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  • Tratat de Pediatrie (Mircea Maiorescu) Vol 5, Bucuresti, 1986

    Enviado por

    Gabriela Manolescu
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    tratat, pediatrie, mircea maiorescu

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    tratat, pediatrie, mircea maiorescu

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    9 visualizações552 páginas

    Tratat de Pediatrie (Mircea Maiorescu) Vol 5, Bucuresti, 1986

    Enviado por

    Gabriela Manolescu
    tratat, pediatrie, mircea maiorescu

    Direitos autorais:

    © All Rights Reserved
    Baixe no formato PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    de 552

    F{,tel

    Sub redactla
    Frof. dr. MIRCEA,,
    MAIORESCU

    TRATAT
    DE
    peoratrre {t t .

    VOL"

    Introducere in genetic&
    Nou-nascutul
    Boll cardiovasculare

    ln cola|orcre cu:
    rit"t(iBN cloFu, IoN ItrARIN DIMBHAN{.I, coI{srANTA
    DRAGOMIR,BRADU FOTIADE,ICON'STANTA{ACOB,IVALERITI
    IONEscu, MARIANA IIARoRnnscu, NIC0I.AE SERAFTM,
    MINCIA STAMATE

    nDITIIRAnAnUlCRtAe
    BUCUftngTI,
    ress
    Lisla co[aboratofilor

    ri l

    I fil , r *h r 1 , # w" $
    :r'ffi, CIOFU EUGEN,docior 1n $tiinle medicole,nredicprimor pediotru, gef
    de lucrdri IMF, Clinicode Pediotrie.InsjitutulpenlruOcrofireoMomei
    9i Copilului,Buc,.tregti
    DTMBEANUION MARIN, nredicprimor, pediofru,geful seclieide No&"
    ndsculi,SpitolulClinicde Femei,,Giule9ti", Bucuregti
    DRAGOMIRCONSIANTA, doctor in gtiinle medicele, medic primor
    T pediotru,osisteniuniversilqrlMF, Clinico de Pediotrie,Institutulpenlru
    OcrolireoMqmei gi Copilului,Bucuregti
    FOTIADEBRADU,docfor in Stiinle medicote,ge{ de lucrdri lMF, leful
    Depo*omenfuluide explordri funclionoie,medic primor, Spr'c'ul iiinic
    ,,Fundeni",Bucuretti
    TACOBCONSTANTA,doctor in $tiiole medicole, medic prirnor pe-
    dlotru, tef de sectie, lnstifdul pentru Ocrotireq Momei 9i Copilului
    Bucuresti
    TONESCU VAIERIU,doctor in giiinle medicole,medic primor cordiolog
    lq Instiiutulde Fiziologienormold 9i Potologicd,Spitolul ,,Filontropio",
    Bucuretli
    MAIORESCUMIRCEA,doctor in gfiinle medicole,prof. dr', geful Cli-
    nicii de PediotrieIMF, q SpitoluluiClinic de Copii ol Municipiului
    Bucuregii
    &TARDARESCU MARIANA"dsistenl universilsr,Disciplino de Fonnoco-
    logie lMF, Bucuregti
    SERAFIMNlcOtAE, doctor in $tiinle rnedicole,medic primor pediolru
    lo InstitutulpenfruOcrotireoMomei 5i Copilului,Bucuregti
    SIAMAIE MIRCEA,docior In 9tiinle medicole,medic primor pediqlru,
    olistent universitqrlMF. Clinicq de Pedioirie,Inslitutul penlru Ocro.
    tireo Mqmei 9i Copilului,Bucuregti.

    l^ ,r'
    l. IN'j'[]OnU{lAnE lN GllNnfi{i.{ - {onstanta I{eob, t{treoa Mqlorcscu

