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5005/jp-journals-10006-1209
Sunita Ghike et al ORIGINAL ARTICLE

Increasing Severity of Oligohydramnios: A Risk Factor for Outcome

Sunita Ghike, Gayathri Reddy, NW Ghike

ABSTRACT
Background: Oligohydramnios is an important obstetric complication, so this study was conducted to determine the correlation between AFI and perinatal outcome. Materials and methods: Design: Prospective case control (longitudinal observational study). Place: Department of Obstetrics and Gynecology, NKP Salve Institute of Medical Sciences, Nagpur. Duration: 1 Nov. 2008 to 1 Nov. 2010 Study population: 100 Group 1: AFI < 5 cm severe oligohydramnios. Group 2: AFI > 5 cm < 8 cm borderline oligohydramnios. Gestational age: 37 to 42 weeks. Results: In presence of low AFI there is increased incidence of perinatal mortality. Conclusion: Oligohydramnios is a significant high-risk factor for adverse perinatal outcome and low AFI is a method of fetal surveillance. Keywords: AFI, MSD, FD, Perinatal outcome, NICU admission. How to cite this article: Ghike S, Reddy G, Ghike NW. Increasing Severity of Oligohydramnios: A Risk Factor for Outcome. J South Asian Feder Obst Gynae 2013;5(1):8-10. Source of support: Nil Conflict of interest: None declared

from 1 Nov, 2008 to 1 Nov, 2010. Patients selected were with singleton pregnancy, sure of gestational age, between 37 and 42 weeks, with cephalic presentation, with intact membranes and having delivered during the same hospitalization when AFI was determined. Women who were not sure of dates, gestational age < 37 weeks or >42 weeks, with abnormal presentation, multiple pregnancy or PROM were excluded. Total 4,782 women delivered during the 2 years, study period of which 156 had AFI < 8 cm and among them only 121 women satisfied the study criteria. Then 100 women were selected randomly from these 121 women and they were followed. These 100 women were further divided into two groupsgroup 1 containing women with AFI < 5 cm and group 2 containing women with AFI > 5 cm and < 8 cm. These 100 women who were fulfilling the inclusion criteria were enrolled for the study. Detailed history, age, obstetric history (past and present), menstrual history (LMP) were noted. A thorough clinical examination was done (general, systemic and obstetric). The perinatal outcome was studied in both the groups, compared and conclusion was reached.

OBSERVATION AND RESULTS

Of the 100 study population 37 women fell into group 1, i.e. oligohydramnios (AFI 5 cm) and 63 women in group 2, i.e. borderline oligohydramnios (AFI > 5 cm and 8 cm) (Table 1). The mean age of women in group 1 was 24.65 4.1 SD years and in group 2 the mean age was 24.00 4.2 SD years. Majority of the women in both the groups were either nulliparous or para 1. Mean age of gestation in group 1 was 40.30 1.64 weeks and in group 2 was 40.08 1.61 weeks. Group 1 women (severe oligohydramnios) showed maximum antenatal complications (54.05%) compared to group 2 (47.62%). When group 1 was compared with group 2 there was no statistical significance (Table 2). Group 1 was associated with maximum antenatal complications like IUGR, PIH and PIH + IUGR, etc. as compared to group 2. Meconium stained liquor was found more in group 1 as compared to group 2 and when compared after applying statistical test (Chi-square) the p-value was significant (Table 3). The cesarian section for FD was significantly higher in group 1 (29.73%) compared to group 2 (9.52%) and the difference was statistically significantChi-square 6.74 and p-value < 0.01. The need for NICU admissions was higher in group 1 (43.24%) compared to group 2 (19.05%) and it was

INTRODUCTION
AF provides the fetus a protective environment suitable for growth and development (oligohydramnios is defined as when deepest vertical pool is less than 8 cm). Its volume is controlled by dynamic interaction among the fetal placenta and maternal compartment, throughout normal pregnancy AF allows the fetus room for growth, movement and development. In oligohydramnios this equilibrium shifts. AFI is determined by directly measuring the vertical pocket (free of any fetal part) in four quadrants of abdomen in pregnant woman. Oligohydramnios is ranked as severe oligohydramnios AFI 5 cm and borderline oligohydramnios as AFI > 5 cm and 8 cm. The aim of this study was to determine the frequency of oligohydramnios and to study the perinatal outcome in oligohydramnios.

