Polyhydramnios/ Hydramnios
DEFINITION:
- Anatomically, polyhydramnios is defined as a state where liquor amnii exceeds 2,000 mL.
- Sonographic diagnosis:
- Amniotic fluid index (AFI) is more than 24cm (more than 95th centile for gestational age)
- Deepest vertical pocket (DVP) is more than 8 cm
INCIDENCE:
- 1–2% of cases
- More common in multiparae than primigravidae
ETIOLOGY:
FETAL ANOMALIES:
- Anencephaly
- Open spina bifida
- Esophageal or duodenal atresia
- Facial clefts and neck masses
- Hydrops fetalis
- Aneuploidy and genetic syndromes
- Chorioangioma of the placenta
- MULTIPLE PREGNANCY:monozygotic twins
- MATERNAL:
- Diabetes(30%)
- Cardiac or renal disease
- IDIOPATHIC: 50–60%
CLINICAL TYPES:
- Chronic
- onset is insidious taking few weeks
- Acute (extremely rare)
- Onset is sudden
- 10 times more common
- Mild: DVP more than 8–11 cm
- Moderate: DVP: 12–15 cm
- severe: DVP more than or equal to 16 cm.
CHRONIC POLYHYDRAMNIOS:
SYMPTOMS:
- Respiratory:dyspnea
- Palpitation
- Edema of the legs, varicosities in the legs or vulva and hemorrhoids
SIGNS:
- Evidence of preeclampsia (edema, hypertension and proteinuria)
ABDOMINAL EXAMINATION:
- Inspection:
- Abdomen enlarged ,Globular with fullness at flanks.
- Skin is tense, shiny with large striae
Palpation:
- ↑Height of the uterus
- Girth of the abdomen round umbilicus is more than normal
- Fluid thrill
- Fetal parts cannot be well-define
- Auscultation:FHS not heard distinctly
INVESTIGATIONS:
Sonography:
- Detect abnormally large echo-free space
- largest vertical pocket more than 8 cm
- AFI is more than 25 cm
- Exclude multiple fetuses
- Detect lie and presentation of the fetus
- Diagnose any fetal congenital malformation
Blood:
- ABO and Rh grouping
- Postprandial sugar and if necessary glucose tolerance test.
Amniotic Fluid:
- Estimation of alpha fetoprotein markedly elevated in the presence of fetus with an open neural tube defect.
COMPLICATIONS:
Maternal:
- During pregnancy
- Preeclampsia (25%)
- Malpresentation
- Premature rupture of membranes
- Preterm labor
- Accidental hemorrhage
During labor:
- Early rupture of the membranes
- Cord prolapse
- Uterine inertia
- Increased operative delivery
- Retained placenta, postpartum hemorrhage and shock
Puerperium:
- Subinvolution
- Increased puerperal morbidity
Fetal:
- Increased perinatal mortality50%
- Prematurity and congenital abnormality (40%)
MANAGEMENT:
- MILD POLYHYDRAMNIOS (DVP: 8–11 cm):
- Midtrimester
- No treatment
SEVERE POLYHYDRAMNIOS (DVP: >16 cm):
- Supportive therapy
- Sulindac
- bed rest
- Further management depends on
- Response to treatment
- Period of gestation
- Presence of fetal malformation
- Associated complicating factors.
Uncomplicated cases:
- Response to treatment is good: The pregnancy is to be continued
- Unresponsive: (with maternal distress)
- Pregnancy less than 37 weeks:amniocentesis
- Pregnancy more than 37 weeks:
- Amniocentesis → drainage of liquor →Check the favorable lie and presentation of fetus → stabilizing oxytocin infusion→ low rupture of membranes is done
Exam Question
- Complications include placental abruption, uterine dysfunction, and postpartum hemorrhage are seen in polyhydramnios
- Polyhydramnios is associated with Diabetes,Anencephaly, Open spina bifida & Tracheo esophageal fistula
- Amniocentesis is the treatment of choice in pregnant women with polyhydramnios and marked respiratory distress at 35 weeks of gestation
- Cleft palate is associated with polyhydramnios
- Clinical signs of Hydramnios can be demonstrated when fluid collection is more than 2 ltr.
- Causes of Hydramnios are Twins,Oesophageal atresia or Anencephaly
- ARM is contraindicated in Hydramnios
- Feature of diabetes mellitus in pregnancy is Hydramnios
- Hydramnios is complicated by Placenta abruptio, Pre-eclampsia & Atonic Hemorrhage
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