Ultrasound Obstet Gynecol 2017; 49: 442–449

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.15929

Oligohydramnios in complicated and uncomplicated

pregnancy: a systematic review and meta-analysis
N. RABIE1 , E. MAGANN1 , S. STEELMAN1 and S. OUNPRASEUTH2
1
Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 2 Department of
Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA

K E Y W O R D S: amniotic fluid; amniotic fluid index; oligohydramnios; pregnancy; ultrasound

ABSTRACT Conclusions This review helps to delineate which adverse

Objective To evaluate adverse pregnancy outcomes in
singleton pregnancies diagnosed with oligohydramnios
through a systematic review and meta-analysis of
controlled trials.
Methods We searched electronic databases via OVID,
EBSCO, Web of Science, Google Scholar and others from
1980 to 2015. Prospective and retrospective studies with a
control group were included. Two authors independently
reviewed the abstracts from the literature search.
Inclusion criteria were: studies in English, singleton
pregnancy, normal fetal anatomy, intact membranes
and oligohydramnios determined by the amniotic fluid
index (AFI) technique. We stratified the meta-analysis
into two groups according to risk: high risk including
studies of oligohydramnios with comorbid conditions (e.g.
hypertension) and low risk including studies of isolated
oligohydramnios.
Results Fifteen trials met the inclusion criteria. Nine were
high-risk and six were low-risk studies, including 8067
and 27 526 women, respectively. Compared with women
with normal AFI, those with isolated oligohydramnios
had significantly higher rates of an infant with meconium
aspiration syndrome (relative risk (RR), 2.83; 95%
CI, 1.38–5.77), Cesarean delivery for fetal distress
(RR, 2.16; 95% CI, 1.64–2.85) and admission to
the neonatal intensive care unit (NICU) (RR, 1.71;
95% CI, 1.20–2.42). Patients with oligohydramnios
and comorbidities were more likely to have an infant
with low birth weight (RR, 2.35; 95% CI, 1.27–4.34).
However, rates of 5-min Apgar score < 7 (RR, 1.85; 95%
CI, 0.69–4.96), NICU admission (RR, 2.09; 95% CI,
0.80–5.45), meconium-stained amniotic fluid (RR, 1.32;
95% CI, 0.62–2.81) and Cesarean delivery for fetal
distress (RR, 1.65; 95% CI, 0.81–3.36) were similar
to those for women with normal AFI. Stillbirth rates were
too low to analyze in the meta-analysis.
outcomes are increased with oligohydramnios in low-risk
pregnancy (NICU admission, Cesarean delivery for fetal
distress and meconium aspiration syndrome), but does
not provide enough data to determine the optimal timing
of delivery in such cases. Oligohydramnios in complicated
pregnancy is associated with an increased risk of delivery
of an infant with low birth weight, but this may be
confounded by the comorbid condition. Therefore, in
high-risk pregnancy, management should be dictated
by the comorbid condition and not the presence of
oligohydramnios. Copyright © 2016 ISUOG. Published
by John Wiley & Sons Ltd.
INTRODUCTION
Amniotic fluid is one of the first visible signs of
pregnancy1,2 . It is critical for a healthy pregnancy, acting
as a physical cushion and promoting expansion and
development of the fetal lungs. Amniotic fluid volume
varies with gestational age, averaging 400 mL at term3,4 .
Assessing amniotic fluid volume is an important part of
obstetric management.
The gold standard for measuring amniotic fluid
volume is the invasive dye dilution technique5 . Validated
non-invasive methods include the four-quadrant amniotic
fluid index (AFI), single deepest pocket (SDP) and
two-diameter pocket6,7 . Oligohydramnios can be defined
as amniotic fluid volume < 5% for gestational age,
AFI < 5 cm or maximal deepest pocket < 2 cm. SDP
is the best method for diagnosing oligohydramnios8 ;
however, most studies evaluating adverse outcomes utilize
AFI. Regardless of the method used, the finding of
oligohydramnios is not normal.
Oligohydramnios can be found in an otherwise
uncomplicated pregnancy or as an additional finding
in a complicated pregnancy (hypertensive disorders,
decreased fetal movement). Many studies have found

Correspondence to: Dr E. Magann, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, 4301 W.
Markham, #518, Little Rock, AR 72205, USA (e-mail: efmagann@uams.edu)
Accepted: 24 March 2016

Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. SYSTEMATIC REVIEW
Oligohydramnios in complicated and uncomplicated pregnancy
that oligohydramnios in the setting of a complicated
pregnancy is associated with an increased risk of
adverse outcome, including admission to the neonatal
intensive care unit (NICU), meconium staining of amniotic
fluid, meconium aspiration syndrome (MAS), Cesarean
delivery, 5-min Apgar score < 7, umbilical cord blood
pH < 7.10, low birth weight (small-for-gestational age)
and respiratory distress syndrome9–17 . However, there
are conflicting data on the significance of isolated
oligohydramnios18–23 .
The diagnosis of oligohydramnios alters pregnancy
management and may be an indication for delivery.
Depending on the gestational age, induction may increase
the risk of Cesarean delivery and the risks associated
with late preterm/early term deliveries. Therefore, it is
important to delineate the risks of oligohydramnios and
the benefits of prompt delivery.
In 1999, Chauhan et al. published a meta-analysis of
studies looking at the perinatal outcomes of pregnancies
with an antepartum or intrapartum AFI of > 5.0 cm
compared with an AFI of ≤ 5.0 cm24 . The purpose of our
study was to expand the original study of Chauhan et al.24
with a more recent comprehensive literature review.
This study is a systematic review and meta-analysis of
all controlled studies examining oligohydramnios and
adverse perinatal outcomes, stratified by complicated and
uncomplicated pregnancies.
METHODS
Literature search
This study was performed following the Preferred
Reporting Items for Systematic reviews and MetaAnalyses
(PRISMA) statement25 . Prior to data abstraction, the
protocol was registered with PROSPERO (registration
no. CRD42015024566)26 .
The clinical question focused on human studies
published between 1980 and 2015 in English. A medical
librarian conducted all searches. A MEDLINE search
utilized medical subject headings and advanced, truncated
text word strings plus compilations of synonymous terms.
Final strategies were revised to utilize specific controlled
vocabularies and/or platform-unique search techniques
for each additional database. All searches were conducted
between January and February 2015. Databases searched
through OVID included The Cochrane Collection, MED-
LINE and International Pharmaceutical Abstracts. Science
Citation Index and Social Sciences Citation Index were
searched via Web of Science. The EBSCO platform was
used to search Cumulative Index of Nursing and Allied
Health Literature, Health Source: Nursing/Academic Edi-
tion, Academic Search Elite, SocINDEX, PsycINFO and
over 20 other databases. Conference proceedings were
identified via ProceedingsFirst and PapersFirst. Clinical
trials registries examined were the US ClinicalTrials.gov,
European Union Clinical Trials Registry, World Health
Organization’s International Clinical Trials Registry Plat-
form and BioMed Central’s ISRCTN Registry of Current
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
443
Records included from
databases
(n = 3444)
Duplicates
(n = 776)
Records remaining after
duplicates excluded
(n = 2668)
Records excluded by abstract
(n = 2577)
Full-text articles screened for
eligibility
(n = 91)
Full-text articles excluded
(n = 73)
Articles included for qualitative
synthesis
(n = 18)
Articles included in
meta-analysis
(n = 15)
Figure 1 Flowchart showing selection of studies for systematic
review and meta-analysis.
Controlled Trials. Additional catalog, biomedical and
gray literature resources included the National Library of
Medicine Catalog, the World Health Organization’s Vir-
tual Health Library (African Index Medicus and LILACS),
OpenGrey.EU, the New York Academy of Medicine’s
Grey Literature Databases/Catalog and Google Scholar.
A complete list of databases searched is available
upon request.
This systematic review involved three main concepts
and various search strings were designed for the
MEDLINE search. Concept 1 was amniotic fluid levels,
Concept 2 was pregnancy outcomes and Concept 3 was
the issue of fetal viability in the second or third trimesters.
Medical subject headings for all pertinent concepts were
identified and combined in unique patterns with text
word and adjacency commands. Concept 1 required use
of headings for oligohydramnios or polyhydramnios,
both of which, by definition, indicate problems with
amniotic fluid levels. These were used with ‘OR’ for
text word searches for these terms. The heading for
amniotic fluid was used with ‘AND’ ultrasonography,
prenatal as a diagnostic tool plus the amniotic fluid
heading was utilized in adjacency strings to identify
articles discussing diagnostic or measurement issues with
the fluid levels. The amniotic fluid term, in addition
to ‘single pocket’ or ‘maximum deep pocket’ phrases,
was combined with adjacency strings at the text word
level. All four of the amniotic fluid strings were used
Ultrasound Obstet Gynecol 2017; 49: 442–449.
444
with ‘OR’ into one set for Concept 1. This same
search methodology was applied to the two remaining
concepts. The final sets were used together with ‘AND’
and language and date limits were applied. RefWorks
was used for citation management and all strategies were
documented.
Study selection
Prospective and retrospective studies with a control
group were considered eligible for the systematic review.
Studies utilizing the Phelan method of four-quadrant AFI6 ,
with a threshold of 5 cm for defining oligohydramnios,
were eligible for inclusion in the meta-analysis. The
adverse outcomes of interest were 5-min Apgar score < 7,
Cesarean delivery for fetal distress, meconium-stained
amniotic fluid, MAS, admission to the NICU and infant
with low birth weight (< 2500 g).
Studies were divided into two groups according to
risk. Low-risk studies were those in which patients
with only isolated oligohydramnios were included; there
was no pregnancy comorbidity that could explain the
oligohydramnios (e.g. chronic hypertension or other
chronic maternal comorbidity). High-risk studies were
those that evaluated oligohydramnios in the setting of
complicated pregnancies, therefore including conditions
that may have led to oligohydramnios. All studies
excluded pregnancies with fetal anomalies known to
cause oligohydramnios (e.g. bladder outlet obstruction,
renal agenesis) and pregnancies with preterm prelabor
rupture of membranes. In addition, we excluded studies
that did not clearly define the timeframe between AFI
measurement and delivery, had a timeframe > 1 week or
included multiple gestations.
Risk of bias
Risk of bias (ROB) was assessed with the QUADAS-2
tool27 . We utilized the available database, spreadsheet and
document templates for recording and displaying the data.
QUADAS-2 utilizes four domains: patient selection, index
test, reference test and flow/timing. Each domain was
assessed for ROB and applicability, except the flow/timing
domain which was assessed only for ROB. ROB and
applicability were ranked as low, high or unclear based
on the authors’ judgment.
Statistical analysis
For each analysis, we calculated and reported the effect
estimates, expressed as relative risk (RR) and 95% CI,
in both low-risk and high-risk groups of women with
oligohydramnios. Moreover, for each outcome of interest
in the low-risk and high-risk groups, the calculated effect
estimates were pooled to obtain the overall effect. We
examined the level of heterogeneity between studies based
on the Q-statistic and Higgins’ I2 statistic28 . I2 ≤ 25%
indicates low heterogeneity, 25–75% indicates moderate
heterogeneity and > 75% indicates high heterogeneity.
The Q-statistic is typically underpowered for detecting
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Rabie et al.
true heterogeneity when the number of studies is small;
therefore, we pooled data using a random-effects model.
Publication bias was evaluated by funnel plot and Egger’s
asymmetrical test29 for those outcomes with at least
six to eight studies available for the meta-analysis. If
potential publication bias was detected, we adjusted our
meta-analysis results using a non-parametric trim-and-fill
approach30 . Finally, to evaluate the constancy of our
results, sensitivity analysis was conducted using a
leave-one-out method. All data analyses were performed
using the R packages ‘metafor’31 and ‘meta’32 .
RESULTS
The literature search identified 3444 records. After
eliminating duplicates and studies that did not meet
the inclusion criteria based on the abstract, 91 studies
examining oligohydramnios and pregnancy outcomes
were identified. Two authors (N.R. and E.M.) indepen-
dently reviewed the full text of these studies and an
additional 73 studies were excluded, leaving 18 studies as
the basis for the systematic review (Figure 1). The reasons
for exclusion are shown in Table S1. Disagreements were
re-examined together. Subsequently, three studies were
excluded from the meta-analysis and are summarized
in Appendix S1. A summary of the characteristics of
the low-risk and high-risk studies is shown in Table 1.
Not every study assessed all outcomes of interest and
therefore only the studies evaluating a particular outcome
were included in the individual analysis.
Six studies that reported on isolated
oligohydramnios18–23 were included in the low-risk
group, with a total of 27 526 patients. Three were
prospective and three were retrospective studies. With the
exception of one study18 , all patients were ≥ 37 + 0 weeks’
gestation. Compared with women with normal AFI,
patients with isolated oligohydramnios were more likely
to have an emergency Cesarean delivery for fetal distress
(RR, 2.16; 95% CI, 1.64–2.85), admission to the NICU
(RR, 1.71; 95% CI, 1.20–2.42) and an infant with MAS
(RR, 2.83; 95% CI, 1.38–5.77) (Figure 2). There was no
difference in the rate of meconium-stained amniotic fluid.
Nine studies reported on oligohydramnios in compli-
cated pregnancies9–17 and were included in the high-risk
group, with a total of 8067 patients. Six were prospec-
tive and three were retrospective studies. Compared with
women with normal AFI, patients with oligohydramnios
and comorbidities were more likely to have an infant with
low birth weight (RR, 2.35; 95% CI, 1.27–4.34). There
was no difference in the rates of emergency Cesarean
delivery for fetal distress, NICU admission, infant with
MAS or 5-min Apgar score < 7 (Figure 3).
There were insufficient data to analyze the risk of
perinatal death/stillbirth or respiratory distress syndrome.
There were inconsistent data to evaluate the umbilical
cord blood pH because studies used different thresholds
for defining abnormality (e.g. pH < 7.0, < 7.1, < 7.2).
ROB was assessed using the QUADAS-2 tool and is
shown in Table S2. In the low-risk group, ROB was low
Ultrasound Obstet Gynecol 2017; 49: 442–449.
Oligohydramnios in complicated and uncomplicated pregnancy 445

