Pathologies of the

amniotic fluid volume

Prepared by Dr n. med. Radosaw Blok
I Katedra Gin - Po. AM Wrocaw
Faculty of Medicine Wrocaw,Gynaecology & Obstetrics Depart.

Amniotic fluid
Amniotic fluid volume measures is one
of the important aspects in perinatal
diagnosis.
Excess or less amount of amniotic fluid
in pregnancy can be a sign of serious
pathology such as polyhydramnios or
oligohydramnios.

Life and growth of the fetus for the whole

period of pregnancy is depending on amniotic
fluid which is one of the factors for a proper
growth.
Since the period of Hipokrates until the
beginning of XX century, it has been believed
that amniotic fluid is a fetus urine, which only:
1. acts as a shock absorber protecting the fetus
from possible extraneous injury.
2.maintenanse an even temperature.
3.the fluid extends the amniotic sac and
thereby allows for growth and free movement
of the fetus.
4.its nutrietive values is negligible because of
small amount of protien and salt content,
however, water supply to the feuts is quite
adequate.

We also know that the amniotic fluid plays

a metabolic role, and its contents has
a significant information about fetus
wellbeing.
The amniotic fluid pH values are responsible
for the implimentation of the fetus acid-base
balance as follows:
Before the 20th week-7.23
Between 25th-31st week-7.17
At labour 7.11

In the amniotic fluid we can find the following

constituents:
Organic:-Protein- 0.3 mg%, Glucose- 20mg%,
Urea-30mg%, Uric acid-4mg%, Creatinine2mg%, Total lipids-50mg%, Hormones
(Prolactin,insulin and renin)

Inorganic:-The concetration of sodium,

chloride and potassium is almost the same as
the maternal blood.
The amniotic fluid has a bacteriostatic nature
guaranteed by lizozomes, properidine and
protein-zinc complex as well as
immunogloblins.

In the first half of pregnancy most of the

amniotic fluid contents are transported
through the fetus skin, but after the 24-26
week that is after the fetal skin keratinization
that path of transport becomes impossible
with an except of the low density substances
dissolved in lipids.

The amniotic fluid volume changes as the

pregnancy grows, and it reaches its peak
around the 32nd week. After that period the
volume decreases systematically.

Its important to note that after the 42nd week

the volume undergoes a sudden decrease being
a sign of placenta disability, as well as
prolonged pregnancy (postdate pregnancy).
The amniotic fluid volume average
25 - 26 week - 669 ml
33 - 34 week - 984 ml
38 - 40 week - 834 ml
41 - 42 week - 544 ml

Embryo at 10 weeks normal AFI

Amniotic fluid circulation after the 20th

week.
The amniotic fluid production is as follows
Fetal kidney 500 - 1000 ml
Fetal lungs 170 ml
Fetal saliva

25 ml

Reabsorbtion of amniotic fluid

By swallowing 500 - 1000 ml

Fetal lungs 170 ml

Intra-membrane transport to the fetus 200 - 500 ml
The fetus-maternal membrane transport only 10 ml

Oligohydramnion
Anhydramnion
Oligohydroamnion is severe deficiency of amniotic
fluid (sometimes defined as maximum vertical
pocket < 1cm determined by sonography)
oligohydramnion measures below 200ml.
Anhydramnion should be diagnosed when the AFI
is below 50ml.
Clinical signs as follows: low uterine volume,
lack of fetal free movements, a low abdominal
circumference, low body weight, easy palpapable
fetal parts and weak fetal movements.

Maximum vertical pocket

The causes of oligohydroamnion

Developmental defects, especially in the urinary
system
Preterm rupture of membranes
Hypotrophy
Postterm pregnancy

Multiple pregnancy transfusion syndrome

Drugs:Prostaglandin synthesis inhibitors
Angiotensin-converting enzyme inhibitors
Mothers diseases with microangiopathy with high
blood pressure, diabetes R or F type

Oligohydramnion diagnosis
Ultrasound diagnosis

Amniotic fluid index - AFI < 5

Low value biochemical profiles Manningas test
Low or lack of fetus movements
Difficulties in fetus anatomical analysis.
Pathological fetus measurements due to
compression

Complications caused by oligohydramnion

Hipotrophy

Fetus lung hipoplasia

Fetus deformation syndrome
Intrauterine infection
Severe fetal condition after birth
Intrauterine fetal death

Complications caused by Anhydramnion

Fetus deformation syndrome
Dysmorphism of facial skeleton
Pathological limb location

Hip dislocation
Excessive skin
Minor thorax causing fetus hypoplastic lung

Complications caused by Anhydramnion

Intrauterine fetal asphyxia

umbilical cord compression

an increase in meconium aspiration syndrom
pathological KTG
a decrease in biophysical profile
poor vessel blood flow - doppler
an icrease in cesarean sections
poor newborns state < 7 points

