POLYHYDROMNIOS

DR.HAJRA HUMA
TMO GYNAE-B UNIT
HMC

Amniotic Fluid:
Surround fetus after first few weeks of
gestation.
Protection
Antibacterial properties
Reservoir for water and nutrients.
Normal development of fetal lung,
musculoskeletal system,GI system.

Sources of AF
:
In early gestation:
derived directly from mother amnion, fetal
surface of placenta and fetal body surface.
In mid gestation:
fetal urine and fetal lung
Near Term:
fetal urine and fetal lung liquid.

Flow into Amniotic

sac

Flow out of Amniotic

sac

Fetal swallowing

Feta urine

(800-1200ml/day)

Fetal lung liquid (170ml/day)

Oral/nasal sec: (25ml/day)

(500-1000ml/day)
Intramembranous flow
(200-400ml/day)
Transmembranous flow (100ml/day)

AF volume
From 10wks (20ml) - 28wks (770ml) increases

dramatically.
After 28 wks until 39weeks little changes .
After 39wks decreases dramatically.
Average AFV in 3rd trimester is 700-800ml
Normal range at 32 weeks is v wide (<2000ml

or >500ml)

Evaluation of AFV
Physical examination:
Examination of fluid compartments.
Dye dilution test (invasive technique).
Ultrasonography (SDP , AFI)

Measuring AFI & SDP

Sonographer measure deepest AF pocket in each 4

quadrants of abdomen.
Pockets measured perpendicular to floor with patient
supine without containing small parts or umblical cord.
AFI: is sum of all these four quadrants measurements.
SDP: is single largest measurement obtained.
ABNORMALITIES:

AFI of 25cm or more OR < 5cm

SDP of 8cm or more OR <2cm.

These values are considerably outside of the 5 th and
95th percentile.
Evidence suggest SDP more specific than AFI.

POLYHYDROMNIOS
Definition:
AFI of 25cm or greater.
OR
SDP of more than 8cm.
The 95th percentile for the maximum AF
volume in normal pregnancy is about 2200ml and the
95th percentile of AFI at maximum fluid volume for
normal gestation is between 18cm to 20cm.
Occurance: 1% to 3% of pregnancies.

Classification
Mild:

AFI -25cm to 30cm

SDP -8cm to 11cm.
Moderate:
AFI -30cm to 35cm
SDP -11cm to 15cm.
Severe:
AFI > 35cm
SDP > 15cm.

ETIOLOGY

Obstetrics
Complication

Fetal Anemias Fetal Anomalies

Rare
Complication

1)TTT syndrome

1)Maternal
alloimunization

1)CNS
abnormalities
(anencephaly)

1)Inherited
Disorder of renal
function

2)Maternal
diabetes

2)Fetal
infections
(Parvovirus
B19 & Cong:
syphilis
infection)

2)Myotonic
dystrophy

a) Barter
syndrome
b) Perlmans synd
c) Beckwith synd
d) Overgrowth
synd

3)Esophageal
blockade

2)Fetal or
placental tumours

4)High gut
obstruction
5)Thoracic tumours
(diaphragmatic
hernia)
6)Cystic
adenomatoid

Complications
Maternal Complication:
1.

abdominal discomfort + dyspnea

2.

Maternal respiratory distress

Edema
Increase prevalence of preeclampsia associated with mirror
syndrome.
Preterm labour

3.
4.
5.
6.
7.
8.
9.

Increase likelihood of C/S due to fetal malpresentation

Abruptio placenta
Amnitic fluid embolus
PPH + uterine atony

Fetal complications:

5.

Fetal macrosomia
Preterm labour(10%-20%)
Fetal malpresentation
Fetal death(3%-5%)
Fetal anomalies

6.

Severe Anemia & TTT syndrome.

1.
2.
3.
4.

Management Options
DIAGNOSTIC WORKUP:
Detailed History:
- drug exposure

-maternal DM

-prior prenatal screening for aneupoloidy

-family history of myotonic dystrophy or

-past history of dysplasia/ arthrogyroposis

-history of red cell alloimunization.

INVESTIGATIONS:
1.

Maternal blood sugar series

2.

GTT

3.

Blood type /AB screening

4.

USG assesment: (degree, fetal anomalies,fetal anemia, fetal tachyarrythmia,

evidence of TTTS)

5.

Karyotyping

6.

Assessment of viral infection

Patient Counselling:
Prognosis depends on severity & etiology.
Best prognosis with mild and idiopathic .
pregnancy with severe polyhydromnios increased risk of preterm
delivery, perinatal mortality.

Treatment:
Mainly to relieve symptoms and to prolong gestation.
Mildly symptomatic: Expectantly managed with no evidence for use

of diuretics , salt or fluid restriction.

SPECIFIC TREATMENT
1. Standard

2. Experimental
Sulinadac:

-NSAIDs

Most effective for specefic diagnosis i.e

Diabetes controll,Fetal TTTS.

Maternal to fetal waterflow

-maternal dehydration
-Diuretics

Maternal administration of PG synthetase

Inhibitor.
Indomethacin

-decreases AF
-less potential to constrict ductus
arteriosis
(<
indomethacin)
Other Therapies:

-Intraamniotic DDAVP
-modulation of Amniotic
membrane water channels
(aquaporin)

INDOMETHACIN:
Mech: Increases water reabsorbtion in renal tubules by

inhibiton

of PGs.

Dose:

25mg 6hrly (max 200mg/day)

Duration:
stopped if oligohydromnios or signs of ductal constriction
otherwise can be continued untill 32-34wks.

not used in TTTS.

A/E:
closure or constriction ofductus arteriosis

development of oligohydromnios

fetal renal damage

If treatment exceed 48hrs need for weekly serial fetal
echocardiography evaluation needed.
Sonographic signs of ductal constriction:

tricuspid regurge

Rt ventricular dysfunction
Stop or discontinue treatment if AFI<8cm.

Amnioreduction
Standard Amnioreduction :
fluid removed at rate of 45-90ml/min
Aggressive Amnioreduction:
fluid removed more rapidly
Complications:
Both associated with similar rates(4%-15%)
PROM
Infections
Placental abrubtion
Fetal death

Fetal Surgery:
No intervention is specifically targeted to
polyhydromnios with the exception of:
fetal laser ablation of vascular anastomosis in
patients with TTTS
Indirect therapy i.e shunting of intrathoracic
cystic leisions
Fetal surgery for thoracic leisions of teratomas

THANKS