Association of isolated polyhydramnios at or beyond 34 weeks of gestation and pregnancy outcome. Obstet Gynecol. 2015;125:825-832. [PMID: 25751210 DOI: 10.1097/aog.0000000000000740]

Idiopathic polyhydramnios and postnatal outcomes of children: The role of exome sequencing

OBJECTIVES

The objective of our study was to evaluate the long-term outcome of children born from a pregnancy complicated by idiopathic polyhydramnios. The secondary objective was to investigate factors associated with adverse outcomes.

METHODS

We conducted a retrospective study in two prenatal diagnosis centers between January 1, 2009 and December 31, 2020. Inclusion criteria were pregnancies with a diagnosis of idiopathic polyhydramnios, defined by a deepest pocket greater than 8 cm, no detectable abnormality at ultrasound and a negative amniotic fluid assessment including karyotype, chromosomal microarray, biochemical assays (electrolytes and digestive enzymes), and viruses (parvovirus B19 and cytomegalovirus). One-year outcomes of these children were collected. The primary endpoint was adverse postnatal outcome, defined by at least one of the following criteria: stillbirth, neonatal death, or serious and incurable condition diagnosed in the first year of life.

RESULTS

Of the 245 women referred for isolated polyhydramnios, 73 were diagnosed with idiopathic polyhydramnios after prenatal investigations. The mean age at follow-up of children was 28 months (95% CI 20-36). An adverse outcome occurred in 25% of cases (18/73), with one stillbirth, two neonatal deaths, and 15 severe conditions diagnosed postnatally, including a rate of monogenic disorders of 8.2% (6/73). Pediatric follow-up was normal for 75% of the children (55/73), including a rate of 9% (5/55) of curable conditions. Repeated amnioreduction was independently associated with an adverse outcome.

CONCLUSION

Pregnant women with polyhydramnios should be informed of the increased risk of 25% of perinatal mortality and serious conditions diagnosed after birth.

Induction of labor in term pregnancies with isolated polyhydramnios: Is it beneficial or harmful?

OBJECTIVE

To compare rates of adverse pregnancy outcomes in term pregnancies complicated by polyhydramnios between women who had induction of labor (IOB) versus women who had expectant management.

METHODS

This multicenter retrospective study included term pregnancies complicated by isolated polyhydramnios. Patients who underwent IOB were compared with those who had expectant management. The primary outcome was defined as a composite adverse maternal outcome, and secondary outcomes were various maternal and neonatal adverse outcomes. Univariate analyses were followed by multivariate logistic regression.

RESULTS

A total of 865 pregnancies with term isolated polyhydramnios were included: 169 patients underwent IOB (19.5%), while 696 had expectant management and developed spontaneous onset of labor (80.5%). Women who underwent IOB had significantly higher rates of composite adverse maternal outcome (23.1% vs 9.8%, P < 0.01), prolonged hospital stay, perineal tear grade 3/4, intrapartum cesarean, postpartum hemorrhage, blood products transfusion, and neonatal asphyxia compared with expectant management. While the perinatal fetal death rate was similar between the groups (0.6% vs 0.6%, P = 0.98), the timing of the loss was different. Four women in the expectant management group had a stillbirth, while in the induction group one case of intrapartum fetal death occurred due to uterine rupture. Multivariate analyses revealed that IOB was associated with a higher rate of composite adverse maternal outcome (adjusted odds ratio, 2.22 [95% CI, 1.28-3.83]; P < 0.01).

CONCLUSION

IOB in women with term isolated polyhydramnios is associated with higher rates of adverse maternal outcomes in comparison to expectant management. Further research is needed to determine the optimal approach for the management of isolated polyhydramnios at term.

Obstetric and neonatal outcomes in pregnant women with idiopathic polyhydramnios: a systematic review and meta-analysis

Although the assessment of the amniotic fluid volume in pregnancy is part of the fetal wellbeing surveillance, the impact of idiopathic polyhydramnios (IP) on maternal and perinatal outcomes in unknown. The aim of this meta-analysis was to investigate the association of IP with different maternal and perinatal outcomes. We screened five electronic databases until December 2023 and performed data extraction and quality assessment using ROBINS-E in duplicates. Pooled risk ratios and 95% confidence intervals (95% CI) were calculated with a random effects model. 38 studies were included. Patients with IP were at increased risk of perinatal complications including preterm delivery (RR 1.96, 95% CI 1.35-2.86; I2 = 92%), placental abruption (RR 3.20, 95% CI 2.20-4.65; I2 = 2%), delivery via caesarean section (RR 1.60, 95% CI 1.39-1.84; I2 = 95%) and postpartum haemorrhage (RR 1.98, 95% CI 1.22-3.22; I2 = 84%). Similarly, IP was associated with increased risk of adverse perinatal outcomes including low APGAR score (RR 3.0, 95% CI 1.23-7.35; I2 = 95%), stillbirth (RR 4.75, 95% CI 2.54-8.86; I2 = 9%) and perinatal mortality (RR 4.75, 95% CI 2.67-8.48; I2 = 37%). This meta-analysis suggests that pregnant women with IP may be at increased risk of perinatal complications and adverse neonatal outcomes. However, data remains inconclusive considering the low quality and high heterogeneity of included studies.PROSPERO registration number: CRD42022359944.

