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Wang CY, Ling C, Yang JJ, Guan LS, Wang XQ. Impact of perinatal factors on meconium aspiration syndrome in full-term newborns and the construction of a column chart prediction model: An observational study. Medicine (Baltimore) 2024; 103:e38279. [PMID: 38758867 PMCID: PMC11098210 DOI: 10.1097/md.0000000000038279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/26/2024] [Indexed: 05/19/2024] Open
Abstract
To explore the influence of perinatal-related factors on meconium aspiration syndrome (MAS) in full-term neonates and construct a nomogram prediction model for risk stratification of neonatal MAS and adoption of preventive measures. A total of 424 newborns and their mothers who were regularly examined at our hospital between January 2020 and December 2023 who had meconium-contaminated amniotic fluid during delivery were retrospectively selected as participants. Neonates were divided into MAS and non-MAS groups based on whether MAS occurred within 3 days after birth. Data from the 2 groups were analyzed, and factors influencing MAS were screened using multivariate logistic regression analysis. The R3.4.3 software was used to construct a nomogram prediction model for neonatal MAS risk. Receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow goodness-of-fit test were used to evaluate the performance of the model, and its clinical effectiveness was evaluated using a decision curve. Among the 424 neonates with meconium-stained amniotic fluid, 51 developed MAS within 3 days of birth (12.03%). Multivariate logistic regression analysis showed that a low amniotic fluid index before delivery (OR = 2.862, P = .019), advanced gestational age (OR = 0.526, P = .034), cesarean section (OR = 2.650, P = .013), severe amniotic fluid contamination (OR = 4.199, P = .002), low umbilical cord blood pH (OR = 2.938, P = .011), and low neonatal Apgar 1-min score (OR = 3.133, P = .006) were influencing factors of MAS in full-term neonates. Based on the above indicators, a nomogram prediction model for MAS risk of full-term newborns was constructed. The area under the ROC curve of the model was 0.931. The model was also tested for goodness-of-fit deviation (χ2 = 3.465, P = .903). Decision curve analysis found that the model was clinically effective in predicting the net benefit of MAS risk in neonates with meconium-stained amniotic fluid. The construction of a column chart prediction model for neonatal MAS risk based on prenatal amniotic fluid index, gestational age, delivery method, amniotic fluid contamination level, newborn umbilical blood pH value, and Apgar 1-min score has a certain application value.
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Affiliation(s)
- Chun-Yu Wang
- Obstetrical Department of Suzhou Ninth People’s Hospital, Suzhou, Jiangsu, China
| | - Chen Ling
- Obstetrical Department of Suzhou Ninth People’s Hospital, Suzhou, Jiangsu, China
| | - Juan-Juan Yang
- Obstetrical Department of Suzhou Ninth People’s Hospital, Suzhou, Jiangsu, China
| | - Li-Sha Guan
- Obstetrical Department of Suzhou Ninth People’s Hospital, Suzhou, Jiangsu, China
| | - Xiao-Qing Wang
- Obstetrical Department of Suzhou Ninth People’s Hospital, Suzhou, Jiangsu, China
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Jindal S, Steer PJ, Savvidou M, Draycott T, Dixon‐Woods M, Wood A, Kim LG. Risk factors for a serious adverse outcome in neonates: a retrospective cohort study of vaginal births. BJOG 2023; 130:1521-1530. [PMID: 37156754 PMCID: PMC10952606 DOI: 10.1111/1471-0528.17531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 03/25/2023] [Accepted: 04/23/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE To investigate the hypothesis that risk factors in addition to an abnormal fetal heart rate pattern (aFHRp) are independently associated with adverse neonatal outcomes of labour. DESIGN Observational prospective cohort study. SETTING 17 UK maternity units. SAMPLE 585 291 pregnancies between 1988 and 2000 inclusive. METHODS Adjusted odds ratios (OR) with 95% confidence