MY NOTES

AMNIOTIC FLUID

• The amniotic fluid is that clear, yellowish fluid surrounding the developing foetus
during pregnancy found within the amniotic sac, the mother's womb.

• It serves several roles during pregnancy. Viz-a-vis -

• It creates a physical space for foetal movement, which is necessary for normal
musculoskeletal development.

• It permits foetal swallowing—essential for gastrointestinal tract development, and

foetal breathing—necessary for lung development.

• It guards against umbilical cord compression and acts as a cushion that protects the
foetus from trauma.

• It also has bacteriostatic properties.

• Amnionic fluid volume abnormalities/ extremes may reflect a problem with fluid
production or its circulation, such as when there is an underlying foetal or placental
pathology.

• These volume extremes may be associated with increased risks for adverse pregnancy
outcome.

• Origin: The following are involved in the production of the amniotic fluid:

• 1- Amniotic membrane

• 2- Maternal tissue or interstitial fluid, by diffusion across the amnio-chorionic

membrane from the decidua parietalis.

• 3- Filtrated from maternal blood.

• 4- Foetal respiratory tract fluid production (300 – 400 ml daily) which enters the
amniotic cavity.

• 5-Fetal urine production.

DEVELOPMENT OF THE AMNIOTIC FLUID SPACE

1
 MY NOTES

Along with the changes in the trophoblast, on the

8th day, the embryoblast differentiates into a
bilaminar germ disc which consists of a dorsal
ectodermal layer of tall columnar cells and a
ventral endodermal layer of flattened polyhedral
cells.

The bilaminar germ disc is connected to the

trophoblast by mesenchymal condensation,
called connecting stalk or body stalk which later forms the umbilical cord.

• Two cavities appear, one on each side of the germ disc.

• (1) On 12th postovulatory day, a fluid filled space appears between the ectodermal
layer and the cytotrophoblast which is called amniotic cavity.

• Its floor is formed by the ectoderm and the rest of its wall by primitive mesenchyme.

• (2) The yolk sac appears on the ventral aspect of the bilaminar disk and is lined
externally by the primitive mesenchyme and internally by the migrating endodermal
cells from the endodermal layer of the germ disc

• Amniogenic cells line the inner surface of

trophoblast.

• Derived from foetal ectoderm of the

embryonic disc.

• Fluid accumulates slowly at first, but ultimately

the fluid-filled cavity becomes large enough to
obliterate the chorionic cavity; the amnion and the
chorion come in loose contact by their mesenchymal layers.

• Initially, the cavity is located on the dorsal surface of the embryonic disk. With the
formation of the head, tail, and lateral folds, it comes to surround the foetus.

• Its two growing margins finally merge into the body stalk.

2
 MY NOTES

• Hence, the liquor amnii surrounds the foetus everywhere except at its
attachment with the body stalk.

• The amnion is firmly attached to the umbilical cord up to its point of insertion to the
placenta, but everywhere it can be separated from the underlying chorion.

Physiology of amniotic fluid

• The maintenance of amniotic fluid is a dynamic process throughout pregnancy, with

differing origins for the amniotic fluid at advancing gestational age.

• Early in pregnancy, the amnionic cavity is filled with fluid that is similar in
composition to extracellular fluid.

• During the first half of pregnancy, transfer of water and other small molecules
takes place across the amnion—trans-membranous flow, across the foetal vessels
on placental surface—intra-membranous flow, and across foetal skin.

• Foetal urine production begins between 8 and 11 weeks, but it does not become a
major component of amnionic fluid until the second trimester.

• This latter observation explains why foetuses with lethal renal abnormalities, may not
manifest severe oligohydramnios, until after 18 weeks.

• Water transport across the foetal skin continues until keratinization occurs at 22 to 25
weeks.

• This explains why extremely preterm infants can experience significant fluid loss
across their skin.

• With advancing gestation, four pathways play a major role in amnionic fluid volume
regulation.

• First, foetal urination is the primary amnionic fluid source by the second half of
pregnancy.

• By term, foetal urine production may exceed 1 liter per day—such that the entire
amnionic fluid volume is recirculated on a daily basis.

