Polyhydramnios Imaging

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Polyhydramnios is the presence of excess amniotic fluid in the uterus. By definition, polyhydramnios is diagnosed if the deepest vertical pool is more than 8 cm or amniotic fluid index (AFI) is more than 95th percentile for the corresponding gestational age. With a deep pocket of 8 cm as criteria of polyhydramnios, the incidence is 1-3% of all pregnancies. About 20% are associated with fetal anomalies.

Polyhydramnios has a variety of causes affecting the mother or the fetus. The presence of polyhydramnios should prompt a search for other fetal anomalies. Some of the anomalies can be diagnosed with sonography, while others require karyotyping.

The diagnostic approach to polyhydramnios consists of (1) physical examination of the mother with an investigation for diabetes mellitus, diabetes insipidus, and Rh isoimmunization; (2) sonographic confirmation of polyhydramnios and assessment of the fetus; (3) fetal karyotyping; and (4) maternal serologic testing for syphilis. ^{[1, 2]}

Clinical examination can reveal a uterine size larger than that expected for the corresponding gestational age of the fetus.

Ultrasonography is the most reliable method for diagnosing and quantifying polyhydramnios. Experienced operators make the diagnosis based on subjective assessment. The height of the deepest pocket and the AFI are objective semiquantitative measurements of the amniotic fluid.

MRI is not necessary for the diagnosis of polyhydramnios, but polyhydramnios can be detected during MRI for other indications. Three limitations of MRI are notable. First, MRI is not cost effective. Second, it is time consuming. For example, the time required for magnetic resonance volumetry can be as long as 6 hours, which is not ideal when sonography can be performed in only a few minutes. Third, MRI requires knowledge of computers and postprocessing.

CT scanning is generally avoided during pregnancy.

MRI is not essential in the imaging protocol for polyhydramnios, but if it is performed for fetal or maternal imaging, it can also be used for diagnosing polyhydramnios.

A customized medical image postprocessing software package can be used for segmentation and 3-dimensional (3D) modeling. Once the structures of interest in a 3D image volume are segmented, the postprocessing software creates a corresponding 3D surface model and automatically calculates the volume of each 3D reconstruction

Although allowances must be made for a smaller fluid volume (except in polyhydramnios) and for segmentation of the amniotic fluid in vivo being slightly more difficult owing to fetal motion, volumetric measurements are likely to represent the real values.

MRI is good for assessing the volume of amniotic fluid and for diagnosing polyhydramnios. However, MRI is not mandatory for the diagnosis of polyhydramnios.

Kubik et al found that MRI is accurate in measuring the amniotic fluid volume, as it is in measuring placental volume and fetal weight. ^[3]

A good correlation was obtained between MR volumetry studies and the actual amniotic fluid volume. Although this would not be a cost effective method of diagnosing polyhydramnios, it would be of greater help in monitoring therapeutic response to polyhydramnios treatment. The common sequences used are T2-weighted single-shot fast spin-echo and high-spatial-resolution T1-weighted fast spin-echo images subsequent to a spoiled gradient-echo localizer.

Measuring the amniotic fluid volume is difficult when the quantity is low because no difference in signal intensity can be noted between a thin rim of fluid and the placenta and uterine wall; this similarity makes postprocessing and automatic segmentation difficult.

Although 3D reconstruction of a fetus is better with a large amount of amniotic fluid present, fetal motion adversely affects image processing and reconstruction.

Use of an automatic threshold for excluding amniotic fluid excludes other tissues containing the same signal intensity, such as fetal brain and fluid-filled fetal organs (eg, the urinary bladder).

