A better understanding of the association between maternal perception of foetal movements and late stillbirth\u2014findings from an individual participant data meta-analysis

John M D Thompson,Robin S Cronin,Edwin A Mitchell,Adrienne Gordon,Lesley M E Mccowan,Louise M O’Brien,Alexander E P Heazell,Jessica Wilson,Camille H Raynes-Greenow,Tomasina Stacey,Billie F Bradford,Lisa M Askie,Vicki M Cullling,Minglan Li

doi:10.1186/s12916-021-02140-z

Abstract

BackgroundLate stillbirth continues to affect 3–4/1000 pregnancies in high-resource settings, with even higher rates in low-resource settings. Reduced foetal movements are frequently reported by women prior to foetal death, but there remains a poor understanding of the reasons and how to deal with this symptom clinically, particularly during the preterm phase of gestation. We aimed to determine which women are at the greatest odds of stillbirth in relation to the maternal report of foetal movements in late pregnancy (≥ 28 weeks’ gestation).MethodsThis is an individual participant data meta-analysis of all identified case-control studies of late stillbirth. Studies included in the IPD were two from New Zealand, one from Australia, one from the UK and an internet-based study based out of the USA. There were a total of 851 late stillbirths, and 2257 controls with ongoing pregnancies.ResultsIncreasing strength of foetal movements was the most commonly reported (> 60%) pattern by women in late pregnancy, which were associated with a decreased odds of late stillbirth (adjusted odds ratio (aOR) = 0.20, 95% CI 0.15 to 0.27). Compared to no change in strength or frequency women reporting decreased frequency of movements in the last 2 weeks had increased odds of late stillbirth (aOR = 2.33, 95% CI 1.73 to 3.14). Interaction analysis showed increased strength of movements had a greater protective effect and decreased frequency of movements greater odds of late stillbirth at preterm gestations (28–36 weeks’ gestation). Foetal hiccups (aOR = 0.45, 95% CI 0.36 to 0.58) and regular episodes of vigorous movement (aOR = 0.67, 95% CI 0.52 to 0.87) were associated with decreased odds of late stillbirth. A single episode of unusually vigorous movement was associated with increased odds (aOR = 2.86, 95% CI 2.01 to 4.07), which was higher in women at term.ConclusionsReduced foetal movements are associated with late stillbirth, with the association strongest at preterm gestations. Foetal hiccups and multiple episodes of vigorous movements are reassuring at all gestations after 28 weeks’ gestation, whereas a single episode of vigorous movement is associated with stillbirth at term.

Highlights

Late stillbirth continues to affect 3–4/1000 pregnancies in high-resource settings, with even higher rates in low-resource settings
Increasing strength of foetal movements was the most commonly reported (> 60%) pattern by women in late pregnancy, which were associated with a decreased odds of late stillbirth (adjusted odds ratio = 0.20, 95% CI 0.15 to 0.27)
Foetal hiccups and regular episodes of vigorous movement were associated with decreased odds of late stillbirth

Summary

Introduction

Late stillbirth continues to affect 3–4/1000 pregnancies in high-resource settings, with even higher rates in low-resource settings. Changes in foetal movements, when they reduce or become absent, are a cause of maternal concern and have been associated with an increased risk of poor outcomes including preterm birth, small for gestational age infants, late stillbirth and neurodevelopmental delay [2]. Translating this information into practical advice for women is complex, because each pregnancy is different, there are no robustly determined ‘alarm limits’ [3], and intervention has the potential for inadvertent harm [4]. A confirmatory multicentre case-control study in New Zealand [5] and a larger study in the UK identified similar prevalence’s and effect sizes [6]

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