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Amniotic fluid disorders
1. D R . O K E C H U K W U A . U G W U
L A G O S U N I V E R S I T Y T E A C H I N G
H O S P I T A L
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DISORDERS OF AMNIOTIC
FLUID VOLUME
4. Origin contd
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First & early second trimester :
Amount is 5-50 ml & arises from:
- ultra filtrate of Maternal plasma through the
vascularized uterine decidua
- Transudation of fetal plasma through the fetal skin &
umbilical cord (up to 20 weeks' gestation).
* It is iso-osmolar with fetal & maternal plasma,
7. Physical features
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Alkaline- 7.2
Low specific gravity – 1.0069 – 1.008.
Hypotonic to maternal serum at term
Osmolarity – 250 Osmol
Colour
– in early pregnancy colourless
- at term it become pale straw colored
8. Physical features-contd
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Appearance Significance
Colorless with slight to
moderate turbidity
Normal
Dark/Blood- streaked Traumatic tap, abdominal
trauma, concealed accidental
haemorrhage
Yellow/Golden HDN/Rhesus Incompatibility
dark- green Meconium
Dark red/ brown Fetal Death/IUD
Greenish yellow
post maturity
10. Functions of A.F
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During pregnancy
Cushions the fetus from physical trauma
Provides a barrier against infection
Permits proper lung development
Thermoregulation
Allow room for fetal growth, movement and development
During labor
The bag of fore water allows regular dilatation of the cervix.
After rupture of membrane the amniotic fluid serves as a lubricant for
fetus descent.
Also the amniotic fluid is bacteriostatic
11. Clinical importance
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Screening for fetal malformation.
Assessment of fetal well-being
Assessment of fetal lung maturity
Diagnosis and follow up of labor.
Detection of congenital fetal infection
Determination of fetal age
Diagnosis of PROM.
Cytogenetic analysis
Detection of fetal distress
12. chemical tests performed on amniotic fluid
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Bilirubin scan 0.025 mg/dl Hemolytic disease
of the newborn
L/S ratio 2.0 Fetal lung maturity
Phosphatidyl- Present Fetal lung maturity
Glycerol
Creatinine 1.3 – 4.0 mg/dl Fetal age
Alpha fetal protein 4.0 mg/dl Neural tube disorders
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13. POLYHYDRAMINOS
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Defined as excessive
amount of amniotic fluid
of 2000 ml or more
AFI of > 25cm
or the deepest vertical
pool of > 8 cm
95th or 97.5th percentile
of GA.
14. Polyhydraminos- contd
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Incidence of 0.5 -1%
50-60% are idiopathic
10-20% of the neonates are born with a congenital anomaly
Gastrointestinal system -40%
central nervous system -26%
cardiovascular system 22%
genitourinary system 13%
15. Measurement of Amniotic Fluid Volume
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AFI
Single deepest pocket method
Two diameter fluid pocket
Several factors may modulate AFI
-increase with high altitude
- Maternal hydration increases AFI
- fluid restriction or dehydration decrease
17. AFI Deep vertical pocket
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6-8 borderline AFI
8-25normal
>25 polyhydramnios
1. Mild hydramnios (80%):
8 to 11 cm.
2. moderate hydramnios
(15%):
12 to 15 cm.
3. Severe hydramnios (5%)
16 cm or more
17
Polyhydraminos- contd
21. Types of Polyhydraminos
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Acute Polyhydraminos:
Is very rare
Usually occurs at about 16- 20
weeks
sudden onset - 3 – 4 days
associated with monozygotic
twins
Ends with spontaneous abortion
most of the time before 28 weeks
Severe abdominal pain is
common symptom
Chronic Polyhydraminos:
Is gradual in onset
Usually from 30 weeks of
pregnancy
Is the most common type
22. Mgt 1- History
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Clinical features
Symptomatic/ asymptomatic:
dyspnea.
edema.
abdominal distention
Abdominal girth increase rapidly in acute Polyhydraminos
Oliguria from ureteric obstruction
preterm labour
Heart burn/Indigestion
Varicose vein
Mirror syndrome
25. Management 4
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The cause of the condition should be determined if
possible.
Management depends on:
1. Condition of the fetus and the mother
2. The cause and degree of Polyhydraminos
3. Stage of pregnancy
4. Fetus Compatible with Extra uterine life
26. Mgt 5
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Mgt of Symptomatic Polyhydraminos
Schedule weekly or twice weekly perinatal visits –depending on GA/severity
Hospital admission- dyspnea, abdominal pain or difficult ambulation.
serial ultrasonography
Antacids to relive heart burn
Reductive Amniocentesis- serially
Induction of labour if worsening- cord prolapse, abruptio
Delivery should be hospital
Role of Indomethacin
27. Mgt 6- Indomethacin
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Impairs fetal lung liquid production
Enhances absorption
Increases fluid movement across fetal membranes
Reduce fetal urinary production
premature closure of the fetal ductus arteriosus
Periventricular Leucomalacia
not used after 35 weeks
28. Mgt 7
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Treat underlying cause
Fetal anemia: Fetal transfusion
TTTS- Laser ablation of placental vessels
Diabetes: control blood sugar
29. Complications of Polyhydraminos contd
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Fetal
Unstable lie
Malpresentation
Cord presentation and cord
prolapse
PROM
Placental abruption
Premature labour
High perinatal mortality rate
Maternal
ureteric obstruction
PPH
Low threshold for C/S
Maternal morbidity and
mortality
30. Oligohydramnios
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Abnormally small amount of amniotic fluid which is
less than 300 – 500 ml at term.
