Amniotic fluid

Normal & abnormal

Dr. Abdalla H. Alsadig

MD
 IMPORTANT TOPICS

Amniotic fluid function

Clinical importance of AF
Volume and composition
Amniotic fluid abnormalities
Amniotic fluid function:

Allow room for fetal growth, movement and

development.
Ingestion into GIT growth and maturation.
Fetal pulmonary development (20 weeks).
Protects the fetus from trauma.
Maintains temperature.
Contains antibacterial activity.
Aids dilatation of the cervix during labour.
 Clinical importance of AF:

Screening for fetal malformation (serum -fetoprotien).

Assessment of fetal well-being (amniotic fluid index).
Assessment of fetal lung maturity (L/S ratio).
Diagnosis and follow up of labour.
Diagnosis of PROM (ferning test).
Amniotic fluid formation and composition:
First & early second trimester :
Amount is 5-50 ml & arises from:
- ultrafiltrate of Maternal plasma through the vascularized
uterine decidua (in early pregnancy).
- Transudation of fetal plasma through the fetal skin &
umbilical cord (up to 20 weeks' gestation).

* It is iso-osmolar with fetal & maternal plasma,

though it is devoid of proteins.
Volume and composition
From 20 weeks up to term (mainly
- fetal urine): At 18th week, the fetus voids 7-14ml/day;
at term fetal kidneys secretes 600-700ml of urine/day
into AF.
- Fetal respiratory tract secretes 250ml/day into AF.
- Fluid transfers across the placenta.
- Fetal oro-nasal secretions.
Secretion is controlled by:
- Fetal swallowing at term removes 500ml/day.
- Reabsorption into maternal plasma (osmotic gradient).
AF constituents:
- urea, creatinine & uric acid + desquamated fetal cells,
vernix, lanugo hair & others hypo-osmolar amniotic
fluid.
Amniotic fluid volume :
About 500 mls enter and leave the amniotic sac each
hour.
gradual up to 36 weeks to around 600 to 1000 ml
then after that.
The normal range is wide but the approximate
volumes are:
- 500 ml at 18 weeks
- 800 ml at 34 weeks.
- 600 ml at term.
Amniotic fluid volume assessment

Clinical assessment is unreliable.

Objective assessment depends on U/S to measure:
- deepest vertical pool (DVP).
- 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.
 Amniotic fluid abnormalities

Oligohydramnios:
Defined as reduced amniotic fluid i.e. amniotic fluid
index of 5 cm or less or the deepest vertical pool < 2 cm.

Polyhydramnios:
Defined as excessive amount of amniotic fluid of 2000 ml or
more (AFI of > 25 cm or the deepest vertical pool of > 8
cm) .
 Causes of oligohydramnios:

1. Fetal causes: * Fetal growth restriction.

* Renal cause (57%): * Fetal death.
- Renal agenesis * Postterm pregnancy.
(Potters syndrome). * Preterm premature
- polycystic kidney. rupture membranes
- Urethral obstruction
(atresia/posterior
urethral valve).
 Causes of oligohydramnios:
2. Maternal causes:
Uteroplacental insufficiency.
Preeclampsia.

3. Placental causes:
twin-twin transfusion.

4. Drug causes:
Prostaglandin synthase inhibitor as NSAID.

5. Idiopathic
 Complications of oligohydramnios:

In early pregnancy:
Amniotic adhesions or bands amputation/death.
Pressure deformities (club feet).
Pulmonary hypoplasia:
- Thoracic compression.
- No breathing movement.
- No amniotic fluid retain.
Flattened face.
Postural deformities.
 In late pregnancy:
Fetal growth restriction.
Placental abruption.
Preterm labour.
Fetal distress.
Fetal death.
Meconium aspiration.
Labour induction/CS.
 Oligohydramnios:
Diagnosis:
- Fundal > date.
- AF I < 5CM , DVP < 2.
- IUGR: abdominal circumference < 10th centile.
- Doppler abnormalities
- Congenital fetal anomalies.
Management:
- Treat the cause (pprom, preeclampsia).
- Assess fatal wellbeing (U/S/CTG/Doppler/BPP).
- Vesicoamniotic shunting (urethral obstruction).
- Amnioinfusion (no in fetal death).
Polyhydramnios
 Polyhydramnios

types
1. Mild hydramnios (80%):
a pocket of amniotic fluid measuring 8 to 11 cm.
2. moderate hydramnios (15%):
a pocket of amniotic fluid measuring 12 to 15 cm.
3. Severe hydramnios (5%) - twin-twin transfusion
syndrome :

a pocket of amniotic fluid measuring 16 cm or more.

 Causes of polyhydramnios
Fetal malformation:
- GIT: esophageal/duodenal
atresia, tracheoesophageal
fistula.
- CNS: anencephaly
(swallowing, exposed
meninges, no antidiuretic
hormone).
Twin-twin transfusion
fetal polyuria.
Hydrops fetalis: congestive
heart failure, severe anaemia
or hypoproteinemia
placental transudation
diabetes mellitus (osmotic
diuresis).
Idiopathic.
 diagnosis of polyhydramnios
Symptoms:
- dyspnea. Ultrasound:
- edema. - excessive amniotic fluid.
- abdominal distention
- fetal abnormalities.
- preterm labour.
Abdominal examination:
- uterus than expected.
- difficult to palpate fetal
parts.
- difficult to hear fetal heart
sound.
- ballotable fetus.
 management
Minor degrees: no treatment.
Bed rest, diuretics, water and salt restriction: ineffective.
Hospitalization: dyspnea, abdominal pain or difficult
ambulation.
Endomethacin therapy: .
- impairs lung liquid production/enhances absorption.
- fluid movement across fetal membranes.
* complications: premature closure of ductus arteriosus,
impairment of renal function, and cerebral
vasoconstriction. So not used after 35 weeks
Amniocentesis: to relieve maternal distress and to test
for fetal lung maturity. Complications: ruptured
membrane, chorioamnionitis, placental abruption,
preterm labour.