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Selective Fetal Growth Restriction
Anne Kennedy, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          • Diagnostic Checklist

            TERMINOLOGY

            • Definitions

              • Literature confusing on topic because of variable nomenclature, definitions of discordant twin growth (DTG) or selective fetal growth restriction (sFGR), and time of onset
              • 2018 Delphi procedure established consensus criteria for sFGR using abdominal circumference (AC), estimated fetal weight (EFW), intertwin difference (Δ EFW), and umbilical artery (UA) pulsatility index (PI) for dichorionic (DC) and monochorionic (MC) twins
              • 2017 American College of Obstetricians and Gynecologists practice bulletin defined DTG as 20% Δ EFW or 20-mm difference in AC
                • Percentage difference in EFW = EFW larger - EFW smaller/EFW larger x 100
              • International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) defined sFGR in DC twins as EFW < 10th percentile in 1 twin
              • Clinically significant discordant twin birth weight (Δ BW) defined in variable terms
                • From 18% to 30%, variable with chorionicity, gestational age (GA) at birth
              • Early onset defined in variable terms: < 24 vs. < 32-weeks GA; proponents of 24 weeks use this date as it is clinical determinant of viability
              • Late onset as > 24-weeks vs. > 32-weeks GA

            IMAGING

            • Ultrasonographic Findings

              • Imaging Recommendations

                DIFFERENTIAL DIAGNOSIS

                  PATHOLOGY

                  • Gross Pathologic & Surgical Features

                    CLINICAL ISSUES

                    • Presentation

                      • Demographics

                        • Natural History & Prognosis

                          • Treatment

                            DIAGNOSTIC CHECKLIST

                            • Consider

                              • Reporting Tips

                                Selected References

                                1. Debbink MP et al: Sonographic assessment of fetal growth abnormalities. Radiographics. 41(1):268-88, 2021
                                2. Amyx MM et al: Intrauterine growth discordance across gestation and birthweight discordance in dichorionic twins. Am J Obstet Gynecol. 222(2):174.e1-10, 2020
                                3. Antonakopoulos N et al: Selective fetal growth restriction in dichorionic twin pregnancies: diagnosis, natural history, and perinatal outcome. J Clin Med. 9(5): 1404, 2020
                                4. Chmait RH et al: Selective intrauterine growth restriction (SIUGR) type II: proposed subclassification to guide surgical management. J Matern Fetal Neonatal Med. Epub, 2020
                                5. Curado J et al: Early- and late-onset selective fetal growth restriction in monochorionic diamniotic twin pregnancy: natural history and diagnostic criteria. Ultrasound Obstet Gynecol. 55(5):661-6, 2020
                                6. Townsend R et al: Core outcome set for studies investigating management of selective fetal growth restriction in twins. Ultrasound Obstet Gynecol. 55(5):652-60, 2020
                                7. Wang SS et al: Double trouble: complications in twin pregnancies. Ultrasound Q. 36(3):240-6, 2020
                                8. Groene SG et al: The impact of selective fetal growth restriction or birth weight discordance on long-term neurodevelopment in monochorionic twins: a systematic literature review. J Clin Med. 8(7), 2019
                                9. Jha P et al: US evaluation of twin pregnancies: importance of chorionicity and amnionicity. Radiographics. 39(7):2146-66, 2019
                                10. Khalil A et al: Study protocol: developing, disseminating, and implementing a core outcome set for selective fetal growth restriction in monochorionic twin pregnancies. Trials. 20(1):35, 2019
                                11. Khalil A et al: Selective fetal growth restriction in monochorionic twin pregnancy: a dilemma for clinicians and a challenge for researchers. Ultrasound Obstet Gynecol. 53(1):23-5, 2019
                                12. Townsend R et al: Perinatal outcome of monochorionic twin pregnancy complicated by selective fetal growth restriction according to management: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 53(1):36-46, 2019
                                13. D'Antonio F et al: Weight discordance and perinatal mortality in twin pregnancy: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 52(1):11-23, 2018
                                14. Khalil A et al: Consensus definition and essential reporting parameters of selective fetal growth restriction in twin pregnancy: a Delphi procedure. Ultrasound Obstet Gynecol. 53(1):47-54, 2018
                                15. Townsend R et al: Fetal growth restriction in twins. Best Pract Res Clin Obstet Gynaecol. 49:79-88, 2018
                                16. Bennasar M et al: Selective intrauterine growth restriction in monochorionic diamniotic twin pregnancies. Semin Fetal Neonatal Med. 22(6):376-82, 2017
                                17. Buca D et al: Outcome of monochorionic twin pregnancy with selective intrauterine growth restriction according to umbilical artery Doppler flow pattern of smaller twin: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 50(5):559-68, 2017
                                18. Townsend R et al: Twin pregnancy complicated by selective growth restriction. Curr Opin Obstet Gynecol. 28(6):485-91, 2016
                                19. Halling C et al: Neuro-developmental outcome of a large cohort of growth discordant twins. Eur J Pediatr. 175(3):381-9, 2015
                                Related Anatomy
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                                Related Differential Diagnoses
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                                References
                                Tables

