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- 2. K.L.M. Newborn, female Chief Complaint:Grunting and unsustained cry CC PASHA, S DOA: 7/27/23 DOB: 7/27/23
- 3. Gestational History ● 30y/o, primigravid, 40-41 wks AOG, Bank employee, BT O+ ● Adequate prenatal checkup starting at 4-5 wks AOG ● (-) exposures to viral exanthems ● (-) smoking, alcohol, substance use ● HIV: non-reactive; OGTT: normal ● HBsAg, HBeAg, Anti-HBc reactive (Chronic Hepatitis: inactive) ● Antenatal ultrasound 3x - Normal ○ Latest (5 days prior to delivery) ○ SLIUP, 37-38 weeks AOG, cephalic, posterior placenta, gr II-III, BPS 8/8, SEFW 3088g ● Congenital Scan not done ● No known comorbidities ● No infections during pregnancy CC PASHA, S
- 4. Labor History CC: HypogastricPain CC PASHA, S TOD: 12 PM 1 wk PTD ● Occasional hypogastric pain ● (-) bloody or watery discharge ● Good fetal movement 4 days PTD ● Occasional hypogastric pain ● (+) min. Bloody mucoid discharge ● (-) watery discharge ● Good fetal movement ● IE: cervix 1 cm Few hrs PTD ● (+) hypogastric pain ● NST: reactive ● IE: cervix 3 cm dilated, 60% effaced, intact BOW, cephalic, station -2, FHT 135 ● Advised for labor induction 8 AM ● Amniotomy done: minimal meconium stained AF ● Live, term (40-41 wks), female, AGA, delivered via NSD ● BW 2.9 kg, BL 50 cm, HC 35.5 ● Meconium stained umbilical cord
- 5. Birth History At birth 1stMOL 3rd MOL 5th MOL 10th MOL ● Acrocyanotic with slow cry ● Immediate and thorough drying ● HR 140s, RR 50 ● T 37.1 ● AS 7: Acrocyanotic with slow cry, some flexion ● Suctioned copious yellowish to light green oronasal secretions ● Grunting & unsustained cry ● Stimulation and suctioning of secretions ● Brought to warmer ● Hooked to pulse oximeter ● Desaturations to 80s ● Hooked to O2 at 2 LPM via nasal cannula ● (+) resolutions ● Routine newborn care ● HR 180 ● RR 50s, T 37.2 ● SpO2 90-95% ● Occasional grunting ● AS 8 CC PASHA, S
- 6. Physical Examination CC PASHA,S GENERAL Awake, alert, in respiratory distress, grunting, unsustained cry VITAL SIGNS HR 122, RR 47, Temp 36.8 C, O2 85% at room air ANTHROPOMETRICS BW: 2.9kg, BL: 50cm, HC: 35.5cm, CC: 32cm AC: 31cm HEAD Normocephalic, patent anterior and posterior fontanels SKIN Pink, (+) irregularly shaped erythematous patch on inner corner of L upper eyelid EENT (+) ROR, OU, normal set ears, (-) preauricular sinus/tags, patent nares, no cleft lip/palate (-) alar flaring CHEST Symmetric chest expansion, (-) retractions, clear breath sounds HEART Adynamic precordium, normal S1 and S2, no murmur ABDOMEN Globular, soft, nondistended abdomen, no palpable mass, (+) meconium stained umbilical cord 2 umbilical arteries, 1 umbilical vein
- 7. Physical Examination CC PASHA,S GENITALIA Grossly female, (+) hymenal tag EXTREMITIES Femoral pulses full and equal, (-) Barlow, (-) Ortolani TRUNK AND SPINE Straight spine, (-) coccygeal pit, (-) tufts of hair ANUS Patent anus REFLEXES (+) Grasp, moro, plantar, palmar reflex
- 8. Salient features ● Liveterm (40-41 wks) female, AGA, delivered via NSD ● Thickly meconium-stained at birth: oronasal secretions, umbilical cord ● In respiratory distress: grunting, desaturations, unsustained cry ● (-) tachypnea, symmetric chest expansion, (-) retractions, (-) alar flaring, clear breath sounds, (-) central cyanosis, (-) heart murmurs ● Afebrile, normoglycemic CC PASHA, H
- 9. Presenting Manifestation Thickly meconium-stained Inrespiratory distress Approach to Diagnosis Look for a symptom, sign or laboratory finding whose mechanism is well understood CC PASHA, H
- 10. Impression Patient Profile MeconiumAspiration Syndrome ● Live term (40-41 wks) female, AGA, delivered via NSD ● Thickly meconium-stained at birth: oronasal secretions, umbilical cord ● In respiratory distress ● (-) tachypnea, symmetric chest expansion, (-) retractions, (-) alar flaring, clear breath sounds, (-) central cyanosis, (-) heart murmurs ● Afebrile, normoglycemic RIsk factors: ● Post-term delivery ● SGA, IUGR ● Maternal drug abuse, especially of tobacco and cocaine ● Maternal infections/ chorioamnionitis ● Uteroplacental insufficiency ● Fetal gasping secondary to hypoxic stress ● Meconium in the amniotic fluid Manifestations ● (+) meconium-stained oronasal secretions ● Respiratory distress within the first hours ● Signs of air trapping ● Cyanosis in severely affected infants Complications: pneumonia, pneumothorax, pneumomediastinum, PPHN CC PASHA, H
- 11. Live, term (40-41wks), female, AGA, delivered via NSD, BW 2.9kg, BL 50cm, HC 35.5, AS 7,8; Meconium Aspiration Syndrome Working Diagnosis CC PASHA, H
- 12. Course at theNICU DIAGNOSTICS MANAGEMENT On admission ● CXR ● CBC w/ platelets ● Blood typing ● Blood CS ● NPO ● O2 at 2LPM via nasal cannula ● OGT inserted ● IVF: D10W at 70mL/kg/day ● Ampicillin 50 mkdose/IV every 12h ● Gentamicin 4 mkdose every 24h ● HepB Ig CC PASHA, H
- 13. Course at theNICU CC PASHA, H Parameter Reference Range Hgb 15.1 15-24 g/L Hct 0.45 0.44-0.70 Platelet 223 84-478 x10^6/L WBC 19.4 9.1--34.0 x10^9/L Differential Count Neutrophils 0.65 0.54-0.62 Bands 0.03 0.03-0.05 Segmenters 0.62 0.54-0.62 Lymphocytes 0.30 0.25-0.33 Monocytes 0.04 0.03-0.07 Eosinophils 0.01 0.01– 0.03 IT ratio 0.05 <0.16 Blood typing: O+
- 15. Course at theNICU SUBJECTIVE/ OBJECTIVE MANAGEMENT 6th hour of life ● No recurrence of retractions nor grunting ● HR 121-130, RR 41-63 T 36.6-36.9 SpO2 98-99% at 2 LPM via NC ● (+) occasional rhonchi probably transmitted sound from oral secretion ● O2 support was then decreased to 1 LPM via nasal cannula 18th hour of life ● Awake, comfortable ● HR 109-156, RR 42-56, T 36.6-36.9, SpO2 97-99% at O2 1 LPM via NC ● No signs of respiratory distress, clear and equal BS ● More distinct heart sounds, no murmurs, abdomen soft nondistended ● Started feeding with 10mL pasteurized EBM per OGT every 6 hours. ● Requested for a repeat CXR (7/28) ● Weaned off oxygen support CC PASHA, H
- 17. Course at theNICU 28th hour of life ● Tolerated weaning off O2 support ● Tolerated feedings with 10 mL EBM per cup every 3 hours ● No recurrence of distress ● Awake, comfortable, pink ● No signs of respiratory distress, still with episodes of resting bradycardia lowest noted 103, RR 40-44, afebrile at T36.7, SpO2 96% ● Clear and equal BS, abdomen soft nondistended ● OGT removed ● Increased feeding to 15-20 mL EBM/cup every 3 hours 3rd day of life ● HR 120-153, w/ occasional resting bradycardia of 105-112, RR 40-48 ● T 36.5-36.9, SpO2 97-100% at RA ● Light jaundice to chest, (+) occasional rhonchi at RLL ● Abdomen soft nondistended, full pulses ● Day 1-2 off O2, D3 of antibiotics ● CRP 1.33, Na 135, K 5.38, tCa 9.83 ● Increased feedings to 25-30 mL every 3 hours ● IVF to consume after able to tolerate 2 feedings of 30 mL CC PASHA, H
- 19. Course at theNICU 5th day of life ● Tolerated 40 ml/cup every 3 hours with direct breastfeeding ● HR 129-143, RR 42-53, T 36.6-36.9, SpO2 97-99% at RA ● (+) slightly icteric sclerae and light jaundice to abdomen, (+) minimal rhonchi, otherwise unremarkable PE. ● Final report of blood CS showed no growth after 5 days of incubation. ● Completed antibiotics for 5 days and was subsequently discharged thereafter ● Take home medications: ○ Vitamin D3 400IU/day CC PASHA, H
- 20. Live, term (40-41wks), female, AGA, delivered via NSD, BW 2.9kg, BL 50cm, HC 35.5, AS 7,8; Meconium Aspiration Syndrome with Pneumothorax & Pneumomediastinum Final Diagnosis CC PASHA, H
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- 22. INCIDENCE CC PASCUAL ● 5%of Meconium-stained Amniotic Fluid (MSAF) ○ 10-15% of all births ○ Usually in term or post-term infants ● 30% require mechanical ventilation ● 3-5% death Nelson’s Textbook of Pediatrics
- 23. CLINICAL MANIFESTATIONS CC PASCUAL ●Respiratory distress ● Tachypnea ● Retractions ● Grunting ● Overdistention of the chest ● Cyanosis (severely affected babies) Nelson’s Textbook of Pediatrics
- 24. PATHOLOGIC MECHANISM CC PASCUAL Nelson’sTextbook of Pediatrics
- 25. DIAGNOSIS CC PASCUAL ● Historyand Physical Examination ○ Identify risk factors ■ Post-term delivery ■ SGA neonates/IUGR ■ Maternal infections/chorioamnionitis ■ Uteroplacental insufficiency ■ Fetal gasping ○ Respiratory distress ○ Meconium-staining of amniotic fluid ○ Overdistention of chest
- 26. NORMAL Meconium Aspiration Syndrome CC PASCUAL DIAGNOSIS Characteristics: ●Coarse streaking patchy infiltrates ● Increase AP diameter ● Flattening of the diaphragm Moore, C., & Naim, K. (2020). Meconium aspiration. Radiopaedia.org. https:/ /doi.org/10.53347/rid-74578
- 27. COMPLICATIONS CC PASCUAL ● Airwayobstruction ○ Atelectasis ○ Pneumothorax ○ Pneumomediastinum ● Surfactant Dysfunction ● Chemical Pneumonitis ● Persistent Pulmonary Hypertension of the Newborn Olicker, A. L., Raffay, T. M., & Ryan, R. M. (2021). Neonatal respiratory distress secondary to meconium aspiration syndrome. Children (Basel), 8(3), 246. https:/ /doi.org/10.3390/children8030246
- 28. Persistent Pulmonary Hypertensionof the Newborn (PPHN) Clinical manifestations: ● Respiratory distress ● Cyanosis ● Hypotension/Shock ● Labile Hypoxemia Diagnosis: ● History & PE ● Ancillary tests ○ Differential oximeter readings ○ Hyperoxia-Hyperventilation test ○ Chest X-ray ○ Echocardiography Treatment: ● Mechanical ventilation ● Surfactant ● PDE inhibitors ● Prostaglandin analogs (PGI) ● Nitric oxide (NO) Nelson’s Textbook of Pediatrics CC PASCUAL
- 29. PNEUMOTHORAX PNEUMOMEDIASTINUM Risk Factors● Respiratory distress syndrome ● Meconium aspiration syndrome ● Need for CPAP or ventilation ● Prematurity ● Pneumonia ● Meconium aspiration syndrome ● Difficult delivery ● Need for CPAP or ventilation History and Physical Examination ● Usually asymptomatic ● Rapid breathing ● Grunting ● Affected side is more prominent than unaffected side ● Positive transillumination ● Low BP ● Bulging of the mid thoracic area ● Distended neck veins Diagnosis ● CXR ● UTZ ● CXR Management ● Close observation and monitoring ● Drainage ● Needle aspiration ● Close observation and monitoring CC PALAD
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- 31. MANAGEMENT CC PALAD ● Thermoregulation ●Minimal handling ● Continued respiratory care ● Surfactant therapy
- 32. PREVENTION CC PALAD ● Rapididentification of fetal distress and initiation of prompt delivery in the presence of late fetal heart rate deceleration or poor beat-to-beat FHR variability.
- 33. PROGNOSIS CC PALAD ● Mortalityrate of meconium-stained infants is considerably higher than that of non stained infants. ● Residual lung problems are rare but include symptomatic cough, wheezing, and persistent hyperinflation for up to 5-10 yr. ● Ultimate prognosis depends on the extent of CNS injury from asphyxia and the presence of associated problems such as pulmonary hypertension
- 34. JOURNAL: Lung Ultrasoundin the Early Diagnosis and Management of the Mild Form of Meconium Aspiration Syndrome: A Case Report Alessandro Perri, Simona Fattore, Giorgia Prontera, Maria Letizia Patti, Annamaria Sbordone, Milena Tana, Vito D’ Andrea, and Giovanni Vento Conducted in Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy Published on February 14, 2023 in the special issue Maternal-Fetal and Neonatal Diagnostics of Multidisciplinary Digital Publishing Institute (MDPI) DOI: 10.3390/diagnostics13040719 Perri, A., Fattore, S., Prontera, G., Patti, M. L., Sbordone, A., Tana, M., D’Andrea, V., et al. (2023). Lung Ultrasound in the Early Diagnosis and Management of the Mild Form of Meconium Aspiration Syndrome: A Case Report. Diagnostics, 13(4), 719. MDPI AG. Retrieved from http://dx.doi.org/10.3390/diagnostics13040719 CC PANGILINAN
- 35. ● Respiratory distress(RD) is one of the most common diseases in the first few hours of life of a neonate ● Meconium aspiration syndrome (MAS) was diagnosed mainly on the basis of history, clinical symptoms & chest radiography; ultrasonography was not used as a diagnostic tool. ● Lung ultrasound (LUS) has many advantages: easy to perform, useful for monitoring, does not use radiation, repeatable, easy to learn, low intra & inter-observer variability, can quickly identify complications, more accurate & specific than chest X-ray Introduction Perri, A., Fattore, S., Prontera, G., Patti, M. L., Sbordone, A., Tana, M., D’Andrea, V., et al. (2023). Lung Ultrasound in the Early Diagnosis and Management of the Mild Form of Meconium Aspiration Syndrome: A Case Report. Diagnostics, 13(4), 719. MDPI AG. Retrieved from http://dx.doi.org/10.3390/diagnostics13040719 CC PANGILINAN
- 36. ● Patients’ Profile ○6 term infants who had aspirated meconium-stained fluid with RD at birth ○ Diagnosed with MAS and non-invasively ventilated ● A lung ultrasound was performed by a trained physician within the first 6 hours after birth ● Position: supine, lateral, or prone ● Areas scanned: anterior, lateral, and posterior chest walls ● Non-pharmacological measures were used to prevent patient agitation ● All examinations were performed using sterile disposable probe covers ● Demographic and LUS characteristics were collected from electronic patient records ● Patients were evaluated post-discharge Materials and Methods Perri, A., Fattore, S., Prontera, G., Patti, M. L., Sbordone, A., Tana, M., D’Andrea, V., et al. (2023). Lung Ultrasound in the Early Diagnosis and Management of the Mild Form of Meconium Aspiration Syndrome: A Case Report. Diagnostics, 13(4), 719. MDPI AG. Retrieved from http://dx.doi.org/10.3390/diagnostics13040719 CC PANGILINAN
- 37. Results ● All theneonates presented the same characteristics: ○ Diffuse coalescing B-lines ○ Pleural line anomalies ○ Disappearance of A lines ○ Subpleural consolidations with irregular shapes, variable sizes, and air bronchograms Perri, A., Fattore, S., Prontera, G., Patti, M. L., Sbordone, A., Tana, M., D’Andrea, V., et al. (2023). Lung Ultrasound in the Early Diagnosis and Management of the Mild Form of Meconium Aspiration Syndrome: A Case Report. Diagnostics, 13(4), 719. MDPI AG. Retrieved from http://dx.doi.org/10.3390/diagnostics13040719 CC PANGILINAN
- 38. R L Upper Anterior LowerAnterior Lateral Results ● Typical ultrasound findings in MAS ● B lines, often coalescing ● A line disappearance ● Pleural line thickened and interrupted ● Small consolidations of < 1 cm ○ ↑ Extent = ↑ Severity Perri, A., Fattore, S., Prontera, G., Patti, M. L., Sbordone, A., Tana, M., D’Andrea, V., et al. (2023). Lung Ultrasound in the Early Diagnosis and Management of the Mild Form of Meconium Aspiration Syndrome: A Case Report. Diagnostics, 13(4), 719. MDPI AG. Retrieved from http://dx.doi.org/10.3390/diagnostics13040719 CC PANGILINAN Pleural Line Consolidation B Lines
- 39. ● LUS hasbeen used to monitor the patients even after clinical remission ● Consolidations persisted after the resolution of the symptoms, despite clinical well-being ● Not necessary to wait for the ultrasound to normalize before discharge from the NICU, can be reevaluated on an outpatient basis. ● Within 4 weeks of life: Normal lung ultrasound, without consolidation or interruption of the pleural line ● Safe and with no complications Results Perri, A., Fattore, S., Prontera, G., Patti, M. L., Sbordone, A., Tana, M., D’Andrea, V., et al. (2023). Lung Ultrasound in the Early Diagnosis and Management of the Mild Form of Meconium Aspiration Syndrome: A Case Report. Diagnostics, 13(4), 719. MDPI AG. Retrieved from http://dx.doi.org/10.3390/diagnostics13040719 CC PANGILINAN
- 40. ● Chest X-raycan identify severe forms of MAS but unable to recognize mild cases ● Milder forms of MAS present as a non-specific radiological picture, not allowing distinction among different causes of RD in the newborn ○ Signs of interstitial or alveolar-interstitial involvement ● In the study, LUS allowed the diagnosis of MAS despite mild clinical picture ● Findings are specific enough to distinguish MAS from other causes of neonatal RD ○ Allows clinicians to optimize therapeutic management Discussion Perri, A., Fattore, S., Prontera, G., Patti, M. L., Sbordone, A., Tana, M., D’Andrea, V., et al. (2023). Lung Ultrasound in the Early Diagnosis and Management of the Mild Form of Meconium Aspiration Syndrome: A Case Report. Diagnostics, 13(4), 719. MDPI AG. Retrieved from http://dx.doi.org/10.3390/diagnostics13040719 CC PANGILINAN
- 41. ● Ultrasound data,clinical history & evaluation, represent a useful tool to optimize the management of neonates with MAS ● LUS can identify mild to severe cases of MAS, allowing more appropriate choice of management and monitoring strategies ○ Could reduce the length of stay in the NICU, with favorable effects on costs, parental anxiety, and child well-being ● Extent of consolidations measured by ultrasound may suggest correlation with severity of the disease ● It allows evaluation of the evolution of the pathology over time and the response to the therapy, due to its repeatability Conclusion Perri, A., Fattore, S., Prontera, G., Patti, M. L., Sbordone, A., Tana, M., D’Andrea, V., et al. (2023). Lung Ultrasound in the Early Diagnosis and Management of the Mild Form of Meconium Aspiration Syndrome: A Case Report. Diagnostics, 13(4), 719. MDPI AG. Retrieved from http://dx.doi.org/10.3390/diagnostics13040719 CC PANGILINAN
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