Fetal Growth Restriction

Fetal growth restriction (FGR), also known as intrauterine fetal growth restriction (IUGR), is an estimated fetal weight (EFW) or abdominal circumference < 10th percentile for gestational age. The term small for gestational age (SGA) is sometimes erroneously used interchangeably with FGR. However, SGA refers to babies born with a birth weight < 10th percentile for gestational age. Defining FGR is challenging because each fetus has a different growth potential that may not be accounted for. The most commonly recognized classifications for FGR are symmetrical or asymmetrical. Symmetrical FGR occurs when all parts of the fetus are equally small and is typically the result of a complication early in pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care. Asymmetrical FGR occurs when there is disproportionately lagging growth in different body parts; most commonly, the fetus will have a normal size head and a small body. The causes of FGR can be broadly grouped into maternal, fetal, and placental. Fetal growth restriction is diagnosed by ultrasonography and confirmed by weight at birth. Management is often targeted to the underlying etiology, if known. Depending on the etiology, these fetuses may be at increased risk for complications such as preterm birth Preterm birth Preterm labor refers to regular uterine contractions leading to cervical change prior to 37 weeks of gestation; preterm birth refers to birth prior to 37 weeks of gestation. Preterm birth may be spontaneous due to preterm labor, preterm prelabor rupture of membranes (PPROM), or cervical insufficiency. Preterm Labor and Birth, intrauterine fetal death, and neurologic sequelae. Close surveillance and delivery planning by a skilled provider is crucial.

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Overview

Definition

Fetal growth restriction (FGR) is the term used to describe fetuses with an estimated fetal weight (EFW) or abdominal circumference < 10th percentile for gestational age.

  • The definition given above is the most common one; however, defining FGR is challenging because the individualized growth potential of each fetus may not be accounted for.
  • Larger fetuses who have not reached their growth potential will not be identified and may be at equal risk of adverse outcomes. 
  • Fetal growth is regulated by multiple factors and varies by: 
    • Race
    • Maternal factors
    • Paternal factors 
  • Establishing definitions and growth curves that address individualized fetal growth potential is an ongoing challenge.

Epidemiology

  • The incidence of FGR varies among populations; it appears to be more prevalent in underdeveloped nations.
    • In developed countries: approximately 4%–8%
    • In developing countries: approximately 6%–30%
    • The true prevalence is difficult to determine, as it depends on which definition is used. 
  • Occurs in all age groups, but the incidence may be higher in extremes of maternal age
  • Can occur at any gestational age
  • Associated with increased morbidity and mortality

Classification

The most commonly recognized classifications of FGR are as follows:

Symmetrical FGR:

  • All parts of the fetus (such as height, weight, and head circumference) are equally affected
  • Accounts for approximately 20%–30% of cases of FGR
  • Typically caused by a problem that started early in pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
  • Most often related to aneuploidy, malformations, or fetal infection

Asymmetrical FGR:

  • Weight is most affected, with relative preservation of the head circumference
  • Accounts for 70%–80% of cases of FGR
  • Typically the result of a problem that began later in pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
  • Most often a result of placental dysfunction

Other less commonly used classifications include:

  • Early FGR: describes FGR occurring at < 32 weeks 
  • Late FGR: describes FGR occurring at ≥ 32 weeks

Etiology

Many potential causes and risk factors contribute to FGR.

Maternal

  • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
  • Pregestational diabetes
  • Substance abuse:
    • Tobacco
    • Alcohol
    • Cocaine
    • Narcotics
  • Autoimmune disorders:
    • Lupus
    • Antiphospholipid antibody syndrome
    • Thyroid disease
  • Multiple gestation
  • Cyanotic heart disease
  • Sickle cell disease Sickle cell disease Sickle cell disease (SCD) is a group of genetic disorders in which an abnormal Hb molecule (HbS) transforms RBCs into sickle-shaped cells, resulting in chronic anemia, vasoocclusive episodes, pain, and organ damage. Sickle Cell Disease
  • High altitude (> 10,000 feet)
  • Restrictive pulmonary disease
  • Chronic renal disease
  • Malabsorption Malabsorption Malabsorption involves many disorders in which there is an inability of the gut to absorb nutrients from dietary intake, potentially including water and/or electrolytes. A closely related term, maldigestion is the inability to break down large molecules of food into their smaller constituents. Malabsorption and maldigestion can affect macronutrients (fats, proteins, and carbohydrates), micronutrients (vitamins and minerals), or both. Malabsorption and Maldigestion/ malnutrition Malnutrition Malnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema). Malnutrition in children in resource-limited countries
  • Extremes of maternal age

