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Amniotic fluid disorder prof.salah
 

Amniotic fluid disorder prof.salah

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    Amniotic fluid disorder prof.salah Amniotic fluid disorder prof.salah Presentation Transcript

    • Learning Objectives• Character of A.F• Functions of A.F• Oligo-Poly-Hydramnios Definition Etiology Diagnosis Treatment
    • The Fetal MembranesDefinition: Fetal membranes are all the structures that develop from thezygote and do not share in the formation of the embryo(extraembryonic structures from the primitive blastomeres).Fetal membranes are:a. Chorion.b. Amnion.c. Yolk sac.d. The umbilical cord including allantois and body stalk.
    • Amnion & Amniotic cavity- It is a membrane which bounds the amnioticcavity.- It is continuous with the ectoderm of the embryo.- It contains about 800-1000 ml of watery and clearfluid at full term.
    • Amniotic FluidThe amniotic fluid is that fluid surrounding the developing fetus that is found within the amniotic sac contained in the mothers womb.• Physical characteristics ; - It is clear pale yellow fluid.- pH of is around 7.2.- Specific gravity of 1.0069 – 1.008.--
    • Composition of amniotic fluid - 98% water, 2% solid substances like inorganic & organic salts, fetal epithelium, protein & enzymes.Origin: The following forms the amniotic fluid: 1- Amniotic membrane 2- Maternal tissue (interstitial) fluid by diffusion across the amnio-chorionic membrane from the deciduas parietalis. 3- Filtrated from maternal blood. 4- Fluid is also secreted by the fetal respiratory tract (300 – 400 ml daily) and enters the amniotic cavity. 5-Fetal urine.
    • Circulation- The amniotic fluid, formed by amniotic membrane & filtrated from maternal blood accumulates in the amniotic cavity,- Then, it is swallowed by the embryo.- Lastly, it passes as fetal urine to accumulate again in the amniotic cavity.Volume of the amniotic fluid:The volume of amniotic fluid increases slowly from 30 ml at 10 weeks gestation to 350 ml at 20 weeks to 700 – 1000 ml by 37 weeks.
    • NORMAL AMNIOTIC FLUID VOLUMEWeeks Fetus Amniotic Fluid PlacentaGestation (g) (ml) (g)16 100 200 10028 1000 1000 20036 2500 900 40040 3300 800 500
    • FunctionBefore labour:1-It forms an isolating bag around the embryo protecting him from external trauma, shock & temperature.2-It prevents adhesion of the embryo to its membranes.3-It allows homogenous media needed for the growth of the embryo.4-It permits the free movement of the embryo needed for muscular exercise.
    • FunctionDuring labor: 1- It forms the bags of fore water and hind water. 2-The bag of fore water allows regular dilatation of the cervix. 3-After rupture of membrane the amniotic fluid serves as a lubricant for fetus descent. 4-Also the amniotic fluid is bacteriostatic.
    • Clinical importance of AF:• Screening for fetal malformation (serum α-fetoprotien).• Assessment of fetal well-being (amniotic fluid index).• Assessment of fetal lung maturity (L/S ratio).• Diagnosis and follow up of labor.• Diagnosis of PROM (ferning test).• Diagnosis of fetal chromosomal abnormalities ( Downsyndrome, Edward syndrome, and others), and for DNA studies fordiagnosis of some single gene disorders.
    • Summary of the routine chemical tests performed on amniotic fluid• Tests for the Well-being and Maturity• __________________________________________________________• Test Normal values at term Significance• __________________________________________________________• Bilirubin scan 0.025 mg/dl Hemolytic disease of the newborn• L/S ratio 2.0 Fetal lung maturity• Phosphatidyl- Present Fetal lung maturityGlycerol• Creatinine 1.3 – 4.0 mg/dl Fetal age• Alpha fetal protein 4.0 mg/dl Neural tube disorders• __________________________________________________________ 12
    • 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.
    • AFI
    • 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) .
    • ETIOLOGY OF POLYHYDRAMNIOS• Idiopathic• Fetal Anomalies• Diabetes• Multifetal gestation• Immune/Non-immune hydrops• Fetal infection• Placental haemangiomas
    • Etiology of Polyhydramnios: Fetal Anomalies• Problems with swallowing and GI absorption• Increased transudation of fluid: anencephaly, spina bifida• Increased urination: anencephaly (lack of ADH, stimulation of urination centers)• Decreased inspiration
    • SYMPTOMS• Dyspnea• Abdominal pain• Contractions  preterm labor• Decreased Perception of Fetal Movements
