CHAPTER 11: SEMEN

Semen is composed of four fractions that are contributed by the testes, epididymis, seminal

vessels, prostate, and bulbourethral glands. The testes contain the seminiferous tubules. Germ cells

for the production of spermatozoa are located in the epithelial cells of the seminiferous tubules.

Specialized Sertoli cells provide support and nutrients for the germ cells as they undergo mitosis and

meiosis (spermatogenesis). The ejaculatory ducts receive both the sperm from the ductus deferens

and fluid from the seminal vesicles. The seminal vesicles produce the majority of the fluid present in

semen (60% to 70%).

SPECIMEN COLLECTION

Specimens are collected following a period of sexual abstinence of from 2 to 3 days to not

longer than 5 days. Specimens collected following prolonged abstinence tend to have higher volumes

and decreased motility. When performing fertility testing, two or three samples are usually tested at 2-

week intervals, with two abnormal samples considered significant.

[AUTHOR NAME] 1
SEMEN ANALYSIS

Appearance

Normal semen has a gray-white color, appears translucent, and has a characteristic musty

odor. Increased white turbidity indicates the presence of white blood cells (WBCs) and infection within

the reproductive tract. If required, specimen culturing is performed prior to continuing with the semen

analysis. During the microscopic examination, WBCs must be differentiated from immature sperm

(spermatids). The leukocyte esterase reagent strip test may be useful to screen for the presence of

WBCs.

Liquefaction

A fresh semen specimen is clotted and should liquefy within 30 to 60 minutes after collection;

therefore, recording the time of collection is essential for evaluation of semen liquefaction. Analysis of

the specimen cannot begin until after liquefaction has occurred.

Volume

Normal semen volume ranges between 2 and 5 mL. It can be measured by pouring the

specimen into a clean graduated cylinder calibrated in 0.1-mL increments. Increased volume may be

seen following periods of extended abstinence. Decreased volume is more frequently associated with

infertility and may indicate improper functioning of one of the semen-producing organs, primarily the

seminal vesicles.

Viscosity

The normal semen specimen should be easily drawn into a pipette and form droplets that do

not appear clumped or stringy when discharged from the pipette. Normal droplets form a thin thread

when released from the pipette. Droplets with threads longer that 2 centimeters are considered highly

viscous. Ratings of 0 (watery) to 4 (gel-like) can be assigned to the viscosity report.

pH

[AUTHOR NAME] 2
 The normal pH of semen is alkaline with a range of 7.2 to 8.0. Increased pH is indicative of

infection within the reproductive tract. A decreased pH is associated with increased prostatic fluid.

Semen for pH testing can be applied to the pH pad of a urinalysis reagent strip and the color

compared with the manufacturer’s chart.

SPERM CONCENTRATION/COUNT

The total sperm count for the ejaculate can be calculated by multiplying the sperm

concentration by the specimen volume. Total sperm counts greater than 40 million per ejaculate are

considered normal (20 million per milliliter x 2 mL).

Using the Neubauer hemocytometer, sperm are usually counted in the four corner and center

squares of the large center square—similar to a manual RBC count.

Only fully developed sperm should be counted. Immature sperm and WBCs, often referred to

as “round” cells, must not be included. However, their presence can be significant, and they may

need to be identified and counted separately. Stain included in the diluting fluid aids in differentiation

between immature sperm cells (spermatids) and leukocytes, and they can be counted in the same

manner as mature sperm. Greater than 1 million leukocytes per milliliter is associated with

inflammation or infection of the reproductive organs that can lead to infertility.

Calculation of Sperm Concentration and Sperm

Count

When using the 1:20 dilution and counting

the five squares (RBCs) in the large center square

as described previously, the number of sperm can

be multiplied by 1,000,000 (add 6 zeros) to equal

the sperm concentration per milliliter. Notice that

unlike blood cell counts, the sperm concentration is

reported in milliliters rather than microliters.

Because this formula provides the number of cells

[AUTHOR NAME] 3
per microliter, the figure must then be multiplied by 1000 to calculate the number of sperm per

milliliter. The total sperm count is calculated by multiplying the number of sperm per milliliter by the

specimen volume.

