International Journal of Infertility & Fetal Medicine

Register      Login

VOLUME 13 , ISSUE 3 ( September-December, 2022 ) > List of Articles


Stage-based FGR (Barcelona Protocol): Perinatal Outcome in SGA and FGR

Mounika Kachakayala, Suseela Vavilala

Keywords : Fetal growth, Fetal growth restriction (FGR), Multivessel fetal Doppler, Perinatal outcome, Small for gestational age (SGA)

Citation Information : Kachakayala M, Vavilala S. Stage-based FGR (Barcelona Protocol): Perinatal Outcome in SGA and FGR. Int J Infertil Fetal Med 2022; 13 (3):101-110.

DOI: 10.5005/jp-journals-10016-1294

License: CC BY-NC 4.0

Published Online: 29-12-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Objective of the study: To identify adverse perinatal outcomes, these include stillbirth, neonatal death, hypoxic-ischemic encephalopathy, need for mechanical ventilation, or severe metabolic acidosis in small for gestational age (SGA) and in all stages of fetal growth restriction (FGR) based on Barcelona Protocol. To evaluate the demographic variables, maternal risk factors, mode of delivery, birthweight, and indications of operative delivery in SGA and all stages of FGR. Materials and methods: It is a prospective observational study underwent from January 2019 to June 2019 at the Department of Fetal Medicine, Fernandez Hospital. All mothers with singleton pregnancies, who came for fetal growth scan, it’s mandatory to have expected delivery date (EDD) confirmed in first trimester itself and estimated fetal weight (EFW) < 10th percentile were included in the study. Multiple pregnancies, structurally abnormal fetuses, first scan >20 weeks (GA not accurate) were excluded from the study. Mothers with EFW < 10th percentile underwent serial sonographic evaluation of estimated fetal weight at 2-weekly intervals including multivessel Doppler assessment based on staged-based protocol. If the EFW 3–10th percentile, multivessel Doppler findings are within normal range the fetus is termed as SGA fetus and is followed up every 2 weeks. If the EFW < 3rd percentile or any of the multivessel Doppler findings show features of placental insufficiency, the fetus is termed as FGR, and management is based on the stage-based Barcelona Protocol. Maternal, fetal, and neonatal characteristics, neonatal morbidity, and adverse perinatal outcome were recorded. Results: Among 6,240 mothers who underwent growth scans during the study period, 14% (n = 858) with EFW < 10th percentile were taken as the study population. A total of 768 pregnant women were included in the study. Based on Barcelona protocol, 68% (n = 521) and 32% (n = 247) were termed FGR and SGA, respectively. FGR fetuses were classified into four stages —488 (95%), 23(14.4%), 10(2%), I, II, III, and IV, respectively. Among 247 pregnant women with SGA fetuses, 42% required induction of labor, FGR stage I (488), 40% required induction of labor. FGR stage II & III fetuses (25) 27% required induction of labor. Fetuses grouped under stages II & III have 61% admissions into NICU, compared to 12% in FGR stage I and 2% SGA group fetuses. There are no adverse perinatal outcomes in SGA group. In FGR stage I group, adverse perinatal outcomes in terms of metabolic acidosis, 5 minutes APGAR < 7, hypoxic ischemic encephalopathy (HIE), need for mechanical ventilation are 1.8%, 0.6%, 0.6%, 0.8%, respectively. In FGR stage II & III, metabolic acidosis was diagnosed in five (15%) neonates, two neonates (6%) required mechanical ventilation with four (12%) of stillbirths. There is one neonatal death (NND) in the entire cohort, classified under FGR stage I. Conclusion: Incorporation of Barcelona protocol as a structured antenatal surveillance protocol discriminates between SGA fetuses and stages of FGR. Prenatal recognition of FGR allows for close monitoring and timely delivery. There is a higher risk for adverse perinatal outcomes in FGR II & III compared to FGR stage I and SGA fetuses.

