This document discusses amniotic fluid disorders including polyhydramnios and oligohydramnios. It defines polyhydramnios as excessive amniotic fluid over 2 liters and oligohydramnios as diminished fluid under 500 ml. Causes, diagnosis, and complications are described for each condition. Polyhydramnios can be caused by fetal abnormalities or diabetes and risks preterm labor and cord problems. Oligohydramnios risks pulmonary hypoplasia and deformities from compression and is often caused by renal issues. Management may include treating underlying issues, monitoring fetal wellbeing, and amnioinfusion.

2. AMNIOTIC FLUID DISORDER
Hamad Emad Hamad Dhuhayr

3. Content
 Amniotic fluid
 Polyhydramnios
 Oligohydramnios

4. Amniotic fluid
Characters of amniotic fluid :
1) Physical properties :
· It is colorless fluid.
· Specific gravity : 1010 - 1020.
· Reaction : neutral or slightly alkaline (pH 7-
7.5).
· Volume : It reaches its maximum volume at 36
weeks (about 1 - 1.5 litre) and gradually
diminishes to be 500-1000 ml at term. It is
completely changed every three hours.
2) Chemical composition :
·Water : 98-99%.
· Solids : 1-2%, half-organic and half-
inorganic. Organic constituents include
carbohydrates as glucose and fructose,
proteins and hormones, the inorganic
constituents are similar to those found in
the maternal plasma as Na and Cl.

5. Origin of liquor aminii :
The amniotic fluid has both fetal and maternal origin.
Fetal origin :
1- Fetal urine.
2- Secretion from the amniotic epithelium.
3- Diffusion from the umbilical cord vessels.
4- Transudation through fetal skin.
5- Secretion from bronchial mucosa, buccal mucosa and salivary glands.
Maternal origin : The liquor is a filtrate from maternal plasma.
Fate of liquor aminii :
1- Fetal : Swallowing.
2- Maternal : Transudation into maternal circulation.

6. Functions of the liquor amnii :
A) During Pregnancy
1. Protection of the fetus.
2. It keeps the fetal temperature constant.
3. It allows free fetal movements .
4. Prevents adhesions between the amnion and fetal skin.
5. Nutrition.
6. Acts as a medium for fetal excretion.
7. Forms a closed sac around the fetus preventing ascent of infection, from the
cervix or vagina.
B) During Labour :
1. helps dilatation of the cervix.
2. It prevents direct compression of the placenta between the uterine wall and
fetus during uterine contraction thus avoiding fetal asphyxia.
3. When the membranes rupture, the fluid washes the birth canal from above
downwards thus removing away any infectious material.

7. 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.

8. Polyhydramnios
Definition :
It means excessive amniotic fluid, more than 2 liters. By ultrasound
the vertical diameter of the largest pocket of amniotic fluid measure 8
cm or more, or the amniotic fluid index (AFI) is 25 cm or more.
It can be classified into :
1- Mild : Largest vertical pocket diameter 8 – 11 c.m.
2- Moderate : Largest vertical pocket diameter 12 -15 c.m.
3- Severe : Largest vertical pocket diameter ≥ 16 c.m.
Incidence : 1 - 3.5% of all pregnancies.

9. Causes of polyhydramnios
 Fetal malformation:
- GIT: esophageal/duodenal
atresia, tracheoesophageal
fistula.
- CNS: anencephaly
(↓swallowing, exposed
meninges, no antidiuretic
hormone).
 Twin-twin transfusion → fetal
polyuria.
 Hydrops fetalis: congestive
heart failure, severe
anaemia or
hypoproteinemia →
placental transudation
 diabetes mellitus (osmotic
diuresis).
 Idiopathic.

10. Pathology
Acute Polyhydramnios :
It is very rare, usually occurs in early pregnancy (l6weeks) .and is almost always
associated with uniovular twins. A large amount of fluid accumulates in a few
days; it leads to abortion or preterm labour.
Chronic Polyhydramnios :
Commoner than acute. Usually in late pregnancy, the fluid accumulates slowly.

