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Correspondence to: Dr E. Magann, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, 4301 W.
Markham, #518, Little Rock, AR 72205, USA (e-mail: efmagann@uams.edu)
Accepted: 24 March 2016
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. SYSTEMATIC REVIEW
Oligohydramnios in complicated and uncomplicated pregnancy 443
METHODS
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 442–449.
444 Rabie et al.
with ‘OR’ into one set for Concept 1. This same true heterogeneity when the number of studies is small;
search methodology was applied to the two remaining therefore, we pooled data using a random-effects model.
concepts. The final sets were used together with ‘AND’ Publication bias was evaluated by funnel plot and Egger’s
and language and date limits were applied. RefWorks asymmetrical test29 for those outcomes with at least
was used for citation management and all strategies were six to eight studies available for the meta-analysis. If
documented. potential publication bias was detected, we adjusted our
meta-analysis results using a non-parametric trim-and-fill
Study selection approach30 . Finally, to evaluate the constancy of our
results, sensitivity analysis was conducted using a
Prospective and retrospective studies with a control leave-one-out method. All data analyses were performed
group were considered eligible for the systematic review. using the R packages ‘metafor’31 and ‘meta’32 .
Studies utilizing the Phelan method of four-quadrant AFI6 ,
with a threshold of 5 cm for defining oligohydramnios,
were eligible for inclusion in the meta-analysis. The RESULTS
adverse outcomes of interest were 5-min Apgar score < 7,
Cesarean delivery for fetal distress, meconium-stained The literature search identified 3444 records. After
eliminating duplicates and studies that did not meet
amniotic fluid, MAS, admission to the NICU and infant
the inclusion criteria based on the abstract, 91 studies
with low birth weight (< 2500 g).
examining oligohydramnios and pregnancy outcomes
Studies were divided into two groups according to
were identified. Two authors (N.R. and E.M.) indepen-
risk. Low-risk studies were those in which patients
dently reviewed the full text of these studies and an
with only isolated oligohydramnios were included; there
additional 73 studies were excluded, leaving 18 studies as
was no pregnancy comorbidity that could explain the
the basis for the systematic review (Figure 1). The reasons
oligohydramnios (e.g. chronic hypertension or other
for exclusion are shown in Table S1. Disagreements were
chronic maternal comorbidity). High-risk studies were
re-examined together. Subsequently, three studies were
those that evaluated oligohydramnios in the setting of
excluded from the meta-analysis and are summarized
complicated pregnancies, therefore including conditions
in Appendix S1. A summary of the characteristics of
that may have led to oligohydramnios. All studies
the low-risk and high-risk studies is shown in Table 1.
excluded pregnancies with fetal anomalies known to
Not every study assessed all outcomes of interest and
cause oligohydramnios (e.g. bladder outlet obstruction,
therefore only the studies evaluating a particular outcome
renal agenesis) and pregnancies with preterm prelabor
were included in the individual analysis.
rupture of membranes. In addition, we excluded studies
Six studies that reported on isolated
that did not clearly define the timeframe between AFI
oligohydramnios18–23 were included in the low-risk
measurement and delivery, had a timeframe > 1 week or
group, with a total of 27 526 patients. Three were
included multiple gestations.
prospective and three were retrospective studies. With the
exception of one study18 , all patients were ≥ 37 + 0 weeks’
Risk of bias gestation. Compared with women with normal AFI,
Risk of bias (ROB) was assessed with the QUADAS-2 patients with isolated oligohydramnios were more likely
tool27 . We utilized the available database, spreadsheet and to have an emergency Cesarean delivery for fetal distress
document templates for recording and displaying the data. (RR, 2.16; 95% CI, 1.64–2.85), admission to the NICU
QUADAS-2 utilizes four domains: patient selection, index (RR, 1.71; 95% CI, 1.20–2.42) and an infant with MAS
test, reference test and flow/timing. Each domain was (RR, 2.83; 95% CI, 1.38–5.77) (Figure 2). There was no
assessed for ROB and applicability, except the flow/timing difference in the rate of meconium-stained amniotic fluid.
