Decreased Fetal Movements With Absent End-Diastolic Flow
Ms. K is a 32-year-old G2P1 at 36+0 weeks’ gestation who presents with decreased fetal movements for 24 hours. She has no contractions, bleeding, or leakage of fluid. Blood pressure is 132/84 mmHg, and urine protein is negative. Fundal height is 32 cm. A nonstress test shows a baseline of 140 beats/min with minimal variability and no accelerations over 20 minutes. Ultrasound shows an amniotic fluid index of 4.8 cm and an estimated fetal weight of 2.3 kg (12th percentile). Umbilical artery Doppler shows a systolic/diastolic ratio of 4.0 with absent end-diastolic flow. She had a previous cesarean delivery for breech presentation. She is Rh negative and has received anti-D. She asks to go home and “come back if anything changes.”
1. Interpret the fetal surveillance and outline your immediate management.
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The combination is high risk: decreased fetal movements, a nonstress test with minimal variability and no accelerations, oligohydramnios (AFI 4.8 cm), fetal growth restriction (estimated weight 12th percentile), and absent end-diastolic flow in the umbilical artery. Absent end-diastolic flow indicates increased placental resistance and is associated with stillbirth, acidosis, and progression to reversed flow. At 36+0 weeks, the risks of continuing pregnancy outweigh the risks of delivery.
Do not send her home. Admit for continuous fetal monitoring, maternal vital signs, and urgent obstetric consultation. Arrange delivery in a centre with appropriate neonatal care. Because the nonstress test is nonreactive and Doppler is abnormal, the fetus needs ongoing assessment while delivery is planned; if the tracing becomes nonreassuring, proceed to emergency cesarean delivery. Antenatal corticosteroids are generally considered for anticipated preterm delivery at 34–36+6 weeks if there is time and no immediate need for delivery, but they should not delay delivery for a nonreassuring fetus. Magnesium sulphate for neuroprotection is not indicated at 36 weeks. Mode of delivery depends on fetal status, cervical findings, and obstetric judgement; prior cesarean and abnormal Doppler make emergency cesarean likely if there is any deterioration.
2. What maternal and fetal risks do you discuss with her regarding expectant management versus delivery?
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Explain that expectant management at 36 weeks with absent end-diastolic flow carries a meaningful risk of stillbirth, fetal acidosis, abruption, and progression to reversed flow. These risks cannot be reliably predicted by how she feels, and decreased movements are themselves a warning sign. Delivery carries risks of prematurity at 36 weeks, including respiratory distress, temperature instability, hypoglycemia, jaundice, and feeding difficulty, but these are usually manageable in a centre with neonatal support and are lower than at earlier gestations.
The goal is shared decision-making with a clear recommendation, not a neutral menu. State that you recommend delivery because the fetal surveillance is abnormal at a gestational age where neonatal outcomes are generally good. Discuss the possibility of cesarean delivery given the previous cesarean and nonreassuring status, and the possibility of induction if the fetus remains stable and cervical conditions are favourable. Document the discussion. Also monitor maternal blood pressure and symptoms of pre-eclampsia, because growth restriction and oligohydramnios can be associated with placental insufficiency.
3. What postpartum and newborn considerations are relevant?
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Inform the pediatric team before delivery so they can attend and anticipate a growth-restricted infant at 36 weeks. The newborn needs monitoring for hypoglycemia, temperature instability, respiratory distress, jaundice, and feeding difficulty. Delayed cord clamping can be considered if the infant is stable. Send the placenta for pathologic examination because placental insufficiency is suspected.
For the mother, monitor blood pressure, bleeding, and uterine tone after delivery; pre-eclampsia can present postpartum. Review thromboprophylaxis risk and analgesia, especially after cesarean. Discuss breastfeeding support and contraception. Because the infant is small for gestational age, arrange pediatric follow-up for growth and development. Document the abnormal Doppler and nonstress test so future pregnancies are managed as higher risk. If the placenta shows infarction or maternal vascular malperfusion, counsel about recurrence risk and consider prepregnancy counselling.