This document discusses amniotic fluid disorders including polyhydramnious and oligohydramnious. It describes how normal amniotic fluid levels change throughout pregnancy, peaking at 38 weeks. The two main abnormalities are defined as polyhydramnious (excess amniotic fluid over 2000ml) and oligohydramnious (less than 300-500ml at term). Causes, signs/symptoms, complications and management are described for each condition. Preeclampsia, premature rupture of membranes, intrauterine growth restriction, intrauterine fetal death, and preterm labor are also summarized.

1. Amniotic Fluid Disorders
• Normal amniotic fluid increases in amount
throughout pregnancy until it reaches its
maximum level(l liter) at 38 weeks of
gestation.
• Amniotic fluid normal decrease 38 weeks
onwards:
– 800 ml at 40 weeks
– 400 ml at 42 weeks
– 300 ml at 43 weeks
1

2. Disorders of Amniotic Fluid cont ….
• There are two chief abnormalities
of amniotic fluid:
1. Polyhydramnious (Hydramnious)
2. Oligohydramnious
2

3. 1. Polyhydramnious
Definition: polyhydramnious is an excess amniotic
fluid which exceeds 2000 ml.
• Incidence: 9 in 1000 pregnancies.
Etiology:
Majority of polyhydramnios is idiopathic (>60 %)
 conditions that increase the surface area of the
placenta and amnion or disrupt the integument
of the fetus or hamper the normal swallowing
process of the fetus:
3

4. Polyhydramnious Cont…
• Diabetes mellitus,
• placental tumors,
• fetal anomalies like esophageal artesia,
tracheoesophageal fistula, spinal bifida and
anencephaly,
• RH isoimmunization,
• multiple gestations are clinical conditions
associated with polyhydraminos
4

5. Polyhydramnious Cont…
Types of Polyhydramnious:
1. Acute Polyhydramnious
2. Chronic Polyhydramnious
A. Acute Polyhydramnious:
• Is very rare
• Usually occurs at about 20 weeks
• Comes on very sudden
• The uterus reaches the xiphisternum with in 3 –
4 days
5

6. Polyhydramnious Cont…
• Frequently associated with severe fetal
malformations and monozygotic twins
• Ends with spontaneous abortion most of the
time
• Severe abdominal pain is common symptom
B. Chronic Polyhydramnious:
• Is gradual in onset
• Usually from 30 weeks of pregnancy
• Is the most common type
6

7. Recognition:
• The mother may complain of breathlessness
and discomfort: the condition may exacerbate
heartburn, indigestion, edema, and
varicosities.
7
Polyhydramnious Cont…

8. S/S :
A. On Inspection:
• The uterus is larger than expected
• The uters is globular in shape
• The abdominal skin appears stretched and
shiny marked straegravidarum
• Obvious superficial blood vessels are seen
8
Polyhydramnious Cont…

9. B. On Palpation:
• The uterus feels tense
• It is difficult to feel fetal parts(may be balloted
b/n two hands)
• Fluid thrill is present
• Abdominal girth increase rapidly(in acute)
9
Polyhydramnious Cont…

10. C. On Auscultation:
• FHB is difficult to hear
D. Ultrasonic Scanning:
• Confirms polyhydramnious by measuring fluid
“pools’’
NB: Investigations are needed to know the cause
of the polyhydramnious.
10
Polyhydramnious Cont…

11. Assignment:
1. Definition of Polyhydramnious based on
ultrasound
– Single pocket_____ cm
– All pockets ________ cm
2. Role of indomethacin in management of
polyhydramnious
11
Polyhydramnious Cont…

12. Complications:
• Maternal ureteric obstruction
• Increased fetal mobility leading to unstable lie
and malpresentation
• Cord presentation and cord prolapse
• Premature rupture of membranes (PROM)
• Placental abruption
• Premature labour
12
Polyhydramnious Cont…

13. Complications cont…
• Increased risk of C/S
• Post partum hemorrhage
• High perinatal mortality rate
13
Polyhydramnious Cont…

