Amniotic Fluid Analysis
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14 amniotic fluid imaging dr ahmed esawy Amniotic Fluid Sources Free floating particles Single pcket volume SPV Polyhydramnios AFI amniotic fluid index OLIGOHYDRAMNIOS Preterm premature rupture of membranes (PPROM) Chorioamnionitis
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Amniotic Fluid Analysis
- 1. الرحيم الرحمن هللا بسم
- 2. Dr. Ahmed Esawy MBBS M.Sc MD Dr/AHMED ESAWY
- 4. Amniotic Fluid US Appearance –Suspended particles: • Vernix (desquamated fetal skin) • Blood • Meconium Normal Amniotic Fluid Dr/AHMED ESAWY
- 5. Amniotic Fluid Sources • Early stages: Skin & placenta • 12 - 14 W: lung & kidney • 20 W: kidney Dr/AHMED ESAWY
- 6. Amount • Normal = 60 ml at 12 wk • 1000 ml at 34 wk • 800 ml at 40 wk • 600 ml at 42 wk • Swallowing 200-400 ml/day from 12 wks Dr/AHMED ESAWY
- 7. Free floating particles What: Multiple linear densities, 1- 5 mm suspended, but gradually settling Significance: • * No • * F. maturity • * F. distress. • * LFGA. Dr/AHMED ESAWY
- 8. AFV Subjective: • Normal • Absent • Reduced • Increased Objective: • 1.Maximum vertical pool (MVP) • 2.Amniotic fluid index (AFI) Dr/AHMED ESAWY
- 9. Single pcket volume SPV • The deepest Longest vertical diameter of echo-free pocket between the fetus and uterine wall • Normal 2-8 cm • Less than 2 is oligohydramnios • More than 8 is polyhydramnios • 8-12 cm mild • 13-16 cm moderate • more than 16 cm severe Dr/AHMED ESAWY
- 10. Subjective methode • This is a qualitative assessment of amniotic fluid volume and is therefore not standardized • Interobserver and intraobserver variability is reported to be very low. Dr/AHMED ESAWY
- 11. Single Deepest Pocket Measurement • Measure the dimensions of the largest vertical pocket of amniotic fluid. Dr/AHMED ESAWY
- 13. Maximum vertical pocket Dr/AHMED ESAWY
- 14. AFI • In third trimester • Uterus divided into four duadrants by two perpendicular planes passing through materanl umblicus • Longest vertical diameter of deepest pocket in each quadrant and collect them • Normal 5-20 cm • more than 20 cm is polyhydramnios • less than 5 cm is oligohydramnios Dr/AHMED ESAWY
- 15. Dr/AHMED ESAWY
- 16. Dr/AHMED ESAWY
- 17. The amniotic fluid index is obtained by summing the largest cord-free vertical pocket in each of the four quadrants of an equally divided uterus.Dr/AHMED ESAWY
- 19. AFI & gestational age Dr/AHMED ESAWY
- 20. AFI • Advantages – Easy to perform. – More subjective – Requires little training – Provides a frame of reference for the inexperienced sonographer. – Gives a better assessment Dr/AHMED ESAWY
- 21. AFI Disadvantages – Wide intraobserver and interobserver error (20- 21). AFI <5cm - interobserver error = 2cm AFI >20cm - interobserver error = 5cm – Technical limitations. – Overestimation. Dr/AHMED ESAWY
- 22. AFI Disadvantages • Overestimation. – in the third trimester the umbilical cord may be extremely lucent and without duplex or color doppler, cord filled pockets of amniotic fluid may be included in the measurement. – Sonography is imprescise in the detection of oligohydramnios and using multiple assessments did not add to the overall accuracy . Dr/AHMED ESAWY
- 24. AFI Disadvantages • Fetal movements. • Pockets with large vertical dimensions and small width's will exaggerate the AFI. • What is the significance of a full fetal bladder in the presence of • Does maternal hydration have any effect on the AFI Dr/AHMED ESAWY
- 26. DEFINITIONS: • Polyhydramnios: 2000 cc amniotic fluid • Amniotic Fluid Index = largest vertical pocket in 4 quadrants polyhydramnios 20 cm. Dr/AHMED ESAWY
- 27. Dr/AHMED ESAWY
