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Meconium AspirationMeconium Aspiration
Syndrome (MAS)Syndrome (MAS)
Dr. Amlendra K.YadavDr. Amlendra K.Yadav
Dr. Bipin KarkiDr. Bipin Karki
Resident (Phase-A)Resident (Phase-A)
NeonatologyNeonatology
(BSMMU)(BSMMU)
ObjectivesObjectives
 DefinitionDefinition
 EpidemiologyEpidemiology
 EtiologyEtiology
 PathophysiologyPathophysiology
 Clinical featuresClinical features
 Differential DiagnosisDifferential Diagnosis
 DiagnosisDiagnosis
 ManagementManagement
 PrognosisPrognosis
DefinitionDefinition
Meconium aspiration syndromeMeconium aspiration syndrome
(MAS) is a respiratory distress in an(MAS) is a respiratory distress in an
infant born throughinfant born through
Meconium stained amniotic fluidMeconium stained amniotic fluid
whose symptoms cannot bewhose symptoms cannot be
otherwise explained.otherwise explained.
EpidemiologyEpidemiology
 MSAF observed in (8-20)% of all births.MSAF observed in (8-20)% of all births.
 MAS occurs in 5% of newborns deliveredMAS occurs in 5% of newborns delivered
through MSAF.through MSAF.
 It is a disease of Term or Post-termIt is a disease of Term or Post-term
Infant.Infant.
Composition of meconium
 Epithelial cells
 Fetal hair
 Mucus
 Bile
Cause of MSAFCause of MSAF
 Normally The passage of meconium from theNormally The passage of meconium from the
fetus into amnion is prevented by lack offetus into amnion is prevented by lack of
peristalsis(low motilin level) , tonic contraction ofperistalsis(low motilin level) , tonic contraction of
the anal sphincter, terminal cap of viscousthe anal sphincter, terminal cap of viscous
meconium.meconium.
 Fetal maturation post term(high motilin level)Fetal maturation post term(high motilin level)
 Vagal stimulation by cord or head compressionVagal stimulation by cord or head compression
in absence of fetal distress.in absence of fetal distress.
 In utero stress(hypoxia, acidosis)producingIn utero stress(hypoxia, acidosis)producing
relaxation of anal sphincter.relaxation of anal sphincter.
Risk factors for MASRisk factors for MAS
 Maternal HTMaternal HT
 Maternal DMMaternal DM
 Maternal heavy cigarette smokingMaternal heavy cigarette smoking
 Maternal chronic respiratory or Cardio vascularMaternal chronic respiratory or Cardio vascular
diseasedisease
 Post term pregnancyPost term pregnancy
 Pre-eclampsia/eclampsiaPre-eclampsia/eclampsia
 OligohydramniosOligohydramnios
 IUGRIUGR
 Abnormal fetal HR patternAbnormal fetal HR pattern
Pathophysiology
Mechanical obstruction of
airways
 Thick and viscous meconium lead to
Complete or partial airway obstruction.
 With onset of respiration – meconium
migrates from central to peripheral
airways.
 Complete obstruction – atelectasis
 Partial obstruction –
- Ball-valve – air trapping.
- Risk of pneumothorax - 15 – 33%
Pathophysiology
 Chemical pneumonitis: with distal
progressing of meconium chemical
pneumonitis develop resulting bronchiolar
edema and narrowing of the small airway.
 Surfactant inactivation: Bilirubin, fatty
acid, triglycerides, cholesterol content of
meconium inhibit surfactant function and
inactivation.
Pathophysiology
 Pulmonary hypertension: meconium in
lungs stimulate release of proinflammatory
cytokines and vasoactive substance which
cause pulmonary vasoconstriction. Also
hypoxia, acidosis, and hyperinflation
contribute to pulmonary hypertension.
CLINICAL FEATURESCLINICAL FEATURES
HistoryHistory
 Infants with MAS must have a historyInfants with MAS must have a history
of MSAF.of MSAF.
 They often are Term or post-termThey often are Term or post-term
 IUGR.IUGR.
 Many are depressed at birth.Many are depressed at birth.
CLINICAL FEATURESCLINICAL FEATURES
Physical examinationPhysical examination   
 Evidence of postmaturity: peeling skin, longEvidence of postmaturity: peeling skin, long
fingernails, and decreased vernix.fingernails, and decreased vernix.
