SUMMARY NOTES

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DISORDERS OF
AMNIOTIC FLUID
Mirriam

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 The amount of fluid gradually increases until
there is about 800-1000mls at 36 to 37 weeks
of pregnancy
 After this, the volume decreases slightly
towards 40weeks
Amniotic fluid

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 In the second half of
pregnancy the main
sources of fluid production
are from the baby:
◦urine (700mls per day)
◦lung secretions (350ml/day)
ct

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 This is when the quantity of amniotic fluid
exceeds 1500mls ,although the definition by
amount is now being is being superseded by
ultra sound measurement of pools of water
around the fetus
polyhydramnios

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 Babies regularly swallow the amniotic fluid and
it is passed out of their bodies as urine hence
the baby controls the volume of amniotic fluid
 When this delicate balance is disturbed, the
amniotic fluid can increase rapidly to be as
much as 3000mls of fluid, or three times the
normal amount
polyhydramnios

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Chronic polyhydramnios-
 gradual in onset.
 most common type.
 occurs from about 30weeks of pregnancy
Acute polyhydramnios-
◦ sudden onset
◦ occurs at about 20weeks of pregnancy
◦ most associated with monozygotic twins of severe fetal
abnormality
◦ it is rare
Types of polyhydramnios

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Maternal factors
- maternal diabetes mellitus where the blood
sugar levels are not well controlled. The baby`s
urine output increases and this in turn
increases the volume of amniotic fluid
Causes of polyhydramnios

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Fetal factors
-gastrointestinal abnormalities that block the
passage of fluid including esophageal atresia
-twin pregnancy
-Congenital infections acquired in pregnancy such
as rubella and syphilis
ct

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Placenta factors
chorioangioma- a tumor of the placenta or there
may be a problem with the arteries in the
umbilical cord resulting in polyhydramnios
ct

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 Rapid growth of the uterus
 Discomfort in the abdomen and the woman
may feel breathless
 Exacerbation of symptoms associated with
pregnancy e.g. indigestion, heartburn,
constipation and back pains
 Edema and varicosities of the vulva and lower
limbs may be present
Clinical features

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On abdominal inspection-
◦ uterus is larger than expected for gestation age
◦ skin appears stretched and shinny
◦ obvious superficial blood vessels
On palpation
◦ uterus feels tense
◦ it is difficult to feel the fetal parts
◦ placing a hand on one side of the abdomen and tapping
the other side with the fingers may elicit a fluid thrill
◦ increased abdominal girth
ct

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 On auscultation-
◦difficult to hear fetal hearts due to
quantity of fluid which allows the
fetus to move away from the fetal
scope
◦ultrasound may reveal multiple
pregnancy or fetal abnormalities

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 Determine the cause of the condition if
possible
 A glucose tolerance test to check the woman`s
blood sugar levels
 Ultrasound scanning can help spot any
problem with the baby
 Subsequent care depends on –
condition of the mother and the
baby
- cause of polyhdramnios
Management of polyhydramnios

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- degree and severity of polyhdramnios
- stage of pregnancy
 Induce labor if gross fetal abnormalities
 Adequate rest
 Regular appointments at the antenatal clinic to
keep a check on the progress
ct

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 severe cases, drain some of the amniotic fluid
to reduce the volume(amniocentesis). reduces
the risk of woman going into premature labor
or the placenta abruption
 Admit to the hospital if in labor before 37weeks
 If the woman is breathless:-get plenty of rest
- eat small amounts regular
ct

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- advice the woman not to lie down after a
meal or eat just before going to bed
-avoid food and drinks that can make
heartburn worse, such as fatty food, coffee and
alcohol
- sleep well propped up in bed
 The mother can get an antacid prescription by
the doctor
ct

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 After delivery, examine the baby carefully to
rule out any abnormalities
 Abdominal girth
 ultrasound
ct

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 Increased fetal abnormalities leading to
unstable lie and malpresentation
 Cord presentation and cord prolapse
 Premature rupture of membranes
 Placenta abruptio when the membranes
ruptures
 Premature labor
 Increased incidences of C/S
Complications of polyhydramnios

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 Post partum hemorrhage
 Raised perinatal mortality
CT

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 Condition in which there is too little amniotic
fluid around the fetus 300-500mls
causes
 conditions that prevent / reduce amniotic fluid
production egg:
-Premature labor
oligohydramnios

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- post-term pregnancy
-birth defects especially kidney and urinary
tract malformations
symptoms of oligohydramnios
 Leaking of amniotic fluid when the cause is
rupture of amniotic sac
 Decreased amount of amniotic fluid on
ultrasound
ct

