Fatal Case of Severe Meconium Aspiration Syndrome in a Neonate Following Out-of-Hospital Water Birth

Meconium aspiration syndrome (MAS) is a disease of near-term, term, or post-term newborns linked to increased infant morbidity. It results from inhalation of meconium-stained amniotic fluid (MSAF). MSAF occurs in 4% to 22% of pregnancies; 3% to 12% of those affected by MSAF develop MAS, which has a fatality rate of <1%. The presence of meconium in the amniotic fluid often indicates fetal distress. We present a case of severe MAS overlooked at birth, highlighting the importance of including MAS in the differential of sudden natural death in infancy, particularly with MSAF, even if APGAR scores are reassuring. This case involves a 1-day-old male, born at 42 weeks after an uncomplicated pregnancy and midwife-led water birth with MSAF. APGAR scores were reported as 8/9 with no initial respiratory issues. He had poor latch and lethargy, became apneic during feeding at 16 hours, and died despite attempted resuscitation. The postmortem revealed meconium staining, right ventricular hypertrophy, diffuse alveolar damage, meconium-laden macrophages, airway obstruction, and histologic evidence of persistent pulmonary hypertension of the newborn (PPHN). MAS is a recognized complication of term deliveries. Postnatal bathing can obscure meconium signs, complicating autopsy confirmation. Out-of-hospital births hinder diagnosis and management, making histology essential. The absence of visible meconium or high reported APGAR scores should not exclude the diagnosis of MAS. This case highlights the forensic pathologist’s role in infant death investigations and the need for heightened clinical vigilance in the postnatal period.