Presenter- Dr Swathi. P.
MS (OBG)
Moderator- Dr Omkar Murthy
SSMC Tumkur
CONTENTS:
Definition
Introduction
Physiology of amniotic fluid
Sonographic Assessment
Abnormalities of amniotic fluid
Uses Diagnostic / Therapeutic
Definition:
Amniotic fluid is a clear, yellowish liquid that surrounds and protects
the unborn baby (fetus) during pregnancy. It is contained in the
amniotic sac.
Introduction:
Amniotic fluid serves several roles during pregnancy.
Its two growing margins finally merge into the body stalk.
Thus, the liquor amnii surrounds the fetus everywhere except at its
attachment with the body stalk.
During the first half of pregnancy, transfer of water and other small
molecules takes place across the amniontransmembranous flow,
across the fetal vessels on placental surfaceintramembranous flow,
and across fetal skin.
First, fetal urination is the primary amnionic fluid source by the second half
of pregnancy.
By term, fetal urine production may exceed 1 liter per daysuch that the
entire amnionic fluid volume is recirculated on a daily basis.
Regulation of inflows and outflows from the fetus: fetal urine flow
and composition are modulated by vasopressin, aldosterone, and
angiotensin II in much the same way as they in adults.
Dark brown (tobacco juice) amniotic fluid is found in IUD. The dark
color is due to frequent presence of old HbA
Constituents of the fluid: In early pregnancy , amniotic fluid is an
ultra filtrate of maternal plasma.
By the beginning of second trimester , it consist largely of
extracellular fluid which diffuse through the fetal skin, and therefore
reflects the composition of fetal plasma it contains:
Prevents adhesion formation between the fetal parts and the amniotic sac
Has some nutritive value because of small amount of protein and salt
content
During Labour:
The volume remained at this level until 40 weeks and then declined
by approximately 8 percent per week thereafter
Although it is considered acceptable for an experienced examiner to
assess the amnionic fluid volume qualitatively, fluid is usually
assessed semiquantitatively (American Institute of Ultrasound in
Medicine, 2013a).
The uterus is divided into four equal quadrantsthe right- and left-
upper and lower quadrants, respectively.
The AFI is the sum of the single deepest pocket from each quadrant.
A fluid pocket may contain fetal parts or umbilical cord loops, but
these are not included in the measurement.
They hypothesized that decreased fetal urine flow was likely the result of
preexisting oligohydramnios that limited fetal swallowing.
*
AMNIOINFUSION:
Transvaginal amnioinfusion has been extended into three clinical
areas.
These include:
(1) treatment of variable or prolonged decelerations,
(2) prophylaxis for women with oligohydramnios, as with prolonged
ruptured membranes, and
(3) attempts to dilute or wash out thick
meconium
Many different amnioinfusion protocols have been reported, but
most include a 500- to 800-mL bolus of warmed normal saline
followed by a continuous infusion of approximately 3 Ml per minute
(Owen, 1990; Pressman, 1996).
Palmer RM, Ashton DS, Moncada S. Vascular endothelial cells synthesize nitric oxide from L-arginine.
Nature 1999;333:664-6.
Act by
L-arginine increases uteroplacental blood flow through nitric oxide
mediated dilatation of vessels thereby increasing the supply of nutrients to
the fetus aiding its growth.
promising in improving
- foetal well-being
-neonatal outcome
- prolonging pregnancy complicated with pre-eclampsia & Oligohydramnios.
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.
History suggestive of Rh iso- immunization such as still birth, fetal hydrops, jaundice
in new born requiring exchange transfusion etc.
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.
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.
The guide increases the ease of needle insertion & reduces the risks
of failed attempts and complications.
5 inch length 22 gauge spinal needle is used.
Rarely 7 inch length needle is used in obese patients.
Amniotic sac is entered and fluid is aspirated using sterile syringes.
The first 1-2ml of the amniotic fluid may be contaminated by
maternal cells and can be discarded.
Fluid subsequently aspirated can be sent for fetal chromosomal
analysis after tissue culture or direct fluorescent insitu hybridization
techniques.
Amount required for chromosomal analysis : 15-20 ml.
Pregnancy loss rate : 1 in 200
Complications :
Infection
Inadvertent trauma to the fetus or placenta
Leakage of amniotic fluid
Miscarriage.
Feto maternal hemorrhage,
Isoimmunization may occur in Rh negative women and it
should be covered by prophylactic antiD in non sensitized
women.
Early amniocentesis:
12-14 WEEKS
Done in order to obtain the results earlier in gestation
Increase in risk of talipes equinovarus.
For patients desiring earlier diagnosis , transabdominal CVS should
be preferred over early amniocentesis.
