Intra Uterine Growth Retardation

Intra UterineIntra Uterine Growth Growth RetardationRetardation

Dr.B Khani MDDr.B Khani MD

12 October 2002 IUGR - Prof.S.N.Panda 2

Case 1Case 1 27 Y G2 L1 36 w 27 Y G2 L1 36 w

CC: VB & LPCC: VB & LPPMH: Iron deficiency anemia (no treatment) PMH: Iron deficiency anemia (no treatment) Spotting in 24 w pregnancy Spotting in 24 w pregnancy PH: The patient was pale FH: 32 cm PH: The patient was pale FH: 32 cm V /E: 4cm V /E: 4cm The newborn birthed after 3 h The newborn birthed after 3 h N: female APGAR: 7/10 & 8/10 (1′ & 5′)N: female APGAR: 7/10 & 8/10 (1′ & 5′) BW: 1590 g HC: 29.5 cm Height: 45 cmBW: 1590 g HC: 29.5 cm Height: 45 cm DX: IUGR DX: IUGR The newborn was Hospitalized and managed The newborn was Hospitalized and managed BS was normal HB: 23.9 BS was normal HB: 23.9 After 2 days bilirubin was 16 and phototherapy was started CXR: normal blood After 2 days bilirubin was 16 and phototherapy was started CXR: normal blood

culture: WNLculture: WNL After one Week the infant was discharged After one Week the infant was discharged


Foetal growth restriction

Small for gestational age (SGA)

'wasted' and 'stunted'

Intra UterineIntra Uterine Growth Growth RetardationRetardation

Please also see notes pages for more details in most of the slides

Intra Uterine Growth Restriction


DefinitionDefinition Intrauterine growth retardation (IUGR)Intrauterine growth retardation (IUGR)

occurs when the unborn baby is at or below the occurs when the unborn baby is at or below the 10th weight percentile for his or her age (in 10th weight percentile for his or her age (in weeks). weeks). The foetus is affected by a pathologic The foetus is affected by a pathologic restriction in its ability to grow.restriction in its ability to grow.

LowLow birth weight (LBW) birth weight (LBW) means a baby means a baby with a birth weight of less than 2500Gms, with a birth weight of less than 2500Gms, which could be due to IUGR or Prematuritywhich could be due to IUGR or Prematurity

Please also see notes pages for more details in most of the slides


ClassificationClassification

SymmetricSymmetricll AAsymmetricalsymmetrical

baby's brain is abnormally baby's brain is abnormally large when compared to the large when compared to the liverliver..may occur when the may occur when the foetusfoetus experiences a problem experiences a problem during later developmentduring later development

the baby's head and body the baby's head and body are proportionately smallare proportionately small. . may occur when the may occur when the foetus foetus experiences a experiences a problem during early problem during early development.development.

In a normal infant, the brain weighs about three times more than the liver. In In a normal infant, the brain weighs about three times more than the liver. In asymmetrical IUGR, the brain can weigh five or six times more than the liver.asymmetrical IUGR, the brain can weigh five or six times more than the liver.


Newer Classification: -

1. Normal small fetuses- have no structural abnormality, normal umbilical artery & liquor but wt., is less.They are not at risk and do not need any special care.

2. Abnormal small fetuses- have chromosomal anomalies or structural malformations. They are lost cases and deserve termination as nothing can be done.

3. Growth restricted fetuses- are due to impaired placental function.Appropriate & timely treatment or termination can improve prospects.

ClassificationClassification


AetiologyAetiology The foetal growth is dependent on multiple factors. The foetal growth is dependent on multiple factors. IUGR resulting in SGA babies can result from many IUGR resulting in SGA babies can result from many

factors known and unknown either acting alone or in factors known and unknown either acting alone or in conjunction or in association .conjunction or in association .

The The aaetiologic determinants of IUGR etiologic determinants of IUGR have have two two measures of effect: relative risk measures of effect: relative risk and and etiologic fraction.etiologic fraction.

Most of the evidence on Most of the evidence on aaetiologic determinants is etiologic determinants is based on observational studies and systematic based on observational studies and systematic overviews or meta-analyses of such studies.overviews or meta-analyses of such studies.

In a majority of cases (40%) the cause is unknown– In a majority of cases (40%) the cause is unknown– probably due to placental insufficiency (idiopathic).probably due to placental insufficiency (idiopathic).


