Oligohydramnios

Nancy Chescheir MD
Basics
Description
Oligohydramnios (oligo) refers to pathologically low volumes of AF.
Age-Related Factors
Not uniquely related to maternal age
Rare in 1st trimester
Epidemiology
The incidence of oligohydramnios ranges from 0.55% or more, depending on the
patient population, high risk factors, and GA.
Risk Factors
Vascular compromise
PROM

Medication use:
o

ACE inhibitors

NSAIDs

Pathophysiology
Abnormal production of AF:
o Poor placental perfusion in response to decreased intravascular volume
or BP, fetus preferentially perfuses vital organs, decreases GFR,
reduces urine production (prerenal)

Abnormal fetal renal function: Any problem that prevents bilateral

renal function or causes complete lower urinary tract obstruction
(postrenal)

Renal toxicity (ACE inhibitors, NSAIDs) nephrosis; (renal)

Loss of fluid:
o

PROM

Prolonged early severe oligo can results in pulmonary hypoplasia, facial and
limb abnormalities.

Cord compression with severe oligo

Associated Conditions
HTN
Severe diabetes

Lupus

Smoking

Unexplained MSAFP elevation

IUGR

Post-dates pregnancy

Placental abnormality:

Chronic abruption

Infarction

Circumvallate

Fetal abnormality:
o

Bilateral renal disease:

Agenesis, multicystic dysplastic kidneys

Lower urinary tract obstruction

Posterior urethral valves

Diagnosis
Signs and Symptoms
History
Typically not helpful
Physical Exam
Size < dates by 3 cm in normal-sized woman
Tests
Imaging
US required to make diagnosis:
Fetal crowding
MVP <1 cm is strictest definition

AFI <5 cm

With subjective oligohydramnios, use color Doppler to confirm that fluid

pocket isn't really loop of cord

Search for anomalies.

May require amnioinfusion to see well

Blue tap with indigo carmine if PROM is suspected but unconfirmed.

Doppler may be useful; color confirms renal artery presence; umbilical artery
assessment if IUGR

Treatment
General Measures
Weigh risks of continuing pregnancy vs. neonatal morbidity and mortality
risks and consider delivery.
Efforts to improve perfusion:

Avoid smoking, ACE inhibitors, NSAIDs

Decrease maternal stress

Complete bed rest not likely helpful, but avoid aerobic exercise.

PROM therapy with latency antibiotics if appropriate

Maternal fluid hydration not useful except for severe maternal dehydration

Pregnancy-Specific Issues
Make as complete a diagnosis as possible.
By Trimester
With absent fetal renal function or urine output, oligohydramnios occurs after
~16 weeks.
With known risk factors, actively assess AF volume at intervals after
intervention is considered.
Risks for Mother
Increased risk for cesarean delivery
Risks for Fetus
Related primarily to etiology, duration
Cord compression with IUFD, possible CNS injury possible
P.411
Medication (Drugs)
Steroids if anticipate preterm birth
Followup
Disposition
Issues for Referral
Perinatal consultation if known or suspected fetal anomaly, severe IUGR, severe
maternal vascular disease
Prognosis
Related to underlying cause, duration, and severity of oligohydramnios
Patient Monitoring
Fetus
If potentially viable fetus, consider fetal monitoring:
o Cord compressions: Variable decelerations
o

Placental insufficiency: Late decelerations, loss of variability

Consider amnioinfusion in labor

Prepare for pulmonary hypoplasia if severe oligohydramnios from 20 weeks or

so.

Miscellaneous
Clinical Pearls
Oligohydramnios is a sign of another problemfind the problem.
Send the placenta to pathology lab if etiology not known.

 High index of suspicion for IUGR, placental insufficiency

Abbreviations
ACEAngiotensin-converting enzyme
AFAmniotic fluid
AFIAmniotic fluid index
GAGestational age
GFRGlomerular filtration rate
IUGRIntrauterine growth restriction
MSAFPMaternal serum -fetoprotein
MVPMaximal vertical pocket
PROMPremature rupture of membranes
Codes
ICD9-CM
658.0 Oligohydramnios
761.2 Oligohydramnios affecting fetus or newborn.
Patient Teaching
Stop smoking
Perform fetal kick counts
Details related to underlying diagnosis if known
Limitations of US: Not a good predictor of pulmonary hypoplasia
Cord accidents can be sudden, unpredictable, lethal