Amniotic Fluid Abnorality PDF'

Amniotic fluid abnormality
Dr Dalya Dler Nuri

In early pregnancy, amniotic
fluid is an ultra filtrate of
maternal plasma.
By the beginning of the second

trimester, it consists largely of
extracellular fluid that diffuses
through the fetal skin and thus
reflects the composition of fetal
plasma .
After 20 weeks, the cornification
of fetal skin prevents this
diffusion, and amniotic fluid is
composed largely of fetal urine.
Fetal kidneys start producing
urine at 12 weeks.
Pulmonary fluid contributes a small
proportion of the amniotic volume, and
fluid filtering through the placenta
accounts for the rest.
The volume of amniotic fluid at each

week is quite variable. In general, the
volume increases by 10 mL per week at
8 weeks and increases up to 60 mL per
week at 21 weeks, then declines
gradually back to a steady state by 33
weeks
Normal Amnionic Fluid Volume
Normally, amnionic fluid volume reaches 1 L by

36 weeks.
decreases thereafter to less than 200 mL at 42
weeks
Diminished fluid is termed Oligohydramnios.
& more than 2 L of amnionic fluid is considered

excessive and is termed hydramnios or
polyhydramnios.
In rare instances, as much as 15 L
chronic hydramnios
develops, which is the
gradual increase of
excessive fluid.
In acute hydramnios,
the uterus may become
markedly distended
within a few days.
.
.Measurement of
Amnionic Fluid
1.the amnionic fluid index—
AFI. This is calculated by
adding the vertical depths
of the largest pocket in
each of four equal uterine
quadrants.
significant hydramnios is
defined by an index greater
than 24 cm.
2.the single deepest-pocket
methods
Polyhydramnios
Incidence:
Excessive amnionic fluid is
identified in approximately 1-3 %
of pregnancies. The diagnosis
usually is suspected clinically and
confirmed by sonographic
examination.
Polyhydramnios is define as an
AFI of greater than 24 to 25 cm—
corresponding to greater than the
95th or 97.5th percentiles.
causes of polyhydramnios
The degree of hydramnios, as well as its prognosis, is often related
to the cause.
1. fetal malformations, especially of the central nervous system or

gastrointestinal tract. anencephaly and esophageal atresia.
2. Idiopathic polyhydramnios 80% of mild,20% of sever cases is
excess amnionic fluid not associated with congenital anomalies, like
in maternal diabetes, isoimmunization, infection, tumors or
multifetal gestation.
3. less common causes of polyhydramnios include fetal
nephrogenic diabetes insipidus, placental chorioangioma, fetal
sacrococcygeal teratoma, and maternal substance abuse, TTTS,
cardiac failure ,
Clinical Manifestations
Major maternal symptoms accompanying

polyhydramnios arise primarily from pressure exerted
within the over distended uterus and upon adjacent
organs.
severe dyspnea, oedema, the consequence of major

venous system compression by the enlarged uterus,
is common. Swelling tends to be especially severe in
the lower extremities, the vulva, and the abdominal
wall.
Rarely, oliguria may result from ureteral obstruction
by the enlarged uterus
polyhydramnios associated with fetal hydrops may

cause the mirror syndrome, whereby the maternal
condition mimics the fetus in that she develops
oedema and proteinuria, and frequently,
preeclampsia.
Chronic hydramnios, the woman may tolerate

excessive abdominal distension with relatively little
discomfort.
Diagnosis
The primary clinical finding with
polyhydramnios is uterine enlargement in
association with difficulty in palpating fetal
small parts and in hearing fetal heart tones.
The differentiation among polyhydramnios,

ascites, or a large ovarian cyst usually can
be made by sonographic evaluation.
Pregnancy Outcome
maternal complications
placental abruption The placenta may prematurely
separate extensively after a rapid decrease in uterine
surface area following uterine decompression due to
amnionic fluid escape
uterine dysfunction
postpartum hemorrhage
Abnormal fetal presentations
operative intervention are also common(cord prolapse,
unstable lie ,Abruptio placentae)
In general, the more severe the degree of hydramnios, the

higher the perinatal mortality rate.
Pregnancy Outcome
fetal complications
Increase prenatal mortality to 10-30% which
is 2ndary to
1. Congenital malformation
2. PROM
3. preterm labour
4. hypoxic event 2ndary to cord prolapse,
placental abruption.
Management
Diagnosis
1. Careful history (DM, RBC
alloimmunization, maternal drug, viral
infection, twin)
2. Examination over distended abdomen
3. High resolution U/S ( degree of
polyhydramnios, multiple gestation,
macrosomia, fetal CNS,GIT, Thorax)
4. Fetal karyotype
5. viral infection
Management
Aim of management
1.Reduce maternal discomfort
2. Prolong the pregnancy.
Minor degrees of polyhydramnios rarely require
treatment.
Even moderate degrees with some discomfort
usually can be managed without intervention
until labor ensues or until the membranes rupture
spontaneously.
If dyspnea or abdominal pain is present or if
ambulation is difficult, hospitalization becomes
necessary.
Bed rest, diuretics, and water and salt
restriction are ineffective.
1.indomethacin therapy has been used for
symptomatic polyhydramnios.
It decrease fetal urine production
2. Therapeutic amnioreduction
The principal purpose of amniocentesis is to
relieve maternal distress, and to that end,
it is transiently successful.
Amnionic fluid also can be tested to
predict fetal lung maturity .
Risk of amniocentesis
1. PROM
2. Chorioamnionitis
3. Placental abruption
4. Fetal inj.
5. RH isoimmunization
Oligohydramnios
defined as an AFI of 5 cm or less.

