Polyhydramnios

Ans. is D. i.e. Complications include placental abruption, uterine dysfunction, and postpartum hemorrhage.

• Polyhydramnios is an excessive quantity of amniotic fluid.
• The frequency of diagnosis varies, but polyhydramnios sufficient to cause clinical symptoms probably occurs in 1 of 1000 pregnancies, exclusive of twins.
• The incidence of associated malformations is about 20%, with CNS and GI abnormalities being particularly common.
• For example, polyhydramnios accompanies about half of cases of anencephaly and nearly all cases of esophageal atresia.
• Edema of the lower extremities, vulva, and abdominal wall results from compression of major venous systems.
• Acute hydramnios tend to occur early in pregnancy and, can leads to labor before the 28th week.
• The most frequent maternal complications are placental abruption, uterine dysfunction, and postpartum hemorrhage.

Ans. is C. i.e. Amniocentesis

• In this clinical scenario, amniocentesis is done to relieve the distress and to continue the pregnancy up to term.
• Slow decompression is done at a rate of about 500ml per hour.
• Normally 1-1.5litres of amniotic fluid is removed.
• Because of slow decompression, there is less chance of accidental hemorrhage, but fluid can reaccumulate soon.
• So amniocentesis has to be repeated.

Ans. is B. i.e. Cleft palate

• Cleft palate in the fetus is associated with the development of maternal polyhydramnios, as the facial cleft interferes with the normal swallowing process.

• Polyhydramnios is defined as a state where liquor amnii exceed 2000ml.

• Sonographically diagnosis is made when the amniotic fluid index is >25cm, and a single pool is >8cm.

Causes of Polyhydrdmnios

• The main contributor of amniotic fluid is fetal urine.
• Amount of amniotic fluid will be more (i.e. polyhydramnios) if:

1. Fetus produces more urine for example:

a. Twin/multifetal pregnancy (number of the fetus is more: more of urine)

b. Maternal hyperglycemia/diabetes Maternal hyperglycemia →Fetal hyperglycemia → Fetalpolyuria →increased amniotic fluid.

c. Twin to Twin transfusion syndrome.

2. Besides producing Amniotic fluid fetus also swallows amniotic fluid. 

→The amount of amniotic fluid will increase if; fetal swallowing is impaired as in case of:

a. Cleft lip and cleft palate

b. Esophageal atresia or stenosis

c. Duodenal atresia or stenosis

d. Bowel obstruction

e. Anencephaly (swallowing is decreased + increased transudation of CSF into amniotic fluid due to absence of cranial vault)

3. Other important causes of polyhydramnios are:

Placental Causes

a. Chorangioma of the placenta and circumvallate placenta.

Fetal Causes

a. Hydrops fetalis

b. Rubella, syphilis, Toxoplasma infection of the fetus.

c. Trisomy (note – Triploidy leads to oligohydramnios)

d. Sacrococcygeal Teratoma

e. Thalassemia of the fetus.

• M/C cause of mild polyhydramnios: idiopathic
• M/C cause of severe polyhydramnios: Gross congenital anomaly i.e. GIT malformations> CNS malformations.

Ans. is B. i.e. polyhydramnios

• The major associations of hypothyroidism in pregnancy are high fetal wastage, abortion, stillbirth, and prematurity, deficient intellectual function.
• A high association of pre-eclampsia and anemia are also seen with hypothyroidism.
• So by exclusion, we can put the answer as polyhydramnios.

Ans. is A. i.e. B/L renal agenesis

Either obstruction of the fetal urinary tract or renal agenesis will lead to oligohydramnios, not polyhydramnios.

• CNS malformations:

• GIT malformations: 

• Nonimmune hydrops

• Fetal pseudohypoaldosteronism
• Fetal Bartter or hyperprostaglandin E syndrome
• Fetal nephrogenic diabetes insipidus
• Placental chorioangioma
• Fetal sacrococcygeal teratoma
• Maternal substance abuse

Ans. is B. i.e. polyhydramnios

The most common cause of hypothyroidism in pregnancy is Hashimoto thyroiditis, characterized by glandular destruction from autoantibodies, particularly antithyroid peroxidase antibodies. There is an increased risk of,

• Preeclampsia
• Placental abruption
• Recurrent abortions
• Intrauterine growth restriction
• Prematurity
• Cardiac dysfunction
• Intrauterine fetal demise

Ans. is D. i.e. Polyhydramnios

Complications of polyhydramnios

Maternal

• Due to excessive fluid membranes are overstretched so it can lead to premature rupture of membranes (PROM) and preterm labor.
• Abruptio placenta
• PPH (due to overstretching & tone of uterus decreases)
• Subinvolution of uterus
• PIH (25% cases)
• Cord prolapse
• Malpresentation
• Unstable lie

In Fetus = Due to prematurity and congenital anomalies, there is increased perinatal mortality.

