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Topic: Lecithin/Sphingomyelin Ratio Other names: Fetal lung maturity profile L/S ratio, amniotic fluid Phospholipid profile,

le, amniotic fluid

Definition: The lecithin/sphingomyelin (L/S) ratio test is a test to evaluate fetal lung maturity. Surfactant is composed of lipids, proteins, and carbohydrates. Most of the lipids are phospholipids including lecithin (L) and sphingomyelin (S). During early pregnancy, lecithin and sphingomyelin make up about 20% and 50%, respectively, of total fetal surfactant lipids. While sphingomyelin remains relatively constant throughout the pregnancy, lecithin levels dramatically increase with lung maturity. There is a sharp increase in lecithin levels after 32-33 weeks gestation. In the mature lung, lecithin comprises about 70% of the total surfactant lipids. Thus, as the lungs matures, the ratio of lecithin to sphingomyelin increases.

Indications:

Assist in the evaluation of fetal lung maturity Determine the optimal time for obstetric intervention in cases of threatened fetal survival caused by stresses related to maternal diabetes, toxemia, hemolytic diseases of the newborn, or postmaturity

Identify fetuses at risk of developing RDS

Interfering Factors:

Fetal blood falsely elevates the L/S ratio. Exposing the specimen to light may cause falsely decreased values. There is some risk to having an amniocentesis performed, and this should be weighed against the need to obtain the desired diagnostic information. A small percentage (0.5%) of patients have experienced complications including premature rupture of the membranes, premature labor, spontaneous abortion, and stillbirth.

Procedure: Although there are many lecithin-based fetal lung maturity tests; thin-layer chormotography (TLC) is widely used in laboratories to determine the L/S ratio. It is a labor intensive test that takes 3 -5 hours to perform. A sample of amniotic fluid is collected by a procedure called amniocentesis. The lipids, including lecithin and sphingomyelin are extracted from the amniotic fluid with a chloroform-methanol mixture. Then the extracted lipids are applied to the channels of a TLC plate. The separation occurs in a solvent system of chloroform, methanol, triethylamine, 2-propanol and water. In this process the lecithin and sphingomyelin bands are well separated from other phospholipids. The phospholipids on the TLC plate are made visible by the process of charring using phosphoric acid with a cupric acetate catalyst.

The intensity of the lecithin and sphingomyelin bands are quantitated using a densitometer and expressed as a ratio. The consistent concentration of sphingomyelin provides a good baseline against which the amount of lecithin can be compared.

Nursing Implications and Procedures Pretest:

Positively identify the patient using at least two unique identifiers before providing care, treatment, or services. Patient Teaching: Inform the parent this test can assist in obtaining an estimate of fetal lung maturity.

Obtain a history of the patients complaints, including a list of known allergens, especially allergies or sensitivities to latex.

Obtain a history of the patients reproductive and respiratory systems, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures. Include any family history of genetic disorders such as cystic fibrosis, Duchennes muscular dystrophy, hemophilia, sickle cell disease, Tay-Sachs disease, thalassemia, and trisomy 21. Obtain maternal Rh type. If Rh-negative, check for prior sensitization. A standard RhoGAM dose is indicated after amniocentesis; repeat doses should be considered if repeated amniocentesis is performed.

Record the date of the last menstrual period, and determine that the pregnancy is in the third trimester between the 28th and 40th wk.

Obtain a list of the patients current medications, including herbs, nutritional supplements, and nutraceuticals (see Appendix F: Effects of Natural Products on Laboratory Values).

Review the procedure with the patient. Warn the patient that normal results do not guarantee a normal fetus. Assure the patient that precautions to avoid injury to the fetus will be taken by localizing the fetus with ultrasound. Address concerns about pain and explain that during the transabdominal procedure, any discomfort with a needle biopsy will be minimized with local anesthetics. Patients who are at 20 wk gestation or beyond should void before the test, because an empty bladder is less likely to be accidentally punctured during specimen collection. Encourage relaxation and controlled breathing during the procedure to aid in reducing any mild discomfort. Inform the patient that specimen collection is performed by an HCP specializing in this procedure and usually takes approximately 20 to 30 min to complete.

Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.

There are no food, fluid, or medication restrictions unless by medical direction.

Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest:

Ensure that the patient has voided before the procedure if gestation is 21 wk or more.

Have emergency equipment readily available. Have patient remove clothes below the waist. Assist the patient to a supine position on the examination table with abdomen exposed. Drape the patient's legs, leaving the abdomen exposed. Raise her head or legs slightly to promote comfort and to relax abdominal muscles. If the uterus is large, place a pillow or rolled blanket under the patient's right side to prevent hypertension caused by great-vessel compression.

Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement during administration of the local anesthetic and the procedure.

Record maternal and fetal baseline vital signs and continue to monitor throughout the procedure. Monitor for uterine contractions. Monitor fetal vital signs using ultrasound. Protocols may vary among facilities.

