PATHOLOGIC OBSTETRICS

Topic: Disorders of the Amniotic Fluid

Lecturer: Dr. Torres (CCT)

AMNIONIC FLUID  Fetal urine production

 Clear, slightly yellowish fluid o Begins between 8-11 wks. AOG
 Approximately 98 % water o NOT a major component of AF till the 2nd trimester
 For proper growth & Fetal urine will only be a significant part of AF during the 2nd
development of fetus: trimester because the fluid transfer during the early
o Fetal breathing - lung pregnancy would be via transmembranous,
growth intramembranous and transcutaneous flow
o Fetal swallowing - GI
development o If with renal abnormality – manifests as oligohydramnios after
 Physical environment for: 18 wks. AOG
o Fetal movement for
neuromuscular maturation  Water transport across the fetal skin
o Guards against umbilical cord compression o Continues until keratinization - 22 - 25 wks.
o Protects fetus from trauma ( cushion)
 Have bacteriostatic properties Four Pathways in AF Regulation in Late Pregnancy

Amnionic Fluid Volume (AFV):

 Increases from early trimester
- primary source
o Fluctuates - mid trimester = approximately 800 ml - primary mechanism
o After 40th week = decreases by 8% per week
 Oligohydramnios
o Abnormal ↓ AFV - F urine (260 = AF osmolality < maternal & fetal plasma (280 mOsm/L))

 Hydramnios or Polyhydramnios
o Abnormal ↑ AFV

AOG AFV (ml) Lecture Discussion: 4 Pathways in AF Regulation in Late Pregnancy

10 30 ml During the late pregnancy (2nd trimester)  we now have the 4th pathway of
16 200 ml AF regulation which is fetal urine production. It will now become the primary
28 1000 ml source of AF production. It would exceed 1 L/day and the entire AF volume
36 900 ml will be recirculated daily
40 800 ml
Fetal urine osmolality is similar to that of the AF which is hypotonic compared
Amnionic Fluid Physiology: to that of the maternal & fetal plasma.
 Early pregnancy o Fetal urine & AF osmolality= 260 mOsm/L
o Major source of AF = amnionic epithelium o Maternal & fetal plasma osmolality = 280 mOsm/L
o AF is similar in composition to extracellular fluid
The hypotonicity of the AF would account for the intramembranous flow
across the fetal vessels on the placental surface and this would reach 400
mL/day. Hence, it is the 2nd regulator of AF volume

Another source of AF volume is the respiratory tract. Approximately about

350 mL of lung fluid secretion is produced daily. Half of which would be
immediately swallowed.

 1st half of pregnancy – transfer of water & other small molecules

takes place via:
1. Transmembranous flow – across the amnion
2. Intramembranous flow – across the fetal vessels on placental
surface
3. Transcutaneous flow – across fetal skin

Fetal swallowing – is the primary mechanism of AF resorption. Around 750

mL is resorbed daily. If there would be impairment due to swallowing (ex.
Impairment due to CNS or GIT abnormality) = would result to Hydramnios
o Since the fetus would not be able to take in the fluid  there would
be too much increase in the AF volume, thus hydramnios

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 PATHOLOGIC OBSTETRICS
Topic: Disorders of the Amniotic Fluid
Lecturer: Dr. Torres (CCT)

Measurement  Single Deepest Pocket

 Measurement of AFV became a standard component in every 2nd & 3rd o Also called single vertical pocket
trimester ultrasound o Normal value: >2 to <8 cm
 Actual volume of AF – research setting
o Contributed to our understand normal physiology Lecture Discussion: Single Deepest Pocket
o Validated sonographic fluid assessment techniques In multiple gestation, each gestational sac should be measured for its single
The actual volume measurement of AF is not actually done. It deepest pocket
has been done in a research setting which has validated
sonographic fluid assessment techniques. It was performed
before but now it is not being done anymore

