Ojog 2018080316254387 PDF
Ojog 2018080316254387 PDF
Ojog 2018080316254387 PDF
http://www.scirp.org/journal/ojog
ISSN Online: 2160-8806
ISSN Print: 2160-8792
Julius Sama Dohbit1,2, Evelyne M. Mah1,2, Felix Essiben1,3, Edmond Mesumbe Nzene1,
Esther U. N. Meka1,2, Pascal Foumane1,2, Joel Noutakdie Tochie4*, Benjamin Momo Kadia5,
Felix A. Elong6, Philip Njotang Nana1,3
1
Department of Obstetrics and Gynecology, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde,
Cameroon
2
Gynaeco-Obstetric and Pediatric Hospital, Yaounde, Cameroon
3
Central Hospital of Yaounde, Yaounde, Cameroon
4
Department of Surgery and Anesthesiology, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde,
Cameroon
5
Foumbot District Hospital, Foumbot, Cameroon
6
Faculty of Health Sciences, University of Buea, Buea, Cameroon
DOI: 10.4236/ojog.2018.89082 Aug. 6, 2018 790 Open Journal of Obstetrics and Gynecology
J. S. Dohbit et al.
orded during the study period among which MSAF was observed in 265 cas-
es, hence a prevalence rate of MSAF of 11.15%. Among these cases of MSAF,
52.1% was thick meconium and 47.9% was light meconium. Maternal mor-
bidity was high in the group with MSAF; these included: Higher proportions
of caesarean delivery (RR = 2.35 p < 10−4) and prolonged labor (RR = 3 p <
10−4). In this same group, the incidences of chorioamnionitis and puerperal
sepsis were low (0.94% and 0.70% respectively), although there was a
three-fold higher risk that was not statistically significant (RR = 3, P = 0.31).
Fetal and neonatal outcomes were poorer in the MSAF group compared to
the CAF group. The complications included fetal heart rate abnormalities,
low Apgar score at the 5th minute, need for neonatal resuscitation, neonatal
asphyxia and neonatal infection which were significantly higher in the MSAF
group (all p < 0.05). Meconium aspiration syndrome (MAS) was found in
2.34% of MSAF cases. Perinatal mortality was 2.34% and all cases of death
occurred in the thick MSAF group. Conclusion: MSAF observed during la-
bour is associated with increased perinatal morbidity and mortality. Its detec-
tion during labor should strongly indicate very rigorous intra partum and
postpartum monitoring. This will ensure optimal management and reduction
in the risks of complications.
Keywords
Meconium Stained Amniotic Fluid, Labour, Maternal and Neonatal Outcomes
1. Introduction
Amniotic fluid is a clear and transparent liquid in which the fetus lives. It is
principally made up of water (96.4%), mineral salts and organic substances [1]
[2]. Its volume increases from 20 ml at 7 weeks of gestation, to 980 ml at 34
weeks and then drops to 540 ml at 42 weeks. Its reabsorption is mainly by fetal
swallowing and absorption through the amniotic membrane [2]. Two main ab-
normalities of amniotic fluid are volume and colour changes. Colour abnormal-
ity could be blood or meconium stained (MSAF) [2]. Meconium is the first stool
of the fetus or neonate and its emission occurs between 24 and 48 hours of extra
uterine life [3] [4] [5]. Certain pathological conditions can cause its emission
before delivery, thus staining the amniotic fluid green. MSAF is a common
finding in obstetric and neonatal practice with occurrence varying from 5% to
24.6% of deliveries [6]. Its incidence increases with gestational age, up to 30% at
40 weeks and 50% at 42 weeks [7] [8].
Although the exact cause of this MSAF is unclear, fetal distress, cord accidents
and maternal hypertension have been identified as potential risk factors [9] [10].
Intrauterine emission of meconium has both fetal and neonatal consequences as
well as maternal risks [5]. Studies done in India and Pakistan showed higher
proportions of caesarean delivery, abnormal fetal heart rhythm, meconium in-
halation syndrome (MIS), low Apgar score (< 7) at the fifth minute, neonatal
sepsis and death in cases of MSAF [11] [12] [13]. In the USA and United King-
doms, guidelines have been set for the management of cases with MSAF in order
to reduce these complications [14] [15] [16]. These guidelines include conti-
nuous surveillance and amnioinfusion in cases of thick MSAF. These have led to
a significant reduction in caesarean section rates [17] [18] [19]. With an exten-
sive literature search, there is lack of studies assessing maternal and neonatal
outcomes in case of MSAF in Cameroon. Therefore, this study aimed at deter-
mining the fetal, neonatal and maternal complications associated with MSAF in
order to improve its management.
beats per minute or above 160 beats per minute [21]), neonatal asphyxia (diag-
nosed based on the diagnosed based on the Modified Sarnat-Sarnat Score [22]
and a five-minute Apgar score ≤ 3 associated with neurological signs such as
hypotonia, coma or convulsions [23]), neonatal resuscitation, admission into the
neonatal unit and neonatal death.
