newborns

aspiration pneumonia

pneumothorax

respiratory distress

persistent pulmonary hypertension

air leak syndrome

List of abbreviations

IVL - artificial lung ventilation

MAP - mean airway pressure

RCTs - randomized controlled trials

CAM - meconium aspiration syndrome

SDR, RDS - respiratory disorder syndrome

CPAP - continuous positive airway pressure / method of respiratory therapy - constant airway pressure

Ultrasound - ultrasound examination

HR - heart rate

ETT - endotracheal tube

f is the frequency of apparatus breaths, per minute

Peep - peak pressure at the end of expiration

Pip - Peak Inspiratory Pressure

SpO2 - oxygen saturation, blood oxygen saturation, measured by pulse oximetry

Ti - inspiration time

raCO2 - concentration of carbon dioxide in blood

paO2 - oxygen concentration in the blood

Terms and Definitions

Meconium aspiration syndrome - severe respiratory distress in newborns caused by the ingress of meconium into the lower respiratory tract.

Surfactant(translated from English - surfactant) - a mixture of surfactants lining the alveoli from the inside.

Air Leak Syndrome- a serious condition of newborns, characterized by rupture of the alveoli, the release of air from them and its spread through the lungs and to other parts of the body.

Persistent pulmonary hypertension - a condition characterized by a decrease in blood flow in the lungs of a newborn and the appearance of a right-left shunt as a result of a return to constriction of pulmonary arterioles or persistence.

Tachypnea -rapid shallow breathing.

1. Brief information

1.1 Definition

Meconium aspiration syndrome (CAM) is a severe respiratory distress in newborns caused by the ingress of meconium into the lower respiratory tract.

CAM synonyms:neonatal meconium aspiration syndrome, neonatal aspiration.

1.2 Etiology and pathogenesis

CAM is more often observed in post-term or full-term newborns who have undergone intrauterine antenatal and / or intrapartum hypoxia and were born in asphyxia, which led to spasm of the mesenteric vessels, increased intestinal motility, relaxation of the anal sphincter, and meconium passage - its release into the amniotic fluid. Winding the umbilical cord around the neck, squeezing it stimulates the vagal response and passage of meconium, even in the absence of asphyxia.

Aspirated meconium (this can occur intrauterinely before childbirth) causes an inflammatory reaction in the trachea, bronchi, pulmonary parenchyma (its maximum is observed after 36-48 hours) - chemical pneumonitis (due to the lipids contained in it, proteolytic enzymes, its increased osmolarity), and also atelectasis, both due to blockage of the bronchi, and due to inactivation of the surfactant, followed by the collapse of the alveoli on exhalation. In addition to inflammation and atelectasis, edema occurs in the lungs during meconium aspiration, often pneumothorax and other types of "air leakage" (in 10-20% of cases with massive aspiration).

1.3 Epidemiology

The frequency of meconium aspiration syndrome is about 1% of all newborns born through the vaginal birth canal, although the frequency of detection of meconium in the amniotic fluid varies, according to different authors, from 5 to 15%. Meconium in amniotic fluid during premature pregnancy is found less often - in 2-4% of cases. It is believed that in about half of the children, if during childbirth the amniotic fluid was stained with meconium, the original feces are present in the trachea (in a part if it is absent in the mouth), but only in 1/3 of them, even if adequate measures are applied (careful suction of meconium from trachea immediately after birth), respiratory disorders develop. They are usually noted when fragments are found in the amniotic fluid - accumulations of meconium (amniotic fluid in the form of "pea soup").

1.4 ICD 10 coding

P24.0 - Neonatal meconium aspiration

1.5 Classification

CAM classification by flow options

First option - from birth there is severe respiratory failure, attacks of secondary asphyxia, shortness of breath, dullness of the pulmonary tone, increased chest rigidity, abundant variegated moist rales in the lungs.

Second option - after birth, there is a light interval, after which the clinic of type II SDS develops (shortness of breath, emphysema). The aggravation of the condition in this variant of the CAM is explained by the gradual movement of small particles of meconium towards the peripheral parts of the respiratory tract. The clinical course of the CAM in terms of the height of lung lesions is, as a rule, severe, with pronounced symptoms of respiratory failure, the involvement of auxiliary muscles in the act of breathing, and an abundance of wheezing in the lungs. Almost all children develop persistent pulmonary hypertension, most of them develop infectious lesions of the lungs - tracheobronchitis, pneumonia, and many have an "air leak" (for example, pneumothorax). CAM is a risk factor for the development of adult-type SDS and chronic bronchopulmonary diseases.

CAM classification by severity

Depending on the amount, consistency of the aspirated liquid, as well as on the timing of aspiration, the following are distinguished:

Mild degree - tachypnea is noted, passing through 42-72 hours. The pCO2 level in arterial blood is within normal limits, blood pH is unchanged. Minor hypoxemia, corrected by oxygen inhalation, is rarely noted.

Average degree - the clinic is similar to a mild degree, but the increase in respiratory failure occurs faster and the peak falls on 24 hours. In arterial blood, hypoxemia is noted, a degree that does not correspond to the severity of pulmonary pathology (comparison with the Rg-gram of the chest). This may indicate persistent pulmonary hypertension with blood shunting from right to left both at the level of the patent ductus arteriosus and at the level of the atria (as confirmed by ultrasound of the heart with the Doppler effect).

Severe degree - Respiratory failure is noted immediately after birth or in the first 24 hours of life. In this case, a combination of respiratory and metabolic acidosis is noted, which require immediate correction.
In severe cases, the development of complications such as tension pneumothorax and almost always the development of persistent pulmonary hypertension is quite common. The persistence of pulmonary hypertension is associated primarily with the thickening of the walls of the vessels of the pulmonary arteries due to their excessive hypertrophy and hyperplasia. Hypertrophy was first reported by Siassi et al. in 1971. In particular, their study proved that chronic hypoxia can cause thickening of the walls of small pulmonary arteries due to hypertrophy of smooth muscles, which in turn leads to persistent narrowing of the vessel lumen. In addition to all of the above, it has now been established that acute fetal hypoxemia causes further narrowing of the pulmonary arteries, which ultimately leads to persistent pulmonary hypertension.

