Download PDF
Am J Perinatol 2002; 19(5): 253-266
DOI: 10.1055/s-2002-33084
Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

A Review of Amniotic Fluid Dynamics and the Enigma of Isolated Oligohydramnios

David M. Sherer
  • Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York
Further Information

Publication History

Publication Date:
09 August 2002 (online)

Also available at
   Permissions and Reprints

ABSTRACT

Traditionally, oligohydramnios has been implemented as a sign of potential fetal compromise and associated with an increased incidence of adverse perinatal morbidity and mortality. Decreased amniotic fluid volume is especially of concern when it occurs in conjunction with structural fetal anomalies, fetal growth restriction, postdates pregnancies, and maternal disease. Consequently, following ultrasonographic diagnosis of oligohydramnios at term, delivery is routinely advocated even in otherwise uncomplicated pregnancies with an appropriate-for-gestational-age fetus, irrespective of the presence of reassuring fetal evaluation and the absence of maternal disease. Numerous factors complicate the ultrasonographic diagnosis of oligohydramnios. These include a lack of complete detailed understanding of the physiology of the dynamics of oligohydramnios, the transient condition at times of decreased amniotic fluid volume, generally poor performance of ultrasonography in detecting oligohydramnios, an array of different ultrasound diagnostic criteria, and varying ultrasonographic thresholds. In light of the latter and the lack of prospective randomized data, is unclear that the practice of effecting delivery for isolated oligohydramnios at term is justified. This article presents physiologic dynamics of amniotic fluid, factors that may affect amniotic fluid volume, possible pitfalls in the ultrasonographic assessment of amniotic fluid volume, and the clinical significance of oligohydramnios. In addition, the literature regarding perinatal outcome associated with oligohydramnios and current available data supporting expectant noninterventional management of cases complicated by isolated oligohydramnios at term are discussed.

KEYWORDS

Amniotic fluid physiology - amniotic fluid volume - ultrasound - amniotic fluid index - isolated oligohydramnios

