TJOK.

GDE AGUNG SUWARDEWA

FETOPMATERNAL DIVISION
DEPARTMENT OF OBSTETRIC-GYNECOLOGY
MEDICAL FACULTY OF UDAYANA UNIVERSITY
SANGLAH GENERAL HOHPITAL
DENPASAR-BALI
AMNIOTIC FLUID
AMNIOTIC FLUID PHYSIOLOGY
Amniotic fluid serves a number of important
functions in the normal development of embryo
and fetus:
As cushions physical trauma
Allow for growth of the fetus free from restriction and
distortion by adjacent structures
Provides for a thermally stable environment
Allow the respiratory, GI tract, and musculoskeletal system
to develop normally
Help to prevent infection
Provides a short-term source of fluid and nutrients to the
developing embryo.
AMNIOTIC FLUID REGULATION
PRODUCTION ABSORPTION
SKIN
GIT
PLACENTAL
RESPIRATORY
MEMBRANE
UTERINE WALL
URINARY

AMNIOTIC
FLUID
VULUME

Under normal circumstances, the amniotic fluid is in a state

of dynamic equilibrium between production and absorption.
Available exchange surfaces are: amniotic epithelium,
umbilical cord, fetal skin, GI tract, and urogenital tract.
Merz, 2005
 REGULATION (continues)
Intra membranous flow reach nearly 400mL/day at
term. Kidney & lung

Diffusion across this permeable barrier continues

until fetal keratinizing at 24 to 26 weeks gestation.

Latter half of gestation, the two primary sources of

AF are the fetal kidneys and lungs.
24-26
The presence of AFV in first and second trimester
implies that at least one functioning kidneys must
be present.

The primary sources of AF removal are the GI tract

(swallowing) and absorption into the fetal blood
per fusing the surface of the placenta. Skin and
Plac. Memb.
Summary of water flows into and out of amniotic space in late gestation. (from Brace RA:
Physiology of amniotic fluid volume regulation. Clin Obstet Gynecol 40:286, 1997)
NORMOGRAM SHOWS AMNIOTIC FLUID VOLUME AS A FUNCTION OF
GESTATIONAL AGE ON LINEAR SCALE

From Brace RA, Wolf EJ: Normal amniotic fluid volume changes
throughout pregnancy. Am J Obstet Gynecol 161: 386,1989
 ULTRASOUND AND AMNIOTIC FLUID
ESTIMATION
The recognition of the importance of amniotic fluid in fetal
development made it imperative to develop methods of
assessing the AFV throughout pregnancy.

Acute and severe excess of AF readily able to recognize, it

was often difficult to recognize too little amniotic fluid.

The technique of subjective assessment of AF involves

comparing the echo-free fluid areas surrounding the fetus
with the space occupied by the fetus and placenta.

Manning et all : single-deepest-perpendicular to the floor

of AF pocket.

Manning FA, Hill LM, Platt LD: Qualitative amniotic fluid volume determination
By ultrasound: Antepartum detection of intrauterine growth retardation. Am J
Obstet Gynecol 139: 254, 1981.
 Amniotic Fluid Index Technique
Position patient supine

A linear, curvilinear, or sector transducer can be used

Divided the uterus into four quadrants using the maternal sagittal
midline vertically, and orbitrary transverse line approximately halfway
between the symphysis pubis and the upper edge of uterine fundus.

The transducer must be kept parallel to the maternal sagittal plane

and perpendicular to the maternal coronal plane throughout

The deepest unobstructed and clear pocket of amniotic fluid is

visualized, and the image frozen. The ultrasound calipers are
manipulated to measure the pocket in a strictly vertical direction

