Amniotic Fluid Leak –The Growing Threat in Pregnant Women

 Every year approx 13 million premature babies are born worldwide out of which almost 11 million are born in Africa and Asia. In 2005, WHO estimated that 12.9 million births, or 9.6 per cent of all births worldwide, were preterm. An average of 10 % of births worldwide occur before 37 weeks gestation and an estimated 28% of the 4 million annual neo-natal deaths are due to pre-term births. However, this rate ranges between 3.8 % for countries in central Asia and 17.5 per cent in southern Africa. In fact, Amniotic Fluid Leak is one of the major causes of Pre-term delivery.

Amniotic Fluid Leak is the most commonly faced problem by pregnant women. If not treated on time, could pose a serious threat to both mother and baby. Amniotic fluid is the baby’s ‘Life Support System’ along with Placenta and Umbilical Cord. It is the liquid that protects the baby and aids in the development of muscles, limbs, lungs and digestive system. This fluid is generated soon after the Amniotic sac is formed i.e. about 12 days after conception. However, initially the fluid is made up of water provided by mother but post 20 weeks into pregnancy; it primarily forms into fetal urine. Amniotic fluid not only facilitates the growing baby’s movement in the womb but also enables the baby to breathe and swallow the liquid in the second semester. Furthermore, Amniotic fluid levels increases regularly until about 32-33 weeks gestation, and then they level off. In some cases the Amniotic fluid may measure too low i.e. Oligohydramnios or too high i.e. Polydramnios. A normal fluid level ranges about 800-1000 ml and may vary.
The Amniotic Sac grows and begins to fill, mainly with water, approx two weeks after fertilization; 10 weeks later the liquid comprises of proteins, carbohydrates, lipids and phospholipids, urea and electrolytes, all of which aids in the fetus growth. Amniotic fluid is produced by exudation of fluid through the skin of the fetus until 14th week of pregnancy at which point keratinization of skin occurs. During weeks 8–11, the fetus begins to swallow and urinate, which is why the Amniotic fluid contains fetal urine in the later stages of gestation. Furthermore, the volume of Amniotic fluid increases as the fetus grows. The amount of Amniotic fluid is greatest approx 34 weeks after conception or 34 weeks ga (gestational age). At 34 weeks ga, the amount of Amniotic fluid is approx 800 ml. The amount of fluid declines to roughly 600 ml at 40 weeks ga, which is usually when the baby is born.
Complications of Pregnancy
Complications of Pregnancy are health problems that occur during pregnancy which could involve the mother's health, the baby's health, or both. Some women have health problems before they become pregnant that could lead to complications and other issues arise during pregnancy. One of the most commonly ignored problems among pregnant women is Amniotic Leak.
The forewaters i.e. bag of water in front of baby’s head are released when the amnion ruptures. 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). If the rupture precedes labour at term, however, it is referred to as "premature rupture of membranes" (PROM). The majority of the hindwaters i.e. bag of water around the body 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.
Amniotic fluid leakages can cause severe complications and therefore it is imperative that the expectant mother receives medical guidance and the proper treatment. However, there are times, when the Amniotic sac may develop a tear or may rupture causing the Amniotic fluid to leak before term. When this occurs 37 – 38 weeks before term, it is referred to as ‘Preterm Premature Rupture of Membrane’ or PPROM.
When either of these cases occurs, the fluid either gushes or leaks out in a continuous trickle resembling a discharge. When premature rupture of the Amniotic sac occurs, it is necessary to determine the cause of the leaking Amniotic fluid. However, if the leaking Amniotic fluid is a result of a severe rupture of the membranes of the Amniotic sac, then labor may begin within 48 hours. When this happens, the mother-to-be must receive treatment in order to avoid causing an infection to the fetus.
But, this is easier said than done especially when the leak is occurring at unearthly hours like midnight. Over time, innovation in science and developments in technology may provide an easy solution to such a potential problem, enabling both the affected patient and the doctor to breathe easy.
Factors Causing Amniotic Fluid Leak –
- A bacterial infection, an injury or trauma or a defect in the Amniotic sac can trigger off this problem including amniocentesis, which is a specialized test that involves taking a sample of Amniotic fluid through a needle from the womb and examining it in the laboratory to check for congenital abnormalities.
- Depending on the severity of the problem, there may be excessive discharge of fluid or a slight trickle.
- This is a serious problem that needs to be addressed as soon as possible as this may cause Oligohydramnios or low levels of Amniotic fluid which in turn increases the chances of a premature delivery.
- Moreover a tear in the Amniotic sac can cause infection in fetus within 24 hours of such a leak.
- The growth of the fetus can also be restricted especially if the tear happens early in pregnancy.
- Stress and other psychological issues could act as a precipitating factor towards the leak.
- Sometimes the tear is quite insignificant and will heal itself after a couple of days.
Detection & Diagnostics –
A general rule of thumb to identify Amniotic Fluid Leak is to ask the mother-to-be to lie down for 30 minutes and once she sits up, there is a gush that occur it may be the result of the broken water bag. There is no other way for a pregnant woman to detect Amniotic fluid leak especially if it is a small one. Moreover in certain cases of pregnancy especially in the last trimester, a woman may have excessive vaginal discharge. This could be urine, the cervical mucus or a combination of both. Hence it is extremely imperative to ascertain the cause of the wetness and evade any confusion to be sure and safer. Thus, routine monitoring of Amniotic Fluid level should be mandatory for preventing pre-term delivery.

Some Remedial Steps to be taken once the leak has been detected –
- In minor leaks, especially if the patient is dilated, the fluid would continue to leak out, even if the patient is up and moving around. It wouldn't be only some nights and only at night but all nights and day long.
- It is important that the attending Doctor is consulted as soon as possible to discern the actual nature of discharge as the Doctor alone is empowered with various options to ascertain the cause of the fluid leak.
Currently there is no non-invasive method available to detect the Amniotic fluid leak. Due to lack of any accurate method available, most commonly, Urine leakage may be mistaken for Amniotic leak. 60% of such complaints are usually false alarm and may cause paranoia in the patient and the family. The best thing to do in such a scenario is to consult your doctor immediately.

- Authored Article by
Dr. B. K. Iyer
Family Physician, Mumbai