    • 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.
    • (fetus)?• Fetal prognosis worsens with more severe hydramnios and congenital anomalies• 15-20% fetal malformations• Preterm delivery• Suspect diabetes• Prolapse of cord• Abruption
    • (Mother)?• Placental abruption• Uterine dysfunction• Post-partum hemorrhage• Abnormal presentation -- C/S
    • TREATMENT• Mild to Moderate hydramnios: rarely requires treatment• Hospitalization, bed rest• Amniocentesis: to relieve maternal distress and to test for fetal lung maturity. Complications: ruptured membrane, chorioamnionitis, placental abruption, preterm labour• Non-steroidal anti-inflammatory analgesia• Blood sugar control
    • management• Indomethacin 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 34 weeks
    • OLIGOHYDRAMNIOS
    • AETIOLOGYFETAL• PROM (50%) MATERNAL • PREECLAMPSIA• CHROMOSOMAL ANOMALIES • CHRONIC HT• CONGENITAL ANOMALIES• IUGR• IUFD• POSTTERM PREGNANCY DRUGS • PG SYNTHETASE INHIBITORSPLACENTAL • ACE INHIBITORS• CHRONIC ABRUPTION• TTTS• CVS IDIOPATHIC 27
    • ETIOLOGY• Postdate• Fetal Anomalies: obstruction of fetal urinary tract/renal agenesis• IUGR• ROM• Twin/Twin transfusion• Exposure to ACE inhibitors, and• Non-steroidal anti-inflammatory
    • DIAGNOSISSYMPTOMS SIGNSNO SPECIFIC Uterus – small for SYMPTOMS date MalpresentationsH/O leaking p/v IUGRPostterms/o preeclampsiaDrugsLess fetal movements 29
    • USGMETHODSDVP <2 cms (<1 severe)AFI <5 cms (5-8 borderline)2D pocket <15 sq cms 30
    • COMPLICATIONS FETAL MATERNALAbortionPrematurity Increased morbidityIUFD Prolonged labour:Deformities –contractures uterine inertiaPotters syndrome pulmonary hypoplasia Increased operativeMalpresentations intervention (malformations,Fetal distress distres)Low APGAR 31
    • MANAGEMENTDEPENDS UPON• AETIOLOGY• GESTATIONAL AGE• SEVERITY• FETAL STATUS & WELL BEING 32
    • DETERMINE AETIOLOGY• R/O PROM• TARGETED USG FOR ANOMALIES• R/O IUGR ,IUFD when suspected• Amniocentesis if chromosomal anomalies suspected – early symmetric IUGR 33
    • TREATMENT• ADEQUATE REST – decreases dehydration• HYDRATION – Oral/IV Hypotonic fluids(2 Lit/d) temperory increase helpful during labour,prior to ECV, USG• SERIAL USG – Monitor growth,AFI,BPP• INDUCTION OF LABOUR/ LSCS Lung maturity attained Lethal malformation Fetal jeopardy Sev IUGR Severe oligo 34
    • • AMNIOINFUSION Decreases cord compression Dilutes meconium 35
    • TREATMENT ACC. TO CAUSE• Drug induced – OMIT DRUG• PROM – INDUCTION• PPROM – Antibiotics,steroid – Induction• FETAL SURGERY VESICO AMNIOTIC SHUNT-PUV Laser photocoagulation for TTTS 36
    • Amniocentesis• Amniocentesis is the removal of a small amount of amniotic fluid from the sac around the baby.• This is usually performed at 16 weeks in pregnancy.• A fine needle is inserted under ultrasound guidance through the mothers abdomen into a pool of amniotic fluid.
    • Amniocentesis
    • AmniocentesisStudies of the cells obtained from the amniotic fluid permit:1- Chromosomal analysis of the cells which can be performed to investigate the following;  Diagnosis of sex of the fetus  Detection of chromosomal abnormalities e.g. trisomy 21 (Down’s syndrome)  DNA studies2- The cells may indicate genetically transmitted diseases( Inherited disorders e.g Cystic Fibrosis).3-To check for developmental problems e.g. Spina Bifida .4- Other studies can be done directly on the amniotic fluid including measurement of alpha-fetoprotein where high levels of alpha-fetoproteins in the amniotic fluid indicate the presence of a severe neural tube defect whereas low levels of alpha- fetoproteins may indicate chromosomal abnormalities .
    • AmniocentesisWho is the proper candidate for an Amniocentesis investigation?1-Those whom are suspected to have possible problems indicated by certain tests conducted previously,(e.g If pregnancy is complicated by a condition such as Rh-incombatibility,the doctor can use amniocentesis to find out if the babys lungs are developed enough to endure an early delivery).2- Family history of genetic abnormalities (in this case would be advisable to seek genetic counseling before becoming pregnant)3-Those that have been exposed to certain risk enviromental factors that might lead to fetal abnormalities .
    • AmniocentesisWhat are the risks of amniocentesis?• - Abortion: about 1 in 200 to 400 women aborted (higher risk if done in the first quarter)• - Uterine infection: 1 in 1000