Assessment of Fetal Lung Maturity

Kiflome Tesfaye
Assistant Professor of Obstetrics & Gynecology
AAU CHS, SOM

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How Did We Get Here?
Prior to the now common practice of
using ultrasound to establish gestational
age and amniotic fluid studies to assess
fetal pulmonary maturation, iatrogenic
prematurity was an important clinical
problem.
Untimely or unwarranted intervention
was responsible for 15 percent of cases of
RDS.
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Available Options
Quantitation of Pulmonary Surfactant
Measurement of Surfactant Function
Evaluation of Amniotic Fluid Turbidity
Appropriate use of Ultrasonography

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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.

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Quantitation of Pulmonary Surfactant: L/S
Ratio
 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.
 Thus, the L/S ratio, like most indices of fetal pulmonary
maturation, rarely errs when predicting fetal pulmonary
maturity, but is frequently incorrect when predicting
subsequent RDS. Many neonates with an immature L/S
ratio will not develop RDS.

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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 μg/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 meconium.

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Quantitation of Pulmonary Surfactant:
TDx Test

 The TDx analyzer is an automated fluorescence

polarimeter to determine surfactant albumin ratio
 The test requires 1 ml of amniotic fluid and can be run in less
than 1 hour.
 The surfactant albumin ratio (SAR) is determined with
amniotic fluid albumin used as an internal reference.
 A ratio of 50 to 70 mg surfactant per gram of albumin is
considered mature.
 The TDx test correlates well with the L/S ratio and has
few falsely mature results, making it an excellent
screening test.

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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.

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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.

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Measurement of Surfactant Function:
Foam Stability Index
 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.

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Measurement of Surfactant Function:
Tap Test

 It is a rapid semiquantitative measurement of

surfactant function.
 In amniotic fluid from the mature fetus, the bubbles quickly
rise from the bottom layer of the amniotic fluid to the surface
and break down, while in amniotic fluid from an immature
fetus the bubbles are stable or break down slowly.
 Note that these end points are opposite those used in the FSI
or shake test.
 The cut-off for maturity is five bubbles. If no more than
five bubbles persist in the ether layer, the test is
considered mature. The test is read at 2, 5, and 10
minutes.
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Measurement of Surfactant Function:
Tap Test
 Fluid obtained from both amniocentesis or a freely flowing
vaginal pool may be used.
 Amniotic fluid contaminated by blood, meconium, or
vaginal mucus should be centrifuged before the assay is
performed.
 Fluid contaminated by blood or meconium or obtained
from the vaginal pool did not demonstrate an increased
incidence of falsely mature tests.
 The tap test may be a valuable screening test, particularly if
a phospholipid profile is not available.

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Evaluation of Amniotic Fluid Turbidity:
Visual Inspection
 During the first and second trimesters, amniotic fluid is
yellow and clear. It becomes colorless in the third trimester.
By 33 to 34 weeks' gestation, cloudiness and flocculation
are noted, and, as term approaches, vernix appears.
 Amniotic fluid with obvious vernix or fluid so turbid will
usually have a mature L/S ratio.

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Evaluation of Amniotic Fluid Turbidity:
Lamellar Body Counts

 Lamellar bodies are the storage form of surfactant. The

test requires <1 ml of amniotic fluid and takes 15
minutes to perform.
 A lamellar body count >30,000/μl is highly predictive
of pulmonary maturity, while a count <10,000/μl
suggests a risk for RDS.
 Neither meconium nor lysed blood has an effect on the
lamellar body count.

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Appropriate use of ultrasound
 Grade 3 placenta in an uncomplicated pregnancy at
term suggests fetal pulmonary maturation. This
approach is not reliable in pregnancies complicated by
hypertension, DM, IUGR, and Rh isoimmunization
 BPD of at least 9.2 cm will reliably predict the absence
of RDS in uncomplicated pregnancies. This approach
should not be used for patients with DM.
 The most appropriate use of ultrasound in predicting
fetal lung maturity is early documentation of
gestational age so that elective delivery later in
pregnancy can be safely undertaken.
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Recommendation
An accurate assessment of gestational age and fetal
maturity is essential
 before an elective induction of labor or cesarean delivery
 before the delivery of a patient whose fetus may not have
matured normally such as a growth-restricted fetus or
the fetus of a poorly controlled diabetic mother.

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