Hydramnios

HYDRAMNIOS, polyhydramnios (from Greek poly- many, hydor- water and amnion- inner fetal membrane), polyhydramnios, excessive accumulation of amniotic fluid in the fetal membranes. The normal amount of amniotic fluid is considered to be from 1 to 1.5 liters. An increased amount of fluid is considered if by the end of pregnancy more than 2 liters accumulate; more than 5 liters is treated as hydramnios. A case is described where the amount of fluid reached 20-30 liters. Since the measure for determining moderate degrees of hydramnios is often subjective, its frequency is also indicated differently. According to large statistics, hydramnios occurs from 1.3% (Hinselmann) to 2.7-2.9% (Mikhailov, N. Ivanov). Taking into account various factors contributing to fluid accumulation in the egg, as well as clinical observations, one cannot stop at any single cause of hydramnios. All etiological moments can be considered depending on changes occurring in the egg, in the fetus and in the mother. According to the view established in recent years, the epithelium of the amniotic sac plays a major role in the secretion of amniotic fluid, which normally has a special structure [see separate table (pp. 267-268), figure 1]. According to Forsell's research, the pathological condition of amniotic epithelial cells [see separate table (pp. 267-268), figure 2] leads to abnormal accumulation of fluid. According to other data (Jungbluth, Levison, A. Lebedev, V. Grudzev), the cause of hydramnios is the failure of the capillary network located between the chorion and amnion (these vessels are usually closed from the second half of pregnancy). Next come chronic inflammatory processes of the placenta and membranes (Franque), as well as all mechanical obstacles to placental circulation (chorioangiomas) and in the umbilical cord (excessive tortuosity, stenoses), with insertio velamentosa, when umbilical vessels experience direct pressure from the uterine walls and bladder (Grudzev). Sometimes stagnation phenomena are noted in the fetal vascular system, caused almost exclusively by mechanical obstacles to blood circulation, such as narrowing of the aortic opening (A. Lebedev), premature closure of the ductus Botalli (Nieberding), cirrhosis of the liver. The latter, due to compression of the portal vein and narrowing of the ductus Arantii, can cause ascites and stagnation in umbilical and placental circulation. Hydramnios quite often coincides with fetal malformations. According to Bar (Bag), out of 100 cases of hydramnios, only in 44 cases were there healthy and well-developed children; in 8 cases malformations were encountered. Burstohl had 4 malformations out of 133 cases of hydramnios, Lau had 9 malformations out of 75 cases, Peck notes 19% malformations in hydramnios, Kraula-37%. Among malformations, first place is taken by developmental defects of the central nervous system - hemicephalia, anencephalia, spina bifida, etc., non-closure of the anterior abdominal wall, ectopia vesicae, cleft palate, atresia of the digestive tube, etc. Multiple pregnancy also often combines with hydramnios, especially in monozygotic twins. In this case, hydramnios may be present in only one fetus, while the other may not have it. Children with polyhydramnios are usually much more developed than with oligohydramnios; sometimes hypertrophy of the heart, kidneys, liver, and bladder was found in them (Schatz, Küstner and others). The reason for the different development of fetuses lies mainly in their unequal blood supply. With a common placenta in twins, a group of villi that belong to both fetuses can often be found; three circles of circulation are formed, including one common to both twins, where one fetus gives the artery and the other gives the vein. That twin who receives the venous bed receives more blood than it gives, which leads to hypertrophy of its organs. In a certain percentage of cases, hydramnios is also observed with singleton pregnancy. N. Ivanov had in 27% of cases children with weight of 4,000 g and above. Fellner on large statistics also confirms the presence of large children (on average from 32.5 to 56 cm in length). Hydramnios is described with triplets. The cause of hydramnios can be various maternal diseases - inflammation of the kidneys, diabetes, decompensated heart defects, leukemia, syphilis (the latter can also be from the side of the fetus). The syphilitic placenta is always of large size and heavier than normal, its vessels are sclerosed, all this causes increased pressure in the fetal and placental circulation system and can serve as a cause of increased water production. The chemical composition of amniotic fluid in hydramnios, according to the latest analyses, does not differ from normal. Polyhydramnios can occur in all months of pregnancy, but is more often observed in the second half. Depending on the rate of fluid accumulation, acute and chronic forms of hydramnios are distinguished. In the chronic form, clinical phenomena are determined almost exclusively by excessive stretching of the uterus, which presses on all abdominal organs. Pressure on the stomach and intestines causes heartburn, vomiting, constipation. The elevated diaphragm