REFERENCES

  • 1 Brace R A. Physiology of amniotic fluid volume regulation.  Clin Obstet Gynecol . 1997;  40 280-289
    CrossrefPubMedSearch in Google Scholar
  • 2 Gilbert W M, Brace R A. Amniotic fluid volume and normal flows to and from the amniotic cavity.  Semin Perinatol . 1993;  17 150-157
    PubMedSearch in Google Scholar
  • 3 Gilbert W M, Brace R A. The missing link in amniotic fluid volume regulation: intramembranous absorption.  Obstet Gynecol . 1989;  74 748-754
    PubMedSearch in Google Scholar
  • 4 Mann S E, Nijland M J, Ross M G. Mathematic modelling of human amniotic fluid dynamics.  Am J Obstet Gynecol . 1996;  175 937-944
    PubMedSearch in Google Scholar
  • 5 Ross M G, Nijland M J. Fetal swallowing: relation to amniotic fluid regulation.  Clin Obstet Gynecol . 1997;  40 352-365
    CrossrefPubMedSearch in Google Scholar
  • 6 Brace R A, Wolf E J. Normal amniotic fluid volume changes throughout pregnancy.  Am J Obstet Gynecol . 1989;  161 382-388
    CrossrefPubMedSearch in Google Scholar
  • 7 Magann E F, Bass J D, Chauhan S P, Young R A, Whitworth N S, Morrison J C. Amniotic fluid volume in normal singleton pregnancies.  Obstet Gynecol . 1997;  90 524-528
    CrossrefPubMedSearch in Google Scholar
  • 8 Wintour E M, Shandley L. Effects of fetal fluid balance on amniotic fluid volume.  Semin Perinatol . 1993;  17 158-172
    PubMedSearch in Google Scholar
  • 9 Moore T R, Cayle J E. The amniotic fluid index in normal human pregnancy.  Am J Obstet Gynecol . 1990;  162 1168-1173
    CrossrefPubMedSearch in Google Scholar
  • 10 McClure Browne C J. Postmaturity.  Am J Obstet Gynecol . 1963;  85 573-581
    PubMedSearch in Google Scholar
  • 11 Clifford S H. Postmaturity with placental dysfunction.  Clinical syndromes and pathologic findings. J Pediatr . 1954;  44 1-13
    CrossrefPubMedSearch in Google Scholar
  • 12 Clement D, Schifrin B S, Kates R B. Acute oligohydramnios in post date pregnancy.  Am J Obstet Gynecol . 1987;  157 884-886
    PubMedSearch in Google Scholar
  • 13 Chamberlain P F, Manning F A, Morrison I, Harman C R, Lange I R. Ultrasound evaluation of amniotic fluid volume. I. The relationship of marginal and decreased amniotic fluid volumes to perinatal outcome.  Am J Obstet Gynecol . 1984;  150 245-249
    PubMedSearch in Google Scholar
  • 14 Manning F A, Hill L M, Platt L D. Qualitative amniotic fluid volume determination by ultrasound: antepartum detection of intrauterine growth retardation.  Am J Obstet Gynecol . 1981;  139 254-258
    PubMedSearch in Google Scholar
  • 15 Dashe J S, Nathan L, McIntire D D, Leveno K J. Correlation between amniotic fluid glucose concentration and amniotic fluid volume in pregnancy complicated by diabetes.  Am J Obstet Gynecol . 2000;  182 901-904
    PubMedSearch in Google Scholar
  • 16 Hanson R S, Powrie R O, Larson L. Diabetes insipidus in pregnancy: a treatable cause of oligohydramnios.  Obstet Gynecol . 1997;  89 816-817
    CrossrefPubMedSearch in Google Scholar
  • 17 Kirshon B, Moise K J, Wasserstrum N, Ou C N, Huhta J C. Influence of short-term indomethacin therapy on fetal urine output.  Obstet Gynecol . 1988;  72 51-53
    PubMedSearch in Google Scholar
  • 18 Goldenberg R L, Davis R O, Baker R C. Indomethacin-induced oligohydramnios.  Am J Obstet Gynecol . 1989;  160 1196-1197
    PubMedSearch in Google Scholar
  • 19 Yancey M K, Richards D S. Effect of altitude on the amniotic fluid index.  J Reprod Med . 1994;  39 101-104
    PubMedSearch in Google Scholar
  • 20 Goodlin R, Anderson J, Gallagher T. Relationship between amniotic fluid volume and maternal plasma expansion.  Am J Obstet Gynecol . 1983;  146 505-510
    PubMedSearch in Google Scholar
  • 21 Sherer D M, Cullen J BH, Thompson H O, Woods J R. Transient oligohydramnios in a severely hypovolemic gravid woman at 35 weeks' gestation with fluid reaccumulating immediately after intravenous hydration.  Am J Obstet Gynecol . 1990;  162 770-771
