Ultrasound Obstet Gynecol 2001; 18: 411– 419
Editorial
Blackwell Science Ltd
Oligohydramnios: use and misuse in clinical
Sherer and Langer
Editorial
management
D. M. SHERER and O. LANGER
Division of Maternal-Fetal Medicine, Department of Obstetrics and
Gynecology, St Luke’s Roosevelt Hospital Center, Columbia University
College of Physicians and Surgeons, New York, USA
THE PROBLEM
Following the observation that decreased amniotic fluid
volume or oligohydramnios when it occurs with other risk
factors is associated with increased perinatal morbidity and
mortality, amniotic fluid volume measurements have become
standard in fetal surveillance and in the evaluation of high-risk
pregnancies. The finding of oligohydramnios in the clinical
settings of fetal growth restriction, postdates pregnancy, or
pregnancies complicated by maternal disease, may indicate
increased risk for intrauterine fetal demise or neonatal morbidity
and may, in such circumstances, be utilized as an indication
for delivery. Significant controversies exist regarding the
physiology of amniotic fluid volume, clinical methodologies in
the assessment of amniotic fluid volume, and clinical manage-
ment of pregnancies complicated by oligohydramnios.
Nevertheless, upon observation of oligohydramnios in other-
wise uncomplicated term gestations, delivery, irrespective of
the presence of reassuring fetal evaluation and the absence of
maternal disease, has become routine. In our assessment,
this may represent overtreatment, exacting a price in maternal
morbidity especially in terms of operative delivery for failed
(and possibly non-indicated) inductions of labor. In this
editorial, we discuss physiological dynamics and factors which
may affect amniotic fluid volume, potential pitfalls in the
sonographic assessment of amniotic fluid volume, the
clinical significance of oligohydramnios, and the prediction
of associated increased adverse perinatal outcome and the
enigma of clinical management of isolated oligohydramnios
at term.
PHYSIOLOGICAL DYNAMICS OF
AMNIOTIC FLUID
The presence of amniotic fluid throughout gestation enables
normal development of the fetal respiratory, gastrointestinal
and urinary tracts, musculoskeletal system and continued
fetal growth in a non-restricted, sterile and thermally controlled
environment1.
Numerous factors contribute to the formation and removal
of amniotic fluid. Following keratinization of the fetal skin
(slightly after mid-gestation), amniotic fluid is considered to
be a product mainly of fetal urination which approximates
EDITORIAL
30% of fetal body weight daily, and at term ranges between
600 and 1200 mL/day1–3.
Other contributions consist of:
1 tracheal secretions excreted during breathing episodes and
ranging between 60 and 100 mL/kg/day fetal weight near term4;
2 the intramembranous pathway which includes transfers
between amniotic fluid and fetal blood perfusing the fetal
surface of the placenta, fetal skin, and umbilical cord, reach-
ing almost 400 mL/day at term2,5;
3 the transmembranous pathway which involves direct
exchange across the fetal membranes between amniotic fluid
and maternal blood within the uterus1,2,5. The net trans-
membranous movement of fluid in human pregnancies has
not been estimated, yet recent studies suggest that under
normal conditions this route conducts only 10 mL/day of
fluid near term1,2.
Removal of amniotic fluid throughout gestation results
mainly from fetal swallowing. It has been estimated previously
at between 200 and 1500 mL/day, and is currently con-
sidered to approximate between 20% and 25% of fetal body
weight per day1. Collectively, data demonstrate that the
amount of fluid removal by fetal swallowing is significantly
less than that produced by fetal urination1,2. Furthermore,
large amounts of fluid are secreted by the fetal lung in the latter
half of gestation, further adding to the amniotic fluid volume.
Nevertheless, the amniotic fluid volume remains in relative
equilibrium1. Recent studies suggest the intramembranous
pathway is responsible for correcting these imbalances, con-
tributing to the regulation of amniotic fluid volume with a net
removal of between 200 and 500 mL/day from the amniotic
cavity1,2. Slight changes in intramembranous permeability
can produce very large effects on intramembranous flux rates.
For example, substances such as prostaglandins excreted by
the fetal kidneys or lungs or released by the amnion or chorion
which enter the amniotic fluid could potentially alter intra-
membranous permeability and directly affect amniotic fluid
volume1. Interestingly, this function of the intramembran-
ous pathway may explain the observation that with upper
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gastrointestinal tract obstruction in humans (no fetal
swallowing), polyhydramnios develops in only 40% of
cases2. Similarly, in animal studies in which fetal swallowing
was prevented, fetal urine output remained normal and
amniotic fluid volume was not different from that of the
controls after 2 –3 weeks2. Gilbert and Brace3 demonstrated
that absorption through the intramembranous pathway was
increased with ligation of the fetal esophagus. Regarding
amniotic fluid turnover, late in gestation when amniotic fluid
volume averages 700 –800 mL, 1000 mL fluid flows into and
out of the amniotic compartment daily1,2.