Sperm Motility

Assessment of sperm motility should be performed on well mixed, liquefied semen within 1

hour of specimen collection. The practice of examining sperm motility

at intervals over an extended period has been shown to serve no

useful purpose. To provide continuity in reporting, laboratories should

place a consistent amount of semen under the same size coverslip,

such as 10 L under a 22 X 22 mm coverslip. The percentage of

sperm showing actual forward movement can then be estimated after

evaluating approximately 20 high-power fields. Motility is evaluated

by both speed and direction. Grading can be done using a scale of 0

to 4, with 4 indicating rapid, straight-line movement and 0 indicating

no movement. A minimum motility of 50% with a rating of 2.0 after 1 hour is considered normal.

Sperm Morphology

Sperm morphology is evaluated with respect to

the structure of the head, neckpiece, midpiece, and tail.

Abnormalities in head morphology are associated with

poor ovum penetration, whereas neckpiece, midpiece,

and tail abnormalities affect motility. The normal sperm

has an oval-shaped head approximately 5 um long and

3 um wide and a long, flagellar tail approximately 45 um

lonb. Critical to ovum penetration is the enzyme-

containing acrosomal cap located at the tip of the head.

[AUTHOR NAME] 4
Sperm morphology is evaluated from a

thinly smeared, stained slide under oil

immersion. Staining can be performed

using Wright’s, Giemsa, or Papanicolaou

stain and is a matter of laboratory

preference. Air-dried slides are stable for

24 hours. At least 200 sperm should be

evaluated and the percentage of abnormal sperm reported. Routinely identified abnormalities in head

structure include double heads, giant and amorphous heads, pinheads, tapered heads, and

constricted heads.

SPERM VIABILITY

Viability is evaluated by mixing the specimen with an eosin-nigrosin stain, preparing a smear,

and counting the number of dead cells in 100 sperm. Living cells are not infiltrated by the dye and

remain a bluish white color, whereas dead cells stain red against the purple background. Normal

viability requires 75% living cells and should correspond to the previously evaluated motility.

SEMINAL FLUID FRUCTOSE

A normal quantitative level of fructose is equal to or greater than 13 umol per ejaculate. This

can be determined using spectrophotometric methods. Specimens for fructose levels should be

tested within 2 hours or frozen to prevent fructolysis.

ANTISPERM ANTIBODIES

Antisperm antibodies can be present in both men and women. They may be detected in semen,

cervical mucosa, or serum and are considered a possible cause of infertility. It is not unusual for both

partners to demonstrate antibodies, although male antisperm antibodies are more frequently

encountered.

[AUTHOR NAME] 5
 The presence of antibodies in a male subject can be suspected when clumps of sperm are

observed during a routine semen analysis. The presence of antisperm antibodies in a female subject,

results in a normal semen analysis accompanied by continued infertility. The presence of antisperm

antibodies in women may be demonstrated by mixing the semen with the female cervical mucosa or

serum and observing for agglutination. A variety of immunoassay kits are available for both semen

and serum testing.

Two frequently used tests to detect the presence of antibody-coated sperm are the mixed

agglutination reaction (MAR) test and the immunobead test. The MAR test is a screening procedure

used primarily to detect the presence of immunoglobulin G (IgG) antibodies. The semen sample

containing motile sperm is incubated with IgG antihuman globulin (AHG) and a suspension of latex

particles or treated RBCs coated with IgG. The bivalent AHG binds simultaneously to both the

antibody on the sperm and the antibody on the latex particles or RBCs, forming microscopically

visible clumps of sperm and particles or cells. immunobead test is a more specific procedure in that it

can be used to detect the presence of IgG, IgM, and IgA antibodies and demonstrates what area of

the sperm (head, neckpiece, midpiece, or tail) the autoantibodies are affecting. Head-directed

antibodies can interfere with penetration into the cervical mucosa or ovum, whereas tail-directed

antibodies affect movement through the cervical mucosa.9 In the immunobead test, sperm are mixed

with polyacrylamide beads known to be coated with either anti-IgG, anti-IgM, or anti-IgA.

MICROBIAL AND CHEMICAL TESTING

[AUTHOR NAME] 6
SPERM FUNCTION TESTS

SEMEN ANALYSIS QUALITY CONTROL

Traditionally, semen routine analysis has been subject to very little quality control. This has

resulted from a lack of appropriate control materials and the subjectivity of the motility and

morphology analyses. The use of CASA has aided in reducing the subjectivity of the analysis.

