Contents

Contents.......................................................................................................................................i

CHAPTER I PRELIMINARY...................................................................................................1

CHAPTER II
DISCUSSION......................................................................................................2
2.1 Amniotic Fluid.........................................................................................................2
2.1.1
Definition...................................................................................................2
2.1.2 Amniotic Fluid Volume.............................................................................2
2.1.3 The Function of Amniotic Fluid................................................................4
2.1.4 Distribution of Amniotic Fluid..................................................................6
2.1.5 Measurement of Amniotic Fluid...............................................................7
2.2 Oligohydramnios......................................................................................................9
2.2.1
Definition...................................................................................................9
2.2.2 Pathophysiology of Oligohydramnios.......................................................9
2.2.3 Epidemiology of Oligohydramnios.........................................................10
2.2.4 Etiology of Oligohydramnios..................................................................10
2.2.5 Risk Factors Oligohydramnios................................................................11
2.2.6 Clinical Manifestations Oligohydramnios...............................................11
2.2.7 Diagnosis and Inspection Oligohydramnios............................................12
2.2.8 Management Oligohydramnios...............................................................12
2.2.9 Prognosis of Oligohydramnios................................................................13
2.2.10 Oligohydramnios Influence on Fetus....................................................13

CHAPTER III CONCLUSION................................................................................................15

REFERENCES.........................................................................................................................16
i
CHAPTER I
PRELIMINARY
Approximately

8%

of

pregnant

women

have

too

little

amniotic

fluid.

Oligohydramnios can occur anytime during pregnancy, although in general often occurs in
the last trimester of pregnancy. Approximately 12% of women whose pregnancies beyond the
limits of the approximate time of birth (gestational age 42 weeks) was also oligohydramnios,
because the amount of amniotic fluid was reduced by almost half of the normal amount
during pregnancy at 42 weeks.1
The cause of oligohydramnios can not be fully understood. The majority of pregnant
women who have not know exactly what causes it. The cause of oligohydramnios that has
been detected is the fetal congenital defects and leaking pouches / membrane of the amniotic
fluid surrounding the fetus in the womb. Approximately 7% of infants of women who have
experienced oligohydramnios congenital defects, such as the kidney and urinary tract because
of the amount of urine produced reduced fetal.1
Other health problems have also been associated with oligohydramnios is high blood
pressure, diabetes, SLE, and problems with the placenta. A series of medications used to treat
high blood pressure, known as angiotensin-converting enxyme inhibitors (eg, captopril), can
damage the fetal kidneys and cause severe oligohydramnios and fetal death. Women who've
had chronic high blood pressure should consult a health care professional before planning a
pregnancy to ensure that their blood pressure remains well supervised and medications that
they take are safe during pregnancy.2
The earlier in pregnancy oligohydramnios, the worse the prognosis. If it occurs in the
second trimester, 80-90% will result in mortality.3

CHAPTER II
DISCUSSION
2.1 Amniotic Fluid
2.1.1 Definition
Amniotic fluid is a fluid that meets the uterus. This fluid is accommodated
inside the amniotic sac or fetal sac. The amniotic fluid is produced by trophoblast
cells, then will increase the production of fetal fluid, that is fetus urine. Since the
gestational age of 12 weeks, the fetus begins to drink amniotic fluid and removing it
back in the form of urine. So there is a circular pattern.4
2.1.2 Amniotic Fluid Volume
Amniotic fluid in normal circumstances is white rather murky because of the
mixture of solid particles that contained there, are derived from lanugo, epithelial cells
and sebaceous material. The volume of amniotic fluid at aterm state is about 800 ml,
or between 400 ml -1500 ml in normal circumstances. At 10 weeks gestation on
average volume was 30 ml, and 300 ml of 20 weeks, 30 weeks of 600 ml. At 30
weeks of pregnancy, amniotic fluid is more dominating than the fetus.1,2
Amniotic fluid is produced by the fetus and the mother, both of them have
separate roles at each gestational age. In early pregnancy, amniotic fluid are mostly
produced by the amnion epithelial secretion. During pregnancy increases, amniotic
fluid production is dominated by the skin of the fetus by means of membrane
diffusion. At 20 weeks of pregnancy, when the fetal skin starts to lose permeability,
fetal kidney takes over this role in producing amniotic fluid.2
In term pregnancies, approximately 500 ml per day of amniotic fluid secreted
from urine fetal and 200 ml of fluid coming from the trachea. In research using
radioisotope, an exchange of approximately 500 ml per hour between maternal plasma
and amniotic fluid.3