    Pag.
    ], 1. Scurt istodc i11 Seoetica rrmnri
    I.2. ractorii geDetici
    1.2. l Frogran ul geactic qormal : 26
    I .1.2. l l aze l e mol ec darc al c c x l ri ntl ri i geueti c e 26
    1...1.1.l . S l ruL,ura ,.rdul ui ,l c s ox i ri bon,k l ei c (A D N ) 26
    l .l .l ... t'odu l ger,et;c
    l .2.2.'1. ceDa
    t.2.1.J. l . Srruc r ur.- ts enc i
    1.2.1.J.2. {'arrc 1' r,rl s egmc D rar ..rJgeoei . 3t
    1.2.2.3 J. Jjc D ol l rer,ul,l e repc rar,. s i -,,mobrl i trtei ,' genel or . 36
    i .?.2.J.4, M c ti l area eerel or
    r.z.r, ::rnl .rJ Ftorernc ,of
    l .l . i . t. Tt.l l n s rri P r;x 37
    1.2 3.2. l-rars111;sia 39
    1.2.3.3. I'roducerea 39
    _ -l
    2.3.4. R nglarea s i ntez c ; protc i c e ,tI
    1.2.4. Il ol i rnorfi s nrul B eromuJ ui
    /. r..:r. r'efnri l nF nl r m.c aj uhi geD eti c 15
    1.2.6,_l i rori .aJc l rogramul ui i mui ati -tF geneti (er 1a
    B c oeti c
    r.z.o.r. rrpur] c l e rD uraFr E enetl c e . 45
    L2.7.,'l ransr)litcrea eredjtar6 a genopatiilor 16
    1.2.7. l . .qnor ruLJ j jmorrogeni c e . , 41
    1.2.7. L L frtrl rs ' rdrc rc a arl os omal rec es i v A . 4E
    1,2,7. 1,2.'l'ransmiterca autosomal dominantE, 49
    1,2,7.1,3, 1'ransmiterea recesive legdtd, de eromosomul X . 5l
    1.2,7.1.{. Eredjtatea, clomjladta legata de, crornosomul tt .
    1,2,7.1,5. l i rerl j trtea tegatl dc c romos omul y
    , -1.2,7,1,6.Mut:Itri i tc tal e
    1.2,7.1, l :rcdj ri tc i r pol i gc nj c e ti rrul Lj { f,c l orj :rl e ,1
    l .2.l t. l i fcdi tatc r S i s i s tc nrul H LA 56
    l.l.0. (;cnelalogia hr intemcti.ulea eleditate-ruediu 60
    LJ. ('r.)rnosoD i i fi nr)oD ri tl i i l e l or . . d0
    1..].1. S tndj rl l .moto$ol l i l or l n j ntc oz fr 62
    1.3,2.-51 dj$) orofiosorrlllor tn jio}I) ] !l1itoz.ej (c0riotiDul) 6,1
    1,3.1.l , (i ui otl prl 1[rfi [ rr)rnrt) 64
    L l 2 , l . l . ( 'l u r i l i i n r o 6,',t
    _t _ l.ut.
    \ ,,1 1 ,/,1 r !:lr , r i r t ( .r ,) r r r 1J.ii) r r r ilL' r ' 6r j 1.5.'1. -,lrron)!rlii llonosonice Fi arornalii ale dilereltierii sexuir-te l1$
    ';rl r)]|
    l ,l \,r.rl r',l L rl rl l l :r slr lr i lr r r ill r r l cfontu) Dtr l|lo 6t- l.-5.-4.
    l. lrcrmula XY/]iX .
    j.5.4.2. T'btmda X/XY (45Xl46Xl) 110
    l l rrl r i i ( , I L() rI I r I I r1r 6l i
    sau disgeielia gonadjc; nri)rtil {ill nrs:aic) 116
    r, rr,,,rr.rl i i r[ r ,lr uif. f3
    \ r!,n ,rl i i {l ,i str( 01r f, 60 1.6. ..l,rolnaljile genetice ti canceill 116
    l , l li ( r l o t i r r ! r x ) x r l iilo f cr o r n o so n liio r - E4
    E5 1.?. Gercpatii tisrrare (hjsroclisplazijle) ll8
    I t i r t l l r r r s l i r r r l r ! r ( )r tu r liiJo f cr o ln o so ln ;lDf j.7. 1. ltecarjsne de proLlucere
    L i I , . 1 . I rr( I i (,rI i i j t| , c ir r io tip r lL r i 3S llE
    39 1 . 7 .l . l . l {'. r o .l i sp l r ,,i i p r j n {,* .t .'n r , p r i n i r I th
    I l . I 'rrr r1, r ' I I r L r L , , r l r u I li .i c cr o m o so m ;1 o r :a u to str ln a ll 1.7.j -, P,istodisplazi;cu rlecr aenic secDndar I?0
    I | | I ' LL ' l , , , t l i r q , r r l r r L l u i .\ ( cf.r r n o so r r ljj l, 2 , l 9i] 1.7.Li. Il:siodjsphzjj cu r{cct genic te4iar 120
    I | -l l' . rr ! i , u i i r i l u r t , r L i t d ll ( o fo m o so n lij ( 4 . 5 1 , 90
    | | . ' I \ r , , | l r i , l i i ; r L r ' c r ,) r lr o so r 1 ]r lu iI 90 !.3, D;sriortolog;a l :0
    . 1 i L l i ( l . 1 i l L l , f r ' 1 u l j scu r t ( sin d r o ir u i 4 !- r . . 9t) tr.3.tr. l-]jstrlgeljle l2l
    |'. .,11.f . i. . l l i i s o l l r i , r l n i r l ,u ] i scu r :t ( tr - jso m ia i f,: 92 X.8,2. ileJorua jile 121
    I I : 1.I \ , , , , I r i r l i i r L l r c r c rn o so m u lli 5 . 92 1.8.3, Maljornralijle (modod;spjazijlc) 12?,
    I 4 . l . l l . l ) r ' l ( , l l r i ) f 1 ' 1 tr ]r ds.u ft { sir td r o r ll l .t!r - - se lr n al adi a ,,mi e1r1ra''nhi'13
    i 1.S .3.l . Frec renl a ti epi denrrol oE j a al { ornl al i :i l or
    l,isilii") 92 I S .3.2. E ti ^loS i e m.l { orn]al i i .,; ,o;l getl i l ate 124
    I . 1. , r . l . ' l i : r o r l r j i , .l , f r lu lu j s.r r r r ( tr jso m ir , 5 p ) 9Z (
    1.E .i .1.1. enz e pndogel e
    t24
    i ' l . l l'. , r, ' l < , r l i r g L f u p t r l u i C { cfo | r | ,r o L n ii a lr to so tlili 6 - 1 2 ;i cro1nD soi rsl tl 1 i.8,3.1.2. Ca.uzeetogene . . 126
    | , 1. . 1l. l f i : r o n l j a c l o r u o so m r n 1 tl ? 91 1.E.3.3.latogenia malfor]na!;ijor 129
    I l. 1. 11 .l r l s o r u i i r l ) f a f u l L d scu r t a l cr o ln o so :n ,r lu i 9 { $ jso tni :L 9 p} 94
    l, l. i i. I ) L l ( 1 i l , f l l r l n i l r u g a l cr o 1 1 ]o so lr r lr i 9 ( si.d r o r n r l 9 q-i !5 1,9. Aronlaijile genetice in bolile aatdjovasculare . , . . . 130
