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Oligohydramnios: a prospective study of fetal, neonatal and maternal outcomes in low-middle income countries

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Background: Oligohydramnios is a condition of abnormally low amniotic fluid volume that has been associated with poor pregnancy outcomes. To date, the prevalence of this condition and its outcomes has not been well described in low and low-middle income countries (LMIC) where ultrasound use to diagnose this condition in pregnancy is limited. As part of a prospective trial of ultrasound at antenatal care in LMICs, we sought to evaluate the incidence of and the adverse maternal, fetal and neonatal outcomes associated with oligohydramnios. Methods: We included data in this report from all pregnant women in community settings in Guatemala, Pakistan, Zambia and the Democratic Republic of Congo (DRC) who received a third trimester ultrasound as part of the First Look Study, a randomized trial to assess the value of ultrasound at antenatal care. Using these data, we conducted a planned secondary analysis to compare pregnancy outcomes of women with to those without oligohydramnios. Oligohydramnios was defined as measurement of an Amniotic Fluid Index less than 5 cm in at least one ultrasound in the third trimester. The outcomes assessed included maternal morbidity and fetal and neonatal mortality, preterm birth and low-birthweight. We used pairwise site comparisons with Tukey-Kramer adjustment and multivariable logistic models using general estimating equations to account for the correlation of outcomes within cluster. Results: Of 12,940 women enrolled in the clusters in Guatemala, Pakistan, Zambia and the DRC in the First Look Study who had a third trimester ultrasound examination, 87 women were diagnosed with oligohydramnios, equivalent to 0.7% of those studied. Prevalence of detected oligohydramnios varied among study sites; from the lowest of 0.2% in Zambia and the DRC to the highest of 1.5% in Pakistan. Women diagnosed with oligohydramnios had higher rates of hemorrhage, fetal malposition, and cesarean delivery than women without oligohydramnios. We also found unfavorable fetal and neonatal outcomes associated with oligohydramnios including stillbirths (OR 5.16, 95%CI 2.07, 12.85), neonatal deaths < 28 days (OR 3.18, 95% CI 1.18, 8.57), low birth weight (OR 2.10, 95% CI 1.44, 3.07) and preterm births (OR 2.73, 95%CI 1.76, 4.23). The mean birth weight was 162 g less (95% CI -288.6, - 35.9) with oligohydramnios. Conclusions: Oligohydramnos was associated with worse neonatal, fetal and maternal outcomes in LMIC. Further research is needed to assess effective interventions to diagnose and ultimately to reduce poor outcomes in these settings. Trial registration: NCT01990625.
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R E S E A R C H Open Access
Oligohydramnios: a prospective study of
fetal, neonatal and maternal outcomes in
low-middle income countries
Lester Figueroa
1
, Elizabeth M. McClure
2*
, Jonathan Swanson
3
, Robert Nathan
3
, Ana L. Garces
1
, Janet L. Moore
2
,
Nancy F. Krebs
4
, K. Michael Hambidge
4
, Melissa Bauserman
5
, Adrien Lokangaka
6
, Antoinette Tshefu
6
,
Waseem Mirza
7
, Sarah Saleem
8
, Farnaz Naqvi
8
, Waldemar A. Carlo
9
, Elwyn Chomba
10
, Edward A. Liechty
11
,
Fabian Esamai
12
, David Swanson
13
, Carl L. Bose
5
and Robert L. Goldenberg
14
Abstract
Background: Oligohydramnios is a condition of abnormally low amniotic fluid volume that has been associated
with poor pregnancy outcomes. To date, the prevalence of this condition and its outcomes has not been well
described in low and low-middle income countries (LMIC) where ultrasound use to diagnose this condition in
pregnancy is limited. As part of a prospective trial of ultrasound at antenatal care in LMICs, we sought to evaluate
the incidence of and the adverse maternal, fetal and neonatal outcomes associated with oligohydramnios.
Methods: We included data in this report from all pregnant women in community settings in Guatemala, Pakistan,
Zambia and the Democratic Republic of Congo (DRC) who received a third trimester ultrasound as part of the First
Look Study, a randomized trial to assess the value of ultrasound at antenatal care. Using these data, we conducted a
planned secondary analysis to compare pregnancy outcomes of women with to those without oligohydramnios.
Oligohydramnios was defined as measurement of an Amniotic Fluid Index less than 5 cm in at least one ultrasound in
the third trimester. The outcomes assessed included maternal morbidity and fetal and neonatal mortality, preterm birth
and low-birthweight. We used pairwise site comparisons with Tukey-Kramer adjustment and multivariable logistic
models using general estimating equations to account for the correlation of outcomes within cluster.
Results: Of 12,940 women enrolled in the clusters in Guatemala, Pakistan, Zambia and the DRC in the First Look Study
who had a third trimester ultrasound examination, 87 women were diagnosed with oligohydramnios, equivalent to
0.7% of those studied. Prevalence of detected oligohydramnios varied among study sites; from the lowest of 0.2% in
Zambia and the DRC to the highest of 1.5% in Pakistan. Women diagnosed with oligohydramnios had higher rates of
hemorrhage, fetal malposition, and cesarean delivery than women without oligohydramnios. We also found
unfavorable fetal and neonatal outcomes associated with oligohydramnios including stillbirths (OR 5.16, 95%CI 2.07,
12.85), neonatal deaths < 28 days (OR 3.18, 95% CI 1.18, 8.57), low birth weight (OR 2.10, 95% CI 1.44, 3.07) and preterm
births (OR 2.73, 95%CI 1.76, 4.23). The mean birth weight was 162g less (95% CI -288.6, 35.9) with oligohydramnios.
Conclusions: Oligohydramnos was associated with worse neonatal, fetal and maternal outcomes inLMIC.Furtherresearch
is needed to assess effective interventions to diagnose and ultimately to reduce poor outcomes in these settings.
Trial registration: NCT01990625.
Keywords: Oligohydramnios, Low and middle-income countries, Ultrasound, Pregnancy outcomes
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: mcclure@rti.org
2
Social Statistical and Environmental Health Sciences, RTI International,
Durham, NC, USA
Full list of author information is available at the end of the article
Figueroa et al. Reproductive Health (2020) 17:19
https://doi.org/10.1186/s12978-020-0854-y
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Plain English summary
Low levels of amniotic fluid (also known as oligohy-
dramnios) have been associated with a number of ad-
verse pregnancy outcomes in high-income countries. In
this analysis of data from pregnancies in the First Look
Trial from Guatemala, Pakistan, Zambia and the Demo-
cratic Republic of Congo involving nearly 13,000 women
with a third trimester ultrasound examination, oligohy-
dramnios was found in about 1 in 150 pregnancies. Oli-
gohydramnios was associated with higher rates of
maternal hemorrhage, fetal malposition and cesarean de-
livery than in pregnancies without oligohydramnios.
Higher rates of poor fetal/neonatal outcomes were also
associated with oligohydramnios, including a 5-fold in-
crease in stillbirths and a 3-fold increase in deaths
among babies less than 28 days of age. The babies were
also twice as likely to be born prematurely or to be low
birth weight (weigh less than 2500 g). The babies from
pregnancies complicated by oligohydramnios weighed
on average 162 g less than those from pregnancies with-
out oligohydramnios. In summary, similar to results
from high-income countries, in the low- and middle-
income countries studied, oligohydramnios was associ-
ated with a number of pregnancy-related complications
for the mother and her fetus and newborn.
Background
An appropriate volume of amniotic fluid is one of the
most important components of a healthy pregnancy, as
it acts as a protective cushion for the fetus, prevents
compression of the umbilical cord, and promotes fetal
lung development [1]. While the average volume of am-
niotic fluid varies with gestational age, abnormally low
amniotic fluid volume has been associated with adverse
pregnancy outcomes. Oligohydramnios, in which the
volume of amniotic fluid is abnormally low (< 500 ml)
between the 32nd and 36th weeks of pregnancy, is a ser-
ious condition for the fetus and the mother [1,2]. Oligo-
hydramnios can be diagnosed with ultrasound
performed during the late second trimester or the third
trimester and is defined by an Amniotic Fluid Index
(AFI) below 5 cms or below the 5th percentile to ap-
proximate the amniotic fluid volume [3,4].