• Foetal urine osmolality is significantly hypotonic to that of maternal and foetal plasma
and similar to that of amnionic fluid.

3
 MY NOTES

• Specifically, the osmolality of maternal and foetal plasma is approximately 280

mOsm/mL, whereas that of amnionic fluid is about 260 mOsm/L.

• This hypotonicity of foetal urine—and thus of amnionic fluid— accounts for

significant intramembranous fluid transfer across and into foetal vessels on the
placental surface, and thus into the foetus.

• This transfer reaches 400 mL per day and is a second regulator of fluid volume
(Mann, 1996).

• In the setting of maternal dehydration, the resultant increase in maternal osmolality

favours fluid transfer from the foetus to the mother, and then from the amnionic fluid
compartment into the foetus.

• An important third source of amnionic fluid regulation is the respiratory tract.

• Approximately 350 mL of lung fluid is produced daily late in gestation, and half of
this is immediately swallowed.

• Last, foetal swallowing is the primary mechanism for amnionic fluid resorption and
averages 500 to 1000 mL per day (Mann, 1996).

• Impaired swallowing, secondary to either a central nervous system abnormality or

gastrointestinal tract obstruction, can result in an impressive degree of hydramnios.

• The other pathways—trans-membranous flow and flow across the foetal skin—
account for a far smaller proportion of fluid transport in the second half of pregnancy.

AMNIOTIC FLUID VOLUME

• 10 weeks – 30mls

• 20 weeks- 300mls

• 28-38 weeks- 1000mls

• 40weeks- 800mls

• 42weeks- 200-350ml

Physical features

• Alkaline- 7-7.5

4
 MY NOTES

• Low specific gravity – 1.0069 – 1.008.

• Hypotonic to maternal serum at term

• Osmolarity – 250 Osmol

• Colour – in early pregnancy colourless - at term it become pale straw colored

Appearance Significance

Colourless with slight to moderate Normal

turbidity

Dark/Blood- streaked Traumatic tap, abdominal trauma,

concealed accidental haemorrhage

Yellow/Golden HDN/Rhesus Incompatibility

dark- green Meconium

Dark red/ brown Foetal Death/IUD

Greenish yellow post maturity

• 98% water, 2% solid substances

• a) Organic.

• b) Non-organic.

• c) Suspended particles

Functions

• During pregnancy

• Cushions the foetus from physical trauma.

• Provides a barrier against infection.

5
 MY NOTES

• Permits proper lung development.

• Thermoregulation

• Allow room for foetal growth, movement, and development.

• During labour

• The bag of fore water allows regular dilatation of the cervix.

• After rupture of membrane the amniotic fluid serves as a lubricant for foetus descent.

• Also, the amniotic fluid is bacteriostatic.

Clinical Relevance

• Screening for foetal malformation.

• Assessment of foetal well-being

• Assessment of foetal lung maturity

• Diagnosis and follow up of labour.

• Detection of congenital foetal infection.

• Determination of foetal age

• Diagnosis of PROM.

• Cytogenetic analysis

• Detection of foetal distress

Bilirubin scan 0.025 mg/dl Haemolytic disease of the newborn

L/S ratio 2.0 Foetal lung maturity

Phosphatidyl-Glycerol Present Foetal lung maturity

Creatinine 1.3 – 4.0 mg/dl Foetal age

Alpha foetal protein 4.0 mg/dl Neural tube disorders

6
 MY NOTES

Amniotic fluid volume assessment

• Clinical assessment is unreliable.

• Objective assessment depends on U/S to measure:

• Deepest vertical pool (DVP). -

• Amniotic fluid index (AFI). It is a total of the DVPs in each four quadrants of
the uterus. it is a more sensitive indicator of AFV throughout pregnancy.

• Normal range is 6 to 24 cm.

• Several factors may modulate AFI.

• increase with high altitude.

• Maternal hydration increases AFI.

• Fluid restriction or dehydration decrease

• 6-8 borderline AFI.

• 8-25 normal

• >25 polyhydramnios

Single deepest pocket

• Normal range is 2-8 cm.

