This document discusses amniotic fluid assessment in ultrasound examinations. It provides details on qualitatively and quantitatively evaluating amniotic fluid volume using methods like the maximum vertical pocket measurement and amniotic fluid index. Abnormalities in amniotic fluid volume can indicate issues like premature rupture of membranes or fetal growth restrictions. Causes of variations in amniotic fluid are discussed, along with criteria for determining normal versus abnormal fluid levels. Measurement techniques and ranges for oligohydramnios and polyhydramnios are also outlined.

1. AMNI OTI CAMNI OTI C
FLUI D USFLUI D US
Dr. DoaaDr. Doaa
IraqiIraqi
M.SCM.SC..

2. Amniotic fluid volumeAmniotic fluid volume ((AFVAFV)) should be assessed eithershould be assessed either
qualitatively or quantitatively at every antenatal ultrasoundqualitatively or quantitatively at every antenatal ultrasound
examinationexamination..
There are a variety of reasons for thisThere are a variety of reasons for this
recommendationrecommendation::
 premature rupture of membranespremature rupture of membranes Reduced orReduced or
absent amniotic fluid is suggestive, but notabsent amniotic fluid is suggestive, but not
diagnostic.diagnostic.
 Fetal congenital anomaliesFetal congenital anomalies ((eg, gastrointestinaleg, gastrointestinal
or urinary tract obstructionor urinary tract obstruction)), chromosomal, chromosomal
abnormalitiesabnormalities ((eg, trisomy 18eg, trisomy 18))..
 fetal growth restrictionfetal growth restriction can be associated withcan be associated with
abnormalities of amniotic fluid volumeabnormalities of amniotic fluid volume
.. Thus, assessment of amniotic fluid volume is oneThus, assessment of amniotic fluid volume is one
of several parameters used in antenatal fetalof several parameters used in antenatal fetal
surveillancesurveillance

3. Criteria for CodingCriteria for Coding Fetal BiophysicalFetal Biophysical
Variables as NormalVariables as Normal
 fetal breathing movementsfetal breathing movements :1 or more episodes:1 or more episodes
of ≥20 s within 30 min.of ≥20 s within 30 min.
 Gross body movementsGross body movements : 2 or more discrete: 2 or more discrete
body/ limb movements within 30 min.body/ limb movements within 30 min.
 Fetal toneFetal tone :1 or more episodes of active:1 or more episodes of active
extension with return to flexion of fetal limb(s) orextension with return to flexion of fetal limb(s) or
trunk .trunk .
 Reactive FHRReactive FHR :2 or more episodes of:2 or more episodes of
acceleration of ≥15 beats per minute (bpm) andacceleration of ≥15 beats per minute (bpm) and
of >15 s associated with fetal movement withinof >15 s associated with fetal movement within
20 min .20 min .

4. Maximum vertical pocketMaximum vertical pocket
 One ultrasound method of assessing theOne ultrasound method of assessing the
AF is toAF is to measure the depth of the largestmeasure the depth of the largest
visible pocket of fluidvisible pocket of fluid surrounding thesurrounding the
fetusfetus.. The normal rangeThe normal range isis 2 cm to 8 cm2 cm to 8 cm
in singleton gestationsin singleton gestations.. The normal rangeThe normal range
for the single deepest pocketfor the single deepest pocket in twinin twin
gestation appears to be 2.2 cm to 7.5 cm.gestation appears to be 2.2 cm to 7.5 cm.

5. Maximum vertical pocketMaximum vertical pocket
 severe oligohydramniossevere oligohydramnios < 1 cm.< 1 cm.
 mild oligohydramniosmild oligohydramnios >> 1 and1 and << 2 cm.2 cm.
 NormalNormal
 polyhydramniospolyhydramnios>> 8 and < 12 cm .8 and < 12 cm .
 moderate polyhydramniosmoderate polyhydramnios >>12 cm and <12 cm and <
16.16.
 severe polyhydramniossevere polyhydramnios >> 16 cm.16 cm.

