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Polyhydramnios: Chronic versus acute
Polyhydramnios: JOHN
T.
QUEENAN,
ENRIQUE New
York,
C. New
GADOW,
Chronic versus acute M.D. M.D.
York
In a review of 86,301 consecutive deliveries at The New York Hospital-Cornell Medical Center during a 20 year period (1948 to 1967), there were 358 cases of polyhydramnios for an incidence of 0.41 per cent. Associated maternal and fetal conditions were evaluated and compared to the clinical course and outcome of each pregnancy. Among the 358 cases of polyhydramnios, 122 (34 per cent) were associated with no cause (idiopathic), 88 (24.6 per cent) with diabetes, 71 (19.8 per cent) with congenital malformations, 41 (11.5 per cent) with erythroblastosis fetalis, 30 (8.4 per cent) with multiple gestations, and 6 (1.7 per cent) were classified as acute polyhydramnios. The value of prenatal diagnosis of congenital malformations for proper management and early neonatal thera@y is discussed. Chronic and acute polyhydramnios are established as 2 distinctly different entities. Diagnosis and management for each condition are outlined. Two cases of acute polyhydramnios treated by multiple amniocenteses are presented.
POLYHYDRAMNIOS, an excess ofamniotic fluid, has been recognized as a complication of pregnancy since ancient times. Most authorities consider a volume beyond 2,000 ml. as pathologic. L 4l 5 Several conditions affecting the patient and the fetus are associated with this complication. In the past, polyhydramnios has been considered a separate obstetric entity. This study analyzes polyhydramnios in order to determine to what extent it is an associated feature of maternal and fetal complications. Material
and
Center during this 20 year period, there were 358 cases of polyhydramnios for an incidence of 0.41 per cent (Table I). Among the 358 cases of polyhydramnios, 122 (34 per cent) had no apparent underlying maternal or fetal conditions (idiopathic), 88 (24.6 per cent) were associated with diabetes, 71 (19.8 per cent) with congenital malformations, 41 ( 11.5 per cent) with erythroblastosis fetalis, and 30 (8.4 per cent) with multiple gestation. Only 6 patients (1.7 per cent) fulfilled the strict criteria for acute polyhydramnios. The patients were further divided into groups according to 5 year periods (Table I ) . Approximately the same number of deliveries were performed in the years 1948 to 1952 and in each of the 3 succeeding periods. During the first decade (1948 to 1957), there were 130 cases of polyhydramnios or approximately half as many as during the second decade ( 1958 to 1967). The doubling of idiopathic and congenital malformation cases from the first to the second decades was rcnsistent with the increase in the over-all incidence of The cases associated with polyhydramnios. diabetes, however, remained relativ(:ly constant despite the increase in the over.“all inci-
methods
Between 1948 and 1967, there were 86,301 consecutive deliveries at The New York Hospital-Cornell Medical Center. Each case of polyhydramnios was reviewed to determine the cause, method of diagnosis, clinical management, and outcome. Results Of the The New
86,301 consecutive York Hospital-Cornell
deliveries at Medical
From the Department of Obstetrics and Gynecology, The New York Hos#italCornell Medical Center. 349
350
Queenan and Gadow
Amer.
Table I. Incidence
of polyhydramnios 1948 to 1967
Center,
at The
New
York
Hospital-Cornell
October J. Obstct.
1, l!?iO Gynrc.
Medical
Polyhydramnios
Deliueries 1948 to 20,031
Idiopathic
Diabetes
-
Congenital m&formations
Erythroblast& fetalis
Ttoi?lS
Acute
Total
1952,
20
16
19
2
6
1
64
1953 to 1957, 20,541
19
29
7
3
7
1
66
1958 to 1962, 23,994
41
20
23
13
13
2
112
1963 to 21,735
42
23
22
23
4
2
116
‘;*4.6%)
‘:19.8%)
‘i*l.S%!
