 quartile bands at ≥32+0 weeks, or UtA PI >95th percentile at diagnosis before 32+0 weeks; EFW or AC <10th percentile (both ≥3rd percentile), with no other FGR findings]
• Consider at 34+0–36+6 weeks in a patient who has not previously received antenatal corticosteroids in this pregnancy, has no pregestational diabetes, and is at high risk of birth within 7 days and before 37+0 weeks — Betamethasone: 12 mg IM, 2 doses 24 hours apart (a single course). [Only if NONE of the following conditions is selected: DV a-wave absent/reversed or low cCTG STV; UA REDF; UA AEDF; UA PI >95th percentile (diastolic flow present); CPR <5th percentile or MCA PI <5th percentile; EFW or AC <3rd percentile; EFW or AC <10th percentile and a fall of >2 quartile bands at ≥32+0 weeks, or UtA PI >95th percentile at diagnosis before 32+0 weeks; EFW or AC <10th percentile (both ≥3rd percentile), with no other FGR findings]
• If birth before 32+0 weeks is expected within 24 hours — Magnesium sulfate (neuroprotection): 4 g IV loading over 20 minutes; then an infusion of 1 g/hour. Stop at birth or no later than 24 hours after the infusion is started; restarting is not recommended if birth does not occur. For planned cesarean delivery, aim for 6–12 hours of maintenance before birth if the clinical condition permits. [Only if NONE of the following conditions is selected: DV a-wave absent/reversed or low cCTG STV; UA REDF; UA AEDF; UA PI >95th percentile (diastolic flow present); CPR <5th percentile or MCA PI <5th percentile; EFW or AC <3rd percentile; EFW or AC <10th percentile and a fall of >2 quartile bands at ≥32+0 weeks, or UtA PI >95th percentile at diagnosis before 32+0 weeks; EFW or AC <10th percentile (both ≥3rd percentile), with no other FGR findings]
• At 32+0–33+6 weeks, if birth is expected within 24 hours, this may be considered according to the guideline (Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV loading over 20 minutes; then an infusion of 1 g/hour. Stop at birth or no later than 24 hours after the infusion is started; restarting is not recommended if birth does not occur. For planned cesarean delivery, aim for 6–12 hours of maintenance before birth if the clinical condition permits. [Only if NONE of the following conditions is selected: DV a-wave absent/reversed or low cCTG STV; UA REDF; UA AEDF; UA PI >95th percentile (diastolic flow present); CPR <5th percentile or MCA PI <5th percentile; EFW or AC <3rd percentile; EFW or AC <10th percentile and a fall of >2 quartile bands at ≥32+0 weeks, or UtA PI >95th percentile at diagnosis before 32+0 weeks; EFW or AC <10th percentile (both ≥3rd percentile), with no other FGR findings]

Note

• In AEDF/REDF, most fetuses may not tolerate labor.
• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Deliver regardless of gestational age in case of maternal indication (PE with uncontrolled severe hypertension, HELLP, eclampsia or other end organ damage, placental abruption or other obstetric emergency requiring delivery).
2. In fetal indication, deliver in weeks considered viability: spontaneous recurrent deceleration; reduced or absent variability and/or recurrent late deceleration; sinusoidal trace; bradycardia whose cause cannot be eliminated; BPP ≤4 (week threshold and criteria: Guideline difference). If reduced fetal movement is reported, evaluate with cCTG without waiting for the planned check-up.
3. Aim for vaginal birth; FGR alone is not an indication for cesarean section.
4. Prefer mechanical method for cervical ripening in induction (Guideline difference).
5. Perform induction on an inpatient basis with continuous FHR monitoring rather than intermittent auscultation; if the FHR tracing becomes abnormal during induction or early labor, proceed to cesarean delivery.
6. Plan your birth at a center with neonatal care appropriate to your gestational age.

