Decreased fetal movement: Diagnosis, evaluation, and management
- Ruth C Fretts, MD, MPH
Ruth C Fretts, MD, MPH
- Assistant Professor of Obstetrics & Gynecology
- Harvard Medical School
Maternal perception of fetal movement is reassuring for pregnant women, while decreased fetal movement (DFM) is a common reason for concern. While an active fetus is a reassuring sign that the fetus is alive and in good condition, the use of fetal kick counting as a fetal surveillance tool has not achieved widespread acceptance. This is, in part, because optimal methods of diagnosis, evaluation, and management of DFM have not been determined. This topic will review normal fetal movement and provide the author’s approach to diagnosis, evaluation, and management of DFM.
NORMAL FETAL MOVEMENT
Sonographically, fetal activity can be noted as early as 7 to 8 weeks of gestation . Maternal perception of fetal movement typically begins in the second trimester at around 16 to 20 weeks of gestation and occurs earlier in parous women than nulliparous women . The mother's first perception of fetal movement, termed "quickening," is often described as a gentle flutter .
In the second and third trimesters, sonography reveals a wide range of movements of the fetal trunk (eg, bending, startle, hiccup, breathing, rotation), limbs (eg, stretch, hand to face, opening and closing of hands), and face and head (eg, head rotation, suck, yawn, tongue protrusion). When sonographically detected movements were correlated with maternal perception, approximately 50 percent of isolated limb movements were perceived by the mother, whereas 80 percent of movements involving both the trunk and limb were perceived in one study . In a literature review, mothers perceived 33 to 88 percent of sonographically visualized fetal movements .
Fetal movement increases throughout day, with peak activity late at night . The frequency of fetal movement in normal pregnancy is probably constant throughout the third trimester ; however, the quality of perceived movements changes. Although some studies report that fetal activity normally decreases near term, this is likely due to counting during fetal quiet cycles, which become longer with advancing gestation, or inclusion of high-risk pregnancies.
PREVALENCE OF DECREASED FETAL MOVEMENT
At least 40 percent of pregnant women become concerned about DFM one or more times during pregnancy . Most cases are transient. Four to 15 percent of pregnant women will contact their care provider because of persistent DFM in the third trimester [8-11].
- de Vries JI, Fong BF. Normal fetal motility: an overview. Ultrasound Obstet Gynecol 2006; 27:701.
- Gillieson M, Dunlap H, Nair R, Pilon M. Placental site, parity, and date of quickening. Obstet Gynecol 1984; 64:44.
- Raynes-Greenow CH, Gordon A, Li Q, Hyett JA. A cross-sectional study of maternal perception of fetal movements and antenatal advice in a general pregnant population, using a qualitative framework. BMC Pregnancy Childbirth 2013; 13:32.
- Hijazi ZR, East CE. Factors affecting maternal perception of fetal movement. Obstet Gynecol Surv 2009; 64:489.
- Patrick J, Campbell K, Carmichael L, et al. Patterns of gross fetal body movements over 24-hour observation intervals during the last 10 weeks of pregnancy. Am J Obstet Gynecol 1982; 142:363.
- Valentin L, Löfgren O, Marsál K, Gullberg B. Subjective recording of fetal movements. I. Limits and acceptability in normal pregnancies. Acta Obstet Gynecol Scand 1984; 63:223.
- Saastad E, Winje BA, Israel P, Frøen JF. Fetal movement counting--maternal concern and experiences: a multicenter, randomized, controlled trial. Birth 2012; 39:10.
- Tveit JV, Saastad E, Bordahl PE, et al. The epidemiology of decreased fetal movements. Proceedings of the Norwegian Perinatal Society Conference, November 2006.
- Frøen JF. A kick from within--fetal movement counting and the cancelled progress in antenatal care. J Perinat Med 2004; 32:13.
- Frøen JF, Saastad E, Tveit JV, et al. [Clinical practice variation in reduced fetal movements]. Tidsskr Nor Laegeforen 2005; 125:2631.
