Current contraceptive use in women with a history of unintended pregnancies: Insights from the Australian Contraceptive ChOice pRoject (ACCORd) trial.

BACKGROUND AND OBJECTIVES: Clinical guidelines advocate using long-acting reversible contraceptives (LARC) to reduce unintended pregnancy, but LARC use in Australia is poor. Additionally, little is known about contraceptive practices of women with a history of unintended pregnancy. The aim of this study was to describe current contraception use according to a history of unintended pregnancy. METHOD: Data were analysed from women recruited into The Australian Contraceptive ChOice pRoject (ACCORd) trial. RESULTS: Approximately 47% (128/275) of women aged 16-45 years reported unintended pregnancies, and 30% had an abortion (83/275). Contraceptive data available from 117 women showed that condoms (24%, n = 28/117) and the oral contraceptive pill (22%, n = 26/117) were most commonly used among women reporting one unintended pregnancy or more. DISCUSSION: These findings support implementing interventions to increase the uptake of effective contraception, as successfully demonstrated in the ACCORd trial, in general practice.

Dietary intake and eating behavior in depot medroxyprogesterone acetate users: a systematic review.

Because of weight gain, women often discontinue hormonal contraception, especially depot medroxyprogesterone acetate (DMPA). Our objective was to conduct a systematic review of studies describing dietary intake or eating behavior in DMPA users to understand whether the use of DMPA is associated with changes in dietary habits and behaviors leading to weight gain. We searched the PubMed, POPLINE, CENTRAL Cochrane, Web of Science, and EMBASE databases for reports published in English between 1980 and 2017 examining dietary intake or eating behavior in healthy women in reproductive age and adolescents using DMPA (150 mg/mL). Of the 749 publications screened, we excluded 742 due to duplicates (96), not addressing the key research question (638), not reporting dietary intake data (4), and not evaluating the relationship of body weight and dietary or eating behaviors (4). We identified seven relevant studies, including one randomized placebo-controlled trial, one non-randomized paired clinical trial, and five cohort studies. The randomized trial found no association and the other reports were inconsistent. Findings varied from no change in dietary intake or eating behavior with DMPA use to increased appetite in the first six months of DMPA use. Few studies report dietary intake and eating behavior in DMPA users and the available data are insufficient to conclude whether DMPA use is associated with changes in dietary habits or behavior leading to weight gain.

Prognostic value of clinical variables in ovarian cancer.

OBJECTIVE: To test the hypothesis that clinical variables, including the patient's symptoms, symptom severity, and co-morbidity, affect the survival rate in patients with ovarian cancer. METHODS: We reviewed the records of 137 cases of ovarian cancer diagnosed and treated between January 1987 and June 1992, and extracted data regarding patients' demographic characteristics, symptoms, medical co-morbidity, stage of disease, tumor histology and grade, treatment, and clinical course. RESULTS: Once cases of borderline tumors were excluded, the overall 3-year and 4-year mortality rate were 38% and 49%, respectively. There was an decrease in 4-year survival with more advanced symptom type ranging from 85% in asymptomatic women to 38% in women with complex symptoms (log rank, p = 0.005). Medical co-morbidity was not found to affect survival in the cohort studied. We performed multivariable analysis using a Cox proportional hazards model and confirmed that the symptom stage was highly prognostic even after controlling for FIGO stage, age and co-morbidity (p = 0.004). CONCLUSION: We found that clinical variables such as patient's symptoms, were associated with prognosis. Symptom classification is a necessary and important component in a system of prognostic stratification for ovarian cancer.

Oral contraceptive risk assessment: a survey of 247 educated women.

OBJECTIVE: To determine womens' beliefs regarding the risks and health benefits of oral contraceptives (OCs). METHODS: Between April 26 and June 7, 1991, 247 women completed a self-administered questionnaire at the Yale University Health Services evaluating their perceptions of the risks and benefits of OC agents. RESULTS: The mean age of the study population was 30.2 years (range 16-68), and more than 90% of the study group had at least 1 year of college education. Forty-nine percent of the study group believed there are substantial risks to OC use. Between 80-95% of women were unaware of the following health benefits of OCs: decreased risks of endometrial cancer, ovarian cancer, pelvic inflammatory disease, ectopic pregnancy, anemia, and benign breast disease. CONCLUSIONS: Perceptions of the risks of OCs are exaggerated and there is a clear knowledge deficit with regard to their health benefits. Increased educational efforts by health care providers should emphasize the health benefits of OCs and attempt to dispel the common misconceptions.

