L - Arginine In OligohydramniosDr. Shashwat Jani.

M. S. ( Obs – Gyn )Diploma in Advance Laparoscopy.

Consultant Assistant Professor,Smt. N.H.L. Municipal Medical College.

Sheth V. S. General Hospital , Ahmedabad.

Mobile : 99099 44160.E-mail : drshashwatjani@gmail.com

Introduction Oligohydramnios is one of the

prevalent threatening conditions to fetal health

Causes for Oligohydroamnios - post-term pregnancy

- pregnancy induced hypertension

- fetal renal agenesis,

Conditions associated with oligohydramnios. -Intrauterine growth restriction -respiratory distress syndrome, -post-maturity syndrome - chronic fetal hypoxia

Oligohydroamnios may be responsible for

-fetal malpresentation-umbilical cord compression-meconium staining-increased prenatal mortality and morbidity-increased operative delivery.

Vascular tone is an essential target of the paracrine and endocrine regulations during pregnancy.

The lowering of arteriolar tonicity precedes blood volume expansion and seems to be the primary step in the physiological hemodynamic modifications.

Poor placentation may be expressed in the persistence of high impedance in the uteroplacental circulation

-assessed by the second trimester Doppler in the uterine vessels,

represents a powerful predisposing factor to

IUGR Oligohydramnios Preeclampsia

Why …???

• The most common placental conditions are alterations in the uteroplacental and fetal-placental circulations.

• In the majority of these cases,

there is diminished maternal uteroplacental blood flow,

caused by insufficient or incomplete trophoblastic invasion of the spiral arteries in the placental bed.

Oligohydramnios is associated with an adverse perinatal and maternal outcome.

Ultrasound guided amnioinfusion is an option for treatment commonly being employed nowadays. Since it is an invasive procedure there is an inherent risk of fetal loss.

Another modality employed since a long period of time is maternal hydration though results have been varied and there is no standard treatment protocol for the same.

‘ A recently propagated alternative for the treatment of oligohydramnios is the administration of L- arginine which has been

found to be effective in- cases of intrauterine growth

restriction - Pregnancy Induced Hypertension.’

L- Arginine is a Nitric Oxide Donor

L – Arginine • L-arginine is a versatile amino acid with a

wide range of biological functions.

• It serves as a precursor not only to proteins but also nitric oxide which has

been identified as endothelium-derived relaxing factor.

Palmer RM, Ashton DS, Moncada S. Vascular endothelial cells synthesize nitric oxide from L-arginine. Nature 1999;333:664-6.

Act by…• L-arginine increases uteroplacental blood

flow through nitric oxide mediated dilatation of vessels thereby increasing the supply of nutrients to the fetus aiding its growth.

• L-Arginine improves Uteroplacental blood flow to overcome placental ischemia by increasing Nitric oxide.

• This results in vasodilation of uterine arteries.

Neri et al evaluated the effects of L-arginine (ARG) infusion, the nitric oxide substrate on the uteroplacental circulation in the third trimester.

Three groups of nine women each were infused with 30 g ARG for 30 min.

One group served as a control. remaining two groups had IUGR,- one with increased resistance in uteroplacental circulation - one without increased resistance. The authors found no haemodynamic changes in the

utero-umbilical circulation. They found that serum nitrites/nitrates as well as serum

growth hormone levels were significantly raised by ARGININE.• Neri I, Mazza V, Galassi MC, et al. Effects of L-arginine on utero-placental circulation in growth related fetuses. • Acta Obstetet Gynecol Scand. 1996; 75:208–212

Rytlewski et al. studied the influence of oral supplementation with low dose of ARG on• biophysical profile, •Oligohydramnios,• feto-placental circulation and •neonatal outcome in preeclampsia. •This was a randomized, placebo-controlled, double-blind, clinical trial.Oral therapy with 3 g of Arginine daily or placebo was given as a supplement to standard therapy. •The results -L arginine treatment accelerated fetal weight gain and -improved biophysical profile. •Starting from the 3rd week of therapy,- the umbilical artery pulsatility indices values were significantly lower in the ARG group. -Neonates in this group revealed higher Apgar scores.

The authors concluded that supplementary treatment with oral ARG seems to be

promising in improving

- foetal well-being - neonatal outcome - prolonging pregnancy complicated with pre-eclampsia &

Oligohydramnios.

• Rytlewski K, Olszanecki R, Lauterbach R, et al. Effects of oralL-arginine on the foetal condition and neonatal outcome in preeclampsia:a preliminary report. Basic Clin Pharmacol Toxicol.2006; 99(2):146–152.

• Interestingly,

the incidence of

-intracranial hemorrhage,

-respiratory distress syndrome

-admission to NICU

are significantly lower in the

L-arginine supplemented patients.

L Arginine is ….

Very effective Cost effective Easily available No adverse effect on Mother & Fetus less side effects Prevents Oligohydramnios Treats Oligohydramnios Highly recommended …

THANK YOU…!!!