Immediate Delivery by Caesarean Section (Option B)
At 35 weeks gestation with fetal growth restriction and absent end-diastolic flow (AEDV) on umbilical artery Doppler, you should proceed with immediate delivery by caesarean section. This clinical scenario represents severe placental insufficiency requiring urgent intervention to prevent fetal demise.
Why Immediate Delivery is Indicated
The Society for Maternal-Fetal Medicine provides clear guidance: delivery is recommended at 33-34 weeks of gestation for pregnancies with fetal growth restriction and absent end-diastolic velocity 1. Since this patient is already at 35 weeks—beyond the recommended delivery window—delivery should not be delayed 1.
Understanding the Severity
- AEDV indicates obliteration of approximately 70% of placental tertiary villi arteries, representing severe placental insufficiency 2
- This finding is strongly associated with severe fetal growth restriction (birthweight <3rd percentile) and adverse outcomes including mortality and developmental disorders 2
- The fundal height discrepancy (35 weeks actual vs. 29 weeks measurement) confirms significant growth restriction 1
Why Caesarean Section is Preferred
For pregnancies with fetal growth restriction complicated by AEDV, cesarean delivery should be strongly considered based on the complete clinical scenario 1, 2, 3.
Evidence Supporting Caesarean Delivery
- Perinatal mortality is significantly reduced with caesarean delivery compared to vaginal birth in cases of AEDV 4
- Newborn intensive care unit admissions are 4.4 times higher with vaginal delivery versus caesarean section when AEDV is present 4
- There is an inverse correlation between caesarean operation rate and perinatal mortality rate with AEDV 4
- Historical data shows that AEDV carries a very specific indication of serious fetal compromise requiring immediate delivery 5
Why Other Options Are Incorrect
Option A (Induce Labor) - Not Recommended
- Labor induction subjects the already compromised fetus to additional stress from contractions 4
- The fetus with severe placental insufficiency may not tolerate the physiologic stress of labor 6, 7
Option C (Forget) - Dangerous
- AEDV is associated with perinatal mortality rates approaching 60% without intervention 7
- Eight of nine fetuses with AEDV resulted in intrauterine or neonatal death in early studies when delivery was delayed 5
Option D (Repeat Doppler in 1 Week) - Inappropriate
- The patient is already past the recommended delivery window of 33-34 weeks 1
- Doppler assessment 2-3 times per week is recommended only for ongoing surveillance when delivery is not yet indicated, not as a reason to delay delivery 1
- Delaying delivery increases risk of intrauterine fetal demise 6, 5
Immediate Pre-Delivery Management
Before proceeding to caesarean delivery, ensure:
- Antenatal corticosteroids should already have been administered if this is a new diagnosis, though at 35 weeks the benefit is limited (recommended before 33 6/7 weeks or between 34 0/7 and 36 6/7 weeks) 1, 3
- Coordinate with neonatology immediately for optimal resuscitation planning 2
- Prepare for potential neonatal complications including respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage 2, 8
Critical Pitfall to Avoid
Do not pursue expectant management—AEDV indicates severe placental compromise requiring prompt delivery 2. The gestational age of 35 weeks provides reasonable neonatal outcomes while avoiding the high risk of intrauterine fetal demise associated with continued expectant management 1, 6, 5.