o Single deep vertical pocket/ Single vertical

DISORDERS OF AMNIOTIC FLUID Pocket

May C. Gabaldon,MD  Probe at perpendicular &
longitudinal position at maternal
Roles of amniotic fluid abdomen
1. Physical space for musculoskeletal development  Measure single deep pocket
2. Permits fetal breathing and swallowing  Normal Value – 2-8 cm (UTZ
a. EGF- promote GIT and Respiratory Dev’t measurement)
3. Prevent umbilical cord compression  For twins, each gestational sac
4. Avertion of trauma should be measure
5. Bacteriostatic properties o Amniotic fluid index
 Divide the uterus into 4 quadrants
Normal AFV  Sum the SVP of all 4 quadrants
- 30 ml – 10 weeks  Exclude umbilical cord and fetus
- 200 ml – 16 weeks  Normal Value – 5-24 cm
- 800 ml – 3rd trimester
 Physical Examination
AFV Compostition: o Hydramnios/Polyhydramnios
 Abnorma AFV
- 98% water
 Seen in 1-2%
- Full-term – 2,800 ml
 Palpation – Increase in uterine size;
- Placenta – 400 ml
Difficulty palpating fetal small
parts
Source of AFV:  Auscultation – difficulty hearing
1. Early half FHT
a. Transmembranous  Differential Diagnosis:
i. Transfer from amnion  Twin pregnancy
b. Intramembranous
 Tumor
i. Transfer across the fetal membrane
 H. Mole
c. Fetal skin
Categories: Normal AFI Value:5-24cm
Amniotic Fluid Index Single Incidence
2. 2nd Trimester
Vertical
a. Fetal urine
Pocket
i. Start of production – 8-11 weeks
ii. Significant production - 18 weeks Mild 25 – 29.9 cm 8-9.9 cm 60%
b. Skin - Most common
i. 22-25 weeks – after which there is - 1-2% chance of congenital
keratinization so that the anomaly (mild to moderate)
transudation of fluid is inhibited Moderate 30- 34.9 cm 9cm 20%
Most common cause of abnormality – renal Usually benign or idiopathic
abnormality Severe >35 cm > 12cm
Preterm – extreme fluid loss - Think of underlying cause 15%
Fetal urine – hypotonic >10% chance of congenital anomaly
3. Late in Gestation
a. Fetal Urine  Theories for Pathology
Effects on Approx o Congenital Anomalies -15%
Volume Daily o Congenital Infections
Volume  CMV
Urination Production 1000ml  RBC alloimmunization
Intramembranous flow Resorption o Hydramnios is secondary to INCREASED
Fetal lung secretion Production fetalcardioactivity
o Diabetic Mellitus –
Fetal Swallowing Resorption 750 ml
 MATERNAL HYPERGLYCEMIA
Primary source – Fetal urine
 FETAL HYPERGLYCEMIA
Primary route of excretion – swallowing
 OSMOTIC DIURESIS 
HYDRAMNIOS
Diagnosis: o Anything that prevents fetal swallowing
 Sonographic assessment  CNS
o 2nd and 3rd trimester(due to 1st tri AFV is  GI Obstrution
30ml only)  Renal Anomaly
 Tumors
1|O B S T E T R I C S , 2 0 1 4
Trans by: Interior,F. & Garcia,J.A. edited by:Baluyot,Basalio,Ilano
  Thoracic anomalies - SVP - <2CM; AFI -<5cm
 Diaphragmatic hernia
 Thoracic sequestration Cause
Clinical Implication - Early onset
1. Targeted sonography/congenital anomaly scan o Abnormal fetal urination
a. No abnormality result – the likelihood of  Renal anomaly
major abnormality identified at birth, 1-2% - o Impaired uteroplacental function
mild to moderate hydramnios, >10% severe  HTN/Eclampsia
hydramnios  ↑fetal AVP - ↓fetal urine
o Rupture membranes
2. Amniocentesis - Prognosis is poor
a. Twin gestation - Diagnosis – targeted sonography
i. Twin-to-twin transfusion syndrome
(1 is polyhydramnios, 1 is - Mid pregnancy
oligohydramnios) o Associated with:
b. Aneuploidy o IUGR – request for Doppler artery studies
i. Abnormal increase risk of  To know degree/ extent
aneuploidy consider  If umbilical flow is DECREASED
amniocentesis consider delivering the baby
o Placental abnormality
HYDRAMNIOS  Vascular disorder/Preeclampsia
Prevalence  Investigate
- Idiopathic – 70% of cases  Membrane rupture
o 2% of infants with 4000g of birth weight  Growth assessment via
(macrosomic fetuses) UTZ
 Umbilical artery doppler
Complication:
1. Chronic - Post term pregnancy
a. Abdominal distention o Production of amniotic fluid
b. Gradual onset  DECREASE 8%/ week after 40
2. Acute weeks
a. Pressure symptoms (experience preterm  Manifested as non-reassuring fetal
labor before 28 weeks) heart pattern
i. Debilitating Dyspnea  Most cases is secondary to GUT
ii. Debilitating Orthopnea abnormality, aneuploidy, genetic
b. Edema of lower extremities and vulva (due syndrome
to aortocaval compression) o Biliary renal agenesis + limb contracture +
c. Oliguria compressed face + Pulmonary hypoplasia =
3. Maternal Complication POTTERS SYNDROME
a. Placental Abruption o Limb contracture + Compressed face +
b. Uterine dysfunction Pulmonary Hypoplasia = POTTERS
i. Inadequate uterine contraction SEQUENCE (no bilateral renal Agenesis)
ii. Over stretching of the abdominal
muscle Medication Induced:
c. Post partum haemorrhage 1. ACEI
i. Uterine atony a. Blocks RAAS fetal hypotension 
DECREASED kidney perfusion renal
Pregnancy Outcome: ischemia FETAL ANURIA(aneuric
- 3 fold increase in CS rate renal failure)
- Birth weight >4Kg 2. NSAID
- INCREASED 4 fold perinatal mortality a. PREMATURE CONSTRICTION OF
o INCREASED 20 fold if with IUGR FETAL DUCTUS ARTERIOSUS
o Associated with trisomy 18 acute/chronic insufficiency 
- Increase risk of preterm delivery DECREASE FETAL URINE
PRODUCTION
*anhydramnios – no pockets
QUESTION: what will you give for a mother in
pain? PARACETAMOL
Oligohydramnios
- Abnormal decrease in AFV

