Number of episodes of reduced fetal movement at term: association with adverse perinatal outcome

Maternal perception of decreased fetal movements is independent of infant size

OBJECTIVE

Fetal movements are often used as a surrogate for fetal wellbeing. Previous research suggests a link between maternal perception of decreased fetal movements (DFM) and small-for-gestational-age (SGA) infants. The aim of this study was to investigate the association between maternal presentation with DFM and birth-weight centile categories at a large Australian perinatal center.

METHODS

This was a retrospective study of non-anomalous singleton infants born at ≥ 28 + 0 weeks' gestation between January 2016 and October 2020 at the Mater Mothers' Hospital in Brisbane, Australia. The primary outcome was the rate of DFM according to birth-weight centile category. Maternal demographic characteristics included age, body mass index, ethnicity, parity, medical conditions and previous stillbirth. The association between DFM and birth-weight centile was evaluated using adjusted multinomial regression models. Robust standard errors were used to account for clustering at the patient level. Wald tests and Akaike's and Bayesian information criteria were used to evaluate models.

RESULTS

Over the 5-year study period, 45 042 women met the inclusion criteria. Of these, 6690 (14.9%) women presented with DFM. Of the DFM cohort, 80.9% (5411/6690) had only one presentation with DFM, and 19.1% (1279/6690) had two or more presentations. The overall stillbirth rate was similar in women with DFM (0.1% (8/6690)) and those without DFM (0.1% (50/38 352)). There was no association between DFM (either single or multiple) and infant birth-weight centile.

CONCLUSIONS

This study suggests that presentation with DFM is not associated with infant size. Clinicians should consider additional risk factors and the overall clinical context when deciding appropriate management. DFM is not necessarily an indication for an immediate or urgent ultrasound scan to assess fetal size. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Poor coverage of quality-adjusted antenatal care services: a population-level assessment by visit and source of antenatal care services in Bihar state of India

Background

Despite the evidence on the poor quality of antenatal care (ANC) services, significant gap remains in the understanding of quality-adjusted coverage at the population-level for each ANC visit and by the source of ANC services, and in equity in this coverage.

Methods

All births between July 2020 and June 2021 were listed from 261,124 households (91.5% participation) representative of the Bihar state. Mothers of all stillbirths and neonatal deaths, and of 25% random sample of livebirths who survived the neonatal period provided data on each ANC visit up to a maximum of first 4 ANC visits, including the source of ANC services and the services received (weight measurement, blood pressure checked, abdomen checked, urine sample taken, and blood sample taken). An ANC visit was deemed of quality if all of these services were received in that visit. We report the coverage of quality-adjusted ANC services (Q-ANC) for ANC visits 1-4 disaggregated by source of ANC services and wealth index (WI). Weighted proportions are reported to take into account the sampling design.

Findings

A total of 30,412 births were reported by 29,517 women, and 7270 (82.1%) of the 8853 eligible women participated. Overall, 19,950 unique ANC visits from 6929 women were available for analysis, of which 41.7%, 13.8% and 44.5% were at Village Health and Nutrition Day (VNHD), public facility, and with a private provider, respectively. A total of 4409 (65.3%) of the 1st ANC visits were undertaken at VHND, with the proportion of private provider ANC visits increasing significantly from ANC visit 1 to ANC visit 4 (p < 0.001). Q-ANC coverage considering all ANC visits was 20.9% (95% CI 20.7-21.2); and was 0.9% (95% CI 0.8-1.0), 29.9% (95% CI 29.2-30.7) and 36.9% (95% CI 36.5-37.4) for ANC visits in VHND, public facilities, and with private provider, respectively. Q-ANC coverage in the public facility was significantly lower in the 4th ANC visit (25.1%; 95% CI 23.4-26.9) as compared with visits 1 to 3, whereas it was the highest for 1st ANC visit with private provider (50.2%; 95% CI 49.2-51.1) and then dropped for visits 2 to 4. Irrespective of the source of ANC services, Q-ANC coverage increased significantly with increasing WI quartile for ANC visits 1 and 2, with WI quartile 3 women having significantly less coverage for ANC visit 3 compared to the rest, and no significant difference seen in the coverage of ANC 4 visit. Varied pattern of Q-ANC coverage by WI for each ANC visit was seen for public facility and private provider visits.

Interpretation

With only 2 of 10 ANC visits deemed of adequate quality, sustainable delivery of quality ANC services are needed for every pregnant woman through-out the pregnancy irrespective of gestation period, number of ANC visit, and source of ANC services.

Funding

The funding was provided by the India office of the Bill & Melinda Gates Foundation, USA.

