AMNOITIC FLUID PHYSIOLOGY.pptxvbbbbvbjfdd

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1. SCHOOL OF CLINICAL SCIENCES MODULE: OBSTETRICS AND GYNECOLOGY TOPIC: AMNIOTIC FLUID PHYSIOLOGY LECTURER: DR. K.S.K JUSU PRESENTED BY: KAMARA MUSTAPHA 6/19/2023 1

2. Table of content Background Definition Volume Composition Physical features Colour Abnormal appearance Functions Clinical importance Measurement Pathological conditions 6/19/2023 2

3. Background Fluid in the amniotic sac surrounding the fetus. Act as a shock absorber to protect the fetus from external injury. It origin is both from mother and fetus. It colour and volume changes according to GA and some pathological conditions eg . Polyhydroamnios (vol >2000mls/AFI>25cm ), Oligohydroamnios (vol<200 at term/AFI<5cm), AFES/ASOP 6/19/2023 3

4. Definition It is the fluid in the amniotic sac surrounding the fetus which act as a shock absorber to protect the fetus from external injury, and allows free movement and growth of fetus . 6/19/2023 4

5. Production Transudation of maternal serum across the placental membranes Transudation from fetal circulation across the umbilical cord or placental membranes Secretion from amniotic epithelium Transudation of fetal plasma through the highly permeable fetal skin before keratinization at 20th week Fetal urine—daily output at term is about 400–1,200 mL Fetal lung that enters the amniotic cavity add to its volume . 6/19/2023 5

6. Removal Fetus swallows about 500–1,000 mL of liquor everyday Intramembranous absorption of water and solutes (200–500 mL/day) from the amniotic compartment to fetal circulation through fetal surface of the placenta. 6/19/2023 6

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8. Volume : this varies according to the gestational age Measures 12 weeks – 50 ml 20 weeks- 400 ml 36 weeks- 800ml-1 liter At term - it reduces to approx. 700ml As the pregnancy continues post-term, further reduction occurs to about 200 mL at 43 weeks. 6/19/2023 8

9. Composition of Amniotic fluid Organic constituents Proteins-0.3 mg/dl Glucose- 20mg/dl Urea- 30 mg/dl Non protein nitrogen-30mg/dl Uric acid – 4 mg/dl Creatinine -2 mg/dl Lipids- 50 mg/ dl Hormones- insulin, prolactin, renin Inorganic constituents- Na, K, Cl 6/19/2023 9

10. Physical features Faintly alkaline Low specific gravity-1.010 Becomes highly hypotonic to maternal serum at term pregnancy Osmolarity of 250 mosmol /liter is suggestive of fetal maturity Suspended particles- Lanugo, exfoliated squamous epithelial cells from the fetal skin, vernix caseosa , cast off amniotic cells and cells from the respiratory tract, urinary bladder. 6/19/2023 10

11. Colour In early pregnancy it is colourless At term becomes pale straw coloured due to preence of exfoliated lanugo and epidermal cells from fetal skin 6/19/2023 11

12. Abnormal appearance Green ( meconium stain)- suggestive of fetal distress Golden colour -due to presence of bilirubin resulting from fetal cell hemolysis due to Rh incompatibility Greenish yellow- in post maturity Dark colour – due to altered blood contamination in accidental hemorrhage Dark brown/tobacco juice - due to IUD( dark color- frequent presence of old HbA . ) 6/19/2023 12

13. Functions of amniotic fluid In pregnancy Act as a shock absorber to protect the fetus from external injury Allows free movement and growth of fetus Prevents adhesion formation between the fetal parts and the amniotic sac Has nutrient due to some amount of protein and salt content Maintains the fetal temperature 6/19/2023 13

14. During Labour It forms hydrostatic wedge to help dilatation of cervix During uterine contractions , the amniotic fluid in the intact membranes prevents interference with placental circulation Provides pool for the fetus to excrete urine Protect the fetus from the ascending infections by its bactercidal action 6/19/2023 14

15. Clinical importance Study of amniotic fluid helps in knowing the well being and maturity of fetus Intramniotic instillation of prostaglandins and hypertonic saline can be used for induction of abortion Artificial rupture of membranes to drain liquor is a method of induction and augmentation of labour Excess liquor (polyhydroamnios), less liquor known as (oligohydroamnios ) can be estimated by ultrasound measurement of amniotic fluid index (AFI ) 6/19/2023 15

16. Measurement of AF Measurement of AFI Q uantitative method of measurement of amniotic fluid by usg. Single largest pocket is measured in four quadrants and added. Normal range is 5-24 cm Single deepest pocket Normal range is 2-8 cm 6/19/2023 16

17. MVP Measurement 6/19/2023 17

18. Polyhydroamnios D efined as excess of amniotic fluid of more than 2000ml E xcessive accumulation of liquor amnii causing discomfort to the fetus / AFI > 2 4 cm or MVP >8cm Types of Polyhydroamnios Acute- sudden increase Chronic- gradual increase 6/19/2023 18

19. Etiology It is Idiopathic and seen in 2/3 rd of the cases Fetal causes Anencephaly spinal bifida Esophageal and duodenal atresia Facial cleft and neck masses Congenital diaphragmatic hernia Fetal sacrococcygeal teratoma Fetal infections Hydrops fetalis Multiple pregnancy 6/19/2023 19

20. Cont. Placental causes- choriangioma of the placenta Maternal causes- Diabetes, cardiac or renal disease 6/19/2023 20