[AUTHOR NAME] 7
SYNOVIAL FLUID
PHYSIOLOGY
 Often referred to as “joint fluid”
 A viscous liquid found in the cavities of the movable joints (diarthroses) or synovial joints.
 The bones in the synovial joints are lined with smooth articular cartilage and separated by a cavity
containing the synovial fluid.
 The joint is enclosed in a fibrous joint capsule lined by the synovial membrane.
 The synovial membrane contains specialized cells called synoviocytes-
The synoviocytes secrete a mucopolysaccharide containing hyaluronic acid and a small amount
of protein (approximately one fourth of the plasma concentration) into the fluid.
 The smooth articular cartilage and synovial fluid reduce friction between the bones during joint
movement.
 In addition to providing lubrication in the joints, synovial fluid provides nutrients to the articular
cartilage and lessens the shock of joint compression that occurs during activities such as walking
and jogging.
 Synovial fluid is formed as an ultrafiltrate of plasma across the synovial membrane.
 The filtration is nonselective except for the exclusion of high molecular weight proteins. Therefore,
the majority of the chemical constituents, although seldom of clinical significance, have
concentrations similar to plasma values.
 They do, however, provide nutrients for the vascular- deficient cartilage.
 The large hyaluronate molecules contribute the noticeable viscosity to the synovial fluid. Damage
to the articular membranes produces pain and stiffness in the joints, collectively referred to as
arthritis.
 Laboratory results of synovial fluid analysis can be used to determine the pathologic origin of
arthritis.

8
SPECIMEN COLLECTION AND HANDLING
 Collected by needle aspiration called arthrocentesis.
 The amount of fluid present varies with the size of the joint and the extent of fluid buildup in the
joint.
 Normal synovial fluid does not clot; however, fluid from a diseased joint may contain fibrinogen
and will clot.
 Therefore, fluid is often collected in a syringe that has been moistened with heparin.
 When sufficient fluid is collected, it should be distributed into the following tubes based on the
required tests:
o A sterile heparinized tube for Gram stain and culture
o A heparin or ethylenediaminetetraacetic acid (EDTA) tube for cell counts
o A nonanticoagulated tube for other tests
o A sodium fluoride tube for glucose analysis
 Powdered anticoagulants should not be used because they may produce artifacts that interfere
with crystal analysis.
 The nonanticoagulated tube for other tests must be centrifuged and separated to prevent cellular
elements from interfering with chemical and serologic analyses.
 Ideally, all testing should be done as soon as possible to prevent cellular lysis and possible
changes in crystals.

9
COLOR AND CLARITY
 Normal synovial fluid appears colorless to pale yellow.
 The word “synovial” comes from the Latin word for egg.
 Normal viscous synovial fluid resembles egg white.
 The color becomes a deeper yellow in the presence of noninflammatory and inflammatory
effusions and may have a greenish tinge with bacterial infection.
 As with cerebrospinal fluid, in synovial fluid the presence of blood from a hemorrhagic arthritis
must be distinguished from blood from a traumatic aspiration.
o This is accomplished primarily by observing the uneven distribution of blood in the specimens
obtained from a traumatic aspiration.
 Turbidity is frequently associated with the presence of WBCs; however, synovial cell debris and
fibrin also produce turbidity. The fluid may appear milky when crystals are present.
VISCOSITY
 Viscosity of the synovial fluid comes from the polymerization of the hyaluronic acid and is
essential for the proper lubrication of the joints.
 Arthritis affects both the production of hyaluronate and its ability to polymerize, thus decreasing
the viscosity of the fluid.
 Methods to measure the viscosity of the fluid:
o The simplest being to observe the ability of the fluid to form a string from the tip of a syringe,
and can be done at the bedside.
 A string that measures 4 to 6 cm is considered normal.
o Measurement of the amount of hyaluronate polymerization can be performed using a Ropes,
or mucin clot, test.
 When added to a solution of 2% to 5% acetic acid, normal synovial fluid forms a solid clot
surrounded by clear fluid.
 As the ability of the hyaluronate to polymerize decreases, the clot becomes less firm, and
the surrounding fluid increases in turbidity.
 The mucin clot test is reported in terms of good (solid clot), fair (soft clot), low (friable clot),
and poor (no clot).
 The mucin clot test is not routinely performed, because all forms of arthritis decrease
viscosity and little diagnostic information is obtained.
 Formation of a mucin clot following the addition of acetic acid can be used to identify a
questionable fluid as synovial fluid.