In settings where ultrasound use is widespread, rates
of oligohydramnios have been reported between 0.5 and
8% among pregnant women [5]. When associated with a
fetal anomaly, oligohydramnios is present in as many as
37% of pregnancies and is higher with other pregnancy
complications [6]. However, because ultrasound is not
commonly used during routine prenatal care in many
low and middle-income country (LMIC) settings, the
population rates of oligohydramnios and the associated
outcomes in LMIC settings are largely unknown.
Maternal conditions such as utero-placental insufficiency,
hypertension, preeclampsia, diabetes, chronic hypoxia, rup-
ture of amniotic membranes, dehydration and post-term
gestation have been associated with oligohydramnios [1,2].
Anomalies of the kidneys including congenital absence of
renal tissue, obstructive uropathy or decreased renal perfu-
sion also may be contributing factors [7]. Most oligohy-
dramnios cases, however, are idiopathic [1,2].
Fetal health can be seriously compromised by oligohydram-
nios, with complications such as pulmonary hypoplasia, meco-
nium aspiration syndrome, fetal compression and, in cases of
prolonged rupture of membranes, infections [1,2,8,9].
Women with oligohydramnios are more likely to have an in-
fant with low birth weight [1013]. In terms of burden of care,
higher rates of cesarean delivery for fetal distress and neonatal
admission to the intensive care unit have also been associated
with oligohydramnios [4,8]. Timely identification and treat-
ment have been associated with improvement in some mater-
nal and fetal/neonatal outcomes. When detected, clinical
management of women with oligohydramnios can include
amnioinfusion, early induction of labor and even cesarean de-
livery [13,14]. However, gaps in knowledge remain, including
the incidence of oligohydramnios in LMIC, the role of the
underlying conditions associated with oligohydramnios and
their association with oligohydramnios and adverse pregnancy
outcomes [1517].
To address this need, we conducted a secondary analysis
of data from the First Look Trial, which aimed to deter-
mine if the introduction of ultrasound examinations dur-
ing antenatal care in low-resource settings improved
maternal mortality, maternal near-miss mortality, stillbirth
and neonatal mortality. The methods and results of the
parent trial have been published [17,18]. Our objectives
in conducting this planned secondary analysis included
determining the prevalence of oligohydramnios, risk fac-
tors for this condition, and the maternal and fetal out-
comes associated with oligohydramnios in LMIC settings.
Methods
We evaluated oligohydramnios among women enrolled
in the First Look Trial, a multi-country cluster random-
ized study that enrolled pregnant women in rural areas
within Guatemala, Pakistan, Kenya, Zambia and the
Democratic Republic of Congo (DRC). Briefly, as part of
the trial, at each site, medical officers, nurses, midwives
and radiographers with no prior ultrasound experience
were trained to perform basic obstetric ultrasound ex-
aminations to determine gestational age and screen for
high-risk conditions. All sonographers received stan-
dardized training using the Basic Obstetric Ultrasound
Training methodology developed by the University of
Washington (UW) team [1921]. This training consisted
of an intensive two-week training led by the UW team
with both didactic and hands-on components. In
Figueroa et al. Reproductive Health (2020) 17:19 Page 2 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
addition, during the next 3 months, a minimum of five
examinations were observed directly by an experienced
sonographer and all ultrasound examinations, including
the images and interpretation, were evaluated by a senior
radiologist either at UW or at the site for quality assur-
ance (QA) [20]. Using the web-based application, all
ultrasound images were uploaded at the site, then
reviewed by the senior QA radiologist with feedback
provided to the field sonographers on a regular basis
[20,21]. Throughout the trial, quality control procedures
were used to assess and maintain a high rate of accuracy
for the ultrasound diagnoses. We emphasize that all sites
used the same equipment and that the criteria for diag-
nosing oligohydramnios were the same for all sites.
For this analysis, we included those participants who had at
least one ultrasound examination in the third trimester. We
defined oligohydramnios as an amniotic fluid index below 5
cms on one or more ultrasound examinations performed after
28 weeks. All cases of oligohydramnios were confirmed by the
central QA team of experienced radiologists at the UW. In
addition, approximately 10% of all ultrasound examinations
other than those with oligohydramnios were also reviewed for
accuracy. Body mass index (BMI) was defined as the mothers
weight in kilograms divided by her height in meters squared.
All maternal and infant outcomes up to 6 weeks postpartum
were collected by the Global Networks Maternal Newborn
Health Registry [22]. We excluded women from the analysis
who were lost to follow-up prior to delivery, maternal deaths
that occurred before 20 weeks, and women who had a miscar-
riage or a medical termination of pregnancy. Because the Ken-
yan site had no cases of oligohydramnios identified in the
third trimester, we present data only from Pakistan, the DRC,
Guatemala and Zambia. However, the results were similar
with and without the Kenyan data.
Data were keyed and edit checks conducted locally before
data were transferred through encrypted transmission to a
central data center. We reported pairwise mean differences
of oligohydramnios for each site and p-values with a
Tukey-Kramer adjustment for multiple comparisons from a
logistic model adjusting for site using generalized estimat-
ing equations (GEE) to account for the correlation of oligo-
hydramnios within cluster. To determine maternal
characteristics associated with oligohydramnios, p-values
were obtained from logistic models using GEE and adjust-
ing for site and each maternal characteristic. In addition,
odds ratios and 95% confidence intervals for delivery com-
plications and fetal/neonatal outcomes were obtained from
logistic models, adjusting for oligohydramnios, study site
and prior live birth using GEE to account for the correl-
ation of outcomes within cluster.
Ethics
This study was reviewed and approved by the institu-
tional review boards of participating institutions (Aga
Khan University, Pakistan; Moi University, Kenya; Uni-
versity of Zambia; INCAP, Guatemala; and Kinshasa
School of Public Health, DRC; University of Washing-
ton, Seattle WA; RTI International, Durham NC). All
women provided informed consent prior to enrollment
in the trial.
Results
A total of 12,940 participants in Guatemala, Pakistan,
Zambia and the DRC received at least one third trimester
study ultrasound examination (Fig. 1). Eighty-seven cases
of oligohydramnios, equivalent to 0.7% of the subjects in
this analysis, were detected on a third trimester ultrasound.
Prevalence of oligohydramnios varied among study sites
with the lowest rates in Zambia and the DRC (0.2%) and
the highest in Pakistan (1.5%) (Table 1). We found differ-
ences in prevalence to be statistically significant between
the Guatemalan and Pakistan sites that had the highest
prevalence,incomparisontotheZambiansitethathadthe
lowest prevalence. Mean gestational age at the time of first
diagnosis of oligohydramnios was 35.5 ± 4.1 weeks.
The only significant difference in the maternal charac-
teristics between those women with and without oligo-
hydramnios using a logistic regression model with
primiparas in the model was found in women with a
previous live birth. There were no statistically significant
differences among the other maternal characteristics in-
cluding in the distribution of maternal age, education,
parity, maternal height, weight and BMI between partici-
pants with or without oligohydramnios (Table 2).
Women with oligohydramnios had significantly higher
incidences of hemorrhage (5.7% vs. 1.7%, OR 2.94, 95% CI
1.31, 6.61) and fetal malposition (5.7% vs. 1.9%, OR 2.44,
95% CI 1.07, 5.59) (Table 3). Cesarean deliveries were
more commonly performed in women with oligohydram-
nios compared to those without oligohydramnios (28.7%
vs. 13.5%, OR 2.07, 95% CI 1.41, 3.03). While hypertensive
disorders were more common in women with oligohy-
dramnios, 4.6% compared to 2.2%, we were not able to get
the model to converge, likely due to the low prevalence of
hypertension in the African sites. There were no maternal
deaths among the women with oligohydramnios.
