Induction of labor in cases of late preterm isolated oligohydramnios: is it justified?

Neonatal Outcomes are Similar between Patients with Resolved and Those with Persistent Oligohydramnios

OBJECTIVE

 Oligohydramnios (defined as amniotic fluid volume < 5 cm or deepest vertical pocket < 2 cm) is regarded as an ominous finding on prenatal ultrasound. Amniotic fluid, however, is not static, and to date, there have been no studies comparing perinatal outcomes in patients who are diagnosed with oligohydramnios that resolves and those who have persistent oligohydramnios.

STUDY DESIGN

 This is a secondary analysis of a National Institutes of Health-funded retrospective cohort study of singleton gestations delivered at a tertiary care hospital between 2002 and 2013 with mild hypertensive disorders and/or fetal growth restriction (FGR). Maternal characteristics, delivery, and neonatal information were abstracted by trained research nurses. Patients with a diagnosis of oligohydramnios were identified, and those with resolved versus persistent oligohydramnios at the time of delivery were compared. The primary outcome was a composite of neonatal resuscitation at delivery: administration of oxygen, bag-mask ventilation, continuous positive airway pressure, intubation, chest compression, or cardiac medication administration. Secondary outcomes included FGR, timing, and mode of delivery.

RESULTS

 Of 527 women meeting study criteria, 42 had oligohydramnios that resolved prior to delivery, whereas 485 had persistent oligohydramnios. There were no significant differences in patient demographics between groups. The gestational age at diagnosis was significantly lower for patients with resolved versus persistent oligohydramnios (median: 33.0 [interquartile range, IQR: 29.1-35.9] vs. 38.0 [IQR: 36.4-39.3], p < 0.001). There was not a substantial difference in rate of neonatal resuscitation (41 vs. 32%, p = 0.31). Patients with resolved oligohydramnios were more likely to have developed FGR than those with persistent oligohydramnios (55 vs. 36%, p < 0.02). There were no significant differences for gestational age at delivery, birth weight, or neonatal intensive care unit admission.

CONCLUSION

 Patients whose oligohydramnios resolved were diagnosed earlier yet had similar rates of neonatal resuscitation but higher rates of FGR than those who had persistent oligohydramnios.

KEY POINTS

· When diagnosed earlier in pregnancy, oligohydramnios was more likely to resolve prenatally.. · Patients who were diagnosed with oligohydramnios earlier in pregnancy had higher rates of FGR.. · There were no differences in the rates of the composite outcome of need for neonatal resuscitation when comparing those with resolved versus those with persistent oligohydramnios. No differences in composite neonatal morbidity were noted between those with resolved versus persistent oligohydramnios..

Delivery Mode among Patients with Oligohydramnios with or without Fetal Growth Restriction by Induction Method

OBJECTIVE

This study aimed to evaluate the association of induction method on delivery mode in pregnancies complicated by oligohydramnios with and without fetal growth restriction (FGR).

STUDY DESIGN

This was a secondary analysis of a National Institutes of Health funded retrospective cohort study of singleton deliveries at a tertiary-care hospital between 2002 and 2013 with diabetes, mild hypertension, and/or FGR. Chart abstraction was performed by trained research nurses. Patients with a diagnosis of fetal oligohydramnios with and without FGR were identified. Our analytic cohort was further stratified into three groups per initial induction agent: prostaglandins (PGEs) alone, PGE plus mechanical ripening, or oxytocin only. Primary outcome was mode of delivery. Secondary outcomes included indications for cesarean delivery and neonatal morbidity.

