Timing and Severity of Fetal Growth Restriction Diagnosis and Association with Perinatal Morbidity

Abstract

Objective

In 2020, the Society of Maternal Fetal Medicine refined fetal growth restriction (FGR) diagnostic criteria by temporal (early-, <32 weeks 0 days [32⁰] weeks; late-onset, ≥32⁰ weeks) and measurement-specific definitions (severe, estimated fetal weight <3rd; mild, estimated fetal weight 3rd–9th percentile and/or abdominal circumference <10th percentile). Using these updated clinical definitions, we sought to determine the association of timing and severity of FGR diagnosis with, and their discriminatory ability for, adverse pregnancy outcomes.

Study Design

This retrospective cohort study included singleton, non-anomalous pregnancies with sonographic FGR diagnosis at ≥18⁰ weeks' gestation from May 2020 to December 2021. We evaluated four FGR classification exposure groups: (1) early-onset, severe FGR; (2) early-onset, mild FGR; (3) late-onset, severe FGR; and (4) late-onset, mild FGR. Outcomes assessed were hypertensive disorders of pregnancy, preterm birth, and small-for-gestational age. Multivariable logistic regression estimated the odds of each outcome associated with each exposure, adjusted for maternal age, insurance, and parity. Receiver-operating characteristic analysis determined test characteristics for the ability of these FGR classification groups to identify the postnatal outcomes, using late-onset, mild FGR as the reference group.

Results

Among 566 eligible pregnancies, early-onset, severe FGR had higher adjusted odds of hypertensive disorders of pregnancy (aOR = 1.3, 95% CI: 1.1–1.7), preterm birth (aOR = 2.1, 95% CI: 1.6–2.6), and small-for-gestational age (aOR = 1.6, 95% CI: 1.3–1.9), compared to late-onset, mild FGR. Late-onset, severe FGR also had higher adjusted odds of preterm birth (aOR = 7.2, 95% CI: 2.9–18.3) and small-for-gestational age (aOR = 5.8, 95% CI: 2.5–13.6). Odds of adverse pregnancy outcomes were similar with early- and late-onset mild FGR. Overall, discriminatory ability of these FGR classification groups for adverse pregnancy outcomes were poor.

Conclusion

Early- and late-onset, severe FGR (versus late-onset, mild FGR) are positively associated with, but have poor discriminatory ability for, adverse pregnancy outcomes.

Key Points

• Early-onset, severe FGR (vs. late-onset, mild FGR) is significantly associated with hypertensive disorders of pregnancy.

• Compared to late-onset mild FGR, severe FGR, whether early- or late-onset, has greater odds of preterm birth and small-for-gestational age.

• All FGR classification groups had weak discriminatory ability for identification of these adverse pregnancy outcomes.

Keywords

fetal growth restriction - Hadlock - neonatal morbidity - preterm birth

Note

This manuscript was presented as a poster at the American Institute of Ultrasound in Medicine Ultracon 2023 meeting from March 25 to 29, 2023 in Orlando, FL.

Publication History

Received: 19 September 2024

Accepted: 03 December 2025

Accepted Manuscript online:
15 December 2025

Article published online:
31 December 2025

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