Amniotic Fluid Dynamics

William M. Gilbert
NeoReviews 2006;7;e292-e299
DOI: 10.1542/neo.7-6-e292

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Article

neonatology

Amniotic Fluid Dynamics

William M. Gilbert, MD*

Author Disclosure
Dr Gilbert did not

Objectives

After completing this article, readers should be able to:

1. Describe clinical assessments of amniotic fluid volume.

2. Explain the processes of amniotic fluid formation and removal.
3. Describe the presentations and treatments for oligohydramnios and polyhydramnios.

disclose any financial

relationships relevant
to this article.

Introduction
Fortunately for most healthy pregnant women, amniotic fluid (AF) is an unimportant
byproduct of the delivery. Little attention, if any, is paid to the AF unless meconium
staining occurs in labor. It is only in the presence of certain complications that may
compromise fetal well-being that any interest is taken in the AF. When there is too much
AF (polyhydramnios) or too little (oligohydramnios), perinatal morbidity or mortality may
be increased significantly, raising sudden concern among patients and clinicians. When
severe oligohydramnios occurs in the second trimester, the perinatal mortality rate
approaches 90% to 100%. (1)(2)(3) Similarly, with severe polyhydramnios in midpregnancy, the perinatal mortality rate can be greater than 50%. (4)(5) Attempts to study
abnormalities of AF are hindered by the realization that little is known about the processes
involved in the regulation of normal amniotic fluid volume (AFV).
This review examines the limited information available on the normal physiology of
AFV regulation, including routes of formation, removal, and regulation and the changes in
AF composition across gestation. Additionally, the clinical impact and treatment options
on disease conditions are discussed.

Normal Amniotic Fluid Volume

Attempts to measure actual AFV are limited by the invasiveness required to access the
amniotic cavity. The most common method is injection of an inert dye into the amniotic
cavity via amniocentesis, followed by timed removals of AF to determine a dilution curve.
(6)(7)(8)(9) This method has been shown to be accurate compared with actual measurement of AF, but because of its invasive nature, has limited application to clinical practice.
Brace and Wolf (10) examined the literature to the time of their publication (1989) and
identified all published measurements of actual AFV in 12 studies that included 705
individual AFV measurements (Fig. 1). They documented a wide variation in AFV for each
week of gestation, which became more pronounced as gestational age advanced. The largest
variation in AFV occurred at 32 to 33 weeks of gestation, with 5th and 95th percentiles being
400 and 2,100 mL, respectively. Although this represents a large normal range, the most
interesting factor was that average AFV remained constant from 22 weeks to 39 weeks of
gestation. The average AFV was the same for a fetus weighing approximately 500 g up to a
term fetal weight of 3.5 kg, suggesting some form of regulation.

Clinical Assessments of Amniotic Fluid Volume

Initial attempts to determine AFV clinically included direct uterine palpation. If the uterus was
large for gestational age or if the fetus could not be palpated by Leopold maneuvers,
polyhydramnios was diagnosed. The ultimate diagnosis of polyhydramnios was made at the
time of delivery. Oligohydramnios often was considered a diagnosis if the uterus measured
small for gestational age or if the fetus could be palpated easily. Methods of determining AFV
by palpation are limited by their subjective nature and poor interobserver reliability.
*Regional Medical Director, Womens Services, Sutter Health, Sacramento Sierra Region; Clinical Professor, Department of OB/
GYN, University of California, Davis, Sacramento, Calif.
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neonatology

amniotic fluid

Figure 1. Nomogram showing amniotic fluid volume as a

function of gestational age. The black dots are the mean for
each 2-week interval. Percentiles calculated from polynomial
regression equation and standard deviation of residuals. Reproduced with permission from Brace RA, Wolf EJ (10) with
permission from Elsevier.

