Hydrocephalus, also known as "water on the brain", is a medical condition in which there is an

abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles, or cavities, of the brain. This
may cause increased intracranial pressure inside the skull and progressive enlargement of the
head, convulsion, and mental disability. Hydrocephalus can also cause death.

Pathology
Hydrocephalus is usually due to blockage of cerebrospinal fluid (CSF) outflow in the ventricles or
in the subarachnoid space over the brain. In a person without hydrocephalus, CSF continuously
circulates through the brain, its ventricles and the spinal cord and is continuously drained away
into the circulatory system. Alternatively, the condition may result from an overproduction of the
CSF fluid, from a congenital malformation blocking normal drainage of the fluid, or from
complications of head injuries or infections.[5]

Compression of the brain by the accumulating fluid eventually may cause convulsions and mental
retardation. These signs occur sooner in adults, whose skulls no longer are able to expand to
accommodate the increasing fluid volume within. Fetuses, infants, and young children with
hydrocephalus typically have an abnormally large head, excluding the face, because the pressure
of the fluid causes the individual skull bones — which have yet to fuse — to bulge outward at
their juncture points. Another medical sign, in infants, is a characteristic fixed downward gaze with
whites of the eyes showing above the iris, as though the infant were trying to examine its own
lower eyelids.[6]

Spontaneous intracerebral andintraventricular hemorrhage with hydrocephalus shown on CT scan[7]

The elevated intracranial pressure may cause compression of the brain, leading to brain damage
and other complications. Conditions among affected individuals vary widely. Children who have
had hydrocephalus may have very small ventricles, and presented as the "normal case".

If the foramina (pl.) of the fourth ventricle or the cerebral aqueduct are blocked, cereobrospinal
fluid (CSF) can accumulate within the ventricles. This condition is called internal
hydrocephalus and it results in increased CSF pressure. The production of CSF continues, even
when the passages that normally allow it to exit the brain are blocked. Consequently, fluid builds
inside the brain causing pressure that compresses the nervous tissue and dilates the ventricles.
Compression of the nervous tissue usually results in irreversible brain damage. If the skull
bones are not completely ossified when the hydrocephalus occurs, the pressure may also
severely enlarge the head. The cerebral aqueduct may be blocked at the time of birth or may
become blocked later in life because of a tumor growing in the brainstem.

Internal hydrocephalus can be successfully treated by placing a drainage tube (shunt) between
the brain ventricles and abdominal cavity to eliminate the high internal pressures. There is some
risk ofinfection being introduced into the brain through these shunts, however, and the shunts
must be replaced as the person grows. A subarachnoid hemorrhage may block the return of CSF
to the circulation. If CSF accumulates in the subarachnoid space, the condition is called external
hydrocephalus. In this condition, pressure is applied to the brain externally, compressing neural
tissues and causing brain damage. Thus resulting in further damage of the brain tissue and
leading to necrotization.


The primary site of CSF formation is believed to be the choroid plexusus of the lateral ventricles. CSF flows
from the lateral ventricles through the foramen of Monro to the third ventricle, then through the aqueduct of
Sylvius into the fourth ventricle through the foramen of Luschka and the midline foramen of Magendie into
the cisterna magna. From there it flows to the cerebral and cerebellar subarachnoid spaces where ti is
absorbed.
 Causes of Hydrocephalus are varied but result in either impaired absorption of CSF within the arachnoid
space (formerly referred to as communicating hydrocephalus) or obstruction to the flow of CSF through the
ventricular system (formerly referred as noncommunicating hydrocephalus.
 Most cases of obstruction are the result of developmental malformations; other causes include
neoplasms, infection and trauma. Obstruction to the normal flow can occur at any point in the CSF pathway,
which produces increased pressure and dilation of the pathways proximal to the site of obstruction.
 Impaired absorption can result form meningitis, prenatal maternal infections, meningeal malignancy
(secondary to leukemia or lymphoma), an arachnoid cyst, and tuberculosis.
Maternal hydration for increasing amniotic fluid volume in oligohydramnios Khilud Al-Salami, Karima Abdulsada
Bas J Surg, September, 13, 2007
59
Basrah Journal
Of Surgery Bas J Surg, September, 13, 2007
MATERNAL HYDRATION FOR INCREASING
AMNIOTIC FLUID VOLUME IN OLIGOHYDRAMNIOS
Khilud S Al-Salami* & Karima Abdul Sada#
*FICOG, CABOG, Lecturer, Dept.of Obstetrics & Gynecology. Basrah Medical College,
Basrah–Iraq.
#MB,ChB, Basrah General Hospital, Basrah–Iraq .

