Clinical Sudy of Pregnancy out Come in Cases of Oligohydramnios Diagnosed After 34 Weeks

OBSTETRIC OUT COME IN CASES OF OLIGOHYDRAMNIOS DIAGNOSED AFTER 34 WEEKS OF GESTATION

NAME OF THE CANDIDATE :: DR. HEMALATHA. P Sri Devaraj Urs Medical College Kolar

NAME OF THE GUIDE :: Prof. Hemalatha Mahant Shetti. M.D Sri Devaraj Urs Medical College Kolar

ABSTRACT

BACKGROUND :: Oligohydramnios occurs in about 1-5% of pregnancies at term. Oligohydramnios is defined as amniotic fluid index (AFI) less than or equal to 5cm. Quantitative estimation of amniotic fluid volume is part of routine obstetric scan. Amiotic fluid monitoring can be done using AFI or single deepest pocket assessment. Oligohydramnios causes a variety of ominous pregnancy outcomes such as Intrauterine growth retardation (IUGR), Cord Compression, Fetal distress in labour, congenital skeletal abnormalities, Meconium staining, poor fetal condition at birth and perinatal death.

AIM :: To know pregnancy outcomes associated with oligohydramnios.

To assess whether antepartum oligohydramnios is associated with adverse perinatal out come.

Materials and Methods :: A prospective study consisting of 50 cases with oligohydramninos diagnosed after 34 weeks of gestation will be taken up for the study, attending R.L.J. Hospital and Research Centre attached to Sri Devaraj Urs Medical College from January 2008 to December 2008. RAJIV GANDHI INSTITUTE OF HEALTH SCIENCES KARNATAKA, BAN GALORE

M.S. (OBSTETRICS & GYNAECOLOGY)

SRI DEVARAJ URS MEDICAL COLLEGE TAMAKA, KOLAR – 563 101

“OBSTETRIC OUT COME IN CASES OF OLIGOHYDRAMNIOS DIAGNOSED AFTER 34 WEEKS OF GESTATION ”

DR. HEMALATHA. P DEPT. OF OBSTETRICS & GYNAECOLOGY SRI DEVARAJ URS MEDICAL COLLEGE TAMAKA, KOLAR – 563 101 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 Name of Candidate : Dr. HEMALATHA P

Address ( in block letters) : PG LADIES HOSTEL SRI DEVRAJ URS MEDICAL COLLEGE, TAMAKA, KOLAR-563101 2 Name of the institution : SRI DEVRAJ URS MEDICAL COLLEGE TAMAKA, KOLAR-563101

3 Course of the study & Subject : M.S. (O.B.G) 4 Date of admission to course : 23-06-07 5 Title of the topic

OBSTETRIC OUT COME IN CASES OF

OLIGOHYDRYAMNIOS DIAGNOSED

AFTER 34 WEEKS OF GESTATION

6 Brief Resume of the intended work 6.1) Need for the Study: Oligohydramnios occurs in about 1% to 5% of pregnancies at term7. The use of amniotic fluid index less than or equal to 5cm to define oligohydramnios was suggested first by Phelan et al in 1987 as an aribitary cutoff value6. Quantitative estimation of amniotic fluid volume is part of routine obstetric scan. It is widely used as an indicator of fetal well being during third trimester. Amniotic fluid monitoring can be done using AFI or single deepest pocket assessment8. The AFI offers no advantage in detecting adverse outcomes compared with the single deepest pocket when performed with BPP. The AFI may cause more interventions by labelling twice as many at risk pregnancies as having oligohydramnios than with single deepest pocket technique. Oligohydramnios, in a pregnancy without a fetal renal abnormality or genito urinary obstruction, is thought to represent “chronic in utero stress8. Perinatal morbidity and mortality are significantly increased when oligohydramnios is present. It causes a variety of ominous pregnancy outcomes such as Intra uterine growth retardation (IUGR), cordcompression, fetal distress in labour, meconium staining, skeletal abnormalities due to compression, poor fetal condition at birth and perinatal death5. No study concerning oligo hydramnios has been done before in rural population attending R.L.J. Hospita,l and Research Center, Kolar. The above facts clearly state a case for further stuy of oligohydramnios to devise methods and means to diagnose and manage in a better way.

6.2) Review of Literature Oligohydramnios is defined as Amniotic Fluid Index (AFI) less than or equal to 5cm5. It may be categorized as mild, moderate, or severe when deepest pocket measures 3cm , 2cm and 1cm respectively6. It may be associated with uteroplacental insufficiency, congenital anomalies, Hypertension, preclampsia, diabetes mellitus, cardiac diseases, anemia, viral diseases, idiopathic fetal growth restriction, Premature rupture of membrane (PROM), fetal hypoxia, meconium stained fluid, drugs and or postmaturity syndrome11. Diagnastoic evaluation of oligohydramnios comprises of a} History taking with an emphasis on maternal symptoms of hypertension, congenital infections, etc B} High resolution ultrasonography to asses the degree of oligohydramnios , presence of growth deficiency. C} Colour Doppler ultrasonography to determine the severity of oligohdramnios by excluding loops of cord. Amnioinfusion may be both diagnostic and therapeutic 6. In diagnostic amnioinfusion normal saline is instilled into the amniotic cavity to improve the ultrasonographic resolution. There is mounting evidence of a role for amnion infusion in the management of oligohydramnios. 5 However, further research is needed to support the above statement. Oligohydramnios may be responsible for malpresentations, umbilical cord compression, and difficult or failed external cephalic version. 11 Severe oligohydramnios poses a diagnostic challenge becauseit impairs ultrasonographic resolution. Oligohydramnios at term in the absence of maternal and fetal complications poses a dilemma in the management. The patient with an uncertain gestational age who presents late in pregnancy poses a difficult diagnostic dilemma. 6 olgohydramnios detected after 36 weeks in the

presence of normal fetal anatomy and growth may be managed expectantly in conjunction with antepartum fetal testing.7 No studies have directly addressed whether labour nduction improves pregnancy outcomes. An antepartum AFI of

