3. POLYHYDRAMNIOS/Hydramnios
Anatomically Polyhydraminios is defined as a state where liquor
amniotic exceeds 2,000 mL.
Clinical definition states the excessive accumulation of liquor
amniotic causing discomfort to the patient. or
• when an imaging help is needed to substantiate the clinical
diagnosis of the lie and presentation of the fetus.
Sonographic diagnosis is made when amniotic fluid index (AFI) is >
24cm and a deepest vertical pocket (DVP) is >8 cm.
4. INCIDENCE
• Because of different criteria is used in the definition of
polyhydramnios, the incidence varies from 1–2% of cases.
•It is more common in multiparae than primigravidae. While minor
degrees of hydramnios are fairly common,
• hydramnios is sufficient to produce clinical symptoms probably
occurs in 1 in 1,000 pregnancies.
5. ETIOLOGY
•the exact cause of excess accumulation AF is speculative.
•It may be the result of deficient absorption as well as excessive
production of liquor amniotic,
•which may be temporary or permanent.
•While certain maternal /fetal factors are found to be associated
with hydramnios, yet the cause remains idiopathic about 50 --
60%.
6. I. FETAL ANOMALIES:
• Congenital fetal malformations(structural and chromosomal) are
associated with polyhydramnios in about 20% of cases.
Such as :
• Anencephaly,
• Open spinal bifida,
• Esophageal or duodenal atresia,
• Facial clefts and neck masses,
• Hydrops fetalis,
• Aneuploidy and genetic syndromes
7. II. PLACENTA:
• Chorioangioma of the placenta, Tumor growing from a single
villus consisting of hyperplasia of blood vessels and connective
tissue results in increased transudation.
III. MULTIPLE PREGNANCY:
•It is about 10 times more common than its overall incidence and
more common in monozygotic twins, usually affecting the second
sac. In TTTS the recipient twin develops polyhydramnios.
8. IV. MATERNAL:
(i) Diabetes is more common about 30% cases. with adequate
supervision, the incidence can be lowered.
1. increased osmotic pressure of liquor amniotic due to its high
sugar content
2. Fetal polyuria resulting from hyperglycemia
(ii) Cardiac or renal disease—may lead to edema of the placenta
leading to increase in transudation.
(III) PIH
9. CLINICAL TYPES:
• Depending on the rapidity of onset, hydramnios can be:
(a) Chronic (most common)—onset is insidious taking few weeks,
occur in late pregnancy and may end up with preterm.
• The chronic variety is 10 times more common than the acute one.
(b) Acute (extremely rare)—onset is sudden, within few days , or may
appear acutely on pre-existing chronic variety.
• occur before 20 weeks , the commonest cause is uniovular twins but
fetal anomalies
• Polyhydramnios can be—(a) mild: DVP : 8–11 cm
__(b) moderate: DVP: 12–15 cm
__(c) severe: DVP +> 16 cm.
10. SYMPTOMS:
• Abdominal pain or discomfort (acute)
• Dyspnea, Palpitation, indigestion, and Edema of the legs,
varicosities in the legs or vulva and hemorrhoids.
SIGNS:
•The patient may be in a dyspneic state in the lying down position.
•Evidence of preeclampsia (edema, hypertension and proteinuria)
may be present.
ABDOMINAL EXAMINATION
Inspection: Abdomen is markedly enlarged, looks globular with
fullness at the flanks and over distended abdomen
The skin is tense, shiny with large striae
11. Palpation:
•Height of the uterus is more than the
period of amenorrhea.
• Girth of the abdomen round the
umbilicus is more than normal
• Fluid thrill can be elicited in all directions
over the uterus.
• Fetal parts cannot be well-defined also
• the presentation and the position.
• External ballottement can be elicited
more easily.
• No engagement of the head in pelvic.
12. Auscultation: Fetal heart sound is not heard distinctly, although its
presence can be picked up by Doppler ultrasound.
INTERNAL EXAMINATION: The cervix is pulled up, may be partially
taken up or at times, dilated, to admit a finger tip through which
tense bulged membranes can be felt.
INVESTIGATIONS:
Sonography is helpful to detect abnormally large echo-free space
between the fetus and the uterine wall (DVP )> 8 cm (AFI) is > 25 cm,
to exclude multiple fetuses, to note the lie and presentation of the
fetus, to diagnose any fetal congenital malformation (Especially the
CNS, gastrointestinal system and musculoskeletal system).
13. Cont..
Blood: BG/RH— Rhesus isoimmunization may cause hydrops fetalis
and fetal ascites.
•Postprandial sugar and if necessary glucose tolerance test.
Amniotic fluid: Estimation of alpha fetoprotein which is markedly
elevated in the presence of a fetus with an open neural tube defect.
DIFFERENTIAL DIAGNOSIS:
(1) Twin pregnancy
(2) Pregnancy with huge ovarian cyst
(3) maternal ascites
14. COMPLICATIONS
Maternal
In pregnancy:
• Preeclampsia (25%),
• Malpresentation and persistence of floating head,
• PROM
• Preterm labor either spontaneous or induced
• Accidental hemorrhage due to decrease in the surface area of the
emptying uterus beneath the placenta, following sudden escape of AF
15. CONT…
In labor:
Early rupture of the membranes
Cord prolapse
Uterine inertia
Increased operative delivery due to Malpresentation
Retained placenta
PPH and shock. the PPH is due to uterine atony
Puerperium: Subinvolution ,Increased puerperal morbidity due to
infection resulting from increased operative interference and blood
loss.
