ABERRANT LIQUOR VOLUME - PowerPoint Presentation

Slide1

ABERRANT LIQUOR VOLUME

Teacher

Prof.

Sukanta

Misra

.

Prof & HOD, G&O, RKMSP, VIMS.

Student

Sumana Nandi

Bidisha

Mallick

Slide2

Topics to be covered

What is it?

Formation of amniotic fluid

Volume and composition

Functions and clinical significance of amniotic fluid

Abnormalities

a) Polyhydramnios-

definition, diagnosis, evaluation & t/t

b) Oligohydramnios-

definition, diagnosis, evaluation & t/t

Slide3

Introduction

The

amniotic fluid

or liquor

amnii

surrounds the fetus during intrauterine development.

This fluid serves as a cushion for the growing fetus. It is the results of contributions from both the mother and the fetus.

Slide4

Factors determining for amniotic fluid volume

Transudation

from maternal circulation through the placental surface & fetal membranes

Intramembranous flow

across fetal vessels on the placental surfaces

Trans-membranous flow

across amniotic membrane

Fetal urination

Fetal swallowing

Fetal lung field secretion

Transcutaneous flow

-across fetal skin (prior to its keratinization)

Slide5

Slide6

Slide7

Normal amniotic fluid volume

The volume of

amniotic

fluid varies according to gestational maturity.

PERIOD OF GESTATION

AMNIOTIC FLUID VOLUME

10 WEEKS

20 ml

20 WEEKS

400 ml

28 WEEKS

750 ml

36 WEEKS

800-1000 ml

TERM

700 ml

43 WEEKS

200 ml

Slide8

Compositions of amniotic fluid at term

Water:

98.4%,

Solid component:

1.6%

Organic Constituents:

Protein(albumin)

Glucose

Urea, Creatinine, Uric acid

Non protein nitrogen

Lipids

Inorganic Constituents:

Na+

K+

Cl-

Slide9

Compositions of amniotic fluid at term

Solid Components:

Lanugo hair

Desquamated fetal skin cells

Vernix

caseosa

Shedded

amniotic cells

Epithelial cells from respiratory tract, gastrointestinal tract of the fetus

Dermal fibroblasts

Slide10

Physical features of amniotic fluid

pH:-

slightly alkaline (around 7)

Specific gravity:-

1.007-1.010

Osmolarity:-

Hypotonic. Osmolarity( 260

mOsm

/L)

** osmolarity of fetal plasma approx. 280

mOsm

/L

Color:-

Colorless in early pregnancy

Pale straw color near term

Slide11

Abnormal appearance of amniotic fluid

Golden yellow:-

In Rh incompatibility patients

Greenish yellow:-

In post-maturity patients

Dark maroon:-

Due to altered blood in accidental hemorrhage

.

Dark brown:-

In presence of retained dead fetus

Blood stained:-

In abruption, vasa previa.

Slide12

What are the functions of amniotic fluid?

Functions during pregnancy:-

Protects fetus from trauma

Allows space for fetal movement which is necessary for

musculo

-skeletal development.

Permits fetal swallowing-essential for

GIT development

Inhalation into respiratory tract-helps in

growth and differentiation of respiratory tract

as amniotic fluid has growth factors in it.

Maintains fetal temperature

Prevents the adhesion formation between fetal parts and amniotic sac.

Functions during labor:-

Slide13

What are the functions of amniotic fluid?

Functions during pregnancy:-

Functions during labor:-

Amniotic fluid forms a hydrostatic wedge(bag of membranes) to help in cervical

dialatation

.

During uterine contractions, amniotic fluid in intact membranes prevents interference with placental circulation.

Protects fetus from ascending infections by its

bacteriostatic

properties.

Slide14

Measurement of amniotic fluid

Direct method by DYE DILUTION TECHNIQUE:-

Injection of a small quantity of dye (amino

hippurate

) into the amniotic cavity under USG guidance.

Then amniotic fluid is sampled to determine the dye concentration to find out the total amniotic fluid volume.

Disadvantages:-

Invasive procedure

Risk of fetal injury

Chorioamnionitis

Rupture of membrane

Slide15

Measurement of amniotic fluid

Sonographic assessment:-

Single deepest pocket (SDP)

The largest pocket of liquor avoiding umbilical cord and fetal extremity is measured

Normal range in

2cm to 8cm.

Slide16

Measurement of amniotic fluid

Sonographic assessment:-

Amniotic fluid index

Maternal abdomen is divided in 4 quadrants by drawing two perpendicular lines through umbilicus.

Measured by sum of single deepest vertical pocket from each quadrant.

Normal range

5cm to 24 cm

Color doppler is used to pick-up the cord free pocket.