RESULTS

Out of 4,929 patients in the original database, 546 subjects with fetal oligohydramnios were identified; of these, 270 were induced and included for analysis. Outcomes were compared between 171 patients who had fetuses with isolated oligohydramnios and 99 patients who had fetuses with oligohydramnios and FGR. There were no significant differences in demographic characteristics between the groups. Patients with fetuses with isolated oligohydramnios had similar rates of spontaneous vaginal delivery (SVD) when PGEs were used (n = 44/79, 55.7% PGE alone, n = 44/76, 57.9% PGE with mechanical ripening) and when they were not used (n = 5/13, 38.5% oxytocin alone; p = 0.43). Similarly, the majority of patients in both cohorts underwent SVD regardless of induction method (n = 30/44, 68.2% PGE alone, n = 30/44, 68.2% PGE with mechanical ripening, and n = 6/10, 60% oxytocin alone; p = 0.90). There was no significant difference in composite neonatal morbidity.

CONCLUSION

In patients with fetuses with oligohydramnios with and without FGR, most patients delivered by SVD regardless of induction method. In this population, PGE use was associated with a high chance of SVD in patients with fetuses with suspected placental insufficiency regardless of the presence of absence of FGR.

KEY POINTS

· The majority of fetuses with oligohydramnios with or without FGR deliver vaginally.. · The use of prostaglandins did not increase rates of cesarean for fetal distress in oligohydramnios.. · Prostaglandin use did not increase rate of neonatal intensive care unit admission among pregnancies with oligohydramnios..

Dynamic thiol/disulphide homeostasis and ischemic modified albumin levels in isolated oligohydramnios

OBJECTIVE

Oligohydramnios is defined as amniotic fluid index in ultrasonographic measurement is less than 5 percentile according to gestational age, the amniotic fluid volume is ≤ 5 cm, or if the single deepest dial is < 2 cm. The condition of oligohydramnios that not with fetal structural/chromosomal abnormalities, intrauterine growth retardation, intrauterine infection and maternal disease is described as isolated oligohydramnios (IO). The aim of this study is to examine whether oxidative stress and reactive oxygen species (ROS) have a place in the pathophysiology of IO.

MATERIALS AND METHODS

In this prospective case-control study, a total of 126 participants were included. The patient group consisted of 65 patients who were diagnosed IO, and the control group consisted of 61 healthy normal pregnants. Native thiol (-SH), total thiol (-SH + -SS), dynamic disulfide (-SS), IMA values from maternal serum were measured and compared between groups.

RESULTS

Maternal serum -SH and -SH + -SS values were significantly lower in the IO group than in the control group (409.47 ± 55.36 μmol/L vs. 437.40 ± 48.68 μmol/L, p = 0.03 and 457.40 ± 63.01 μmol/L vs. 484.59 ± 52.75 μmol/L, p = 0.01). In the IO group when -SS/-SH and -SS/-SH + -SS ratio was found to be statistically significantly higher than control group (5.84 ± 1.1 vs 5.41 ± 0.71, p = 0.01 and 5.2 ± 0.88 vs 4.8 ± 0.58, p = 0.01), -SH/-SH + -SS ratio was significantly lower (89.56 ± 1.7 vs 90.24 ± 1.16, p = 0.01). There was no significant difference in terms of -SS value (p = 0.66). IMA value was significantly higher in the IO group than control group (0.76 ± 0.10 ABSU vs 0.68 ± 0.06, p < 0.01). It is seen as a result of ROC analysis that -SH, -SH + -SS, -SS/-SH, -SS/-SH + -SS, -SH/-SH + -SS and IMA values have a diagnostic value for IO (p < 0.05).

CONCLUSION

The thiol/disulfide balance shifted towards oxidative stress in IO compared to control group. So oxidative stress and ROS have a place in the pathophysiology of IO.

Management of isolated oligohydramnios in Korea: a questionnaire-based study of clinical practice patterns among the members of the Korean Society of Maternal Fetal Medicine

Objective

The aim of this survey was to investigate the recommendations and clinical practice patterns of the Korean Society of Maternal and Fetal Medicine (KSMFM) members, regarding management of isolated oligohydramnios (IO).

Methods

From December 2018 to February 2019, questionnaires were e-mailed to the KSMFM members at 257 institutes that are listed by the Korean Statistical Information Services (KOSIS) as suitable labor premises. Responses to the seven questions on the management of IO, from diagnosis to treatment, were evaluated.

