AMNIOINFUSION

Definition

■ Amnioinfusion refers to the instillation of fluid into

the amniotic cavity
■ This procedure is typically performed during labor
through an intrauterine catheter introduced
transcervically after rupture of the fetal
membranes.
■ Alternatively, fluid can be infused through a needle
transabdominally, the reverse process of
amniocentesis.

Khatun, T., Ansari, A.A., Hamid, I., Gupta, R.S. and Ahmad, M.P., 2017. oligohydramnios and
fetal outcome: A Review. Med Phoenix, 1(1), pp.23-30.
Amniotic Fluid Function
■ helps to protect the fetus from trauma to the maternal
abdomen
■ cushions the umbilical cord from compression between
the fetus and uterus
■ has antibacterial properties that provide some
protection from infection
■ serves as a reservoir of fluid and nutrients for the fetus
■ provides the necessary fluid, space, and growth factors
to permit normal development of the fetal lungs and
musculoskeletal and gastrointestinal systems.

Khatun, T., Ansari, A.A., Hamid, I., Gupta, R.S. and Ahmad, M.P., 2017.
oligohydramnios and fetal outcome: A Review. Med Phoenix, 1(1), pp.23-30.
Potential Indications

Prevention and Reduction in

treatment of Prevention of cesarean for
repetitive variable meconium aspiration repetitive FHR
decelerations decelerations

Improved Treatment or
visualization during prevention of As an aid to external
sonographic or chorioamnionitis in cephalic version
fetoscopic PROM
Eliminate repetitive variable
decelerations
■ The most effective use of amnioinfusion is to
prevent or relieve umbilical cord compression
during labor.
■ is benefit was confined to women receiving a
therapeutic procedure after the occurrence of FHR
abnormalities
■ There was NO advantage to routine prophylactic
amnioinfusion because of oligohydramnios when
the tracing was normal

Miyazaki FS, Taylor NA. Saline amnioinfusion for relief of variable or prolonged
decelerations. A preliminary report. Am J Obstet Gynecol 1983; 146:670.
■ Prevention and treatment of repetitive variable decelerations
[1]
■ Prevention of meconium aspiration [2,3]
■ Reduction in cesarean deliveries performed for repetitive
FHR decelerations [4]
■ Improved visualization during sonographic or fetoscopic
assessment of fetal anomalies [5-7]
■ Treatment or prevention of chorioamnionitis in premature
rupture of membranes [8]
■ As an aid to external cephalic version [9].
Prevent meconium aspiration

■ Amnioinfusion has been advocated for women

laboring with thick meconium to reduce the
incidence of meconium aspiration and meconium
below the vocal cords.
■ However, amnioinfusion did not significantly reduce
the risk of meconium aspiration syndrome
compared to no amnioinfusion

Wenstrom KD, Parsons MT. The prevention of meconium aspiration in labor using
amnioinfusion. Obstet Gynecol 1989; 73:647.
 To reduce need for cesarean
delivery
■ Amnioinfusion reduce the rate of cesarean delivery
for persistent FHR abnormalities if the procedure
lowers the frequency of cord compression leading
to these abnormalities.
■ there was NO advantage to routine amnioinfusion
among women with oligohydramnios or meconium
stained amniotic fluid in the absence of FHR
decelerations

Miyazaki FS, Nevarez F. Saline amnioinfusion for relief of repetitive variable

decelerations: a prospective randomized study. Am J Obstet Gynecol 1985; 153:301.
To improve neonatal outcome

■ Amnioinfusion did not significantly reduce the risk

of low Apgar score, but was associated with a
significant reduction in risk of neonatal acidosis
■ Patients with repetitive variable FHR decelerations
during labor who also had moderate to thick
meconium appear most likely to benefit

Fisk NM, Ronderos-Dumit D, Soliani A, et al. Diagnostic and therapeutic transabdominal

amnioinfusion in oligohydramnios. Obstet Gynecol 1991; 78:270.
To visualize the fetus better

