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MRCOG PART 2 SBAs and EMQs

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ESSAY 227 - Polyhydramnios

Posted by Sarwat F.
Fasting blood glucose can be checked as diabetes can cause polyhydramnios. Ultrasound examination for anyevidence of fetal hydrops will be done as this is another cause of polyhydramnios. However most cases are idiopathic. If there is any evidence of fetal hydrops then other investigations like maternal rhesus status, TORCH screening, kleihauer test, haemoglobin electrophoresis will be needed to check for the causes of immune and nonimmune hydrops.
Treatment options include bed rest, medical treatment and amnioreduction. For mild symptoms of shortness of breath and abdominal discomfort, bed rest can lead to some improvement. Medical treatment can be offered in the form of indomethacin which is a nonsteroidal anti-inflammatory drug. Its side effects include premature closure of ductus arteriosus and effects on fetal kidneys. Sulindac is another therapeutic option for improvement of symptoms. In severe cases therapeutic amnioreduction can be done. Upto 1 to 2 litres fluid can be removed. It leads to improvement of symptoms. However side effects include infection, placental abruption due to sudden release of pressure, preterm labour and still birth. It should be done under ultrasound guidance. In severe cases, elective preterm delivery can be done for improvement of symptoms.
Intrapartum care includes identifying risks associated with severe polyhydramnios. These include risk of cord prolapse, unstable lie, placental abruption and need for caesarean section. Labour should be managed as high risk. Blood should be sent for group and hold. Continuous CTG monitoring is done. Partogram is maintained. Controlled artificial rupture of membranes is done with all facilities for immediate caesarean section. Labour ward staff should be well aware of management of cord prolapse. Anaesthetist and paediatrician should be informed in case of emergency delivery. In case of slow progress of labour syntocinon augmentation can be done. In case of cord presentation emergency caesarean section is done. Baby is examined postnatally by paediatrician for any anomalies and blood glucose is checked. Patient and her partner are informed at all stages of management and their wishes are respected in decision making.
Posted by neera  B.
a) Severe polyhydramnios at 30 wks, is associated with high perinatal mortality and morbidity due to risk of preterm labour.
Though she is healthy, gestational diabetes can present as polyhydramnios at 30 wks. Thus glucose screening test should be offered .
Red cell antibodies , parvo virus B19 Ig M and TORCH IgM should be tested in maternal blood because these conditions can cause polyhydramnios in an otherwise healthy lady.
A tertiary level ultrasound should be arranged to look for evidence of hydrops ( fluid collection in 2 or more serous cavities) : to recheck for congenital anomalies and measure amniotic fluid index and /or deepest pocket of liquor.
If no cause is found it may be idiopathic polyhydramnios.
b) Aim of treatment is to prolong the pregnancy while decreasing maternal morbidity from severe polyhydramnios. Two doses of betamethasone intramuscularly 24 hours apart must be given because they decrease the incidence of respiratory distress syndrome, intrventricular haemorrhage, neonatal death and PVL in premature babies. It also decreases the cost and duration of NICU stay.
The patient should be kept propped up to decrease breathlessness. Mobilisation is encouraged. If she is confined to bed due to breathlessness, then thromboprophylaxis should be considered. Diuretics and restriction of fluid intake have not been found effective.
Indomethcin is a cyclooxygenase inhibitor & potent vasoconstricter. It causes fetal renal artery stenosis, causing oliguria and hence decreases liqour volume. It is given orally and is quite effective with good patient complience. However it must be stopped around 32 weeks due to risk of premature closure of ductus arteriosus. It may cause intracranial haemorrhage & necrotising enterocolitis. Sulindac is an alternative medication with lesser side effects than indomethacin but is effective in decreasing liqour volume. Cox II inhibitors are also efective in decreasing liquor volume and thereby allowing prolongation of pregnancy.
If she has severe shortness of breath affecting her quality of life, immediate relief can be provided by therapeutic amniocentesis. But liquor often recollects within a few days. Risk of introducing infection exists and amniocentesis can precipitate preterm labour. Serial amnioreduction may be beneficial.
With these measures an attempt is made to prolong the pregnancy to at least 34 weeks when neonatal survival is considerably improved . However if maternal condition is worsening with incresing pain or breathlessness, induction of labour or cesarian before 34 wks may have to be offered . Complications of induction such as accidental hemorrhage , cord prolapse and PPH are discussed versus the increased maternal morbidity and mortality with caesarian.
All options are offered. written information is given so that she can make an informed choice.

