Hydrominos in Pregnancy

HYDRAMNIOS
Presented By,
Ms. Gauri Waghamare
MSc Nursing
Assistant Professor
Vijaysinh Mohite-Patil College of Nursing
And Medical Research Institute, Akluj.

 Amniotic fluid
 Polyhydramnios
 Oligohydramnios

1) Physical properties :-
It is colorless fluid.
Specific gravity : 1.010 – 1.020
Reaction : neutral or slightly alkaline (pH 7- 7.5)
Volume : It reaches its maximum volume at 36 weeks
(about 1 - 1.5 litre) and gradually diminishes to be 500-
1000 ml at term. It is completely changed every three
hours.

2) Chemical composition :
Water : 98-99%.
Solids : 1-2%, half-organic and half- inorganic.
Organic constituents include
carbohydrates as glucose and fructose, proteins and
hormones, the inorganic
constituents are similar to those found in the maternal
plasma as Na and Cl.

The amniotic fluid has both fetal and maternal origin.
 Fetal origin :
1- Fetal urine.
2- Secretion from the amniotic epithelium.
3- Diffusion from the umbilical cord vessels.
4- Transudation through fetal skin.
5- Secretion from bronchial mucosa, buccal
mucosa and salivary glands.

 Maternal origin :
The liquor is a filtrate from
maternal plasma.
Fate of liquor amni :
1- Fetal : Swallowing.
2- Maternal : Transudation into maternal circulation.

A) During Pregnancy:-
1. Protection of the fetus.
2. It keeps the fetal temperature constant.
3. It allows free fetal movements .
4. Prevents adhesions between the amnion and fetal
skin.
5. Acts as a medium for fetal excretion.
6. Forms a closed sac around the fetus preventing
ascent of infection, from the cervix or vagina

B) During Labour :
1. helps dilatation of the cervix.
2. It prevents direct compression of the placenta
between the uterine wall and fetus during uterine
contraction thus avoiding fetal asphyxia.
3. When the membranes rupture, the fluid washes the
birth canal from above downwards thus removing
away any infectious material.

 Clinical assessment is unreliable.
 Objective assessment depends on U/S to measure:
-Deepest vertical pool (DVP).
-Amniotic fluid index (AFI).
It is a total of the DVPs in each four quadrants of the
uterus. it is a more sensitive indicator of AFV
throughout pregnancy.

DEFINITION:-
Anatomically, polyhydramnios is defined as a state
where liquor amni exceeds 2,000 ml.
Clinical definition states—the excessive accumulation
of liquor amnii causing discomfort to the patient
and/or when an imaging help is needed to substantiate
the clinical diagnosis of the lie and presentation of the
fetus.

Ultrasound the vertical diameter of the
largest pocket of amniotic fluid measure 8 cm or more,
or the amniotic fluid index (AFI) is 25 cm or more.
It can be classified into :
1- Mild : Largest vertical pocket diameter 8 – 11 cm.
2- Moderate : Largest vertical pocket diameter 12 -15
cm.
3- Severe : Largest vertical pocket diameter ≥ 16 cm.

Because of different criteria used in the
definition of polyhydramnios, the incidence varies
from 1–2% of cases.
It is more common in multipara than primigravidae.
clinical symptoms probably occurs in 1 in 1,000
pregnancies.

I. Fetal Anomalies :-
Congenital fetal malformations
(structural and chromosomal) are associated with
polyhydramnios in about 20% cases.
 Anencephaly
 Open spina
 Esophageal or duodenal atresia
 Facial clefts and neck masses
 Hydrops fetalis
 Aneuploidy

II. Placenta: Chorioangioma of the placenta

III. Multiple pregnancy : Hydramnios is more
common in monozygotic twins, usually affecting the
second sac.

Maternal: i) Diabetes
ii) Cardiac or renal disease

Depending on the rapidity of onset, hydramnios may
be:
(a) Acute (extremely rare)—onset is sudden, within
few days or may appear acutely on pre-existing
chronic variety. The chronic variety is 10 times more
common than the acute one.
(b) Chronic (most common)—onset is insidious taking
few weeks.

Acute hydramnios is
extremely rare. The
onset is acute and the
fluid accumulates within
a few days. It usually
occurs before 20 weeks
of pregnancy. It is
usually associated with
monozygotic twins with
TTTS or chorioangioma
of the placenta.

Features of acute abdomen predominate—such as
 Abdominal pain
 Nausea and vomiting.

i) The patient looks ill
ii) Edema of the legs
iii) Abdomen is hugely enlarged
iv) Fluid thrill is present
v) Fetal parts cannot be felt nor is the fetal heart
sound audible
vi) Internal examination reveals—taking up of the
cervix or even dilatation of the os through which the
bulged membranes are felt
vii) Sonography shows multiple fetuses or at times
fetal abnormalities.

