Polyhydramnios is defined as a pathological increase of amniotic fluid volume in pregnancy and is associated with increased perinatal morbidity and mortality. Common causes of polyhydramnios include gestational diabetes, fetal anomalies with disturbed fetal swallowing of amniotic fluid, fetal infections and other, rarer causes. The diagnosis is obtained by ultrasound. The prognosis of polyhydramnios depends on its cause and severity. Typical symptoms of polyhydramnios include maternal dyspnea, preterm labor, premature rupture of membranes (PPROM), abnormal fetal presentation, cord prolapse and postpartum hemorrhage. Due to its common etiology with gestational diabetes, polyhydramnios is often associated with fetal macrosomia. To prevent the above complications, there are two methods of prenatal treatment: amnioreduction and pharmacological treatment with non-steroidal anti-inflammatory drugs (NSAIDs). However, prenatal administration of NSAIDs to reduce amniotic fluid volumes has not been approved in Germany. In addition to conventional management, experimental therapies which would alter fetal diuresis are being considered. • Fetal malformations and genetic anomalies (8–45 %) • maternal diabetes mellitus (5–26 %) • multiple pregnancies (8–10 %) • fetal anemia (1–11 %) • other causes, e.g. viral infections, Bartter syndrome, neuromuscular disorders, maternal hypercalcemia. Viral infections which can lead to polyhydramnios include parvovirus B19, rubella, and cytomegalovirus. Other infections, e.g. toxoplasmosis and syphilis, can also cause polyhydramnios 80, 81, 82. Advances in detailed ultrasound scanning and the prevention of Rhesus isoimmunization in the last decades have changed the relative frequency of these etiologies and significantly reduced the number of idiopathic cases Single deepest pocket measurement For this type of measurement the uterus is divided into four quadrants. The amniotic fluid volume is measured vertically in the deepest amniotic fluid pocket. Values below 2 cm indicate oligohydramnios, values over 8 cm indicate polyhydramnios 30. The advantage of this method is its simplicity, making it the most commonly used method in practice. It is also the method of choice in multiple gestation. In cases with multiple gestation, a range of 3–8 cm is defined as normal. With this method, polyhydramnios is classified as mild, moderate or severe. Mild polyhydramnios is characterized by a value of 8–11 cm, moderate polyhydramnios by a value between 12–15 cm and severe polyhydramnios by values above 16 cm

1. POLYHYDRARNNIOS
1
DR ALKA MUKHERJEE
DR APURVA MUKHERJEE
NAGPUR M.S.

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty
Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN
RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Organizing secretary AMWICON – 2019
 Life member, IMA, NOGS, NARCHI, AMWN &
Menopause Society, India, Indian medico-legal &
ethics association(IMLEA), ISOPARB, HUMAN RIGHTS
 Founder Member of South Rapid Action Group,
Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS
Nagpur, NKPSIMS, ESIS and Treasury, Nagpur for “
WOMEN SEXUAL HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 VIDARBHA RATNA PURASKAR - 2019
Past Position
 Vice President of NOGS(2016-2017)
 Organizing joint secretary ENDO-GYN
 Vice President IMA Nagpur (2017-2018)
 Organizing joint secretary ENDO-GYN 2019

3. DEFINITION
• Polyhydramnios is defined as a pathological increase of
amniotic fluid volume greater than 2000 ml known to be
associated with adverse pregnancy outcomes.
• Polyhydramnios is a medical condition seen in about 1% of
pregnancies
• It is typically diagnosed when the amniotic fluid index (AFI) is
greater than 24 cm
• There are two clinical varieties of polyhydramnios:
• Chronic polyhydramnios where excess amniotic fluid
accumulates gradually, and
• Acute polyhydramnios where excess amniotic fluid collects
rapidly.
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5. AMNIOTIC FLUID FORMATION AND
SECRETION
Sources of amniotic fluid:
1. In the first trimester is derived from the blood plasma
that diffuses through the thin tissues of the foetus into
the surrounding space.
2. After the development of foetal kidneys after jo- 12
weeks, mainly from the foetal urine, till the rest of the
pregnancy.
3. Lungs also produce liquid
4. Foetal and nasal secretions and from the foetal surface
of the placenta.
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7. AMNIOTIC FLUID REMOVAL OR EXCRETION
I. Foetal swallowing and absorption into the foetal blood
remains the main phenomenon of the fluid removal or
excretion, by term, the foetus swallows 210-760 ml,
of amniotic fluid per day.
II. Under physiological conditions, there is a dynamic
equilibrium between the production and resorption of
amniotic fluid, A disturbed equilibrium can be the
result of compromised swallowing function or
increased urination and Can lead to polyhydramnios.
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9. AMNIOTIC FLUID VOLUME
• The amniotic fluid volume increases from
• 50 ml, at 12 weeks to 400 mL at 20 weeks and
reaches at about 1000 mL or little more by 36
weeks but decreases thereafter.
• It reaches a peak at about 32-33 weeks and
remaining fairly constant or decreasing slightly
thereafter.
