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Toward consistent terminology: Assessment and reporting of amniotic uid volume

Kenneth J. Moise Jr, MDa,b,n
a

Department of Obstetrics, Gynecology and Reproductive Sciences, Division of MaternalFetal Medicine, UT Health School of Medicine, 6410 Fannin, Suite 210, Houston, TX 77030 b Texas Fetal Center, Children's Memorial Hermann Hospital, Houston, TX

A RT I C L E IN F O

A B S T R A C T
Amniotic uid is typically measured by ultrasound using the amniotic uid index (AFI) or

Keywords: Amniotic uid Maximum vertical pocket Amniotic uid index Deepest vertical pocket

the maximum vertical pocket (MVP). Although both parameters correlate poorly with the actual amniotic uid volume measured with dye-dilution methods, cross-sectional studies have been used to establish gestational norms. The current acceptable denition of polyhydramnios in the late second and the third trimester in both singleton and multiple gestations is a MVP 4 8 cm, while the denition of oligohydramnios is a MVP o 2 cm. The pocket to be measured should exclude the umbilical cord or fetal parts. Randomized clinical trials have indicated that dening oligohydramnios as a MVP o 2 cm will result in fewer obstetrical interventions and similar perinatal outcomes when compared to an AFI o 5 cm. & 2013 Elsevier Inc. All rights reserved.

1.

Introduction

Although the exact source of amniotic uid in the rst trimester of pregnancy is poorly understood, later in gestation the fetus clearly is the major contributor to its surrounding liquid environment. Excessive amounts (polyhydramnios) usually reect fetal polyuria, gastrointestinal obstruction, or dyskinesia syndromes while decreased amounts (oligohydramnios) reect urinary tract obstruction or lack of production of fetal urine. Thus the study of amniotic uid is a study of fetal well-being. This review will describe the methods of assessment and the denition of abnormal amniotic uid volume with a special emphasis on oligohydramnios.

2.

Direct assessment of amniotic uid

Various investigators have utilized dye-dilution methodology to determine the actual amniotic uid volume. Typically, an

amniocentesis is performed, a dye injected and then a second sample is obtained after a prescribed period of time using either the original needle or at the time of a second amniocentesis. Assuming an equal distribution of the dye throughout the amniotic cavity and the lack of fetal metabolism of the agent, the concentration of the dye is then used to calculate the actual amniotic uid volume. Radio-active iodinated serum albumin, Congo red, Evans blue, Coomassie blue, cardiogreen and para-aminohippurate (PAH) have all been used in these studies.1 PAH has provided the most reproducible results with complete mixing and stable concentrations between 20 min and 40 min post injection.2 The rst large study of normal amniotic uid volumes was reported by Brace and Wolfe in 1989.3 A cross-sectional analysis of data from 12 different studies in a total of 705 patients was undertaken to create a longitudinal curve based on gestational age.1 Seven of the studies used ve different agents in dye-dilution methodology and ve of the studies involved direct measurements of amniotic uid at

Disclosures: Kenneth J. Moise, Jr. MD receives consultative fees from LabCorp, Inc. to serve on their clinical testing advisory board. He also receives royalty payments for various chapters that he has authored in UpToDate, Inc. n Corresponding author. E-mail address: Kenneth.J.Moise@uth.tmc.edu 0146-0005/13/$ - see front matter & 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.semperi.2013.06.016

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hysterotomy between 1020 weeks of gestation. A polynomial regression of the data points revealed that amniotic uid volume increased until 22 weeks of gestation and then remained stable until 39 weeks when it began to decline. More recently, Magann and associates1 prospectively studied 144 singleton pregnancies between 15 and 40 weeks of gestation using a PAH dye-dilution method. Contrary to the previously published cross-sectional study, they found that amniotic uid volume continued to increase well into the third trimester. The 95th percentile condence interval at 40 weeks of gestation was between 150 cc and 2100 cc.

4.

Ultrasound denition of polyhydramnios

3.

