amniotic fluid disorder prof.salah
TRANSCRIPT
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Learning Objectives
• Character of A.F
• Functions of A.F
• Oligo-Poly-Hydramnios
Definition
Etiology
Diagnosis
Treatment
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The Fetal Membranes
Definition:
Fetal membranes are all the structures that develop from the
zygote and do not share in the formation of the embryo (extraembryonic structures from the primitive blastomeres).
Fetal membranes are:
a. Chorion.
b. Amnion.
c. Yolk sac.
d. The umbilical cord including allantois and body stalk.
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Amnion & Amniotic cavity
- It is a membrane which bounds the amniotic
cavity.
- It is continuous with the ectoderm of the embryo.
- It contains about 800-1000 ml of watery and clear
fluid at full term.
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Amniotic Fluid The amniotic fluid is that fluid surrounding the developing fetus
that is found within the amniotic sac contained in the mother's womb.
• Physical characteristics ;
- It is clear pale yellow fluid. - pH of is around 7.2. - Specific gravity of 1.0069 – 1.008. -
-
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Composition of amniotic fluid
- 98% water, 2% solid substances like inorganic & organic salts, fetal epithelium, protein & enzymes.
Origin: The following forms the amniotic fluid:
1- Amniotic membrane
2- Maternal tissue (interstitial) fluid by diffusion across the amnio-chorionic membrane from the deciduas parietalis.
3- Filtrated from maternal blood.
4- Fluid is also secreted by the fetal respiratory tract (300 – 400 ml daily) and enters the amniotic cavity.
5-Fetal urine.
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Circulation
- The amniotic fluid, formed by amniotic membrane & filtrated from maternal blood accumulates in the amniotic cavity,
- Then, it is swallowed by the embryo.
- Lastly, it passes as fetal urine to accumulate again in the amniotic cavity.
Volume of the amniotic fluid: The volume of amniotic fluid increases slowly
from 30 ml at 10 weeks gestation to 350 ml at 20 weeks to 700 – 1000 ml by 37 weeks.
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NORMAL AMNIOTIC FLUID VOLUME
Weeks Gestation
Fetus Amniotic Fluid Placenta (g) (ml) (g)
16 28 36 40
100 200 100 1000 1000 200 2500 900 400 3300 800 500
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Function
Before labour: 1-It forms an isolating bag around the embryo protecting him
from external trauma, shock & temperature.
2-It prevents adhesion of the embryo to its membranes.
3-It allows homogenous media needed for the growth of the embryo.
4-It permits the free movement of the embryo needed for muscular exercise.
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Function
During labor:
1- It forms the bags of fore water and hind water.
2-The bag of fore water allows regular dilatation of the cervix.
3-After rupture of membrane the amniotic fluid serves as a lubricant for fetus descent.
4-Also the amniotic fluid is bacteriostatic.
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Clinical importance of AF:
• Screening for fetal malformation (serum α-fetoprotien).
• Assessment of fetal well-being (amniotic fluid index).
• Assessment of fetal lung maturity (L/S ratio).
• Diagnosis and follow up of labor.
• Diagnosis of PROM (ferning test).
• Diagnosis of fetal chromosomal abnormalities ( Down
syndrome, Edward syndrome, and others), and for DNA studies for diagnosis of some single gene disorders.
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Summary of the routine chemical tests performed on
amniotic fluid
• Tests for the Well-being and Maturity • __________________________________________________________ • Test Normal values at term Significance • __________________________________________________________ • 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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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.
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AFI
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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
AFI of > 25 cm
or the deepest vertical pool of > 8 cm) .
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ETIOLOGY OF POLYHYDRAMNIOS
• Idiopathic
• Fetal Anomalies
• Diabetes
• Multifetal gestation
• Immune/Non-immune hydrops
• Fetal infection
• Placental haemangiomas
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Etiology of Polyhydramnios: Fetal Anomalies
• Problems with swallowing and GI absorption
• Increased transudation of fluid:
anencephaly, spina bifida
• Increased urination: anencephaly (lack of ADH, stimulation of urination centers)
• Decreased inspiration
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SYMPTOMS
• Dyspnea
• Abdominal pain
• Contractions preterm labor
• Decreased Perception of Fetal
Movements
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diagnosis of polyhydramnios
• Symptoms:
- dyspnea.
- edema.
- abdominal distention
- preterm labour.
• Abdominal examination:
- ↑uterus than expected.
- difficult to palpate fetal parts.
- difficult to hear fetal heart sound.
- ballotable fetus.
• Ultrasound:
- excessive amniotic fluid.
- fetal abnormalities.
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(fetus)?
• Fetal prognosis worsens with more severe hydramnios and congenital anomalies
• 15-20% fetal malformations
• Preterm delivery
• Suspect diabetes
• Prolapse of cord
• Abruption
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(Mother)?