Decreased fetal movements: Report from the International Stillbirth Alliance conference workshop

Maternal reports of decreased fetal movement (DFM) are a common reason to present to maternity care and are associated with stillbirth and other adverse outcomes. Promoting awareness of fetal movements and prompt assessment of DFM has been recommended to reduce stillbirths. However, evidence to guide clinical management of such presentations is limited. Educational approaches to increasing awareness of fetal movements in pregnant women and maternity care providers with the aim of reducing stillbirths have recently been evaluated in a several large clinical trials internationally. The International Stillbirth Alliance Virtual Conference in Sydney 2021 provided an opportunity for international experts in fetal movements to share reports on the findings of fetal movement awareness trials, consider evidence for biological mechanisms linking DFM and fetal death, appraise approaches to clinical assessment of DFM, and highlight research priorities in this area. Following this workshop summaries of the sessions prepared by the authors provide an overview of understandings of fetal movements in maternity care at the current time and highlights future directions in fetal movement research.

Assessment of quality of antenatal care services in public sector facilities in India

OBJECTIVES

We undertook assessment of quality of antenatal care (ANC) services in public sector facilities in the Indian state of Bihar state delivered under the national ANC programme (Pradhan Mantri Surakshit Matritva Abhiyan, PMSMA).

SETTING

Three community health centres and one subdistrict hospital each in two randomly selected districts of Bihar.

PARTICIPANTS

Pregnant women who sought ANC services under PMSMA irrespective of the pregnancy trimester.

PRIMARY AND SECONDARY MEASURES

Quality ANC services were considered if a woman received all of these services in that visit-weight, blood pressure and abdomen check, urine and blood sample taken, and were given iron and folic acid and calcium tablets. The process of ANC service provision was documented.

RESULTS

Eight hundred and fourteen (94.5% participation) women participated. Coverage of quality ANC services was 30.4% (95% CI 27.3% to 33.7%) irrespective of pregnancy trimester, and was similar in both districts and ranged 3%-83.1% across the facilities. Quality ANC service coverage was significantly lower for women in the first trimester of pregnancy (6.8%, 95% CI 3.3% to 13.6%) as compared with those in the second (34.4%, 95% CI 29.9% to 39.1%) and third (32.9%, 95% CI 27.9% to 38.3%) trimester of pregnancy. Individually, the coverage of weight and blood pressure check-up, receipt of iron folic acid (IFA) and calcium tablets, and blood sample collection was >85%. The coverage of urine sample collection was 46.3% (95% CI 42.9% to 49.7%) and of abdomen check-up was 62% (95% CI 58.6% to 65.3%). Poor information sharing post check-up was done with the pregnant women. Varied implementation of ANC service provision was seen in the facilities as compared with the PMSMA guidelines, in particular with laboratory diagnostics and doctor consultation. Task shifting from doctors to ANMs was observed in all facilities.

CONCLUSIONS

Grossly inadequate quality ANC services under the PMSMA needs urgent attention to improve maternal and neonatal health outcomes.

Fetal movements: A framework for antenatal conversations

BACKGROUND

Presentations for decreased fetal movements comprise a significant proportion of acute antenatal assessments. Decreased fetal movements are associated with increased likelihood of adverse pregnancy outcomes including stillbirth. Consensus-based guidelines recommend pregnant women routinely receive information about fetal movements, but practice is inconsistent, and the information shared is frequently not evidence-based. There are also knowledge gaps about the assessment and management of fetal movement concerns. Women have indicated that they would like more accurate information about what to expect regarding fetal movements.

DISCUSSION

Historically, fetal movement information has focussed on movement counts. This is problematic, as the number of fetal movements perceived varies widely between pregnant women, and no set number of movements has been established as a reliable indicator of fetal wellbeing. Of late, maternity care providers have also advised women to observe their baby's movement pattern, and promptly present if they notice a change. However, normal fetal movement patterns are rarely defined. Recently, a body of research has emerged relating to maternal perception of fetal movement features such as strength, presence of hiccups, and diurnal pattern as indicators of fetal wellbeing in addition to frequency.

CONCLUSION

Sharing comprehensive and gestation-appropriate information about fetal movements may be more satisfying for women, empowering women to identify for themselves when their baby is doing well, and importantly when additional assessment is needed. We propose a conversational approach to fetal movement information sharing, focusing on fetal movement strength, frequency, circadian pattern, and changes with normal fetal development, tailored to the individual.

Impact of Covid-19 on attendances for a 1st episode of reduced fetal movements: A retrospective observational study

Background

Prior studies have demonstrated an increased stillbirth rate. It was suggested that the COVID-19 pandemic may have impacted on attendances for reduced fetal movements. Thus, we sought to ascertain the impact of the pandemic on attendances for reduced fetal movements (RFM) in our unit, ultrasound provision for reduced fetal movements, and the stillbirth rate.

Methods

This was a single site retrospective cohort study involving all women complaining of a 1^st episode of reduced fetal movements between 01/03/2020-30/04/2020 (COVID) to 01/03/2019-30/04/2019 (Pre-COVID). Data were retrieved from computerised hospital records and statistical analyses were performed using GraphPad Prism and SPSS.