Table 1 Descriptive characteristics of low-risk studies of isolated oligohydramnios and high-risk studies of oligohydramnios in complicated
pregnancy

Oligo- Mean GA
Normal hydramnios at delivery
Study Country Study design AFI (n) (n) GA (weeks) (weeks)

Isolated oligohydramnios
Conway (1998)21 USA Prospective case–control 183 183 37 + 0 to 41 + 6 40.8
Rainford (2001)20 USA Retrospective chart review 188 44 37 + 0 to 42 + 0 40.1
Locatelli (2004)19 Italy Prospective observational 2708 341 40 + 0 to 41 + 6 40.6
Melamed (2011)18 Israel Retrospective cohort 324 108 24 + 0 to 36 + 6 33.9
Bachhav (2014)23 India Prospective observational 90 90 37 + 0 to 42 + 0 NS
Ashwal (2014)22 Israel Retrospective cohort 22 280 987 37 + 0 to 41 + 6 39.8
Oligohydramnios in complicated pregnancy
Rutherford (1987)12 USA Retrospective chart review 303 27 NS NS
Youssef (1993)9 Egypt and USA Prospective observational 104 70 NS NS
Magann (1999)10 USA Prospective case–control 79 79 ≥ 34 + 0 NS
Casey (2000)14 USA Retrospective chart review 6276 147 ≥ 34 + 0 39.1
Magann (2003)13 USA Prospective observational 76 24 ≥ 35 + 0 36.4
Driggers (2004)11 USA Retrospective cohort 131 131 ≥ 26 + 0 34.1
Venturini (2005)17 Italy Prospective case–control 120 120 ≥ 38 + 0 40.4
Alchalabi (2006)15 Jordan Prospective observational 114 66 37 + 0 to 42 + 0 NS
Sultana (2008)16 Pakistan Prospective case–control 100 100 37 + 0 to 42 + 0 38.1

Only first author of each study is given. High-risk conditions include hypertensive disorders, pregestational diabetes, rhesus isoimmunization
and fetal growth restriction. Studies excluded cases of preterm prelabor rupture of membranes, fetal anomalies, multiple gestations and any
medical complications of pregnancy. AFI, amniotic fluid index; GA, gestational age; NS, not specified.