1967,
Totals 86,301
122 (34.O%j
Table II. Perinatal
deaths associated
Polyhydramnios
L and
Chronic Idiopathic Diabetes Class A Classes B, C, and D Twins Erythroblastosis fetalis Congenital malformations Acute Idiopathic Congenital Twins L
and
W
with
W
106 23 52 33 11 9
30 (8.4%
6 1
(1.7%)
358 (0.41%)
polyhydramnios
NND
IUD
IPD
Total
Perinatal deaths (%I
8
8
0
122
13.1
2 7 15 7 33
0 4
0 0 0 1 15
25 63 60 41 71
8.0 17.5 45.0 73.2 87.3
:: 14
2 malformations =
livins
and
1 3 well;
NND
=
neonatal
deaths;
dence. A marked increase in the number of cases associated with erythroblastosis fetalis was attributable to the establishment of an immunology clinic. The incidence of acute polyhydramnios showed no statistically significant change. Perinatal deaths associated with polyhydramnios are presented in Table II. Of the 352 patients with chronic polyhydramnios, 122 were idiopathic. There were 8 neonatal deaths and 8 intrauterine deaths. The perinatal mortality rate was 13.1 per cent. The
IUD
=
intrauterine
9 deaths;
IPD
= iatrapartum
100 deaths.
high neonatal death rate was due to prematurity. Polyhydramnios associated with diabetes deserves special attention. Class A diabetes associated with pregnancy must be differentiated from Classes B, C, and D diabetes.’ Among the 25 patients with Class A diabetes, 23 delivered infants who were living and well, and 2 had neonatal deaths. There were no intrauterine deaths. The perinatal mortality rate was 8 per cent. Among the 32 patients with Class B diabetes, there were 4 neonatal
Volume Number
Polyhydramnios
108 3
__-_-_-_--_------_-_--------
___-_-
----------(Class
351
A]
3750
- ---------------
----------------------
Ildiopathicl
~---------------------------~l
1250
----
-----
1
Acute
1
0 20
24
28 Weeks
Fig. 1. Interval
32
40
gestation
between diagnosis and deIivery according
deaths and 2 intrauterine deaths. Among the 29 patients with Class C diabetes, there were 3 neonatal deaths and one intrauterine death. Of the 2 patients with Class D diabetes, one delivered an infant who was living and well and there was one intrauterine death. The combined perinatal mortality rate for patients with Classes B, C, and D diabetes was double (17.5 per cent) that for Class A. Thirty patients had polyhydramnios associated with multiple gestations. There were 15 neonatal deaths and 12 intrauterine deaths. The perinatal mortality rate was 45 per cent. Forty-one patients had polyhydramnios associated with erythroblastosis fetalis. There were 7 neonatal deaths, 22 intrauterine deaths, and one intrapartum death. The perinatal mortality rate was 73.2 per cent. Seventy-one patients had polyhydramnios associated with congenital malformations. There were 33 neonatal deaths, 14 intrauterine deaths, and 15 intrapartum deaths.
36
to causes of polyhydramnios.
The perinatal mortality rate was 87.3 per cent. Among the 6 patients with acute polyhydramnios, there were 2 neonatal deaths and one congenitally malformed fetus who died in utero. The 3 sets of twins died in utero. The rate of amniotic fluid formation for the different conditions associated with polyhydramnios can be estimated by the intervals from diagnosis until delivery. This is represented in Fig. 1. The average birth weight for the various causes of polyhydramnios is recorded on the vertical axis. The average week of diagnosis is presented on the horizontal axis. The diagnosis of polyhydmmnios was made clinically in almost every instance. In some patients, however, it was first noted by roentgenogram and, in a very smalI number, at the time of the rupture of membranes. The striking difference in intervals between diagnosing congenital malformations and acute polyhydramnios could be interpreted as
352
Queenan
Table III.
and Gadow
Polyhydramnios
Amer.
: Chronic
versus
acute Polyhydramnios
Week of diagnosis
Chronic 28 - 38
Acute 20 - 24
Height fundus by 24 weeks’ gestation (cm.1
20 - 26
29 - 32
Weight gain per 4 weeks interval at diagnosis (pounds)
2-8
10-12
Week of delivery
32-40
24-27
Outcome
Varies according to cause
Perinatal death
Mild to severe
Severe
Maternal
symptoms
a more rapid formation of fluid in the latter. The average week of diagnosis of acute polyhydramnios was 23.4 and the average week of delivery was 26. The average birth weight was 514 grams. This clearly demonstrates why the classification of acute polyhydramnios as a separate entity is justified. The premature deliveries of the patients with Classes B, C, and D diabetes (35.2 weeks) and erythroblastosis fetalis (33.4 weeks) were mainly the result of artificial termination of pregnancy. The infants delivered of mothers with Class A diabetes were above average in birth weights. The infants with congenital malformations generally had Iower birth weights than normal. Some infants with erythroblastosis fetalis had increased birth weights due to hydrops fetalis. The multiple-gestation infants had lower birth weights as expected. In considering the average birth weight of infants born to patients with acute polyhydramnios, the statistics are small. All the birth weights are extremely low because the patients go into premature labor during the second trimester. Nonetheless, the birth weights of these infants are generally normal for the weeks of gestation. The chronic and acute forms of polyhydramnios are compared in Table III. In dif-
October J. Ohstet.
