Outcome of pregnancy in women diagnosed with idiopathic polyhydramnios

Prenatal diagnosis of chromosomal aberrations by chromosomal microarray analysis and pregnancy outcomes of fetuses with polyhydramnios

OBJECTIVES

To explore the prenatal clinical utility of chromosome microarray analysis (CMA) for polyhydramnios and evaluate the short and long-term prognosis of fetuses with polyhydramnios.

METHODS

A total of 600 singleton pregnancies with persistent polyhydramnios from 2014 to 2020 were retrospectively enrolled in this study. All cases received amniocentesis and were subjected to CMA results. All cases were categorized into two groups: isolated polyhydramnios and non-isolated polyhydramnios [with soft marker(s) or with sonographic structural anomalies]. All fetuses were followed up from 6 months to five years after amniocentesis to acquire short and long-term prognosis.

RESULTS

The detection rates of either aneuploidy or pathogenic copy number variants in fetuses with non-isolated polyhydramnios were significantly higher than those with isolated polyhydramnios (5.0 vs. 1.5%, p = 0.0243; 3.6 vs. 0.8%, p = 0.0288). The detection rate of total chromosomal abnormalities in the structural abnormality group was significantly higher than that in the isolated group (10.0 vs. 2.3%, p = 0.0003). In the CMA-negative cases, the incidence of termination of pregnancy, neonatal and childhood death, and non-neurodevelopmental disorders in fetuses combined with structural anomalies was significantly higher than that in fetuses with isolated polyhydramnios (p < 0.05). We did not observe any difference in the prognosis between the isolated group and the combined group of ultrasound soft markers. In addition, the risk of postnatal neurodevelopmental disorders was also consistent among the three groups (1.6 vs. 1.3 vs. 1.8%).

CONCLUSION

For low-risk pregnancies, invasive prenatal diagnosis of isolated polyhydramnios might be unnecessary. CMA should be considered for fetuses with structural anomalies. In CMA-negative cases, the prognosis of fetuses with isolated polyhydramnios was good, and polyhydramnios itself did not increase the risk of postnatal neurological development disorders. The worse prognosis mainly depends on the combination of polyhydramnios with structural abnormalities.

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.

Induction of labor versus expectant management in patients with idiopathic polyhydramnios

OBJECTIVE

To evaluate whether induction of labor is associated with lower risk of cesarean section compared to expectant management in patients with isolated polyhydramnios.

STUDY DESIGN

This is a single-center, retrospective cohort study of patients with pregnancies complicated by idiopathic polyhydramnios, documented between 34 and 38 weeks gestation, who were delivered between July 2012 and February 2020. The primary outcome was cesarean delivery. Secondary outcomes included chorioamnionitis, endometritis, postpartum hemorrhage, preeclampsia/gestational hypertension, and composite neonatal morbidity.

RESULTS

There were 194 patients included with idiopathic polyhydramnios - 115 underwent induction and 79 patients were expectantly managed. Planned induction was associated with a lower rate of CD compared with expectant management but did not meet statistical significance (19.1 % vs 30.4 %, aOR 0.51, 95 % CI 0.24, 1.05). A similar effect was seen when stratifying for parity: both nulliparous (9.1 % vs 16.3 %, aOR 0.59, 95 % CI 0.17, 1.98) and multiparous (32.7 % vs 47.2 %, aOR 0.45, 95 % CI 0.18, 1.15) patients had a lower CD rate when there was a planned induction, though neither group met statistical significance. No differences in maternal or fetal secondary outcomes were identified (chorioamnionitis, endometritis, postpartum hemorrhage, preeclampsia/gestational hypertension, composite neonatal morbidity).

CONCLUSION

Lower rates of cesarean section were associated with labor induction for patients with isolated polyhydramnios, but confidence intervals did not reach statistical significance.

