amniotic fluid disorders
TRANSCRIPT
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DR.OKECHUKWU A.UGWULAGOS UNIVERSITY TEACHING
HOSPITAL
DISORDERS OF AMNIOTIC FLUID
VOLUME
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Outline
Origin physical features Components Functions of A.F Clinical Relevance Oligo/Poly-Hydramnios Definition Etiology Diagnosis Treatment Complications
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ORIGIN
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Origin contd
First & early second trimester : Amount is 5-50 ml & arises from:- ultra filtrate of Maternal plasma through the
vascularized uterine decidua
- Transudation of fetal plasma through the fetal skin & umbilical cord (up to 20 weeks' gestation).
* It is iso-osmolar with fetal & maternal plasma,
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Amniotic Fluid circulation
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Circulation AMNIOTIC FLUID VLOUME
10 weeks – 30mls20 weeks- 300mls30 weeks- 600mls38weeks- 1L40weeks- 800mls42weeks- 200-
350mls
CONTD
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Physical features
Alkaline- 7.2Low specific gravity – 1.0069 – 1.008. Hypotonic to maternal serum at termOsmolarity – 250 OsmolColour – in early pregnancy colourless - at term it become pale straw
colored
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Physical features-contd
Appearance SignificanceColorless with slight to
moderate turbidityNormal
Dark/Blood- streaked Traumatic tap, abdominal trauma, concealed
accidental haemorrhageYellow/Golden HDN/Rhesus
Incompatibilitydark- green Meconium
Dark red/ brown Fetal Death/IUDGreenish yellow post maturity
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Composition
98% water, 2% solid substances a)Organic
b) Non organic
c) Suspended particles
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Functions of A.F
During pregnancyCushions the fetus from physical traumaProvides a barrier against infectionPermits proper lung developmentThermoregulationAllow room for fetal growth, movement and development
During labor The bag of fore water allows regular dilatation of the cervix. After rupture of membrane the amniotic fluid serves as a lubricant
for fetus descent. Also the amniotic fluid is bacteriostatic
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Clinical importance
Screening for fetal malformation.
Assessment of fetal well-being Assessment of fetal lung maturity
Diagnosis and follow up of labor. Detection of congenital fetal infection
Determination of fetal age
Diagnosis of PROM. Cytogenetic analysis
Detection of fetal distress
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chemical tests performed on amniotic fluid
Bilirubin scan 0.025 mg/dl Hemolytic disease of the newborn
L/S ratio 2.0 Fetal lung maturity
Phosphatidyl- Present Fetal lung maturity
Glycerol
Creatinine 1.3 – 4.0 mg/dl Fetal age
Alpha fetal protein 4.0 mg/dl Neural tube
disorders
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POLYHYDRAMINOS
Defined as excessive amount of amniotic fluid of 2000 ml or more
AFI of > 25cm
or the deepest vertical pool of > 8 cm
95th or 97.5th percentile of GA.
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Polyhydraminos- contd
Incidence of 0.5 -1%
50-60% are idiopathic 10-20% of the neonates are born with a congenital anomaly
Gastrointestinal system -40%
central nervous system -26%
cardiovascular system 22%
genitourinary system 13%
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Measurement of Amniotic Fluid Volume
AFI
Single deepest pocket method
Two diameter fluid pocket
Several factors may modulate AFI -increase with high altitude - Maternal hydration increases AFI - fluid restriction or dehydration decrease
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AFI
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AFI Deep vertical pocket
6-8 borderline AFI
8-25normal
>25 polyhydramnios
1. Mild hydramnios (80%):
8 to 11 cm.2. moderate hydramnios
(15%):
12 to 15 cm.
3. Severe hydramnios (5%)
16 cm or more
Polyhydraminos- contd
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DVP
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AETIOLOGY OF POLYHYDRAMNIOS
Idiopathic (50-60 %)
MATERNALDiabetesSubstance abuseRhesus isoimmunisation
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Fetal causes
Anencephaly Oesophageal atresia
Duodenal atresia
Multifetal gestation /TTTS
Fetal hydrops/Rhesus Fetal akinesia syndrome
Fetal infection
Fetal pseudohypoaldosteronism
Fetal Barter or Hyperprostaglandin E synd
Fetal Nephrogenic Diabetes insipidus
Fetal saccrococcygeal teratoma
Placental haemangiomas
AETIOLOGY OF POLYHYDRAMNIOS- 2
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Types of Polyhydraminos
Acute Polyhydraminos: 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 Polyhydraminos:
Is gradual in onset
Usually from 30 weeks of pregnancy
Is the most common type
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Mgt 1- History
Clinical featuresSymptomatic/ asymptomatic:
dyspnea.
edema.
abdominal distention
Abdominal girth increase rapidly in acute Polyhydraminos
Oliguria from ureteric obstruction
preterm labour
Heart burn/Indigestion
Varicose vein
Mirror syndrome
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Mgt 2- Physical ExaminationAbdominal examination: Obvious superficial blood vessels
Globular
abdominal skin appears stretched and shiny
marked striae gravidarum
Uterus is tense
↑SFH
difficult to palpate fetal parts.