The case-control study: a primer for the obstetrician-gynecologist.

Case-control studies begin at the end. Two groups of patients, those with disease (cases) and those without (controls), are compared to determine the degree of exposure to a presumed risk factor. This research method is commonly used to study rare diseases or diseases that take years to develop. If a higher proportion of cases than controls has the exposure of interest, the exposure may be associated with illness. The strength of this association is measured by an "odds ratio," which is a good proxy for a relative risk when the illness in question is infrequent. Although some case-control studies are easy to do, all are easy to do poorly, especially because of selection bias in the choice of controls. A greater familiarity with the case-control study should enable obstetrician-gynecologists to evaluate critically published studies using this research method.

Diagnostic testing in obstetrics and gynecology: a clinician's guide.

As we enter a new era of health care in the United States with limited economic resources, there will be an increasing demand for thoughtful and critical evaluation of the diagnostic tests used in clinical medicine. To interpret the clinical utility of diagnostic tests, the physician must understand the fundamental concepts of sensitivity, specificity, and predictive values. The purpose of this paper is to define these terms, demonstrate the use of receiver operating characteristic curves and Bayes' theorem, and provide clinical examples in obstetrics and gynecology to illustrate their use. Practitioners must be able to interpret the results of diagnostic tests to provide accurate information to their patients.

Maternal age: an independent risk factor for cesarean delivery.

OBJECTIVE: To evaluate whether there is an increased risk of cesarean delivery in women who delay childbearing into their later reproductive years, using a well-defined cohort and controlling for difference in baseline susceptibility such as complications of pregnancy and labor. METHODS: The current study included all women at least 20 years of age delivering their first child and evaluated between 1988-1991 as part of the prospective Yale Health in Pregnancy Study (N = 735). All women planned to deliver at Yale-New Haven Hospital. The study group was divided into three maternal age groups: 20-29 (N = 422), 30-34 (N = 239), and 35 and over (N = 74). Information collected included demographic characteristics, medical history, pregnancy complications, labor complications, mode of delivery, and pregnancy outcome. RESULTS: The cesarean delivery rates for the three age groups were 16.8% (71 of 422), 26.8% (64 of 239), and 32.4% (24 of 74), respectively. This trend was highly significant when evaluated with chi 2 for linear trend (P = .0002). Within groups of women with and without complications of pregnancy or labor, cesarean rates increased with maternal age. Using stepwise logistic regression to adjust simultaneously for confounding variables, adjusted odds ratios were 1.6 (95% confidence interval [CI] 0.9-2.7) for the women aged 30-34 and 2.3 (95% CI 1.1-4.8) for the 35 and older age group. CONCLUSIONS: Maternal age appears to be an independent risk factor for cesarean delivery. The reasons for this clinically important and statistically significant increased risk are unclear, but may be due to physician and patient concern over pregnancy outcome in older women.

Epidemiology of adolescent sexual assault.

OBJECTIVE: To describe the epidemiology of sexual assault in adolescents and to compare this group with sexual assault victims over 20 years of age. METHODS: Charts were reviewed of 405 women presenting for sexual assault evaluation between January 1, 1990 and December 31, 1993, and demographic, historical, and laboratory data were extracted. RESULTS: The median age of the study population was 21 years. Adolescent victims (less than 20 years old, N = 178) were more likely to be assaulted by an acquaintance or relative (77 versus 56%; P < .0001) and to delay medical evaluation (11 versus 7 hours; P < .02) than were women 20 years of age and older (N = 227). CONCLUSIONS: The epidemiology of sexual assault in adolescents is unique and poses special challenges to the health care provider and the sexual assault evaluation team. Clinicians evaluating adolescents should be familiar with the epidemiology of sexual assault in this age group and the widespread problem of acquaintance rape. Adolescents should be offered preventive strategies to help them avoid future violence in dating relationships and the sequelae of sexual assault, such as unwanted pregnancy and sexually transmitted diseases.

Systematic reviews of medical evidence: the use of meta-analysis in obstetrics and gynecology.

