Re: Question for the Nurses...

[Guest guest]

Polyhydramnios is the diagnosis of an abnormal amount of amniotic

fluid. It has been recognized for several decades that an excess of

amniotic fluid does carry an association with maternal or fetal

complications. Hence, over the last decade, progress has been made

towards defining the disorder as well as possible treatment to prevent

untoward outcome. The amniotic fluid index (AFI) is the usual manner

of diagnosing this disorder. When performing an amniotic fluid index

the abdomen is split into four quadrants by placing the intersection

of two perpendicular lines at the belly button. The ultrasound beam is

then moved from quadrant to quadrant and the maximum pocket of fluid

is measured by ultrasound. An amniotic fluid index above the 95th

percentile or greater than an absolute value of 25 is thought to be

abnormal. In general, the causes of polyhydramnios are due to either

excessive production of fluid or inadequate utilization or removal of

fluid. Interestingly, greater than 65 percent of cases of

polyhydramnios are due to unknown causes. However, it is important to

look for causes via ultrasound. For example, several causes are due to

abnormal swallowing by the fetus. This baby manifested secondary to

either to an abnormality of the fetal brain or an abnormality of the

intestinal tract with a blockage. These etiologies are much less

likely when the fluid volumes are just over the abnormal range. The

higher the amniotic fluid volume the higher the likelihood of finding

a congenital problem. Another possible cause is the increased

production of fluid.

It is thought that diabetes is one of the major causes of increased

production. This is thought to be possibly caused by the increased

lode of sugar seen in the fetus and increased fetal urination.

Treatment for this disorder falls into two different categories. Most

commonly, however, treatment of this is not needed. One utilized

treatment is reduction of the amniotic fluid by amniocentesis.

Utilizing this technique, large volumes (approximately one liter) may

be removed. The problem with this is does involve a procedure that has

a risk of complication. Additionally, this fluid often reaccumulates.

Therefore, this option is often used only in people who have extreme

discomfort and shortness of breath from the expanding fluid volume

pushing up on their diaphragm making breathing uncomfortable. Another

possible option is that of medications to decrease fluid production.

This sometimes involves a medication called Indocin. Indocin decreases

fluid production, but in long-term usage may cause changes in the

fetal circulation through the heart. In rare instances, this may be

irreversible. Additionally, this is not an option after approximately

32 weeks of gestation when utilization of Indocin is more likely to

cause irreversible fetal circulation changes.

When a pregnancy is discovered to have polyhydramnios, several options

are available. For those patients with an amniotic fluid index of

greater than 25 cm. there is a known possible increase in chromosome

abnormalities in the fetus and consideration should be given to

amniocentesis. Much more commonly, this is a late finding in

pregnancy, however, and chromosome analysis via amniocentesis does not

change the management of the pregnancy. Other options include diabetes

testing which is a common disorder during pregnancy and is a common

cause of polyhydramnios. Furthermore, the patient with polyhydramnios

needs additional monitoring to ensure the well being of her unborn

infant. This includes growth sonography every three to four weeks.

This is done due to the increased risk of diabetes and possible

increased risk of macrosomia (or large infant), or also to keep an eye

on a possible expansion in the fluid volume further. Additionally,

ultrasonography may look for the defects sometimes seen in these

fetuses. Also, fetal assessment is performed via heart rate monitoring

much like that performed in a hospital during labor where contractions

and the tracing of the fetus' heart rate is accomplished over a period

of approximately twenty to thirty minutes. This may be combined with a

test of fetal well being called the biophysical profile. When

utilized, these methods of fetal surveillance dramatically decrease

the risk of abnormal outcome. If one considers the uterus much like a

balloon and the air being blown into the balloon similar to the blood

flow through the arteries of the uterus into the uterus and the

placenta, one can make the analogy that as the balloon becomes more

distended it is harder to blow air into the balloon. Similarly, as the

uterus becomes distended with amniotic fluid, the tension on the

uterus becomes greater and effective blood flow into the uterus may be

decreased. Antepartum fetal surveillance monitors the mother's

condition to make sure that this blood flow is not possibly decreased

to an amount that may cause fetal harm. At the same, one may check for

uterine contractions that are more common due to the distension making

the uterus irritable. Overall, many cases of polyhydramnios are easily

treated and are not complicated as long as pregnancy is closely

monitored, especially in cases of polyhydramnios just slightly above

the normal range.

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[Guest guest]

Rather than posting all of this information and scaring your pants

off, I should have prefaced it by saying that in all of the deliveries

I have seen or heard, problems from polyhydramnios have been rare. You

post that you have been seeing prominent amounts of fleck, so your Dr

seems to be watching your levels closely. That's good!!

