EVIDENCE BASED APPROACH

BY:

Dr. AHMAD M. FAROUKResident of GYN/OBS.; MTH

UNDER SUPERVISION OF:

DR YASSER EL-SAEEDMD. CONSULTANT OFGYN/OBS. ; MTH

2014

FETAL MOVEMENTS

DFMC (Nr.& abnr.)

Factors affecting FM

Optimal management

I. HISTORY

II. EXAMINATIONS

III. CTG

IV. U/S

MANAGEMENT of special situations

I. RECURRENT

II. Before 24 wga

III. 24 -28 wga

Documentation.

Types of Fetal movements Respiratory movement

Simple movement :like kicks or limb movement.(short duration-variable amplitude)

Rolling movement : Due to changing position.(long duration-high amplitude).

Hiccough like movement.

OTHER activities like suckling the thumb or blinking.

Daily fetal movement count(DFMC) Clinically important parameter of fetal wellbeing.

It is the EASIEST & MOST AVAILABLE method for evaluating fetal condition.

Fetal movements should be assessed by subjective maternal perception of fetal movements.

FM is one of the first signs of fetal life. Fetal activity serves as an indirect measure of CNS 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 16weeks of gestation .

Normally: Most women are aware of fetal movements by 20 wga.

Increasing gradually till 32 wga (at 24wga=86….at 32wga=132/12 hrs.)however most of these movements are not felt by the mother .

Clinicians should be aware (and should advise women) that although fetal movements tend to plateau at 32 weeks of gestation, there is no reduction in the frequency of fetal movements in the late third trimester.

SLEEP CYCLES :20-40 min. rarely exceed 90 min in nr. Healthy fetus

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+0 weeks of gestation, they should contact their maternity unit.

If women are unsure whether movements are reduced after 28+0 weeks of gestation, they should be advised to lie on their left side and focus on fetal movements for 2 hours. If they do not feel 10 or more discrete movements in 2 hours, they should contact their midwife or maternity unit immediately.

Factors associated with RFMMaternal Perception Foetal movement

Busy mother

Anxiety

Placenta ant.prior 28 wga.

Poly hydramnios

Glucose& CO2 conc. In matrnal blood

lying down/sitting/standing

Alcohol,sedatives,

Corticosteroides

Fetal sleep.

Placental insufficiency

IUGR

NEURO-MUSCULAR anomalies(anencephaly )

Oligo-hydramnios

What Is the Optimal Management of

Women with Reduced Fetal Movements (RFM)?

exclude fetal death,

exclude fetal compromise,

and to identify pregnancies at risk of adverse pregnancy outcome

while avoiding unnecessary interventions.

What Should Be Included in the Clinical History?

duration of RFM,

whether :absence , first occasion OR recurrent RFM.

The history must include comprehensive stillbirth risk evaluation, including a

review of the presence of other factors associated with an increased risk of stillbirth, such as multiple consultations for RFM, known IUGR, hypertension, diabetes, extremes of maternal age, smoking, congenital malformation, racial/ethnic factors, poor past obstetric history,

CORTICOSTEROIDS in last 48 hrs.

Clinicians should be aware that a woman's risk status is fluid throughout pregnancy and that women should be transferred from low-risk to high-risk care program if complications occur.

If after discussion with the clinician it is clear that the woman does not have RFM, in the absence of further risk factors and the presence of a normal fetal heart rate on auscultation, there should be no need to follow up with further investigations.

What Should Be Covered in the Clinical Examination?

The key priority when a woman presents with RFM is

to confirm fetal viability. In most cases, a handheld Doppler device will confirm the presence of the fetal heart beat(exclude fetal death)

If the presence of a fetal heart beat is not confirmed,

immediate referral for ultrasound scan assessment of fetal cardiac activity must be undertaken.

BP measuerment to exclude pregnancy associated HTN.

Assessment of fetal size with the aim of detecting (SGA) fetuses.

Urine analysis (ptnuria). PET.

What Is the Role of Cardiotocography (CTG)?

After fetal viability has been confirmed and history confirms a decrease in fetal movements, arrangements should be made for the woman to have a cardiotocography to exclude fetal compromise if the pregnancy is over 28+0 weeks of gestation.

At least 20 min.

Normal FHR pattern healthy fetus with a properly functioning autonomic nervous system.

Computer systems for inter-pretation of CTG..!!!

>80 MIN. no acceleration fetal compromise

3.2% RFM.= ABNORMALITIES(IUGR-DISTRESS-

OLIGOHYDRAMNIOS-MALFORMATIONS)

56% RFM +high risk pregnancy =abnormal CTG.

What Is the Role of Ultrasound Scanning?

RFM persists despite a normal CTG

risk factors for FGR/stillbirth. AC

EFW {detect the SGA}

AFV

Fetal Doppler :more useful test of fetal wellbeing than CTG or BPP.

Is There Any Role for the Biophysical Profile (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.

If after discussion with the clinician it is clear that the woman does not have RFM, there are no other risk factors for stillbirth and there is the presence of a fetal

heart rate on auscultation, she can be reassured.

However, if the woman still has concerns, she should be advised to attend her maternity unit.

What Is the Optimal Surveillance Method for

Women Who Have Presented with RFM in Whom Investigations Are Normal?

Women should be reassured that 70% of pregnancies with a single episode of RFM are uncomplicated.

There are no data to support (kick charts) use.

Another episode RFM =immediate contact matrnityunit.

In a single retrospective cohort study, perinatal outcome was worse in women who had presented on more than one occasion with RFM. If a woman experiences a further episode of definite RFM,sheshould be referred for hospital assessment to exclude signs of compromise through the use of CTG and ultrasound.

Recurrent RFM

POOR perinatal outcome.(IUGR-stillbirth-PTL)

U/S

Exclude predisposing causes

TOP at term in nr. CTG &U/S.

RFM before 24 wga 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 .

RFM (24-28 wga)

Presence of a fetal heartbeat should be confirmed by auscultation with a Doppler handheld device.

What Should We Document in the Maternal Records?

It is important that full details of assessment and management are documented.

It is also important to record the advice given about follow-up and when/where to present if a further episode of RFM is perceived.

Accurate record keeping is needed in sufficient detail to ensure that the consultation and outcome can be easily audited and continuity of care provided.

RFM

YES

Recurrent

AUSCULTATE , CTG &U/S

1st episode

RISK

Auscultate,CTG&U/S

NO RISK

Auscultate &arrange for

CTG

NO

FHR nr.

Reassure &

Instruct

THANKS

SPECIAL THANKS TO DR/YASSER ELSAEED &DR WAFAA BENJAMIN