Etiology

Small Gestational Age (SGA), Meconium Aspiration Syndrome (MAS), and Respiratory Distress Syndrome (RDS)
are distinct conditions impacting neonates, each characterized by specific etiological factors. SGA, delineated by birth
weight below the 10th percentile for gestational age, can arise from intrauterine growth restriction (IUGR) stemming from
maternal malnutrition, placental insufficiency, or chronic maternal conditions. Additionally, genetic factors and maternal
behaviors, such as smoking or substance use during pregnancy, contribute to the manifestation of SGA. MAS,
characterized by neonatal inhalation of meconium, leading to respiratory distress, has multifaceted origins. Fetal distress
during labor prompts the release of meconium into the amniotic fluid, while post-term pregnancies elevate the risk of
meconium passage before birth. Maternal conditions such as hypertension, diabetes, or infections, as well as
compromised blood flow to the placenta, further contribute to the development of MAS.RDS, a respiratory disorder
primarily afflicting premature infants, is intricately linked to inadequate surfactant production. Prematurity, wherein
surfactant production is not yet optimal, stands as a prominent causative factor. Maternal diabetes can also induce a delay
in surfactant production, and infants delivered via Cesarean section without the initiation of labor may present with
underdeveloped lungs. Multiple pregnancies and male gender are additional elements associated with an increased
susceptibility to RDS. These conditions collectively underscore the complexity of neonatal health, necessitating a
comprehensive understanding of genetic, environmental, and maternal influences. Timely prenatal care, early
identification, and judicious medical interventions are imperative for managing these conditions and enhancing outcomes
for affected infants within the realm of perinatal care. Patient R, a 35-year-old woman with a history of obesity, diabetes,
and asthma, faced obstetric challenges in previous pregnancies, including an oversized baby, meconium passage, and a
neonate at risk for respiratory distress syndrome. Her current pregnancy involved fetal bradycardia, necessitating
resuscitation and resulting in a 30-week gestational age neonate diagnosed with Meconium Aspiration Syndrome and
Respiratory Distress Syndrome. The complexity is heightened by Regina's suspected COVID-19 status.

Predisposing Present Justification

Factors

Intrauterine check Infants born with fetal growth restriction,

Growth characterized by being small for gestational age
Restriction-SGA (FGR SGA), face elevated risks of both short-term
and long-term complications, as well as an increased
likelihood of mortality. Factors such as maternal
hypertension, kidney disease, infections, malnutrition,
smoking, and substance abuse contribute to a
heightened risk of delivering an infant with FGR SGA
(Osuchukwu and Reed, 2022).

Maternal check Factors contributing to fetal malnutrition (FM) in

Factors-SGA mothers encompass unfavorable age, being a
first-time mother, low pre-pregnancy weight and
height, a problematic obstetric history, and the
presence of pregnancy-induced hypertension.
 Relying solely on intrauterine growth curves for
evaluation might lead to overlooking malnutrition in
the newborn (IGM Publication, 2020).

Placental x Placental insufficiency is linked to a decrease in

Insufficiency-SGA blood flow through the umbilical cord to the fetus,
often due to heightened resistance in the
umbilical-placental vascular system. This elevated
resistance is observable through atypical wave
patterns in umbilical artery Doppler flow velocity and
may result from issues such as irregular villi insertion
into the placental membrane, disturbances in
perfusion between the umbilical cord and placenta, or
a decrease in blood flow from the uterus to the
placenta (Ambati and Wardinger, 2022).

Multiple check Multiple gestation births exhibit elevated mortality

Pregnancies-SGA rates and extended length of hospital stays (LOS) in
comparison to singleton births. Despite adjustments
for baseline characteristics, multiple gestation births
persistently face increased risks of various
 morbidities and mortality when contrasted with
singletons. Additionally, the LOS for multiple
gestation births surpasses that of singletons at a
similar gestational age (GA), (Klar, Patel, and
Thekkeveedu, 2021).

Fetal check Meconium aspiration syndrome (MAS) commonly

Distress-MAS arises due to fetal distress and post-term delivery.
Additionally, it is linked to factors such as
small-for-gestational-age infants, complications with
the umbilical cord, chronic medical conditions, and
inadequate intrauterine growth (MSD MANUAL,
2024)

Post-Term check Meconium Aspiration Syndrome (MAS) diagnosis

Pregnancy-MAS involves considering maternal history (term/post-term
pregnancy, perinatal distress, MSAF), clinical signs
(meconium-stained skin, respiratory distress), and
chest X-ray findings (pulmonary hyperinflation,
patchy infiltrates, increased transparency areas).

Premature check Premature birth is closely linked to Respiratory

Birth-RDS Distress Syndrome (RDS) primarily due to the
 insufficient production of surfactants in premature
infants. Surfactant, a substance crucial for
maintaining lung expansion and facilitating breathing,
is typically produced in the later stages of pregnancy,
particularly in the third trimester. Premature infants,
however, are born with underdeveloped lungs,
lacking adequate surfactant levels. This deficiency
leads to collapsed air sacs (alveoli) after each breath,
making breathing difficult. Furthermore, premature
birth often results in structural immaturity of the
lungs, decreased lung compliance, and an increased
risk of lung injury, further exacerbating the
susceptibility to RDS (Smith and Johnson, 2021)

Lack of check The absence of surfactant leads to respiratory failure

Surfactant-RDS due to complications such as collapsed alveoli
(atelectasis), flooding of the alveoli, and severe
oxygen deprivation (hypoxemia). With the
introduction of exogenous surfactant replacement
therapy, mortality rates associated with respiratory
distress syndrome in newborns have decreased by
more than half. (Amigoni, Circelli, Pettenazzo,
 Stritoni, 2017).

