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CLINICAL OBSTETRICS AND GYNECOLOGY


Volume 45, Number 4, 1026–1038
© 2002, Lippincott Williams & Wilkins, Inc.

Sonographic
Evaluation of
Amniotic
Fluid Volume
DAVID B. SCHRIMMER, MD, and THOMAS R. MOORE, MD
Division of Perinatal Medicine, Department of Reproductive
Medicine, University of California San Diego, San Diego, California

Over the past 20 years, evaluation of amni- tive delivery,2 more recent studies have fo-
otic fluid volume has evolved into a critical cused on correlating amniotic fluid volume
component of prenatal care and intrapartum estimates with underlying fetal abnormali-
management. Using progressively improv- ties, including growth disturbances and ana-
ing imaging techniques, the practice of am- tomic malformations. Important spin-offs
niotic fluid volume assessment has evolved from improved amniotic fluid volume esti-
from subjective observations of what ap- mation include its inclusion in antepartum
peared to be to too little or too much fluid to testing regimens as an indicator of fetal
an experienced (or inexperienced) practitio- well-being, as well as the technique of am-
ner, to more sophisticated techniques for nioinfusion to improve labor outcome. In
quantifying volume yielding surprisingly re- pregnancies complicated by oligohydram-
producible accuracy. As the acceptance and nios, transcervical and transabdominal am-
clinical use of various amniotic fluid- nioinfusion have been shown to be useful in
measuring techniques has grown, progres- reducing maternal and fetal morbidity dur-
sively better correlations between fluid vol- ing labor, and as a diagnostic tool.3
ume and fetal outcome have been obtained.1 Although estimating amniotic fluid vol-
While early work focused on using amniotic ume has become the standard of care in the
fluid volume estimates to predict the likeli- management of high-risk pregnancies, there
hood of adverse perinatal events such as fe- is still not universal agreement as to which
tal distress, meconium passage, and opera- method of measuring the fluid is most accu-
rate or predictive of perinatal morbidity.
The dramatic rise in multiple gestations
Correspondence: David B. Schrimmer, MD, Division of and their associated problems has also
Perinatal Medicine, Department of Reproductive Medi- raised the question of how best to quantitate
cine, University of California San Diego, 200 W. Arbor
Drive, Mail Code 8433, San Diego, CA 92103. E-mail: fluid in separate sacs. The advent of three-
trmoore@ucsd.edu dimensional ultrasound and rapid MRI scan-

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 45 / NUMBER 4 / DECEMBER 2002

1026
Sonographic Evaluation of Amniotic Fluid Volume 1027

ning promises to provide improvements in provides more accurate trending of volume


solving the practical dilemma of how to re- over time and comparison to established
producibly and precisely measure amniotic norms.
fluid volume.
SEMIQUANTITATIVE METHODS