    1. , 1.I I l ) i , l . l i i r " l ) l r t r j u i s cu r i a ] cr o n o so m llu i 9 { sild r o m uf 9 p-l 95 ! 10. lrar$acogenetica,
    I 1t . 5. \ r u r n l l i r l c c r o m o so m u lu i 1 0 9-t 130
    I 1. . 1. (' \ r j r ) r ) r l i i r l . . . r o mo so ln r llu j 1 1 9t5 i,11. ?re..7erireabolilor genetice
    | . . 1. . l7. A L r { r r n r j i i : r l cc r L ' n r o so m r ld 1 2 . 96
    96 Ltr 1.1. Consdiatia genetidl t:t'e
    l . '1. ' 1. l' , L 1 ' l L ) i l ;qr r L r r ) n l r i D ( cr o m o so tr r ij 1 :1 , 1 ' 1 . 1 5 ) 1.11.1.1. Col.ulta]ia gsneti*i retrospectiv:i
    | 4, 1 L l f i n , l n i r 1 3 ( s j r dr o r l Pa ta d 96 " 135
    1.11.1.f. Consultalia geneti.i, proslective l 4t)
    1. 4 . 1. . 1 .I ) 1 , r f l i r 1 , r l t l r l t l Jo 1 lg { sin d lo m u l 1 3 ,i- j 99
    1.11.2.Dagrosticql preratal
    | ' 1. 1. I l r ; s o r r t i r o r - o o L o s.tn u lu i 1 4 . 99 14r
    1.11.2.1. Indica-liile diagnosricrlui Feratal l 4l
    L l I . I 'rrr , , i o t i r r ,g f u p u l l j E ( cr o m o so m ji 1 6 , 1 ;' 1 3 ) 99
    99 1.11.2.2. I,IetoCele de diagnostic plenatal 744
    I . 1. : ).l. I f i s 0 l l r i . L L r r . r r L ost' ]lu 1 lli 1 3 ( sin d r o m u l ld li- a r d s) 1,12. liataDrentnl. !o1i)or- geaetice
    1. 1. 5. : r.l ) ( 1 , 1 ; r !c r o m o s o mtlu j 1 8 ( sln d r o m u l 1 3 q - ) . i {1 1 150
    1, , 1, 5. . 1S. j n l l r o r r x L l 1 3 p - 102 f. i2,1. Trataneltul preratal 150
    l. ' l, J . l. S i r ( L r o u , 1 l 1 3 r ' , se u cr o m o so n 1 8 i1 1 e lsL ^: . .... . . 102 1.tr2.?, Traaamentnl postnatal . 150
    I . 4(r l',r ( o l o g j a g r u p L r ) uj Ii ( cir m o so r n ij 1 9 ,2 L ll - :..... i02
    i.13, Ingine a geretica 1i1
    I l. / , lr. rr , , l , t . t i i Lg ' i r p ' i t n ; i; ( cfo m o so tn ji :L u to so d ii!' r 3i i.? 2 5 1 crornosornui T) 1( Z ...t
    I l / I l r i . , r i , . t : 1 um r ' r i jl ( - . tr ' tr r l :) o \' li- ' r<1*l 1.13.1.Tehnologia lecombi!5rii ADl.i 15,t
    r. r. . , . I F - , . r : , i i i n c :L ll , L r mono\ori i G 1.13.2, Aplicaliile inginedei geretice 154
    - f i . -f,r .' ln ..ilF . 1.13.2.1.Sirieza de medicar}1eDte 155
    I .1.;, r ir {;nia (:rrlnosomniui 22 (sindlon:; Schlilidt-Fraccaro sau sirdro$rul
    I , . 1 ( , i ! r n r t l a t r czio a n :L li,) 1A7 1.13.2.1.n. Sintezainsulitreintrlane 155
    1.13,2,1,2,Sirteza horEionului de creFtere t57
    1 . \ , , , )l| r, 1 ] 1 r . r. . r l , n i , s t j r n i l o r sc\$ a lj 109 1.13,2.i,3. Sinleza de irteri€ron x5 5
    1 1. 1. ( li,i l i l j L r , , 1!9 1,13,2.1,{.Si teza de {actcri antihemo{ilici . . 1-59
    1 , . r. r\ r, r i r i l i i t ' f i r ( 1 , , / i i rf;ed e la Jo r ln | lla ' t6 XKla fe d e ie 109 1.13.2.1.i, Sinteza de factori ce iniervin in sistemul iibriiolilic 159
    l. 'j. l I \ j L , , r i r i r l i ; i L L ,r n 1 1 [Arin { o r m ]:la 4 tj !X. 109 1.13,2,1,6,Si teza de alla-1'antitrjpsina 160
    Ll. lll : l i r r l r l ) L 1 1 u l t dp Jo ) i 109 l.li.?,:, EJrbo'ar.cade vac"ir,u:i 160
    1. 1.' 1 . . / , . \ 1 i c t , ( ) l i s o m ij d o tip n l' 1 8 XXXX.4 ! IiXXXX 109 1.13,2.3. Probe de ADN pentru diagrosticul pre- ti postnatal 10t
    l. ), .1.L i. Sirx Lro|lr ql '.1'!rrnci sa1llrlonosomia }i (15 \) sindromul XO. nonosornia n.13.2.4.hcbe de ADN pentru diagEosticareaageolilor irleclioli 161
    , , / . , I i . .r . . r 118 tr.13.3, Tehnologja articorpilor 101
    ' 'Iro$oclonali
    X.13.3.t. Aplicalii ale antjcorpilor n1oiroclorali 16')
    t . lj, l. I L N t o t r i , ; n r - i X / \x, X/Xxx, XIXS/1 _ X} ; 113
    1. 5 -1. . 1 .A r , , L r u ! l i i , l ( : s l fr lr jtflr .l i,13.{. Gene grelate la aEimal 1a:
    I : j. r, , \ r r l l r L l j j 1 , r i l l c l , , r i | .1 iccL rJr
    : { o l1 n r ]a ' 1 6 ]it ia b iib a t . . . , 11i l]ibliogratie
    | 'r. 1.l. l r r r , r | t r r l i i l . ] j i r i ( f ( 1 c cfo n lo so m u l X
    l. ' ). I . I. l l i i l L l l r ' n n L l l (li ( ,l, l1 o r IXK\l) 2- l\lOU-N.nSCUl'UL- Mi.cea Maloloscu, lon-Marln Dlmb.atru
    r. | , \ t . , t"r.-.,,. 115
    2. 1. I'crioada dezvolterii inhautedne 161
    " .5 I l . l , l , i i r l ) ' { i l .
    "1. \\ 1[5
    l: 1. 1. 2 \ r , , r r r l , i l l , , r fo r r r o ii,r r r r lr r i \' . 11,1.1.Pcrioada embrionare t6 t
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    ' . 1. . i. I l . l ) . 2 / , t l : r f ( i r l {u n cjici r o n a l,:l ttr .'. '.1 '. ( ,.urj u' rl |i . :).t.:
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    2.1'"rr.t,ri
    .i. l,l-':l,r1r(:!r1l:rpcrr.trrjui !espirator_ 214
    \ , l. rr)lrLI i i r r r r r - | l : ! s r : r r t l l u i 1 :r wia la e \lr d lltcl' i ai \-__-/ 1.1r.1. lix!rLerlrl ap.Lr-a1ul i (iar.iiovascnlar 215