We also found unfavorable fetal and neonatal out-
comes among women with oligohydramnios. Women
with oligohydramnios compared to those without had
higher risk for stillbirths (80.5 per 1000 births vs. 14.9
per 1000 births, OR 5.16, 95% CI 2.07, 12.85), neonatal
deaths within 28 days (75.0 vs 16.7 per 1000 live births,
OR 3.18, 95% CI 1.18, 8.57), low birth weight (29.9% vs
11.7%, OR 2.10, 95% CI 1.44, 3.07) and preterm birth
(31.8% vs 11.4%, OR 2.73, 95% CI 1.76, 4.23). Congenital
anomalies were more common among the offspring of
women with oligohydramnios compared to without oli-
gohydramnios (2.6% vs. 0.1%, respectively) but likely due
Figueroa et al. Reproductive Health (2020) 17:19 Page 3 of 7
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to small numbers, the logistic regression model did not
converge. The mean birth weight was significantly lower
in the oligohydramnios group based on the model, with a
mean difference of 162.3 g (95% CI 288.6 g, 35.9 g).
Discussion
The overall prevalence of oligohydramnios on a third tri-
mester ultrasound examination performed on average
around 35 weeks of pregnancy was 0.7% across sites,
with the lowest incidence in Zambia and the DRC (0.2%)
and highest in Pakistan (1.5%). These rates are within
the ranges found in high-income countries and provide
evidence regarding the rate of oligohydramnios in LMIC
settings [4,812].
We found no substantial demographic differences
among women with or without this condition. However,
we did find significant differences in delivery complica-
tions; hemorrhage, fetal malposition and cesarean sec-
tion were significantly more common in women with
oligohydramnios. The higher rates of these complica-
tions have been noted in studies from high-income
countries. Most interesting were the fetal and neonatal
outcomes associated with oligohydramnios. The stillbirth
rate was five-fold higher and the neonatal death rate
three-fold higher in this group. The mean birth weight
was lower in women with oligohydramnios by 162 g and
the incidences of low birth weight and preterm birth
were higher. Similar results have been found in stud-
ies from high-income settings [4,8,9,1113]. During
the parent study we emphasized appropriate referral
and hospital care for conditions diagnosed by ultra-
sound including oligohydramnios. However, care at
many of the study hospitals was less than optimal
and we do not know if better care for women with
oligohydramnios and their neonates would have im-
proved the outcomes.
The strengths of the study included the large sample
size, more than 12,900 pregnant women had a third tri-
mester ultrasound examination. In addition, we had
broad representation with women from 4 countries on 3
continents included in this analysis. The data were all
Table 1 Incidence of oligohydramnios by FIRST LOOK study site
Overall DRC Zambia Guatemala Pakistan
At least one US exam
28 weeks, n
12,940 1978 3571 5507 1884
Incidence of
oligohydramnios, n (%)
87
(0.7)
4
(0.2)
6 (0.2) 49 (0.9) 28 (1.5)
GA at first diagnosis,
Mean (sd)
35.5
(4.1)
37.8
(1.4)
35.9
(1.3)
36.6 (3.7) 33.0
(4.3)
Fig. 1 CONSORT diagram
Figueroa et al. Reproductive Health (2020) 17:19 Page 4 of 7
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collected prospectively. Every case in which oligohy-
dramnios was diagnosed was also confirmed by a radi-
ologist with extensive expertise in ultrasonography in
pregnancy [1821]. Outcome data were collected inde-
pendently from the ultrasound study team as part of an
ongoing pregnancy outcome registry.
Potential weaknesses included the fact that the
sonographers were recently trained and had limited
ultrasound experience, although they received excel-
lent training and their examinations were monitored
during the study. The timing of the stillbirth was
not routinely collected so whether the stillbirth pre-
ceded the diagnosis of oligohydramnios or followed
it is unclear. There were few congenital anomalies in
the oligohydramnios group, so further study of this
issue was impractical. While there was little evidence
of membrane rupture at the time of the diagnosis of
oligohydramnios, routine testing for membrane rup-
ture was not done at that time. The potential rea-
sons for the lower reported rates of oligohydramnios
in the African sites compared to the Guatemalan
and Pakistan sites are unexplained; however, this dis-
crepancy may suggest that some women with oligo-
hydramnios were missed. We emphasize, however,
that every examination diagnosed as having oligohy-
dramnios was confirmed by the QA radiologist. We
also emphasize that since data for this analysis came
from four countries on three continents, and in-
cluded 87 cases of third trimester oligohydramnios,
we believe the maternal, fetal and neonatal outcomes
associated with oligohydramnios are generalizable to
many LMIC.
Conclusions
The incidence of oligohydramnios in our LMIC was
not generally associated with the maternal demo-
graphic characteristics assessed, but oligohydramnios
was associated with a variety of materrnal, fetal and
neonatal adverse outcomes. While this study demon-
strated that newly trained sonographers were capable
of diagnosing oligohydramnios [1922]andthat
women with oligohydramnios often had worse out-
comes than women withoutoligohydramnios,our
data do not prove that diagnosing oligohydramnios
during pregnancy with ultrasound improves
outcomes.
Some studies from high income countries suggest
that treating some cases of oligohydramnios may im-
prove certain outcomes [13,14,23], but whether in-
terventions such as amnioinfusion or early delivery
or delivery by cesarean section would achieve similar
results in LMICs is unknown [24,25]. The overall
trial showed no benefit of ultrasound for any im-
portant outcome including maternal death or near-
Table 2 Maternal characteristics in women with and without oligohydramnios
With Oligohydramnios No Oligohydramnios Overall p-Value
1
At least one US exam 28 weeks, n 87 12,853 12,940
Maternal age (years), n (%) 87 12,849 12,936 0.2766
< 20 17 (19.5) 2185 (17.0) 2202 (17.0)
2035 61 (70.1) 9577 (74.5) 9638 (74.5)
> 35 9 (10.3) 1087 (8.5) 1096 (8.5)
Maternal education, n (%) 87 12,851 12,938 0.1698
No formal schooling 30 (34.5) 3209 (25.0) 3239 (25.0)
Primary 37 (42.5) 4403 (34.3) 4440 (34.3)
Secondary 19 (21.8) 4873 (37.9) 4892 (37.8)
University 1 (1.1) 366 (2.8) 367 (2.8)
Parity, n (%) 82 12,660 12,742 0.1253
0 25 (30.5) 2993 (23.6) 3018 (23.7)
1 14 (17.1) 2847 (22.5) 2861 (22.5)
2+ 43 (52.4) 6820 (53.9) 6863 (53.9)
Previous live birth among multipara, n/N (%) 52/57 (91.2) 9092/9667 (94.1) 9144/9724 (94.0) 0.5814
Previous live birth with primipara in denominator, n/N (%) 52/82 (63.4) 9092/12,660 (71.8) 9144/12,742 (71.8) 0.0421
Maternal height, Mean (sd) 151.1 (7.6) 153.5 (8.1) 153.5 (8.1) 0.7097
Maternal weight, Mean (sd) 55.1 (10.0) 55.9 (10.1) 55.9 (10.1) 0.0713
Maternal BMI, Mean (sd) 24.2 (4.2) 23.8 (4.2) 23.8 (4.2) 0.1007
1
P-value from a logistic regression model for at least one oligohydramnios finding adjusting for site and maternal characteristics using general estimating
equations to account for the correlation of outcomes within cluster
Figueroa et al. Reproductive Health (2020) 17:19 Page 5 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
miss maternal mortality, stillbirth and neonatal mor-
tality [19]. However, since the main trial was not
specifically aimed at improving outcomes associated
with oligohydramnios, the benefit of these interven-
tions in LMIC, if any, remains unknown.
