Reduced foetal movements

Question 1

Define RFM. How many movements should occur according to RCOG?

Answer 1

Here RFM is defined as maternal perception of reduced or absent fetal movements.

RCOG considers <10 movements within 2 hours (in pregnancies >28 weeks gestation) an indication for further assessment.

But there is no set number of normal movements. Usually a fetus will have its own pattern of movements that the mother should be advised to get to know.

Question 2

Define recurrent RFM.

Answer 2

2 or more episodes of RFM in a 3 week period after 26/40

Question 3

Why can RFM be indicative of fetal compromise?

Answer 3

Adaptive mechanism to reduce oxygen consumption

Intrauterine death is often preceded by RFM for _>_24hrs according to research

40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis.

Question 4

When do fetal movements start and how do they change until labour?

Answer 4

They start between 18-20 weeks gestation. Multips may experience foetal movements at 16-18 weeks. (The first onset of FM is known as quickening.)

Fetal movements increase until 32 weeks gestation at which point the frequency of movement tends to plateau.

Towards the end of pregnancy, fetal movements should not reduce.

Question 5

What gestation should fetal movements be established by?

Answer 5

Fetal movements should be established by 24 weeks gestation - if not then refer to obstetrician

Question 6

What are the risk factors for RFM (both perceptive and actual).

Answer 6

Perceptive:

• Posture - there can be positional changes in fetal movement awareness; more prominent during lying down and less when sitting and standing
• Distraction - if a woman is busy or concentrating on something else, these can be less prominent

Actual:

Maternal:

• Medication - both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause RFM
• Body habitus - obese patients are less likely to feel prominent fetal movements

Fetal:

• Fetal position - anterior fetal position means movements are less noticeable
• Fetal size - up to 29% of women presenting with RFM have a SGA fetus

Placental/other:

• Amniotic fluid volume - both oligohydramnios and polyhydramnios can cause reduction in fetal movements
• Placental position - with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements

Question 7

How do you diagnose RFM?

Answer 7

Usually based solely on history/mother’s perception

Although can be assessed with handheld Doppler or US

Question 8

What else would you like to know if a patient has come in with RF

Answer 8

• Risk factors for SGA/IUGR
• Maternal obs - BP, HR, temperature, urinalysis
• Abdominal palpation
• SFH (plotted)
• FHR

Question 9

What is the management of RFM <24 weeks?

Answer 9

If below 24 weeks gestation, and fetal movements have previously been felt: a handheld Doppler should be used.

If fetal movements have not yet been felt by 24 weeks: onward referral should be made to a maternal fetal medicine unit.

Question 10

What it the management of RFM between 24-28 weeks?

Answer 10

If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat.

Question 11

What is the management of RFM >28 weeks gestation?

Answer 11

If past 28 weeks gestation:

1. Initially, handheld Doppler to confirm FHR.
   
   • If no FHR detectable –> immediate USS.
2. If FHR present –> CTG for at least 20 minutes to monitor FHR to excluding fetal compromise.
3. If concern remains, despite normal CTG –> urgent (<24hr) USS
   
   • USS assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement

Question 12

What is advised with RFM >39 weeks?

Answer 12

If the mother has RFM at or after 39 weeks, IOL could be offered if vaginal delivery is appropriate.

Question 13

What is the management of recurrent RFM?

Answer 13

Serial USS: - 3 weekly growth scans and Doppler if ongoing RFM

Advise IOL after 39 weeks + discussion with senior obstetrician

Question 14

What is the management if a mother presents with RFM >39 weeks, but has a normal CTG and declines IOL?

Answer 14

• Urgent (<24hr) USS
• Offer cervical assessment +/- sweep
• If scan normal offer - twice weekly CTG and weekly USS (LV and Doppler)
• Offer IOL at any time if FM remains reduced

Question 15

What are 4 risk factors for adverse outcomes with RFM?

Answer 15

• Cigarette smoking
• Hx of SGA/stillbirth
• PMH e.g. diabetes, HTN
• Recurrent RFM (_>_2)
• SFH <10th centile
• Raised uterine artery PI in 2nd trimester

Question 16

What is the prognosis with RFM?

Answer 16

In 70% of pregnancies with a single episode of RFM, there is no onward complication.