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Reduced fetal movements

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Reduced fetal movements

Post by mandible on Fri Mar 05, 2010 2:47 am

Introduction
A reduction of fetal movements causes concern
and anxiety, both for the mother and obstetrician,
and is a common reason for referral to hospital.
Decreased fetal movements affect 5–15% of
pregnancies;1,2 85% of these women are concerned
about fetal wellbeing and 53% are afraid that the
baby may die.3 The perception of reduced
movements by the mother is highly subjective and
any concerns should be taken seriously.
A number of conditions are associated with
reduced fetal movements (Box 1). Some reports
suggest that 11–29% of women presenting with
reduced fetal movements carry a small-forgestational-
age fetus below the 10th centile.4,5
Sergent et al.1 retrospectively reviewed 160 women
complaining of reduced fetal movements and
reported that 4.3% of fetuses in their cohort had
severe growth restriction. The clinical significance
of reduced fetal movements may be unclear until
pathological underlying causes have been
excluded. There is a wide variety of investigations
available, some of which have not been proven to
be useful in the detection of a fetus at risk. This
can lead to unnecessary investigation of otherwise
uncomplicated pregnancies, resulting in maternal
anxiety, inconvenience and increased obstetric
intervention that carries a risk.
The Confidential Enquiry into Stillbirths and
Deaths in Infancy (CESDI), under the umbrella of
the National Institute for Health and Clinical
Excellence (NICE) collected and analysed data of
deaths between 20 weeks of gestation and 1 year of
life. In their eighth annual report6 they reviewed
422 stillbirths and found that 45% of them were
associated with suboptimal care; 69 cases (16.4%)
were related to fetal movements.Concerns were
raised over the failure of (i) the mothers to report
reduced fetal movements, (ii) the clinician to
explain the importance of changes in fetal
movements to women and (iii) professionals to
act appropriately when decreased fetal movements
occurred.
We review the clinical significance, investigation
and management of reduced fetal movements in
the low risk pregnant population at 24 weeks of
gestation.We aim to provide guidance to the
clinician in the critical assessment of these
pregnancies to ensure high quality antepartum
and intrapartum care, safe delivery and good
perinatal outcomes.
Physiology
Mothers usually report fetal movements from
~20 weeks of gestation,with a peak at 28–34
weeks.7Multiparous women may notice
movements earlier (16–20 weeks) than
primiparous women (20–22 weeks).8 Fetal
movements follow a circadian pattern and are an
expression of fetal wellbeing. It has been suggested
that a gradual decline during the third trimester is
due to improved fetal coordination and reduced
amniotic fluid volume, coupled with increased
fetal size.8 Some ultrasound studies on fetal
behaviour show that fetal movements do not
become less frequent in the third trimester but
that the movements change as coordination
improves and a cycle becomes established.
Decreased fetal movements are regarded as a
marker for suboptimal intrauterine conditions.
The fetus responds to chronic hypoxia by
conserving energy and the subsequent reduction
of fetal movements is an adaptive mechanism to
reduce oxygen consumption. It is recognised that
intrauterine death is preceded by cessation of fetal
movements for 24 hours.9
Definition
There is a lack of consensus on how many
movements are regarded as normal or abnormal.
Fetal movements in a healthy fetus vary from
4–100 per hour.7Maternal perception of fetal
movements ranges from 4–94% of actual
movements seen on concurrent ultrasound
scanning.2 The positive predictive value of the
maternal perception of reduced fetal movements
for fetal compromise is low: 2–7%.10Heazell et al.2
have confirmed that there is little agreement
among midwives and obstetricians on the
definition of reduced fetal movements.