10
CELL COUNTS
 The total leukocyte count is the most frequently performed cell count on synovial fluid.
 To prevent cellular disintegration, counts should be performed as soon as possible or the
specimen should be refrigerated.
 Very viscous fluid may need to be pretreated by adding a pinch of hyaluronidase to 0.5 mL of fluid
or one drop of 0.05% hyaluronidase in phosphate buffer per milliliter of fluid and incubating at 37C
for 5 minutes.
 Manual counts on thoroughly mixed specimens are done using the Neubauer counting chamber
in the same manner as cerebrospinal fluid counts.
 Clear fluids can usually be counted undiluted, but dilutions are necessary when fluids are turbid or
bloody.
 Traditional WBC diluting fluid cannot be used because it contains acetic acid that causes the
formation of mucin clots.
 Normal saline can be used as a diluent.
 If it is necessary to lyse the RBCs, hypotonic saline (0.3%) or saline that contains saponin is a
suitable diluent.
 Methylene blue added to the normal saline stains the WBC nuclei, permitting separation of
the RBCs and WBCs during counts performed on mixed specimens.
 Automated cell counters can be used for synovial fluid counts; however, highly viscous fluid may
block the apertures, and the presence of debris and tissue cells may falsely elevate counts. As
described previously, incubation of the fluid with hyaluronidase decreases the specimen viscosity.
 Analysis of scattergrams can aid in the detection of tissue cells and debris. Properly controlled
automated counts provide higher precision than manual counts.
 WBC counts less than 200 cells/L areL considered normal and may reach 100,000 cells/L or
higher in severe infections.There is, however, considerable overlap of elevated leukocyte counts
between septic and inflammatory forms of arthritis.
 Pathogenicity of the infecting organisms also produces varying results in septic arthritis, as does
antibiotic administration.
DIFFERENTIAL COUNT
 Differential counts should be performed on cytocentrifuged preparations or on thinly smeared
slides.
 Fluid should be incubated with hyaluronidase prior to slide preparation.
 Mononuclear cells, including monocytes, macrophages, and synovial tissue cells, are the primary
cells seen in normal synovial fluid.

11
 Neutrophils should account for less than 25% of the differential count and lymphocytes less than
15%.
o Increased neutrophils indicate a septic condition, whereas an elevated cell count with a
predominance of lymphocytes suggests a nonseptic inflammation.
 In both normal and abnormal specimens, cells may appear more vacuolated than they do on a
blood smear.
 Besides increased numbers of these usually normal cells, other cell abnormalities include the
presence of eosinophils, LE cells, Reiter cells (vacuolated macrophages with ingested neutrophils),
and RA cells or ragocytes (neutrophils with small, dark, cytoplasmic granules that consist of
precipitated rheumatoid factor).
 Lipid droplets may be present following crush injuries, and hemosiderin granules are seen in
cases of pigmented villonodular synovitis.

12
CRYSTAL IDENTIFICATION
 Crystal formation in a joint frequently results in an acute, painful inflammation. It can also become
a chronic condition.
 Causes of crystal formation include metabolic disorders and decreased renal excretion that
produce elevated blood levels of crystallizing chemicals, degeneration of cartilage and bone, and
injection of medications, such as corticosteroids into a joint
TYPES OF CRYSTALS
 The primary crystals seen in synovial fluid are monosodium urate (uric acid) (MSU) found in
cases of gout and calcium pyrophosphate (CPPD) seen with pseudogout.
 Increased serum uric acid resulting from impaired metabolism of purines; increased consumption
of high-purine-content foods, alcohol, and fructose; chemotherapy treatment of leukemias; and
decreased renal excretion of uric acid are the most frequent causes of gout.
 Pseudogout is most often associated with degenerative arthritis, producing cartilage calcification
and endocrine disorders that produce elevated serum calcium levels.
 Additional crystals that may be present include hydroxyapatite (basic calcium phosphate)
associated with calcified cartilage degeneration, cholesterol crystals associated with chronic
inflammation, corticosteroids following injections, and calcium oxalate crystals in renal dialysis
patients.
 Artifacts present may include talc and starch from gloves, precipitated anticoagulants, dust, and
scratches on slides and coverslips.