Abbreviations
LMIC: Low-middle income countries; US: Ultrasound
Acknowledgements
The authors wish to acknowledge the FIRST LOOK Study staff who contributed
to the study including: University of Zambia: Melody Chiwala, Musaku M
Mwenechanya, Dorothy Hamsumonde; Kinshasa School of Public Health: Victor
Lokombo Bolamba; Moi University: Nancy Kanaiza, David Muyodi; INCAP: Irma
Sayury Pineda
,
Walter López-Gomez; RTI International: Dennis D Wallace, Holly
Franklin. We thank the women who participated in the study.
Authorscontributions
LF and ALG conceived of the study concept; JS, RN and DS developed the study
ultrasound training and together with WM and LF reviewed study ultrasounds;
JLM performed study analyses with EMM; NFK, KMH, MB, AL, AT, SS, FN, WAC, EC,
EAL, FE, CLB and RLG developed the study protocol and monitored
implementation; LF, RLG and EMM developed the initial manuscript with input
from CLB, WAC. All authors reviewed and approved the final manuscript.
Funding
The study was funded by grants from the Bill & Melinda Gates Foundation and
from the U.S. National Institutional of Child Health and Human Development.
Ultrasound equipment was loaned for the period of the trial by GE Healthcare,
which also provided a grant to the University of Washington to provide training
and quality assurance of the ultrasound examinations.
Availability of data and materials
The dataset analysed during the current study are available at NICHD Data
and Specimen Hub (NDASH) (https://dash.nichd.nih.gov/).
Ethics approval and consent to participate
This trial was reviewed and approved by the institutional review committee at
Columbia University (FWA00002636; New York, NY) (approved 9/30/2013), RTI
International (FWA00003331 Durham, NC) (approved 7/19/2013) and the ethics
review committees at Aga Khan University (FWA00001177; Karachi Pakistan)
(approved 8/7/14), Kinshasa School of Public Health (FWA000003581 Kinshasa, DRC)
(approved 2/13/14), Universidad Francisco Marroquin Facultad de Medicina
(FWA000003581 Guatemala City, Guatemala) (approved 12/06/13), Moi University
(FWA000003128; Eldoret, Kenya) (approved 6/10/14), and the University of Zambia
(FWA00000338; Lusaka, Zambia) (approved 2/13/14). All women who participated
provided informed consent.
Table 3 Delivery complications and fetal/neonatal outcomes in women with and without oligohydramnios
With
Oligohydramnios
No
Oligohydramnios
Overall Odds Ratio
b
or Mean Difference
c
(95% CI)
Delivery complications
Obstructed labor, n/N (%) 5/87 (5.7) 531/12,852 (4.1) 536/12,939 (4.1) 0.84 (0.36, 1.93)
Hemorrhage, n/N (%) 5/87 (5.7) 212/12,666 (1.7) 217/12,753 (1.7) 2.94 (1.31, 6.61)
Hypertensive disorder
d
, n/N (%) 4/87 (4.6) 277/12,851 (2.2) 281/12,938 (2.2)
Fetal malposition, n/N (%) 5/87 (5.7) 243/12,852 (1.9) 248/12,939 (1.9) 2.44 (1.07, 5.59)
C-section delivery, n/N (%) 25/87 (28.7) 1736/12,851 (13.5) 1761/12,938
(13.6)
2.07 (1.41, 3.03)
Maternal death < 42 days
d
, n/N (rate/100,000
deliveries)
0/87 (0) 12/12,800 (94) 12/12,887 (93)
Maternal sepsis, n/N (%) 1/87 (1.1) 134/12,720 (1.1) 135/12,807 (1.1) 0.82 (0.19, 3.57)
Fetal/Neonatal outcomes
a
Stillbirth, n/N (rate/1000) 7/87 (80.5) 192/12,852 (14.9) 199/12,939
(15.4)
5.16 (2.07, 12.85)
Male, n/N (%) 43/86 (50.0) 6578/12,849 (51.2) 6621/12,935
(51.2)
0.99 (0.69, 1.41)
Low birth weight, n/N (%) 26/87 (29.9) 1507/12,849 (11.7) 1533/12,936
(11.9)
2.10 (1.44, 3.07)
Multiple gestation, n/N (%) 2/87 (2.3) 76/12,851 (0.6) 78/12,938 (0.6) 1.93 (0.26, 14.37)
Congenital anomaly
d
, n/N (%) 2/77 (2.6) 18/12,513 (0.1) 20/12,590 (0.2)
Birth weight, Mean (sd) 2710 (595) 2971 (441) 2969 (443) 162.3 (288.6, 35.9)
GA at delivery, Mean (sd) 37.7 (2.9) 38.6 (2.0) 38.6 (2.0) 0.53 (1.07, 0.00)
Preterm Birth, n/N (%) 27/85 (31.8) 1438/12,566 (11.4) 1465/12,651
(11.6)
2.73 (1.76, 4.23)
Neonatal death < 28 days, n/N (rate/1000) 6/80 (75.0) 211/12,613 (16.7) 217/12,693
(17.1)
3.18 (1.18, 8.57)
a
Fetal/Neonatal outcomes are calculated at the maternal level if at least one fetus/neonate has the outcome
b
Odds ratios from a multivariable logistic regression model adjusting for at least one oligohydramnios finding, previous
live birth and site using general estimating equations to account for the correlation of outcomes within cluster
c
Mean difference from a multivariable regression model adjusting for at least one oligohydramnios finding and site, previous live birth and site using general
estimating equations to account for the correlation of outcomes within cluster
d
Model did not converge
Figueroa et al. Reproductive Health (2020) 17:19 Page 6 of 7
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Competing interests
The authors declare that they have no competing interests.
Author details
1
Instituto de Nutrición de Centro América y Panamá (INCAP), Guatemala City,
Guatemala.
2
Social Statistical and Environmental Health Sciences, RTI
International, Durham, NC, USA.
3
Department of Radiology, University of
Washington Medical Center, Seattle, WA, USA.
4
Department of Pediatrics,
University of Colorado, Denver, CO, USA.
5
Department of Pediatrics,
University of North Carolina School of Medicine, Chapel Hill, NC, USA.
6
Kinshasa School of Public Health, Kinshasa, Democratic Republic of the
Congo.
7
Department of Radiology, Aga Khan University, Karachi, Pakistan.
8
Department of Community Health Sciences, Aga Khan University, Karachi,
Pakistan.
9
Department of Pediatrics, University of Alabama at Birmingham,
Birmingham, AL, USA.
10
Department of Pediatrics, University of Zambia,
Lusaka, Zambia.
11
Department of Pediatrics, Indiana University, Indianapolis,
IN, USA.
12
School of Medicine, Moi University, Eldoret, Kenya.
13
Department
of Radiology, Harborview Medical Center, University of Washington Medical
Center, Seattle, WA, USA.
14
Department of Obstetrics/Gynecology, Columbia
University, New York, NY, USA.
Received: 16 February 2019 Accepted: 6 January 2020
References
1. Cunningham FG, Williams JW (John W. Williams Obstetrics. McGraw-Hill
Medical; 2010. https://www.ncbi.nlm.nih.gov/nlmcatalog/101510655.
2. Fischer RL. Amniotic fluid: physiology and assessment. Glob Libr Womens
Med. 2009. https://doi.org/10.3843/GLOWM.10208.
3. Brace RA. Physiology of amniotic fluid volume regulation. Clin Obstet
Gynecol. 1997;40:2809.
4. Locatelli A, Zagarella A, Toso L, Assi F, Ghidini A, Biffi A. Serial assessment of
amniotic fluid index in uncomplicated term pregnancies: prognostic value
of amniotic fluid reduction. J Matern Neonatal Med. 2004;15:2336.
