AMNIOTIC FLUID

DISORDERS

BY
R. LIANGKIUWILIU
MSC OBG
 POLYHYDRAMNIOS
(Syn: Hydramnios)
DEFINITION: Anatomically, polyhydramnios
is defined as a state where liquor amnii
exceeds 2,000 mL.
 Sonographic diagnosis is made when

amniotic fluid index (AFI) is more than 24

cm (more than 95th percentile for
gestational age) and a deepest vertical
pocket (DVP) is more than 8 cm.
 INCIDENCE
 the incidence varies from 1–2% of cases.
 It is more common in multiparae than
primigravidae.
 ETIOLOGY
i. FETAL ANOMALIES: Congenital fetal
malformations are associated with
polyhydramnios in about 20% cases.
ii. PLACENTA: Chorioangioma of the placenta
iii. MULTIPLE PREGNANCY: more common
in monozygotic twins.
iv. MATERNAL: Diabetes, Cardiac or renal
disease
v. IDIOPATHIC: 50–60%
 Clinical types of polyhydramnios
(a) Chronic (most common)—onset is gradually
taking few weeks. (10 time more than acute)
(b) Acute (extremely rare)—onset is sudden,
within few days or may appear acutely on
pre-existing chronic variety.
Polyhydramnios may be—
(a) mild: DVP more than 8–11 cm
(b) moderate: DVP: 12–15 cm and
(c) severe: DVP more than or equal to 16 cm.
 CHRONIC POLYDRAMNIOS
SYMPTOMS:
 Respiratory— 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:
 dyspneic state in the lying down position.
 Evidence of preeclampsia (Oedema,

hypertension and proteinuria)

ABDOMINAL EXAMINATION
 Inspection:

-Abdomen is markedly enlarged,

-The skin is tense, shiny with large striae.
 Palpation:

-Height of the uterus is more than the period of

amenorrhea.
-Girth of the abdomen is more than normal
-Fluid thrill can be elicited in all directions over
the uterus -Fetal parts cannot be well-defined
 Auscultation:

-Fetal heart sound is not heard

 INVESTIGATIONS
1) Sonography: Sonography is helpful
-(1) to detect abnormally large echo-free space between the fetus
and the uterine wall , (AFI) is more than 25cm,
- (2) to exclude multiple fetuses,
- (3) to note the lie and presentation of the fetus,
-(4) to diagnose any fetal congenital malformation.
2) Blood: -(1) ABO and Rh grouping — Rhesus isoimmunization
may cause hydrops fetalis and fetal ascites.
- (2) Postprandial sugar and if necessary glucose tolerance test.
3) Amniotic fluid: Estimation of alpha fetoprotein which is
markedly elevated in the presence of a fetus with an open neural
tube defect.
 DIFFERENTIAL DIAGNOSIS
(1) Twins
(2) Pregnancy with huge ovarian cyst
(3) Maternal ascites.
The complications of hydramnios are grouped into:
 Maternal:

-During pregnancy— Preeclampsia (25%),

Malpresentation, Premature rupture of the
membranes, Preterm labor, Accidental
hemorrhage
-During labor: - Early rupture of the membranes,
Cord prolapse, Increased operative delivery due
to malpresentation, Retained placenta,
postpartum hemorrhage and shock due to uterine
atony.
-Puerperium:- Subinvolution, Increased
puerperal morbidity
Conti….
Fetal:
 There is increased perinatal mortality to the

extent of about 50%.

 The deaths are mostly due to prematurity

and congenital abnormality (40%).

 Other contributing factors are cord

prolapse, hydrops fetalis, effects of increased

operative delivery and accidental
hemorrhage.
 MANAGEMENT
MILD POLYHYDRAMNIOS (DVP: 8–11
cm):
 It is commonly found in midtrimester and

usually requires no treatment, except extra

bed rest for a few days.
 The excess liquor is expected to be

diminished as pregnancy advances

(transient).
SEVERE POLYHYDRAMNIOS (DVP: ≥16
cm):
 the patient should be shifted in a hospital

equipped to deal with “high-risk” patients.