AetiologyAetiology1.1. General- General- Racial / Ethnic origin, Small maternal / Racial / Ethnic origin, Small maternal /

paternal height / weight, Foetal sex.paternal height / weight, Foetal sex.

2.2. Maternal causesMaternal causes..3.3. Foetal causes.Foetal causes.4.4. Placental causes.Placental causes.5.5. Idiopathic- In a majority of cases (40%) the Idiopathic- In a majority of cases (40%) the

cause is unknown– probably due to placental cause is unknown– probably due to placental insufficiency.insufficiency.


Maternal Risk FactorsMaternal Risk Factors Has had a previous baby who suffered from Has had a previous baby who suffered from

IUGR.IUGR. Extremes of age. Extremes of age. Is small in sizeIs small in size (Ht & Wt) (Ht & Wt).. Has poor weight gain and Has poor weight gain and malmalnutrition during nutrition during

pregnancypregnancy.. Is socially deprived.Is socially deprived. Uses substances (like tobacco, narcotics, alcohol) Uses substances (like tobacco, narcotics, alcohol)

that can cause abnormal development or that can cause abnormal development or birth birth defectsdefects..

Has a low total blood volume during early Has a low total blood volume during early pregnancy.pregnancy.


Maternal Risk FactorsMaternal Risk Factors Is pregnant with more than one baby.Is pregnant with more than one baby. High altitude.High altitude. Drugs like anticoagulants, anticonvulsants.Drugs like anticoagulants, anticonvulsants. Has a Has a cardio-cardio-vascular diseasevascular disease--preeclampsiapreeclampsia, ,

hypertension, cyanotic heart disease, cardiac hypertension, cyanotic heart disease, cardiac disease Gr III & IV, diabetic vascular lesions.disease Gr III & IV, diabetic vascular lesions.

Chronic Chronic kidney diseasekidney disease Chronic infection- UTI, Malaria, TB, genital Chronic infection- UTI, Malaria, TB, genital

infectionsinfections Has an antibody problem that can make Has an antibody problem that can make

successful pregnancy difficult (antiphospholipid successful pregnancy difficult (antiphospholipid antibody syndromeantibody syndrome, SLE, SLE).).


Fetal Risk FactorsFetal Risk Factors Exposure to an infectionExposure to an infection--German German measles measles ((rubellarubella), ),

cytomegalovirus, cytomegalovirus, herpes simplex, tuberculosisherpes simplex, tuberculosis, , syphilis,syphilis, or or toxoplasmosis, TB, Malaria, Parvo virus B19.toxoplasmosis, TB, Malaria, Parvo virus B19.

A birth defect (cardiovascularA birth defect (cardiovascular, renal, anencephally, , renal, anencephally, limb defect, etclimb defect, etc).).

A chromosome defectA chromosome defect-- trisomytrisomy--18 (18 (Edwards’ Edwards’ syndromesyndrome)),21(Down’s syndrome), 16, 13, xo (turner’s ,21(Down’s syndrome), 16, 13, xo (turner’s syndrome.syndrome.

A primary disorder of bone or cartilage.A primary disorder of bone or cartilage. A chronic lack of oxygen during development A chronic lack of oxygen during development

(hypoxia).(hypoxia). Developed outside of the uterus.Developed outside of the uterus. Placenta or umbilical cord defects.Placenta or umbilical cord defects.


Placental FactorsPlacental Factors Uteroplacental insufficiency resulting from -.Uteroplacental insufficiency resulting from -.

Improper / inadequate trophoblastic invasion and Improper / inadequate trophoblastic invasion and placentation in the first trimester.placentation in the first trimester.

Lateral insertion of placenta.Lateral insertion of placenta. Reduced maternal blood flow to the placental bed.Reduced maternal blood flow to the placental bed.

Foetoplacetal insufficiency due to-.Foetoplacetal insufficiency due to-. Vascular anomalies of placenta and cord.Vascular anomalies of placenta and cord. Decreased placental functioning mass-.Decreased placental functioning mass-.

» Small placenta, abruptio placenta, placenta previa, post Small placenta, abruptio placenta, placenta previa, post term pregnancy.term pregnancy.


DiagnosisDiagnosis

IUGR can be difficult to diagnoseIUGR can be difficult to diagnose.. Presence of risk factors.Presence of risk factors. Inadequate growth detected by serial Inadequate growth detected by serial

measurement of Wt., abdominal girth and measurement of Wt., abdominal girth and fundal Ht.fundal Ht.

