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ESSAY 207 - Polyhydramnios

Posted by Sreekala S.
Polyhydramnios is a high risk pregnancy. The aim is to relieve maternal discomfort and prolong the pregnancy.
Therapeutic amnioreduction should be offered in the event of increasing maternal discomfort, but it is associated with the risk of preterm delivery, PPROM, abruption, cord prolapse, chorioamnionitis and a high rate of recurrence.
Indomethacin is a NSAID which is known to reduce the amnionitic fluid volume, but it is associated with premature closure of ductus arteriosus, renal impairment and cerebral vasoconstriction in the baby.It should be stopped at 32-35 weeks or when the AFI becomes normal. Sulindac is an alternative which is less likely to cause premature closure of the ductus arteriosus and renal impairment. Nimesulide is a COX 2 inhibitor which is also known to reduce the AFI.
There is no evidence to suggest that diuretics, salt/fluid restriction is beneficial. On the contrary this may be hazardous as it can impede the uteroplacental circulation.
OGTT should be carried out 32-34 weeks to rule out gestational diabetes.
A serial ultrasound scan should be performed to monitor the amniotic fluid volume and to rule out malpresentations.
Tocolytics and Corticosteroids should be considered if preterm labour is suspected. Corticosteroids are known to reduce the risk of RDS and Intraventricular haemorrhage in the neonate if born between 1-7 days of administration. Tocolytics should be given for the duration of corticosteroid administration for a maximum of 48hrs because of their side effect profile and lack to evidence to support their use beyond this period.
In case of successful completion of pregnancy to 38 weeks, delivery should be planned. Malpresentation should be ruled out by an ultrasound scan. A controlled amniotomy reduces the risk of cord prolapse and abruption.
An elective caesarean section may be the safest option in the event of severe polyhydramnios. The woman should be offered an informed choice after discussing the risks of caesarean delivery like bleeding, infection, DVT/Venous thromboembolism, injury to viscera, reduced fertility, repeat caesaean section in future pregnancies and the risks of vaginal delivery like cord prolapse and malpresentation.
Whichever is the mode of delivery, PPH should be anticipated and measures taken to combat it. Paediatrician should be present at delivery to rule out tracheo-esophageal fistula or any congenital anomaly.
The woman should be supported with her decision.
Posted by Zaharuddin R.
Treatment of idiopathic polyhydramnios depends on symptoms and to prolong the pregnancy.

Polyhydramnios associated with maternal discomfort and difficulty in breathing especially in severe cases due to severely distended abdomen with splinting of diaphragm. Hospitalization with bed rest is needed but risk of deep vein thrombosis must be explained. Thrombo-embolic deterrent stoking is advisable to reduce the risk.

Amniocentesis could be done to reduce amount of amniotic fluid and to reduce intrauterine pressure to relieve maternal discomfort. However repeated amniocentesis might be needed because recurrent polyhydramnios. The procedure is associated with risk of infection, placenta abruptio and premature labour.

Low salt diet and diuretic drugs have no role in polyhydramnios and asssociated with more side effect such as hypotension and reduced intravascular volume.

NSAIDS such as indomethacin could reduce amount of amniotic fluid and polyhydramnios but limited use until 32 weeks gestation due to risk of premature closure of ductus arteriosus. Newer drugs such as sulindac has less risk.

Polyhydramnios associated with premature labour due to increased intrauterine pressure. Hospitalization is needed especially at tertiary hospital with good SCBU with ventilator stand by. Paediatician should be informed rearding the case.Corticosteroid should be prescribed for lung maturity and reduced risk of intraventricular haemorrhage and reduced prolonged admission at SCBU. Tocolytics as local hospital protocols is needed for completion of a course of steroid or tranfer to another tertiary hospital with ventilator standby. Side effect of tococlytics especially with betamimetics must be watched likes tremors, pulmonary oedema and palpitation. Side effect is less with nifedipine.

