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Published on: June 29, 2013
A systematic review and critical evaluation of quality of clinical practice guidelines on fetal growth restriction
Sara Alameddine1, Giulia Capannolo1, Giuseppe Rizzo2
1Center for High-Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy.
Insights
This study reviewed clinical practice guidelines (CPGs) for fetal growth restriction (FGR). Management recommendations varied significantly across the evaluated CPGs, indicating a need for standardization in FGR care.
Area of Science:
- Obstetrics and Gynecology
- Perinatology
- Clinical Practice Guideline Analysis
Background:
- Fetal growth restriction (FGR) is a critical obstetric complication requiring standardized management strategies.
- Existing clinical practice guidelines (CPGs) for FGR management need systematic evaluation for quality and consistency.
Approach:
- A systematic literature search was conducted across major databases (Medline, Embase, Scopus, Web of Science, Google Scholar) to identify FGR CPGs.
- Twelve CPGs were critically assessed using the AGREE II tool, evaluating recommendations on diagnostic criteria, monitoring, and delivery timing.
- Specific management elements analyzed included diagnostic criteria, growth charts, fetal surveillance frequency, and induction of labor protocols.
Key Points:
- Significant heterogeneity exists in FGR diagnostic criteria, with varying definitions based on estimated fetal weight percentiles and longitudinal growth.
- Fifty percent of CPGs recommended customized growth charts, while Doppler assessment frequencies for umbilical artery flow abnormalities were inconsistently reported.
- Only three CPGs provided specific recommendations on the type of induction of labor to be employed.
Conclusions:
- Published CPGs demonstrate considerable variability in managing pregnancies complicated by FGR.
- The overall quality assessment using AGREE II yielded a mean score of 50%, suggesting room for improvement in guideline development and reporting.
- There is a clear need for more consistent and evidence-based recommendations to standardize FGR management globally.
Introduction:
To systematically identify and critically assess the quality of clinical practice guidelines (CPGs) on management fetal growth restriction (FGR).
Content:
Medline, Embase, Google Scholar, Scopus and ISI Web of Science databases were searched to identify all relevant CPGs on FGR.
Summary:
Diagnostic criteria of FGR, recommended growth charts, recommendation for detailed anatomical assessment and invasive testing, frequency of fetal growth scans, fetal monitoring, hospital admission, drugs administrations, timing at delivery, induction of labor, postnatal assessment and placental histopathological were assessed. Quality assessment was evaluated by AGREE II tool. Twelve CPGs were included. Twenty-five percent (3/12) of CPS adopted the recently published Delphi consensus, 58.3% (7/12) an estimated fetal weight (EFW)/abdominal circumference (AC) EFW/AC <10th percentile, 8.3% (1/12) an EFW/AC <5th percentile while one CPG defined FGR as an arrest of growth or a shift in its rate measured longitudinally. Fifty percent (6/12) of CPGs recommended the use of customized growth charts to assess fetal growth. Regarding the frequency of Doppler assessment, in case of absent or reversed end-diastolic flow in the umbilical artery 8.3% (1/12) CPGs recommended assessment every 24-48, 16.7% (2/12) every 48-72 h, 1 CPG generically recommended assessment 1-2 times per week, while 25 (3/12) did not specifically report the frequency of assessment. Only 3 CPGs reported recommendation on the type of Induction of Labor to adopt. The AGREE II standardized domain scores for the first overall assessment (OA1) had a mean of 50%.
Outlook:
There is significant heterogeneity in the management of pregnancies complicated by FGR in published CPGs.
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