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Hayes DJL, Dumville JC, Walsh T, Higgins LE, Fisher M, Akselsson A, Whitworth M, Heazell AEP. Effect of encouraging awareness of reduced fetal movement and subsequent clinical management on pregnancy outcome: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:100821. [PMID: 36481411 DOI: 10.1016/j.ajogmf.2022.100821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Reduced fetal movement, defined as a decrease in the frequency or strength of fetal movements as perceived by the mother, is a common reason for presentation to maternity care. Observational studies have demonstrated an association between reduced fetal movement and stillbirth and fetal growth restriction related to placental insufficiency. However, individual intervention studies have described varying results. This systematic review and meta-analysis aimed to determine whether interventions aimed at encouraging awareness of reduced fetal movement and/or improving its subsequent clinical management reduce the frequency of stillbirth or other important secondary outcomes. DATA SOURCES Searches were conducted in MEDLINE, Embase, CINAHL, The Cochrane Library, Web of Science, and Google Scholar. Guidelines, trial registries, and gray literature were also searched. Databases were searched from inception to January 20, 2022. STUDY ELIGIBILITY CRITERIA Randomized controlled trials and controlled nonrandomized studies were eligible if they assessed interventions aimed at encouraging awareness of fetal movement or fetal movement counting and/or improving the subsequent clinical management of reduced fetal movement. Eligible populations were singleton pregnancies after 24 completed weeks of gestation. The primary review outcome was stillbirth; a number of secondary maternal and neonatal outcomes were specified in the review. METHODS Risk of bias was assessed using the Cochrane Risk of Bias 2 and Risk of Bias in Non-Randomized Studies I tools for randomized controlled trials and nonrandomized studies, respectively. Variation caused by heterogeneity was assessed using I2. Data from studies employing similar interventions were combined using random effects meta-analysis. RESULTS A total of 1609 citations were identified; 190 full-text articles were evaluated against the inclusion criteria, 18 studies (16 randomized controlled trials and 2 nonrandomized studies) were included. The evidence is uncertain about the effect of encouraging awareness of fetal movement on stillbirth when compared with standard care (2 studies, n=330,084) with a pooled adjusted odds ratio of 1.19 (95% confidence interval, 0.96-1.47). Interventions for encouraging awareness of fetal movement may be associated with a reduction in neonatal intensive care unit admissions and Apgar scores of <7 at 5 minutes of age and may not be associated with increases in cesarean deliveries or induction of labor. The evidence is uncertain about the effect of encouraging fetal movement counting on stillbirth when compared with standard care with a pooled odds ratio of 0.69 (95% confidence interval, 0.18-2.65) based on data from 3 randomized controlled trials (n=70,584). Counting fetal movements may increase maternal-fetal attachment and decrease anxiety when compared with standard care. When comparing combined interventions of fetal movement awareness and subsequent clinical management with standard care (1 study, n=393,857), the evidence is uncertain about the effect on stillbirth (adjusted odds ratio, 0.86; 95% confidence interval, 0.70-1.05). CONCLUSION The effect of interventions for encouraging awareness of reduced fetal movement alone or in combination with subsequent clinical management on stillbirth is uncertain. Encouraging awareness of fetal movement may be associated with reduced adverse neonatal outcomes without an increase in interventions in labor. The meta-analysis was hampered by variations in interventions, outcome reporting, and definitions. Individual studies are frequently underpowered to detect a reduction in severe, rare outcomes and no studies were included from high-burden settings. Studies from such settings are needed to determine whether interventions can reduce stillbirth.
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Affiliation(s)
- Dexter J L Hayes
- Tommy's Stillbirth Research Centre, School of Medical Sciences, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (Mr Hayes and Drs Higgins, Whitworth, and Heazell).
