Physical properties:

 Volume: From 10th to 20th Weeks, it

increases from 25 ml to 400 ml

 It reaches its maximum volume at 36

weeks (about 800 ml) and gradually
diminishes to be 500 ml at term.

 It is completely changed every three

hours.
Chemical composition:
 Water: 98-99%.
 Solids: 1-2%, half-organic and half-inorganic.

 Inorganic constituents are similar to those found in

the maternal plasma as Na & Cl.

 Organic constituents include carbohydrates as glucose

and fructose, proteins, lipids and hormones

 contains fetal cells, which can be examined

for
genetic defects.
A) During Pregnancy

1. Protection of the fetus against external trauma.

2. It keeps the fetal temperature constant.
3. It allows free fetal movements helping the
development of fetal muscles.
4. Prevents adhesive bands between the amnion and
fetal skin.
5. Nutrition as some of the fluid is swallowed by the
fetus.
6. Acts as a medium for fetal excretion.
7. Forms a closed sac around the fetus preventing ascent
of infection, from the cervix or vagina.
B) During Labour:
1. The bag of forewater helps
dilatation of the cervix.

2. It prevents direct compression

of the placenta between the
uterine wall and fetus during
uterine contraction thus
avoiding fetal asphyxia.

3. When the membranes rupture,

the fluid washes the birth canal
from above downwards thus
removing away any infectious
material.
 It is excessive amniotic fluid, more than 2 liters

Since it is impractical to measure AF volume,

the most commonly used definition is by
ultrasound assessment
 Occursin around 1% of pregnancies and is often
suspected clinically and confirmed using
ultrasonography

a uterus that feels large for dates

 Clinically:
or measures more than 10% above the normal
fundal height for gestational age

 Ultrasound: vertical diameter of the largest

pocket of amniotic fluid measure ≥ 8 cm, or
amniotic fluid index (AFI) is ≥25 cm
 vertical diameter of the largest pocket of amniotic fluid measure
8 cm or more, or amniotic fluid index (AFI) is 25 cm or more
1- Mild: Largest vertical
pocket diameter 8 – 11
c.m.
2- Moderate: Largest
vertical pocket
diameter 12 -15 c.m.
3- Severe: Largest
vertical pocket
diameter ≥ 16 c.m.
A- Fetal Causes
1. Congenital anomalies ( 25%)
2. Twins ( 7%)
3. Hydrops fetalis
4. Congenital inections: Toxoplasmaosis, rubella, CMV, herpes
simplex
B- Maternal causes
1. Maternal diabetes (5%)
2. Rhesus isoimmunization
3. Severe generalized edema
C - placental causes
1. Chorio-angioma
2. Large placental surface
C- idiopathic 30%
A- Fetal Causes
1. Congenital anomalies ( 25%)
That interfere with swallowing or associated
with increased production
1- Congenital anomalies ( 25%)
i. Anencephaly due to:
 Loss of cerebrospinal fluid from the exposed meninges.
 Lack of antidiuretic hormone.
 Impairment of swallowing may also play a role
1- Congenital anomalies ( 25%)

ii open spina bifida due to:

 Loss of cerebrospinal fluid from the exposed meninges.
1- Congenital anomalies ( 25%)

iii. Congenital obstruction of the esophagus or

duodenum (interfering with swallowing of amniotic
fluid).
1- Congenital anomalies ( 25%)

iii. Neuromuscular conditions that interfere with

swallowing due to persistent contraction of the
Masseters muscle
A- Fetal Causes

2- Monochorionic twin pregnancy (7%)

 Polyhydramnios affects
the sac of the larger
fetus due to
 Larger blood volume
 cardiac hypertrophy
 increased urine output
Twin to twin transfusion
A- Fetal Cause

3- Hydrops fetalis
These lead to edema of the placenta and
increased transudation.
lung
A- Fetal Causes

4- Congenital infection
4-
lead to hydrops fetalis and placental enlargement
through:

 Myocarditis with pump deficit

 Hemolytic anemia

 Hepatitis-induced hypoproteinemia

 Sepsis with secondary endothelial damage

B- Maternal Causes:

1. generalized edema as heart or renal failure

2. Diabetes mellitus, due to (5%)

 Polyuria of the fetus because of hyperglycemia.

 Increased osmotic pressure of liquor amnii due to

the presence of sugar.

 Associated CFMF.

3- Erythroblastosis fetalis
C- Placental causes
chorioangioma

Normal placenta
Chorioangioma
Acute Polyhydramnios:
 It is very rare, usually occurs in early pregnancy
(< 24Wks) and in uniovular twins and CFMF.

