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ESSAY 187 - POLYHYDRAMNIOS

Posted by Sarwa aldoori A.
Polyhydraminos is pathologic accumlation of excessive amount of aminiotic fluid .To identify the the underlying cause the , the majority are idiopathic ,and the degree of polyhydramino affect the probability that an aetiology can be identified prior to delivery.to identify the underlying cause detailed ultrasound examination should be performed for fetal anomaliesor evidence of hydrops.Laboratory studies for gestational diabetes,Kleihaue Betke test,serologic studies for maternal infectionAs for CMV, parvovirusB19, toxoplasmosis, rubella, and syphilis.also workup for hemoglobinopathiesshold be performed. toxicologic screen to look for substance abuse.then aminocenetesis for fetal karyotype.,as there is 10% risk for aneuploidy in the presence of anomaly, and 1% when no anomaly identified.
Measures to improve outcome depend on the cause,as there are potentially treatable causes as glucose control, substance abuse isoimmunization, however in the idiopathic cuases close fetal surveillance in the form of 1-2 weekly ultrasound ,biophysiscal profile , crdiotoccogram,,as well a monitoring aminiotic fluid index, monitoring the patient for preterm laborsymptoms. If there is evidence of preterm labor and the patient is less than 34 weeks then steroid and tocclysis and if it did not work one has to consider aminoreduction. Maternal discomfort can be an important issue here and associated shortness of breath. In that case aminoreduction using 18 gauge needle attached to suction and removal of at 1000 ml in 20 minutes period.No more than 5 liters removed in each time.While this is regrded as safe,aminoreduction can be associated with chorioaminionitis, preterm labor, premayure rupture of membrane,fetal brdycardi and abruption.the role of antibiotics is controversial, toccolytivcs are used if needed. If gesatational age is >34 week the fluid can be used to assess lung maturity and expedite delivery. The process can be repeated if fluid reaccumlate,and if repeated process required then we need to think of indomethacin, which helpto reduce fetal urine productionand enhance lung fluid absorption when the gestational age is less than 32weeks.the statring dose is 25 mg po four time a day.the AFI is monitored 3 tims a week.We aim to deliver at term or if any complication occurs be it fetal or maternal when lung maturity attained.
Posted by Aroosha B.
A moderately severe polyhydroamnios ocures when the amniotic fluid DP > 15 cm. It is associated with considerable neonatal morbidity, mortality and maternal discomfort. Polyhydroamnios even in the presence of normal growth is associated with many underlying fetal and maternal conditions. The aim of investigation is to identify the cause and if possible to treat it. Fetal investigations which needs to be undertaken are high resolution ultrasound to assess degree of hydroamnios (AFI) and any other abnormalities in fetal GIT and central nervous system. The other possible causes are fetal infection and chromosamal abnormalities in 3% of cases so Karyotyping is recommended, and this may be performed by aminocentis. In cases of hydrops a fetal vital infections and anemia should be sort by obtaining fetal blood sample. Maternal investigations are GTT, meternal blood serology for alloimmunization and infection.
The aim of interventions are to relieve maternal symptoms and prolong pregnancy. There are no data to support dietary restriction of salt and fluids, similarly diuretics administered to the mothers seem ineffective and any reduce uteroplacental perfution. The various options are serial amino reduction and prostaglandin synthase inhibitors. Amino reduction is associated with risk of pre-term labor, PPROM, chorioamniotus and planctal abruption.

The other management options are indomethacin which cause decrease urine out put and decreases aminotic fluid but are associated with risk of premature closure of ducts arteriosus and impaired renal function .
The steroids should be administered as it will increase perinatal survival if preterm delivery is anticipated. Normal vaginal delivery is an option but is associated with risk of cord prolabse abnormal lie, abruptioplacenta. LSCS may be considered because of severe maternal distress and to decrease the risk of cord prolapsa. A pediatrician should be present at delivery. Post delivery, there is risk of PPH and syntocinon infusion should be commenced. Baby should be seen by neonatologist to rule out oesophageal artesian before oral feeding is started.
Posted by hala M.
The investigations available to identify the cause of polyhydroaminus in this patient include a detailed USS, maternal blood test for infections serology, red cells antibodies, kliehauer test, GTT and amniocentesis.

