MECONIUM ASPIRATION SYNDROME

INTRODUCTION:-
Meconium aspiration syndrome (MAS) also known as neonatal
aspiration of meconium is a medical condition affecting newborn infants. Neonates born to
mother with thick or thin meconium stained liquor can aspirate meconium into lungs and
develop respiratory distress. This is known as meconium aspiration syndrome. Aspiration of
meconium can occur in utero, during birth or immediately after birth. Thick meconium
aspiration can block large and small airway causing areas of atelectasis and emphysema
which can progress to develop air leak syndrome like pneumothorax.

DEFINITION:-
1. Meconium aspiration syndrome is respiratory distress in a newborn who has aspirated
a green, sterile fecal material called meconium into the lungs before or around the time of
birth.

-According to Wikipedia

2. Neonates aspirate meconium into the lungs in utero, during delivery or immediately
after birth, and develop respiratory distress. This is termed Meconium aspiration syndrome
(MAS).

-According to Suraj Gupta

INCIDENCE:-
Meconium aspiration syndrome occur in 5-10% of births. About 13% of all
deliveries have meconium staining of amniotic fluid (MSAF). Around 6% of such neonates
aspirate meconium into the lungs in utero, during delivery or immediately after birth. It
generally occurs in term or post term newborn who are immature or small for gestational age.

ETIOLOGY:-
1. Fetal hypoxia or fetal asphyxia
2. Children born after 37 weeks
3. Prolonged gestation
4. Fetal distress
5. Maternal hypertension, diabetes, anaemia, aging, drug abuse
6. Viral pneumonia, Bacterial pneumonia, Aspiration pneumonia
7. Placental dysfunction
PATHOPHYSIOLOGY :-
Due to physiologic maturational event
(For e.g. plasma protein leaking into the airway from epithelial)

A response to acute hypoxic events

If an infant inhales this mixture before, during or after birth, it may be sucked deep
into the lungs

The material may block the airway

Efficiency of gas exchange in the lungs is lowered

The meconium stained fluid is irritating inflaming airway

Pneumonia

Meconium aspiration syndrome

CLINICAL MANIFESTATION:-
1. Respiratory distress
2. Tachypnoea
3. Grunting
4. Retractions
5. Cyanosis
6. High fever
7. Cough
8. Pneumothorax
9. Vomiting
10. Abdominal distension
11. Barrel shaped chest
12. Nasal flaring
DIAGNOSTIC EVALUATIONS:-

1. Blood examination:- Blood examination shows the following:-

 Haemoglobin percentage - 2 to 6 gm/dl

 RBC count - 2 to 3 million/cmm
 Haematocrit values are reduced, MCV, MCH, MCHC values are low.
 Reticulocyte count increased or may be low.
 WBC count may be reduced or sometimes increased.
 Platelet count is usually normal or increased.
 Serum bilirubin level is moderately elevated.
 Serum iron level is high.

2. Physical examination:- Lung sound (coarse, crackly sound), low APGAR score
after birth.

3. Blood gas analysis:- Hypoxemia, some degree of metabolic acidosis, decreased

oxygen and increased carbon dioxide, low blood acidity.

4. Chest x-ray:- Patchy or streaky areas in lungs, hyperinflation, diaphragmatic

flattering, patchy atelectasis and consolidation

5. Urine analysis:- Urine colour may appear dark brown.

MANAGEMENT:-

1. 1. Suctioning:- Prevention of meconium aspiration begins with suctioning the

mouth, nose and posterior pharynx just after the head is delivered and the chest is still
compressed in the birth canal. Following delivery, the need for tracheal suctioning is
based on infant assessment. Infants who are vigorous with strong, stable respiratory
effort, good muscle tone and heart rate greater than 100 beats/min should not undergo
tracheal suctioning but should be closely monitored. On the other hand, infants who
demonstrate poor respiratory effort, low heart rate and poor tone should be rapidly
intubated, suctioned appropriately and resuscitated according to clinical status post
suctioning.