In conditions where there are disturbances in fetal kidneys, such as renal

agenesis, will cause oligohydramnios and if there are swallowing disorders in the
fetus, such as esophageal atresia, or anencephaly, will cause polyhydramnios.4
Amniotic fluid volume at each week of gestation varies, the general volume
increased 10 ml per week at week 8 of gestation and increased to 60 ml per week in
gestational age 21 weeks, which will then decrease gradually until a fixed volume
after age 33 weeks of pregnancy. Normal amniotic fluid volume increases of 50 ml at
12 weeks gestation to 400 ml at mid-gestation and 1000-1500 ml at term. In
pregnancy postterm amount of amniotic fluid is only 100 to 200 ml.3,4
The main factors affecting the volume of amniotic fluid:

Setting the physiological flow of the fetus.

The movement of water and the solution within and across the membrane.
Effect of maternal transplacental fluid movement.1
The volume of amniotic fluid is a predictor of the ability of the fetus to face

childbirth, because of the possibility of umbilical cord sandwiched between the baby
and the uterine wall increases when the waters a bit. This will lead to fetal distress and
ends with surgical cesarean delivery.4
Normal state of amniotic fluid:

At the age of full-term pregnancy 1000-1500 cc volume.

The situation bit murky crystal clear.
Sterile.
Distinctive smell.
Made up of 98-99% water, 1-2% of inorganic salts and organic matter (proteins,

especially albumin), the rubble of lanugo hair, vernix caseosa and epithelial cells.
Cirkulation about 500 cc / hour.4

2.1.3 The Function of Amniotic Fluid

Amniotic fluid is an important component for the growth and development of
the fetus during pregnancy. In early embryogenesis, the amnion is an extension of the
extracellular matrix and there occurs diffusion in both directions between the fetus
and the amniotic fluid. At the age of 8 weeks of pregnancy, the fetus is formed urethra
and kidneys begin producing urine. Furthermore, the fetus begins to swallow.
Excretion of urine, respiratory system, digestive system, umbilical cord and placental
surface becomes a source of amniotic fluid. It is known that the amniotic fluid serves
as a protective bag around the fetus which provide space for the fetus to move and
prevent trauma mechanical and thermal trauma.2
Amniotic fluid also plays a role in the innate immune system because it has
antimicrobial peptides against some types of bacteria and fungi specific pathogen.
Amniotic fluid is 98% water and electrolytes, proteins, peptides, hormones,
carbohydrates, and lipids. In some studies, the components of the amniotic fluid was
found to have a function as a potential biomarker for abnormalities in pregnancy. In
recent years, a number of proteins and peptides in amniotic fluid known as growth
factors or cytokines, which levels will vary according to gestational age. Amniotic
fluid also alleged to have potential in the development of stem cell medication.2,3

Picture 1. The Amnion Fluid

Source: www.google.com

There are various functions of the amniotic fluid, such as a cushion or damper
or fetus protective guard against impact from the outside.3
The amniotic fluid also allows the fetus to move freely and grow freely in any
direction. In addition, as a bulwark against the germs from outside the mother's body
and maintain a stable body temperature of the fetus. The amniotic fluid is also a
diagnostic aid doctors in the examination amniocentesis.2
Keep in mind, the amniotic fluid is not open or push the fetus out. Charge for
it is the contraction of the uterus (his). So even if the membranes have ruptured or
little water content, the opening of the cervix and urge the baby to be born will still
occur during the contraction.3
In normal pregnancy, amniotic fluid provide a space for the fetus to move and
expand. Without amniotic fluid, uterus will contract and suppress the fetus. If the
reduction in volume of amniotic fluid early in pregnancy, the fetus will experience a
variety of disorders such as developmental disorders limb, abdominal wall defects,
and the Potter syndrome, a syndrome with facial features such as eyes are far apart,
there are creases epikantus, bridge of the nose is wide, ears low and chin pulled
back.3,4
At mid-gestation, amniotic fluid becomes very important for fetal lung
development. Insufficient amniotic fluid at mid-gestation will lead to pulmonary
hypoplasia which can cause death.2
Besides this fluid also has a protective role in the fetus, this fluid containing
anti-bacterial agents and inhibit the growth of bacteria which have the potential
pathogens. During labor and birth the amniotic fluid continues to act as a protective
medium in the fetus to monitor cervical dilatation. Besides the amniotic fluid also
serves as a means of communication between the fetus and the mother. Maturity and
readiness of the fetus to be born can be seen from the fetal urinary hormone that is
excreted into the amniotic fluid.2

