Fetal growth restriction and small-for-gestational-age infant — case

Case summary

A term male infant is born at 38 weeks to a 31-year-old primigravida whose pregnancy was complicated by pre-eclampsia. Antenatal growth scans showed the estimated fetal weight falling from the 40th to the 5th centile, with absent end-diastolic flow on the umbilical artery Doppler in the last week, prompting induction. Birthweight is 2280 g (below the 3rd centile on an INTERGROWTH-21st chart). He is wasted with a disproportionately large head, loose dry skin and a low Ponderal Index. At two hours of age he is cool and a pre-feed glucose is low after a breastfeed. [1] [3] [6]

Candidate tasks

1. Take a focused history and examine the infant; formulate a one-line problem representation. [5]
2. Outline your immediate and stepwise management of the neonatal complications. [6]
3. Counsel the parents about the diagnosis, the early plan and the long-term outlook. [4]

Focused history and examination

• Antenatal: maternal pre-eclampsia, serial growth showing a falling velocity, Doppler showing absent end-diastolic flow, steroids and magnesium coverage, reason for and timing of induction. [3]
• Anthropometry: weight 2280 g (<3rd centile), length and head circumference plotted on a gestation- and sex-specific INTERGROWTH-21st chart; Ponderal Index calculated; asymmetry confirmed (head relatively spared, body wasted). [2] [5]
• Functional assessment: tone, colour, perfusion, temperature (cool), feeding and respiratory effort. [6]
• Screen for a cause: no dysmorphism, no organomegaly, no rash or petechiae — consistent with placental insufficiency rather than a syndromic or infective cause. [5]

One-line summary: "A 38-week male, severe asymmetric late-onset fetal growth restriction secondary to pre-eclampsia and placental insufficiency, now hypothermic and hypoglycaemic — early neonatal metabolic compromise." [1]

Immediate and stepwise management

• Warmth: dry, wrap, hat, warm room; aim for normothermia and skin-to-skin when stable. [6]
• Early feeding within the first hour, then 2–3 hourly; breast milk first. [6]
• Scheduled pre-feed glucose monitoring; treat hypoglycaemia up the ladder: feed, then buccal 40% dextrose gel (200 mg/kg) with a feed and recheck, then intravenous 10% dextrose bolus and an escalating infusion for persistent hypoglycaemia. [6]
• Check a venous haematocrit for polycythaemia and a bilirubin for jaundice; manage by thresholds. [6]
• Admit to a transitional or NICU environment; plan discharge once thermally stable, glucose-stable on full enteral feeds, gaining weight, feeding competently, and with confident parents. [6]
• Long-term: growth monitoring, neurodevelopmental surveillance, and family counselling about cardiovascular and metabolic implications of FGR. [4]

Counselling the parents

• Explain clearly that their baby is small not because of anything they did wrong in labour, but because the placenta could not supply enough nutrients and oxygen, and that the baby redirected blood to the brain to protect it. [4]
• Set immediate expectations: the team will focus on warmth, feeding and blood sugar in the first hours, and most babies stabilise quickly with this care. [6]
• Be honest about the longer view: most catch up well, but severe growth restriction can carry risks to development and later heart and metabolic health, which is why follow-up is part of the plan — delivered supportively, not alarmingly. [4]
• Invite questions and check understanding; offer written information and a follow-up contact. [4]