domain which was assessed only for ROB. ROB and Nine studies reported on oligohydramnios in compli-
applicability were ranked as low, high or unclear based cated pregnancies9–17 and were included in the high-risk
on the authors’ judgment. group, with a total of 8067 patients. Six were prospec-
tive and three were retrospective studies. Compared with
Statistical analysis women with normal AFI, patients with oligohydramnios
and comorbidities were more likely to have an infant with
For each analysis, we calculated and reported the effect low birth weight (RR, 2.35; 95% CI, 1.27–4.34). There
estimates, expressed as relative risk (RR) and 95% CI, was no difference in the rates of emergency Cesarean
in both low-risk and high-risk groups of women with delivery for fetal distress, NICU admission, infant with
oligohydramnios. Moreover, for each outcome of interest MAS or 5-min Apgar score < 7 (Figure 3).
in the low-risk and high-risk groups, the calculated effect There were insufficient data to analyze the risk of
estimates were pooled to obtain the overall effect. We perinatal death/stillbirth or respiratory distress syndrome.
examined the level of heterogeneity between studies based There were inconsistent data to evaluate the umbilical
on the Q-statistic and Higgins’ I2 statistic28 . I2 ≤ 25% cord blood pH because studies used different thresholds
indicates low heterogeneity, 25–75% indicates moderate for defining abnormality (e.g. pH < 7.0, < 7.1, < 7.2).
heterogeneity and > 75% indicates high heterogeneity. ROB was assessed using the QUADAS-2 tool and is
The Q-statistic is typically underpowered for detecting shown in Table S2. In the low-risk group, ROB was low
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 442–449.
Oligohydramnios in complicated and uncomplicated pregnancy 445
Table 1 Descriptive characteristics of low-risk studies of isolated oligohydramnios and high-risk studies of oligohydramnios in complicated
pregnancy
Oligo- Mean GA
Normal hydramnios at delivery
Study Country Study design AFI (n) (n) GA (weeks) (weeks)
Isolated oligohydramnios
Conway (1998)21 USA Prospective case–control 183 183 37 + 0 to 41 + 6 40.8
Rainford (2001)20 USA Retrospective chart review 188 44 37 + 0 to 42 + 0 40.1
Locatelli (2004)19 Italy Prospective observational 2708 341 40 + 0 to 41 + 6 40.6
Melamed (2011)18 Israel Retrospective cohort 324 108 24 + 0 to 36 + 6 33.9
Bachhav (2014)23 India Prospective observational 90 90 37 + 0 to 42 + 0 NS
Ashwal (2014)22 Israel Retrospective cohort 22 280 987 37 + 0 to 41 + 6 39.8
Oligohydramnios in complicated pregnancy
Rutherford (1987)12 USA Retrospective chart review 303 27 NS NS
Youssef (1993)9 Egypt and USA Prospective observational 104 70 NS NS
Magann (1999)10 USA Prospective case–control 79 79 ≥ 34 + 0 NS
Casey (2000)14 USA Retrospective chart review 6276 147 ≥ 34 + 0 39.1
Magann (2003)13 USA Prospective observational 76 24 ≥ 35 + 0 36.4
Driggers (2004)11 USA Retrospective cohort 131 131 ≥ 26 + 0 34.1
Venturini (2005)17 Italy Prospective case–control 120 120 ≥ 38 + 0 40.4
Alchalabi (2006)15 Jordan Prospective observational 114 66 37 + 0 to 42 + 0 NS
Sultana (2008)16 Pakistan Prospective case–control 100 100 37 + 0 to 42 + 0 38.1
Only first author of each study is given. High-risk conditions include hypertensive disorders, pregestational diabetes, rhesus isoimmunization
and fetal growth restriction. Studies excluded cases of preterm prelabor rupture of membranes, fetal anomalies, multiple gestations and any
medical complications of pregnancy. AFI, amniotic fluid index; GA, gestational age; NS, not specified.
