Influence of polyhydramnios on perinatal outcomes. WOGS MEETING - 16TH March 2012 Dr. Mugdha Wakodkar, Trust SHO Dr. Shweta Joshi, ST6 Mrs. Kalpana Upadhyay, Consultant O&G WREXHAM MAELOR HOSPITAL (BCUHB North Wales)

Introduction Polyhydramnios - excess amniotic fluid for given gestation in pregnancy It complicates 0.5- 1% of all pregnancies Prognosis depends on cause - good prognosis in idiopathic type

Causes Fetal Maternal Placental Idiopathic 55% Tracheoesophageal fistula, oesophageal atresia, duodenal atresia, diaphragmatic hernia Maternal Diabetes 25% Chorioangioma (rare) Lethal skeletal dysplasia Twin Pregnancy (mostly monochorionic with TTTS) Open neural tube defects TORCH and Parvovirus infection Fetal macrosomia, fetal anaemia – Rh disease

Physiology of Amniotic Fluid Amniotic fluid after 20 weeks largely consists of fetal urine Volume depends on urine production, fetal swallowing and absorption Amniotic fluid - 250 ml at 16 wks 1000 ml at 34 wks declines to 800 ml at term

Diagnosis - ultrasonography Subjective assessment – by experienced trained sonographer OR Single deepest vertical pool – > 8cm is polyhydramnios Amniotic fluid index - varies with gestational age An AFI < 5 cm - oligohydramnios An AFI > 25 cm – polyhydramnios AFI > 95th centile for the gestational age Obstetric ultrasound- Trish Chudleigh and Basky Thilanganathan, Progress in Obstetrics and Gynaecology –John Studd , Vol 18

Reference range AFI used at WMH

Standard Currently no standard guideline in RCOG / NICE Literature search Little evidence on diagnosis and management of polyhydramnios No large studies done on the optimum management

Aim of study Study demographics Assessing outcome- maternal and fetal To look into what investigations were done To propose a guideline

Methods Retrospective study Jan 2010 to August 2010 Cases identified by using help of ultrasonography department Identified all scan reports With term “polyhydramnios” on growth scan Looked into 48 cases

Gravidity ( n =18 ) ( n =30 )

Family h/o Diabetes ( n =8) ( n = 40)

Anomaly scan 4% (n=2) 96% (n=46)

AFI

Deepest vertical pool 6 out of 48 had deepest vertical pool used as criteria for polyhydramnios Between 7 and 8

GTT (*n=8) (n=40) *6 of 8 cases already diagnosed with IDDM, 2 of 8 diagnosed near term

GTT positive (**n=6) (n=34) **these 6 positive results were newly diagnosed with GDM

TORCH and Parvo testing

TORCH and Parvovirus results Positive results were only for IgG antibiodies and none for IgM antibodies.

Gestation at delivery

Onset of labour

Reasons for IOL SROM- 3 Medical reasons-3 DM- 10 Polyhydramnios-4 Postdates-9

Mode of delivery

Baby weight

Neonatal outcomes 42 had no problems identified 6 had some problems – incidental abnormality, nothing to account for polyhydramnios

Summary Out of 48 cases, 6 were diagnosed to have pre existing diabetes, 6 new cases were diagnosed- 25% cases had identifiable cause 75% cases had idiopathic cause for polyhydramnios No obvious fetal abnormality to account for polyhydramnios None of the cases were positive for TORCH or Parvovirus IgM antibody IOL in 4 cases due to polyhydramnios – none of them had cord prolapse or complications seen with polyhydramnios. Concern regarding the diagnostic criteria – Are we over diagnosing polyhydramnios?

Suggestions/Recommendations Formulation of departmental guideline on specific ultrasonographic diagnostic criteria for diagnosis of polyhyramnios What tests should be offered? Is there a role for TORCH+Parvo? Is there a role of GTT? IOL individualised and to be discussed with senior staff if being done for polyhydramnios

Limitation of the study Looked into small number of cases Non availability of national guidelines/standards

Acknowledgement Audit department at Wrexham Maelor Hospital post graduate center Radiology department at Wrexham Maelor Hospital

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