Immediate Delivery by Caesarean Section
At 35 weeks gestation with severe fetal growth restriction (fundal height corresponding to 29 weeks) and absent end-diastolic flow (AEDV) on umbilical artery Doppler, you should proceed with immediate delivery by caesarean section (Option B). This patient has already exceeded the recommended delivery window of 33-34 weeks for AEDV, making further delay inappropriate 1.
Rationale for Immediate Delivery
The Society for Maternal-Fetal Medicine explicitly recommends delivery at 33-34 weeks of gestation for pregnancies with fetal growth restriction and absent end-diastolic velocity, and this patient is already at 35 weeks, meaning delivery should not be delayed 1, 2.
AEDV represents severe placental insufficiency with obliteration of approximately 70% of placental tertiary villi arteries, creating high risk for intrauterine fetal demise and adverse developmental outcomes 2.
The neonatal morbidity and mortality rates associated with AEDV at this gestational age are lower than the risks of continued intrauterine exposure to severe placental insufficiency 3.
Why Caesarean Section Over Induction
For pregnancies with fetal growth restriction complicated by AEDV, cesarean delivery should be strongly considered based on the complete clinical scenario, as recommended by the Society for Maternal-Fetal Medicine 1, 2.
Growth-restricted fetuses with AEDV demonstrate intrapartum fetal heart rate decelerations requiring emergency cesarean delivery in 75-95% of cases, making planned cesarean delivery the safer approach 3.
These fetuses are at markedly increased risk for metabolic acidemia and emergency situations during labor, which can be avoided with planned cesarean delivery 3.
Why Not the Other Options
Option A (Induce labor) is inappropriate because:
- The fetus is already severely compromised with AEDV, indicating inability to tolerate the stress of labor 3.
- The high likelihood (75-95%) of requiring emergency cesarean delivery during labor makes planned cesarean delivery safer 3.
Option C (Repeat Doppler in 1 week) is contraindicated because:
- The patient has already passed the recommended delivery window of 33-34 weeks 1.
- When AEDV is detected, Doppler assessment should be performed 2-3 times per week to monitor for deterioration to reversed end-diastolic velocity, not to delay delivery beyond the recommended gestational age 1.
- Further delay increases the risk of intrauterine fetal demise without providing fetal benefit 2, 4.
Pre-Delivery Preparations
Coordinate with neonatology for optimal resuscitation planning, as these infants are at risk for respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage 2.
While antenatal corticosteroids are recommended if delivery is anticipated before 33 6/7 weeks or between 34 0/7 and 36 6/7 weeks, at 35 weeks the benefit is limited but should be considered if not previously administered 1, 2.
Magnesium sulfate for neuroprotection is not indicated at 35 weeks, as this is reserved for pregnancies <32 weeks gestation 1.
Common Pitfalls to Avoid
Do not attempt expectant management beyond the recommended delivery window hoping for additional fetal maturation—the risks of continued placental insufficiency outweigh any potential benefits 4, 5.
Do not rely on biophysical profile or cardiotocography alone to determine delivery timing when AEDV is present, as these may appear reassuring even when the fetus is severely compromised 3.
Do not delay delivery to reach 37 weeks—the recommendation for delivery at 33-34 weeks with AEDV is based on evidence that neonatal outcomes at this gestational age are superior to the risks of continued intrauterine exposure 1, 3.