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Essay 290 - Polyhydramnios

Posted by S D.
a) I will explain to her that the fluid around the baby is increased. In most cases, the cause is unknown but it could be associated with maternal diabetes mellitus and structural abnormalities of the baby. Risks to her include abdominal discomfort, respiratory embarrasment and preterm delivery. Risks to the baby include prematurity, cord prolapse and consequently increased perinatal morbidity and mortality.
b) Maternal investigations include Glucose tolerance test as maternal diabetes is associated with polyhydramnios; TORCH screening especially parvovirus can cause hydrops and polyhradmnios. Detailed anatomy scan, ideally in a tertiary centre should be performed to exclude structural abnormalities such as neural tube defects, abdominal wall defects, tracheoesophageal fistula and presence of hydrops. If hydrops found, then further investigations such as maternal blood group, red cel antibodies, kleihauer performed. Depending on ethnicity Hb electrophoresis done to rule out alpha-thalassemia.
c) Aim of subsequent management is to relieve maternal discomfort, decrease the risk of preterm delivery and improve perinatal outcome. Mother should be given Indomethacin as it decreases amniotic fluid by decreasing fetal urinary output. But it causes premature closure of ductus arteriosus, cerebral vasoconstriction and impaired renal function in fetus. Hence it should be stopped at 34 weeks or when amniotic fluid returns to normal. Other agents such as Sulindac produces lower fetal side effects and specific cox2 inhibitors such as nimesulide can be used which has fewer side-effects.
Amnioreduction is where the fluid is drained out under ultrasound guidance but it needs repeated procedures due to re-accumulation. There is a risk of PPROM, abruption, sepsis and preterm labour. There is no role for diuretics or salt restriction.
Corticosteroids (Betamethasone 12 mg IM 24 hours apart, 2 doses) should be given as at increased risk of preterm delivery. This decreases respiratory distress syndrome, intraventricular haemorrhage, necrotising enterocolitis and duration and cost of neonatal intensive care unit.
Tocolytics may be helpful for threatened preterm delivery to effect in-utero transfer if no SCBU beds or for administration of steroids.
Serial growth scans should be arranged to assess fetal growth as clinical examination is difficult and unreliable.
She should be advised hospital admision at 37-38 wks as at higher risk of cord prolapse if SROM and the higher risk of abruption and fetal distress.
IOL may be necesary at around 38 wks due to maternal discomfort and the higher risk of caesaren section should be explained due to malpresentations and unstable lie.
Vaginal delivery should be anticipated and neonatal alert form done antenatally.
d) The woman is at higher risk of cord prolapse, abruption and operative deliveries intrapartum, so IV access obtained and bloods taken for FBC and group and save. Scan for presentation should be done. If cephalic and free and cervix is 1-2 cm dilated, controlled ARM done in theare as at higher of cord prolapse and Em.CS may be required. If spontaneous rupture of membranes, then VE should be done to exclude cord prolapse. Continuous CTG done as at risk of fetal distress. Neonatologist should be present at delivery and NG tube passed, X-ray taken to make sure it is in the stomach to rule out tracheo esophageal fistula and then feeding commenced. Post partum syntocinon infusion should be started as per unit protocol as at higher risk of PPH.
Normal deli
Posted by clarice M.
a) Polyhydramnios means that there is excess fluid around the baby. In the majority of cases no cause is ever found. Some of the causes include diabetes in pregnancy which causes the baby to urinate more, infections and abnormalities that affect the baby’s swallowing. Further tests will be needed to identify a cause. Written information will be provided.

b) An oral glucose tolerance test will be requested to exclude gestational diabetes.
A referral to the fetal medicine department would be requested to identify any structural anomalies that could have been missed on the anomaly scan.
A blood sample would be obtained to exclude parvovirus infection, toxoplasmosis, rubella and cytomegalovirus.
Rhesus sensitisation and ABO incompatibilities are often accompanied by fetal hydrops and if this is identified on ultrasound scan a Kleihauer test and anti-D antibody titres would be requested.

c) Generally the pregnancy outcome for idiopathic polyhydramnios is good hence the patient should be reassured. However, complications can occur and this includes preterm labour, unstable lie and malpresentation. The patient would be advised to contact the hospital for a medical review if she has symptoms of preterm labour or rupture of membranes. Due to the increased distension, placental abruption can also occur and she should ring for an ambulance if there is bleeding in association with abdominal pain.
Fortnightly ultrasound scans to monitor growth and liquor volume would be requested. If there is a sudden increase in liquor volume, amniocentesis may be necessary. Amniocentesis should also be considered if abdominal distension is severe enough to cause maternal breathing difficulties. Medical treatment with indomethacin or sulindac is an alternative to amniocentesis.
A vaginal delivery is not contraindicated if the presentation is cephalic and there are no other contraindications to a vaginal birth (eg 2 previous caesarean sections). If the pregnancy progresses beyond 37 weeks, an induction of labour could be planned between 38-39 weeks. The cervix is likely be more favourable. If induction of labour fails, a caesarean section at this gestation is less likely to result in transient tachypnoea of the newborn.

d) An abdominal palpation should be performed to assess the degree of engagement of the presenting part. A free presenting part increases the risk of cord prolapse when the membranes rupture. An ultrasound scan should be performed to check for presentation and lie as malpresentation and unstable lie is common in polyhydramnios.
Electronic further monitoring should be commenced as the patient is high risk.
Intravenous access should be sited as the patient is at risk of post-partum haemorrhage and cord prolapse. Blood should be sent for a full blood count and group and save.
If the presenting part is not engaged and artificial rupture of the membranes is indicated it should be performed in theatre to allow for rapid access to an emergency Caesarean in the event of a cord prolapse.
Active management of the 3rd stage should be performed. An oxytocin infusion should also be commenced to reduce the risk of uterine atony.
The baby should be examined post-natally for an occult tracheo-oesophageal fistula before commencing with feeds in order to avoid aspiration pneumonia.
Posted by Neelam A.
NA
(a)I would explain the diagnosis of polyhydramnios and its implications. The consequences could be maternal and foetal. Maternal consequences would be – respiratory compromise, abdominal discomfort, abnormal presentation, abruption, increased risk of instrumental or caesarean section and postpartum haemorrhage.
Foetal implications are foetal abnormality, preterm labour, preterm rupture of membrane, cord prolapsed and increased perinatal morbidity and mortality.

(b)Investigations should be done to find out the aetiology of polyhydramnios, however it is idiopathic in majority of cases. GTT (glucose tolerance test) should be done to diagnose gestational diabetes or undiagnosed diabetes mellitus as it is associated with polyhydramnios. Maternal infection screen should be performed to rule out TORCH, syphilis and Parvo virus infection. Detailed anomaly scan should be done to make diagnosis of multiple pregnancy and to rule out any structural anomalies in foetus, if it has already not been done, size of placenta and to measure amniotic fluid index. Swallowing defects in foetus such as oesophageal atresia or duodenal atresia and diaphragmatic hernia are associated with this condition. Growth should also be plotted. Doppler of middle cerebral artery should be performed to make the diagnosis of foetal anaemia as Parvo virus infection or foeto-maternal haemorrhage result foetal anaemia. Amniocentesis should also be offered especially if foetus has got structural anomalies to diagnose 21, 18 and 13 trisomies.
Main aim of management is to prolong the pregnancy.

(c)Amnioreduction can be performed for maternal respiratory compromise or to prevent preterm labour. However it is associated with risk of infection, preterm labour, rupture of membrane and repeated procedure might require to prolong the pregnancy. NSAIDs such as indomethacin can be prescribed as it reduces foetal urinary out-put. Side effects are preterm closure of ductus arteriosus, impaired renal function and cerebral vasoconstrictions. It should be stopped at 32 weeks. Sulindac is associated with less probability of ductus arteriosus closure. Selective COX 2 inhibitor is more selective drug. Steroids should be given to improve lung maturity. Nifedipine can be prescribed as a tocolytic drug, however, it is not licensed in the UK. She needs serial scan to see growth of baby and amount of liquor.There is no role of fluid restriction or reduced salt intake.

(d)Scan should be done to in labour to confirm the presentation. There is no indication for caesarean section if baby presentation is cephalic. I V access and blood should be obtained for FBC and group and save. She would need continuous monitoring. Controlled ARM should be performed in theatre for labour augmentation. Vaginal examination should be done to rule out cord prolapse once she ruptures membrane. Baby should be delivered by caesarean section in case of abnormal lie, cord prolapsed or abruption. Active management of third stage should be done to reduce the risk of postpartum haemorrhage. Baby should be examined by paediatrician after delivery and tube should be passed to rule out trachea-oesophageal fistula before feeding.