OBJECTIVE: To review the technique of meta-analysis and its uses and limitations in obstetrics and gynecology. DATA SOURCES: We reviewed four major journals in obstetrics and gynecology (American Journal of Obstetrics and Gynecology, Fertility and Sterility, Journal of Reproductive Medicine, and Obstetrics & Gynecology). METHODS OF STUDY SELECTION: Journals were reviewed to determine frequency of meta-analysis as a method of systematic review in obstetrics and gynecology. We also summarized objectives and scientific guidelines for performing a meta-analysis. TABULATION, INTEGRATION, AND RESULTS: Meta-analysis is used with increased frequency in obstetrics and gynecology as a way of systematically reviewing medical evidence. This technique is an attempt to improve on traditional methods of narrative review by an expert and as a framework for evidence-based medicine and developing practice guidelines. By combining data from replicate studies, a meta-analysis can increase statistical power, more precisely estimate the typical effect size of treatment or risk factor, and attempt to resolve controversies in the medical literature. Meta-analysis is a retrospective look at data already collected and is therefore subject to the biases of all retrospective studies. CONCLUSIONS: The technique of meta-analysis requires all the scientific rigor of a randomized clinical trial with careful attention to study design, including a formal protocol for literature search strategies, quality assessment of candidate studies, specific inclusion and exclusion criteria, issues of sampling and publication bias, statistical tests of homogeneity, and sensitivity analysis.

Sample size and statistical power in reproductive research.

The calculation of sample size should be an integral part of the planning stages of all research projects to avoid wasting time, money, and valuable resources. The necessary information for sample size calculations includes the alpha (type I) error level, the beta (type II) error, delta (or the difference you would like to be able to detect), and, for continuous variables, the variance. We review these terms and outline their importance in the calculation of sample size and statistical power. When necessary, the investigator should seek expertise and advice to perform these calculations.

Research design and methods of quantitative synthesis of medical evidence.

OBJECTIVE: To review the scientific principles, strengths, and limitations of research designs and methods of quantitative synthesis of medical evidence. DATA SOURCES: We used MEDLINE to perform a systematic search for literature using the keywords research design, epidemiology, and biometry. Journals searched included six major journals in obstetrics and gynecology and three in general medicine. These sources were supplemented with texts and reviews from the general medical literature. METHODS OF STUDY SELECTION: We reviewed the publications identified by our search and evaluated critically the relevant reports. We summarized objectives and scientific guidelines for the common research methodologies and outlined their advantages and disadvantages. TABULATION, INTEGRATION, AND RESULTS: The standard of clinical research design is the randomized controlled trial (RCT), which, if performed with sufficient methodologic rigor, is least likely to have serious biases. Cohort, case-control, and cross-sectional studies are common observational studies used in reproductive health; such observational studies are more susceptible to biases that can distort the researcher's results and conclusions. Descriptive studies such as case series and case reports are often interesting as clinical vignettes but have limited scientific merit. Methods for quantitative synthesis of medical evidence, including meta-analysis, decision analysis, and cost-effectiveness analysis are being used with increased frequency in the reproductive health literature to summarize medical evidence. CONCLUSION: Various research methods have their own inherent advantages and disadvantages. An understanding of the scientific principles of these methods will enable the clinician to evaluate medical evidence critically.

A prevalence survey of abuse and screening for abuse in urgent care patients.

OBJECTIVE: To determine the prevalence of physical and sexual abuse in pregnant and nonpregnant women in an urgent care obstetrics and gynecology triage unit and the frequency with which these patients recall being screened by their health care provider. METHODS: We carried out a structured survey of 255 pregnant and 142 nonpregnant women presenting to an urban New England urgent care obstetrics and gynecology unit between February 1995 and September 1995. Patients in advanced stages of labor or unable to participate due to a language barrier were excluded. The survey consisted of 22 questions, seven of which were modified from the abuse assessment screen. RESULTS: Among 397 participants with complete data, we found that 184 (46%) reported a history of physical or sexual abuse in the past, and 38 (10%) reported recent abuse. Young age and insurance status (Medicaid or uninsured) were associated significantly with recent abuse after we controlled for race, education, and pregnancy status. Only 18% of women recalled being asked about abuse by a health care provider. Young women were more likely to report being asked about abuse. Among women reporting recent abuse, white women were significantly more likely to report being asked about abuse than nonwhite women (P=.02). The majority of women reporting a history of abuse did not recall being screened for violence by a health care provider. CONCLUSION: Women of all ages, income, and ethnic backgrounds reported a history of domestic violence or sexual assault. Providers should incorporate routine screening into the assessment of all women.

