DISORDERS OF AMNIOTIC FLUID Intramembranou Resorptio 400

Dra. MCG s flow n

Fetal lung Productio 350
Roles of amniotic fluid
1. Physical space for musculoskeletal secretion n
development
Fetal Swallowing Resorptio 750 ml
2. Permits fetal breathing and swallowing
n
a. EGF- promote GIT and Respiratory
Dev’t Primary source – Fetal urine
3. Prevent umbilical cord compression Primary route of excretion – swallowing
4. Avertion of trauma
5. Bacteriostatic properties


Diagnosis:

1. Sonographic assessment
Normal AFV o 2nd and 3rd trimester
- 30 ml – 10 weeks ▪ Single deep vertical pocket
- 200 ml – 16 weeks • Probe at longitudinal
- 800 ml – 3rd trimester position at maternal

abdomen
AFV Compostition: • Measure single deep
- 98% water pocket
- Full-term – 2,800 ml • Normal Value – 2-8
- Placenta – 400 ml cm

• For twins, each
gestational sac
Source of AFV:
1. Early half should be measure
a. Transmembranous flow ▪ Amniotic fluid index
i. Transfer across amnion • Divide the maternal
b. Intramembranous abdomen into 4
i. Transfer across the fetal quadrants
vessels in placental • Sum the 4 quadrants
membrane/surface • Exclude umbilical
c. Fetal skin cord and fetus

• Normal Value – 5-24
cm
2. 2nd Trimester
a. Fetal urine 2. Physical Examination
i. Start of production – 8-11 a. Hydramnios/Polyhydramnios
weeks ▪ Palpation – Increase in
ii. Significant production - 18 uterine size; Difficulty
weeks (start of palpating fetal small parts
manifestation of ▪ Auscultation – difficulty
oligohydramnios on fetus hearing FHT
with renal problem) ▪ Differential Diagnosis:
b. Skin • Twin pregnancy
i. 22-25 weeks – after which • Tumor
there is keratinization so • H. Mole
that the transudation of Categories:
fluid is inhibited Amniotic Fluid Single Vertical
Most common cause of abnormality – renal Index Pocket
abnormality
Preterm – extreme fluid loss Mild 25 – 29.9 cm 8-9.9 cm
Fetal urine – hypotonic - Most common – 60%
3. Late in Gestation

Pathways that play role on AF regulation -
prevalence
1-2% chance of

congenital anomaly
(mild to moderate)
Urination Productio 1000ml
n Moderate 30- 34.9 cm 9. Cm
 - Usually benign or - DIffuculty in plapating fetal part and
idiopathic auscultation of FHT
- 20% prevalence

Complication:
Severe >35 cm > 12cm 1. Chronic
a. Abdominal distention
- Think of underlying
b. Gradual onset
cause
2. Acute
- >10% chance of
a. Pressure symptoms
congenital anomaly
i. Dyspnea
- 15% prevalence
ii. Orthopnea
▪ Theories for Pathology b. Edema of lower extremities and
• Hydramnios is vulva
secondary to c. Oliguria
INCREASED fetal 3. Maternal
cardioactivity a. Placental Abruption
• Diabetic Mellitus – b. Uterine disruption
15-20% i. Inadequate uterine
o MATERNAL contraction
HYPERGLYCEM ii. Over stretching of the
IA ! FETAL abdominal muscle
HYPERGLYCEM c. Post partum hemorrhage
IA ! i. -d/t Uterine atony
OSMOTIC
DIURESIS !


Outcome:
HYDRAMNIOS - 3 fold increase in CS rate
• Anything that - Birth weight >4Kg
prevents fetal - INCREASED 4 fold perinatal mortality
swallowing o INCREASED 20 fold if with IUGR
o CNS o Associated with trisomy 13
o GI Obstruction - Preterm delivery
o Thoracic
anomalies


*anhydramnios – no pockets
▪ Diaphr
agmati


Oligohydramnios
c - d/t chronic pulmonary fetal condition
hernia
- SVP - <2CM; AFI -<5cm
▪ Thorac
- Cause
ic
- 1. Early onset
seques
tration

Etiology:
3. Targeted sonography/congenital anomaly
o Abnormal fetal urination
scan

▪ Renal anomaly
o Impaired uteroplacental function
4. Amniocentesis ▪ HTN/Eclampsia
a. Twin gestation o Rupture membranes
i. Twin-to-twin transfusion - Prognosis is poor
syndrome - Diagnosis – targeted sonography

