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Add as FriendDisorders of Amniotic Fluid

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1 : Dr.Uma Gupta, Dr.NK Gupta 1 Dr.Uma Gupta MD,FICMCH. Professor,Dept of Obstetrics & Gynecology Era’s Lucknow Medical College.Lucknow umankgupta@gmail.com Dr.N.K.Gupta,MS,M.Ch. Professor,Dept of Surgery, Era’s Lucknow Medical College.Lucknow. drnkgupta2000@yahoo.com DISORDERS OF AMNIOTIC FLUID 7/30/2011
2 : Introduction Amniotic fluid- it provides fetus a protective environment for growth and development. The volume of amniotic fluid increases from 200ml at 16 weeks of gestation to 1 L at 28 weeks, there by gradually decreases to around 900 ml at term to 800ml at 40 weeks(Queenan-1991). Queenan JT: Polyhydramnios and oligohydramnios. Contemp.Obstet. Gynecol 36:60,1991 7/30/2011 2 Dr.Uma Gupta, Dr.NK Gupta
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5 : Diminished fluid volume is termed oligohydramnios. More than 2 L of amniotic fluid is considered excessive and known as polyhydramnios (Cunnignham 2005). Cunningham FG,Leveno KJ, Bloom SL, Hauth JC, Gilstrap III LC: Williams Obstetrics, Edi Wenstrom KD, McGraw Hill,Medical Publishing Division, New York, 22Edi, 2005, 526-534. 7/30/2011 5 Dr.Uma Gupta, Dr.NK Gupta
6 : Measurement of Amniotic fluid: In clinical practice, ultrasonographic measurement of amniotic fluid volume is used as an integral part of biophysical profile and most commonly used as USG based antenatal test of well being. Amniotic fluid index – The vertical depths of the largest pocket in each of the four equal quadrant is measured and added. If the index is greater than 24 cms the condition is defined as hydramnios and if less than 5 cms is known as oligohydramnios (Phelan 1987). Phelan JP,Smith CV,Broussard P: Amniotic fluid volume assessment with the four-quadrant technique at 36 -42 weeks gestation. J Reprod. Med 32: 540.1987 7/30/2011 6 Dr.Uma Gupta, Dr.NK Gupta
7 : Another method of quantifying amniotic fluid is by estimating single deepest pocket(SDP) without loop of cord. With this criteria hydramnios is the finding of a pocket of fluid measuring 8 cms or more in vertical diameter and oligohydramnios as SDP does not exceed 1 - 2cm. 7/30/2011 7 Dr.Uma Gupta, Dr.NK Gupta
8 : POLYHYDRAMNIOS Incidence varies from 0.4 to 2% (Queenan 1970, Biggio et al 1999). Degrees of hydramnios: Mild – pocket measures 8-11cms Moderate – 12 – 15 cms Severe - > 15 cms. Queenan J and Gadow E: ( 1970)Polyhydramnios: Chronic versus acute.Am J Obstet Gynecol; 108:349 Biggio JR Jr., Wenstrom KD, Dubard MB,Cliver SP. (,1999):Hydramnios prediction of adverse perinatal outcome. Obstet Gynecol.94;773-777. 7/30/2011 8 Dr.Uma Gupta, Dr.NK Gupta
9 : If the USG evaluation is normal in hydramnios, the risk of major anomaly is 1% with mild hydramnios, 2% with moderate hydramnios, and 11% with severe hydramnios(Dashe 2002). Dashe JS,McIntire DD, Ramus RM et al: Hydramnios: Anomaly prevalence and sonographic detection. Obstet Gynecol 2002; 100(1)134-139. 7/30/2011 9 Dr.Uma Gupta, Dr.NK Gupta
10 : Acute hydramnios: refers to sudden accumulation of amniotic fluid aasociated with maternal symptoms. It is almost exclusively manifestation of TTTS before 26 weeks. 7/30/2011 10 Dr.Uma Gupta, Dr.NK Gupta
11 : Table :Etiologies of Amniotic Fluid Volume Abnormalities Oligohydramnios: Fetal renal ageneis Severe placental insufficiency Bilateral multicystic kidney disease Posterior urethral valves Premature rupture of membranes Donor twin to twin transfusion syndrome Polyhydramnios: Maternal diabetes Fetus macrosomia CNS anomaly GIT obstructions Nonimmune hydrops CVS anomaly Myotonic disorders Recipient twin to twin transfusion syndrome 7/30/2011 11 Dr.Uma Gupta, Dr.NK Gupta
12 : Table Diagnostic evaluation of Hydramnios History taking- emphasis on maternal symptoms, diabetes mellitus, maternal drug ingestion, red cell alloimmunization. High resolution USG- AFI, Multiple gestation, macrosomia,growth deficiency, anomaly of systems Bladder dynamics Middle cerebral artery peak velocity – suspected fetal anemia Chorionicity (For evidence of TTTS monochorionic twin- single placenta, polyhydramnios-oligohydramnios sequence, same sex) Fetal specimens for karyotyping and viral infections 7/30/2011 12 Dr.Uma Gupta, Dr.NK Gupta
