Reduced FM Flashcards
Normal pattern of FM
First felt around 18-20/40
Any discrete kick, flutter, swish or roll
Nulliparous aware at later gestation
Acquire a regular pattern
Indicate integrity of CNS + MSK systems
Periods of sleep and rest (20-40 mins – rarely exceed 90mins)
Number of movements tends to increases until 32/40
Frequency of FM plateaus until onset of labour
Type of FM may change as pregnancy advances in 3rd trimester
Association between RFM and poor outcomes
- 55% experiencing stillbirth perceived RFM prior
- 11-16% RFMs have IUGR; >40% pregnancies with recurrent RFMs have IUGR
- Inappropriate response to RFM contribute to stillbirth
- No RCTs addressing optimum management of RFM
-RFM associated with increased risk for stillbirth, neonatal death, preterm birth, SGA & IUGR, oligohydramnios, fetomaternal haemorrhage, placental insufficiency, fetal distress, low birth weight, congenital malformation, perinatal brain injury/abnormal neurodevelopment, intrauterine infection, low APGARs and acidemia, hypoglycaemia, emergency delivery, IOL, CS
Limitations of research into association between RFM and still birth
Stillbirth is relatively uncommon and adequately powered studies of different management protocols require large numbers of participants
Study limitations – definition of RFM + outcome ascertainment bias + selection bias
Risk factors for stillbirth
Prev stillbirth Prev PTB w SGA Maternal overweight/obesity (BMI >25) Infrequent ANC AMA >/= 40yo IVF pregnancy Parity of 0 >/=4 Low Papp-A Multiple pregnancy Indian/Pacific ethnicity Smoking/ substance use SES – deprived Pre-existing DM or GDM Gest HTN/Essential HTN APH IUGR/SGA Prev RFM Gest >41/40
Assessment of reduced FM
Aim is to exclude IUD
Then exclude fetal compromise + identify those at risk of adverse outcome while avoiding unnecessary interventions
- Women with RFM should be assessed within 2 hours
- Hx to assess RF for stillbirth + IUGR + congenital malformations
- Abdo palp – uterine tone/tenderness + fetal lie & presentation
- SFH and plotted on CGC
- FH doppler or CTG if >28/40 + maternal HR to ensure different
- BP, temperature + urine dip
- USS: growth, LV, UAPI and MCA within 24 hours if available
- Consider kleihauer / flow cytometry
- LMC review within 1 week
- Education and written PSANZ leaflet re. RFMS
Management of recurrent reduced FM
Case r/v to exclude predisposing causes
Abdominal palpation
SFH measurement and plot on customised chart
FHR auscultation
Kelihauer/flow cytometry
USS as part of the Ix within 24 hrs - growth, liquor and UAPI and MCA
Increase observation - consider regular monitoring by ausculataiotn or CTG
Consultant-led decision regarding IOL at term (with recurrent RFM + N Ix) as no studies to determine whether perinatal morbidity or mortality is altered
RANZCOG Q:
1) i)Define ‘perceived fetal movements’ (1 mark)ii)
Maternal detection of fetal movements- can be kick, swish, roll, flutter.
RANZCOG Q:
Describe the normal maternal perception of fetal movements through pregnancy (4 marks)
- Normally perceived after 18/40 (can be earlier if multiparous or later if nulliparous)
- FM tends to increase until 32/40 and then pattern should remain the same from then until labour
- Typically form a pattern
- In 3rd trimester the type of movement may change
- FM sleep/wake cycles occur average of 20-40 mins, should not exceed 90 mins
- Perception may be improved with change of position e.g. lying on one side and in quiet environment
- often diurnal variation: peak activity afternoon/evening
- transiently affected by EtOH, benzos, opioids
RANZCOG Q:
2) At 28/40 in a routine antenatal setting, what advice do you give women regarding monitoring fetal movements (6 marks)
- Advise that it is good to get to know baby’s normal pattern of movement
- Normal to expect an increase in movement until 32/40 and then should remain the same until delivery
- If she has concerns that baby isn’t moving as frequently as normal then to contact LMC at the time and arrange FHR monitoring
- If perception of FM is reduced it is important to act on it that day and not to ‘wait and see’
- It isn’t normal for baby’s movements to slow down towards the end of pregnancy- if this happens then fetal wellbeing should be checked
- Address any risk factors for still birth and discuss any preventable risks e.g. smoking
- Particular emphasis on FM perception in high risk pregnancies
- If uncertain about FM – lie on lefthand side in quiet room, if not felt >10 movements in 2hrs, come into maternity unit for r/v (although no evidence for what number of FM in a certain time frame is ‘normal’)
- Never delay in seeking advice/assessment for RFM
RANZCOG Q:
3) AT 36/40 a woman with BMI 36 presents to her maternity unity with a strong history of reduced FM
i) Justify organising an USS after a CTG has demonstrated N FHR (4 marks)
Raised BMI + certain Hx of RFM are risk factors for SB – further information regarding fetal wellbeing is indicated
CTG does not give information about medium to long-term fetal wellbeing and may give false reassurance (10% w RFM will have abnormal USS, only 3% will have abnormal CTG)
Measurement of SFH not reliable in obese – therefore cannot clinically assess growth – could have undiagnosed IUGR/SGA
USS will provide biometry of fetus + LV – oligohydramnios associated with placental insufficiency
BPP good negative predictive value but limited positive predictive value
A case-control study from the UK reported that FGR was present in 11% of women with DFM compared with 0% in the control group
Guideline links
RANZCOG 2016 PSANZ: https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/DFM-Clinical-Practice-Guideline-Update_Final_05102016.pdf?ext=.pdf
RCOG 2011: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_57.pdf
What is the “Safer Baby Bundle”? What is its aim? What are the 5 interventions in the bundle?
An Australian Initiative launched in 2019 to reduce stillbirth. Aims to prevent avoidable stillbirths and thus reduce stillbirth by 20%. When a similar initiative was started in the UK, effectively reduced stillbirth by 20%.
Interventions:
- Education and appropriate assessment of RFMs
- Smoking cessation support
- Education around avoiding sleeping on back
- Detection and monitoring of FGR
- Timely delivery in pregnancies at risk for stillbirth
What factors can cause RFMs?
High BMI Low exercise Anterior placenta Anterior fetal position (legs to back) Working ≥8 hours per day Smoking Drugs: MgSo4, corticosteroids, opiates, benzos
What is a recognised cut-off for seeking medical review for RFMs?
<10 movements in 2 hours observation
ACOG
Are kick charts recommended?
PSANZ says no.
No evidence to support a reduction in stillbirth, but significant increase in antenatal assessment and unnecessary investigations.
