PEMERIKSAAN LABORATORIUM UNTUK DETEKSI KELAINAN PADA JANIN

Rini Riyanti, dr., Sp.PK

Fetal Lung Maturity

Fetal Lung Maturation is marked by production surfactant/ Surfactant (detergent-like material), which forms a film on the alveolar surface. The presence of Surfactant reduces surface tension at the lung's tissue-air interface. Surfactant decreases the work of breathing by

Reducing resistance the lung expansion during inspiration Preventing alveolar collapse during expiration

Deficiency of Surfactant produces

Respiratory distress syndrome (RDS) results in hypoxia, acidemia and vascular protein transudation into alveolar air spaces

Prior to 35 weeks gestation, the major component of surfactant is -palmitic -myristic lecithin. Minor component of Surfactant include sphingomyelins

Quantitation of Pulmonary Surfactant: L/S Ratio

It is the most valuable assay for the assessment of fetal pulmonary maturity.

At 32 weeks the L/S ratio reaches 1. Lecithin then rises rapidly, and an L/S ratio of 2.0 is observed at 35 weeks.
A ratio of 2.0 or greater has repeatedly been associated with pulmonary maturity.

A mature L/S ratio predicted the absence of RDS in 98 percent of neonates.

With a ratio of 1.5 to 1.9, approximately 50 percent of infants will develop RDS. Below 1.5, the risk of subsequent RDS increases to 73 percent.

L/S is determined by thin-layer chromatography. Following extraction and purification with solvents. It is made visible by heat charring or staining Densitometric quantification determines L/S ratio

L/S ratio method is slow, labor intense, insensitive and pre-analytical variables affect accurracy

Dilution by fluids secretions (AF is aspirated from the vagina)

Analytical error

Over centrifugation (speed and time) Blood contamination (hemolysis)

Meconium interfere (prevent clear separation of L and S)

Phosphatidyl glycerol (PG)

PG increases at 36 weeks until term and maintains alveolar stability.

Quantitation of Pulmonary Surfactant: Test for PG

A rapid immunologic semiquantitative agglutination test (Amniostat-FLM) can be used to determine the presence of PG. It can detect PG at a concentration >0.5 g/ml. It takes 20 to 30 minutes to perform and requires only 1.5 ml of amniotic fluid. It is highly sensitive. A positive Amniostat-FLM correlates well with the presence of PG by thin-layer chromatography and the absence of subsequent RDS. It can be applied to samples contaminated by blood and

Measurement of Surfactant Function:

Shake Test It evaluates the ability of pulmonary surfactant to generate a stable foam in the presence of ethanol.

Ethanol, a nonfoaming competitive surfactant, eliminates the contributions of protein, bile salts, and salts of free fatty acids to the formation of a stable foam.

At an ethanol concentration of 47.5 percent, stable bubbles that form after shaking are due to amniotic fluid lecithin.
Positive tests, a complete ring of bubbles at the meniscus with a 1:2 dilution of amniotic fluid, are rarely associated with neonatal RDS. It is a screening test that gives useful information if mature.

Measurement of Surfactant Function:

Foam Stability Index

The test is based on the manual foam stability index (FSI), a variation of the shake test.

The kit currently available contains test wells with a predispensed volume of ethanol. The addition of 0.5-ml amniotic fluid to each test well in the kit produces final ethanol volumes of 44 to 50 percent. A control well contains sufficient surfactant in 50 percent ethanol to produce an example of the stable foam end point. The amniotic fluid:ethanol mixture is first shaken, and the FSI value is read as the highest value well in which a ring of stable foam persists.

This test appears to be a reliable predictor of fetal lung maturity.

Subsequent RDS is very unlikely with an FSI value of 47 or higher. The methodology is simple, and the test can be performed at any time of day by persons who have had only minimal instruction. The assay appears to be extremely sensitive, with a high proportion of immature results being associated with RDS, as well as moderately specific, with a high proportion of mature results predicting the absence of RDS. Contamination of the amniotic fluid specimen by blood or meconium invalidates the FSI results. The FSI can function well as a screening test.

Premature Rupture of Membrane

PROM occurs when AF escapes before the onset of labor.

It may be followed by a variety of complications including chorioamnionitis, fetal pulmonary hypoplasia,placental abruption, neonatal repiratori distress

Clinical manifestation
Fluid passing through the vagina suddenly, and then small amounts of fluid flow through the vagina intermitently, particularly when the increased of abdorminal pressure (cough,sneeze,et al)

Free flowing amniotic fluid Fever / heart rate of mother and

infants / WBC and CRP / Uterine

tenderness on palpation