Download - Serous, Amniotic, and Sweat
UNIVERSITY OF SANTO TOMASFACULTY OF PHARMACY
DEPARTMENT OF MEDICAL TECHNOLOGY
CSF AND OTHER BODY FLUIDS
AQUINO, CHRISTIALANE JOYPASCUAL, BOB DYLANQUERO, MARC DELVIN
ROSARIO, KRISELLE DIANNEVILLANUEVA, JOSE LORENZO
4E-Medical Technology
MR. ALVIN REY FLORES, RMT, MT (ASCPi)Seminar II Instructor
SEROUS FLUIDS
A. Composition and Formation
Serous fluid is the small amount of fluid that lies between the membranes lining the body cavities (parietal) and those covering the organs within the cavities (visceral).
1. It is considered an “ultrafiltrate” of the plasma and closely resembles it.
2. Production and reabsorption are normally at a constant rate. They are influenced by:
a. Changes in osmotic and hydrostatic pressure in the bloodb. Concentration of the chemical constituents in the plasmac. Permeability of blood vessels and the membranes
3. There are three types of serous fluids
a. Peritoneal fluid (ascetic fluid) – from the abdominal cavity – paracentesisb. Pleural fluid (thoracic fluid) – lung – thoracentesisc. Pericardial fluid – heart – pericardiocentesis
B. Indications – infections, hemorrhages, malignancies, other disorders
C. Collection
1. Needle aspiration – parecentesis, thoracentesis, pericardiocentesis; 3 sterile tubes, often in EDTA to prevent clotting
2. Lavage – peritoneal
D. Transudates vs. Exudates
A build up of serous fluid is called an effusion.
1. Transudatea. Due to a systemic disorder, ex. CHFb. Disruption in the balanced regulation of fluid filtration (formation) and its
reabsorptionc. Thought of as a mechanical process
2. Exudatea. Produced by conditions that directly involve the membranes of the particular
cavity, ex. Infections, inflammation, and malignancies
b. Thought of as an inflammatory process
Transudate ExudateAppearance Clear CloudySpecific Gravity <1.015 >1.015Total Protein <3.0 g/dl >3.0 g/dlFluid Protein : Serum Protein Ratio <0.5 >0.5Lactic Dehydrogenase (LDH) <200 IU >200 IUFluid LD : Serum LD Ratio <0.6 >0.6WBC Count <1000/ul >1000/ulRBC Count O-low high
I. PLEURAL FLUID
Pleural fluid – from pleural cavity, located between the parietal pleural membrane lining the chest wall and the visceral pleural membrane covering the lungs.
Transudate ExudatePleural fluid cholesterol < 60 mg/dl >60 mg/dlPleural fluid : Serum cholesterol ratio <0.3 >0.3Pleural fluid : Serum TB ratio <0.6 >0.6
1. Appearance
Appearance SignificanceClear, pale yellow Normal
Turbid, white Microbial infection (tuberculosis)Bloody Hemothorax, Hemmorhagic effusion, pulmonary embolis,
tuberculosis, malignancyMilky Chylous material from thoracic duct leakage
Brown Rupture of amoebic liver abcessBlack Aspergillous
Viscous Malignant mesothelioma (↑ hyaluronic acid)
2. Hematology TestsPrimary cells associated: neutrophils, lymphocytes, eosinophils, mesothelial cells, plasma cells, and malignant cells
Cell SignificanceNeutrophils Pneumonia; Pancreatitis; Pulmonary infarction
Lymphocytes Tuberculosis; Viral infection; Autoimmune disorders; Malignancy
Mesothelial cells Normal and reactive forms have no clinical significance; ↓ mesothelial cells are associated
