Oligohydramnios, polyhydramnios and intrauterine growth retardation elaboration: Piotr Uzar Department for Pathology of Pregnancy and Labour PAM

Amniotic fluid volume during pregnancy Amniotic fluid volume is in a dynamic balance state and it is determinated by: placental, fetal and maternal factors.

Oligohydramnios Definition: Considerable deficiency of amniotic fluid volume< 200ml, 0,5%- 5,5% of all pregnancies Reasons: fetal diseasies (malformations, hypotrophia, TTTS, acardiacus); maternal diseasies (diabetes with microangiopathy, gestosis, ); PROM; bad hydration; post-term pregnancy Symptoms:  SF,  fetal movements,  circumference of the abdomen, too little weight, easy to feel fetus parts, hard to move presenting part

Oligohydramnios USG estimation: - difficult anatomy estimation - AFI < 5cm (amniotic fluid index by Phelan) -  biophysical profil and  fetal movements -  biometrics values (compression of fetus) - disturbances of blood flow in AU and AA

Oligohydramnios Complications: IUGR, hypoplasia of fetuses lungs, deformations fetus syndrome, amniotic bands syndrome, intrauterine infections, poor general condition of fetus, fetal necrosis or perinatal death, umbilical cord compression, meconium aspiration syndrome (MAS), brady- and tachycardia of fetus, inconstant decelerations, intrauterine fetal anoxia

Oligohydramnios Prophylaxis and treatment: - preconception care: hypertension, nephropathy, systemic disease, diabetes with microangiopathy - prenatal care: - treatment above mentioned diseases, detection of malformations, treatment of infections and ionic disorders; - conservative therapy (diet, rest); - operative therapy (amnioinfusion) - during labour: CTG, intranatal amnioinfusion- in case of green amniotic fluid

Polyhydramnios Definition: Pathologic increase of amniotic fluid volume, volume > 2 l ; 0,1%- 3,5% of all pregnancies Reasons:

Polyhydramnios Symptoms: weak sensation of fetal movements, fetal pulse ausculation with difficulty, excessive diaphragm elevation, pain, pregnant circulatory-respiratory system disorders USG estimation: AFI > 20cm Complications: PROM, prolapse of the umbilical cord, premature placental ablation, intrauterine fetal anoxia, premature labour, incorrect lie, weak labour activity, postpartum uterine atonia and hemorrhage in the immediate postpartum period

Polyhydramnios Prophylaxis and treatment: - preconception care: malformations prophylaxis and diabetes control - prenatal care: - primary disease treatment (diabetes, infections, Rh isoimmunization) - symptomatic treatment- amnioreductions; take care!- premature labour, premature placental ablation, PROM and intrauterine infection; Indomethacin- fetal membranes permeability, fetus miction, resorption of amniotic fluid by lungs; take care!-narrowing of Botall’s duct

Intrauterine growth retardation Definition: Type I - IUGR of weight and height of the fetus or newborn <10 centile for gestational age Type II - IUGR of weight of the fetus or newborn <10 centile for gestational age; SGA (small for gestational age) Clinical classification of hypotrophia: - Type I - symmetrical: 20%, low weight and height - reasons: smaller genetic potential, race, chromosome aberrations, hypovitaminosis, intrauterine infections, drugs

IUGR - Type II - asymmetrical: 80%, low weight with normal height and head circumference, „brain sparing efect”- brain and heart without lesions - reasons: uteroplacental insufficiency, smoking, drinking, multiple pregnancy, diabetes, chronic hypertension with proteinuria, bleeding in the III period of pregnancy, malnutrition  hypovolemia placental blood flow  size of placenta

IUGR USG estimation Complications:  of: IQ, activity, attention, tension, behaviour; short stature; slim body build Treatment: primary disease, uteroplacental insufficiency, rest

Rh Isoimmunization elaboration: Piotr Uzar Department for Pathology of Pregnancy and Labour PAM

Rh Isoimmunization Pathomechanism: a women immunization by erythrocytic Ag transmision of antierythrocytic Ig by placenta Ig bindings with fetus blood cells Ig damages blood cells haemolysis (hyperbilirubinemia) anaemiatissue hypoxia damage of: heart (circulatory insufficiency), epithelium, liver oedema and transudate in the body cavities, hypoalbuminemia fetal death 0,2ml shunt is enough to immunize (labour, abortion) Reasons: pregnancy, transfusion of incompatible blood group, drug addicts

Rh Isoimmunization Diagnostics: - blood group and Coombs test- a) if negative then tests in I, II, III trimester; b) if positive then once a month+ USG - USG estimation: hyperplacentosis (>4,5cm, in I trim. only), hepatosplenomegaly,  umbilical v., cardiomegaly (surface of the heart> 1/3 of breast), transudate in the peritoneum, oedema ( >0,5cm), transudate in the pleura and pericardium - Invasive diagnostics- cordocentesis - indications: Rh isoimmunization in anamnesis, Ig anti D1:16 or Ig anti D<1:16 with USG symptoms

Rh Isoimmunization Determination of: blood group and Rh, direct Coombs test, blood cell count (estimation of anaemia), serum protein, bilirubin, gasometry CTG monitoring 1h after procedure (FHR- small shunt, FHR- reaction after puncture of artery, if long-lasting then big blood loss) Start of diagnostics: after 28Hbd if Ig anti D1:16 or Ig anti D<1:16 with USG symptoms of oedema of fetus or 4 weeks before the term fetal oedema appeard during the last pregnancy

Rh Isoimmunization Treatment: - earlier pregnancy termination (36-38Hbd) - Sandoglobulin (0,4mg/kg i.v.) - intrauterine transfusions (triple the survival rate) transfusion indications: - grave anaemia of fetus - fetal hydrops- the only treatment - anamnesis- several fetal necrosis and father DD transfusion complications: bleeding, fetus infection, premature labour, umbilical cord tamponade, umbilical venous thrombosis

Rh Isoimmunization Prophylaxis: intramuscular administration of Ig anty-D results in 96-98% effectivness if indirect antiglobulin reaction is negative 150g: after -abortion, -missed labour, -ectopic pregnancy, -intrauterine procedure, -labour, -bleeding (imminent abortion, placenta praevia) 300g: after -multiple pregnancy, cesarean section, -instrumental delivery, - manual removal of placenta Gestational administration of 150g Ig anty-D about 28Hbd effectivness to 99%