As my pregnancy progresses, this whole too-much-amniotic-fluid issue is proving itself to be a bigger complication than I originally thought. Here's a quick explanation of the condition from www.americanpregnancy.org with notes about the particulars of my polyhydramnios in italics:
The amniotic fluid is part of the baby’s life support system. It protects your baby and aids in the development of muscles, limbs, lungs and the digestive system. Amniotic fluid is produced soon after the amniotic sac forms, about 12 days after conception. It is first made up of water that is provided by the mother. After about 20 weeks into the pregnancy, it is primarily made up of fetal urine. As the baby grows, he or she will move and tumble in the womb with the help of the amniotic fluid. In the second trimester the baby will begin to breathe and swallow the amniotic fluid. Amniotic fluid levels increase regularly until about 32-33 weeks gestation, and then they level off. In some cases the amniotic fluid may measure too low or too high. Normal fluid levels may vary, but are usually considered an AFI of 5-25 centimeters or a fluid level of about 800-1000 mL. At my first ultrasound, I had a level of 21. A subsequent ultrasound at the maternal/fetal specialist shows it to be closer to 25 now. So, I'm considered to have a "mild" case. If the measurement of amniotic fluid is too low it is called oligohydramnios. If the measurement of amniotic fluid is too high it is called polyhydramnios.
What is Polyhydramnios?
Polyhydramnios is the condition of having too much amniotic fluid. Doctors can measure the amount of fluid through a few different methods, most commonly through amniotic fluid index (AFI) evaluation or deep pocket measurements. If an AFI shows a fluid level of more than 25 centimeters (or above the 95th percentile), a single deep pocket measurement of <8, or a fluid level of 2000mL or more, then a diagnosis of polyhydramnios would be made. About 1-2% of pregnant women have too much amniotic fluid. Most of these cases are mild, with only slightly elevated levels.
Mild is such a relative term. I complained to the doctor initially about really intense abdominal pain. It was actually the intensity of hard labor, but not in any of the right places. Luckily it only happened once. I'd been coping with general abdominal pain for much longer than that. He ordered all kinds of tests, including an ultrasound, and the ultrasound picked up my excess amniotic fluid. At which point the fun began. You wouldn't think excess fluid would be so painful, but it is. My abdomen is very distended and hard to the touch. It's also particularly tender and sensitive to the sensation of John kicking. What shouldn't be painful feels like bone scraping on bone. On top of that, because I'm in my third trimester, my uterus is pressing into my organs, causing lots of heartburn and difficulty breathing anyway. I don't know how women with more severe cases stand it.
What causes levels of amniotic fluid to be elevated?
Congenital defects – The higher the fluid level, the increased chance of a congenital defect. These birth defects hinder swallowing, which can prohibit ingestion of the amniotic fluid, resulting in build up of fluid. Other birth defects could also include intestinal tract blockage or neurological abnormalities.
Rh Factor – As screening for the Rh factor has increased, this is no longer a common cause of elevated fluid levels.
Maternal Diabetes – Experts have found some correlation between diabetes and too much amniotic fluid.
Twin-to-twin transfusion syndrome – This is a complication that can affect identical twin pregnancies. This syndrome is when one baby gets too much blood flow and the other too little due to connections between blood vessels in their shared placenta.
Unknown Reasons – According to the Center for Maternal Fetal Medicine, about 65% of cases of polyhydramnios are due to unknown causes. This would be me.
What are the risks of having too much amniotic fluid?
Most cases of polyhydramnios are mild and result in few, if any, complications. Those with higher levels of fluid could experience one or more of the following risks:
Premature rupture of the membranes (PROM)
Preterm labor and delivery (approximately 26%) I was already at risk for this because of my history of preterm labor with Sam. On Tuesday, I was having contractions 10 minutes apart, but the doctor decided not to stop them.
Growth restriction (IUGR) resulting in skeletal malformations
Stillbirth occurs in about 4 in 1000 pregnancies that suffer from polyhydramnios vs. about 2 in1000 pregnancies with normal fluid levels.
Another complicating factor lately has been John's reaction to the Non-Stress Test. I go in at least once a week now to have his well being and my contractions monitored. Doctors consider a baby's NST to be reassuring when the baby's heartrate accelerates during the test. The thinking is that this corresponds to fetal movement. They don't like to see "flat" heartrates or deaccelerations. John has already had multiple tests, and several of them have been less than stellar. Twice they've been non-assuring, and once he passed to assuring by the skin of his teeth. Whenever the tests are non-reassuring, I have to go up the road a few blocks to the maternal/fetal specialist for a very detailed biophysical profile ultrasound. He has always been fine on ultrasound, which is why I'm not hysterical at this point, but I'm sure our insurance provider is less than happy with these thousand dollar ultrasounds on a now almost weekly basis.
What are the treatments for elevated amniotic fluid levels?
Many cases of polyhydramnios are easily treated and do not result in complications if the pregnancy is monitored closely. Monitoring would include frequent sonograms measuring growth, biophysical profile and fetal assessment. Lately, I've had it all. You've gotta love access to good medical care.
Other treatments could include:
Medication that can reduce fluid production and are as much as 90% effective. This treatment is not used after 32 weeks gestation because of possible complications.
Amnioreduction is a procedure that can be used to drain excess fluids. This is done through amniocentesis, which may carry certain risks. There is, however, the chance that fluid could build back up even after draining.
Delivery of the baby I'm getting closer and closer to this one. My theory is that the doctor is letting me have pre-term contractions in the hopes that I'll be ready to deliver in another two weeks when John is mature enough for delivery. I'm at the stage in the pregnancy now, however, that if I did actually deliver John in the next few weeks, he wouldn't require a lot of intervention. Sometimes at 35/36 weeks, babies haven't cooked long enough to 1) breathe well on their own 2) regulate body temperature on their own 3) coordinate a good sucking motion on their own. All of this would obviously require some extra intervention, but is hardly cause for alarm, just concern.
It is amazing how wonderful the internet is--how much information one can glean from reading all the different sites. I've tried to educate myself as much as possible, not to give myself something else to worry about, but because I like to have a good idea about what's likely to happen next. Given my doctor's general lack of explanation about what is going on, it's a good thing I know how to do research. I have a very capable doctor, don't get me wrong, but he is very much a let-me-do-the-thinking kind of person.
Today I have another NST test--my second this week--and am curious to see what will come of it. Because of the excess fluid, it's hard for me to tell if I'm still having contractions. My guess is that I am because I've felt crampy all week. I don't know what will happen in the next few weeks, but I feel like I can almost guarantee that John will be a May baby.