Labor Induction in Women with Isolated Polyhydramnios at Term: A Multicenter Retrospective Cohort Analysis

Background: With the increasing popularity of elective induction after 39 + 0 weeks, the question of whether induction of labor (IOL) is safe in women with isolated polyhydramnios has become more relevant. We aimed to evaluate the pregnancy outcomes associated with IOL among women with and without isolated polyhydramnios. Methods: This was a multicenter retrospective cohort that included women who underwent induction of labor at term. The study compared women who underwent IOL due to isolated polyhydramnios to low-risk women who underwent elective IOL due to gestational age only. The main outcome measure was a composite adverse maternal outcome, while the secondary outcomes included maternal and neonatal adverse pregnancy outcomes. Results: During the study period, 1004 women underwent IOL at term and met inclusion and exclusion criteria; 162 had isolated polyhydramnios, and 842 had a normal amount of amniotic fluid. Women who had isolated polyhydramnios had higher rates of the composite adverse maternal outcome (28.7% vs. 20.4%, p = 0.02), prolonged hospital stay, perineal tear grade 3/4, postpartum hemorrhage, and neonatal hypoglycemia. Multivariate analyses revealed that among women with IOL, polyhydramnios was significantly associated with adverse composite maternal outcome [aOR 1.98 (1.27-3.10), p < 0.01]. Conclusions: IOL in women with isolated polyhydramnios at term was associated with worse perinatal outcomes compared to low-risk women who underwent elective IOL. Our findings suggest that the management of women with polyhydramnios cannot be extrapolated from studies of low-risk populations and that clinical decision-making should take into account the individual patient's risk factors and preferences.

Amnioreduction vs expectant management in pregnancies with moderate to severe polyhydramnios

BACKGROUND

The rate of polyhydramnios is higher in pregnancies complicated by congenital anomalies. These pregnancies have higher rates of peripartum complications. Amnioreduction is offered to relieve maternal symptoms such as dyspnea, abdominal and respiratory discomfort, and other issues like satiety.

OBJECTIVE

This study aimed to report the rates of amnioreduction and its associated complications in pregnancies with moderate to severe polyhydramnios secondary to fetal anomalies. We also sought to determine if amnioreduction provided additional benefits, including prolongation of pregnancy and a decrease in the rates of peripartum morbidities associated with moderate to severe polyhydramnios.

STUDY DESIGN

This was a retrospective review of anomalous singleton pregnancies with moderate to severe polyhydramnios that were evaluated and delivered at a single center between 2013 and 2021. Peripartum outcomes were compared between pregnancies that underwent amnioreduction and those that were expectantly managed. Mann-Whitney U tests were used to compare continuous variables and Fisher's exact tests were used for categorical variables. A multiple regression model was created to understand the effects of amnioreduction on gestational age at delivery.

RESULTS

A total of 218 singleton pregnancies met the inclusion criteria of moderate to severe polyhydramnios in the study period. Of those, 110 patients (50.5%) underwent amnioreduction and 108 patients (49.5%) opted for expectant management. A total of 147 procedures were performed at a median gestational age of 32.5 weeks and a median of 1900 mL of amniotic fluid was removed per procedure. Complications occurred in 10.9% (n=16) of procedures, including preterm delivery within 48 hours in 5.4% cases (n=8). The median amniotic fluid index was higher in the amnioreduction group than in the expectant group (38.9 cm vs 35.5 cm; P<.0001). Patients who underwent amnioreduction had an earlier median gestational age at delivery (36.3 weeks vs 37.0 weeks; P=.048), however, the rates of spontaneous preterm delivery were similar. A higher percentage of women in the amnioreduction group had vaginal delivery (49.4% vs 30.5%; P=.01) and lower rates of uterine atony (2.4% vs 13.7%; P=.006). In the multiple linear regression analysis, the gestational age at delivery positively correlated with gestational age at amnioreduction after controlling for amniotic fluid volume (P<.0001; 95% confidence interval, 0.34-0.71). In addition, the patients in the amnioreduction group were twice as likely to have a vaginal delivery (P=.02).

CONCLUSION

Amnioreduction in the setting of moderate-severe polyhydramnios has a reasonably low rate of complications but does not provide any benefits in terms of prolonging the pregnancy. The procedure may increase the likelihood of vaginal delivery and lower the rates of uterine atony.

Idiopathic polyhydramnios and pregnancy outcome: systematic review and meta-analysis

OBJECTIVE

To analyze outcomes of singleton pregnancies with idiopathic polyhydramnios through a systematic review and meta-analysis.

METHODS

Electronic databases, including MEDLINE, OVID, EBSCO, Cochrane collection and Science Citation Index, were searched from 1946 to 2019. Gray literature and tables of contents of relevant journals were also screened. Prospective and retrospective studies with a control group were included. Two authors independently reviewed the abstracts retrieved from the literature search. Inclusion criteria were: studies documented in English, singleton pregnancy and idiopathic polyhydramnios determined by amniotic fluid volume assessment on ultrasound. Exclusion criteria were: maternal diabetes, fetal structural or chromosomal anomaly, alloimmunization and intrauterine fetal infection.

RESULTS

Twelve studies met the inclusion criteria, giving a total of 2392 patients with idiopathic polyhydramnios and 160 135 patients with normal amniotic fluid volume. Pregnancies complicated by idiopathic polyhydramnios were at a higher risk of neonatal death (odds ratio (OR), 8.68 (95% CI, 2.91-25.87)), intrauterine fetal demise (OR, 7.64 (95% CI, 2.50-23.38)), neonatal intensive care unit admission (OR, 1.94 (95% CI, 1.45-2.59)), 5-min Apgar score < 7 (OR, 2.21 (95% CI, 1.34-3.62)), macrosomia (OR, 2.93 (95% CI, 2.39-3.59)), malpresentation (OR, 2.73 (95% CI, 2.06-3.61)) and Cesarean delivery (OR, 2.31 (95% CI, 1.79-2.99)).