The USS is for the identification of foetal anomalies like oesophageal atresia (absence of stomach bubble), duodenal atresia (double bubble), jejunal atresia (triple bubble), foetal and placental tumours. This needs good equipment and an expert sonographer and the absence of sonographic features does not exclude the abnormalities.

Maternal blood test for Kliehauer Betke test and red cell antibodies is used for the detection of feto- maternal haemorrhage. This FMH might occur even without a recognised bleeding event.

Maternal blood serology for syphilis, hepatitis, parvovirus B19, and TORCH can identify the maternal infection but this does not necessary mean foetal infection. The finding of maternal infection would be followed by the necessary interventions such as giving treatment and close surveillance.
Amniocentesis helps in the confirmation of foetal infection using the PCR techniques, karyotyping in case of suspected anuepliody (trisomy 21, 18 and 13). These tests can be done at the same time of the therapeutic interventions by amnioreductions.

The role of GTT in a healthy primiparous is limited but it will help in the diagnosis of asymptomatic DM. DM causes macrosomia (which is excluded in this patient) leading to a polyhydroamnios.

Severe polyhydroamnios is associated with maternal risks (discomfort, placental abruption, CS and PPH) and fetal risks (prematurity, malpresebtation, cord prolapse and perinatal mortality).

The interventions needed to optimise the outcome aim at relieving maternal discomfort and prolongation of pregnancy.
Amnioreduction improves suivival and relive maternal discomfort, but it is associated with the risk of PPROM, infection, PTL and the high rate of recurrence.

NSAID such as indomethacin reduces the liquor production, but it is associated with the premature closure of the ductus arteriosus and impairment of foetal renal function, therefore its use should be monitored by weekly USS and it should be stopped at 35 weeks. Other NSAID such as nimsulide are associated with fewer side effects.

Tocolytics are helpful in case of uterine activity and risks of pre term labour. It prolongs pregnancy up to 7 days but it has a side effect profile related to the drug used.

Corticosteroids are necessary in case of PTL anticipation. It reduces the risks of RDS and intavetricular haemorrhage IVH when given between 1-7 days of PTD without increasing the risk of foetal or maternal infection. The SCBU needs to be informed in these cases.

Diet and salt restriction is ineffective and the use of diuretics is associated with uteroplacental insufficiency.