" In cases of mild polyhydramnios, the likelihood of finding a

significant problem is only about 16.5%; this should be communicated

to the parents "

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The amniotic fluid that bathes the fetus is necessary for its proper

growth and development. It cushions the fetus from physical trauma,

permits fetal lung growth, and provides a barrier against infection.

Normal amniotic fluid levels vary; however, the average volume

increases with gestational age, peaking at 800-1000 mL(same amount as

half of a 2 liter Pepsi bottle), which coincides with 36-37 weeks'

gestation. An abnormally high level of amniotic fluid, polyhydramnios,

alerts the clinician to possible fetal anomalies.

Inadequate levels of amniotic fluid (too little fluid),

oligohydramnios, results in poor development of the lung tissue and

can lead to fetal death.

In pregnancies affected by polyhydramnios, approximately 20% of the

neonates are born with a congenital anomaly of some type; therefore,

the delivery of these newborns in a tertiary care setting is

preferred. This article presents the causes, outcomes, and treatments

of polyhydramnios and oligohydramnios, as well as their effects on the

developing fetus and neonate.

Pathophysiology: Fetal swallowing, which occurs physiologically,

reduces the amount of fluid, and an absence of swallowing or a

blockage of the fetus' gastrointestinal tract can lead to polyhydramnios.

Frequency:

*In the US: Polyhydramnios occurs in 1% of pregnancies.

Mortality/Morbidity:

* Chamberlin used ultrasonography to evaluate the perinatal

mortality rate (PMR) in 7562 patients with high-risk pregnancies. The

PMR of patients with normal fluid volumes was 1.97 deaths per 1000

patients. The PMR increased to 4.12 deaths per 1000 patients with

polyhydramnios and 56.5 deaths per 1000 patients with oligohydramnios.

* Preterm labor and delivery occurs in approximately 26% of

mothers with polyhydramnios. Other complications are premature rupture

of the membranes (PROM), abruptio placenta, malpresentation, cesarean

delivery, and postpartum hemorrhage.

* Studies show an increased risk of associated fetal anomalies in

more severe forms of polyhydramnios. In series in 1990, 20% of cases

of polyhydramnios involved associated fetal anomalies, including

problems of the gastrointestinal system (40%), central nervous system

(26%), cardiovascular system (22%), or genitourinary system (13%).

Among these cases of polyhydramnios, multiple gestations occurred in

7.5%, 5% were due to maternal diabetes, and the remaining 8.5% were

due to other causes. However, at least 50% of the patients had no

associated risk factors.

* The mortality rate in oligohydramnios is high. The lack of

amniotic fluid allows compression of the fetal abdomen, which limits

movement of its diaphragm. In addition to chest wall fixation, this

limitation leads to pulmonary hypoplasia. Oligohydramnios is also

associated with meconium staining of the amniotic fluid, fetal heart

conduction abnormalities, poor tolerance of labor, lower Apgar scores,

and fetal acidosis. In cases of intrauterine growth restriction

(IUGR), the degree of oligohydramnios is often proportional to growth

restriction, and it is associated with a corresponding increase in the

PMR.

* In twin gestation with twin-to-twin transfusion, polyhydramnios

may exist in the recipient twin, and oligohydramnios may exist in the

donor. This complication is associated with high morbidity and

mortality rates.

o Polyhydramnios is usually defined as an amniotic fluid

index (AFI) more than 24 cm or a single pocket of fluid at least 8 cm

in deep that results in more than 2000 mL of fluid.

* Polyhydramnios

o Visual inspection may reveal a rapidly enlarging uterus in

the pregnant mother.

o Multiple gestations are associated with polyhydramnios.

o Fetal abnormalities associated with polyhydramnios include

neonatal macrosomia, fetal or neonatal hydrops with anasarca, ascites,

and pleural or pericardial effusions.

o Skeletal malformations also can occur; these include

congenital hip dislocation, clubfoot, and limb reduction defect.

o Attempt to identify abnormalities in fetal movement

suggestive of neurologic abnormalities and obstruction of the

gastrointestinal tract.

Causes:

* Polyhydramnios

o Twin gestation with twin-to-twin transfusion (increased

amniotic fluid in the recipient twin and decreased amniotic fluid in

the donor) or multiple gestations, which can lead to twin-to-twin

transfusion syndrome

o Fetal anomalies, including esophageal atresia (usually

associated with a tracheoesophageal fistula), tracheal agenesis,

duodenal atresia, and other intestinal atresias

o CNS abnormalities and neuromuscular diseases that cause

swallowing dysfunction

o Congenital cardiac-rhythm anomalies associated with

hydrops, fetal-to-maternal hemorrhage, and parvovirus infection

o Maternal type 2 diabetes mellitus (more often than in

oligohydramnios)

o Chromosomal abnormalities, most commonly trisomy 21,

followed by trisomy 18 and trisomy 13.