11. Diagnosis of polyhydramnios
 Symptoms:
- dyspnea.
- edema.
- abdominal distention
- preterm labour.
 Abdominal examination:
- ↑uterus than expected.
- difficult to palpate fetal parts.
- difficult to hear fetal heart
sound.
- ballotable fetus.
 Ultrasound:
- excessive amniotic fluid.
- fetal abnormalities.
- assess fetal wellbeing: BPP & Doppler
 Fetal karyotyping.

12. Complication
I. Maternal :
A) During Pregnancy :
1- Abortion (as a result of overdistension of the uterus).
2- Preterm labour.
3- Premature rupture of membranes.
4- Cord prolapse.
5- Placental abruption.
6- Malpresentation.
7- Nonengagement of the presenting part.
8- Pressure symptoms : as dyspnea, palpitation and edema of lower limbs.

13. B) During Labour :
1- Premature rupture of membranes.
2- Prolapse of arm, cord or both.
3- Abruptio placentae due to rapid escape of liquor with premature separation
of the placenta.
4- Splanchnic shock occurs if the fluid escapes rapidly, so the pressure exerted
by the uterus on the splanchnic vessels drops suddenly leading to pooling of
blood in the splanchnic area and shock.
5- Postpartum hemorrhage due to :
- Uterine atony due to overdistension of the uterus.
- Retained placenta.
- Prolonged labour.
C) During Purperium : The uterus may take a longer time to involute
(subinvolution).

14. management
 Minor degrees: no treatment.
 Bed rest, diuretics, water and salt restriction: ineffective.
 Hospitalization: dyspnea, abdominal pain or difficult ambulation.
 Endomethacin 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 35
weeks
 Amniocentesis: to relieve maternal distress and to test for fetal lung
maturity. Complications: ruptured membrane, chorioamnionitis,
placental abruption, preterm labour.

15. Oligohydramnios
Definition :
Diminished amniotic fluid less than 500 ml. By ultrasound the vertical diameter of
the largest pocket of amniotic fluid measures 2 cm or less, or the amniotic fluid
index is 5 cm or less.
Incidence : about 0.5% of all pregnancies.
Time of onset may be :
1- Midgestation (poor prognosis).
2- Third trimester.

16. Causes of oligohydramnios:
1. Fetal causes:
* Renal cause (57%):
- Renal agenesis
(Potter’s syndrome).
- polycystic kidney.
- Urethral obstruction
(atresia/posterior
urethral valve).
* Fetal growth restriction.
* Fetal death.
* Postterm pregnancy.
* Preterm premature
rupture membranes

17. Causes of oligohydramnios:
2. Maternal causes:
• Uteroplacental insufficiency.
• Preeclampsia.
3. Placental causes:
• twin-twin transfusion.
4. Drug causes:
Prostaglandin synthase inhibitor as NSAID.
• 5. Idiopathic

18. Diagnosis
Diagnosis :
1- The fundal level is lower than the
period of amenorrhea.
2- Breech presentation is common.
3- The fetal parts are easily felt and the
fetus is almost immobile.
4- The FHS are clearly heard.
Investigation :
1- Ultrasound : Values :
· Confirm diagnosis : DVP ≤2 cm or AFI ≤5
cm.
· Detect a cause : - Fetal growth
restriction. - Congenital anomalies.
· Malpresentation.
· Assess fetal wellbeing : BPP and Doppler.
2- Evaluation of fetal wellbeing
(serial) : DFMC – NST – BPP - Doppler.
3- Fetal karyotyping.

19. Complications of oligohydramnios:
 In early pregnancy:
• Amniotic adhesions or bands→ amputation/death.
• Pressure deformities (club feet).
• Pulmonary hypoplasia:
- Thoracic compression.
- No breathing movement.
- No amniotic fluid retain.
 Flattened face.
 Postural deformities.

20. Management
- Treat the cause (pprom, preeclampsia).
- Assess fetal wellbeing (U/S/CTG/Doppler/BPP).
- Vesicoamniotic shunting (urethral obstruction).
- Amnioinfusion (no↓ in fetal death).

21. References
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