Sleep in multiple pregnancy: Obstructive sleep apnoea and beyond

Dear Editor, We read with great interest a most engaging and pragmatic clinical guideline for decreased fetal movements (DFM).1 Between 30– 55% of women who experience a stillbirth retrospectively noted DFM in the preceding week.2 This presumed negative clinical incident has long been perceived as opportunity for intervention. The AFFIRM study, recently published (November, 2018), was to be the first randomised trial involving 409 175 pregnancies that used a similar intervention package as in Norway (subjective perception of DFM by a patient in a contemporaneous setting) and was expected to deliver a 30% reduction in the rate of stillbirths.2 The results of the AFFIRM study have been disappointing to the supporters of intervention for reduced fetal movements. There was no statistically significant reduction in the stillbirth rate but rather an increase in induction and caesarean section rates, and average neonatal length of stay in neonatal intensive care.2 Also, in the intervention group there was a higher rate of post neonatal deaths. In our exuberance to prevent stillbirths, have we violated the principle of nonmaleficence? Alternatively, as suggested by Walker and Thornton, it might be safer to retain our current approach but rather place limits on awareness campaigns to gestations greater than 37 weeks.3 Reflecting upon the negative or null findings of the AFFIRM study, should the local guideline have an immediate addendum to clarify that there is no robust scientific approach to reduced fetal movements while awaiting further evidence?