In the Trial of Randomized Umbilical and Fetal Flow in Europe (TRUFFLE), ductus venosus Doppler evaluation was compared with fetal heart rate monitoring. There were 310 pregnancies between 26 and 32 weeks' gestation with fetuses displaying an abdominal circumference < 10th percentile and an umbilical artery pulsatility index >95th percentile (Lees, 2015). Delivery timing was determined by the results of three difering antenatal fetal assessment arms that were: short-term fetal heart rate variability, early ductus venosus Doppler velocimetry changes, or late ductus changes. he proportion of children with neuroimpairment at 2 years of age was not diferent among the groups. Of note, only 32 percent of the newborns overall were delivered according to this randomization. Safety net criteria and other maternal/fetal indications prompted these protocol deviations (Visser, 2016). In a post-hoc analysis, these authors concluded that before 32 weeks, delaying delivery until ductus venosus Doppler or fetal heat rate abnormalities occur is likely safe and possibly beneits long-term outcome (Ganzevoort, 2017).
he Disproportionate Intrauterine Growth Intervention Trial at Term (DIGITAT) study examined the delivery timing of growth-restricted fetuses who were 36 weeks' gestation or older. In these 321 women who were randomized to induction or to expectant management, composite neonatal morbidity did not difer, except that neonatal admissions were lower after 38 weeks in a secondary analysis (Boers, 2010, 2012). Another secondary analysis of DIGITAT did not identiy a clear subgroup that beneited from labor induction (T ajik, 2014). Other secondary analyses included assessment of neurodevelopmental and behavioral outcomes at age 2, and these also were similar between the randomized groups (Van Wyk, 2012).
Management of the Near-Term Fetus
As shown in Figure 44-9, delivery of a suspected growthrestricted fetus with normal umbilical artery Doppler velocimetry, normal amnionic luid volume, and reassuring fetal heart rate testing can likely be deferred until 38 weeks' gestation. Said another way, uncertainty regarding the diagnosis should preclude intervention until fetal lung maturity is assured. Expectant management can be guided using antepartum fetal surveillance techniques described in Chapter 17. Most clinicians, however, recommend delivery at 34 weeks or beyond if there is clinically signiicant oligohydramnios. Consensus statements by the Society for Maternal-Fetal Medicine (Spong, 2011) and the American College of Obstetricians and Gynecologists (2017a) are similar. These recommend delivery between 34 and 37 weeks when there are comorbid conditions such as oligohydramnios. With a reassuring fetal heart rate pattern, vaginal delivery is planned. Notably, some of these fetuses do not tolerate labor.
Management of the Fetus Remote from Term
If growth restriction is identiied in an anatomically normal fetus before 34 weeks, and amnionic luid volume and fetal surveillance indings are normal, observation is recommended. Screening for toxoplasmosis, cytomegalovirus infection, rubella, herpes, and other infections is recommended by some. However, we and others have not found this to be productive (Yamamoto, 2013).