Less than 5th centile for GA
INCIDENCE
8.2-37.8% pregnancies
-8.2% of antenatal patients(50% post-term)
-37.8% of patients in labor(50% ROM)
35. SYMPTOMS
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NO SPECIFIC SYMPTOMS
H/O leaking p/v
Post term
CHT/preclampsia
Drugs
Less fetal movements
SIGNS
Uterus – small for date
Malpresentation
IUGR
FHR
normal/nonreassuring
Small columns by
ultrasound
36. Management 1
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MANAGEMENT DEPENDS UPON
AETIOLOGY
GESTATIONAL AGE
SEVERITY
FETAL STATUS & WELL BEING- fetus surviving
extra uterine life
37. Management 2
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DETERMINE AETIOLOGY
R/O PROM
TARGETED USG FOR ANOMALIES
R/O IUGR ,IUFD when suspected
Amniocentesis if chromosomal anomalies suspected
– early symmetric IUGR
38. Mgt 3- Investigations
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instillation of indigo carmine may be used to
evaluate for PROM
Amniosure- PROM
Nitrazine yellow paper/litmus paper
Ultrasound scan
FBC/FBS/OGTT
39. TREATMENT
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ADEQUATE REST – decreases dehydration
HYDRATION – Oral/IV Hypotonic fluids(2 Lit/d)
Amino infusion by normal saline (helpful during labour, prior
to ECV, USG
•SERIAL USG – Monitor growth, AFI,BPP
INDUCTION OF LABOUR/ LSCS
Lung maturity attained
Lethal malformation
Fetal jeopardy
Sev IUGR
Severe oligo
40. Treatment- contd
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DIRECTED TO CAUSE
•Drug induced – OMIT DRUG
•PROM –
•PPROM – Antibiotics, steroid – Induction
•FETAL SURGERY
VESICO AMNIOTIC SHUNT-PUV
Laser photocoagulation for TTTS
41. •AMNIOINFUSION
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Reasonable approach in
the treatment of
repetitive variable
decelerations
Decreases incidence of
- meconium
aspiration syndrome
- Neonatal Acidemia
-cord compression
43. Pregnancy Outcome in Oligohydramnios
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The mortality and morbidity rate in Oligohydramnios is high
Pulmonary hypoplasia
IUGR
Meconium aspiration
Non reassuring Fetal heart rate
Poor tolerance of labor
Stillbirth
Fetal malformation
Fetal acidosis
Neonatal death
44. Pulmonary Hypoplasia and Oligohydramnios
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thoracic compression may prevent chest wall
excursion and lung expansion
lack of fetal breathing movement decreases lung
inflow
a failure to retain intrapulmonary amniotic fluid or
an increased outflow with impaired lung growth and
development
45. Conclusion
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Amni0tic fluid evaluation allows assessment of the
fetal intrauterine environment
Potentially invaluable information
Requires close follow-up and evaluation
Fetal swallowing- 25% of fetal weight
Fetal urine- Daily urine production is approximately 30% of fetal weight
Amniotic fluid index (AFI). It is a total of the DVPs in each four quadrants of the uterus. it is a more sensitive indicator of AFV throughout pregnancy
In Dm, reflex hyperglycemia in fetus leads to osmotic diuresis , women requiring insulin have five fold increase of hydraminos.
Anencephaly/spina bifida- increased fluid transudation from exposed meninges, abnormal swallowing, excessive urination from either stimulation of cerebrospinal centers or deprived of their protective coverings or by lack of antidiuretic effect because of impaired arginine vasopressin production. Hyperprostaglandin E syndrome (HPS) is the antenatal variant of Bartter syndrome and characterized by polyhydramnios and preterm delivery in the antenatal period and salt-wasting, isosthenuric or hyposthenuric polyuria, hypercalciuria and nephrocalcinosis in the postnatal period. We report a one-month-old infant with HPS with a 15-year-old sister with Bartter syndrome
Hydrops fetalis: congestive heart failure, severe anaemia or hypoproteinemia → placental transudation
Symptoms mostly from pressure symptoms. Mirror syndrome was defined by Ballantyne in 1892- the mother develops edema and protinuria and frequently eclampsia