  1. Figueras F, Gratacós E. Update on the diagnosis and classification of fetal growth restriction and proposal of a stage-based management protocol. Fetal Diagn Ther 2014;36(2):86–98. DOI: 10.1159/000357592
  2. The Investigation and Management of the Small-for-Gestational Age Fetus.London (UK): Royal College of Obstetricians and. Gynecologists(RCOG); 2013.2nd edn.
  3. Lausman A, Kingdom J, Maternal Fetal Medicine Committee. Intrauterine growth restriction: screening, diagnosis, and management. J Obstet Gynaecol Can 2013;35(8):741–748. DOI: 10.1016/S1701-2163(15)30865-3
  4. [Intra-uterine growth retardation: guidelines for clinical practice–Short text]. J Gynecol Obstet Biol Reprod (Paris) 2013;42(8):1018–1025. DOI: 10.1016/j.jgyn.2013.09.023
  5. ACOG Practice bulletin no. 134: fetal growth restriction. Obstet Gynecol 2013;121(5):1122–1133. DOI: 10.1097/01.AOG.0000429658.85846.f9
  6. Unterscheider J, O’Donoghue K, Daly S, et al. Fetal growth restriction and the risk of perinatal mortality-case studies from the multicentre PORTO study. BMC Pregnancy Childbirth 2014;14:63. DOI: 10.1186/1471-2393-14-63
  7. Baschat AA, Viscardi RM, Hussey-Gardner B, et al. Infant neurodevelopment following fetal growth restriction: relationship with antepartum surveillance parameters. Ultrasound Obstet Gynecol 2009;33(1):44–50. DOI: 10.1002/uog.6286
  8. India Birth Rate 1950–2021[Internet].Available from:’>India Birth Rate 1950–2019.
  9. Registrar General of India. Sample registration system (SRS) statistical report 2013. New Delhi: 2013.
  10. Devi KS, Aziz N, Gala A, et al. Incidence of stillbirths and risk factors at a tertiary perinatal center in Southern India: retrospective observational study. Int J Gynecol and Reprod Sci 2018;1(1):14–22.
  11. Singh A, Ambujam K. Maternal socio-demographic determinants and fetal outcome of intrauterine growth restriction. Int J Reprod Contracept Obstet Gynecol. 2018;7:3843–3847. DOI: 10.18203/2320-1770.ijrcog20183805
  12. Chauhan SP, Beydoun H, Chang E, et al. Prenatal detection of fetal growth restriction in newborns classified as small for gestational age: correlates and risk of neonatal morbidity. Am J Perinatol 2014;31(3):187–194. DOI: 10.1055/s-0033-1343771
  13. Clifford S, Giddings S, Southam M, et al. The Growth Assessment Protocol: a national programme to improve patient safety in maternity care. MIDIRS Midwifery Digest 2013;23(4):516–523.
  14. Trudell AS, Cahill AG, Tuuli MG, et al. Risk of stillbirth after 37 weeks in pregnancies complicated by small-for-gestational-age fetuses. Am J Obstet Gynecol 2013;208(5):376.e1–376.e7. DOI: 10.1016/j.ajog.2013.02.030
  15. Bhide A, Acharya G, Bilardo CM, et al. ISUOG practice guidelines: use of Doppler ultrasonography in obstetrics. Ultrasound Obstet Gynecol 2013;41(2):233–239. DOI: 10.1002/uog.12371
  16. Del Río M, Martínez JM, Figueras F, et al. Doppler assessment of fetal aortic isthmus blood flow in two different sonographic planes during the second half of gestation. Ultrasound Obstet Gynecol 2005;26(2):170–174. DOI: 10.1002/uog.1955
  17. Salomon LJ, Alfirevic Z, Berghella V, et al. Practice guidelines for performance of the routine mid-trimester fetal ultrasound scan. Ultrasound Obstet Gynecol 2011;37(1):116–126. DOI: 10.1002/uog.8831
  18. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 348, November 2006: Umbilical cord blood gas and acid-base analysis. Obstet Gynecol 2006;108(5):1319–1322. DOI: 10.1097/00006250-200611000-00058
  19. Şahin Uysal N, Gülümser Ç, Bilgin Yanık F. Maternal and perinatal characteristics of small-for-gestational-age newborns: ten-year experience of a single center. J Turk Ger Gynecol Assoc 2017;18(2):90–95. DOI: 10.4274/jtgga.2016.0228
  20. McCowan L, Horgan RP. Risk factors for small for gestational age infants. Best Pract Res Clin Obstet Gynaecol 2009;23(6):779–793. DOI: 10.1016/j.bpobgyn.2009.06.003
  21. Thompson JM, Clark PM, Robinson E, et al. Risk factors for small-for-gestational-age babies: The Auckland Birthweight Collaborative Study. J Paediatr Child Health 2001;37(4):369–375. DOI: 10.1046/j.1440-1754.2001.00684.x
  22. Teixeira MP, Queiroga TP, Mesquita MD. Frequency and risk factors for the birth of small-for-gestational-age newborns in a public maternity hospital. Einstein (Sao Paulo) 2016;14(3):317–323. DOI: 10.1590/s1679-45082016ao3684
  23. Satyavrathan V, Ahmed N, Sundrappa S. Study of perinatal outcomes of pregnancies with intrauterine growth restriction in a tertiary care centre in North Kerala. J Evid Based Med Healthc 2017;4(37):2203–2208.
  24. Sharma DD, Chandnani KC. Clinical study of IUGR cases and correlation of Doppler parameters with perinatal outcome. Int J Reprod Contracept Obstet Gynecol 2016;5(12):4290–4296. DOI: 10.18203/2320-1770.ijrcog20164330
  25. Shenoy HT, James SX, Shenoy ST. Maternal risk factors and perinatal outcomes in fetal growth restriction using obstetric Doppler in South Kerala, India. Int J Reprod Contracept Obstet Gynecol 2019;8(1):6–13. DOI: 10.18203/2320-1770.ijrcog20185062
  26. Gagnon R, Harding R, Brace RA. Amniotic fluid and fetal urinary responses to severe placental insufficiency in sheep. Am J Obstet Gynecol 2002;186(5):1076–1084. DOI: 10.1067/mob.2002.122291
  27. Fratelli N, Valcamonico A, Prefumo F, et al. Effects of antenatal recognition and follow-up on perinatal outcomes in small-for-gestational age infants delivered after 36 weeks. Acta Obstet Gynecol Scand 2013;92(2):223–229. DOI: 10.1111/aogs.12020
  28. 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.e1–420.e5. DOI: 10.1016/j.ajog.2014.07.033
  29. Seal A, Dasgupta A, Sengupta M, et al. Analysis of fetal growth restriction in pregnancy in subjects attending in an obstetric clinic of a tertiary care teaching hospital. Int J Reprod Contracept Obstet Gynecol. 2018;7:973–80. DOI:
  30. Sinha S, Kurude VN. Study of obstetric outcome in pregnancies with intrauterine growth retardation. Int J Reprod Contracept Obstet Gynecol. 2018;7:1858–63. DOI:
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.