6. Maximum vertical pocketMaximum vertical pocket

7. Amniotic Fluid IndexAmniotic Fluid Index
 The AFI is a semiquantitative method for evaluating the AFVThe AFI is a semiquantitative method for evaluating the AFV.. TheThe
AFI is derived by adding the largest vertically measured fluid pocketAFI is derived by adding the largest vertically measured fluid pocket
from each uterine quadrantfrom each uterine quadrant.. This method appears to be at least asThis method appears to be at least as
accurate as the largest–pocketaccurate as the largest–pocket--ofof--fluid method .fluid method . Using this method,Using this method,
the normal range for the AFI is 5 to 25 cmthe normal range for the AFI is 5 to 25 cm .. oligohydramnios isoligohydramnios is
defined as an AFI of less than 5defined as an AFI of less than 5..
 To obtain an AFI, the mother must be in the supine position and theTo obtain an AFI, the mother must be in the supine position and the
linear ultrasonographic probe must be parallel to the maternal spinelinear ultrasonographic probe must be parallel to the maternal spine
and perpendicular to the floor for all measurements. The abdomenand perpendicular to the floor for all measurements. The abdomen
is divided into 4 quadrants, with the umbilicus delineating the upperis divided into 4 quadrants, with the umbilicus delineating the upper
and lower halves and the linea nigra delineating the left and rightand lower halves and the linea nigra delineating the left and right
halves.halves.
 The largest pocket of fluid in each quadrant is measured along theThe largest pocket of fluid in each quadrant is measured along the
vertical dimension, which is the dimension perpendicular to thevertical dimension, which is the dimension perpendicular to the
ultrasonographic probe. The pockets must be free of umbilical cordultrasonographic probe. The pockets must be free of umbilical cord
or fetal extremities, although brief appearances of these areor fetal extremities, although brief appearances of these are
acceptable. The video below demonstrates measurement of theacceptable. The video below demonstrates measurement of the
AFI.AFI.

10. Some causes of polyhydramniosSome causes of polyhydramnios
((too much amniotic fluidtoo much amniotic fluid([([
 IdiopathicIdiopathic ((unknownunknown)) ~ most cases~ most cases
 Gastrointestinal abnormalitiesGastrointestinal abnormalities
 Esophageal atresiaEsophageal atresia
 Intestinal obstructionIntestinal obstruction
 Central nervous system abnormalitiesCentral nervous system abnormalities
 AnencephalyAnencephaly
 Chromosomal abnormalitiesChromosomal abnormalities
 Nonimmune hydropsNonimmune hydrops
 Skeletal dysplasiasSkeletal dysplasias
 DiabetesDiabetes
 TwinTwin-- toto --twin transfusiontwin transfusion

11. Some causes ofSome causes of
oligohydramniosoligohydramnios ((too littletoo little
amniotic fluidamniotic fluid(( Ruptured membranesRuptured membranes
 Congenital abnormalitiesCongenital abnormalities
 Bilateral renal agenesis or cystic dyplasiaBilateral renal agenesis or cystic dyplasia
 Obstruction of the urinary tractObstruction of the urinary tract
 MeckelMeckel--Gruber syndromeGruber syndrome
 VACTERLVACTERL ((vertebral, anal, cardiac, tracheovertebral, anal, cardiac, tracheo--esophageal,esophageal,
renal, limbrenal, limb)) associationassociation
 SirenomeliaSirenomelia
 Sacral agenesisSacral agenesis
 Growth restrictionGrowth restriction ((placental insufficiencyplacental insufficiency))
 Postterm pregnancyPostterm pregnancy
 DrugsDrugs::AngiotensinAngiotensin--converting enzyme inhibitorsconverting enzyme inhibitors
 Prostaglandin synthase inhibitorsProstaglandin synthase inhibitors
 TwinTwin-- toto --twin transfusiontwin transfusion
 TRAPTRAP ((twin reverse arterial perfusion sequencetwin reverse arterial perfusion sequence))

12.  excess amniotic fluidexcess amniotic fluid
((the largest singlethe largest single
pocket measuring 11pocket measuring 11
cmscms.. approximatelyapproximately).).
This suggests mild toThis suggests mild to
moderatemoderate
polyhydramniospolyhydramnios..
Particulate matterParticulate matter
seen in the fluid isseen in the fluid is
due to fetaldue to fetal
meconiummeconium..