5. Han CS. Fetal Biophysical Profile. Obstet Imaging Fetal Diagnosis Care
[Internet]. Elsevier; 2018;537540.e1. [cited 2020 Jan 12]. Available from:
https://www.sciencedirect.com/science/article/pii/B978032344548100125X.
6. Coady AM. Amniotic Fluid. Twinings Textb Fetal Abnorm [Internet].
Churchill Livingstone; 2015;8199. [cited 2020 Jan 12]. Available from:
https://www.sciencedirect.com/science/article/pii/B97807020459120000485.
7. Boubred F, Simeoni U. Pathophysiology of fetal and neonatal kidneys. In:
Neonatology. Cham: Springer International Publishing; 2017. p. 115.
8. Patel A, Patel HV. Role of amniotic fluid index in pregnancy outcome, vol. 2;
2015. p. 112.
9. Voxman EG, Tran S, Wing DA. Low amniotic fluid index as a predictor of
adverse perinatal outcome. J Perinatol. 2002;22:2825.
10. Mathuriya G, Verma M, Rajpoot S. Comparative study of maternal and fetal
outcome between low and normal amniotic fluid index at term. Int J
Reprod contraception. Obstet Gynecol. 2017;6:640.
11. Rabie N, Magann E, Steelman S, Ounpraseuth S. Oligohydramnios in
complicated and uncomplicated pregnancy: a systematic review and meta-
analysis. Ultrasound Obstet Gynecol. 2017;49:4429.
12. Madhavi K, Pc R, Professor A. Clinical study of oligohydramnios, mode of
delivery and perinatal outcome. IOSR J Dent Med Sci. 2015;14:2279861.
13. Butt FT, Ahmed B. The role of antepartum transabdominal amnioinfusion in
the management of oligohydramnios in pregnancy. J Matern Fetal Neonatal
Med. 2011;24:4537.
14. Turhan NÖ, Atacan N. Antepartum prophylactic transabdominal
amnioinfusion in preterm pregnancies complicated by oligohydramnios. Int
J Gynecol Obstet. 2002;76:1521.
15. Hesson A, Langen E. Outcomes in oligohydramnios: the role of etiology in
predicting pulmonary morbidity/mortality. J Perinat Med. 2018;46:94850.
16. Melamed N, Pardo J, Milstein R, Chen R, Hod M, Yogev Y. Perinatal outcome
in pregnancies complicated by isolated oligohydramnios diagnosed before
37 weeks of gestation. Am J Obstet Gynecol. 2011;205:241 e16.
17. McClure EM, Nathan RO, Saleem S, Esamai F, Garces A, Chomba E, et al. First look: a
cluster-randomized trial of ultrasound to improve pregnancy outcomes in low
income country settings. BMC Pregnancy Childbirth. 2014;14:73.
18. Goldenberg RL, Nathan R, Swanson D, Saleem S, Mirza W, Esamai F, et al.
Routine antenatal ultrasound in low- and middle-income countries: first
look - a cluster randomised trial. BJOG. 2018;125:15919.
19. Nathan R, Swanson JO, Marks W, Goldsmith N, Vance C, Sserwanga NB, et al.
Screening obstetric ultrasound training for a 5-country cluster randomized
controlled trial. Ultrasound Q. 2014;30:2626.
20. Nathan RO, Swanson JO, Swanson DL, McClure EM, Bolamba VL, Lokangaka
A, et al. Evaluation of focused obstetric ultrasound examinations by health
care personnel in the Democratic Republic of Congo, Guatemala, Kenya,
Pakistan, and Zambia. Curr Probl Diagn Radiol. 2017;46:2105.
21. Swanson JO, Plotner D, Franklin HL, et al. Web-based quality assurance
process drives improvements in obstetric ultrasound in 5 low- and middle-
income countries. Glob Heal Sci Pract. 2016;4:67583.
22. Bose CL, Bauserman M, Goldenberg RL, Goudar SS, McClure EM, Pasha O,
et al. The Global Network Maternal Newborn Health Registry: a multi-
national, community-based registry of pregnancy outcomes. Reprod Health.
2015;12(2):S1.
23. Gizzo S, Noventa M, Vitagliano A, Dall'Asta A, D'Antona D, Aldrich CJ, et al.
An update on maternal hydration strategies for amniotic fluid improvement
in isolated Oligohydramnios and Normohydramnios: evidence from a
systematic review of literature and meta-analysis. PLoS One. 2015;10:
e0144334.
24. Umber A, Chohan MA. Intravenous maternal hydration in third trimester
oligohydramnios: effect on amniotic fluid volume. J Coll Physicians Surg
Pak. 2007;17:3369.
25. Haws RA, Yakoob MY, Soomro T, Menezes EV, Darmstadt GL, Bhutta ZA.
Reducing stillbirths: screening and monitoring during pregnancy and
labour. BMC Pregnancy Childbirth. 2009;9(Suppl 1):S5.
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... 4 It is associated with unfavourable maternal and foetal health outcomes, including a 5-fold increase in stillbirths and a 3-fold increase in deaths among neonates. 5 The weight of babies from pregnancies complicated by oligohydramnios is, on average, 162 g less than those without oligohydramnios. 5 It is a cause of concern since Pakistan has the highest incidence of oligohydramnios during the third trimester of pregnancy among low-middle-income countries. ...
... 5 The weight of babies from pregnancies complicated by oligohydramnios is, on average, 162 g less than those without oligohydramnios. 5 It is a cause of concern since Pakistan has the highest incidence of oligohydramnios during the third trimester of pregnancy among low-middle-income countries. 5 One of the reasons is the self-administration of NSAIDs by pregnant females due to a lack of proper medical supervision. ...
... 5 It is a cause of concern since Pakistan has the highest incidence of oligohydramnios during the third trimester of pregnancy among low-middle-income countries. 5 One of the reasons is the self-administration of NSAIDs by pregnant females due to a lack of proper medical supervision. Hence, a multifaceted approach involving healthcare professionals, policymakers, and general population is required to address this issue of NSAIDs misuse in Pakistan. ...
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The non-steroidal anti-inflammatory drugs (NSAIDs) are a class of drug with analgesic, anti-inflammatory, and antipyretic effects. Their primary mechanism of action is the inhibition of the cyclooxygenase (COX) enzyme and a consequent reduction in prostaglandin levels. There is a high global prevalence of NSAIDs used by pregnant females for pain management because of the abundance and ease of access to these compounds. In Pakistan, the most commonly used OTC analgesic medications during pregnancy include acetaminophen, ibuprofen and aspirin.1 A study by Bohio et al discovered that 77.4% of women taking these medications have no knowledge about their dosage and potential adverse effects.2 A recent systematic review by Ambrosio et al. established that the use of NSAIDs during pregnancy can cause oligohydramnios by blocking the synthesis of prostaglandins responsible for normal foetal renal perfusion.3 Oligohydramnios is a serious condition characterised by abnormally low volume (< 500 ml) of amniotic fluid between the 32nd and 36th weeks of pregnancy.4 It is associated with unfavourable maternal and foetal health outcomes, including a 5-fold increase in stillbirths and a 3-fold increase in deaths among neonates.5 The weight of babies from pregnancies complicated by oligohydramnios is, on average, 162 g less than those without oligohydramnios.5 It is a cause of concern since Pakistan has the highest incidence of oligohydramnios during the third trimester of pregnancy among low-middle-income countries.5 One of the reasons is the self-administration of NSAIDs by pregnant females due to a lack of proper medical supervision. Hence, a multifaceted approach involving healthcare professionals, policymakers, and general population is required to address this issue of NSAIDs misuse in Pakistan. This includes education of pregnant women regarding the safe and appropriate management of pain, existing alternate treatment options and consequences of non-prescribed OTC analgesic use during pregnancy. Secondly, the use of NSAIDs should be limited to lowest effective dose for the shortest duration and only in situations where maternal benefits outweigh the potential foetal risk. Lastly, ultrasound monitoring of amniotic fluid should be considered beyond 48 h of NSAIDs treatment and if a decline Amniotic Fluid Index (AFI) is present, therapy should be discontinued. Furthermore, government authorities and community stakeholders should implement regulatory policies to restrict the sale of NSAIDs without a prescription and conduct public awareness campaigns regarding their potential adverse effects. Continued...