    PubMedSearch in Google Scholar
  • 22 Kilpatrick S J, Safford K L. Maternal hydration increases amniotic fluid index in women with normal amniotic fluid.  Obstet Gynecol . 1993;  81 49-52
    PubMedSearch in Google Scholar
  • 23 Kilpatrick S J, Safford K L, Pomeroy T, Hoedt L, Scheerer L, Laros R K. Maternal hydration increases amniotic fluid index.  Obstet Gynecol . 1991;  78 1098-1102
    PubMedSearch in Google Scholar
  • 24 Flack N J, Sepulveda W, Bower S, Fisk N M. Acute maternal hydration in third-trimester oligohydramnios: effects on amniotic fluid volume, uteroplacental perfusion and fetal blood flow and urine output.  Am J Obstet Gynecol . 1995;  173 1186-1191
    CrossrefPubMedSearch in Google Scholar
  • 25 Robinson J N, Tice K, Kolm P, Abuhammad A Z. Effect of maternal hydration on fetal renal pyelectasis.  Obstet Gynecol . 1998;  92 137-141
    CrossrefPubMedSearch in Google Scholar
  • 26 Babcock C J, Silvera M, Drake C, Levine D. Effect of maternal hydration on mild fetal pyelectasis.  J Ultrasound Med . 1998;  17 539-544
    PubMedSearch in Google Scholar
  • 27 Oosterhof H, Haak M C, Aarnoudse J G. Acute maternal rehydration increases the urine production rate in the near-term fetus.  Am J Obstet Gynecol . 2000;  183 226-229
    CrossrefPubMedSearch in Google Scholar
  • 28 Doi S, Osada H, Sei K, Sekiya S. Effect of maternal hydration on oligohydramnios: a comparison of three volume expansion methods.  Obstet Gynecol . 1998;  92 525-529
    CrossrefPubMedSearch in Google Scholar
  • 29 Chandra P C, Schiavello H J, Lewandowski M A. Effect of oral and intravenous hydration on oligohydramnios.  J Reprod Med . 2000;  45 337-340
    PubMedSearch in Google Scholar
  • 30 Wolman I, Groutz A, Gull I. Is amniotic fluid influenced by a 24-hour fast?.  J Reprod Med . 2000;  45 685-687
    PubMedSearch in Google Scholar
  • 31 Petrikovsky B M, Schifrin B, Diana L. The effect of fetal acoustic stimulation on fetal swallowing and amniotic fluid index.  Obstet Gynecol . 1993;  81 548-550
    PubMedSearch in Google Scholar
  • 32 Brost B C, Scardo J A, Newman R B, Van Dorsten P J. Effect of fetal presentation on the amniotic fluid index.  Am J Obstet Gynecol . 1999;  181 1222-1224
    PubMedSearch in Google Scholar
  • 33 Coulson C C, Thorp J M, Purrington J, Slotchiver J M, Anath C V, Hartmann K. Effects of maternal smoking on amniotic fluid volume and fetal urine output.  Am J Perinatol . 1996;  13 195-197
    PubMedSearch in Google Scholar
  • 34 Magann E F, Nolan T E, Hess L W, Martin R W, Whitworth N S, Morrison J L. Measurement of amniotic fluid volume: accuracy of ultrasonography techniques.  Am J Obstet Gynecol . 1992;  167 1533-1537
    CrossrefPubMedSearch in Google Scholar
  • 35 Horsager R, Nathan L, Leveno K J. Correlation of measured amniotic fluid volume and sonographic predictions of oligohydramnios.  Obstet Gynecol . 1994;  83 955-958
    PubMedSearch in Google Scholar
  • 36 Magann E F, Bass J D, Chauhan S P, Young R A, Whitworth N S, Morrison J C. Amniotic fluid volume in normal singleton pregnancies.  Obstet Gynecol . 1997;  90 524-528
    CrossrefPubMedSearch in Google Scholar
  • 37 Phelan J P, Ahn M O, Smith C V, Rutherford S E, Anderson E. Amniotic fluid index measurements during pregnancy.  J Reprod Med . 1987;  32 601-604
    PubMedSearch in Google Scholar
  • 38 Phelan J P, Smith C V, Broussard, Small M. Amniotic fluid volume assessment with the four-quadrant technique at 36-42 weeks' gestation.  J Reprod Med . 1987;  32 540-542
    PubMedSearch in Google Scholar
  • 39 Rutherford S E, Phelan J P, Smith C V, Jacobs N. The four-quadrant assessment of amniotic fluid volume: an adjunct to antepartum fetal heart rate testing.  Obstet Gynecol . 1987;  70 353-356
