Subject: OB Topic: Hydramnios / PROM Lecturer: Dra.

Brion Shifting /Date: 1st Shifting / July 21, 2008 Trans group: hotstuff! Normal Amniotic Fluid AOG (weeks) AFV (mL) % fluid 16 200 50 28 1000 46 36 900 24 40 800 17 *postpartum – oligohydramnios *decreased amniotic fluid - rehydrate Measurement of Amniotic Fluid Volume 1. Amniotic Fluid Index • increased by: o high altitude o maternal hydration o administration of L-deamino-8-Darginine vasopressin increasing maternal serum osmolality • decreased by: o maternal dehydration (diarrhea or hyperemesis) by fluid restriction 2. Single Suspended Pocket • single deepest pocket 3. Doppler Imaging with AFI HYDRAMNIOS • aka polyhydramnios • excessive AFV • usually more than 2 liters of AFV • defined as AFI > 24-25 cm • may lead to uterine atony/PPH because of too much stretching Classification according to severity: • mild o 8-11 cm vertical pocket o found in 80% • moderate o a pocket with only the small parts o 12-15 cm vertical pocket o found in 15% • severe o free floating fetus o fluid pocket ≥ 16 cm o found in 5% only

Causes: • commonly associated with fetal malformations (congenital) that can be in combinations: o GIT (esophageal atresia) o CNS (anencephaly) – meninges are open o Cardiac o Thoracic o Skeletal o Chromosomal • Less common cause: o Fetal Pseudoaldosteronism o Nephrogenic Diabetes Insipidus o Placental Chorioangioma o Fetal Bartter or Hyperprostaglandin E Syndrome o Sacrococcygeal Teratoma* o Maternal Substance Abuse* *most commonly seen in practice Pathogenesis: • impaired fetal swallowing • transudation of fluid from exposed meninges in the amniotic cavity as in anencephaly and spina bifida • excessive urination due to hyperstimulation of the exposedncerebrospinal center or lack in ADH because of impaired AVP secretion • in monozygotic twins, due to cardiac hypertrophy in the recipient twin causing increased urine output • associated with maternal DM during the 3rd trimester, maternal hyperglycemia, causing fetal hyperglycemia, resulting in osmotic dieresis Diagnosis: • History: o severe dyspnea o excessive edema of the lower extremities, vulva, and abdominal wall o oliguria because of ureteral obstruction from the enlarged fetus


Subject: OB Topic: : Hydramnios / PROM
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mirror syndrome when associated with fetal hydrops (mother mimics the fetus) onset:  acute • early onset • starts in 16-20 weeks • leads to labor before 28 weeks of gestation • severe symptoms requiring prompt intervention because of possible congenital anomalies (do work-up ASAP)  chronic • starts later • less discomfort for the mother

Clinical Findings: • difficulty in palpating fetal small parts • difficulty in hearing the fetal heart tone • very tense uterine wall (unable to palpate fetal parts) • greater fundic height measurement Differential Diagnoses: • ascites • large ovarian cyst Outcome: • guarded because of fetal malformations • increased perinatal morbidity and mortality because of increased risk of preterm labor • increased association with: o abruptio placenta shearing effect (because of sudden release of amniotic fluid) o uterine cord prolapse due to sudden gush of fluid o umbilical cord prolapse due to overdistention o post partum hemorrhage due to overdistention Management: • no intervention required for mild to moderate cases • treatment necessary with maternal compromise like difficulty of breathing • bed rest, salt and water restriction • diuretics are not effective

Treatment Modalities: • Amniocentecis o diagnostic and therapeutic (releases some of the pressure) • Amniotomy o rupture of membranes (pinpoint holes) will relieve maternal discomfort o risk of cord prolapse and abruptio placenta o there is commitment to deliver (should be done near term) • Indomethacin Therapy o impairs lung liquid function and enhances absorption o decreases fetal urine production o increases fluid movement across fetal membrane o dose: 1.5 – 3 mg/kg/day o causes premature closure of fetal ductus arteriosus o studies show constriction (not persistent) OLIGOHYDRAMNIOS • Diminished AFV below normal limits (<5cm AFI) • acute oligohydramnios carries worst prognosis • common in post-term pregnancies Mechanism: • chronic severe placental insufficiency • increased risk for cord compression and fetal distress Early Onset: • commonly due to obstruction in the fetal urinary tract or renal agenesis • chronic leak from defect in the fetal membranes • exposure to ACE inhibitors • conditions associated to: o Fetal  chromosomal abnormalities  congenital malformations  IUGR (Intrauterine Growth Restriction)  death of baby  PROM  post-term pregnancy o Placental

Subject: OB Topic: : Hydramnios / PROM
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abruption twin-to-twin transfusion syndrome Maternal  uteroplacental insufficiency  maternal hypertension  DM Drugs  prostaglandin sythetase inhibitors  ACE inhibitors Idiopathic  

