The Amnion and Amniotic Fluid

Aisling Murphy and Brian Koos, University of California, Los Angeles, Los Angeles, CA, United States
© 2018 Elsevier Inc. All rights reserved.

Introduction

Throughout gestation, the amniotic fluid (AF) not only protects the fetus from trauma, but also permits normal fetal growth and
movement, and prevents compression of the umbilical cord. Its bacteriostatic properties defend against infection and analysis of AF
enables prenatal genetic diagnosis. AF also provides an acoustic interface that facilitates fetal ultrasound imaging. Disorders of
amniotic fluid volume are among the most common obstetric complications and arise from a diverse number of underlying
pathological processes. This chapter reviews amnion embryology, AF volume regulation and clinical disorders of amniotic fluid
volume.

Embryology

Humans belong to amniotes, a large vertebrate subgroup with a fluid-containing membrane (amnion) encapsulating the embryo.
The development of an amnion enabled our remote tetrapod ancestors to lay their eggs on land rather than in water, and therefore
ranks as among the most important evolutionary developments (Hickman et al., 2013).
The human blastocyst contains an outer layer of trophoectodermal cells and an inner cell mass. Before implantation, the inner
cell mass differentiates into two layers. Epiblast, the outer upper layer, is the morphologic precursor to the amnion, which ultimately
encompasses the entire embryo and surrounding fluid. The hypoblast underlying the epiblast forms the endodermal lining of the
yolk sac. Developing ventral to the epiblast, the extra-embryonic mesoderm becomes the inner layer of the chorionic membrane
(Fig. 1; Carlson, 2014). The trophoectodermal cells of the cytotrophoblast and syncytiotrophoblast form the outer layer.
The enlarging amnion completely surrounds the embryo upon merging with the body stalk, a precursor of the umbilical cord.
The amnion forms the epithelial layer of the umbilical cord. Surrounding the amnion is the chorionic cavity or extra-embryonic
coelom, which is formed within the extra-embryonic mesoderm (Fig. 2; Carlson, 2014). In early gestation, the coelomic cavity
is filled with fluid, but at the end of the first trimester (12–14 weeks’ gestation) the enlarging amnion fuses with the chorion, oblit-
erating the coelomic cavity.

Amniotic Fluid Circulation in Early Gestation

The coelomic cavity, (secondary) yolk sac, and amniotic cavity are present in the first-trimester. Coelomic fluid (CF) has a similar
composition to maternal plasma, suggesting that CF is an ultrafiltrate of maternal plasma (Jauniaux and Gulbis, 2000).
The very early origin of amniotic fluid is CF rather than the fetus, since AF is present in anembryonic gestations (Seeds, 1980).
Later on in the first trimester, the compositions of CF and AF differ significantly (Campbell et al., 1992, 1993; Jauniaux and Gulbis,
2000), and at this time transudation of fluid and nutrients across the non-keratinized epithelium appears to be a major source of AF
(Jauniaux et al., 1994). The magnitude of contribution from the maternal circulation across the chorion and amnion (transmem-
branous pathway) in the first trimester is unknown.

Amniotic Fluid Circulation in Late gestation

Fetal Urine
Fetal urine contributes to AF volume when the kidneys begin to function by the end of the first trimester. Fetal urine becomes the
major source of AF once fetal skin is keratinized in the second trimester. The volume of urine production has been estimated using
ultrasound assessment of fetal bladder volume. These data suggest that fetal urine output increases from 110 mL/kg fetal weight/day
at 25 weeks up to approximately 200 mL/kg fetal weight/day at term (Rabinowitz et al., 1989; Fägerquist et al., 2001). Fetal urine
production decreases after 40 weeks’ gestation (Abramovich et al., 1979; Wladimiroff and Campbell, 1974).

Fetal Lung Fluid

Another major source of AF is the secretion of pulmonary fluids. Based on animal studies, fetal lungs excreted about 60–100 mL/kg
fetal weight/day) (Gilbert and Brace, 1993). About half of the volume flows into the amniotic cavity, while the other portion is
swallowed.
Fetal lung fluid differs from urine in having a higher chloride content, and lower concentration of protein and bicarbonate.
Pulmonary phospholipids are present, particularly in late gestation. These phospholipids are critical for postnatal lung function,
and levels in AF can provide a risk assessment for neonatal respiratory distress syndrome.