1, 19X Gynrc.
ferentiating between these 2 forms, careful attention was paid to the clinical features. Acute polyhydramnios. Six cases were singled out as acute polyhydramnios. The diagnosis is made extremely early. It is a rampant fulminating process terminating in spontaneous labor, usually before the end of the second trimester.G On the basis of week of onset, rate of uterine growth, and week of delivery, acute polyhydramnios can easily be differentiated from the chronic form, regardless of cause. In each instance, the fetus or neonate died. Since this study ( 1948 to 1967)) 2 cases of acute polyhydramnios were managed by multiple amniocenteses. Case 1. A 23-year-old Caucasian woman, para 0, gravida 1, with type 0, Rh-positive blood, was seen at 8 weeks’ gestation with a uterus compatible with the duration of amenorrhea. At 20 weeks, the fundal height measured 33 cm. She complained of severe lower abdominal pain and shortness of breath. Fetal parts were not palpable and fetal heart was not audible. Acute polyhydramnios was diagnosed. A medical work-up ruled out diabetes, erythroblastosis fetalis, and other systemic diseases. An amniogram, performed by injecting 30 ml. of Hypaque-M, 75 per cent, ruled out any skeletal or soft tissue congenital malformations. Eleven amniocenteses were performed over the following 3 weeks, removing a total of 7,820 ml. of amniotic fluid (Fig. 2). The volume of amniotic fluid by the para-aminohippuric acid-dilution technique3 was determined on 3 occasions. Serum proteins decreased from 7.2 to 5.3 Gm. per 100 ml., requiring the administration of 25 Gm. of albumin intravenously. At 24% weeks’ gestation, the cervix was 6 cm. dilated with 80 per cent effacement. Amniotthe pregnancy. omy was done to terminate Labor was complicated by premature separation of the placenta. A dead baby weighing 800 grams was delivered. Postmortem examination revealed organs to be grossly and microscopically normal. Microscopic sections of the placenta were normal; it weighed 320 grams (expected weight 240 grams).
Case 2. A 25-year-old Caucasian 2, gravida 3, with 2 living children Rh-positive blood, was seen at 16 tion with a uterus compatible with of amenorrhea.
woman, para with type 0, weeks’ gestathe duration
Polyhydramnios
353
AFV CC
I
3000270024002100I600 15001200900 6003000
A Amniography
il
22
A
Weeks AFV:
23
215
24
gestation anormal
0 meosured
i
removed
Fig. 2. Volume of amniotic fluid removed according to weeks’ gestation.
At 20 weeks, the fundal height measured 27 cm., and 2 days later she complained of severe lower abdominal and back pain and respiratory distress. The fundal height was 32 cm. Amniography ruled out fetal malformations. An intrauterine contraceptive device was also visualized, and the fetus was observed lying in the left side of the uterine cavity. Eight hundred and thirtyfive milliliters of amniotic fluid was removed by amniocentesis. Repeat amniography showed twins with no evidence of skeletal or soft tissue malformation. Only the right fetal sac demonstrated polyhydramnios. Over the next 14 days, 9 amniocenteses were performed, removing 5,275 ml. of amniotic fluid. Serial amniotic fluid volumes are presented in Fig. 3. The serum proteins decreased from 5.3 to 4.9 Gm. per 100 ml., and she received 25 Gm. of albumin intravenously. Amniotic fluid proteins ranged between 1.6 and 2.0 Gm. per cent. Electrophoresis showed that albumin accounted for 72.2 per cent, alpha-l globulin 11.1 per cent, alpha-2 globulin 5.6 per cent, and beta globulin 11 .I per cent. No gamma globulin was demonstrated. The patient went into spontaneous labor at
35 weeks’ gestation with a fundal height of 35 cm. Amniotomy was performed, and 7,500 ml. of amniotic fluid were carefully released. Twin girls were delivered. The monochorionic biamniotic placenta weighed 910 grams. Baby A weighed 2,380 grams and was slightly depressed and pale at birth. Her hematocrit was 42.7 per cent and blood group was A, Rh-negative, with a negative Coombs test. Jaundice ap peared at one day of age, and the highest bilirubin was 16.7 mg. per 100 ml. (indirect). Baby B weighed 2,100 grams. Her Apgar score was 8. She was plethoric. Her hematocrit was 63 per cent. She became jaundiced at 21 hours of age and required 3 exchange transfusions because of hyperbilirubinemia. Both infants were sent home in good condition, with the diagnosis of fetofetal transfusion syndrome--Twin A. donor, and Twin B, recipient. Comment When the clinician makes the diagnosis of polyhydramnios, he must rule out diabetes, erythroblastosis fetalis, and multiple gestation. Time of diagnosis and rate of fluid accumulation are helpful in establishing the cause
354
Queenan
and Gadow
October J. Obstet.
