TECHNICAL UPDATE

No. 340, January 2017

Amniotic Fluid: Technical Update on

Physiology and Measurement
This Technical Update has been prepared by the
Abstract
Diagnostic Imaging committee, reviewed by the Society of
Objective:
Obstetricians and Gynaecologists of Canada (SOGC)
Guideline Management and Oversight Committee and 1. To provide an update on the use of ultrasound to evaluate amniotic
approved by the Board of the SOGC. fluid volume.

PRINCIPAL AUTHORS 2. To provide an update on amniotic fluid physiology.

Kenneth I. Lim, MD, Vancouver BC 3. To promote evidence based assessment techniques and definitions
for amniotic fluid volume.
Kimberly Butt, MD, Fredericton NB
Kentia Naud, MD, Edmonton AB Outcomes:

Mila Smithies, MD, Halifax NS 1. Reduced interventions as a result of the diagnosis of oligohy-
dramnios without increasing adverse outcomes.

DIAGNOSTIC IMAGING COMMITTEE 2. By understanding the limitations of amniotic fluid assessment, pro-
mote more efficient use of ultrasound assessment.
Kimberly Butt, MD, Fredericton NB
Evidence: A MEDLINE and KFINDER search was used to identify
Yvonne Cargill, MD, Ottawa ON
relevant articles, with review of bibliography identified article
Nanette Denis, RDMS, Saskatoon SK including Cochrane reviews and recent review articles.
Johanne Dubé, MD, Mont-Royal QC Values: The evidence collected was reviewed by the Diagnostic
Phyllis Glanc, MD, Toronto ON Imaging Committee of the Society of Obstetricians and
Gynecologists of Canada. The recommendations were made
Kenneth I. Lim (co-chair) MD, Vancouver BC according to the guidelines developed by The Canadian Task Force
Lucie Morin (co-chair), MD, Outremont QC on Preventative Health Care (Table 1).

Kentia Naud, MD, Edmonton AB
Mila Smithies, MD, Halifax ON
Disclosure statements have been received from all members
of the committee(s).
http://dx.doi.org/10.1016/j.jogc.2016.09.012
J Obstet Gynaecol Can 2017;39(1):52e58
Copyright ª 2017 The Society of Obstetricians and Gynaecologists of
Canada/La Société des obstétriciens et gynécologues du Canada.
Published by Elsevier Inc. All rights reserved.
Benefits, Harms and Costs: Amniotic fluid assessment by ultrasound
has become an integral part of fetal assessment in modern
obstetrics. Abnormalities of fluid volume result in obstetrical
intervention and further investigations. In Canada, there are no
standard definitions of fluid volume estimation, nor a standard
approach to assessing fluid. Multiple randomized trials have
suggested that using a Single Pocket Estimation technique (rather
than the multi pocket assessment approach known as the amniotic
fluid index), will result in fewer obstetrical interventions without any
increase in adverse outcomes. Recent literature suggests that there
are detectable, modest changes in amniotic fluid that can occur
within an hour or two of normal physiological maneuvers. This may
account for the variability and inconsistent results from repeated
assessments within a short period of time which can lead to
confusion and generate further testing. This article hopes to
describe the limitations of amniotic fluid assessment, promote a
standard method of amniotic fluid assessment, and propose a
common set of definitions to be used to describe amniotic fluid
volume.

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be
construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions.
They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written
permission of the publisher.

52 l JANUARY JOGC JANVIER 2017

 Amniotic Fluid: Technical Update on Physiology and Measurement

Table. Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on
Preventative Health Care
Quality of evidence assessment* Classification of recommendations†
I: Evidence obtained from at least one properly randomized controlled A. There is good evidence to recommend the clinical preventive
trial action
II-1: Evidence from well-designed controlled trials without B. There is fair evidence to recommend the clinical preventive
randomization action
II-2: Evidence from well-designed cohort (prospective or C. The existing evidence is conflicting and does not allow to make a
retrospective) or case-control studies, preferably from recommendation for or against use of the clinical preventive action;
more than one centre or research group however, other factors may influence decision making
II-3: Evidence obtained from comparisons between times or D. There is fair evidence to recommend against the clinical preventive
places with or without the intervention. Dramatic results action
in uncontrolled experiments (such as the results of E. There is good evidence to recommend against the clinical
treatment with penicillin in the 1940s) could also be preventive action
included in the category L. There is insufficient evidence (in quantity or quality) to make a
III: Opinions of respected authorities, based on clinical experience, recommendation; however, other factors may influence
descriptive studies, or reports of expert committees decision-making
*The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive
Health Care.
†
Recommendations included in these guidelines have been adapted from the Classification of recommendations criteria described in The Canadian Task Force on
Preventive Health Care.

