Ahmed Walid Anwar Morad, Professor Obstetrics and Gynecology Reduced fetal movements, evidence-based management,

1. Professor of OB/GYN
Benha University
2018
Dr/ Ahmed Walid Anwar Morad

2. • Introduction (Fetal movement)
• Sequence of fetal response to stress.
• Reduced fetal movement (RFM)
• Optimum management of RFM
• Recommendations for management RFM
• Algorithms for management of pregnant women with RFM
• Conclusions.

3. Introduction

4. Fetal movements (FM)
• FM refer to the muscular movements of the
developing baby inside the mother's womb.
• FM may be:
– spontaneous (reflex) or
– elicited in response to noise or touch.
(Thomas, 2018)

5. Fetal Movement: may be
Perceived Non-perceived
-Kick (limb), flutter, & swish movement -Respiratory movement
Movement of Short duration& variable amplitude -Hiccough
-Rolling movement -Thumb suckling
Movement of long duration& high amplitude -Blinking
N.B: Both can be visualized by sonographic examination

6. • Time of FM perception:
– Mean timing: 20 wks gestation
• MP: 16-20 wks gestation
• PG: 20-22 wks gestation
– Peak: 28-34 wks.
– Plateau at 32 wks
– Late 3rd
trimester: no reduction of FM (strong and rolling
movements reduced, while weak movements increase)
• Number at term: up to 30/h ( longest period between
2 movements 50-75 min). (RCOG 2011)
Fetal Movements

7. • Absent FM during fetal sleep→ last 20-40 min
& rarely exceed 90 min.
• Diurnal change: peak fetal activity at afternoon
and evening periods. (i.e., most active between the hours
of 9 am and 2 pm, and 7 pm to 4 am) (RCOG 2011)
Fetal Movement: Rhythms

8. Perception of fetal movement
• Best maternal perception of FM when mother:
– lying down on the left side (↑blood flow to the fetus),
– or sitting with her feet up, and
– concentrating on the movements.
• When she is busy or anxious, she may not
even notice them. (Thomas, 2018)

9. • Subjective methods: Maternal Perception “kick count”
Fetal Movement: Assessment
FK count Period Maternal status
10 Over 12h Normal maternal activity
10 Over 2h Maternal rest and focused
on counting (best after
evening meal(
4 Over 1h
10 -Over 25min between 22-36 wks
gestation - Over 35min ≥ 37wks

11. Objective methods: US assessment
• Mothers perceived only 33-88% US visualized FM.
(Hijazi et al., 2009)
• No studies had evaluated the use of US counting of
FM over long period (Restricted to 20-30 min).
• Results are not correlated strongly to perinatal
outcomes. (Lowery et al., 1997(

12. Subjective methods for FM
counting are recommended
(RCOG, NICE, ACOG)

13. Significance of FM Perception
• FM is one of the 1st
signs of fetal life.
• FM is an indirect indicator of neuromuscular
integrity.
• FM is an indicator of fetal wellbeing. 55% of
pregnant women experiencing stillbirth perceived a RFM prior to
diagnosis. (Efkarpidis et al., 2004)

14. Sequence of fetal response to stress

15. Sequence of fetal response to stress

16. Alarming
Early recognition of RFM makes it is
probable for the clinician to interfere
at a stage when the fetus is still
compensated, and therefore prevent
progression to fetal or neonatal injury
or death. (Heazell et al., 2008)

17. Reduced fetal movement (RFM)

18. Reduced Fetal Movements (RFM)
• Def: no universally agreed definition for RFM.
• More than 10 kicks in 2 hours is usually deemed normal.
• Complicate 40% of pregnancies (single or multiple
episodes). Majority are transient.
• A single episode of decreased fetal activity is not significant
in 70% of mothers. (RCOG 2014, NICE & ACOG GUIDELINES)

19. Factors Associated with RFM
Maternal perception Fetal movement↓↓
Mother ( Busy, anxious, position) Physiological:
Maternal blood
( ↓glucose or ↑ CO2)
-Fetal sleep
Pathology barrier -Impending preterm labor
-P. Previa before 28 wks Pathological:
-Polyhydraminos Oligohydramnios, Placental insufficiency
(30%of cases (IUGR
Fetomaternal hemorrhage
Neuromuscular anomalies
Maternal anemia, hypothyroidism & metabolic D
Intrauterine infections
Iatrogenic: corticosteroids, alcohol &sedatives