14. Polyhydramnious Cont…
Management:
• The cause of the condition should be
determined if possible.
• Management depends on:
1. Condition of the fetus and the mother
2. The cause and degree of polyhydramnious
3. Stage of pregnancy
14

15. Polyhydramnious Cont…
Mgt of Asymptomatic Polyhydramnious:
• Managed expectantly
• The woman is not necessarily admitted to
hospital but should be advised that if she
suspects that her membranes has been
ruptured, immediate admission is
recommended
• Bed rest.
15

16. Polyhydramnious Cont…
Mgt of Symptomatic Polyhydramnious:
• Hospital admission for at least 2 weeks.
• Upright position to relive dyspnea
• Anti acids to relive heart burn
• Amniocentesis
• Induction of labour if worsening
• Delivery should be hospital
16

17. Polyhydramnious Cont…
NB: Before inducing labour any malpresentation
should be checked. While rupturing the
membranes, hand should be in cervix for the
following reasons:
1. To prevent cord prolapse
2. Feta and maternal distress are avoided
3. To prevent placental abruption
17

18. Polyhydramnious Cont…
• Be ready to manage PPH!!!
• The baby should up sided down
at birth and also carefully
examined for congenital
abnormalities!!!
18

19. 2. Oligohydramnious
Definition: Abnormally small amount of amniotic
fluid which is less than 300 – 500 ml at term.
• Is a rare condition.
Causes:
• Renal agenesis in early pregnancy
• Fetal malformations and PROM in late pregnancy
• Postterm pregnaancy
19

20. Oligohydramnious Cont…
Note: The lack of amniotic fluid reduces the
intrauterine space and over time causes
compression deformities:
• Squashed looking face
• Flattening of the nose
• Migrognathia
• Talipes equine varus
• Dry and leathery appearance of the skin
20

21. Oligohydramnious Cont…
S/S:
• Uterus is small for dates (early)
• Uterus feels full of fetus (late)
• Breech presentation is common
• FHR is normal
• Small columns by ultrasound
Management:
• Renal agenesis: Termination of pregnancy
• PROM: Amino infusion by normal saline
21

22. Premature Rupture of
Membranes(PROM)
Definition: PROM Defined as spontaneous
rupture of membranes at any(formerly 1 hr)
time prior to on set of labour.
1. Preterm PROM (PPROM): if < 37 weeks
2. Tem PROM: if >37 weeks
Causes of PROM:
Precise cause is unknown but it is associated
with:
22

23. PROM Cont…
Causes of PROM:
• Malpresentation
• Infection – chorioamnionitis
• Trauma:
– Pelvic examination
– Coitus
• Increased intrauterine pressure
– Multiple pregnancy
– Polyhydramnious
23

24. PROM Cont…
• STIs
• Low soc economic status
• Incompetent cervix
• Possible weak areas in the amnion and
chorion
24

25. PROM Cont…
Diagnosis:
History: patients often report a leakage or gush
of clear fluid from the vagina.
Investigations:
1. Sterile speculum examination: Escape of
fluid from the cervix may be seen
spontaneously or following the pressure from
the abdomen – valsalva maneuver
25

26. PROM Cont…
2. Nitrazine paper test:
– Amniotic fluid is alkaline
– Vaginal secretions are acidic
3. Fern test: The best method;
4. Ultrasound: little or no amniotic fluid will be
seen
5. Intra amniotic injection of dye
26

27. PROM Cont…
Management of PROM:
The two main approaches of management are:
1. Conservative/ expectant and
2. Active
27

28. PROM Cont…
1. Active Management: is preferred when the risk
associated with PROM is greater than that is
associated with termination of
pregnancy(INFECTION)
When GA is less than 37 weeks
• Confirm diagnosis
• R/O Chorioamnionitis: fever, thachycardia,
purulent vaginal discharge, uterine tenderness(
When there is chorioamnionis induction is a
must!)
28