CONCLUSIONS

This study suggests that pregnancies complicated by idiopathic polyhydramnios are at increased risk of adverse outcome. Future investigations should aim to determine an amniotic fluid volume threshold above which antenatal fetal surveillance is appropriate in the management of these pregnancies. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Window to the Womb: Amniotic Fluid and Postnatal Outcomes

Amniotic fluid volumes are tightly regulated, and amniotic fluid derangement can indicate maternal complications or fetal abnormalities. Ultrasound estimate of amniotic fluid provides a tool to evaluate the maternal-fetal-placental interface in real-time. Oligohydramnios and polyhydramnios are associated with adverse maternal and neonatal outcomes. Oligohydramnios is associated with adverse maternal and neonatal outcomes including cesarean delivery, operative vaginal delivery, induction of labor, postpartum hemorrhage, small for gestational age neonate, intrauterine demise, neonatal death, NICU admission, and APGAR less than 7 at. 5 minutes of life Polyhydramnios is associated with adverse outcomes including cesarean delivery, induction of labor, placental abruption, shoulder dystocia, cord prolapse, postpartum hemorrhage, intrauterine fetal demise, NICU admission, neonatal death, APGAR less than 7 at 5 minutes of life, large for gestational age neonate, and respiratory distress syndrome. Therefore, Amniotic fluid should be evaluated when maternal or fetal well-being is in question.

Term Idiopathic Polyhydramnios, and Labor Complications

Background and Aim: Polyhydramnios is associated with an increased risk of various adverse pregnancy outcomes, yet complications during labor have not been sufficiently studied. We assessed the labor and perinatal outcomes of idiopathic polyhydramnios during term labor. Methods: Retrospective cohort study at a tertiary medical center between 2010 and 2014. Women with idiopathic polyhydramnios defined as an amniotic fluid index (AFI) greater than 24 cm or a deep vertical pocket (DVP) > 8 cm (cases) were compared with women with a normal AFI (5-24 cm) (controls). Statistics: Descriptive, means ± SDs, medians + IQR. Comparisons: chi-square, Fisher's exact test, Mann-Whitney Test, multivariate logistic models. Results: During the study period 11,065 women had ultrasound evaluation completed by a sonographer within two weeks of delivery. After excluding pregnancies complicated by diabetes (pre-gestational or gestational), fetal anomalies, IUFD, multifetal pregnancies, elective cesarean deliveries (CD) or missing data, we included 750 cases and 7000 controls. The degree of polyhydramnios was mild in 559 (75.0%) cases (AFI 24-30 cm or DVP 8-12 cm), moderate in 137 (18.0%) cases (30-35 cm or DVP 12-15 cm) and severe in 54 (7.0%) cases (AFI >35 cm or DVP > 15 cm). Idiopathic polyhydramnios was associated with a higher rate of CD 9.3% vs. 6.2%, p = 0.004; a higher rate of macrosomia 22.8% vs. 7.0%, p < 0.0001; and a higher rate of neonatal respiratory complications 2.0% vs. 0.8%, p = 0.0001. A multivariate regression analysis demonstrated an independent relation between polyhydramnios and higher rates of CD, aOR 1.62 (CI 1.20-2.19 p = 0.002) and composite adverse neonatal outcome aOR 1.28 (CI 1.01-1.63 p = 0.043). Severity of polyhydramnios was significantly associated with higher rates of macrosomia and CD (p for trend <0.01 in both). Conclusions: The term idiopathic polyhydramnios is independently associated with macrosomia, CD and neonatal complications. The severity of polyhydramnios is also associated with macrosomia and CD.

Transient Polyhydramnios during Pregnancy Complicated with Gestational Diabetes Mellitus: Case Report and Systematic Review

Polyhydramnios is an obstetrical condition defined as a pathological increase in the amniotic fluid and is associated with a high risk of maternal-fetal complications. Common causes of polyhydramnios include fetal anatomical and genetic abnormalities, gestational diabetes mellitus, and fetal viral infections. We present the case of a 30-year-old Caucasian woman with transient polyhydramnios associated with gestational diabetes mellitus and obstetric complications. The diagnosis was based on the ultrasound assessment of amniotic fluid volume during a common examination at 26 weeks. Two weeks prior, the patient had been diagnosed with gestational diabetes mellitus. After 4 days, the patient was examined, and the amniotic fluid index returned to normal values. At 38 weeks, the patient presented to the emergency room due to lack of fetal active movement. Ultrasound revealed polyhydramnios, the patient was admitted for severe fetal bradycardia, and fetal extraction through emergency cesarian section was performed. Six weeks after birth, the patient underwent an oral glucose tolerance test with normal values, confirming gestational diabetes mellitus. We performed a systematic review of the literature on polyhydramnios, from January 2016 to April 2022, to analyze all recent published cases and identify the most common etiological causes and important aspects related to maternal-fetal outcomes.

Comparing pregnancy, childbirth, and neonatal outcomes in women with idiopathic polyhydramnios: a prospective cohort study

BACKGROUND

In this prospective cohort study, the perinatal outcome in idiopathic polyhydramnios compared with normal pregnancies was examined.

