International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Aggarwal P et al. Int J Reprod Contracept Obstet Gynecol. 2018 Feb;7(2):671-676

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20180192
Original Research Article

Correction with oral hydration improves maternal and perinatal

outcome in women with third trimester isolated oligohydramnios
Pragati Aggarwal*, Sharda Patra

Department of Obstetrics and Gynecology, Lady Hardinge Medical College, New Delhi, India

Received: 13 December 2017

Accepted: 08 January 2018

*Correspondence:
Dr. Pragati Aggarwal,
E-mail: pragati8989@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Oligohydramnios is related to serious maternal and fetal complications. In case of isolated
oligohydramnios in third trimester maternal oral hydration has shown promising results in improving maternal and
perinatal outcome.
Methods: This study was conducted on 50 pregnant women complicated by idiopathic oligohydramnios (AFI<5) in
third trimester. Their pre hydration daily fluid intake was noted and they were advised to take oral fluids more than
their usual intake (according to their convenience). The daily fluid intake and AFI was measured on day1, day2, day3
then weekly till delivery. At delivery maternal and fetal outcome were measured.
Results: The mean AFI of the study population at the time of enrolment was 4.25±1.01 and daily mean fluid intake
was 1.46±0.41. The post hydration fluid intake per day was significantly high as compared to pre hydration fluid
intake (4.40±0.51 litres vs 1.46±0.41 litres, p<0.001). A significant difference in the amniotic fluid index was seen
post hydration. The mean AFI on day 1, day 2, day 3 was 6.19±0.93, 7.33±1.13, 8.0±1.07 as compared to pre
hydration AFI 4.25±1.01 (p<0.001). The amniotic fluid index post hydration normalized (AFI>8) in 6%, 30%, 61%
and 100% of women on day1, day2, day3 and after a week. The perinatal outcome was favourable in all the women
with 100% live births and a mean birth weight of 2.77±0.29 kg.
Conclusions: A simple correction of maternal dehydration by an adequate and sustained daily oral fluid intake in
pregnancies complicated by isolated third oligohydramnios in third trimester significantly improves amniotic fluid
index, maternal outcome and perinatal outcome.

Keywords: Amniotic fluid index, Isolated oligohydramnios, Oral hydration, Perinatal outcome

INTRODUCTION could be due to maternal dehydration preferably due to

inadequate oral intake, maternal fever, diarrhoea etc.
Oligohydramnios is defined quantitatively as an amniotic Multiple therapeutic options have been suggested for
fluid volume <500ml, and semi- quantitatively as restoring the amniotic fluid index in women with isolated
amniotic fluid index <5cm or single deepest pocket <2cm oligohydramnios especially remote from term aiming to
on ultrasound.1 The overall prevalence of prolong pregnancy till term and optimise perinatal
Oligohydramnios is 3-5%.2 It is more common in 3rd outcome. The treatment modalities are serial
trimester. In 2-3% of women with oligohydramnios no transabdominal or transcervical amnioinfusion,
cause (like fetal disorders, maternal disorders, rupture of intravenous hydration, desmopressin (dDAVP) and
membranes) is attribute, which is termed as isolated amniotic membrane sealing techniques in rupture of
oligohydramnios. Isolated oligohydramnios at times membranes cases. All these mechanisms have been tried

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 Aggarwal P et al. Int J Reprod Contracept Obstet Gynecol. 2018 Feb;7(2):671-676