2. Diagnostics

2.1 Complaints and anamnesis

Anamnesis consists in identifying risk factors such as postmaturity, eclampsia of a pregnant woman, hypertension of a pregnant woman, diabetes mellitus of a pregnant woman.

2.2 Physical examination

Comments:Early (within 2 hours) the appearance of symptoms of respiratory failure is observed: tachypnea, swelling of the wings of the nose, retraction of the compliant places of the chest, cyanosis. An increase in the anterior-posterior size of the chest.

• It was recommended to perform percussion and auscultation of the lungs at the stage of diagnosis.

Comments:When percussion, areas of dullness are revealed, alternating with a boxed sound. Weakened or hard breathing with a lot of wire and crepitant wheezing is heard. Extended exhalation. Heart sounds are muffled, systolic murmur can be heard. Due to the violation of peripheral blood flow, the skin becomes marbled, edema may appear.

2.3 Laboratory diagnostics

• It is recommended to analyze the acid-base state and blood gases at the stage of diagnosis

Comments:In CAM, pronounced hypoxemia and mixed acidosis are detected.

• At the stage of diagnosis, culture of tracheal contents and blood culture is recommended.

Comments:Because meconium can enhance bacterial growth and CAM is difficult to distinguish from bacterial pneumonia.

2.4 Instrumental diagnostics

• It is recommended that a chest x-ray be taken at the stage of diagnosis to confirm the fact of aspiration

Comments: On the roentgenogram of the lungs, a combination of areas of apnematosis (large, irregularly shaped darkening) extending from the roots of the lungs, interspersed with emphysematous areas, is noted. The lungs initially look emphysematous, the diaphragm is flattened, the anteroposterior chest size is increased. Abundant aspiration is characterized by an X-ray symptom of a "snow storm" and cardiomegaly, which develops on the first day of pneumothorax.

2.5 Differential diagnosis

Differential diagnosis is carried out with RDS, persistent pulmonary hypertension caused by severe asphyxia and sepsis, congenital pneumonia, in a moderate state - with transient tachypnea of \u200b\u200bnewborns.

When diagnosing RDS characteristic signs on an X-ray image are: a diffuse decrease in the transparency of the pulmonary fields, a reticulogranular pattern and stripes of enlightenment in the area of \u200b\u200bthe lung root (air bronchogram).

Diagnosis of transient tachypnea newborns. The disease can occur at any gestational age of newborns, but is more common in term infants, especially after delivery by caesarean section. The disease is characterized by negative markers of inflammation and rapid regression of respiratory disorders. Nasal CPAP is often required, a method of creating constant airway pressure. Characterized by a rapid decrease in the need for additional oxygenation against the background of CPAP. It is extremely rare that invasive mechanical ventilation is required. There is no indication for the administration of an exogenous surfactant.

Diagnosis of early neonatal sepsis, congenital pneumonia ... Characterized by positive markers of inflammation, determined over time in the first 72 hours of life. Early neonatal sepsis / pneumonia is indistinguishable from CAM on X-ray, with a homogeneous process in the lungs. However, if the process in the lungs is focal (infiltrative shadows), then this sign is characteristic of the infectious process and is not characteristic of the CAM. In the case of CAM on the chest radiograph, infiltrative shadows are interspersed with emphysematous changes, atelectasis (pneumomediastinum and pneumothorax are possible).

Diagnosis of persistent pulmonary hypertension of the newborn ... There are no changes characteristic of the CAM on the chest X-ray. Echocardiographic examination reveals a right-left discharge and signs of pulmonary hypertension.

3. Treatment

3.1 Conservative treatment

Surfactant therapy

Comments:The method of surfactant therapy consists in carrying out lavage of the tracheobronchial tree with the diluted preparation Poractant alfa **. For this, the drug (75 mg in a vial) is diluted in 2.5 ml of saline, according to the manufacturer's instructions. From this emulsion, take 0.5 ml and additionally dilute with saline to 5.0 ml (gently stirring and not shaking) and lavage the tracheobronchial tree fractionally in two or three portions. The remaining 2.0 ml (60 mg) of the emulsion is injected alternately in 1.0 ml each into the left and right bronchus as a bolus through a sanitation catheter. The second vial of the drug was administered by micro-stream, so that the total dose was 50 mg / kg. Treatment of severe meconium aspiration syndrome by conducting surfactant therapy in the form of lavage of the tracheobronchial tree with diluted Poractant alfa ** followed by the introduction of a small dose of the drug can reliably reduce the time to reach a non-toxic oxygen concentration in the supplied gas mixture, the time spent by children on artificial lung ventilation and in the department resuscitation and intensive care of newborns. It is known that meconium effectively binds to lung surfactant through chemical and physical interaction mechanisms and inactivates it. In this case, the criterion of inactivation is the loss of the properties of the surfactant to effectively reduce the surface tension at the air-water interface. Meconium adsorbed on particles of exogenously administered surfactant is removed during lavage, and the subsequent administration of a therapeutic dose of Poractant alfa ** 50 mg / kg acts as a replacement therapy, leading to an increase in lung compliance, elimination of atelectasis and improvement of ventilation-perfusion ratio. The effect of therapy was manifested by an improvement in the auscultatory picture in the lungs and positive dynamics on chest radiographs.

Sedation and muscle relaxation

• To reduce oxygen consumption and eliminate the work of breathing in the intensive care unit, deep sedation and muscle relaxation are recommended. Comments:trimeperidine ** - saturation dose - 0.5 mg / kg, maintenance dose - 20-80 μg / (kghh); fentanyl ** - saturation dose 5-8 μg / kg, maintenance dose - 1-5 μg / (kghh)); pipcuronium bromide # ** - 0.1 mg / kg.

Antibacterial therapy

• It is recommended that initial antibiotic therapy be administered before culture results are obtained.

Comments: Antibiotic therapy is indicated for meconium aspiration as it promotes bacterial growth. They start with cephalosporins and aminoglycosides. According to the results of cultures from the trachea, a change in antibiotic therapy is carried out.

Respiratory therapy for newborns with CAM

Helping a newborn with CAM in the delivery room

• It is recommended that all newborns with CAM be assisted in the delivery room.

