1. Priorities and challenges of perinatal and neonatal periods Prof
Priorities and challenges of perinatal and neonatal periods Prof. Karimjanov I.A.

2. Lecture
The purpose of the lecture - to acquaint students with intrauterine fetal hypoxia, asphyxia, neonatal encephalopathy
Objectives: - risk factors for fetal and newborn hypoxia  - Classification, clinical syndromes of encephalopathy in children - Diagnosis, treatment, prevention - Breastfeeding in children

3. Maternity and Childhood Protection
The Constitution of the RUz
The state program "For the younger generation," "Mother and Child“
Resolution of the Cabinet of Ministers № 242 from 2002 from 2009 № 1096 " On increasing the medical culture in a family run main lines, women's health, birth and raising a healthy generation "

4. The main objectives of Pediatrics
Work with healthy children
Creating optimal conditions for their growth and harmonious development
Development of preventive measures that increase the body's resistance to unfavorable influences

5. Achieving objectives will contribute to:
The study of anatomical and physiological characteristics of the child's body
Timely detection, treatment and prevention of disease
Reducing the mordibity of child
Reduce child mortality

6. Intrauterine asphixia
Perinatal asphixia of fetus - a pathological condition associated with oxygen deficiency during pregnancy and childbirth. This pathology is one of the most common of perinatal pathology and is one of the most frequent cause of perinatal morbidity (21-45%) in the structure of all perinatal pathology

7. Hypoxic-ishemic encephalopathy
pathology is a common complication of pregnancy and childbirth, and diagnosed in newborns up to 5% of cases.
Perinatal brain damage is more than 60% of the pathology of the nervous system in childhood, are directly involved in the development of diseases such as: - Cerebral palsy - Epilepsy minimal brain dysfunction

8. Risk Factors Mother's age (younger than 20 and older than 35 years)
Premature placental abruption
Placenta previa
Preeclampsia
Premature or late birth
Coloration of amniotic fluid with meconium
Prolonged dry period
Diabetes mothers
Any diseases of mother during pregnancy
Fetus potentially dangerous drugs
Ceser section (planned or emergency)
The use of forceps (акушерские щипцы)
Smoking or other drug addiction during pregnant

9. Newborn asphyxia - syndrome, characterized by the absence of breathing and the individual not regular, not effective in the presence of cardiac activity

10. Diagnostics
Assessment of the newborn in a number of parameters: Apgar score (1910)
Signs on the 0-1-2 system: state of the heart, respiratory, skin, muscle tone, reflex irritability
A perfect score 10, the rate of 8-10. distinguish between middle (6-5 points) and heavy(4-1 points) the degree of asphyxia. 0 points - a dead birth
The visual characteristics of neonatal asphyxia: blue asphyxia (6-5 p) white asphyxia(4-1 p)

11. The sequence of reanimation activities in asphyxia moderate:
Release of the respiratory tract (suction, pear).
Warming the child, MV(ИВЛ)
To the vessels in the umbilical cord is introduced: glucose 10%-5ml per 1 kg of weight, sodium bicarbonate 2-4 ml / kg of calcium gluconate 1ml/kg

12. The sequence of resustitation activities in asphyxia moderate:
restore patency of the upper respiratory tract
warming of the child
intubation, АV
I/V(В\В) products listed higher than 5mg/kg + hydrocortisone or prednisolone 1 mg / kg
if needed external cardiac massage
Reanimation of the newborn is terminated: 1.If the cardiac activity is not restored within 8-10 min. 2.If the heart efficiently, but breathing is not restored within 15-20 minutes. On mechanical ventilation.

13. suctioning of meconium
Visualizing the glottis and suctioning meconium from the trachea using a laryngoscope and endotracheal tube are demonstrated in this video. Lesson 5 provides details on endotracheal intubation. When using suction from the wall or from a pump, the suction pressure should be set so that, when the suction tubing is blocked, the negative pressure (vacuum) reads approximately 100 mm Hg. Monitor heart rate during this procedure.
Click on the image to play video

14. Clearing respiratory tract: no meconium
First, clear the mouth, then nose
"M" (Mouth) in the Latin alphabet is facing "N" (Nose)
As a rule, fairly short, light extraction
If no meconium is present, simply suction the mouth, then nose, with a bulb syringe. The mouth is suctioned before the nose to ensure that there is nothing for the newborn to aspirate if he or she should gasp when the nose is suctioned. If the newborn has copious secretions coming from the mouth, turn the head to the side so that secretions will collect in the cheek and be easily removed.
When you suction, particularly when using a catheter, be careful ot to suction vigorously or deeply. Stimulation of the posterior pharynx during the first few minutes after birth can produce a vagal response, causing severe bradycardia or apnea.
Click on the image to play video

