Amnioinfusion: Indications and outcome

Catherine Spong MD, Michael G Ross, Charles J lockwood, Vanessa A Barss

Last literature review version 16.1: January 2008 | This topic last updated: February 6, 2008 (More)

INTRODUCTION Amnioinfusion refers to the instillation of fluid into the amniotic cavity. This procedure is typically performed during labor through an intrauterine catheter introduced transcervically after rupture of the fetal membranes. Alternatively, fluid can be infused through a needle transabdominally, the reverse process of amniocentesis. (See "Amniocentesis: Technique and complications"). Amniotic fluid is primarily the product of fetal urine and lung liquid, and is resorbed via fetal swallowing and intramembranous flow across the chorioamnion. The relative contribution of each route of fluid exchange changes across gestation. (See "Physiology of amniotic fluid volume regulation"). The fluid surrounding the fetus serves a variety of functions:

It helps to protect the fetus from trauma to the maternal abdomen It cushions the umbilical cord from compression between the fetus and uterus It has antibacterial properties that provide some protection from infection It serves as a reservoir of fluid and nutrients for the fetus It provides the necessary fluid, space, and growth factors to permit normal development of the fetal lungs and musculoskeletal and gastrointestinal systems.

Therefore, a severe reduction or absence of amniotic fluid can increase the risk of certain pregnancy complications, including fetal heart rate (FHR) decelerations from cord compression during labor, fetal acidosis, and cesarean delivery. The indications and outcome of amnioinfusion will be reviewed here. The technical aspects of the procedure are discussed separately. (See "Amnioinfusion: Technique"). CRITERIA FOR PATIENT SELECTION Amnioinfusion is considered for pregnancies complicated by oligohydramnios when the physician feels that augmenting the amniotic fluid volume will provide diagnostic or therapeutic benefit (see below). Placenta previa is the major contraindication to transcervical amnioinfusion. The transabdominal route is relatively contraindicated if the needle must traverse an anterior placenta, especially in isoimmunized women.

POTENTIAL

INDICATIONS Amnioinfusion

can

be

prophylactic,

diagnostic,

or

therapeutic intervention. Potential indications include:

Prevention and treatment of repetitive variable decelerations [1] Prevention of meconium aspiration [2,3] Reduction in cesarean deliveries performed for repetitive FHR decelerations [4] Improved visualization during sonographic or fetoscopic assessment of fetal anomalies [5-7] Treatment or prevention of chorioamnionitis in premature rupture of membranes [8] As an aid to external cephalic version [9] .

To eliminate repetitive variable decelerations The most effective use of amnioinfusion is to prevent or relieve umbilical cord compression during labor. Two meta-analyses of randomized trials compared amnioinfusion to no amnioinfusion in women with fetuses at risk of umbilical cord compression because of oligohydramnios or variable FHR decelerations [10,11] . Amnioinfusion was associated with a 50 to 75 percent reduction in FHR abnormalities compared to controls. However, upon more detailed analysis, this benefit was confined to women receiving a therapeutic procedure after the occurrence of FHR abnormalities; there was no advantage to routine prophylactic amnioinfusion when the tracing was normal [12] . Thus, therapeutic amnioinfusion is an effective method for eliminating repetitive variable decelerations in labor. The potential benefits of this intervention would be a reduction in the number of cesarean deliveries performed because of a nonreassuring FHR tracing and, possibly, improved neonatal outcome, which are discussed below. Prophylactic amnioinfusion does not appear to confer any advantage over therapeutic amnioinfusion after the development of an abnormal FHR pattern. Indeed, prophylactic amnioinfusion performed routinely in women with oligohydramnios to prevent FHR abnormalities would result in overtreatment of 80 percent of patients as only 20 percent of laboring term patients with oligohydramnios develop these abnormalities [13] . To reduce need for cesarean delivery Amnioinfusion should result in a reduction in the rate of cesarean delivery for persistent FHR abnormalities if the procedure lowers the frequency of cord compression leading to these abnormalities. One systematic review of the effect of amnioinfusion on risk of cesarean delivery in women with meconium stained amniotic fluid found no significant reduction compared to no amnioinfusion (RR 0.89, 95%CI 0.73-1.10) [14] , while other systematic reviews in populations of laboring women at risk of cord compression reported amnioinfusion was associated with a 65 to 80 percent reduction in the rate of cesarean delivery for FHR abnormalities [10,11] . These differences may be due to disparities in the indications for and timing of amnioinfusion among trials, as well as differences in the interpretation of FHR tracings and threshold for intervention for FHR abnormalities. As described above, studies that showed a benefit primarily involved women who underwent amnioinfusion upon initiation of FHR changes; there

