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2.1 General clinical characteristic of surveyed children.

Work was spent in unit for not full-term children and the aftertreatment Center malovesnyh children (zav.otd. - d.m.n, prof. G.V.Jatsyk.), laboratories of the general pathology (zav.otd. - d.m.n., prof.

I.E.Smirnov), unit of ultrasonic diagnostics (zav.otd. - d.m.n, prof. Dvorjakovskij I.V.), unit of functional diagnostics (zav.otd. d.m.n. Lukina O. F), biochemistry laboratories (zav.otd. - d.m.n, the prof. Bakanov M. I) scientific research institute of Pediatrics GU NTSZD the Russian Academy of Medical Science.

Within 8 years (1998 - 2006) 360 children at the age from 5 days till 9 months have been surveyed. Gestatsionnyj the age of patients fluctuated from 28 till 42 weeks. The most part of the surveyed patients was made by not full-term children (55,5 %).

200

Fig. 3. A parity of full-term and not full-term children,

Included in research

The clinical characteristic of surveyed children is presented in table 1.

The clinical characteristic of surveyed children.

Table 1.

1 group P group
Gestatsionnyj

Age (ned.)

28-36 37-42
g

Masses

1 and at

1 birth

300

Ogr

10 100
Otsen

ka on

To scale

APGAR

0-5 80 10
6-8 90 30
> =8 30 120
Labours the cesarean

Section

40 20
Two at a birth 20 pairs (40 children)
Boys 80 64
Girls 120 96
IN TOTAL CHILDREN 200 160

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All surveyed children have been parted on two groups on severity level of lesion TSNS and degrees of a maturity (tab. 2). Patients looked round at

postuplenni at the age of 5-7 days, and then repeatedly in dynamics. An estimation of severity level of a cerebral ischemia at children spent according to classification perinatalnyh lesions of nervous system at newborn children [N.N.Volodin, 2000] on the basis of anamnesis data about a current of pregnancy and sorts, gestatsionnogo age, dynamics of indicators poshkale Apgar and scale Silvermana, volume and duration of reanimation actions, character of neurologic disturbances [G.V.Jatsyk, 2005].

Table 2.

Distribution of surveyed children on severity level of lesion TSNS and gestatsionnomu to age.

Severity level

Lesions TSNS at

Entering

The full-term

(gestatsionnyj

Age> 36 weeks)

p = 160

Not full-term:

p = 200

Srednstjazhslaja Absolute number

/ %

Absolute | number / %
150/46,1 + 1,3 170/47,1 + 1,3
The serious 10/2,7 + 1,7 30/8,3 1,8

For children who have arrived in a moderately severe condition, implications of the general oppression (68 %) were in most cases characteristic: slackness, a hypodynamia, the general hypomyotonia and a hyporeflexia, bulbar and pseudobulbar disturbances, a nystagmus converging and dispersing strabismus (tab.

3).

Table 3.

Frequency of various implications of a cerebral ischemia at newborns of 1 group.

Nosological forms

Syndromes

Frequency in

%

(p = 320)

Syndrome of oppression TSNS 68
Convulsive syndrome 8
gipertenzionno - gidrotssfalnyj a syndrome 9
vsgsto - visceral disturbances 44
Syndrome raised nervously-reflex

Excitabilities

31
Syndrome of a muscular dystonia on the hypertensive

To type

32
Syndrome of a muscular dystonia on hypotonic type 68

At smaller number of children symptoms of excitation of the central nervous system (31 %) in the form of the general impellent anxiety, a muscular dystonia with predilection to a hypertonia, a tremor of extremities, intensifying of a spontaneous motor performance, an uneasy dream, unmotivated crying, revival congenital and suhozhilnyh reflexes, a tremor became perceptible.

Local neurologic symptoms at children of this group became perceptible extremely seldom (only in 3 % - the phenomena of a paresis of a facial nerve).

At the newborn children who have arrived in unit in a grave condition, pathological deviations have been more expressed (tab. 4). At them excitation or oppression symptoms were more distinctly shown. With smaller frequency the expressed hypomyotonia (20 %), oppression were taped

Physiological reflexes newborn (21 %), usually against motor performance depression (20 %).

Table 4.

Frequency of various implications of a cerebral ischemia at newborns of 2 groups.