• 1. Mild hydramnios (80%): 8 to 11 cm.

• 2. moderate hydramnios (15%): 12 to 15 cm.

• 3. Severe hydramnios (5%) 16 cm or more

Amniotic fluid abnormalities

• Oligohydramnios:

• Defined as reduced amniotic fluid i.e., amniotic fluid index of 5 cm or less or the
deepest vertical pool < 2 cm.

• Polyhydramnios:

• Defined as excessive amount of amniotic fluid of 2000 ml or more.

7
 MY NOTES

• AFI of > 25 cm or the deepest vertical

pool of > 8 cm, or more

POLYHYDRAMNIOS

AETIOLOGY:

• Idiopathic

• Foetal Anomalies (Oesophageal atresia,

Duodenal atresia)

• Diabetes

• Multifetal gestation / TTTS

• Immune/Non-immune hydrops (Foetal hydrops/Rhesus, Foetal akinesia syndrome)

• Foetal infection

• Placental haemangiomas

• Foetal pseudo hypoaldosteronism

• Foetal Barter or Hyper prostaglandin E syndrome.

• Foetal Nephrogenic Diabetes insipidus

• Foetal sacrococcygeal teratoma

Acute Polyhydramnios:

• Is very rare.

• Usually occurs at about 16- 20 weeks.

• sudden onset - 3 – 4 days

• associated with monozygotic twins.

• Ends with spontaneous abortion most of the time before 28 weeks.

• Severe abdominal pain is common symptom.

Chronic Polyhydramnios:

• Is gradual in onset.

8
 MY NOTES

• Usually from 30 weeks of pregnancy

• Is the most common type.

Clinical features Symptomatic/ asymptomatic:

• dyspnoea.

• oedema.

• abdominal distention

• Abdominal girth increases rapidly in acute Polyhydramnios.

• Oliguria from ureteric obstruction

• preterm labour

• Heart burn/Indigestion

• Varicose vein

• Mirror syndrome

Abdominal examination:

• Obvious superficial blood vessels

• Globular

• abdominal skin appears stretched and shiny.

• marked striae gravidarum.

• Uterus is tense.

• ↑SFH

• difficult to palpate foetal parts.

• Fluid thrill

• difficult to hear foetal heart sounds.

• Investigations

• Full blood count

9
 MY NOTES

• TORCH screening

• FBS/OGTT.

• Serum EUCr + uric acid

• Abd X-ray- historic importance

• Placenta Biopsy

• Assess fatal wellbeing (U/S/CTG/Doppler/BPP,

• - excessive amniotic fluid. - foetal abnormalities

• Management

• The cause of the condition should be determined if possible.

• Management depends on:

• 1. Condition of the foetus and the mother

• 2. The cause and degree of Polyhydramnios

• 3. Stage of pregnancy

• 4. Foetus Compatible with Extra uterine life

• Mgt of Symptomatic Polyhydramnios

• Schedule weekly or twice weekly perinatal visits –depending on GA/severity.

• Hospital admission-dyspnoea, abdominal pain or difficult ambulation.

• serial ultrasonography

• Antacids to relive heart burn.

• Reductive Amniocentesis-serially

• Induction of labour if worsening-cord prolapse, abruptio-placenta.

• Delivery should be in hospital.

• Role of Indomethacin

• Indomethacin

10
 MY NOTES

• Impairs foetal lung liquid production.

• Enhances absorption.

• Increases fluid movement across foetal membranes.

• Reduce foetal urinary production.

• premature closure of the foetal ductus arteriosus

• Periventricular Leukomalacia

• not used after 35 weeks

• Treat underlying cause

• Foetal anaemia: Foetal transfusion

• TTTS- Laser ablation of placental vessels

• Diabetes: control blood sugar

• Complications

• Foetal

• Unstable lie

• Malpresentation

• Cord presentation and cord prolapse.

• PROM

• Placental abruption

• Premature labour

• High perinatal mortality rate

• Maternal

• ureteric obstruction

• PPH

• Low threshold for C/S

11
 MY NOTES

• Maternal morbidity and mortality

OLIGOHYDRAMNIOS

• Abnormally small amount of amniotic

fluid which is less than 300 – 500 ml at
term.