5cm is associated with risk of cesarean delivery for fetal distress and an apgar score of less than 7 at 5min.3 Stephen et al studied that women with oligohydramnios are at increased risk of intrapartum fetal distress as evidenced by thick meconium staining, fetal heart rate abnormalities and that they are more likely to require operative delivery4. The best management of oligohydramnios includes individualized care, consideration of maternal and fetal factors, including time of day, cervical readiness, and emotional readiness for labour.11

6.3) Objective of the study is 1. To know Obstetric outcome associated with oligohydramnios. 2. To assess whether antepartum oligohydramnios is associated with

deverse perinatal outcome.

7 MATERIALS AND METHODS 7.1 SOURCE OF DATA: Study will be carried out in pregnant women with oligohydramnios diagnosed after 34 weeks of gestation attending R.L.Jalappa Hospital and Research center, attached to sri Devaraj urs Medical college, Tamaka, Kolar. A minimum of 50 cases will be taken up for the study. 7.2 Method of collection of Data : Is a prospective study conducted in the Department of OBG attached to Sri Devaraj Urs Medical College, from January 2008 to December 2008. The study covers 50 cases diagnosed with oligohydramnios. Patient presenting to hospital with above complaints will be considered for enrolment into the study. A written consent would be taken. Inclusion criteria : The criteria for selection of cases are based on detailed clinical history like duration of amenorehoea, decreased fetal movements and detailed obstetric history regarding previous congenital abnormalities, oligohydramnios and preclampsia. Patients with singleton pregnancies with oligohydramios diagnosed at or beyond 34 weeks of gestation. Exclusion criteria : i) Multiple Pregnancy ii) Intrauterine death of the fetus. iii) Patients with ruptured membrane. iv) Fetal anomalies. 7.3) Does the study require any investigations or intervention to be conducted on patients : If so please describe briefly : The Study requires USG abdomen, Doppler, NST 7.4) Has ethical clearance been obtained from your institution in case of 7.3 The study has been discussed and obtained clearance from ethical clearance committee of Sri Devraj urs Medical College, Tamaka, Kolar. 8 List of references 1. Casey BM, McIntire DD, Bloom SL, Lucas MJ, Santos R, Twickler DM, Remus RM. “Pregnancy outcomes after antepartum diagnosis of oligohydramnios at or beyond 34 weeks gestation”. Am Jobstet Gynecol 2000; 182:909-920. 2. Peipert JF, Donnenfeld AE “Oligohydramnios: A Review’’ Obstetrical and Gyanecological survey 1991;46;325 –339. 3. Chauhan SP, Sanderson M, Hendrix NW, Magann EF Devoe CD. “Perinatal outcome and amniotic fluid index in the antepartum and intrapartum periods. A meta-analysis”. Am Jobstet Gynecol, 1999;181:1473-1480. 4. Robson SC, Crawford RA, Spenser JA, Lee A. “Intrapartum amniotic fluid index and its relationship to fetal distress”. Am Jobstet Gynecol, Jan. 1992; 166:78-82. 5. Gabbe SG, Niedyl JR, Simpson JL. “ Obstetrics Normal and problem pregnancies”. 4th edition Churchill Livingstone publication 876, 937-938. 6. James DK ,Steer PJ, Weiner CP, Gonik B. “High risk preganancy”. 2nd edition WB Saunder publications 313- 318. 7. Lawrence Leeman. “Isolated oligohydramnios at term : is induction indicated?” Journal of family practice, 2007; 54-58. 8. Everett F, Magan, Dorota A, Doherty, KarenField, Suneet P Chauhan, Patrick E. Muffley, John C. Morrison. “Bio physical profile with amniotic fluid volume assessments”. Journal of The American college of obstetricians and gynaeologists, 2004;104:5-10. 9. Peter R Muller, Andra James. “Pregnancy with prolonged fetal exposure to an ACE inhibitor”. Journal of perinatology, Oct/Nov 2002;22:582-584. 10. Elsandabesee D, Majumdar S, Sinha S. “Obstetricians attitudes towards isolated oligohydramnios at term”. Journal of Obstet and Gynacol, 2007 Aug;27:574-576. 11. Maria L Lanni, Elizabeth A Loueless, CNM, MS. “Oligohydramnios at term: A case Report”. Journal of midwifery womens Health 2007;52:73-76. 9 Signature of candidate :

10 Remarks of the Guide : Oligohydramnios being major complication of pregnancy, commonly seen in association with medical complications like hypertension, cardiac diseases, anemia and diabetes requires tertiary care center. This institution being tertiary care center provides an ideal place to study oligohydramnios as they are referred from periphery. Since oligohydramnios has significant impact on maternal and fetal health, it is an important subject to be studied in detail at post graduate training center. 11 Name and Designation of : Prof Dr. Hemalatha Mahantshetti M.D the Guide Professor and Head of Department Department of Obstetrics and Gynecology. Sri Devraj Urs Medical College Tamaka, Kolar-563101 Signature : Co-guide (If any) :

Signature : Head of the Department : Prof Dr. Hemalatha Mahantshetti M.D Professor and Head of Department Department of Obstetrics and Gynecology. Sri Devraj Urs Medical College Tamaka, Kolar-563101

Signature :

12 Remarks of the Chairman /Principal :

Signature :