**8. Reduced fetal movements in multiple gestations**

There is little guidance on the assessment and management of reduced FM in multiple gestations but a practical approach would incorporate clinical assessment and CTG followed by sonographic evaluation of chorionicity, biometry, liquor volume and umbilical artery Doppler. Given that fetal biometries are concordant and appropriate for gestational age, there are no structural abnormalities, signs of selective IUGR or twin-to-twin transfusion syndrome (TTTS), the mother can be reassured but careful follow-up should be arranged. Serial sonographic assessment for multiple gestations, more frequently in monochorionic gestations, is recommended.

#### **9. Documentation of reduced fetal movements in maternal records**

As in all areas of good clinical practice, meticulous documentation about the history and duration of the presenting complaint, stillbirth risk assessment, examination methods, recommendation for follow-up and advice is essential.

#### **10. Summary and recommendation**

Every mother who presents with the concern of reduced or altered fetal movements should be taken seriously. The initial assessment should include a detailed history of the presenting complaint, maternal observations, abdominal palpation, SFH measurement and CTG. If this is reassuring for the mother and clinician, no further evaluation is needed. Amniotic fluid assessment should be added in postdates pregnancies. If the mother re-presents or initial assessment is non-reassuring further tests should be performed; these include amniotic fluid assessment and estimation of fetal weight. Kickcharts are of no value and should therefore not be given out to pregnant women. Biophysical profile scoring has not been shown to be of benefit either, and UA Doppler velocimetry and vibroacoustic stimulation are of limited use in the assessment of reduced FM.

This review describes significant variation in clinical routines reported in the management of reduced FM, which do not correlate well with current information given to pregnant women, the available literature, or expert guidelines. This leads to clinical uncertainty for both pregnant women and healthcare professionals.

Up to 5% of women will re-present with reduced FM (Sinha *et al*., 2007). If the perception of reduced FM persists, consideration should be given to other causes such as fetal structural anomalies (4.3%), anaemia or feto-maternal haemorrhage. There is little evidence how to manage these pregnancies, however women who present on two or more occasions with reduced FM are at increased risk of poor perinatal outcome compared with those who attend only once (OR 1.92; 95% CI 1.21 – 2.02) (O'Sullivan *et al*., 2009). A practical approach would be to perform ultrasound assessment to rule out SGA, structural anomalies and oligo- or polyhydramnios and invite the woman for daily CTGs until mother and clinician are reassured. A blood test should ultimately be considered looking for maternal metabolic disorders or feto-maternal haemorrhage. Smoking should be discouraged. If concerns

There is little guidance on the assessment and management of reduced FM in multiple gestations but a practical approach would incorporate clinical assessment and CTG followed by sonographic evaluation of chorionicity, biometry, liquor volume and umbilical artery Doppler. Given that fetal biometries are concordant and appropriate for gestational age, there are no structural abnormalities, signs of selective IUGR or twin-to-twin transfusion syndrome (TTTS), the mother can be reassured but careful follow-up should be arranged. Serial sonographic assessment for multiple gestations, more frequently in monochorionic

As in all areas of good clinical practice, meticulous documentation about the history and duration of the presenting complaint, stillbirth risk assessment, examination methods,

Every mother who presents with the concern of reduced or altered fetal movements should be taken seriously. The initial assessment should include a detailed history of the presenting complaint, maternal observations, abdominal palpation, SFH measurement and CTG. If this is reassuring for the mother and clinician, no further evaluation is needed. Amniotic fluid assessment should be added in postdates pregnancies. If the mother re-presents or initial assessment is non-reassuring further tests should be performed; these include amniotic fluid assessment and estimation of fetal weight. Kickcharts are of no value and should therefore not be given out to pregnant women. Biophysical profile scoring has not been shown to be of benefit either, and UA Doppler velocimetry and vibroacoustic stimulation are of limited

This review describes significant variation in clinical routines reported in the management of reduced FM, which do not correlate well with current information given to pregnant women, the available literature, or expert guidelines. This leads to clinical uncertainty for

**7. Management of second and subsequent presentations** 

persist in later gestation, induction of labour or delivery can be considered.

**9. Documentation of reduced fetal movements in maternal records** 

**8. Reduced fetal movements in multiple gestations** 

recommendation for follow-up and advice is essential.

**10. Summary and recommendation** 

use in the assessment of reduced FM.

both pregnant women and healthcare professionals.

gestations, is recommended.

This comprehensive review is based on current evidence and experience from expert groups and reflects good clinical practice. For the development of evidence-based guidelines the authors suggest further randomised controlled trials to assess the different suggested management plans. This is likely to be difficult given current established clinical practice and ethical difficulties surrounding trials in pregnancy. Therefore, a sensible approach to the management of reduced FM based on good clinical practice as set out in this chapter seems reasonable.

#### **11. References**


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**14** 

*Sweden* 

**Lactate Level in Amniotic Fluid,** 

*Karolinska Institute, South General Hospital, Stockholm,* 

*Department of Clinical Science and Education, Section of Obstetrics and Gynecology,* 

If exhaustion or muscle fatigue is discussed in a general conversation, usually people will refer lactate accumulation as a primary cause. Lactate accumulates in blood and tissues during exercise, particularly when oxygen is lacking. The concentration is highest at or just following exhaustion. Lactate has historically been considered as a dead-end waste product of anaerobic metabolism due to hypoxia and the primary cause of fatigue (Berzelius 1808; Araki 1891; Hartree & Hill 1921; Hill 1922). Lactate has also been considered as a key factor in acidosis-induced tissue damage; however the role of lactate in metabolism has changed during the last decade (Brooks 1986; Brooks 2002; Brooks 2002) Lactate is no longer considered as a harmful end-product, but mainly one of the central players in cellular and

The breakdown of glycogen during anaerobic conditions leads to intracellular accumulation lactic acid. Lactic acid is a strong monocarboxylic acid (Pka 3, 86) and it dissociates easily at physiological pH into lactate and hydrogen ions (H+). The lactate itself has been considered to have little effect on muscle contractions. However, increased production of H+ and reduced pH with acidosis has classically been considered as the cause of muscle fatigue. The role of reduced pH as an important cause of fatigue has been challenged (Karlsson et al. 1975). Present day knowledge is that anaerobic metabolism with the production of lactic acid might also lead to increased production of other factors, like phosphate (Allen et al. 2002; Westerblad & Allen 2002; Westerblad et al. 2002) which is likely to have a more

One important finding, which has influenced the hypotheses for this thesis, is that the myometrium is a lactate producer (Taggart & Wray 1993; Taggart et al. 1996; Taggart et al. 1997; Taggart & Wray 1998; Wray et al. 2003; Quenby et al. 2004), and the level will increase

The essential function of amniotic fluid (AF) is to cushion the fetus. The fluid gives the fetus space to grow, and allows it to undergo a `physical´ development. The AF function is also to protect the fetus from trauma and to maintain temperature. It also has a minimal nutritive

**1. Introduction** 

whole body metabolism.

prominent role in muscle fatigue.

when there is a lack of oxygen.

function.

**a New Diagnostic Tool** 

Eva Wiberg-Itzel

Winje B, Saastad E, Gunnes N, Tveit J, Stray-Pedersen B, Flenady V & Frøen J. (2011). Analysis of 'count-to-ten' fetal movement charts: a prospective cohort study. *BJOG*. doi: 10.1111/j.1471-0528.2011.02993.x. [Epub ahead of print]