intervals (95% CI) were estimated from multivariable logistic regression. MAIN OUTCOME MEASURES Adverse neonatal outcome at term (5-minute Apgar score <7, and a composite measure comprising 5-minute Apgar score <7, resuscitation by intubation and/or perinatal death). RESULTS Analysis was based on 302 137 vaginal births at 37-42 weeks inclusive. We found a higher odds of Apgar score at 5 minutes <7 with suspected fetal growth restriction (OR 1.34, 95% CI 1.16-1.53), induction of labour (OR 1.41, 95% CI 1.25-1.58), nulliparity (OR 1.48, 95% CI 1.34-1.63), booking body mass index ≥30 (OR 1.18, 95% CI 1.02-1.37), maternal age <25 (OR 1.23, 95% CI 1.10-1.39), black ethnicity (OR 1.21, 95% CI 1.03-1.43), early-term birth at 37-38 weeks (OR 1.13, 95% CI 1.02-1.25), late-term birth at 41-42 weeks (OR 1.14, 95% CI 1.01-1.28), use of oxytocin (OR 1.27, 95% CI 1.14-1.41), maternal pyrexia (OR 1.87, 95% CI 1.46-2.40), aFHRp and presence of meconium (aFHRp without meconium: OR 2.40, 95% CI 2.15-2.69; meconium without aFHRp: OR 2.20, 195% CI.94-2.49; both aFHRp and meconium: OR 4.26, 95% CI 3.74-4.87). The results were similar when the composite adverse outcome was considered. CONCLUSIONS A range of risk factors, including suspicion of fetal growth restriction, maternal pyrexia and presence of meconium, are implicated in poor birth outcomes in addition to aFHRp. Interpretation of the fetal heart rate pattern alone is insufficient as a basis for decisions about escalation and intervention.
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Affiliation(s)
- Sita Jindal
- Academic Department of Obstetrics and GynaecologyImperial College London, Chelsea and Westminster HospitalLondonUK
| | - Philip J. Steer
- Academic Department of Obstetrics and GynaecologyImperial College London, Chelsea and Westminster HospitalLondonUK
| | - Makrina Savvidou
- Academic Department of Obstetrics and GynaecologyImperial College London, Chelsea and Westminster HospitalLondonUK
| | - Tim Draycott
- The Royal College of Obstetricians and GynaecologistsLondonUK
- Department of Women's HealthNorth Bristol NHS TrustWestbury on TrymUK
| | - Mary Dixon‐Woods
- Department of Public Health and Primary CareUniversity of Cambridge, Strangeways Research LaboratoryCambridgeUK
| | - Angela Wood
- Department of Public Health and Primary Care / Cardiovascular Epidemiology Unit, Victor Phillip Dahdaleh Heart and Lung Research InstituteUniversity of CambridgeCambridgeUK
- Health Data Research UK CambridgeWellcome Genome Campus and University of CambridgeCambridgeUK
| | - Lois G. Kim
- Department of Public Health and Primary Care / Cardiovascular Epidemiology Unit, Victor Phillip Dahdaleh Heart and Lung Research InstituteUniversity of CambridgeCambridgeUK
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Osman A, Halling C, Crume M, Al Tabosh H, Odackal N, Ball MK. Meconium aspiration syndrome: a comprehensive review. J Perinatol 2023; 43:1211-1221. [PMID: 37543651 DOI: 10.1038/s41372-023-01708-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/02/2023] [Accepted: 06/19/2023] [Indexed: 08/07/2023]
Abstract
Meconium aspiration syndrome (MAS) is a complex respiratory disease that continues to be associated with significant morbidities and mortality. The pathophysiological mechanisms of MAS include airway obstruction, local and systemic inflammation, surfactant inactivation and persistent pulmonary hypertension of the newborn (PPHN). Supplemental oxygen and non-invasive respiratory support are the main therapies for many patients. The management of the patients requiring invasive mechanical ventilation could be challenging because of the combination of atelectasis and air trapping. While studies have explored various ventilatory modalities, evidence to date does not clearly support any singular modality as superior. Patient's pathophysiology, symptom severity, and clinician/unit expertise should guide the respiratory management. Early identification and concomitant management of PPHN is critically important as it contributes significantly to mortality and morbidities.