Fetal

  • Teratogen exposure:
    • Cyclophosphamide
    • Valproic acid
    • Warfarin
  • Structural abnormalities:
    • Gastroschisis Gastroschisis Gastroschisis is a congenital abdominal wall defect characterized by the complete lack of closure of the abdominal musculature. A portion of intestine does not return to the abdominal cavity, thereby remaining in its early embryonic herniated state but with no coverings. Gastroschisis
    • Congenital heart disease
  • Genetic disorders:
    • Trisomy 13 Trisomy 13 Trisomy 13, or Patau syndrome, is a genetic syndrome caused by the presence of 3 copies of chromosome 13. As the 3rd most common trisomy, Patau syndrome has an incidence of 1 in 10,000 live births. Most cases of Patau syndrome are diagnosed prenatally by maternal screening and ultrasound. More than half of the pregnancies result in spontaneous abortions. Patau Syndrome (Trisomy 13)
    • Trisomy 18 Trisomy 18 Edwards syndrome, or trisomy 18, is a genetic syndrome caused by the presence of an extra chromosome 18. The extra chromosome is either from 3 full copies of chromosome 18 or an additional segment of chromosome 18. As the 2nd most common trisomy, Edwards syndrome is seen in 1 out of every 5,500 live births. Edwards Syndrome (Trisomy 18)
  • Fetal infection:
    • Malaria Malaria Malaria is an infectious parasitic disease affecting humans and other animals. Most commonly transmitted via the bite of a female Anopheles mosquito infected with microorganisms of the Plasmodium genus. Patients present with fever, chills, myalgia, headache, and diaphoresis. Malaria (most common infectious cause worldwide)
    • Cytomegalovirus Cytomegalovirus CMV is a ubiquitous double-stranded DNA virus belonging to the Herpesviridae family. CMV infections can be transmitted in bodily fluids, such as blood, saliva, urine, semen, and breast milk. The initial infection is usually asymptomatic in the immunocompetent host, or it can present with symptoms of mononucleosis. Cytomegalovirus
    • Rubella Rubella Rubella (also known as German measles or three-day measles) is caused by a single-stranded, positive-sense RNA virus of the Togaviridae family. Rubella only infects humans and spreads prenatally via vertical transmission or postnatally via droplet contact. Congenital rubella is associated with a classic triad of symptoms: cataracts, cardiac defects, and deafness. Infection in children and adults may be mild and present with constitutional symptoms along with a viral exanthem. Rubella Virus
    • Toxoplasmosis Toxoplasmosis Toxoplasmosis is an infectious disease caused by Toxoplasma gondii, an obligate intracellular protozoan parasite. Felines are the definitive host, but transmission to humans can occur through contact with cat feces or the consumption of contaminated foods. The clinical presentation and complications depend on the host's immune status. Toxoplasma/Toxoplasmosis
    • Syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis
    • Varicella zoster
    • Herpes simplex

Placental

  • Placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity abruption
  • Placental masses:
    • Chorioangioma
    • Hemangioma
  • Placental mosaicism
  • Single umbilical artery

Clinical Presentation and Diagnosis

Clinical presentation

  • Often asymptomatic
  • May present with symptoms of the underlying etiology, such as hypertension or diabetes

Diagnostic evaluation

Dating:

  • Accurate knowledge of gestational age is crucial to avoid incorrect diagnosis.
  • Dating by last menstrual period is valuable if menstrual cycles are regular. 
  • Crown-rump length (CRL) measured by ultrasonography between 7 and 10 weeks of gestation is the most accurate way to date a pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care (± 3 days).