to increase amniotic fluid index. But these are invasive Women were asked to continue to take plenty of oral
method and there clinical utility is still debated.4 fluid according to their convenience. Ultrasound was
done daily during the fluid therapy consecutively for
Maternal hydration, for restoring the amniotic fluid three days and weekly thereafter till delivery. The
volume in pregnant women with oligohydramnios is a deepest, unobstructed and clear pockets of amniotic fluid
newer method which in recent studies has shown without limb buds or cord structures were visualized and
promising results. Maternal hydration being non invasive, the vertical pocket was measured in each quadrant. All
is a simple, safe, cheap and easy method for treating the four measurements of the largest vertical pocket were
isolated oligohydramnios without conferring any risks to summed up to calculate amniotic fluid index. The fetal
the mother and fetus.4 monitoring with FHS, DFMC and daily NST continued
till AFI normalised (more than 8). Those who attained a
Regarding the amount and duration of fluid therapy, normal AFI after hydration therapy were discharged and
many investigators have tried a fixed dose for a short were followed up weekly in the antenatal clinic till
duration (orally 2litres/hour) or a forced hydration and delivery. At delivery the maternal and fetal outcomes
have reported convincing results, though for a short were measured.
period. However as regards the long term effects are
concerned, the results are still grim. Thus, there is no Statistical analysis
consensus on how much fluid and for how long maternal
hydration therapy should be administered in pregnancy The statistical analysis was done by using latest version
complicated by oligohydramnios for an optimum of Statistical Package for the social sciences (SPSS)
outcome. software. The results were expressed as mean±standard
deviation. Comparison was done using student’s t-test
The present study was undertaken to define an and ANOVA test.
appropriate volume and correct way of administration of
fluid as oral hydration therapy in women with isolated RESULTS
oligohydramnios and to evaluate its effect on amniotic
fluid volume and perinatal outcome. In the present study, mean age of the women was
25.98±3.96 years ranging from 20-37 years. Out of the
METHODS studied population 62% were booked. The mean
gestational age at presentation was 34.1±2.1 weeks
This was an observational study done in department of ranging from 28.6 to 37.4 weeks. Majority of women
obstetrics and gynaecology at Lady hardinge medical (44%) were between 34-36 weeks of gestation.
college, Delhi over a period of one year. Ethical clearance
was taken from institutional ethical committee. Fifty Table 1: Demographic and clinical profile of pregnant
women with isolated oligohydramnios (AFI<5) in third women with isolated oligohydramnios.
trimester of pregnancy were included in the study after a
written informed consent. Women attending the routine Variables No. %
antenatal clinic or presenting in emergency in third Age (In years)
trimester of pregnancy with oligohydramnios were 20-24 23 46
admitted for a complete maternal –fetal evaluation. These 25-30 15 30
women were subjected to thorough history followed by >30 12 24
detailed physical examination and obstetric examination. Mean±SD (in years) 25.98±3.96
This was followed by non stress test, and baseline Range (in years) 20-37