2|O B S T E T R I C S , 2 0 1 4
Trans by: Interior,F. & Garcia,J.A. edited by:Baluyot,Basalio,Ilano
Pregnancy Outcome  Augmentation
- Malformation o Enhance spontaneous contractions of the
- Stillbirth patient
- Preterm birth  Done because of insufficient
- Growth restriction uterine contractions for cervical
- Non reassuring fetal status dilation and fetal descend.
- Meconium aspiration syndrome
Indication for induction of labor:
Pulmonary Hypoplasia 1. Membrane rupture without labor
- Associated with oligohydramnios occurring 20-23  During very early pregnancy with leaking bag of
weeks AOG water:
- Chronic abruption sequence →placental hematoma o Expectant management done
→oligo: causes growth restriction and with poorer  Bed rest
prognonis  Antibiotics: prevent or avoid
- Expectant management – if baby is doing okay chorioamnionitis
continue pregnancy  Watchful waiting
- Variable deceleration
 During midpregnancy or late pregnancy
o Due to cord compression
o Induction of labor must be done to prevent
o Treatment- amnioinfusion
Management: development of infection
- Underlying etiology 2. Gestational hypertension
- Evaluation for fetal abnormality and growth o Causes uteroplacental insufficiency leading
- Preterm delivery for maternal complication to undesirable environment for the baby to
stay in the womb.
- Normal fetal anatomy and growth do expectant
3. Oligohydramnios
management and close surveillance
4. Nonreassuringfetal heart status
- AMNIOINFUSION- indicated only in Variable Fetal
5. Post term pregnancy
Heart Rate Deceleration due to cord compression.
6. Chronic hypertension
Significance
7. Diabetes mellitus
VFHRD: Cord Compression
o CAUTION: delay in pulmonary maturity
Early Deceleration: head compression
Contraindications for induction of Labor
Borderline Oligohydrmanios
MATERNAL CONTRAINDICATIONS:
- AFI 5-8 cm (BPS=2,with in Normal limit)
- Hindi siya oligohindi din poly 1. Uterine incision type
Types of uterine incisions:
Complication o CLASSICAL incision: vertical incision
- CS above the lower uterine segment, MOST
- Preterm delivery commonly associated with uterine rupture
- FGR o KERR incision: transverse incision in the
Management lower uterine segment, LEAST associated
- Insufficient evidence to support fetal testing or with uterine rupture
delivery o KRONIGS incision: longitudinal incision in
- Correlate clinically the lower uterine segment
2. Distorted maternal pelvic anatomy
INDUCTION OF LABOR 3. Abnormal placental implantation
o Ex: placenta previa
 Stimulation of uterine contraction BEFORE
4. Maternal genital herpes
spontaneous onset of labor
o Must be ACTIVE GENITAL HERPES
o Example: walang uterine contraction,
o If (+) history of genital herpes with no
walang spontaneous onset of labor, may
active lesion during labor or delivery,
rupture of bag of water: angtawag pa din jan
induction CAN PROCEED
ay INDUCTION OF LABOR
5. Cervical cancer
o Increased risk for bleeding
Initial step in doing induction for close and uneffaced
*** sa exam daw tignanngmaigi kung anoangtinatanong.
cervix : CERVICAL RIPENING