c) There is risk of accidental hemorrhage due to sudden rupture of membranes in polyhydramnios. Risk of unstable lie , cord prolapse and atonic PPH can cause maternal or fetal mortality .
So I shall inform my consultant and involve multidisciplinary team with senior anaesthetist, neonatologist and senior midwife. Propped up position is likely to help with shortness of breath . Blood will be sent for group and save , FBC. Four units of blood will be kept cross matched . Intravenous access will be secured with 2 large bore intravenous cannulae . Continuous CTG monitoring is done and 1:1 midwife care is provided . Therapeutic amniocentesis in early labor may provide symptomatic relief . Senior anaesthetist should be involved because it may be technically difficult to administer an epidural. Ambulation should be allowed and hydration should be maintained. If she cannot move around due to shortness of breath, thromboprophylaxis should be discussed. Controlled ARM is done once the head is fixed and cord prolapse is ruled out. If there is accidental hemorrhage, cord presentation, cord prolapse or severe maternal distess , cesarian section should be offered . Active management of third stage should be dne due to risk of atonic PPH . Ten units oxytocin infusion should be started after the birth of baby and continued for 4-6 hrs. after delivery. Neonatologist should be present due to risks of prematurity at 35 wks. Neonatal examination to rule out congenital anomalies should be performed. Mother should be kept informed and involved in decision making.
Posted by Dr Saibal  S.
Subsequent investigation important because severe polyhydramnios is assosiated with increased perinatal mortality and maternal morbidity.
As mother is healthy maternal blood for,grouping and typing,antibodies and kleihuaer test and IgM /IgG for CMV, Parvovirus , rubella to rule out fetomaternal haemorrhage, isoimmunisation or infection which could cause fetal hydrops and polyhydramnios. Maternal ultrasound to rule out twin gestation and macrosomia,and see fetal presentation in case early delivery anticipated. Detailed cardiac scan and echo may rule out undetected cardiac or other structural anomalies.
Fetal cordocentesis though associated with 2% risk of fetal loss will help determine infection, hemoglobin, hemoglobinopathy like Barts., chromosomal anomaly like trisomy21, 18 and 13.
Amniocentesis associated with 1% risk of fetal loss can be done for infection screen, chromosomal analysis. Most cases will be idiopathic and no cause found.
B.
Treatment should be directed to stabilise maternal complication like pain , respiratory difficulty, risk of preterm labour, abruptio, cord prolapse and PPH and fetal monitoring for growth and well being. If woman is asymptomatic regular monitoring of liquor by ultrasound along with growth velocity, presentation and doppler of umbilical arteries will indicate development of macrosomia, unstable lie ,and placental insufficiency (in a small proportion of cases of polyhydramnios). Woman should be asked to report onset of pain or loss of liquor as the cause could be abruptio or cord prolapse necessitating immediate delivery.
Medical manage ment with indomethacin can reduce liquor but cannot be used after 32 weeks due to premature closure of the ductus and renal insufficiency in fetus.NSAIDS like sulindac are safer but efficacy of use is not clear.
Severe symptoms like respiratory compromise need amnioreduction. This is associated with preterm labour, abruptio,infection, fetal distress and fluid can reaccumulate. May need to be done repeatedly and 1-2 litres of fluid can be removed at each attempt.
Maternal steroids for fetal lung maturity should be given as preterm delivery is common.Fetal monitoring by biweeekly growth velocimetry, doppler umbilical flow and liquor volume check.
Pediatrics and scbu must be prewarned and be on standby if preterm delivery occurs.
Woman should be under consultant care and be informed about the risks and benefits of all the above procedures.Consent must be taken for all procedures .
C.
Continuous CTG to check fetal wellbeing though monitoring can be difficult,monitoring of maternal blood pressure, and IV cannula sited in case assisted delivery needed and for group and save.
Vaginal examination to check dilatation, membrane status, cord prolapse, liqour colour is essential,membranes should be left intact as long as possible but if rupture then prolapse of cord should be ruled out.
Pediatrician and SCBu should be informed and be on standby for resuscitation when delivery occurs .
In case of cord prolapse or acute fetal bradycardia delivery should be be emergency section,Fetal distress \\in 2nd stage can be managed by instrumental delivery though ventouse associated with increased fetal scalp trauma and bleeding.Anticipation of pph is important, and should be managed accordingly.
woman should be under care of named midwife and given information about any interventions and consent taken for such.[:rolleyes:]
Posted by Misbah W.
a] More chances of identifying a cause with severe polyhadramnios than mild or moderate.Fasting bloodsugar and oral GTT should be asked to identify GDM.Viral screening profile as they may be asymtomatic in some cases.Confirm blood gp and RH status to idntify isoimmunisation.High resolution scan can be asked to find any missed fetal structural abnormalites with thorough sysmatic checkforCSN,GIT,chestand bladeras wellmultiple gestation.In suspected cases fetal karyotyping andviral screening with FBS can be asked
b] Manaement is reduce maternal and fetal complications due to abdominal distention.Mation are aternal complication are abd discomfort,uterine irritibility,repiratory distress,Abrtioplcenta,PPH and eclampsia.fetal risk are due to hypoxia dueto cord prolapsePPROM,PTD.
So aim is to relieve maternal symptoms and prolong gestation.
There is no data to support deit restriction of salt or fluid.Diuretic adminstration to mother seem ineffective rather reduce placental blood flow.Medical treatment with NSAID indomethacin is helpful by reduce urine production in fetusBut it is associated with premature closure of
Ductus artreosus,cerebral vasoconstriction and reduced fetal renalblood flow.To avoid theh is requiredse complication should be stopped at 36 wees.Sulindac ,another PG have lesser effect onductus and urine output but further research is required.
amnireduction is transabdominal aspiration of amniotic fluid under USG guidence.Known to reduce maternal discomfort,prolog gestation and perinatal mortality.Risks of procedure are that it is required repeatedly,associated with preterm hment.labour,chorioamnionitis,placental abruption and membrane detac.
Combine medical and amnoreduction ca be offered to reduce no of surgical procedure.
c] women should be admitted in labour ward and assessed for stage of labour,maternal discomfort and fetal condition. Paediatrician should be informed In very early labourshe can be offered steroids,tocolysis with amnireductionand shift to ward if pain stops.
If she is in establihed labour and vertex is high she can be given option of conrolled ARM with Augumentation of labour,provided all set for emergency lLSCS in case of cord prolapse or placental abruption.Delivered by any mean,Vaginal or abdominal route,3rd stage should be monitored closely,with in time adminstration of syntometrine.Baby should be examined by neonatologist after delivery.
Posted by Freha Z.
Maternal fasting blood glucose should be performed to rule out Diabetes. Maternal blood group and Rh antibodies should be done to check for Rhesus alloimmunisation. Viral ( cytomegalovirus, parvovirus) and syphilis screen can be done and compared with antenatal booking bloods to look for seroconversion. Most common cause of polyhydramnios is idiopathic. Some anomalies may be missed on anomaly scan. A repeat scan may be considered. Fetal echocardiography should also be done to look fetal cardiac anomalies.

