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Amniotic Fluid Abnormalities Guide
- 1. AMNIOTIC FLUID ABNORMALITIES Dr. Saima Chaudhary
- 2. AMNIOTIC FLUID What is amniotic fluid?
- 3. What is the function of amniotic fluid?
- 4. FUNCTIONS OF AMNIOTIC FLUID Before labour: 1. Protection from external trauma, shock & temperature. 2. Prevention of adhesion between embryo & membranes. 3. Homogenous medium for the growth of the embryo. 4. Permits the free movement of the embryo. 5. Reservoir of water and nutrients.
- 5. FUNCTIONS OF AMNIOTIC FLUID During labor: 1. Allows regular dilatation of the cervix. 2. Lubricant for fetus descent. 3. Bacteriostatic 4. Avoids compression of fetus and cord
- 6. PRODUCTION • Mother through amnion • By 10 weeks transudate of fetal serum via fetal skin and cord. • By 16 weeks fetal kidney, lung fluids and oro-nasal secretions
- 7. Clearance • Fetal swallowing • AF to fetal circulation • AF to maternal circulation
- 8. MEASUREMENT OF AMNIOTIC FLUID 1. Clinical assessment 2. Ultrasound Single deep pocket (SDP) Amniotic fluid index (AFI)
- 9. SINGLE DEEP POCKET (SDP) Normal = 2-8 cm
- 10. AMNIOTIC FLUID INDEX Normal value= 5-24
- 12. AMNIOTIC FLUID INDEX (AFI)
- 13. POLYHYDRAMNIOS
- 14. POLYHYDRAMNIOS Defined as excessive amount of amniotic fluid • AFI of ≥ 25 cm • Deepest vertical pool of > 8 cm Incidence: 1-3% of pregnancies
- 15. Severity AFI SDP Mild 25-30 8-11 Moderate 30-35 11-15 Severe More than 35 More than 15 SEVERITY OF POLYHYDRAMNIOS
- 16. ETIOLOGY • Idiopathic • Maternal Diabetes • Rh alloimmunization • Fetal Anomalies • Duodenal atresia • Oesophageal atresia • Anencephaly • Neuromuscular fetal condition • Fetal chromosomal defects • Fetal infection like parvovirus / syphilis • Fetal tumors like thoracic tumor • TTTS in multifetal gestation • Placental haemangiomas / AV fistula
- 17. SYMPTOMS • Abdominal discomfort/pain • Dyspnea • Preterm labor • PPROM • Increased / Decreased Perception of Fetal movements • Edema of lower extremities
- 18. SIGNS •Uterus : Gestation • Difficult to palpate fetal parts. • Difficult to hear fetal heart sound. • Ballotable fetus. • Shiny abdominal skin • Varicose veins
- 19. MATERNAL COMPLICATIONS • Preterm labor/ PROM • Uterine dysfunction • Abnormal lie / presentations • Cord prolapse • Cesarean section • Placental abruption after ruptured membranes • Amniotic fluid embolism • Uterine atony - Post-partum hemorrhage • PIH
- 20. FETAL COMPLICATIONS Prognosis depends upon cause. • Fetal malformations • Preterm delivery • *Fetal distress due to prolapse of cord/ abruption • Nuchal cord • Neonatal death • Intrauterine death
- 21. DIAGNOSTIC WORKUP 1. Detailed history+ examination 2. Ultrasound Goals • Number and chorionicity of fetus • Quantitate fluid • Look for structural anomalies,anemia, FHR & hydrops 3. Amniocentesis • Infection screen • Karyotyping 4. Maternal testing for blood sugar & blood group
- 22. POLYHYDRAMNIOS
- 23. MANAGEMENT Depends upon ？Cause ？Severity ？Symptoms: yes/no • Most effective treatment in DM and TTTS • Best outcome in idiopathic polyhydramnios
- 24. MANAGEMENT Counselling Mild to Moderate hydramnios: Expectant management (counseling + serial AFI) Severe/ symptomatic: • Hospitalization • Bed rest • Blood sugar control • Non-steroidal anti-inflammatory analgesia • Intravascular fetal transfusion in fetal anemia
- 25. TREATMENT IN CASE OF TTTS
- 26. INDOMETHACIN THERAPY Mechanism: • Impairs lung liquid production/enhances absorption in renal tubules. • ↓Fluid movement across fetal membranes. Dose: 25 mg 6 hourly up to 200mg/day. Complications: premature closure of ductus arteriosus, impairment of renal function,oligohydramnios and cerebral vasoconstriction. So not used after 34 weeks
- 27. INDOMETHACIN THERAPY • Monitoring : weekly fetal echocardiography and AFI. • Stopped: if ductal constriction or AFI< 8 Sulindac: another NSAID under research
- 28. AMNIOREDUCTION BY AMNIOCENTESIS To relieve maternal distress & to test fetal lung maturity
- 31. AMNIOCENTESIS • Preterm labor/PROM • Alloimmunization • Fetal injury • Miscarriage <1% n • Oligohydramnios • Abruption • Infection