- 28. ETIOLOGY OF POLYHYDRAMNIOS • Idiopathic (most common) • Fetal Anomalies • Diabetes • Multifetal gestation • Immune/Non-immune hydrops • Fetal infection • Placental haemangiomas • Twin- to -twin transfusion Dr/AHMED ESAWY
- 29. FOETAL ANOMALIES WITH POLYHYDRAMNIOS • • CNS: Hydrocephaly, Anencephaly, S. bifida • • Neck &face: Cystic hygroma. • • Pulmonary: Diaphragmatic hernia. • • GIT: Oesophygeal atresia, Dud. atresia, Omphalocele • •Other: Cong. infection, Chromosomal anomalies • Skeletal dysplasias Dr/AHMED ESAWY
- 30. How Fetal Anomalies cause Polyhydramnios • 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 Dr/AHMED ESAWY
- 31. • excess amniotic fluid (the largest single pocket measuring 11 cms. approximately). This suggests mild to moderate polyhydramnios. Particulate matter seen in the fluid is due to fetal meconium . Dr/AHMED ESAWY
- 33. DEFINITION • AFI 5 • SPV Less than 2 is oligohydramnios Dr/AHMED ESAWY
- 34. etiology of oligohydramnios • Postdate • Fetal Anomalies: obstruction of fetal urinary tract/renal agenesis • Congenital abnormalities – Bilateral renal agenesis or cystic dyplasia – Obstruction of the urinary tract – Meckel-Gruber syndrome – VACTERL (vertebral, anal, cardiac, tracheo-esophageal, renal, limb) association – Sirenomelia – Sacral agenesis Dr/AHMED ESAWY
- 35. etiology of oligohydramnios • IUGR (placental insufficiency) • ROM • Twin/Twin transfusion • Drugs:Angiotensin-converting enzyme inhibitors Prostaglandin synthase inhibitors ACE inhibitors Non-steroidal anti-inflammator • TRAP (twin reverse arterial perfusion sequence) • Fetal demise • Idiopathic Dr/AHMED ESAWY
- 36. Dr/AHMED ESAWY
- 37. • Cord Compression -- >fetal hypoxia • Passage of meconium into low AF volume: thick particulate suspension -->respiratory compromise Dr/AHMED ESAWY
- 38. Ultrasound estimate of amniotic fluid in twin Dr/AHMED ESAWY
- 39. • The transducer is held perpendicular in the floor. Dr/AHMED ESAWY
- 40. AFI in twin • four quadrants method. Dr/AHMED ESAWY
- 41. AFI in twin • four quadrants method • The AFI applied to a twin gestation, does not take into account the membrane placement. An MVP measurement may cross the membrane and go form one twin sac to another. Dr/AHMED ESAWY
- 42. AFI four quadrants method in twin • The AFI method applied to twins poorly detects fluid discordance since it does not take into account the membrane placement. Dr/AHMED ESAWY
- 43. The two-quadrant AFI method in twin Dr/AHMED ESAWY
- 44. The four-quadrant AFI in each sac in twin Dr/AHMED ESAWY
- 45. Single Deepest Pocket (SDP) in twin Dr/AHMED ESAWY
- 46. The two-diameter pocket method in twin Dr/AHMED ESAWY
- 47. • Amniotic fluid volume in normal diamniotic twin pregnancies in the third trimester of pregnancy is similar to the normal volumes in singleton pregnancies in the third trimester. The amniotic fluid volume can be measured accurately in each sac Dr/AHMED ESAWY
- 48. Preterm premature rupture of membranes (PPROM) • rupture of membranes prior to 37 weeks of gestation Risk factors include: • multifetal pregnancy • smoking • previous PPROM • cervical incompetence Dr/AHMED ESAWY
- 49. Complications • fetal – Pulmonary hypoplasia – fetal/maternal RDS – Fetal jiont contracture – infection: chorioamniotis • maternal – the main maternal risk is infection Dr/AHMED ESAWY
- 50. TVU • Cervical weakness is one of the few identifiable causes of PROM • Cervical length less than 25 mm in 23 wk Dr/AHMED ESAWY
- 51. Dr/AHMED ESAWY
- 52. TVU • A shortened cervix (i.e., generally less than 3.0 cm) or a funneling configuration at the internal os observed in second trimester Dr/AHMED ESAWY
- 53. injuries that can be caused by PROM • Periventricular leukomalacia. • Hypoxic ischemic encephalopathy. • Sepsis • Meningitis Dr/AHMED ESAWY
- 54. Dr/AHMED ESAWY
- 55. Chorioamnionitis in PROM Dr/AHMED ESAWY