Meconium aspiration syndrome

Meconium aspiration syndrome (MAS) refers to breathing problems that

a newborn baby may have when:

There are no other causes, and

The baby has passed meconium (stool) into the amniotic fluid
during labor or delivery
MAS may occur if the baby breathes in (aspirates) this fluid into the
lungs.

Causes
Meconium is the early feces (stool) passed by a newborn soon after
birth. It is passed from the body before the baby has started to digest
breast milk (or formula).

In some cases, the baby passes meconium while still inside the uterus.
This will happen when babies are "under stress" because their supply of
blood and oxygen decreases. This is often due to problems with the
placenta or the umbilical cord.

Once the meconium has passed into the surrounding amniotic fluid, the
baby may breathe meconium into the lungs. This may happen while the
baby is still in the uterus, or still covered by amniotic fluid after birth.
The meconium can also block the infant's airways right after birth.

It can cause breathing problems due to swelling (inflammation) in the

baby's lungs after birth.

Risk factors that may cause stress on the baby before birth include:

"Aging" of the placenta if the pregnancy goes far past the due date
Decreased oxygen to the infant while in the uterus
Diabetes in the pregnant mother
Difficult delivery or long labor
High blood pressure in the pregnant mother
Symptoms
 Some babies do not breathe the meconium fluid into their lungs during
labor and delivery. They are unlikely to have any symptoms or
problems.

Babies who do breathe in this fluid may have the following:

Bluish skin color (cyanosis) in the infant

Working hard to breathe (noisy breathing, grunting, using extra
muscles to breathe, breathing rapidly)
No breathing
Limpness at birth
Exams and Tests
Before birth, the fetal monitor may show a slow heart rate. During
delivery or at birth, meconium can be seen in the amniotic fluid and on
the infant.

The infant may need help with breathing or heartbeat right after birth,
and may have a low Apgarscore.
The health care team will listen to the infant's chest with a stethoscope
and may hear abnormal breath sounds, especially coarse, crackly sounds.

A blood gas analysis will show low (acidic) blood pH, decreased
oxygen, and increased carbon dioxide.

A chest x-ray may show patchy or streaky areas in the infant's lungs.

Treatment
A special care team should be present when the baby is born if traces of
meconium are found in the amniotic fluid. This happens in more than
10% of normal pregnancies. If the baby is active and crying, no
treatment is needed.

If the baby is not active and crying right after delivery, a tube is placed
in the infant's airway by a nurse, therapist, or doctor. Suction is used to
remove any meconium. This procedure may be repeated more than once.

If the baby is not breathing or has a low heart rate:

 The team will help the baby breathe using a face mask attached to
a bag that delivers an oxygen mixture to inflate the baby's lungs.
The infant may be placed in the special care nursery or newborn
intensive care unit in order to be watched closely.
Other treatments may include:

Antibiotics to treat infection.

Breathing machine (ventilator): Not commonly needed. Many
problems can develop while the child is using a breathing machine.
Oxygen to keep blood levels normal.
Radiant warmer to maintain body temperature.
Surfactant to help lungs exchange oxygen.
Nitric oxide (also referred to as NO, an inhaled gas) to help blood
flow and oxygen exchange in the lungs.
ECMO (extracorporeal membrane oxygenation) is a kind of
heart/lung bypass. It may be used in very severe cases.
Outlook (Prognosis)
In most cases, the outlook is excellent and there are no long-term health
effects.

Only about half of babies with meconium stained fluid will have
breathing problems and only about 5% will have MAS.
Breathing problems may be more severe in some cases. These will
often go away in 2 to 4 days. However, rapid breathing may continue for
several days.
MAS rarely leads to permanent lung damage.
Meconium may be present at birth in the amniotic fluid because there is
a serious problem with the blood flow to and from the lungs. This is
called persistent pulmonary hypertension of the newborn (PPHN).

Prevention
Staying healthy during pregnancy and following your health care
provider's advice can often prevent problems that lead to meconium
being present.
 Your providers will want to be prepared for meconium being present at
birth if:

Your water broke at home and the fluid was clear or stained with a
greenish or brown substance.
Any testing done during your pregnancy indicates there may be
problems present.
Fetal monitoring shows any signs of fetal distress can be found
early.
Alternative Names
MAS; Meconium pneumonitis (inflammation of the lungs); Labor -
meconium; Delivery - meconium; Neonatal - meconium; Newborn care -
meconium

Meconium is a dark green liquid normally passed by the newborn baby,

containing mucus, bile and epithelial cells.

However, in some cases the meconium is passed when the baby is still in
the womb, staining the amniotic fluid. This can vary from light to heavy
staining. It is considered significant if dark green or black, with a thick,
tenacious appearance.

Components of the meconium, especially the bile salts and enzymes, can
cause serious complications if they are inhaled by the fetus at any stage
of labour. This can result in meconium aspiration syndrome (MAS).
There are several pathological mechanisms participating in MAS,
particularly airway obstruction, surfactant dysfunction, inflammation,
lung oedema, pulmonary vasoconstriction and bronchoconstriction.[1]

Meconium staining often occurs in conjunction with other causes of fetal

distress. It is rare in babies born at <34 weeks of gestation.