21. Symptoms breathlessness due to mechnacial compression edema of legs varicosities in legs , Signs Abdomen is markedly distended skin is tense,shiny fundal height high for GA Fetus not easily palpable 6/19/2023 21

22. Diagnosis = Sonography to: 1 measure AFI >25/MVP>8 2 rule out multiple fetuses , 3 note the lie and presentation of the fetus , 4 diagnose any fetal congenital malformation =Blood : 1. ABO and Rh grouping—Rhesus isoimmunization may cause hydrops fetalis and fetal ascites. 2. Postprandial sugar and if necessary glucose tolerance test . = Amniotic fluid: Estimation of alpha fetoprotein which is markedly elevated in the presence of a fetus with an open neural tube defect 6/19/2023 22

23. Complications Maternal During pregnancy Incresed incidence of preeclampsia Malpresentation Premature rupture of membranes Preterm labour Abruptio placentae Cardiorespiratory embrassment 6/19/2023 23

24. Cont. During labour Premature rupture of membranes Cord prolapse Uterine inertia PPH Puerperium Subinvolution Puerperal sepsis Fetal Complications High perinatal mortality due to prematurity and congenital malformations 6/19/2023 24

25. Management Rule out fetal congenital anomalies Bed rest Amnioreduction- 1-1.5 liters of amniotic fluid is removed over 3 hours to relieve maternal distress Indomethacin therapy- impairs lung fluid production, enhances absorption of amniotic fluid, decreases fetal urine production, increases fluid movement across fetal membranes Dose – 1.5-3 mg/kg from 24-35 weeks for 2 weeks S/E- premature closure of patent ductus arterious 6/19/2023 25

26. Oligohydroamnios Amniotic fluid is less than 200 ml at term or AFI < 5 cm OR MV P < 2 cm Etiology Fetal chromosomal anomalies Intrauterine infections Drugs- PG inhibitors, ACE inhibitors Renal agenesis or obstruction of the urinary tract IUGR associated with placental insufficency Amnion nodosum - failure of secretion by the cells of the amnion Post maturity 6/19/2023 26

27. Diagnosis AFI < 5 cm OR MVP< 2 cm Smaller uterus Less fetal movements The uterus is full of fetus because of scanty liquor Malpresentation is common In third trimester, it is usually mild and not associated with a structural defect. 6/19/2023 27

28. Complications Fetal Abortion Adhesions due to intramniotic adhesions Fetal pulmonary hypoplasia, cord compression Maternal Prolonged labour due to inertia Increased operative interference due to malpresentation 6/19/2023 28

29. Management Malformation? referral to SCBU Conservative treatment Oral administration of H2O increases AFV In labor, cord compression Amnioinfusion improve neonatal outcome 6/19/2023 29

30. Amniotic fluid embolism/Anaphylactic syndrome of pregnancy It is a clinical syndrome of hypoxia, hypotension, and coagulopathy that results from entry of AF, fetal debris and fetal antigens into the maternal circulation This happen through venous channel in cervix and uterus. 6/19/2023 30

31. Risk factors Cesarean delivery Advanced maternal age Multifetal pregnancy Abruptio placentae Abdominal trauma Placenta previa Uterine rupture Cervical lacerations Forceps delivery Polyhydramnios Induction of labor 6/19/2023 31

32. Pathophysiology Open venous channel AF, fetal debris and antigens enter M circulation fetal antigens during delivery activates proinflammatory mediators trigger an overwhelming inflammatory cascade releasing vasoactive substances similar to SIRS that occurs in sepsis and septic shock . organ damage(lungs and heart) triggering coagulation cascade resulting in DIC and PE Result in hypoxia and hypotension and have profound adverse effects on the fetus . 6/19/2023 32

33. Signs and symptoms The first sign may be sudden cardiac arrest . Other patients suddenly develop dyspnea and have tachycardia, tachypnea, and hypotension. Respiratory failure, with significant cyanosis, hypoxia and pulmonary crackles, often quickly follows. Coagulopathy manifests as bleeding from the uterus and/or sites of incisions and venipuncture. Uterine hypoperfusion causes uterine atony and fetal distress. 6/19/2023 33

34. Diagnosis Diagnosis is suspected when the classic triad develops during labor or immediately after delivery: Sudden hypoxia , Hypotension , Coagulopathy Diagnosis is clinical and by excluding other causes of the following : Sudden cardiac arrest ( eg , coronary artery dissection, congenital heart disease) Acute respiratory failure (pulmonary embolism, pneumonia) Coagulopathy ( eg , sepsis, postpartum hemorrhage, uterine atony ) 6/19/2023 34

35. Treatment Treatment is supportive. It includes transfusion of red blood cells, fresh frozen plasma and clotting factors, ventilatory and circulatory support, CPR, Monitor closely. Immediate operative delivery can improve maternal outcome and can be critical for survival of a fetus that is a viable gestational age. 6/19/2023 35

36. Complications Maternal mortality Neurological effect on mother Neonatal mortality Neurological effect on the baby 6/19/2023 36

37. References DC dutta’s text book of Obstetrics 9 th E DC dutta’s text book of Gynecology 8 th E GABBE’S Obstetrics Essentials –Normal and Abnormal MSD Pro Manual (Professional Version) Blueprints Obstetrics and Gynecology 7 th E 6/19/2023 37

38. THANK YOU ALL . ALL PRAISES GO TO ALLAH 6/19/2023 38