 Direct measurement fluid quantification by dye dilution – inject dye -

aminohippurate to the cavity under USG — sampling of AF by
determining the dye concentration= calculate the volume
The direct measurement of AF contributed to our understanding of
the normal physiology of AF production. How was it done? They
injected a dye (aminohippurate) to the cavity and then a sample of
the AF was obtained to determine the dye concentration. Eventually
they calculated the volume of AF

Black part  amniotic fluid ; White part  fetal part

Sonographic Measurement
 By the 2 semi quantitative techniques:
The maximal vertical pocket of AF is what we are measuring. It should be >1
1. Single deepest (vertical) pocket cm in width to be considered adequate
2. Amniotic Fluid Index (AFI)
 Amniotic Fluid Index (AFI)
 Both techniques are: o The uterus is divided into 4
o Reproducible quadrants – sum of SDP
You can repeat it again and again (single deepest pocket) of
each quadrant = AFI
o Can be followed serially to assess trends o Normal value: >5-<24 (ACOG)
For example the patient is oligohydramnios  after a day or 25 cm (research)
or two, you can measure it again to check if it increasing or  Approximately 3x
not
SVP – guide

o To aid communication among providers

o Use of AFI identifies more pregnancies as oligohydramnios
Before, when a woman’s pregnancy is near term that’s the
 How is it performed? only time AFI is used. But nowadays we don’t use it
o USG transducer held perpendicular to floor & parallel to long anymore because AFI identifies more pregnancies as
axis of woman oligohydramnios. So even if the woman is in her near term
So the ultrasound transducer should never be angulated so or term, we only use single deepest pocket
that it can give a precise measurement
It should be longitudinal  parallel to the long axis of the POLYHYDRAMNIOS
patient  Also called Hydramnios
 Occurs in 1-2% singleton pregnancies
 Fluid pocket at least 1 cm in width o More frequently (18%) in multifetal gestations
So using either of the 2 techniques (single deepest pocket or AFI),
fluid pocket should at least be 1 cm in width to be considered as
Classification of Hydramnios (Degree)
adequate.
Mild Moderate Severe
If the fluid pocket is <1 cm in width = inadequate measurement (it
AFI 25 - 29.9 cm 30 - 34.9 cm ≥ 35 cm
is considered 0 even if there is a little space measured)
SVP 8-9.9 cm 10 - 11.9 cm ≥ 12 cm
Incidence 2/3 – most common 20% 15%
 Fetal parts or umbilical cord:
with underlying
o Not included Cause Idiopathic & benign
pathology
o Color Doppler – to verify
Prev of
Note that when measuring, fetal parts or umbilical cord should Anomalous 8 12 30
never be included in the measurement. Use a color Doppler to Infant
verify its presence

Picture on Left:
The black part  amniotic fluid
The blue part  umbilical cord
You cannot include the umbilical cord or
fetal part in the AF measurement so if you
see this, you have to move on another
area

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 PATHOLOGIC OBSTETRICS
Topic: Disorders of the Amniotic Fluid
Lecturer: Dr. Torres (CCT)

Etiology of Hydramnios: **Study This Table**

 Fetal cause - 15% = Targeted USG
o Structural abnormalities
o Genetic syndromes

Lecture Discussion:
When hydramnios is identified, regardless of the degree of hydramnios 
targeted sonography (congenital scanning) is indicated. If it is (+), you have
to ask for amniocentesis because amniotic fluid could tell something about
the baby such as genetic syndrome or structural abnormalities

 Diabetes - 15 - 20%
o Maternal hyperglycemia causes
fatal hyperglycaemia = fetal
osmotic diuresis  the baby urines
too much causing an excessive
increase in the AF

 Congenital infections
o CMV, toxoplasmosis, Syphilis, Parvovirus Symptoms & Complications:
Symptoms
 RBC alloimmunization they are
 Placental chorioangioma not common
 Infrequent unless rapidly accumulating or severe hydramnios
 Symptoms would arise due to pressure exerted within the over
distended uterus & on adjacent organs:
Hydramnios is often a component of Hydrops Fetalis 1. Dyspnea & orthopnea (respiratory compromise)
2. Edema
 A consequence of major venous system compression
 More pronounced in LE, vulva, abdominal wall
3. Oliguria – from ureteral obstruction

