The National Ribat University

Faculty of Graduate Studies and Scientific Research

Sonographic Evaluation of Amniotic Fluid Volume In Diabetic

Pregnant women During 2nd

& 3rd

Trimesters In

Khartoum State.

A thesis submitted for partial fulfillment for the degree of master (M.Sc.) in medical

diagnostic ultrasound.

By: Faisal Abdelaziz Fadul Awad

Supervisor:Dr. Elsir Ali Saeed

(PhD Medical Diagnostic Ultrasound)

March 2015

اآليـة

لبي هللا رؼب :

} مزآ ثب ل رؼد حك ه ا ا فزؼبى هللاه أ لج

ب رة سد ػ ل ح ه {مضى إؼظـــــص ــــــــــ ذق هللاه ا

{ 111طرح ط ، اخ }

Dedication I dedicated this work to:

My Parents.

My Brothers and sisters.

My Teachers.

My Colleagues and friends.

ACKNOWLEDGEMENT

First and above all, thanks and praises to Allah, the almighty for

providing me this opportunity and granting me the capability to

proceed successfully, and the prayers and peace be upon the

merciful prophet Mohamed.

I want to express my sincere thanks and deep graduate to my

faithful supervisor Dr. Elsir Ali Saeed for his guidance

throughout this thesis and sharing his knowledge through the

entire study.

I would also like to pass my special thanks to my friends and

colleagues whom help me.

ملخص البحث

ف اظبء احا ثبد اذي حظاظبئ حد رم أخزذ ثغزض ذ دراطخ رح صفخ

رأثز زض اظىز ػ حد اظبئ ال رأثز ؼزف ثذاء اظىزي ف لخ اخزط اصبثبد

ػ اد.

اصبثبد ثذاء خبد فق اصرخ ظبء احااؼب ف ػ ا اطزخذذ ذ اذراطخ اجزروي

لذ ر 4115 برص حز 4111دظجز ف افززح خؼب ر اظىزي خالي الطزجببد از

. اإلحصبئ ازح ف SPSSاــ ثزبح ثبطزخذا ازبئح رحاصف خغ اجببد

خذد ثذاء اظىزي اح صبثخ خاثبث خاثب فززححب ف ا شذ ذ اذراطخ ئخ ازأح

ظزشفبد % حد اؼخ، ر خغ اجببد 51طخ ثظجخ 11-11اغبجخ رززاذ اػبر

اظزشف اظؼدي أ أ درب الد ب ظزشف اخزط لخ ف خزفخ زاوش رشخصخ

طف. وبذ األخشح از خذذ ثبحبج اجب اززو ثبىالوخ ، ظزشف اظزشف درب

طاطىت ص اصغ ، خبس صغ ،اخزذ ثب اخزجبراد اخبد فق اصرخ ذري ص ا

.وري اصغأج

ظجخ ثلبص األرثؼخ خة ، خذد اذراطخ اوجز خت ظبئ ال ذ اذراطخ لبص طزخذذ فا

ظبئ اظبئ ال ف اظبء احا اصبثبد ثذاء اظىزي وبذ اػ اؼذي اطجؼ

اصبثبد ثذاء ا ف اظبء اح اظبئ ال اطجؼ ظجخ ، اؼخ حد % 18 ال

. حد اؼخ %( 54اظىزي وبذ )

% ع اظىزي اؼزذ 14%، رب 51ظ ثظىزي اح ف ع اظىزي ب وبذ اػ ظجخ

اظىزي غز اؼزذ ػ الظ.% ع 15ػ الظ ، وب أل ظجخ

% حد اؼخ ذ حطب )صذي( ف اظبئ احظ ثبد أ 18خذد اذراطخ اضب" ا

% حد اؼخ ذ ػمخ اد ) اد وجز احد(.ض 49 ،% ب خبخ اصذي84

% سبدح اظبئ ال 54ذح زض اظىزي حث خذد بن ػاللخ ث سبدح اظبئ ال

أل طخ )ال ذح(.

اضحذ اذراطخ ثأ داء اظىزي ذ رأثز ػ وخ اظبئ ال ف اظبء احا اصبثبد ثذا

اذاء .

أصذ اذراطخ ثزػبخ خبصخ ظبء احا اصبثبد ثزض اظىز زبثؼز ثصرح درخ

زىزر اضب اصذ ثذراط اؼا الخزي از ثؤثز ف وخ اظبئ ال ثبلضبفخ ذاء اظىزي

رأثز اظىز ف حد اشخ ؼزفخ اؼاللخ ازذاخ ث.

اذراطخ ثزذرت اىادر اطجخ حث ػ لبص اظبئ ال ػذ اب زشخص وب اصذ

اجىز رفبدي الثبر ابرد ػ اشبد ا امصب اغز طجؼ ػالخب جىزا، وب اصذ ثزفز اخشح

اجىز زغزاد اغز ازشخص ثبخبد افق صرخ ف خغ اظزشفبد ازاوش اصحخ الوزشبف

طجؼخ ف اظبئ ال.

Abstract

This analytical and descriptive study was conducted in order to assess the

amniotic fluid in diabetic pregnant women in the Khartoum state to see the effect

of diabetes on the amniotic fluid volume and its effect on the fetus.

This study used the Universal Protocol in the work of ultrasound for pregnant

diabetic women through questionnaires that were collected in the period from

December 2014 until March 2015 has been disaggregated data collection and

analysis of the results using the SPSS program in statistical analysis.

This study included 100 diabetic pregnant women in the second and third

trimesters of pregnancy and found the majority between the ages of 31-40 years by

54% of the sample size, data were collected from hospitals and different diagnostic

centers in the Khartoum state, including Omdurman Maternity Hospital , Saudi

hospital Omdurman , Turkish hospital , and Alban jaded hospital. The equipments

by which ultrasound exams was done: Mindray Chinese-made, and Sonoscape

Chinese-made ،ALPINON (E-CUBE) Korean-made device.

This study measuring the amniotic fluid volume by using Single Deepest Pocket

(SDP) and AFI (4 Pockets), the study found abnormally increase in amniotic fluid

volume (AFV) polyhydramnios represent (48%) of sample size, and normal

amniotic fluid volume (AFV) represent (52%) of sample size.

The highest rate of diabetes from type called gestational diabetes 53%, followed

by 32% of the insulin-dependent type, and was less than 15% of diabetes type non-

insulin-dependent.

The study also found that "18% of the sample size have debris (echo) in the fluid

surrounding the fetus and that 82% of them are free from echo, and 29% of the

sample size have macrosomic fetus (large fetus size) .

The study recommended special care for diabetic pregnant women followed

periodically Frequently also recommended studying other factors that effect in the

amount of amniotic fluid as well as diabetes and the effect of diabetes in the size

of the placenta and see them overlapping relationships.

The study also recommended the training of medical staff and urged them to

measure amniotic fluid volume for early diagnosis to any abnormality

(polyhydrmnios or oligohydrmnios) that may affect either the fetus or the pregnant

diabetic women and to treat it early.

It is recommended to facilitate ultrasound machine in every hospital and medical

health centers.

List of Contents

NO subject Page No

I اــــخ

Dedication II

Acknowledgement III

IV خص اجحث

Abstract VI

List of contents VIII

List of tables XI

List of figures XIII

List of Abbreviation XV

Chapter one

1.1 Introduction 1

1.2 Objectives 3

1.2.1 General objectives 3

1.2.2 Specific objectives 3

1.3 Study problem 3

1.4 The importance of the study 4

Chapter two – Literature Review

2.1 Anatomy 5

2.1.1 The amnion 5

2.1.2 Amniotic fluid 7

2.1.2.1 Development of amniotic fluid 6

2.1.2.2 Components of amniotic fluid 8

2.2 Physiology 9

2.2.1 Functions of amniotic fluid 9

2.2.2 Production and absorption 10

2.2.3 Production of amniotic fluid 10

2.2.4 Fetal urine production 10

Topic Page No

2.2.5 Source and regulation amniotic fluid volume 11

2.2.6 Fetal circulation 12

2.3 Assessment of amniotic fluid volume 13

2.4 Consistency of Amniotic Fluid 15

2.5 Pathology 17

2.5.1 Polyhydramnios (hydramnios) 17

2.5.1.1 Polyhydramnios Classification 17

2.5.1.2 Causes of polyhydramnios 18

2.5.1.3 Complications of polyhydramnios 19

2.5.1.4 Symptoms of Polyhydramnios 20

2.5.1.5 Polyhydramnios Diagnostic Criteria 21

2.5.1.6 Amniocentesis 21

2.5.1.7 Treatment of polyhydramnios 22

2.5.2 Oligohydramnios(Anhydramnios) 22

2.5.2.1 Causes of Oligohydramnios: 23

2.5.3 Diabetes Mellitus 26

2.5.3.1 Types of diabetes mellitus 26

2.5.3.2 Risks of Diabetes On Pregnancy 27

2.5.4 Gestational diabetes 28

2.5.4.1 Causes OF Gestational Diabetes in Pregnancy 29

2.6 Previous studies 30

Chapter three - methodology

Methods 34

Sonographic technique 36

Ethical consideration 38

…………………….………………….…………………األخ

Dedication………………….………………….……………

i

ii

NO Subject Page No

Acknowledgement………………………………………… iii

Chapter four

The results 39

Chapter five

Discussion 61

Conclusion 65

Recommendations 66

References 67

Appendix

Ultrasound images of amniotic fluid

Data master sheet

Data collection sheet

iv ……….…………………………………………خص اجحث

Abstract …………………………………………………… v- vi

List of tables

List of tables………………………..…………………….. vii- viii

No of tables Subjects Page No

Table 2.1 Chamberlain Method 20

Table 4.1 Sample distribution for patients by age 39

Table 4.2 Sample distribution for patients by type of

diabetes

40

Table 4.3 Sample distribution for patients by duration of

diabetes

41

Table 4.4 Sample distribution for patients by treatment

type

42

Table 4.5 Sample distribution for patients by diabetes status 43

Table 4.6 Sample distribution for patients by history of

polyhydramnios

44

Table 4.7 Sample distribution for patients by gravity

status

45

Table 4.8 Sample distribution for patients by gestational

age

46

Table 4.9 Sample distribution for patients by amniotic

fluid volume single deepest pocket (SDP)