Observe standard precautions, and follow the general guidelines in Appendix A: Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate collection containers with the corresponding patient demographics, date and time of collection, and site location.

Assess the position of the amniotic fluid, fetus, and placenta using ultrasound.

Assemble the necessary equipment, including an amniocentesis tray with solution for skin preparation, local anesthetic, 10- or 20-mL syringe, needles of various sizes (including a 22-gauge, 5-in. spinal needle), sterile drapes, sterile gloves, and foil-covered or amber specimen collection containers.

Cleanse suprapubic area with an antiseptic solution and protect with sterile drapes. A local anesthetic is injected. Explain that this may cause a stinging sensation.

A 22-gauge, 5-in. spinal needle is inserted through the abdominal and uterine walls. Explain that a sensation of pressure may be experienced when the needle is inserted. Explain to the patient how to use focusing and controlled breathing for relaxation during the procedure.

After the fluid is collected and the needle withdrawn, apply slight pressure to the site. Apply a sterile adhesive bandage to the site.

Monitor the patient for complications related to the procedure (e.g., premature labor, allergic reaction, anaphylaxis).

Place samples in properly labeled specimen container and promptly transport the specimen to the laboratory for processing and analysis.

Post-test:

A report of the results will be sent to the requesting HCP, who will discuss the results with the patient.

Fetal heart rate and maternal vital signs (i.e., heart rate, blood pressure, pulse, and respiration) must be compared to baseline values and closely monitored every 15 min for 30 to 60 min after the amniocentesis procedure. Protocols may vary among facilities.

Observe/assess for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.

Observe/assess the amniocentesis site for bleeding, inflammation, or hematoma formation.

Instruct the patient to report any redness, edema, bleeding, or pain at the site.

Instruct the patient in the care and assessment of the amniocentesis site. Instruct the patient to expect mild cramping, leakage of small amount of amniotic fluid, and vaginal spotting for up to 2 days following the procedure. Instruct the patient to immediately report moderate to severe abdominal pain or cramps, change in fetal activity, increased or prolonged leaking of amniotic fluid from abdominal needle site, vaginal bleeding that is heavier than spotting, and either chills or fever to the HCP.

Instruct the patient to rest until all symptoms have disappeared before resuming normal levels of activity.

Administer standard dose of Rho(D) immune globulin RhoGAM IM or Rhophylac IM or IV to maternal Rh-negative patients to prevent maternal Rh sensitization should the fetus be Rh-positive.

Administer mild analgesic and antibiotic therapy as ordered. Remind the patient of the importance of completing the entire course of antibiotic therapy, even if signs and symptoms disappear before completion of therapy.

Recognize anxiety related to test results, and offer support. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Encourage the family to seek counseling if concerned with pregnancy termination or to seek genetic counseling if a chromosomal abnormality is determined. Decisions regarding elective abortion should take place in the presence of both parents. Provide a nonjudgmental, nonthreatening atmosphere for discussing the risks and difficulties of delivering and raising a developmentally challenged infant as well as for exploring other options (termination of pregnancy or adoption). It is also important to discuss feelings the mother and father may experience (e.g., guilt, depression, anger) if fetal abnormalities are detected.

Reinforce information given by the patients HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.

Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated

with the prescribed medication. Encourage her to review corresponding literature provided by a pharmacist.

Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patients symptoms and other tests performed.

Interpretation of L/S Ratio: L/S ratio values, as related to fetal lung maturity, are divided into three categories: immature, transitional, and mature. A L/S ratio of < 1.5 indicates that the lungs are immature. The fetus is not producing enough surfactant. Infants delivered with a L/S ratio < 1.5 have a high risk of respiratory distress syndrome. A L/S ratio between 1.5 and 1.9 indicates a transitional situation. The lungs are on the threshold of maturity. Lung maturity is expected within 2 weeks. A L/S ratio of 2 is the commonly accepted standard value indicating lung maturity in the fetus. Infants delivered after attaining an L/S ratio of 2.0 or higher rarely develop RDS.

3 Causes of Erroneous Results Diabetes mellitus can result in a falsely elevated L/S ratio. The result will suggests the lung is more mature then it really is. Meconium is fetal waste inside the amniotic fluid. Meconium will make amniotic fluid samples appear yellow/green. Meconium in the sample can result in a falsely decreased L/S ratio. The result will suggest the lung is less mature then it really is. Blood contains phospholipids including lecithin and sphingomyelin. Thus, contamination of amniotic fluid with blood will affect the L/S ratio. Contaminating blood can increase

low amniotic fluid L/S ratios and lower high amniotic fluid L/S ratios. The degree of change is dependant on the level of contamination.

Reference http://katiebird.hubpages.com/hub/The-Lecithin-Sphingomyelin-RatioEvaluating-Fetal-Lung-Maturity http://www.unboundmedicine.com/nursingcentral/ub/view/Davis-Lab-andDiagnostic-Tests/425366/6/lecithin_sphingomyelin_ratio_

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