across most studies in the domain of patient selection
except for one study18 that utilized a case–control design
and included only preterm pregnancies and one study for
which the ROB was unclear21 . In the high-risk group,
four studies10,11,16,17 had an unclear ROB for patient
selection due to utilizing a case–control design, and a
fifth study13 had an unclear ROB as it did not specify
high-risk patients; subjects were recruited because they
were undergoing a planned Cesarean delivery and were
not necessarily complicated.
DISCUSSION
In the previous meta-analysis performed by Chauhan
et al. in 199924 , the risk of three specific adverse out-
comes (Cesarean delivery for fetal distress, 5-min Apgar
score < 7, umbilical artery pH < 7.0) was compared
between women with antepartum and intrapartum AFI of
≤ 5.0 cm vs > 5.0 cm. They found that both antepartum
and intrapartum oligohydramnios was associated with an
increased risk of Cesarean delivery for fetal distress and
5-min Apgar score < 7, but it had no effect on acidosis.
Our study expands on theirs by studying oligohydramnios
within 1 week of delivery, stratified by low-risk and
high-risk pregnancies, and studying several other adverse
outcomes, including amniotic fluid meconium staining
and MAS.
There are two important findings in this meta-analysis
of oligohydramnios compared with normal amniotic
fluid in uncomplicated and complicated pregnancies. In
the low-risk (uncomplicated) pregnancies with isolated
oligohydramnios, there is an increased risk of MAS,
Cesarean delivery for fetal distress and admission to the
NICU. A critical outcome that could not be evaluated is
the risk of stillbirth or perinatal mortality. In this group
of studies, the rate of stillbirth was minimal, such that
most studies did not include stillbirth as an outcome,
and those that did had very few occurrences. Casey
et al.14 showed an association between stillbirth and
oligohydramnios but they commented on the difficulty
in determining whether intervention for oligohydramnios
would improve the stillbirth rate. Because of this
association, some suggest delivery at 36 to 37 + 6 weeks’
gestation to minimize the risk of stillbirth33 . However,
in an otherwise uncomplicated pregnancy, it may be
reasonable to consider prolonging the pregnancy to
38–39 weeks’ gestation with reassuring antenatal fetal
testing. In addition, although it is not always possible to
avoid an emergency Cesarean delivery, it is reasonable
to perform an admission contraction stress test on
patients undergoing induction of labor for isolated
oligohydramnios. This may help predict which patients
would benefit from a non-urgent Cesarean delivery. In
addition, maternal hydration is a management strategy
that is suggested for isolated oligohydramnios and is safe
and well tolerated34 .
In the high-risk (complicated) pregnancies, there was an
increased risk only of delivering smaller infants and this
risk may be due to the underlying condition. This group
of pregnancies encompassed a variety of comorbid con-
ditions including pregestational and gestational diabetes,
the spectrum of hypertensive disorders of pregnancy, rhe-
sus isoimmunization and fetal growth restriction. Despite
these complications, the only difference in outcomes for
those with oligohydramnios was the increased risk of hav-
ing an infant with low birth weight. This may be explained
by the comorbid condition, nearly all of which were asso-
ciated with fetal growth restriction, or it could be a sign of
more severe disease. As the oligohydramnios is probably

Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 442–449.
446 Rabie et al.

(a) Oligohydramnios Normal W W

Study Events Total Events Total Relative risk RR (95% CI) (fixed) (random)

Melamed (2011)18 9 108 9 324 3.00 (1.22, 7.36) 9.5% 9.5%

Locatelli (2004)19 28 341 106 2708 2.10 (1.40, 3.13) 47.6% 47.6%
Ashwal (2014)22 23 987 249 22 280 2.09 (1.37, 3.18) 42.9% 42.9%
Fixed-effect model 1436 25 312 2.16 (1.64, 2.85) 100%
Random-effects model 2.16 (1.64, 2.85) 100%
Heterogeneity: I2 = 0%, τ2 = 0, P = 0.7553
0.5 1 2 6

(b) Oligohydramnios Normal W W

Study Events Total Events Total Relative risk RR (95% CI) (fixed) (random)

Bachhav (2014)23 17 90 4 90 4.25 (1.49, 12.14) 46.0% 45.9%

Melamed (2011)18 0 108 0 324 0.0% 0.0%
Locatelli (2004)19 0 341 7 2708 0.53 (0.03, 9.24) 6.2% 6.2%
Ashwal (2014)22 4 987 38 22 280 2.38 (0.85, 6.64) 47.9% 47.8%

Fixed-effect model 1526 25 402 2.83 (1.39, 5.76) 100%

Random-effects model 2.83 (1.38, 5.77) 100%
Heterogeneity: I2 = 0.5%, τ2 = 0.0022, P = 0.3662
0.15 0.5 1 2 56

(c) Oligohydramnios Normal W W

Study Events Total Events Total Relative risk RR (95% CI) (fixed) (random)

Melamed (2011)18 2 108 14 324 0.43 (0.10, 1.86) 0.9% 2.1%

Locatelli (2004)19 36 341 276 2708 1.04 (0.75, 1.44) 18.8% 25.2%
Rainford (2001)20 7 44 65 188 0.46 (0.23, 0.93) 4.1% 8.0%
Conway (1998)21 44 183 43 183 1.02 (0.71, 1.48) 16.1% 22.0%
Ashwal (2014)22 108 987 2351 22 280 1.04 (0.86, 1.24) 61.2% 42.6%
Fixed-effect model 1663 25 683 0.99 (0.86, 1.14) 100%
Random-effects model 0.95 (0.77, 1.18) 100%
Heterogeneity: I2 = 34.6%, τ2 = 0.0197, P = 0.1908
0.15 0.5 1 2

(d) Oligohydramnios Normal

W W
Study Events Total Events Total Relative risk RR (95% CI) (fixed) (random)

Bachhav (2014)23 30 90 9 90 3.33 (1.68, 6.61) 10.3% 16.4%

Melamed (2011)18 12 108 16 324 2.25 (1.10, 4.60) 9.4% 15.5%
Rainford (2001)20 6 44 17 188 1.51 (0.63, 3.60) 6.4% 11.8%
Conway (1998)21 30 183 21 183 1.43 (0.85, 2.40) 17.9% 22.5%
Ashwal (2014)22 45 987 795 22 280 1.28 (0.95, 1.71) 56.0% 33.8%

Fixed-effect model 1412 23 065 1.53 (1.23, 1.91) 100%

Random-effects model 1.71 (1.20, 2.42) 100%
Heterogeneity: I2 = 47%, τ2 = 0.0715, P = 0.11 0.5 1 2 6

Figure 2 Forest plots of risk of: (a) emergency Cesarean delivery for fetal distress; (b) meconium aspiration syndrome; (c) meconium-stained
amniotic fluid; and (d) admission to neonatal intensive care unit in low-risk uncomplicated pregnancies with isolated oligohydramnios. RR,
relative risk; W, weight.

Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 442–449.
Oligohydramnios in complicated and uncomplicated pregnancy 447

(a) Oligohydramnios Normal W W

Study Events Total Events Total Relative risk RR (95% CI) (fixed) (random)

Youssef (1993)9 16 70 2 104 11.89 (2.82, 50.09) 15.4% 16.7%

Magann (1999) 10 0 79 1 79 0.33 (0.01, 8.06) 3.1% 7.0%
Driggers (2004)11 5 131 6 131 0.83 (0.26, 2.66) 23.6% 19.1%
Rutherford (1987)12 3 27 5 303 6.73 (1.70, 26.66) 16.8% 17.2%
Alchalabi (2006) 15 1 66 1 114 1.73 (0.11, 27.16) 4.2% 8.6%
Sultana (2008)16 8 100 6 100 1.33 (0.48, 3.70) 30.5% 20.3%
Venturini (2005)17 1 120 3 120 0.33 (0.04, 3.16) 6.3% 11.1%

Fixed-effect model 593 951 1.95 (1.11, 3.42) 100%

Random-effects model 1.85 (0.69, 4.96) 100%
Heterogeneity: I2 = 60.9%, τ2 = 0.9766, P = 0.0179
0.15 0.5 1 2 56

(b) Oligohydramnios Normal W W

Study Events Total Events Total Relative risk RR (95% CI) (fixed) (random)

Magann (1999)10 7 79 6 79 1.17 (0.41, 3.32) 11.9% 15.5%

Driggers (2004) 11 8 131 16 131 0.50 (0.22, 1.13) 19.7% 17.8%
Rutherford (1987)12 3 27 7 303 4.81 (1.32, 17.54) 7.8% 13.1%
Casey (2000)14 7 147 181 6276 1.65 (0.79, 3.45) 24.0% 18.6%
Alchalabi (2006) 15 18 66 6 114 5.18 (2.16, 12.40) 17.1% 17.2%
Venturini (2005) 17 11 120 10 120 1.10 (0.49, 2.49) 19.5% 17.8%
Fixed-effect model 570 7023 1.53 (1.07, 2.19) 100%
Random-effects model 1.65 (0.81, 3.36) 100%
Heterogeneity: I = 73%, τ = 0.5696, P < 0.01
2 2 0.25 0.5 1 2 6

(c) Oligohydramnios Normal W W

Study Events Total Events Total Relative risk RR (95% CI) (fixed) (random)

Youssef (1993)9 28 70 16 104 2.60 (1.52, 4.44) 22.8% 21.1%

Magann (1999) 10 5 79 10 79 0.50 (0.18, 1.40) 6.2% 16.4%
Rutherford (1987)12 15 27 64 303 2.63 (1.76, 3.93) 40.3% 22.2%
Casey (2000)14 9 147 907 6276 0.42 (0.22, 0.80) 16.1% 20.3%
Alchalabi (2006) 15 16 66 13 114 2.13 (1.09, 4.14) 14.7% 20.0%
Fixed-effect model 389 6876 1.71 (1.33, 2.21) 100%
Random-effects model 1.32 (0.62, 2.81) 100%
Heterogeneity: I2 = 87.2%, τ2 = 0.6267, P < 0.0001
0.15 0.5 1 2 5

(d) Oligohydramnios Normal W W

Study Events Total Events Total Relative risk RR (95% CI) (fixed) (random)

Magann (1999)10 6 79 8 79 0.75 (0.27, 2.06) 19.4% 29.5%

Casey (2000)14 10 147 98 6276 4.36 (2.32, 8.18) 50.2% 37.0%

Alchalabi (2006) 15 12 66 9 114 2.30 (1.03, 5.17) 30.4% 33.5%
Fixed-effect model 292 6469 2.55 (1.63, 3.98) 100%
Random-effects model 2.09 (0.80, 5.45) 100%
Heterogeneity: I2 = 76%, τ2 = 0.5415, P = 0.01 0.25 0.5 1 2 6

Figure 3 Forest plots of risk of: (a) 5-min Apgar score < 7; (b) emergency Cesarean delivery for fetal distress; (c) meconium-stained
amniotic fluid; (d) admission to neonatal intensive care unit; and (e) delivery of infant with low birth weight (< 2500 g) in high-risk
complicated pregnancies with oligohydramnios. RR, relative risk; W, weight.

Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 442–449.
448
(e)
Oligohydramnios Normal
Study Events Total Events Total
Magann (1999)10 8 79 4 79
Casey (2000)14 51 147 557 6276
Alchalabi (2006)15 7 66 8 114
Sultana (2008)16 9 100 6 100
Fixed-effect model 392 6569
Random-effects model
Heterogeneity: I2 = 59.5%, τ2 = 0.2238, P = 0.0599
0.25
Figure 3 Continued
a function of the underlying condition, it is reasonable to
base management on the complication of pregnancy and
not alter the management because of the oligohydramnios.
Strengths of this study include the low ROB and
the number of studies reviewed. The primary domain
at ROB was patient selection. Although all controlled
studies were included, those that used a case–control
design, non-random patient selection or included preterm
pregnancies (in the low-risk group) were at increased
risk of patient selection bias. We did not consider the
inclusion of preterm pregnancies an increased ROB in
the high-risk group because complicated pregnancies,
by their nature, include a significant portion of preterm
gestations. The remaining domains had a low ROB due
to the specific criteria of our study. As all studies used the
same method/threshold for oligohydramnios (index and
reference test) and had less than 1 week between diagnosis
and delivery (flow/timing), they all had a low ROB and a
low concern for applicability.
This study is limited by the available outcome data. The
individual studies each looked at several outcome vari-
ables but, in order to perform a meta-analysis, we needed
consistent outcome variables. This limited our review
to only those variables that were common among the
studies. Another limitation, as noted above, is the inability
to comment on the risk of stillbirth/perinatal mortality.
Finally, we included studies that utilized AFI instead of
SDP for diagnosis of oligohydramnios. Current data,
including the recently published SAFE trial35 , suggest that
the SDP is a better method of diagnosing oligohydramnios
because it has a lower detection rate although there is no
change in the rate of intervention (i.e. induction of labor)
or adverse outcomes. However, there are significantly
more data on adverse outcomes with oligohydramnios
diagnosed by AFI, and the purpose of this study was to
assess adverse outcomes and not compare methods of
diagnosis. Other limitations of this and other studies that
evaluate the ultrasound estimate of amniotic fluid volume
are both antepartum and intrapartum events, including
the intraobserver and interobserver variability36 , amount
of pressure on the transducer during the ultrasound
scan37 , ambient temperature38 , altitude39 , maternal
position40,41 and biases of maternal comorbidities42 .
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Rabie et al.
W W
Relative risk RR (95% CI) (fixed) (random)
2.00 (0.63, 6.37) 3.6% 17.2%
3.91 (3.09, 4.95) 86.5% 41.3%
1.51 (0.57, 3.98) 5.1% 21.1%
1.50 (0.55, 4.06) 4.8% 20.4%
3.47 (2.79, 4.32) 100%
2.35 (1.27, 4.34) 100%
0.5 1 2 6
Although oligohydramnios in low-risk pregnancies is an
abnormal finding, there are not enough data to determine
the optimal timing of delivery to reduce the risk of
adverse outcomes. Future research looking specifically
at perinatal mortality associated with oligohydramnios is
needed. Complicated pregnancies with oligohydramnios
should be managed based on the comorbid conditions.
REFERENCES
1. Timor-Tritsch IE, Farine D, Rosen MG. A close look at early embryonic development
with the high-frequency transvaginal transducer. Am J Obstet Gynecol 1988; 159:
676–681.
2. de Crespigny LC, Cooper D, McKenna M. Early detection of intrauterine pregnancy
with ultrasound. J Ultrasound Med 1988; 7: 7–10.
3. Gadd RL. The volume of the liquor amnii in normal and abnormal pregnancies. J
Obstet Gynaecol Br Commonw 1966; 73: 11–22.
4. Brace RA, Wolf EJ. Normal amniotic fluid volume changes throughout pregnancy.
Am J Obstet Gynecol 1989; 161: 382–388.
5. Charles D, Jacoby HE. Preliminary data on the use of sodium aminohippurate to
determine amniotic fluid volumes. Am J Obstet Gynecol 1966; 95: 266–269.
6. Phelan JP, Smith CV, Broussard P, Small M. Amniotic fluid volume assessment with
the four-quadrant technique at 36–42 weeks’ gestation. J Reprod Med 1987; 32:
540–542.
7. Manning FA, Platt LD, Sipos L. Antepartum fetal evaluation: development of a fetal
biophysical profile. Am J Obstet Gynecol 1980; 136: 787–795.
8. Nabhan AF, Abdelmoula YA. Amniotic fluid index versus single deepest vertical
pocket as a screening test for preventing adverse pregnancy outcome. Cochrane
Database Syst Rev 2008; 16: CD006593.
9. Youssef AA, Abdulla SA, Sayed EH, Salem HT, Abdelalim AM,Devoe LD. Superiority
of amniotic fluid index over amniotic fluid pocket measurement for predicting bad
fetal outcome. South Med J 1993; 86: 426–429.
10. Magann EF, Kinsella MJ, Chauhan SP, McNamara MF, Gehring BW, Morrison JC.
Does an amniotic fluid index of </=5 cm necessitate delivery in high-risk pregnancies?
A case–control study. Am J Obstet Gynecol 1999; 180: 1354–1359.
11. Driggers RW, Holcroft CJ, Blakemore KJ, Graham EM. An amniotic fluid index < or
=5 cm within 7 days of delivery in the third trimester is not associated with decreasing
umbilical arterial pH and base excess. J Perinatol 2004; 24: 72–76.
12. Rutherford SE, Phelan JP, Smith CV, Jacobs N. The four-quadrant assessment of
amniotic fluid volume: an adjunct to antepartum fetal heart rate testing. Obstet
Gynecol 1987; 70: 353–356.
13. Magann EF, Chauhan SP, Martin JN Jr. Is amniotic fluid volume status predictive of
fetal acidosis at delivery? Aust N Z J Obstet Gynaecol 2003; 43: 129–133.
14. Casey BM, McIntire DD, Bloom SL, Lucas MJ, Santos R, Twickler DM, Ramus RM,
Leveno KJ. Pregnancy outcomes after antepartum diagnosis of oligohydramnios at
