Etiology and Perinatal Outcome of Polyhydramnios

Abstract

Purpose: To determine causes of polyhydramnios and the respective perinatal outcome.

Materials and Methods: We retrospectively analyzed cases with polyhydramnios at the Medical University Graz, Austria from 2003 – 2011. Inclusion criteria were single deepest pocket ≥ 8 cm, amniotic fluid index ≥ 25 cm, each of the latter parameters > 95th percentile or subjective impression. Etiologies, including TORCH infection, diabetes and congenital malformations, as well as perinatal outcome were evaluated.

Results: Out of 860 singleton pregnancies with polyhydramnios, 2.9 % had positive TORCH serology, 8.5 % had congenital anomalies, 19.8 % had maternal diabetes, and 68.8 % were idiopathic. The most common fetal anomalies were cardiac defects (32.9 %). Elective caesarean sections were more common in the groups with malformations and maternal diabetes. Low birth weight combined with severe polyhydramnios or maternal diabetes was associated with malformations.

Conclusion: Diagnosis of polyhydramnios should prompt glucose-tolerance testing, detailed sonography including fetal echocardiography, and TORCH serology. Especially pregnancies with polyhydramnios and small fetuses as well as those with maternal diabetes should be carefully evaluated for malformations.

Zusammenfassung

Ziel: Ein Polyhydramnion tritt in 1 – 2 % aller Schwangerschaften auf. Ziel der vorliegenden Studie ist die Ermittlung repräsentativer Zahlen über mögliche Ursachen und das perinatale Outcome betroffener Schwangerschaften.

Material und Methoden: In einer retrospektiven Analyse wurden Einlingsschwangerschaften mit einem Polyhydramnion, welche zwischen 2003 und 2011 an der Universitätsklinik für Frauenheilkunde und Geburtshilfe in Graz betreut wurden, evaluiert. Ein Polyhydramnion wurde definiert als „single deepest pocket“ (SDP) ≥ 8 cm, „amniotic fluid index“ (AFI) ≥ 25 cm, das Überschreiten der 95. Perzentile des entsprechenden Gestationsalters einer der beiden Parameter oder der subjektive Eindruck. Zielparameter waren die zugrundeliegende Ätiologie, im speziellen eine Infektion mit Toxoplasmose, anderen Viren, Röteln, Cytomegalovirus oder dem Herpes simplex Virus (TORCH), ein mütterlicher Diabetes oder angeborene fetale Fehlbildungen sowie das perinatale Outcome.

Ergebnisse: Im untersuchten Zeitintervall trat bei 973 Einlingsschwangerschaften ein Polyhydramnion auf. Bei 2,9 % der Patientinnen lag eine positive TORCH-Serologie vor, in 8,5 % konnte prä-, oder postnatal eine strukturelle Anomalie oder eine Aneuploidie festgestellt werden. 19,8 % waren mit einem mütterlichen Diabetes assoziiert und 68,8 % der Fälle waren idiopathisch. Die primäre Sectiorate war höher in den Gruppen mit fetalen Fehlbildungen und mütterlichem Diabetes. Niedriges Geburtsgewicht mit ausgeprägtem Polyhydramnion und mütterlicher Diabetes waren häufiger mit fetalen Fehlbildungen assoziiert.

Schlussfolgerung: Die diagnostische Abklärung bei vorliegendem Polyhydramnion, sollte ein Diabetesscreening, eine detaillierte Ultraschalluntersuchung mit Echokardiografie, sowie eine TORCH-Serologie umfassen. Ist das Polyhydramnion mit einem kleinen Kind oder mütterlichem Diabetes assoziiert sollte ein sorgfältiger Fehlbildungsausschluss erfolgen.