Posted by dr neelangini G.
a)I will tell her ,that her waters surrounding the fetus is more than normal for this gestational age. I would like to tell her that cause in majority of cases is not known. But the known causes are like IDDM,TORCH ,parvovirus,syphilis hepatitis infection,congenital anomalies like duodenal atresia,esophageal atresia,gastroschisis,fetal hydropes .Because of hydramnious ,she may get some difficulty in breathing,abdominal discomfort, which may impact on her day to day activities & latter on ther may be PPH,Increased chance of CS. .As pregnancy advances,symptoms may be aggravated & it may affect her pregnancy.She may deliver early ,before 37 weeks &.other complications may arise like PROM,cord prolapse,abruptio placenta, fetal acidosis, altogether increased risk of perinatal morbidity & mortality of about 30%.

b)Investigations like,FBC to rule out anaemia,,Bl grop & Rh typing, Rh antibody titer ,Klehauer test incase of fetomaternal haemorrhage in Rh negative mother,Urine microscopy ,Blood urea & electrolyte,.Serial USG for growth of the fetus,To diagnose any anomalies,& AFI for amount of AF, Placental scan for location & number of placenta(chorionicity) in case of twin pregnancy.

c)As this is severe hydramnious ,it should be treated as high risk pregnancy. She should have frequent antenatal visit. During the visits serial USG for fetal growth,,CTG for fetal wellbeing,, investigations like ,repeat HB for anemia,URINE microscopy for infection. I will tell her , If she develops any complications like PROM,contractions,severe pain in abdomen,should come to hospital immediately or contact to hospital .Information leaflet should be provided to her. This antenatal management should continue till 37 weeks.In case complications like severe respiratory compromise ,she will require serial amnioreduction, followed by treatment like Sulindac, It has less fetal complication than other drugs. Drugs like Indomethsin or nimesulide can be used. till AFI is within normal limit or upto 34 weeks of gestation .NSAID should not be given for prolonged period especially Indomethasin..

d )I will examine her for confirmation of labour and of presentation, fixity of presenting part should be ascertained for further plan of management .VE should be done to note Bishops score. Parental line shoul be established with a large bore canula because there is possibility of PPH ,abruptio placenta. I will send blood for crossmatching . Intrapartum period should be monitored by continuous fetal monitoring ,for early diagnosis of cord prolapse or cord presentation, abruptio placenta in case it develops .If cervix is favourable,(usually in hydramnious), & presenting part is is fixed . I will do sweeping of membrane which may help in speedy progress of labor. Once contrctions are established ,at 2 cm of dilation I will like to do controlled AROM so that maternal discomfort can be reduced. & it also helps in speedy progress of labour.I will inform the paediatrician, Anaesthesist & OT staff about the case & possible requirement of CS .Immediate after delivery ,20 units of oxytocin should be given in infusion to prevent PPH. If any complications develop like cord prolapse ,abruptio, malpresentation, emergency CS should be done.
Posted by zakaria M.
A) I will explain that amniotic fluid surrounding the baby is increased. We will do further work-up to identify the cause, in 50-60% of the cases no cause is found. Maternal causes include gestational/pre-existing diabetes, and common fetal causes are structural/ chromosomal abnormalities, fetal infection & fetal anemia. Severe Maternal risks are abdominal discomfort, uterine irritability, respiratory compromise, increased risk of placental abruption, cesarean section and post-partum hemorrhage Fetal risks are preterm delivery/ rupture of membranes, underlying congenital anomalies, increased risk of hypoxemia and acidosis with antepartum fetal death.
Posted by Farzana N.
a)I will explain to the patient that the water around her baby is more than normal.The cause may be detected in 80% of cases with severe hydramnios ,which may be due to fetal anomalies or infections,maternal problems or placental lesions.
She would hhave to undergo some investigations which would help us in finding a cause for this excessive water around her baby which can be treated
b) First and foremost she should be referred to a fetalmedicine unit for a detailed anomaly scan. Number of fetuses should be looked for ,as multiple pregnancy is associated with polyhydramnios. Associated fetal hydrops should be noted.If hydrops is present, she should be investigated for DM,isoimmunisation or Hb electrophoresis for alpha thalassemia.or parvo virus.
Structural anomalies with particular emphasis on CNS-anencephaly,GIT-TOf,,esophageal and duodenal atresia. Or gastroshisis.CVS for cardiac anomalies which may be further investigated by ECHO.
Placenta is looked to detect placental chorioangioma.
Markers for aneuploidies such as trisomy 21,18 and 13. should be looked for.Presense of such markers may reuire a karyotype .
If there is no hydrops and no structural anomalies detected, maternal and fetal viral infection workup should be done for TORCH and syphilis.If there is evidence of fetal infection by USS ,amniocentesis should be done.
c)If no cause has been found,antenatal managment would aim at relieving maternal distress and prevention of preterm delivery .
Maternal symptoms may be relieved by doing amnioreduction.Recollection of liquor may occur requiring serial amnioreduction.
Pharmacological treatment with NSAIDS such as Indomethacin is given which causes fetal oliguria and reduce amount of liquor.There is risk of premature closure of ductus arteriosus,so treatment should be discontinued at 32-35wks or when AFV is normal. Sulindac or Nimesulide may be given with less adverse effects.Diuretics or salt restriction may be harmful,hence no role.
Corticosteroids should be given for fetal lung maturity.
USS scan should be done 2weekly for fetal wellbeing and growth.
She should be advised to report to hospital in case of labor pain or SROM,since there is risk of cord prolapse.Since there is high risk of pretermdelivery SCBU should be kept informed.
d)Thorogh examination should be done to note lie and presentation ,since unstable lie and malpresentation is common with polyhydramnios. If the lie is transverse CS may be considered.Vaginal examination is done to note presense of membranes, if ruptured membranes, cord prolapse should be ruled out.Continuous EFM is done .
Neonatologist should attend the delivery and baby examined to ruleout TOF before feeding.
Venous access secured and she should be grouped and saved as there is high risk of PPH. Active management of third stage is done and oxytocin infusion given.
Posted by Ahmad A.
I would tell her that the amniotic fluid around the baby is significantly increased in volume. This finding either physiological-unexplained in more than 70% of cases or due to pathological finding. We have to rule out either through detailed foetal scan or maternal investigations.

Ultrasound for detailed scan should be reviewed and request another scan to check foetal anomaly may cause polyhydramnios. There are different causes may cause increase amniotic fluid volume, neural tubal defect (NTD), oesphageal atresia, duodenal atresia, tracheo oesphageal fistula, difficulty in foetal swallowing, upper foetal chest compression, diaphragmatic hernia, and cystic hygroma. Placental cause may be rule out in case of large placenta or placental tumour (chorioangioma). All cases of hydrops foetalis (immune or non immune) may cause polyhydramnios, so should be excluded firstly by antibody screen and other possible cause of none immune hydrops. Maternal investigations included, screen for gestational DM, glycosylated Hb. Investigations for maternal infection, TORCH with parovirus (IgG and IgM) to rule out recent infection. Amniocentesis may be requested as therapeutic (tapping) and diagnostic (chromosomal analysis, aneuploidy and infectious screen, IgM like, CMV, rubella, syphilis, parovirus)

Antenatal management with unexplained polyhydramnios, can be by conservatively without intervention and should be advised to report pt the hospital in case of increase abdominal distension with tense abdomen, dyspnoea, chest compression. I would offer her non estroidal anti-inflammatory (Indomethasin) it may reduce excessive secretion of the amniotic fluid.. This could be given till 32 weeks gestation, as it increase the incidence of premature closure of the ductus arteriosus. I may offer her abdominal tapping for release of the pressure symptoms. However there is increase incidence of infection(chorioamnitis), placental abruption, and preterm labour. I would advise her to report to the hospital directly in case of labour pain or rupture of membrane as the incidence of preterm labour is high. I would ask her to have an elective admission in case she reaches to 37 weeks without complications, also, in case of signs of threatened preterm labour and untolerated discomfort.

I would confirm her labour with gentle vaginal examination for cervical dilatation, effacement, membrane condition, evaluation the presenting part and possibility of compound presentation or cord prolapse. I would confirm the presentation and lie of the baby by bed side ultrasound. I would discuss with her the mode of delivery according the findings. This could be by vaginal delivery in case of cephalic well applied over the cervix. I would offer controlled rupture of membrane in case of cephalic presentation with the availability of emergency type I cesarean section.. I would offer her a type 2 cesarean section in case of un identified presenting part, oblique or transverse lie with possibility of breech extraction with Cesarean section. I would offer her an active third stage management as there is increase post partum haemorrhage.
Posted by zakaria M.
A)
I will explain that amniotic fluid surrounding the baby is increased. Finding requires further work-up to identify the cause and in 50-60% of the cases no cause is found. Maternal causes include gestational/pre-existing diabetes, and common fetal causes are structural/ chromosomal abnormalities, fetal infection & fetal anemia. Severe Maternal risks are abdominal discomfort, uterine irritability, respiratory compromise, increased risk of placental abruption, cesarean section and post-partum hemorrhage Fetal risks are preterm delivery/ rupture of membranes, underlying congenital anomalies, increased risk of hypoxemia and acidosis with antepartum fetal death.
B)
Severe polyhydramnios is associated with increased perinatal mortality and morbidity, investigations needed to identify treatable causes I will request a detailed high resolution ultrasound to look for fetal hydrops, any structural anomalies, placental tumor (chorioangioma), and growth restriction/macrosomia. Abnormalities associated with fetal infection i.e. intracranial calcification will be looked for. Doppler studies of middle cerebral arteries as high systolic velocities are relevant to fetal anemia. Chance of fetal abnormality or genetic condition is increased in cases of severe polyhydramnios (90% Vs 10% in mild cases).
In the absence of hydrops and structural anomalies, or If the woman has any other features associated with gestational diabetes (increased BMI, family history of gestational diabetes or NIDDM), history of PCOS then GTT advised to exclude GDM Screening tests for maternal infection include VDRL, and screening for rubella, toxoplasmosis, parvovirus and CMV – will be done if there is evidence of fetal infection on ultrasound scan • Invasive fetal testing (amniocentesis for karyotype / infection screen) is considered only in the presence of other anomalies .

