22/10/2017 Oligohydramnios Imaging: Overview, Workup

Oligohydramnios Imaging
Updated: Mar 11, 2016
Author: Jason K Baxter, MD, MS; Chief Editor: Eugene C Lin, MD more...

OVERVIEW

Overview
Multiple definitions of oligohydramnios are used because no ideal cutoff level for intervention
exists. [1, 2, 3, 4, 5, 6, 7]

Oligohydramnios is characterized by the following features:

Diminished amniotic fluid volume (AFV)

Amniotic fluid volume of less than 500 mL at 32-36 weeks' gestation - Amniotic fluid volume
depends on the gestational age; therefore, the best definition may be AFI less than the fifth
percentile.
Single deepest pocket (SDP) of less than 2 cm
Amniotic fluid index (AFI) of less than 5 cm or less than the fifth percentile

See the images below.

Sonogram obtained before second-trimester amnioinfusion. This fetus has bilaterally absent kidneys
consistent with a diagnosis of Potter syndrome. The cystic structures in the renal fossae are most likely the
adrenal glands.
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22/10/2017 Oligohydramnios Imaging: Overview, Workup

Sonogram obtained after second-trimester amnioinfusion. This fetus has bilaterally absent kidneys consistent
with a diagnosis of Potter syndrome. The cystic structures in the renal fossae are most likely the adrenal
glands.
View Media Gallery

The earlier in pregnancy that oligohydramnios occurs, the poorer the prognosis. Fetal mortality
rates as high as 80-90% have been reported with oligohydramnios diagnosed in the second
trimester. Most of this mortality is a result of major congenital malformations and pulmonary
hypoplasia secondary to PROM before 22 weeks' gestation. Midtrimester PROM (premature
rupture of membranes) often leads to pulmonary hypoplasia, fetal compression syndrome, and
amniotic band syndrome. The inspiration of amniotic fluid at regular intervals is probably needed
for terminal alveolar development.

The assessment of amniotic fluid volume is important in pregnancies complicated by abnormal

fetal growth or IUGR. AFV has been shown to be predictive in discriminating normal from
decreased growth. Oligohydramnios is a frequent finding in pregnancies involving IUGR and is
most likely secondary to decreased fetal blood volume, renal blood flow, and, subsequently, fetal
urine output. Pregnancies complicated by severe oligohydramnios have been shown to be at
increased risk for fetal morbidity. [8, 9]

AFV is an important predictor of fetal well-being in pregnancies beyond 40 weeks' gestation. AFV
must be closely monitored, with measurements obtained at least once per week. The diagnosis of
oligohydramnios may help in identifying postterm fetuses in jeopardy.

AFV is a predictor of the fetal tolerance of labor, and it is associated with an increased risk of
abnormal heart rate, meconium-stained amniotic fluid, and cesarean delivery. An increased
incidence of cord compression is associated with oligohydramnios; this can lead to variable
decelerations, with cord occlusion as the proximate cause of fetal distress.

According to one study, pregnancies with decreased AFI between 24 and 34 weeks, including
borderline AFI and oligohydramnios, were significantly more likely to be associated with major fetal
malformations, and, in the absence of malformations, to be complicated by fetal growth restriction
and preterm birth. Major malformations were more common in pregnancies with oligohydramnios
(25%) and borderline AFI (10%) than in those with normal fluid (2%). [10]

Hydration (intravenous and oral) has been found to significantly improve the volume of amniotic
fluid in third-trimester pregnancies with isolated oligohydramnios. [11] For more information, see
Polyhydramnios and Oligohydramnios.