History and physical:

  • Fundal height 
    • Measured in centimeters between 24 and 37 weeks
    • FGR: ≥ 3 cm less than the expected height for gestational age
    • A good screening tool, but when used alone, the diagnosis is often inaccurate
  • A thorough assessment of maternal and fetal health is warranted to potentially elicit the cause.
  • Screening for maternal conditions such as:
    • 1-hour glucose-challenge test or HbA1c to screen for diabetes
    • Thyroid function testing
    • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension screening
  • Screening for fetal conditions such as infection or aneuploidy may be considered based on the clinical scenario.
Fundal height measurement

Fundal height measurement:
As shown, the measuring tape is placed between the pubic symphysis and the top of the uterine fundus. The height is reported in centimeters and should match the gestational age (in weeks) within 3 cm.

Image: “Fundal Height Management” by Katrina Wittkamp/Getty Images. License: Public Domain

Ultrasonography:

  • The best way to diagnose FGR prior to delivery
  • Used to measure:
    • EFW 
    • Head circumference and biparietal diameter
    • Abdominal circumference
    • Femur length
  • Can also evaluate for:
    • Placental abnormalities Placental abnormalities Normal placental structure and function are essential for a healthy pregnancy. Some of the most common placental abnormalities include structural anomalies (such as a succenturiate lobe or velamentous cord insertion), implantation anomalies (such as placenta accreta and placenta previa), and functional anomalies (such as placental insufficiency). Placental Abnormalities
    • Oligohydramnios Oligohydramnios Oligohydramnios refers to amniotic fluid volume less than expected for the current gestational age. Oligohydramnios is diagnosed by ultrasound and defined as an amniotic fluid index (AFI) of ‰¤ 5 cm or a single deep pocket (SDP) of < 2 cm in the 2nd or 3rd trimester. Oligohydramnios
Crl measurement

An ultrasound showing a crown-rump length (CRL) measurement, which is the most accurate way to date a pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care.

Image: “Ultrasound image of a 12-week fetus.” by hild Health, Royal Aberdeen Children’s Hospital, University of Aberdeen, Foresterhill, Aberdeen. License: CC BY 3.0

Management

General approach

Management starts with adequate treatment of the underlying cause, if identified, such as:

  • Diabetes
  • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension 
  • Autoimmune conditions

Surveillance

  • Continued fetal growth and amniotic fluid volume assessment should be performed every 3–4 weeks until delivery. 
  • Doppler velocimetry of the umbilical artery: assesses the pattern and resistance of blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure by measuring the systolic-to-diastolic ratio (S/D ratio) 
    • Normal pregnancies: The umbilical artery resistance shows gradual decline, forward diastolic flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure, and a low S/D ratio.
    • Growth restriction: The S/D ratio is elevated and diastolic flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure may become absent or reversed with disease progression.
  • Once- or twice-weekly monitoring with a biophysical profile or nonstress test

Delivery

  • Timing of delivery should be individualized. 
  • In cases of isolated FGR with normal antenatal testing and:
    • EFW between the 3rd and 10th percentile, the recommendation is 38–39 weeks.
    • EFW below the 3rd percentile, the recommendation is 37 weeks.

Complications

Fetal growth restriction is associated with several complications. These complications can be seen before or immediately after delivery but can also been seen months to years after.

Immediate

  • Perinatal asphyxia
  • Preterm delivery
  • Meconium aspiration
  • Low Apgar scores
  • Hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia
  • Polycythemia
  • Hyperbilirubinemia
  • Intraventricular hemorrhage
  • Impaired thermoregulation
  • Necrotizing enterocolitis Necrotizing enterocolitis Necrotizing enterocolitis (NEC) is an intestinal inflammatory process that can lead to mucosal injury and necrosis. The condition is multifactorial, with underlying risk factors that include prematurity and formula feeding. The clinical presentation varies in severity from feeding intolerance, acute findings on abdominal exam, and systemic symptoms. Necrotizing Enterocolitis
  • Respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure
  • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures
  • Sepsis Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock
  • Increased risk for stillbirth

