I.POLYHYDRAMNIOUS

Definition: Excess amount of A.F that interfers with normal pregnancy,labor,palpation of fetal parts or hearing FHS (±2 liters.)

U/S definition: Amniotic fluid index > 25 cm.

Types:

Acute hydramnious: Sudden accumulation of A.F ,usually in the 2nd trimester, commonly due to uniovular twins.

Chronic hydramnious: Gradual accumulation of A.F, usually after 28 wks, due to the usual aetiology&gradually developing CP.

AETIOLOGY:

			1.Idiopathic
		2.Fetal causes: C.F.M.F : 1)C.N.S anomalies: Spina bifida & anencephaly, microcephaly as: -Exposure of choriod plexus-->CSF added to A.F. -Maldeveloped pituitary-->lack of ADH--> micturition -Exposure of cerebrospinal centre---> micturition 2)G.I.T anomalies:Tracheo-oesophageal fistula ,oesophageal & duodenal atresia as liquor is swallowed by the fetus. 3)C.V.S anomalies leading to non-immune hydrops fetalis. 4)Fetal tumours e.g Sacrococcygeal teratoma 5)Chromosomal abnormalities:as Trisomy 13,18 & Down's syn. 6)Hematological disorders e.g Homozygous alpha thalassemia 7)Intrauterine infections: e.g Rubella, Syphilis , Toxoplasmosis 8)Skeletal malformations: e.g Osteogenesis imperfecta, achondrop.
	3.Placental causes: -Large placental or amniotic surface: e.g multiple preg.(especially uniovular),placental tumour as chorioangioma,large placenta.
4.Maternal causes: 1.D.M as hyperglycemia stimulates excess amnion secretion. 2.Causes of generalized edema[cardiac,renal,hepatic,hypoprot.] 3.Rh isoimmunization and immune hydrops fetalis.

COMPLICATIONS OF HYDRAMNIOUS

	A/MATERNAL
PREGNANCY		LABOR	PUERPERIUM
1-Pressure C/O 2-APN 3-ARF 4-PMD 5-PROM		1-Uterine inertia 2-prolonged lab. 3-ROM 4-Chorioamn. 5-Obst.lab.	1-Puerperal sepsis 2-Subinvolution 3-2ry PPHge
6-PET 7-Accidental hge 8-Plac. previa		6-Postpartum hge 7-Splanchnic shock
9-Malpresentations.

II.Fetal complications:

1.Prematurity.

2.CFMF.

3.IUFD or SB secondary to maternal complication.

CLINICAL PICTURE

HISTORY &SYMPTOMS

C/O of Ae e.g	complication	Acute hydramn.	Chronic hydramnious
-Previous abortion, or CFMF +ve Family history for D.M, twin,	*Headache,blurring of vision. *FAHM	-sudden Abdom. enlargment -F.K not percieved -Abdominal pain	-gradual Abdominal enlargment -F.K:Hardly percieved -Abd. discomfort
CFMF	+Loin pain	.Pressure C/O: DDD

EXAMINATION & SIGNS

General examination *Blood pressure & proteins in urine edema of lower limbs *Weight gain .		Abdominal examination *F.L > amenorrhea *Leopold grips show increased liqour ,fetus not felt or if felt=> malpresent. *FHS may not be heard[A] or heard with difficulty[C]
	-Skin signs: skin is glistening,stretched with dilated veins. -Positive fluid thrill.

INVESTIGATIONS:

I.Investigations to detect a possible aetiology:e.g Blood sugar tests, Alpha fetoprotein for NTD, Amniography to detect fetal GIT anomalies

II.Investigations for polyhydramnious:

1.U/S--> -Conclusive for hydramnious

-May detect a fetal cause

-Hydramnious may be classified to:

Mild if vertical depth of pockets = < 11cm

Moderate ================= 12-15 cm

Severe =================== > 16 cm

2.Assessment of F.W.B. during pregnancy:....................

III.Investigations for a possible complication: e.g Urine analysis for Proteins, C&S for urinary tract infections,Kidney fn. tests.

DD: Causes of F.L > amenorrhea . Ascitis . Acute abdomen.

MANAGMENT

Conservation of pregnancy

Termination of pregnancy

1.Exclude CFMF. 2.Treatment of the cause e.g 3.If no cause is found : Bed rest + Diet +Sedation . 4.Follow up of mother: -Regular evaluation of symptoms -Serial F.L & Abdominal girth assessment -Serial U/S evaluation. 5.Follow up of the fetus: -Regular evaluation of the fetal condition by assessment of F.W.B +DRUGS: *.Moderate symptomatic cases may benefit by indomethacin therapy[Pg synthetase inhibitor ---> fetal UOP] *.Markedly symptomatic cases are reliefed by amniocentesis .Not more than 500cc /tap are removed to avoid preterm delivery.