Ans. is d i.e. Bilateral renal agenesis

Renal agenesis leads to oligohydramnios and not polyhydramnios

• Polyhydramnios is a condition where liquor amnii is in excessive amount i.e., > 2 liters.
• But since quantitative assess­ment of liquor amnii is impractical.
• The most commonly used definition is by ultrasound assessment i.e., when the amniotic fluid index (AFI) is > 25 cms or finding a pocket of fluid measuring 8 cms or more in vertical diameter.

Grades of Polyhydramnios

• Mild defined as pockets measuring 8 – 11 cm in the vertical dimension (seen in 80% cases).
• Moderate defined as pocket measuring 12 – 15 cms in the vertical dimension (seen in 15% cases).
• Severe defined as free-floating fetus found in pockets of fluid of 16 cms or more (seen in 5% cases).

Ans. is  D. i.e. a & c 

Causes of Polyhydrdmnios

• The main contributor of amniotic fluid is fetal urine.
• Amount of amniotic fluid will be more (i.e. polyhydramnios) if:

1. Fetus produces more urine for example:

a. Twin/multifetal pregnancy (number of the fetus is more: more of urine)

b. Maternal hyperglycemia/diabetes Maternal hyperglycemia →Fetal hyperglycemia → Fetalpolyuria →increased amniotic fluid.

c. Twin to Twin transfusion syndrome.

2. Besides producing Amniotic fluid fetus also swallows amniotic fluid. 

→The amount of amniotic fluid will increase if; fetal swallowing is impaired as in case of:

a. Cleft lip and cleft palate

b. Esophageal atresia or stenosis

c. Duodenal atresia or stenosis

d. Bowel obstruction

e. Anencephaly (swallowing is decreased + increased transudation of CSF into amniotic fluid due to absence of cranial vault)

3. Other important causes of polyhydramnios are:

Placental Causes

a. Chorangioma of the placenta and circumvallate placenta.

Fetal Causes

a. Hydrops fetalis

b. Rubella, syphilis, Toxoplasma infection of the fetus.

c. Trisomy (note – Triploidy leads to oligohydramnios)

d. Sacrococcygeal Teratoma

e. Thalassemia of the fetus.

• M/C cause of mild polyhydramnios: idiopathic
• M/C cause of severe polyhydramnios: Gross congenital anomaly i.e. GIT malformations> CNS malformations.

Ans. is D. i.e. All.

Causes of Polyhydramnios

• The main contributor of amniotic fluid is fetal urine.
• Amount of amniotic fluid will be more (i.e. polyhydramnios) if:

1. Fetus produces more urine for example:

a. Twin/multifetal pregnancy (number of the fetus is more: more of urine)

b. Maternal hyperglycemia/diabetes Maternal hyperglycemia →Fetal hyperglycemia → Fetalpolyuria →increased amniotic fluid.

c. Twin to Twin transfusion syndrome.

2. Besides producing Amniotic fluid fetus also swallows amniotic fluid. 

→The amount of amniotic fluid will increase if; fetal swallowing is impaired as in case of:

a. Cleft lip and cleft palate

b. Esophageal atresia or stenosis

c. Duodenal atresia or stenosis

d. Bowel obstruction

e. Anencephaly (swallowing is decreased + increased transudation of CSF into amniotic fluid due to absence of cranial vault)

3. Other important causes of polyhydramnios are:

Placental Causes

a. Chorangioma of the placenta and circumvallate placenta.

Fetal Causes

a. Hydrops fetalis

b. Rubella, syphilis, Toxoplasma infection of the fetus.

c. Trisomy (note – Triploidy leads to oligohydramnios)

d. Sacrococcygeal Teratoma

e. Thalassemia of the fetus.