                                Tables

                                KEY FACTS

                                • Terminology

                                  • Imaging

                                    • Top Differential Diagnoses

                                      • Clinical Issues

                                        • Diagnostic Checklist

                                          TERMINOLOGY

                                          • Definitions

                                            • Literature confusing on topic because of variable nomenclature, definitions of discordant twin growth (DTG) or selective fetal growth restriction (sFGR), and time of onset
                                            • 2018 Delphi procedure established consensus criteria for sFGR using abdominal circumference (AC), estimated fetal weight (EFW), intertwin difference (Δ EFW), and umbilical artery (UA) pulsatility index (PI) for dichorionic (DC) and monochorionic (MC) twins
                                            • 2017 American College of Obstetricians and Gynecologists practice bulletin defined DTG as 20% Δ EFW or 20-mm difference in AC
                                              • Percentage difference in EFW = EFW larger - EFW smaller/EFW larger x 100
                                            • International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) defined sFGR in DC twins as EFW < 10th percentile in 1 twin
                                            • Clinically significant discordant twin birth weight (Δ BW) defined in variable terms
                                              • From 18% to 30%, variable with chorionicity, gestational age (GA) at birth
                                            • Early onset defined in variable terms: < 24 vs. < 32-weeks GA; proponents of 24 weeks use this date as it is clinical determinant of viability
                                            • Late onset as > 24-weeks vs. > 32-weeks GA

                                          IMAGING

                                          • Ultrasonographic Findings

                                            • Imaging Recommendations

                                              DIFFERENTIAL DIAGNOSIS

                                                PATHOLOGY

                                                • Gross Pathologic & Surgical Features

                                                  CLINICAL ISSUES

                                                  • Presentation

                                                    • Demographics

                                                      • Natural History & Prognosis

                                                        • Treatment

                                                          DIAGNOSTIC CHECKLIST

                                                          • Consider

                                                            • Reporting Tips

                                                              Selected References

                                                              1. Debbink MP et al: Sonographic assessment of fetal growth abnormalities. Radiographics. 41(1):268-88, 2021
                                                              2. Amyx MM et al: Intrauterine growth discordance across gestation and birthweight discordance in dichorionic twins. Am J Obstet Gynecol. 222(2):174.e1-10, 2020
                                                              3. Antonakopoulos N et al: Selective fetal growth restriction in dichorionic twin pregnancies: diagnosis, natural history, and perinatal outcome. J Clin Med. 9(5): 1404, 2020
                                                              4. Chmait RH et al: Selective intrauterine growth restriction (SIUGR) type II: proposed subclassification to guide surgical management. J Matern Fetal Neonatal Med. Epub, 2020
                                                              5. Curado J et al: Early- and late-onset selective fetal growth restriction in monochorionic diamniotic twin pregnancy: natural history and diagnostic criteria. Ultrasound Obstet Gynecol. 55(5):661-6, 2020
                                                              6. Townsend R et al: Core outcome set for studies investigating management of selective fetal growth restriction in twins. Ultrasound Obstet Gynecol. 55(5):652-60, 2020
                                                              7. Wang SS et al: Double trouble: complications in twin pregnancies. Ultrasound Q. 36(3):240-6, 2020
                                                              8. Groene SG et al: The impact of selective fetal growth restriction or birth weight discordance on long-term neurodevelopment in monochorionic twins: a systematic literature review. J Clin Med. 8(7), 2019
                                                              9. Jha P et al: US evaluation of twin pregnancies: importance of chorionicity and amnionicity. Radiographics. 39(7):2146-66, 2019
                                                              10. Khalil A et al: Study protocol: developing, disseminating, and implementing a core outcome set for selective fetal growth restriction in monochorionic twin pregnancies. Trials. 20(1):35, 2019
                                                              11. Khalil A et al: Selective fetal growth restriction in monochorionic twin pregnancy: a dilemma for clinicians and a challenge for researchers. Ultrasound Obstet Gynecol. 53(1):23-5, 2019
                                                              12. Townsend R et al: Perinatal outcome of monochorionic twin pregnancy complicated by selective fetal growth restriction according to management: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 53(1):36-46, 2019
                                                              13. D'Antonio F et al: Weight discordance and perinatal mortality in twin pregnancy: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 52(1):11-23, 2018
                                                              14. Khalil A et al: Consensus definition and essential reporting parameters of selective fetal growth restriction in twin pregnancy: a Delphi procedure. Ultrasound Obstet Gynecol. 53(1):47-54, 2018
                                                              15. Townsend R et al: Fetal growth restriction in twins. Best Pract Res Clin Obstet Gynaecol. 49:79-88, 2018
                                                              16. Bennasar M et al: Selective intrauterine growth restriction in monochorionic diamniotic twin pregnancies. Semin Fetal Neonatal Med. 22(6):376-82, 2017
                                                              17. Buca D et al: Outcome of monochorionic twin pregnancy with selective intrauterine growth restriction according to umbilical artery Doppler flow pattern of smaller twin: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 50(5):559-68, 2017
                                                              18. Townsend R et al: Twin pregnancy complicated by selective growth restriction. Curr Opin Obstet Gynecol. 28(6):485-91, 2016
                                                              19. Halling C et al: Neuro-developmental outcome of a large cohort of growth discordant twins. Eur J Pediatr. 175(3):381-9, 2015