Amer.
AFV
cc
4230
,
7000
1, 1970 Cynec.
cc
cm 34 33 32 3000 i
31 2700 30 2400 29 2100 28
1800
27
1500
26
1200
25
900 600
A
21
A Amniography Fig. 3. VoIune gestation.
of amniotic
$2
A
24 gestotion
Weeks
AFV: fluid
ffl norm01 removed
0 measured and
and prognosis. When no associated condition is present, congenital malformations must be suspected since they are present in over one third of the remaining patients. Roentgenography is useful in detecting skeletal defects. Amniography should be performed for the detection of soft tissue maIformations and gastrointestinal anomalies. The prognosis of infants with congenital malformations is poor. The high incidence of intrapartum deaths (21 per cent) could be attributable in some instances to destructive procedures; however, some infants had corrective anomalies. This emphasizes the importance of prenatal diagnosis of congenita1 malformations. The prognosis for patients with Class A diabetes is favorable, whereas that for Classes B, C, and D diabetes is guarded. In patients with diabetes, however, the over-all prognosis is better when the pregnancy is not complicated by polyhydramnios.
fundal
25
26
I removed
height measurement
t3
Fundal
height
according
to
weeks’
The poor fetal outcome in erythroblastosis fetalis with polyhyramnios (only one out of 3 infants survive) can be attributed to 2 factors. First, polyhydramnios is often associated with the development of hydrops fetalis. Second, the dilution effect of polyhydramnios may mask the severity of the bilirubin peak in amniotic fluid analysis. Aggressive management of chronic polyhydramnios by amniocentesis is indicated only for extreme maternal symptoms. It is apparent from this study that the management of polyhydramnios must be directed toward treatment of the underlying cause. Acute poIyhydramnios is a compIetely different clinical situation. The cause must be determined immediately. If the condition is due to congenital anomalies not amenable to surgical correction, the pregnancy should be terminated. If the polyhydramnios is idiopathic or due to multiple gestation, depend-
Volume 108 Number 3
ing on the clinical situation, attempts should be made to prolong the pregnancy by multiple amniocenteses. The procedure is safe, and even though many amniocenteses are performed, it is helpful in maintaining the pregnancy to viability. Increase in uterine
REFERENCES
1. 2. 3. 4.
Barry, A. P.: Obstet. Gynec. 11: 667, 1958. Caldeyro-Barcia, R., Pose, S. V., and Alvarez, H.: AMER. J. OBSTET. GYNEC. 73: 1238, 1957. Charles, D., and Jacoby, H. E.: AMER. J. OBSTET. GYNEC. 95: 266, 1966. Eastman, N. J., and Hellman, L. M.: Williams Obstetrics, ed. 13, New York, 1966, AppletonCentury-Crofts, Inc., Chap. 23, p. 603.
Polyhydramnios
contractility after fluid, as has been not significant in internal recording be done in future servation further.
5. 6. 7.
355
the removal of amniotic previously reported,: was these cases. Esternai and of uterine contractilitv will cases to elucidate this oh-
Moya, F., Apgar, V., James, L. S., and Berrien, C.: J. A.M. A. 173: 1552, 1960. Queenan, J, T.: AMER. J. OBSTET. C~YNEC. 104: 397, 1969. White, P.: Pregnancy Complicating Diabetes in the Treatment of Diabetes Mellitus, ed. 10, Philadelphia, 1958, Lea & Febiger, Publishers, p. 690.