• M/C cause of mild polyhydramnios: idiopathic
• M/C cause of severe polyhydramnios: Gross congenital anomaly i.e. GIT malformations> CNS malformations.

Ans. is c i.e. Amniocentesis

• The patient in the question has marked respiratory distress (i.e. it is severe polyhydramnios and requires treatment) and gestational age is 35 weeks (i.e., fetal maturity is not yet achieved).
• So our aim should be to relieve the distress of the patient in the hope of continuing the pregnancy until at least 37 weeks.

Amniocentesis :

• The main aim of amniocentesis is to relieve maternal distress with the added advantage that the lung maturity of the fetus can be predicted by Lecithin / Sphingomyelin ratio in the expressed fluid.
• Slow decompression is done at a rate of 500 ml/hr.
• The maximum fluid removed is 1.5 — 2 liters.

Use of Indomethacin

Ans. is C. i.e. Posterior urethral valve

Causes of Polyhydramnios

• The main contributor of amniotic fluid is fetal urine.
• Amount of amniotic fluid will be more (i.e. polyhydramnios) if:

1. Fetus produces more urine for example:

a. Twin/multifetal pregnancy (number of the fetus is more: more of urine)

b. Maternal hyperglycemia/diabetes Maternal hyperglycemia →Fetal hyperglycemia → Fetal polyuria →increased amniotic fluid.

c. Twin to Twin transfusion syndrome.

2. Besides producing Amniotic fluid fetus also swallows amniotic fluid. 

→The amount of amniotic fluid will increase if; fetal swallowing is impaired as in case of:

a. Cleft lip and cleft palate

b. Esophageal atresia or stenosis

c. Duodenal atresia or stenosis

d. Bowel obstruction

e. Anencephaly (swallowing is decreased + increased transudation of CSF into amniotic fluid due to absence of cranial vault)

3. Other important causes of polyhydramnios are:

Placental Causes

a. Chorangioma of the placenta and circumvallate placenta.

Fetal Causes

a. Hydrops fetalis

b. Rubella, syphilis, Toxoplasma infection of the fetus.

c. Trisomy (note – Triploidy leads to oligohydramnios)

d. Sacrococcygeal Teratoma

e. Thalassemia of the fetus.

• M/C cause of mild polyhydramnios: idiopathic
• M/C cause of severe polyhydramnios: Gross congenital anomaly i.e. GIT malformations> CNS malformations.

Ans. is D. i.e. Renal agenesis

Causes of Polyhydramnios

• The main contributor of amniotic fluid is fetal urine.
• Amount of amniotic fluid will be more (i.e. polyhydramnios) if:

1. Fetus produces more urine for example:

a. Twin/multifetal pregnancy (number of the fetus is more: more of urine)

b. Maternal hyperglycemia/diabetes Maternal hyperglycemia →Fetal hyperglycemia → Fetalpolyuria →increased amniotic fluid.

c. Twin to Twin transfusion syndrome.

2. Besides producing Amniotic fluid fetus also swallows amniotic fluid. 

→The amount of amniotic fluid will increase if; fetal swallowing is impaired as in case of:

a. Cleft lip and cleft palate

b. Esophageal atresia or stenosis

c. Duodenal atresia or stenosis

d. Bowel obstruction

e. Anencephaly (swallowing is decreased + increased transudation of CSF into amniotic fluid due to absence of cranial vault)

3. Other important causes of polyhydramnios are:

Placental Causes

a. Chorangioma of the placenta and circumvallate placenta.

Fetal Causes

a. Hydrops fetalis

b. Rubella, syphilis, Toxoplasma infection of the fetus.

c. Trisomy (note – Triploidy leads to oligohydramnios)

d. Sacrococcygeal Teratoma

e. Thalassemia of the fetus.

• M/C cause of mild polyhydramnios: idiopathic
• M/C cause of severe polyhydramnios: Gross congenital anomaly i.e. GIT malformations> CNS malformations.

Ans. is B. i.e.  2000 ml

Ans. is C. i.e. Polyhydramnios

Polyhydramnios is not an indication for elective cesarean section in a patient with a history of cesarean section in the previous pregnancy.

Ans,D. Polyhydramnios

External auditory canal atresia:

• The precise etiology of the failure of EAC canalization is not known.
• Associations have been postulated between EACA and low birth weight, intrauterine trauma, toxins, infection.
• Genetic defects are being identified for several craniofacial anomalies.