amniotic fluid disorder in obstetrics and gynecology.pptx

More about amniotic fluid disorder

1. - OB&GY BLOCK(5 th –level- O&G DEPARTMENT) Course Code -BMD 36 Faculty of medicine& Health sciences Obstetrics & Gynecological Department Bachelor of Medicine & Surgery Dr. Maha.Abdulaziz E-mail: [email protected] 1 Faculty of Medicine &Health sciences

2. Disorder of amniotic fluid volume DR.Hanan Mohamed Hassan Faculty of Medicine &Health sciences

3. Objectives Identify the embryology , physiology & function of amniotic fluid How measure the amniotic fluid? What is disorder of amniotic fluid, causes & complications How dose the patient present? What is the treatment plane?

4. Embryology of the amniotic cavity The amnion is a thin fetal membrane that begins to form on 8 th post conceptional day as a small sac covering the dorsal surface of the embryonic disc. The amnion gradually encircles the growing embryo. Amniotic fluid fills the amniotic cavity. Amniotic fluid dynamics Maintenance of amniotic fluid volume is a dynamic process that reflect balance between fluid its production and absorption . Fluid product Prior to 8 weeks, amniotic fluid is produced by passage of fluid across the amnion and fetal skin(transudation). At 8 weeks, the fetus begins to urinate into the amniotic cavity. Fetal urine quickly becomes the primary source of amniotic fluid production. Near tearm,800-1000 ml of fetal urine is produced each day. The fetal lungs produce some fluid(300 ml per day at term),but much of it is swallow before entering the amniotic space.

5. Fluid absorption Prior to 8 wks. gestation, transudation of amniotic fluid is passively reabsorbed. At 8 weeks gestation, the fetus begins to swellow.Fetal swallowing quickly becomes the primary source of amniotic of amniotic fluid absorption. Near tearm,500-1000 ml of fluid are absorbed each day by fetal swallowing. A lesser amount amniotic fluid is absorbed through the fetal membranes and enters the fetal bloodstream. Near tearm,250 ml of amniotic fluid is absorbed by this route every day. Small quantities of amniotic fluid across the amnion and enter the maternal bloodstream(10 ml per day near term). Changes in volum during pregnancy production of amniotic fluid is begin at 8 wks. It 250 mi at 16 wks.gestation& Amniotic fluid volume is maximal at 34 wks. (750-800ml) and decrease to 600 ml at 40 wks. The amount continues to decrease beyond 40 wks.

6. The role of amniotic fluid Protection of umbilical cord from compression. Allowing unrestricted fetal movement, by cushioning of fetus from external trauma. promoting the development of the fetal musculoskeletal system. Contributing to fetal pulmonary development. Lubricate the fetal skin. Preventing maternal chorioamnionitis and fetal infection through its bacteriostatic properties. Assisting in fetal temperature control.

7. Measurement of amniotic fluid volume Ultrasonography is more accurate method of estimating amniotic fluid ,several techniques are described: Subjective assessment of amniotic fluid. Measurement of the single deepest pocket (free of umbilical cord),it 2-10cm. Amniotic fluid index(AFI) is a semi quantitative method for estimating amniotic fluid volume ,it refers to the sum of the maximum vertical pocket 0f amniotic fluid (in cm) in each of the four quadrants of the uterus. Normal AFI beyond 20 weeks gestation ranges from 5 to 20 cm. Clinical importance of of amniotic fluid volume It is a marker of fetal well-being. Normal amniotic fluid volume suggest that uteroplacental perfusion is adequate. Abnormal amount of amniotic fluid volume is associated with un unfavorable perinatal outcome.

8. Polyhydramnios( hydramnios ) Definition : it means excessive amniotic fluid which is detected clinically or by ultrasound. In this case amount of fluid is more than 2 liters.By ultrasound the vertical diameter 0f of the largest pocket of amniotic fluid measures 10 cm or more, or the amniotic fluid index(AFI) is 20 cm or more. Aetology: The amniotic fluid has both fetal and maternal origin, so the causes are: Fetal causes : 1. Twins ,uniovular or binovular.Acute polyhydramnios is almost always associated with uniovular twins. 2. Congenital fetal anomalies: a. Anencephaly and open spine bifida due to loss of CSF from the exposed menings.Other factors is irritation of uncovered Cerebrospinal center with increase urination, lack of antidiuretics hormone and impairment of swallowing.

