About decreased fetal movement

• Decreased fetal movement occurs in 5-10% of all pregnancies.
• These pregnancies are at increased risk for fetal growth restrictions, preterm births, and stillbirths.
• Fetal deaths are not sudden. 50% of unexplained stillbirths are growth restricted, suggesting that there is a time window for intervention and prevention of deaths.
  
  
• MOMS Study. 50% of the moms perceived gradual decreased fetal movement several days prior to death. 56% of the moms reported decreased fetal movement as the first reason to believe that the baby is not doing well. Only 50% of moms were told to do kick count by their doctors.
  
  
• FEMINA Norway. The first 1000 cases reveal that women still do not get enough information on the importance of fetal activity to act in such a way to protect their baby.
  
  
• Patient educational materials are an important part of promoting Kick Count awareness and patient compliance. We provide Kick Count FAQs, Stillbirth FAQs and a Kick Count Chart to facilitate your patient education on this website.

During the 1970s and 1980s, several reports showed that fetal Kick Counting significantly reduced stillbirth rates.^1,2,3 Moore and Piacquadio⁴ observed a significant decline in fetal mortality from 8.7 to 2.1 per 1000 after institution of formal movement counting where maternal perception of 10 fetal movements within 2 hours is considered normal. The count-to-10 fetal movement screening program is deemed simple and effective in reducing fetal mortality rate. However, Grant et al⁵ in Lancet reported no significant benefit.

In "A kick from within--fetal movement counting and the cancelled progress in antenatal care,"⁶ Froen reanalyzed the study's methodology and conclusion. In fact, the literature review of 24 studies from Western countries after 1970 concluded the following:

• Reduced fetal movements are associated with adverse pregnancy outcome in both high- and low-risk pregnancies
• Maternal vigilance with fetal movement counting reduces stillbirth rate, in particular stillbirths deemed avoidable

In the recently completed "MOMS Study"⁷ (Maternal Observations and Memories of Stillbirths), data from 5,000 women who had a stillbirth is currently being analyzed. Early results reveal the following:

• Fifty percent of the women perceived gradual decreased fetal movement several days prior to fetal death
• Fifty six percent of women reported decreased fetal movement as the first reason to believe that the baby was not doing well
• Only about 50 percent of women were told by their doctors about Kick Counting

FEMINA⁸ (Fetal Movement Intervention Assessment) is an ongoing international research collaboration to improve pregnancy outcome through better understanding of reduced fetal activity. Froen previously reported that 50% of affected mothers waited more than 24 hours without any fetal activity before contacting health professionals - 1 in 3 waited more than 48 hours. Public relations efforts in Norway as well as in the U.S. are on the way to educating the public regarding Kick Count.

Stillbirth is "unexplained" when no obvious cause is found despite thorough postmortem investigation. Unexplained stillbirth represents 25-60% of all fetal death with risk increasing late in pregnancy, particularly after 37 to 39 weeks of gestation. Froen and Gardosi⁹ reported that 52% of unexplained stillbirths have intrauterine growth restriction. Maternal overweight or obesity, high maternal age, and low education further increase the risk. Perhaps the unexplained stillbirths are not "sudden," suggesting that there is a window of time where intervention may prevent stillbirth.

Literature review by Fretts¹⁰ identified 15 risk factors for stillbirth, with pre-pregnancy obesity, low social economic status, and advanced maternal age being the most prevalent risk factors. Unexplained stillbirths and stillbirths related to growth restriction are leading contributors to late fetal losses after 28 weeks. Antepartum testing in patients at risk decreases the risk of late fetal loss, however is associated with higher intervention rates.

Smith et al¹¹ found that maternal serum marker Pregnancy-associated Plasma Protein A (PAPP-A) in the lowest fifth percentile between 10-14 weeks is associated with increased risk of premature delivery, preeclampsia, and stillbirth.

Dr. Uma Reddy from the National Institute of Health (NIH), is leading the Stillbirth Collaborative Research Network (SCRN), which aims to (1) obtain a geographic population-based determination of the incidence of stillbirth defined as fetal death at 20 weeks gestation or greater; (2) determine the causes of stillbirth using a standard stillbirth postmortem protocol that includes review of clinical history, protocols for autopsies and pathologic examinations of the fetus and placenta, and other postmortem tests to illuminate genetic, maternal, and other environmental influences; and (3) elucidate risk factors for stillbirth.