- Tveit JV, Saastad E, Stray-Pedersen B, et al. Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement. BMC Pregnancy Childbirth 2009; 9:32.
- Frøen JF, Tveit JV, Saastad E, et al. Management of decreased fetal movements. Semin Perinatol 2008; 32:307.
- Dutton PJ, Warrander LK, Roberts SA, et al. Predictors of poor perinatal outcome following maternal perception of reduced fetal movements--a prospective cohort study. PLoS One 2012; 7:e39784.
- Flenady V, MacPhail J, Gardener G, et al. Detection and management of decreased fetal movements in Australia and New Zealand: a survey of obstetric practice. Aust N Z J Obstet Gynaecol 2009; 49:358.
- Mangesi L, Hofmeyr GJ, Smith V, Smyth RM. Fetal movement counting for assessment of fetal wellbeing. Cochrane Database Syst Rev 2015; :CD004909.
- Winje BA, Wojcieszek AM, Gonzalez-Angulo LY, et al. Interventions to enhance maternal awareness of decreased fetal movement: a systematic review. BJOG 2016; 123:886.
- Sheikh M, Hantoushzadeh S, Shariat M. Maternal perception of decreased fetal movements from maternal and fetal perspectives, a cohort study. BMC Pregnancy Childbirth 2014; 14:286.
- Moore TR, Piacquadio K. A prospective evaluation of fetal movement screening to reduce the incidence of antepartum fetal death. Am J Obstet Gynecol 1989; 160:1075.
- Minors DS, Waterhouse JM. The effect of maternal posture, meals and time of day on fetal movements. Br J Obstet Gynaecol 1979; 86:717.
- http://www.firstcandle.org/cms/wp-content/uploads/2010/09/Kicks-Count-ABC-Brochure-English1.pdf (Accessed on August 06, 2012).
- Royal College of Obstetricians and Gynaecologists. Green-top Guideline 57. Reduced Fetal Movements. http://www.rcog.org.uk/guidelines (Accessed on April 01, 2011).
- Neldam S. Fetal movements as an indicator of fetal wellbeing. Lancet 1980; 1:1222.
- Grant A, Elbourne D, Valentin L, Alexander S. Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons. Lancet 1989; 2:345.
- Sadovsky E, Ohel G, Havazeleth H, et al. The definition and the significance of decreased fetal movements. Acta Obstet Gynecol Scand 1983; 62:409.
- Pearson JF, Weaver JB. Fetal activity and fetal wellbeing: an evaluation. Br Med J 1976; 1:1305.
- Kuwata T, Matsubara S, Ohkusa T, et al. Establishing a reference value for the frequency of fetal movements using modified 'count to 10' method. J Obstet Gynaecol Res 2008; 34:318.
- Smith CV, Davis SA, Rayburn WF. Patients' acceptance of monitoring fetal movement. A randomized comparison of charting techniques. J Reprod Med 1992; 37:144.
- Winje BA, Saastad E, Gunnes N, et al. Analysis of 'count-to-ten' fetal movement charts: a prospective cohort study. BJOG 2011; 118:1229.
- Pillai M, James D. The development of fetal heart rate patterns during normal pregnancy. Obstet Gynecol 1990; 76:812.
- Pillai M, James D. Behavioural states in normal mature human fetuses. Arch Dis Child 1990; 65:39.
- Tuffnell DJ, Cartmill RS, Lilford RJ. Fetal movements; factors affecting their perception. Eur J Obstet Gynecol Reprod Biol 1991; 39:165.
- Linde A, Pettersson K, Rådestad I. Women's Experiences of Fetal Movements before the Confirmation of Fetal Death--Contractions Misinterpreted as Fetal Movement. Birth 2015; 42:189.
- Winje BA, Røislien J, Frøen JF. Temporal patterns in count-to-ten fetal movement charts and their associations with pregnancy characteristics: a prospective cohort study. BMC Pregnancy Childbirth 2012; 12:124.
- Sergent F, Lefèvre A, Verspyck E, Marpeau L. [Decreased fetal movements in the third trimester: what to do?]. Gynecol Obstet Fertil 2005; 33:861.