(b)Aim of management is to relieve maternal discomfort and prevent preterm labour. Salt and water restriction has no role in the management.
CoX inhibitors such as indomethacin and sulindac are effective in reducing liqour volume and therefore prolonging pregnancy. However they should be stopped before 34 weeks because of the risk of premature closure of ductus arteriosus.
Surgical amnioreduction can provde immediate relief but is associated with the risk of introducing infection and may initiate labour.
Corticosteroids should be started because of the risk of preterm delivery. Two doses of betamethasone 12.5 mg 24 hours apart reduce neonatal mortality, intraventricular haemorrhage, respiratory distress syndrome and necrotising enterocolitis.
Thromboprophylaxis may be required.

(c) Delivery should be planned at 37-38 weeks to reduce maternal discomfort. Controlled Amniotomy can be done to start labour. It is associated with the risk of cord prolapse and placental abruption.
In case of gross polyhydramnios it may be safer to deliver by caesarean section. Other indications are unstable lie or malpresentation.
Active maagement of third stage should be done due to increased risk of postpartum haemorrhage. Neonatologist should be present at the time of delivery to look for any congenital abnormality and tube should be passed before starting feeding to the baby.
Posted by Shatha A.
(a)
Polyhydramnios can be associated with 10-30 % neonatal mortality and significant maternal morbidity. The aim of management is to try to find the underlying cause and to minimise risks to mother and foetus. One of the possible causes is diabetes mellitus therefore, arranging a glucose tolerance test is important. Bloods for group and antibodies to exclude foetal haemolysis which can be a cause for hydrops foetalis associated with polyhydramnios. Maternal serum should be tested for evidence of parvovirus infection and TORCH screen( toxoplasmosis, rubella, cytomegalo virus and herpes). An ultrasound scan for foetal growth, umbilical artery Doppler and biophysical prophile exclude foetal macrosomia associated with diabetes and hydrops foetalis and to assess foetal wellbeing. However; it has limited value in excluding condition such as oesophageal atresia. Amniocentesis for karyotyping may be done if there is a high index of suspicion of chromosomal anomaly.


(b)
severe polyhydramnios can be associated with shortness of breath, abdominal discomfort and pain, and uterine irritability and preterm labour. Steroids may be given for lung maturity and nifidipine can be used in case of preterm labour to. Treatment can be expectant if symptoms are not severe and there is no foetal compromise. However; medical treatment may be indicated in some cases. Non steroidal anti inflammatory like indomethacin has been used, to reduce liquor volume by reducing foetal urine output. But their use is associated with risk of premature closure of ductus arteriosus, and the treatment should be stopped between 32-34 weeks. Other drugs like sulindac and nimesulide can be used with less risk of premature closure of ductus arteriosus. Amnioreducdtion can be offered when there is severe maternal discomfort, but there is risk of infection and preterm prelabour rupture of membrane. Also, liquor is likely to recollect and repeat procedure may be necessary. Delivery may be indicated when there is maternal or foetal compromise.

(c)
The patient should be admitted to labour ward, an intravenous line should be inserted and blood for full blood count and group and save should be sent off. SCBU should be informed and the importance of exclusion of oesophageal atresia before initiating oral feeding should be stressed. Abdominal examination to assess engagement of foetal head and to palpate for tenderness bearing in mind placental abruption can be a associated with polyhydramnios. Continuous electronic foetal monitoring should be started. Vaginal examination to assess cervical dilatation, and to exclude cord prolapse in case of rupture membrane. Pain relief should be discussed. The station of the foetal head should be noted. If the head is not engaged and artificial rupture of membrane (ARM) is indicated, then a controlled ARM should be done in theatre prepared for an emergency caesarean section in case of cord prolapse. There is a risk of shoulder dystocia if there is associated foetal macrosomia, and birth attendant should be aware. However; at 35 weeks the risk is less than at term.
Active management of the third stage is indicated with a prophylactic syntocinon infusion for 4 hours after delivery to minimise the risk of postpartum haemorrhage associated with over distension of the uterus. Thromboembolic risk should be assessed and prophylaxis given accordingly.
Posted by Fahima A.
a) I will refer the patient to tertiary centre for high resolution ultrasound scan to detect fetal anomaly (like oesophageal atresia, diaphragmatic hernia,cardiac anomaly, hydrops fetalis) because though the previous scan is normal still it may miss some defects. The aim of the investigations is to find out the cause of polyhydramnios & to monitor fetal wellbeing and should be according to the clinical clue. Maternal blood should be taken for glucose tolerance test as diabetes mellitus is a common cause of polyhydramnios. Investigations of infectious serology of mother include parvovirus, TORCH, syphilis serology, cocksackie virus. Red cell antibodies and Kleihaurs test (if mother is Rh negative) should be done specially if hydrophic fetus. If ethnicity suggests haemoglobin electrophoresis to detect alpha thalassemia shold be done.
Weekly ultrasound scan to measure liquor volume & regular growth scan if fetal macrosomia present is necessary. Regular CTG monitoring,umbilical artery doppler, Biophysical profile can be done for monitoring of fetal wellbeing but the sensitivity is low.
b)Antenatal management should be aimed to relief maternal discomfort & to reduce the risk of premature delivery by reducing intrauterine pressure.If mother has no complaint no intervention is required .But in severe polyhydramnios mother usually presents with abdominal discomfort, respiratory embarrassment. Medical management can be done with Indomethacine. It acts by reducing fetal urinary output but may cause premature closure of ductus arteriosus & impaired renal function. So the treatment should be discontinued from 32 weeks. Sulindac another options less likely to cause closure of ductus arteriosus. Periodic surveillance to detect aortic regurgitation should done if this treatment offered. Salt restrictions & diuretics has no role here.
Mother should be given steroid injection to enhance fetal maturity as there is risk of premature delivery. If mother has severe discomfort Ultrasound guided amnioreduction may help to relief it. But there is risk of infection, PROM, abruption placenta . If reaccumulation of fluid occurs serial amnioreduction may be needed. Nifedipine acts as tocolysis may reduce uterine irritability but its role between benefits & side effects is unclear and therefore it is not given. During her antenatal check up abdominal examination to detect fetal macrosomia & malpresentation is important. Regular ultrasonography for liquor volume & fetal growth is necessary. Regular CTG,doppler, biophysical profile may help in fetal wellbeing the sensitivity is low. Mother should be informed about the risk of polyhydramnios like PROM, cord prolapse, abruptio placenta, increased caesaren section rate, PPH. she should be asked to contact hospital immediately if labour starts or membrane ruptured.
c) She should be admitted. Early venous access is important with blood should be sent for group & save as there is increase risk of PPH . SCBU should be informed for neonatal management. Careful monitoring is necessary to exclude abruptio placenta and cord prolapse if membrane ruptures suddenly. Amniotomy can be done after engagement of head or controlled amniotomy can be done to relief maternal symptoms. Facilities of emergency section should available if there is cord prolapse. Neonatologist should be present at delivery. Active management of 3rd stage is indicated as there is increased risk of PPH.

