Evaluation of fetal growth restriction guidelines Based on AGREE II, STAR and RIGHT Tools

Evaluation of fetal growth restriction guidelines Based on AGREE II, STAR and RIGHT Tools | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of fetal growth restriction guidelines Based on AGREE II, STAR and RIGHT Tools Mingyue Guo, Ruohan Wang, Weishe Zhang, Qi Li, Yiran Fu, Qi Wang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6582108/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 5 You are reading this latest preprint version Abstract Objectives To comprehensively evaluate the quality of guidelines related to fetal growth restriction(FGR), with a view to provide recommendations for the development of high-quality guidelines. Methods CNKI, Wanfang, Chinese Medical journal, PubMed, Embase, Web of Science and other databases were searched for FGR guidelines published from database establishment to September, 2024. Used the Appraisal of Guidelines for Research and Evaluation II(AGREEII)instrument, the Reporting Items for practice Guidelines in Health care (RIGHT) checklist and Scientific, Transparent and Applicable Rankings (STAR) tool to assess the quality of guidelines. We tested the consistency of the evaluation results of researchers by calculating the intraclass correlation coefficient (ICC). Results A total of 10 guidelines were included in this study, including nine English CPGs and one Chinese CPG. According to the AGREE II instrument, two CPGs were “recommended,” while eight were “suggested with modifications”. STAR tool results showed scores of 0.00%, 0.00%, 26.41%, 18.49%, 38.28%, 55.85%, 62.55%, 26.54%, 88.66%, 27.54%, and 70.00% for registry, protocol, funding, guideline development groups, conflicts of interest, clinical questions, evidence, consensus method, recommendations, accessibility, and other aspects, respectively. RIGHT checklist reporting rates were 76.67% (basic information), 66.25% (background), 68.00% (evidence), 68.57% (recommendations), 70.00% (review and quality assurance), 40.00% (funding and declaration and management of interests), and 73.34% (other information). Conclusions The quality of FGR guidelines still needs to be further improved. It is recommended that future guideline development and updates should pay more attention to clarifying the target populations and settings of guideline use. Guideline authors should involve experts in statistics and guideline methodology to enhance the quality of evidence supporting the guidelines. Additionally, the influencing factors during guideline dissemination to clinical practice, as well as the practical implementation of guidelines in clinical settings, should be considered more comprehensively. Furthermore, the independence of guideline development, including the management of conflicts of interest and funding issues, also requires improvement. fetal growth restriction guidelines AGREE II STAR RIGHT Figures Figure 1 Key message The quality of internationally published guidelines on FGR varies significantly. High-quality guidelines effectively inform clinical practice, while low-quality ones may lead to erroneous recommendations and jeopardize patient health. The guidelines were assessed using the AGREE II, STAR, and RIGHT tools. Among the 10 included guidelines, two were recommended, and the results demonstrated overall consistency across the three evaluation tools. Guideline quality requires improvement, particularly in addressing target populations, settings for application, applicability, and editorial independence in future development. Introduction Fetal growth restriction (FGR) is a common pregnancy complication, which traditionally refers to the failure of a fetus to achieve its genetically determined growth potential 1 , with particular need to be distinguished from children who are small for gestational age (SGA).Placental insufficiency is the main cause of FGR 3 – 4 ,leading to chronic fetal hypoxia and ultimately increasing the risk of perinatal mortality, morbidity, and long-term adverse infant outcomes 2 .The diagnosis, management, and treatment of FGR remain significant clinically challenging 5 . Several clinical guidelines have been published to guide clinical decisions. Clinical Practice Guideline (CPG) is a statement that contains recommendations designed to assist physicians and patients in making appropriate decisions based on specific clinical situations 6 . Trustworthy clinical practice guidelines should base on a systematic review of the literature, provide ratings of the quality of evidence and the strength of recommendations, consider patient values, and be developed by a multidisciplinary panel of experts 7 . High-quality guidelines can regulate physician behavior, improve patient satisfaction, and serve as an effective tool for addressing public health issues. Many guidelines related to FGR have been published internationally. However, the published guidelines have inconsistent methodological reports, vary in clinical utility, and have no systematic quantitative comparisons. This study used Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument 8 , The Reporting Items for practice Guidelines in Healthcare (RIGHT)checklist 10 and Scientific, Transparent and Applicable Rankings (STAR) tool 9 to comprehensively evaluate the quality of guidelines related to fetal growth restriction, with a view to provide recommendations for the development of high-quality guidelines. Method Retrieval strategy China National Knowledge Infrastructure (CNKI), Wanfang, Chinese Medical journal, PubMed, Embase, Web of Science, as well as the International Guide Assistance Network ( https://guidelines.ebmportal.com/ ), National Institute for Health and Care Excellence (NICE; https://www.nice.org.uk/ ), National Clinical Guidelines Database ( https:// www.ahrg.gov/gam/index.hxml/ ), the World Health Organization website (WHO, https://www.who.int/ ), and the American College of Obstetricians and Gynecologists (ACOG; https://www.acog.org/ ), International Federation of Obstetrics and Gynecology ( https://www.figo.org/ ), were searched for relevant studies published up to September 2024. Our searched terms included “fetal growth restriction”, “Intrauterine Growth Restriction”, “guideline”. Inclusion and exclusion criteria Inclusion criteria were as follows: (1) English or Chinese language, (2) based on systematic evidence synthesis and containing specific statements that guide fetal growth restriction decisions, (3) developed by professional organization(s) for the diagnosis and management of fetal growth restriction. Exclusion criteria were as follows: Previous editions published by the same academic organization, expert consensus and recommendations. Guideline quality evaluation The search results were imported into the Endnote(X9) for literature screening for further research. The researcher independently extracted the general characteristics of the included guidelines, year of publication, updating status, method of evidence identification, etc. Two researchers evaluated the quality of included CPGs using the AGREE II, RIGHT, and STAR evaluation tools. Disagreements were resolved by discussion or consultation with a third reviewer. The AGREE II instrument includes 23 key items, grouped into six domains (scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence) 8 .Each item is graded on 7-point scale, with 1 indicating significant disagreement and 7 indicating strong agreement. We standardized each field score to a percentage according to the formula in the AGREE II User manual. The overall average score is derived using the average of the six domains. Finally, the CPGs were classified into 11 – 12 :“recommended” (total score ≥ 60%), “recommended with modifications” (total score between 30% and 60%) or “not recommended” (total score ≤ 30%) according to the AGREE II evaluation method. The Scientific, Transparent and Applicable Rankings (STAR) tool 9 is a novel guideline evaluation instrument jointly developed by the Chinese Medical Association Publishing House and the World Health Organization Collaborating Centre for Guideline Implementation and Knowledge Translation. It was designed to address key limitations of existing tools, including insufficient emphasis on guideline applicability, limited methodological transparency, and an overly narrow scope. The STAR tool includes 39 items grouped into 11 domains with different weights: registry (items 1 to 2), protocol (items 3 to 4), funding (items 5 to 7), guideline development groups (items 8 to 12), conflicts of interest (items 13 to 14), clinical questions (items 15 to 18), evidence (items 19 to 27), consensus method (items 28 to 30), recommendations (items 31 to 34), accessibility (items 35 to 38) and other(items 39), each item corresponds to the corresponding item score (0.90 ~ 6.40 points) 9 .According to the recommendations of the STAR Evaluation Tool Manual, CPGs were scored by 2 researchers and 1 methodologist, assigning a value to each entry: 1 point for complete compliance, 0.5 point for partial compliance, and 0 point for complete non-compliance. Total score is the sum of the scores of each item. After evaluation by the STAR evaluation tool, the score rate of the 11 domainsis calculated, and the quality of the CPGs is evaluated based on the total score of the CPGs. In addition, we also use the RIGHT checklist for evaluation, the RIGHT checklist has 7 domains, with 22 items and 35 subitems: : basic information (items 1 to 4), background (items 5 to 9), evidence (items 10 to 12), recommendations (items 13 to 15), review and quality assurance (items 16 and 17), funding and declaration and management of interests (items 18 and 19), and other information (items 20 to 22) 10 . Two researchers evaluated each subproject according to the RIGHT checklist, and the results were categorised as “reported” or “not reported”. We analyzed the reporting rate for the results of the RIGHT assessment as number of compliant subitems/total sub items × 100%. Higher values indicate higher quality reporting. In case of inconsistency in the evaluation results, agreement was reached through discussion. We tested the consistency of the evaluation results of researchers by calculating the intraclass correlation coefficient (ICC) 13 . ICC 0.01 ~ 0.20 means slight consistency, 0.21 ~ 0.40 means average, 0.41 ~ 0.60 means medium, 0.61 ~ 0.80 means reliable. 