Pregnancies with decreased fetal movements : risk factors and strategies for mitigation of poor neonatal outcomes

Abstract: Background and aims: The most feared complication of pregnancy is stillbirth. Globally there are 2.6 million stillbirths annually with more than 7000 deaths a day. Pregnancies with reduced fetal movements have a higher risk of stillbirth and growth restriction. In this thesis, we aimed to identify risk factors that are associated with poor neonatal outcome in the group of women with reduced fetal movements; to identify preventable stillbirths through an audit process; to investigate the intrauterine milieu and the existence of a placental microbiome in full-term pregnancies; to investigate if ultrasound and angiogenic markers can be used as predictors of the neonatal outcome in pregnancies with reduced fetal movement. Methods: Study I was a retrospective cohort study were all women with pregnancies who attended health care for decreased fetal movements at Soder Hospital were included. A composite neonatal outcome was constructed and the risk factors for poor neonatal outcome were analyzed for this group. Study II was a retrospective cohort study conducted as an audit by a multidisciplinary team. All stillbirths in Stockholm 2017 were included and the intention was to investigate the preventable deaths and standard of care. Study III investigated the potential presence of a placental microbiome in full-term pregnancies in pregnancies with pre-labor cesarean deliveries and in vaginal deliveries. Study IV was a pilot study in which it was investigated if the cerebroplacental ratio, the flow in the uterine artery and angiogenic factors could be used as predictors of poor neonatal outcome. Results: There was an increased risk of having an Apgar ≤7 at 5’ (RR 1.56, 95% CI 1.25-1.96), pH ≤ 7.10 (RR 1.34 CI 95% 1.12-1.61) and stillbirth (RR 5.53, CI 95% 2.81-10.85) in the RFM group compared with pregnancies without RFM. 30% of the stillbirth analyzed by the audit were assessed as preventable/possible preventable. The non-Swedish speaking women were overrepresented in this group. When adding a Doppler examination to standard care for RFM there was a significant increase in the obstetrical intervention rate without improvement of the neonatal outcome. The predictive model for composite neonatal outcome based on additional Doppler angiogenic factors and parity had an AUC of 0.89 (95% CI 0.81–0.97). Conclusion: The highest risk of having a poor neonatal outcome were the small for gestational babies (SGA) and the IVF pregnancies in the group of pregnancies with RFM. The audit process of stillbirth identified preventable deaths, delays in the health care system and cases with substandard care. This leads us to the conclusion that national audits can further improve the care for these patients and can possibly help us to reduce the rate of stillbirths. Non-Swedish women have a higher risk of stillbirth and those not speaking the language need individualized antenatal care. The angiogenic factors can be useful predictors of the neonatal outcome, but larger studies are needed. There is no evidence for a placental microbiome in human pregnancies at term.