Posted by Srivas  P.
a) She should have blood group and antibody screen. Maternal serum tests for infection like rubella, toxoplasmosis and CMV are of limited value when there are no congenital anomalies detected on USG. Screening for Toxoplasmosis can be justified if there is history of exposure to cats or gardening. Besides treatment initiated with Spiramycin and Pyrimethamins and sulfadiazine can control fetal infection. Infection can be confirmed by PCR of amniotic fluid. Maternal blood serology for syphilis, parvovirus B19 can identify the maternal infection and maternal syphilis can be treated to prevent congenital syphilis. and contacts screening can be done.

In suspected fetal Parvo virus infections Doppler examination of middle cerebral artery waveform can give early detection of developing fetal anemia and hydrops and effective intra uterine therapy can give good prognosis.

Karyotyping to detect suspected aneupliody is not justified in this young woman with normal anomaly scan.

If the woman has any other features associated with gestational diabetes--increased BMI, family history of gestational diabetes or NIDDM, PCOS then GTT should be done to exclude GDM.

b)Severe polyhydroamnios is associated with maternal risks like discomfort, placental abruption, preterm labor, PROM, malpresentation , PPH and fetal risks prematurity, IUGR, undetected congenital anomalies , cord prolapse and increased perinatal morbidity and mortality. The interventions are aimed at relieving maternal discomfort and prolong pregnancy.

Serial amnioreductions to reduce amniotic fluid can be complicated by PPROM, infection, rhesus sensitization,PTL and a high rate of recurrence. Medical treatment to reduce amniotic fluid volume include drugs like COX inhibitors--e.g. indomethacin, but it is not recommended beyond 32 weeks because complications are more and can cause unfavorable fetal effects like premature closure of ductus arteriosis, NEC, IVH and renal dysfunction. Sulindac is an alternative less likely to cause premature closure of ductus arteriosus and lesser fetal renal effects. COX 2 inhibitors like Nimesulide has lesser side effect but there is limited data about the drug. Medical treatments take time to have effect and she may need surgical amnioreduction to bring quicker relief. A combination of surgical and medical methods could be more effective.

She should receive Corticosteroids 2 doses 12mg 24 hrs apart if she has threatened prelabor. It reduces the risks of RDS, IVH and NEC without increasing the risk of fetal or maternal infection. The SCBU needs to be informed about it. Tocolytics are given to gain time to have corticosteroids have effect and to aid Intra uterine transfer to tertiary centre if there are no SCBU facilities or bed available. By themselves tocolytics have not been found to improve perinatal mortality. Atosiban has best side effect profile but is costly. Nefidipine also has low side effects but is still unlicensed in UK pending more study.

Use NSAIDs for analgesia. Diet and salt restriction are ineffective and the use of diuretics is associated with uteroplacental insufficiency.

She should have serial growth scans to assess severity of hydramnios and fetal growth. She is at increased risk of developing PIH and BP record must be done on a regular basis?twice weekly. She may be higher risk of thromboembolism due to decreased mobility?her risk profiling should be done.

In case of successful prolongation of pregnancy, delivery should be planned at 38 weeks. Leaflets should be given.

c)Malpresentation is excluded by USS. The controlled artificial rupture of membrane ARMS reduces the risk of placental abruption and cord prolapse but is preferably done in theatre so that immediate C.S can be done if there is cord prolapse. She should have continuous CTG in labor as it may be difficult to monitor fetal heart manually. She is risk for brisk hemorrhage in 3rd stage due to uterine atony. Large bore I/V access should be started and blood should be cross matched at kept ready. Ergometrine and I/v Oxytocin use minimizes bleeding.

If the presenting part is very high up or lie is unstable, ARM is risky; C.S could be a safer option for both mother and baby. Senior anesthetist should be involved. Regional anesthesia could be difficult due to difficulty is maintaining posture. She should be told that absence of sonographic features of fetal anomoly does not exclude the possibility. She should be explained about this and consent taken.

