AMNIOTIC FLUID

AND CORD
ABNORMALITIES

Dr.Saswati Tripathy
Professor
OBGY
The composition of amniotic fluid
 proteins (albumins & globulins),
 lipids (phospholipids, cholesterol and lecithin),
 carbohydrates (predominantly glucose),
 inorganic salts,
 cells derived from fetal epithelium, amniotic
membrane, & dermal fibroblasts.
(This latter cell type grows well in culture and
is frequently used for karyotyping).
 The perinatal mortality
rate (PMR) approaches
90% to 100% with severe
oligohydramnios in the
second trimester.
 PMR can exceed 50%
with significant
polyhydramnios in
midpregnancy .
 AMNİOTİC FLUİD FORMATİON
Fetal Urine
 The main source of AF is
fetal urination.
 Human fetal urine-
production rate appears
to be approximately 1000
to 1200 mL/day at term,
which suggests that the
entire AFV is replaced
more frequently than
every 24 hours.
 Lung Liquid
 The trachea acts as a one-way valve in most situations
preventing amniotic fluid from entering the lungs [1].
 In fetal sheep experiments, the lungs have been
reported to produce volumes of up to 400 mL/day,
with 50% being swallowed and 50% exiting via the
mouth. [2,3].
 Although we do not have direct measurements in
humans, the presence of surfactant in the AF near
term provides evidence for the outward flow of lung
liquid.

1- Dubil et al. AJUM 2013:16,2

2- Adamson TM, et al. Foetal and Neonatal Physiology. 1973Cambridge University
Press Cambridge, UK 208
3- Brace RA, et al.Am J Obstet Gynecol. 1994;171:764 
 AMNİOTİC FLUİD REMOVAL
Fetal Swallowing
 In the human, fetal swallowing begins early in
gestation and contributes to the removal of
AF.
 Human fetal swallowing was studied by
injecting radioactive chromium-labeled
erythrocytes and hypaque into the amniotic
compartment, and swallowing rates of 72 to
262 ml/kg/day were found.
Intramembranous Absorption
 This process describes the movement of water
and solutes between the amniotic compartment
and the fetal blood, which circulates through the
fetal surface of the placenta.
 Researchers have noted that 200 to 500 mL/day
leaves the amniotic compartment under normal
physiologic conditions [4,5].

4- Gilbert WM , RA Brace. Obstet Gynecol. 1989;74:748 

5- Brace RA , et al.Am J Physiol Regul Integr Comp
Physiol. 2014;307 (10):R1260-R1273 
Measurement of amniotic fluid volume
 made directly, indirectly, or estimated
sonographically.
 Direct measurement is done at the time of
cesarean or uterine hysterotomy [6].
 Indirect measurement is done via amniocentesis
by dye-dilution techniques. Dye-dilution using
para-amino hippurate has been shown to be
representative of actual AFV obtained by direct
measurement at the time of cesarean delivery [7].

6-Horsager R, et al. Obstet Gynecol 1994; 83: 955–58.

7-Magann EF, et al. J Matern Fetal Neonatal Med 2002; 11: 167–70 .
 Because these techniques to measure amniotic
fluid volume are time consuming, invasive, and
may require laboratory support, amniotic fluid
volumes are usually estimated by ultrasound.
 Magnetic resonance imaging (MRI) has also been
evaluated as a means for estimating AFV [8];
however, this is an impractical approach to
everyday screening.

8-Zaretsky MV, et al. Am J Obstet Gynecol 2004; 191: 2148–53.

 There are four methods of sonographic
evaluation of amniotic fluid volume:
 subjective assessment,
 2 x 2 measurement,
 single deepest pocket (SDP), which is also known
as maximum vertical pocket (MVP),
 amniotic fluid index (AFI).
Amniotic fluid index
 first proposed by Phelan and Rutherford
 the summation of the vertical diameter of the
largest pocket in each of the four quadrants with
the maternal umbilicus as a central reference
point [9].
 The transducer should be oriented in the
longitudinal plane and there should be a
minimum horizontal measurement of one
centimeter for each pocket.

9-Phelan JP, et al. J Reprod Med 1987; 32: 540–42.

Single deepest vertical pocket
proposed by Chamberlain
simply found by identifying the largest pocket of
amniotic fluid after a global assessment and
selecting the largest vertical measurement with a
minimum horizontal measurement of one
centimeter [10].

Two-diameter pocket (cm2) is calculated by

multiplying the depth and width of the largest
single pocket [11,12].

10-Chamberlain PF, et al. Am J Obstet Gynecol 1984; 150: 250–54.