Amniotic fluid can also be used as a diagnostic tool to see any abnormalities in
the growth and development of fetuses with cell cultures. So amniotic fluid plays a
fairly important in the process of pregnancy and childbirth.4
2.1.4 Distribution of Amniotic Fluid

Fetal Urine
The main source of amniotic fluid is fetal urine. Fetal kidneys begin producing
urine before the end of the first trimester, and continued in production until term
pregnancies. Fetal urine production average is about 1000-1200 ml / day in aterm

pregnancy.
Lungs Liquids
Fetal lung liquid plays an important role in the formation of amniotic fluid. In
research using a sheep, it was found that the fetal lungs produce fluid to about
400 ml / day, of which 50% of production and 50% swallowed back again
removed through the mouth. Although measurements directly to humans is never
done, but this data has value representratif for humans. In normal pregnancy, fetal
breathing movements of inspiration and expiration, or movement in and out
through the trachea, lungs and mouth. So it is clear that the lungs of the fetus is

also instrumental in the formation of amnion liquid.

Swallow Movement
In humans, fetal swallowing in early gestation. In the fetal sheep, swallowing
process increased along with increasing gestational age. Sherman and friends
reported that fetal sheep gradually swallowed with a volume of about 100-300

ml / kg / day.
Intramembranous Absorption
The one major obstacle in understanding the regulation of amniotic fluid is a
mismatch between the production of amniotic fluid by the kidneys and the lungs
of the fetus, with consumption by ingestion. If the calculated difference between
the production and consumption of amniotic fluid, obtained a margin of about
500-750 ml / day, which of course will lead to polyhydramnios. However, after
some research, finally missed, that about 200-500 ml of amniotic fluid is absorbed
through intramembranous. The image shows the distribution of amniotic fluid in
the fetus. With the absorption intramembranous discovered this, it seems clear that
there is a real balance between the production and consumption of amniotic fluid
in normal pregnancy.5

Picture 2. Distribution of Amniotic Fluid in Pregnancy

Quoted from Gilbert

2.1.5 Measurement of Amniotic Fluid

There are 3 ways that are often used to determine the amount of amniotic
fluid, with a single pocket technique, using amnion fluid index (ICA), and
subjectively examiner.5
Examination with single pocket method was first introduced by Manning and
Platt in 1981 as part of the examination of biophysical, where 2 cm is considered as
the minimum and 8 cm is considered as polyhydramnios.5
Pocket single method has been compared with the AFI using amniocentesis as
the gold standard. Three studies have shown that the method of measurement of
amniotic fluid with the techniques index Fluid amnion (ICA) has a weak correlation
with the volume of amniotic actual (R2 of 0:55, 0:30 and 0:24) and two of the three
studies showed that the technique of single pocket has a better ability.5,6

Excess amniotic fluid as polyhydramnios, does not affect the fetus directly, but
can lead to premature birth. Broadly speaking, the lack of amniotic fluid may be a
negative effect on the development of lungs and legs of the fetus, which both require
the amniotic fluid to grow.6

Picture 3. Measurement of Amniotic Fluid Based on The Four Quadrants.