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    i fi l - (,:'. l ; nul 220
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    r, \ { lir t ) l : r f l i r l t r L n o l o sic:r trt J)0
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    . l. | : rrl , ) r i ( l ( r i s c c e p r cccd i sa r cin a . . . _ -! ' ro \j l .-
    'i . l rLLt o r i r l c f i s c p r o z c n li itl tim p u l sa r cin ii l Ett . I.l . \, z or t" , , rr f ; l i l ' j . t25
    ' ' t il, rl 1 , f i , t ( . r i s c c e a c fio n e a zij in tin p u l n a ttcr ii i8!' :.:i . l . l . N , o i r" , r. ^ ri . t i L c ll5
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    ',r ' r tu l 'rtr,.,t .'.E. 1. . \r ',c-, r' rrl .1. lj':^i1n; . 227
    ' , . l r, l , , l r . ' . . i l , / , o L . L lu lu ^ i.L h ip o .{ ici ' l )l 1.3.1.i . r \r :c c s a rrl d c h i t l ra f i de c a rb o n 12,\
    I ' . l, ; rr 1 r i , i l i c u l h i p o x j ei 19:'i :..i'i 1.5, Sair:uririrrerrb fi ouiioele]rrentc -t2t;
    I i li, i I i r r r r . I n o t r - n nscr ttfu i 191 .'.\.1.6. \l tal ri l r 22')
    ' I i L S , , ) ^ , r L 1 . r r r l o n e Tte lo r d e r e a n isr a r e 195 : S-2. IlilDcntr4itL crlo!:llil 230
    f 'l. i. l. ( i)l| n cinlc]e ii prognosticul hipoxiei ]a tastere - 1q7 ) r.l l . .\l i r..nrrri .r l a .i n 230
    l l. ( ,,r'tnicr(;ilo hiooxiei nconatalc (si11dromul poshs{irric) tlrt Lrt:.1. .\6 r' r^a' :t!,, .,1 l ,i L"!o rul 235
    ' . 1 , lii 1 , 1 , c ( , , r . r t i | l rt8 i .i l .-. i . .\l i r rc r.,r' 1r., 1' ,i r,; r:tj 2t5
    f,.8.2.4. AU cri.llia continu;r pd'l so da nasoga,st ci. . 23(r
    . lrirl'1| r i r l i $ r r l c i ct [ c c i ] n i c c la la tte r e 199 23(t
    2.11.2.5. Atirncntaljtr cor*inBi, nasoiejunale . -
    :" I t.)
    ' l. 1. ,/ i , . t , i , 1 1 i l o r 'n lo i. -1.8.2.6. Frcparatc dc lapte {olosite irr a]imentatia prematurului ::i..'u
    'j. r. | ,,/inr)ik: cnnierre ;i crorliocerebrale ?.00 ..r..1- \l i ,,r,, . !j " Frr^nr, ral L -J
    ' ,. l.l. ll^()elrloldtia traum.ltidL obstetricali, 200
    .l.;.1,.lbsrl soros;r. guin:1 200 I !|. 'I' llrrutri dc crostere Fi dez?oltare . . /24it
    '
    , 'i. | | ll,,-nr.,,,flrul 200
    2\11 _ 'r . I LtJ ',;l i r ^ , , , f s r. i , r. s l i rl i o t rc J F 2J:i
    '. ' . ' 1. I l , , r l l , r a g i r n r a siv:! su b a p o n e .,,:t o tici. r ,
    24'
    l'...,,lrliil( L L .i e le 2ul 1.9. 1.1. Tchnica slabilirii vilstei gesta-tionale
    '. jl. 9. 1.2, 247
    ' ' l. {r. l r f r r : l l l l i l o o r l s c l of fe } e i ( m a r d ib u l5 , o a se n a za le . maxi Jar) 202 "ilprccierea virstei gestafjoEalc dupA
    2.9. 1.3. Aprecierea virstei gesta-liorale dupd, !rerrologict 2,1li
    ' I i,r.,rl, , rrl" c ztJ2,
    ' ). I I r)r i l l L r i i ( i i f u , u r r r : r t j cece r vic..le ti a ]e ce I1 iu lii sca p r lare '" 1 . 4 . t u tr cl e d c c.cfl ( r e i n l r a u l cr i D i 250
    2U2
    '' 'i. l. 1 . , , r r r L l u , /L u l5 2\,2 il. ). l\-c,n t ! i,rir^ l.J (J:''
    ' ). l. ' l ' , L r i r l i z i i l , : r t c p Je r b r a h ia l ?"1)3 2.9.?.1. Ca,tegorii de prernalrrj 254
    l. ' ) i. l . l . I ' r f r l i r i A d e pie x b r a h ia l su p e r io r ( Er b - D1 1 cildnne) 20i 1,9.2.2. 'l'rogrostic ti c"3,uze do dsces la prema,tu. ?J5
    , ' 1 1l. 1 . l ' , L r i r J i z i o d e?lc: b r a h ia l in { e io r ( d e tip l{ lu r n pke) 203 -.ir.-..t. l .^ /.ni-ea pr.enr.Fdririlii J55
    ' '. ' . , . . , i i r r . L l c n c r r r | e n ic 214 2.9,2.4.'I'rata11-lcntulprctiJactic al pre$aturiior .)56
    I i. I l,{,i/iufiilo rnu$ciriului sternoc]eidomastoidian (to*icolisul muscular') 204 ,1.9,2.5-CorDplicatijle prenralurjtiil1l 25(t
    . r l. lf r , L r L r I i s m c l c c o l o a n ci ve r te b r a le 205 , . r 1 6 , ( f i r( r j i l .cn r r u e xtcr r r r e 251!
    '' . 1 1, , : r ' i r r r r i J ro:r i t r [ r o ] o r a b { io llin a le . - . 206 pismatlritratea 25S
    '. , . l. | , . ' . r , i l . l r 1 , rir ^ 206 -i,9.3, C-opilnl ll1ic petrtm virsta gestaliodalA. 'r5!)
    ,/.rr.L l. ComJi orprtlui drsmrlurulDi
    ' , 'i. . l i ' . , | | r . . J . . : . l , l i| i 206 'rilia :51)
    . . r . : r . : . l j j i o i u sj a Ji sm 6 r u r j tSl j i
    ' , '; . 1 1 ,, , , , . t r i , , . s I t , ' .r f, n cli 206 :160
    . l'. 1. , i 207 ^1.9.3.3,Aspcctul cliric r-l dis attrxlai .
    ' , i l , , r ' r , r l , , ' tl ,r f '.rr 3.4. ifJj rrrr..nr[1rlismaruritirlii :th.l
    , , , , r 1 . , r , , L l , r ,,.,- r ii llr u lu i 20"/ .l.r).4. (ipilnl rilarc pcntru -rilsta gestatjonal5 '-lt' 1
    '' I \
    '' L, )l r / ' l r : , r ' r ' r r ' r , ) J. ?08 ..',r).J. I)0!tma1.uriti,l!a . :0 4
    'r, llrt , r, . ) , i . , 1 :1{)li ..s
    "

