Temporal patterns in count-to-ten fetal movement charts and their associations with pregnancy characteristics: a prospective cohort study

BMC Pregnancy and Childbirth

J Frederik Frøen¹  Jo Røislien²  Brita Askeland Winje¹ 

[1] Division of Epidemiology, Norwegian Institute of Public Health, PO Box 4404 , Nydalen, 0403, Oslo, Norway;Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway

关键词: Temporal pattern;    Principal components;    Functional data analysis;    Decreased fetal movement;    Kick counting;    Fetal movement;   

Others  :  1151902
DOI  :  10.1186/1471-2393-12-124

 received in 2012-06-25, accepted in 2012-10-29,  发布年份 2012

【 摘 要 】

Background

Fetal movement counting has long been suggested as a screening tool to identify impaired placental function. However, quantitative limits for decreased fetal movement perform poorly for screening purposes, indicating the need for methodological refinement. We aimed to identify the main individual temporal patterns in fetal movement counting charts, and explore their associations with pregnancy characteristics.

Methods

In a population-based prospective cohort in Norway, 2009–2011, women with singleton pregnancies counted fetal movements daily from pregnancy week 24 until delivery using a modified "count-to-ten” procedure. To account for intra-woman correlation of observations, we used functional data analysis and corresponding functional principal component analysis to identify the main individual temporal patterns in fetal movement count data. The temporal patterns are described by continuous functional principal component (FPC) curves, with an individual score on each FPC for each woman. These scores were later used as outcome variables in multivariable linear regression analyses, with pregnancy characteristics as explanatory variables.

Results

Fetal movement charts from 1086 pregnancies were included. Three FPC curves explained almost 99% of the variation in the temporal data, with the first FPC, representing the individual overall counting time, accounting for 91% alone. There were several statistically significant associations between the FPCs and various pregnancy characteristics. However, the effects were small and of limited clinical value.

Conclusions

This statistical approach for analyzing fetal movement counting data successfully captured clinically meaningful individual temporal patterns and how these patterns vary between women. Maternal body mass index, gestational age and placental site explained little of the variation in the temporal fetal movement counting patterns. Thus, a perceived decrease in fetal movement should not be attributed to a woman’s basic pregnancy characteristics, but assessed as a potential marker of risk.