Summary Statements 7. It is proposed that the Chamberlain classification of amniotic fluid be

1. Changes in amniotic fluid volume are usually gradual, however used to define oligohydramnios (single deepest pocket [SDP]
modest shifts can occur within hours due to hydration, maternal smaller than 2 cm in depth  1 cm wide) and polyhydramnios (SDP
positioning, and/or activity. Water channels such as aquaporins greater than 8 cm in depth  1 cm wide) for the initial assessment of
likely facilitate these rapid changes. (I and II-2) amniotic fluid during routine obstetrical scanning. (I)

2. Accurate quantification of amniotic fluid volumes using current ul- Recommendation:

trasound technology remains challenging. (II-2)
1. It is recommended that the initial, general evaluation of amniotic fluid
3. Various techniques for single pocket estimation of amniotic fluid are volume during routine obstetrical ultrasound be a single pocket
described in the literature. Most of these descriptions are open to estimation. The Chamberlain method of amniotic fluid assessment is
interpretation, and no particular method has been shown to be su- the preferred method for estimation. (I-A)
perior to the other in direct comparison. (III)
4. Using the single pocket estimation method of amniotic fluid
INTRODUCTION
assessment in the third trimester to diagnose oligohydramnios,
rather than the amniotic fluid index method, will result in fewer in-
terventions without increasing adverse perinatal outcomes. (I)
5. Polyhydramnios as defined using amniotic fluid index is associated
T he assessment of AFV has been an integral component
of obstetrical scanning and fetal health surveillance for
many years. Abnormalities of amniotic fluid are associated
with a variety of adverse outcomes. More studies are needed
looking at outcomes of polyhydramnios using the single pocket with a variety of adverse maternal, fetal, and obstetrical con-
estimation definitions of polyhydramnios. (II-2)
ditions. Modern obstetrical management relies significantly on
6. There is insufficient literature to determine which method of amniotic
assessment of amniotic fluid as a measure of fetal well-being.
fluid assessment is more reproducible than the other. (II-1)

However, amniotic fluid assessment by two-dimensional

ultrasound is at best semi-quantitative. It is not a true
ABBREVIATIONS quantitative measurement and is probably more qualitative
AFI amniotic fluid index
than quantitative. The volume and shape of the amniotic
fluid compartment is very dynamic due to fetal and
AFV amniotic fluid volume
maternal factors, which introduces a subjective component
BPP biophysical profile
to its measurement. It can be difficult to duplicate and
CS Caesarean section
obtain accurate assessments of the volume of amniotic
RCT randomized controlled trial fluid, especially at the extremes.
SDP single deepest pocket
SOGC Society of Obstetricians and Gynaecologists of Canada The SOGC guideline on fetal surveillance (2007) provides
SPE single pocket estimation an overview of the use of amniotic fluid estimation in fetal

