DOI: 10.1111/tog.

12113 2014;16:207–13
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Polyhydramnios in singleton pregnancies: perinatal

outcomes and management
a, b
Pallavi Karkhanis MBBS MS MRCOG, * Shalini Patni MRCOG, MD
a
Specialist Trainee in Obstetrics and Gynaecology, Princess of Wales Unit, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham
B9 5SS, UK
b
Consultant in Obstetrics and Fetomaternal Medicine, Clinical Lead Fetomaternal Medicine at the Heart of England NHS Foundation Trust and
Honorary Senior Clinical Lecturer, University of Birmingham B15 2TT, UK
*Correspondence: Pallavi Karkhanis. Email: [email protected]

Accepted on 26 March 2014

Key content  To understand the implications of mild and unexplained

 Polyhydramnios is a common obstetric condition, but its polyhydramnios for both mother and fetus.
management can often be challenging.  To develop an evidence-based approach for managing this
 Mild polyhydramnios resolves frequently and is not usually condition and provide a surveillance strategy.
associated with adverse perinatal outcomes.
Ethical issues
 There is a higher prevalence of aneuploidy (10–20%) in
 Can we justify the benefits of early induction in unexplained
severe polyhydramnios.
 Unexplained polyhydramnios has been associated with increased
polyhydramnios in the face of associated risks?
rates of perinatal morbidity and mortality. Keywords: fetal abnormalities / fetal macrosomia / maternal
diabetes / polyhydramnios / unexplained
Learning objectives
 To gain an overview of the aetiology and investigations for
polyhydramnios in singleton pregnancies.

Please cite this paper as: Karkhanis P, Patni S. Polyhydramnios in singleton pregnancies: perinatal outcomes and management. The Obstetrician & Gynaecologist
2014;16:207–13.

Introduction pregnancies have a unique association that is beyond the

scope of this article.
Polyhydramnios is defined as excessive accumulation of
amniotic fluid. Its reported incidence varies between 0.2 and
3.9%.1,2 The frequency of detecting polyhydramnios depends Physiology
upon the criteria used for diagnosis, the proportion of high-
In a normal singleton pregnancy, amniotic fluid volume
and low-risk patients, and the frequency with which
increases progressively until 33 weeks of gestation, with a
ultrasound examinations are performed in any unit.
plateau between 33 and 38 weeks which is followed by a
Increasing use of ultrasound in day-to-day practice has led
decline between 38 and 42 weeks. The mean amniotic fluid
to increased detection of this condition.
volume between 22 and 39 weeks ranges from 630 to 817 ml.
Despite extensive prenatal assessment, in 50–60% of
The amniotic fluid volume above the 95th centile is defined
pregnancies, polyhydramnios remains unexplained.1 The
as polyhydramnios.3
management and counselling of such cases proves to be
The amount of amniotic fluid volume present at any one
difficult for a practising obstetrician, given the lack of
time reflects a balance between the production and removal
good-quality evidence and a two- to five-fold increase in
of the amniotic fluid. The factors affecting this are:
perinatal mortality.1 The aim of this article is to provide the
 amniotic fluid production
clinician with up-to-date and relevant information
concerning the potential perinatal outcomes, surveillance -fetal urine production
strategies and management of the condition. We focus on -secretions from the respiratory tract
singleton pregnancies only, as polyhydramnios and multiple -oral secretions

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 Polyhydramnios in singleton pregnancies

 amniotic fluid removal ≥8 cm can be used across all gestational ages.1,8,9 Neither
method has been shown to be superior to the other.9 Based on
-fetal swallowing
AFI, the condition can be classified as mild (25.0–29.9 cm),
 fluid dynamics across the membranes moderate (30–34.9 cm) or severe (>35 cm).10 Experimental
dilutional techniques are the most accurate predictor of
-transfer across the placenta, umbilical cord, and fetal skin
amniotic fluid volume. However, their invasive nature limits
(intramembranous flow)
their clinical use.
-across the fetal membranes (transmembranous flow).4
Abnormality in any of the above mechanisms leads to
Aetiology
excessive accumulation of amniotic fluid.
A wide variety of maternal and fetal conditions are seen in
nearly half the cases of polyhydramnios. In the remaining
Methods for assessment of amniotic fluid
half, no apparent cause is discernible and polyhydramnios
Ultrasound evaluation of the amount of amniotic fluid can remains unexplained.1 The common aetiological associations
be achieved by a subjective assessment or a semiquantitative with polyhydramnios in a singleton pregnancy are
estimation. This involves measurement of either the deepest highlighted in Box 1 and Table 1, and this list is by no
vertical pocket (DVP) or amniotic fluid index (AFI),5,6 or means exhaustive.4
two-diameter pocket6 or three-dimensional measurements.7 Among the maternal causes, it is well known that suboptimal
The AFI is calculated by obtaining a sum of the vertical glycaemic control in pregnancies complicated by maternal
dimensions of four imaginary cord- and limb-free quadrants diabetes often leads to fetal macrosomia and polyhydramnios.
of the uterus, whereas the deepest vertical pool measurement Fetal hyperglycaemia and hyperinsulinaemia that results from
is of the largest visible cord- and limb-free pocket of amniotic maternal hyperglycaemia results in polyuria through an
fluid (Figures 1 and 2). Although gestational-age-specific osmotic action.10 Fetal nephrogenic diabetes insipidus
thresholds can be applied to define polyhydramnios, resulting from maternal use of lithium is also found to be
generally speaking, a constant value of AFI ≥25 cm or DVP associated with polyhydramnios.11