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Affiliation(s)
- Ahmed Osman
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA.
| | - Cecilie Halling
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Mary Crume
- Neonatal-Perinatal Fellowship Program, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Hayat Al Tabosh
- Pediatrics Residency Program, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Namrita Odackal
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Molly K Ball
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
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Zhu X, Huang S, Tang Y, Wu Z, Sun Y, Ren H, Lu H, Yin T, Zuo Q, Ge Z, Jiang Z. Once We Find Grade III Meconium Stained Amniotic Fluid, Must We Act as Early as Possible? Int J Womens Health 2023; 15:7-23. [PMID: 36636514 PMCID: PMC9830073 DOI: 10.2147/ijwh.s385356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 12/06/2022] [Indexed: 01/06/2023] Open
Abstract
Background Grade III meconium stained amniotic fluid (MSAF) is a common obstetric disease, and has the greatest impact on poor maternal and neonatal outcomes. Question or Hypothesis or Aim There is no consensus on treatment, especially on the timing of delivery. Methods We collected the medical records of 345 women who gave birth with grade III MSAF and analyzed the difference in baseline characteristics and maternal and neonatal outcomes relative to different labor stage, observation times in the first stage of labor, and the presence or absence of abnormal fetal heart rate (FHR) or thick amniotic fluid. Findings Higher rate of cesarean section was observed when grade III MSAF was found in active labor. Intervention occurred at an observation time of 90-120 min, but there were no significant differences in maternal or neonatal outcomes shown when the observation time was greater than 3 or 4 hours. However, a higher rate of admission to the neonatal intensive care unit was demonstrated in cases with grade III MSAF with abnormal FHR either in the first or second stage of labor or in cases with thick MSAF in the second stage of labor. Discussion Higher rate of composite adverse neonatal outcomes was found when secondary MSAF (a transition from clear AF to MSAF) was diagnosed >3 h before delivery. Conclusion In the first stage of labor, an observation time of greater than 4 hours might be possible after grade III MSAF is found if the labor has progressed and is without abnormal FHR.
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Affiliation(s)
- Xinxin Zhu
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Shiyun Huang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Yuxuan Tang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Zhonglan Wu
- Department of Obstetrics and Gynecology, Women’s Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, People’s Republic of China
| | - Yue Sun
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Huiyan Ren
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Hongmei Lu
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Tingting Yin
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Qing Zuo
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Zhiping Ge
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Ziyan Jiang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China,Correspondence: Ziyan Jiang, Department of Obstetrics, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People’s Republic of China, Tel +86-13512534017, Email
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Luo L, Zhang M, Tang J, Li W, He Y, Qu Y, Mu D. Clinical characteristics of meconium aspiration syndrome in neonates with different gestational ages and the risk factors for neurological injury and death: A 9-year cohort study. Front Pediatr 2023; 11:1110891. [PMID: 36959842 PMCID: PMC10027737 DOI: 10.3389/fped.2023.1110891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/16/2023] [Indexed: 03/25/2023] Open
Abstract