 The vernix, umbilical cord, and nails may beThe vernix, umbilical cord, and nails may be
meconium-stained, depending upon how longmeconium-stained, depending upon how long
the infant has been exposed in utero.the infant has been exposed in utero.
 In general, nails will become stained after 6In general, nails will become stained after 6
hours and vernix after 12 to 14 hours ofhours and vernix after 12 to 14 hours of
exposure .exposure .
 umbilical cord staining (thick-15min, thin-1hour)umbilical cord staining (thick-15min, thin-1hour)
Umbilical cord stained with meconium
CLINICAL FEATURESCLINICAL FEATURES
Physical examinationPhysical examination   
 Affected patients typically have respiratoryAffected patients typically have respiratory
distress with marked tachypnea anddistress with marked tachypnea and
cyanosis.cyanosis.
 Use of accessory muscles of respirationUse of accessory muscles of respiration
are evidenced by intercostal andare evidenced by intercostal and
subcostal retractions and abdominalsubcostal retractions and abdominal
(paradoxical) breathing, often with(paradoxical) breathing, often with
grunting and nasal flaring.grunting and nasal flaring.
CLINICAL FEATURESCLINICAL FEATURES
Physical examinationPhysical examination   
 The chest typically appears barrel-shaped, withThe chest typically appears barrel-shaped, with
an increased anterior-posterior diameter causedan increased anterior-posterior diameter caused
by overinflation.by overinflation.
 Auscultation reveals rales and rhonchiAuscultation reveals rales and rhonchi
-immediately after birth.-immediately after birth.
 Some patients are asymptomatic at birth andSome patients are asymptomatic at birth and
develop worsening signs of respiratory distressdevelop worsening signs of respiratory distress
as the meconium moves from the large airwaysas the meconium moves from the large airways
into the lower tracheobronchial tree.into the lower tracheobronchial tree.
Differential Diagnosis
 Perinatal Asphyxia
 Bacterial Pneumonia
 Respiratory Distress Syndrome
 Transient Tachypnea Of Newborn
 Congenital Heart Disease
DiagnosisDiagnosis
MAS must be considered in any infantMAS must be considered in any infant
born through MSAF who developsborn through MSAF who develops
symptoms of RD with typical chest xsymptoms of RD with typical chest x
ray findingsray findings
DiagnosisDiagnosis
 A chest radiographs shows hyperinflationA chest radiographs shows hyperinflation
of the lung field and flatten diagphragms.of the lung field and flatten diagphragms.
 There are coarse irregular patchyThere are coarse irregular patchy
infiltratesinfiltrates
 A pneumothorax and pneumomediastinumA pneumothorax and pneumomediastinum
may be present .may be present .
Coarse irregular patchy infiltrate with emphysema.Coarse irregular patchy infiltrate with emphysema.
Areas of opacification due to atelectasisAreas of opacification due to atelectasis
bilaterally.bilaterally.
left lung demonstrating the streaky lucencies of the air inleft lung demonstrating the streaky lucencies of the air in
the interstitiumthe interstitium (red arrows)(red arrows) complicated by acomplicated by a
pneumothoraxpneumothorax (yellow arrow).(yellow arrow).
DiagnosisDiagnosis
 Arterial blood gas measurements typicallyArterial blood gas measurements typically
show hypoxemia and hypercarbia.show hypoxemia and hypercarbia.
 Infants with pulmonary hypertension andInfants with pulmonary hypertension and
right-to-left shunting may have a gradientright-to-left shunting may have a gradient
in oxygenation between preductal andin oxygenation between preductal and
postductal samples.postductal samples.
 Echocardiogram for evaluation of PPH.Echocardiogram for evaluation of PPH.
Management
 Prenatal management: Key management lies
in prevention during prenatal period.
 Identification of high risk pregnancies and
close monitoring. Pregnancy that continue
past due date, induction as early as 41 weeks
may help prevent meconium aspiration.
 If there is sign of fetal distress corrective
measure should be undertaken or infant
should be delivered in timely manner.
ManagementManagement
ManagementManagement
 When the infant is not vigorous:When the infant is not vigorous:
1.1. Clear airways as quickly as possible.Clear airways as quickly as possible.
2.2. Free flow 0Free flow 02.2.
3.3. Radiant warmer but drying and stimulationRadiant warmer but drying and stimulation
should be delayed.should be delayed.
