European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 149–154

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Review

Perinatal outcomes of isolated oligohydramnios at term and post-term

pregnancy: a systematic review of literature with meta-analysis
A. Cristina Rossi a,*, Federico Prefumo b
a
Department of Obstetrics and Gynecology, University of Bari, Bari, Italy
b
Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy

A R T I C L E I N F O A B S T R A C T

Article history: Objective: The management of isolated oligohydramnios (IO) in post/term pregnancies is controversial.
Received 28 December 2012 The aim of this paper was to review outcomes of term and post-term pregnancies with IO versus normal
Received in revised form 6 March 2013 amniotic fluid (AF) at labor assessment.
Accepted 8 March 2013
Study design: A search in PubMed, Medline, EMBASE, and reference lists was performed. Inclusion
criteria for articles selection: singleton pregnancy, definition of olgohydramnios as AFI <5 cm, AF
Keywords: assessment at 37–42 gestational weeks. Exclusion criteria: fetal malformations, preterm delivery,
Isolated oligohydramnios
premature rupture of membranes, intrauterine growth restriction. Perinatal outcomes were: obstetric
Amniotic fluid
Term pregnancies
intervention for non-reassuring fetal heart rate (cesarean section, operative delivery), meconium-
Post-term pregnancies stained AF, Apgar score <7 at 5 min, umbilical artery pH <7.0, small for gestational age infants (SGA),
Amniotic fluid index (AFI) admission to neonatal intensive care unit (NICU) and perinatal death. Meta-analysis compared outcomes
Perinatal outcomes of pregnancies with IO vs normal AF. Inter-studies heterogeneity was tested. Pooled odds ratio (OR) and
95% confidence interval (95% CI) were calculated. Differences between the two groups were considered
significant if 95% CI did not encompass 1. MOOSE guidelines were followed.
Results: Four articles provided 679 (17.2%) cases with IO and 3264 (82.8%) with normal AF. Obstetric
interventions occurred more frequently in the IO than normal AF group (IO: 89/679, 13% vs normal; AF:
166/3354, 5%; OR: 2.30; 95% CI: 1.00–5.29). Meta-analysis did not show differences with regard to
meconium, Apgar, pH, SGA, NICU and perinatal death.
Conclusion: In term or post-term pregnancies, IO is associated with increased risk of obstetric
interventions but outcomes are similar to those of pregnancies with normal AF.
ß 2013 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

1. Introduction congenital anomalies. While perinatal outcomes of associated

oligohydramnios are related to the underlying condition, the
The incidence of oligohydramnios varies widely, from approxi- natural history of isolated oligohydramnios is unclear. In post-term
mately 0.5% [1] to 5% [2], depending on the study population and pregnancies, placental insufficiency has been proposed as main
definition of oligohydramnios. Oligohydramnios can be isolated or factor of reduced amniotic fluid volume [3]. Alternatively, the
associated with maternal or fetal conditions such as hypertension, maturation of the renal system can lead to a physiological increase
premature rupture of membranes, fetal growth restriction and of amniotic fluid absorption [3].
The optimal management of term or post-term pregnancies
with isolated oligohydramnios is controversial. The most recent
* Corresponding author at: Via Celentano, 42, 70121 Bari, Italy. Tel.: +39
meta-analysis on this topic showed that AFI <5 cm is associated
0805248039; fax: +39 0805248039; mobile: +39 3334476630. with 2-fold increased risk of cesarean delivery for fetal distress and
E-mail address: acristinarossi@yahoo.it (A.C. Rossi). 5-fold increase in Apgar score <7 at 5 min compared with

