A kick from within-fetal movement counting and the cancelled progress in antenatal care

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1 Studier om fosteraktivitet Kvinnens oppmerksomhet rundt barnets spark og bevegelser i magen har eksistert gjennom menneskehetens historie. Rikelig og konsistent fosteraktivitet har trolig blitt oppfattet av gravide som et betryggende tegn. Kvinnens subjektive opplevelse av fosteraktivitet fikk liten vitenskaplig fremgang før den kunne erstattes av objektive ultralydmålinger. Lite liv er en hyppig kilde til bekymring både for den gravide og den profesjonelle svangerskapsomsorgen. I artikkelen A kick from within gir Frederik Frøen en oppsummering av tidligere publikasjoner, og viser behovet for mer omfattende forskning på temaet fosteraktivitet. Det internasjonale forskningsprosjektet FEMINA (Fetal Movement Intervention Assessment) har som hovedmål å redusere sykelighet og dødelighet for barn fra svangerskap rammet av lite liv - redusert fosteraktivitet. De neste artiklene er alle et resultat av data hentet fra FEMINA prosjektet. Tell med meg er et av flere underprosjekter som springer ut fra hovedstudien FEMINA. Under finner du korte sammendrag av artiklene. Referanseliste over artiklene i fulltekst ligger nederst på denne siden. Artikkel 1 A kick from within-fetal movement counting and the cancelled progress in antenatal care Frøen JF Department of Obstetrics and Gynecology, Rikshospitalet University Clinic, University of Oslo, Norway. j.f.froen@klinmed.uio.no Interest for maternal fetal movement counting as a method of screening for fetal wellbeing boomed during the 1970's and 1980's. Several reports demonstrated that the introduction of counting charts significantly reduced stillbirth rates. However, in 1989, a large study appeared in The Lancet that annihilated research in this field by deeming charts ineffective. In retrospect, it seems evidence was lacking. This review revisits the subject of the significance of fetal movement counting in predicting outcome and reducing stillbirth rates. A structured search was performed to identify studies relating to pregnancy outcome and its association with maternal perception of fetal movements. Suspected preliminary or redundant material was excluded. Only publications from Western countries dating from after 1970 were included. Twenty-four studies were identified. Available data demonstrate that reduced fetal movements are associated with adverse pregnancy outcome, both in high and low risk pregnancies. Increased vigilance towards maternal perception of movements (e.g. by performing movement counting studies) reduces stillbirth rates, in particular stillbirths deemed avoidable. While screening for fetal well-being by maternal fetal movement counting can reduce fetal mortality rates, a resurrection in research activity is urgently needed to optimize its benefits(1).

2 Artikkel 2 Store praksisvariasjoner ved redusert fosteraktivitet J F Frøen, E Saastad, J V H Tveit, P E Børdahl, B Stray-Pedersen Sammendrag Bakgrunn: Redusert fosteraktivitet indikerer risikosvangerskap. Dette angår mange gravide, men det er varierende kvalitet på informasjonen de får og hvordan et slikt svangerskap blir håndtert klinisk. Materiale og metode: Samtlige fødeinstitusjoner på Østlandet og i Bergen har registrert utredninger pga. redusert fosteraktivitet. Dette er en del av det internasjonale samarbeidet Fetal Movement Intervention Assessment (Femina). Av fødsler ble svangerskap utredet. De der kvinnen på eget initiativ hadde meldt fra om bekymring for lite liv, ble inkludert i analysene. Resultater: Alvorlig asfyksi, død, veksthemming eller for tidlig født barn ble registrert i 19,6% av tilfellene (95% KI 16,6 22,6%), fra 9,1% til 26,5% ved de forskjellige sykehusene. Rutineutredningen varierte betydelig ultralydundersøkelse ble brukt i 39,0 98,6% av tilfellene, doppler i 4,5 74,6%, avhengig av sykehus. Det var sammenheng mellom sykehusrutiner og svangerskapsutfall. Størst risiko for negativt svangerskapsutfall var det hos kvinner som hadde ventet i 24 timer før de tok kontakt med helsevesenet pga. redusert eller opphørt fosteraktivitet. Blant dem med opphørt fosteraktivitet hadde 47% (95% KI 42 52%) slik risikoatferd. Fortolkning: Kvalitetsforbedring i informasjonsarbeidet overfor gravide og bedre behandling av kvinner som merket redusert fosteraktivitet kan gi store helsegevinster. Vi anbefaler nye retningslinjer(2). Artikkel 3 Fetal movement assessment Frøen JF, Heazell AE, Tveit JV, Saastad E, Fretts RC, Flenady V Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway. frederik.froen@fhi.no Maternal perception of fetal movements is the oldest and most commonly used method to assess fetal well-being. While almost all pregnant women adhere to it, organized screening by fetal movements has seen variable popularity among health professionals. Early results of screening were promising and fetal movement counting is the only antepartum testing method that has shown effect in reducing mortality in a randomized controlled trial comparing testing versus no testing. Although awareness of fetal movements is associated with improved perinatal outcomes, the quest to define a quantitative "alarm limit" to define decreased fetal movements has so far been unsuccessful, and the use of most such limits developed for fetal movement counting should be discouraged(3).