with tuberculosisPlasma cells Tuberculosis
Malignant cells Primary adenocarcinoma and small cell carcinoma; Metastatic carcinoma
3. Chemistry Tests
a. Glucose - ↓ in tuberculosis, rheumatoid inflammation, purulent infectionsb. pH - <7.2 may indicate pneumonia; <6.0 indicates esophageal rupturec. Adenosine Deaminase (ADA) - >40 U/L is indicative of TBd. Amylase - ↑ in pancreatitise. Lactate - ↑ in bacterial infection
4. Microbiologic and Serologic Tests
Bacteria primary associated with pleural effusions:Staphylococcus aureusEnterobacteriaceaeAnaerobesMycobaterium tuberculosis
Serologic Tests:Antinuclear antibody (ANA)Rheumatoid factor (RF)CEA - metastatic uterine cancerCA 15-3 – breast cancerCA 549 – breast cancerCYFRA 21-1 – lung cancer
II. PERICARDIAL FLUID
Pericardial fluid – found between the pericardial serous membranes; 10-50mL
Pericardial effusion due to:a. Infection (pericarditis)b. Metabolic disorders e.g. uremia, hypothyroidism c. Cardiac compression (tamponade)
1. Appearance
2. Hematologic Testsa. Neutrophils - ↑ in bacterial endocarditis
Apperance SignificanceClear, pale yellow Normal, transudate
Blood-streaked Infection, malignancyGrossly bloody Cardiac puncture, anticoagulant medications
Milky Chylous and pseudochylous material
b. Malignant cells – metastatic carcinoma
3. Chemistrya. Adenosine deaminase – tubercular effusion
4. Microbiologic and Serologic Tests
Bacteria/ viruses primary associated with pericardial effusions:HaemophilusStreptococcusStaphylococcusAdenovirusCoxsackievirus
GS/CS – bacterial endocarditis Acid Fast stain – tubercular effusion
III. PERITONEAL FLUID
Accumulated fluids between the peritoneal membranes
Peritoneal lavage - 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
Normal saline - use as a lavage
Cirrhosis -frequent causes of ascitic transudates.
Bacterial infections (peritonitis)—often as a result of intestinal perforation or a ruptured appendix—and malignancy are the most frequent causes of exudative fluids
Transudates vs. Exudates
The serum-ascites albumin gradient (SAAG) is recommended over the fluid:serum total protein and LD ratios for the detection of transudates of hepatic origin.
1. AppearanceAppearance Significance
Clear, pale yellow NormalTurbid Microbial infectionGreen Gallbladder, pancreatic disorders
Blood-streaked Trauma, infection or malignancyMilky Lymphatic trauma and blockage
2. Hematologic Tests
Normal WBC counts are less than 350 cells/uL, and the count increases with bacterial peritonitis and cirrhosis.
RBC counts greater than 100,000/uL are indicative of blunt trauma injuries.< 500 cells/uL – normal> 500 cells/uL – bacterial peritonitis, cirrhosis
3. Chemistrya. Glucose - ↓ in tubercular peritonitis, malignancyb. Amylase - ↑ in pancreatitis, gastrointestinal perforationc. Alkaline Phosphatase - ↑ in gastrointestinal perforationd. BUN/Creatinine – ruptured or punctured bladdere. Adenosine deaminase – tubular peritonitis
4. Microbiologic and Serologic Tests
GS/CS for both aerobes and anaerobes when bacterial peritonitis is suspected.