Management in oligohydramnion
Preconception management in women with :

hypertension
chronic kidney diseases
autoimmunological diseases
diabetes mellitus type R and F
obstetrical load

Management in oligohydramnion
care during pregnancy :

early diagnosis
proper treatment of common diseases in time
infection prophylaxis
water and electrolite balance
bedrest
the use of tocolytic agents
adequate hydration

Management in oligohydramnion
Care during labor :
Intensive care: KTG, doppler-flows, gasometry,
puls rate control
Amniotic fluid infusion (not common)
Labor induction (oxcytocin) or caesarean section

Anhydramnion

Polyhydramnion (hyramnion)

Amniotic fluid volume of 2000 ml or more in the III

trimester
Amniotic fluid indeks > 18 cm

Polyhydramnion etiology
idiopathic causes about 60%
19 % congenital fetal malformations - Anencephaly
(a) transudationn from the exposed meninges, (b)
absence of fetal swallowing reflex, (c) suppression
of fetal ADH leading to excessive urination
Open spina bifida, oesophageal or duodenal atresia,
facial clefts and neck masses, hydrops fetalis
Placenta-chorioangioma of the placenta
Multiple pregnancy- in uniovular twins, usually
affecting the second sac. 10%
Maternal causes - diabetes about 30%

Duodenal atresia
double bubble sympthom

Compolications caused by polyhydramnion

PROM-prelabour rupture of the membrane
(spontaneous rupture of the membranes any time
beyond 28th week but before onset of labour)
malpresentation
Accidental haemorrhage due to decreased in
surface area of the emptying uterus beneath the
placenta. (placenta previa)
Preterm labor due to- pre-eclampsia, premature
rupture etc.
Increased perinatal mortality about 50%
(prematurity and congenital abnormality, cord
prolapse, hydrops fetalis).

Compolications caused by polyhydramnion

Pathological fetus lie

Secondary labor weakness

postpartum uterus atony
haemorrhage in III and IV labour period
Acute polyhydroamnion is between the 5 - 8 month
of pregnancy

Polyhydramnion treatment
Abdominal amniocentesis-decompression
The speed should not be more than 50ml/1h
Complications due to is about 8%, placenta previa,
intrauterine infection, preterm labor, PROM.

Treatment continued
Indomethacin

prostaglandyn syntetaze blocker

it increases fetal breathing rate by 50%
it as well increases fetus membrane permeable
ability
it changes membrane character from secretion to
resorbtion
it reduces the fetus urine production

Treatment continued
Indometacyna

The first dose 50 mg in suppository

Next dose 25mg p.o. every 6 hours
Fetus ECC at a 3 days interval

AFI level every after 7 days

daily blood pressure control

Treatment continued
The side effects of Indomethacin use

nausea, abdominal discomfort, gastric ulcers

headache and dizzness
It causes hypertention effects as it is a hypotensive
drugs antagonist
It causes a duretic decrease in pregnant women
It also causes platelets disbalance

The side effects of Indomethacin use in the

fetus
the newborn colon inflammation
fetal aterial stenosis

right ventricle hypertrophy

an increase in pulmonary artery blood pressure
a decrease in stroke volume

Care in polyhydramnion

during labour:
intensive care: KTG, flows, gasometry, puls
rate control

Care during amniocentesis

The placenta
The placenta (Greek, plakuos = flat cake)
named on the basis of this organs
appearance. The placenta a mateno-fetal
organ which begins developing at
implantation of the blastocyst and is
delivered with the fetus at birth.

The placenta

The placenta

During that 9 month period it provides

nutrition, gas exchange, waste removal,
endocrine and immune support for the
developing fetus.

The placenta - development

embryonic/maternal organ

villous chorion/decidua basalis

continuous with amniotic and chorionic sacks

Dimensions
discoid up to 20cm diameter and 3 cm thick (in term)
weighs 500-600 gm

Shapes
accessory placenta, bidiscoid, diffuse, horseshoe

maternal and embryonic surface

delivered at parturition

retention may cause uterine hemorrhage

The placenta - development

Maternal Surface
Cotyledons - form cobblestone appearance
originally placental septa formed grooves
covered with maternal decidua basalis
Fetal Surface
umbilical cord attachment
cord 1-2 cm diameter, 30-90cm long

covered with amniotic attached to chorionic plate

umbilical vessels branch into chorionic vessels which anastomose

Placental function
3 main functions
metabolism

transport
endocrine

Placental Metabolism
synthesizes
glycogen

cholesterol
fatty acids

provides nutrient and energy

Placental Transport
gases and nutrition
oxygen, carbon dioxide, carbon monoxide

water, glucose, vitamins

hormones, mainly steroid not protein
electrolytes
maternal antibodies
waste products
urea, uric acid, bilirubin
drugs and their metabolites

fetal drug addiction

infectious agents
cytomegalovirus, rubella, measles, microorganisms

Placental Endocrine
Human chorionic gonadotrophin (hCG)
like leutenizing hormone, supports corpus luteum
Human chorionic somatommotropin (hCS)
or placental lactogen
hormone level increases in maternal blood through pregnancy
decreases maternal insulin sensitivity (raising maternal blood
glucose levels and decreasing maternal glucose utilization) aiding
fetal nutrition
"anti-insulin" function