Preterm premature rupture of membrane (PPROM) is another risk associated with polyhydramnios. The patient should be hospitalized with bed rest. High vaginal swab for culture and sensitivity sholud be taken as PPROM is also associated with risk of ascending infection. Antibiotic (erythromycin) for 10 days will prolong pregnancy and reduce risk of ascending infection. A course of corticosteroid is needed for lung maturity. Paediatrician should be informed regarding the case.

Patients with polyhydramnios need frequent visit to antenatal clinic to monitor her symptoms, blood pressure and weight gain. Local midwives and GP should be informed as home visits is necessary as part of monitoring her symptoms. The patient should be given a contact number directly to hospital to report any symptoms and advice. Letter to employer should be given as the patient may need light duty or rest from work.
Posted by Kishor S.
The treatment options of idiopathic polyhydramnios are relief of maternal discomfort / pain / respiratory embarrassment (if any), prolongation of pregnancy preferably till term, prevention of complications/problems, which may arise during prolongation. The complications are preterm labour, PPROM with/without cord prolapse and abruption placentae. Therefore, corticosteroid prophylaxis should be given as these complications will necessitate immediate delivery any time.

Symptoms that require treatment are severe discomfort affecting respiration. Quick relief can be obtained by amniocentesis. This should be done under ultrasound guidance to avoid fetal or placental injury. But it can be associated with preterm labour, placental separation, feto-placental bleeding (important in Rh negative), choriamnionitis (more in repeated attempts) and amniotic fluid embolism. Placental abruption can be minimized by withdrawing the liquor slowly over a few hours. Rh Ant D prophylaxis is to be given if Rh negative nonimmunised.

Amnio-reduction by this method is short lasting and liquor gets accumulated very fast. Indomethacin, anti-prostaglandin has been found to be effective in this regard to decrease liquor formation, but it is associated with potential danger of constriction / closure of ductus arteriosus and renal failure. Therefore, if it is to be given for a longer period, it has been shown to be a good practice to give a drug holiday of 5 ? 7 days for every week. It should be stopped at 35 ? 36 weeks. Other drug which is theoretically more scientific and with less side effects is COX2 inhibitors (eg. Nimesulide) because induced prostaglandins are responsible for labour/liquor formation and are formed through COX2. However, experience with these drugs is very limited as of now.

Though she is healthy at present, she is still at a higher risk for pre-eclampsia and gestational diabetes. Thus she requires close monitoring to detect these complications including blood sugar testing at around 34 weeks.

In case of preterm labour, use of indomethacin can take care both hydramnios and tocolysis, but nifedepine can still be used as an additional medicine (if necessary) while awaiting action of steroids or transfer to a tertiary centre.

It is associated with high incidence of mal presentation such as breech and tranverse lie. Placental praevia should be excluded if it was shown in early trimester scan by a repeat USS between 32 ? 34 weeks. If the pregnancy continues, these abnormal presentations should be given standard treatment e.g. ECV after 36 weeks and CS as and when indication arises.

In case of labour (preterm/term), vaginal delivery is contemplated. The most important complications are spontaneous rupture of membrane with associated cord prolapse or placental separation. Controlled drainage of liquor should be done by rupturing the membrane at around 3 ? 4 cm dilated cervix in order to prevent these complications. CS will be done in case obstetric indications. Whatever form of delivery it may be, there is an increased incidence of PPH (atonic), hence oxytocin drip should be continued post partum for at least one hour and availability should be ensured before delivery.

Though the polyhydramnios is idiopathic, yet the neonate should be examined by paediatrican to rule out any congenital malformation such as tracheo-esophageal fistula. The perinatal mortality even in the absence of any abnormality is higher than normal.

Standard risk assessment for VTE and thromboprophylaxis, if required should be done as per protocol.

Posted by Vinayak B.
Treatment options available for this patient are Supportive , medical, and surgical treatment. Management depends on severity of polyhydramnios , leading to maternal discomfort, or preterm labour.

