Case Study 25 : Obstetrics

Reduced Fetal Movement

History :

> 25 y/o, para 1+0

> 32 weeks of gestation

> 2 day history of changed fetal movement

> Still birth pregnancy at 38 weeks in previous pregnancy

> Patient is crying and upset, worried that baby kick is not as
strong.
> Fetal movement includes kick, flutter, swish or roll

> The first time pregnant mother feel the movement is called
'quickening'.

> Usually first felt during 18-20 weeks of gestation and

rapidly acquire regular pattern.

> Some multigravid mother able to feel movement as early

as 16 weeks.

> Diminished of fetal activity may indicate chronic hypoxia

and growth failure, and may be a precursor for fetal death

> It is an important screening tool for further investigation

http://www.medicalnewstoday.com/articles/217555.php
http://www.americanpregnancy.org/duringpregnancy/firstfetalmovement.htm
Question 1
- What are the possible underlying reasons for her concern?

- previous history of stillbirth

- her current pregnancy date is nearing the gestation age her

previous baby died

- there is change in her fetal movement for 2 days and her baby
kick is not as strong as it used to be
Question 2
- What features in the history and examination would you be
interested in?
History
Complications for present pregnancy
- Pregnancy induced hypertension
- Pre-eclampsia / Eclampsia
- Infections e.g syphillis
- Anaemia
- PIH

Past obstetrics history

- Placenta problems → abnormal placentation, abruptio placenta with
concealed haemorrhage
- Fetal abnormalities
- Intrauterine death, age of gestation, investigations and cause of
death
Past medical history
- Diabetes mellitus *sudden unexplained late stillbirth about 10-30%
- Renal disease
- Heart disease e.g rheumatic heart disease, congenital heart disease
- Clotting disorders – e.g thrombophilia
- Autoimmune disease – SLE, antiphospholipid syndrome
- Chronic pulmonary disease
- Hypertension

Medication
- e.g phenytoin
- sedating drug e.g benzodiazepines

Social History
- substance abuse, alcohol/drug intake – e.g cocaine
- patient diet / nutrition
Physical Examination
- Blood pressure, pulse rate
- Maternal weight
- Palmar / conjunctiva pallor
- Symphysio-fundal height
- Estimate liquor volume
- Leg swelling

Ultrasound Scan
- Fetal biometry : Head circumference, biparietal diameter, abdominal
circumference, femur length
- Fetal abnormalities
- Placenta location, condition

Doppler U/S
- Fetal vessels
- Fetal heart beat

http://www.hindawi.com/journals/ijped/2010/401323/
http://www.ucsfbenioffchildrens.org/pdf/manuals/21_IUG.pdf
Question 3

- What investigation would you organize?

> Blood Investigations
- FBC : Hb, Platelets, MCV, MCHC
- BUSE
- PT/APTT/INR
- Blood group and rhesus
- Blood film
- ANA, Anti-dsDNA, Antiphospholipid antibody

>UFEME

>Vaginal swab → infection

>Fetal movement chart

>CTG

>Ultrasound
Question 4
- What advice would you wish to give the mother?
a. If the investigations showed no abnormality
- ensure patient that there is no abnormality
- number of movement tends to increase until 32 week of gestation, which then
plateaus until the onset of labour
- She would be discharged with a fetal movement chart and lie left lateral and
focus on fetal movement. If there is <10 movement in 2 hours contact
maternity unit.

b. If an abnormality was defined

- She needs to be admitted for further investigations and management
- Close surveillance in fetal well-being
- There is probability that she has to deliver early

http://www.rcog.org.uk/files/rcog-corp/GTG57RFM25022011.pdf
Question 5

- When should she be delivered?

- If no abnormalities found in patient and fetus, deliver at term.

- Close monitoring of fetus, in case need to deliver early.

- Give dexamethasone if there is risk, and need to deliver early

http://www.ncbi.nlm.nih.gov/pubmed/20070714