In case of successful prolongation of pregnancy, delivery should be planned at 38 weeks. Malpresentation is excluded by USS. The controlled artificial rupture of membrane ARMS reduces the risk of placental abruption and cord prolapse. The active management of third stage of labour reduce the risk on PPH.
In severe cases an ELCS would be the safest option.
Passing an NG tube by the paediatricin is helpful to check for the tracheo- oesophageal fistula.
Maternal continuos counselling and support helps in the management of the stress and anxiety associated with the condition.
Posted by Sarwat F.
Investigations include checking for diabetes and detailed anomaly scan to exclude structural defects like oesophageal atresia, tracheooesophageal fistula. For diabetes random blood sugar is checked however its sensitivity is low and fasting blood sugar has more sensitivity. Glucose tolerance test has the highest sensitivity and specificity in detecting diabetes. Detailed scanning of the fetus to check for structural anomalies. If the fetus shows any sign of hydrops then woman is asked about any history of viral illnesses, any family history of congenital anomalies, chromosomal defects and metabolic disorders like glucose 6 phosphate dehdrogenase deficiency. Full blood count, liver and renal function test and electrolytes, viral screen (TORCH, respiratory syncytial virus, HPV B19 and syphilis), hemoglobin electrophoresis, kleihauer test, anticardiolipin and antinuclear antibodies. If any cardiac abnormalities are suspected then fetal echocardiography and Doppler studies. Amniocentesis for viral culture and karyotyping will be required. Cordocentesis for full blood count, viral markers, metabolic function and haemoglobin electrophoresis. Referral to fetal medicine unit will be required for detailed evaluation.
In case of idiopathic polyhydramnios, aims of management include relieving maternal discomfort and prolonging pregnancy to achieve fetal maturity. To decrease the production of amniotic fluid indomethacin can be given which is a prostaglandin synthetase inhibitor but its side effects include persistent ductus arteriosus and adverse effects on fetal renal function. For this reason indomethacin is not advocated after 32 weeks. Any signs of ductal constriction like tricuspid regurgitation are carefully seached for in subsequent scanning. Sulindac can also be given. For abdominal pain due to uterine irritability nifedipine can be given however side effects include headaches and tachycardia and benefits are weighed against side effects.
Paracentesis to remove amniotic fluid can also be done to relieve maternal discomfort. 500mls to 1 litre can be removed at a time. Risks of paracentesis include infection, preterm prelabour rupture of membranes and abruption. It needs to be done under ultrasound guidance. Steroids will be administered in case emergency delivery is needed. Dietary salt restriction has no role and diuretics are potentially harmful. Fetal growth is monitored by serial ultrasound scan preferably every week. There is a risk of preterm labour with polyhydramnios and in such case patient should be transferred to a tertiary care unit where SCBU facilities are available. A paediatrician should be available at the time of delivery. Labour is managed as a high risk as there is risk of cord prolapse, placental abruption and malpresentations. Caesarean section will be done for malpresentations or if there is any fetal distress. In case there is no preterm labour but fetus has achieved suffiecient maturity upto 36 weeks and there is considerable maternal distress, induction of labour will be required. However in cases of severe polyhydramnios, an elective lower segment caesarean section is a safer option. Mother will be counseled at each steo of management and informed consent is obtained. There is a risk of postpartum haemorrhage and active management of third stage is done.
Posted by adnan S.
Investigations required to identify the causes are fasting &post-prondial blood sugar to R/O diabetes.Blood grouping &antibodies are done to exclude rhesus disease.Infection screening is done for TORCH &parvovirus, syphilis is done to r/o congenital infections.Detailed USS is done for fetal anatomy &look for neural tube defects like anencephaly,maningomyeloceal,oesophageal atresia,tracheo-oesophageal- fistula(TOF) diaphragmatic hernia, gastroschisis,.Amniocentesis for kariotyping to r/o chromosomal aneuploidy like tisomy 21,13,&18.

Risks associated with poly-hydromnios are abdominal distension,uterine irritability,respiratory compromise&PPH.Fetal risks are prematurity,placental abruption&IUD..As the woman is found to have idiopathic poly-hydromnios the aim of interventions are to prolong pregnancy ,prevent prematurity& to reduce maternal discomfort .To reduce the amniotic fluid index NSAIDs such as indomethacine reduces fetal urine output&reduces amniotic fluid volume,but there is risk of premature closure of the ductus arteriosusas well as cerebral vasoconstriction and impaired renal functions.Treatment is discontinued when amniotic fluid volume returns to normal or at 35 wks of gestation.Sulindac is an alternative to NSAID with lesser effect on ductus arteriosus.Nimesulide a selectiveCOX-2 inhibitors may be useful in reducing amniotic fluid volume.Salt reduction and diuretics are ineffective and potentially dangerous.Therapeutic amnioreduction may improve perinatal outcome but repeated procedures may be required .Risks associated with amnioreduction are placental abruption ,PPROM,chorio-amnionitis& membrane detachment.Simple analgesics are given for maternal discomfort.
To prevent morbidity from prematurity corticosteroids are given for fetal lung maturity.Value of repeated courses is not known.
Preterm labour is likely but induction of labour may be required for maternal discomfort but there is risks of cord prolapse ,placental abruption,&PPH hence elective c-section is considerd
Posted by Vaani M.
Polyhydramnios is excessive amniotic fluid. The causes could be maternal, fetal, placental or idiopathic.

