3.1. Features perinatalnogo the period of observable children
For comparison of indicators of health, character and gravity porayozhenija the central nervous system, the comparative estimation of anamnestic data and features of a clinical current perinayotalnogo the period of all children included in given research is spent.
The comparative estimation of data of the obstetric anamnesis has taped naliyochie adverse factors in ante - and perinatalnom the periods at all children I and II groups (table З.1.1.).
Table 3.1.1.
Data of the obstetric anamnesis at mothers of observable children
| Data The obstetric The anamnesis | I group п=51 | II group п=35 | ||
| abs. | % | abs. | % | |
| Medical abortions | 20 | 39,2 | 15 | 42,9 |
| The spontaneous Abortions | 3 | 5,8 | 2 | 5,7 |
| Stood beremenyonost | 1 | 1,9 | 1 | 2,8 |
| Antenatalnaja destruction Foetus | 1 | . 1,9 | - | - |
| The first labours | 39 | 76,5 | 26 | 74,3 |
| 2 and more sorts | 12 | 23,5 | 9 | 25,7 |
Antenatalnye losses in the anamnesis (spontaneous abortions,
The stood pregnancy) identical frequency met at mothers obyosledovannyh us of children, frequency of medical abortions in II group okazayolas slightly above in comparison with I group.
Indicatings in the anamnesis on an unsuccessful current of pregnancy and sorts were characteristic for all mothers of children of both groups. SravniYOtelnyj the analysis of a current and outcomes of the present pregnancy at mothers of children participating in research are reflected in table 3.1.2.
Table 3. 2.
Current of pregnancy and sorts • at матёрей5 observable children: (%)
| Indicators of a current present be - remennosti And sorts; | . - Ggruppa п=51 | II group п=35 |
| Gestoz I half of pregnancy | 39,2 | 34,2 |
| Gestoz ІГ half of pregnancy | 31,4 | 37,1 ■ |
| Discontinuing threat beremennos ti | 84,3 | .77,1 |
| Anaemia І - ІІ half of pregnancy | 41,2 | 40,0 |
| Exacerbation chronic and acute Diseases of mother during the period bereyomennosti | 49,0 | 42,9 |
| Births in time | 86,3 | 88,5 |
| Premature birth; | 13,7 | 11,5 |
| dvu pl odnaja pregnancy | 3,9 | 5,7 |
| Untimely izlitie nearby - nlodnyhvod | 21,5 | 17,1 |
| Anomaliifodovoj activity | 56,8. | 34,2 |
| Meditsinskaja.stimuljatsija in sorts | 33,3 | 31,4 |
| Manual inspection of a cavity of the uterus; | 3,9 | 2,8. |
| Кесарево5 Section | 19; | 14,2 |
So, at 36 (70,6 %) interrogated mothers I and 25 (71,3 %) II groups during pregnancy took place early and late gestozy.
Expressed sochetannyj; gestoz (edemas of brushes, anticnemions і and rising of a BP to ’ 160/90 mm hg, or a combination of edemas and fiber presence in urine to 2 g/l) diagnostiroyovan.u 4 women (11,4 %) II groups of research.Threat of discontinuing of the present: pregnancy? It became perceptible at bolyoshinstva mothers of the surveyed groups, in G to group a little bit more often, than in
II. During pregnancy practically at half it is established obostreyonie chronic or presence of acute diseases.
The anaemia of 1-2 degrees during pregnancy was diagnosed odiyonakovo often for mothers of both groups.
That fact, that the complicated current of pregnancy otrayozhaetsja not only on character of a current of sorts, but also on terms rodorazresheyonija is conclusive. The analysis of a current of sorts in our researches has shown, that at 88,2 % of mothers of children of I group and 51,4 % - II groups, labours proceeded with mnogochisyolennymi complications (fixing, prompt, use akuyosherskih grants, etc.).
On our data the majority of pregnant women were rodorazresheny in time. The percent of premature birth on terms gestatsii has made 34-36 weeks 13,7 % in I and 11,5 % - in II group. Two-foetal pregnancy ustayonovlena only in 2 cases (on one in investigated groups). The big number of cases untimely izlitija amniotic waters and an operative delivery in both groups is taped.
Distribution of surveyed children to a sexual sign pokazayolo, that in I group of boys has appeared 33,3 %, girls - of 66,7 %. II group was made by 42,8 % of boys and 57,2 % of girls.