0.81 ~ 1.00 is high quality. SPSS 29.0 was used for analysis. Result Results of the Literature Search In total, 10 guidelines were included, comprising 9 English CPGs and 1 Chinese CPG. The screening process is summarized in the flowchart (Figure 1). The general characteristics of the guidelines are presented in Table 1. Table 1 General Characteristics Guideline Organization Year of Publication Country Main Topic Version Evidence Quality CMCHA 14 2020 China Diagnosis, treatment and health care of sIUGR First - SMFM 15 2020 — Diagnosis and management Update - ISUOG 16 2020 — Diagnosis and management First - RCOG 17 2024 Britain Investigation and Care Update - FIGO 18 2021 — Screening, Diagnosis, and Management First GRADE ACR 19 2019 USA Diagnosis and management Update - SOGC 20 2023 Canada Screening, Diagnosis, and Management Update GRADE CNGOF 21 2015 France Screening, Diagnosis, and Management First - PTGiP 22 2022 Poland Diagnosis and management of multiple-gestation pregnancy complicated by FGR First - ACOG 23 2022 USA Screening, Diagnosis, and Management Update - Abbreviation: CMCHA, China Maternal and Child Health Association; SMFM, Society for Maternal-Fetal Medicine; ISUOG, The International Society of Ultrasound in Obstetrics and Gynecology; RCOG, Royal College of Obstetricians and Gynaecologists; FIGO, International Federation of Gynecology and Obstetrics; ACR, American College of Radiology ; SOGC, Society of Obstetrician and Gynaecologists of Canada; CNGOF, The French College of Obstetricians and Gynecologists; PTGiP, The Polish Society of Gynecologists and Obstetricians; ACOG, American College of Obstetricians and Gynecologists; sIUGR, selective intrauterine growth restriction; FGR, Fetal growth restriction; GRADE, the Grading of Recommendations Assessment, Development and Evaluation. Results of the quality evaluation of the guidelines The Intraclass correlation coefficients with 95% CIs and p-values are provided in Appendix 1. The overall intraclass correlation coefficients ranged from 0.881 to 0.996, indicating good consistency between researchers‘ and methodologists’ assessments. Table 2 shows the standardized scores of each guidelines assessed by the AGREE-II Instrument (%). The overall quality of the ten guidelines varies greatly, the average score was from 38.48% to 77.90%. The average standardized scores of the six domains were 78.61%, 32.22%, 46.46%, 80.56%, 39.17%, and 47.08%, respectively.“Scope and purpose” and “clarity” domains were of high quality overall, both being greater than 70%. The remaining domains were of low quality, with the lowest quality in the domain “stakeholder involvement”, which scored only 32.22%.In terms of the standard deviation of the domains, the largest variation is within the “editorial independence” domain, with an overall range of 0 % to 100 %.Based on the overall evaluation of the 10 CPGs, two of them 17-18 were “recommended”, and the remaining eight 14-16, 19-23 were “suggested with modification”. Table 2 Standardized Scores of the Ten Guidelines Assessed by Using the AGREE-II Instrument (%) Guideline Organization scope and purpose stakeholder involvement rigor of development clarity of presentation applicability editorial independence Overall evaluation Whether to recommend CMCHA 14 77.78 25.00 30.21 63.89 25.00 50.00 45.31 RM SMFM 15 72.22 11.11 47.92 94.44 37.50 75.00 56.37 RM ISUOG 16 83.33 25.00 35.42 77.78 35.42 0.00 42.83 RM RCOG 17 91.67 52.78 66.67 91.67 68.75 95.83 77.90 R FIGO 18 94.44 44.44 36.46 88.89 58.33 41.67 60.71 R ACR 19 72.22 41.67 67.71 83.33 41.67 33.33 56.66 RM SOGC 20 77.78 44.44 59.38 88.89 39.58 41.67 58.62 RM CNGOF 21 61.11 44.44 58.33 72.22 41.67 0.00 46.30 RM PTGiP 22 77.78 22.22 19.79 61.11 16.67 33.33 38.48 RM ACOG 23 77.78 11.11 42.71 83.33 27.08 100.00 57.00 RM Mean value 78.61 32.22 46.46 80.56 39.17 47.08 SD 9.63 15.11 16.27 11.56 15.37 34.70 Abbreviation: CMCHA, China Maternal and Child Health Association; SMFM, Society for Maternal-Fetal Medicine; ISUOG, The International Society of Ultrasound in Obstetrics and Gynecology; RCOG, Royal College of Obstetricians and Gynaecologists; FIGO, International Federation of Gynecology and Obstetrics; ACR, American College of Radiology ; SOGC, Society of Obstetrician and Gynaecologists of Canada; CNGOF, The French College of Obstetricians and Gynecologists; PTGiP, The Polish Society of Gynecologists and Obstetricians; ACOG, American College of Obstetricians and Gynecologists; AGREE Ⅱ, The Appraisal of Guidelines for Research and Evaluation Ⅱ; R, Recommended; RM, Recommended with modifications; NR, Not recommended; SD, Standard deviation. Table 3 shows the results by using the STAR tool. The STAR tool has a total score of 100. Only one guideline from RCOG 17 had a total score greater than 60, four guidelines 18-21 had a total score between 50 and 60, and five guidelines 14-16, 22-23 had a total score below 50. The 11 domains of registry, protocol, funding, guideline development groups, conflicts of interest, clinical questions, evidence, consensus method, recommendations, accessibility, and other had scores of 0.00%, 0.00%, 26.41%, 18.49%, 38.28%, 55.85%, 62.55%, 26.54%, 88.66%, 27.54%, and 70.00%, respectively. The areas with lower scores included registry, protocol, guideline development groups, funding, accessibility, and consensus methods, while recommendations received the highest score. Table 3 Scores of the Ten Guidelines Assessed by Using the STAR Tool Guideline Organization Registry(%) protocol(%) funding(%) guideline development groups(%) conflicts of interest(%) clinical questions(%) evidence(%) consensus method(%) recommendations(%) accessibility(%) other(%) Total points CMCHA 14 0.00 0.00 51.56 36.99 0.00 51.46 42.90 35.51 58.19 17.12 0.00 35.40 SMFM 15 0.00 0.00 40.63 0.00 71.74 51.46 42.90 0.00 88.60 46.58 100.00 43.90 ISUOG 16 0.00 0.00 0.00 12.33 0.00 51.46 22.78 35.51 100.00 31.51 100.00 37.95 RCOG 17 0.00 0.00 79.69 12.33 71.74 51.46 100.00 35.51 100.00 31.51 100.00 60.35 FIGO 18 0.00 0.00 51.56 12.33 50.00 66.08 52.96 35.51 100.00 46.58 100.00 52.90 ACR 19 0.00 0.00 0.00 12.33 22.92 66.08 100.00 43.93 100.00 31.51 100.00 56.60 SOGC 20 0.00 0.00 0.00 12.33 71.74 51.46 82.25 35.51 100.00 0.00 100.00 52.50 CNGOF 21 0.00 0.00 0.00 61.64 0.00 66.08 82.25 43.93 100.00 31.51 100.00 55.00 PTGiP 22 0.00 0.00 0.00 12.33 22.92 51.46 17.16 0.00 39.77 39.04 0.00 24.45 ACOG 23 0.00 0.00 40.63 12.33 71.74 51.46 82.25 0.00 100.00 0.00 0.00 48.80 Mean value 00.0 0.00 26.41 18.49 38.28 55.85 62.55 26.54 88.66 27.54 70.00 SD 0.00 0.00 29.81 17.68 32.46 7.06 30.69 18.62 21.65 16.82 48.30 Abbreviation: CMCHA, China Maternal and Child Health Association; SMFM, Society for Maternal-Fetal Medicine; ISUOG, The International Society of Ultrasound in Obstetrics and Gynecology; RCOG, Royal College of Obstetricians and Gynaecologists; FIGO, International Federation of Gynecology and Obstetrics; ACR, American College of Radiology ; SOGC, Society of Obstetrician and Gynaecologists of Canada; CNGOF, The French College of Obstetricians and Gynecologists; PTGiP, The Polish Society of Gynecologists and Obstetricians; ACOG, American College of Obstetricians and Gynecologists; STAR, Scientific, Transparent and Applicable Rankings; SD, Standard deviation. Table 4 presents the evaluation results using the RIGHT checklist. Among the ten guidelines, two 17-18 achieved a total reporting rate of over 80%, while four 16, 19-21 had a total reporting rate ranging from 60% to 80%. The domain with the highest reporting rate was “basic information,” whereas the lowest was “funding and the declaration and management of interests.” Table 4 Evaluation results of the Ten Guidelines Assessed by Using the RIGHT checklist(%) Guideline Organization basic information background evidence recommendations review and quality assurance funding and declaration and management of interests other information Overall CMCHA 14 83.33 62.50 60.00 71.43 0.00 25.00 33.33 57.14 SMFM 15 83.33 37.50 60.00 42.86 100.00 50.00 66.67 57.14 ISUOG 16 83.33 62.50 60.00 71.43 100.00 0.00 66.67 62.86 RCOG 17 83.33 75.00 60.00 85.71 100.00 100.00 100.00 82.86 FIGO 18 83.33 87.50 100.00 85.71 0.00 75.00 100.00 82.86 ACR 19 83.33 62.50 100.00 71.43 100.00 25.00 66.67 71.43 SOGC 20 83.33 75.00 60.00 85.71 100.00 50.00 66.67 74.29 CNGOF 21 66.67 75.00 80.00 100.00 100.00 0.00 66.67 77.14 PTGiP 22 66.67 62.50 40.00 28.57 0.00 25.00 100.00 48.57 ACOG 23 50.00 62.50 60.00 42.86 100.00 50.00 66.67 57.14 Mean value 76.67 66.25 68.00 68.57 70.00 40.00 73.34 SD 11.65 13.24 19.32 23.13 48.30 31.62 21.08 Abbreviation: CMCHA, China Maternal and Child Health Association; SMFM, Society for Maternal-Fetal Medicine; ISUOG, The International Society of Ultrasound in Obstetrics and Gynecology; RCOG, Royal College of Obstetricians and Gynaecologists; FIGO, International Federation of Gynecology and Obstetrics; ACR, American College of Radiology ; SOGC, Society of Obstetrician and Gynaecologists of Canada; CNGOF, The French College of Obstetricians and Gynecologists; PTGiP, The Polish Society of Gynecologists and Obstetricians; ACOG, American College of Obstetricians and Gynecologists; RIGHT, Reporting Items for Practice Guidelines in Healthcare; SD, Standard deviation. Figure 2 presents the results of the evaluation of the ten guidelines combining the three tools. It can be seen that the RCOG 17 guideline is of the highest quality and classified as “recommended”, and the PTGiP 22 guideline is of the lowest quality, regardless of the tool used. The results are also generally consistent across the three tools, with differences in the results for individual guidelines. Two guidelines, ISUOG and CNGOF, scored lower when using the STAR and AGREE tools, while the RIGHT checklist evaluation results show higher reporting rates. Recommended content analysis results Of the 10 guidelines included, two 14,22 are relevant to multiple pregnancies (including twins) combined with FGR, and eight 15-21,23 provid recommendations for FGR in singleton pregnancies. Four guidelines, SMFM, RCOG, FIGO, and SOGC, state that low-molecular-weight heparin is not recommended for the prevention in women at high risk of FGR. The RCOG, FIGO, SOGC, and CNGOF guidelines suggest that low-dose aspirin can be used for women at risk of pre-eclampsia and/or placental dysfunction to reduce the risk of FGR, and recommend starting aspirin (100-150 mg/d) at 12-16 weeks of gestation. ISUGO, RCOG, CNGOF suggest that FGR should be suspected when there is reduced and static fetal growth, which can be assessed with the help of Abdominal Circumference (AC) and Estimated Fetal Weight (EFW). RCOG, FIGO, ACR, CNGOF suggest that for those who are at high risk of FGR, ultrasound Doppler evaluation should be performed, especially Umbilical Artery, Uterine Artery, and Middle Cerebral Artery Doppler. Almost all guidelines recommend that patients with a diagnosis of FGR should undergo procedural testing based on the severity of FGR and umbilical artery changes, including cardiotocography (CTG) or computerized CTG (cCTG), umbilical artery Doppler, middle cerebral artery Doppler, and intravenous catheter Doppler,. FIGO guideline strongly suggests that for late-onset FGR, middle cerebral artery Doppler may provide additional fetal deterioration information, but the SMFM guidelines advise against the use of venous catheterisation, middle cerebral artery or uterine artery Doppler assessment for routine clinical management of early-onset or late-onset FGR. SMFM, RCOG, FIGO, SOGC state that prenatal diagnosis is recommended for pregnant women with isolated premature or severe (EFW < 3rd percentile) FGR. Delivery is currently the only definitive treatment, timing of termination should be individualized as appropriate and FGR alone is not an indication for caesarean section. For cCTG showing fetal heart rate variability (STV), altered venous conduit, umbilical artery agenesis or reversed end-diastolic flow velocities, caesarean section is recommended for delivery