AMNIOTIC FLUID

A fluid that is present in the membranous sac (amnion) that surrounds the fetus
FUNCTIONS
1. Provide protective cushion for the fetus
2. Allows fetal movement
3. Stabilize the temperature to protect the fetus from extreme temperature changes
4. Permit proper lung development
5. Allow the exchange of water and chemicals between the fluid, fetus, and the maternal
circulation
FORMATION
Amniotic fluid is regulated by a balance between the production of fetal urine and lung fluid
absorption from fetal swallowing and intramembranous flow
Intramembranous flow- absorption of amniotic fluid water and solutes into the fetal
vascular system
The amount of amniotic fluid increases throughout pregnancy
-Reaches approximately 1L at the 3rd trimester
- Gradually decreases prior to delivery
1st trimester: 35 mL of amniotic fluid is derived primarily from the maternal circulation
Latter third to half of pregnancy: The fetus secretes a volume of lung liquid necessary to
expand the lungs with growth
- Fetal breathing movement: lung liquid enters the amniotic fluid which is evidenced by
lung surfactants that serve as index of fetal lung maturity
After the 1st trimester: Fetal urine is the major contributor to the amniotic fluid
At the time fetal urine production occurs, fetal swallowing of the amniotic fluid begins and
regulates the increase in fluid from the fetal urine
POLYHDYRAMNIOS
Excessive accumulation of amniotic fluid
Results from the failure of the fetus to swallow the fluid
Indicates fetal distress, often associated with neural tube defects
Also associated with fetal structural abnormalities, cardiac arrhythmias, congenital
infections or chromosomal abnormalities
OLIGOHYRAMNIOS
Decreased amniotic fluid
Results from increased fetal swallowing, urinary tract deformities, and membrane
leakage
Associated with umbilical cord compression, resulting in decelerated heart rate and fetal
death
CHEMICAL COMPOSITION
Placenta is the major source on amniotic fluid water and solutes
Has a similar composition to maternal plasma and contains a small amount of sloughed
fetal cells form the skin, digestive system, and urinary tract
- These cells provide the basis for cytogenetic analysis
Contains bilirubin, lipids, enzymes, electrolytes, nitrogenous compounds, and proteins
- Can be tested to determine the health or maturity of the fetus
A portion of the fluid comes from the fetal respiratory system, fetal urine, amniotic
membrane, and the umbilical cord
When fetal urine production begins, creatinine, urea, and uric acid increases while
glucose and protein decreases

Amniotic fluid creatinine has been used to determine fetal age

GA <36 weeks: 1.5-2.0 mg/dL creatinine
GA > 36 weeks: creatinine exceeds 2.0 mg/dL

AMNIOTIC FLUID VS MATERNAL URINE

INDICATIONS: To determine possible premature membrane rupture or accidental puncture of
maternal bladder during pregnancy
AMNIOITIC FLUID
URINE
Creatinine: does not exceed 3.5 mg/dL
Creatinine: as high 10 mg/dL
Urea: does not exceed 30 mg/dL
Urea: 300 mg/dL
Positive for Fern test
Negative for Fern test
More likely to contain protein and glucose
SPECIMEN COLLECTION
Obtained through needle aspiration into the amniotic sac, a procedure called
amniocentesis
In general amniocentesis is a safe procedure after the 14 th week of gestation
Fluid for chromosome analysis is usually collected at 16 weeks of gestation
Tests for fetal distress and maturity are performed later in the 3 rd trimester
A maximum of 30 mL is collected in sterile syringes
Indicated when abnormal results are obtained in the triple screening test (maternal AFP,
HCG, and unconjugated estriol) or the quadruple screening test (AFP, HCG, unconjugated
estriol, and inhibin A
Abnormal ultrasonography result
- Requires amniocentesis and measurement of fetal lung maturity
Amniocentesis may be indicated at 15-18 weeks of gestation for the following conditions
Mothers age of 35 or more at delivery
Family history of chromosome abnormalities, such as trisomy 21 (Downs
syndrome)
Parents carry an abnormal chromosome rearrangement
Earlier pregnancy or child with birth defect
Parent is a carrier of a metabolic defect
History of sickle cell disease, Tay-Sachs disease, haemophilia, muscular dystrophy,
sickle cell anemia, Huntington chorea, and cystic fibrosis
Elevated maternal serum AFP
Abnormal triple marker screening test
Previous child with a neural tube disorder such as spina, bifida, or ventral wall
defects (gastroschisis)
Three or more miscarriages
Evaluation at 20-42 weeks
Fetal lung maturity
Fetal distress
Hemolytic disease of the newborn caused by Rh blood type incompatibility
Infection
SPECIMEN HANDLING AND PROCESSING
Fluid for fetal lung maturity (FLM) testing should be placed in ice during delivery to the
laboratory and refrigerated at up to 72 hours prior to testing or kept frozen and tested
within 72 hours
Repeated freeze-thawing is not recommended
Specimens for cytogenetic studies should be maintained at room temperature or
incubated at (37C) to prolong the life of the cells