Ultrasound assessment of oligohydramnios

In 1980, Manning et al.4 proposed ve categories of ultrasound assessment to comprise the biophysical prole (BPP). A deepest pocket 4 1 cm measured vertically in the anterior posterior plane at any location in the amniotic cavity was considered evidence of normal uid. In this initial report, the width of the pocket was not described. In a later study, this group retrospectively analyzed the amniotic uid determinations in over 7500 women undergoing BPPs for high-risk conditions. A uid measurement o 1 cm was described as decreased while a measurement between 1 and 2 cm was considered marginal and 42 cm and o8 cm was considered normal. The corresponding corrected perinatal mortality rates were 109.4/1000, 37.74/1000, and 1.97/1000, respectively. This data led to a change in the denition of the BPP score of 2 for amniotic uid to the presence of a deepest vertical pocket of 2 cm.5 Later, Manning et al.6 dened normal amniotic uid as a pocket measuring 2 2 cm. Since these initial observations, this ultrasound parameter of amniotic uid assessment has come to be known as the maximum vertical pocket (MVP), deepest vertical pocket (DVP), or single deepest vertical pocket (SDVP). Perhaps the most commonly used ultrasound measurement of amniotic uid assessment is the amniotic uid index (AFI). First introduced by Phelan et al.7 the method involves dividing the amniotic cavity into four quadrants using the maternal linea nigra as the midline. The deepest vertical pocket is then ascertained in each quadrant and the four measurements summed. Although not well dened in the original description, it is generally accepted that if a uid pocket contains a fetal small part or the umbilical cord, the vertical measurement should not include the uid posterior to the element. Limited data in the rst report suggested that an AFI r 5 cm indicated oligohydramnios. Two groups have reported cross-sectional studies of the AFI. Moore and Cayle8 studied 791 women and developed polynomial equations to determine percentile data based on gestational age. In distinction to the previous o 5 cm rule as the denition of oligohydramnios, they proposed that an AFI o 5th percentile for gestational age should be the more precise denition. This led some obstetricians to use an AFI o 8 cm at term to dene oligohydramnios. Magann et al.9 studied 50 patients at each week of gestation between 14 and 41 weeks of gestation (Table 1). These authors conrmed that an AFI o 5 cm was below the 5th percentile for gestational ages greater than 37 weeks.

The denition of polyhydramnios has not undergone the same scrutiny as the denition of oligohydramnios. Chamberlain et al.10 arbitrarily dened the upper limits of normal amniotic uid as an MVP of 8 cm based on their clinical impression while performing a large series of biophysical proles. A later cross-sectional study indicated that the 95th percentile for the MVP between 30 and 37 weeks of gestation ranges between 7.0 and 7.2 cm.9 At the initial introduction of the AFI method, the authors suggested that an AFI 4 20 cm was indicative of polyhydramnios.11 Later, Carlson et al.12 studied the AFI in a diabetic population and found that an AFI 4 24 cm was superior to an MVP 4 8 cm as a predictor of severe polyhydramnios. In the cross-sectional study of Moore et al.8 the 95th percentile for the AFI between 31 and 38 weeks approached or exceeded 24 cm. Magann et al.9 found the 95th percentile at these same gestational ages to be 20.6 to 15.9 cm.

5. Ultrasound estimation of amniotic volume in multiples

Both the AFI and MVP have been used to assess amniotic uid volume in twin gestations.13 The AFI requires that the intertwin membrane be easily seen and that each twin's amniotic compartment be divided into four quadrants. Given these technical limitations, most centers use the MVP of each twin's amniotic uid compartment to assess the volume. In a large study of 299 pregnancies involving 232 dichorionic and 67 monochorionic uncomplicated twin gestations, the MVP in the amniotic cavity of each twin remained relatively stable between 17 and 37 weeks of gestation. The average 2.5th percentile and 97.5th percentile were 2.3 and 7.6 cm, respectively.14 This data would support the use of 2 cm and 8 cm to dene oligohydramnios and polyhydramnios which is used in the staging of twintwin transfusion.15 Data on normal amniotic uid measurements in higher order multiples are lacking in the literature. The same denitions for oligohydramnios and polyhydramnios for twin gestations are typically used.