... Oligohydramnios is a significant obstetric condition that can lead to fetal distress, umbilical cord compression, increased cesarean delivery rates, and adverse neonatal outcomes [1]. It can result from maternal conditions, such as dehydration, hypertensive disorders, or diabetes, as well as fetal and placental factors like growth restriction, congenital renal anomalies, or placental insufficiency [2,3]. ...
... However, isolated oligohydramnios, where there are no identifiable maternal or fetal complications, remain a concern due to their association with higher rates of labor induction, abnormal fetal heart patterns, and neonatal intensive care unit (NICU) admissions [4]. 1 Maternal hydration therapy has been explored as a non-invasive, cost-effective method to increase amniotic fluid volume [5,6]. The underlying physiological mechanism suggests that increased maternal plasma volume enhances placental perfusion and fetal urine output, contributing to improved AFI [7]. ...
... Oligohydramnios may, in some cases, be idiopathic or associated with factors such as maternal dehydration or specific medications. Vigilant monitoring of amniotic fluid levels through ultrasound and other diagnostic tests is essential for healthcare providers to promptly detect and manage oligohydramnios, as it has the potential to lead to various pregnancy complications and impact the overall well-being of the developing baby (Figueroa et al., 2020). The prognosis and management of oligohydramnios depend on factors such as underlying causes, gestational age at diagnosis, and severity of the condition (Keilman & Shanks, 2024). ...
... This often entails collaboration with maternal-fetal medicine specialists and neonatologists to tailor individualised care plans, determine the optimal timing for delivery, and ensure comprehensive postpartum care (Twesigomwe et al., 2022). When oligohydramnios is detected in the last trimester, potential complications may include congenital disabilities, preterm birth, or stillbirth (Figueroa et al., 2020). The diagnosis of oligohydramnios is typically conducted through ultrasound examinations, allowing healthcare providers to assess amniotic fluid levels accurately. ...
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This comprehensive review examines the potential role of sildenafil citrate in ameliorating oligohydramnios in pregnant women, focusing on its impact on amniotic fluid indices. Oligohydramnios, characterised by insufficient amniotic fluid, pose significant risks to fetal and maternal health. This review begins by elucidating the definition of oligohydramnios and its implications in pregnancy, emphasising the critical role of amniotic fluid in foetal development. The rationale for studying sildenafil citrate lies in its vasodilatory properties and potential to improve uteroplacental blood flow, thereby influencing amniotic fluid dynamics. The importance of amniotic fluid indices, particularly the amniotic fluid index (AFI), is discussed, highlighting their relevance as critical indicators of fetal well-being. This review synthesises evidence from experimental studies, both animal and human, exploring the effects of sildenafil citrate on amniotic fluid levels. Safety considerations, maternal and fetal outcomes, and the limitations of existing research are also addressed. The conclusions summarise vital findings, discuss implications for clinical practice, and emphasise the need for further research to establish the safety and efficacy of sildenafil citrate in managing oligohydramnios. This review contributes valuable insights for healthcare professionals, researchers, and policymakers seeking evidence-based approaches to enhance pregnancy outcomes in cases of oligohydramnios.
... Oligohydramnios may lead to adverse feto-maternal outcomes like fetal malposition, stillbirth, neonatal death, low birth weight, and preterm deliveries. [7] L-arginine facilitates vasodilatation and improves placental perfusion, [8] plays a promising role in improving amniotic fluid volume. In some studies [2,8,9,10], an increase in AFI index and gestational age were noted, leading to better fetal and maternal outcomes. ...
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Background: Oligohydramnios referred to as decreased amniotic fluid index (AFI) <5 cm [1] is a serious disorder affecting 4.4% of pregnancies [2]. Borderline oligohydramnios, i.e. AFI between 5.1 to 8 cm also can lead to unwanted outcomes in pregnancy. Less than normal amount of amniotic fluid may lead to complications like restricted growth, underdeveloped organs, fetal distress, less birth weight, preterm birth, prolonged labor, uteroplacental insufficiency, etc. [3] L-arginine, a semi-essential amino acid is suggested to improve amniotic fluid index. [2] Hence our study was planned to know effect of L-arginine in oligohydramnios patients at our centre. Materials and Methods: This was a prospective observational study undertaken in a tertiary care teaching hospital which included 200 patients diagnosed with oligohydramnios from 1st January 2023 to 31st October 2024. Institutional ethics committee permission (PUIECHR/PIMSR/00/081734/5306) was obtained before data collection. All pregnant women with singleton pregnancies diagnosed with oligohydramnios and satisfying inclusion criteria were included and data was recorded for those who received L-arginine along with those who came directly for delivery without receiving L-arginine. Results: Out of 200 patients diagnosed with oligohydramnios, 100 patients received L-arginine and 100 patients came directly for delivery and did not receive L-arginine. Of those receiving L-arginine, the average gestational age of starting L-arginine therapy was 35.3 ± 2.1 weeks while gestational age at delivery was 37.4 ± 1.82. Hence, there was an increase of 2.1 ± 0.27 weeks of gestational age at an average. The increase in AFI after treatment with L-arginine was 0 to 3 cm with a mean of 0.735 cm. Conclusion: Our study showed a significant increase in gestational age as well as an increase in AFI with the administration of L-arginine. For establishing beneficial role of L-arginine in oligohydramnios, more such studies with bigger sample size are needed.
... Journal of Neonatal Surgery | Year: 2025 | Volume: 14 | Issue: 8s of membranes is a common cause of oligohydramnios, with many cases being idiopathic, and the resulting diminished amniotic fluid often leads to an increased rate of cesarean delivery, primarily due to non-reassuring fetal heart rate [11,12]. ...
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Introduction: Amniotic fluid plays a critical role in fetal development, providing protection, facilitating movement, and supporting respiratory functions. Oligohydramnios, defined as an amniotic fluid index (AFI) ≤5 cm, is associated with increased perinatal risks, including umbilical cord compression and impaired fetal circulation. This study aims to evaluate maternal and fetal outcomes associated with oligohydramnios in a tertiary care setting. Materials and Methodology: A prospective, observational hospital-based study was conducted over 1.5 years in the Obstetrics and Gynecology Department at a tertiary care hospital in Gujarat. A total of 163 pregnant women with singleton pregnancies between 28-42 weeks gestation and intact membranes were enrolled. Detailed demographic, clinical, and ultrasonographic assessments were performed. Maternal parameters such as parity, gestational age, and associated conditions were recorded. Neonatal outcomes, including birth weight, APGAR scores, NICU admissions, and perinatal mortality, were analyzed. Statistical analysis was performed using rates, proportions, and percentages. Results: Most participants (80.98%) were aged 21-30 years, with 50.30% delivering preterm. PIH (22.7%) and idiopathic factors (41.1%) were the most common causes of oligohydramnios. LSCS was performed in 46.62% of cases. NICU admission was required for 69.94% of neonates, primarily due to preterm birth (29.82%) and low birth weight (16.81%). APGAR scores >7 were observed in 92.64% of neonates. Perinatal mortality was 1.59%. Conclusion: Oligohydramnios is significantly associated with increased rates of preterm birth, LSCS, and NICU admissions. Early diagnosis and fetal surveillance are crucial in optimizing perinatal outcomes and reducing neonatal complications.
