Ultrasound Obstet Gynecol 2012; 39: 648653

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.10093

Maximal amniotic fluid index as a prognostic factor in

pregnancies complicated by polyhydramnios
S. PRI-PAZ*, N. KHALEK, K. M. FUCHS* and L. L. SIMPSON*
*Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New
York, USA; The Center for Fetal Diagnosis and Treatment, The Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania, USA

K E Y W O R D S: AFI; amniotic fluid index; polyhydramnios; pregnancy outcome

ABSTRACT
Objectives Polyhydramnios is present in approximately
2% of pregnancies and has been associated with a variety
of adverse pregnancy outcomes. Our aim was to evaluate
the association between the maximal amniotic fluid index
(AFI) and the frequency of specific adverse outcomes.
Methods This was a retrospective chart review of 524 singleton pregnancies diagnosed with polyhydramnios and
delivered in a single tertiary referral center between 2003
and 2008. Polyhydramnios was defined as either AFI
25 cm or a maximum vertical pocket (MVP) 8 cm
even in the presence of AFI < 25 cm. The cohort was
stratified into four groups based on the maximal AFI
noted during the pregnancy: < 25 cm but with MVP
8 cm; 2529.9 cm; 3034.9 cm; and 35 cm. Data
were collected to determine the frequency of the following adverse pregnancy outcomes: prenatally diagnosed
congenital anomalies, fetal aneuploidy, preterm delivery,
Cesarean delivery, low birth weight, 5-min Apgar score
< 7 and perinatal mortality.
Results Higher AFI was associated with a statistically
significant increase in the frequency of adverse pregnancy
outcomes. The most severe form of polyhydramnios,
as based on the maximal AFI ( 35 cm; n = 67), was
associated with the highest rates of prenatally diagnosed
congenital anomalies (79%), preterm delivery (46%),
small-for-gestational-age neonate (16%), aneuploidy
(13%) and perinatal mortality (27%). No significant
association between degree of polyhydramnios and
adverse outcome was demonstrated in cases of idiopathic
polyhydramnios (n = 253).
Conclusions There is an association between the frequencies of a variety of adverse pregnancy outcomes and the
severity of polyhydramnios as reflected by the maximal
AFI. Copyright 2012 ISUOG. Published by John Wiley
& Sons, Ltd.

INTRODUCTION
Polyhydramnios, defined as excessive accumulation of
amniotic fluid, affects 12% of pregnancies, but the
incidence has been reported to range from as low as 0.2%
to as high as 3.9%1 3 . Although historically the detection
of polyhydramnios was made clinically by abdominal
palpation or at the time of delivery4 , the diagnosis is now
commonly made sonographically. Ultrasound evaluation
of the amount of amniotic fluid can be either a subjective
assessment or a semiquantitative estimation using the
maximal vertical pocket (MVP), amniotic fluid index
(AFI)5,6 , two-diameter pocket7 or three-dimensional
measurements8 . While semiquantitative measurements
have only moderate accuracy in assessing the actual
volume of amniotic fluid, especially at the extremes of
volumes, these remain the preferred approach to amniotic
fluid volume estimation5,9 11 . Dilutional techniques are
the most accurate predictor of amniotic fluid volume,
but their invasive nature limits their use. When defining
the upper limit of normal amniotic fluid indices, a
constant value of AFI 25 cm can be used across all
gestational ages, or gestational-age specific thresholds can
be utilized1,12 . Neither method has been shown to be
superior to the other13 .
Both fetal and maternal conditions can lead to an
accumulation of excess amniotic fluid. Fetal anomalies
associated with polyhydramnios in singleton pregnancies include central nervous system anomalies affecting
the fetuss ability to swallow or gastrointestinal anomalies causing obstruction. Additionally, aneuploidy, other
structural anomalies and hydrops can result in polyhydramnios. The most common maternal reason for
polyhydramnios is poorly controlled diabetes mellitus,
with additional etiologies including infections and exposure to medication, for example lithium, which may cause
fetal diabetes insipidus. Approximately 50% of cases are
idiopathic with no known etiology1 .

Correspondence to: Dr S. Pri-Paz, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University
Medical Center, 622 West 168th PH16-66, New York, New York, 10032, USA (e-mail: smp9009@med.cornell.edu)
Accepted: 18 August 2011

Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd.

