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DR.OKECHUKWU A.UGWULAGOS UNIVERSITY TEACHING

HOSPITAL

DISORDERS OF AMNIOTIC FLUID

VOLUME

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Outline

Origin physical features Components Functions of A.F Clinical Relevance Oligo/Poly-Hydramnios Definition Etiology Diagnosis Treatment Complications

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ORIGIN

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Origin contd

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,

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Amniotic Fluid circulation

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Circulation AMNIOTIC FLUID VLOUME

10 weeks – 30mls20 weeks- 300mls30 weeks- 600mls38weeks- 1L40weeks- 800mls42weeks- 200-

350mls

CONTD

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Physical features

Alkaline- 7.2Low specific gravity – 1.0069 – 1.008. Hypotonic to maternal serum at termOsmolarity – 250 OsmolColour – in early pregnancy colourless - at term it become pale straw

colored

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Physical features-contd

Appearance SignificanceColorless with slight to

moderate turbidityNormal

Dark/Blood- streaked Traumatic tap, abdominal trauma, concealed

accidental haemorrhageYellow/Golden HDN/Rhesus

Incompatibilitydark- green Meconium

Dark red/ brown Fetal Death/IUDGreenish yellow post maturity

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Composition

98% water, 2% solid substances a)Organic

b) Non organic

c) Suspended particles

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Functions of A.F

During pregnancyCushions the fetus from physical traumaProvides a barrier against infectionPermits proper lung developmentThermoregulationAllow 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

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Clinical importance

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

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chemical tests performed on amniotic fluid

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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POLYHYDRAMINOS

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.

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Polyhydraminos- contd

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%

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Measurement of Amniotic Fluid Volume

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

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AFI

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AFI Deep vertical pocket

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

Polyhydraminos- contd

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DVP

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AETIOLOGY OF POLYHYDRAMNIOS

Idiopathic (50-60 %)

MATERNALDiabetesSubstance abuseRhesus isoimmunisation

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Fetal causes

Anencephaly Oesophageal atresia

Duodenal atresia

Multifetal gestation /TTTS

Fetal hydrops/Rhesus Fetal akinesia syndrome

Fetal infection

Fetal pseudohypoaldosteronism

Fetal Barter or Hyperprostaglandin E synd

Fetal Nephrogenic Diabetes insipidus

Fetal saccrococcygeal teratoma

Placental haemangiomas

AETIOLOGY OF POLYHYDRAMNIOS- 2

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Types of Polyhydraminos

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

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Mgt 1- History

Clinical featuresSymptomatic/ 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

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Mgt 2- Physical ExaminationAbdominal examination: Obvious superficial blood vessels

Globular

abdominal skin appears stretched and shiny

marked striae gravidarum

Uterus is tense

↑SFH

difficult to palpate fetal parts.

Fluid thrill difficult to hear fetal heart sound

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Mgt 3- Investigation

Full blood count

TORCH screening

FBS/OGTT

SEUCR+ uric acid

Abd X-ray- historic importance

Placenta Biopsy

Assess fatal wellbeing (U/S/CTG/Doppler/BPP - excessive amniotic fluid. - fetal abnormalities

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Management 4

The cause of the condition should be determined if possible.

Management depends on:1. Condition of the fetus and the mother2. The cause and degree of Polyhydraminos3. Stage of pregnancy 4. Fetus Compatible with Extra uterine life

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Mgt 5

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

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Mgt 6- Indomethacin

Impairs fetal lung liquid productionEnhances absorptionIncreases fluid movement across fetal membranesReduce fetal urinary production

premature closure of the fetal ductus arteriosusPeriventricular Leucomalacia not used after 35 weeks

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Mgt 7

Treat underlying cause

Fetal anemia: Fetal transfusion

TTTS- Laser ablation of placental vessels

Diabetes: control blood sugar

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Complications of Polyhydraminos contd

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

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Oligohydramnios

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)

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Oligohydraminos Normal

Oligohydramnios contd

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AETIOLOGY

FETAL •PROM (50%) •CHROMOSOMAL ANOMALIES •CONGENITAL ANOMALIES – porter's

syndrome •IUGR •IUFD •POSTTERM PREGNANCY

PLACENTAL •CHRONIC ABRUPTION •TTTS

IDIOPATHIC

MATERNAL – Placental insufficiency

•PREECLAMPSIA •CHRONIC HT Diabetes

DRUGS •PG SYNTHETASE INHIBITORS •ACE INHIBITORS

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Potter’s Syndrome

Pulmonary hypoplasiaOligohydrominiosTwisted skin (wrinkly

skin)Twisted face (Potter

facies)Extremities defectsRenal agenesis

(bilateral)

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PUV

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SYMPTOMS

NO SPECIFIC

SYMPTOMS

H/O leaking p/v Post term

CHT/preclampsiaDrugs

Less fetal movements

SIGNS Uterus – small for date

Malpresentation

IUGR

FHR normal/nonreassuring

Small columns by ultrasound

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Management 1

MANAGEMENT DEPENDS UPON AETIOLOGY

GESTATIONAL AGE

SEVERITY

FETAL STATUS & WELL BEING- fetus surviving extra uterine life

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Management 2

DETERMINE AETIOLOGY R/O PROM

TARGETED USG FOR ANOMALIES

R/O IUGR ,IUFD when suspected

Amniocentesis if chromosomal anomalies suspected – early symmetric IUGR

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Mgt 3- Investigations

instillation of indigo carmine may be used to evaluate for PROM

Amniosure- PROM

Nitrazine yellow paper/litmus paper

Ultrasound scanFBC/FBS/OGTT

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TREATMENT

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

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Treatment- contd

DIRECTED TO CAUSE •Drug induced – OMIT DRUG •PROM – •PPROM – Antibiotics, steroid – Induction •FETAL SURGERY

VESICO AMNIOTIC SHUNT-PUV Laser photocoagulation for TTTS

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•AMNIOINFUSION

Reasonable approach in the treatment of repetitive variable decelerations

Decreases incidence of - meconium

aspiration syndrome - Neonatal

Acidemia -cord compression

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FETAL MATERNAL

Abortion

Prematurity

IUFD

Deformities –contractures

Potters syndrome

pulmonary hypoplasia

Malpresentations

Fetal distress

Low APGAR

Increased morbidity Prolonged labour:

uterine inertia

Increased operative intervention

COMPLICATIONS

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Pregnancy Outcome in Oligohydramnios

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

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Pulmonary Hypoplasia and Oligohydramnios

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

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Conclusion

Amni0tic fluid evaluation allows assessment of the fetal intrauterine environment

Potentially invaluable information

Requires close follow-up and evaluation

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END