Investigations would be for the mother and the fetus. Maternal investigations would include diabetes investigations as oral glucose tolerance test with a raised fasting blood glucose above 7.8mmol/l, and post prandial blood glucose above 11mmol/l being in the diabetic range. Maternal serum investigations to rule out viral infections, haemoglobin electrophoresis to rule out alpha thalassemia, glucose 6 phosphate dehydrogenase deficiency.
A detailed ultrasound preferably in a tertiary fetal medicine unit to rule out cardiac anomalies, or any other anomalies not diagnosed earlier by routine anomaly scan that have presented later needs to be looked for, placental examination also need to be done. Amniocentesis could be done as a diagnostic procedure to look for viral infections and karyotyping. Cordocentesis to test fetal blood for viral infections, haemoglobinopathies in fetus, karyotyping could be done. All these investigations are preferably done in a specialised fetal medicine unit. If all causes are ruled out it could be an idiopathic polyhydramnios as is commonly seen.

Management could be conservative, medical or surgical. Conservative management would include observation and regular ultrasound monitoring to watch for spontaneous resolution or worsening of the polyhydramnios. Medical management would include treatment with prostaglandin synthetase inhibitors as indomethacin with side effects on premature ductus arteriosus closure, renal side effects. Betamethasone for fetal lung maturity needs to be given if premature delivery is anticipated. If maternal discomfort ensues by worsening polyhydramnios it needs to be drained by amniocentesis with gradual decompression of amniotic fluid under ultrasound guidance. Side effects could include preterm labour, premature rupture of membranes, abruption. Anti-D injection needs to be administered after the procedure if the mother is Rh negative and non immunised. Malpresentations could be seen at term which could be corrected by ECV. Controlled artificial rupture of membranes may be required in labour to avoid cord prolapse. Caeserean may be required for a cord prolapse, or malpresentation otherwise a vaginal delivery could be allowed. Watch for postpartum haemorrhage and appropriate management of third stage of labour is required. Counselling and reassurance of the woman and her partner is required at all stages.



Posted by Sreekala S.
The woman should be advised fasting and post lunch blood sugars to detect the presence of Gestational Diabetes. OGTT is indicated if the blood tests have been inconclusive. She should undergo a detailed fetal anatomy scan to detect any gastro intestinal, genito urinary, cardiac, neural tube defects or any structural or chromosomal defects or multiple pregnancy or placental tumours which would have predisposed for polyhydramnios. Even in the presence of a normal scan, there can be a possibility of a major anomaly in 11% of cases. Middle cerebral artery peak systolic velocity by Doppler scan should be considered if fetal anemia is suspected. Maternal serum should be tested for TORCH, Parvo virus and Syphilis infections and red cell allo immunization. Maternal Lithium levels have to be checked if substance abuse is suspected. Amniocentesis should be considered for Karyotyping and electrolyte levels. All the electrolytes except Potassium levels are elevated in Bartter syndrome which is an autosomal Recessive condition with hypokalemic alkalosis and hypercalciuria. Amniocentesis carries the risk of preterm labour, abruption and chorio amnionitis.Cord blood sampling can be considered to confirm fetal anemia, karyotyping and fetal infections. This is also associated with the risk of preterm labour, abruption and chorio amnionitis.