The diagnosis of a chronic pre-natal hypoxia of a foetus was postavyolen in a patrimonial hall 25 (49 %) the newborn I and 19 (54.3 %) to children II grupyopy.
The cerebral ischemia of 1-2 degrees has been diagnosed during the first hours lives at 36 newborn (70,6 %), 2-3 severity levels at 15 cheloyovek (29,4 %) in I group and for 26 children (74,3 %) and 9 persons (25,7%о) sootvetstyovenno in II group.
Distribution of newborns on scale Apgar is presented in tabyolitse 3.1.3.
Table 3.1.3.
Distribution of newborns on scale Apgar (Ryot)
| Estimation in points | I group п=51 | II group N=35 | ||
| abs. | % | abs. | % | |
| Estimation on scale Apgar on the first minute | ||||
| 8-9 points | 24 | 47,0 | 15 | 42,8 |
| 6-7 points | 25 | 49,0 | 17 | 48,6 |
| 4-5 points | 1 | 2,0 | 2 | 5,7 |
| 3 and less points | 1 | 2,0 | 1 | 2,9 |
| Estimation on scale Apgar on the fifth minute | ||||
| 8-9 points | 26 | 51,0 | 19 | 54,2 |
| 6-7 points | 23 | 45,0 | 14 | 40,0 |
| 4-5 points | 1 | 2,0 | 1 | 2,9 |
| 3 and less points | 1 | 2,0 | 1 | 2,9 |
Estimations on Apgar at 23 (45,1 %) newborns of I group on the first minute have averaged 8,14 points, on the fifth minute - of 8,35 points. At 24 (47,1 %) newborns of the given group of an estimation on Apgar on 1st and on 5 oh have averaged to minute 6,86 and 7,13 points accordingly. Low estimations on scale Apgar had 4 children (7,8 %) (1 minute - 4,75 points, and on 5 minute - of 6,75 points). Distribution on scale Apgar at newborns of II groups has appeared approximately same.
Authentic differences at comparison anthopometrical pokazayotelej surveyed children at a birth us it has not been received (tabliyotsa 3.1.4.).
Table 3.1.4.
Indicators of physical development in observable newborns (Myosh)
| The anthopometrical Indicators | I group п=51 | II group N=35 |
| The length of a body, see | 52,65±2,5 | 52,86±2,3 |
| Body mass, gr. | 3271,46±46,2 | 3290,55±45,6 |
| The head circle, see | 33,58±0,7 | 33,75±0,6 |
| The circle thoracal KL=TKI ' see | 33,20±0,8 | 33,50±0,7 |
Average indexes of mass of a body at a birth of newborns II
Groups were a little above, than at children of I group.
Indicators of length of a body of newborns of I group varied in preyodelah from 47 to 54 sm, in II group of newborns - from 48 to 55 see
Average value mass - rostovogo factor at novorozhdenyonyh I groups was peer 62,4, masso-rostovoj factor novorozhyodennyh in II group - 61,8. It is not taped statistically significant difference of Indicators of the CIRCLE of the HEAD And the CIRCLE of the Thorax at Children I And ' II groups.
The central nervous system, owing to anatomo-physiological features at early stages of development and especially fetally more than others organyi systems, it is subject to influence neblagoyoprijatnyh factors [10, 14-18].
At comparison of frequency of occurrence of separate neurologic symptoms and their expression in various groups of newborns, we had been received following results.
The syndrome of impellent disturbances in the form of change of an active and passive muscle tone is diagnosed for all children both in I, and in II groups. Among newborns of I group the hypertonus of muscles konechnoyostej is noted at 35 (68,6 %) children, at the others 16 (31.4 %) had children meyo
Hundred various deviations in the form of asymmetry of a muscle tone, an easy and moderate hypotension.
In II group of newborns of change of a muscle tone raspreyodelilis as follows: the muscular hypertonus became perceptible in 80 % of observations (28 children), an easy and moderate hypotension at 20 % (7 persons).
Activity research suhozhilnyh reflexes has shown them mA - loinformativnost and situational conditionality (at anxiety or drowsiness of the child, stay in a new situation, a hypothermia or a hyperthermia, research before or after feeding (transitional gi - on - or a hyperglycaemia), emotional excitability. Authentic razyolichy in change proprioretseptivnyh reflexes at children early vozyorasta us it has not been fixed.