The process is repeated in each of four quadrant and the pocket

measurement summed = AFI

If the AFI < 8 cm, perform the four quadrant evaluation three times
and average the values
 AMNIOTIC FLUID ABNORMALITY
(OLIGOHYDRAMNION)
Technique Definition Study
Ultrasound Single vertical pocket < 0,5 cm Mercer et all
Ultrasound Single vertical pocket < 1,0 cm Manning, Hill, an Platt
Ultrasound Single vertical pocket < 2,0 cm Manning et all
Ultrasound Single vertical pocket < 3,0 cm Halperin et all, Crowly, OHerlihy,
and Boylan
Ultrasound Two diameter pocket (vertical x Magann et all
horizontal) < 15,0 cm
Ultrasound Amniotic Fluid Index < fifth Moore and Cayle
percentile for gestational age
Ultrasound Amniotic Fluid Index < 5,0 cm Phelan et all
Ultrasound Amniotic Fluid Index < 7,0 cm Dizon-Townson et all
Ultrasound Amniotic Fluid Index < 8,0 cm Jeng at all

From Callen: Amniotic Fluid: Its Role in Fetal Health and Disease.
Ultrasonographic In Obstetric and Gynecology, 4th ed: 642, 2000.
CAUSES OF OLIGOHYDRAMNIOS

Oligohydramnios may be due to

a variety of conditions, including:
1. Urinary tract abnormality:
Renal agenesis
Bilateral renal obstruction
Bilateral renal dysplasia
Posterior urethral valves or atresia

2. Utereroplacental insufficiency
leading to IUGR

3. Premature Rupture of
the Membranes (PROM)

4. Post term pregnancy

 AMNIOTIC FLUID ABNORMALITY
(POLYHYDRAMNIOS)
Polihydramnios or hydramnion is an excessive
accumulation of amniotic fluid at same time
during pregnancy.

Incidence varies from 0,2%-3,3% and depends

on how this abnormality is defines.

Pathologically and clinically it is define as an

excess of amniotic fluid greater than 1500 to
2000 ml.

Aside of association with fetal and maternal abnormalities, polyhydramnios itself

may result in perinatal morbidity.

In patient with severe polyhydramnios and difficulties with pain and breathing,
therapeutic amniocenteses are often performed.
DIAGNOSIS HYDRAMNION

SUBJECTIVE
Second trimester : fluid-fetus ratio > 1 : 1
Third trimester : excessively large pocket of fluid
Fetus displaced away from anterior uterine wall

SEMIQUANTITATIVE
Maximum vertical pocket (MVP) : > 8 cm
Amniotic fluid index (AFI) : > 24 cm
Two diameter pocket (TDP) : > 50 cm2
POSSIBLE CAUSES OF HYDRAMNION
Fetal causes:
Neural tube defect
Obstruction of upper and middle digestive tract
Cardiac anomalies
Immune and non Immune fetal hydrops
Arthrogryposis multiplex congenita

Maternal causes:
Diabetes millitus
Rh incompatibility

Other causes:
Chorioangioma
Fetofetal transfusion syndrome
UMBILICAL
CORD
 NORMAL ABNORMAL
ANATOMY AND PHYSIOLOGY SINGLE UMBILICAL ARTERY
LENGTH
VESSELS PERSISTENT RIGHT UMBILICAL VEIN

UMBILICAL CORD BIOMETRY KNOTTING

CORD DIAMETER
UMBNILICAL VESSEL DIAMETERS COILING

CYST

HEMATOMA, VENOUS THROMBOSIS

TUMORS

VARIATION OF UMBILICAL CORD

INSERTION
 ANATOMY AND PHYSIOLOGY
Length : 50-70 cm in the end of
pregnancy (long > 90 cm, short < 40 cm )

Thick : 1-1.5 cm (<2cm,Weissman,1994)

Vessels : two arteries, carry

deoxygenated blood, and one vein,
return oxygenated blood.

Vein larger than arteries

Weissman A, Jacobi P, Bronshtem M, et all: Sonographic measurement of

Umbilical cord and vessels during normal pregnancies. J Ultrasound Med 13:11,1994
UMBILICAL CORD BIOMETRY
Cord diameter :
Averaging the largest and smallest cross
section.
Measurement is an outer-to-outer

Vessel diameter :
Inner-to-inner
Vein > arteries
Diameter artery > 4 mm (20-36 weeks),
considered strong evidence SUA
 Single Umbilical Artery

Incidence : 0,5-2,5% of pregnancy

Etiology and pathogenesis:

Primary agenesis of umbilical artery
Secondary atrophy or atresia of an
original normal umbilical artery
Persistence of an original allantoic
artery

Risk factors:
Maternal diabetes,
Epilepsy,
Hypertension,
Oligo and polyhydramnios
 Single Umbilical Artery
Ultrasound evaluation:
Cross scan : Mickey mouse pattern
Color Doppler

Associated anomalies
Benirschke and Brown : 27 0f 55 patients
(49%) exhibited congenital anomalies.
Other studies: perinatal mortality,
premature delivery, IUGR, chromosome
abnormality.

