DIPLOMA PEMBANTU PERUBATAN

TAHUN 3 SEMESTER 1
CASE STUDY :
POLYHYDRAMNIOS

NAMA: SITI NUR AMIRAH BT MOHD NAZIR

NO.MATRIK: BPP2014-2068
NO.I/C :950823-11-5036

INTRODUCTION:
The amniotic fluid is the normally clear fluid that collects within the amniotic cavity increases
as pregnancy progress until abput 34 weeks,where there is a decrease in volume.An average
volume of about 1000ml is found at term,although this may very widely from a few mililiters
to many liters in abnormal conditions (Barss VA et al.,1984).
Polyhydramnios is a medical condition describing an excess of amniotic fluid im the amniotic
sac.It seen in about 1% of pregnancies.It i typically diagnosed when the amniotic fluid index
(AFI) is greater than 24cm.There are two clinical variety of polyhydramnios.Chronic
polyhydramnios where excess amniotic fluid accumulates gradually.Acute polyhydramnios
where excess amniotic fluid collects rapidly.Normal range from 500 to 1000 ml a
term.Typically greater than 2000ml in polyhydramnios at 40 weeks gestation.
Possible complication prolapsed umbilical cord when membranes rupture,increased incidence
of malpresentations,increased perinatal mortality from fetal malformations and premature
deliveries,and increasesd incidence of postpartum maternal hemorrrhage.
Predisposing factors of polyhydramnios are multiple prgnancy,fetal abnormalities(esophageal
atresia,anencephaly,spina bifida,diabetes mellitus.Pathophysiology polyhydramnious
normally ,amniotic volume is maintained by a balance of fetal fluid production(lung liquid
and urine) and fluid resorption (fetal swallowing and flow across the membrane to the fetus or
the maternal uterus),Fetal urine is the primary source of amiotic fluid with output at term
ranging from 400 to 1200ml/day.Fetal swallowing is believed to be the major route of
amniotic fluid resorption.With polyhydramnios,fluid accumulates because of a problem with
the fetuss ability to swallow or absorb the fluid or as a result of over production of
urine.Fluid may have increased gradually(chronic type) by the third trimester or rapidly(acute
type) between 20 and 24 weeks gestation.

Cause of polyhydramnios are,may be assiociated with diabetes mellitus(about 25

%),erythroblastosis (about 10%),multiple gestations (about 10%),anomalies of the central
nervous system(such as neutral tube defects).,or GI anomalies such as tracheoesophageal
fistula that prevent ingestion of the amniotic fluid(about 20%).
Assement findings depnd on the length of gestation,amount of amniotic fluid and wheter the
disorder is chronic or acute.Mild signs and symptoms,maternal abdominal discomfort,slight
dyspnea,and edema of feet and ankles.Severe signs and syptoms,severe dyspnea ,orthopnea
and significant edema of the vulva,legs,and abdomen.Symptoms common to mild and severe
cases:uterine enlargement greater than expected for the lenght of gestation,and difficulty in
outlining the fetal parts and in detecting fetal heart sounds.
Test results ultrasonography shows evidence of excess amniotic fluid as well as underlying
conditions.The treatment are high protein ,low sodium diet,mild sedation.Indomethacin
therapy-a drug that decreases the fetal urine formation .The side effect of indomethacin,as
with other prostaglandin synthase inhibitor,is the potential premature closure of the ductus
arteriousus.Amniotomy the fluid is removed by a needle inserted through the cervix.The
danger of this procedure is cord proplase and abruption placenta to prevent these
complications,amniotic fluid must be removed gradually.Watch closely for hemorrhage after
delivery,prevent uterine relaxation by massaging the uterus and administering oxytocin as
ordered.

PROBLEM STATEMENT :
A pregnancy woman (Gravida 6 Para 4 + 2) was refer from KKIA Sg Siput and admit at 15
April 2016 ,10.00 am..Patient came with complain that she had a heavy contraction and was
38 weeks for gestation(full term).After registration,vital sign and fetal heart rate had take,
(Blood Pressure :110/62,Pulse rate :87,SPO2 :100 in room air ,Fetal Heart Rate :151 ).Patient
had history gestational diabetes mellitus since 2014.Fundus height was measured and the
result was 45cm. Polyhydramnios has been defined as an AFV of greater than 2000ml by
ultrasound techniques.Inspection may reveal a rapidly enlarging uterus in the pregnant
mother.Palpation had done, ,the malpresentation of fetus was vertex.Vagina examination must
do 4 hourly.The opening servix was5cm.Patient was monitor closely to prevent any
complication.At 3.00 pm,opening servix was open for 10 cm,preparation instrucment had
done.At stage 2,baby had safely delivery but had a cord round neck and staff immediatelly cut
the cord.Apgar scor had done : 9/10.No complication

