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Amnioreduction Technique

  • Author: Jenny E Halfhill, DO; Chief Editor: Carl V Smith, MD  more...
 
Updated: Feb 04, 2015
 

Ultrasonography

Ultrasound-guided needle placement is the standard for amnioreduction. Transplacental procedures should be avoided if possible.

A surgical site is created with appropriate skin scrubs and sterile towels. Sterile covers and sleeves should be available for the ultrasound transducer. Typically, the site chosen for amnioreduction is ventral to the fetus—that is, between the knees and the elbows. Before needle insertion, sonographic calipers may be used to calculate the approximate depth to which the needle should be advanced.

Current practice is to perform needle placement under direct ultrasonographic guidance, with the needle adjacent to the ultrasound transducer and sterile cover (see the image below). The needle is observed within the 2-dimensional image generated by the transducer as it moves into the target location.

Image of ultrasound-guided amnioreduction. The son Image of ultrasound-guided amnioreduction. The sonogram shows needle placement for amnioreduction in a case of polyhydramnios.

Amnioreduction may be useful in singleton pregnancies complicated by polyhydramnios.[10] If a substantial amount of fluid is to be removed, the reduction in the size of the uterus may be sufficient to change the anatomic orientation. As a preemptive measure in these circumstances, inserting the needle in a cephalic direction may be prudent. As drainage continues, the needle will then become caudally directed and thus will be less likely to disengage from the amniotic cavity.

If the pregnancy is viable, a nonstress test may be performed at the completion of amnioreduction to document fetal well-being. Testing may continue to be performed weekly or twice weekly thereafter, including biophysical profiles as appropriate, depending on the indication for the procedure. If the amnioreduction was performed for twin-twin transfusion syndrome (TTTS), additional amnioreduction procedures may be required.

In cases of mirror syndrome associated with TTTS, amnioreduction alone or with selective feticide may result in complications such as a transient exacerbation of anemia and hemodilution which may cause severe maternal complications.[11]

In a Cochrane database meta-analysis of treatment interventions to improve maternal-fetal outcomes in TTTS, investigators found no difference between amnioreduction and endoscopic laser coagulation of anatomic vessels and between amnioreduction and septostomy in the following[12] : overall death, death of at least one infant per pregnancy, or death of both infants per pregnancy. Between amnioreduction and septostomy, there was also no difference in gestational age at birth. Over the long term, although more surviving babies were neurologically intact at age 6 years in the laser group than in the amnioreduction groups, no significant difference was seen between the surviving babies alive at 6 years who had major neurologic abnormalities who were treated with these interventions (laser or amnioreduction).[12]

 
 
Contributor Information and Disclosures
Author

Jenny E Halfhill, DO Resident Physician, Department of Obstetrics and Gynecology, Western Pennsylvania Hospital

Jenny E Halfhill, DO is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Ronald Lee Thomas, MD Associate Professor, Department of Obstetrics and Gynecology, Drexel University College of Medicine; Director, Division of Maternal-Fetal Medicine and Obstetrical Services, Director, Department of Obstetric/Gynecological Ultrasound, Allegheny General Hospital, West Penn Allegheny Health System

Ronald Lee Thomas, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Pennsylvania Medical Society, Society for Maternal-Fetal Medicine, Allegheny County Medical Society, Johns Hopkins Medical and Surgical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center

Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association

Disclosure: Nothing to disclose.

References
  1. Coviello D, Bonati F, Montefusco SM, Mastromatteo C, Fabietti I, Rustico M. Amnioreduction. Acta Bio Medica Ateneo Parmense. 2004. 75:31-33.

  2. Piantelli G, Bedocchi L, Cavicchioni O, et al. Amnioreduction for treatment of severe polyhydramnios. Acta Bio Medica Ateneo Parmense. 2004. 75:56-58.

  3. Fisk NM, Tannirandorn Y, Nicolini U, Talbert DG, Rodeck GH. Amniotic pressure in disorders of amniotic fluid volume. Obstet Gynecol. 1990. 76:210-214.

  4. Queenan JT, Gadow EC. Polyhydramnios. Am J Obstet Gynecol. 1970. 108:349-355.

  5. Makino Y, Makino I, Tsujioka H, Kawarabayashi T. Amnioreduction in patients with bulging prolapsed membranes out of the cervix and vaginal orifice in cervical cerclage. J Perinat Med. 2004. 32.

  6. Jan E Dickinson. Amnioreduction therapy for twin-twin transfusion syndrome. Quintero RA. Twin-Twin Transfusion Syndrome. Informa Healthcare; 2007. 891-97.

  7. Leung W, Jouannic J, Hyett J, Rodeck C, Jauniaux E. Procedure-related complications of rapid amniodrainage in the treatment of polyhydramnios. Ultrasound Obstet Gynecol. 2003. 23:154-158.

  8. ACOG Committee Opinion No. 402: Antenatal corticosteroid therapy for fetal maturation. Obstet Gynecol. 2008 Mar. 111(3):805-7. [Medline].

  9. Beloosesky R, Ross MG. Polyhydramnios [database online]. UpToDate. Accessed December 17, 2011:

  10. Dickinson JE, Tjioe YY, Jude E, Kirk D, Franke M, Nathan E. Amnioreduction in the management of polyhydramnios complicating singleton pregnancies. Am J Obstet Gynecol. 2014 Oct. 211(4):434.e1-7. [Medline].

  11. Chai H, Fang Q, Huang X, Zhou Y, Luo Y. Prenatal management and outcomes in mirror syndrome associated with twin-twin transfusion syndrome. Prenat Diagn. 2014 Jul 9. [Medline].

  12. Roberts D, Neilson JP, Kilby MD, Gates S. Interventions for the treatment of twin-twin transfusion syndrome. Cochrane Database Syst Rev. 2014 Jan 30. 1:CD002073. [Medline].

 
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Image of ultrasound-guided amnioreduction. The sonogram shows needle placement for amnioreduction in a case of polyhydramnios.
 
 
 
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