Decreased fetal movements

1. Prof. Aboubakr Elnashar
Benha university, Egypt
Decreased fetal movements
Aboubakr Elnashar

2. Fetal movements
Kick
wave
swish (his) or
roll
First felt by the mother between 18-20 w
and rapidly acquire a regular pattern.
 an indication of the integrity of the central nervous
system and musculoskeletal systems.
Aboubakr Elnashar

3. Women perceive
most movement when lying down,
fewer when sitting and
least while standing.
Busy pregnant women for example who are not
concentrating on fetal activity often report a
misperception of RFM.
Aboubakr Elnashar

4. A significant reduction or sudden change in
movement is an important clinical sign.
Mothers may feel anxious if there is a decrease in
fetal movement however there are often reasonable
reasons for this.
The fetus may be in a state of sleep or the mother
may be too busy to focus on fetal activity.
Aboubakr Elnashar

5. Two common ways to record fetal kicks.
1. Cardiff Count to Ten Method.
This is an 8 to 12 hour period that records at least
ten of baby’s movement.
Aboubakr Elnashar

6. 2. One to Two Hours Method.
This is done while lying down on your left side for 30
minutes after eating without distractions. After an
evening meal might be ideal time to record. Baby
should move 10 times within an hour to 75 minutes.
Aboubakr Elnashar

7. Aboubakr Elnashar

8.  although fetal movements tend to plateau at 32
w, there is no reduction in the frequency of fetal
movements in the late third trimester.
Aboubakr Elnashar

9. Should fetal movements be counted routinely in a
formal manner?
There is insufficient evidence to recommend
formal fetal movement counting using specified
alarm limits.
Women should be advised to be aware of their
baby’s individual pattern of movements.
If they are concerned about a reduction in or
cessation of fetal movements after 28+0weeks of
gestation, they should contact their doctor.
and should not wait until the next day for
assessment of fetal wellbeing.
Aboubakr Elnashar

10. After 28 w if a woman is unsure whether
movements are reduced she is advised to lie on her
left side and focus on fetal movement for 2 hours.
If she does not feel 10 or more discrete movements
then she should contact her doctor immediately.
If a clinician is presented with a woman reporting
RFM, a relevant history should be taken to assess the
woman’s risk factors for stillbirth and FGR
Aboubakr Elnashar

11.  a handheld Doppler device can be used to confirm
the presence of the fetal heart beat.
 If the presence of a fetal beat is not confirmed then
immediate ultrasound scan is needed to assess fetal
cardiac activity.
CTG monitoring
should be used if the pregnancy is over 28 w and
there is still RFM after fetal viability has been
confirmed.
for at least 20 minutes
Aboubakr Elnashar

12. Ultrasound scanning
can also be used as part of the preliminary
investigations of a woman reporting RFM if the
perception of RFM persists despite a normal CTG.
Aboubakr Elnashar

13. Women should be reassured that 70%of
pregnancies with a single episode of RFM are
uncomplicated.
There are no data to support formal fetal
movement counting (kick charts) after women have
perceived RFM in those who have normal
investigations.
Women who have normal investigations after one
presentation with RFM should be advised to contact
doctor if they have another episode of RFM.
Aboubakr Elnashar

14. Women who report RFM on two or more
occasions are at an increased risk of a poorer
perinatal outcome including an increased risk of
stillbirth, fetal growth restriction and/or preterm
birth.
Aboubakr Elnashar

15. What is the optimal management of RFM before
24+0 weeks of gestation?
Presence of a fetal heartbeat should be confirmed
by auscultation with a Doppler handheld device.
If fetal movements have never been felt by 24
weeks of gestation, referral to a specialist fetal
medicine centre should be considered to look for
evidence of fetal neuromuscular conditions
Aboubakr Elnashar

16. What is the optimal management of RFM between
24+0 and 28+0 weeks of gestation?
Presence of a fetal heartbeat should be confirmed
by auscultation with a Doppler handheld device.
Aboubakr Elnashar

17. RCOG, 20011
1. History
Risk factors for stillbirth and FGR.
Sudden change in fetal activity
2. Auscultate the fetal heart
Doppler device to exclude fetal death.
3. CTG
{exclude fetal compromise}
Aboubakr Elnashar

18. 4. US
RFM persists despite a normal CTG
risk factors for FGR/stillbirth.
 AC
EFW {detect the SGA}
AFV
Fetal morphology
Doppler
Aboubakr Elnashar

19. US/2w: HC and AC.
AC
most sensitive predictor of fetal growth.
increases 2cm/2w after 24 w in the average fetus.
measurements are plotted on centile charts.
fall in the growth velocity of AC indicates IUGR.
AC used to assess fetal growth
Aboubakr Elnashar

20. Aboubakr Elnashar

21. Doppler
more useful test of fetal wellbeing than CTG or FBP.
Umbilical arterial blood flow becomes abnormal when
there is placental insufficiency.
Middle cerebral artery
Aboubakr Elnashar

22. a. Umbilical artery Doppler
Idea:
Umbilical Arterial Flow is normally low resistance.
In hypoxic states:
relative placental hypoxia:
reactive VC of umbilical artery tributaries:
higher resistance:
relative decrease in diastolic flow detectable by
Doppler.
Aboubakr Elnashar

23. Doppler indices
Aboubakr Elnashar

24. •Resistance index:
Best ability to predict abnormal outcomes
(RCOG,2002 Evidence level II)
 Normal pregnancy:
{progressive increase in end-diastolic velocity
{growth& dilatation of the umbilical circulation}:
Resistance index falls.
Fetal growth restriction and/or PET:
> 0.72 is outside the normal limits from 26 w.
Aboubakr Elnashar

25. •S/D should be <3.
small increases in S/D= 3-5: chronic intrauterine
disease manifest by IUGR.
Not strictly useful:
{1. low sensitivity.
2. Gestation age dependent}.
•Diastolic flow is absent or reversed:
Fetal distress is almost certain:
Delivery may be indicated.
Aboubakr Elnashar

26. Normal
Absent
Reversed
Aboubakr Elnashar

27. 5. ± BPP:
± a role in high risk pregnancies:
Systematic review of RCT:
does not support its use as a test of fetal wellbeing
Uncontrolled observational studies:
BBP has good NPV
Fetal death is rare with normal BPP.
Aboubakr Elnashar

28. Thank you
Aboubakr Elnashar