Results

22% (179/810) of women presented with a 1^st episode of reduced fetal movements Pre-COVID compared to 18% (145/803) during COVID (p = 0.047). Primiparous women were significantly over-represented in this population with a 1.4-fold increase in attendances during COVID (67% vs 48%, p = 0.0005). Neither the total stillbirth rate nor the stillbirth rate amongst women who presented with reduced fetal movements changed during COVID. Ultrasound provision was not impacted by COVID with 95% of the scans performed according to local guidelines, compared to Pre-COVID (74%, p = 0.0001).

Conclusions

There is a significant decrease in 1^st attendances for reduced fetal movements during COVID-19 pandemic. Primiparous women were 1.4 times more likely to attend with RFM. Women should be reassured that COVID-19 has not resulted in a decreased provision of care for RFM, and has not impacted on the stillbirth rate.

Fetal movement counting is associated with the reduction of delayed maternal reaction after perceiving decreased fetal movements: a prospective study

Maternal perception of decreased fetal movement is associated with adverse perinatal outcomes. Although there have been several studies on interventions related to the fetal movements count, most focused on adverse perinatal outcomes, and little is known about the impact of the fetal movement count on maternal behavior after the perception of decreased fetal movement. We investigated the impact of the daily fetal movement count on maternal behavior after the perception of decreased fetal movement and on the stillbirth rate in this prospective population-based study. Pregnant women in Shiga prefecture of Japan were asked to count the time of 10 fetal movements from 34 weeks of gestation. We analyzed 101 stillbirths after the intervention compared to 121 stillbirths before the intervention. In multivariable analysis, maternal delayed visit to a health care provider after the perception of decreased fetal movement significantly reduced after the intervention (aOR 0.31, 95% CI 0.11–0.83). Our regional stillbirth rates in the pre-intervention and post-intervention periods were 3.06 and 2.70 per 1000 births, respectively. Informing pregnant women about the fetal movement count was associated with a reduction in delayed maternal reaction after the perception of decreased fetal movement, which might reduce stillbirths.

Pregnancy outcomes among women born in Somalia and Sweden giving birth in the Stockholm area - a population-based study

Background

Studies report that women born in some African countries, after migrating to the Nordic countries, have worse pregnancy outcomes than women born in the receiving countries. With the aim of identifying unmet needs among Somali-born women, we here study this subgroup.

Objective

We compared pregnancy outcomes among women born in Somalia to women born in Sweden. Further, we investigated whether the proactive maternal observation of fetal movements has effects on birth outcomes among women born in Somalia.

Methods

In Stockholm, half of the maternity clinics were randomized to intervention, in which midwives were instructed to be proactive towards women by promoting daily self-monitoring of fetal movements. Data for 623 women born in Somalia and 26 485 born in Sweden were collected from a population-based register.

Results

An Apgar score below 7 (with stillbirth counting as 0) at 5 minutes was more frequent in babies of women born in Somalia as compared to babies of women born in Sweden (RR 2.17, 95% CI 1.25–3.77). Babies born small for gestational age were more common among women born in Somalia (RR 2.22, CI 1.88–2.61), as were babies born after 41 + 6 gestational weeks (RR 1.65, CI 1.29–2.12). Somali-born women less often contacted obstetric care for decreased fetal movements than did Swedish-born women (RR 0.19, CI 0.08–0.36). The differences between women born in Somalia and women born in Sweden were somewhat lower (not statistically significant) among women allocated to proactivity as compared to the Routine-care group.

Conclusions

A higher risk of a negative outcome for mother and baby is seen among women born in Somalia compared to women born in Sweden. We suggest it may be worthwhile to investigate whether a Somali-adapted intervention with proactivity concerning self-monitoring of fetal movements may improve pregnancy outcomes in this migrant population.

ACR Appropriateness Criteria® Growth Disturbances-Risk of Fetal Growth Restriction

Fetal growth restriction, or an estimated fetal weight of less than the 10th percentile, is associated with adverse perinatal outcome. Optimizing management for obtaining the most favorable outcome for mother and fetus is largely based on detailed ultrasound findings. Identifying and performing those ultrasound procedures that are most associated with adverse outcome is necessary for proper patient management. Transabdominal ultrasound is the mainstay of initial management and assessment of fetal growth. For those fetuses that are identified as small for gestational age, assessment of fetal well-being with biophysical profile and Doppler velocimetry provide vital information for differentiating those fetuses that may be compromised and may require delivery and those that are well compensated. Delivery of the pregnancy is primarily based upon the gestational age of the pregnancy and the ultrasound findings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Fetal Movement Counting and Perinatal Mortality: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the association of fetal movement counting with perinatal mortality.

