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Oligohydramnios and PPROM (query bank)

Published: 18/10/2013

Question

Is severe oligohydramnios or anhydramnios secondary to PPROM an indication for delivery in an otherwise stable patient between 26–34 weeks of gestation?

Answer

Guidelines from RCOG and ACOG do not mention oligohydramnios or anhydramnios specifically as indications for delivery in a woman with preterm premature rupture of the membranes (PPROM) at 26-34 weeks gestation.

The chapter on premature rupture of membranes in online textbook eMedicine (Jazayeri) says:

“While oligohydramnios, defined as an amniotic fluid index of less than 2 cm, has been associated with short latency and chorioamnionitis, it alone is not an indication for delivery when other means of surveillance are reassuring.”

Studies show variation in the risk of adverse events in women with PPROM and oligohydramnios although not all studies are restricted to severe oligohydramnios, for example:

Severe oligohydramnios

  • Rotschild et al report 88 infants with rupture of the membranes of greater than or equal to 7 days with onset before 29 weeks' gestation. The development of skeletal compression deformities was associated with severe oligohydramnios (p = 0.05)
  • Thibeault et al assessed pulmonary function and compression deformities in 76 preterm infants less than or equal to 34 weeks gestation who had premature rupture of membranes (PROM) for longer than 5 days. They conclude that pulmonary hypoplasia can result from PROM associated with severe oligohydramnios of as short as 6 days duration.
  • Vintzileos et al’s retrospective study of 298 patients with pprom found that patients with severe oligohydramnios (largest pocket less than 1 cm) seem to be at particular risk for developing abruptio placentae
  • An earlier, smaller study by Vintzileos suggested that in patients with PROM the degree of oligohydramnios is positively correlated with unfavorable pregnancy outcome.

No clear link to adverse effects

  • Zhang et al reported 15,151 low risk pregnant women screened by ultrasound at 15-22 and 31-35 weeks of gestation. Oligohydramnios (amniotic fluid index < or =5 cm) was diagnosed in 1.5% (113/7617) of women with ultrasound screening compared with 0.8% (57/7534) among the controls. Approximately half of the oligohydramnios cases in the screening group were isolated with no clearly associated factors (e.g. premature rupture of the fetal membranes). Pregnancies with isolated oligohydramnios had perinatal outcomes similar to pregnancies with a normal amniotic fluid index.
  • Coolen et al report a retrospective cohort study comparing the outcomes of pregnancies with an initial amniotic fluid index (AFI) < 5 cm with the outcomes of pregnancies with an AFI of 5 to 10 cm. They concluded that initial oligohydramnios is associated with decreased latency in singleton pregnancies complicated by PPROM at 30 to 36 weeks’ gestation; however, it does not appear to influence maternal or neonatal infectious morbidity, and it may not be useful to determine candidacy for expectant management or intentional delivery.

Link to adverse effects

  • Melamed et al compared 488 women with PPROM at gestational age 28-33 weeks with a matched control group of 1464 women with spontaneous preterm delivery, and found that neonates in the uncomplicated PPROM group were at increased risk for composite adverse outcome (53.7% vs 42.0%; P < .001), mortality (1.6% vs 0.0%; P < .001), respiratory morbidity (32.8% vs 26.4%; P = .006), necrotizing enterocolitis, jaundice, hypoglycemia, hypothermia, and polycythemia. Neonatal adverse outcome was more likely in cases of latency period >7 days, oligohydramnios, male fetus, and nulliparity
  • Ananth et al report a retrospective study cohort study including 11,777 patients with an overall incidence of placental abruption of 0.87%. Preterm PROM accompanied by oligohydramnios conferred over a 7.17-fold risk (95% CI 1.35-38.10) for abruption compared with women with neither of these 2 conditions.
  • Xie et al retrospectively studied 230 women with PPROM and found oligohydramnios (OR = 2.937) to be significantly associated with histologic chorioamnionitis (HCA).
  • Messerschmidt et al report a retrospective study including 300 infants with pPROM derived from a cohort of 1,435 very low birth weight (VLBW) infants. Anhydramnios correlated with higher mortality.
  • Huang et al report on 145 pregnant women with PPROM during 28 - 34 gestational weeks. The group with oligohydramnios had a shorter latent period (P < 0.05) compared with women with borderline oligohydramnios, or normal amniotic fluid; and had a higher rate of cesarean section (69%), Intra-amniotic infection (IAI, 36%), fetal distress (19%), neonatal asphyxia (28%), early-onset neonatal sepsis (28%) and hypoxic-ischemic myocardial injury (56%) than those in Group of normal amniotic fluid (39%, 9%, 3%, 8%, 9%, 13%; P < 0.01)