investigations. These women were asked about their daily ANC registration
intake of fluids at home, which was noted. An ultrasound Booked 31 62
examination was done for confirmation and to rule out Unbooked 19 38
other causes of oligohydramnios like PROM, FGR and Presentation during admission
any fetal anomalies. A colour doppler and AFI was done. USG based diagnosis of oligohydramnios 24 48
Those with normal doppler flows and an amniotic fluid
Preterm labour pains 16 32
index <5 were included in the study.
Perception of decrease fetal movements 10 20
POG at admission (in weeks)
Management protocol
28-30 2 4
30-32 5 10
These women were asked to drink plenty of water more
32-34 13 26
than their usual intake (according to their convenience) in
24 hours. Intake - output charting was done. Fetal 34-36 22 44
monitoring was done with FHS charting, DFMC chart 36-38 8 16
and a baseline NST. The next day (after 24 hours) on day Mean±SD (in weeks) 34.1±2.1
1, the total amount of fluid taken by the women in 24 Range (in weeks) 28.6-37.4
hours was calculated and the AFI was measured on day 1.

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Maximum women (48%) presented with ultrasound hydration therapy compared to the fluid intake prior to
showing oligohydramnios and 20% with decreased therapy (4.40+0.51 litres vs 1.46±0.41 litres, p<0.001).
perception of fetal movements (Table 1). However, the difference in the mean daily fluid intake
from day 1 (4.07+0.76 litres) to week 4 (5.0+0.66 litres)
Table 2: Distribution of pregnant women according to during the hydration therapy was statistically not
their amniotic fluid index (AFI) on ultrasound at the significant (p=0.024) (Table 4).
time of admission (<5).
Table 4: Comparison of pre hydration and post
AFI at Number of hydration daily mean oral fluid intake.
admission (<5) pregnant woman Percentage
(in cm) (N=50) Fluid intake Mean±SD (In litres) P-value
<2 2 4 Prehydration
2-4 11 22 Day 0 1.46±0.41
>4 37 74 Post Mean±SD Mean±SD
Mean amniotic fluid index 4.25±1.01cm hydration (In litres) (In litres)
Day1 4.07±0.76
Amniotic fluid index in study population was less than 5 Day2 4.38±0.62
<0.001
cm with a mean amniotic fluid index of 4.25+1.01cm Day3 4.45±0.60
(Table 2). Prior to treatment, average daily fluid intake in Week1 4.70±0.52 4.40 +0.51
the study population was 1.46+0.4 litres ranging between Week 2 4.62±0.53
500 ml to 2 litres (Table 3). Week 3 4.67±0.60
Week 4 5.0±0.66
Table 3: Distribution of pregnant women according to
their daily fluid intake prior to hydration therapy at On day 0 (at enrolment) all women (n=50, 100%) had
the time of admission. AFI<5 cm with mean AFI of 4.25±1.01. On day1 of oral
hydration the AFI was between 5-8 cm in 45 (90%) and
Daily fluid Number of more than 8 in 3 women (6%). There remained only 2
Intake (in pregnant women Percentage women with an AFI <5.
Litres) (N=50)
0.5-1 19 38 However, on day 2 and day 3 of oral hydration the AFI in
1-1.5 16 32 30% and 60% of women was more than 8 respectively.
1.5-2 15 30 There was only one woman out of 50 with an AFI <5 on
Mean±SD 1.46±0.4 day 3. At the end of first week all of the women had AFI
Range (Litres) 0.5-2 >8cm which continued to be in the same level (>8) till
fourth week (Table 5).
After increasing the fluid intake, the overall mean fluid
intake per day was significantly more during the oral