13. Severe oligohydramnios in late 2ndSevere oligohydramnios in late 2nd
trimestertrimester
 Among the Causes ofAmong the Causes of
oligohydramnios areoligohydramnios are--
premature rupture ofpremature rupture of
membranes, Fetalmembranes, Fetal
hypoxaemia, renal agenesis orhypoxaemia, renal agenesis or
dysgenesis, intake of certaindysgenesis, intake of certain
drugs, Fetal demise and alsodrugs, Fetal demise and also
Fetal IUGRFetal IUGR.. oligohydramniosoligohydramnios
is diagnosed when the fouris diagnosed when the four
quadrant AFI or amniotic fluidquadrant AFI or amniotic fluid
index is less than five or theindex is less than five or the
maximum vertical fluid pocketmaximum vertical fluid pocket
is less than 2 cmis less than 2 cm.. Among theAmong the
complications of such severecomplications of such severe
oligohydramnios are Fetal limboligohydramnios are Fetal limb
contractures and Fetal lungcontractures and Fetal lung
hypoplasiahypoplasia..

14. Hyperechoic amniotic fluidHyperechoic amniotic fluid// LiquorLiquor
 Increased echogenicity ofIncreased echogenicity of
Liqor amni TheseLiqor amni These
ultrasound images revealultrasound images reveal
markedly echogenicmarkedly echogenic
((hyperechoichyperechoic)) amnioticamniotic
fluidfluid.. The fluid showsThe fluid shows
almost the samealmost the same
echogenicity as theechogenicity as the
placentaplacenta.. SuchSuch
appearances of the liquorappearances of the liquor
amni on sonography areamni on sonography are
seen due presence ofseen due presence of
vernix caseosavernix caseosa
((commonest causecommonest cause)), Very, Very
echogenic amniotic fluidechogenic amniotic fluid
has been variably

15. This 21 week gestation had labour contractions with leakingThis 21 week gestation had labour contractions with leaking
per vaginumper vaginum.. On color doppler scan, the internal os appearsOn color doppler scan, the internal os appears
dilated with umbilical cord seen within the cervixdilated with umbilical cord seen within the cervix.. TheseThese
ultrasound and color doppler images are diagnostic ofultrasound and color doppler images are diagnostic of
umbilical cord prolapseumbilical cord prolapse..

16. Routine obstetric sonography was done on this patientRoutine obstetric sonography was done on this patient..
Images reveal aImages reveal a cystic lesion in the umbilical cord close to thecystic lesion in the umbilical cord close to the
fetal abdomenfetal abdomen.. On color doppler scan,On color doppler scan, flow is presentflow is present in thein the
cystic area which shows continuity with the umbilical veincystic area which shows continuity with the umbilical vein..
These ultrasound and color doppler imagesThese ultrasound and color doppler images suggestsuggest
umbilical vein varixumbilical vein varix ((within the cordwithin the cord(((.(.

17. The normal umbilical cord with three vessels within itThe normal umbilical cord with three vessels within it
(compare with the 2 vessel cord(. Cross section ultrasound(compare with the 2 vessel cord(. Cross section ultrasound
images of the normal umbilical cord show 2 umbilical arteriesimages of the normal umbilical cord show 2 umbilical arteries
(the smaller caliber vessels( and the larger caliber umbilical(the smaller caliber vessels( and the larger caliber umbilical
veinvein..

18. there is only one umbilical artery and an umbilical vein withinthere is only one umbilical artery and an umbilical vein within
this cordthis cord.. This ultrasound finding is called a single umbilicalThis ultrasound finding is called a single umbilical
arteryartery ((SUASUA(( or 2 vessel cord and is associated withor 2 vessel cord and is associated with
increased fetal morbidity including singleincreased fetal morbidity including single// multiple fetalmultiple fetal
congenital anomalies, still birth and premature deliverycongenital anomalies, still birth and premature delivery..

19. ‫سبحانكا اللهما وا بحمدكا اشهدا انا لا الها إلا‬ ‫سبحانكا اللهما وا بحمدكا اشهدا انا لا الها إلا‬
‫انتا استغفركا وا اتوبا اليك‬‫انتا استغفركا وا اتوبا اليك‬