562 Encyclopedia of Reproduction, 2nd edition, Volume 2 https://doi.org/10.1016/B978-0-12-801238-3.64687-1

 Pregnancy j The Amnion and Amniotic Fluid 563

Fig. 1 (A) Late blastocyst. (B) Beginning of implantation at 6 days. (C) Implanted blastocyst at 7.5 days. (D) Implanted blastocyst at 8 days. (E)
Embryo at 9 day. (F) Late second week. Reproduced from Carlson, B. (2014). Formation of germ layers and early derivatives. Human embryology and
developmental biology (5th edn.) Elsevier (Chapter 5).

Lung fluid secretion is essential for normal lung development. Cortisol and catecholamines lower lung fluid production.
Neonates who have undergone the forces of vaginal delivery have higher levels of these hormones than those delivered by cesarean.
The higher hormone concentrations enhance clearance of lung fluid as the fetus transitions to postnatal life and likely account for
the lower rates of transient tachypnea in vaginally delivered newborns.
Very little amniotic fluid (< 2 mL) is normally exchanged per single breathing movement. But the train of breaths in a breathing
episode increases lung volume, and this expansion contributes to lung growth (Harding and Hooper, 1996). Hypoxia normally
inhibits breathing movements, but severe hypoxia/asphyxia can elicit intermittent, strong gasping efforts. Large transthoracic pres-
sure gradients produced by isolated gasps can result in a net inflow of amniotic fluid. This phenomenon is supported by autopsies of
stillborn infants revealing meconium in the pulmonary tissue (Brown and Gleicher, 1981) and by the finding of meconium aspi-
ration syndrome in neonates without postnatal aspiration (Byrne and Gau, 1987; Sarno Jr et al., 1990).

Intramembranous Pathway
The intramembranous pathway involves absorption of AF across the vasculature of the chorionic plate into the fetal circulation. The
amount of fluid passing through this pathway is highly variable, ranging from 200 to 500 mL per day (Wintour and Shandley,
1993) (Fig. 3).

Transmembranous Pathway
The transmembranous pathway involves fluid passage through fetal membranes to the maternal blood in capillaries within the
uterine wall. This pathway has a minimal effect of AF volume with only about 10 mL/day transferred at term (Gilbert and Brace,
1993; Seeds, 1980).
564 Pregnancy j The Amnion and Amniotic Fluid

Fig. 2 Origins of the major extraembryonic tissues. Reproduced from Carlson, B. (2014). Formation of germ layers and early derivatives. Human
embryology and developmental biology (5th edn.) (Chapter 5).

Fetal Swallowing
Fetal swallowing is the predominant AF outflow, about 200–250 mL/kg fetal weight/day (Abramovich et al., 1979). Although swal-
lowing activity can be observed in late first trimester, these movements become well-coordinated with behavioral states only in later
gestation (Grassi et al., 2005). Dipsogenic (thirst) and orexigenic (appetite) pathways stimulate swallowing activity in near-term
fetal sheep (Xu et al., 2001; El-Haddad et al., 2004). Fetal swallowing is also augmented by increased volume of AF, decreased
 Pregnancy j The Amnion and Amniotic Fluid 565

Fig. 3 Amniotic fluid pathways. Reproduced from Underwood, M. A., Gilbert, W. M. and Sherman, M. P. (2005). Amniotic fluid: Not just fetal urine
anymore. Journal of Perinatology 25(5), 341–348.

AF osmolarity and elevated fetal plasma osmolarity (Moore, 2010). On the other hand, fetal swallowing diminishes in response to
oligohydramnios, hypotension, and hypoxia (Brace et al., 1994; Sherman et al., 1991).
Fetal CNS lesions (e.g., anencephaly) and some neuromuscular disorders can elicit polyhydramnios by inhibiting fetal swallow-
ing. Likewise, conditions interrupting passage of AF through the gastrointestinal tract (e.g., esophageal or duodenal atresia) can also
cause polyhydramnios. In obstruction cases without polyhydramnios, AF volume is likely normalized via the intramembranous
pathway.

