OLIGOHYDRAMNIOS

*Dr Mona Shroff

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PHYSIOLOGY OF AMNIOTIC FLUID

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INFLOW (1000 ml/d)

1.FETAL URINE2.LUNG LIQUID

INTRAMEMBRANOUS (placenta,cord) TRANSMEMBRANOUS(amniotic

membranes) RECYCLING – 3hrs

OUTFLOW (1000 ml/d)

1.FETAL SWALLOWING

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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<500mlDr Mona Shroff

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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

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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

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INCIDENCE

0.5 – 5%

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AETIOLOGYFETAL● 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

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DIAGNOSIS

SYMPTOMSNO SPECIFIC

SYMPTOMS

H/O leaking p/vPostterms/o preeclampsiaDrugsLess fetal movements

SIGNSUterus – small for

dateFeels full of fetusMalpresentationsIUGR

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USGMETHODS MVP <2 cms (<1 severe)

AFI <5 cms (5-8

borderline)

2D pocket <15 sq cms

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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

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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

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COMPLICATIONS FETALAbortionPrematurityIUFDDeformities –

CTEV,contractures,amputation

Potters syndrome- pulmonary hypoplasia

MalpresentationsFetal distressMSAF – MASLow APGAR

MATERNAL

Increased morbidity

Prolonged labour: uterine inertia

Increased operative intervention

(malformations,distres)

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MANAGEMENT

DEPENDS UPON

● AETIOLOGY● GESTATIONAL AGE● SEVERITY● FETAL STATUS & WELL BEING

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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

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Techniques for Monitoring● Single pocket without cord● AFI = sum of deepest pocket in each of 4 quadrants without

cord● BPP =

1. NST2. breathing 30sec in 30min3. move 3 limb/body in 30min4. extension of extremity with flexion or open/close hand5. 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

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

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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.

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●AMNIOINFUSION

INDICATIONS 1.Diagnostic 2.Prophylactic 3.Therapeutic Decreases cord

compression Dilutes meconium

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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.

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DDAVP

● Oral hydration + DDAVP :Prevents diuresis

● Results in maternal plasma hypotonicity –-fetal plasma hypotonicity—increased fetal urine production—reduced fetal swallowing—increased AFI

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DDAVP : concerns

●Effect on maternal & fetal bld volume

●Long term effects on AFI●Prophylactic or chronic use●Mask oligohydramnios ??

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Therapeutic Interventions: Oligohydramnios

TREATMENT ACC. 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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Posterior urethral valves

● Sonographic findings:● Keyhole sign

Posterior urethral valves

● Management:●Karyotyping●Perform serial bladder drainage every 3-

4 days●Use sample of 3rd drainage● Isotonic urine indicate poor function

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

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