Fetal Dopplers in early-onset FGR — structured oral station (12 minutes)

Opening prompt — "Interpret these findings and tell me your immediate plan."

Model response: ^[1][5]

• "This is severe early-onset fetal growth restriction: the EFW is on the 2nd centile, the umbilical artery pulsatility index is above the 95th centile, and there is absent end-diastolic flow — the most severe category of placental disease short of reversed flow."
• "Combined with a blood pressure of 142 over 92 and 1+ proteinuria, this woman is also evolving pre-eclampsia — the two pathologies share failed placentation."
• "I would admit her for inpatient surveillance, start daily-to-alternate-day Doppler and computerised CTG, administer corticosteroids for fetal lung maturation and magnesium sulfate for neuroprotection if delivery before 32 weeks is likely, and arrange senior obstetric and physician review for the pre-eclampsia."

Examiner is listening for: recognition of the convergent pathologies, inpatient surveillance, and the steroid/neuroprotection bundle. ^[1][2]

Probe 1 — "Describe the Doppler surveillance you will perform and what each vessel tells you."

• "Four vessels: the umbilical artery tells me about placental impedance — here it is critically raised with AEDF. The middle cerebral artery tells me about the brain-sparing response — I would expect a low MCA-PI as the fetus redistributes blood to the brain. The ductus venosus tells me about cardiac compromise — a rising DV-PI or an absent a-wave is late-stage decompensation. The uterine artery tells me about placentation, but I already know it is abnormal here."^[5]
• "The deterioration sequence is predictable: umbilical artery first, MCA second, ductus venosus last. I would monitor all four, in combination with the computerised CTG short-term variation."^[1]

Probe 2 — "What is the TRUFFLE trial, and how does it inform your delivery timing?"

• "TRUFFLE was a European multicentre randomised trial of 503 women with early-onset FGR between 26 and 32 weeks, randomised to delivery based on reduced cCTG short-term variation, early ductus venosus change, or late ductus venosus change. Among survivors, the late-DV group had the best 2-year neurodevelopmental outcome — 95% free of neuroimpairment versus 85% for cCTG alone."^[1]
• "The TRUFFLE insights paper is explicit: there is no rationale for delivery based on cerebral Doppler changes alone. Cerebral redistribution is a compensation, not an endpoint."^[2]
• "So my delivery triggers are a late ductus venosus change — absent or reversed a-wave — or an abnormal cCTG short-term variation. I would also have a safety-net: any acute deterioration in the UA Doppler or the CTG."

Probe 3 — "Her blood pressure is now 156/100 with 2+ proteinuria and a headache. How does this change the fetal plan?"

• "The maternal condition now drives the timing. This is severe pre-eclampsia — I would stabilise her with antihypertensives and magnesium sulfate for seizure prophylaxis, and the fetal plan is now expedited birth because the maternal risk of expectant management outweighs the fetal benefit."^[2]
• "The TRUFFLE insights paper notes that most women with early-onset FGR develop hypertension, and this is that trajectory. I would deliver, by caesarean if the fetal status is non-reassuring, after corticosteroids where time allows."^[2]

Probe 4 — "She asks what the long-term outcome for her baby will be. Talk me through your counselling."

• "I would be honest: babies with AEDF delivered preterm have a higher risk of neurodevelopmental impairment than term babies — the TRUFFLE trial found cerebral palsy in about 1% of survivors, and overall 2-year survival without impairment was around 84% with the best monitoring strategy."^[1][3]
• "I would also counsel on the increased risk of pre-eclampsia and fetal growth restriction in future pregnancies, and the role of aspirin prophylaxis next time."
• "I would invite her questions and offer a follow-up with the neonatologist to discuss neonatal outcomes."

Probe 5 — "What does the Cochrane review say about the value of Doppler in this situation?"

• "The Cochrane review of umbilical artery Doppler in high-risk pregnancies found that surveillance reduced perinatal death — risk ratio 0.71, 95% confidence interval 0.52 to 0.98 — and reduced inductions and caesareans. This is the foundational evidence that Doppler surveillance in pregnancies like hers improves outcomes."^[4]