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Assessment of fetal lung maturity

Authors:Jonathan Gillen-Goldstein, MDAndrew P MacKenzie, MDEdmund F Funai,


MDSection Editor:Charles J Lockwood_ MD MHCMDeputy Editor:Vanessa A Barss,
MD, FACOG
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer
review process is complete.
Literature review current through: Aug 2017. I This topic last
updated: Jun 01, 2017.

INTRODUCTION The pulmonary system is among the last of the fetal


organ systems to mature, both functionally and structurally. Fetal sex and
race/ethnicity appear to play a role in this process: respiratory problems
near term are more common among white male fetuses than among female
fetuses, blacks, and South Asians r J.
Because the immature pulmonary system may not oxygenate the neonate
adequately, preterm birth can lead to significant neonatal morbidity or
mortality. Therefore, fetal lung maturity is sometimes assessed before
iatrogenic preterm delivery and can be a factor in determining the timing of
delivery in these cases. Several laboratory tests are available for this
purpose. All involve testing amniotic fluid and provide an indirect
assessment of the likelihood of lung maturity: direct studies of fetal lung
function are not possible.
This topic will discuss tests for assessment of fetal lung maturity. Clinical
manifestations, diagnosis, treatment, sequelae, and prevention of neonatal
pulmonary immaturity are reviewed separately. (See "Pathophysiolociy,
clinical manifestations, and diagnosis of respiratory distress syndrome in
the newborn" and Prevention and treatment of respiratory distress
syndrome in preterm infants" and "Antenatal corticosteroid therapy for
nenat
delivery".)
WHEN IS FETAL LUNG MATURITY TESTING PERFORMED? In most
clinical settings. testing for fetal lung maturity is not performed because (1)
delaying delivery because of lung immaturity would place the mother or
fetus at significant risk, or (2) the fetus would benefit from delaying delivery.
even if lung maturity is documented, and delaying delivery does not place
the mother at significant risk klj. However, these assessments are not
always black and white, and information about lung maturity may
sometimes be helpful in the balance (.11. Also. the information may be
helpful in estimating the level of newborn care that will be required. Thus, a
test for fetal lung maturity may be performed before semielective but
medically indicated births <39 weeks when this information significantly
impacts assessment of the balance between the maternal-fetal risks of
continuing the pregnancy versus the maternal-fetal risks of preterm birth.
This is an infrequent occurrence.
Tests for fetal lung maturity are generally not performed before 32 weeks of
gestation. given the high prevalence of fetal pulmonary immaturity and the
lower predictive value of a mature test result at this gestational age.
Tests for fetal lung maturity are not performed in pregnancies with a
reliable gestational age .?39 weeks. At this gestational age. fetal lung
maturity can be inferred; test results are not more predictive of respiratory
outcome than gestational age alone. The American College of Obstetricians
and Gynecologists (ACOG) considers gestational age assessment
unreliable (ie, suboptimally dated pregnancy) if no ultrasound examination
was performed before 22a7ths weeks of gestation confirming or revising the
estimated due date [4 ACOG recommends not performing amniocentesis
for fetal lung maturity testing in suboptimally dated pregnancies to guide
timing of delivery as this decision should be based on the best clinical
estimate of gestational age and standard indications for intervention, rather
than results from fetal lung maturity testing [1.
In the past, fetal lung maturity testing was performed prior to elective
cesarean delivery or induction at 37 or 38 weeks of gestation (eg. repeat
cesarean, induction for logistical indications): however, both elective
delivery at this gestational age and fetal lung testing should be avoided.
Even when lung maturity test results suggest a low risk of respiratory
problems, neonates delivered at 37 or 38 weeks are at higher risk of
adverse outcome than those delivered at 39 to 40 weeks of gestation
without fetal lung maturity testing M. A fetal lung maturity test consistent
with maturity is not an appropriate indication for early delivery in the
absence of appropriate clinical indications [!"].
FETAL MATURITY TESTS Fetal lung maturity is evaluated by
biochemical tests or biophysical tests. Biochemical tests measure the
concentration of particular components of pulmonary surfactant.
Biophysical tests evaluate the surface-active effects of these phospholipids.
The choice of test (table 1) should be based upon availability. presence or
absence of contaminants (see 'Blood, meconium below). and physician
preference. Although randomized trials comparing multiple tests have not
been performed, controlled studies suggest that no test in the table
performed significantly better than the others [3,8-111 All are better at
predicting the absence, rather than the presence, of respiratory distress. All
perform less well at earlier gestational ages, which should be taken into
account when interpreting results.
If the first test performed on an amniotic fluid sample is immature. we
suggest not performing a second different test on the same sample, as
medicolegal issues may arise if the neonate is delivered after discordant
results and develops respiratory problems.
Lamellar body count This is probably the most common test currently
in use for assessing fetal lung maturity in the United States. Lamellar body
counts are a direct measurement of surfactant production by type-II
pneumocytes. A standard hematology analyzer (eg. Coulter LH 750,
Coulter Ac.T diff. Sysmex XE-2100) can be used for quantification because
of the similar size of lamellar bodies and platelets. Values less than 15,000
per microliter are almost always associated with lung immaturity; values
.50,000 per microliter strongly suggest lung maturity [1:2-11]. However,
there is no consensus on the optimal threshold for predicting lung matunty:
values greater than 30.000 to 40,000 per microliter, as well as higher levels.
have been suggested (t,lole 1) [1 " I. As with all tests of fetal lung
-