Amniotic fluid volume is gestational-age dependent, is
maintained within a normal range, appears highly regulated
(although the precise regulation mechanism remains elusive),
and peaks between 36 and 38 weeks’ gestation, decreasing
thereafter6, or according to recent data (obtained by the
dye-dilution technique) attaining maximum volume near term7.
The observed etiology of the relative reduction in amniotic
fluid volume towards term and in uncomplicated post-term
pregnancies remains unclear. Nevertheless, experimental
and clinical studies support the theory that the properties
of the fetal membranes are of paramount importance in the
maintenance of amniotic fluid volume and composition of
amniotic fluid8. It is enticing therefore to consider that tele-
ologically the fetus, by reducing amniotic fluid volume at
advanced gestational ages, may contribute to the induction,
or indirectly initiate, spontaneous uterine contractions (and
subsequent labor) simply by virtue of amniotic fluid volume
reduction. This proposed mechanism would in essence be
similar to the observed increased uterine contractility observed
following spontaneous or artificial rupture of membranes, or
even amniocentesis remote from term. Established nomograms
regarding amniotic fluid volume vs. gestational age have been
constructed6,7,9. Utilization of such nomograms enable appli-
cation of more stringent gestational-age dependent criteria in
detecting abnormal (either high or low) amniotic fluid volumes.
FACTORS WHICH MAY AFFECT
AMNIOTIC FLUID VOLUME
Factors well established as affecting amniotic fluid volume
include: the postmaturity syndrome; maternal disease, includ-
ing hypertension, diabetes in pregnancy (especially poorly
controlled), and auto-immune disorders; maternal medications
(prostaglandin synthetase inhibitors); altitude; fetal anomalies
(including immune and non-immune fetal hydrops); fetal
weight (macrosomic and growth-restricted)10–19.
Amniotic fluid volume is significantly affected by maternal
hydration status20. Sherer et al.21 in 1990 reported a severely
dehydrated patient with oligohydramnios in whom massive
intravenous maternal hydration was associated with sono-
graphic confirmation of increasing amniotic fluid volume.
Subsequent prospective studies confirmed this observation,
noting significant increases in the amniotic fluid index (AFI)
after oral or intravenous maternal hydration22–24. Further-
more, in a prospective study, Flack et al.24 demonstrated that
short-term maternal oral hydration significantly increased
the AFI in women with third-trimester oligohydramnios (AFI
≤ 5 cm) but not those with normal amniotic fluid volume. Of
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Sherer and Langer
note, these authors attributed the increase to improved utero-
placental perfusion and not to fetal urination as might have
been expected24. Other authors differ in this regard, and
attribute increased amniotic fluid volume in response to acute
maternal hydration to increased fetal urine output as demon-
strated indirectly by increasing diameters of fetal pyelectasis
in hydrated patients25,26, and by sonographically measured
hourly fetal urine production rate27. Doi et al.28 studied the
effect of acute maternal hydration (2 L/2 h) with either intra-
venous isotonic fluid, hypotonic fluid or oral water upon the
AFI in patients > 35 weeks’ gestation with AFI values ≤ 5 cm.
These authors concluded that maternal osmotic change, rather
than maternal volume expansion, exhibited a more direct
impact upon increasing amniotic fluid volume as assessed by
AFI measurements obtained within 1 h following short-term
acute hydration28. Chandra et al.29 also confirmed that either
oral or intravenous hydration may correct uncomplicated
oligohydramnios, demonstrating that neither intake route
appears to be advantageous over the other. Interestingly, the
amount of intravenous hydration did not correlate with the
frequency of AFI change (46.6% increase with intravenous
volumes ≤ 2000 mL vs. 40% with volumes > 2500 mL) or
with the magnitude of change (average 1.3 cm and 0.6 cm,
respectively)29. Conversely, Wolman et al.30 recently demon-
strated that, as might have been expected, fasting may reduce
the AFI, with a significant difference in the AFI in 22 patients
who did, vs. 25 patients who did not, fast (11.7 cm vs. 15.4 cm,
respectively). Of note, after 1 week there was no difference in
the AFI between the two groups30.
Despite the recognized association between maternal hydra-
tion status and amniotic fluid volume as assessed sonograph-
ically, it is surprising that to our knowledge strict, uniform,
pre-examination maternal hydration status criteria have not
been suggested, established or implemented.
Petrikovsky et al.31 demonstrated that fetal vibroacoustic
stimulation induces an increase in fetal swallowing activity
which may result in a diminution of amniotic fluid volume.