T.
QUEENAN,
ENRIQUE New
York,
C. New
GADOW,
Chronic versus acute M.D. M.D.
York
In a review of 86,301 consecutive deliveries at The New York Hospital-Cornell Medical Center during a 20 year period (1948 to 1967), there were 358 cases of polyhydramnios for an incidence of 0.41 per cent. Associated maternal and fetal conditions were evaluated and compared to the clinical course and outcome of each pregnancy. Among the 358 cases of polyhydramnios, 122 (34 per cent) were associated with no cause (idiopathic), 88 (24.6 per cent) with diabetes, 71 (19.8 per cent) with congenital malformations, 41 (11.5 per cent) with erythroblastosis fetalis, 30 (8.4 per cent) with multiple gestations, and 6 (1.7 per cent) were classified as acute polyhydramnios. The value of prenatal diagnosis of congenital malformations for proper management and early neonatal thera@y is discussed. Chronic and acute polyhydramnios are established as 2 distinctly different entities. Diagnosis and management for each condition are outlined. Two cases of acute polyhydramnios treated by multiple amniocenteses are presented.
POLYHYDRAMNIOS, an excess ofamniotic fluid, has been recognized as a complication of pregnancy since ancient times. Most authorities consider a volume beyond 2,000 ml. as pathologic. L 4l 5 Several conditions affecting the patient and the fetus are associated with this complication. In the past, polyhydramnios has been considered a separate obstetric entity. This study analyzes polyhydramnios in order to determine to what extent it is an associated feature of maternal and fetal complications. Material
and
Center during this 20 year period, there were 358 cases of polyhydramnios for an incidence of 0.41 per cent (Table I). Among the 358 cases of polyhydramnios, 122 (34 per cent) had no apparent underlying maternal or fetal conditions (idiopathic), 88 (24.6 per cent) were associated with diabetes, 71 (19.8 per cent) with congenital malformations, 41 ( 11.5 per cent) with erythroblastosis fetalis, and 30 (8.4 per cent) with multiple gestation. Only 6 patients (1.7 per cent) fulfilled the strict criteria for acute polyhydramnios. The patients were further divided into groups according to 5 year periods (Table I ) . Approximately the same number of deliveries were performed in the years 1948 to 1952 and in each of the 3 succeeding periods. During the first decade (1948 to 1957), there were 130 cases of polyhydramnios or approximately half as many as during the second decade ( 1958 to 1967). The doubling of idiopathic and congenital malformation cases from the first to the second decades was rcnsistent with the increase in the over-all incidence of The cases associated with polyhydramnios. diabetes, however, remained relativ(:ly constant despite the increase in the over.“all inci-
methods
Between 1948 and 1967, there were 86,301 consecutive deliveries at The New York Hospital-Cornell Medical Center. Each case of polyhydramnios was reviewed to determine the cause, method of diagnosis, clinical management, and outcome. Results Of the The New
86,301 consecutive York Hospital-Cornell
deliveries at Medical
From the Department of Obstetrics and Gynecology, The New York Hos#italCornell Medical Center. 349
350
Queenan and Gadow
Amer.
Table I. Incidence
of polyhydramnios 1948 to 1967
Center,
at The
New
York
Hospital-Cornell
October J. Obstct.
1, l!?iO Gynrc.
Medical
Polyhydramnios
Deliueries 1948 to 20,031
Idiopathic
Diabetes
-
Congenital m&formations
Erythroblast& fetalis
Ttoi?lS
Acute
Total
1952,
20
16
19
2
6
1
64
1953 to 1957, 20,541
19
29
7
3
7
1
66
1958 to 1962, 23,994
41
20
23
13
13
2
112
1963 to 21,735
42
23
22
23
4
2
116
‘;*4.6%)
‘:19.8%)
‘i*l.S%!