【 授权许可】

   
2012 Winje et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

【 参考文献 】

• [1]Coppens M, Vindla S, James DK, Sahota DS: Computerized analysis of acute and chronic changes in fetal heart rate variation and fetal activity in association with maternal smoking. Am J Obstet Gynecol 2001, 185:421-426.
• [2]Warrander LK, Batra G, Bernatavicius G, Greenwood SL, Dutton P, Jones RL, et al.: Maternal perception of reduced fetal movements is associated with altered placental structure and function. PLoS One 2012, 7:e34851.
• [3]Winje BA, Roald B, Kristensen NP, Froen JF: Placental pathology in pregnancies with maternally perceived decreased fetal movement–a population-based nested case-cohort study. PLoS One 2012, 7:e39259.
• [4]Frøen JF, Arnestad M, Frey K, Vege Å, Saugstad OD, Stray-Pedersen B: Risk factors for sudden intrauterine unexplained death: Epidemiologic characteristics of singleton cases in Oslo, Norway, 1986–1995. Am J Obstet Gynecol 2001, 184:694-702.
• [5]Heazell AE, Frøen JF: Methods of fetal movement counting and the detection of fetal compromise. J Obstet Gynaecol 2008, 28:147-154.
• [6]O'Sullivan O, Stephen G, Martindale E, Heazell AE: Predicting poor perinatal outcome in women who present with decreased fetal movements. J Obstet Gynaecol 2009, 29:705-710.
• [7]Sadovsky E, Ohel G, Havazeleth H, Steinwell A, Penchas S: The definition and the significance of decreased fetal movements. Acta Obstet Gynecol Scand 1983, 62(5):409-413.
• [8]Sinha D, Sharma A, Nallaswamy V, Jayagopal N, Bhatti N: Obstetric outcome in women complaining of reduced fetal movements. J Obstet Gynaecol 2007, 27:41-43.
• [9]Frøen JF: A kick from within - fetal movement counting and the cancelled progress in antenatal care. J Perinat Med 2004, 32:13-24.
• [10]Flenady V, Middleton P, Smith GC, Duke W, Erwich JJ, Khong TY, et al.: Stillbirths: the way forward in high-income countries. Lancet 2011, 377:1703-1717.
• [11]Frøen JF, Heazell AE, Tveit JV, Saastad E, Fretts RC, Flenady V: Fetal movement assessment. Semin Perinatol 2008, 32:243-246.
• [12]Grant A, Valentin L, Elbourne D, Alexander S: Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons. Lancet 1989, 2:345-349.
• [13]Mangesi L, Hofmeyr GJ: Fetal movement counting for assessment of fetal wellbeing. Cochrane Database Syst Rev 2007, 1:CD004909.
• [14]Moore TR, Piacquadio K: A prospective evaluation of fetal movement screening to reduce the incidence of antepartum fetal death. Am J Obstet Gynecol 1989, 160:1075-1080.
• [15]Saastad E, Winje BA, Stray Pedersen B, Frøen JF: Fetal movement counting improved identification of fetal growth restriction and perinatal outcomes - a multi-centre, randomized, controlled trial. PLoS One 2011, 6:e28482.
• [16]Frøen JF, Saastad E, Tveit JV, Børdahl PE: Stray-Pedersen B: [Clinical practice variation in reduced fetal movements]. Tidsskr Nor Laegeforen 2005, 125:2631-2634.
• [17]Tveit JVH, Saastad E, Stray-Pedersen B, Børdahl PE, Flenady V, Fretts R, et al.: Correction: reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement. BMC Pregnancy Childbirth 2010, 10:49. BioMed Central Full Text
• [18]Tveit JV, Saastad E, Stray-Pedersen B, Bordahl PE, Flenady V, Fretts R, et al.: Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement. BMC Pregnancy Childbirth 2009, 9:32. BioMed Central Full Text
• [19]Birger M, Homburg R, Insler V: Clinical evaluation of fetal movements. Int J Gynaecol Obstet 1980, 18:377-382.
• [20]Ehrstrom C: Fetal movement monitoring in normal and high-risk pregnancy. Acta Obstet Gynecol Scand Suppl 1979, 80:1-32.
• [21]Kuwata T, Matsubara S, Ohkusa T, Ohkuchi A, Izumi A, Watanabe T, et al.: Establishing a reference value for the frequency of fetal movements using modified 'count to 10' method. J Obstet Gynaecol Res 2008, 34:318-323.
• [22]Pearson JF, Weaver JB: Fetal activity and fetal wellbeing: an evaluation. Br Med J 1976, 1:1305-1307.
• [23]Rayburn WF, McKean HE: Maternal perception of fetal movement and perinatal outcome. Obstet Gynecol 1980, 56:161-164.
• [24]Wood C, Gilbert M, O'Connor A, Walters WA: Subjective recording of fetal movement. Br J Obstet Gynaecol 1979, 86:836-842.
