Growth Disturbances–Risk of Fetal Growth Restriction

Variant: 1 Growth disturbance. Low risk for fetal growth restriction. Initial evaluation.

Procedure	Appropriateness Category	Relative Radiation Level
US pregnant uterus transabdominal	Usually Appropriate	O
US duplex Doppler ductus venosus	Usually Not Appropriate	O
US duplex Doppler fetal middle cerebral artery	Usually Not Appropriate	O
US duplex Doppler fetal umbilical artery	Usually Not Appropriate	O
US duplex Doppler maternal uterine artery	Usually Not Appropriate	O
US pregnant uterus biophysical profile	Usually Not Appropriate	O

Variant: 2 Growth disturbance. High risk for fetal growth restriction. Initial evaluation.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler fetal umbilical artery	Usually Appropriate	O
US pregnant uterus biophysical profile	Usually Appropriate	O
US pregnant uterus transabdominal	Usually Appropriate	O
US duplex Doppler ductus venosus	May Be Appropriate	O
US duplex Doppler maternal uterine artery	May Be Appropriate	O
US duplex Doppler fetal middle cerebral artery	Usually Not Appropriate	O

Variant: 3 Established fetal growth restriction. Follow-up evaluation.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler ductus venosus	Usually Appropriate	O
US duplex Doppler fetal middle cerebral artery	Usually Appropriate	O
US duplex Doppler fetal umbilical artery	Usually Appropriate	O
US pregnant uterus biophysical profile	Usually Appropriate	O
US pregnant uterus transabdominal	Usually Appropriate	O
US duplex Doppler maternal uterine artery	May Be Appropriate	O

Panel Members

Thomas D. Shipp, MD, RDMS^a; Carolyn M. Zelop, MD^b; Katherine E. Maturen, MD, MS^c; Sandeep Prakash. Deshmukh, MD^d; Kika M. Dudiak, MD^e; Tara L. Henrichsen, MD^f; Edward R. Oliver, MD, PhD^g; Liina Poder, MD^h; Elizabeth A. Sadowski, MDⁱ; Lynn Simpson, MD^j; Therese M. Weber, MD^k; Tom Winter, MD^l; Phyllis Glanc, MD^m.

Summary of Literature Review

Introduction/Background

Discussion of Procedures by Variant

Variant 1: Growth disturbance. Low risk for fetal growth restriction. Initial evaluation.

Variant 1: Growth disturbance. Low risk for fetal growth restriction. Initial evaluation.
A. US Pregnant Uterus Transabdominal

Variant 1: Growth disturbance. Low risk for fetal growth restriction. Initial evaluation.
B. US Pregnant Uterus Biophysical Profile

Variant 1: Growth disturbance. Low risk for fetal growth restriction. Initial evaluation.
C. US Duplex Doppler Velocimetry Maternal Uterine Artery

Variant 1: Growth disturbance. Low risk for fetal growth restriction. Initial evaluation.
D. US Duplex Doppler Velocimetry Fetal Umbilical Artery

Variant 1: Growth disturbance. Low risk for fetal growth restriction. Initial evaluation.
E. US Duplex Doppler Velocimetry Fetal Middle Cerebral Artery

Variant 1: Growth disturbance. Low risk for fetal growth restriction. Initial evaluation.
F. US Duplex Doppler Velocimetry Ductus Venosus

Variant 2: Growth disturbance. High risk for fetal growth restriction. Initial evaluation.

Variant 2: Growth disturbance. High risk for fetal growth restriction. Initial evaluation.
A. US Pregnant Uterus Transabdominal

Variant 2: Growth disturbance. High risk for fetal growth restriction. Initial evaluation.
B. US Pregnant Uterus Biophysical Profile

Variant 2: Growth disturbance. High risk for fetal growth restriction. Initial evaluation.
C. US Duplex Doppler Velocimetry Maternal Uterine Artery

Variant 2: Growth disturbance. High risk for fetal growth restriction. Initial evaluation.
D. US Duplex Doppler Velocimetry Fetal Umbilical Artery

Variant 2: Growth disturbance. High risk for fetal growth restriction. Initial evaluation.
E. US Duplex Doppler Velocimetry Fetal Middle Cerebral Artery

Variant 2: Growth disturbance. High risk for fetal growth restriction. Initial evaluation.
F. US Duplex Doppler Velocimetry Ductus Venosus

Variant 3: Established fetal growth restriction. Follow-up evaluation.