13 : MANAGEMENT Minor asymptomatic hydramnios is managed expectantly. Even moderate degrees with some discomfort can usually be managed without intervention until labor ensues or until the membranes rupture spontaneously. If dyspnea or abdominal pain is present, or if ambulation is difficult, hospitalization becomes necessary. 7/30/2011 13 Dr.Uma Gupta, Dr.NK Gupta
14 : Indomethacin Indomethacin , Class E of prostaglandins antagonize the antidiuretic effect of arginine vasopressin on the collecting tubules of kidney, prostaglandin inhibition enhances proximal tubular resorption of sodium and water. Indomethacin is known to decrease urine output by either or both the mechanism(Usberti,1985). The dose of indomethacin varies from 50-200 mg/day, depending on AF volume response. The time interval between commencing treatment and achieving normal AF ranges from 4 to 20 days. Usberti M, Pecoraro C, Federico S et al. Mechanism of action of indomethacin in tubular defects.Pediatrics 198; 75(3): 501-507. 7/30/2011 14 Dr.Uma Gupta, Dr.NK Gupta
15 : Therapeutic Amniocentesis The principal purpose of amniocentesis is to relieve maternal distress by decompressing the uterus. The rate of flow of amnionic fluid is controlled with the screw clamp so that about 500 mL/hr has usually decreased in size sufficiently so that the catheter may be withdrawn from the amniotic sac. At the same time, maternal relief is dramatic and the risk of placental separation from decompression is very low. 7/30/2011 15 Dr.Uma Gupta, Dr.NK Gupta
16 : Degree of polyhydramnios is directly associated with the perinatal mortality rate. Association between PTL and gestational diabetes is of particular interest, since fetal lung maturation is retarded by the effect of hyperinsulinemia. Therefore prophylactic measures should be adopted to avoid preterm delivery in polyhydramnios associated with diabetes. CLINICAL RELEVANCE 7/30/2011 16 Dr.Uma Gupta, Dr.NK Gupta
17 : CLINICAL RELEVANCE The most frequent maternal complications associated with an excess of amniotic fluid are placental abruption, uterine dysfunction and postpartum hemorrhage. Prolapse of the umbilical cord during membrane rupture and placental abruption as the uterus rapidly decreases in size, add further to bad outcomes. Abnormal presentation and operative intervention are also common. 7/30/2011 17 Dr.Uma Gupta, Dr.NK Gupta
18 : OLIGOHYDRAMNIOS Oligohydramnios affects approximately 3-9% of all pregnancies(Sarmiento 1993). Oligohydramnios is defined as the SDP devoid of cord or limbs measuring less than 3,2,1 cm, and the latter indicating moderate to severe oligohydramnios. Sarmiento A and Arias F.Fetal Dismorphology. In Practical guide to high risk pregnancy and delivery. 2nd edition, 1993Mosby, Missouri pg 319-353. 7/30/2011 18 Dr.Uma Gupta, Dr.NK Gupta
19 : EARLY-ONSET OLIGOHYDRAMNIOS Oligohydramnios is almost evident when there is either obstruction of the fetal urinary tract or renal agenesis; 15 to 25 percent of cases are associated with the fetal anomalies (McCurdy 1993). A chronic leak from a defect in the membranes may reduce the volume of fluid appreciably, but most often labor soon ensues. Exposure to angiotensin-converting enzyme inhibitors also has been associated with oligohydramnios. McCurdy CM Jr, Seeds JW. Oligohydramnios: problems and treatment. Semin Perinatol. 1993 Jun;17(3):183-96 7/30/2011 19 Dr.Uma Gupta, Dr.NK Gupta
20 : Prognosis Fetal outcome is poor with early-onset oligohydramnios and only half survive. Preterm delivery and neonatal death are also common. Oligohydramnios is associated with adhesions between the amnion and serious deformities including amputation are reported. Moreover, in the absence of amniotic fluid, the fetus is subjected to pressure from all sides and musculoskeletal deformities such as clubfoot are observed frequently. 7/30/2011 20 Dr.Uma Gupta, Dr.NK Gupta