Quoted from Gilbert

The amount of amniotic fluid can be monitored by ultrasound, exactly using

the parameters AFI (Amniotic Fluid Index). Basically, the amniotic fluid can be
detected as a mother late period and is already visible with ultrasound fetal sac
because it means is formed of amniotic fluid. In normal pregnancy at term, the
amount of amniotic fluid around 1000 cc. The amniotic fluid is said to be less when
the volume is less than 500 cc. It is known from the results of the ultrasound
examination.5,6

2.2 Oligohydramnios
2.2.1 Definition
Oligohydramnios is a condition where the amniotic fluid less than normal,
which is less than 500 cc.5,6 Other definitions mentioned as an AFI less than 5 cm.
Because Amniotic Fluid Volume depending on gestational age, the more precise
definition is AFI less than 5 percentile (approximately AFI <6.8 cm at full-term
pregnancy).7
2.2.2 Pathophysiology of Oligohydramnios
The mechanism or pathophysiology of oligohydramnios can be associated
with the potter syndrome and pottern phenotype, which, Potter syndrome and Potter
phenotype is a complex situation that is associated with congenital renal failure and is
associated with oligohydramnios (amniotic fluid that bit).7
Potter phenotype described as a typical state in the newborn, in which
amniotic fluid is very little or nothing. Oligohydramnios causing the baby has no
bearing on the wall of the uterus. The pressure of the uterine wall causes a typical
facial features (facial Potter). In addition, because of the narrow space in the uterus,
then the members of the body into abnormal movements or have contractures and
fixed on an abnormal position.5
Oligohydramnios also cause the cessation of the development of the lungs
(pulmonary hypoplastic), so that at birth, the lungs do not function properly. In Potter
syndrome, the primary abnormality is congenital kidney failure, either due to the
formation of kidney failure (renal agenesis bilateral) as well as other diseases of the
kidneys which causes the kidneys fail to function. 7 In a normal state, the kidneys to
form the amniotic fluid (as urine) and the absence of amniotic fluid causes the typical
picture of Potter syndrome.8
Potter syndrome symptoms include:

Face Potter (both eyes are far apart, there are creases epikantus, broad bridge of

the nose, the ears are low and chin pulled back).
No form of urine.
Respiratory distress.8

2.2.3 Epidemiology of Oligohydramnios

Approximately 8% of pregnant women have too little amniotic fluid.
Olygohydramnion can occur anytime during pregnancy, although in general often
occurs in the last trimester of pregnancy. Approximately 12% of women whose
pregnancies beyond the limits of the approximate time of birth (gestational age 42
weeks) was also olygohydrasmnion, because the amount of amniotic fluid was
reduced by almost half of the normal amount during pregnancy 42 weeks.1
2.2.4 Etiology of Oligohydramnios
The cause of oligohydramnios can not be fully understood. The majority of
pregnant women who have not know exactly what causes it. The cause of
oligohydramnios that has been detected is the fetal congenital defects and leaking
pouches / membrane of the amniotic fluid surrounding the fetus in the womb.
Approximately 7% of infants of women who have experienced oligohydramnios
congenital defects, such as the kidney and urinary tract because of the amount of urine
produced reduced fetal.1
Other health problems have also been associated with oligohydramnios is high
blood pressure, diabetes, SLE, and problems with the placenta. A series of
medications used to treat high blood pressure, known as angiotensin-converting
enxyme inhibitors (eg, captopril), can damage the fetal kidneys and cause severe
oligohydramnios and fetal death. Women who've had chronic high blood pressure
should consult a health care professional before planning a pregnancy to ensure that
their blood pressure remains well supervised and medications that they take are safe
during pregnancy.2
Fetal:

Chromosome.
Congenital.
Intrauterine growth retardation in the womb.
Pregnancy postterm.
Premature ROM (Rupture of amniotic membranes).2

Maternal:

Dehydration.
Uteroplacental insufficiency.
Preeclampsia.
Diabetes.
Chronic Hypoxia.2

Induction Medication:

Indomethacin and ACE inhibitors.

Idiopatik.2

2.2.5 Risk Factors Oligohydramnios

Women with these conditions have a high incidence of oligohydramnios:

Congenital anomalies (eg: agenosis renal syndrome patter).

Intra-uterine growth retardation.
Membranes ruptured early (24-26 weeks).
Syndrome of post maturitas.2

2.2.6 Clinical Manifestations Oligohydramnios

The uterus looks smaller than gestational age and no ballotemen.