In mild poly hydramnios( vertical pool depth less than 8 cm) no active interference done . patient should be explained about aetiology of polyhydramnis as idiopathic which relieves her anxiety. instructed to follow up if respiratory discomfort or gets abdominal pain with contractions. As chances orf preterm labour. Increased in polyhydramnios. This supportive management needs explaination to the patient. regular follow up and treatment if patient gets respiratory discomfort..No role of restriction of dietary salts or diuretics .

Severe poly hydramnios may lead to respiratory discomfort and increases chances of going into preterm labour. Medical management with prostaglandin synthatase inhibitor ( indomethacin) can be considered . Indomethacin Acts on fetal kidney ,decreases urinary output , and amniotic volume .It also helps to inhibit preterm labour. Can be given up to 32-35 weeks as it causes premature closure of ductus arteriosis, some studies also shown fetal effects such as necrotizing enterocollitis, cerebral hemorrhagege. This treatment needs follow up scans to avoid oligo amnios . serial fetal echocardiography to exclude closure of ductus arteriosus is not cost effective hence not adv routinely.


Serial amniocentesis is another alternative. Where amniotic fluid is removed , which relieves discomfort. But cavity refills again and not permanent treatment. To be done undr ultrasound guidance, ir ti has risk of chorioamnionitis, preterm rupture of membranes , onset of premature contractions and few cases with placental abruption.