C)
Management aim is to reduce maternal discomfort, prolong pregnancy and prevent maternal and fetal complications. Treatment is required as severe polyhydramnios is associated with increased intra-amniotic pressure.Sulindac(200mg bid) a prostaglandin synthase inhibitor is prescribed. It reduces amniotic fluid volume without evidence of ductal constriction during prolonged therapy, and has lesser effect on fetal urine output compared to indomethacin. In case of excessive maternal symptoms of abdominal discomfort and respiratory compromise, amnioreduction is performed under ultrasound guidance prior to medical therapy.Corticosteroids Betamethasone (12mg) I/M X 2-doses, 24 hours apart given in case of uterine irritability, when preterm labour is likely.
Diuretics are not recommended as associated with reduced uteroplacental perfusion. Dietary and salt restriction are of no benefit.
Regular scans done to monitor fetal growth and amniotic fluid volume. The combination of growth restriction and hydramnios is a risk factor for intrapartum complications and perinatal mortality even in the absence of congenital malformations.
Patient will be counseled about likely complications including PPROM, cord prolapse, placental abruption and preterm labour. She is advised to report immediately in case of abdominal pain, per vaginal bleeding or rupture of membranes. If polyhydramnios persist induction of labour may be required because of excessive maternal discomfort .Vaginal delivery is anticipated in stable cephalic presentations.Elective C/S considered in case of severe hydramnios.

C)
I will assess for amniotic fluid volume and engagement of fetal head. In case normal volume, there are no additional risks. While in case of persistent polyhydramnios, and unengaged head there is a risk of unstable lie / cord prolapse, abruption and risk of PPH. I/V line maintained with large bore canulas (14-16) and blood grouped & saved. SCBU is informed as there is risk of undetected esophageal atresia .Anesthetist and theatre staff informed about the case.Controlled ARM if required will be performed in theatre and emergency C/S done in case of placental abruption or cord prolapse. Continuous fetal monitoring done. Anticipating high risk of PPH, active management of third stage done followed by continuous syntocinon infusion for 4-6 hours. Neonatologist will be present at delivery.
In case of severe polyhydramnios and unstable lie cesarean section is the safer option.








Posted by Manoj Babu  R.
(a) What would you tell her about this finding? [3 marks].

She should be told that there is excessive accumulation of amniotic fluid around her baby and it can occur in about 1-3% of pregnancies. She should made aware of the need for futher investigations to look for any serous causes and it may be present in up to 80% cases when polyhydramnios is severe.

She should be told that even if no abnormalities are found there are risks like maternal discomfort, preterm labor and need for interventions like amniocentesis and operative deliveries. She should be provided with written information.

b) which investigations will you perform and why? [5 marks]

The investigations are aimed at determining ant fetal or maternal causes for polyhydramnios. The antenatal investigations should be reviewed and screening for diabetes and blood grouping and Rh typing should be done if not done already. Uncontrolled maternal diabetes and red cell isoimmunisation can cause polyhydramnios. Maternal screening for infection like parvovairus should be done if history is suggestive or if there is associated fetal hydrops.

A high-resolution targeted fetal USG should be done at fetal medicine centre to rule any fetal anomalies, hydrops and placental abnormalities like chorioangiomas. Fetal abnormalties which can cause polyhydramnios include upper gastrointestinal tract anomalies like oesophagial atresia, thoracic anomalies like diaphragmatic hernias, like cystic adenoid malformations of the lung, CNS anomalies like anencephaly and cardiac and musculoskeletal abnormalities. The presence pf hydrops may need cordocentesis to screen for fetal infections and anaemia. The presence of multiple pregnancies can suggest causes like TTTS.

Amniocentesis may be needed for karyotyping in the presence of anomalies which may suggest a chromosomal aneuploidy.

c) Justify your subsequent antenatal management given that no cause has been identified [7 marks].

If no cause is found she should be counseled about the implications. In around 10% of cases there can anomalies which may not be detectable by USG when the hydramnios is severe. Other risks like preterm labour, premature rupture of membranes fetal malpresentations and the increased need for ceasaran sections should be told.

The aims of treatment are to reduce occurrence of preterm labour and to relieve maternal symptoms. Severe polyhydramnios with AFI greater than 40 cm there chance of placental hypoperfusion also. Medical treatment is mainly aimed at reducing the production of amniotic fluid. Indomethacin can given to reduce the fetal urination. But it should be stopped at aroung 32 weeks as it can cause premature closure of ductus arteriosus. Other side effects include shot term and long term damage to the fetal kidneys, neonatal necrotizing enterocolitois, and intracranial haemorrhage. USG monitoring of amniotic fluid should be done to assess response and it may detect fetal renal failure.

Serial amnioreducation should be to reduce maternal discomfort and to maintain the response to medical treatment. But it is associated with small risk of infection, rapid reaccumulation and rarely abruptio placenta if large volumes are removed in a single setting. TVS screening can be employed to detect shortening of cervix which may predict preterm labour. But interventions to prevent preterm delivery are limited. Antenatal steroids should be given if preterm labour occurs before 34 weeks.

d) She presents in spontaneous labour at 36 weeks gestation. Justify your interventions to optimise outcome. [5 marks]

At admission she should asked about leaking and bleeding PV as they are prone for PROM and abruptio placenta if rupture. Presentation should be confirmed by clinical examination well as USG due higher incidence of malpresentations and palpation is less sensitive due to excess liquor. Continuous electronic fetal monitoring should be started. Vaginal examination should be repeated after rupture of membranes to rule out cord prolapse and to confirm presentation and position. CTG should be revaluated to rule out abruption.

There may be increased need for operative vaginal delivery and cesarean section due more frequent malpostions. Postpartum hemorrhage should be anticipated due to the over distention of uterus. Blood bank should be alerted and active management of third stage should be done to reduce atonic PPH. Oxytocin infusion should be started after delivery to maintain uterine contraction.

Paediatric surgeon and neonatologist should be alerted about the clinical details. Neonatologist should be present at delivery. The neonate may need early intubation and ventilation considering the possibility of anomalies like eosophagial atresia, tracheoesophagial fistula and diaphragmatic hernia.
Posted by Joanna L.

a) I would tell her that there appears to be more fluid surrounding the baby than usual, I would explain that we need to investigate to see whether there is an identifiable reason, which may need to be treated. I would reassure her that there is no major problem in the majority of cases. I would explain the various investigations to her. I would explain the possible symptoms to her ie contractions, and explain the risk of preterm labour.
b) I would review the history, particularly the screening for aneuploidy. I would perform a detailed anonmaly scan if not already done to determine whether ther are any soft markers of chromosomal abnormalities or any sign of tracheal or intestinal atresia, as well as fetal presentation and to look at the placenta in case of chorioangioma. I would also request a GTT to check for diabetes as this is a leading cause of polyhydramnios (I would also check the fetal growth)
c) With no cause identified the treatment is supportive. She needs to be seen regularly in ANC with regular scans for growth and liquor volume, as it will be difficult to clinically assess growth, and to see if the liquor volume is increasing. If she becomes symptomatic from the polhydramnios (shortness of breath or contractions) then amniodrainage may be considered. During consultations the risks of preterm labour, cord prolapse and options for delivery would be discussed. If she remained undelivered at 37 weeks I would admit her to the antenatal ward due to the risk of cord prolapse if the membranes rupture, and also because of the risk of placental abruption after abrupt decompression of the uterus. I would not induce labour early unless there were other indications.
d) I would admit her to the labour ward (rather than midwifery led unit) as she is high risk, for the same reason I would commence continuous CTG once she is in active labour. Vigilance is required to the risk of cord prolapse and if ARM is required this should be controlled if the head is not engaged. Presentation should be checked with portable ultrasound as it will be difficult to palpate. Care should be taken at the time of SRM that the fetal heart is monitored throughout, and any decelerations should prompt a vaginal examination. If the feus is large, particularly if she has diabetes, her attendants should be prepared for the possibilty of shoulder dystocia and the middle grade should be present for delivery.
Posted by Mark D.
a)
I will tell her that the amount of water around the fetus is more than expected for this gestation.It may be due to various causes like occult gestational diabetes, viral infections ,or fetal anomalies like abdominal wall defects, oesophagial atreia,upper GI obstruction impairing swallowing, or renal or CNS anomalies.
We will have to do few tests to try to diagnose the cause.In 60% cases no cause will be found and the outcome is likely to be good.i will provide written information.

b)
I will check maternal urine for sugar and blood sample for GTT to look for gestational diabetes. I will also ask for atypical antibodies and kleihauer test to rule out isoimmunization. Virals serology by TORCH test will be done to check for infections like parvovirus,CMV,and toxoplasma which can cause polyhydramnious.i will ask for a tertiary level scan to rule out anomalies of GIT and renal ,cardiac and CNS anomalies like omphalocele,spina bifida, polycystic kidneys , oesophagial atresia. Scan will also detect markers of fetal infection like hydrocephalus, intracerebral calcifications or microcephaly and hydrops.
If any anomalies are present I will ask for karyotying to rule out chromosomal abnormalities like aneuploidies . amniocentesis should laso be requested for confirmation of viral infections by PCR test if serology is positive.
c)
If mild polyhydramnious no treatment may be required and 2 weekly anc visits for AFI and symptoms is enough.she should be advised to report immediately if leak or pains occur as there is risk of cord prolapse with PPROM which significantly increases perinatal morbidity and mortality.
If mother has symptoms like respiratory difficulty then she can be offered treatment with indomethacin or sulindac.they decrease fetal urine output and thus reduce polyhydramnious. They cause gastric upset and epigastric burning and cause premature closure of ductus arteriosus hence not recommended beyond 34 weeks.
Bed rest and diuretics are not useful and not recommended. Admission should be offered for early delivery if cord prolapse occurs.
Therapeutic amniocentesis can be considered with severe maternal symptoms ,it significantly reduces symptoms but is associated with PPROM or infection in 2-3 % cases. Repeat sessions may be needed. If PPROM occurs or preterm delivery occurs then steriods should be given for fetal lung maturity.
d)
General examination to check P BP,temperature is done as usual.i will review the delivery plan if made earlier.Perabdominal examination to check for presentation , engagement of presenting part should be done and a continous CTG started .in doubt about presentation it should be confirmed by ultrasound. if breech or transverse lie is found then delivery should be by ceserrean section.if she comes with leak then immediate perspeculum examination should be done to rule out cord prolapse and to expedite delivery if it is detected.
She should be admited in consultant unit.Partogram should be maintained,ARM avioded if head is high .if deemed necessary then all preparation for CS must be in place like iv access alerting the OT staff. Controlled ARM should be done with slow release of liquor and oxytocin started if contractions are not adequate.in case of spontaneous rupture of membranes cord prolapse should be excluded by pv examination . if cord prolapse occurs delivery should be expediated by category I CS if vaginal delivery is not imminent.
Posted by G. K.
a) The patient should be apprised of the findings in simple words.She should be told about the presence of excessive amniotic fluid around the baby which in about 30% is without a cause; but at other times there is a reason for it. The reason can be in the mother herself, the baby or the the placenta which needs to be investigated in order to tailor her care according to the findings.

