AMNIOTIC FLUID MUHAMMAD IZZAT

DISODER
AMNIOTIC FLUID
It creates a physical space for fetal movement,which is necessary
for normal musculoskeletal development.
It permits fetal swallowing—essential for gastrointestinal tract
development, and fetal breathing—necessary for lung
development.
Amnionic fluid guards against umbilical cord compression and
protects the fetus from trauma.
It even has bacteriostatic properties.
NORMAL AMNIOTIC FLUID
VOLUME
Amnionic fluid volume increases from approximately 30 mL at 10
weeks to 200 mL by 16 weeks and reaches 800 mL by the mid-third
trimester.
This fluid is approximately 98-percent water.
A full-term fetus contains roughly 2800 mL of water, and the
placenta another 400 mL, such that the term uterus holds nearly 4
liters of water
Abnormally decreased fluid volume is termed oligohydramnios,
whereas abnormally increased fluid volume is termed hydramnios
or polyhydramnios.
ORIGIN OF LIQUOR :
The amniotic fluid has both fetal and maternal origin.
Fetal origin :
• Fetal urine.
• Secretion from the amniotic epithelium.
• Diffusion from the umbilical cord vessels.
• Transudation through fetal skin.
• Secretion from bronchial mucosa, buccal
mucosa and salivary glands.
Maternal origin : The liquor is a filtrate from
maternal plasma.
Fate of liquor aminii :
1 Fetal : Swallowing.
2 Maternal : Transudation into maternal
circulation.
 AMNIOTIC FLUID VOLUME
ASSESSMENT

 Clinical assessment is unreliable.

 Objective assessment depends on U/S to measure:

Amniotic fluid index (AFI) or four-quadrant method: the uterine
cavity is divided into four quadrants or pockets. The largest
vertical pocket in each quadrant is measured in centimetres and
the total volume is calculated by adding the four together. A total
of more than 24 cm defines polyhydramnios.
Single deepest pocket (SDP) method: the deepest pocket is
measured vertically. A measurement under 2 cm defines
oligohydramnios and where it is over 8 cm there is
polyhydramnios.
SINGLE DEEPEST POCKET
also called the maximum vertical pocket/ deepest vertical pocket.
The ultrasound transducer is held perpendicular to the floor and
parallel to the long axis of the pregnant woman.
In the sagittal plane, the largest vertical pocket of fluid is identified.
The fluid pocket may contain fetal parts or loops of umbilical cord, but
these are not included in the measurement.
The normal range for single deepest pocket that is most commonly
used is 2 to 8 cm
When evaluating twin pregnancies and other multifetal gestations, a
single deepest pocket of amnionic fluid is assessed in each
gestational sac, again using a normal range of 2 to 8 cm
AMNIONIC FLUID INDEX
(AFI)
With this method, the deepest amniotic pocket in each of the four
quadrants is measured vertically and the values added together.
The uterus is divided vertically into two halves by an imaginary line
along the linea nigra. An imaginary horizontal line through the
umbilicus divides the uterus into an upper and a lower half.
The measured amniotic fluid pockets must be free of fetal
extremities and the umbilical cord and must be at least 0.5 cm
wide.
The Amniotic Fluid Index (AFI) is the sum of measurements of all
four quadrants.
POLYHYDRAMNIOS
Definition :
It means excessive amniotic fluid, more than 2 liters.
By ultrasound
the vertical diameter of the largest pocket of amniotic
fluid measure 8 cm or more, or the amniotic fluid
index (AFI) is 25 cm or more.
It can be classified into :
1 Mild : Largest vertical pocket diameter 8 – 9.9 c.m.
AFI is 25 to 29.9 cm
2 Moderate : Largest vertical pocket diameter 10-
11.9 c.m.AFI 30 to 34.9 cm
3 Severe : Largest vertical pocket diameter ≥ 12 c.m.
AFI 35 cm
 CAUSES OF POLYHYDRAMNIOS

 Fetal malformation:  Hydrops fetalis:

congestive heart
-GIT: failure, severe
esophageal/duodenal anaemia or
atresia, hypoproteinemia →
tracheoesophageal placental transudation
fistula.
-CNS: anencephaly  diabetes mellitus
(↓swallowing, (osmotic diuresis).
 Idiopathi
exposed meninges,
no antidiuretic c.
hormone).
 Twin-twin transfusion →
 TYPES OF
POLYHYDRAMINOS
Acute Polyhydraminos: Chronic
Polyhydraminos:
 Is very rare  Is gradual in onset

