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Meconium Aspiration Syndrome
Meconium Aspiration Syndrome
Causes
Meconium is the early feces (stool) passed by a newborn soon after
birth. It is passed from the body before the baby has started to digest
breast milk (or formula).
In some cases, the baby passes meconium while still inside the uterus.
This will happen when babies are "under stress" because their supply of
blood and oxygen decreases. This is often due to problems with the
placenta or the umbilical cord.
Once the meconium has passed into the surrounding amniotic fluid, the
baby may breathe meconium into the lungs. This may happen while the
baby is still in the uterus, or still covered by amniotic fluid after birth.
The meconium can also block the infant's airways right after birth.
Risk factors that may cause stress on the baby before birth include:
"Aging" of the placenta if the pregnancy goes far past the due date
Decreased oxygen to the infant while in the uterus
Diabetes in the pregnant mother
Difficult delivery or long labor
High blood pressure in the pregnant mother
Symptoms
Some babies do not breathe the meconium fluid into their lungs during
labor and delivery. They are unlikely to have any symptoms or
problems.
The infant may need help with breathing or heartbeat right after birth,
and may have a low Apgarscore.
The health care team will listen to the infant's chest with a stethoscope
and may hear abnormal breath sounds, especially coarse, crackly sounds.
A blood gas analysis will show low (acidic) blood pH, decreased
oxygen, and increased carbon dioxide.
A chest x-ray may show patchy or streaky areas in the infant's lungs.
Treatment
A special care team should be present when the baby is born if traces of
meconium are found in the amniotic fluid. This happens in more than
10% of normal pregnancies. If the baby is active and crying, no
treatment is needed.
If the baby is not active and crying right after delivery, a tube is placed
in the infant's airway by a nurse, therapist, or doctor. Suction is used to
remove any meconium. This procedure may be repeated more than once.
Only about half of babies with meconium stained fluid will have
breathing problems and only about 5% will have MAS.
Breathing problems may be more severe in some cases. These will
often go away in 2 to 4 days. However, rapid breathing may continue for
several days.
MAS rarely leads to permanent lung damage.
Meconium may be present at birth in the amniotic fluid because there is
a serious problem with the blood flow to and from the lungs. This is
called persistent pulmonary hypertension of the newborn (PPHN).
Prevention
Staying healthy during pregnancy and following your health care
provider's advice can often prevent problems that lead to meconium
being present.
Your providers will want to be prepared for meconium being present at
birth if:
Your water broke at home and the fluid was clear or stained with a
greenish or brown substance.
Any testing done during your pregnancy indicates there may be
problems present.
Fetal monitoring shows any signs of fetal distress can be found
early.
Alternative Names
MAS; Meconium pneumonitis (inflammation of the lungs); Labor -
meconium; Delivery - meconium; Neonatal - meconium; Newborn care -
meconium
However, in some cases the meconium is passed when the baby is still in
the womb, staining the amniotic fluid. This can vary from light to heavy
staining. It is considered significant if dark green or black, with a thick,
tenacious appearance.
Components of the meconium, especially the bile salts and enzymes, can
cause serious complications if they are inhaled by the fetus at any stage
of labour. This can result in meconium aspiration syndrome (MAS).
There are several pathological mechanisms participating in MAS,
particularly airway obstruction, surfactant dysfunction, inflammation,
lung oedema, pulmonary vasoconstriction and bronchoconstriction.[1]
Epidemiology
The figure quoted for infants born with meconium-stained liquor in the
industrialised world is 8-25% of births after 34 weeks of gestation. MAS
occurs in around 1-3% of live births.[2]
Placental insufficiency.
Oligohydramnios.
Smoking.
Cocaine abuse.
Management
These recommendations are from the National Institute for Health and
Care Excellence (NICE), 2014.[5]
Intrapartum
Complications
This occurs where the fetal circulation persists with blood being
shunted away from the lungs through the foramen ovale and a patent
ductus arteriosus.
It is a consequence of raised pulmonary vascular resistance.
Clinical features include cyanosis, tachypnoea and the murmur of
patent ductus arteriosus.
Treatment[7]
This includes:
Prostacyclin infusion.
Prognosis
Prevention
Mechanism
The pathophysiology of MAS is due to a combination of primary
surfactant deficiency and surfactant inactivation as a result of plasma
proteins leaking into the airways from areas of epithelial disruption and
injury.
The leading three causes of MAS are:
-Due to physiologic maturational event,
A response to acute hypoxic events, and
A response to chronic intrauterine hypoxia.
If an infant inhales this mixture before, during, or after birth, it may be
sucked deep into the lungs.
Three main problems occur if this happens:
-the material may block the airways
efficiency of gas exchange in the lungs is lowered
the meconium-tainted fluid is irritating, inflaming airways (pneumonitis)
and possibly leading to chemical pneumonia.
These can lead to significant morbidity and mortality if severe enough.
Diagnosis
High risk infants may be identified by fetal tachycardia, bradycardia or
absence of fetal accelerations upon CTG in utero, at birth the infant may
look cachexic and show signs of yellowish meconium staining on skin,
nail and the umbillical cord, these infants usually progress onto Infant
Respiratory distress syndrome within 4 hours. Investigations which can
confirm the diagnosis are fetal chest x-ray, which will show
hyperinflation, diaphragmatic flattening, cardiomegaly, patchy
atelectasis and consolidation, and ABG samples, which will show
decreased oxygen levels.
Prevention
MAS is difficult to prevent.[citation needed] Amnioinfusion, a method
of thinning thick meconium that has passed into the amniotic fluid
through pumping of sterile fluid into the amniotic fluid, has not shown a
benefit.[6][7]
Treatment
Surfactant appears to improve outcomes when given to infants follow
meconium aspiration.
It has been recommended that the throat and nose of the baby be
suctioned as soon as the head is delivered. However, this is not really
useful and the revised Neonatal Resuscitation Guidelines no longer
recommend it. citation needed] When meconium staining of the amniotic
fluid is present and the baby is born depressed, it is recommended that
an individual trained in neonatal intubation use a laryngoscope and
endotracheal tube to suction meconium from below the vocal cords.
[citation needed] If the condition worsens, extracorporeal membrane
oxygenation (ECMO) can be useful.
Albumin-lavage has not demonstrated to benefit outcomes of MAS.
Steroid use has not demonstrated to benefit the outcomes of MAS.
Prognosis
The mortality rate of meconium-stained infants is considerably higher
than that of non-stained infants; meconium aspiration used to account
for a significant proportion of neonatal deaths. Residual lung problems
are rare but include symptomatic cough, wheezing, and persistent
hyperinflation for up to five to ten years. The ultimate prognosis depends
on the extent of CNS injury from asphyxia and the presence of
associated problems such as pulmonary hypertension. Fifty percent of
newborns affected by meconium aspiration would die fifteen years ago;
however, today the percent has dropped to about twenty.
Epidemiology
In a study conducted between 1995 and 2002, MAS occurred in 1,061 of
2,490,862 live births, reflecting an incidence of 0.43 of 1,000. MAS
requiring intubation occurs at higher rates in pregnancies beyond 40
weeks. 34% of all MAS cases born after 40 weeks required intubation
compared to 16% prior to 40 weeks.