9. b. congenital obstruction of esophagus or duodenum(interfering with swallowing of fluid). c . Hypoplastic lungs(interfere with inspiration of amniotic fluid and its absorption by bronchial mucosa and leads to polyhydramnios). 3. Knot of the umbilical cord,cardic abnormalities, and cirrhosis of fetal liver due to congenital syphilis,erythroblastosis fetalis,cytomegalo virus and toxoplasmosis. These lead to obstruction of circulation in umbilical vein, edema of the placenta and increased transudation. 4. Chorioangioma which is a benign tumor of placenta. It is haemangioma of fetal capillaries. 5. A large placenta(leading to increased transudation of amniotic fluid).

10. Maternal causes: 1.Causes of generalizes edema as heart or renal failure. 2.Preclampsia due to edema of placenta and membranes. 3.Diabetes mellitus, due to polyuria of the fetus because of hyperglycemia or increased osmotic pressure of liquor amnii due to the presence of sugar. 4.Syphilis, it causes cirrhosis of fetal liver. 5.Maternal prolactin may play a role.Prolactine control passage of water and solutes across the fetal membrane. In polyhydramnios the level of prolactin in amniotic fluid is lower than that expected for gestational age. 6.RH negative mother with isoimmunization. Idiopathic In about 30% of cases no cause is found.

11. Clinical picture 1.Acute polyhydramnios It is very rare,usualy occurs in early pregnancy(less than 28 wks.)&is almost always associated with uniovular twins. A-symptoms Abdominal pain. Nausea &vomiting. Pressure symptoms: as dyspnea,palptation,piles,varicosity &edema of lower limbs,vulva &abdominal wall. B-Signs General examination: signs of, preeclampsia usually present, increase weight& edema. Abdominal examination: The abdomen is huge &overdistended.The fundal level is higher than the period of amenorrhoea.Fetal parts&heart sounds cannot be detected.There is a fluid thrill. Vaginal examination: The cervix is high &usually partially dilated admitting1 or 2 fingers.

12. 2.Chronic polyhydramnios Commoner than the acute, usually occurs in late pregnancy(after 28 wks.), the fluid accumulates slowly. A-Symptoms Abdominal discomfort Pressure symptoms as dyspnea,palptation&oedema of lower limbs,vulva&abdominal wall B.Signs General examination: preeclampsia usually present. Abdominal examination: abdomen is overdistended&skin is thin stretch with, excessive striae gravdarum.The fundal level is higher than period of amenorrhoea.Thefetal heart sounds are faint or inaudible. There is a fluid thrill &no comment on present part. Vaginal examination cervix is partial dilated& 1 or 2 can admitted.

13. Ultrasound examination: it must be done in every case of polyhydramnios to confirm the diagnosis ,to exclude multiple pregnancy, to show fetal abnormalities, and to diagnose position &presentation. Differential diagnosis 1.Causes of an oversized pregnant uterus: wrong gestational age, multiple pregnancy& fetal macrosoma. 2.Ascites. 3.Ovarian cyst with pregnancy. Management 1.Acute polyhydramnio Pregnancy terminated by rupture of membranes ( amniotomy).The liquors is allowed to escape slowly by putting 2 fingers in the cervix to avoid splanchnic shock &bleeding from premature separation of placenta.

14. 2.Chronic polyhydramnios During pregnancy : 1.Rest in bed. 2.Glucose tolerance test is done to exclude Dm.,RFT,LFT,blood group&Rh 3.Treatment the cause if detected as preeclampsia,DM. 4.TheProstoglandin inhibitor (indomethacin) can be given orally or rectally to avoid gastric irritation. The oral dose is 25mg every 6 hrs. or a suppository 100mg twice daily. It is given 3 or 4 days but not more to avoid fetal complication, as drug act on fetal kidneys reducing the amount of urine &increase fetal respiratory movement thus increasing the absorption of amniotic fluid by bronchial mucosa. 5.Amniocentesis is indicated if pressure symptoms are severe &not relieved by treatment. Under local anesthesia, ultrasound guid,fluid drain slowly at rate of 500 ml\hr. About 1500-2000 ml are removed. If fetal anomalies present so induction of labour after amniocentesis. 6.If fetal abnormality ,refer to fetal medicine center as twin- twin transfusion syndrome is best mange with laser ablation of placenta anastomoses.