Results of this study suggest that the AFI should be assessed
before vibroacoustic stimulation is applied, and that caution
should be exercised if vibroacoustic stimulation is to be utilized
in the presence of low amniotic fluid volume31. Brost et al.32,
in a prospective study before and after attempted external
cephalic version, assessed the affect of fetal presentation upon
the AFI. These authors concluded that successful conversion
from a breech to a cephalic presentation resulted in a significant
increase in the AFI, and suggested that this should be considered
when a breech-presenting fetus with a low normal AFI is evalu-
ated32. Interestingly, maternal smoking appears to affect
neither amniotic fluid volume nor fetal urine output33.
SONGRAPHIC MODALITIES TO ASSESS
AMNIOTIC FLUID VOLUME
The dye-dilution test is considered the gold standard in the
assessment of amniotic fluid volume against which all other
prenatal diagnostic methods should be compared7,34,35.
Unfortunately this modality is invasive, entailing amniocentesis,
the complications of which may be higher in association with
decreased amniotic fluid volumes.
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Editorial
All current sonographic methods of amniotic fluid assess-
ment are adversely affected by virtue of the two-dimensional
nature of real-time ultrasound representation of the three-
dimensional aspects of amniotic fluid pockets dispersed un-
equally throughout the amniotic cavity. Precise sonographic
assessment of the amniotic fluid volume may also be further
impaired by the presence of a constantly active fetus and loops
of umbilical cord in the amniotic fluid cavity, and the resulting
differences in fluid dispersion throughout the amniotic cavity.
Readers of this Journal are undoubtedly familiar with the
various reported sonographic modalities to assess amniotic
fluid volume, which include: (1) single vertical pocket14,
(2) two-diameter pocket34, and (3) amniotic fluid index
(AFI)36–38. The number of sonographic modalities applied to
assess amniotic fluid volume reflect the inaccuracies inherent
in each of these modalities. Further complicating the issue of
amniotic fluid volume assessments are the implications of
various cut-off threshold points in the diagnosis of abnormally
low amniotic fluid levels, which have been suggested regarding
each of these various techniques.
Dildy et al.39 compared the accuracy of clinical ultrasound
techniques of amniotic fluid volume assessment with dye-
dilution technique assessments. These authors reported that
the AFI overestimated the actual volume by as much as 88.7%
at lower amniotic fluid volume levels and underestimated the
actual volume by as much as 53.9% at higher amniotic fluid
volumes39. Similarly, Magaan et al.40 in a dye-dilution con-
trolled study demonstrated that although the two-diameter
pocket method was significantly more accurate in detecting
oligohydramnios, neither operator experience nor sono-
graphic technique (largest vertical pocket, AFI or two-diameter
pocket method), greatly affected the accuracy of ultrasound
estimates of amniotic fluid volume.
Also in a dye-dilution controlled study, Chauhan et al.41,
in addition to the various described measurement techniques,
described mathematical models to correlate AFI measure-
ment with amniotic fluid volume, enhancing the detection
rate of oligohydramnios. Recognizing the limited correlation
between AFI and the two-dimensional area of amniotic fluid,
Mann et al.42 recently applied the bladder volume instrument
(utilizing a rotating 2-MHz transducer, a computer-defined
fluid interface and computer integration of 12 cross-sectional
images) to calculate a three-dimensional amniotic fluid
volume. These authors demonstrated that one AFI cm was
equivalent to 30 mL amniotic fluid, and was not affected by
gestational age. As expected, the three-dimensional amniotic
fluid volume assessment demonstrated a parabolic pattern
throughout gestation and significantly correlated with previ-
ously established gestational-age related changes in amniotic
fluid volume42.
Interestingly, Del Valle et al.43 demonstrated that AFI
values obtained with either sector or convex-array transducers
are reliable (correlating well with values obtained with the
linear transducer).
Finally, transvaginal ultrasound has been applied to depict
the amniotic fluid volume potentially located in the forewaters,
a location suboptimally depicted by transabdominal sono-
graphy, in patients ≥ 37 weeks’ gestation with either oligo-
hydramnios or AFI > 5 cm44. No significant difference was
Ultrasound in Obstetrics and Gynecology
Sherer and Langer
noted between the mean forewater measurement of patients
with oligohydramnios vs. controls (0.2 ± 0.1 and 0.4 ± 0.1 cm,
respectively). Furthermore, various permutations of the
AFI, which included sonographic assessment of the forewaters,
did not impact on the diagnosis of oligohydramnios44.
POTENTIAL PITFALLS IN THE
SONOGRAPHIC ASSESSMENT OF
AMNIOTIC FLUID VOLUME
The AFI and single deepest pocket assessments are significantly
sensitive to the abdominal pressure applied by the sono-
grapher45. Flack et al.45 demonstrated that when compared
with medium pressure, low pressure results in a 13% increase
in the AFI, vs. a 21% decrease in the AFI with high pressure.
Furthermore, measurements obtained at the lowest pressure
that will prevent image fallout will result in the highest AFI
values and the lowest intraobserver variablity45.
