What is the management of absent end diastolic flow in fetal monitoring?

Management of Absent End Diastolic Flow in Fetal Monitoring

For pregnancies with absent end-diastolic flow (AEDF) in the umbilical artery before 34 weeks' gestation, management includes daily cardiotocograph monitoring, twice weekly umbilical artery Doppler assessment, amniotic fluid volume evaluation, and delivery should be considered no later than 34 weeks gestation. 1

Surveillance Protocol for AEDF

Monitoring Requirements

• Daily cardiotocograph (CTG) monitoring to assess fetal well-being 1
• Twice weekly umbilical artery Doppler assessment to monitor for progression to reversed end-diastolic flow 1
• Regular amniotic fluid volume assessment (twice weekly) 1
• Daily discussion with the team consultant about the clinical situation 1
• Consider hospital admission depending on the clinical scenario and gestational age 1

Doppler Assessment

• Umbilical artery Doppler assessment should be performed 2-3 times per week once AEDF is detected 1
• Serial evaluation is crucial to detect deterioration to reversed end-diastolic flow, which requires more intensive management 1

Timing of Delivery

AEDF-Specific Recommendations

• Delivery should be considered no later than 34 weeks gestation with AEDF 1
• Earlier delivery may be indicated in cases of:
  • Poor interval fetal growth 1
  • Deterioration of sonographic variables (Doppler patterns, amniotic fluid) 1
  • Abnormal cardiotocography 1

Society for Maternal-Fetal Medicine Recommendations

• Delivery at 33-34 weeks of gestation is recommended for pregnancies with FGR and AEDF 1
• Mode of delivery should be considered based on the entire clinical scenario, with cesarean delivery likely when AEDF is present 1

Antenatal Interventions

Corticosteroids

• Administer prenatal corticosteroids for fetal lung maturation between 24+0 and 34+0 weeks gestation 1
• Steroids should be administered in a timed manner 1
• Multiple courses of steroids are not recommended 1

Magnesium Sulfate

• MgSO4 for fetal neuroprotection should be administered if delivery is planned before 32 weeks gestation 1

Special Considerations

Fetal Growth Restriction Management

• Consultation with experienced obstetrician or fetal medicine specialist is recommended, particularly in severe, preterm fetal growth restriction 1
• Histopathologic examination of the placenta is strongly recommended in all cases where fetal growth restriction is diagnosed prenatally or at birth 1
• Cord arterial and venous pH should be recorded for all fetal growth restricted infants 1

Prognostic Implications

• AEDF represents significant placental insufficiency and is associated with increased perinatal morbidity and mortality 2, 3
• Cesarean delivery may improve outcomes compared to vaginal birth in cases of AEDF 4
• Intermittent AEDF may have better outcomes than persistent AEDF but still requires close monitoring 3

Clinical Pitfalls to Avoid

• Do not delay delivery beyond 34 weeks in cases of AEDF, as this increases risk of adverse outcomes 1
• Do not manage AEDF cases without daily team consultant involvement 1
• Do not fail to differentiate between AEDF and reversed end-diastolic flow, as the latter requires earlier delivery (30-32 weeks) 1
• Do not miss underlying fetal anomalies or aneuploidy, which may be associated with AEDF 5
• Avoid inadequate surveillance frequency, as deterioration can occur rapidly 6