matunty. gestational age affects the positive predictive value (see


'Gestational age' below). Gestational-age specific lamellar body count
cutoffs for risk assessment of fetal lung maturity are available [ '

Some clinicians use the lamellar body count as an initial screening test and
perform the lecithinisphingomyelin (LIS) ratio if the lamellar body count is
neither clearly mature (50,000 per microliter) nor immature (<30.000 per
microliter).
Compared with thin-layer chromatography techniques, the lamellar body
count is faster, more objective, less labor intensive. less technique
dependent. and less expensive [8]. In meta-analyses. the lamellar body
count performed as well or slightly better than the lecithinIsphingomyelin
ratio in predicting respiratory distress [19.24 The lamellar body count
performs as well as the formerly available TDx-FLM II (see 'Surfactant'
albumin ratio below): both perform best when interpreted according to
gestational age [
Blood contamination can lead to false elevation of the lamellar body count
because platelets are counted as lamellar bodies; the effect of meconium is
minimal.
All laboratories need to establish their own cutoffs for lamellar body count
since hematology analyzers vary in sensitivity and gain settings.
Establishment of internal quality control is also important for this test. The
Clinical and Laboratory Standards Institute provides guidance for the use of
automated cell counting to count lamellar bodies in amniotic fluid. The
document "Assessment of Fetal Lung Maturity by the Lamellar Body Count
(C58-A)" provides guidelines for the use of automated cell counting to
perform lamellar body counts. describes methods to assist in test
verification and validation, and describes methods to select an appropriate
maturity cutoff [.21].
Phosphatidylglycerol Phosphatidylglycerol (PG) is a minor constituent
of surfactant. It begins to increase appreciably in amniotic fluid after 35
weeks, several weeks after the rise in lecithin [22]. Because PG enhances
the spread of phospholipids on the alveoli. its presence indicates an
advanced state of fetal lung development and function.
PG testing can be performed by thin-layer chromatography, so it can be
determined alone or in conjunction with testing for the lecithin/
sphingomyelin ratio. It may be reported qualitatively as positive or negative.
where positive represents an exceedingly low risk of respiratory distress. or
quantitatively. where a thin-layer chromatography value >2 percent is
associated with a minimal rate of respiratory distress (table 1)[23].
Because thin-layer chromatography is a complicated and time-consuming
technique, a rapid, semiquantitative immunologic slide agglutination test
(AmnioStat-FLM) and several enzymatic assays were developed and have
been validated as acceptable alternative techniques [24-24 The slide
agglutination test is the most common method for testing for PG: however.
it appears to be less sensitive for detecting fetal lung maturity than thin-
layer chromatography [28].
An advantage of testing for PG is that blood or meconium usually does not
affect test results [:.:]. A disadvantage is that the absence of PG, especially
before 36 weeks of gestation, is less predictive of the occurrence of
respiratory distress than immature results from other tests.
Lecithin/sphingomyelin ratio The lecithin/sphingomyelin (US) ratio for
assessment of fetal lung maturity was first introduced by Gluck and
colleagues in 1971 [2:_)]. It is based upon the observation that there is
outward flow of lung secretions from the lungs into the amniotic fluid. This
process changes the phospholipid composition of amniotic fluid. thereby
enabling indirect assessment of fetal lung maturity through evaluation of
this fluid.
The concentrations of lecithin and sphingomyelin in amniotic fluid are
approximately equal until 32 to 33 weeks of gestation, at which time the
concentration of lecithin begins to increase significantly while the
sphingomyelin concentration remains about the same. The measurement of
sphingomyelin serves as a constant comparison for control of the relative
increases in lecithin because the volume of amniotic fluid cannot be
accurately measured clinically.
Determining the lecithinisphingomyelin ratio involves thin-layer
chromatography after organic solvent extraction. It is a technically difficult
test to perform and interpret; care at each step of sample handling is critical
for consistent results [30]. The sample should be kept on ice or refrigerated
if transport to a laboratory is required (most laboratories cannot perform this
test). Improper storage conditions can change the lecithinisphingomyelin
ratio since amniotic fluid contains enzymes that can be affected by
temperature [ __ il]. The amniotic fluid sample must be well mixed before
testing. It takes several hours to perform the test and may take 24 hours
when both transport and testing time are considered, which is another
disadvantage of this method.
Individual laboratories should calculate a threshold value for predicting lung
maturity by correlating their test results with clinical outcome as the
variation within and between laboratories can be considerable. Empirically.
the risk of respiratory distress is exceedingly low when the lecithin!
sphingomyelin ratio is greater than 2.0 (table 1) [iL].
Optical density at 650 nm An indirect measurement of lamellar bodies
car be obtained by measuring the optical density of amniotic fluid at a
wavelength of 650 nanometers. It is based upon the concept that
increasing opalescence is due to increasing numbers of lamellar bodies. An
optical density reading n.15 is used as the indicator of lung maturity [ 31:1.
Foam stability index The foam stability index (FSI) assesses total
surfactant activity. It is a rapid predictor of fetal lung maturity based upon
the ability of surfactant to generate stable foam in the presence of ethanol
Ethanol is added to a sample of amniotic fluid to eliminate the effects
of nonsurfactant factors on foam formation. The mixture is then shaken and
will generate a stable ring of foam if surfactant is present. The FSI is