Following the initial report of Rutherford et al.46 stating
that fetal movements could alter the size and location of
amniotic fluid pockets, Wax et al.47 assessed the effect of fetal
movement upon the AFI. The mean change in matched pre-
movement and postmovement AFI values following three
discrete episodes of fetal movements was statistically signi-
ficant at 2.5 ± 0.2 cm. However, this finding lacked clinical
significance as determined by the intraobserver and inter-
observer variation of the four-quadrant technique47. The
authors concluded that the significant change in the AFI
assessments associated with fetal movements is an artifact of
the measurement’s intrinsic variability and should not be
considered of clinical consequence in the hands of reliable
examiners47.
Following the original description of the AFI, in which this
question was not addressed, Rutherford et al.46 reported that
the umbilical cord or a fetal extremity may traverse a meas-
ured pocket of amniotic fluid. It is now clear, however, that
many sonographers prefer to include only pockets entirely
devoid of umbilical cord or extremities. Subsequently, Sadovsky
et al.48 reported a decreased perinatal risk if cases with an
AFI < 5 cm included a cord-containing pocket of amniotic
fluid > 5 cm, suggesting a reduced need for intervention with
the latter.
Infrequently, for as yet undetermined reasons, amniotic
fluid may appear echogenic, containing dense ‘free-floating’
particles resulting in the pockets of fluid available for measure-
ment being considerably less clear. Although earlier studies
considered this to be suggestive of the presence of meconium-
stained amniotic fluid49, a number of subsequent prospective
studies have negated this sonographic finding as a predictor
of meconium50,51. Nevertheless, in the presence of echogenic
amniotic fluid it may be difficult to ascertain the interface
between amniotic fluid/membranes and uterine wall, resulting
in underassessment of the true amniotic fluid volume.
Initially, it was considered by many that the application of
color Doppler imaging would enhance detection of oligohy-
dramnios by virtue of avoiding incorrect inclusion of sono-
lucent areas of umbilical cord inadvertently considered as
amniotic fluid. In line with this hypothesis, Bianco et al.52
reported that the application of color Doppler imaging resulted
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in significantly lower amniotic fluid volume estimation by
ultrasound. Specifically, these authors reported that the AFI
is decreased by 20% by using color Doppler imaging52.
Recently, Magaan et al.53 reported amniotic fluid volume
assessments (AFI and single-pocket techniques) with and
without concurrent color Doppler imaging, followed by
amniocentesis and dye-dilution calculated volumes. They
concluded that the concurrent use of color Doppler imaging
with AFI measurements leads to overdiagnosis of oligo-
hydramnios53. However, surprisingly, when the diagnosis of
low fluid volume with and without color Doppler imaging
was correlated with dye-determined volumes, the application
of color Doppler imaging did not, in fact, enhance detection
of true oligohydramnios. Of specific concern was the finding
that with color Doppler imaging, nine of 42 women (21%)
with normal amniotic fluid volume were diagnosed as having
low fluid volume53. This study supported the concept that
AFI and single-deepest pocket (without color Doppler imaging)
perform similarly, yet both are weak indicators of abnormal
amniotic fluid volumes53.
OLIGOHYDRAMNIOS: DEFINITION AND
SONOGRAPHIC THRESHOLDS
Oligohydramnios or decreased amniotic fluid volume is
extremely poorly defined yet is often acted upon clinically,
even when occurring as an isolated finding. Utilizing precise
dye-dilution techniques, varying definitions of 200 and
500 mL have been applied34,35. A meta-analysis including
12 studies of either direct or dye measurement suggested
a cut-off of 318 mL for oligohydramnos6.
Cut-off criteria for oligohydramnios according to various
sonographic volume assessment techniques are:
1 single vertical pocket; definitions range between < 0.5 cm54,
< 1.0 cm13, < 2 cm55, and < 3 cm56.
2 two-diameter pocket; vertical × horizontal < 15 cm34.
3 AFI technique; definitions of oligohydramnios include
< 5 cm (which represents < 1st centile37, < 5th centile for
gestational age (which translates into an AFI value of between
7.1 and 9.7 cm)9, < 5 cm38, < 7 cm57), and < 8 cm58,59. Others
have considered AFI > 5 and < 10 cm as ‘borderline’60.
Moore and Cayle9 reported a wider variation in AFI values
in association with oligohydramnios and as a result advocate
averaging three AFI values for amniotic fluid volumes < 10 cm.
Although a number of studies note that the AFI closely relates
to the amniotic fluid volume based on dye-dilution studies, as
mentioned earlier, Dildy et al.39 reported that the AFI over-
estimated the actual volume by as much as 88.7% at lower
volumes. Similarly, Chauhan et al.61 compared semiquanti-
tative methods (AFI and two-diameter pocket assessment)
with amniotic fluid volume assessments by dye-dilution at
amniocentesis, again demonstrating a poor correlation. These
authors concluded that for any specific AFI or two-diameter
amniotic fluid pocket assessment, the range of the 95% con-
fidence intervals is so wide that sonographic assessment is not
a reasonable reflection of the actual amniotic fluid volume61.
