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Oligohydramnios
Oligohydramnios is defined as too little amniotic fluid. There is an association between oligohydramnios and both
intrauterine growth restriction and increased perinatal mortality. [1] Normal amniotic fluid volume changes with
gestational age and ways of accurately estimating it have changed over the years. Oligohydramnios has been
defined as: [2]

Amniotic fluid volume of less than 500 ml at 32-36 weeks of gestation.

Maximum vertical pocket (MVP) of less than 2 cm from late mid-trimester.
Amniotic fluid index (AFI) of less than 5 cm or less than the 5th percentile, from late mid-trimester.

Physiology
Amniotic fluid volume (AFV) increases throughout most of pregnancy, with a volume of about 30 ml at 10 weeks
of gestation and a peak of about 1 L at 34-36 weeks of gestation. AFV decreases towards term, with a mean AFV
of 800 ml at 40 weeks.

Amniotic fluid constantly circulates, with an estimated exchange rate as high as 3600 ml/hour. Excretion of urine
by the fetus is the major source of amniotic fluid production in the second half of the pregnancy. Fluid secreted by
the fetal respiratory tract also contributes to AFV.

Fetal swallowing is the major pathway of amniotic fluid clearance in the last half of gestation. Fetal skin is highly
permeable in the first half of pregnancy but becomes keratinised at 22-25 weeks of gestation, significantly
reducing transfer.

The mother's fluid balance (and also therefore the fetus') has a major effect on the AFV. Increased maternal fluid
intake has been shown to increase the AFV in women with oligohydramnios. [3]

Pathology
Oligohydramnios is secondary to either an excess loss of fluid, or a decrease in fetal urine production or
excretion. Oligohydramnios is usually associated with one of the following conditions:

Rupture of amniotic membranes (ROM).

Congenital absence of functional renal tissue or obstructive uropathy:
Conditions that prevent the formation of urine or the entry of urine into the amniotic sac.
Fetal urinary tract malformations, including renal agenesis, cystic dysplasia and ureteral
atresia.

Decreased renal perfusion leading to reduced urine production:

As a sequela of hypoxaemia-induced redistribution of fetal cardiac output.
In growth-restricted fetuses, chronic hypoxia results in shunting of fetal blood away from the
kidneys to more vital organs.
Anuria and oliguria lead to oligohydramnios.

Post-term gestation:
The cause of decreased AFV in post-term pregnancies is unknown.
The decreased efficiency of placental function has been proposed as a cause but this has
not been confirmed histologically.
Decreased fetal renal blood flow and decreased fetal urine production have been
demonstrated beyond 42 weeks in pregnancies involving oligohydramnios.
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Epidemiology
Oligohydramnios is a complication in approximately 4.5% of all pregnancies and severe oligohydramnios is a
complication in 0.7% of pregnancies. [4] Oligohydramnios is more common in pregnancies beyond term, as the
AFV normally decreases at term. It complicates as many as 12% of pregnancies that last beyond 41 weeks.

Aetiology
Fetal causes include:
Chromosomal factors.
Congenital factors.
Intrauterine growth restriction.
Post-term pregnancy.
Premature ROM (PROM).
Fetal demise.

Placental causes include:

Abruption.
Twin-to-twin transfusion syndrome (monochorionic twins).

Maternal causes include:

Maternal dehydration.
Uteroplacental insufficiency.
Hypertension.
Pre-eclampsia.
Diabetes (either pre-existing or gestational diabetes).
Chronic hypoxia.

Drug-induced causes include indometacin and angiotensin-converting enzyme (ACE) inhibitors.

Idiopathic.

Investigations
Test for systemic lupus erythematosus (causes immune-mediated infarcts in the placenta and placental
insufficiency). Other maternal risk factors (including hypertension and diabetes) should also be assessed.

Ultrasound
The diagnosis is confirmed by ultrasound. It may be discovered incidentally during routine scanning, or noted
during antepartum surveillance for other conditions.