DATA SOURCES

Electronic databases (ie, MEDLINE, ClinicalTrials.gov, ScienceDirect, the Cochrane Library at the CENTRAL Register of Controlled Trials) were searched from inception until May 2019. Search terms used were: "fetal movement," "fetal movement counting," "fetal kick counting," "stillbirth," "fetal demise," "fetal mortality," and "perinatal death."

METHODS OF STUDY SELECTION

We included all randomized controlled trials comparing perinatal mortality in those women randomized to receive instructions for fetal movement counting compared with a control group of women without such instruction.

TABULATION, INTEGRATION AND RESULTS

The primary outcome was perinatal mortality. Five of 1,290 identified articles were included, with 468,601 fetuses. Definitions of decreased fetal movement varied. In four of five studies, women in the intervention group were asked to contact their health care providers if they perceived decreased fetal movement; the fifth study did not provide details. Reported reduction in fetal movement usually resulted in electronic fetal monitoring and ultrasound assessment of fetal well-being. There was no difference in the incidence of perinatal outcome between groups. The incidence of perinatal death was 0.54% (1,252/229,943) in the fetal movement counting group and 0.59% (944/159,755) in the control group (relative risk [RR] 0.92, 95% CI 0.85-1.00). There were no statistical differences for other perinatal outcomes as stillbirths, neonatal deaths, birth weight less than 10th percentile, reported decreased fetal movement, 5-minute Apgar score less than 7, neonatal intensive care unit admission or perinatal morbidity. There were weak but significant increases in preterm delivery (7.6% vs 7.1%; RR 1.07, 95% CI 1.05-1.10), induction of labor (36.6% vs 31.6%; RR 1.15, 95% CI 1.09-1.22), and cesarean delivery (28.2% vs 25.3%; RR 1.11, 95% CI 1.10-1.12).

CONCLUSION

Instructing pregnant women on fetal movement counting compared with no instruction is not associated with a clear improvement in pregnancy outcomes. There are weak associations with some secondary outcomes such as preterm delivery, induction of labor, and cesarean delivery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019123264.

Cerebroplacental ratio (CPR) and reduced fetal movement: predicting neonatal outcomes

Objective: The aim of this study was to evaluate the role of cerebroplacental ratio (CPR) in term pregnancies with reduced fetal movements (RFM) and appropriate for gestational age (AGA)fetuses to predict poor neonatal outcomes.Methods: A prospective cohort study was performed on 150 singleton pregnancies with gestational age of 37-41 weeks and multiple episodes of RFM (case group) and 150 pregnancies within the same criteria only without RFM (control group). Both groups had appropriate for gestational age (AGA)fetuses. Umbilical artery (UA) and middle cerebral artery (MCA) pulsatility indices (PI) were measured, and MCA to UA ratio (CPR) was calculated. Doppler indices and neonatal outcomes were compared between the two groups. Independent prediction role of CPR MoM was evaluated through a binary logistic regression method.Results: The RFM group had significantly higher UA- PI MoM (1.01 ± 0.19 versus 0.86 ± 0.05, p < .001), lower MCA MoM (1.28 ± 0.20 versus 1.40 ± 0.13, (p < .001)) and lower CPR MoM (0.98 ± 0.24 versus 1.23 ± 0.12, (p < .001)) compared to the control group. Mean umbilical artery pH was lower in the RFM group and the frequency of neonatal UA cord pH <7.2 was higher in the RFM group. In RFM group, CPR MoM showed a significant linear correlation with birth weight centiles (r = 0.244, p = .003), umbilical artery pH (r = 0.319, p < .001) and Apgar score at minute 1 (r = 0.332, p < .001). CPR MoM exhibited negative correlation with duration of NICU stay (r= -0.187, p = .022). No similar correlation was observed in the control group. In binary logistic regression analysis, CPR MoM was adjusted for the results of NST; and it was concluded that CPR MoM was the only significant predictor of Apgar score minute 1 = <7 (OR: 0.004; 95% CI: 0.0002-0.0673, p < .001), umbilical artery ph <7.2 (OR: 0.019; 95% CI: 0.00005-0.0423, p < .001) and NICU admission (OR: 0.116; 95% CI: 0.018-0.744, p = .023). In multivariate binary logistic regression analysis included parity, history of abortion and ART, AFI, BPP and CPR MoM; the AFI (OR: 0.976; 95% CI: 0.957-0.995, p = .014), BPP (OR: 0.306; 95% CI: 0.172-0.545, p < .001) and CPR MoM (OR: 0.00005 95% CI: 0.000003-0.00061, p < .001) were the significant predictor of RFM. Area under the curve in receiver operating characteristics (ROC) curve was calculated as 0.828 for CPR MoM as a predictor of RFM (SE: 0.024, p < .001), yielding sensitivity and specificity estimates of 80.0% and 65.0%, respectively, using an optimal cutoff level of = < 1.19.Conclusion: This study concluded that reduced fetal movement was significantly related to low CPR MOM. Also, it showed the independent role of CPR MoM for prediction of lower neonatal umbilical artery pH, lower Apgar score minute 1 and higher rate of NICU admission in AGA term fetuses without considering NST results. Also, AFI, BPP and CPR MoM are significant predictors of RFM.