METHODS

This was a prospective cohort study of 180 singleton pregnancies who received care at the referral gynecology clinic of Yasuj, Iran between 2018-2020. The inclusion criteria comprised singleton pregnancies, gestational age > 34 weeks; fetuses without structural and chromosomal abnormalities in pregnancy screening test, no maternal diabetes, negative TORCH negative screening test, no Rh factor isoimmunization. Polyhydramnios was defined as: (i) amniotic fluid index ≥ 24 cm; (ii) maximal vertical pocket of ≥ 8 cm. Perinatal outcomes were recorded in both groups.

RESULTS

Postpartum hemorrhage (7.8% vs. 2.2; OR: 1.60; 95% CI 1.09-2.34) and cesarean delivery (51.11% vs. 21.11; OR: 1.88; 95% CI 1.42-2.50) and respiratory distress (4.4 v vs. 0; OR: 2.04; 95 C CI 1.75-2.80) was significantly higher in the idiopathic polyhydramnios (P ≤ 0.05) compared to normal pregnancy, which increased with severity of idiopathic polyhydramnios.

CONCLUSION

In conclusion, the results of the current study, suggest that idiopathic polyhydramnios may be associated with a higher rate of postpartum hemorrhage, cesarean delivery, and respiratory distress than a normal pregnancy.

The Inconsistency Between Women's Preference and Actual Mode of Delivery in China: Findings From a Prospective Cohort Study

Background

Previous studies have found that the rates of cesarean preference were much lower than the actual rates of cesarean births in China. We aimed to observe this inconsistency between preferred and actual modes of delivery and the factors associated with the inconsistency.

Methods

We conducted a prospective cohort study at the maternity hospital with the largest number of deliveries in Beijing. We collected data through a questionnaire applied in the outpatient department, and medical records from the hospital's information system. Unconditional logistic regression was used to identify factors influencing the inconsistency between preferred and actual delivery mode.

Results

The rates of actual cesarean section and of cesarean preference were 41 and 17%, respectively (χ² = 82.9, P < 0.0001). The overall inconsistency rate was 31%, with 119 women preferred vaginal delivery but experienced cesarean section, accounting for 67% women undergoing cesarean section. Risk factors for this inconsistency between preferred vaginal delivery and actual cesarean section included: maternal obesity, receiving assisted reproduction, having an abnormal amniotic fluid volume, and fetal distress. Pre-labor rupture of membranes was a unique factor associated with such inconsistency between cesarean section preference and vaginal delivery at delivery.

Conclusions

The inconsistent rate between preferred delivery at late pregnancy and actual delivery is high in China. Further research is needed to understand how to lower cesarean rates in China, taking maternal preferences for vaginal deliveries into account.

The effect of polyhydramnios on the success of trial of labor after cesarean delivery (TOLAC): A retrospective cohort

OBJECTIVE

Prediction of success of trial of labor after cesarean delivery (TOLAC) is of major importance. We investigated the impact of polyhydramnios on the success rate of TOLAC.

STUDY DESIGN

A retrospective cohort study of all women with singleton pregnancies ≥ 34th weeks of gestation who underwent TOLAC after one previous cesarean delivery, between 2011 and 2016 in a single tertiary care center. Polyhydramnios was defined as amniotic fluid index ≥ 240 mm. Primary outcome was defined as the rate of successful TOLAC.

RESULTS

31,245 women gave birth during the study period, of them 1637 (5.3 %) women underwent TOLAC and met inclusion criteria. 39 (2.4 %) women with polyhydramnios were compared to a control group of 1598 (97.6 %) women with amniotic fluid index < 240 mm. Polyhydramnios significantly reduced the rate of successful TOLAC: 69.2 % (27/39) in the study group compared to 85.8 % (1371/1598) in the control group (P = 0.009). In a subgroup analysis based on amniotic fluid index, women with AFI > 270 mm had substantially lower TOLAC success rate [9/19 (47.4 %) vs 18/20 (90 %); P = 0.006]. There was no difference in the rate of uterine rupture between the groups (0/39 (o%) vs 9/1598 (0.56 %); P = 0.64). Logistic regression analysis revealed that polyhydramnios remained significantly associated with higher rates of cesarean delivery [OR 3.09 (95 % CI, 1.37-6.98)] after adjustment for confounding factors.

CONCLUSION

Polyhydramnios was associated with significantly reduced TOLAC success rate with no statistical difference in the rate of uterine rupture. This information should be considered in physician counseling.

Prenatal exposure to isolated amniotic fluid disorders and the risk for long-term endocrine morbidity of the offspring

BACKGROUND

Amniotic fluid abnormalities may be associated with adverse perinatal outcomes, some of which are endocrine related.

OBJECTIVE

To evaluate whether in utero exposure to amniotic fluid abnormalities is associated with long-term endocrine morbidity in the offspring.

STUDY DESIGN

In this cohort study, the incidence of long-term endocrine disorders was compared between singletons exposed and non-exposed to oligohydramnios or polyhydramnios.

RESULTS

During the study period, 195 943 newborns were included in the study, of them 2.0% (n = 4072) and 2.9% (n = 5684) were exposed to oligohydramnios and polyhydramnios, respectively. Long-term endocrine morbidity was higher among children exposed to isolated amniotic fluid disorders, as was also noted in the Kaplan-Meier survival curve (log-rank test p < 0.001). Abnormal amniotic fluid volume was found to be independently associated with long-term endocrine morbidity of the offspring according to a Cox regression model controlled for clinically related confounders.