Ultrasound to evaluate the Ultrasound to evaluate the foetal foetal growth.growth. Inadequate foetal growth.Inadequate foetal growth. Reduced AFI.Reduced AFI. Placental calcification.Placental calcification.

Intrauterine -


DiagnosisDiagnosis

Low ponderal index (Wt./Fl).Low ponderal index (Wt./Fl). Decreased subcutaneous fat.Decreased subcutaneous fat. Presence / appearance of – Presence / appearance of –

Hypoglycemia, Hypoglycemia, Hyperbilirubinemia, Hyperbilirubinemia, Narcotizing enterocolitis, Narcotizing enterocolitis, Hyper viscosity syndrome Hyper viscosity syndrome

Neonatal -


Neonate and Placenta in IUGRNeonate and Placenta in IUGR

Normal & IUGR Newborn Normal & IUGR Newborn babiesbabies

Normal & IUGR PlacentasNormal & IUGR Placentas


Prevention Prevention Strategies include Strategies include

prenatal care modalities, prenatal care modalities, protein/energy supplementation, protein/energy supplementation, treatment of anaemia, treatment of anaemia, vitamin/mineral supplementation, vitamin/mineral supplementation, fish oil supplementationfish oil supplementation prevention and treatment of prevention and treatment of

» hypertensive disorders, hypertensive disorders, » foetal compromise foetal compromise » infection.infection.


Prevention Prevention Strong Strong evidence of benefit only for the evidence of benefit only for the

following interventions: following interventions: balanced protein/energy supplementation,balanced protein/energy supplementation, strategies to reduce maternal smoking, strategies to reduce maternal smoking, antibiotic administration to prevent urinary tract antibiotic administration to prevent urinary tract

infectionsinfections and and antimalarial prophylaxis.antimalarial prophylaxis.

Few statistically significant reductions in the Few statistically significant reductions in the risk of IUGR have been demonstrated with risk of IUGR have been demonstrated with other other interventions. interventions.


SSurveillanceurveillance Unless delivery occurs, once treatment begins the Unless delivery occurs, once treatment begins the

foetus must undergo surveillance. foetus must undergo surveillance. The purposeThe purpose - - to identify further progression of to identify further progression of

the disease process that would jeopardize the the disease process that would jeopardize the foetus to a point that it would be better to be foetus to a point that it would be better to be delivered than to remain in utero. delivered than to remain in utero.

There are four testing modalities which are helpful There are four testing modalities which are helpful --Non-Stress Test, Amniotic Fluid Index, Doppler of the Umbilical Artery & Biophysical Profile, each of which addresses different each of which addresses different aspects of surveillanceaspects of surveillance..

CCombination of tests are better than an isolated ombination of tests are better than an isolated test.test.


SSurveillanceurveillance

This simplest to perform test should b used first in This simplest to perform test should b used first in the surveillance of IUGR foetuses. With the help of the surveillance of IUGR foetuses. With the help of a heart rate monitor, the changes in the foetal heart a heart rate monitor, the changes in the foetal heart rate with foetal movement are to be determined. If rate with foetal movement are to be determined. If the heart rate increases more than 15 beats for the heart rate increases more than 15 beats for more than 15 seconds, this is considered to be a more than 15 seconds, this is considered to be a reactive test. If the heart rate does not accelerate, reactive test. If the heart rate does not accelerate, remains flat, or decreases, then this is an abnormal remains flat, or decreases, then this is an abnormal test. The problem with this test is that it changes test. The problem with this test is that it changes late in the course of the disease and is not an early late in the course of the disease and is not an early predictor of adverse outcome.predictor of adverse outcome.

Non- Stress Test (NST)Non- Stress Test (NST)



The vertical depth of four pockets of amniotic The vertical depth of four pockets of amniotic fluid are measured by USG, to obtain a total fluid are measured by USG, to obtain a total AFI. This method allows for comparison of AFI. This method allows for comparison of changes in amniotic fluid with time. In the changes in amniotic fluid with time. In the normal foetus the AFI remains relatively normal foetus the AFI remains relatively constant. In the foetus with IUGR, it may constant. In the foetus with IUGR, it may decrease slowly, or decrease abruptly with decrease slowly, or decrease abruptly with time. A decrease in AFI may occur before time. A decrease in AFI may occur before there are changes in the non-stress test. there are changes in the non-stress test.

Amniotic Fluid Index (AFI)Amniotic Fluid Index (AFI)



The current The current recommendations recommendations are that if the AFI are that if the AFI decreases below 8 decreases below 8 after 35 weeks, after 35 weeks, then delivery then delivery should occur. should occur.

