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    Fetal Growth Restriction

     

    Management/delivery

    Finally there is the thorniest question of all: when to deliver. The growth-restricted preterm fetus is the most challenging. In the case of the periviable fetus, it is important to take parental wishes into account, and multiple variables can affect prognosis, including weight and gestational age.

    PB 134 reviews data from several large studies looking at expectant versus aggressive management at different gestational ages. Both the GRIT study (<34 weeks’ gestation) and the DIGITAT trial (>36 weeks) show no benefit or harm for immediate delivery, leaving a major clinical quandary.2,3

    PB 134 concludes with a rational standardized approach to this issue. It is worth quoting directly:

    Delivery at 38 0/7–39 6/7 weeks of gestation in cases of isolated [FGR] and 2) delivery at 34 0/7–37 6/7 weeks of gestation in cases of FGR with additional risk factors for adverse outcome (eg, oligohydramnios, abnormal umbilical artery Doppler velocimetry results, maternal risk factors, or co-morbidities).

    When delivery for FGR is antici­pated before 34 weeks of gestation, the delivery should be planned at a center with a neonatal intensive care unit and, ideally, after consultation with a maternal–fetal specialist. Antenatal corticosteroids should be adminis­tered before delivery because they are associated with improved preterm neonatal outcomes. For cases in which delivery occurs before 32 weeks of ges­tation, magnesium sulfate should be considered for fetal and neonatal neuroprotection in accordance with one of the accepted published protocols.

     

    References

    1. Smith CA. Effects of maternal under nutrition upon the newborn infant in Holland (1944–1945). J Pediatr. 1947;30:229–243.

    2. A randomised trial of timed delivery for the compro­mised preterm fetus: short term outcomes and Bayesian interpretation. GRIT Study Group. BJOG. 2003;110:27–32.

    3. Boers KE, Vijgen SM, Bijlenga D, van der Post JA, Bekedam DJ, Kwee A, et al. Induction versus expectant monitoring for intrauterine growth restriction at term: randomised equivalence trial (DIGITAT). DIGITAT Study Group. BMJ. 2010;341:c7087. 

    Joshua A. Copel, MD
    DR. COPEL is Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Director of ...

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