POLYHYDRAMNIOS AND OLIGOHYDRAMNIOS

1. POLYHYDRAMNIOS AND OLIGOHYDRAMNIOS DR MODOU JOBE HOUSE OFFICER, RVTH

2. Amniotic fluid volume changes steadily throughout pregnancy - 30mL at 10 wks, 1L at 34-36wk and 0.8L at 40 wks

3. PHYSIOLOGY OF AMNIOTIC FLUID VOLUME

4. 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

5. POLYHYDRAMNIOS

6. POLYHYDRAMNIOS • Can be defined as: • Amniotic fluid > 2000mL • 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

7. 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%)

8. 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

9. Routine ObsHx • History suggestive of Rhiso- 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%

10. 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

11. 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)

12. 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

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

14. 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

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

16. 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

17. OLIGOHYDRAMNIOS

18. 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

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

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

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

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

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

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

25. 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

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

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

28. THANK YOU FOR YOUR ATTENTION!!! QUESTIONS, COMMENTS, CONTRIBUTIONS?