The woman should be counselled that there is an increased risk of PPROM, preterm labour, abruption, malpresentation, cord prolapse and PPH. She should be informed of the signs and symptoms of preterm labour and advised to get immediate medical attention if preterm labour is suspected. Admission to the hospital for rest should be offered if she is unable to cope at home so that immediate care can be provided if preterm labour sets in. SCBU should be informed in the presence of Preterm labour and tocolysis for steroid action should be considered.
Amnio reduction under ultrasonographic control should be considered in the presence of respiratory compromise or abdominal discomfort after counselling that it may predispose to preterm labour, abruption, infection, re-accumulation and repeated procedures may be required. Indomethacin can be considered which is shown to reduce the amniotic fluid volume with the risks of premature closure of ductus arteriosus, cerebral vaso constriction and impaired renal function. It should be stopped by 32-35 weeks or when the AFI becomes normal.Sulindac is an alternative which is less likely to result in premature closure of ductus arteriosus and impair renal functions. Nimesulide is a COX 2 inhibitor which can also be tried to reduce the amniotic fluid volume.There is no evidence to suggest that diuretics or salt/fluid restriction is beneficial. On the contrary it may reduce the uteroplacental perfusion and can be harmful. Malpresentations should be excluded.An elective caesarean section should be considered as there is a high probability of malpresentations, cord prolapse, abruption and PPH.
In the presence of a cephalic presentation, IOL can be considered after 37 weeks by a controlled ARM with/without syntocinon in the theatre with a consent taken for emergency caesarean section in the event of cord prolapse. Blood should be kept crossmatched. Continuous EFM is required in labour. PPH should be anticipated and active management of 3rd stage of labour considered.Paediatrician should be available at delivery to detect any fetal anomalies and to take immediate required action.