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 Neonatal Morbidity at Term

OBJECTIVE

Idiopathic polyhydramnios is among the most common etiologies of polyhydramnios. However, conflicting evidence exists regarding the relationship between polyhydramnios and neonatal morbidity. We investigated the association between pregnancies with and without idiopathic polyhydramnios and neonatal morbidity at term.

STUDY DESIGN

This is a retrospective cohort study of singleton, term (i.e., ≥370/7 weeks) pregnancies from 2014 to 2018. Pregnancies complicated by fetal anomalies, pregestational diabetes, and multifetal gestation were excluded. Pregnancies complicated by idiopathic polyhydramnios were defined by the deepest vertical pocket (DVP) ≥8 cm or amniotic fluid index (AFI) ≥24 cm after 20 weeks' gestation and were compared with women without polyhydramnios at time of delivery. These groups were matched 1:2 by gestational age within 7 days at delivery and maternal race. The primary outcome was a composite neonatal morbidity (neonatal death, respiratory morbidity, hypoxic-ischemic encephalopathy, therapeutic hypothermia, seizures, and umbilical artery pH < 7.10). Outcomes were compared between pregnancies with and without idiopathic polyhydramnios. Unadjusted and adjusted risk ratios were estimated using multivariable logistic regression.

RESULTS

Idiopathic polyhydramnios was diagnosed in 192 pregnancies and were matched to 384 pregnancies without polyhydramnios. After adjustment for obesity, women with pregnancies complicated by idiopathic polyhydramnios had an increased risk of composite neonatal morbidity 21.4 versus 5.5% (adjusted risk ratio [aRR] = 4.0, 95% confidence interval [CI]: 2.3-6.7). Term neonatal respiratory morbidity was the primary driver 20.3 versus 4.2%, (aRR = 4.8, 95% CI: 2.7-8.7) and included higher use of continuous positive airway pressure 19.8 versus 3.4%, p <0.01 and the need for supplemental oxygen at >12 hours of newborn life 6.8 versus 1.8%, p <0.01.

CONCLUSION

Idiopathic polyhydramnios is associated with term neonatal respiratory morbidity at delivery and during the subsequent hours of newborn life, compared with pregnancies without idiopathic polyhydramnios. Further studies are needed to minimize neonatal morbidity at term.

KEY POINTS

· Idiopathic polyhydramnios is associated with increased risk of neonatal morbidity at term.. · Increasing idiopathic polyhydramnios severity was associated with a trend toward worsening morbidity at term.. · Idiopathic polyhydramnios at term requires respiratory support at delivery and during neonatal care..

Discrimination of blood metabolomics profiles in neonates with idiopathic polyhydramnios

This study aimed to compare the blood metabolic status of neonates with idiopathic polyhydramnios (IPH) and those with normal amniotic fluid, and to explore the relationship between IPH and fetal health. Blood metabolites of 32 patients with IPH and 32 normal controls admitted to the Sixth Affiliated Hospital of Sun Yat-sen University between January 2017 and December 2022 were analyzed using liquid chromatography-mass spectrometry (LC-MS/MS). Orthogonal partial least squares discriminant analysis (OPLS-DA) and metabolite enrichment analyses were performed to identify the differential metabolites and metabolic pathways. There was a significant difference in the blood metabolism between newborns with IPH and those with normal amniotic fluid. Six discriminant metabolites were identified: glutamate, serine, asparagine, aspartic acid, homocysteine, and phenylalanine. Differential metabolites were mainly enriched in two pathways: aminoacyl-tRNA biosynthesis, and alanine, aspartate, and glutamate metabolism.

CONCLUSIONS

This study is the first to investigate metabolomic profiles in newborns with IPH and examine the correlation between IPH and fetal health. Differential metabolites and pathways may affect amino acid synthesis and the nervous system. Continuous attention to the development of the nervous system in children with IPH is necessary.