was no advantage to routine amnioinfusion among women with oligohydramnios or meconium stained amniotic fluid in the absence of FHR decelerations [12,15] . There are also concerns [16] about the inclusion and exclusion criteria for studies of the meta-analysis [14] itself. To prevent meconium aspiration Amnioinfusion has been advocated for women laboring with thick meconium to reduce the incidence of meconium aspiration and meconium below the vocal cords. If amnioinfusion reduces meconium aspiration syndrome, the mechanism likely derives from two factors: (1) dilution of thick clumps of meconium and (2) elimination of fetal cord compression, which may cause fetal hypoxemia [17] . Fetal hypoxemia associated with FHR decelerations provokes gasping, with aspiration of meconium containing amniotic fluid. The hypoxemic fetus who has aspirated meconium is more likely to develop meconium aspiration syndrome than a normoxic fetus. A systematic review found that amnioinfusion of pregnancies complicated by meconium stained amniotic fluid was associated with a significant reduction in observation of meconium below the vocal cords compared to no amnioinfusion (RR 0.29, 95% CI 0.14-0.57, 10 trials including approximately 3000 pregnancies) [14] . However, amnioinfusion did not significantly reduce the risk of meconium aspiration syndrome compared to no amnioinfusion (RR 0.59, 95% CI 0.28-1.25, 12 trials including approximately 4000 pregnancies). Continuous electronic fetal heart rate monitoring was used for fetal surveillance. These results were limited by large differences among the trials, as well as the inclusion and exclusion criteria of the meta-analysis itself [16] . Most studies did not indicate if oligohydramnios or FHR decelerations were present at the time of amnioinfusion, nor did the authors evaluate whether replacement of amniotic fluid, rather than dilution of meconium, was the principle therapeutic intervention. Furthermore, a significant proportion of infants with meconium-stained amniotic fluid already have meconium within the trachea or bronchioles before meconium passage has been noted by the obstetrical provider, and in some cases meconium aspiration may have even predated labor [18] . (See "Clinical features and diagnosis of meconium aspiration syndrome" and see "Management of meconium aspiration syndrome"). To improve neonatal outcome The systematic review described above also reported the effect of amnioinfusion on the risk of five-minute Apgar score less than 7 and neonatal acidosis (umbilical arterial pH <7.20) [14] . Amnioinfusion did not significantly reduce the risk of low Apgar score (RR 0.90, 95% CI 0.58-1.41), but was associated with a significant reduction in risk of neonatal acidosis (RR 0.62, 95%CI 0.40-0.96). The specific fetal groups that benefited from amnioinfusion were not clearly defined, but, as described above, patients with moderate to thick meconium and repetitive variable FHR decelerations during labor appear most likely to benefit. To visualize the fetus better Diagnostic amnioinfusion (most often performed

transabdominally) may facilitate sonographic fetal imaging and increase diagnostic precision in the setting of severe oligohydramnios. As an example, a review of patients with unexplained