47

Table 4.10 Sample distribution for patients by amniotic fluid

volume (4 pockets(

48

Table 4.11 Sample distribution for patients by consistency of

amniotic fluid

49

Table 4.12 Sample distribution for patients by fetal macrosomia 50

Table 4.13 Sample distribution for patients by fetal anomalies 51

Table 4.14 Diabetes status * Amniotic fluid volume Cross

tabulation

52

Table 4.15 History of polyhydramnios * Amniotic fluid volume

(AFV) Cross tabulation

53

Table 4.16 Type of diabetes * Amniotic fluid volume Cross

tabulation

54

Table 4.17 Amniotic fluid volume (AFV) * Consistency of

amniotic fluid Cross tabulation

55

Table 4.18 Amniotic fluid volume (AFV) * Fetal macrosonia

Cross tabulation

56

Table 4.19 Diabetes status * Fetal macrosomia Cross tabulation 57

Table 4.21 Type of treatment and diabetes status Cross

tabulation

58

Table 4.21 Type of treatment and amniotic fluid volume Cross

tabulation

59

Table 4.24 Means, and Standard deviations for amniotic fluid

volume (4 pockets) and amniotic fluid volume (SDP)

by diabetes status

61

Objectives…………………………...……………………… 4

List of figures

No of figure subject No

Figure 2.1 show embryo within amniotic sac 4

Figure 2.2 embryo within the uterine cavity 5

Figure 2.3 show amniotic membrane 7

Figure 2.4 Single deepest pool (SDP) of amniotic fluid 13

Figure 2.5 polyhydramnios with debris 16

Figure 2.6 Oligohydramnios. 24

Figure 2.7 gestational diabetes 27

Figure 3.1 Single largest pocket 37

Figure 4.1 Sample distribution for patients by age 39

Figure 4.2 Sample distribution for patients by type of diabetes 40

Figure 4.3 Sample distribution for patients by duration of diabetes 41

Figure 4.4 Sample distribution for patients by treatment type 42

Figure 4.5 Sample distribution for patients by diabetes status 43

Figure 4.6 Sample distribution for patients by history of

polyhydraminos

44

Figure 4.7 Sample distribution for patients by gravity status 45

Figure 4.8 Sample distribution for patients by gestational age 46

Figure 4.9 Sample distribution for patients by amniotic fluid

volume single deepest pocket (SDP)

47

Figure 4.10 Sample distribution for patients by amniotic fluid

volume (4 pockets)

48

Figure 4.11 Sample distribution for patients by consistency of

amniotic fluid

49

Figure 4.12 Sample distribution for patients by fetal macrosomia 50

Figure 4.13 Sample distribution for patients by fetal anomalies 51

Figure 4.14 Diabetes status * Amniotic fluid volume tabulation 52

Figure 4.15 History of polyhydramnios * Amniotic fluid volume

Cross tabulation

53

Figure 4.16 Type of diabetes * Amniotic fluid volume Cross

tabulation

54

Figure 4.17 Amniotic fluid volume (AFV) * Consistency of

amniotic fluid Cross tabulation

55

Figure 4.18 Amniotic fluid volume (AFV) * Fetal macrosonia Cross

tabulation

56

Figure 4.19 Diabetes status * Fetal macrosomia Cross tabulation 57

Figure 4.21 Type of treatment and diabetes status Cross tabulation 58

Figure 4.21 Type of treatment and amniotic fluid volume Cross

tabulation

59

List of Abbreviations

AFI Amniotic fluid index

BW Birth Weight

SDP Single deepest pool

AF Amniotic fluid

AFV Amniotic fluid volume

GDM Gestational diabetes mellitus

G.A Gestational age

u/s ultrasound

IUGR Intrauterine growth retardation

PROM Premature rupture of membrane

SROM Spontaneous rupture of membrane

ARM Artificial rupture of membrane

DM Diabetes Mellitus

TAS Trans-abdominal sonography

CNS Central nervous system

IDDM Insulin dependent diabetes mellitus

NIDDM Non-Insulin dependent diabetes mellitus

EDD Estimated delivery date

WHO World health organization

CHAPTER ONE

CHAPTER ONE

1.1 Introduction:

The fluid in the amniotic cavity bathing the fetus is known as amniotic

fluid (AF). (1)

Normal amount of AF is important for normal fetal development and

growth, too little or too much AF is associated with different conditions and places

the fetus at risk for perinatal complications. (1)

Amniotic fluid consist of desquamated fetal epithelial cells and

approximately equal portions of organic and inorganic salts, in 98 - 99%

water. it provides a medium in which the fetus can move, grow, and develop

symmetrically without pressure on its delicate tissues.(1)

Amniotic fluid is derived from several sources and the contribution of these

sources varies during the pregnancy. In early pregnancy, the primary source

of the fluid appears to be the amniotic membrane and transudate from the

maternal blood by transport across the amniotic membrane. The fetal kidneys

begin to function in the second trimester and contribute fluid volume to the

amniotic fluid. Fetal urinary output as a source of amniotic fluid becomes

increasingly important as pregnancy advances. It is estimated that about 500 ml of

fetal urine is added daily to the amniotic fluid. The fluid is constantly being

formed and reabsorbed with replacement about every 3 hours. Large volumes of

fluid move in both directions between the fetal and maternal circulations. (1)

The amniotic fluid volume increases from approximately 250 ml at 16

weeks to 1000 ml at 34 weeks, declining thereafter to approximately 800 ml at

term. The amniotic fluid volume reflects the status of both the mother and

the fetus and is altered in many physiological and patho –logical conditions.

Ultrasound has a potential role in the management of such conditions, by the

assessment of amniotic fluid volume. (2)

The subjective term used to describe amniotic fluid volume is Virtually

none (oligohydramnios), average (normal), excess (polyhydraminos). (1)

Oligohydramnios is defined as reduced of amniotic fluid volume for a given

gestational age. An amniotic fluid index less than 5 cm, is classified as

oligohydramnios, in early pregnancy is often associated with fetal

malformations. (4)

Polyhydramnios is described as a subjective increase of amniotic fluid volume,

i.e. single pocket with vertical measurement greater than 8 cm, or amniotic

fluid index greater than 20 cm. (5)

About 14% of cases of Polyhydramnios are due to maternal diabetes

mellitus which causes fetal hyperglycemias and resulting polyuria (fetal urine

is a major source of amniotic fluid) and also rh-isoimmunisation can cause it.(1)

1.2 Objectives:-

1.2.1 General objectives:-

To evaluate the amount of amniotic fluid volume and its consistency in diabetic

patient by ultrasound in second and third trimesters in Khartoum state.

1.2.2 Specific objective:-

To estimate and measure the amniotic fluid volume.

To determine the effect of diabetes on amniotic fluid volume.

To evaluate the consistency of amniotic fluid.

To estimate fetal weight (EFW).

To correlate between the amniotic fluid volume and EFW.

To correlate between the amniotic fluid volume and diabetes status.

To correlate between the amniotic fluid volume and its consistency.

To determine any congenital fetal abnormalities.

1.3 Study problem:

Diabetes is one of the common causes of polyhydramnios, pregnancies

complicated by polyhydramnios are at high risk and need optimal care and

management.

1.4 The importance of the study:

- Evaluate the amount of amniotic fluid so can select the best method to

determine AFV in the uterus.

- Determine diabetic effect on amniotic fluid and the pregnancy.

CHAPTER TWO

Literature review

Chapter two - Literature review

2.1Anatomy

2.1.1 The amnion

The amnion is a membranous sac which surrounds and protects the embryo. It is

the first of the three cavities (amnion, chorion and yolk sac) in the embryo and is

formed on 8 dpc. (6)

The amniotic cavity is roofed in by a single stratum of flattened, ectodermal cells,

the amniotic ectoderm, and its floor consists of the ectoderm of the embryonic disc.

A thin layer of mesoderm, continuous with that of the somatopleure, is located just

outside the amniotic ectoderm, and is connected to the mesodermal lining of the

chorion by the body stalk. (6)

Origin and early development of the amnion and amniotic cavity:-

Figure (2.1) show embryo within amniotic sac (cityimaging.com.au).

