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Three Part Question

In [a pregnant patient with a blunt abdominal trauma] are [foetal movements effective] at [corroborating foetal health]?

Clinical Scenario

A pregnant woman of 34 weeks gestation is the restrained passenger of a car that was involved in an impact at 50mph, she appears fine and relatively uninjured but she tells you that her baby’s movements appear to have slowed; you wonder if you should bleep O&G immediately.

Search Strategy

Medline 1950 to 06/2008 using Ovid Interface
EMBASE 1980-2008 Week 1
The Cochrane Library
[{exp fetal movements/ OR foetal movements.mp. OR fetal movements.mp} AND {fetal health.mp. OR foetal health }] LIMIT to human and English language

Search Outcome

37 articles were found with 7 being relevant, 1 article by Gribbin was listed twice as it had also been published in another journal therefore only the later article appears in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
James D, 2002 UK	Pregnant patients	Review of various studies with varying levels of evidence	Decreased FM is associated with and increased likelihood of foetal death	Normal quantity of movement as perceived by the mother may indicate foetal wellbeing.	No search strategy No references included.
Baser et al, 1992 USA	166 3rd trimester women undergoing foetal testing using a Doppler device that recognized FHR and foetal movement.	Diagnostic study	Synchronous FM and foetal heart rate (FHR) accelerations reveal a coordination of function by the foetal CNS	Decreased FM is equal to increased risk of perinatal mortality and morbidity.	Clinical outcomes not fully evaluated
Bocking AD, 1989 Canada	Pregnant patients	Review of articles investigating FBM,GBM and FHR	FBM increase with CO2 except in methadone users, increase in growth restricted foetus when the mother is administered oxygen. There is no effect on GBM in the same situations.	There are many variations within the activity cycles of healthy foetuses that must be accounted for. The incidence and amplitude of FBM are highly influence by maternal meals and therefore by plasma glucose concentrations but the there is no effect on GBM or foetal heart rate.	No search strategy No methods or conclusion No study of the relationship of movement with foetal health
Gribbin C, James D, 2005 UK	Pregnant women	Review of current tools to assess foetal health	Evidence shows that reporting of decreased FM is associated with an increased likelihood of foetal death	FM may be associated with foetal health	No search strategy
Manning et al, 1987 USA	Pregnant patients attending antenatal clinic	Narrative review of method of biophysical profile scoring	Evidence from observations of foetuses whose mothers are hypoxaemic from disease or smoking show there is a reduction in movement. Normal is at least 1 FBM of at least 30s in 30mins and 3 or more GBM in 30minutes. Abnormal is no episode of more than 30s or no episode in 30mins of FBM or less than 2 GBF in 30 minutes.	Movement alone is not sufficient enough in accuracy to use as a sole measure of foetal condition	No search strategy. Difficult to fully comprehend aim of article.
Platt et al, 1983 USA	Pregnant patients referred for antenatal FHR testing. 283 women (286 foetus – 3 sets of twins)	Diagnostic study/review.	FBM defined as normal = 1 episode of at least 60s in a 30 min observation period. GBM defined as normal = 3 episodes within a 30 min observation period. Less that 2 =abnormal. FBM 252 =normal of those 230 were normal, GBM 282=normal of those 257 were normal.FBM – negative predictive value = 91% positive predictive value = 18% GBM – negative predictive value = 91% positive predictive value = 75%	Decreased foetal movements both breathing and body may indicate decreasing foetal health but they may also remain normal in these cases so it is best if they are use in combination with other screening tools	No search strategy. Number of foetus tested different in abstract from main body, possible typing error.
Fai FY et al, 1996 Singapore	45 pregnant women between 29-40 weeks gestation	Observational study	Found clusters of FM >15 s are more reliable, also found that they are less likely to be misinterpreted.	FM can indicate foetal health and clusters of movement are a more reliable indicator	Small sample size Only non smokers Monitoring was one session of 60 minutes

Comment(s)

Foetal movements (FM) can be divided into 2 categories foetal breathing movements (FBM) which occur approximately 30% of the time in the last 10 weeks of pregnancy and gross body movements (GBM) which occur approximately 10 percent of the time. It is important to be aware of the fact that there are episodic variations that can occur due to diurnal rhythm, meals, smoking, and prematurity for example [Bocking AD]. Most studies used single episodes of movements as a measure but one looked at clusters of movement and found that clusters are less likely to be misinterpreted as “it is not uncommon even after a foetal death for the mother to claim that she perceives weak foetal movements [Fai FY et al]. It is important to be aware that even though the likelihood of death is increased it is not reduced by this method of monitoring which may be due to false reassurances being given and/or inappropriate interpretation of subsequent investigations such as CTG occurring [Gribbin C, James D.].

Clinical Bottom Line

Maternal perception of foetal movements may be a useful indicator with regards to the health of the foetus.

References

1. James D. Assessing fetal health. Current obstetrics and gynaecology. 12(5);2002:243-249
2. Baser I, Johnson TR, Paine LL. Coupling of fetal movement and fetal heart rate accelerations as an indicator of foetal health. Obstetrics & gynecology. 80(1);1992:62-6
3. Bocking AD, Observations of biophysical activities in the normal fetus. Clinics in perinatology. 16(3);1989:583-594
4. Gribbin C, James D. Assessing fetal health. Current Obstetrics and Gynaecology. 15(4):2005;221-227
5. Manning FA et al. Antepartum foetal risk assessment: the role of the foetal biophysical profile score. Baillieres Clinical Obstetrics and Gynaecology. 1(1):1987;55-72
6. Platt LD et al. Further experience with the foetal biophysical profile. Obstetrics and Gynecology. 61(4):1983;480-5
7. Fai FY, Singh K, Malcus P. Assessment of foetal health should be based on maternal perception of clusters rather than episodes of foetal movements. Journal of Obstetrics and Gynaecology Research 22(3):1996;299-304