JANUARY JOGC JANVIER 2017 l 53

TECHNICAL UPDATE
surveillance.1 It describes both the Amniotic Fluid Index
(AFI) and Single Pocket Estimation (SPE) techniques of
measurement and suggests that SPE is preferable. How-
ever, no specific recommendations relating to amniotic
fluid assessment were included in that guideline. Across the
country, amniotic fluid is assessed using various methods,
in isolation or in combination, without uniformly agreed
upon definitions. There is currently no Canadian consensus
on how to best measure and document/describe amniotic
fluid volume. The intent of this technical update is to re-
view the most recent relevant literature and to make rec-
ommendations on amniotic fluid assessment during
obstetrical ultrasound. A future, separate publication will
cover the subject in more detail.
Physiology
The volume of amniotic fluid relies on a balance between
production and uptake.2,3 In the second half of pregnancy,
amniotic fluid volume (AFV) is mostly a balance between
fetal urine output and fetal swallowing. Prior to that,
maternal plasma and solutes, driven by hydrostatic and
osmotic forces, form the bulk of the fluid in the amniotic
space.4 Therefore, one cannot attribute AFV solely on fetal
renal function in the first half of pregnancy. Later in
gestation, additional sources of fetal contribution to am-
niotic fluid include lung and gastrointestinal secretions.
Estimated levels of output from all fetal components
suggest that only a small fraction of the AFV is being
turned over on an hourly basis, which led to the belief that
AFV does not change rapidly.2,3
Under conditions of utero-placental insufficiency, the fetus
regionalizes blood flow to critical areas such as the heart
and brain, at the expense of renal perfusion. Decreased
blood flow to the kidneys results in decreased renal output,
leading to oligohydramnios. Given the above, a reduction
in amniotic fluid to the point of oligohydramnios repre-
senting fetal compromise may take a few days to fall below
a level where ultrasound may detect it.
However, a more modern concept recognizes that amniotic
fluid is dynamic and can rapidly change due to normal
maternal physiological processes (hydration, activity/rest,
position, etc.). There is likely a limit to how much amniotic
fluid can be affected by these factors, but this modifiable
component, as assessed by AFI, is as much as 45 mm.5,6
due to the dynamic nature of amniotic fluid, and the
resulting imprecision in its measurement, this is unlikely to
make a difference in most situations; however, it may alter
the diagnosis when closer to the upper and lower thresh-
olds of normal.
54 l JANUARY JOGC JANVIER 2017
Ulker demonstrated that detectable changes in AFI (and
fetal urine output) can occur within an hour or so of
initiation of a maneuver such as hydration, rest, or
maternal positioning.5,7e9 These findings may help
explain the inconsistency of results when tests are
repeated within hours of each other or performed by
different operators. Furthermore, it is unclear whether
manipulation of these modifiable factors affects fetal
outcomes or changes the diagnostic value of amniotic
fluid assessment.
These rapid fluid shifts may be attributable to the intra-
membranous and transmembranous pathways that allow
solutes and free water to move back and forth between
maternal and fetal compartments. Free water channels
known as aquaporins are up-regulated when needed, such
as in idiopathic polyhydramnios,10e12 to help modulate
the amount of amniotic fluid. It is probable that this
“rapid transient” component is applicable to only a
portion of the total AFV. Ulker’s work suggests that AFV
behaves like a saturation curve in response to hydration
and rest.5
It would be difficult to control all of the physiological
factors that may affect the AFV in the typical diagnostic
ultrasound lab. While simple to ensure maternal hydration,
positioning women in the left lateral position for a suffi-
cient duration would be more difficult, given that patients
are scanned in a supine (commonly wedged) position.
Physiologically, it is unknown if rest in the supine position,
as opposed to left lateral, would increase or decrease AFV
(presumably due to uterine compression of vena cava and/
or aorta leading to decreased placental perfusion). It is
suggested that women be well hydrated prior to the
ultrasound exam to ensure that maternal hydration is not a
factor in the diagnosis of oligohydramnios.
Summary Statements
1. Changes in amniotic fluid volume are usually gradual,
however modest shifts can occur within hours due to
hydration, maternal positioning, and/or activity. Water
channels such as aquaporins likely facilitate these rapid
changes. (I and II-2)
Technical Aspects
The volume of amniotic fluid that surrounds a fetus is a
complex 3-dimensional form that is difficult to quantify
with single axis vectors. Methods that employ summation
of parallel multi-planar slices are cumbersome and time
consuming, limiting their regular use. The dye dilution
 Amniotic Fluid: Technical Update on Physiology and Measurement
technique is far too invasive and complex to be considered
on a wide scale, notwithstanding the potential toxicities to
the fetus with the use of a dye or measurable solutes.
Thus, we are left with either qualitative (visual estimation)
or semi-quantitative methods of amniotic fluid determi-
nation. The semi-quantitative methods can be loosely
described as multi-pocket (AFI) or single pocket estimation
(SPE) based on the largest pocket of fluid found on
ultrasound. There are many different methods of SPE,