0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejogrb.2013.03.011
150 A.C. Rossi, F. Prefumo / European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 149–154
pregnancies with normal amniotic fluid [4]. That meta-analysis
was published in 1999. The aim of this review was to analyze
subsequent literature, in order to define whether the risk of
adverse perinatal outcomes in pregnancies complicated with
isolated oligohydramnios at labor is increased compared with
pregnancies with normal amniotic fluid.
2. Materials and methods
As in the previous meta-analysis by Chauhan et al. [4], we
defined oligohydramnios as AFI <5 cm in the setting of active
labor.
A search in PubMed, EMBASE, Medline and reference lists
was performed for relevant articles that compared perinatal
outcomes in term and post-term pregnancies complicated with
isolated oligohydramnios (study group) with term or post-term
pregnancies with normal amniotic fluid volume (control group).
The study period of the review ranged from January 2000 to
January 2012. Key words were: amniotic fluid, term pregnancy,
isolated oligohydramnios, amniotic fluid volume (AFI), perinatal
outcomes. Inclusion criteria for study selection were: singleton
pregnancy, definition of olgohydramnios as AFI <5 cm, detection
of oligohydramnios at 37–42 gestational weeks, assessment of
amniotic fluid volume upon admission to labor and delivery in
active labor, oligohydramnios assessed during labor, and out-
comes compared with controls. Exclusion criteria were:
omitting at least one inclusion criterion, fetal malformations,
preterm delivery, oligohydramnios secondary to premature
rupture of membranes, antenatal detection of intrauterine
Potentially relevant
studies concerning
isolated
oligohydramnios in
post/term pregnancies
N=710
Studies retrieved for
more detailed
evaluation
N=17
Potentially appropriate
studies to be included
in the systematic
review
N=10
Studies with usable
information included
in the systematic
review
N=4
Fig. 1. flow chart for study selection.
growth restriction, and data reported in graph or percentage
form rather than proportional rates. Personal communications,
letters and non-English language publications were also
excluded.
Perinatal outcomes were defined as rates of meconium-stained
amniotic fluid, obstetric intervention for non-reassuring fetal heart
rate (operative vaginal delivery or emergency cesarean section),
Apgar score <7 at 5 min, umbilical artery pH <7.0, small for
gestational age infants (SGA, i.e. birth weight <20th centile for
gestational age), admission to neonatal intensive care unit (NICU)
and perinatal death (stillbirth or neonatal death within 28 days
from birth). Data were stratified for pregnancies at high or low risk.
Women at high risk were defined as pregnancies complicated with
pre/eclampsia, intrauterine growth restriction, fetal malformation
leading to oligohydramnios, maternal renal disease, or any
hypertensive disorder.
An effort to contact the corresponding author was made in an
attempt to get unpublished or incomplete data. The two authors
independently reviewed articles and abstracted data. Discordance
was resolved with consensus. MOOSE guidelines were followed.
Risk of bias within and across studies was assessed according to the
Cochrane Collaboration’s tool for assessing risk of bias.
Comparative analysis was performed between the study and
control groups. For this purpose, inter-studies heterogeneity was
defined according to Higgins et al. [5] as the percentage of total
variation across studies due to heterogeneity rather than chance (I2)
and was tested with chi-squared test for heterogeneity at a
significant level of P = 0.10. A random effect model was generated
whenever I2 was 25%. Pooled odds ratio (OR) and 95% confidence
Studies excluded based on title or
abstract
N=693
Studies excluded from
the systematic review
because did not meet
the inclusion criteria
N=6
 A.C. Rossi, F. Prefumo / European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 149–154 151

Table 1
Characteristics of the included studies.

Author Year Sample Sample size Maternal risk factors Indication for assessment Gestational age
at assessment

Locatelli 2004 Oligohydramnios 341 Low Routine 40–42

Control 2708 Low

Alchalabi 2006 Oligohydramnios 66 High Induction 37–42

Control 114 High

Rainford 2001 Oligohydramnios 44 Low Post-term, decreased fetal 37–42

movement
Control 188 Low

Manzanares 2007 Oligohydramnios 206 Low N/A 37–42

Control 206 Low

interval (95% CI) were calculated. Intergroup comparisons were
considered statistically significant if 95% CI did not encompass 1.
Meta-analysis was performed with RevMan (Revision Manager,
Version 4.2 for Windows, Copenaghen: The Nordic Cochrane Centre,
The Cochrane Collaboration 2003).
3. Results
The steps for meta-analysis are reported in Fig. 1. Four articles
were available, of which one article [6] included pregnancies at
high risk for oligohydramnios because of maternal conditions and
three studies [7–9] were performed in pregnancies without
maternal risk factors for oligohydramnios. Table 1 shows
characteristics of the included articles. Overall, 3873 cases were
pooled, of which 657 (17.0%) cases presented isolated oligohy-
dramnios (study group) and 3216 (83.0%) had normal amniotic
fluid volume (control group). Obstetric interventions for non-
reassuring fetal heart rate were performed in 254 cases and
consisted of operative vaginal delivery in 76 (29.8%) and
emergency cesarean section in 178 (70.2%) pregnancies. Meta-
analysis showed a higher incidence of obstetric interventions in
the study group (89/657;13.5%) compared with the control group
(165/3306; 5.0%) (Fig. 2). Meconium-stained amniotic fluid was
equally present in the study (86/657; 13.1%) and control groups
(387/3216; 12.0%; Fig. 3). At birth, no differences were found with
regard to Apgar score <7.0 (study group: 4/657, 0.6% versus control
group: 18/3216, 0.5%) (Fig. 4), umbilical artery pH <7 (study group:
11/547, 2.0% vs control group: 24/2914, 0.8%) (Fig. 5), and NICU
admission (study group: 18/316, 5.7% vs control group: 27/428,
6.3%) (Fig. 6). From two articles, the incidence of SGA neonates was
analyzed [7,8]. It occurred in the study (57/547; 10.4%) and control
groups (166/2914; 5.7%) with similar frequency (Fig. 7).
Neonatal death was observed in only one pregnancy. It occurred
at 41.2 gestational weeks, following an uncomplicated pregnancy
with an AFI of 10 cm and was probably secondary to a true knot in
the umbilical cord and three loops around the neck [7].