Magaan et al.34 reported a sensitivity of 6.7% in predicting true
oligohydramnios (< 500 mL). Subsequently, Magaan et al.62
studied 179 women with singleton gestations assessed with
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sequential ultrasound estimations of amniotic fluid volume
by AFI and single deepest pocket techniques followed by
amniocentesis with dye-dilution spectrophotometric calcula-
tions of actual amniotic volume. Actual amniotic fluid volumes
were low (under 5% by volume for gestational age) in 62
women, normal (5–95%) in 100 women, and high (more
than 95%) in 17 women. An AFI of up to 5 cm (sensitivity
10%; specificity 96%) and a single deepest pocket up to 2 cm
(sensitivity 5%; specificity 98%), were similarly inadequate
in identifying dye-determined low amniotic fluid volumes62.
It therefore appears that, in general, sonography is at best
imprecise in the detection of oligohydramnios. Recognizing
these deficiencies in accurate sonographic assessment of
amniotic fluid volume, Magann et al.63 demonstrated that
using multiple assessments (AFI and deepest pocket), did not
add to the overall estimation accuracy.
Intuitively, decreased amniotic fluid volume in a structur-
ally normal fetus is considered to possibly reflect impaired
uteroplacental flow. Redistribution of oxygenated fetal blood
towards essential organs (brain, heart and adrenal glands)
resulting in decreased peripheral and renal perfusion would
explain decreased urine output and associated oligohy-
dramnios. This concept has been supported by Doppler
velocimetry studies of the renal arteries depicting decreased
flow in fetuses with concurrent oligohydramnios64,65. Other
studies have not confirmed this finding, suggesting that the
cause for oligohydramnios in these patients may be related to
significantly lower birth weight rather than a major redistribu-
tion of fetal blood flow66. Alternatively, decreased fetal urine
volume output in this clinical picture may result from decreased
fetal swallowing in the presence of oligohydramnios due to
less available amniotic fluid67. Nevertheless, as yet undeter-
mined and possibly of clinical significance is the not uncom-
mon documentation of a full fetal bladder in the presence of
oligohydramnios (Figure 1). To our knowledge, to date no
study has evaluated whether inclusion of this measurable
‘pocket’ of what will inevitably, upon fetal urination, become
amniotic fluid, would or would not affect subsequent AFI
measurement. Yet it remains logical to believe that if a repeat
AFI measurement were performed subsequent to fetal urina-
tion, the AFI would be increased and otherwise non-indicated
inductions of labor due to oligohydramnios might be avoided
in these circumstances. Furthermore, it is logical to infer that
in the presence of fetal urine production (as evident by a
depicted fetal bladder), renal blood perfusion is not impaired.
This finding of a visualized fetal bladder, if supported by
normal Doppler velocimetry indices of the umbilical artery
(reflecting normal placental resistance), would suggest that
placental insufficiency would be an unlikely explanation for
the observed decreased amniotic fluid volume in an appropriate-
for-gestational age fetus.
CLINICAL SIGNIFICANCE OF
OLIGOHYDRAMNIOS
Historically, oligohydramnios has been associated with an
increased incidence of adverse perinatal outcome13,14, possibly
due to an increase in umbilical cord compression, uteroplacental
insufficiency, or an increased incidence of meconium-stained
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amniotic fluid (and its inherent risks of meconium aspiration
syndrome)68. This reported increased incidence of adverse
perinatal outcome has led to an almost uniform recommenda-
tion for delivery following the diagnosis of oligohydramnios,
at least of patients > 37 weeks’ gestation. Clearly, original
reports of this association included fetuses with structural
anomalies (most commonly of the urinary tract), small-for-
gestational age and growth-restricted fetuses, postmaturity
syndrome, and fetuses of mothers with various underlying
medical conditions mentioned previously which may affect
amniotic fluid volume13,14,66,68,69. Furthermore, oligohy-
dramnios may be a transient finding. Lagrew et al.70 in 1992
repeated AFI assessments of patients 3 –4 days after values
≤ 5 cm had been observed. Of two hundred and forty-eight
with AFI values ≤ 5 cm, the majority were subsequently
Figure 1 Sonographic depiction of fetal bladder in association with
oligohydramnios (AFI = 3.5 cm) of appropriate-for-gestational-age
fetus at 39 weeks’ gestation in sagittal (a) and axial (b) views. Induction
of labor was performed and following artificial rupture of membranes,
abundant clear amniotic fluid was demonstrated. In this clinical
condition (isolated oligohydramnios at term), should any bladder
measurement (and if so which) be utilized in the calculation of the AFI?