CONCLUSION

In utero exposure to isolated amniotic fluid abnormalities is independently associated with long-term endocrine morbidity in the offspring.

Cost effectiveness of different screening strategies for gestational diabetes mellitus screening: study protocol of a randomized community non-inferiority trial

BACKGROUND

There is lack of ideal and comprehensive economic evaluations of various GDM strategies. The aim of this study is to the compare efficacy and cost-effectiveness of five different methods of screening for gestational diabetes mellitus (GDM).

METHODS

This study is a randomized community non-inferiority trial among 30,000 pregnant women in five different geographic regions of Iran, who were randomly assigned to one of the five GDM screening methods. All first trimester pregnant women, seeking prenatal care in governmental health care systems, who met our eligibility criteria were enrolled. The criteria suggested by the International-Association-of-Diabetes-in-Pregnancy-Study-Group, the most intensive approach, were used as reference. We used the non-inferiority approach to compare less intensive strategies to the reference one. Along with routine prenatal standard care, all participants were scheduled to have two phases of GDM screening in first and second-trimester of pregnancy, based on five different pre-specified protocols. The screening protocol included fasting plasma glucose in the first trimester and either a one step or a two-step screening method in the second trimester of pregnancy. Pregnant women were classified in three groups based on the results: diagnosed with preexisting pre-gestational overt diabetes; gestational diabetes and non-GDM women. Each group received packages for standard-care and all participants were followed till delivery; pregnancy outcomes, quality of life and cost of health care were recorded in detail using specific standardized questionnaires. Primary outcomes were defined as % birth-weight > 90th percentile and primary cesarean section. In addition, we assessed the direct health care direct and indirect costs.

RESULTS

This study will enable us to compare the cost effectiveness of different GDM screening protocols and intervention intensity (low versus high).

CONCLUSION

Results which if needed, will also enable policy makers to optimize the national GMD strategy as a resource for enhancing GDM guidelines.Trial registration Name of the registry: Iranian Registry of Clinical Trials. Trial registration number: IRCT138707081281N1. Date of registration: 2017-02-15. URL of trial registry record: https://www.irct.ir/trial/518.

Polyhydramnios among women in a cluster-randomized trial of ultrasound during prenatal care within five low and low-middle income countries: a secondary analysis of the first look study

Background

In many low and low-middle income countries, the incidence of polyhydramnios is unknown, in part because ultrasound technology is not routinely used. Our objective was to report the incidence of polyhydramnios in five low and low-middle income countries, to determine maternal characteristics associated with polyhydramnios, and report pregnancy and neonatal outcomes.

Methods

We performed a secondary analysis of the First Look Study, a multi-national, cluster-randomized trial of ultrasound during prenatal care. We evaluated all women enrolled from Guatemala, Pakistan, Zambia, Kenya and the Democratic Republic of Congo (DRC) who received an examination by prenatal ultrasound. We used pairwise site comparisons with Tukey-Kramer adjustment and multivariable logistic models with general estimating equations to control for cluster-level effects. The diagnosis of polyhydramnios was confrimed by an U.S. based radiologist in a majority of cases (62%).

Results

We identified 305/18,640 (1.6%) cases of polyhydramnios. 229 (75%) cases were from the DRC, with an incidence of 10%. A higher percentage of women with polyhydramnios experienced obstructed labor (7% vs 4%) and fetal malposition (4% vs 2%). Neonatal death was more common when polyhydramnios was present (OR 2.43; CI 1.15, 5.13).

Conclusions

Polyhydramnios occured in these low and low-middle income countries at a rate similar to high-income contries except in the DRC where the incidence was 10%. Polyhydramnios was associated with obstructed labor, fetal malposition, and neonatal death.

Trial registration

NCT01990625, November 21, 2013.

The association between polyhydramnios and the risk of placenta abruption: a meta-analysis

Background: The results of studies about the effect of polyhydramnios on the risk of placental abruption are a controversy. This study was conducted to determine the association between polyhydramnios and the risk of placental abruption.Methods: PubMed, Scopus, and Web of Science were searched in September 2017 along with references from meta-analyses and reviews. We assessed publication bias using the rank correlation test (Begg's test) and the regression asymmetry test (Egger's test). The studies' heterogeneity was measured by the Q-statistic and I-squared (I²) tests. The random-effects model was conducted to obtain pooled odds ratio (OR) as a measure of the association between polyhydramnios and the risk of placental abruption.Results: A total of 10 studies were included in this meta-analysis with a sample of 198,359 participants. There was a significant association between polyhydramnios and the risk of placental abruption [OR: 1.93 (95% CI: 1.23-2.63)].Conclusions: The present study is the first meta-analysis that reported polyhydramnios is a risk factor for placental abruption.