MATERIALS AND METHODS

This prospective case control study (longitudinal observational study) was conducted in the Department of Obstetrics and Gynecology, NKPSIMS, LMH, Nagpur over a period of 2 years

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Increasing Severity of Oligohydramnios: A Risk Factor for Outcome

Table 1: Distribution of women in two groups (n = 100) Groups Group 1 Group 2 AFI 5 cm >5 cm and 8 cm No. of women 37 63

Table 2: Distribution of complications in two groups (n = 100) Complications Yes (+) No () Group 1 20 (54.05%) 17 (45.95%) Group 2 30 (47.62%) 33 (52.38%)

women with MSL in group 1 (66.7%) and group 2 (62.1%) (p > 0.05 between groups 1 and 2). But in most of the studies conducted by Rutherford et al (1987),1 Sarno et al (1989),10 Robson et al (1992),2 Ergun et al (1998),11 Tsang et al (1998),3 Magann et al (1999),4 Casey et al (2000)5 and Raj Sriya et al (2001)7 the percentage of women with MSL was significantly higher in group 1 compared to group 2 (see Table 5).

Cesarean Section for Fetal Distress

It was found that 29.73% of women in group 1 underwent LSCS for FD while 9.52% in group 2. So the rate of LSCS for FD was significantly higher in group 1 followed by group 2 in the present study. In the studies conducted by Sarno et al (1989),10 Jeng CJ et al (1992),9 Robson et al (1992),2 Conway et al (1998),8 Phoolchandra et al (2000)6 and Raj Sriya et al (2001)7 also the rate of LSCS for FD was higher in group 1 when compared to group 2 which is similar to that found in the present study. So the discovery of decreased AFV should alert the obstetrician to consider that the woman is at increased risk and should warrant increased antepartum surveillance (see Table 5).

statistically significantChi-square 6.77 and p-value < 0.01 (Table 4). The percentage of neonatal deaths was significantly higher in group 1 (10.8%) as compared to group 2 (3.17%), but the difference was not statistically significant.

DISCUSSION Abnormal Fetal Heart Rate

In the present study in group 145.95%, in group 223.8% and in group 314% women had abnormal fetal heart rate indicating higher percentage of women with abnormal fetal heart rate in group 1 followed by group 2. Observations of the present study are similar to the study by Rutherford et al (1987),1 Robson et al (1992),2 Tsang et al (1998),3 Magann et al (1999),4 Casey et al (2000),5 Phoolchandra et al (2000 et al)6 and Raj Sriya et al (2001)7 who also found higher percentage of women with abnormal fetal heart rate in group 1 compared to group 2 (Table 5).

CONCLUSION
It was found that the occurance of abnormal FHR was significantly higher in severe oligohydramnios group 1 (45.95%) followed by borderline oligohydramnios group 2 (23.8%). Meconium stained liquor was found more commonly in severe oligohydramnios group 1 (54.05%), followed by borderline oligohydramnios group 2 (26.98%). Fetal distress as the indication for cesarean section was significantly higher in severe oligohydramnios group 1 (29.73%) followed by borderline oligohydramnios group 2 (9.52%). The percentage of neonates with APGAR <7 at 1 minute was higher in severe oligohydramnios group 1 (32.43%) followed by borderline oligohydramnios group 2 (17.46%). The percentage of neonates with APGAR <7 at 5 minutes was also higher in severe oligohydramnios group 1 (13.51%) followed by borderline oligohydramnios group 2 (3.17%).

Meconium Stained Liquor

In the present study 54.05% of women in group 1 had meconium stained liquor compared to 26.98% in group 2 indicating significantly higher percentage of women with meconium stained liquor in group 1 followed by group 2. In the study by Conway et al (1998)8 the percentage of women with MSL was almost similar in group 1 (24%) and in group 2, signifying no difference in the occurance of MSL in these groups. In a study conducted by Jeng et al (1992)9 it was found that there was no significant difference in the percentage of

Table 3: Distribution of meconium stained liquor in two groups and p-value Nature of amniotic fluid Thin MSL Thick MSL Clear liquor Group 1 11 (29.73%) 9 (24.32%) 17 (45.95%) 37 (100%) Group 2 7 (11.11%) 10 (15.87%) 46 (73.02%) 63 (100%) Chi-square (group 1 vs group 2) 7.33 p-value <0.01 Significance Significant

Table 4: Distribution of NICU admission in two groups and their p-value Groups Group 1 Group 2 NICU admissions 16 12 Percentage 43.24 19.05 Chi-square 6.77 p-value <0.01 Significance Significant

Journal of South Asian Federation of Obstetrics and Gynaecology, January-April 2013;5(1):8-10

