Reduced Fetal Movements Research Articles

Standard care informed by the result of a placental growth factor blood test versus standard care alone in women with reduced fetal movement at or after 36+0 weeks\u2019 gestation: a pilot randomised controlled trial

BackgroundBiomarkers of placental function can potentially aid the diagnosis and prediction of pregnancy complications. This randomised controlled pilot trial assessed whether for women with reduced fetal movement (RFM), intervention directed by the measurement of a placental biomarker in addition to standard care was feasible and improved pregnancy outcome compared with standard care alone.MethodsWomen aged 16–50 years presenting at eight UK maternity units with RFM between 36+0 and 41+0 weeks’ gestation with a viable singleton pregnancy and no indication for immediate delivery were eligible. Participants were randomised 1:1 in an unblinded manner to standard care and a biomarker blood test result revealed and acted on (intervention arm) or standard care where the biomarker result was not available (control arm). The objectives were to determine the feasibility of a main trial by recruiting 175–225 participants over 9 months and to provide proof of concept that informing care by measurement of placental biomarkers may improve outcome. Feasibility was assessed via the number of potentially eligible women, number recruited, reasons for non-recruitment and compliance. Proof of concept outcomes included the rates of the induction of labour and caesarean birth, and a composite adverse pregnancy outcome.ResultsOverall, 2917 women presented with RFM ≥ 36 weeks, 352 were approached to participate and 216 (61%) were randomised (intervention n = 109, control n = 107). The main reason for not approaching women was resource/staff issues (n = 1510). Ninety-seven women declined the trial, mainly due to not liking blood tests (n = 24) or not wanting to be in a trial (n = 21). Compliance with the trial interventions was 100% in both arms. Labour was induced in 97 (45%) participants (intervention n = 49, control n = 48), while 17 (9%) had planned caesarean sections (intervention n = 9, control n = 8). Overall, 9 (8%) babies in the intervention arm had the composite adverse pregnancy outcome versus 4 (4%) in the control arm.ConclusionsA main trial using a placental biomarker in combination with delivery, as indicated by the biomarker, in women with RFM is feasible. The frequency of adverse outcomes in this population is low, hence, a large sample size would be required along with consideration of the most appropriate outcome measures.Trial registrationISRCTN, ISRCTN12067514; registered 8 September 2017.

Fetal Movement Counting and Perinatal Mortality: A Systematic Review and Meta-analysis.

To assess the association of fetal movement counting with perinatal mortality. Electronic databases (ie, MEDLINE, ClinicalTrials.gov, ScienceDirect, the Cochrane Library at the CENTRAL Register of Controlled Trials) were searched from inception until May 2019. Search terms used were: "fetal movement," "fetal movement counting," "fetal kick counting," "stillbirth," "fetal demise," "fetal mortality," and "perinatal death." We included all randomized controlled trials comparing perinatal mortality in those women randomized to receive instructions for fetal movement counting compared with a control group of women without such instruction. The primary outcome was perinatal mortality. Five of 1,290 identified articles were included, with 468,601 fetuses. Definitions of decreased fetal movement varied. In four of five studies, women in the intervention group were asked to contact their health care providers if they perceived decreased fetal movement; the fifth study did not provide details. Reported reduction in fetal movement usually resulted in electronic fetal monitoring and ultrasound assessment of fetal well-being. There was no difference in the incidence of perinatal outcome between groups. The incidence of perinatal death was 0.54% (1,252/229,943) in the fetal movement counting group and 0.59% (944/159,755) in the control group (relative risk [RR] 0.92, 95% CI 0.85-1.00). There were no statistical differences for other perinatal outcomes as stillbirths, neonatal deaths, birth weight less than 10th percentile, reported decreased fetal movement, 5-minute Apgar score less than 7, neonatal intensive care unit admission or perinatal morbidity. There were weak but significant increases in preterm delivery (7.6% vs 7.1%; RR 1.07, 95% CI 1.05-1.10), induction of labor (36.6% vs 31.6%; RR 1.15, 95% CI 1.09-1.22), and cesarean delivery (28.2% vs 25.3%; RR 1.11, 95% CI 1.10-1.12). Instructing pregnant women on fetal movement counting compared with no instruction is not associated with a clear improvement in pregnancy outcomes. There are weak associations with some secondary outcomes such as preterm delivery, induction of labor, and cesarean delivery. PROSPERO, CRD42019123264.