ORIGINAL PAPER

AFI and adverse pregnancy outcome

Polyhydramnios has previously been associated with
an increased risk of a number of adverse perinatal
outcomes, such as preterm delivery12,14 , aneuploidy15 ,
Cesarean delivery16 , fetal anomalies17,18 and perinatal
mortality18,19 . Our study aimed to confirm these
associations and to determine if there is a relationship
between the degree of polyhydramnios and the risk of
these adverse outcomes.

METHODS
This was a retrospective cohort study of patients cared
for in our institution between 2003 and 2008 that was
approved by the institutional review board. We searched
the electronic reports of all obstetrical ultrasound examinations performed during the study period to identify
all cases with a subjective diagnosis of polyhydramnios,
an MVP of 8 cm or an AFI of 25 cm. Patients were
included in the cohort if they had had at least one scan
in our ultrasound unit, a singleton pregnancy and either
an AFI 25 cm or an MVP 8 cm even with an AFI
< 25 cm. Patients were excluded from the analysis if outcome data were unavailable.
Electronic medical records were reviewed to determine
the MVP and AFI measured during pregnancy. In addition, the following data were collected for each patient:
maternal age, presence or absence of maternal diabetes
(pre-existing or gestational), pregnancy outcome, gestational age at delivery, presence of prenatally detected fetal
anomalies, estimated fetal weight < 10th percentile for a
given gestational age, fetal karyotype, mode of delivery
and in cases of live birth birth weight, Apgar scores
and neonatal outcome. Small for gestational age (SGA)
was defined as birth weight below the 10th percentile for
the gestational age and sex. Macrosomia was defined as
birth weight 4500 g. Perinatal mortality was determined
by assessing the rate of intrauterine fetal death (IUFD) and
infant deaths that occurred during the newborns initial
hospitalization, including those after the initial 28-day
neonatal period.
The cohort was stratified into four groups based on
the maximal AFI: < 25 cm but with an MVP of 8 cm;
2529.9 cm; 3034.9 cm; and 35 cm. Because of the
varying definitions of polyhydramnios, the first group was
included as the baseline group within the stratification.
Pregnancy outcomes were compared between groups
to determine the association between the degree of
polyhydramnios, as reflected by the maximal AFI, and the
frequency of adverse outcomes. Additional analysis was
performed after stratifying the cohort into two groups:
one including those cases with mild polyhydramnios
(defined as AFI < 25 cm but with an MVP 8 cm or
AFI of 2529.9 cm) and the other including those cases
with moderate-to-severe polyhydramnios (defined as AFI
30 cm).
Statistical analysis was performed with ANOVA, the
chi-square test and Students t-test using SPSS version 17
(SPSS Inc., Chicago, IL, USA) and P < 0.05 was considered
statistically significant.

Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd.