The amniotic cavity starts as a small space which soon expands to fill the whole

uterine cavity. This occurs in the following way. (6)

The amniotic cavity appears – during implantation of the blastocyst -as small

clefts between the ectoderm (of the inner cell mass) and trophoblast ; very early in

pregnancy the ectodermal cells are attached to the trophoblast. (6)

As the development proceeds (at about day (8)) small intracellular clefts appear

between the ectoderm and trophoblast. When these clefts join together they form a

small space called the amniotic cavity. (6)

As the amniotic cavity enlarges, layer of large flattened cells called amnioblasts

develops from the inner surface of the trophoblast and form the roof of the

amniotic cavity. (6)

Figure (2.2): Embryo within the uterine cavity. (1)

2.1.2 Amniotic fluid

2.1.2.1 Development of amniotic fluid

Amniotic fluid is water-like fluid originates from the maternal plasma, and passes

through the fetal membranes by osmotic and hydrostatic forces. As the Placental

and fetal vessels develop, the fluid passes through the fetal tissue, as the exsudatum

of the skin. (7)

The volume of amniotic fluid increases with linear regression to the growth

of fetus. From the 10th to the 20th week its, carbohydrate and lipid increases from

25ml to 400ml approximately. From the 8th week, when the fetal kidneys begin to

function, fetal urine is also present in the AF. Approximately in the 10th week the

breathing and swallowing of the fetus slightly decrease the amount of AF, but

neither urination nor swallowing contributes significantly to AF quantity changes,

up until the 25 week, when keratinisation of skin is complete. Then the linear

regression between AF and fetal growth cease to exist. It reaches the plateau of

800ml at the 28 week (gestational age) the amount of fluid declines to roughly 400

ml at 42 weeks. (8)

The fore waters are released when the amnion rupture. This is commonly known as

the time when a woman's "water breaks". When this occurs during labour at term,

it is known as "spontaneous rupture of membranes"(SROM). (9)

If the rupture precedes labour at term, however, it is referred to as "premature

rupture of membrane” (PROM).The majority of the hind waters remain inside the

womb until the baby is born. Artificial rupture of membrane (ARM), a manual

rupture of the amniotic sac can also be performed to release the fluid if the amnion

has not spontaneously ruptured. (9)

Figure (2.3) show amniotic membrane

2.1.2.2 Components of amniotic fluid:

Amniotic fluid is a solution in which undissolved material is suspended. It consists

of desquamated fetal epithelial cells and approximately equal portions of organic

and inorganic salts, in 98 - 99% water. Half of the organic constituents are protein;

and the other half consists of carbohydrates, fats, enzymes, hormones, and

pigments. As pregnancy advances, the composition of the amniotic fluid changes

as fetal excreta (fetal urine, meconium) are added. Because fetal urine is added to

amniotic fluid, studies of fetal enzyme systems, amino acids, hormones, and other

substances can be conducted on fluid obtained by amniocentesis.(1)

2.2 Physiology:-

Maintenance of normal amniotic fluid volume is essential for normal

fetal development. An excess or deficiency of amniotic fluid is associated with an

increased incidence of fetal and neonatal morbidity and mortality. (10)

2.2.1 Functions of amniotic fluid:

Amniotic fluid is "inhaled" and "exhaled" by the fetus. It is essential that fluid be

breathed into the lungs in order for them to develop normally. Swallowed amniotic

fluid also creates urine and contributes to the formation of meconium. As well,

amniotic fluid protects the developing baby by cushioning against blows to the

mother's abdomen, allows for easier fetal movement, promotes muscular/skeletal

development, and helps protect the fetus from heat loss. )9)

Analysis of amniotic fluid, drawn out of the mother's abdomen in an

amniocentesis procedure, can reveal many aspects of the baby's genetic health.

This is because the fluid also contains fetal cells, which can be examined for

genetic defects. (11)

2.2.2 Production and absorption:-

Under normal circumstances, the amniotic fluid is in a state of dynamic

equilibrium between production and absorption .Available exchange surfaces are

the amniotic epithelium. umbilical cord, fetal skin, gastrointestinal tract, and

urogenital tract. (10)

2.2.3 Production of amniotic fluid:-

Amniotic fluid production is attributed initially to the amniotic fluid

epithelium and later to fetal kidneys. (12)

The fetal membrane and umbilical cord are the most important structures for

continues exchange of water and electrolytes, while the swallowing of amniotic

fluid by the fetus and fetal urine output into the amniotic fluid are intermittent

process. (2)

2.2.4 Fetal urine production:-

Fetal urine production contributed to formation of the amniotic

fluid .hypotonic urine can be detected in fetal bladder as early as

12weeks gestation. The 24 hour fetal urinary output has been

calculated at 7-17 ml based on ultrasound studies at 18 weeks.the

daily urine output increases to 600-800ml by the end of

pregnancy. (13)

2.2.5 Source and regulation of amniotic fluid volume:-

Amniotic fluid is derived from several sources and the contribution of these

Sourcesvaries during the pregnancy. In early pregnancy, the primary source of the

fluid appears to be the amniotic membrane and transudate from the maternal blood

by transport across the amniotic membrane. (1)

After the first trimester the greatest contribution is from the fetal kidneys,

producing 800 to 1200 cc per day. Also, there is a positive flow across the

membranes of about 200 to 500 cc per day. Interestingly, although the fetal lungs

contribute about 360 cc to the amniotic cavity per day, about half of this moves

back into the lungs. Fluid is removed mostly through fetal swallowing (500 to

1000 cc per day). Inconsequential amounts leave the cavity through the

membranes. The amniotic fluid volume rises linearly to about 33 to34 weeks, when

the average is about 1000 cc, after which it generally drops slowly to about 800 cc

at 40 weeks of gestation and to 600 cc at 42 weeks. (14)

Fetal swallowing of amniotic fluid begins at about 11-13 weeks of gestation. Most

of the fluid passes into the fetal gastrointestinal tract, but some of it also passes

into the fetal lungs. In either case, the fluid is absorbed into the fetal circulation

and then passes into the maternal circulation via the placental membrane. In the

final stages of pregnancy, the fetus swallows up to 400 ml of amniotic fluid per

day. Some fluid also passes from the amniotic cavity into the maternal blood

across the chorioamniotic membrane. If the fetus is unable to swallow adequate

amounts of amniotic fluid or if the fetus swallows the fluid but it is not absorbed

properly because of an obstruction in the upper fetal GI tract, polyhydramnios will

occur. (1)

2.2.6 Fetal circulation:

Oxygen and nutrients from the mother's blood are transferred across the

placenta to the fetus. The enriched blood flows through the umbilical cord to the

liver and splits into three branches. The blood then reaches the inferior vena cava,

a major vein connected to the heart. Most of this blood is sent through the ductus

venosus. It is also a shunt that passes highly oxygenated blood through the liver to

the inferior vena cava and then to the right atrium of the heart. A small amount of

this blood goes directly to the liver to give it the oxygen and nutrients it needs.(9)

Waste products and carbon dioxide from the fetus are sent back through the

umbilical cord and placenta to the mother's circulation to be eliminated. (9)

2.3 ASSESSMENT OF AMNIOTIC FLUID VOLUME:-

The amniotic fluid volume Reflects the status of both the mother and the fetus and

is altered in many physiological and pathological conditions. Ultrasound has a

potential role in the management of such conditions, by the assessment of amniotic

fluid volume. (4)

There are three methods for assessing amniotic fluid volume:

1- Subjective assessment:

With experience, it is possible to classify amniotic fluid volume

into the broad categories absent, low, normal, Increased and excessive. Although

reliable in the hands of an experienced operator, this method has proved impossible

to standardize in clinical and research terms. (4)

2- Single deepest pool (SDP)– (largest pocket)

The size of the deepest, cord-free pool of amniotic fluid is assessed with the

ultrasound probe perpendicular to the maternal abdomen. The vertical depth of the

largest pool is measured. When this method was first introduced, a 1-cm pool was

considered acceptable in normal pregnancy, but subsequent studies have suggested

that minimum depth of 2–3 cm is a more appropriate threshold. (4)

Figure (2.4): Single deepest pool (SDP) of amniotic fluid. (4)

3- Amniotic fluid index (AFI):

This is a semi quantitative technique for assessing amniotic fluid

volume. Using the maternal umbilicus as a reference point, the abdomen is

divided into four quarters. With the ultrasound probe held in the

longitudinal axis of the mother and perpendicular to the floor, the largest

vertical pool depth in each quadrant is recorded, the sum of these

measurements represents the amniotic fluid index (AFI). (4)

Although the AFI is known to vary with gestational age, an AFI < 5 cm is

classified as oligohydramnios and an AFI > 20 cm is classified as polyhydramnios

Even though this method is accepted as superior to the single deepest pool

technique, considerable. (4)

2.4 Consistency of Amniotic Fluid:

- In general, amniotic fluid appears anechoic throughout pregnancy in the majority

of patients at normal gain settings and transducer frequencies. Echogenic amniotic

fluid at different stages of gestation can occur and is associated with different

etiologies, some physiological and others pathological. (1)

