What is the management of reversed end diastolic flow?

Management of Reversed End Diastolic Flow

For pregnancies with fetal growth restriction and reversed end-diastolic flow in the umbilical artery, delivery should be considered at 30-32 weeks of gestation as long as fetal surveillance remains reassuring. 1

Surveillance Protocol

• Hospitalization is recommended when reversed end-diastolic flow (REDF) is detected in the umbilical artery 1
• Heightened surveillance with cardiotocography (CTG) should be performed at least 1-2 times per day 1
• Doppler assessment should be increased to 2-3 times per week when abnormal umbilical artery flow is detected 1, 2
• Regular amniotic fluid volume assessment (twice weekly) is recommended for pregnancies with abnormal umbilical artery Doppler findings 2
• Daily discussion with the consultant obstetrician about the clinical situation is essential 2

Antenatal Interventions

• Antenatal corticosteroids should be administered if reversed end-diastolic flow is noted at <34 weeks in a pregnancy with suspected intrauterine growth restriction (IUGR) 1
  • This is a Level I evidence, level A recommendation 1
  • Corticosteroid administration may result in transient return of end-diastolic flow in about two-thirds of cases, attributed to altered tone of the placental vasculature 1
• Magnesium sulfate for fetal neuroprotection should be administered if delivery is planned before 32 weeks gestation 1, 2

Timing of Delivery

• Delivery at 30-32 weeks of gestation is recommended for pregnancies with fetal growth restriction and reversed end-diastolic flow 1
  • This is a Level 1B recommendation according to the Society for Maternal-Fetal Medicine 1
• Earlier delivery may be indicated if there is:
  • Poor interval fetal growth
  • Deterioration of sonographic variables
  • Abnormal cardiotocography 2
• Delaying delivery beyond the recommended gestational age increases the risk of adverse outcomes 2

Mode of Delivery

• Cesarean delivery should be considered for pregnancies with fetal growth restriction complicated by reversed end-diastolic velocity, based on the entire clinical scenario 1
• Studies show high rates of emergency cesarean section (80%) due to acute fetal distress in cases with REDF 3

Prognostic Implications

• Reversed end-diastolic flow is associated with significantly worse outcomes compared to absent end-diastolic flow:
  • Higher perinatal mortality rates (up to 50-63%) 4, 3
  • Lower mean birth weights 4
  • Higher rates of admission to neonatal intensive care units 3
• REDF represents an ominous finding that warrants urgent evaluation and intervention 5, 6
• Placental examination often reveals significant infarcts (80% of cases) 3

Clinical Pitfalls to Avoid

• Failing to differentiate between absent end-diastolic flow (delivery at 33-34 weeks) and reversed end-diastolic flow (delivery at 30-32 weeks) 1, 2
• Managing these high-risk cases without daily consultant involvement 2
• Delaying administration of corticosteroids, which should be given promptly when REDF is detected before 34 weeks 1
• Expectant management beyond recommended delivery timing, which has not shown benefits in terms of long-term morbidity 7