■ Diagnostic amnioinfusion may facilitate sonographic fetal

imaging and increase diagnostic precision in the setting of
severe oligohydramnios.
■ a review of patients with unexplained midtrimester
oligohydramnios who underwent diagnostic antenatal
amnioinfusion found that the overall rate of adequate
visualization of fetal structures improved from 51 to 77
percent after amnioinfusion

Pryde PG, Hallak M, Lauria MR, et al. Severe oligohydramnios with intact membranes: an
indication for diagnostic amnioinfusion. Fetal Diagn Ther 2000; 15:46.
 To facilitate external cephalic
version
■ Transabdominal amnioinfusion has been used to
facilitate external cephalic version
■ In one study, version after amnioinfusion was
successful in a series of six patients who had
previously failed the procedure
■ In another similar series, version after
amnioinfusion was unsuccessful in all seven
patients
Benifla JL, Goffinet F, Darai E, Madelenat P. Antepartum transabdominal amnioinfusion to facilitate
external cephalic version after initial failure. Obstet Gynecol 1994; 84:1041.
Adama van Scheltema PN, Feitsma AH, Middeldorp JM, et al. Amnioinfusion to facilitate external
cephalic version after initial failure. Obstet Gynecol 2006; 108:591.
 For management of PPROM

■ The effects of amnioinfusion on pregnancy outcome in

PPROM are unproven, given available data are limited
to one small randomized trial and observational series
■ A randomized trial including 34 women with PPROM at
24 to 33 weeks of gestation reported treatment with
transabdominal amnioinfusion resulted in significant
prolongation of pregnancy (median latency 21 versus 8
days) and better neonatal outcomes (increased
survival, decreased pulmonary hypoplasia) compared
to standard expectant management

Tranquilli AL, Giannubilo SR, Bezzeccheri V, Scagnoli C. Transabdominal amnioinfusion in preterm

premature rupture of membranes: a randomised controlled trial. BJOG 2005; 112:759.
 To reduce infection

■ Antibiotics have been administered either

prophylactically or therapeutically during
amnioinfusion
■ The only randomized trial of amnioinfusion with an
antibiotic solution (cefazolin 1 g per 1000 mL) or
normal saline in laboring women with meconium
stained amniotic fluid found no differences in the
rate of clinically diagnosed chorioamnionitis,
endometritis, or neonatal infection

Edwards RK, Duff P. Prophylactic cefazolin in amnioinfusions administered for meconium-stained

amniotic fluid. Infect Dis Obstet Gynecol 1999; 7:153.
Kontraindikasi

Placenta previa  History of

contraindication caesarean
for transcervical delivery or major
approach uterus surgery

Chorioamnionitis
 relative
 Complications
Centers Reporting
Complication No. (%)
Uterine hypertonus 27 (14)
Abnormal fetal heart rate tracing 17 (9)
Amnionitis 7 (4)
Cord prolapse 5 (2)
Uterine rupture 4 (2)
Maternal cardiac or respiratory compromise 3 (2)
Placental abruption 2 (1)
Maternal death 2 (1)

Wenstrom, K., Andrews, W.W. and Maher, J.E., 1995. Amnioinfusion survey:
prevalence, protocols, and complications. Obstetrics & Gynecology, 86(4),
pp.572-576.
Technique
“Protocols for amnioinfusion vary across
institutions. There is no evidence that any
one method is superior in terms of safety,
efficacy, or complications rates”
Prophylactic Antibiotics

■ A randomized trial showed that prophylactic use of

cefazolin in the infusate (1 g/1000 mL of normal
saline) did not significantly reduce rates of maternal or
neonatal infection.
■ There is no evidence that antibiotic prophylaxis against
chorioamnionitis is useful in women undergoing
amnioinfusion.