Dr. Ruth Fretts presented the following strategy to prevent stillbirth at the recent 2006 International Stillbirth Alliance conference:

• Institute program for stillbirth evaluation, including standard autopsy protocol
• Institute on going risk assessment for each individual woman for unexplained stillbirth risks, including obesity, advanced maternal age >35, smoking, low social economic status, infertility, decrease fetal movement, and black race
• Vigilance of fetal growth, including using customized fetal growth chart
• Kick Count
• Antepartum testing for at risk pregnancy
• Induction with its risk and benefit evaluation

Even low risk pregnancies with decreased fetal movement are associated with having a higher risk of fetal distress during labor, restricted intrauterine growth, oligohydramnios, polyhydramnios, low Apgar scores, asphyxia, higher frequency of stillbirth and neonatal deaths. It is recommended that low risk pregnancies with decreased fetal movement should be considered high risk and thus should have increased surveillance.¹²

There is no standard management protocol for evaluating women with reduced fetal movement. However, a reasonable approach to these women who are at risk for stillbirth could include:

• Evaluate the complaint
• Perform antepartum testing to evaluate imminent danger
• Evaluate for other risk factors, including fetal growth to avoid adverse outcome
• Follow up

In cases of stillbirth, autopsy and placental evaluation are important to the understanding of stillbirth and counseling for subsequent pregnancies. The success rate of karyotyping using placental tissue is much better than skin.

Journal Articles

¹ Pearson JF, Weaver JB. Fetal activity and fetal wellbeing: an evaluation. Br Med J. 1976 May 29;1(6021):1305-7. PMID: 1268677 [PubMed - indexed for MEDLINE]

² Sadovsky E, Yaffe H. Daily fetal movement recording and fetal prognosis. Obstet Gynecol. 1973 Jun;41(6):845-50. No abstract available. PMID: 4196643 [PubMed - indexed for MEDLINE]

³ Neldam S. Fetal movements as an indicator of fetal well-being. Dan Med Bull. 1983 Jun;30(4):274-8. No abstract available. PMID: 6872585 [PubMed - indexed for MEDLINE]

⁴ Moore TR, Piacquadio K. A prospective evaluation of fetal movement screening to reduce the incidence of antepartum fetal death. Am J Obstet Gynecol. 1989 May;160(5 Pt 1):1075-80. PMID: 2729383 [PubMed - indexed for MEDLINE]

⁵ Grant A, Valentin L, et al. Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons. Lancet. 1989 Aug 12;2 (8659):345-9. PMID: 2569550 [PubMed - indexed for MEDLINE]

⁶ Froen JF. A kick from within--fetal movement counting and the cancelled progress in antenatal care. J Perinat Med. 2004;32(1):13-24. J Perinat Med. 2004;32(1):13-24. Review. PMID: 15008381 [PubMed - indexed for MEDLINE

⁷ Froen et al MOMS Study (2005)
www.momstudy.com

⁸ Froen et al FEMINA (on going)
http://folk.uio.no/jfr/Protocol.pdf

⁹ Froen JF, Gardosi JO, Thurmann A, Francis A, Stray-Pedersen B. Restricted fetal growth in sudden intrauterine unexplained death. Acta Obstet Gynecol Scand. 2004 Sep;83(9):801-7. PMID: 15315590 [PubMed - indexed for MEDLINE

¹⁰ Fretts, RC. Etiology and prevention of stillbirth. Am J Obstet Gynecol. 2005 Dec;193(6):1923-35. Review. PMID: 16325593 [PubMed - indexed for MEDLINE]

¹¹Smith GC, Shah I, Crossley JA, Aitken DA, Pell JP, Nelson SM, Cameron AD, Connor MJ, Dobbie R. Pregnancy-associated plasma protein A and alpha-fetoprotein and prediction of adverse perinatal outcome. Obstet Gynecol. 2006 Jan;107(1):161-6. PMID: 16394054 [PubMed - indexed for MEDLINE]

¹²http://www.sidsalliance.org/conf2005/library/Preventin_of_Unexplained.pdf

Current Scientific Research

MOMS Study (Study of Maternal Observations and Memories of Stillbirths) 5000 moms with stillbirths participated for better understanding of stillbirths and prevention.
www.momstudy.com

FEMINA (Fetal Movement Intervention Assessment), an ongoing international, interdisciplinary collaborative research effort to improve pregnancy outcomes through better understanding of reduced fetal activity.
http://folk.uio.no/jfr/images/L%20JFF%20Femina%20English%202004_files/frame.htm

Stillbirth Collaborative Research Network (SCRN), five-year NIH study to understand the epidemiology and etiology of stillbirth. This network includes: five clinical centers at Brown University, Emory University, University of Utah, University of Texas Medical Branch, and University of Texas at San Antonio; and a data coordinating center at Research Triangle International. The goal of the research is to standardize stillbirth evaluation protocols of postmortem, maternal and placental examination which will improve diagnoses of stillbirth causes and identify possible risk factors for stillbirth.
http://www.nichd.nih.gov/cdbpm/pp/research_programs.htm

Customized fetal growth chart

http://www.gestation.net/fetal_growth/fetal_growth.htm
http://www.perinatal.nhs.uk

Conferences

10^th Annual SIDS International Conference, 2008 Portsmouth, UK
http://firstcandle.org

3^rd Annual Conference of the International Stillbirth Alliance, 2007 London, UK
www.isa2007.org