4.4. Direct laryngoscopy with suction of theDirect laryngoscopy with suction of the
mouth and hypopharynx under directmouth and hypopharynx under direct
visualization, followed by intubation andvisualization, followed by intubation and
then suction directly to the ET tube .then suction directly to the ET tube .
5.5. The process is repeated until either ‘‘littleThe process is repeated until either ‘‘little
additional meconium is recovered, or untiladditional meconium is recovered, or until
the baby’s heart rate indicates thatthe baby’s heart rate indicates that
resuscitation must proceed without delay’’.resuscitation must proceed without delay’’.
Postnatal ManagementPostnatal Management
ApparentlyApparently well childwell child born throughborn through
MSAFMSAF
 Most of them do not require anyMost of them do not require any
interventions besides close monitoring forinterventions besides close monitoring for
RD.RD.
 Most infants who develop symptoms willMost infants who develop symptoms will
do so in the first 12 hours of life.do so in the first 12 hours of life.
Postnatal ManagementPostnatal Management
Approach to theApproach to the ill newbornsill newborns ::
 Transfer to NICU.Transfer to NICU.
 Monitor closely.Monitor closely.
 Full range of respiratory support should beFull range of respiratory support should be
given.given.
 Sepsis w/up and ABx indicated.Sepsis w/up and ABx indicated.
Treatment in NICUTreatment in NICU
Goals:Goals:
 Increased oxygenation while minimizingIncreased oxygenation while minimizing
the barotrauma (may lead to air leak).the barotrauma (may lead to air leak).
 Prevent pulmonary hypertension.Prevent pulmonary hypertension.
 Successful transition from intrauterine toSuccessful transition from intrauterine to
extrauterine life with a drop in pulmonaryextrauterine life with a drop in pulmonary
arterial resistance and an increase inarterial resistance and an increase in
pulmonary blood flow.pulmonary blood flow.
Treatment in NICUTreatment in NICU
Ventilatory supportVentilatory support depends on the amount ofdepends on the amount of
respiratory distress:respiratory distress:
 OO22 hoodhood
 CPAPCPAP
 Mechanical ventilationMechanical ventilation
 HFV should reduce air leaks.
 High-frequency ventilators may slow the progression ofHigh-frequency ventilators may slow the progression of
meconium down the tracheobronchial tree and allowmeconium down the tracheobronchial tree and allow
more time for meconium removal.more time for meconium removal.
Treatment in NICUTreatment in NICU
surfactant therapy in MAS showed
promising results with decrease in the
number of infants requiring ECMO and
possible reduction of pneumothorax
Treatment in NICUTreatment in NICU
Inhaled Nitric oxide (NO)
 Selective pulmonary vasodilation.
 Activate guanylate cyclase and increases
cyclic GMP and acting directly on the
vascular smooth muscle.
 Decreased need for ECMO but no
difference in mortality.
 Pretreatment with surfactant improves in
delivery of iNO to the alveoli.
ECMOECMO
 40% of infants with MAS treated with40% of infants with MAS treated with
inhaled NO fail to respond and requireinhaled NO fail to respond and require
ECMO.ECMO.
 35% of ECMO patients are with MAS.35% of ECMO patients are with MAS.
 Survival rate after ECMO 93-100%.Survival rate after ECMO 93-100%.
ProgonosisProgonosis
 Mortality reduced to <5% with new modalities ofMortality reduced to <5% with new modalities of
therapy such as administration of surfactant,therapy such as administration of surfactant,
HFV, iNO, ECMO.HFV, iNO, ECMO.
 Chronic lung disease may result from prolongChronic lung disease may result from prolong
mechanical ventilationmechanical ventilation
 Those with significant asphyxial insult mayThose with significant asphyxial insult may
demonstrate neurologic sequele.demonstrate neurologic sequele.
SummarySummary
 Optimal care of an infant born throughOptimal care of an infant born through
MSAF involves close collaborationMSAF involves close collaboration
between OBs and Neonatoloy team.between OBs and Neonatoloy team.
 Effective communication and anticipationEffective communication and anticipation
of potential problems is a corner stone ofof potential problems is a corner stone of
the successful partnership.the successful partnership.
