Amniotic Fluid

OLIGOHYDRAM NIOS Presented By
Doctor Sana Rabbani

POLYHYDRAM NIOS Gynae Trainee Registrar
CONTENTS
• Aminotic Fluid • Management

• Aminotic Fluid Formation • Polyhydramnios
• Aminotic Fluid Functions • Causes
• Aminotic Fluid Abnormalities • Complications
• Oligo Hydramnios • Management
• Causes
AMNIOT IC F L U ID F OR M
AT ION
• Amniotic fluid is chiefly fetal in origin with small

contribution from mother.
It arises from
• Ultra filtration of maternal plasma through
vascularized uterine decidua (early Pregnancy).
• Transudation of fetal plasma through fetal skin and
umbilical cord (up to 20 weeks gestation).
AMNIOT IC F L U ID VOL U
ME
• About 500mls enter and leave the amniotic sac
each hour.
• Gradual ↑ up to 36 weeks to around 600 to 1000ml
than ↓ after that.
• The normal range is wide but the approximate
volumes are:
- 500ml at 18 weeks
- 800ml at 34 weeks
- 600ml at term
FUNCTIONS OF AMNIOTIC FLUID
• Allows room for fetal growth, movement &
development.
• Acts as a causation & prevents fetus from trauma.
• Prevents adhesion formation between fetus and
amnion.
• Contains anti bacterial activity.
• Maintains temperature.
• Aids dilatation of cx during labor.
AMNIOTIC FLUID VOLUME ASSESSMENT
• Clinical assessment is
unreliable.
• Objective assessment
depends on U/S to measure:
Deepest vertical pool (DVP)
&
Amniotic fluid index (AFI)
DVP:
It is performed by assessing pocket of maximal depth
of amniotic fluid which is free of an umbilical cord
& fetal parts.
Measurement – 2- 8cm- normal.
<2cm – oligohydramnios
> 8cm – Polyhydramnios
AFI:
Is measured by dividing uterus into four
ultrasound quadrants, it is more sensitive
indicator of AFV throughout pregnancy.
AMNIOTIC FLUID ABNORMALITIES
▪ Oligohydramnios:
It is defined as reduced amniotic fluid i.e. amniotic
fluid index of 5cm or less or the deepest vertical pool <
2cm.
▪ Polyhydramnios:
It is defined as excessive amount of amniotic fluid of
2000 ml or more
AFI of > 25 cm or the deepest vertical pool of > 8cm
OLIGOHYDRAMNIOS
NOT ENOUGH FLUID
AROUND FETUS
CAUSES OF OLIGOHYDRAMNIOS
A.Reduced production of liquor
1. Intrauterine growth restriction
2. Prolonged Pregnancy
3. Fetal Abnormality
i. Renal agenesis/dysplasia
ii. Polycystic/multi cystic kidney
iii. Urethral Obstruction
4. Maternal drugs (NSAIDs)
B.Continuous drainage of liquor
1. Prelabour rupture of membranes
C.Idiopathic
COMPLICATIONS OF OLIGOHYDRAMNIOS
In early pregnancy:
Amniotic adhesions or bands → amputations/death
Pressure deformities(club feet)
Pulmonary hypoplasia:
□ Thoracic compression
□ No breathing movements
□ No amniotic fluid retain
Flattened face
Postural deformities
In late pregnancy:
Fetal growth restriction
Placental abruption
Preterm labour
Fetal distress
Fetal death
Meconium
aspiration
Labour and
induction/c
section
MANAGEMENT OF OLIGOHYDRAMNIOS
1.HISTORY
• Age of pt.
• LMP
• Nutritional status
• Hx of anemia
• Past and family history of renal diseases.
• Hx of IUGR
• Hx of HTN
• Hx of DM
• Hx of any congenital malformation in previous pregnancies .
GPE:
EXAMINATION
BP, pulse, temp, height, weight, signs of malnutrition, pallor.
ABDOMINAL EXAMINATION:
Ut size is smaller than expected for gestation.
Liquor volume assessment
Fetus is in attitude of hyperflexion
Symphisio fundal height
Fetal lie and presentation
PER SPECULUM EXAMINATION:

when there is doubt of rupture of membranes, otherwise
pelvic interference is unnecessary.
INVESTIGATIONS
▪ Ultrasound
▪ FBC
▪ OGTT
▪ Fetal karyotyping
▪ Maternal renal functions test
TREATMENT
CONSERVATIVE MANAGEMENT:
Prolong pregnancy as closer to term as possible when there is no risk factor
To prevent the baby from sudden IUFD, pt should remain admitted in
hospital until delivery
Cause of oligohydramnios should be identified and treated
Monitoring of baby daily CTG + ultrasound +BPP and Doppler twice a weak
DELIVERY:
indications for normal delivery
▪ Grossly malformed baby
▪ IUD
▪ Prolonged pregnancy
▪ IUGR
▪ Chorioamnionitis (rupture membranes)
POLYHYDRAMNIOS
Defined as excessive
amount of amniotic
fluid of 2000ml or more.
AFI of > 25cm or

