D (4:11)

But it doesn't matter. It just doesn't matter. It just doesn't matter. I tell you, it just doesn't matter.

C (4:19)

So that's the question that we're gonna cover, is that the case, is MVP better or is AFI or does it just doesn't matter. Let's figure it out when we come back. This is Dr. Chapas obgyn no spin podcast. So what's neat about being in the OB community is it really is a small world. We talked about SMFM console series number 46, which we will touch on in this episode, which has to do with the management of polyhydramnios. But one of the authors was. Is Jodi Dash. So Jody was an MFM fellow when I was still a resident in the lands. That's parkland and phenomenal. She's just great. She's just a great person. But I remember when she first started first year as a fellow and then it went on to do look amazing, great things. So great job, Jody. But that was console series number 46. That was in 2018. But our main focus is this new BJOG publication from January 2026. Now, let me just. We're going to cover lots of things, but it's going to be fast. But what I really want to cover is the main finding of this January 2026 piece from Vince et al. Which we'll, we'll cover this. But more importantly, what it is and what it is not. What it is is a great attempt to an question that we just don't have the data for. And so hopefully this was going to figure it out because as it says in the intro, which methodology AFI versus MVP has a stronger association with adverse perinatal outcomes is uncertain. In other words, while we know that MVP is better for oligo, we've already said that because that's a better predictor of adverse things happening. We don't really know if it's AFI or MVP for poly. So we're going to figure it out. So this was a systematic review of the literature. Phenomenal. So we're like, yes, it's going to fill a gap. So let me just tell you very briefly what it is. What this paper is, is a great attempt to answer that question that we just stated. What it isn't is a good answer. Because they're like, man, we had these high hopes and we had 133 studies that we screened. We're like, yeah. And then they found, quote, well, there's no real RCTs comparing the outcomes using MVP, AFI or both. And while there are five non RCT studies that were assessed for eligibility, they had 5,319 patients. That's good. However, only one retrospective study reported neonatal outcomes, end quote. So like, well, we had high hopes for this, but we have, there just really isn't high quality RCTs to tell us which one's better. So again, what it is is a great attempt to answer a question. What it isn't is a real solid answer. But I'm gonna tell you what they found. Should we do MVP or AFI for poly? Because it's kind of disappointing. All right, so in their final statement here, before I tell you which one is better, AFI or MVP, quote, there's an urgent need for RCTs comparing different ultrasound methodologies for the diagnosis of poly in terms of adverse perinatal outcomes so that we can have a solid evidence based management of polygon poly in everyday clinical practice, end quote. So they're like, hey, look, I'm gonna tell you what I found. I'm gonna tell you which one is better or if it really doesn't matter at all. But we really need much better, higher quality data to guide us here. Okay? So what it is is a valiant attempt to answer a question while we know that MVP is better. For oligo. Is that the same for poly? What it isn't is a real, firm, solid, high quality data answer, because we just don't have that. So it's like. In other words, I'm going to give you an answer, but it's kind of crappy data because we need lots better randomized clinical trials to answer this. Okay, anyway, so let me just go back for a minute. Before we get into the Pauli thing, let me just remind all of us about the oligo issue in ACOG's practice bulletin number 229. That's one on endopartum fetal surveillance, and it says, determination of the amniotic fluid volume by a deepest vertical pocket greater than 2 cm is considered evidence of adequate amniotic fluid, although oligohydramniose. I'm reading directly here from the practice bulletin. Although oligohydramnios has been commonly defined as a single deepest vertical pocket fluid of two or less. Again, not contained in umbilical cord of fetal extremities or an AFI of 5cm or less, available data from randomized controlled trials supports the use of the deepest vertical pocket for the diagnosis of oligo. End quote. All right, so again, a single deepest vertical pocket of 2 centimeters or less is oligo. So it's inclusive of the two. All right, so every. Everybody good. Remember, normal fluid is greater than 2. So if it's 2.1, technically you dodged it by 0.1. Still normal, right? Now, if you really have to do a 2.1, I mean, please make sure you're not missing oligo. All right, but the point is it is greater than 2. So oligo is defined as a fluid Maxwell vertical pocket of 2cm. So 2.0 or less, it has to be greater than 2. 2 is still considered low. So we get that RCT support that. So for all ago, we've got solid evidence. Rather than AFI of 5, please use an MVP of 2. That is what ACOG and SMFM say for surveillance. Okay, now just so we remind ourselves of the definitions of polyhydramnios and their different categories. Mild, moderate or severe. Let's go back to console series number 46, where Jody Dash was part of that authorship. Okay, so remember that a deepest vertical pocket of 8cm or more is considered poly. Or if you're going to use an AFI, it's 24cm or more. But these are further subdivided. Mild, moderate or severe. So let's do. First, the Deepest vertical pocket, 8 to 11 is considered mild, 12 to 15 is considered moderate. More than 16 is considered severe. All right, so deepest vertical pocket, 8 to 11, 12 to 15, and then greater than 16 for AFI, 24 to 30 is mild, 30 to 35 is moderate, and then more than 35 is severe. Okay, now I am going to touch on that consult series, the management of poly. I'm just going to read one right after the other. Boom, boom, boom, boom. We're just going to go rapid fire. There's six recommendations on how to manage poly, which we've covered in the past, but it's going to tie in nicely to this new publication from bjog. Okay. Okay. So we get it for oligo. And if you're going to do endopartic fetal surveillance, I'm a big fan of modified biophysical profile. Just getting the deepest vertical pocket and NST as the acute and chronic marker. Acute is the nst, chronic is the masculine fluid pocket, maximum vertical pocket, because that is the same risk of stillbirth as a full. You need to know how to do a full biophysical in case the modified is not conclusive. In other words, if one of the values is off, if it's two out of four, you need to do the full to get more information. Unless you're missing that minus two is for fluid. Then you got to figure out why there's low fluid. Is she ruptured? Is it really amniotic fluid as a result of placental insufficiency? And remember, the ACOG says persistent oligo over 36 weeks is a standalone indication for. For induction because of the potential. The potential of umbilical cord compression. So I'm a big fan of modifieds, getting the NST and the maximum vertical pocket. And if it's four out of four, you're done. So the point is, if you're going to do surveillance, ACOG and SMFM prefer the maximum vertical pocket. For the diagnosis of normal fluid, which is greater than 2, 2 or less is considered oligo. And remember, we covered this in the past. Also, what gets you the two on a biophysical profile, either the full or the modified, is if the fluid is greater than 2. So even if it's poly, you still get a 2. But it should be a biophysical profile score of this with an asterisk. It says, hey, even though we gave two points for fluid which is above two, you got to know that the fluid is still not normal because it's poly. So it's not. If the fluid is within the normal range, the only thing that counts is that it's greater than 2. For a maximum or vertical pocket to be considered normal or greater than 5 on an AFI to say normal fluid, you get a checkbox. All right, so polyhydramniose. There's no specific caveat that would take away the points on the either a full or modified biophysical profile that still gets a 2 determination because it's greater than 2 centimeters or 5 centimeters on the A5. Okay, so very quickly, let me just. Let me just kill this fast, because it's going to be relatively fast, because this research letter, by the way, I love the way BJOG does research letters, y'. All. It's like three pages long. I mean, it's like, hey, here's what we found. Boom, boom, boom. Here's the results, and here's what you need to know. Very nice. Okay, now, some studies are amenable to research letters, others aren't. But this one definitely was because there was very little data to look at. The short of it was in this publication, whether you use an MVP or an afi, knowing, of course, that the data was very limited, it didn't matter. Both of them were linked to adverse perinatal outcomes. Now, as it says, quote, this is interesting, and in contrast with the literature regarding oligo, where oligo seems to have a much better prediction of morbidity mortality based on maximal vertical pocket. But in this case, the same is not true for poly. So whether you call poly mild, moderate, or severe by deepest vertical pocket or by afi, it doesn't matter. Both of them seem to be predictive against adverse perinatal issues. So remember, guys, that we worry about core compression with oligo. We get that. But poly also is linked with some adverse perinatal outcomes. So poly isn't good either. That's got its own set of issues. Okay, so oligo is not good for perinatal outcomes, and poly is not good for perinatal outcomes. Both of these are associated with adverse issues. And on the poly side, unlike for oligo, it really doesn't matter if you use the AFI or if you use the maximum vertical pocket. The morbidities were reflected in either determination method.