Edwards RK, Duff P. Prophylactic cefazolin in amnioinfusions administered for

meconium-stained amniotic fluid. Infect Dis Obstet Gynecol 1999; 7:153.
Transcervical Amnioinfusion
 Transcervical Approach

■ The transcervical approach is preferred for women

in labor because it does not require ultrasound
guidance and the catheter can be used for
repeated fluid instillation
■ After rupture of the fetal membranes, an
intrauterine pressure catheter is inserted using
standard technique and attached to intravenous
extension tubing

Gonzalez JL, Mooney S, Gardner MO, et al. The effects of amnioinfused solutions for
meconium-stained amniotic fluid on neonatal plasma electrolyte concentrations and
pH. J Perinatol 2002; 22:279.
Transcervical Approach

Method Used:
■ a fluid bolus (50 to 1000 mL) followed by a
constant infusion,
■ serial boluses (200 to 1000 mL administered every
20 minutes to four hours), and
■ constant infusion (15 to 2250 mL/hour).
■ A randomized trial found that continuous and
intermittent infusions were similarly effective.

Wenstrom K, Andrews WW, Maher JE. Amnioinfusion survey: prevalence,

protocols, and complications. Obstet Gynecol 1995; 86:572.
 There is no evidence that the fluid needs to be
warmed above ambient room temperature prior to
administration; however, warming the fluid to body
temperature is a common practice. A blood warmer
should be used rather than a blanket or surgical fluid
warming oven, since ovens warm fluid to a wide range
of temperatures

Glantz JC, Letteney DL. Pumps and warmers during amnioinfusion: is either necessary? Obstet
Gynecol 1996; 87:150.
Nageotte MP, Bertucci L, Towers CV, et al. Prophylactic amnioinfusion in pregnancies complicated
by oligohydramnios: a prospective study. Obstet Gynecol 1991; 77:677.
 Monitoring

■ The fetal heart rate should be monitored

continuously to determine whether the variable
decelerations resolve and to identify the
occurrence of new nonreassuring fetal heart rate
patterns.
■ If the intrauterine pressure between contractions
rises by more than 15 mm Hg above the baseline,
we suggest discontinuing the infusion until the
pressure returns to its normal range

Nageotte MP, Bertucci L, Towers CV, et al. Prophylactic amnioinfusion in pregnancies complicated
by oligohydramnios: a prospective study. Obstet Gynecol 1991; 77:677.
Transabdominal
Amnioinfusion
 Transabdominal Approach

■ The transabdominal approach is primarily restricted

to pregnancies with midtrimester oligohydramnios
or anhydramnios, where it is used to enhance
ultrasound imaging
■ The transabdominal procedure does not differ from
amniocentesis, except fluid is instilled rather than
removed

Porat, S., Amsalem, H., Shah, P.S. and Murphy, K.E., 2014. Transabdominal
Amnioinfusion for Preterm Premature Rupture of Membranes: A Systematic Review
and Meta-analysis of Randomized and Observational Studies. Obstetric Anesthesia
Digest, 34(1), p.18.
 Transabdominal Approach

■ The patient's abdomen is prepped with an

antiseptic solution and draped.
■ Under ultrasound guidance, a pocket of fluid is
identified.
■ Color Doppler sonography is useful for identifying
an area devoid of umbilical cord in these cases.

Porat, S., Amsalem, H., Shah, P.S. and Murphy, K.E., 2014. Transabdominal
Amnioinfusion for Preterm Premature Rupture of Membranes: A Systematic Review
and Meta-analysis of Randomized and Observational Studies. Obstetric Anesthesia
Digest, 34(1), p.18.
 Transabdominal Approach

■ The tip of a 20 gauge spinal needle is advanced

into the pocket and a small amount of amniotic
fluid is withdrawn to insure proper needle
placement.
■ A syringe is used to infuse the minimum volume of
fluid required to provide the desired effect.
■ This volume is typically 100 to 1000 mL and can be
infused by slow manual push or an infusion pump.
Porat, S., Amsalem, H., Shah, P.S. and Murphy, K.E., 2014. Transabdominal
Amnioinfusion for Preterm Premature Rupture of Membranes: A Systematic Review
and Meta-analysis of Randomized and Observational Studies. Obstetric Anesthesia
Digest, 34(1), p.18.