Review Article Indian Journal of Obstetrics and Gynecology Volume 7 Number 4 (Part - II), October – December 2019 DOI: http://dx.doi.org/10.21088/ijog.2321.1636.7419.12 Amnioinfusion Alka Patil1, Sayli Thavare2, Bhagyashree Badade3 How to cite this article: Alka Patil, Sayli Thavare, Bhagyashree Badade. Amnioinfusion. Indian J Obstet Gynecol. 2019;7(4)(Part-II):641–644. 1Professor and Head, 2,3Junior Resident, Department of Obstetrics and Gynaecology, ACPM Medical College, Dhule, Maharashtra 424002, India. Corresponding Author: Alka Patil, Professor and Head, Department of Obstetrics and Gynaecology, ACPM Medical College, Dhule, Maharashtra 424002, India. E-mail: [email protected] Received on 20.11.2019; Accepted on 16.12.2019 Abstract potentially at risk. Oligohydramnios is one of the high-risk pregnancy, posing diagnostic challenge Amniotic fluid is a dynamic medium that plays and dilemma in management. These high-risk a significant role in fetal well-being. It is essential pregnancies should be monitored, managed during pregnancy for normal fetal growth and organ and delivered at a tertiary care center for good development. About 4% of pregnancies are complicated pregnancy outcome. by oligohydramnios. It is associated with an increased incidence of perinatal morbidity and mortality due to its Amniotic fl uid is essential for the continued well antepartum and intrapartum complications. Gerbruch being of the fetus and has following functions: and Hansman described a technique of Amnioinfusion • Shock absorber preventing hazardous to overcome these difficulties to prevent the occurrence pressure on the fetal parts of fetal lung hypoplasia in pregnancies complicated by oligohydramnios. Amnioinfusion reduces both • Prevents adhesion formation between fetal the frequency and depth of FHR deceleration. The parts and amnion mechanisms through which amnioinfusion acts • Protects the fetus from ascending infection include mechanical cushioning of the umbilical cord to prevent recurrent umbilical compressions that lead to • During labor, amniotic fl uid and fetal fetalacidemia, predisposition to meconium aspiration membranes constitute the water bag Syndrome (MAS). containing forewaters which act as a fl uid Keywords: Amnioinfusion, Amniotic fluid; wedge, providing best natural dilator of Oligohydramnios; Preterm premature rupture of cervix.1 membrane; Meconium stained amniotic fluid (MSAF). Oligohydramnios is defi ned as reduced amniotic fl uid as evidenced by an AFI <5 cm or SDP <2 cm. Introduction An AFI between 5 and 8 cm is considered borderline/low normal AFV.2 High-risk pregnancy is defi ned as one which Causes of Oligohydramnios is complicated by factors that adversely affect the pregnancy outcome—maternal or perinatal or Oligo is more often due to decreased production of both. Actually all pregnancies and deliveries are amniotic fl uid. The conditions that lead to reduced © Red Flower Publication Pvt. Ltd. 642 Indian Journal of Obstetrics and Gynecology uteroplacental perfusion result in placental second trimester as prolonged decrease in amniotic insuffi ciency. Various fetal and maternal conditions fl uid may cause compression sequences, such as associated with oligohydramnios are following:- pulmonary hypoplasia, muscle hypotrophy or joint constriction.4 Fetal abnormalities Intrapartum amnioinfusion involves instillation • Chromosomal of isotonic fl uid through an intrauterine catheter • Anomalies: Renal agenesis into the amniotic cavity to restore the amniotic Urinary tract obstruction fl uid volume to normal or near normal levels. The procedure is intended to relieve intermittent • Growth restriction umbilical cord compression, variable FHR • Infections decelerations, and transient episodes of interrupted fetal oxygenation. The impact of amnioinfusion on Maternal late deceleration is not known.5 • Placental insuffi ciency HP PIH, long- standing DM Indications of Amnioinfusion • Placental infections: Malaria Antenatal Drug • Severe oligohydramnios to prevent • PG synthetic inhibitors pulmonary hypoplasia. To achieve this it should be done serially at weekly interval • Beta blocker or ACE inhibitors before 28 weeks. Other obstetric conditions • As an aid to ultrasonography imaging in • High prelabor rupture of membranes patients with severe oligohydramnios. • Post-term pregnancy1 • Administration of antibiotic therapy in chorioamnionitis. Oligohydramnios causes adverse fetal outcome. The condition is associated with maternal problems. Intranatal • Correcting variable decelerations because of Fetal Effects cord compression. Early problems • Reduced fetal distress caused by meconium • Pulmonary hypoplasia staining of fl uid. • Limb deformities • Correction of oligohydramnios.6 • Amniotic adhesions Contraindications