Meconium aspiration syndrome_

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Meconium aspiration syndrome_

  • 1. Meconium AspirationMeconium Aspiration Syndrome (MAS)Syndrome (MAS) Dr. Amlendra K.YadavDr. Amlendra K.Yadav Dr. Bipin KarkiDr. Bipin Karki Resident (Phase-A)Resident (Phase-A) NeonatologyNeonatology (BSMMU)(BSMMU)
  • 2. ObjectivesObjectives  DefinitionDefinition  EpidemiologyEpidemiology  EtiologyEtiology  PathophysiologyPathophysiology  Clinical featuresClinical features  Differential DiagnosisDifferential Diagnosis  DiagnosisDiagnosis  ManagementManagement  PrognosisPrognosis
  • 3. DefinitionDefinition Meconium aspiration syndromeMeconium aspiration syndrome (MAS) is a respiratory distress in an(MAS) is a respiratory distress in an infant born throughinfant born through Meconium stained amniotic fluidMeconium stained amniotic fluid whose symptoms cannot bewhose symptoms cannot be otherwise explained.otherwise explained.
  • 4. EpidemiologyEpidemiology  MSAF observed in (8-20)% of all births.MSAF observed in (8-20)% of all births.  MAS occurs in 5% of newborns deliveredMAS occurs in 5% of newborns delivered through MSAF.through MSAF.  It is a disease of Term or Post-termIt is a disease of Term or Post-term Infant.Infant.
  • 5. Composition of meconium  Epithelial cells  Fetal hair  Mucus  Bile
  • 6. Cause of MSAFCause of MSAF  Normally The passage of meconium from theNormally The passage of meconium from the fetus into amnion is prevented by lack offetus into amnion is prevented by lack of peristalsis(low motilin level) , tonic contraction ofperistalsis(low motilin level) , tonic contraction of the anal sphincter, terminal cap of viscousthe anal sphincter, terminal cap of viscous meconium.meconium.  Fetal maturation post term(high motilin level)Fetal maturation post term(high motilin level)  Vagal stimulation by cord or head compressionVagal stimulation by cord or head compression in absence of fetal distress.in absence of fetal distress.  In utero stress(hypoxia, acidosis)producingIn utero stress(hypoxia, acidosis)producing relaxation of anal sphincter.relaxation of anal sphincter.
  • 7. Risk factors for MASRisk factors for MAS  Maternal HTMaternal HT  Maternal DMMaternal DM  Maternal heavy cigarette smokingMaternal heavy cigarette smoking  Maternal chronic respiratory or Cardio vascularMaternal chronic respiratory or Cardio vascular diseasedisease  Post term pregnancyPost term pregnancy  Pre-eclampsia/eclampsiaPre-eclampsia/eclampsia  OligohydramniosOligohydramnios  IUGRIUGR  Abnormal fetal HR patternAbnormal fetal HR pattern
  • 8. Pathophysiology Mechanical obstruction of airways  Thick and viscous meconium lead to Complete or partial airway obstruction.  With onset of respiration – meconium migrates from central to peripheral airways.  Complete obstruction – atelectasis  Partial obstruction – - Ball-valve – air trapping. - Risk of pneumothorax - 15 – 33%
  • 9. Pathophysiology  Chemical pneumonitis: with distal progressing of meconium chemical pneumonitis develop resulting bronchiolar edema and narrowing of the small airway.  Surfactant inactivation: Bilirubin, fatty acid, triglycerides, cholesterol content of meconium inhibit surfactant function and inactivation.
  • 10. Pathophysiology  Pulmonary hypertension: meconium in lungs stimulate release of proinflammatory cytokines and vasoactive substance which cause pulmonary vasoconstriction. Also hypoxia, acidosis, and hyperinflation contribute to pulmonary hypertension.
  • 11.
  • 12. CLINICAL FEATURESCLINICAL FEATURES HistoryHistory  Infants with MAS must have a historyInfants with MAS must have a history of MSAF.of MSAF.  They often are Term or post-termThey often are Term or post-term  IUGR.IUGR.  Many are depressed at birth.Many are depressed at birth.
