Amniotic Fluid

Group 5
 o To describe the production and composition
of amniotic fluid
o To list the common reasons for performing
amniocentesis
o To discuss how to differentiate amniotic fluid
from maternal urine

Learning o To describe the testing available for genetic

and congenital abnormalities

outcomes
o To explain the disease process of hemolytic
disease of the newborn and summarize testing
available to detect HDN
o To list the testing available for fetal lung
maturity
o To discuss the risks of fetus in preterm
delivery and explain the assessment of fetal
risks using the Liley graph 2
Amniotic Fluid

Amniotic fluid is present in the amnion, a

membranous sac that surrounds the fetus. The primary
functions of the amniotic fluid are to provide a
protective cushion for the fetus, allow fetal movement,
stabilize the temperature to protect the fetus from
extreme temperature changes, and permit proper lung
development.
The amount of amniotic fluid increases in quantity
throughout pregnancy, reaching a peak of
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approximately 800 to 1200 mL during the third
Production of amniotic fluid
• During the first trimester, the approximately 35 mL of amniotic fluid is derived primarily
from the maternal circulation. During the latter third to half of pregnancy, the fetus secretes
a volume of lung liquid necessary to expand the lungs with growth. During each episode of
fetal respiratory movement, secreted lung liquid enters the amniotic fluid, bathing the lungs
and washing pulmonary and alveolar contents such as lecithin, sphingomyelin, and
phosphatidyl glycerol into the amniotic fluid surrounding the fetus. These lung surfactants
serve as an index of fetal lung maturity. After the first trimester, fetal urine is the major
contributor to the amniotic fluid volume. At the time that fetal urine production occurs, fetal
swallowing of the amniotic fluid begins and regulates the increase in fluid from the fetal
urine. The fetus swallows amniotic fluid, which is absorbed through the gastrointestinal tract
and reexcreted by the kidneys from the blood into fetal urine and back into amniotic fluid.

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Chemical Composition
• Amniotic fluid has a composition similar to that of the maternal plasma and contains a small
amount of sloughed fetal cells from the skin, digestive system, and urinary tract. The fluid
also contains biochemical substances that are produced by the fetus, such as :
• bilirubin
• lipids
• enzymes
• electrolytes
• urea, creatinine
• uric acid
• proteins
• and hormones that can be tested to determine the health or maturity of the fetus. 5
Indications for Amniocentesis
• Amniocentesis is recommended for neural tube defects when screening blood tests such as the maternal
serum alphafetoprotein test are abnormal or to detect genetic disorders or to evaluate the health of the
fetus.
• Fetal epithelial cells in amniotic fluid indicate the genetic material of the fetus and the biochemical
substances that the fetus has produced. These cells can be separated from the fluid, cultured, and examined
for chromosome abnormalities by karyotyping, fluorescence in situ hybridization (FISH), fluorescent
mapping spectral karyotyping (SKY), and DNA testing. Biochemical substances produced by the fetus can
be analyzed by thin-layer chromatography to evaluate the health of the fetus.
• In general, amniocentesis is a safe procedure, particularly when performed after the 14th week of
gestation. Fluid for chromosome analysis is usually collected at approximately 16 weeks’ gestation and
tests for intrauterine growth retardation are performed near the end of the second trimester, whereas tests
for fetal distress and maturity are performed later in the third trimester

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 common reasons for performing
amniocentesis
Collection
• Amniotic fluid is obtained by needle aspiration into the amniotic sac, a
procedure called amniocentesis. . Using continuous ultrasound for guidance,
the physician locates the fetus and placenta to safely perform the procedure. A
thin, hollow needle is inserted through the mother’s abdomen into the
mother’s uterus and into the amniotic sac to aspirate the amniotic fluid.
Vaginal amniocentesis may also be performed; however, this method carries a
greater risk of infection. A maximum of 30 mL of amniotic fluid is collected in
sterile syringes. The first 2 or 3 mL collected can be contaminated by maternal
blood, tissue fluid, and cells and are discarded. Specimens should be
transferred to sterile plastic containers and taken immediately to the
laboratory. Fluid for bilirubin analysis in cases of hemolytic disease of the
newborn (HDN) must be protected from light at all times.