and should be performed according to week of gestation after the use of glucocorticoids and magnesium sulphate. Discussion FGR is strongly associated with adverse outcomes for maternal and infant outcomes. CPGs can help doctors and patients make clinical decisions for different situations, but their quality varies. Recommendations from high-quality guidelines are usually more reliable and can guide clinical practice to a higher degree. In this study, FGR guidelines were evaluated using the AGREE II, STAR, and RIGHT tools, a total of 10 guidelines were included after a comprehensive search and rigorous screening process. The results of the AGREE II Instrument showed that of the 10 CPGs, two of them 17-18 were “recommended”, and the eight 14-16, 19-23 were “suggested with modification”. Guidelines classified as “recommended” are generally considered to be of high quality. “Recommended with modifications” means that the openness and transparency of the guideline development process needs to be improved, and could be improved when the guideline is revised and updated. “Not recommended” means that the quality of the guideline needs to be improved. A previous study 24 evaluated quality differences in FGR guidelines using the AGREE II tool, and its findings were consistent with those of the present study, with both the RCOG and FIGO guidelines categorized as “recommended”. When analysised from the perspective of the domains, the “scope and purpose” and “clarity” domains were of high quality, with average scores of over 60%, while the remaining domains all scored lower, and the “editorial independence” domain being the most polarised. The “scope and purpose” domain scored above 60% for each guideline, with a relative weakness being the lack of clarity in defining the target population to which the guidelines apply. The “stakeholder involvement” domain performed poorly overall, with nine guidelines 14-16, 18-23 achieving a standardized score below 50.00%. The main shortcomings included: (1) failure to incorporate the perspectives and preferences of the target population (e.g., patients, the public), and (2) insufficient description of the intended users of the guidelines and how they should be utilized. The “rigor of development” domain, which focuses on the methodological aspects of guideline development and is closely tied to guideline quality, received lower scores in six guidelines 14-16, 18, 22-23 . This was primarily due to: (1) the absence of clearly defined criteria for evidence retrieval, selection, and exclusion; (2) the lack of a specified method for formulating recommendations (e.g., voting, consensus, Delphi method); (3) no indication of external review prior to publication; and (4) insufficient details regarding updates (e.g., timing, criteria).The “clarity of presentation” domain is central to the guidelines and, consequently, achieved the highest average score. The “applicability” domain also scored lower with eight guidelines 14-16,19-23 scoring <50% on a standardized basis, mainly due to a lack of description of factors affecting the implementation of the guideline and a lack of consideration of the economic aspects of application. The “editorial independence” domain exhibited the most variability, with scores ranging from 0 to 100. Notably, the ISUOG and CNGOF guidelines failed to disclose sponsorship details and conflicts of interest. The results of the STAR tool evaluation showed that the average score rates for the three domains of evidence, recommendations, and other aspects were high, all exceeding 60%, with the recommendations domain achieving the highest score rate. All of the guidelines included in this study scored 0 for “registry” and “protocol”, with the main problems being: (1) fail to register or provide a platform prior to publication of the guideline; and (2) fail to write a protocol, which suggests that published guidelines do not pay much attention to registration and writing protocols, a problem that could reduce the overall reliability of the guidelines. These indicate that the published guidelines do not pay much attention to registration and writing protocols, which will reduce the reliability of the guidelines as a whole. “funding”, “guideline development groups”, “consensus method”, and “accessibility” also scored poorly, with none exceeding 30%. The problems in each area were (1) funding sources and roles were not indicated; (2) participants were not grouped (including evidence and consensus groups); (3) recommendation consensus methods and records were not provided; and (4) different user versions of the guidelines were not provided. In terms of the overall quality of the guidelines, the RCOG guidelines had the highest score, which is consistent with the AGREE II tool results. The results of the RIGHT checklist showed that two guidelines had an overall reporting rate of more than 80 %, one of which was from the RCOG, and the results were also consistent with the AGREE II Instrument and the STAR tool. The average reporting rate was above 60 % for six among the seven domains, with the only domain, “funding and declaration and management of interests”, having a low average reporting rate, mainly due to: (1) not reporting of sources of funding and roles of the various phases of the guidelines; and (2) not reporting on the evaluation and management of conflicts of interest. This study presents the results of ten guideline evaluations in the form of a bubble chart (Figure 2). The closer the guideline is to the upper right corner of the axis and the larger the bubble, the higher the quality of the guideline. The results showed that RCOG had the highest quality and PTGiP had the lowest quality. In this study, each researcher was required to assess a guideline using all three tools simultaneously, minimizing potential discrepancies in understanding the same guideline at different times and thus enhancing comparability. The trend of the results of the three tools is basically similar, with high quality and lower quality presenting consistent results regardless of the tool used, while medium quality articles will show differences, possibly due to the following reasons: (1) the evaluation forms of the three tools are different, and (2) the evaluation content is not entirely consistent. AGREE II is one of the most popular and established guideline assessment tools in use globally 25 , covering the six domains of scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence, with each item scored on a 7-point scale, and with the researcher's subjective perceptions influencing the results. Compared to AGREE II, the RIGHT checklist also requires the reporting of basic information in the guidelines. Each sub-item is assessed against the content of the guideline and the results are categorised only as “reported” and “not reported”, but there is no quantitative assessment of the content of the report. The RIGHT checklist is mainly used to guide developers in reporting guidelines, but can also be used to assess the reporting quality of guidelines. The STAR evaluation tool is a newly developed guideline evaluation method in China, which increases the content of registry, protocol, accessibility, etc., and at the same time refines the areas of funding, evidence, recommendations, etc., which improves the narrower focus of most of the current evaluation tools on the quality of the methodology, the quality of the report, etc. STAR can be regarded as an alternative to the comprehensive use of multiple assessment tools. At the same time, STAR assigns weights to domains and projects, which allows for better evaluation and ranking of guideline quality, but at the same time, its score is also affected by the weights. Treatment of FGR is based on early diagnosis, optimal fetal monitoring and timely delivery. This study summarized the common recommendations of the 10 included guidelines, including the prevention, screening, management and treatment of FGR panel, and most of the guidelines agreed on CTG and ultrasound Doppler management of pregnant women with FGR, the timing of delivery, and what kind of cesarean section to be performed, and were supported by relatively sufficient evidence. In addition, the guidelines recommend women quite smoking and alcohol to reduce the risk of FGR. Early FGR should be monitored and managed in a tertiary ward with the highest level of neonatal care. Individual guidelines give opposing opinions on whether to use middle cerebral artery Doppler and venous catheter Doppler for prediction and management, but the strength of the recommendations is not high. There is no international consensus on the best way to manage FGR, and more research could be conducted on this component in the future, with a view to reducing perinatal mortality and improving prognosis. This study has some limitations:(1) AGREE II, STAR, RIGHT are assessment tools only and cannot guide the assurance of clinical validity or usefulness, and clinical judgement should always be exercised when applying guideline recommendations in individual patient care. (2) Reporting bias may exist: the researcher's subjective awareness may potentially affect the evaluation results of the guidelines. This study adopted double-blind assessment to reduce bias. (3) Restricted languages and the small number of FGR guidelines show issues that do not fully represent the current international situation. Conclusions The quality of FGR guidelines still needs to be further improved. It is recommended that future guideline development and updating should pay attention to clarifying the target populations and settings of guideline use. Guideline authors should involve experts in statistics and guideline methodology to enhance the quality of evidence supporting the guidelines. Additionally, the influencing factors during guideline dissemination to clinical practice, as well as the practical implementation of guidelines in clinical settings, should be considered more comprehensively. Furthermore, the independence of guideline development, including the management of conflicts of interest and funding issues, also requires improvement. Declarations Ethics approval and consent to participate：Not Applicable Consent for publication Availability of data and material All data generated or analyzed during this study are included in this published article. Competing interests All authors declare no conflict of interest. Funding This research was funded by the Natural Science Foundation of Hunan Province (2022JJ40789), the National Natural Science Foundation of China (82301927, 82371700), the Major Scientific and Technological Projects for Collaborative Prevention and Control of Birth Defects in Hunan Province (2019SK1010, 2019SK1015), the Key Research and Development Program of Hunan Province (2020SK2072). Authors' contributions Conceptualization, Jingrui Huang; Data curation, Mingyue Guo, Ruohan Wang; Formal analysis, Mingyue Guo, Ruohan Wang; Funding acquisition, Weishe Zhang and Jingrui Huang; Investigation, Mingyue Guo, Ruohan Wang, Caihong Hu; Methodology, Weishe Zhang, Caihong Hu, Jingrui Huang; Resources, Weishe Zhang, Qi Li, Yiran Fu, Qi Wang, Biaobiao Wang; Writing—original draft, Mingyue Guo, Ruohan Wang; Writing—review and editing Caihong Hu, Jingrui Huang. Acknowledgements Not Applicable References Smith GCS. Developing Novel Tests to Screen for Fetal Growth Restriction. Trends Mol Med. 2021;27(8):743–52. 