    PubMedSearch in Google Scholar
  • 40 Dildy G A, Lira N, Moise K J, Riddle G D, Deter R L. Amniotic fluid volume assessment: comparison of ultrasonographic assessments versus direct measurements with a dye-dilution technique in human pregnancy.  Am J Obstet Gynecol . 1992;  167 986-994
    PubMedSearch in Google Scholar
  • 41 Magann E F, Perry K G, Chauhan S P, Anfanger P J, Whitworth N S, Morrison J C. The accuracy of ultrasound evaluation of amniotic fluid volume in singleton pregnancies: the effect of operator experience and ultrasound interpretive technique.  J Clin Ultrasound . 1997;  25 249-253
    CrossrefPubMedSearch in Google Scholar
  • 42 Chauhan S P, Magann E F, Cowan B D, Perry K G, Morrison J C. Mathematical model to correlate amniotic fluid index and amniotic fluid volume.  J Miss State Med Assoc . 1998;  39 6-9
    PubMedSearch in Google Scholar
  • 43 Mann S E, Grover J, Ross M G. Novel technique for assessing amniotic fluid volume: use of a three-dimensional scanner.  J Matern Fetal Med . 2000;  9 308-310
    CrossrefPubMedSearch in Google Scholar
  • 44 Del Valle O G, Bateman L, Gaudier F L, Sanchez-Ramos L. Comparison of three types of ultrasound transducers in evaluating the amniotic fluid index.  J Reprod Med . 1994;  339 869-872
    PubMedSearch in Google Scholar
  • 45 Sherer D M, Mann S E, Sardo M P, Divon M Y. Transvaginal sonography of the forewaters in the assessment of amniotic fluid volume in patients with oligohydramnios.  Am J Perinatol . 1998;  15 129-132
    PubMedSearch in Google Scholar
  • 46 Flack N, Dore C, Southwell D, Kourtis P, Sepulveda W, Fisk N M. The influence of operator transducer pressure on ultrasonographic measurements of amniotic fluid volume.  Am J Obstet Gynecol . 1994;  171 218-222
    CrossrefPubMedSearch in Google Scholar
  • 47 Rutherford S E, Smith C V, Phelan J P, Kawakami K, Ahn M O. Four-quadrant assessment of amniotic fluid volume.  Intraobserver and interobserver variation. J Reprod Med . 1987;  32 587-589
    PubMedSearch in Google Scholar
  • 48 Wax J R, Costigan K, Callan N A, Gegor C, Johnson T RB. Effect of fetal movement on the amniotic fluid index.  Am J Obstet Gynecol . 1993;  168 188-189
    PubMedSearch in Google Scholar
  • 49 Sadovsky Y, Christensen M W, Scheerer L, Crombleholme W R. Cord-containing amniotic fluid pocket: a useful measurement in the management of oligohydramnios.  Obstet Gynecol . 1992;  80 775-777
    PubMedSearch in Google Scholar
  • 50 Benacerraf B R, Gatter M A, Ginsburg F. Ultrasound diagnosis of meconium-stained amniotic fluid.  Am J Obstet Gynecol . 1984;  149 570-572
    PubMedSearch in Google Scholar
  • 51 Sherer D M, Abramowicz J S, Smith S A, Woods J R. Sonographically homogeneous echogenic amniotic fluid in detecting meconium-stained amniotic fluid.  Obstet Gynecol . 1991;  78 819-822
    PubMedSearch in Google Scholar
  • 52 Brown D L, Polger M, Clark P K, Bromely B S, Doubliet P M. Very echogenic amniotic fluid: ultrasonography-amniocentesis correlation.  J Ultrasound Med . 1994;  13 95-97
    PubMedSearch in Google Scholar
  • 53 Bianco A, Rosen T, Kuczynski E, Tetrokalashvilli M, Lockwood C J. Measurement of the amniotic fluid index with and without color Doppler.  J Perinat Med . 1999;  27 245-249
    CrossrefPubMedSearch in Google Scholar
  • 54 Magann E F, Chauhan S P, Barrillaeux P S, Whitworth N S, McCurley S, Martin J N. Ultrasound estimate of amniotic fluid volume: color Doppler overdiagnosis of oligohydramnios.  Obstet Gynecol . 2001;  98 71-74
    CrossrefPubMedSearch in Google Scholar
  • 55 Mercer L J, Brown L G, Petres R E, Messer R H. A survey of pregnancies complicated by decreased amniotic fluid.  Am J Obstet Gynecol . 1984;  149 355-356
    PubMedSearch in Google Scholar