 Principles:

(1) To relieve the symptoms

(2) To find out the cause
(3) To avoid and to deal with the
complication.
 Supportive therapy:
-includes bed rest, if necessary, with a back
rest
-treatment of the associated conditions like
preeclampsia or diabetes on the usual line.
The use of diuretic is of little value.
-Sulindac (COX-2 inhibitor), 200 mg every
12 hours, (under supervision). It has been
found to decrease amniotic fluid as it
reduces fetal urine output.
 ACUTE POLYHYDRAMNIOS

 Acute hydramnios is extremely rare. The

onset is acute and the fluid accumulates
within a few days.
 It usually occurs before 20 weeks of
pregnancy.
 It is usually associated with monozygotic
twins with TTTS or chorioangioma of the
placenta.
 SYMPTOMS: Features of acute abdomen predominate
—such as abdominal pain, nausea and vomiting.
 SIGNS:
(i) The patient looks ill
(ii) Absence of features of shock
(iii) Edema of the legs
(iv) Abdomen is hugely enlarged
(v) Fluid thrill is present
(vi) Fetal parts cannot be felt nor is the fetal heart
sound audible
(vii) Internal examination reveals—taking up of the
cervix or even dilatation of the os through which the
bulged membranes are felt
(viii) Sonography shows multiple fetuses or at times
fetal abnormalities.
TREATMENT: Most often, spontaneous
abortion occurs.
 In case with severe TTTS, repetitive amnio-

reduction until the AFI is normal, may

improve the perinatal outcome.
 Laser ablation may cure the cause of TTTS

whereas amnio-reduction only treats the

symptoms
 OLIGOHYDRAMNIOS
DEFINITION: It is an extremely rare
condition where the liquor amnii is deficient
in amount to the extent of less than 200 mL
at term.
Sonographically, it is defined when the
maximum vertical pocket of liquor is less
than <2 cm or when amniotic fluid index
(AFI) is less than 5 cm (less than 5
percentile).
 ETIOLOGY
A. Fetal conditions:
(i) Renal agenesis
(ii) Obstructed uropathy
(iii) Spontaneous rupture of the membrane
(iv) Intrauterine infection
(v) Postmaturity
(vi) IUGR
(vii) Amnion nodosum
B. Maternal conditions:
(i) Hypertensive disorders
(ii) Uteroplacental insufficiency
(iii) Dehydration
(iv) Idiopathic.
 DIAGNOSIS
(1) Uterine size is much smaller than the period of amenorrhea
(2) Less fetal movements
(3) The uterus is “full of fetus” because of scanty liquor
(4) Malpresentation (breech) is common
(5) Evidences of intrauterine growth retardation of the fetus
(6) Sonographic diagnosis is made when largest liquor pool is
less than 2 cm. Ultrasound visualization is done following
amnioinfusion of 300 mL of warm saline solution
(7) Visualization of normal filling and emptying of fetal
bladder essentially rules out urinary tract abnormality.
(8) Oligohydramnios with fetal symmetric growth restriction is
associated with increased chromosomal abnormality
 COMPLICATIONS
Fetal:
(1) Abortion
(2) Deformity due to intra-amniotic
adhesions or due to compression.
(3) Fetal pulmonary hypoplasia
(4) Cord compression
(5) High fetal mortality.
Maternal:
(1) Prolonged labor due to inertia
(2) Increased operative interference
 TREATMENT
 Presence of fetal congenital malformation needs
referral to a fetal medicine unit.
 When decision for delivery is made, it should be
done irrespective of the period of gestation.
 Isolated oligohydramnios in the third trimester with
a normal fetus may be managed conservatively.
 Oral administration of water increases amniotic
fluid volume. In labor, cord compression is common.
 Amnioinfusion (prophylactic or therapeutic) for
meconium liquor is found to improve neonatal
outcome.