10.1016/j.molmed.2021.05.006 . Miller SL, Huppi PS, Mallard C. The consequences of fetal growth restriction on brain structure and neurodevelopmental outcome. J Physiol. 2016;594(4):807–23. 10.1113/JP271402 . Kamphof HD, Posthuma S, Gordijn SJ, et al. Fetal Growth Restriction: Mechanisms, Epidemiology, and Management. Maternal-Fetal Med. 2022;4(3):186–96. 10.1097/FM9.0000000000000161 . Audette MC, Kingdom JC. Screening for fetal growth restriction and placental insufficiency. Semin Fetal Neonatal Med. 2018;23(2):119–25. 10.1016/j.siny.2017.11.004 . Giouleka S, Tsakiridis I, Mamopoulos A, et al. Fetal Growth Restriction: A Comprehensive Review of Major Guidelines. Obstet Gynecol Surv. 2023;78(11):690–708. 10.1097/OGX.0000000000001203 . Chen Y, Wang C, Shang H, et al. Clinical practice guidelines in China. BMJ. 2018;360:j5158. 10.1136/bmj.j5158 . Sarkies MN, Jones LK, Gidding SS, et al. Improving clinical practice guidelines with implementation science. Nat Rev Cardiol. 2022;19(1):3–4. 10.1038/s41569-021-00645-x . Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839–42. 10.1503/cmaj.090449 . Yang N, Liu H, Zhao W, et al. Development of the Scientific, Transparent and Applicable Rankings (STAR) tool for clinical practice guidelines. Chin Med J (Engl). 2023;136(12):1430–8. 10.1097/CM9.0000000000002713 . Chen Y, Yang K, Marušic A, et al. A Reporting Tool for Practice Guidelines in Health Care: The RIGHT Statement. Ann Intern Med. 2017;166(2):128–32. 10.7326/M16-1565 . Sun W, An LY, Bao XD, et al. Consensus and controversy among severe pancreatitis surgery guidelines: a guideline evaluation based on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Gland Surg. 2020;9(5):1551–63. 10.21037/gs-20-444 . Wang Q, Zhang WS, Fu YR, et al. Evidence-based evaluation of guidelines for hypertensive disorders in pregnancy. Chin J Perinat Med. 2024;27(1):40–50. 10.3760/cma.j.cn113903-20230808-00089 . Kramer MS, Feinstein AR. Clinical biostatistics. LIV. The biostatistics of concordance. Clin Pharmacol Ther. 1981;29(1):111–23. 10.1038/clpt.1981.18 . Zhang ZT, Liu CX, Yin SW, et al. Guidelines for the diagnosis, treatment, and healthcare of selective intrauterine growth restriction (2020). Chin J Practical Gynecol Obstet. 2020;36(7):618–25. 10.19538/j.fk2020070112 . Society for Maternal-Fetal Medicine (SMFM). Electronic address: [email protected] , Martins JG, Biggio JR, Abuhamad A. Society for Maternal-Fetal Medicine Consult Series #52: Diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012). Am J Obstet Gynecol 2020;223(4):B2-B17. 10.1016/j.ajog.2020.05.010 Lees CC, Stampalija T, Baschat A, et al. ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction. Ultrasound Obstet Gynecol. 2020;56(2):298–312. 10.1002/uog.22134 . Morris RK, Johnstone E, Lees C et al. Investigation and Care of a Small-for-Gestational-Age Fetus and a Growth Restricted Fetus (Green-top Guideline No. 31). BJOG 2024;131(9):e31-e80. 10.1111/1471-0528.17814 Melamed N, Baschat A, Yinon Y, et al. FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction. Int J Gynaecol Obstet. 2021;152(1Suppl 1):3–57. 10.1002/ijgo.13522 . Expert Panel on Women’s Imaging, Shipp TD, Zelop CM, et al. ACR Appropriateness Criteria® Growth Disturbances-Risk of Fetal Growth Restriction. J Am Coll Radiol. 2019;16(5S):S116–25. 10.1016/j.jacr.2019.02.009 . Kingdom J, Ashwal E, Lausman A, et al. Guideline 442: Fetal Growth Restriction: Screening, Diagnosis, and Management in Singleton Pregnancies. J Obstet Gynaecol Can. 2023;45(10):102154. 10.1016/j.jogc.2023.05.022 . Vayssière C, Sentilhes L, Ego A, et al. Fetal growth restriction and intra-uterine growth restriction: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol Reprod Biol. 2015;193:10–8. 10.1016/j.ejogrb.2015.06.021 . Kosinska-Kaczynska K, Torbé A, Kwiatkowski S, et al. The Polish Society of Gynecologists and Obstetricians Guideline for the diagnostic assessment and management of multiple-gestation pregnancy complicated by fetal growth restriction. Ginekol Pol. 2022;93(3):256–63. 10.5603/GP.a2021.0244 . Fetal Growth Restriction. ACOG Practice Bulletin, Number 227. Obstet Gynecol. 2021;137(2):e16–28. 10.1097/AOG.0000000000004251 . Alameddine S, Capannolo G, Rizzo G, et al. A systematic review and critical evaluation of quality of clinical practice guidelines on fetal growth restriction. J Perinat Med. 2023;51(8):970–80. 10.1515/jpm-2022-0590 . Published 2023 Mar 29. Gavriilidis P, Askari A, Roberts KJ, et al. Appraisal of the current guidelines for management of cholangiocarcinoma-using the Appraisal of Guidelines Research and Evaluation II (AGREE II) Instrument. Hepatobiliary Surg Nutr. 2020;9(2):126–35. 10.21037/hbsn.2019.09.06 . Supplementary Files Appendix1InterRaterReliabilityStudyResults.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Major revision 14 May, 2026 Reviewers agreed at journal 12 Jan, 2026 Reviewers invited by journal 12 Jan, 2026 Editor assigned by journal 11 Jun, 2025 First submitted to journal 10 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6582108","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":573395417,"identity":"efa2a2b2-1ca8-4976-87fd-ca9aee6b8144","order_by":0,"name":"Mingyue Guo","email":"","orcid":"","institution":"Xiangya Hospital Central South University","correspondingAuthor":false,"prefix":"","firstName":"Mingyue","middleName":"","lastName":"Guo","suffix":""},{"id":573395418,"identity":"5620af7c-8f52-4050-95a4-390e5ecf2803","order_by":1,"name":"Ruohan Wang","email":"","orcid":"","institution":"Xiangya Hospital Central South 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10:11:50","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":138784,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-6582108/v1/5b4adfed3283041f2fba2467.html"},{"id":100224908,"identity":"5bfb440c-0c32-4be1-ae23-57b74e54b6b8","added_by":"auto","created_at":"2026-01-14 10:11:50","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":88674,"visible":true,"origin":"","legend":"\u003cp\u003eDiagram of the search strategy\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6582108/v1/c3535ba290c7a8433d477b40.jpg"},{"id":100382973,"identity":"6f486c96-26b4-4e94-ba6f-929881671b0c","added_by":"auto","created_at":"2026-01-16 10:45:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":823288,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6582108/v1/3f14c0a9-625d-420d-8d72-2df4964757cb.pdf"},{"id":100224909,"identity":"f27e173b-4ff0-409d-a452-f5cdd78ed7b8","added_by":"auto","created_at":"2026-01-14 10:11:50","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":19192,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1InterRaterReliabilityStudyResults.docx","url":"https://assets-eu.researchsquare.com/files/rs-6582108/v1/ae27c81d6f61a45817da7ac6.docx"}],"financialInterests":"","formattedTitle":"Evaluation of fetal growth restriction guidelines Based on AGREE II, STAR and RIGHT Tools","fulltext":[{"header":"Key message","content":"\u003cp\u003eThe quality of internationally published guidelines on FGR varies significantly. High-quality guidelines effectively inform clinical practice, while low-quality ones may lead to erroneous recommendations and jeopardize patient health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe guidelines were assessed using the AGREE II, STAR, and RIGHT tools. Among the 10 included guidelines, two were recommended, and the results demonstrated overall consistency across the three evaluation tools.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGuideline quality requires improvement, particularly in addressing target populations, settings for application, applicability, and editorial independence in future development.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eFetal growth restriction (FGR) is a common pregnancy complication, which traditionally refers to the failure of a fetus to achieve its genetically determined growth potential\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e, with particular need to be distinguished from children who are small for gestational age (SGA).Placental insufficiency is the main cause of FGR\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e,leading to chronic fetal hypoxia and ultimately increasing the risk of perinatal mortality, morbidity, and long-term adverse infant outcomes \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.The diagnosis, management, and treatment of FGR remain significant clinically challenging\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSeveral clinical guidelines have been published to guide clinical decisions. Clinical Practice Guideline (CPG) is a statement that contains recommendations designed to assist physicians and patients in making appropriate decisions based on specific clinical situations\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Trustworthy clinical practice guidelines should base on a systematic review of the literature, provide ratings of the quality of evidence and the strength of recommendations, consider patient values, and be developed by a multidisciplinary panel of experts\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. High-quality guidelines can regulate physician behavior, improve patient satisfaction, and serve as an effective tool for addressing public health issues.\u003c/p\u003e \u003cp\u003eMany guidelines related to FGR have been published internationally. However, the published guidelines have inconsistent methodological reports, vary in clinical utility, and have no systematic quantitative comparisons. This study used Appraisal of Guidelines for Research \u0026amp; Evaluation II (AGREE II) instrument\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, The Reporting Items for practice Guidelines in Healthcare (RIGHT)checklist\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e and Scientific, Transparent and Applicable Rankings (STAR) tool\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e to comprehensively evaluate the quality of guidelines related to fetal growth restriction, with a view to provide recommendations for the development of high-quality guidelines.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eRetrieval strategy\u003c/h2\u003e \u003cp\u003eChina National Knowledge Infrastructure (CNKI), Wanfang, Chinese Medical journal, PubMed, Embase, Web of Science, as well as the International Guide Assistance Network (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://guidelines.ebmportal.com/\u003c/span\u003e\u003cspan address=\"https://guidelines.ebmportal.