2. Ventilation:- In case of MAS, there is a need for supplemental oxygen for at least
12 hours in order to maintain oxygen saturation of haemoglobin at 92% or more. The
severity of respiratory distress can vary significantly between newborns with MAS, as
some require minimal or no supplemental oxygen requirement and, in severe cases,
mechanical ventilation may be needed. The desired oxygen saturation is between 90-
95% and PaO2 may be as high as 90mmHg. In cases where there is thick meconium
deep within the lungs, mechanical ventilation required. In extreme cases,
extracorporeal membrane oxygenation (ECMO) may be utilise in infants who fail to
respond to ventilation therapy.
 3. Inhaled nitric oxide (iNO):- Inhaled nitric oxide is a selective pulmonary
vasodilator and hence will decrease pulmonary arterial pressure if it gets into the
airways. Inhaled nitric oxide (iNO) acts on vascular smooth muscle causing selective
pulmonary vasodilation. This is ideal in the treatment of PPHN as it causes
vasodilation within ventilated areas of the lungs, decreasing the ventilation-perfusion
mismatch and thereby, improves oxygenation.

4. Surfactant therapy:- Meconium inactivates endogenous surfactant. Surfactant

improves gas exchange and decreases the oxygenation index. The need for ECMO has
significantly reduced since iNO and surfactant have been administered to infants with
severe MAS. Exogenous surfactant may be given every 6 hours and the dose may be
repeated as many times as needed. Surfactant can be given either a bolus therapy or
Broncho alveolar lavage.

5. High Frequency Jet Ventilation (HF JV):- The combination of atelectasis

and air trapping that occurs in MAS may be managed better with HF JV than high
frequency oscillation ventilation (HFOV). Use lower HF JV rate to avoid air trapping,
and higher PEEP to splint airways and allow meconium to evacuate.

6. Extra Corporeal Membrane Oxygenation (ECMO):- ECMO has been

used as a final rescue therapy in infants with severe and refractory hypoxemia
associated with MAS. Typically the infants more than 34 weeks gestation and more
than 2000 g weight with reversible cardiac/pulmonary failure and no major
neurological insult are potential candidates for ECMO.

7. Anti-inflammatory drugs:- Steroids may be beneficial in severe MAS with

apparent lung oedema, pulmonary vasoconstriction and inflammation.
Glucocorticoids have a strong anti-inflammatory activity and works to reduce the
migration and activation of neutrophils, eosinophils, mononuuclears and other cells.
Glucocorticoids reduce the migration of neutrophils into the lungs and decreasing the
adherence to the endothelium.

8. Antibiotics:- The presence of meconium increases the chances of positive cultures

from amniotic fluid in preterm and term infants. Infection/inflammation of the lungs
can lead to difficulty in breathing, reduced oxygen levels and pneumonia. Antibiotics
have been used to prevent infection in babies exposed to meconium during delivery.
Treat with antibiotics until sepsis excluded.

9. Minimal handling:- Typically the infants with MAS are very sensitive to
handling. Frequency of routine cares and handling should be discussed with
consultant and senior nursing staff. Ensure pressure relieving devices are utilised.

NURSING MANAGEMENT:- Nursing care of an infant with meconium aspiration

syndrome include following:-

 Nursing Assessment:-
 During labour, continuously monitor the fetus for sign and symptoms of distress.
  Baby born with meconium stained liquor requires close observation for the
assessment of respiratory distress.
 Monitoring of oxygen during this period helps to assess severity of infant’s condition
and avoids hypoxemia.
 Monitor lung status closely, including breath sounds and respiratory rate.
 Frequently assess the neonate’s vital signs. Maintain adequate BP and perfusion.
 Maintain a neutral thermal environment.
 Minimal handling protocols to avoid agitation.
 Blood glucose and calcium level should be monitored and corrected if necessary.
 Fluid should be restricted as far as possible to prevent cerebral and pulmonary
edema.