In this case, replacing any of the ‘vertical’ bladder dimensions with
zero-values at AFI (2.6 cm or 3.5 cm) would have negated the diagnosis
of oligohydramnios (resulting in AFI values of 6.1 or 7.0 cm,
respectively) and induction of labor could have been avoided.
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Sherer and Langer
delivered. However, 41% of undelivered patients had a normal
or low normal repeat AFI upon follow-up70. Unfortunately,
no information was forwarded regarding maternal or neonatal
outcomes of patients delivered immediately, those with resolu-
tion of oligohydramnios or those with continuing oligo-
hydramnios70. These authors concluded that in patients
< 41 weeks’ gestation with normal AFI values, a repeat AFI
assessment is not necessary for 7 days. In contrast, due to
concerns of uteroplacental insufficiency in post-term patients
and the potential relatively rapid decrease of amniotic fluid
volume that may occur in this clinical condition, twice-
weekly amniotic fluid volume assessments are uniformly
practiced12,70–74. Nevertheless, while induction of labor of
post-term patients with oligohydramnios (AFI ≤ 5 cm or no
vertical pocket > 2 cm) is considered standard care, adherence
to this practice clearly results in subsequent increases in labor
complications and the incidence of operative delivery poten-
tially without significantly improving outcome75–77.
Doppler velocimetry has assisted management of preg-
nancies complicated by oligohydramnios. Carroll and Bruner78
retrospectively assessed pregnancies complicated by oligohy-
dramnios evaluated by Doppler velocimetry of the umbilical
artery. Patients with ruptured membranes and congenital
anomalies were excluded. Seventy-six subjects were included
in the study. Forty-six patients had normal systolic/diastolic
ratios and 17 (37%) were associated with unidentifiable peri-
natal morbidity. When prematurity due to delivery for the
sole indication of oligohydramnios was excluded, morbidity
occurred in five (11%) patients. Conversely, of the 30 patients
with abnormal Doppler velocimetry, 80% sustained adverse
perinatal outcomes78. These authors concluded that preg-
nancies with oligohydramnios and normal umbilical artery
Doppler velocimetry were significantly less likely to exhibit
abnormal perinatal outcome compared to those with abnormal
Doppler velocimetry. Furthermore, these data suggest that
avoiding intervention in pregnancies with oligohydramnios
and normal umbilical artery Doppler velocimetry may decrease
iatrogenic morbidity due to prematurity by as much as 26%78.
Stipulations for effecting delivery for patients at term with
isolated oligohydramnios therefore appear to have been
derived from studies including extremely heterogeneous groups
of patients. To us it is entirely unclear whether this practice
is appropriate for patients at term with isolated oligohy-
dramnios, i.e. in the presence of an appropriate-for-gestational
age, non-compromised fetus in the absence of maternal disease.
AMNIOTIC FLUID VOLUME AS A
PREDICTOR OF PERINATAL OUTCOME
Amniotic fluid volume assessment has been suggested by
numerous authors as an intrapartum screening tool for women
admitted in early labor. Significant recent literature supports
the association of an increased incidence of adverse perinatal
outcome and oligohydramnios79–81. Chauhan79 et al., in a
meta-analysis of 18 reports describing 10 551 patients,
demonstrated that an antepartum or intrapartum AFI < 5 cm
is associated with a significantly increased risk of Cesarean
delivery for ‘fetal distress’ and a low Apgar score at 5 min.
Unfortunately this review, like many other such publications
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regarding the association of oligohydramnios and subsequent
perinatal outcome, did not randomize, stratify or control
patients according to essential entry criteria which may affect
amniotic fluid volume. These include: maternal hydration
status, absence of maternal disease, fetal or neonatal weight,
and status of amniotic membranes (ruptured or intact). In
addition the meta-analysis did not include precise neonatal
outcome parameters (umbilical artery blood gases) and only
one of the assessed studies included randomization of
knowledge of AFI status of patients in labor80. At least intui-
tively, it appears inappropriate to extrapolate such data
regarding intrapartum patients to the management of those
patients not in labor at term with isolated oligohydramnios.
Similarly, Casey et al.81 retrospectively analyzed 6423
patients undergoing ‘clinically indicated’ (rather than routine)
antepartum ultrasound at ≥ 34 weeks’ gestation defined by
an AFI of < 5 cm. Oligohydramnios complicated 2.3% of the
gestations and was significantly associated with an increase
in labor induction, still birth, non-reassuring fetal heart rate,
admission to the neonatal intensive care unit, meconium
aspiration syndrome and neonatal death. However, due to
the study design (including only clinically indicated studies)
selection bias may have been introduced and may have con-
tributed to observed results81. Interestingly, birth weights
were significantly less in infants with oligohydramnios than
in those with AFI values > 5 cm. The proportion of low birth-
weight infants (< 2500 g) was significantly increased in the
presence of oligohydramnios, findings which have also been
confirmed by other authors67,71,81. A significantly higher
incidence of congenital syndromes was diagnosed in the oligo-
hydramnios group. Of specific interest was the fact that if
infants with major malformations were excluded, admissions
to the neonatal intensive care unit, respiratory distress and
neonatal deaths were no longer significantly associated with
oligohydramnios. Despite the above results these authors
acknowledge that these results do not necessarily prove that
antepartum oligohydramnios requires intervention81.