Epidemiology

The figure quoted for infants born with meconium-stained liquor in the
industrialised world is 8-25% of births after 34 weeks of gestation. MAS
occurs in around 1-3% of live births.[2]

Deliveries complicated with meconium-stained amniotic fluid are

associated with additional adverse pregnancy outcomes (eg, increased
rates of labour dystocia, delivery by caesarean section and fetal distress).
[3]

Risk factors include:

Placental insufficiency.

Maternal hypertension and pre-eclampsia.

Oligohydramnios.

Smoking.

Cocaine abuse.

Increased maternal age.

Meconium-stained amniotic fluid is really worrisome from both the

obstetrician's and the paediatrician's point of view, as it increases the
caesarean rates, and causes birth asphyxia, MAS and an increase in
neonatal intensive care unit admissions.[4]

Management

These recommendations are from the National Institute for Health and
Care Excellence (NICE), 2014.[5]

Intrapartum

If significant meconium staining is noted in labour, there should be

continuous electronic fetal monitoring.

This is defined as dark green or black amniotic fluid that is thick or

tenacious, or any amniotic fluid that contains lumps of meconium.

Transfer mother to obstetric-led care, if it is safe to do so and

delivery is not imminent.

If there are signs of fetal distress, a fetal blood sample should be

obtained. If pH is <7.21, there should be emergency delivery.

Ensure that the advanced resuscitation unit and appropriately

trained staff are available.

There should be no suction prior to delivery.

At delivery - healthy neonate

If the baby is in good condition (Apgar score >5, based on colour,

tone, heart rate and breathing), there should be no suction.

The baby should be observed for signs of respiratory distress in the

first hour of life, in the second hour and then two-hourly until 12
hours old.

If there is blood or if there are lumps of meconium in the

oropharynx, suction should be used in the upper airways.

Endotracheal intubation at birth in otherwise healthy, term

meconium-stained babies, is no longer recommended.

At delivery - sick neonate

Complications

Infant respiratory distress syndrome

Respiratory distress that usually occurs within four hours of birth

and becomes persistently worse for 48 to 72 hours is known as infant
respiratory distress syndrome. If not fatal, it resolves by 72 hours.

A deficiency of surfactant produces high alveolar surface tension.

The baby must re-inflate the collapsed alveoli with every breath.
Thus, every breath takes a lot of effort for relatively poor expansion.

Surfactant replacement therapy has shortened the duration of the

disease and significantly reduced mortality.[6] It is treated with
administration of synthetic or animal surfactant.

Persistent pulmonary hypertension of the newborn

Babies may have persistent pulmonary hypertension of the

newborn, as a consequence.

This occurs where the fetal circulation persists with blood being
shunted away from the lungs through the foramen ovale and a patent
ductus arteriosus.
 It is a consequence of raised pulmonary vascular resistance.
Clinical features include cyanosis, tachypnoea and the murmur of
patent ductus arteriosus.

Treatment[7]
This includes:

Supportive measures, including ventilation.

Prostacyclin infusion.

Extracorporeal membrane oxygenation (ECMO).

Several promising therapeutic modalities for this condition: these

include oxygen supplementation, mechanical ventilation, nitric
oxide, phosphodiesterase enzyme inhibitors, endothelin receptor
antagonists, and ECMO.

Chronic lung disease

Children with meconium aspiration may develop chronic lung

disease as a result of intense pulmonary intervention.

Infants with meconium aspiration have a slightly increased

incidence of infections in the first year of life because the lungs are
still in recovery.

Prognosis

Up to 10% of cases of meconium staining develop MAS.[2]

Nearly all infants with MAS have complete recovery of pulmonary

function.

Initial hypoxic events may cause the infant to have long-term

neurological problems, including seizures, general learning
disability and cerebral palsy.

Prevention

Elective induction of labour for pregnancies at or beyond 41 weeks has

been shown to be associated with significant reduction in the incidence
of MAS and fewer perinatal deaths compared to expectant management.
[8]
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 520 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. Amniotic fluid is normally clear, but becomes
greenish if it is tinted with meconium.YR
Maternal risk factors can include: preeclampsia, maternal hypertension,
oligohydramnios, maternal infections, maternal drug use, placental
insufficiency, and/or intrauterine growth restriction.
The risk of MAS increases after the 40th week of pregnancy.

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.
The leading three causes of MAS are:
-Due to physiologic maturational event,
A response to acute hypoxic events, and
A response to chronic intrauterine hypoxia.
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.

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.[citation needed] 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.
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. citation needed] 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.
[citation needed] If the condition worsens, extracorporeal membrane
oxygenation (ECMO) can be useful.
Albumin-lavage has not demonstrated to benefit outcomes of MAS.
Steroid use has not demonstrated to benefit the outcomes of MAS.

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.

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.