OLIGOHYDRAMNIOS 1 Dr abdullahwww.obgyntoday.info

PHYSIOLOGY OF AMNIOTIC FLUID 2

INFLOW INFLOW (1000 ml/d) (1000 ml/d) 1.FETAL URINE 2.LUNG LIQUID INTRAMEMBRANOUS (placenta,cord) INTRAMEMBRANOUS (placenta,cord) TRANSMEMBRANOUS(amniotic membranes) TRANSMEMBRANOUS(amniotic membranes) RECYCLING – 3hrs RECYCLING – 3hrs OUTFLOW OUTFLOW (1000 ml/d) (1000 ml/d) 1.FETAL SWALLOWING 3 Dr abdullahwww.obgyntoday.info

Dr Mona Shroff 4

Amniotic fluid volume 8 weeks : 15 ml,increases 10 ml/wk 8 weeks : 15 ml,increases 10 ml/wk 17 wks :250 ml,increases 50 ml/wk 17 wks :250 ml,increases 50 ml/wk wks : ml (decreases after 34 wks) wks : ml (decreases after 34 wks) 42 wks<500ml 42 wks<500ml Dr abdullahwww.obgyntoday.info 6

FUNCTIONS OF AMNIOTIC FLUID Shock absorber – protects from external trauma. Shock absorber – protects from external trauma. Protects cord from compression. Protects cord from compression. Permits fetal movements – development of musculoskeletal system, prevents adhesions. Permits fetal movements – development of musculoskeletal system, prevents adhesions. Swallowing of AF enhances growth & development of GIT. Swallowing of AF enhances growth & development of GIT. AF volume maintains AF pressure – reduces loss of lung liquid – pulmonary development. AF volume maintains AF pressure – reduces loss 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 for infection Bacteriostatic properties – decreases potential for infection 7

DEFINITION AMNIOTIC FLUID VOLUME < 5 th percentile for gestational age AMNIOTIC FLUID VOLUME < 5 th percentile for gestational age AMNIOTIC FLUID INDEX < 5 AMNIOTIC FLUID INDEX < 5 SINGLE VERTICAL POCKET < 2 cms SINGLE VERTICAL POCKET < 2 cms Amniotic fluid volume of less than 500 mL at weeks' gestation Amniotic fluid volume of less than 500 mL at weeks' gestation 8

9

INCIDENCE 0.5 – 5% 0.5 – 5% 10

AETIOLOGY FETAL PROM (50%) PROM (50%) CHROMOSOMAL ANOMALIES CHROMOSOMAL ANOMALIES CONGENITAL ANOMALIES CONGENITAL ANOMALIES IUGR IUGR IUFD IUFD POSTTERM PREGNANCY POSTTERM PREGNANCY MATERNAL PREECLAMPSIA PREECLAMPSIA APLA SYNDROME APLA SYNDROME CHRONIC HT CHRONIC HT PLACENTAL CHRONIC ABRUPTION CHRONIC ABRUPTION TTTS TTTS CVS CVS DRUGS PG SYNTHETASE INHIBITORS PG SYNTHETASE INHIBITORS ACE INHIBITORS ACE INHIBITORS IDIOPATHI C 11

DIAGNOSIS SYMPTOMS SYMPTOMS NO SPECIFIC SYMPTOMS H/O leaking p/v Postterm s/o preeclampsia Drugs Less fetal movements SIGNS SIGNS Uterus – small for date Feels full of fetus MalpresentationsIUGR 12

USG METHODS MVP <2 cms (<1 severe) (<1 severe) AFI <5 cms (5-8 borderline) (5-8 borderline) 2D pocket <15 sq cms 13

Technique of AFI Uterus divided into 4 quadrants Uterus divided into 4 quadrants Transducer in vertical plane Transducer in vertical plane Sum of 4 quadrants max pocket depth excluding cord & limbs. Sum of 4 quadrants max pocket depth excluding cord & limbs. Prior to 20 wks 2 halves Prior to 20 wks 2 halves Twins: composite AFI or individual vertical pockets Twins: composite AFI or individual vertical pockets 14