With the advent of real-time ultrasonography, AF

could be seen, and attempts to measure it began. Initial
ultrasonographic estimations of AFV were made by measuring the largest vertical pocket (LVP) of AF (11) or the
largest two-dimensional pocket of AF. (12) Chamberlain
and associates (12) and others (13) demonstrated that
when the LVP was less than 1 cm, perinatal morbidity
was increased, and when it was less than 0.5 cm, the
perinatal mortality rate was increased. The use of small
cutoff values for the LVP identified high-risk groups but
missed other patients who had higher values of the LVP
but significant perinatal morbidity.
Attempts to improve the sensitivity for measuring
AFV by ultrasonography resulted in the amniotic fluid
index (AFI), which is the measurement of the LVP in
each of four quadrants of the pregnant uterus. Initially
termed the AFI by Phelan and associates (14) and more
extensively studied by others, (15) the normal range of
the AFI can be seen in Figure 2. This graph of the AFI
looks fairly similar to the nomogram of AFV as a function
of gestational age (Fig. 1), including wide ranges at each
gestational age and a consistent average AFI from
22 weeks of gestation until term. The AFI normal range
varies for each gestational age, suggesting that a single
value for the AFI does not determine the upper (or
lower) limits of normality. The clinician must know the
gestational age to determine the individual 5th and 95th
percentiles. Today, the AFI is used widely to estimate the

Figure 2. Amniotic Fluid Index (in mm) plotted with gestational age (weeks). The solid line denotes the 50th percentile,
dashed lines the 5th and 95th percentiles, and the dotted lines
2 standard deviations (2.5th and 97.5th percentiles). Reproduced with permission from Moore TR, Cayle JE (15) with
permission from Elsevier.

AFV in pregnancy, despite poor sensitivity documented

in studies comparing AFI with measured AFV by dye
dilution techniques. (6)(7)(8)(9)(16)

Amniotic Fluid Formation

Fetal Urine
The largest single source of AF is fetal urine. The human
fetus begins to excrete urine by the end of the first
trimester and continues to excrete it in ever-increasing
volumes until term. The primary animal model used to
study fetal urine production is the fetal sheep.
(17)(18)(19) The fetal sheep is similar in size to the
human and excretes approximately 200 to 1,200 mL/d
of urine in the last third of pregnancy. (17)(20)(21)
Human fetal urine production has been measured by
ultrasonography. Wladimiroff and Campbell (22) initially determined a fetal urine production rate of
230 mL/d at 20 weeks of gestation that increased to
655 mL/d at term by measuring the change in bladder
volume every 15 minutes. Others reported similar urine
production rates using the same technique. (23)(24)
(25)(26) When Rabinowitz and colleagues (27) increased the frequency of bladder volume measurement to
every 2 to 5 minutes, they found a much greater producNeoReviews Vol.7 No.6 June 2006 e293

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amniotic fluid

Figure 3. Normal changes in fetal urine flow rates across

gestation. Lines represent mean values for six studies in the

literature, with the individual first authors shown in the figure
key. The highest line represents bladder volume measurements
every 5 minuets instead of every 15 minutes, as in the other
five studies. Reproduced with permission from Gilbert WM,
Brace RA. Amniotic fluid volume and normal flows to and
from the amniotic cavity. Semin Perinatol. 1993;7:150.

tion rate of 1,224 mL/d. Figure 3 demonstrates the

human fetal urine production rate of the major studies
using change in bladder volume by ultrasonography.
(22)(23)(24)(25)(26)(27)

gestational age. Sherman and associates (32) reported

that the ovine fetus swallows in bouts lasting 2 minutes
and at volumes of 100 to 300 mL/kg per day. This rate
equals 350 to 1,000 mL/d for a 3.5-kg fetus at term.
Swallowing in the human fetus was studied in the
1960s by the injection of compounds into the amniotic
compartment prior to delivery by cesarean section. Pritchard (28)(33) studied both healthy fetuses and those
that had anencephaly by injecting radioactive chromiumlabeled erythrocytes and diatrizoate sodium/meglumine
into the amniotic compartment and found swallowing
rates of 72 to 262 mL/kg per day. Using a similar
technique, Abramovich (34) found that fetal swallowing
increased with advancing gestational age, with swallowing rates similar to those cited by Pritchard. Measured
swallowing volumes cannot account for the removal of
the large volume of fetal urine and lung liquid that enters
the amniotic cavity every day. Other routes of AF clearance must be present to explain the differences.