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), National Institute for Health and Care Excellence (NICE; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nice.org.uk/\u003c/span\u003e\u003cspan address=\"https://www.nice.org.uk/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), National Clinical Guidelines Database (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://\u003c/span\u003e\u003cspan address=\"https://\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.ahrg.gov/gam/index.hxml/\u003c/span\u003e\u003cspan address=\"http://www.ahrg.gov/gam/index.hxml/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), the World Health Organization website (WHO, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/\u003c/span\u003e\u003cspan address=\"https://www.who.int/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), and the American College of Obstetricians and Gynecologists (ACOG; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.acog.org/\u003c/span\u003e\u003cspan address=\"https://www.acog.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), International Federation of Obstetrics and Gynecology (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.figo.org/\u003c/span\u003e\u003cspan address=\"https://www.figo.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), were searched for relevant studies published up to September 2024. Our searched terms included \u0026ldquo;fetal growth restriction\u0026rdquo;, \u0026ldquo;Intrauterine Growth Restriction\u0026rdquo;, \u0026ldquo;guideline\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eInclusion criteria were as follows: (1) English or Chinese language, (2) based on systematic evidence synthesis and containing specific statements that guide fetal growth restriction decisions, (3) developed by professional organization(s) for the diagnosis and management of fetal growth restriction. Exclusion criteria were as follows: Previous editions published by the same academic organization, expert consensus and recommendations.\u003c/p\u003e\n\u003ch3\u003eGuideline quality evaluation\u003c/h3\u003e\n\u003cp\u003eThe search results were imported into the Endnote(X9) for literature screening for further research. The researcher independently extracted the general characteristics of the included guidelines, year of publication, updating status, method of evidence identification, etc.\u003c/p\u003e \u003cp\u003eTwo researchers evaluated the quality of included CPGs using the AGREE II, RIGHT, and STAR evaluation tools. Disagreements were resolved by discussion or consultation with a third reviewer.\u003c/p\u003e \u003cp\u003eThe AGREE II instrument includes 23 key items, grouped into six domains (scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence)\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.Each item is graded on 7-point scale, with 1 indicating significant disagreement and 7 indicating strong agreement. We standardized each field score to a percentage according to the formula in the AGREE II User manual. The overall average score is derived using the average of the six domains. Finally, the CPGs were classified into\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e:\u0026ldquo;recommended\u0026rdquo; (total score\u0026thinsp;\u0026ge;\u0026thinsp;60%), \u0026ldquo;recommended with modifications\u0026rdquo; (total score between 30% and 60%) or \u0026ldquo;not recommended\u0026rdquo; (total score\u0026thinsp;\u0026le;\u0026thinsp;30%) according to the AGREE II evaluation method.\u003c/p\u003e \u003cp\u003eThe Scientific, Transparent and Applicable Rankings (STAR) tool\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e is a novel guideline evaluation instrument jointly developed by the Chinese Medical Association Publishing House and the World Health Organization Collaborating Centre for Guideline Implementation and Knowledge Translation. It was designed to address key limitations of existing tools, including insufficient emphasis on guideline applicability, limited methodological transparency, and an overly narrow scope. The STAR tool includes 39 items grouped into 11 domains with different weights: registry (items 1 to 2), protocol (items 3 to 4), funding (items 5 to 7), guideline development groups (items 8 to 12), conflicts of interest (items 13 to 14), clinical questions (items 15 to 18), evidence (items 19 to 27), consensus method (items 28 to 30), recommendations (items 31 to 34), accessibility (items 35 to 38) and other(items 39), each item corresponds to the corresponding item score (0.90\u0026thinsp;~\u0026thinsp;6.40 points)\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.According to the recommendations of the STAR Evaluation Tool Manual, CPGs were scored by 2 researchers and 1 methodologist, assigning a value to each entry: 1 point for complete compliance, 0.5 point for partial compliance, and 0 point for complete non-compliance. Total score is the sum of the scores of each item. After evaluation by the STAR evaluation tool, the score rate of the 11 domainsis calculated, and the quality of the CPGs is evaluated based on the total score of the CPGs.\u003c/p\u003e \u003cp\u003eIn addition, we also use the RIGHT checklist for evaluation, the RIGHT checklist has 7 domains, with 22 items and 35 subitems: : basic information (items 1 to 4), background (items 5 to 9), evidence (items 10 to 12), recommendations (items 13 to 15), review and quality assurance (items 16 and 17), funding and declaration and management of interests (items 18 and 19), and other information (items 20 to 22)\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Two researchers evaluated each subproject according to the RIGHT checklist, and the results were categorised as \u0026ldquo;reported\u0026rdquo; or \u0026ldquo;not reported\u0026rdquo;. We analyzed the reporting rate for the results of the RIGHT assessment as number of compliant subitems/total sub items \u0026times; 100%. Higher values indicate higher quality reporting. In case of inconsistency in the evaluation results, agreement was reached through discussion.\u003c/p\u003e \u003cp\u003eWe tested the consistency of the evaluation results of researchers by calculating the intraclass correlation coefficient (ICC)\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. ICC 0.01\u0026thinsp;~\u0026thinsp;0.20 means slight consistency, 0.21\u0026thinsp;~\u0026thinsp;0.40 means average, 0.41\u0026thinsp;~\u0026thinsp;0.60 means medium, 0.61\u0026thinsp;~\u0026thinsp;0.80 means reliable. 0.81\u0026thinsp;~\u0026thinsp;1.00 is high quality. SPSS 29.0 was used for analysis.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003e\u003cstrong\u003eResults of the Literature Search\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn total, 10 guidelines were included, comprising 9 English CPGs and 1 Chinese CPG. The screening process is summarized in the flowchart (Figure 1). The general characteristics of the guidelines are presented in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1 General Characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGuideline Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYear of Publication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCountry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMain Topic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eVersion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEvidence Quality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCMCHA\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiagnosis, treatment and health care of sIUGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFirst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMFM\u003csup\u003e\u0026nbsp;15\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiagnosis and management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUpdate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eISUOG\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiagnosis and management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFirst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRCOG\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBritain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInvestigation and Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUpdate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFIGO\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eScreening, Diagnosis, and Management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFirst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGRADE\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eACR\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiagnosis and management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUpdate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSOGC\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCanada\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eScreening, Diagnosis, and Management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUpdate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGRADE\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCNGOF\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eScreening, Diagnosis, and Management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFirst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePTGiP\u003csup\u003e\u0026nbsp;22\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePoland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiagnosis and management of multiple-gestation pregnancy complicated by FGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFirst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eACOG\u003csup\u003e\u0026nbsp;23\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eScreening, Diagnosis, and Management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUpdate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviation: CMCHA, China Maternal and Child Health Association; SMFM, Society for Maternal-Fetal Medicine; ISUOG, The International Society of Ultrasound in Obstetrics and Gynecology; RCOG, Royal College of Obstetricians and Gynaecologists; FIGO, International Federation of Gynecology and Obstetrics; ACR, American College of Radiology ; SOGC, Society of Obstetrician and Gynaecologists of Canada; CNGOF, The French College of Obstetricians and Gynecologists; PTGiP, The Polish Society of Gynecologists and Obstetricians; ACOG, American College of Obstetricians and Gynecologists; sIUGR, selective intrauterine growth restriction; FGR, Fetal growth restriction; GRADE, the Grading of Recommendations Assessment, Development and Evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults of the quality evaluation of the guidelines\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Intraclass correlation coefficients with 95% CIs and p-values are provided in Appendix 1.\u003c/strong\u003e The overall intraclass correlation coefficients ranged from 0.881 to 0.996, indicating good consistency between researchers\u0026lsquo; and methodologists\u0026rsquo; assessments.\u003c/p\u003e\n\u003cp\u003eTable 2 shows the standardized scores of each guidelines assessed by the AGREE-II Instrument (%). The overall quality of the ten guidelines varies greatly, the average score was from 38.48% to 77.90%. The average standardized scores of the six domains were 78.61%, 32.22%, 46.46%, 80.56%, 39.17%, and 47.08%, respectively.