Comments: The widespread use in previous years of the sanation of the nasopharynx and oropharynx of the fetus before the birth of the shoulder with a preventive purpose has not confirmed its effectiveness, therefore, at present, this manipulation is not recommended for routine use. Sanitation of the child's nasopharynx and oropharynx should be carried out after the child has been moved to the resuscitation table. At the same time, despite the fact that the amniotic fluid contains meconium, if the child immediately after birth has good muscle tone, active spontaneous breathing or a loud cry, then tracheal sanitation is not indicated.

If the amniotic fluid contains meconium and the child has reduced muscle tone, ineffective or weakened spontaneous breathing, tracheal intubation should be performed immediately after birth, followed by sanitation through an endotracheal tube. Special attention should be paid to the fact that sanitation is carried out by connecting the aspirator hose through the T-shaped connector or meconium aspirator directly to the endotracheal tube. Sanitation is performed until the contents of the trachea are completely aspirated. If the endotracheal tube is blocked by meconium, remove the tube, re-intubate the child's trachea, and continue debridement. Usee for this purpose, suction catheters, the diameter of which is always smaller than the diameter of the endotracheal tube, are not permitted. If, against the background of sanitation, an increase in bradycardia of less than 80 beats / min is noted, sanitation should be stopped and artificial lung ventilation (ALV) should be started until theheart rate (Heart rate) more than 100 beats / min. The question of the need for re-sanitation of the trachea is decided after the restoration of the child's cardiac activity on an individual basis.

The use of mechanical ventilation in the delivery room

Comments:Use of the self-expanding bag in newborns:

A self-expanding bag with a maximum volume of 240 ml should be used. This size is more than sufficient for ventilation in newborns. After compression, the bag expands on its own due to its elastic properties, regardless of the source of the gas mixture, which makes the use of this device convenient and simple. However, for ventilation with an air-oxygen mixture, it is necessary to connect the bag to an oxygen source and set the flow rate to 8 l / min. This speed allows you to achieve a concentration in the respiratory mixture of about 40%. To create a higher oxygen concentration (80-90%), an additional oxygen tank must be connected to the self-expanding bag. It should be remembered that it is difficult to maintain the same peak pressure from inspiration to inspiration when performing ventilation with a self-expanding bag. Therefore, it is advisable to use a pressure gauge connected to the bag. The maximum peak pressure is limited by an overpressure relief valve, which is activated when it exceeds about 40 cmH2O. To create more inspiratory pressure, use your finger to block the pressure relief valve. Sometimes this may be required if the first mandatory breaths are ineffective in the process of mask ventilation in large full-term newborns. When using a self-expanding bag, it is impossible to create positive end-expiratory pressure without additionally connecting an end-expiratory pressure valve. The use of a self-expanding bag does not allow for inflation of the lungs lasting more than one second.

Using a ventilator with a T-connector:

In ventilators with a T-connector, the gas mixture enters the mask or endotracheal tube through a circuit connected to a compressed air and oxygen mixer and to a pressure gauge. Ventilation is ensured by periodically occluding the T-connector outlet tube with a finger. The device allows you to create and regulate the required pressure, both on inspiration and by changing the diameter of the outlet tube opening on expiration (CPAP, PEEP). Inspiratory time is adjusted by changing the duration of finger occlusion of the T-connector outlet tube. For the device to function, it must be connected to a gas mixture source. The flow rate is set at 8 l / min. Compared to self-expanding and flow-expanding bags, devices with a T-connector are the most convenient for ventilating newborns in the delivery room.

Mechanical ventilation as a method of respiratory therapy for newborns with CAM

• With pronounced signs of respiratory failure, confirmed on the CAM X-ray, it is recommended to start mechanical ventilation.

Comments: Moderate hypoxemia can be corrected by inhalation of humidified oxygen through an oxygen tent. The effect of CPAP in newborns with CAM is unpredictable and therefore not recommended for routine use.

Indications for mechanical ventilation: 1) refractory hypoxemia - pa02<50, при f02 >0.9; 2) respiratory acidosis - pCO2\u003e 60, pH<7,2.

Starting parameters: f - 40-60 rpm, PIP - 25-30 cm of water column, Ti - 0.3-0.35 s, PEEP + 4-5 cm water column, fO2 - 0.8- 1.0.

The purpose of ventilation: in the first 24-48 hours - controlled ventilation with maintenance of moderate hypocapnia (pCO2 - 30-35 mm Hg) and good oxygenation (pa02 - 60-90 mm Hg). It should be remembered that severe hypocapnia (raCO2<30 мм рт.ст.) потенциально опасна для новорождённых и может привести к усилению церебральных расстройств, обусловленных перинатальной гипоксией. С 3-4-х суток при улучшении состояния ребёнка переводят на вспомогательные режимы вентиляции. При возникновении пневмоторакса предпочтительнее проведение высокочастотной осцилляторной ИВЛ.

4. Rehabilitation

There are no specific measures for rehabilitation after CAM.

5. Prevention and dispensary observation

5.1 Prevention

• During childbirth, at a high risk of fetal hypoxia, the fetus is monitored.

Comments: If the results indicate a critical condition, delivery is indicated in the most acceptable way (cesarean section, obstetric forceps).

5.2 Dispensary observation

• After the end of treatment and the child is discharged from the hospital, dynamic observation in the clinic is recommended.

Comments: Examination by a district pediatrician - once a month; neurologist and ophthalmologist - once every 3 months.

6. Additional information affecting the course and outcome of the disease

Negatively affect the outcome of treatment:

The development of chemical pneumonitis.

Accession of infectious complications.

Development of one of the manifestations of the "air leakage" syndrome (pneumothorax).

Indications for mechanical ventilation:

- lack of breathing;

- irregular breathing;

- heart rate< 100 уд/мин.

IVL in the delivery room for children with CAM can be performed:

- self-expanding bag;

- manual ventilator with T-connector;

- traditional ventilator

Immediate tracheal intubation is indicated:

- children with suspected diaphragmatic hernia;

- children born with an admixture of meconium in the amniotic fluid with suppressed spontaneous respiration, or its absence and decreased muscle tone;

- children born before the 27th week of pregnancy, with the aim of prophylactic administration of a surfactant.