D (16:45)

But it doesn't matter. It just doesn't matter. It just doesn't matter. I tell you. It just doesn't matter.

C (16:53)

So in this case, unlike for oligo, it really doesn't matter. Once again, guys, we're covering BJOG's January 2026amniotic fluid index versus maximal vertical pocket versus both for polyhydramnios. And even though the data is limited, and even though we need much better RCTs. It just doesn't matter. Both of them are linked with increased perinatal adverse events. Now that we've covered that very quickly, let me just give you the recommendation. Six of them. What to do with polyhydramniose once you find it. Remember, mild, moderate or severe, either by deepest vertical pocket or afi. So let's do this. Now, the six recommendations for management, and we've covered this in the past, what to do regarding poly Number one, we suggest that polyhydramniose in singleton pregnancies, that's the catch. For twins, you gotta use maximum vertical pocket. But for singletons, defined as either a deepest vertical pocket or as an amniotic fluid index. So again, deepest vertical pocket of 8 or an amniotic fluid index of greater than 24. So even in SMFM's guidance, it's exactly what we stated here. You can do one or the other. Because the truth is, based on adverse outcomes, it really just doesn't matter.

D (18:19)

Well, it doesn't matter. It just doesn't matter. It just doesn't matter. I tell you, it just doesn't matter.