b) The patient should have an oral glucose tolerance test to rule out the possibility of diabetes mellitis since polyhydramnios is associated with it.
Her blood group should be ascertained to rule out the possibility of an immune cause.
Other tests in the mother include a serological testing for syphilis, CMV, Parvovirus infection since these infections can cause fetal hydrops and polyhydramnios.
Also it is important to rule out the possibility of alpha thalassemia leading to the present condition by doing Hb electrophoresis of the mother and her partner.
The fetus should have a detailed u/s to rule out structural anomalies like duodenal atresia, tracheo esophagial atresia,diaphragmatic hernia. In case of detection of any physical abnormalities, amniocentesis and karyotyping shuld beoffered to comfirm or rule out any chromosomal anomaly.
A middle cerebral artery doppler should be carried out to rule out the possibilty of anemia in the fetus leading to polyhydramnios.

C) If no cause is discovered for the present condition, the mother should be reassured.
She should have regular A/N checks to monitor fetal growth and liquor volume.
If the patient is asymptomatic, no further action is taken.If she is distressed due to the condition leading to breathlessness, serial amnioreduction can be carried out to relieve her symptoms.The patient should be councelled about te risk of precipitation of preterm labour with the procedure.
Also the administration of indomethacin and solindac to the mother can reduce amniotic volume.Indomethacin, however is associated with the risk of fetal renal failure, necrotizing enterocolitis and most important of all , premature closure of PDA. The mother should be counselled regarding these potential complications.
The patient should receive A/N corticosteroids in case she delivers prematurely.

d) If she presents in spontaneous labour at 36 weeks, she should be admitted ot the labour ward, IV access obtained and bloods taken for group and save, keeping in mind the posibility of cord prolapse if the membranes rupture either artificially or spontaneously.
Her abdomen should be palpated to ascertain the position of the baby\'s head, whether it is engaged or not.
Vaginal examination should be carried out to asess bishop score and suitability for artificial rupture of membranes ARM. If bishop score is favourable, a stabilization induction with controlled ARM is the best option in this scenario to minimize the possibility of cord prolapse.In case of cord prolapse, a grade one ceasarian section is needed. Otherwise the rest of the labour can be managed according to the labour ward protcol.

d) If she presents in spontaneous labour at 36/40
Posted by S M.
a) I would explain that polyhydramnios is excess amniotic fluid around the baby. In most cases no cause of the polyhydramnios is found but investigations should be done to rule out potential causes such as structural fetal abnormalities. The excess fluid may cause abdominal discomfort. The risks of polyhydramios are preterm labour, placental abruption and unstable lie. I would provide her with written information.

b) I would do both fetal and maternal investigations. I would perform a fetal anomaly scan to identify upper gastrointestinal atresias, anomalies of the central nervous system and diaphragmatic hernia which are associated with polyhydramnios. The anomaly scan would also identify hydrops with features of pleural effusions, pericardial effusions or ascites. If any anomalies are identified by the ultrasound scan then further fetal investigations should be done. An amniocentesis can be done for fetal karyotype to identify chromosomal abnormalitites which could cause fetal anomalies and polyhydramnios.

Maternal investigations would include an oral glucose tolerance test for gestational diabetes. I would perform blood group and antibody screen since alloimmunisation could cause immune hydrops and polyhydramnios. A Kleihauer test should be done to identify feto-maternal haemorrhage.

c) I would advise that the woman comes in to hospital immediately if she goes in to labour or if rupture of membranes occurs, because of the risk of cord prolapse or placental abruption. Serial ultrasound scans should be done to assess fetal growth and amniotic fluid volume. Simple analgesia such as paracetamol or cocodamol can be used for mild abdominal pain or discomfort. Indomethacin can be used to reduce the amniotic fluid volume which would lessen the abdominal pain or discomfort. This would also reduce the risk of pre-term delivery. Invasive amnioreduction can also be done to lessen the abdominal discomfort and reduce the chances of pre-term delivery.

d) I would inform the neonatologist because the baby is preterm and should also be examined for anomalies which may not have been detected by the fetal ultrasound scan. Anomalies such as fetal esophageal atresia should ideally be identified before feeding and a plan put in place for early surgical intervention.
I would take blood for full blood count and group and save; and insert a large bore cannula because of the risk of cord prolapse requiring emergency caesarean section and the risk of postpartum haemorrhage requiring blood transfusion.
I would do an abdominal examination to determine the fetal lie and engagement of the head. The reason for this is that polyhydramnios can cause unstable lie which increases the risk for cord prolapse.
Vaginal examination after rupture of membranes for the early identification of cord prolapse. Cardiotocograph monitoring to identify changes associated with cord prolapse.
Active management of the third stage should be done because of the risk of postpartum haemorrhage.
Posted by Manoj M.
A) I will explain to her the ultrasound scan findings are suggestive of excessive amniotic fluid surrounding her baby.
She will be offered more investigation to find any treatable conditions and also measure to improve the outcome of her pregnancy.
I will provide her with written informations and answer her querries.

B) Severe polyhydramnios is associated with increased perinatal mortality and morbidity and investigations are needed to identify treatable causes.
A detailed pregnancy scan to identify any fetal hydrops which would need further testing to exclude immune red cell antibodies or viral testing for non immune conditions like parvoviral infection with fetal anaemia which is treatable with in-utero transfusion.
A scan would also sugest any fetal growth with macrosomia/ growth restriction, placental chorioangioma and other fetal abnormalities like intracranial calcification suggestive of fetal infections.
If no other abnormality is detected an oral glucose tolerance test to exclude maternal diabetes.

C) Treatment is justified to provide symptomatic relief to the patient and to minimise the risk associated with prematurity.
Medical treatment with non steroidal anti-inflammatory drugs like indomethacin to reduce fetal polyuria and amniotic fluid volume is beneficial, indomethacin may risk with premature closure of ductus arteriosus and affect fetal renal function.
Alternative like sulindac or selective COX-2 inhibitors may be used.
Limit the use when amniotic fluid volume is normal or by 34 weeks.
Uterine irritability with severe polyhydramnios may be relieved with tocolytics like oral nifedepine( side effects headaches, tachycardia, hypotension)
Surgical therapeutic amnio reduction may be beneficial on its own or in combination with medical treatment, small risk of chorioamninitis and risk of reaccumulation may need repeated procedures.
If combination therapy is not heplful may need to consider early delivery.
Consider steroid therapy with preterm labour to provide fetal lung maturity.

D) If the amniotic fluid normalises no possible additonal risk in labour.
Persistant polyhydramniosis is associated with increased risk of cord prolapse, unstable lie, abruption and post partum haemorrhage (PPH).
Assessment of engagement of fetal head in labour as unengaged head increases the risk of unstable lie and cord prolapse.
Continous electronic fetal monitoring as high risk delivery and inform paediatritian as preterm and possible occult oesophageal atresia.
Obtain proper intravenous access and blood for group and save as increased risk of abruption and PPH.
Active management of third stage of labour and adherance to hospital protocols to optimise the outcome.
Posted by A H.
A
a) She would be told that the fluid around her baby is much more than is expected. No cause can be identified in the majority of cases. It can be caused by maternal conditions like diabetes and infections and fetal infection,or congenital gastrointestinal and central nervous malformations. It is necessary to perform investigations to identify possible causes in order to plan further care. Informed consent will be obtained if invasive testing is required to reach a diagnosis.

b)A detailed ultrasound scan will be done to identify malformations in the gastrointestinal and central nervous systems. Pleural and pericardial effusions as well as ascites will also be noted.
An oral glucose tolerance test will be done if there are risk factors for development of gestational diabetes.
If there is hydrops, maternal blood will be taken to screen for red cell antibodies and for Kleihauer testing which will indicate possible feto-maternal haemorrhage.
If there is evidence of fetal infection on ultrasound, an infection screen will be done on maternal blood for maternal infection and
amniocentesis for fetal infection. karyotyping for chromosomal abnomalities will also be done on amniotic fluid.