Amniotic fluid testing
Testing amniotic fluid for AFP and AChE can predict open neural tube
defects more accurately than maternal serum screening.
Patient with unexplained high maternal serum AFP levels and normal
ultrasonography findings should be offered amniotic fluid testing.
Any patient who has had a child with a neural tube defect has 3%
to5% risk for recurrence and also should be offered amniotic fluid
AFP testing
Lileys zone III (High zone): The fetus is severely affected and death
is imminent. Pregnancy > 34 weeks delivery.
Pregnancy <34 weeks cordocentesis hematocrit < 30%
intrauterine transfusion to raise hematocrit 4045%. Preterm
delivery may be needed after 34 weeks.
Advantages:
Spectrophotometric analysis when plotted in relation to the Lileys
zone can predict with fair degree of accuracy, the degree of
hemolytic process in the fetus.
This can give indications when to terminate the pregnancy and when
to give intrauterine fetal transfusion.
Assessment of fetal anemia is more accurate by fetal umbilical cord
blood sampling
Cordocentesis also helps to detect fetal blood type, hematocrit, DCT
and total bilirubin level.
Fetal hematocrit value <15 percent is associated with hydrops.
Tests for Lung Maturity
a. Method:____________________________
b. Principles: Lecithin is produced at a relatively low and constant rate until the 35th week of gestation
while sphingomyelin is produced at a constant rate after about 26 week gestation and therefore conserve
as a control on which to base the rise in lecithin. Prior to 35 week gestation, L/S ratio is 1.6 and rises
to >2.0 when lecithin production increases.
2. Amniostat-FLM
a. Method:________________________
b. Principle: the test uses antisera for phosphatidly glycerol and is affectected by specimen contamination with blood and
meconium.
3. Foam stability index
a. method:_____________________________
b. Principle: a semiquatitative measure of the amount of surfactant is done by adding 0.5 mL of amniotic fluid to increasing
amounts of 95% ethanol (0.42 mL to 0.55 mL in 0.01-mL increments), shaken for 15 seconds, and allowed to sit undisturbed
for 15 minutes. If a sufficient amount of phospholipid is present, a continuous line of bubbles will be observed even in the
presence of alcohol, an anti-foaming agent.
4. Microviscosity
a. Method:______________________
b. Principle: Phospholipids decrease the microviscosity of amniotic fluid and the change is detected by determining the
surfactant to albumin ratio (mg/g) based on the polarization of a fluorescent dye that combines (internal standard,
decreased fluorescence lifetime and high polarization).
5. Lamellar body count
a. Method:___________________________
b. Principle: Lamellar bodies (lamellated phospholipids that represent a storage from of surfactants secreted by the type
II pneumocytes of the fetal lung)range in size from 1.7 to 7.3 fL, and therefore can be counted using the platelet
channel of hematology analyzers.
a. Method:_________________________
b. Principle : the increase in OD of the amniotic fluid caused by the presence of lamella bodies in determined by
centrifuging the specimen at 2000 g for 10 min and reading the absorbance at 650 nm.
Table 24. Tests for fetal lung maturity
Normal values Significance
1. Bilirubin assay
a. Method: _____________________
b. Principle: the optical density of amniotic fluid is normally highest at 365 nm and decreases linearly to 550 nm
except when bilirubin is present where a rise in OD is seen at 450 nm. The 450 is then plotted on a liley graph
to determine the severity of HDN and the need for interventions.
2. Alpha fetoprotein
a. Method:_________________
b. Principle: The Test is based on the measurement of the neural tube defects using an automated
immunoassay method: results are reported in terms of multiples of the median with a value >2 MoM
considered abnormal
3. Acetylcholinesterase
a. Method: ____________________
b. Principle: Ache is an enzyme derived primarily from the neural tissue and is normally absent in amniotic
fluid. Its presence in amniotic fluid in conjunction with elevated AFP values is highly diagnostic of NTDs.
Other Tests
3. Kleihauer-Betke test
All of the available biochemical tests for fetal lung maturity rely on
the amniotic fluid content of surfactant .
Any stable foam layer that persists after shaking is due to the
presence of surfactant in a critical concentration.
It is found that the shake test was comparable to the L/S ratio and
had a high predictive value for RDS when applied to
uncontaminated amniotic fluid.
Tap Test
The tap test examines the ability of surfactant within amniotic fluid
to break down bubbles within an ether layer.
The tube is tapped 4 times and examined for the presence of bubbles
within the ether layer.
In mature samples, the bubbles quickly breakdown, whereas in
immature amniotic fluid specimens more than 5 bubbles persist in
the ether layer.
This rapid test was comparable with the phospholipid profile.
Visual Inspection
When the OD 650 was less than 0.15, only 6% of L/S ratios were
greater than 2