Suspicion of oligohydramnios may be prompted by discrepancies in sequential fundal height

measurements, or by fetal parts that are easily palpated through the maternal abdomen.
During ultrasound, normal-appearing fetal kidneys and fluid-filled bladder may be observed to rule out
renal agenesis, cystic dysplasia and ureteral obstruction.
Fetal growth should be checked to exclude intrauterine growth restriction leading to oliguria. Doppler
ultrasound could be used to assess placental insufficiency, if suspected.

Measurement of AFV
The two most commonly used objective methods of determining AFV include measurement of the
maximum vertical pocket depth and the summation of the depths of the largest vertical pocket in each
quadrant, or the AFI. (The pregnant abdomen is divided into four quadrants by using the umbilicus as a
reference point to divide the uterus into upper and lower halves, and by using the linea nigra to divide
the uterus into left and right halves.) The four measurements are summed to obtain the AFI in
centimetres.
Pockets should be free of fetal limbs and the umbilical cord. AFV may be artificially increased if the
transducer is not maintained perpendicular to the floor. Excessive pressure on the maternal abdomen
with the transducer may lead to an artificially reduced measurement.
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A meta-analysis of randomised controlled trials has concluded that the MVP measurement during fetal
surveillance is a better choice. [5] The use of the AFI increases the rate of diagnosis of
oligohydramnios and the rate of induction of labour without any improvement in peripartum
outcomes. [6]
However, there is no evidence that routine measurement and identification of oligohydramnios in
normal term pregnancies reduces perinatal mortality. [7]

Sterile speculum examination

Sterile speculum examination should be performed to check for ROM. Amniotic fluid may pool in the
vagina and a ferning pattern may be observed when fluid from the posterior vault is dried and
examined under a microscope.
Cervical mucus may cause false positive results (as can semen and blood).
Nitrazine paper/sticks turn blue. (The amniotic fluid is more alkaline - pH 6.5-7.0 - than normal vaginal
discharge - pH 4.5.)

Management
Management of oligohydramnios is based on gestational age. Planned birth in an obstetric unit is
recommended. [8] Transfer to a tertiary referral centre may be appropriate if oligohydramnios is severe.

Before term:
Expectant management is often the most appropriate course of action, depending on
maternal and fetal condition.
Ongoing antepartum surveillance (including assessment of fetal growth and follow-up
monitoring of AFV) is necessary.
Continuous fetal heart rate monitoring during labour has been advocated for all pregnancies
complicated by oligohydramnios.

At term:
Delivery is often the most appropriate management.
With reassuring fetal testing, delivery may be safely delayed on the basis of the parity, the
gestational age, the inducibility of the mother's cervix and the severity of the
oligohydramnios.

After term:
Isolated oligohydramnios in the post-term patient has no greater risk for caesarean delivery
and there is insufficient evidence to support induction for women with oligohydramnios. [9,
10]

The treatment of maternal dehydration with oral or intravenous rehydration has been shown to increase the AFV
by 30%. [4]

Amnioinfusion
Increasing the amount of fluid within the amniotic cavity can be accomplished with the use of amnioinfusion. In
this process, sodium chloride or Ringer's lactate is infused under ultrasound guidance via a needle inserted
through the uterine wall. The current evidence on the safety and efficacy of this procedure means it is only
undertaken in the UK under special arrangements that include audit and research. [3]

Amnioinfusion can also be undertaken during labour transcervically via an intrauterine catheter. However, The
Royal College of Obstetricians and Gynaecologists does not recommend this for women with preterm rupture of
membranes.