Treatment

• Mechanical cervical ripening (balloon catheter) if the cervix is ​​immature.
• Direct induction with oxytocin without mechanical maturation if Bishop score >6 — Oxytocin (IV infusion, preferably with a variable rate infusion pump): 5 IU (10 mU/mL) into 500 mL 0.9% sodium chloride; initial 1–4 mU/min; increase by no more than 1–2 mU/min each time, at least 20 minutes apart; The highest recommended rate is 20 mU/min. Once 3–4 contractions every 10 minutes are achieved, the infusion rate can usually be reduced; In case of uterine hyperactivity or fetal compromise, the infusion is stopped immediately.
• 37+0 weeks and above, prostaglandin as reversible method if necessary — Dinoprostone vaginal insert (10 mg; 0.3 mg/hour release): place an insert in the upper part of the posterior vaginal fornix; Then have the patient lie on her back for 20-30 minutes. Remove the insert when cervical ripening is complete or when regular painful contractions begin every three minutes, regardless of cervical change; Remove it no later than 24 hours. Remove immediately if spontaneous rupture of membranes, amniotomy, uterine hyperstimulation or hypertonic contraction, fetal distress or systemic side effects such as nausea, vomiting, hypotension or tachycardia develop.
• If birth before 34+0 weeks is expected within 7 days — Betamethasone: 12 mg IM, 2 doses 24 hours apart (a single course). [Only if NONE of the following conditions is selected: DV a-wave absent/reversed or low cCTG STV; UA REDF; UA AEDF; UA PI >95th percentile (diastolic flow present); CPR <5th percentile or MCA PI <5th percentile; EFW or AC <3rd percentile; EFW or AC <10th percentile and a fall of >2 quartile bands at ≥32+0 weeks, or UtA PI >95th percentile at diagnosis before 32+0 weeks; EFW or AC <10th percentile (both ≥3rd percentile), with no other FGR findings]
• Consider at 34+0–36+6 weeks in a patient who has not previously received antenatal corticosteroids in this pregnancy, has no pregestational diabetes, and is at high risk of birth within 7 days and before 37+0 weeks — Betamethasone: 12 mg IM, 2 doses 24 hours apart (a single course). [Only if NONE of the following conditions is selected: DV a-wave absent/reversed or low cCTG STV; UA REDF; UA AEDF; UA PI >95th percentile (diastolic flow present); CPR <5th percentile or MCA PI <5th percentile; EFW or AC <3rd percentile; EFW or AC <10th percentile and a fall of >2 quartile bands at ≥32+0 weeks, or UtA PI >95th percentile at diagnosis before 32+0 weeks; EFW or AC <10th percentile (both ≥3rd percentile), with no other FGR findings]
• If birth before 32+0 weeks is expected within 24 hours — Magnesium sulfate (neuroprotection): 4 g IV loading over 20 minutes; then an infusion of 1 g/hour. Stop at birth or no later than 24 hours after the infusion is started; restarting is not recommended if birth does not occur. For planned cesarean delivery, aim for 6–12 hours of maintenance before birth if the clinical condition permits. [Only if NONE of the following conditions is selected: DV a-wave absent/reversed or low cCTG STV; UA REDF; UA AEDF; UA PI >95th percentile (diastolic flow present); CPR <5th percentile or MCA PI <5th percentile; EFW or AC <3rd percentile; EFW or AC <10th percentile and a fall of >2 quartile bands at ≥32+0 weeks, or UtA PI >95th percentile at diagnosis before 32+0 weeks; EFW or AC <10th percentile (both ≥3rd percentile), with no other FGR findings]
• At 32+0–33+6 weeks, if birth is expected within 24 hours, this may be considered according to the guideline (Guideline difference) — Magnesium sulfate (neuroprotection): 4 g IV loading over 20 minutes; then an infusion of 1 g/hour. Stop at birth or no later than 24 hours after the infusion is started; restarting is not recommended if birth does not occur. For planned cesarean delivery, aim for 6–12 hours of maintenance before birth if the clinical condition permits. [Only if NONE of the following conditions is selected: DV a-wave absent/reversed or low cCTG STV; UA REDF; UA AEDF; UA PI >95th percentile (diastolic flow present); CPR <5th percentile or MCA PI <5th percentile; EFW or AC <3rd percentile; EFW or AC <10th percentile and a fall of >2 quartile bands at ≥32+0 weeks, or UtA PI >95th percentile at diagnosis before 32+0 weeks; EFW or AC <10th percentile (both ≥3rd percentile), with no other FGR findings]

Note

• There is no FGR-specific dose on the oxytocin and dinoprostone labels; Fetal distress is a contraindication for both (drug-specific contraindications are in the drug's notes).
• Do not delay indicated delivery to complete a course of steroids or MgSO₄.
• Oxytocin (IV infusion, preferably with a variable rate infusion pump): The transition interval to oxytocin after vaginal prostaglandin is different in the two Turkish labels: the oxytocin SPC does not administer within 6 hours after prostaglandin, while the dinoprostone SPC recommends an interval of at least 30 minutes after insert removal. It is not used long-term in severe pre-eclamptic toxemia and severe cardiovascular disorders. Oxytocin is not used in hypersensitivity, mechanical obstruction of labor, hypertonic uterine contractions, and maternal or fetal conditions that prevent vaginal birth; Contraindications include marked cephalopelvic disproportion, malpresentation, placenta or vasa previa, abruption, cord presentation or prolapse, uterine overdistention, polyhydramnios, grand multiparity, and uterine scarring due to major surgery, including classic cesarean section.
• Dinoprostone vaginal insert (10 mg; 0.3 mg/hour release): Do not use after active labor has begun and while an oxytocic drug or other induction agent is being administered. It is contraindicated in cases where forceful prolonged contraction is not appropriate—prior cesarean section or major uterine surgery, cephalopelvic disproportion, fetal malpresentation, evidence or suspicion of fetal distress. It is also contraindicated in placenta previa or unexplained vaginal bleeding, untreated pelvic inflammatory disease, history of cervical rupture or major cervical surgery, and hypersensitivity to prostaglandin E2 or excipients. According to the Turkish label, it is used only in pregnant women who have completed 37 weeks; Any use before 37+0 is off-label. Aspirin and other non-steroidal anti-inflammatory drugs should be discontinued before administering dinoprostone; It is not used together with dinoprostone.
• Betamethasone: If there is no birth after the first cycle, the second cycle is given only if there are rescue cycle conditions. Post-steroid hyperglycemia in pregnant women with diabetes can be severe if not closely monitored and treated; The effect begins approximately 12 hours after the first dose and may last up to 5 days. 2nd–3rd day after steroids Decreased FHR variability per day is not itself an indication for delivery; In these pregnancies, an abnormal test may indicate true deterioration, so evaluate the finding together with other fetal and maternal findings.
• Magnesium sulfate (neuroprotection): do not use in myasthenia gravis. Use cautiously in myocardial injury or cardiac conduction disorders. Monitor the patellar reflex, respiratory rate (>12/min) and urine output (>100 mL/4 hours); do not continue maintenance treatment if these conditions are not met. In renal impairment (serum creatinine >1.0 mg/dL), give the standard loading dose; if maintenance is given, adjust or stop it while monitoring serum magnesium. Use extreme caution with GFR <30 mL/min. Do not delay urgent or expedited delivery to administer MgSO₄ or complete maintenance treatment.

