The 11th Obstetric Malpractice Conference was hosted in Melbourne on 22 and 23 August 2019. Guest speakers included various obstetric experts and lawyers who practice in the area of medical negligence. Topics were wide ranging and informative.
An update on the clinical conundrum of best practice for women with decreased fetal movements in the context of stillbirth
Honorary Professor Vicky Flenady from the Mater Research Institute UQ, Faculty of Medicine gave an insightful presentation on the “clinical conundrum of best practice for women with decreased foetal movements in the context of stillbirth”.
Interestingly, Ms Flenady suggests that most women who experience decreased fetal movement will deliver a healthy newborn. 7/1000 births per year in Australia result in stillbirth. Historically, pregnant women were encouraged to count the number of fetal movements per 24 hours and keep a “kick chart”, charting the number of movements during a specified period of the day. According to Ms Flenady, there is now widespread agreement that there is no evidence that “kick counting” is helpful or predictive of stillbirth.
Therefore, it is now thought that “kick charts” should no longer be “standard practice” in respect of ante-natal care. In addition, Ms Flenady indicated that the Decreased Fetal Movement Guidelines in Australia and New Zealand are currently under review. Current thought is to focus on closer monitoring from 28 weeks onwards and to enter discussions with mothers regarding birthing from 39 weeks onwards.
Information was also presented that decreased fetal movement detected in women aged 35 years and above at 37 to 38 weeks, benefit from induction and delivery rather than progressing to term. Conversely, the accepted standard of care for women under 35 years of age is to monitor and wherever possible, to progress to 39 to 40 weeks.
Recent Australian developments
A recent initiative ‘My Baby’s Movements’ (MBM) trial app was developed by the Mater Research Institute – The University of Queensland, by researchers, obstetricians, midwives and pregnant women. The trial involved 26 hospitals with 260,000 women participating. A mobile phone app was provided to participants at 27-28 weeks of gestation. The app prompted participants in respect of fetal movements as a support for pregnant women regarding foetal movement. The results will be published in 2020.
Recent UK developments
A 2018 trial in the UK ‘AFFIRM’ was initiated (like MBM) to raise awareness about the importance of foetal movements among pregnant women and to explore how to reduce the number of stillbirths in the UK. AFFIRM introduced a package of care when women presented to their ante natal clinic with a history of reduced foetal movements. According to the UK Royal College of Midwives “…the package of care did not lead to a statistically significant reduction in the number of stillbirths and led to a significant increase in medical interventions including induction of labour and caesarean section.”
As Ms Flenady discussed, the AFFIRM trial suggests that a reliance on reduced foetal movements alone will not lead to reduction of stillbirths. There remains consensus that decreased foetal movement is linked to stillbirth and that nearing the end of pregnancy the risks are higher. Counselling and support toward the end of pregnancy (from 32 weeks according to Ms Flenady) is essential. It is important to remember that all pregnant women should become familiar with their baby’s movements and always contact their health professional if they notice any change or reduction in movement or if they feel concerned.
Pre-eclampsia screening, treatment and long-term implications
Dr Amanda Henry, Senior Lecturer, School of Women’s and Children’s Health, UNSW Medicine, Clinical Academic Obstetrician, St George Hospital Sydney, Senior Research Fellow, Global Women’s Health Program, The George Institute for Global Health – presented a paper on “Pre-eclampsia screening, treatment and long-term implications” at the Obstetric Malpractice Conference.
According to Dr Henry 30,000 pregnancies per year are affected by pregnancy induced hypertension (high blood pressure) in Australia. Pre-eclampsia is high blood pressure during the second half of pregnancy and one or more other symptoms e.g. protein in the urine; headache; oedema (puffiness) of the feet. Gestational hypertension is common in pregnancy and at least half of women have no symptoms of pre-eclampsia, especially in the early stages.
According to Dr Henry, “pre-eclampsia is one of the top five direct causes of maternal death globally.” Further, Dr Henry articulated certain risk factors including but not limited to the following factors which increase the likelihood of a pregnant women developing pre-eclampsia.
- History (15-50% recurrence);
- Genetic factors – relative had pre-eclampsia;
- Immunological factors;
- First pregnancy;
- First pregnancy with new partner;
- Assisted reproductive technology, especially donor gametes;
- Cardiovascular risk factors;
- High body mass index (>30);
- Diabetes;
- Pre-pregnancy hypertension; and
- Multiple pregnancy.
Can pre-eclampsia be prevented
According to Dr Henry, “aspirin in high-risk women may decrease early preterm (<34 weeks) pre-eclampsia by as much as 80%. However, does not prevent term pre-eclampsia, which is more common and will most likely not assist women who have chronic hypertension.
Prevention begins with risk-factor screening for pre-eclampsia and treatment with aspirin for those at high risk and who qualify for aspirin treatment (<16 weeks and definitely <20 weeks). In addition to treatment with aspirin where prescribed, pregnant women should be encouraged to undertake regular exercise to maintain a healthy weight which also assists in maintaining a healthy blood pressure.
In addition, it is important to monitor and establish a system for follow-up by GPs, midwives and ante natal clinics so that early detection and treatment where required, decreases the risks of developing pre-eclampsia and any potential ongoing health concerns associated with pre-eclampsia.
Also discussed were recent state reviews of assisted reproduction and surrogacy legislation regulation in rapidly changing environment. You can read more about that here.