If patient goes into pretem labour RDS prophylaxis given . and patient should be delivered at centre where scbu facilities available.
Induction at 37 weeks or earlier can be offered for maternal discomfort. if sure about gestational age . there is risk of cord prolapse or placental abruption. Elective lscs can be done in severe polyhydramnios. Post partum PPH treated with active management of third stage with oxytocics.
Posted by Ismatara B.
The aim of intervention is to optimize the outcome at relieving maternal discomfort and prevent the consequences of preterm delivery. Severe polyhydramnios is associated with maternal risk (discomfort, placental abruption, caesarean section and PPH) and fetal risks (prematurity, malpresentation, cord prolapse and perinatal mortality).
Management depends upon the severity and duration of symptom, weather it is chronic or acute. At first it is important to look for the severity of the symptom: mild (vertical amniotic fluid pocket {AFP} 8-12cm), moderate (AFP 12-16cm) and severe (AFP>16cm). This can be detected by clinical examination and USG findings. At the same time fetal can be monitored by serial growth scan 2-4 weekly to look for severity of hydramnios and fetal growth. The combination of small for gestational age and hydramnios is a risk factor for intrapartum complications and perinatal mortality.
Usually mild polyhydramnios is asymptomatic and need no treatment .
Diuretics and salt restriction are not of any proven benefits and are potentially harmful due reduction of uteroplacental perfusion. In severe hydramnios hospitalisation with bed rest is necessary but risk of DVT should be explained. Thromboprophylaxis is considered according to risk factor.
NSAIDs (such as indomethacin) acts by decreasing fetal urinary output or by increasing the resorption of fluid via the lungs. So can reduce the amniotic fluid volume, reduce maternal discomfort and also the risk of preterm delivery. Treatment should be suspended at 35 weeks gestation as it may cause neonatal haemodynamic complication such as pramature closure of ductus arteriosus (PCDA), cerebral vasoconstriction and impaired renal function. So, periodic surveillance is necessary during treatment. Suilindac is an alternative and is less likely to cause PCDA and renal impairment. COX 2 inhibitors like Nimesulide is a theoretically more scientific and lesser side effect but limited data about the drug.
As there is chance of premature delivery corticostroids (Betamethasone 12mg 24 hrly) should be administered for lung maturity. It reduces the risks of RDS, intraventricular haemorrhage and necrotising enterocolitis without increasing the risk of foetal and maternal infection. Maximum effects are within 1-7 days. The role of repeated corticosteroid administration is controversial. The SCBU needs to be informed if preterm labour is anticipated.
Tocolytics are helpful if risks of preterm labour. It prolongs pregnancy up to 7 days for the complete the action of steroids and transfers the baby to SCBU. But side effect of tocolytics especially betamimetics is considered like tremors palpitation, pulmonary oedema which is less with nifedipine (not licensed) and atosibun (licensed).
If there is severe polyhydramnios serial amnioreduction under USG guidance is the option. It relieves maternal discomfort and improves survival. But value of this is questionable as there is more chance onset of preterm labour, preterm premature rupture of membranes, chorioamnionitis, abruptio placentae and fetoplacental bleeding (important in Rh-negative) and high rate of recurrences. Placental abruption can be minimized by slowly amnioreduction over a few hours. Rh-anti D prophylaxis is needed, if Rh-negative.
Though she is healthy, but she is at risk of pre-eclmpsia and gestational diabetes. So close monitoring with symptoms, BP, weight gain and OGTT at 32-34 weeks should be done.
Induction of labour may be needed at 37-40 weeks if maternal discomfort but it carries risk of cord prolapse and placental abruption. So malpresentation should be excluded by USS. And controlled amniotomy reduces these risks. Elective caesarean section is safer in severe cases. The risk benefit of C/S (increased risk of infection, bleeding, thromboembolism, visceral injury etc) versus vaginal delivery should be discussed with the woman. Risk assessment for thromboprophylaxix should be done according to hospital protocol. The woman should be involved in decision making after informed choice. Neanatologist should present during delivery to examine the baby weather there is any congenital anomalies and exclude tracheo-oesophageal atresia by passing an NG tube before feeding. There is significant risk of Postpartum Haemarrhage, so blood should be grouped and saved with I.V. access. Active management of third stage of labour should be done with oxytocin infusion after delivery. Continuous maternal counselling and support helps in the management of stress and anxiety associated with the condition.
Posted by Mini K.
Polyhydramnios is excessive collection of amniotic fluid more than 95th percentile for thr correspondig gestational age.It can be defined as amniotic fluid index more than 20 0r the deepest vertical pocket more than 8.Since it is ideopathic all the recognised causes like diabetes,twin gestation,foetal anomalies,infections and placental pathologies would have been ruled out.Degree of severity can be categorised as mild ,moderate or severe.
.History of decreased foetal movements might be the only presenting symptom.It can be assessed by maternal abdominal palpation.Symphysio fundal height might be more than normal and fluid thrill might be elicited.Difficulty in palpation of foetal parts and difficulty in locating the foetal heart confirms the suspicion.Diagnosis and severity of the condition are assessed by ultrasonogram which has to be ideally done by an expert sonologist to rule out any missed foetal anomalies.Downs screening would have been done earlier.
It can present as an acute or a chronic condition.In chronic collection patient may be asymptomatic and well compensated.
In acute polyhydramnios patient may present as an acute emergency condition with respiratory distress,or pain abdomen.
Commonest cause is ideopathic.It increases the risk of maternal morbidity and perinatal morbidity and mortality.Maternal complications include preterm labour,preterm premature rupture of membranes,cord prolapse,unstable lie,placental abruption and respiratory distress.
Foetal complications include prematurity,foetal distress,un explained still birth and un diagnosed anomalies.
Treatment options include medical and surgical methods.Drugs like prostaglandin synthetase inhibitor like Indomethacin or COX 11 inhibitors.They can be given as a short course with careful monitoring as it can cause foetal renal failure causing severe oligo hydramnios.It may also cause premature closure of foetal ductus arteriosus.In patient monitoring may be needed in severe condition.
Severe maternal distress has to be alleviated by invasive procedure like Amnireduction.Patient has to be informed about her condition ,the details of the procedure and its complicatios.I nformed consent has to be obtained.Under ultrasound guidence trans abdominally amniocentesis done to reduce intra abdominal pressure and thereby maternal distress.It can be done under local infiltration anaesthesia.Volume of fluid removed depends on the severity of polyhydramnios.Maximum 1 litre of fluid can be removed depending on patients clinical situation.It has to be done under consutant guidance.Anaesthatist help has to be sought before the procedure as patient can go into sudden respiratory distress due to sudden decompression.
Betamethasone has to be given for foetal pulmonary maturity as the procedure can itself stimulate premature labour.The procedure may have to be repeated as fluid may get accumulated again.Complications include pre term labour preterm rupture of membrane and its coplications ,chorioamnionitisand abruptio placenta.
Rh negative non immunised patient has to be given prophylactic