Kung MATERNAL or FETAL contraindications
 Kasi dapat munang palambutin ang
cervix para makapagdilate
o Use of PROSTAGLANDIN
3|O B S T E T R I C S , 2 0 1 4
Trans by: Interior,F. & Garcia,J.A. edited by:Baluyot,Basalio,Ilano
FETAL CONTRAINDICATIONS 2. Woman who lives in a long distance from the
1. Macrosomnia hospital
2. Severe hydrocephalus 3. Psychological manifestations
3. Malpresentation
4. Nonreassuring fetal status in abnormal fetal Factors affecting successful induction:
environment 1. Multiparity
2. BMI: <30
Before induction: 3. Favourable cervix: (Bishop’s score)
 CST must be done to know if the baby can tolerate 4. Birth weight: <3500g
the stress of labor 5. Bishop score: equal or more than 9
6. Latent phase of 18 hours
Techniques for labor induction:
1. Oxytoxin Preinduction Cervical Ripening
2. Prostaglandin (Misoprostol/Dinoprostol)  Use of prostaglandin E2 (dinoprostone), PGE1
3. Mechanical methods: (misoprostol)
o Membrane stripping  Use of mechanical techniques
o Amniotomy o Transcervical catheter
o Cervical dilators o Extra-amniotic saline infusion
o Extra-amniotic saline infusion o Hygroscopic cervical dilators
Cervical Favorability
Maternal complications  Bishop score: 9 = high likelihood of successful
1. Increase for cesarian section rate induction
o Risk is not affected by Bishop’s score  Bishop score: less than 4 = unfavourable and may be
o 2-3x increased in nulliparas however they an indication of cervical ripening
are inversely related to bishop’s score
o If Bishop’s score is high = favorable cervix
= increased chance of vaginal delivery
o If Bishop’s score is low = increased cesarian
section rate
2. Risk for chorioamnionitis
3. Uterine rupture from prior uterine incision
o History of CS then nagvaginal delivery un
mother, risk for rupture is increased 3x
o But if with history of CS then oxytoxin was Pharmaceutical techniques
given, risk for rupture is increased 5x 1. Prostaglandin E2 – dinoprostone
o But if (+) history of CS + oxytoxin +  Three forms: gel form, vaginal insert, suppository
prostaglandin = risk for rupture increased  Expected time of delivery: within 24 hours, however
16x it does not decrease CS rate
o Recommendation: ACOG: Misoprostol  ↑ risk of maternal complication
(prostaglandin) use is contraindicated for  ↑ risk of uterine tachysytole
cervical ripening or labor induction among o Prepidil:
patient with prior uterine scar.  Gel form
4. Postpartum hemorrhage from uterine atony  When coupled with OXYTOXIN:
o Uterotonics can cause uterine muscle fatigue improves bishop score and lowered
o Because all receptors are already occupied induction-to-delivery
overwhelming the receptors thus saturating  No benefit for lowering cesarian
the receptors delivery rate
5. Uterine Atony o Cervidil
o Associated with selective induction  Vaginal insert
o ↑risk: 3x  Combined with OXYTOXIN:
shortens induction-to-delivery
Elective Labor Induction interval
 Not usually done because of increased risk for
maternal outcome
 Accepted only with the following logistical reasons:
1. Risk of rapid labor