In the first trimester of pregnancy, normal amniotic fluid should appear

echo free. In contrast, chorionic fluid frequently appears to have dispersed low

amplitude echoes which is especially evident at higher transducer frequencies and

gain settings. (1)

In the second and third trimesters of pregnancy, amniotic fluid echoes may

be seen in normal pregnancies or may be associated with underlying pathological

causes including anencephaly and intra-amniotic bleeding. The source of amniotic

fluid debris echoes in normal pregnancies is mainly related to desquamated or

exfoliated fetal skin cells and vernixcaseosa. Vernixcaseosa is the normal oily

substance produced by fetal skin and covering the fetal skin to protect it in its

aqueous environment. (1)

Near term, meconium released into the amniotic fluid by the fetus may be

another source of amniotic fluid debris echoes. Under ordinary circumstances,

meconium is usually not released in utero although it may be a normal event that

occurs with progressive fetal maturation, without evidence of fetal distress or poor

outcome. Other causes associated with meconium passage in utero include

hypoxia-induced peristalsis and sphincter relaxation, and umbilical cord

compression-induced vagal stimulation in mature fetuses. There appears to be a

link between gestational age and meconium passage after the 38th week.The cause

of the meconium passage may vary from patient to patient, and in some patients

may result from a combination of causes which may explain why there has not

been a clear relationship demonstrated between its passage in utero and fetal

outcome. (1)

Other potential causes of amniotic fluid debris echoes include fetal bleeding

associated with percutaneous umbilical cord sampling, rupture of an umbilical

vessel associated with velamentous insertion of the umbilical cord,

chorioamnionitis, and idiopathic causes.(1)

2.5 Pathology :

2.5.1 Polyhydramnios (hydramnios):

Polyhydramnios is an abnormal condition occurring in pregnancy, characterized by

excessive amniotic fluid build-up (the fluid surrounding the baby in the

uterus). (11)

Figure (2.5 ): polyhydramnios with debris.

2.5.1.1 Polyhydramnios Classification:

- Chronic polyhydramnios: Characterized by gradual accumulation of

amniotic fluid.

- Acute polyhydramnios: Characterized by sudden and rapid accumulation

of amniotic fluid. (11)

2.5.1.2 Causes of polyhydramnios:-

1- Maternal abnormalities :

a- Diabetes mellitus (15 to 25 percent).

b- Pre eclampsia (6 to 15 percent).

c- Erythroblast sis fetalis induced RH isoimmunisation.

d- Congestive heart failure.

e- Syphilis , Anaemia.

f- Pregnancy- induced hypertension .

g- Multiple gestations may associate with polyhydramnios. (11)

2- Fetal anomalies :

a- Anomalies of the C.N.S (anencephaly, meningocele, cephalocele,

hydroancephaly, hydrocephalus, and cebocephaly) .

b- Anomalies of G.I.T (esophageal and duodenal atresia).

c- abdominal wall defects.

d- fetal and placental tumor’s.

e- cardiovascular disorders(cardiac arrhythmias, coarctation and interruption of

fetal aorta , myocardial disorder , fetal Hydrops , fetal _fetal transfusion).

f- miscellaneous lesions such as true knot of the umbilical cord , hypo plastic lung,

cystic hygroma , thanatophoric dwarfism, and other short –limbed dwarfism. (11)

3- Idiopathic ( Other causes ) :-

Impaired amniotic fluid absorption:-

a- Cleft lip and palate .

b- Esophageal stenosis or atresia.

c- Duodenal stenosis or atresia.

d- Bowel obstruction. (11)

2.5.1.3 Complications of polyhydramnios:-

Premature labor , Premature rupture of membranes (PROM), Umbilical cord

prolapsed , Abruption placenta , Premature delivery , Increased prenatal mortality ,

Placenta previa. Polyhydramnios complicated by fetal C.N.S anomalies, isusually

diagnosed earlier than 30 weeks. Disorder is diagnosed later than 30 weeks in

pregnancies associated with G.I.T anomalies. Sever polyhydramni is associated

with a high incidence of fetal anomalies (75%). (11)

2.5.1.4 Symptoms of Polyhydramnios:

Mild cases of polyhydramnios may not cause any noticeable signs in the mother.

However, severe cases can lead to the following symptoms:

Difficulty breathing unless standing or sitting in an upright position.

Difficulty climbing stairs.

Decreased urine production.

Larger belly size for one’s gestational age.

Swelling of the abdominal wall, vulva and legs.

Indigestion.

Constipation a Stretch marks.

Abdominal pain and Heartburn.

Varicose veins (when the valves within the veins stop working, causing the

venous walls to become weak, leading to blood accumulation in the weak

spots). (11)

Polyhydramnios complicated by fetal C.N.S anomalies, is usually diagnosed

earlier than 30 weeks. Disorder is diagnosed later than 30 weeks in pregnancies

associated with G.I.T anomalies. Sever polyhydramni is associated with a high

incidence of fetal anomalies (75%). (11)

2.5.1.5 Polyhydramnios Diagnostic Criteria:-

The principal diagnostic criterion is an amniotic fluid index (AFI) over 20 cm or

largest pocket over 8 cm shown on ultrasound findings. (11)

A detailed ultrasound may be ordered to estimate the amniotic fluid levels by

assessing the deepest pockets in four particular regions of the uterus. These

measurements are then used for determining the AFI.(11)

Chamberlain Method

Single Vertical Pocket Measurement

< 1 cm severe oligohydramnios

1-2 cm significant oligohydramnios

2-8 cm Normal

8-12 cm mild polyhydramnios

12-16 cm moderate polyhydramnios

> 16 cm severe polyhydramnios

Table (2.1) quantitative determination of amniotic fluid volume by single vertical

pocket. (1)

2.5.1.6 Amniocentesis :

This diagnostic procedure involves collecting an amniotic fluid sample (containing

fetal cells and fetus produced chemicals) and testing it in a laboratory for evidences

of any infections or other abnormalities. (15)

2.5.1.7 Treatment of polyhydramnios:-

Definite clinical symptoms such as abdominal pain or dyspnea are indication for

the treatment of polyhydramnios. Serial amniotic fluid decompressions removing

2-4 litters of amniotic fluid are the treatment of choice in many cases.

Large fluid volume should not be removed in one sitting, as excessive

decompression can lead to placenta abruption. (11)

Indomethacin, a prostaglandin synthesise inhibitor, is available for the medical

treatment of polyhydrmnios. It acts by decreasing the fetal urine output.(11)

2.5.2 Oligohydramnios(Anhydramnios) :

Oligohydramnios is defined as diminished AFV. Anhydramniosis defined as

severe oligohydramnios and is indicated when there is no detectable amniotic fluid

pockets on ultrasound examination. There are no associated maternal risks.

Oligohydramnios may be suspected clinically if the measured uterine fundal height

is small-for-dates. With theChamberlain method, oligohyramnios is indicated if the

single largest pocket of amnioticfluid measured is less than 2 cm; with the Phelan

method, oligohydramnios is indicated if the sum of the four measured pockets of

amniotic fluid is 8 cm or less. (1)

Visual ultrasound features of oligohydramnios include:

A. lack of an amniotic fluid space between the anterior uterine wall and the fetal

Body.

B. relative crowding of fetal parts.

C. difficulty outlining the umbilical cord. (1)

2.5.2.1 Most Common Causes of Oligohydramnios:

1. premature rupture of membranes.

2. chronic fetal death.

3. postterm pregnancy.

4. advanced intrauterine growth retardation.

5. fetal genitourinary (GUT) tract anomalies associated with decreased renal

function and diminished urinary output or anomalies compromising the

flow of urine into the ureters, bladder, or urethra:

A. bilateral renal agenesis (Potter's syndrome).

B. bilateral ureteropelvic junction obstruction.

C. bilateral multicystic dysplastic kidneys.

D. infantile polycystic kidneys.

E. posterior urethral valves.

F. urethral agenesis.

6. chromosome defects (especially triploidy).(1)

Oligohydramnios related to fetal GU tract anomalies typically manifests early in

the 2nd trimester. The fetal bladder is a good place to start when assessing the

cause of oligohydramnios. Certain visualization of a normal-appearing fetal

bladder and fetal kidneys rules out bilateral renal agenesis and points to ruptured

membranes as the cause of oligohydramnios. Inability to visualize the fetal bladder

is suspicious of bilateral renal agenesis and should prompt careful evaluation of the

fetal kidneys. The diagnosis of bilateral renal agenesis is indicated if the fetal

kidneys cannot be visualized. (1)

Oligohydramnios due to a renal problem is alway bilateral therefore both kidneys

will be affected and appear abnormal. Demonstration of an abnormally enlarged

fetal bladder (megacystis) with evidence of bilateral hydronephrosis indicates a

bladder outlet level obstruction which is most commonly due to posterior urethral

valves. There is an increased risk of a chromosome abnormality when

oligohydramnios is associated with IUGR or renal abnormalities. In the early 2nd

trimester, the presence of severe oligohydramniosfavours the diagnosis of a serious

fetal abnormality with a poor prognosis (most often involving the GU tract)

whereas in the 3rd trimester, the etiology of severe oligohydramnios is more

commonly associated with ruptured membranes and placental insufficiency. (1)

The presence of an adequate volume of amniotic fluid is a factor in normal

fetal lung maturation, since in infants with prolonged reduction there is usually

severe pulmonary hypoplasia. (1)

Figure (2.6): Oligohydramnios.