Chronic Hydramnios Acute Hydramnios

 Gradual
 Last weeks of pregnancy
 Uncomfortable than painful
Hydramnios results to hydrophobic fetus & placenta (hydrops fetalis)
Pathophysiology: Due to high cardiac output state
 Rapid development
 Early development 22- 32 wks
 With pain — may result to PTL
(preterm labor) before 28 weeks or
in
 Symptoms that would necessitate
intervention

 Multifetal Gestation Maternal Complications

o Accounts for 18% of cases  Placental abruption
o In monochorionic gestation - one sac with hydramnios & the o Results from rapid decompression after fetal membrane
other is with oligohydramnios = Diagnostic of TTTS (twin-to- rupture or after amnioreduction
twin syndrome)

 Idiopathic - 70%
o Found in 1% of pregnancies
o Incidental finding in later gestation (32 - 35 wks.)
o Mild degree in 80% and resolution occurs in more than a third
o Pregnancy outcomes are usually good

 Uterine Dysfunction, PPH (postpartum

hemorrhage/atony)

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 PATHOLOGIC OBSTETRICS
Topic: Disorders of the Amniotic Fluid
Lecturer: Dr. Torres (CCT)

Pregnancy Outcomes: OLIGOHYDRAMNIOS

 Birth weight >4000 gms (25%)  Found in 1-4 % of pregnancies
o Larger fetus has higher urine output – happens especially if patient  In any trimester
is diabetic  Anhydramnios = NO measurable pocket of AF
o End up with Cesarean Section (Delivery) in 35-55%  When Diagnosed = Always a cause a concern
 Prognosis – varies depending on underlying cause
 Perinatal mortality
o Greater stillbirth risk especially if with growth restriction
 IUGR – intrauterine growth restriction
o Associated with Trisomy 18
o Preterm labor
o Small for Gestational Age

Diagnosis:
 Clinical
o Uterine size exceeds that for expected for GA (gestational age)
Picture Above: Oligohydramnios
When does fundic height correspond to gestational age? 18
to 30 weeks If you would note here, there is no more space for the fetus to move (too
So if you have a patient comes to you that is confirmed 24 crowded). Regardless of the gestational age, it is a cause of concern.
weeks AOG and her fundic height is 28  you could suspect
that she might be having polyhydramnios (a differential Etiology:
diagnosis)  Early Onset Oligohydramnios
o Early 2nd trimester = poor prognosis
o Uterus feels tense
o Difficulty in: o Reflects fetal abnormality that:
 Palpating fetal small parts 1. Precludes normal urination
 Auscultating FHT (fetal heart tones) 2. Placental abnormality that impairs perfusion
So it is possible that the oligohydramnios is due to:
 Sonography o Urination problem
o Placental abnormality
Management:
 Treatment of the underlying cause If the patient has Oligohydramnios
 Amnioreduction – large volume amniocentesis ALWAYS RULE OUT RUPTURED MEMBRANES!
o Only if gross hydramnios causing discomfort
o Goal = restore AFV to the upper normal range

Technique how to perform Amnioreduction:

o 18 - 20 gauge needle
o 1-2 L is slowly withdrawn over 20 – 30 min depending on the  Midpregnancy Oligohydramnios
severity of hydramnios & GA o Late 2nd or 3rd trimester

Complications of Amnioreduction: 1. Associated with FGR (fetal growth restriction), placental

o Delivery abnormality, maternal complications (preeclampsia, vascular
o Ruptured membranes within 48 hrs. disease)
No corioamnionitis, abruption, bradycardia Take note that uteroplacental insufficiency impairs fetal
growth & reduces fetal urine output
 Indomethacin therapy
o Already removed as management in the book 2. Exposure to medications
o Decreases urine & lung fluid production or it enhances 3. Late term or post term pregnancies
absorption of fluid Because after the 40th week, there is 8% decrease in the
o Premature closure of fetal ductus arteriosus AFV per week
 Due to this adverse effect it is NOT recommended
anymore