Methods of Evaluating Single Deepest Pocket Technique


Amniotic Fluid In 1984, Chamberlain et al1,6 introduced the
concept of estimating amniotic fluid volume
SUBJECTIVE EVALUATION using the depth of the maximum vertical
Before the widespread availability of ultra- pocket (MVP) visible with ultrasound. This
sound, amniotic fluid volume estimations methodology provided the first semiquanti-
were generally subjective and most com- tative estimate of amniotic fluid volume.
monly made at the time of delivery. While The technique involves measuring the deep-
these findings often helped explain certain est clear amniotic fluid pocket (free of um-
clinical conditions (eg, the association be- bilical cord or fetal small parts) anteroposte-
tween hydramnios and fetal esophageal atre- riorly in the uterus. These investigators de-
sia), the information was retrospective and fined oligohydramnios as a pocket of less
often inaccurate. Today, ultrasound visual- than 1 cm in depth, and “reduced” fluid vol-
ization of amniotic fluid pockets permits ume as a pocket of 1 to 2 cm in depth. Am-
both subjective and objective estimates of niotic fluid volume was considered normal
amniotic fluid volume. While infinitely im- when the MVP was greater than 2 cm but
proved from observations at delivery, sub- less than 8 cm in depth. Cases in which
jective sonographic estimates of amniotic pockets deeper than 8 cm were observed
fluid volume are closely dependent on the were classified as hydramnios.
sonographer’s experience.4 Despite obvious The study by Chamberlain et al also pro-
reproducibility problems with subjective as- vided a quantitative correlation between oli-
sessment, Moore et al5 demonstrated that gohydramnios and poor pregnancy out-
well-trained observers can reliably assign come: the perinatal mortality rate increased
patients with oligohydramnios to a subjec- 13-fold in pregnancies with sonographically
tive scale with an intraclass correlation co- reduced amniotic fluid volume and in-
efficient of 0.81. Halperin et al4 performed a creased 47-fold (187.5/1,000) when severe
similar study in which experienced sonogra- oligohydramnios was present. With hydram-
phers subjectively assigned patients to nios, perinatal mortality was 4.12/1,000,
groups with normal, borderline-low, or re- compared with 1.97/1,000 when the amni-
duced amniotic fluid volume. They found otic fluid was normal.
that more experienced sonographers had In subsequent investigations, the “single
significantly better intraobserver correlation deepest pocket technique” has been shown
scores (kappa = 0.94 vs. 0.63) than those to have several shortcomings.7 Bottoms et
with less experience. Thus, while subjective al8 suggested that the 1-cm pocket depth cri-
methods are convenient and simple, experi- terion for oligohydramnios was an insensi-
enced sonographers are necessary for the tive marker for poor outcome, as an MVP of
best results. Most practitioners today rely to less than 1 cm was rare (<1% of normal
some degree on the subjective appearance of pregnancies). Bottoms et al8 also studied the
amniotic fluid volume on the ultrasound im- effect of gestational age on MVP in 487
ages, especially in cases examined previous high- and low-risk patients, noting that the
to 20 weeks. However, as noted in the dis- mean MVP varied significantly with gesta-
cussion below, use of a numerical estimate tional age, ranging from 57 mm at 26 to 30
1028 SCHRIMMER AND MOORE

weeks to 48 mm at 40 to 43 weeks, with a and Phelan et al10 proposed a range of nor-


peak value of 58 mm at 31 to 33 weeks. They mal for the AFI of 8 to 18 cm. Delivery was
