Meconium aspiration syndrome

Meconium aspiration syndrome
Micrograph of fetal membranes with meconium-laden macrophages, a finding that may accompany meconium aspiration. H&E stain.
Classification and external resources
Specialty pediatrics
ICD-10 P24.0
ICD-9-CM 770.11, 770.12
DiseasesDB 7907
MedlinePlus 001596
eMedicine ped/768
MeSH D008471

Meconium aspiration syndrome (MAS) also known as neonatal aspiration of meconium is a medical condition affecting newborn infants. It occurs when meconium is present in their lungs during or before delivery. Meconium is the first stool of an infant, composed of materials ingested during the time the infant spends in the uterus.

Meconium is normally stored in the infant's intestines until after birth, but sometimes (often in response to fetal distress and hypoxia) it is expelled into the amniotic fluid prior to birth, or during labor. If the baby then inhales the contaminated fluid, respiratory problems may occur.

Signs and symptoms

Meconium aspiration syndrome (MAS)

The most obvious sign that meconium has been passed during or before labor is the greenish or yellowish appearance of the amniotic fluid. The infant's skin, umbilical cord, or nailbeds may be stained green if the meconium was passed a considerable amount of time before birth. These symptoms alone do not necessarily indicate that the baby has inhaled in the fluid by gasping in utero or after birth. After birth, rapid or labored breathing, cyanosis, slow heartbeat, a barrel-shaped chest or low Apgar score are all signs of the syndrome. Inhalation can be confirmed by one or more tests such as using a stethoscope to listen for abnormal lung sounds (diffuse 'wet' crackles and rhonchi), performing blood gas tests to confirm a severe loss of lung function (respiratory acidosis as a consequence of hypercapnia), and using chest X-rays to look for patchy or streaked areas on the lungs. Infants who have inhaled meconium may develop respiratory distress syndrome often requiring ventilatory support. Complications of MAS include pneumothorax and persistent pulmonary hypertension of the newborn.

Causes

Fetal distress during labor causes intestinal contractions, as well as relaxation of the anal sphincter, which allows meconium to pass into the amniotic fluid and contaminate the amniotic fluid. Meconium passage into the amniotic fluid occurs in about 5–20 percent of all births and is more common in overdue births. Of the cases where meconium is found in the amniotic fluid, meconium aspiration syndrome develops less than 5 percent of the time.[1] Amniotic fluid is normally clear, but becomes greenish if it is tinted with meconium.

Maternal risk factors can include: preeclampsia, maternal hypertension, oligohydramnios, maternal infections, maternal drug use, placental insufficiency, and/or intrauterine growth restriction.[2]

The risk of MAS increases after the 40th week of pregnancy.[3]

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.[4]

The leading three causes of MAS are

  1. Due to physiologic maturational event,[5]
  2. A response to acute hypoxic events,[5] and
  3. A response to chronic intrauterine hypoxia.[5]

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.[5]

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. 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.[8]

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. 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. If the condition worsens, extracorporeal membrane oxygenation (ECMO) can be useful.[9]

Albumin-lavage has not demonstrated to benefit outcomes of MAS.[10] Steroid use has not demonstrated to benefit the outcomes of MAS.[11]

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.[2]

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.[12]

See also

References

  1. ↑ Usta, I.; Mercer, B.; Sibai, B. (1995). "Risk factors for meconium aspiration syndrome". Obstetrics and gynecology. 86 (2): 230–234. doi:10.1016/0029-7844(95)00124-A. PMID 7617354.
  2. 1 2 Edmonds, P (2014). "An introduction to meconium". Midwifery today with international midwife (111): 32–3. PMID 25975076.
  3. ↑ Cheng, Y.; Nicholson, J.; Nakagawa, S.; Bruckner, T.; Washington, A.; Caughey, A. (2008). "Perinatal outcomes in low-risk term pregnancies: do they differ by week of gestation?". American Journal of Obstetrics and Gynecology. 199 (4): 370.3e1–7. doi:10.1016/j.ajog.2008.08.008. PMID 18928977.
  4. ↑ Wirbelauer, J.; Speer, C. (2009). "The role of surfactant treatment in preterm infants and term newborns with acute respiratory distress syndrome". Journal of perinatology : official journal of the California Perinatal Association. 29. Suppl 2: S18–S22. doi:10.1038/jp.2009.30. PMID 19399004.
  5. 1 2 3 4 Klingner, MC; Kruse, J (1999). "Meconium aspiration syndrome: pathophysiology and prevention". The Journal of the American Board of Family Practice / American Board of Family Practice. 12 (6): 450–66. doi:10.3122/jabfm.12.6.450. PMID 10612363.
  6. ↑ Hofmeyr, G. (2009). "What (not) to do before delivery? Prevention of fetal meconium release and its consequences". Early human development. 85 (10): 611–615. doi:10.1016/j.earlhumdev.2009.09.010. PMID 19822401.
  7. ↑ Xu, H.; Hofmeyr, J.; Roy, C.; Fraser, W. (2007). "Intrapartum amnioinfusion for meconium-stained amniotic fluid: a systematic review of randomised controlled trials". BJOG: an International Journal of Obstetrics & Gynaecology. 114 (4): 383–90. doi:10.1111/j.1471-0528.2007.01262.x. PMID 17378813.
  8. ↑ El Shahed, AI; Dargaville, PA; Ohlsson, A; Soll, R (14 December 2014). "Surfactant for meconium aspiration syndrome in term and late preterm infants.". The Cochrane database of systematic reviews. 12: CD002054. doi:10.1002/14651858.CD002054.pub3. PMID 25504256.
  9. ↑ Short, B. L. (2008). "Extracorporeal membrane oxygenation: use in meconium aspiration syndrome". Journal of Perinatology. 28: S79–83. doi:10.1038/jp.2008.152. PMID 19057615.
  10. ↑ Salvesen, B.; Mollnes, T. E.; Saugstad, O. D. (2008). "Albumin lavage does not improve the outcome of meconium aspiration syndrome". Journal of Maternal-Fetal and Neonatal Medicine. 21 (10): 719–25. doi:10.1080/14767050802255561. PMID 19012188.
  11. ↑ Ward, M. C.; Sinn, J. K. (2003). "Steroid therapy for meconium aspiration syndrome in newborn infants". Cochrane Database of Systematic Reviews (1): CD003485. doi:10.1002/14651858.CD003485. PMID 14583981.
  12. ↑ Dargaville, P. A.; Copnell, B.; Australian and New Zealand Neonatal Network (2006). "The Epidemiology of Meconium Aspiration Syndrome: Incidence, Risk Factors, Therapies, and Outcome". Pediatrics. 117 (5): 1712–21. doi:10.1542/peds.2005-2215. PMID 16651329.

[1] ^Edmonds, P.(2014). An Introduction to Meconium.Midwifery Today.(111), 32-33. PMID 25975056

  1. ↑ Edmonds, Patricia. "An Introduction to Meconium". Midwifery Today. Retrieved 4 August 2015.
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