13
SLIDE PREPARATION
 Fluid must be examined prior to WBC disintegration.
 Fluid is examined as an unstained wet preparation.
 One drop of fluid is placed on a precleaned glass slide and coverslipped.
 The slide can be initially examined under low and high power using a regular light microscope (Fig.
12-2).
 Crystals may be observed in Wright stained smears (Fig. 12-3), however this should not replace
the wet prep examination and the use of polarized and compensated polarized light for
identification.
 MSU crystals are routinely seen as needle-shaped crystals.
o They may be extracellular or located within the cytoplasm of neutrophils.
o They are frequently seen sticking through the cytoplasm of the cell.
 CPPD crystals usually appear rhombic-shaped or square but may appear as short rods.
o They are usually located within vacuoles of the neutrophils as shown in Figure 12-3.
 MSU crystals lyse phagosome membranes and therefore do not appear in vacuoles
 To avoid misidentification of CPPD crystals, the classic rhomboid shape should be observed and
confirmed with compensated polarized microscopy.

CRYSTAL POLARIZATION
 Once the presence of the crystals has been determined using direct polarization, positive
identification is made using compensated polarized light.
 A control slide for the polarization properties of MSU can be prepared using betamethasone
acetate corticosteroid.
 Both MSU and CPPD crystals have the ability to polarize light, however, MSU is more highly
birefringent and appears brighter against the dark background (Figs. 12-4 and 12-5).

14
 When compensated polarized light is used, a red compensator is placed in the microscope
between the crystal and the analyzer.
o The compensator separates the light ray into slow-moving and fast-moving vibrations and
produces a red background (Fig. 12-6).
o The molecules in MSU crystals run parallel to the long axis of the crystal and, when aligned
with the slow vibration, the velocity of the slow light passing through the crystal is not
impeded as much as the fast light, which runs against the grain and produces a yellow color.
o This is considered negative birefringence (subtraction of velocity from the fast ray).
o In contrast, the molecules in CPPD crystals run perpendicular to the long axis of the crystal;
when aligned with the slow axis of the compensator, the velocity of the fast light passing
through the crystal is much quicker, producing a blue color and positive birefringence.
o When the crystals are aligned perpendicular to the slow vibration, the color is reversed as
shown in Figure 12-6.
o Notice how the colors of the MSU crystals in Figure 12-6 vary with the alignment.
o Figures 12-7 and 12-8 illustrate the characteristics of MSU and CPPD crystals under
compensated polarized light.
o Crystal shapes and patterns of birefringence that vary from the standard MSU and CPPD
patterns may indicate the presence of one of the less commonly encountered crystals and
that further investigation is required (Fig. 12-9).
Cholesterol, oxalate, and corticosteriod crystals exhibit birefringence, as do many contaminants.
Apatite crystals are not birefringent.