asserted that applying a single pocket depth recommended for AFI values below 5 cm
criterion throughout pregnancy may be in- due to the significantly increased risk of fe-
appropriate. Moreover, when Goldstein and tal complications, poor tolerance of labor,
Filly compared the MVP to subjective and perinatal death (Table 1). As in the MVP
evaluations of amniotic fluid volume, the studies by Chamberlain et al, a shortcoming
former technique was no better than the vol- of the boundaries of normal proposed in the
ume assessments rendered by expert sonog- early AFI studies was the use of a reference
raphers.9 population with significant potential perina-
Since the definitions of “normal” amni- tal risk factors (patients undergoing antena-
otic fluid volume in the Chamberlain study tal testing) to define normal.
population were derived from a predomi- Subsequently, Moore and Cayle12 more
nantly a high-risk, post-dates population, rigorously defined the range and distribution
their definitions of normal may have limited of AFI measurements in a population of pa-
applicability in other populations. Neverthe- tients with normal pregnancies. This study
less, the MVP technique has the virtues of found that the mean AFI at term (40 weeks)
simplicity and reproducibility and a large is 12 cm. Hydramnios (95th percentile) was
volume of experience. It is probably the best 21 cm, and oligohydramnios (5th percentile)
technique to apply in estimating amniotic was 7 cm. However, significant variation in
fluid volume in the sacs of multifetal preg- AFI was noted across gestational age, with
nancies. the median AFI varying from approximately
15 cm in the midtrimester to less than 11 cm
after 42 weeks (Fig. 1). In contrast to the
Amniotic Fluid Index definition of oligohydramnios from the
In 1987 Phelan et al10 introduced the amni- work of Phelan et al (AFI = 5 cm), Moore
otic fluid index (AFI) to help identify which and Cayle found an AFI of 5 cm or less in
patients undergoing external breech version only 1% of normal term patients. Con-
were most likely to be successful. The AFI versely, more than 15% of the normal popu-
technique involves summing the deepest lation had an AFI of 18 cm or more. This
vertical pockets in each of four quadrants of study, derived from a population of average
the uterus. Uterine quadrants were defined risk, demonstrates the importance of estab-
sagittally by the linea nigra for right and left, lishing norms from a normal population.
and the umbilicus for upper and lower. Moore et al also evaluated the interob-
When obtaining AFI measurements, the ul- server and intraobserver variability ex-
trasound transducer should be positioned pected with multiple measurements by one
parallel to the patient’s sagittal plane and or more practitioners in the same patient; the
perpendicular to the coronal plane, not intertest variability was approximately 1
angled to accommodate the uterine fundal
curvature. The measurements in each pocket
TABLE 1. Diagnostic Categories of the
should be clear of umbilical cord and fetal Amniotic Fluid Index (AFI)
small parts. Very narrow slices (<5 mm in
width) of amniotic fluid should not be mea- Amniotic Fluid Percent of
sured. Studies by subsequent investigators Volume AFI Value Patients
have divided the upper and lower uterine Very low ⱕ5 cm 8%
quadrants at half of fundal height, regardless Low 5.1–8.0 cm 20%
of umbilical position, to allow calculation of Normal 8.1–18.0 cm 66%
High >18 cm 6%
the AFI in preterm pregnancies.
The original studies by Rutherford et al11 Adapted from Phelan et al.10
Sonographic Evaluation of Amniotic Fluid Volume 1029