... Additionally, pregnant individuals who experienced water loss during pregnancy were more likely to undergo CD. According to a previous study, low amniotic fluid levels during pregnancy are linked to a higher likelihood of cesarean delivery and may prompt the need for delivery to occur earlier [54]. Those with low amniotic fluid levels often face complications that could require a cesarean delivery. ...
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Background: The rising prevalence of cesarean deliveries (CD) is a major public health problem worldwide, especially in Bangladesh. This study aims to investigate the prevalence and factors associated with cesarean deliveries in the Jashore district of Bangladesh. Study design: This cross-sectional study, conducted from December 2022 to February 2023 in Jashore district, Bangladesh, involved face-to-face interviews with 662 mothers during hospital visits. Methods: A pretested, structured, and validated questionnaire was employed to gather information on socio economic characteristics, obstetric history, maternal healthcare utilization, and factors influencing the choice of delivery method. Multinomial logistic regression models were employed to assess and predict determining fac tors influencing cesarean delivery. Results: The study revealed a high cesarean delivery (CD) prevalence of 70.5 %, exceeding the WHO recommended threshold. Key socioeconomic factors associated with increased CD rates included rural residence, younger maternal age (15–20 years), nuclear family structure, and husbands in business. Additionally, private hospital deliveries, a history of previous CD, maternal self-preference, and doctor’s influence were significant predictors of CD. The majority of participants believed CD enhances maternal safety (74.6 %) and alleviates pain (74.8 %). Conclusion: The high rate of cesarean deliveries in Jashore highlights the need for public health interventions that improve access to quality maternal care and promote evidence-based decision-making. Reducing unnecessary cesarean procedures, particularly in private hospitals, and enhancing patient education can significantly improve maternal and neonatal health outcomes.
... The lung also secretes about 10% to amniotic uid. Any minor inconsistency through the production and swallowing [17] process may lead to polyhydramnios. [18] Shiferaw MA (2024). ...
Article
Introduction : Oligohydramnios, dened as when the Amniotic uid index is less than 5. Denition of increased or decreased amniotic uid volume or based on sonographic criteria. Oligohydramnios complicates 1-2 % of pregnancies. Amniotic uid provides the cushion effect against the constricting connes of the gravid uterus. It creates space and help in musculoskeletal development of fetus, helps in normal fetal lung development and prevents compression of umbilical cord, placenta and hence protects the fetus from vascular and nutritional compromises. Oligohydramnios is associated with high-risk adverse perinatal outcome like fetal distress, meconium aspiration, low APGAR, joint contracture, pulmonary hypoplasia etc., and associated with maternal morbidity in the form of increased rates of induction and/or operative interference. Materials & Methods : This is the prospective observational study of parturient with oligohydramnios admitted in the department of OBG, BMCRC Ballari, study conducted for a period of 6 months August 2023 to January 2024 consist of 70 subjects. This study is conducted on all singleton, non-anomalous, low risk pregnant women with AFI less than or equal to 5 with intact membranes and gestational age between 37-42 weeks. After obtaining approval and clearance from the institutional ethical committee, the pregnant woman meeting the inclusion and exclusion criteria was enrolled in the study after obtaining informed consent. Detailed clinical history including obstetric, menstrual, past and personal history was taken and detailed examination was done. Basic routine blood investigations were done. Liquor volume was estimated by ultrasonography by measuring the AFI by four quadrant technique of Phelan or when the single deepest vertical pocket measures less than 2cms. Delivery was optimized depending on antepartum fetal surveillance. The mean age of mothers at time o Results: f delivery was lower (25.84 yrs) in the oligohydramnios group. Most of the patients were primiparous, this difference was found to be non-signicant. Out of 70 cases, majority of cases were between 39-39.6 weeks of gestation 31 cases (44.28%). Comparison of pregnancy outcome between the two groups is represented in Table 2. Low birth weight, NICU admission, fetal distress, fetal death, APGAR score, preterm delivery, and neonatal death. However, meconium staining, mode of delivery and postpartum hemorrhage were almost equal in the two groups (p>.05). The average and standard deviation of AFI were in 6.14±1.08 cm in oligohydramnios group. APGAR score was above 7 in 80% patients in oligohydramnios group. The table and graph show the distribution of cases based on admission NST. It was reactive in 37 cases (52.85%) at the time of admission. Augmentation was done for 23 cases (32.8%). : Our present study shows that even though there is an increased rate of caesarean se Conclusion ction, NICU admission and observation, meconium stained liquor and NST changes there is no signicant increase in the perinatal morbidity and mortality.
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Mid-trimester preterm premature rupture of membranes is a rare complication of pregnancy associated with significant maternal and fetal risks. The ensuing prolonged oligohydramnios can lead to fetal pulmonary hypoplasia. In addition, there is an increased risk of miscarriage, preterm birth, and chorioamnionitis, contributing to septic morbidity in the mother–baby dyad. This case report describes the management and outcomes of an infant born at 32 weeks following the rupture of membranes at 16 weeks of gestation, resulting in severe oligohydramnios. Soon after birth, the infant had respiratory compromise, requiring high-frequency oscillatory ventilation and nitric oxide. Despite the initial poor prognosis, the infant remained stable with various ventilation modalities managed by a multidisciplinary team. He was discharged home after 108 days in the hospital and remained on non-invasive ventilatory support until 8 months of age while the home care and hospital specialty teams monitored him. The favorable respiratory outcome of this case is a rarity for cases with similar clinical circumstances, in which the managing team counsels parents about poor fetal outcomes and many proceed to terminate the pregnancies. In this reported case, we highlight the importance of multidisciplinary and interprofessional team management from antepartum monitoring and planning delivery time to subsequent short- and long-term postnatal care involving maternal-fetal medicine specialists, neonatologists, pediatric cardiology and respiratory specialists, and home care teams.
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Full-text available
Objective: Ultrasound is widely regarded as an important adjunct to antenatal care (ANC) to guide practice and reduce perinatal mortality. We assessed the impact of ANC ultrasound use at health centers in resource-limited countries. Design: Cluster randomized trial. Setting: Clusters within five countries (Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia). Methods: Clusters were randomized to standard ANC or standard care plus two ultrasounds and referral for complications. The study trained providers in intervention clusters to perform basic obstetric ultrasounds. Main outcome measures: The primary outcome was a composite of maternal mortality, maternal near-miss mortality, stillbirth, and neonatal mortality. Results: During the 24-month trial, 28 intervention and 28 control clusters had 24,263 and 23,160 births, respectively; 78% in the intervention clusters received at least one study ultrasound; 60% received two. The prevalence of conditions noted including twins, placenta previa and abnormal lie were within expected ranges. 9% were referred for an ultrasound-diagnosed condition and 71% attended the referral. The ANC (RR 1·0 95% CI 1·00, 1·01) and hospital delivery rates for complicated pregnancies (RR 1·03 95% CI 0·89, 1·20) did not differ between intervention and control clusters nor did the composite outcome (RR 1·09 95% CI 0·97, 1·23) or its individual components. Conclusions: Despite availability of ultrasound at ANC in the intervention clusters, neither ANC nor hospital delivery for complicated pregnancies increased. The composite outcome as well as the individual components were not reduced. This article is protected by copyright. All rights reserved.
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High quality is important in medical imaging, yet in many geographic areas, highly skilled sonographers are in short supply. Advances in Internet capacity along with the development of reliable portable ultrasounds have created an opportunity to provide centralized remote quality assurance (QA) for ultrasound exams performed at rural sites worldwide. We sought to harness these advances by developing a web-based tool to facilitate QA activities for newly trained sonographers who were taking part in a cluster randomized trial investigating the role of limited obstetric ultrasound to improve pregnancy outcomes in 5 low- and middle-income countries. We were challenged by connectivity issues, by country-specific needs for website usability, and by the overall need for a high-throughput system. After systematically addressing these needs, the resulting QA website helped drive ultrasound quality improvement across all 5 countries. It now offers the potential for adoption by future ultrasound- or imaging-based global health initiatives.