Slide17

Slide18

Clinical significance of amniotic fluid

Diagnosis of fetal genetic disorders:-

By doing

cytogenic-analysis

of amniocytes obtained by amniocentesis to diagnose chromosomal-abnormalities using CMA/ Karyotyping/ FISH.

Diagnosis of congenital infections:-

e.g. CMV infection by PCR or viral culture

Screening for congenital malformations:-

By doing

biochemical analysis

for

-Alpha-

feto

protein estimation

-Acetylcholinesterase level estimation

Slide19

Clinical significance of amniotic fluid

Assessment of fetal well-being:-

By measuring the amniotic fluid index

As it is component a Biophysical profile

.

Assessment of fetal lung maturity:-

By measuring

Lecithin-sphingomyelin

ratio

If it is >2.0; it indicates fetal lung maturity

If it is less, fetus is susceptible to respiratory distress syndrome.

By assessing the

phosphatidyl-glycerol

in amniotic fluid

Slide20

Clinical significance of amniotic fluid

Assessment of severity of Rh isoimmunization:-

Measurement of

bilirubin

is an indication of degree of

haemolysis

occurring in utero, therefore an indication of danger of

anaemia

in the fetus.

Amniotic fluid testing for fetal age determination:-

At 36 weeks, fetal kidneys excrete >2.0 mg/dl

creatinine

This test now has been replaced by ultrasound measurements.

**

the above mentioned two tests are not used now-a-days.

Slide21

Slide22

Polyhydramnios

Polyhydramnios is defined as:-

clinically demonstrable increased amount of amniotic fluid

The sonographic diagnosis of oligohydramnios is usually based on

Amniotic fluid index

25 or above

or

Single deepest pocket

8cm or above.

SEVERITY

AFI (cm)

SDP (cm)

Mild

25-29.9

8-9.9

Moderate

30-34.9

10-11.9

Severe

≥ 35

≥12

Slide23

Etiology of polyhydramnios

Idiopathic

Maternal causes

Placental causes

Fetal causes

Slide24

Etiology of Polyhydramnios

Idiopathic

(50-60%)

Maternal causes

Diabetes

Cardiac or renal disease

Substance abuse

Placental causes

Chorioangioma of placenta

Slide25

Etiology of polyhydramnios

Fetal causes

Anencephaly

Cystic hygroma

Cleft lip/palate

Open spina bifida

eg

.

meningocele

meningomyelocele

Slide26

Etiology of Polyhydramnios

Fetal causes

Esophageal atresia

Duodenal atresia

Congenital diaphragmatic hernia

Slide27

Etiology of Polyhydramnios

Fetal Causes

Erythroblastosis fetalis

Fetal sacrococcygeal teratoma

Multiple gestation

Fetal barter syndrome

Congenital infections

Non-immune hydrops

etc

Slide28

Differential diagnosis

Multiple pregnancy

Pregnancy with large ovarian cyst

Pregnancy with fibroid

Maternal ascites

Concealed abruption

Full bladder

Hydatidiform mole

Slide29

Types of Polyhydramnios

Acute Polyhydramnios

Is very rare

Sudden onset

Severe abdominal pain is common symptom

Chronic Polyhydramnios

Most common type

Is gradual in onset

Slide30

Complications of Polyhydramnios

Fetal Complications

Unstable lie

Malpresentation

Cord prolapse

PROM

Placental abruption

Premature labor

High perinatal mortality rate

Maternal Complications

Cardiorespiratory embarrassment

Maternal mirror syndrome

seen especially with hydrops fetalis

Premature labor

Increased LSCS rate

Retained placenta, PPH

Subinvolution of uterus, Puerperal sepsis

Maternal morbidity

Slide31

Diagnosis of Polyhydramnios

Clinical features:-

Breathlessness

Palpitation

Swelling of the lower extremities, vulva and abdominal wall

Heart burn/ Indigestion

Varicose vein in legs and vulva

Slide32

Diagnosis of Polyhydramnios

Abdominal examination

Excessive rounded distension of abdomen

Abdominal skin stretched, tense and shiny

Marked

striae

gravidarum

Increased fundal height and abdominal girth

Difficult to palpate fetal parts

Difficult to auscultate fetal heart sound

Fluid thrill may be present

Ultrasound evaluation for confirmation of the diagnosis

Slide33

Management of Polyhydramnios

Treatment according to underlying pathology

Treatment according to symptoms

Role of Indomethacin

Impairs fetal lung fluid production

Enhances absorption

Increases fluid movement across fetal membranes

Reduce fetal urinary production

SIDE EFFECTS-

premature closure of fetal ductus arteriosus

-not used after 35 weeks

Slide34

Management of Polyhydramnios

4. Amnioreduction

-

around 1000-1500 ml fluid withdrawn

-

procedure is done slowly

-done weekly or semiweekly

SIDE EFFECTS

-

PROM

-Preterm labor

-Abruption

Slide35

Oligohydramnios

Oligohydramnios is defined as:-

clinically demonstrable decreased amount of amniotic fluid.