Abstract
The aim of this study was to evaluate the effect of acute maternal hydration on amniotic fluid
volume in pregnancies with third trimester olighydramnios. The study was done at Al-Basrah
General and Al-Basrah Maternity and Child Hospitals. A prospective case control study in which
amniotic fluid volume was evaluated in 100 pregnant women between (32-40) weeks of
gestational age with oligohyramnios (Case) and normal amniotic fluid index (AFI) and normal
AFI (Control). Fifty women of oligohydramnios and fifty of control were made to drink 2 litres of
water over 2 hours before repeating AFI measurement. The pre & post-hydration AFI were
compared between the two groups. The AFI in olighydramnios & control groups were increased
significantly by mean of 1.91 ± 0.61, P< 0.001 and 2.57 ± 1.37, p< 0.001 respectively . The
data were analyzed with paired t-test for statistical significance . In conclusion, maternal oral
hydration could be of therapeutic value in women with oligohydramnios.
Introduction
Physiology of Amniotic Fluid
mniotic fluid (AF) is derived from
maternal plasma in very early
pregnancy by the 10th week of
pregnancy, it is mainly a transudation
of foetal serum via the skin and
umbilical cord1.
From 16 weeks gestation the foetal
skin becomes impermeable to water
and the amniotic fluid is formed
increasingly from the foetal urine and
lung fluid1. At term the human foetus is
estimated to secrete 600–700 ml of
hypotonic urine into the amniotic
cavity per day, accounting for the
hypoosmolarity of the amniotic fluid.
The foetal respiratory tract secretes up
to 250 ml/day into the amniotic fluid
cavity2.
Foetal swallowing at term removes
50ml of fluid per day and the
remainder is reabsorbed by a flow of
water across the chorioamnion2.
The volume of fluid continues to
increase to a maximum at 34-36 weeks,
then gradually decreases, the volume is
approximately 50ml at 12 weeks and
doubles by 16 weeks. By 34-36 weeks
it reachs 1 liter3 and by 40 weeks 800
ml and 42 weeks 350 ml. The reason
for the late reduction in AF volume has
not been explained1. Amniotic fluid is
usually slightly turbid from mixture of
solid particles composed of lanugo
hairs, epithelial cells, sebaceous
material from the foetal skin and cast
off amniotic epithelial cells3.
At term the amniotic fluid has a
specific gravity of 1010 and contains
99% water and the fluid has organic,
inorganic and cellular contents.
Concentrations of some of the important
contents near term are as follow:
Sodium 130 mmol/L
Urea 3-4 mmol/L
Lecithin 30-100 mg/L