Authors' conclusions The single deepest vertical pocket measurement in the assessment of amniotic fluid volume during fetal surveillance seems a better choice since the use of the amniotic fluid index increases the rate of diagnosis of oligohydramnios and the rate of induction of labor without improvement in peripartum outcomes. A systematic review of the diagnostic accuracy of both methods in detecting decreased amniotic fluid volume is required. The single deepest vertical pocket measurement in the assessment of amniotic fluid volume during fetal surveillance seems a better choice since the use of the amniotic fluid index increases the rate of diagnosis of oligohydramnios and the rate of induction of labor without improvement in peripartum outcomes. A systematic review of the diagnostic accuracy of both methods in detecting decreased amniotic fluid volume is required. Nabhan AF, Abdelmoula YA. Amniotic fluid index versus single deepest vertical pocket as a screening test for preventing adverse pregnancy outcome. Cochrane Database of Systematic Reviews 2008, Issue 3 Nabhan AF, Abdelmoula YA. Amniotic fluid index versus single deepest vertical pocket as a screening test for preventing adverse pregnancy outcome. Cochrane Database of Systematic Reviews 2008, Issue 3 15

COMPLICATIONS FETAL FETALAbortionPrematurityIUFD Deformities – CTEV,contractures,amputation Potters syndrome- pulmonary hypoplasia Malpresentations Fetal distress MSAF – MAS Low APGAR MATERNAL Increased morbidity Prolonged labour: uterine inertia Increased operative intervention (malformations,distres) 16

MANAGEMENT DEPENDS UPON AETIOLOGY GESTATIONAL AGE SEVERITY FETAL STATUS & WELL BEING 17

DETERMINE AETIOLOGY R/O PROM, h/o medical illness R/O PROM, h/o medical illness TARGETED USG FOR ANOMALIES TARGETED USG FOR ANOMALIES R/O IUGR,IUFD when suspected R/O IUGR,IUFD when suspected Amniocentesis if chromosomal anomalies suspected – early symmetric IUGR Amniocentesis if chromosomal anomalies suspected – early symmetric IUGR Tests for APLA Syndrome, if suspected Tests for APLA Syndrome, if suspected 18

Dr Mona Shroff 19

Techniques for Monitoring Single pocket without cord Single pocket without cord AFI = sum of deepest pocket in each of 4 quadrants without cord AFI = sum of deepest pocket in each of 4 quadrants without cord BPP = BPP = 1. NST 2. breathing 30sec in 30min 3. move 3 limb/body in 30min 4. extension of extremity with flexion or open/close hand 5. single vertical non-cord pocket of 2 cm Scoring: 0 or 2 for each, 10 is normal, 6 equivocal, 4 abnormal Scoring: 0 or 2 for each, 10 is normal, 6 equivocal, 4 abnormal Modified BPP = NST, +/- acoustic stimulation, AFI Modified BPP = NST, +/- acoustic stimulation, AFI AFI > 5 ok AFI > 5 ok AFI < 5 or non-reactive NST not ok AFI < 5 or non-reactive NST not ok modified BPP equally useful as BPP for monitoring, per ACOG modified BPP equally useful as BPP for monitoring, per ACOG

TREATMENT ADEQUATE REST – decreases dehydration ADEQUATE REST – decreases dehydration HYDRATION – Oral/IV Hypotonic fluids(2 Lit/d) HYDRATION – Oral/IV Hypotonic fluids(2 Lit/d) temperory increase temperory increase helpful during labour,prior helpful during labour,prior to ECV, USG to ECV, USG SERIAL USG – Monitor growth,AFI,BPP SERIAL USG – Monitor growth,AFI,BPP INDUCTION OF LABOUR/ LSCS INDUCTION OF LABOUR/ LSCS Lung maturity attained Lung maturity attained Lethal malformation Lethal malformation Fetal jeopardy Fetal jeopardy Sev IUGR Sev IUGR Severe oligo Severe oligo DDAVP: ? Research settings DDAVP: ? Research settings 21

