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large for date Posted by rasheeda B.

a) which additional investigation and why?

Polyhydramnios is a risk factor for perinatal mortality and intrapartum complications.Hence need to check ogtt,to know if GDM.Also measure BMI.Detailed ultrasound-mother is 35 yrs additional risk for congenital anomaly,to check if oesophageal or duodenal atresia,anencephaly,aneuploidy.In case of twins for twin to twin transfusion syndrome.Sacrococygeal teratoma.Any maternal alloimunisation causing fetal anaemia-klieihauer betke test,parvovirus b19 infection.

In case ogtt is abnormal to check maternal fundoscope exam of retina,maternal kidney function test.

b)subsequent antenatal management if no cause.

Major management aim is to reduce maternal discomfort and prolong pregnancy.Treatment indicated if hydramnios is severe(afi>40cms,or deep vertical pocket >12 cm)as this has increase amniotic pressure..

Treatment options-pharmacological management .serial amnio reduction.

pharm. options-indomethacin,sulindac,COX-2,may be uded to decrease fetal urine output.Indomethacin associated with renal failure and prem. closure of DA.

serial amnioreduction at risk of precipitating preterm labor.Termination of preg maybe offered if lethal anomalies detected.Counsel with paed surgeon.Pt. should be counselled about pprom,,malpresentation,cord prolapse,chorioamnionitis.

If polyhydramnios persists  elective delivery at 38 weeks,in view of increase risk by 2-5 times of unexplained still birth.

c)spontaneous labour at 36 Wks.-additional intervention optimise outcome..

If head is fixed in pelvis may go ahead for normal delivery.Very close monitoring in labour,for fetal distress.To do controlled arm,with needle.After artificial rupture of memb,with needle and liqor draining, to start oxytocin drip with continuous fetal monitoring.Keep pt. in left lateral position throughout preferrably.Upon ant shoulder presentation for methergine administration.Active management of third stage.To  prevent  post partum hemorrhage.