Variant 3: Established fetal growth restriction. Follow-up evaluation.
A. US Pregnant Uterus Transabdominal

Variant 3: Established fetal growth restriction. Follow-up evaluation.
B. US Pregnant Uterus Biophysical Profile

Variant 3: Established fetal growth restriction. Follow-up evaluation.
C. US Duplex Doppler Velocimetry Maternal Uterine Artery

Variant 3: Established fetal growth restriction. Follow-up evaluation.
D. US Duplex Doppler Velocimetry Fetal Umbilical Artery

Variant 3: Established fetal growth restriction. Follow-up evaluation.
E. US Duplex Doppler Velocimetry Fetal Middle Cerebral Artery

Variant 3: Established fetal growth restriction. Follow-up evaluation.
F. US Duplex Doppler Velocimetry Ductus Venosus

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Safety Considerations in Pregnant Patients

Imaging of the pregnant patient can be challenging, particularly with respect to minimizing radiation exposure and risk. For further information and guidance, see the following ACR documents:

· ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI)

· ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation

· ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound

· ACR Manual on Contrast Media

· ACR Manual on MR Safety

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Copel JA, Bahtiyar MO. A practical approach to fetal growth restriction. Obstet Gynecol. 2014;123(5):1057-1069.
2.	Figueras F, Gratacos E. An integrated approach to fetal growth restriction. Best Pract Res Clin Obstet Gynaecol. 2017;38:48-58.
3.	Ott WJ. Intrauterine growth restriction and Doppler ultrasonography. J Ultrasound Med. 2000;19(10):661-665; quiz 667.
4.	Savchev S, Sanz-Cortes M, Cruz-Martinez R, et al. Neurodevelopmental outcome of full-term small-for-gestational-age infants with normal placental function. Ultrasound Obstet Gynecol. 2013;42(2):201-206.
5.	Morales-Rosello J, Khalil A, Morlando M, Papageorghiou A, Bhide A, Thilaganathan B. Changes in fetal Doppler indices as a marker of failure to reach growth potential at term. Ultrasound Obstet Gynecol. 2014;43(3):303-310.
6.	Prior T, Paramasivam G, Bennett P, Kumar S. Are fetuses that fail to achieve their growth potential at increased risk of intrapartum compromise? Ultrasound Obstet Gynecol. 2015;46(4):460-464.
7.	A randomised trial of timed delivery for the compromised preterm fetus: short term outcomes and Bayesian interpretation. Bjog. 2003;110(1):27-32.
8.	Figueras F, Gratacos E. Stage-based approach to the management of fetal growth restriction. Prenat Diagn. 2014;34(7):655-659.
9.	Thornton JG, Hornbuckle J, Vail A, Spiegelhalter DJ, Levene M. Infant wellbeing at 2 years of age in the Growth Restriction Intervention Trial (GRIT): multicentred randomised controlled trial. Lancet. 2004;364(9433):513-520.
10.	Scala C, Bhide A, Familiari A, et al. Number of episodes of reduced fetal movement at term: association with adverse perinatal outcome. Am J Obstet Gynecol. 2015;213(5):678 e671-676.
11.	ACOG Practice bulletin no. 134: fetal growth restriction. Obstet Gynecol. 2013;121(5):1122-1133.
12.	Morales Rosello J, Hervas Marin D, Perales Marin A, Lopez Fraile S. Doppler study of the fetal vertebral and middle cerebral arteries in fetuses with normal and increased umbilical artery resistance indices. J Clin Ultrasound. 2013;41(4):224-229.
13.	Flood K, Unterscheider J, Daly S, et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. Am J Obstet Gynecol. 2014;211(3):288 e281-285.
14.	Spinillo A, Gardella B, Bariselli S, Alfei A, Silini EM, Bello BD. Cerebroplacental Doppler ratio and placental histopathological features in pregnancies complicated by fetal growth restriction. J Perinat Med. 2014;42(3):321-328.
15.	DeVore GR. The importance of the cerebroplacental ratio in the evaluation of fetal well-being in SGA and AGA fetuses. Am J Obstet Gynecol. 2015;213(1):5-15.