Background The presence of meconium is associated with gestational age, and the incidence of meconium aspiration syndrome (MAS) increases with gestational age. Our study compared the differences in the clinical characteristics of patients with MAS at different gestational ages and discussed the risk factors for neurological injury and death from MAS. Methods A total of 294 neonates diagnosed with MAS between 2013 and 2021 were included. Patients were divided into preterm, early-term, full-term, and late-term groups according to gestational age. We compared the patients' basic demographic, treatment, complications, and clinical outcomes in the different groups. We also analyzed the risk factors of neurological injury and death in patients with MAS. Results The mean age at admission (0.55 ± 0.9 h) was lower and the proportion of cesarean deliveries (90.00%, 27/30) was higher in the preterm group than in the other three groups. There was no statistically significant difference among the four groups regarding 1- and 5-min Apgar scores and the need for delivery room resuscitation. In terms of complications, early-term infants had the highest incidence of neurological injury (52.9%, 27/51), and late-term infants had the highest incidence of pneumothorax (37.8%, 17/45). The overall mortality rate of children with MAS was 7.80% (23/294), and the difference in mortality rates among the four groups was not significant. Low 1-min Apgar score and gestational age, metabolic acidosis, and respiratory failure were independent risk factors for neurological injury; metabolic acidosis, respiratory failure, and sepsis were independent risk factors for death in neonates with MAS. Conclusion The clinical characteristics of MAS neonates of different gestational age are different mainly in complications. Early-term infants are more likely to complicate with neurological injury, and late-term infants are more likely to complicate with pneumothorax. Low 1-min Apgar score and gestational age, metabolic acidosis, and respiratory failure were established as risk factors for neurological injury; metabolic acidosis, respiratory failure, and sepsis were independent risk factors for death in neonates with MAS.
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Affiliation(s)
- Lei Luo
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Meng Zhang
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Jun Tang
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Correspondence: Jun Tang
| | - Wenxing Li
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Yang He
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Yi Qu
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Dezhi Mu
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
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Tantu T, Zewdu D, Degemu F, Yehualeshet T. The incidence and determinants of the meconium-aspiration syndrome among mothers with meconium-stained amniotic fluid after emergency cesarean section: A prospective cross-sectional study in a specialized hospital, south Ethiopia. Front Pediatr 2023; 11:1149398. [PMID: 37033171 PMCID: PMC10076781 DOI: 10.3389/fped.2023.1149398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/02/2023] [Indexed: 04/11/2023] Open
Abstract
Background Meconium aspiration syndrome is respiratory distress diagnosed in neonates delivered with meconium-stained amniotic fluid that is unexplained by other pathologies. It has severe neonatal respiratory complications and a significant impact on the prevalence of neonatal mortality. Objective To identify the incidence and determinants associated with meconium aspiration syndrome among mothers with meconium-stained amniotic fluid after emergency cesarean section in Wolkite University specialized hospitals in Ethiopia from September 1, 2021, to August 30, 2022. Method An institution-based cross-sectional study was done prospectively through meticulous chart review and interviews with 275 mothers with meconium-stained amniotic fluid who gave birth with an emergency cesarean section. Data were entered using EpiData 7 and analyzed with SPSS 26. The association between independent variables and the meconium-aspiration syndrome was estimated using an odds ratio with 95% confidence intervals. The statistical significance of the association was declared at a p-value of 0.05. Result The prevalence of the meconium-aspiration syndrome is 28.7%. The factors associated are: latent phase (AOR: 2.580; 95% CI: 1.126, 5.913), low 1st minute APGAR score (AOR: 2.43; 95% CI: 0.892, 6.625), and thick meconium (AOR: 31.018; 95% CI: 9.982, 96.390). The neonatal death rate associated with meconium aspiration syndrome is 1.8%, and thick meconium contributed to 65% of admissions to the neonatal intensive care unit and all deaths. Conclusion The incidence of meconium aspiration syndrome is high, and thick meconium, meconium at early labor, and low APGAR scores all contributed to this. Thick meconium has a substantial effect on neonatal mortality and morbidity. Therefore, an improvement in the quality of obstetric and neonatal care through early intervention in the case of thick meconium and meconium in the early phase of labor is recommended.