SMFM Consult Series #46: Evaluation and management of polyhydramnios

Polyhydramnios, or hydramnios, is an abnormal increase in the volume of amniotic fluid. Identification of polyhydramnios should prompt a search for an underlying etiology. Although most cases of mild polyhydramnios are idiopathic, the 2 most common pathologic causes are maternal diabetes mellitus and fetal anomalies, some of which are associated with genetic syndromes. Other causes of polyhydramnios include congenital infection and alloimmunization. The purpose of this document is to provide guidance on the evaluation and management of polyhydramnios. The following are Society for Maternal-Fetal Medicine recommendations: (1) we suggest that polyhydramnios in singleton pregnancies be defined as either a deepest vertical pocket of ≥8 cm or an amniotic fluid index of ≥24 cm (GRADE 2C); (2) we recommend that amnioreduction be considered only for the indication of severe maternal discomfort, dyspnea, or both in the setting of severe polyhydramnios (GRADE 1C); (3) we recommend that indomethacin should not be used for the sole purpose of decreasing amniotic fluid in the setting of polyhydramnios (GRADE 1B); (4) we suggest that antenatal fetal surveillance is not required for the sole indication of mild idiopathic polyhydramnios (GRADE 2C); (5) we recommend that labor should be allowed to occur spontaneously at term for women with mild idiopathic polyhydramnios; that induction, if planned, should not occur at <39 weeks of gestation in the absence of other indications; and that mode of delivery should be determined based on usual obstetric indications (GRADE 1C); and (6) we recommend that women with severe polyhydramnios deliver at a tertiary center due to the significant possibility that fetal anomalies may be present (GRADE 1C).

Updating the amniotic fluid index nomograms according to perinatal outcome

Background: The two most commonly used nomograms for amniotic fluid index (AFI) were developed by Moore and Cayle and Magann et al. However, there are several inconsistencies between the two methods.Objective: The aim of the study was to determine whether these differences carry clinical significance.Methods: A retrospective cohort of women with singleton pregnancies evaluated for AFI during pregnancy at a tertiary medical center in 2007-2014 were divided into five groups: group A, definite oligohydramnios-AFI below the fifth percentile according to the nomograms of both Moore and Cayle and Magann et al.; group B, intermediate oligohydramnios-AFI below the fifth percentile according to only one nomogram (Moore and Cayle); group C, euhydramnios-normal AFI according to both nomograms; group D, intermediate polyhydramnios-AFI above the 95th percentile according to one nomogram (Magann et al.); group E, definite polyhydramnios-above the 95th percentile according to both nomograms. The association of group by maternal and perinatal outcomes was analyzed.Results: A total of 6987 women were included: group A, 996 (14%); group B, 1344 (19%); group C, 2561 (37%); group D, 1051 (15%); group E, 1034 (15%). Group B (intermediate oligohydramnios) was characterized by significantly lower rates of adverse perinatal outcomes than group A (definite oligohydramnios): small for gestational age neonate (12.3 versus 15.2%, p = .05), neonatal intensive care unit admission (11.1 versus 21.5%; p < .001), composite respiratory outcome (4.8 versus 9.8%; p < .001), and neonatal sepsis (6.4 versus 10.8%; p < .001). No such differences were found between groups B and C. Group D (intermediate polyhydramnios) differed from group E (definite polyhydramnios) by lower rates of 5 minutes Apgar score <7 (1.3 versus 3.2%; p = .003), neonatal intensive care unit admission (10.9 versus 14.4%; p = .02), and major congenital anomalies (1.7 versus 5.6%; p = .02). There was no difference in these parameters between groups D and C.Conclusion: This study suggests that intermediate oligohydramnios and intermediate polyhydramnios are not associated with adverse perinatal outcomes. Outcome in these pregnancies is similar to pregnancies with euhydramnios. Commonly used AFI nomograms should be updated.

Fetal brain MRI in polyhydramnios: is it justified?

Introduction: Despite meticulous investigation of polyhydramnios cases, in many of these cases, congenital anomalies are detected only after birth. The aim of our study was to explore the contribution of fetal brain MRI to the detection of CNS anomalies in cases of polyhydramnios. Materials and methods: This was retrospective cohort study on fetuses referred for the investigation of polyhydramnios at a single tertiary center. All fetuses underwent a detailed sonographic anatomical scan and a fetal brain MRI. Isolated and nonisolated polyhydramnios were differentiated according to associated anomalies. MRI findings were compared between the groups. Results: A total of 46 fetuses were included in the study. Brain anomalies were detected in ultrasound in 12 (26%) cases while MRI detected brain anomalies in 23 (50%) cases. MRI detected more anomalies in fetuses with nonisolated compared to isolated polyhydramnios (62.9% and 31.6%, respectively, p = .019). Conclusions: Fetal brain MRI may contribute to the evaluation of fetuses with polyhydramnios. The clinical value and cost-effectiveness of MRI use in the routine work-up of polyhydramnios should be assessed in future studies.

Risk factors and short outcome of bowel atresia in neonates at Tertiary Hospital

BACKGROUND

Bowel atresia is a rare congenital anomaly that could affect any part of the bowel. It is categorized based on the type and location of the affected bowel with jejunoileal being the most common type worldwide. Risk factors for developing intestinal atresia are not well established, but we know that genetics, poor prenatal care, and low birth weight are considered risk factors.

PATIENTS AND METHODS

This is a case-control study conducted in King Abdulaziz Medical City tertiary hospital in Nursery Intensive Care Unit from 2004 to 2015 with a total number of 50 cases. Each case was matched with two control groups: a female and a male; the matching was based on the date of birth.

RESULTS

Our study showed an interesting results with esophageal atresia being the most common type (n = 16, 32%) after that jejunoileal (n = 11, 22%). Both genders were affected almost equally with no gender predominance. Twenty-six (51%) of the cases were having below normal birth weight (odds ratio [OR] =0.07; 95% confidence interval [CI] =0.03-0.2). One mother of the control groups had cesarean section in comparison to 15 mothers from the cases (OR 42.4; 95% CI 5.4-333.09). The study also showed that there is no correlation between the number of pregnancies and the risk of atresia (P = 0.798) (OR 0.9; 95% CI 0.72-1.3).