29. PROM Cont…
When there is no Chorioamnionitis and GA is
less than 37 weeks conservative management
is favored.
Conservative management at Hospital:
Purpose: to allow the fetus to reach stage of
maturity.
• Bed rest
• Temperature and pulse 4 hourly
29

30. PROM Cont…
• WBC count daily
• Avoid digital exam
• U/S weekly to assess amniotic fluid volume &
fetal growth
• Steroids to mature fetal lungs
• Infection – induction is a must
30

31. PROM Cont…
Conservative management a home:
• When all parameters are stable
• There is no excessive loss of amniotic fluid
• No coitus, no douche or vaginal tampons
• Temperature every 4 hr by the pt
31

32. PROM Cont…
If GA is > 37 weeks:
• Induction of labour in absence of complications
Dangers of PROM:
• Cord prolapse
• Preterm labour
• Malpresentation(breech)
• Infection(Chorioamnionitis)
• APH
32

33. PROM Cont…
Assignment
• Go to Arbaminch Hospital OB/GYN ward and
ask:
1. Antibiotics used to:
1. Prevent infection in woman with PROM including
dose.
2. Treat infection in woman with PROM including
dose.
33

34. Fetal Growth Abnormalities
1. Intrauterine Growth Restriction (IUGR)
2. Intrauterine Fetal Death (IUFD)
A. Intrauterine Growth Restriction (IUGR)
Definition: IUGR is fetal condition characterized by
failure to grow at the expected rate that can
result in birth of small for gestational age (SGA)
baby. (Estimated wt less than 10th percentile and
abdominal circumference less than2.5th
percentile).
34

35. IUGR Cont…
Causes:
• Maternal malnutrition
• Premature placental aging
• Placental infarcts
• Congenital infections
• Environmental hazards (teratogenes, maternal
substance abuse etc.)
35

36. IUGR Cont…
Types of IUGR:
There are two types of IUGR:
1. Symmetrical(proportional) IUGR and
2. Asymmetrical(Disproportional) IUGR
36

37. IUGR Cont…
I. Symmetrical IUGR:
• Occurs when the fetus has experienced early
and prolonged nutritional deprivation caused by
severe chronic maternal malnutrition, placental
insufficiency, intrauterine infection or fetal
chromosomal abnormalities.
• Hypoplastic cell growth and development
occurs
• There is generalized defficency of cell number
through out the body in all organ system.
37

38. IUGR Cont…
• The neonate's body and head both appears small.
• The condition is associated with diminished brain size
and permanent mental retardation.
II. Asymmetrical IUGR:
• Results from nutritional deficiencies and placental
insufficiency in late pregnancy.
• Atrophy of pre existing cells occur, resulting in
diminished cell size but cell numbers are not reduced.
• The neonate appears to have disproportionally large
head in relation to his body.
38

39. IUGR Cont…
• The body is long and emaciated with little
subcutaneous fat, generalized muscle wasting,
abdomen is scaphoid I shape, and the skin has
poor skin turgor.
• Postnatal growth and development are rapid,
and potential for normal intellectual function
is excellent.
39

40. IUGR Cont…
Management:
• Check for possible causes and try to treat the
cause
• Check for the fetal heart rate frequently
• Instruct the mother to count fetal movements by
kick chart
• Termination of pregnancy to get alive baby if
– The fetus is at high risk
– Fetal lung maturity is adequate
– GA is > 43 weeks
40

41. B. Intrauterine Fetal Death (IUFD)
• Death of a fetus in uterus after 28 weeks of
pregnancy.
Causes:
• Maternal HTN(Pre eclampsia-eclampsia)
• Placental abruption
• Transplacental infections (Syphilis, typhoid
fever…)
• Cord entanglement (rarely)
41

42. IUFD Cont…
• Rh –isoimmunization
• Maternal diabetes mellitus (DM)
• Post term pregnancy (Hypoxia)
• Severe anemia etc
Note:
• In great number of instance, no cause is found
• In majority of IUFDs, labour starts spontaneously
with in 2 weeks
• Induction of labour should be done at 3 – 4
weeks to prevent DIC.
42