across most studies in the domain of patient selection the risk of stillbirth or perinatal mortality. In this group
except for one study18 that utilized a case–control design of studies, the rate of stillbirth was minimal, such that
and included only preterm pregnancies and one study for most studies did not include stillbirth as an outcome,
which the ROB was unclear21 . In the high-risk group, and those that did had very few occurrences. Casey
four studies10,11,16,17 had an unclear ROB for patient et al.14 showed an association between stillbirth and
selection due to utilizing a case–control design, and a oligohydramnios but they commented on the difficulty
fifth study13 had an unclear ROB as it did not specify in determining whether intervention for oligohydramnios
high-risk patients; subjects were recruited because they would improve the stillbirth rate. Because of this
were undergoing a planned Cesarean delivery and were association, some suggest delivery at 36 to 37 + 6 weeks’
not necessarily complicated. gestation to minimize the risk of stillbirth33 . However,
in an otherwise uncomplicated pregnancy, it may be
reasonable to consider prolonging the pregnancy to
DISCUSSION 38–39 weeks’ gestation with reassuring antenatal fetal
testing. In addition, although it is not always possible to
In the previous meta-analysis performed by Chauhan avoid an emergency Cesarean delivery, it is reasonable
et al. in 199924 , the risk of three specific adverse out- to perform an admission contraction stress test on
comes (Cesarean delivery for fetal distress, 5-min Apgar patients undergoing induction of labor for isolated
score < 7, umbilical artery pH < 7.0) was compared oligohydramnios. This may help predict which patients
between women with antepartum and intrapartum AFI of would benefit from a non-urgent Cesarean delivery. In
≤ 5.0 cm vs > 5.0 cm. They found that both antepartum addition, maternal hydration is a management strategy
and intrapartum oligohydramnios was associated with an that is suggested for isolated oligohydramnios and is safe
increased risk of Cesarean delivery for fetal distress and and well tolerated34 .
5-min Apgar score < 7, but it had no effect on acidosis. In the high-risk (complicated) pregnancies, there was an
Our study expands on theirs by studying oligohydramnios increased risk only of delivering smaller infants and this
within 1 week of delivery, stratified by low-risk and risk may be due to the underlying condition. This group
high-risk pregnancies, and studying several other adverse of pregnancies encompassed a variety of comorbid con-
outcomes, including amniotic fluid meconium staining ditions including pregestational and gestational diabetes,
and MAS. the spectrum of hypertensive disorders of pregnancy, rhe-
There are two important findings in this meta-analysis sus isoimmunization and fetal growth restriction. Despite
of oligohydramnios compared with normal amniotic these complications, the only difference in outcomes for
fluid in uncomplicated and complicated pregnancies. In those with oligohydramnios was the increased risk of hav-
the low-risk (uncomplicated) pregnancies with isolated ing an infant with low birth weight. This may be explained
oligohydramnios, there is an increased risk of MAS, by the comorbid condition, nearly all of which were asso-
Cesarean delivery for fetal distress and admission to the ciated with fetal growth restriction, or it could be a sign of
NICU. A critical outcome that could not be evaluated is more severe disease. As the oligohydramnios is probably
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 442–449.
446 Rabie et al.
Figure 2 Forest plots of risk of: (a) emergency Cesarean delivery for fetal distress; (b) meconium aspiration syndrome; (c) meconium-stained
amniotic fluid; and (d) admission to neonatal intensive care unit in low-risk uncomplicated pregnancies with isolated oligohydramnios. RR,
relative risk; W, weight.
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 442–449.
Oligohydramnios in complicated and uncomplicated pregnancy 447
Figure 3 Forest plots of risk of: (a) 5-min Apgar score < 7; (b) emergency Cesarean delivery for fetal distress; (c) meconium-stained
amniotic fluid; (d) admission to neonatal intensive care unit; and (e) delivery of infant with low birth weight (< 2500 g) in high-risk
complicated pregnancies with oligohydramnios. RR, relative risk; W, weight.
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 442–449.
448 Rabie et al.
(e) W W
Oligohydramnios Normal
Relative risk RR (95% CI) (fixed) (random)
Study Events Total Events Total
Figure 3 Continued
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 442–449.
Oligohydramnios in complicated and uncomplicated pregnancy 449
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The following supporting information may be found in the online version of this article:
Appendix S1 Studies included in systematic review but excluded from meta-analysis
Table S1 Articles excluded from systematic review
Table S2 Risk of bias in studies of low-risk isolated oligohydramnios and studies of high-risk oligohydramnios
in complicated pregnancy
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 442–449.