3 Artikkel 4 Management of decreased fetal movements Frøen JF, Tveit JV, Saastad E, Børdahl PE, Stray-Pedersen B, Heazell AE, Flenady V, Fretts RC Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway. frederik.froen@fhi.no Maternal perception of decreased fetal activity is a common complaint, and one of the most frequent causes of unplanned visits in pregnancy. No proposed definitions of decreased fetal movements have ever been proven to be superior to a subjective maternal perception in terms of identifying a population at risk. Women presenting with decreased fetal movements do have higher risk of stillbirth, fetal growth restriction, fetal distress, preterm birth, and other associated outcomes. Yet, little research has been conducted to identify optimal management, and no randomized controlled trials have been performed. The strong associations with adverse outcome suggest that adequate management should include the exclusion of both acute and chronic conditions associated with decreased fetal movements. We propose guidelines for management of decreased fetal movements that include both a nonstress test and an ultrasound scan and report findings in 3014 cases of decreased fetal movements(4). Artikkel 5 Lite liv klinisk praksis og brukerinformasjon ved redusert fosteraktivitet E Saastad, J F Frøen Sammendrag Bakgrunn: Dette er en oversikt over klinisk praksis, norske retningslinjer, litteratur for helsepersonell og informasjonsmateriell for gravide angående svangerskap med redusert fosteraktivitet. Vi identifiserer hvilke rutiner og råd som har vitenskapelig bakgrunn. Materiale og metode: Klinisk praksis ved gravides bekymring for redusert fosteraktivitet ble kartlagt via et spørreskjema til alle norske fødeinstitusjoner. Informasjon om fosteraktivitet og sparketelling ble hentet i anbefalt litteratur for lege- og jordmorstudenter og ved søk i databaser, bøker, tidsskrifter og blader. Resultater: Klinisk praksis varierer. Alle fødeinstitusjoner inkluderer kardiotokografi (CTG) i utredningen hvis dette er tilgjengelig, kun et mindretall inkluderer ultralyd- og dopplerundersøkelser rutinemessig. Ved fem av 55 institusjoner får gravide beskjed om at fravær av fosteraktivitet i opptil 24 timer er normalt. Retningslinjer og lærebøker angir at en markant reduksjon i fosteraktivitetsnivå krever undersøkelse. Sparketelling vurderes som enten nyttig, det anbefales eller frarådes. Informasjonen for gravide

4 formidler betydningen av årvåkenhet overfor fosterets aktivitetsmønster, men det er også motstridende opplysninger om når helsepersonell bør kontaktes. Fortolkning: Det savnes kunnskapsbaserte retningslinjer for rådgivning til gravide og for håndtering av svangerskap med redusert fosteraktivitet. Det er ikke overensstemmelse mellom anbefalinger til gravide, retningslinjer og lærebøker for helsepersonell og klinisk praksis. Dette kan bidra til usikkerhet både for gravide og for helsepersonell i vurderingen av fosterets aktivitet(5). Artikkel 6 Low maternal awareness of fetal movement is associated with small for gestational age infants Saastad E, Ahlborg T, Frøen JF Norwegian Institute of Public Health, Division of Epidemiology, PB 4404 Nydalen, N-0403 Oslo, Norway. eli.saastad@fhi.no Our aim was to identify associations between information given to pregnant women about fetal activity, level of maternal awareness of fetal activity, maternal concern about decreased fetal movement, and pregnancy outcomes. This was a population-based crosssectional study. Mothers with a singleton delivery were invited to answer an anonymous structured questionnaire before discharge from the delivery unit. Six hundred and ninety-one mothers participated (60.4% of eligible women). Women were highly aware of fetal activity. Yet, 25% did not receive any information from care providers about expected normal fetal activity. Receiving information about fetal activity was associated with increased maternal awareness (odds ratio, 2.0; 95% confidence interval [CI], ). Low maternal awareness of fetal activity was associated with an increased risk of having a small for gestational age infant (odds ratio, 6.5; 95% CI, ). Expectations about the normal frequency of fetal movements, as reported by the mothers, varied from 25 kicks/hour to 3 kicks/24 hours. Receiving information about expected fetal activity was associated with maternal concerns about decreased fetal movement, but not with improved outcomes. We conclude that receiving information about expected fetal activity was associated with maternal concerns, but not with improved outcomes(6).