• At 40 weeks, it measures about 8oo mL
• In post-term (>42 weeks), there may be only 100-
200 ml
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11. FUNCTIONS
Amniotic fluid serves various purposes,
such as:
a. Protecting the foetus from trauma and
infection
b. Allowing lung development
c. Facilitating the development and
movements of the limbs and other
skeletal parts.
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12. PATHOGENESIS
Factors responsible for the regulation of
fluid volume includes
i. Foetal swallowing,
ii. Micturition,
iii. Respiratory movements,
iv. Uteroplacental blood flow and
v. The function of maternal-membrane
interface.
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13. TWO MAJOR CAUSES OF POLYHYDRAMNIOS
1. Reduced foetal swallowing or absorption
of amniotic fluid and increased foetal
urination. E.g.
a) Craniospinal defects (e.g. anencephaly)
• Facial tumours
b) Gastrointestinal obstruction (such as
oesophageal atresia, duodenal atresia and
small bowel obstruction)
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14. c) Compressive pulmonary disorders (e.g.
pleural effusion, diaphragmatic hernia or
cystic adenomatoid malformation of the
lungs)
d) Narrow thoracic cage (due to skeletal
dysplasias)
e) foetal akinesia deformation sequence
(due neuromuscular impairment of foetal
svc-allowing).
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15. 2. Increased foetal urination is observed in
a. Maternal diabetes mellitus
b. Maternal uraemia (increased glucose and
urea cause osmotic diuresis)
c. Foetal circulation due to foetal anaemia
(due to red cell isoimmunisation or
congenital infection), or
d. Foetal and placental tumours or cutaneous
arteriovenous malformations (such as
sacrococcygeal teratoma, placental
chorioangioma),
e. Twin-to-twin transfusion syndrome.
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16. AETIOLOGY
A) Idiopathic (the most common—around 50% of
cases)
B) Maternal :
• 1. Maternal diabetes—5-26% of cases
 Poorly managed gestational diabetes
associated with foetal macrosomia and
polvhydramnios. Foetal hyperglycaemia resulting
in increased osmotic diuresis which subsequently
leads to polyhydramnios.
 This theory is supported by evidence of a strong
association with high glycosylated haemoglobin
values (HBAlc) in cases with polyhydramnios
-
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17. Maternal causes
2. Rh isoimmunisation - Hydrops
foetalis
3. Maternal substance abuse
4. Maternal metabolic abnormalities
such as hypercalcaemia
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18. C) Foetal causes
 Multiple pregnancy 8-10% of cases
 Congenital anomalies and genetic disorders—8-24%
isolated or due to a genetic disorder
 Oesophageal or duodenal atresia
 Cardiovascular defects
 Microcephaly or anencephaly
 Neural tube defects
 Renal defects, including Bartter's syndrome
 Genetic disorders as referred to above include:
 Trisomy21, 18 and 13
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19.  Pena-Shokeir syndrome (Contracture of the joints
(arthrogryposis) , growth problems , underdeveloped
lungs , facial deformities)
 Beckwith – wiedemann syndrome (Overgrowth
disorder)
 Foetal anaemia – 1 – 11 % of cases
 Congenital infections (e.g toxoplasmosis , rubella ,
cytomegalo virus)
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20. D) Placental causes
Incidence - < 1 %
- Placental chorioangioma
- Circumvallate placenta syndrome.
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21. EPIDEMIOLOGY
• Affect 0.2-1.6% of all pregnancies.
• Rates are much higher in pregnancies for women with
diabetes or gestational diabetes.
• Mild polyhydramnios – 17% & Moderate-to-severe
polyhydramnios - 91%. have congenital abnormality
• Also an association with increasing maternal age and
with foetal macrosomia
• Advances in detailed ultrasound scanning and the
prevention of Rhesus isoimmunisation in the last
decades have changed the relative frequency of these
aetiologies and significantly reduced the number of
idiopathic cases
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22. CLASSIFICATION (FLOW CHART 10.1)
According to Severity:
• The single deepest pocket of liquor is measured
• Mild 8-11 cm (80% cases)
• Moderate 12-15 cm (15% cases)
• Severe >16 cm (5% cases)
According to Time of development:
• Acute
• chronic
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23. ACUTE HYDRAMNIOS
• Sudden onset and collection of
Amniotic fluid over a short time
period.
• Rare condition
• Occurs in early pregnancy
• Caused by monozygotic twin
pregnancy or chrioangioma of the
placenta
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24. Chronic Hydramnios
• There is gradual increase of fluid over
weeks
• More common variety
• Usually occurs after 32 weeks
• Symptoms are not so marked.
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26. DIAGNOSIS
• History
• It many present with
• Excessive maternal breathlessness
• Early onset of labour or rupture of
membranes ,
• Cord prolapse , or
• Abnormal foetal presentation.
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27. EXAMINATION
On examination:
• Uterus size large for dates
• Foetal parts difficult to palpate
• Foetal heart sound difficult to
auscultate.
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28. ULTRASOUND
• Amniotic fluid index (AFI) or four-quadrant method:
• The uterine cavity is divided into four quadrants or pockets—
vertically into two halves by an imaginary line along the linea nigra.
• An imaginary horizontal line through the umbilicus divides the
uterus into an upper and a lower half.