 Usually occurs at about  Usually from 30

16- 20 weeks weeks of pregnancy

 sudden onset - 3 – 4 days  Is the most common

type
 associated with
monozygotic twins

 Ends with spontaneous

abortion most of the time
before 28 weeks

 Severe abdominal
pain is common
symptom
DIAGNOSIS OF POLYHYDRAMNIOS
 Symptoms:  Ultrasound:
- dyspnea. - excessive amniotic fluid.
 edema. - fetal abnormalities.

 abdominal distention - assess fetal wellbeing: Doppler

 preterm labour.
 Abdominal examination:
- ↑uterus than expected.
 difficult to palpate fetal parts.
- difficult to hear fetal
sound.
heart
- ballotable
fetus.
 COMPLICA
TION
I. Maternal :
A) During Pregnancy :
1- Abortion (as a result of overdistension of the
uterus).
2- Preterm labour.
3 Premature rupture of membranes.
4 Cord prolapse.
5 Placental abruption.
6 Malpresentation.
7 Nonengagement of the presenting part.
8 Pressure symptoms : as dyspnea, palpitation
and edema of lower limbs.
B) During Labour :
• Premature rupture of
membranes.
• Prolapse of arm, cord or
both.
• Abruptio placentae due to rapid escape of liquor with
premature separation of the placenta.
• Splanchnic shock occurs if the fluid escapes rapidly, so the
pressure exerted by the uterus on the splanchnic vessels
drops suddenly leading to pooling of blood in the
splanchnic area and shock.
• Postpartum hemorrhage due to :
• Uterine atony due to overdistension of the uterus.
• Retained placenta.
• Prolonged labour.

C) During Purperium : The uterus may take a longer

MANAGEMENT
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
SYMPTOMATIC POLYHYDRAMINOS
 Schedule weekly or twice weekly perinatal visits –depending on severity

 Hospital admission- dyspnea, abdominal pain or difficult ambulation.

 serial ultrasonography

 Antacids to relive heart burn

 Reductive Amniocentesis- serially to relieve maternal distress and to test for fetal lung
maturity. Complications: ruptured membrane, chorioamnionitis, placental abruption, preterm
labour

 Induction of labour if worsening- cord prolapse, abruptio

 Delivery should be hospital

 Role of Indomethacin
 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
 OLIGOHYDRA
MNIOS
Definition :
Diminished amniotic fluid less than 500 ml. By ultrasound the vertical
diameter of the largest pocket of amniotic fluid measures 2 cm or less,
or the amniotic fluid index is 5 cm or less.

Incidence : about 0.5% of all pregnancies.

Time of onset may be :
1- Midgestation (poor
prognosis).
2- Third trimester.
CAUSES OF OLIGOHYDRAMNIOS:
1. Fetal causes: * Fetal growth
restriction.
* Renal cause (57%):
* Fetal death.
- Renal agenesis
(Potter’s syndrome). * Postterm pregnancy.
- polycystic kidney. *Preterm
- Urethral obstruction premature
rupture
(atresia/posterior
membranes
urethral valve).
POTTER’S
SYNDROME

 Pulmonary hypoplasia
 Oligohydrominios
 Twisted skin (wrinkly skin)
 Twisted face (Potter facies)
 Extremities defects
 Renal agenesis (bilateral)
CAUSES OF
OLIGOHYDRAMNIOS:
2. Maternal causes:
• Uteroplacental insufficiency.
• Preeclampsia.

3. Placental causes:
• twin-twin transfusion.

4. Drug causes:
ACE inhibitor and NSAID.

• 5. Idiopathic
DIAGNO
SIS
1The fundal level is lower than
the period of amenorrhea.
Investigation :
Ultrasound : Values :
2 Breech presentation is
common.  Confirm diagnosis : DVP ≤2 cm or AFI ≤5 cm.

3 The fetal parts are easily felt ·Detect a cause :

and the
fetus is almost immobile.  - Fetal growth restriction.

4 The FHS are clearly heard.  - Congenital anomalies.

· Malpresentation.
· Assess fetal wellbeing : Doppler.
COMPLICATION
S
FETAL MATERNAL

 Abortion
Increased morbidity
 Prematurity

 IUFD

 Deformities –contractures Prolonged labour:

 Potters syndrome uterine inertia
 pulmonary hypoplasia

 Malpresentations
Increased
 Fetal distress

 Low APGAR
operative
intervention
MANAGEME
NT
MANAGEMENT DEPENDS UPON
 AETIOLOGY

 GESTATIONAL AGE

 SEVERITY

 FETAL STATUS & WELL BEING- fetus surviving

extra uterine life
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

 INDUCTION OF LABOUR/ LSCS

 Lung maturity attained
 Lethal malformation
 Fetal jeopardy
 Sev IUGR
 Severe oligo
END
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