Intramembranous Absorption
The route of AF removal that explains the differences
between fetal urine and lung liquid production and swallowing is termed intramembranous absorption.
(35)(36)(37)(38). This route of absorption involves direct absorption of AF from the amniotic cavity into blood
within fetal vessels on the fetal surface of the placenta.
The significant osmotic gradient (Fig. 4) between AF
and fetal blood results in a major driving force for the
movement of water and solutes out of the amniotic
cavity. Intramembranous absorption has been studied in

Lung Liquid
Fetal lung liquid also plays a role in AF formation. For
years, most investigators believed that there was a net
movement of AF into the fetal lungs (respiration of AF),
as demonstrated by the finding of meconium (aspiration)
within the lungs of certain newborns. (28) Fetal sheep
studies, however, document a net outflow of fetal lung
liquid (400 mL/d), 50% of which is swallowed and 50%
of which exits by the mouth, entering the amniotic
cavity. (29)(30)(31) In humans, indirect evidence confirms that lung liquid enters the amniotic cavity, based on
the finding of surfactant within the AF at term.

Amniotic Fluid Removal

Fetal Swallowing
Fetal swallowing is the primary route by which AF exits
the amniotic cavity. This route of AF removal has been
studied in multiple animal models, primarily the sheep
fetus. Swallowing appears to increase with advancing
e294 NeoReviews Vol.7 No.6 June 2006

Figure 4. Change in maternal and fetal plasma and in amni-

otic fluid osmolality during gestation. Reproduced with permission from Gilbert WM, Moore TR, Brace RA. Amniotic fluid
volume dynamics. Fetal Med Rev. 1991;3:89.

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neonatology

Figure 5. Schematic diagram of all known pathways for fluid

and solute entry and exit from the amniotic fluid in the fetus
near term. Arrow size is relative to associated flow rate. The
solid arrows represent directly measured flows; the hatched
arrows represent estimated flows. The numbers represent
volume flow in mL/d. The curved portion of the double arrow
represents lung fluid that is swallowed directly after leaving
the trachea; the straight portion represents lung fluid that
enters the amniotic cavity from the mouth and nose. Reproduced with permission from Gilbert WM, Moore TR, Brace RA.
Amniotic fluid volume dynamics. Fetal Med Rev. 1991;3:89.

the fetal sheep and rhesus monkey. (35)(36)(37)(38) Reports in humans suggest that intramembranous absorption
plays a major role in AFV regulation. (39)(40) The animal
studies suggest that a minimum of 200 to 500 mL/d leaves
the amniotic compartment under normal physiologic conditions. (35)(36)(41) Intramembranous absorption can be
increased tenfold under experimental conditions in the
sheep fetus, further suggesting a regulatory function. (42)
All of the measured and potential routes of AF entry and
removal roughly add up to a balanced equation (Fig. 5).

Oligohydramnios
Oligohydramnios is one of the common indications for
antepartum testing at term and in the postdate period. Its
incidence varies, depending on the particular definition
used, but is reported to be approximately 1% to 3%. (43)
Oligohydramnios is diagnosed in as many as 20% of
high-risk pregnancies and frequently is related to the
underlying maternal or fetal condition. The definition of
oligohydramnios from studies in which the true volume
was measured ranged from 200 to 500 mL at term
gestation. (6)(7)(10) Using ultrasonography to determine the LVP, Chamberlain and associates found a 50fold increase in the perinatal mortality rate with a value of
less than 1 cm. (12) It was this early study that alerted
clinicians to the possible significant high risk of oligohydramnios at this level of LVP. The major drawback of the

amniotic fluid

study was the codiagnosis (40%) of intrauterine growth

restriction (IUGR) and other high-risk factors such as hypertensive disorders in the mother. It has become clear that
oligohydramnios in concert with other high-risk conditions
is associated with increased perinatal morbidity and mortality. (12)(43) When oligohydramnios is diagnosed in the
postdate period, there is an increased risk of meconium
staining of the AF, meconium aspiration syndrome, fetal
distress in labor, and increased cesarean section rates.
(44)(45)(46) With severe oligohydramnios in cases of
IUGR or maternal hypertensive disorders, delivery often is
indicated to decrease the perinatal mortality rate.
Much more common is the mother who presents with
the isolated finding of oligohydramnios. Often, results of
the cervical examination are not favorable for labor induction, but because of the oligohydramnios and fear of
a poor outcome, the patient undergoes a trial of induction
that frequently ends in cesarean section. Recent studies have
shown that in otherwise low-risk women, the finding of
isolated oligohydramnios is not an indication for induction.
Magann and associates (47) examined 1,001 high-risk
women undergoing antepartum testing and found those
who had AFIs of less than 5 cm (19%) had equal perinatal
outcomes to those who had normal AFIs. Others found
similar outcomes when high-risk women were examined
and separated into normal and low AFV. (43)(44) It is
important to remember that in cases of isolated oligohydramnios with a normally grown fetus, the absence of other
high-risk maternal conditions, and an unfavorable cervix,
the patient may be a candidate for observation or possible
therapeutic intervention to increase the AFV.