5 Artikkel 7 Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement Tveit JV, Saastad E, Stray-Pedersen B, Børdahl PE, Flenady V, Fretts R, Frøen JF. Division of Obstetrics and Gynecology, and Centre for Perinatal Research, Rikshospitalet University Hospital, University of Oslo, Medical Faculty, Norway. julievh@medisin.uio.no Background: Women experiencing decreased fetal movements (DFM) are at increased risk of adverse outcomes, including stillbirth. Fourteen delivery units in Norway registered all cases of DFM in a population-based quality assessment. We found that information to women and management of DFM varied significantly between hospitals. We intended to examine two cohorts of women with DFM before and during two consensus-based interventions aiming to improve care through: 1) written information to women about fetal activity and DFM, including an invitation to monitor fetal movements, 2) guidelines for management of DFM for health-care professionals. Methods: All singleton third trimester pregnancies presenting with a perception of DFM were registered, and outcomes collected independently at all 14 hospitals. The quality assessment period included April 2005 through October 2005, and the two interventions were implemented from November 2005 through March The baseline versus intervention cohorts included: 19,407 versus 46,143 births and 1215 versus 3038 women with DFM, respectively. Results: Reports of DFM did not increase during the intervention. The stillbirth rate among women with DFM fell during the intervention: 4.2% vs. 2.4%, (OR % CI ), and 3.0/1000 versus 2.0/1000 in the overall study population (OR % CI ). There was no increase in the rates of preterm births, fetal growth restriction, transfers to neonatal care or severe neonatal depression among women with DFM during the intervention. The use of ultrasound in management increased, while additional follow up visits and admissions for induction were reduced. Conclusion: Improved management of DFM and uniform information to women is associated with fewer stillbirths(7). Artikkel 8 What investigation is appropriate following maternal perception of reduced fetal movements? Heazell AE, Sumathi GM, Bhatti NR It has been proposed that maternal perception of reduced fetal movements may be indicative of placental insufficiency, and that women who present with reduced fetal movements should be investigated for evidence of placental insufficiency. A retrospective case notes-based analysis of patients presenting with reduced fetal movements was undertaken. There were 92 live-born infants, the mean gestation at delivery was 39(+4) weeks. The median birth weight was 3,140 g. A total of 29.1% of

6 infants had a birth weight of less than the 10th centile. A total of 35 women underwent ultrasound assessment of fetal growth and liquor volume. Measurement of symphyseal fundal height (SFH) had a greater specificity than a single ultrasound assessment in the prediction of IUGR at delivery. To reduce unnecessary intervention, SFH measurement may be used as a screening tool for those who merit ultrasound assessment of growth and umbilical artery Doppler(8). Artikkel 9 Methods of fetal movement counting and the detection of fetal compromise Heazell AE, Frøen JF Division of Human Development, Maternal and Fetal Health Research Centre, St Mary's Hospital, University of Manchester, UK. Maternal perception of fetal movements is widely used as a marker of fetal viability and well-being. A reduction in fetal movements is associated with fetal hypoxia, increased incidence of stillbirth and fetal growth restriction (FGR). Therefore, a reduction in fetal movements has been proposed as a screening tool for FGR or fetal compromise. The problem of this approach is that there is no widely accepted definition of reduced fetal activity or 'alarm limits', and pregnant women are currently given a wide range of nonevidence-based advice. We have reviewed the background of published definitions and their potential usefulness in screening. A formal meta-analysis of these studies is not possible due to variation in methodology and definitions of reduced fetal movements. Assessment of fetal movements using formal fetal movement counting has shown equivocal results. Importantly, in all studies, there was a decrease in perinatal mortality suggesting a beneficial role for raising maternal awareness of fetal movements. Most studies implemented limits to define reduced fetal movements based on small groups of high risk pregnancies and obsolete counting methodology. A single case-control study developed 'normal limits' in a low risk population, and successfully implemented it prospectively for screening. At present, there is no evidence that any absolute definition of reduced fetal movements is of greater value than maternal subjective perception of reduced fetal movements in the detection of intrauterine fetal death or fetal compromise. Further investigation is required to determine an effective method of identifying patients with reduced fetal movements and to determine the best subsequent management(9).