Amniotic band syndrome: a case report

A case of amniotic band syndrome (ABS) was reported here. No obvious fetal abnormality was revealed by systematic ultrasound at 22+4 weeks of gestation. At 30 weeks of gestation, the pregnant woman was found to have excessive amniotic fluid and possible fetal edema according to ultrasound images and admitted to the First Affiliated Hospital of Nanjing Medical University. After admission, she received diet control to lower blood glucose and amniotic fluid reduction. The dynamic amniotic fluid index was measured by ultrasound, and the electrical fetal heart rate was monitored daily. Since 32 weeks of gestation, progressive reduction in fetal movement with sinusoidal fetal heart rate pattern was observed. An emergent cesarean section was performed due to fetal distress at a gestational age of 32+3 weeks. During the operation, a porous amniotic membrane was found, from the umbilical cord insertion of the placenta to the ankle of the left lower limb of the fetus. Amniotic band constricting left ankle of newborn and the edema of the left foot was obvious, then ABS was diagnosed. This amniotic band affected the left foot of the fetus directly, while there was not enough evidence whether the flake amniotic membrane near the umbilical cord insertion of the placenta could affect the fetus. This premature infant died of neonatal asphyxia 24 hours after birth. Key words: Amniotic band syndrome; Ultrasonography, prenatal; Abnormalities, multiple

Reduced Fetal Movements and Perinatal Mortality.

Introduction:Counting of fetal movement (FM) during pregnancy is believed to be a method by which a woman estimates the fetal well-being. In 2015, it was estimated that 2.6 million babies had died in utero. A percentage of 30-55% of women who experience an episode of reduced fetal movement (RFM) within a week may face stillbirth.Aim:The aim of this review was to assess the impact of reduced fetal movements and of educational interventions on maternal counting of fetal movements on perinatal mortality, perinatal outcome and mode of delivery.Methods:A search of electronic databases was conducted for detecting studies that examine the coincidence of reduced fetal movements (RFM) in combination with stillbirth and perinatal morbidity.Results:The findings of this review suggest that there is an association between the incidence of stillbirth and the experience of alterations in fetal movements’ quantity and quality in the preceding weeks. Interventions on fetal movement counting, concerning both the number and the density of fetal movements, may reduce the adverse perinatal outcomes to an extent, after informing and making aware of the pregnant women for their meaning.Conclusion:Maternity care professionals should: a) inform pregnant women about the importance of FM counting, b) encourage pregnant women to be familiarized on the recognition of theirs’ baby normal pattern of fetal movements and c) alarm women when this pattern changes. Care professionals should emphasize that counting of fetal movements is not related only to movements’ quantity (number) but also to movements’ quality (density).

The outcomes of pregnancies with reduced fetal movements: A retrospective cohort study.

The objective of this study was to examine the outcomes and interventions in pregnant women presenting with a perception of reduced fetal movements (RFM), and to determine if repeated episodes of RFM increase the risk of adverse outcomes. This was a retrospective cohort study conducted in six NHS hospitals within the Thames Valley network region, UK and one neighboring hospital, an area with approximately 31000 births annually. All women with a primary presentation of perceived RFM after 24 completed weeks of gestation during the month of October 2016 were included in the study. Prospective records in all units were examined and individual case-notes were reviewed. Pregnancy and neonatal outcomes and their relation with recurrent presentations with RFM were examined using relative risks with 95% CI. The main outcome measures are described. Neonatal outcomes measured were perinatal mortality, neonatal unit admission, abnormal cardiotocography at presentation, a composite severe morbidity outcome of Apgar <7 at 5minutes or arterial pH <7.0 or encephalopathy, and birthweight. Pregnancy outcomes measured were induction of labor, cesarean section, admission and ultrasound usage rates. In all, 591 women presented with RFM during the month; using annual hospital birth figures, the incidence of RFM was estimated at 22.6% (range 14.9%-32.5%). More than 1 presentation of RFM occurred in 273 (46.2%). All 3 deaths (0.5%) were at the first presentation. More than 1 presentation was associated with higher induction rates (56.0% vs 31.9%), but no increase in any adverse outcomes including small-for-gestational-age. Reduced fetal movements, and recurrent episodes, are common, and lead to considerable resource usage and obstetric intervention. We found no evidence to suggest that recurrent episodes increase pregnancy risk.

