POLYHYDRAMNIOS AND OLIGOHYDRAMNIOS DR MODOU JOBE HOUSE OFFICER

POLYHYDRAMNIOS AND OLIGOHYDRAMNIOS DR MODOU JOBE HOUSE OFFICER, RVTH

• Amniotic fluid volume changes steadily throughout pregnancy - 30 m. L at 10 wks, 1 L at 34 -36 wk and 0. 8 L at 40 wks

PHYSIOLOGY OF AMNIOTIC FLUID VOLUME

Functions of amniotic fluid • Shock absorber • Protects cord from compression • Permits foetal movement • Swallowing of AF enhances growth & development of GIT • AF volume maintains AF pressure – reduces loss of lung liquid – pulmonary development • Maintains foetal body temperature • Provides some foetal nutrition and water • Bacteriostatic properties

POLYHYDRAMNIOS

POLYHYDRAMNIOS • Can be defined as: - Amniotic fluid > 2000 m. L - AFI of more than 24 -25 cm by ultrasound - Single pocket of amniotic fluid greater than 8 cm by ultrasound • Occurs in 1% of pregnancy • No age variables are recognised

Causes • Maternal (15%)- DM, pre-eclampsia, heart disease • Placental (less than 1%)- Placental chorioangioma, Circumvallate placental syndrome • Fetal (18%) Multiple pregnancies Fetal anomalies Infections TTTS • Drugs • Idiopathic (65%)

Clinical types • Depending on the rapidity of onset - Acute (rare): appears in a matter of a few days - Chronic: 10 times commoner, occurs in a matter of few months

• Routine Obs Hx • History suggestive of Rh iso- immunization such as still birth, fetal hydrops, jaundice in new born requiring exchange transfusion etc. • History suggestive of DM – Previous big baby fetal death at 35 weeks, classical symptoms of DM like polyurea, polydypsia, polyphagia • History of Drug intake especially in First trimester • History of Previous fetal anomalies like Anencephaly -risk of recurrence is 2%

Presentation • Acute Polyhydramnios: - Onset is acute usually occurs before 20 weeks of pregnancy and presents usually with symptoms and labour starts before 28 weeks of pregnancy. It may present as Acute abdomen - abdominal pain, nausea, vomiting Breathlessness which increases on lying down position Palpitation Oedema of legs, varicosities in legs, vulva and hemorroids • Signs: Patient looks ill, without features of shock Oedema of legs with signs of PIH Abdomen unduly enlarged with shiny skin Fluid thrill may be present • Internal examination may show dilatation with bulging membranes

• Chronic Polyhydramnios • More common than acute (10% more common) • Since accumulation of liquor is gradual, so patient may be symptomatic or asymptomatic. • Symptoms are mainly due to mechanical causes Dyspnoea is more in supine position Palpitation Oedema Oliguria may result from ureteral obstruction by enlarged uterus • Pre-eclampsia 25 % (oedema, hypertension and proteinuria)

Signs GPE • Patient may be dyspnoic at rest • Pedal Oedema • Evidence of PIH Abdominal examination Inspection • Abdomen is markedly enlarged, globular with fullness of flanks • Skin over the abdomen is tense, shiny with large striae Palpation • Height of uterus is more than the corresponding periods of amenorrhoea • Abdominal girth is more • Fetal parts cannot be well defined • Malpresentations are more common and presenting part is usually high up • Fluid thrill is present Auscultation • Fetal heart sounds are not heard distinctly

• Multiple pregnancy • Ovarian cyst • Hydatidiform mole • Full bladder

Investigations • Ultrasonography • Laboratory studies - Glucose tolerance test - Fetal hydrops testing - Kleihauer-Betke - Hemoglobin Bart - Fetal karyotyping for trisomy 21, 13, and 18 - Amniotic fluid analysis • Histology

Management • Antepartum - Observe patient very closely - If idiopathic, wait until L/S ratio is 2 - Amniocentesis - Indomethacin - Weekly USS exams - Notify neonatologist

• Intrapartum - Obtain baseline Full blood count - Slowly reduce the amniotic fluid volume before any induction - Look for complications- abruptio, umbilical cord prolapse, postpartum uterine atony - Consider the need for a caesarian - Send placenta to the pathologist

OLIGOHYDRAMNIOS

OLIGOHYDRAMNIOS • Can be defined as: • amniotic fluid volume < 5 th percentile for gestational age • amniotic fluid index < 5 • single vertical pocket < 2 cm • Occurs in 4% of pregnancies

Causes Fetal • • • PROM (50%) chromosomal anomalies congenital anomalies IUGR IUFD Post-term pregnancy Maternal • Pre-eclampsia • Chronic hypertension Drugs Placental • Chronic abruption • TTTS • PG synthetase inhibitors • ACE inhibitors Idiopathic

Diagnosis SYMPTOMS SIGNS NO SPECIFIC SYMPTOMS - Uterus – small for date - Feels full of fetus - Malpresentations - IUGR - H/O leaking p/v - Post term - s/o preeclampsia - Drugs - Less fetal movements

Utrasonography METHODS MVP AFI <2 cms (<1 severe) <5 cms (5 -8 borderline) 2 D pocket <15 sq cms

Complications FETAL Abortion MATERNAL Increased morbidity Prematurity IUFD Potters syndrome- pulmonary hypoplasia Malpresentations Fetal distress Low APGAR Prolonged labour: uterine inertia Increased operative intervention (malformations, Distress)

MANAGEMENT DEPENDS UPON • • Aetiology Gestational age Severity Fetal status & well being

Determine the cause • R/O PROM • TARGETED USS FOR ANOMALIES • R/O IUGR , IUFD when suspected • Amniocentesis if chromosomal anomalies suspected – early symmetric IUGR

Treatment • ADEQUATE REST – decreases dehydration • HYDRATION – Oral/IV Hypotonic fluids(2 Lit/d) temporary increase helpful during labour, USG • SERIAL USS – Monitor growth, AFI, BPP • INDUCTION OF LABOUR/ LSCS Lung maturity attained Fetal jeopardy Severe IUGR Severe oligohydramnios

• AMNIOINFUSION INDICATIONS 1. Diagnostic 2. Prophylactic 3. Therapeutic - Decreases cord compression - Dilutes meconium

Treatment according to cause • Drug induced – OMIT DRUG • PROM – Induction • PPROM – Antibiotics, steroid – Induction • FETAL SURGERY Vesico amniotic shunt-puv Laser photocoagulation for TTTS

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