`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