c) The aim of further antenatal care will be to prolong pregnancy so as to reduce the complications of preterm delivery, and to relieve maternal symptoms.
The risks associated with severe polyhydramnios include preterm prelabour rupture of membranes which can result in preterm delivery and cord prolapse and increased perinatal morbidity and mortality.
Fetal and maternal risks can be reduced if the volume of amniotic fluid is reduced by either the use of nonsteroidal anti-inflammatory drugs or surgically removing the fluid under ultrasound guidance by a suitably trained person. The latter is associated with an increased risk of infection and preterm prelabour rupture of membranes. Indomethacin is effective but can cause premature closure of the ductus arteriosus and will be stopped once the amniotic fluid is reduced to normal or by32 to 34 weeks. Sulindac is associated with a lesser risk of closure of the ductus.
The fluid may reaccumulate and therefore serial ultrasound will be done forthnightly for monitoring liquor volume and fetal weight.
Maternal discomfort and pain will be treated with simple analgesia Threatened preterm labour due to uterine distension will de treated with tocolytics like nifedipine. Maternal corticcosteroids will be given to enhance fetal lung maturity and reduce the risk of respiratory distress, intraventricular haemorrhage and necrotising enterocolitis.
Diuretics and salt restriction will not be recommended becausethere is no evidence that it is of benefit and can even be dangerous.
Because of the risk of cord prolapse if membranes spontaneously rupture, she will be offered induction of labour or elective caesarean sectionat 37 completed weeks after appropriate counselling.

d) It is important to exclude ruptured membranes and possible cord prolapse in which case immediate delivery is required to reduce the risk of perinatal morbidity and mortality. The neonatal staff will be informed and arrangement for NICU made.
If membranes are intact. the abdomen will be palpated to determine fetal lie and presentation. This may be difficult if there is severe polyhydramnios. An ultrasound will therefore be done.
For a longitudinal lie and cephalic presentation, a vaginal examination will be offered andshe will be counselled and offered artificial rupture of membranes(AROM) with controlled release of liquor once the cervix is effaced and at least 3 to 4 centimetres dilated. If AROM is declined, or deferred because of the cervical length and/or dilatation continuous CTG monitoring will be commenced and vaginal examination done to exclude cord prolapse once membranes have ruptured or CTG abnomalities are present . Blood will be taken for group and save because of the risk of placental abruption and post-partum haemorrhage. Alternatively, caesarean section will be offered as it may be a safer option in severe polyhydramnios.
The baby will be thoroughly examined by the paediatrician to exclude tracheo-oesophageal fistula or oesaphageal atresia prior to feeding.
Posted by Priti T.
prt

a] I would like to tell this women that the fluid surrounding the baby in her womb is more.She needs investigations for this execessive liquor.In cases upto 40% no cause may be detected,but polyhydramnios increases the risk of maternal morbidity and perinatal mortality due to various complications like Preterm labour,abruptio placenta and cord prolapse.Written information is given for the same.

b]Detailed USG should be done for this patient at the tertiary centre with High resolution sonography.This is done to identify any multiple pregnancy and the associated TTTS .Other causes like congenital anomalies,IUGR,macrosomia,fetal hydrops and placental chorioangioma should be ruled out.
The diagnosis of polyhydramnios is confirmed by measuring AFI more than 95% or Deepest Vertical pocket more than 8cms.Any abnormalities associated with fetal infections like intracranial calcification is excluded.Fetal wellbeing is assessed and biophysical profile done.
In the presence of fetal hydrops ,various investigations like BG-ABO and Rh,maternal red cell antibodies to Kell antigen is done.KHB[Kleihauer Betke] test is done to detect fetal maternal haemorrhage.Parvovirus infection is ruled out.Hb electrophoresis with alpha probe DNA is done on both the parents to rule out alpha thalessemia.
GTT 75gms 2hrs is done to detect GDM.TORCH and VDRL is done to detect fetal infection.
Further Doppler studies for the Middle Cerebral Artery is done to detect fetal anaemia in the case of fetal hydrops.
Foetal Karyotype is done in case the structural anomalies are suspected.

c] The aim of the antenatal management is to relieve the maternal symptoms and minimise the risks associated with preterm delivery.Medical treatment with NSAIDs like Indomethacin,or Sulindac reduces fetal urine output and amniotic fluid volume.These should be given till 34-35 weeks of pregnancy or earlier gestation if amniotic fluid has become normal.
Indomethacine has adverse effects like premature closure of Ductus Arteriosus,impaired renal function and cerebral vasoconstriction.Sulindac is a better drug& causes less constriction of ductus arteriosus.Nimesulide is a selective COX 2 inhibitor,but with a limited data.Nifedipine can be used to decrease the uterine contractility and maternal discomfort.It has adverse effects like tacycardia,hypotension and headache;which should be balanced with the potential benefits.
Surgical amnioreduction can reduce maternal discomfort and improve perinatal outcome with prolongation of gestation.Reaccumulation is very common.It has adverse effects of Chorioamnionitis,preterm labour and abruptio placenta.It should be combined with the medical treatment.
Bed rest,diuretics and fluid restriction have no role.
Prophylactic corticosteroids should be given in the case of preterm delivery before 34 weeks.

d] If the amniotic fluid has become normal then there may be no additional risks.
Persistant hydramnios in spontaneous labour is associated with the risk of abruption,unstable lie,cord prolapseand PPH.
With the patient in labour,with cephalic presentation and head engaged,controlled ARM is done to prevent sudden decompression and reduce the risk of Abruptio placenta and cord prolapse.Continuous CTG monitoring is done as its a high risk labour.BG is saved and good I/V access is maintained.Partogram is maintained and labour should be augmented if there is uterine inertia.Active management of the third stage of labour is indicated to prevent PPH.
SCBU is informed for the delivery of this high risk pregnancy.Neonatologist should rule out TOF or oesophageal atresia before feeding the baby.CS is indicated for Malpresentations and for other Obstetric indications.
Posted by M M.
a) I will tell her that there is excess fluid around the baby. I will reassure her that in most cases, no cause is found and the outcome is good. However, she will need investigations to rule out other causes such as maternal diabetes, infection & congenital abnormalities. She is at risk of abdominal discomfort, difficulty breathing, PPROM, placental abruption and also post-partum haemorrhage. The fetus is at risk of premature delivery, cord prolapse and infection. She will be given written information.

b) An oral glucose tolerance test will be performed to exclude maternal diabetes. Maternal blood will be tested for parvovirus, toxoplosmosis, rubella and CMV infections. Blood group & irregular antibodies will be checked. Detailed ultrasound will be performed to exclude structural abnormalities or features of hydrops. Abnormal middle cerebral artery doppler indicates fetal anaemia as a cause. Aminocentesis for karyotyping can be done if suspicious of chromosomal abnormality. Biophysical profile will be done to confirm fetal well being.
c) Aim of management is to improve maternal discomfort, prolong pregnancy and reduce risks of premature labour. Expectant management is appropriate at 28weeks gestation. NSAIDS such as indomethacin or sulindac can be given to reduce fetal urinary output. Indomethacin is associated with premature closure of ductus arteriosus, cerebral vasoconstriction & renal impairment. Treatment should be discontinued at 32-35 weeks or when liquor volume returns to normal. Sulindac is associated with less risk of premature closure of ductus venosus compared to indomethacin. Selective cox-2 inhibitor nimesulide also effective to reduce urinary output. Nifedipine can be given to reduce uterine irritability. Corticosteroids will be given to induce lung maturity, reduce risk of necrotising enterocolitis & intraventricular haemorrhage. The woman will be advised to attend the hospital immediately if any symptoms of labour or pv bleeding. Ultrasound scan will be done to monitor growth and confirm presentation & lie. She will be admitted to the hospital at 37 weeks as she is at high risk of unstable lie, SROM with cord prolapse & placental abruption. Delivery should be planned. Vaginal delivery is anticipated when there are no other contraindications. Induction of labour may be necessary at 38-39weeks.
d) Ultrasound scan will be done to confirm lie & presentation. If cephalic presentation and no other contraindications to vaginal delivery, she will be allowed to progress in labour. For non-cephalic presentation or abnormal lie, she will require emergency caesarean delivery. IV access & bloods will be taken for FBC and group& save in view risk of postpartum haemorrhage. If artifial rupture of membranes is necessary, it should be performed in OT in view of risk of cord prolapse. Third stage should be managed actively due to high risk of postpartum haemorrhage. Neonatologist should be present at delivery & tube passed to exclude tracheo-oesophageal fistula.
Posted by R M.
A)I would tell her that she has got severe polyhydramnios – that means the fluid around the baby is markedly increased. I would tell her that in nearly 80-90% of cases of severe polyhydramnios there could be an underlying cause. Further investigations are needed to find out the cause. The condition carries some risks to herself and her baby. Maternal risks include: uterine irritability and respiratory compromise; increased risk of preterm delivery and placental abruption; increased risk of caesarean section and postpartum hemorrhage. Foetal risk include: a risk of congenital anomaly; increased perinatal morbidity and mortality associated with preterm delivery / cord prolapse/ placental abruption.I would provide her with written information.

B)Information particularly with reference to maternal diabetes or drug abuse or infections and also regarding any abnormalities detected during anomaly scan / serum screening should be gathered prior to investigations. Detailed high resolution USG preferably in a foetal medicine unit to exclude foetal anomalies like neural tube defect /duodenal atresia / diaphragmatic hernia / gastroschisis. Various soft markers should be looked for and amniocentesis and karyotyping should be offered if suspicion of fetal aneuploidy .USG will also help to make diagnosis of multiple pregnancy if it was previously missed.Glucose tolerance test should be done to exclude maternal diabetes. Maternal infection screen(particularly if there is evidence of fetal hydrops): TORCH ; syphilis ; parvo virus ; hepatitis. Blood grouping and antibody testing to exclude red cell antibodies and RH sensitization. Haemoglobin electrophoresis to identify any maternal haemoglobinopathy if not done at booking.Fetal blood sampling for furthur investiations(like FBC,Hb electrophoresis,infection screen)if evidence of fetal hydrops.