Battering in pregnancy: an assessment of two screening methods.

OBJECTIVE: To compare two different screening techniques for identifying women with a history of domestic violence or battering in the current pregnancy. METHODS: The five-question Abuse Assessment Screen was incorporated into routine social service interviews and applied prospectively to all registrants for routine prenatal care at Women & Infants' Hospital during an initial social service evaluation from September 7 through October 29, 1993. This group (N = 143) was compared to a historical control group of all new registrants from July 12 through September 3, 1993 (N = 191) who had routine interviews by social services. Demographic and medical data were compared, as well as the specific information addressed by the screen, including history of domestic violence, physical or sexual violence within the last year, violence during the current pregnancy, recent sexual abuse, and fear of partner. RESULTS: The median age of the study population was 23 years old, 50% were white, 63% were single, and 42% had no insurance. There was a higher detection of violence in all categories using the Abuse Assessment Screen compared with the standard interview--any history: 41 versus 14% (relative risk [RR] 3.0, 95% confidence interval [CI] 2.0-4.5); recent history: 15 versus 3% (RR 5.6, CI 2.2-14.5); during pregnancy: 10 versus 1% (RR 9.3, CI 2.2-40.5); recent sexual abuse: 4 versus 0% (P = .006); and fear of abuser: 6 versus 3% (RR 1.8, CI 0.6-5.0). CONCLUSION: Use of a structured screen improves detection rates of battering both before and during pregnancy, enabling clinicians to have a greater opportunity to intervene.

Laboratory evaluation of acute upper genital tract infection.

OBJECTIVE: To evaluate the diagnostic test characteristics of common tests used to diagnose upper genital tract infection. METHODS: Subjects included women who either met the Centers for Disease Control and Prevention's minimal criteria for acute pelvic inflammatory disease or who had other signs of upper genital tract infection (i.e., atypical pelvic pain, abnormal uterine bleeding, or cervicitis). The subjects were evaluated with a baseline interview, comprehensive laboratory testing, and either an endometrial biopsy or laparoscopy for definitive diagnosis of upper genital tract infection. Patients were considered positive for upper genital tract infection if they had any of the following findings: 1) histologic evidence of acute endometriosis or salpingitis, 2) laparoscopic visualization of purulent exudate in the pelvis without another source, or 3) positive testing for Neisseria gonorrhoeae or Chlamydia trachomatis from the endometrium, fallopian tubes, or pelvis. RESULTS: One hundred twenty women with adequate endometrial samples were evaluated between August 1993 and September 1995. The median age of the study population was 24 years: 38% were white, 52% were smokers, 81% were insured by Medicaid or were uninsured, and 67% were single. Sensitivities for elevated white blood cell count (WBC), erythrocyte sedimentation rate, C-reactive protein, and increased vaginal white blood cells are 57, 70, 71, and 78%, respectively. If any one test is abnormal, the sensitivity is 100% and specificity is 18%. If all four tests are abnormal, sensitivity is 29% and specificity is 95%. CONCLUSION: Testing for increased vaginal white blood cells was found to be the most sensitive laboratory indicator for upper genital tract infection, whereas serum WBC was the most specific. No one diagnostic laboratory test is pathognomonic for upper genital tract infection. Combinations of positive tests can improve diagnostic specificity and positive predictive value, but with a diminution of sensitivity and negative predictive value. Combinations of negative tests can reliably exclude upper genital tract infection.

Endovaginal sonography for the diagnosis of upper genital tract infection.

