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MECONIUM STAINED LIQUOR

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MECONIUM STAINED LIQUOR

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MECONIUM STAINED LIQUOR

  1. 1. • Composition of Meconium: 1. Small dried amniotic fluid debris 2. Bile pigment 3. The residue from intestinal secretions. Aboubakr Elnashar
  2. 2. • Mechanisms of Meconium passage: (1) Physiologic maturational event, (2) Response to acute hypoxic events (3) Response to chronic intrauterine hypoxia. Aboubakr Elnashar
  3. 3. 12% to 16% of all deliveries (Cleary &Wiswell, 1998) <5 % of pre term pregnancies Up to 20% of term gestations Up to 50 % of post-mature infants INCIDENCE Aboubakr Elnashar
  4. 4. AETIOIOGY Hypoxia and acidemia: a. Relaxation of anal sphincter b. increasing the production of motilin, which promotes peristalsis. Aboubakr Elnashar
  5. 5. RISK FACTORS (Gregory et al, 1985) • Small-for-gestational-age • Postmature infants. • Cord complications • Chronic medical conditions , which can compromise the uteroplacental circulation. Aboubakr Elnashar
  6. 6. CONSISTENCY OF MECONIUM • Visually diagnosed thin meconium can be thick meconium when examined objectively and visual diagnosis is not always reliable and should be replaced with a new objective method. • All labors with meconium-stained amniotic fluid (either thin or thick) should be continuously monitored (Holtzman et al,1989) Aboubakr Elnashar
  7. 7. • Thin meconium: • Yellow to light green and is watery (Hagemanet al, 1988). • 10% to 40% of the cases of meconium passage. • Passed as a maturational event in most cases • infants are more likely to be healthy at birth. • 10% to 20% of cases of MAS occur with thin meconium. Aboubakr Elnashar
  8. 8. • Thick or particulate meconium: • is pasty or granular (Meis et al,1978). • The risk of perinatal death is increased (5-7times). • Early in labor generally reflects: a. Oligohydramnios b. risk factor for neonatal morbidity and mortality. Aboubakr Elnashar
  9. 9. Aboubakr Elnashar
  10. 10. Meconium aspiration • The presence of meconium below the vocal cords (Wiswell & Bent, 1993). • 20% to 30% of all infants with meconium-stained amniotic fluid. Meconium aspiration syndrome (MAS) 1-5 % of deliveries with MSL History of MSL Respiratory distress that develops shortly after birth, Radiographic evidence of aspiration pneumonitis Aboubakr Elnashar
  11. 11.  SEQUELE 1. Persistent pulmonary hypertension related to meconium. 2. Pneumothorax. 3. 4 -10 % neonatal death. Aboubakr Elnashar
  12. 12. PATHOPHYSIOLOGY • Aspiration of meconium can occur either antenatally or postnatally but in the majority of cases the exact timing is not clear. a. Antenatally, as meconium has been found in the lungs of stillbirths and in infants delivered by elective caesarean section without evidence of fetal distress. Aboubakr Elnashar
  13. 13. b. Postnatal inhalation can occur: late in the second stage or immediately after delivery if the infant gasps or makes breathing movements while the oropharynx, nasopharynx or trachea contains MSL Aboubakr Elnashar
  14. 14.  Meconium: 1. Causes mechanical blockage of the airway, 2. Acts as a chemical irritant causing pneumonitis, alveolar collapse and cell necrosis 3. Although initially sterile, predisposes to secondary bacterial infection Aboubakr Elnashar
  15. 15. PREVENTION A. Antenatal B. Intrapartum C. Postnatal Aboubakr Elnashar
  16. 16. A. Antenatal therapies 1. Amnioinfusion 2. Delivery by C.S. 3. Maternal sedation Aboubakr Elnashar
  17. 17. 1. Amnioinfusion • Meconium will be diluted. • A meta-analysis showed that this therapy has a role in the prevention of MAS. • But,it requires further evaluation, as it is associated with a number of complications, (higher incidence of instrumental delivery and endometritis) (Hofmeyr GJ. 2002, Cochrane Review). Aboubakr Elnashar
  18. 18. 2. Delivery by C.S. • Although most studies suggest that infants with meconium-stained liquor are more likely to be delivered by C.S. {suspicion or confirmation of fetal distress}. • There is currently no evidence that MAS would be prevented by elective C.S. {neither the conditions for, nor the timing of aspiration can be predicted}. Aboubakr Elnashar
  19. 19. 3. Maternal sedation • Administration of narcotics to laboring women will prevent fetal gasping in utero by suppressing fetal breathing (RCOG GRADE C). • Although there has been success in the prevention of MAS in animal models, there are no data to support this therapy in humans. Aboubakr Elnashar
  20. 20. B. Intrapartum management 1. Oropharyngeal suctioning 2. Physical manoeuvres Aboubakr Elnashar