Ultrasound Obstet Gynecol 2017; 49: 442–449
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.15929
Oligohidramnios en embarazos complicados y sin complicaciones: una revisi ón sistem ática y
metaan álisis
RESUMEN
Objetivo Evaluar, mediante una revisión sistemática y metaanálisis de ensayos controlados, los resultados adversos en embarazos
con feto único diagnosticados con oligohidramnios.
Métodos Se realizó una búsqueda en bases de datos electrónicas mediante el uso de OVID, EBSCO, Web of Science, Google
Scholar y otras, para el periodo 1980–2015. Se incluyeron estudios prospectivos y retrospectivos con un grupo de control.
Dos de los autores revisaron de forma independiente los resúmenes obtenidos en la búsqueda bibliográfica. Los criterios de
inclusión fueron: estudios en inglés, embarazo con feto único, anatomı́a del feto normal, membranas intactas y oligohidramnios
diagnosticado mediante la técnica del ı́ndice de lı́quido amniótico (ILA). El metaanálisis se estratificó en dos grupos, según el
riesgo: un grupo de alto riesgo, que incluyó estudios de oligohidramnios con condiciones comórbidas (p. ej. hipertensión) y otro
de bajo riesgo, que incluyó estudios de oligohidramnios aislado.
Resultados Quince ensayos cumplieron los criterios de inclusión. Nueve eran de alto riesgo y seis de bajo riesgo, e incluı́an un total
de 8067 y 27526 mujeres, respectivamente. En comparación con las mujeres con un ILA normal, aquellas con oligohidramnios
aislado mostraron tasas significativamente más altas de lactante con sı́ndrome de aspiración de meconio (riesgo relativo (RR),
2,83; IC 95%, 1,38–5,77), parto por cesárea motivado por sufrimiento fetal (RR 2,16; IC 95%, 1,64–2,85) e ingreso en la unidad
de cuidados intensivos para recién nacidos (UCI neonatal) (RR 1,71; IC 95%, 1,20–2,42). Las pacientes con oligohidramnios y
comorbilidades fueron más propensas a tener recién nacidos con bajo peso al nacer (RR 2,35; IC 95%, 1,27–4,34). Sin embargo,
las tasas del ı́ndice de Apgar a los 5 min <7 (RR 1,85; IC 95%, 0,69–4,96), del ingreso a la UCI neonatal (RR 2,09; IC 95%,
0,80–5,45), del lı́quido amniótico teñido de meconio (RR 1,32 ; IC 95%, 0,62–2,81) y del parto por cesárea motivado por
sufrimiento fetal (RR 1,65; IC 95%, 0,81–3,36) fueron similares a las de las mujeres con un ILA normal. Las tasas de éxitus fetal
fueron demasiado bajas como para analizarlas en el metaanálisis.
Conclusiones Esta revisión ayuda a definir los resultados adversos que aumentan con el oligohidramnios en embarazos de
bajo riesgo (ingreso a la UCI neonatal, parto por cesárea motivado por sufrimiento fetal y sı́ndrome de aspiración de meconio),
pero no proporciona datos suficientes para determinar el momento óptimo del parto en estos casos. En embarazos complicados,
el oligohidramnios está asociado con un mayor riesgo de partos de recién nacidos con bajo peso al nacer, pero esto se puede
confundir con la comorbilidad. Por lo tanto, en embarazos de alto riesgo, el tratamiento lo debe dictar la condición comórbida y
no la presencia de oligohidramnios.
有和无妊娠并发症情况下的羊水过少:系统评价和meta分析
目的: 对对照试验进行系统评价和meta分析,评估诊断为羊水过少的单胎妊娠中的不良妊娠结局。
(RR,1.65;95% CI,0.81∼3.36)的发生率与AFI正常的孕妇相似。死产率过低,因此未进行meta分析。
结论: 本篇综述有助于阐明低危妊娠中哪些不良结局(NICU住院、因胎儿窘迫行剖宫产和胎粪吸入综合征)由于羊水过少而
增加,但未能为确定这类病例行剖宫产的最佳时间提供足够依据。妊娠并发症伴有羊水过少则分娩低出生体重儿的风险增加,
但可能是由于并发症所致。因此,高危妊娠中应针对并发症而不是羊水过少采取治疗。
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. SYSTEMATIC REVIEW