43. IUFD Cont…
S/S of IUFD:
• Loss of fetal movements
• FHRs are absent
• No fetal movements by ultrasound
• Spalding’s sign - (overlapping skull bones by x-ray
• Roberts's sign – Gas in the heart & great vessels
by x- ray
• Exaggeration of fetal spine curvature by x- ray
• Maceration
43

44. IUFD Cont…
Complications of IUFD:
• Bleeding
• DIC (>3 weeks in utero)
• Infection
• Psychological trauma
Management:
• Induction of labour if not started spontaneously
• Antibiotics
• Investigate for underlying causes: Rh, syphilis …
44

45. IUFD Cont…
Assignment:
Write down the degrees(s/s, time span) of
maceration of IUFD.
45

46. Preterm Labour(PTL)
Definition: PTL is defined as labour occurring
after 28 weeks but before 37 completed
weeks of gestation.
• Complicates 5 – 15 % of all pregnancies.
• The single most important complication of PTL
is prematurity and the care of premature
infant is costly compared with term infants.
• Those born prematurely suffer greatly from
increased morbidity and mortality.
46

47. PTL Cont….
• Thus every effort should be made to prevent
or inhibit preterm labor.
• If it can not be inhibited or is best allowed
continuing, it should be conducted with the
least possible trauma to the mother and
infant.
47

48. PTL Cont…
Risk Factors:
• Race (Black > non back)
• Low socio economic status
• Poor nutrition and low pre pregnancy weight
• History of previous PTL.
• Second trimester abortion
• Negative attitude towards pregnancy
• Current pregnancy complications including placenta
previa, abruptio placenta, polyhydramnious,
Oligohydramnious, 1st trimester pregnancy and
multiple pregnancies.
48

49. PTL Cont…
• Cervical conization
• Age <18y or >40 y
• Uterine anomaly or fibroids( Tumors)
• Maternal stress
• Anemia
• Cigarette smoking
• Genital infection or colonization
• Medical diseases(anemia, DM, HTN,
pyelonephritis, and febrile illness)
49

50. PTL Cont…
Diagnosis of PTL:
A. Signs and symptoms:
• Uterine contraction 2/10/30”
• Cervical dilation and effacement.
– Progressive change in the cervix
• Cervical dilatation of 2 cm or more
• Cervical effacement of 80% or more
B. Visual estimates:
• During speculum exam, if fetal parts or membranes are
visible, cervix is 2 cm or more dilated.
C. Trans vaginal ultrasound showing:
• Cervical length (normally 2.5 – 3 cm)
50

51. PTL Cont…
Laboratory Studies:
• CBC with differentials
• U/A and sensitivity
• U/S for fetal size
• Amniocentesis for
– Maturity assessment
– Bacteriological study
• Electrolyte and blod sugar for pt requiring toclysis
51

52. PTL Cont…
Management:
• The pt should be observed for ½ - 1 hr to
determine appropriate management.
• See the table on the next slide.
52

53. PTL Cont…
Group Uterine
contractions
Cxal Dilatation
& Effacement
Diagnosis Management
I No No No labour None
III Yes No 2 Pre term labor Hydration &
sedation
IV No Yes 3 Incompetent
Cx
Bed rest,
consider
cercalage
V Yes Yes 3 Pre term labor Tocolysis
53

54. PTL Cont…
1 = two or more contractions per 10 minutes for
30 seconds
2 = Dilatation < 4cm and effacement < 80%
3 = Effacement of 80% with dilatation of 2 cm or
more changes with observation.
54

55. PTL Cont…
A. Cases in whom PTL should be allowed to
continue.:
1. Maternal diseases and disorders:
– Severe hypertensive disease (Pre eclampsia-eclampsia)
– Pulmonary or cardiac diseases (Pulmonary
edema, ARDS, Valvular heart diseases)
– Maternal bleeding (APH, DIC)
55

56. PTL Cont…
2. Fetal Disease and disorders:
– Fetal death
– Polyhydramnious
– Severe IUGR
– Fetal distress
– Intrauterine infection (Chorioamnionitis)
– Erythroblast sis fetalis
56