LITERATURE REVIEW :
Polyhydarmnios can be define as the total volume of amniotic are high the range from the
normal (Bella and Rosess 2011).
The normal range of amniotic volume are 500-1000ml.The balancing act required to maintain
a healthy AFV may be influenced by hormones(Prolactin and Prostaglandins),osmotic and
hydrostatic forces,and the fetus.(Patrielli et al.2012).
Method are supported to define polyhydramnios are Measurement of Amniotic Fluid Index
(Nebhan& Abdelmoula 2008;Magann et al.2011)
In the human,fetal swallowing begins early in gestation.Sherman et al. have reported that the
ovine fetus swallows in eposides lasting 2 minutes and at volue of 100 to 300 ml/kg/day.In the
term ovine fetus,the volume represents a daily swallowing rate 350 to 1000 ml/day for 3.5 kg
fetus (Sherman et al,1990)

DISCUSSION :
Polyhydramnios defined as an abnormally large volume of amniotic fluid.There is range of
normal fluid volumes and an abnormally large volume may raise suspicion of problem in
pregnancy.In this case,this patient had a problem with her uterus that suddenly larger than
usual,and the medical officer do some the ultrasound and found that the amniotic volume was
2000ml..Her gestation was 24 weeks.
The investigation that have to do for polyhydramnios are ultrasound.Aquantitative approach
can be taken by dividing the uterine cavity into four quadrant pockets.The largest
verticalpocket measured in centimeters and the total volue is calculated by multiplying this
level by 4.This is known as amniotic fluid index(AFI).During the investigations that have
done,we found that the value of amniotic fluid index was 26 and single pocket of fluid was
8cm deep.So the diagnosis is polyhydramnios.The total volue of fluid is 2000ml.
So the mangement for the patient are first,identify if there is an underlying cause.Mild
polyhydramnious can be simply monitored and treated conservatively.Preterm labour is
common due to overdistension of the uterus,and measures should be taken to minimise this
complication.This includes regular antenatal checks and inspection of the uterus and bedrest
toward the latter stages.Intramuscular steroid shoul be given to the mother antenatally if
preterm deliver is considered.This improved lung maturity.Serial ultrasound scans should be
carried out to monitor the AFI and monitor growth.Fetal hydrops anaemia should be treated
with erythrocyte transfusion,either intravascularly or via the fetal abdomen.This reduce
likelihood of fetal congestive failure,thereby allowing prolongation of the pregnancy and
improving survival.If gestational diabetes is diagnosed,tight glyceamic control shoul be
maintained.This is usually done with dietary manipulation and insulin is rarely
needed.Indomethacin is the drug of choice for medical treatment of polyhydramnios.It is very

effective,particularly in cases where the condition is related to increasing fetal urine

production.The mechanism of action appears to be an affect on urine production by the fetal
kidney,possibly by enchancing the effect of vasopressin.It is not effective in cases where the
underlying cause is neuromuscular disease affecting fetal swallowing or hydracephalus .
Amniocentesis is recommended in cases where indometacin is contra-indicated,in severe
polyhydramnios or in patients who are sypmtomatic.It is contra-indicated in premature
rupture or detachment of the placenta.Induction of labour should be considered if fetal distress
develops.

CONCLUSION :
Polyhydramnios is defined as a pathological increase of amniotic fluid volume in pregnancy
and is associated with increase perinatal and morbidity and mortality.Common cause of
polyhydramnios include gestational diabetes,fetal anomalies with disturbed fetal swallowing
of amniotic fluid,fetal infections and other,rarer causes.The diganosis is obtained by
ultrasound.The prognosis of polyhydramnios depends cause and severity.Typical symptoms of
polyhydramnios include maternal dyspnea,preterm labor,premature rupture membrane and
postpartum haemorrhage.So,daily checkup is important for look any obvious or change
during prenancy to avoid any comlication.

REFERENCES :
Beall MH,van den Wijngaard JP ,van Gemert MJ, Ross MG.
Amniotic fluid water dynamics,Placenta 2007;28:816-23

Lee SM,Park SK,Shim SS,Jun JK ,Park JS,Syn HC.

Measurement of fetal urine production by three-dimensional ultrasonography in
normal pregnancy.Ultrasound Obstet Gynecol 2007;30:281-86

Golan A,Wolman I,Sagi J,et al.Persistance of Polyhdramnious during pregnancy-its

significance and correlation with maternal and fetal complications.Gyneol Obstet
Invest 1994;37:18.

Pri-Paz S,Khalek N,Fuchs KM ,Simpson LL.

Maximal amniotic fluid index as a prognostic factor in pregnancies complicated by
polyhydramnious.Ultrasound obstet Gynecol 2012;39:648.

Pritchard JA.Fetal swallowing and amniotic fluid volume .Obstet Gynecol

1996;28:606

https://en.m.wikipedia.org/wiki/Polyhydramnious
:August 2015)

(Topic:Polyhydramnious,Edited