Congenital Anomalies Associated with Oligohydramnios: • Amniotic Band syndrome • Cardiac – Tetralogy of Fallot, septal defects • GI – cloacal dysgenesis • GU – renal agenesis, renal dysplasia (anuria) • Skeletal – sacral agenesis • Chromosomal abnormalities • Hypothyroididsm • Twin-to-twin Transfusion • VACTERL (vertebral, anal, cardiac, transesophageal, renal, limb associated defects) • Diaphragmatic hernia

before 36 weeks with normal fetal anatomy and growth o close fetal surveillance (stress test, non-stress test, fetal movement monitoring, UTZ, Doppler) o watch out for fetal growth retardation (FTR) and fetal distress o anticipate possible problems at delivery  increased cord compression  variable deceleration  increased CS rate (because of fetal distress)  meconium – increased aspiration causing fetal hypoxia and fetal distress Amnioinfusion o to allow lungs to grow especially in premature babies o done intrapartum o warmed NSS of 500-800 mL is infused through an intrauterine pressure catheter and continuous infusion at 3 mL/min gives good results


Complications: • pulmonary hypoplasia in 1.1-1.4/1000 infants o increased risk of stillbirths and neonatal deaths • possible mechanism for pulmonary hypoplasia o thoracic compression preventing lung expansion o lack of fetal breathing movements decrease lung inflow o no expansion of lungs o failure to retain intrapulmonary amniotic fluid or increase outflow (impairs lung growth and development)  most widely accepted model Management: • Expectant Management

PROM • Premature Rupture of Membrane • Preterm Rupture of Membrane (old name) • Prelabor Rupture of Membrane (preferred) o increased risk for infection o cervix is closed o no effacement Definition: • rupture of fetal membrane with a latent period before the onset of spontaneous uterine activity Incidence: • 10% of all pregnancies • majority of cases occur in >37 weeks PPROM (Preterm Premature Rupture of Membrane) • PROM < 37 weeks • 2% in all pregnancies • very high chance of infection Maternal Risk Associated with PROM: 1. Chorioamionitis • localized to the uterus

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up to 30% in PPROM serious maternal systemic infection is rare with prompt treatment Abruptio Placenta • 4-7% incidence Increased operative delivery (>24 hrs) Increased incidence of retained placenta • due to more cases of marginal cord insertion and battledore placenta Postpartum Hemorrhage (from infection) Puerperal Maternal Morbidities • endomyometritis • impaired maternal-fetal bonding


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additional tests: ferning (smear of amniotic fluid on a slide), nitrozine test, presence of vernix or meconium intra-amniotic dye injection – not usuallu done fetal fibronectin testing – if increased, there is an increase in preterm delivery ultrasound – oligohydramnios is only detectable in large fluid loss

Fatal/Neonatal Risks Associated with PROM 1. Prematurity • delivery occurs within 7 days in over 80% of cases 2. Neonatal Sepsis • 2-4% • consider gestational age, length, latent period 3. Oligohydramnios Tetrad (FLIP) • F – Facial anomalies • L – Limb position defects • I – Impaired fetal growth • P – Pulmonary hypoplasia 4. Fetal Hypoxia • cord prolapsed and compression, abruptio placenta 5. Birth Injuries • difficult deliveries due to malpresentation and oligohydramnios Management Options: • Pre-pregnancy o counsel about recurrent risks (21-32%) o search for causes/precipitating factors (due to infection) o advice against cigarette smoking o vaginal bacteriological screening o antimicrobial treatment not proven

Vigilance for Chorioamnionitis: a. Clinical 1. maternal fever 2. tachycardia 3. uterine pain/tenderness 4. purulent vaginal discharge b. Laboratory (unreliable) 1. WBC (differential count) 2. C-Reactive Protein (CRP) 3. Amniotic Fluid gram stain, WBC and culture 4. Gas Chromatography – not done c. Biophysical Testing 1. NST (non-stress test) 2. BPS (biophysical stress) Delivery Indicated if: • chorioamnionitis is diagnosed • fetal distress occurs o fetal heart rate abnormalities o variable decelerations which signifies cord compression If NO chorioamnionitis, management depends on AOG: • <24 weeks o increased risk for pulmonary hyperplasia o individualize management o careful counseling of parents o if pregnancy is to be continued, do surveillance for sepsis o Management: patient is supine – don’t let amniotic fluid flow out • 24-31 weeks o upper gestational age cut-off will vary with different institutions depending on the survival rates o conservative rather than aggressive o if NO chorioamnionitis,  use of steroids, tocolytics, and antibiotics is not variable  assessment of fetal pulmonary maturity is a variable practice

Prenatal o diagnosis (patient presents with watery discharge) o history and examination (sterile speculum exam) o repeated pad check (sanitary napkin)

Subject: OB Topic: : Hydramnios / PROM
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31-36 weeks o options used in practice are: (depends on the hospital)  conservative: • wait for 24 hours and if NOT in labor, go for INDUCTION  aggressive: • induce labor at presentation (less chance of chorioamnionitis) • RTC’s (Randomized Control Trials) o waiting up to 4 days increases the maternal septic morbidity

Labor and Delivery: 1. maintain vigilance and screening for infections 2. use of maternal antibiotics for prophylaxis 3. consider amnioinfusion for fetal distress 4. caesarian sections for usual obstetric indications 5. pediatrician attendance during delivery Postnatal Management: 1. maintain vigilance and screening for infection 2. neonatal screen for sepsis

Hi classmates! Malapit na shiftings!! Goodluck saten.. Aral ng madame at mgimbak na ng mraming kape.. haha! Kyth,

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