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OLIGOHYDRAMNIOS

OLIGOHYDRAMNIOS. PHYSIOLOGY OF AMNIOTIC FLUID. OUTFLOW (1000 ml/d) 1.FETAL SWALLOWING. INFLOW (1000 ml/d) 1.FETAL URINE 2.LUNG LIQUID INTRAMEMBRANOUS ( placenta,cord ) TRANSMEMBRANOUS(amniotic membranes) RECYCLING – 3hrs.

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OLIGOHYDRAMNIOS

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  1. OLIGOHYDRAMNIOS Dr Mona Shroff www.obgyntoday.info

  2. PHYSIOLOGY OF AMNIOTIC FLUID

  3. OUTFLOW (1000 ml/d) 1.FETAL SWALLOWING INFLOW (1000 ml/d) 1.FETAL URINE 2.LUNG LIQUID INTRAMEMBRANOUS (placenta,cord) TRANSMEMBRANOUS(amniotic membranes) RECYCLING – 3hrs Dr Mona Shroff www.obgyntoday.info

  4. Dr Mona Shroff www.obgyntoday.info

  5. Amniotic fluid volume • 8 weeks : 15 ml,increases 10 ml/wk • 17 wks :250 ml ,increases 50 ml/wk • 28-38 wks :750-1000ml (decreases after 34 wks) • 42 wks<500ml Dr Mona Shroff www.obgyntoday.info

  6. FUNCTIONS OF AMNIOTIC FLUID • Shock absorber – protects from external trauma. • Protects cord from compression. • Permits fetal movements – development of musculoskeletal system, prevents adhesions. • Swallowing of AF enhances growth & development of GIT. • AF volume maintains AF pressure – reduces loss of lung liquid – pulmonary development. • Maintenance of fetal body temperature. • Some fetal nutrition, water supply. • Bacteriostatic properties – decreases potential for infection Dr Mona Shroff www.obgyntoday.info

  7. DEFINITION • AMNIOTIC FLUID VOLUME < 5 th percentile for gestational age • AMNIOTIC FLUID INDEX < 5 • SINGLE VERTICAL POCKET < 2 cms • Amniotic fluid volume of less than 500 mL at 32-36 weeks' gestation Dr Mona Shroff www.obgyntoday.info

  8. Dr Mona Shroff www.obgyntoday.info

  9. INCIDENCE 0.5 – 5% Dr Mona Shroff www.obgyntoday.info

  10. AETIOLOGY FETAL PROM (50%) CHROMOSOMAL ANOMALIES CONGENITAL ANOMALIES IUGR IUFD POSTTERM PREGNANCY MATERNAL PREECLAMPSIA APLA SYNDROME CHRONIC HT PLACENTAL CHRONIC ABRUPTION TTTS CVS DRUGS PG SYNTHETASE INHIBITORS ACE INHIBITORS IDIOPATHIC Dr Mona Shroff www.obgyntoday.info

  11. SYMPTOMS NO SPECIFIC SYMPTOMS H/O leaking p/v Postterm s/o preeclampsia Drugs Less fetal movements SIGNS Uterus – small for date Feels full of fetus Malpresentations IUGR DIAGNOSIS Dr Mona Shroff www.obgyntoday.info

  12. USG METHODS MVP <2 cms (<1 severe) AFI <5 cms (5-8 borderline) 2D pocket <15 sq cms Dr Mona Shroff www.obgyntoday.info

  13. Technique of AFI • Uterus divided into 4 quadrants • Transducer in vertical plane • Sum of 4 quadrants max pocket depth excluding cord & limbs. • Prior to 20 wks 2 halves • Twins: composite AFI or individual vertical pockets Dr Mona Shroff www.obgyntoday.info

  14. Authors' conclusions • The single deepest vertical pocket measurement in the assessment of amniotic fluid volume during fetal surveillance seems a better choice since the use of the amniotic fluid index increases the rate of diagnosis of oligohydramnios and the rate of induction of labor without improvement in peripartum outcomes. A systematic review of the diagnostic accuracy of both methods in detecting decreased amniotic fluid volume is required. Nabhan AF, Abdelmoula YA. Amniotic fluid index versus single deepest vertical pocket as a screening test for preventing adverse pregnancy outcome. Cochrane Database of Systematic Reviews 2008, Issue 3 Dr Mona Shroff www.obgyntoday.info

  15. FETAL Abortion Prematurity IUFD Deformities –CTEV,contractures,amputation Potters syndrome- pulmonary hypoplasia Malpresentations Fetal distress MSAF – MAS Low APGAR MATERNAL Increased morbidity Prolonged labour: uterine inertia Increased operative intervention (malformations, distres) COMPLICATIONS Dr Mona Shroff www.obgyntoday.info