The special attention has been given symmetric and azygomorphous cervical tonic to reflexes, as most diagnostically neblagoyoprijatnym to the symptoms which are taking place at development rasping nevrologiyocheskih of impellent defects
The expressed symmetric cervical tonic reflex in I group has been found out in 3 children (5,9 %), in 7 cases (13,7 %) was defined vyyorazhennyj an azygomorphous cervical tonic reflex at children is more senior 3 monthly age. In II group investigated SSHTR it is registered at 2 children (5,7 %), ASHTR - at 5 children (14,3 %).
Among conditionally pathological symptoms most often at novoroyozhdennyh I and II groups there was following: a symptom of "calcaneal feet” — at 22,5 %, neurogenic krivosheja - at 10,5 %, a symptom “free nadpleyochy” - 11,5 %. From pathological eye symptoms the symptom Gref (32,5 %) was more often found out. Melkorazmashistyj steady rotatornyj nisyotagm the strabismus - in 2,5 % of cases took place at 12,5 % of newborns.
The tremor of a chin and arms in the situations which have been not bound with “startl - reyoaktsijami” was registered at 34,6 % of newborns I and II groups, as prayo
Twisted, in the presence of a syndrome raised nervously-reflex vozbudiyomosti (jitteriness).
The phenomena of a Crocq's disease and-or diffuse cyanosis, with a grey shade zayofiksirovany at 19 newborn (37,3 %) I groups and 4 (11,4 %) - II grupyopy. Signs of disturbance of microcirculation, in the form of peripheric mra - mornosti skins, palenesses of integuments, cold brushes and feet met at 1/3 newborns I and II groups.
At 7 (13,7 %) children of I group and 6 (17,1 %) newborns of II group took place hemorrhages in a sclera.
gipoksicheski — ischemic lesion TSNS in the form of easy or moderate expansion likvoroprovodjashchih ways, an ischemia of basal ganglions, periventrikuljarnogo an edema has been fixed in 72,5 % sluchayoev. Gipoksicheski-Haemorragichesky changes in a kind of hemorrhages it has been diagnosed clinically and proved to be true nejrosonograficheskim research at 9 newborn I groups, of them: subarachnoidal — at 5 persons, intraventricular - at 3, in substance of a brain at 1 noyovorozhdennogo. At 5 persons (9,8 %) by data sonograficheskogo issledoyovanija significant changes it has not been established.
Subarachnoidal hemorrhages were accompanied expressed gipertenzionnym by a syndrome. For one newborn with vnutrizheluyodochkovym a hemorrhage and at one with a hemorrhage in substance golovyonogo a brain it is diagnosed gipertenzionno-gidrotsefalnyj a syndrome.
For newborns of II group also have been diagnosed with gipok - sicheski-ischemic (74,3 %) and gipoksicheski-hemorrhagic (20 %) poyorazhenija TSNS: the intraventricular hemorrhage was registered at 2 children, at one child a hemorrhage in substance of a brain socheyotalos with a cephalohematoma, subarachnoidal hemorrhages had meyosto at 4 newborns. At three children has developed expressed gipertenzion - nyj a syndrome and at one child — gidrotsefalnyj. By data sonogra -
ficheskogo researches at 5,7 % of newborns for a moment sonograficheyoskogo researches of significant changes it is not revealed.
The analysis of histories of development of newborns has allowed to observe dynamics of a state of health of children of the surveyed groups for the period nayohozhdenija in a maternity home (a drawing 3.1.1).
Drawing 3.1.1.
Background conditions of the period novorozhdennosti at children of group I and II (’ / •).
In one case are taped: a congenital heart disease, vrozhdenyonaja a cyst of a brain and nezarashchenie an upper lip.
Considering presence of neurologic semiology at a birth and the run courses of medical actions during the acute period of the disease, all newborns were are in due time taken under dispensary nabljudeyonie the neuropathologist that has allowed to estimate clinico-functional osoyobennosti perinatalnoj encephalopathies in the regenerative period.
By way of illustration to stated above we give an example clinical observation.
Girl P (clinical observation 25).
Anamnesis data: Mothers of 27 years, a chronic adnexitis, bakteriyoalnyj a colpitis. Pregnancy II, labours 1. The first pregnancy is interrupted - medical abortion, without complications. The present pregnancy proceeded with an anaemia in the third trimester of pregnancy (N 96 g/l), proceeding more than 2 weeks, threat of a spontaneous abortion on 16 and 29 week gestatsii, a hydramnion.
