Decreased fetal movements

(DFM)Alarm before fetal death

Ahmad Saber SolimanA. Lecturer

Obstetrics and gynecology DepartmentBenha University

Objectives

• FETAL MOVEMENTS

• DFMC (Nr.& abnr.)

• Factors affecting FM

• Optimal management

I. HISTORYII. EXAMINATIONSIII. CTGIV. U/S

• MANAGEMENT of special situations

I. RECURRENTII. Before 24 wgaIII. 24 -28 wga

• Documentation.

Background

In their 8th annual report (London 2001) The Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) under the umbrella of NICE reviewed 422 stillbirths and found that 69 cases (16.4%) were related to altered or reduced fetal

movements.

Over 55% of women experiencing a stillbirth perceive a reduction in fetal movements prior to diagnosis (Efkarpidis et al., 2004).Early recognition of (DFM) makes it possible for the clinician to intervene at a stage when the fetus is still compensated, and thus prevent progression to fetal or neonatal injury or death.(Heazell et al; 2008).

PREVALENCE

40 % of pregnant women experience DFM one or more times during pregnancy most of them are transient.(Saastad et al; 2012).

Physiology

Types of Fetal movements

• Respiratory movement • Simple movement :like kicks or limb

movement.(short duration-variable amplitude)

• Rolling movement : Due to changing position.(long duration-high amplitude).

• Hiccough like movement.• OTHER activities like suckling the thumb

or blinking.

Start around 20 weeks gestation peak at 28- 34 weeks gestation (Mangesi & Hofmeyr, 2007).

N.B: Multiparous may notice movements earlier (16-20 wks) than primi (20-22 wks gestation) (Grant et al., 1989).

Fetal movements tend to plateau at 32 weeks of gestation, there is no reduction in the frequency of fetal movements in the late third trimester.

By term, the average number of movements per hour is 30,with the longest period between movements ranging from 50 to 75 minutes.

Fetal movements show diurnal changes. The afternoon and evening periods are periods of peak activity. (Minors et al; 1979).

Fetal movements follow a circadian pattern and absent during fetal sleep, periods which usually last 20-40 minutes and rarely exceed 90 minutes (Harrington et al; 1998) , (Velazquez et al; 2002).

Decreased maternal sensitivity to fetal

movement:

• early gestational age.

• maternal position (sitting or standing versus lying).

• maternal physical activity (or just being mentally distracted).

• fetal position (anterior position of the fetal spine). Fisher ML 1999.

• Fetal presentation ????• anterior placenta. (Only Prior to 28+0 weeks of

gestation …. Neldam et al; 1980)

• Administration of corticosteroids for fetal lung maturity

(Hijazi et al; 2009)

While, sudden decrease in fetal movement even with presence of these factors should be evaluated as a potential marker of risk (Winje et al; 2012).

The most common single cause of stillbirth is IUGR.

Some reports suggest 11-29% of women presenting with reduced FM carry a small for gestational age (SGA) fetus under the 10th centile (Heazell et al., 2005; Sinha et al., 2007).

Conditions associated with diminished fetal movements (Unterscheider et al., 2009)

Maternal causes : Maternal anemia, metabolic disorders, hypothyroidism

Fetal causes: IUD, FGR and oligohydramnios, and polyhydramnios CFMF (i.e. neurological, musculo-skeletal) Fetal anaemia or hydrops30%

Again ,55% of cases of still birth are associated with DFM and 30% of stillbirths are

due to IUGR

Increased fetal movements Following the elevation of glucose concentration in maternal blood, although other studies refute these findings. (Zisser et al; 2006)

Excessive fetal activity has been reported in anencephalic fetuses. (Baskett et al; 1989)

Fetal movements and CFMF

• Fetuses with major malformations are generally more likely to demonstrate reduced fetal activity. (Christensen et al; 1999)

• A lack of vigorous motion may relate to abnormalities of the central nervous system, muscular dysfunction or skeletal abnormalities. (Tveit et al; 2009)

Assessment of fetal movements

Subjective maternal perception VS Objective assessment by US.Can we depend only on the US detected movements ?????

Duration of recording is restricted to 20–30 minutes with the mother in a semi-recumbent position but results not correlate strongly to perinatal outcome. (Lowery et al; 1997)No studies which had evaluated the use of longer periods of fetal movement counting by ultrasound .

When correlated sonographically,

• 50% with isolated limb movements • 80% of movements involving both the trunk

and limb (de Vries et al; 2006).

In a literature review, mothers perceived 33 to 88 percent of ultrasonographically visualized fetal movements (Hijazi et al; 2009).