20. Outcomes associated with RFM
Fetal Morbidity Mortality Labor
-Congenital anomalies
-Preterm birth
-Cerebral palsy
-Intellectual disability
-Low birth weight
-Hypoglycemia
-Fetal death
-Neonatal death
-↑risk of C-section
- ↑Induction of labor

21. Optimal management of RFM

22. Exclusion of fetal
Death &
Compromise
Identification of
pregnancies at
risk of adverse
pregnancy out
come.
Avoid
unnecessary
interventions.
Optimal management of women with RFM will be done
What is the aim of the optimal management of
women with RFM ?
Through
(RCOG Green-top Guideline 57)

23. Optimal management of women with RFM
Ask Is there maternal perception of reduced fetal movements? (No/ Yes)
-Duration since onset - Pattern (Absent or reduced)
-Episodes (1st
or recurrent)
Assess Are there risk factors for IUGR or Stillbirth?
Consider - multiple consultations for RFM, known FGR, maternal hypertension, diabetes, extremes of
maternal age, primiparity, smoking, obesity, racial/ethnic factors, past obstetric history of FGR or stillbirth)
and issues with access to care
Act - Auscultate fetal heart (hand-held Doppler / Pinnard)
- Assess fetal size
- Perform CTG to assess fetal heart rate in accordance with national guidelines
- If risk factors for FGR/Stillbirth, or persistent RFM perform ultrasound scan for fetal growth, liquor
volume and umbilical artery Doppler within 24 hours.
- Ask about Corticosteroid or other therapies in the last 48 h.
Advise - Transfer results of investigations to the mother.
- Mother should re-attend if further reductions in fetal movements at any time
Act Act upon abnormal results promptly

24. RCOG 2011
Recommendations for management of
pregnant women with decreased fetal
movements

28. • Fetal compromise is likely to be present if CTG shows no FHR
acceleration over 80 min. (Leveno et al., 1983)
• NPV of NST alone in predicting stillbirth within one week of normal
test is 99.8%; for BPP, modified BPP & CST is greater than 99.9%.
(ACOG 2014)

30. Fetal Biophysical
Profile Based
Management
• Available evidence from RCTS does not support the use of BPP as a
test of fetal wellbeing in high-risk pregnancies. (Cochrane Review Lalor
et al., 2008)
• Evidence from uncontrolled observational studies in high-risk
pregnancies shows that BPP has a good NPV for stillbirth. (Dayal et
al., 1999)

31. Role of
Doppler
• No evidence: UtA Doppler has an extra benefit in management
of RFM in normally growing fetus. (ACOG 2014)
• ACOG stats that; UtA Doppler is of value in cases of IUGR
associated RFM and treatment plan should be done in
conjunction with other tests of fetal wellbeing.

32. Testing for Fetomaternal Hemorrhage
• How?
• The Kleihauer–Betke ("KB") test, or
• Flow cytometery
• When? (indications): RFM+
1.Unexplained fetal tachycardia
2.Sinusoidal FHR pattern
3. Fetal hydrops on US with elevated MCA Doppler velocity.
• Significance: Moderate to severe FMH (50-150 Ml) occurs in 4% of
stillbirths and in 0.04% of neonatal. (Eichbaum et al., 2006)

33. Management of women with persistently
RFM
Depends on
1.Gestational age at presentation
2.Presence of recognized risk factors for still birth
3.Whether, it is the1st
or a recurrent episode of
RFM

34. • RFM after 37 wks gestation → induction of labor
when cervix is favorable. (ACOG 2014, Grade C2)

35. Postdate
• AFV assessment should be considered.
• UtA Doppler would not expected to be helpful as
in postdate the problem is related to impaired
placental gas exchange rather than impaired
blood flow. (ACOG 2014)

36. The same as singleton pregnancy with focus
on
Chorionicity
EFW Concordant
and appropriate
for gestational
age
Structural
abnormalities
Management of multiple gestations with RFM
Sings of
•Selective IUGR
•TTTS

37. Algorithms for management
of pregnant women with RFM

41. Conclusions

42. • RFM is an important alarming sign of fetal
compromise or death.
• The initial work up should include detailed
history, confirmation of fetal life & CTG.
• If results are non reassuring or reassuring but
there is persistent RFM other investigations are
required.

43. • US for AC & EFW to exclude IUGR & Oligohydramnios or
structural anomalies.
• Doppler is not beneficial in assessment of RFM in women
with normal fetal growth, only in cases of IUGR.
• Testing for Fetomaternal Hemorrhage should be
considered in certain situations of RFM.
• The available evidence does not support the use of BPP
as a test of fetal wellbeing in high-risk pregnancies.