Prof. Aboubakr Elnashar

Benha university, Egypt

Decreased fetal movements

Aboubakr Elnashar

Fetal movements

Kick

wave

swish (his) or

roll

First felt by the mother between 18-20 w

and rapidly acquire a regular pattern.

an indication of the integrity of the central nervous

system and musculoskeletal systems.

Aboubakr Elnashar

Women perceive

most movement when lying down,

fewer when sitting and

least while standing.

Busy pregnant women for example who are not

concentrating on fetal activity often report a

misperception of RFM.

Aboubakr Elnashar

A significant reduction or sudden change in

movement is an important clinical sign.

Mothers may feel anxious if there is a decrease in

fetal movement however there are often reasonable

reasons for this.

The fetus may be in a state of sleep or the mother

may be too busy to focus on fetal activity.

Aboubakr Elnashar

Two common ways to record fetal kicks.

1. Cardiff Count to Ten Method.

This is an 8 to 12 hour period that records at least

ten of baby’s movement.

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2. One to Two Hours Method.

This is done while lying down on your left side for 30

minutes after eating without distractions. After an

evening meal might be ideal time to record. Baby

should move 10 times within an hour to 75 minutes.

Aboubakr Elnashar

Aboubakr Elnashar

although fetal movements tend to plateau at 32

w, there is no reduction in the frequency of fetal

movements in the late third trimester.

Aboubakr Elnashar

Should fetal movements be counted routinely in a

formal manner?

There is insufficient evidence to recommend

formal fetal movement counting using specified

alarm limits.

Women should be advised to be aware of their

baby’s individual pattern of movements.

If they are concerned about a reduction in or

cessation of fetal movements after 28+0weeks of

gestation, they should contact their doctor.

and should not wait until the next day for

assessment of fetal wellbeing.

Aboubakr Elnashar

After 28 w if a woman is unsure whether

movements are reduced she is advised to lie on her

left side and focus on fetal movement for 2 hours.

If she does not feel 10 or more discrete movements

then she should contact her doctor immediately.

If a clinician is presented with a woman reporting

RFM, a relevant history should be taken to assess the

woman’s risk factors for stillbirth and FGR

Aboubakr Elnashar

a handheld Doppler device can be used to confirm

the presence of the fetal heart beat.

If the presence of a fetal beat is not confirmed then

immediate ultrasound scan is needed to assess fetal

cardiac activity.

CTG monitoring

should be used if the pregnancy is over 28 w and

there is still RFM after fetal viability has been

confirmed.

for at least 20 minutes

Aboubakr Elnashar

Ultrasound scanning

can also be used as part of the preliminary

investigations of a woman reporting RFM if the

perception of RFM persists despite a normal CTG.

Aboubakr Elnashar

Women should be reassured that 70%of

pregnancies with a single episode of RFM are

uncomplicated.

There are no data to support formal fetal

movement counting (kick charts) after women have

perceived RFM in those who have normal

investigations.

Women who have normal investigations after one

presentation with RFM should be advised to contact

doctor if they have another episode of RFM.

Aboubakr Elnashar

Women who report RFM on two or more

occasions are at an increased risk of a poorer

perinatal outcome including an increased risk of

stillbirth, fetal growth restriction and/or preterm

birth.

Aboubakr Elnashar

What is the optimal management of RFM before

24+0 weeks of gestation?

Presence of a fetal heartbeat should be confirmed

by auscultation with a Doppler handheld device.

If fetal movements have never been felt by 24

weeks of gestation, referral to a specialist fetal

medicine centre should be considered to look for

evidence of fetal neuromuscular conditions

Aboubakr Elnashar

What is the optimal management of RFM between

24+0 and 28+0 weeks of gestation?

Presence of a fetal heartbeat should be confirmed

by auscultation with a Doppler handheld device.

Aboubakr Elnashar

RCOG, 20011 1. History

Risk factors for stillbirth and FGR.

Sudden change in fetal activity

2. Auscultate the fetal heart

Doppler device to exclude fetal death.

3. CTG

{exclude fetal compromise}

Aboubakr Elnashar

4. US

RFM persists despite a normal CTG

risk factors for FGR/stillbirth.

AC

EFW {detect the SGA}

AFV

Fetal morphology

Doppler

Aboubakr Elnashar

US/2w: HC and AC.

AC

most sensitive predictor of fetal growth.

increases 2cm/2w after 24 w in the average fetus.

measurements are plotted on centile charts.

fall in the growth velocity of AC indicates IUGR.

AC used to assess fetal growth

Aboubakr Elnashar

Aboubakr Elnashar

Doppler

more useful test of fetal wellbeing than CTG or FBP.

Umbilical arterial blood flow becomes abnormal when

there is placental insufficiency.

Middle cerebral artery

Aboubakr Elnashar

a. Umbilical artery Doppler

Idea:

Umbilical Arterial Flow is normally low resistance.

In hypoxic states:

relative placental hypoxia:

reactive VC of umbilical artery tributaries:

higher resistance:

relative decrease in diastolic flow detectable by

Doppler.

Aboubakr Elnashar

Doppler indices

Aboubakr Elnashar

•Resistance index:

Best ability to predict abnormal outcomes

(RCOG,2002 Evidence level II)

Normal pregnancy: {progressive increase in end-diastolic velocity

{growth& dilatation of the umbilical circulation}:

Resistance index falls.

Fetal growth restriction and/or PET: > 0.72 is outside the normal limits from 26 w.

Aboubakr Elnashar

•S/D should be <3.

small increases in S/D= 3-5: chronic intrauterine

disease manifest by IUGR.

Not strictly useful:

{1. low sensitivity.

2. Gestation age dependent}.

•Diastolic flow is absent or reversed:

Fetal distress is almost certain:

Delivery may be indicated.

Aboubakr Elnashar

Normal

Absent

Reversed

Aboubakr Elnashar

5. ± BPP:

± a role in high risk pregnancies:

Systematic review of RCT:

does not support its use as a test of fetal wellbeing

Uncontrolled observational studies:

BBP has good NPV

Fetal death is rare with normal BPP.

Aboubakr Elnashar

Thank you Aboubakr Elnashar