C)Subsequent management is aimed to prolong pregnancy and prevent maternal and foetal complications. If the mother is asymptomatic she can be managed expectantly with frequent antenatal visitsevery1-2 weeks. She should be informed of the risk of preterm labour and premature rupture of membrane and advised to seek early medical help if any signs of labor like abdominal pain or vaginal loss. NSAIDs like Indomethacin can be given which will reduce foetal urine output and thereby cause reduction in the fluid volume. But associated with risks of premature closure of ductus arteriosus / cerebral vasoconstriction / renal dysfunction for the foetus – so discontinue treatment at 32-34 weeks or once the liquor volume is normal, whichever is early. Agents like Sulindac are less likely to cause constriction of ductus arteriosus-so can be offered. Selective COX-2 inhibiters like Nimusulide may be useful , but not licensed for use in pregnancy. Amnioreduction under USG guidance should be considered if there is marked maternal respiratory compromise / abdominal discomfort. Risk of preterm PROM / infection / abruption /preterm labour.Repeated procedures may be necessary due to reaccumulation of fluid. May be more effective if performed prior to starting NSAIDs. Tocolytics should be considered to reduce uterine irritability. Corticosteroids should be given to decrease the perinatal morbidity associated with respiratory distress syndrome, necrotising enterocolitis and intra ventricular hemorrhage. Serial growth scans should be arranged to assess foetal growth as clinical examination is unreliable. Planned delivery around 38 weeks to avoid the risk of cord prolapse / placental abruption in case of SROM / spontaneous labor at home .

D)Foetal malpresentaion has to be excluded and an USG may be needed for that as clinical assessment is difficult in presence of hydramnios. If foetal malpresentation is detected I would do an emergency caesarean section after taking an informed consent from the patient and after informing the Consultant as an ECV at this situation is difficult and carries increased risks. If the presentation is cephalic and head engaged a vaginal delivery can be anticipated. Blood should be sent for grouping and cross matching as increased risk of caesarian section and PPH. Continuous electronic monitoring during labor is necessary. Preemptive preparation should be there for shoulder dystocia as there could be associated macrosomia.
I’d inform Consultant Obstetrician regarding the case .Neonatologist and SCBU will be informed as bed may be needed.Vaginal examination should be done immediately after rupture of membranes to exclude cord prolapse.A controlled ARM can also be done after alerting the anaesthetic team regarding the possibility of a category 1 caesarean section.Patient should be offered epidural analgesia as there is increased likelihood of interventions during delivery.Active management of third stage to decrease the risk of PPH.Neonatologist should be available at delivery as baby is preterm and also to exclude the possibility of esophageal atresia/tracheoesophageal fistula.

Posted by Marcus M.
a) Polyhydramnios is an excess of fluid around the baby. There are multiple causes but is often an incidental finding with no obvious pathology. There are risks associated with the condition including pre-term labour, cord prolapse and post-partum haemorrhage so she will require consultant-led care for the rest of the pregnancy.

b) Maternal diabetes can lead to polyhydramnios whether pre-existing or gestational. A 75g oral glucose tolerance test can detect it and allow interventions to normalise blood sugar levels. A detailed ultrasound scan of the fetus should be performed if not already done. This allows detection of anomalies associated with polyhydramnios such as oesophageal or duodenal atresia or anencephaly. Delivery can then be planned a suitable tertiary centre for surgery if required or if a more severe anomaly is seen feticide and induction can be discussed. The placenta should also be visualised at scan as haemangiomas can lead to polyhydramnios.

c) She can be reassured by the normal investigations that this is likely to be a benign case, however she must be aware of the risks associated with polyhydramnios. She will require ultrasound scans for growth and liquor volume every 2 weeks as assessment by palpation will be difficult if not impossible. She should attend her consultant clinic fortnightly following these scans for review as long as they remain abnormal. She is at risk of cord prolapse and pre-term labour and should be aware she needs to attend hospital should she begin labour or if her membranes rupture. The lie of the baby may be unstable with polyhydramnios, and admission to hospital from 36 weeks should be discussed. She still requires all routine monitoring of BP and urine dipstick at ante-natal visits.

d) She should be managed in a consultant-led labour ward. Labour at 36 weeks gestation is unlikely to be associated with a poor outcome from a prematurity point of view, however the paediatric team should be informed and aware of the risk of cord prolapse and should have a cot available if required. She is at increased risk of cord prolapse which is associated with significant perinatal morbidity and mortality and the consultant obstetrician on-call should be called to labour ward. Anaesthetic input is also required as there is a significant risk of caesarean section. Ultrasound may be required to determine presentation but this is not sensitive enough to detect a cord presentation. Unstable or non-cephalic presentation will require caesarean section to reduce neonatal morbidity and mortality. Labour should be confirmed by vaginal examination and the cord should be felt for. If labour is confirmed and the head is fixed in the pelvis wth no cord present then consideration could be given to rupturing her membranes in theatre. IV access and group and save should be performed due to the increased risk of PPH and an active 3rd stage should be recommended.
Posted by Ron C.
RnRn
A.
I will explain that amount of liquor varies, but in her case it is above the upper threshold of what is considered normal spread at this gestational age. There may be no specific cause at all, but possible causes may be (gestational) diabetes, a fetal infection, fetal anemia or cardiac problem, a problem in fetal swallowing liquor or obstruction in the bowel system or abnormal chromosomes. Further investigations are thus needed to optimize the maternal & fetal outcome.

B.
If not done yet, fetal anomaly scan in a tertiary centre is needed; this can identify obstruction (ie duodenal atresia), cardiac abnormalities and hydrops related to this or anemia. General fetal condition can be assessed with umbilical artery Doppler flow and Doppler of the medial cerebral artery can additionally identify anemia. (soft) markers suggestive for chromosomal anomaly may be picked up, and if strongly suggestive amniocentesis for karyotyping must be offered. An OGTT test to rule out gestational diabetes is arranged and bloods for TORCH serology are taken to identify infection as causal factor. Maternal bloodgroup and irregular antibodies are checked once more.

C.
If all findings are normal, further fetal growth and condition must be monitored by means of serial ultrasound growth (4-weekly), Doppler flow & AFI to assess fetal condition. An OGTT test may be repeated at 34 weeks as GDM may only then fully develop after all. Polyhydramnion may cause much maternal discomfort. Liquor production can be tried to reduce using indomethacin to lower fetal urine-output, but renal function may be compromised and there may be premature closure of arteriosus duct especially after 32 weeks, so it should be stopped before this time. Newer COX-2 inhibitors may have less negative impact for the fetus, but not enough data are available. Alternatively repeated amniocenteses may reduce discomfort, but is associated with risk for premature labour & infection. As risk for premature labour is increased anyway, giving 2 doses prophylactic Beta-methasone 12 mg i.m with 24 hours interval would promote fetal lung maturation. Risks for malpresentation and, if SROM, cord prolapse or abruption are increased, so patient must be instructed to call in early if contractions develop or membranes rupture. To avoid SROM in uncontrolled circumstances I would discuss with the patient whether it would be safer to induce labour around 38-39 weeks.

D.
Presentation scan needs to be done as risk for malpresentation is increased. With colour Doppler cord presentation may be identified. Though no abnormalities were found, paediatric colleagues will be informed of her being in labour, as their assistance and presence during delivery is likely needed. As she is at increased risk of abruption, postpartum haemorrhage and uterine atony, I’ll ensure iv. access and is x-matched blood present. With increased risk for surgical procedures I will keep her fasted during labour in view of possible general anesthesia, for example if abruption or cord prolapse occurs. Continuous CTG to enable early identification of fetal distress is needed. In view of risk for cord prolapse I’ll avoid artificial rupture of membranes, but if necessary, I’ll let someone stabilize the head in the pelvis on AROM and then try to release liquor gradually in controlled manner. For risk of postpartum haemorrhage active 3rd stage is indicated with Synthometrin i.m. following delivery of baby and Synthocinon 30 iu infusion standby, to start after delivery of placenta for 4 hours
Posted by Maayka ..
nellie

a) I would tell her that this finding means that there is an excessive amount of fluid surrounding the baby and most cases have an unknown cause but in others, the reasons are likely because of reduced fetal urine output or reduced intestinal absorption. There are associated causes like maternal diabetes and maternal infection, which may lead to this problem. There is an increased risk of perinatal mortality, dependent on the underlying cause. Risks to both her and the fetus like of abdominal discomfort, respiratory problems, postpartum haemorrhage, preterm labour with cord prolapse. The fetal risks are related to the underlying cause and also from premature delivery.

b) The mother will be screened for diabetes using the OGTT since maternal diabetes is one known risk factor. A history from the mother of any viral infections would prompt a more likely possibility of the cause due to TORCH, parvovirus B19 for instance. Both maternal and fetal blood samples may need to be obtained if possible to check for relevant antibody titres. The fetus needs a detailed high resolution ultrasound to detect other structural abnormalities like duodenal, oesopageal atresia or renal abnormalities for instance. Karyotyping can be done with a late amnocentesis after explaining the risks and benefits associated. This will detect probable chromosomal abnormalities like Trisomies 13, 18 and 21.

c) At 28 weeks gestation she should be offered prophylactic steroids to improve fetal lung maturity since there is a risk of preterm delivery in this condition. The neonatologist should meet with her and discuss the likely problems which may be detected upon delivery of the fetus such as tracheo- oesophageal fistula or other effects of prematurity.
The mother’s complaints of discomfort, abdominal or respiratory should be alleviated as best as possible. Some interventions can be offered, e.g NSAIDS- explain risk involved of reducing urine output and of PG synthesase inhibitors – risk of NEC in infant. Amnioreduction can be offered in severe cases but the associated risks of preterm delivery, infection, postpartum haemorrhage and abruption and quick re- accumulation needs to be conveyed.
In hospital stay can be offered, especially from 36weeks, because of the risks of cord prolapse and intrapartum intervention hence requirement of being in tertiary setting with the facilities of OT staff and SCBU closeby.
The aim would be to prolong the pregnany till fetal lung maturity achieved and ideally beyond 37 weeks to avoid prematurity. The mode of delivery will be dependent on the lie and presentation of the fetus and the favourability of the cervix should vaginal delivery be considered. Because there is a risk of fetal macrosomia, there should be a senior obstetrician in labour suite for anticipated vaginal delivery difficulty.

d) She would be placed on CTG monitoring immediately and an assessment would be done abdominally if possible or by ultrasound to determine the lie and presentation of fetus – to find out if vaginal delivery is an option. A vaginal examination will be done to ascertain if SROM occurred and if so, to rule out cord presentation/ prolapse. If the membranes are bulging and vaginal delivery imminent, one may wish to perform controlled release of liquour to avoid cord prolapse should spontaneous rupture occur. Blood would be sent for Matching to have blood available in anticipation of placental abruption and PPH occurring. Active management of 3rd stage should be done following either vaginal delivery or C/ Section. The attending paediatrician should be informed of the antenatal condition and be forewarned to check for tracheo – oesophageal fistula.

