Meconium Aspiration syndrome

By

Krishnadas.A

INTRODUCTION

Meconium is the earliest stools of an infant.

The term Meconium derives from meconium-arion, meaning "opium-like", in reference either to its tarry appearance or to Aristotle's belief that it induces sleep in the fetus Meconium is almost sterile, unlike later feces, is viscous and sticky like tar, and has no odor. It should be completely passed by the end of the first few days of life

INTRODUCTION

1.
2.

3.

Meconium is composed of : Small dried amniotic fluid debris, Bile pigment and The residue from intestinal secretions. It is a sterile compound made up primarily of water (75 %), with mucous glycoproteins, lipids and proteases.

INTRODUCTION
Although

meconium is sterile, its passage into amniotic fluid is important because of the risk of meconium aspiration syndrome (MAS) and its sequelae.

INTRODUCTION
Infants

delivered through meconium-stained amniotic fluid are more likely to be depressed at birth and to require resuscitation and neonatal intensive care.

INCIDENCE
Meconium-stained

liquor is rare in premature infants (<5 % of preterm pregnancies)

INCIDENCE
Passage

of meconium is increasingly common in infants >37 weeks' gestation and occurs in up to 50 % of post-mature infants ( >42 weeks).

Definition
Meconium aspiration syndrome is a serious condition in which a newborn breathes a mixture of meconium and amniotic fluid into the lungs around the time of delivery.

Risk factors
There are a number of factors associated with an increased risk of developing MAS; these include a: 1. Lack of antenatal care, 2. Black race, 3. Male fetus, 4. Abnormal fetal heart rate monitoring, 5. Thick meconium, 6. Oligohydramnios, 7. Operative delivery, 8. Poor Apgar scores, 9. No oropharyngeal suctioning and 10.The presence of meconium in the trachea.

Riskfactors
Decreased oxygen to the infant while in .11 the uterus Diabetes in the pregnant mother .12 Difficult delivery or long labor .13 High blood pressure in the pregnant .14 mother Passing the due date .15

Etiology Many theories have been proposed to explain the passage of meconium in utero; however, the precise mechanisms remain unclear. The fetal bowel has little peristaltic action and the anal sphincter is contracted. It is thought that hypoxia and academia cause the anal sphincter to relax, whilst at the same time increasing the production of motilin, which promotes peristalsis.

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY
Meconium:
1. 2.

3.

Causes mechanical blockage of the airway, Acts as a chemical irritant causing pneumonitis, alveolar collapse and cell necrosis Although initially sterile, predisposes to secondary bacterial infection

Clinical findings
Bluish skin color (cyanosis) in the infant Breathing problems Difficulty breathing (the infant needs to work hard to breathe) No breathing Rapid breathing Limpness in infant at birth

Clinical findings
Cyanosis End-expiratory grunting Alar flaring Intercostal retractions Tachypnea Barrel chest in the presence of air trapping Auscultated rales and rhonchi (in some cases

PREVENTION OF MECONIUM ASPIRATION SYNDROME

Because

of potential morbidity and mortality from MAS, prevention would clearly be beneficial. This has led to a number of antenatal, intrapartum and postnatal preventative therapies, with a varying degree of success.

Antenatal therapies
1.
2. 3.

Amnioinfusion Delivery by caesarean section Maternal sedation

Amnioinfusion

1. 2.

3.
4.

The idea behind amnioinfusion is that by increasing the liquor volume, meconium will be diluted. In addition, in cases of oligohydramnios, the increased volume will prevent : cord compression, subsequent hypoxia, fetal gasping and passage of meconium.

Maternal sedation

It has been suggested that the administration of narcotics to laboring women will prevent fetal gasping in utero by suppressing fetal breathing.

Intrapartum/postpartum management

Oropharyngeal suctioning 2. Physical manoeuvres

1.

Postnatal intervention
Intratracheal

suctioning

DELIVERY ROOM MANAGEMENT OF INFANTS BORN WITH MECONIUM-STAINED LIQUOR

is important that a person experienced in neonatal resuscitation attends the delivery of all infants in whom thick meconium-stained liquor is noted, particularly if accompanied by suspected fetal compromise.

It

DELIVERY ROOM MANAGEMENT OF INFANTS BORN WITH MECONIUM-STAINED LIQUOR

1. 2.

3.

The Neonatal Resuscitation Program of the American Academy of Pediatrics incorporates guidelines for the management of these infants If an infant is vigorous after delivery: No tracheal suctioning should be undertaken, Secretions should be cleared from the mouth and nose using a wide-bore suction catheter, Routine care should be given.

DELIVERY ROOM MANAGEMENT OF INFANTS BORN WITH MECONIUM-STAINED LIQUOR

1.
2.

However, if an infant is not vigorous afterbirth (defined as : depressed respirations, decreased muscle tone and/or heart rate < 100 beats per minute): Direct endotracheal suctioning should be undertaken as soon as possible, Suction should be applied for no more than 5 seconds and the tube withdrawn.

DELIVERY ROOM MANAGEMENT OF INFANTS BORN WITH MECONIUM-STAINED LIQUOR

1.

2.

If meconium is aspirated from below the cords, the infant should be reintubated and the process repeated, Unless the infant has a profound bradycardia, in which case: Resuscitation should proceed with intermittent positive pressure ventilation (IPPV) without suctioning, Further suctioning can be attempted at a later stage.

DELIVERY ROOM MANAGEMENT OF INFANTS BORN WITH MECONIUM-STAINED LIQUOR

1. 2.

If after the first suctioning no meconium is aspirated : No further suctioning should be attempted and The infant should be resuscitated using IPPV via an endotracheal tube.

IS MENONIUM PRESENT
NO
YES SUCTION MOUTH,NOSE AND POSTERIOR PHARYNX AFTER DELIVERY OF HEAD BUT BEFORE DELIVERY OF SHOULDERS IS THE BABY VIGOROUS? YES NO

CONTINUE WITH RESUSCITATION

CLEAR MOUTH AND NOSE FROM

SUCTION MOUTH AND TRACHEA

SECRETIONS

DRY,STIMULATE AND REPOSITION GIVE OXYGEN AS NECESSARY

General Sedation Analgesia Muscle Relaxants Alkalinization

Infection & Inflammation Antibiotics Anti-inflammatory agents

Pharmaco therapy

Pulmonary hypertension Vasodilators Hemodynamic stabilizers

Pulmonary care Surfactant treatment Surfactant lavage Ventilator support