| | - Jo C Dumville
- Division of Nursing, Midwifery, and Social Work, School of Health Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester Academic Science Centre, Manchester, United Kingdom (Dr Dumville)
| | - Tanya Walsh
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (Dr Walsh)
| | - Lucy E Higgins
- Tommy's Stillbirth Research Centre, School of Medical Sciences, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (Mr Hayes and Drs Higgins, Whitworth, and Heazell)
| | - Margaret Fisher
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, United Kingdom (Dr Fisher)
| | - Anna Akselsson
- Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden (Dr Akselsson)
| | - Melissa Whitworth
- Tommy's Stillbirth Research Centre, School of Medical Sciences, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (Mr Hayes and Drs Higgins, Whitworth, and Heazell)
| | - Alexander E P Heazell
- Tommy's Stillbirth Research Centre, School of Medical Sciences, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (Mr Hayes and Drs Higgins, Whitworth, and Heazell)
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Sterpu I, Pilo C, Lindqvist PG, Åkerud H, Wiberg Itzel E. Predictive factors in pregnancies with reduced fetal movements: a pilot study. J Matern Fetal Neonatal Med 2022; 35:4543-4551. [DOI: 10.1080/14767058.2020.1855135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Irene Sterpu
- Department of Clinical Science and Education, Karolinska Institute, Soder Hospital, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Soder Hospital, Stockholm, Sweden
| | - Christina Pilo
- Department of Obstetrics and Gynecology, Soder Hospital, Stockholm, Sweden
| | - Pelle G. Lindqvist
- Department of Clinical Science and Education, Karolinska Institute, Soder Hospital, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Soder Hospital, Stockholm, Sweden
| | - Helena Åkerud
- Department of Immunology, Genetics, and Pathology, Minerva Fertility Clinic, Uppsala University, Uppsala, Sweden
| | - Eva Wiberg Itzel
- Department of Clinical Science and Education, Karolinska Institute, Soder Hospital, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Soder Hospital, Stockholm, Sweden
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Gent J, Bullough S, Harrold J, Jackson R, Woolfall K, Andronis L, Kenny L, Cornforth C, Heazell AEP, Benbow E, Alfirevic Z, Sharp A. The PLANES study: a protocol for a randomised controlled feasibility study of the placental growth factor (PlGF) blood test-informed care versus standard care alone for women with a small for gestational age fetus at or after 32 + 0 weeks' gestation. Pilot Feasibility Stud 2020; 6:179. [PMID: 33292754 PMCID: PMC7677818 DOI: 10.1186/s40814-020-00722-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 11/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background Stillbirth remains a major concern across the globe and in some high-resource countries, such as the UK; efforts to reduce the rate have achieved only modest reductions. One third of stillborn babies are small for gestational age (SGA), and these pregnancies are also at risk of neonatal adverse outcomes and lifelong health problems, especially when delivered preterm. Current UK clinical guidance advocates regular monitoring and early term delivery of the SGA fetus; however, the most appropriate regimen for surveillance of these babies remains unclear and often leads to increased intervention for a large number of these women. This pilot trial will determine the feasibility of a large-scale trial refining the risk of adverse pregnancy outcome in SGA pregnancies using biomarkers of placental function sFlt-1/PlGF, identifying and intervening in only those deemed at highest risk of stillbirth. Methods PLANES is a randomised controlled feasibility study of women with an SGA fetus that will be conducted at two tertiary care hospitals in the UK. Once identified on ultrasound, women will be randomised into two groups in a 3:1 ratio in favour of sFlt-1/PlGF ratio led management vs standard care. Women with an SGA fetus and a normal sFlt-1/PlGF ratio will have a repeat ultrasound and sFlt-1/PlGF ratio every 2 weeks with planned birth delayed until 40 weeks. In those women with an SGA fetus and an abnormal sFlt-1/PlGF ratio, we will offer birth from 37 weeks or sooner if there are other concerning features on ultrasound. Women assigned to standard care will have an sFlt-1/PlGF ratio taken, but the results will be concealed from the clinical team, and the woman’s pregnancy will be managed as per the local NHS hospital policy. This integrated mixed method study will also involve a health economic analysis and a perspective work package exploring trial feasibility through interviews and questionnaires with participants, their partners, and clinicians. Discussion Our aim is to determine feasibility through the assessment of our ability to recruit and retain participants to the study. Results from this pilot study will inform the design of a future large randomised controlled trial that will be adequately powered for adverse pregnancy outcome. Such a study would provide the evidence needed to guide future management of the SGA fetus. Trial registration ISRCTN58254381. Registered on 4 July 2019
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Affiliation(s)
- Joanna Gent
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
| | - Sian Bullough
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
| | - Jane Harrold
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
| | - Richard Jackson
- Liverpool Clinical Trials Unit, University of Liverpool, Liverpool, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Lazaros Andronis
- Division of Health Sciences and Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Louise Kenny
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | | | - Alexander E P Heazell
- Maternal and Fetal Research Centre, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, 5th Floor (Research), St Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Emily Benbow
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
| | - Zarko Alfirevic
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
| | - Andrew Sharp
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK.
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