\u0026ldquo;Scope and purpose\u0026rdquo; and \u0026ldquo;clarity\u0026rdquo; domains were of high quality overall, both being greater than 70%. The remaining domains were of low quality, with the lowest quality in the domain \u0026ldquo;stakeholder involvement\u0026rdquo;, which scored only 32.22%.In terms of the standard deviation of the domains, the largest variation is within the \u0026ldquo;editorial independence\u0026rdquo; domain, with an overall range of 0 % to 100 %.Based on the overall evaluation of the 10 CPGs, two of them\u003csup\u003e17-18\u0026nbsp;\u003c/sup\u003ewere \u0026ldquo;recommended\u0026rdquo;, and the remaining eight\u003csup\u003e14-16, 19-23\u0026nbsp;\u003c/sup\u003ewere \u0026ldquo;suggested with modification\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eTable 2 Standardized Scores of the Ten Guidelines Assessed by Using the AGREE-II Instrument (%)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGuideline Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003escope and purpose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003estakeholder involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003erigor of development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eclarity of presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eapplicability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eeditorial independence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOverall evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWhether to recommend\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCMCHA\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e77.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e63.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMFM\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e94.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eISUOG\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e77.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRCOG\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e91.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e91.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e95.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e77.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFIGO\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e94.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eACR\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSOGC\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e77.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e59.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCNGOF\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePTGiP\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e77.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eACOG\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e77.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMean value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e78.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e32.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e46.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e80.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e39.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e47.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e9.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e15.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e16.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e11.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e15.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e34.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviation: CMCHA, China Maternal and Child Health Association; SMFM, Society for Maternal-Fetal Medicine; ISUOG, The International Society of Ultrasound in Obstetrics and Gynecology; RCOG, Royal College of Obstetricians and Gynaecologists; FIGO, International Federation of Gynecology and Obstetrics; ACR, American College of Radiology ; SOGC, Society of Obstetrician and Gynaecologists of Canada; CNGOF, The French College of Obstetricians and Gynecologists; PTGiP, The Polish Society of Gynecologists and Obstetricians; ACOG, American College of Obstetricians and Gynecologists; AGREE\u0026nbsp;Ⅱ, The Appraisal of Guidelines for Research and Evaluation\u0026nbsp;Ⅱ; R, Recommended; RM, Recommended with modifications; NR, Not recommended; SD, Standard deviation.\u003c/p\u003e\n\u003cp\u003eTable 3 shows the results by using the STAR tool. The STAR tool has a total score of 100. Only one guideline from RCOG\u003csup\u003e17\u0026nbsp;\u003c/sup\u003ehad a total score greater than 60, four guidelines\u003csup\u003e18-21\u003c/sup\u003e had a total score between 50 and 60, and five guidelines\u003csup\u003e14-16, 22-23\u0026nbsp;\u003c/sup\u003ehad a total score below 50. The 11 domains of registry, protocol, funding, guideline development groups, conflicts of interest, clinical questions, evidence, consensus method, recommendations, accessibility, and other had scores of 0.00%, 0.00%, 26.41%, 18.49%, 38.28%, 55.85%, 62.55%, 26.54%, 88.66%, 27.54%, and 70.00%, respectively. The areas with lower scores included registry, protocol, guideline development groups, funding, accessibility, and consensus methods, while recommendations received the highest score.\u003c/p\u003e\n\u003cp\u003eTable 3 Scores of the Ten Guidelines Assessed by Using the STAR Tool\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"747\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGuideline Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRegistry(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eprotocol(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003efunding(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eguideline development groups(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003econflicts of interest(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eclinical questions(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eevidence(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003econsensus method(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003erecommendations(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eaccessibility(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eother(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal points\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCMCHA\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e51.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e36.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e42.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e35.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e58.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e17.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMFM\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e71.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e42.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e88.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e46.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e43.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eISUOG\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e22.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e35.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e31.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRCOG\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e79.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e71.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e35.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e31.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFIGO\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e51.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e66.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e35.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e46.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eACR\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e22.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e66.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e43.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e31.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSOGC\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e71.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e82.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e35.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCNGOF\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e66.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e82.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e43.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e31.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePTGiP\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e22.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e17.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e39.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e39.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eACOG\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e71.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e82.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMean value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e00.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e88.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e70.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e29.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e17.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e32.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e7.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e30.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e18.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e21.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e16.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e48.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviation: CMCHA, China Maternal and Child Health Association; SMFM, Society for Maternal-Fetal Medicine; ISUOG, The International Society of Ultrasound in Obstetrics and Gynecology; RCOG, Royal College of Obstetricians and Gynaecologists; FIGO, International Federation of Gynecology and Obstetrics; ACR, American College of Radiology ; SOGC, Society of Obstetrician and Gynaecologists of Canada; CNGOF, The French College of Obstetricians and Gynecologists; PTGiP, The Polish Society of Gynecologists and Obstetricians; ACOG, American College of Obstetricians and Gynecologists; STAR, Scientific, Transparent and Applicable Rankings; SD, Standard deviation.\u003c/p\u003e\n\u003cp\u003eTable 4 presents the evaluation results using the RIGHT checklist. Among the ten guidelines, two\u003csup\u003e17-18\u0026nbsp;\u003c/sup\u003eachieved a total reporting rate of over 80%, while four\u003csup\u003e16, 19-21\u0026nbsp;\u003c/sup\u003ehad a total reporting rate ranging from 60% to 80%. The domain with the highest reporting rate was \u0026ldquo;basic information,\u0026rdquo; whereas the lowest was \u0026ldquo;funding and the declaration and management of interests.