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Lection 2-neonatology.ppt

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PERINATAL LESIONS OF NEURAL SYSTEM PERINATAL LESIONS OF NEURAL SYSTEM

Medical & social gravity of PLNS problem • High frequency of psychical & neural Medical & social gravity of PLNS problem • High frequency of psychical & neural problems (10% of children in the world suffer from mental disorders, 80% of than caused by perinatal lesions of neural system)

Medical & social gravity of PLNS problem • High perinatal death’ rates, especially in Medical & social gravity of PLNS problem • High perinatal death’ rates, especially in VLBW group. In severe cases the mortality rate is as high as 50%. • BW less than 2, 5 kg increase death risk in 40 times, less than 1, 5 kg – in 200 times

Medical & social gravity of PLNS problem • Among infants who survive severe PLNS, Medical & social gravity of PLNS problem • Among infants who survive severe PLNS, the most frequent sequelae are mental retardation, epilepsy, and cerebral palsy • Economical factor – money's-worth to child-invalid care may obtain 80 -100 000$ per year.

NEONATAL NEURAL SYSTEM PHYSIOLOGICAL FEATURES • High neural plasticity • Neurons amount in 1 NEONATAL NEURAL SYSTEM PHYSIOLOGICAL FEATURES • High neural plasticity • Neurons amount in 1 mm³ 60% more than in adults • Increased glycolytic activity • Sensitize for damaged factors • Comparative resistance to cerebral vessels hypertension

NEUROLOGICAL STATUS OF NORMAL NEWBORN INFANT • INTERCOMMUNICATION – negative reaction due to any NEUROLOGICAL STATUS OF NORMAL NEWBORN INFANT • INTERCOMMUNICATION – negative reaction due to any stimuli • SPONTANEOUS MOVEMENTS atetosis-like motions of extremities, symmetrical & without any restriction, tremors & convulsions

NEUROLOGICAL STATUS OF NORMAL NEWBORN INFANT • EYES MOVING – incoordination, strabismus & optico-kinetic NEUROLOGICAL STATUS OF NORMAL NEWBORN INFANT • EYES MOVING – incoordination, strabismus & optico-kinetic nystagmus are present • CRYING – vigorous, emotional, well modulate, audio frequency 400 -650 hertz

NEUROLOGICAL STATUS OF NORMAL NEWBORN INFANT • MUSCLE TONE – flexor hypertonia, embryonic posture NEUROLOGICAL STATUS OF NORMAL NEWBORN INFANT • MUSCLE TONE – flexor hypertonia, embryonic posture • PRIMITIVE REFLEXES – rooting & sucking responses, Moro reflex, glabellar tap, tonic neck reflex, palmar & plantar grasp, traction reflex • TENDOM JERKS – labile & symmetrical

Grasping reflex (high) Grasping reflex (high)

Grasping reflex (low) Grasping reflex (low)

Protective reflex Protective reflex

Footing reflex Footing reflex

AETYOLOGY of PLNS • PRENATAL FACTORS: hereditary diseases, chronic fetal distress – maternal diabetes AETYOLOGY of PLNS • PRENATAL FACTORS: hereditary diseases, chronic fetal distress – maternal diabetes mellitus, toxicosis, placental failure, intrauterine infections, medicaments, ecological pollutions

AETYOLOGY of PLNS • POSTPARTUM FACTORS: neonatal distress, premature infant, blood pressure instability, infections, AETYOLOGY of PLNS • POSTPARTUM FACTORS: neonatal distress, premature infant, blood pressure instability, infections, metabolic dysfunctions - magnesium, calcium, natrium, bilirubin fluctuations, hypoglycemia; sepsis, cardiovascular & respiratory failure.

Pathophysiology: 1 st stage – reducing of cerebral blood flow 2 nd stage – Pathophysiology: 1 st stage – reducing of cerebral blood flow 2 nd stage – glutamate and aspartate toxic effects presenting 3 rd stage – increasing of intracellular concentration of calcium 4 th stage - increasing of intracellular enzymes activity

Pathophysiology: 5 th stage – increasing of NO synthesis & oxygenous stress progressing 6 Pathophysiology: 5 th stage – increasing of NO synthesis & oxygenous stress progressing 6 th stage – genes expression 7 th stage – “late” ischemia aftereffects presenting 8 th stage - apoptosis (programmed cell death).

CLASSIFICATION of PLNS 1. HYPOXIC-ISCHEMIC ENCEPHALOPATHY • Cerebral ischemia - Р 91. 0 • CLASSIFICATION of PLNS 1. HYPOXIC-ISCHEMIC ENCEPHALOPATHY • Cerebral ischemia - Р 91. 0 • Hypoxic cerebral bleeding - Р 52. 0 • Ischemia & bleeding conjunction 2. BURTH TRAUMA OF NEURAL SYSTEM • Cerebral birth trauma - Р 10. 0 • Spinal birth trauma - Р 11. 5 • Peripheral nerve injury - Р 14. 0

CLASSIFICATION of PLNS 3. DYSMETABOLIC & TOXYC LESSIONS OF CNS: bilirubin encephalopathy, decreasing of CLASSIFICATION of PLNS 3. DYSMETABOLIC & TOXYC LESSIONS OF CNS: bilirubin encephalopathy, decreasing of magnesium, calcium, natrium, glucose, fetal drug abuse, maternal alcoholism & tobacco smoking. - Р 70 -71 4. CNS LESSIONS DUE TO PERINATAL INFECTIONS - Р 35 -37.