2.5.3 Diabetes Mellitus:

Diabetes is a condition in which the body cannot change sugars and starches

(carbohydrates) into energy. This happens when the body cannot make enough

insulin or cannot use the insulin it makes. As a result, extra sugar in the blood can

lead to damage in the blood vessels, eyes, kidneys, heart, and nerves. (6)

2.5.3.1 Types of diabetes mellitus:

A- Gestational diabetes:

Is a type of diabetes that is first diagnosed in a pregnant woman. Out of every

100 pregnant women in the U.S, tow to ten will have gestational diabetes.

Gestational diabetes usually goes away after pregnancy, but if it does not go

away, it is known as type 2 diabetes. Many women who have had gestational

diabetes will develop type 2 diabetes later. (6)

B- Type 1 diabetes (Insulin dependent ) :

Is a condition in which the body makes no insulin or so little insulin that the

body cannot change blood sugar into energy. Type 1 diabetes usually develops

during childhood or adolescence, before a woman gets pregnant. (16)

C- Type 2 diabetes ( Non-insulin dependent ) :

Is a condition in which the body makes too little insulin or cannot use the

insulin it makes to change blood sugar into energy, Type2 diabetes often occurs

after childbearing age, although it is becoming more common for childbearing-

aged women to develop type2 diabetes. (16)

Approximately 87.5% of pregnancies complicated by diabetes are due to

gestational diabetes, 7.5% are due to type 1 diabetes and 5% are due to type 2

diabetes. (17)

2.5.3.2 Risks of Diabetes On Pregnancy :

1-Miscarriages:

Women with poor blood sugar control or many severe complications are at

greater risk for miscarriage. In otherwise healthy diabetic women, the risk of

miscarriage is no greater than that of the general population - approximately one

out of every nine or ten early-stage pregnancies. (17)

2-Large Babies (macrosomia):

Women with diabetes may have large babies because of their high blood

sugar levels. This effect can be reduced by keeping blood sugar levels as close

to normal as possible. Obviously, a big baby makes delivery more difficult and

for this reason, Caesarean sections are frequently performed. (17)

3- Polyhydramnios:

This condition - excessive amounts of amniotic fluid throughout pregnancy is

somewhat less common. Aside from the discomfort of an overly distended belly,

polyhydramnios rarely has harmful consequences. However, it is a sign that the

diabetes has not been under optimal control. The fluid builds up because the

baby is urinating large quantities due to elevated glucose levels. (17)

4- Toxaemia: -

Toxaemia is characterized by an increase in blood pressure, the presence of

protein in the urine, and the swelling of hands and feet. Toxaemia was once a

common complication of diabetic pregnancy, but with good blood sugar control,

this problem is no more common than in a non-diabetic pregnancy. (17)

2.5.4 Gestational Diabetes:

Gestational diabetes is a condition characterized by high blood sugar

(glucose) levels that is first recognized during pregnancy. The condition occurs in

approximately 4% of all pregnancies. (18)

Figure (2.7) gestational diabetes. (18)

2.5.4.1 Causes OF Gestational Diabetes in Pregnancy:

Almost all women have some degree of impaired glucose intolerance as a

result of hormonal changes that occur during pregnancy. That means that their

blood sugar may be higher than normal, but not high enough to have diabetes.

During the later part of pregnancy (the third trimester), these hormonal changes

place pregnant woman at risk for gestational diabetes. During pregnancy, increased

levels of certain hormones made in the placenta (the organ that connects the baby

by the umbilical cord to the uterus) help shift nutrients from the mother to the

developing fetus. Other hormones are produced by the placenta to help prevent the

mother from developing low blood sugar. They work by stopping the actions of

insulin. Over the course of the pregnancy, these hormones lead to progressive

impaired glucose intolerance (higher blood sugar levels). To try to decrease blood

sugar levels, the body makes more insulin to get glucose into cells to be used for

energy. Usually the mother's pancreas is able to produce more insulin (about three

times the normal amount) to overcome the effect of the pregnancy hormones on

blood sugar levels. If, however, the pancreas cannot produce enough insulin to

overcome the effect of the increased hormones during pregnancy, blood

sugar levels will rise, resulting in gestational diabetes. (18)

2.6 Previous studies:

Joy Y. Vink MD, Sarah H. Poggi MD, Alessandro Ghidini MD, Catherine

Y. Spong MD, 2007

Research name Amniotic fluid index and birth weight: Is there a

relationship in diabetics with poor glycaemia control

Result of research the poorly controlled diabetic population, a linear relationship

existed between AFI and BW centiles, with the largest BW centiles having the

highest AFI centiles (P< .0001) and he previously noted relationship between

elevated AFI and BW centiles in the general patient population is linear in diabetic

patients with poor glycemic control.

Department of Obstetrics and Gynecology, Kofinas Perinatal and Fertility

Institute, New York Methodist Hospital, Brooklyn, New York, 2006

Differences in amniotic fluid patterns and fetal biometric parameters in

third trimester pregnancies with and without diabetes. Reported that AFI in normal

pregnancies was less than that in diabetic pregnancies throughout the gestational

ages studied (27–42 weeks). In normal pregnancy, the mean AFI was 14.0 cm at 27

weeks and decreased to 11.4 cm at 42 weeks (r¼0.25, p¼0.0005), whereas in

diabetic pregnancies, the values remained stable throughout the gestational ages

studied. There exist significant differences in AFI, estimated fetal weight,

estimated fetal weight %, abdominal circumference. Abdominal circumference,

and head circumference to abdominal circumference ratio between the two groups.

In both Normal and diabetic pregnancies, there is a positive correlation between

the AFI and the percentile of abdominal Circumference (p50.0001), and between

the AFI and the percentile of estimated fetal weight (p50.0001).

Amniotic fluid volume reflects recent glycemic status in gestational diabetes

mellitus. Significantly higher mean blood glucose values 1 day (114.7 mg/dl vs

102.8 mg/dl, p < 0.01) and 1 week before (111.0 mg/dl vs. 102.0 mg/dl, p < 0.05)

were calculated for examinations resulting in elevated amniotic fluid index values

compared with normal amniotic fluid index values, respectively. Similarly,

significantly higher percents of hyperglycemia 1 day (32% vs. 16.5%, p < 0.05) but

not 1 week (30.8% vs. 21.7%, p > 0.05) before the elevated amniotic fluid index

were documented.

Perinatal Research Laboratory, Departments of Pediatrics and Obstetrics,

University of Alabama in Birmingham, University of Alabama in

Birmingham, University Station, Birmingham.2011

Reported that Amniotic fluid volume estimates were obtained in 37

diabetic women at 33½–38½ weeks of gestation. The technique employed, sodium

aminohippurate (PAH) dilution, allowed estimation of both volume and turnover’.

Hydramnios was common in the patients studied earlier in their third trimester;

fetal macrosomia and increased severity of maternal disease was also evident in

this group. Volumes comparable to those reported from normal patients were

observed in the women studied later in their third trimester. Amniotic fluid volume

appeared to be related to fetal growth with hydramnios accompanying macrosomia

and oligohydramnios in fetal growth retardation. A positive correlation of PAH

clearance and amniotic fluid volume was found.

Rian Omer Massaad Elbasheer, Sudan University of science and technology,

MS.c degree in medical Diagnostic Ultrasound, Khartoum, SUDAN.2012

The study was conducted to evaluate the amniotic fluid volume in diabetic

patient to show the effects of diabetes in pregnancy.

The study was conducted on 49 women with diabetes mellitus pregnant

women in the third trimester at period from December 2011 to April 2012.

Ultrasound was done by using mindray 6600, 2200 with 3.5 MHZ convex

probe .after measuring amniotic fluid volume by deepest pocket (large pocket) and

AFI (4 pocket) in the third trimesters .it was observed that the AFI in millimeters

in all patient with diabetes mellitus 26% of pt have increasing AFV. It is

concluded that the measurement of AFV by two measurement and compared with

type of diabetic and diabetic status is important to show the effect of diabetic in

pregnant women’s.

Moaz Saliman Hamad Adam, Alzaiem Alazhari University, M.Sc

degree in medical diagnostic ultrasound, Khartoum, sudan.2012

The study was conducted to evaluate the amniotic fluid volume in

diabetic pregnancy.

This study included 100 pregnant diabetic and data was collected from 18

March 2012 to 13 November 2012.

The study depends on the large single vertical deepest pocket and

found the majority of diabetic pregnant women are found to have

polyhydramnios (abnormal increase in amniotic fluid volume) which

represent (56%) of the sample size.

The majority of diabetic pregnant women are among type1 D.M

with (38%), and the age group (31 to 40) which represent (46%) of the

sample size, and treated by using insulin represent (54%) of the sample

size. The majority of diabetic pregnant women are well controlled from

DM represent (56%) of the sample size with (44%) of sample are

uncontrolled.