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Affiliation(s)
- Temesgen Tantu
- Obstetrics and Gynecology, Wolkite University College of Medicine and Health Sciences, Wolkite, Ethiopia
- Correspondence: Temesgen tantu
| | - Dereje Zewdu
- Anesthesia, Wolkite University College of Medicine and Health Sciences, Wolkite, Ethiopia
| | - Fikretsion Degemu
- Pediatrics and Child Health, Wolkite University College of Medicine and Health Sciences, Wolkite, Ethiopia
| | - Tsiyon Yehualeshet
- Internal Medicine, College of Health Science and Medicine, Wolkite University, Wolkite, Ethiopia
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Tiozzo C, Mukhopadhyay S. Noninfectious influencers of early-onset sepsis biomarkers. Pediatr Res 2022; 91:425-431. [PMID: 34802035 PMCID: PMC8818022 DOI: 10.1038/s41390-021-01861-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 01/21/2023]
Abstract
Diagnostic tests for sepsis aim to either detect the infectious agent (such as microbiological cultures) or detect host markers that commonly change in response to an infection (such as C-reactive protein). The latter category of tests has advantages compared to culture-based methods, including a quick turnaround time and in some cases lower requirements for blood samples. They also provide information on the immune response of the host, a critical determinant of clinical outcome. However, they do not always differentiate nonspecific host inflammation from true infection and can inadvertently lead to antibiotic overuse. Multiple noninfectious conditions unique to neonates in the first days after birth can lead to inflammatory marker profiles that mimic those seen among infected infants. Our goal was to review noninfectious conditions and patient characteristics that alter host inflammatory markers commonly used for the diagnosis of early-onset sepsis. Recognizing these conditions can focus the use of biomarkers on patients most likely to benefit while avoiding scenarios that promote false positives. We highlight approaches that may improve biomarker performance and emphasize the need to use patient outcomes, in addition to conventional diagnostic performance analysis, to establish clinical utility.
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Affiliation(s)
- Caterina Tiozzo
- Division of Neonatology, Department of Pediatrics, New York University, Langone Health, New York City, New York, United States
| | - Sagori Mukhopadhyay
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA. .,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Amitai Komem D, Meyer R, Yinon Y, Levin G. Prediction of meconium aspiration syndrome by data available before delivery. Int J Gynaecol Obstet 2021; 158:551-556. [PMID: 34796482 DOI: 10.1002/ijgo.14034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 11/05/2021] [Accepted: 11/17/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To identify risk factors associated with the occurrence of meconium aspiration syndrome (MAS) among neonates. METHODS A retrospective case-control study in a university affiliated tertiary medical center, including all neonates born with meconium stained amniotic fluid (MSAF) between March 2011 and March 2020. Patients were categorized by the occurrence of MAS. Demographic, pregnancy and delivery characteristics were compared between the two groups. Risk factors for MAS were analyzed. RESULTS Of 90 579 singleton deliveries, a total of 11 856 with MSAF were included. Of these newborns, 78 (0.66%) were diagnosed with MAS Four factors were independently associated with MAS: delivery at <38 0/7 weeks (aOR [95% CI]: 3.48 (1.02-11.84), P = 0.046); higher body mass index (aOR [95% CI]: 1.09 (1.02-1.16), P = 0.003); lower amniotic fluid index (aOR [95% CI]: 0.99 (0.98-0.99), P = 0.032); higher white blood cell count (aOR [95% CI]: 1.11 (1.02-1.20), P = 0.009). The presence of one, two and three of the above-mentioned risk factors yielded a risk for MAS of 0.8%, 2.5% and 100%, respectively. CONCLUSION We identified independent risk factors for MAS and developed a risk score calculator. This tool may assist physicians in the management of deliveries complicated by MSAF.
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Affiliation(s)
- Daphna Amitai Komem
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Ramat-Gan, Israel.,The Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raanan Meyer
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Ramat-Gan, Israel.,The Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Yoav Yinon
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Ramat-Gan, Israel.,The Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gabriel Levin
- The Department of Gynecologic Oncology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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