2. By:
DR. SALAH ROSHDY
Professor of OB/GYN
Qassim College of
Medicine,KSA
Sohag University,Egypt
3. Introduction
Maternal perception of decreased fetal
movements (FMs) is a cause of concern and
a common reason for visits to the antenatal
clinic or delivery room. Several studies have
shown that a reduction or cessation of FMs
may result in poor pregnancy outcome and
increased risk of serious perinatal morbidity
and mortality.
4. However, the assessment and management of
pregnancies with reduced FMs is challenging
and controversial. When signs of a
compromised fetus are detected, there is a
need for appropriate action, but the risk of
iatrogenic damage must be considered.
5. Fetal activity in normal
pregnancies
FM is one of the first signs of fetal life. Fetal
activity serves as an indirect measure of
central nervous system integrity and function.
Regular FM can, therefore, be regarded as
an expression of fetal well-being . Pregnant
women usually sense FM from 18 to 20
weeks of gestation . Some multiparous
women may perceive FMs at 16 weeks of
gestation . As pregnancy proceeds, the
weekly number of FM increases, peaking
between 29 and 38 weeks of gestations.
6. These complex and integrated FM require a
certain neuromuscular development and a
normal metabolic state of the central
nervous system. A gradual decline in the
total amount of FM during the last trimester
is suggested to be due to improved
coordination and reduced amniotic fluid
volume coupled with the increased fetal size
.
7. Decreased FMs
The fetus responds to chronic hypoxia by conserving
energy. Subsequent reduction in FMs has been
described as an adaptive mechanism to reduce
oxygen consumption . The human fetus is
characterized by wide ranges of normal variation in
FM, resulting in difficulty to define what constitutes a
clinically important reduction in FM. Unable to
quantify normal FMs, most investigators have
resorted to arbitrary answers. Differences between
the activities of individual fetuses and the perception
of individual mothers are probably the major
component of the variation in the FMs. There is at
present no general agreement as to what constitutes
decreased FM .
8. Table I. Factors associated with decreased fetal mov.
Maternal anxiety
Busy mother
Alcohol use
Sedative use
Corticosteroids
Fetal sleep
Intrauterine growth retardation
Hypoxia
Hypothyroidism
Fetal anemia
Neurological or muscular abnormality
Poly- or oligohydramnios
9. Monitoring of FMs by the
pregnant woman
Because fetal motor activity may reflect the
fetal condition in utero, maternal counting of
FMs has been suggested as a useful method
for monitoring fetal condition .
Several methods for monitoring FM have been
described. However, neither the optimal
number of movements nor the ideal
duration for counting has been determined.
Most of these methods imply long and
repeated daily counting sessions. A simple
screening program is the count-to-ten
technique by Pearson .
10. Moore et al. have shown that the count-to-
ten method of FM is effective in reducing
the intrauterine death rate in low-risk
pregnancies. The intrauterine death rate fell
from 8.7 to 2.1 per 1000 after initiation of
the FM program and was associated with a
significantly higher proportion of labor
inductions and cesarean sections for fetal
distress .
11. Rayburn et al. have studied the hypothesis
that the maternal perception of FM is as
useful as antepartum FHR testing [non-
stress test (NST) and contraction stress test
(CST)] in high-risk pregnancies. They
concluded that an active fetus (four or
more movements perceived for each
convenient hour of daily counting) is as
predictive as a normal FHR testing for a
favorable perinatal outcome .
12. Application of FM counting to low-risk
pregnancies is attractive, because about half
of stillbirths occur without obvious cause .
However, presently there is no conclusive
evidence of a reduction in the antepartum
death rate by introducing a formal counting
program of FM.
13. Assessment of fetal well-being in
pregnancies with decreased FM
The fact that the compromised fetus reduces its
oxygen requirements by diminishing activity
could indicate that the reduced fetal activity is an
expression of fetal distress and placental
dysfunction . Thus, there is a need for fetal
assessment in this situation. During the last
decades, new methods for fetal assessment in
various clinical settings have been introduced.
These include NST (CTG), CST, vibroacoustic
stimulation, Doppler velocimetry [umbilical artery
(UA) and uterine artery (Ut.A)], biophysical
profile, and the real-time ultrasonography.