CHAPTER THREE

METHODOLOGY

Chapter three - Study Methods

3.1 Study design:

This study was analytical and descriptive study deal with the role of

ultrasound in evaluation of amniotic fluid volume and it’s consistency in

diabetic pregnant women among Sudanese population .

3.2 Study area: The study was conducted in:

- Alsuody hospital.

- Alturky hospital.

- Alban-jaded teaching hospital.

- Omdurman maternity hospital.

- Some other diagnostic health and private centers.

3.3 Study duration:

The study was carried out From 10 of December 2014 to 10 of May 2015.

3.4 Study population:

Sudanese pregnant women in second and third trimesters.

3.5Inclusion criteria:

All diabetic pregnant women in 2nd

and 3rd

trimesters.

3.6Exclusion criteria:

Non diabetic pregnant women.

3.7 Study variables:

- Maternal age.

- Type of diabetes mellitus.

- Amniotic fluid index.

- Gestational age.

- Consistency of amniotic fluid.

- Any anomalies seen.

3.8 Study sample:

The study done for 100 diabetic pregnant women.

3.9 Tool of data collection:

- The data was collected by using ultrasound machine.

- data collection sheet ( Questionnaire ).

3.10 Equipments:

Different types of ultrasound machines were used:

1-ALPINON ultrasound system, model: E-CUBE, Probe T.A convex 3.5 MHZ,

made of manufacturing: korea.

2- MINDRAY 1100 with TA 3.5MHZ , made of manufacturing : china.

3- Sonoscape portable ultrasound diagnostic system, model: A5, probe T.A 3.5

MHZ, made Of Manufacturing: china.

3.11Sonographic technique and guideline protocol:

Any diabetic patient comes to the obstetrics department:-

Firstly identify myself to patient, and explain about study in simple language then

clinical information was taken and data collection sheet filled.

3.11.1 Patient position:

All Trans Abdominal Sonography (TAS) study is generally performed with the

patient in Supine position.

3.11.2 Coupling gel:

A copious amount of scanning gel is applied to the transducer tip to ensure good

transducer skin contact and easy movement of the transducer.

3.11.3 Transducer Frequency:

Use 3.5 MHz trans abdominal transducers, 5 MHz for thin women.

3.11.4 Ultrasound procedure:

An ultrasound procedure used to assess the amount of amniotic fluid.

The single largest pocket measured the normal values range from 3 to 8cm

(figure3.1), then the amniotic fluid index is measured by dividing the uterus into

four imaginary quadrants. The linea nigra is used to divide the uterus into right

and left halves. The umbilicus serves as the dividing point for the upper and lower

halves.

The transducer is kept parallel to the patient longitudinal axis and perpendicular to

the floor. The deepest, unobstructed, vertical pocket of fluid is measured in each

quadrant in centimeters. The four pocket measurements are then added to calculate

the AFI. Normal AFI values range from 5to20cm.

Figure (3.1): Single largest pocket.

Each patient will be scanned twice, in an international scan guidelines and

protocols. Firstly by the researcher then by a qualified sinologist to confirm the

findings and diagnosis.

3.12 Data analysis:

- The data analyzed by statistically package for social sciences (SPSS).

3.13 data storage:

- The data was stored on personal computer and compact disk.

3.14 Ethical consideration:

- Data was collected from different patient with maintain privacy and

confidentiality.

- No patient information was published throughout this study.

Chapter four

The results

The results:

Table (4.1) Sample distribution for patients by age:

Maternal age Frequency Percent

≤ 20 years 10 10%

21 - 30 years 29 29%

31 - 40 years 54 54%

>40 years 7 7%

Total 100 100%

Figure (4.1) Sample distribution for patients by age:

0%

10%

20%

30%

40%

50%

60%

Less than or

equal 20 years

From 21 to 30

years

From 31 to 40

years

Greater than 40

years

10%

29%

54%

7%

Age

Percent

Table (4.2) Sample distribution for patients by type of diabetes:

Type of diabetes Frequency Percent

Insulin dependent 32 32%

Non insulin dependent 15 15%

Gestational diabetes 53 53%

Total 100 100%

Figure (4.2) Sample distribution for patients by type of diabetes:

0%

10%

20%

30%

40%

50%

60%

Insulin dependent Non insulin

dependent

Gestational diabetes

32%

15%

53%

Type of diabetes

Percent

Table (4.3) Sample distribution for patients by duration of diabetes:

Duration of diabetes Frequency Percent

Less than 1 year (GD) 53 53%

1 - 5 years 20 20%

6 - 10 years 21 21%

Greater than 10 years 6 6%

Total 100 100%

Figure (4.3) Sample distribution for patients by duration of diabetes:

0%

10%

20%

30%

40%

50%

60%

Less than one

year

From 1 to 5

years

From 6 to 10

years

Greater than 10

years

53%

20% 21%

6%

Duration of diabetes

Percent

Table (4.4) Sample distribution for patients by treatment type:

Treatment type Frequency Percent

Insulin 56 56%

Metformin 19 19%

Diet 25 25%

Total 100 100%

Figure (4.4) Sample distribution for patients by treatment type:

0%

10%

20%

30%

40%

50%

60%

Insulin Metformin Diet

56%

19% 25%

Treatment type

Percent

Table (4.5) Sample distribution for patients by diabetes status:

Diabetic status Frequency Percent

Controlled 76 76%

Uncontrolled 24 24%

Total 100 100%

Figure (4.5) Sample distribution for patients by diabetes status:

76%

24%

Diabetic status

Controlled

Uncontrolled

Table (4.6) Sample distribution for patients by history of polyhydramnios:

History of polyhydramnios Frequency Percent

Yes 17 17%

No 83 83%

Total 100 100%

Figure (4.6) Sample distribution for patients by history of polyhydraminos:

17%

83%

History of polyhydraminos

Yes

No

Table (4.7) Sample distribution for patients by gravity status:

Gravity status Frequency Percent

1 ( Primi-Gravida) 15 15%

2 17 17%

3 15 15%

4 17 17%

5 14 14%

6 9 9%

7 5 5%

8 4 4%

9 4 4%

Total 100 100%

0%2%4%6%8%

10%12%14%16%18% 15%

17% 15%

17%

14%

9%

5% 4% 4%

Gravity status

Percent

Figure (4.7) Sample distribution for patients by gravity status:

Table (4.8) Sample distribution for patients by gestational age:

Gestational Age (GA) Frequency Percent

From 20 to 21 weeks and 6 days 2 2%

From 22 to 23 weeks and 6 days 8 8%

From 24 to 25 weeks and 6 days 7 7%

From 26 to 27 weeks and 6 days 13 13%

From 28 to 29 weeks and 6 days 3 3%

From 30 to 31 weeks and 6 days 8 8%

From 32 to 33 weeks and 6 days 17 17%

From 34 to 35 weeks and 6 days 12 12%

From 36 to 37 weeks and 6 days 18 18%

From 38 to 39 weeks and 6 days 10 10%

Greater than or equal 40 weeks 2 2%

Total 100 100%

0%2%4%6%8%

10%12%14%16%18%

2%

8% 7%

13%

3%

8%

17%

12%

18%

10%

2%

Gestational age

Percent

Figure (4.8) Sample distribution for patients by gestational age:

Table (4.9) Sample distribution for patients by amniotic fluid volume single

deepest pocket (SDP):

AFV (SDP) Frequency Percent

Normal (3-8cm) 52 52%

Polyhydramnios( > 8cm) 48 48%

Total 100 100%

Figure (4.9) Sample distribution for patients by amniotic fluid volume single

deepest pocket (SDP):

52 %

48%

Amniotic fluied volume(SDP)

Normal

Polyhydramnios

Table (4.10) Sample distribution for patients by amniotic fluid volume (4 pockets):

AFV (4pockets) Frequency Percent

Normal (5-20cm) 52 52%

Polyhydramnios ( > 20cm) 48 48%

Total 100 100%

Figure (4.10) Sample distribution for patients by amniotic fluid volume (4

pockets):

52%

48%

amniotic fluid volume (4 pockets)

Normal

Polyhydramnios

Table (4.11) Sample distribution for patients by consistency of amniotic fluid:

Consistency of amniotic fluid Frequency Percent

Echo free 82 82%

With debris 18 18%

Total 100 100%

Figure (4.11) Sample distribution for patients by consistency of amniotic fluid:

82 %

18 %

Consistency of amniotic fluid

Echo free

With debris

Table (4.12) Sample distribution for patients by fetal macrosomia:

Fetal macrosomia Frequency Percent

Yes 29 29%

No 71 71%

Total 100 100%

Figure (4.12) Sample distribution for patients by fetal macrosomia:

29 %

71%

by fetal macrosomia

Yes

No

Table (4.13) Sample distribution for patients by fetal anomalies:

Fetal anomalies Frequency Percent

Yes 1 1%

No 111 111%

Total 100 100%

Figure (4.13) Sample distribution for patients by fetal anomalies:

.

