Mode of delivery and fetal outcome in meconium stained amniotic fluid in DMCH

Background : Meconium is a dark greenish mass of desquamated cells, mucus, and bile that accumulates in the bowel of a fetus and is typically discharged shortly after birth. Meconium stained amniotic fluid (MSAF) has long been considered to be a bad predictor of fetal outcome. Objective : The aim of this study was to determine if the perinatal outcome is affected by mode of delivery in meconium-stained amniotic fluid. Methodology : This ovservational study was carried out in the department of Obstetrics and Gynaecology in Dhaka Medical College Hospital from July 2016 to June 2017. A total of 204 women who satisfied the inclusion and exclusion criteria were taken for the study. The study group comprised of 102 women admitted in labour and having meconium stained amniotic fluid and 102 women in labour but having clear amniotic fluid were taken as comparision group. Results : The mean age was found 26.6±5.9 years in MSAF group and 26.2±5.0 years in clear liquor group. The mean gestational age was found 38.9±1.8 weeks in MSAF group and 38.5±1.3 weeks in clear liquor group. Risk factors were not statistically significant (p>0.05) between two groups. Forty-one (40.2%) patients had caesarian section in MSAF group and 19(18.6%) in clear liquor group. APGAR score at 1 minute and at 5 minute were statistically significant (p<0.05) between two groups. About 100(98.0%) babies were alive in MSAF group and 101(99.0%) in clear liquor group. Conclusion : Meconium stained amniotic fluid group was associated with higher rate of cesarean delivery, increased need for neonatal resuscitation, increased rate of PIH, pre-eclamsia, Oligohydramnios, IUGR, Post dated pregnancy, Rh incompatibility, GDM and long time hospital stay and hospital mortality.


Introduction
Meconium is a dark greenish mass of desquamated cells, mucus, and bile that accumulates in the bowel of a fetus and is typically discharged shortly after birth.Meconium stained amniotic fluid has long been considered to be a bad predictor of fetal outcome.Presence of meconium in amniotic fluid is a potentially serious sign of fetal compromise and associated with poor perinatal outcome. 1 The classical signs of fetal hypoxia are decreased fetal movements, variations in the heart rate patterns, presence of meconium in amniotic fluid, decrease in fetal scalp blood pH, etc.The significance of meconium in amniotic fluid as a sign of fetal distress is controversial.There are various theories ascribing it to different mechanisms.The pathological explanation proposes that foetuses pass meconium in response to fetal hypoxia. 2 Meconium staining of the amniotic fluid (MSAF) has reported less common in preterm labors (5%) but is more common in term (7-22%) and postterm deliveries (23-52%). 3fants born through meconium-stained amniotic fluid are about 100 times more likely to develop respiratory distress than those which are born through clear fluid. 4Even in women who are at very low risk for obstetric complications, meconium-stained amniotic fluid is common and it is associated with a five-fold increase in perinatal mortality as compared with low-risk patients with clear amniotic fluid. 4

Methodology
The ovservational study was carried out in the Original Article department of Obstetrics and Gynaecology in Dhaka Medical College Hospital from July 2016 to June 2017.
A total of 204 women who satisfied the inclusion and exclusion criteria were taken for the study.The study group comprised of 102 women in labour with meconium stained amniotic fluid and 102 women in labour with clear amniotic fluid were taken as control group.
A structured questionnaire was administered for both cases and control group and it was same for all patients.Basic information's (demographic profile) about all the patients were filled up followed by specific answers to the questionnaires.Detailed information of maternal and fetal outcome was recorded.
Maternal outcome was measured by socio demography, history of home trial, presence of risk factors, Mode of delivery was recorded as spontaneous vaginal delivery, caesarean section and instrumental delivery (Forceps and ventouse).
Fetal outcome was measured by APGAR score at 1 and 5 minutes, weight, sex, development of meconium aspiration syndrome (MAS), requirement of neonatal resuscitation special care-baby unit admission, live birth, or neonatal death.
All babies were followed up maximum up to 7 days after delivery, collected data were compiled in a master sheet.comparison were made between clear amniotic fluid group and meconium stained group to find out if any difference could exist between the two groups regarding mode of delivery or fetal outcome.