Figure 1. Amniotic fluid index (AFI) in polyhydramnios.

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 Karkhanis and Patni

Box 1. Causes of polyhydramnios in a singleton pregnancy

Maternal

 Uncontrolled diabetes mellitus (pre-gestational and gestational)

 Rhesus and other blood group isoimmunisation leading to immune
hydrops
 Drug exposure, e.g. lithium leading to fetal diabetes insipidus

Fetal

 Structural/congenital malformations (see Table 1)

 Chromosomal and genetic abnormalities, e.g. trisomies, Beckwith–
Wiedemann syndrome, fetal akinesia–dyskinesia syndrome
 Congenital infections, e.g. toxoplasma, rubella, cytomegalovirus,
and parvovirus
 Macrosomia
 Fetal tumours, e.g. teratomas, nephromas, neuroblastoma, and
haemangiomas
Figure 2. Deepest vertical pool in polyhydramnios. Placental

 Tumours such as chorioangiomas and metastatic neuroblastoma

Among the fetal causes, the most frequent conditions are
Unexplained
those that affect the ability of the fetus to swallow the
amniotic fluid.12 These include:
 structural abnormalities of the gastrointestinal tract, e.g.
oesophageal atresia and tracheo-esophageal fistula, bowel adenomatoid malformations, bronchogenic cysts, head
obstruction such as pyloric stenosis and duodenal and neck masses and lethal skeletal dysplasias that restrict
atresia (Figure 3) the contents of the chest
 physical obstruction of an otherwise normal upper  neurological conditions that interfere with the
gastrointestinal tract, e.g. intrathoracic masses such as neurological control of swallowing, e.g. anencephaly,
congenital diaphragmatic hernia, congenital cystic myotonic dystrophy, arthrogryposis
 genetic conditions, such as Beckwith–Wiedemann
syndrome, in which the associated macroglossia
Table 1. Fetal structural abnormalities causing polyhydramnios in a interferes with fetal swallowing.
singleton pregnancy
The other fetal causes include fetal hydrops (immune and
System affected Condition non-immune) where both hydrops and polyhydramnios
develop from the same aetiology, and fetal tumors (eg.
Central nervous system Anencephaly sacrococcygeal teratomas) that cause vascular steal, resulting
Spina bifida
Encephalocele
in high-output cardiac failure.
Hydrocephalus Finally, vascular placental chorioangiomas have been
Microcephaly associated with an increased incidence of polyhydramnios
Dandy–Walker malformation in ~30% of cases.13
Head and neck Goitre, cystic hygroma, cleft palate
Respiratory system Tracheal agenesis
Congenital diaphragmatic hernia
Congenital cystic adenomatoid malformation
Unexplained polyhydramnios
Bronchopulmonary sequestration In the absence of a maternal, fetal, and placental aetiology,
Gastrointestinal system Esophageal atresia and tracheo-oesophageal
fistula, duodenal and intestinal atresia polyhydramnios is thought to be unexplained or idiopathic.
Exomphalos This category accounts for 50–60% of all cases of
Gastroschisis polyhydramnios.1 It has been linked with significantly
Genitourinary system Pelvi-uretric junction obstruction
higher rates of malpresentation, macrosomia, and primary
Bartter syndrome
Skeletal system Lethal skeletal dysplasia caesarean sections. Moreover, a two- to five-fold increase in
Cardiovascular system Cardiac anomalies perinatal morbidity and mortality has been associated with
Fetal tumours Sacrococcygeal teratoma unexplained polyhydramnios.1,14
Other Immune and non-immune hydrops fetalis
Every case of polyhydramnios requires a systematic search
Fetal akinesia–dyskinesia syndrome
for an underlying cause and unexplained polyhydramnios is a
diagnosis of exclusion.