15. Rating: breathing, heart rate, color
Making decisions and execution of actions in reanimation of newborns shall be based on assessment of respiration, heart rate and color
Evaluate vital signs to determine if further resuscitation is necessary.
Respirations: good chest movement with adequate rate and depth of respirations. (Gasping is ineffective.)
Heart rate: should be >100 bpm. Count beats in 6 seconds (eg, 7 beats), multiply by 10 (equals 70 bpm), and announce the actual heart rate.
Color: pink lips and pink trunk. (Central cyanosis indicates hypoxemia.)
Instructor Tip: Feel the umbilical pulse at every delivery so that you are skilled at this procedure. If you cannot palpate the pulse, use a stethoscope.
Click on the image to play video

16. Oxygen free-flow through tubes

17. Oxygen free flow through the mask

18. Oxygen free-flow through bag and mask

19. Indirect massage of heart: big fingers technique
Thumbs (big fingers) compress the sternum
Palm support your back
The thumb technique is accomplished by encircling the torso with both hands and placing the thumbs on the sternum and the fingers under the baby’s back, supporting the spine. The thumbs can be placed side by side or, on a small baby, one over the other.

20. Indirect massage of heart: two fingers technique of one hand
The tips of the middle and index (or nameless) finger compress the sternum
With the other hand supported back
Position the 2 fingers perpendicular to the chest, as shown, and press vertically with your fingertips.
When compressing the chest, only the 2 fingertips should rest on the chest. This gives the best control of the pressure applied to the sternum.
If you rest other portions of your hand on the chest, you can restrict chest expansion during ventilation and apply pressure to the vulnerable area of the chest, risking a pneumothorax or fractured ribs.

21. Indications for transfer to the NICU(ОИТН )
Birth weight <2500 grams
Gestational age <36 weeks
The presence of a newborn:
Infections
respiratory problems
Gastrointestinal problems
metabolic problems      (hypoglycemia)
Problems of the central nervous system (convulsions)
developmental anomalies
cardiovascular

22. Neonatal intensive care departament or chamber
Preventing GI
The use of disposable equipment;
Maintain cleanliness and order,  particularly careful treatment of the shells  and surfaces that come into contact with sterile materials;
Timely and qualitative processing equipment (incubators,Ambu bags, thermometers, etc.);
Do not pour in sink      hand washing remains the blood,      milk or milk formula      etc.;

24. Risk Factors
High-risk factor is the neonatal period, the period of adaptation to extrauterine conditions
Processes of respiration, circulation, selection performed with maximum intensity, rapidly growing body weight, renal failure and neuroendocrine regulation of metabolism of water causes dehydration
Transient deficiency of coagulation factors and increased vascular permeability leads to increased bleeding, acidosis

25. The neonatal period
Border states: physiological jaundice, mastitis, transient fever, the physiological weight loss, albuminuria, sexual crises, urine acid renal infarct
Diseases of the newborn period: viral hepatitis, cytomegaly, malaria, syphilis, toxoplasmosis, CDF(ВПР), birth injuries, cerebral hemocirculation violation, neonatal hemolytic and hemorrhagic disease , septic diseases

27. Anatomical and physiological features of the nervous system in children
Distinguish the central nervous system (consisting of the brain and spinal cord), peripheral and autonomic nervous system and their activities are coordinated by the cerebral cortex
Brain of newborn is big, functionally immature, and differentiation of its improvementis up to 20-25 years, the size of 400g, which is 1 / 8 of the body (adult 1 / 40), doubling the mass is at 9 months, tripling, to 3 years to 20 years increased by 4-5 times
In the hemispheres of the well-defined grooves and large gyrus, cortical cells, the nervecenters, striate body, the pyramidal paths are not well developed
Gray and white matter little differentiated, neural cortex cells have no processes, no myelinated

28. Anatomical and physiological features of the nervous system in children
Characterized by weakness and functional, the pulses from Intero and extero receptors cause a passive, long-term deceleration, so the children of the first months of life sleeping most of the time of day.
Basic life functions are regulated by the subcortical centers of the newborn thalamo-phaliodar system, which explains the unconscious, uncoordinated movements of the newborn