Key words

obstetrics - fetus - ultrasound

• References

• 1 Magann EF, Chauhan SP, Doherty DA et al. A review of idiopathic hydramnios and pregnancy outcomes. Obstet Gynecol Surv 2007; 62: 795-802
• 2 Biggio Jr JR, Wenstrom KD et al. Hydramnios prediction of adverse perinatal outcome. Obstet Gynecol 1999; 94: 773-777
• 3 Barnhard Y, Bar-Hava I, Divon MY. Is polyhydramnios in an ultrasonographically normal fetus an indication for genetic evaluation?. Am J Obstet Gynecol 1995; 173: 1523-1527
• 4 Manning FA, Platt LD, Sipos L. Antepartum fetal evaluation: development of a fetal biophysical profile. Am J Obstet Gynecol 1980; 136: 787-795
• 5 Phelan JP, Smith CV, Broussard P et al. Amniotic fluid volume assessment with the four-quadrant technique at 36–42 weeks' gestation. J Reprod Med 1987; 32: 540-542
• 6 Rutherford SE, Smith CV, Phelan JP et al. Four-quadrant assessment of amniotic fluid volume. Interobserver and intraobserver variation. J Reprod Med 1987; 32: 587-589
• 7 Moore TR. Clinical assessment of amniotic fluid. Clin Obstet Gynecol 1997; 40: 303-313
• 8 Magann EF, Perry Jr KG, Chauhan SP et al. The accuracy of ultrasound evaluation of amniotic fluid volume in singleton pregnancies: the effect of operator experience and ultrasound interpretative technique. J Clin Ultrasound 1997; 25: 249-253
• 9 Brace RA, Wolf EJ. Normal amniotic fluid volume changes throughout pregnancy. Am J Obstet Gynecol 1989; 161: 382-388
• 10 Underwood MA, Gilbert WM, Sherman MP. Amniotic fluid: not just fetal urine anymore. J Perinatol 2005; 25: 341-348
• 11 Chamberlain PF, Manning FA, Morrison I et al. Ultrasound evaluation of amniotic fluid volume. II. The relationship of increased amniotic fluid volume to perinatal outcome. Am J Obstet Gynecol 1984; 150: 250-254
• 12 Moore TR, Cayle JE. The amniotic fluid index in normal human pregnancy. Am J Obstet Gynecol 1990; 162: 1168-1173
• 13 Barry AP. Hydramnios; a survey of 100 cases. Ir J Med Sci 1953; 331: 257-264
• 14 Hara K, Kikuchi A, Miyachi K et al. Clinical features of polyhydramnios associated with fetal anomalies. Congenit Anom (Kyoto) 2006; 46: 177-179
• 15 Magann EF, Doherty DA, Lutgendorf MA et al. Peripartum outcomes of high-risk pregnancies complicated by oligo- and polyhydramnios: a prospective longitudinal study. J Obstet Gynaecol Res 2010; 36: 268-277
• 16 Nobile de Santis MS, Radaelli T, Taricco E et al. Excess of amniotic fluid: pathophysiology, correlated diseases and clinical management. Acta Biomed 2004; 75 (Suppl. 01) 53-55
• 17 Brady K, Polzin WJ, Kopelman JN et al. Risk of chromosomal abnormalities in patients with idiopathic polyhydramnios. Obstet Gynecol 1992; 79: 234-238
• 18 Dashe JS, McIntire DD, Ramus RM et al. Hydramnios: anomaly prevalence and sonographic detection. Obstet Gynecol 2002; 100: 134-139
• 19 Shoham I, Wiznitzer A, Silberstein T et al. Gestational diabetes complicated by hydramnios was not associated with increased risk of perinatal morbidity and mortality. Eur J Obstet Gynecol Reprod Biol 2001; 100: 46-49
• 20 Bartha JL, Martinez-Del-Fresno P, Comino-Delgado R. Early diagnosis of gestational diabetes mellitus and prevention of diabetes-related complications. Eur J Obstet Gynecol Reprod Biol 2003; 109: 41-44
• 21 Keshavarz M, Cheung NW, Babaee GR et al. Gestational diabetes in Iran: incidence, risk factors and pregnancy outcomes. Diabetes Res Clin Pract 2005; 69: 279-286
• 22 Kishore J, Misra R, Paisal A et al. Adverse reproductive outcome induced by Parvovirus B19 and TORCH infections in women with high-risk pregnancy. J Infect Dev Ctries 2011; 5: 868-873
• 23 Touboul C, Boileau P, Picone O et al. Outcome of children born out of pregnancies complicated by unexplained polyhydramnios. BJOG 2007; 114: 489-492
• 24 Boyd PA, Haeusler M, Barisic I et al. Paper 1: The EUROCAT network--organization and processes. Birth Defects Res A Clin Mol Teratol 2011; 91 (Suppl. 01) S2-S15