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    | 1r6. I,lg.

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    ,1 , r,: j. l. ( l , r n l r ( r r r . : t l x r s l t r r lr t! r tiilii ( ( [1 l,r i Clifto r d ) patibilitale lth '
    165 j , 11,1.-:.1, ,r oi l rJ lrdfr6litict
    2,-11',{.ITilloala l l c mol ttc a prin
    o n inco
    r L. . ' . .
    ,) .(). J , 1, . I I I I t I ! l I r c | | t 2.11,4.2.2.llorlDe ctinice de boalA hemoliticE, prin incompatibilitate Rt! '
    265
    .1r , , (), l'f rt ; | l r ) s l ; r i ( L r n ) u - r l : ! s o r tL r lr i { iu g !cu ta ie in ic:l 2.11,4,2,3, lloa.la hemolidce pdn incompatibilitate ABO .
    .l l (r liir f , : i rLr Lr L l r l l i p l i r '-256'-' 2,11.4.2.4,'Ir€,tar:r,errtulbolii hemolitice a nou-nescuhrlui
    2.11.4.2.5, L]le cauze (rnai rate) de icter neonalel ' 34t.-
    .. l l .
    26E t"11,4.3, trsrijirea gererale a nou-ni,scutuhi icteiic . 342
    l); rlr)l(, g i ( fu c o l l a k r l S ,
    2. 1L,4,4, lct er $l ii,zi.ologic 54.i
    L lll. llol r l ( f a p . [ a t u l u i r esF ila to r . 2,11.4.5. lliperbilirubinemia prin inhibitori din laptel€ matero ' . 34t.
    ,l I L l. L l)('if(:sa lespiratorje idiopatigl(Boa.1?, merllbtanei hialine I{M}f1
    2. 11.{.6, SindronulLnce_v-Ddscoll 34[
    ,r.I L l.r. si-,( t{)ll,;fri-ft G;6ffi e licbiduiui pulmonar let:tl-- " 2,11.5. Singele;i coagularea 3 {l
    21'5
    .1.I l, 1..1. Sirt{lrcr1rrll de aspiialie pullnorar,. 2 . 1 1 . 5 , 1 .A n e i a 3-tI
    27 8l
    ,f . ll. 1. 11. I l r c u r o i a c o n g e n ita lS " 2J9 2. 11.5,2. $ocul hipol.olemic 316
    ,1.I t,1.5, lr,d(jrtllrt tllrnoriar, hemoragjc (hemo€gia pulmonarS) .
    : 279 2.11.5,3. Policitemia - sindronri de hiperconcentratie saoguina 34S
    ,1.I l.l,(,. (;iizolc di apnee ale premaiurului (apCeea idiopaticd' a nou-niscutulti)
    2,11.5.4. Tulbur:irile de coagulare ;i bollle hemcragice 34lt
    ,1.I L, 1,7, ll{,ala pulmJlari cron"ici a prematuruhi (lrrsrL{icicnla prtltrronara croticir 2. 11.5.4.1. Coagulotatii congenitale 449
    2S0
    ll Frerrratuftr]ui) 2.11.5.4.2.Coagtlopatii dobindite 349
    .1.I l.l,fi. l'ricunotora:.u1 ti pneu1]lo cdiastinui
    28r
    232 2. 11.5.4.3.Trombocitoperua 35'J
    , 1.I i. l. ! ). ( ) x i g e u o t c r a ? i a l a r o - n a scu t 2, 11.5.4.4.Trombocitopatiile . 35{
    ,/,,l l. l,!, l, fiibroplazia retrolentala
    3S2
    253 2. 11,6. Tulbtlbli ale :Lparatului urogenital
    ,1.I l.l.l0. Vcntil:4ia. p€ masce cu pompa manu:tia de tip 'qI$JU ' 2.11.6.1. Tnsuficierla reralar acuta .i5.{
    .1.I L l, I l, Vcrrtilafia :!sistat:! 233
    2A3 2. 11.6.2. Anbiguitatea genitale la nou-lescut 35s
    l ' r c s i u n e a co ltin u e a CP' \P 2. 11.6.2.1. Pseudober-malroditismnlfeminin . 360
    -'. . 11. 1, 1 2 . ? o z itivA 2ttf
    ,1,I l. l.l.l. \rcrrtilaiia artiliciai:t 2. 11.6.2.2,Pseudoherma{roditismul m:r"sculirr . 360
    , 1.1 1,l. 14 . t I ( u b a i , i a t r a h ee l:I 23i
    '(entilili 2,11.6.2.3. Anomalii ale diferen-lielii se:.uale . . 360
    .l l l, l. 14.l, lrrierp,:ct.Lrea tczdtatelor dozS.rilor de gaze ia nou_ndscrit11l 2. 11.6.2.4.Ciptorhidismul . 360
    2Es
    artiticial
    2,33 2.11.6.2.5. TEtame tnl nou-nascutuhi cu organe g€:dtale anbigue , 360
    .' ll. , l, llt i l c c l | i d i a c e 2. 11.7. Infeclia neonataE 361
    ,1.II.2, i, I)ii .lnosticul cardopatiilor congenitale 294 2.11.7.1. Rol uI c ol os trul ui s i al l apLel u m,rtern in cretterc!, rezistertei la in{eclii 361
    .'. I l.;1,2. l,.xplor':!d palaclinice 295
    in ]]elioada neora,tale
    . 1.I l. ll. il. ( : i i u r o z t ! l r e o n a l .L J:l 297 :;6:
    2.11.7.2. Fa;torii etrologici ai idecliei reotiatale
    .' ll.,l.'1. ( irr(lioiotii specilice perioadei neonable care !.ecesitd' diagnostic de 2.11.7.3. Rotul lactorilor ma.terni ln 1nlectia neonetala 362
    303
    llf*ofl1ir.
    303 2.11"7.4. Aln lactori favodzanti ai infectS,rii neonatale 362
    ,', | 1.2,4. l. :tlnr$pozitia atterelol i1al1 . . . 2.11.7.5. Evaluarea metodelor pa@clitrce de diagnostic in ilfeclia deooatale 361
    2. ll. ; 1.' 1 . . 1 (. i i i l c t a l j a d e a o r te
    30{ 364
    2. 11,7.6. In{ecfia intrautcdna
    /,. I1.2,4,:], Sindroniul cordului sting hipoplazia . ' ' '
    305 2.11.7.6.1. Idectia cn virllsul citomegalic 35{L,
    2. | 1.2.4,-r', lloli pdmare iocatdice
    3oj l . 11,7.b.2. Inj -ec 1i a tul ,eol i c a
    . 1.I l. / . . . 1 . I r g ' . r l c l e ( r r d r o r u g i, e
    . , ' , ll 2.5 . l . l l i - . r f i ( i , n L n L r r d ir ca
    307 2. 1i .7.6.i . Tox oD l ai rnoz 3 ronec
    :.11.7.ur. fiGf, ia-SFipFtrc;
    ni rc l e
    *!frc
    rpix sinrplex- T1Sv)
    W,I
    1 ' , ] | l'l. 5'2 . , | . u l i J l l r ; | | i I c d e t i |r n d r d ja (
    309 35S
    ' cu detrestr tespiratorrc
    ,1.tt I5.-]. l,cfsisterlra c.,najuLui artedal la prernatulul 36E
    310
    idioplltici(nembrana hialini) C/'o,
