Meconium Aspiration

Meconium-stained amniotic fluid is found in 10–15% of births and usually occurs in term or postterm
infants. Meconium aspiration syndrome (MAS) develops in 5% of such infants; 30% require
mechanical ventilation, and 3–5% die. Usually, but not invariably, fetal distress and hypoxia occur
before the passage of meconium into amniotic fluid. The infants are meconium stained and may be
depressed and require resuscitation at birth. Fig. 122.8 shows the pathophysiology of the MAS.
Infants with MAS are at increased risk of persistent pulmonary hypertension (see Chapter 122.9).

CLINICAL MANIFESTATIONS

Either in utero or with the first breath, thick, particulate meconium is aspirated into the lungs. The
resulting small airway obstruction may produce respiratory distress within the 1st hours, with
tachypnea, retractions, grunting, and cyanosis observed in severely affected infants. Partial
obstruction of some airways may lead to pneumomediastinum, pneumothorax, or both. Over
distention of the chest may be prominent. The condition usually improves within 72 hr, but when its
course requires assisted ventilation, it may be severe with a high risk for mortality. Tachypnea may
persist for many days or even several weeks. The typical chest radiograph is characterized by patchy
infiltrates, coarse streaking of both lung fields, increased anteroposterior diameter, and flattening of
the diaphragm. A normal chest radiograph in an infant with severe hypoxemia and no cardiac
malformation suggests the diagnosis of pulmonary hypertension.

PREVENTION

The risk of meconium aspiration may be decreased by rapid identification of fetal distress and
initiation of prompt delivery in the presence of late fatal heart rate deceleration or poor beat-to-
beat FHR variability. Despite initial enthusiasm for amnio infusion, it does not reduce the risk of
MAS, cesarean delivery, or other major indicators of maternal or neonatal desmorbidity.
Intrapartum nasopharyngeal suctioning in infants with meconium-stained amniotic fluid does not
reduce the risk for MAS. Routine intubation and aspiration of depressed infants (those with
hypotonia, bradycardia, or decreased respiratory effort) born through meconium-stained fluid is not
effective in reducing the MAS or other major adverse outcomes and is not recommended for
neonatal resuscitation.

TREATMENT

Treatment of the MAS includes supportive care and standard management for respiratory distress.
The beneficial effect of mean airway pressure on oxygenation must be weighed against the risk of
pneumothorax. Administration of exogenous surfactant and/or iNO to infants with MAS and
hypoxemic respiratory failure, or pulmonary hypertension