WHAT IS KNOWN

• There is an increased risk of adverse pregnancy outcomes with IPH, such as perinatal death, neonatal asphyxia, neonatal intensive care admission, cesarean section rates, and postpartum hemorrhage. • Children with a history of IPH have a higher proportion of defects than the general population, particularly central nervous system problems, neuromuscular disorders, and other malformations.

WHAT IS NEW

• In neonates with IPH, six differential metabolites were identified with significant differences and good AUC values using LC-MS/MS analysis: glutamic acid, serine, asparagine, aspartic acid, homocysteine, and phenylalanine, which were mainly enriched in two metabolic pathways: aminoacyl-tRNA biosynthesis and alanine, aspartate, and glutamate metabolism. • These differential metabolites and pathways may affect amino acid synthesis and development of the nervous system in neonates with IPH.

Amniotic Fluid Disorders: From Prenatal Management to Neonatal Outcomes

Amniotic fluid volume assessment has become standard in the surveillance of fetal well-being, especially in high-risk pregnancies. Amniotic fluid disorders are a frequent and important topic in fetal and perinatal medicine. However, although important advances have been achieved, many important and challenging questions remain unanswered to date. An abnormally low amniotic fluid volume, referred to as oligohydramnios, has been traditionally considered a possible indicator of placental insufficiency or fetal compromise and is associated with an increased rate of obstetric interventions. An excess of amniotic fluid, referred to as polyhydramnios, may be secondary to fetal or maternal conditions and has been associated with a variety of adverse pregnancy outcomes, especially when it is severe. The ultrasonographic detection of an amniotic fluid disorder should prompt a proper workup to identify the underlying etiology. Data on the association of isolated oligohydramnios or idiopathic polyhydramnios with adverse obstetric and perinatal outcomes are conflicting. While the management of secondary oligohydramnios is usually guided by the underlying condition, the management of isolated oligohydramnios is poorly defined. Similarly, the management of idiopathic and secondary polyhydramnios is not yet standardized. There is an urgent need for randomized clinical trials to provide stronger recommendations on the management of these two common conditions.

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.

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 Idiopathic Polyhydramnios: Maternal and Perinatal Outcomes: Maternal and Perinatal Outcomes

OBJECTIVES

To compare maternal and perinatal outcomes in pregnancies with transient and persistent idiopathic polyhydramnios to those with normal amniotic fluid volume.

METHODS

This retrospective cohort study included subjects delivering a singleton pregnancy between January 1, 2015, and June 30, 2020, with sonography ≥26 weeks' gestation demonstrating transient or persistent idiopathic polyhydramnios (amniotic fluid index [AFI] ≥24.0 cm) or normal AFI (referent group). The primary maternal outcome was a composite of spontaneous preterm delivery <37 weeks, cesarean delivery for malpresentation, abnormal labor progress, or nonreassuring fetal status, operative vaginal delivery, hemorrhage requiring transfusion, and umbilical cord prolapse. The primary perinatal outcome was a composite of birthweight >4500 g, fetal or neonatal death, 5-minute Apgar score <7, and neonatal intensive care unit admission for >24 hours.

RESULTS

Patients with transient polyhydramnios (n = 259) exhibited maternal outcomes similar to those of the referent group (n = 435) but had significantly increased odds for the primary perinatal outcome (odds ratio [OR] 1.70, 95% confidence interval [CI] 1.15-2.53; P = .008) and for birthweight ≥4500 g (OR 8.70, 95% CI 1.89-40.0; P = .005). Persistent polyhydramnios (n = 176) was significantly associated with both the primary maternal (OR 1.93, 95% CI 1.27-2.95, P = .002) and primary perinatal outcome (OR 2.15, 95% CI 1.40-3.30; P < .001), and individually with cesarean delivery for abnormal labor (OR 3.22, 95% CI 1.55-6.68; P = .002) and birthweight ≥4500 g (OR 8.97, 95% CI 1.84-43.6; P = .007).

