Immediate Delivery by Caesarean Section
At 35 weeks gestation with fetal growth restriction and absent end-diastolic flow (AEDF) on umbilical artery Doppler, proceed with immediate cesarean delivery—do not delay, do not induce labor, and do not repeat the Doppler. 1, 2
Why Immediate Delivery is Mandatory
The delivery window has already passed. The Society for Maternal-Fetal Medicine and American College of Obstetricians and Gynecologists recommend delivery at 33-34 weeks for AEDF, and this patient is already at 35 weeks—beyond the recommended threshold. 1, 2
AEDF represents severe placental insufficiency with obliteration of approximately 70% of placental tertiary villi arteries, creating an extremely high-risk situation where intrauterine fetal demise can occur at any moment. 1, 2
Perinatal mortality exceeds 20% in pregnancies with AEDF, with significantly worse outcomes when delivery is delayed or vaginal delivery is attempted. 2
Why Cesarean Section Over Labor Induction
Never attempt labor induction with AEDF. The fetus cannot tolerate the stress of contractions given the severe placental compromise. 2
Growth-restricted fetuses with AEDF are at markedly increased risk for intrapartum fetal heart rate decelerations requiring emergency cesarean delivery and metabolic acidemia at delivery. 2
The American College of Radiology and American College of Obstetricians and Gynecologists both recommend cesarean section as the preferred mode of delivery for AEDF due to the high risk of intrapartum fetal compromise. 2
Why Repeating the Doppler is Dangerous
AEDF is the most predictive Doppler finding for adverse perinatal outcomes, outperforming other antenatal tests like non-stress testing and biophysical profile. 2
Delaying delivery beyond 34 weeks in AEDF cases significantly increases adverse outcomes, and waiting another week would place this fetus at 36 weeks—unacceptably late. 2
The diagnosis is already definitive—AEDF on umbilical artery Doppler combined with growth restriction (fundal height 6 weeks behind) confirms severe placental insufficiency requiring immediate action. 1, 2
Pre-Delivery Preparation
Coordinate immediately with neonatology for optimal resuscitation planning, as these infants are at high risk for respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage. 1, 3
Antenatal corticosteroids should be considered if not previously administered, though at 35 weeks the benefit is limited. 1
Obtain cord arterial and venous pH at delivery to assess the degree of fetal compromise. 2
Send the placenta for histopathologic examination to guide future pregnancy management. 2