16. Fetal:
There is increased prenatal mortality to the extent of about 50%.
The deaths are mostly due to prematurity and congenital abnormality
(40%). Other is asphyxia and contributing factors are cord prolapse,
hydrops fetalis, effects of increased operative delivery and accidental
hemorrhage.
17. •MANAGEMENT
Recently there is a falling trend in the incidence of hydramnios of
severe magnitude. Due to:
Early detection and control of diabetes.
Rhesus isoimmunization is now preventable.
Genetic counseling in early months and detection of fetal
congenital abnormalities with U/S and their termination, reduce
their number in late pregnancy.
18. CONT…
Treatment of polyhydramnios is tailored according to The
• Underlying cause
• severity and
• gestational age
MILD POLYHYDRAMNIOS (DVP: 8–11 cm): It is commonly found
midtrimester and usually requires no treatment, except extra bed
rest for a few days. The excess liquor is expected to be diminished
as pregnancy advances (transient).
19. CONT…
SEVERE POLYHYDRAMNIOS (DVP: ≥16 cm): In view of the risks
involved and the high prenatal mortality rate, the patient should be
shifted in a hospital equipped to deal with “high-risk” patients.
Principles:
To relieve the symptoms ,
To find out the cause ,
To avoid and deal with the complications.
Polyhydramnios may be
(a) transient where LVP returned to normal and pregnancy progress
20. CONT….
(b) persistent cases with persistent polyhydramnios need
investigations for congenital fetal anomalies, genetic syndromes also
need close monitoring.
Supportive therapy include
Sulindac (COX-2 inhibitor), 200 mg every 12 hours, (under
supervision) has been found to be most effective in unexplained
cases.
• It has been found to decrease amniotic fluid as it reduces
fetal urine output.
21.
22. Unresponsive: (with maternal distress).
•Pregnancy less than 37 weeks: An attempt is made to relieve the
distress with a hope of continuation of pregnancy by amniocentesis
(amnio reduction).
•Slow decompression is done at the rate of about 500 mL per hour and
the amount of fluid to be removed should be sufficient enough to
relieve the mechanical distress.
•Normally amniodrainage is stopped when the AFI is less than 25 cm.
but liquor amniotic may again accumulate, for which the procedure
may have to be repeated. Amniotic fluid can be tested for fetal lung
maturity.
• Pregnancy more than 37 weeks: Induction of labor is done.
23. •Amniocentesis → drainage of good amount of liquor → to check the
favorable lie and presentation of the fetus → a stabilizing oxytocin
infusion is started → low rupture of the membranes is done when the
lie becomes stable and the presenting part gets fixed to the pelvis.
•This will minimize sudden decompression with separation of the
placenta, change in the lie of the fetus and cord prolapse.
24. OLIGOHYDRAMNIOS/ Oligoamnios
• It is a condition where the liquor amniotic is deficient in amount to
the extent of less than 200 mL at term.
• Sonographically, it is defined when the maximum vertical pocket of
liquor is <2 cm or when amniotic fluid index (AFI) is <5 cm (< 5
percentile).
•Oligohydramnios occurs in about 1–5 % of pregnancies at term .
•In pregnancies of more than 40 weeks of gestation, the incidence
may be more than 12 % as the amniotic fluid volume declines
progressively after 41 weeks of gestation.
25. ETIOLOGY
A. Fetal conditions:
• Fetal chromosomal or structural anomalies,
• Renal agenesis
• Obstructed uropathy
• Spontaneous rupture of the membrane
• Intrauterine infection
• Drugs: PG inhibitors, ACE inhibitors
• Post maturity and IUGR
• Amnion nodosum (failure of secretion by the cells of the amnion
covering the placenta).
26. Cont…
B. Maternal conditions:
• idiopathic
• Hypertensive disorders
• Uteroplacental insufficiency
• hypovolumia or Dehydration
• post term pregnancy
27. Clinical features :
• Uterine size is much smaller than the period of amenorrhea ,
• Less fetal movements ,
• The uterus is “full of fetus” because of scanty liquor ,
• Malpresentation (breech) is common,
• Evidences of IUGR of the fetus
Sonographic diagnosis is made when largest liquor pool is <2 cm.
Ultrasound visualization is done following amnioinfusion of 300 mL
of warm saline solution and Visualization of normal filling and
emptying of fetal bladder essentially rules out urinary tract
abnormality.
28. COMPLICATIONS
Fetal:
• preterm delivery
•Deformity due to intra-amniotic adhesions or due to compression.
•The deformities include alteration in shape of the skull, wry neck,
club foot, or even amputation of the limb,
• Fetal pulmonary hypoplasia
• Cord compression and malposition
• muconium aspiration IUGR ,IUD
• intra uterine infection following ROM.
29. Maternal:
• Prolonged labor due to uterine inertia
• Increased operative interference due to Malpresentation.
•The sum effect may lead to increased maternal morbidity.
30. management:
Presence of fetal congenital malformation needs referral to a fetal
medicine unit.
• When decision for delivery is made, it should be done irrespective of
the period of gestation.
• Isolated oligohydramnios in the third trimester with a normal fetus
may be managed conservatively with Oral administration of water
increases amniotic fluid volume.
• In labor, cord compression is common.
• Amnioinfusion (prophylactic or therapeutic) for meconium liquor is
found to improve neonatal outcome.
