OLIGOHYDRAMNIOSOLIGOHYDRAMNIOS

11Dr Dr abdullahwww.obgyntoday.infabdullahwww.obgyntoday.inf

oo

PHYSIOLOGY OF AMNIOTIC FLUIDPHYSIOLOGY OF AMNIOTIC FLUID

22

INFLOWINFLOW (1000 ml/d)(1000 ml/d)

1.FETAL URINE1.FETAL URINE2.LUNG LIQUID2.LUNG LIQUID

INTRAMEMBRANOUS (placenta,cord)INTRAMEMBRANOUS (placenta,cord) TRANSMEMBRANOUS(amniotic membranes)TRANSMEMBRANOUS(amniotic membranes) RECYCLING – 3hrsRECYCLING – 3hrs

OUTFLOWOUTFLOW (1000 ml/d)(1000 ml/d)

1.FETAL 1.FETAL SWALLOWINGSWALLOWING

33Dr Dr abdullahwww.obgyntoday.infabdullahwww.obgyntoday.inf

oo

Dr Mona Shroff Dr Mona Shroff www.obgyntoday.info www.obgyntoday.info

44

Amniotic fluid volumeAmniotic fluid volume8 weeks : 15 ml,increases 10 8 weeks : 15 ml,increases 10

ml/wkml/wk17 wks :250 ml ,increases 50 17 wks :250 ml ,increases 50

ml/wkml/wk28-38 wks :750-1000ml (decreases 28-38 wks :750-1000ml (decreases

after 34 wks)after 34 wks)42 wks<500ml42 wks<500ml

Dr Dr abdullahwww.obgyntoday.infabdullahwww.obgyntoday.inf

oo

66

FUNCTIONS OF AMNIOTIC FLUIDFUNCTIONS OF AMNIOTIC FLUID Shock absorber – protects from external Shock absorber – protects from external

trauma.trauma. Protects cord from compression.Protects cord from compression. Permits fetal movements – development of Permits fetal movements – development of

musculoskeletal system, prevents adhesions.musculoskeletal system, prevents adhesions. Swallowing of AF enhances growth & Swallowing of AF enhances growth &

development of GIT.development of GIT. AF volume maintains AF pressure – reduces loss AF volume maintains AF pressure – reduces loss

of lung liquid – pulmonary development.of lung liquid – pulmonary development. Maintenance of fetal body temperature.Maintenance of fetal body temperature. Some fetal nutrition, water supply.Some fetal nutrition, water supply. Bacteriostatic properties – decreases potential Bacteriostatic properties – decreases potential

for infection for infection 77

DEFINITIONDEFINITION AMNIOTIC FLUID VOLUME < 5 th percentile AMNIOTIC FLUID VOLUME < 5 th percentile

for gestational agefor gestational age

AMNIOTIC FLUID INDEX < 5AMNIOTIC FLUID INDEX < 5

SINGLE VERTICAL POCKET < 2 cmsSINGLE VERTICAL POCKET < 2 cms

Amniotic fluid volume of less than 500 mL at Amniotic fluid volume of less than 500 mL at 32-36 weeks' gestation32-36 weeks' gestation

88

99

INCIDENCEINCIDENCE

0.5 – 5%0.5 – 5%

1010

AETIOLOGYAETIOLOGYFETALFETAL PROM (50%)PROM (50%) CHROMOSOMAL ANOMALIESCHROMOSOMAL ANOMALIES CONGENITAL ANOMALIESCONGENITAL ANOMALIES IUGRIUGR IUFDIUFD POSTTERM PREGNANCYPOSTTERM PREGNANCY

MATERNALMATERNAL PREECLAMPSIAPREECLAMPSIA APLA SYNDROMEAPLA SYNDROME CHRONIC HTCHRONIC HT

PLACENTALPLACENTAL CHRONIC ABRUPTIONCHRONIC ABRUPTION TTTSTTTS CVSCVS

DRUGSDRUGS PG SYNTHETASE INHIBITORSPG SYNTHETASE INHIBITORS ACE INHIBITORSACE INHIBITORS

IDIOPATHIIDIOPATHICC1111

DIAGNOSISDIAGNOSIS SYMPTOMSSYMPTOMS

NO SPECIFIC NO SPECIFIC SYMPTOMSSYMPTOMS

H/O leaking p/vH/O leaking p/vPosttermPostterms/o preeclampsias/o preeclampsiaDrugsDrugsLess fetal movementsLess fetal movements

SIGNSSIGNS

Uterus – small for Uterus – small for datedate

Feels full of fetusFeels full of fetusMalpresentationsMalpresentationsIUGRIUGR

1212

USGUSGMETHODSMETHODS MVP <2 cmsMVP <2 cms (<1 severe)(<1 severe)

AFI <5 cmsAFI <5 cms (5-8 borderline)(5-8 borderline)