of Amnioinfusion • Potter’s facies • Amnionitis • Fetal growth restriction • Polyhydramnios Late problems • Uterine hypertonus • Cord compression in labor causing variable • Multiple gestation deceleration • Known fetal anomaly • Meconium aspiration syndrome • Known uterine anomaly Maternal Problems • Severe fetal distress • Prolonged labor due to uterine inertia and • Non vertex presentation dysfunctional labor • Fetal scalp pH <7.2 • High chances of operative delivery due to • Placental abruption or Placenta previa malpresentations. There is higher maternal morbidity due to these factors.3 Two techniques used for amnioinfusion are Although oligohydramnios affects only 4–5.5% of all pregnancies, the prognosis remains poor 1. Transabdominal especially if oligohydramnios is severe or noted in 2. Transvaginal IJOG / Volume 7, Number 4 (Part - II)/ October – December 2019 Amnioinfusion 643 Method 2. USG: Amniotic Fluid Index- 8 cm7 Intrauterine Pressure During Amnioinfusion It is done under strict aseptic precautions and local anesthesia. Ultrasonography or Doppler color fl ow Isolated reports of iatrogenic polyhydramnios mapping is done to identify a pool of amniotic and uterine hypertonicity during amnioinfusion fl uid devoid of cord. The catheter or needle is emphasize the need of monitoring uterine pressure guided under ultrasonography control. Position during the procedure. Intra amniotic pressure (IAP) is confi rmed by aspiration of amniotic fl uid or in pregnancies complicated by oligohydramnios by injecting 1–2 ml of infusate to visualise fl uid is below the normal mean for gestation and turbulence. Continuous or intermittent infusion amnioinfusion results in rise in pressure to normal can be done by 50 ml syringe or infusion pump or high depending upon the volume infused. at rate of 20–30 ml per minute. Repeat infusion Increase IAP may compromise uteroplacental weekly to maintain AFI>10. Infusion of 250 ml perfusion to result in fetal bradycardia. To avoid this of saline increases AFI by 4.3 ± 1.5 cm. There is adverse effects intrauterine pressure monitoring is small risk of uterine rupture if effl ux of infusate recommended during the procedure, along with 8 blocked.6 fetal monitoring. Antibiotic Infusion Discussion PPROM carries the risk of ascending infection which may result in No matter whatever is the cause of oligohydramnios, 1 • Chorioamnionitis the general outcome is usually poor. Because of poor outcomes, termination of the pregnancies • Preterm labor was the most common decision in early-onset • Neonatal infection oligohydramnios several decades ago. The current trend is different. Augmenting the amniotic fl uid • Maternal morbidity volume may provide diagnostic or therapeutic The longer the latency period, greater the risk of benefi ts.10 infection. Administration of antibiotics directly into the amniotic cavity has been proposed to treat the It is effective in local infection. Antibiotic infusion ensures rapid • Improving the biophysical scores. delivery of antibiotics in desired concentration to • By prolonging the pregnancy, it has improved the site of infection. Amnioinfusion by irrigating the perinatal outcome. effect also dilutes the infection load.8 • Reducing the intrapartum complications. Patients at increased risk of umbilical cord compression are • Decreasing the incidence of operative intervention and also for fetal distress with • Post-term pregnancy statistical signifi cance. • Preterm labor with ruptured membranes • Improved 1 min and 5 min Apgar scores • Oligohydramnios7 when compared with the control group. • Unnecessary continuation of pregnancy with Complications anomalies can be curtailed as it increases 13 1. Uterine overdistention and hyperactivity sonovisibility. • Increasing the latency period, it decreases 2. Amniotic fl uid embolism the occurrence of fetal distress, preterm 3. Placental abruption deliveries, need for cesarean or instrumental 4. Uterine rupture deliveries.11 5. Cord prolapse Future Prospects of Amnioinfusion 6. Amnionitis 7. Maternal cardiopulmonary compromise9 Amnioinfusion could be helpful in following conditions: Monitoring of patients treated with amnioinfusion • Facilitate easy delivery of a fetus 1. Measure intrauterine pressure compromised with certain anomalies such IJOG / Volume 7, Number 4 (Part - II)/ October – December 2019 644 Indian Journal of Obstetrics and Gynecology as Potter’s syndrome or perhaps stuck twin Fundamentals of reproduction. Shirish Daftary. fetus. Sudeep Chakravarti. Holland and Brews Manual of Obstetrics, Elsevier 4th edition. • Fetal medical therapy: Drugs as Thyroxine, digoxin, antimetabolites and 2. Lakshmi Seshadri, Gita Arjun. Disorder of amniotic fluid. Lakshmi Seshadri, Gita Arjun. immunosuppressants have been successfully