Amniotic Fluid Index (AFI)Amniotic Fluid Index (AFI)



Doppler of the Umbilical Artery When IUGR is diagnosed, the value of sequential studies of the umbilical artery Doppler waveform is to determine if the Resistance Index is increasing or decreasing. If it is increasing, then this signifies a deteriorating condition.



This test combines the NST and the AFI with foetal movement, breathing, and muscle tone. If each of the tests are normal they are given a score

of 2. If abnormal, a score of 0. A score of 6 or less suggests the foetus is at risk for

adverse outcome. While the biophysical profile is an useful test,

when it becomes abnormal the foetus may have already suffered some damage

Biophysical Profile


TreatmentTreatment

IUGR has IUGR has many causes, therefore, there is causes, therefore, there is not one treatment that always works. not one treatment that always works.


TreatmentTreatment Although there are many causes of IUGR, the treatment

consists of either delivery or remaining in utero and improving blood flow to the uterus.

When blood flow is improved, the delivery of oxygen and other nutrients to the foetus occurs. If the foetus is lacking in these substances, their increased availability may result in improved growth and development.

If IUGR is caused by a problem with the placenta and the baby is otherwise healthy, early diagnosis and treatment of the problem may reduce the chance of a serious outcome.

There is no treatment that improves foetal growth, but IUGR babies who are at or near term have the best outcome if delivered promptly.


TreatmentTreatment

This is the initial approach for the treatment of IUGR. The benefit of bed rest is that it results in increased blood flow to the uterus. Studies have shown, however, that in most cases bed rest at home is just as effective as bed rest in the hospital environment.

Maternal bed rest


TreatmentTreatment Maternal bed rest


TreatmentTreatment

The use of aspirin to treat foetuses with IUGR is The use of aspirin to treat foetuses with IUGR is still controversial. still controversial.

If If aspirin is usedaspirin is used, it may be advantageous if , it may be advantageous if given to patients before 20 weeks of gestation. given to patients before 20 weeks of gestation. It is minimal to limited benefit if given at the time It is minimal to limited benefit if given at the time of diagnosis (third trimester). of diagnosis (third trimester).

At the present time it is not recommended as a At the present time it is not recommended as a form of prevention for low risk patients. form of prevention for low risk patients.

Aspirin TherapyAspirin Therapy


TreatmentTreatment

Other forms of treatment that have been studied are nutritional supplementation, zinc supplementation, fish oil, hormones and oxygen therapy.

Limited studies are available regarding the use of these modalities in the treatment of IUGR.

Other Forms of TreatmentOther Forms of Treatment


TreatmentTreatment

RISK OF PREMATURITYRISK OF PREMATURITY DIFFICULT DIFFICULT EXTRA EXTRA

UTERINEUTERINE EXISTENCEEXISTENCE

RISK OF IUD RISK OF IUD HOSTILE HOSTILE INTRA INTRA

UTERINEUTERINE ENVIRONMENTENVIRONMENT

Judge Optimum Time Of DeliveryJudge Optimum Time Of Delivery


Short Term Risks of IUGRShort Term Risks of IUGR Increased perinatal morbidity and mortality.Increased perinatal morbidity and mortality.

Intra uterine / Intrapartum death.Intra uterine / Intrapartum death. Intrapartuum foetal acidosis characterized by-.Intrapartuum foetal acidosis characterized by-.

» Late deceleration.Late deceleration.» Severe variable deceleration.Severe variable deceleration.» Beat to beat variability.Beat to beat variability.» Episodes of bradicardia.Episodes of bradicardia.

Intrapartum foetal acidosis may occur in as many as Intrapartum foetal acidosis may occur in as many as 40 % of IUGR, leading to a high incidence of LSCS.40 % of IUGR, leading to a high incidence of LSCS.

IUGR infants are at greater risk of dyingIUGR infants are at greater risk of dying because of because of neonatal complications- neonatal complicationsasphyxia, acidosis, meconium asphyxia, acidosis, meconium aspiration syndrome, infection, aspiration syndrome, infection, hypoglycemiahypoglycemia,, hypothermia hypothermia, , sudden infant death syndrome. sudden infant death syndrome.

