Frusca T, et al. - Researchers undertook the Trial of Umbilical and Fetal Flow in Europe to determine according to which criteria delivery should be triggered in early fetal growth restriction. In this trial, those randomized to delivery based on late ductus venosus changes showed the best 2-year neurodevelopmental outcome among survivors. Deciding delivery based on late ductus venosus changes and abnormal computerized fetal heart rate variability seemed reasonable because of the high rate of delivery based on the safety-net criteria. They identified no rationale for delivery based on cerebral Doppler changes alone. Most women with early-onset fetal growth restriction were observed to develop hypertension.

Methods

• Researchers performed randomization of women with fetal abdominal circumference <10th percentile and umbilical pulsatility index >95th percentile between 26-32 weeks to 1 of 3 monitoring and delivery protocols.
• These protocols were: fetal heart rate variability based on computerized cardiotocography; and early or late ductus venosus Doppler changes.
• Based on fetal heart rate abnormalities or umbilical Doppler changes, a safety net mandated delivery irrespective of randomized group.
• Normal neurodevelopmental outcome at 2 years was the primary outcome.

Results

• Researchers randomized 511 women; 362/503 (72%) showed associated hypertensive conditions.
• In all, survival was noted for 463/503 (92%) fetuses; cerebral palsy occurred in 6/443 (1%) with known outcome.
• No difference in outcome based on randomized group was noted among all women; however, of survivors, significantly more fetuses randomized to the late ductus venosus group had a normal outcome (133/144; 95%) than those randomized to computerized cardiotocography alone (111/131; 85%).
• The indication was safety-net criteria in 118/310 (38%) of babies delivered <32 weeks: 55/106 (52%) in late ductus venosus, 37/99 (37%) in early ductus venosus, and 26/105 (25%) in computerized cardiotocography groups.
• Although birthweight and gestational age were identified as the more significant determinants, higher middle cerebral artery impedance adjusted for gestation was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02–1.52) and infant survival without neurodevelopmental impairment at 2 years (odds ratio, 1.33; 95% confidence interval, 1.03–1.72).