3. Results
3.1. Characteristics of the Study Population
A total of 2376 deliveries were registered during the study period. Among these
there were 265 cases of MSAF, hence, a prevalence of 11.15% for MSAF. Of the
265 cases of MSAF, 52 cases (19.6%) were excluded because of post term gesta-
tion, prematurity, breech presentation and multiple gestations. Two-hundred
and thirteen (213) labour cases with CAF were matched to the remaining 213
cases of MSAF. The average age of the pregnant women was 27.72 ± 5.34 years
with extremes of 15 and 40 years. There was no significant difference in ages
between the two study groups (Table 1). The majority of the women were spin-
sters (60.3%) and had at least attended secondary education (93.5%). Out of the
426 cases analysed in this study, 248 babies were male and 178 female, giving a
sex ratio of 1.39 with a male preponderance. This ratio was similar in the differ-
ent subgroups. The mean gestational age at delivery was significantly greater in
the MSAF group as compared to the CAF group (39.7 weeks vs 39.2 weeks: P =
0.0001). Gestational ages ranging between 40 to 42 weeks was significantly more
common in the MSAF group than the CAF group (41.78% vs 26.76%, p = 0.0011).
The mean birth weight was 3277.11 ± 493.59 g. The weights were similar in the
two groups. Cases of prolonged premature rupture of fetal membranes were sig-
nificantly higher in the MSAF group (p = 0.0047) (Table 2). Out of the 213 cases
with MSAF, 111 (52.1%) were thick meconium stained amniotic fluid and 102
(47.9%) were lightly stained. In 23.5% of the cases, the amniotic fluid was initially
clear at the beginning of labour before becoming meconium stained. Most (63.8%)
of the MSAF were detected during the active phase of labour. Nuchal cord and
cord knots were respectively found in 21 (9.9%) and 20 (9.39%) cases of MSAF
and CAF; the difference was not statistically significant (Table 3).
Sub-groups
Total
Variables MSAF CAF
N (%) [95% CI] P-value
n(%) n(%)
Age (years):
[25 - 30] 191 (44.8) [40.1 - 49.7] 88 (41.31) 103 (48.36) 0.1435
Marital status
Level of Education
Occupation
in cases of MSAF and especially when the stain was thick; 30.5% and 44.6% re-
spectively (p < 0.001). Common indications of caesarean delivery were cepha-
lo-pelvic disproportion and acute fetal distress. Chorioamnionitis, instrumental
delivery and puerperal sepsis were also higher in cases of MSAF although the
differences were not statistically significant (P > 0.05) (Table 4).
Sub-groups
Total
Variables MSAF CAF
n(%) [95% CI] P-value
n(%) n(%)
Parity
Number of ANC
]38 - 40] 220 (51.6) [46.8 - 56.5] 105 (49.30) 115 (53.99) 0.3328
Pathologies in pregnancy
Artificial 233 (54.7) [49.8 - 59.5] 108 (50.70) 125 (58.69) 0.0976
ANC = Antenatal care; C/S = Cesarean section; MSAF = meconium stained amniotic fluid; CAF = clear
amniotic fluid; STIs = sexually transmitted infections.
Colour
Yellow 58 27.2
Consistency
Continued
Odour
Fetid 11 5.2
Chronology
Moment of detection
Latent phase 17 8
AF = amniotic fluid.
N∕A: not applicable (The relative risk could not be calculated because all the cases were in the exposed
group).
Fetal heart beat anomaly 71 (33.3) 29 (13.6) 2.90 [1.79 - 4.72] <0.001
N∕A: not applicable (The relative risk could not be calculated because all the cases were in the exposed
group); NNI: Neonatal infection, NNA: Neonatal asphyxia.
4. Discussion
The aim of this study was to determine the maternal and fetal outcomes in case
of meconium stained amniotic fluid observed during labour of term singleton
pregnancy in cephalic presentation. We found that the prevalence of MSAF was
11.15%. MSAF was associated with a significant risk of caesarean delivery and
prolonged labor. Also, MSAF was associated with the following fetal and neo-
natal complications; fetal heart rate abnormalities, low Apgar score at the 5th
minute, need for neonatal resuscitation, neonatal asphyxia and neonatal infec-
tion. Meconium aspiration syndrome (MAS) was found in 2.34% of MSAF cases.
Perinatal mortality was 2.34% and all cases of death occurred in the thick MSAF
group.
We found a prevalence of MSAF of 11.15%. This finding is within the 5% to
24.6% interval stated in the literature [6], although higher than the 8.3% re-
ported by Patil K.et al. in 2006 in India [18]. The higher prevalence observed in
the current study could be explained by the fact that the study was conducted in
two tertiary level hospitals in the capital city that receive referrals from the peri-
pheral health facilities. Thick MSAF represented 52.1% and light MSAF
represented 47.9%. This concurs with findings from other low-and-middle in-
come countries; 53% in Guinea [24] and 64.3% in India [18]. The high frequency
of thick MSAF could be due to the fact that evaluating amniotic fluid as lightly
stained is very subjective and as such, the prevalence may greatly vary from one
author to the other [9].