Nosological forms of syndromes Frequency in %
Syndrome of oppression TSNS 21
Convulsive syndrome 18
gipertenzionno - a hydrocephalus nyj a syndrome 24
vegeto - visceral disturbances 98
Syndrome raised nervously-reflex

Excitabilities

79
Syndrome of a muscular dystonia on the hypertensive

To type

79
Syndrome of a muscular dystonia on the hypotonic

To type

20

At some newborns alternating of signs of oppression and excitation, and also such neurologic symptoms, such, as a converging squint, a horizontal nystagmus, an exophthalmos, a symptom Gref, spastichnost or paretichnost brushes, presence atetoidnyh movements, klonusoida stop was observed.

G ipertenzionno-gidrotsefal nyj the syndrome (24 %) was characterised by fast increase of a circle of a head, disclosing of a sagittal seam more than 0,5 sm, augmentation of the big fontanel, occurrence s it Gref, a nystagmus, a converging squint, spontaneous starts, joining somato - vegetative disturbances (regurgitations, "mramornosti" integuments, etc.).

At children with a syndrome vegeto-vistseralnyh disturbances (98 %) were most often observed: a dyskinesia GASTROINTESTINAL TRACT (persistent regurgitations, intensifying of a peristalsis of an intestine, a meteorism, constipations), mramornost integuments, perioral and a Crocq's disease, thermoregulation disturbances, tachy - and a bradycardia.

The syndrome of impellent disturbances was characterised as presence of a hypomyotonia with oppression suhozhilnyh and congenital instinctive reflexes, and a muscular hypertonia with presence of focal semiology.

At many children the combination of the given syndromes was observed.

The estimation of the somatic status at children with moderate severity level is presented in table 5.

Table 5.

Frequency of a somatic pathology and developmental anomalies at children] groups.

Somatic pathology Frequency
And developmental anomalies In %
PR zhkg -
PR sss -
I IP mve -
Sochetannye developmental anomalies -
Stigmy dizembriogeneza 29
Ischemic cardiomyopathies 31
Oligotrophy of 2-3 degrees 9
Partial atelectases 13
Sepsis 8
Konyongatsionnaja an icterus 2 -

3 items

33
GBN 5
Anemias 31

At the age of 4-5 days of a life level of the general bilirubin of the blood serum, corresponding srednetjazhsloj and serious degree of a neonatal icterus, became perceptible at 33 % of children of I group. Variability of indicators of the general bilirubin at the majority of patients was within 120,5 - 92, 5 mkmol/l (max 135,5 mkmol/l + 12,4). Depression of level of the general bilirubin of blood serum observed in dynamics for 10-14 days of a life (max 100 mkmol/l yo 8,4); at survey it became perceptible subikterichnost a skin and scleras.

The most serious implications sochetannyh somatic disorders are noted by us at the least full-term patients. For them for 4-5 days of a life fluctuation of level of the general bilirubin of blood serum within 145 mkmol/l (+ 9,4) was characteristic, that corresponded to the third degree konjugatsionnoj icteruses; the fixing current of a neonatal icterus was accompanied by the phenomena gepatosplenomegalii and a hypochromia anaemia. Deficiency of mass of a body of patients varied from 15 to 18 %.

Against sochetannoj the therapy including dszintoksikatsionnuju and symptomatic therapy, additional oxygenation, it was possible to achieve steady stabilisation of a condition of children by 14-21 day of a life. At newborns gradual reduction of a hyperbilirubinemia to is conditional-standard value became perceptible, to the extremity of 3 weeks of a life level of the general bilirubin of blood serum has made from 35,4 to 40, 2 mkmol/l (+ 10,4). According to ultrasonic of organs of an abdominal cavity, the sizes of a liver and a lien at newborn children of this subgroup did not exceed age norm. Auskultativno breath weakening, mainly in the bottom departments was defined; variability of a rhythm of heart and breath (mostly a bradycardia in a combination with dispnoe in the morning - according to daily monitoring) on occasion became perceptible.

It is necessary to underline, that gestatsionnyj the age of patients above described нодіруппьі fluctuated between 33 and 36 weeks, i.e.

somaticheshy the status of the given subgroup of children has not been burdened by presence of a deep prematurity; masso - rostovoj the factor at these children was in limits from 46, 4 + 4, 6 to 53,6 + 4,9.