649

RESULTS
We identified 702 pregnancies complicated by polyhydramnios, of which 178 were excluded owing to a lack
of objective evidence meeting the study criteria for the
definition of polyhydramnios or because of multiple gestation or a lack of sufficient outcome data. Thus, over the
6-year study period, a cohort of 524 cases was identified.
During this period there were 22 778 singleton deliveries
at our institution, for an overall incidence of polyhydramnios of 2.3%. The mean maternal age at the time
of delivery was 31.6 6.65 (range, 1454) years, with
no significant difference between the four groups. Diabetes, gestational or pre-existing, was present in 26.1%
of women with maximal AFI < 25 cm, 20.6% with AFI
2529.9 cm, 20.6% with AFI 3034.9 cm and 4.5% with
AFI 35 cm (P = 0.007).
Almost 70% (360/524) of our cohort had mild
polyhydramnios. Table 1 shows the association of the
different degrees of AFI and the frequency of adverse
pregnancy outcome. Data on birth weight were available
for 444/524 (84.7%) neonates. A non-statistically
significant inverse correlation was noted between maximal
AFI and mean birth weight, while a statistically
significant positive correlation was noted between
increased AFI and rates of SGA (P = 0.030). There was no
statistically significant correlation with the incidence of
macrosomia.
Higher AFI was found to be associated with an
increased frequency of prenatally detected congenital
anomalies (Table 1). The most common structural anomalies detected sonographically were cardiac, followed by
anomalies of the thorax and lungs, gastrointestinal system, musculoskeletal system, central nervous system and
genitourinary system (Table 2).
Karyotypes, the majority of which were determined
prenatally, were available for 183 patients (34.9%). There
was a correlation between the degree of abnormal AFI and
the frequency of fetal aneuploidy, with abnormal fetal
karyotype noted in 11/89 (12.4%) cases of moderate-tosevere polyhydramnios six cases of trisomy 18 and five
cases of trisomy 21. It is of note that all the pregnancies
complicated by fetal trisomy had other anomalies detected
on obstetric sonography in addition to polyhydramnios
(Table 3).
Pregnancies complicated by polyhydramnios were
associated with a high rate of Cesarean delivery, regardless
of the maximal AFI. There were a total of three exutero intrapartum therapy procedures, and one Cesarean
hysterectomy performed in a case of placenta percreta
in a patient with four prior Cesarean deliveries, placenta
previa and an AFI of 25.4 cm.
A statistically significant association was noted between
the severity of polyhydramnios and the frequency of perinatal mortality, including both IUFD (n = 19) and infant
deaths that occurred before hospital discharge (n = 24).
While there were no cases of mortality when AFI was
< 25 cm, there was an almost 27% risk of perinatal mortality when the AFI was 35 cm. It is important to note,

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Pri-Paz et al.

650

Table 1 Adverse outcomes at different degrees of maximal amniotic fluid index in 524 singleton pregnancies with polyhydramnios
Maximal amniotic fluid index:
Outcome
Normal anatomy scan
Aneuploidy
Mean gestational age at delivery (weeks)
Preterm delivery < 37 weeks
Early preterm delivery (< 34 weeks)
Cesarean delivery
Mean birth weight (g)
Small-for-gestational age
Macrosomia (> 4500 g)
5-min Apgar score < 7
Intrauterine fetal death
Perinatal mortality

< 25 cm
(n = 69)

2529.9 cm
(n = 291)

3034.9 cm
(n = 97)

35 cm
(n = 67)

P*

58 (84.1)
0/15 (0.0)
39
5 (7.2)
0 (0.0)
44 (63.8)
3577
2/57 (3.5)
4/57 (7.0)
2/57 (3.5)
0 (0.0)
0 (0.0)

217 (74.6)
3/79 (3.8)
38 + 3
46 (15.8)
17 (5.8)
153 (52.6)
3449
14/250 (5.6)
15/250 (6.0)
9/236 (3.8)
7 (2.4)
16 (5.5)

51 (52.6)
5/43 (11.6)
37 + 5
19 (19.6)
7 (7.2)
54 (55.7)
3385
7/81 (8.6)
3/81 (3.7)
7/84 (8.3)
3 (3.1)
9 (9.3)

14 (20.9)
6/46 (13)
36 + 1
31 (46.3)
13 (19.4)
42 (62.7)
2910
9/56 (16.1)
2/56 (3.6)
12/52 (23.1)
9 (13.4)
18 (26.9)

< 0.005
0.124
0.027
< 0.005
< 0.005
0.431
0.155
0.030
0.732
< 0.005
< 0.005
< 0.005

Data are given as n (%) except where indicated. Denominators vary because outcome data were not available in all cases. *Pearsons
chi-square test or ANOVA. Normal anatomy scan included cases of isolated intracardiac echogenic foci and pyelectasis. Karyotype
determined in 183 cases. Small-for-gestational age defined as birth weight < 10th percentile.
Table 2 Congenital anomalies diagnosed by ultrasound in 524 singleton pregnancies with polyhydramnios, according to maximal amniotic
fluid index
Maximal amniotic fluid index:
Anomaly

< 25 cm
(n = 69)

2529.9 cm
(n = 291)

3034.9 cm
(n = 97)

35 cm
(n = 67)

Total
(n = 524)

Cardiac
Thorax and lungs
Gastrointestinal
Genitourinary
Musculoskeletal
Central nervous system
Single umbilical artery
Hydrops
Estimated fetal weight < 10th percentile
Total anomalies

