OLIGOHYDRAMNIOS

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OLIGOHYDRAMNIOS
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PHYSIOLOGY OF AMNIOTIC FLUID
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• INFLOW
• (1000 ml/d)
• 1.FETAL URINE
• 2.LUNG LIQUID
• INTRAMEMBRANOUS (placenta,cord)
• TRANSMEMBRANOUS(amniotic membranes)
• RECYCLING 3hrs

• OUTFLOW
• (1000 ml/d)
• 1.FETAL SWALLOWING

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Amniotic fluid volume

• 8 weeks 15 ml,increases 10 ml/wk
• 17 wks 250 ml ,increases 50 ml/wk
• 28-38 wks 750-1000ml (decreases after 34 wks)
• 42 wkslt500ml

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FUNCTIONS OF AMNIOTIC FLUID

• Shock absorber protects from external trauma.
• Protects cord from compression.
• Permits fetal movements development of
  musculoskeletal system, prevents adhesions.
• Swallowing of AF enhances growth development of
  GIT.
• AF volume maintains AF pressure reduces loss of
  lung liquid pulmonary development.
• Maintenance of fetal body temperature.
• Some fetal nutrition, water supply.
• Bacteriostatic properties decreases potential
  for infection

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DEFINITION

• AMNIOTIC FLUID VOLUME lt 5 th percentile for
  gestational age
• AMNIOTIC FLUID INDEX lt 5
• SINGLE VERTICAL POCKET lt 2 cms
• Amniotic fluid volume of less than 500 mL at
  32-36 weeks' gestation

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INCIDENCE

• 0.5 5

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AETIOLOGY

• FETAL
• PROM (50)
• CHROMOSOMAL ANOMALIES
• CONGENITAL ANOMALIES
• IUGR
• IUFD
• POSTTERM PREGNANCY

• MATERNAL
• PREECLAMPSIA
• APLA SYNDROME
• CHRONIC HT

• DRUGS
• PG SYNTHETASE INHIBITORS
• ACE INHIBITORS
• IDIOPATHIC

• PLACENTAL
• CHRONIC ABRUPTION
• TTTS
• CVS

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DIAGNOSIS

• SYMPTOMS
• NO SPECIFIC SYMPTOMS
• H/O leaking p/v
• Postterm
• s/o preeclampsia
• Drugs
• Less fetal movements

• SIGNS
• Uterus small for date
• Feels full of fetus
• Malpresentations
• IUGR

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USG

• METHODS
• MVP lt2 cms
• (lt1 severe)
• AFI lt5 cms
• (5-8 borderline)
• 2D pocket lt15 sq cms

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Technique of AFI

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

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• 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.
• 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

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COMPLICATIONS

• FETAL
• Abortion
• Prematurity
• IUFD
• 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)

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MANAGEMENT

• DEPENDS UPON
• AETIOLOGY
• GESTATIONAL AGE
• SEVERITY
• FETAL STATUS WELL BEING

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DETERMINE AETIOLOGY

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

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Techniques for Monitoring

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

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TREATMENT

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

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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.

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

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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.

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DDAVP

• Oral hydration DDAVP Prevents diuresis
• Results in maternal plasma hypotonicity -fetal
  plasma hypotonicityincreased fetal urine
  productionreduced fetal swallowingincreased AFI

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DDAVP concerns

• Effect on maternal fetal bld volume
• Long term effects on AFI
• Prophylactic or chronic use
• Mask oligohydramnios ??

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Therapeutic Interventions Oligohydramnios
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TREATMENT ACC. TO CAUSE

• Drug induced OMIT DRUG
• PROM INDUCTION
• PPROM Antibiotics,steroid Induction
• FETAL SURGERY
• VESICO AMNIOTIC SHUNT-PUV
• Laser photocoagulation for TTTS

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Posterior urethral valves

• Sonographic findings
• Keyhole sign

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Posterior urethral valves

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

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Posterior urethral valves

• Good prognostic biochemical markers
• Na lt 100meq/L
• Cl lt 90meq/L
• Osmolarity lt210mOsm/L
• B2 microglobulin lt 4mg/L
• Ca lt 8mg/dl
• Indication for vesico amniotic shunts

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