CONCLUSIONS

Transient idiopathic polyhydramnios does not impact maternal outcomes but is associated with increased odds of newborn birthweight >4500 g. Persistent polyhydramnios is associated with both adverse maternal and perinatal outcomes.

Moderate-to-Severe Polyhydramnios: Cutoffs for Deepest Vertical Pocket Corresponding to Amniotic Fluid Index

OBJECTIVE

Society for Maternal-fetal medicine Consult Series (#46) states "antenatal fetal surveillance is not required for mild idiopathic" polyhydramnios defined as amniotic fluid index (AFI) of 24 cm or a deepest vertical pocket (DVP) between 8 and 11 cm. The objective of this study was to determine the cutoff for DVP which correlates with AFI ≥ 30 cm.

METHODS

This retrospective study of singleton third trimester ultrasounds included a study group randomly divided into test and validation. In the test group, DVP cutoffs correlating with AFI ≥ 30 cm which was used to define moderate-severe polyhydramnios were calculated in two ways, rounded to the nearest whole number: 1) a receiver operating curve and Youden's J statistic (DVP-Youden) and 2) calculation of the DVP percentile that corresponded with AFI of 30 cm (DVP-Percentile). Using the validation group, diagnostic characteristics were DVP-Youden and DVP-Percentile for diagnosis of AFI ≥ 30 cm and were compared against SMFM cutoffs (DVP-SMFM).

RESULTS

Seventy one thousand eight hundred and ninety three ultrasound exams in the 3rd trimester had assessment of AFI and DVP. Moderate-severe polyhydramnios occurred in 286 (1.2%) in test group and 571 (1.2%) in validation group. AFI of 30 cm corresponded to the 98.9th percentile, which in turn correlated to a DVP of 10 cm (DVP-Percentile). The calculated cutoff for moderate-severe polyhydramnios was 8 cm for DVP-Youden.

CONCLUSION

Using 8.0 cm rather than 12.0 cm increased the detection of moderate-severe polyhydramnios to 100% with a false positive rate under 5%. For those utilizing DVP for amniotic fluid evaluation, identification of a DVP ≥ 8.0 cm should prompt further evaluation with complete AFI.

Obstetric and Neonatal Outcomes in Mild Idiopathic Polyhydramnios

Background: Idiopathic polyhydramnios is a controversial clinical condition, as data on perinatal outcomes are conflicting and vary depending on the severity of the condition. The aim of the present study was to compare obstetric and neonatal outcomes between pregnant women with mild idiopathic polyhydramnios and a control population. Methods: A retrospective cohort study was performed at a single university hospital comparing the obstetrics and neonatal outcomes of pregnancies with mild idiopathic polyhydramnios (n = 109) and control pregnancies (n = 2550). Results: Cesarean section (CS) was significantly increased in the group with polyhydramnios compared to controls (46% vs. 32%, respectively, p = 0.047) due to a higher rate of emergency CS in the polyhydramnios group (p = 0.041) because of abnormal cardiotocography (7.3% vs. 2.9%; p = 0.018) or labor dystocia (8.2% vs. 2.9%; p = 0.006). No statistically significant difference was found in the Apgar score, in the rate of neonatal hypoxia, or in the incidence of macrosomia between groups. In four cases, additional diagnoses of anomalies were made after birth, with a rate of 3.2%, which is comparable to the general population. Conclusion: Besides an increased risk of CS, patients with mild idiopathic polyhydramnios should be reassured regarding maternal and feto-neonatal outcomes. The management of pregnancies with stable mild idiopathic polyhydramnios should not differ from uncomplicated pregnancies, except for the need for increased labor surveillance.

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.

Falling insulin requirement in late pregnancy: association with obstetric and neonatal outcomes

OBJECTIVE

To investigate whether diminishing insulin requirement in the third trimester is associated with placental dysfunction.