Posted by Farzana N.
Polyhydramnios is associated with maternal and fetal causes.
.IDDM in mother can be investigated by doing screening tests such as glycosuria,but it has low sensitivity and specificity.Random blood glucose measurement has a sensitivity of ~40%,and aspecificity of ~90%.HbA1c measures in blood.75g oral GTT.is the gold standard diagnostic test for diabetes mellitus.Blood tests are done to detect Rh antibodies in cases of alloimunization.Rising titres are found in cases of fetal anemia with antiD titrse >1:64.The correlation between Non-D antibody levels and disease severity is poor and careful monitoring is required even if the titters are low.Infection screening would detect viral illnesses such as parvovirus,torch,syphilis or hepatitis.Maternal infection may not necessarily reflect fetal infection, which may require amniocentesis.
Detailed anomaly scan -would detect fetal abnormalities such as GI obstruction-duodenal or oesophageal atresia,diaphragmatic hernia, gastroschisis.Anencephaly and features suggestive of trisomy .18,21and 13 may require fetal karyotyping.Chorionicity .can be seen in multiple pregnancy.BIOphysical assessment can be done by uss for fetal wellbeing.These investigations would help identify any cause ,asses severity and .plan treatment..
In cases of moderate-severe idiopathic polyhydramnios management may be expectant or different pharmacological agents can be used such as NSAIDs-reduce fetal urine output.Indomethacin is associated with risk of closure of ductus arteriosus-should be discontinued at ~35wks or when AF volume is normal.Alternatively,Sulindac may be given which is less likely to cause constriction of ductus arteriosis.Nimesulide-selective COX-2 inhibitor may be useful.Nifedipine may reduce uterine mobility.Salt restriction/diuretics are usually not effective and may be harmful.
Surgical treatment can be done by amnioreduction .But it is associated with risk of PPROM,infection/abruption/re-accumulation.Corticosteroids .should be given for lung maturity as there is risk of preterm labour in these cases. Neonatologist and SCBU should be informed
Once the patient presents in labour,malpresentations should be excluded ,which are commonly associated with polyhydramnios.Labour should be carefully monitored as there is high risk of cord prolapse,and PPH/dystocia in case the baby is macrosomic.Elective c-section may have to be considered in case of severe polyhydramnios.
Posted by BAHAA-Uddin BOR B.
Investigations should be undertaken ,Detailed ultrasound scan to detect the fetal anomalies that impair fetal swallowing or which impair absorption of amniotic fluid from the gut.Gastrointestinal obstructions such as duodenal atresia presents with polyhdramnios and a characteristic \"double-boubble\" sign and up to one third of it associated with Down\'s syndrome.,So karyotyping should be considered.
Oesophageal atresia may be suspected by absence of stomach bubble associated with polyhydramnios However these signs may not be present in majority of cases due to the presence of tracheo-oesophageal fistula. Isolated hyperechogenicity of the gut may be secondary to aneuploidy or fetal infection ,but it may occur in normal fetuses.
Ultrasound scan ,also detect anterior abdominal wall defect like gastroschisis ,or intraluminal masses such as intraoral teratomas that obstruct the swallowing mechanism. Ultrasound scan identify central nervous system malformations which include open neural tube defect,and also thoracic abnormalities like diaphragmatic hernia and congenital heart defects associated with chromosomal abnormalities such as trisomy 21. USS also detect congestive heart failure in cases of left heart outflow obstruction such as critical aortic stenosis. Polyhydramnios may be secondary to nonimmune hydrops in cases of arrhythmia.Rare fetal tumours can be a cause of polyhdramnios such as sacrococcygeal teratomas,intracranial teratomas,renal hamartomas and even placental tumours such as chorioangiomas, all could be detected by USS.There is no substantive evidence of adverse effects from obstetric US and it is an excellent modality for detection of malformations associated with polyhydramnios .If no anomalies are found sonographically ,the prognosis is good.
Maternal blood tests such as,Kleihauer test and red cell antibodies is used for detection of chronic feto-maternal haemorrhage. Maternal blood serology and investigations for infections exposure as parvovirus B19,rubella,cytomegalovirus,toxoplasma and hepatitis.Amniocentesis could be done for detection of viral infection and karyotyping amniotic fluid cells for aneuploidy
( trisomy 21, 18 and 13 )., Amniocentesis is technically easy and with the advent of molecular biological technique like PCR has reduced the need for FBS..,but carry the risk of preterm labour,IUFD .
The aim of interventions in moderately severe idiopathic polyhydramnios is to prolong pregnancy, reduce the risk of prematurity and alleviate the maternal discomfort .
The use of prostaglandin synthetase inhibitors ,Indomethacin acts by decreasing fetal urinary output or increasing the absorption of fluid via the lungs.It should be suspended at 34-35 weeks gestation to avoid neonatal haemodynamic complications such as premature closure of ductus arteriosus and also,cerebral vasoconstriction and fetal renal dysfunction.Periodic surveillance during treatment to search of signs of ductal constriction ,such as tricuspid regurgitation is warranted . Sulindac may be a safer alternative to indometacin. Nimesulide-selective COX-2 inhibitor may be useful .Dietary salt restriction has no benefit ,and diuretics are potentially harmful.
Serail Therapeutic amnioreduction may improve perinatal outcome. The disadvantages include the risk of preterm premature rupture of membranes,chorio-amnionitis, abruptio placentae and onset of preterm labour. It needs to be done under U/S guidance every time. A course of corticosteroids for lung maturity should be administered to the mother if delivery is anticipated. Induction of labour may be required after 36-37 weeks . It carries the risk of cord prolapse and abruption.
Lower segment caesarean section is safer if done as an elective procedure in severe polyhydramnios. Active management of third stage of labour reduces the risk of postpartum haemorrhage.
Posted by SWATI M.
a) In majority cases Polyhydramnios is idiopathic but may be associated with variety of causes and should be ruled out.
Detail ultrasound examination should be done to rule out any fetal anomalies such as upper gastrointestinal obstruction ,neural tube defects or abdominal wall defects.Also look for any evidence of hydrops fetalis.Most of these anomalies can be diagnosed by ultrasound examination.
Karyotyping should be performed if anomalies such as dueodenal atresia or exomphalous as they may be associated with chromosomal anomalies although fetal growth is normal.
Glucose tolerence test will be performed especially if family history of DM and taking into consideration of her age.
Maternal virology screen is done if history suggestive of viral illness but positive tests do not imply fetal infection.Fetal blood sampling will be required to detect specific antibodies.Test for syphilic infection by VDRL titres should be performed and compare results to booking results .Significant rise in titres or positive results which were negative at booking may indicate syphyllis as a cause.
Haemoglobin electrophoresis will be performed if from ethnic group suggesting possibilities of haemoglobinopathies.Maternal blood for Kleihauer test to detect fetomaternal haemorrhages and atypical antibodies done.

