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AMNIOTIC FLUID

By La Lura White MD
Maternal Fetal
Medicine

AMNIOTIC FLUID
The amniotic fluid that bathes the fetus is necessary for
its proper growth and development.
It cushions the fetus from physical trauma
Provides a barrier against infection
Allowing for freedom of fetal movement and permitting
symmetrical musculoskeletal development
Maintaining a relatively constant temperature for the
environment surrounding the fetus, thus protecting the
fetus from heat loss
Permitting proper lung development

AMNIOTIC FLUID
Cleavage of zygote
Zygote begins cleavage in the
fallopian tube
s/p 3 days in the fallopian tube,
the morula enters uterine cavity
After 3 days floating in the
uterine cavity it will implant
Gradual accumulation of fluid
between blastomeres within the
morula results in the formation
of the blastocyst
Inner cell mass-embryo
Outer cell mass-trophoblast

AMNIOTIC FLUID

7 1/2 days:
Trophoblast
Cytotrophoblast: individual, pale staining cells
Syncytiotrophoblast: dark staining nuclei within
an amorphous common cytoplasm
Inner cell mass: embryonic disc thick ectoderm
and underlying endoderm
Between the embryonic disc and the trophoblast,
small cells appear that enclose a space that will
become the amniotic cavity

AMNIOTIC FLUID

AMNIOTIC FLUID

AMNIOTIC FLUID
Small cells line the inner surface of the trophoblast
called amniogenic cells, later to become amniotic
epithelium
The amnion develops by the 7-8 th day
Derived from fetal ectoderm
As the amnion enlarges, it gradually engulfs the embryo
which prolapses into its cavity
Distention of the amniotic sac brings it in contact with the
chorion laeve
The chorion and amnion are juxtaposed but not connected

AMNIOTIC FLUID

AMNIOTIC FLUID
Clear fluid collects within the
amniotic cavity and increases with
gestational age. Normal amniotic
fluid levels vary.

50 ml
12 weeks
400 ml midpregnancy
800 ml 34 weeks
1000ml 36-38 weeks
At full term, there is between 5001000 cc of amniotic fluid.

AMNIOTIC FLUID

AMNIOTIC FLUID

AMNIOTIC FLUID
Composition and volume of amniotic fluid
changes as pregnancy advances
In the first half of pregnancy, the fluid is
the same as the extracellular fluid of the
fetus, devoid of particulate matter
Produced by amniotic membranes
Fluid also passes across fetal skin

AMNIOTIC FLUID
By the fourth month, the fetus contributes to
amniotic fluid via:
urinating
swallowing
movement of fluid in and out of the respiratory
tract
Fetal urination will eventually comprise the
majority of the amniotic fluid

AMNIOTIC FLUID
The fetal kidneys start to develop during the 4th and 5th
weeks of gestation and begin to excrete urine into the
amniotic fluid at the 8th to 11th week
At the 20th week the fetal kidneys produce most of the
amniotic fluid
Fetal urine is hypotonic (c/w plasma) because of lower
electrolyte concentration
Contains more urea, creatinine and uric acid
Osmolality decrease with increasing gestational age

AMNIOTIC FLUID
An important function of the fetal kidney is to
maintain a urine output sufficient to maintain
amniotic fluid volume
Daily urine production is approximately 30% of
fetal weight
The excreted urine does not serve real excretory
or homeostatic function because the urine, via the
amniotic fluid, is recycled back to the fetus by
swallowing (25% of fetal weight)

AMNIOTIC FLUID
The factors involved in regulating
amniotic fluid volume are still not
completely understood. The 6
proposed pathways (Brace, 1997) for
fluid movement into and out of the
amniotic cavity include:

AMNIOTIC FLUID
Pathway
Fetal swallowing

Volume (ml)/day
to the fetus
to amniotic fluid
500-1000

Oral secretions
Secretions from the
respiratory tract

25

170

Fetal urination
Intramembranous flow
across the placenta,
umbilical cord

170
800-1200

200-500

Transmembraneous flow
from the amniotic cavity into
the uterine circulation

10

AMNIOTIC FLUID
Glycerophospholipids (lecithin, sphingomyelin)
from the lungs accumulate in AF
Desquamated fetal cells, lanugo, scalp hair and
vernix caseosa are shed
Also contains albumin, urea, uric acid,
creatinine,, bilirubin, fat, fructose, leukocytes,
proteins, epithelial cells, enzymes