Workup

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22/10/2017 Oligohydramnios Imaging: Overview, Workup

Ultrasonography

The diagnosis is confirmed by means of ultrasonography (see the images below). Oligohydramnios
may be discovered incidentally during routine ultrasonography and noted during antepartum
surveillance for other conditions. The diagnosis may be prompted by a lag in sequential fundal
height measurements (size less than that expected for the dates) or by fetal parts that are easily
palpated through the maternal abdomen. [12, 13, 14, 15, 16, 17]

During ultrasonography of the fetal anatomy, normal-appearing fetal kidneys and fluid-filled bladder
may be observed to rule out renal agenesis (see the following 2 images), cystic dysplasia, and
ureteral obstruction. Check fetal growth to rule out intrauterine growth restriction (IUGR) leading to
oliguria.

Sonogram obtained before second-trimester amnioinfusion. This fetus has bilaterally absent kidneys
consistent with a diagnosis of Potter syndrome. The cystic structures in the renal fossae are most likely the
adrenal glands.
View Media Gallery

Sonogram obtained after second-trimester amnioinfusion. This fetus has bilaterally absent kidneys consistent
with a diagnosis of Potter syndrome. The cystic structures in the renal fossae are most likely the adrenal
glands.
View Media Gallery

Sterile speculum examination

Sterile speculum examination may be performed to check for range of motion (ROM). Amniotic
fluid may pool in the vagina, and an arborization or ferning pattern may be observed when dried
posterior vault fluid is examined microscopically. Cervical mucous may cause false-positive results,
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22/10/2017 Oligohydramnios Imaging: Overview, Workup

as can semen and blood. Nitrazine paper turns blue. The amniotic fluid is more basic (pH 6.5-7.0)
than normal vaginal discharge (pH 4.5).

Measurement of amniotic fluid volume

Initial studies to objectively measure amniotic fluid volume (AFV) involved dye dilution techniques.
The techniques were accurate, although they required amniocentesis, an invasive procedure that
increased the risk of perinatal morbidity.

The routine use of ultrasonography has created a safe, reliable, and repeatable method of
measuring AFV. Early methods of assessing AFV with ultrasonography involved nonquantitative
assessments, including sonographers' subjective impression of AFV.

Subjective oligohydramnios criteria have included the following:

The absence of fluid pockets throughout the uterine cavity

Crowding of the fetal limbs
The absence of pockets surrounding the fetal legs
Overlapping of the fetal ribs (in severe cases)

The 2 most commonly used objective methods of determining AFV include measurement of the
single deepest pocket (SDP) and the summation of the SDPs in each quadrant, or the amniotic
fluid index (AFI). [18] These tests are routinely performed with the patient in the supine or semi-
Fowler position, although studies have demonstrated accuracy in the lateral decubitus position as
well. [9, 19, 20, 21, 22, 23]

The ultrasound transducer is held along the maternal longitudinal axis and maintained
perpendicular to the floor while the SDP of the amniotic fluid is measured. Pockets should be free
of fetal limbs and the umbilical cord, although some authors allow for a single loop of cord to be
within the fluid pocket. AFV may be artificially increased if the transducer is not maintained
perpendicular to the floor. Excessive pressure on the maternal abdomen with the transducer may
lead to an artificially reduced measurement (see the image below).

Amniotic fluid index (AFI) measurement technique.

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22/10/2017 Oligohydramnios Imaging: Overview, Workup

Phelan et al described the AFI as a quantitative measurement to predict a poor pregnancy

outcome and the success of external cephalic versions. [1] The pregnant abdomen is divided into 4
quadrants by using the umbilicus as a reference point to divide the uterus into upper and lower
halves and by using the linea nigra to divide the uterus into left and right halves. The 4
measurements are summed to obtain the AFI in centimeters. [20, 21]

In gestations earlier than 20 weeks, measurements from the 2 halves are divided by the linea nigra
to obtain the AFI. Tables of the normal limits for AFI, based on the gestational age (see the
Gestational Age from Estimated Date of Delivery calculator), have been published for singleton
and multiple pregnancies (see an example below). The mean AFI for normal pregnancies is 11-16
cm.

