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Polyhydramnios: Causes, Diagnosis and Therapy Das Polyhydramnion: Ursachen, Diagnostik Und Therapie

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Polyhydramnios: Causes, Diagnosis and Therapy Das Polyhydramnion: Ursachen, Diagnostik Und Therapie Review 1241 Polyhydramnios: Causes, Diagnosis and Therapy Das Polyhydramnion: Ursachen, Diagnostik und Therapie Authors A. Hamza1, D. Herr 1, E. F. Solomayer2, G. Meyberg-Solomayer1 Affiliations 1 Gynäkologie und Geburtshilfe, Universitätsklinikum des Saarlandes, Homburg/Saar 2 Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar Key words Abstract Zusammenfassung l" polyhydramnios ! ! l" amniotic fluid Polyhydramnios is defined as a pathological in- Als Polyhydramnion bezeichnet man eine patho- l" high risk pregnancy crease of amniotic fluid volume in pregnancy logische Vermehrung von Fruchtwasser bei der Schlüsselwörter and is associated with increased perinatal mor- Schwangeren, die mit einer erhöhten perinatalen l" Polyhydramnion bidity and mortality. Common causes of Morbidität und Mortalität vergesellschaftet ist. l" Fruchtwasser polyhydramnios include gestational diabetes, fe- Häufige Ursachen eines Polyhydramnions sind l" Risikoschwangerschaft tal anomalies with disturbed fetal swallowing of der Gestationsdiabetes, fetale Fehlbildungen, die amniotic fluid, fetal infections and other, rarer z.B. zu einem gestörten Schluckvorgang von causes. The diagnosis is obtained by ultrasound. Fruchtwasser führen, fetale Infektionen und an- The prognosis of polyhydramnios depends on its dere seltene Ursachen. Die Diagnostik des Poly- cause and severity. Typical symptoms of hydramnions erfolgt dabei v.a. sonografisch. Die Deutschsprachige polyhydramnios include maternal dyspnea, pre- Prognose des Polyhydramnions hängt von der Ur- Zusatzinformationen term labor, premature rupture of membranes sache sowie der klinischen Ausprägung ab: Typi- online abrufbar unter: (PPROM), abnormal fetal presentation, cord pro- sche Folgen des Polyhydramnions beinhalten ma- www.thieme-connect.de/ lapse and postpartum hemorrhage. Due to its ternale Atembeschwerden, die Frühgeburtlich- ejournals/toc/gebfra common etiology with gestational diabetes, keit, den vorzeitigen Blasensprung, regelwidrige polyhydramnios is often associated with fetal Kindslagen, den Nabelschnurvorfall, sowie die macrosomia. To prevent the above complications, postpartale Blutung. Aufgrund einer gemein- there are two methods of prenatal treatment: samen Ätiologie mit einem Gestationsdiabetes ist amnioreduction and pharmacological treatment das Polyhydramnion darüber hinaus mit einer fe- with non-steroidal anti-inflammatory drugs talen Makrosomie assoziiert. Zur Vermeidung der (NSAIDs). However, prenatal administration of o.g. Komplikationen bestehen pränatal grund- NSAIDs to reduce amniotic fluid volumes has not sätzlich 2 Therapieformen: die invasive Entlas- been approved in Germany. In addition to con- tungspunktion und die medikamentöse Amnion- ventional management, experimental therapies reduktion mit z.B. Non-Steroidal Anti-inflamma- received 21.10. 2013 which would alter fetal diuresis are being consid- tory drugs (NSAID), die jedoch in Deutschland bei revised 12.11. 2013 ered. dieser Indikation nicht zugelassen sind. Darüber accepted 12.11. 2013 hinaus gibt es in jüngster Zeit experimentelle Therapieansätze, die auf die Beeinflussung der fe- Bibliography DOI http://dx.doi.org/ talen Diurese zielen. 10.1055/s-0033-1360163 Geburtsh Frauenheilk 2013; 73: – 1241 1246 © Georg Thieme Introduction Under physiological conditions there is a dynamic Verlag KG Stuttgart · New York · ! ISSN 0016‑5751 equilibrium between the production and resorp- Polyhydramnios is the term used to describe an tion of amniotic fluid. Fluid levels are influenced Correspondence excess accumulation of amniotic fluid. This clini- by fetal urination and fetal lung liquid production. Mr. Amr Hamza, Postgraduate Universitätsklinikum cal condition is associated with a high risk of poor Amniotic fluid is reabsorbed by fetal swallowing des Saarlandes pregnancy outcomes [1–3]. The reported preva- and intramembranous and intravascular absorp- Gynäkologie und Geburtshilfe lence of polyhydramnios ranges from 0.2 to 1.6% tion. The relative attribution of each of these Kirrberger Straße 100 – 66424 Homburg/Saar of all pregnancies [4 7]. mechanisms varies over the course of the preg- [email protected] nancy. A disturbed equilibrium can be the result Hamza A et al. Polyhydramnios: Causes, Diagnosis… Geburtsh Frauenheilk 2013; 73: 1241–1246 1242 GebFra Science of compromised swallowing function or increased urination and examiners are less experienced, while evaluation based solely can lead to polyhydramnios [8–11]. on subjective assessment is associated with good results if done A fetus close to term will produce between 500–1200 ml urine by an experienced