57. PTL Cont…
3. Miscellaneous:
• Ruptured membranes
• Bulging membranes
• Cervical dilatation >4 cm and effacement >
80%
• Mature fetus
57

58. PTL Cont…
B. Cases who need sedation and tocolysis:
• As for group II in the table above.
C. Tocolysis:
• Group IV and failed group II Pts
• Approximately 10 – 30% of pts with PTL are
eligible.
58

59. PTL Cont…
Criteria to use tocolysis:
1. The fetus is apparently healthy
2. GA is b/n 28 & 37 weeks)
3. Cervical dilation is < 4 cm & effacement <
80%
4. The membranes are intact
59

60. PTL Cont….
Drugs used for tocolysis:
1. First line agents:
– - drenergics(ritodrine, terbutaline, fenoterol)
– Magnisum sulphate
2. Second line drugs
– Antiprostaglandines( Indomethacin, Naperoxen)
– Calcium channel blokers ( Nifedipine)
60

61. PTL Cont…
Delivery:
• Vaginal delivery:
– Wide episiotomy
– “Prophylactic” forceps)
• C/S: for LBW and non vertex presentation.
61

62. PTL Cont…
Identification and prevention of pre term
labour:
1. Identification:
• Prior pre term birth
• Cervical dilatation
• S/S including:
– Uterine contractions - Blood stained discharge
– Pelvic pressure - Pain in the lower back
– Menstural like cramps
62

63. PTL Cont…
Prevention of PTL:
• Educate woman at high risk about s/s of
preterm labor
• Follow closely with weekly or biweekly
examination
63

64. Prolonged/Postterm/ Pregnancy
Definition: Postterm pregnancy is defined as the
one that exceeds 294 days/42 weeks from the
first date of the last menstrual period.
Incidence: 10% of all pregnancies. High in
primigravidae.
Diagnosis:
1. EDD calculation: do not forget to ask history
of hormonal method of contraception.
64

65. Postterm Cont…
2. Quickening: can be heard from 16 – 20 weeks
(pregnant women should be asked to note the
date they felt fetal movement first time).
3. Ultrasound: Better if done before 20 weeks of
gestation: accuracy with in 5 days n 95 % of
cases.
4. FHB: heard from 20 weeks onwards
5. X-ray
65

66. Postterm Cont…
S/S of Postterm:
• Diminished liquor
• Reduced fetal movements
• Abnormal fetal heart rate
• Maternal wt loss
• Decreased uterine size
• Meconium stained liquor
• Advanced bone maturation- hard fetal skull
66

67. Postterm Cont…
Note: pregnancy can not be said Postterm
without accurate dating.
Effects of Postterm:
A. On the mother:
• Anxiety
• CPD
• Prolonged labour
• Risks related to C/S
67

68. Postterm Cont…
B. On the fetus:
• Placental insufficiency  fetal hypoxia fetal
distress meconium aspiration  IUFD
Mental Retardation
• Macrosomia- b/s the fetus has longer time to
grow in the uterus  Birth trauma
68

69. Postterm Cont…
Appearance of post mature baby:
• Hard skull bones
• Small fontanelles with narrow suture
• Long finger nails
• Absence of vernix casiosa
• Dry, peeling and cracked skin
69

70. Postterm Cont…
Factors increasing Risk:
• Congenital anomalies:
– Hydrocephaly
– Anencephaly
• Older primigravidae
• Poor obstetric history
• Pre-eclampsia
• DM
• Previous history of big baby
70

71. Postterm Cont…
Management:
A. Expectant: is appropriate when there are no
complication:
– Rest
– Biophysical profile
– Amniotic fluid measurement
– Reassurance
B. Active:
– ARM/Oxytocin- induction of labour if fail C/S
71

72. Postterm Cont…
Assignment:
1. What is bio physical profile: Write its 5
components with detail explanations.
2. What is non reassuring fetal heart rate
pattern (NRFHRP)
72