• Less than 5th centile for GA

• INCIDENCE: 8.2-37.8% of pregnancies

• 8.2% of antenatal patients (50% post-term)

• 37.8% of patients in labour (50% ROM)

AETIOLOGY

• FOETAL

• PROM (50%)

• CHROMOSOMAL ANOMALIES

• CONGENITAL ANOMALIES

• IUGR

• IUFD

• POST TERM PREGNANCY

• MATERNAL

• PREECLAMPSIA

• CHRONIC HT

• PLACENTAL

• CHRONIC ABRUPTION

• TTTS

• CVS

• DRUGS

12
 MY NOTES

• PG SYNTHETASE INHIBITORS

• ACE INHIBITORS

• IDIOPATHIC

• Postdate

• Foetal Anomalies:

• obstruction of foetal

• urinary tract/renal agenesis

• IUGR

• ROM

• Twin/Twin transfusion

• Exposure to ACE inhibitors, and

• Non-steroidal anti-inflammatory

• DIAGNOSIS:

• SYMPTOMS:

• NO SPECIFIC SYMPTOMS

• H/O leaking p/v

• Post term

• s/o preeclampsia

• Drugs

• Less foetal movements

• DIAGNOSIS:

• SIGNS

• Uterus – small for date

• Malpresentations

13
 MY NOTES

• IUGR

• METHODS

• DVP: <2 cm, <5 cm

• AFI: (<1 severe), (6-8 borderline)

• 2D pocket <15 sq cm

• MANAGEMENT DEPENDS UPON

• AETIOLOGY

• GESTATIONAL AGE

• SEVERITY

• FOETAL STATUS & WELL BEING- foetus surviving extra uterine life.

• DETERMINE AETIOLOGY

• R/O PROM

• TARGETED USG FOR ANOMALIES

• R/O IUGR, IUFD when suspected.

• Amniocentesis if chromosomal anomalies suspected – early symmetric IUGR.

• Investigations:

• instillation of indigo carmine may be used to evaluate for PROM.

• Amnisure- PROM

• Nitrazine yellow paper/litmus paper

• Ultrasound scan

• FBC/FBS/OGT

• ADEQUATE REST – decreases dehydration.

• HYDRATION – Oral/IV Hypotonic fluids (2 Lit/d)

• Amino infusion by normal saline (helpful during labour, prior to ECV, USG

14
 MY NOTES

• SERIAL USG – Monitor growth, AFI, BPP

• INDUCTION OF LABOUR/ LSCS.

• Lung maturity attained Lethal malformation Foetal jeopardy Severe IUGR, Severe
oligohydramnios.

• DIRECTED AT CAUSE

• Drug induced – OMIT DRUG

• PROM –Induction

• PPROM – Antibiotics, steroid – Induction

• FOETAL SURGERY

• VESICO AMNIOTIC SHUNT-PUV (posterior urethral valve)

• Laser photocoagulation for TTTS

• AMNIOINFUSION

• Reasonable approach in the treatment of repetitive variable decelerations

• Decreases incidence of

• meconium aspiration syndrome

• Neonatal Acidemia

• cord compression

• COMPLICATIONS

• FOETAL:

• Abortion

• Prematurity

• IUFD

• Deformities

• contractures

• Potters’ syndrome

15
 MY NOTES

• pulmonary hypoplasia

• Malpresentations

• Foetal distress and Low APGAR

Potters’ syndrome

• Pulmonary hypoplasia

• Oligohydramnios

• Twisted skin (wrinkly skin)

• Twisted face (Potter facies)

• Extremities defects

• Renal agenesis (bilateral)

• MATERNAL
16
 MY NOTES

• Increased morbidity

• Prolonged labour: uterine inertia

• Increased operative intervention (malformations, distress)

• The mortality and morbidity rate in Oligohydramnios is high.

• Pulmonary hypoplasia

• IUGR

• Meconium aspiration

• Non reassuring Foetal heart rate

• Poor tolerance of labour

• Stillbirth

• Foetal malformation

• Foetal acidosis

• Neonatal death

17