BRIDLES screening: 15-16 weeks - threat of a spontaneous abortion; 24 weeks - a low placentation; 34 weeks - signs FPN (individual petrifikaty);
Hormonal screening: the negative. Survey medical genetiyoka: FPN I-II degrees. A hypochromia anaemia:
The present pregnancy has ended with births in time in 38 - 39 weeks, through natural patrimonial ways, the general duration of sorts 9 chayosov (I period-8ch 20мин; II - 40 mines), antenatal izlitie amniotic waters (an anhydrous interval - 10 ch 30 mines), physical stimulation.
The girl with mass of a body 2850 gr was born., length of a body 50 sm, okruzhyonostju heads of 32 sm, окружностью1 a thorax - 31 see the Estimation on scale Apgar of 6/8 points. The condition is estimated as moderately severe. VyraYOzhenie persons suffering, cry weak, signs physiological neyozrelosti. CHDD - 40 in minute, the CARDIAC CONTRACTIONS RATE 136 1 minute, tones rhythmical, koyorotky systolic hum. The liver acts on 1,5 sm from under edge reyobernoj arches, elastic. A lien at edge of a costal arch, elastic.
In the neurologic status: the expressed hypotension of muscles, slackness, depression of a spontaneous motor performance is replaced by the periods vozyobuzhdenija, anxieties. Physiological reflexes of the newborn weak, quickly are exhausted, cause after repeated stimulations,
Bauer's reflex, Robinsona, legs, an automatic gait are absent. Suhozhilnye reflexes are recovered. Periodically it becomes perceptible gorizonyotalnyj a nystagmus.
The girl for 4 days of a life has been translated in hospital GDB №1 with the diagnosis: perinatalnoe a lesion of a brain of the admixed genesis, NMK II degrees, an oppression syndrome. A pre-natal becoming infected? Physiological immaturity. A congenital oligotrophy of I degree.
At entering in a hospital a condition of the child serious at the expense of neurologic semiology: the tremor of a chin, extremities remain spontaneous, painful, the spontaneous motor performance is enlarged, the hyperesthesia phenomena, spontaneous reflex Moro, asymmetry of palpebral fissures and nosogubnoj cords, muscle tone rising in koyonechnostjah, pathological symptoms Bogolepova, a symptom Gref, postoyojannyj a horizontal nystagmus, is expressed ASHTR and SSHTR.
The centres of a local inflammation are taped: an omphalitis, a link sided average otitis.
Laboratory researches are carried out:
The general analysis of blood: erythrocytes - 4,8x10/l, N — 128 g/l, a colour indicator - 0,8; leucocytes — 10,8x10/l, eosinocytes — 3 %, p/ja-3 %, segyomentojadernye - 34 %, lymphocytes - 48 %, monocytes - 12 %; rate osedayonija erythrocytes - 25 mm/hour.
Serologichesky research: a toxoplasmosis — negative; tsiyotomegalovirus - negative, a virus of simple herpes - negative.
Data nejrosonografii: rising ehogennosti periventriku - ljarnoj areas. Data of survey of the ophthalmologist: an optic disk is acyanotically - pink, borders are washed away. Arteries are narrowed, veins are dilated.
Treatment is spent: intramusculary — magnesia of Zinci sulfas of 25 % №10; aktovegin №10; Pyracetamum №10; inside: Pantogamum №15; Vinpocetinum
№10; meksidol №10; massage №10; an electrophoresis spazmolitikov on shejyonyj department of a backbone №7.
The final diagnosis of a hospital: Perinatalnoe a lesion of the central nervous system (a cerebral ischemia of 2 degrees), spastiyochesky tetraparez. A delay of psychomotor development. Congenital giyopotrofija 1 degrees.
3.2. Clinico - functional characteristics of children with perinatalyonoj an encephalopathy in the regenerative period
Complex clinico-tool inspection of children in vozyoraste from 2 about 12 months was carried out in dekretirovannye terms.
At the beginning of rehabilitational actions of all children included in research, we have conditionally distributed in 4 groups depending on their age (2-4 months; 5-7 months; 8-9 months and 10-12 months). NaibolYOshee the number of children has made an age category from 10 till 12 months (51 % in group I and 52 % in group II) (a drawing 3.2.1).
[? 2-4 months SH 5-7 months And 8-9 months In 10-12 months |
Drawing 3.2.1.
Age structure of children from survey samples (%).
At entering of children of I group in unit of regenerative treatment of MUSES «GDB №1», parents noted complaints on dviyogatelnye disturbances (change of a muscle tone, volume of active and passive movements), a delay in psychomotor and psychological development (table 3.2.1) more often.