Late

  • Spastic cerebral palsy Cerebral palsy Cerebral palsy (CP) refers to a group of conditions resulting in motor impairment affecting tone and posture and limiting physical activity. Cerebral palsy is the most common cause of childhood disability. It is caused by a nonprogressive CNS injury to the fetal or infant brain. Cerebral Palsy
  • Neurodevelopmental abnormalities
  • Increased risk of developing chronic conditions later in life, such as:
    • Chronic hypertension
    • Ischemic heart disease Ischemic heart disease Coronary heart disease (CHD), or ischemic heart disease, describes a situation in which an inadequate supply of blood to the myocardium exists due to a stenosis of the coronary arteries, typically from atherosclerosis. Coronary Heart Disease
    • Type 2 diabetes
    • Obstructive lung disease

Clinical Relevance

  • Constitutionally small babies: This term is used to describe babies who are born with a birth weight < 10th percentile for their gestational age without evidence of underlying pathology. These babies are a challenge to treat in the antepartum period because it can be hard to distinguish them from growth-restricted fetuses. Therefore, the management before delivery is identical.
  • Placental abruption: complete or partial premature detachment of a normally implanted placenta before birth of the infant. Small, partial abruptions may be less dramatic and present with smaller amounts of bleeding over time (chronic abruptions), oligohydramnios, and FGR. The diagnosis is usually clinical. Management depends on the severity, but includes frequent maternal and fetal assessments and delivery if the mother or infant decompensates.
  • Patau syndrome Patau syndrome Trisomy 13, or Patau syndrome, is a genetic syndrome caused by the presence of 3 copies of chromosome 13. As the 3rd most common trisomy, Patau syndrome has an incidence of 1 in 10,000 live births. Most cases of Patau syndrome are diagnosed prenatally by maternal screening and ultrasound. More than half of the pregnancies result in spontaneous abortions. Patau Syndrome (Trisomy 13): also known as trisomy 13. Patau syndrome Patau syndrome Trisomy 13, or Patau syndrome, is a genetic syndrome caused by the presence of 3 copies of chromosome 13. As the 3rd most common trisomy, Patau syndrome has an incidence of 1 in 10,000 live births. Most cases of Patau syndrome are diagnosed prenatally by maternal screening and ultrasound. More than half of the pregnancies result in spontaneous abortions. Patau Syndrome (Trisomy 13) is a genetic syndrome caused by the presence of 3 copies of the 13th chromosome. Findings include craniofacial and cardiac malformations, severe intellectual disability, and greatly reduced life expectancy. Most babies do not survive past 3 months. Most cases are diagnosed prenatally with the aid of maternal screening and ultrasonography. If pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care reaches term, it is recommended that a specialized center handle the delivery and neonatal care. 
  • Edwards syndrome Edwards syndrome Edwards syndrome, or trisomy 18, is a genetic syndrome caused by the presence of an extra chromosome 18. The extra chromosome is either from 3 full copies of chromosome 18 or an additional segment of chromosome 18. As the 2nd most common trisomy, Edwards syndrome is seen in 1 out of every 5,500 live births. Edwards Syndrome (Trisomy 18): also known as trisomy 18. Edwards syndrome Edwards syndrome Edwards syndrome, or trisomy 18, is a genetic syndrome caused by the presence of an extra chromosome 18. The extra chromosome is either from 3 full copies of chromosome 18 or an additional segment of chromosome 18. As the 2nd most common trisomy, Edwards syndrome is seen in 1 out of every 5,500 live births. Edwards Syndrome (Trisomy 18) is a genetic condition caused by the presence of an extra chromosome 18. Many cases are detected prenatally with maternal screening and ultrasound findings. Abnormalities include FGR, overlapping fingers, typical craniofacial features, rocker bottom feet, and congenital heart defects. Trisomy 18 Trisomy 18 Edwards syndrome, or trisomy 18, is a genetic syndrome caused by the presence of an extra chromosome 18. The extra chromosome is either from 3 full copies of chromosome 18 or an additional segment of chromosome 18. As the 2nd most common trisomy, Edwards syndrome is seen in 1 out of every 5,500 live births. Edwards Syndrome (Trisomy 18) frequently results in fetal loss. Delivery in a specialized center is recommended for full-term pregnancies, and intervention is based on associated abnormalities.
  • Congenital TORCH infections Congenital TORCH infections Congenital infections are acquired in utero or during passage through the birth canal at birth and can be associated with significant morbidity and mortality for the infant. The TORCH infections are a group of congenital infections grouped due to their similar presentation. The acronym TORCH arises from the names of the infectious agents that cause the diseases included in this group: toxoplasmosis, other agents (syphilis, varicella zoster virus (VZV), parvovirus B19, and HIV), rubella, CMV, and herpes simplex. Congenital TORCH Infections: group of infections acquired in utero, including toxoplasmosis, syphilis, varicella-zoster virus Varicella-Zoster Virus Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Varicella-zoster infections are highly contagious and transmitted through aerosolized respiratory droplets or contact with infected skin lesions. Varicella-Zoster Virus/Chickenpox, parvovirus B19 Parvovirus B19 Primate erythroparvovirus 1 (generally referred to as parvovirus B19, B19 virus, or sometimes erythrovirus B19) ranks among the smallest DNA viruses. Parvovirus B19 is of the family Parvoviridae and genus Erythrovirus. In immunocompetent humans, parvovirus B19 classically results in erythema infectiosum (5th disease) or "slapped cheek syndrome." Parvovirus B19, HIV, rubella, cytomegalovirus, and herpes simplex. These diseases can have significant consequences, such as FGR, preterm birth Preterm birth Preterm labor refers to regular uterine contractions leading to cervical change prior to 37 weeks of gestation; preterm birth refers to birth prior to 37 weeks of gestation. Preterm birth may be spontaneous due to preterm labor, preterm prelabor rupture of membranes (PPROM), or cervical insufficiency. Preterm Labor and Birth, congenital abnormalities, or fetal death.