  • 56 Manning F A, Harmon C R, Morrison I. Fetal assessment based on fetal biophysical profile scoring. IV. An analysis of perinatal morbidity and mortality.  Am J Obstet Gynecol . 1990;  162 703-709
    CrossrefPubMedSearch in Google Scholar
  • 57 Halperin M E, Fong K W, Zalev A H. Reliability of amniotic fluid volume estimation from ultrasonograms: intraobserver and interobserver variation before and after the establishment of criteria.  Am J Obstet Gynecol . 1985;  153 264-267
    PubMedSearch in Google Scholar
  • 58 Dizon-Townson D, Kennedy K A, Dildy G A, Wu J, Egger M, Clark S L. Amniotic fluid index and morbidity.  Am J Perinatol . 1996;  13 231-234
    PubMedSearch in Google Scholar
  • 59 Jeng C J, Lee J F, Wang K G, Yang Y C, Lan C C. Decreased amniotic fluid index in term pregnancy: clinical significance.  J Reprod Med . 1992;  37 789-792
    PubMedSearch in Google Scholar
  • 60 Rodgers M S, Wang C C. A comparison of three ultrasound estimates of intrapartum oligohydramnios for prediction of fetal hypoxia-reperfusion injury.  Early Hum Dev . 1999;  56 117-126
    CrossrefPubMedSearch in Google Scholar
  • 61 Banks E H, Miller D A. Perinatal risks associated with borderline amniotic fluid index.  Am J Obstet Gynecol . 1999;  180 1461-1463
    PubMedSearch in Google Scholar
  • 62 Chauhan S P, Magann E F, Morrison J C, Whitworth N S, Hendrix N W, Devoe L D. Ultrasonographic assessment of amniotic fluid does not reflect actual amniotic fluid volume.  Am J Obstet Gynecol . 1997;  177 291-297
    CrossrefPubMedSearch in Google Scholar
  • 63 Magann E F, Chauhan S P, Barrilleaux P S, Whitworth N S, Martin J N. Amniotic fluid index and single deepest pocket: weak indicators of abnormal amniotic fluid volumes.  Obstet Gynecol . 2000;  96 737-740
    CrossrefPubMedSearch in Google Scholar
  • 64 Magann E F, Chauhan S P, Whitworth N S, Klausen J H, Saltzman A K, Morrison J C. Do multiple measurements employing different ultrasonic techniques improve the accuracy of amniotic fluid volume assessment?.  Aust NZ J Obstet Gynecol . 1998;  38 172-175
    PubMedSearch in Google Scholar
  • 65 Veille J C, Penry M, Mueller-Heubach E. Fetal renal pulsed Doppler waveform in prolonged pregnancies.  Am J Obstet Gynecol . 1993;  169 882-884
    CrossrefPubMedSearch in Google Scholar
  • 66 Selam B, Koksal R, Ozcan T. Fetal arterial and venous Doppler parameters in the interpretation of oligohydramnios in postterm pregnancies.  Ultrasound Obstet Gynecol . 2000;  15 403-406
    PubMedSearch in Google Scholar
  • 67 Bar-Hava I, Divon M Y, Sardo M, Barnhard Y. Is oligohydramnios in postterm pregnancy associated with redistribution of fetal blood flow?.  Am J Obstet Gynecol . 1995;  173 519-522
    CrossrefPubMedSearch in Google Scholar
  • 68 Trimmer K J, Leveno K J, Peters M T, Kelley M A. Observation on the cause of oligohydramnios in prolonged pregnancy.  Am J Obstet Gynecol . 1990;  163 1900-1903
    PubMedSearch in Google Scholar
  • 69 Leveno K J, Quirk J G, Cunningham F G. Prolonged pregnancy. I. Observations concerning the causes of fetal distress.  Am J Obstet Gynecol . 1984;  150 465-473
    PubMedSearch in Google Scholar
  • 70 Divon M Y, Haglund B, Nisell H, Otterblad P O, Westgren M. Fetal and neonatal morbidity in the postterm pregnancy: the impact of gestational age and fetal growth restriction.  Am J Obstet Gynecol . 1998;  178 726-731
    CrossrefPubMedSearch in Google Scholar
  • 71 Divon M Y, Marks A D, Henderson C E. Longitudinal measurement of amniotic fluid index in postterm pregnancies and its association with fetal outcome.  Am J Obstet Gynecol . 1995;  172 142-146
    CrossrefPubMedSearch in Google Scholar
  • 72 Lagrew D C, Pircon R A, Nageotte M, Freeman R K, Dorchester W. How frequently should the amniotic fluid index be repeated?.  Am Obstet Gynecol . 1992;  167 1129-1133