Management of reduced fetal movement: A comparative analysis of two audits at a tertiary care clinical service

OBJECTIVES

Reduced fetal movement (RFM) is a commonly presenting worrisome complaint, both for mothers and attending clinicians. The aim of this study was to review the management of RFM before and following the implementation of new hospital guideline and to determine pregnancy outcomes following single vs repeated consultations with complaints of RFM. We also compared the standards in our old and new trust guidelines against published guidance from the Royal College of Obstetricians and Gynaecologists (RCOG).

STUDY DESIGN

This retrospective cohort study was conducted between June -November 2016 (audit 1) and July- December 2018 (audit 2). All women with a non-anomalous singleton pregnancy, attending the Day Assessment Unit of the Jessop Wing Hospital Sheffield UK with a primary presentation of perceived RFM after 24 weeks of gestation were included. The electronic maternity database was used to collect information regarding their presentations and pregnancy outcomes. Adherence to the old and the new local guidelines for the respective epochs of the assessment were reviewed by two independent observers using the Appraisal of Guidelines for Research and Evaluation (AGREE) 11 tool.

RESULTS

A total of 1775 women presented with RFM during the two study periods. Of these, 632 attended with more than 1 presentation of RFM (35.6 %). There were 3 stillbirths; all diagnosed at the first presentation with RFM. In the second audit, prevalence of RFM increased by 10 %, CTG documentation improved by 1% and ultrasound scan requests decreased by 6.6 %. Women with more than one episode of RFM were more likely to be younger, smokers, nulliparous, have raised BMI, had a higher IOL rate and had more ultrasound scans compared to those with one episode. However, neonatal outcome, onset of labour and mode of delivery remained unchanged between the two groups. While the RCOG guideline was superior to both (old and new) guidelines, the overall scores increased in the new guideline by 22 %.

CONCLUSION

After implementing the new guideline, the re-audit demonstrates a reduction in the number of requested ultrasound scans without any compromise on the perinatal outcome.

Risk factors for poor neonatal outcome in pregnancies with decreased fetal movements

INTRODUCTION

The incidence of Swedish stillbirths has varied little in the past 40 years, with a reported frequency of 400-450 stillbirths/y (approximately 4‰), despite increased information about fetal movement in the media and awareness among healthcare providers. The objectives of this project were to describe the outcome of pregnancies with reduced fetal movement in a Swedish context and to investigate factors associated with poor neonatal outcome in this group.

MATERIAL AND METHODS

A retrospective cohort study was performed at Soder Hospital, Stockholm, Sweden. All single pregnancies at the hospital from January 2016 to December 2017 presenting with reduced fetal movement after 22 gestational weeks were included in the study. A composite neonatal outcome was constructed: 5-minute Apgar score ≤7, arterial pH in the umbilical cord ≤7.10, transfer to neonatal care unit for further care or intrauterine fetal death.

RESULTS

For women seeking care for reduced fetal movement, the occurrence of composite poor neonatal outcome ranged from 6.2% to 18.4% within different groups. The highest risk for poor neonatal outcome (18.4%) was found in the group of women with a small-for-gestational-age fetus. Another high-risk group (12.8%) was the one comprising women with normal birthweight/large-for-gestational-age fetuses with an in vitro fertilization pregnancy.

CONCLUSIONS

The highest incidence of poor neonatal outcome among women with reduced fetal movement was found in the groups with small-for-gestational-age fetuses in nulliparous and multiparous women. A routine ultrasound assessment for fetal growth in third trimester is supposedly most efficient to identify undiagnosed small for gestational age.

Decreased fetal movements: Perinatal and long-term neurological outcomes

BACKGROUND

While maternal perception of decreased fetal movements during advanced stages of pregnancy may be an indicator for adverse perinatal outcome, the long-term neurological outcome of offspring of affected pregnancies remains largely unknown.

OBJECTIVE

To examine whether maternal complaint of decreased fetal movements is associated with adverse perinatal outcomes, and to assess the implications of decreased fetal movements on long-term neurological morbidity of the offspring.

STUDY DESIGN

A single center cohort analysis including deliveries between the years 1991-2014 was conducted. The association between decreased fetal movements and adverse perinatal outcome was evaluated using a general estimation equation (GEE) multivariable analyses. Incidence of hospitalizations (up to age 18 years) due to various neurological conditions was compared between offspring of affected pregnancies, and those who were not, using a Kaplan-Meyer survival curve. A Cox proportional hazards model was used to control for confounders.