    ;1.I l. ;1.5. 4, Sindromtri persistenfei circula{iei'f etale (37t)
    7, I l. ; 1 . 5 . 5 . S o c u l c a r d i o g e n
    314
    2.1!.7.9. 't1+
    ; 1,I 1, 2 . 5 , 4 . I ' r{ cL r l o p e r i ca r d u l
    i15
    2,| .7.n. cu streptococ B 3 ;6
    ;1.11.2.6.(llrinrLUiacardiacS"
    1a no -n;,scut . . . 2.11.7.| L cu Escherichia coli tip I{1 :'i7
    315
    .,ll. ; 1, lt r l '
    '\,r,j,r
    r l ' . a t e r r d ctu lu i o ;8 e slj
    3t5
    2.11,7.1 2. cu Listena monocytogeneJ
    , 1,I 1. . 1,| , \ : i i f s i , t u r i l e
    319
    2.11.7.13. urinari 3'17
    . 1.I l : 1. 1 . A t r c z i l t d c c s o { a g 2.11.7.14. 377
    , 1.I 1, . 1, . 1 .l i s t l r l a c s o - t r a h e a la 320 f,.11 7,15. Inl ec l i i c 11tana.te
    .1.I 1..1,4. ()l,struclii congerdtale alc tractului digestiv
    52r 2 . I i . 7 . l r i . C o n j u n ci /i r a
    . 1. 1I . ll 5 . A | r c z i a $ i s t e n o za in te stil1 a la 2, 11.7.17. tr{oniliaza (mug€t) 379
    : 1,I l, : J . ( ' , i U n l r o t a l i l l i n l e s tin u lld j . 1 1 . 7 . 's. U n r ta ,l ;1 r 37tJ
    . 1,I l. : 1, 7 . l l c u s L l l r u e c o r Lia l. . 2. 11,7,1r. Di.lrcca e!;dcmic:. a nod-nescutului (Enterita) :r8(l
    ;1,I l.:],8. X'hlodi:r llirschsprung
    322
    L 11.1.. 10. fr c rrnnr i r
    322 a i nl ec ti i l or s c -
    ; 1,I l, : i, 9 . l t r l b | ] r l . I i i i l e a r o te cta le 2.11.7.:1. i r' aotol -i { av oi z anl i s i l nl j l oac e de c onbatere
    '' , ll. . i. l ( , . L r p " . , l i t ) r ; r i l r ir m c.o n r r ln i cluldarc in serriciile de not-.r:lsouti :ltt.l
    '(ilirnidl(ii :;8:]
    .1,I l.:1. 11. l,it)sr" scfttnclor de dranlitie ?. 1 1.7.2.1. Lnurmentul infecJiilor nou-nb,scrtnlui
    I . I l. : 1.1 2 . ( : L r u z o( l c o b d o fiIcn scir fo id .l t Li i . l i ,l l n,r"' |ri c n(l oc dfl c :j8{
    , . 1,I 1, . ! .I l . l i r t c f o r x r , i l ; r ( It,N ) Ll l .tl .t. r \l r,rIi l i c nri al c s c c fc l i ei l ror,rorl rl l i i ti foi di l l n l i l l D c i i r S rav i dI fi
    .1 .! l. 'l llL U . r l , i , i r r l ) i n ( l r t t i a' r {| l(
    icrr )(r)rrlrl|lir
    r r tir 327 l.r rr,' u n.' L. ut i3.t
    : 1, | 1. 4, 1 , l ' l r r r r ' f l l r r q r r " l i :lrr ilr :r l) ilir r r l) lr Iir n ir lf i' l0 1 r r l r r r t| lcl r
    327
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    .ilil; . l/"
    .i b(i
    :t3l . 47tl
    .156 . 17],
    . tt I
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    387 tt,t
    i67 Iti T
    i90 lNiI
    :i90 -1ri ;f
    :)97 i o7
    391 5i )7
    !01 5{ 7
    -10i 5L7
    t0i i l\
    10,1 .i ttt
    {0 5 ilt
    404 5l i
    4l I cafllil)":tsrhLali illi.{,{'rr
    411 .52{}
    416 52(l
    521|
    ,.i1{; 5.i I
    4t7 -tJ.r
    . 4t9
    . 421 5J 5
    . 422 5.lr'
    . 422
    . 123 .5.17
    . ,123 5t.l
    . 423 J tl
    . 424 5l . i
    . 424 544
    . 424 5-1t1
    . 426 ll.llbiiogr.a{ic s.']ocliv.-l 5.5o
    - 426 i.2.7. Catetcrisrrul cardiac si au8iooardiogra{ia - IJrirniu lrotin{is i50
    i .2.7. l . I L ori , 550
    . ,132 3.2.7.2. lndicatiile catrtelisrrEtlri cardiac i5l
    .4y r.2.-. l . (
    . 433 ^nt|-:nJ i .d!j i -tJI
    .1.2.7.,1.Irci dentc S i ac c i dc nte 5-5?-
    . J35n 3.2.7.5. Iteaciii la angioglafie 55.i
    . Aif ' J.2.7.6.'JeLn i c a 5.'ii;
    , 440 3.2.7.6. 1. S orrdfl e dc c atc l c ri :i rl .t5;l
    14] i1.2.7.6.2. Irrtroducero.r sondei 55r
    44t {.2.7.^. \. -\1,, r.rr.rr
    -55tt
    441 t 2 7./;. l . 0j 1 qj ri r.i l ,ol I j l rl l l uj 55r'
    441 3.2.7.7. -lt clictl catctedsmului carCiac . :)-)/
    1.2.-.\. l i . /-l ri r^ c ohl i nD r, rr;r, , r.,;,; In .J r.. 5.5S
    F p e r in a till; '
    .. 1t . l\ rlo r l r r l i t r t e o .1 l c o t a r . ' ia li! 446 3.2.7.9- Calculul parametf ib! Lemodirarnici 5().;
    .'. 11, nslxrL,tf pdholoqi rx: privind relatia dintr€ rnetlic ;i pirir'gi in perio'dr reorl.l,irali {50 J.i .7. 10. l rr:i o.,rrui ogrdl i , 57()
    I l : l, lirrlit ufi c 4.54 i.2.7.10. 1. Aspectul de;troglamei norm:L1c 5'7tl
    i.2.7. 10.2. Aspectul 1e'rogramci nor'riale 51),
    A .,, rror,tt;nrtttttlv,ls{:rtlAnr 3.2.7. 10,3. Calcr]luL vohrmelor yentriculului s tx rg 57:i
    r. t, '\l)rn-(hr( N rlia.guo:rii,.:rr]r1i.nlililuj cu boslii de oord - Ilireea Maiorelcu. Mfua€ll 3.2.7. 11. -\specic hernol]ilalnicc patologi.r 575
    s l! lml l l c ri i 6.,, ti ^ 5 /5
    l. l, l. A l r x r r r r r c / i l 458 :1.i. ]]oli congenitalc - lIir{rea }Iniora5ou, Ilirrea Stltnullo 5'77
    L l. ll. I l l l r n r t r r l ( l i r r r ' r tl1 [cr ili 460 .i.3. l. lncidenli, 577
    J . 1, . i. 'l i r s l c ( I ( I r r I r ' / - , I ' ,I r le r r r iin it in ( lr r d n to g jr | ( !liitlr tcf' 475 :i ..j .2. .D ti ol ogi e 519
    )Il , li. , | , irlit ' I n I r r l r r i r . 475 .'1.3.:.1. Fac tori c l i D l ot{ i c i Ji i 9
    :1.i ..1. N oti rl ]i (l c { i rl rl ni ol ,)gi , ,,ri .i 90
    l4
    1.t,

