Subject: OB

Topic: Hydramnios / PROM

Lecturer: Dra. Brion
Shifting /Date: 1st Shifting / July 21, 2008
Trans group: hotstuff!

Normal Amniotic Fluid

AOG (weeks) AFV (mL) % fluid
16 200 50 Causes:
28 1000 46 • commonly associated with fetal
36 900 24 malformations (congenital) that can be in
40 800 17 combinations:
*postpartum – oligohydramnios o GIT (esophageal atresia)
*decreased amniotic fluid - rehydrate o CNS (anencephaly) – meninges are open
o Cardiac
Measurement of Amniotic Fluid Volume o Thoracic
1. Amniotic Fluid Index o Skeletal
• increased by: o Chromosomal
o high altitude • Less common cause:
o maternal hydration o Fetal Pseudoaldosteronism
o administration of L-deamino-8-D- o Nephrogenic Diabetes Insipidus
arginine vasopressin o Placental Chorioangioma
increasing maternal serum o Fetal Bartter or Hyperprostaglandin E
osmolality Syndrome
• decreased by: o Sacrococcygeal Teratoma*
o maternal dehydration (diarrhea o Maternal Substance Abuse*
or hyperemesis) by fluid *most commonly seen in practice
restriction
2. Single Suspended Pocket Pathogenesis:
• single deepest pocket • impaired fetal swallowing
3. Doppler Imaging with AFI
• transudation of fluid from exposed
meninges in the amniotic cavity as in
HYDRAMNIOS
anencephaly and spina bifida
• aka polyhydramnios
• excessive urination due to hyperstimulation
• excessive AFV
of the exposedncerebrospinal center or lack
• usually more than 2 liters of AFV in ADH because of impaired AVP secretion
• defined as AFI > 24-25 cm • in monozygotic twins, due to cardiac
• may lead to uterine atony/PPH because of hypertrophy in the recipient twin causing
too much stretching increased urine output
• associated with maternal DM during the 3rd
Classification according to severity:
trimester, maternal hyperglycemia, causing
• mild
fetal hyperglycemia, resulting in osmotic
o 8-11 cm vertical pocket dieresis
o found in 80%
• moderate Diagnosis:
o a pocket with only the small parts • History:
o 12-15 cm vertical pocket o severe dyspnea
o found in 15% o excessive edema of the lower
• severe extremities, vulva, and abdominal
o free floating fetus wall
o fluid pocket ≥ 16 cm o oliguria because of ureteral
o found in 5% only obstruction from the enlarged fetus

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI

o mirror syndrome when associated
with fetal hydrops (mother mimics
the fetus)
o onset:
 acute
• early onset
• starts in 16-20 weeks
• leads to labor before
28 weeks of gestation
• severe symptoms
requiring prompt
intervention because
of possible congenital
anomalies (do work-up
ASAP)
 chronic
• starts later
• less discomfort for the
mother
Clinical Findings:
• difficulty in palpating fetal small parts
• difficulty in hearing the fetal heart tone
• very tense uterine wall (unable to palpate
fetal parts)
• greater fundic height measurement
Differential Diagnoses:
• ascites
• large ovarian cyst
Subject: OB
Topic: : Hydramnios / PROM
Page 2 of 5
Treatment Modalities:
• Amniocentecis
o diagnostic and therapeutic (releases
some of the pressure)
• Amniotomy
o rupture of membranes (pinpoint
holes) will relieve maternal
discomfort
o risk of cord prolapse and abruptio
placenta
o there is commitment to deliver
(should be done near term)
• Indomethacin Therapy
o impairs lung liquid function and
enhances absorption
o decreases fetal urine production
o increases fluid movement across
fetal membrane
o dose: 1.5 – 3 mg/kg/day
o causes premature closure of fetal
ductus arteriosus
o studies show constriction (not
persistent)
OLIGOHYDRAMNIOS
• Diminished AFV below normal limits (<5cm
AFI)
• acute oligohydramnios carries worst
prognosis
• common in post-term pregnancies

Outcome: Mechanism:
• guarded because of fetal malformations • chronic severe placental insufficiency
• increased perinatal morbidity and mortality • increased risk for cord compression and
because of increased risk of preterm labor fetal distress
• increased association with:
o abruptio placenta shearing effect Early Onset:
(because of sudden release of amniotic • commonly due to obstruction in the fetal
fluid) urinary tract or renal agenesis
o uterine cord prolapse due to • chronic leak from defect in the fetal
sudden gush of fluid membranes
o umbilical cord prolapse due to
• exposure to ACE inhibitors
overdistention
• conditions associated to:
o post partum hemorrhage due to
o Fetal
overdistention
 chromosomal abnormalities
Management:  congenital malformations
• no intervention required for mild to  IUGR (Intrauterine Growth
moderate cases Restriction)
• treatment necessary with maternal  death of baby
compromise like difficulty of breathing  PROM
• bed rest, salt and water restriction  post-term pregnancy
• diuretics are not effective o Placental

