Decreased foetal movements
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Decreased foetal movements

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Decreased fetal movements

Decreased fetal movements

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Decreased foetal movements Decreased foetal movements Presentation Transcript

  • 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. Aboubakr Elnashar
  • 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