ANALYSIS OF URINE AND OTHER BODY FLUIDS

MLS 303 | A.Y. 2022 - 2023

AMNIOTIC FLUID

• At the time that fetal urine production occurs, fetal

AMNIOTIC FLUID swallowing of amniotic fluid begins and regulates
increase in fluid from the fetal urine
AMNION • The fetus swallows amniotic fluid, absorbed through GIT
and re-excreted by the kidneys from the blood into fetal
• A membranous sac that surrounds the fetus urine and back into amniotic fluid
• The amnion is: • Failure of the fetus to begin swallowing results in
o Metabolically active excessive accumulation of amniotic fluid
o Involved in the exchanges of water and chemicals (polyhydramnios) and is an indication of fetal diseases
between the fluid, fetus, and maternal circulation (neural tube disorders)
o Produces peptides, growth factors, and cytokines • Polyhydramnios may be secondarily associated with:
o Fetal structural anomalies
o Cardiac arrhythmias
o Congenital infections
o Chromosomal abnormalities
• Increased fetal swallowing, urinary tract deformities, and
membrane leakage are possible causes of decreased
amniotic fluid (oligohydramnios)
• Oligohydramnios may be associated with:
o Congenital malformations
o Premature rupture of amniotic membranes
o Umbilical cord compression decelerated
heart rate and fetal death
AMNIOTIC FLUID
TESTS FOR FETAL WELL-BEING AND MATURITY
• Fluid in the amnion
• Provide a protective cushion for the fetus TESTS REFERENCE SIGNIFICANCE
• Allow fetal movement VALUES AT
• Stabilize the temperature to protect the fetus from TERM
extreme temperature changes Bilirubin scan ∆𝐴450 > .025 Hemolytic
• Permit proper lung development disease of the
newborn
Alpha-fetoprotein < 2.0 MoM Neural tube
disorders
Lecithin – ≥ 2.0 Fetal lung
sphingomyelin maturity
ration
Amnio stat – fetal Positive Fetal lung
lung maturity maturity /
Phosphatidyl
glycerol
VOLUME Foam Stability ≥ 47 Fetal lung
Index maturity
• Regulated by a balance between: Optical density 650 ≥ 0.150 Fetal lung
o Production of fetal urine and lung fluid nm maturity
o The absorption from fetal swallowing Lamellar body ≥ 32,000 / mL Fetal lung
o Intramembranous flow (the absorption of amniotic count maturity
fluid water and solutes into the fetal vascular
system) CHEMICAL COMPOSITION
• Amount increases in quantity throughout pregnancy,
reaching a peak of approximately 800 to 1200 mL during • Placenta is the ultimate source of amniotic fluid water
the 3rd trimester and solutes
• It will gradually decrease prior to delivery • Amniotic fluid has similar composition to maternal
• Polyhydramnios – volume greater than 1200 mL plasma, contains small amount of sloughed fetal cells and
• Oligohydramnios – volume less than 800 mL biochemical substances produced by fetus that can be
• 1st trimester: approximately 35 mL of amniotic fluid is tested to determine health and maturity
derived primarily from the maternal circulation • Amniotic fluid analysis is done to:
• Latter third to half of pregnancy: the fetus secretes a o Detect fetal abnormalities
volume of lung liquid necessary to expand the lungs with o Assess fetal health
growth o Detect fetal age
• Fetal urine is the major contributor to the amniotic fluid o Monitor pulmonary maturity
volume after 1st trimester • Collection and analysis are recommended when the
following screening blood tests yield abnormal results:

1 | ARGA, DELA ROSA, PITA, SIANQUITA

 ANALYSIS OF URINE AND OTHER BODY FLUIDS
MLS 303 | A.Y. 2022 - 2023
AMNIOTIC FLUID

o Triple screening tests including AFP, hCG, estriol SPECIMEN HANDLING AND PROCESSING
o Quadruple screening tests including AFP, hCG,
estriol, and inhibin A • Fluid for fetal lung maturity (FLM) test should be placed
• After the 14th week AOG: Amniocentesis is generally in ice (transport) and kept refrigerated prior
safe to perform • Specimens for bilirubin testing must be immediately
• At approximately 16 weeks AOG: Fluid for chromosome protected from light
analysis is usually collected • Specimens for cytogenetic studies / microbial studies
• Near the end of 2nd trimester: Tests for intrauterine must be processed aseptically, maintained at room
growth retardation are performed temperature or body temperature, to prolong life of cells
• 3rd trimester: Tests for fetal distress and maturity are • All fluid for chemical testing should be separated from
performed cellular elements and debris ASAP to prevent cellular
metabolism or disintegration
INDICATIONS FOR AMNIOCENTESIS • For FLM, low speed centrifugation is required, or filtration
must be performed to prevent loss of phospholipids
AT 15 – 18 WEEKS AOG • In some instances, instead of puncturing the amniotic
 Mother’s age of 35 or older at delivery sac, the maternal bladder is the one that is punctured
 Family history of chromosome abnormalities, such • To differentiate amniotic fluid from maternal urine, one
as trisomy 21 (Down syndrome) should measure the creatinine and BUN concentration
 Parents carry an abnormal chromosome • Measurement of glucose and protein by a reagent strip is
rearrangement a less reliable indicator
 Earlier pregnancy or child with birth defect
 Parent is a carrier of a metabolic disorder ANALYTE AMNIOTIC MATERNAL
 Family history of genetic diseases such a sickle cell FLUID URINE
disease, Tay-Sachs disease, hemophilia, muscular Creatinine < 3.5 mg / dL > 10 mg / dL
dystrophy, sickle cell anemia, Huntington chorea,
and cystic fibrosis Blood urea < 30 mg / dL > 300 mg / dL
 Elevated maternal serum alpha-fetoprotein nitrogen (BUN)
 Abnormal triple marker screening test
 Previous child with a neural tube disorder such as FERN TEST
spina bifida, or ventral wall defects (gastroschisis)
 Three or more miscarriages • Can differentiate amniotic fluid from urine and other body
fluids
AT 20 – 42 WEEKS AOG • Used to evaluate premature rupture of the membranes
 Fetal lung maturity • A vaginal fluid specimen is spread on a glass slide and
 Fetal distress allowed to completely air dry at room temperature; then it
 HDN caused by Rh blood type incompatibility is observed microscopically
 Infection • Presence of “fern-like” crystals due to the protein and
sodium chloride content is a positive screen for
amniotic fluid
AMNIOCENTESIS

• Method of collection of amniotic fluid via needle aspiration

• Two types:
o Vaginal – carries a greater risk of infection
o Transabdominal – most frequently performed
procedure (ultrasound guided)
• A maximum of 30 mL of amniotic fluid is collected in
sterile syringes
• The first 2 or 3 mL collected can be contaminated by
maternal
blood,
tissue fluid,
and cells
and are
discarded COLOR AND APPEARANCE
• Specimens
should be • Colorless
transferred • May exhibit slight to moderate turbidity from cellular
to sterile plastic containers and taken immediately to the debris, particularly in later stages of fetal development
laboratory
• Fluid for bilirubin analysis in cases of HDN must be
always protected from light

2 | ARGA, DELA ROSA, PITA, SIANQUITA

 ANALYSIS OF URINE AND OTHER BODY FLUIDS
MLS 303 | A.Y. 2022 - 2023
AMNIOTIC FLUID

COLOR SIGNIFICANCE
Colorless Normal
Blood – streaked Traumatic tap, abdominal trauma,
intra-amniotic hemorrhage
Yellow Hemolytic disease of the newborn
(bilirubin)
Dark green Meconium
Dark red brown Fetal death

MECONIUM

• A newborn’s first bowel movement formed in the

intestine from fetal intestinal secretions and swallowed
amniotic fluid
• Dark green, mucus-like material
• May be present as a result of fetal distress
• Fetal aspiration of meconium during fetal swallowing is a
concern when increased amounts are present in the fluid
• Very dark red brown fluid is associated with fetal death
TEST FOR NEURAL TUBE DEFECTS

• Detected by MSAFP blood test, high-resolution

ultrasound, amniocentesis
• Screening test: Measure Alpha-feto protein (AFP) N.V.
= 2 MoM
• Confirmatory test – Acetylcholinesterase (AChE)

