Meconium Stain Amniotic

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Meconium-stained amniotic fluid

Dahiana M. Gallo, MD, PhD; Roberto Romero, MD, DMedSci; Mariachiara Bosco, MD; Francesca Gotsch, MD;
Sunil Jaiman, MD; Eunjung Jung, MD; Manaphat Suksai, MD; Carlos López Ramón y Cajal, MD;
Bo Hyun Yoon, MD, PhD; Tinnakorn Chaiworapongsa, MD
Green-stained amniotic fluid, often referred to as meconium-stained amniotic fluid, is present in 5% to 20% of patients in labor and is
considered an obstetric hazard. The condition has been attributed to the passage of fetal colonic content (meconium), intraamniotic
bleeding with the presence of heme catabolic products, or both. The frequency of green-stained amniotic fluid increases as a function of
gestational age, reaching approximately 27% in post-term gestation. Green-stained amniotic fluid during labor has been associated with
fetal acidemia (umbilical artery pH <7.00), neonatal respiratory distress, and seizures as well as cerebral palsy. Hypoxia is widely
considered a mechanism responsible for fetal defecation and meconium-stained amniotic fluid; however, most fetuses with meconium-
stained amniotic fluid do not have fetal acidemia. Intraamniotic infection/inflammation has emerged as an important factor in meconium-
stained amniotic fluid in term and preterm gestations, as patients with these conditions have a higher rate of clinical chorioamnionitis and
neonatal sepsis. The precise mechanisms linking intraamniotic inflammation to green-stained amniotic fluid have not been determined,
but the effects of oxidative stress in heme catabolism have been implicated. Two randomized clinical trials suggest that antibiotic
administration decreases the rate of clinical chorioamnionitis in patients with meconium-stained amniotic fluid. A serious complication of
meconium-stained amniotic fluid is meconium aspiration syndrome. This condition develops in 5% of cases presenting with meconium-
stained amniotic fluid and is a severe complication typical of term newborns. Meconium aspiration syndrome is attributed to the me-
chanical and chemical effects of aspirated meconium coupled with local and systemic fetal inflammation. Routine naso/oropharyngeal
suctioning and tracheal intubation in cases of meconium-stained amniotic fluid have not been shown to be beneficial and are no longer
recommended in obstetrical practice. A systematic review of randomized controlled trials suggested that amnioinfusion may decrease the
rate of meconium aspiration syndrome. Histologic examination of the fetal membranes for meconium has been invoked in medical legal
litigation to time the occurrence of fetal injury. However, inferences have been largely based on the results of in vitro experiments, and
extrapolation of such findings to the clinical setting warrants caution. Fetal defecation throughout gestation appears to be a physiologic
phenomenon based on ultrasound as well as in observations in animals.
Key words: bilirubin, biliverdin, discolored amniotic fluid, fetal colonic content, fetal defecation, green-stained amniotic fluid, hypoxia,
intraamniotic infection, intraamniotic inflammation, meconium aspiration syndrome, placenta histology, seizures, Soret band
From the Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver
National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services,
Bethesda, MD, and Detroit, MI (Drs Gallo, Romero, Bosco, Gotsch, Jaiman, Jung, Suksai, and Chaiworapongsa); Department of Obstetrics and
Gynecology, Wayne State University School of Medicine, Detroit, MI (Drs Gallo, Bosco, Gotsch, Jung, Suksai, and Chaiworapongsa); Department of
Gynecology and Obstetrics, Universidad Del Valle, Cali, Colombia (Dr Gallo); Department of Obstetrics and Gynecology, University of Michigan, Ann
Arbor, MI (Dr Romero); Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (Dr Romero); Department of Pathology,
Wayne State University School of Medicine, Detroit, MI (Dr Jaiman); Unit of Prenatal Diagnosis, Service of Obstetrics and Gynecology, Álvaro Cunqueiro
Hospital, Vigo, Spain (Dr López Ramón y Cajal); and Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul,
Republic of Korea (Dr Yoon).
Received Aug. 31, 2022; revised Nov. 9, 2022; accepted Nov. 9, 2022.
The Perinatology Research Branch, NICHD/NIH/DHHS, has been renamed as the Pregnancy Research Branch, NICHD/NIH/DHHS.
The authors report no conflict of interest.
This research was supported, in part, by the Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural
Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and
Human Services (NICHD/NIH/DHHS); and, in part, by federal funds from NICHD/NIH/DHHS (Contract No. HHSN275201300006C). R.R. has contributed
to this work as part of his official duties as an employee of the US Federal Government.
Corresponding author: Roberto Romero, MD, DMedSci. [email protected]
0002-9378/$36.00 Published by Elsevier Inc. https://doi.org/10.1016/j.ajog.2022.11.1283
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S1158 American Journal of Obstetrics & Gynecology MAY 2023

ajog.org Expert Review
Introduction
Green-stained amniotic fluid, often TABLE 1
referred to as meconium-stained Meconium composition
amniotic fluid (MSAF), has been Water (70%e80%)
considered an obstetrical hazard for cen- Intestinal epithelial cells
Squamous cells
turies. However, not all green-stained Vernix caseosa
amniotic fluid is meconium, and not all Fetal hair
meconium is green. This article will re- Amniotic fluid
view the composition of meconium, the Bile pigments (eg, bilirubin, zinc-coproporphyrin)
clinical significance of MSAF and its im- Bile acids (eg, chenodeoxycholic and cholic acids)
Pancreatic enzymes
plications for obstetrical practice, the Free fatty acids
pathophysiology of meconium aspiration
Gallo. Meconium-stained amniotic fluid. Am J Obstet Gynecol 2023.
syndrome (MAS), and the physiology of
fetal defecation.
FIGURE 1
Meconium-stained neonate at 39D4 weeks of gestation
A, Yellow-greenish discoloration of fetal skin at different body sites. The evidence of peripheral cyanosis is shown in B, lips, C, ears, and D, fingertips. C,
Meconium is also present in the ear canal.
Photos courtesy of Dr Sunil Jaiman.
MAY 2023 American Journal of Obstetrics & Gynecology S1159