15
 o
CHEMISTRY TESTS
 Because synovial fluid is chemically an ultrafiltrate of plasma, chemistry test values are
approximately the same as serum values. Therefore, few chemistry tests are considered
clinically important.
 The most frequently requested test is the glucose determination, as markedly decreased values
are indicative of inflammatory (group 2) or septic (group 3) disorders.
o Because normal synovial fluid glucose values are based on the blood glucose level,
simultaneous blood and synovial fluid samples should be obtained, preferably after the
patient has fasted for 8 hours to allow equilibration between the two fluids.
o Under these conditions, normal synovial fluid glucose should not be more than 10 mg/dL lower
than the blood value.
o To prevent falsely decreased values caused by glycolysis, specimens should be analyzed
within 1 hour or preserved with sodium fluoride.
16
 Other chemistry tests that may be requested are the total protein and uric acid determinations.
o Because the large protein molecules are not filtered through the synovial membranes, normal
synovial fluid contains less than 3 g/dL of protein (approximately one third of the serum
value).
o Increased levels are found in inflammatory and hemorrhagic disorders; however, measurement
of synovial fluid protein does not contribute greatly to the classification of these disorders.
o When requested, the analysis is performed using the same methods used for serum protein
determinations.
o Measurement of serum uric acid is often performed as a first evaluation of suspected cases of
gout. Fluid analysis for crystals is frequently still required.
MICROBIOLOGIC TESTS
 An infection may occur as a secondary complication of inflammation caused by trauma or through
dissemination of a systemic infection; therefore, Gram stains and cultures are two of the most
important tests performed on synovial fluid.
 Both tests must be performed on all specimens, as organisms are often missed on Gram stain.
 Bacterial infections are most frequently seen; however, fungal, tubercular, and viral infections also
can occur. When they are suspected, special culturing procedures should be used.
 Patient history and other symptoms can aid in requests for additional testing.
 Routine bacterial cultures should include an enrichment medium, such as chocolate agar,
because in addition to Staphylococcus and Streptococcus, the common organisms that infect
synovial fluid are the fastidious Haemophilus species and N. gonorrhoeae.
SEROLOGIC TESTS
 Because of the association of the immune system to the inflammation process, serologic testing
plays an important role in the diagnosis of joint disorders. However, the majority of the tests are
performed on serum, with actual analysis of the synovial fluid serving as a confirmatory measure
in cases that are difficult to diagnose.
 The autoimmune diseases rheumatoid arthritis and lupus erythematosus cause very serious
inflammation of the joints and are diagnosed in the serology laboratory by demonstrating the
presence of their particular autoantibodies in the patient’s serum. These same antibodies can also
be demonstrated in the synovial fluid, if necessary.
 Arthritis is a frequent complication of Lyme disease. Therefore, demonstration of antibodies to the
causative agent Borrelia burgdorferi in the patient’s serum can confirm the cause of the arthritis.
 The extent of inflammation can be determined through measurement of the concentration of acute
phase reactants such as fibrinogen and C-reactive protein

17
 CHAPTER 13. SEROUS FLUID
● Formation
- Serous fluids are formed as ultrafiltrates of plasma, with no additional material contributed by the
mesothelial cells that line the membranes.
- Disruption of the mechanisms of serous fluid formation and reabsorption causes an increase in
fluid between the membranes. This is termed an effusion.
- Primary causes of effusions include increased hydrostatic pressure (congestive heart failure),
decreased oncotic pressure (hypoproteinemia), increased capillary permeability (inflammation
and infection), and lymphatic obstruction (tumors).
● Specimen Collection and Handling
- Fluids for laboratory examination are collected by needle aspiration from the respective cavities.
- These aspiration procedures are referred to as thoracentesis (pleural), pericardiocentesis
(pericardial), and paracentesis (peritoneal)
- Abundant fluid (greater than 100 mL) is usually collected
- An ethylenediaminetetraacetic acid (EDTA) tube is used for cell counts and the differential.
- Sterile heparinized evacuated tubes are used for microbiology and cytology.
- Chemistry tests can be run on clotted specimens in plain tubes or on heparinized tubes.
● Transudates and Exudates
- Effusions that form because of a systemic disorder that disrupts the balance in the regulation of
fluid filtration and reabsorption—such as the changes in hydrostatic pressure created by
congestive heart failure or the hypoproteinemia associated with the nephrotic syndrome— are
called transudates.
- Exudates are produced by conditions that directly involve the membranes of the particular cavity,
including infections and malignancies.
● General Laboratory Procedures
- Tests that are usually performed on all serous fluids include evaluation of the appearance and
differentiation between a transudate and an exudate.
- Effusions of exudative origin are then examined for the presence of microbiologic and cytologic
abnormalities
- WBC counts greater than 1000/L and RBC counts greater than 100,000/L are indicative of an
exudate.
● Pleural Fluid
- Pleural fluid is obtained from the pleural cavity, located between the parietal pleural membrane
lining the chest wall and the visceral pleural membrane covering the lungs.
- Pleural effusions may be of either transudative or exudative origin.

18
➢ Appearance

- hemothorax (traumatic injury)

➢ Hematology Tests

➢ Chemistry Tests
- Pleural fluid glucose levels parallel plasma levels with values less than 60 mg/dL considered
decreased.
- Pleural fluid pH at least 0.30 degrees lower than the blood pH is considered significant
- ADA levels over 40 U/L are highly indicative of tuberculosis. They are also frequently elevated
with malignancy.