STUDY DESIGN

Two-year retrospective cohort study at one tertiary care center of women with pregestational or gestational diabetes, their insulin requirements, and complications associated with placental dysfunction.

RESULTS

Of 157 women, 21 (13%) experienced declining insulin requirement, with average decline of 28% at 34 weeks. They were more likely to have pregestational diabetes (71.4% vs. 42.6%; p < 0.01) and delivered earlier (median 36w4d vs. 37w4d; p < 0.01). There was no difference in placental dysfunction related complications (33% vs. 24%; p = 0.37). There was an increased rate of polyhydramnios (42.9% vs. 8.8%; p < 0.01). NICU admission (62% vs. 33%; p < 0.01) and neonatal respiratory distress (52% vs. 24%; p < 0.01) was higher in cases of declining insulin requirement independent of gestational age.

CONCLUSIONS

A decline in insulin requirement should raise concern for increased risk of NICU admission and neonatal respiratory distress.

Prediction of adverse neonatal outcome among newborns born through meconium-stained amniotic fluid

OBJECTIVE

To study maternal and intrapartum factors associated with adverse neonatal outcome in deliveries complicated by meconium-stained amniotic fluid (MSAF).

METHODS

A retrospective cohort study of all women with singleton gestations undergoing trial of labor with MSAF during 2011-2020. Deliveries with adverse neonatal outcome were compared with deliveries without.

RESULTS

Overall, 11 329 were included; 376 (3.3%) neonates were diagnosed with adverse neonatal outcomes. Multivariable regression analysis underlined the following factors as independently associated with composite adverse neonatal outcome: pregestational diabetes (odds ratio [OR] 3.21, 95% confidence interval [CI] 1.09-9.43, P = 0.031), polyhydramnios (OR 2.14, 95% CI 1.33-3.44, P = 0.002), fever (OR 2.52, 95% CI 1.67-3.80, P < 0.001), and amnioinfusion (OR 1.73, 95% CI 1.24-2.2438, P = 0.003). When 0, 1, 2, and 3 of the independent risk factors identified were present, the rates of adverse neonatal outcome were 2.9%, 5.5%, 10.0%, and 100%, respectively.

CONCLUSION

The current study's results suggest that special attention should be payed to deliveries complicated by MSAF and with any of the following factors-polyhydramnios, intrapartum fever, amnioinfusion, and pregestational diabetes.

Performance of diagnostic ultrasound to identify causes of hydramnios

INTRODUCTION

We aimed to assess the diagnostic yield of ultrasonography in the identification of the etiology of hydramnios, and the added value of MRI or amniocentesis.

METHODS

We conducted a single-center retrospective study including pregnancies with confirmed hydramnios (defined as deepest pocket ≥8 cm) between January 2013 and May 2017. Twin pregnancies, secondary hydramnios discovered after the diagnosis of a causal pathology, and pregnancies of unknown outcome were excluded. All pregnancies underwent a targeted scan, and selected cases underwent MRI or amniocentesis.

RESULTS

A total of 158 patients with confirmed hydramnios were included. Hydramnios was associated with a fetal pathology in 37 cases (23.4%), with diabetes in 39 (24.6%), isolated macrosomia in 16 (10.1%), and considered idiopathic in 66 (41.7%). Ultrasonography established a diagnosis of the underlying pathology in 73% of cases. Amniocentesis was done in 31 cases (20%) and it allowed diagnosis of chromosome anomalies, esophageal atresia, myotonic dystrophy congenital type, Prader-Willi syndrome, and Bartter syndrome. MRI was done in 15 cases (10%) and it allowed one additional diagnosis of esophageal atresia. The diagnostic yields of MRI and amniocentesis were 91.7% and 95.2%, respectively. There were five false positive diagnoses at ultrasonography, and one false positive diagnosis at MRI.

CONCLUSION

Hydramnios can be associated with a wide variety of underlying pathologies. Diagnostic ultrasound can attain a diagnosis in the majority of cases. Amniocentesis offers a valuable complementary assessment.