CONCLUSION

Unlike western countries, esophageal atresia was the most common type with no gender differences. Interestingly, both groups had high rates of low birth weight.

Placental abruption after amnioreduction for polyhydramnios caused by chorioangioma

Placental chorioangioma is the most common type of a benign placental tumour that occurs in 1% of pregnancies. A large chorioangioma is associated with adverse pregnancy outcomes. We present a case of placental abruption necessitating preterm delivery after multiple amnioreductions for polyhydramnios caused by a large chorioangioma. If antenatal diagnosis of a significant chorioangioma is made as the cause of polyhydramnios, caution should be taken when performing rapid amnioreductions.

The impact of third-trimester genetic counseling

OBJECTIVE

To evaluate the impact of genetic counseling (GC) during the third trimester by analyzing changes in pregnancy management and the correlation with postnatal findings.

METHODS

This was a retrospective study. Pregnancy course and neonatal follow-up were analyzed according to the reason for referral and implementation of recommendations.

RESULTS

The records of neonates born to 181 women were retrieved. Fifty-two women (group 1-29%) qualified for pregnancy termination under Israeli guidelines and laws, and 129 (group 2-71%) were not at the time they were referred. By another division: 104 women (group 3-57%) followed the physician's diagnostic recommendations completely after counseling including amniocentesis, fetal MRI, targeted ultrasound scans, fetal echocardiography. Seventy-seven declined amniocentesis (group 4-43%). Additional abnormalities were detected postpartum in all groups without statistically difference: 3/52 (10%) in group 1, 9/129 (7%) in group 2, 6/104 (6%) in group 3, and 6/77 (8%) in group 4).

CONCLUSION

GC in the third trimester of pregnancy provided the couple with a sharper more focused picture and assisted them to perceive the significance of new, significant fetal findings which attest to the value of the GC.

Choice of scheduled cesarean delivery versus trial of labor for advanced maternal age primiparous women

OBJECTIVE

We aimed to evaluate perinatal outcomes of advanced maternal age (AMA) primiparous women seeking scheduled cesarean delivery (CD) versus a trial of labor (TOL).

MATERIALS AND METHODS

This was a retrospective cohort study of primiparous women ≥40 years of age carrying a single fetus, who delivered at a tertiary, university-affiliated medical center (2007-2014). We compared perinatal outcomes of women who chose a scheduled CD with those who chose TOL. Subsequently, we compared women who had successful TOL (sTOL) with those who had a failed TOL (fTOL).

RESULTS

Out of 62 102 deliveries during the study period, inclusion criteria were met by 374 women. Of them, 83 (22.2%) women had a scheduled CD, and 291 (77.8%) had TOL. Of the TOL group, 118 women (40.5%) had fTOL and 173 (59.5%) had sTOL. Women in the fTOL had higher rates of 1-min Apgar score <7, neonatal asphyxia and adverse neonatal composite outcome compared with women in the sTOL group (p < .05). After adjusting for potential confounders, compared with sTOL, fTOL was not associated with adverse neonatal composite outcome. Compared with scheduled CD, fTOL was associated with an increased risk for adverse neonatal composite outcome (aOR 2.65, 95% CI 1.13-6.19, p = .03).

CONCLUSION

AMA primiparous women attempting TOL have comparable outcome to those seeking scheduled CD, however, women with fTOL have higher rates of adverse neonatal outcome.

Outcome of pregnancy in women diagnosed with idiopathic polyhydramnios

INTRODUCTION

Polyhydramnios is present in approximately 2% of pregnancies and it has been associated with a variety of adverse pregnancy outcomes.

OBJECTIVES

The aim of our study was to evaluate the association between polyhydramnios and adverse pregnancy outcomes.

METHODS

This was a retrospective case control study of 288 singleton pregnancies delivered in the Rotunda Hospital, Dublin, between 2013 and 2014. Polyhydramnios was defined as: (i) amniotic fluid index (AFI) ≥ 25 cm; (ii) maximal vertical pocket (MVP) of ≥8 cm; and (iii) a gestational age-specific threshold for AFI. Demographic information, obstetric and neonatal outcomes were obtained by review of hospital databases. Exclusion criteria included gestational or pre-existing diabetes, multiple pregnancy, carrying a fetus with structural or chromosomal abnormalities, Rhesus factor isoimmunisation, and TORCH screen positive. Outcomes were compared with outcomes of those without polyhydramnios.

RESULTS

A total of 8798 deliveries occurred during the study period. The frequency of polyhydramnios was 1.6%. One hundred and forty-four women were selected in each group. There was no significant difference in preterm deliveries, low birth weight, low Apgar score at one minute and five minutes and perinatal mortality. However, increase in caesarean delivery rate (43.1% vs 21.5%), number of fetal distresses (17.4% vs 6.9%) and number of neonatal intensive care unit (NICU) admissions (17.4% vs 4.9%) were observed in our study.

CONCLUSION

In conclusion, idiopathic polyhydramnios is associated with specific adverse outcomes, such as higher rate of caesarean delivery, fetal distress and NICU admissions. Therefore, close surveillance of these pregnancies is required, especially near term.

Amount of polyhydramnios attributable to diabetes may be less than previously reported

AIM

To evaluate the frequency and the quantity of polyhydramnios attributable to diabetes in pregnancy.