- 32. LABOUR MANAGEMENT • Vigilance for cord prolapse • Increased chance of cesarean section • Vigilance for PPH
- 33. OLIGOHYDRAMNIOS Defined as reduced amount of amniotic fluid • AFI of < 5 cm • Deepest vertical pool of <2 cm Incidence: 3-4% of pregnancies
- 34. OLIGOHYDRAMNIOS
- 35. ETIOLOGY Fetal • PROM (50%) • Chromosomal anomalies • Structural anomalies • IUGR • Post term pregnancy Maternal • Dehydration Placental •Abruption •TTTS Drugs •PG synthetase inhibitors •ACE inhibitors Idiopathic
- 37. FETOMATERNAL RISKS* FETAL • Abortion • Prematurity • IUFD • Skeletal deformities • Contractures • Pulmonary hypoplasia • Malpresentations • Fetal distress • Meconium aspiration • Low APGAR • Fetal anomalies MATERNAL • Increased morbidity • Prolonged labour uterine inertia • Chorioamnionitis and p. sepsis in PROM • Labor induction • Increased chance of cesarean
- 38. DIAGNOSIS SYMPTOMS • No specific symptoms • H/O leaking p/v • Less fetal movements • Post term • Preeclampsia • Drugs • Detected on USG SIGNS • Uterus – small for date • Reduced liqor on abdominal examination • Fetal heart rate abnormality may be present • Liqor draining on pad/ exam
- 39. DIAGNOSIS 1. Detailed history to know the cause+ fetal movements 2. Examination 3. Ultrasound goals • Quantitate liqor by AFI • Look for anomalies • Growth deficiency • Fetal and uterine blood flow • Fetal well being 4. *Karyotyping
- 40. OLIGOHYDRAMNIOS
- 42. MANAGEMENT Management depends upon • Etiology • Gestational age • Severity • Fetal status & well being
- 43. MANAGEMENT • Counselling: regarding cause and prognosis • Adequate rest – decreases dehydration • Hydration – oral/iv hypotonic fluids (2 liter/day) • Serial USG – monitor growth, AFI, BPP • Induction of labour/ LSCS once lung maturity attained • Lethal malformation- termination of pregnancy
- 44. MANAGEMENT Treatment acc. To cause • Drug induced – omit drug • Postdate pregnancy- delivery • PROM – induction • PPROM – antibiotics, steroid – induction • Fetal surgery • Vesico amniotic shunt- PUV obstruction • Laser photocoagulation for TTTS Vasopressin –experimental
- 45. MANAGEMENT AMNIOINFUSION • Decreases cord compression • Dilutes meconium
- 47. Any Questions
Editor's Notes
- The amniotic fluid is clear fluid surrounding the developing fetus that is found within the amniotic sac.
- It forms an isolating bag around the embryo protecting him from external trauma, shock & temperature. Adhesion bands may cause anomalies in development Especially for gastrointestinal, musculoskeletal and lung growth reduced liqor may cause lung hypoplasia Permitting free movement preventing limb contractures
- It forms the bags of fore water and hind water. The bag of fore water allows regular dilatation of the cervix. After rupture of membrane the amniotic fluid serves as a lubricant for fetus descent.
- Swallowing of amniotic fluid AF to fetal circulation AF to maternal circulation
- Importance of understanding this. Any problem in production of swallowing may lead to poly or oligo hydramnios.
- Preferable over AFI due to better specificity without sacrificing sensitivity.
- It is a total of the DVPs in each four quadrants of the uterus. Quadrants divided by linea nigra and line passing through umbiloicus.Taken with probe placed perpendicular to floor.
- Sum of all 4 pockets normal=5-24
- Poly-excecssive Hydra- fluid / water Amnios- amnion
- Either due to increased production or decreased resoption 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
- Raised intraamniotic pressure compromise placental blood flow leading to reduced fetal oxygenation.
- Karyotyping not recommended in absence of anomalies in mild cases
- Anomalies like renal agenesis, multicystic kidneys, polycystic kidneys, obstruction of urinary tract IUGR due to medical disorders like HTN, APLS
- *Mild idiopathic oligohydramnios- good prognosis *Third trimester oligohydramnios – good prognosis
- Karyotyping – on placental tissue or amnioinfusion followed by liqor removal
- temporary increase helpful during labour, prior to ECV, USG