FIG. 1. Normal values for the amniotic fluid index. (Adapted from Moore
and Cayle12 and Rutherford et al11).

cm.11–14 At low levels of AFI (<7 cm), 1 cm


represents more than a 15% variation in the
estimate. To optimize the accuracy of the
AFI in these instances, Moore 7 recom-
mended taking the average of three AFI
measurements.

Two-Diameter Pocket
The two-diameter pocket, the next variation
on semiquantitative measurements of amni-
otic fluid volume, was introduced by
Magann et al15 in 1992. This method multi-
plies the vertical depth of the MVP in the
uterus by its largest horizontal diameter.
Once again, the pocket should be free of um-
bilical cord or fetal extremities. Using this
technique, normal amniotic fluid volume
was defined as 15.1 to 50 cm2, hydramnios FIG. 2. Normal amniotic fluid volume in hu-
as more than 50 cm2, and oligohydramnios man pregnancy throughout gestation. (From
Brace and Wolf16).
as 0 to 15 cm2.
1030 SCHRIMMER AND MOORE

CORRELATION OF SONOGRAPHIC ies21 comparing the AFI and MVP with


AMNIOTIC FLUID ESTIMATES WITH volume estimates based on dye dilutional
ACTUAL VOLUME studies continue to suggest that linear mea-
The MVP, AFI, and two-diameter pocket all surements of fluid in the presence of poly-
represent attempts to apply a numeric value hydramnios or oligohydramnios are of more
to the volume of amniotic fluid found on ul- limited accuracy than what would be ideal.
trasound examination. Accurately estimat- On a logical basis, a one-dimensional MVP
ing volume in an irregularly shaped cavity measurement is unlikely to be as capable of
that contains a moving fetus is not easy, and representing a three-dimensional quantity
there has been much debate over the preci- such as amniotic fluid volume. Even the es-
sion of the available tests. In 1989, Brace timates using the dye dilution technique, an
and Wolf16 reported the normal values for invasive and theoretically accurate method
amniotic fluid volume during gestation. Us- of volume estimation, have been found to be
ing data from over 700 direct observations of limited reliability in predicting actual vol-
of amniotic fluid volume in human preg- ume in cases of oligohydramnios.16 This is
nancy, these investigators showed that am- probably due to loculation of fluid pockets,
niotic fluid volume rises progressively to a which leads to inadequate mixing/dilution
peak of 800 mL at 32 weeks and declines of the dye and variable volume measure-
into the term and postterm period. At term, ments. The problem of accurately measur-
normal amniotic fluid volume averages 700 ing volume with oligohydramnios is particu-
mL, with a surprisingly wide normal range larly troublesome, as overestimates in vol-
from 250 to 1,400 mL (Fig. 2). ume at a time of declining placental function
Using dye dilutional studies, Dildy et al17 may be falsely reassuring.
showed reasonable correlation between AFI Recently Magann et al20 performed a
and the term pregnancy volumes reported by large-scale reassessment of the longitudinal
Brace and Wolf. Injecting para-amino hip- changes in AFI, MVP, and the two-
purate (PAH) into the amniotic fluid, Dildy dimensional pocket techniques. They per-
developed an exponential curve relating am- formed a well-designed cross-sectional
niotic fluid volume and AFI (fluid volume = comparison of each of these modalities, re-
exp (5.19 + 0.093 – AFI). Using this method, cruiting 50 subjects into each week of gesta-
an AFI of 14 cm at term would correlate with tion. Only normal pregnancies were in-
a fluid volume of 660 mL, which is very cluded. Their results, which should be con-
close to the 700-mL volume proposed by sidered authoritative at this time, are shown
Brace and Wolf. Like other investigators,18 in Figures 3 and 4, as well as Tables 2, 3,
Dildy’s work also highlighted the problems and 4.
of measuring amniotic fluid when either As shown in Figure 4, the median and 5th
polyhydramnios or oligohydramnios was and 95th percentiles for the MVP are largely
present. With polyhydramnios the true vol- constant throughout the latter half of gesta-
ume was underestimated by 54%, and with tion, whereas the AFI curve (see Fig. 3)
oligohydramnios the volume was overesti- mimics the changes plotted by Brace and
mated by as much as 89%. Wolf from direct measurements. For refer-
Moore 19 compared the four-quadrant ence purposes, the MVP and AFI 5th, 50th,
AFI to the MVP technique and found the and 95th percentile values, in even centime-
AFI to be the better screening tool for iden- ters, are shown in Table 4. Since the intratest
tifying abnormal amniotic fluid volumes. accuracy of these measurements is ±1 cm,
These data have recently been challenged by the values for the boundaries of normal and
Magann et al,20 who recommend the MVP abnormal should be rounded to the nearest
technique, citing less false-positive diagno- even centimeter.
sis for oligohydramnios. Other recent stud- Clearly, the research cited above demon-
Sonographic Evaluation of Amniotic Fluid Volume 1031

TABLE 2. Amniotic Fluid Index: Normal TABLE 3. Maximum Vertical Pocket:


Values in Pregnancy Normal Values in Pregnancy
Percentile Percentile
(Values in Centimeters)
Week 5th 50th 95th
Week 5th 50th 95th
16 2 4 6
16 3 6 9 17 3 4 6
17 3 6 9 18 3 4 6
18 4 7 10 19 3 4 7
19 4 7 10 20 3 4 7
20 5 8 11 21 3 5 7
21 5 9 12 22 3 5 7
22 6 9 13 23 3 5 7
23 6 10 14 24 3 5 7
24 6 11 15 25 3 5 7
25 7 11 16 26 3 5 7
26 7 12 17 27 3 5 7
27 7 13 18 28 3 5 7
28 8 13 19 29 3 5 7
29 8 13 19 30 3 5 7
30 8 14 20 31 3 5 7
31 8 14 20 32 3 5 7
32 8 14 21 33 3 5 7
33 7 13 21 34 3 5 7
34 7 13 20 35 3 5 7
35 7 12 20 36 3 5 7
36 6 12 19 37 3 5 7
37 6 11 19 38 2 4 7
38 6 10 18 39 2 4 7
39 5 9 17 40 2 4 6
40 5 9 16 41 2 4 6
41 4 8 15
Values in cm.
Values in cm. Adapted from Magann et al.20
Adapted from Magann et al.20

