MECONIUM ASPIRATION
INTRODUCTION
Meconium is thick , pasty, greenish- black substance that is present in the fetal bowel,
which is first stool passed by new born.
Meconium is typically passed for 2-3 days after birth.
Sometimes, the fetus passes the meconium while it is still in the womb.
Meconium consists of bile, intestinal secretions, amniotic fluid, lanugo, mucus.
DEFINITION
Meconium Aspiration Syndrome is a serious medical condition where neonates born to
mother with thick or thin meconium stained liqor aspirate the meconium into the lungs and
develop respiratory distress.
INCIDENCE
It occurs approximately in 8-15% of live births.
Approximately 5% of neonates born through meconium stained amniotic fluid
develop MAS OF MEC stained infants:
30 % depressed at birth
10 % meconium aspiration syndrome (range 2-36 %)
OF infants with MEC aspiration syndrome
17 % deliver through thin meconium (range 7-35 %) 35 % need mechanical ventilation
(range 25-60 %)
12 % die (range 5-37 %)
Frequency of Mec stained amniotic fluid = 10-25%
ETIOLOGY OR CAUSES
Hypoxia in distressed baby
Meconium Stained Liqor
Uterine Infections
Difficulty during labour process
RISK FACTORS
Post maturity
Prolonged and obstructed delivery
Maternal hypertension or diabetes mellitus
Placental dysfunction and infection like chorioamnitis
Intra uterine growth retardation
Umbilical cord complications
Ageing of placenta
Intrauterine fetal hypoxia
Maternal heavy smoking
Oligohydraminous
Pre eclampsia and eclampsia
PATHOPHYSIOLOGY
PASSAGE Of MECONIUM IN UTERO:MSAFeconium stained aminiotic fluid)may
result from of post – term fetus with rising motilin levels and normal gastrointestinal
function ,vagal stimulation produced by cord or head compression ,or in utero fetal
stress.
ASPIRATION OF MECONIUM:In the presence of fetal stress ,gasping by the fetus
can result in aspiration of meconium before,during or immediately following
delivery.Severe MAS appears to be caused by pathologic intrauterine processes
,primarily chronic hypoxia ,acidosis ,and infection .
EFFECTS OF MECONIUM ASPIRATION: When aspirated into the lungs
,meconium may stimulate the release of cytokines and vasoactive substances that
result in cardiovascular and inflammatory responses in the fetus and newborn
.Meconium its self ,or the resultant chemical pneumonitis,mechanically obstructs the
small airways,causes atelectasis and a “ball-valve” effect with resultant air trapping
and possible air leak.Aspirated meconium leads to vasospasm,hypertrophy of the
pulmonary arterial musculature,and pulmonary hypertension that lead to extra
pulmonary right- to –left shunting through the ductus arteriosus or the foramen ovale
and results in worsened ventilation – perfusion(v/Q)mismatch ,leading to severe
arterial hypoxemia .Aspirated meconium also inhibits surfactant function.
CLINICAL FEATURES
Difficulty in breathing
Cyanosis
End expiratory grunting
Greenish appearance of amniotic fluid
Intercoastal retraction
Tachypnea, flaring
Barrel chest(increased anteroposterior diameter due to presence of air trapping
Auscultated rales and rhonchi (in some cases)
Yellow green staining of finger nail,umbilical cord and skin may be observed
Grunting
Arterial PO2 may be low
If hypoxia metabolic acidosis is present
Pulmonary edema
DIAGNOSTIC EVALUATION
Before birth the fetal monitor may show bradycardia
During delivery or at birth ,meconium can be seen in the amniotic fluid and on the
infant.
Low APGAR score after birth
Physical examination: lungs sound (coarse, crackly sound)
Blood gas analysis: low blood acidity ,decreased oxygen and increased carbon
dioxide.
Chest x-ray may show patchy or streaky areas in lungs.
Urine colour may appear dark brown.
MANAGEMENT OF INFANT DELIVERED THROUGH MECONIUM-STAINED
FLUID INITIAL ASSESSMENT-At a delivery complicated by MSAF determine whether
the infant is vigorous, demonstrated by:
heart rate more than 100 beats/min spontaneous respiration
good tone(spontaneous movement or some degree of flexion).
If the infant appears vigorous,routine care should be provided,regardless of the
consistency of the meconium.
Initiate suctioning as soon as the baby is delivered.
If the baby has continuous breathing problem, continue suctioning using laryngoscope
The infant should be placed on a radiant warmer and given free flow oxygen.
Delay drying and stimulation and postpone emptying of any gastric contents until the
infant has stabilized.
Intubation should be done under direct laryngoscopy before inspiratory efforts have
been initiated.