Criteria for assessing the quality of medical care

Group name:Meconium aspiration syndrome

ICD codes: P24.0

Type of medical assistance: specialized

Age group: children

Conditions for the provision of medical care:stationary

Medical assistance form:urgent

List of references

Neonatology: Textbook. allowance: In 2 volumes / N.P. Shabalov. - T. 1. - 3rd ed., Rev. and add. - M .: MEDpress-inform, 2004 .-- 608 p.

I.V. Vinogradov, G.I. Nikiforova - "Use of Surfactant BL in newborns with meconium aspiration syndrome". - Russian Bulletin of Perinatology and Pediatrics. - 4th ed., 2011.

V.V. Bondareva, K. D. Gorelik - “Meconial aspiration, etiology, pathophysiological mechanisms, prehospital and hospital care”. http://www.airspb.ru/c_tez_9.shtml.

Propedeutics of childhood diseases. / A.V. Mazurin, I.M. Vorontsov - 1985 - 441 p.

Appendix A1. Composition of the working group

Shabalov N.P. - Doctor of Medical Sciences, Professor, President of the St. Petersburg Regional Branch of the "Union of Pediatricians of Russia", Honored Scientist of the Russian Federation, Honored Doctor of the Russian Federation, Laureate of the Government of the Russian Federation, Head of the Department and Clinic of Children's Diseases of the FSBVOI HE CM. Kirov "Ministry of Defense of the Russian Federation.

Ivanov D.O. - Doctor of Medical Sciences, Professor, Chief Freelance Specialist of the Ministry of Health of the Russian Federation in Neonatology, Acting Rector of the St. Petersburg State Pediatric Medical University of the Ministry of Health of Russia, member of the Russian Association of Specialists of Perinatal Medicine.

Yu.V. Petrenko - Candidate of Medical Sciences, Acting Vice-Rector for Medical Work of the Federal State Budgetary Educational Institution of Higher Education "St. Petersburg State Pediatric Medical University" of the Ministry of Health of Russia.

Lee A.G. - Head of the Department of Anesthesiology, Reanimation and Intensive Care of Newborns at the Perinatal Center of the St. Petersburg State Pediatric Medical University of the Ministry of Health of Russia.

Merzlikina S.S. - anesthesiologist-resuscitator of the Department of Anesthesiology, Reanimation and Intensive Care of Newborns of the Perinatal Center of the St. Petersburg State Pediatric Medical University of the Ministry of Health of Russia.

Conflict of interest.All Working Group members have confirmed no financial support / conflict of interest to be reported.

Doctor-anesthesiologist-resuscitator;

Neonatologist;

Medical students, residents, graduate students.

Help form

Despite the planning of diagnostic and therapeutic measures for newborns with meconium aspiration, help is urgency... Delaying the onset of urgent actions and adequate therapy leads to a decrease in overall survival rates among newborns and complicates the prognosis for a particular patient.

Table A.1 -Confidence Levels of Evidence According to International Criteria

Confidence level

Data type

Meta-analysis of randomized controlled trials

At least 1 randomized controlled trial

At least 1 controlled trial without randomization

At least 1 quasi-experimental study

Descriptive studies such as comparative studies, correlation studies, or case-control studies

Expert committee report or opinion and / or clinical experience of the called authority

Table A.2 -Strengths of recommendations

Credibility level

Level of evidence 1

Level 2 evidence or extrapolated level 1 evidence recommendation

Level of evidence 3 or extrapolated recommendation of level 1 or 2 evidence

Evidence level 4 or extrapolated recommendation level 2 or 3 evidence

Appendix A3. Related documents

Methodological letter of the Ministry of Health and Social Development of the Russian Federation of April 21, 2010 N 15-4 / 10 / 2-3204 "Primary and intensive care for newborn children" for use in the work of medical institutions providing medical care to newborns.

Appendix B. Patient management algorithms

Flowchart for diagnosing and treating a suspected patient

for meconium aspiration syndrome (MAS)

Appendix B. Information for Patients

Risk factors for developing meconium aspiration syndrome:

postmaturity of the child (pregnancy over 40 weeks);

the umbilical cord entwined around the child's neck;

hypoxia (lack of oxygen) in a child intrauterine or during childbirth;

rh-conflict (negative Rh factor in the mother and positive in the child, different blood groups);

diabetes mellitus (a chronic disease accompanied by a constant increase in blood glucose levels) in the mother;

hypertension (high blood pressure) in the mother;

preeclampsia (complication of pregnancy in the 3rd trimester of pregnancy, characterized by a disorder of the functions of vital organs and systems, primarily cardiovascular and urinary) of a pregnant woman;

mother's age (over 35).

Prevention is possible only from a pregnant woman:

treatment of diabetes mellitus (a chronic disease accompanied by a constant increase in blood glucose levels);

timely detection and elimination of fetal hypoxia (lack of oxygen);

prevention of fetal overdue (by administering drugs that provoke contractions; cesarean section);

amnioinfusion (the introduction of a saline solution warmed up to 37 ° C into the amniotic cavity) in order to dilute meconium (original feces). Indications for amnioinfusion: lack of water, the presence of meconium in the amniotic fluid;

careful management of childbirth: an adequate choice of delivery depending on the condition of the mother and fetus, avoidance of injuries during childbirth.

Outcomes and prognosis for a newborn undergoing CAM:

The prognosis of a child's life and health largely depends on the severity of the condition at birth, the quality of primary resuscitation measures and the level of intensive care in the first 48 hours of life. According to various sources, the mortality rate in CAM ranges from 4 to 19%. Since virtually all children who have aspirated meconium suffer severe perinatal hypoxia, there is a high likelihood of neurological impairment. According to Russian authors, at the age of one and a half years of life, about 20% of such patients have a lag in physical and neuropsychic development.

Appendix D.

Downs scale for assessing the severity of respiratory distress syndrome in term infants

I. Definition. Normally, meconium is the first discharge from the intestines of a newborn and consists of epithelial cells, fetal hair, mucus and bile. However, intrauterine stress can cause meconium to pass into the amniotic fluid during the antenatal period. Subsequently, the amniotic fluid stained with meconium can be aspirated by the fetus in the prenatal period or by the newborn in the intranatal period. When meconium enters the airways, it causes airway obstruction and a severe inflammatory reaction, resulting in severe respiratory failure. The presence of meconium in amniotic fluid is an alarming sign of fetal distress, requiring careful monitoring of childbirth and fetal health.