• The largest vertical pocket in each quadrant is measured in
centimetres and the total volume is calculated by adding the four
together.
• A total of more than 24 cm defines polyhydramnios.
• Based on AFI values obtained during prenatal screening,
• some clinicians categorise polyhydramnios into three groups
according to severity:
1. mild (AFI of 25-30 cm),
2. moderate (30.1-35 cm) and
3. severe (235.1 cm).6
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29. • Single deepest pocket (SDP) method:
The deepest pocket is measured vertically. A
measurement over 8 cm denotes
polyhydramnios.
Further Diagnostic Test
• Ultrasound investigation: To screen for foetal
anomalies. Risk of foetal malformation is
around 11% with severe polyhydramnios
compared to 2% with moderate and 1% with
mild forms.
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30. LABORATORY TESTS
• Blood glucose and oral glucose tolerance test
• Maternal infection screen
• If foetal anaemia or hydrops foetal is is suspected, the
following may also be appropriate:
- Screening for maternal antibodies against foetal red
blood cells
- Screening for cytomegalovirus , syphilis, rubella,
toxoplasmosis, parvovirus 19
- karyotyping
• Amniocentesis and foetal karyotyping may be
considered.
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31. COMPLICATIONS AND PROGNOSIS
• The risk of the following obstetric complications is
increased when polyhydramnios is present
Due to overexpansion of the uterus
• Maternal dyspnoea
• Preterm labour
• Premature rupture of membranes
• Abnormal foetal presentation
• Umbilical cord prolapse
• Postpartum haemorrhage
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32. COMPLICATIONS
• MATERNAL
• Antepartum: abortions,
UTI, preterm labour, PIH,
PROM,Malpresentation
• Intrapartum: placental
abruption, cord prolapse,
placental insufficiency,
high incidence of c-
section
• Postpartum: PPH,
Subinvolution
• Complications of DM
• FOETAL
• Malformations
• Macrosomia, Shoulder
dystocia, birth truama
• High NICU admissions
• Low apgar
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33. MANAGEMENT
• Management of polyhydramnios focuses on reduction of
amniotic fluid volume so as to improve maternal well-
being and prolong pregnancy
• Management is undertaken in secondary care.
• The first step is to identify & T/t of underlying cause.
• Foetal hydrops anaemia - intravascular transfusion.
• Gestational diabetes - tight glycaemic control with
dietary manipulation, oral medication or insulin
• Mild polyhydramnios can be simply monitored and
treated conservatively.
• Preterm labour - measures should be taken to minimise
this complication - regular antenatal check ups
• - Serial USG FOR AFI & Foetal growth
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34. • Induction of labour should be considered if foetal
distress develops,
• Induction by artificial rupture of the membranes (ARM)
should be controlled, performed by an obstetrician and
with consent to proceed to lower-segment Caesarean
section if required,
• Corticosteroids should be given to the mother
antenatally if preterm delivery is emminent or
considered, This helps to improve lung maturity.
• The following methods are used to reduce amniotic fluid
volume:
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35. Amnioreduction
• Slow drainage of amniotic fluid under
ultrasound guidance
• Use of antibiotics and tocolytlcs Volume of
aspírated fluid and the speed of aspiration has
to individualised
• The intervention is usually concluded when
ultrasound examination shows an AFI of 15-20
cm or if intra-amniotic pressure drops to 20 mm
Hg.
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38. Pharmacological treatment
• Prostaglandin synthetase inhibitor
(indomethacin).
• Prostaglandin synthetase inhibitors stimulate
foetal secretion of arginine vasopressin, resulting
in vasopressin-induced antidiuresis.
• Dose—2.2 mg/kg/day orally every 6 hours.
• Reduced renal blood flow reduces foetal urine
production. These substances can also inhibit
foetal lung liquid production or increase
reabsorption rates. They are advised against
using these substances after the 28th week of
gestation. 38DR ALKA MUKHERJEE

39. SULINDAC
• Sulindac is a non-steroidal anti-
inflammatory drug, used to reduce
amniotic fluid volume. There are
some reports that sulindac decreases
pulsatility in foetal ductus arteriosus
less than indomethacin
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40. DECISION FOR CHOOSING MANAGEMENT
OPTIONS
• Expectant management versus intervention depends on severity of
symptoms and occurrence of complications.
• Delivery
• The following points need to be taken care of during delivery:
• Foetal head presentation should be checked several times during
labour
• Spontaneous rupture of membranes can lead to acute uterine
decompression with the risk of cord prolapse or placental abruption
• Artificial rupture of membranes should, therefore, only be done
under controlled conditions.
• There is no contraindication for the use uterotonics , but oxtocin
and prostaglandins should be very carefully used
• There is increased risk of atonic bleeding and amniotic fluid
embolism.
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41. CONCLUSION
• Polyhydramnios is a condition which not only
raises an alarm for its management but also
more importantly the search of the underlying
cause. Detailed evaluation of the etiology is of
utmost importance for the most favorable
prognosis. Specific management tailored to the
cause with close supervision , monitoring and
attention during labour is required for a good
outcome
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