Preterm Oligohydramnios
When severe oligohydramnios occurs prior to term gestation, the perinatal mortality rate can approach 100%.
(1)(2)(3) The indication for decreased or absent AF (eg,
renal agenesis, marked IUGR) usually predicts survival.
Table 1 lists many of the causes of oligohydramnios from
either the maternal or fetal condition. When a pregnant
patient presents with markedly reduced or absent AF in
mid-gestation, an evaluation for ruptured membranes
should be performed in addition to detailed ultrasonography to diagnosis fetal abnormalities. If underlying maternal conditions are ruled out, attention can focus on
the fetus. Survival may be much better with rupture of
the membranes with an otherwise normal fetus compared with the fetus that has renal agenesis.

Treatment
The status of maternal and fetal fluids is tightly linked,
with dehydration in one resulting in dehydration in the
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neonatology

amniotic fluid

Fetal and Maternal

Causes of Oligohydramnios

Maternal and Fetal

Causes of Polyhydramnios

Table 1.

Table 2.

Fetal Conditions

Maternal Conditions

Spontaneous rupture of the membranes

Premature rupture of the membranes
Abnormal placentationelevated MSAFP/MSHCG
Renal agenesis or obstructed uropathy
Postmaturity syndrome

Fetal Conditions

Maternal Conditions

Antiphospholipid syndrome
Dehydrationhypovolemia
Hypertensive disorders
Uteroplacental insufficiency
Idiopathic

MSAFPmaternal serum alpha-fetoprotein,

serum human chorionic gonadotropin

MSHCGmaternal

other. Goodlin and associates (48) reported that low

maternal intravascular volume was associated with an
increase in idiopathic oligohydramnios. The oligohydramnios improved with maternal hydration and correction of low intravascular volume. (48) Kilpatrick and
colleagues (49)(50) examined the effects of maternal oral
hydration on the AFI among women who had oligohydramnios and those who had normal AFIs. They studied
women who presented to their fetal testing center with a
low AFI and randomized them to drinking 2 L of water
or the usual amount of liquids followed by repeat AFI
measurement at least 2 to 4 hours later. A significant
increase in AFI (24%) was seen in the oral hydration
group compared with the unhydrated group. (49) In the
second study in a clinical research center, women who
had normal AFIs similarly were randomized to drinking
2 L or normal amounts of water. An increase of 3 cm in
the AFI was reported with oral hydration over 4 to
6 hours. (50) Other researchers have found that oral or
intravenous hydration improves the AFI, and oral hydration generally can be used when isolated oligohydramnios has occurred before the postdate period. For the
normal pregnant woman who carries a normally grown
fetus before 40 to 41 weeks of gestation, isolated oligohydramnios may be treated with oral hydration and
follow-up in 4 to 7 days.
The use of amnioinfusion in labor has been reported
to be successful in cases of variable heart rate decelerations and thick meconium. (51)(52)(53)(54)(55)(56)
A recent large, prospective, multicenter, randomized
trial compared amnioinfusion with controls among ale296 NeoReviews Vol.7 No.6 June 2006

Idiopathic
Poorly controlled diabetes

Congenital anomalies
Central nervous system abnormalities
Cystic hygromas
Gastrointestinal obstruction
Nonimmune hydrops
Sacrococcygeal teratoma
Aneuploidy
Twin transfusion syndrome
Muscular dystrophy syndromes

most 2,000 women who had thick meconium. (57) No

improvement in neonatal outcome or change in cesarean
section rate was seen with amnioinfusions in labor.