References

  1. American College of Obstetricians and Gynecologists. (2021). Fetal growth restriction. ACOG Practice Bulletin Summary, number 227. Obstetrics & Gynecology 137:385–387. https://journals.lww.com/greenjournal/Abstract/2021/02000/Fetal_Growth_Restriction__ACOG_Practice_Bulletin.38.aspx
  2. Cunningham, F. G. (2018). Fetal growth disorders. In: Williams Obstetrics, 25th ed. McGraw-Hill Medical, pp. 843–886.
  3. Resnik, R., et al. (2019). Creasy and Resnik’s Maternal-Fetal Medicine: Principles and Practice. Elsevier.
  4. Gabbe, S. G. (2020). Fetal growth restriction. In: Obstetrics Normal and Problem Pregnancies, 8th ed. Elsevier, pp. 555–585.
  5. Divon, M. Y. (2021). Fetal growth restriction: screening and diagnosis. UpToDate. Retrieved September 03, 2021, from https://www.uptodate.com/contents/fetal-growth-restriction-screening-and-diagnosis
  6. Mari, G. (2021). Fetal growth restriction: evaluation and management. UpToDate. Retrieved September 3, 2021, from https://www.uptodate.com/contents/fetal-growth-restriction-evaluation-and-management
  7. Mandy, G. T. (2021). Infants with fetal (intrauterine) growth restriction. UpToDate. Retrieved September 12, 2021, from https://www.uptodate.com/contents/infants-with-fetal-intrauterine-growth-restriction
  8. Balest, A. L. (2021). Small for gestational age infant. MSD Manual Professional Version. Retrieved October 26, 2021, from https://www.msdmanuals.com/professional/pediatrics/perinatal-problems/small-for-gestational-age-sga-infant
  9. Ross, M. G. (2020). Fetal growth restriction. Medscape. Retrieved October 26, 2021, from https://emedicine.medscape.com/article/261226-overview#a4

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