19
 ➢ Microbiologic and Serologic Tests
- Microorganisms primarily associated with pleural effusions include Staphylococcus aureus,
Enterobacteriaceae, anaerobes, and Mycobacterium tuberculosis.
- Gram stains, cultures (both aerobic and anaerobic), acid-fast stains, and mycobacteria cultures
are performed on pleural fluid when clinically indicated.
- Tests for antinuclear antibody (ANA) and rheumatoid factor (RF) are the most frequently
performed.
● Pericardial Fluid
➢ Appearance

➢ Laboratory Tests

20
● Peritoneal Fluid
- Accumulation of fluid between the peritoneal membranes is called ascites, and the fluid is commonly
referred to as ascitic fluid rather than peritoneal fluid
- Peritoneal lavage is a sensitive test for the detection of intra-abdominal bleeding in blunt trauma
cases, and results of the RBC count can be used along with radiographic procedures to aid in
determining the need for surgery
➢ Transudates Versus Exudates
- A difference (gradient) of 1.1 or greater suggests a transudate effusion of hepatic origin, and
lower gradients are associated with exudative effusions
➢ Appearance

➢ Laboratory Tests

21
 AMNIOTIC FLUID

Amniotic fluid
Amniotic fluid is a clear, slightly yellowish liquid
that surrounds the unborn baby (fetus) during
pregnancy. It is contained in the amniotic sac.

Amniotic fluid formation and composition:

First & early second trimester:
 Amount is 5-50 ml & arises from:
ultrafiltrate of maternal plasma through
the vascularized uterine decidua (in early
pregnancy).

 Transudation of fetal plasma through the fetal skin & umbilical cord (up to 20 weeks'
gestation). * it is iso-osmolar with fetal & maternal plasma, though it is devoid of proteins.

Volume and composition

 From 20 weeks up to term (mainly fetal urine)

 At 18th week, the fetus voids 7-14ml/day; at term fetal kidneys secretes 600- 700ml of
urine/day into af.
 Fetal respiratory tract secretes 250ml/day into af.
 Fluid transfers across the placenta.
 Fetal oro-nasal secretions.
 Secretion is controlled by: - fetal swallowing at term removes 500ml/day. - reabsorption
into maternal plasma (osmotic gradient).
Amniotic fluid constituents:
- urea, creatinine & uric acid + desquamated fetal cells, vernix, lanugo hair & others→ hypo-osmolar
amniotic fluid.
Amniotic fluid circulation
 About 500mls enter and leave the amniotic sac each hour.
 Gradual ↑ up to 36 weeks to around 600 to 1000 ml then↓ after that.
 The normal range is wide but the approximate volumes are: - 500 ml at 18 weeks - 800
ml at 34 weeks. - 600 ml at term.

22
Amniotic fluid function:

1. Allow room for fetal growth, movement and development.

2. Ingestion into git→ growth and maturation.
3. Fetal pulmonary development (20 weeks).
4. Protects the fetus from trauma.
5. Maintains temperature.
6. Contains antibacterial activity.
7. Aids dilatation of the cervix during labour.

Clinical importance of amniotic fluid:

1. Screening for fetal malformation (serum α- fetoprotien).

2. Assessment of fetal well-being (amniotic fluid index).
3. Assessment of fetal lung maturity (l/s ratio).
4. Diagnosis and follow up of labour.
5. Diagnosis of prom (ferning test).

Amniotic fluid volume assessment

•clinical assessment is unreliable.

•objective assessment depends on u/s to measure:
- deepest vertical pool (dvp).
- amniotic fluid index (afi).
- it is a total of the dvps in each four quadrants of the uterus. It is a more sensitive indicator of afv
throughout pregnancy.

Amniotic fluid abnormalities

1. Oligohydramnios: defined as reduced amniotic fluid of 200ml or less i.e. Amniotic fluid index of
5 cm or less or the deepest vertical pool < 2 cm.

2. Polyhydramnios: defined as excessive amount of amniotic fluid of 2000ml or more (afi of > 25
cm or the deepest vertical pool of > 8 cm).