examiner [27]. and swallow between 210–760 ml of amniotic fluid per day. Even Various semi-quantitative methods to measure amniotic fluid small changes in this equilibrium can result in significant changes volumes have been described. But these methods also have their in amniotic fluid volumes [9–11]. limitations which must be taken into account [28]. Single deepest pocket measurement Etiology For this type of measurement the uterus is divided into four ! quadrants. The amniotic fluid volume is measured vertically in An underlying disease is only found in 17% of cases in mild the deepest amniotic fluid pocket. Values below 2 cm indicate oli- polyhydramnios. In contrast, an underlying disease is detected gohydramnios, values over 8 cm indicate polyhydramnios [30]. in 91% of cases in moderate to severe polyhydramnios [5]. The lit- The advantage of this method is its simplicity, making it the most erature lists the following potential etiologies [5,7,12–19]: commonly used method in practice. It is also the method of " fetal malformations and genetic anomalies (8–45%) choice in multiple gestation. In cases with multiple gestation, a " maternal diabetes mellitus (5–26%) range of 3–8 cm is defined as normal. With this method, " multiple pregnancies (8–10%) polyhydramnios is classified as mild, moderate or severe. Mild " fetal anemia (1–11%) polyhydramnios is characterized by a value of 8–11 cm, moderate " other causes, e.g. viral infections, Bartter syndrome, neuro- polyhydramnios by a value between 12–15 cm and severe muscular disorders, maternal hypercalcemia. Viral infections polyhydramnios by values above 16 cm [86]. which can lead to polyhydramnios include parvovirus B19, ru- bella, and cytomegalovirus. Other infections, e.g. toxoplasmo- The 4-quadrant method (AFI – Amniotic Fluid Index) sis and syphilis, can also cause polyhydramnios [80–82]. With this method, the deepest amniotic pocket in each of the four Advances in detailed ultrasound scanning and the prevention of quadrants is measured vertically and the values added together. Rhesus isoimmunization in the last decades have changed the The uterus is divided vertically into two halves by an imaginary relative frequency of these etiologies and significantly reduced line along the linea nigra. An imaginary horizontal line through the number of idiopathic cases [12–19]. the umbilicus divides the uterus into an upper and a lower half. Well-known malformations which impair the swallowing reflex During measurement the transducer is held at right angles to include esophageal atresia, duodenal atresia [16,17] and neuro- the sagittal plane of the patientʼs abdomen. The transducer muscular disorders such as myotonic dystrophy. Increased urine should not be tilted along the maternal abdomen, i.e. it must be production, as occurs with increased cardiac output associated kept at a right angle. The measured amniotic fluid pockets must with fetal anemia, can also result in increased production of be free of fetal extremities and the umbilical cord and must be at amniotic fluid [20,21]. These changes can also occur in the con- least 0.5 cm wide. The Amniotic Fluid Index (AFI) is the sum of text of chromosomal disorders such as trisomy 21 and different measurements of all four quadrants. According to one study syndromes. Duodenal atresia is the most important etiology in group, AFI values between 8.1 and 18 cm are normal, values be- cases with trisomy 21 [79]. tween 5.1 und 8.0 cm indicate oligohydramnios, an AFI value of Poorly managed gestational diabetes is associated with fetal mac- less than 5.0 cm indicates severe oligohydramnios and a value rosomia and polyhydramnios but the pathogenesis has not been above 18 cm is classified as polyhydramnios [31]. elucidated yet [22]. One possible explanation is fetal hyperglyce- Based on AFI values obtained during prenatal screening, some mia resulting in increased osmotic diuresis which subsequently clinicians categorize polyhydramnios into three groups according leads to polyuria. This theory is supported by evidence of a strong to severity: mild polyhydramnios (AFI of 25–30 cm), moderate association with high glycosylated hemoglobin values (HBA1c)in polyhydramnios (30.1–35 cm) and severe polyhydramnios cases with polyhydramnios [22,23]. According to the AWMF (≥ 35.1 cm) [87]. S3‑guideline, polyhydramnios can be an indication of diabeto- Moore und Cayle [32] investigated the distribution of AFI mea- genic fetopathy. However, due to the wide range in amniotic fluid surements in a population with normal pregnancies. In contrast volumes, polyhydramnios does not play an important role in to the definition of oligohydramnios proposed by Phelan et al. monitoring gestational diabetes [68]. The prevalence of poly- (AFI less than 5 cm [31]) they found that an AFI of 5 cm was only hydramnios in maternal cases with diabetes mellitus
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