Placental dysfunction drives fetal growth restriction: mechanisms and translational perspectives.

Fetal growth restriction (FGR) is a major obstetric complication characterized by the inability of the fetus to reach its genetic growth potential, most commonly due to placental insufficiency. It contributes substantially to perinatal morbidity, stillbirth, and long-term cardiometabolic disease. Emerging evidence indicates that FGR arises not from a single defect but from a convergent, self-reinforcing network of placental dysfunction involving impaired trophoblast invasion, defective spiral artery remodeling, oxidative stress, angiogenic imbalance, immune dysregulation, nutrient transport failure, and epigenetic reprogramming. In early-onset FGR, hypoxia-driven HIF-1α signaling serves as an important integrating node linking angiogenic, inflammatory, and metabolic dysfunction, whereas additional HIF-1α-independent pathways appear to contribute more prominently in late-onset disease. Advances in single-cell and multi-omics technologies have refined the cellular and molecular landscape of the placenta, revealing complex intercellular interactions and regulatory circuits underlying disease heterogeneity. Clinically, diagnosis relies on integrated assessment of fetal biometry, Doppler velocimetry, and biomarkers such as the sFlt-1/PlGF ratio, while management remains largely surveillance-based with limited effective therapeutic options once placental dysfunction is established. Translational research is increasingly focused on precision approaches, including multi-omics biomarker panels, machine learning-based risk prediction, and pathway-targeted interventions. However, clinical implementation remains constrained by biological heterogeneity and lack of standardized validation. This review synthesizes current mechanistic insights and highlights emerging diagnostic and therapeutic strategies, emphasizing the need to shift from single-pathway models toward network-based and mechanism-stratified approaches. Advancing toward precision obstetrics will require integration of molecular profiling with clinical decision-making to improve outcomes for pregnancies affected by FGR.