0%

20%

40%

60%

80%

100%

Yes No

0%

100%

Fetal anomalies

Percent

Chi-Square tests:

1- Chi-Square test for amniotic fluid volume:

o Chi-Square test for amniotic fluid volume and diabetes status:

Table (4.14) Diabetes status * Amniotic fluid volume Cross tabulation:

Amniotic fluid volume(AFV)

Total Normal Polyhydramnios

Diabetes

status

Controlled Count 43 33 76

% within (AFV) 82.7% 68.8% 76%

Uncontrolled Count 9 15 24

% within (AFV) 17.3% 31.2% 24%

Total Count 52 48 100

% within (AFV) 100% 100% 100%

Figure (4.14) Diabetes status * Amniotic fluid volume Cross tabulation:

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Controlled Uncontrolled

82.70%

17.30%

68.80%

31.20% Normal

Polyhydramnios

o Chi-Square test for amniotic fluid volume and history of

polyhydramnios:

Table (4.15) History of polyhydramnios * Amniotic fluid volume (AFV) Cross

tabulation:

Amniotic fluid

volume(AFV)

Total Normal Polyhydramnios

History of

polyhydramnios

Yes Count 8 9 17

% within (AFV) 15.4% 18.8% 17%

No Count 44 39 83

% within (AFV) 84.6% 81.2% 83%

Total Count 52 48 100

% within (AFV) 100% 100% 100%

Figure (4.15) History of polyhydramnios * Amniotic fluid volume Cross

tabulation:

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

Yes No

15.40%

84.60%

18.80%

81.20%

Normal

Polyhydramnios

o Chi-Square test for amniotic fluid volume and type of diabetes:

Table (4.16) Type of diabetes * Amniotic fluid volume Cross tabulation

Amniotic fluid volume(AFV)

Total Normal Polyhydramnios

Type of

diabetes

Insulin

dependent

Count 18 14 32

% within (AFV) 34.6% 29.2% 32%

Non insulin

dependent

Count 5 10 15

% within (AFV) 9.6% 20.8% 15%

Gestational

diabetes

Count 29 24 53

% within (AFV) 55.8% 50.0% 53%

Total Count 52 48 100

% within (AFV) 100% 100% 100%

Figure (4.16) Type of diabetes * Amniotic fluid volume Cross tabulation

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Insulin dependent Non insulindependent

Gestational diabetes

34.60%

9.60%

55.80%

29.20%

20.80%

50.00%

Normal

Polyhydramnios

2- Chi-Square test for consistency of amniotic fluid:

Chi-Square test for consistency of amniotic fluid and

amniotic fluid volume:

Table (4.17) Amniotic fluid volume (AFV) * Consistency of amniotic fluid Cross

tabulation

Consistency of amniotic

fluid

Total Echo free With debris

Amniotic

fluid volume

(AFV)

Normal Count 42 10 52

% within Consistency 51.2% 55.6% 52%

Polyhydra-

mnios

Count 40 8 48

% within Consistency 48.8% 44.4% 48%

Total Count 82 18 100

% within Consistency 100% 100% 100%

Figure (4.17) Amniotic fluid volume (AFV) * Consistency of amniotic fluid Cross

tabulation

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Normal Polyhydramnios

51.20% 48.80%

55.60%

44.40%

Echo free

With debris

3- Chi-Square Test for fetal macrosomia:

Chi-Square test for fetal macrosomia and amniotic fluid volume

(AFV):

Table (4.18) Amniotic fluid volume (AFV) * Fetal macrosonia Cross tabulation

Fetal macrosomia

Total Normal Macrosomia

Amniotic

fluid

volume

(AFV)

Normal Count 42 10 52

% within Fetal 59.2% 34.5% 52%

Polyhydramnios Count 29 19 48

% within Fetal 40.8% 65.5% 48%

Total Count 71 29 100

% within Fetal 100% 100% 100%

Figure (4.18) Amniotic fluid volume (AFV) * Fetal macrosonia Cross tabulation

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

Normal Polyhydramnios

59.20%

40.80%

34.50%

65.50%

Normal

Macrosomia

Chi-Square test for fetal macrosomia and diabetes status:

Table (4.19) Diabetes status * Fetal macrosomia Cross tabulation

Fetal macrosomia

Total Normal Macrosomia

Diabetes

status

Controlled Count 55 21 76

% within Fetal 77.5% 72.4% 76%

Uncontrolled Count 16 8 24

% within Fetal 22.5% 27.6% 24%

Total Count 71 29 100

% within Fetal 100% 100% 100%

Figure (4.19) Diabetes status * Fetal macrosomia Cross tabulation

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Controlled Uncontrolled

77.50%

22.50%

72.40%

27.60% Normal

Macrosomia

4- Chi-Square test Type of treatment:

o Chi-Square test for type of treatment and diabetes status:

Table (1.21) test for type of treatment and diabetes status Cross tabulation:

Treatment type

Total Insulin Metformin diet

Diabetes

status

Controlled Count 50 15 8 76

% within Treatment

type 89.3% 80.0% 31.6% 76.0%

Uncontrolled Count 6 1 17 24

% within Treatment

type 10.7% 20.0% 68.4% 24.0%

Total Count 56 19 45 100

% within Treatment

type 100% 100% 100% 100%

Figure (4.21) Type of treatment and diabetes status Cross tabulation:

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Insulin Metformin diet

89.30%

80.00%

31.60%

10.70% 20.00%

68.40%

Controlled

Controlled

o Chi-Square test for type of treatment and amniotic fluid

volume :

Table (4.21) test for type of treatment and amniotic fluid volume Cross tabulation:

Treatment type

Total Insulin Metformin diet

Amniotic

fluid

volume

Normal Count 33 11 8 52

% within Treatment type 58.9% 52.0% 31.6% 52.0%

Polyhydra

-mnios

Count 23 8 17 48

% within Treatment type 41.1% 48.0% 68.4% 48.0%

Total Count 56 19 45 100

% within Treatment type 100% 100% 100% 100%

Figure (4.21) Type of treatment and amniotic fluid volume Cross tabulation:

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

Insulin Metformin diet

58.90%

52.00%

31.60%

41.10%

48.00%

68.40%

Normal

Polyhydra-mnios

Independent samples t-test for equality of means:

Table (4.24) Means, and Standard deviations for amniotic fluid volume (4 pockets)

and amniotic fluid volume (SDP) by diabetes status:

Diabetes status N Mean Std.

Deviation

Std. Error

Mean

Amniotic fluid

volume(4 pockets)

Controlled 76 19.03 7.82 0.90

Uncontrolled 24 22.98 7.66 1.56

Amniotic fluid

volume(SDP)

Controlled 76 7.44 2.14 0.25

Uncontrolled 24 8.24 2.21 0.45

CHAPTER FIVE DISCUSSION,conclusion,recommendation

Chapter five

5.1 Discussion

5.1.1 Distribution of sample according to maternal factors (age, type

of diabetes, treatment type, diabetes status):

- From the result we observed the majority of diabetic pregnant

women were among the age group (31 to 40) years which represent 54%

of sample volume, this agree with research done by Rian Omer Massaad

Elbasheer, Sudan University, which was the common affected ages

between(30-34) is 24.5%, and also agree with that done by Moaz

Saliman Hamad Adam, Alzaiem Alazhari University, which was the

majority of diabetic pregnant women were among the age group (31to

40) represent (46%).

- The majority of patients among group of gestational diabetes represent

53% this result was not agree with that finding by both Rian Omer

Massaad Elbasheer, Sudan University, and Moaz Saliman Hamad Adam,

Alzaiem Alazhari University, which were the majority of patients among

the type 1 DM, this different for unknown cause.

- The majority of patients were using insulin for diabetes treatment,

which represent 56% , and this correlation with study conducted by

Moaz Saliman Hamad Adam, Alzaiem Alazhari University, which

represented 54% of patients under insulin treatment.

- Also study found that the majority of patients were well controlled for

DM, which represent 76%, and this agree with that finding by both Rian

Omer Massaad Elbasheer, Sudan University, the common of diabetic status

is control (71.4%), and Moaz Saliman Hamad Adam, Alzaiem Alazhari

University, The majority of diabetic pregnant women were well

controlled from D.M represent (56%) of the sample size.

5.1.2 Distribution and correlation according u/s findings:

study found that 48% of patients had polyhydramnios (abnormal

increase in amniotic fluid volume), and 52% of patients had normal

amniotic fluid volume, There was strong correlation with that result of

Rian Omer Massaad Elbasheer research, Sudan University of science and

technology, MS.c degree in medical Diagnostic Ultrasound, Khartoum,

SUDAN, which represented that the AFI in millimeters in all patients

with diabetes mellitus 26 out of 49 patients had increasing AFV. Also

this result agree with study of Department of Obstetrics and Gynecology,

Kofinas Perinatal and Fertility Institute, New York Methodist Hospital,

Brooklyn, New York, which reported that AFI in normal pregnancies was

less than that in diabetic pregnancies throughout the gestational ages

studied (27–42 weeks). In normal pregnancy, the mean AFI was 14.0 cm

at 27 weeks and decreased to 11.4 cm at 42 weeks (r¼0.25, p¼0.0005),

whereas in diabetic pregnancies, the values remained stable throughout

the gestational ages studied.