Fig. 2. Meta-analysis for obstetric interventions.

Fig. 3. Meta-analysis for meconium stained amniotic fluid.

152 A.C. Rossi, F. Prefumo / European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 149–154

Fig. 4. Meta-analysis for Apgar score < 7 at 5 min.

Fig. 5. Meta-analysis for pH < 7.0.

When the meta-analysis was performed by pooling low-risk
pregnancies only, perinatal outcomes were similar in isolated
oligohydramnios and the control group (Table 2).
4. Discussion
This review shows that isolated oligohydramnios in uncompli-
cated term and post-term pregnancies is associated with an
approximately two-fold increased risk of operative delivery and
cesarean section because of fetal distress. Nonetheless, fetal
distress secondary to oligohydramnios does not lead to an
increased risk of low Apgar score, low umbilical artery pH, NICU
admission and mortality rates compared with pregnancies with
normal amniotic fluid. It might be argued that perinatal outcomes
were not significantly different between the oligohydramnios and
normal amniotic fluid groups because the interventions triggered
by oligohydramnios (whether by institutional policy or obste-
tricians’ attitude) prevented perinatal mortality in the oligohy-
dramnios group. There is no evidence, however, that systematic
assessment of amniotic fluid volume and identification of isolated
oligohydramnios in term pregnancies reduce perinatal mortality
[10].
A major problem in the interpretation of these data is that in
all studies included in the review the managing clinicians were
not blinded to the results of amniotic fluid assessment and that
in two of them the institutional policy specifically indicated
induction of labor in cases of isolated oligohydramnios.
Therefore, fetuses with AFI <5 cm are more likely to undergo
induction of labor and fetal testing by cardiotocography.
Because the interpretation of fetal heart tracings is highly
subjective, it may be speculated that the presence of oligohy-
dramnios influences the obstetrician to perform obstetric
interventions which might be unnecessary, as suggested by
the normal outcomes at birth. The obstetricians’ attitude toward
interventions in cases of isolated oligohydramnios in otherwise
normal pregnancies was demonstrated by Elsandabesee et al.
[11], who reported that even in the absence of a specific
institutional policy, 50% of low-risk women with oligohydram-
nios faced the risk of obstetric intervention, mainly represented
by induced labor, which in turn puts women at increased risk of
operative delivery [12]. In our opinion, it would be interesting to
investigate whether obstetricians’ management of labor would
change if they were blinded to the sonographic assessment of
amniotic fluid. In addition, if the study that included high-risk
pregnancies is excluded, there is still a higher incidence of
obstetric intervention for fetal distress in the oligohydramnios
group compared to the control group, although the difference
did not reach statistical significance. It would also be important

Fig. 6. Meta-analysis for neonatal intensive care unit admission.

