Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. List the causes of polyhydramnios 2. Define polyhydramnios
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
The term polyhydramnios, also known as hydramnios, refers to an excessive amount of amniotic fluid. The primary sources of amniotic fluid are fetal urine production, fetal lung fluid and fetal oral and nasal secretions. The main routes of amniotic fluid removal are fetal swallowing and absorption via the intramembranous pathway.
Incidence and Causes
The overall incidence is 0.2-2.0 % of pregnancies
More common in twins, likely due to complications of monochorionic placentation
Idiopathic polyhydramnios will occur in approximately 1% of pregnancies
Causes of polyhydramnios are many and account for varying percentages of cases:
Idiopathic polyhydramnios (50-60%)
Congenital anomalies and genetic disorders (8-45%)
Maternal diabetes (5-26%)
Multiple gestation (8-10%)
Fetal anemia (1-11%)
Two commonly used sonographic measurements that suggest an increased volume of amniotic fluid include (Grade 2C)
Amniotic fluid index (AFI) of ≥24 cm based on a total measurement of 4 different quadrants
A single deepest pocket (SDP) of ≥8 cm, measured by holding the ultrasound transducer perpendicular to the floor in the sagittal plane
SMFM states in the consult series (see ‘Learn More – Best Practices’ below) that polyhydramnios can be defined by either AFI or SDP using the above parameters, but also recommends use of SDP in the 3rd trimester (see ‘Related ObG Topics’ below)
ACOG states that “best available evidence supports using the deepest vertical pocket method of measurement because it leads to fewer interventions with no increase in poor perinatal outcomes compared with use of the AFI”
Mild AFI: 24.0-29.9 cm or SDP 8-11 cm
Moderate AFI: 30.0-34.0 cm or SDP 12-15 cm
Severe AFI: ≥35 cm or SDP ≥16 cm
Recommended AFI technique
Amniotic fluid pocket must be ≥1 cm wide
Measured pocket(s) should not contain fetal parts or loops of umbilical cord
Color Doppler can be used to identify cord
Increasing severity of polyhydramnios correlates with an increased risk of perinatal mortality and congenital abnormalities
Idiopathic polyhydramnios is a diagnosis of exclusion
At diagnosis, refer for anatomic survey and work up to rule out alloimmunization, congenital infection, diabetes and other causes
Alert patient that even with a full and thorough ‘negative’ work-up, and underlying cause may be identified following delivery
Assess fetal growth
Association between macrosomia and polyhydramnios
IUGR may be related to single gene or chromosomal anomaly such trisomy 13 or 18
Rescreening for diabetes (data limited)
Consider if polyhydramnios identified in the 3rd trimester or more than 1 month since diabetes screen
Especially if early in pregnancy, should be considered concerning and generate a referral to high-risk and genetic specialists
Detailed medical and family history is required
SMFM recommends delivery at a specialized, tertiary care unit (GRADE 1C)
No data to support amniocentesis specifically for isolated polyhydramnios
However, additional findings such as altered growth or movement may involve offering invasive testing to determine underlying cause
Note: ACOG/SMFM guidelines state that invasive testing should be made available to all women
SMFM recommends against amnioreduction except in the presence of severe polyhydramnios and (GRADE 1C)
Severe maternal discomfort and/or
Not recommended for the sole purpose of decreasing amniotic fluid (GRADE 1B)
Increased neonatal risks including
Decreased neonatal (preterm) urine output and elevated
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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