strates the limitations of all techniques in- tive NSTs, fetal heart rate decelerations, ce-
volving two-dimensional estimates of amni- sarean section for fetal distress, and low Ap-
otic fluid volume. In present practice, the gar scores. With an AFI of less than 5.0 cm,
AFI remains the most accepted method for the risk of an Apgar of less than 7 at 5 min-
assessing fluid status in singleton gestations utes increased dramatically (relative risk
and the one most likely to reflect actual vol- 6.73, 95% confidence interval 1.70–26.66),
ume. as did the risk of cesarean delivery for fetal
distress (relative risk 4.81, 95% confidence
CORRELATION OF AMNIOTIC FLUID interval 1.32–17.54). In the meta-analysis
ESTIMATES WITH PERINATAL published by Chauhan et al in 1999, the au-
OUTCOME thors focused on perinatal outcome and AFI
In 1987, the same year that Phelan et al10 in the antepartum and intrapartum periods.23
originally described the AFI, Rutherford et Combining 18 selected studies that encom-
al22 also published data on 330 high-risk passed 10,551 patients, they found that both
pregnancies and the relationship between antepartum and intrapartum AFI values of
AFI and perinatal morbidity. In their work, less than 5.0 cm were associated with an in-
they reported an inverse relationship be- creased risk of cesarean delivery for fetal
tween AFI and meconium staining, nonreac- distress, as compared with the group with an
1032 SCHRIMMER AND MOORE

41

2
4
6

15
8
AFI of more than 5.0 cm (Table 5). Similar
correlations were found with regard to

40

2
4
6

5
9
16
5-minute Apgar scores of less than 7 (see
Table 5).
39 Interestingly, Rutherford et al22 raised the

2
4
7

5
9
17
question of the possibility of “treatment

18
38

2
4
7

6
10
paradox” with regard to antenatal testing.
The paradox, they suggest, is the concept of
37

11
19
3
5
7

6
the diagnostic test (AFI) leading to a diag-
nosis (oligohydramnios) that leads to inter-
36

12
19
3
5
7

6
vention (induction) resulting in adverse out-
Normal Values for the Amniotic Fluid Index and Maximum Vertical Pocket in Normal Pregnancy

come (cesarean delivery). This in turn raises


35

12
20
3
5
7

the outcome question of neonatal acidosis


and its association with oligohydramnios.
34

13
20
3
5
7

Only one study from the combined 18 at-


tempted to assess the frequency of neonatal
33

13
21
3
5
7

acidosis and predelivery AFI. Poor correla-


tion was found, though the study lacked suf-
32

14
21
3
5
7

ficient power to conclusively answer this


important question. Because of the lack of
31

14
20
3
5
7

data actually correlating neonatal acidosis


with a low AFI, the authors were appropri-
30

3
5
7

8
14
20

ately reluctant to make specific recommen-


dations regarding intervention based on a
29

3
5
7

8
13
19

low AFI alone.


Casey et al24 also studied the relationship
28

3
5
7

8
13
19

of adverse pregnancy outcome to antepar-


tum oligohydramnios (AFI < 5.0 cm) at
13
18
27

3
5
7

Parkland Hospital. A total of 6,423 pregnan-


cies were evaluated, 2.3% (147) of which
26

12
17
3
5
7

had an AFI of less than 5.0 cm. In the group


with oligohydramnios by this definition,
25

11
16
3
5
7

significant increases in induction of labor,


meconium aspiration syndrome, Apgar less
24

11
15
3
5
7

than 3 at 5 minutes, and neonatal deaths


were noted. The authors concluded that an-
23

10
14
3
5
7

tepartum oligohydramnios is associated


with increased perinatal morbidity and mor-
22

9
13
3
5
7

tality (Table 6). In contrast to previous stud-


ies, the work of Casey et al did not show a
Maximum vertical pocket (cm)
21

3
5
7

5
9
12

significant increase in cesarean deliveries,


Amniotic fluid index (cm)

nor in fetal acidemia, defined as umbilical


Adapted from Magann et al.20
20

3
4
7

5
8
11

artery pH less than 7.0 (see Table 6).