midtrimester oligohydramnios who underwent diagnostic antenatal amnioinfusion found that the overall rate of adequate visualization of fetal structures improved from 51 to 77 percent after amnioinfusion [19] . There was also an improvement (from 12 to 31 percent) in the identification of associated anomalies in fetuses having preinfusion-identified obstructive uropathy. A second study reported that information obtained at amnioinfusion led to a change of etiologic diagnosis in 13 percent of cases [5] . To facilitate external cephalic version Transabdominal amnioinfusion has been used to facilitate external cephalic version. In one study, version after amnioinfusion was successful in a series of six patients who had previously failed the procedure [9] . In another similar series, version after amnioinfusion was unsuccessful in all seven patients [20] . Large randomized studies are needed to define the risks and true success rate of this procedure. We feel there are inadequate data to recommend amnioinfusion for this indication. (See "External cephalic version"). For management of PPROM The effects of amnioinfusion on pregnancy outcome in preterm premature rupture of membranes (PPROM) are unclear [21] . Purported benefits include prolongation of the latency period and prevention of pulmonary hypoplasia and infection. Observational studies have provided some support for this theory. One such series of amnioinfusion in 49 women with PPROM reported that patients with persistent oligohydramnios despite the procedure had a significantly shorter interval to delivery, lower neonatal survival, and higher rates of pulmonary hypoplasia and abnormal neurologic outcomes than women in whom amnioinfusion was not necessary or was successful [22] . Similar results were obtained in other observational reports [8,23-26] . In addition, a randomized trial including 34 women reported treatment with transabdominal amnioinfusion after PPROM resulted in significant prolongation of pregnancy and better neonatal outcomes compared to standard expectant management [27] . To reduce infection Antibiotics have been administered either prophylactically or therapeutically during amnioinfusion [28,29] . The only randomized trial of amnioinfusion with an antibiotic solution (cefazolin 1 g per 1000 mL) or normal saline in laboring women with meconium stained amniotic fluid found no differences in the rate of clinically diagnosed chorioamnionitis, endometritis, or neonatal infection [30] . There is no evidence of an advantage of antibiotic-containing amnioinfusion versus parenteral antibiotics [29] . SUMMARY AND RECOMMENDATIONS

Amnioinfusion (instillation of fluid into the amniotic cavity via a catheter) is performed in pregnancies complicated by oligohydramnios when the clinician believes that augmenting the amniotic fluid volume will provide diagnostic or therapeutic benefit. (See "Introduction" above and see "Criteria for patient selection" above).

Amnioinfusion is an effective method for eliminating repetitive variable decelerations in laboring patients. Prophylactic amnioinfusion confers no advantage over therapeutic

amnioinfusion after the development of an abnormal fetal heart rate pattern. Therefore, in women with oligohydramnios, we suggest not performing routine amnioinfusion (Grade 2B). (See "To eliminate repetitive variable decelerations" above).

Routine amnioinfusion does not reduce the rate of cesarean delivery. Therapeutic amnioinfusion performed in women with recurrent variable decelerations does appear to reduce the number of cesarean deliveries performed for fetal heart rate abnormalities. However, this benefit may not apply to centers that use stringent criteria, such as documentation of a low fetal pH, prior to proceeding to cesarean delivery. We suggest amnioinfusion in women with recurrent variable decelerations if other measures to ascertain fetal well-being (eg, scalp sampling, fetal electrocardiogram) are unavailable before resorting to cesarean delivery (Grade 2C). Additional factors that should be considered include labor stage and progress and underlying maternal and fetal conditions. (See "To reduce need for cesarean delivery" above and see "To eliminate repetitive variable decelerations" above).

There is insufficient evidence that amnioinfusion reduces meconium-related neonatal morbidity, therefore we do not suggest amnioinfusion for women with meconium stained amniotic fluid (Grade 2B). (See "To prevent meconium aspiration" above).

In the setting of severe oligohydramnios, diagnostic amnioinfusion (most often performed transabdominally) can facilitate sonographic fetal imaging of congenital anomalies. (See "To visualize the fetus better" above).

There is insufficient evidence that amnioinfusion facilitates external cephalic version (see "To facilitate external cephalic version" above).

There is insufficient evidence for either prophylactic amnioinfusion or amnioinfusion with antibiotics to improve pregnancy outcome in women with premature rupture of membranes. (See "For management of PPROM" above and see "To reduce infection" above).