Significance of oligohydramnios complicating pregnancy

Lewis Shenker, MD, Kathryn L. Reed, MD, Caroline F. Anderson, RDMS, and
Nydia A. Borjon, RDMS
Tucson, Arizona

Oligohydramnios is a serious complication of pregnancy that is associated with a poor perinatal outcome.
Eighty pregnancies complicated by oligohydramnios constitute the basis for this retrospective study. Forty
patients had premature rupture of the membranes; of these, outcomes were good in 25. Twelve of 14
fetuses with oligohydramnios and intrauterine growth retardation survived. None of the nine fetuses with
severe renal anomalies lived. None of the twins with twin-twin transfusion and oligohydramnios survived.
Six pregnancies with oligohydramnios and premature separation of the placenta were identified; all of
these resulted in fetal or neonatal death during the second trimester. (AM J OSSTET GVNECOL
1991 ;164:1597-600.)

Key words: Oligohydramnios, premature rupture of membranes, renal anomalies,

premature separation of the placenta

The accurate diagnosis of oligohydramnios became Table I. Causes of oligohydramnios

possible with the introduction of ultrasonographic ex- -N-o,-of-
aminations during pregnancy. Outcomes for this com-
plication of pregnancy have been reported by several
Cause
I
. patients Survived
----
Premature rupture of membranes 40 25 (62%)
authors. l -6 There is a consensus that severe oligohy- Intrauterine growth retardation 14 12 (84%)
dramnios identified in the second trimester of preg- Fetal renal anomalies 9 o
nancy is an indication that perinatal outcome will be Renal agenesis 3
Urethral obstruction 3
poor. Oligohydramnios may be associated with fetal Multicystic kidneys 3
anomalies, intrauterine growth retardation, and ele- Premature separation of placenta 6 o
vated perinatal mortality rates. The present paper in- Twin-twin transfusion 3 o
Congenital anomalies (nonrenal) 2 o
vestigates the causes for oligohydramnios and corre- Unknown 6 1 (18%)
lates the causes with outcome. A special group of
second-trimester patients with both oligohydramnios TOTAL 80 38 (48%)

and premature separation of the placenta is identified.

The ultrasonographic and Doppler flow characteristics
and differential diagnosis in patients with oligohydram- nios was diagnosed when no pockets of amniotic fluid
nios and premature separation of the placenta are pre- > 1 em were observed. The patients' charts were re-
sented. viewed, and neonatal outcomes were recorded.

Material and methods Results

Fetal ultrasonographic studies performed at the Ar-
izona Health Sciences Center Department of Obstetrics
and Gynecology between January 1986 and June 1989
(8443 studies) were reviewed. Two-dimensional ex-
aminations were performed with 3.5 and 5 MHz trans-
ducers, and Doppler umbilical cord velocities were
measured in selected patients. The diagnosis of oligo-
hydramnios was made in 80 patients. Oligohydram-
From the Department of Obstetrics and Gynecology, Arizona Health
Sciences Center.
Presented at the Fifty-seventh Annual Meeting of the Pacific Coast
Obstetncal and Gynecologtcal SOCiety, Sun Valley, Idaho, September
9-14,1990.
Reprint requests: Lewis Shenker, MD, Dept. of Obstetrics and Gy-
necology, Arizona Health Sciences Center, 1501 N. Campbell Ave.,
Tucson, AZ 85724.
6/6/28665
The causes of oligohydramnios in our patients are
summarized in Table I. The overall survival rate was
49%. Survival varied with the cause of oligohydram-
nios, from 84% in intrauterine growth retardation and
61 % in premature rupture of the membranes to 0% in
renal anomalies and premature separation of the pla-
centa. Among those patients with premature rupture
of the membranes, survival was related to gestational
age at the time of rupture. At ::;25 weeks, only two of
15 babies survived (13%); after 25 weeks, 23 of 25 ba-
bies survived (92%).
The etiologic factors in growth retardation in our
patients were hypertensive disorders in six, anomalies
in two (Russell-Silver syndrome in 1, multiple malfor-
mations in another), and maternal drug use in two.
Four patients had no identifiable risk factors. Doppler

