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Low Amniotic fluid levels. Time to panic?

17 Sep

http://www.themidwifenextdoor.com/?p=1141

Written on September 14, 2010 at 6:51 pm by Birth Sense

Have you ever noticed how many recommendations in modern obstetrics end with the caveat, “However, studies have not shown a difference in perinatal outcomes”.

What exactly do those words mean? In plain English, the authors could say, “None of these interventions we’re recommending have made a difference in how many babies end up having problems”.

Take, for example, the situation of oligohydramnios, or low levels of amniotic fluid, in late pregnancy. Oligo, as those in the medical professions call it for short, has many possible causes. Some of them are serious. In most cases, the earlier in pregnancy that the oligo appears, the more potential risk it carries. It may be caused by kidney problems in the baby, or congenital defects.

The type of oligo I’d like to discuss today is the type that shows up late in pregnancy, with a normal baby, and no known cause. The type that causes everyone to panic and decide to induce the mother with low fluid, even if her cervix is not very favorable for induction. The poor mother as often as not then ends up with a cesarean for failure to progress or fetal distress.

We seem to have had a run of women diagnosed with oligo late in their pregnancies, along with suspicion of growth restricted babies. The two often go hand-in-hand, as fluid levels may decrease if the growth-restricted baby’s kidneys are receiving less blood in order to protect the brain.

But in all but one of the dozen or so recent cases I was involved in, every baby ended out NOT being growth restricted and most of the women did not even have oligo! You don’t have oligo when you are soaking chux pad after chux pad throughout several hours of labor. This trend concerns me, because we are doing a lot of inductions unnecessarily. I decided to see what the literature says.

Interestingly, much of the recent literature states that the two most common techniques of measuring fluid levels, the AFI (aminiotic fluid level index) and SDP (single deepest pocket) “were unreliable for detecting true AF volumes” (Magann, et al). Yet we keep using these tests and subjecting women to fear and stress through repeated testing and screening, and even inductions when there is no indication that the baby is not doing well. Over and over, I read that inducing a woman with low amniotic fluid when there is no indication of fetal distress does NOT improve outcomes. But we do know that inductions can lead to other problems, such as increased c-section rates, increased use of pain medication, and increased need for forceps or vaccuum.
What is more, other studies have indicated that two simple interventions can help bring amniotic fluid levels up: drinking lots of water, and immersing the body in water daily. In my practice, women who have religiously had extra water to drink and spent at least one hour daily submerged in water have all succeeded in raising their AFI’s to normal or nearly normal levels. Of course, my experience is purely anecdotal, but I include a reference below to a study that validated the use of submersion to raise AFI levels.

So what can you do if you are diagnosed with oligo? First, consider where you are in your pregnancy. If this occurs late in prenancy, it is less likely to indicate a problem with the baby. Rather than rushing to an induction out of fear or stress, reassure yourself by reviewing the studies below that indicate no change in outcomes by hurrying to induction. Talk with your provider about trying hydration and submersion to raise your fluid levels. Consider the possibility that the test may be inaccurate, and that if your baby is doing well, there is no need to induce labor. Arm yourself with the facts, and advocate intelligently for yourself and your baby.

Literature supporting oral hydration and immersion in water to improve amniotic fluid levels:
1. Chandra PC, Schiavello HJ, Lewandowski MA. (2000). Effect of oral and intravenous hydration on oligohydramnios. The Journal of Reproductive Medicine, 45(4), 337-341.
2. Deka D, Malhotra B. (2000). Role of maternal oral hydration in increasing amniotic fluid volume in pregnant women with oligohydramnios. International Journal of Gynecology & Obstetrics, 73, 115-156.
3. Strong TH. (1993). Reversal of oligohydramnios with subtotal immersion: A report of five cases, American Journal of Obstetrics & Gynecology, 169(6), 1595-1597.
Literature reporting overdiagnosis of low amniotic fluid index measurements and lack of improved outcomes with induction:
1. Maann EF. Chauhan SP, Barrilleaux PS, Whitworth NS, McCurley S, Martin JN. Ultrasound estimate of amniotic fluid volume: color Doppler overdiagnosis of oligohydramnios. Obstet Gynecol 2001 Jul;98(1):71-4.
2. Magann EF, Chauhan SP, Doherty DA, Magann MI, Morrison JC. The evidence for abandoning the amniotic fluid index in favor of the single deepest pocket. Am J Perinatol. 2007 Oct;24(9):549-55. Epub 2007 Oct 1.
3. Magann EF, Chauhan SP, Barrilleaux PS, Whitworth NS, Martin JN. Amniotic fluid index and single deepest pocket: weak indicators of abnormal amniotic volumes. Obstet Gynecol. 2000 Nov; 96(5 Pt 1):737-40.

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Posted by on September 17, 2010 in All, induction

 

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