What is the management for a patient at 26.6 weeks gestation with decreased fetal movement in triage?

Management of Decreased Fetal Movement at 26.6 Weeks Gestation

At 26.6 weeks gestation with decreased fetal movement, perform immediate cardiotocography (CTG/NST) and comprehensive ultrasound assessment including fetal biometry, amniotic fluid volume, and umbilical artery Doppler velocimetry to exclude both acute fetal compromise and chronic placental insufficiency. 1, 2

Initial Triage Assessment

Immediate Evaluation Required

• Cardiotocography (non-stress test) is the essential first-line assessment to exclude acute fetal distress and should be performed immediately upon presentation 1, 2, 3
• Comprehensive ultrasound examination must include:
  • Fetal biometry to assess for growth restriction (estimated fetal weight <10th percentile) 4, 1
  • Amniotic fluid volume assessment (oligohydramnios is associated with placental insufficiency) 4, 1
  • Umbilical artery Doppler velocimetry to evaluate placental function 4, 1
  • Fetal anatomic survey if not previously completed 1

Critical History Elements

• Duration of decreased movement (12 hours vs 24 hours of perceived decreased activity) 3
• Timing of last normal fetal movement and whether complete cessation or reduction 5, 2
• Adequacy of prenatal care (insufficient prenatal care increases risk of poor outcome, OR 2.85) 6
• Pregnancy complications including hypertension, diabetes, or prior growth restriction (increases risk of poor outcome, OR 3.01) 6

Risk Stratification Based on Findings

High-Risk Features Requiring Intensive Management

At 26.6 weeks gestation, the following findings indicate significantly increased risk:

• Pathological cardiotocography (increases risk of poor outcome, OR 1.66) 6
• Estimated fetal weight <10th percentile (defines fetal growth restriction at this gestational age) 4
• Estimated fetal weight <3rd percentile (severe FGR requiring weekly surveillance) 4, 7
• Abnormal umbilical artery Doppler (increased pulsatility index >95th percentile, OR 6.51 for poor outcome) 4, 6
• Oligohydramnios (associated with placental insufficiency) 4
• Symphysio-fundal height small for gestational age (OR 6.17 for poor outcome) 6

If Normal Initial Assessment

• Reassure the patient but emphasize importance of continued fetal movement monitoring 2
• Provide clear return precautions for recurrent decreased fetal movement 2
• Schedule follow-up ultrasound in 2 weeks if any concern for growth restriction 4

Management Algorithm for Abnormal Findings

If Fetal Growth Restriction Detected (EFW <10th percentile)

For severe FGR (EFW <3rd percentile) or abnormal umbilical artery Doppler:

• Weekly umbilical artery Doppler evaluation is required 4, 7
• Weekly cardiotocography testing after viability 4
• Serial fetal biometry every 2 weeks to assess growth velocity 4

For decreased diastolic flow (PI >95th percentile but present end-diastolic velocity):

• Weekly umbilical artery Doppler surveillance 4, 7
• Plan delivery at 37 weeks gestation if this pattern persists 4, 7

For absent end-diastolic velocity (AEDV):

• Doppler assessment 2-3 times per week 4, 7
• Daily cardiotocography monitoring 4
• Administer antenatal corticosteroids immediately (indicated before 33 6/7 weeks) 4, 7
• Plan delivery at 33-34 weeks gestation 4, 7

For reversed end-diastolic velocity (REDV):

• Immediate hospitalization 4
• Cardiotocography 1-2 times daily 4, 7
• Doppler assessment 3 times per week 4
• Administer antenatal corticosteroids and magnesium sulfate for neuroprotection 4, 7
• Plan delivery at 30-32 weeks gestation 4, 7

If Acute Fetal Distress on Cardiotocography

• Immediate obstetric consultation for potential emergent delivery 2
• At 26.6 weeks, coordinate with neonatology regarding viability and resuscitation planning (survival approximately 58-76% at 26 weeks) 7
• Administer antenatal corticosteroids and magnesium sulfate if delivery anticipated 4, 7

Common Pitfalls to Avoid

• Do not dismiss maternal perception of decreased fetal movement - subjective maternal perception has not been proven inferior to formal kick counts for identifying at-risk pregnancies 1
• Do not rely on cardiotocography alone - ultrasound assessment is essential to exclude chronic placental insufficiency and growth restriction 1, 2
• Do not use ductus venosus, middle cerebral artery, or uterine artery Doppler for routine management - these are not recommended for routine clinical decision-making 4, 7
• Multiple presentations with decreased fetal movement significantly increase risk of stillbirth, growth restriction, and preterm birth 2, 6
• Gestational age <37 weeks at presentation increases risk of poor outcome (OR 9.42) 6

Disposition from Triage

Admit if:

• Pathological cardiotocography 2, 6
• Severe fetal growth restriction (EFW <3rd percentile) 4
• Absent or reversed end-diastolic velocity 4
• Oligohydramnios 4

Discharge with close outpatient follow-up if:

• Reassuring cardiotocography 2
• Normal fetal biometry and amniotic fluid 1
• Normal umbilical artery Doppler 4
• Arrange follow-up within 1-2 weeks for repeat assessment 2