Avoid positive pressure ventilation if possible until tracheal suctioning is
accomplished.
Do NOT perform the following harmful techniques in an attempt to prevent aspiration of
meconium-stained amniotic fluid:
Squeezing the chest of the baby
Inserting a finger into the mouth of the baby
MANAGEMENT OF MECONIUM ASPIRATION
Observation:
o Baby born with meconium stained liqor requires close observation for the
assessment of respiratory distress.
o A chest radiograph may be helpful to determine signs of respiratory distress.
o Monitoring of oxygen during this period helps to assess severity of infant’s
condition and avoids hypoxemia.
Routine care:
o neutral thermal environment should be maintained with minimum of tactile
stimulation.
o Blood glucose and calcium level should be monitored and corrected if
necessary.
o Fluid should be restricted as far as possible to prevent cerebral and pulmonary
edema.
o Special therapy for hypotension and poor cardiac output is required including
cardiotonic medicines such as dopamine.
o Circulatory support with normal saline or packed redblood cells should be
provided in patients with marginal oxygenation.(Hb above 15g and
haematocrit above 40% should be maintained)
o Renal function should be continuously monitored.
Oxygen therapy:Hypoxia should be managed by increasing inspired oxygen
concerntration and monitoring of blood gases and PH.
Asissted Ventilation:
o Continuous Positive Airway Pressure(CPAP)
o Mechanical ventilation
Medications:
o Antibiotics(ampicillin, gentamicin).
o Surfactants
o Corticosteroids
Guidelines for management of meconium aspiration
The American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee
and the American Heart Association’s current guidelines are as follows:
If the baby is not vigorous
Use direct laryngoscopy, intubate and suction the trachea immediately after delivery.
Suction for no longer than 5 seconds.
If no meconium is retrieved, do not repeat intubation and suction.
If meconium is retrieved and no bradycardia is present, reintubate and suction.
If the heart rate is low, administer positive pressure ventilation and consider
suctioning again later.
If the baby is vigorous
Do not electively intubate.
Clear secretions and meconium from the mouth and nose with a bulb syringe or a
large-bore suction catheter.
NURSING INTERVENTIONS
In both cases, the remainder of the initial resuscitation steps should ensure, including
drying, stimulating, repositioning and administering oxygen as necessary.
During labor, continuously monitor the fetus for signs and symptoms of distress.
Immediately inspect any fluid passed with rupture of the membrane.
Assist with immediate endotracheal suctioning before the first breaths, as indicated.
Monitor lung status closely, including breath sounds and respiratory rate and
character.
Frequently assess the neonate’s vital signs.
Administer oxygen and respiratory support as ordered.
Warm and humidify oxygen
Institute measures to maintain a neutral thermal environment
Provide the family with emotional support and guidance.
Interventions for thermo regulation
Place warm blankets on scales, x-ray plates, or other surfaces in contact with the baby
Warm blankets and clothing before use
Preheat incubators, radiant warmers, heat shield
Maintain room temperature at levels adequate to provide a safe thermal environment
for neonate
PREVENTION OF MAS
ANTEPARTUM PERIOD: Women should be carefully monitored during pregnancy
and should be encouraged for hospital delivery.
INTRAPARTUM PERIOD: Fetal heart rate should be monitored every half an hourly
to determined the sign of fetal distress and Babies born to mother with meconium
stained liqor should have oropharyngeal suction before the delivery of shoulder.
AMNIOINFUSION
TIMING AND MODE OF DELIVERY: Pregnancy that crosses the date should be
induced as early as 41weeks which helps to prevent MAS by avoiding passage of
meconium .Delivery mode does not appear to significantly impact the risk of
aspiration.
PROGNOSIS
Recovery usually occurs within 3-5days but tachypnea may persist for a longer period
Prognosis depends on frequent accompanying of asphyxia insult rather than severity
of pulmonary disease
Mortality rate is as high as 50%if PPHN(Persistant Pulmonary Hypertension of
neonates) is present.
Residual problem is rare but cough, wheezing and persistent hyperinflation may
extend upto 5-10years.
50%of MAS cases require mechanical ventilation out of which 60- 70%neonate
survive.
Its mortality rate is 3-5%.
COMPLICATION
Pneumothorax(15-33%)
Massive atelectasis
Obstructive emphysema leading to pneumothorax
Pneumopericardium
Pneumomediastinum(15-33%)
Persistent pulmonary hypertension in neonates ( one third of cases)
If prolonged assisted ventilation , bronchopulmonary dysplasia
Meconium aspiration pneumonia 5%.
Other Things to Watch For
Hypoxia
Acidosis
Hypoglycemia
Hypocalcemia
End-organ damage due to perinatal asphyxia