(Evidence level III)

References

  • American College of Obstetricians and Gynecologists. Premature Rupture of Membranes. Practice Bulletin 139. Obstet Gynecol. 2013 Oct;122(4):918:30
  • Ananth CV, Oyelese Y, Srinivas N, Yeo L, Vintzileos AM. Preterm premature rupture of membranes, intrauterine infection, and oligohydramnios: risk factors for placental abruption. Obstet Gynecol. 2004 Jul;104(1):71-7. Abstract.
  • Coolen J. Kabayashi K. Wong K. Mayes DC. Bott N. Demianczuk N. Influence of oligohydramnios on preterm premature rupture of the membranes at 30 to 36 weeks’ gestation. Journal of Obstetrics & Gynaecology Canada: JOGC. 32(11):1030-4, 2010 Nov. Abstract.
  • Huang S. Qi HB. Li L. [Residue amniotic fluid volume after preterm premature rupture of membranes and maternal-fetal outcome.]. [Chinese] Chung-Hua Fu Chan Ko Tsa Chih [Chinese Journal of Obstetrics & Gynecology]. 44(10):726-30, 2009 Oct. Abstract.
  • Jazayeri, A. Premature rupture of membranes. In: eMedcine. 2013
  • Melamed N, Ben-Haroush A, Pardo J, Chen R, Hadar E, Hod M, Yogev Y. Expectant management of preterm premature rupture of membranes: is it all about gestational age? Am J Obstet Gynecol. 2011 Jan;204(1):48.e1-8. Abstract.
  • Messerschmidt A. Olischar M. Birnbacher R. Sauer A. Weber M. Puschnig D. Unterasinger L. Pollak A. Leitich H. Is it possible to make a reliable prognosis within the first hour of life for very low birth weight infants delivered after preterm premature rupture of membranes?. Neonatology. 99(2):146-52, 2011. Abstract.
  • RCOG. Preterm prelabour rupture of the membranes. Green-top guideline 44. London: RCOG, 2006.
  • Rotschild A. Ling EW. Puterman ML. Farquharson D. Neonatal outcome after prolonged preterm rupture of the membranes. American Journal of Obstetrics & Gynecology. 162(1):46-52, 1990 Jan. Abstract.
  • Thibeault DW. Beatty EC Jr. Hall RT. Bowen SK. O’Neill DH. Neonatal pulmonary hypoplasia with premature rupture of fetal membranes and oligohydramnios. Journal of Pediatrics. 107(2):273-7, 1985 Aug. Abstract.
  • Vintzileos AM. Campbell WA. Nochimson DJ. Weinbaum PJ. Preterm premature rupture of the membranes: a risk factor for the development of abruptio placentae. American Journal of Obstetrics & Gynecology. 156(5):1235-8, 1987 May. Abstract.
  • Vintzileos AM. Campbell WA. Nochimson DJ. Weinbaum PJ. Degree of oligohydramnios and pregnancy outcome in patients with premature rupture of the membranes. Obstetrics & Gynecology. 66(2):162-7, 1985 Aug. Abstract.
  • Xie AL. DI XD. Chen XM. Hu YC. Wang YH. [Factors and neonatal outcomes associated with histologic chorioamnionitis after premature rupture of membranes in the preterms]. [Chinese] Chung-Hua Fu Chan Ko Tsa Chih [Chinese Journal of Obstetrics & Gynecology]. 47(2):105-9, 2012 Feb. Abstract.
  • Zhang J, Troendle J, Meikle S, Klebanoff MA, Rayburn WF. Isolated oligohydramnios is not associated with adverse perinatal outcomes. BJOG. 2004 Mar;111(3):220-5.

Search date

October 2013

Classification of evidence levels

  • Ia: Evidence obtained from meta-analysis of randomised controlled trials.
  • Ib: Evidence obtained from at least one randomised controlled trial.
  • IIa: Evidence obtained from at least one well-designed controlled study without randomisation.
  • IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study.
  • III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
  • IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

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