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Differentiating Maternal Urine From
Amniotic Fluid
• Differentiation between amniotic fluid and maternal urine may be necessary to determine possible
premature membrane rupture or accidental puncture of the maternal bladder during specimen collection.
Chemical analysis of creatinine, urea, glucose, and protein aids in the differentiation.
• Amniotic fluid: Creatinine = (=/<) 3.5 mg/dL, Urea = (=/<) 30 mg/dL
• Urine: Creatinine = > 10 mg/dL, Urea > 300 mg/dL
• Measurement of glucose and protein by a reagent strip is a less reliable indicator, because glucose and
protein are not uncommon urine constituents during pregnancy. However, under normal circumstances,
the presence of glucose, protein, or both is associated more closely with amniotic fluid.
• The fern test also can differentiate amniotic fluid from urine and other body fluids. Presence of “fern-
like” crystals due to the protein and sodium chloride content is a positive screen for amniotic fluid.

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testing available for genetic and congenital
abnormalities
• How are birth defects diagnosed?
• Some birth defects can be diagnosed before birth through ultrasound, 
amniocentesis or chronic villus sampling (CVS). Most women have blood tests
to screen for their risk of having a baby with a specific birth defect, such as 
Down syndrome and spina bifida. While it does not usually lead to a cure for the
baby's birth defect, prenatal diagnosis can prepare the parents emotionally and
help them prepare for a child with a birth defect.
• In other cases a birth defect is diagnosed after birth through physical
examination or a blood test that screens for several disorders in newborns.

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genetic and congenital abnormalities
and testing
• Hemolytic Disease of the Newborn ( Amniotic fluid bilirubin )
• Neural tube defects (NTD) ( maternal serum alpha-fetoprotein
(MSAFP) blood test, high-resolution ultrasound, and amniocentesis )
• Respiratory distress syndrome (RDS) ( Lecithin-Sphingomyelin Ratio,
Phosphatidyl Glycerol, Lamellar Bodies, Foam Stability Index )

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Hemolytic Disease of the Newborn
• The oldest routinely performed laboratory test on amniotic fluid evaluates the severity of the fetal
anemia produced by HDN. The incidence of this disease has been decreasing rapidly since the
development of methods to prevent anti-Rh antibody production in postpartum mothers.
• However, antibodies against other red cell antigens are also capable of producing HDN, and
immunization of Rh-negative mothers may not be effective or even performed in all cases. Initial
exposure to foreign red cell antigens occurs during gestation, delivery of the placenta, or a previous
pregnancy when fetal red blood cells enter into the maternal circulation and stimulate the mother to
produce antibodies to the antigen.
• When these antibodies present in the maternal circulation cross the placenta into the fetal circulation
and bind to the antigen on the fetal cells, the cells are destroyed. The destruction of fetal red blood
cells results in the appearance of the red blood cell degradation product, unconjugated bilirubin, in
the amniotic fluid. By measuring the amount of bilirubin in the fluid, the extent of hemolysis taking
place may be determined, and the danger this anemia presents to the fetus may be assessed
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Testing available for hdn
• Amniotic fluid bilirubin is measured by spectrophotometric analysis
using serial dilutions. As illustrated in Figure 13–3, the optical density
(OD) of the fluid is measured in intervals between 365 nm and 550 nm
and the readings plotted on semilogarithmic graph paper. In normal
fluid, the OD is highest at 365 nm and decreases linearly to 550 nm,
illustrated by a straight line. When bilirubin is present, a rise in OD is
seen at 450 nm because this is the wavelength of maximum bilirubin
absorption. The difference between the OD of the theoretic baseline
and the OD at 450 nm represents the amniotic fluid bilirubin
concentration. This difference in OD, referred to as the absorbance 12
Testing available for hdn

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Tests for Fetal Maturity
• Lecithin-Sphingomyelin Ratio
• Phosphatidyl Glycerol
• Lamellar Bodies
• Foam Stability Index