IUGR infants are likely to be susceptible to infections IUGR infants are likely to be susceptible to infections because of impaired immunitybecause of impaired immunity


Long term Long term PrognosisPrognosis Babies who suffer from IUGR are at an increased risk for Babies who suffer from IUGR are at an increased risk for

deathdeath, low blood sugar, low blood sugar, , low body temperaturelow body temperature, , and and abnormal development of the nervous system. These risks abnormal development of the nervous system. These risks increase with the severity of the growth restriction.increase with the severity of the growth restriction.

The growth that occurs after birth cannot be predicted with The growth that occurs after birth cannot be predicted with certainty based on the size of the baby when it is born.certainty based on the size of the baby when it is born.

Infants with asymmetrical IUGR are more likely to catch Infants with asymmetrical IUGR are more likely to catch up in growth after birth than are infants who suffer from up in growth after birth than are infants who suffer from prolonged symmetrical IUGR.prolonged symmetrical IUGR.

If IUGR is related to a disease or a genetic defect, the If IUGR is related to a disease or a genetic defect, the future of the infant is related to the severity and the nature future of the infant is related to the severity and the nature of that disorder.of that disorder.


Long term Long term PrognosisPrognosis IUGR infants are more likely to remain small than those of IUGR infants are more likely to remain small than those of

normal birth weight. They will need the special attention of normal birth weight. They will need the special attention of primary health, nutrition and social services during infancy primary health, nutrition and social services during infancy and early childhood.and early childhood.

Implication of IUGR can be life long affecting:Implication of IUGR can be life long affecting: Body sizeBody size growth growth, composition and physical , composition and physical

performanceperformance.. Immunocompetence.Immunocompetence.

It appears to predispose to adult It appears to predispose to adult adult-onset, degenerative adult-onset, degenerative diseasediseases s like maturity onset diabetes and cardiovascular like maturity onset diabetes and cardiovascular diseases.diseases.

Each case is unique. Each case is unique. CCanan not reliably predict an infant's not reliably predict an infant's future progress.future progress.

syndromesyndrome


““mekonionarion” – “opium like” (Aristotle) – “opium like” (Aristotle)

Meconium stained amniotic fluid – 8-15 % of all Meconium stained amniotic fluid – 8-15 % of all deliveries.deliveries.

5% of them – meconium aspiration syndrome5% of them – meconium aspiration syndrome

5% mortality5% mortality


Origin and compositionOrigin and composition Meconium is recognized – 70-85 d of gestation Meconium is recognized – 70-85 d of gestation

Composition:Composition:

» Water, Mucopolysaccharides, Cholesterol and sterol precursos, Water, Mucopolysaccharides, Cholesterol and sterol precursos, Protein, Lipid, Bile acids and salts, Enzymes, Blood group Protein, Lipid, Bile acids and salts, Enzymes, Blood group substances, Squamous cell, Vernix caseosasubstances, Squamous cell, Vernix caseosa

No bacteria!No bacteria!


In utero passageIn utero passage Risk factors associated with in utero passage of meconium:Risk factors associated with in utero passage of meconium:

Postterm pregnancyPostterm pregnancy Little/no amniotic fluid at amniotomyLittle/no amniotic fluid at amniotomy Oligohydramnion by USOligohydramnion by US IUGR/ placental insufficiencyIUGR/ placental insufficiency Maternal HTNMaternal HTN PreeclampsiaPreeclampsia Maternal drug abuse (tobacco, cocaine).Maternal drug abuse (tobacco, cocaine).

Gestational age > 34w – increasingly present with advancing Gestational age > 34w – increasingly present with advancing gestational age.gestational age.


PathophysiologyPathophysiology

As the GI tract matures: As the GI tract matures: vagal stimulation vagal stimulation peristalsis+ rectal sphincter peristalsis+ rectal sphincter

relaxation relaxation meconium meconium Etiology not well understood:Etiology not well understood:

Fetal response to intra-uterine stress: hypoxia Fetal response to intra-uterine stress: hypoxia increased vagal tone increased vagal tone

Transient compression of umbilical cord/head Transient compression of umbilical cord/head increased vagal toneincreased vagal tone

Maturation of of fetal intestinal functionMaturation of of fetal intestinal function


Timing of the initial insult:Timing of the initial insult:

Traditional belief: immediately after birthTraditional belief: immediately after birth

Several investigations: Most cases occur in Several investigations: Most cases occur in utero when fetal gasping is initiated before utero when fetal gasping is initiated before delivery.delivery.


