Seminar On Amniotic Fluid Disorder

Resident
Seminar on Amniotic Fluid disorder

PRESENTER:Dr.Yehualashet A(OBGYN Year II
Resident)
MODERETOR: Dr.Beshir (Assistant Professor of
Gynecology and Obstetrics)
Outline
• Objective
• Amniotic fluid physiology
• Polyhydramnious and Oligohydramnious
– Definition
– Incidence
– Cause
– Diagnosis
– Management options
• Reference
01/16/2024 Amniotic fluid disorder 2
Objective
• At the end of this seminar attendants will able

to:-
– Understand physiology of amniotic fluid.
– Define polyhydramnious and oligohydramnious
– Describe Cause, diagnosis and management of
polyhydramnious and oligohydramnious

Physiology
 Amniotic fluid origin:-

• Early pregnancy –
– As an ultrafiltrate of maternal plasma.
– Secretions from body of the embryo.
– fetal surface of the placenta.
• Beginning of the second trimester –
– It consists of extracellular fluid which diffuses
through the fetal skin
– . until keratinization occurs at 22 to 25 weeks.
…
 After 20 weeks – fetal urine
• Fetal urine production begins between 8 and 11
weeks’ gestation.
• Its primary source of amniotic fluid in the second
half of pregnancy

Composition of Amniotic Fluid
• Colourless
• Water-98-99%.
• Solids-1-2%:-
– organic solids like proteins, glucose, lipid, urea,
uric acid, creatinine and hormones like—Prolactin,
insulin and renin.
– Inorganic solids like Na, K and C.
 Specific gravity of Amniotic fluid: 1.008 to 1.010.
 Osmolality: 260 mosm/L.

functions
• It helps to protect the fetus from trauma to the

maternal abdomen.
• It cushions the umbilical cord from compression
between the fetus and uterus.
• It has antibacterial properties that provide some
protection from infection.
• It serves as a reservoir of fluid and nutrients for the
fetus.

...
• It provides the necessary fluid, space, and growth
factors to permit normal development of the fetal
lungs and musculoskeletal and gastrointestinal
systems.

Amnionic fluid volume regulation
 With advancing gestation,four pathways play a major

role in amniotic fluid volume regulation:-
• fetal urination
• Fetal swallowing
• Fetal lung fluid secreation
• Intramembranous fluid transfer across fetal vessels on
the placental surface
• Transmembraneous flow across amniotic membrane

…
All known pathways for fluid and

solute entry and exit from the
amniotic fluid in the fetus near
term.
Measurement
 Sonographic Assessment
• Amniotic fluid volume evaluation is a component of
every standard sonogram performed in the second or
third trimester.
• Using either of two semi-quantitative techniques:-
– Single deepest pocket (SDP)
– Amniotic fluid index (AFI)

…
• Using either technique, a fluid pocket must be at least
1 cm in width to be considered adequate.
• Fetal parts or loops of umbilical cord may be visible
in the pocket, but they are not included in the
measurement.
• Color Doppler is generally used to verify that
umbilical cord is not within the measurement.

Single Deepest Pocket
• This is also called the largest or maximal

vertical pocket of amnionic fluid.
• The ultrasound transducer is held perpendicular to the
floor and parallel to the long axis of the woman.
• considered normal if above 2 cm and less than 8 cm
• correspond to the 3rd and 97th percentiles

Amniotic Fluid Index
• The uterus is divided into four equal quadrants—

the right and left upper and lower quadrants,
respectively.
• The AFI is the sum of the single deepest pocket from
each quadrant.
• The intraobserver variability of the AFI approximates
1 cm, and the interobserver variability is about 2 cm.
• Variations are larger when fluid volumes are above
the normal range.

…
• Determination of whether the AFI is normal may be
based on either a static numerical threshold or a
gestational age-specific percentile reference range.
• The AFI is generally considered normal if greater
than 5 cm and below 24 .

Dye dilution curve

Amniotic Fluid Disorder
• Polyhydramnious
• Oligohydramnious

polyhydramnious
• This is an abnormally increased amniotic fluid

volume.
• Acute polyhydramnios is a sudden and rapid increase
in amniotic fluid volume.
• Chronic polyhydramnios on the other hand is a
gradually developing increase in amniotic fluid
volume.

Incidence
• It complicates 1 to 2 percent of singleton pregnancies.

