Amniotic fluid disorders

Peer review

1. DR.OKECHUKWU A.UGWU Lagos University teaching hospital 5/31/2016 OKEY UGWU 1 DISORDERS OF AMNIOTIC FLUID VOLUME

2. Outline 5/31/2016 OKEY UGWU 2 Origin physical features Components Functions of A.F Clinical Relevance Oligo / Poly- Hydramnios Definition Etiology Diagnosis Treatment Complications

3. ORIGIN 5/31/2016 OKEY UGWU 3

4. Origin contd 5/31/2016 OKEY UGWU 4 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,

5. Amniotic Fluid circulation 5/31/2016 OKEY UGWU 5

6. Circulation AMNIOTIC FLUID VLOUME 5/31/2016 OKEY UGWU 10 weeks – 30mls 20 weeks- 300mls 30 weeks- 600mls 38weeks- 1L 40weeks- 800mls 42weeks- 200-350mls 6 CONTD

7. Physical features 5/31/2016 OKEY UGWU 7 Alkaline- 7.2 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

8. Physical features- contd 5/31/2016 OKEY UGWU 8 Appearance Significance Colorless with slight to moderate turbidity Normal Dark/Blood- streaked Traumatic tap, abdominal trauma, concealed accidental haemorrhage Yellow/Golden HDN/Rhesus Incompatibility dark- green Meconium Dark red/ brown Fetal Death/IUD Greenish yellow post maturity

9. Composition 5/31/2016 OKEY UGWU 9 98% water, 2% solid substances a)Organic b) Non organic c) Suspended particles

10. Functions of A.F 5/31/2016 OKEY UGWU 10 During pregnancy Cushions the fetus from physical trauma Provides a barrier against infection Permits proper lung development Thermoregulation Allow 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

11. Clinical importance 5/31/2016 OKEY UGWU 11 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

12. chemical tests performed on amniotic fluid 5/31/2016 OKEY UGWU 12 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 __________________________________________________________

13. POLYHYDRAMINOS 5/31/2016 OKEY UGWU 13 Defined as excessive amount of amniotic fluid of 2000 ml or more AFI of > 25cm or the deepest vertical pool of > 8 cm 95 th or 97.5 th percentile of GA.

14. Polyhydraminos- contd 5/31/2016 OKEY UGWU 14 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%

15. Measurement of Amniotic Fluid Volume 5/31/2016 OKEY UGWU 15 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

16. AFI 5/31/2016 OKEY UGWU 16

17. AFI Deep vertical pocket 5/31/2016 OKEY UGWU 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 17 Polyhydraminos- contd

18. DVP 5/31/2016 OKEY UGWU 18

19. A ETIOLOGY OF POLYHYDRAMNIOS 5/31/2016 OKEY UGWU 19 Idiopathic (50-60 %) MATERNAL Diabetes Substance abuse Rhesus isoimmunisation

20. Fetal causes 5/31/2016 OKEY UGWU 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 20 A ETIOLOGY OF POLYHYDRAMNIOS- 2

21. Types of Polyhydraminos 5/31/2016 OKEY UGWU 21 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

22. Mgt 1- History 5/31/2016 OKEY UGWU 22 Clinical features Symptomatic/ 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

23. Mgt 2- Physical Examination 5/31/2016 OKEY UGWU 23 Abdominal 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

24. Mgt 3- Investigation 5/31/2016 OKEY UGWU 24 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

25. Management 4 5/31/2016 OKEY UGWU 25 The cause of the condition should be determined if possible. Management depends on: Condition of the fetus and the mother The cause and degree of Polyhydraminos Stage of pregnancy Fetus Compatible with Extra uterine life

26. Mgt 5 5/31/2016 OKEY UGWU 26 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

27. Mgt 6- Indomethacin 5/31/2016 OKEY UGWU 27 Impairs fetal lung liquid production Enhances absorption Increases fluid movement across fetal membranes Reduce fetal urinary production premature closure of the fetal ductus arteriosus Periventricular Leucomalacia not used after 35 weeks

28. Mgt 7 5/31/2016 OKEY UGWU 28 Treat underlying cause Fetal anemia: Fetal transfusion TTTS- Laser ablation of placental vessels Diabetes: control blood sugar

29. Complications of Polyhydraminos contd 5/31/2016 OKEY UGWU 29 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

30. Oligohydramnios 5/31/2016 OKEY UGWU 30 Abnormally small amount of amniotic fluid which is less than 300 – 500 ml at term. Less than 5 th 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)

31. O ligohydraminos Normal 5/31/2016 OKEY UGWU 31 Oligohydramnios contd

32. AETIOLOGY 5/31/2016 OKEY UGWU 32 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

33. Potter’s Syndrome 5/31/2016 OKEY UGWU 33 P ulmonary hypoplasia O ligohydrominios T wisted skin (wrinkly skin) T wisted face (Potter facies ) E xtremities defects R enal agenesis (bilateral)

34. PUV 5/31/2016 OKEY UGWU 34 5/31/2016 OKEY UGWU 34

35. SYMPTOMS 5/31/2016 OKEY UGWU 35 NO SPECIFIC SYMPTOMS H/O leaking p/v Post term CHT/ preclampsia Drugs Less fetal movements SIGNS Uterus – small for date Malpresentation IUGR FHR normal/ nonreassuring Small columns by ultrasound

36. Management 1 5/31/2016 OKEY UGWU 36 MANAGEMENT DEPENDS UPON AETIOLOGY GESTATIONAL AGE SEVERITY FETAL STATUS & WELL BEING- fetus surviving extra uterine life

37. Management 2 5/31/2016 OKEY UGWU 37 DETERMINE AETIOLOGY R/O PROM TARGETED USG FOR ANOMALIES R/O IUGR ,IUFD when suspected Amniocentesis if chromosomal anomalies suspected – early symmetric IUGR

38. Mgt 3- Investigations 5/31/2016 OKEY UGWU 38 instillation of indigo carmine may be used to evaluate for PROM Amniosure - PROM Nitrazine yellow paper/litmus paper Ultrasound scan FBC/FBS/OGTT

39. TREATMENT 5/31/2016 OKEY UGWU 39 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

40. Treatment- contd 5/31/2016 OKEY UGWU 40 DIRECTED TO CAUSE •Drug induced – OMIT DRUG •PROM – •PPROM – Antibiotics, steroid – Induction •FETAL SURGERY VESICO AMNIOTIC SHUNT-PUV Laser photocoagulation for TTTS

41. •AMNIOINFUSION 5/31/2016 OKEY UGWU 41 Reasonable approach in the treatment of repetitive variable decelerations Decreases incidence of - meconium aspiration syndrome - Neonatal Acidemia -cord compression

42. FETAL MATERNAL 5/31/2016 OKEY UGWU Abortion Prematurity IUFD Deformities –contractures Potters syndrome pulmonary hypoplasia Malpresentations Fetal distress Low APGAR Increased morbidity Prolonged labour: uterine inertia Increased operative intervention 42 COMPLICATIONS

43. Pregnancy Outcome in Oligohydramnios 5/31/2016 OKEY UGWU 43 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

44. Pulmonary Hypoplasia and Oligohydramnios 5/31/2016 OKEY UGWU 44 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

45. Conclusion 5/31/2016 OKEY UGWU 45 Amni0tic fluid evaluation allows assessment of the fetal intrauterine environment Potentially invaluable information Requires close follow-up and evaluation

46. END 5/31/2016 OKEY UGWU 46