 A.C. Rossi, F. Prefumo / European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 149–154
Fig. 7. Meta-analysis for small for gestational age.
to investigate further whether the increased rates of operative
deliveries that we observed in our review were secondary to
labor induction or oligohydramnios.
According to our review, when fetal electronic monitoring was
used, oligohydramnios was consistently reported to be associated
with fetal heart rate abnormalities in labor, which were reported as
the main indication for obstetric interventions.
Controversies exist with regard to the relationship between
oligohydramnios and meconium-stained amniotic fluid. Our
review shows that isolated oligohydramnios does not cause
meconium passage and further confirms that this condition does
not represent a risk factor for fetal well-being.
It has been suggested that the reduction of amniotic fluid at
term of pregnancy could be related to placental involution, leading
to growth restriction [13]. Therefore, oligohydramnios has been
proposed as a simple screening method to detect SGA neonates at
term, since in uncomplicated term pregnancies it carries a >2-fold
increased risk of SGA neonates [7]. We found that the incidence of
neonates with birth weight <10th was higher in the oligohy-
dramnios group (10%) than controls (5%), but this difference did
not reach a statistically significant level. In the reviewed articles,
no information was available about fetal growth during pregnancy.
When the reduction of amniotic fluid is detected before 37 weeks,
obstetric interventions might result in neonates with low birth
weight. Although the association between oligohydramnios and
preterm SGA neonates has been clearly attributed to iatrogenic
prematurity, the relationship between oligohydramnios and
reduced fetal growth in term pregnancies remains uncertain.
Compared with the previous meta-analysis [4], we agree in
finding a significantly increased risk of cesarean delivery for fetal
distress in pregnancies with isolated oligohydramnios in labor.
However, Chauhan et al. also reported a lower Apgar score at
5 min in the oligohydramnios group, whereas we did not find
higher rates of neonatal morbidity [4]. A possible explanation
could be that we included umbilical artery pH <7.0 and NICU
admission as adverse neonatal outcomes, in contrast to Chauhan
et al., who examined only the Apgar score because of lack of
information in their reviewed articles. In addition, Chauhan et al.
pooled articles that were published in the period 1987–1997.
Because our reviewed articles were published in the last decade, it
Table 2
Meta-analysis of women at low risk pregnancies.
Isolated
oligohydramnios n (%)
Meconium 70/591 (11.8%)
Obstetric intervention for fetal distress 71/613 (11.6)
Apgar <7 3/591 (0.5)
NICU 6/250 (2.4)
Perinatal death 0 1 (<1)
A random effect model was generated if heterogeneity was >25%. OR: odds ratio; CI: confidence interval.
153
is reasonable to assume that we found a lower morbidity rate
thanks to the improvement in obstetric and pediatric care over the
last ten years.
Limitations of this review should be pointed out. In one article,
oligohydramnios was assessed in high-risk pregnancies, and thus
could be associated with maternal conditions rather than being
isolated. We believe, however, that the presence of maternal
disease might not have biased our results, since it affected women
in both the study and control groups. In addition, neonatal
morbidity and mortality were similar between the two groups, and
were therefore not conditioned by maternal conditions. This is
confirmed by our finding that if this study is excluded from our
meta-analysis, perinatal outcomes are similar between pregnan-
cies with isolated oligohydramnios and controls.
Obstetric characteristics other than reduced amniotic fluid
could be responsible for the observed differences in rates of
operative delivery and cesarean section. This is confirmed by
Locatelli et al., who found higher rates of cesarean deliveries in
term pregnancies complicated with oligohydramnios compared
with term pregnancy with normal amniotic fluid volume [7]. This
difference, however, was lost after controlling for nulliparity and
induction of labor. The time interval between the assessment of
amniotic fluid and delivery was not addressed in our meta-
analysis. This was due to the fact that in approximately 30% of
women labor was induced, and this obviously shortened the
assessment to delivery time.
Included studies focused on the comparison between pregnan-
cies with oligohydramnios and those with a normal amount of
amniotic fluid. We believe that future studies are needed in order
to compare expectant management versus obstetric intervention
in pregnancies with isolated oligohydramnios. In one article, which
was limited by the small sample size, the authors did not find
significant differences in neonatal morbidity and mortality
between fetuses with oligohydramnios undergoing labor induc-
tion or elective cesarean section for oligohydramnios as unique
indication and fetuses with oligohydramnios managed conserva-
tively [10]. Similarly, a randomized study which compared
