[Clinical practice variation in reduced fetal movements].
ABSTRACT Reduced fetal movements imply a risk pregnancy. This condition is present in a significant proportion of pregnancies, but both the quality of information and that of clinical care is variable.
All delivery units in Eastern Norway and Bergen have registered all consultations for reduced fetal movements, as part of the international collaborative project "Fetal Movement Intervention Assessment" (Femina). Out of 23,933 deliveries, 1200 pregnancies were examined. In 1043 pregnancies the mother had spontaneously presented her concern over reduced fetal movements; these were included in analyses. Results are presented with a 95% confidence interval.
Asphyxia, death, growth restriction or preterm birth occurred in 19.6% (16.6-22.6%) of cases, ranging between units from 9.1% to 26.5%. Standard procedures varied extensively; ultrasonography was used in 39.0% to 98.6% and Doppler in 4.5% to 74.6% of cases. There was an association between outcomes and the procedures used. Women who waited 24 hours with reduced or absent movements before contacting healthcare had increased risk. Among those with absent movements, 47% (42-52%) had such risk behaviour.
There is a need for quality improvements in the information to pregnant women as well as in the clinical management of affected pregnancies. This could have large health benefits. We propose new guidelines for information and management.
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ABSTRACT: BACKGROUND: Fetal movement counting has long been suggested as a screening tool to identify impaired placental function. However, quantitative limits for decreased fetal movement perform poorly for screening purposes, indicating the need for methodological refinement. We aimed to identify the main individual temporal patterns in fetal movement counting charts, and explore their associations with pregnancy characteristics. METHODS: In a population-based prospective cohort in Norway, 2009--2011, women with singleton pregnancies counted fetal movements daily from pregnancy week 24 until delivery using a modified "count-to-ten" procedure. To account for intra-woman correlation of observations, we used functional data analysis and corresponding functional principal component analysis to identify the main individual temporal patterns in fetal movement count data. The temporal patterns are described by continuous functional principal component (FPC) curves, with an individual score on each FPC for each woman. These scores were later used as outcome variables in multivariable linear regression analyses, with pregnancy characteristics as explanatory variables. RESULTS: Fetal movement charts from 1086 pregnancies were included. Three FPC curves explained almost 99% of the variation in the temporal data, with the first FPC, representing the individual overall counting time, accounting for 91% alone. There were several statistically significant associations between the FPCs and various pregnancy characteristics. However, the effects were small and of limited clinical value. CONCLUSIONS: This statistical approach for analyzing fetal movement counting data successfully captured clinically meaningful individual temporal patterns and how these patterns vary between women. Maternal body mass index, gestational age and placental site explained little of the variation in the temporal fetal movement counting patterns. Thus, a perceived decrease in fetal movement should not be attributed to a woman's basic pregnancy characteristics, but assessed as a potential marker of risk.BMC Pregnancy and Childbirth 11/2012; 12(1):124. DOI:10.1186/1471-2393-12-124 · 2.15 Impact Factor
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ABSTRACT: Pregnant women with decreased fetal movements (DFM) are at increased risk of adverse outcomes such as fetal growth restriction, preterm birth, and fetal death. There is no universally accepted methodology for assessing or defining DFM and no universally accepted guidelines for the management of DFM. This prospective population-based cohort study evaluated the effectiveness of 2 specific interventions to reduce the rate of adverse pregnancy outcomes associated with decreased fetal movement in the third trimester. The first intervention was provision of information to the women on fetal activity and DFM and an invitation to monitor fetal movement. The second was preparation and distribution of DFM management guidelines for health-care professionals. All participants had singleton pregnancies of at least 28 weeks' gestation and had registered prospectively at 14 delivery units in Norway. The baseline control cohort was a group of women who had no intervention. Between 2005 and 2007, 7 months of baseline observation was followed by 17 months of intervention. The total births before and during the intervention were 19,407 and 46,143, respectively. Of these, 1215 and 3038 women with DFM were identified in the baseline and intervention cohorts, respectively. No increase was found in the number of women with DFM during the intervention. Among women with DFM, stillbirth rates were reduced by nearly 50% (adjusted odds ratio [OR], 0.51; 95% confidence interval [CI] 0.32–0.81, P = 0.004) from 4.2% (n = 50) to 2.4% (n = 73) during the intervention. Among women in the entire cohort, stillbirth rates were reduced by one-third from 3.0/1000 to 2.0/1000 (unadjusted OR, 0.67; 95% CI, 0.48–0.93, P = 0.02). No increase was found during the intervention period in rates of preterm births, fetal growth restriction, severe neonatal depression, or transfers to neonatal care among women with DFM. There was increased use of ultrasound in management and fewer additional follow up consultations and admissions for induction. These findings show that providing improved guidelines for management of DFM to health professionals together with uniform information on fetal activity to expectant women is associated with reduced stillbirth rates in this patient population.Obstetrical and Gynecological Survey 12/2009; 65(1):8-9. DOI:10.1097/01.ogx.0000367504.24255.a8 · 2.36 Impact Factor
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ABSTRACT: Fetal movement (FM) counting is a simple and widely used method of assessing fetal well-being. However, little is known about what women perceive as decreased fetal movement (DFM) and how maternally perceived DFM is reflected in FM charts. We analyzed FM counting data from 148 DFM events occurring in 137 pregnancies. The women counted FM daily from pregnancy week 24 until birth using a modified count-to-ten procedure. Common temporal patterns for the two weeks preceding hospital examination due to DFM were extracted from the FM charts using wavelet principal component analysis; a statistical methodology particularly developed for modeling temporal data with sudden changes, i.e. spikes that are frequently found in FM data. The association of the extracted temporal patterns with fetal complications was assessed by including the individuals' scores on the wavelet principal components as explanatory variables in multivariable logistic regression analyses for two outcome measures: (i) complications identified during DFM-related consultations (n = 148) and (ii) fetal compromise at the time of consultation (including relevant information about birth outcome and placental pathology). The latter outcome variable was restricted to the DFM events occurring within 21 days before birth (n = 76). Analyzing the 148 and 76 DFM events, the first three main temporal FM counting patterns explained 87.2% and 87.4%, respectively, of all temporal variation in the FM charts. These three temporal patterns represented overall counting times, sudden spikes around the time of DFM events, and an inverted U-shaped pattern, explaining 75.3%, 8.6%, and 3.3% and 72.5%, 9.6%, and 5.3% of variation in the total cohort and subsample, respectively. Neither of the temporal patterns was significantly associated with the two outcome measures. Acknowledging that sudden, large changes in fetal activity may be underreported in FM charts, our study showed that the temporal FM counting patterns in the two weeks preceding DFM-related consultation contributed little to identify clinically important changes in perceived FM. It thus provides insufficient information for giving detailed advice to women on when to contact health care providers. The importance of qualitative features of maternally perceived DFM should be further explored.BMC Pregnancy and Childbirth 09/2013; 13(1):172. DOI:10.1186/1471-2393-13-172 · 2.15 Impact Factor