Anti D IgG.
Inform Neonatologist and SCBU if preterm delivery is anticipated.
In mild cases out patient monitoring is sufficient. Patient has to be informed about the clinical situation ,the symtoms of complications that can occur and to report immediately if untoward symptoms are experienced.Verbal informations have to be supported by written informations and leaflets.
Posted by Aroosha B.
Maternal risks with polyhydramnios are abdomominal discomforts, uterine irriterability, postpartum hammorrhage, compromised respiratory functions, unstablie, placenta abruption and rarely ureteric obstruction (with gross uterine distension).
The fetal risks are high perinatal mortality rate of about 13% even in normal fetuses with idiopathic hydramnios. The aim of treatment is to alleviate maternal discomfots and to reduce the risk of pre term labor and other complications as stated above.
The treatment depends upon the severity of the condition mild asymptomatic hydramnios (means vertical amniotic fluid pocketbetween 8 cm and 12 cm) is managed expectantly. There are no data to support dietary restrictions of salts and fluids or the use of diuretics which may in fact reduce placental perfusion. Moderate (12 cm to 15 cm)to severe hydramnios (more than 15 cm) can be managed by the medical and surgical means. Medical options are, prostaglanding synthetase inhabitors e.g. Indomathcin and Sulindac which act by reducing the fetal urinary output but indomethacin causes premature closure of ductus arteriosus therefore periodic survillance for signs of cardiac effects has to be done. Sulindac is a safer alternative as it has less fetal effect. Recently a new drug of the same group, Nimesulide has been introduced with out fetal side effects but further experience awaited. These drugs have to be stopped at 32 weeks gestation to avoid neonetal haemodynamic complications. A course of corticosteroids should be adminsitered to the mother if delivery is anticipated before 36 weeks.

The surgicals options include serial amnioreductions usually in severe cases but the disadvantanges include risk of pre term labor, rupture of membranes, infections, abruptio placentae and it needs to be done under USS guidence everytime. It will reduce maternal discomfort but the fluid reaccumulates rapidly.
Fetal growth needs to be monitored by serial USS and the presentation need to be confirmed when signs of labor. If the patient is managed as outpatient she needs to be explained that she should report immediately to the emergency department when she has any symptoms of labor or leacking.

The options for delivery are induction of labor after 36 weeks if the presentation is cephalic but it carrys risk of cord prolapse and abruption. LSCS is a safer option if done as an electice procedure in severe polyhydramnios. Postpartum active management of 3rd stage reduced the risk of post partum haemorrhage.


Posted by Srivas  P.
The aim of treatment of this patient is relief of maternal symptoms, and prolongation of pregnancy. Mild and asymptomatic woman can be managed expectantly.

If hydramnios is moderate or severe, and woman is symptomatic she needs treatment. Measures like restriction of fluid, salts have no role and diuretics may be harmful. The reduction in hydramnios has potential to improve utero placental flow due to improvement in cardiac return. The drugs which help reduce amniotic fliud volume are Indomethacin and sulindac. But the complications of use include risk of premature closure of the ductus arteriosus, impairment of renal function, and cerebral vasoconstriction of the fetus. There are risks of necrotizing enterocolitis and IVH when infant is treated in-utero and the risk increases from 5 % at 27 weeks to nearly 50% at 32 weeks. Hence treatment should be discontinued at 32-35 weeks or when amniotic fluid volume gets normal or she develops oligohydramnios. Sulindac is another PG synthase inhibitor but is less likely to cause constriction of the ductus arteriosus. Nimesulide, a selective COX-2 inhibitor has been tried but is still being evaluated.

If severe hydramnios and patient requires immediate relief, therapeutic amnioreduction can be done. Risks include PPROM, abruption and infection. Reaccumulation can happen and repeated procedures may be necessary.