SPINA BIFIDA
LABORATORY TESTS  Condition where one or more vertebrae fails to
TEST FOR FETAL HEMOLYTIC DISEASE develop completely, leaving a portion of the spinal
cord unprotected
OPTICAL DENSITY (OD)  Strongly linked with a deficiency in folate (folic acid)
in the diet especially in pregnancy
 Read at wavelength of 365 nm to 550 nm
 Normal: Highest absorption at 365 nm, decrease
linearity at 550 nm
 If there is HDN: increased absorbance at 450 nm
(maximum absorbance of bilirubin)
 Absorbances are plotted in a Liley graph
 Interpretation:
o Zone 1 – Normal or mildly affected
o Zone 2 – Moderate hemolysis or moderately
affected
▪ Requires close monitoring anticipating ANENCEPHALY
early delivery or exchange transfusion
upon delivery  Most of the infant’s brain is missing because it
o Zone 3 – Severe hemolytic disease doesn’t develop
▪ Intervention thru induction of labor  They can’t survive or
▪ Intrauterine exchange transfusion is either is stillborn or
considered dies within a few
 Precautions: days
o Specimens must not be contaminated with
meconium, cellular fluid, and hemoglobin
because they interfere with spectroanalysis
o Maximum absorbance of oxyhemoglobin
TEST FOR FETAL LUNG MATURITY
occurs at 410 nm and can interfere with
bilirubin absorption peak
o Remedy: Extraction with chloroform RESPIRATORY DISTRESS SYNDROME
o Do not expose specimen to light  The most frequent complication of early delivery
 7th most common cause of morbidity and mortality in
premature infants
 Caused by insufficiency of lung surfactant production
and structural immaturity of fetal lungs

3 | ARGA, DELA ROSA, PITA, SIANQUITA

 ANALYSIS OF URINE AND OTHER BODY FLUIDS
MLS 303 | A.Y. 2022 - 2023
AMNIOTIC FLUID

1. LECITHIN / SPHINGOMYELIN RATIO (L/S RATIO) 4. LAMELLAR BODIES

 Lecithin  Densely packed layers of phospholipids representing
o Primary component of surfactants a storage form of pulmonary surfactant
(phospholipids, neutral lipids, proteins) that  Secreted by Type II pneumocytes of fetal lung at
makes up alveolar lining and account for about 24 weeks AOG
alveolar stability  Provides surfactant
o Produced at relatively low and constant rate until  As fetal lung matures, production increase is
35th week AOG = increase production to reflected by increase phospholipids and L/S ratio
stabilize fetal lung alveoli
 Sphingomyelin – lipid constantly produced starting
after 26 weeks AOG
 Usually measured by thin layer chromatography
 Normal ratio: Greater than or equal to 2.0
 NOTE: Can’t be done on specimen contaminated
with blood or meconium

2. PHOSPHATIDYL GLYCEROL
 PG is also essential for adequate lung maturity,
detected after 35th week AOG
 Production parallels to lecithin but delayed in
maternal diabetes
 TLC lung profile must include lecithin,
sphingomyelin, and PG to provide accurate
measurement of FLM

3. FOAM STABILITY INDEX

 Mechanical screening test to determine presence of
lung-surface lipids
 Still in use because it can be performed bedside or
in the laboratory
 Shows good correlation with L/S ratio and tests for
PG
 Cannot be performed on contaminated samples =
falsely mature index

FOAM SHAKE TEST

1. Mix equal parts of amniotic fluid with 95% ethanol
2. Vigorously shake for 15 seconds
3. Allow to sit undisturbed for 15 minutes
4. Observe for the presence of a continuous line of
bubbles around the outside edge

FOAM STABILITY INDEX

1. Add 0.5 mL of amniotic fluid to tubes containing
increasing amounts of 95% ethanol ranging from 0.42
to 0.55 mL in 0.01 mL increments
2. Vigorously shake for 15 seconds
3. Allow to sit undisturbed for 15 minutes
4. Observe for the presence of a continuous line of
bubbles around the outside edge
5. Values ≥ 47 indicate fetal lung maturity

4 | ARGA, DELA ROSA, PITA, SIANQUITA