15. B. During labor 1.Correction of any malprestation. 2.When cervix is half dilated the membrane are rupture &liquor is allowed to escape slowly as before. 3.The patient is kept under observation for 2 hrs., after delivery to detect any postpartum hemorrhage. Outcome: Polyhydamnios has been associate with increase maternal morbidity as well as perinatal morbidity& mortality.

16. Complications : Maternal: a.During pregnancy Abortion Preterm labor Premature rupture of membrane Preeclampsia Abruption placenta Malpresentation Non engagement of presenting part Pressure symptoms as dyspnea, pills, palptation&oedema of lower limbs

17. b.during labour Premature rupture of membranes Prolapse of arm, cord or both. Obstructed labour due to malpresentation. Abruptio placenta. Uterine atony due to over distention of uterus. Retained placenta, due to uterine atony. Postpartum hemorrhage due to uterine atony. Splanchnic shock, occurs if the fluid escapes rapidly, so the pressure exerted by the uterus on the splanchnic vessels drops suddenly leading to pooling of blood in the splanchnic area &shock.

18. c.During puerperium The uterus sub involution . Fetal complications : Prematurity &its complications as infection& respirator distress. Congenital fetal malformations. Care of newborn: After delivery the fetus is examined for congenital malformation &a soft rubber catheter is passed into the stomach to test for esophageal atresia.

19. Oligohydramnios It means diminish amniotic fluid which is detected clinically or by ultrasound. In this case the amount of the fluid is less than 500ml. By ultrasound the vertical diameter of the largest pocket of fluid measures 2cm or less, or the amniotic fluid index is 5cm or less. Aetology Fetal causes: 1.Congenital fetal anomalies of urinary tract as bilateral renal agenesis(potter syndrome) 2.Fetal chrosomal abnormalities as trisomy's. 3.Intrautrrine growth restriction, there is decrease urine production. 4.Postterm pregnancy due to placenta aging &insufficiency.

20. Maternal causes: 1.Premature rupture of membranes. 2.Placenta insufficiency as in preeclampsia chronic hypertension. 3.Diabetic vasculopathy,atherosclerosis of pelvic arteries which occurs in advanced diabetes with reduces uteroplacental blood flow. 4.Maternal ingestion of indomethacin in treatment of polyhydramnios which lead to oligohydramnios&capotin ingestion. Idiopathic No apparent cause is detected.

21. Diagnosis Fundal level is lower than gestation age. Breech presentation is common. The fetal parts are easily felt &fetus is almost immobile.FHS are clearly heard. Ultrasound scan diagnoses reduced amount of liquor, intrauterine growth restriction, fetal presentation& fetal anomalies as renal agenesis. Difrential diagnosis all causes of small pregnant uterus: Wrong gestational age IUGR IUFD

22. Management High vaginal swab for culture &sensitivity ,AB is given to avoid chorioamnitis in case PRO is indicated& if rupture before 37 wks. Give prophylactic AB&mointer sign of infection (4 hrs. temperature&pulse)&daily CTG.If rupture of membrane after 37 wks. Induction of labor unless cs is indicated. If IUGR manage according to umbilical artery Doppler&CTG. Antepartum treatment options are limited, unless a structural defect as posterior urethral valve in male infant is amenable to in utero surgical repair. During labour, fetus is observe for distress, if it occurs so fetus delivered immediately, either vaginally or CS according to the condition. Amnioinfusion can be done during labour to prevent compression of umbilical cord &fetal asphyxia. Fetus examine for any congenital abnormalities.

23. Outcomes: Oligohydramnios is associated with increased perinatal morbidity& mortality at any gestational age. Complications: Amniotic band syndrome(adhesion between the amnion&fetus causing serious deformities, including limb amputation) . Musculoskeletal deformities as club foot due to uterine compression. Pulmonary hypoplasia due to lack of fluid need for inhalation into terminal air sac &compression on the lung. Cord compression&fetal distress.

24. THAK YOU