1 (1.4)
6 (8.7)
0 (0.0)
2 (2.9)
2 (2.9)
1 (1.4)
0 (0.0)
0 (0.0)
0 (0.0)
12

20 (6.9)
19 (6.5)
14 (4.8)
10 (3.4)
16 (5.5)
18 (6.2)
2 (0.7)
7 (2.4)
4 (1.4)
110

17 (17.5)
12 (12.4)
10 (10.3)
8 (8.2)
5 (5.2)
5 (5.2)
4 (4.1)
6 (6.2)
1 (1)
68

18 (26.9)
18 (26.9)
13 (19.4)
3 (4.5)
14 (20.9)
7 (10.4)
5 (7.5)
7 (10.4)
2 (3)
87

56 (10.7)
55 (10.5)
37 (7.1)
23 (4.4)
37 (7.1)
31 (5.9)
11 (2.1)
20 (3.8)
7 (1.3)
277

Data are given as n (%). If a fetus was diagnosed with multiple anomalies, each anomaly was considered separately.

however, that none of the cases with severe polyhydramnios and perinatal mortality was noted to have idiopathic
polyhydramnios. In fact all of these cases of severe
polyhydramnios with fetal or infant death were complicated by additional abnormalities that probably contributed to the outcome (Table 4). After excluding all
cases of maternal diabetes, isoimmunization, hydrops
fetalis and fetal structural anomalies, 253 cases (48.3%) of
idiopathic polyhydramnios were identified in the cohort.
Among all these pregnancies there were three cases of
IUFD for an incidence of 1.2% and one additional case
of neonatal demise due to myopathy, thus resulting in a
perinatal mortality rate of 1.6%.
A similar set of associations was noted when comparing
mild polyhydramnios (n = 360) vs. pregnancies with
moderate-to-severe polyhydramnios (n = 164). The mild
polyhydramnios group had a higher mean gestational
age at delivery (38 + 4 vs. 37 + 1 weeks; P < 0.005) and
a higher mean birth weight (3472 vs. 3193 g; P < 0.005).
Pregnancies with mild polyhydramnios were less likely

Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd.

to result in preterm delivery prior to 34 weeks (4.7 vs.

12.2%; P = 0.002) or prior to 37 weeks (14.2 vs. 30.5%;
P < 0.005). They were more likely to have normal fetal
anatomical surveys (76.4 vs. 39.6%; P < 0.005) and
were associated with a lower incidence of SGA (5.2 vs.
11.7%; P = 0.015), 5-min Apgar score < 7 (3.8 vs. 14.0%;
P < 0.005), aneuploidy (3.2 vs. 12.4%; P = 0.025), IUFD
(1.9 vs. 7.3%; P = 0.004) and perinatal mortality (4.4 vs.
16.5%; P < 0.005).
However, in the cohort of 253 women with idiopathic
polyhydramnios, moderate-to-severe degree of polyhydramnios (AFI 30 cm) was not associated with an
increased risk of adverse pregnancy outcome when compared to pregnancies with mild polyhydramnios (AFI
< 30 cm). The average maximal AFI of this entire idiopathic group was 27.8 cm. Preterm delivery < 37 weeks
complicated 9.5% of such pregnancies and 2.4% were
delivered < 34 weeks. The mean birth weight was 3556 g,
with a 2.8% incidence of SGA. The Cesarean delivery rate
was 55% and 1.4% had a 5-min Apgar score < 7.

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AFI and adverse pregnancy outcome

651

Table 3 Details of the 14 pregnancies with polyhydramnios and aneuploidy

Aneuploidy

Maximal AFI (cm)

Associated anomalies

Comments

Trisomy 18

38.5

IUFD

28.4
33.0
31.1
35.0
27.2

CDH, CHD (DORV, VSD), clenched hand, absent

left forearm, single umbilical artery
CPC, VSD, clenched hands, succenturiate lobe
CPC, dilated cavum septum defect, AV canal defect,
clenched hands, clubbed feet
CPC, AV canal defect, clenched hands, clubbed feet
VSD, clinodactyly, cleft lip, EFW < 10th percentile
VSD, DORV
CDH, AV canal defect, ascites and dilated bowel
AV canal defect, pleural effusion