Neonatologist should be present at delivery.Baby should be examined for any anomalies and oesophageal atresia should be excluded before feeding.
Senior consultant should be involved throughout in decision making.
Posted by sailaja devi K.
Investigate polyhydramnio as it is associated with maternal & fetal risk.Maternal risk like compromised respiratory function ,preeclampsia ,increased caesarean section due to unstable lie & abruption, postpartum haemorrhage.The fetal risk are congenital malformation ,PPROM & preterm delivery.

10 % of severe polyhydramnios is due to idiopathic cause,so need to identify the cause.Glucose tolerance test to exclude diabetes. Exclude maternal alloimmunisation by maternal serological testing for red cell antibodies.
Repeat ultrasound even if 21 wks scan is normal .Rule out multiple gestation & twin to twin transfusion syndrome.Exclude congenital anamolies , fetal hydrops & identify any aneuploidy markers.Identify growth abnormalities like macrosomia ,growth restriction.If suspecting fetal anaemia do middle cerebral artery peak systolic flow. Fetal specimen for karyotype & viral screen for TORCH & parvovirus if hydrops fetalis is unassociated with structural abnormalities.

In this women polyhydramnios is idiopathic in origin,so direct treatment to relieve symptoms & prolong pregnancy.Women needs admission if associated with symptoms .Prostaglandin synthase inhibitors like indomethacin decrease fetal urine production.Use of indomethacin is associated with premature closure of ductus arteriosus ,impaired renal function & cerebral vasoconstriction.Saftey of indomethacin in pregnancy is not established ,so avoid long term use .Short term use before 32 wks is associated with minimal side effects.Sulindac is an alternate prostaglandin synthase inhibitor .It has less effect on fetal urine output & ductus arteriosus so advantage in long term treatment. Nimusilide a selective COX 2 inhibitor can be used.

Amnioreduction is transabdominal aspiration of amniotic fluid under ultrasound guidance.Amnioreduction is advised if associated with severe symotomr like shortness of breath.It is associated with risk of preterm labour,PPROM,chorioamnionitis , abruption.After amnioreduction consider CTG to assess the fetus.If the women is Rhesus negative administer anti D immunoglobulin.
Offer antenatal steroids as she is at risk of preterm labour ,counsel the need of steroids & provide with information leaflets.Explain to the women that she is at risk of pretern labour & PPROM with the risk of cord prolapse & infection , advise her to report if pain abdomen or fluid leak per vaginum is present.
Bed rest ,tocolytic,diuretic & fluid restriction are of no benefit.
Amnioreduction & sulindac to be considered . Avoid indomethacin because of adverse fetal effects.
There is increased incidence of preeclampsia ,malpresentation & abruption in polyhydramnios , so during checkups identify this risk factors.
Decide about time & mode of delivery .If polyhydramnios persist consider elective delivery at 38 wks in view of increased risk of unexplained stillbirth.If stable cephalic presentation consider vaginal delivery.
Counsel the women about risks ,involve her in decision making process ,provide with written information & document the same in notes.

Polyhydramnios is associated with early rupture of membranes,cord prolapse, uterine inertia,increased operative delivery & postpartum haemorrhage.Measures to be taken to identify this complications early.Monitor uterine contractions ,monitoring may be difficult because of severe poyhydromnios.Monitor fetus by continuous electronic fetal monitoring because of risk of unexplained stillbirth.Maintain partogram & assess progress of labour because of risk of uterine inertia .If uterine contractions are inadequate & if progress of labour is slow consider augmentation of labour with Oxytocin infusion.Internal examination should be done immediately after rupture of membranes to exclude cord prolapse.Provide adequate analgesia.Be aware of risk of abruption placenta .Assess for risk factors of thromboembolism & plan for thromboprophylaxis.
Inform SCBU as there is need to exclude oesophageal atresia or TOF before feeding the neonate.
In second stage of labour be aware of dystocia if associated with macrosomia.
Active management of third stage of labour to avoid postpartum haemorrhage .Make sure that pediatrician has assessed the newborn .

Posted by SWATI M.

a)Severe polyhydramnios is associated with increased maternal / perinatal morbidity and mortality .Further investigations are needed to identify the treatable cause so as to minimize these risks.
GTT should be performed as diabetes can lead to polyhydramnios .Repeat ultrasound scan should be performed ,preferably at fetomaternal unit to recheck if any fetal anomalies and evidence of fetal hydrops. If hydrops is detected, maternal blood group, red cell antibodies, Kleihauer test , TORCH screening, screening for syphilis and parvo virus should be done to identify its cause. Invasive tests such as CVS / amniocentesis should be recommended for karyotyping if other anomalies are detected.

b)Aim of antenatal treatment is to control her symptoms and prolong pregnancy to optimize perinatal outcome. No treatment is required if symptoms are minimal. This is unlikely in her case as severe polyhydramnios.
NSAIDs such as indomethacin / sulindac are effective to reduce amniotic fluid volume and maternal discomfort which reduces risk of preterm labour.With indomethacin, there is a risk of premature closure of ductus arteriosus and may compromise fetal renal function. Sulindac is less likely to cause premature closure of ductus arteriosus.
Therapeutic amnioreduction is effective to relieve maternal symptoms, has immediate effect and useful in severe cases.Associated risks are abruption, PPROM, Preterm labour ,infection and need for repeated procedures.
Use of prophylactic tocolytics such as nifedipine may reduce uterine irritability and help for maternal comfort but does not reduce risk of preterm labour.
Use of prophylactic corticosteroids to enhance fetal lung maturity and minimize neonatal morbidity may not be helpful as action with single dose lasts for 7 days and repeated doses may be needed. Concern with repeated doses are long term effects on neurodevelopment of fetus.
Tocolytics and corticosteroids are of limited benefit for treatment of preterm labour in presence of polyhydramnios.
Serial ultrasound scans are indicated to assess degree of polyhydramnios , fetal growth and fetal presentation around term as clinical examination will be of limited value.