Definitions ranged from 10 movements in
2 hours11 to 12 and 24 hours. In this study, the
maternal perception of decreased movements for
24 hours gained the greatest acceptance and the
authors suggest that this is the most appropriate
method to identify reduced fetal movements.2,12
Reports on published definitions found that most
midwives and obstetricians favoured the
Box 1
Conditions associated with
maternal perception of reduced
fetal movements1,4,5,10,14
• Intrauterine death
• Fetal sleep
• Congenital fetal malformation (i.e. neurological,
musculoskeletal)
• Fetal anaemia or hydrops
• Acute or chronic hypoxia from placental insufficiency
leading to:
• reduced amniotic fluid volume (oligohydramnios); or
• fetal growth restriction
• Polyhydramnios
• Increased maternal weight
• Anterior placental localisation
• Maternal sedating drugs that cross the placenta (alcohol,
benzodiazepines, barbiturates, methadone, narcotics)
• Smoking
• Administration of corticosteroids for enhancement of fetal
lung maturity
• A busy mother who is not concentrating on fetal activity
• Maternal anaemia, metabolic disorders, hypothyroidism
• Acute or chronic fetomaternal haemorrhage
definition of 10 movements in 12 hours.2 This
concurs with the 1976 definition of Pearson and
Weaver,who developed the ‘count-to-ten’ kick
chart.Using this kick chart,women record their
first 10 movements of each day; if this is not
reached after 12 hours, they are advised to seek
further assessment.2,8,13
There is no evidence that any formal definition of
reduced fetal movements is of greater value than
subjective maternal perception in the detection of
fetal compromise. Therefore maternal perception
of reduction or change of fetal movements should
be considered clinically important.
Current practice
A wide range of investigations are performed for
the complaint of reduced fetal movements.
Investigations considered include symphyseal–
fundal height measurement (SFH),
cardiotocography (CTG), biophysical profiling,
estimation of fetal weight (EFW), liquor
assessment, umbilical artery Doppler velocimetry,
formal fetal movement counting (kick charts) and
vaginal examination. These investigations may
lead to interventions such as membrane sweeping
or induction of labour.
An anonymous online questionnaire performed
among 101 obstetricians in the Republic of
Ireland14 found that there was a lack of guidance in
the management of reduced fetal movements,
with only one-third of clinicians having a clinical
practice guideline in their institution. Results of
this study also showed that CTG was the most
favoured method of assessing fetal wellbeing
(93%), followed by the use of kick charts (65%),
while 53% of obstetricians assessed the fetus
with a biophysical profile and 52% performed
ultrasound scanning to assess liquor volume. Only
33% measured the SFH and 22% assessed
umbilical artery Doppler velocimetry. In the same
study, fetal biometry was performed by 19% of
obstetricians and the same percentage offered
vaginal examination to assess favourability.A
minority recommended admission (3%) or
induction of labour (4%).
Heazell et al.2 reviewed the current practice in the
UK, where most obstetricians (70%) had
institutional guidelines available. In contrast with
the Irish study they found that only 3% of
midwives and 5% of obstetricians were using kick
charts in their routine antenatal care. The
majority of respondents in this questionnaire
performed CTG and SFH measurement. Further
evaluation, including fetal biometry, umbilical
artery Doppler or full biophysical profiling, was
based on the results of CTG, SFH measurement
and clinical situation. The most frequently
reported management option for both midwives
and obstetricians was to consider admission and
delivery.
Which investigations are of
use in assessing reduced fetal
movements?
Basic assessment
Assessment of every woman who presents with
reduced fetal movements at 24 weeks of
gestation should include:
• a detailed history of the presenting complaint
• assessment of risk factors in this or the previous
pregnancy
• maternal blood pressure, pulse rate,
temperature reading and urinalysis
• auscultation of the fetal heart or CTG for
15–20 minutes15
• clinical examination, including abdominal
palpation and measurement of SFH.
Symphyseal–fundal height measurement
A clinical opinion about the size of the baby,
including abdominal palpation and the
measurement of SFH, should be part of every
assessment and is helpful in the management of
reduced fetal movements. Despite the fact that
abdominal palpation only detects 30% of small
fetuses,16 SFH measurement has a positive
predictive value of 60% and a negative predictive
value of 76.8%.4 This implies that if the SFH is
within normal limits, fetal growth restriction or
placental insufficiency are unlikely to be present.
