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DeIinition:
he amniotic fluid is the normally clear fluid that
collects within the amniotic cavity increases as
pregnancy progresses until about 34 weeks, when there is a
decrease in volume. An average volume of about 1000 mL is
found at term, although this may vary widely from a few
milliliters to many liters in abnormal conditions (Barss VA et
al., 1984).
EmbryoIogy of amniotic membranes & amniotic cavity:
Amnion
%he amnion at term is a tough and tenacious but
pliable membrane. t is the innermost fetal membrane and is
contiguous with amnionic fluid. %his particular avascular
structure occupies a role of incredible importance in human
pregnancy. n many obstetrical populations, preterm
prematurely ruptured fetal membranes are the single most
common antecedent of preterm delivery. %he amnion is the
tissue that provides almost all of the tensile strength of the
fetal membranes. %herefore, the development of the
components of the amnion that protect against its rupture or
tearing is vitally important to successful pregnancy outcome
(Piantelli et al., 2004).
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Amnion Structure
Bourne (1962) described five separate layers of
amnion tissue. %he inner surface, which is bathed by
amnionic fluid, is an uninterrupted, single layer of cuboidal
epithelial cells, believed to be derived from embryonic
ectoderm. %his epithelium is attached firmly to a distinct
basement membrane that is connected to the acellular
compact layer, which is composed primarily of interstitial
collagens. On the outer side of the compact layer, there is a
row of fibroblast-like mesenchymal cells, which are widely
dispersed at term. %hese are probably derived from
mesoderm of the embryonic disc. %here also are a few fetal
macrophages in the amnion. %he outermost layer of amnion
is the relatively acellular zona spongiosa, which is
contiguous with the second fetal membrane, the chorion
laeve. %he human amnion lacks smooth muscle cells,
nerves, lymphatics, and importantly, blood vessels.
Amnion DeveIopment
Early in the process of implantation, a space develops
between the embryonic cell mass and adjacent trophoblasts.
Small cells that line this inner surface of trophoblasts have
been called amniogenic cells, the precursors of amnionic
epithelium. %he human amnion is first identifiable about the
seventh or eighth day of embryo development. nitially a
minute vesicle, the amnion develops into a small sac that
covers the dorsal surface of the embryo. As the amnion
enlarges, it gradually engulfs the growing embryo, which
prolapses into its cavity (Benirschke et al., 2000).
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from Cilbert WM, Moore 1R, Brace RA: Amniotic fluid volume
dynamics. etal Med Review 3:89, 1991) (Cabbe et al., 27).
ormal amniotic fluid volume:
As a result of various limitations, attempts to measure
actual AFV are difficult. t is not easy to get near, or into, the
amniotic compartment. %o enter the amniotic cavity, an
invasive procedure such as an amniocentesis must be
performed. %o measure the volume of AF, an inert dye must
be injected, which dilutes to fill the amniotic cavity. Follow-up
samples of amniotic fluid are then obtained to determine a
dilution curve. Obviously, an amniocentesis has a small but
real risk of interrupting the pregnancy, and any substance
injected into the uterus can cause infection despite every
precaution being taken. %he dye injection technique is
considered the "gold standard for determining actual AFV
and is compared with other methods of estimating AFV, such
as ultrasound (Magann et al., 1992).
Despite these measurement limitations, Brace and Wolf
identified all published measurements of AFV in 12 studies
with 705 individual AFV measurements. %heir findings are
demonstrated in Figure 4 . From this figure, it can be seen
that for each week of gestation, there can be widely varying
amounts of AF, which increase with advancing gestational
age. %he largest variation occurs at 32 to 33 weeks of
gestation. At this time, the normal range (5th to 95th percent)
is from 400 to 2100 ml. %his represents a wide "normal
range. One of the most interesting findings of the Brace and
Wolf study is that from 22 weeks through 39 weeks of
gestation, the average volume of AF (black dots on Fig. 1 )
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Pulyhydramnius
Midgestation PoIyhydramnios:
%he pregnant woman who presents with a rapidly enlarging
uterus in midpregnancy, or who presents in preterm labor,
will most likely have a fetus with a congenital malformation
or aneuploidy, or both. Severe polyhydramnios in the second
trimester has a significant PMR, which is most commonly
due to prematurity or aneuploidy.
%he more common
congenital malformations associated with severe
polyhydramnios include the host of defects associated with
gastrointestinal obstruction. Esophageal atresia with or
without tracheoesophageal fistula can present with early-
onset severe polyhydramnios owing to the blockage of fetal
swallowing.
With certain malformations, AFV may still be normal
because a tracheoesophageal fistula, for example, provides
for the movement of fluid into the stomach, and thus,
polyhydramnios may not develop. Other gastrointestinal
obstructions such as duodenal atresia may result in
polyhydramnios. Whenever a structural defect is seen in a
fetus, consideration should be given to performing a
karyotype owing to the dramatic increase in aneuploidy seen
with one or more structural defects. Knowing the karyotype
of the fetus with a defect may allow for further treatment
options, or possible pregnancy termination. %he fetus with
polyhydramnios and trisomy 18 would be a candidate for
pregnancy termination at any point in the pregnancy owing
to the lethal nature of trisomy 18 (Pauer et al., 2003).
Another common cause of acute, severe,
polyhydramnios in the second trimester is the condition
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