What are the guidelines for managing reported absent fetal movements in pregnancy?

Management of Reported Absent Fetal Movements in Pregnancy

Women reporting absent fetal movements should receive immediate evaluation with non-stress testing (NST) as the initial assessment, followed by biophysical profile and Doppler studies if indicated, as absent fetal movements are strongly associated with adverse pregnancy outcomes including stillbirth and placental insufficiency. 1

Initial Assessment

Immediate Actions

• Perform cardiotocography/non-stress test (NST) immediately as first-line assessment 1
• Complete fetal heart rate evaluation for baseline, variability, accelerations, and decelerations
• Document duration of absent movements and any associated symptoms
• Assess for risk factors: growth restriction, hypertensive disorders, diabetes, previous stillbirth

Critical Timing Considerations

• Any woman reporting complete absence of fetal movements should be evaluated urgently, regardless of gestational age
• Concerning finding: absence of movements for >24 hours (25% of women with adverse outcomes waited this long) 2
• Do not delay evaluation for home monitoring or "kick counts" when movements are reported as absent

Secondary Assessment

If NST is normal/reactive (showing at least two accelerations of ≥15 beats per minute lasting ≥15 seconds within 20 minutes):

• Proceed with biophysical profile (BPP) assessment 1
• Perform ultrasound evaluation for:
  • Estimated fetal weight and growth parameters
  • Amniotic fluid volume
  • Placental assessment
  • Fetal breathing movements (absence strongly associated with imminent delivery) 3

If NST is non-reactive or shows concerning patterns:

• Initiate immediate intrauterine resuscitation measures
• Perform urgent BPP
• Consider delivery based on gestational age and clinical context

Doppler Assessment

• Umbilical artery Doppler studies should be performed if:
  • Any evidence of growth restriction is present
  • NST or BPP shows concerning findings
  • Recurrent episodes of reduced/absent movements
• Middle cerebral artery (MCA) Doppler should be considered if umbilical artery Doppler is abnormal 4
• Cerebroplacental ratio (CPR) provides additional information about fetal redistribution

Management Based on Findings

Normal Assessment Findings

• If all testing is normal (reactive NST, normal BPP, normal Doppler studies):
  • Consider discharge with clear return precautions
  • Schedule follow-up within 1 week
  • Educate patient about monitoring movements and when to return

Abnormal Assessment Findings

• Deliver by 37 weeks if:

  • MCA pulsatility index <5th percentile
  • Abnormal umbilical artery Doppler
  • Static growth over 3 weeks 4

• Consider immediate delivery regardless of gestational age if:

  • Absent or reversed end-diastolic flow in umbilical artery
  • Abnormal ductus venosus Doppler
  • Abnormal CTG/NST with other concerning findings 4

Special Considerations

Gestational Diabetes

• Women with GDM should be taught to monitor fetal movements during the last 8-10 weeks of pregnancy and report any reduction immediately 4
• More intensive fetal monitoring may be warranted in GDM patients with other risk factors

Recurrent Episodes

• Women presenting multiple times with decreased/absent fetal movements are at significantly increased risk for adverse outcomes 2
• Consider admission for continuous monitoring and expedited delivery if recurrent episodes occur, especially if >37 weeks gestation

Common Pitfalls to Avoid

1. Delayed evaluation: Never delay assessment of reported absent fetal movements
2. Reassurance without testing: Clinical examination alone is insufficient; objective testing with NST and ultrasound is required
3. Ignoring maternal concerns: Maternal perception has high sensitivity for detecting fetal compromise 5
4. Failure to follow up: Even with normal initial assessment, follow-up within 1 week is recommended
5. Overlooking rare normal variants: While extremely rare, some normal pregnancies may have periods of absent movements 6, but this should never be assumed without thorough evaluation

Mode of Delivery Considerations

• Individualize based on gestational age and severity of findings
• Consider cesarean delivery for:
  • Very preterm fetuses with severe Doppler abnormalities
  • Non-reassuring fetal status during labor induction
• Continuous fetal monitoring during labor is essential for all cases with history of absent fetal movements 4

Remember that absent fetal movements are strongly associated with placental insufficiency and increased risk of stillbirth 7, warranting thorough evaluation and a low threshold for intervention, particularly at later gestational ages.