3. Disorders of the amniotic fluid

4. Normal amniotic fluid increases in amount throughout pregnancy
- at 38 weeks- 1 L.
-it diminishes to approximately 800 mL at term.
Amniotic fluid is not static.
- the water of which it is largely composed changes every hour and the solutes change about every 3 hrs

5. *There are two chief abnormalities of amniotic fluid:
-hydramnios (or polyhydramnios)
-oligohydramnios

6. Hydramnios:
-The amount of liquor around the fetus is called (the amniotic fluid volume (AFV).
-could be known by ultrasound scanning.
-measuring the liquor in each of four quadrants around the fetus named an amniotic fluid index (AFI).
Hydramnios is said to be excessive amount of amniotic fluid ,AFI is above the 95th centile for gestational age

7. Causes and predisposing factor:
in many cases the cause is unknown.
• esophageal atresia
• open neural tube defect
• multiple pregnancy, monozygotic twins(identical twin)
• maternal diabetes mellitus
• rarely, with Rhesus isoimmunization
• chorioangioma, tumour of the placenta
• an encephalic fetus.

8. Types
1-Chronic hydramnios
It is the most common type.
gradual in onset
usually starting from about the 30th week of pregnancy.

9. 2-Acute hydramnios
This is very rare.
It usually occurs at about 20 weeks
comes suddenly.
The uterus reaches the xiphisternum in about 3 or 4 days.
It is frequently associated with monozygotic twins or severe fetal abnormality.

10. Clinical presentation :
breathlessness and discomfort.
have severe abdominal pain (acute form ).
exacerbation of symptoms associated with pregnancy such as indigestion, heartburn and constipation.
Edema
varicosities of the vulva and lower limbs

11. Abdominal examination
On inspection:
the uterus is larger than expected for the period of gestation
globular in shape.
The abdominal skin appears stretched and shiny
marked striae gravidarum
clear appearance of superficial blood vessels.

12. On palpation:
the uterus tense .
it is difficult to feel the fetal parts
the fetus may be balloted between the two hands.
A fluid thrill may be elicited by placing a hand on one side of the abdomen and tapping the other side with the fingers

13. A wave of fluid will move across from the side that is tapped and this is felt by the opposite examining hand.
It may be helpful to measure the abdominal girth ,particularly in cases of acute hydramnios, in order to observe the rate of increase.
Auscultation of the fetal heart can be difficult .
Ultrasonic scanning is used to

14. 1- confirm the diagnosis of hydramnios
2 – calculate the DP, AFV and AFI, and therefore the severity of the hydramnios
3-may reveal a multiple pregnancy or fetal abnormality.
X-ray examination is not often performed.

15. .Complications
• maternal ureteric obstruction
• increased fetal mobility leading to unstable lie and malpresentation
• cord presentation and prolapse
• pre-labour (and often preterm) rupture of the membranes
• placental abruption when the membranes rupture
• pre-term labour
• a higher incidence of pre-eclampsia
• increased incidence of caesarean section
• postpartum haemorrhage
• raised perinatal mortality rate.

16. Management
The aim of managing this condition is:
to relieve maternal symptoms
prolonging of pregnancy it if safe.
Management :depond on
- the condition of the woman and fetus
-the cause of hydromnous
-degree of the hydramnios
-the stage of pregnancy

17. 1-The woman may be admitted to a consultant obstetric unit.
2-The cause of the condition should be determined
3-fetal karyotyping may be indicated.
4-Diabetes mellitus will be managed
. N.B: The presence of fetal abnormality will be taken into consideration in choosing the mode and timing of birth.
If gross abnormality is present, labour may be induced.
if the fetus is suffering from an operable condition such as esophageal atresia, transfer will be arranged to a neonatal surgical unit

18. Mild case of hydromnious:
. She should be encouraged to get adequate rest
-if she is working it may be helpful to discuss maternity leave
- assess nature of her job and the stress
-if the hydramnios is found to be idiopathic, in mild asymptomatic cases, she can be reassured that fetal outcome is likely to be good.
-Regular ultrasound scans will reveal whether or not the hydramnios is progressive.
- Many cases of idiopathic hydramnios resolve spontaneously as pregnancy progresses.