Composition of Amniotic Fluid

Early Gestation (First Trimester)
AF is isotonic with fetal plasma with very low protein concentrations except for a-fetoprotein. AF is a milieu of low oxygen tension.
High levels of polyols are present, suggesting activity of the polyol pathway, which is involved in generating NADþ from NADH.
Given the low oxygen tensions of embryonic tissues, increased NADH production allows glycolysis to continue, while limiting
lactate generation and fall in pH (Jauniaux et al., 2005). This pathway is also involved in the production of precursors for nucleic
acids, important in rapidly dividing tissues.

Later Gestation (Second and Third Trimesters)

With keratinization of fetal skin, AF approximates urine in composition, containing carbohydrates, proteins, amino acids, and
lipids, as well as the electrolytes, enzymes, and hormones (Underwood et al., 2005). Amino acids levels drop across gestation
and are lower than serum levels, with the exception of taurine (Reid et al., 1971; Kerr and Kennan, 1969; Cockburn et al.,
1970). In the ovine fetus, swallowed AF amino acids appear important in the development of the intestinal mucosa (Kwon
et al., 2003). Swallowed AF lipid and carbohydrates unlikely contribute significantly to fetal nutrition, and nutritional supplemen-
tation via AF does is not improve weight-gain in experimental fetal growth restriction (Buchmiller et al., 1994).
AF contains multiple growth factors including epidermal growth factor, transforming growth factor alpha, transforming growth
factor beta-1, insulin-like growth factor I, erythropoietin, and granulocyte colony stimulating factor. These substances appear to
have significant trophic effects in the intestinal mucosa (Underwood et al., 2005). Antimicrobial substances are also present in
AF, such as a-defensins [HNP1–3] and lactoferrin (Underwood et al., 2005).

Amniotic Fluid Volume

Based on dye dilution studies, AF volume normally rises progressively from early pregnancy to about 32–34 weeks and thereafter
declines until delivery (Brace and Wolf, 1989). The normal range of AF across gestation is quite broad. The decline in AF volume
may involve relative changes in swallowed fluid relative urine production as well as alterations in fluid transfer across the intramem-
branous pathway (Fig. 4).

Regulation of Amniotic Fluid Volume

AF volume changes little from day to day, despite the daily fluid turnover. Thus, AF volume is regulated. Fetal sheep studies indicate
that the intramembranous pathway is the primary controller of AF volume (Brace and Cheung, 2014). Putative components of this
566 Pregnancy j The Amnion and Amniotic Fluid

2500

2000

AMNIOTIC FLUID VOLUME (ml) 1500

99%

1000 95%

75%
500
50%
25%
5%
1%
0
8 12 16 20 24 28 32 36 40 44
GESTATIONAL AGE (weeks)
Fig. 4 Amniotic fluid volumes as a function of gestational age. Shaded area covers 95% confidence interval. Reproduced from Brace, R. A., Wolf, E.
J. (1989). Normal amniotic fluid volume changes throughout pregnancy. American Journal of Obstetrics and Gynecology 161, 382.

regulatory pathway include chorioamnion vascular endothelial growth factor (Matsumoto et al., 2001; Feng et al., 1999; Cheung
et al., 2010; Shandley et al., 1997), transmembrane water channels (aqueporins) (Brace and Wolf, 1989; Mann et al., 2006; Beall
et al., 2007) absorption inhibitors in fetal urine, intra-amniotic prostaglandin E2 via its stimulation of vascular endothelial growth
factor production in the fetal membranes and membrane stretch via a negative feedback effect (Brace and Cheung, 2014).