Serial SFH measurements have an increased
specificity and sensitivity,4,17 as the trend in growth
is of more value than a single measurement in
predicting poor fetal outcome.16 As 50–70% of
fetuses with a birthweight below the 10th centile
are constitutionally small,16 Gardosi et al.18
suggested that plotting measurements on
customised SFH charts adjusted for maternal
weight, height, parity and ethnic group results in
increased detection of growth restriction
and fewer hospital referrals. The mean SFH at
36 weeks of gestation on drawn charts is 34–34.8 cm
(Calvert, Quaranta,Nottingham, UK),which
implies that using height in centimetres as an
indirect measure of gestational age would lead to
significant overdiagnosis of small-for-gestationalage
fetuses.
We conclude that, in the absence of anything
better, the measurement of SFH and its plotting
on customised charts is recommended in selecting
which women should undergo further
investigation.4
Non-stress test: cardiotocography
Cardiotocography is widely accepted as the
primary method of antenatal fetal monitoring to
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©️ 2009 Royal College of Obstetricians and Gynaecologists
assess the current status of the fetus,19 but its use is
particularly difficult and cannot be recommended
before 28 weeks of gestation.15 Between 24–28 weeks
of gestation, auscultation of the fetal heart may be
sufficient and CTG can be performed. A reactive
CTG is defined by two accelerations exceeding
15 beats per minute sustained for at least
15 seconds in a 20-minute period.19 Loss of
variability is associated with fetal sleep, sedation
or central nervous system depression, including
fetal acidosis.15 The absence of accelerations or the
appearance of decelerations along with a history
of reduced fetal movements may indicate fetal
hypoxia20 and is associated with fetal demise and
caesarean section delivery.21 Cardiotocography is
useful in the detection of acute hypoxia but is a
poor test for chronic hypoxia.4 Large-scale studies
show that CTG does not reduce rates of stillbirth
or perinatal morbidity.19Nevertheless, a reactive
CTG is significantly more likely to be followed by a
normal delivery and a normal perinatal condition
than non-reactive tests.22
Computerised CTG is used in many units in the
UK and is thought to be more reliable, objective
and accurate than visual inspection.23 Fetal heart
rate measurements are automatically calculated
by computer and compared to reference values
(centiles) according to gestation. Its use
improves discrimination between normal and
questionable records in gestations ranging from
24–42 weeks.23
Amniotic fluid index or deepest vertical
pool assessment
There are three ways to assess liquor volume: these
include the amniotic fluid index (AFI), deepest
vertical pool (DVP) and subjective ‘eyeball’
assessment. In 1980 Manning and Platt24 proposed
the measurement of the DVP for assessment of
fetal wellbeing. In 1987 this was revised by Phelan,
who suggested that four pockets are better than
one.25 Some studies show that the AFI has poor
correlation with actual fluid volume and suggest
that measuring the DVP is slightly more reliable in
assessing liquor volume.26 Figure 1 shows the
reference values for the AFI according to gestation.
An AFI 5 cm is associated with adverse
outcome.27
In general, if reduced liquor volume is detected,
further evaluation of the fetus is recommended,
given the association of oligohydramnios with
placental insufficiency, premature rupture of
membranes and fetal renal abnormality. Lin
et al.28 found that oligohydramnios was present
in 29% of growth restricted fetuses. An AFI or
DVP measurement is also recommended in
postdates pregnancies. The 5th centile for the
AFI at 37 weeks is 8.8 cm (Moore) or 6.9 cm
(Magann).
Fetal biometry
A Cochrane review29 showed that routine
ultrasound after 24 weeks of gestation in low risk
pregnancy does not improve perinatal outcome.