OBJECTIVE: To determine the clinical utility of transvaginal sonography for the diagnosis of upper genital tract infection. METHODS: Fifty-five women who either met the Centers for Disease Control and Prevention's minimal criteria for acute pelvic inflammatory disease or were being seen for non-classic signs of upper genital tract infection were evaluated. During abdominal and endovaginal ultrasound testing, fluid in the cul-de-sac, discrete tubes with or without tubal fluid, multicystic ovaries, and adnexal masses were noted. Upper genital tract infection was confirmed by laparoscopic visualization or histologic or microbiologic evidence of salpingitis of endometritis. RESULTS: The specificity of identifying fallopian tubes with or without intraluminal fluid on ultrasound was 97% (35 of 36); the sensitivity, however, was only 32% (six of 19). Calculated using Bayes theorem and based on a prevalence rate of 50%, the positive predictive value of visualizing fallopian tubes was 91%. The sensitivities associated with the visualization of a multicystic ovary or tubo-ovarian abscess were 42% (eight of 19) and 32% (six of 19), with specificities of 86% (31 of 36) and 97%, (35 of 36), and positive predictive values of 75% and 91%, respectively. Cul-de-sac fluid was associated with low sensitivity (37%; seven of 19), low specificity (58%; 21 of 36), and the lowest positive predictive value (47%). CONCLUSION: Endovaginal sonography has limited clinical utility in the diagnosis of upper genital tract infection due to its low sensitivity.

Prognostic value of clinical variables in invasive cervical cancer.

OBJECTIVE: To test the hypothesis that clinical variables, such as patients' symptoms, symptom severity, and co-morbidity, affect the survival rate of patients with invasive cervical cancer. METHODS: From the medical records of 251 cases of invasive cervical cancer treated at Yale-New Haven Hospital between 1984 and 1988, information was extracted for patients' demographic characteristics, symptoms, symptom severity, comorbidity, physical findings, laboratory data, treatment, and subsequent course. RESULTS: Three-year survival data were available for 250 (99%) of the 251 cases. For a composite clinical predictive system based on symptom status and co-morbidity, the 3-year survival rates were as follows: 85% (64 of 75) for the patients who were asymptomatic without co-morbidity; 63% (58 of 92) for the group that was either symptomatic or co-morbid, but not both; and 40% (33 of 83) for symptomatic patients with co-morbidity or patients with systemic, metastatic, or severe symptoms (P < .0001, chi 2 for linear trend). When entered into a Cox proportional hazards model along with other variables that might affect prognosis, including International Federation of Gynecology and Obstetrics stage, the composite symptom-co-morbidity stage remained statistically significant. CONCLUSIONS: Our findings demonstrate the importance of clinical variables, such as symptoms and co-morbidity, in estimating prognosis in cervical cancer, even after stage and other factors are controlled. Unless the clinical variables are suitably analyzed, prognostic estimates based on morphology alone will be imprecise and therapeutic evaluations may be misleading.

Cytologic-histologic discrepancy in human immunodeficiency virus-positive women referred to a colposcopy clinic.

OBJECTIVE: To evaluate the rate of discrepancy between cytology and histology in a referral-based population of human immunodeficiency virus (HIV)-positive women compared to HIV-negative women and women whose HIV status was unknown. METHODS: From January 1, 1990 to December 31, 1993, approximately 830 women underwent evaluation at Women and Infants' Hospital colposcopy clinic. Women who had histologic diagnosis and recent cytologic evaluation during this interval (N = 678) were selected for study. Forty-one HIV-positive women were compared to 228 HIV-negative women and 409 women whose HIV status was unknown. RESULTS: Of the 41 HIV-positive women, seven (17%) were noted to have a discrepancy between cytologic and histologic findings. In HIV-negative and HIV-unknown women, 15% (34 of 228) and 22% (91 of 409) were discrepant, respectively. Using HIV-negative women as the reference group, the relative risk of cytologic-histologic discrepancy was 1.1 (95% confidence interval [CI] 0.51-2.41) for HIV-positive women and 1.5 (95% CI 1.04-2.14) for women whose HIV status was unknown. CONCLUSION: Human immunodeficiency virus-positive women referred for colposcopic evaluation have no more cytologic-histologic discrepancy than HIV-negative women or women whose HIV status is unknown.

Progesterone, inhibin, and hCG multiple marker strategy to differentiate viable from nonviable pregnancies.