• [25]Ramsay JO, Silverman BW: Functional data analysis. 2nd edition. New York, NY 10013, USA: Springer; 2005.
• [26]Backe B: [Routine ultrasonography in obstetric care in Norway, 1994]. Tidsskr Nor Laegeforen 1997, 117:2314-2315.
• [27]Medical Birth Registry of Norway: Norwegian Institute of Public Health, Bergen, Norway Last update:19-12-2011. http://mfr-nesstar.uib.no/mfr/ webcite; Ref Type: Electronic Citation
• [28]Winje B, Saastad E, Gunnes N, Tveit J, Stray-Pedersen B, Flenady V, et al.: Analysis of 'count-to-ten' fetal movement charts: a prospective cohort study. BJOG 2011, 118:1229-1238.
• [29]Crainiceanu CM, Goldsmith AJ: Bayesian functional data analysis using WinBUGS. J Stat Softw 2010, 32(11):pii: i11.
• [30]Joliffe I: Principal Components Analysis. 2nd edition. NY: Springer; 2002.
• [31]Johnson RA, Wichern DW: Applied Multivariate Statistical Analysis. 6th edition. Upper Saddle River: Pearson Prentice Hall; 2007.
• [32]BMI classification: World Health Organization: Geneva, Switzerland. Last update:16-2-2012. http://apps.who.int/bmi/index.jsp?introPage=intro_3.html webcite Ref Type: Electronic
• [33]Valentin L, Lofgren O, Marsal K, Gullberg B: Subjective recording of fetal movements I. Limits and acceptability in normal pregnancies. Acta Obstet Gynecol Scand 1984, 63:223-228.
• [34]Valentin L, Marsal K: Subjective recording of fetal movements. II. Screening of a pregnant population; methodological aspects. Acta Obstet Gynecol Scand 1986, 65:639-644.
• [35]Grant AH: Merits of an individualized approach to fetal movement counting compared with fixed-time and fixed-number methods. Br J Obstet Gynaecol 1984, 91:1087-1090.
• [36]Valentin L, Marsal K: Fetal movement in the third trimester of normal pregnancy. Early Hum Dev 1986, 14:295-306.
• [37]Neldam S: Fetal movements A comparison between maternal assessment and registration by means of dynamic ultrasound. Dan Med Bull 1982, 29:197-199.
• [38]Tveit JV, Saastad E, Stray-Pedersen B, Bordahl PE, Froen JF: Maternal characteristics and pregnancy outcomes in women presenting with decreased fetal movements in late pregnancy. Acta Obstet Gynecol Scand 2009, 88:1345-1351.
• [39]Hijazi ZR, East CE: Factors affecting maternal perception of fetal movement. Obstet Gynecol Surv 2009, 64:489-497.
• [40]Tuffnell DJ, Cartmill RS, Lilford RJ: Fetal movements; factors affecting their perception. Eur J Obstet Gynecol Reprod Biol 1991, 39:165-167.
• [41]Flenady V, Koopmans L, Middleton P, Froen JF, Smith GC, Gibbons K, et al.: Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet 2011, 377:1331-1340.
• [42]Hofmeyr GJ, Novikova N: Management of reported decreased fetal movements for improving pregnancy outcomes. Cochrane Database Syst Rev 2012, 4:CD009148.
• [43]Neldam S: Fetal movements as an indicator of fetal well-being. Dan Med Bull 1983, 30:274-278.
• [44]Preston S, Mahomed K, Chadha Y, Flenady V, Gardener G, MacPhail J, for the Australia and NewZealand Stillbirth Alliance (ANZSA), et al.: Clinical practice guideline for the management of women who report decreased fetal movements. 11th edition. Brisbane: Australia and New Zealand Stillbirth Alliance (ANZSA); 2010.
• [45]Radestad I: Fetal movements in the third trimester–Important information about wellbeing of the fetus. Sex Reprod Healthc 2010, 1:119-121.
• [46]Tukey JW: Exploratory data analysis. 5th edition. MA, Addison-Wesley Pub: Reading; 1977.
• [47]Di CZ, Crainiceanu CM, Caffo BS, Punjabi NM: Multilevel functional principal component analysis. Ann Appl Stat 2009, 3:458-488.
• [48]Gelman A, Carlin J, Stern H, Rubin D: Bayesian Data Analysis. Boca Raton, Florida: Chapman&Hall/CRC; 2004.
• [49]R Development Core Team: R version 2.11.1: A language and environment for statistical computing. Downloaded 15 Aug 2010. Vienna, Austria: R Foundation for Statistical Computing; 2010. Ref Type: Computer Program
• [50]Sturtz S, Ligges U, Gelamn A: R2WinBUGS: A Package for Running WinBUGS from R. J Stat Softw 2005, 12:1-16.
• [51]Lunn D, Thomas A, Best N, Spiegelhalter D: WinBUGS - A Bayesian modelling framework: concepts, structure, and extensibility. Stat Comput 2000, 10:325-337.
• [52]Ntzoufras I: Bayesian Modeling Using WinBUGS. New Jersey: Wiley; 2009.