Discussion
In this study it was observed that mean age was found 26.6±5.9 years in MSAF group and 26.2±5.0 years in clear liquor group.Akhtar et al. 5 showed that the mean age of mother was 26.2 ± 5.2 years.Gupta et al. 6 found significant increased rate (86.7%) of meconium in amniotic fluid after 37 weeks.Mundhra and Agarwal study observed that approximately 50% cases had gestational ages of more than 40 weeks as compared to 14.2% controls who showed similar gestational ages, suggesting that advancing gestation increased meconium staining of amniotic fluid. 4Wong et al. 7 and Karineimi and Harrela 8 that socio-economic condition did not influence that MSAF in labour.
In our study it was observed that risk factors were not statistically significant (p>0.05) between the two groups.In Vaghela et al. study 59% patients had associated obstetric risk factors like PIH, post-datism, oligohydramnios, PROM. 1 Out of this 13% patients had PIH.Bhide et al. found 13.8% having PIH. 9 In this present study it was observed that hypertensive disorders was not statistically significant (p>0.05) between two groups.Mundhra and Agarwal 4 pregnancy induced hypertension (PIH) was associated with MSAF, but the incidence in our study was 16.97%, unlike the incidence of 13% in studies of Bhide et al. 9 and Khatun et al. 10 In this study it was observed that 41(40.2%)patients had caesarian section in MSAF group and 19(18.6%) in clear liquor group.The difference was statistically significant (p<0.05) between two groups.Mundhra and Agarwal study observed that caesarean section was very commonly done in MSAF cases and it accounted for 49.09% cases as compared to 25.79% cases in control group, rates being nearly double and difference being statistically significant. 4In contrast to our study, Wong et al. found that 13.2% of MSAF had undergone caesarean sections as compared to 8.8% cases who had undergone them in clear amniotic fluid. 7Such lower rates of caesarean section could be due to incorporation of scalp pH sampling in their study, unlike ours.Naveen et al. also reported a caesarean section rate of 49.1% in MSAF. 11n this series it was observed that APGAR score at 1 minute and at 5 minute were statistically significant (p<0.05) between the two groups.Present Vaghela et al. study shows birth weight of 2.6-3 kg in majority of patients. 1Sedaghatian et al. observed similar result in their study. 12Akhtar et al. found that 77.5% babies had birth weight >2.5 kg. 1 1 Birth asphyxia, aspiration pneumonia, respiratory distress syndrome and febrile illness contribute to perinatal morbidity.Perinatal mortality was 5%.Mundhra and Agarwal study showed meconium aspiration was seen in 5 cases and 5 babies who were born to cases had early neonatal deaths, though the difference was not statistically significant as compared to controls. 4Incidence of birth asphyxia and NICU admissions were statistically higher among babies born to cases as compared to those who were born to control group.
In this current study it was observed that 9(29.4%)babies was stay in SCBU >5 days in MSAF group and not found in clear liquor group.The difference was statistically significant (p<0.05) between two groups.Vaghela et al. study showed out of 13 new-born having APGAR score <7 at 1 minute, 8 improved with resuscitation and 5 neonates needed NICU admission. 1 this present study it was observed that 100(98.0%)babies were alive in MSAF group and 101(99.0%) in clear liquor group.The difference was not statistically significant (p>0.05) between two groups.Gupta et al. found 4.9% of MSAF babies to have neonatal death as compared to 2.8% in clear liquor babies. 6

Conclusion
In this study we found that Meconium stained amniotic fluid was associated with higher rate of cesarean delivery, increased need for neonatal resuscitation, increased rate of PIH, pre-eclampsia, Oligohydramnios, IUGR, Post dated pregnancy, Rh incompatibility, GDM and longtime hospital stay and hospital mortality.
1%) in clear liquor group.Fifty-one (50%) patients come from up to 3000-taka income in MSAF group and 56 (54.9%) in clear liquor group.Fifty-five (53.9%) patients were multi gravida in MSAF group and 54(52.9%) in clear liquor group.Mean gestational age was found 38.9±1.8 weeks in MSAF group and 38.5±1.3 weeks in clear liquor group.The difference were not statistically significant (p>0.05) between two groups (Table-I).Risk factors were not statistically significant (p>0.05) between two groups (Table-II).Hypertensive disorders were not statistically significant (P >0.05) between two groups (Table-II).Forty-one (40.2%) patients were caesarian section in MSAF group and 19(18.6%) in clear liquor group.The difference was statistically significant (P <0.05) between two groups (Table III).APGAR score at 1 minute and at 5 minute were statistically significant between two groups (Table-IV).Seventeen (16.7%) babies had admission in SCABU of MSAF group and 9(8.8%) of clear liquor group.The difference was not statistically significant between two groups (Table-V).Nine (29.4%) babies was stay in SCABU >5 days in MSAF group but no one in clear liquor group.The difference was statistically significant (p<0.05) between two groups (Table-VI).

Table V : Admission special care baby unit
14,4l et al.observed that 6.74% of patients within meconium and 26.25% of patients with thick meconium had low (<7) APGAR score.13Anotherstudyhasalso found the higher proportion of LBW babies in MSAF group like Narang et al. 24.4%.Mundhra and Agarwal study showed infants with MSAF had low APGAR scores at birth and 21.21% cases needed intensive care unit admissions.14,4Patilet al.