Table 5: Distribution of pregnant women according to pattern of AFI from day 0 (pre hydration) to week 4
(post hydration).

Day 0 Day 1 Day 2 Day 3 Week1 Week 2 Week 3 Week 4

AFI (cm)
n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)
<5 50 (100) 2 (4) 1 (2) 1 (2) 0 0 0 0
5-8 0 45 (90) 34 (68) 18 (37) 0 0 0
>8 0 3 (6) 15 (30) 30 (61) 46 (100) 36 (100) 18 (100) 9 (100)
Total (no. of
50 50 50 49* 46* 36* 18* 9*
pregnant women)
*rest of the women delivered during the study

The mean AFI on day 1, day 2, day 3 and first week week to fourth week and the difference with the pre
during the oral hydration therapy was significantly more hydration AFI was highly significant (Table 6).
compared to the pre hydration AFI (6.19±0.93 vs
4.25±1.01, 7.33±1.13 vs 4.25±1.01, 8±1.07 vs 4.25±1.01 All women had normal amniotic fluid index at the time of
and 9.3±0.98 respectively, p<0.001). The AFI was delivery. Total mean+SD amniotic fluid index at the time
consistently in the normal level (9.64+0.94) from first of delivery was 9.8+0.43 cm (Table 7).

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Table 6: Comparison of pre hydration and post The results of the present study indicated that the age of
hydration mean AFI from enrolment to 4 weeks. the studied women ranged between 20 and 37 years with
a mean age of 25.98±3.96 years. Majority of the women
Mean±SD (in cm) p-value (76%) were in the age group of 20-30 years (Table 1).
At enrolment 4.25±1.01 <0.001 Magnan et al, Patrelli et al and Shikha et al have quoted a
Day1 6.19±0.93 <0.001 similar age between 24-26 years.3-5 In the present study,
Day2 7.33±1.13 <0.001 maximum number of women were literate (80%) (table
Day3 8.0±1.07 <0.001 1). The result was in accordance to Shikha et al showing
Week1 9.3±0.98 <0.001 77% of study population to be literate.3
Week2 9.79±0.96 <0.001
Week3 9.64±0.94 <0.001 The mean gestational age at the time of presentation was
Week4 9.31±0.63 <0.001 34.1±2.1 weeks ranging from 28.6 to 37.4 weeks.
Majority of women (44%) were between 34-36 weeks of
Table 7: Mean AFI at the time of delivery with respect gestation (Table 1). Mean gestational age was
to gestational age at delivery. comparable to studies by Magnan et al, and Patrelli et al
in which it was ranging between 31 to 36 weeks.4,5
Gestational age at delivery Mean AFI at the time
(in weeks) of delivery (in cm) Present study included women who had isolated
36-37 (N=14) 9.6 oligohydramnios in third trimester with an amniotic fluid
37-38 (N=21) 9.9 index of less than 5cm and with normal doppler flows.
38-39 (N=12) 9.4 The mean amniotic fluid index at the time of admission
39-40 (N=3) 10.4 was 4.25±1.01 cm which ranged from 0 to 5 cm (Table
Mean±SD 9.8±0.43 2). There are numerous studies which have shown the
beneficial effect of oral hydration on initial AFI in
women with isolated oligohydramnios. The amniotic
Out of all the enrolled women, 72% delivered at term, 49
fluid index in most of the studies varied from less than
women went into spontaneous labour and 1 woman was
5cm to between 5-8 cm. The pre-hydration AFI in the
induced, out of which 48 had vaginal delivery and 2 had
studies by Umber et al, Patrelli et al and Shehzad et al
caesarean section which was done for oblique lie with
was less than 5.5-7
CPD and failed induction. All women had 100% live
birth with no NICU admission and all having APGAR
The average daily fluid intake in the study population
8,9,9. Majority had birth weight >2.5kg with mean of
was 1.46±0.4 litres ranging between 500 ml to 2 litres
2.77+0.29 kg (Table 8).
(Table 3). Nearly forty percent of the women’s daily fluid
intake prior to pre hydration therapy was less than one
Table 8: Maternal and perinatal outcome.
litre per day. Montgomery et al, recommended 8-10
Maternal outcome N Percentage glasses of water each day during pregnancy, which is
around 2-2.5 litres per day.8 Similarly, European food
Gestation at delivery
authority, reported that water intake in pregnant women
Preterm delivery 14 28
to be around 2700 ml per day.9 This clearly shows that in
Term delivery 36 72
present study fluid intake (1.46±0.4 litres) of women was
Onset of labour below the recommended amount and could be the cause
Spontaneous 49 98 of maternal dehydration leading to oligohydramnios.
Induced 1 2
Mode of delivery The present study aimed to define the appropriate volume
Normal vaginal delivery 48 96 and the correct way of administration of daily water
LSCS 2 4 intake in women with isolated oligohydramnios in third
N (no. of trimester and to evaluate whether a continuous prolonged
Perinatal outcome Percentage
babies) hydrotherapy instead of a fixed and shorter therapy can
Birth weight normalize the AFI and the AFI remains sustained,
>2.5 kg 40 80 particularly till the time of delivery. Thus in the present
<2.5kg 10 20 study, with continuous and sustained oral intake of fluids,
the average daily fluid intake of women was 4.07±0.76
DISCUSSION litres (table 4) with more than two third took between 4-6
litres. A method similar to ours was followed by Patrelli
The purpose of present study was to evaluate whether et al and Shikha et al.3,5
simple maternal oral hydration is able to normalize the
amniotic fluid index in women with isolated In the present study it was observed that there was a
oligohydramnios in the third trimester. Also, we wanted significant increase in the mean AFI on day1, day2, day3,
to define the appropriate volume and the correct way of first week then at subsequent weeks after fluid therapy
administration of daily water intake to reach this aim. (4.25cm to 6.19cm, 4.25cm to 7.33cm, 4.25cm to 8.0cm

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 Aggarwal P et al. Int J Reprod Contracept Obstet Gynecol. 2018 Feb;7(2):671-676

