REDUCED FETAL MOVEMENTS - HOW TO PROCEED BY DR SHASHWAT JANI

Dr. Shashwat Jani.M. S. ( Obs – Gyn )

Diploma in Advance Laparoscopy.

Consultant Assistant Professor,Smt. N.H.L. Municipal Medical College.

Sheth V. S. General Hospital , Ahmedabad.Mobile : 99099 44160.

E-mail : [email protected]

Reduced Fetal Movements

( How To Proceed …??? )

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).

May 3, 2023Dr Shashwat Jani. 99099441602

In 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.

Ahmad saber

National institute of clinical excellence

Prevalence

May 3, 2023 Dr Shashwat Jani. 9909944160 3

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


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.

Types of Fetal movements

Daily fetal movement count(DFMC) Clinically important parameter of fetal wellbeing.

It is the EASIEST & MOST AVAILABLE method for evaluating fetal condition.

Fetal movements should be assessed by subjective maternal perception of fetal movements.


FM is one of the first signs of fetal life. Fetal activity serves as an indirect measure of

CNS integrity and function. Regular FM can, therefore, be regarded as an

expression of fetal well-being . Pregnant women usually sense FM from 18 to

20 weeks of gestation . Some multiparous women may perceive FMs

at 16 weeks of gestation .



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

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.


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+0 weeks of gestation, they should contact their maternity unit.

If women are unsure whether movements are reduced after 28+0 weeks of gestation, they should be advised to lie on their 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 midwife or maternity unit immediately.

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).


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 10 of baby’s movement.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.


Factors associated with RFMMaternal Perception Foetal movementBusy motherAnxietyPlacenta ant.prior 28 wga.Poly hydramniosGlucose& CO2 conc. In

matrnal bloodlying down/sitting/standing

Alcohol,sedatives,CorticosteroidesFetal sleep.Placental insufficiencyIUGRNEURO-MUSCULAR

anomalies(anencephaly )Oligo-hydramnios


Pregnancy factors and outcomes associated with decreased fetal movementsPregnancy factors associated with DFM

Outcomes associated with DFM

Fetal growth restriction

Small for gestational age

Placental insufficiency Oligohydramnios Threatened preterm

labour Fetomaternal

transfusion Intrauterine infections

Congenital malformation Preterm birth Perinatal brain injury Disturbed

neurodevelopment Low birth weight Low Apgar score Hypoglycemia Cesarean section Induction of labour Fetal death Neonatal deathMay 3, 2023 12Dr Shashwat Jani. 9909944160

What Is the Optimal Management of Women with Reduced Fetal Movements (RFM)?

exclude fetal death,

exclude fetal compromise,

and to identify pregnancies at risk of adverse pregnancy outcome

while avoiding unnecessary interventions.May 3, 2023 Dr Shashwat Jani. 9909944160 13


What Should Be Included in the Clinical History?

Time since onset of DFM any fetal movements have been felt – can the DFM be

attributed to being too busy to feel movements? previous episodes of DFM known intrauterine growth restriction (IUGR), placental

insufficiency or congenital malformation maternal factors such as the presence of hypertension,

diabetes, smoking, extremes of age, primi parity, obesity, racial or ethnic risk factors

previous obstetric adverse events.


What Should Be Covered in the Clinical Examination?

The key priority when a woman presents with RFM is to confirm fetal viability. In most cases, a handheld Doppler device will confirm the presence of the fetal heart beat(exclude fetal death)

If the presence of a fetal heart beat is not confirmed, immediate referral for ultrasound scan assessment of fetal cardiac activity must be undertaken.


BP measuerment to exclude pregnancy associated HTN.

Assessment of fetal size with the aim of detecting (SGA) fetuses.

Urine analysis (ptnuria). PET.

Clinical Approaches :


1. physical examination including FHS2. 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.

Fetal movement counting (count-to-ten kickcharts)The use of kickcharts is easy, simple and can be done at home.



What Is the Role of Cardiotocography (CTG)?

After fetal viability has been confirmed and history confirms a decrease in fetal movements, arrangements should be made for the woman to have a cardiotocography to exclude fetal compromise if the pregnancy is over 28+0 weeks of gestation.


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 .


RFM persists despite a normal CTG risk factors for FGR/stillbirth. AC EFW {detect the SGA} Amniotic Fluid Volume Fetal Movements Fetal Anatomic survey Fetal Doppler : more useful test of fetal wellbeing

than CTG or BPP.

What Is the Role of Ultrasound ?

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)


Ahmad saber

A normal BPP score along with a reactive NST is an indication of fetal well-being. The BPP provides 2 points each for fetal breathing, movement, and fetal tone in 30 minutes and 2 points for normal amniotic fluid volume. There has been debate regarding the ultrasound definition of oligohydramnios and whether a single deepest vertical pocket of fluid of ≤2 cm, as recommended in the Practice Bulletin, is more acceptable as a predictor than an amniotic fluid index (AFI) of <5 cm.


Doppler Velocimetry

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. 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


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.

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 ).

RFM before 24 wgaPresence 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 .


RFM (24-28 wga)

Presence of a fetal heartbeat should be confirmed by auscultation with a Doppler handheld device.


•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 limited use in the assessment of reduced FM.

BPP scoring has not been shown to be of benefit.

As Previously Said ,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%.May 3, 2023 Dr Shashwat Jani. 9909944160 34

THANK YOU…!!!


REDUCED FETAL MOVEMENTS - HOW TO PROCEED BY DR SHASHWAT JANI

Health & Medicine

Transcript of REDUCED FETAL MOVEMENTS - HOW TO PROCEED BY DR SHASHWAT JANI