Posted by J P.
a.I will explain the diagnosis in simple terms as fluid around the baby [liquor] is markedly increased.This may have maternal effects liks abdominal discomfort,uterine irritability,preterm labour,abruptio placenta ,caessarean sections and post partum haemorrhage.Fetal risks are due to prematurity,cord prolapse,anomalies if anypresent and perinatal morbidity and mortality..The reason for this is mostly not known but investigations may be needed to rule out maternal diabetes ,fetal anomalies and red cell antibodies.Written information will be provided.
b.Investigations will be needed to rule out maternal diabetes by oral GTT.Fetal anomalies like eosophageal atresia ,neural tube defects are to be ruled by USS preferably done ina tertiary fetal medicine centre.Infection screen also to be done for TORCH and particularly parvo virus infection in evidence of hydrops by USS.TTS to ruled out in case of twin pregnancy.Maternal blood grouping,red cell antibodies and haemoglobin electro phoresis for certain ethnic origin in case of association with hydrops.
c.Antenatal management includes medical treatment to relieve discomfort to mother ,to prolong pregnancy and decrease morbidity due to prematurity.Indomethacin is the drug of choice which decrease the liquor amount by preventing fetal urine production.But there is the risk of premature closure of ductus arteriosus.Hence has to be stopped by 32-35 weeks of gestation.Sulindac can also be tried which has less side effects.Cox-2 inhibitors have selective action and less gastro intestinal side effects.Surgical management includes serial amnioreduction which has to be done before drug treatment.Risks include infection,PPROM,reaccumulation .Frequent monitoring by ultrasound is needed every 2 weeks for assessment of growth.In case of persistent malpresentation with severe hydamnios elective caesarean has to be planned.
c.Management depends on clinical examination.Abdominal examination is done to find out the presentation,uterine contractility and pelvic examination for assessment of status of membranes ,bishops score.If pelvic examination is favourable and the patient in active phase of labour ,controlled ARM followed by augmentation if needed is done.Continuous fetal monitoring is done.If the head is high in labour,stablising induction followed by ARM can be done.In case of malpresentation caesarean section is advocated.There is risk of PPH ,hence Iv access and group and save serum taken.Neonatologist informed because of risk of cord prolapse .Feeds for baby has to be withheld till esophageal atresia ruled out by neonatologist.

Posted by A S.
Aa
a) I will tell her that the water amount around the baby is increased more than normal . The causative factors may be in the abnormalities in the baby or the placenta or diseases or infections of the mother . She We will do some tests to try to find the reason . After all the tests are done, we may not discover the reason. She may have some complications due to the excess water like pains in the abdomen , more possibility of cord prolapse and caesarean birth , abnormal presentation and preterm labour.
b) To find causes in the mother, we will do an oral glucose tolerance test to exclude diabetes M. Blood grouping and Rh typing with antibody screening will be done to exclude allo-immune causes. We will do serological testing for infections like toxoplasmosis, CMV, syphilis , parvovirus 19 , and rubella . Detailed anomaly scan must be done for cardiac abnormalities, exompholus , GIT abnormalities like duodenal atrisia, oesophagial atresia . Searching for fluid in other body spaces must be looked for carefully to exclude hydrops. Other anomalies like neck masses (large cystic hygroma) or mediastinal masses may obstruct the oesophagus and prevent swallowing of liquor. Placental heamangioma may be the reason. Amnio centithis will be done looking for aneuploidies (down syndrome, turner syndrome, triosomy 13 and 18) and testing for myotonia dystrophy.
c) Maternal anxiety will be dealt with sympathetic support and specialist counseling if needed. Serial growth scans and follow up of the fetal condition regarding severity of hydramnios . Liasion with neonatologist during antenatal care is important. The mother will be warned against signs of preterm-labour like pains or passage of liquor per vagina. If marked pain of suspicion of preterm labour is present corticosteroids will be given intramuscular for enhancement of lung maturity . Medications to reduce liquor production by the fetal kidney like indomethasin may be tried bearing in mind the possibily of premature closure of the ductus arteriosus . If hydramnios is causing maternal distress and pressure symptoms like dyspnea or abd pains, amnioreduction will be done but cautiously to avoid development of placental abruption . Arrangement for the place of birth must take in consideration the possible need for operative delivery , specialized neonatal care and peadiatric surgery.
d) Upon delivery the neonatologist will be notified . We will verify Fetal presentation and hear the heart beats . If this is not possible because of the excess liquor U/S will be done . Avoiding early amiotomy is important to prevent cord prolapse or placental abruption due to sudden decompression . If the membranes ruptured spontaneously examination for the cord will be done . Careful monitoring of the fetal heart is important as abnormal heart rate pattern may reflect APH or cord prolapsed . Vaginal delivery will be the aim unless complications developed .Epidural analgesia is not contraindicated and will be offered together with maternal support . After delivery she is at risk of postpartum hge so will actively manage the third stage of labour by controlled cord traction and giving oxytocin 5 IU IM and ergometrine IM after anterior shoulder delivery . Examination of the neoborn by a specialist to look for any anomalies will be carried on.
Posted by Sowmithya B.
A. Woman should be explained in a sensitive way as it can provoke her anxiety. She should be told that fluid surrounding the baby is more than normal and it needs investigations to find out the cause. But in the nearly one third of the patients, no cause can be found. And it can also be lead to preterm delivery, cord prolapse and abruption. Written information should be given with further appointments.
B. First I would perform an ultrasound examination to rule out structural anomalies like open neural tube defects, abdominal wall defect, fetal infections(intra cranial calcifications), macrosomia, intra uterine growth restrictions, hydrops and also to assess fetal well being. In the presence of hydrops and structural anomalies. I would perform tests to look for atypical antibodies, Parvovirus B19 infection and alpha thalassemia if ethnicity also suggest. In the absence of hydrops, maternal diabetes and fetal infections should be ruled out.
C. There is increased risk of pre term delivery and maternal discomfort. For acute relief surgical amino reduction can be performed in severe cases. But it needs to be repeated in view of rapid re accumulation. So it has to be combined with medical treatment. It is also associated with complications like pre mature rupture of membranes, abruption, fetomaternal haemorrhage and infection. In less severe cases, medical treatment with NSAIDs can be given to reduce amniotic fluid volume. Indomethacin and sulindac can be given until the fluid volume becomes normal or until 32 to 34 weeks as they cause premature closure of ductus arteriosus. Indomethacin also causes fetal renal impairment. In view of increased risk of pre term delivery steroid should be given. Nifidepine can be given for tocolysis but again it is also associated with complications like head ache, hypo tension and flushing. Ultrasound should be done every 2-3 weeks to check the fluid volume, fetal biometry, and fetal well being. Frequent antenatal visit should be arranged. Induction of labour should be considered in view of maternal discomfort at 37-40 weeks of gestation. Neonatologist input should also be obtained.
D. If amniotic fluid volume is normal usually labour would be uneventful. If fluid volume is more then there is increased risk of abruption, unstable lie, cord prolapsed and postpartum haemorrhage. Blood should be grouped and saved and venous access established. Delivery should be undertaken only in centres where facilities are available for emergency caesarean section. Continuous electronic fetal monitoring should be done.Artificial rupture of membranes should be undertaken in operation theatre. Neonatologist should be present at the time of delivery in view of high risk and to rule out undiagnosed oesophageal atresia before feeding. Active management of third stage of labour should be undertaken and uterotonics should be given for at least 24 hours after delivery in view of high risk of postpartum haemorrhage.
Posted by Arun J.
a -I would tell her that the waters in her womb are in excess.I would tell her that immediate indentification of the cause and treatment necessary to decrease maternal and perinatal morbidity and mortality.I would tell her that the cause could be with the fetus ( structural anomalies-NTd\'s, or infection or twin twin transfusion syndrome)) or the mother(diabetes ) ,placental tumors, or idiopathic.I would provide her with written information.
b -Maternal blood grouping and typing and klehauver test to rule out rhesus isoimmunisation.Oral glucose challenge test done to screen for gestational diabetes.TORCH titer done for infection screen. Obstetric USS done to ascertain number of fetuses( for TTTS),to rule out structural anomalies of the fetus, placental tumor and to look for signs of fetal infection like intracranial calcifications and hydrops and to asses fetal wellbeing and placental position (helpful if amniocentesis is done). Amniocentesis done if suspicion of chromosomal anomalies or infection is present for karyotyping and antibody titers respectively.
c --I would explain that no cause for her status has been identified and reassure her in a sympathetic way.I would tell her that she needs treatment to decrease complications such as preterm labour,relieve maternal pressure symptoms(pp symp) if any,and PPH at the time of delivery.Steroids given to to prevent complications of prematurity .If her pp symp are more she needs immediate treatment in the way of therapeutic amniocentesis as it causes immediate relief.I would give her anti-D if she is Rh negative after the procedure to prevent sensitisation. Indomethacin orally is given upto 32-34wks as it decreases liquor volume and is noninvasive .If given beyond 34 wks if causes fetal necrotising enterocolitis and constriction of renal and cerebral vasculature.Sulindac is also efficatious in decreasing liquor but without side effects of indomethacin.Serial scans needed to monitor response to treatment and to asses fetal growth and well being.Anaesthetic and pediatricians review needed to plan for labour and susequent newborn care.Clear plan of management documented in consultation with the senior obstetrician for use later.I would provide her with written information.
d -I would admit the patient as there is risk of cord prolapse and abruption with labour and rupture of membranes which needs immediate intervention.Re assesment required to asses whether polyhydramnios has been treated or is still present.I would reassure her that her outcome would be as those with uncomplicated pregnancies if her polyhydramnios has been treated.I would carry out the agreed plan of management.Fetal lie , presentation ,fetal heart rate assesed so to plan delivery.Electronic fetal heart monitoring and partogram made use offf to monitor labour.Cesarean section is done for obstetric reasons and if polyhydramnios is severe to reduce complications such as cord prolapse. Active management of third stage of labour done to reduce chances of PPH.
Posted by Atashi S.
a)I will explain her there is excess accumulation of amniotic fluid. It needs investigation to find out the cause. In majority of the cases causes are unknown. But in some cases it is associated with maternal diabetes mellitus and some foetal congenital structural anomaly, chromosomal anomaly, congenital infection or cardiac failure 2ndary to foetal anaemia. It may lead to severe maternal discomfort, preterm labour, premature rupture of membrane, preterm labour, malpresentation, cord prolapse, abruptio placenta and increase risk of caesarean section. She needs frequent antenatal check up with special attention.
(b) USG for detailed anomaly scan to detect foetal structural anomaly including anencephaly, duodenal or oesophageal atresea, sign of congenital TORCH infection, foetal hydrops and to exclude multiple pregnancy as it may cause TTSS. Blood grouping and Rh typing of both partner to detect any Rh incompitability which may be the cause hydramnions. Maternal glucose tolerence test to be done to explore latent diabetes mellitus. VDRL for screening of syphilis and TORCH screening of maternal serum is to be done as it may cause foetal congenital infection which may be the cause of polyhydramnions.