14. Cardiotocography (NST
and CST)
CTG is applied to pregnancy complications
where fetal well-being is questioned,
including reduced FMs, post-term pregnancy,
hypertensive disease, growth restriction, and
bleeding in pregnancy .
FMs and the onset of FHR accelerations are
synchronized and coordinated functions . In a
study by Rabinowitz et al. , adequate
accelerations have been reported in the
association with 79% of FMs perceived by the
mother and 99% of FMs seen
sonographically. Lee and Drukker have
15. demonstrated that absence of accelerations or
appearance of decelerations concomitant to
FM may indicate the beginning of fetal
hypoxia. FHR decelerations during a CTG that
persist for 1 min or longer are associated with
a markedly increased risk of both cesarean
delivery and fetal demise .
The non-stress CTG with the loss of reactivity is
associated most commonly with a fetal sleep
cycle but may result from any cause of
central nervous system depression, including
fetal acidosis .
16. The CST is based on simultaneous recording of
the FHR and uterine contractions induced by
the administration of oxytocin. It is assumed
that fetal oxygenation may be transiently
reduced by the uterine contractions.
Therefore, in the suboptimally oxygenated
fetus, the resultant intermittent reduction in
oxygenation will lead to late decelerations in
FHR .
17. Nageotte et al. have examined the outcome of
pregnancies in high-risk patients whose last
antepartum fetal assessment was a normal
CST or a normal modified biophysical profile
[a combination of a NST (CTG) and an
amniotic fluid index]. In this study, the
frequency of adverse perinatal outcome
following a normal modified biophysical
profile was not significantly higher than that
following a normal CST.
18. A meta-analysis of four studies has assessed
the effects of antenatal CTG on perinatal
morbidity and mortality in high-risk and
intermediate-risk pregnancies. There were
no significant effects of CTG monitoring on
rates of stillbirth or measures of perinatal
morbidity.
19. Fetal vibroacoustic
stimulation
Fetal sleeping periods can lead to falsely
nonreactive CTG tests, thus increasing the risk of
unnecessary obstetric intervention . A
vibroacoustic stimulus may elicit FHR
accelerations, which appear to be valid in the
prediction of fetal well-being . Tan and Smyth
concluded in a meta-analysis of seven trials that
fetal vibroacoustic stimulation could reduce the
number of non-reactive CTG tests. Such
stimulation offers the advantage of safely
reducing overall testing time by reducing the
number of non-reactive CTG traces due to fetal
sleep states .
20. Doppler velocimetry (UA
and Ut.A)
The use of Doppler ultrasound to investigate
the pattern of waveforms in the UA was first
reported in 1977 . It has been evaluated
more rigorously than any other biophysical
test of fetal growth and well-being . UA
Doppler velocimetry has not been shown to
be of value as a screening test for detecting
fetal compromise in the general obstetric
population . Neilson et al. have published a
meta-analysis of 11 studies of the effects of
Doppler ultrasound in high-risk pregnancies.
21. Compared to no Doppler ultrasound
examination, Doppler ultrasound in high-risk
pregnancies (especially those complicated
by hypertension or presumed IUGR) was
associated with a trend to a reduction in
perinatal deaths and was also associated
with fewer inductions of labor. There were
no significant differences in rates of fetal
distress in labor or cesarean delivery.
22. Dubiel et al. compared the use of CTG and UA
Doppler velocimetry in low-risk pregnancies
where decreased FM was the only indication
for fetal assessment. They found that the
CTG seemed to be a better predictor of
mortality and infant handicap than Doppler
velocimetry.
23. Adding UA and Ut.A Doppler velocimetries to
the conventional CTG surveillance might
be of clinical value in cases with
decreased FM .
24. Biophysical profile
Several studies have suggested a link between
low biophysical scores and poor pregnancy
outcome, resulting in its widespread use,
particularly in the United States and Canada .
Manning et al. have proposed that the
combined use of five fetal biophysical
variables as a more accurate means of
assessing fetal wellbeing than any one used
alone.