Effects of meconium:Effects of meconium: Reduce antibacterial activity (perinatal bacterial Reduce antibacterial activity (perinatal bacterial

infection)infection) Irritating to fetal skin ( erythema toxicum)Irritating to fetal skin ( erythema toxicum) The most severe complication of meconium The most severe complication of meconium

passage in utrro is aspiration of stained amniotic passage in utrro is aspiration of stained amniotic fluid before, during, and after birthfluid before, during, and after birth


Meconium aspiration syndrome - Meconium aspiration syndrome - pathophysiologypathophysiology

Airway obstruction:Airway obstruction: Chemical pneumonitis:Chemical pneumonitis: Surfactant dysfunction:Surfactant dysfunction: Umbilical vessel damageUmbilical vessel damage Persistent pulmonary hypertension of the Persistent pulmonary hypertension of the

newbornnewborn


Airway obstruction:Airway obstruction:

ImmediateImmediate : : obstruction of large airways: (volume obstruction of large airways: (volume dependent ):dependent ):

hypoventilation => hypoxemia, hypercapnea, acidosishypoventilation => hypoxemia, hypercapnea, acidosis

Central clearingCentral clearing – – obstruction of small airways:obstruction of small airways:

CompleteComplete athelectasis athelectasis Partial Partial air trapping (ball valve phenomenon) air trapping (ball valve phenomenon) hyperdistention of hyperdistention of

alveoli alveoli increaesed lung resistance during exhalation increaesed lung resistance during exhalation pneumothorax, pneumomediastinum , pneumopericardiumpneumothorax, pneumomediastinum , pneumopericardium. .





Chemical pneummonitis:Chemical pneummonitis:

50% of cases50% of cases Enzemes, bile salts, fats – irritantsEnzemes, bile salts, fats – irritants PMN, MQ, PMN, MQ,

inflammatory mediators.inflammatory mediators. Chemical pneumonitis, edema (6h) Chemical pneumonitis, edema (6h) inflamation inflamation

(24h)(24h) Hyalin membranes, hemorrhage, vascular necrosis can Hyalin membranes, hemorrhage, vascular necrosis can

occur.occur. Bacterial superinfection.Bacterial superinfection. Activated Vasoactive mediators play a role in the Activated Vasoactive mediators play a role in the

develipment of PPHN.develipment of PPHN.


Chemical pneummonitis:Chemical pneummonitis:

50% of cases50% of cases Enzemes, bile salts, fats – irritantsEnzemes, bile salts, fats – irritants PMN, MQ, PMN, MQ,

inflammatory mediators.inflammatory mediators. Chemical pneumonitis, edema (6h) Chemical pneumonitis, edema (6h) inflamation inflamation

(24h)(24h) Hyalin membranes, hemorrhage, vascular necrosis can Hyalin membranes, hemorrhage, vascular necrosis can

occur.occur. Bacterial superinfection.Bacterial superinfection. Activated Vasoactive mediators play a role in the Activated Vasoactive mediators play a role in the

develipment of PPHN.develipment of PPHN.



Surfactant dysfunctionSurfactant dysfunction

Free fatty acids (paimitic, stearic, oleic) – Free fatty acids (paimitic, stearic, oleic) – higher minimal surface tention than surfactant higher minimal surface tention than surfactant (striping effect)(striping effect)

decreased lung compliance decreased lung compliance concentration dependentconcentration dependent


Umbilical vessel damageUmbilical vessel damage

Umbilical vessels exposed to meconium Umbilical vessels exposed to meconium may may cause severe focal inflammation injury.cause severe focal inflammation injury.

Spasm and necrosis Spasm and necrosis fetal hypoperfusion fetal hypoperfusion 1% meconium induced umbilical vascular 1% meconium induced umbilical vascular

necrosis among meconium stained placentas.necrosis among meconium stained placentas.


Persistent pulmonary hypertension of Persistent pulmonary hypertension of the newbornthe newborn

Final common pathway for the severe morbidity and Final common pathway for the severe morbidity and mortality in infants with MAS.mortality in infants with MAS.

Hypoxia Hypoxia Pulmonary arterial vasoconstriction. Pulmonary arterial vasoconstriction.