Polyhydramnios
Previously, polyhydramnios was diagnosed when the
uterus was large for gestational age or the fetus could not
be easily palpated by Leopold maneuvers. The diagnosis
was either confirmed or refuted by the AFV at the time of
delivery. Like oligohydramnios, polyhydramnios can result in a marked increase in perinatal morbidity and
mortality, depending on the AFV, the presence of other
fetal or placental abnormalities, and when in gestation it
occurs. (4) Severe polyhydramnios in mid-gestation usually is associated with congenital malformations, (with or
without aneuploidy) and monozygotic twins. (58) The
maternal and fetal causes of polyhydramnios are displayed in Table 2.
Ultrasonography has been used to measure or estimate AFV. Initial attempts employing the LVP reported
a value of greater than 8 cm as representing polyhydramnios. (58) These investigators categorized patients who
had polyhydramnios into three groups, depending on
the LVP measurement: mild (LVP 8 to 11 cm) (79% of
cases), moderate (LVP 12 to 15 cm) (16.5% cases), and
severe (LVP 16 cm) (5% of cases). The perinatal mortality rate was 127.5 per 1,000 for all cases of polyhydramnios, which corrected to 58.8 per 1,000 when lethal
malformations were removed. (58) This perinatal mortality rate was greatly increased over background rates.
Causes of polyhydramnios could be determined in only
16% of the milder forms compared with almost 90% of
moderate or severe cases.

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neonatology

With the increased clinical use of the AFI compared

with the LVP, investigators began to study the AFI.
Moore and Cayle (15) reported the AFI across gestation,
concluding that the AFI must be referenced to gestational age. The upper limit of normal for the AFI at any
point in gestation occurred at 35 weeks of gestation and
was 27.9 cm (Fig. 2). This value clearly would be abnormal earlier or later in gestation.

Third Trimester Polyhydramnios

When polyhydramnios occurs in the last third of pregnancy, it is usually mild and not associated with a structural defect. (58) Patients who have persistent polyhydramnios and do not have any structural defects still have
an increase in perinatal mortality rate and should be
watched closely. (59) One of the most common causes of
polyhydramnios in the third trimester is poorly controlled or undiagnosed diabetes. All women should be
screened for gestational diabetes at some point in their
pregnancies, usually by 28 weeks gestation. If their
initial test result is normal, and idiopathic polyhydramnios develops near the end of pregnancy, retesting for
gestational diabetes may be appropriate.

Treatment
The underlying cause of the polyhydramnios usually
directs the treatment. Milder forms of the disease that do
not involve congenital malformations require either
follow-up repeat measurement of the AFI or antepartum
testing if the mild polyhydramnios persists.
For pregnancies complicated by the twin-twin transfusion syndrome, the two treatment modalities of amnioreduction and laser ablation of the vascular connections on the surface of the placenta have been shown to
improve pregnancy outcome. Laser ablation currently is
performed in mid-pregnancy and, if effective, cures the
placental cause of the polyhydramnios. (5)(60) Ongoing
multicenter trials are comparing amnioreduction with
laser ablation for the treatment of twin-twin transfusion
syndrome.
EDITORS NOTE. For further information about polyhydramnios, in either singleton or twin pregnancies, see
the articles by Dr John Yeast in this issue of NeoReviews.

References
1. Hackett GA, Nicolaides KH, Campbell S. The value of Doppler
ultrasound assessment of fetal and uteroplacental circulations when
severe oligohydramnios complicates the second trimester of pregnancy. Br J Obstet Gynaecol. 1987;94:1074 1077