A
Maternal hydration for increasing amniotic fluid volume in oligohydramnios Khilud Al-Salami, Karima Abdulsada
Bas J Surg, September, 13, 2007
60
Protein 3 gm/L
Alpha fetoprotein 0.5-5 mg/L
In addition to hormones and enzymes4.
Amniotic fluid have many functions; it
allow freedom of movement and
prevent limb contracture4. It is also a
bacteriostatic providing some protection
from infection3. Prevent
adhesions between foetus and amnion1.
Protect the foetus from mechanical
injury4. Permit foetal lung development
in which there is two-way movement of
fluid into the foetal bronchioles and
absence of AF in the second trimester
is associated with pulmonary hypoplasia1
allow transmitting sounds freely
provide excellent view of the foetus by
ultrasonic examination3, and in labour
the distribution of fluid allows for the
force of uterine contractions to be
applied to the cervix when the
presenting part is high3.
Oligohydramnios can be defined as
reduced amniotic fluid or a pocket
measuring less than 1 cm in vertical
diameter, it is becoming more popular
to use an amniotic fluid index of less
than 5cm to define this condition5.
Incidence is approximately 3.9% of all
pregnancies6; however, it has been
estimated to be 12% of pregnancies 41
weeks or greater7.
Oligohydramnios can be caused by
post term pregnancy, pre mature
rupture of membrane, severe foetal
intra uterine growth restriction, foetal
renal anomalies, non renal foetal
abnormalities and leaking fluid
following amniocentesis or chorionic
villus sampling,
Aim of the study
To evaluate the effect of acute
maternal hydration on amniotic fluid
volume in pregnancies with third
trimester oligohydramnios.
Material Methods
Aprospective case-control study on
which participants were recruited
between March 2005 to June 2006 in
the out-patient clinic, department of
obstetric & gynaecology in Al-Basrah
General and Al-Basrah Maternity and
child Hospitals.
The study population consisted of 100
women with normal singleton pregnancies
between 32-40 weeks of gestation
in whom congenital abnormalities excluded.
Careful history was taken including
their history of present pregnancy, past
medical and obstetrical history.
Women with diabetes Mellitus, hypertension,
renal disease and ruptured
membranes were excluded from the
study.
Amniotic fluid index is currently the
preferred method for quantitating
liquor volume where the fluid is measured
vertically in each of the four
uterine quadrants and added together to
obtain the AFI, the largest pocket is
measured and care must be taken not to
include segment of umbilical cord in
the measurement. A sum of 5 cm or
less indicates significant oligohydramnios
regardless of the
gestational age5.
Control group are those women with
normal AF volume API >5cm while
case group are those women with third
trimester oligohydramnios with API
≤5cm5.
Pre hydration API of both control and
oligohydramnios patients have been
checked after which women in both
groups were instructed to drink 2 liters
of water in 2 hours. Women who
vomited or intolerate to take oral water
in 2 hours were excluded from the
study.
Repeat API by the same observer has
been done after 2 hours from finshing
drinking water.
The difference between the post and
pre-hydration API of both groups were
evaluated. The data were analyzed with
paired t- test for statistical significance
P value < 0.001.
Maternal hydration for increasing amniotic fluid volume in oligohydramnios Khilud Al-Salami, Karima Abdulsada
Bas J Surg, September, 13, 2007
61
Results
Maternal oral hydration was associated
with significant increase in API of both
oligohydramnios and control. The API
increase in oligohydramnios group by
mean of 1.91±0.61, 95% confidence
intervals (1.73 to 2.08), P<0.001 .
The API increase significantly in the
control group by a mean of 2.57±1.37,
95% confidence intervals (2.18 to
2.96), P<0.001. Table I.
Discussion
Amniotic fluid is essential for the
normal growth and wellbeing of the
featus (Chamberlain etal 1984)8.
Maternal oral hydration with 2 liters of
water in women with normal amniotic
fluid and oligohydramnios were
associated with significant increase in
API.
This finding suggests that maternal
hydration status has an important role
to play in normal regulation of
amniotic fluid volume, beside other
factors such as foetal urination and
foetal swallowing. Amniotic fluid
volume regulation and response to fluid
in take or withdrawal has been studied
in animal experiments, but very few
studies have been carried in humans.
In our study maternal oral hydration of
pregnant women with normal AFI
associated with increased AF volume
by mean of 2.57 cm, 95% confidence
interval 2.18 to 2.96, p<0.001 while in
oligohydramnios group the amniotic
fluid volume increase by mean of 1.91
cm, 95%, confidence interval 1.73 to
2.08, p<0.001.
The results obtained in our study were
found to be comparable to those
reported by Cochrane review9 who
demonstrated that maternal hydration
in women with and with out
oligohydramnios was associated with
an increase in amniotic fluid volume
(weighted mean difference for women
with oligohydramnios 2.01, 95% confidence
interval 1.43 to 2.60 and
weighted mean difference for women
with normal amniotic fluid volume 4.5,
95% confidence interval 2.92 to 6.08).
Similarly Flack etal10 demonstrated a
mean change in AFI in third trimester
oligohydramnios group of 3.2 cm, 95%
confidence interval 1.1 to 5.3, p<0.02.
This is similar to study performed by
Bhawna Malhotra India in 200211 on
which fifty women were made to drink
two liters of water before repeat AFI
measurement and it show significant
increament of AFI by mean of 2.01±
3.73 cm (p< 0.001).
Brace ST Moore 199112 demonstrated
that two hours were necessary before
direct amniotic fluid infusion in sheep
was associated with a significant
increase amniotic fluid volume, hence
2 hours was the time in our study to
measure the effect of hydration on
amniotic fluid volume.
In conclusion our study strongly
suggests that maternal hydration status
has a definite role in amniotic fluid
regulation and oral hydration increases
amniotic fluid volume in normal
pregnant and oligohydramnios patients.
Maternal hydration with hypotonic
solution (water) causes osmotic
changes, which relates to parallel
decrease in foetal osmolarity, increase
in foetal urine flow and formation of
amniotic fluid. Controlled trials are
needed to assess the clinical benefit and
possible risks of maternal hydration for
specific clinical purposes.