II. Frequency. The frequency of staining amniotic fluid with meconium ranges from 8 to 20% of the total number of births. Discharge of meconium in fetuses less than 34 weeks of gestation in response to asphyxia is extremely rare; thus, meconium aspiration syndrome is characteristic mainly of full-term and post-term infants.

III. Pathophysiology

A. Intrauterine discharge of meconium. Asphyxia and other forms of intrauterine stress to the fetus can cause increased intestinal motility, relaxation of the external anal sphincter, and the passage of meconium. The effect of intrauterine hypoxia on peristalsis and sphincter tone increases with increasing gestational age, therefore, when staining amniotic fluid with meconium in the case of a premature baby, it should be assumed that he has suffered more severe hypoxia than a post-term newborn.

B. Aspiration of meconium. After the passage of meconium into the amniotic fluid, the appearance of convulsive breaths in the fetus exposed to asphyxia in the antenatal or intranatal periods can lead to the aspiration of water stained with meconium into the large respiratory tract (normally, respiratory movements of the fetus cause the evacuation of pulmonary secretions from the respiratory tract into the amniotic fluid). Viscous meconium causes airway obstruction, leading to respiratory distress syndrome.

1. Airway obstruction. Penetration of meconium into the distal airways causes their complete or partial obstruction. In areas of the lungs with complete obstruction, atelectasis is formed; in areas with partial obstruction as a result of the valve mechanism, the formation of "air traps" and hyperextension of the lungs occur. "Air traps" increase the risk of air leaks from the lungs by up to 10-20%.

2. Chemical pneumonitis. Ultimately, interstitial chemical pneumonitis develops with edema of the bronchioles and narrowing of the lumen of the small airways. Uneven ventilation due to the formation of areas in the lungs with partial obstruction of the airways and associated pneumonitis cause severe CO2 retention and hypoxemia. A direct consequence of hypoxia, acidosis and pulmonary distention is an increase in pulmonary vascular resistance, which leads to right-left shunting of blood at the level of the atria or ductus arteriosus and a further deterioration in blood oxygen saturation.

IV. Clinical manifestations. The clinical picture of meconium aspiration syndrome can be very different. The nature of the symptoms depends on the severity of the hypoxic stroke, as well as on the amount and viscosity of the aspirated meconium.

A. General symptoms

1. Newborn. Newborns with meconium aspiration syndrome are often post-term babies, young by gestational age, with long nails and flaky yellow or green pigmented skin. At birth, they may have depression of the central nervous system, respiratory distress and decreased muscle tone due to severe perinatal asphyxia, which is also associated with the passage of meconium into the amniotic fluid.

2. Amniotic fluid. Meconium in amniotic fluid can be found in different quantities, have different viscosity and color: from a small impurity to an abundant amount, from a slight staining of amniotic fluid with greens to the appearance and thickness of "pea soup". It is believed that thick staining of amniotic fluid with meconium is associated with the development of severe respiratory distress syndrome and higher morbidity and mortality than mild staining.

B. Airway obstruction. If a newborn has aspirated a large amount of viscous meconium, he will develop acute airway obstruction, manifested by deep convulsive breaths, cyanosis and gas exchange disturbances. It is necessary to immediately restore a clear airway by suctioning meconium from the trachea.

B. Syndrome of respiratory disorders. A newborn who has aspirated meconium into the distal airways without complete obstruction develops a syndrome of respiratory disorders caused by an increase in airway resistance and the formation of "air traps" in the lungs and manifested by tachypnea, swelling of the wings of the nose, retraction of the intercostal space and cyanosis. In some children without acute airway obstruction, clinical manifestations of meconium aspiration may appear later. Immediately after birth, they have a mild respiratory distress syndrome, the severity of which increases after a few hours as chemical pneumonitis develops.

Note. Although in many cases of meconium staining of amniotic fluid, a healthy baby is born without signs of respiratory distress syndrome, the presence of meconium in the amniotic fluid may indicate that the fetus has suffered a short-term episode of asphyxia that caused the passage of meconium.

D. Changes in the lungs. With the formation of "air traps" in the lungs, the anteroposterior size of the chest increases markedly. Signs of impaired ventilation are determined by auscultation: various wheezing and stridor.

V. Diagnosis

A. Laboratory research

1. When determining arterial blood gases, hypoxemia is usually detected. In mild cases, hyperventilation can lead to the development of respiratory alkalosis, but neonates with massive meconium aspiration usually have respiratory acidosis with hypercapnia due to airway obstruction and pneumonitis. If the newborn has suffered severe perinatal asphyxia, combined respiratory-metabolic acidosis is found.

B. X-ray examination. Excessive stretching of the lungs and flattening of the diaphragm are typical changes on the chest x-ray. Coarse, irregular infiltrates and increased fluid in the lungs are found. Pnemothorax or pneumomediastinum may also occur.

Vi. Treatment

A. Antenatal prophylaxis. The key to treating meconium aspiration is to prevent it during the prenatal period.

1. Identification of high risk pregnancies. Prevention begins with the identification of predisposing maternal factors that can cause the development of uteroplacental insufficiency with subsequent fetal hypoxia during labor. High-risk pregnancies are associated with the following factors:

and. Preeclampsia-eclampsia.

b. Arterial hypertension.

in. Overburdening.

d. Diabetes mellitus in the mother.

e. Reduced fetal motor activity and signs of intrauterine growth retardation.

e. Maternal smoking, chronic lung or cardiovascular disease.

2. Monitoring. During childbirth, it is necessary to carefully monitor labor and continuous monitoring of the fetus. Any signs of fetal distress (discharge of amniotic fluid stained with meconium after rupture of the fetal bladder, disappearance of fetal heart rate variability, the appearance of decelerations on the cardiotocogram, etc.) indicate the need for an assessment of its condition through a thorough blood analysis of the heart rate and, depending on from evaluation - determination of pH in the skin of the fetal head. If the results of the assessment indicate a critical condition of the fetus, urgent delivery is indicated in the most appropriate way.

B. Treatment in the delivery room. The care of neonates with meconium aspiration in the delivery room has been described previously.

