Amniotic Fluid Disorders • Normal amniotic fluid increases in amount throughout pregnancy until it reaches its maximum level(l liter) at 38 weeks of gestation. • Amniotic fluid normal decrease 38 weeks onwards: – 800 ml at 40 weeks – 400 ml at 42 weeks – 300 ml at 43 weeks 1
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Amniotic Fluid Disorders
• Normal amniotic fluid increases in amount throughout pregnancy until it reaches its maximum level(l liter) at 38 weeks of gestation.
• Amniotic fluid normal decrease 38 weeks onwards:– 800 ml at 40 weeks
– 400 ml at 42 weeks
– 300 ml at 43 weeks
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Disorders of Amniotic Fluid cont ….
• There are two chief abnormalities of amniotic fluid:
1. Polyhydramnious (Hydramnious)
2. Oligohydramnious
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1. Polyhydramnious
Definition: polyhydramnious is an excess amniotic fluid which exceeds 2000 ml.
• Incidence: 9 in 1000 pregnancies.
Etiology:
Majority of polyhydramnios is idiopathic (>60 %)
conditions that increase the surface area of the placenta and amnion or disrupt the integument of the fetus or hamper the normal swallowing process of the fetus:
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Polyhydramnious Cont…
• Diabetes mellitus,
• placental tumors,
• fetal anomalies like esophageal artesia, tracheoesophageal fistula, spinal bifida and anencephaly,
• RH isoimmunization,
• multiple gestations are clinical conditions associated with polyhydraminos
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Polyhydramnious Cont…
Types of Polyhydramnious:
1. Acute Polyhydramnious
2. Chronic Polyhydramnious
A. Acute Polyhydramnious:
• Is very rare
• Usually occurs at about 20 weeks
• Comes on very sudden
• The uterus reaches the xiphisternum with in 3 –4 days
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Polyhydramnious Cont…
• Frequently associated with severe fetal malformations and monozygotic twins
• Ends with spontaneous abortion most of the time
• Severe abdominal pain is common symptom
B. Chronic Polyhydramnious:
• Is gradual in onset
• Usually from 30 weeks of pregnancy
• Is the most common type
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Recognition:
• The mother may complain of breathlessness and discomfort: the condition may exacerbate heartburn, indigestion, edema, and varicosities.
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Polyhydramnious Cont…
S/S :
A. On Inspection:
• The uterus is larger than expected
• The uters is globular in shape
• The abdominal skin appears stretched and shiny marked straegravidarum
• Obvious superficial blood vessels are seen
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Polyhydramnious Cont…
B. On Palpation:
• The uterus feels tense
• It is difficult to feel fetal parts(may be balloted b/n two hands)
• Fluid thrill is present
• Abdominal girth increase rapidly(in acute)
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Polyhydramnious Cont…
C. On Auscultation:
• FHB is difficult to hear
D. Ultrasonic Scanning:
• Confirms polyhydramnious by measuring fluid “pools’’
NB: Investigations are needed to know the cause of the polyhydramnious.
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Polyhydramnious Cont…
Assignment:
1. Definition of Polyhydramnious based on ultrasound
– Single pocket_____ cm
– All pockets ________ cm
2. Role of indomethacin in management of polyhydramnious
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Polyhydramnious Cont…
Complications:
• Maternal ureteric obstruction
• Increased fetal mobility leading to unstable lie and malpresentation
• Cord presentation and cord prolapse
• Premature rupture of membranes (PROM)
• Placental abruption
• Premature labour
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Polyhydramnious Cont…
Complications cont…
• Increased risk of C/S
• Post partum hemorrhage
• High perinatal mortality rate
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Polyhydramnious Cont…
Polyhydramnious Cont…
Management:
• The cause of the condition should be determined if possible.
• Management depends on:
1. Condition of the fetus and the mother
2. The cause and degree of polyhydramnious
3. Stage of pregnancy
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Polyhydramnious Cont…
Mgt of Asymptomatic Polyhydramnious:
• Managed expectantly
• The woman is not necessarily admitted to hospital but should be advised that if she suspects that her membranes has been ruptured, immediate admission is recommended
• Bed rest.
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Polyhydramnious Cont…
Mgt of Symptomatic Polyhydramnious:
• Hospital admission for at least 2 weeks.
• Upright position to relive dyspnea
• Anti acids to relive heart burn
• Amniocentesis
• Induction of labour if worsening
• Delivery should be hospital
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Polyhydramnious Cont…
NB: Before inducing labour any malpresentationshould be checked. While rupturing the membranes, hand should be in cervix for the following reasons:
1. To prevent cord prolapse
2. Feta and maternal distress are avoided
3. To prevent placental abruption
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Polyhydramnious Cont…
• Be ready to manage PPH!!!
• The baby should up sided down at birth and also carefully examined for congenital abnormalities!!!
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2. Oligohydramnious
Definition: Abnormally small amount of amniotic fluid which is less than 300 – 500 ml at term.
• Is a rare condition.
Causes:
• Renal agenesis in early pregnancy
• Fetal malformations and PROM in late pregnancy
• Postterm pregnaancy
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Oligohydramnious Cont…
Note: The lack of amniotic fluid reduces the intrauterine space and over time causes compression deformities:
• Squashed looking face
• Flattening of the nose
• Migrognathia
• Talipes equine varus
• Dry and leathery appearance of the skin
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Oligohydramnious Cont…
S/S:• Uterus is small for dates (early)• Uterus feels full of fetus (late)• Breech presentation is common• FHR is normal• Small columns by ultrasoundManagement: • Renal agenesis: Termination of pregnancy• PROM: Amino infusion by normal saline
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Premature Rupture of Membranes(PROM)
Definition: PROM Defined as spontaneous rupture of membranes at any(formerly 1 hr) time prior to on set of labour.