EARLY PHASE SYNDROMS of PLNS • Cerebral depression syndrome Hypotonic babies with weak Moro EARLY PHASE SYNDROMS of PLNS • Cerebral depression syndrome Hypotonic babies with weak Moro reflex and poor spontaneous movements, weak crying. They suck poorly. Brain stem encephalopathy is less common. There may be intermittent decerebration.

Cerebral depression syndrome Cerebral depression syndrome

Cerebral depression syndrome Cerebral depression syndrome

EARLY PHASE SYNDROMS of PLNS • Cerebral irritation syndrome – Hypertonic infants are generally EARLY PHASE SYNDROMS of PLNS • Cerebral irritation syndrome – Hypertonic infants are generally hyperalert. These infants have extensor posture, brisk stretch reflexes and strong Moro reflex with low threshold. Most of these develop normally but may develop seizures.

Cerebral irritation syndrome – Cerebral irritation syndrome –

Cerebral irritation syndrome – Cerebral irritation syndrome –

RECOVERING SYMDROMS • • • Neonatal seizures Hydrocephalus Cerebral hypertension Vegetative dysfunctions Motor dysfunctions RECOVERING SYMDROMS • • • Neonatal seizures Hydrocephalus Cerebral hypertension Vegetative dysfunctions Motor dysfunctions Mental retardation

LATE SEQUILAE • • • Recovering Psycho-motor retardation Language difficulties Encephalopathy Hard organic lesions LATE SEQUILAE • • • Recovering Psycho-motor retardation Language difficulties Encephalopathy Hard organic lesions of CNS Neuro-developmental handicaps

DIAGNOSTICS Imaging Studies: • Cranial ultrasound: • CT scan of the head • MRT DIAGNOSTICS Imaging Studies: • Cranial ultrasound: • CT scan of the head • MRT Cerebro-vascular Studies: • Dopplerography • Cerebral scintigram

Cranial ultrasound Cranial ultrasound

Cranial ultrasound Cranial ultrasound

Cranial ultrasound & CT scan Cranial ultrasound & CT scan

CT scan of the head CT scan of the head

US of scalp MRT US of scalp MRT

DIAGNOSTICS • • Other Tests: EEG Special sensory evaluation Retinal and ophthalmic examination Histologic DIAGNOSTICS • • Other Tests: EEG Special sensory evaluation Retinal and ophthalmic examination Histologic Findings: Parasagittal cerebral necrosis Status marmoratus: the basal ganglia, especially the caudate nucleus, putamen, and thalamus, demonstrate neuronal loss, gliosis, and hypermyelination, leading to a marble white discoloration of these regions. • Focal and multifocal ischemic brain necrosis • Periventricular leukomalacia

EEG EEG

Other Problems to be Considered: Brain tumors Developmental defects Infections Inherited metabolic disorders such Other Problems to be Considered: Brain tumors Developmental defects Infections Inherited metabolic disorders such as disorders of urea cyclase deficiency

Fetal Medical Care: – Magnesium sulphate – stimulate tocolysis – Vitamin K – Dexametazone Fetal Medical Care: – Magnesium sulphate – stimulate tocolysis – Vitamin K – Dexametazone – cerebral bleeding prophylaxis – Nootropil – prophylaxis of cerebral ischemia

Medical Care after birth: – The elements of supportive care as follows: • • Medical Care after birth: – The elements of supportive care as follows: • • • Maintain adequate ventilation, perfusion, and metabolic status Prevent hypoxia, hypercapnia, and hypocapnia; Maintain the blood gases and acid-base status in the physiological ranges including partial pressure of arterial oxygen (Pa. O 2), 80 -100 mm Hg; partial pressure of arterial carbon dioxide (Pa. CO 2), 35 -40 mm Hg; and p. H, 7. 35 -7. 45.

Maintaining of the blood gases Maintaining of the blood gases

Medical Care after birth: • The elements of supportive care as follows • Maintain Medical Care after birth: • The elements of supportive care as follows • Maintain the mean BP above 35 mm Hg. Dopamine or dobutamine can be used to maintain adequate cardiac output. • Fluid, electrolyte, and nutritional status should be monitored and corrected and adequate calories and proteins provided.

Medical Care after birth: • • Seizures should be treated with phenobarbital or lorazepam Medical Care after birth: • • Seizures should be treated with phenobarbital or lorazepam Surgical Care: In cases of posterior cranial fossa hematoma, surgical drainage may be lifesaving if no additional pathologies are present.

Neonatal Seizures Neonatal Seizures

OUTPATIENT REHABILITATION • • Cerebral protectors & stimulants Cerebrolysin, Tanakan, Piracetam, Pantogam, Nootropil, Cogitum, OUTPATIENT REHABILITATION • • Cerebral protectors & stimulants Cerebrolysin, Tanakan, Piracetam, Pantogam, Nootropil, Cogitum, Glycinum, Cortexinum Massage & physiotherapy Hydrotherapy Improving of myelination Vit B group

Massage & physiotherapy (dry pool ) Massage & physiotherapy (dry pool )

Treatment of the dominant syndrome • Motor dysfunctions – Mydocalm, Amisil • Muscle hypotension Treatment of the dominant syndrome • Motor dysfunctions – Mydocalm, Amisil • Muscle hypotension – Proserin, Sanguiritin, Dibasol • Seizures – Phenobarbital, Depakine, Convulex • Hydrocephalus – Diacarb, surgical correction

OUTPATIENT REHABILITATION Alternative medical care • • • Aromatherapy Music therapy Fetal brain tissues OUTPATIENT REHABILITATION Alternative medical care • • • Aromatherapy Music therapy Fetal brain tissues

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