11-Johnson JM, et al. Am J Obstet Gynecol 1986; 154: 269–73.
12-Magann EF, et al. Am J Obstet Gynecol 1992; 167: 1533–37.
Normal volume
 Ulker et al. demonstrated that detectable changes
in AFI (and fetal urine output) can occur within an
hour or so of initiation of a maneuver such as
hydration, rest, or maternal positioning[13,14].
 These findings may help explain the inconsistency
of results when tests are repeated within hours of
each other or performed by different operators.

13- Ulker K, et al. J Ultrasound Med 2011;30:481e6.

14- Ulker K, et al. J Reprod Med 2012;57:270e6.
  
OLIGOHYDRAMNIOS
 Oligohydramnios has been defined as an AFV that is
less than 200 mL or 500 mL [16].
 By ultrasound techniques, it has been estimated as;
 a SDP less than 2 cm [17],
 an AFI less than 5 cm [18],
 an AFI below the 5th percentile for gestational age
[19],
 a subjectively low AFV [20].

16-Dildy GA 3rd, et al. Am J Obstet Gynecol 1992; 167: 986–94.

17-Chamberlain PF, et al. Am J Obstet Gynecol 1984; 150: 245–49.
18-Phelan JP, et al. J Reprod Med 1987; 32: 540–42.
19-Chauhan SP, et al. Am J Obstet Gynecol 2004; 191: 661–67.Discussion 7–8.
20-Magann EF, et al. J Clin Ultrasound 1997; 25: 249–53.
 Borderline fluid
 between 5–8 cm or 5–10 cm
 been associated with fetal malformations if
diagnosed at age 24–34 weeks [20,21].

21-Petrozella LN, et al. Obstet Gynecol 2011; 117: 338–42.

22-Magann EF, et al. J Ultrasound Med 2011; 30: 523–28.
 The incidence of oligohydramnios varies
depending on which definition is used, with a
general reporting rate between 1 and 3%.
 When women undergoing antepartum testing for
high-risk pregnancy conditions are examined, the
incidence of oligohydramnios is much higher (19
to 20%).
 In clinical practice, an MVP less than 2 cm or an
AFI less than 5 cm are commonly used as criteria
for the diagnosis of oligohydramnios.
Evaluation and Treatment of Oligohydramnios
 When the diagnosis of oligohydramnios is made in
the second trimester, it is vitally important to
obtain a complete history and physical exam and
to perform a targeted ultrasound to help identify
a cause.
 Ifthere is a question of possible
rupture of the membranes
(ROM),
 Specific tests include evidence
of ferning on microscopy
examination, a neutral pH on
nitrazine paper, and pooling of
fluid in the posterior vagina.
 Commercial tests : AmniSure
(Qiagen, Hilden, Germany) and
ROM Plus (Clinical Innovations,
Murray, Utah), which check for
certain proteins from the AF in
the vagina.
 Although severe oligohydramnios has an
increased PMR later in the third trimester, it is
still not as high as earlier in pregnancy [22,23].  It
is reported a 50-fold increase in PMR when
the LVP of AF was less than 1 cm.

22- Mercer LJ, et al. Obstet Gynecol. 1986:67;840

23- Casey BM,et al. Am J Obstet Gynecol. 2000: 182;909  
Management of Oligohydramnios
 Many other studies have shown an improvement
in AFV with either oral or intravenous
administration of water and/or crystalloids [24].
 Several researchers have reported success in
improving AFV in women with oligohydramnios by
the injection of a crystalloid solution into the
amniotic compartment during an amniocentesis
[25,26].

24-
Flack NJ, et al. Am J Obstet Gynecol. 1995;173:1186-1191 
25-Doi S, et al. Obstet Gynecol. 1995;92:525 
26-
Sepulveda W, et al. Am J Obstet Gynecol.1994; 170:1160 
 Itis worth remembering that oligohydramnios
may appear idiopathic at diagnosis, but may
be a sign of an anomaly not detected until
after birth.
 Chromosomal anomalies have been found in
13% of pregnancies with oligohydramnios [27],
and late diagnosis of oligohydramnios in
pregnancies with normal anatomy has also
been found to be associated with undiagnosed
renal anomalies up to 9.8% of the time [28].

27-Stoll C, et al. Community Genet 1998; 1: 71–77.

28-Leibovitch L, et al. Acta Paediatr 2012; 101: 727–30.
Oligohydramnios in Labor
 Multiple investigators have studied
amnioinfusion as a technique by which to
treat variable decelerations in labor. 
 Although most report a decrease in the
frequency of variable decelerations, few have
demonstrated any decrease in perinatal
morbidity or mortality or in the cesarean
delivery rate [29,30,31].