C (18:28)

So once again, as I've said many times before, you'll see the trend here. Nothing is new under the sun. Vanity, vanity. Anybody get that? Anybody? Little Ecclesiastes for you. All right, so number one, in the first recommendation, you can use either AFI or MVP according to SMFM's console series. Number two, we recommend amnioreduction be considered only for the indication of severe maternal discomfort, dyspnea, or both in the setting of severe poly. So don't go sticking needles in mild or moderate. They're gonna be fine. Just do it for severe if the patient can't breathe. Number three, we recommend that indomethacin should not be used just for the sole purpose of decreasing amniotic fluid in the setting of poly. Please don't do that. That's got its own set of issues. Good idea, but horrible, horrible outcome. So. So don't use indomethacin for poly. Number four, we suggest that antenatal fetal surveillance is not required for the sole indication of mild idiopathic poly. So if you find. Hey, based on deepest vertical pocket, it's between 8 and 11. You don't need surveillance for that. Or if it's between 24 and 30, it should be fine. You really don't need surveillance for that. Based on afi. Number five, we recommend that labor should be allowed to occur spontaneously at term for women with mild idiopathic poly and induction if it is planned, should not occur under 39 weeks in the absence of other indications, and that the mode of delivery be determined based on usual obstetrical indications. In other words, you don't have to do an early induction just because they have mild idiopathic poly. And in general, you shouldn't be inducing under 39 weeks for Poly period. Unless other issues are going on. The last recommendation, number six, and then we're wrapping this up. Number six, quote, we recommend that women with severe poly deliver at a tertiary center due to the significant possibility that fetal anomalies may be present. End quote. Now you go. Well, I did a level 2 ultrasound. Kid looks fine. That's phenomenal. Good. And we start from. Start from the face all the way down. Good. There's no facial structures. There's no evidence of oral facial clefts or defects. It doesn't look like maybe a duodenal atresia where the fluid can't recycle. It doesn't look like it's a GI issue. You see a stomach bubble, all that's fine. There's no sacral teratoma that could leak some fluid into the cavity. That's all great. Phenomenal. There are things that the baby may have that are not able to be seen. And even if the anatomical survey is normal, the baby may have a neuromuscular issue that can prevent proper swallowing. You cannot see that on ultrasound because that's a functional defect. All right? So while it's very reassuring in the cases of a normal anatomical survey, in cases of mild poly, in cases of moderate or severe poly, even if the child looks normal, which again is a good sign, it doesn't rule out functional. Functional neuromuscular issues where swallowing could potentially be impaired. So the recommendation from smfm, their six, and their final in their list of six is that they really should be at a tertiary center because the possibility of some fetal anomaly and. Or neuromuscular issue, and you got to get the proper people in place. So even back in consult series on the management of polyhydramnios, number 46 from 2018, it said, whether you choose to do an AFI or an MVP for something like poly, it's good to have a preference. That's fine for af. For oligo, it definitely does make a difference. But that's not the case for poly.

D (22:25)

Doesn't matter. It just doesn't matter. It just doesn't matter. I tell you, it just doesn't matter.

C (22:33)

Anybody knows where that sound clip came from? Anyone? Does that voice sound familiar? No. No idea. No. Bill Murray. That is Bill Murray. Thank you to our producer for finding the most awkward and and non clinically relevant sound bites. Yeah, this was the old coming of age comedy. Meatballs. My goodness, Meatballs. What year was that? 1917. What? 1979. 1979. Bill Murray. It just doesn't matter.

D (23:05)

It just doesn't matter. It just doesn't matter.

C (23:09)

Oh, my God. I can't do that again. Be done with that. All right, so anyway, that's what we're talking about here. We've covered brand new again, our job, guys, to let you know what is hot in press. This came out January 2026, the same month that we are recording this. And as point of reference, it is the 23rd of January. And in Texas, as most parts of the country, we are bracing for the snow ice apocalypse. So you all take care. Be careful in this crazy weather. It may or may not happen. I know in Texas weather is very bipolar, but I think we're gonna start wrapping this up. We have covered Vince Brigea's publication called Amniotic Fluid Index versus maximal Vertical Pocket versus both for polyhydramniose. And in this case, even though we need a lot better data because this one was surprisingly disappointing, that we didn't have a lot of RCTs and only one, which was retrospective, actually looked at perinatal outcomes. It doesn't seem to matter. Oh, my God. Now he's playing again.

D (24:07)

Trinidad Tobago. But it doesn't matter.

C (24:10)

Oh, my God.

D (24:11)

It just doesn't matter. It just doesn't matter.

C (24:15)

Meatballs. 1979. Not definitely not a sponsor podcast family. As always, we're thankful for you. We're glad you're part of our podcast community. Stay safe in this January 2026 ice storm, wherever you are in the country. And if you're abroad again, thank you for being part of our podcast family. All right, I think I've done it all here. Are we done now, Michael? Yep. All right, let's take it home. This has been Dr. Chapa Zobi Gyn, no Spin podcast podcast family. Thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin Podcast. It.