OLIGOHYDRAMNIOS Dr abdullahwww obgyntoday info 1 PHYSIOLOGY OF

OLIGOHYDRAMNIOS Dr abdullahwww. obgyntoday. info 1

PHYSIOLOGY OF AMNIOTIC FLUID 2

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

Dr Mona Shroff www. obgyntoday. info 4

Amniotic fluid volume l 8 weeks : 15 ml, increases 10 ml/wk l 17 wks : 250 ml , increases 50 ml/wk l 28 -38 wks : 750 -1000 ml (decreases after 34 wks) l 42 wks<500 ml Dr abdullahwww. obgyntoday. info 6

FUNCTIONS OF AMNIOTIC FLUID l l l l 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 7

DEFINITION l AMNIOTIC FLUID VOLUME < 5 th percentile for gestational age l AMNIOTIC FLUID INDEX < 5 l SINGLE VERTICAL POCKET < 2 cms l Amniotic fluid volume of less than 500 m. L at 32 -36 weeks' gestation 8

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INCIDENCE 0. 5 – 5% 10

AETIOLOGY FETAL l l l PROM (50%) CHROMOSOMAL ANOMALIES CONGENITAL ANOMALIES IUGR IUFD POSTTERM PREGNANCY MATERNAL PREECLAMPSIA l APLA SYNDROME l CHRONIC HT l DRUGS PG SYNTHETASE INHIBITORS l ACE INHIBITORS l PLACENTAL CHRONIC ABRUPTION l TTTS l CVS l IDIOPATHIC 11

DIAGNOSIS 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 12

USG METHODS MVP AFI <2 cms (<1 severe) <5 cms (5 -8 borderline) 2 D pocket <15 sq cms 13

Technique of AFI l Uterus divided into 4 quadrants l Transducer in vertical plane l Sum of 4 quadrants max pocket depth excluding cord & limbs. l Prior to 20 wks 2 halves l Twins: composite AFI or individual vertical pockets 14

Authors' conclusions l 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 15

COMPLICATIONS FETAL MATERNAL Abortion Increased morbidity Prematurity IUFD Prolonged labour: Deformities – uterine inertia CTEV, contractures, amputation Potters syndrome- pulmonary Increased operative hypoplasia intervention Malpresentations (malformations, distres) Fetal distress MSAF – MAS Low APGAR 16

MANAGEMENT DEPENDS UPON l AETIOLOGY l GESTATIONAL l SEVERITY l FETAL AGE STATUS & WELL BEING 17

DETERMINE AETIOLOGY l R/O PROM, h/o medical illness l TARGETED USG FOR ANOMALIES l R/O IUGR , IUFD when suspected l Amniocentesis if chromosomal anomalies suspected – early symmetric IUGR l Tests for APLA Syndrome , if suspected 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 l BPP = l l 1. 2. 3. 4. 5. l l NST breathing 30 sec in 30 min move 3 limb/body in 30 min 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 l l l AFI > 5 ok AFI < 5 or non-reactive NST not ok modified BPP equally useful as BPP for monitoring, per ACOG

TREATMENT l l • • l 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 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 l 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. 22

l AMNIOINFUSION INDICATIONS 1. Diagnostic 2. Prophylactic 3. Therapeutic Decreases cord compression Dilutes meconium 23

Hofmeyr GJ. Prophylactic versus therapeutic amnioinfusion for oligohydramnios in . labour. Cochrane Database of Systematic Reviews 1996, Issue 1 Authors' conclusions l 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. 24

DDAVP l Oral hydration + DDAVP : Prevents diuresis l Results in maternal plasma hypotonicity –fetal plasma hypotonicity—increased fetal urine production—reduced fetal swallowing —increased AFI 25

DDAVP : concerns l Effect on maternal & fetal bld volume l Long term effects on AFI l Prophylactic or chronic use l Mask oligohydramnios ? ? 26

Therapeutic Interventions: Oligohydramnios

TREATMENT ACC. TO CAUSE l Drug induced – OMIT DRUG l PROM – INDUCTION l PPROM – Antibiotics, steroid – Induction l FETAL SURGERY VESICO AMNIOTIC SHUNT-PUV Laser photocoagulation for TTTS 28

Posterior urethral valves l Sonographic findings: l Keyhole sign

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

Posterior urethral valves l Good l Na prognostic biochemical markers: < 100 meq/L l Cl < 90 meq/L l Osmolarity <210 m. Osm/L l B 2 microglobulin < 4 mg/L l Ca < 8 mg/dl l Indication for vesico amniotic shunts

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