OSPITAL NG MAYNILA MEDICAL

CENTER
DEPARTMENT OF PEDIATRICS
NEONATAL INTENSIVE CARE UNIT

MECONIUM
ASPIRATION
By: JI GRACE ANTONETTE PATI

OUTLINE:
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Definition
Epidemiology
Etiology
Pathophysiology
Clinical features
Differential Diagnosis
Diagnosis
Management
Prognosis

MECONIUM
ASPIRATION
Prolonged labor, post term, difficult deliveries
fetus initiate vigorous respiratory movement in utero
(interference with the supply of oxygen through the
placenta)
Aspiration of amniotic fluid

(may contain vernix caseosa, epithelial cells,

meconium, blood, or material from the birth
canal)

block the smallest airways and interfere with alveolar

exchange of oxygen and carbon dioxide

-Nelson 19th ed

MECONIUM ASPIRATION
PNEUMONIA
fetus initiate vigorous respiratory movement in utero
(interference with the supply of oxygen through the
placenta)
Aspiration of amniotic fluid

(may contain vernix caseosa, epithelial cells,

meconium, blood, or material from the birth
canal)

Pathogenic bacteria may accompany the aspirated

material
Pneumonia
may ensue

-Nelson 19th ed

MECONIUM ASPIRATION
SYNDROME
is a respiratory distress in an infant born through
meconium stained amniotic fluid whose
symptoms cannot be otherwise explained
Meconium found below vocal cord defines MAS

(Cajal & Martinez, 2003)

EPIDEMIOLOGY
MECONIUM ASPIRATION SYNDROME

Observed in (8-20)% of all births

Occurs in 5% of newborns delivered through
MSAF
disease of Term or Post-term Infant

(Cajal & Martinez, 2003)

MECONIUM
Meconium, Description of

pH of meconium : 5.5-7.0
Sterile, viscous, dark green, odorless substance
Light amniotic fluid thinly
stained
Moderate opaque without
particles
Thick pea soup particles

(Cajal & Martinez, 2003)

MECONIUM
Meconium, Composition of

75-80% water
Epithelial cells
Fetal hair
Mucus
Bile
Fatty material from vernix caseosa

(Cajal & Martinez, 2003)

MECONIUM
Meconium, Physiology of

Fetal ileum between the 10th and 16th week of

gestation
In utero passage of meconium uncommon due
to :
lack of strong peristalsis (low motilin level)
good anal sphinter
a cap of viscious meconium in the rectum

(Klinger & Kruse, 1999)

MECONIUM
Meconium, Physiology of

Meconium passage uncommon before 36

weeks but occurs more than 30% beyond
42 weeks due to :
Fetal maturation post term (high motilin
level)
In utero stress (hypoxia, acidosis)
Relaxation of anal sphincter

(Klinger & Kruse, 1999)

MECONIUM ASPIRATION
SYNDROME

Meconium Aspiration Syndrome, RISK FACTORS

of

Maternal Hypertension
Maternal DM
Maternal heavy cigarette smoking
Maternal chronic respiratory or Cardio vascular
disease
Post term pregnancy
Pre-eclampsia/eclampsia
Oligohydramnios
IUGR
Abnormal fetal HR pattern

(Klinger & Kruse, 1999)

PATHOPHYSIOLOGY
Meconium Aspiration Syndrome,
Pathophysiology of
Physiological meconium
passage

Fetal Distress

Intrauterine Gasping

Meconium stained amniotic

fluid

Meconium Aspiration

Mechanical Obstruction
Chemical Pneumonitis
Surfactant Inactivation
Pulmonary Hypertensi
(Fanaroff, 2008)

PATHOPHYSIOLOGY
Meconium Aspiration Syndrome,
Pathophysiology of

Thick and viscous meconium

Mechanical Obstruction of central airways (trachea

& main bronchi)
With onset of respiration meconium migrates from
central to peripheral airways
COMPLETE
ATELECTASIS
V/Q Mismatch (dec.)

eolar collapse

PARTIAL
BALVE VALVE EFFECT
Air Trapping & Air leaks
(risk of penumothorax 15-33%)
HYPOXEMIA
HYPERCAPNIA
overdistention
ACIDOCIS

(Fanaroff, 2008)