METHODS

The charts of patients with a four-quadrant amniotic fluid index (AFI) ≥ 20 cm and either a diagnosis of diabetes or a diabetes screening test during the index pregnancy were retrospectively reviewed. AFI was stratified into 5 categories and the frequency of diabetes was evaluated for each group. The frequency of polyhydramnios attributable to diabetes was compared to the frequency of polyhydramnios in the setting of fetal anomalies or no known cause.

RESULTS

One thousand five hundred and forty-five patients were included in the study. Eight point five percent (n = 131) had diabetes and no other cause for polyhydramnios. Eleven point two percent (173) had antenatally diagnosed anomalies. For all categories of AFI except the largest (> 40.9 cm) the most common cause of polyhydramnios was idiopathic. In patients with diabetes the AFI was most likely to be between 26 cm and 35.9 cm.

CONCLUSION

The rate of polyhydramnios in this study is 8.5%. Patients with diabetes most commonly have mild polyhydramnios between 26 and 35.9 cm of fluid on a four-quadrant AFI.

Mode of delivery among women admitted with polyhydramnios

A retrospective matched case control study was conducted to examine the incidence of caesarean delivery (CD) among women admitted with polyhydramnios with and without a trial of labour compared to women with normal amniotic fluid index (AFI). Singleton pregnancies diagnosed with polyhydramnios upon admission to labour between 2003 and 2013 were included. A control group (normal AFI) matched at a ratio of 1:1 was randomly selected. Primary outcome was the incidence of CD. A total of 588 women were included. The overall incidence of CD was significantly higher among women with polyhydramnios (31.3%) compared to the controls (18.7%), (p < .001). The incidences of both non-labouring caesarean and intrapartum operative deliveries were significantly higher among women with polyhydramnios compared to the controls (p = .007 and p = .01, respectively). On a multiple logistic regression model, polyhydramnios was found to be an independent risk factor for delivery by a caesarean (p = .0015; OR 2.0; 95%CI 1.30-2.90).

Can the Myocardial Performance Index Be Used as a New Predictive Factor for a Poor Prognosis in Fetuses With Idiopathic Polyhydramnios?

OBJECTIVES

The purpose of this study was to determine whether there are any changes in cardiac function in fetuses with idiopathic polyhydramnios and also to evaluate the value of the myocardial performance index for prediction of adverse perinatal outcomes.

METHODS

A prospective case-control study was conducted with a total of 134 fetuses between 24 and 40 weeks' gestation. Polyhydramnios was defined as an amniotic fluid index of greater than 24 cm. Seventy-three fetuses of healthy mothers were assigned as the control group whereas 36 fetuses with an amniotic fluid index of 24 to 34 cm constituted the nonsevere polyhydramnios group, and 31 fetuses with an amniotic fluid index of 35 cm or greater constituted the severe polyhydramnios group. Fetal echocardiography was performed to compare cardiac function parameters among groups. To determine which perinatal outcomes were independently associated with an increased myocardial performance index, a multivariate logistic regression analysis was performed.

RESULTS

The myocardial performance index was significantly higher in polyhydramnios groups compared with controls (P < .001). Among fetuses with polyhydramnios, the myocardial performance index was significantly higher in severe polyhydramnios compared with nonsevere polyhydramnios (P = .003). An increased myocardial performance index in polyhydramnios was independently associated with nonreassuring fetal status (odds ratio, 2.12; 95% confidence interval, 1.41-4.53; P = .005), emergency cesarean delivery (odds ratio, 1.54; 95% confidence interval, 1.12-2.37; P= .025), and respiratory distress syndrome (odds ratio, 1.79; 95% confidence interval, 1.21-3.87; P = .012).

CONCLUSIONS

An increased myocardial performance index is an early indicator of adverse perinatal outcomes in pregnancies complicated by idiopathic polyhydramnios.

Effects of Thyroid Peroxidase Antibody on Maternal and Neonatal Outcomes in Pregnant Women in an Iodine-Sufficient Area in China

Purposes. To evaluate the effects of thyroid peroxidase antibodies (TPOAb) on maternal and neonatal adverse outcomes in pregnant women. Methods. 208 pregnant women at 24-28 weeks were divided into two groups, TPOAb-positive and TPOAb-negative groups. Thyroid function and TPOAb were determined in all subjects until 12 months postpartum. Levothyroxine was supplemented to maintain euthyroid with periodical checking of thyroid functions. The prevalence of postpartum thyroiditis (PPT), placenta previa, placental abruption, premature rupture of membrane, postpartum haemorrhage, polyhydramnios, oligohydramnios, preterm birth, low birth weight, congenital hypothyroidism, and neonatal diseases were observed in two groups. Results. Of all women, 11.54% had a PPT. The prevalence of PPT was significantly higher in TPOAb-positive than TPOAb-negative group (42.31% versus 7.14%, P < 0.001), with 45.46% and 53.85% of PPT happening at 6 weeks postpartum in TPOAb-positive and TPOAb-negative groups. The incidence of polyhydramnios was significantly higher in TPOAb-positive than TPOAb-negative group (15.38% versus 2.74%, P = 0.02). Conclusion. Pregnant women with TPOAb-positive had increased risk of PPT, predominantly happening at 6 weeks postpartum. TPOAb was associated with increased incidence of polyhydramnios and the underlying mechanisms required further investigation. Earlier screening of thyroid function during pregnancy and postpartum was warranted in our region.