British Jourrrd of Ohtetric.\ rind Gyrimcology Dccember 1990, Vol. 97, pp. 1115-1122
Polyhydramnios and associated maternal and fetal complications in singleton pregnancies ELS J. DESMEDT, OLIVIA A.HENRY,
NORMAN A. BEISCHER
Summary. During the 10-year period 1 January 1979 to 31 December 1988, polyhydramnios occurred in 537 patients with singleton pregnancies delivered at the Mercy Maternity Hospital. Associated maternal and fetal complications and the perinatal outcome of thcsc prcgnancics with polyhydramnios were analysed. In 248 of the 537 pregnancies (46%) in this group there were no maternal complications or fetal malformations and the perinatal mortality (PNM) rate w a s 2.4%. The PNM rate increased significantly to 13.1Yo when thcrc was iissociated pre-eclampsia, 10% with gestational diabetes, and to 7.6% with miscellaneous complications. When polyhydramnios was associated with a fetal or placental malformation the PNM rate was 61.4%. The commonest malformations were central nervous system (31%), musculoskcletal (12%) and gastrointestinal system anomalies (1 0%). Placental chorioangioma occurred in two patienlh ( 0 .4 % ) and both babies died. In women with low oestriol excretion (18% of the 455 tcsted) the PNM rate increased five times to 22.7%.
Polyhydramnios occurs in 0.4%-1.2% of pregnancies (Mi~cafee 1950: Queenan & Gadow 1970) and it is associated with a high perinatal mortality ratc duc to fetal malformations and immaturity; it is also associated with diabetes and possibly with pre-eclampsia. This study analyses these and other associations of thc various typcs of polyhydramnios in 51 022 consecutive singleton pregnancies managed at the Mercy Maternity Hospital. Melbourne, during the 10-years. 3979-1988. Subjects and methods
From 1 January 1979 to 31 December 1988, University Department of Obstetrics and Gynaecologl, Mercy hlaternity Hospital, Clarcndun Street, East Melhourne 3002, Awtralia E J DESMEDT Re,eurch Fellow 0 A HENRY Researcli F d o ~ N A BEISCHER ProfaTor iri Obrtptrics urrd G\nuerology
Correspondence Piofcssot N A Beische~
there were 51 022 singleton deliveries at thc Mercy Maternity Hospital. Coding for polyhydramnios and other obstetric complications was carried out after delivery. All histories where polyhydramnios was rccordcd were reviewed to verify the diagnosis and the 537 resulting cases were classified according to the rapidity of onset: acutc polyhydramnios was il rapid increase o f diagnosed when there amniotic fluid resulting in an enlarged tender uterus causing pain and respiratory symptoms within 3-5 day5 (Queenan & Gadow 1970; Weir et nl. 1979); subacute polyhydramnios was diagnosed when signs of excessive amniotic fluid developed over an interval of 1 to 2 weeks and associated symptoms were less severe or were difficult to diffcrentiate from other obstetric conditions such as preterm labour or placental abruption; chronic polyhydramnios was diagnosed when thcrc was a gradual onsct of cxcessive amniotic fluid and, although the volume of amniotic fluid varied enormously. the associated symptoms were usually mild. In some patients
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E. J. Desmedt et al.