Expert Review ajog.org
neonatal sepsis,3,32,33 neonatal seizures,34

TABLE 2 MAS,35e39 and cerebral palsy.40e43
Risk factors for meconium-stained amniotic fluid Several clinical conditions (eg, pro-
Postterm pregnancy longed labor, fetal growth restriction,
Prolonged labor oligohydramnios, vaginal breech delivery,
Clinical chorioamnionitis
Fetal growth restriction etc.) have been related to the passage of
Preeclampsia meconium into the amniotic fluid,44e51
Oligohydramnios and the risk factors for MSAF are re-
Vaginal breech delivery ported in Table 2.
Maternal drugs (eg, cocaine, castor oil, bowel purgatives)
Herbal substances (eg, “isihlambezo”)
Intrahepatic cholestasis of pregnancy
Factors associated with meconium-
stained amniotic fluid
Gestational age
The rate of MSAF increases as a function
What is meconium? pigment in meconium, is detectable in of gestational age and can reach 27% at 42
The word “meconium” is derived from the fetal liver and gallbladder from 14 weeks of gestation44,45,50,52e60 (Figure 2).
the Greek word mekoni, which means weeks of gestation.19 Whereas the intes- A subset of postterm neonates is affected
“poppy juice” or “opium-like,” referring tinal content of children and adults is by the postmaturity syndrome, defined as
to the belief that fetal exposure to rich in bacteria, meconium during fetal fetal growth restriction in a postterm
meconium would lead to neonatal life is sterile,20 as shown by metagenomic gestation.61 The presence of MSAF is a
sleepiness or depression,1e3 a concept studies21 that controlled for contamina- criterion of stage II postmaturity syn-
generally attributed to Aristotle.1,2,4 tion of reagents and by studies in drome proposed by Clifford61 (Figure 3).
Meconium is the fetal colonic content, nonhuman primates and mice.22,23 The higher rate of meconium passage
which is mainly composed of water reported in term gestations is thought to
(72%e80%),2 exfoliated skin cells, Meconium as an obstetrical hazard reflect maturation of the gastrointestinal
lanugo, vernix caseosa, and gastrointes- Völtern reported in 1687 that MSAF was system. Observational studies in guinea
tinal secretions5e16 (Table 1). The associated with fetal death,24 an observa- pigs62 and monkeys63 have shown that
typical greenish-yellow color of meco- tion subsequently confirmed by multiple intestinal peristalsis increases with
nium is attributed to bile authors25e28(Figure 1). Indeed, MSAF is advancing gestational age. Similar evi-
pigments.7e11,17,18 Bilirubin, a product considered a risk factor for neonatal dence in human fetuses was reported in
of heme catabolism and the main hypoxic-ischemic encephalopathy,3,29e31 studies documenting fetal gastrointes-
tinal motility with amniography.64
The following endocrine factors have
FIGURE 2 been implicated in the increased fre-
Frequency of MSAF as a function of gestational age quency of meconium passage at term:
1. Motilin, a gut hormone produced by

enteroendocrine cells in the duo-
denum,65 is capable of inducing
intestinal peristalsis.66 The concen-
tration of motilin is significantly
higher in umbilical cord blood from
term neonates than from preterm
neonates67 and in those with MSAF
versus clear fluid.68,69
2. Cortisol increases in fetal plasma at
the time of parturition70,71 and can
also induce intestinal motility, as
demonstrated in an observational
study of pregnant monkeys where
intraamniotic injection of glucocorti-
coids resulted in meconium passage.72
Modified from Balchin et al.50 3. Corticotropin-releasing factor, a
MSAF, meconium-stained amniotic fluid. hormone that increases with gesta-
Gallo. Meconium-stained amniotic fluid. Am J Obstet Gynecol 2023. tional age,73e76 can also accelerate
fetal gut motility.77e82