Hofmeyr GJ, Gülmezoglu AM. Maternal hydration for increasing amniotic fluid volume in oligohydramnios and normal amniotic fluid volume. Cochrane Database of Systematic Reviews 2002, Issue 1. Hofmeyr GJ, Gülmezoglu AM. Maternal hydration for increasing amniotic fluid volume in oligohydramnios and normal amniotic fluid volume. Cochrane Database of Systematic Reviews 2002, Issue 1. Authors' conclusions Simple maternal hydration /IV Hypotonic fluid (2 lit) appears to increase amniotic fluid volume and may be beneficial in the management of oligohydramnios and prevention of oligohydramnios during labour or prior to external cephalic version. Controlled trials are needed to assess the clinical benefits and possible risks of maternal hydration for specific clinical purposes. Simple maternal hydration /IV Hypotonic fluid (2 lit) appears to increase amniotic fluid volume and may be beneficial in the management of oligohydramnios and prevention of oligohydramnios during labour or prior to external cephalic version. Controlled trials are needed to assess the clinical benefits and possible risks of maternal hydration for specific clinical purposes. 22

AMNIOINFUSION AMNIOINFUSION INDICATIONS INDICATIONS 1.Diagnostic 1.Diagnostic 2.Prophylactic 2.Prophylactic 3.Therapeutic 3.Therapeutic Decreases cord compression Decreases cord compression Dilutes meconium Dilutes meconium 23

Hofmeyr GJ. Prophylactic versus therapeutic amnioinfusion for oligohydramnios in labour. Cochrane Database of Systematic Reviews 1996, Issue 1. Hofmeyr GJ. Prophylactic versus therapeutic amnioinfusion for oligohydramnios in labour. Cochrane Database of Systematic Reviews 1996, Issue 1. Authors' conclusions There appears to be no advantage of prophylactic amnioinfusion over therapeutic amnioinfusion carried out only when fetal heart rate decelerations or thick meconium-staining of the liquor occur. There appears to be no advantage of prophylactic amnioinfusion over therapeutic amnioinfusion carried out only when fetal heart rate decelerations or thick meconium-staining of the liquor occur. 24

DDAVP Oral hydration + DDAVP :Prevents diuresis Oral hydration + DDAVP :Prevents diuresis Results in maternal plasma hypotonicity –- fetal plasma hypotonicity—increased fetal urine production—reduced fetal swallowing—increased AFI Results in maternal plasma hypotonicity –- fetal plasma hypotonicity—increased fetal urine production—reduced fetal swallowing—increased AFI 25

DDAVP : concerns Effect on maternal & fetal bld volume Effect on maternal & fetal bld volume Long term effects on AFI Long term effects on AFI Prophylactic or chronic use Prophylactic or chronic use Mask oligohydramnios ?? Mask oligohydramnios ?? 26

Therapeutic Interventions: Oligohydramnios

TREATMENT ACC. TO CAUSE Drug induced – OMIT DRUG Drug induced – OMIT DRUG PROM – INDUCTION PROM – INDUCTION PPROM – Antibiotics,steroid – Induction PPROM – Antibiotics,steroid – Induction FETAL SURGERY FETAL SURGERY VESICO AMNIOTIC SHUNT-PUV VESICO AMNIOTIC SHUNT-PUV Laser photocoagulation for TTTS Laser photocoagulation for TTTS 28

Posterior urethral valves Sonographic findings: Sonographic findings: Keyhole sign Keyhole sign

Posterior urethral valves Management: Management: Karyotyping Karyotyping Perform serial bladder drainage every 3-4 days Perform serial bladder drainage every 3-4 days Use sample of 3 rd drainage Use sample of 3 rd drainage Isotonic urine indicate poor function Isotonic urine indicate poor function

Posterior urethral valves Good prognostic biochemical markers: Good prognostic biochemical markers: Na < 100meq/L Na < 100meq/L Cl < 90meq/L Cl < 90meq/L Osmolarity <210mOsm/L Osmolarity <210mOsm/L B2 microglobulin < 4mg/L B2 microglobulin < 4mg/L Ca < 8mg/dl Ca < 8mg/dl Indication for vesico amniotic shunts Indication for vesico amniotic shunts

32