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Delay of pre-natal fetation


In literature it is possible to meet a huge number of terms: "a delay of uterine development", "a pre-natal arrest of development", "small-for-date fetus", "a fruit retardation", "small to gestational age", etc. The heading P05 combines all terms stated above in MKB-10 the concept "the slowed-down growth and lack of food of a fruit".

The term "delay of pre-natal development" means the fruit pathology which resulted from influence of disturbing factors. ZVUR diagnose for the children having insufficient body weight at the birth in relation to their gestational age i.e. when body weight is lower than 10% центиля at this duration of gestation of mother and/or the morphological index of a maturity lags behind for 2 and more weeks true gestational age.

Disturbance of fetation is one of the most frequent reasons of decrease in adaptation of the newborn in the neonatal period, high incidence, disturbances of psychological development of the child. Perinatal mortality at ZVUR reaches 80–100%.

Symptoms of the Delay of pre-natal fetation:

Allocate three clinical options of ZVUR: hypotrophic, hypoplastic and dysplastic. Severity of hypoplastic option is determined by deficit of length of a body and a circle of the head in relation to gestation term: easy — deficit of 1,5-2 sigma, average — more than 2 and heavy — more than 3 sigma. Severity of dysplastic option is defined not so much by expressiveness of deficit of length of a body, how many existence and the nature of malformations, quantity and weight of stigmata of a dizembriogenez, a condition of TsNS, the nature of the disease which led to ZVUR.

In English-speaking literature instead of the term "hypotrophic option of ZVUR" use the concept "asymmetric ZVUR", and hypoplastic and dysplastic options combine the concept "symmetric ZVUR".

In the textbook of pediatrics M. V. Ehrman notes that 25% of cases, on asymmetric – 75% are the share of symmetric option of ZVUR. T. M. Dyomina and соавт. observed the following situation: 56,4% of newborns with ZVUR had hypotrophic option, 43,5% — hypoplastic. Interesting data are provided by I. O. Kelmanson: the different ratio of certain options of ZVUR is characteristic of different regions of the world. In developing countries from 67,5 to 79,1% of all cases it is the share of the ZVUR hypoplastic type while in industrially developed countries 20–40% are the share of hypoplastic option of ZVUR.

At hypoplastic option of ZVUR at children rather proportional reduction of all parameters of physical development — lower than 10% центиля — is observed at the corresponding gestational age. Look they in proportion put, but small. There can be single stigmata of a dizembriogenez (no more than 3-4). In the early neonatal period they are inclined to bystry cooling, development of polycythemic, hypoglycemic, giperbilirubinemichesky syndromes, respiratory frustration, stratification of an infection.

The dysplastic option of ZVUR usually is display of hereditary pathology (chromosomal or genomic anomalies) or generalized pre-natal infections, teratogenic influences. Typical manifestations of ZVUR of this option are malformations, disturbances of a constitution, dizembriogenetichesky stigmata. The clinical picture significantly depends on an etiology, but heavy neurologic frustration, exchange disturbances are, as a rule, typical, it is frequent — anemias, symptoms of an infection. At children with hypotrophic option of ZVUR body weight is reduced disproportionately in relation to growth and a circle of the head. The circle of the head and growth is closer to expected перцентилям for this gestational age, than body weight. These children have trophic disorders of skin (dry, wrinkled, shelled, pale, there can be cracks); the hypodermic fatty layer is thinned, and at heavy degree can be absent absolutely; turgor of fabrics is reduced considerably; the mass of muscles, especially buttock and femoral, is reduced; the circle of the head of the child on 3 and more than a cm exceeds a breast circle, seams wide, a big fontanel hollow, edges its pliable, soft.

Usually children with hypotrophic option of ZVUR are inclined to bigger loss of initial body weight and its slower recovery, is long to the keeping tranzitorny jaundice of newborns, slow healing of an umbilical wound after falling away of the funic rest.

Frequent development of complications is characteristic of children with ZVUR. At them asphyxia in labor owing to bad portability of a patrimonial stress often develops. Many newborns with ZVUR have the chronic pre-natal hypoxia leading to a thickening of unstriated muscles of small pulmonary arteries. Therefore newborns with ZVUR have high risk of development of a syndrome of persistent fetalis blood circulation. Often at such children the hypothermia is noted. Disturbance of thermal control at children with ZVUR is caused by reduced stocks of a hypodermic fatty layer. The polycythemic syndrome in the first days of life is observed at 10–15% of children with a small weight at the birth. At the same time the gematokritny number raises to 0,65 and more, and hemoglobin — to 220 g/l and more. Frequent symptoms of a polycythemia are preferential peripheral cherry cyanosis and other displays of heart failure, respiratory frustration, a hyperbilirubinemia, spasms, an oliguria. Also at newborns with ZVUR disturbance of metabolism of carbohydrates therefore they are predisposed to development of a hypoglycemia is noted. The hypothermia promotes aggravation of a hypoglycemia. At these children the hypocalcemia, a hypomagnesiemia can also take place.