FIGURE 3
Meconium in postmaturity syndrome with fetal death at 40 weeks of gestation
AeE, The neonate shows the classical features of postmaturity syndrome characterized by loss of vernix caseosa, loss of subcutaneous fat and presence
of macerated, wrinkled skin. Meconium passage is documented by A, the discoloration of the skin, F, the greenish-yellow discoloration of the anus, and
G, the green-yellow staining of placental membranes.
Fetal hypoxia heart rate monitoring. In the first regulation of pathologic fetal defecation
MSAF has been associated with fetal study,34 surveillance was performed with has been proposed. Indeed, sympathetic
acidemia34,83,84 and chronic hypoxia intermittent auscultation, whereas in the system blockade, achieved chemically
(assessed by erythropoietin concentra- second study,54 continuous electronic with 6-hydroxydopamine, in the same
tions in umbilical cord blood).85e87 The fetal heart rate monitoring was used. It is experimental paradigm of cord occlu-
largest study to examine the relationship possible that improved surveillance al- sion does lead to meconium passage.98 It
between MSAF and fetal acidemia lows earlier detection of a compromised is also noteworthy that normal fetal
included 42,709 term pregnancies, of fetus, and thus the association between defecation in animal studies is observed
which 8136 had MSAF. Meconium was MSAF and umbilical artery acidemia was in the absence of fetal hypoxemia or
associated with a significantly higher rate not observed. acidemia.99
of umbilical artery pH 7.00 (7% [56/ It is widely accepted that fetal hypoxia
8136] vs 3% [95/34,573]; P<.001; odds leads to meconium passage.34,83,84,94 Intraamniotic infection/inflammation
ratio [OR], 2.5; 95% confidence interval However, experimental studies have MSAF is associated with microbial in-
[CI], 1.8e3.4)34 (Table 3). However, challenged this view. For example, vasion of the amniotic cavity in term and
most neonates born to mothers with maternal aortic constriction in pregnant preterm gestations.57,58,100,101 In pa-
MSAF do not have evidence of metabolic rabbits to induce fetal distress is not tients with preterm labor and intact
acidemia at birth.56,85,88e93 Indeed, in a associated with meconium passage,95 membranes, those with green-colored
recent retrospective study including 3590 and neither is acute hypoxia of preg- amniotic fluid have a higher rate of
deliveries, MSAF was not associated with nant sheep sufficient to drop the fetal positive amniotic fluid cultures for bac-
umbilical artery acidemia, and 80% of partial pressure of oxygen.96,97 Similarly, teria compared to those with clear am-
neonates with MSAF had a pH 7.20.54 repeated cord occlusion leading to fetal niotic fluid (33% [10/30] vs 11% [75/
These conflicting results between the 2 acidemia is not associated with meco- 677]; P¼.001).58 Mazor et al102
largest studies may be explained by dif- nium passage in fetal sheep. A role for confirmed the association between
ferences in the use of intrapartum fetal the autonomic nervous system in the MSAF and the presence of bacteria in the

TABLE 3
Outcomes in neonates born with meconium-stained amniotic fluid compared to neonates born with clear
amniotic fluid
Outcome MSAF Clear AF P value Odds ratio 95% CI
Total infants 8136 34,573
Apgar score 3
1-min 123 (15) 201 (6) <.001 2.6 2.1e3.2
5-min 14 (2) 19 (1) .003 3.1 1.6e6.0
Umbilical artery pH 7.00 56 (7) 95 (3) <.001 2.5 1.8e3.4
Apgar score 3 at 5 min and pH 7.00 9 (1) 5 (0.1) <.001 7.6 3.0e19.3
Special care nursery admission 193 (24) 248 (7) <.001 3.3 2.8e3.9
Respiratory distress a
223 (27) 288 (8) <.001 3.3 2.8e3.9
IVH grade III or IV 1 (0.1) 2 (0.1) .5 2.1 0.2e22.2
Seizures in the first 24 h 17 (2) 13 (0.4) <.001 5.6 2.9e10.5
Cesarean delivery
Total 1170 (14) 2420 (7) <0.001 2.1 1.9e2.2
Dystocia 609 (7) 1328 (4) <0.001 1.9 1.8e2.1
Fetal distress 472 (6) 628 (2) <0.001 3.2 2.9e3.6
Modified from Nathan et al.34
AF, amniotic fluid; CI, confidence interval; IVH, intraventricular hemorrhage; MSAF, meconium-stained amniotic fluid.
a
Halo or ventilator therapy.
amniotic fluid in patients with preterm

FIGURE 4 labor and intact membranes (38 [17/45]
Meconium-stained amniotic fluid vs 11% [15/135]; P<.001) and also with
clinical chorioamnionitis (22 [10/45] vs
6% [8/135]; P¼.003).102 The same as-
sociation between meconium and
intraamniotic infection has been re-
ported at term. In patients with clinical
chorioamnionitis, those with MSAF
have a higher rate of microbial invasion
of the amniotic cavity and bacterial
endotoxin compared to those with clear
amniotic fluid (19.6% [13/66] vs 4.7%
[2/42]; P<.05; and 46.9% [31/66] vs
4.7% [2/42]; P<.001; respectively).100 In
addition, the concentrations of inter-
leukin (IL)-6 are higher in MSAF,
providing evidence of an intraamniotic
inflammatory response.100
The green discoloration of amniotic
fluid in the context of intraamniotic
infection/inflammation has been attrib-
uted either to the passage of meconium
AeB, Green meconium. CeD, “Thin,” yellow meconium. The traditional concept is that meconium is or to oxidative stress in the amniotic
green when first passed and can become yellow over time. cavity. Bacteria can elicit intraamniotic
Gallo. Meconium-stained amniotic fluid. Am J Obstet Gynecol 2023. inflammation, which in turn leads to the
generation of reactive oxygen

TABLE 4 FIGURE 5
Adverse neonatal and maternal outcomes associated with thick Spectrophotometric analysis of
meconium-stained amniotic fluid amniotic fluid
Neonatal outcomes Maternal outcomes
Abnormal fetal heart rate tracing Cesarean delivery
Meconium aspiration syndrome Puerperal endometritis
Neonatal intensive care unit admission Clinical chorioamnionitis
Need for neonatal ventilation Intrapartum fever
Hypoxic-ischemic encephalopathy of the neonate Intraamniotic infection
Small for gestational age
Low Apgar score
species103,104 capable of inducing (2) a clear contrast between the amniotic