Overall incidence 20%-50% :

Musculoskeletal (23%)
Genitourinary (20%)
Cardiovascular (19%)
Gastrointestinal (10%)
 Single Umbilical Artery

Increased incidence of chromosomal disorders.

The most common is Trisomy 13, Turner syndrome,

and Triploides.

Growth restriction : 20%

Management :
Detailed USG
Fetal echocardiography
Karyotyping
Regular monitoring fetal growth and condition
Thorough examination of the neonate
 Coiling of the Cord

Incidence: 20-33% Merz,2005

The normal umbilical cord coiling index (UCI) is calculated as

the number of complete coils divided by the length of the
cord in centimeters.

The mean (SD) UCI was 0.17 (+/- 0.009) coil/cm.

Abnormal coiling: UCI < 10th centile (<0.07) or greater than

90th centile (>0.03) has been associated with adverse
pregnancy outcome.
Callen,2008
 Coiling of the Cord
Hypocoiling: ass. with increased incidence of
Fetal demise
Intrapartum fetal heart deceleration
CS due to fetal distress
Cromosome abnormalities
Chorioamnionitis

Hypercoiling: ass. with increased incidence of

Fetal growth restriction
Intrapartum fetal heart deceleration
Vascular thrombosis
Cord stenosis
 Umbilical cord abnormalities
(Others)

HEMATOMA
KNOTTING
CYST

THROMBOSIS

PERSISTENT RIGHT
UMBILICAL VEIN
TRUE KNOT
Umbilical cord abnormalities
(OTHERS)
PLACENTA
 NORMAL PLACENTA

MORFOLOGY
PLACENTAL CIRCULATION
ULTRASOUND ANATOMY
PLACENTAL BIOMETRY
PLACENTAL STRUCTURE & MATURATION
 PLACENTAL ABNORMALITIES
ABNORMALITIES OF PLACENTAL SHAPE
ABNORMALITIES OF PLACENTAL LOCATION
ABNORMAL PLACENTAL BIOMETRY
PLACENTA: ACCRETA, INCCRETA, PERCCRETA
PLACENTAL HORMONAL
PLACENTAL ABRUPTION
PLACENTAL INFARCTION
TUMORS OF PLACENTA
UNFUSED AMNION
AMNIOTIC BANDS
AMNIOTIC BAND SYNDROME
NORMAL PLACENTAL LOCATION

ANTERIOR, AT 20 WKS POSTERIOR, AT 27 WKS

RIGHT SIDEWALL 21 WKS FUNDAL (long scan) 21 WKS

ABNORMAL PLACENTAL LOCATION
Vaginal bleeding in the second and third trimester is always
suspicious for an abnormal placenta location with premature
abruption or marginal sinus hemorrhage.

Ultrasound in the second trimester can demonstrate placenta

previa in more than 5% of all pregnancy, but the incidence of
placenta previa at term is only 0.5%.

The phenomenon of superior placental migration appear to

result from then longitudinal and transverse growth of the
lower uterine segment.