calculated by utilizing serial dilutions of ethanol to quantitate the amount of
surfactant present p.`_T
Amniotic fluid samples for FSI should not be collected in silicone tubes. as
the silicone will produce "false foam." The discriminating value indicative of
lung maturity is usually set at ?47. A positive result virtually excludes the
risk of respiratory distress; however. a negative test often occurs with
mature lungs [36]. The presence of blood or meconium interferes with
results of the FSI.
Surfactant/albumin ratio The surfactant/albumin ratio also assesses
total surfactant activity. Currently. there are no commercially available tests
for measuring this ratio.
The TDx-FLM II was a commercially available test for measuring the
surfactant/albumin ratio. It was based on the pnnciple of fluorescence
polarization and used an automated analyzer to quantitate the competitive
binding of a fluorescent probe to both surfactant and albumin in a sample of
amniotic fluid: thus, it was a true direct measurement of surfactant
concentration [3 (]. An elevated surfactantfalbumin ratio correlated with fetal
lung maturity; the threshold for maturity was 55 mg of surfactant per gram
albumin ____ Test performance compared favorably with the well-
established lecithin/sphingomyelin ratio and PG tests (table 1) and was
gestational age dependent (table 2) [10,39,40].
Advantages of the TDx-FLM II were that it was a simple, automated, rapid
test that varied minimally between laboratories and required only a small
volume of amniotic fluid [4 A disadvantage was the large quantification
scale: Values greater than 55 were considered mature, and values less
than 40 were considered immature. while values of 40 to 54 were
considered "indeterminate" ____ Blood or meconium in the amniotic fluid
also affected results.
The manufacturer retired the analytical systems for the TDx-FLM II test and
ended production of the reagent required to perform it.
FACTORS THAT MAY AFFECT INTERPRETATION
Gestational age For each test, the ability to predict respiratory distress
is influenced by the prevalence of respiratory distress in the population
tested; thus. the predictive value vanes with gestational age [11A1,42]. For
example. in one analysis, the risk of respiratory distress after a TDx-FLM II
of 60 mgig at 29 and 37 weeks of gestation was 16 and 1 percent,
respectively Nit In another analysis, the risk of respiratory distress after a
lamellar body count of 60,000 per microliter at 32 and 37 weeks of
gestation was 11 and 1.2 percent. respectively [18].
Gestational age is an important factor for predicting readiness for neonatal
life and absence of neonatal morbidity, even when fetal lung maturity is
documented prenatally. In a retrospective, cohort study of neonatal
outcomes of newborns with mature fetal lung indices, the rate of composite,
adverse neonatal outcome with delivery at 34o to 366 weeks, 37o to 386
weeks, and weeks was 21. 13, and 4 percent, respectively _
Blood, meconium Phosphatidylglycerol (PG) determination generally is
not affected by blood, meconium. or other contaminants; its ability to predict
lung maturity is the same whether or not contamination is present This
is an advantage for assessing fetal lung maturity status since these
substances are commonly found in amniotic fluid.
The surfactantialbumin ratio is usually reliable if mature since contaminants
tend to cause falsely immature findings, although the degree and direction
of interference are not well defined [1,1-.11.
The presence of blood or meconium can interfere with interpretation of the
lecithinisphingomyelin ratio 111. Bloody samples give false information
because blood contains sphingomyelin and decreases extraction of lecithin
by cold acetone techniques (falsely low "L" and falsely high "S") [54
Therefore, if blood or other particulate matter is present in the amniotic fluid
sample, a low-speed, short centrifugation should be used to remove the
cellular component [31: however, this does not guarantee an accurate
result. especially when there is a lot of blood or meconium.
Oligohydramnios and polyhydramnios The effect of amniotic fluid
volume (oligohydramnios, polyhydramnios) on test results has not been
studied extensively [51,52]. Theoretically, tests that are expressed as a
ratio or proportion of two solutes released into the amniotic fluid should
remain accurate independent of amniotic fluid volume, while tests that
reflect the concentration of a substance in the amniotic fluid (eg, lamellar
body count, PG) may be affected by amniotic fluid volume.
Vaginal pool samples In women with intact membranes, amniotic fluid
is obtained by amniocentesis. (See "Diagnostic amniocentesis", section on
'Third trimester amniocentesis'.)
In women with ruptured membranes, a syringe can be used to aspirate
amniotic fluid pooled in the posterior vaginal fornix. Vaginal pool specimens
can also be collected using a sterile sponge.
However, the lecithinisphingomyelin ratio can be higher in the vaginal pool
than in fluid obtained by amniocentesis [53], and false-positive PG have
been reported in vaginal pool samples due to bacterial contamination
[54,55].
Antenatal corticosteroids Standard tests for predicting fetal lung
maturity may be less reliable for predicting absence of fetal lung maturity in
women who have received antenatal corticosteroids to enhance fetal lung
maturation. (See "Antenatal corticosteroid therapy for reduction of neonatal
respiratory morbidity and mortality from preterm delivery'. section on
'Testing for fetal lung maturity after antenatal corticosteroid therapy'.)
Maternal diabetes mellitus Most experts use the same threshold value
for lung maturity for nondiabetic and diabetic patients (pregestational or
gestational diabetes) [56-64
Twin pregnancy Lung maturation of twins, the upper and lower
gestational ages when lung maturity should be evaluated before delivery,
and assessment of lung maturity in one or both twins are discussed
separately. (See "Twin pregnancy: Labor and delivery", section on
'Assessment of pulmonary maturity')
SUMMARY AND RECOMMENDATIONS

