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# GRF20401
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-
1026
Sonographic Evaluation of Amniotic Fluid Volume 1027
FIG. 1. Normal values for the amniotic fluid index. (Adapted from Moore
and Cayle12 and Rutherford et al11).
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
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
12
20
3
5
7
13
20
3
5
7
13
21
3
5
7
14
21
3
5
7
14
20
3
5
7
3
5
7
8
14
20
3
5
7
8
13
19
3
5
7
8
13
19
3
5
7
12
17
3
5
7
11
16
3
5
7
11
15
3
5
7
10
14
3
5
7
9
13
3
5
7
3
5
7
5
9
12
3
4
7
5
8
11
50th percentile
95th percentile
5th percentile
5th percentile
Values in cm.
Gestation
Week of
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
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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