b. Aneuploidy
2. Mid pregnancy
HYDRAMNIOS o Associated with
Prevalence ▪ IUGR – request for Doppler
- Idiopathic – 70% of cases artery studies
o 2% of infants with 4000g of birth • To know degree/
weight extent
PE: • If umbilical flow is
- uterine size greater than expected AOG DECREASED consider
- Tense uterus delivering the baby
▪ Placental abnormality
 ▪ Vascular disorder
3. Post term pregnancy
o INCREASED production of amniotic
fluid
▪ DECREASE 8%/ week after 40
weeks
Significance:
▪ Manifested as non-reassuring
fetal heart pattern
▪ Adverse pregnancy outcome
o Biliary renal agenesis + limb
contracture + compressed face +
Pulmonary hypoplasia = POTTERS
SYNDROME
o Limb contracture + Compressed
face + Pulmonary Hypoplasia =
POTTERS SEQUENCE
Medication Induced:
1. ACEI
a. INIBIT RAAS ! fetal hypotension
! DECREASED kidney perfusion
!renal ischemia !FETAL
ANURIA
2. NSAID
a. PREMATURE CONSTRICTION OF
FETAL DUCTUS ARTERIOSUS!
acute/chronic insufficiency !
FETAL ANURIA
QUESTION: what will you give for a mother
in pain? PARACETAMOL
Pulmonary Hypoplasia
- Associated with oligohydramnios occurring
before 20-22 weeks AOG
- Expectant management – if baby is doing
okay continue pregnancy
- Variable deceleration
o Due to cord compression
o Treatment- amnioinfusion
Borderline Oligohydramnios
- AFI 5-8 cm (BPS=2, ibig sabihin w/in the
normal range ang AFI)
- Hindi siya oligo hindi din poly
Complication
- CS for NRFHRP
- Preterm delivery
- FGR
Management:
- underlying etiology
- Evaluation for fetal abnormality and growth
- Preterm delivery for fetal maternal
complication
- Normal fetal anatomy and growth do expectant
management and close fetal surveillance
- AMNIOINFUSION - intrapartum variable FHR
deceleration
Variable FHR deceleration: cord compression
Early deceleration: Head-compression
INDUCTION OF LABOR
➢ Stimulation of uterine contraction BEFORE
spontaneous onset of labor
o Example: walang uterine
contraction, walang spontaneous
onset of labor, may rupture of bag
of water: ang tawag pa din jan ay
INDUCTION OF LABOR
Initial step in doing induction: CERVICAL
RIPENING
▪ Kasi dapat munang
palambutin ang cervix para
makapagdilate
o Use of PROSTAGLANDIN
• Augmentation
o Enhance spontaneous contractions
of the patient
▪ Done because of insufficient
uterine contractions for
cervical dilation and fetal
descend.
Indication for induction of labor:
1. Membrane rupture
➢ During very early pregnancy with leaking
bag of water:
o Expectant management done
▪ Bed rest
▪ Antibiotics: prevent or avoid
chorioamnionitis
▪ Watchful waiting
➢ During midpregnancy or late pregnancy
o Induction of labor must be done to
prevent development of infection
2. Gestational hypertension
o Causes uteroplacental insufficiency
leading to undesirable environment
for the baby to stay in the womb.
3. Oligohydramnios
4. Nonreassuring fetal heart pattern
5. Post term pregnancy
6. Chronic hypertension
7. Diabetes mellitus
o CAUTION: delay in pulmonary
maturity

