Evidence base concerning management of recurrent Reduced Fetal Movements (RFMs)
RFMs can be a presentation of actual or impending fetal demise. The latter is an emergency. Small for gestational age babies are over represented among women with RFMs. This is because placental dysfunction, which can cause SGA, is a major cause of actual or impending fetal demise and RFMs can be a presentation of this.
However, the evidence that recurrent episodes suggest compromise is much poorer. The original RCOG Guidance (1) was based on 1 small series of 160 women with RFMs (2). Analysis of ultrasound findings (3,4) have shown conflicting results despite having overlapping cohorts of women with recurrent RFMs. They do suggest small increases in the risk of ultrasound markers of placental compromise but the level of risk is much less than for most established risk factors. A cohort of 591 women from 6 local units with RFMs (5) during a single month estimated that 16% of all pregnancies had multiple episodes. It demonstrated no increase in perinatal risk when comparing women with a single and multiple episodes. The AFFIRM study (6) was a multicentre large RCT evaluating a package of increased awareness and structured management of RFMs. Part of the structured management involved offering induction of labour to women with recurrent RFMs. The trial showed no benefit to the package but a significant increase in neonatal unit admission. This suggests that some of the package was potentially harmful.
- Induction of labour. Prior to 39 weeks, this can increase neonatal and long term morbidity and increase CS rates. The implications on other women because of increased delivery suite activity should be considered. All these are highlighted in SBLV2 (7). The baby with a markedly abnormal CTG should be delivered by CS.
- This may detect the SGA baby but umbilical artery Doppler may be normal in an IUGR baby at term. Ultrasound will often not detect other causes of fetal demise eg feto-maternal haemorrhage or sepsis and should not reassure in the presence of an abnormal CTG.
- RCOG Green-top Guideline No. 57. 2011 Reduced Fetal Movements. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_57.pdf
- O’Sullivan O, Stephen G, Martindale E, Heazell AE. Predicting poor perinatal outcome in women who present with decreased fetal movements. J Obstet Gynaecol. 2009;29:705–10.
- Scala C, Bhide A, Familiari A, Pagani G, Khalil A, Papageorghiou A, Thilaganathan B. 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.
- Binder J, Monaghan C, Thilaganathan B, Morales-Roselló J, Khalil A.Reduced fetal movements and cerebroplacental ratio: evidence for worsening fetal hypoxemia. Ultrasound Obstet Gynecol. 2018 Mar;51(3):375-380.
- Bhatia M, Mitsi V, Court L, Thampi P, El-Nasharty M, Hesham S, Randall W, Davies R, Impey L. The outcomes of pregnancies with reduced fetal movements: A retrospective cohort study. Acta Obstet Gynecol Scand. 2019 May 31. doi: 10.1111/aogs.13671.
- Norman JE, Heazell AEP, Rodriguez A, Weir CJ, Stock SJE, Calderwood CJ, Cunningham Burley S, Frøen JF, Geary M, Breathnach F, Hunter A, McAuliffe FM, Higgins MF, Murdoch E, Ross-Davie M, Scott J, Whyte S; AFFIRM investigators. Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trial. Lancet. 2018 Nov 3;392(10158):1629-1638.
- Saving Babies Lives 2. https://www.england.nhs.uk/wp-content/uploads/2019/07/saving-babies-lives-care-bundle-version-two-v5.pdf
Mr Lawrence Impey, Oxford PSC Maternity Clinical Lead, Fetal Medicine Consultant, OUHFT