which include different pocket dimensions: 2  2,13
2  1,14,15 2-dimensional product,16 or a single vertical
depth measurement of the largest pocket.17
The technical methods of obtaining SPE are difficult to
describe since the literature descriptions are very old or
of insufficient detail. Generally, the maternal position is
not described for SPE, nor is the transducer orientation.
For example, Chamberlain’s method specifies that the
pocket width must be at least 1 cm and at least 2 cm in
the depth axis, which is at right angles to the uterus.
Some operators look for any 2 cm  1 cm pocket
regardless of transducer angle, orientation, or plane.
Sande describes his technique as “ultrasound probe be-
ing held vertical to the uterine contour onto the
abdomen and parallel to the maternal sagittal plane.”17
This does not appear to match the Chamberlain defini-
tion, particularly since the minimum width of the pocket
is not included. The commonly used biophysical profile
(BPP) 2  2 pocket does not specify transducer plane
nor orientation. Kehl describes a 2  1 pocket in which
the long axis is vertical.15 There are no outcome studies
that directly compare the various methods of SPE.
A number of papers18e21 compared determining AFI with
and without using color Doppler. In the past, the literature
showing a difference in measurements was likely a result of
the inability to see the umbilical cord, which is unlikely
today using modern ultrasound machines.
Summary Statements
2. Accurate quantification of amniotic fluid volumes
using current ultrasound technology remains
challenging. (II-2)
3. Various techniques for single pocket estimation of
amniotic fluid are described in the literature. Most of
these descriptions are open to interpretation, and no
particular method has been shown to be superior to
the other in direct comparison. (III)
Terminology
The terminology used to describe AFV assessment is
varied and inconsistent, adding to the confusion when
assessing the literature. For example, Chamberlain’s paper
has been referenced using the following terms: single
deepest pocket (SDP),15,18 maximum vertical pocket,22
maximum pool depth,23 and single deepest vertical
pocket.24 Sande uses the terms “single deepest vertical
pool” or “maximum vertical pocket” to describe his.17
For this technical update, it was felt that using the term
“single deepest pocket” was the one most often ascribed to
Chamberlain and removes the word “vertical,” which
suggests that the ultrasound plane has to be vertical or
perpendicular to the floor, which is not included in
Chamberlain’s description.
Recent and Major Literature Review
The Nabhan Cochrane meta-analysis included five ran-
domized trials comparing AFI (oligo definition of less than 5
cm) versus SPE (2 cm  1 cm pocket).25 No differences in
pH <7.0, low Apgar scores, neonatal intensive-care unit
admission, non-reassuring fetal heart rate tracing, meco-
nium, or CS rates were seen. The use of AFI, however,
resulted in significant differences in diagnosis of oligohy-
dramnios and rate of induction of labour and CS for fetal
distress. It should be noted that three of the five randomized
control trials (RCTs)24e26 referenced Chamberlain directly
whereas the fourth27 can be ascribed to Chamberlain.
A recently published randomized trial is not yet incorporated
in the most recent meta-analysis.15 It supports the findings of
the Nabhan meta-analysis suggesting that SDP be used over
AFI. However, the AFI group had fewer gestational di-
abetics and patients with previous CS than the SDP group,
and the studied population was a mixture of low and high risk
patients (15%), although post dates were not considered a
high risk indication. A significantly higher rate of abnormal
blood gases found in the group assigned to SDP was
considered clinically non-significant as base excess and low
Apgar scores were not different between the two groups.
Moore has argued that the RCTs comparing AFI to SDP
are not based on technique but definitions of oligohy-
dramnios for the two.2 He points out the normal curve
percentile thresholds for diagnosis of oligohydramnios
between AFI and SDP (using AFI <5 cm, SDP <2 cm)
are different, so the RCTs compared different percentile
thresholds. He suggests the definition of oligo using AFI
should be reduced to 3.0 cm. However, this threshold has
not been studied, and so it would be difficult to bring to
clinical practice without sufficient supporting evidence as
to its safety relative to the original <5.0 cm.
Morris performed a meta-analysis and systematic review of
the literature looking at perinatal outcomes of
JANUARY JOGC JANVIER 2017 l 55
TECHNICAL UPDATE
oligohydramnios and comparing results of studies using
SPE versus AFI.28 One conclusion was that both AFI and
SPE estimations have very similar associations to adverse
outcomes, and he could not find a statistical reason to
choose one over the other. The analysis for outcomes
associated with polyhydramnios is limited to papers using
AFI only, and so no comparison can be made with regards
to outcomes of polyhydramnios comparing definitions by
AFI and SPE.
Sande et al. recently published a study looking at inter- and
intra-observer limits of agreement for both AFI and their
definition of SPE.17 They found that the limits of variation
for both were quite wide. Williams et al. found that the
SPE method they used had poorer reproducibility than
AFI.22 Therefore, the studies on reproducibility of the
different techniques are inconsistent.
Some have noted that all of the randomized trials were