The mother feels pain in the abdomen on every movement of the child.
Often ends with parturition prematurus.
Child heart sound was heard starting in the fifth and heard more clearly.
Maternity longer than usual.
When will his pain.
If your water breaks, even a little amniotic fluid no exit.5

2.2.7 Diagnosis and Inspection Oligohydramnios

Ultrasound scan can diagnose whether amniotic fluid too little or too much.
Generally, the doctor will measure the height of the liquid in the four quadrants in the

uterus and add them up. This method is known as Amniotic Fluid Index (AFI). If the
height of amniotic fluid is measured less than 5 cm, expectant mothers are diagnosed
with oligohydramnion. If the amount of the liquid is more than 25 cm, he was
diagnosed with polihydramnion.5,7
2.2.8 Management Oligohydramnios
Actually, the amniotic fluid will not be discharged during pregnancy is normal
and the fetus was still alive. Even the waters will still be produced, despite being
broken in days. Although partly derived from fetal pee, amniotic fluid is different
from regular urine, it smelled very typical. This is a guide for expectant mothers to
distinguish whether it's coming out of amniotic fluid or urine.1
In order to return to normal amniotic fluid volume, doctors generally
recommend that pregnant women to lead a healthy lifestyle, especially eating with
balanced nutrition. The argument that the only way to reproduce the amniotic fluid is
to multiply the portions and frequency of drinking was "misguided". It is not true that
the lack of amniotic fluid the fetus could not be born normal, so must cesarean
surgery. However, spawned by way of caesarean section is the last option in case of
deficiency of amniotic fluid. Although the membranes rupture prematurely, it remains
to be undertaken by way of induction of vaginal delivery is good and right.1
Recent studies have suggested that women with normal pregnancies but
experienced in times past oligohydramnion pregnancy may not need to undergo
special treatment, and their babies tend to be born healthy premises. However, the
woman should undergo continuous monitoring. Doctor may recommend to undergo
an ultrasound examination every week even more often to observe whether the
amount of amniotic fluid is decreasing. If indications of a reduction of the amniotic
fluid persists, doctors may recommend early delivery with the help of induction to
prevent complications during labor and birth. Approximately 40-50% of cases
oligohydramnion lasted until delivery without any treatment at all. In addition to
ultrasound, the doctor may recommend a test of the condition of the fetus, such as test
record contraction to replace the absence of fetal stress conditions, by recording the
fetal heart rate. These tests can provide important information to the doctor if the fetus
in the womb trouble. In such cases, the doctor is likely to recommend early delivery
to prevent more serious problems. The fetus is not fully developed in the womb of a

mother who suffered oligohydramnion high risk of complications during labor, such
as asphyxia (lack of oxygen), either before or after birth. Mothers with fetal
conditions such as these will be monitored closely even sometimes have to stay in
hospital.5
If a woman has oligohydramnion at moments almost birth, the doctor may
perform actions to enter normal saline through the cervix into the uterus. This method
may reduce complications during labor and birth also avoid delivery by caesarean
section. Studies show that this approach is very significant at the time of the fetal
heart rate monitor that showed the presence of difficulty. Some studies also suggest
women with oligohydramnion can help increase the amount of amniotic fluid by
drinking plenty of water. Also many doctors recommend to reduce physical activity
even do bedrest.8
2.2.9 Prognosis of Oligohydramnios

The oligohydramnios early in pregnancy, the worse the prognosis

If it occurs in the second trimester, 80-90% mortality.3

2.2.10 Oligohydramnios Influence on Fetus

Lack of amniotic fluid will certainly disrupt the life of the fetus, it can even
lead to fetal distress condition. As if the fetus grows in "cramped room" which made
him unable to move freely. Even in the extreme case where the already formed
amniotic band (yarn or fiber amnion) it is not impossible for limb disability fetus
"pinched" or "truncated" by amniotic bands.3
Other effects of the fetus is likely to have birth defects in the urinary tract,
stunted growth, even die before being born. Shortly after birth, it is strongly may no
immediate risk infants breathe spontaneously and regularly.5
Additional hazards will occur when the membranes tear and water seeps
before arriving childbirth. This condition can be risky cause infection by germs that
come from below. In the past month of pregnancy, lack of amniotic fluid is also
common for the larger body size of the fetus.9
The problems associated with too little amniotic fluid varies depending on the
age of the pregnancy. Oligohydramnion may occur during the first trimester of

