Recurrent Reduced Fetal Movements

Recurrent reduced fetal movements is 2 or more episodes of reduced fetal movements in one pregnancy. It suggests chronic placental insufficiency or fetal vulnerability. It matters because the risk of stillbirth rises with each episode, and normal cardiotocography at one visit does not guarantee safety.

• Associated with growth restriction, low liquor and fetal anomaly.
• Risk factors: smoking, hypertension, diabetes, obesity, previous stillbirth, placental disease.
• Each episode needs full assessment.

Women report repeated episodes of less fetal movement, often with several visits for assessment. Fundal height may be small.

• Repeated reassuring cardiotocography with persisting concern.
• Small fundal height in some.
• Differential diagnosis: growth restriction, oligohydramnios, fetal anomaly, anterior placenta, maternal anxiety, fetomaternal haemorrhage, maternal sedation.
• Complications: stillbirth, fetal hypoxia, growth restriction, preterm birth, emergency caesarean section, neonatal intensive care admission.

The approach is full assessment at each episode with growth and Doppler review.

• Cardiotocography for 20 to 40 minutes each time.
• Ultrasound for estimated fetal weight, abdominal circumference, deepest vertical pocket, umbilical artery Doppler, middle cerebral artery Doppler and cerebroplacental ratio at the first and later episodes.
• Maternal tests: blood pressure, urine protein, glucose, full blood count, malaria rapid test, syphilis test, thyroid tests, antiphospholipid antibodies, blood group and Kleihauer test.
• Fetal anomaly scan review and growth chart.

The principle is to find a cause at each episode and offer delivery from 37 weeks.

• Supportive: teach counting of 10 movements in 2 hours; same day review for every episode; admit for abnormal tests; deliver in a facility with continuous cardiotocography and caesarean ability.
• Pharmacological: labetalol 200 mg oral every 8 to 12 hours (maximum 2.4 g daily) or nifedipine modified release 30 to 60 mg oral once daily (maximum 120 mg) for hypertension; insulin or metformin for diabetes; enoxaparin 40 mg subcutaneous daily with aspirin 150 mg oral at night for antiphospholipid syndrome; betamethasone 12 mg IM twice, 24 hours apart, between 24 and 34 weeks and 6 days if delivery is likely; aspirin 150 mg oral at night from 12 weeks to 36 weeks in the next pregnancy.
• Procedures: induction at 37 to 39 weeks for 2 or more episodes with normal tests, using misoprostol 25 micrograms vaginal 6-hourly (maximum 4 doses) or Foley catheter with a 30 mL balloon; earlier delivery for growth restriction, abnormal Doppler or pathological cardiotocography; continuous cardiotocography in labour.
• Special groups: RhD negative women with a Kleihauer test showing fetal cells give anti-D immunoglobulin 500 IU IM within 72 hours, increased by 125 IU for each 1 mL of fetal red cells above 4 mL.
• Red flags: no fetal heart, abnormal cardiotocography, oligohydramnios, absent or reversed end diastolic flow, bleeding, severe hypertension.
• Follow-up: growth scan with Doppler every 2 weeks; cardiotocography twice weekly from 34 weeks; antenatal visit weekly from 36 weeks.