• Placental abruption
• Uterine dysfunction
• Post-partum hemorrhage
• Abnormal presentation -- C/S
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TREATMENT
• Mild to Moderate hydramnios: rarely requires treatment
• Hospitalization, bed rest
• Amniocentesis: to relieve maternal distress and to test for
fetal lung maturity. Complications: ruptured membrane, chorioamnionitis, placental abruption, preterm labour
• Non-steroidal anti-inflammatory analgesia
• Blood sugar control
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management
• Indomethacin therapy: .
- impairs lung liquid production/enhances absorption.
- ↓fluid movement across fetal membranes.
* complications: premature closure of ductus arteriosus, impairment of renal function, and cerebral vasoconstriction. So not used after 34 weeks
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OLIGOHYDRAMNIOS
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AETIOLOGY FETAL • PROM (50%)
• CHROMOSOMAL ANOMALIES
• CONGENITAL ANOMALIES
• IUGR
• IUFD
• POSTTERM PREGNANCY
MATERNAL • PREECLAMPSIA
• CHRONIC HT
PLACENTAL • CHRONIC ABRUPTION
• TTTS
• CVS
DRUGS • PG SYNTHETASE
INHIBITORS
• ACE INHIBITORS
IDIOPATHIC
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ETIOLOGY
• Postdate
• Fetal Anomalies: obstruction of fetal
urinary tract/renal agenesis
• IUGR
• ROM
• Twin/Twin transfusion
• Exposure to ACE inhibitors, and
• Non-steroidal anti-inflammatory
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DIAGNOSIS
SYMPTOMS NO SPECIFIC
SYMPTOMS H/O leaking p/v Postterm s/o preeclampsia Drugs Less fetal movements
SIGNS Uterus – small for
date Malpresentations IUGR
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USG
METHODS
DVP <2 cms
(<1 severe)
AFI <5 cms
(5-8 borderline)
2D pocket <15 sq cms
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COMPLICATIONS
FETAL Abortion
Prematurity
IUFD
Deformities –contractures
Potters syndrome
pulmonary hypoplasia
Malpresentations
Fetal distress
Low APGAR
MATERNAL
Increased morbidity
Prolonged labour: uterine inertia
Increased operative intervention
(malformations,
distres)
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MANAGEMENT
DEPENDS UPON
• AETIOLOGY
• GESTATIONAL AGE
• SEVERITY
• FETAL STATUS & WELL BEING
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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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TREATMENT • ADEQUATE REST – decreases dehydration • HYDRATION – Oral/IV Hypotonic fluids(2 Lit/d) temperory increase 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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• AMNIOINFUSION Decreases cord
compression Dilutes meconium
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TREATMENT ACC. TO CAUSE
• Drug induced – OMIT DRUG
• PROM – INDUCTION
• PPROM – Antibiotics,steroid – Induction
• FETAL SURGERY
VESICO AMNIOTIC SHUNT-PUV
Laser photocoagulation for TTTS
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Amniocentesis • Amniocentesis is the
removal of a small amount of amniotic fluid from the sac around the baby.
• This is usually performed at 16 weeks in pregnancy.
• A fine needle is inserted under ultrasound guidance through the mothers' abdomen into a pool of amniotic fluid.
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Amniocentesis
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Amniocentesis Studies of the cells obtained from the amniotic fluid permit: 1- Chromosomal analysis of the cells which can be performed to investigate the
following; Diagnosis of sex of the fetus
Detection of chromosomal abnormalities e.g. trisomy 21 (Down’s syndrome)
DNA studies
2- The cells may indicate genetically transmitted diseases( Inherited disorders e.g Cystic Fibrosis).
3-To check for developmental problems e.g. Spina Bifida .
4- Other studies can be done directly on the amniotic fluid including measurement of
alpha-fetoprotein where high levels of alpha-fetoproteins in the amniotic fluid indicate the presence of a severe neural tube defect whereas low levels of alpha-fetoproteins may indicate chromosomal abnormalities .
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Amniocentesis
Who is the proper candidate for an Amniocentesis investigation?
1-Those whom are suspected to have possible problems indicated by certain tests conducted previously,(e.g If pregnancy is complicated by a condition such as Rh-incombatibility,the doctor can use amniocentesis to find out if the baby's lungs are developed enough to endure an early delivery).
2- Family history of genetic abnormalities (in this case would be advisable to seek genetic counseling before becoming pregnant)
3-Those that have been exposed to certain risk enviromental factors that might lead to fetal abnormalities .
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Amniocentesis
What are the risks of amniocentesis?
• - Abortion: about 1 in 200 to 400 women aborted (higher risk if done in the first quarter)
• - Uterine infection: 1 in 1000
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