PATHOPHYSIOLOGY
Meconium Aspiration Syndrome,
Pathophysiology of
2) CHEMICAL PNEUMONITIS
inflammation of the central to distal airways progressive
hyperreactivity bronchiolar edema and narrowing of the
small airway
3) SURFACTANT INACTIVATION
Bilirubin, fatty acid, triglycerides, cholestrol content
of meconium inhibit surfactant function and
inactivation
4) PULMONARY HYPERTENSION
Meconium stimulates proinflammatory cytokines and
vasoactive substance
pulmonary vasoconstriction
Hypoxia, acidosis, hyperinflation
pulmonary hypertension

(Fanaroff, 2008)

CLINICAL FEATURES
Meconium Aspiration Syndrome, Clinical
Features of
HISTORY
term, posterm
History of MSAF
Depressed at birth

PHYSICAL EXAMINATION
POSTMATURE: Peeling skin, long fingernails,
Reduced vernix
Umbilical cord, Nails and Vernix are meconium
stained
o Nails after 6 hrs
o Vernix 12-14 hrs
o umbilical cord staining thick 15 min, thin
1 hour

CLINICAL FEATURES
Meconium Aspiration Syndrome, Clinical
Features of
PHYSICAL EXAMINATION

Respiratory distress tachypnea and cyanosis

Use of accessory muscles of respiration Intercostal
and subcostal retractions & abdominal breathing) ,
grunting and nasal flaring
Chest : appears barrel shape with increase AP diameter
due to overinflation
Auscultation : Rhonchi immmediately after birth

CLINICAL FEATURES
Meconium Aspiration Syndrome, Clinical
Features of
PHYSICAL EXAMINATION

Sign of cerebral irritation from cerebral edema or

hypoxia : jitteriness, seizures
Asymptomatic at birth and develop worsening signs of
respiratory distress as the meconium moves from large
airways into the lower tracheobronchial tree

DIFFERENTIAL DIAGNOSES
Meconium Aspiration Syndrome, Differential
Diagnoses for

Perinatal Asphyxia
Bacterial Pneumonia
Respiratory Distress Syndrome
Transient Tachypnea Of Newborn
Congenital Heart Disease

MECONIUM ASPIRATION
SYNDROME

MAS must be considered in any infant born through

MSAF who:
develops symptoms of Respiratory Distress
and/or with
typical chest x ray findings

MECONIUM ASPIRATION
SYNDROME

A chest radiographs shows hyperinflation of the

lung field and flatten diaphragm
Coarse irregular patchy infiltrates
Pneumothorax and pneumomediastinum may be
present

RADIOGRAPHIC FINDINGS

hyperinflation of the lung

field and flatten diagphragms
Diffuse, Coarse irregular
patchy infiltrates (areas of
consolidation)
Air trapping and
hyperexpansion due to
airway obstruction

( Cleary GM & Wiswell TE,

1998)

RADIOGRAPHIC FINDINGS

Areas of opacification d/t

atelectasis

( Cleary GM & Wiswell TE,

1998)

RADIOGRAPHIC FINDINGS

Diffuse chemical pneumonitis

( Cleary GM & Wiswell TE,

1998)

LABORATORY AND DIAGNOSTIC

INVESTIGATIONS

Arterial blood gas hypoxemia and hypercarbia.

Echocardiogram for evaluation of PPH

MANAGEMENT
Meconium Aspiration Syndrome, Management
for

Prenatal management: Key management lies in prevention

during prenatal period
o Identification of high risk pregnancies and close
monitoring.
o Pregnancy that continue past due date, induction as early
as 41 weeks
Sign of fetal distress infant should be delivered in timely
manner.

MANAGEMENT
Meconium Aspiration Syndrome, Management
for

All infants delivered through MSAF

Assess 10-15 seconds after delivery

Vigorous activity:
HR >100bpm
Spontaneous respirations
Tone: Spontaneous
movement, some flexion

May proceed to EINC

Non-vigorous activity

Intubate
Tracheal Suction

MANAGEMENT
Meconium Aspiration Syndrome, Management
for

Klingner M.C., Kruse, J.1999.J Am Board Fam Prac. 12:450-66

MANAGEMENT
Meconium Aspiration Syndrome, Management
for
When APPARENTLY WELL CHILD born through MSAF:
Most of them do not require any interventions
besides close monitoring for RD.
Most infants who develop symptoms will do so in
the first 12 hours of life