The sonographic diagnosis of oligohydramnios is based on

Amniotic fluid index

<5cm

or

Single deepest pocket

<2cm

Slide36

Etiology of oligohydramnios

Fetal causes

Maternal causes

Placental causes

Drugs

Idiopathic

Iatrogenic

Slide37

Etiology of Oligohydramnios

Fetal Causes

PROM

Chromosomal abnormalities -Trisomy 18,

Triploidy

, Turner syndrome

Post term pregnancy

Fetal growth restriction

Intrauterine fetal death

Congenital anomalies

-

renal agenesis

-renal dysplasia

-posterior urethral valve

-bladder outlet obstruction

-amniotic band syndrome

-cardiac defects- septal defects, Fallot’s tetralogy

-CNS defects- microcephaly

Slide38

Etiology of oligohydramnios

Maternal causes

Uteroplacental insufficiency

Hypertension

Pre-eclampsia

Placental causes

Abruption

Twin-twin transfusion syndrome

Drugs induced

PGs synthesis inhibitors

ACE inhibitors

Idiopathic

Amnion nodosum

Iatrogenic

Amniocentesis, CVS

Slide39

Potter Syndrome

P

ulmonary Hypoplasia

O

ligohydramnios

T

wisted skin(wrinkly skin)

T

wisted face (

Potter’s facies

)-

low set ears -epicanthic folds -receding mandible

-flattened nose

E

xtremities defects

R

enal agenesis ( bilateral)

Slide40

Potter sequence

When the abnormalities same as potter syndrome result from another etiology (not due to renal agenesis) such as

bilateral

multicystic

dysplastic kidney, autosomal recessive polycystic kidney disease,

it is called

Potter sequence.

Slide41

Complications of Oligohydramnios

Fetal effects

EARLY PROBLEMS

Pulmonary hypoplasia

Limb deformities like

talipes

Potter’s facies

Amniotic adhesions or bands

causing deformities like amputation of digits

Fetal growth restriction, IUD

LATE PROBLEMS

Cord compression

Meconium aspiration syndrome

Maternal effects

Prolonged labor(d/t uterine

intertia

and dysfunctional labor)

Higher chances of operative delivery d/t malpresentations

Increased maternal morbidity

Slide42

Diagnosis of Oligohydramnios

History:

H/O of leaking P/V

Post term

H/O drugs intake

Examination:

Uterus-small for date

Malpresentation

USG:

Decreased AFI & SDP

Slide43

Management of Oligohydramnios

Directed to the causes

Drug induced- omit drug

PROM- antibiotics, steroid

Post urethral valve- VESICO AMNIOTIC SHUNT

Amnio

infusion

** oligohydramnios associated with FGR requires antepartum fetal surveillance and doppler and proper timing of delivery

Slide44

Amnioinfusion

Instillation of sterile fluid into the amniotic cavity to increase liquor volume is called

amnioinfusion

Indications

In variable decelerations

In prophylaxis for women with oligohydramnios

To dilute / wash-out thick meconium

Procedure

500 ml bolus of NS/RL is instilled within 30 minutes f/b continuous infusion to be given at the rate of 3ml/min.

Amnioinfusion

is stopped after infusion of 1000 ml or delivery imminent or any complication arises

Slide45

Amnioinfusion

Complications:-

Uterine overdistension

Uterine hypertonicity

Fetal bradycardia

Umbilical cord prolapse

Amniotic fluid embolism

Contraindications:-

Severe preeclampsia

Classical cesarean section

Maternal cardiac disease

Slide46

Slide47

Slide48

POLY-OLY SYNDROME/ TTTS

Seen in monochorionic twin pregnancies.

Antenatal criteria for defining TTTS:-

Same sex fetuses

Monochorionicity

with placental vascular anastomosis

Weight difference between twins greater than 20%

Hydramnios

in the larger twin, oligohydramnios in the smaller twin

Stuck smaller twin

Hemoglobin difference >5 g/dl

Slide49

POLY-OLY SYNDROME

Quintero staging system

Stage I

- discordant amniotic fluid volume but urine is still visible

sonographically

within donor twin’s bladder.

Stage-II

- Stage I + but urine is not visible within donor’s bladder.

Stage III

- Stage II + abnormal doppler studies of umbilical artery, ductus venosus or umbilical vein.

Stage IV

- ascites or frank hydrops in either twin.

Stage V

- it is most severe form with demise of either twin.

Slide50

Treatment of TTTS

Amnioreduction

treats polyhydramnios

Laser treatment

includes the ablation of communicating vascular anastomosis.

Septostomy

aims to equilibrate the discordant amniotic fluid between the two sacs.