B. Treatment of neonates with meconium aspiration. Newborns who have had meconium aspirated from the trachea are at risk of developing pneumonia and lung air leak syndromes, so it is necessary to closely monitor for signs of respiratory distress syndrome. In addition, infants with meconium aspiration who have a low Apgar score will experience asphyxia and should be examined for symptoms of central nervous system, heart, kidney, and liver damage.

1. Respiratory therapy

and. Sanitation of the tracheobronchial tree. If during tracheal sanitation it is not possible to completely remove meconium and mucus, it is recommended to leave an endotracheal tube in it for regular toilet of the tracheobronchial tree. Physiotherapy on the chest every 30-60 minutes (depending on tolerance) will help clear the airways.

b. Arterial blood gases. On admission to the neonatal center, the child should be tested for arterial blood gases in order to assess ventilation disorders and the need for additional oxygenation. If the newborn needs oxygenation with an air-oxygen mixture with an oxygen concentration of more than 40%, arterial catheterization is indicated.

in. Oxygenation monitoring. A transcutaneous monitor or pulse oximeter provides information about the adequacy of oxygenation and helps prevent hypoxemia.

d. Chest X-ray. If the baby is in serious condition immediately after birth, a chest x-ray should be taken. With its help, it is possible to identify children who are at high risk of developing respiratory distress syndrome.

e. Antibiotic therapy. Meconium promotes bacterial growth in vitro. Since it is radiologically impossible to distinguish aspiration of meconium from pneumonia, infants with infiltrates on a chest x-ray should be given broad-spectrum antibiotics after taking appropriate culture materials.

e. Supplemental oxygenation. If the baby's oxygen demand continues to increase and adequate oxygenation cannot be achieved with conventional methods, continuous positive airway pressure (CPAP) may be tried. CPAP improves oxygenation in certain patients, but it can also increase the formation of "air traps" in the lungs and increase the risk of barotrauma. It is necessary, if possible, to maintain the partial tension of oxygen in the arterial blood within 80-90 mm Hg. Art. in order to prevent hypoxic vasoconstriction in the lungs, which can lead to the development of persistent fetal circulation syndrome.

g. Mechanical ventilation of the lungs. Newborns with massive meconium aspiration who rapidly develop respiratory failure with hypercapnia and persistent hypoxemia are indicated for mechanical ventilation.

(1) Respiration rate selection. Ventilation parameters must be selected for each patient individually. Neonates with meconium aspiration generally require a higher inspiratory pressure than infants with hyaline membrane disease; they also respond better to respiratory rates of 60-120 breaths / min. In patients with "air traps" in the lungs, using a relatively short inspiratory time provides sufficient time to exhale.

(2) Complications. The physician must be extremely careful about the development of pulmonary air leakage syndromes. Any unexplained deterioration in the child's clinical condition requires a chest x-ray to rule out pneumothorax. The progression of edema, exudation, the formation of "air traps" in the lungs and the resulting decrease in their compliance force to increase the average pressure in the airways in patients at risk of developing syndromes of air leakage from the lungs. The main purpose of mechanical ventilation is to prevent hypoxemia and to provide adequate ventilation with the lowest possible mean airway pressure, which can reduce the risk of catastrophic air leakage from the lungs.

h. Extracorporeal membrane oxygenation (ECMO). Patients who fail to provide adequate gas exchange by traditional methods are candidates for ECMO.

and. Jet ventilation. Preliminary evidence suggests that high-frequency jet ventilation is an alternative ventilation method for selected patients.

2. Treatment of cardiovascular disorders. Persistent fetal circulation syndrome (PFC) is a common complication in neonates with meconium aspiration. The development of pulmonary hypertension may result from hypoxic vasoconstriction in the lungs, abnormal vascularization of the microvasculature, or both. To reduce the risk of developing PFC syndrome, active resuscitation and stabilization of the child's condition from the first minutes of life are required.

3. General activities. Metabolic disorders such as hypoxia, acidosis, hypoglycemia, hypocalcemia, and hypothermia often develop in neonates with meconium aspiration who have received resuscitation. Since these children, as a rule, undergo perinatal asphyxia, it is necessary to monitor the appearance of symptoms of ischemic damage to any organ.

D. Forecast. The mortality rate can exceed 50%, complications are frequent. In surviving patients with meconium aspiration, as a result of prolonged use of mechanical ventilation and the toxic effect of oxygen, bronchopulmonary dysplasia may develop. Children with severe asphyxia are more likely to have distant neurological disorders.

The fetus develops rapidly every week. Starting from the middle of pregnancy, the differentiation of the large and small intestines of the fetus occurs, and soon peristalsis is added to this. The fetal intestine begins to perform its immediate functions. This may result in the release of meconium.

Where does it come from?

The environment surrounding the fetus - amniotic fluid - contains scales of the fetal epidermis, vellus hairs, mucus, bile. The fetus swallows this liquid, and undigested residues are excreted from the body. As a result, it is revealed meconium in amniotic fluid, causes the appearance of which, as we can see, is absolutely physiological. Most often, the original feces are excreted after birth or during childbirth, however, the excretion of meconium in utero is also a kind of norm.

How to identify

Timely ultrasound diagnostics allows, among other things, to control the degree of transparency of the waters and their quantity. If the waters tend to become cloudy, and, in addition, are diagnosed, this is a warning sign. The large amount of water makes the presence of meconium less significant.

The presence of meconium can be determined with an amnioscope, a device that allows you to examine water without damaging the fetal bladder.

If a woman is already in labor, an artificial rupture of the fetal bladder is often performed, one of the purposes of which is to assess the waters for the presence of meconium.

Possible problems

During childbirth, the baby can additionally swallow amniotic fluid, but the main danger is meconium aspiration... This phenomenon is possible if hypoxia or asphyxia took place during childbirth. Physiologically, this can be explained simply: the accumulation of carbon dioxide in the blood stimulates the respiratory center in the medulla oblongata, resulting in a reflex inhalation. And if childbirth is delayed, then the child takes this first breath while still in the womb, and as a result, meconium enters the lungs. As a result, in addition to the problems associated with hypoxia, another one is added - the risk of developing pneumonia. Pneumonia is especially dangerous for, because they already have vulnerable lungs.

It should be remembered that hypoxia itself causes additional release of meconium, which aggravates the situation. Meconium in amniotic fluid also cause and effect of postmaturity. That is why you should not expect the onset of labor outside medical supervision if the gestational age has exceeded 40 weeks.

