Fetal Growth Restriction Management with Umbilical Artery Doppler

Primary Surveillance: Umbilical Artery

The American College of Obstetricians and Gynecologists recommends umbilical artery Doppler as the primary vessel to observe in fetal growth restriction (FGR), with Level I evidence demonstrating reduction in perinatal mortality, as it is the only vessel with this level of evidence 1, 2
Umbilical artery Doppler should be initiated once FGR is suspected and the fetus is considered potentially viable, with serial assessments to monitor for deterioration 3, 4
The use of umbilical artery Doppler is supported by randomized controlled trial evidence (Level I) showing a significant reduction in perinatal deaths (RR 0.71; 95% CI, 0.52-0.98), cesarean deliveries, and inductions of labor 1, 2

Weekly umbilical artery Doppler evaluation is recommended for severe FGR (estimated fetal weight <3rd percentile) or when decreased end-diastolic velocity is present, with a strength of evidence based on clinical guidelines 3, 5
Doppler assessment 2-3 times per week is recommended when umbilical artery absent end-diastolic velocity (AEDV) is detected, due to the potential for rapid deterioration to reversed end-diastolic velocity (REDV) 3
When REDV is present, heightened surveillance with cardiotocography at least 1-2 times per day is recommended, based on clinical expertise 3

Once FGR is suspected, initiate umbilical artery Doppler as the primary surveillance tool, with a normal umbilical artery Doppler allowing for less frequent intervals of weekly Doppler assessment 3, 4, 6, 7
For decreased diastolic flow (but forward flow present), weekly umbilical artery Doppler and delivery at 37 weeks of gestation are recommended, based on clinical guidelines 3, 5
For absent end-diastolic velocity (AEDV), Doppler assessment 2-3 times per week, delivery at 33-34 weeks of gestation, and administration of antenatal corticosteroids are recommended, with a strength of evidence based on clinical trials 3, 5
For reversed end-diastolic velocity (REDV), hospitalization, CTG monitoring at least 1-2 times per day, delivery at 30-32 weeks of gestation, and administration of antenatal corticosteroids are recommended, based on clinical expertise 3, 5, 6

The American College of Obstetricians and Gynecologists recommends not relying on middle cerebral artery or ductus venosus Doppler for timing of delivery decisions, as these vessels lack the evidence base that umbilical artery Doppler possesses 3
Umbilical artery Doppler is not recommended as a screening tool for identifying pregnancies that will develop intrauterine growth restriction (IUGR), but rather for management once IUGR is suspected, based on clinical guidelines 2