29. Spinal cord at birth 2-6 g to 5 years tripled, to 20 years and increases by 5-8 times. It is more perfect than the brain. Myelination antlers of spinal cord occurs in utero, mostly closed arc of innate unconditioned reflexes
The peripheral nervous system of a newborn is presented with rare, not enough myelinated (myelination 2-4 year) and uneven distribution of nerve fibers
The autonomic nervous system function in the newborn, sympathetic nodes merge into a powerful plexus, sympathicotonia is physiologic, replaced by a 3-4 year vagotonia

30. 3. Distinguish the following stages of morphological changes in the hypoxic brain:
Stage I - edematous-hemorrhagic, Stage II - encefal gliosis, Stage III - leukomalacia (necrosis) Stage IV - leukomalacia with hemorrhage.
4.The clinical picture of hypoxic encephalopathy divided into three periods - Acute (1st month of life) - Reduction (from 1 month to 1 year, and in immature  preterm infants under 2 years) - outcome

31. According To the stream
Light form
Moderate
Heavy
In the acute period allocate 5 clinical syndromes:
Increase of neuro-reflex excitability
Convulsive
Hypertension - hydrocephalic
Depression syndrome 
Comatose

32. The syndrome of increased neuro-reflex excitability.
- Spontaneous motor activity
- troubled - superficial sleep - Lengthening the period of active wakefulness - Difficulty falling asleep - Frequent crying unmotivated - Revitalization of unconditioned innate reflexes  - Muscle dystonia - Improvement of knee reflexes - Tremor of extremities and chin

33. Hypertension-hydrocephalic syndrome
- Increasing the size of the head of 1-2 sm compared with the norm (or the circumference of the chest) - Unlocking the sagittal suture over 0.5 sm - Increase and a bulging fontanelle large - Graefe symptom - A symptom of "sunset" - Intermittent horizontal nystagmus - Convergent squint

34. Depression syndrom Apathy Hypodynamy Reduction of spontaneous activity
The general muscle hypotonia
Hyporeflexia (decreased reflexes, sucking and swallowing)
Divergent and convergent squint
Nystagmus
Bulbar and pseudobulbar symptoms

35. Comatose syndrome
reaction to light a small or absent.
no response to painful stimuli.
"floating" movement of the eyeballs.
adynamia, severe lethargy.
hypotonia to atony.
innate reflexes are not detected.
pupils contracted.
horizontal and vertical nystagmus.
tendon reflexes were depressed.
Irregular breathing with frequent apnea bradycardia
low blood pressure.
Convulsive seizures may occur.
does not sulk and swallowing.

36. Convulsive syndrome
- In the acute stage is usually / combined with the syndrome of depression or comatose - Arises as a result of hypoxic brain edema -  - Hypomagnemy or intracranial hemorrhage  - Appears in the first days of life tonic-clonic or tonic convulsions  - Convulsions in neonates differ brevity of sudden onset  - The lack of regularity and repetition of the state of sleep or wakefulness  - Convulsions are observed in the small amplitude tremor guide short-term cessation of breathing  - Tonic spasm of the eyeballs by the type of paresis of gaze upwards  - Simulate the symptoms of "sunset" and nystagmus  - Convulsions, by its nature is sometimes reminiscent of spontaneous movements 

37. hypoxic encephalopathy syndromes include the following
The recovery period
hypoxic encephalopathy syndromes include the following
improvement of neuro-reflex excitability  
hypertension-hydrocephalic
  vegetative-visceral dysfunctions
  movement disorders
  psychomotor retardation

38. А. Syndrome increase the neuro-reflex excitability
During the recovery period has two      current version:
marked decrease or disappearance of symptoms of increased neuro-reflex excitability in a period of 4 - 6 months to 1 year.
In the worst case, especially in premature infants, may develop epileptic syndrome

39. B. Hypertension-hydrocephalic syndrome
Has two current version:
1) hypertension-hydrocephalic syndrome with favorable course, in which the disappearance of hypertensive symptoms, delay in hydrocephalic;
2) The worst case of hypertension- hydrocephalic syndrome occurring in organic symptom complex cerebral syndrome Outcomes of hypertension - hydrocephalic syndrome: 1. Normalization of growth in head circumference at  months. 2. Compensated hydrocephalic syndrome in 8 - 12 months. 3. The development of hydrocephalus

40. C. The syndrome of vegetative-visceral dysfunctions
Begins to emerge after 1-1.5 months of life on background of increased neuro-reflex excitability and hypertension - hydrocephalic syndrome. The clinical picture:
persistent regurgitation.
persistent hypotrophy.
violation of the respiratory rate and apnea.
discoloration of the skin, acrocyanosis.
paroxysmal tachycardia - and bradipnoe.
disorder of thermoregulation.
dysfunction of the gastrointestinal tract.
temporal alopecia.

