Grand Rounds

Decreased Fetal Movement: Quantifying Risk for Stillbirth and Other Adverse Outcomes

BACKGROUND AND PURPOSE:

Turner et al. (JAMA Network Open, 2021) examined the association of decreased fetal movement (DFM) and pregnancy outcomes in a setting where a management algorithm was in use

Cohort study (2009 to 2019)
- Australia’s largest maternity hospital
Population
- All singleton births
- >28 weeks
- No known congenital anomalies
Exposure
- Presentation to hospital with DFM >28 weeks
Study design
- Multivariate analysis was used to account for covariates
Primary outcome
- The incidence of stillbirth
Secondary outcomes
- Obstetric intervention
- Small for gestational age (SGA)
- Composite adverse perinatal outcome ≥1 of the following: NICU admission | Severe acidosis (UA pH <7.0 or base excess ≤−12.0 mmol/L) | 5-minute Apgar score <4 | Stillbirth or neonatal death

101,597 pregnancies
- Presented ≥1 episode of DFM: 8821 (8.7%)
- No DFM (controls): 92 776 women (91.3%)
Women who presented with DFM were
- Younger (P < 0.001)
  - DFM: mean age 30.4 years
  - Control mean age: 31.5 years
- More likely to be nulliparous (P < 0.001)
  - DFM: 54.9%
  - Control: 45.5%
- More likely to have had a previous stillbirth (P < 0.001)
  - DFM: 2.1%
  - Control: 1.2%
- Less likely to have a previous cesarean delivery (P < 0.001)
  - DFM: 13.6%
  - Control: 18.8%

Risk for Stillbirth

Stillbirth rate during the study period (>28 weeks)
- 2.0 per 1000 births
Overall, presenting with DFM was not associated with higher odds of stillbirth
- DFM: 0.1% (9 women)
- Control: 0.2% (185 women)
- Adjusted odds ratio (aOR) 0.54 (95% CI, 0.23 to 1.26; P=0.16)
Odds of stillbirth were significantly higher in women with ≥2 presentations vs 1
- aOR 4.96 (95% CI, 0.98 to 24.98; P=.05)
Presenting with DFM was associated with higher odds of
- SGA: aOR 1.14 (95% CI, 1.03 to 1.27; P=0.01)
- The composite adverse perinatal outcome: aOR 1.14 (95% CI, 1.02 to 1.27; P=0.02)
- Planned early term birth: aOR 1.26 (95% CI, 1.15 to 1.38; P<0.001)
- Induction of labor: aOR 1.63 (95% CI, 1.53 to 1.74; P<0.001)
- Emergency cesarean delivery: aOR 1.18 (95% CI, 1.09 to 1.28; P<0.001)

Overall, there was no significant difference in incidence of stillbirth between women with decreased fetal movement and the control population
Authors suggest that the lack of difference in stillbirth between groups, despite increased risk for adverse perinatal outcomes, may be due to enhanced awareness that leads to quickly seeking care if movements are perceived to be reduced

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