c)Maternal risks during labour are abruption, PPH. Fetal risks are cord prolapse, fetal distress and operative delivery. Multidisciplinary management with involvement of consultant obstetrician, anaesthetist and neaonatologist should be recommended. Nurse woman in position comfortable to her.CTG should be recommended as high risk labour and also clinical assessment of uterine contractions is difficult and of limited value. IV access and cross match should be done as increased risk of haemorrhage.Keep informed SCBU. Exclude cord prolapse at membrane rupture. Caesarean section should be recommended for obstetric indication only.Paediatrician should be present at delivery. Active management of third stage should be done and oxytocin drip continued for 4 ? 6 hours prophylactically to reduce risk of PPH.

Posted by Shyamaly S.
A healthy 20 year old woman is found to have severe polyhydramnios at 30 weeks gestation. The anomaly scan at 21 weeks was reported as normal. (a) Justify your subsequent investigations [5 marks]. (b) Evaluate the antenatal treatment options given that no cause has been identified [10 marks]. (c) She presents in spontaneous labour with a cephalic presentation at 35 weeks gestation. Justify your intra-partum care [5 marks].

A) The aim of investigations is to establish the cause of the polyhydramnios and assess the fetal condition so that management can be planned. Maternal Glucose Tolerance Test should be performed to investigate for Diabetes. A further detailed Ultrasound should be organised. If this is a twin pregnancy, evidence of Twin to twin transfusion syndrome should be assessed. Any structural abnormalities e.g. gastrointestinal artesian, pulmonary abnormalities, tracheo-esophageal atresia or renal abnormalities should be looked for. Evidence of neuromuscular problems causing abnormal posturing and poor swallowing may cause polyhydramnios, particularly when there is a mternal history of Grave?s disease. Soft markers for chromosomal abnormalities should be assessed. Fetal growth should be assessed- is it macrosomic, suggestive of diabetes or is growth restricted suggestive of chromosomal problems. Evidence of fetal hydrops should also be noted.
Maternal infection screening for toxoplasmosis, rubella, CMV, Parvovirus and Syphilis should be performed.
Maternal blood group and antibody screen should be performed- there maybe rhesus isoimmunisation or other antibodies against fetal cells e.g. anti kell.
Haemoglobin electrophoresis may be appropriate in Asian or Mediterranean ethnicities as thalassaemia may be the cause.
Maternal auto antibodies e.g. anti Ro, ANF should be performed as a cause of immune hydrops.
Amniocentesis maybe considered to exclude an abnormal karyotype.
It is possible that no cause is found, or despite all the investigations, a cause is only found at delivery.

B) The aim of treatment is to prolong the pregnancy and reduce maternal discomfort and respiratory problems caused by the enlarged uterus.
Medical management with NSAIDS maybe instituted e.g. indomethacine. This acts to reduce fetal renal function thereby reducing urine output and therefore reducing liquor volume. This is effective, but the disadvantages are premature closure of the fetal ductus arteriosus, irreversible fetal renal damage and maternal hypersensitivity reactions. Sulindac has a similar mechanism of action but is associated with a lower incidence of premature closure of the ductus arteriosus.
Surgical management with amnioreduction maybe performed under ultrasound guidance. This can be performed repeatedly. This enables rapid improvement in symptoms for the mother (medical management takes several days to work), and the amniotic fluid maybe sent for further investigations e.g. karyotype. The disadvantages are an increased risk of preterm labour, premature rupture of membranes and chorioamnionitis.
Conservative management is another option if the patient is not severely affected by the mass effect, with fortnightly scans to assess growth and liquor volume. There is a significant risk of preterm labour because of the enlarged uterus and therefore prophylactic betamethasone injections should be considered to improve fetal lung development.