The definitive placenta previa should not be diagnosed until

the third trimester.,
ABNORMAL PLACENTAL LOCATION
PLACENTA PREVIA

a. Low-lying placenta (0,5-5 cm)

b. Marginal placenta previa

c. Partial placenta previa

d. Complete placenta previa

Ratko Matijevic. The placenta. In Donald School, Text Book of Ultrasound

in Obstetrics and Gynecology, 2003; 326 .
 Low-lying placenta
Low-lying placenta, longitudinal scan at 18 weeks 0.5-5.0 cm from the OUI
(from Merz, 2005)

A low lying placentathe

placenta is implanted in
the lower uterine segment
Placenta such that the placental
edge is within 2 cm of
internal cervical os but
not covering any
2,0 cm significant portion of it.
Internal cervical os

Harris RD, Alexander RD. Ultrasound of the placenta and umbilical cord.
In Callen, Ultrasonography in Obstetry and Gynecology 4th ed, 2000; 607.
 Marginal placenta previa
Marginal placenta previa on the posterior uterine wall
Longitudinal scan at 17 weeks

Marginal placenta
previa the edge of
Placenta
the placental is at
the margin
of the internal os

Harris RD, Alexander RD. Ultrasound of the placenta and umbilical cord.
In Callen, Ultrasonography in Obstetry and Gynecology 4th ed, 2000; 607.
 Partial placenta previa
Partial placenta previa on the anterior uterine wall The edge of the
Longitudinal at 14 weeks
placenta partially
covers the
internal os
Placenta

vu

vagina

Harris RD, Alexander RD. Ultrasound of the placenta and umbilical cord.
In Callen, Ultrasonography in Obstetry and Gynecology 4th ed, 2000; 607.
 Complete placenta previa
Complete placenta previa the internal
cervical os is covered completely by the
placenta

Avoid over distension of the bladder

or uterine contraction causing a
false-positive diagnosis of a previa

Trans-vaginal USG early in pregnancy:

The chance of a term previa is 5% if
the placenta extends > 15 mm over
the cervical os at 12 to 16 weeks.
Complete placenta previa.
Longitudinal scan at 17 weeks.

Harris RD, Alexander RD. Ultrasound of the placenta and umbilical cord.
In Callen, Ultrasonography in Obstetry and Gynecology 4 th ed, 2000; 607.
ABNORMAL PLACENTAL SHAPE
 PLACENTAL BIOMETRY
Placental thickness :
In normal pregnancy the placental
thickness increases steady between
15 and 37 weeks.

Thereafter, the placenta thickness

decreases slightly until the 40 weeks.

Hoddick at all : max placental

thickness 3 cm up to 20 weeks and
maximum of 4-5 cm thereafter.
 Abnormal placental biometry
Thick placenta :
Found in cases where the basal plate has a very small area of
myometrial attachment.
Can occurs in : DM, maternal anemia, hydrops, placental
hemorrhage, intrauterine infection, congenital neoplasm,
Beckwith-Wiedemann syndrome, sacrococcygeal teratoma.

DM Hydrops XXX, triploidi

5 cm
7,4 cm
6,4 cm
 Abnormal placental biometry
Placental hydrops :
Thickest placentas are found in cases of Rh incompatibility and non
immune fetal hydrops. A placental thickness greater than 5 cm is
term placental hydrops. Causes by fluid retention.

Hydrops

6,4 cm
 Abnormal placental biometry
Large, vacuolated placenta :
When combined with oligohydramnios, this type of placenta is
suspicious for triploidi.
 Abnormal placental biometry
Small or thin placenta :
A small placenta is found in cases of IUGR, intrauterine
infection, and chromosome abnormalities. Very thin
placentas may be found in massive polyhydramnios.
Placenta Acreta, Increta, Percreta
Definitions
Abnormal penetration of placental tissue beyond
endometrial lining of uterus.
Three varians of the spectrum collectively termed
placenta accreta.
Placenta accreta vera (80%)
Attaches to myometrium without muscular invasion
Placenta increta ( 15%)
Chorionic villi invade the myometrium
Placenta percreta (5%)
Penetration of chorionic villi through uterus
May also invade rectum and bladder
Predisposing factors and pathogenesis

Predisposing :
High parity
Scarring of uterine corpus
Prior cesarean section
Placenta previa
 Ultrasound Findings
Best diagnostic clue :
Loss of subplacengtal hypoechoic zone
Irregular placental vascular lacunae
Placenta previa in almost all cases
Large vessels extending through myometrium +/- into
bladder
Incidence : one in 500-70,000 pregnancies
 Imaging Findings

ACCRETA INCRETA PERCRETA