This woman is at risk of preterm labour ,abruptio placenta and cord prolapse if she ruptures membrane. If she goes into preterm labour at 28 weeks she will need corticosteroids and may need transfer to tertiary centre in-utero if facilities do not exist for a preterm baby. If she is in advanced labour, better to transfer the baby ex utero. If the unit has facilities for premature care, SCBU should be informed about it.

Mode of delivery should be discussed with couple and consultant should be consulted. C.S may be preferable in severe hydramnios because of risks of cord prolapse and abruption.
Posted by neera  B.
Polyhydramnios is associated with increased perinatal mortality, chiefly due to prematurity. thus aim of treatment is to prolong pregnancy and relieve maternal symptoms.
In case of mild polyhydramnios with no maternal symptoms, conservative management and follow up should be offered.Serial scans would detect worsening polyhydramnios. Regular antenatal followup should be emphasised.
Severe polyhydramnios pushes the diaphragm up, causing breathlessness. If this is incapacitating, amnio reduction should be concidered. Though it relieves maternal symptoms, risk of reaccumalation of fluid, procedure related infection and preterm labour must be explained.
Prostaglandin synthetase inhibitors like indomethacin and sulindac are other options to treat moderate and severe polyhydrimos these act by decreasing fetal urine production. However premature closure of ductus arteriosus and necrotising entrocolitis are the side effects since they are potent vaso constrictors. Nimesulide is selective Cox II inhibitor and has been found effective in some trials but is not yet recommended for treatment for polyhydramnios. Bedrest and diuretics have not been found to be helpful.
In severe polyhydramnios she should be advised hospitilisation due to risk of abruptio and cord prolapse if she ruptures her membranes. Vaginal examination should be done at rupture of membranes.
If she presents in preterm labour, transfer in utero or ex utero to tertiary care centre should be considered depending on how advanced labour is. Short term tocolysis for steroids to have the effect or in utero transfer have a role but evidence does not support the use of long term tocolysis. Lie and presentation should be palpated and confermed by ultrasound. transverse lie is an indication for caesarian, though classical caesarian may have to be done because lower segment is not well formed. Vaginal delivery is permissible for cephalic, ideal route of delivery for preterm breech remains debatable.
All options should be discussed with the women and she should be alowed to make informed choice.Leaflets should be given.
Posted by afroz S.
In this case,the causes of the polyhydramnios have already been excluded by history,examination & investigations which are all normal.The condition and it\'s implications are explained to the patient.There is increased risk of preterm labour,premature rupture of membranes, abruptio placenta, cord prolapse & malpresentations.The maternal complications include abdominal distention leading to discomfort and respiratory distress. The management depends on the severity of polyhydramnios, gestational age and associated complications.
If it is mild polyhydramnios, conservative management is the preferred option at 28 weeks gestation.Regular fetal monitoring is done by 2 weekly growth scans, CTG, biophysical profile & Doppler studies. Increase in the severity of polyhydramnios is monitored on regular basis.If the maternal and fetal condition is satisfactory, delivery at term is adviced.
Moderate to severe polyhydramnios is associated with increase in maternal and fetal complications.Medical treatment in the form of NSAIDs like Indomethacin reduces the fetal urine output and hence liquor volume.But it is associated with early closure of ductus arteriosus and fetal renal impairment. It should not be continued beyond 32 weeks of gestation. Steroids are given for the fetal lung maturity due to risk of preterm delivery which are most effective between 48 hrs to 7 days.Giving repeated doses of steroids is a controversial issue as it may be associated with neurodevelopmental impairment and fetal adrenocortical suppression.Tocolytics are used only in cases of preterm labour for the steroid action and for in utero transfer if NICU facilities are not available.
Serial amnioreduction may be required if it is severe polyhydramnios causing respiratory distress which is done under ultrasound guidance. This also reduces the risk of preterm delivery. It is associated with risk of chorio-amnionitis. Salt restriction and bed rest is not useful. Diuretics cause more harm than good.During labour there is a risk of cord prolapse , abruption & malpresentations.Continous CTG monitoring is required.Controlled ARM is done to avoid the risk of cord prolapse.Neonatologist should attend the delivery. Vaginal delivery is preferred.LSCS ia indicated only is there is a fetal compromise of associated complications.
There is a risk of PPH. Hence active management of the 3rd stage of labour is required with Ergometrine and Syntocinon infusion.The patient is kept well informed about the management plans.
Posted by neera  B.
Dear Dr .Paul,
Since the ques was treatment options {AND NOT YOUR MANAGEMENT} ,I did not write about PPH and neonataal examination. Please comment.
THX Neera
Posted by Samir A.
Polyhydramnios is defined as AMF >90% centile. I\'ll explain the finding to the woman and reassure her that no detectable cause for her condition as well as no congenital anomalies were so far detected.
The aim of treatment is to prolong pregnancy, relieve maternal discomfort and prevent complications.