Conversely, Magaan et al.82 evaluated amniotic fluid
volumes in 1001 patients receiving antepartum fetal testing.
Oligohydramnios defined by an AFI ≤ 5 cm occurred in
approximately 20% of patients and was not associated with
an increase in the incidence of non-reactive non-stress tests,
meconium-stained amniotic fluid, Cesarean delivery for fetal
distress, low Apgar scores, or infants with cord pH levels of
< 7.1082. Accordingly, the authors concluded that the AFI
was a poor diagnostic test with which to determine whether a
patient is at increased risk for an adverse perinatal outcome82.
Regarding the significance of amniotic fluid volume in patients
with pregnancies complicated by severe pre-eclampsia, Schucker
et al.83 retrospectively reviewed records of 136 such women
managed conservatively for at least 48 h. They reported that
for women with severe pre-eclampsia remote from term, an
AFI of < 5 cm, although lacking sensitivity, is predictive of
fetal growth restriction. However, no association was observed
between the AFI status and frequency of Cesarean delivery
for fetal distress or non-reassuring fetal testing83. In a study
designed to assess the performance of intrapartum AFI for
predicting fetal acidemia, Chauhan et al.84 assessed data
obtained from 256 patients at ≥ 37 weeks’ gestation which
416
Sherer and Langer
indicated that the mean intrapartum AFI among 12 newborns
with respiratory acidosis and 26 with metabolic acidosis was
significantly lower than the mean index in 218 newborns
without fetal acidemia. Despite the differences in the mean
intrapartum AFI in the three groups analyzed, receiver operator
characteristic curves indicated that an intrapartum AFI alone
was a poor test for predicting acidosis (respiratory or meta-
bolic) in the neonate84. Rainford et al.85 assessed pregnancy
outcomes of 232 women at ≥ 37 weeks’ gestation with AFI
assessments performed within 4 days of delivery. Of the study
group, 44 (19%) had an AFI ≤ 5 cm. The authors reported no
difference in the operative delivery rate for non-reassuring
fetal heart rate tracings, rates of neonatal intensive care unit
admissions or 5-min Apgar scores < 7, between patients with
normal amniotic fluid volumes or those with oligohydramnios.
Patients with normal AFI values had a significantly lower
labor induction rate (96 (51%) vs. 42 (98%)) and a signific-
antly higher rate of meconium-stained amniotic fluid (65
(35%) vs. 7 (16%)) than those with a lower AFI85!
THE ENIGMA OF ISOLATED
OLIGOHYDRAMNIOS
In a recent retrospective analysis, Kreiser et al.86 assessed
perinatal outcomes of 150 low-risk pregnancies at > 30 weeks’
gestation complicated by isolated oligohydramnios (AFI ≤ 5
or > 5 cm but < 2.5th centile for gestational age). Cases com-
plicated by preterm rupture of membranes, insulin requiring
diabetes mellitus, pre-eclampsia, confirmed fetal growth restric-
tion, or severe systemic maternal disease were excluded. The
outcomes of 57 pregnancies with AFI ≤ 5 cm were compared
with those of 93 pregnancies with AFI > 5 cm but < 2.5th
centile (borderline AFI). There were no significant differences
between the pregnancies with respect to labor induction for
an abnormal non-stress test, overall Cesarean deliveries for
fetal heart rate abnormalities, overall presence of meconium
and Apgar score < 7 at 5 min86. There were no perinatal
deaths in either group. Antepartum variable decelerations of
the fetal heart rate were more common with AFI ≤ 5 cm com-
pared to those with AFI > 5 cm but < 2.5th centile (63.1%
vs. 45.1%; P = 0.007). The authors concluded that with
antepartum monitoring (one to three times weekly non-stress
test and AFI), perinatal outcome in low-risk pregnancies with
isolated oligohydramnios appears to be good86.
Conway et al.87 in a controlled trial assessed the hypothesis
that isolated oligohydramnios in the otherwise normal term
pregnancy does not indicate fetal compromise. One hundred
and eighty-three women undergoing induction of labor
for isolated oligohydramnios (AFI < 5 cm) between 37 and
41+6 weeks’ gestation, were matched to 183 women present-
ing in spontaneous labor with normal AFI measurements by
gestational age and parity upon admission. Patients with
pregnancies complicated by hypertension, diabetes, fetal
anomalies or suspected fetal growth restriction were excluded.