Fetal lung maturity testing before delivery is rarely performed. It is not


useful as a component of delivery timing decision-making in pregnancies
with well-documented gestational age ?_39 weeks (because lung maturity is
likely), pregnancies less than 32 weeks of gestation (because lung
immaturity is likely), and when delivery is obstetrically medicallyindicated
(because delaying delivery will place the mother or fetus at significant risk).
If a pregnancy is suboptimally dated (no ultrasound examination before
22or7ths weeks), timing of delivery should be based on the best clinical
estimate of gestational age and standard indications for intervention: fetal
lung maturity testing is not recommended as a component of decision-
making. (See 'When is fetal lung maturity testing performed?' above.)

A test for fetal lung maturity may be performed before semielective but
medically indicated births <39 weeks when this information significantly
impacts assessment of the balance between the maternal-fetal risks of
continuing the pregnancy versus the maternal-fetal risks of preterm birth.
This is an infrequent occurrence. (See 'When is fetal lung maturity testing
performed?' above.)

Fetal lung maturity can be assessed by testing for components of fetal lung
secretions in amniotic fluid. No test performs significantly better than
another. and all are better at predicting the absence, rather than the
presence, of respiratory distress. (See 'Fetal maturity tests above.)

The choice of test should be based upon availability, presence or absence


of contaminants, and physician preference. A summary of the different tests
available and the assets and liabilities associated with each is shown in the
table (table 1). We suggest use of the lamellar body count. (See 'Fetal
maturity tests' above.)

We suggest performing only one test for fetal lung maturity on an amniotic
fluid sample. (See 'Fetal maturity tests above.)

Gestational age is an important factor in interpreting tests of fetal lung


maturity. All tests perform less well at earlier gestational ages. which should
be taken into account when interpreting results. Gestational age-specific
tables for prediction of respiratory distress have been published. (See
'Gestational age above.)

Blood or meconium in amniotic fluid affects some test results (table 1).
Oligohydramnios, polyhydramnios, and source of amniotic fluid (vaginal
pool versus amniocentesis) can also affect results. The same threshold
value for lung maturity can be used for both nondiabetic and diabetic
patients (pregestational or gestational diabetes). (See 'Factors that may
affect interpretation' above.)
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