Approach

1. Evaluate FGR and PE risk factors with detailed history at first visit; Reassess risk throughout pregnancy.
2. Ask about smoking, alcohol and substance use; Give quitting support.
3. Target pregnancy weight gain based on prepregnancy BMI (targets: Guideline difference).
4. Measure SFH at every visit from 24+0 weeks; If the threshold is exceeded, perform USG (Guide difference).
5. Perform serial SFH and selective USG instead of routine 3rd trimester USG.

Note

• Do not initiate aspirin in pregnant women at low risk of PE.
• Do not recommend routine nutrition or dietary supplementation for FGR prevention.

Approach

1. Determine risk class with guideline criteria (Guideline difference).
2. Schedule serial growth USG; The starting week and interval vary depending on the risk level (Guideline difference).
3. Consider second trimester UtA Doppler at high risk (Guideline difference).
4. Provide smoking cessation support.

Treatment

• Aspirin (oral, evening): 81–162 mg per day — recommended dose varies by guideline (Guideline difference); Start before 16 weeks, at 12 weeks if possible; end week and initiation after 16 weeks: Guideline difference.

Note

• Do not routinely use LMWH for FGR prevention (selected group: Guideline difference).
• Aspirin (oral, evening): Hypersensitivity to acetylsalicylic acid, other salicylates, or product ingredients, history of salicylate or non-steroidal anti-inflammatory drug-induced asthma, acute gastrointestinal ulcer, bleeding diathesis (hemophilia or other hemorrhagic disorders), severe renal, liver, or heart failure and in combination with methotrexate at doses of 15 mg or more per week. using; Gout is also a contraindication on the Turkish label of the 81 mg product. In Turkish labels, the last trimester of pregnancy is also a contraindication and PE/FGR precaution is not a label indication; Preventive use is off-label (Guideline difference).

Approach

1. Evaluate details of the previous pregnancy (gestational age at delivery, PE, placental pathology); explain the risk of recurrence.
2. Start growth monitoring at 24–28 weeks; Stratify risk with UtA Doppler and markers (Guideline difference).
3. If previous FGR required preterm birth, consider antenatal fetal monitoring in this pregnancy, even if the fetus is of appropriate size.
4. Provide smoking cessation support.

Treatment

• Aspirin (oral, evening): 81–162 mg per day — recommended dose varies by guideline (Guideline difference); Start before 16 weeks, at 12 weeks if possible; end week and initiation after 16 weeks: Guideline difference.

Note

• Do not use LMWH solely to prevent recurrent FGR (selected highest-risk group: Guideline difference); assess independent indications, such as antiphospholipid syndrome, separately.
• Do not order hereditary thrombophilia testing.
• Aspirin (oral, evening): Hypersensitivity to acetylsalicylic acid, other salicylates, or product ingredients, history of salicylate or non-steroidal anti-inflammatory drug-induced asthma, acute gastrointestinal ulcer, bleeding diathesis (hemophilia or other hemorrhagic disorders), severe renal, liver, or heart failure and in combination with methotrexate at doses of 15 mg or more per week. using; Gout is also a contraindication on the Turkish label of the 81 mg product. In Turkish labels, the last trimester of pregnancy is also a contraindication and PE/FGR precaution is not a label indication; Preventive use is off-label (Guideline difference).

Approach

1. Send the placenta for histopathological examination.
2. Refer the growth-restricted infant for close monitoring and serial neurodevelopmental evaluation.
3. Perform postpartum counseling: discuss possible cause, risk of recurrence and plan for subsequent pregnancy (aspirin, smoking).
4. Inform the mother of increased cardiovascular risk; Give healthy life advice.
5. Discuss effective contraception and pregnancy spacing.

Note

• Do not routinely order hereditary thrombophilia screening; test antiphospholipid antibodies only with a selected relevant history (criteria: Guideline differences).