oxidation of heme catabolic products fluid and the umbilical vessels; and (3)
such as bilirubin.105,106 We have previ- layering in the more dependent areas.110
ously proposed that bacteria and amni- However, this appearance is not specific
otic fluid with inflammatory products, to meconium and can be seen in the
when ingested by the fetus, may stimu- presence of vernix or even blood.111e115
late bowel peristalsis.58,100 An alternative In a study of 278 patients who were
explanation for the association between scanned 24 hours before delivery, the
intraamniotic infection/inflammation prevalence of echogenic amniotic fluid
and MSAF is that meconium enhances was 3.2%, and of these patients, 44% (4/ The absorption spectra of amniotic fluid (after
bacterial proliferation by serving as a 9) had MSAF, with a sensitivity of 14% centrifugation) with different concentrations of
growth factor57,58,102 and by inhibiting and a positive predictive value of 44%.116 meconium are shown. The band height is line-
the bacteriostatic properties of amniotic Therefore, ultrasound has limited diag- arly correlated with meconium concentration.
fluid or antagonizing host defense nostic value for identifying MSAF. Modified from Molcho et al.131
systems,107e109 thus increasing the risk Green-colored amniotic fluid has OD, optical density.
of infection. been detected at amniocentesis for ge- Gallo. Meconium-stained amniotic fluid. Am J Obstet
Prolonged gestation, fetal hypoxia, netic indications in the midtrimester or Gynecol 2023.
and intraamniotic infection/inflamma- in the third trimester. In the past, serial
tion could explain only a subset of pa- transabdominal amniocenteses were
tients with MSAF. The causes for the used as a method of surveillance in obstetrical practice divides MSAF into
remaining cases have yet to be eluci- women with prolonged gestations to “thick” and “thin” (Figure 4). Thick
dated. Omics analysis of amniotic fluid detect postmaturity syndrome117 or in meconium is associated with higher
stained with meconium would provide patients with intrahepatic cholestasis of rates of abnormal fetal heart trac-
an insight into the pathophysiology of pregnancy to assess the risk of fetal ings,54,83,121,122 MAS,121,123e127 neonatal
MSAF and could allow the identification death.118 However, serial amniocenteses intensive care unit (NICU)
of biomarkers that can serve in the for these indications have been aban- admission,84,127e129 need for neonatal
stratification of patients according to doned because of the lack of evidence ventilation,123 hypoxic-ischemic en-
MSAF etiology. that detection of meconium and induc- cephalopathy of the neonate,123,130 small
tion of labor improve pregnancy for gestational age,123 and low Apgar
Assessment of meconium-stained outcomes.119 scores.32,83,124,125,128,129 Similarly, higher
amniotic fluid Meconium in amniotic fluid has been rates of cesarean delivery,6,66,79,131e133
Typically, MSAF is diagnosed after classified according to its thickness into puerperal endometritis,134 clinical cho-
rupture of membranes or by amniocen- grades 1 to 3 (grade 1: lightly stained rioamnionitis,84,134 intrapartum fever,54
tesis. Occasionally, sonographic partic- amniotic fluid, green or yellow; grade 2: and intraamniotic infection135 have
ulate matter in amniotic fluid raises the green- or yellow-stained amniotic fluid been reported in women with thick
suspicion for MSAF. The ultrasound with some particulate matter; and grade MSAF (Table 4). Obstetrical conditions,
criteria proposed for the identification of 3: dense meconium with “pea-soup” such as oligohydramnios associated with
MSAF include (1) a diffuse echogenic consistency).120 However, the most postterm pregnancies136,137 or utero-
pattern throughout the amniotic cavity; commonly used classification in placental insufficiency,122,138e141 altered

FIGURE 6
The catabolism of heme
Heme is first transformed into biliverdin and then to bilirubin in the reticuloendothelial system. The first reaction consists of the conversion of c to
biliverdin, and it is catalyzed by the heme oxygenase system. Subsequently, biliverdin reductase reduces biliverdin to bilirubin.
Modified from Rodwell et al.149
COOH, carboxyl group; NADPþ, nicotinamide adenine dinucleotide phosphate; NADPH, nicotinamide adenine dinucleotide phosphate hydrogen.
fetal swallowing,142 increased meconium to biliverdin,148 an intermediate product shows additional peaks (attributed to
passage, and impaired reabsorption of of heme catabolism that can be subse- oxyhemoglobin, methemoglobin, and
meconium by amniotic membrane quently reduced to bilirubin in the methemalbumin) that can be used in the
macrophages,143,144 have been impli- reticuloendothelial system through a differential diagnosis with MSAF.158
cated in the genesis of thick MSAF. reversible reaction (Figure 6). Indeed, Amniotic fluid contaminated with
A quantitative approach to assess the oxidation of bilirubin leads to bili- meconium at term usually tests negative
meconium load in the amniotic fluid is verdin.106,150,151 Bilirubin, a yellow for hemoglobin and shows no extra
the “meconium-crit.”145 This test is pigment, is consistently detected in peaks at spectrophotometric analysis
based on the same principle as that used meconium,17,19 whereas there is paucity (Figure 7).
to calculate the hematocrit with a capil- of evidence that this is the case for
lary tube, and results correlate well with biliverdin.17 Maternal implications of meconium-
meconium concentrations145 but may Green- and brown-discolored amni- stained amniotic fluid
not reflect neonatal outcomes. Other otic fluid at the time of midtrimester MSAF is associated with intraamniotic
methods such as spectrophotometry131 amniocentesis has been reported in infection,58,100,101 clinical chorioam-
and nuclear magnetic resonance spec- 1.2% to 8% of cases152e161 and is asso- nionitis,47,58,102,134,164e168 puerperal
troscopy have also been proposed as ciated with pregnancy loss in 9% of endometritis,134,169 postcesarean infec-
tools to estimate meconium concentra- those cases.160 Brown amniotic fluid was tion,170 postpartum hemorr-
tion in amniotic fluid. The band height considered an indicator of intraamniotic hage,169,171e173 and dehiscence of peri-
in the spectrophotometric tracing cor- hemorrhage, whereas green fluid was neal lacerations.174,175 The association
relates with meconium concentra- attributed to the presence of meconium. between meconium and infection pro-
tions131 (Figure 5). Nuclear magnetic Spectrophotometric analysis of mid- vides a rationale for exploring the role of
resonance spectroscopy can also be used trimester discolored amniotic fluid per- antibiotic administration in MSAF. A
to quantitate meconium in amniotic formed by Hankins et al159 reported that systematic review of 2 randomized clin-
fluid on the basis of T1 and T2 relaxation green and brown discolorations were ical trials176e178 of women with MSAF
times that decrease with increasing attributable to previous episodes of allocated to intravenous ampicillin/sul-
concentrations of meconium.146,147 intraamniotic bleeding, as reflected by bactam vs placebo showed that intra-
Neither spectrophotometry, nuclear the presence of free hemoglobin. Clear partum antibiotic administration
magnetic resonance spectroscopy, nor amniotic fluid has a smooth absorption reduced the frequency of clinical cho-
meconium-crit have been implemented spectrum (Figure 7), whereas contami- rioamnionitis (relative risk [RR], 0.36;
in clinical practice. nation with either blood or meconium 95% CI, 0.21e0.62) but not the fre-
typically adds an absorption peak near quency of postpartum endometritis (RR,
Green-stained amniotic fluid is not 400 nm (also known as “Soret 0.50; 95% CI, 0.18e1.38), neonatal
always indicative of meconium band”)149,162 attributable to the pres- sepsis (RR, 1.00; 95% CI, 0.21e4.76), or
The traditional view that all green- ence of hemoglobin in the former and of NICU admission (RR, 0.83; 95% CI,
stained amniotic fluid is due to meco- meconium pigments (eg, bilirubin) in 0.39e1.78). An alternative approach is
nium has been challenged. The green the latter.149,158,159,163 The absorption administering antibiotics selectively
color of meconium has been attributed spectrum in intraamniotic bleeding to patients at particularly high risk