1597
 1598 Shenker et al. June 1991
Am J Obstet Gynecol

Table II. Premature separation of the placenta and oligohydramnios

Onset of Onset of Gestational
Case Age Gravidity and bleeding oligohydramnIOs age at dehvery Weight
No. (yr) parity (wk) (wk) (wk) (gm) Outcome Remarks

1 24 G3 P2 23 26 27 475 Stillborn Doppler normal

2 35 Gl PO 10 23 27 320 Stillborn Doppler systolic/diastolic high
3 23 G2 PI ? 20 29 1100 Death Doppler normal
4 21 G4 PI 19 22 24 535 Death Doppler normal
5 32 G4 PI 15 22 25 880 Death Doppler normal
6 22 G4 P3 19 25 26 755 Stillborn Doppler not done

G, Gravidity; P, parity.

umbilical cord flow studies were performed in all these
patients. Systolic! diastolic ratios were high in eight,
four of whom had absent diastolic flows. One fetus with
absent diastolic flow was stillborn at 20 weeks' gestation.
The other seven fetuses with high systolic! diastolic
ratios or absent diastolic flows were delivered by cesar-
ean section for fetal distress. Six fetuses had normal
systolic/ diastolic ratios; two of these were delivered by
cesarean section for fetal distress.
In five of six cases, when premature separation of
the placenta was diagnosed clinically and confirmed by
ultrasonography, Doppler umbilical flow studies were
performed. Four of the five studies were normal; one
fetus had absent diastolic flow. The clinical features of
the patients with oligohydramnios and premature sep-
aration of the placenta are summarized in Table II.
Comment
Causes of oligohydramnios in other studies 1. 2 include
spontaneous rupture of the membranes, intrauterine
growth retardation, genitourinary anomalies, use of in-
domethacin in the treatment of premature labor? and
abnormal karyotypes, including triploidy.B
The most common cause of oligohydramnios in this
study is premature rupture of the membranes, and in
a diagnostic plan membrane status (ruptured or intact)
should be established initially. The quality of ultraso-
nographic examination is considerably reduced by the
absence of fluid surrounding the fetus, and special care
must be taken to identify fetal renal structures to ex-
clude or establish the diagnosis of renal agenesis. Mul-
ticystic renal disease is less difficult to diagnose, because
of the appearance of the kidneys and often the dis-
tended bladder on ultrasonographic examination. Oli-
gohydramnios in twin gestation may be due to circu-
latory alterations, intrauterine growth retardation, or
fetal death.
There have been several reports describing oligo-
hydramnios accompanying intrauterine growth retar-
dation. Hill et al. 9 used oligohydramnios as a screening
tool for the diagnosis of intrauterine growth retarda-
tion. Philipson et al. 10 recognized that the presence of
oligohydramnios should increase the clinical suspicion
of growth retardation, but, if it is used as the only
screening tool, 84% of cases would be missed. Steele
et al. II suggested that four severely growth retarded
infants with severe oligohydramnios had fetal renal fail-
ure. Severe oligohydramnios worsens the prognosis for
survival in the growth retarded fetus; however, with
active intervention 12 of 14 newborns in our series
survived. Doppler umbilical flow studies with a high
systolic/ diastolic ratio were seen in fetuses who devel-
oped severe distress, as defined by positive contraction
stress tests and fetal bradycardia. All of the viable fe-
tuses with high ratios were delivered by cesarean
section.
The early appearance of oligohydramnios in twin
gestation is a very poor prognostic sign. In our three
cases, all the fetuses were stillborn or died because of
immaturity.
The six patients with oligohydramnios and prema-
ture separation of the placenta were of particular in-
terest. Every attempt was made to be certain that rup-
tured membranes was not responsible for the oligo-
hydramnios. Leakage of amniotic fluid could not be
demonstrated in any of these patients despite multiple
examinations. All patients spent several weeks in the
hospital, and some received blood transfusions. All
pregnancies ended in the second trimester with a uni-