2D pocket <15 sq 2D pocket <15 sq cmscms

1313

Technique of AFITechnique of AFIUterus divided into 4 quadrantsUterus divided into 4 quadrantsTransducer in vertical planeTransducer in vertical planeSum of 4 quadrants max pocket Sum of 4 quadrants max pocket

depth excluding cord & limbs.depth excluding cord & limbs.Prior to 20 wks 2 halvesPrior to 20 wks 2 halvesTwins: composite AFI or individual Twins: composite AFI or individual

vertical pocketsvertical pockets

1414

Authors' conclusionsAuthors' conclusions

The single deepest vertical pocket measurement The single deepest vertical pocket measurement in the assessment of amniotic fluid volume during in the assessment of amniotic fluid volume during fetal surveillance seems a better choice since the fetal surveillance seems a better choice since the use of the amniotic fluid index increases the rate use of the amniotic fluid index increases the rate of diagnosis of oligohydramnios and the rate of of diagnosis of oligohydramnios and the rate of induction of labor without improvement in induction of labor without improvement in peripartum outcomes. A systematic review of the peripartum outcomes. A systematic review of the diagnostic accuracy of both methods in detecting diagnostic accuracy of both methods in detecting decreased amniotic fluid volume is required.decreased amniotic fluid volume is required.

Nabhan AF, Abdelmoula YA. Amniotic fluid index versus single Nabhan AF, Abdelmoula YA. Amniotic fluid index versus single deepest vertical pocket as a screening test for preventing adverse deepest vertical pocket as a screening test for preventing adverse pregnancy outcome. pregnancy outcome. Cochrane Database of Systematic ReviewsCochrane Database of Systematic Reviews 2008, Issue 32008, Issue 3

1515

COMPLICATIONSCOMPLICATIONS FETALFETALAbortionAbortionPrematurityPrematurityIUFDIUFDDeformities –Deformities –

CTEV,contractures,amputationCTEV,contractures,amputationPotters syndrome- pulmonary Potters syndrome- pulmonary

hypoplasiahypoplasiaMalpresentationsMalpresentationsFetal distressFetal distressMSAF – MASMSAF – MASLow APGARLow APGAR

MATERNALMATERNAL

Increased morbidityIncreased morbidity

Prolonged labour: Prolonged labour: uterine inertiauterine inertia

Increased operative Increased operative interventionintervention

(malformations,(malformations,distres)distres)

1616

MANAGEMENTMANAGEMENTDEPENDS UPONDEPENDS UPON

AETIOLOGYAETIOLOGYGESTATIONAL AGEGESTATIONAL AGESEVERITYSEVERITYFETAL STATUS & WELL BEINGFETAL STATUS & WELL BEING

1717

DETERMINE AETIOLOGYDETERMINE AETIOLOGY

R/O PROM, h/o medical illnessR/O PROM, h/o medical illnessTARGETED USG FOR ANOMALIESTARGETED USG FOR ANOMALIESR/O IUGR ,IUFD when suspectedR/O IUGR ,IUFD when suspectedAmniocentesis if chromosomal Amniocentesis if chromosomal

anomalies suspected – early anomalies suspected – early symmetric IUGRsymmetric IUGR

Tests for APLA Syndrome , if suspected Tests for APLA Syndrome , if suspected 1818

Dr Mona Shroff Dr Mona Shroff www.obgyntoday.infowww.obgyntoday.info

1919

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

without cordwithout cord BPP = BPP =

1.1. NSTNST2.2. breathing 30sec in 30minbreathing 30sec in 30min3.3. move 3 limb/body in 30minmove 3 limb/body in 30min4.4. extension of extremity with flexion or open/close handextension of extremity with flexion or open/close hand5.5. single vertical non-cord pocket of 2 cmsingle vertical non-cord pocket of 2 cm Scoring: 0 or 2 for each, 10 is normal, 6 equivocal, 4 abnormalScoring: 0 or 2 for each, 10 is normal, 6 equivocal, 4 abnormal

Modified BPP = NST, +/- acoustic stimulation, AFIModified BPP = NST, +/- acoustic stimulation, AFI AFI > 5 okAFI > 5 ok AFI < 5 or non-reactive NST not okAFI < 5 or non-reactive NST not ok modified BPP equally useful as BPP for monitoring, per ACOGmodified BPP equally useful as BPP for monitoring, per ACOG

TREATMENTTREATMENT ADEQUATE REST – decreases dehydrationADEQUATE REST – decreases dehydration HYDRATION – Oral/IV Hypotonic fluids(2 Lit/d)HYDRATION – Oral/IV Hypotonic fluids(2 Lit/d) temperory increasetemperory increase helpful during labour,prior helpful during labour,prior to ECV, USGto ECV, USG• SERIAL USG – Monitor growth,AFI,BPPSERIAL USG – Monitor growth,AFI,BPP• INDUCTION OF LABOUR/ LSCSINDUCTION OF LABOUR/ LSCS Lung maturity attainedLung maturity attained Lethal malformationLethal malformation Fetal jeopardyFetal jeopardy Sev IUGRSev IUGR Severe oligoSevere oligo DDAVP: ? Research settingsDDAVP: ? Research settings

2121

Hofmeyr GJ, Gülmezoglu AM. Maternal hydration for increasing amniotic fluid Hofmeyr GJ, Gülmezoglu AM. Maternal hydration for increasing amniotic fluid volume in oligohydramnios and normal amniotic fluid volume. volume in oligohydramnios and normal amniotic fluid volume. Cochrane Cochrane

Database of Systematic ReviewsDatabase of Systematic Reviews 2002, Issue 1. 2002, Issue 1.