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Lecithin-Sphingomyelin Ratio
• The reference method to which tests of FLM are compared is the lecithin-sphingomyelin (L/S) ratio.
• Lecithin is the primary component of the surfactants (phospholipids, neutral lipids, and proteins) that make up the alveolar
lining and account for alveolar stability.
• Lecithin is produced at a relatively low and constant rate until the 35th week of gestation, at which time a noticeable
increase in its production occurs, resulting in the stabilization of the fetal lung alveoli. Sphingomyelin is a lipid that is
produced at a constant rate after about 26 weeks’ gestation; therefore, it can serve as a control on which to base the rise in
lecithin. Both lecithin and sphingomyelin appear in the amniotic fluid in amounts proportional to their concentrations in the
fetus. Prior to 35 weeks’ gestation, the L/S ratio is usually less than 1.6 because large amounts of lecithin are not being
produced at this time. After 35 weeks’ gestation, the lecithin concentration increases while the sphingomyelin concentration
remains constant. The L/S ratio will rise to 2.0 or higher as the lecithin production increases to prevent alveolar collapse.
Therefore, when the L/S ratio reaches 2.0, a preterm delivery is usually considered to be a relatively safe procedure. Falsely
elevated results are encountered in fluid contaminated with blood or meconium because both these substances contain
lecithin and sphingomyelin. Quantitative measurement of lecithin and sphingomyelin is performed using thin-layer
chromatography (TLC). Because the procedure is labor intensive and subject to high coefficients of variation, many
laboratories have replaced the L/S ratio with the quantitative phosphatidyl glycerol immunoassays and lamellar body density
procedures.
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Phosphatidyl Glycerol
• The presence of another lung surface lipid, phosphatidyl glycerol (PG), is also essential for adequate lung maturity
and can be detected after 35 weeks’ gestation.
• The production of PG normally parallels that of lecithin, but its production is delayed in cases of maternal diabetes.
In this circumstance, respiratory distress occurs in the presence of an L/S ratio of 2.0.
• Therefore, a thin-layer chromatography lung profile must include lecithin, sphingomyelin, and PG to provide an
accurate measurement of FLM.
• Development of an immunologic agglutination test for PG has provided a more rapid and easy to perform method for
assessment of fetal maturity that does not require a laboratory to be equipped to perform thin-layer chromatography.
• The Aminostat-FLM (Irving Scientific, Santa Ana, CA) uses antisera containing polyclonal anti-PG antibodies that
are specific for PG-containing lamellar bodies in the amniotic fluid. The size of the agglutinates is read
macroscopically and the results are reported as either negative, indicating pulmonary immaturity, or low positive or
high positive, indicating pulmonary maturity.
• The test is not affected by specimen contamination with blood and meconium. Studies have shown good correlation
with thin-layer chromatography but with a slightly higher incidence of false-negative results that may need to be
followed up with further testing. 16
Lamellar Bodies
• Surfactant is composed of approximately 90% phospholipid and 10% protein and is packaged into layered
storage granules called lamellar bodies.
• Lamellar bodies are densely packed layers of phospholipids that represent a storage form of pulmonary
surfactant. They are secreted by the type II pneumocytes of the fetal lung at about 24 weeks of gestation
and are absorbed into the alveolar spaces to provide surfactant.
• They enter the amniotic fluid at about 26 weeks of gestation and increase in concentration from 50,000 to
200,000 per microliter by the end of the third trimester.
• As the fetal lung matures, increased lamellar body production is reflected by an increase in amniotic fluid
phospholipids and the L/S ratio. Therefore, the number of lamellar bodies present in the amniotic fluid
correlates with the amount of phospholipid present in the fetal lungs.
• The presence of lamellar bodies increases the OD of the amniotic fluid. Specimens are centrifuged at 2000
g for 10 minutes and examined using a wavelength of 650 nm, which rules out interference from
hemoglobin but not other contaminants, such as meconium. An OD of 0.150 has been shown to correlate
well with an L/S ratio of greater than or equal to 2.0 and the presence of phosphatidyl glycerol. 17
Lamellar Body Count
• Lamellar body diameter is similar to that of small platelets ranging in size from 1.7 to 7.3 fL, or 1 to 5m; therefore, lamellar
body counts (LBCs) can be obtained using the platelet channel of automated hematology analyzers using either optical or
impedance methods for counting. Some automated cell counters use both impedance and optical methods for counting.
• Because the various hematology analyzers count lamellar bodies differently and require different specimen preparation, cutoff
values for FLM vary, making it necessary to establish analyzer-specific LBC clinical decision limits.
• The advantages of lamellar body counting include: (1) rapid turnaround time, (2) low reagent cost, (3) wide availability, (4) low
degree of technical difficulty, (5) low volume of amniotic fluid required, and (6) excellent clinical performance.
• Amniotic fluid specimens containing whole blood, meconium, and mucus should not be used. Blood initially raises the LBC
because of the presence of platelets and then can lower the LBC as lamellar bodies are trapped in the fibrin strands.
• Meconium and mucus cause a false increase in the LBC and should not be used for testing.
• Specimens may be stored at 2°C to 8°C but never frozen. A consensus protocol for performing LBC has been published by
CLSI and is described in Procedure 13–3. Results are reported in units of lamellar bodies per microliter and should be
accompanied by the laboratory’s established values for maturity and the instrument that was used. A consensus protocol for
noncentrifuged samples considers LBCs greater than 50,000/L an indication of FLM and values below 15,000/L as immature.
Results in between these two values are considered indeterminate and further testing using alternate methods is recommended.

