OP-004 Reversing the reversed: successful case of early-onset fetal growth retardation

A fetus that has failed to reach its growth potential due to a pathologic process has fetal growth restriction. Fetal growth restriction is said to be of early-onset if it is diagnosed before 32 weeks. Many interventions were investigated, but when there is a high-risk for fetal death, the only management option of significance is iatrogenic preterm birth, with corticosteroids and magnesium sulfate to improve outcome. However, early delivery in a setting where medical support of very preterm neonates is lacking is a challenge. We present here a case of early-onset fetal growth restriction complicated with anhydramnios and reversed diastolic flow of the umbilical artery at 22 weeks. Review of lifestyle, and other work-up done for antiphospholipid syndrome, systemic lupus erythematosus and endocrine disorders, all yielded negative results. Aside from mild fetal hydronephrosis and single umbilical artery,  there was no other fetal structural anomaly seen. Non-invasive prenatal testing was low risk for aneuploidy. The patient was serially treated with aspirin, tinzaparin, intralipid infusions and intravenous immunoglobulin and monitored bimonthly with biometry, biophysical profile and Doppler velocimetry, with improvement of the amniotic fluid volume and Doppler velocimetry findings to normal. The fetus however remained below 1 percentile by Hadlock. A complete course of betamethasone was given at 28 weeks to improve pulmonary maturity.  At 34 weeks, occasional absent end diastolic flow of the umbilical artery was again noted, prompting delivery by cesarean section. She delivered a live baby girl, 1472 grams, APGAR 8-9, with pelvocaliectasia.  The baby stayed in the NICU for 19 days, during which, she was treated for pneumonia and was discharged well. This case illustrates that with close fetal surveillance, it is possible to have a good outcome in a very early onset of fetal growth restriction. Further studies are needed to identify the certain populations where anti-thrombotic, anti-inflammatory treatment may work for the treatment of fetal growth restriction.