 A large amount of fluid accumulates in a few days;

it leads to abortion or preterm labour.

Chronic Polyhydramnios:
 Commoner than the acute, about 1 in 100 singleton
pregnancies.
 Usually occurs in late pregnancy, the fluid
accumulates slowly.
Main problem is over-distended uterus
Symptoms: arise primarily from pressure exerted within
the overdistended uterus and upon adjacent organs.
Acute type:
1- Pressure symptoms: as dyspnea, palpitation and
edema of lower limbs, vulva and abdominal wall
(interference with venous return), rarely,
oliguria (ureteral obstruction).
2- Abdominal pain.
3- Nausea and vomiting.
Chronic type: as severe type but less severe & less
acute.
Signs:
1. General examination: Pre-eclampsia
may be present.

2. Abdominal examination:
- Inspection :Abdominal distension with
thin stretched skin & excessive striae

- Palpation: Fundal level more than

period of amenorrhea,
- fetal parts difficult to be felt
( chronic type) or can not be felt
( acute type),

- marked ballottement.

- Percussion : Thrill test is positive.

- Auscultation : F.H.S either difficult to

be heard (chronic type) or can not be
heard (acute type).
A-To confirm diagnosis:
Ultrasound can reveal :
1- Excessive amount of liquor by DVP ≥ 8 cm or
AFI ≥ 25 cm.
2- Multiple pregnancy
3- Mal-presentation

B-To detect the cause: Prenatal diagnosis of

congenital fetal malformations, PIH, DM..etc

C- To clarify complications: evaluation of fetal

well-being (serial)
I. Maternal:
A) During Pregnancy
B) During labor
C) During the purperium

II fetal
I. Maternal:
A) During Pregnancy:
1- Abortion (as a result of overdistension of the uterus)
2- Preterm labour.
3- Premature rupture of membranes.
4- Pre-eclampsia (present in about 25% of cases).
5- Placenta previa (due to large placenta).
6- Malpresentation.
7- Nonengagement of the presenting part.
8- Pressure symptoms: as dyspnea, palpitation and edema of
lower limbs.
I. Maternal:
B) During Labour:
1- PROM
2- Prolapse of arm, cord or both.
3- Obstructed labour due to malpresentation.
4- Abruptio placentae due to rapid escape of liquor with
premature separation of the placenta.
5- Uterine dysfunction due to overdistension of the uterus.
6- Retained placenta, due to uterine atony.
7- Postpartum hemorrhage due to uterine atony.
8- Splanchnic shock occurs if the fluid escapes rapidly, so the
pressure exerted by the uterus on the splanchnic vessels drops
suddenly leading to pooling of blood in the splanchnic area
and shock.
I. Maternal:
C) During Purperium:
The uterus may take a longer time to involute
(subinvolution).
II. Fetal:

1. Prematurity and its complications as respiratory

distress syndrome and infection
2. Congenital fetal malformations are frequent.
Causes of an oversized pregnant uterus:
1. Ascites.
2. Macrosomia
3. Twins
4. Ovarian cyst with pregnancy.
5. Fibroid
A) Acute Polyhydramnios:
Pregnancy is terminated by
rupture of membranes
using Drew Smyth catheter
(amniotomy).

The liquor is allowed to escape

slowly to avoid splanchnic shock
and bleeding from premature
separation of placenta.
B) Chronic Polyhydramnios:

1. During pregnancy:

US :
 If there is congenital fetal abnormality
pregnancy is terminated by amniotomy.
 B) Chronic Polyhydramnios:

1. During pregnancy:
US :
 If there is no fetal anomaly:
 Minor degrees rarely require treatment
 Moderate degree can be managed without intervention until
labor ensues or membrane rupture spontaneously
 If dyspnea or abdominal pain is present or if ambulation is
difficult, hospitalization becomes necessary.
 The prostaglandin inhibitor indomethacin 1.5 to 3 mg/kg/D
( before 34 weeks). It can be given orally or rectally as it
decrease fetal urine and lung fluid production, not given for
more than 72 hours as it causes renal abnormalities in the
neonatal period & premature closure of ductus arteriosus.
B) Chronic Polyhydramnios:
 Treatment of the cause if detected as diabetes
mellitus.

Amniocentesis. Indicated if pressure symptoms are

severe and not relieved by treatment.
 Under local anaesthesia, and ultrasound guide, a
plastic catheter is passed and amniotic fluid is
drained slowly at a rate of 500 ml per hour.