Reduced fetal movement intervention Trial-2 (ReMIT-2): protocol for a pilot randomised controlled trial of standard care informed by the result of a placental growth factor (PlGF) blood test versus standard care alone in women presenting with reduced fetal movement at or after 36+\u20090 weeks gestation

BackgroundForty percent of babies who are stillborn born die after 36 weeks gestation and have no lethal structural abnormality. Maternal perception of reduced fetal movement (RFM) is associated with stillbirth and is related to abnormal placental structure and function. The ultimate objective of this trial is to assess whether for women with RFM, intervention directed by measurement of placental biochemical factors in addition to standard care improves pregnancy outcome compared with standard care alone. This is the protocol for a pilot trial to determine the feasibility of a definitive trial and also provide proof of concept that informing care by measurement of placental factors improves neonatal outcomes.MethodsReMIT-2 is a multicentre, pilot randomised controlled trial of care informed by results of an additional placental factor blood test versus standard care alone for women presenting with RFM at or after 36+ 0 weeks gestation. Participants will be randomised 1:1 to the intervention arm where the blood test result is revealed and acted on, or to the control arm where the blood sample is not tested immediately and therefore the result cannot be acted on. All participants will be followed up six weeks after delivery to assess their health status and views of the trial, along with healthcare costs. A sub-group will be interviewed within 16 weeks after delivery to further explore their views of the trial. Outcomes to determine feasibility of a definitive trial include number of potentially eligible women, proportion lost to follow-up, clinical characteristics at randomisation, reasons for non-recruitment, compliance with the trial intervention and views of participants and clinicians about the trial. Proof of concept outcomes include: rates of induction of labour; Caesarean birth; and a composite neonatal outcome of stillbirths and deaths before discharge, 5-min Apgar score < 7, umbilical artery pH < 7.05 and admission to neonatal unit for > 48 h.DiscussionResults from this pilot trial will help determine whether a large definitive trial is feasible. Such a study would provide evidence to guide management of women with RFM and reduce stillbirths.Trial registrationISRCTN Registry, ISRCTN12067514. Registered on 8 September 2017.

Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trial

SummaryBackground2·6 million pregnancies were estimated to have ended in stillbirth in 2015. The aim of the AFFIRM study was to test the hypothesis that introduction of a reduced fetal movement (RFM), care package for pregnant women and clinicians that increased women's awareness of the need for prompt reporting of RFM and that standardised management, including timely delivery, would alter the incidence of stillbirth.MethodsThis stepped wedge, cluster-randomised trial was done in the UK and Ireland. Participating maternity hospitals were grouped and randomised, using a computer-generated allocation scheme, to one of nine intervention implementation dates (at 3 month intervals). This date was concealed from clusters and the trial team until 3 months before the implementation date. Each participating hospital had three observation periods: a control period from Jan 1, 2014, until randomised date of intervention initiation; a washout period from the implementation date and for 2 months; and the intervention period from the end of the washout period until Dec 31, 2016. Treatment allocation was not concealed from participating women and caregivers. Data were derived from observational maternity data. The primary outcome was incidence of stillbirth. The primary analysis was done according to the intention-to-treat principle, with births analysed according to whether they took place during the control or intervention periods, irrespective of whether the intervention had been implemented as planned. This study is registered with www.ClinicalTrials.gov, number NCT01777022.Findings37 hospitals were enrolled in the study. Four hospitals declined participation, and 33 hospitals were randomly assigned to an intervention implementation date. Between Jan 1, 2014, and Dec, 31, 2016, data were collected from 409 175 pregnancies (157 692 deliveries during the control period, 23 623 deliveries in the washout period, and 227 860 deliveries in the intervention period). The incidence of stillbirth was 4·40 per 1000 births during the control period and 4·06 per 1000 births in the intervention period (adjusted odds ratio [aOR] 0·90, 95% CI 0·75–1·07; p=0·23).InterpretationThe RFM care package did not reduce the risk of stillbirths. The benefits of a policy that promotes awareness of RFM remains unproven.FundingChief Scientist Office, Scottish Government (CZH/4/882), Tommy's Centre for Maternal and Fetal Health, Sands.