MANAGEMENT
Meconium Aspiration Syndrome, Management
for
When INFANT is NOT VIGOROUS:
Clear airways as quickly as possible
Free flow 02
Radiant warmer but drying and stimulation should be
delayed
Direct laryngoscopy with suction of the mouth and
hypopharynx under direct visualization, followed by
intubation and then suction directly to the ET tube
The process is repeated until either little additional
meconium is recovered, or until the babys heart rate
indicates that resuscitation must proceed without
delay

MANAGEMENT
Meconium Aspiration Syndrome, Management
for
AFTER RESUSCITATION:

Transfer to NICU
Monitor closely.
Full range of respiratory support should be given
Sepsis w/up

GENERAL

MANAGEMENT :
Maintain a neutral thermal environment
Minimal handling protocol to avoid agitation
Maintain adequate BP and perfusion
Correct any abnormalities
Sedation

MANAGEMENT: NICU
Meconium Aspiration Syndrome, Management
for
GOALS OF TREATMENT AT NICU:
Increased oxygenation while minimizing the
barotrauma (may lead to air leak)
Prevent pulmonary hypertension
Successful transition from intrauterine to extrauterine
life with a drop in pulmonary arterial resistance and
an increase in pulmonary blood flow

MANAGEMENT: RESPIRATORY MANAGEMENT

Meconium Aspiration Syndrome, Management
for

Ventilatory support depends on the amount of respiratory distress:

O2 hood (prevent alveolar hypoxia, pulmo VC leading to pulmo HPN

CPAP ( improved oxygenation if the FiO2 exceeds 40-50%)
Mechanical ventilation
for impending resp. failure with hypercapnea and persistent
hypoxemia
Volume targeted ventilation decreased lung overdistention
Use of relatively short inspiratory time limit potential air trapping
Requires high pressure and faster rate

MANAGEMENT
Meconium Aspiration Syndrome, Management
for
Pulmonary toilet - from the ETT + chest physiotherapy every 30 min to 1 hr
Arterial blood gas level - to assess infant ventilatory compromise
Oxygen monitoring
Severity of infants respiratory status and to prevent hypoxemia
Antibiotic COverate
Start broad spectrum antibiotic

MANAGEMENT
Meconium Aspiration Syndrome, Management
for
SURFACTANT
RCT show infant with severe MAS who require mechanical ventilation and
radiologic findings of parenchymal lung disease benefit from early
surfactant therapy
INHALED NO
MAS with pulmonary hypertension
In setting without iNO, sildenafil reduced PVR and improves oxygenation and
decrease mortality
Oxygen monitoring
Severity of infants respiratory status and to prevent hypoxemia
Antibiotic COverate
Start broad spectrum antibiotic

MANAGEMENT
Meconium Aspiration Syndrome, Management
for
ExTRACORPOREAL MEMBRANE OXYGENATION

Heart and lung bypass

Providing both cardiac andrespiratorysupport unable to
provide an adequate amount of gas exchange to sustain life
40% of infants with MAS treated with inhaled NO fail to respond
and require ECMO
35% of ECMO patients are with MAS
Survival rate after ECMO 93-100%.

PROGNOSIS
Meconium Aspiration Syndrome, Prognosis for

Mortality reduced to <5% with new modalities of therapy such as

administration of surfactant, HFV, iNO, ECMO.
Chronic lung disease may result from prolong mechanical ventilation
Those with significant asphyxial insult may demonstrate neurologic
sequele (e.g. GDD, CP, and autism )

REFERENCE
Meconium Aspiration Syndrome

Klingner M.C., Kruse, J.1999.Meconium Aspiration Syndrome:Pathophysiology&Prevention.

.J Am Board Fam
Prac. 12:450-66
Cleary GM, Wiswell TE. 1998. Meconium-stained amniotic fluid and the meconium
aspiration syndrome. An update. Pediatric Clinical North Am. 45:511-29
Fanaroff AA. 2008. Meconium aspiration syndrome: historical aspects. Journal of
Perinatology. 28: S3-S7
Ramon Y, Cajal CL, Martinez RO. Defecation in utero: a physiologic fetal function. Am J
Obstet Gynecol 2003; 188: 153.
Nelson, 19th edition

THANK YOU!
By: JI GRACE ANTONETTE PATI