deepest vertical pool of
>8cm
CAUSES OF POLYHYDRAMNIOS
• A. POOR DISPOSAL (IMPAIRED Compression from outside:
OF SWALLOWING)
Diaphragmatic hernia
• 1. NEUROLOGICAL IMPAIRMENTS
OF SWALLOWING pharyngeal or esophageal tumors
▪ CNS LESIONS EG;ANENCEPHALY Hypertension of the head
▪ CHROMOSOMAL ABNORMALITIES
EG;TRISOMY 18
▪ MUSCULAR DYSTROPHIES B. Over production
1.Fetal polyuria
• 2. MECHANICAL OBSTRUCTION OF GIT
Maternal diabetes
• FROM WITHIN: mellitus
Twin to twin transfusion syndrome
OESOPHAGEAL ATRESIA
Fetal diabetes insipidus
DUODENAL ATRESIA
Barter syndrome
2. High output cardiac failure
CLASSIFICATIONS OF POLYHYDRAMNIOS
Mild: a pocket of amniotic fluid measuring 8-12cm

(80%)
Moderate: a pocket of amniotic fluid measuring

12-15cm(15%)
Severe: a pocket of amniotic fluid measuring more

than 15cm.(5%)
COMPLICATIONS OF
POLYHYDRAMNIOS
Maternal risk: Fetal risk:

□ Dyspnea
□ Abdominal pain □ Fetal prognosis worsens with
more severe hydramnios and
□ Venous stasis congenital anomalies
□ Contractions leading preterm □ □ 15-20% fetal
labour
□ Decreased perception of fetal malformations
movements □ Preterm delivery
□ Placental abruption □ Suspect diabetes
□ Postpartum hemorrhage □ Prolapse of cord
□ Malpresentationleading to c
section
MANAGEMENT OF
POLYHYDRAMNIOS
1. history:
▪ Age
▪ LMP
▪ Blood group of both partners
▪ Cousin marriage
▪ Past and family history of diabetes
▪ Twin gestation
▪ Hx of any congenital malformation
CONT:-
2. Examination GPE:
BP, pulse, temp, height, weight,
pallor, legs for any varicosities
ABDOMINAL EXAMINATION:
• Skin stretched and shiny
• Ut globular and tense
• FH is larger than duration of gestation
• Fetal malpresentation
• Fluid thrill may also be present
• FHS not audible
INVESTIGATIONS
• Ultrasound
• FBC
• Blood group and Rh factor
• RBS(OGTT)
• Viral antibody titer
• Fetal karyotyping
TREATMENT
Minor degree:
No treatment
Ultrasound on every visit for measurement of liquor volume
Assessment of fetal condition
Moderate to severe degree:

Admit the pt
Should be in prop up and left lateral position
Ultrasound and BPP should be performed at regular intervals
Dietray restriction of salt and fluid
SPECIFIC THERAPIES
1. DRUGS
A. Indomethacin:
Is a prostaglandin synthetase inhibitor
Dose 50 – 200mg/ day
It normalizes amniotic fluid volume with 4-20days through reduction in fetal urine
output It should not be given after 32wks of gestation
COMPLICATION OF INDOMETHACIN:
Preterm closure of ductus arteriosus
Cerebral vasoconstriction
Renal function impairment
necrotizing enterocolitis
Intracranial hemorrhage in fetus
CONT:-
B. Sulindic
Prostaglandin synthetize inhibitor
Dose 200mg every 12hrly
It reduces amniotic fluid volume effectively
No evidence of complications have been noted
CONT:-
2. Therapeutic amniocentesis(amnioreduction)
Removing small amount of amniotic fluid with help of needle for the
relieve of discomfort to mother.
20-22G spinal needle is inserted into amniotic cavity through
abdominal wall under ultrasound guidance after administration of
local anesthesia
About 5-10litres of fluid can be removed
Complications:
• Rupture Membrane
• Chorioamnionitis
• Placental Abruption
• Pre Term Labor
Amnioreduction though risky and provides short term relief may help in
prolongation of pregnancy when performed repeatedly
CONT:-
3. TIME OF DELIVERY:
Delivery is indicated once maturity is reached

CONT:
4. MODE OF DELIVERY:
• Vaginal delivery
• C section when polyhydramnios is associated
with obstetrical complications
• Labour should be closely monitored and one must
have low threshold for c section during labour
• Pediatrician should be present and time of delivery
for examination of baby
• Baby should be kept under observation for 48hrs
• During discharge pt should be counselled
regarding recurrence of polyhydramnios and
need early booking in next pregnancy

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OLIGOHYDRAM NIOS Presented By

Doctor Sana Rabbani

• Aminotic Fluid • Management

• Amniotic ﬂuid is chieﬂy fetal in origin with small

PER SPECULUM EXAMINATION:

AFI of > 25cm or

Mild: a pocket of amniotic ﬂuid measuring 8-12cm

Moderate: a pocket of amniotic ﬂuid measuring

Severe: a pocket of amniotic ﬂuid measuring more

Maternal risk: Fetal risk:

Moderate to severe degree:

Delivery is indicated once maturity is reached

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