What is the appropriate workup for a pregnant patient presenting with decreased fetal movement?

Workup for Pregnant Patient with Decreased Fetal Movement in Urgent Care

A pregnant patient reporting decreased or absent fetal movements requires immediate evaluation with non-stress testing (NST) followed by biophysical profile (BPP) and Doppler studies if indicated, as this complaint is strongly associated with adverse pregnancy outcomes including stillbirth and placental insufficiency. 1

Initial Assessment

• Gestational age determination: Confirm gestational age as management differs based on viability
• Detailed history:
  • Duration of decreased movement (hours/days)
  • Complete cessation vs. reduction in movements
  • Previous episodes of decreased movement
  • Risk factors: diabetes, hypertension, prior growth restriction, advanced maternal age

Immediate Testing

1. Non-stress test (NST) - First-line assessment 1, 2

   • Evaluates fetal heart rate patterns and reactivity (correlates with oxygenation status)
   • A reactive NST shows at least two accelerations of ≥15 beats per minute lasting ≥15 seconds within 20 minutes
   • For pregnancies <32 weeks: acceleration defined as 10 beats/minute above baseline for 10 seconds 2

2. If NST is reactive and reassuring:

   • Proceed with amniotic fluid assessment
   • Ultrasound for fetal biometry if not done recently

3. If NST is non-reactive or shows concerning patterns:

   • Proceed immediately to BPP
   • Consider intrauterine resuscitation measures
   • Prepare for possible urgent delivery depending on findings

Secondary Testing

1. Biophysical Profile (BPP) 2

   • Includes four ultrasound components:
     • Fetal breathing movements (≥30 seconds within 30 minutes)
     • Fetal body/limb movements (≥3 discrete movements)
     • Fetal tone (≥1 episode of active extension with return to flexion)
     • Amniotic fluid volume (≥1 pocket measuring 2×2 cm)
   • Each component meeting criteria receives 2 points (total score out of 8)
   • Score 8: Normal
   • Score 6: Equivocal
   • Score ≤4: Abnormal, requires intervention

2. Modified BPP 2

   • Combines NST with amniotic fluid assessment
   • More time-efficient alternative to full BPP

3. Doppler Studies (if available and indicated) 2, 1

   • Umbilical artery Doppler: Assess placental function
   • Middle cerebral artery Doppler: Evaluate for brain-sparing effect
   • Ductus venosus: Assess for cardiac decompensation

Management Algorithm

1. Normal test results:

   • Patient education on kick counts and movement monitoring
   • Clear return precautions
   • Follow-up within 1 week
   • Consider more frequent antenatal testing

2. Abnormal test results:

   • Immediate delivery regardless of gestational age if:

     • Absent or reversed end-diastolic flow in umbilical artery
     • Abnormal ductus venosus Doppler
     • Abnormal NST with other concerning findings 1

   • Deliver by 37 weeks if:

     • MCA pulsatility index <5th percentile
     • Abnormal umbilical artery Doppler
     • Static growth over 3 weeks 1

Clinical Significance and Cautions

• Women presenting with decreased fetal movements have higher risk of stillbirth, fetal growth restriction, fetal distress, and preterm birth 3

• Multiple presentations with decreased movements significantly increases risk of poor perinatal outcomes 4

• False reassurance is a significant risk - a normal NST alone does not exclude all pathology, particularly in cases of chronic placental insufficiency 2, 3

• The absence of meconium does not rule out fetal compromise, as it's present in only about 50% of cases with decreased fetal movement 5

• Positioning during testing is critical - pregnant women should be positioned with left lateral tilt to avoid vena cava compression, which can cause maternal hypotension and decreased placental perfusion 2