6. Reproducibility and accuracy of ultrasound measurements

In one study of 20 cases, the intra-observer variation in AFI averaged 3% (5.0 7 1.2 mm).8 However, with AFI values o 10 cm, the intra-observer variation was 20% or more; at AFI values 4 20 cm, it was less than 5%. Inter-observer variation among ve sonographers and 50 patients was 6.7% (9.7 7 0.7 mm). A second study compared the intraobserver variation in the AFI and MVP measurements.16 Measurements from the same sonographer were compared before and after fetal biometric measurements. The overall kappa value for the AFI was 0.72 (kappa 0.6 with AFI o 5% and 0.84 with AFI 4 95%). The overall kappa value for the MVP was only 0.33 and did not change with oligohydramnios

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Table 1 Amniotic uid parameters based on gestational age (Modied from Magann et al.9).
Gestational age (weeks) Maximum vertical pocket (cm) 5th percentile 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 1.7 2.0 2.3 2.5 2.7 2.8 2. 2.9 3.0 3.0 3.1 3.0 3.0 3.0 3.0 2.9 2.9 2.9 2.9 2.9 2.8 2.8 2.7 2.6 2.4 2.3 2.1 1.9 95th percentile 5.0 5.5 5.9 6.2 6.4 6.6 6.7 6.8 6.8 6.8 6.8 6.8 6.8 6.9 6.9 6.9 6.9 7.0 7.1 7.2 7.2 7.2 7.1 7.0 6.8 6.6 6.2 5.7 Amniotic uid index (cm) 5th percentile 2.8 3.2 3.6 4.1 4.6 5.1 5.5 5.9 6.3 6.7 7.0 7.3 7.5 7.6 7.6 7.6 7.5 7.3 7.1 6.8 6.4 6.0 5.6 5.1 4.7 4.2 3.7 3.3 95th percentile 8.6 9.1 9.6 10.3 11.1 12.0 12.9 13.9 14.9 15.9 16.9 17.8 18.7 19.4 19.9 20.4 20.6 20.6 20.4 20.0 19.4 18.7 17.9 16.9 15.9 14.9 13.9 12.9

or polyhydramnios. The authors concluded that the AFI was superior to MVP for reproducibility. Studies have also evaluated the correlation between the AFI and MVP and the actual amniotic uid volume as determined with dye-dilution methods. Dildy et al.17 measured amniotic uid in 50 patients using PAH. Both the AFI and MVP showed similar R2 values in their correlation to actual volumes (74.4% and 71.2%, respectively). Both methods appeared to overestimate the amniotic uid volume at low volumes and to underestimate the actual volume at higher levels. In a similar study of 75 women, Magann et al.9 noted that both the AFI and MVP were poor predictors of the actual amniotic uid volume in cases of oligohydramnios or polyhydramnios.

increasing AFI; with an AFI 4 35 cm, 79% of pregnancies were associated with a structural anomaly. Not surprising, the increasing category of AFI was also associated with progressively higher rates of IUFD (0%-13%) and perinatal mortality (0%-30%).

7.2.

Borderline oligohydramnios

7.
7.1.

Clinical Outcomes
Polyhydramnios

Chamberlain et al.10 were the rst to study the association between increased amniotic uid (MVP 4 8 cm) and poor perinatal outcome. In a series of 243 patients, eight perinatal deaths occurredseven were due to major congenital anomalies. A more recent study evaluated the degree of polyhydramnios based on the AFI.18 Categories of o 25 cm, 2530 cm, 3035 cm, and 435 cm were studied. A progressive increase in the rate of congenital anomalies was noted with