25. A meta-analysis of four studies has assessed the
effects of biophysical profile tests on pregnancy
outcome in high-risk pregnancies (decreased
FM, hypertension, IUGR, post-term pregnancy,
diabetes, previous stillbirth, antepartum
hemorrhage, premature labor, and Rhesus
disease). The effects of biophysical profile
testing on perinatal outcome were not
significantly different when compared with
conventional fetal monitoring (usually CTG). At
present, the data are insufficient to reach any
definite conclusion about the benefit of the
biophysical profile as a test of fetal well-being
in high-risk pregnancies .
26. Real-time ultrasonography
Real-time ultrasonography enables the
detection of several variables (Table III) .
Whitty et al. studied a low-risk population
whose only complaint was decreased FM.
Initial testing included a CTG and an
ultrasound examination. Approximately 9% of
patients have incidental
27. abnormal ultrasonographic findings, and it
was concluded that ultrasound examination of
these low-risk patients with the only
complaint of decreased FM might provide
useful information . However, there is a need
for further studies of the use of
ultrasonography in this situation.
28. The ultrasound observations made when decreased fetal
movement perception persists
•Fetal weight To evaluate the possibility for
intra-uterine growth retardation.
•Fetal movement Three or more discrete
movements within 30 min
•Fetal breathing movements One or more movements within
30 min
•Evaluation of the amniotic fluid A single pocket of amniotic fluid
volume exceeding 2 cm is considered as
adequate amniotic fluid
•Malformations Should be excluded
29. Management of pregnancies
with decreased FMs
Only few studies have presented management
guidelines for pregnancies with decreased
FM. It should be noted that none of these
guidelines have been evaluated in
randomized controlled trials.
30. Cont.
• Patients with decreased FM & abnormal CTG
require further investigation.
• Patients with decreased FM & a normal CTG
,normal AFV,& no other indication for
examination do not require follow-up testing.
• If there is a continuing complaint of
decreased FM ,it seems reasonable to
undertake a follow-up evaluation.
31. American College of Obstetricians and
Gynecologists (ACOG) , it is suggested that
maternal complaints of decreased FM should
be evaluated by a NST and modified
biophysical profile (NST combined with
determination of the amniotic fluid volume) to
exclude imminent fetal jeopardy. If these
tests are abnormal, the patient should be
further evaluated by a CST and/or a full
biophysical profile. If the woman continues to
report decreased FM, a reassuring test should
32. be repeated periodically (either weekly or
twice weekly). However, it was concluded
that antepartum fetal surveillance has not
definitively demonstrated improved perinatal
outcome and that ACOG’s recommendations
are based on limited and inconsistent
scientific evidence .
33. CTG Deviantly CTG Repeated CTG If still deviantly CTS abnormal
the same day may be a CTS
Normal, in an otherwise No further investigation
Uncomplicated pregnancy if FM are normal
Consider:
Decreased FM perception persists
Induction
Of Labor
Ultrasound examination: Decreased FM Decreased FM
USG normal perception persists perception persists
Fetal weight, movements, Or
breathing movements, USG Abnormal Cesarean
Decreased FM Repeated CTG
Malformations, and evaluation next step perception persists the same day
Section
Of the amniotic fluid volume Doppler flow
velocimetry
Reporting of normal fetal activity again
Repeated USG after 1-2weeks
Flow chart for proposed management of decreased Fetal movements after 28weeks of
pregnancy. CST, Contraction stress test; CTG, cardiotocography; FM, fetal movement.
34. Conclusion
A perception of decreased FMs is frequently
reported by pregnant women and causes
much concern. However, there is no
universal agreement on the definition of
decreased FMs, or whether this is
associated with a poor pregnancy outcome.
Formal counting of FM by the pregnant
woman could possibly find the fetuses,
which have stopped performing strong,
complex movements but still are in a
35. reasonably good health, allowing for
intervention. Presently, the benefit of this
protocol has not been definitely proven.
CTG, UA/Ut.A artery Doppler velocimetry,
and ultrasonography have been used for
antepartum fetal assessment in pregnancies
with decreased FMs, but the evidence of a
clinical benefit is not convincing. The effects
of fetal assessment with vibroacoustic
stimulation and biophysical profile are
unknown and should be further evaluated.
36. Present recommendations regarding the
management of pregnancies with a
complaint of decreased FMs are based on
limited and inconsistent scientific evidence.
There is a need for well-designed studies in
order to provide evidence-based guidelines
in the future.
