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Case 322

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Newborn with apnea at birth after emergency cesarean section, received two cycles of positive pressure ventilation (PPV) with bag and mask ventilation and application of continuous positive airway pressure (CPAP) in the delivery room. Admitted to the neonatal ICU and submitted to orotracheal intubation. Chest and abdomen x-ray were requested (picture 1). Primipara subjected to induction of labor at 40 weeks due to gestational diabetes controlled with diet. It evolved with amniorrexe of meconial liquid and report of fetal tachycardia after 7 hours of amniorrhexis.

Considering the most likely diagnosis, what treatment should be done in all patients with this disorder?

a) Ventilatory support

25%

b) Ventilatory support and administration of exogenous surfactant

25%

c) Ventilatory support and antibiotics

25%

d) Ventilatory support and bronchodilators

25%
   

Image analysis

 

Image 1: Chest and abdomen radiograph, anteroposterior view, supine. Bilateral diffuse interstitial pulmonary infiltrate, predominantly nodular pattern. Flattening of the diaphragmatic domes, compatible with pulmonary hyperinflation. Signs of presence of small pneumothorax (yellow arrow). Orotracheal tube artifact (blue arrow) with the tip projected above the carina, vertebrae level T3. Umbilical catheter-compatible artery (red arrow) with the tip projected onto the vertebral body of T9.

 Highlights

- Meconium amniotic fluid is present in about 10% of deliveries; however, only 2-10% of these newborns will develop meconium aspiration syndrome;

- The pathogenesis involves partial and total obstruction of the airways, with areas of atelectasis, air trapping and chemical pneumonitis;

- The diagnosis is made considering the clinical findings, the presence of meconial amniotic fluid and the changes in the chest X-ray;

- Prevention includes the induction of labor in pregnancies above 41 weeks and intrapartum fetal monitoring, representing the main measure to reduce its morbidity and mortality;

- The treatment is predominantly supportive care and includes: supply of supplemental oxygen; continuous positive airway pressure (CPAP) ventilation; and conventional mechanical ventilation.

References

- Swarnam K, Soraisham A, Sivanandan S. Advances in the management of meconium aspiration syndrome. International Journal of Pediatrics. 2012;2012:1-7.

- Garcia-Prats J, Martin R, Kim M. Prevention and management of meconium aspiration syndrome. UpToDate. 2018. Acessado em 21/05/2018.

-  Garcia-Prats J, Martin R, Kim M. Clinical features and diagnosis of meconium aspiration syndrome. UpToDate. 2018. Acessado em 21/05/2018.

- Bilyk, I. Meconium aspiration syndrome. DynaMed Plus: EBSCO Information Services. 2018. Acessado em 03/06/2018.

Author

Thiago Ruiz Rodrigues Prestes, 5th year medical student at Universidade Federal de Minas Gerais.

ruiz.thiago[arroba]hotmail.com

Supervisor

Márcia Gomes Penido Machado, Adjunct Professor of the Department of Pediatrics at Medical School of UFMG.

mgpenido[arroba]gmail.com

 

Júlio Guerra Domingues. Substitute Professor at the Department of Anatomy and Image at Medical School of Universidade Federal de Minas Gerais.

E-mail: jgdjulio[arroba]gmail.com

Reviewers

Amanda Lauar, William Alves, Guilherme Carvalho, Ariádna Andrade, Luana Almeida, Prof. José Nelson Mendes Vieira, Pra. Viviane Santuari Parisotto Marino

Test question

(Federal University of Uberlândia – 2016) Preterm new born, 36 weeks of gestational age, was born of cesarean delivery, due to fetal bradycardia, with rupture of membranes during the labor and outlet of fluid meconial amniotic fluid. The newborn in poor conditions with need of resuscitation in the delivery room, including orotracheal intubation. Referred to the Neonatal ICU and maintained in invasive ventilatory support. Chest radiograph with diffuse coarse infiltrate. The diagnosis for this case is:

a) Respiratory distress syndrome

25%

b) Transient tachypnea of the newborn

25%

c) Meconium aspiration syndrome

25%

d) Persistent pulmonary hypertension of the newborn

25%

e) Group B beta hemolytic Streptococcus pneumonia

25%
   

Commentics

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