Male Gender-RDS check Recent findings indicate that male infants are at a
higher risk of developing term neonatal respiratory
distress syndrome (RDS) compared to females, with
a relative risk of 2.641 times higher. This gender
disparity is attributed to delayed surfactant production
in male fetal lungs, likely influenced by hormonal
factors such as androgens inhibiting
fibroblast-pneumocyte factor secretion and
estrogen-promoting surfactant synthesis and lung
development. (Liu, J., Yang, N., & Liu, Y., 2014).

Previous Obstetric check A comprehensive obstetric assessment is essential

History to detect SGA risk factors. While constitutionally
small SGA fetuses may not exhibit maternal
symptoms, pre-eclampsia markedly increases the
likelihood of SGA. While pre-eclampsia can be
asymptomatic and diagnosed through routine tests,
symptoms such as severe headache and sudden
swelling may also manifest (Pidd, 2021).
Family Health check A significant proportion of infants born small for
History gestational age (SGA) often have a family history of
SGA, with maternal relatives showing a higher
incidence compared to paternal relatives. This study
revealed that 22% of parental siblings were SGA,
further suggesting a potential genetic influence in the
transmission of the SGA trait. In clinical settings,
obtaining a detailed familial birthweight history,
particularly focusing on maternal relatives, can
provide valuable insights when counseling parents
about a growth-restricted fetus of unknown cause.
This approach may not only aid in reducing parental
anxiety but also assist in better understanding the
underlying factors contributing to SGA (Barzali,
Bronshhtein, Gover, Steinberg, and Weiner, 2022).

Precipitating Present Justification

Factors

Premature Birth- check Infants with fetal growth restriction (FGR) and small
SGA for gestational age (SGA) are at risk of various

perinatal complications, including prematurity,

 perinatal asphyxia, impaired thermoregulation,

hypoglycemia, polycythemia, impaired immune

function, and hypocalcemia. Prematurely born FGR

SGA infants are particularly vulnerable to mortality

and complications such as necrotizing enterocolitis,

respiratory distress syndrome, retinopathy of

prematurity, and bronchopulmonary dysplasia

(Osuchukwu, and Reed, 2022).

Maternal Health check Maternal health issues, spanning pregnancy,

Issues- SGA childbirth, and postpartum, significantly impact both
mothers and children. Factors like limited healthcare
access contribute to adverse outcomes such as
maternal mortality and complications like hemorrhage
and sepsis. Addressing these issues requires
improving healthcare access, promoting maternal
nutrition and hygiene, and tackling social
determinants of health (Word Hleath Organization,
2019).
Placental X Placental issues, such as insufficiency, dysfunction
Problems- SGA (e.g., due to conditions like preeclampsia or
gestational diabetes), and abnormalities (e.g.,
placenta previa or infarctions), can impede fetal
nourishment, leading to intrauterine growth restriction
(IUGR) and Small for Gestational Age (SGA) infants,
highlighting the importance of early detection and
management for favorable pregnancy outcomes
(Bhide, Prefumo, Hollis, and Thilanganathan, 2015).

Inhalation of CHECK The inhalation of meconium-stained amniotic fluid

meconium-stained (MSAF) during labor and delivery is closely related to
amniotic fluid the development of meconium aspiration syndrome
during labor and (MAS) in newborns. MAS occurs when the fetus
delivery -MAS inhales meconium, its first stool, usually due to fetal
distress or hypoxia. When meconium enters the
lungs, it can block airways, causing respiratory
distress and inflammation, potentially leading to
severe complications such as pneumonia and
respiratory failure (De Luca, van Kaam, Tingay,
Courtney, Danhaive, Carnielli, and Zimmermann,
2017).
Aspiration of CHECK Aspiring meconium into the airways can cause
meconium into the airway blockage and respiratory complications,
airways, leading
disrupting lung function and leading to meconium
to airway
aspiration syndrome (MAS). Meconium, the initial
obstruction and
fetal stool, is a thick substance that can obstruct air
respiratory issues
-MAS passages, trigger inflammation, and result in

chemical pneumonitis, ultimately causing respiratory

distress (Narang, Kumar, P., Kumar, R., 2021).

Premature CHECK Premature rupture of membranes (PROM) increases

Rupture of the likelihood of respiratory distress syndrome (RDS)
Membranes-RDS in newborns. When the amniotic sac ruptures early, it
may lead to reduced levels of surfactant in the lungs,
which is crucial for lung maturity, thereby increasing
the risk of RDS in premature infants (Lee, and Yang,
2018).

Maternal check Maternal diabetes can influence the occurrence of

Diabetes-RDS respiratory distress syndrome (RDS) in newborns,
impacting pregnancy outcomes. Elevated blood
sugar levels in diabetic mothers can induce fetal
 hyperinsulinemia, which suppresses the production
of pulmonary surfactant in fetal lungs, increasing the
susceptibility to RDS (Ye, Zhang, and Zhao, 2019).

COVID-19 CHECK Maternal COVID-19 suspicion, virus can pose risks to

Suspect Status both maternal and fetal health, potentially affecting
gestational outcomes between March 5, 2020, and
July 4, 2021, out of 73,666 pregnant individuals, 882
tested positive for SARS-CoV-2 during pregnancy.
This infection increased the risk of preterm delivery
and stillbirth, especially in the first and second
trimesters. The timing of infection correlated with
gestational age at delivery, but the severity of
COVID-19 symptoms did not affect delivery timing
(Hadlock, Hood, Hwang, Piekos, Price, Roper, and
Sorensen, 2022).