    I
    l'ag.
    r.. l , . t .l . \ j , 1 1 , , 1r i ( . -ji] ..
    J96 3.4.1.1, :l 'r { 01{ (j
    I i i .r. rri l mi i l ar 7) \
    . i i . , 1 , . 1 ,l l r r L , r l i r i | )r i, t( .tir li 5g1 11.4.1.4.:l l ti ol ogi c 'l!l
    ll.. i . - l . i i . l l , , r o s t i r zil| ( iir tr r tl| ,to r if icl.a ]f! J99
    .l .1,-.,,i1.ft]r,rliti(lrri {:r"rrlioviLsculiu.e neon:rtale . lJ,4.2. ( J:rsilicare a , l ()
    j. j j . , 1 . 5 , i t r l r r c t i ' r r rio c.r ,Id icir 5gg .1.4.i. Diagroslic
    r r e o tla .ia id 602
    i. j . . l 6 S i r i , l r o l r . n l 3.{.3.1. Aritrnii prin tultuinri :n torrna.rea ilnprlsntui 7. n)
    fe r siste r r ie i cir .cd a - tie i { e ta le 602 3.{.3.2. Aritmii prin tulbur6ri ir conducerea in?nlsurilcrr
    ll i r. (hritir.rc -- ttirccn trIrrinrescu lfiftca Stamate ;1-l
    602 3.C.i.3. Disocia.tia atdo-yeDtricqlar:,
    .i..;.5-1. (ll.rsilicarca" anatornic.l a tr[,C.C, ; r(l
    Fi ana]iza secvea.liali, a corclului . . 6A2 l ._t.i .4. S indr, muI de prc e' } , i l J l i e \ ei .tri !,rl g"a
    i. : ; . j . f . ( t . r s r l i L f i L a lizr o p a to to g icd , a M .C.C. ?01
    610 J.{.4. I r.rl a mc r
    r. : i . 5 . . 1 .( l c s i l i c . | c , r clir ice a ]\L C.C. tr'.i
    612 3.4.4.1- Clasificalea substanlelor
    i.:i.(,. ( Nrdioprrtii oonsenit-a.le cr ciaroTr, - llireea ltaioleseu,
    Mileea Stalnate, .
    aritiari,rnlice .itrl
    612 3.{.4.2, 1 armacologia cUnicl a lldn.jpa]elor i7l\I
    : i. :; . ( i . l , ( i a r o z a aDljaritltie
    612_ 3.4.{.:1. -q'.itudi11ea pr?ctica in tratamentul prjrcipalelor lullnrriri
    '
    F ,, l,'; l,'t,,f. l o l r a J:t lo t . . - _ /^A ) dej riirn .!r-{jiac
    -
    |, -.." :rffiffr r o r u r r e ............ :.::.'.'..'.'.'.t# la copil . -7.1
    l:'l:,:. \, n ccm p r ica lii 624 ',N o
    I
    l1l.ra)ncnr 624
    .1.3.6.:1. Sleloz.r pnlmorlar:, cr sep,. iDtel.Tentricular intaet (Trilogia Faltct) . . . 625 (;\tJ
    . 1. i . ( i 4 . 1 ] n c h i u l ar tcr ia l co n } !! 6),7
    F- r.i. , , s . ' t r , , : t o, , il i trrl e r,.rri /.* ...:.:' ,' ,affi B i Ll i osraIi e s deLri r t. i llr
    r ',, s:f-nt5;1;-.-"6;;-;; ,,.r.i 7as-(l)-,ranspozilia). . . :: : :'.63;'
    I l fanspozrlLa 3.6, Bolilc orioccrdului - llircca Slam$fe. ll;rsca lllaioreseu rt)o )
    ( corertJti z llradlor ./ase (Lrtranspozilia)
    -_. I l(l.rtz.
    'i..i.(;.6. " " . . 6{l
    Mala(lia libsteii 642 3.6. l, lliocoldopalia hjpeltrofic:! prisliti?.], obst rctiyA l, r-l
    1..i.6.7.
    -\tlozia tdcuspidianir 647 .1.".1.I. \l i oc rrdop.rri j l Lj p.r".ari "c r dl Ii ,j ,- neobs rruc ri ,e ;9 1
    -i. 116 ... lri""r'-,i] in im ii ,r r r r e i 652 1.6.2. 1l i u,.,r r' uj .rri i ,oJ l g.,' ' " .]I)1,
    i /. t.,rdia!a1ii cofi8enitalc f;_r6 cianoze sa1 cu cjanoz5 minorb, (slrrrri stfnga_ 3,6.3. Ilio(xlrdopalii residcti?c -/\7
    ( l f c a p t l L d o n d D an t) - n lir e e a } Iflio r cse E, lllir e e a S ta& rl te ,....,.. 656 3.f).3,1, jiibrocjasioza eldoniocar.lic; prilnitiy6, .]t7
    { ; . '7 . l . r r r J} :j,()..1.2. Il()rma contractat; de fibroelasiozt endo8iocardici, sigrgi :{,,{
    I| ' : :.'...,. " e l , . L r u l " e DL ,l
    ; . l * fuf.rc.L
    i r "Jrrs=yr''.
    ep J r ' r e. Lr r . Li. r
    :. : : : : : : : : : : : : : . . , .
    : : : : "651 )
    Sit 3,6.3,11, .iribroclostoza endorniocardice ierdocardita iibropla-€i:ic5, Ijlfiler)
    ()-4.
    .
    . . \t),1
    r nr . , . u s h, , ,t s l i n g a - d r e l ! 1 ay n j n j m s a u :1. Itiorlfditclc acrte x05
    rr.o ,l-i.. ; i t . r r d , ' ' oJ jlic - * r r eli. r en1- c l o 1
    r i ple.iuniior J,u:momre - 3.().5. lliof rdopaLii inetabolire
    I _.. 065 st0
    3.(t.5.1. (;Ji(r()genoz e j\,l 0
    \- ., I.riatl r ur m o ) r . L { DSV Sr dp, !J J _a; i 11 b ) , . - . . J.(r.5.2. l \l n c opol i z ahaddoz e ti l f,
    'll;,'{;L'l*!alt4e"1'
    . ., i . / , ; . 1 . o n - l o , o t,r fr l.r ^ d e ..!JI:r t( io - 7 F
    1;;,.--..
    -gig_ 3-6.5.3. J)i s l j poi doz c
    3.0.5.4. Alte tullufrd
    l\ l'-'
    tr i.1 l rrr . . . . melabolice l i l .l
    l r o f l n F t c p r fti::e .d ^ ,.r :a l d r r io - /e n ,fi.u l 3.6.6. Miocrrdopatii degeneraiive ri l .i
    . ,
    \ . ]
    1..l l
    / .
    . ,
    { t
    . l . p ,6Z0-
    ^
    I r , . . \ r s r F F t l . . , -\079) :t. l r,i'. l. ]-1oii clcgener ative ale pan.rea.suhi |j ,J
    "J,r .r tfltu i :_ g t -