Fetal Movements in a healthy fetus vary from 4 to 100 per hour (Mangesi & Hofmeyr, 2007).

Definition of DFM

No universally agreed definition of RFM. RCOG 2014

level of fetal movement that reliably distinguishes a healthy fetus from a fetus at risk has not been determined (Flenady et al; 2009).

NICE and ACOG guidelines do not provide a definition of reduced fetal movements, which reflects the dilemma and controversy of the definition and management of reduced FM.

Till now the alarm limit of perceived fetal movements is not determined

Least number of maternally perceived fetal movements that reflect fetal well-being.

Perception of at least • 10 FMs during 12 hours of normal maternal activity.

•10 FMs over two hours when the mother is at rest and focused on counting.

•4 FMs in one hour when the mother is at rest and focused on counting.

•10 FMs within 25 minutes in pregnancies 22 to 36 weeks and 35 minutes in pregnancies 37 or more weeks of gestation.

Various methods for counting fetal kicks have been proposed, four examples of criteria for reassurance of fetal well-being (Kuwata et al; 2008)

A recent prospective cohort study showed that the mean time to perceive 10 movements is approximately 10 minutes in normal 3rd trimester pregnancies (Winje et al., 2011).

If women are unsure of RFM after 28+0 wks,

Patient on left side and focus on fetal movements for 2 hours. If they do not feel 10 or more discrete movements in 2 hours, they should contact their doctor immediately. level C RCOG 2011

• perception of 10 distinct movements in a period of up to 2 continuous or interrupted hours is considered reassuring. ACOG 2014

The only numerical limit that has been derived from a total population, and subsequently evaluated as a screening test in the same population, is the perception of 10 distinct movements during focused counting over a period of two hours, which is reassuring ("count to 10" method) ( Moore et al; 1989).

qualitative vs quantitative!!

There is no evidence that any quantitative limit is more effective than qualitative maternal perception of DFM for identifying pregnancies at risk of adverse outcome.

EVALUATION  

Rationale :

• Fetal movements decrease as the fetus attempts to conserve energy . The loss of fetal movement can be a sign of ongoing central nervous system hypoxia and injury. (Olesen and Svare JA. 2004)

• Fetal heart rate, fetal movements are impacted by uteroplacental blood flow alterations and are thereby sensitive to fetal hypoxemia and acidemia. ACOG 2014

• Any diminution in fetal activity requires fetal reevaluation , regardless of the amount of time that has elapsed since the last test. level B ACOG 2014

Goals: 1.rule out imminent fetal demise.

2.Assessment for common risk factors, such as fetal growth restriction and decreasing placental function.

1st History taking (FGR, placental insufficiency and congenital malformations).

• Confirm RFM if not present reassure and discharge. If confirmed :

comprehensive stillbirth risk evaluation • multiple consultations for RFM, known FGR, • HTN, DM, • extremes of maternal age, • smoking,• placental insufficiency, • CFM, • obesity,• poor past obstetric history (e.g.FGR and

stillbirth)• genetic factors.

Women with high risk factors for stillbirth should undergo antepartum fetal surveillance using NST, modified BPP. ACOG 2014 level B

Clinical approaches described in observational studies include:

1. physical examination including SFH2. non-stress and contraction stress tests.3. ultrasound examination (biophysical profile [BPP]).4. umbilical artery Doppler.5. testing for fetomaternal hemorrhage (eg, Kleihauer-Betke test).6. Amnioscopy.

In one study CTG was the most favored method of assessing fetal wellbeing (93%) followed by the use of • kickcharts (64%). • biophysical score (54%). • liquor volume (52%). • SFH (34%). • umbilical artery Doppler velocimetry (23%) .

(Unterscheider et al., 2010)

Fetal movement counting (count-to-ten kickcharts)

The use of kickcharts is easy, simple and can be done at home.

Using kickcharts were associated with higher intervention rates 32% and caesarean section rates 24% (Sinha et al., 2007).

Routine formal FM counting should not be offered as a fetal well being test . NICE 2003 renewed in their 2008

guideline.

In contrast, ACOG supports formal movement counting. In their bulletin on antepartum fetal surveillance they instruct the woman to count 10 movements, preferably after a meal, and to write down the hours this takes (ACOG, 2000).

Role of CTGFor how long CTG should be done?

Even without movements if the term fetus does not experience a fetal heart rate acceleration for more than 80 minutes, fetal compromise is likely to be present (Leveno et al; 1983).

