Evaluation of Pregnancy Outcomes Among Women With Decreased Fetal Movements
Authors: Jessica M. Turner, Vicki Flenady, David Ellwood, Michael Coory, Sailesh Kumar
Journal: JAMA Network Open (2021)

<h3>Importance</h3> Stillbirth is a devastating pregnancy outcome with far-reaching economic and psychosocial consequences, but despite significant investment, a screening tool for identifying those fetuses at risk for stillbirth remains elusive. Maternal reporting of decreased fetal movements (DFM) has been found to be associated with stillbirth and other adverse perinatal outcomes. <h3>Objective</h3> To examine pregnancy outcomes of women presenting with DFM in the third trimester at a tertiary Australian center with a clear clinical management algorithm. <h3>Design, Setting, and Participants</h3> This cohort study used data on all births meeting the inclusion criteria from 2009 through 2019 at Mater Mothers' Hospital in Brisbane, Australia. This is a tertiary center and Australia's largest maternity hospital. All singleton births without a known congenital anomaly after 28 weeks' gestation were included. Among 203 071 potential participants identified from the hospital database, 101 597 individuals met the eligibility criteria. Data analysis was performed from May through September 2020. <h3>Exposure</h3> Presentation to hospital with DFM after 28 weeks gestation. <h3>Main Outcomes and Measures</h3> The primary outcome of this study was the incidence of stillbirth. Multivariate analysis was undertaken to determine the association between DFM and stillbirth, obstetric intervention, and other adverse outcomes, including being born small for gestational age (SGA) and a composite adverse perinatal outcome (at least 1 of the following: neonatal intensive care unit admission, severe acidosis [ie, umbilical artery pH &lt;7.0 or base excess −12.0 mmol/L or less], 5-minute Apgar score &lt;4, or stillbirth or neonatal death). The hypothesis being tested was formulated prior to data collection. <h3>Results</h3> Among 101 597 women with pregnancies that met the inclusion criteria, 8821 (8.7%) presented at least once with DFM and 92 776 women (91.3%) did not present with DFM (ie, the control population). Women presenting with DFM, compared with those presenting without DFM, were younger (mean [SD] age, 30.4 [5.4] years vs 31.5 [5.2] years;<i>P</i> &lt; .001), more likely to be nulliparous (4845 women [54.9%] vs 42 210 women [45.5%];<i>P</i> &lt; .001) and have a previous stillbirth (189 women [2.1%] vs 1156 women [1.2%];<i>P</i> &lt; .001), and less likely to have a previous cesarean delivery (1199 women [13.6%] vs 17 444 women [18.8%];<i>P</i> &lt; .001). During the study period, the stillbirth rate was 2.0 per 1000 births after 28 weeks' gestation. Presenting with DFM was not associated with higher odds of stillbirth (9 women [0.1%] vs 185 women [0.2%]; adjusted odds ratio [aOR], 0.54; 95% CI, 0.23-1.26,<i>P</i> = .16). However, presenting with DFM was associated with higher odds of a fetus being born SGA (aOR, 1.14; 95% CI, 1.03-1.27;<i>P</i> = .01) and the composite adverse perinatal outcome (aOR, 1.14; 95% CI, 1.02-1.27;<i>P</i> = .02). Presenting with DFM was also associated with higher odds of planned early term birth (aOR, 1.26; 95% CI, 1.15-1.38;<i>P</i> &lt; .001), induction of labor (aOR, 1.63; 95% CI, 1.53-1.74;<i>P</i> &lt; .001), and emergency cesarean delivery (aOR, 1.18; 95% CI, 1.09-1.28;<i>P</i> &lt; .001). <h3>Conclusions and Relevance</h3> The presence of DFM is a marker associated with increased risk for a fetus. This study's findings of a nonsignificantly lower rate of stillbirth among women with DFM may be reflective of increased community awareness of timely presentation to their obstetric care clinician when concerned about fetal movements and the benefits of tertiary level care guided by a clear clinical management protocol. However, DFM was associated with increased odds of an infant being born SGA, obstetric intervention, early term birth, and a composite of adverse perinatal outcomes.