Structure of complaints at observable children (abs. Numbers)
Table 3.2.1.
| Complaints | I group п=51 | II group п=35 |
| Disturbance of processes of a dream | 47 | 29 |
| G ipervozbudimost | 32 | 19 |
| Chin tremor, konechnoyostej | 35 | 19 |
| Muscle tone change | 51 | 35 |
| Change impellent akyotivnosti | 51 | 35 |
Authentic differences on character of complaints of children I and II groups vyjavyoleno were not.
At an estimation of the neurologic status the special attention addressed on following indicators: a motor performance; a muscle tone condition; presence and expression of physiological reflexes; patologicheyoskie neurologic symptoms as obshchemozgovye (a syndrome gipervozbuyodimosti, an oppression syndrome), and focal (a syndrome Gref in opredeyolennyh situations, and “the coming sun”, “an intense view”, goriyozontalnyj and a vertical steady nystagmus, an anisocoria, paresises, payoralichi, etc.).
The results received at comparison of character of lesion TSNS, frequencies of occurrence and expression separate neurologic sinyodromov in groups of surveyed children are presented in table 3.2.2.
Table 3.2.2.
Frequency of neurologic syndromes at observable children (%)
| Neurologic syndromes | I group п=51 | II group N=35 |
| Syndrome of impellent disturbances | 100,0 | 100,0 |
| Muscle tone rising | 68,6 | 80,0 |
| Muscle tone depression | 21,6 | 20,0 |
| Delay of motor development | 7,8 | 17,1 |
| Delay of mental development | 7,8 | P, 4 |
| Delay of psychomotor development | 11,8 | 22,9 |
Easy degree of impellent disturbances at an estimation on scale Ashworth in 1 + a point took place at 11 children (21,6 %). Average degree nayorushenija movements with the kept active movements and an estimation on a scale 2 points - 15 children (29,4 %). The expressed degree spastichnosti with nayorusheniem active movements and an estimation in 3 points — 8 children (15,7 %). TjaYOzhelaja degree spastichnosti, corresponding to an estimation on a scale in 4 points took place at 1 child (1,96 %).
At objective survey of children of II group syndrome signs dviyogatelnyh disturbances in the form of muscle tone depression took place at 7 persons (20 %), and in the form of rising of a muscle tone at 28 children (80 %). At rising of a muscle tone at all 28 persons also have been recovered a reflex background; at muscle tone dropping the reflex background has been recovered, invariable or lowered. The estimation spastichnosti on scale Ashworth is resulted in a drawing 3.2.2.
? 1 point In 2 points And 3 points ■ 4 points
? 0 points
Drawing 3.2.2.
Estimation spastichnosti on scale Ashworth at children of II group.
At 4 (7,8 %) children of I group it is diagnosed a delay in mental development, in 6 persons (11,8 %) took place backlog in psychomotor development. The delay of motor development has been registered at 4 (7,8 %) children of I group and at 6 persons (17,1 %) II groups. In II group of a deviation in psychospeech development had 4 children (11,4 %), a delay psihomotornoyogo developments - 8 persons (22,9 %).
According to the questioning of children spent by us on scales KID - R, backlog in impellent development for 2 months on the average from dolzhenyostvujushchih parametres was revealed at 15 children (29,4 %) I and for 2,1 month - 20 children (57,1 %) II groups. Backlog in kognitivnoj to sphere on the average for 2 months from the forced was registered at 9 children (17,6 %) I grupyopy; for 2,6 months - at 7 (20 %) the person - of II group. Practically identical in investigated groups there was a specific gravity of children having backlog in speech sphere (21,6 % and 22,9 accordingly). However, more serious steyopen arrests of development (on the average for 2,4 months from forced)
It has been fixed in II group while in group I it has made 2 months. The greatest number of children had backlog in development of skills self-service (49,0 % - in I group and 54,3 % - in II group) and sotsialiyozatsii (49,0 % - in I group and 48,6 % in II group). Backlog in development nayovykov at children of I group has averaged self-services 1,7 months from forced, and in II group backlog has made 2,2 months. ZaYOderzhka socialisation developments in I group of children has averaged 2 meyosjatsa, and in II group - 2,1 month.
The general level of development of the child received by results otsenyoki full scale, testified to an arrest of development of 14 children (27,5 %)
I groups and 18 children (51,4 %) II groups (a drawing 3.2.3.).
ЕГруппаІ ІІ рупій II