1967,
Totals 86,301
122 (34.O%j
Table II. Perinatal
deaths associated
Polyhydramnios
L and
Chronic Idiopathic Diabetes Class A Classes B, C, and D Twins Erythroblastosis fetalis Congenital malformations Acute Idiopathic Congenital Twins L
and
W
with
W
106 23 52 33 11 9
30 (8.4%
6 1
(1.7%)
358 (0.41%)
polyhydramnios
NND
IUD
IPD
Total
Perinatal deaths (%I
8
8
0
122
13.1
2 7 15 7 33
0 4
0 0 0 1 15
25 63 60 41 71
8.0 17.5 45.0 73.2 87.3
:: 14
2 malformations =
livins
and
1 3 well;
NND
=
neonatal
deaths;
dence. A marked increase in the number of cases associated with erythroblastosis fetalis was attributable to the establishment of an immunology clinic. The incidence of acute polyhydramnios showed no statistically significant change. Perinatal deaths associated with polyhydramnios are presented in Table II. Of the 352 patients with chronic polyhydramnios, 122 were idiopathic. There were 8 neonatal deaths and 8 intrauterine deaths. The perinatal mortality rate was 13.1 per cent. The
IUD
=
intrauterine
9 deaths;
IPD
= iatrapartum
100 deaths.
high neonatal death rate was due to prematurity. Polyhydramnios associated with diabetes deserves special attention. Class A diabetes associated with pregnancy must be differentiated from Classes B, C, and D diabetes.’ Among the 25 patients with Class A diabetes, 23 delivered infants who were living and well, and 2 had neonatal deaths. There were no intrauterine deaths. The perinatal mortality rate was 8 per cent. Among the 32 patients with Class B diabetes, there were 4 neonatal
Volume Number
Polyhydramnios
108 3
__-_-_-_--_------_-_--------
___-_-
----------(Class
351
A]
3750
- ---------------
----------------------
Ildiopathicl
~---------------------------~l
1250
----
-----
1
Acute
1
0 20
24
28 Weeks
Fig. 1. Interval
32
40
gestation
between diagnosis and deIivery according
deaths and 2 intrauterine deaths. Among the 29 patients with Class C diabetes, there were 3 neonatal deaths and one intrauterine death. Of the 2 patients with Class D diabetes, one delivered an infant who was living and well and there was one intrauterine death. The combined perinatal mortality rate for patients with Classes B, C, and D diabetes was double (17.5 per cent) that for Class A. Thirty patients had polyhydramnios associated with multiple gestations. There were 15 neonatal deaths and 12 intrauterine deaths. The perinatal mortality rate was 45 per cent. Forty-one patients had polyhydramnios associated with erythroblastosis fetalis. There were 7 neonatal deaths, 22 intrauterine deaths, and one intrapartum death. The perinatal mortality rate was 73.2 per cent. Seventy-one patients had polyhydramnios associated with congenital malformations. There were 33 neonatal deaths, 14 intrauterine deaths, and 15 intrapartum deaths.
36
to causes of polyhydramnios.
The perinatal mortality rate was 87.3 per cent. Among the 6 patients with acute polyhydramnios, there were 2 neonatal deaths and one congenitally malformed fetus who died in utero. The 3 sets of twins died in utero. The rate of amniotic fluid formation for the different conditions associated with polyhydramnios can be estimated by the intervals from diagnosis until delivery. This is represented in Fig. 1. The average birth weight for the various causes of polyhydramnios is recorded on the vertical axis. The average week of diagnosis is presented on the horizontal axis. The diagnosis of polyhydmmnios was made clinically in almost every instance. In some patients, however, it was first noted by roentgenogram and, in a very smalI number, at the time of the rupture of membranes. The striking difference in intervals between diagnosing congenital malformations and acute polyhydramnios could be interpreted as
352
Queenan
Table III.
and Gadow
Polyhydramnios
Amer.
: Chronic
versus
acute Polyhydramnios
Week of diagnosis
Chronic 28 - 38
Acute 20 - 24
Height fundus by 24 weeks’ gestation (cm.1
20 - 26
29 - 32
Weight gain per 4 weeks interval at diagnosis (pounds)
2-8
10-12
Week of delivery
32-40
24-27
Outcome
Varies according to cause
Perinatal death
Mild to severe
Severe
Maternal
symptoms
a more rapid formation of fluid in the latter. The average week of diagnosis of acute polyhydramnios was 23.4 and the average week of delivery was 26. The average birth weight was 514 grams. This clearly demonstrates why the classification of acute polyhydramnios as a separate entity is justified. The premature deliveries of the patients with Classes B, C, and D diabetes (35.2 weeks) and erythroblastosis fetalis (33.4 weeks) were mainly the result of artificial termination of pregnancy. The infants delivered of mothers with Class A diabetes were above average in birth weights. The infants with congenital malformations generally had Iower birth weights than normal. Some infants with erythroblastosis fetalis had increased birth weights due to hydrops fetalis. The multiple-gestation infants had lower birth weights as expected. In considering the average birth weight of infants born to patients with acute polyhydramnios, the statistics are small. All the birth weights are extremely low because the patients go into premature labor during the second trimester. Nonetheless, the birth weights of these infants are generally normal for the weeks of gestation. The chronic and acute forms of polyhydramnios are compared in Table III. In dif-
October J. Ohstet.
