Abstract
Stillbirth is a devastating pregnancy outcome with far-reaching economic and psychosocial consequences, but despite significant investment, a screening tool for identifying those fetuses at risk for stillbirth remains elusive. Maternal reporting of decreased fetal movements (DFM) has been found to be associated with stillbirth and other adverse perinatal outcomes. To examine pregnancy outcomes of women presenting with DFM in the third trimester at a tertiary Australian center with a clear clinical management algorithm. This cohort study used data on all births meeting the inclusion criteria from 2009 through 2019 at Mater Mothers' Hospital in Brisbane, Australia. This is a tertiary center and Australia's largest maternity hospital. All singleton births without a known congenital anomaly after 28 weeks' gestation were included. Among 203 071 potential participants identified from the hospital database, 101 597 individuals met the eligibility criteria. Data analysis was performed from May through September 2020. Presentation to hospital with DFM after 28 weeks gestation. The primary outcome of this study was the incidence of stillbirth. Multivariate analysis was undertaken to determine the association between DFM and stillbirth, obstetric intervention, and other adverse outcomes, including being born small for gestational age (SGA) and a composite adverse perinatal outcome (at least 1 of the following: neonatal intensive care unit admission, severe acidosis [ie, umbilical artery pH <7.0 or base excess -12.0 mmol/L or less], 5-minute Apgar score <4, or stillbirth or neonatal death). The hypothesis being tested was formulated prior to data collection. Among 101 597 women with pregnancies that met the inclusion criteria, 8821 (8.7%) presented at least once with DFM and 92 776 women (91.3%) did not present with DFM (ie, the control population). Women presenting with DFM, compared with those presenting without DFM, were younger (mean [SD] age, 30.4 [5.4] years vs 31.5 [5.2] years; P < .001), more likely to be nulliparous (4845 women [54.9%] vs 42 210 women [45.5%]; P < .001) and have a previous stillbirth (189 women [2.1%] vs 1156 women [1.2%]; P < .001), and less likely to have a previous cesarean delivery (1199 women [13.6%] vs 17 444 women [18.8%]; P < .001). During the study period, the stillbirth rate was 2.0 per 1000 births after 28 weeks' gestation. Presenting with DFM was not associated with higher odds of stillbirth (9 women [0.1%] vs 185 women [0.2%]; adjusted odds ratio [aOR], 0.54; 95% CI, 0.23-1.26, P = .16). However, presenting with DFM was associated with higher odds of a fetus being born SGA (aOR, 1.14; 95% CI, 1.03-1.27; P = .01) and the composite adverse perinatal outcome (aOR, 1.14; 95% CI, 1.02-1.27; P = .02). Presenting with DFM was also associated with higher odds of planned early term birth (aOR, 1.26; 95% CI, 1.15-1.38; P < .001), induction of labor (aOR, 1.63; 95% CI, 1.53-1.74; P < .001), and emergency cesarean delivery (aOR, 1.18; 95% CI, 1.09-1.28; P < .001). The presence of DFM is a marker associated with increased risk for a fetus. This study's findings of a nonsignificantly lower rate of stillbirth among women with DFM may be reflective of increased community awareness of timely presentation to their obstetric care clinician when concerned about fetal movements and the benefits of tertiary level care guided by a clear clinical management protocol. However, DFM was associated with increased odds of an infant being born SGA, obstetric intervention, early term birth, and a composite of adverse perinatal outcomes.
Highlights
Reducing the tragedy of the estimated 2 million deaths that occur in the antenatal and intrapartum period remains the focus of significant national and international[1] efforts
Presenting with decreased fetal movements (DFM) was not associated with higher odds of stillbirth (9 women [0.1%] vs 185 women [0.2%]; adjusted odds ratio [aOR], 0.54; 95% CI, 0.23-1.26, P = .16)
Presenting with DFM was associated with higher odds of planned early term birth, induction of
Summary
Reducing the tragedy of the estimated 2 million deaths that occur in the antenatal and intrapartum period remains the focus of significant national and international[1] efforts. In low-income and middleincome countries, almost 1 in 2 stillbirths occurs during labor. In high-income countries, most stillbirths occur in the antenatal period,[2] potentially allowing time to mitigate this risk through lifestyle and behavior change, optimization of management of comorbidities, identification of fetuses who are small for gestational age (SGA),[3,4] and education regarding the importance of monitoring fetal movements. The causative pathways that culminate in fetal death are often poorly understood, making complete prevention of stillbirth problematic. Because of this difficulty, most stillbirth mitigation strategies involve a package of interventions addressing different elements of prenatal care, education, and risk factors.[5,6]. Maternal perception of fetal movements is highly subjective, and there is no universally agreed upon definition.[18]
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