Reduced fetal movements and cerebroplacental ratio: evidence for worsening fetal hypoxemia.

To investigate the fetal cerebroplacental ratio (CPR) in women presenting with reduced fetal movements (RFM). This was a retrospective cohort study of data collected over an 8-year period at a fetal medicine unit at a tertiary referral center. The cohort comprised 4500 singleton pregnancies presenting with RFM at or after 36 weeks' gestation and 1527 control pregnancies at a similar gestational age without RFM. Fetal biometry and Doppler parameters were recorded and converted into centiles and multiples of the median (MoM). CPR was defined as the ratio between the fetal middle cerebral artery (MCA) pulsatility index (PI) and the umbilical artery (UA) PI. Subgroup analysis for fetal size and for single vs multiple episodes of RFM was performed. Compared with controls, pregnancies with RFM had lower MCA-PI MoM (median, 0.95 vs 0.97; P< 0.001) and CPR MoM (median, 0.97 vs 0.99; P= 0.018). Compared with women presenting with single episodes of RFM, pregnancies with multiple episodes (≥ 2 episodes) had lower CPR MoM (median, 0.94 vs 0.98; P= 0.003). On subgroup analysis for fetal size, compared with controls, appropriate-for-gestational-age fetuses in the RFM group had lower MCA-PI MoM (median, 0.96 vs 0.97; P= 0.003) and higher rate of CPR below the 5th centile (5.3% vs 3.6%; P= 0.015). Logistic regression analysis demonstrated an association of risk of recurrent RFM with maternal age (OR, 0.96; 95% CI, 0.93-0.99), non-Caucasian ethnicity (OR, 0.72; 95% CI, 0.53-0.97), estimated fetal weight centile (OR, 1.01; 95% CI, 1.00-1.02) and CPR MoM (OR, 0.24; 95% CI, 0.12-0.47). Pregnancies complicated by multiple episodes of RFM show significantly lower CPR MoM and MCA-PI MoM compared with those with single episodes and controls. This is likely to be due to worsening fetal hypoxemia in women presenting with recurrent RFM. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

EP17.10: Pregnancy outcome of presentation with reduced fetal movements (RFM) to day assessment unit

EP17.10: Pregnancy outcome of presentation with reduced fetal movements (RFM) to day assessment unit

Can promoting awareness of fetal movements and focusing interventions reduce fetal mortality? A stepped-wedge cluster randomised trial (AFFIRM)

BackgroundIn 2013, the stillbirth rate in the UK was 4.2 per 1000 live births, ranking 24th out of 49 high-income countries, with an annual rate of reduction of only 1.4%...

Perinatal outcomes of reduced fetal movements: a cohort study.

BackgroundThe perception of reduced fetal movement (RFM) is an important marker of fetal wellbeing and is associated with poor perinatal outcome (such as intra-uterine death).MethodsWe conducted a prospective study of women presenting with RFM over 28 weeks’ gestation to a tertiary-level maternity hospital. We examined pregnancy outcomes and compared them to a retrospectively collected control group delivering contemporaneously.ResultsIn total, 275 presentations were analysed in the RFM group, with 264 in the control group. Women with RFM were more likely to be nulliparous (p = 0.002) and have an induction of labour (p = 0.0011). 26.5 % (n = 73) of cases were admitted following presentation with RFM, and 79.4 % (n = 58) delivered on primary presentation. Overall, 15.2 % (n = 42) women were induced for RFM specifically.ConclusionThis prospective study shows the increased burden of care required by those with RFM, including increased neonatal unit admission rates, increased induction rates and higher surveillance demands, demonstrating the need for increased attention to this area of practice.