• It is more frequently noted in multifetal gestations.
• Reported rates are influenced by:-
– variations in diagnostic criteria
– the population studied (low or high risk)
– the threshold used (eg, mild, moderate, or severe)
– gestational age (preterm, term, or postterm)

Degree of polyhydramnious
• Mild if the AFI is 25 to 29.9 cm.
• Moderate if 30 to 34.9 cm.
• Severe if 35 cm or more.
• Mild hydramnios is the most common, comprising
approximately two thirds of cases.
• Moderate hydramnios accounts for about 20 percent.
• Severe hydramnios for approximately 15 percent.

…
 Using the single deepest pocket of amniotic fluid
• Mild hydramnios is defined as 8 to 9.9 cm
• Moderate as 10 to 11.9 cm
• Severe hydramnios as 12 cm or more

…
• In general, severe hydramnios is far more likely to
have an underlying etiology.
• Mild hydramnios, which is frequently idiopathic and
benign.

Etiology
 Causes of hydramnios include:-

• Idiopathic is the most common
• fetal anomalies in 15 percent of cases, this are:-
 Fetal structural anomaly that impedes swallowing .
• Primary gastrointestinal obstruction
– Esophageal atresia
– Duodenal atresia
– Ileal, Jejunal atresia

…
• Secondary gastrointestinal obstruction
– Congenital diaphragmatic hernia
– Cervical or thoracic mass
• Craniofacial abnormality
– Cleft lip/palate
– Facial tumor-oropharyngeal teratoma
– micrognathia

…
• Fetal neuromuscular disorder that impedes
swallowing.
– Myotonic dystrophy
– Anencephaly
– Hydranencephaly
– Holoprosencephaly

…
• Genetic syndrome
– Trisomy 18 or 21
– Prader-willi
– Bartter
– Beckwith-wiedemann
– RASopathy(noon syndrome, cardiofaciocutaneous
syndrome, Costello syndrome, neurofibromatosis
type 1,cappilary malformation, atrioveneous
malformation

…
• High fetal cardiac output state
– Supraventricular tachycardia
– Severe anemia
– Fetal or placental mass with arteriovenous shunt
– Thyrotoxicis

…
 Maternal DM
• Account for 8-25%
• Its varies with
– Gestational A1 5.4%
– Gestational A2 13.4%
– T1dm 21.2%
– T2dm 15.3%

…
• Twin to twin transfusion syndrome
– Multiple gestation account for 10 percent of
cases.
– In monochronic oligo -poly sequence
suggest TTTS.
• Macrosomia

…
• Neoplastic etiology
– Sacrococcygeal teratoma
– Wilmis tumor
– Mesoblastoma tumor
– Placental chorioangioma

…
• Hydrops fetalis
– Immune
– Non immune

Idiopathic Polyhydramnious
• accounts for up to 70 percent of cases.

• Rarely identified during mid trimester sonography
and is often an incidental finding later in gestation.
• The gestational age at sonographic detection usually
lies between 32 and 35 weeks.

…
• It is a diagnosis of exclusion
• An underlying fetal abnormality may subsequently
become apparent with advancing gestation
particularly if the degree of hydramnios becomes
severe.
• Idiopathic hydramnios is mild in approximately 80
percent of cases, and resolution is reported in more
than a third of affected pregnancies.

…
• Mild, idiopathic hydramnios is most commonly a
benign finding.
• Associated pregnancy outcomes are usually good .

diagnosis
 History
• Sudden increase in abdominal girth
• Respiratory difficulty
• Abdominal discomfort
• Decreased perception of fetal movement
• Abdomen felt to be larger than previous deliveries for
the same gestational age

…
 Physical exam
• Increased fundal height compared to gestational age
• Difficult to palpate fetal parts
• Difficult to auscultate fetal heart tones
• Tense uterus
• Positive fluid thrill

…
 Sonography
• Maximum vertical pocket > 8 cms
• Amniotic fluid index for gestational age – compare
with nomogram for gestational age
• General assessment of amniotic fluid

Evaluate for
• Fetal anomalies
• fetal hydrops
– Measure middle cerebral artery peak systolic velocity
• Maternal serology to determine exposure to infectious
agents
• Kleihauer-Betke test
• Glucose challenge test
• Appropriate tests for hereditary anemias or metabolic
abnormalities.

…
• Amniocentesis can be undertaken for karyotype
analysis.
• Noon syndrome
• Bartter syndrome

Management
 Treatment is directed to the underlying cause

 Amnioreduction
 Criteria for Amnioreduction
– Severe shortness of breath
– Severe abdominal discomfort
– Uterine irritability
– Severe range of amniotic fluid volume

…
• If criteria fulfilled
• Perform amnioreducton
• Start corticosteroid for lung maturity per protocol
• If uterine irritability present manage as preterm labor.
– GA< 32 wks use indomethacin.
– GA>32 wks use nifedipine or beta-
sympathomimetic agent.
– GA≥34 no tocolysis

…
• If adequate resolution of symptoms:-
– manage expectantly
• If there is refractory severe symptom:-
– If<34wks repeat amnioreduction
– If≥34 wks consider possible termination

…
• Approximately 1000 of fluid is slowly withdrawn
over 20 to 30 minutes.
• Up to 5liter possible to remove per once.
• Stop when AFI normalized to 15-20cm.
• Or when intraamniotic pressure is less than 20
mmHg.