Fluid thrill difficult to hear fetal heart sound
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Mgt 3- Investigation
Full blood count
TORCH screening
FBS/OGTT
SEUCR+ uric acid
Abd X-ray- historic importance
Placenta Biopsy
Assess fatal wellbeing (U/S/CTG/Doppler/BPP - excessive amniotic fluid. - fetal abnormalities
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Management 4
The cause of the condition should be determined if possible.
Management depends on:1. Condition of the fetus and the mother2. The cause and degree of Polyhydraminos3. Stage of pregnancy 4. Fetus Compatible with Extra uterine life
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Mgt 5
Mgt of Symptomatic Polyhydraminos
Schedule weekly or twice weekly perinatal visits –depending on GA/severity
Hospital admission- dyspnea, abdominal pain or difficult ambulation. serial ultrasonography
Antacids to relive heart burn
Reductive Amniocentesis- serially
Induction of labour if worsening- cord prolapse, abruptio Delivery should be hospital
Role of Indomethacin
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Mgt 6- Indomethacin
Impairs fetal lung liquid productionEnhances absorptionIncreases fluid movement across fetal membranesReduce fetal urinary production
premature closure of the fetal ductus arteriosusPeriventricular Leucomalacia not used after 35 weeks
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Mgt 7
Treat underlying cause
Fetal anemia: Fetal transfusion
TTTS- Laser ablation of placental vessels
Diabetes: control blood sugar
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Complications of Polyhydraminos contd
Fetal 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
Maternal morbidity and mortality
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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% pregnancies -8.2% of antenatal patients(50% post-term) -37.8% of patients in labor(50% ROM)
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Oligohydraminos Normal
Oligohydramnios contd
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AETIOLOGY
FETAL •PROM (50%) •CHROMOSOMAL ANOMALIES •CONGENITAL ANOMALIES – porter's
syndrome •IUGR •IUFD •POSTTERM PREGNANCY
PLACENTAL •CHRONIC ABRUPTION •TTTS
IDIOPATHIC
MATERNAL – Placental insufficiency
•PREECLAMPSIA •CHRONIC HT Diabetes
DRUGS •PG SYNTHETASE INHIBITORS •ACE INHIBITORS
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Potter’s Syndrome
Pulmonary hypoplasiaOligohydrominiosTwisted skin (wrinkly
skin)Twisted face (Potter
facies)Extremities defectsRenal agenesis
(bilateral)
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PUV
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SYMPTOMS
NO SPECIFIC
SYMPTOMS
H/O leaking p/v Post term
CHT/preclampsiaDrugs
Less fetal movements
SIGNS Uterus – small for date
Malpresentation
IUGR
FHR normal/nonreassuring
Small columns by ultrasound
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Management 1
MANAGEMENT DEPENDS UPON AETIOLOGY
GESTATIONAL AGE
SEVERITY
FETAL STATUS & WELL BEING- fetus surviving extra uterine life
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Management 2
DETERMINE AETIOLOGY R/O PROM
TARGETED USG FOR ANOMALIES
R/O IUGR ,IUFD when suspected
Amniocentesis if chromosomal anomalies suspected – early symmetric IUGR
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Mgt 3- Investigations
instillation of indigo carmine may be used to evaluate for PROM
Amniosure- PROM
Nitrazine yellow paper/litmus paper
Ultrasound scanFBC/FBS/OGTT
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TREATMENT
ADEQUATE REST – decreases dehydration
HYDRATION – Oral/IV Hypotonic fluids(2 Lit/d)
Amino infusion by normal saline (helpful during labour, prior to ECV, USG
•SERIAL USG – Monitor growth, AFI,BPP
INDUCTION OF LABOUR/ LSCS
Lung maturity attained Lethal malformation Fetal jeopardy Sev IUGR Severe oligo
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Treatment- contd
DIRECTED TO CAUSE •Drug induced – OMIT DRUG •PROM – •PPROM – Antibiotics, steroid – Induction •FETAL SURGERY
VESICO AMNIOTIC SHUNT-PUV Laser photocoagulation for TTTS
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•AMNIOINFUSION
Reasonable approach in the treatment of repetitive variable decelerations
Decreases incidence of - meconium
aspiration syndrome - Neonatal
Acidemia -cord compression
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FETAL MATERNAL
Abortion
Prematurity
IUFD
Deformities –contractures
Potters syndrome
pulmonary hypoplasia
Malpresentations
Fetal distress
Low APGAR
Increased morbidity Prolonged labour:
uterine inertia
Increased operative intervention
COMPLICATIONS
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Pregnancy Outcome in Oligohydramnios
The mortality and morbidity rate in Oligohydramnios is high
Pulmonary hypoplasia
IUGR
Meconium aspiration
Non reassuring Fetal heart rate
Poor tolerance of labor
Stillbirth
Fetal malformation
Fetal acidosis
Neonatal death
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Pulmonary Hypoplasia and Oligohydramnios
thoracic compression may prevent chest wall excursion and lung expansion
lack of fetal breathing movement decreases lung inflow
a failure to retain intrapulmonary amniotic fluid or an increased outflow with impaired lung growth and development
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Conclusion
Amni0tic fluid evaluation allows assessment of the fetal intrauterine environment
Potentially invaluable information
Requires close follow-up and evaluation
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END