Definitions
Small for gestational age (SGA) – an infant with a birth weight <10th centile for its gestational
age.
Severe SGA – a birth weight < 3rd centile.
Fetal SGA – an estimated fetal weight (EFW), or abdominal circumference (AC) <10th centile.
Severe fetal SGA – an EFW or AC <3rd centile.
Fetal growth restriction (FGR) – when a pathological process has restricted genetic growth
potential. This can present with features of fetal compromise including reduced liquor volume (LV) or
abnormal doppler studies.
The likelihood of FGR is higher in a severe SGA fetus.
Low birth weight refers – an infant with a birth weight <2500g.
Aetiology and Pathophysiology
Normal (Constitutionally) Small
50 to 70% of SGA fetuses/infants are constitutionally small, identified by small size at all stages
but growth following the centiles. No pathology is present. Contributing factors include ethnicity, sex,
and parental height.
Placenta Mediated Growth Restriction
Growth is usually normal initially but slows in utero. This is a common cause of FGR. Maternal
factors that can result in placental insufficiency include low pre-pregnancy weight, substance abuse,
autoimmune disease, renal disease, diabetes and chronic hypertension.
Non-Placenta Mediated Growth Restriction
Growth is affected by fetal factors such as a chromosomal or structural anomaly, an error in
metabolism or fetal infection.
Risk Factors
At booking, and again at 20 weeks gestation, all women should be assessed for risk factors for
SGA.
Minor risk factors Major risk factors
Maternal age ≥35 Maternal age >40
Smoker 1-10/day Smoker ≥11/day
Nulliparity Previous SGA baby
BMI<20 or 25-34.9 Maternal/paternal SGA
IVF singleton Previous stillbirth
Previous pre-eclampsia Cocaine use
Pregnancy interval <6 or ≥60 months Daily vigorous exercise
Low fruit intake pre-pregnancy Maternal disease*
Heavy bleeding
Low PAPP-A^
* Chronic hypertension, renal impairment, diabetes with vascular disease and antiphospholipid
syndrome
^PAPP-A = pregnancy associated plasma protein, a hormone produced by the placenta
Diagnosis and Clinical Features
Ultrasound is used for the diagnosis and surveillance of an SGA fetus. Ultrasound biometrics,
including EFW and AC, are plotted on customised centile charts. These charts take into account maternal
characteristics (height, weight, ethnicity and parity), gestational age and sex.
The ratio of head circumference (HC) and AC may be significant; a symmetrically small fetus is
more likely to be constitutionally small whilst an asymmetrically small fetus is more likely to be caused
by placental insufficiency. The ‘brain-sparing’ effect can be identified by abnormal doppler studies.
Placental insufficiency can result in impaired fetal kidney function which will result in reduced
amniotic fluid volume.
Investigations
Other investigations that may be appropriate include:
Detailed fetal anatomical survey
Uterine artery Doppler (UAD)
Karyotyping
Screening for infections including congenital cytomegalovirus, toxoplasmosis, syphilis and
malaria
Management
Prevention
Modifiable risk factors should be managed to help prevent SGA, including promoting smoking
cessation and optimising maternal disease.
Women at high risk for pre-eclampsia should be started on 75mg of aspirin 16 weeks gestation
until delivery.
Surveillance
UAD should be the primary surveillance tool in the SGA fetus. If it is normal repeat every 14
days. If it is abnormal repeat more frequently or consider delivery.
Other tests useful in surveillance include symphysis fundal height (SFH), middle cerebral artery
(MCA) Doppler, ductus venosus (DV) Doppler, cardiotocography (CTG) and amniotic fluid volume.
Delivery
If delivery is being considered between 24 and 35+6 weeks gestation a single course of
antenatal steroids should be given.
The table below demonstrates the indications for delivery by gestation and the recommended
mode of delivery.
Gestation Indication for delivery Mode of delivery
<37 weeks Absent/reverse end-diastolic flow on Doppler C-section
By 37 weeks Abnormal UAD or MCA Doppler Can offer induction
At 37 weeks Normal UAD Can offer induction
Induction for an SGA fetus is associated with a higher rate of C-section. Continuous fetal heart
rate monitoring is required from the onset of contractions.
Complications
The use of these customised centile charts has been shown to reduce neonatal morbidity and
mortality. Increased morbidity and mortality are most closely associated with FGR. Antenatally, there is
an increased risk of stillbirth. Potential neonatal and long-term complications are demonstrated in the
table below.
Neonatal complications Long-term complications
Birth asphyxia Cerebral palsy
Meconium aspiration Type 2 diabetes
Hypothermia Obesity
Hypo-/hyperglycaemia Hypertension
Polycythaemia Precocious puberty
Retinopathy of prematurity Behavioural problems
Persistent pulmonary hypertension Depression
Pulmonary haemorrhage Alzheimer’s disease
Necrotising enterocolitis Cancer*
*Breast, ovarian, colon, lung and blood
Summary
SGA = birth weight/EFW/AC <10th centile
Severe SGA = birth weight/EFW/AC <3rd centile
SGA is not always pathological
If ³3 minor risk factors present refer for UAD
If major risk factor present refer for serial ultrasound and UAD
UAD used for surveillance
If UAD is normal induction can be offered at 37 weeks
If pre-term delivery planned give course of antenatal steroids
Complications include stillbirth, birth asphyxia, hypothermia, obesity and cancer