or beyond 34 weeks’ gestation. Am J Obstet Gynecol 2000; 182: 909–912.
15. Alchalabi HA, Obeidat BR, Jallad MF, Khader YS. Induction of labor and perinatal
outcome: the impact of the amniotic fluid index. Eur J Obstet Gynecol Reprod Biol
2006; 129: 124–127.
16. Sultana S, Akbar Khan MN, Khanum Akhtar KA, Aslam M. Low amniotic fluid
index in high-risk pregnancy and poor apgar score at birth. J Coll Physicians Surg
Pak 2008; 18: 630–634.
17. Venturini P, Contu G, Mazza V, Facchinetti F. Induction of labor in women with
oligohydramnios. J Matern Fetal Neonatal Med 2005; 17: 129–132.
18. Melamed N, Pardo J, Milstein R, Chen R, Hod M, Yogev Y. Perinatal outcome in
pregnancies complicated by isolated oligohydramnios diagnosed before 37 weeks of
gestation. Am J Obstet Gynecol 2011; 205: 241.e241–241.e246.
19. Locatelli A, Vergani P, Toso L, Verderio M, Pezzullo JC, Ghidini A. Perinatal
outcome associated with oligohydramnios in uncomplicated term pregnancies. Arch
Gynecol Obstet 2004; 269: 130–133.
Ultrasound Obstet Gynecol 2017; 49: 442–449.
Oligohydramnios in complicated and uncomplicated pregnancy
20. Rainford M, Adair R, Scialli AR, Ghidini A, Spong CY. Amniotic fluid index in
the uncomplicated term pregnancy. Prediction of outcome. J Reprod Med 2001; 46:
589–592.
21. Conway DL, Adkins WB, Schroeder B, Langer O. Isolated oligohydramnios in the
term pregnancy: is it a clinical entity? J Matern Fetal Med 1998; 7: 197–200.
22. Ashwal E, Hiersch L, Melamed N, Aviram A, Wiznitzer A, Yogev Y. The association
between isolated oligohydramnios at term and pregnancy outcome. Arch Gynecol
Obstet 2014; 290: 875–881.
23. Bachhav AA, Waikar M. Low amniotic fluid index at term as a predictor of adverse
perinatal outcome. J Obstet Gynaecol India 2014; 64: 120–123.
24. Chauhan SP, Sanderson M, Hendrix NW, Magann EF, Devoe LD. Perinatal outcome
and amniotic fluid index in the antepartum and intrapartum periods: A meta-analysis.
Am J Obstet Gynecol 1999; 181: 1473–1478.
25. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items
for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol
2009; 62: 1006–1012.
26. PROSPERO: International prospective register of systematic reviews. http://www
.crd.york.ac.uk/PROSPERO/display&uscore;record.asp?ID=CRD42015024566
[Accessed 8 January 2016].
27. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang
MM, Sterne JA, Bossuyt PM, QUADAS-2 Group. QUADAS-2: a revised tool for
the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011; 155:
529–536.
28. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in
meta-analyses. BMJ 2003; 327: 557–560.
29. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by
a simple, graphical test. BMJ 1997; 315: 629–634.
30. Duval S, Tweedie R. Trim and fill: A simple funnel-plot-based method of testing and
adjusting for publication bias in meta-analysis. Biometrics 2000; 56: 455–463.
31. Viechtbauer W. Conducting meta-analyses in R with the metafor package. J Stat Soft
2010; 36: 1–48.
32. Schwarzer G. Meta: An R package for meta-analysis. R News 2007; 7: 40–45.
SUPPORTING INFORMATION ON THE INTERNET
The following supporting information may be found in the online version of this article:
Appendix S1 Studies included in systematic review but excluded from meta-analysis
Table S1 Articles excluded from systematic review
Table S2 Risk of bias in studies of low-risk isolated oligohydramnios and studies of high-risk oligohydramnios
in complicated pregnancy
Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
449
33. Spong CY, Mercer BM, D’Alton M, Kilpatrick S, Blackwell S, Saade G. Timing of
indicated late-preterm and early-term birth. Obstet Gynecol 2011; 118: 323–333.
34. Gizzo S, Noventa M, Vitagliano A, Dall’Asta A, D’Antona D, Aldrich CJ, Quaranta
M, Frusca T, Patrelli TS. An Update on maternal hydration strategies for amniotic
fluid improvement in isolated oligohydramnios and normohydramnios: evidence
from a systematic review of literature and meta-analysis. PLoS One 2015; 10:
e0144334.
35. Kehl S, Schelkle A, Thomas A, Puhl A, Meqdad K, Tuschy B, Berlit S, Weiss
C, Bayer C, Heimrich J, Dammer U, Raabe E, Winkler M, Faschingbauer F,
Beckmann MW Sutterlin M. Single deepest vertical pocket or amniotic fluid index as
evaluation test for preventing adverse pregnancy outcome (SAFE trial): a multicenter,
open-label, randomized controlled trial. Ultrasound Obstet Gynecol 2016; 47:
674–679.
36. Sande JA, Ioannou C, Sarris I, Ohuma EO, Papageorghiou AT. Reproducibility of
measuring amniotic fluid index and single deepest vertical pool throughout gestation.
Prenat Diagn 2015; 35: 434–439.
37. Flack NJ, Dore C, Southwell D, Kourtis P, Sepulveda W, Fisk NM. The influence
of operator transducer pressure on ultrasonographic measurements of amniotic fluid
volume. Am J Obstet Gynecol 1994; 171: 218–222.
38. Sciscione AC, Costigan KA, Johnson TR. Increase in ambient temperature may
explain decrease in amniotic fluid index. Am J Perinatol 1997; 14: 249–251.
39. Yancey MK, Richards DS. Effect of altitude on the amniotic fluid index. J Reprod
Med 1994; 39: 101–104.
40. Patrelli TS, Berretta R, Noventa M, Gizzo S. Reply: To PMID 22298867. J Ultrasound
Med 2014; 33: 922–923.
41. Gizzo S, Di Gangi S, Noventa M, Bacile V, Zambon A, Nardelli GB. Women’s choice
of positions during labour: return to the past or a modern way to give birth? A
cohort study in Italy. Biomed Res Int 2014; 2014: 638093.
42. Gizzo S, Patrelli TS, Rossanese M, Noventa M, Berretta R, Di Gangi S, Bertin M,
Gangemi M, Nardelli GB. An update on diabetic women obstetrical outcomes linked
to preconception and pregnancy glycemic profile: a systematic literature review.
Scientific World Journal 2013; 2013: 254901.
Ultrasound Obstet Gynecol 2017; 49: 442–449.
Ultrasound Obstet Gynecol 2017; 49: 442–449
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.15929