Indications: -Mature fetus -Fetal distress or CFMF [NC] -Patient in labour -Acute polyhydramnious -Chronic not responding to ttt Method : Vaginal delivery is allowed by correcting fetal presentation then performing AROM with slow drainage of AF, the PP evetually fits into the pelvis.Labor then continues under careful monit.. -C.S is indicated if: Failure of correction of malpres. or AOI Postpartum care: a-Of the mother: -Control of D.M if present -Supression of lactation if IUFD or S.B or CFMF -Contraceptive advice ? b-Of the neonate: Care of Premature/look for CFMF

OLIGOHYDRAMNIOUS

Definition:

Decrease in AF volume interfering with normal preg.or lab.

U/S def.: AFI < 5cm or absence of an AF pocket measuring > 1cm vd.

Aetiology:

1.Undetected PROM - Leakage following amniocentesis.

2.CFMF: -Renal anomalies e.g agenesis(Potter's syndrome),UT dysplasia or obstruction, Congenital polycystic kidney.

-Nonrenal anomalies: Triploidy, Thyroid gland agenesis.

3.Fetal growth retardation

5.Post maturity [not simple postdate]

4.Drugs as indomethacin [used as tocolytic]

5.Idiopathic.

Clinical picture:

C/O:Slow abd. enlargment,+/-F.K.,+/-ROM

O/E:FL<amenorrhea,easy palpation of fetal parts&auscultation of FHS

Complications:

1.During pregnancy:

1.Malpresentation commonly breech with failure of ECV.

2.Amniotic fluid bands.

3.Pressure on the fetus-->talipes equinovarus,stiff joints....

4.Lung hypoplasia [cause or result.How?]

2.During labor:

1.Slow cx dilatation-->prolonged labor...

2.Cord compression&excess retraction-->fetal distress or death.

3.Complications of malpresentation....?

Investigations:

1.To detect a cause(especially PROM)

2.U/S : May show fetal aetiology, IUGR , PLacental insufficiency.

3.Assessment of FWB : [85% of IUGR are associated with oligohyd.]

Managment:

I.During pregnancy:Exclude CFMF./ PROM./ Fetal distress.

II.During labor: careful intrapartum monitoring is important (Why?)

Indications of C.S: 1.Fetal distress or prolonged labor.

III.PREMATURE RUPTURE OF THE MEMBRANES

Definition: Rupture of the membranes before the onset of true labor.

-Preterm PROM = PROM < 37wks.

-Latent period = interval between ROM to onset of labor.

Incidence: +/- 10% PROM. +/- 2% PPROM

Aetiology:

1.Vagina&cx:Incomptent cx,cx. anomalies,cevicitis,vaginitis.how?

2.Membranes: Inherent weakness of the membranes.

3.Liqour : -Increased intraamniotic pressure as in hydramnious.

-Infection [amnionitis]

4.Fetus : Malpresentations,Nonengagment(?),Multiple pregnancy .

5.Maternal : deficiency of vit C,Cu,Zn. Smoking.

6.Iatrogenic : as with version, amniocentesis or during cerclage .

7.Sexual intercouse--> Pg from semen +/- introduction of infection.

Complications:

I.Maternal:

A-During pregnancy: Abortion - PMD - Infection(chorioamnionitis).

B-During labor :-->Dry labor=prolonged->infections->pphge&sepsis.

II.Fetal:

1.Prematurity with all its complications.

2.Congenital & neonatal infections.

3.Oligohydramnious with all its complications.

4.Malpresentation [cause or result]

5.Cord prolapse.

6.Accidental hge especially if ROM in polyhydramnious.

CLINICAL PICTURE

HISTORY AND SYMPTOMS

C/O of Ae e.g	C/Oof complication	Mian presentation
Following coitus ECV, ... Past history of PMD	FAHM = Infection , abd. pain of PMD or infection.	-Vag. discharge: Sudden gush of watery fluid from the vagina followed by reduction of the size of the abdomen & better perception of fetal kicks.

EXAMINATION & SIGNS

General examination FAHM infection if occurs		Abdominal examination *F.L <amenorrhea *Leopold grips fetus easily palpated , Decreased amount of liqour *FHS easily heard
	Local examination (NO T.O.P = NO P/V) Instead Sterile speculum ex is done for: a)Inspection of fluid leaking out from the cervix. b)Swab is taken from the cx. canal for C&S. c)Exclude cord prolapse, inspect cervical changes. d)Samlple of AF taken to test for fetal maturity.[How?]