FIGURE 7
Spectrophotometric analysis of amniotic fluid at different gestational ages
A, Normal term amniotic fluid spectrum. The typical spectrum shows a smooth declining slope without peaks, suggesting lack of chemical compounds
absorbing light. B, Typical spectrophotometric tracing of discolored second-trimester amniotic fluid with a maximum peak near 405 nm (“Soret band”)
(red arrow) and several secondary absorption peaks at 450 nm, 550 nm, and 620 nm (blue arrows). C, Spectrophotometric tracing of term meconium-
stained amniotic fluid. There is a peak at 405 nm (red arrow) and a smooth declining slope without additional peaks.
Modified from Alger et al.158
for infection, determined by a high pulmonary disease,84,183 neonatal sei- meconium passage, fetal gasping,192,193
concentration of IL-8 in amniotic fluid zures34,184 and long-term neurologic and meconium aspiration before birth.
obtained through a transcervical cath- disability (eg, cerebral palsy).40e42 However, a large fraction of neonates
eter coupled with point-of-care MAS is defined as respiratory distress with MAS do not have acidemia at
testing.179 The value of this approach in term neonates born to mothers birth55,88e93 (Table 5); therefore, alter-
should be the subject of prospective with MSAF that cannot be native mechanisms must be involved in
studies. otherwise explained (Figure 8). MAS is the pathogenesis of this syndrome.
a cause of neonatal morbidity and Meconium itself can cause local damage
Neonatal implications of meconium- mortality,1,3,30,35,88,122,185 and the reason in the fetal lungs through (1) a me-
stained amniotic fluid: meconium why only 5%35e39 of infants exposed to chanical effect, which can cause airway
aspiration syndrome meconium develop MAS remains an obstruction leading to atelectasis or air
MSAF occurs in 5% to 20% of deliveries at enigma (Figure 9). Typically, MAS affects trapping within the bronchioles and the
term3,35,84,165,180e182 and is a risk factor for neonates with an intrauterine event that alveoli101,194,195 (Figure 10); (2) a
neonatal complications131,136,137,142,143,145 causes intrapartum or antepartum fetal chemical effect of meconium content
such as MAS,35e39 neonatal sepsis,3,32,33 hypoxia129,165,180,186e191 leading to (eg, free fatty acids, bile salts, pancreatic