As mentioned earlier, some centers use an AFI o 8 cm to dene relative oligohydramnios near term. This is based on the 5th percentile for AFI determined by the study of Moore and Cayle.8 A systematic review of six studies was undertaken to evaluate the perinatal outcome of patients with an AFI between 5 and 8 cm as compared to a normal uid group with an AFI 4 8 cm.19 Patients with borderline oligohydramnios were found to have a 1.58-fold (95% CI: 1.032.42) increased rate of an Apgar score at 5 min o 7, a 1.48-fold (95% CI: 1.171.88) increased rate of admission to the neonatal intensive care unit and a 1.38-fold (95% CI: 1.061.81) increased rate of an IUGR or SGA infant. Quinones et al.20 reported an unblinded prospective study of perinatal outcomes in patients with decreased amniotic uid near term as assessed by AFI. A composite neonatal morbidity index was evaluated in fetuses with AFI categories of o 5 cm, o 8 cm, and o10 cm. Although an AFI o 8 cm was associated with a higher rate of neonatal morbidity, the authors felt that the low positive predictive value was not sufcient to

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Table 2 Outcome of review of AFI o 5 cm vs MVP o 2 cm in the management of oligohydramnios. (The Cochrane Collaboration. Amniotic uid index versus single deepest vertical pocket as a screening test for preventing adverse pregnancy outcome. 2009; Issue 3, pp. 131). Signicant differences are noted in boldface, italic font.
Parameter Diagnosis of oligohydramnios Induction of labor Assisted vaginal delivery Assisted vaginal delivery for fetal distress Overall cesarean delivery Cesarean delivery for fetal distress Perinatal outcomes Presence of meconium Non-reassuring fetal heart rate tracing Apgar score o 7 at 5 min Umbilical cord pH o 7.1 Admission to neonatal intensive care unit No. of patients 3226 2138 3125 1625 3226 3226 3226 2726 3226 2625 3226 RR (95% CI) 2.39 (1.393.28) 1.92 (1.502.46) 1.08 (0.921.27) 1.07 (0.801.44) 1.09 (0.921.29) 1.46 (1.081.96) 1.09 1.13 1.15 1.10 1.04 (0.901.30) (0.931.36) (0.701.89) (0.741.65) (0.851.26)

warrant routine obstetrical intervention if no other problems were noted.

7.3.

Oligohydramnios

Randomized clinical trials have indicated that dening oligohydramnios as an MVP o 2 cm will result in fewer obstetrical interventions and similar perinatal outcomes when compared to an AFI o 5 cm.

As noted above, controversy exists as to what ultrasound measurement should indicate oligohydramnios - MVP o 2 cm, AFI o 5 cm, AFI o 8 cm, or AFI o 5th percentile. In general, the rst two denitions enjoy the most widespread acceptance. A Cochrane Review was conducted to compare the perinatal outcomes of these two parameters. Over 3000 women from ve randomized trials were analyzed (see Table 2). When the AFI o 5 cm was used, more cases of oligohydramnios were diagnosed (RR 2.39), more women underwent induction of labor (RR 1.92), and more emergent Cesarean deliveries were performed (RR 1.46). Assisted vaginal deliveries and the overall rate of Cesarean deliveries were not different whether MVP or AFI was used. More importantly, perinatal morbidity, including admission to the neonatal intensive care unit, did not differ based on the denition of oligohydramnios. The authors of the Cochrane Review concluded that the MVP appeared to be a better choice for the assessment of amniotic uid for fetal surveillance.

refere nces

8.

Conclusions
Amniotic uid volume should be measured or subjectively assessed at all ultrasound examinations. The amniotic uid index (AFI) is a method of measurement of amniotic uid. In the late second and in the third trimester, a range of 5 cm to 24 cm has been dened as normal. The maximum vertical pocket (MVP) has also been proposed as an alternative approach for measurement. The current acceptable denition of polyhydramnios in the late second and the third trimester in both singleton and multiple gestations is an MVP 4 8 cm while the denition of oligohydramnios is an MVP o 2 cm. The pocket to be measured should exclude the umbilical cord or fetal parts.

 

 

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