Results

A total of 72 KSMFM members responded to this survey. Nearly all participants (90.1%) used the amniotic fluid index (AFI) as the primary method for estimating amniotic fluid volume. The majority of the participants (73.6%) believed that IO was a risk factor for adverse pregnancy outcomes, including abnormal fetal heart rate (73.6%), need for cesarean delivery (58.3%), intrauterine fetal demise (52.8%), and meconium aspiration syndrome (50%). Almost 70% of the participants believed that induction of labor might decrease perinatal morbidities, and that late-preterm to early-term period (36–38 gestational weeks) was a suitable timeframe for delivery, if the fetus was sufficiently grown and antenatal testing revealed reassuring results. Less than half of the participants (47.2%) believed that maternal oral or intravenous hydration was a useful intervention for IO management.

Conclusions

KSMFM members preferred labor induction at late-preterm to early-term, to decrease perinatal morbidity in cases of IO, although it was still uncertain whether labor induction improved the outcomes. Further prospective studies are needed regarding IO management.

[Kidney Cysts and Cystic Nephropathies in Children - A Consensus Guideline by 10 German Medical Societies]

This consensus-based guideline was developed by all relevant German pediatric medical societies. Ultrasound is the standard imaging modality for pre- and postnatal kidney cysts and should also exclude extrarenal manifestations in the abdomen and internal genital organs. MRI has selected indications. Suspicion of a cystic kidney disease should prompt consultation of a pediatric nephrologist. Prenatal management must be tailored to very different degrees of disease severity. After renal oligohydramnios, we recommend delivery in a perinatal center. Neonates should not be denied renal replacement therapy solely because of their age. Children with unilateral multicystic dysplastic kidney do not require routine further imaging or nephrectomy, but long-term nephrology follow-up (as do children with uni- or bilateral kidney hypo-/dysplasia with cysts). ARPKD (autosomal recessive polycystic kidney disease), nephronophthisis, Bardet-Biedl syndrome and HNF1B mutations cause relevant extrarenal disease and genetic testing is advisable. Children with tuberous sclerosis complex, tumor predisposition (e. g. von Hippel Lindau syndrome) or high risk of acquired kidney cysts should have regular ultrasounds. Even asymptomatic children of parents with ADPKD (autosomal dominant PKD) should be monitored for hypertension and proteinuria. Presymptomatic diagnostic ultrasound or genetic examination for ADPKD in minors should only be done after thorough counselling. Simple cysts are very rare in children and ADPKD in a parent should be excluded. Complex renal cysts require further investigation.

Maternal and perinatal outcomes of induction of labor in oligohydramnios at term-a retrospective cohort study

Objective: To evaluate the maternal and perinatal outcomes of labor induction in women at term with oligohydramnios.Methods: A retrospective cohort of women with a singleton pregnancy, who had oligohydramnios at or beyond term (37-42 weeks) and underwent induction of labor for oligohydramnios were studied. Antenatally diagnosed fetal anomalies and intrauterine fetal demise were excluded. The women were categorized into two groups: 1) women with isolated oligohydramnios (n = 166) and 2) women with oligohydramnios associated with other maternal or fetal complications (n = 43). Maternal and perinatal outcomes were collected from the records of all deliveries, data compiled, and appropriate statistical tests were applied.Results: The study included 209 women with mean gestational age of 38.76 ± 1.00 weeks and mean induction-delivery interval of 17.45 ± 8.70 hours (16.98 hours in group 1 versus 19.23 hours in group 2). Most (75%) women delivered vaginally. Only one of the neonates had an Apgar score of less than 7 at 5 min. Average neonatal ICU length of stay was 5.52 days (5.27 days in group 1 versus 6.17 days in group 2). Among all the maternal and neonatal outcomes studied, only the mean birth weights among the two groups was found to be statistically significant (p = 0.0017).Conclusions: Women with isolated oligohydramnios and their neonates were not found to suffer any additional harm due to labor induction at term than women who had oligohydramnios associated with other complications.