RESULTS

439 (0.18%) of 242,342 deliveries included in this study were accompanied by maternal complaint of decreased fetal movements. Perinatal outcome was comparable between the groups, with no cases of perinatal mortality observed among the exposed group. Total neurological-related hospitalization rate of the offspring, as well as hospitalizations due to movement disorders, were higher among the exposed group (Kaplan-Meyer log-rank test P < 0.05). This association between decreased fetal movements and increased long-term neurological hospitalization proved to be independent of potential confounders with an adjusted hazard ratio of 1.54 (95% CI 1.0-2.37).

CONCLUSION

Maternal complaint of decreased fetal movements does not predict adverse perinatal outcome but is associated with an elevated risk for long-term neurological morbidity of the offspring.

Measurement of Maternal Mindful Awareness of Fetal Movement

INTRODUCTION

Decreased fetal movement is a common concern late in pregnancy that may be associated with increased fetal morbidity and mortality. Limited research suggests a relationship between maternal psychological factors and perception of fetal movement. The goal of this study was to test the reliability and external validity of a novel self-report instrument for maternal mindful awareness of fetal movement.

METHODS

Pregnant women who were at 20 weeks' gestation or later and feeling regular fetal movement (N = 497) were recruited online through a commercial pregnancy website to complete an internet survey from April to May 2016. The online survey included demographic and pregnancy characteristics, psychological and mindfulness measures, and investigator-developed items on mindful awareness of fetal movement. Reliability and validity of the instrument were tested with exploratory factor analysis, correlations with psychological variables, and hierarchical linear regression.

RESULTS

Exploratory factor analysis of mindful awareness of fetal movement items using principal components analysis showed a 2-factor structure, noticing and distracted, with internal consistency of α equal to .69 and .57, respectively. Hierarchical multiple regression analysis showed that noticing was associated with increased gestational age, mindfulness (observing facet), and maternal-fetal attachment. Distracted was associated with increased education level and prenatal anxiety and with decreased mindfulness (nonjudging facet).

DISCUSSION

There was moderate internal consistency in the items measuring mindful awareness of fetal movement. Findings suggest relationships between mindful awareness of fetal movement and state mindfulness, maternal-fetal attachment, and prenatal anxiety. More research is needed to further develop items for a mindful awareness of fetal movement scale suitable for research and clinical practice.

Counting fetal movements of small-for-gestational infants using a fetal movement acceleration measurement recorder

Background: Our purpose was to clarify whether small-for-gestational (SGA) infants is associated with a decrease in fetal movements (FMs) even in the absence of hypoxia. We used a fetal movement acceleration measurement (FMAM) recorder, which enabled counting gross FMs for hours at a time.Methods: (1) Parameters of FMs for 13 women who delivered SGA infants were plotted over normal reference value curves made from 64 normal pregnant women in another study. (2) Linear regression analysis was conducted for the women with SGA infants and the normal pregnant women.Results: Thirty-eight data recordings were available in the SGA group. (1) For the ratio of movement positive 10-s epoch, 14 recordings (36.8%) were below 10% of the normal values. For an average number of movements, 13 (34.2%) were below 10%. Regarding average number, average duration, and longest duration of non-movement period, 12 (31.6%), 13 (34.2%), and 15 records (39.4%) were above 90% of the normal values, respectively. (2) SGA was a factor that decreased the positive epoch ratio and the average movements number, and increased the average number and duration, and the longest duration of non-movement period.Conclusions: SGA is associated with decreased movements even in the absence of hypoxia.

Alterations in maternally perceived fetal movement and their association with late stillbirth: findings from the Midland and North of England stillbirth case-control study

OBJECTIVE

To report perception of fetal movements in women who experienced a stillbirth compared with controls at a similar gestation with a live birth.

DESIGN

Case-control study.

SETTING

41 maternity units in the UK.

PARTICIPANTS

Cases were women who had a late stillbirth ≥28 weeks gestation (n=291) and controls were women with an ongoing pregnancy at the time of the interview (n=733). Controls were frequency matched to cases by obstetric unit and gestational age.

METHODS

Data were collected using an interviewer-administered questionnaire which included questions on maternal perception of fetal movement (frequency, strength, increased and decreased movements and hiccups) in the 2 weeks before the interview/stillbirth. Five fetal movement patterns were identified incorporating the changes in strength and frequency in the last 2 weeks by combining groups of similar pattern and risk. Multivariable analysis adjusted for known confounders.

PRIMARY OUTCOME MEASURE

Association of maternally perceived fetal movements in relation to late stillbirth.