Sunita Ghike et al
Table 5: Relationship between AFI and perinatal outcome (Summary) Parameter Abnormal FHR Meconium stained liquor Instrumental deliveries Cesarean section LSCS for fetal distress Birth wt <2.5 kg 1 min APGAR <7 5 mins APGAR <7 NICU admission Intrauterine growth restriction Perinatal mortality Group 1 n (%) 17 (45.95) 20 (54.05) 4 (10.80) 13 (35.14) 11 (29.73) 19 (51.35) 12 (32.43) 5 (13.51) 16 (43.24) 15 (40.54) 2 (5.4) Group 2 n (%) 15 (23.8) 17 (26.98) 5 (7.93) 9 (14.28) 6 (9.52) 19 (30.16) 11 (17.46) 2 (3.17) 12 (19.05) 16 (25.40) 1 (1.59)

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So the above study concludes that amniotic fluid is a helpful tool in determining high risk patients during labor. The high statistical significance between low AFI and prediction of CS for FD would help to identify patients who may require an emergency CS with a sensitivity of 84.61%, specificity of 47.05%, PPV of 55% and NPV of 72.72%. So AFI when used as an admission test in intrapartum period can categorize the fetuses into high-risk and low-risk depending on their susceptibility to FD. In the presence of low AFI, the incidence of MSL, abnormal FHR, low apgar, rate of LSCS, low birth weight, NICU admissions and perinatal mortality are high. So determination of AFI can be used as an adjunct to other fetal surveillance methods to identify fetuses at risk of poor perinatal outcome.

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5 cm necessitate delivery in high-risk pregnancies? A casecontrol study. Am J Obstet Gynecol 1999June;180:e1354-59. Casey BM, McIntire DD, Bloom SL, Lucas MJ, Santos R, Twickler DM, Ramus RM, Leveno KJ. Pregnancy outcomes after antepartum diagnosis of oligohydramnios at or beyond 34 weeks gestation. Am J Obstet Gynecol 2000 April;182: 909-12. Chandra P, Kaur SP, Hans DK, Kapila AK. The impact of amniotic fluid volume assessed intrapartum on perinatal outcome. Obs and Gynae 2000 Aug;5:478-81. Sriya Raj, Singhal S, Rajan M, Sharma M, Nagpal P. Perinatal outcome in patients with amniotic fluid index < 5 cm. J Obstet Gynecol India 2001;51:98-100. Conway DL, Adkins WB, Schroeder B, Langer O. Isolated oligohydramnios in the term pregnancy: Is it a clinical entity? J Matern-Fetal Medicine 1998;7:197-200. Jeng CJ, Lee JF, Wang KG, Yang YC, Lan CC. Decreased amniotic fluid index in term pregnancies. Clinical significance. J Reprod Med 1992 Sep;37(9):789-92. Sarno AP Jr, Ahn MO, Brar HS, Phelan JP, Platt LD. Intrapartum Doppler velocimetry, amniotic fluid volume, and fetal heart rate as predictors of subsequent fetal distress. I. An initial report. Am J Obstet Gynecol 1989 Dec;161(6 Pt 1):1508-14. Ergun A, Atay V, Pabuccu R, Baser I, Duru NK, Tokac G. Predictive value of amniotic fluid volume measurements on perinatal outcome. Gynecol Obstet Invest 1998;45:19-23.

ABOUT THE AUTHORS Sunita Ghike

Professor, Department of Obstetrics and Gynecology, NKP Salve Institute of Medical Sciences, Nagpur, Maharashtra, India Correspondence Address: 57, 4A, Madhuban Apartments, Khare Town Dharampet, Nagpur-440010, Maharashtra, India, Phone: 09763726957 e-mail: sunita_dr@ yahoo.co.in

REFERENCES
1. Rutherford SE, Phelan JP, Smith CV, Jacobs N. The fourquadrant assessment of amniotic fluid volume: An adjunct to antepartum fetal heart rate testing. Obstet Gynecol 1987 Sep; 70(3 Pt 1):353-56. 2. Robson SC, Crawford RA, Spencer JA, Lee A. Intrapartum amniotic fluid index and its relationship to fetal distress. Am J Obstet Gynecol 1992 Jan;166(1 Pt 1):78-82. 3. Tsang-Tang H, Tai-Ho H, Kuang-Chao C, Ching-Chang H, Liang-Ming L, Chiu TH. Perinatal outcome of oligohydramnios without associated premature rupture of membranes and fetal anomalies. Gynecol Obstet Invest 1998;45:232-36. 4. Magann Kinsella MJ, Chauhan SP, McNamara MF, Beth W, Gehring RN, Morrison JC. Does an amniotic fluid index of

Gayathri Reddy
Senior Resident, Department of Obstetrics and Gynecology, NKP Salve Institute of Medical Sciences, Nagpur, Maharashtra, India

NW Ghike
Consultant Radiologist, Imaging Point, X-ray Ultrasound Clinic Dharampet, Nagpur, Maharashtra, India

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