Trisomy 18
Trisomy 18

41.2
44.7

Trisomy 18
Trisomy 18
Trisomy 18
Trisomy 18
Trisomy 21
Trisomy 21
Trisomy 21
Trisomy 21
Trisomy 21
Trisomy 21
Trisomy 21

29.8
33.9
39.9
45.7
30.0
33.7

AV canal defect, EFW < 10th percentile

AV canal defect, pyelectasis, hydrops fetalis
VSD, duodenal atresia
VSD, duodenal atresia, double bubble
AV canal defect, hypoplastic right ventricle
Duodenal atresia

IUFD
Neonatal demise on 13th day

IUFD
IUFD
Thoracocentesis performed
antenatally

Amnioreduction performed

AFI, amniotic fluid index; AV, atrioventricular; CDH, congenital diaphragmatic hernia; CHD, congenital heart disease; CPC, choroid plexus
cyst; DORV, double outlet right ventricle; EFW, estimated fetal weight; IUFD, intrauterine fetal death; VSD, ventricular septal defect.
Table 4 Details of the 19 pregnancies with polyhydramnios that
resulted in intrauterine fetal death (IUFD)
GA at IUFD (weeks)

Findings

AFI 2529.9 cm
28 + 0
28 + 1
28 + 6
29 + 2
34 + 5
35 + 6
36 + 2

Idiopathic
VSD, hydrops
Sacrococcygeal teratoma
CDH
Pre-existing diabetes, previous IUFD
Truncus arteriosus, hydrops
Two-vessel cord, dilated bowel

AFI 3034.9 cm
24 + 6
37 + 2
40 + 2
AFI 35 cm
28 + 4
31 + 0
31 + 4
32 + 2
33 + 1
33 + 1
34 + 0
34 + 0
35 + 1

Maternal ESRD, chronic hypertension

Trisomy 18, EFW < 10th percentile, cleft lip
Idiopathic; normal biophysical profile
5 days earlier
Sacrococcygeal teratoma
Aortic stenosis, hydrops
CDH
DandyWalker malformation, HRHS
Trisomy 18, CDH
Craniofacial anomaly
Trisomy 18
Cystic hygroma, EFW < 10th percentile
Trisomy 18, CDH

CDH, congenital diaphragmatic hernia; EFW, estimated fetal

weight; ESRD, end-stage renal disease; GA, gestational age; HRHS,
hypoplastic right heart syndrome; IUFD, intrauterine fetal death;
VSD, ventricular septal defect.

DISCUSSION
Several findings in our study shed new light on
issues related to polyhydramnios, and may affect the
management of such pregnancies. While this is not a new
observation, our findings again note the high frequency of
mild polyhydramnios among all cases of polyhydramnios
and the relatively low incidence of associated anomalies

Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd.

in these mild cases14,20,21 . Similarly, our findings support

an association between the severity of polyhydramnios
(as reflected in the maximal AFI) and the frequency of
adverse outcomes including prematurity, SGA, low 5-min
Apgar score, prenatally diagnosed congenital anomalies
and perinatal mortality. The lower mean birth weight
is likely to be secondary to the lower gestational age
and higher prematurity rate that were noted as the AFI
increased, although the increased proportion of SGA
babies cannot be attributed to prematurity.
Magann et al.7 endorsed measurement of the single
deepest pocket of amniotic fluid, rather than AFI, as
the preferred method for assessing amniotic fluid volume,
suggesting that this method is less likely to classify patients
with uncomplicated pregnancies as having abnormal
amounts of fluid either too little or too much. However,
the low incidence of adverse outcomes in the presence
of an elevated MVP but a normal AFI as seen in our
study suggests that diagnosing polyhydramnios based on
the AFI is reasonable, while as suggested by others, a
diagnosis based solely on an MVP 8 cm is probably less
important22 .
A diagnosis of polyhydramnios especially severe polyhydramnios with AFI 35 cm warrants careful sonographic evaluation of the fetus, as almost 80% of these
pregnancies are associated with a prenatal diagnosis of
fetal structural anomalies. This trend is consistent with
that found in other reports that have demonstrated sonographic anomalies in over 80% of severe cases23 . While
some have emphasized focused evaluation of the gastrointestinal and central nervous systems, our findings, showing
a high incidence of cardiac anomalies, support the routine performance of a fetal echocardiogram, especially
in cases with moderate-to-severe polyhydramnios. This
recommendation is also supported by a study by Dashe
et al.24 , which demonstrated that only 40% of cardiac
anomalies were detected prenatally among pregnancies

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Pri-Paz et al.