Authors' conclusionsAuthors' conclusions Simple maternal hydration /IV Hypotonic fluid (2 Simple maternal hydration /IV Hypotonic fluid (2

lit) appears to increase amniotic fluid volume and lit) appears to increase amniotic fluid volume and may be beneficial in the management of may be beneficial in the management of oligohydramnios and prevention of oligohydramnios and prevention of oligohydramnios during labour or prior to external oligohydramnios during labour or prior to external cephalic version. Controlled trials are needed to cephalic version. Controlled trials are needed to assess the clinical benefits and possible risks of assess the clinical benefits and possible risks of maternal hydration for specific clinical purposes.maternal hydration for specific clinical purposes.

2222

AMNIOINFUSIONAMNIOINFUSION

INDICATIONSINDICATIONS 1.Diagnostic1.Diagnostic 2.Prophylactic2.Prophylactic 3.Therapeutic3.Therapeutic Decreases cord Decreases cord

compressioncompression Dilutes meconiumDilutes meconium

2323

Hofmeyr GJ. Prophylactic versus therapeutic amnioinfusion for Hofmeyr GJ. Prophylactic versus therapeutic amnioinfusion for oligohydramnios in labour. oligohydramnios in labour. Cochrane Database of Systematic ReviewsCochrane Database of Systematic Reviews

1996,1996,Issue 1Issue 1. . Authors' conclusionsAuthors' conclusionsThere appears to be no advantage of There appears to be no advantage of

prophylactic amnioinfusion over prophylactic amnioinfusion over therapeutic amnioinfusion carried out therapeutic amnioinfusion carried out only when fetal heart rate only when fetal heart rate decelerations or thick meconium-decelerations or thick meconium-staining of the liquor occur.staining of the liquor occur.

2424

DDAVPDDAVPOral hydration + DDAVP :Prevents Oral hydration + DDAVP :Prevents

diuresisdiuresis

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

2525

DDAVP : concernsDDAVP : concerns

Effect on maternal & fetal bld Effect on maternal & fetal bld volumevolume

Long term effects on AFILong term effects on AFIProphylactic or chronic useProphylactic or chronic useMask oligohydramnios ??Mask oligohydramnios ??

2626

Therapeutic Interventions: Therapeutic Interventions: OligohydramniosOligohydramnios

BPP asphyxia? RiskFetal Death (/1000/week) Management

10 or 8 + normal AFI not 0% 0.565 no intervention

8 + oligo chronic compensated 5-10% 20-30if >37 wks deliver, else serial testing 2x/wk

6 + normal AFI acute possibly 10% 50

if >37 wks deliver, else repeat testing 24hrs, if score same, then deliver

6 + oligo chronic +/- acute >10% >50if >32 wks deliver, else daily testing

4 + normal AFI acute likely 36% 115 if >26 wks deliver4 + oligo chronic and acute likely >36% >115 if >26 wks deliver2 + normal AFI acute certain 73% 220 if >26 wks deliver2 + oligo chronic and acute certain >73% >220 if >26 wks deliver0 gross severe 100% 550 if >26 wks deliver

TREATMENT ACC. TO CAUSETREATMENT ACC. TO CAUSEDrug induced – OMIT DRUGDrug induced – OMIT DRUGPROM – INDUCTIONPROM – INDUCTIONPPROM – Antibiotics,steroid – PPROM – Antibiotics,steroid –

InductionInductionFETAL SURGERYFETAL SURGERY VESICO AMNIOTIC SHUNT-PUVVESICO AMNIOTIC SHUNT-PUV Laser photocoagulation for TTTS Laser photocoagulation for TTTS

2828

Posterior urethral valvesPosterior urethral valves Sonographic findings:Sonographic findings:

Keyhole signKeyhole sign

Posterior urethral valvesPosterior urethral valvesManagement:Management:

KaryotypingKaryotypingPerform serial bladder drainage every 3-Perform serial bladder drainage every 3-

4 days4 daysUse sample of 3Use sample of 3rdrd drainage drainageIsotonic urine indicate poor functionIsotonic urine indicate poor function

Posterior urethral valvesPosterior urethral valvesGood prognostic biochemical Good prognostic biochemical

markers:markers:Na < 100meq/LNa < 100meq/LCl < 90meq/LCl < 90meq/LOsmolarity <210mOsm/L Osmolarity <210mOsm/L B2 microglobulin < 4mg/LB2 microglobulin < 4mg/LCa < 8mg/dlCa < 8mg/dl

Indication for vesico amniotic shuntsIndication for vesico amniotic shunts

3232