16.	Warshak CR, Masters H, Regan J, DeFranco E. Doppler for growth restriction: the association between the cerebroplacental ratio and a reduced interval to delivery. J Perinatol. 2015;35(5):332-337.
17.	Dunn L, Sherrell H, Kumar S. Review: Systematic review of the utility of the fetal cerebroplacental ratio measured at term for the prediction of adverse perinatal outcome. Placenta. 2017;54:68-75.
18.	Cosmi E, Ambrosini G, D'Antona D, Saccardi C, Mari G. Doppler, cardiotocography, and biophysical profile changes in growth-restricted fetuses. Obstet Gynecol. 2005;106(6):1240-1245.
19.	Baschat AA, Cosmi E, Bilardo CM, et al. Predictors of neonatal outcome in early-onset placental dysfunction. Obstet Gynecol. 2007;109(2 Pt 1):253-261.
20.	Hassan WA, Brockelsby J, Alberry M, Fanelli T, Wladimiroff J, Lees CC. Cardiac function in early onset small for gestational age and growth restricted fetuses. Eur J Obstet Gynecol Reprod Biol. 2013;171(2):262-265.
21.	Gudmundsson S, Flo K, Ghosh G, Wilsgaard T, Acharya G. Placental pulsatility index: a new, more sensitive parameter for predicting adverse outcome in pregnancies suspected of fetal growth restriction. Acta Obstet Gynecol Scand. 2017;96(2):216-222.
22.	Snijders RJ, Sherrod C, Gosden CM, Nicolaides KH. Fetal growth retardation: associated malformations and chromosomal abnormalities. Am J Obstet Gynecol. 1993;168(2):547-555
23.	Contro E, Cha DH, De Maggio I, et al. Uterine artery Doppler longitudinal changes in pregnancies complicated with intrauterine growth restriction without preeclampsia. Prenat Diagn. 2014;34(13):1332-1336.
24.	Savchev S, Figueras F, Sanz-Cortes M, et al. Evaluation of an optimal gestational age cut-off for the definition of early- and late-onset fetal growth restriction. Fetal Diagn Ther. 2014;36(2):99-105.
25.	Crimmins S, Desai A, Block-Abraham D, Berg C, Gembruch U, Baschat AA. A comparison of Doppler and biophysical findings between liveborn and stillborn growth-restricted fetuses. Am J Obstet Gynecol. 2014;211(6):669 e661-610.
26.	Roma E, Arnau A, Berdala R, Bergos C, Montesinos J, Figueras F. Ultrasound screening for fetal growth restriction at 36 vs 32 weeks' gestation: a randomized trial (ROUTE). Ultrasound Obstet Gynecol. 2015;46(4):391-397.
27.	Manning FA. The use of sonography in the evaluation of the high-risk pregnancy. Radiol Clin North Am. 1990;28(1):205-216
28.	Carter EB, Goetzinger K, Tuuli MG, et al. Evaluating the Optimal Definition of Abnormal First-Trimester Uterine Artery Doppler Parameters to Predict Adverse Pregnancy Outcomes. J Ultrasound Med. 2015;34(7):1265-1269.
29.	Parry S, Sciscione A, Haas DM, et al. Role of early second-trimester uterine artery Doppler screening to predict small-for-gestational-age babies in nulliparous women. Am J Obstet Gynecol. 2017;217(5):594 e591-594 e510.
30.	Shwarzman P, Waintraub AY, Frieger M, Bashiri A, Mazor M, Hershkovitz R. Third-trimester abnormal uterine artery Doppler findings are associated with adverse pregnancy outcomes. J Ultrasound Med. 2013;32(12):2107-2113.
31.	Newnham JP, Patterson LL, James IR, Diepeveen DA, Reid SE. An evaluation of the efficacy of Doppler flow velocity waveform analysis as a screening test in pregnancy. Am J Obstet Gynecol. 1990;162(2):403-410.
32.	American College of Radiology. ACR Appropriateness Criteria®: Assessment of Fetal Well-Being. Available at: https://acsearch.acr.org/docs/3094108/Narrative/.
33.	Lesmes C, Gallo DM, Saiid Y, Poon LC, Nicolaides KH. Prediction of small-for-gestational-age neonates: screening by uterine artery Doppler and mean arterial pressure at 19-24 weeks. Ultrasound Obstet Gynecol. 2015;46(3):332-340.
34.	Cruz-Martinez R, Savchev S, Cruz-Lemini M, Mendez A, Gratacos E, Figueras F. Clinical utility of third-trimester uterine artery Doppler in the prediction of brain hemodynamic deterioration and adverse perinatal outcome in small-for-gestational-age fetuses. Ultrasound Obstet Gynecol. 2015;45(3):273-278.