conducted in patients at later gestational ages, typically
from mid-third trimester onwards, with the majority of
data at or beyond term. Whether the findings in those
studies can be extrapolated to preterm pregnancies, espe-
cially before 32 weeks, remains to be seen.
With regards to polyhydramnios, the vast majority of the
literature uses AFI as the assessment technique. Cham-
berlain’s original study using his method of SPE for
defining polyhydramnios, retrospectively found that cor-
rected perinatal mortality is modestly increased using that
definition.14 There are no prospective studies of outcomes
of polyhydramnios using an SPE definition. Therefore, in
some situations, the continued use of the AFI to help
define and/or clinically manage polyhydramnios may be
appropriate until such time as more data is available.
Summary Statements
4. Using the single pocket estimation method of amniotic
fluid assessment in the third trimester to diagnose
oligohydramnios, rather than the amniotic fluid index
method, will result in fewer interventions without
increasing adverse perinatal outcomes. (I)
5. Polyhydramnios as defined using amniotic fluid index
is associated with a variety of adverse outcomes. More
studies are needed looking at outcomes of
polyhydramnios using the single pocket estimation
definitions of polyhydramnios. (II-2)
6. There is insufficient literature to determine which
method of amniotic fluid assessment is more
reproducible than the other. (II-1)
56 l JANUARY JOGC JANVIER 2017
Definitions
Originally, Chamberlain defined levels of amniotic fluid
according to the largest pocket of fluid having depth
as decreased (<1 cm), marginal (1e2 cm), normal (>2
cm, less than or equal to 8 cm), and polyhydramnios
(>8 cm).14 The Cochrane meta-analysis RCT used
depth measurements between 1.8 and 2.0 cm as the
lower threshold for normal. The following definitions
are proposed for the initial assessment of amniotic
fluid during general, routine obstetrical scanning. The
largest pocket of fluid found is referred to as the
SDP.
Oligohydramnios: SDP smaller than 2 cm in depth by
1 cm wide
Normal: SDP 2e8 cm in depth (and at least 1 cm in
width)
Polyhydramnios: SDP of fluid greater than 8 cm depth
(and at least 1 cm in width)
Further subdivisions for clinical use (e.g., severe oligohy-
dramnios, severe polyhydramnios) may be possible, but at
present, there is insufficient literature to determine what
those threshold levels should be using SPE. As more data
becomes available, individual centers may need to modify
the definition of polyhydramnios.
Based on Magann’s published normal curves, thresholds of
2 and 8 cm would be well below and well above the 5th
percentile and 95th percentile, respectively, across both the
second and third trimesters so gestational age adjustments
are not needed.
The use of blended methods of amniotic fluid assessment
for initial assessment of amniotic fluid is discouraged to
avoid confusion and to maintain simplicity. However, as
discussed earlier, AFI may still be used to help define/
stratify polyhydramnios for referral and/or clinical
management.
Amniotic fluid assessment during BPP deserves special
mention. All methods of fluid assessment are ascribed in
the literature to BPP (vertical depth, SDP dimensions of
2  1, 2  2, 1  1, and AFI), with the original being
a 1 cm  1 cm pocket.13 There are few studies which
compare methods of fluid assessment during BPP.
Chauhan, in his randomized trial, used the Chamberlain
2 cm  1 cm definition and showed it to be preferable
over AFI.18 A SPE of fluid during BPP is advocated,
but there is no clear evidence one is superior to the
other.
 Amniotic Fluid: Technical Update on Physiology and Measurement
Summary Statement
7. It is proposed that the Chamberlain classification of
amniotic fluid be used to define oligohydramnios
(single deepest pocket [SDP] less than 2 cm in depth 
1 cm wide) and polyhydramnios (SDP greater than 8
cm in depth  1 cm wide) for the initial assessment of
amniotic fluid during routine obstetrical scanning. (I)
Future Direction
It is clear that there needs to be more contemporary studies
looking at the methodology of amniotic fluid assessment,
comparing measurement techniques and correlating out-
comes with different levels of AFV. In particular, SPE
thresholds for polyhydramnios and its clinical associations
are lacking. More in depth understanding of the physio-
logical factors that influence AFV is required.
CONCLUSION
This technical update reflects an attempt to assess the
current available literature, noting its limitations, to opti-
mize the use of ultrasound in the measurement of amniotic
fluid.
The available evidence indicates that using the AFI to di-
agnose oligohydramnios leads to more interventions
without any significant improvement in outcomes. Neither
is superior based on association of outcomes or repro-
ducibility. We propose that a single pocket technique be
used to estimate AFV and specifically advocate the
Chamberlain method. Other methods of SPE may be as
valid but do not have the preponderance of evidence that
the Chamberlain method does. The Chamberlain definition
is somewhat open to interpretation. Adaption of other
definitions, such as Kehl’s, may also be considered as they
have evidence to support its use.
Recommendation
8. It is recommended that the initial, general evaluation
of amniotic fluid volume during routine obstetrical
ultrasound be a single pocket estimation. The
Chamberlain method of amniotic fluid assessment is
the preferred method for estimation. (I-A)
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