But Australian study found higher risk for other adverse outcomes

Late-stage decreased fetal movement (DFM) was not linked with an increased risk of stillbirth, according to researchers in Australia, but DFM at their institution is heavily managed, and DFM was associated with other negative outcomes.

At the country’s largest maternal hospital, all women presenting with DFM after 28 weeks and 0 days gestation receive electronic fetal heart rate monitoring and a blood test to detect fetomaternal hemorrhage, as well as consideration for ultrasonography to assess fetal growth and well-being, explained Sailesh Kumar, DPhil, Mater Research Institute at the University of Queensland in South Brisbane, and co-authors.

Among more than 8,000 women, 8.7% presented with DFM, but having the condition was not associated with higher odds of stillbirth (0.1% versus 0.2% who presented without DFM) for an adjusted odds ratio 0.54 (95% CI 0.23-1.26, P=0.16), they reported in JAMA Network Open.

Still, presenting with DFM was linked with higher odds of a fetus being born small for gestational age (SGA), adverse perinatal outcome, planned early-term birth, induction of labor, and emergency C-section, leading the authors to emphasize that “any decision for obstetric intervention should not be based on the perceived risks of stillbirth solely associated with DFM and that management should be individualized, taking into account other potential associated maternal and fetal risk factors.”

In an invited commentary accompanying the study, Lay-Kok Tan, MBBS, M.MED (O&G), of the KK Women’s and Children’s Hospital in Singapore, said that the “most important finding from this paper is the association of DFM with the birth of an infant who is small for their gestational age, with the symptom of DFM being a reflection of the fetal response to a hypoxic milieu generated by placental dysfunction.”

He urged clinicians to add “ultrasonographic fetal growth and well-being assessment into their clinical algorithm” to their existing methods for managing DFM, and cited a Scandinavian study, along with guidelines from the U.K. Royal College of Obstetricians and Gynecologists, as two supportive sources for this approach. The Royal Australian and New Zealand College of Obstetricians and Gynecologists, the American College of Obstetrics and Gynecology, and the Society for Maternal-Fetal Medicine also have guidance for antepartum/intrapartum fetal surveillance.

The authors noted that “the management of DFM changed over the study period” at their hospital, such that in 2016, all women presenting with DFM after 28 weeks underwent more extensive testing.

However, Tan also cautioned that because the current study was performed at a center with “adherence to a clear clinical guideline,” the findings should not be applied to “DFM in other settings… DFM is a symptom that women should report and clinicians should investigate, especially if recurrent.”

The cohort study focused on 101,597 women with singleton births and no known congenital anomaly after 28 weeks’ gestation, of whom 8.7% presented with DFM. Women in the DFM group and the no-DFM group were majority White with a BMI of around 23 kg/m2.

Kumar’s group reported that compared with women presenting without DFM, those with DFM were younger (mean age, 30.4 vs 31.5, P<0.001), more likely to be nulliparous (54.9% versus 45.5%, P<0.001) and have a previous stillbirth (2.1% versus 1.2%, P<0.001). They were less likely to have a previous C-section delivery (13.6% versus 18.8%, P<0.001).

While the study data on the primary outcome — incidence of stillbirth — did not show an increased risk with DFM, it was a different story with other outcomes:

  • Higher odds of a fetus being born SGA: adjusted OR 1.14 (95% CI 1.03-1.27, P=0.01).
  • Higher odds of planned early term birth: aOR 1.26 (95% CI 1.15-1.38, P<0.001).
  • Higher odds of induction of labor: aOR 1.63 (95% CI 1.53-1.74, P<0.001).
  • Higher odds of emergency C-section: aOR 1.18 (95% CI 1.09-1.28, P<0.001).

Finally, the authors calculated a composite adverse perinatal outcome of at least one of the following: neonatal ICU admission, umbilical artery pH <7.0 or base excess ≤ −12.0 mmol/L, 5-minute Apgar score <4, or stillbirth or neonatal death. The aOR for this outcome was 1.14 (95% CI 1.02-1.27, P=0.02).

Kumar and co-authors explained that “Over the study period, the absolute number of women presenting with DFM increased, but the rate of increase was similar before the introduction of national guidelines compared with after the introduction. The increase in the number of women presenting with DFM is likely associated with increased community awareness, through frequent media campaigns, of the importance of monitoring fetal movements.”

  1. Decreased fetal movement (DFM) was not associated with an increased risk of stillbirth, but there was significant association with small for gestational age, planned early-term birth, C-section delivery, and a composite of adverse perinatal outcomes.

  2. The study was done at the largest maternal hospital in Australia where, since 2016, all women who present with DFM after 28 weeks and 0 days gestation receive electronic fetal heart rate monitoring and a blood test to detect fetomaternal hemorrhage, as well as consideration for ultrasonography to assess fetal growth and well-being.

Shalmali Pal, Contributing Writer, BreakingMED™

The study was supported by the Mater Foundation.

Kumar reported no relationships relevant to the contents of this paper to disclose. Co-authors reported support from the Mater Foundation and the National Health and Medical Research Council of Australia.

Tan reported no relationships relevant to the contents of this paper to disclose.

Cat ID: 41

Topic ID: 83,41,730,41,192,925