What is the next step for a 38-week pregnant female patient with severe hypertension, 1cm dilation, and absent Doppler flow, but a reassuring Electronic Fetal Heart Tracing (ETG) and intact membranes?

Immediate Cesarean Section is the Next Step

This patient requires immediate cesarean delivery due to the combination of severe hypertension (160/100 mmHg) and absent end-diastolic flow (AEDF) at 38 weeks gestation. 1, 2

Rationale for Cesarean Section Over Other Options

Why Not Amniotomy or Induction of Labor

• AEDF represents severe placental insufficiency with obliteration of approximately 70% of placental tertiary villi arteries, making the fetus unable to tolerate the stress of labor contractions. 2
• At 38 weeks with AEDF, the fetus has already exceeded the recommended delivery window of 33-34 weeks for AEDF, making immediate delivery mandatory rather than attempting labor induction. 1, 2
• Labor induction or augmentation should never be attempted with AEDF, as the severely compromised placenta cannot support the fetus through contractions. 2
• Cesarean section is the preferred mode of delivery when absent end-diastolic flow is present due to the high risk of intrapartum fetal compromise and metabolic acidemia. 2

Why Cesarean Section is Indicated

• The combination of severe hypertension (≥160/100 mmHg) and AEDF indicates severe placental insufficiency and fetal compromise requiring rapid delivery. 1
• AEDF is the most predictive Doppler finding for adverse perinatal outcomes, with perinatal death occurring in >20% of pregnancies with AEDF when vaginal delivery is attempted. 2
• Despite the reassuring fetal heart tracing, AEDF outperforms other antenatal tests like NST in predicting adverse outcomes. 2

Critical Pre-Delivery Management

Blood Pressure Control

• Initiate immediate antihypertensive treatment for BP ≥160/110 mmHg with first-line agents being IV labetalol or oral nifedipine to achieve target BP <160 mmHg systolic and diastolic BP around 85-100 mmHg. 1
• Continue antihypertensive treatment during cesarean section to maintain BP control. 1

Seizure Prophylaxis

• Administer magnesium sulfate for seizure prophylaxis given the severe hypertension in this preeclamptic patient. 1

Fetal Assessment at Delivery

• Obtain cord arterial and venous pH at delivery to assess the degree of fetal compromise. 1, 2
• Send the placenta for histopathologic examination to understand underlying causes and guide management in subsequent pregnancies. 1, 2

Common Pitfalls to Avoid

• Do not be falsely reassured by the reassuring fetal heart tracing - AEDF indicates severe compromise that can deteriorate rapidly regardless of current fetal heart rate patterns. 2
• Do not delay delivery to attempt cervical ripening or induction - the unfavorable cervix (1cm dilation, -2 station) combined with AEDF makes cesarean section the only safe option. 2
• Do not manage this case without specialist consultation if you lack experience with AEDF, as these cases require experienced obstetric or maternal-fetal medicine involvement. 2