b)To optimize the pregnancy outcome,prolonging pregnancy until fetal maturity is important.Treat Polyhydramnios by indomethacin until 34 weeks of gestation .Increased risk of developing patent ductus arteriosus or impaired renal function if used beyond this.Suldinac can be used as alternative.
Serial amnioreduction can be used but associated with risk of PPROM,Preterm labour cord prolapse and abruption.
Involve neonatologist and in-utero transfer will be preferred if optimum neonatal fascilities are not available locally.
Educate woman to recognize signs and symptoms of Preterm labour and to contact in emergency with contact details.Treat threatened Preterm labour with tocolytics and use of corticosteroids which reduces incidence of RDS,IVH.
Plan elective caesarean delivery if severe Polyhydramnios with unstable lie at 38 weeks.Plan stabilizing induction at 38 weeks if undelivered, by rupture of membranes. Exclude cord prolapse and abruption after membranes are ruptured.Continuouse CTG should be recommended. Blood should be crossmatched .Ensure availability of neonatologist at delivery.Manage third stage by active management.Exclude upper gastrointestinal tract obstruction by passing the nasogastric tube.
Posted by M H.
Severe polyhydramnios is associated with multiple pregnancies, congenital gastrointestinal malformation (duodenal or oesophageal atresia), infection (TORCH organism, Parvovirus B), chromosomal abnormalities (Trisomy 21), maternal diabetes mellitus and immune causes (rhesus disease). In majority of cases however, the cause is idiopathic.

An ultrasound examination would help pinpoint the diagnosis of polyhydramnios as well as its cause but this is operator dependant. The finding of a polyhydramnios should prompt a further detailed ultrasound to determine if there are any other associated abnormalities (eg duodenal atresia is a common finding in Trisomy 21) and a karyotype examination offered if necessary. Testing for a possible infection (using mum?s serum) can also help in the diagnosis. A modified glucose tolerance test may be undertaken to identify gestation diabetes may be undertaken. If not yet known, her rhesus status should also be checked. A history of thalassaemia may prompt a testing to determine if the baby is at risk of thalassaemia.

The aim of management in polyhydramnios is to prolong the pregnancy while balancing risks to baby and mum. Women with polyhydramnios are at an increased risk of preterm delivery, post partum haemorrhage. There is also an increased risk of cord prolapse and malpresentation. She may be offered amnioreduction but should be made aware of the risk of reaccumulation and infection, especially if repeat procedures are required. NSAIDS can also work to reduce polyhydramnios via reduction of foetal urine but there is a risk of premature ductus arteriosus closure, renal and cerebral impairment (especially with indomethacin). Nifedipine may act to reduce uterine irritability but evidence of its effectively is lacking. If she labours before 34 weeks, antenatal corticosteroids may be beneficial for foetal lung maturation.

Caesarean section should be considered in severe cases as there increased risk of cord prolapse, malpresentation, placental abruption. If she opts for vaginal delivery, she should be delivered in a hospital with operating facilities and she should be made aware that she may require active third stage management, emergency caesarean section. Staff should be aware that she is at increased risk of post partum haemorrhage and intrapartum, intravenous access obtained and blood should be sent for screen and hold. A paediatrician should be available during delivery to examine the baby. Feeding should not commence till duodenal or oesophageal atresia has been ruled out. Breastfeeding should still be encouraged (after).