expectant management and induction of labor in pregnancies
with oligohydramnios beyond 40 weeks was unable to detect
significant differences between the two groups with regard to
Control n (%) OR (95% CI) Number Heterogeneity (%)
of articles
374/3102 (12.0) 0.75 (0.45–1.26) 3 61
160/3240 (5.0) 1.73 (0.68–4.39) 4 79
17/3102 (0.5) 1.02 (0.32–3.30) 3 0
18/314 (5.7) 0.77 (0.30–2.00) 2 0
NA 4 NA
154 A.C. Rossi, F. Prefumo / European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 149–154
umbilical artery pH, Apgar scores at 1, 5 and 10 min and transfer
rates to NICU [3].
Because of lack of information, we could not differentiate
between term and post-term pregnancies. There is insufficient
evidence as to exactly when the amniotic fluid assessment was
undertaken. This is critical, because it is common for such an
assessment to be undertaken routinely as a screening test at 41 or
42 weeks, as an aid in deciding whether to allow the pregnancy to
continue, or to advise induction of labor.
We did not analyze whether other methods for quantifying
amniotic fluid volume, such as percentiles for gestational age and
deepest vertical pocket, are more sensitive in detecting fetuses at
high risk of adverse neonatal outcomes. Magann et al. showed that
both AFI <5 cm and deepest vertical pocket <2 cm do not differ for
identifying abnormal amniotic fluid volumes [14].
The sample size of the review might be unbalanced, being 17%
the study group and 83% the control group. This is due to the fact
that the reviewed articles did not calculate the sample size to
achieve 80% of power to detect a statistical difference at an alpha
level of two-tailed P  0.05.
In conclusion, isolated oligohydramnios in term pregnancies
is associated with an increased risk of obstetric intervention.
The literature lacks information, however, as to whether
interventions are more likely to be performed in the presence
of isolated oligohydramnios for non-reassuring fetal heart rate
or are performed because of obstetricians’ attitude. In our view,
the current literature does not really provide further informa-
tion in understanding the significance of oligohydramnios at a
particular gestational age, in terms of both the pathophysiology
and the management. Possibly the only truly valid way of
investigating this would be by randomized controlled trial, in
which women with oligohydramnios were randomized to
induction versus expectant management, and then those
managed by expectant management compared to a normal
control group.
References
[1] Hill LM, Breckle R, Wolfgram KR, O’Brien PC. Oligohydramnios: ultrasonically
detected incidence and subsequent fetal outcome. American Journal of Ob-
stetrics and Gynecology 1983;147:407–10.
[2] Mercer LJ, Brown LG, Petres RE, Messer RH. A survey of pregnancies compli-
cated by decreased amniotic fluid. American Journal of Obstetrics and Gyne-
cology 1984;149:355–61.
[3] Ek S, Andersson A, Johansson A, Kublicas M. Oligohydramnios in uncompli-
cated pregnancies beyond 40 completed weeks. A prospective, randomised,
pilot study on maternal and neonatal outcomes. Fetal Diagnosis and Therapy
2005;20:182–5.
[4] Chauhan SP, Sanderson M, Hendrix NW, Magann EF, Devoe LD. Perinatal
outcome and amniotic fluid index in the antepartum and intrapartum periods:
a meta-analysis. American Journal of Obstetrics and Gynecology 1999;181:
1473–8.
[5] Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in
meta-analyses. BMJ 2003;327:557–60.
[6] Alchalabi HA, Obeidat BR, Jallad MF, Khader YS. Induction of labor and
perinatal outcome: the impact of the amniotic fluid index. European Journal
of Obstetrics Gynecology and Reproductive Biology 2006;129:124–7.
[7] Locatelli A, Vergani P, Toso L, Verderio M, Pezzullo JC, Ghidini A. Perinatal
outcome associated with oligohydramnios in uncomplicated term pregnan-
cies. Archives of Gynecology and Obstetrics 2004;269:130–3.
[8] Manzanares S, Carrillo MP, Gonzalez-Peran E, Puertas A, Montoya F. Isolated
oligohydramnios in term pregnancy as an indication for induction of labor.
Journal of Maternal-Fetal and Neonatal Medicine 2007;20:221–4.
[9] Rainford M, Adair R, Scialli AR, Ghidini A, Spong CY. Amniotic fluid index in the
uncomplicated term pregnancy. Prediction of outcome. The Journal of Repro-
ductive Medicine 2001;46:589–92.
[10] Haws RA, Yakoob MY, Soomro T, Menezes EV, Darmstadt GL, Bhutta ZA.
Reducing stillbirths: screening and monitoring during pregnancy and labour.
BMC Pregnancy Childbirth 2009;9(Suppl. 1):S5.
[11] Elsandabesee D, Majumdar S, Sinha S. Obstetricians’ attitudes towards ‘iso-
lated’ oligohydramnios at term. Journal of Obstetrics and Gynaecology
2007;27:574–6.
[12] Xenakis EM, Piper JM, Conway DL, Langer O. Induction of labor in the nineties:
conquering the unfavorable cervix. Obstetrics and Gynecology 1997;90:
235–9.
[13] Bar-Hava I, Divon MY, Sardo M, Barnhard Y. Is oligohydramnios in postterm
pregnancy associated with redistribution of fetal blood flow? American Jour-
nal of Obstetrics and Gynecology 1995;173:519–22.
[14] Magann EF, Chauhan SP, Barrilleaux PS, Whitworth NS, Martin JN. Amniotic
fluid index and single deepest pocket: weak indicators of abnormal amniotic
volumes. Obstetrics and Gynecology 2000;96:737–40.