managament meconium as of thu

8/3/2019 Managament Meconium as of Thu

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Management of Infants Born through Meconium

Stained Amniotic FluidIn 10-20% of deliveries, there is meconium in the amniotic fluid. Aspiration of

meconium results in respiratory distress that, in severe cases, can be life threatening. There isstrong suggestive evidence that prevention of meconium aspiration, by its removal from the

respiratory tract, can ameliorate or prevent the vast majority of cases of severe meconium

aspiration syndrome (MAS). Recently reported data indicate that infants who are vigorousimmediately after birth do not benefit from routine endotracheal intubation and suctioning to

remove the meconium. The following are in accord with the International Guidelines for

Neonatal Resuscitation (Pediatrics 106: E29, 2000).

A. Forall infantsborn with meconium in the amniotic fluid:

1. All infants with meconium in the amniotic fluid, should have their nose, mouth

and pharynx suctioned as soon as the head is delivered (intrapartum suctioning)regardless of whether the meconium is thin or thick.

2. If the amniotic fluid is merely colored or stained with meconiumbut there is no

particulate meconium in the fluid, no further special intervention for meconium is

indicated and the infant should receive routine resuscitation as indicated by the

infants condition.

B. For infants born with any particulate meconium in the amniotic fluid:

1. Assess the infant immediately after birth (in the first 15 sec after birth), before

any drying or stimulation.

2. If the infant is depressed (i.e., absent or depressed respirations, or heart rate


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as indicated by the infants condition. There is no evidence that routine intubation

and tracheal suctioning ofvigorous infants is beneficial.

4. Meconium stained infants, who develop apnea or respiratory distress at any timeduring resuscitation, should receive tracheal suctioningbefore positive-pressure

ventilation, even if they had been vigorous initially.

5. There is no evidence that lavage of the trachea is beneficial. Conversely, it mayfacilitate movement of the meconium into the distal airways and worsen the infants

respiratory status.

C. Ifrespiratory distress develops in an infant born through meconium, that infantrequires close observation and early intervention:

Provide liberal amounts of humidified oxygen to maintain adequate systemic and

alveolar oxygenation and correct acidosis, if present, to avoid development of

Persistent Pulmonary Hypertension (See P. 87).

Obtain chest radiograph immediately.

Consider early insertion of an umbilical arterial catheter to monitor arterial

oxygenation and acid-base status. Many infants who go on to have severe MAS

appear relatively mildly affected for the first few hours of life.If the infant requires assisted ventilation, avoid high inspiratory pressures in an

attempt to prevent pneumothorax.Tension pneumothorax is common with meconium aspiration syndrome and may

occur with spontaneous breathing or assisted ventilation.


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Pathophysiology ofMeconium- stained

Gestational Diabetes

mellitus

Gestational Diabetes

mellitus

Maternal hyperglycemiaMaternal hyperglycemia

Fetal hyperglycemiaFetal hyperglycemia

Episodic fetal hyperinsulinemiaEpisodic fetal hyperinsulinemia

Energy expenditure due to glucose to fat

conversion

Energy expenditure due to glucose to fat

conversion

Fetal oxygen levels Fetal oxygen levels

2nd hand smoking2nd hand smoking

Carbon monoxide induced tissue hypoxia and placental

insufficiency

Carbon monoxide induced tissue hypoxia and placental

insufficiency

Reduced availability of oxygenated blood to the fetusReduced availability of oxygenated blood to the fetus

PIHPIH

VasospasmVasospasm

Circulation of blood to the placenta Circulation of blood to the placenta

Less oxygen and blood supply of the fetusLess oxygen and blood supply of the fetus

Fetal compromiseFetal compromise

Peristalsis Stimulate vagal reflex

Fetal distress and fetal hypoxia

Production in motilin Relaxed anal sphincter Compression of the cord or fetal head

Breech presentationBreech presentation

Pressure in the anus Pressure in the anus

Post-term

pregnancy

Post-term

pregnancy

Maturation of the gastrointestinal tractMaturation of the gastrointestinal tract

Meconium passage

Meconium staining


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November 7, 2011

Urinalysis

NORMAL VALUE RESULT INTERPRETATION

MACROSCOPIC

Color Light Yellow Yellow Normal

Character Clear Slightly turbid Abnormal, may suggest presence

of infection or presence of crystalsin the urine

Specific Gravity 1.005-1.030 1.010 Normal

pH 4.6-8.0 6.0 Normal

Sugar Negative Negative Normal

Albumin Negative Negative Normal

MICROSCOPIC

Pus cell 0-4/hpf 0-1/hpf Normal

RBC < 2/hpf None seen Normal

Bacteria few few Normal


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November 7, 2011

HEMATOLOGY

COMPLETE BLOOD COUNT


Hemoglobin 120-150g/mL 173g/mL Normal

Hematocrit 0.37- 0.45 0.50 Normal

White Blood Cell 5-10 x 10 9/L 18.50 x 109 /L Normal

Red Blood Cell 4.6-6 x 1012/L 5.56 x 1012/L Normal


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DIFFERENTIAL COUNT


Eosinophils 0.0-0.05 0.02 Normal

Lymphocytes 0.10- 0.70 0.42 Normal

Monocytes 0.0 - 0.07 315 x10 /L Normal

Platelet Count 150-450 x10 /L 315 x10 /L Normal

Segmenters 0.50- 0.70 0.42 Normal

Blood Type AB (+)


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Meconium is composed of small dried amniotic fluid debris, bile pigment and the residue from

intestinal secretions. It is a sterile compound made up primarily of water (75 %), with mucous

glycoproteins, lipids and proteases. Although meconium is sterile, its passage into amniotic fluidis important because of the risk of meconium aspiration syndrome (MAS).

Infants delivered through meconium-stained amniotic fluid are more likely to be depressed atbirth and to require resuscitation and neonatal intensive care.

Meconium-stained is rareinpremature infants (37 weeks' gestation and occurs in up to 50 % of post-mature infants ( >42

weeks).

Many theories have been proposed to explain the passage of meconium in utero; however, the

precise mechanisms remain unclear. The fetal bowel has little peristaltic action and the anal

sphincter is contracted. It is thought that hypoxia and academia cause the anal sphincter to relax,

whilst at the same time increasing the production of motilin, which promotes peristalsis.

Meconium has a number of adverse effects on the neonatal lung, which may ultimately lead tothe respiratory failure (and hypoxemia). It causes mechanical blockage of the airway, acts as a

chemical irritant causing pneumonitis, alveolar collapse and cell necrosis although initially

sterile, predisposes to secondary bacterial infection.

managament meconium as of thu

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