C) This is a high-risk labour. Continuous electronic fetal heart monitoring should be instituted as there is an increased risk of abruption and cord prolapse. The patient should be informed that there is a higher risk than normal of needing Caesarean section for delivery. The Consultant Obstetrician, anaesthetist and paediatrician should be informed of this patient?s presence. Betamethasone injections should be considered if not previously given. Tocolysis is not indicated as this is greater than 34 weeks and with an increased uterine size is more likely to fail. Large bore IV access should be gained and blood sent for FBC and Group and save as there is an increased risk of postpartum haemorrhage.
ARM should be avoided as this increases the risk of cord prolapse. When the membranes rupture spontaneously vaginal examination should be performed to exclude cord prolapse.
The neonatal registrar should attend at delivery and assess the neonate for Gastrointestinal or tracheoesophageal atresia prior to feeding.
After delivery active management of the third stage should be instituted to minimise the risk of PPH. This involves clamping the cord and giving syntometrine for the delivery of the placenta. Further measures should be considered if there is significant atony and blood loss.
Posted by neera  B.
Dear Dr.Paul,
Your feedback is really helpful for us to assess and improve our answering skills.Thanks a lot for ur time.
with the exam approaching,may i request u to give us questions more often in the next 15 days.I shall be indebted.
thanx,neera
Posted by Randa E.
a)Polyhydramnios even in structurally normal fetuses is associated with a higher prenatal mortality and morbidity. It is important to screen for maternal gestational diabetes using OGTT. It is also important to perform an u/s to detect the degree of the polyhyramnios, prescence of macrosomia , hydrops or significant deflection of the head. Also to exclude fetal, or placental tumours e.g. placental chorioangiomas. Detailed cardiac scan to rule out undetected or missed cardiac anomalies should be done. If hydrops is suspected then maternal blood group+ antibodies, Hb electrophoreses (depending on ethnic group) and infection screen (TORCH+ parvovirus B19+ syphilis+coxsackie) should also be done. A biophysical assessment for fetal wellbeing is also important.
b) Aim of treatment is to relieve maternal discomfort and to reduce the risk of preterm labour. Dietary salt restriction has no benefit and diuretics are potentially harmful. Several options are available. One option is the use of NSAIDs. Indomethacin acts by decreasing fetal urinary output or by increasing reabsorbtion of fluids via the lungs. The drawback of this is its association with premature closure of the ductus arteriosu, cerebral vasoconstriction and impaired renal function.The treatment should be suspended at 32 weeks gestation or when amniotic fluid volume is normal to avoid complications. Periodic surveillance during treatment to search for signs of ductal constriction is warranted. Another option is Sulindac which is less likely to cause constriction of the ductus but efficacy is not yet clear. Selective COX-2 inhibitors may be a useful alternative. In the presence of very severe symptoms therapeutic amnioreduction is the treatment of choice which may increase perinatal survival but repeated taps may be required. The risks include PROM, chorioamnionitis, abruption and membrane detachment. It needs to be done under u/s guidance. If the symptoms are very severe and persistent then delivery by IOL or LSCS might be the only treatment, irrespective of the gestation. A course of corticosteroids should be administered to the mother if delivery is anticipated before 36 weeks. The condition and risks should be explained clearly to the mother supported with written information. Her wishes should be respected. Clear documentation is necessary.
c) Severe polyhydramnios is associated with an increased risk of cord prolapse, placental abruption, PPH, unstable lie and dystocia( if associated with macrosomia). Therefore a multidisciplinary approach is important involving an experienced Obstetrician, neonatologist, senior anaesthetist, haematologist and an experienced midwife. SCABU should be informed. Bloods for FBC, group& hold, should be sent. Venous access should be secured using wide bore cannulae. Continuous CTG monitoring for fetal wellbeing should be set up although monitoring might be difficult. Spontaneous rupture of the membranes should be awaited and when it occurs cord prolapse should be ruled out. The colour of the liquor should also be noted. Neonatologist should attend delivery and baby should be examined for anomalies and oesophageal atresia. Active management of third stage of labour reduces the risk of postpartum haemorrhage. Oxytocin infusion should be started in the third stage of labour and continued for 4-6 hours after delivery. C/S should be reserved for obstetrical cases. The mother should be kept informed throughout.
Posted by Abi T.
healthy 20 year old woman is found to have severe polyhydramnios at 30 weeks gestation. The anomaly scan at 21 weeks was reported as normal. (a) Justify your subsequent investigations [5 marks]. (b) Evaluate the antenatal treatment options given that no cause has been identified [10 marks]. (c) She presents in spontaneous labour with a cephalic presentation at 35 weeks gestation. Justify your intra-partum care [5 marks].

a) Polyhydramnios is associated with increased risk of perinatal morbidity and mortality associated with prematurity. Investigations are necessary to find causes and institute treatment and ascertain fetal well being to minimize risks. The majority of cases are idiopathic.
Gestational diabetes needs to be ruled out by performing a glucose tolerance test.
Infection is another cause and blood taken to detect parvovirus and the TORCH viruses.
Blood group and anitbody screen should be done to detect red cell alloimunisation.
If the patient is of Asian or mediteranean origin a hemoglobin electrophoresis should be done as thalassemia can cause hydrops and polyhdramnios.
A tertiary level scan should be offered to look for esophageal atresia, diaphragmatic hernias, lung malformations, and musculoskeletal anomalies which are commonly associated with polyhydramnios. There may be associated hydrops. Cardiac echo should also be done to detect any malformations previously missed on anomaly scan. The patient should be warned of the limitations of these scans in detecting any malformations and the cause may not be evident till after delivery. If this is a twin gestation, evidence of TTTS should be carefully sought.
Amniocentesis may be offered in the presence of any soft markers suggestive of aneuploidy.
Fetal well being is ascertained by measuring growth and doppler flow. If hydrops is present then MCA measurement may be necessary to detect degree of anemia.
b) Antenatal treatment is directed at prolonging pregancy, reducing maternal discomfort and ensuring fetal well being.
As there is a high risk of premature labour, prophylactic corticosteroids should be adminstered as it reduces RDS, IVH and prolonged NICU stay.
Expectant management is an option if there is minimal maternal discomfort and no fetal problems. However serial growth and liquor volume assesments need to be done and delivery aimed for 36 weeks provided there is no complications requring delivery prior to that.
Indomethacin is an NSAID which can be used to reduce liquor volume but must be discontinued after 32 weeks due to premature ductus arteriosus closure or when loquor volume normalizes. It also reduces fetal urine output and causes cerebral vasoconstriction.
Sulindac is another NSAID alternative which causes less vasoconstriction of the ductus.
Nimesulide is a selective COX 2 inhibitor which reduces liquor volume.
Amnioreduction can be helpful in reducing maternal respiratory discomfort secondary to diaphragmatic splinting by the large uterus. This needs to be done serially as liquor recollects quite quickly. There is a potential risk of precipitating labour and introducing infection.
Delivery may be indicated , either IOL or Caesarean section if there is increasing maternal discomfort or respiratory embarassment.
Written information should be provided for her to make an informed choice if treatment required.
c) This is high risk labour with potential risks of cord prolapse, abruption, PPH and needing caesarean section.
A mutidisciplinary team should be involved with her care including obsterician, senior midwife and neonatologist. SCBU should be informed.
Vaginal delivery should be aimed for and Caesarean section done for usual obstetric reasons.
Iv access with 2 large bore cannula must be obtained and bloods sent off for FBC and Group and save.
Continous CTG is indicated due to high risk of abruption and cord prolapse.
A vaginal examination should be done if membranes rupture to exclude cord prolapse and ARM is not indicated unless for usual obsteric reasons to prevent inadvertent cord prolapse.
Effective analgesia should be provided.
Neonatologist should be present at delivery to rule out esophageal atresia and TOF prior to feeding.
Active third stage management is necessary to prevent PPH.
Posted by kiria O.
The main aim of investigation is to detrmine the cause of polyhydramnios although in the most cases no cause is found.
As maternal diabetes is one of the important causes of polyhydramnios,fasting blood sugar or glucose tolerance test is justified especially if she has high BMI or positive family history of DM.
Torch screen and paravo virus (B19) serology is indicated to exclude infective causes and can be done for both mother and fetus
Blood group and antibody titer to exclude Rh isoimmunisation.

