OLIGOHYDRAMNIOS

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Dr abdullahwww.obgyntoday.info
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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Dr abdullahwww.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<500ml
Dr abdullahwww.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
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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
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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

PLACENTAL
CHRONIC ABRUPTION
TTTS
CVS
DRUGS
PG SYNTHETASE
INHIBITORS
ACE INHIBITORS

IDIOPATHIC
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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 <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

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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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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. 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


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Hofmeyr GJ, Glmezoglu 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
BPP asphyxia? Risk
Fetal Death
(/1000/week)
Management
10 or 8 + normal AFI not 0% 0.565 no intervention
8 + oligo chronic compensated 5-10% 20-30
if >37 wks deliver, else
serial testing 2x/wk
6 + normal AFI acute possibly 10% 50
if >37 wks deliver, else
repeat testing 24hrs, if
score same, then deliver
6 + oligo chronic +/- acute >10% >50
if >32 wks deliver, else
daily testing
4 + normal AFI acute likely 36% 115 if >26 wks deliver
4 + oligo chronic and acute likely >36% >115 if >26 wks deliver
2 + normal AFI acute certain 73% 220 if >26 wks deliver
2 + oligo chronic and acute certain >73% >220 if >26 wks deliver
0 gross severe 100% 550 if >26 wks deliver
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
Posterior urethral valves
Management:
Karyotyping
Perform serial bladder drainage every 3-4
days
Use sample of 3
rd
drainage
Isotonic urine indicate poor function

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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