    PubMedSearch in Google Scholar
  • 73 Eden R D, Seifert L S, Winegar A, Spellacy W N. Perinatal characteristics of uncomplicated postdate pregnancies.  Obstet Gynecol . 1987;  9 296-299
    PubMedSearch in Google Scholar
  • 74 Phelan J P, Platt L D, Yeh S Y, Broussard P, Paul R H. The role of ultrasound assessment of amniotic fluid volume in the management of the postdate pregnancy.  Am J Obstet Gynecol . 1985;  151 304-308
    PubMedSearch in Google Scholar
  • 75 Wing D A, Fishman A, Gonzalez C, Paul R H. How frequently should the amniotic fluid index be performed during the course of antepartum testing?.  Am J Obstet Gynecol . 1996;  174 33-36
    PubMedSearch in Google Scholar
  • 76 Alexander J M, McIntire D D, Leveno K J. Forty weeks and beyond: pregnancy outcomes by week of gestation.  Obstet Gynecol . 2000;  96 291-294
    CrossrefPubMedSearch in Google Scholar
  • 77 O'Reilly-Green C P, Divon M Y. Predictive value of amniotic fluid index for oligohydramnios in patients with prolonged pregnancies.  J Matern Fetal Med . 1996;  5 218-226
    CrossrefPubMedSearch in Google Scholar
  • 78 Alfirevic Z, Lucas M, Walkinshaw S A, McFarlane M, Curran R. A randomized comparison between amniotic fluid index and maximum pool depth in the monitoring of postterm pregnancy.  Br J Obstet Gynaecol . 1997;  104 207-211
    PubMedSearch in Google Scholar
  • 79 Carroll B C, Bruner J P. Umbilical artery Doppler velocimetry in pregnancies complicated by oligohydramnios.  J Reprod Med . 2000;  45 562-566
    PubMedSearch in Google Scholar
  • 80 Chauhan S P, Sanderson M, Hendrix N W, Magann E F, Devoe L D. Perinatal outcomes and amniotic fluid index in the antepartum and intrapartum periods: a meta-analysis.  Am J Obstet Gynecol . 1999;  181 1473-1478
    CrossrefPubMedSearch in Google Scholar
  • 81 Chauhan S P, Washburne J F, Magann E F, Perry K G, Martin J N, Morrison J C. A randomized study to assess the efficacy of the amniotic fluid index as a fetal admission test.  Obstet Gynecol . 1995;  86 9-13
    CrossrefPubMedSearch in Google Scholar
  • 82 Casey B M, McIntire D D, Bloom S L. Pregnancy outcomes after antepartum diagnosis at or beyond 34 weeks gestation.  Am J Obstet Gynecol . 2000;  182 909-912
    CrossrefPubMedSearch in Google Scholar
  • 83 Magann E F, Chauhan S P, Kinsella M J, McNamara M F, Whitworth N S, Morrison J C. Antenatal testing among 1001 patients at high risk: the role of ultrasonographic estimates of amniotic fluid volume.  Am J Obstet Gynecol . 1999;  180 1330-1336
    CrossrefPubMedSearch in Google Scholar
  • 84 Schucker J C, Mercer B M, Audibert F, Lewis R L, Friedman S A, Sibai B M. Serial amniotic fluid index in severe preeclampsia: a poor predictor of adverse outcome.  Am J Obstet Gynecol . 1996;  175 1018-1023
    PubMedSearch in Google Scholar
  • 85 Chauhan S P, Cowan B D, Martin J N, Morrison J C. Intrapartum amniotic fluid index for predicting fetal acidemia.  J Reprod Med . 1995;  40 561-564
    PubMedSearch in Google Scholar
  • 86 Rainford M, Adair R, Scialli A R, Ghidini A, Spong C Y. Amniotic fluid index in the uncomplicated term pregnancy: prediction of outcome.  J Reprod Med . 2001;  46 589-592
    PubMedSearch in Google Scholar
  • 87 Kreiser D, El-Sayed Y, Sorem K A, Chitkara U, Holbrook R H, Druzin M L. Decreased amniotic fluid index in low-risk pregnancy.  J Reprod Med . 2001;  46 743-746
    PubMedSearch in Google Scholar
  • 88 Conway D L, Adkins W B, Schroeder B, Langer O. Isolated oligohydramnios in the term pregnancy: is it a clinical entity?.  J Matern Fetal Med . 1998;  7 197-200
    CrossrefPubMedSearch in Google Scholar
  • 89 Conway D L, Groth S, Adkins W B, Langer O. Management of isolated oligohydramnios in the term pregnancy: a randomized clinical trial.  Am J Obstet Gynecol . 2000;  182 S21
    PubMedSearch in Google Scholar