The cells must be separated through centrifugation ASAP to prevent the consumption of
chemicals to be tested
COLOR AND APPEARANCE
Normal- colorless and may exhibit slight turbidity from cellular debris
Blood-streaked fluid- may be present as a result of traumatic tap, abdominal trauma, or
intra-amniotic haemorrhage
Yellow- presence of bilirubin and indicates RBC destruction
Green- First bowel movement of the fetus (Meconium)
Dark red-brown- Fetal death
*KLEIHAUER-BETKE- A test used to differentiate maternal blood from fetal blood
TESTS FOR FETAL DISTRESS
HEMOLYTIC DISEASE OF THE NEWBORN

The measurement of bilirubin in the fluid determines the extent of hemolysis, and the
danger that the anemia presents to the fetus may be assessed
Bilirubin measurement is performed by spectrophotometric analysis
The fluid is measured in intervals between 365nm and 550 nm
Normal fluid OD is highest at 365nm and decreases linearly to 550nm
When bilirubin is present, a rise in OD is seen at 450nm because this is the
wavelength of maximum bilirubin absorption
Maximum absorbance of oxyhemoglobin is at 410nm and can interfere with the
bilirubin absorption peak
The absorbance difference at 450nm is plotted on a Liley graph
LILEY GRAPH
Plots the absorbance change at 450nm against gestational age and is divided into
three zones that represent the extent of hemolytic disease
ZONE I- indicates no more than a mildly affected fetus
ZONE II- Require carefu monitoring
ZONE III- Suggests a severly affected fetus

NEURAL TUBE DEFECTS

Increased AFP in both maternal circulation and amniotic fluid can be indicative of fetal
neural tube defects (anencephaly and spina bifida)
AFP is the major protein produced by the fetal liver during early gestation (prior to 18
weeks)
Increased levels are found in maternal circulation and amniotic fluid when the skin fails to
close over the neural tissue
Normal values are based on the week of gestational age, as the fetus produces maximal AFP
between 12 and 15 weeks of gestation

Reported in multiples of the median (MoM)

Median- Laboratorys reference value for a given week of gestation
A value of greater than 2 MoM is abnormal
Elevated AFP level is followed by the measurement of amniotic acetylhcholinesterase (AChe)
which is more specific for neural tube defects

TESTS FOR FETAL MATURITY

Fetal lung maturity must be assessed first before a preterm delivery can be performed due
to fetal distress
Respiratory distress syndrome is the most frequent complication of early delivery and is a
cause of mortality in the premature infant
-RDS is caused by a lack of lung surfactant, a substance that normally appears in mature
lungs and allows the alveoli to remain open throughout the normal cycle of inhalation and
exhalation.
LECITHIN-SPHINGOMYELIN RATIO
Reference method to which FLM tests are compared
Lecithin is the primary component of the surfactants (phospholipids, neutral lipids, and
proteins) that make up the alveolar lining and account for alveolar stability
Lecithin is produced at a relatively low and constant rate until the 35 th week of gestation
wherein a noticeable increase in production occurs, resulting in the stabilization of the
alveoli
Sphingomyelin is a lipid that is produced at a constant rate after about 26 weeks gestation;
therefore, it can serve as a control on which to base the rise in lecithin
Prior to 35 weeks gestation, L/S ratio less than 1.6: Not enough lecithin
Safe preterm delivery: when L/S ratio reaches 2.0
Replaced by phosphatidyl glycerol immunoassay and lamellar body density procedure
AMNIOSTAT-FLM
The presence of another lung surface lipid, phospatidyl glycerol, is also essential for
adequate lung maturity
Production of phosphatidyl glycerol parallels that of lecithin
Amniostat-FLM is an immunologic agglutination test for phosphatidyl glycerol and provides
a rapid method for FLM assessment
It uses anti-sera specific for phosphatidyl glycerol and is not affected by specimen
contamination with blood and meconium
FOAM STABILITY TEST
Amniotic fluid is mixed with 95% ethanol, shaken for 15 seconds, and allowed to sit
undisturbed for 15 minutes
The surface of the fluid is observed for the presence of a continuous line of bubbles around
the outside edge
The presence of bubbles indicates that a sufficient amount of phospholipid is available
MICROVISCOSITY FLUORESCENCE POLARIZATION ASSAY
Measures the change in microviscosity caused by the presence of phospholipids by using
fluorescence polarization
Provides a ratio of surfactant to albumin in amniotic fluid for assessment of lung maturity in
fetus
LAMELLAR BODIES AND OPICAL DENSITY
Lamellar bodies are lamellated phospholipids that represent a storage form of surfactant
Surfactants responsible for FLM are produced and secreted by type II pneumocytes of the
fetal lung and stored in the form of lamellar bodies
Lamellar bodies enter the alveoli and amniotic fluid at 26 weeks gestation

Increased lamellar body is indicated by an increase in amniotic fluid phospholipid and L/S
ratio
Lamellar body increases the OD of amniotic fluid, it is examined at 650nm
An OD of 0.150 has been shown to correlate well with an L/S ratio equal to 2.0 and
presence of phosphatidyl glycerol
Lamellar body diameter is similar to that of small platelets: therefore lamellar body counts
(LBCs) can be obtained rapidly with use of platelet channel hematology analyzers