Management of Decreased Fetal Movements J. Frederik Frøen, MD, PhD,* ,† Julie Victoria Holm Tveit, MD, ‡ Eli Saastad, RN, RM, MSc,* ,§ Per E. Børdahl, MD, PhD,  Babill Stray-Pedersen, MD, PhD, ‡ Alexander E.P. Heazell, MBChB(hons), ¶ Vicki Flenady, RN, RM, MMedSc, # and Ruth C. Fretts, MD, MPH † Maternal perception of decreased fetal activity is a common complaint, and one of the most frequent causes of unplanned visits in pregnancy. No proposed definitions of decreased fetal movements have ever been proven to be superior to a subjective maternal perception in terms of identifying a population at risk. Women presenting with decreased fetal movements do have higher risk of stillbirth, fetal growth restriction, fetal distress, preterm birth, and other associated outcomes. Yet, little research has been conducted to identify optimal management, and no randomized controlled trials have been performed. The strong associations with adverse outcome suggest that adequate management should include the exclusion of both acute and chronic conditions associated with decreased fetal move- ments. We propose guidelines for management of decreased fetal movements that include both a nonstress test and an ultrasound scan and report findings in 3014 cases of decreased fetal movements. Semin Perinatol 32:307-311 © 2008 Elsevier Inc. All rights reserved. KEYWORDS decreased fetal movements, guidelines, management, stillbirth, fetal growth re- striction, fetal distress Adverse Outcomes in Decreased Fetal Movements A lmost all pregnant women perceive fetal movements and intuitively view their experience of normal fetal activity as a sign of fetal well-being, engaging in self-screening by reporting their concerns for decreased fetal movements (DFM). In a Western society such as Norway, as many as 51% of women report that they were concerned for DFM once or more in pregnancy. 1 Not all these concerns are brought to the attention of health care professionals, but in different popu- lations, between 4 and 15% will contact care providers with such concerns in the third trimester. 2 Contemporary guidelines for the management of uncom- plicated pregnancies provide little guidance for pregnant women and their care providers on DFM. While existing guidelines acknowledge the importance of DFM by recom- mending that women should be informed about the need to contact health care professionals when they perceive DFM, little, if any, provide further guidance in how to define or manage DFM. 3-5 DFM has a well-established role as an adaptive response to the various stages of placental insufficiency and hypoxia. In early stages, DFM may represent compensatory adaptations in line with the redistribution of blood flow to essential or- gans as the brain, heart, and adrenals, and in later stages, a sign of decompensation warning imminent injury and death. Details of this pathophysiology are beyond the scope of this review, but in terms of management, it is important to acknowledge the significant association between DFM and fetal growth restriction (FGR) across difference definitions of *Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway. †Brigham and Women’s Hospital, Div. of Maternal-Fetal Medicine, Harvard Medical School, Boston, MA. ‡Dept. of Obstetrics and Gynecology, and Center for Perinatal Research, Rikshospitalet, University of Oslo, Oslo, Norway. §Akershus University College, Lillestrøm, Norway. Dept. of Clinical Medicine, Section for Obstetrics and Gynecology, Univer- sity of Bergen, Bergen, Norway. ¶Maternal and Fetal Health Research Group, University of Manchester, Manchester, UK. #Centre for Clinical Studies, Mater Mothers’ Hospital, School of Medicine, University of Queensland, Brisbane, Australia. This work was supported in part by The Norwegian Research Council, The Norwegian Women’s Public Health Association, The Norwegian Medical Association, and Unexpected Child Death Society of Norway. Address reprint requests to J. Frederik Frøen, MD, PhD, Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, N-0403 Oslo, Norway. E-mail: frederik.froen@fhi.no 307 0146-0005/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.semperi.2008.04.015