Ultrasonography is the main modality for the diagnosis of polyhydramnios and evaluation of the fetus. Features that are assessed in polyhydramnios include amniotic fluid, possibly of multiple pregnancy, chorionicity in multiple pregnancy, fetal macrosomia, fetal thorax, fetal central nervous system, fetal gastrointestinal tract, cervical length, and posttreatment follow-up results. ^{[4, 1, 2]}

There are at least 3 methods for measuring amniotic fluid: (1) depth of the deepest vertical pool, (2) the 2-diameter pocket (depth X width of the longest pocket), and (3) the AFI. ^{[5, 6, 7, 8, 9]}

With the AFI method, the uterus is divided into 4 quadrants. The depths of the deepest vertical pool in the 4 quadrants are measured and added to give the index. Occasionally, at less than 20 weeks, only the right and left lower quadrants are used. The normal index is 5-24. In polyhydramnios, it is more than 24. AFI of a normal population (ie, normative values) corresponding to the gestational age can be noted, and the percentile value of the particular patient can be calculated by using the mean and standard deviation.

The graph below shows the normal limits of AFI based on gestational age. The mean AFI for normal pregnancies is 11-16 cm. Polyhydramnios is diagnosed when the AFI is more than the 95th percentile value. Normative values are not available before 16 weeks of gestation.

The incidence of polyhydramnios can vary with the technique used. A single deep pocket more than 8 cm is diagnostic of polyhydramnios. With the single-pocket technique, the incidence is 0.7% (1.1% for oligohydramnios). With the 2-diameter pocket, the rate is 3% (30% for oligohydramnios), and with the AFI method, the rate is 0% (8% for oligohydramnios). Therefore, the single-deep-pocket method is the best technique because it classifies the least number of cases as being abnormal.

A simple rule of thumb is that in the first trimester, the fluid is more than the embryo/fetus; in the second trimester, the fluid is equal to the fetus; and in the third trimester, the fluid is less than the fetus.

Twins can be monochorionic or dichorionic. The difference can be assessed by careful observation. In dichorionic twins, the intermembrane septum is thick, with 3 or 4 membrane layers, and the membrane is more than 2 mm. The triangular sign is present and very specific. In dichorionic twins, the cause of polyhydramnios is the same as that in a singleton pregnancy.

In monochorionic twins, the intermembrane septum is thin, and the junction of membranes forms a T shape. In monochorionic twins, the most common cause of polyhydramnios is twin-to-twin transfusion syndrome

Sonography may be useful in screening for growth retardation.

Ultrasonography may be helpful in evaluating the mouth, stomach, small bowel, and abdominal wall.

One technique involves the change in bladder dimension observed over 20-minute intervals. These changes can differentiate fetal polyuria from other causes of polyhydramnios. However, this technique has its limitations. It underestimates the degree of fetal urine production by at least 50%, and it is not useful in severe hydramnios because the bladder is already filled with urine, and any further increase in the bladder size is minimal. ^[10]

Cervical length is essential for assessing the risk of preterm labor. If the fetus is less than 24 weeks and if after amniotic drainage the cervical length is less than 25 mm, a cervical suture is required to prevent preterm labor. ^[11]

The AFI should be monitored twice a week when the patient is being treated with indomethacin. The treatment is stopped when the AFI is less than normal. The response is seen usually between 4 and 20 days.

Doppler imaging of the ductus arteriosus is also done within 24 hours of starting treatment and once weekly thereafter. Indomethacin is known to cause premature closure of ductus arteriosus, and if this happens, indomethacin is stopped.

The values for amniotic fluid index, single deepest pocket, and 2 diameter pockets are not normally distributed throughout pregnancy. Therefore, a logarithmic transformation is required for gestational age–specific ranges. Normative values also vary within a population.

The incidence of detection of polyhydramnios varies with the technique used, as discussed in Amniotic fluid above.

Sonographic assessment of amniotic fluid is a poor indicator of amniotic volume. The 95% confidence limit is wide compared with the dye-dilution technique for the measurement of amniotic fluid volume.

Magann et al showed that, while sonography and the single-deep-pocket method are good for measuring normal amniotic fluid volume (83-94%), they are not accurate in diagnosing polyhydramnios (33-46%) and oligohydramnios (11-27%). ^{[6, 7]}

If color Doppler imaging is used along with normal scanning, the AFI is less than that obtained without Doppler techniques. This difference increases the diagnosis of oligohydramnios.