7 Artikkel 10 Midwives' and obstetricians' knowledge and management of women presenting with decreased fetal movements Heazell AE, Green M, Wright C, Flenady V, Frøen JF. Maternal and Fetal Health Research Group, University of Manchester, Manchester, UK. Background: Maternal perception of decreased fetal movements (DFM) affects 5-15% of pregnancies. DFM is associated with intra-uterine fetal death (IUFD) and intra-uterine growth restriction (IUGR). It has been proposed that maternal perception of DFM may be used as a screening tool for IUFD or IUGR. However, this proposal is complicated by variations in definitions and management of DFM. Hypothesis: We hypothesised that uncertainties in the definition and management of women presenting with DFM leads to variation in clinical practice. Methods: A postal questionnaire was sent to midwives and consultant obstetricians in the UK. Results: The majority of respondents enquired about the presence of fetal movements after 28 weeks gestation. There was little agreement on a definition of DFM, with a maternal perception of decreased movements for 24 h gaining the greatest acceptance. Few practitioners used formal fetal movement counting, with the majority of respondents stating they were ineffective in the prevention of IUGR or IUFD and led to increased intervention. There was large variation in the knowledge of associations with DFM and management of women presenting with DFM. Conclusions: There were wide variations in the practice of obstetricians and midwives with regard to women presenting with DFM; many aspects of practice were not based on the available evidence. The variation in practice may result from a lack of robust evidence on which to base the provision of care. Further research is needed to provide and disseminate evidence to direct the management of women presenting with DFM(10). Artikkel 11 Detection and management of decreased fetal movements in Australia and New Zealand: a survey of obstetric practice Flenady V, MacPhail J, Gardener G, Chadha Y, Mahomed K, Heazell A, Fretts R, Frøen F Department of Obstetrics and Gynecology, University of Queensland, Brisbane, Queensland, Australia. vicki.flenady@mater.org.au

8 Background: Decreased fetal movement (DFM) is associated with increased risk of adverse pregnancy outcome. However, there is limited research to inform practice in the detection and management of DFM. Aims: To identify current practices and views of obstetricians in Australia and New Zealand regarding DFM. Methods: A postal survey of Fellows and Members, and obstetric trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Results: Of the 1700 surveys distributed, 1066 (63%) were returned, of these, 805 (76% of responders) were currently practising and included in the analysis. The majority considered that asking women about fetal movement should be a part of routine care. Sixty per cent reported maternal perception of DFM for 12 h was sufficient evidence of DFM and 77% DFM for 24 h. KICK charts were used routinely by 39%, increasing to 66% following an episode of DFM. Alarm limits varied, the most commonly reported was < 10 movements in 12 h (74%). Only 6% agreed with the internationally recommended definition of < 10 movements in two hours. Interventions for DFM varied, while 81% would routinely undertake a cardiotocograph, 20% would routinely perform ultrasound and 20% more frequent antenatal visits. Conclusions: While monitoring fetal movement is an important part of antenatal care in Australia and New Zealand, variation in obstetric practice for DFM is evident. Large-scale randomised controlled trials are required to identify optimal screening and management options. In the interim, high quality clinical practice guidelines using the best available advice are needed to enhance consistency in practice including advice provided to women(11). Referanseliste 1. Frøen JF. A kick from within - fetal movement counting and the cancelled progress in antenatal care. J Perinat Med 2004;32: Frøen JF, Saastad E, Tveit JV, Børdahl PE, Stray-Pedersen B. [Clinical practice variation in reduced fetal movements]. Tidsskr Nor Laegeforen 2005;125: Frøen JF, Heazell AE, Tveit JV, Saastad E, Fretts RC, Flenady V. Fetal movement assessment. Semin Perinatol 2008;32: Frøen JF, Tveit JV, Saastad E, Bordahl PE, Stray-Pedersen B, Heazell AE, et al. Management of decreased fetal movements. Semin Perinatol 2008;32: Saastad E, Frøen JF. [Reduced fetal movements--clinical management, recommendations and information]. Tidsskr Nor Laegeforen 2005;125: Saastad E, Ahlborg T, Froen JF. Low maternal awareness of fetal movement is associated with small for gestational age infants. J Midwifery Womens Health 2008;53:

9 7. Holm Tveit JV, Saastad E, Stray-Pedersen B, Bordahl PE, Flenady V, Fretts R, et al. Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement. BMC Pregnancy Childbirth 2009;9: Heazell AE, Sumathi GM, Bhatti NR. What investigation is appropriate following maternal perception of reduced fetal movements? J Obstet Gynaecol 2005;25: Heazell AE, Frøen JF. Methods of fetal movement counting and the detection of fetal compromise. J Obstet Gynaecol 2008;28: Heazell AE, Green M, Wright C, Flenady V, Frøen JF. Midwives' and obstetricians' knowledge and management of women presenting with decreased fetal movements. Acta Obstet Gynecol Scand 2008;87: Flenady V, MacPhail J, Gardener G, Chadha Y, Mahomed K, Heazell A, et al. Detection and management of decreased fetal movements in Australia and New Zealand: a survey of obstetric practice. Aust N Z J Obstet Gynaecol 2009;49: