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Table of Content - Volume 12 Issue 3 - December 2019
Study of feto-maternal outcome in deliveries with meconium stained amniotic fluid at a tertiary care hospital
Naresh P Motwani1, Atindra Jain2*
1Associate Professor, 2Assistant Professor, Department of Pediatrics, Shri Shankaracharya Institute of Medical Sciences (SSIMS), Bhilai Email: atindrainstinct@gmail.com
Abstract Background: A fetal condition during labor is usually assessed by fetal heart rate and checking the presence of meconium in the amniotic fluid. The significance of meconium passage claimed to vary between its entirely being physiological to a sign of fetal distress. It has been observed that passage of meconium is associated with poor perinatal outcome including low Apgar scores, increased rate of chorioamnionitis, increased incidence of neonatal intensive care admission and high rate of perinatal death. As meconium staining amniotic fluid is associated adverse outcome of fetus, we planned this study to assess fetomaternal outcome in deliveries with meconium stained amniotic fluid. Material and Methods: This prospective observational study was conducted patients with cephalic presentation and meconium stained amniotic fluid after spontaneous or artificial rupture of membrane irrespective of age, parity and stage of labor. Results: A total 168 deliveries were included in present study. Age 20-25 years age group was most common maternal age-group in present study, with 112 (67 %) patients. As per gestational age, term patients were 123 (74 %), followed by post-dated (>40 weeks) patients 31 (18 %) and preterm (34-37 weeks) patients 14(8%). Of these, 104(62%) were delivered by vaginal route, 51(30%) by caesarean section and 13(8%) by instrumental delivery. We noted high risk pregnancies like post-dated pregnancy 31(18%), premature rupture of membranes 28(17%), previous caesarian section 26(15%), pregnancy-induced hypertension (PIH) 23(14%), intrauterine growth retardation (IUGR) 11 (7%) patients. Among these, 66 (39 %) had no antenatally diagnosed high-risk. Neonatal follow-up was done only for early neonatal period. We noted that 131(78%) babies were discharged without any complications. Those with complications,19(11%) had hypoxic ischemic encephalopathy,14(8%) developed neonatal jaundice, 8(5%) meconium aspiration syndrome (MAS) and 4(2%) baby died in early neonatal period. Conclusion: In utero passage of meconium is associated with adverse neonatal outcome. Early identification of pregnant woman at risk of passage of meconium during labor, intensive fetal surveillance and early intervention may improve neonatal adverse outcome. Key Words: Meconium-stained amniotic fluid (MSAF), neonate, Hypoxic ischemic encephalopathy.
INTRODUCTION A fetal condition during labor is usually assessed by fetal heart rate and the presence of meconium in the amniotic fluid1. Meconium is a viscous green-black substance that consists of denuded intestinal epithelial cells, ingested lanugo hair, swallowed amniotic fluid, mucus, digestive enzymes, bile acids, and water. It has been suggested that the fetus passes meconium in response to hypoxia and that meconium passage in utero therefore signals fetal compromise. Alternatively, in-utero passage of meconium may represent normal gastrointestinal tract maturation under neuronal control. Meconium passage could also follow vagal stimulation from common but transient umbilical cord entrapment. Passage of meconium by some is considered physiological, exhibiting sign of fetal maturity on one hand and a sign of fetal distress and response to hypoxic insult on the other hand. Aspiration of the meconium into fetal or neonatal lungs is associated with clinical disease ranging from mild respiratory distress to severe respiratory compromise and causes significant increase in perinatal morbidity and mortality2.It has been associated with poor perinatal outcome including low Apgar scores chorioamnitis with sepsis and increased incidence of neonatal intensive care admission and high rate of perinatal death. Globally, 7-22% of all live births are complicated by meconium stained amniotic fluid. But meconium aspiration syndrome (MAS) occurs in only 1-3% of all cases of MSAF and in 10-30% of these neonates, meconium is present below the vocal cords3,4. The exact etiology of meconium stained amniotic fluid is not clearly understood. Though previous studies have suggested that obstetric factors such as (prolonged labor, post-term pregnancy, low-birth weight babies, oligohydramnios, intrauterine growth retardation and hypertensive disorders of pregnancy), medical factors (cholestasis of pregnancy and anemia) and socio-demographic and behavioral risk factors (higher maternal age, maternal drug abuse especially tobacco and cocaine use) contribute for the passage of meconium into the amniotic fluid5,6.As meconium staining amniotic fluid is thought to be associated with adverse outcome of fetus, we did this observational study to assess fetomaternal outcome in deliveries with meconium stained amniotic fluid at a tertiary care hospital.
MATERIAL AND METHODS This prospective observational study was conducted in the Department of Obstetrics and Gynecology and NICU at SSIMS, Bhilai, India over a period of 4 months (August 2019 to November 2019) Inclusion criteria Patients with cephalic presentation and meconium stained amniotic fluid after spontaneous or artificial rupture of membrane irrespective of age, parity and stage of labor. Exclusion criteria
Written informed consent was taken from all the subjects for participation in present study. Patients detailed history (demographic, obstetric, past medical and surgical), gestational age, per abdominal examination, per speculum and per vaginal examination were recorded in a pre-designed proforma. Fetal heart rate monitoring was done with intermittent auscultation. The rate of cervical dilatation, duration and progress of labor was noted by plotting the parameters on a partogram. If there are any associated complications like PIH, PROM, anemia, the specific treatment was given. The mode of delivery was considered depending on the feto-maternal condition and progress of labor. Delivery (vaginal, instrumental or caesarean section) was attended by a pediatrician to record perinatal events and any resuscitation if required. The APGAR score of neonates at 1 and 5 minutes, NICU admission, the neonates who had meconium aspiration syndrome and birth asphyxia (HIE) were recorded. Statistical analysis of the study data was done with Microsoft excel. Statistical analysis was done using descriptive statistics.
RESULTS Total 168 deliveries were included in present study. Age between 20-25 years age group was most common maternal age-group in present study, with 112 (67 %) patients. Table 1: Distribution of cases according to age of patient
Gestational age-wise term patients were 123 (74 %), followed by post-dated (>40 weeks) patients 31 (18 %) and preterm (34-37 weeks) patients 14 (8 %).
Table 2: Distribution according to gestational age during delivery
Mode of delivery in present study is shown in table 3. Among them 104(62%) were born by vaginal route, 51(30%) by caesarean section and 13(8%) by instrumental delivery.
Table 3: Distribution of cases according to mode of delivery
Maternal risk factors are shown in table 4. In present study we noted postdated pregnancy 31(18%), premature rupture of membranes 28(17%), previous caesarian section 26(15%), pregnancy-induced hypertension (PIH) 23(14%), intrauterine growth retardation (IUGR) 11 (7%), anemia 10(6%), cephalopelvic disproportion 8(5%) and gestational diabetes mellitus (GDM) 4(2%). Among these, 66 (39 %) had no antenatally diagnosed high-risk.
Table 4: Maternal Risk Factors
Neonatal follow-up was done for only early neonatal period. We noted that 131(78%) babies were discharged without any complications, 14(8%) developed neonatal jaundice, 8(5%) meconium aspiration syndrome (MAS), 6(4%) had aspiration pneumonia, 4(2%) baby died in early neonatal period 3(1.91%), 3(2%) septicemia and 19(11%)hypoxic-ischemic encephalopathy (HIE). Table 5: Outcome of Neonates
DISCUSSION Meconium stained liquor (MSL) is the passage of meconium by a fetus in utero during the antenatal period or in labor. Intrauterine distress cause relaxation of anal sphincter leading to the passage of meconium into the amniotic fluid. There are so many predisposing risk factors that promote the passage of meconium into the amniotic fluid in utero like utero-placental insufficiency, maternal hypertension, cord around neck, oligohydramnios, diabetes mellitus, heavy smoking, post term pregnancy and intra uterine growth restriction, ante-partum hemorrhage and anemia. The detection of MSAF during labor often causes apprehension and anxiety for the patient as well as for the health provider as it is often considered an indication of fetal distress. The cause for the passage of meconium in the amniotic fluid is not well understood. It could reflect the state of compensated fetal distress as seen in babies who are actually acidotic during labor. Acute or chronic fetal hypoxia can result in the passage of meconium in utero5,7. According to Royal College of Obstetricians and Gynecologists (RCOG) intrapartum care guideline, meconium stained amniotic fluid is classified as significant MSL and non-significant MSL. Non- significant MSL is defined as a thin yellow or greenish tinged fluid; containing non-particulate meconium whereas significant MSL is explained as dark green or black amniotic fluid that is thick and tenacious and consists lumps of meconium8.In our study age group 20-25 years was most common maternal age-group with 112 (67 %) patients. Of the total, 84 % of patient belonged to age group 21-30 years correlating to with study conducted by Gokhroo K (86.6%)9 and Sandhu SK (80%)10. Other studies noted high incidence of MSAF was noted in primigravida’s such as Surekha (71.66%)11 and Gokhroo K (54%)10 et al. This may be due to increased duration of labor and increased incidence of post-dated pregnancies in primigravida. In our study 8% neonates were less than 37 weeks of gestation, 74% of neonates were between 37-40 weeks and 18% were more than 40 weeks. In study conducted by Urvashi et al12, 5% neonates were less than 37 weeks of gestation, 77.50% of neonates were between 37-40 weeks and 17.50% were more than 40 weeks and was consistent with our study. Due to better facilities to assess fetal wellbeing, we reported lower rates of caesarean (30%) and instrumental deliveries (8%) in present study. Naveen S et al13, Patil et al14 and Unnisa S15 reported a caesarian section rate of 49.1%, 42% and 45% respectively. Becker16 reported that all sorts of operative interventions are more frequent in MSAF group. In their study 17.4 % of patients in meconium group had caesarean section as compared to 9.6 % of control group (P value 0.01). The significant high rate of emergency caesarean section partly reflects the care providers dilemma in managing such labors as they become more concerned about the fetuses and any minute alterations in normal labor patterns end up in caesarean sections17. In the present study, postdated pregnancy was a major risk factor was observed in 18% of the cases. In a study by Ramakishore et al, it was observed that fetal distress as a major risk factor was observed in 28% of the cases followed by anemia which was 22% of the cases18.Whereas Chandran et al noted anemia as a major risk factor which was observed in 23% of the cases 19. In present study 14(8%) developed neonatal jaundice, 8(5%) meconium aspiration syndrome (MAS), 6(4%) had aspiration pneumonia, 4(2%) baby died in early neonatal period 3(1.91%), 3(2%) septicemia and 19(11 %) hypoxic-ischemic encephalopathy (HIE). Ashtekar S et al20 in their study concluded that HIE (42%), Sepsis (23.2%), and Jaundice (23.2%) and others (7.8%) including intraventricular hemorrhage and Necrotizing Enterocolitis were complications seen in neonates born with meconium stained amniotic fluid.
CONCLUSION Early identification of pregnant woman at risk of passage of meconium during labor, intensive fetal surveillance and early intervention may improve neonatal adverse outcome. Strict monitoring of neonate is required to reduce morbidity and mortality, as symptoms may appear after 48 hours. Postdated pregnancies should be delivered at a tertiary care hospital, due to increased incidence of in-utero passage of meconium and these patients may require emergency caesarian section.
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