The somatic pathology at children of 1 group was most often shown by an anaemia, stigmami dizembriogsneza and clinical implications of an ischemic cardiopathy (31, 29 and 31 % accordingly). Thus for newborns the frequent combination of a transitional myocardial ischemia to an anaemia whereas small anomalies of development quite often met at them mainly separately or without the expressed accompanying somatic pathology was characteristic.

Auskultativnaja the picture of an ischemic cardiomyopathy developed of set of respiratory disturbances, a cyanosis, a tachycardia and tahipnoe; at separate patients the cantering rhythm was auscultated. As Ehografichesky addition the found out open oval window in diameter of 3-4 mm without a regurgitation often served, is more rare - prolabirovavie than cusps of the mitral valve; the analysis of peripheric blood taped depression of haemoglobin to 130 - 110 yo 2,3 g/l. These patients demanded more steadfast attention, constant monitoring of the basic indicators of vital activity, additional oxygenation (kuvez, KP).

Partial atelectases of lungs met at 13 % of patients of the given group and were harakternee for the least mature patients.

It is essential, that, despite high enough percent of occurrence of small anomalies of development in this group of children (29 %), a surveyed indicator, basically, reflects variability of implications dizembriogsneza, in various combinations. Anomalies of a structure of an auricle and a facial skeleton, and also a xanthopathy most often became perceptible. At the same time, their character and localisation did not render essential influence on the somatic status of patients, supplementing fenotipicheskuju a picture
And, on occasion, allowed to specify probability of presence toju or other genetically determined disorder.

At an estimation of a somatic pathology at children, whose condition at entering has been estimated as serious (tab. 6), is important to note much higher percent of frequency of local infectious processes (a catarral omphalitis, an otitis, a conjunctivitis) (37 % from the general number of children in the given group) (< 0,05).

rtablitsa 6.

Frequency of a somatic pathology and developmental anomalies at children of 2 groups.

Somatic pathology

And developmental anomalies

Frequency

Observations

In %

Developmental anomalies DS 20
Developmental anomalies SSS 20
Developmental anomalies MVS 6
Sochetannye developmental anomalies 20
Stigmy dizembriogeneza 78
Ischemic cardiomyopathies 99,9
Oligotrophy of 2-3 degrees 75
Partial atelectases 51
Konjuigatsionnaja an icterus 2 -

3 items

98
Sepsis 12,3
The local infectious

Processes

37
GBN 51
Anemias 60

At the majority of children of the given group (76 %) the expressed cyanosis of dermal and mucous integuments, and also various hemorrhagic implications (mainly petehialnogo and linear character) on a face skin, necks, a conjunctiva of eyelids, a sclera of eyes became perceptible. To all newborns, especially in the first 7-10 days of a life, it was inherent expressed pastoznost. Retrogress of the specified changes was observed at children only by 15—17 days of a life (< 0,05).

rrezkaja the head configuration was defined at all newborns. At 30 % of children cranial seams (coronal and sagittalnyj) have been opened within 1 see the Big fontanel has been a little enlarged in sizes (to 3,0 3,5 h 3,5-3,5 sm) and strained at all surveyed newborn children; the condition small and lateral fontanels at children has not been changed. The patrimonial tumour at newborns disappeared, basically, to the extremity of the first 10 days of a life, the strain of the big fontanel continued to remain at the majority of children till the end of the period novorozhdennosti.

Certain interest represents, in our opinion, a phenomenon of "pulsation" of the big fontanel which became perceptible at 65 % of newborns of the given group - clinically it there were the most serious children. The similar pulsation was found out visually and, in larger degree, ialpatorno; its rhythm coincided with frequency of warm reductions. The most expressed the pulsation was at newborns at the age of 5 and 10 - 12 days; after the second week of a life it has decreased.

At the age of 4-5 days of a life level of the general bilirubin of the blood serum, corresponding srednetjazheloj and serious degree of a neonatal icterus, became perceptible practically at all children of II group (130 yo 2,7 %). Variability of indicators of the general bilirubin at the majority of patients was within 167,5 - 132, 5 mkmol/l (max 175 mkmol/l + 12,4). Depression of level of the general bilirubin of blood serum was observed in dynamics slowly, for 10-14 days of a life having reached level 97 - 99 mkmol/l (max 119,7
Mkmol/l yo 10,4) (< 0,05). У всех пациентов при осмотре отмечалась субъиктеричность кожи и склер.

rnaibolee serious implications sochetannyh somatic disorders are noted by us at the least mature children (8,3 % from the general number of surveyed children). For the given subgroup of patients for 4-5 days of a life fluctuation of level of the general bilirubin of blood serum within 168 - 176 mkmol/l (yo 9,3) was characteristic, that corresponded to the third degree konjugatsionnoj icteruses; the fixing current of a neonatal icterus was accompanied by the phenomena expressed gepatosplenomegalii and a hypochromia anaemia. Deficiency of mass of a body of patients varied from 17 to 21 %. It is essential, that the clinical picture at surveyed newborns was supplemented with implications of hemorrhagic illness of newborns.