Nevertheless, if reduced fetal movements are
reported, fetal ultrasound assessment for
abdominal circumference or EFW is indicated in
cases where SFH measurement suggests a smallfor-
gestational-age fetus.More than 40 formulae
to estimate fetal weight exist and numerous
growth curves have been designed to plot these
serial measurements. In late gestation, a single
abdominal circumference measurement is more
accurate than head measurement.Abdominal
circumference measurements have reported
sensitivities of 72.9–94.5% and specificities of
50.6–83.3% ; EFW has sensitivities of
33.3–89.2% and specificities of 53.7–90.9%.16
Abdominal circumference and EFW
measurements are better at predicting small-forgestational-
age fetuses below the 10th centile
than large-for-gestational-age fetuses.16 Similar
to SFH, serial measurements, ideally 2 weeks
apart, are more accurate than single estimates in
the prediction of growth restriction.16 As with
SFH measurements, they can be plotted on
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Review 2009;11:245–251 The Obstetrician & Gynaecologist
©️ 2009 Royal College of Obstetricians and Gynaecologists
Figure 1
Amniotic fluid index and deepest
vertical pool (maximum vertical
pocket) centile curves.37
(Copyright 2000, with permission
from Elsevier)
customised centile charts to increase sensitivity
and specificity.
In conclusion, fetal biometry assessment
should be performed if SFH suggests a smallfor-
gestational-age fetus and if there is
suspected oligohydramnios. It should also be
considered in second and subsequent
presentations or if neither the pregnant woman
nor the clinician are reassured by the initial
assessment.
Which investigations are
of limited value in the
management of reduced
fetal movements in the low
risk population?
Umbilical artery Doppler velocimetry
This is of benefit in high risk pregnancies in
reducing perinatal mortality30 but has not been
shown to be of value as a screening test for
detecting fetal compromise in the general
obstetric population.1,30 Korszun et al.31 suggested
that adding umbilical artery and uterine artery
Doppler velocimetry to conventional CTG in the
assessment of reduced fetal movements may be
reassuring for the managing clinician. Dubiel
et al.32 compared CTG with umbilical artery
Doppler in the assessment of 599 women with
low risk pregnancies complaining of reduced
fetal movements; both were normal in 93% of
women. The overall perinatal mortality in their
study was 3.8%. They found that the CTG
seemed to be a better predictor of mortality and
infant handicap than Doppler velocimetry.
Sergent et al.1 reported only one highly
pathological umbilical artery Doppler in their
retrospective review of 160 pregnancies affected
by reduced fetal movements.
We conclude that umbilical artery Doppler is of
limited use in the assessment of reduced fetal
movements.
Fetal vibroacoustic stimulation testing
This test may elicit fetal heart rate accelerations
and increased fetal body movements and may
reduce the incidence of non-reassuring CTG and
subsequent obstetric intervention.13 A Cochrane
review by Tan and Smyth33 examining 4838
participants confirmed that fetal vibroacoustic
stimulation reduced the incidence of nonreactive
CTGs (relative risk [RR] 0.62; 95%
CI 0.52–0.74) and reduced the overall mean
testing time. The authors concluded that further
randomised trials were needed to determine the
optimal intensity, frequency, duration and
position of vibroacoustic stimulation and to
evaluate the efficacy, predictive reliability, safety
and perinatal outcome.
Which investigations are of
no value in the management
of reduced fetal movements in
the low risk population?
Fetal movement counting (kick charts)
Formal fetal movement counting was first
suggested in 1973 by Sadovsky and Yaffe.9 Sadovsky
instructed women to count movements three times
a day after meals.Counting movements using a kick
chart (Cardiff ‘count-to-ten’ chart)13 is now more
frequently employed.We have recently shown that
65% of obstetricians working in the Republic of
Ireland handed out kick charts to women
presenting with reduced fetal movements.14 The use
of kick charts is easy, simple and can be done at
home.However, in a large study of 68 000 women,
Grant et al.8 were unable to demonstrate a
reduction in the incidence of antepartum fetal
death using formal movement counting.They
reported that formal fetal movement counting by
1250 women prevented, at best, one unexplained
antepartum late fetal death and that a random
adverse effect was just as likely.8 The use of kick
charts increased attendences for assessment of fetal
wellbeing (15.5% versus 9.8%) and was associated
with a 2.6-fold increased obstetric intervention
rate.4,11Another report demonstrated higher
intervention rates (32% versus 21%) and caesarean
section rates (24% versus 14%).5
In October 2003, NICE and the National
Collaborating Centre for Women’s and Children’s
Health published their guideline on the routine
antenatal care of healthy pregnant women. They
concluded that routine formal fetal movements
counting should not be offered. This statement
was renewed in their 2008 guideline.34 In contrast,
the American College of Obstetricians and
Gynecologists supports formal movement
counting. In their bulletin on antepartum fetal
surveillance,21 they instruct the woman to count
ten movements, preferably after a meal, and to
write down the hours this takes. They neither
provide a definition of reduced fetal movements
nor advise a time-frame in which these
movements should be achieved,which reflects the
dilemma and controversy of the definition and
management of reduced fetal movements.