Do not lose vigilance

Immediately after delivery, the doctor must remove fluid from the baby's airways. Sometimes a chest x-ray is required.

Meconium retained in the newborn's body will be completely excreted naturally during the first days of the baby's life. Frequent bowel movements in a newborn are a sign of emptying the intestines from original feces. Meconium in newborns differs from normal baby feces in dark green color, sticky consistency and lack of smell.

Medical monitoring of the baby in the postpartum period will dispel all doubts of the mother and eliminate problems if they arise.

In the first hours and days of life (2-3 days), the so-called original feces - meconium , which looks like a thick mass of dark olive or dark green color, reminiscent of condensed poppy juice. This is where the word "meconium" comes from.

The original feces are odorless and the first portions are free of bacteria. Its amount is approximately equal to 60–90 g. In most cases, the discharge of meconium stops on the 2nd day. It also happens that meconium is secreted longer. Then it can be assumed that the child is receiving insufficient nutrition.

From the 7th to 8th day, the usual newborn stool begins to form - a yellowish-golden color with a sour odor. It happens 4 to 5 times a day or more. It can contain impurities of greenery and mucus, as well as white lumps. If a child is bottle-fed, then his stool is usually more abundant and uniform in consistency. Depending on the amount of the mixture, its color can vary - from light yellow to brown. Its smell is quite pungent. The number of bowel movements per day is less than that of breastfed babies, usually one to two per day.

When bottle feeding, you must carefully monitor the consistency of the newborn's bowel movements. If it became more liquid, lumps of undigested curdled milk appeared in the feces, this may indicate an overdose of the mixture. You can reduce the amount yourself, but it is still better to consult a doctor.

In an uncomplicated pregnancy, the fetus is kept in sterile conditions. But after birth, the baby's body is very quickly colonized by microbes. Therefore, in the middle of the 1st week (usually on the 3rd day), almost all newborns have transient stool disorder . It becomes more frequent, heterogeneous both in color and consistency. Lumps, mucus may appear in it. Often it is completely liquid, watery... Areas of dark green color can alternate with greenish, yellow, and even whitish. Such a chair is also called transitional, and the state is called physiological dyspepsia. After 2–4 days, these phenomena disappear: mushy stools, homogeneous in consistency, become golden yellow.

Not all children have physiological dyspepsia equally. Some have very watery stools, more frequent up to 6 or more times a day, others do not have more than 2-3 bowel movements a day. Physiological dyspepsia does not require treatment.

Another transitional condition that occurs in newborns is transient dysbiosis associated with the formation of the child's own intestinal microflora. It plays a large role in the digestion of food and the formation of certain vitamins (for example, vitamin K). When breastfeeding a child, Bacterium bifidum predominates in the intestinal flora - a microorganism that has the most beneficial effect on the digestive processes, with artificial - Escherichia coli. In case of errors in artificial feeding, dysbiosis can be delayed and cause the child's illness.

It is quite rare that newborns do not excrete meconium. This may be due to intestinal obstruction due to a meconium plug in the rectum, which can only be removed by a doctor, or a severe hereditary disease - cystic fibrosis (cystic fibrosis)... In the latter case, lipase and trypsin enzymes are absent in the digestive juice, as a result of which meconium becomes viscous and adheres to the intestinal walls. Peristalsis is unable to propel it. Complete intestinal obstruction occurs... As a rule, at the end of the 1st day, the child begins to vomit. it the extremely serious condition of the newborn is called meconium ileus... It is treated only by surgery. There are other causes of intestinal obstruction.

Constipation can also develop after the safe passage of meconium. However, infrequent bowel movements - for example, every other day - are not necessarily associated with constipation if the child's stool remains soft. Most often, this frequency of stool occurs in children who are bottle-fed. If the stool is delayed for 2-3 days, and then the baby has to push for a long time to empty the intestines, then they talk about constipation.

If a newborn has frequent constipation, be sure to pay attention to this doctor ... Chronic constipation in a newborn can be associated with narrowing (stenosis) of the anus or with megacolon - expansion of the rectum with a significant thickening of its walls, which weakens the intestinal motility. In any case, the child must be under medical supervision.

If constipation is an accident, then the child will usually be helped by additional drinks. If it does not lead to a change in the consistency of feces, half a teaspoon of sugar is added to the milk mixture. Or, after the morning feeding, the baby is given some sweet, water-diluted fruit juice (such as plum). On rare occasions, and better on the advice of a doctor, you can resort to an enema. Often, constipation is a harbinger of a child's illness (colds or infectious).

If the newborn the stool has become liquid, and before that it had a normal appearance, you should immediately see a doctor - the baby may have any of the intestinal infections. In this case, other signs usually appear: the stool becomes more frequent, its texture and color change - it becomes greenish or dirty green with white blotches, later traces of blood and pus are found in it. It can be frothy, light yellow, or green. The chair can also be fat - light yellow, voluminous, sliding over the pot. The appearance of the stool depends on the disease. During diarrhea, their smell becomes very unpleasant.

If your baby has mild diarrhea, continue feeding the baby while you are waiting for the doctor. Breast milk helps with many types of intestinal disorders. But it is better for the baby to eat less. If a newborn is fed with artificial milk formulas, then they are half-diluted with boiled water. The kid may not be full. Then he is fed little by little, but often.

With severe diarrhea, the child vomits and the temperature rises above 38 ° C. Dehydration of the body begins, which is very dangerous, - the baby looks emaciated, with gray circles under the eyes. If you do not have the opportunity to urgently deliver him to the hospital, before the doctor arrives, give the child a drink of the following composition instead of milk: for 250 ml of water - 1 tablespoon of sugar (no top) and a teaspoon of salt. Let the baby drink as much as he can. This is to prevent dehydration.

With some diseases, it also happens bloody stool (melena) - it is black... This is a sign of heavy bleeding in the upper intestines. On the diaper, a red border forms around the stool. The child needs to be urgently taken to the hospital, otherwise he may die!

If the baby is under medical supervision for diarrhea, still be attentive to the child's condition. It also happens that the prescribed treatment is ineffective, and meanwhile, the symptoms of the disease weaken during the water-tea break - the baby definitely becomes better. But his health deteriorates immediately after feeding. This is a very important sign and the doctor should be aware of it.