Oligohidramnios en embarazos complicados y sin complicaciones: una revisi ón sistem ática y
metaan álisis
RESUMEN

Objetivo Evaluar, mediante una revisión sistemática y metaanálisis de ensayos controlados, los resultados adversos en embarazos
con feto único diagnosticados con oligohidramnios.
Métodos Se realizó una búsqueda en bases de datos electrónicas mediante el uso de OVID, EBSCO, Web of Science, Google
Scholar y otras, para el periodo 1980–2015. Se incluyeron estudios prospectivos y retrospectivos con un grupo de control.
Dos de los autores revisaron de forma independiente los resúmenes obtenidos en la búsqueda bibliográfica. Los criterios de
inclusión fueron: estudios en inglés, embarazo con feto único, anatomı́a del feto normal, membranas intactas y oligohidramnios
diagnosticado mediante la técnica del ı́ndice de lı́quido amniótico (ILA). El metaanálisis se estratificó en dos grupos, según el
riesgo: un grupo de alto riesgo, que incluyó estudios de oligohidramnios con condiciones comórbidas (p. ej. hipertensión) y otro
de bajo riesgo, que incluyó estudios de oligohidramnios aislado.

Resultados Quince ensayos cumplieron los criterios de inclusión. Nueve eran de alto riesgo y seis de bajo riesgo, e incluı́an un total
de 8067 y 27526 mujeres, respectivamente. En comparación con las mujeres con un ILA normal, aquellas con oligohidramnios
aislado mostraron tasas significativamente más altas de lactante con sı́ndrome de aspiración de meconio (riesgo relativo (RR),
2,83; IC 95%, 1,38–5,77), parto por cesárea motivado por sufrimiento fetal (RR 2,16; IC 95%, 1,64–2,85) e ingreso en la unidad
de cuidados intensivos para recién nacidos (UCI neonatal) (RR 1,71; IC 95%, 1,20–2,42). Las pacientes con oligohidramnios y
comorbilidades fueron más propensas a tener recién nacidos con bajo peso al nacer (RR 2,35; IC 95%, 1,27–4,34). Sin embargo,
las tasas del ı́ndice de Apgar a los 5 min <7 (RR 1,85; IC 95%, 0,69–4,96), del ingreso a la UCI neonatal (RR 2,09; IC 95%,
0,80–5,45), del lı́quido amniótico teñido de meconio (RR 1,32 ; IC 95%, 0,62–2,81) y del parto por cesárea motivado por
sufrimiento fetal (RR 1,65; IC 95%, 0,81–3,36) fueron similares a las de las mujeres con un ILA normal. Las tasas de éxitus fetal
fueron demasiado bajas como para analizarlas en el metaanálisis.
Conclusiones Esta revisión ayuda a definir los resultados adversos que aumentan con el oligohidramnios en embarazos de
bajo riesgo (ingreso a la UCI neonatal, parto por cesárea motivado por sufrimiento fetal y sı́ndrome de aspiración de meconio),
pero no proporciona datos suficientes para determinar el momento óptimo del parto en estos casos. En embarazos complicados,
el oligohidramnios está asociado con un mayor riesgo de partos de recién nacidos con bajo peso al nacer, pero esto se puede
confundir con la comorbilidad. Por lo tanto, en embarazos de alto riesgo, el tratamiento lo debe dictar la condición comórbida y
no la presencia de oligohidramnios.

有和无妊娠并发症情况下的羊水过少：系统评价和meta分析

目的： 对对照试验进行系统评价和meta分析，评估诊断为羊水过少的单胎妊娠中的不良妊娠结局。

方法： 检索OVID、EBSCO、Web of Science、Google Scholar和其他数据库，检索时间为1980–2015年。纳入设立对照组的

前瞻性和回顾性研究。由两名作者独立阅读检索到的文献摘要。纳入标准包括：语种为英语，单胎妊娠，胎儿解剖结构正

常，胎膜完整且羊水指数（amniotic fluid index，AFI）检测结果证实羊水过少。meta分析中我们进行分层分析，根据风险分

为2组：高危研究（羊水过少伴并发症如高血压的研究）和低危研究（单纯羊水过少的研究）。

结果： 15项研究符合纳入标准。9项为高危研究（包括8067例孕妇），6项为低危研究（包括27 526例孕妇）。与AFI正常的

孕妇相比，单纯羊水过少的孕妇其婴儿出现胎粪吸入综合征[相对危险度（relative risk，RR），2.83；95% CI，1.38∼5.77]、

因 胎 儿 窘 迫 行 剖 宫 产 （RR，2.16；95% CI，1.64∼2.85） 和 新 儿 重 症 监 护 病 房 （neonatal intensive care unit，NICU）

住 院 （RR，1.71；95% CI，1.20∼2.42） 的 发 生 率 明 显 较 高 。 伴 有 并 发 症 的 羊 水 过 少 的 孕 妇 分 娩 低 出 生 体 重 儿 的

概率更大（RR，2.35；95% CI，1.27∼4.34）。然而，5分钟Apgar评分<7（RR，1.85；95% CI，0.69∼4.96）、NICU住

院 （RR，2.09；95% CI，0.80∼5.45） 、 羊 水 胎 粪 污 染 （RR，1.32；95% CI，0.62∼2.81） 和 因 胎 儿 窘 迫 行 剖 宫 产

（RR，1.65；95% CI，0.81∼3.36）的发生率与AFI正常的孕妇相似。死产率过低，因此未进行meta分析。

结论： 本篇综述有助于阐明低危妊娠中哪些不良结局（NICU住院、因胎儿窘迫行剖宫产和胎粪吸入综合征）由于羊水过少而
增加，但未能为确定这类病例行剖宫产的最佳时间提供足够依据。妊娠并发症伴有羊水过少则分娩低出生体重儿的风险增加，
但可能是由于并发症所致。因此，高危妊娠中应针对并发症而不是羊水过少采取治疗。

Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. SYSTEMATIC REVIEW