652

with polyhydramnios, whereas over 90% of non-cardiac

anomalies were detected.
Unlike some studies that showed no correlation between the severity of polyhydramnios and
prematurity14 , our study has shown that the rate of
preterm delivery at < 34 weeks increases as the maximal
AFI increases, and reaches 19.4% with an AFI 35 cm
(Table 1). Although the strength of our findings may be
insufficient to dictate clinical practice, this increased risk
may justify increased surveillance and a lower threshold when deciding on the timing of administration of
antenatal corticosteroids.
Our study confirms a significant risk of fetal aneuploidy
when fetal anomalies are present in the setting of
polyhydramnios, an association that is more apparent
as the degree of polyhydramnios worsens, supporting the
role of amniocentesis for fetal karyotyping in these cases
of moderate-to-severe polyhydramnios.
Brady et al.15 reported a 3.2% incidence of aneuploidy
in cases of polyhydramnios initially classified as idiopathic
even in the absence of fetal structural anomalies, and
therefore recommended fetal cytogenetic analysis for
all cases of polyhydramnios. Dashe et al.24 reported
a 1% risk of fetal aneuploidy when no anomaly
was detected sonographically, and therefore did not
recommend routine karyotyping; this approach has been
supported by others17,18,22 . Our study demonstrates
no findings to support a recommendation for routine
amniocentesis in the setting of isolated polyhydramnios
without sonographic evidence of other abnormalities. In
these cases, however, comprehensive genetic counseling,
including three-generation pedigree analysis, should be
considered to assess for neuromuscular disorders that
may affect fetal swallowing.
Physicians should be aware of the high risk of perinatal
mortality associated with severe polyhydramnios. Antenatal surveillance has previously been suggested, but without
specific recommendations18,25 . At our institution, once
polyhydramnios has been diagnosed weekly antenatal
testing is recommended, and delivery is usually suggested
at 39 weeks gestation. The mode of delivery is based on
standard obstetrical indications and is not affected solely
by the presence of polyhydramnios. However, we noted
one case of IUFD that occurred at 40 + 2 weeks gestation
in the setting of idiopathic polyhydramnios after a normal biophysical profile 5 days earlier. Although antenatal
testing may be warranted in pregnancies complicated by
polyhydramnios, further studies are needed to assess the
benefit of such testing and to determine the optimal mode
of antenatal testing and timing of delivery.
There are limitations to our study. The demographic
information is limited to maternal age at delivery and
the presence of diabetes and does not allow assessment
of diabetic control or evaluation of other possible
confounding factors. The study aimed to compare
different degrees of severity of polyhydramnios and, as
such, did not include a control group of pregnancies
without polyhydramnios that would have represented the
incidence of the abovementioned adverse outcomes in the

Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd.

general population. Because our facility, the Center for

Prenatal Pediatrics, is a tertiary referral center that focuses
on pregnancies with fetal anomalies, our population likely
includes a higher proportion of such pregnancies in
comparison to other institutions. As a referral center,
some of the patients may also have had additional
sonograms that were not available to us when calculating
the maximal AFI. Lastly, our study was limited by a lack
of complete neonatal data, including rates of postnatal
diagnosis of structural abnormalities and other relevant
conditions such as neuromuscular disease. Nevertheless
we believe that the strengths of this study outweigh
the limitations. Specifically, we present data from a
large cohort of women who were followed and treated
at a single institution according to set guidelines, and
with high-quality and high-resolution prenatal ultrasound
scans. In this setting, we were able to demonstrate
an association between the degree of polyhydramnios
and the frequency of adverse pregnancy outcomes, as
well as the importance of a detailed fetal anatomical
survey and fetal echocardiogram (especially in cases of
severe polyhydramnios), the role of fetal karyotyping in
the presence of associated structural anomalies and the
rationale for antenatal testing in pregnancies complicated
by polyhydramnios.

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