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 Close monitoring of the amount of fluid and
frequent follow up visit with the obstetrician
 Amnioinfusion- instilling a special fluid into the
amniotic sac to replace lost or low levels of
amniotic fluid.
 (Amnioinfusion is still experimental), may be
offered during pregnancy in attempt to help
prevent pulmonary
hypoplasia( underdeveloped lungs) or at
delivery to help prevent compression of
umbilical cord
Treatment for oligohdramnios

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 Delivery: if oligohydramnios endangers the
well-being of the fetus, then an early delivery
may be necessary
ct

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 Amniotic fluid embolism is a rare condition.
 amniotic fluid, fetal cells, or hair enters the
mother`s blood stream via the placental bed of
the uterus and triggers an allergic reaction
 The reaction then results in cardio
respiratory( heart and lung) collapse and
coagulopathy
 occur at any gestation but it is most common at
the end of the first stage of labor
AMNIOTIC FLUID EMBOLISM

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 Foetal antigens enter maternal circulation and
trigger systemic inflammatory response syndrome
with activation of coagulation cascade leading to
DIC.
pathophysiology

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Occurs in two phases:
Phase one- the woman experiences acute
shortness of breath and hypotension. This
rapidly progresses to cardiac arrest as the
chamber of the heart fail to dilate and there is
reduction of oxygen to the heart and lungs
ct

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Phase two- (haemorrhagic phase)
accompanied by severe shivering, coughing,
vomiting, and sensation of bad taste in the
mouth. It is also accompanied by excessive
bleeding as the blood loses its ability to clot.
Collapse of the cardiovascular system leads to
fetal distress and death unless the child is
delivered urgently
ct

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 amniotic fluid entering the uterine veins and in
order for this to occur there are three
prerequisites
 Ruptured membranes
 Ruptured uterine or cervical vein
Causes of amniotic fluid embolism

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 abdominal trauma
 amniocentesis
 Caesarean section
 Invasive procedures eg. external and internal
version, insertion of intrauterine catheter
 Placenta abruption
Other predisposing factors

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 Maternal mortality approaches 80%
 50% die within the first hour of onset of
symptoms
 Survival is uncommon, although the prognosis
is improved with early recognition and prompt
resuscitation
Mortality morbidity

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 Hypotension – blood pressure may drop
significantly with loss of diastolic measurement
 Dyspnea- labored breathing and tachypnea
may occur
 Seizure- tonic clonic seizures are seen in 50%
of the women
 Cough- this is usually manifestation of dyspnea
Signs and symptoms

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 Cyanosis-
 Fetal bradycardia- in response to hypoxic insult,
fetal heart rate may drop to less than 110 beats
per minute.
 Pulmonary edema- this is usually identified on
chest radiograph
 Cardiac arrest
ct

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 Altered mental status/confusion/agitation
 Uterine atony- uterine atony usually results in
excessive bleeding after delivery.
 Coagulopathy or severe hemorrhage in
absence of other explanation( DIC occurs in
83% of women)
ct

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The goal of management are to maintain systolic
blood pressure at or above 90 mmHg, urine
output at 25mls/hour or greater and oxygen
saturation greater than or equal to 90%
 Immediate intubation and oxygenation in
intensive unit since patients identified with
respiratory compromised probably have
cardiovascular collapse
Management of amniotic fluid
embolism

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 Give aminophylline IV slowly to reduce
bronchial spasms
 Give steroid treatment( hydrocortisone 500mgs
IV every 6 hours)
 Give fresh blood or fibrinogen to combat hypo
fibrinogen anemia
 Maintain input output chart
 Assist delivery
ct

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 Early and aggressive management of amniotic
fluid embolism is vital in preventing
 The diagnosis of amniotic fluid embolism must
be made clinically, based on recognition of its
rapid and dramatic evolution from respiratory
distress and cyanosis to hypotension/shock to
cardiac collapse, disseminated intravascular
coagulation and hemorrhage
Prevention of maternal death

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 Fetal distress is often the first apparent
manifestation
 Maternal seizures often result from the
hypoxia, which can lead to a misdiagnosis of
pre-eclampsia. The difference is that the
respiratory distress and cardiac collapse
resulting from amniotic fluid embolism occur
before the onset of seizures
ct

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 Disseminated intravascular coagulation
 Hemorrhage
 Acute renal failure
 High perinatal mortality morbidity if it occurs
before the birth of the baby.
Complications associated with AFE

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