Steady stabilisation of a condition of children against sochetannoj managed to achieve therapy to 18 - to 28 day of a life. At newborns gradual reduction of a hyperbilirubinemia to is conditional-standard value became perceptible, to the extremity of 1 month of a life level of the general bilirubin of blood serum has made from 35,4 to 40, 2 mkmol/l (yo 8,4). According to ultrasonic of organs of an abdominal cavity, the sizes of a liver and a lien at newborn children of this subgroup did not exceed age norm. Auskultativio breath weakening, mainly in the bottom departments was defined; variability of a rhythm of heart and breath (mostly a bradycardia in a combination with dispnoe in the morning - according to daily monitoring) on occasion became perceptible.

At all newborn children with serious degree of a cerebral ischemia clinical implications of an ischemic cardiopathy are taped, auskultativnaja which picture developed of set of respiratory disturbances, a cyanosis, a tachycardia and tahipnoe; at separate patients the cantering rhythm was auscultated. As Ehografichesky addition the found out open oval window in diameter of 3-4 mm without a regurgitation often served,
prolabirovanie cusps of the mitral valve; the analysis of peripheric blood taped depression of haemoglobin to 130 - 110 + 2,6 g/l.

In the majority of children of 2 groups (78 %) at survey are found out various stigmy dizembriogeneza (anomalies of a structure of an auricle and a facial skeleton, a xanthopathy etc.). At some patients these data supplemented the general fenotipicheskuju a picture in structure of the certain genetic syndromes defects of formation and development of internal organs were which basic implications.

Frequency of somatic developmental anomalies is presented in a drawing 4. It is essential, that formation disturbances it is warm - vascular and respiratory systems in the given group of children met identical frequency (43 %). Anomalies of development mochevydelitelnoj systems (a congenital hydronephrosis, ureteronefroz, a congenital hypoplasia of a kidney) were observed less often - only at 14 % of children with serious lesion TSNS.

Fig. 4. Frequency of defects of formation and development of internal organs in children of 2 groups

We carry out the careful analysis somatic and akushersko - the gynecologic anamnesis of mothers, surveyed children, a current of the present pregnancy and sorts. Data are presented in table 7.

Table 7.

The characteristic meterej which children participated in research.

1 group P group
In

zrast

Mothers

Less than 18 years 30 15
More than 30 years 150 60
Burdeness of the somatic anamnesis %
The chronic

Pyelonephritis

16 7
Vegeto-vascular

Dystonia

27 12
Myopia 18 8
The endocrine

Diseases

28 3
Chronic infectious pathology 20 10
Burdeness

akushersko -

The gynecologic

The anamnesis

%
medaborty 42 13
Abortions 14 8
Dysfunction of ovaries, sterility 13 5
Chronic adnexitis 17 3
Erosion of a neck of a uterus 8 7
Colpitis 6 2
Myoma 2 2
%
Nalich ie bad habits Smoking 22 8
Alcoholism 3
Narcomania 1
Pathology

Pregnancy

%
Toxicosis 21 13
Nephropathy 22 16
Discontinuing threat 39 18
Anaemia 12 6
ORVI 17 12

That fact is of great importance, that in 1 group the number starorodjashchih mothers was authentic above. In both groups the somatic anamnesis of mothers has been most often burdened by presence of a chronic infectious pathology. In group of mothers who have given birth before term, authentically there were endocrine diseases and a myopia is more often.

The carried out analysis of results of complex clinical inspection allows to confirm with high reliability (r

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Scientific source STEPANOV Andrey Alekseevich. CEREBRAL ISCHEMIA At CHILDREN of the FIRST MONTHS of the LIFE: MODERN CRITERIA of DIAGNOSTICS And TREATMENT PRINCIPLES. The dissertation on competition of a scientific degree of the doctor of medical sciences. Moscow - 2007. 2007

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