formly lethal fetal outcome. Premature rupture of the
membranes with severe oligohydramnios has been de-
scribed as a risk factor for premature separation of the
placenta. 12 In our cases the separation of the placenta
preceded the appearance of oligohydramnios. In one
study, two cases of antepartum hemorrhage were noted
among 113 patients referred for fetal assessment be-
cause of oligohydramnios in the absence of ruptured
membranes. 3 On that basis, active intervention for
oligohydramnios when "perinatal salvage was consid-
ered feasible" was recommended. Delivery would have
been inappropriate and not resulted in improved sal-
vage in our six patients because of fetal immaturity. It
is interesting to note that Doppler umbilical flow studies
were normal in four of five patients with oligohydram-
nios and bleeding in the second trimester and were not
helpful in the prediction of the adverse outcomes that
Volume 164
Number 6, Part 1
occurred, This is in contrast to the outcomes in fetuses
with oligohydramnios and intrauterine growth retar-
dation, We speculate that inadequate placental function
leading to inadequate fetal renal perfusion may be re-
sponsible for the oligohydramnios when premature
separation of the placenta is present in the second
trimester.
REFERENCES
1. Mercer Lj, Brown LG, Petres RE, Messer RH. A survey
of pregnancies complicated by decreased amniotic fluid.
AMj OBSTET GVNECOL 1984;149:355-61.
2. Barss VA, BenacerrafBR, Frigoletto FDJr. Second trimes-
ter oligohydramnios, a predictor of poor fetal outcome.
Obstet Gynecol 1984;64:608-10.
3. Bastide A, Manning F, Harman C, Lange 1, Morrison I.
Ultrasound evaluation of amniotic fluid: outcome of preg-
nancies with severe oligohydramnios. AM j OBSTET Gv-
NECOL 1986; 154:895-900.
4. Mercer Lj, Brown LG. Fetal outcome with oligohydram-
nios in the second trimester. Obstet Gynecol 1986;67:
840-2.
5. Varma TR, Bateman S, Patel RH, Chamberlain GV, Pillai
U. Ultrasound evaluation of amniotic fluid: outcome of
pregnancies with severe oligohydramnios. Intj Gynaecol
Obstet 1988;27:185-92.
6. Moore TR, Longo j, Leopold GR, Casola G, Gosink BB.
The reliability and predictive value of an amniotic fluid
scoring system in severe second-trimester oligohydram-
nios. Obstet Gynecol 1989;73:739-42.
7. Marpeau L, Keskes j, Vincenti 0, Boyer F, et al. Value
and dangers of indomethacin used in pregnancy. j Gy-
necol Obstet Bioi Reprod 1988;17:115-22.
8. Crane jP, Beaver HA, Cheung SW. Antenatal ultrasound
findings in fetal triploidy syndrome. j Ultrasound Med
1985;4:519-24.
9. Hill LM, Breckle RT, Wolfgram KR, O'Brien PC. Oligo-
hydramnios: ultrasonically detected incidence and sub-
sequent fetal outcome. AM j OBSTET GVNECOL 1983;
147:407-10.
10. Phillipson EH, Sokol Rj, Williams T. Oligohydramnios:
clinical associations and predictive value for intrauterine
growth retardation. AM j OBSTET GVlIOECOL 1983;146:
271-8.
11. Steele BT, Paes B, Towell ME, Hunter Dj. Fetal renal
failure associated with intrauterine growth retardation.
AMj OBSTET GVNECOL 1988;159:1200-2.
12. Vintzileos AM, Campbell WA, Nochimson Dj, Weinbaum
Pj. Preterm premature rupture of the membranes: a risk
factor for the development of abruptio placentae. AM j
OBSTET GVNECOL 1987;156:1235-8.
Discussion
DR. RUSSELL K. LAROS, JR., San Francisco, Califor-
nia. Dr. Shenker and colleagues have described their
experience with 80 cases of severe oligohydramnios dis-
covered during the second trimester of pregnancy. Ap-
propriately, they analyzed the pregnancy outcomes
with respect to the cause of the oligohydramnios.
Clearly, the best survival (84%) was in the 14 cases of
intrauterine growth retardation. The overall survival
of 62% in the 40 patients with prolonged ruptured
membranes is compatible with other reports in the lit-
erature. The authors stress the importance of gesta-
Oligohydramnios complicating pregnancy 1599
tional age at the time of rupture as a predictor of
outcome.
The study group includes nine patients with renal
anomalies. Three of these were cases of urethral ob-
struction. Our genetics group has been quite successful