Most often, spontaneous abortion occurs. In
case with severe TTTS, repetitive amnioreduction
until the AFI is normal, may improve the perinatal
outcome. Laser ablation may cure the cause of TTTS
whereas amnioreduction only treats the symptoms

In the majority of cases, the accumulation of
liquor is gradual increase in fluid over few weeks. It
usually occurs after 32 weeks
Symptoms:- The symptoms are mainly from
mechanical causes.
 Respiratory—The patient may suffer from dyspnea
or even remain in the sitting position for easier
breathing.
 Palpitation
 Edema of the legs, varicosities in the legs or vulva
and hemorrhoids.

Signs:-
 The patient may be in a dyspnea state in the lying
down position.
 Evidence of preeclampsia (edema, hypertension
and proteinuria) may be present.

Inspection:
 Abdomen is markedly enlarged, looks globular
with fullness at the flanks.
 The skin is tense, shiny with large striae.

Palpation:
o Height of the uterus is more than the period of
amenorrhea.
o Girth of the abdomen round the umbilicus is more
than normal
o Fluid thrill can be elicited in all directions over the
uterus.
o Fetal parts cannot be well-defined; so also the
presentation or the position. External ballottement
can be elicited more easily.

Auscultation:
Fetal heart sound is not heard distinctly,
although its presence can be picked up by Doppler
ultrasound.
Internal Examination:-
The cervix is pulled up, may be partially
taken up or at times, dilated, to admit a fingertip
through which tense bulged membranes can be felt.

o Sonography:
1.To detect abnormally large echo-free space between
the fetus and the uterine wall (largest vertical pocket
more than 8 cm). Amniotic fluid index (AFI) is more
than 25 cm
2. To exclude multiple fetuses
3. To note the lie and presentation of the fetus
4. To diagnose any fetal congenital malformation.

o Blood:-
1. ABO and Rh grouping —
Rhesus isoimmunization may
cause hydrops fetalis and fetal
ascites.
2. Postprandial sugar and if
necessary glucose tolerance
test.
o Amniotic fluid: Estimation
of alpha fetoprotein which is
markedly elevated in the
presence of a fetus with an
open neural tube defect.

 Maternal:
During pregnancy—There is increased incidence of:
(1) Preeclampsia (25%)
(2) Malpresentation and persistence of floating head
(3) Premature rupture of the membranes
(4) Preterm labor either spontaneous or induced
(5) Accidental hemorrhage due to decrease in the
surface area of the emptying uterus beneath the
placenta, following sudden escape of liquor amni.

During labor:-
(1) Early rupture of the membranes
(2) Cord prolapse
(3) Uterine inertia
(4) Increased operative delivery due to
malpresentation
(5) Retained placenta, postpartum hemorrhage
and shock. The postpartum hemorrhage is due to
uterine atony.

Puerperium:-
(1) Subinvolution
(2) Increased puerperal morbidity due to
infection resulting from increased operative
interference and blood loss.

Fetal:
There is increased perinatal mortality to the
extent of about 50%. The deaths are mostly due to
prematurity and congenital abnormality (40%). Other
contributing factors are cord prolapse, hydrops fetalis,
effects of increased operative delivery and accidental
hemorrhage

Recently there has been a falling trend in the
incidence of hydramnios of severe magnitude. The
reasons are:
(1) Early detection and control of diabetes.
(2) Rhesus isoimmunization is now preventable.
(3) Genetic counseling in early months and detection
of fetal congenital abnormalities with ultrasound
and their termination, reduce their number in late
pregnancy.

It is commonly found in midtrimester and usually
requires no treatment, except extra bed rest for a few
days. The excess liquor is expected to be diminished as
pregnancy advances (transient).

Principles:-
(1) To relieve the symptoms
(2) To find out the cause
(3) To avoid and to deal with the complication.
Polyhydramnios may be
(a) transient where LVP returned to normal with
progress of pregnancy or
(b) persistent cases with persistent polyhydramnios
need investigations for congenital fetal anomalies,
genetic syndromes and also need close monitoring.

 Supportive therapy
 Investigations
 Further management depends on:
1) Response to treatment
2) Period of gestation
3) Presence of fetal malformation
4) Associated complicating factors.

 Uncomplicated cases: (No demonstrable fetal
malformation)
1. Response to treatment is good: The pregnancy is to
be continued awaiting spontaneous delivery at term.
2. Unresponsive: (with maternal distress).
A) Pregnancy less than 37 weeks:Amniocentesis
B) Pregnancy more than 37 weeks: Amniocentesis →
drainage of good amount of liquor → to check the
favorable lie and presentation of the fetus → a
stabilizing oxytocin infusion is started → low
rupture of the membranes is done when the lie
becomes stable and the presenting part gets fixed
to the pelvis.