35.	Alfirevic Z, Neilson JP. Doppler ultrasonography in high-risk pregnancies: systematic review with meta-analysis. Am J Obstet Gynecol. 1995;172(5):1379-1387.
36.	Figueras F, Savchev S, Triunfo S, Crovetto F, Gratacos E. An integrated model with classification criteria to predict small-for-gestational-age fetuses at risk of adverse perinatal outcome. Ultrasound Obstet Gynecol. 2015;45(3):279-285.
37.	Isalm ZS, Dileep D, Munim S. Prognostic value of obstetric Doppler ultrasound in fetuses with fetal growth restriction: an observational study in a tertiary care hospital. J Matern Fetal Neonatal Med. 2015;28(1):12-15.
38.	Siddiqui TS, Asim A, Ali S, Tariq A. Comparison of perinatal outcome in growth restricted fetuses retaining normal umbilical artery Doppler flow to those with diminished end-diastolic flow. J Ayub Med Coll Abbottabad. 2014;26(2):221-224.
39.	O'Dwyer V, Burke G, Unterscheider J, et al. Defining the residual risk of adverse perinatal outcome in growth-restricted fetuses with normal umbilical artery blood flow. Am J Obstet Gynecol. 2014;211(4):420 e421-425.
40.	Unterscheider J, Daly S, Geary MP, et al. Predictable progressive Doppler deterioration in IUGR: does it really exist? Am J Obstet Gynecol. 2013;209(6):539 e531-537.
41.	Lee VR, Pilliod RA, Frias AE, Rasanen JP, Shaffer BL, Caughey AB. When is the optimal time to deliver late preterm IUGR fetuses with abnormal umbilical artery Dopplers?. J Matern Fetal Neonatal Med. 29(5):690-5, 2016 Mar.
42.	Dahlke JD, Mendez-Figueroa H, Maggio L, Albright CM, Chauhan SP, Wenstrom KD. Early term versus term delivery in the management of fetal growth restriction: a comparison of two protocols. Am J Perinatol. 2015;32(6):523-530.
43.	Maggio L, Dahlke JD, Mendez-Figueroa H, Albright CM, Chauhan SP, Wenstrom KD. Perinatal outcomes with normal compared with elevated umbilical artery systolic-to-diastolic ratios in fetal growth restriction. Obstet Gynecol. 2015;125(4):863-869.
44.	Korkalainen N, Rasanen J, Kaukola T, Kallankari H, Hallman M, Makikallio K. Fetal hemodynamics and adverse outcome in primary school-aged children with fetal growth restriction: a prospective longitudinal study. Acta Obstet Gynecol Scand. 2017;96(1):69-77.
45.	Lakshmi CV, Pramod G, Geeta K, et al. Outcome of very low birth weight infants with abnormal antenatal Doppler flow patterns: a prospective cohort study. Indian Pediatr. 2013;50(9):847-852.
46.	Meher S, Hernandez-Andrade E, Basheer SN, Lees C. Impact of cerebral redistribution on neurodevelopmental outcome in small-for-gestational-age or growth-restricted babies: a systematic review. Ultrasound Obstet Gynecol. 2015;46(4):398-404.
47.	Lees CC, Marlow N, van Wassenaer-Leemhuis A, et al. 2 year neurodevelopmental and intermediate perinatal outcomes in infants with very preterm fetal growth restriction (TRUFFLE): a randomised trial. Lancet. 2015;385(9983):2162-2172.
48.	Bilardo CM, Hecher K, Visser GHA, et al. Severe fetal growth restriction at 26-32 weeks: key messages from the TRUFFLE study. Ultrasound Obstet Gynecol. 2017;50(3):285-290.
49.	Visser GHA, Bilardo CM, Derks JB, et al. Fetal monitoring indications for delivery and 2-year outcome in 310 infants with fetal growth restriction delivered before 32 weeks' gestation in the TRUFFLE study. Ultrasound Obstet Gynecol. 2017;50(3):347-352.
50.	American College of Radiology. ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI). Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=89+&releaseId=2.
51.	American College of Radiology. ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=23+&releaseId=2.
52.	American College of Radiology. ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=28+&releaseId=2.
53.	American College of Radiology. Manual on Contrast Media. Available at: https://www.acr.org/Clinical-Resources/Contrast-Manual.
54.	Expert Panel on MR Safety, Kanal E, Barkovich AJ, et al. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 37(3):501-30, 2013 Mar.
55.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.