23
Types:
1. Mild hydramnios (80%): a pocket of amniotic fluid measuring 8 to 11 cm.
2. Moderate hydramnios (15%): a pocket of amniotic fluid measuring 12 to 15 cm.
3. Severe hydramnios (5%) - twin-twin transfusion syndrome: a pocket of amniotic fluid
measuring 16 cm or more.

Etiology of polyhydramnios

1. Idiopathic
2. Fetal anomalies
3. Diabetes
4. Multifetal gestation
5. Immune/non-immune hydrops
6. Fetal infection
7. Placental hemangiomas
Fetal anomalies
 Problems with swallowing and gi absorption
 Increased transudation of fluid: anencephaly, spina bifida
 Increased urination: anencephaly (lack of adh, stimulation of urination centers)
 Decreased inspiration
Symptoms
1. Dyspnea
2. Abdominal pain
3. Venous stasis
4. Contractions  preterm labor
5. Decreased perception of fetal movements
Diagnosis of polyhydramnios
Symptoms:
 Dyspnea.
 Edema.
 Abdominal distention
 Preterm labour.

24
Abdominal examination:
 ↑ uterus than expected.
 Difficult to palpate fetal parts.
 Difficult to hear fetal heart sound.
 Ballotable fetus.
 decreased fetal movement
 Ultrasound: - excessive amniotic fluid. - fetal abnormalities.

Complications (fetus)

 Fetal prognosis worsens with more severe hydramnios and congenital anomalies
 15-20% fetal malformations
 Preterm delivery
 Suspect diabetes
 Prolapse of cord
 Abruption
Mother
 Dyspnea
 Venous stasis
 Placental abruption
 Uterine atony
 Pph
 Abnormal presentation -- c/s
Treatment
 Mild to moderate hydramnios: rarely requires treatment
 Hospitalization, bed rest
 Amniocentesis
 Nsaids
 Blood sugar control
Oligohydramnios
 Refers to reduced amniotic fluid <200mls
i. e. Amniotic fluid index of 5 cm or less or the deepest vertical pool < 2 cm.

25
Etiology:
o prom (50%)
o chromosomal anomalies
o congenital anomalies
o iugr
o iufd
o postterm pregnancy maternal
o preeclampsia
o apla syndrome
o chronic ht placental
o chronic abruption
o ttts
o cvs drugs
o pg synthetase inhibitors
o ace inhibitors idiopathic
Complications of oligohydramnios in early pregnancy:
o Amniotic adhesions or bands→ amputation/death.
o Pressure deformities (club feet).
o Pulmonary hypoplasia: - thoracic compression. - no breathing movement. - no amniotic
fluid retain.
o Flattened face.
o Postural deformities.
In late pregnancy:
o Fetal growth restriction.
o Placental abruption.
o Preterm labour.
o Fetal distress.
o Fetal death.
o Meconium aspiration.
o Labour induction/cs
Extremely poor fetal prognosis, especially in early pregnancy can cause:
 Adhesions between amnion and fetal parts --- malformations and amputations
 Musculoskeletal deformities
 Pulmonary hypoplasia
 Cord compression -- >fetal hypoxia

26
  Passage of meconium into low af volume: thick particulate suspension -->respiratory
compromise
Management
Minor degrees: no treatment.
• bed rest, diuretics, water and salt restriction: ineffective.
• hospitalization: dyspnea, abdominal pain or difficult ambulation.
• endomethacin therapy - impairs lung liquid production/enhances absorption. -
↓fluid movement across fetal membranes.
*Complications: premature closure of ductus arteriosus, impairment of
renal function, and cerebral vasoconstriction. Do not used after 35 weeks.
•amniocentesis: to relieve maternal distress and to test for fetal lung maturity.
*Complications: ruptured membrane, chorioamnionitis, placental abruption,
preterm labour.
Treatment

• Adequate rest – decreases dehydration

• hydration – oral/iv hypotonic fluids(2 lit/d) temporary increase helpful during
labour,
• serial usg – monitor growth, afi, bpp
• induction of labour/ lscs lung maturity attained lethal malformation fetal jeopardy
severe iugr severe oligohydramnios
• amnioinfusion
Amnioinfusion indications
1.diagnostic
2.prophylactic
3.therapeutic • decreases cord compression • dilutes meconium

27