Oligohydramnios
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OLIGOHYDRAMNIOS
*Dr Mona Shroff
www.obgyntoday.info
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PHYSIOLOGY OF AMNIOTIC FLUID
*
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INFLOW (1000 ml/d)
1.FETAL URINE2.LUNG LIQUID
INTRAMEMBRANOUS (placenta,cord) TRANSMEMBRANOUS(amniotic
membranes) RECYCLING – 3hrs
OUTFLOW (1000 ml/d)
1.FETAL SWALLOWING
*Dr Mona Shroff
www.obgyntoday.info
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Dr Mona Shroff www.obgyntoday.info
*
Dr Mona Shroff www.obgyntoday.info
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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 wks<500mlDr Mona Shroff
www.obgyntoday.info
*
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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 *Dr Mona Shroff
www.obgyntoday.info
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DEFINITION● AMNIOTIC FLUID VOLUME < 5 th
percentile for gestational age
● AMNIOTIC FLUID INDEX < 5
● SINGLE VERTICAL POCKET < 2 cms
● Amniotic fluid volume of less than 500 mL at 32-36 weeks' gestation
*Dr Mona Shroff
www.obgyntoday.info
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Dr Mona Shroff
www.obgyntoday.info
*
Dr Mona Shroff www.obgyntoday.info
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INCIDENCE
0.5 – 5%
*Dr Mona Shroff
www.obgyntoday.infoDr Mona Shroff www.obgyntoday.info
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AETIOLOGYFETAL● PROM (50%)● CHROMOSOMAL ANOMALIES● CONGENITAL ANOMALIES● IUGR● IUFD● POSTTERM PREGNANCY
MATERNAL● PREECLAMPSIA● APLA SYNDROME● CHRONIC HT
PLACENTAL● CHRONIC ABRUPTION● TTTS● CVS
DRUGS● PG SYNTHETASE INHIBITORS● ACE INHIBITORS
IDIOPATHIC
*Dr Mona Shroff
www.obgyntoday.info
Dr Mona Shroff www.obgyntoday.info
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DIAGNOSIS
SYMPTOMSNO SPECIFIC
SYMPTOMS
H/O leaking p/vPostterms/o preeclampsiaDrugsLess fetal movements
SIGNSUterus – small for
dateFeels full of fetusMalpresentationsIUGR
*Dr Mona Shroff
www.obgyntoday.infoDr Mona Shroff www.obgyntoday.info
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USGMETHODS MVP <2 cms (<1 severe)
AFI <5 cms (5-8
borderline)
2D pocket <15 sq cms
*Dr Mona Shroff
www.obgyntoday.info
Dr Mona Shroff www.obgyntoday.info
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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
Dr Mona Shroff
www.obgyntoday.info
*
Dr Mona Shroff www.obgyntoday.info
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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
Dr Mona Shroff
www.obgyntoday.info
*
Dr Mona Shroff www.obgyntoday.info
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COMPLICATIONS FETALAbortionPrematurityIUFDDeformities –
CTEV,contractures,amputation
Potters syndrome- pulmonary hypoplasia
MalpresentationsFetal distressMSAF – MASLow APGAR
MATERNAL
Increased morbidity
Prolonged labour: uterine inertia
Increased operative intervention
(malformations,distres)
*Dr Mona Shroff
www.obgyntoday.infoDr Mona Shroff www.obgyntoday.info
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MANAGEMENT
DEPENDS UPON
● AETIOLOGY● GESTATIONAL AGE● SEVERITY● FETAL STATUS & WELL BEING
*Dr Mona Shroff
www.obgyntoday.infoDr Mona Shroff www.obgyntoday.info
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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
*Dr Mona Shroff
www.obgyntoday.infoDr Mona Shroff www.obgyntoday.info
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Dr Mona Shroff www.obgyntoday.info
*
Dr Mona Shroff www.obgyntoday.info
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Techniques for Monitoring● Single pocket without cord● AFI = sum of deepest pocket in each of 4 quadrants without
cord● BPP =
1. NST2. breathing 30sec in 30min3. move 3 limb/body in 30min4. extension of extremity with flexion or open/close hand5. 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 > 5 ok● AFI < 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
*Dr Mona Shroff
www.obgyntoday.infoDr Mona Shroff www.obgyntoday.info
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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.
Dr Mona Shroff
www.obgyntoday.info
*
Dr Mona Shroff www.obgyntoday.info
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●AMNIOINFUSION
INDICATIONS 1.Diagnostic 2.Prophylactic 3.Therapeutic Decreases cord
compression Dilutes meconium
*Dr Mona Shroff
www.obgyntoday.info
Dr Mona Shroff www.obgyntoday.info
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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.
Dr Mona Shroff
www.obgyntoday.info
*
Dr Mona Shroff www.obgyntoday.info
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DDAVP
● Oral hydration + DDAVP :Prevents diuresis
● Results in maternal plasma hypotonicity –-fetal plasma hypotonicity—increased fetal urine production—reduced fetal swallowing—increased AFI
Dr Mona Shroff
www.obgyntoday.info
*
Dr Mona Shroff www.obgyntoday.info
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DDAVP : concerns
●Effect on maternal & fetal bld volume
●Long term effects on AFI●Prophylactic or chronic use●Mask oligohydramnios ??
Dr Mona Shroff
www.obgyntoday.info
*
Dr Mona Shroff www.obgyntoday.info
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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
*Dr Mona Shroff
www.obgyntoday.infoDr Mona Shroff www.obgyntoday.info
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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 < 100meq/L●Cl < 90meq/L●Osmolarity <210mOsm/L ●B2 microglobulin < 4mg/L●Ca < 8mg/dl
● Indication for vesico amniotic shunts
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*Dr Mona Shroff www.obgyntoday.infoDr Mona Shroff
www.obgyntoday.info