Also agree with result of Moaz Saliman Hamad Adam, Alzaiem Alazhari

University, M.Sc degree in medical diagnostic ultrasound, Khartoum,

sudan.2012 which reported that the majority of diabetic pregnant women

were found to had polyhydramnios (abnormal increase in amniotic fluid

volume) which represented (56%) of the sample size.

- From uncontrolled DM patients, the majority were polyhydramnios

which represented 62.5% of uncontrolled group , and 27.6% of these

group had macrosomic fetuses, this agree with Joy Y. Vink MD, Sarah

H. Poggi MD, Alessandro Ghidini MD, Catherine Y. Spong MD, 2007 Result of

research the poorly controlled diabetic population, a linear relationship

existed between AFI and BW centiles (elevated AFI and BW centiles is

linear in diabetic patients with poor glycemic control).

- The most fetuses with macromomia had polyhydramnios which

present 65.5% of macrosomic group, this correlation with Research

Laboratory, Departments of Pediatrics and Obstetrics, University of Alabama

in Birmingham, University of Alabama in Birmingham, University Station,

Birmingham.2011, which reported that amniotic fluid volume appeared to

be related to fetal growth with hydramnios accompanying macrosomia.

5.1.3 Discussion of T-Test:

The mean of amniotic fluid volume (4 pockets) for controlled

group is 19.43 that means the mean of amniotic fluid volume (4 pockets)

is normal for controlled group), and the mean of amniotic fluid volume

(4 pockets) for uncontrolled group is 22.98 (that means the mean of

amniotic fluid volume (4 pockets) is polyhydramnios for uncontrolled

group). And the mean of amniotic fluid volume (SDP) for controlled

group is 7.44 (that means the mean of amniotic fluid volume (SDP) is

normal for controlled group), and the mean of amniotic fluid volume

(SDP) for uncontrolled group is 8.24 (that means the mean of amniotic

fluid volume (SDP) is Polyhydramnios for uncontrolled group).

Conclusion

This study deals mainly with diabetic pregnancies to measure AFV the

concluded that:-

- The commonest type of diabetes in Sudanese pregnant women was type of

gestational diabetes (53%) of sample size. - Most Sudanese pregnant women have abnormally increased of amniotic

fluid volume (polyhydramnios).

- 48% of Sudanese pregnant women have polyhydramnios, while 52% of

sample size has normal amniotic fluid volume.

- 24% from patients they have uncontrolled diabetes status, and 76% from

patients they have controlled diabetes status.

- 17% from patients they have history of polyhydramnios.

- 29% of sample size has macrosomic fetuses (large EFW).

- The mean of amniotic fluid volume (4 pockets) for controlled group is 19.43

(that means the mean of amniotic fluid volume (4 pockets) is normal for

controlled group), and the mean of amniotic fluid volume (4 pockets) for

uncontrolled group is 22.98 (that means the mean of amniotic fluid volume

(4 pockets) is polyhydramnios for uncontrolled group). And the mean of

amniotic fluid volume (SDP) for controlled group is 7.44 (that means the

mean of amniotic fluid volume (SDP) is normal for controlled group), and

the mean of amniotic fluid volume (SDP) for uncontrolled group is 8.24

(that means the mean of amniotic fluid volume (SDP) is Polyhydramnios for

uncontrolled group).

- Diagnostic ultrasound is a good modality for assessing the AFV with high

accuracy and efficiency.

Recommendations With reference to the results and conclusion concerning this research, it’s to be

recommended that:

- Diabetes is a common causes of many maternal and fetal complications during

pregnancy so; special care with special diagnosis and treatment of this problem

should be available.

- Any diabetic pregnant lady should be assess by u/s several scans from 20weeks

up to delivery date (EDD).

- Primary health care centers should be with ultrasound machine.

- All doctors and sonologists should be well training in fetal well-bearing and

mother health , the assessment of fetal well-bearing to decrease the mortality and

morbidity.

- WHO and humanist associations must help for provide the health care centers by

u/s machines and support staff training courses.

- The operators should update their knowledge about techniques used and any

information regarding ultrasound.

- It is recommended that other factors which can effect on accuracy of amniotic

fluid volume and contribute to differences should evaluate in further studies.

- Further studies should be established for effect of diabetes in AFV, placenta,

fetal biometry and fetal weight, employing large samples to confirm these

findings.

References:

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https://en.wikipedia.org/?title=Amniotic_fluid

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pm.

appendices

Ultrasound images for amniotic fluid volume:

Figure (1): 25 weeks gestation show polyhydramnios( largest pocket =10.4cm),

Controlled type2 DM.

Figure (2): 46 weeks + 1 day gestation show normal amniotic fluid volume of

controlled type 1 DM.

Figure (3): 37 weeks+4days gestation (large fetus), show normal amniotic fluid

volume &normal Dopplerwaveform of umbilical artery for controlled GDM

women.

Figure (4): 36 weeks + 3 days gestation show macrosomic fetus with normal

amniotic fluid (largest pocket 7.4cm), uncontrolled GDM lady.

Figure (5): 38weeks+2days gestation show polyhydramnios (SDP=9.5CM) ,

uncontrolled GDM lady.

Figure (6): 34 weeks gestation with normal amniotic fluid volume, (SDP= 4.6CM)

controlled type2 DM lady.

Figure (7): 35 weeks+5days gestation (male) show polyhydramnios with debris,

uncontrolled GDM lady.

Figure (8) : 37 weeks + 1day gestation show polyhydramnios,Uncontrolled type 2

DM lady.

Figure (9): 26 weeks gestation show normal amniotic fluid (largest pocket 5.4cm),

controlled type 1 DM lady.

Figure (10): 31 weeks gestation (female) with polyhydramnios with debris

(largest pocket 10.6cm), uncontrolled GDM lady.

Figure (11): 25 weeks+2days gestation show normal amniotic fluid (SDP= 6.7CM)

of controlled type2 DM women.

Figure (12): 37 weeks+5days gestation show polyhydramnios )largest 11.4 cm),

uncontrolled type 2 DM Lady.

Figure (13): 33 weeks gestation show polyhydramnios( SDP=11.4cm), controlled

type 1 DM ( multiparous with history of polyhydramnios).

Figure (14): 32 weeks + 1day gestation show polyhydramnios (SDP=8.6CM),

uncontrolled GDM.

Figure (15): 21 weeks gestation with normal amniotic fluid volume, controlled

type 1 DM lady.

Figure (16): 33 weeks gestation show polyhydramnios , controlled type2 DM.

Figure (17): 37 weeks + 3daysgestation with normal amniotic fluid volume and

consistency of controlled type 1 DM.

Figure (18): 37 weeks + 3 days gestation show polyhydramnios of uncontrolled

GDM.

Figure (19): 41 weeks gestation with polyhydramnios (macrosomic fetus),

Controlled type 2 DM lady.

Figure (20): 32 weeks gestation show polyhydramnios (largest pocket=9.07cm),

Controlled GDM lady.

Figure (21): 29 weeks gestation (normal AFI) , controlled type 1 DM.

Figure (22): 31 weeks gestation show normal liquor volume and normal Doppler

flow, of controlled GDM.

Figure (23): 38 weeks + 6 days gestation with normal amniotic fluid volume and

normal Doppler flow, controlled type 1 DM lady.

Figure (24): 32 weeks gestation show polyhydramnios, uncontrolled GDM lady.

Figure (25): 27 weeks + 3 days gestation show polyhydramnios of uncontrolled GD

women.

Figure (26): 24 weeks gestation (polyhydramnios), uncontrolled type2 DM.

Figure (27): 41 weeks gestation show polyhydramnios of controlled type1 DM

lady.

Figure (28): 26 weeks gestation (male) show polyhydramnios, controlled GDM

lady .

Figure (29): 21 weeks+ 3 days gestation with polyhydramnios , controlled type1

DM.

Figure (30): 37 weeks gestation show polyhydramnios with debris, Controlled

Type 2 DM lady.

The National Ribat University

Faculty of Graduate Studies and Scientific Research

Data Collection Sheet

Sonographic Evaluation of Amniotic Fluid Volume in Diabetic Pregnant women

During 2nd & 3rd Trimesters in Khartoum State

Patient Number:(………). Date:......\......\2015.

1-Patient age: (………) Years.

2-Patient weight: (……….) Kg.

3-Type of DM:

Type 1(………..). Type 2(...……..)= medication (……………………..).

4-Duration of DM: (…………………...).

5-Diabetes status:

Controlled (……..). Uncontrolled (………).

6- History of polyhydramnios:

Yes (……………...). No (………………..).

7- Parity status: G (……...), P (…………).

8- Gestational Age :(…….………….) weeks. BPD (………...….), FL (………..……), AC (…….….……).

9- Amniotic fluid volume: SDP (………………). 4 pockets (…………….).

Normal (……….…) Polyhydramnios (……….).

10- Consistency of amniotic fluid:

Echo free (………..). With debris (………).

11- EFW :(………..…) kg.

Normal (……….) Macrosomia (………).

12- Congenital fetal anomalies:

Yes (……….) No (……………..)