Prenatal ultrasound factors and genetic disorders in pregnancies complicated by polyhydramnios.

The objective of the study is to examine the incidence of chromosomal or genetic abnormalities in pregnancies complicated by polyhydramnios and to assess the value of prenatal ultrasound findings in the prediction of cases associated with such disorders. We searched the prenatal records of all patients delivered in our hospital with a diagnosis of polyhydramnios during pregnancy. For each case, maternal characteristics, ultrasound findings, and genetic testing results were recorded. A postnatal follow-up program of at least 6 months, including a clinical assessment by a clinical geneticist, was carried out in all cases. On a total of 195 cases, genetic testing and clinical examination identified a chromosomal or genetic disease in 26 (13.3%) cases. Multivariate analysis demonstrated that significant predictors of a genetic disorder were a deepest vertical pocket of amniotic fluid of ≥13.0 cm (OR 4.306, 95%CI: 1.535-12.079) and reduced fetal movements (OR 25.084, 95%CI: 4.577-137.461), but not the presence of a structural defect. A postnatal clinical follow-up program can reveal chromosomal or genetic disorders in about 13% of neonates with a prenatal diagnosis of polyhydramnios. The severity of polyhydramnios and the reduction of fetal movements are independently associated with the presence of such diseases. © 2016 John Wiley & Sons, Ltd.

Placental PHLDA2 expression is increased in cases of fetal growth restriction following reduced fetal movements.

BackgroundMaternal perception of reduced fetal movements (RFM) is associated with increased risk of fetal growth restriction (FGR) and stillbirth, mediated by placental insufficiency. The maternally expressed imprinted gene PHLDA2 controls fetal growth, placental development and placental lactogen production in a mouse model. A number of studies have also demonstrated abnormally elevated placental PHLDA2 expression in human growth restricted pregnancies. This study examined whether PHLDA2 was aberrantly expressed in placentas of RFM pregnancies resulting in delivery of an FGR infant and explored a possible relationship between PHLDA2 expression and placental lactogen release from the human placenta.MethodsVillous trophoblast samples were obtained from a cohort of women reporting RFM (N = 109) and PHLDA2 gene expression analysed. hPL levels were assayed in the maternal serum (N = 74).ResultsPlacental PHLDA2 expression was significantly 2.3 fold higher in RFM pregnancies resulting in delivery of an infant with FGR (p < 0.01), with highest levels of PHLDA2 expression in the most severe cases. Placental PHLDA2 expression was associated with maternal serum hPL levels (r = −0.30, p = 0.008, n = 74) although this failed to reach statistical significance in multiple linear regression analysis controlling for birth weight (p = 0.07).ConclusionsThese results further highlight a role for placental PHLDA2 in poor perinatal outcomes, specifically FGR associated with RFM. Furthermore, this study suggests a potential relationship between placental PHLDA2 expression and hPL production by the placenta, an association that requires further investigation in a larger cohort.Electronic supplementary materialThe online version of this article (doi:10.1186/s12881-016-0279-1) contains supplementary material, which is available to authorized users.

Massive fetomaternal hemorrhage as a cause of severe fetal anemia.

