Poly + Oligohydramnios Flashcards
Diagnosis polyhydrammios? (3)
- Uterine size large for Ga
- sob, uterine irritability/contraction, abdominal discomfort
- ultrasound: MVP (maximal vertical pocket) 8 cm or more; or AFI (amniotic fluid index) 24 cm or more
Name 6 causes polyhydrammios
- foetal anomalies: primary git obstruction (esophageal , duodenal, intestinal atresia ), neuromuscular disorders (anencephaly), secondary obstruction of git
- genetic disorders: trisomy 18 and 21
- high cardiac output states: foetal anaemia, infection, haemorrhage
- maternal diabetes
- multiple gestations: twin - twin transfusion syndrome
- idiopathic
Name 9 complications polyhydrammios
Maternal
- Maternal respiratory compromise
- preterm labour, prom
- postpartum uterine atony
- increased c/ s rate
- abruptio placenta upon Rom
Foetal
- foetal malposition
- macrosomia
- umbilical cord prolapse
- neonatal ICU
Post-diagnostic evaluation for polyhydramnios? (6)
History: detailed medical
Investigations
- Comprehensive foetal sonar: anomalies, hydrops
- suspected congenital anomalies:foetal chromosomal analysis
- screen for gestational diabetes
- if hydrops (oedema): evaluate for foetal anaemia (mca-psv). Fetomaternal haemorrhage, parvovirus B19, haemoglobinopathy
- congenital infection (rubella, CMV, toxoplasmosis, syphilis): associated with iugr, hydrops, hepatosplenomegaly, ventriculomegaly, intracranial + abdominal calcification…
Approach to management of polyhydramnios (3)
- Determine ga: differ less/ more than 32 weeks
- severity: mild to moderate follow up 2 weekly for foetal well-being; severe weekly
- presence of severe + symptoms (preterm labour, maternal discomfort, maternal resp distress): amnioreduction by drainage or pg synthesis inhibitor (nsaids)
Management polyhydramnios 32 weeks or less? (3)
- Severe symptomatic → amnioreduction (drainage) + indomethacin max 2-3 mg / kg /day (NSAID) to maintain AFI
- prophylactic steroids bc increased risk preterm birth
- monitor AFI weekly; discontinue indomethacin by 32 - 34 weeks
Management polyhydramnios > 32 weeks? (2)
- severe symptomatic: amnioreduction
- if > 34 weeks and mature lungs, deliver
Management polyhydramnios at labour? (3)
- Check foetal lie frequently
- IOL: use oxytocin and prostaglandins with caution
- increased PPH due to atony
- mild to moderate: IOL at 39-40 weeks
- severe: 37 weeks unless intolerable maternal symptoms
- best IOL: controlled amniotomy with small gauge needle to perforate membranes
Name 7 maternal risks / complications multiple pregnancy
- Hyperemesis gravidarum
- GDM
- hypertension + complications
- anaemia
- caesarean
- haemorrhage
- pp depression
Higher costs
Name 5 complications monochorionic twins
- Turn to twin transfusion syndrome from a-v anastomosis in monochorionic placenta
- Acardiac foetus ( TRAP sequence)
- TAPS (twin - anaemia - polycythaemia sequence)
- selective iugr
- conjoined twins
- prematurity
- congenital infections higher risk
How differentiate mono and dichorionic pregnancy on ultrasound? (6)
Dichorionic:
- 2 placentas
- lambda ! / twin peak/ delta sign at <24 weeks if single placenta
- may be different sexes
Monochorionic
- always same sex
- single placenta
- t sign at < 24 weeks
How often should growth scan be done in multiple pregnancy, what looking for and why
ANC every 4 weeks to 28 weeks, then every 2 weeks (mcda every 2 weeks from 16 weeks)
Every 3-4 weeks from 28 weeks, do:
- deepest vertical pool (MVP)
- estimated foetal weight
- umbilical artery Doppler
If weight difference increase in percentage at each visit or weight discordance > 20%, refer to fuetal unit
Staging twin to twin transfusion syndrome?
Quintero staging
Stage 1: mcda twin with oligohydramnios (MVP < 2 cm) and polyhydramnios (MVP > 8 cm)
Stage 2: absent (empty) bladder in donor twin
Stage 3: abnormal umbilical artery Doppler flow (absent / reversed )
Stage 4: hydrops
Stage 5: death 1 or both twins
How should DCDA twins be delivered (4)
- Vaginal if leading foetus in vertex position, otherwise c/s
- 38 weeks if uncomplicated
- induce preferably with Foley catheter
- monitor with continuous ctg
How should MCDA twins be delivered (2)
- if spontaneous onset labour <36 weeks, and leading foetus vertex, allow vaginal delivery with continuous ctg
- plan elective c/s preferably to prevent intrapartum acute tttts at 34 weeks - 37.6 weeks