Despite the documented increase in peri-
50th percentile
95th percentile

50th percentile
95th percentile
5th percentile

5th percentile

natal morbidity and mortality with antepar-


tum oligohydramnios, Casey et al concluded
TABLE 4.

Values in cm.
Gestation
Week of

that their work, as well as the collective re-


ports in the literature, did not “necessarily
prove that antepartum oligohydramnios re-
Sonographic Evaluation of Amniotic Fluid Volume 1033

FIG. 3. Normal values for the amniotic fluid index during pregnancy.
(Adapted from Magann et al20).

quires intervention.” Citing a power calcu- timating amniotic fluid within the uterus.
lation that would require more than 2 million Evaluating 155 term gestations, Bianco et
subjects to demonstrate a 20% difference in al25 reported a significant decrease in the
the stillborn rate with oligohydramnios, the measured AFI and a significant increase in
authors concluded that the benefit of inter- the diagnosis of oligohydramnios when
vention for antepartum oligohydramnios re- color Doppler was used. Presumably this
mains questionable. Even though the associ- was associated with exclusion of potentially
ated increase in morbidity and mortality measurable amniotic fluid pockets when
with a low AFI appears clear, a prospective color Doppler showed them to be filled with
study is needed to demonstrate that routine umbilical cord.
induction of labor reduces overall maternal Magann et al26 showed that the addition
and perinatal mortality and morbidity.
of color Doppler reduced the measured AFI
and MVP by 20% compared with standard
Color Flow Doppler and gray-scale ultrasound techniques. However,
Amniotic Fluid Evaluation comparative measurements of AFI, MVP,
The addition of color flow Doppler capabil- and dye dilutional volumes showed that
ity to obstetrical ultrasound units, which ef- color Doppler led to the overdiagnosis of
fectively illuminates loops of umbilical cord oligohydramnios. Disturbingly, 9 of 42
within amniotic fluid pockets, has compli- women (21%) with normal dye dilutional
cated the question of accuracy of AFI in es- volumes were incorrectly labeled as having
1034 SCHRIMMER AND MOORE

FIG. 4. Normal values for the maximum vertical pocket during preg-
nancy. (Adapted from Magann et al20).

oligohydramnios when color Doppler was has led to a marked increase in the frequency
used to measure the AFI. of multifetal gestations in the United States.
The question remains: should color This increase in multiples, combined with
Doppler be used when identifying pockets the high-risk nature of these pregnancies,
of amniotic fluid to be included in the AFI has intensified the need for accurate esti-
measurements? Since the original studies
and the more recent nomograms correlating
AFI and outcome were not conducted using TABLE 5. Correlation of Amniotic Fluid
color Doppler, and since color Doppler does Index and Perinatal Morbidity
not improve the diagnosis of abnormal am- 95%
niotic fluid volume, it appears that standard Relative Confidence
ultrasound techniques can be used with rela- Antepartum AFI <5.0 cm Risk* Interval
tive confidence. Nevertheless, amniotic Risk of cesarean delivery
fluid pockets should be scrutinized for evi- for fetal distress 2.22 1.47–3.37
dence of umbilical cord, and only cord-free Risk of Apgar score <7
pockets should be measured. at 5 min 5.16 2.36–11.29
Intrapartum AFI <5.0 cm
Risk of cesarean delivery
Amniotic Fluid Volume in for fetal distress 1.69 1.12–2.57
Multiple Gestations Risk of Apgar score <7 1.78 1.18–2.67
The contemporary increase in the use of as- * Pooled relative risks from meta-analysis.
sisted reproductive technology techniques Adapted from Chauhan et al.23
Sonographic Evaluation of Amniotic Fluid Volume 1035