1. Preterm PROM (PPROM): if < 37 weeks
2. Tem PROM: if >37 weeks
Causes of PROM:
Precise cause is unknown but it is associated with:
History: patients often report a leakage or gush of clear fluid from the vagina.
Investigations:
1. Sterile speculum examination: Escape of fluid from the cervix may be seen spontaneously or following the pressure from the abdomen – valsalva maneuver
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PROM Cont…
2. Nitrazine paper test:
– Amniotic fluid is alkaline
– Vaginal secretions are acidic
3. Fern test: The best method;
4. Ultrasound: little or no amniotic fluid will be seen
5. Intra amniotic injection of dye
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PROM Cont…
Management of PROM:
The two main approaches of management are:
1. Conservative/ expectant and
2. Active
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PROM Cont…
1. Active Management: is preferred when the risk associated with PROM is greater than that is associated with termination of pregnancy(INFECTION)
When GA is less than 37 weeks
• Confirm diagnosis
• R/O Chorioamnionitis: fever, thachycardia, purulent vaginal discharge, uterine tenderness( When there is chorioamnionis induction is a must!)
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PROM Cont…
When there is no Chorioamnionitis and GA is less than 37 weeks conservative management is favored.
Conservative management at Hospital:
Purpose: to allow the fetus to reach stage of maturity.
1. Prevent infection in woman with PROM including dose.
2. Treat infection in woman with PROM including dose.
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Fetal Growth Abnormalities
1. Intrauterine Growth Restriction (IUGR)2. Intrauterine Fetal Death (IUFD)
A. Intrauterine Growth Restriction (IUGR)Definition: IUGR is fetal condition characterized by
failure to grow at the expected rate that can result in birth of small for gestational age (SGA) baby. (Estimated wt less than 10th percentile and abdominal circumference less than2.5th
• Occurs when the fetus has experienced early and prolonged nutritional deprivation caused by severe chronic maternal malnutrition, placental insufficiency, intrauterine infection or fetal chromosomal abnormalities.
• Hypoplastic cell growth and development occurs
• There is generalized defficency of cell number through out the body in all organ system.
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IUGR Cont…
• The neonate's body and head both appears small.
• The condition is associated with diminished brain size and permanent mental retardation.
II. Asymmetrical IUGR:
• Results from nutritional deficiencies and placental insufficiency in late pregnancy.
• Atrophy of pre existing cells occur, resulting in diminished cell size but cell numbers are not reduced.
• The neonate appears to have disproportionally large head in relation to his body.
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IUGR Cont…
• The body is long and emaciated with little subcutaneous fat, generalized muscle wasting, abdomen is scaphoid I shape, and the skin has poor skin turgor.
• Postnatal growth and development are rapid, and potential for normal intellectual function is excellent.
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IUGR Cont…
Management:• Check for possible causes and try to treat the
cause• Check for the fetal heart rate frequently• Instruct the mother to count fetal movements by
kick chart• Termination of pregnancy to get alive baby if
– The fetus is at high risk– Fetal lung maturity is adequate– GA is > 43 weeks
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B. Intrauterine Fetal Death (IUFD)
• Death of a fetus in uterus after 28 weeks of pregnancy.
• Rh –isoimmunization• Maternal diabetes mellitus (DM)• Post term pregnancy (Hypoxia)• Severe anemia etcNote:• In great number of instance, no cause is found• In majority of IUFDs, labour starts spontaneously
with in 2 weeks• Induction of labour should be done at 3 – 4
weeks to prevent DIC.
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IUFD Cont…
S/S of IUFD:
• Loss of fetal movements
• FHRs are absent
• No fetal movements by ultrasound
• Spalding’s sign - (overlapping skull bones by x-ray
• Roberts's sign – Gas in the heart & great vessels by x- ray
• Exaggeration of fetal spine curvature by x- ray
• Maceration
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IUFD Cont…
Complications of IUFD:• Bleeding• DIC (>3 weeks in utero)• Infection• Psychological traumaManagement:• Induction of labour if not started spontaneously• Antibiotics• Investigate for underlying causes: Rh, syphilis …
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IUFD Cont…
Assignment:
Write down the degrees(s/s, time span) of maceration of IUFD.
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Preterm Labour(PTL)
Definition: PTL is defined as labour occurring after 28 weeks but before 37 completed weeks of gestation.
• Complicates 5 – 15 % of all pregnancies.
• The single most important complication of PTL is prematurity and the care of premature infant is costly compared with term infants.
• Those born prematurely suffer greatly from increased morbidity and mortality.
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PTL Cont….
• Thus every effort should be made to prevent or inhibit preterm labor.
• If it can not be inhibited or is best allowed continuing, it should be conducted with the least possible trauma to the mother and infant.
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PTL Cont…
Risk Factors: • Race (Black > non back)• Low socio economic status• Poor nutrition and low pre pregnancy weight• History of previous PTL.• Second trimester abortion• Negative attitude towards pregnancy• Current pregnancy complications including placenta