The mean gestational age was greater in the group with MSAF compared to the
CAF group (39.7 vs 39.2 weeks: p = 0.0001). Moreover, the incidence of MSAF was
60.9% in cases with gestational age greater than 40 weeks. This positive correlation
between advanced gestational age and the prevalence of MSAF concurs with pre-
vious observations made by Meis et al. [7] and Millar et al. [8] who found that the
prevalence of MSAF could be up to 50% at 42 weeks of gestation.
Similar to studies done by by Erum et al. [11] and Salma et al. [12], we found
MSAF to be associated with some maternal morbidities; a two-fold increase in
caesarean delivery and a three-fold increase in chorioamnionitis and prolonged
labour. We may attribute the high incidence of caesarean deliveries in this study
to inadequate intrapartum fetal heart monitoring. As such, the presence of me-
conium in the amniotic fluid was an alarming sign of fetal distress and treated
accordingly by emergency caesarean section.
After stratifying maternal morbidities according to the consistency of the
MSAF, it was noted that thick MSAF compared to light MSAF and clear amni-
otic fluid (CAF) respectively increased the risk of caesarean delivery by 1.67 and
2.48. Similar results were found by Aparna et al. [9] and Nirmala et al. [13] in
India where the risk of caesarean delivery was multiplied by 3 in case of thick
MSAF. Likewise, all the cases of puerperal infections were found in the group
with thick MSAF. Thick MSAF increased maternal morbidities significantly in
cases of MSAF.
5. Conclusion
MSAF observed during labour of term singleton pregnancies in cephalic presen-
tations was associated with maternal and fetal complications. Its detection dur-
ing labor warrants rigorous intra partum and postpartum monitoring for a
timely diagnosis and management of these complications.
Declaration of Interest
The authors report no declaration of interest.
Funding
This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
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Appendix 1. Questionnaire
Patient identification:
File N˚: _________ Date: ____ /____/____
Contact adresss: ___________________ Age (years): _______
Marital Status: maried □; single □; divorced ; widow
Level of education: not formal; primary ; secondary ; higher
Occupation: housewife student civil servant private worker
independant
Monthly revenu (Fcfa):
<25,000 [25,000 - 50,000[ [50,000 - 100,000[ ≥ 100,000
Last mentrual period:__/__/__ Expected day of confinment: _/_/_ Gesta-
tional age (weeks-days) ____________________
Presenting complaint: labour pains □; vaginal bleeding; lost of liquoir□;
others____________________
History of pregnancy:
No of antenatal care visits: ___; VIH serology: negative positive
Level of haemoglobin: <10 g/dl ; ≥ 10g/dl
Pathologies in pregnanacy: anaemia□; malaria □; urinary infection ; di-
abetes ; Hypertension others ___________________________________
Gravida ___ Para__________________; No of past cesarean sections: ____
Medical History: None □; Hypertension: Yes /No ; diabetes: Yes /No
Cardiopathy: Yes □/No □ others ____________________
Monitoring of labour (partograph)
Mode of rupture of membranes: Spontanous Artificial
Delay of rupture of membranes: Premature Rupture: Yes /No
Prolonged Rupture: Yes /No
Maternal fever (temp > 37.8): Yes /No ; Maternal tachycardia (>100):
Yes /No
Mode of delivery:
Normal vaginal delivery □;
Instrumental □ (Indication: fetal distress cephalopelvic disproportion ; fa-
tigue others___________)
Cesaerian section □ (Indication: fetal distress □; cephalopelvic disproportion □;
others ____________________________)
Duration of labour: Normal Prolonged
If prolonged: 1st stage duration____ 2nd stage duration____ 3rd stage
duration____
Placenta: weight(g) __________; meconial stained: Yes □ /No □
Calcifications: Yes /No ; other anomalies________________________
Umbilical Cord: meconial stained: Yes □ /No □; cord knot: Yes □ /No □
Cord round neck: Yes /No ; cord prolapse: Yes /No other anomalies
_________________________
State of newborn:
Gender: Male Female ; Weight(g) _______________
APGAR: 1st min____/10; 5th min____/10
Resuscitation: Yes /No ; if yes: Duration____________________ min,
Method_________________
Respiratory distress: Yes /No ; Neonatal Asphyxia: Yes /No
Meconium inhalation syndrome: Yes □/No ; Neonatal Infection: Yes
/No
Neonatal unit admission: Yes /No ;
Neonatal death: Yes /No
Follow-up of the mother and newborn
Newborn Mother
Days - date
Complications Post partum Complications
Day 1 NNI NNA RD MIS died Non Puerperale infection: Yes_ No_
NNI: Neonatal infection, NNA: Neonatal asphyxia, RD: Respiratory distress, MIS: Meconium inhalation
syndrome.