19. Management For a woman with symptomatic hydramnios,:
- an upright position will help to relieve any dyspnoea
-she may be given antacids to relieve heartburn and nausea.
-If the discomfort from the swollen abdomen is severe, therapeutic amniocentesis, or amnioreduction, may be considered.

20. Risk of this procedure :
infection may be introduced
the onset of labour initiated
a temporary relief .
accumulate fluid again
the procedure may need to be repeated.

21. Acute hydramnios managed by :
amnioreduction
a poor prognosis for the baby.
the fluid continues to increase at an alarming rate
the membranes rupture spontaneously
and the fetus or fetuses are born
grossly premature, in a river of amniotic fluid.

22. Administration of drugs such as indomethacin and sulindac reduce fetal urine production
-IOL in late pregnancy if the symptoms become worse.
- The lie must be corrected if it is not longitudinal
-the membranes will be ruptured cautiously, allowing the amniotic fluid to drain out slowly in order to
* avoid altering the lie
*to prevent cord prolapse.
* to avoid Placental abruption

23. -Labour is usually normal
-the midwife should be prepared for the possibility of postpartum haemorrhage.
-The baby should be carefully examined for abnormalities
-Check for the patency of the esophagus by passing a nasogastric tube.

24. Oligohydramnios:
-definition : is an abnormally small amount of amniotic fluid At term, it may be 300–500 mL or less.

25. Causes of oligohydromnious in the first half of pregnancy:
-renal agenesis (absence of kidneys)
- Potter's syndrome in which the baby also has pulmonary hypoplasia.

26. pregnancy before 37 weeks:
-fetal abnormality
- pre-term pre-labour rupture of the membranes
-the amniotic fluid fails to re-accumulate.
- The lack of amniotic fluid reduces the intrauterine space and over time will cause compression deformities.

27. characteristics of the baby
has a squashed-looking face,
flattening of the nose
micrognathia
a deformity of the jaw
talipes of the feet.
The skin is dry
leathery in appearance

28. -Oligohydramnios sometimes occurs in the post-term pregnancy has been linked to the development of placental insufficiency.
As placental function reduces, blood perfusion to the fetal organ systems including the kidneys also decrease . decrease fetal urine formation leads to oligohydramnios, as the major component of amniotic fluid is fetal urine.

29. Recognition
Abdominal examination :
the uterus appear smaller than expected for the period of gestation.
a reduction in fetal movements.
When the abdomen is palpated the uterus is small and compact and fetal parts are easily felt.
Breech presentation is possible.
Auscultation is normal.

30. -Ultrasonic scanning will enable differentiation of oligohydramnios from intrauterine growth restriction (although both may occur together where there is placental insufficiency).
-Renal abnormality may be visible on the scan.
- measurement of amniotic fluid and the AFI below the 5th centile

31. Management
-The woman may be admitted to hospital.
-If the ultrasound scan demonstrates renal agenesis the baby will not survive.
-if renal agenesis is not present then further investigations for the woman to check the possibility of pre-term rupture of the membranes.
- Placental function tests will also be performed.
When the cause of the oligohydramnios is not known

32. prophylactic amnioinfusion with normal saline, Ringer's lactate or 5% glucose may be performed in order to :
1-prevent compression deformities
2-avoid hypo plastic lung disease
3- prolong the pregnancy.

33. Benefit of this procedure :
-resulted in lower caesarean section rates
-improved neonatal outcome for normal babies

34. Follow up(full term ) fetal surveillance bycardiotocography(CTG) amniotic fluid measurement by ultrasoundDoppler assessment of fetal and uteroplacental arteries maternal counting, recording and reporting of fetal movement was not effective in reducing stillbirths

35. -At any stage of pregnancy labour may intervene by IOL.
- Epidural analgesia may be indicated because uterine contractions are often unusually painful with this condition.
- Impairment of placental circulation or cord compression may result in fetal hypoxia and therefore continuous fetal heart rate monitoring is desirable

36. -At any stage of pregnancy labour may intervene by IOL.
- Epidural analgesia may be indicated because uterine contractions are often unusually painful with this condition.
- Impairment of placental circulation or cord compression may result in fetal hypoxia and therefore continuous fetal heart rate monitoring is desirable

37. - In rare cases the membranes may adhere to the fetus.
- if meconium is passed in utero it will be more concentrated and represent a greater danger to an asphyxiated baby during birth.

38. Thank you