TABLE 6. Pregnancy Outcomes With Antepartum Oligohydramnios


AFI ≤ 5.0 cm AFI > 5.0 cm Statistical
Outcome (n = 147) (n = 6,276) Significance
Induction of labor 61 (42%) 1116 (22%) P < 0.001
Cesarean delivery
Total 47 (32%) 1802 (29%) P = 0.38
Dystocia 8 (5%) 369 (6%) P = 0.82
Fetal distress 7 (5%) 181 (3%) P = 0.18
Apgar score ⱕ3 at 5 min 9 (6%) 28 (0.5%) P < 0.001
Meconium aspiration syndrome 2 (1.4%) 6 (0.1%) P < 0.001
Stillbirth 2 (1.4%) 19 (0.3%) P < 0.03
Umbilical artery pH ⱕ7.0 2 (1.4%) 29 (0.5%) P = 0.10
AFI, amniotic fluid index.
Adapted from Casey et al.24

mates of amniotic fluid volume. Moreover, curacy of prediction by all measurement


estimating amniotic fluid volume in multife- techniques fell to 3–57%. To achieve a posi-
tal pregnancies is particularly challenging tive predictive value of 75% in the oligohy-
since the cavity occupied by each individual dramnios group, a false-positive rate of 55%
fetus is irregular and the location of the in- would be incurred. Thus, as is true with
tervening membrane may be difficult to singleton gestations, the accumulated litera-
identify. To take into account these issues, a ture confirms the difficulty in accurately
number of methodologies have been pro- identifying oligohydramnios with ultra-
posed. sound in multiple gestation.30 Given the
Magann et al27 evaluated amniotic fluid convoluted position of the dividing mem-
volume in 45 diamniotic gestations using branes, combined with frequently changing
dye injections into each individual sac. The fetal position and pressure/volume differ-
AFI, MVP, and two-diameter pockets were ences within each sac, it is logical that a
measured in each case for comparison. The four-quadrant approach based on a series of
AFI was measured by dividing each amni- right-angle measurements may be even less
otic sac into quadrants and summing the to- accurate in multiple gestations than with
tal for each sac to achieve the AFI. This tech- singletons. Because of their relative simplic-
nique of measuring the AFI, which attempts ity, assessing amniotic fluid in multifetal
to take into account the position of the divid- gestations using either the MVP or the two-
ing membrane, appeared to be more accurate diameter technique will probably provide
than simply measuring the four quadrants of the best accuracy and reproducibility. Oli-
the entire uterus and ignoring the dividing gohydramnios should be suspected if no
membrane.28,29 When amniotic fluid was in pocket of amniotic fluid measuring at least 3
the normal range, all three measurement cm in depth can be identified in an indi-
techniques were found to be approximately vidual sac. Hydramnios should be suspected
equivalent (81–98% accurate) in predicting if any single pocket exceeds 8 cm.
volume. Although these investigators fa-
vored the two-diameter pocket technique,
the differences in accuracy, compared with Three-Dimensional
dye dilution, were not statistically signifi- Ultrasound
cant. Contemporary estimation of amniotic fluid
When the amniotic fluid volume esti- volume remains a crude process in the sense
mated by the dye infusion technique was that existing techniques attempt to correlate
less than 500 mL (oligohydramnios), the ac- two-dimensional (linear) measurements
1036 SCHRIMMER AND MOORE