there was clinical and/or ultrasonographic evidence of polyhydramnios during pregnancy but the cxcessive amniotic fluid volume returncd to normal before the onset of labour. A major congenital malformation was defined as a malformation that interfered with life oifunction of all or part of the infant and these were classified according to the W H O system: non-immunological hydrops fetalis was also included with congenital malformations. Glucose tolcrance testing ((31 ‘r) was performed at 30-32 weeks gestation using a 5U g glucose load. Gestational diabetes was dcfincd as carbohydrate intolerance first recognized during pregnancy whcther or not insulin was required and whether or not it persisted after delivery (International Workshop on Gcstational Diabctes 1985). The criterion for diagnosis was the combination of capillary plasma glucose levels of b 9 mmol/l at 1 h and 7 rninolil at 2 11. The criterion for diagnosis of hypoglycaemia was the combination of plasma glucose levels of < 4 nimol/l fasting and S 3 mmolil at 3 h. Previous studies from this institution have shown that maternal hypoglycaemia has a significant positive association with perinatal mortality. fetal growth retardation and major malformations of the fetal genitourinary system. (Ahell& Beischer 1076; Oats & Beischer 19S6). Urinary oestriol excretion was measured by the rapid method of Brown et nl. (1968). The lower limit of normal was defined as a line joining 27-8 1mo1124 ti (8 mgi24 h) at 30 weeks gestation and 41.6 umo1/24 h (12 mgi24 h) at 40 wccks and thcrcaftcr. This linc corresponds approximately to the tenth centile for a normal obstetric population. We attempted to perPorm 24 h urinary oestriol estiniatioiis in all patients at 30 and 36 weeks and additionally when indicated by clinical complications. In this series only the non-booked patients and those delivered before 30 weeks gestation did not receive these routine antenatal investigations. Prc-eclampsia was defined when two o r more of the following signs were present: hypertension > 140/00 mmI-ig, generalized oedema. proteinuria not due to contamination or urinary infection. Antepartum haemorrhage included accidental haemorrhage which was confirmed when retroplacental clot was present on examination of the placenta after delivery. Placenta praevia was diagnosed when thc placenta was felt with the examining finger in the vagina, the placenta
was seen to occupy all or part of thc lower uterine segmcnt at caesarean section, or the membranes were observed to have ruptured at the edge of the placenta when thc secundines were examined aftcr vaginal delivery. A diagnosis of antepartum haemorrhage of unknown cause was made only after delivery when accidcntal hacmorrhagc and placenta praevia had been excluded. The criterion used for the diagnosis of anaemia was a hacmoglobin valuc of < 10 g/dl bcfore delivery in women without antepartum haemorrhage. In this study all infants with a birthweight of b 40U g were included; a stillborn infant was defined as an infant who showed no signs of life and had a birthweight of 3 400 g; a neonatal death was defined as death within 28 days of birth of liveborn infant with birthweight of b 400 g. The perinatal mortality rate was the number of neonatal deaths plus stillbirths per 1000 total births. (Consultative Council on Obstetric and Pacdiatric Mortality and Morbidity 1987). Results ‘There were 537 women with polyhydramnios in singleton pregnancies. The mean gestation at onset was 31.4 weeks and at delivery 37.2 wccks; 154 patients (28.6%) were delivered preterni (
Polyhydramnios and associated maternal and fetal complications in singleton pregnancies ELS J. DESMEDT, OLIVIA A.HENRY,
NORMAN A. BEISCHER
Summary. During the 10-year period 1 January 1979 to 31 December 1988, polyhydramnios occurred in 537 patients with singleton pregnancies delivered at the Mercy Maternity Hospital. Associated maternal and fetal complications and the perinatal outcome of thcsc prcgnancics with polyhydramnios were analysed. In 248 of the 537 pregnancies (46%) in this group there were no maternal complications or fetal malformations and the perinatal mortality (PNM) rate w a s 2.4%. The PNM rate increased significantly to 13.1Yo when thcrc was iissociated pre-eclampsia, 10% with gestational diabetes, and to 7.6% with miscellaneous complications. When polyhydramnios was associated with a fetal or placental malformation the PNM rate was 61.4%. The commonest malformations were central nervous system (31%), musculoskcletal (12%) and gastrointestinal system anomalies (1 0%). Placental chorioangioma occurred in two patienlh ( 0 .4 % ) and both babies died. In women with low oestriol excretion (18% of the 455 tcsted) the PNM rate increased five times to 22.7%.