amniotic fluid

2. Barss VA, Benacerraf BR, Frigoletto FD. Second trimester oligohydramnios, a predictor of poor fetal outcome. Obstet Gynecol.
1984;64:608 610
3. Mercer LJ, Brown LG. Fetal outcome with oligohydramnios in
the second trimester. Obstet Gynecol. 1986;67:840 842
4. Wier PE, Raten G, Beisher N. Acute polyhydramnios: a complication of monozygous twin pregnancy. Br J Obstet Gynaecol. 1979;
86:849 853
5. Reisner DP, Mahony BS, Petty CN, et al. Stuck twin syndrome:
outcome in thirty-seven consecutive cases. Am J Obstet Gynecol.
1993;169:991995
6. Magann EF, Nolan TE, Hess LW, et al. Measurement of amniotic fluid volume: accuracy of ultrasonography techniques. Am J
Obstet Gynecol. 1992;167:15331537
7. Horsager R, Nathan L, Leveno KJ. Correlation of measured
amniotic fluid volume and sonographic predictions of oligohydramnios. Obstet Gynecol. 1994;83:955958
8. Magann EF, Bass JD, Chauhan SP, et al. Amniotic fluid volume
in normal singleton pregnancies. Obstet Gynecol. 1997;90:524 528
9. Magann EF, Doherty DA, Chauhan SP, et al. How well do the
amniotic fluid index and single deepest pocket indices (below the 3rd
and 5th and above the 95th and 97th percentiles) predict oligohydramnios and hydramnios? Am J Obstet Gynecol. 2004;190:164 169
10. Brace RA, Wolf EJ. Characterization of normal gestational
changes in amniotic fluid volume. Am J Obstet Gynecol. 1989;161:
382388
11. Manning FA, Hill LM, Platt LD. Qualitative amniotic fluid
determination by ultrasound: antepartum detection of intrauterine
growth retardation. Am J Obstet Gynecol. 1981;139:254 258
12. Chamberlain PF, Manning FA, Morrison I, et al. Ultrasound
evaluation of amniotic fluid volume. I: The relationship of marginal
and decreased amniotic fluid volumes to perinatal outcome. Am J
Obstet Gynecol. 1984;150:245249
13. Mercer LJ, Brown LG, Petres RE, et al. A survey of pregnancies
complicated by decreased amniotic fluid. Am J Obstet Gynecol.
1984;149:355361
14. Phelan JP, Ohn MO, Smith CV, et al. Amniotic fluid index
measurements during pregnancy. J Reprod Med. 1987;32:601 604
15. Moore TR, Cayle JE. The amniotic fluid index in normal
human pregnancy. Am J Obstet Gynecol. 1990;162:1168 1173
16. Dildy GA III, Lira N, Moise KJ, et al. Amniotic fluid volume
assessment: comparison of ultrasonographic estimates versus direct
measurements with a dye-dilution technique in human pregnancies.
Am J Obstet Gynecol. 1992;167:986 994
17. Tomoda S, Brace RA, Longo L. Amniotic fluid volume and
fetal swallowing rate in sheep. Am J Physiol. 1985;249:R133R138
18. Alexander DP, Nixon DA, Widdas WF, et al. Gestational
variations in the composition in the foetal fluids and foetal urine in
the sheep. J Physiol. 1958;140:113
19. Mellor DJ, Slater JS. Daily changes in foetal urine and relationships with amniotic and allantoic fluid and maternal plasma during
the last two months of pregnancy in conscious, unstressed ewes with
chronically implanted catheters. J Physiol. 1972;227:503525
20. Gresham EL, Rankin JHG, Makowski EL, et al. An evaluation
of fetal renal function in a chronic sheep preparation. J Clin Invest.
1972;51:149 156
21. Wintour EM, Barnes A, Brown EH, et al. Regulation of
amniotic fluid volume and composition on the ovine fetus. Obstet
Gynecol. 1978;52:689 693
22. Wladimiroff JW, Campbell S. Fetal urine-production rates in
normal and complicated pregnancy. Lancet. 1974;1:151154
NeoReviews Vol.7 No.6 June 2006 e297

Downloaded from http://neoreviews.aappublications.org by J Michael Coleman on August 19, 2010