Diarrhea in a child may be associated with hereditary intolerance to one of the sugars in milk or formula. The baby needs dietary food. Diarrhea often occurs in other metabolic diseases.

The functioning of the newborn's digestive system largely determines the general state of his health in the first years of life.

The feces of infants are different from the faeces that are thought to be common in older children and adults. Newborn chair in medical practice it is called meconium.

The passage of meconium from the newborn should be carried out for a certain time, and the consistency meet specific criteria. Deviations from the norm indicate the risk of developing pathologies associated with the gastrointestinal tract system.

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Concept and general information

Meconium is original fecesin newborns.

Specific stools have a viscous and sticky consistency (may resemble tar). Meconium is practically odorless.

Colourthese stools can range from a light green to black hue. In his compositionoriginal feces contain water, particles of epithelial cells and bile, prenatal hairs, and a small amount of mucus.

Features of meconium:

1. The body of a newborn contains about 100 g of meconium (this amount of original feces should be excreted by an infant in the first day of life).
2. In the first few hours, the original feces are sterile, gradually the number of lactobacilli and other types of microorganisms begins to increase.

How long does it take?

Infant stool in a child forms about seven days after birth... The first bowel movements occur within twenty hours after the birth of the baby. Gradually, meconium acquires a yellowish tint and a mushy consistency.

The stool has a sour smell. The presence of small veins and lumps in the feces is acceptable.

Meconium separation process carried out after each feeding, but its frequency up to ten times a day is not a deviation.

Options for the release of meconium in newborns:

1. At the stage of intrauterine development (not always considered the norm, in most cases it is an alarming symptom).
2. In the first three hours after birth (in some cases, the first original feces are released almost during the birth of a baby).
3. In the first twenty hours after birth (there are no abnormalities).
4. From the second day, the original feces become transitional (a change in color and structure occurs).

What can lead to delayed discharge?

The delay in the passage of meconium may be due to external or internal factors. The second category includes congenital pathologies of the digestive system or the consequences of a difficult delivery. It is much easier to eliminate the influence of external factors.

In this case, it is necessary to identify the exact cause of the violation of the bowel movement process and eliminate it.

If the baby's lips or mother's nipples have some anatomical features, then the feeding process can be adjusted with the help of special pads.

Delay the passage of meconium the following factors can:

Meconium ileus - treatment

Meconium ileus is a pathological condition that occurs due to excessive viscosity of meconium. Stool clogs the ileal lumen and causes the newborn to have no stool for several days.

The condition gives the baby serious discomfort. Characteristic symptomsfor such a pathology, the capriciousness of the child and his refusal to feed are considered.

Treatmentis carried out in several stages:

What is meconium aspiration?

Aspiration of meconium is a dangerous condition. With this syndrome, the original feces enter the lungs of the newborn... Such a problem may arise not only after the birth of a child, but also in the last months of intrauterine development.

An alarming signal is the presence of meconium in the amniotic fluid. The original feces, when they enter the lungs of an infant, can cause a serious inflammatory process or.

The reasons

Post-term babies are at risk of developing meconium aspiration. In the late stages of intrauterine fetal formation, natural processes begin to work in such babies, including bowel emptying.

Early release of meconium provokes it getting into amniotic fluid... Under the influence of some pathological conditions, the fetus takes a deep breath, as a result of which the feces penetrate into its lungs.

TO causes of meconium aspiration factors include:

• fetal consequences;
• rhesus conflict during pregnancy;
• complications during labor stimulation;
• excessive presence of carbonic acid in the blood;
• the birth of a baby from the first birth in a woman over 35 years old;
• abuse of bad habits during pregnancy;
• the consequences of low water in the process of bearing a fetus;
• the consequences of diabetes in a woman;
• presentation of the fetus in late pregnancy;
• intrauterine growth retardation or fetal growth;
• regular toxicosis in a woman;
• fetal hypoxia.

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Aspiration syndrome - symptoms and signs

It is possible to identify aspiration syndrome at the stage of intrauterine development of the fetus... The amniotic fluid changes color and becomes greenish.

This pathology is clearly visible during a routine examination of a pregnant woman. If a newborn has aspiration syndrome, then this condition cannot be asymptomatic. It is determined by a number of characteristic features.

Signsaspiration syndrome are the following factors:

Necessary measures

The method for eliminating meconium aspiration depends on the period of detection of such a condition. Pathology can manifest itself at the stage of intrauterine development of the fetus or after the birth of the baby.

No matter the time performing lung cleaning procedureschild, all methods are difficult to perform.

After them, the first day of the little patient should not be fed. His body fully recovers in about two weeks.

Meconium aspiration is eliminated in the following ways:

1. Suction of amniotic fluid with previous tracheal intubation.
2. Using antibiotics to prevent pneumonia.
3. Artificial ventilation of the child's lungs.
4. Thermal effect on a newborn (in a maternity hospital).
5. Cleaning the respiratory system of a small patient with special solutions.

Meconium in the amniotic fluid - consequences for the child

The presence of meconium in the amniotic fluid is alarm signal.

Such a pathology can harm the unborn baby and become the cause of his death.

If the release of the original feces occurred prematurely, then there is the danger of getting them into the lungs of the fetus.

The lack of timely elimination of such a problem can provoke serious pathological processes in the respiratory system.

Meconium from the amniotic fluid is removed by special procedures or becomes the basis for an emergency caesarean section.

For a child, meconium in the amniotic fluid may have the following effects:

• the development of respiratory failure;
• chemical pneumonia;
• pulmonary edema;
• nervous system disorders;
• infectious tissue lesions;
• death of brain cells;
• excessive pressure in the lungs;
• the risk of developing at an early age;
• tendency to severe infectious diseases;
• persistent pulmonary hypertension;
• mechanical;
• rupture of the tissues of the airways;
• death (in rare cases).

The discharge of meconium is natural stage development of the newborn.

Women need to be attentive to the state of health of their children from the first days of their lives.

If the original feces differ from the standard description, then the infant must be examined.

Some diseases, the symptoms of which are changes in the structure and color of meconium, are easily treatable in the initial stages and can change the quality of life of a small patient if they go unnoticed.

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