 About 1500-2000 ml is removed. Procedure may be

repeated as the fluid recollects again.
 B) Chronic Polyhydramnios:
2. During labour:
CS if there is malpresentation or contracted pelvis.

Amniotomy: When the cervix is half dilated the

membranes are ruptured and the liquor is allowed to
escape slowly by putting 2 fingers in the cervix, to
avoid splanchnic shock, bleeding from premature
separation of the placenta and prolapse of the cord
or arm.
To avoid these complications the hindwaters may be
ruptured by (Drew Smith catheter).

Observation: The patient is kept under observation

for 2 hours after delivery to detect any post partum
hemorrhage.
 Diminished amniotic fluid less than 500 ml.
 a uterus that feels small for dates
 Clinically:
or measures less than 10% below the normal
fundal height for gestational age

 Ultrasound: vertical diameter of the largest

pocket of amniotic fluid measures 2 cm or less,
or amniotic fluid index is 5 cm or less.
 About 0.5% of all pregnancies.

a) Midgestation ( poor prognosis).

b) Third trimester.
A. Fetal Causes:
1. Congenital anomalies of the fetal urinary tract
as

i bilateral renal agenesis

ii renal dysplasia
iii posterior urethral valve in a male fetus.
Bilateral renal agenesis Urethral agenesis

Polycystic kidneys
A. Fetal Causes:
2. Fetal chromosomal abnormalities as trisomies ,
triploidy.
A. Fetal Causes:

3-Intrauterine growth restriction, There is decreased

production of fetal urine.

4. Post-term pregnancy (placental aging and

insufficiency).

5. Premature rupture of membranes

B. Placental causes:
 Abruption
 Twin-twin transfusion ( donor twin)

C. Maternal Causes:
1. Preeclampsia and chronic hypertension.
2. Diabetic vasculopathy: Atherosclerosis of pelvic arteries
which occurs in advanced diabetes (class D and above)
reduces uteroplacental blood flow.

D. Drugs: Prostaglandin inhibitors & angitensin converting

enzyme inhibitor.

C. Idiopathic.
1. Amniotic band syndrome which is characterized by
adhesions between the amnion & the fetus causing
serious deformities including limb amputation.
2. Fetal pulmonary hypoplasia (compression of the
thorax by the uterus preventing lung growth),
usually occurs in early onset oligohydraminos.
3. Musclo-skeletal deformities (e.g. Club foot).
5- During labour, there is slow dilatation of the cervix
due to a small bag of fore-water.

6. Increased incidence of meconium aspiration syndrome

& fetal asphyxia may occur due to cord compression .
1. Amniotic band syndrome which is characterized
by adhesions between the amnion & the fetus
causing serious deformities including limb
amputation.
2. Fetal pulmonary hypoplasia (compression of the
thorax by the uterus preventing lung growth),
usually occurs in early onset oligohydraminos.
3. Musclo-skeletal deformities (e.g. Club foot).
4. Breech presentation is common (Oligohydramnios
interferes with spontaneous cephalic version).
5. During labour, there is slow dilatation of the
cervix due to a small bag of forewaters.
6. Increased incidence of meconium aspiration
syndrome & fetal asphyxia may occur due to cord
compression .
1. The fundal level is lower than the
period of amenorrhea.
2. Breech presentation is common.
3. The fetal parts are easily felt and the
fetus is almost immobile.
4. The FHS are clearly heard.
1- To confirm diagnosis:
Ultrasound can reveal: reduced amount of
liquor by DVP ≤2 cm or AFI ≤5 cm

2- To detect the cause:

* congenital fetal malformation
* Intra-uterine growth restriction

3- To clarify complications:
Evaluation of fetal well-being (serial)
Causes of undersized pregnant uterus:
1- Wrong calculation
2- Small fetus
3- Intra-uterine fetal death
4- Oligohydramnios
5- Malpresentations as transverse lie
A- During pregnancy
1- PPROM → management of PPROM
2- IUGR → management of IUGR
3- Renal anomalies: no intervention is possible and
the management will depend on whether the
condition is expected to be lethal either inutero or
to the neonate, whether survival is anticipated. In
some cases of LUTO, fetal intervention may be
considered (vesico-amniotic shunt)
4- Idiopathic: oral administration of water. Solcoseryl
(amp)
5- Amnio-infusion: the routine use cannot be
justified.
B-During labour
Amnio-infusion:
Amnio-infusion is a reasonable approach in
the treatment of repetitive variable
decelerations.
 A 24-year-old lady presents at 30 weeks with a
fundal height of 50 cm. Which of the following
statements concerning polyhydramnios is true?

