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Polyhydramnios

(Hydramnios)

By

Antonette T. Dulay

, MD, Main Line Health System

Reviewed/Revised Oct 2022 | Modified Nov 2022
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Polyhydramnios is excessive amniotic fluid; it is associated with maternal and fetal complications. Diagnosis is by ultrasonographic measurement of amniotic fluid volume. Management is by treating maternal disorders contributing to polyhydramnios. If symptoms are severe or if painful preterm contractions occur, treatment may also include manual reduction of amniotic fluid volume.

Causes of polyhydramnios include the following:

Complications

With polyhydramnios, risk of the following complications is increased:

Risk of complications tends to be proportional to the degree of fluid accumulation and vary with the cause. Other problems (eg, low Apgar score, fetal distress, nuchal cord, malpresentation requiring cesarean delivery) may occur.

Symptoms and Signs of Polyhydramnios

Polyhydramnios is often asymptomatic. Sometimes the uterus is larger than expected for dates. Some women, especially when polyhydramnios is severe and causes uterine distention, have difficulty breathing and/or painful preterm contractions.

Diagnosis of Polyhydramnios

  • Ultrasonographic measurement of amniotic fluid index (AFI)

  • Comprehensive ultrasonographic examination, including evaluation for fetal malformations

  • Maternal testing for causes suspected based on history

Polyhydramnios is usually suspected based on ultrasonographic findings or uterine size that is larger than expected for dates. However, qualitative estimates of amniotic fluid volume tend to be subjective. So if polyhydramnios is suspected, amniotic fluid should be assessed using one of the following ultrasonographic criteria:

  • AFI ≥ 24 cm: AFI is the sum of the vertical depth of fluid measured in each quadrant of the uterus; normal AFI ranges from > 5 to < 24 cm.

  • SDP ≥ 8 cm: SDP is a measurement of the deepest pocket of amniotic fluid; normal SDP is ≥ 2 to < 8 cm.

Excessive fluid is defined indirectly using ultrasonographic criteria, typically the AFI. The AFI is the sum of the vertical depth of fluid measured in each quadrant of the uterus. The normal AFI ranges from > 5 to < 24 cm; values ≥ 24 cm indicate polyhydramnios.

Identification of cause

If polyhydramnios is present, further testing is recommended to determine the cause. The tests done depend on which causes are suspected clinically (usually based on history or other ultrasound findings). Tests may include

  • Comprehensive ultrasonographic examination for fetal malformations (always recommended)

  • Maternal glucose challenge test

  • Maternal serologic tests (eg, for syphilis, parvovirus, cytomegalovirus, toxoplasmosis, and rubella)

  • Amniocentesis and fetal karyotyping

  • Tests for clinically suspected hereditary disorders, such as anemias

Diagnosis references

  • 1. Kehl S, Schelkle A, Thomas A, et al: Single deepest vertical pocket or amniotic fluid index as evaluation test for predicting adverse pregnancy outcome (SAFE trial): A multicenter, open-label, randomized controlled trial. Ultrasound Obstet Gynecol 47 (6):674–679, 2016. doi: 10.1002/uog.14924

  • 2. Nabhan AF, Abdelmoula YA: Amniotic fluid index versus single deepest vertical pocket as a screening test for preventing adverse pregnancy outcome. Cochrane Database Syst Rev 2008 (3):CD006593, 2008.

Treatment of Polyhydramnios

  • Delivery at about 39 weeks

  • Possibly manual withdrawal of amniotic fluid (amnioreduction)

Recommendations for prenatal monitoring depend on the severity of polyhydramnios, based on AFI:

Delivery at about 39 weeks should be planned. Mode of delivery should be based on the usual obstetrical indications (eg, presenting part).

Reducing amniotic fluid volume (eg, by amnioreduction) or reducing its production should be considered only if preterm labor occurs or if polyhydramnios causes severe maternal symptoms; however, there is no evidence that this approach improves outcomes. Also, there is no consensus on how much fluid to remove and how rapidly it should be removed, although removal of about 1 L over 20 minutes has been suggested.

Disorders that could be contributing to polyhydramnios (eg, maternal diabetes) should be controlled.

Treament reference

Key Points

  • Polyhydramnios is excessive amniotic fluid; it can be caused by fetal malformations, multiple gestation, maternal diabetes, and various fetal disorders.

  • It is associated with increased risk of preterm contractions, premature rupture of membranes, maternal respiratory compromise, fetal malposition or death, and various problems during labor and delivery.

  • If polyhydramnios is suspected, do ultrasonography to determine amniotic fluid index or single deepest pocket, and test for possible causes (including a comprehensive ultrasonographic evaluation).

  • Consider reducing amniotic fluid volume only if preterm labor occurs or if polyhydramnios causes severe symptoms.

  • Begin prenatal monitoring with weekly nonstress tests as early as 32 weeks in patients with an amniotic fluid index of ≥ 30 cm.

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