1, 19X Gynrc.
ferentiating between these 2 forms, careful attention was paid to the clinical features. Acute polyhydramnios. Six cases were singled out as acute polyhydramnios. The diagnosis is made extremely early. It is a rampant fulminating process terminating in spontaneous labor, usually before the end of the second trimester.G On the basis of week of onset, rate of uterine growth, and week of delivery, acute polyhydramnios can easily be differentiated from the chronic form, regardless of cause. In each instance, the fetus or neonate died. Since this study ( 1948 to 1967)) 2 cases of acute polyhydramnios were managed by multiple amniocenteses. Case 1. A 23-year-old Caucasian woman, para 0, gravida 1, with type 0, Rh-positive blood, was seen at 8 weeks’ gestation with a uterus compatible with the duration of amenorrhea. At 20 weeks, the fundal height measured 33 cm. She complained of severe lower abdominal pain and shortness of breath. Fetal parts were not palpable and fetal heart was not audible. Acute polyhydramnios was diagnosed. A medical work-up ruled out diabetes, erythroblastosis fetalis, and other systemic diseases. An amniogram, performed by injecting 30 ml. of Hypaque-M, 75 per cent, ruled out any skeletal or soft tissue congenital malformations. Eleven amniocenteses were performed over the following 3 weeks, removing a total of 7,820 ml. of amniotic fluid (Fig. 2). The volume of amniotic fluid by the para-aminohippuric acid-dilution technique3 was determined on 3 occasions. Serum proteins decreased from 7.2 to 5.3 Gm. per 100 ml., requiring the administration of 25 Gm. of albumin intravenously. At 24% weeks’ gestation, the cervix was 6 cm. dilated with 80 per cent effacement. Amniotthe pregnancy. omy was done to terminate Labor was complicated by premature separation of the placenta. A dead baby weighing 800 grams was delivered. Postmortem examination revealed organs to be grossly and microscopically normal. Microscopic sections of the placenta were normal; it weighed 320 grams (expected weight 240 grams).
Case 2. A 25-year-old Caucasian 2, gravida 3, with 2 living children Rh-positive blood, was seen at 16 tion with a uterus compatible with of amenorrhea.
woman, para with type 0, weeks’ gestathe duration
Polyhydramnios
353
AFV CC
I
3000270024002100I600 15001200900 6003000
A Amniography
il
22
A
Weeks AFV:
23
215
24
gestation anormal
0 meosured
i
removed
Fig. 2. Volume of amniotic fluid removed according to weeks’ gestation.
At 20 weeks, the fundal height measured 27 cm., and 2 days later she complained of severe lower abdominal and back pain and respiratory distress. The fundal height was 32 cm. Amniography ruled out fetal malformations. An intrauterine contraceptive device was also visualized, and the fetus was observed lying in the left side of the uterine cavity. Eight hundred and thirtyfive milliliters of amniotic fluid was removed by amniocentesis. Repeat amniography showed twins with no evidence of skeletal or soft tissue malformation. Only the right fetal sac demonstrated polyhydramnios. Over the next 14 days, 9 amniocenteses were performed, removing 5,275 ml. of amniotic fluid. Serial amniotic fluid volumes are presented in Fig. 3. The serum proteins decreased from 5.3 to 4.9 Gm. per 100 ml., and she received 25 Gm. of albumin intravenously. Amniotic fluid proteins ranged between 1.6 and 2.0 Gm. per cent. Electrophoresis showed that albumin accounted for 72.2 per cent, alpha-l globulin 11.1 per cent, alpha-2 globulin 5.6 per cent, and beta globulin 11 .I per cent. No gamma globulin was demonstrated. The patient went into spontaneous labor at
35 weeks’ gestation with a fundal height of 35 cm. Amniotomy was performed, and 7,500 ml. of amniotic fluid were carefully released. Twin girls were delivered. The monochorionic biamniotic placenta weighed 910 grams. Baby A weighed 2,380 grams and was slightly depressed and pale at birth. Her hematocrit was 42.7 per cent and blood group was A, Rh-negative, with a negative Coombs test. Jaundice ap peared at one day of age, and the highest bilirubin was 16.7 mg. per 100 ml. (indirect). Baby B weighed 2,100 grams. Her Apgar score was 8. She was plethoric. Her hematocrit was 63 per cent. She became jaundiced at 21 hours of age and required 3 exchange transfusions because of hyperbilirubinemia. Both infants were sent home in good condition, with the diagnosis of fetofetal transfusion syndrome--Twin A. donor, and Twin B, recipient. Comment When the clinician makes the diagnosis of polyhydramnios, he must rule out diabetes, erythroblastosis fetalis, and multiple gestation. Time of diagnosis and rate of fluid accumulation are helpful in establishing the cause
354
Queenan
and Gadow
October J. Obstet.