Polyhydramnios occurs in 0.4%-1.2% of pregnancies (Mi~cafee 1950: Queenan & Gadow 1970) and it is associated with a high perinatal mortality ratc duc to fetal malformations and immaturity; it is also associated with diabetes and possibly with pre-eclampsia. This study analyses these and other associations of thc various typcs of polyhydramnios in 51 022 consecutive singleton pregnancies managed at the Mercy Maternity Hospital. Melbourne, during the 10-years. 3979-1988. Subjects and methods
From 1 January 1979 to 31 December 1988, University Department of Obstetrics and Gynaecologl, Mercy hlaternity Hospital, Clarcndun Street, East Melhourne 3002, Awtralia E J DESMEDT Re,eurch Fellow 0 A HENRY Researcli F d o ~ N A BEISCHER ProfaTor iri Obrtptrics urrd G\nuerology
Correspondence Piofcssot N A Beische~
there were 51 022 singleton deliveries at thc Mercy Maternity Hospital. Coding for polyhydramnios and other obstetric complications was carried out after delivery. All histories where polyhydramnios was rccordcd were reviewed to verify the diagnosis and the 537 resulting cases were classified according to the rapidity of onset: acutc polyhydramnios was il rapid increase o f diagnosed when there amniotic fluid resulting in an enlarged tender uterus causing pain and respiratory symptoms within 3-5 day5 (Queenan & Gadow 1970; Weir et nl. 1979); subacute polyhydramnios was diagnosed when signs of excessive amniotic fluid developed over an interval of 1 to 2 weeks and associated symptoms were less severe or were difficult to diffcrentiate from other obstetric conditions such as preterm labour or placental abruption; chronic polyhydramnios was diagnosed when thcrc was a gradual onsct of cxcessive amniotic fluid and, although the volume of amniotic fluid varied enormously. the associated symptoms were usually mild. In some patients
111s
1116
E. J. Desmedt et al.
there was clinical and/or ultrasonographic evidence of polyhydramnios during pregnancy but the cxcessive amniotic fluid volume returncd to normal before the onset of labour. A major congenital malformation was defined as a malformation that interfered with life oifunction of all or part of the infant and these were classified according to the W H O system: non-immunological hydrops fetalis was also included with congenital malformations. Glucose tolcrance testing ((31 ‘r) was performed at 30-32 weeks gestation using a 5U g glucose load. Gestational diabetes was dcfincd as carbohydrate intolerance first recognized during pregnancy whcther or not insulin was required and whether or not it persisted after delivery (International Workshop on Gcstational Diabctes 1985). The criterion for diagnosis was the combination of capillary plasma glucose levels of b 9 mmol/l at 1 h and 7 rninolil at 2 11. The criterion for diagnosis of hypoglycaemia was the combination of plasma glucose levels of < 4 nimol/l fasting and S 3 mmolil at 3 h. Previous studies from this institution have shown that maternal hypoglycaemia has a significant positive association with perinatal mortality. fetal growth retardation and major malformations of the fetal genitourinary system. (Ahell& Beischer 1076; Oats & Beischer 19S6). Urinary oestriol excretion was measured by the rapid method of Brown et nl. (1968). The lower limit of normal was defined as a line joining 27-8 1mo1124 ti (8 mgi24 h) at 30 weeks gestation and 41.6 umo1/24 h (12 mgi24 h) at 40 wccks and thcrcaftcr. This linc corresponds approximately to the tenth centile for a normal obstetric population. We attempted to perPorm 24 h urinary oestriol estiniatioiis in all patients at 30 and 36 weeks and additionally when indicated by clinical complications. In this series only the non-booked patients and those delivered before 30 weeks gestation did not receive these routine antenatal investigations. Prc-eclampsia was defined when two o r more of the following signs were present: hypertension > 140/00 mmI-ig, generalized oedema. proteinuria not due to contamination or urinary infection. Antepartum haemorrhage included accidental haemorrhage which was confirmed when retroplacental clot was present on examination of the placenta after delivery. Placenta praevia was diagnosed when thc placenta was felt with the examining finger in the vagina, the placenta
was seen to occupy all or part of thc lower uterine segmcnt at caesarean section, or the membranes were observed to have ruptured at the edge of the placenta when thc secundines were examined aftcr vaginal delivery. A diagnosis of antepartum haemorrhage of unknown cause was made only after delivery when accidcntal hacmorrhagc and placenta praevia had been excluded. The criterion used for the diagnosis of anaemia was a hacmoglobin valuc of < 10 g/dl bcfore delivery in women without antepartum haemorrhage. In this study all infants with a birthweight of b 40U g were included; a stillborn infant was defined as an infant who showed no signs of life and had a birthweight of 3 400 g; a neonatal death was defined as death within 28 days of birth of liveborn infant with birthweight of b 400 g. The perinatal mortality rate was the number of neonatal deaths plus stillbirths per 1000 total births. (Consultative Council on Obstetric and Pacdiatric Mortality and Morbidity 1987). Results ‘There were 537 women with polyhydramnios in singleton pregnancies. The mean gestation at onset was 31.4 weeks and at delivery 37.2 wccks; 154 patients (28.6%) were delivered preterni (