Associations of History of Displacement, Food Insecurity, and Stress With Maternal-Fetal Health in a Conflict Zone: A Case Study

Background: In populations with a history of conflict, early identification of pregnant women who are at risk of adverse pregnancy outcomes is challenging, especially if sonography is not available. We evaluated the performance of symphysis-fundal height (SFH) for identification of high-risk pregnancies and investigated if food security and diet quality, clinical biomarkers, and stress were associated with SFH and two known indicators of maternal-fetal well-being, sonography-estimated fetal weight and amniotic fluid index (AFI).

Methods: For this cross-sectional study, 61 women with high-risk pregnancies were recruited after referral to the obstetrics and gynecology unit at San José Hospital in Popayán, Colombia. Multiple stepwise linear and ordered logistic regressions were used to identify associations of SFH, sonography-estimated fetal weight and AFI classification with history of displacement, food insecurity, post-traumatic stress symptoms as well as biopsychosocial risk evaluated through the Colombian risk scale.

Results: History of displacement was associated with lower SFH Z-scores, but higher hemoglobin, taking iron supplements and a higher diastolic blood pressure were associated with higher SFH Z-scores. SFH was also associated with AFI but not with sonography-estimated fetal weight. Stress indicators were associated with a higher AFI. In contrast family support, an element of the Colombian biopsychosocial risk assessment, was associated with a higher sonography-estimated fetal weight, whereas more hours of sleep/day were associated with lower sonography-estimated fetal weight.

Conclusion: SFH was not only associated with biological factors known to affect maternal/fetal health but also with history of displacement, thus validating its use in conflict areas for pregnancy assessment. Associations of biopsychosocial stressors with maternal-fetal outcomes highlight the need for a systematic assessment of stress in pregnant women from conflict zones.

The Efficacy and Efficiency of Uterocervical Angle Measurements to Predict Preterm Labor in Idiopathic Polyhydramnios Patients: A Prospective Cohort Study

INTRODUCTION

Uterocervical angle measurements in pregnant women with idiopathic polyhydramnios were appraised for their predictive value for spontaneous preterm labor.

MATERIAL AND METHODS

In this prospective study, we included nulliparous and multiparous pregnant women diagnosed with idiopathic polyhydramnios at 24-28 weeks at our polyclinic; the uterocervical angle and cervical length were measured by transvaginal ultrasound at the time of diagnosis. Routine pregnancy follow-up was done by our team and gestational age at delivery and maternal-fetal outcomes were noted.

RESULTS

In total, 24 patients delivered before 37 weeks and 36 patients delivered at 37 weeks or later. Preterm labor subjects had larger UCA values (126.7±12.9° vs. 100.8±16.2°) and term labor patients had larger cervical length values (34.3±4.5 mm vs. 40.6±5.2 mm). In women with idiopathic polyhydramnios, the area under the curve for the uterocervical angle was 0.885 (p<0.001) and it was 0.823 for the cervical length (p<0.001).

DISCUSSION

The uterocervical angle, a sagittal transvaginal cervical image measurement, is a practical method that successfully predicts spontaneous preterm labor risk in singleton pregnancies with idiopathic polyhydramnios. In addition, the uterocervical angle displayed greater sensitivity, but lower specificity, compared with cervical length measures.