ª 2014 Royal College of Obstetricians and Gynaecologists 209

 Polyhydramnios in singleton pregnancies

Karyotyping should be considered while evaluating

polyhydramnios on an individual case basis.14,18
Chromosomal abnormalities are known to be present in
10% of fetuses with sonographic anomalies and
polyhydramnios, but in only 1% when the ultrasound
examination is considered to be normal.16 Similarly, in
persistent polyhydramnios, the prevalence of aneuploidy is
increased (10–20%) as compared to polyhydramnios with
spontaneous resolution.13 However, with the introduction of
nuchal translucency measurement as a part of a universal,
national, screening programme in UK, this proportion may
be significantly lower in the cohort of patients who have been
screened. The results of the nuchal translucency testing and
Down syndrome screening should be taken into account
Figure 3. Double-bubble sign in a case of duodenal atresia leading to while assessing the risk of aneuploidy and counselling. This is
polyhydramnios – distended stomach to the left and duodenum to the particularly relevant while evaluating polyhydramnios when
right of the image.
the fetus is small for gestational age or has
structural abnormalities.
Moreover, an assessment of cervical length by transvaginal
Assessment and investigations
ultrasound scan to quantify the risk of preterm labour is
Rapidly increasing symphysis fundal height measurements, helpful in planning further management of the pregnancy.
above the 90th centile on customised growth charts, may be
indicative of polyhydramnios. Clinical findings may also
include a tense uterus and difficulty in palpating fetal parts. Management in pregnancy
More often, polyhydramnios is incidentally diagnosed at a
This is largely dependent on the possible underlying
routine ultrasound examination or when the ultrasound is
aetiology. In cases of poorly controlled maternal diabetes
performed for another indication. Once polyhydramnios is
mellitus, a multidisciplinary approach with involvement of
confirmed, the next step is to search for an
maternal medicine specialists, diabetologists, and dieticians is
underlying aetiology.
essential. Management of diabetes in pregnancy is an
Maternal investigations such as random blood sugars and/
extensive topic and beyond the scope of this review.
or oral glucose tolerance test and glycosylated haemoglobin
However, it should be remembered that polyhydramnios
as appropriate are recommended. If there are signs of fetal
with maternal diabetes is associated with fetal macrosomia
infection on ultrasound, then testing for congenital infections
and that improved outcomes are known to occur with
such as toxoplasma, parvovirus, and cytomegalovirus
improved glycaemic control.19
(TORCH) is advisable. One must also check the maternal
Referral to maternal–fetal medicine specialists is advisable
blood-group status for any atypical red cell antibodies, which
in cases of:
is routinely done at booking and around 28 weeks in the UK.
 suspected fetal anomaly
Detailed examination of the fetus for any structural
 small for gestational age fetus
abnormality is essential (Table 1). The likelihood of
 concerns with fetal movements
congenital anomaly increases with the severity of
 persistent or worsening polyhydramnios.
polyhydramnios.15 In spite of a normal sonographic
evaluation, the risk of a major anomaly is 1% with mild, 2% Patients with polyhydramnios should be informed of
with moderate, and 11% with severe polyhydramnios.16 Small increased risk of preterm delivery. Evaluation of the cervical
stomach or a non-visualisation of stomach, despite 45 minutes length to determine the need for administration of steroids to
of scanning, is considered abnormal and gestational-age- promote fetal lung maturity is advisable. Similarly, patients
specific charts provide the upper and lower limits of the should be informed of the risks of unstable lie requiring
stomach dimensions.17 Evaluation of the long bones and the delivery by caesarean section, umbilical cord prolapse,
thorax will determine the presence of a skeletal dysplasia. abruptio placentae, and postpartum haemorrhage.
Although rare, congenital cardiac disease can also be one of the Therapeutic amniocentesis or amniodrainage has been
causes and a targeted fetal echocardiography may be helpful. used to treat symptomatic polyhydramnios in order to
Assessment of fetal movements, tone, and examination of the minimise respiratory embarrassment. It can also be used for
joints can be the key to the diagnosis of neuromuscular patients with significant cervical shortening to avoid preterm
abnormalities such as arthrogryposis multiplex congenita. birth. The clinical methods for amniodrainage include either

