Meconium Aspiration Syndrome (Case 35)

Chapter 76 Meconium Aspiration Syndrome (Case 35)



Jane S. Lee, MD, MPH




Case


A term infant is delivered emergently by cesarean delivery because of a nonreassuring fetal heart tracing. The infant is covered in thick particulate meconium and following resuscitation develops severe respiratory distress.




Differential Diagnosis




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Speaking Intelligently


In the setting of meconium-stained amniotic fluid, I rapidly assess if the infant is vigorous following delivery. Vigor is defined as the presence of spontaneous respirations, reasonable tone, and sustained heart rate above 100 beats per minute. If an infant is crying, he or she is vigorous. If the infant appears depressed at birth, immediate intervention is required. Additional personnel should be summoned at this time so that subsequent resuscitative measures may be performed simultaneously. Using either a bulb syringe or large-bore suction catheter, I clear any visible meconium from the infant’s mouth and nose. It is important to suction the mouth first because nasopharyngeal suctioning may induce gasping and further aspiration of meconium. I then place the infant in the “sniffing” position so that the airway is as unobstructed as possible. While another member of the delivery room team administers free-flow oxygen to the infant, I perform endotracheal intubation and tracheal suctioning of meconium. This process is repeated until no meconium is recovered.



Patient Care



Clinical Thinking



• Initiate neonatal resuscitation if the infant appears depressed at birth or develops respiratory distress shortly after birth.

• Remember the ABCs of resuscitation: airway, breathing, and circulation.

• If the infant remains cyanotic despite adequate ventilation, evaluate the infant for an acute, superimposing cause for the hypoxia such as air leak.

• When did the aspiration occur—in utero or following delivery? Is there evidence of chronic hypoxia? Consider an echocardiogram to evaluate for evidence of pulmonary hypertension.

• If no meconium is obtained upon tracheal suctioning, consider other diagnoses because meconium aspiration is less likely.


History



• Is there antenatal history of maternal diabetes, hypertension, preeclampsia, or maternal drug abuse?

• Did prenatal ultrasonography reveal evidence of congenital anomalies or abnormalities in amniotic fluid volume or uteroplacental blood flow?

• Were there signs of fetal hypoxia such as a nonreassuring fetal heart pattern, abnormal biophysical profile, oligohydramnios, intrauterine growth restriction, or metabolic acidosis on umbilical artery blood gas sampling?

• Evaluate intrapartum risk factors. Was the infant born by cesarean delivery without labor or a precipitous vaginal delivery? Is the pregnancy postterm? Are there other reasons for respiratory depression such as magnesium prophylaxis for preeclampsia or maternal narcotic administration within 4 hours before delivery?

• Are there risk factors for neonatal sepsis such as rupture of membranes of greater than 18 hours duration, maternal fever, chorioamnionitis, group B streptococcal vaginal colonization, presence of urinary tract infection or history of recurrent urinary tract infections in the mother, birth of previous infant with neonatal infection, or fetal tachycardia?


Physical Examination



• Vital signs: Bradycardia, tachypnea, oxygen desaturation.

• Overall condition: Determine the infant’s vigorousness, alertness, tone.

• Symptoms of respiratory distress: Varying degree of tachypnea, nasal flaring, grunting, retractions, and cyanosis may be present. Central cyanosis is assessed by examining the face, trunk, and mucous membranes.

• Signs of postmaturity: Inspect for weight loss, loose skin folds, peeling of the skin, long fingernails, and yellowish staining of the skin, finger nails, and umbilical cord.

• Signs of shock: Evaluate for pallor, delayed capillary perfusion, and peripheral pulses that are not easily palpable.

• Cardiac examination: Assess for cardiac murmur or signs of congestive heart failure.


Tests for Consideration



• Arterial blood gas (ABG) $156

• Complete blood count (CBC) with differential $53

• Electrolytes, including glucose and calcium $29

• Blood culture $100


Imaging Considerations


→ Chest radiograph $75


→ Echocardiogram: To evaluate for pulmonary hypertension, ventricular filling, cardiac contractility, and structural cardiac anomalies $325

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Meconium Aspiration Syndrome (Case 35)

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