  21. 21. 1. Oropharyngeal suctioning • Suction of the oropharynx and nasopharynx before delivery of the shoulders and trunk is a well- established practice that has been used since the 1970s. • Oropharyngeal suctioning would minimize the amount of meconium in the upper airway and thus reduce the amount aspirated during the onset of respiration (American Academy of Pediatrics, 2000). Aboubakr Elnashar
  22. 22. • Routine intrapartum oropharyngeal and nasopharyngeal suctioning of term-gestation, does not prevent MAS or its complication (Vain et al,2004). • The evidence relating to routine suctioning of the oropharynx as a preventative measure is conflicting (Cochrane library, 2004) • What is clear, is that meticulous cleaning of the upper airway after delivery is beneficial in reducing MAS. Aboubakr Elnashar
  23. 23. 2. Physical manoeuvres • MAS may be prevented if the infant is prevented from breathing after delivery. Aboubakr Elnashar
  24. 24. a. Thoracic compression thoracic cage of the infant is compressed to prevent respiration and subsequent aspiration of the contents of the upper airway b. Cricoid pressure external pressure is applied to the cricoid, thus preventing aspiration. Aboubakr Elnashar
  25. 25. • It is suggested that these interventions be continued until a second resuscitator undertakes oral and/or endotracheal suctioning. • There is no evidence supporting the use of either of these methods in preventing MAS. Aboubakr Elnashar
  26. 26. C. Postnatal intervention 1. Intratracheal suctioning 2. Aspiration of gastric contents 3. Saline lavage Aboubakr Elnashar
  27. 27. 1. Intratracheal suctioning • Until relatively recently, all infants with MSL underwent endotracheal intubation and suction, as this was known to reduce the incidence of MAS. More recently, evidence has suggested a change in practice depending on whether an infant is vigorous or not. • Vigorous infant is with (Good muscle tone, HR>100/m, strong respiratory effort) (American Academy of Pediatrics, 2000) Aboubakr Elnashar
  28. 28. • Routine intubation of vigorous term infants in order to aspirate the lungs should be abandoned (Cochrane library, 2003) Aboubakr Elnashar
  29. 29. 2. Aspiration of gastric contents To remove swallowed meconium is still done in many centers (American Academy of Pediatrics, 2000). • The passage of an orogastric tube is likely to cause apnoea and/or bradycardia and is potentially harmful. • This practice should be abandoned Aboubakr Elnashar
  30. 30. 3. Saline lavage • is used in order to loosen meconium in the distal airways. • It is potentially harmful, as it will displace endogenous surfactant, which could worsen the respiratory illness. • Infants developed respiratory distress secondary to 'wet lung'. Aboubakr Elnashar
  31. 31. DELIVERY ROOM MANAGEMENT OF INFANTS BORN WITH MECONIUM-STAINED LIQUOR • It is important that a person experienced in neonatal resuscitation attends the delivery of all infants in whom thick meconium-stained liquor is noted. Aboubakr Elnashar
  32. 32. • If an infant is vigorous after delivery: 1. No tracheal suctioning should be undertaken, 2. Secretions should be cleared from the mouth and nose using a wide-bore suction catheter, 3. Routine care should be given (American Academy of Pediatrics International Guidelines for Neonatal Resuscitation 2000). Aboubakr Elnashar
  33. 33. • If an infant is not vigorous afterbirth , 1. Do not stimulate 2. Direct endotracheal suctioning should be undertaken as soon as possible, 3. Suction should be applied for no more than 5 seconds and the tube withdrawn. Aboubakr Elnashar
  34. 34. • If meconium is aspirated from below the cords, the infant should be reintubated and the process repeated, • If there is profound bradycardia : 1. Resuscitation should proceed with intermittent positive pressure ventilation (IPPV) without suctioning 2. Further suctioning can be attempted at a later stage. Aboubakr Elnashar
  35. 35. • If after the first suctioning no meconium is aspirated: 1. No further suctioning should be attempted and 2. The infant should be resuscitated using IPPV via an endotracheal tube. Aboubakr Elnashar
  36. 36. IS MECONIUM PRESENT CONTINUE WITH RESUSCITATION  CLEAR MOUTH AND NOSE FROM SECRETIONS  DRY,STIMULATE AND REPOSITION  GIVE OXYGEN AS NECESSARY NO YES SUCTION MOUTH,NOSE AND POSTERIOR PHARYNX AFTER DELIVERY OF HEAD BUT BEFORE DELIVERY OF SHOULDERS IS THE BABY VIGOROUS? YES NO SUCTION MOUTH AND TRACHEAAboubakr Elnashar
  37. 37. CONCLUSIONS • The evidence relating to routine suctioning of the oropharynx as a preventative measure is conflicting. • Intratracheal suctioning should be reserved for the non-vigorous baby. • In the prevention of MAS, there is no evidence supporting the use of: 1. Saline lavage, 2. Gastric aspiration or 3. Thoracic & or cricoid compression Aboubakr Elnashar
  38. 38. Aboubakr Elnashar

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