a. Acute polyhydramnios usually leads to labor prior to

28 weeks.
b. The incidence of associated malformations is
approximately 3%.
c. Maternal edema, especially of the lower extremities
and vulva, is rare.
d. Esophageal atresia is accompanied by
polyhydramnios in nearly 10% of cases
e. Complications include placental abruption, uterine
dysfunction, and postpartum hemorrhage
 A 24-year-old lady presents at 30 weeks with a
fundal height of 50 cm. Which of the following
statements concerning polyhydramnios is true?

a. Acute polyhydramnios usually leads to labor prior to

28 weeks.
b. The incidence of associated malformations is
approximately 3%.
c. Maternal edema, especially of the lower extremities
and vulva, is rare.
d. Esophageal atresia is accompanied by
polyhydramnios in nearly 10% of cases
e. Complications include placental abruption, uterine
dysfunction, and postpartum hemorrhage
 A 32-year-old G3P2002 presents to the obstetrician’s
office for a routine OB visit at 30 weeks.

 She has had no complications during the pregnancy

and has had regular prenatal care.

 Her gestational age is confirmed with a first-

trimester sonogram.

 During the routine OB visit, the fundal height

measures 35 cm.

All of the following can explain the size-date

discrepancy except
a. The 5-cm difference is within the error for
fundal height measurements.
b. Leiomyomas
c. Polyhydramnios
d. Fetal macrosomia
e. Twin gestation
 The answer is a

a. The 5-cm difference is within the error for

fundal height measurements.
b. Leiomyomas
c. Polyhydramnios
d. Fetal macrosomia
e. Twin gestation
 Oligohydramnios is associated with the following
fetal conditions:

a) Tracheo-oesophageal fistula.
b) Talipes.
c) Intrauterine growth restriction.
d) Anecephaly.
e) Premature rupture of the fetal membranes.
 Oligohydramnios is associated with the following
fetal conditions:

a) Tracheo-oesophageal fistula.
b) Talipes.
c) Intrauterine growth restriction.
d) Anecephaly.
e) Premature rupture of the fetal membranes.
Polyhydramnios is associated with the
following:

a) Maternal diabetes.
b) Neuromuscular fetal conditions.
c) Maternal non-steroidal anti-
inflammatory drugs.
d) Postmaturity.
e) Chorioangioma of the placenta.
Polyhydramnios is associated with the
following:

a) Maternal diabetes.
b) Neuromuscular fetal conditions.
c) Maternal non-steroidal anti-
inflammatory drugs.
d) Postmaturity.
e) Chorioangioma of the placenta.
A 26-year-old woman presents in clinic at 30
weeks’ gestation.
 The community midwife has referred her
because she is ‘large for dates’.
 An ultrasound scan has demonstrated
polyhydramnios.
Discuss the possible causes of polyhydramnios in
this pregnancy.
 Thecauses of polyhydramnios can be divided into
maternal, fetal and placental. The aim of any
investigation of polyhydramnios is to establish a
diagnosis, so that a prognosis can be determined.
(2 marks)
 Initially a full maternal history should be
taken.

 The most common maternal disease

associated with polyhydramnios is poorly
controlled diabetes mellitus.

 Maternal red cell antibodies should be

checked to exclude isoimmunization, as this
is associated with fetal hydrops.
(4 marks)
A detailed ultrasound should be arranged to
check fetal growth, quantify the amniotic fluid
index and examine for fetal abnormality.
(1 mark)
 Fetal abnormalities that can cause
polyhydramnios include the following.
• Neuromuscular conditions that have the effect
of obstructing the swallowing of amniotic fluid
by the fetus.
• Fetal gastrointestinal abnormalities, including
oesophageal and duodenal atresia.
 Fetal hydrops, which should be excluded on
an ultrasound scan, as this is associated with
polyhydramnios secondary to cardiac failure
or anaemia.
 In twin-to-twin transfusion is a rare cause
of acute polyhydramnios in the recipient sac
of monochorionic twins.

A detailed examination of the placenta may

reveal a chorioangioma.
(5 marks)
How to approach?
 Number?
Growth
Restriction? Anomalies?
Hydrops?
• The incidence of associated malformations is about 20%, with
CNS and GI abnormalities being particularly common.
• Edema of the lower extremities, vulva, and abdominal wall
results from compression of major venous systems.
• Acute hydramnios tends to occur early in pregnancy and, as a
rule, leads to labor before the 28th week.
• The most frequent maternal complications are placental
abruption, uterine dysfunction, and postpartum hemorrhage.