The groups did not differ significantly in gestational age
(40.8 ± 0.1 weeks vs. 40.2 ± 0.1 weeks; P = 0.2), ethnic dis-
tribution or parity. The mean AFI on admission was 3.1 cm
in the oligohydramnios group (range, 1.0–4.9 cm) and
7.1 cm in the control group (range, 5.0–18 cm; P < 0.001). In
Ultrasound in Obstetrics and Gynecology
Editorial
Table 1 Infant characteristics and outcome in patients with isolated
oligohydramnios (AFI < 5.0) who underwent induction of labor versus
control group of patients with normal AFI (AFI ≥ 5.0) presenting in
spontaneous labor. (From Conway et al.87 with permission.)
AFI < 5.0 AFI ≥ 5.0
(n = 183) (n = 183)
Birth weight (g, mean (SEM)) 3398 (34) 3428 (35)
Ponderal index (mean (SEM)) 2.48 (0.02) 2.51 (0.02)
pH < 7.15 (%) 10.4 7.1
pH < 7.00 (%) 2.7 2.7
Low Apgar at 5 min (%) 1.1 0.6
NICU admission (%) 16.4 11.5
SEM, standard error of the mean; NICU, neonatal intensive care
unit; NS, not significant.
comparison to the control group, neonatal outcome measure-
ments did not differ in the group induced for oligohydramnios
(Table 1)86. Significantly higher Cesarean delivery rates were
observed among women whose labor was induced vs. con-
trols (15.8% vs. 6.6%, respectively). The increased need for
operative delivery was not attributable to an increase in fetal
distress in the oligohydramnios group. The authors concluded
that isolated oligohydramnios in the otherwise normal term
pregnancy may not be a marker for fetal compromise and
that induction of labor may therefore not be warranted in
most cases87. It should however, be emphasized that in this
study the safety of embarking upon a non-interventional,
expectant management of cases with isolated oligohydramnios
at term was not evaluated. In an additional analysis, infants
were subsequently stratified according to amniotic fluid
index (oligohydramnios (AFI < 5.0) vs. normal (AFI ≥ 5.0))
and ponderal index (low vs. normal), in an attempt to identify
whether neonates with evidence of compromised intrauterine
nutrition and oligohydramnios were at particularly high risk
for adverse outcome. Interestingly, no significant differences
were noted between the four groups.
In the only study in which women (n = 61) with isolated
oligohydramnios diagnosed by AFI values ≤ 5 cm were
randomly allocated to expectant management vs. induction
of labor, Conway et al.88 reported that the majority of patients
managed expectantly entered spontaneous labor within 3 days
of sonographic diagnosis. Interestingly, this observation
indirectly supports the previously mentioned consideration
that the physiology of decreasing amniotic fluid volume at term
or thereafter may represent a normal component of the mechan-
ism of spontaneous labor. Patients in the expectant manage-
ment group underwent twice-weekly fetal testing. Maternal
hydration was not utilized prior to enrolment and intrapartum
amnioinfusion was not used. None of the patients in the expect-
antly managed group was induced due to fetal compromise
and the authors concluded that expectant management of
patients with isolated oligohydramnios was appropriate88.
CONCLUSION
Recent evidence is accumulating that suggests that in the
presence of an appropriate-for-gestational age fetus, with
reassuring fetal well-being (including Doppler velocimetry of
Ultrasound in Obstetrics and Gynecology
Sherer and Langer
the umbilical artery) and the absence of maternal disease,
oligohydramnios is not associated with an increased incidence
of adverse perinatal outcome. Accordingly, given the poor
current sonographic capability to correctly diagnose decreased
amniotic fluid volume (other than overt oligohydramnios),
P the reported transient nature of oligohydramnios, and evidence
that amniotic fluid volume may be increased with maternal
NS hydration, it appears that induction of labor (or delivery) at term
NS
for decreased amniotic fluid volumes should be reconsidered.
NS
NS In summary, in our view, four challenging questions
NS remain unanswered at this time.
NS 1 In an attempt to decrease the overdiagnosis of isolated
oligohydramnios, should strict uniform maternal hydration
status criteria be implemented prior to ultrasound assessment
of amniotic fluid volume? This would clearly assist in avoid-
ing inadvertent inclusion of relatively dehydrated women in
whom oligohydramnios may reflect a transient and correct-
able finding.
2 Should patients with isolated oligohydramnios at term
continue to undergo induction of labor? Clearly the time has
arrived for seeking prospective randomized data regarding
the value of delivery indicated solely on the basis of decreased
amniotic fluid volume in the absence of any other objective
concerns.
3 Should other (less invasive) management paradigms of the
patient at term with isolated oligohydramnios including
increase in maternal volume intake (either oral or intravenous)
and subsequent reassessment of amniotic fluid volume be
entertained?
4 Finally, what is the significance of a full (or distended) fetal
bladder noted in conjunction with isolated oligohydramnios?
Alternatively, should any bladder measurement be considered
when diagnosing oligohydramnios?
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