Amniotic fluid abnormalities: Poly and oligo - What to do? William M. Gilbert, MD Regional Medical Director, Sutter Health, Valley Region Women’s Services Definitions Introduction What is normal Oligohydramnios Polyhydramnios Pregnancy outcomes Treatment options Delivery options The speaker has no financial conflicts of interest The best clinical test for determining amniotic fluid A. B. Leopold’s Maneuvers C. Amniotic fluid index (AFI) Largest vertical pocket (LVP) volume is 48% 52% 1% Leopold’s Maneuvers Amniotic fluid index (AFI) Largest vertical pocket (LVP) Isolated Oligohydramnios is NOT associated with Isolated polyhydramnios is NOT associated with worst pregnancy outcomes worst pregnancy outcomes A. True A. True 59% 51% B. False 49% B. False 41% True False True False Normal AF volume Brace and Wolf AJOG (1989) Actual measurement 705 separate pregnancies Gestational age dependent Clinical Assessments of AF Volume Leopolds - Hands on!! Actual measurement – invasive (amniocentesis) Ultrasound Largest vertical pocket of AF, (LVP, DVP, MVP) 2 diameter pocket Amniotic Fluid Index (AFI) Deepest Vertical Pocket (DVP) Oligohydramnios - < 2 cm Severe oligohydramnios < 1 cm Mild oligohydramnios < 2 cm, > 1 cm Normal – 2 to 8 cm Polyhydramnios Mild polyhydramnios - > 8 cm < 12 cm Moderate polyhydramnios - > 12 cm < 16 cm Severe polyhydramnios - > 16 cm Best Test for Determination of AFV Nabhan et Abdelmoula. AFI vs SDP as a screening test for preventing adverse pregnancy outcome. Cochrane database (2010) Five trials (3226 women) AFI vs SDP – Neither method was superior but AFI more Dx of oligohydramnios - OR 2.39 (1.7, 3.3) More inductions - OR 1.9 (1.5, 2.5) More C/S for fetal distress - OR 1.5 (1.1, 2.0) Perinatal Outcomes Oligohydramnios - Outcomes Oligohydramnios – anhydramnios Increase in adverse perinatal outcome 75 to 100 % PMR 50 x greater perinatal death rate, Chamberlain et al (1984) Renal agenesis, obstructive uropathy 2.0 vs 109 deaths/1000 < 1 cm vs. < 2 cm but < 8 cm Polyhydramnios – marked 40% IUGR 75 to 100% PMR Cord compression Bowel Obstruction, genetic, TTTS Uteroplacental insufficiency Meconium Oligohydramnios - Outcomes Adverse outcomes Old studies included Morris et al. Association and prediction of AF Structural abnormalities measurements for adverse pregnancy outcome: IUGR, SGA Systematic review and meta-analysis. BJOG (2014) Postmaturity syndrome 43 studies 244,493 fetuses Maternal conditions Results Led to inductions with low AFI Oligohydramnios strong association with: SGA OR 6.3 (4.15, 9.58) Neonatal Mortality 8.7 (2.4, 31.2) PMR OR 11.5 (4.1 32.9) How About Isolated Oligohydramnios? Isolated Oligohydramnios Transient finding Lagrew et al. (1992) Conway et al (1998) 183 patients 3-4 days later 41% normal Isolated oligo induction matched to AFI good for 7 days Spontaneous labor with normal AFI Post dates AFI twice a week No difference in gest age, race, pariety Clement et al (1987) Neonatal outcomes no different Induction C/S rate 16% vs 7% Conclusion: Induction not indicated Isolated Oligohydramnios Isolated oligohydramnios Rainford et al (2001) 232 > 37 weeks Naveiro-Fuentes et al. J Perinat Med (2016) AFI < 5 cm (19%) Retrospective 27,708 patients, into three groups No difference in: Induction because of oligo OVD, NICU, Low Apgars at 5 min Spontaneous labor with normal AFV Normal AFI Postdate inductions with normal AFV fewer inductions C/S and SGA in oligo increased compared to both MORE meconium 35 vs 16% Conclusion: Question induction for oligo Polyhydramnios Adverse Outcomes 113 cases of polyhydramnios Golan et al (1994) Morris et