41. D. Epileptic syndrome
Observed in generalized convulsive seizures (Tonic-clonic, clonic, tonic)
abortive
Focal
Hemi-convulsive
polymorphic convulsions
simple and complex absences. In terms of frequency, is dominated by polymorphic forms of convulsions.. Premature infants with perinatal encephalopathy and propulsive impulse paroxysms in isolation does not occur, and occur only in the polymorphic convulsions. The greatest difficulty in diagnosis are aborted and non-convulsive form of paroxysms

42. E. The syndrome of motor disorders
proceeds with muscular hypotonia or hypertonia.
When the syndrome of motor disorders with hypotonia there is a decrease of spontaneous motor activity.
suppression of tendon reflexes and innate unconditioned reflexes of newborns.
The increase in muscle hypertension in term infants, the emergence of multilateralism focal symptoms should alert in terms of development infantile cerebral paralysis.

43. Begins to manifest itself with 1 - 2 months
F. Psychomotor retardation syndrome
Begins to manifest itself with 1 - 2 months
violation of unconditional reduction innate reflexes
retention the formation of rectifying the labyrinth of chain tonic reflexes
to months of age there is not enough stable fixation
short-term follow up with the rapid depletion
unfavorable long-term mental retardation.

44. G. Psychomotor retardation syndrome
No reaction to his mother's voice, acoustic concentration
By 2 to 3 months of age there is insufficient recovery in communication, low-expressive cry, there is no "hoolin"
For half a year - are not actively interested in the toys and the surrounding objects, there is no active attention.
Age-related motor function are beginning to be compensated after 6-7 months and usually are restored to 1 - 1.5 years. Prognostically unfavorable long delay in psychomotor development

45. Diagnostics
In the study of ocular fundus in the acute period of moderately degree dilatated veins mark, edema, some hemorrhage. In Heavy degree damage on the background of edema, vasodilatation observed stushevannost border of the optic nerve, hemorrhage.

46. Neurosonography - two-dimensional ultrasonic research anatomical structures of the brain through a large fontanel - allows setting of periventricular hemorrhage,leukomalacia centers, expansion of the ventricular system - ventriculomegaly.
Signs of hypoplasia of the brain: an increase in subarachnoid space, the expansion ofthe interhemispheric gap, ventriculomegaly, increased density in the brain parenchymawithout clear differentiation of gyri

47. In the cerebrospinal fluid detected changes in the presence of intracranial hemorrhage.In these cases, the cerebrospinal fluid are fresh and leached red blood cells.
After 7 - 10 days of life confirmation the transferred hemorrhage is the presence of macrophages in the cerebrospinal fluid.

48. Electroencephalographic (EEG) study reveals centers of slow-wave activity, reduction centers of cortical rhythm, centers of epileptic activity.
EEG is used to allocate risk for convulsions and diagnosis of clinically "silent" attacks. An indirect confirmation of convulsive syndrome, as well as a sign of lowering the threshold of convulsive readiness of patients is the presence of paroxysmal EEG changes. Repeated convulsions can lead to increased expression of paroxysmal activity on EEG.

49. From biochemical researches in acute hypoxic disorders the depth indicator is assessment of a mixed acidosis to expressed decompensated, metabolic.
At heavy hypoxia increases the osmotic pressure of blood plasma, increased levels of lactate dehydrogenase.

50. Treatment of the acute period
1. Reduction of vascular permeability: 12.5% etamzilate solution intramuscularly or intravenously, 1% vikasol 0.1 ml / kg. 2. Metabolic and anti-oxidant therapy: piracetam 50 mg / kg, 10% glucose 10 ml / kg, ,Actovegin - intravenously, 5% vitamin E 0.1 ml per day. 3. Vascular Therapy: Vinpocetine 1mg/kg intravenously. 4. Dehydration therapy: 3-10 mg hydrocortisone / kg prednisolone 1 - 2 mg / kg, 25% magnesium sulfate 0.2 ml / kg. 5. Improvement of cardiac muscle tissue metabolism: cocarboxylase 8 mg / kg, ATP10 mg / kg. 6. Anticonvulsant therapy: diazepam 1mg/kg intramuscularly or intravenously, GHB, 50 mg / kg, barbiturates.