Amer.
AFV
cc
4230
,
7000
1, 1970 Cynec.
cc
cm 34 33 32 3000 i
31 2700 30 2400 29 2100 28
1800
27
1500
26
1200
25
900 600
A
21
A Amniography Fig. 3. VoIune gestation.
of amniotic
$2
A
24 gestotion
Weeks
AFV: fluid
ffl norm01 removed
0 measured and
and prognosis. When no associated condition is present, congenital malformations must be suspected since they are present in over one third of the remaining patients. Roentgenography is useful in detecting skeletal defects. Amniography should be performed for the detection of soft tissue maIformations and gastrointestinal anomalies. The prognosis of infants with congenital malformations is poor. The high incidence of intrapartum deaths (21 per cent) could be attributable in some instances to destructive procedures; however, some infants had corrective anomalies. This emphasizes the importance of prenatal diagnosis of congenita1 malformations. The prognosis for patients with Class A diabetes is favorable, whereas that for Classes B, C, and D diabetes is guarded. In patients with diabetes, however, the over-all prognosis is better when the pregnancy is not complicated by polyhydramnios.
fundal
25
26
I removed
height measurement
t3
Fundal
height
according
to
weeks’
The poor fetal outcome in erythroblastosis fetalis with polyhyramnios (only one out of 3 infants survive) can be attributed to 2 factors. First, polyhydramnios is often associated with the development of hydrops fetalis. Second, the dilution effect of polyhydramnios may mask the severity of the bilirubin peak in amniotic fluid analysis. Aggressive management of chronic polyhydramnios by amniocentesis is indicated only for extreme maternal symptoms. It is apparent from this study that the management of polyhydramnios must be directed toward treatment of the underlying cause. Acute poIyhydramnios is a compIetely different clinical situation. The cause must be determined immediately. If the condition is due to congenital anomalies not amenable to surgical correction, the pregnancy should be terminated. If the polyhydramnios is idiopathic or due to multiple gestation, depend-
Volume 108 Number 3
ing on the clinical situation, attempts should be made to prolong the pregnancy by multiple amniocenteses. The procedure is safe, and even though many amniocenteses are performed, it is helpful in maintaining the pregnancy to viability. Increase in uterine
REFERENCES
1. 2. 3. 4.
Barry, A. P.: Obstet. Gynec. 11: 667, 1958. Caldeyro-Barcia, R., Pose, S. V., and Alvarez, H.: AMER. J. OBSTET. GYNEC. 73: 1238, 1957. Charles, D., and Jacoby, H. E.: AMER. J. OBSTET. GYNEC. 95: 266, 1966. Eastman, N. J., and Hellman, L. M.: Williams Obstetrics, ed. 13, New York, 1966, AppletonCentury-Crofts, Inc., Chap. 23, p. 603.
Polyhydramnios
contractility after fluid, as has been not significant in internal recording be done in future servation further.
5. 6. 7.
355
the removal of amniotic previously reported,: was these cases. Esternai and of uterine contractilitv will cases to elucidate this oh-
Moya, F., Apgar, V., James, L. S., and Berrien, C.: J. A.M. A. 173: 1552, 1960. Queenan, J, T.: AMER. J. OBSTET. C~YNEC. 104: 397, 1969. White, P.: Pregnancy Complicating Diabetes in the Treatment of Diabetes Mellitus, ed. 10, Philadelphia, 1958, Lea & Febiger, Publishers, p. 690.