Background: Airway obstruction is a life-threatening cause of neonatal respiratory distress. While common aetiologies include congenital malformations and acquired lesions, aspiration of placental tissue is particularly uncommon and discussed rarely in journals.
We present a case of perinatal respiratory failure due to obstructive aspiration of placental membrane, highlighting the importance of considering rare mechanical causes when treating refractory neonatal respiratory distress.
Case Presentation Summary: The patient was a female infant born at term via ventouse-assisted vaginal delivery to a 38-year-old primiparous mother following in vitro fertilisation. The pregnancy was uncomplicated; however, labour was prolonged following spontaneous rupture of membranes.
At birth, the infant was cyanotic but had normal tone and attempted to cry. She was initially handed to her mother. At four minutes of life, she ceased respiratory effort, and resuscitation commenced. The infant was pale, floppy, and bradycardic. Initial attempts at positive pressure ventilation yielded poor chest movement. Intubation was attempted at 16 minutes of life, again without an effective chest rise.
The infant developed episodes of rigidity, upper limb extension, and coughing movements. Phenobarbitone was administered with partial reduction of symptoms. No obvious obstruction (e.g., meconium or secretions) was observed on laryngoscopy. Bag-valve-mask ventilation briefly produced effective chest movement, and intubation was reattempted and successfully achieved at 25 minutes with improvement in observations. An umbilical venous catheter (UVC) was placed, and initial investigations revealed hypoglycaemia, metabolic acidosis with elevated lactate, and raised white cell count. Chest X-ray was unremarkable. Broad-spectrum antibiotics, fluid resuscitation, and 10% dextrose were administered.
At 4.5 hours of life, the infant desaturated to 65% while ventilated on 100% oxygen. Global hypertonia was noted. The ventilator alarmed for obstruction, although suctioning yielded no obstructing material. Due to poor lung compliance, a half dose of surfactant was administered despite being a term birth. Blood-stained bubbles were noted in the endotracheal tube, raising suspicion for pulmonary haemorrhage. Further suctioning revealed membranous material, which was sent for histological analysis. Following this, the infant's respiratory function improved markedly, with oxygen saturations reaching 100%.
The patient was transferred to the local tertiary centre for therapeutic cooling. Histopathological examination of the aspirated tissue demonstrated “membranous tissue [which] could be in keeping with placental membrane." The patient continued to improve clinically with cranial ultrasound on day 2 and MRI on day 9 of life, showing no abnormality. The infant was discharged home on day 15 with outpatient neurology follow-up.
Learning points Discussion: This case highlights an exceptionally rare cause of neonatal respiratory failure: aspiration of placental tissue. While meconium and other common causes of airway compromise should be first considered, maintaining a broad differential diagnosis in resuscitation is crucial. Symptoms in this case were atypical and fluctuating improvement with repeated intubations and bag-valve-mask ventilation should prompt consideration of mechanical obstruction.
As in this case, poor response to ventilation and intubation should prompt re-evaluation, with repeated assessments and suctioning, which ultimately led to the patient's recovery. This patient had favourable outcomes due to timely intervention and transfer for prompt therapeutic hypothermia.