RESULTS

In multivariable analyses, women who reported increased strength of movements in the last 2 weeks had decreased risk of late stillbirth compared with those whose movements were unchanged (adjusted OR (aOR) 0.18, 95% CI 0.13 to 0.26). Women with decreased frequency (without increase in strength) of fetal movements were at increased risk (aOR 4.51, 95% CI 2.38 to 8.55). Daily perception of fetal hiccups was protective (aOR 0.31, 95% CI 0.17 to 0.56).

CONCLUSIONS

Increased strength of fetal movements and fetal hiccups is associated with decreased risk of stillbirth. Alterations in frequency of fetal movements are important in identifying pregnancies at increased risk of stillbirth, with the greatest risk in women noting a reduction in fetal activity. Clinical guidance should be updated to reflect that increase in strength and frequency of fetal movements is associated with the lowest risk of stillbirth, and that decreased fetal movements are associated with stillbirth.

TRIAL REGISTRATION NUMBER

NCT02025530.

Reduced fetal movements and cerebroplacental ratio: evidence for worsening fetal hypoxemia

OBJECTIVE

To investigate the fetal cerebroplacental ratio (CPR) in women presenting with reduced fetal movements (RFM).

METHODS

This was a retrospective cohort study of data collected over an 8-year period at a fetal medicine unit at a tertiary referral center. The cohort comprised 4500 singleton pregnancies presenting with RFM at or after 36 weeks' gestation and 1527 control pregnancies at a similar gestational age without RFM. Fetal biometry and Doppler parameters were recorded and converted into centiles and multiples of the median (MoM). CPR was defined as the ratio between the fetal middle cerebral artery (MCA) pulsatility index (PI) and the umbilical artery (UA) PI. Subgroup analysis for fetal size and for single vs multiple episodes of RFM was performed.

RESULTS

Compared with controls, pregnancies with RFM had lower MCA-PI MoM (median, 0.95 vs 0.97; P < 0.001) and CPR MoM (median, 0.97 vs 0.99; P = 0.018). Compared with women presenting with single episodes of RFM, pregnancies with multiple episodes (≥ 2 episodes) had lower CPR MoM (median, 0.94 vs 0.98; P = 0.003). On subgroup analysis for fetal size, compared with controls, appropriate-for-gestational-age fetuses in the RFM group had lower MCA-PI MoM (median, 0.96 vs 0.97; P = 0.003) and higher rate of CPR below the 5^th centile (5.3% vs 3.6%; P = 0.015). Logistic regression analysis demonstrated an association of risk of recurrent RFM with maternal age (OR, 0.96; 95% CI, 0.93-0.99), non-Caucasian ethnicity (OR, 0.72; 95% CI, 0.53-0.97), estimated fetal weight centile (OR, 1.01; 95% CI, 1.00-1.02) and CPR MoM (OR, 0.24; 95% CI, 0.12-0.47).

CONCLUSION

Pregnancies complicated by multiple episodes of RFM show significantly lower CPR MoM and MCA-PI MoM compared with those with single episodes and controls. This is likely to be due to worsening fetal hypoxemia in women presenting with recurrent RFM. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Management and Outcome of Reduced Fetal Movements-is Ultrasound Necessary?

OBJECTIVE

To review the management and outcome of pregnancies of women presenting to obstetrical triage with decreased fetal movements (DFM).

STUDY DESIGN

A retrospective review of women presenting with DFMs to two large Canadian obstetrical centres with a combined 9490 deliveries per year. The charts were reviewed for compliance with the Canadian guidelines for demographics (age, parity, GA, comorbidities, etc.), pregnancy management (admission vs. discharge, need to deliver), and pregnancy outcomes (mortality, morbidity, GA at delivery, Apgar scores, etc.). Patients who did not comply with the Canadian guidelines (requiring the patient to count six movements within two hours) were not excluded.

RESULTS

The charts of 579 patients who self-reported DFMs between January 2012 and December 2012 were reviewed. The distribution of ages was between 18 and 47 year old. The majority of these patients had no comorbidities (454/579). A significant minority of patients had FM in the triage area (231/579). The Canadian guidelines were interpreted differently in the two centres. In one (level 3), the protocol was to have a biophysical profile (BPP) on all patients prior to discharge, whereas in the other (level 2), only patients with a non-reactive non-stress test (NST) and/or oligohydramnios or intrauterine growth restriction (IUGR) underwent a BPP. All patients had an evaluation by an RN and MD and had a NST on arrival. A combination of NST and BPP was performed on 235/579. The frequency of DFM was 6.1% (level 3 centre: 5.6%, level 2 centre: 7.8%). There were 8 stillbirths on arrival. The 187 patients who had a reactive NST and a normal BPP and were sent home did not have a single stillbirth within 2 weeks. In the level 3 centre, 19 patients were sent home without a BPP and one had a stillbirth within 2 days (5%); in the level 2 hospital, there was only one stillbirth among the NST-only group (0.35%). There were 65 admissions; 46 of them (71%) were delivered, and 50% of them had a Caesarean delivery (baseline around 30%).