Abnormal pulmonary arterial muscularization Abnormal pulmonary arterial muscularization m/p chronic change m/p chronic change

Association between MAS and PPHN : Association between MAS and PPHN : Direct pathogenic cause of lung damageDirect pathogenic cause of lung damage Simple marker of chronic intrauterine hypoxiaSimple marker of chronic intrauterine hypoxia


Risk factors of MAS developing into Risk factors of MAS developing into PPHNPPHN ““Risk factors of meconium aspiration syndrome Risk factors of meconium aspiration syndrome

developing into persistent pulmonary developing into persistent pulmonary hypertension of newborn.hypertension of newborn.Acta Paediatr Taiwan. 2004 Jul-Aug;45(4):203-Acta Paediatr Taiwan. 2004 Jul-Aug;45(4):203-7” – 362 cases of MAS (17% with PPHN).7” – 362 cases of MAS (17% with PPHN).

Pneumothorax, change in FHR base line, Pneumothorax, change in FHR base line, asphyxia asphyxia most important risk factors most important risk factors



Risk and severety of MAS:Risk and severety of MAS: Degree of contamination of the amniotic fluid and Presence Degree of contamination of the amniotic fluid and Presence

of meconium in the airway at deliveryof meconium in the airway at delivery is meconium itself a is meconium itself a direct primary cause of morbidity mortality?direct primary cause of morbidity mortality?

MAS is commonly associated with chronic hypoxiaMAS is commonly associated with chronic hypoxia is is meconium a marker of fetal maturation of chronic fetal meconium a marker of fetal maturation of chronic fetal hypoxia?hypoxia?

Asphyxia, pneumothorax, PPHN – the most important risk Asphyxia, pneumothorax, PPHN – the most important risk factors of mortality in MAS.factors of mortality in MAS.


Clinical presentation:Clinical presentation:

Depressed at birthDepressed at birth

Early onset of respiratory distress (within 2 h)Early onset of respiratory distress (within 2 h)

» Mild tachypneaMild tachypnea» cyanosis cyanosis » Dyspnea: granting, ala nazi, intercostal retractionDyspnea: granting, ala nazi, intercostal retraction» Barral chest (presence of air trapping)Barral chest (presence of air trapping)» respiratory failurerespiratory failure

Auscultayion: “wet” inspiratory crackles, occasional expiratory noises Auscultayion: “wet” inspiratory crackles, occasional expiratory noises

Severe Mas:Severe Mas:» Hypoxemia – RHypoxemia – RL shant L shant » Persistant fetal circulationPersistant fetal circulation» PPHN – hypoxic pulmonary arterial vasoconstriction – acidosis, hypercapnea, PPHN – hypoxic pulmonary arterial vasoconstriction – acidosis, hypercapnea,

hypoxemia (prenatal & perinatal maladaptation)hypoxemia (prenatal & perinatal maladaptation)» Cardiopulmonary failureCardiopulmonary failure» acidosisacidosis


Complication:Complication:

PPHNPPHN AIR LEAKAIR LEAK PULMONARY HEMORRAGEPULMONARY HEMORRAGE ASPHYXIA COMPLICATIONSASPHYXIA COMPLICATIONS


Laboratory:Laboratory:

Hypoxemia (RHypoxemia (RL shunt)L shunt) Hypercarbia (in significant obstruction)Hypercarbia (in significant obstruction) Respiratory alkalosis (hyperventilation)Respiratory alkalosis (hyperventilation) Combined respiratory and metabolic acidosis Combined respiratory and metabolic acidosis

(severe disease – respiratory failure)(severe disease – respiratory failure)


Chest x-rayChest x-ray 73% - positive x-ray findings73% - positive x-ray findings Global atelectasis – earlyGlobal atelectasis – early

Patchy dense opacifications (decreased vantilation) Patchy dense opacifications (decreased vantilation) accompanied by areas of hyperinflationaccompanied by areas of hyperinflation

Widespread infiltratesWidespread infiltrates ConsolidationsConsolidations Small pleural effusion (30%)Small pleural effusion (30%) Pneumothorax/ pneumomediastinum (25%)Pneumothorax/ pneumomediastinum (25%)



Prenatal diagnosis and prevention:Prenatal diagnosis and prevention:

Diagnosis of fetus “at risk” – monitoring fetal Diagnosis of fetus “at risk” – monitoring fetal status.status.

Thick VS thin meconiumThick VS thin meconium Meconium and FHR abnormalitiesMeconium and FHR abnormalities Amnioinfusion during laborAmnioinfusion during labor Nasopharyngeal suctioningNasopharyngeal suctioning


Upon delivery intervention:Upon delivery intervention: ““combined approach” : nasopharengeal suctioning + combined approach” : nasopharengeal suctioning +

neonatal trachea suction.neonatal trachea suction.