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eTable 4 Evaluation results of the Ten Guidelines Assessed by Using the RIGHT checklist(%)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"680\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGuideline Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ebasic information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ebackground\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eevidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003erecommendations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ereview and quality assurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003efunding and declaration and management of interests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eother information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCMCHA\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMFM\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eISUOG\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRCOG\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e82.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFIGO\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e87.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e82.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eACR\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSOGC\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e74.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCNGOF\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e80.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e77.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePTGiP\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eACOG\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMean value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviation: CMCHA, China Maternal and Child Health Association; SMFM, Society for Maternal-Fetal Medicine; ISUOG, The International Society of Ultrasound in Obstetrics and Gynecology; RCOG, Royal College of Obstetricians and Gynaecologists; FIGO, International Federation of Gynecology and Obstetrics; ACR, American College of Radiology ; SOGC, Society of Obstetrician and Gynaecologists of Canada; CNGOF, The French College of Obstetricians and Gynecologists; PTGiP, The Polish Society of Gynecologists and Obstetricians; ACOG, American College of Obstetricians and Gynecologists; RIGHT, Reporting Items for Practice Guidelines in Healthcare; SD, Standard deviation.\u003c/p\u003e\n\u003cp\u003eFigure 2 presents the results of the evaluation of the ten guidelines combining the three tools. It can be seen that the RCOG\u003csup\u003e17\u003c/sup\u003e guideline is of the highest quality and classified as \u0026ldquo;recommended\u0026rdquo;, and the PTGiP\u003csup\u003e22\u0026nbsp;\u003c/sup\u003eguideline is of the lowest quality, regardless of the tool used. The results are also generally consistent across the three tools, with differences in the results for individual guidelines. Two guidelines, ISUOG and CNGOF, scored lower when using the STAR and AGREE tools, while the RIGHT checklist evaluation results show higher reporting rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommended content analysis results\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 10 guidelines included, two\u003csup\u003e14,22\u0026nbsp;\u003c/sup\u003eare relevant to multiple pregnancies (including twins) combined with FGR, and eight\u003csup\u003e15-21,23\u003c/sup\u003e provid recommendations for FGR in singleton pregnancies. Four guidelines, SMFM, RCOG, FIGO, and SOGC, state that low-molecular-weight heparin is not recommended for the prevention in women at high risk of FGR. The RCOG, FIGO, SOGC, and CNGOF guidelines suggest that low-dose aspirin can be used for women at risk of pre-eclampsia and/or placental dysfunction to reduce the risk of FGR, and recommend starting aspirin (100-150 mg/d) at 12-16 weeks of gestation. ISUGO, RCOG, CNGOF suggest that FGR should be suspected when there is reduced and static fetal growth, which can be assessed with the help of Abdominal Circumference (AC) and Estimated Fetal Weight (EFW). RCOG, FIGO, ACR, CNGOF suggest that for those who are at high risk of FGR, ultrasound Doppler evaluation should be performed, especially Umbilical Artery, Uterine Artery, and Middle Cerebral Artery Doppler.\u003c/p\u003e\n\u003cp\u003eAlmost all guidelines recommend that patients with a diagnosis of FGR should undergo procedural testing based on the severity of FGR and umbilical artery changes, including cardiotocography (CTG) or computerized CTG (cCTG), umbilical artery Doppler, middle cerebral artery Doppler, and intravenous catheter Doppler,. FIGO guideline strongly suggests that for late-onset FGR, middle cerebral artery Doppler may provide additional fetal deterioration information, but the SMFM guidelines advise against the use of venous catheterisation, middle cerebral artery or uterine artery Doppler assessment for routine clinical management of early-onset or late-onset FGR. SMFM, RCOG, FIGO, SOGC state that prenatal diagnosis is recommended for pregnant women with isolated premature or severe (EFW \u0026lt; 3rd percentile) FGR. Delivery is currently the only definitive treatment, timing of termination should be individualized as appropriate and FGR alone is not an indication for caesarean section. For cCTG showing fetal heart rate variability (STV), altered venous conduit, umbilical artery agenesis or reversed end-diastolic flow velocities, caesarean section is recommended for delivery and should be performed according to week of gestation after the use of glucocorticoids and magnesium sulphate.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFGR is strongly associated with adverse outcomes for maternal and infant outcomes. CPGs can help doctors and patients make clinical decisions for different situations, but their quality varies. Recommendations from high-quality guidelines are usually more reliable and can guide clinical practice to a higher degree. In this study, FGR guidelines were evaluated using the AGREE II, STAR, and RIGHT tools, a total of 10 guidelines were included after a comprehensive search and rigorous screening process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results of the AGREE II Instrument showed that of the 10 CPGs, two of them\u003csup\u003e17-18\u0026nbsp;\u003c/sup\u003ewere \u0026ldquo;recommended\u0026rdquo;, and the eight\u003csup\u003e14-16, 19-23\u0026nbsp;\u003c/sup\u003ewere \u0026ldquo;suggested with modification\u0026rdquo;. Guidelines classified as \u0026ldquo;recommended\u0026rdquo; are generally considered to be of high quality. \u0026ldquo;Recommended with modifications\u0026rdquo; means that the openness and transparency of the guideline development process needs to be improved, and could be improved when the guideline is revised and updated. \u0026ldquo;Not recommended\u0026rdquo; means that the quality of the guideline needs to be improved. A previous study\u003csup\u003e24\u003c/sup\u003e evaluated quality differences in FGR guidelines using the AGREE II tool, and its findings were consistent with those of the present study, with both the RCOG and FIGO guidelines categorized as \u0026ldquo;recommended\u0026rdquo;. When analysised from the perspective of the domains, the \u0026ldquo;scope and purpose\u0026rdquo; and \u0026ldquo;clarity\u0026rdquo; domains were of high quality, with average scores of over 60%, while the remaining domains all scored lower, and the \u0026ldquo;editorial independence\u0026rdquo; domain being the most polarised. The \u0026ldquo;scope and purpose\u0026rdquo; domain scored above 60% for each guideline, with a relative weakness being the lack of clarity in defining the target population to which the guidelines apply. The \u0026ldquo;stakeholder involvement\u0026rdquo; domain performed poorly overall, with nine guidelines\u003csup\u003e14-16, 18-23\u0026nbsp;\u003c/sup\u003eachieving a standardized score below 50.00%. The main shortcomings included: (1) failure to incorporate the perspectives and preferences of the target population (e.g., patients, the public), and (2) insufficient description of the intended users of the guidelines and how they should be utilized. The \u0026ldquo;rigor of development\u0026rdquo; domain, which focuses on the methodological aspects of guideline development and is closely tied to guideline quality, received lower scores in six guidelines \u003csup\u003e14-16, 18, 22-23\u003c/sup\u003e. This was primarily due to: (1) the absence of clearly defined criteria for evidence retrieval, selection, and exclusion; (2) the lack of a specified method for formulating recommendations (e.g., voting, consensus, Delphi method); (3) no indication of external review prior to publication; and (4) insufficient details regarding updates (e.g., timing, criteria).The \u0026ldquo;clarity of presentation\u0026rdquo; domain is central to the guidelines and, consequently, achieved the highest average score. The \u0026ldquo;applicability\u0026rdquo; domain also scored lower with eight guidelines\u003csup\u003e14-16,19-23\u003c/sup\u003e scoring \u0026lt;50% on a standardized basis, mainly due to a lack of description of factors affecting the implementation of the guideline and a lack of consideration of the economic aspects of application. The \u0026ldquo;editorial independence\u0026rdquo; domain exhibited the most variability, with scores ranging from 0 to 100. Notably, the ISUOG and CNGOF guidelines failed to disclose sponsorship details and conflicts of interest.\u003c/p\u003e\n\u003cp\u003eThe results of the STAR tool evaluation showed that the average score rates for the three domains of evidence, recommendations, and other aspects were high, all exceeding 60%, with the recommendations domain achieving the highest score rate.\u0026nbsp;All of the guidelines included in this study scored 0 for \u0026ldquo;registry\u0026rdquo; and \u0026ldquo;protocol\u0026rdquo;, with the main problems being: (1) fail to register or provide a platform prior to publication of the guideline; and (2) fail to write a protocol, which suggests that published guidelines do not pay much attention to registration and writing protocols, a problem that could reduce the overall reliability of the guidelines. These indicate that the published guidelines do not pay much attention to registration and writing protocols, which will reduce the reliability of the guidelines as a whole. \u0026ldquo;funding\u0026rdquo;, \u0026ldquo;guideline development groups\u0026rdquo;, \u0026ldquo;consensus method\u0026rdquo;, and \u0026ldquo;accessibility\u0026rdquo; also scored poorly, with none exceeding 30%. The problems in each area were (1) funding sources and roles were not indicated; (2) participants were not grouped (including evidence and consensus groups); (3) recommendation consensus methods and records were not provided; and (4) different user versions of the guidelines were not provided. In terms of the overall quality of the guidelines, the RCOG guidelines had the highest score, which is consistent with the AGREE II tool results.\u003c/p\u003e\n\u003cp\u003eThe results of the RIGHT checklist showed that two guidelines had an overall reporting rate of more than 80 %, one of which was from the RCOG, and the results were also consistent with the AGREE II Instrument and the STAR tool. The average reporting rate was above 60 % for six among the seven domains, with the only domain, \u0026ldquo;funding and declaration and management of interests\u0026rdquo;, having a low average reporting rate, mainly due to: (1) not reporting of sources of funding and roles of the various phases of the guidelines; and (2) not reporting on the evaluation and management of conflicts of interest.