Fetomaternal hemorrhage (FMH) is a transfu-sion of fetal blood into the maternal circulation. A volume of transfused fetal blood required to cause severe, life-threatening fetal anemia, is not clearly defined. Some authors suggest vol-umes of 80 mL and 150 mL as a threshold which defines mas-sive FMH. Therefore, a rate of massive FMH is 1 : 1,000 and 1 : 5,000 births, respectively. Fetal and neonatal anemia is one of the most serious complications of the FMH. Clinical manifesta-tions of FMH are nonspecific, and mostly it presented as re-duced fetal movements and changes in cardiotocography (CTG). The standard for diagnosing FMH is Kleihaurer-Betke test. A 34-year-old gravida (G) 1, para (P) 1 was hospitalized due to uterine contractions at 39 weeks of gesta-tion. CTG monitoring revealed sinusoidal fetal heart rate and clinical examination showed complete cervical dilatation. Im-mediately after admission, the women delivered vaginally. Ap-gar scores were 1 and 2 at the first and fifth minute, respec-tively. Immediately baby was intubated and mechanical ventila-tion started. Initial analysis revealed pronounced acidosis and severe anemia. The patient received intravenous fluid therapy with sodium-bicarbonate as well as red cell transfusion. With all measures, the condition of the baby improved with normaliza-tion of hemoglobin level and blood pH. Kleihaurer-Betke test revealed the presence of fetal red cells in maternal circulation, equivalent to 531 mL blood loss. The level of maternal fetal hemoglobin (HbF) and elevated alpha fetoprotein also con-firmed the diagnosis of massive FMH. For the successful diagnosis and management of FMH direct commu-nication between the obstetrician and the pediatrician is neces-sary as presented in this report.

Maternal perception of fetal movements in late pregnancy is affected by type and duration of fetal movement

Objective: A reduction in fetal movements has been proposed to identify pregnancies at risk of stillbirth. The utility of this approach is limited by variability in maternal perception of fetal movements. We aimed to determine the proportion of fetal movements observed by ultrasound that were maternally perceived and identify factors that affected maternal perception.Method: During 30-min recordings, women (n = 21) depressed a trigger upon perception of a fetal movement, while an ultrasound operator recorded observed movements according to the fetal parts involved.Results: Women perceived between 2.4% and 81.0% (median 44.8%) of movements observed on scan. Synchronous movement of the fetal trunk and limbs was more likely to be recognized than either part in isolation (60.5% versus 37.5% and 30%, respectively). The ultrasound operator judged the fetus to be moving for a significantly greater proportion of the time than mothers (median 1.5% of total recording time versus 0.7%). There was no significant relationship between the ability to perceive fetal activity and placental site, parity, amniotic fluid index or maternal body mass index.Conclusion: Variations in maternal perception of fetal movements may affect detection of a clinically significant reduction in fetal movements for some women.

Number of episodes of reduced fetal movement at term: association with adverse perinatal outcome

The aims of this study were evaluation of the association of reduced fetal movements (RFM) and small-for-gestational-age (SGA) birth at term and to explore if fetal and maternal outcomes are different with single vs repeated episodes of RFM and normal fetal assessment test results. This was a retrospective cohort study of all singleton pregnancies referred for RFMs at a tertiary fetal medicine unit from January 2008 through September 2014. Ultrasound and Doppler indices were obtained from a computerized ultrasound database and pregnancy outcome was collected from hospital records. Of the 21,944 women with a singleton pregnancy booked for maternity care during the study period, 1234 women (5.62%) reported RFMs >36+0 weeks. Of these, 1029 women (83.4%) reported a single episode of RFM and 205 (16.6%) had ≥2 presentations for RFM. Women with repeated RFMs had a significantly higher mean uterine artery pulsatility index in the second trimester. The prevalence of SGA baby at birth in women presenting with a single episode as compared to repeated episodes of RFM was 9.8% and 44.2%, respectively (odds ratio, 7.3; 95% confidence interval, 5.1-10.4; P < .05). Repeated episodes of RFMs at term are more likely to occur in women with high second-trimester uterine artery Doppler resistance indices and are strongly associated with the birth of SGA infants. Women presenting with repeated episodes of RFM should be treated as being at high risk of placental dysfunction irrespective of the results of prenatal ultrasound and Doppler assessment.