The negative predictive value of NST alone for predicting stillbirth within 1 week of a normal test is 99.8%; for BPP, modified BPP, and CST, it is greater than 99.9%. ACOG 2014 

There are no randomised controlled trials of ultrasound scan versus no ultrasound scan in women with RFM

ultrasound examination of pregnancies complicated by persistent DFM despite a reactive NST is a valuable assessment tool.• Fetal activity• Fetal growth velocity• Amniotic fluid volume• Fetal anatomic survey (CFMF)• EFW if there is a size-dates discrepancy

(Heazell et al; 2005).Growth restriction has been associated with a decrease in the number, quality, strength, and duration of fetal movements (Bekedam et al;1985 ).

Ultrasound examination

Remember The most 2 important US markers are :• Amniotic fluid volume • Abdominal circumference

Perfusion

Growth velocity

Biophysical profile (BPP)

A normal BPP score along with a reactive NST is an indication of fetal well-being.  ACOG 2014

A total biophysical score of <4 is abnormal and suggestive of fetal compromise and increased risk of adverse outcome. ACOG 2014

Randomized controlled trials does not support the use of BPP as a test of fetal wellbeing . There was no significant difference between the groups in perinatal deaths. (Cochrane review Lalor et al.,2008)

Useful only if IUGR is diagnosed. A study of 599 cases of DFM evaluated by nonstress testing found no additional benefit of Doppler assessment ( Dubiel et al;1997).Doppler demonstrated a pathological pattern in 1 % of the 1151 cases. Most of these abnormalities were associated with growth restricted fetuses.

In 940 cases ; after exclusion of cases of non reactive CTG and IUGR fetuses >>>>>Doppler velocimetry was abnormal Only in 1 Case.

Doppler velocimetry  

Norwegian Perinatal Society Conference, November 2006

Sequence of fetal response to stress

ACOG support the use of UA Doppler assessments only in the management of suspected IUGR, instructing that decisions regarding the timing of delivery should be based on UA Doppler results in combination with other tests of fetal well-being . 

No evidence that inclusion of umbilical artery Doppler in antenatal surveillance provides additional benefit in the assessment of a normally growing fetus. ACOG 2014

Abnormal elevation of Doppler indices precedes loss of fetal heart rate variability and reactivity, eventually leading to decline and loss of fetal breathing and body movements (Williams et al; 2003).

Testing for feto-maternal transfusion

Kleihauer-Betke stain or flow cytometry

pregnant patient who presents with DFM +• sinusoidal fetal heart rate pattern or• unexplained fetal tachycardia or• Fetal hydrops on ultrasound associated with

elevated middle cerebral artery Doppler velocity.

A large fetomaternal transfusion (FMT) is estimated to occur in 0.3 % of pregnancies, and is a significant contributor to stillbirth. (Sebring et al;1990)

FOLLOW-UP AND DELIVERY

Persistent DFM and normal evaluation 

There are no studies evaluating the optimal frequency and method of follow-up of pregnancies complicated by persistent DFM in which the antepartum evaluations are all normal. no data from randomized trials to guide practice recommendations for management of DFM (Cochrane Database Syst Rev 2012 ).

Management of patients with persistently decreased fetal movement depends on:1. gestational age 2. presence of other identifiable risk factors for

stillbirth.

If no cause for decreased fetal movement is determined, pregnancies under 37 weeks of gestation be monitored with nonstress testing and ultrasound examination twice weekly. ACOG 2014

After 37 wks >> labor induction of these pregnancies when the cervix is favorable ( Grade 2C ).

Reduced fetal movements in multiple gestationsThe same but focus in Evaluation of chorionicity,concordant and appropriate for gestational age,there are no structural abnormalities, signs of selective IUGR or twin-to-twin transfusion syndrome (TTTS).

Postdates

Amniotic fluid assessment should be added in postdates pregnancies.

UA Doppler would not be expected to be helpful since elevated fetal risk in postdates pregnancy is related to impaired placental gas exchange rather than impaired blood flow ACOG

2014

•Every mother who presents with the concern of reduced or altered fetal movements should. be taken seriously .

•The initial assessment should include a detailed history + AC to rule out IUGR + CTG.

Summary and recommendation

If the mother re-presents or initial assessment is non-reassuring further tests should be performed include amniotic fluid assessment and EFW.

If this is reassuring for the mother and clinician, no further evaluation is needed.

Kickcharts are of no value and should therefore not be given out to pregnant women.

UA Doppler velocimetry and vibroacoustic stimulation are of limiteduse in the assessment of reduced FM.

BPP scoring has not been shown to be of benefit.

NST alone for predicting stillbirth within 1 week of a normal test is 99.8%; for BPP, modified BPP, and CST, it is greater than 99.9%.

Knowledge Practice

Thank you