Qassim Univesity Faculty of Medicine Obstetrics and Gynecology

Polyhydramnios and Oligohyramnios

Prepared by: Ayman Al-Jaafry.

Objectives:
Physiological

aspects of amniotic fluid Techniques for assessing AFV Amniotic fluid disorders: Polyhydramnios. Oligohydramnios.

Post-term pregnancy

Defintion:
42

completed weeks or more (294 days or more) from last menstrual period (LMP).

Incidence:

Removal:
via fetal

swallowing and absorption by the amniotic-chorionic surface.

Composition:

Nature: - It is a clear pale, slightly alkaline pH 7.2 fluid. Normally the amniotic fluid volume is around 5001500 ml Water (98-99%) carbohydrates ( glucose and fructose) proteins ( albumin and globulins), lipids, hormones (estrogen and progesterone), enzymes ( alkaline phosphatase). Minerals (sodium, potassium and chloride) Suspended materials ; desquamated epithelial cells and meconium.

Functions:
During

pregnancy:

Protects the fetus against injury. A medium for free fetal movement.. Maintains the fetal temperature. Source for nutrition of the fetus. A medium for fetal excretion. Essential for lung development .

During

Labour:

The fore-bag of water helps the dilatation of the cervix. Antiseptic for the birth canal .

Techniques for Assessing AFV

Techniques for Assessing AFV

By measurement at time of Dye dilution techniques.

hysterotomy .

Most accurate techniques but they are invasive .

Ultrasound

Commonly used , less invasive .

US methods for assessment of AFV:

Single deepest pocket
Normal

2- 8 Cm. Oligohydramnios <2 Cm. Ployhydrmnios > 8 Cm. Less Accurate for low AFV.

 Amniotic fluid

index (AFI)

Measurement and summation of deepest pocket in each of four quadrants

Normal

= 5.1-25 cm. Oligo 5 cm. Poly 25 cm. Hight false positive rates.

Amniotic Fluid Disorders

Polyhydramnios

Polyhydramnios
Pathologic

accumulation of amniotic fluid.

Defined as more than 2,000 mL at any gestational age, more than the 95th percentile for gestational age, or an amniotic fluid index (AFI) greater than 25 cm at term. Prevalence:

In 0.9% to 1.6% of women, some increase in amniotic uid is seen during pregnancy (80% mild, 5% severe).

Causes:
Idiopathic (two thirds). Maternal diabetes. Multiple gestation. Fetal anomalies

Risk Factors:
Fetal anomalies that impair swallowing or alter urine production. Multiple gestation (twintwin transfusion). Maternal diabetes. Erythroblastosis.

a)Fetal Structural Malformations :

Acrania

or anencephaly due to :

Impairment of

the swallowing mechanism. Lack of antidiuretic hormone with resultant polyuria. Transudation of fluid across the exposed fetal meninges

Fetal Structural Malformations:

Gastrointestinal malformations : Obstructions of the GI tract, such as esophageal and duodenal atresia due to decreased absorption, as swallowing in these fetuses is usually normal. Ventral wall defects : may result in increased AFV due to transudation of fluid across the peritoneal surface or bowel wall .

B) Chromosomal and genetic abnormalities : The most common abnormalities are trisomies 13, 18, and 21 C) Neuromuscular disorders : May cause excess AFV, likely due to impaired swallowing . D) Abruptio placentae :
Is associated

with polyhydramnios at the time of rupture of membranes, due to rapid decompression of the overdistended uterus.

E) Isoimmunization : Can result in polyhydramnios associated with hydrops fetalis F) Congenital infections : Such as toxoplasmosis, cytomegalovirus, and syphilis Are rare causes of polyhydramnios G) Twin-to-twin transfusion syndrome (TTTS):
The recipient twin develops polyhydramnios and,

occasionally, hydrops fetalis, whereas the donor twin develops growth retardation and oligohydramnios.

H) Diabetes mellitus common cause of polyhydramnios , is often associated with poor glycemic control or fetal malformations.

Fetal hyperglycemia may increase oncotic pressure, causing transudation of fluid across the placental interface to the amniotic cavity , as well as increased glomerular filtration rate.

I) Multiple Gestation: - Occurs in 5% to 8% of multiple pregnancies, particularly with monoamniotic twins.