(c ) Aim of treatment is to relief maternal symptoms and to prolong pregnancy.I will explain her the diagnosis and she need frequent ANC, special attention and may need early admission if severe symptom appear.
It can be treated medically and /or surgically.Cox inhibitor such as indomethacin, sulindac reduce liquor volume by decreasing foetal urine output and relives maternal discomfort but it may cause premature closure of ductus arteriosus. Dose should be reduce once amniotic fluid indexis normal and stopped at 34 to 35 week.Sulindac has fewer foetal or neonatal complication .Surgical amnioreduction is effective in reducing maternal symptoms and may reduced the risk of preterm delivery. Repeated procedure may be required but risk include PPROM, infection, reshus sensitization and placental abruption. If symptoms are severe then a combination of medical and surgical treatment is appropriate. As there is a risk of premature labour corticosteroid is to be administer to accelerate lung maturation and to prevent intraventricular haemorrhage.Serial growth scan is to be done to asses response to treatment and foetal growth . Use of dirutics and salt restriction are not of proven benefit and may be harmful. Cosultation with a neonatologist and will be available at the time of delivery as investigation of the baby is important to exclude duodenal or oesophageal fistula. I will inform her induction of labour may be required between 37 to 40 week gestation if symptoms become severe but there is risk of cord proplapse and placental abruption. Elective C/S may be safer in progressively severe case .I will provide her written information.

( d ) I will call for assistance of consultant obstetrician,neonatologist, anesthetist,senior nurse and midwife.IV access is to be done immediately and blood should be sent for FBC, group & save. USS scanning to be done to confirm presentation. If presentation is cephalic and cervix at least 1 to 2 cm dilated then controlled ARM is to be done in the theatre with every thing ready for emergency C/S as it may cause cord prolapse or abruptio placenta.Continuous CTG monitoring is to be done to detect early any sign of foetal distress.Neonatologist must be present at the time of delivery and NG tube must be given to the baby to exclude duodenal or oesophageal atresea .As there is risk of PPH all of the team should remain vigillant against PPH. Active management of third stage of labour is to be done.
Posted by Shoba V.
a)I would explain to her that the amniotic fluid around her baby is increased.The patient may become anxious.I would explain to her that in majority of cases it would be ideopathic without a known cause,but there is a possibilty that there could be a fetal or maternal cause & so further investigations will be required.Risk to the mother is abdominal discomfort,respiratory compromise or preterm delivery,placental abruptio,increased risk of Caesarean section & malpresentation.
Risk to the baby is congential anomalies,increased pernatal mortality,infection,cord prolapse & hypoxemia
b)There are several maternal & fetal investigations that need to be performed.The maternal investigations are GTT to look for diabetis mellitus,screen for Viral infections like Parvo B16,hepatitis,TORCH infections,rhesus sensitisation & ABO incompatability,Hb electrophoresis depending on ethinicity,VDRL for syphillis.
The fetal investigations should include a detailed anomaly scan in a tertiary centre to look for any neural tube defects(which may prevent baby from swallowing the fluid),hydrops fetalis (fluid in at least two fetal cavities like the abd or scalp),renal malformations or infections where there is increased urine formation,abdominal defects like gastroscisis,karyotyping studies,trache-oesophageal fistulas & twins.
c)The management may be either in the form of expectant ,medical or sugical management.The medical management includes NSAIDS like Indomethacin which decreases the fetal urinary out flow,but it should be discontinued once the amniotic fluid volume becomes normal or before 32-35 wks,as its use further may cause premature closure of ductus arteriosis,impaired fetal renal function or cerebral vasoconstriction.The other drugs with lesser side effects are Sulindac or cox2 inhibitors like Nimesulide.
The surgical management involves amnioreduction ,which may need to be done repeatedly till the maternal resp distress or discomfort is reduced as there may be re accumulation of amniotic fluid.Amnioreduction may be done prior to administration of NSAIDS.
Fornightly ultrsound scanning should be done to monitor the fluid level,biophysical profile.Colour doppler study for abruptio placenta .Informed consent & information leaflets should be provided to the patient.
Corticosteroid ,inj Betamethasone 12mg IM,2 doses at an interval of 24hrs for decreasing risk of resp distress syndrome,intaventricular haemorrhage,necrotising enterocolitis .Tocolytics may be given to allow the cortcosteroid to act & for in utero transfer of the patient to a higher centre where proper arrangement foy baby care can be provided.Other wise tocolytics have no much role.
d)In the event of spontaneous labour,IV lines should be placed,blood for FBC,grouping & saving should be done,SCBU unit should be informed,the senior must be called for,anesthetist & a senior midwife & neonatologist should be available in the theatre as this patient may have a normal delivery or a caesarean so the preferred place of delivery is the theatre.Continuous fetal monitoring by CTG should be done.If the cevix is favourable & no signs of fetal distress & no contraindication to vaginal delivery,vaginal delivery should be done by controlled ARM by taking proper care against cord prolapse.If there is a contraindication for vaginal delivery,or a malpresentation or cord prolapse,abruptio placenta, emergency caesareal section is the prefered route.Active third stage management is to be done as PPH can be anticipated.
Posted by G. K.
Dear Dr. Paul:

The causes of polyhydramnios and hydrops are overlapping. If there is no evidence of hydrops on ultrasound, should we not investigate for maternal infections i.e TORCH, CMV, parvovirus and maternal blood group and Kleuheiur test?
regards
Ghazala
Posted by Shoba V.
Dear Dr Paul,could you please mark my answer too,I have just started getting the idea of answering the short answers ,so please bear my mishaps & help me thank you,
Regards,
Dr Shoba
Posted by GHADA AHMAD  M.
a) I will tell her that there is excessive fluid around her baby above the normal threshold. In most cases the cause is unknown, but this can occur due to some maternal and fetal cause. So, I will advice her to do some further investigations to find out the known causes that is likely to be associated with that condition.

b) Detailed anomaly scan is required to rule out fetal conditions like nueral tube defects, tracheo-oesophageal fistula, and fetal infection like TORCH by detecting cerebral calcifications. If no fetal abnormality Glucose Tolerance Test is required to Exclude Diabtes as a likely cause for macrosomia and Polyhydramnios.

c) I will reasure the mother that there no Identified, though there is risk for preterm birth. Expectant management if there no maternal discofort. Corticosteroid like betamethasone 12 mg 24 hourly two doses to be given for fetal lung maturity.
If the patient feel dicomfort medical and surgical amnoireduction is considered.
NSAIDs like Indomethacin my be used to reduce renal secrtion of fetal urine . Indomethacin is to avoided after 32 week\' gestation as it may cause premature closure of ductus arteriosus. surgical ammnoreduction can be used in severe case under ultrasound guidace either transabdominal or transvaginal to relief the maternal discomfort. Amnioreduction can be repeated whenever liquor re-accumulates, considering adverse effect like placental abruption, sensetisations of Rh negative mother, likelihood of infection.
d) Continuous CTG as it in considered high risk. IV line , blood group cross match and save. Neonatologist to informed. caesarean section is justified in severe case of Polyhydramnios. Avoid ARM to reduce the incidence of cord accedent and abruption. Active mangement of the placenta to reduce PPH