disease with poor alveolar recruitment

FIGURE 8
and decreased functional residual ca-
Chest X-ray showing bilateral patchy opacifications pacity (FRC) or hyperinflation with
increased FRC contribute to elevations
in pulmonary vascular resistance.203 In
addition, the release of chemically vaso-
active mediators, such as endothelin-1,
thromboxane-A2, and prostaglandins,
has also been shown to contribute to the
development of PPHN in MAS.204
Vascular changes such as hyperplasia of
the vascular media and interstitium,
narrowing of the vessel lumen, tortuosity
of the arteries, and muscularization of
the alveolar septal arterioles have been
described in MAS.205,206
In the context of intraamniotic
infection/inflammation, fetal swallowing
of amniotic fluid containing bacte-
ria,207,208 endotoxins,58,100,101,209
132,207,210e215
alarmins, inflammatory
mediators,100,101,133,216,217 and phospholi-
pase A2 can induce fetal inflam-
Photo courtesy of Dr Tejo Pratap.
matory response syndrome (FIRS)
resulting in diffuse lung injury.55,101,218
The combination of pulmonary
phospholipases) that can result in Persistent pulmonary hypertension inflammation and capillary damage/
surfactant inactivation196,197; and (3) (PPHN) occurs in 20% to 40% of infants leakage occurring during FIRS could
a local inflammatory response (pneu- with MAS. Several mechanisms have explain the association between MSAF,
monitis)194,195,198,199 that can lead to been implicated in the development of intraamniotic inflammation/infection,
decreased pulmonary function.200,201 PPHN in MAS.202 Parenchymal lung and MAS.55 The observation that FIRS is a
risk factor for MAS has clinical implica-
FIGURE 9 tions. Indeed, umbilical cord blood con-
Autopsy of a neonate with evidence of meconium in the trachea from MAS centrations of IL-6 or C-reactive protein
could assist in the identification of infants
who have systemic inflammation.
Prophylactic intrapartum trans-
cervical amnioinfusion was proposed to
reduce the rate of MAS and other adverse
neonatal outcomes. Subsequently, this
procedure was abandoned after the
publication of a meta-analysis reported
no evidence of benefit (RR, 0.59; 95%
CI, 0.28e1.25), 5-minute Apgar score
<7 (RR, 0.90; 95% CI, 0.58e1.41), or
cesarean delivery (RR, 0.89; 95% CI,
0.73e1.10). Prophylactic amnioinfusion
seems to have a role only in clinical set-
tings with limited peripartum surveil-
lance given that it helps to reduce the risk
of MAS (RR, 0.25; 95% CI,
0.13e0.47).219 However, these results
The arrow points to fetal hair within the trachea.
and interpretation have been a subject of
MAS, meconium aspiration syndrome.
debate.220,221 Recently, a new meta-
Photo courtesy of Dr Sunil Jaiman.
analysis that reassessed the value of
prophylactic amnioinfusion in the

presence of MSAF reported a reduction

of MAS by 67% (pooled OR, 0.33; 95% TABLE 5
CI, 0.21e0.51). Amnioinfusion is Prevalence of neonatal acidemia in meconium aspiration syndrome
thought to dilute thick meconium, Neonatal umbilical artery pH at birth in MAS cases
thereby decreasing its mechanical and Author, date pH ‡7.20 pH <7.20 pH <7.10 pH <7.00
proinflammatory effects. This meta- 55
Lee et al, 2016 58.3% (7/12) 41.7% (5/12) 16.7% (2/12) 8.3% (1/12)
analysis is reported in detail in this 88
Blackwell et al, 2001 60.4% (29/48) 39.6% (19/48) na na
issue of the American Journal of Obstet-
rics & Gynecology. Yeomans et al,90 1989 83.3% (5/6) 16.7% (1/6) na na
91
Because neonatal airway obstruction Trimmer et al, 1991 50%e100% (1e2/2) 0%e50% (0e1/2) na na
by meconium is believed to be causal of MAS, meconium aspiration syndrome; na, not applicable.
MAS, several approaches have been Gallo. Meconium-stained amniotic fluid. Am J Obstet Gynecol 2023.
proposed to remove meconium from
the fetal and neonatal airways to prevent
aspiration (reviewed in detail by Wis- delivery of the chest and onset of air Observational studies also showed no
well185). Routine endotracheal intuba- breathing as a method to prevent benefit in the reduction of MAS.234e238
tion was introduced in the 1970s after meconium aspiration. This procedure Such findings led to the design and
Burke-Strickland and Edwards222 and was performed with either a bulb syringe execution of randomized controlled
Gregory223 reported a favorable expe- or a suction catheter. The combined trials183,229,239e244 and subsequent
rience with this practice. Gregory approach consisted of immediate oro/ meta-analyses,226e228 which demon-
et al223 found that 56% of newborns nasopharyngeal suctioning at the time of strated that neither routine suctioning of
delivered by mothers with MSAF delivery of the fetal head, followed by the oro/nasopharynx after the delivery of
already had meconium in the trachea at endotracheal intubation and suctioning the head,226 nor intubation with tracheal
the time of birth, and that in 10% of the after birth. This management was re- suctioning in both vigorous227 and
cases, meconium was present below ported to reduce the rate of MAS from nonvigorous newborns,228 prevented or
the vocal cords, although not visible in 1.9% (18/947) to 0.4% (1/273) with altered the frequency and course of
the mouth or pharynx. The authors endotracheal aspiration alone.224 The MAS. Consensus has emerged that in-
further noted a reduction in the fre- combined approach has been used in fants born to mothers with MSAF
quency of pneumothorax, mechanical labor and delivery units for decades225; should no longer routinely receive suc-
ventilation, and continuous positive however, subsequent studies questioned tioning at birth, whether or not they
airway pressure after early endotracheal efficacy226e228 and safety.229e233 Indeed, are vigorous. The current recommen-
intubation.223 complications such as laryngeal lesions dation is that management should be
Other investigators advocated com- leading to stridor and hoarseness,229 guided by general neonatal resuscitation
plete removal of meconium from the bradycardia,230 apnea,230 hypoxemia, principles rather than a prespecified
oropharynx and nasopharynx before the and desaturation231e233 were reported. approach.245
FIGURE 10
Meconium in the fetal bronchioles and alveoli
A, Bronchioles. B, Alveoli. The arrows indicate fetal anucleated squamous cells, one of the components of meconium. Stained with H&E.
H&E, hematoxylin and eosin.