in treating cases such as this in utero with a current
survival rate of 40% in 40 cases.' Both catheter drainage
of the fetal bladder into the amniotic sac and intra-
uterine surgery have been accomplished successfully.
Were any of your three cases appropriate candidates
for surgery?
Dr. Shenker's experience includes three cases of twin-
twin transfusion with the "stuck twin" phenomenon.
This is a problem exclusive to monochorionic, diam-
niotic pregnancies." 3 The Seattle group has reported
significant improvement in outcome with serial amnio-
centesis (31 % versus 80% mortality); we have had sim-
ilar results at our institution."
The most significant contribution of this study is the
delineation of a previously unrecognized association
between chronic abruptio placentae and oligohydram-
nios. It will be important for the authors and others to
expand the numbers of these cases to document
whether the dismal prognosis observed to date holds
up with larger numbers. Incidentally, my genetics col-
leagues tell me that they have observed persistent oli-
gohydramnios in association with subchorionic hem-
orrhage after chorionic villus sampling; again the prog-
nosis was very poor.
Finally, I would like to spend a moment reviewing a
plan of action for the clinician presented with a case of
oligohydramnios in the second trimester of pregnancy.
The first question is, are the membranes ruptured? In
general, we do not feel it necessary to attempt injection
of indigo carmine under these circumstances but accept
the evidence gathered by several pelvic examinations,
searching for evidence of amniotic fluid leakage. If the
answer is "yes," the couple should be carefully coun-
seled about survival data on the basis of the gestational
age at rupture. It is particularly important, if possible,
for the couple to be fully counseled and reach a decision
to terminate while the opportunity is still available, i.e.,
before the twenty-fourth week.
If the membranes are not ruptured, a careful ultra-
sonographic evaluation (searching for fetal anomalies)
should be carried out. We frequently will reconstitute
the amniotic fluid with an infusion of saline solution.
The couple is then counseled on the basis of the prog-
nosis for the anomaly discovered. In general, we do
not do percutaneous umbilical cord sampling for chro-
mosome analysis because the yield is quite low. Re-
gardless of whether the membranes are ruptured, it is
exceedingly important to keep the 24-week time frame
in mind, so that the couple can receive complete coun-
seling and reach their decision while termination is still
possible.
I congratulate Dr. Shenker and his colleagues on a
fine study and particularly look forward to seeing more
data on the group with chronic abruptio placentae.
1600 Shenker et al.
REFERENCES
1. Crombleholme TM, Harrison MR, Golbus MS, et al. Fetal
intervention in obstetric uropathy: prognostic indications
and efficacy of intervention. AM J OBSTET GYNECOL 1990;
162: 1239-44.
2. Mahoney BS, Filly RA, Callen pw. Amnionicity and cho-
rionicity in twin pregnancies: prediction using ultrasound.
Radiology 1985;155:205-9.
3. Patten RM, Mack LA, Harvey D, et al. Disparity of amniotic
fluid volume and fetal size: problem of the stuck twin-US
studies. Radiology 1989; 172: 153-7.
4. Petty CN, Mahoney BS, Luthy DA, et al. The stuck twin
phenomenon: treatment with therapeutic amniocenteses
[Abstract]. In: Proceedings of the tenth annual meeting of
the Society of Perinatal Obstetricians, Houston, Texas, Jan-
uary 23-27, 1990. Houston: Society of Perinatal Obstetri-
cians, 1990.
DR. ROBERT C. GOODLIN, Denver, Colorado. Doing
cesarean sections when Doppler studies are abnormal
seems rather radical to me, unless diastolic flow is ab-
sent. Perhaps this was the case. Was any therapy used
for oligohydramnios? In 1982 I presented some data
to this society in which we used amnioinfusion and
expanded the maternal plasma volume; we had cases
in which the oligohydramnios was corrected. 1 In the
last 2 years we have bad three cases of chronic abruptio
placentae, all starting before 20 weeks, and all devel-