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 PATHOLOGIC OBSTETRICS
Topic: Disorders of the Amniotic Fluid
Lecturer: Dr. Torres (CCT)

Congenital Anomalies: Summary of Risk Factors of Oligohydramnios:

 At 18 wks. - fetal kidneys are main contributors to AFV  Chromosomal abnormality
Remember that during the early part of gestation, the fetal  Post-term pregnancies
kidney has not much role in the AFV. But during the 2nd trimester,  IUGR
the fetal kidney becomes the main contributor of AFV  Preeclampsia
 Medication (ACE inhibitors, indomethacin)
So in early onset oligohydramnios  you do targeted sonography
 Multiple pregnancy
(congenital anomaly scan) because it is possible that the fetus has
an abnormal kidneys
Diagnosis of Oligohydramnios:
 Clinical
 Some renal abnormality = absent urine production
a. bilateral renal agenesis (Potter’s syndrome) o Small for dates or ↓ fundic height
o Fetal parts easily palpable
b. bilateral multicystic dysplastic kidney
o Rule out RBOM (ruptured bag of membrane)
c. unilateral renal agenesis with contralateral multicysytic kidney
d. infantile form of autosomal recessive polycystic kidney disease History & PE – risk factor for uteroplacental insufficiencies -
Chronic renal disease/HPN, Abruption
 Urinary abnormality – fetal bladder outlet obstruction
a. posterior urethral valves  USG
b. urethral atresia/stenosis o Targeted USG - to assess fetal anomalies/ growth & well-being
c. mega cystis microcolon intestinal hypo peristalsis syndrome & placental abnormality
Whenever there is a diagnosis of oligohydramnios 
always ask for a targeted sonography since it causes a
 Complex fetal genitourinary abnormalities
concern
a. persistent cloaca
b. sireno melia
Pregnancy Outcomes:

 If there is NO AF beyond mid 2nd trimester due to GUT etiology -

prognosis is very poor unless fetal therapy is an option
(vesicoamnionic shunt placement)

Potter’s Syndrome

Pulmonary Hypoplasia:
 A significant concern in oligohydramnios amid 2nd trimester – before 20-
22 weeks
 Etiology:
1. Renal abnormality = lethal prognosis
2. Placental hemoatoma or Chronic abruption = resulting to
Chronic abruption oligohydramnios sequence (CAOS) = fetal
growth restriction

Medication: Management:
 Another cause of Oligohydramnios  Dependent on etiology
 Exposure to drugs that block the RAS o Renal agenesis – counselling
1. Angiotensin converting enzyme inhibitor (ACEIs) o Medication exposure – stop medication
2. Angiotensin receptor blockers (ARBs) o Dehydration – hydration
ACEIs & ARBs leads to fetal hypotension — renal o
hypoperfusion—renal ischemia === anuric renal failure =
 Close fetal surveillance - asstd MM
fetal skull bone hypoplasia & limb contractures
o Antenatal monitoring: BPS, NST
3. Non-steroidal anti-inflammatory drugs (NSAIDs)
 Before 36 weeks
Associated with fetal ductus arteriosus constriction &
o With oligohydramnios but normal fetal anatomy & growth 
lowers fetal urine production - in neonates == acute & CHR
renal insufficiency expectant management together with fetal surveillance
o With fetal or maternal compromise  delivery

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 PATHOLOGIC OBSTETRICS
Topic: Disorders of the Amniotic Fluid
Lecturer: Dr. Torres (CCT)

Management continued…..
 Antepartum management = Maternal hydration (oral or IV)
 Intrapartum management = Amnioinfusion
1. Help resolve variable FHR deceleration (UC compression)
2. Prevent morbidity from meconium-stained AF
Amnioinfusion:
 Not a standard of care for other etiologies
 Not generally recommended

Borderline Oligohydramnios:
 AFI between 5 and 8
Remember that an AFI of 5 is still normal
If it is <5 = Oligohydramnios

 Conclusion:
o Insufficient to support fetal testing or delivery

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