Reasons of the Delay of pre-natal fetation:

Conditionally etiological factors leading to ZVUR can be divided into 4 groups. Maternal factors — the hypertension induced by pregnancy concern to the first group; an increase in weight less than 0,9 kg each 4 weeks (there is an accurate correlation between the body weight of mother, addition of weight during pregnancy and the mass of a fruit); lag in increase in height of standing of an uterine fundus (less than 4 cm for this gestational age); heart diseases (at women with rheumatic heart diseases of ZVUR of a fruit it is observed by 2,8 times more often than at healthy mothers); food shortcomings during pregnancy (sharp deficit of proteins, vitamins, zinc, selenium and other microelements); existence of addictions at mother — smoking (the pregnant women smoking more than 20 cigarettes a day have a gain of mass of a fruit on average 533 g less in comparison with non-smoking women), alcoholism (the daily use on average of 28,5 ml of alcohol before pregnancy and in its early terms reduces the mass of a fruit at the birth by 91 g, and the use of the same amount of alcohol in late durations of gestation leads to decrease in mass of a fruit by 160 g), drug addiction; short term between pregnancies (less than 2 years); polycarpous pregnancy (pregnancy by two and more fruits can be followed by fruit ZVUR in 15–50% of cases); young age of mother; diseases of cardiovascular system, kidneys and lungs at mother; hemoglobinopathies; a diabetes mellitus of the I type with vascular complications; obesity; diseases of connecting fabric; long sterile period; abortions in the anamnesis; the birth of children with ZVUR at the previous pregnancies; gestoses; reception of some medicines (antimetabolites of folic acid, beta-blockers, anticonvulsant drugs, anticoagulants of indirect action, tetracyclines, etc.). Negative influence on growth of a fruit of vibration, ultrasonic, production factors, overheatings, coolings, mental stresses is noted. A number of women origins of ZVUR of a fruit can have anomalies of the constitution, sexual and general infantility owing to inferiority of adaptation reactions of a maternal organism in response to the developing pregnancy.

Placental factors, i.e. the factors providing a fruit with adequate amount of nutrients concern to the second group of the factors leading to fruit ZVUR. It is first of all the insufficient mass and a surface of a placenta, its structural anomalies (heart attacks, calcification, fibrosis, a hemangioma, fibrinferments of vessels, a placentitis, etc.), placental detachment, placenta malformations (both primary, and secondary in relation to maternal pathology). Dependence between development and growth of a fruit and a growth inhibition of a pregnant uterus is noted. Some scientists claim that the fruit arrest of development during pregnancy depends on localization of a placenta. At low and average placement of a placenta in a uterus the frequency of premature births increases, and children who were born at this pathology have small body weight.

Carry social and biological factors to the third group — the low social and economic and educational level of mother; teenage age (primapara at the age of 15–17 years make group of high risk of emergence of ZVUR of a fruit); accommodation in the mountain area; twice ZVUR of a fruit meets in group of the pregnant women who are not married more often.

Hereditary factors — maternal and fruit genotypes concern to the last group. ZVUR of a fruit consider as one of characteristic features of trisomies on the 13, 18, 21 and other couples of chromosomes. Besides, at ZVUR a number of authors note a trisomy on the 22nd couple of autosomes, Shereshevsky's syndrome — Turner (45, HO), a triploidy, additional X-or Y-chromosomes.

Treatment of the Delay of pre-natal fetation:

The special attention needs to be given to nursing of children with ZVUR. Treatment and nursing of such children — rather expensive business demanding big financial expenses, high qualification of doctors and nurses, providing with the specialized help. However experience of economically developed countries shows that these expenses are not vain. On condition of the birth of such children and nursing them in the specialized well equipped perinatal centers the lethality in the first 7 days of life makes no more than 35%, and 54% among survivors have no serious effects.

Newborns from the symmetric ZVUR caused by the lowered growth potential usually have more adverse forecast while children from asymmetric ZVUR at whom the normal growth of a brain, as a rule, is kept have more favorable forecast. On the first year of life such children have considerably a bigger infectious index in comparison with healthy children. By prospective observations it is established that lag in physical development is observed almost at 60% of children, its disgarmonichnost — at 80%, a delay of rates of psychomotor development — at 42%, neurotic reactions — at 20%. Permanent severe damages of the central nervous system in the form of cerebral palsy, the progressing hydrocephaly, oligophrenias, etc. were noted at 12,6% of children. Such children 1,8 times more often have rickets, have pneumonia 3 times more often.

The remote effects of ZVUR began to be studied actively at the end of the last century. It is proved that at such children much more often than in population, neurologic frustration are noted low coefficient of intellectuality at school age. In the late eighties — the beginning of the 90th years there were works in which communication of ZVUR with development further, already at adult age, an idiopathic hypertensia, coronary heart disease, a diabetes mellitus is proved.

Thus, the problem of ZVUR remains urgent in modern medicine and owing to the social importance demands further researches in respect of studying of an etiology, a pathogeny, diagnosis, treatment and prevention of this pathology.

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