Alhough, anomaly scan is reported normal, detailed ultrasound examination is essential to determine causes such as doudenal atresia, diphragmatic hernia, neural tube defects and cardiac failure.
Antenatal treatment is indicated in symptomatic woman with sever polyhydramnios and its aiming for reduce risk of preterm labour and relieve maternal discomfort.
Salt reduction and diuretice use has no value in treatment of polyhydramnios and could be harmful.
Medical treatment with prostaglandin inhibitores such as endometacine, sulindac is very effective in reducing amniotic fluid by decrease fetal urination and effect on fetal renal function.
It can be started at 30 weeks gestation and stoped before 36 weeks as it cause premature closure of ductus arterosus and pulmonary hypertension. However selective prostaglandin inhibitores can be used safely and free from side effects caused by none selective agents.
The other option is amnioreduction in which anmniotic fluid drained under ultrasound guidance. This option is very effective in relieving maternal symptoms and in reducing the risk of preterm labour. However, it needs to be repeted and woman to attend frequently to hospital with increase risk of infection, premature rupture of membranse and abruptio placenta.
In acute polyhydraminos woman may experiance sever pain, analgesia is needed and oxygen by mask if respiratory distressed.

Her intrapartum care is essential to reduce risks such as cord prolapse and antepartum heamorrhage which may result from sudden decompression of fluid.
So, its essential at initial presentation to exclude ruptured membranse and cord prolapse.
woman should be on left lateral position to avoid pressure effect and hypotension.
If the head not engaged, there is a risk of rupture of membranse and cord prolapse. So,controled ARM is essential to avoid such complication.
Continous fetal monitoring may be justified as there is increased risk of abruption and fetal death.
In addition, partogram is essential to assess progress of labour with adequate maternal analgesia should be ensured.
SCBU should be informed and neonatologist should attend delivery as preterm baby may need resuscitation and support.
Posted by Parveen  Q.
Severe polyhydramnios is associated with maternal discomfort and increase perinatal mortality and morbidity. Investigation is done to identify the cause and provide treatment to optimise the best outcome. OGTT should be done to screen for maternal gestational diabetes. Maternal blood group, kleihauer betke test is done for antibody estimation to identify chronic fetomaternal hemorrhage. Maternal serology for infection like TORCH, parvovirus B19 and compared with booking results to identify seroconversion, VDRL and TPHA done for syphilis. Polyhydramnios is associated with NI hydrops, so repeat uss to look for fluid in the pleural and pericardial cavity. Also detail anomaly scan to exclude CNS like open NTD , upper GIT and CVS anomalies. If she belongs to SE asian or mediterranean region , hb electrophoresis done to rule out haemoglobinopathies. Serail growth scan to assess severity of hydramnios and fetal growth. Biophysical profile for fetal well being done. Most of the cases are idipathic, no cause can be found.

(b)Treatment is essential to minimise disease progression and to maximise the outcome. Maternal discomfort can be relieved by NSAID like indomethacin. It reduces fetal urinary output, amniotic fluid volume,but associated with premature closure of ductus arteriosus, cerebral vasoconstriction, and impaired renal function. COX inhibitors like sulindac, nimesulide reduces amniotic fluid volume, but less likely to cause premature closure of ductus arteriosus. Therapeutic amnio reduction is another option,but it has to be done repeatedly and this can introduce infection, which can lead to abruption, preterm labour,and chorioamnionitis. Dietary restriction of salt and fluid has no benefit. Similarly diuretics has no role, but it reduces the uteroplacental perfusion. The timing and mode of delivery should be decided , giving the patient an informed choice. If the symptoms persist, consider delivering her by elective CS . To optimise perinatal outcome, corticosteriods given . If facilities are not available, consider transfering inutero to a tertiay unit.
(c)Polyhydramnios is associated with preterm labour, placental abruption, cord prolapse, unstable lie, and PPH. Blood taken for fbc, blood group and save. Wide bore cannula for venous access. and patient examined abdominally to look for the lie, presenting part and fetal heart, to decide for the mode fo delivery. Continuous CTG monitoring for fetal wellbeing. Vaginal examination when the membranes had ruptured spontanously to rule out cord prolapse and colour of liquor. Paediaterician should be informed, to attend the baby at birth, to put NGT before feeding to rule out oesophageal atresia, tracheo oesophageal fistula. Patient may need CS, for obstetric reasons.The anaesthetist and operating theatre informed. Patient should be given adequate analgesia. Active mangement of third stage to reduce the risk of PPH. Patient may need thromboprophylaxis in the presence of other risk factors like casarean section if she had.