o Fetal akinesia syndrome with absence of swallowing

* Polyhydramnios

o Glucose tolerance test for mothers with suspected type 2

diabetes mellitus

o If associated fetal hydrops is present, screening for

maternal antibodies to D, C, Kell, Duffy, and Kidd antigens to

determine the mother's immunity

o Kleihauer-Betke test to evaluate fetal-maternal hemorrhage

o Venereal Disease Research Laboratories (VDRL) test to

screen for syphilis

o Immunoglobulin G (IgG) and immunoglobulin M (IgM) titers

to evaluate for exposure to rubella, cytomegalovirus (CMV), and

toxoplasmosis

o Hemoglobin Bart in patients of Asian descent (who may be

heterozygous for alpha-thalassemia)

o Fetal karyotyping for trisomy 21, 13, and 18

o Test for congenital viruses in the amniotic fluid by using

the polymerase chain reaction

Procedures:

* Polyhydramnios

o Reductive amniocentesis may be performed and has

contributed to prolonged pregnancy in patients who are severely

affected by hydramnios.

o This procedure can reduce the risk of preterm labor, PROM,

umbilical cord prolapse, and placental abruption.

o However, if too much fluid is removed, the risk of

placental abruption due to uterine compression increases.

o Other risks of the procedure include infection, bleeding,

and trauma to the fetus.

Medical Care: The first step is identifying the etiology of the

abnormal volume of amniotic fluid. Medical care includes use of

steroids to enhance fetal lung maturity if preterm delivery is

anticipated.

* Polyhydramnios

o Patients with polyhydramnios tend to have a higher

incidence of preterm labor secondary to overdistention of the uterus.

o Schedule weekly or twice weekly perinatal visits and

cervical examinations.

o Place patients on bed rest to decrease the likelihood of

preterm labor.

o Perform serial ultrasonography to determine the AFI and

document fetal growth.

o In some cases of polyhydramnios associated with fetal

hydrops, the direct intravascular transfusion of erythrocytes may

increase the fetal survival rate.

Consultations:

* A specialist in maternal-fetal medicine may be helpful in

significant oligohydramnios or polyhydramnios, especially when the

condition is unexplained, involves hydrops fetalis, or is associated

with congenital malformations.

* Genetic counseling may be helpful in cases in which congenital

anomalies are identified.

* Consult a neonatologist, pediatric surgeon, pediatric

cardiologist, pediatric nephrologist, or genetics other specialist as

required to care for the infant.

Diet:

* In cases of polyhydramnios in which maternal diabetes is

suspected, perform a glucose tolerance test. If the test results are

positive, treat the mother with an American Diabetes Association (ADA)

diet. Insulin is rarely needed.

Most cases of polyhydramnios respond in the first week of treatment

with indomethacin. The approach appears to be highly effective

(90-100% in some studies), provided that the cause is not

hydrocephalus or a neuromuscular disorder that alter fetal swallowing.

Complications:

* Polyhydramnios

o Risks and complications of amnioinfusion include amniotic

fluid embolism, maternal respiratory distress, increased maternal

uterine tone, and transient fetal respiratory distress. An increase in

the risk of maternal or fetal infection is not substantiated.

o Risks of amniocentesis include fetal loss (1-2%). Other

complications are placental abruption, preterm labor, fetal-maternal

hemorrhage, maternal Rh sensitization, and fetal pneumothorax. The

risk of fetal infection is slightly increased.

* Oligohydramnios

o The primary complications are those related to fetal

distress before or during labor.

o The risk of fetal infection is increased in the presence

of prolonged rupture of the membranes.

Prognosis:

* Polyhydramnios

o If the condition is not associated with any other

findings, the prognosis is usually good.

o According Desmedt et al, the PMR in polyhydramnios

associated with a fetal or placental malformation was 61%.

o As mentioned in Background and Mortality/Morbidity 20% of

infants with polyhydramnios have some anomaly; in these cases, the

prognosis depends on the severity of the anomaly.

o Studies show that, as the severity of polyhydramnios

increases, so does the likelihood of determining the etiology.

o In cases of mild polyhydramnios, the likelihood of finding

a significant problem is only about 16.5%; this should be communicated

to the parents.

[Guest guest]

About 6 weeks ago my fluid was up to 28 and they ahd me redo an US the

following week and it had gone back down, they said it was not unusual to do

that. I

have gained 42 pounds now and counting, i sure hope i can get it off easier

than before WLS.

God Bless,

Robin, NorthEastern, NY

Age- 41

EDD- July 27th, 2004

IT'S A BOY!!!!!!

Mommy to:

&

(twin boys 8 years),

Madison, daughter, 5 years and

Wife to Pup 15 years (October 31, 1988)

Gastric Bypass Surgery-

October 18th 2002

Start-378, current- 246(pregnant)

goal 170 after baby

It's a BOY!!!!!

Emerson Roger