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 Karkhanis and Patni

a slower technique using a three-way stopcock with a 50 ml obstetric practice is not recommended and is
syringe or a more rapid method using a vacuum-assisted sometimes contraindicated.24
drainage system.20 Normally the procedure is discontinued Once the cause is ascertained, it is good practice to follow
when the AFI returns to normal (<25 cm) or until maternal up these patients with serial ultrasound scans to monitor the
discomfort is relieved. The overall risk of complications such liquor volume and fetal growth. Mild polyhydramnios
as preterm labour, premature rupture of membranes, resolves frequently without any intervention. Except for a
chorioamnionitis, and of placental abruption is relatively higher incidence of large-for-gestational-age fetuses, mild
small (~1.5%).21 However, there is a high likelihood of polyhydramnios by itself is not associated with an increased
recurrence, thus requiring repeated procedures. Serial risk of adverse perinatal outcomes.25
amniodrainages can be technically difficult and the risk
of the aforementioned complications increases with
Management of labour
each procedure.
Prostaglandin synthetase inhibitors such as indomethacin There is insufficient evidence in the literature for induction
(cyclooxygenase [COX]-1 and -2 inhibitor) and sulindac of labour for polyhydramnios alone. The benefits do not
(COX-2) have been used in the management of seem to outweigh the risks associated with the induction
polyhydramnios. These drugs reduce amniotic fluid volume process.26 However, induction of labour is indicated when
by decreasing fetal urinary output and by enhancing the polyhydramnios is a part of the clinical picture such as
resorption of lung fluid. Some fetal medicine units in the UK uncontrolled maternal diabetes or associated with other
use sulindac as it is a selective COX-2 inhibitor and has a obstetric conditions such as prolonged pregnancy, maternal
better adverse-effect profile. Sulindac dose of 200 mg every 12 hypertension, etc.
hours has been shown to be most effective in unexplained Once labour is established, close monitoring for signs of
polyhydramnios or polyhydramnios associated with distal labour dystocia in cases with associated macrosomia is
gastrointestinal obstruction. However, these medications are recommended. Safe obstetric practices, such as controlled
associated with significant fetal adverse effects such as dose- amniotomy in theatre, and anticipation and preparation for
and gestational-age-dependent constriction of the ductus complications such as shoulder dystocia and postpartum
arteriosus and impaired renal function.22,23 In view of such haemorrhage, are advisable.
significant adverse effects, these drugs are to be used only In case of unexplained polyhydramnios, a thorough
under strict specialist supervision. Their use in general neonatal examination, with a minimum of checking the

Polyhydramnios
detected on USS

Maternal investigations Consider antenatal steroids if

Detailed ultrasound for fetal
• RBS/GTT/HbA1c cervical shortening on
• abnormalities
• toxoplasma, CMV, transvaginal USS
• weight
parvovirus
• stomach
• red cell antibodies
• movements

Counsel regarding risks of

• preterm labour
• unstable lie
Suspected • Maternal diabetes mellitus
• cord prolapse
• fetal congenital • Maternal infection
• antepartum and
abnormality • Red cell antibodies
postpartum haemorrhage
• fetal aneuploidy
• increased operative
p
• fetal infection
intervention
• SGA/IUGR
• concerns regarding
movements Refer to maternal and fetal
medicine specialist team
Management of pregnancy as per
the fetal/maternal abnormality
detected; for unexplained
Urgent referral to fetal medicine polyhydramnios (see Figure 5)
specialist team

Figure 4. Management of polyhydramnios in a singleton pregnancy. CMV = cytomegalovirus; GTT = glucose tolerance test; HbA1c = glycosylated
haemoglobin; IUGR = intrauterine growth restriction; RBS = random blood sugar; SGA = small for gestational age; USS = ultrasound scan.

ª 2014 Royal College of Obstetricians and Gynaecologists 211

 Polyhydramnios in singleton pregnancies

Unexplained
polyhydramnios

Severe (AFI >35 cm) Mild (AFI 25–29.9 cm) and

• Persistent moderate (AFI 30–34.9 cm)
• Worsening
• Fetal abnormalities
• Serial growth scans
• TVS for cervical length

Refer to a fetal medicine specialist If maternal discomfort/ • No benefit from induction

respiratory compromise from of labour for isolated/
polyhydramnios or risk of unexplained polyhydramnios
preterm labour • Induction of labour only for
maternal or fetal indications

Therapeutic amniocentesis/
amniodrainage • Monitor progess of labour
• Watch for shoulder
dystocia and postpartum
haemorrhage

• Thorough neonatal
examination
• Check patency of upper GI
tract with nasogastric tube

Figure 5. Management of unexplained polyhydramnios in a singleton pregnancy. AFI = amniotic fluid index; GI = gastrointestinal; TVS =
transvaginal sonography.

patency of upper gastrointestinal tract using a nasogastric References

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