neonatology

amniotic fluid

23. Campbell S, Wladimiroff JW, Dewhurst CJ. The antenatal

measurement of fetal urine production. J Obstet Gynaecol Br Commonw. 1973;80:680 686
24. Van Otterlo LC, Wladimiroff JW, Wallenburg HCS. Relationship between fetal urine production and amniotic fluid volume in
normal pregnancy and pregnancy complicated by diabetes. Br J
Obstet Gynaecol. 1977;84:205209
25. Kurjak A, Kirkinsen P, Latin V, et al. Ultrasonic assessment of
fetal kidney function in normal and complicated pregnancies. Am J
Obstet Gynecol. 1981;141:266 270
26. Deutinger J, Bartl W, Pfersmann C, et al. Fetal kidney volume
and urine production in cases of fetal growth retardation. J Perinat
Med. 1987;15:307315
27. Rabinowitz R, Peters MT, Vyas S, et al. Measurement of fetal
urine production in normal pregnancy by real-time ultrasonography. Am J Obstet Gynecol. 1989;161:1264 1266
28. Duenhoelter JH, Pritchard JA. Fetal respiration: quantitative
measurements of amniotic fluid inspired near term by human and
rhesus fetuses. Am J Obstet Gynecol. 1976;125:306 309
29. Adamson TM, Brodecky V, Lambert TF, et al. The production
and composition of lung liquids in the in-utero foetal lamb. In:
Foetal and Neonatal Physiology. Cambridge, England: Cambridge
University Press; 1973:208
30. Mescher EJ, Platzker A, Ballard PL, et al. Ontogeny of tracheal
fluid, pulmonary surfactant, and plasma corticoids in the fetal lamb.
J Appl Physiol. 1975;39:10171021
31. Brace RA, Wlodek ME, Cook ML, et al. Swallowing of lung
liquid and amniotic fluid by the ovine fetus under normoxic and
hypoxic conditions. Am J Obstet Gynecol. 1994;171:764 770
32. Sherman DJ, Ross MG, Day L, et al. Fetal swallowing: correlation of electromyography and esophageal fluid flow. Am J Physiol.
1990;258:R1386 R1394
33. Prichard JA. Deglutition by normal and anencephalic fetuses.
Obstet Gynecol. 1965;25:289 297
34. Abramovich DR. Fetal factors influencing the volume and
composition of liquor amnii. J Obstet Gynaecol Br Commw. 1970;
77:865 877
35. Gilbert WM, Brace RA. The missing link in amniotic fluid
volume regulation: intramembranous absorption. Obstet Gynecol.
1989;74:748 754
36. Gilbert WM, Cheung CY, Brace RA. Rapid intramembranous
absorption into the fetal circulation of arginine vasopressin injected
intraamniotically. Am J Obstet Gynecol. 1991;164:10131018
37. Gilbert WM, Moore TR, Brace RA. Amniotic fluid volume
dynamics. Fetal Med Rev. 1991;3:89
38. Gilbert WM, Eby-Wilkens EM, Tarantal AF. The missing-link
in Rhesus monkey amniotic fluid volume regulation: intramembranous absorption. Obstet Gynecol. 1997;89:462 465
39. Heller L. Intrauterine amino acid feeding of the fetus. In: Bode
H, Warshaw J, eds. Parenteral Nutrition in Infancy and Childhood.
New York, NY: Plenum Press; 1974:206
40. Renaud R, Kirschtetter L, Koehl D, et al. Amino-acid intraamniotic injections. In: Persianinov LS, Chervakova TV, Presl J,
eds. Recent Progress in Obstetrics and Gynaecology. Amsterdam, The
Netherlands: Excerpta Medica; 1974:234
41. Jang PR, Brace RA. Amniotic fluid composition changes during urine drainage and tracheoesophageal occlusion in fetal sheep.
Am J Obstet Gynecol. 1992;167:17321734
42. Faber JJ, Anderson DF. Absorption of amniotic fluid by am-

e298 NeoReviews Vol.7 No.6 June 2006

niochorion in sheep. Am J Physiol Heart Circ Physiol. 2002;282:

H850 H854
43. Casey BM, McIntire DD, Bloom SL, et al. Pregnancy outcomes after antepartum diagnosis of oligohydramnios at or beyond
34 weeks gestation. Am J Obstet Gynecol. 2000;182:909 912
44. Crowley P, OHerlihy C, Boylan P. The value of ultrasound
measurement of amniotic fluid volume in the management of
prolonged pregnancies. Br J Obstet Gynaecol. 1984;91:444 448
45. Jeng CJ, Lee JF, Wang KG, et al. Decreased amniotic fluid
index in term pregnancy. Clinical significance. J Reprod Med. 1992;
37:789 792
46. Grubb DK, Paul RH. Amniotic fluid index and prolonged
antepartum fetal heart rate decelerations. Obstet Gynecol. 1992;79:
558 560
47. Magann EF, Chauhan SP, Barrilleaux PS, et al. Amniotic fluid
index and single deepest pocket: weak indicators of abnormal
amniotic volumes. Obstet Gynecol. 2000;96:737740
48. Goodlin RC, Anderson JC, Gallagher TF. Relationship between amniotic fluid volume and maternal plasma volume expansion. Am J Obstet Gynecol. 1983;146:505511
49. Kilpatrick SJ, Safford K, Pomeroy T, et al. Maternal hydration
increases amniotic fluid index (AFI). Am J Obstet Gynecol. 1991;78:
1098 1102
50. Kilpatrick SJ, Safford KL. Maternal hydration increases amniotic fluid index in women with normal amniotic fluid volumes.
Obstet Gynecol. 1993;81:49 52
51. Nageotte MP, Bertucci L, Towers CV, et al. Prophylactic
amnioinfusion in pregnancies complicated by oligohydramnios: a
prospective study. Obstet Gynecol. 1991;77:677 680
52. Schrimmer DB, Macri CJ, Paul RH. Prophylactic amnioinfusion
as a treatment for oligohydramnios in laboring patients: a prospective
randomized trial. Am J Obstet Gynecol. 1991;165:972975
53. Miyazaki FS, Taylor NA. Saline amnioinfusion for relief of
variable or prolonged decelerations. Am J Obstet Gynecol. 1983;
146:670 678
54. Eriksen NL, Hostetter M, Parisi VM. Prophylactic amnioinfusion in pregnancies complicated by thick meconium. Am J Obstet
Gynecol. 1994;171:1026 1030
55. Macri CJ, Schrimmer DB, Leung A, Greenspoon JS, Paul PH.
Prophylactic amnioinfusion improves outcome of pregnancy complicated by thick meconium and oligohydramnios. Am J Obstet
Gynecol. 1992;167:117121
56. Sadovsky Y, Amon E, Bade ME, Petrie PH. Prophylactic
amnioinfusion during labor complicated by meconium: a preliminary report. Am J Obstet Gynecol. 1989;161:613 617
57. Frasier WD, Hofmeyr J, Lede R, et al. Amnioinfusion for the
prevention of the meconium aspiration syndrome. N Engl J Med.
2005;353:909 917
58. Hill LM, Breckle R, Thomas ML, Fries JK. Polyhydramnios:
ultrasonically detected prevalence and neonatal outcome. Obstet
Gynecol. 1987;69:2125
59. Golan A, Wolman I, Sagi J, Yovel I, David MP. Persistence of
polyhydramnios during pregnancy: its significance and correlation
with maternal and fetal complications. Gynecol Obstet Invest. 1994;
37:18 20
60. De Lia JE, Cruikshank DP, Keye WR. Fetoscopic neodymium:
YAG laser occlusion of placental vessels in severe twin-twin transfusion syndrome. Obstet Gynecol. 1990;75:1046 1053

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neonatology

amniotic fluid

NeoReviews Quiz
1. Amniotic fluid volume varies substantially at each week of human gestation, as reflected in the wide range
of normal values. Of the following, the largest variation in amniotic fluid volume occurs at the gestational
age of:
A.
B.
C.
D.
E.

26
29
32
35
38

to
to
to
to
to

27
30
33
36
39

weeks.
weeks.
weeks.
weeks.
weeks.

2. Deviations in amniotic fluid volume, as seen with polyhydramnios or oligohydramnios, are associated with
significant perinatal morbidity and/or mortality. Sequential assessment of amniotic fluid volume, therefore,
is an important part of clinical care during pregnancy. Of the following, the most widely used and accurate
method for estimating amniotic fluid volume is by:
A.
B.
C.
D.
E.

Determination of dye dilution by timed amniocentesis.

Palpation of the fetus by the Leopold maneuver.
Palpation of the uterus for fundal height.
Ultrasonographic measurement of the amniotic fluid index.
Ultrasonographic measurement of the largest vertical pocket.

3. Amniotic fluid volume is determined by a balance between the rate of its production and the rate of its
removal from the amniotic cavity. Experimental studies in sheep and observations in humans have shown
that the amniotic fluid volume is tightly regulated. Of the following, the function that plays a major role in
regulation of the amniotic fluid volume is:
A.
B.
C.
D.
E.

Fetal lung fluid secretion.

Fetal swallowing.
Fetal urine formation.
Intramembranous absorption.
Transmembranous flux.

NeoReviews Vol.7 No.6 June 2006 e299

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Amniotic Fluid Dynamics

William M. Gilbert
NeoReviews 2006;7;e292-e299
DOI: 10.1542/neo.7-6-e292

Updated Information
& Services

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s;7/6/e292

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