51. Treatment in the recovery period
1. Syndrome of increased excitability of the neuro-reflex manifestations of vegetative-visceral dysfunctions are shown sedative: Diazepam 0.001 g, 2 times a day, with citral mixture of 1 teaspoon 3 times a day. 2. When hypertension-hydrocephalic syndrome advisable to appoint furosemide 0, 002 g / kg per day with panangina, glycerol and 1 teaspoon 3 times a day. When expressed forms of hypertension-hydrocephalic syndrome diakarb is useful 0.02 g / kg per day once under the scheme: 3 days - reception, a 1 day of break, the course of3 weeks to 1 - 1.5 months, with panangina. 3. Syndrome of motor disorders: vitamin B6 5 mg, Vitamin B1 2 mg, 0.5 ml ATP  injections, piritinol 10 - 20 drops to 1 kg of body weight 2 times a day in the morning 1-3 months. Massage. Gymnastics, mothers are trained rehabilitation skills  4. At a syndrome of psychomotor retardation: Piracetam   mg / kg in 3 divided doses.

52. Safe and proper use of technology

53. proper technology The effectiveness and safety (DM)
Effectiveness and stability
Eligibility for both patient and healthcare workers

54. Being together mother and child, and kangaroo method are the appropriate technologies

55. Benefits of breastfeeding
Natural feeding - feeding infants breast milk, followed by supplemental feeding with 6 months
Breastfeeding the most physiologic of quantitative and qualitative composition and optimally cover all the needs of the child in proteins, fats, carbohydrates, vitamins, minerals, etc.

56. Benefits of breastfeeding
Breastmilk is dominated by fine dispersed proteins (albumins), cow's milk proteinscoarsely dispersed (casein) and protein is smaller than in cow's milk
Breast milk contains several times more polyunsaturated fatty acids and lipolysis in the stomach in children begins under the influence of breast milk lipase
Breast milk contains large amounts of carbohydrates (b-lactose) in the cow's milk is a-lactose. Lactose milk stimulates the growth of bifidobacteria.

57. Benefits of breastfeeding
Breast milk is rich in enzymes: amylase (100 times), trypsin, lipase (15 times). This compensates for the temporary low enzyme activity and provides digestibility 
The concentration of microelements, vitamins, enzymes in human breast milk is optimal and corresponds to the needs of the child
Breast milk is rich in immunoglobulins (A, G), contains the factors of specific and nonspecific resistance
Formed a psychological link between baby and mother, developed a sense of parenting

58. Reasons of hypogalactia
Later breastfeeding, a rare breastfeeding, reglementation of breastfeeding a technical approach to control the process of lactation disorder, hurrying
In case of insufficient lactation recommended frequent (2-2,5 hours, without night interval) feeding
The mother produced as much milk as a baby needs to feed to give both breasts to prevent lactostasis and to stimulate lactation 
Child with  breastfeeding  should not drink water, because breast milk to 80% water and therefore quench the thirst

59. Reasons of hypogalactia
Violation of the regime breastfeeding women (excessive physical and mental stress, lack of sleep disorders to diet, disease, age) reduces the lactation
Less likely to breast feed very young and elderly mother. In elderly is attributable to biological causes, the young - the social and psychological (absence family planning, casual birth, lack of spirit in breastfeeding) Incorrectly feeding techniques

60. Attaching to breast - view from aside
What difference do you see?
What difference do you see?
Infant in image1 attached to the breast correct
Infant in image2 attached to the breast incorrect
ENCBF PBF 5 RUS-ppt Reviewed 31 May 2002

61. Constraining factors of the production of breast milk (inhibitors)
Inhibitor in breast milk
If the chest not emptied milk secretion stops
inhibitor
ENCBF PBF 5 RUS-ppt Reviewed 31 May 2002

62. Regulation secretion of milk in the mammary gland
Inhibitor of lactation in breastmilk synthesized by  stagnation of milk in the ducts
Synthesis and secretion are regulated by extension alveolar cells
ENCBF PBF 5 RUS-ppt Reviewed 31 May 2002

63. Factors that increase formation and excretion the mother's milk
Convince the mother to the ability of breast-feeding her baby
Eliminate the disturbing state of the mother
The mother should sit down and try to express her milk
Before pumping it is desirable to lay the child on the mother's abdomen

64. Factors that increase formation and excretion the mother's milk
It is recommended to drink hot milk and tea to keep warm in the chest, pinch the tips of the breast
You can do a back massage along the spine
Massage the breast before feeding (longitudinal movement from the base of glands to the nipple)
Nicotinic acid, vitamin E, UFL, UHF, ultrasound, herbal medicine

65. Thank you for your attention