21 : Pulmonary Hypoplasia Pulmonary hypoplasia is associated with early – onset ( first two trimester) oligohydramnios and occurs in about 15 percent of fetuses. There are several possibilities for pulmonary hypoplasia in these pregnancies; thoracic compression may prevent chest wall excursion and lung expansion. secondly, lack of fetal breathing movements decrease fluid inflow to the lung. The third and most widely accepted model suggests that there is a failure to retain amniotic fluid or increased outflow with impaired lung growth and development (Lauria 1995). Lauria MR, Gonik B, Romero R :(1995) Pulmonary hypoplasia: Pathogenesis, diagnosis and antenatal prediction. Obstet Gynecol 86;466. 7/30/2011 21 Dr.Uma Gupta, Dr.NK Gupta
22 : Thus the appreciable volume of amniotic fluid inhaled by the normal fetus plays an important role in growth of the lung. During normal fetal life, the fetus performs breathing movements that provide a “to-and-fro” movement of AF into and out of the trachea, upper lungs and mouth. Although AF may move back and forth, there is a net outward movement of fetal lung liquid. Clearly, the fetal lungs provide a volume of liquid to the AF, which adds to that of the fetal urine. 7/30/2011 22 Dr.Uma Gupta, Dr.NK Gupta
23 : LATE-ONSET OLIGOHYDRAMNIOS Management depends on clinical situation. Evaluation of fetal anomaly and growth is critical. Patients diagnosed with oligohydramnios during second trimester have higher incidence of congenital anomalies(50%) and a lower survival rate (10%) than with those diagnosed in third trimester(22% with anomalies and 85% survival)(Gagnon 2009). Gagnon R and Ross MG: Management of oligohydramnios and polyhydramnios.In High Risk Obstetrics- The requisites in Obstetrics and Gynecology. Edi Evans MI. First Edition, Mosby, Philadelphis. 2009,pg 137-145. 7/30/2011 23 Dr.Uma Gupta, Dr.NK Gupta
24 : Table – Conditions Associated with Oligohydramnios Fetal Chromosomal abnormalities Congenital anomalies Growth restriction Demise Postterm pregnancy Ruptured membranes Placenta Abruption Twin –twin transfusion Maternal Ulteroplacental insufficiency Hypertension Preeclampsia Diabetes Drugs Prostaglandin synthase inhibitors Angiotensin – converting enzyme inhibitors 7/30/2011 24 Dr.Uma Gupta, Dr.NK Gupta
25 : Table – Congenital Anomalies Associated with Oligohydramnios Amnionic band syndrome Cardiac: Fallot tetralogy, septal defects Central nervous system: holoprosencephaly, meinngocoele, encephalocoele, microcephaly Chromosomal abnormalities: triloidy, trisomy 18, Turner syndrome Cloacal dysgenesis Cystic hygroma Diaphragmatic hernia Genitourinary: renal agenesis, renal dysplasia, urethral obstruction, bladder esxtrophy, Meckel – Gruber syndrome, ureteropelvic junction obstruction, prune – belly syndrome. Hypothyroidism Skeletal: sirenomelia, sacral agenesis, absent radius, facial clefting Twin – reversed – arterial – perfusion (TRAP) sequence Twin – twin transfusion VACTERL (vertebral, anal, cardiac, tracheo – esophageal, renal, limb) association 7/30/2011 25 Dr.Uma Gupta, Dr.NK Gupta
26 : MANAGEMENT: Conservative Amnioinfusion- Serial transabdominal amnioinfusion are reported with mixed results. Maternal hydration(drinking 2L of water prior to USG) increases AFI by 2-4 cm at term(Hofmeyr 2002) .This short term improvement will persist if hydration is maintained for long term. Hofmeyr GJ,Gulmezoglu AM: Maternal hydration for increasing amniotic fluid volume in oligohydramnios and normal amniotic fluid volume. Cochrane Database Syst Rev 2002(1):CD000134. 7/30/2011 26 Dr.Uma Gupta, Dr.NK Gupta
27 : Conservative Desmopressin- ( 8 D-arginine vasopression). Cervical canal occlusion fibrin gel. Intra-amniotic sealing techniques Vasoamniotic shunting in obstructive uropathies. 7/30/2011 27 Dr.Uma Gupta, Dr.NK Gupta
28 : Definitive: With PPROM careful monitoring for signs and symptoms of chorioamnionitis is recommended. If chorioamniotis develops, delivery should be expedited regardless of gestational age. Long term survival beyond 32 weeks is good. In absence of infection elective LSCS is recommended between 32-36 weeks. Enhanced survillence, glucocorticoid administration, Doppler studies and timely intervention are the practices. 7/30/2011 28 Dr.Uma Gupta, Dr.NK Gupta
29 : ?? 7/30/2011 29 Dr.Uma Gupta, Dr.NK Gupta
30 : Thank You 7/30/2011 30 Dr.Uma Gupta, Dr.NK Gupta
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