Amniotic fluid index (AFI) during a normal human singleton pregnancy. The solid line is the mean AFI, the
lower dotted line is the 5th percentile value, and the upper dotted line is the 95th percentile value (data
adapted from Moore, 1990). Image courtesy of Christopher L. Sistrom, MD.
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The test is reproducible, with interobserver and intraobserver variations of about 10-15% or 1-2 cm
in pregnancies with normal AFVs. The margin of error is less in patients with decreased amounts
of amniotic fluid.

Oligohydramnios has been defined as an AFI less than 5 cm, although 8 cm has occasionally been
used as a cut-off threshold. Because the AFV depends on the gestational age, oligohydramnios
has been defined as an AFI less than the fifth percentile (corresponding to an AFI of < 6.8 cm at
term).

Oligohydramnios has been defined as an SDP less than 2 cm. Perinatal morbidity rates have been
shown to increase sharply with SDPs below this value. Some have suggested that an SDP of 2.5-
3.0 cm is a better lower limit for separating normal SDPs from those consistent with
oligohydramnios.

Many studies have shown that the SDP and the AFI methods have equal diagnostic accuracies.
The SDP technique may be a better means of assessing the AFV in twin gestations and in
pregnancies at an early gestational age. Some study results have shown that the AFI has greater
sensitivity and a higher predictive value than the SDP in diagnosing abnormally high and low
AFVs. Most obstetricians prefer to assess a broader area of the uterine cavity by using the AFI
because the single measurement of the SDP does not allow for an asymmetric fetal position in the
uterus.

According to a survey of members of the Society of Maternal-Fetal Medicine, deepest vertical

pocket is considered to be the most accurate method of evaluating amniotic fluid in the second
trimester, and amniotic fluid index is considered to be the most accurate method of evaluating fluid
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in the third trimester. Over 50% of respondents felt that oligohydramnios is overdiagnosed when
using amniotic fluid index compared with deepest vertical pocket. [24]

Other examinations
MRI and 3-dimensional (3D) ultrasonography are newer (and more expensive) modalities for
accurately assessing the AFV. [25, 26, 27]

Fetal MRI can complement ultrasonography by providing better visualization in the fetus when
ultrasound may be limited, in cases such as severe maternal obesity. Although MRI may offer a
larger field of view and better tissue contrast and not be limited by shadowing from osseous
structures, it has a limited resolution when compared with ultrasonography and is less readily
available and is more expensive. [27]

In 35 women with healthy singleton pregnancies, rapid MRI-based projection hydrography (PH)
measurement was found to be a better predictor of amniotic fluid volume than ultrasonography (in
utero at 28-32 weeks gestation). For the ultrasound measurements, single deepest vertical pocket
(SDVP) measurement related most closely to amniotic fluid volume, with amniotic fluid index (AFI)
demonstrating a weaker relationship. Manual multisection planimetry (MSP)-based measurement
of AFV was used as a proxy reference standard. [26]

Amniotic wrinkle

Finberg reported a possible pitfall in the sonographic analysis of amniotic fluid in twin pregnancies,
the "amniotic wrinkle," which may give the misleading impression of adequate amniotic fluid for
both twins when one twin actually has little to none.

The author reevaluated sonograms of twin pregnancies in which an initial sonographer's

assessment was adequate fluid for each twin but which the author's own imaging assessment on
the same day showed oligohydramnios in one twin.

He found either of the following may occur when oligohydramnios of one twin is present:

The intertwin membrane may fold in on itself, creating an amniotic wrinkle (a short linear
structure that extends perpendicularly away from the twin with decreased amniotic fluid in
toward the amniotic space of the other twin)
An intrauterine sling or "cocoon" may be present, in which a fetus appears to be suspended
within the amniotic space of the other twin may be present

Finberg recommended showing the intertwin membrane in all images used to document each
twin's amniotic fluid, with additional right-angle images to identify amniotic wrinkles. [28]

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