  16. MANAGEMENT DEPENDS UPON • AETIOLOGY • GESTATIONAL AGE • SEVERITY • FETAL STATUS & WELL BEING Dr Mona Shroff www.obgyntoday.info

  17. DETERMINE AETIOLOGY • R/O PROM, h/o medical illness • TARGETED USG FOR ANOMALIES • R/O IUGR ,IUFD when suspected • Amniocentesis if chromosomal anomalies suspected – early symmetric IUGR • Tests for APLA Syndrome , if suspected Dr Mona Shroff www.obgyntoday.info

  18. Dr Mona Shroff www.obgyntoday.info

  19. Techniques for Monitoring • Single pocket without cord • AFI = sum of deepest pocket in each of 4 quadrants without cord • BPP = • NST • breathing 30sec in 30min • move 3 limb/body in 30min • extension of extremity with flexion or open/close hand • single vertical non-cord pocket of 2 cm • Scoring: 0 or 2 for each, 10 is normal, 6 equivocal, 4 abnormal • Modified BPP = NST, +/- acoustic stimulation, AFI • AFI > 5 ok • AFI < 5 or non-reactive NST not ok • modified BPP equally useful as BPP for monitoring, per ACOG

  20. TREATMENT • ADEQUATE REST – decreases dehydration • HYDRATION – Oral/IV Hypotonic fluids(2 Lit/d) temperory increase helpful during labour,prior to ECV, USG • SERIAL USG – Monitor growth,AFI,BPP • INDUCTION OF LABOUR/ LSCS Lung maturity attained Lethal malformation Fetal jeopardy Sev IUGR Severe oligo • DDAVP: ? Research settings Dr Mona Shroff www.obgyntoday.info

  21. Hofmeyr GJ, Gülmezoglu AM. Maternal hydration for increasing amniotic fluid volume in oligohydramnios and normal amniotic fluid volume. Cochrane Database of Systematic Reviews 2002, Issue 1. Authors' conclusions • Simple maternal hydration /IV Hypotonic fluid (2 lit) appears to increase amniotic fluid volume and may be beneficial in the management of oligohydramnios and prevention of oligohydramnios during labour or prior to external cephalic version. Controlled trials are needed to assess the clinical benefits and possible risks of maternal hydration for specific clinical purposes. Dr Mona Shroff www.obgyntoday.info

  22. AMNIOINFUSION INDICATIONS 1.Diagnostic 2.Prophylactic 3.Therapeutic Decreases cord compression Dilutes meconium Dr Mona Shroff www.obgyntoday.info

  23. Hofmeyr GJ. Prophylactic versus therapeutic amnioinfusion for oligohydramnios in labour. Cochrane Database of Systematic Reviews 1996,Issue 1. Authors' conclusions • There appears to be no advantage of prophylactic amnioinfusion over therapeutic amnioinfusion carried out only when fetal heart rate decelerations or thick meconium-staining of the liquor occur. Dr Mona Shroff www.obgyntoday.info

  24. DDAVP • Oral hydration + DDAVP :Prevents diuresis • Results in maternal plasma hypotonicity –-fetal plasma hypotonicity—increased fetal urine production—reduced fetal swallowing—increased AFI Dr Mona Shroff www.obgyntoday.info

  25. DDAVP : concerns • Effect on maternal & fetal bld volume • Long term effects on AFI • Prophylactic or chronic use • Mask oligohydramnios ?? Dr Mona Shroff www.obgyntoday.info

  26. Therapeutic Interventions: Oligohydramnios

  27. TREATMENT ACC. TO CAUSE • Drug induced – OMIT DRUG • PROM – INDUCTION • PPROM – Antibiotics,steroid – Induction • FETAL SURGERY VESICO AMNIOTIC SHUNT-PUV Laser photocoagulation for TTTS Dr Mona Shroff www.obgyntoday.info

  28. Posterior urethral valves • Sonographic findings: • Keyhole sign

  29. Posterior urethral valves • Management: • Karyotyping • Perform serial bladder drainage every 3-4 days • Use sample of 3rd drainage • Isotonic urine indicate poor function

  30. Posterior urethral valves • Good prognostic biochemical markers: • Na < 100meq/L • Cl < 90meq/L • Osmolarity <210mOsm/L • B2 microglobulin < 4mg/L • Ca < 8mg/dl • Indication for vesico amniotic shunts

  31. Dr Mona Shroff www.obgyntoday.info

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