Vesico-amniotic shunts
Vesico-amniotic shunts may be used to divert fetal urine to the amniotic fluid cavity in women in whom a fetal
obstructive uropathy is determined to be the cause of oligohydramnios. Although it is effective in reversing
oligohydramnios, its ability to achieve sustainable good renal function in infancy is variable. [11] Pulmonary
function cannot be guaranteed with restoration of the AFV. Although an established procedure, there are limited
safety and efficacy data and uncertainty regarding selection criteria; hence it is only undertaken in the UK under
special arrangements that include audit and research. [12]
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Prognosis
The earlier in pregnancy that oligohydramnios occurs, the poorer the prognosis. Fetal mortality rates
as high as 80-90% have been reported with oligohydramnios diagnosed in the second trimester. Most
of this mortality is a result of major congenital malformations and pulmonary hypoplasia secondary to
PROM before 22 weeks of gestation. Mid-trimester PROM often leads to pulmonary hypoplasia, fetal
compression syndrome and amniotic band syndrome. The inspiration of amniotic fluid at regular
intervals is probably needed for terminal alveolar development.
The assessment of AFV is important in pregnancies complicated by abnormal fetal growth or
intrauterine growth restriction. Oligohydramnios is a frequent finding in pregnancies involving
intrauterine growth restriction and is most likely secondary to decreased fetal blood volume, renal
blood flow and subsequently fetal urine output. Pregnancies complicated by severe oligohydramnios
have been shown to be at increased risk of fetal morbidity.

Complications
Pulmonary hypoplasia.
Fetal compression syndrome.
Amniotic band syndrome.
The risk of fetal infection is increased (by the presence of prolonged ROM).

Further reading & references

Therapeutic amnioinfusion for oligohydramnios during pregnancy (excluding labour); NICE Interventional Procedure
Guidance, November 2006

1. Morris RK, Meller CH, Tamblyn J, et al; Association and prediction of amniotic fluid measurements for adverse pregnancy
outcome: systematic review and meta-analysis. BJOG. 2014 May;121(6):686-99. doi: 10.1111/1471-0528.12589. Epub
2014 Feb 7.
2. Moise KJ Jr; Toward consistent terminology: assessment and reporting of amniotic fluid volume. Semin Perinatol. 2013
Oct;37(5):370-4. doi: 10.1053/j.semperi.2013.06.016.
3. Therapeutic amnioinfusion for oligohydramnios during pregnancy (excluding labour); NICE Interventional Procedure
Guidance, November 2006
4. Luton D, Alran S, Fourchotte V, et al; Paris heat wave and oligohydramnios. Am J Obstet Gynecol. 2004 Dec;191(6):2103-5.
5. Nabhan AF, Abdelmoula YA; Amniotic fluid index versus single deepest vertical pocket: a meta-analysis of randomized
controlled trials. Int J Gynaecol Obstet. 2009 Mar;104(3):184-8. Epub 2008 Nov 30.
6. Nabhan AF, Abdelmoula YA; Amniotic fluid index versus single deepest vertical pocket as a screening test for preventing
adverse pregnancy outcome. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006593.
7. Rossi AC, Prefumo F; Perinatal outcomes of isolated oligohydramnios at term and post-term pregnancy: a systematic
review of literature with meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2013 Jul;169(2):149-54. doi:
10.1016/j.ejogrb.2013.03.011. Epub 2013 Apr 2.
8. Intrapartum care: care of healthy women and their babies during childbirth; NICE Clinical Guideline (Dec 2014)
9. Verrotti C, Bedocchi L, Piantelli G, et al; Amniotic fluid index versus largest vertical pocket in the prediction of perinatal
outcome in post-term pregnancies. Acta Biomed. 2004;75 Suppl 1:67-70.
10. Mozurkewich E, Chilimigras J, Koepke E, et al; Indications for induction of labour: a best-evidence review. BJOG. 2009
Apr;116(5):626-36. Epub 2009 Feb 4.
11. Biard JM, Johnson MP, Carr MC, et al; Long-term outcomes in children treated by prenatal vesicoamniotic shunting for
lower urinary tract obstruction. Obstet Gynecol. 2005 Sep;106(3):503-8.
12. Fetal vesico-amniotic shunt for lower urinary tract outflow obstruction; NICE Interventional Procedure Guidance, December
2006

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but makes no warranty as to its
accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions.
For details see our conditions.

Original Author: Current Version: Peer Reviewer:

Dr Hayley Willacy Dr Jacqueline Payne Dr John Cox
Document ID: Last Checked: Next Review:
2987 (v23) 07/01/2016 05/01/2021
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