Sindroma Aspirasi Mekonium

Meconium Aspiration Syndrome

( MAS )

Bambang Mulyawan
FK-UMM

Pendahuluan
MAS merupakan masalah kegawatan yg
sering dijumpai di ruang bersalin
( hipoksia intrauterine aspirasi
pneumoni BBL )
Biasanya pd bayi cukup bulan dan lebih
bulan ( : Kecil untuk Masa Kehamilan /
KMK )
Waspada : jika BBL lahir dg cairan
ketuban campur mekonium dg gejala RDS

Patogenesis dan
patofisiologi
Stress intrauterin mekonium
in-utero ke dlm cairan ketuban,
terhisap janin ketika inspirasi
o.k hipoksi dan stimulasi vagal
fetal distres / sebelum persalinan
Mekanisme keluarnya mekonium
in-utero masih belum jelas

Patogenesis dan
patofisiologi ( lanj.)
BBL dg cairan ketuban mekonial asfiksia
antepartum atau intrapartum obstruksi
jalan nafas, turunnya kapasitas paru, pe>
expiratory large airway resistancxe
Obstruksi total : atelektasis.
Partial : trapping udara dan hiperekspansi
alveolar
Mekonium pd alveolar me< fungsi surfaktan
kolaps RDS

Patogen . . . . . ( lanj. )
Hipoksia intrauterin aspirasi
mekonium obstruksi mekanik /
keradangan kimiawi air
trapping / atelektasis ventilasi
tidak seimbang / intrapulmonal
shunting kebocoran udara
hipoksemia asidosis sirkulasi
fetal persistent

SINDROM ASPIRASI
MEKONIUM (SAM)
Hipoksia janin
Mekonium keluar & janin gasping
Cairan amnion yang terkontaminasi mekonium
terhirup ke larings dan trakhea
Pembersihan sal. napas
tidak adekuat

Mekonium masuk saluran napas lebih kecil dan

alveolus
Kerusakan paru

Kerusakan paru

Mekonium mengandung enzim

merusak epitel bronkus, bronkiolus dan
alveolus

Mekonium menyumbat sal. napas

secara total/parsial beberapa bagian
paru kolaps, bagian paru lain
hiperinflasi
7

What Is Meconium?
Odorless, thick, blackish green
material
First seen during the third
month of gestation
Accumulation of desquamated
cells from GI tract, skin, lanugo,
fatty material from the vernix,
amniotic fluid

Manifestasi klinis
Bervariasi : tergantung keparahan serangan
hipoksik dan jumlah viskositas mekonium
teraspirasi
Sering pada gestasi post matur : warna meko. pd
kuku, rambut, tali pusat
Gejala RDS ( takipnea, NCH, retraksi interkostal,
diameter AP dada >, sianosis
Pada gejala MAS lambat : distres nafas awal
ringan. Semakin parah bbrp jam : atelektasis dan
pneumonitis kimia
Auskultasi : vesikular lemag, ronki/rales,
wheezing/mengi

Pemeriksaan radiologis
Foto polos dada : infiltrat kasar
menyebar pd kedua lap.paru,
dapat disertai pneumotoraks,
atelektasis, emfisema

Chest X-Ray

Hyperinflation
Coarse, patchy
densities
representing
scattered areas of
atelectasis and
consolidation
mixed with air
trapping

Faktor predisposisi
Insufisiensi plasenta, hipertensi,
oligohidramnion, ibu kecanduan
( rokok, kokain), infeksi (chorioamnionitis) hipoksia,
manajemen jalan nafas tidak
adekuat, defisiensi surfaktan,
hipertensi pulmonal

Risk Factors for

Meconium Passage

Postterm pregnancy
Preeclampsia-eclampsia
Maternal hypertension
Maternal diabetes
mellitus
Abnormal fetal heart rate
IUGR
Abnormal biophysical
profile
Oligohydramnios
Maternal heavy smoking

Meconium in Amniotic Fluid

Intrapartum suctioning of mouth,
nose, pharynx
Infant Active

Observe

Infant Depressed

Intubate and suction

trachea

Other resuscitation as indicated

Langkah diagnostik
Riwayat : PJT ( pertumbuhan janin terhambat ),
kesulitan persalinan / gawat janin, persalinan
dg air ketuban mekonial, asfiksia berat
Pemerksaan fisik : cair ketuban mekonial/ bayi
diliputi mekonium, tl pusat/kulit bayi warna
hijau, asfiksia berat bbrp jam gangguan
nafas/RDS, td bayi lebih bulan
Foto toraks : AP dan Lateral
Laboratorium: Hb, Ht, darah tepi, kultur
Analisa Gas Darah : hipoksemia, asidemia :
asidosis metabolik, respiratorik,/kombinasi