Ante-nataly, the treatment options are: expectant managment, amnioreduction or NSAID (Non steroidal anti inflammatory drugs) plus Steriod injection in all treatment options.

If no respiratory embrassment nor abdominal discomfort and no fetal compromise (CTG, BPP, Doppler) I\'ll not interfer and reassure the woman, give steroid (2 doses of 12 mg betamethasone IM 24 h apart after conselling) to improve lung maturity and I\'ll see her every 2 weeks for re-evaluation + US + sreial growth scan untill term.

If she has that symptoms, I\'ll counsel her for serial amnioreduction and NSAIDs.

Serial amnioreduction has tha advantage of symptoms relief, prolongs pregnancy (by decrease the risk of PPROM, cord prolapse), decreases the risk of unstable lie, emergency CS, prematurity and possibly the risk of PPH (post patrum haemorrhage).However it has the risks of premature rupture of membranes, chorio-amnionitis and anti D senistisaion if mother is Rh negative.

NSAIDs (Indomethasine, cox II inhibitor: nimesulid, sulindac) reduce the amniotic fluid volume by decreasing the fetal urine formation. The have the same advantages of amnioreduction, but has the risks of premature closure of the patent ductus arteriosus (with risk of the sequlae of pulmonary hypertension), fetal cerebral vasoconstriction and risk of maternal gastric problems (gastritis, peptic ulcer disease and diarrhoea).
Sulindac has less risk of ductus closure as well as cerebral vaso constriction.NSAID should be stopped at 34-35 weeks to avoid premature closure of the ductus arteriosus or whenever AMFI is in the normal range or when gastric symptoms appear.During treatment I\'ll do clinical and ultrasound monitoring every 1-2 weeks and serial growth scan every 2 weeks according to severity of hydramnios.

If the presentation is breech or the lie is oblique or transverse I\'ll do elective CS at 37-38 weeks.

If cephalic presntation, at 37-38 weeks I\'ll induce her (after counselling) by prostaglandin + controlled ARM + syntocinon + continueous CTG, and theatre is ready for emergency CS, and the anaesthetist and neonatologist are informed. I\'ll counsel her for epidural/systemic analgesia. If the head became well applied to the cervix after ARM the risk of cord orolapse is very small, then I\'ll contiue managment as the usual IOL.
If cord prolapses I\'ll put the patient in the knee chest position or keep the examining hand inside the vagina reducing the cord untill the patient is ready for CS. If fetal distress develop (CTG) I\'ll do emergrncy CS also.

I\'ll mange the 3rd stage actively, make sure that uterus is contracted and give 40 units syntocinon in 500 ml saline over 4 h to avoid PPH, and give thrombo prophylaxis (hydration, early mobilisation ? ETD ? LMWH according risk assessment)

I\'ll examine the neonate for congenital anomalies.





Posted by Samir A.
Dear Dr Paul,
I noticed that some candidates (including myself ) awrded one mark for a certain point in their answers. However in the model answer the same point (almost expressed in the same way) was awarded two marks. This is an example;

? Know that mild asymptomatic polyhydramnios requires no treatment (2).

Please can you explain, to get the best chance of getting more marks.
Thanks for excellent guidance.