What is the management for a 37-week gestation patient who is a Gravida 3 (G3), Para 1 (P1), Live birth 1 (L1)?

From the Guidelines

At 37 weeks of gestation with a history of G3P1L1, delivery should be considered if there is evidence of fetal growth restriction (FGR) with an umbilical artery Doppler waveform showing decreased diastolic flow but without absent or reversed end-diastolic velocity, or with severe FGR and estimated fetal weight less than the third percentile, as recommended by the Society for Maternal-Fetal Medicine 1.

Key Considerations

• The patient's obstetric history should be reviewed to anticipate potential complications, and her previous delivery records should be examined to inform the current pregnancy management.
• Fetal growth restriction is defined as an ultrasonographic estimated fetal weight or abdominal circumference below the 10th percentile for gestational age, and population-based fetal growth references such as Hadlock should be used to determine fetal weight percentiles 1.
• The decision for delivery in FGR is driven by fetal and maternal factors, including estimated fetal weight, gestational age, and findings on fetal surveillance, as well as the presence of comorbidities such as hypertension 1.
• For pregnancies with FGR and an umbilical artery Doppler waveform with decreased diastolic flow but without absent or reversed end-diastolic velocity, or with severe FGR and estimated fetal weight less than the third percentile, delivery at 37 weeks of gestation is recommended 1.

Management Recommendations

• Regular prenatal visits should continue, typically weekly at this point, to monitor fetal well-being and watch for signs of labor or complications.
• The patient should be educated on signs of labor, including regular contractions, rupture of membranes, bloody show, or decreased fetal movement, and instructed to contact her healthcare provider immediately or go to the hospital if any of these occur.
• A detailed obstetrical ultrasound examination should be performed to assess fetal growth and well-being, and fetal diagnostic testing, including chromosomal microarray analysis, should be offered if FGR is detected and a fetal malformation, polyhydramnios, or both are also present, regardless of gestational age 1.
• Serial umbilical artery Doppler assessment should be performed to assess for deterioration, and Doppler assessment up to 2-3 times per week should be considered when umbilical artery absent end-diastolic velocity is detected 1.

From the Research

Pregnancy at 37 Weeks with G3P1L1

• A woman who is 37 weeks pregnant with a history of G3P1L1 (three pregnancies, one previous live birth, and one or more previous losses) is considered to be at a relatively advanced stage of gestation.
• At this stage, the primary concerns are ensuring fetal well-being and preparing for a safe delivery.
• According to the study by 2, antenatal corticosteroids can reduce the risk of perinatal death, neonatal death, and respiratory distress syndrome in preterm births.
• However, the study by 3 suggests that antenatal corticosteroids may not be necessary for pregnancies at 37 weeks of gestation, as the risks of respiratory distress syndrome and other complications are lower at this stage.
• The study by 4 recommends planned delivery at 37-38 weeks of gestation for women with chronic hypertension, as this can minimize the risk of perinatal death and severe adverse events.
• The study by 5 found that estimated fetal weight (EFW) at 35-37 weeks' gestation is a strong predictor of small-for-gestational-age (SGA) neonates, but the addition of fetal growth velocity between 32 and 36 weeks' gestation does not significantly improve the predictive performance.

Key Considerations

• Fetal well-being and preparation for a safe delivery are the primary concerns at 37 weeks of gestation.
• Antenatal corticosteroids may not be necessary at this stage, but their use should be considered on a case-by-case basis.
• Women with chronic hypertension may benefit from planned delivery at 37-38 weeks of gestation.
• EFW at 35-37 weeks' gestation is a strong predictor of SGA neonates, but fetal growth velocity between 32 and 36 weeks' gestation may not add significant value to the prediction.