Assessment of Amniotic Fluid Volume

Estimation of AF volume involves ultrasound measurement of the maximum vertical pocket or the four quadrant sum of the deep-
est vertical pockets, the amniotic fluid index (AFI). Excessive AF volume (polyhydramnios) is generally identified with a single
pocket > 8 cm or AFI > 25 cm with low volumes (oligohydramnios) having a single pocket < 2 cm or AFI < 5 cm. These extremes
of AF volume have important clinical implications.
Polyhydramnios. Complicating about 1% of pregnancies, polyhydramnios is associated with variety of conditions including
maternal diabetes mellitus, malformations which may inhibit fluid passage through the gastrointestinal tract, neuromuscular
impairments which may inhibit fetal swallowing, and fetal anemia (Table 1). About 40% of cases are unexplained. Polyhydramnios
increases the risk of a number of complications, including preterm labor, cesarean delivery, stillbirth, cord prolapse, and postpartum
hemorrhage (Biggio Jr et al., 1999; Pilliod et al., 2015). The enlarged uterus can also cause shortness of breath in the mother.
Oligohydramnios. The progressive fall in AF after about 32 weeks increases the prevalence of oligohydramnios, particularly after
41 weeks’ gestation. The normal decline in AF volume is likely due to changes in fluid transfer via the intramembranous pathway.
Oligohydramnios can also accompany premature (before onset of contractions) rupture of the membranes, fetal growth restriction,
renal disorders, and chronic disruptions in placental function. Early onset, severe oligohydramnios greatly increases risk of pulmo-
nary dysplasia and compression abnormalities of the fetus. Preterm (< 37 weeks) premature rupture of the membranes only
complicates 1%–2% of pregnancies but is a major cause of preterm birth and its adverse sequelae. Even at term, oligohydramnios
increases fetal morbidity and mortality (Shipp et al., 1996; Sarno Jr et al., 1990; Chauhan et al., 1999) (Table 2).

Summary

The amnion arises from the epiblast cells of the blastocyst and grows to surround the developing embryo, creating a fluid-filled
cavity. Thus, throughout prenatal life, humans are surrounded by AF. This fluid serves many functions critical for prenatal develop-
ment. In very early gestation AF appears to arise from the nearby coelomic cavity. As the fetus grows, the transudation of fluid across
the fetal skin becomes an important source of fluid. In second trimester, after keratinization of the fetal skin, fetal urine becomes the
 Pregnancy j The Amnion and Amniotic Fluid 567

Table 1 Causes of polyhydramnios

Idiopathic
Fetal macrosomia
Maternal diabetes
Gastrointestinal anomalies, e.g., cleft palate, esophageal atresia, duodenal atresia, annular pancreas, jejunal atresia, volvulus,
gastroschisis
CNS lesions/musculoskeletal disorders, e.g., anencephaly, hydranecephaly, microcephaly, encephalocele, myoclonic
dystrophy, Pena-Shokeir syndrome, fetal akinesia syndrome
Obstructive chest lesions, e.g., congenital diaphragmatic hernia, CPAM
Hydrops/fetal high output cardiac failuredisoimmunization, congenital cardiac lesions, fetal arrhythmias, TORCH infections,
Alpha thalessimia, fetal anemia, sacrococcygeal teratoma, chorioangioma
Twin to twin transfusion syndrome
Aneuploidydtrisomy 18, trisomy 21
Skeletal dysplasiasdosteogenesis imperfecta, thanatophoric dysplasia
Renal disordersdunilateral uteropelvic junction obstruction, Bartter syndrome

Table 2 Causes of oligohydramnios

Rupture of membranes
Placental insufficiency/fetal growth restriction/placental abruption
Posterm pregnancy
Fetal urinary tract anomalies, e.g., renal agenesis, multicystic dysplastic kidneys, polycystic kidneys, fetal bladder outflow tract
obstruction, bilateral ureteropelvic junction obstruction
Maternal medications, e.g., prostaglandin synthetase inhibitors, angiotensin converting enzyme inhibitors
Chromosomal anomalies
Other causes, e.g., donor twin in twin to twin transfusion syndrome, fetal demise

primary source of AF, with a lesser contribution from lung fluid. Fluid is removed from the cavity by fetal swallowing and via
absorption back into the fetal circulation, known as the intramembranous pathway.
AF volume normally rises to a peak in the early third trimester, and then subsequently declines. Estimation of AF volume can be
made by use of prenatal ultrasound and disorders of AF volume are common obstetric complications.

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Further Reading

Sunoo, C., Kosasa, T. S., & Hale, R. W. (1989). Meconium aspiration syndrome without evidence of fetal distress in early labor before elective cesarean delivery. Obstetrics and
Gynecology, 73(5 Pt1), 707–709.