Occasionally be reduced to only a few
milliliters.
Oligohydramnios developing early in
pregnancy is less common and
frequently has a poor prognosis.
By contrast, in pregnancies that
continue beyond term, diminished fluid
volume may be found often.
Conditions Associated with
Oligohydramnios
1-Fetal
Chromosomal abnormalities
Congenital anomalies
Growth restriction
Demise
Post term pregnancy
Ruptured membrane
2-Placenta 4-Drugs
Abruption PG synthase
Twin-twin transfusion
inhibitors
3- Maternal ACE inhibitors
PPROM
Uteroplacental 5-Idiopathic
insufficiency
IUGR
Hypertension
Preeclampsia
post maturity
Congenital Anomalies Associated with
Oligohydramnios
1-Amnionic band syndrome
2-Cardiac: Fallot tetralogy, septal defects
3-Central nervous system: holoprosencephaly,
meningocoele, encephalocoele, microcephaly
4-Chromosomal abnormalities: triploidy, trisomy 18,
Turner syndrome
5-Cloacal dysgenesis
6-Cystic hygroma
7-Diaphragmatic hernia
8-Genitourinary: renal agenesis, renal dysplasia,
urethral obstruction, bladder exstrophy,
ureteropelvic junction obstruction, prune-belly
syndrome
9-Hypothyroidism
10-Skeletal: sirenomelia, sacral agenesis, absent
radius, facial clefting
11-TRAP (twin reverse arterial perfusion)
sequence
12-Twin-twin transfusion
13-VACTERL (vertebral, anal, cardiac, tracheo-
esophageal, renal, limb)
Prognosis
Fetal outcome is generally poor with early-

onset oligohydramnios.
Appropriately grown fetuses associated with

oligohydramnios prior to 37 weeks had a
threefold increase in preterm birth but not of
later growth restriction or fetal death
Prognosis
Maternal risk
Increase risk of C/S & its complication
Amnioinfusion carry the risk of Abruptio
placenta & Chorioamnionitis.
Fetal risk
prematurity
pulm,.hypoplasia
Cong. malformation
Management of oligohydramnios in late
pregnancy depends on the clinical
situation.
1. an evaluation for associated fetal

anomalies and growth.
2. Establish the aetiology
In a pregnancy complicated by
oligohydramnios and fetal-growth
restriction, close fetal surveillance is
important because of associated morbidity.
Diagnostic evaluation
1. History taken (HTN,PE,RM history of gush
of fluid loss per vagina),h.of congenital
infection
2. Examination to diagnose PROM
3. High resolution U/S
4. Doppler U/S
5. Fetal specimen for karyotype & viral
infection
However, oligohydramnios detected before
36 weeks in the presence of normal fetal
anatomy and growth may be managed
expectantly in conjunction with increased
fetal surveillance.
The outcomes of pregnancies with
intrapartum oligohydramnios are
conflicting.
treatment
1.Serial trans abdominal Amnioinfusion
2. Trans cervical catheter
3. Maternal hydration
4. Cervical canal occlusion by fibrin gel
5. Intra amniotic sealing technique.
Transvaginal amnioinfusion has been
extended into three clinical areas:
1-Treatment of variable or prolonged
decelerations
2-Prophylaxis for women with oligohydramnios, as
with prolonged ruptured membranes
3-Attempts to dilute or wash out thick meconium.
include a 500- to 800-mL bolus of warmed normal
saline followed by a continuous infusion of
approximately 3 mL per minute
Complications Associated with
Amnioinfusion :
Uterine hypertonus
Abnormal fetal heart rate tracing
Chorioamnionitis
Cord prolapse
Uterine rupture
Maternal cardiac or respiratory compromise
Placental abruption
Maternal death

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Amniotic fluid abnormality

Dr Dalya Dler Nuri

By the beginning of the second

The volume of amniotic fluid at each

Normally, amnionic fluid volume reaches 1 L by

& more than 2 L of amnionic fluid is considered

1. fetal malformations, especially of the central nervous system or

Major maternal symptoms accompanying

severe dyspnea, oedema, the consequence of major

polyhydramnios associated with fetal hydrops may

Chronic hydramnios, the woman may tolerate

The differentiation among polyhydramnios,

In general, the more severe the degree of hydramnios, the

defined as an AFI of 5 cm or less.

Fetal outcome is generally poor with early-

Appropriately grown fetuses associated with

1. an evaluation for associated fetal

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