ABNORMALITIES OF

AMNIOTIC FLUID

Presented By ;
Ms. K.D. SHARON
Final Year MSc [N]
Obstetrics and Gynaecology nursing
 POLYHYDRAMINOS
Polyhydramnios is defined as a state where liquor amnii exceeds
2000ml. Clinical definition states that the excessive accumulation of
liquor amnii causing discomfort to the patient.

OR
Hydramnios is a condition in which there is overproduction of liquor
amni in the uterus surrounding the fetus.

[The normal amniotic fluid volume at term is 800-1,000 Ml. The

volume in polyhydramnios exceeds 2000 Ml between 32 and 36
weeks]
 Conti…

Incidence:
The incidence varies from 1-2% of the cases. It is more common among multipare
than the primi pare. While minor degrees of hydramnios are fairely common. It
occurs 1 in 1000 pregnancies.
 Causes of Polyhydramnios
Exact cause of the excess accumulation of the liquor is still speculative. It may be the
result of deficient absorption of as well as the excessive production of the liquor amnii.
While certain maternal or fetal factors are found to be associated with hydramnios, yet
the cause remains unknown in about 60%.
1. Fetal Anomalies

Congenital fetal malformations is associated with Polyhydramnios in about 20%

cases

a) Anencephaly
b) Open spina bifida

c) Esophageal or duodenal Artesia

d. Facial clefts and neck masses

e. Hydrops fetalis
f. Twin –to-Twin transfusion syndrome

2. Placental Factors

a. Chorioangioma of the placenta

3. Maternal Factors
b. Multiple pregnancies

c. Diabetes
d. Cardio or renal diseases
Clinical Types of Polyhydramnios
1. CHRONIC HYDRAMIOS
CHRONIC : It is the commonest onset is insidious taking few weeks.
In the majority of cases, the accumulation of liquor is gradual and as such, the
patient is not very much inconvenienced.

Symptoms :-
The symptoms are mainly from mechanical causes
 Respiratory : pt may suffer from dyspnea or even remain in the sitting position for
easier breathing.
 Palpitation : edema of the legs, varicosities in the legs or vulva and hemorrhoids.
Signs :-
 The patient may be dyspnea state in the lying down position.

 Evidence of pre-eclamsia (edema, hypertension and protenuria) may be present.

Abdominal Examination:
A. Inspection:
 Abdomen is markedly enlarged, looks globular with fullness at the flanks
 The skin is tense, shiny with large straiae.

B. Palpation
 Height of the uterus is more than the period of amenorrhea
 Girth of the abdomen round the umbilical is more than the normal.
 Fluid thrill can be elicited in all direction over the uterus
 Fetal parts cannot be well defined : also the presentation or the position: External
ballottement can be elicited more easily.
C. Auscultation
Fetal heart sound is not heard distinctly, although its presence can be picked up
Doppler Ultrasound.
D. 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
 Ultrasonography : Amniotic fluid is more than 25cm
 Radiography : Not commonly performed
 Blood : ABO and Rh grouping, post prandial sugar and if necessary glucose
tolerance test
 AMNIOCENTESIS: Amniotic fluid ; Estimation of alpha feto-protein which is
markedly elevated in the presence of a fetus with an open neural tube defect.
 NON-STRESS TEST: This test check how the baby’s heart rate reacts when baby
moves.
 Complications
The complications of hydramnios are grouped in to
1. Maternal : During pregnancy
 Pre-eclampsia
 Malprsentation
 Premature rupture of the membrane
 Preterm labor
 Accidental hemorrhage

During labor :
 Early rupture of the membrane
 Cord prolapse
 Uterine inertia
 Increased operative delivery due to Malpresentation
 Retained placenta, PPH and shock
During Puerperium :
 Sub involution
 Increased puerperial morbidity
 Blood loss

2. Fetal : There is increased Perinatal mortality to the extent of about 50%. The
deaths are mostly due to prematurity and congenital abnormality (20%). Other
contributory fcators are cord prolapse, Hydrops fetalis, effects of increased operative
delivery and accidental hemorrhage.
MEDICAL MANAGEMENT
Monitor fluid levels
Remove excess amniotic fluid
Administer Indomethacin-decreases fetal urinary
output.
 Management :
Management of hydramnios is determined by the obstetrician based on :
 Overall health, medical history, and condition of the mother
 The mothers tolerance to specific medications and procedures or therapies
 Expectation for the course of the condition
 Patient preferences

The main aim of treatment for hydramnios may include the following:
 Closely monitoring the amount of amniotic fluid and frequent follow-up visits to the
obstetrician
 Medication (to decrease fetal urine production)
 Amniocentesis to remove the amniotic fluid 500-1000 mL withdrawn at a time; this
procedure may need to be repeated
 If the complications adversely affect the lives of the mother and fetus, delivery is
planned if necessary.
Minor degree hydramnios :

It is commonly found in midtrimister and usualyy requires no treatment except extra

bed rest for a few days. The excess liquor is expected to be diminished as
pregnanacy advances.