Although formal fetal movement counting is not
recommended,women should be educated about
the physiology of fetal movements and the need to
seek assessment if movements change, decrease or
cease, given the association with stillbirth and the
identification of these concerns in the recent
CESDI report.6
Biophysical profiling
This combines CTG with ultrasound
assessment of fetal movements, fetal tone, fetal
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©️ 2009 Royal College of Obstetricians and Gynaecologists
breathing movements and AFI. A score of 8–10
confirms fetal wellbeing. Lalor et al.35 report
that the available evidence from randomised
controlled trials does not support the use of
the biophysical profile as a test of fetal
wellbeing in high risk pregnancy.35 There was
no significant difference between the groups
with regard to perinatal deaths (RR 1.33; 95%
CI 0.60–2.98). Combined data from two high
quality trials36 suggest an increased risk of
caesarean section in the biophysical profile
group (RR 1.60; 95% CI 1.05–2.44; n  280;
interaction test: P  0.03).
Second and subsequent
presentations
Between 3–5% of women will re-present with
reduced fetal movements.5 If the perception of
reduced fetal movements persists, consideration
should be given to other causes such as fetal
structural anomalies (4.3%),1 anaemia or
fetomaternal haemorrhage. There is little evidence
about how to manage these pregnancies.
A practical approach would be to perform
ultrasound assessment to rule out a small-forgestational-
age fetus, structural anomalies and
oligo-or polyhydramnios and invite the woman for
daily CTG until mother and clinician are reassured.
A blood test should ultimately be considered, to
look for maternal metabolic disorders or
fetomaternal haemorrhage. Smoking should be
discouraged. If concerns persist in later gestation,
induction of labour or delivery can be considered.
Conclusion
Every mother who presents with concern about
reduced fetal movements should be taken seriously.
The initial assessment should include a detailed
history of the presenting complaint, maternal
observations, abdominal palpation,SFH
measurement and CTG. If this is reassuring for the
mother and clinician, no further evaluation is
needed.Amniotic fluid assessment should be added
in postdates pregnancies. If the mother re-presents
or initial assessment is not reassuring, further tests
should be performed; these include amniotic fluid
assessment and EFW.Kick charts are of no value
and should, therefore, not be given out to women.
Biophysical profiling has not been shown to be of
benefit; umbilical artery Doppler velocimetry and
vibroacoustic stimulation are of limited use in the
assessment of reduced fetal movements.
We have described significant variation in clinical
routines reported in the management of reduced
fetal movements (Figure 2),which do not correlate
well with current information given to pregnant
women, the available literature, or with expert
guidelines. This leads to clinical uncertainty for
both pregnant women and healthcare
professionals and may put patient safety at risk.
This paper is based on current evidence and
experience and reflects good clinical practice. For
the development of evidence-based guidelines we
suggest further randomised controlled trials to assess
the different suggested management plans. This may
be difficult given current established clinical practice
and ethical difficulties surrounding trials in
pregnancy.The development and circulation of
good practice guidelines by expert groups would be
helpful.We look forward to the Green-top Guideline
on the management of reduced fetal movements
which is being formulated by the RCOG.
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250
Review 2009;11:245–251 The Obstetrician & Gynaecologist
©️ 2009 Royal College of Obstetricians and Gynaecologists
First presentation
Detailed history
Risk factors
Maternal observations
Auscultation/ CTG
Abdominal palpation
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Discharge home
SGA ?
Oligo?
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AFI/ DVP
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Reduced fetal movements: flow
chart, excluding kick charts and
biophysical profile (not
recommended)
BMI  body mass index;
BPP biophysical profile;
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