makes breathing and cardiac activity difficult. Urination is often delayed, the amount of urine decreases, it becomes thicker and contains protein. Sometimes ascites is observed. Swelling of the lower extremities, abdominal walls and lumbar region appears. Pregnant women suffer greatly from stretching of the abdominal walls and shortness of breath, especially when lying down. Quite often pains in the abdomen, lower back, and painful neuralgias (ischias, intercostal neuralgia, etc.) are added. All these phenomena are directly dependent on the rate of accumulation of amniotic fluid. With moderately expressed hydramnios, pregnancy often proceeds quite easily. But with acute hydramnios, the picture of the disease passes very violently. Sometimes within a few days, with a rapidly growing abdomen, a severe general condition develops. Shortness of breath develops, reaching true suffocation, cyanosis of the face, extremities appears, attacks of palpitation occur. Facial features become sharper. Sometimes there is vomiting. Pains in the abdomen and almost the whole body do not stop day or night. Sitting and lying is agonizing. Sometimes bedsores form. In some cases, spontaneous rupture of the membranes occurs with termination of pregnancy. Recognition of hydramnios is based on a large, stretched abdomen that does not correspond to the duration of pregnancy, and on the easy mobility of the fetus. On palpation, a slight contraction of the uterine walls can be obtained, round uterine ligaments can be found, and at least some fluctuation can be determined. Parts of the fetus are felt with difficulty, and sometimes slight ballottement can be elicited. It is equally difficult to listen to the fetal heart tones. The movements of the fetus are felt weakly by the pregnant woman. In addition to the anamnesis characteristic of pregnancy, the diagnosis is confirmed by internal examination: a shortened cervix drawn upward with a dilated opening (for 1-2-3 fingers) is found, through which a tense fetal bladder and even parts of the fetus can be palpated. It is often difficult to distinguish hydramnios from multiple pregnancy, especially if the latter is combined with polyhydramnios. In twins, uterine growth is observed from the first months, sometimes a groove between the fetuses can be determined, fluctuation and ballottement are more difficult than in hydramnios, but diagnostic errors are mainly avoided by repeated palpation and auscultation. In recent years, radiodiagnosis has been used with great success in recognition. Ascites, cyst, tuberculous peritonitis are excluded based on known signs of pregnancy. - Therapy. There are no means against excessive accumulation of amniotic fluid; treatment has to be symptomatic. Under the influence of rest, bed rest, milk diet, the increase in fluid sometimes stops. Means that increase diuresis and mild laxatives are successfully recommended. In syphilis - specific treatment. Pinard used iodine with mercury in all cases, even where he found no signs of syphilis. Dubois recommends bloodletting. Wearing a bandage is recommended. In threatening cases - termination of pregnancy. The latter is most often performed by puncturing the fetal bladder. Only in twins, if the fetus with a small amount of fluid is presenting, and in placenta previa, this method is inconvenient; in these cases, it is recommended (Lepage) to perform puncture through the abdomen. - Labor in hydramnios proceeds sluggishly, weak and irregular contractions are observed. In cases of artificial termination of pregnancy by puncture, it is recommended to release the fluid slowly, through a small hole, tearing the membranes above the internal os. The latter is necessary to avoid rapid emptying of the uterus and thus prevent collapse in the mother and premature detachment of the placenta with all the serious consequences for the child. It is also necessary to watch for the prolapse of the umbilical cord and small parts of the fetus, which often occurs with great mobility of the fetus and frequently encountered malpresentations. After the waters are released, labor usually ends quickly. N. Ivanov in 187 cases of hydramnios in 106 notes the birth of an infant within 1 hour (57%), in 21 cases - earlier than 2 hours after the waters have departed. - The postpartum period of labor is often complicated by atonic bleeding due to overstretching of the uterus.

In the postpartum period, poor involution is observed. The prognosis for the mother depends on complications during childbirth (surgical intervention, atonic bleeding). For children, the prognosis in hydramnios is always serious. Some of them are born prematurely, weak, and underdeveloped. Some quickly die after birth (up to 25%), while others suffer from deformities and die from non-viability. According to Bara's statistics, 25% of cases result in the birth of dead children; according to Ivanov's data, only 9.6%. Ginzelman presents extremely high figures for child mortality (according to various authors): 25% (Flores), 59% (Peck), and even 96% (Kraula). In acute H. almost all children die (Ginzelman). Fortunately, this form of H. is very rare compared to the chronic form (8:623, according to Baudelocque).