Determination of reference values for third trimester amniotic fluid index: a retrospective analysis of a large cohort of pregnancies with comparison to previous nomograms

Purpose: To establish a new set of reference values for third-trimester amniotic fluid index (AFI) and compare them to other previously published normograms.Methods: A retrospective cross-sectional cohort analysis of all singleton sonographic evaluations >22 gestational weeks in one university affiliated medical center between 2013 and 2017. Pregnancies complicated by rupture of membranes, major anomalies/chromosomal abnormalities were excluded. One evaluation per patient per pregnancy was randomly selected. Reference values were constructed using a best-fit regression model for estimation of mean and standard deviation at each gestational age after normalization of variables and compared with previously published norms.Results: A total of 7037 ultrasound evaluations entered the analysis. Correlation between AFI and gestational age was best represented by a first-degree polynomial equation. AFI decreased gradually from 16.4 at 22 weeks to 13.3 at 40 weeks (cm, median). The standard deviation increased with gestational age with AFI ranging from 12.9-20.2 at 22 weeks and 4.7-26.2 at 40 weeks (cm, 2.5-97.5 percentile). Compared to other curves, our reference values demonstrated a higher median AFI throughout all gestation.Conclusions: Reference values for the third trimester AFI were established. Curves should be correlated with perinatal outcome prior to wide clinical implementation.

Comparative proteome analysis of amniotic fluids and placentas from patients with idiopathic polyhydramnios

INTRODUCTION

Idiopathic polyhydramnios (IPH) is an abnormal increase in amniotic fluid volume (AFV). This condition has unknown etiologies and is associated with various adverse pregnancy outcomes including maternal and fetal complication. This study aims to establish a comparative proteome profile for the human amniotic fluid (AF) of IPH and normal pregnancies and identify the responsible mediators and pathways that regulate AFV.

METHODS

We first employed coupled isobaric tags for relative and absolute quantitation (iTRAQ) proteomics and bioinformatics analysis to examine the differentially expression proteins (DEPs) in the AF of IPH and normal pregnancies. Second, CUL5, HIP1, FSTL3, and LAMP2 proteins were selected for verification in amnion, chorion, and placental tissues by Western blot analysis.

RESULTS

We identified 357 DEPs with 282 upregulated and 75 downregulated. Bioinformatics analysis revealed that cell, cellular process, and binding were the most enriched Gene Ontology terms. Amoebiasis, hematopoietic cell lineage, and NF-kappa B signaling pathway were the top significant pathways. In the verification procedure, FSTL3 protein had a highly significant expression in the amnion, chorion, and placentas of IPH and normal AFV groups (p < 0.05).

DISCUSSION

Our results provide new insights into idiopathic polyhydramnios and offer fundamental points for future studies on AFV.

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.

Transport-associated pathway responses in ovine fetal membranes to changes in amniotic fluid dynamics

Current evidence suggests that amniotic fluid volume (AFV) is actively regulated by vesicular transport of amniotic fluid outward across the amnion and into the underlying fetal vasculature in the placenta. Our objective was to determine whether gene expression profiles of potential stimulators, inhibitors, and mediators of vesicular transport are altered in response to changes in intramembranous absorption (IMA) rate. Samples of ovine amnion and chorion were obtained from fetal sheep with normal, experimentally reduced or increased AFVs and IMA rates. Amnion and chorion levels of target mRNAs were determined by RT‐qPCR. In the amnion, caveolin‐1 and flotillin‐1 mRNA levels were unchanged during alterations in IMA rate. However, levels of both were significantly higher in amnion than in chorion. Tubulin‐α mRNA levels in the amnion but not in chorion were reduced when IMA rate decreased, and amnion levels correlated positively with IMA rate (P < 0.05). Dynamin‐2 mRNA levels were not altered by experimental conditions. Vascular endothelial growth factor (VEGF₁₆₄ and VEGF₁₆₄b) mRNA levels increased during both increases and decreases in IMA rate, whereas soluble Flt‐1 levels did not change. Neither HIF‐1α nor PBEF mRNA levels in the amnion were correlated with VEGF₁₆₄ expression levels and were not related to IMA rate. Collectively, our findings suggest that changes in amnion microtubule expression may be important in the regulation of transcellular vesicular transport of amniotic fluid and thus modulate IMA rate. Further, our results are consistent with the concept that the amnion is the rate‐limiting layer for amniotic fluid transport.