Reduced FM

Question 1

Normal pattern of FM

Answer 1

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

Question 2

Association between RFM and poor outcomes

Answer 2

• 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

Question 3

Limitations of research into association between RFM and still birth

Answer 3

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

Question 4

Risk factors for stillbirth

Answer 4

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

Question 5

Assessment of reduced FM

Answer 5

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

Question 6

Management of recurrent reduced FM

Answer 6

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

Question 7

RANZCOG Q:

1) i)Define ‘perceived fetal movements’ (1 mark)ii)

Answer 7

Maternal detection of fetal movements- can be kick, swish, roll, flutter.

Question 8

RANZCOG Q:

Describe the normal maternal perception of fetal movements through pregnancy (4 marks)

Answer 8

• 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

Question 9

RANZCOG Q:

2) At 28/40 in a routine antenatal setting, what advice do you give women regarding monitoring fetal movements (6 marks)

Answer 9

• 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

Question 10

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)

Answer 10

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

Question 11

Guideline links

Answer 11

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

Question 12

What is the “Safer Baby Bundle”? What is its aim? What are the 5 interventions in the bundle?

Answer 12

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

Question 13

What factors can cause RFMs?

Answer 13

High BMI
Low exercise
Anterior placenta
Anterior fetal position (legs to back)
Working ≥8 hours per day
Smoking
Drugs: MgSo4, corticosteroids, opiates, benzos

Question 14

What is a recognised cut-off for seeking medical review for RFMs?

Answer 14

<10 movements in 2 hours observation

ACOG

Question 15

Are kick charts recommended?

Answer 15

PSANZ says no.
No evidence to support a reduction in stillbirth, but significant increase in antenatal assessment and unnecessary investigations.

Question 16

Findings of AFFIRM trial.

Answer 16

Multicentre randomised Stepped-wedge controlled trial

Intervention
• eLearning package about RFM (clinicians/ patients)
• CTG within 2 hours/ AFI within 12 hours
• Growth scan the next day
• IOL at or after 37 w if <10th; Recurrent
DFM; DVP <2cm

Findings:
• no reduction of stillbirth >24 weeks;
• no reduction perinatal mortality
• increased induction of labour, C-section, prolonged nursery admission
• reduction in babies born small for gestational age