 Nursing Care Plan:-

NURSING GOAL NURSING INTERVENTIONS EVALUATION

DIAGNOSIS
Ineffective To improve  Assess the general condition, After the
breathing pattern breathing vital signs and check APGAR interventions
related to meconium pattern and score of the client. client’s breathing
aspiration syndrome maintain patent pattern is
 Perform suctioning of the
as evidence by airway. improved.
mouth, nose and posterior
respiratory distress.
pharynx
(According to
Henderson’s  Provide well ventilation and
Virginia Needs supplemental oxygen as needed.
Theory)  Maintain oxygen saturation of
haemoglobin at 92% or more.
 Provide surfactant therapy to
improve gas exchange.

Altered tissue To improve  Assess quality and strength of After the

perfusion related to tissue perfusion peripheral pulses. interventions
impaired transport  Assess respiratory rate, depth client’s tissue
of oxygen across and quality. perfusion is
alveolar and  Assess skin for changes in improved.
capillary membrane colour, temperature and
as evidence by moisture.
cyanosis.  Provide oxygen therapy and well
(According to ventilation as needed.
Henderson’s  Provide a quiet and restful
Virginia Needs atmosphere.
Theory)

Hyperthermia To maintain  Assess the general condition and After the

related to normal body vital sign of the client. interventions
inflammatory temperature  Provide TSB to help lower down normal body
process as evidence the temperature. temperature is
by increased body  Ensure that all equipment used maintained.
temperature. for the infant is sterile,
(According to scrupulously clean.
Henderson’s  Do not share equipment with
Virginia Needs other infant’s to prevent spread
Theory) of pathogens.
 Administer Antipyretics as
ordered.

Interrupted The mother  Demonstrate use of manual After the

breastfeeding will identify piston-type breast pump. interventions
related to neonate’s and  Review technique for use of mother able to
present illness as demonstrate expressed breast milk. identify and
evidence by techniques to  Determine routine visiting demonstrate
separation of mother sustain schedule or advance warming techniques to
to infant. lactation until can be provided. sustain lactation.
(According to breastfeeding is  Provide privacy, calm
Henderson’s initiated. surroundings when mother
Virginia Needs breast feeds.
Theory)  Recommend for infant sucking
on a regular basis.

Fluid volume deficit To maintain  Monitor and record vital sign. After the
related to failure of fluid volume at  Note for the causative factors interventions
regulatory a normal that contribute to fluid volume neonate’s fluid
mechanism. functional deficit. volume maintained
(According to level.  Provide oral care by moistening at normal
Henderson’s lips and skin care by providing functional level.
Virginia Needs daily bath.
Theory)  Administer IV fluids
replacements as ordered.

COMPLICATIONS:-
 Lung over expansion
 Pneumothorax
 Pulmonary hypertension
 Permanent brain damage
 Emphysema
 Atelectasis
 Pulmonary abscess
 Respiratory failure
 BIBLIOGRAPHY

BOOK REFERANCE:-
1. Data Parul, 2018, “Pediatric Nursing”, 4th edition, published by Jaypee Brothers
medical Publishers (P) Ltd, page no- 67-70
2. Ghai O.P, 2007, “Essential Pediatrics”, 6th edition, published by Dr. O.P. Ghai, Delhi-
110092, page no- 220-224
3. Kaur Navdeep, 2015, “Textbook of Advance nursing practice”, 1st edition, published
by Jaypee Brothers medical Publishers (P) Ltd, page no- 555, 570
4. Manivannan C, 2010, “Textbook of Pediatric Nursing”, 2nd edition, published by
EMMESS Medical Publishers, page no- 372-375
5. Marlow Dorothy R, 2013, “Textbook of Pediatric Nursing”, south esian edition,
published by Elsevier Indian Private Limited, page no- 953-955
6. Sherma Rimple, 2017, “Essentials of Pediatric Nursing”, 2nd edition, published by
Jaypee Brothers medical Publishers (P) Ltd, page no-138-141
7. Yadav Manoj, 2016, “Child health nursing”, published by S.Vikas and company
(Medical Publisher), page no- 335-336

NET REFERANCE:-
1. https://wwwhealthline.com>health
2. https://wwwmsdmanuals.com>home
3. https://emedicine.medscape.com>9
4. https://kidshealth.org>parents>me
5. Htpps://medlineplus.gov>article