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

Am J Obstet Gynecol. 2015 Nov;213(5):678.e1-6. doi: 10.1016/j.ajog.2015.07.015. Epub 2015 Jul 20.

Editor’s comment: Prof. Dan Farine: Reduced fetal movements
This is another interesting development in the saga of reduced fetal movements. The Canadian (1) and Australian NZ (2) guidelines ask women to monitor for Reduced Fetal Movements (RFM) while the British (3) and the American (4) ones make it an option and not a recommendation. These divergent approaches are interesting and maybe concerning as there is a large study from Norway (5) that showed that in a large cohort that Monitoring and managing RFM may eliminate one 1/3 of stillbirths. The current study goes beyond assessing RFM as it looked at the women that had repeated RFM. There was very limited data on repeated RFM prior to this study and most of us managed the subsequent episode similarly to the first one. In this study a subset of the patient had more than 1 episode of RFM. These women had a high incidence of placental insufficiency as well as high incidence of SGA (close to 50%) that was often not there in the first episode of the RFM. AS the authors outline this suggests that placental insufficiency as associated and possibly the cause of both RFM and growth restriction.

This study may have very important clinical implications. Women may need to be advised that repeated episodes of RFM may carry an increased risk to the baby and clinicians may consider a change in mat on the form of either increased fetal surveillance or delivery close to term.

Objective

The aims of this study were evaluation of the association of reduced fetal movements (RFM) and small-for-gestational-age (SGA) birth at term and to explore if fetal and maternal outcomes are different with single vs repeated episodes of RFM and normal fetal assessment test results.

Study Design

This was a retrospective cohort study of all singleton pregnancies referred for RFMs at a tertiary fetal medicine unit from January 2008 through September 2014. Ultrasound and Doppler indices were obtained from a computerized ultrasound database and pregnancy outcome was collected from hospital records.

Results

Of the 21,944 women with a singleton pregnancy booked for maternity care during the study period, 1234 women (5.62%) reported RFMs >36+0 weeks. Of these, 1029 women (83.4%) reported a single episode of RFM and 205 (16.6%) had ≥2 presentations for RFM. Women with repeated RFMs had a significantly higher mean uterine artery pulsatility index in the second trimester. The prevalence of SGA baby at birth in women presenting with a single episode as compared to repeated episodes of RFM was 9.8% and 44.2%, respectively (odds ratio, 7.3; 95% confidence interval, 5.1–10.4; P < .05).

Conclusion

Repeated episodes of RFMs at term are more likely to occur in women with high second-trimester uterine artery Doppler resistance indices and are strongly associated with the birth of SGA infants. Women presenting with repeated episodes of RFM should be treated as being at high risk of placental dysfunction irrespective of the results of prenatal ultrasound and Doppler assessment.

Key words: maternal outcomes, newborn outcomes, reduced fetal movements, small gestational age, uterine artery Doppler.

Footnotes

Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, United Kingdom

Corresponding author: Carolina Scala, MD.

The authors report no conflict of interest.