 Usual management is followed as outlined in twin
pregnancy.
 Internal examination should be done soon after the
rupture of the membranes to exclude cord prolapse.
 If the uterine contraction becomes sluggish,
oxytocin infusion may be started, if not
contraindicated.
 To prevent postpartum hemorrhage, intravenous
methergine 0.2 mg should be given with the delivery
of the anterior shoulder.
 One must remain vigilant following the birth of the
baby for retained placenta, postpartum hemorrhage
and shock. Baby should be thoroughly examined for
any congenital anomaly.

Definition:-
“It is an extremely rare condition where the liquor
amni is deficient in amount to the extent of less than
200 ml at term”.

Sonographically, it is defined when the
maximum vertical pocket of liquor is less than <2 cm
or when amniotic fluid index (AFI) is less than 5 cm
(less than 5 percentile). With AFI less than 5 cm (below
5th percentile) or more than 24 cm (above 95th
percentile) was considered abnormal at gestational
age, from 28 to 40 weeks.
Absence of any measurable pocket of amniotic
fluid is defined as Anhydramnios. AFI between 5 and 8
is termed as borderline AFI or borderline
Oligohydramnios

A. Fetal conditions:
i) Fetal chromosomal or structural anomalies
(ii) Renal agenesis
(iii) Obstructed uropathy
(iv) Spontaneous rupture of the membrane
(v) Intrauterine infection
(vi) Postmaturity
(vii) IUGR
(viii) Amnion nodosum (failure of secretion by the cells
of the amnion covering the placenta).

B. Maternal Conditions:-
(i) Hypertensive disorders
(ii) Uteroplacental insufficiency
(iii) Dehydration
(iv) Idiopathic

(1) Uterine size is much smaller than the period of
amenorrhea
(2) Less fetal movements
(3) The uterus is “full of fetus” because of scanty
liquor
(4) Malpresentation (breech) is common
(5) Evidences of intrauterine growth retardation of
the fetus

(6) Sonographic diagnosis is made when largest
liquor pool is less than 2 cm. Ultrasound
visualization is done following amnioinfusion of 300
mL of warm saline solution
(7) Visualization of normal filling and emptying of
fetal bladder essentially rules out urinary tract
abnormality.
(8) Oligohydramnios with fetal symmetric growth
restriction is associated with increased chromosomal
abnormality

 History
 Watery/ blood stained vaginal discharge
 Hypertension
 Preeclampsia
 Pregestational hypertension
 Family history Congenital anomalies Chromosomal
abnormalities

 Physical examination
 Small uterine size
 Less fetal movements
 Uterus is full of fetus
 Malpresentations
 IUGR
 USG: AFI< 5cm
 Speculum examination: watery vaginal discharge

Fetal:
(1) Abortion
(2) Deformity due to intra-amniotic adhesions
or due to compression. The deformities include
alteration in shape of the skull, wry neck, club foot, or
even amputation of the limb
(3) Cord compression
(4) High fetal mortality.

Maternal:
(1) Prolonged labor due to inertia
(2) Increased operative interference due to
malpresentation. The sum effect may lead to increased
maternal morbidity.

Presence of fetal congenital malformation
needs referral to a fetal medicine unit. When decision
for delivery is made, it should be done irrespective of
the period of gestation. Isolated oligohydramnios in
the third trimester with a normal fetus may be
managed conservatively.
Oral administration of water increases
amniotic fluid volume. In labor, cord compression is
common. Amnioinfusion (prophylactic or therapeutic)
for meconium liquor is found to improve neonatal
outcome.

First Trimester:-
 Counselling
 Serial USG
Second trimester:-
 Counselling
 Consider Amnioinfusion
 Serial USG
 Exclude PROM
 Termination of pregnancy

Third Trimester :-
 Deliver post term cases
 Serial USG and Doppler in IUGR
 Conservative management for preterm prelabor
rupture of membranes till 34 weeks
 Idiopathic cases: NST, serial USG & BPP

 USG to exclude placenta
 Painting and draping
 20 G needle
 Connected to sterile tubing, 3 way stopcock and a
50ml syringe
 NS is injected under USG

 Consent
 Baseline FHR, vital signs, uterine activity
 Monitor FHR and uterine activity
 Measure and mark fundal height and reassess every
hour
 Notify if
 non resolving variable deceleration even with 800ml
of solution infused
 Non reassuring maternal/fetal response
 Intrauterine pressure> 25mmHg

According to
fetal condition and
specific conditions such as
preeclampsia
growth restriction
fetal anomaly

 Close monitoring by EFM
 Rupture the membranes in active phase of labor
 Amnioinfusion in case of meconium staining
 If FHR abnormality: immediate CS

 DFMC
 Left lateral position
 FHR monitoring
 Administration of fluids
 Close monitoring during labour

Risk for prolonged labor r/t uterine inertia
Risk for infection related to
Anxiety
Ineffective coping
 Knowledge deficit
 Risk for fetal compromise related to reduced
amniotic fluid volume

Hydrominos in Pregnancy

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