Nageotte MP, et al. Obstet Gynecol.1991;77:677 

29-

Ogundipe OA, et al. Obstet Gynecol.1994; 84:544 

30-

Schrimmer DP, et al. Am J Obstet Gynecol 1991; 165:972 

31-
 POLYHYDRAMNIOS
 Polyhydramnios has been defined as an AFV of
greater than 2000 mL [37].
 By ultrasound techniques, it has been estimated as
 SDP greater than 8 cm [38],
 AFI greater than 25 cm [39],
 above the 95th percentile for gestational age [40],
 subjectively high AFV [41].

37-Magann EF, et al. Obstet Gynecol 1994; 83: 959–62.

38-Chamberlain PF, et al. Am J Obstet Gynecol 1984; 150: 245–49.
39-Baron C, et al. Am J Obstet Gynecol 1995; 173: 167–74.
40-Moore TR, et al. Am J Obstet Gynecol 1990; 162: 1168–73.
41-Magann EF, et al. J Clin Ultrasound 1997; 25: 249–53.
 The incidence of polyhydramnios is 1% to 2%. The
earlier in gestation polyhydramnios occurs and the
greater the amount of fluid, the higher the
perinatal morbidity and mortality [42].
 Hill and colleagues divided their patients with
polyhydramnios into three groups [43].  
mild (MVP 8 to 11 cm), 
moderate (MVP 12 to 15 cm),
 severe (MVP ≥16 cm).

42-Wier PE, et al. Br J Obstet Gynaecol. 86:849 197

43-Hill LM, et al. Obstet Gynecol. 69:21 1987
 Severe polyhydramnios in the second trimester
has a significant PMR due to prematurity or
aneuploidy [44,45].  
 Pregnancy complications associated with
polyhydramnios have been reported to
increase the risk for placental abruption and
postpartum hemorrhage as a result of
overdistension or rapid deflation of the uterus.

44-Pauer HU, et al. Arch Gynecol Obstet. 2003;268:52 

45-Desmedt EJ, et al. Br J Obstet Gynaecol. 1990;97:1115 
 EVALUATİON AND TREATMENT OF
POLYHYDRAMNİOS
 Management of pregnancies with
polyhydramnios, if identified early, should
include;
 sonographic evaluation for anatomical causes,
 evaluation for maternal diabetes,
 TORCH serology testing,
 consideration of isoimmunisation as a cause.
 If polyhydramnios is present with a growth
restricted fetus, evaluation for chromosomal
abnormalities should be undertaken [46].

46-Barnhard Y, et al. Am J Obstet Gynecol 1995; 173: 1523–27.

 The pregnant woman who presents with a rapidly
enlarging uterus in mid pregnancy, with or
without preterm labor, needs to be evaluated by
an ultrasound examination to measure the AFV
and assess fetal anatomy.
 When a structural defect is seen in a fetus with
polyhydramnios, consideration should be given to
performing an amniocentesis for microarray
analysis.
 Antenatal testing should be initiated at 24
weeks gestation, although there is no
consensus on what type of testing should be
begun, or at what interval [47].
 Therapeutic approaches to polyhydramnios
include amnioreduction and the use of
indomethacin, which have been studied in
randomized controlled trials.
 Comparisons of rapid versus slow drainage,
large volume versus repeated small volumes,
and the use of tocolysis during amnioreduction
have not shown significant differences.
47-O’Neill E, Thorp J. Clin Obstet Gynecol 2012; 55: 722–30.
 As amniotic fluid is removed, expansion of the
placenta drains blood from the fetus, which
can cause long-term central nervous system
and cardiac injury.
 Serial amniodrainage has been successfully
conducted in a number of cases, reducing the
impact of prematurity.
 This benefit must be weighed against the
potential risk to mother and fetus should
aggressive preterm labor or placental
abruption follow the procedure.
 With severe polyhydramnios associated with
preterm labor, one medical treatment option
involves the administration of a prostaglandin
inhibitor such as indomethacin, which
decreases fetal urine production [48,49].

48-
Stevenson KM, et al. J Dev Physiol. 1992;17:257
49-Mamopoulos M, et al. Am J Obstet Gynecol. 1990;162:1225 
Although indomethacin has been shown to be
relatively safe when given over a short period of
time, such as 72 hours, prolonged use may be
associated with risks to the fetus such as
 premature closure,
 narrowing of the ductus arteriosus within the
fetal heart,
 renal abnormalities in the newborn period
[50,51].

Kirshon B, et al. Obstet Gynecol. 1988;72:51 

50-

Mamopoulos M, et al. Am J Obstet Gynecol. 1990;162:1225 

51-
Thank you for attention