 abruption
 twin-to-twin transfusion
syndrome
o Maternal
 uteroplacental insufficiency
 maternal hypertension
 DM
o Drugs
 prostaglandin sythetase
inhibitors
 ACE inhibitors
o Idiopathic
Congenital Anomalies Associated with
Oligohydramnios:
• Amniotic Band syndrome
• Cardiac – Tetralogy of Fallot, septal defects
• GI – cloacal dysgenesis
• GU – renal agenesis, renal dysplasia
(anuria)
• Skeletal – sacral agenesis
• Chromosomal abnormalities
• Hypothyroididsm
• Twin-to-twin Transfusion
• VACTERL (vertebral, anal, cardiac,
transesophageal, renal, limb associated
defects)
• Diaphragmatic hernia
Complications:
• pulmonary hypoplasia in 1.1-1.4/1000
infants
o increased risk of stillbirths and
neonatal deaths
• possible mechanism for pulmonary
hypoplasia
o thoracic compression preventing
lung expansion
o lack of fetal breathing movements
decrease lung inflow
o no expansion of lungs
o failure to retain intrapulmonary
amniotic fluid or increase outflow
(impairs lung growth and
development)
 most widely accepted model
Management:
• Expectant Management
Subject: OB
Topic: : Hydramnios / PROM
Page 3 of 5
obefore 36 weeks with normal fetal
anatomy and growth
o close fetal surveillance (stress test,
non-stress test, fetal movement
monitoring, UTZ, Doppler)
o watch out for fetal growth
retardation (FTR) and fetal distress
o anticipate possible problems at
delivery
 increased cord compression
 variable deceleration
 increased CS rate (because of
fetal distress)
 meconium – increased
aspiration causing fetal
hypoxia and fetal distress
• Amnioinfusion
o to allow lungs to grow especially in
premature babies
o done intrapartum
o warmed NSS of 500-800 mL is
infused through an intrauterine
pressure catheter and continuous
infusion at 3 mL/min gives good
results
PROM
• Premature Rupture of Membrane
• Preterm Rupture of Membrane (old name)
• Prelabor Rupture of Membrane (preferred)
o increased risk for infection
o cervix is closed
o no effacement
Definition:
• rupture of fetal membrane with a latent
period before the onset of spontaneous
uterine activity
Incidence:
• 10% of all pregnancies
• majority of cases occur in >37 weeks
PPROM (Preterm Premature Rupture of
Membrane)
• PROM < 37 weeks
• 2% in all pregnancies
• very high chance of infection
Maternal Risk Associated with PROM:
1. Chorioamionitis
• localized to the uterus

• up to 30% in PPROM
• serious maternal systemic infection is
rare with prompt treatment
2. Abruptio Placenta
• 4-7% incidence
3. Increased operative delivery (>24 hrs)
4. Increased incidence of retained placenta
• due to more cases of marginal cord
insertion and battledore placenta
5. Postpartum Hemorrhage (from infection)
6. Puerperal Maternal Morbidities
• endomyometritis
• impaired maternal-fetal bonding
Fatal/Neonatal Risks Associated with PROM
1. Prematurity
• delivery occurs within 7 days in over
80% of cases
2. Neonatal Sepsis
• 2-4%
• consider gestational age, length, latent
period
3. Oligohydramnios Tetrad (FLIP)
• F – Facial anomalies
• L – Limb position defects
• I – Impaired fetal growth
• P – Pulmonary hypoplasia
4. Fetal Hypoxia
• cord prolapsed and compression,
abruptio placenta
5. Birth Injuries
• difficult deliveries due to
malpresentation and oligohydramnios
Management Options:
• Pre-pregnancy
o counsel about recurrent risks (21-32%)
o search for causes/precipitating factors
(due to infection)
o advice against cigarette smoking
o vaginal bacteriological screening
o antimicrobial treatment not proven
• Prenatal
o diagnosis (patient presents with watery
discharge)
o history and examination (sterile
speculum exam)
o repeated pad check (sanitary napkin)
Subject: OB
Topic: : Hydramnios / PROM
Page 4 of 5
o additional tests: ferning (smear of
amniotic fluid on a slide), nitrozine test,
presence of vernix or meconium
o intra-amniotic dye injection – not usuallu
done
o fetal fibronectin testing – if increased,
there is an increase in preterm delivery
o ultrasound – oligohydramnios is only
detectable in large fluid loss
Vigilance for Chorioamnionitis:
a. Clinical
1. maternal fever
2. tachycardia
3. uterine pain/tenderness
4. purulent vaginal discharge
b. Laboratory (unreliable)
1. WBC (differential count)
2. C-Reactive Protein (CRP)
3. Amniotic Fluid gram stain, WBC and
culture
4. Gas Chromatography – not done
c. Biophysical Testing
1. NST (non-stress test)
2. BPS (biophysical stress)
Delivery Indicated if:
• chorioamnionitis is diagnosed
• fetal distress occurs
o fetal heart rate abnormalities
o variable decelerations which
signifies cord compression
If NO chorioamnionitis, management
depends on AOG:
• <24 weeks
o increased risk for pulmonary
hyperplasia
o individualize management
o careful counseling of parents
o if pregnancy is to be continued, do
surveillance for sepsis
o Management: patient is supine –
don’t let amniotic fluid flow out
• 24-31 weeks
o upper gestational age cut-off will
vary with different institutions
depending on the survival rates
o conservative rather than aggressive
o if NO chorioamnionitis,
 use of steroids, tocolytics,
and antibiotics is not variable
 assessment of fetal
pulmonary maturity is a
variable practice
 Subject: OB
Topic: : Hydramnios / PROM
Page 5 of 5

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

Labor and Delivery:

1. maintain vigilance and screening for
infections
2. use of maternal antibiotics for prophylaxis
3. consider amnioinfusion for fetal distress
4. caesarian sections for usual obstetric
indications
5. pediatrician attendance during delivery

Postnatal Management:
1. maintain vigilance and screening for
infection
2. neonatal screen for sepsis

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

Kyth,