and 4.25 cm to 9.3cm respectively) (Table 6). The AFI in 14% in control group.12 The reported rate of caesarean
90% of the women increased to between 5-8cm on day1 was very low (4%) in present study. Anna et al, studied
of an adequate intake of oral fluids. It was more than 8cm that 15.2% caesarean section delivery among 341
in 100% of the women at the end of first week with oligohydramnios patients.13 Oligohydramnios is
continued oral hydration therapy (Table 5). The associated with increased maternal and foetal morbidities.
difference in the AFI after first week during oral Maternal morbidity is due to increased rates of induction
hydration therapy was highly significant (p value<0.001). of labour and caesarean deliveries. Perinatal morbidity
This is clear that women were dehydrated before the and mortality is due to umbilical cord compression
therapy and after taking adequate fluids orally their leading to fetal distress, low APGAR scores and
dehydration got corrected leading to increase in amniotic meconium aspiration syndrome. This clearly states that
fluid volume in them. Our results are consistent with that restoration of normal amniotic fluid at delivery decreases
of the study by Patrelli et al who reported that by giving rate of induction of labour and caesarean section. Intra-
oral hydration therapy of 2.5 litres per day plus routine partum distress is the commonest problem with
intake of water, significantly improves the quantity of oligohydramnios cases and presents as abnormal
amniotic fluid, resulting in a normal AFI at birth.5 In fact, contraction stress test, fetal bradycardia, or passage of
they noted that an increased AFI at birth was significant meconium, leading to poor fetal outcome. In present
in the group who took 2500 mL of water daily (AFI study, all women had normal AFI at the time of delivery
increased from 7.7 to 11.2 cm at birth, ΔAFI = 3.5cm) with no perinatal complications. All women had live
compared to the group who took 1500 mL daily (AFI babies with normal APGAR score and none had NICU
increased from 7.5 at to 8.6 cm, ΔAFI =1). Similarly, admission. Shikha et al found meconium stained liqour in
Shikha et al demonstrated that sustained fluid intake i.e. 54.5% of cases, 18% being thick and 36.4% thin
two litres of fluid over one hour daily, have significant meconium stained during labour.3 It has to be noted that
increment in the mean post hydration AFI, 6.09±1.65 cm in above study most of the women with thick MSL had
at 3 hour, 7.41±1.46 cm at 24 hours (p <0.001) and AFI between 5-7 cm and thin MSL was seen in women
8.06±1.55 cm at 48 hours (p <0.001) from a baseline of with AFI 7-9 cm during labour. At birth 96% of babies
5.75±1.59 cm.3 Abbasalizadeh et al also showed a had APGAR < 7 in severe oligohydramnios group (AFI
significant rise in AFI from a baseline of 5.75 to 8.06 cm <5) while only 32% in cases with decreased liquor group
at 48 hour, 5.25 to 6.40 at week1 and 7.14 at week 2 (AFI 6-8). Shikha et al showed that the cases in which
respectively when the oral hydration was sustained at 20 AFI improved to 7 and above after oral hydration had
ml/kg/day.10 This suggests that duration is more higher vaginal delivery rate, better APGAR score and
important than the dose of fluid intake. lesser NICU admission which was in agreement with
present study.3 In present study, 80% of babies had birth
In contrast, Nada et al, reported that the duration of the weight above 2.5kg and 20% had low birth weight babies
increase in AFI after oral maternal hydration remained till with overall mean birth weight of 2.77 kg (Table 7), this
one week post hydration when oral hydration was given result could be explained due to normal AFI of pregnant
at 2 litres in 2 hours and the AFI was measured at 2hours, women at the time of delivery. In consensus with present
2nd day, 4th day and 9th day.11 Number of women with study, Bachhav et al, reported 33 % neonates in the
AFI > 6 was 100% at 2 hours, 35% on day 2, 11% on day control group and 64 % in the study group (having AFI
4 and 0.05% on day 9. Thus, they reported that most of <5 cm) had birth weight <2.5 kg.14
the pregnant women’s (99.5%) AFI returned to the pre-
treatment levels by the end of first week post hydration. Thus, present study favours a positive role of oral
The maximum duration of the increase in AFI after hydration therapy with an adequate amount of fluid
hydration was about one week. This could be because the intake, extended over a long duration (till delivery) in
fluid intake was not sustained. women with third trimester oligohydramnios. Thus, a
simple correction of maternal dehydration in women with
Simply by allowing the study population to drink isolated oligohydramnios by taking adequate and
adequate fluids daily as per their convenience (mean sustained daily oral fluids normalizes amniotic fluid
intake being 4.40 +0.51 litres during hydration compared index thereby improving maternal and perinatal outcome.
to 1.46±0.41 litres pre-hydration) which has to be
continued till delivery, we were able to suggest that the ACKNOWLEDGMENTS
correct daily and sustained oral fluid intake helps in
maintaining adequate AFI till delivery. Author wish to express heartily thanks and gratitude with
full respect to Dr. Sharda Patra, Professor, Dept of
All of the women achieved normal amniotic fluid index Obstetrics and Gynaecology, Lady Hardinge Medical
at first week of oral hydration therapy. At the time of College, New Delhi. Her support, encouragement,
delivery all had normal amniotic fluid index. Out of 50 guidance and great personal interest was a constant
women enrolled in present study 2% were induced in driving inertia to finish this work.
view of postdated pregnancy, 98% went into spontaneous
labour. Hina et al reported induction rate was 63% in Funding: No funding sources
women with isolated oligohydramnios as compared to Conflict of interest: None declared

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 Aggarwal P et al. Int J Reprod Contracept Obstet Gynecol. 2018 Feb;7(2):671-676

Ethical approval: The study was approved by the therapy on women with oligohydramnios. Res J
Institutional Ethics Committee Obstet Gynecol. 2008;1(1):25-9.
8. Montgomery KS. An Update on Water Needs during
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