CONCLUSIONS

This is the first study looking at the performance of the Canadian guidelines of 2007. We found that the DFM rate was compatible with the literature (6.1% vs. 5%). The frequency of stillbirth on arrival was 1.4% (8/579). Patients discharged after normal NST and BPP did extremely well (no stillbirths), whereas those admitted following DFM had a relatively high Caesarean delivery rate (50%). This study was not designed to address changes in stillbirth rate, but it outlines the patients who experience DFM and their eventual outcomes.

Understanding the associations and significance of fetal movements in overweight or obese pregnant women: a systematic review

INTRODUCTION

Presentation with decreased fetal movement (DFM) is associated with fetal growth restriction and stillbirth. Some studies report that DFM is frequent among overweight or obese mothers. We aimed to determine the significance and associations of fetal movements in women of increased body size.

MATERIAL AND METHODS

This systematic review was conducted in accordance with the PRISMA statement and the protocol was registered with PROSPERO (CRD42016046352). Major databases were explored from inception to September 2017, using a predefined search strategy. We restricted inclusion to studies published in English and considered studies of any design that compared fetal movements in women of increased and normal body size. Two authors independently extracted data and assessed quality.

RESULTS

We included 23 publications from 19 observational studies; data were extracted from 10 studies. Increased maternal body size was not associated with altered perception of fetal movement (four studies, 95 women, very low-quality evidence), but was associated with increased presentation for DFM (two cohort studies, 20 588 women, OR 1.56, 95% CI 1.27-1.92: three case-control studies, 3445 women, OR 1.32, 95% CI 1.12-1.54; low-quality evidence). Among women with DFM, increased maternal body size was associated with increased risk of stillbirth and fetal growth restriction (one study, 2168 women, very low-quality evidence).

CONCLUSIONS

This systematic review identified limited evidence that women with increased body size are more likely to present with DFM but do not have impaired perception of fetal movements. In women with DFM, increased body size is associated with worse pregnancy outcome, including stillbirth.

Breech presentation at term and associated obstetric risks factors-a nationwide population based cohort study

PURPOSE

The aim of this study was to estimate whether breech presentation at term was associated with known individual obstetric risk factors for adverse fetal outcome.

METHODS

This was a retrospective, nationwide Finnish population-based cohort study. Obstetric risks in all breech and vertex singleton deliveries at term were compared between the years 2005 and 2014. A multivariable logistic regression model was used to determine significant risk factors.

RESULTS

The breech presentation rate at term for singleton pregnancies was 2.4%. The stillbirth rate in term breech presentation was significantly higher compared to cephalic presentation (0.2 vs 0.1%). The odds ratios (95% CIs) for fetal growth restriction, oligohydramnios, gestational diabetes, a history of cesarean section and congenital fetal abnormalities were 1.19 CI (1.07-1.32), 1.42 CI (1.27-1.57), 1.06 CI (1.00-1.13), 2.13 (1.98-2.29) and 2.01 CI (1.92-2.11).

CONCLUSIONS

The study showed that breech presentation at term on its own was significantly associated with antenatal stillbirth and a number of individual obstetric risk factors for adverse perinatal outcomes. The risk factors included oligohydramnios, fetal growth restriction, gestational diabetes, history of caesarean section and congenital anomalies.

Fetal movement in late pregnancy - a content analysis of women's experiences of how their unborn baby moved less or differently

Background

Pregnant women sometimes worry about their unborn baby’s health, often due to decreased fetal movements. The aim of this study was to examine how women, who consulted health care due to decreased fetal movements, describe how the baby had moved less or differently.

Methods

Women were recruited from all seven delivery wards in Stockholm, Sweden, during 1/1 – 31/12 2014. The women completed a questionnaire after it was verified that the pregnancy was viable. A modified content analysis was used to analyse 876 questionnaires with the women’s responses to, “Try to describe how your baby has moved less or had changes in movement”.

Results

Four categories and six subcategories were identified: “Frequency” (decreased frequency, absence of kicks and movement), “Intensity” (weaker fetal movements, indistinct fetal movements), “Character” (changed pattern of movements, slower movements) and “Duration”. In addition to the responses categorised in accordance with the question, the women also mentioned how they had tried to stimulate the fetus to move and that they had difficulty in distinguishing fetal movements from contractions. Further, they described worry due to incidents related to changed pattern of fetal movements.

Conclusion

Women reported changes in fetal movement concerning frequency, intensity, character and duration. The challenge from a clinical perspective is to inform pregnant women about fetal movements with the goal of minimizing unnecessary consultations whilst at the same time diminishing the length of pre-hospital delay if the fetus is at risk of fetal compromise.

Trial registration

Not applicable.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-0922-z) contains supplementary material, which is available to authorized users.