A kick in the right direction - reduced fetal movements and stillbirth prevention

Multiple studies using various approaches have associated reduced fetal movements (RFM) with stillbirth and small for gestational age infants [1,2]. More recently, RFM has been linked to neurodevelopmental delay and a lack of response to treatment for hypoxic-ischaemic encephalopathy [3,4]. The relationship between adverse pregnancy or infant outcome is thought to be mediated by placental dysfunction [5]; thus RFM represents a symptom of placental insufficiency, when a placenta cannot meet the metabolic demands of the growing fetus. This hypothesis is now supported by evidence of changes in placental structure, inflammation and function in women who present with RFM [6,7]. Critically, some of these changes in placental size, structure and pathology differentiate between pregnancies with RFM that end in healthy pregnancy or adverse outcomes [8,9]. Thus, assessment of fetal growth and placental function in mothers presenting with RFM may offer new avenues to identify babies at risk of stillbirth to target intervention. A prospective control study found that 67 out of 303 women (22%) presenting with RFM to St Mary’s Hospital, Manchester, UK had adverse perinatal outcome. Significant predictors of adverse outcome were diastolic blood pressure, estimated weight centile, liquor volume and log[human placental lactogen (hPL)] [10]. Four cases had abnormalities on cardiotocography and 20 cases had abnormal ultrasound findings and 24 had an hPL <0.8 MoM; further work is needed to predict remaining adverse pregnancy outcomes in women with RFM. Recent interest in placental biomarkers, particularly placental growth factor (PlGF), shows encouraging data to predict adverse outcomes (e.g. true fetal growth restriction) in late pregnancy and should be explored in high-risk mothers with RFM [11]. A feasibility study of 120 women found that an intensive approach to the management of RFM using a biomarker was well adhered to and women’s anxiety decreased after investigation irrespective of the management strategy [12]. Encouragingly, the rate of composite adverse perinatal outcome reduced from 29% to 12%. This indicates that a larger definitive trial should be conducted [12]. Current data, based on a large quality improvement study, suggest that mothers should be educated about reporting changes in fetal movements and units should provide standardised care including cardiotocography/non-stress test and ultrasound scan [13]. However, implementing these changes into clinical practice has been more challenging. The UK Royal College of Obstetricians and Gynaecologists (RCOG) introduced a guideline for the management of RFM in 2011 [14]. A cross-sectional survey of UK maternity units in 2013 found that 12% of units had no guideline, and where guidelines were in place they contained a median of 7/12 recommendations ranging from 3-11. Two key challenges i) to improve maternal education about fetal movements and ii) to standardise high-quality care when women present with RFM need to be addressed to reduce stillbirths using a RFM-based approach. The AFFIRM study, a stepped-wedge customised trial will address the hypothesis that education for mothers and professionals, in combination with a standard management plan can reduce stillbirth [15]. It is hoped that this strategy understanding the associations with RFM, developing effective investigations in combination with intervention will reduce stillbirth.

Evaluation of the quality of guidelines for the management of reduced fetal movements in UK maternity units.

BackgroundThe development of evidence-based guidelines is a key step in ensuring that maternity care is of a universally high standard. To influence patient care national and international guidelines need to be interpreted and implemented locally. In 2011, the Royal College of Obstetricians and Gynaecologists published guidelines for the management of reduced fetal movements (RFM), which can be an important symptom of fetal compromise. Following dissemination it was anticipated that this guidance would be implemented in UK maternity units. This study aimed to assess the quality of local guidelines for the management of RFM in comparison to published national standards.MethodsCross-sectional survey of maternity unit guidelines for RFM. The guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool and scored by two independent investigators. Two national guidelines were used as standards to evaluate unit guidelines.ResultsResponses were received from 98 units (42%); 12 units had no guideline. National guidelines scored highly using the AGREE II tool but there was wide variation in the quality of individual maternity unit guidelines, which were frequently of low quality. No guidelines incorporated all the recommendations from the national guideline. Maternity unit guidelines performed well for clarity and presentation but had low scores for stakeholder involvement, rigour of development and applicability.ConclusionsIn contrast to national evidence based guidance the quality of maternity unit guidelines for RFM is variable and frequently of low quality. To increase quality, guidelines need to include up to date evidence and audit standards which could be taken directly from national evidence-based guidance. Barriers to local implementation and resource implications need to be taken into consideration. Training may also improve the implementation of the guideline. Research is needed to inform strategies to realize the benefits of clinical guidance in practice.