al. (2013) Association and prediction of AF 65 remained poly, 48 returned to normal measurements for adverse pregnancy outcome: Morb/Mort OR Systematic review and meta-analysis. BJOG (2014) Polyhydramnios PIH 2.7 LGA fetuses OR 11.4 (7.1, 18.4) PTD 2.7 Despite strong associations with poor outcomes: they do C/S 4.0 not accurately predictive outcomes for individuals IUFD 7.7 Neo Death 7.7 Isolated polyhydramnios Polyhydramnios Treatment Aviram et al. Obstet Gynecol (2015) Amnioreduction – Kleine et al. (2016) Retrospective study 31,376 > 34 week Singleton IUP with Severe polyhydramnios 215 with isolated polyhydramnios (AFI > 25 cm) With and without maternal symptoms Pregnancy outcomes – increase in: Retrospective 135 patients Induction OR 1.7 (1.01, 2.8), Cesarean OR 2.6 (1.7, 4.0) 44 needed amnioreduction Shoulder dystocia OR 3.4 (1.2, 9.7), Prolonged 1st Stage OR No difference in Maternal or newborn outcomes 3.6 (2.0, 6.7), Abruption OR 8.4 (2.0, 35) Mild poly (AFI 25.0 to 30) Still increased Polyhydramnios Treatment Polyhydramnios Treatment Dickinson et al. Am J O&G (2014) Dickinson et al. Am J O&G (2014) Retrospective study of amnioreductions Final Diagnosis 138 patients with polyhydramnios (LVP > 8 cm) GI malformations 21% 271 reductions, Median age 31.4 weeks and 1 procedure Idiopathic 20.3% 45.6% required > 1 procedure, Volume 2100 ml Chromosomal abnormalities 15.2 % Medium duration 26 days between procudures Syndromic condition 13.7% Medium Del 36 .4 weeks, 2 dels within 48 hours Neurologic condition 8% Amnioreduction was useful and safe procedure Treatment Options Oligohydramnios Treatment Options Oral hydration, Kilpatrick et al (1991) Intravenous hydration Oligohydramnios, 2 liters of water Doi et al (1998) > 35 wks AFI < 5cm Increased AFI 3.5 cm PO vs IV isotonic or hypotonic Normal AFI (Kilpatrick et al 1993) 2 liters/2 hours Increased AFI 1.6 cm Osmotic change more important than volume Flack et al (1995) Chandra et al (2000) Increased AFI in oligo but not normal Oral or IV increase AFI Oligohydramnios Treatment Treatment Options Patrelli et al. J Ultrasound Med (2012) Contraction Stress Test RCT of isolated oligo (66 with Oligo, 71 controls) “Stresses” the fetus 6 days of IV 1500 ml isotonic per day. Good for one week NST, AFI, BPP days 0 and 7 May put into labor Change in AFI 3.9 cm to 7.7 cm, control unchanged Oligo group then RCT to oral 1500 vs 2500 ml At delivery AFI 8.6 vs 11.2 cm Conclusion – Hydration works Summary and Conclusions: Summary and Conclusions: Polyhydramnios Oligohydramnios Is it true polyhydramnios? Check LVP Ultrasound only method of diagnosis LVP better than AFI Ultrasound for anatomy If AFI is low (< 5 cm), Check LVP. If normal OK Check diabetes screen Major cause for induction in US today If real and/or persistent, Antepartum testing Poor pregnancy outcome in older studies Watch for LGA Included malformations, IUGR, Maternal disease If isolated oligohydramnios and AGA: Oral hydration and OK to wait Summary and Conclusions: Isolated Oligohydramnios before 40-41 wks Hydration, 2 liters minimum per day Ultrasound to rule out IUGR (Doppler) If LVP low (< 2 cm) at term, consider above or induction Isolated Oligohydramnios is NOT associated with A. B. True False worst pregnancy outcomes The best clinical test for determining amniotic fluid A. B. Leopold’s Maneuvers C. Amniotic fluid index (AFI) Largest vertical pocket (LVP) volume is 84% Isolated polyhydramnios is NOT associated with True 16% A. 92% B. True 0% False False worst pregnancy outcomes Leopold’s Maneuvers 8% Amniotic fluid index (AFI) Largest vertical pocket (LVP) 32% 68% True False.