Contraindications for induction of Labor
MATERNAL CONTRAINDICATIONS:
1. Uterine incision type
Types of uterine incisions:
o CLASSICAL incision: vertical incision
above the lower uterine segment,
MOST commonly associated with
uterine rupture
o KERR incision: transverse incision in
the lower uterine segment, LEAST
associated with uterine rupture
o KERRNIGS incision: longitudinal
incision in the lower uterine
segment
2. Distorted maternal pelvic anatomy
3. Abnormal placental implantation
o Ex: placenta previa
4. Maternal genital herpes
o Must be ACTIVE GENITAL HERPES
o If (+) history of genital herpes with
no active lesion during labor or
delivery, induction CAN PROCEED
5. Cervical cancer
o Increased risk for bleeding
*** sa exam daw tignan ng maigi kung ano ang
t i n a t a n o n g . K u n g M AT E R N A L o r F E TA L
contraindications
FETAL CONTRAINDICATIONS
1. Macrosomnia
2. Multifetal gestation
3. Severe hydrocephalus
4. Malpresentation
5. Nonreassuring fetal status
Before induction:
➢ CST must be done to know if the baby can
tolerate the stress of labor
Techniques for labor induction:
1. Oxytoxin
2. Prostaglandin
3. Mechanical methods:
o Membrane stripping
o Amniotomy
o Cervical dilators
o Extra-amniotic saline infusion
Maternal complications
1. Increase for cesarian section rate
o 2-3x increased in nulliparas
however they are inversely related
to bishop’s score
o If Bishop’s score is high = favorable
cervix = increased chance of vaginal
delivery
o If Bishop’s score is low = increased
cesarian section rate
2. Risk for chorioamnionitis
3. Uterine rupture from prior uterine incision
o History of CS then nagvaginal
delivery un mother, risk for rupture
is increased 3x
o But if with history of CS then
oxytoxin was given, risk for rupture
is increased 5x
o But if (+) history of CS + oxytoxin +
prostaglandin = risk for rupture
increased 15x
o Recommendation: NO
PROSTAGLANDIN to patients with
previous CS or previous operations
4. Postpartum hemorrhage from uterine atony
o Because all receptors are already
occupied overwhelming the
receptors thus saturating the
receptors
Elective Labor Induction
➢ Not usually done because of increased risk
for maternal outcome
➢ Accepted only with the following logistical
reasons:
1. Risk of rapid labor
2. Woman who lives in a long distance
from the hospital
3. Psychological manifestations
Factors affecting successful induction:
1. Multiparity
2. BMI: <30
3. Favourable cervix
4. Birth weight: <3500g
5. Bishop score: equal or more than 9
6. Latent phase of 18 hours
Preinduction Cervical Ripening
➢ Use of prostaglandin E2 (dinoprostone),
PGE1 (misoprostol)
➢ Use of mechanical techniques
o Transcervical catheter
o Extra-amniotic saline infusion
o Hygroscopic cervical dilators
Cervical Favorability
➢ Bishop score: 9 = high likelihood of
successful induction
 ➢ Bishop score: less than 4 = unfavourable
and may be an indication of cervical
ripening
" Side Effects:
Pharmaceutical techniques
1. Prostaglandin E2 – dinoprostone
➢ Three forms: gel form, vaginal insert,
suppository
➢ Expected time of delivery: within 24 hours
o Prepidil:
▪ Gel form
▪ When coupled with
OXYTOXIN: improves bishop
score and lowered induction-
to-delivery
▪ No benefit for lowering
cesarian delivery rate
o Cervidil
▪ Vaginal insert
▪ Combined with OXYTOXIN:
shortens induction-to-
delivery interval
Administration:
o Depends on UTERINE ACTIVITY
o If given, WAIT FOR 12HOURS
BEFORE GIVING OXYTOXIN; may
lead to UTERINE TACHYSYSTOLE IF
GIVEN IMMEDIATELY(gel preparation)
o If vaginal insert, wait for 30minutes
o UTERINE ACTIVITY and FETAL HEART
R AT E M O N I TO R I N G s h o u l d b e
performed.
o Uterine tachysystole: equal or more
than 5 contractions in a 10-minute
period, fetal heart rate abnormality
MAY/MAY NOT be present
o Other name: “uterine hypertonus,”
“uterine hyperstimulation”
Contraindications:
o same as the contraindications for
induction
o hypersensitivity to the drug
o Fetal compromise
o Acute vaginal bleeding
o (+) history of >6 preterm deliveries
o Any obstetrical contraindications
for vaginal delivery
2. Prostaglandin E1 – Misoprostol (Cytotec)
➢ Marketed for peptic ulcer prevention
➢25mcg: recommend dose for cervical
ripening for vaginal dose
➢For postpartum haemorrhage: 4
whole tablets rectally
➢Decreases the need for oxytoxin
induction and reduce induction-to-
delivery intervals
➢CAUTION: increased rate of uterine
hyperstimulation with fetal heart rate
changes
➢50mg intravaginal dose: effects:
• significant increased
uterine tachysytole
• meconium passage
• meconium aspiration
➢Uterine rupture: risk for women with
prior cesarian delivery.
3.Nitric Oxide Donors – Isosorbide
mononitrate, glycerol trinitrate
➢NOT USEFUL
Mechanical Techniques
1.Transcervical Catheter
2.Extra-amniotic Saline Infusion
3.Hygroscopic cervical dilators
 4. Membrane stripping for labor induction


Labor Induction and Augmentation with Oxytoxin
Goal: To effect uterine activity sufficient
to produce cervical change and fetal
descend while avoiding development of a
nonreassuring fetal status
➢ Discontinued if:
o Uterine tachysystole persist
o Persistent nonreassuring fetal heart
rate pattern
➢ Conditions stated above returns to normal
since HALF-LIFE of oxytoxin is
approximately 3-5 MINUTES.
➢ Responses are variable due to the following
determinants:
o Pre-existing uterine activity
o Cervical status
o Pregnancy duration
o Individual biologic differences
➢ Dose: 10-20 units per 1L of crystalloids
o NEVER MIX OXYTOXN TO FLUIDS
WITH NO ELECTROLYTES: increases
risk for water intoxication
o Adjustments:
➢ Side effects:
o Uterine rupture
o Antidiuretic: homologue of AVP
o Wa t e r i n t o x i c a t i o n : i n c r e a s e
concentration rather than the flow
rate


Amniotomy
Indications:
➢ Direct fetal heart rate monitoring
➢ Accelerate labor: increased by 1-1 ½ hours
specially if amniotomy done with 5cm
dilatation (active labor)
Complications:
➢ Cord prolapse
➢ Increased risk of developing
chorioamnionitis


Membrane Stripping
➢ Done to decrease the incidence of post
term delivery
Advantage:
➢ Does not cause uterine rupture
➢ Causes minimal bleeding
Disadvantage:
➢ discomfort