Characteristics of amniotic fluid:

Watery, clear or turbid, alkaline, (Thus it turns nitrazine paper blue), contains fetal cells, +ve ferning, white residue on evaporation .

INVESTIGATIONS

-For diagnosis of ROM:

1.U/S-----> Diagnosis oligohydramnious + ............

2.Dye test : 1ml of sterile solution of 5% flourescine inected into the amniotic cavity and tested for in the vaginal fluid.

3.Testing leaking fluid for contents of AF e.g fetal fibronectin, alpha feto-protein

For diagnosis of complications:

1.Blood tests for infection: ESR , total &differential WBC count,

C-reactive protein on admission then day after day for follow up.

2.C&S from the cx for fear of infection.

3.Assessment of fetal wellbeing.

TREATMENT

I.Prophylactic ttt:

1.Proper ttt of cervicitis & vaginitis,better before pregnancy starts.

2.Cerclage ttt of cervical incompetence.

3.Bed rest & vaginal instructions for the high risk.

ACTIVE MANAGMENT

Conservation of pregnancy

Termination of pregnancy

1.Hospitalization & bed rest. 2.Instructions: No P/V,No vag. douching + sterile vulval pad. If vag.cerclage--> must be removed 3.Monitoring of the mother for: i.Onset of labor. ii.Temperature chart / 4 hrs. iii.Total & differential WBC count every other day. iv.Signs&symptoms of infection. 4.Monitoring of the fetus for: i.FHS / 12hrs [>160bpm = infection] ii.F.W.B twice weekly. iii.Fetal maturity tests when TOP is decided.

Indications: -Mature fetus [L/S ratio > 2 ] -Fetal distress or CFMF [NC] -Patient in labour -Evidence of chorioamnionitis. -Fetus remote from term with drained liqour( <26wks). Method : *Vaginal delivery has better maternal prognosis than C.S *C.S is indicated if-Living fetus + Ch.amnionitis & remote from delivery TOP is done under cover of AB. Postpartum care of the mother: 1.Hospitalization&Prophylactic AB continued 48hrs PP. 2.Guard against pphge & p.sepsis. Of the fetus: 1.Managment of premature. 2.Swabs are taken from nose , throat, ear for C&S. 3.If ROM>24 Hrs-->may give prophylactic AB.

5. Controversial Medications during conservation of pregnancy:

A.Antibiotics as prophylaxis ?:

with------> May have prophylactic effect till TOP

aginst-----> Masks diagnosis of early infection .

B.B-sympathomimetics ?:

against---> Mask signs of early infection+Inhibits labor which is considered the initial sign of infection+Makes VD difficult.

with--->? short term use to delay labor for 24 hrs till lung maturity is enhanced by Crst

C.Corticosteroids ?:

against----> Flaring of infection

with----> Only short term use + risk of RDS(no ttt)>infection

IV.CHORIOAMNIONITIS

Acute inflammation of the chorion&amnion in late preg.

AETIOLOGY:

1.Routes of infection:

1.Ascending infection from vagina or cx or during P/V ex.

2.Blood born or transplacental e.g Listeria amnionitis.

3.Descending infection via the tubes but this is remotely possible.

2.Organisms:

Vaginal flora, E.Coli, Aerobic&anaerobic strept.,staph,Listeria monocytogenes,bacteroids,closteridia,+/-chlamydia.

3.Predisposing factors:

1.Presence of F.B = tape of cerclage, IUD.

2.Invasive procedures = amniocentesis,amniography,fetoscopy..

3.PROM & deficient cervical plug(as in incomptent cx)

4.General maternal cause e.g D.M.

Complications of chorioamnionitis:

I.Maternal:

1.Bacteremia, septicemia, pyaemia=>Septic shock.=>DIC=>ARF

5.Prolonged labor.

6.Puerperium ; 3 S

II.Fetal:-swallows&excretes infected liqour-

Congenital pneumonia, Entritis, Meningitis, Umb.stump infection...

Diagnosis:

Symptoms: History of a PF followed by FAHM with abdominal pain and lately offensive vaginal discharge.

Signs: Fever, tachycardia, tachypnea.

Tender uterus & uterine contractions+fetaltachycardia.

Offensive vaginal discharge.

+ CP of maternal complication.

Treatment:

1.Prophylactic managment: Avoid PROM.HOW?

2.Active: AB + TOP

Antibiotics: Route / Regimen

TOP: After control of fever.

Method: V.D carries better maternal prognosis, However prolonged labor carries risk of complications to both mother & fetus.

C.S is indicated if delivery is remote.