AMNIOTIC FLUID
Amniotic fluid volume (AFI)
The volume of the amniotic fluid is evaluated by

visually dividing the mother's abdomen into 4


quadrants
The largest vertical pocket of fluid in each quadrant is
measured in centimeters
Cord containing pocket < 30%
The total volume is calculated by adding these values
<5 oligohydramnios

AMNIOTIC FLUID
The 2 cm x 2 cm pocket definition (Magann,
1999a) and an AFI < 5 cm (Horsager, 1994) were
compared to the actual amniotic fluid volume as
measured by a dye-dilution technique.
The single 2 cm pocket had a sensitivity of 9.5%
AFI < 5.0 cm had a sensitivity of 18% for the
detection of oligohydramnios

AMNIOTIC FLUID
6-8 borderline AFI
8-24 normal
>24 polyhydramnios

AMNIOTIC FLUID

Oligohydramnios

Normal

AMNIOTIC FLUID
Polyhydramnios is usually defined as;
Amniotic fluid index (AFI) more than 24 cm
Single pocket of fluid at least 8 cm in deep that results in
more than 2000 mL of fluid
Occurs in 1% of pregnancies
Preterm labor and delivery occurs in approximately 26%
of mothers with polyhydramnios.
Other complications are premature rupture of the
membranes (PROM), abruptio placenta, malpresentation,
cesarean delivery, and postpartum hemorrhage

AMNIOTIC FLUID
An abnormally high level of amniotic fluid,
polyhydramnios, alerts the clinician to possible
fetal anomalies
80-90% are idiopathic
In pregnancies affected by polyhydramnios,
approximately 20% of the neonates are born with
a congenital anomaly of some type
Gastrointestinal system (40%), central nervous
system (26%), cardiovascular system (22%),
genitourinary system (13%) and 50% of the
patients had no associated risk factors.

AMNIOTIC FLUID
Fetal akinesia syndrome: Absence of
swallowing
Blockage of the fetus' gastrointestinal tract
Esophageal atresia (usually associated with
a tracheoesophageal fistula)
Tracheal agenesis
Duodenal atresia
.

AMNIOTIC FLUID
Non-genetic
Congenital cardiac-rhythm anomalies

associated with hydrops, fetal-to-maternal


hemorrhage, and parvovirus infection
Maternal type 2 diabetes mellitus
Multiple gestations

AMNIOTIC FLUID
Polyhydramnios: treatment
Patients with polyhydramnios tend to have a higher

incidence of preterm labor secondary to overdistention


of the uterus.
Schedule weekly or twice weekly perinatal visits and
cervical examinations.
Place patients on bed rest to decrease the likelihood of
preterm labor.
Perform serial ultrasonography to determine the AFI
and document fetal growth.

AMNIOTIC FLUID
Polyhydramnios
Treat underlying cause
Fetal anemia: Fetal transfusion
Diabetes: control blood sugar
Twin-Twin Transfusion: ablation

AMNIOTIC FLUID
Polyhydramnios: Treatment
Procedures:
Reductive amniocentesis may be performed and has contributed

to prolonged pregnancy in patients who are severely affected by


hydramnios.
This procedure can reduce the risk of preterm labor, PROM,
umbilical cord prolapse, and placental abruption.
However, if too much fluid is removed, the risk of placental
abruption due to uterine compression increases.
Other risks of the procedure include infection, bleeding, and
trauma to the fetus.
Laser ablation of placental vessels may be efficacious in cases of
fetal-fetal transfusion syndrome

AMNIOTIC FLUID
Most cases of polyhydramnios respond in the first week of
treatment with indomethacin
The approach appears to be highly effective (90-100% in some
studies), provided that the cause is not hydrocephalus or a
neuromuscular disorder that alter fetal swallowing.
Drug Category: Prostaglandin inhibitors -- When administered to
pregnant women with polyhydramnios, these drugs can reduce
fetal urinary flow, decreasing the volume of amniotic fluid.
Drug Name
Indomethacin (Indocin) -- Rapidly absorbed; metabolism occurs in
liver by demethylation, deacetylation, and glucuronide conjugation
Inhibits prostaglandin synthesis.
Adult Dose25 mg PO q6h

