Oligohydramnios: DR Mona Shroff WWW - Obgyntoday.info

OLIGOHYDRAMNIOS
Dr Mona Shroff *
www.obgyntoday.info
PHYSIOLOGY OF AMNIOTIC
FLUID
*
INFLOW OUTFLOW
(1000 ml/d) (1000 ml/d)
1.FETAL URINE 1.FETAL

SWALLOWING
2.LUNG LIQUID
INTRAMEMBRANOUS (placenta,cord)
TRANSMEMBRANOUS(amniotic membranes)
RECYCLING – 3hrs
Dr Mona Shroff *
www.obgyntoday.info
*
Dr Mona Shroff
Dr Mona Shroff
www.obgyntoday.info
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<500ml
Dr Mona Shroff *
www.obgyntoday.info
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
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
Dr Mona Shroff *
Dr Mona Shroff
www.obgyntoday.info
INCIDENCE
0.5 – 5%
Dr Mona Shroff *
Dr Mona Shroff
www.obgyntoday.info
AETIOLOGY
FETAL
● PROM (50%)
MATERNAL
● CHROMOSOMAL ANOMALIES ● PREECLAMPSIA
● CONGENITAL ANOMALIES ● APLA SYNDROME
● CHRONIC HT
● IUGR
● IUFD
● POSTTERM PREGNANCY DRUGS
● PG SYNTHETASE
INHIBITORS
PLACENTAL
● ACE INHIBITORS
● CHRONIC ABRUPTION
TTTS
IDIOPATHIC
●
● CVS
*
Dr Mona Shroff Dr Mona Shroff
www.obgyntoday.info
www.obgyntoday.info
DIAGNOSIS
SYMPTOMS SIGNS
NO SPECIFIC Uterus – small for
SYMPTOMS date
H/O leaking p/v Feels full of fetus
Postterm Malpresentations
s/o preeclampsia IUGR
Drugs
Less fetal movements
Dr Mona Shroff *
Dr Mona Shroff
www.obgyntoday.info
USG
METHODS
MVP <2 cms

(<1 severe)
AFI <5 cms

(5-8 borderline)
2D pocket <15 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
Dr Mona Shroff *
Dr Mona Shroff
www.obgyntoday.info
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 *
Dr Mona Shroff
www.obgyntoday.info
COMPLICATIONS
FETAL MATERNAL
Abortion
Increased morbidity
Prematurity
IUFD Prolonged labour:
uterine inertia
Deformities –
CTEV,contractures,amputation Increased operative
Potters syndrome- pulmonary intervention
hypoplasia (malformations,
distres)
Malpresentations
Fetal distress
MSAF – MAS
Low APGAR Dr Mona Shroff *
Dr Mona Shroff
www.obgyntoday.info
MANAGEMENT
DEPENDS UPON
● AETIOLOGY
● GESTATIONAL AGE
● SEVERITY
● FETAL STATUS & WELL BEING
Dr Mona Shroff *
Dr Mona Shroff
www.obgyntoday.info
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 *
Dr Mona Shroff
www.obgyntoday.info
Dr Mona Shroff *
www.obgyntoday.info
Dr Mona Shroff
Techniques for Monitoring
● Single pocket without cord
● AFI = sum of deepest pocket in each of 4 quadrants without
cord
● 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
● 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
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 *
Dr Mona Shroff
www.obgyntoday.info
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.
● 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 *
Dr Mona Shroff
www.obgyntoday.info
●
● 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 .

● 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 *
Dr Mona Shroff
www.obgyntoday.info
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 *
Dr Mona Shroff
www.obgyntoday.info
DDAVP : concerns
● Effect on maternal & fetal bld

volume
● Long term effects on AFI
● Prophylactic or chronic use
● Mask oligohydramnios ??
Dr Mona Shroff *
Dr Mona Shroff
www.obgyntoday.info
Therapeutic Interventions:
Oligohydramnios
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 *
Dr Mona Shroff
www.obgyntoday.info
Posterior urethral valves
● Sonographic findings:
● Keyhole sign
● Management:
● Karyotyping
● Perform serial bladder drainage every 3-4
days
● Use sample of 3rd drainage
● Isotonic urine indicate poor function
● 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
*
www.obgyntoday.info
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OLIGOHYDRAMNIOS

1.FETAL URINE 1.FETAL

●8 weeks : 15 ml,increases 10 ml/wk

● AMNIOTIC FLUID INDEX < 5

● SINGLE VERTICAL POCKET < 2 cms

● Amniotic fluid volume of less than 500 mL at

MVP <2 cms

AFI <5 cms

2D pocket <15 sq cms

● The single deepest vertical pocket measurement in

● R/O PROM, h/o medical illness

● Modified BPP = NST, +/- acoustic stimulation, AFI

labour. Cochrane Database of Systematic Reviews 1996,Issue 1 .

● Oral hydration + DDAVP :Prevents diuresis

● Effect on maternal & fetal bld

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