with a three-dimensional quantity. Dye dilu- found similar results, with a 1.7% chance in
tional studies remain time-consuming and the same gestational age group with an AFI
invasive, and both methods have their limi- of more than 8 cm. In cases with borderline
tations with regard to accuracy. Over the AFI values (5.1–8.0 cm), Lagrew et al34 and
past 5 years, three-dimensional ultrasound Wing et al35 reported oligohydramnios risks
has undergone progressive advancement, of 5% and 18%, respectively.
and one of its reported uses is that of volume Beyond 41 weeks of gestation, Marks and
calculation.31 While the majority of early Divon36 reported a potential decline in the
work has focused on fetal volume (ie, esti- AFI of 25% per week. This rate of change is
mated fetal weight), there are limited reports similar to that reported from direct measure-
in the literature of estimates of amniotic ments by Brace and Wolf16 as well as the
fluid volume. Mann and Grover32,33 have decreases in AFI reported by Lagrew et al34
reported the use of an ultrasound instrument and Wing et al.35 Based on the above, fluid
designed to measure adult bladder volume evaluation can be done weekly in pregnan-
(BVI 2500, Diagnostic Ultrasound Corp., cies less than 41 weeks’ gestation if the AFI
Redmond, WA), which uses a rotating is more than 8 cm. In pregnancies beyond 41
2-MHz transducer and computer integration weeks, or with an AFI of less than 8 cm,
to calculate three-dimensional volume. twice-weekly evaluation is recommended.
Their initial work showed an average three-
dimensional volume of 215 ± 134 (range
23–497) cm3 in 14 term pregnancies, 36 Conclusions
to 42 weeks. Three-dimensional volume Quantification of amniotic fluid volume has
correlated well with both AFI and two- become an important component of antepar-
dimensional area. One centimeter of AFI tum and intrapartum care. It is also consid-
was reported as equivalent to a volume of 30 ered a standard part of the routine ultrasound
cm3, suggesting that the four-quadrant AFI examination, as well as a useful tool in pre-
measurement accounts for only about 50% natal diagnosis. The diagnosis of oligohy-
of amniotic fluid volume. More recently, the dramnios has clearly been shown to be asso-
same authors have published early work on ciated with increased perinatal morbidity.
normal gestational values for BVI- The treatment of oligohydramnios in labor
determined three-dimensional amniotic via amnioinfusion has also been shown to be
fluid volume.33 Thus, three-dimensional ul- useful. While further research is needed, the
trasound may hold some promise for evalu- four-quadrant amniotic fluid index currently
ation of amniotic fluid volume, though remains the most widely applied and most
clearly more research is required. accurate method to measure fluid volume in
the singleton gestation. The average of three
AFI measurements, particularly with sus-
Frequency of Amniotic Fluid pected oligohydramnios, is recommended
Evaluation for best accuracy. For multiple gestations,
An important consideration with regard to measuring the single deepest amniotic fluid
amniotic fluid volume is the recommended pocket in each sac provides the simplest and
frequency of evaluation. Lagrew et al,34 in a most reproducible results.
review of more than 10,000 AFI measure- The addition of color Doppler has not
ments in a single institution, showed that been shown to be useful and in fact may be
amniotic fluid index values obtained before disadvantageous in identifying pregnancies
41 weeks’ gestation and measuring more with oligohydramnios. For antepartum test-
than 8 cm were associated with a less than ing, measuring the AFI on a weekly basis is
0.5% chance of developing oligohydram- sufficient if the AFI is above 7.5 cm and the
nios within the next 4 days. Wing et al35 pregnancy is less than 41 weeks’ gestation.
Sonographic Evaluation of Amniotic Fluid Volume 1037

After 41 weeks, or if an AFI of less than 7.5 Limitations of using maximum vertical
cm is measured, the interval should be short- pocket and other sonographic evaluations of
ened to twice weekly. Future research amniotic fluid volume to predict fetal
should focus on three-dimensional ultra- growth: technical or physiologic. Am J Ob-
sound and techniques to measure fetal uri- stet Gynecol. 1986;155:154–158.
9. Goldstein RB, Filly RA. Sonographic esti-
nary output more reliably. Despite short-
mation of amniotic fluid volume. Subjective
comings in current methodologies, estimat- assessment versus pocket measurements. J
ing amniotic fluid volume improves fetal Ultrasound Med. 1988;7:363–369.
outcome overall. Recognizing that the 10. Phelan JP, Ahn MO, Smith CV, et al. Am-
aquatic environment surrounding the fetus niotic fluid index measurements during
is, in great measure, a reflection of fetal sta- pregnancy. J Reprod Med. 1987;32:601–
tus, helps significantly in deciding on man- 604.
agement plans for the pregnancy at risk. 11. Rutherford SE, Smith CV, Phelan JP, et al.
Four-quadrant assessment of amniotic fluid
volume. Interobserver and intraobserver
variation. J Reprod Med. 1987;32:587–589.
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