MATERNAL AND NEONATAL OUTCOME OF TERM PREGNANCIES PRESENTED WITH REDUCED FETAL MOVEMENT

Background &#x0D; Maternal perception of fetal movements is the most common method to assess fetal wellbeing in most communities nowadays. It is regarded as unstructured screening on which most pregnant women depend.Significant reduction or sudden alteration in fetal movement is a potentially important sign of impending fetal death. Studies of fetal physiology using ultrasound have demonstrated an association between reduced fetal movement and poor perinatal outcome.&#x0D; Objectives&#x0D; To observe the outcome of pregnancies presented with reduced fetal movement (RFM ) at term regarding intra-partum complications, time and mode of delivery and neonatal outcome.&#x0D; Methods&#x0D; A prospective case –control study. The data collected at Sulaimania Maternity Teaching Hospital throughout the period from the 1st of September 2012 to the 1st of March 2013. One-hundred low risk pregnant ladies at term were included in the study; fifty of them with reduced fetal movements and the other fifty with good fetal movement. After taking full history and examination including fetal heart rate and manual non stress test(MNST), they were sent to ultrasound (US) examination for amniotic fluid index and Umbilical artery Doppler velocimetery. Then they were followed up until delivery when intrapartum complications, mode of delivery and neonatal outcome were recorded and tabulated for comparison between the two groups.&#x0D; Results&#x0D; Regarding the mode of delivery, although the rate of C/S for fetal distress was more among the cases (45.8%) than control (29.4%) it didn’t reach significant statistical difference. The number of stillbirth were just 2 babies in the case group. There were significant neonatal complications as birth asphyxia 24% with meconium&#x0D; aspiration syndrome 16%, seizures 10% and early neonatal death 6% in the studied (case) group.&#x0D; Conclusion&#x0D; Reduced fetal movement is an important symptom that should be taken seriously and manage accordingly, to reduce perinatal morbidity and mortality. Each maternity hospital should have a protocol to deal with every pregnant presents with reduced fetal movement.

G.P.40: Skeletal muscle MRI in an X-linked myotubular myopathy patient who became ambulatory

X-linked myotubular myopathy (XLMTM), one of the most severe forms of centronuclear myopathy Cis caused by mutations in the <i>MTM1</i> gene. XLMTM usually has a neonatal onset requiring respiratory support due to severe respiratory muscle weakness and patients remain bed-ridden. The few past reports on skeletal muscle imaging of the lower limbs in XLMTM patients showed involvement of the soleus muscles and of the posterior thigh. We present the magnetic resonance imaging (MRI) findings of both upper and lower limbs in an XLMTM patient, who survived with Non-invasive Positive Pressure Ventilation (NPPV) support and ultimately became ambulatory. The patient was a 12-year old boy. His older brother, who also had XLMTM, had died during infancy. The patient presented with reduction of fetal movements, and had needed artificial respirator support at birth. He was genetically diagnosed as having XLMTM. Although he suffered repeated exacerbations of respiratory failure due to infection, the frequency of mechanical ventilation decreased after the initiation of NPPV at the age of 21months. He obtained an independent gait at the age of 7years, and he also gained the ability to walk up the stairs while holding onto a railing. T1-weighted muscle MRI tended to show high intensity areas in the flexor group of both brachial muscles and muscles in the forearms. Whole muscles in the thighs were mildly affected, but the soleus muscles were preserved. We have presented a rare XLMTM case achieving satisfactory progress. Muscle imaging showed differences from past reports in terms of the affected muscles. The degree of muscle atrophy was milder, most notably, than previously thought. This is consistent with our patient's good clinical course. We speculate that skeletal muscle MRI shows specific muscle involvements also in the upper limbs. We advocate accumulating muscle imaging data not only for the lower but also for the upper limbs, to shed further light on the pathophysiology of XLMTM.