pregnancy or middle age tend to have serious repercussions than if it occurs in the last
trimester of pregnancy. Too little amniotic fluid early days of pregnancy can suppress
fetal organs and cause disability, such as damage to the lungs, legs and arms.9
Olygohydramnion that occurred in mid pregnancy also raise the risk of
miscarriage, premature birth and infant mortality in the womb. If oligohydramnion
happened in the last trimester of pregnancy, it may be associated with poor fetal
growth. In times when the end of pregnancy, oligohydramnion may increase the risk
of complications of labor and delivery, including damage to the placenta decided to
channel oxygen to the fetus and cause fetal death. Women who experience
oligohydramnion more likely to experience a caesarean when her labor.9

CHAPTER III
CONCLUSION
Oligohydramnios is a condition where the amniotic fluid less than normal, which is
less than 500 cc. The mechanism or pathophysiology of oligohydramnios can be associated
with the potter syndrome and pottern phenotype, which, Potter syndrome and Pottern

phenotype is a complex situation that is associated with congenital renal failure and is
associated with oligohydramnios (amniotic fluid that bit).
Cause oligohydramnion can not be fully understood. The majority of pregnant women
who have not know exactly what causes it. Cause oligohydramnion that has been detected is
the fetal congenital defects and leaking pouches / membrane of the amniotic fluid
surrounding the fetus in the womb. Approximately 7% of infants of women who have
experienced oligohydramnion congenital defects, such as the kidney and urinary tract because
of the amount of urine produced reduced fetal.
Ultrasound scan can diagnose whether amniotic fluid too little or too much. Generally,
the doctor will measure the height of the liquid in the four quadrants in the uterus and add
them up. This method is known as Amniotic Fluid Index (AFI). If the height of amniotic fluid
is measured less than 5 cm, expectant mothers are diagnosed with oligohydramnion. If the
amount of the liquid is more than 25 cm, he was diagnosed with polihydramnion.Actually,
the amniotic fluid will not be discharged during pregnancy is normal and the fetus was still
alive. Even the waters will still be produced, despite being broken in days. Although partly
derived from fetal pee, amniotic fluid is different from regular urine, it smelled very typical.
This is a guide for expectant mothers to distinguish whether it's coming out of amniotic fluid
or urine.
In order to return to normal amniotic fluid volume, doctors generally recommend that
pregnant women to lead a healthy lifestyle, especially eating with balanced nutrition. The
earlier in pregnancy oligohydramnios, the worse the prognosis. If it occurs in the second
trimester, 80-90% mortality.Lack of amniotic fluid will certainly disrupt the life of the fetus,
it can even lead to fetal distress condition. As if the fetus grows in "cramped room" which
made him unable to move freely. Even in the extreme case where the already formed
amniotic band (yarn or fiber amnion) it is not impossible for limb disability fetus "pinched"
or "truncated" by amniotic bands.
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1. Rustam, mochtar.1998. Synopsis of Obstetrics; obstetric physiology, obstetrics pathology
edition 2. Jakarta: EGC.
2. Wikojosastro, Hanifa. 2005. Science Ingredients Matter 4th 2nd Edition. Jakarta: YBBSP.
3. Wiknjosastro Haanifa, Obstetrics, YBP-SP, Jakarta, in 2005.

4. Wiknjosastro Hanifa, National Reference books Maternal and Neonatal Health Services,
YBP-SP, Jakarta, in 2006.
5. Gilbert WM. Amniotic fluid dynamics. NeoReviews 2006; 7; e292-e299.
6. Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC, Hauth JC, KD Wenstorm. Williams
obstetrics. 22nd ed. New York. McGraw-Hill Companies, Inc; 2005.
7. Fox H. The placenta, membranes and umbilical cord. In: Chamberlain G, Steer P, editors.
Turnbull's obstetrics. 3rd ed. London: Churchill Livingstone; 2002.
8. Laughlin D, Knuppel RA. Maternal-fetal-placental unit; fetal and early neonatal
physiology. In: DeCherney AH, Nathan L. Current obstetric and gynecologic diagnosis
and treatment. 9th ed. New York: The McGraw-Hill Companies; 2003.
9. Chamberlain G, editors. Obstetrics by ten teacher. 16th ed. New York: Oxford University
Press, 1995.