Approach to DFM

Introduction

 A significant reduction or sudden alteration in FM may be a warning sign of

impending fetal death. Studies have shown an association between DFM and poor
perinatal outcome.
 About 55% of women experiencing a SB perceived a reduction in FMs prior to
diagnosis.
 There is no universally agreed definition of DFM, due to the paucity of studies on
fetal activity patterns and maternal perception of fetal activity in normal
pregnancies.
 There is an association of DFM with FGR, SGA fetus, placental insufficiency, and
congenital malformations.
 A normal quantity and quality of fetal virtually ensures functional integrity of
fetal regulatory systems.
 When these regulatory systems are subjected to mild hypoxemia, DFM is
believed to represent a compensatory fetal behavioral response, analogous to the
compensatory physiological response of redistribution of blood flow to essential
organs.
 As hypoxemia becomes more severe and prolonged, compensatory responses may
fail to protect the fetus, eventually leading to organ damage or death.
Normal fetal movement

 Fetal activity can be noted as early as 7 to 8 weeks of gestation by US.

 Maternal perception of fetal movement typically begins in the second trimester at
around 16 to 20 weeks of gestation, and the first sensation is termed quickening.
 Approximately 50 percent of isolated limb movements were perceived by the
mother, whereas 80 percent of movements involving both the trunk and limb were
perceived.
 FMs show diurnal changes which maybe absent in a sleep cycle (rarely exceeds
90 mins).
 Various observations was reported regarding fetal movements near term.
 40 percent of pregnant women get concerned about DFM, while 4 to
15 percent C/O persistent feeling of DFM.
Factors influence perception of FMs

 Maternal position: There is some evidence that women perceive most FMs when
lying down, fewer when sitting, and fewest while standing.
 Fetal position might influence maternal perception: 80% of fetal spines lay
anteriorly in women who were unable to perceive FMs despite being able to
visualize them on USS.
 FMs increase following increase in serum glucose concentration.
 Fetal presentation has no effect on perception of FMs.
Factors associated with reduced FMs

 Sedating drugs which cross the placenta such as alcohol, benzodiazepines,

methadone, and other opioids
 Corticosteroids has been reported to decrease FMs and fetal heart rate variability
on CTG over the 2 days following administration.
 Fetuses with major malformations. A lack of vigorous motion may relate to
abnormalities of the central nervous system, muscular dysfunction or skeletal
abnormalities.
 Cigarette smoking associated with decreased fetal movements (evident from 30
wks onwards).
Diagnosis

There is no consensus for the diagnosis of DFM

 Qualitative maternal perception
 Others Quantitative
 Perception of least 10 fetal movements (FMs) over up to two hours when the
mother is at rest and focused on counting ("count to 10" method).
 Perception of at least 10 FMs during 12 hours of normal maternal activity.
 Perception of at least 4 FMs in one hour when the mother is at rest and focused on
counting.
 Perception of at least 10 FMs within 25 minutes in pregnancies 22 to 36 weeks
and 35 minutes in pregnancies 37 or more weeks of gestation.
DDx

 Fetal sleep states

 Maternal smoking
 Sedative drugs that cross the placenta
 Poor maternal perception
Assessment

 History:
 Duration of DFM, whether there has been absence of FMs, and whether this is the
first occasion the woman has perceived DFM
 Evaluate SB risk for the presence of factors such as:
multiple consultations for RFM, known FGR, HT, DM, extremes of maternal age,
primiparity, smoking, placental insufficiency, congenital malformation, obesity,
racial/ethnic factors, poor past obstetric history, genetic factors, and issues with
access to care.
 Examination
 Confirm fetal viability, Doppler or US
 Clinically assess fetal size to detect SGA fetuses by abd. Exam and SFH
measurement
 Measure maternal BP.
Investigation

 Role of CTG:
 CTG for at least 20 minutes to exclude fetal compromise if the pregnancy is >
28+0 weeks. The presence of a normal FHR pattern is indicative of a healthy fetus
with a properly functioning autonomic nervous system.
 If the term fetus does not experience a FHR acceleration for > 80 minutes, fetal
compromise is likely to be present.
 Role of US
 Perform USS assessment in a woman presenting with RFM after 28+0 weeks if
RFM persists despite a normal CTG or if there are any additional risk
factors for FGR/SB.
 Perform it within 24 hours and include assessment of AC and/or EFW to detect
the SGA fetus, AFV, and fetal morphology if this has not previously been
performed.
 Further testing:
 Doppler velocimetry:
 Do if fetal growth restriction has been identified on ultrasound examination
*Abnormal CTG and US as well*
 Testing for fetomaternal hemorrhage:
 Do if DFM and signs of fetal anemia?
Sinusoidal FHR pattern
Fetal hydrops on US with elevated MCA peak systolic velocity
Management

 Before 24+0 weeks of gestation:

 Confirm fetal heartbeat by auscultation with a Doppler handheld device. It is done
to exclude fetal demise.
 If no FMs at all or FMs not felt by 24 week; it is maybe due to neuromuscular
dysfunction.
 Between 24+0 and 28+0 weeks of gestation:
 Confirm fetal heartbeat by auscultation with a Doppler handheld device.
 Undertake a comprehensive SB risk evaluation.
 Placental insufficiency may present at this gestation. If there is clinical suspicion
of FGR, consider USS.
 After 28+0 weeks of gestation:
 If women are unsure whether FMs are reduced, advise them to lie on their left
side and focus on FMs for 2 hours.
 If they do not feel 10 or more discrete movements in 2 hours:
 Undertake a history and examination as above.
 Confirm fetal heartbeat by auscultation with a Doppler handheld device.
 Reassure: if woman does not have RFM any longer, there are no other risk factors
for SB and FHR is present on auscultation.
 Do CTG/US: if women noticing a sudden change in fetal activity or in whom
other risk factors for SB are identified.
Pregnancy managment

 Return of normal fetal activity and normal evaluation: continue routine

antenatal care
 Persistent DFM and normal fetal evaluation:
 For patients ≥39 weeks of gestation, delivery is recommended
 For patients <37 weeks of gestation, we recommend nonstress testing and
ultrasound examination twice weekly.
 or patients ≥37 weeks and <39 weeks, it is a shared decision with patient either to
choose induction or expectant management.
Qs