oping oligohydramnlos. We treated these patients with
ampioinfusion, plasma volume expansion, and bed rest.
All three went beyond 30 weeks' gestation. While the
series is limited, I thiak there is some value in this form
of therapy.
REFERENCE
1. Goodlin RC, AndenonJC, Gallagher TF. Relationship be-
tween amniotic fluid volume and maternal plasma volume
expansion. AM J OBSTET GYNECOL 1983; 146:505-11.
DR. E. PAUL KIRK, Portland, Oregon. Dr. Shenker,
both your article and that of Dr. Platt illustrate a prob-
lem that seems to be facing us increasingly-incidental
findings in second-trimester ultrasonographic exami-
nations. Could you help me understand the natural
history of retroplacental clot or the partial placental
separation found by ultrasonography in the second
trimester without the presence of clinical bleeding? The
relative frequency with which this incidental finding is
reported presents difficulty in counseling patients.
DR. LAWRENCE D. PLATT, Los Angeles, California.
What were the criteria you used to diagnose oligohy-
dramnios? Did you use the amniotic fluid index, the
I em pocket, or sim ply gestalt? Knowing the method
used is important for others to be able to reproduce
this important study.
One should not be surprised that Doppler studies
June 1991
Am J Obstet Gyneco1
would be normal with placental separation. Consider
why Doppler velocimetry is abnormal in intrauterine
growth retardation. At the microscopic level, there is
obliteration of the tertiary stem villi and smaller num-
bers of vessels at the 50 to 100 f.Lm size in the tertiary
villi. However, there is no evidence of these abnor-
malities after placental separation.
DR. SHENKER (Closing). Dr. Laros, one of our pa-
tients with urethral obstruction was referred to your
department for placement of a catheter in the dis-
tended bladder. The baby, unfortunately in the group
of 60% with failure, survived 10 weeks after the pro-
cedure but then was delivered in Tucson and died of
pulmonary hypoplasia. One other fetus with urethral
obstruction was tapped, and the fluid never re-formed
in the bladder, indicating severe renal malfunction.
The third fetus was not considered a candidate for
surgery.
None of our patients with "stuck twin" phenomenon
was treated by amniocentesis. Published results indicate
that amniocentesis is a reasonable approach, a 31 % sur-
vival being better than our 0%.
Dr. Goodlin, I am sorry that I did not make it clear
that no cesarean sections were done because of an ab-
normal Doppler study. These patients had cesarean
section because of fetal distress, a diagnosis based on
fetal bradycardia, abnormal monitoring patterns, or
positive contraction stress tests. It is only now becoming
clear that the abnormal Doppler patterns are warning
signs that precede the need to do anything, usually by
a week or two. More data about the time of appearance
of abnormal Doppler flow studies in particular groups
of patients will become available. The only therapy we
used for premature separation of the placenta and
oligohydramnios was bed rest. Since this was not suf-
ficient to produce any survivors, I would be interested
in seeing the results of amnioinfusion in these patients.
Dr. Kirk, our two patients with premature separation
of the placenta and oligohydramnios had demonstrable
clots and were bleeding externally. We have seen pa-
tients with subchorionic blood collections in pregnancy
with reduced or normal amniotic fluid volumes; in that
case our experience has been that the prognosis is fairly
good if the bleeding remains minimal and is not ac-
companied by severe oligohydramnios.
Dr. Platt, in defining severe oligohydramnios we used
the I em pocket criterion. It was essentially impossible
to identify any amniotic fluid in the patients constitut-
ing this series. I am familiar with your work on trying
to quantitate indices for amniotic fluid volume. We too
were not surprised at the Doppler findings and in-
cluded that information in this report to emphasize that
the value of Doppler flow studies, as I emphasized be-
fore, is in the particular groups of patients who do have
placental disease.