condition. These phagocytic cells can be

FIGURE 11
identified by the presence of brown-
Chorioamniotic membranes stained with H&E in a case of MSAF yellowecolored cytoplasmic granules on
hematoxylin and eosin staining143,246
(Figure 11). However, similar granules
can be observed in the placentas of pa-
tients who had intraamniotic
bleeding.246 Histochemistry staining for
hemosiderin247e249 (eg, Perls Prussian
blue stain, Gomori Trichrome stain, or
Berlin blue stain) can assist in the dif-
ferential diagnosis of bleeding vs meco-
nium. The rationale is that bilirubin in
meconium does not contain iron,
whereas hemosiderin (an iron-storage
complex in cells) does. Pathologists rely
on this approach to diagnose meconium
staining of the fetal membranes. If iron
staining is negative, the diagnosis of
Meconium is visualized within macrophages (blue arrows) in the amnion and chorion stroma (blue meconium is made. Meconium contains
squared parenthesis). Meconium-laden macrophages are recognized by the pink staining of the zinc-coproporphyrin I,10,250 and in-
cytoplasm after excluding hemosiderin pigment with Prussian blue staining (not shown). vestigators have recently developed a
H&E, hematoxylin and eosin.; MSAF, meconium-stained amniotic fluid
monoclonal antibody for this com-
Photo courtesy of Dr Sunil Jaiman.
pound and identified this molecule in
chorioamniotic membranes.250 This
would provide direct evidence of the
Placental histopathologic findings in membranes and umbilical cord at gross presence of meconium.
meconium-stained amniotic fluid placental inspection (Figure 3, G). Meconium in the chorioamniotic
MSAF often results in green-yellow Microscopically, meconium-laden mac- membranes has been used in medical
staining of the chorioamniotic rophages are the hallmark of this legal litigations to time adverse events
and to formulate arguments about
medical negligence. Desmond et al251
FIGURE 12 reported that immersion of the lower
Chorioamniotic membranes stained with H&E in a case of MSAF extremities of neonates in MSAF would
cause mild yellow staining of toenails in
4 to 6 hours, whereas yellow staining of
the vernix caseosa would take 12 to 14
hours. The time required to stain the
chorioamniotic membranes has been a
subject of debate. For example, Miller
et al252 incubated disks of chorioamni-
otic membranes with meconium and
reported that meconium-laden macro-
phages were present in the amnion after
1 hour of exposure and in the chorion
after 3 hours. A subsequent experiment
in which the exposure to meconium was
restricted to the amnion found that it
took 24 to 48 hours for a substantial
number of meconium-laden macro-
phages to be observed.143 This finding
Reactive amnion hyperplasia (red arrows) and cytoplasmic vacuolation (blue arrows) are observed. has been interpreted as indicating that
H&E, hematoxylin and eosin; MSAF, meconium-stained amniotic fluid. meconium staining of the membranes
Photo courtesy of Dr Sunil Jaiman. reflects fetal defecation that occurred at
Gallo. Meconium-stained amniotic fluid. Am J Obstet Gynecol 2023. least 1 day before delivery of the
placenta. By contrast with these in vitro

FIGURE 13
Meconium-induced umbilical cord vessel myonecrosis
A, Gross image of the umbilical cord in a case of fetal death with meconium-stained amniotic fluid at term. Several areas of ulceration are observed. The
Wharton’s jelly is eroded and the vessels are exposed. The dark color represents the muscularis of the vessels. B, Shallower ulcerations of the cord. The
muscularis is not eroded in this part of the cord. C, Hematoxylin and eosin staining of the umbilical cord. The umbilical vein is on the top and the 2 arteries
below. At this magnification, myonecrosis is not evident. D, The wall of the umbilical vein with evidence of myonecrosis. E, Umbilical artery with damaged
myocytes (blue arrows) is observed in the muscular layer closer to the amniotic cavity. Cytoplasmic hypereosinophilia with nuclear pyknosis is evident.
The red line indicates the outer perimeter of the umbilical vessel closer to the amniotic cavity, and the red arrow indicates the umbilical cord artery lumen.
F, Cytoplasmic and nuclear changes are better seen at higher magnification (blue arrows).
experiments, an in vivo observational Placental inflammatory lesions chorioamniotic membranes and

study documented the duration of associated with meconium exposure umbilical cord are present in approxi-
meconium exposure (by change in the A large body of evidence supports an mately 60% of cases of MSAF.199,255,256
color of amniotic fluid from clear to association between inflammation and Given that MSAF is associated with
meconium-stained). This study showed MSAF. Indeed, MSAF contains media- intraamniotic infection in approxi-
that meconium was present in most tors such as IL-6,217 tumor necrosis mately 20% of cases, it is difficult
placental tissues within 10 minutes from factor alpha,133 IL-1b,133 IL-8,133 and to determine to what extent these
exposure and that there was no rela- phospholipase A2,101 with inflammatory lesions are attributable to MSAF or
tionship between the duration of expo- and/or chemotactic properties.133,198,254 rather to intraamniotic infection/
sure to meconium and the extent and Meconium can have a direct effect on inflammation.164,255e257
intensity of meconium uptake by mac- the amnion. Indeed, incubation of Attempts have been made to identify
rophages in the placental membranes.253 amnion with meconium resulted in specific placental lesions associated with
We are not persuaded that examination reactive amnion hyperplasia and cyto- meconium, such as necrosis of the cho-
of the placenta for meconium staining plasmic vacuolation after 1 hour of rionic plate and the muscular layer of the
can lead to reliable inferences about the meconium exposure252 (Figure 12). In- umbilical cord vessels199,258 (Figure 13).
timing of fetal injury. flammatory lesions of the Moreover, of note is that meconium has

FIGURE 14
Evidence of in utero fetal defecation in goats by serial radiographic examinations
A, After intragastric injection via nasogastric tube, the nonhydrosoluble contrast medium persists in the stomach (red arrow) 4 hours after injection. B,
Evidence of contrast media in the small bowel (red arrow) 8 hours from injection. C, Eventually, the contrast material is excreted in the amniotic cavity (red
arrow) where it delineates the fetal body surface and fills the fetal airways.
Reproduced with permission from Kizilcan et al.99
been proposed to cause vasoconstriction