Diagnosis
Cukup/lebih bulan, jarang sekali kurang
bulan
Cairan amnion terkontaminasi mekonium
Mekonium tampak/dapat dihisap dari
saluran napas atas (bantuan laringoskop)
Kulit bayi diwarnai mekonium
Sesak napas
Foto toraks : hiperinflasi paru disertai
banyak daerah paru yang kolaps
17

Pencegahan

Pembersihan saluran napas atas

sebelum bayi bernapas saat lahir
Penghisapan saluran napas
sebelum bahu dilahirkan
Penghisapan saluran napas (larings
dan trakea) secara langsung
dengan bantuan laringoskop
18

penatalaksanaan
Prevensi slm periode prenatal,
antenatal, tindaka tepat slm
intrapartum
Diagram Alur Resusitasi Neonatus

Pengobatan / terapi
Suportif : oksigen, suhu lingkungan,
perawatan pernafasan, kadar gas darah
arteri, terapi surfaktan, ventilasi mekanik,
cairan infus glukosa 10%
Antibiotik spektrum luas
Tindakan bedah :pd pneumotoraks,
pneumomediastinum, empisema subkutan :
pungsi toraks, drainase

Perjalanan Penyakit
SAM : sesak napas sejak lahir
SAM ringan :
membaik
secara bertahap
dalam beberapa
hari beberapa
minggu

SAM

berat
Memburuk
secara
progresif
tidak
tertolong

Tertolong
kerusakan paru
perlu waktu
lama untuk
sembuh
sempurna
21

Komplikasi
1. Pneumotoraks /
pneumomediastinum
2. Kerusakan akibat hipoksia pada
organ lain

22

Pemantauan/Monitoring
Tumbuh kembang
pd bayi yg selamat, hidup tanpa
komplikasi (survival intact)
baik
Pada bayi dg komplikasi hipoksi
serebri, gagal ginjal, efek tosik
O2, epilepsi, palsi serebral
gangguan tumbuh kembang

Pathogenesis
Meconium stained
amniotic fluid
(MSAF) occurs in
10-25% of all
deliveries
Meconium
aspiration
syndrome (MAS)
occurs in 2-5% of
infants born
through MSAF

Pathogenesis
Risk increases
with gestational
age
Before 37 weeks
the risk of MSAF
is 2%
After 44 weeks
the risk of MSAF
is 44%

Pathogenesis

Cause of MSAF is unclear

Studies have not shown that it is
synonymous with fetal asphyxia
MSAF with fetal bradycardia
does correlate with increased
perinatal morbidity

Pathogenesis
Normal fetuses have respiratory
movements in utero
If a fetus is hypoxemic,
respirations briefly stop
With prolonged hypoxia, apnea
turns into gasping

Pathogenesis
Gasping meconium
stained fluid can lead
to mechanical
obstruction of the
airways
Yeomans et al
showed that cord
arterial pH is lower in
infants with
meconium in their
trachea at delivery
which suggests in
utero stress

Pathogenesis
If meconium is not suctioned out of
the airway at delivery, it can migrate
to the periphery of the lung
Small airway obstruction produces
patchy atelectasis and hyperinflation
This leads to a chemical pneumonitis
and interstitial edema
Alveoli are infiltrated with debris,
neutrophils, and necrosed epithelial
cells

Pathogenesis
Pulmonary vascular resistance
can be increased by increased
vascular smooth muscle in the
normally nonmuscularized intraacinar arterioles
Pulmonary hypertension
frequently complicates MAS

Pathogenesis
Endogenous surfactant can be
inactivated by meconium and
the chemical pneumonitis
This may worsen the severity of
the illness

Clinical Manifestations
Often postmature
Meconium staining
of skin and nails
Distressed
Barrel chest from
hyperinflation
Crackles in lungs

Clinical Manifestations
Pneumothorax is a common
complication
Symptoms progress over 12 to
24 hours as the meconium
migrates
Phagocytes remove the
meconium which takes days to
weeks

Delivery Room Therapy

Wiswell and his colleagues
performed a multicenter study
on delivery room management of
the apparently vigorous
meconium stained neonate
Routine suctioning of the
trachea no better than
expectant management

Therapy: Wiswell Cont.

Oropharyngeal suctioning with a bulb
suction before the delivery of an
infants shoulders is still
recommended
Amnioinfusion did not help prevent
MAS
NRP recommends tracheal suction of
the nonvigorous infant born
through meconium

Treatment

Oxygen
Mechanical ventilation if
necessary
Keep in mind that PPHN may be
a component and treat
appropriately
iNO
ECMO

Treatment
Surfactant

Cochran review showed it may reduce

the severity of respiratory illness and
decrease need for ECMO

Antibiotics

Controversial: no studies have shown a

role of infection in MAS
Difficult to distinguish infectious
pneumonia from MAS

Treatment
Steroids

Prolongs the
course of MAS
by increasing
the time to
wean to room
air

Outcome

Infants with MAS do very well

Overall mortality of infants with
MSAF is 0.15%
Infants with MAS on ECMO have
a mortality range of 0-5%
depending on the institution