…
• Following amnioreduction, monitoring amniotic fluid
volume every one to three weeks.
• can be repeated if severe polyhydramnios recurs.
• Complications occur in 1 to 3 percent.

…
• In a review of 138 singleton pregnancies
requiring amnioreduction.
– fetal GI malformation was identified in 20
percent.
– chromosomal abnormality or genetic condition in
almost 30 percent.
– neurological abnormality in 8 percent.

Prostaglandin synthetase inhibitors
• It stimulate fetal secretion of arginine vasopressin.

• facilitate vasopressin-induced renal antidiuretic
responses, and reduced renal blood flow, thereby
reducing fetal urine flow.
• These agents also impair production or enhance
reabsorption of lung liquid.

…
• Indomethacin is started at 25 mg orally four times
daily.
• If there is no reduction in amniotic fluid volume after
two or three days, then the dose is gradually increased
up to 2 to 3 mg/kg per day.
• The drug is tapered when there is a reduction in
amniotic fluid volume, and stopped when
polyhydramnios is no longer severe.

Eligible groups
• Severe symptomatic polyhydramnios at less than 32

weeks of gestation.
• Begin with amnioreduction (to normalize fluid
volume) followed by treatment with indomethacin to
maintain normal amniotic fluid volume.

…
• The primary fetal concern with use of indomethacin
is constriction of the ductus arteriosus.
• Serial fetal echocardiographic evaluation with
Doppler is recommended at intervals of two days to
one week if the duration of therapy exceeds 48 hours.
• Sonographic signs of ductal narrowing include
tricuspid regurgitation and right ventricular
dysfunction.

Timing of delivery
• Mild to moderate polyhydramnous and Normal BPP

– At 39-40 wks.(SMFM Recommendation)
– At 39-40+6 wks. (ACOG Recommendation)
• Severe Polyhydramnous
– At 37 wks.
• If symptom intolerable and no response to
amnioreducton
– 34-37wks

Intrapartum follow up
• Fetal presentation
• Continuous fetal heart rate monitoring
• Membrane rupture
– Trans cervical amnioreduction with needle when
head engage.
– Controlled ARM In operating room.
– Do between contraction.

complication
• Maternal respiratory compromise

• Prom
• Preterm labor and birth
• Fetal malpresentation
• Umbilical cord prolapse
• Abruption
• Post partum uterine atony
• Macrosmia for shoulder dystocia

OLIGOHYDRAMNIOS
• AFV that is less than expected for gestational age.

• MVP less than 2 cm or an AFI less than 5 cm.

Incidence
• Approximately 1 to 2 percent of pregnancies.
• Its Influenced by: -
• Variations in diagnostic criteria.
• The population studied (low or high risk, screening or
indicated examination).
• The threshold used (eg, mild, moderate or severe).

…
• The gestational age at the time of examination
(preterm, term, or post term).
• More common beyond term and labor
• Complicates as many as 12% beyond 41 weeks.
• Severe oligohydramnios (0.7% of pregnancies)

Etiology
 First trimester
• The etiology of first trimester oligohydramnios is
often unclear.
• Reduced amniotic fluid prior to 10 weeks of gestation
is rare because gestational sac fluid is primarily
derived from the
– fetal surface of the placenta
– transamniotic flow from the maternal compartment
– and secretions from the surface of the body of the embryo.

…
• Criteria suggested for determining reduced amniotic
fluid at this gestational age have included
– a difference between mean gestational sac size
(MGSS) and crown-rump length of less than 5 mm
or
– a mean gestational sac diameter/crown-rump
length ratio outside the normal range for
gestational age.

…
 Second trimester
• Trisomy 13 and triploidy are the most common
chromosomal abnormalities associated with early
oligohydramnios
• fetal abnormality that precludes normal urination
• placental abnormality sufficiently severe to impair
perfusion.
• Ruptured membranes

…
 In the third trimester

• It is very often associated with
– Fetal growth restriction
– Placental abnormality
– Maternal complication such as preeclampsia or
vascular disease.
– Many cases are idiopathic

Congenital Anomalies
• By approximately 18 weeks, the fetal kidneys are the

main contributor to amniotic fluid volume.
• Selected renal abnormalities that lead to absent fetal
urine production include;-
– bilateral renal agenesis
– bilateral multicystic dysplastic kidney
– unilateral renal agenesis with contralateral
multicystic
– dysplastic kidney

…
• infantile form of autosomal recessive polycystic
kidney disease.