4|O B S T E T R I C S , 2 0 1 4
Trans by: Interior,F. & Garcia,J.A. edited by:Baluyot,Basalio,Ilano
 Administration:  25mcg: recommend dose for cervical ripening for
vaginal dose
 For postpartum haemorrhage: 4 whole
tablets rectally
 Decreases the need for oxytoxin
induction and reduce induction-to-delivery
intervals
 CAUTION: increased rate of uterine
hyperstimulation with fetal heart rate changes
 50mg intravaginal dose: effects:
 significant
increased uterine
tachysytole
 meconium
passage
 meconium
aspiration
 Uterine rupture: risk for women with
prior cesarian delivery.

3. Nitric Oxide Donors –

Isosorbidemononitrate, glycerol trinitrate
 NOT USEFUL

Mechanical Techniques in comparison with:

o Prostaglandin – reduces risk of uterine
tachysystole but CS rate in unchanged.
o Oxytocin lowes the CS rate
o Depends on UTERINE ACTIVITY
o Dinoprostone
o If given, WAIT FOR 12HOURS BEFORE GIVING
o Higher rate of multiparous women delivered
OXYTOXIN; may lead to UTERINE
in 24hours
TACHYSYSTOLE IF GIVEN IMMEDIATELY(gel
o Similar rates of CS and lesser tachysytole
preparation)
o If vaginal insert, wait for 30minutes
Mechanical Techniques
o UTERINE ACTIVITY and FETAL HEART RATE
1. TranscervicalCatheter
MONITORING should be performed.
a. Only used when cervix in unfavourable
b. Higher infection rates compared to pg unless
Side Effects:
saline is infused
o Uterine tachysystole: more than 5 contractions in a
c. Do not show reduction in CS rate compared
10-minute period, fetal heart rate abnormality
to PG
MAY/MAY NOT be present
d. Similar outcome to vaginal PG
o Other name: “uterine hypertonus,” “uterine
2. Extra-amniotic Saline Infusion
hyperstimulation”
3. Hygroscopic cervical dilators
a. Osmotic cervical dilators
Contraindications:
b. Laminaria
o Cephalo-pelvic disproportion
c. Rare reports of anaphylaxis
o Same as the contraindications for induction
d. Inexpensive
o Hypersensitivity to the drug
e. MOA: H20 absoprtion, dilating cervix
o Fetal compromise
4. Membrane stripping for labor induction
o Acute vaginal bleeding
o (+) history of >6 preterm deliveries
Labor Induction and Augmentation with Oxytoxin
o Any obstetrical contraindications for vaginal delivery
(uterotonic)
Goal: To effect uterine activity sufficient to produce
2. Prostaglandin E1 – Misoprostol (Cytotec)
cervical change and fetal descend while avoiding
 Marketed for peptic ulcer prevention
development of a non reassuringfetal status
5|O B S T E T R I C S , 2 0 1 4
Trans by: Interior,F. & Garcia,J.A. edited by:Baluyot,Basalio,Ilano
  Discontinued if:
o Uterine tachysystole persist
o Persistent nonreassuringfetal heart rate
pattern
 Conditions stated above returns to normal since
HALF-LIFE of oxytoxin is approximately 3-5
MINUTES.
 Responses are variable due to the following
determinants:
o Pre-existing uterine activity
o Cervical status
o Pregnancy duration
o Individual biologic differences
 Dose: 10-20 units per 1L of crystalloids
o NEVER MIX OXYTOXN TO FLUIDS
WITH NO ELECTROLYTES: increases
risk for water intoxication
o Adjustments:
o Interval 15-40 minutes
 Side effects:
o Uterine rupture
o Antidiuretic: homologue of AVP
o Water intoxication: to prevent, increase
concentration rather than the flow rate, mix
with electrolyte containing fluid

Elective Amniotomy
Indications:
 Direct fetal heart rate monitoring
 Accelerate labor: increased by 1-1 ½ hours specially
if amniotomy done with 5cm dilatation (active labor)

Complications:
 Cord prolapsed-to avoid:make sure the head cannot
dislodge to cervix,hold the fundus.
 Increased risk of developing chorioamnionitis

Membrane Stripping
 Done to decrease the incidence of post term delivery
Advantage:
 Does not cause uterine rupture,infection
 Causes minimal bleeding
 Safe

Disadvantage:
 Discomfort
 Minimal bleeding.

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6|O B S T E T R I C S , 2 0 1 4
Trans by: Interior,F. & Garcia,J.A. edited by:Baluyot,Basalio,Ilano