Risperidone in Pregnancy:
A Case of Oligohydramnios
Sandeep Grover and Ajit Avasthi
From the Department of Psychiatry, Postgraduate Institute of Medical Education &
Research, Chandigarh,
India
Corresponding author: Dr. Ajit Avasthi, Department of Psychiatry, Postgraduate
Institute of Medical Education &
Research, Chandigarh 160012, India, E-mail: pgimer@chd.nic.in
Abstract
Randomized controlled trials in relation to psychopharmacological agents are
not possible in pregnant women. There
are only very few prospective studies and most information which is available
is from retrospective studies, case series
and case reports. Data of use of risperidone in pregnancy is sparse, case
reports have suggested agenesis of corpus callosum;
9 live births with no malformation and 2 spontaneous abortions. Till now no
study or case report has suggested
association of oligohydraminos with risperidone (German J Psychiatry 2004;
7: 56-57).
Keywords: Risperidone, pregnancy, oligohydraminos
Received: 2.9.2004
Published: 17.10.2004
Introduction
The safety of psychotropics has not been established in
human pregnancy; therefore risks and benefits of their use
have to be carefully considered (Cohen & Rosenbaum,
1998). A literature search revealed case reports, case series
and reviews of use of clozapine and olanzapine in pregnancy
(Waldman & Safferman, 1993; Ernst & Goldberg, 2002;
Goldstein et al, 2000), but data of use of risperidone in pregnancy
is sparse. Animal studies in rats has shown increased
incidence of pup deaths and still birth with use of risperidone
during pregnancy (Ernst & Goldberg, 2002). Rosengarten
and Quartermain (2002) reported impaired learning and
disrupted short term retention in adulthood (2 months) with
use of risperidone in dam during pregnancy. In humans, case
reports with use of risperidone in pregnancy suggested agenesis
of corpus callosum (Physician‘s Desk Reference, 2001);
9 live births with no malformation and 2 spontaneous abortions
(Levinson et al., 2003); no abnormality in two cases
(Ratnayake & Libretto, 2002). To the best of our knowledge
till now no study/case report have documented oligohydramnios
with use of risperidone in pregnancy. We present
the following case as it highlights an interesting clinical situation
associated with the use of risperidone in pregnancy in a
patient of chronic schizophrenia and expand the data regarding
the use of psychopharmacological agents in pregnancy.
Case History
N.G., 24 years old, belonging to a Hindu nuclear family of
middle socioeconomic status from an urban background,
presented with an acute onset, continuous gradually deteriorating
illness of 3 years duration precipitated by failure in an
examination; characterized by thought broadcast, visual
hallucinations, delusion of reference, persecution and grandiosity,
muttering to self, labile affect and disturbed biofunctions.
She was started on tablet risperidone 4 mg per day 6-8
months after the onset of the illness, with which she showed
improvement and got married about 18 months after the
onset of the illness. The patient continued to be symptomatic
for a year after marriage because of irregular drug
GROVER & AVASTHI
57
compliance, after which she conceived. Pregnancy was detected
only after 8 weeks. Both the patient and her husband
decided to continue the pregnancy even after being counseled
about the risks. Because of increase in the symptoms,
from the second trimester, the patient was continued on
risperidone 4 mg per day with regular compliance. All the
investigations i.e. VDRL, HIV, HBsAg were negative during
the first trimester. Her blood group was “O +ve” and alpha
fetoprotein levels done at 8 weeks was 5.1 ng/ml (normal
<10ng/ml). She was started on vitamin (folic acid), calcium
& iron supplements at 10th week of pregnancy. Ultrasound
examination at 16th week showed no abnormality, but at 27th
weeks showed mild reduction in amniotic fluid quantity.
There was no evidence of premature rupture of membranes,
intrauterine growth retardation, renal and urinary tract malformations
in the feotus, any other drug use, maternal hypertension,
and maternal diabetes. By the 39th week there was
severe reduction in amniotic fluid, but there was no evidence
of other causes which could contribute to oligohydraminos
as described above in the negative findings. At the 39th week
the patient was admitted for induction of labour. Within 2
days, the patient developed a poor biophysiological profile
and had to undergo emergency caesarean section and gave
birth to a female child weighing 3.2 kilograms. There was no
evidence of congenital malformations at birth and Apgar
score was 9 at both 1 and 5 minutes. Patient was advised not
to breast-feed the baby. The baby is growing normally (currently
2 years of age).
Discussion
Oligohydramnios is a condition in which there is too little
amniotic fluid around the fetus. Generally, it is caused by
conditions that prevent or reduce amniotic fluid production.
Factors that are associated with oligohydramnios include
premature rupture of membranes, intrauterine growth retardation,
post-term pregnancy, birth defects, especially kidney
and urinary tract malformations, non-renal abnormalities like
heart block, thyroid gland agenesis, cloacal dysgenesis,
chronic abruptio, twin-to-twin transfusion syndrome, karyotype
abnormalities like triploidy, turner syndrome, maternal
hypertension, maternal diabetes, uteroplacental insufficiency
and maternal use of prostaglandin synthase inhibitors or
angiotensin-converting enzyme (ACE) inhibitors. A diagnosis
of oligohydraminos is usually made using ultrasound,
pockets of amniotic fluid can be measured and the total amount estimated.
Ultrasound can also show fetal growth,
the structure of the kidneys and urinary tract, and detect
urine in the fetal bladder. Doppler flow studies (a type of
ultrasound used to measure blood flow) may be used to
check the arteries of the kidneys (Arias, 2000; Peipert &
Donnenfeld, 1991). It has been documented that oligohydraminos
developing in the second trimester with normal
alpha fetoprotein levels is associated with good prognosis
(Peipert & Donnenfeld, 1991) as was seen in our case.
Our observation implies that risperidone should be used
with caution and regular monitoring in pregnancy.