Consensus and controversies of international guidelines for the diagnosis, surveillance, and management of fetal growth restriction: an updated comparison

Fetal growth restriction remains a major contributor to perinatal morbidity and mortality, yet its management varies across clinical settings. The aim of this study was to compare areas of consensus and disagreements across contemporary international and national guidelines on the diagnosis, surveillance, and management of fetal growth restriction. Electronic searches of Medline from database inception up to March 2026 using Medical Subject Headings terms and keywords related to fetal growth restriction and guidelines. Critical, structured comparison of national or international guidelines on fetal growth restriction published since 2010. Final inclusion required unanimous agreement from all authors. Prespecified extraction across domains: definition, prediction/prevention, surveillance tools and frequency, delivery timing and mode, and labor induction methods. Dual data checking with consensus resolution. We focused mainly on areas of cross-guideline agreement and divergence in (1) definitions (fetal growth restriction vs small for gestational age; early vs late), (2) diagnostic/surveillance tools (biometry, Doppler, cardiotocography [conventional or computerized], biophysical profile, biomarkers), and (3) management (aspirin/low-molecular-weight heparin, steroids, magnesium sulfate, induction methods, delivery timing/mode). Six guidelines, 3 national (Canada, United Kingdom, and France), 1 US society guideline (Society for Maternal-Fetal Medicine), and 2 international societies (International Society of Ultrasound in Obstetrics and Gynecology and International Federation of Gynecology and Obstetrics) published predominantly between 2015 and 2024 were included. Broad agreement exists on the central role of Doppler-especially umbilical artery and, in early-onset cases, ductus venosus (except for Society for Maternal-Fetal Medicine)-for risk stratification and delivery timing. Other consensus points include antenatal corticosteroids, magnesium sulfate for anticipated preterm birth, early aspirin in high-risk pregnancies, and access to genetic counseling/testing in severe or early-onset fetal growth restriction with structural anomalies. Universal third-trimester ultrasound is not recommended in low-risk pregnancies. Controversies remain on the definition of fetal growth restriction vs small for gestational age (Society for Maternal-Fetal Medicine biometric threshold vs Delphi criteria), routine use of angiogenic biomarkers, low-molecular-weight heparin for prevention, choice of growth charts, the role of the biophysical profile, computerized cardiotocography, and induction methods (mechanical generally favored but with limited evidence). Current guidelines converge on Doppler-based surveillance and standard preterm interventions, but substantial heterogeneity persists in definitions and several management domains, reflecting variable evidence and resource contexts. Priorities include harmonizing definitions, validating surveillance algorithms (notably computerized cardiotocography and ductus venosus), clarifying growth-chart selection, and rigorously testing the added value of angiogenic biomarkers and induction strategies to improve fetal growth restriction outcomes.