AMNIOTIC FLUID
A. Composition and Formation1. Found in membranous sac (amnion) surrounding fetus2. Formed by
a. Metabolism of fetal cellsb. Transfer of water across placental membranec. Fetal urine (later stages of development)
3. Serves as a protective cushion for the fetus4. Allow fetal movement5. Stabilize temperature to protect the fetus from extreme temperature changes6. Permit proper lung development7. Water and molecule exchange between mother and child8. Composition is similar to the maternal plasma with a small number of cells from the
skin, urinary tract, digestive tract9. Volume: increases throughout the pregnancy up to 1100-1500mL at 36 weeks10.Increased: creatinine (1.5-2.0 mg/dL at 36 weeks) (>2.0 mg/dL after 36 weeks)11.Regulation of the amniotic fluid is facilitated by the swallowing of the developing fetus12. Polyhydraminos – failure of the fetus to begin swallowing results in excessive
accumulation of amniotic fluid 13. Oligohydraminos- decreased amniotic fluid production
14.The fetus secretes lung fluid and pulmonary substances
B. Indications – suspected chromosomal abnormalities, metabolic disorders, neural tube defects HDN, gestational age, infections, fetal maturity
C. Collection and HandlingUse ultrasound (sonography) to locate placenta and fetal position
1. Amniocentesis – 15 weeks to 18 weeks gestation thru needle aspiration2. Specimen – collection of no more than 30 mL or may cause premature labor or rupture
membranes3. Special precautions – protect from light, process immediately
D. Amniotic Fluid Color
Color SignificanceColorless Normal
Blood-streaked Traumatic tap; abdominal trauma; intra-amniotic hemorrhage
Yellow HDN (bilirubin)Dark Green Meconium
Dark Red-Brown Fetal Death
E. Differentiation of Amniotic Fluid from Maternal Urine
Amniotic Maternal urineCreatinine Higher
Urea Higher Glucose Higher protein Higher
Fern test Fernlike crystals
F. Tests for Fetal Status
1. Genetic and Congenital disordersa. Alpha-fetoprotein and Acetylcholinesterase – neural tube defects
2. Fetal Distressa. HDN (Erythroblastosis fetalis) – when mother develops Ab against the childb. Amniotic fluid bilirubin – uncojugated bilirubin, may determine anemiac. Infection – Bacterial vaginosis and trichomoniasisd. Respiratory distress syndrome – most common cause of fetal death
3. Fetal Lung Maturity Testa. Lecithin : Sphingomyelin ratio (L/S Ratio)
L/S ratio routinely used to determine fetal lung maturity and to determine if it is safe to deliver a premature baby.
Hyalin membrane disease – most common cause of death of a newborn
Lecithin – produces at constant rate, equal to sphingomyelin until 33-35th week of gestation. Then there is a sharp increase in lecithin production
Sphingomyelin – produced at a constant rate throughout pregnancy
Ration of 2:1 (L/S) or greater indicates that the lungs are mature enough for delivery
b. Phosphatidyl glycerol – surface lipid that increases greatly after 35th week gestation. More sensitive method than L/S
4. Foam Test or Shake Testa. Screening test for FLS(fetal lung surfactant) in amniotic fluidb. The highest conc of 95% etOH able to support a ring of foamc. More surfactant is needed to maintain foam in greater conc of etOHd. ≥0.47 is considered maturee. Interferences: blood and meconium
5. Amniostat-FLMa. Uses anti-sera specific for phosphatidylglycerolb. Not affected by blood and meconiumc. Good correlation with TLCd. Slightly higher incidence of false-negative results
6. Micro Viscosity Fluorescence Polarization Assaya. To evaluate the amniotic fluid content of pulmonary surfactant relative to
albuminb. < 40mg/g indicates immature lungsc. >70 mg/g indicates mature lungsd. Fluorophore is mixed with amniotic fluid
7. Lamellar Bodiesa. Storage forms of lung phospholipids b. Secreted into the alveolar lumen at approximately 20 to 24 weeks of
gestation.
c. Not affected by bilirubin or lysed whole blood
SWEAT
A. Indication – sweat test is used to confirm the diagnosis of cystic fibrosis (most common fatal inherited disease of Americans)
B. Source: Sweat glands (of skin)
C. Appearance: clear and colorless
D. Laboratory Procedure : Policarpine iontophoresis
1. Sweat glands on the cleansed forearm are subject to the sweat inducing alkaloid pilocarpine in the presence of a mild electrical current for 5-10 min.
2. Sweat is then collected for 25-30 minutes onto filter paper or a tubing apparatus3. Chloride content is measured4. Sodium levels are measured in conjunction with chloride5. Results: Na and Cl values over 50 mEq/L = CF; 40-70 mEq/L = borderline
Sources:
Strasinger, S., & Di Lorenzo, M. (2008). Urinalysis and Body Fluids. 5th Edition. Bangkok, Thailand: iGroup Press Co., Ltd
Jarreau, P. (2012). Clinical Laboratory Science Review. New Orleans, USA: LSU Medical Center
Henry, J., McPherson, R., & Pincus, M. (2011). Henry’s Clinical Diagnosis and Management by Laboratory Methods. 21st Edition. Philadelpia, USA: Elsevier/Saunders.