- Acute polyhydramnios before 28 weeks' gestation

has been reported to occur in 1.7% of all twin pregnancies; the perinatal mortality in these cases approaches 90%.

 Symptoms:

There may be abdominal pain. Discomfort and dyspnoea. Indigestion. Oedema, increase of varicose veins and haemorrhoids.

Signs:
The uterus is bigger than expected. Identification of the fetus and fetal parts is difficult. The fetal heart is difficult to hear. Ballottement of the fetus is easy. Abdominal girth at the umbilicus is more than 100 cm before term. The abdominal girth varies a little an ebb and flow.

Investigations:
Ultrasonographic

Examination

Necessary to both quantify amniotic fluid

volume and identify multiple fetuses and fetal abnormalities .

Amniocentesis
To obtain

karyotype and fluid for viral

studies.

Treatment:
Minor and

moderate degrees of polyhydramnios can be managed expectantly until the onset of labor or spontaneous rupture of membranes. If the patient develops dyspnea, abdominal pain, or difficulty ambulating, treatment becomes necessary

A) Amnioreduction
the most common

treatment If performed, the rate of withdrawal should be about 500 mL/hour and limited to 1500 to 2000 mL total volume or until the SDP < 8cm) is less often associated with preterm labor than less frequent removal of larger volumes. Amnioreduction is repeated every 1 to 3 weeks as needed. Antibiotic prophylaxis is not necessary.

B) Pharmacologic treatment:
Indomethacin.
Decrease

fetal renal blood flow and therefore fetal urine production. The greatest drawback of indomethacin use is the potential closure of the fetal ductus arteriosus which has been detected as early as 48 hours after initiating therapy. Ductal closure is uncommon before 27 weeks. Treatment is limited to pregnancies less than 32 weeks, and the duration of therapy is <48 hours.

Oilgohydramnios

Definition
AFI of

less than the fifth percentile for gestational age or less than 5 cm at term.
perinatal morbidity and mortality are particularly high when it is detected during the second trimester.

Risks of

 Perinatal

mortality may approach 80% to 90% when it is detected during the second trimester . Pulmonary hypoplasia. Lack expansion and Failure of growth. Prolonged oligohydramnios in the 2nd and 3rd trimester can lead to deformation sequence in 10 - 15% characterized by facial , cranial and skeletal abnormalities .

Etiology :

Ruptured membranes (most common) at any gestational age. Fetal urinary tract malformations(renal agenesis, dysgnesis outlet obstruction , NSAIDs , IUGR) Placental insufficiency Postdate pregnancy : may be due to deterioration in placental function causing a less efficient transfer of water from the mother to the fetus

Diagnosis
History:

ruptured membrane Examination: Fundal height less than expected for gestational age. Rupture of membranes should be ruled out via a sterile speculum exam. US examination: is necessary to quantify amniotic fluid and to identify fetuses with IUGR or abnormalities.

Treatment
Hydration of

the mother : (transient effect ) In cases in which oligohydramnios is caused by obstructive genitourinary defect, in utero surgical diversion of urine flow has produced promising results. Urinary diversion must be accomplished before the development of renal dysplasia and early enough in gestation to allow for lung development. Until near term, oligohydramnios should be managed with frequent fetal surveillance. Amnioinfusion. Induction of labor at 38 wks of gestation or if nonreassuring fetal tests after 34 w.

Johns Hopkins Manual of Gynecology and Obstetrics. Oligohydramnios and. Polyhydramnios: Mechanisms and. Therapy. Michael G. Ross, M.D., M.P.H.. Harbor-UCLA Medical Center. UCLA School of Medicine. www.medscape.com J Matern Fetal Neonatal Med. 2002 Mar;11(3):167-70. Dyedilution techniques using aminohippurate sodium: do they accurately reflect amniotic fluid volume? Magann EF, Whitworth NS, Files JC, Terrone DA, Chauhan SP, Morrison JC. Source Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, USA. Am J Obstet Gynecol. 1992 Oct;167(4 Pt 1):986-94. Amniotic fluid volume assessment: comparison of ultrasonographic estimates versus direct measurements with a dye-dilution technique in human pregnancy. Dildy GA 3rd, Lira N, Moise KJ Jr, Riddle GD, Deter RL. Source Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas. Netter, Obstetrics and Gynecology Second_Edition.