\u003c/p\u003e\n\u003cp\u003eThis study presents the results of ten guideline evaluations in the form of a bubble chart (Figure 2). The closer the guideline is to the upper right corner of the axis and the larger the bubble, the higher the quality of the guideline. The results showed that RCOG had the highest quality and PTGiP had the lowest quality. In this study, each researcher was required to assess a guideline using all three tools simultaneously, minimizing potential discrepancies in understanding the same guideline at different times and thus enhancing comparability.\u0026nbsp;The trend of the results of the three tools is basically similar, with high quality and lower quality presenting consistent results regardless of the tool used, while medium quality articles will show differences, possibly due to the following reasons: (1) the evaluation forms of the three tools are different, and (2) the evaluation content is not entirely consistent. AGREE II is one of the most popular and established guideline assessment tools in use globally\u003csup\u003e25\u003c/sup\u003e, covering the six domains of scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence, with each item scored on a 7-point scale, and with the researcher\u0026apos;s subjective perceptions influencing the results. Compared to AGREE II, the RIGHT checklist also requires the reporting of basic information in the guidelines. Each sub-item is assessed against the content of the guideline and the results are categorised only as \u0026ldquo;reported\u0026rdquo; and \u0026ldquo;not reported\u0026rdquo;, but there is no quantitative assessment of the content of the report. The RIGHT checklist is mainly used to guide developers in reporting guidelines, but can also be used to assess the reporting quality of guidelines. The STAR evaluation tool is a newly developed guideline evaluation method in China, which increases the content of registry, protocol, accessibility, etc., and at the same time refines the areas of funding, evidence, recommendations, etc., which improves the narrower focus of most of the current evaluation tools on the quality of the methodology, the quality of the report, etc. STAR can be regarded as an alternative to the comprehensive use of multiple assessment tools. At the same time, STAR assigns weights to domains and projects, which allows for better evaluation and ranking of guideline quality, but at the same time, its score is also affected by the weights.\u003c/p\u003e\n\u003cp\u003eTreatment of FGR is based on early diagnosis, optimal fetal monitoring and timely delivery. This study summarized the common recommendations of the 10 included guidelines, including the prevention, screening, management and treatment of FGR panel, and most of the guidelines agreed on CTG and ultrasound Doppler management of pregnant women with FGR, the timing of delivery, and what kind of cesarean section to be performed, and were supported by relatively sufficient evidence. In addition, the guidelines recommend women quite smoking and alcohol to reduce the risk of FGR. Early FGR should be monitored and managed in a tertiary ward with the highest level of neonatal care. Individual guidelines give opposing opinions on whether to use middle cerebral artery Doppler and venous catheter Doppler for prediction and management, but the strength of the recommendations is not high. There is no international consensus on the best way to manage FGR, and more research could be conducted on this component in the future, with a view to reducing perinatal mortality and improving prognosis.\u003c/p\u003e\n\u003cp\u003eThis study has some limitations:(1) AGREE II, STAR, RIGHT are assessment tools only and cannot guide the assurance of clinical validity or usefulness, and clinical judgement should always be exercised when applying guideline recommendations in individual patient care. (2) Reporting bias may exist: the researcher\u0026apos;s subjective awareness may potentially affect the evaluation results of the guidelines. This study adopted double-blind assessment to reduce bias. (3) Restricted languages and the small number of FGR guidelines show issues that do not fully represent the current international situation.\u003c/p\u003e"},{"header":"Conclusions ","content":"\u003cp\u003eThe quality of FGR guidelines still needs to be further improved. It is recommended that future guideline development and updating should pay attention to clarifying the target populations and settings of guideline use. Guideline authors should involve experts in statistics and guideline methodology to enhance the quality of evidence supporting the guidelines. Additionally, the influencing factors during guideline dissemination to clinical practice, as well as the practical implementation of guidelines in clinical settings, should be considered more comprehensively. Furthermore, the independence of guideline development, including the management of conflicts of interest and funding issues, also requires improvement.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate：Not Applicable\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eAvailability of data and material\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eAll authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research was funded by the Natural Science Foundation of Hunan Province (2022JJ40789), the National Natural Science Foundation of China (82301927, 82371700), the Major Scientific and Technological Projects for Collaborative Prevention and Control of Birth Defects in Hunan Province (2019SK1010, 2019SK1015), the Key Research and Development Program of Hunan Province (2020SK2072).\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eConceptualization, Jingrui Huang; Data curation, Mingyue Guo, Ruohan Wang; Formal analysis, Mingyue Guo, Ruohan Wang; Funding acquisition, Weishe Zhang and Jingrui Huang; Investigation, Mingyue Guo, Ruohan Wang, Caihong Hu; Methodology, Weishe Zhang, Caihong Hu, Jingrui Huang; Resources, Weishe Zhang, Qi Li, Yiran Fu, Qi Wang, Biaobiao Wang; Writing\u0026mdash;original draft, Mingyue Guo, Ruohan Wang; Writing\u0026mdash;review and editing Caihong Hu, Jingrui Huang.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSmith GCS. 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Hepatobiliary Surg Nutr. 2020;9(2):126\u0026ndash;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21037/hbsn.2019.09.06\u003c/span\u003e\u003cspan address=\"10.21037/hbsn.2019.09.06\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"systematic-reviews","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sysr","sideBox":"Learn more about [Systematic Reviews](http://systematicreviewsjournal.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/sysr/default.aspx","title":"Systematic Reviews","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"fetal growth restriction, guidelines, AGREE II, STAR, RIGHT","lastPublishedDoi":"10.21203/rs.3.rs-6582108/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6582108/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTo comprehensively evaluate the quality of guidelines related to fetal growth restriction(FGR), with a view to provide recommendations for the development of high-quality guidelines.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eCNKI, Wanfang, Chinese Medical journal, PubMed, Embase, Web of Science and other databases were searched for FGR guidelines published from database establishment to September, 2024. Used the Appraisal of Guidelines for Research and Evaluation II(AGREEII)instrument, the Reporting Items for practice Guidelines in Health care (RIGHT) checklist and Scientific, Transparent and Applicable Rankings (STAR) tool to assess the quality of guidelines. We tested the consistency of the evaluation results of researchers by calculating the intraclass correlation coefficient (ICC).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 10 guidelines were included in this study, including nine English CPGs and one Chinese CPG. According to the AGREE II instrument, two CPGs were \u0026ldquo;recommended,\u0026rdquo; while eight were \u0026ldquo;suggested with modifications\u0026rdquo;. STAR tool results showed scores of 0.00%, 0.00%, 26.41%, 18.49%, 38.28%, 55.85%, 62.55%, 26.54%, 88.66%, 27.54%, and 70.00% for registry, protocol, funding, guideline development groups, conflicts of interest, clinical questions, evidence, consensus method, recommendations, accessibility, and other aspects, respectively. RIGHT checklist reporting rates were 76.67% (basic information), 66.25% (background), 68.00% (evidence), 68.57% (recommendations), 70.00% (review and quality assurance), 40.00% (funding and declaration and management of interests), and 73.34% (other information).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe quality of FGR guidelines still needs to be further improved. It is recommended that future guideline development and updates should pay more attention to clarifying the target populations and settings of guideline use. Guideline authors should involve experts in statistics and guideline methodology to enhance the quality of evidence supporting the guidelines. Additionally, the influencing factors during guideline dissemination to clinical practice, as well as the practical implementation of guidelines in clinical settings, should be considered more comprehensively. Furthermore, the independence of guideline development, including the management of conflicts of interest and funding issues, also requires improvement.\u003c/p\u003e","manuscriptTitle":"Evaluation of fetal growth restriction guidelines Based on AGREE II, STAR and RIGHT Tools","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-14 10:11:45","doi":"10.21203/rs.3.rs-6582108/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2026-05-14T20:37:06+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2026-01-13T00:48:55+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-12T15:53:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-12T03:13:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Systematic Reviews","date":"2025-05-10T07:49:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"systematic-reviews","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sysr","sideBox":"Learn more about [Systematic Reviews](http://systematicreviewsjournal.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/sysr/default.aspx","title":"Systematic Reviews","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"84b4d49d-e108-4f81-baa3-3207e215b4da","owner":[],"postedDate":"January 14th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Major revision","date":"2026-05-14T20:37:06+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T00:38:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-14 10:11:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6582108","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6582108","identity":"rs-6582108","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}