  • 13. CLINICAL FEATURESCLINICAL FEATURES Physical examinationPhysical examination     Evidence of postmaturity: peeling skin, longEvidence of postmaturity: peeling skin, long fingernails, and decreased vernix.fingernails, and decreased vernix.  The vernix, umbilical cord, and nails may beThe vernix, umbilical cord, and nails may be meconium-stained, depending upon how longmeconium-stained, depending upon how long the infant has been exposed in utero.the infant has been exposed in utero.  In general, nails will become stained after 6In general, nails will become stained after 6 hours and vernix after 12 to 14 hours ofhours and vernix after 12 to 14 hours of exposure .exposure .  umbilical cord staining (thick-15min, thin-1hour)umbilical cord staining (thick-15min, thin-1hour)
  • 14. Umbilical cord stained with meconium
  • 15. CLINICAL FEATURESCLINICAL FEATURES Physical examinationPhysical examination     Affected patients typically have respiratoryAffected patients typically have respiratory distress with marked tachypnea anddistress with marked tachypnea and cyanosis.cyanosis.  Use of accessory muscles of respirationUse of accessory muscles of respiration are evidenced by intercostal andare evidenced by intercostal and subcostal retractions and abdominalsubcostal retractions and abdominal (paradoxical) breathing, often with(paradoxical) breathing, often with grunting and nasal flaring.grunting and nasal flaring.
  • 16. CLINICAL FEATURESCLINICAL FEATURES Physical examinationPhysical examination     The chest typically appears barrel-shaped, withThe chest typically appears barrel-shaped, with an increased anterior-posterior diameter causedan increased anterior-posterior diameter caused by overinflation.by overinflation.  Auscultation reveals rales and rhonchiAuscultation reveals rales and rhonchi -immediately after birth.-immediately after birth.  Some patients are asymptomatic at birth andSome patients are asymptomatic at birth and develop worsening signs of respiratory distressdevelop worsening signs of respiratory distress as the meconium moves from the large airwaysas the meconium moves from the large airways into the lower tracheobronchial tree.into the lower tracheobronchial tree.
  • 17. Differential Diagnosis  Perinatal Asphyxia  Bacterial Pneumonia  Respiratory Distress Syndrome  Transient Tachypnea Of Newborn  Congenital Heart Disease
  • 18. DiagnosisDiagnosis MAS must be considered in any infantMAS must be considered in any infant born through MSAF who developsborn through MSAF who develops symptoms of RD with typical chest xsymptoms of RD with typical chest x ray findingsray findings
  • 19. DiagnosisDiagnosis  A chest radiographs shows hyperinflationA chest radiographs shows hyperinflation of the lung field and flatten diagphragms.of the lung field and flatten diagphragms.  There are coarse irregular patchyThere are coarse irregular patchy infiltratesinfiltrates  A pneumothorax and pneumomediastinumA pneumothorax and pneumomediastinum may be present .may be present .
  • 20. Coarse irregular patchy infiltrate with emphysema.Coarse irregular patchy infiltrate with emphysema.
  • 21. Areas of opacification due to atelectasisAreas of opacification due to atelectasis bilaterally.bilaterally.
  • 22. left lung demonstrating the streaky lucencies of the air inleft lung demonstrating the streaky lucencies of the air in the interstitiumthe interstitium (red arrows)(red arrows) complicated by acomplicated by a pneumothoraxpneumothorax (yellow arrow).(yellow arrow).
  • 23. DiagnosisDiagnosis  Arterial blood gas measurements typicallyArterial blood gas measurements typically show hypoxemia and hypercarbia.show hypoxemia and hypercarbia.  Infants with pulmonary hypertension andInfants with pulmonary hypertension and right-to-left shunting may have a gradientright-to-left shunting may have a gradient in oxygenation between preductal andin oxygenation between preductal and postductal samples.postductal samples.  Echocardiogram for evaluation of PPH.Echocardiogram for evaluation of PPH.
  • 24. Management  Prenatal management: Key management lies in prevention during prenatal period.  Identification of high risk pregnancies and close monitoring. Pregnancy that continue past due date, induction as early as 41 weeks may help prevent meconium aspiration.  If there is sign of fetal distress corrective measure should be undertaken or infant should be delivered in timely manner.