AMNIOTIC FLUID

Contraindications
Documented hypersensitivity; GI bleeding; renal insufficiency
Interactions:
Co administration with aspirin increases risk of serious
NSAID-related adverse effects
Probenecid may increase concentrations and, possibly, toxicity
of NSAIDs
Decrease effect of hydralazine, captopril, and beta-blockers
Decrease diuretic effects of furosemide and thiazides
Monitor PT closely (instruct patients to watch for signs of
bleeding)
Increase risk of methotrexate toxicity
Increase phenytoin levels when administered concurrently

AMNIOTIC FLUID
Usually safe but benefits must outweigh the risks
Can cause fetal renal and CNS complications; associated
with premature closure of the fetal ductus arteriosus when
administered near term
Periventricular leukomalacia has been reported in infants
whose mothers have received indomethacin as a tocolytic.
Acute renal insufficiency, hyperkalemia, hyponatremia,
interstitial nephritis, and renal papillary necrosis may occur;
increases risk of acute renal failure in patients with
preexisting renal disease or compromised renal perfusion;
Reversible leukopenia may occur (discontinue if persistent
leukopenia, granulocytopenia, or thrombocytopenia present).

AMNIOTIC FLUID
Oligohydramnios occurs in 4% of pregnancies
Sonographically defined as an AFI less than 5 cm or the
absence of a fluid pocket 2-3 cm in depth.
Inadequate levels of amniotic fluid, oligohydramnios,
results in poor development of the lung tissue and can
lead to fetal death secondary to bronchopulmonary
dysplasia (BPD) and pulmonary hypoplasia
Rupture of the membranes is the most common cause of
oligohydramnios and if prolonged can result in chorio

AMNIOTIC FLUID
Oligohydramnios
Fetal urinary tract anomalies, such as renal agenesis

(Potters syndrome), polycystic kidneys, or any


urinary obstructive lesion (eg, posterior urethral
valves)
Placental insufficiency, as seen in PIH, maternal
diabetes, or postmaturity syndrome when the
pregnancy extends beyond 42 weeks' gestation
Maternal use of prostaglandin synthase inhibitors or
angiotensin-converting enzyme (ACE) inhibitors

AMNIOTIC FLUID
Severe oligohydramnios

Marked deformation of the fetus due to of intrauterine constraint


External compression with a flattened facies
Epicanthal folds
Hypertelorism
Low-set ears
Mongoloid slant of the palpebral fissure
Crease below the lower lip
Micrognathia
Thoracic compression
Bowed legs
Clubbed feet

AMNIOTIC FLUID
The mortality rate in oligohydramnios is high

Pulmonary hypoplasia
IUGR
Meconium stainin
Fetal heart conduction abnormalities
Poor tolerance of labor
Lower Apgar scores
Fetal acidosis
Physical deformities

AMNIOTIC FLUID
Oligohydramnios: Treatment
Maternal bed rest and hydration promote the
production of amniotic fluid by increasing the
maternal intravascular space.
Bed rest may also help when PIH is present,
allowing prolongation of the pregnancy.
Oral hydration

AMNIOTIC FLUID
Oligohydramnios: Treatment
The transabdominal instillation of indigo carmine
may be used to evaluate for PROM
The transcervical instillation of isotonic sodium
chloride solution (ie, amnioinfusion) at the time
of delivery reduces the risk of cord compression,
fetal distress and meconium dilution.
It also reduces the potential need for cesarean
delivery.

AMNIOTIC FLUID
15 week fetus with
posterior urethral
valves.
The fetus is in breech
presentation. The
bladder (b) is
massively distended.

AMNIOTIC FLUID
15 week fetus with
posterior urethral
valves.
) Enlarged "key-hole"
bladder associated
with posterior urethral
valves.

AMNIOTIC FLUID
19 week fetus with
Turner's syndrome,
cystic hygroma
(arrows) and
oligohydramnios

AMNIOTIC FLUID
Mortality/Morbidity:
Chamberlin used ultrasonography to evaluate the
perinatal mortality rate (PMR) in 7562 patients
with high-risk pregnancies.
The PMR of patients with normal fluid volumes
was 1.97 deaths per 1000 patients.
The PMR increased to 4.12 deaths per 1000
patients with polyhydramnios
56.5 deaths per 1000 patients with
oligohydramnios

AMNIOTIC FLUID
Amnionitic fluid evaluation allows assessment
of the fetal intrauterine environment
Potentially invaluable information
Requires close follow-up and evaluation
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