OBJECTIVE: To determine whether a combination of serum and urine biomarkers drawn from symptomatic pregnant women will help early differentiation of viable from nonviable pregnancies. METHODS: We conducted a prospective cohort study of 220 women who presented in the first trimester of pregnancy with complaints of pain, cramping, bleeding, or spotting. Serum samples for progesterone, inhibin A, and hCG, and urine beta-core hCG, were collected at presentation. To evaluate whether those biomarkers could predict viable and nonviable outcomes in pregnancy, we used likelihood ratios to compare operating characteristics of single and multiple biomarker strategies. RESULTS: Of 220 pregnancies studied, 98 were viable and 122 nonviable. Among single biomarkers, progesterone alone appears to have the greatest utility (area under the receiver operator characteristic curve = 0.923). Among dual-biomarker strategies, progesterone plus hCG and progesterone plus inhibin A improved specificity but not sensitivity. At 95% sensitivity, the combination of progesterone and hCG improved specificity from 0.29 to 0.66 (improvement = 0.37 [95% confidence interval 0.23, 0.52]). A triple-biomarker combination did not show substantial improvement over the dual-biomarker strategy. Also, combinations that used urine beta-core hCG did not improve diagnostic accuracy. CONCLUSION: Serum progesterone appeared to be the single most specific biomarker for distinguishing viable from nonviable pregnancies. When a dual-biomarker strategy was applied, combining serum progesterone with hCG, specificity improved significantly, which suggests that a multiple biomarker strategy might help distinguish viable from nonviable pregnancies in early gestation.

Screening for bacterial vaginosis in pregnancy.

CONTEXT: Bacterial vaginosis (BV) is a strong independent risk factor for adverse pregnancy outcomes. BV is found in 9% to 23% of pregnant women. Symptoms include vaginal discharge, pruritus, or malodor, but often women with BV are asymptomatic. OBJECTIVES: To determine whether screening and treating pregnant women for BV reduces adverse pregnancy outcomes, as part of an assessment for the U.S. Preventive Services Task Force. DATA SOURCES: Randomized clinical trials of BV treatment in pregnancy that measured pregnancy outcomes were identified from multiple searches in MEDLINE from 1966 to 1999, the Cochrane Controlled Trials Register and Library, and national experts. STUDY SELECTION: All randomized controlled trials of BV treatment in pregnancy that specifically measured pregnancy outcomes. DATA EXTRACTION: The following information was abstracted: study design and blinding, diagnostic methods, antibiotic interventions, timing of antibiotic treatment in pregnancy, criteria for treatment, comorbidities, demographic details, risk factors for preterm delivery such as previous preterm delivery, compliance, rates of spontaneous and total preterm delivery less than 37 weeks and less than 34 weeks, preterm premature rupture of membranes, low birth weight less than 2500 grams, spontaneous abortion, postpartum endometritis, and neonatal sepsis. For each study, we measured the effect of treatment by calculating the difference in the rate of a given pregnancy outcome in the control group minus the treatment group (the absolute risk reduction [ARR]). A stepwise procedure based on the profile likelihood was applied to assess heterogeneity, to pool studies when appropriate, and to calculate the mean and 90% confidence intervals (CIs) for the effect of treatment. DATA SYNTHESIS: Seven randomized controlled trials met inclusion criteria for the meta-analysis. We found no benefit to BV treatment in average-risk women for any pregnancy outcome. Results of studies of high-risk populations, women with previous preterm delivery, were statistically heterogeneous. They clustered into two groups; one showed no benefit (ARR=-0.08, 90% CI=-0.19 to 0.04), whereas the three homogeneous studies showed potential benefit of BV treatment (pooled ARR=0.22; 90% CI=0.13 to 0.31) for preterm delivery before 37 weeks. Four high-risk studies reported results for preterm delivery less than 34 weeks. The pooled estimate showed no benefit (ARR=0.04; 90% CI=-0.02 to 0.09), but variation was noted among individual studies. Two trials of high-risk women found an increase in preterm delivery less than 34 weeks in women who did not have BV but received BV treatment. Comparisons of patient populations, treatment regimens, and study designs did not explain the heterogeneity among studies. CONCLUSIONS: We found no benefit to routine BV screening and treatment. A subgroup of high-risk women may benefit from BV screening and treatment; however, there may be a subgroup for whom BV treatment could increase the occurrence of preterm delivery.

Oligohydramnios: a review.

Oligohydramnios is a relatively common complication of pregnancy. Etiologies include congenital anomalies, intrauterine growth retardation, premature rupture of the membranes, drugs, postterm gestation and postmaturity. Sequelae from prolonged oligohydramnios including pulmonary hypoplasia and fetal compression syndrome can be devastating. Perinatal morbidity and mortality are both significantly increased in pregnancies complicated by oligohydramnios. Successful management requires a thorough search for the cause of the decreased amniotic fluid volume, and close antenatal surveillance.