Placental Endocrine
Human chorionic thyrotropin (hCT)
(hCT) Peptide placental hormone, similar to anterior
pituitary released thyroid stimulating hormone (TSH),
which along with human chorionic gonadotrophin (hCG) is
thought to act on maternal thyroid. There is little recent
research published on this hormone, its level and activities.
Human chorionic corticotropin (hCACTH)
placental hormone thought to have corticotropin (ACTH)like activity, increasing maternal cortisol levels.

Placental Endocrine
Steroid Hormones
progestins - progesterone, support of the endometrium
and suppress uterine smooth muscle contractility.
estrogens - estriol, stimulate growth of the myometrium
and mammary gland development.
both hormones support maternal endometrium
Relaxin Humans high levels early in pregnancy than at
birth promotes angiogenesis probably plays a role in
development of the uterus/ placenta than in the birth
process

Human chorionic gonadotrophin (hCG)

After implantation cells within the developing
placenta (syncitiotrophoblasts) synthesize and
secrete Human chorionic gonadotrophin (hCG)
into the maternal bloodstream. The main
function of serum hCG is to maintain the corpus
luteum in the maternal ovary and therefore
maintain the early pregnancy, that is block the
menstrual cycle.

Ultrasonography
A methodical sonographic evaluation of the
placenta should include: location, visual
estimation of the size (and, if appearing
abnormal, measurement of thickness and/or
volume), implantation, morphology, anatomy,
as well as a search for anomalies, such as
additional lobes and tumors. Additional
assessment for multiple gestations consists
of examining the intervening membranes
(if present).

Placenta the both sides

Placenta umbilical cord

Placenta umbilical cord

The umbilical cord (also called the birth cord
or funiculus umbilicalis) is the connecting
cord from the developing embryo or fetus to
the placenta. Developed from the same
zygotre as the fetus, the human umbilical
cord normally contains two arteries and one
vein, buried within Whartons jelly.

Placenta umbilical cord

The umbilical cord develops from and contains
remnants of the yolk sac and allantois (and is
therefore derived from the same zygote as the
fetus). It forms by the fifth week of fetal
development, replacing the yolk sac as the source
of nutrients for the fetus. The umbilical cord in a
full term neonate is usually about 50 centimeters
long and about 2 centimetres diameter. This
diameter decreases rapidly within the placenta.

Placenta umbilical cord

The umbilical vein supplies the fetus with
oxygeneted, nutrietent-rich blood from the
placenta. Conversely, the umbilical arteries return
the deoxygenated, nutrient-depleted blood
Occasionally, only two vessels (one vein and one
artery) are present in the umbilical cord. This is
sometimes related to fetal abnormalities, but it may
also occur without accompanying problems.

Placenta umbilical cord

It is unusual for a vein to carry oxygenated blood,
and for arteries to carry deoxygenated blood
(the only other examples being the pulmonary
veins and arteries, connecting the lungs to the
heart). However, this naming convention reflects
the fact that the umbilical vein carries blood
towards the fetus's heart, whilst the umbilical
arteries carry blood away.

Placenta umbilical cord

Connection to fetal circulatory system
The umbilical vein continues towards the transverse
fissure of the liver, where it splits into two. One of
these branches joins with the hepatic portal vein
(connecting to its left branch), which carries blood into
the liver. The second branch (known as the ductus
venosus) allows the majority of the incoming blood
(approximately 80%) to bypass the liver and flow via
the left hepatic vein into the inferior vena cava, which
carries blood towards the heart.
The two umbilical arteries branch from the internal
iliac arteries, and pass on either side of the urinary
bladder before joining the umbilical cord.

Placenta umbilical cord

postnatal datachement
Shortly after birth, upon exposure to
temperature change, the gelatinous Wharton's
Jelly substance undergoes a physiological
change that collapses previous structure
boundaries and in effect creates a natural
clamp on the umbilical cord which halts
placental blood return to the neonate. This
process will take as little as five minutes if left
to proceed naturally.

umbilical cord clamp

The sinew-like cord stump of

a seven-day-old