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Prior studies have suggested that obstetric ultrasound in low and middle income countries has aided in detection of high-risk conditions, which in turn could improve obstetric management. We are participating in a cluster-randomized clinical trial of obstetric ultrasound which is designed to assess the impact of basic obstetric ultrasound on maternal mortality, fetal mortality, neonatal mortality, and maternal near-miss in five low income countries. We designed a two-week course in basic obstetric ultrasound, followed by 12 weeks of oversight, to train healthcare professionals with no prior ultrasound experience to perform basic obstetric ultrasound to screen for high-risk pregnancies. All patients with identified high-risk pregnancies identified by the trainees were referred to higher level health facilities where fully trained sonographers confirmed the diagnoses before any actions were taken. While there have been several published studies on basic obstetric ultrasound training courses for healthcare workers in low and middle income countries, quality control reporting has been limited. The purpose of this study is to report on quality control results of these trainees. Healthcare workers trained in similar courses could have an adjunctive role in ultrasound screening for high-risk obstetric conditions where access to care is limited. After completion of the ultrasound course, 41 trainees in five countries performed 3801 ultrasound examinations during a 12-week pilot period. Each examination was reviewed by ultrasound trainers for errors in scanning parameters and errors in diagnosis, using pre-determined criteria. Of the 32,480 images comprising the 3801 exams, 94.8% were rated as satisfactory by the reviewers. There was 99.4% concordance between trainee and reviewer ultrasound diagnosis. The results suggest that trained healthcare workers could play a role in ultrasound screening for high-risk obstetric conditions.
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Objective: Several trials aimed at evaluating the efficacy of maternal hydration (MH) in increasing amniotic-fluid-volume (AFV) in pregnancies with isolated oligohydramnios or normohydramnos have been conducted. Unfortunately, no evidences support this intervention in routine-clinical-practice. The aim of this systematic-literature-review and meta-analysis was to collect all data regarding proposed strategies and their efficacy in relation to each clinical condition for which MH-therapy was performed with the aim of increasing amniotic-fluid (AF) and improving perinatal outcomes. Materials and methods: A systematic literature search was conducted in electronic-database MEDLINE, EMBASE, ScienceDirect and the Cochrane-Library in the time interval between 1991 and 2014. Following the identification of eligible trials, we estimated the methodological quality of each study (using QADAS-2) and clustered patients according to the following outcome measures: route of administration (oral versus intravenous versus combined), total daily dose of fluids administered (<2000 versus >2000), duration of hydration therapy: (1 day, >1 day but <1 week, >1 week), type of fluid administered (isotonic versus hypotonic versus combination). Results: In isolated-oligohydramnios (IO), maternal oral hydration is more effective than intravenous hydration and hypotonic solutions superior to isotonic solutions. The improvement in AFV appears to be time-dependent rather than daily-dose dependent. Regarding normohydramnios pregnancies, all strategies seem equivalent though the administration of hypotonic-fluid appears to have a slightly greater effect than isotonic-fluid. Regarding perinatal outcomes, data is fragmentary and heterogeneous and does not allow us to define the real clinical utility of MH. Conclusions: Available data suggests that MH may be a safe, well-tolerated and useful strategy to improve AFV especially in cases of IO. In view of the numerous obstetric situations in which a reduced AFV may pose a threat, particularly to the fetus, the possibility of increasing AFV with a simple and inexpensive practice like MH-therapy may have potential clinical applications. Considering the various strategies of maternal hydration implemented in the treatment of IO, better results were observed when treatment was based on a combination of intravenous (for a period of 1 day) and oral (for a period of at least 14 days) hypotonic fluids (≥2000ml).
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Objective Early-onset oligohydramnios is typically secondary to renal-urinary anomalies (RUA) or preterm premature rupture of membranes (PPROM). We compared neonatal pulmonary outcomes between these etiologies. Methods We conducted a retrospective cohort study of women with oligohydramnios identified before 24 completed weeks of gestation attributed to either PPROM or RUA. Patients were excluded if other fetal anomalies were noted. Respiratory morbidity was assessed by the need for oxygen at 36 corrected weeks or at hospital discharge. Results Of 116 eligible patients, 54 chose elective pregnancy termination. A total of 39.5% of PPROM (n=17/43) and 36.8% of RUA (n=7/19) pregnancies experienced pre-viable loss (P=1.00). Significantly fewer PPROM live births resulted in neonatal mortality (26.9% vs. 75.0%, P<0.01). There was no difference in respiratory morbidity (57.9% vs. 66.6%, P=1.00). The collective incidence of respiratory mortality and morbidity was not different between etiologies (P=0.06). Conclusion This analysis suggests that the prognoses for oligohydramnios due to pre-viable PPROM vs. renal anomalies are similarly grave, though RUA infants experienced a higher rate of neonatal respiratory mortality.
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Multiple indications exist for use of the biophysical profile (BPP) in antepartum surveillance. The BPP is usually initiated only after 32 weeks for patients at risk of stillbirth, including various maternal, fetal, and obstetrical comorbidities. The scoring system assigns two points to each of five categories: breathing, movement, tone, amniotic fluid, and nonstress test. External factors, such as medications, exposures, and gestational age, may also affect BPP scores. The examination should be continued until completion of 30 minutes, if the fetus does not meet criteria, to allow for completion of a sleep cycle. Perinatal mortality and morbidity is inversely proportional to BPP score, with delivery usually indicated with BPP < 4/10.
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Objective: To evaluate adverse pregnancy outcomes in singleton pregnancies diagnosed with oligohydramnios through a systematic review and meta-analysis of controlled trials. Methods: We searched electronic databases via OVID, EBSCO, Web of Science, Google Scholar and others from 1980 to 2015. Prospective and retrospective studies with a control group were included. Two authors independently reviewed the abstracts from the literature search. Inclusion criteria were: studies in English, singleton pregnancy, normal fetal anatomy, intact membranes and oligohydramnios determined by the amniotic fluid index (AFI) technique. We stratified the meta-analysis into two groups according to risk: high risk including studies of oligohydramnios with comorbid conditions (e.g. hypertension) and low risk including studies of isolated oligohydramnios. Results: Fifteen trials met the inclusion criteria. Nine were high-risk and six were low-risk studies, including 8067 and 27 526 women, respectively. Compared with women with normal AFI, those with isolated oligohydramnios had significantly higher rates of an infant with meconium aspiration syndrome (relative risk (RR), 2.83; 95% CI, 1.38-5.77), Cesarean delivery for fetal distress (RR, 2.16; 95% CI, 1.64-2.85) and admission to the neonatal intensive care unit (NICU) (RR, 1.71; 95% CI, 1.20-2.42). Patients with oligohydramnios and comorbidities were more likely to have an infant with low birth weight (RR, 2.35; 95% CI, 1.27-4.34). However, rates of 5-min Apgar score < 7 (RR, 1.85; 95% CI, 0.69-4.96), NICU admission (RR, 2.09; 95% CI, 0.80-5.45), meconium-stained amniotic fluid (RR, 1.32; 95% CI, 0.62-2.81) and Cesarean delivery for fetal distress (RR, 1.65; 95% CI, 0.81-3.36) were similar to those for women with normal AFI. Stillbirth rates were too low to analyze in the meta-analysis. Conclusions: This review helps to delineate which adverse outcomes are increased with oligohydramnios in low-risk pregnancy (NICU admission, Cesarean delivery for fetal distress and meconium aspiration syndrome), but does not provide enough data to determine the optimal timing of delivery in such cases. Oligohydramnios in complicated pregnancy is associated with an increased risk of delivery of an infant with low birth weight, but this may be confounded by the comorbid condition. Therefore, in high-risk pregnancy, management should be dictated by the comorbid condition and not the presence of oligohydramnios. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.