Case Report

Maternal Blood Aspiration Syndrome

Zozaya C*, Magariño P, Villar G, Cuesta MT, Castro A and Cabanillas L
Neonatology Section, Getafe Universitary Hospital, Madrid, Spain


*Corresponding author: Zozaya C, Neonatology Section, Getafe Universitary Hospital, Madrid, Spain


Published: 31 Aug, 2017
Cite this article as: Zozaya C, Magariño P, Villar G, Cuesta MT, Castro A, Cabanillas L. Maternal Blood Aspiration Syndrome. Ann Med Case Rep. 2017; 1: 1018.

Abstract

Respiratory distress in newborns within the first hours after birth includes airway obstruction etiologies. Among them, the leading cause is meconium aspiration. However, other substances can stain amniotic fluid as well and share common pathogenic mechanisms. Maternal blood aspiration is a specific diagnostic entity and should be considered in any newborn baby with respiratory distress or apnea of unknown cause. We present a case of blood aspiration syndrome along with melena neonatorum with Apt test maternal hemoglobin confirmation.
Keywords: Respiratory distress; Amniotic fluid; Placental inspection


Introduction

Respiratory distress in the newborn baby within the first hours after birth includes airway obstruction due to diverse substances. Among them, meconium aspiration has centered most of the literature attention. However, other substances can stain amniotic fluid as well and share common pathogenic mechanisms. Maternal blood aspiration is a specific diagnostic entity, probably underdiagnosed. It should be considered in any newborn baby with respiratory distress or apnea of unknown cause.


Case Presentation

A female newborn baby was born by spontaneous vaginal delivery at 36+4 weeks of gestational age. Birth weight: 2,695 g. Amniotic fluid was hemorrhagic. There was no data to suggest fetal distress. Placental inspection revealed no anomalies at insertion.
The patient showed inefficient respiratory effort at birth and bradycardia which did not improve after upper airway secretions suction (red blood) and intermittent positive pressure ventilation (1 min). Endotracheal intubation was required at 1½ minutes from birth. Apgar test scores were 5 at 1 min and 6 at five min of life. Umbilical artery pH was 7.32 and base excess was 8.9. From the first minute of life, copious and continuous bloody stool passage was noted (Figure 1). Antihemorrhagic prophylaxis was administered in the delivery room.
The patient required conventional mechanical ventilation (maximum FiO2 0.4) for 14 h and CPAP for 6 h after extubation. Chest X-ray (Figure 2) showed parenchymal opacification with bilateral infiltrates and increased lung volume (8-9 intercostal spaces). Tracheal suction was often needed during the first hours and revealed fresh red blood. Laboratory results showed hemoglobin 15.1 g/dL and platelet count and coagulation parameters were within the normal range. The patient did not have hemodynamic instability signs at any time. A rectal blood sample was sent to Apt-Downey test performance which confirmed adult hemoglobin origin.
Enteral feedings were started at 44 h with breast milk with suboptimal tolerance at beginning. Bloody stools and gastric residual lasted until the fourth day. Ranitidine treatment was implemented. Full enteral nutrition was achieved at 4th day. The patient was discharged after 5 days and evaluated at 9 days old in the outpatient clinic where no sequels were found.


Discussion

Respiratory distress at birth can be secondary to amniotic fluid aspiration stained with meconium [1], vernix [2], cellular debris [3,4] maternal blood [5] or even clear amniotic liquid [6]. Immediate respiratory distress along with hemorrhagic amniotic fluid and blood in upper and lower airway aspirates and melena raised the clinical suspicion for blood aspiration syndrome. Blood aspiration syndrome affects predominantly term or late preterm neonates and surprisingly all reported cases were female.
A patent maternal bleeding is not always found and amniotic fluid might be clear which has been noticed at least in two previous reported cases [7]. However, it has been postulated, based in post mortem studies [5], that a small volume of blood can be enough to completely fill a newborn´s lung space. When a neonate´s head is engaged in the birth canal, the mouth is directly exposed to the uterine wall and its contractions could potentially induce aspiration of blood products. In other cases, maternal hemorrhage was obvious and amniotic fluid was bloody, as it was in our case. It has been reported bloody upper airway secretions at birth in up to 43% of deliveries by cesarean section [8]. Abruptio placentae indeed can be another specific risk factor for this condition.
Chest X-ray is usually consistent with an aspiration syndrome. Hyperinflation with varying degrees of lung opacification has been described as its main features. Apt-Downey [9,10] or Kleihauer-Betke tests might be used to determine the maternal origin of the blood. In other cases, diagnosis has been determined by high plasmatic concentrations in lung fluid [7].
Differential diagnosis should consider lung hemorrhage, which usually manifests as severe respiratory distress, massive bleeding, trombopenia and coagulopathy [11]. Apt test determined maternal origin in our patient.
Supportive care remains as the treatment of choice. All previously published cases required mechanical ventilation. The true incidence of maternal blood aspiration syndrome at birth remains unknown and it most likely is an underdiagnosed entity, especially in mild cases. In fact, all reported patients required conventional mechanical ventilation but around half of them were initially managed in a conservative manner (age at endotracheal intubation ranges from birth to 5 h). In the alveolar barrier, blood products inactivates surfactant function and harm type II pneumocytes. This could explain the progressive worsening course and relatively good condition at birth described in some patients. Exogenous surfactant replacement treatment has been considered as a potential treatment in lung hemorrhage cases [12] and it has successfully been used in blood aspiration syndrome as well [13].
Prognosis appears to be favorable and ventilator support is often withdrawn within the first 72 h and systemic complications are rare although secondary hemoglobinuria [14] multiorganic failure [15] and death [5] have been reported following maternal blood aspiration.


Figure 1

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Figure 1
Bloody stool passage from first minute.

Figure 2

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Figure 2
Increase in lung volume.

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