• 25 Magann EF, Sanderson M, Martin JN et al. The amniotic fluid index, single deepest pocket, and two-diameter pocket in normal human pregnancy. Am J Obstet Gynecol 2000; 182: 1581-1588
• 26 Glantz JC, Abramowicz JS, Sherer DM. Significance of idiopathic midtrimester polyhydramnios. Am J Perinatol 1994; 11: 305-308
• 27 Abele H, Starz S, Hoopmann M et al. Idiopathic Polyhydramnios and Postnatal Abnormalities. Fetal Diagn Ther 2012; 32: 251-255
• 28 Panting-Kemp A, Nguyen T, Chang E et al. Idiopathic polyhydramnios and perinatal outcome. Am J Obstet Gynecol 1999; 181: 1079-1082
• 29 Weiss PA, Scholz HS, Haas J et al. Effect of fetal hyperinsulinism on oral glucose tolerance test results in patients with gestational diabetes mellitus. Am J Obstet Gynecol 2001; 184: 470-475
• 30 Damato N, Filly RA, Goldstein RB et al. Frequency of fetal anomalies in sonographically detected polyhydramnios. J Ultrasound Med 1993; 12: 11-15
• 31 Zahn CM, Hankins GD, Yeomans ER. Karyotypic abnormalities and hydramnios. Role of amniocentesis. J Reprod Med 1993; 38: 599-602
• 32 Lazebnik N, Many A. The severity of polyhydramnios, estimated fetal weight and preterm delivery are independent risk factors for the presence of congenital malformations. Gynecol Obstet Invest 1999; 48: 28-32
• 33 Phelan JP, Ahn MO, Smith CV et al. Amniotic fluid index measurements during pregnancy. J Reprod Med 1987; 32: 601-604
• 34 Pri-Paz S, Khalek N, Fuchs KM et al. Maximal amniotic fluid index as a prognostic factor in pregnancies complicated by polyhydramnios. Ultrasound Obstet Gynecol 2012; 39: 648-653
• 35 Raupach K, Zimmermann R. False diagnosis in prenatal sonography – analysis of causes and formulation of conclusions for the quality management of prenatal sonographic diagnostics. Ultraschall in Med 2004; 25: 438-443
• 36 Meyberg-Solomayer G, Schlaegel F, Lindinger A et al. Pränatale Diagnose eines großen kardialen Rhabdomyoms der linksventrikulären Hinterwand mit Mediastinalverschiebung und assoziiertem Hydrops fetalis bei tuberöser Sklerose. Ultraschall in Med 2012; 33: A725
• 37 Spitz L. Oesophageal atresia. Orphanet J Rare Dis 2007; 2: 24
• 38 Loane M, Dolk H, Kelly A et al. Paper 4: EUROCAT statistical monitoring: identification and investigation of ten year trends of congenital anomalies in Europe. Birth Defects Res A Clin Mol Teratol 2011; 91 (Suppl. 01) S31-S43
• 39 Carlson DE, Platt LD, Medearis AL et al. Quantifiable polyhydramnios: diagnosis and management. Obstet Gynecol 1990; 75: 989-993
• 40 Abdel-Fattah SA, Bhat A, Illanes S et al. TORCH test for fetal medicine indications: only CMV is necessary in the United Kingdom. Prenat Diagn 2005; 25: 1028-1031
• 41 Fayyaz H, Rafi J. TORCH screening in polyhydramnios: an observational study. J Matern Fetal Neonatal Med 2012; 25: 1069-1072
• 42 Polilli E, Parruti G, D'Arcangelo F et al. Preliminary evaluation of the safety and efficacy of standard intravenous immunoglobulins in pregnant women with primary cytomegalovirus infection. Clin Vaccine Immunol 2012; 19: 1991-1993
• 43 Buxmann H, Stackelberg OM, Schlosser RL et al. Use of cytomegalovirus hyperimmunoglobulin for prevention of congenital cytomegalovirus disease: a retrospective analysis. J Perinat Med 2012; 40: 439-446
• 44 De Jong EP, Lindenburg IT, van Klink JM et al. Intrauterine transfusion for parvovirus B19 infection: long-term neurodevelopmental outcome. Am J Obstet Gynecol 2012; 206: 204.e1-204.e5
• 45 Magann EF, Chauhan SP, Doherty DA et al. The evidence for abandoning the amniotic fluid index in favor of the single deepest pocket. Am J Perinatol 2007; 24: 549-555
• 46 Magann EF, Doherty DA, Chauhan SP et al. How well do the amniotic fluid index and single deepest pocket indices (below the 3rd and 5th and above the 95th and 97th percentiles) predict oligohydramnios and hydramnios?. Am J Obstet Gynecol 2004; 190: 164-169