FIGURE 15 of the umbilical cord vessels258 and cord
Experimental study in rabbits investigating excretion of a radioactive vessel necrosis,199,259 hence fetal distress
substance (99mTc-HIDA) or death.199
Fetal defecation as a physiological

event
The traditional view has been that the
fetus does not pass meconium in the
absence of a pathologic process such as
hypoxia or infection. However, an
accumulating body of evidence suggests
that defecation in utero is a physiological
phenomenon, and this is supported by
the following observations: (1) when a
nonhydrosoluble contrast medium is
administered via nasogastric tube in fetal
goats, the contrast is subsequently
detected in the amniotic fluid by
Analysis of radioactivity of tissues from fetuses harvested at a rate of 1 per hour demonstrates that serial radiographic examinations99
there is physiological transit of radioactive meconium through the gastrointestinal tract (proximal (Figure 14); (2) radioactive
bowel, mid-bowel, and distal bowel) into the amniotic fluid. The colored lines represent the technetium-99m (99mTc- hepatobiliary
magnitude of radioactivity in different tissues. iminodiacetic acid [HIDA]), injected
Modified from Ciftci et al.260 intramuscularly in fetal rabbits, is
HIDA, hepatobiliary iminodiacetic acid, 99mTc, technetium-99m. detectable in the gastrointestinal tract
Gallo. Meconium-stained amniotic fluid. Am J Obstet Gynecol 2023. and then in the amniotic cavity260
(Figure 15); and (3) closure of the fetal

FIGURE 16
Evidence of fetal defecation with 4-dimensional ultrasound
The anus was examined for 10 to 15 minutes.

Courtesy of López Ramón y Cajal et al.264
anus with a purse-string suture prevents

the technetium from appearing in the FIGURE 17
amniotic fluid.261 Electron microscopic image of fetal cells found in fetal defecation
Detailed high-resolution ultrasound
has shown defecation by the human
fetus.262 López Ramón y Cajal and
Ocampo Martínez262,263 evaluated fetal
anal sphincter behavior in pregnancies
between 15 and 41 weeks of gestation.
Defecation was documented in all cases,
with the highest frequency between 28
and 34 weeks of gestation (Figure 16).
Amniocentesis performed shortly after
defecation in a subset of patients
demonstrated clear amniotic fluid con-
taining “whitish” material, which was
consistent with bowel epithelium at
microscopic examination264 (Figure 17).
The passage of meconium has also been
observed during fetoscopy in a case of
stage III twin-to-twin transfusion syn-
drome at 19 weeks of gestation266
(Figure 18; Videos 1 and 2). In this
case, the stool was green in color, which
could be attributed to oxidative stress
during the pathologic process. Electronic microscopic image showing structures resembling primitive villi on the cell surface (boxed
Further evidence supporting that area).
defecation occurs in utero derives from Reproduced with permission from López Ramón y Cajal.265
a study of 31 fetal autopsies, ranging Gallo. Meconium-stained amniotic fluid. Am J Obstet Gynecol 2023.
from 14 to 27 weeks of gestation. The

FIGURE 18
Meconium debris in amniotic cavity of twin B (recipient) during fetoscopy
Courtesy of Dr Ramen Chmait.

presence of green-colored meconium continuous fetal heart rate electronic meconium debris in the amniotic cavity of twin B
at different levels of the intestinal tract monitoring is indicated as a normal (recipient) during fetoscopy. Dr Chmait has no
conflict of interest in relation to our expert review.
was detected in 28 cases, and evidence cardiotocographic tracing that effec- We thank Julian Conde, MA (Wayne State
of defecation, determined by the pres- tively excludes fetal hypoxia. Assess- University) for creating the figures and preparing
ence of meconium in the anus, was ment of intraamniotic infection/ the video for the article, and Maureen McGerty,
less frequent after 21 weeks of gesta- inflammation can be performed by an MA (Wayne State University) for editorial sup-
tion,267 which is the time when the analysis of amniotic fluid with a rapid port. They have no conflict of interest in relation
to our expert review.
external anal sphincter becomes fully point-of-care test for IL-6 or MMP-8. The authors also thank the Fernandez
developed.268e270 These findings are Antibiotic treatment of mothers with Foundation (Hyderabad, India) and its team—Dr
consistent with the observation that MSAF can reduce the rate of clinical Pramod G, Dr Tejopratap, and Dr Asha—for
the concentrations of intestinal en- chorioamnionitis. Defecation in utero administrative support; and to Dr Anupama
zymes (alkaline phosphatase and di- is a physiological phenomenon; how- Singh, Dr Nuzhat Aziz, and Dr Kasturi Sarvotham
for perinatal autopsy referrals.
saccharidases) in amniotic fluid peaked ever, hypoxia, intraamniotic infection/
at 17 to 18 weeks of gestation, and inflammation, and postterm pregnan-
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Meconium-stained amniotic fluid

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neonatal sepsis,3,32,33 neonatal seizures,34

1. Motilin, a gut hormone produced by

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amniotic ﬂuid in patients with preterm

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species103,104 capable of inducing (2) a clear contrast between the amniotic

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disease with poor alveolar recruitment

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presence of MSAF reported a reduction

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condition. These phagocytic cells can be

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experiments, an in vivo observational Placental inflammatory lesions chorioamniotic membranes and

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been proposed to cause vasoconstriction

Fetal defecation as a physiological

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The anus was examined for 10 to 15 minutes.

anus with a purse-string suture prevents

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Courtesy of Dr Ramen Chmait.

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