  • 26. ManagementManagement  When the infant is not vigorous:When the infant is not vigorous: 1.1. Clear airways as quickly as possible.Clear airways as quickly as possible. 2.2. Free flow 0Free flow 02.2. 3.3. Radiant warmer but drying and stimulationRadiant warmer but drying and stimulation should be delayed.should be delayed. 4.4. Direct laryngoscopy with suction of theDirect laryngoscopy with suction of the mouth and hypopharynx under directmouth and hypopharynx under direct visualization, followed by intubation andvisualization, followed by intubation and then suction directly to the ET tube .then suction directly to the ET tube . 5.5. The process is repeated until either ‘‘littleThe process is repeated until either ‘‘little additional meconium is recovered, or untiladditional meconium is recovered, or until the baby’s heart rate indicates thatthe baby’s heart rate indicates that resuscitation must proceed without delay’’.resuscitation must proceed without delay’’.
  • 27. Postnatal ManagementPostnatal Management ApparentlyApparently well childwell child born throughborn through MSAFMSAF  Most of them do not require anyMost of them do not require any interventions besides close monitoring forinterventions besides close monitoring for RD.RD.  Most infants who develop symptoms willMost infants who develop symptoms will do so in the first 12 hours of life.do so in the first 12 hours of life.
  • 28. Postnatal ManagementPostnatal Management Approach to theApproach to the ill newbornsill newborns ::  Transfer to NICU.Transfer to NICU.  Monitor closely.Monitor closely.  Full range of respiratory support should beFull range of respiratory support should be given.given.  Sepsis w/up and ABx indicated.Sepsis w/up and ABx indicated.
  • 29. Treatment in NICUTreatment in NICU Goals:Goals:  Increased oxygenation while minimizingIncreased oxygenation while minimizing the barotrauma (may lead to air leak).the barotrauma (may lead to air leak).  Prevent pulmonary hypertension.Prevent pulmonary hypertension.  Successful transition from intrauterine toSuccessful transition from intrauterine to extrauterine life with a drop in pulmonaryextrauterine life with a drop in pulmonary arterial resistance and an increase inarterial resistance and an increase in pulmonary blood flow.pulmonary blood flow.
  • 30. Treatment in NICUTreatment in NICU Ventilatory supportVentilatory support depends on the amount ofdepends on the amount of respiratory distress:respiratory distress:  OO22 hoodhood  CPAPCPAP  Mechanical ventilationMechanical ventilation  HFV should reduce air leaks.  High-frequency ventilators may slow the progression ofHigh-frequency ventilators may slow the progression of meconium down the tracheobronchial tree and allowmeconium down the tracheobronchial tree and allow more time for meconium removal.more time for meconium removal.
  • 31. Treatment in NICUTreatment in NICU surfactant therapy in MAS showed promising results with decrease in the number of infants requiring ECMO and possible reduction of pneumothorax
  • 32. Treatment in NICUTreatment in NICU Inhaled Nitric oxide (NO)  Selective pulmonary vasodilation.  Activate guanylate cyclase and increases cyclic GMP and acting directly on the vascular smooth muscle.  Decreased need for ECMO but no difference in mortality.  Pretreatment with surfactant improves in delivery of iNO to the alveoli.
  • 33. ECMOECMO  40% of infants with MAS treated with40% of infants with MAS treated with inhaled NO fail to respond and requireinhaled NO fail to respond and require ECMO.ECMO.  35% of ECMO patients are with MAS.35% of ECMO patients are with MAS.  Survival rate after ECMO 93-100%.Survival rate after ECMO 93-100%.
  • 34. ProgonosisProgonosis  Mortality reduced to <5% with new modalities ofMortality reduced to <5% with new modalities of therapy such as administration of surfactant,therapy such as administration of surfactant, HFV, iNO, ECMO.HFV, iNO, ECMO.  Chronic lung disease may result from prolongChronic lung disease may result from prolong mechanical ventilationmechanical ventilation  Those with significant asphyxial insult mayThose with significant asphyxial insult may demonstrate neurologic sequele.demonstrate neurologic sequele.
  • 35. SummarySummary  Optimal care of an infant born throughOptimal care of an infant born through MSAF involves close collaborationMSAF involves close collaboration between OBs and Neonatoloy team.between OBs and Neonatoloy team.  Effective communication and anticipationEffective communication and anticipation of potential problems is a corner stone ofof potential problems is a corner stone of the successful partnership.the successful partnership.