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Foam Stability Index
• Until the development of biochemical techniques to measure the individual lung-surface lipid concentrations, a
mechanical screening test, called the “foam” or “shake” test, was used to determine their presence. Because it
can be performed at the bedside or in the laboratory, the test is still in use.
• Amniotic fluid is mixed with 95% ethanol, shaken for 15 seconds, and allowed to sit undisturbed for 15 minutes.
At the end of this time, the surface of the fluid is observed for the presence of a continuous line of bubbles
around the outside edge.
• The presence of bubbles indicates that a sufficient amount of phospholipid is available to reduce the surface
tension of the fluid even in the presence of alcohol, an antifoaming agent.
• A modification of the foam test uses 0.5 mL of amniotic fluid added to increasing amounts of 95% ethanol,
providing a gradient of ethanol/fluid ratios ranging from 0.42 mL to 0.55 mL in 0.01-mL increments, which can
be used to provide a semiquantitative measure of the amount of surfactant present. A value of 47 or higher
indicates FLM.
• The Foam Stability Index has shown good correlation with the L/S ratio and tests for phosphatidyl glycerol. The
test cannot be used with contaminated amniotic fluid because blood and meconium also reduce surface tension,
yielding a falsely mature index result. 19
risks of fetus in preterm delivery
A premature birth is one that happens at least three weeks
before your estimated 40-week due date — so, before the 37th
week of pregnancy. That said, “premature” is a range.
Premature birth ranges are called:
• extremely preterm (before 28 weeks)
• very preterm (28 to 32 weeks)
• moderate preterm (32 to 34 weeks)
• late preterm (34 to 37 weeks)
• You may also hear the term “periviable birth,” which refers
to delivery between 20 and 26 weeks, according to the 
American College of Obstetricians and Gynecologists. 20
Babies born at 24 weeks
Skin and warmth
•Your tiny one will need to go into an incubator (like a portable womb) right away to keep them warm. Babies born this early have not yet
had the chance to develop brown fat — the kind just under the skin that keeps them toasty. Their skin will also be extremely thin and
delicate.
Breathing
•A baby’s lower lungs and airways are only just beginning to develop around 24 weeks. A baby born at this time will need help to breathe.
This might mean little tubes going into their nose, as they grow in the incubator.
Eyesight
•At about 24 weeks in the womb, a baby’s eyes are still closed. Their eyelids and eyes are not yet developed enough to open them. Your
baby will need to have soft cotton or gauze taped over their eyes to protect them from the light as their sight continues to develop. In
some cases, a baby’s eyes might not grow as they should, which could lead to vision problems or even blindness.
Hearing
•Amazingly, an extremely premature baby already has fully formed ears. Your baby can start to hear you at about 18 weeks gestation!
However, your little one’s eardrums are still very delicate and sensitive at 24 weeks. Some babies born this early may have 
problems hearing or experience deafness.
Other issues
•Some extremely premature babies may have issues that affect the brain and nervous system as they get older. Some of these are serious.
Complications include cerebral palsy, learning problems, and behavioral issues. 21
Babies born at 26 weeks
• About 20 percent of babies born at 26 weeks may still have some health problems as they
age. These might include issues with:
• seeing
• hearing
• learning
• understanding
• behavior
• social skills
• Babies born at 26 weeks may also develop heart problems.

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Babies born at 28 weeks
• Only 10 percent of babies born at 28 weeks risk long-term complications.
These can include:
• breathing problems
• infections
• digestive problems
• blood problems
• kidney problems
• brain and nervous system problems like seizures
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Babies born at 30 to 32 weeks
• What a difference a few womb weeks make! Babies born between 30
and 32 weeks, while still considered preterm, have at least a 99
percentTrusted Source chance of survival. They also have very low
risk of health and development complications later on.

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Babies born at 34 to 36 weeks
• If your baby is born at 34 to 36 weeks they are in a new category
called “late preterm.” This is the most common kind of premature
baby. It’s also the one with the least risks because your baby has more
time to grow and develop inside you.
• In fact — good news — a preemie baby born at 34 to 36 weeks has 
nearly a 100 percent chance at survival and the same chances at long-
term health as a baby who was born full-term.

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assessment of fetal risks using the
Liley graph
• Liley graph plots the D A450 against gestational age and is divided
into three zones that represent the extent of hemolytic severity. Values
falling in zone I indicate no more than a mildly affected fetus; those in
zone II indicate moderate hemolysis and require careful monitoring
anticipating an early delivery or exchange transfusion upon delivery,
whereas a value in zone III indicates severe hemolysis and suggests a
severely affected fetus.

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assessment of fetal risks using the
Liley graph

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