What is the best course of action for a pregnant woman at 35 weeks gestation with decreased fetal movement, low amniotic fluid index (oligohydramnios), and undetectable umbilical cord vessels?

Immediate Cesarean Section is Indicated

This patient requires immediate cesarean delivery given the constellation of severe fetal compromise: decreased fetal movements, severe oligohydramnios (AFI 3), fetal growth restriction (fundal height 28cm at 35 weeks, 10th percentile), and critically, undetectable umbilical cord vessels suggesting absent or reversed end-diastolic flow. 1

Critical Clinical Features Demanding Immediate Delivery

• At 35 weeks gestation with absent end-diastolic flow (AEDF), this patient has already exceeded the recommended delivery window of 33-34 weeks for AEDF, making immediate delivery mandatory rather than attempting labor induction or expectant management 2, 3

• AEDF indicates severe placental insufficiency with obliteration of approximately 70% of placental tertiary villi arteries, strongly associated with severe fetal growth restriction and adverse outcomes including intrauterine fetal demise 3

• Severe oligohydramnios (AFI 3) combined with decreased fetal movements and AEDF represents a triad of severe fetal compromise requiring urgent intervention 4, 5

Why Cesarean Section Over Other Options

Option A: Cesarean Section - CORRECT CHOICE

• Cesarean delivery should be strongly considered for pregnancies with fetal growth restriction complicated by absent or reversed end-diastolic velocity based on the complete clinical scenario 2, 3

• Mode of delivery needs to be discussed on an individual basis, but cesarean section is likely when absent or reversed end-diastolic flow umbilical artery Doppler waveforms are present 1

• Studies report rates of intrapartum fetal heart rate decelerations requiring cesarean delivery in 75-95% of pregnancies with FGR and AEDF/REDV, making primary cesarean section the safer approach 2

Option B: Induction of Labor - INCORRECT

• Induction of labor is contraindicated in a patient with a fetus demonstrating severe compromise, as labor contractions would worsen placental perfusion and accelerate fetal deterioration 2

• Fetuses with antepartum decelerations and AFI <5 have significantly increased rates of neonatal acidosis and low Apgar scores, making vaginal delivery attempt too risky 4

• At 35 weeks with established fetal compromise, there is no benefit to attempting vaginal delivery 2

Option C: Expectant Management - INCORRECT

• Delivery should be considered no later than 34 weeks gestation in cases of absent end-diastolic flow, and this patient is already at 35 weeks 1

• Earlier delivery is indicated in cases of deterioration of sonographic variables (Doppler, amniotic fluid), both of which are severely abnormal in this case 1

• Decreased fetal movements with severe oligohydramnios and AEDF indicates impending fetal demise, making expectant management dangerous 6

Option D: Tocolytics - INCORRECT

• Tocolytics are used to transiently stop contractions in cases of abnormal fetal heart rate tracings during labor, not for antepartum management of severe fetal compromise 1

• This patient requires delivery, not pregnancy prolongation, making tocolytics contraindicated 1

Immediate Pre-Delivery Management

• Coordination with neonatology is crucial for optimal resuscitation planning in cases of fetal growth restriction with absent end-diastolic flow 3

• Antenatal corticosteroids should be considered if not previously administered, even at 35 weeks, though benefit is limited at this gestational age 2, 3

• Preparation for potential neonatal complications including respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage is essential 3

Post-Delivery Recommendations

• Cord arterial and venous pH should be recorded given the fetal growth restriction and AEDF to assess fetal well-being 1

• Histopathologic examination of the placenta is strongly recommended to understand underlying causes and guide management in subsequent pregnancies 1

Common Pitfalls to Avoid

• Do not attempt vaginal delivery in the setting of severe fetal compromise with AEDF, as this dramatically increases risk of intrapartum fetal demise and emergency cesarean under worse conditions 2

• Do not delay delivery for additional testing when AEDF is present beyond 34 weeks gestation 1

• Do not rely solely on biophysical profile or cardiotocography for surveillance when Doppler abnormalities are this severe 2