 Severe degree hydramnios :

In view of the risks involved and high perinatal mortality rate, the patient should be
shifted in a hospital equipped to deal with ‘high risk’ patients.
Supportive Therapy:
Bed rest, treatment associate with condition like pre-eclampsia

Investigation are done to exclude congenital fetal malformation

Further management depends on

o Response to treatment

o Period of gestation

o Presence of fetal malformation

o Associated complicating factors

Response to treatment is good means pregnacy is continued

Unresponsive

a) Pregnancy less than 37 weeks- amniocentesis

b)Pregnancy more than 37 weeks- induction of labor is done

 Amniocentesis, termination of pregnancy.
During labour:
Usual management is followed. If the uterine contractions become sluggish,
oxytocin infusion may be started . To prevent PPH, IV administration of methargin.
 MANAGEMENT OF POLYHYDRAMNIOS
 Hospitalization
 Post pandrial blood glucose
 ABO AND Rh grouping
 USG

No fetal abnormality
Fetal abnormality

Response to treatment Maternal distress Termination of pregnancy

Continuing the pregnancy irrespective of gestation
Managing the complicating
factors Cervical ripening and AROM
Less than 37 weeks More than 37 weeks

Amnio reduction Amnioreduction

[may be repeatedly needed]
Stabilizing with oxytocin drip
ARM
 2.ACUTE POLYHYDRAMNIOS
Acute hydramnios is extremely a rare condition where it is acute in onset and the
fluid accumulates within a few days. It usually occurs before 20 weeks of pregnancy.
It is usually associated with uniovular twins or chorioanzioma of the placenta.

Symptoms : Features of acute abdomen predominate such as abdominal pain, nausea

and vomiting.

Signs : Edema of the legs, absence of the features of shock, fetal parts cannot be felt,
fluid thrill.Internal examination reveals that taking up of the cervix or even
dilatation of the OS through which the bulged membrane are felt. Sonography
fetal anomaly present.
TREATMENT
Spontaneous abortion occurs most often. To
relieve the distress, decompression has to be done.
 On the rare occasion where the baby especially
valuable, repeated amniocentesis have to be done
to continue the pregnancy.
Of course, foetal congenital anomalies are to be
excluded. Otherwise pregnancy is terminated by
low rupture of membrane.
NURSING MANAGEMENT
1. Monitor for abdominal pain, dyspnea, uterine contractions
and oedmea of the lower extremities
2. Due to over extension of the uterus educate the mother
about the signs & symptoms of preterm labor.
3. Monitor foetal well being
4. Care full monitoring of mothers well being
5. Assist in procedure such as amniocentesis
6. Consent to be taken.
7. Provide bed rest
8. Monitor blood sugars and vital signs.etc
 OLiGOHYDRAMNIOS
Olygohydramnios is a condition in pregnancy characterized by a deficiency of
amniotic fluid. It is almost invariably associated with Potter’s syndrome.

 Definition:-

Olygohydramnios is a extremely a rare condition where the liquor amni is

deficient in amount to the extent of less than 200 mL at term.

OR
Olygohydramnios is an abnormally small amount of amniotic fluid around 300-500
mL at term.
Causes/ Etiology
1. Chromosomal abnormalities

2. PROM
3. Uteroplacental insufficiency

4. Renal Agenesis
5. Multicystic or polycystic kidney diseases

6. Urethral obstruction
7. Intrauterine obstruction

8. Amnion Nodosom

9. Post maturity
Amnion nodosum are nodules found on the fetal surface of the amnion,
and is frequently present in oligohydramnios.
 Diagnostic Evaluation
1. History collection

2. Clinical examination

3. Abdominal examination Includes:

a. Inspection: The uterine size is smaller than the period of amenorrhea

b. Palpation:
 Fundal height is less

Fetal parts can be easily palpated because the uterus is full of fetus seconadry to

less of A/F
Parts can be seen and also its movements.
 C.Auscultation : If the fetus is aloive FHS can be easily heard.

4. USG
 Malpresentaions are common

Evidence of IUGR

Amniotic fluid is very less i.e. less than 5 cm

Detection of dilated bladder in case of urethral obstruction and multicystic

kidney renal diseases.

Complications of Oligohydramnios
Management of Oligohydramnios
Conti…..
 Mother with oligohydramnios must be admitted to the hospital

 Careful questioning of women to be done to check the possibility of PROM

 As per USG reports if the renal agenesis is found then the baby will not be survived

 Amnioinfusion with normal saline or RL may be given in order to prevent

compression and increase the amount of A/F

 Labor may be induced because of placental insufficiency

 Profilactic antibiotics has to be given in case of PROM

 If possible vaginal delivery can be conducted

 Paediatrician should be present during the birth of baby to undertake initial

examination and observe for any deformities.

NURSING RESPONSIBILITIES
1. Monitor Foetal well being.
2. Educate mother about positions that will encourage
the best blood flow to the foetus
3. Assist with amnion Infusion.
4. Asses foetal well being especially heart rate.
5. Monitor vital signs of mother
6. Provide bed rest especially side laterals.
7. Assist in procedure such as amnio-infusion. Etc.
SUMMARY.............................

BIBLIOGRAPHY
HiralalKonar. DC Dutta’s Textbook of Obstetrics AYPEE BROTHERS
MEDICAL PUBLISHERS private limited 9THedition, 2019.
Annamma Jacob. A COMPREHENSIVE TEXTBOOK OF
MIDWIFERY AND GYNECOLOGICAL NURSING JAYPEE BROTHERS
MEDICAL PUBLISHERS private limited 5THedition, 2019.
Nima Bhaskar.Text book of Midwifery & Obstetrical Nursing,
EMMESS Medical Publishers, First Edition, 2012.

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