Chorioangiomas larger than 5 cm can produce complications including polyhydramnios, preeclampsia, preterm delivery, congenital malformation, congestive cardiac failure, antepartum hemorrhage, intrauterine growth retardation, and microangiopathic hemolytic anemia.

Sonograms show a placental mass with anechoic spaces, which demonstrate flow on color Doppler studies and pulsatile flow on spectral Doppler trace studies.

Nuclear medicine studies have no role in the evaluation of polyhydramnios.

Nelson DB, Dashe JS, McIntire DD, Twickler DM. Fetal skeletal dysplasias: sonographic indices associated with adverse outcomes. J Ultrasound Med. 2014 Jun. 33 (6):1085-90. [Medline].

Santana EF, Oliveira Serni PN, Rolo LC, Araujo Júnior E. Prenatal Diagnosis of Arthrogryposis as a Phenotype of Pena-Shokeir Syndrome using Two- and Three-dimensional Ultrasonography. J Clin Imaging Sci. 2014. 4:20. [Medline].

Kubik-Huch RA, Wildermuth S, Cettuzzi L, et al. Fetus and uteroplacental unit: fast MR imaging with three-dimensional reconstruction and volumetry–feasibility study. Radiology. 2001 May. 219(2):567-73. [Medline].

Benzer N, Pekin AT, Yılmaz SA, Kerimoğlu ÖS, Doğan NU, Çelik Ç. Predictive value of second and third trimester fetal renal artery Doppler indices in idiopathic oligohydramnios and polyhydramnios in low-risk pregnancies: a longitudinal study. J Obstet Gynaecol Res. 2015 Apr. 41 (4):523-8. [Medline].

Alfirevic Z, Luckas M, Walkinshaw SA, et al. A randomised comparison between amniotic fluid index and maximum pool depth in the monitoring of post-term pregnancy. Br J Obstet Gynaecol. 1997 Feb. 104(2):207-11. [Medline].

Magann EF, Sanderson M, Martin JN, Chauhan S. The amniotic fluid index, single deepest pocket, and two-diameter pocket in normal human pregnancy. Am J Obstet Gynecol. 2000 Jun. 182(6):1581-8. [Medline].

Magann EF, Doherty DA, Chauhan SP, et al. How well do the amniotic fluid index and single deepest pocket indices (below the 3rd and 5th and above the 95th and 97th percentiles) predict oligohydramnios and hydramnios?. Am J Obstet Gynecol. 2004 Jan. 190(1):164-9.

Moore TR, Cayle JE. The amniotic fluid index in normal human pregnancy. Am J Obstet Gynecol. 1990 May. 162(5):1168-73. [Medline].

Hebbar S, Rai L, Adiga P, Guruvare S. Reference ranges of amniotic fluid index in late third trimester of pregnancy: what should the optimal interval between two ultrasound examinations be?. J Pregnancy. 2015. 2015:319204. [Medline].

Kirshon B. Fetal urine output in hydramnios. Obstet Gynecol. 1989 Feb. 73(2):240-2. [Medline].

Engineer N, O’Donoghue K, Wimalasundera RC, Fisk NM. The effect of polyhydramnios on cervical length in twins: a controlled intervention study in complicated monochorionic pregnancies. PLoS ONE. 2008. 3(12):e3834. [Medline].

Prabhakar Rajiah, MD, MBBS, FRCR Associate Professor, Department of Radiology, Division of Cardiothoracic Imaging, Associate Director of Computer Tomography (CT) and Magnetic Resonance Imaging (MRI), UT Southwestern Medical Center

Prabhakar Rajiah, MD, MBBS, FRCR is a member of the following medical societies: American Roentgen Ray Society, European Society of Radiology, Indian Radiological and Imaging Association, North American Society for Cardiac Imaging, Radiological Society of North America, Royal College of Radiologists, Society for Cardiovascular Magnetic Resonance, Society of Cardiovascular Computed Tomography

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Karen L Reuter, MD, FACR Professor, Department of Radiology, Lahey Clinic Medical Center

Karen L Reuter, MD, FACR is a member of the following medical societies: American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Nothing to disclose.

Polyhydramnios Imaging

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