Case Study 25 : ObstetricsReduced 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.phphttp://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