Fetal Growth Restriction as a Perinatal and Long-Term Health Problem: Clinical Challenges and Opportunities for Future (4P) Fetal Medicine

standards according to the expected individual growth potential has been a step forward. In the future we will see more refined standards for the definition of FGR, combining estimated fetal weight with hemodynamic (i.e. brain Doppler indices) or maternal blood biomarkers (i.e. placental growth factor). Another emerging need is to improve the characterization of the clinical phenotypes of FGR. For instance, placental patterns of insufficiency may differ in earlyas compared to late-onset FGR, and may or may not be present. Clarifying the association of placental disease with the variable clinical presentations of FGR and with perinatal and postnatal outcomes will improve our understanding and clinical management. From a long-term perspective, FGR probably represents the best paradigm of the impact of adverse environment during fetal life, the opportunities for public health, and the role of future personalized fetal medicine in improving quality of life. FGR is associated with neurodevelopmental disabilities, cardiovascular remodeling, and metabolic programming. Early-life preventive measures can have a strong impact in the future health of these children. With the development of new and more accurate, but more sophisticated, definitions, the identification of FGR will, in most instances, be possible only in utero and not when the fetus is born. Consequently, advances in the diagnosis and in the characterization of the various clinical phenotypes under the common diagnosis of FGR will open new public health opportunities. We expect that the results of current research will reinforce the role of fetal medicine in the prediction and prevention of the long-life consequences of prenatal conditions. Eduard Gratacós, Barcelona Francesc Figueras, Barcelona Fetal growth restriction (FGR) is possibly the most common of the great obstetric syndromes. Even under optimal healthcare conditions, at least 8–10% of fetuses are born small, i.e. less than the 10th centile for gestational age. Small fetuses and newborns have poorer perinatal outcome, including a higher risk of intrauterine fetal death. In addition, despite the relatively short duration, exposure to an adverse environment during a highly critical moment of development will lead to life-long consequences that may decrease life expectancy and quality of life. In a minority of cases, FGR presents as a severe disease early in pregnancy and is associated with high perinatal mortality and morbidity. Early-onset FGR has a strong association with placental insufficiency and preeclampsia. Despite early-onset FGR and preeclampsia sharing common features, prediction and prevention of isolated early-onset FGR is still a challenge, as the performance of first trimester predictive algorithms and the effectiveness of prophylactic strategies with aspirin are far worse than the results reported for preeclampsia. However, the majority of FGR cases will present as a milder, late-onset problem in gestation and is delivered at term. The main clinical challenge here is the detection in utero. Concerning detection of growth restriction, fetal smallness (estimated fetal weight <10th centile) is only an imperfect clinical surrogate. On the one hand, detection of fetal smallness has proven elusive, with high-quality ultrasound programs detecting not more than 50% of the cases. In addition, a definition based on fetal smallness cannot pick up fetuses suffering restriction but with a birth weight above the 10th centile. In reality, it is the existence of growth restriction, and not absolute size, which matters. In that sense, customization of weight Published online: August 21, 2014