- Heazell AE, Bernatavicius G, Roberts SA, et al. A randomised controlled trial comparing standard or intensive management of reduced fetal movements after 36 weeks gestation--a feasibility study. BMC Pregnancy Childbirth 2013; 13:95.
- Heazell AE, Sumathi GM, Bhatti NR. What investigation is appropriate following maternal perception of reduced fetal movements? J Obstet Gynaecol 2005; 25:648.
- Bekedam DJ, Visser GH, de Vries JJ, Prechtl HF. Motor behaviour in the growth retarded fetus. Early Hum Dev 1985; 12:155.
- Scala C, Bhide A, Familiari A, et al. Number of episodes of reduced fetal movement at term: association with adverse perinatal outcome. Am J Obstet Gynecol 2015; 213:678.e1.
- Saastad E, Winje BA, Stray Pedersen B, Frøen JF. Fetal movement counting improved identification of fetal growth restriction and perinatal outcomes--a multi-centre, randomized, controlled trial. PLoS One 2011; 6:e28482.
- Dubiel M, Gudmundsson S, Thuring-Jönsson A, et al. Doppler velocimetry and nonstress test for predicting outcome of pregnancies with decreased fetal movements. Am J Perinatol 1997; 14:139.
- Sebring ES, Polesky HF. Fetomaternal hemorrhage: incidence, risk factors, time of occurrence, and clinical effects. Transfusion 1990; 30:344.
- Giacoia GP. Severe fetomaternal hemorrhage: a review. Obstet Gynecol Surv 1997; 52:372.
- Bakas P, Liapis A, Giner M, et al. Massive fetomaternal hemorrhage and oxytocin contraction test: case report and review. Arch Gynecol Obstet 2004; 269:149.
- Lau MS, Tan JV, Tan TY, et al. Idiopathic chronic fetomaternal haemorrhage resulting in hydrops--a case report. Ann Acad Med Singapore 2003; 32:642.
- Malcus P, Bjorklund LJ, Lilja M, et al. Massive feto-maternal hemorrhage: diagnosis by cardiotocography, Doppler ultrasonography and ST waveform analysis of fetal electrocardiography. Fetal Diagn Ther 2006; 21:8.
- Sueters M, Arabin B, Oepkes D. Doppler sonography for predicting fetal anemia caused by massive fetomaternal hemorrhage. Ultrasound Obstet Gynecol 2003; 22:186.
- Thomas A, Mathew M, Unciano Moral E, Vaclavinkova V. Acute massive fetomaternal hemorrhage: case reports and review of the literature. Acta Obstet Gynecol Scand 2003; 82:479.
- Weisberg L, Kingdom J, Keating S, et al. Treatment options in fetomaternal hemorrhage: four case studies. J Obstet Gynaecol Can 2004; 26:893.
- Zizka Z, Calda P, Zlatohlavkova B, et al. Massive fetomaternal transplacental hemorrhage as a perinatology problem, role of ABO fetomaternal compatibility--case studies. Med Sci Monit 2001; 7:308.
- Hofmeyr GJ, Novikova N. Management of reported decreased fetal movements for improving pregnancy outcomes. Cochrane Database Syst Rev 2012; :CD009148.
- Frøen JF, Arnestad M, Frey K, et al. Risk factors for sudden intrauterine unexplained death: epidemiologic characteristics of singleton cases in Oslo, Norway, 1986-1995. Am J Obstet Gynecol 2001; 184:694.
- NORMAL FETAL MOVEMENT
- PREVALENCE OF DECREASED FETAL MOVEMENT
- PATHOPHYSIOLOGY AND SIGNIFICANCE
- DIAGNOSIS OF DECREASED FETAL MOVEMENT
- Our approach
- Kick counts
- DIFFERENTIAL DIAGNOSIS
- Initial evaluation
- Additional testing
- - Ultrasound examination
- - Doppler velocimetry
- - Testing for fetomaternal transfusion
- PREGNANCY MANAGEMENT
- SUMMARY AND RECOMMENDATIONS