…
• fetal bladder outlet obstruction
– Posterior urethral valves
– urethral atresia or stenosis
– megacystis microcolon
– intestinal hypoperistalsis syndrome

Medication
• exposure to drugs that block the renin-angiotensin

system.
• These include:-
– angiotensin-converting enzyme (ACE)
inhibitors.
– angiotensin-receptor blockers
– no steroidal antiinflammatory drugs
(NSAIDs).

…
When taken in the second or third trimester, ACE
inhibitors and angiotensin-receptor blockers may
create
– fetal hypotension
– renal hypoperfusion
– and renal ischemia
– With subsequent anuric renal failure

Diagnosis
• Uterine size less than for expected for gestational age.

• SDP<2cm
• AFI≤5cm

Post diagnostic evaluation
• Check for Prom

• Detailed evaluation for fetal anomalies,
placental abnormality and fetal biometry.

Management
• No treatment has been proven to be effective long

term.
• Short term improvement of amniotic fluid volume is
possible.

…
 Amnioinfusion
 It is not considered treatment for oligohydramnios but
– To improve detection of fetal anomalies
– To facilitate cephalic version
– To prevent fetal sequelae of
oligohydramnios
 Maternal hydration
• Treatment of maternal dehydration with oral or IV
rehydration has been shown to ↑se the AFV by 30%.
…
• In a systematic review,found that amniotic fluid
volume is increased in women who have reduced or
normal AFI and who drank 2 liters of water or who
received IV hypotonic hydration.
• Isotonic IV hydration had no measurable effect.
• AFV increase by an average effect size of
– 2.01 (95% CI, 1.43-2.60) with oral hydration.
– 2.3 (95% CI, 1.36-3.24) with a hypotonic IV
solution.

Timing of delivery
• Attributable to a specific condition:-

– PE
– PROM
– Fetal growth restriction
– congenital anomaly
– post term pregnancy
– Etc.

…
• Idiopathic(Isolated) oligohydramnious
– RBPP - 36-37+6wks(ACOG)
– NRBPP -Immediate delivery

Reference
1.F Garr C,Kenneth J,Steven L.William obstetric. 25th

edition.Newyork:McGraw-Hill Education; 2018.p.590-
607.
2. Gabbe S, Jennifer R, Henry L.Normal and Problem
Pregnancies.7th edition. Elsevier;2017.p.787-793.
3.DUTTA DC.Text book of obestatrics.7th edition.New
delhi.Jaypee brothers medical publishers;2013.p.43-45.
4.Uptodate 18 edition

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Resident

Seminar on Amniotic Fluid disorder

• At the end of this seminar attendants will able

01/16/2024 Amniotic fluid disorder 3

 Amniotic fluid origin:-

01/16/2024 Amniotic fluid disorder 5

01/16/2024 Amniotic fluid disorder 6

• It helps to protect the fetus from trauma to the

01/16/2024 Amniotic fluid disorder 7

01/16/2024 Amniotic fluid disorder 8

 With advancing gestation,four pathways play a major

01/16/2024 Amniotic fluid disorder 9

All known pathways for fluid and

01/16/2024 Amniotic fluid disorder 11

01/16/2024 Amniotic fluid disorder 12

• This is also called the largest or maximal

01/16/2024 Amniotic fluid disorder 13

• The uterus is divided into four equal quadrants—

01/16/2024 Amniotic fluid disorder 14

01/16/2024 Amniotic fluid disorder 15

01/16/2024 Amniotic fluid disorder 16

01/16/2024 Amniotic fluid disorder 17

• This is an abnormally increased amniotic fluid

01/16/2024 Amniotic fluid disorder 18

• It complicates 1 to 2 percent of singleton pregnancies.

01/16/2024 Amniotic fluid disorder 19

01/16/2024 Amniotic fluid disorder 20

01/16/2024 Amniotic fluid disorder 21

01/16/2024 Amniotic fluid disorder 22

 Causes of hydramnios include:-

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• accounts for up to 70 percent of cases.

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 Treatment is directed to the underlying cause

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• It stimulate fetal secretion of arginine vasopressin.

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• Severe symptomatic polyhydramnios at less than 32

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• Mild to moderate polyhydramnous and Normal BPP

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