Thick meconium + depressed infant Thick meconium + depressed infant tracheal suction tracheal suction - marked reduction in morbidity and mortality.- marked reduction in morbidity and mortality.

The American Academy of pediatrics Neonatal The American Academy of pediatrics Neonatal Resuscitation Program Steering Guidelines Resuscitation Program Steering Guidelines


managementmanagement Minimize agitation (prevent additional acidosis and Minimize agitation (prevent additional acidosis and

hypoxemia) – optimal thermal environment, minimal hypoxemia) – optimal thermal environment, minimal handling, muscle relaxation.handling, muscle relaxation.

NGTNGT Respiratory care Respiratory care Maintain systemic blood pressure (RMaintain systemic blood pressure (RL shunt)L shunt) Antibiotics.Antibiotics.


MAS treatment – ventilation MAS treatment – ventilation support:support: Main target: oxigenation! – PaO2 60-90mmHgMain target: oxigenation! – PaO2 60-90mmHg

difficulty with oxigenationdifficulty with oxigenation positive airway pressure (CPAP) – positive airway pressure (CPAP) – improves improves ventilation, stabilizes small airways.ventilation, stabilizes small airways.

Respiratory acidosis/severe respiratory distress Respiratory acidosis/severe respiratory distress mechanical ventilation – mechanical ventilation – sPO2> sPO2> 50 mm Hg with FiO2 – 100% & pH< 7.2 . 50 mm Hg with FiO2 – 100% & pH< 7.2 . sedation! Relaxationsedation! Relaxation!!

SurfactantSurfactant

iNOiNO

failed conventional ventilation – HFJV, HFOfailed conventional ventilation – HFJV, HFO

ECMOECMO


SURFACTANTSURFACTANT Lung lavage using sufractant in MAS is currently being investigatedLung lavage using sufractant in MAS is currently being investigated

““Treatment of severe meconium aspiration syndrome with porcine Treatment of severe meconium aspiration syndrome with porcine surfactant: a multicentre, randomized, controlled trial”surfactant: a multicentre, randomized, controlled trial”Acta Paediatr. 2005 Jul;94(7):896-902.Acta Paediatr. 2005 Jul;94(7):896-902.

“ “ Pulmonary function after surfactant lung lavage followed by surfactant Pulmonary function after surfactant lung lavage followed by surfactant administration in infants with severe meconium aspiration syndrome”.administration in infants with severe meconium aspiration syndrome”.J Matern Fetal Neonatal Med. 2004 Aug;16(2):125-30. J Matern Fetal Neonatal Med. 2004 Aug;16(2):125-30.


SteroidsSteroids Pathophysiology: anti-infalammatory properties.Pathophysiology: anti-infalammatory properties. Corticosteroid treatment, started early, show some Corticosteroid treatment, started early, show some

improvement in oxigenation and pulmonary improvement in oxigenation and pulmonary hemodynamics durind acute phase.hemodynamics durind acute phase.

Effect on morbidity and mortality Effect on morbidity and mortality Cochrane Cochrane Database Syst Rev, 2003 Database Syst Rev, 2003 insufficient evidence. insufficient evidence.

Further research: clinucal significant, optimal timing, Further research: clinucal significant, optimal timing, dosing.dosing.


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Case 2Case 2 25 Y G1 42 W Single 25 Y G1 42 W Single CC: LP CC: LP PNC: (-) PNC: (-) PMH: opiate abuser PMH: opiate abuser FH: Term V/E: 3 – 4 cm & me conium stained Amniotic fluid FH: Term V/E: 3 – 4 cm & me conium stained Amniotic fluid The new born birthed by C/S The new born birthed by C/S The vernix , umbilical cord and nails was me conium – stained The vernix , umbilical cord and nails was me conium – stained

endoteracheal suction was performed endoteracheal suction was performed The new born had respiratory distress with marked tachypnea and The new born had respiratory distress with marked tachypnea and

cyanosis . cyanosis . APGAR: 3/10 & 6/10 (1′ & 5′) APGAR: 3/10 & 6/10 (1′ & 5′) Auscultation reveals rales Auscultation reveals rales The new born was hospitalized in NICU The new born was hospitalized in NICU Because of Eyes Discharged Gentamicin and cefotaxim was started Because of Eyes Discharged Gentamicin and cefotaxim was started After 6 days the infant was discharged After 6 days the infant was discharged



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Intra Uterine Growth Retardation

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