    I .r r ' { - i. I ; hlF ; i- l ;i :;L fl = n .,i u rrd ia pr-Lnrrur.
    .L rL c ri ir . . .:::: Xj il.(r,6.2. Distroliile musculare progicsire . , . . s 1.l
    t i il1:,r. J. .Lncliderca inlirz,:.rd a canatuld arterial la iou_n!,scurulJa termen 6B3 .l ('.0.1. 1 fcrcdoLlegcrcrescenta, spiEo-cerebeloasA, Friedreich r^t4
    J ersrstc4a dclrnrtlva a canllului artelial .1.( Ii
    | '. 1. 1
    t.l.l q l-",e .le .anat arter"ial asociate co hipertetsiune
    684 ',1'..1. r onri l l o/e tl 4
    pullllon&re . ilg6 I o. /. Sirtlror rl de ischemie miorardici ta slgar . li l4
    I .l
    u8u l l i l )l !4i 11'{i (} fit0
    -,;!i;l Jii,',iii"T"1ll;",:";,;,;
    JrLo.lulrno'
    i,,a","".,io;;";t;;;;;;, u"r""*,i"n*o, l. / l,l,,lil(f l,( rirLudului - llir€ea Maioleseu, Constanla Ihagomir, t!l { ,
    n
    ---_
    '. ). / . { ' . - l n l o r r c e r e o ..cn o r sa p n lm o n a r 5 a n o r m a lS,
    , 6S 0
    1.\ . / . o . r . J n t o s r c e re a vcn o cs; p u ln lo r a r e a r o r m a la total e l .'/. l . l l .' i ( [rr l i t{ :t ilill)
    690
    I.lloarcerca.venoasJ luJnroaard anormali parliat5, (Lv.p..f:p,) 695 .i ,7. L l , l l ri ( x di ta l ermati s ai d, l{?4
    . ::,..J.6.3. .
    " .1.7.1,f,,l 'or i oardi ta purul erti 820
    r':iltll):si$iiis,ll't I'i : : : : : : : : : : : : : : : : : : : : :,33i
    -1.1.1.f,,. f,larrrr€srcrrctnlce r: sugar q00
    ,1,7,1..1. I l, ir:arditer aout5, virale (idiopatici)
    .],7, L.l. lt,ricardita tuberculoase
    8:]q
    ti!7
    I1-
    3.3.ti,1,2. f,{ani{estlri ciidce la copi}ul ma:e . . . . . . _-q\Z .1.? 1.5, 1,,:' i (r' i l i ra .u J l Ti germerri li2r'{
    .17. 1.h, I'(!i (:x r' (ti 1a rr LoJ i l c A enFr.rl e lJ2l(
    :t,7. 1,7, l'cfi(:ardita constrictiv-tr It]9
    1. 1.3.i, l. .1)e\tropor'iria cardiac, sa1! de:trocardia extrirsec!, qlz .1.7.1. l(ovllrsrtrul pericardic cronio idiopatic ti30
    3.3,1i.3.2..Dcrtror.ot:rtja sa dextiocardia prin dextroyersie . . , . : : . , . U\3 ,1,7..1.I I rcuI n ol nj ri c ardul 830
    i],:l.ti.:;.:].Sitrs irr.rersus. . . . .. - - 1713 ,1,'/.4, I l (1r()por.i c atd!1 8,]t
    . Schr',llit,pontru abordarea diagnosticului cardiopatiilor congenitale . 714 .1,?J. S i 'xl l un l rrl pos l puri c ardotomi c 83t
    ?.|, -
    d! 11- . t q\ . 1ly:i ! . . ." . .. .. . . .. .., . .. " . v16 | 7 t'. M l fi ru rl i i tori c c r.di c c tJSt
    ,{:irrilo ,tc ritm crrdicc -- t{h.cea Maioreser,NiconaeSeraffifrE66i3iiiaiif,---yf9-- l .?.(r,l . A pl u z i i c orgc ni tl rl e al c pc ri c arc l uhri 631
    4, l, I'r(r( i .7.0.2. l )rv' .rtj c U l i i pc l i u l rl rrl rri It33
    ,lc r ir m ca ld isc . ?20
    . ] . 4. 1 , 1 . . \ r r r r , , r U i r r) i l riit.n ,Uiir 1 ij$ u h r i n o d a l 3. ?,(r.3. ( hi $tc l o ttc rrrpori c ardi c e 8J.,
    ti a cS,ilorde conducere .
    : 1. J . l.? . l : 1 , r o f i z i , , l ( u io .
    ':l 122 l l l l 1l i ofirx fi r xo l ({ j ti y ai 833
    l0
    l' u.
    'I. I.l .
    \ llv Jol .i !ti i tc r(rr ri ttrs rnl ,l Lrr()rrirc -.- lllir'reir lll iolcs(u, ltluc! tlotu 9fi.)
    .i.l.l. I, Inslficicnla itrat:! (,85
    .1.12"2.Stenoza mitrala 9t)
    I, 12.3.-lnsuficicnfe aorticir, l00o
    .1.12.{.Sterora aordca . , 1005
    Lil,s. lnsuiicienla '.ftl,rei tric[spidc 100r,
    l.l^1.6. Stcrloza valvei tricrs,pide 1007
    i.12.7. t,lsuficienta -/al7ci puluoDarc . 100?
    E 5l
    , . r l. S ir i rl r l o l n a t o l o g i e . J.12.$. Skxloza ./iitvci lu]morare t()07
    i I r' . r)i i L e r o s t r c l 9i lliLtiosm.fir sclcctiyi, t00i
    tt60
    { f i. , '. 'lri l t * l r r . r L t
    r.':irJii"-tttr paiogellic (meciicarrrertos sau licmodjnapi") " " - ' 86? 3.13. Sirr(lrorhl prolapsului .ralvci mitrale - illirce.{ j}:taioreseu,Eu0cn CloXo. , . i00b
    '.i.1. 870
    i. \ . 7. : . ' l r r l t a e r r t u l c t io ]o g lc Itibliosraficneiecljvir
    883 ,. l0t.l
    t. .. I,rogtostio'l
    88'l
    rl,l r,,,gr,"iil'.,':""ii'a J, 14. l:lipcrlclrsilrrea arterialtr pulmoDari, (HAP) - }{irecr ltraioDcaou,(,{rns[alru
    /+i1 l eolr. . l 0 tl
    i,' trr$uti(i(.Ia c.rrcliacn (I sulicier,ta cardiacd. co{gestit-;t) - rUircert lttdotescu {885,,
    .;.14,1, H_ilert(r$inrlca artelja.ln pulmonarS, cserli.ali (prin:itiv:! sau lrimarr)
    cardraci(I C') 885
    I a"i;;ilil;iiG"n1i ( 991 ( l r A p E) . 1016
    1,r,1.l) ('lL,,r1re " 88B ''1.14.2.I"Iilrertersitnea pull]lono,rA blpoxici, , 101i\i
    I ir. i. lit i d o 8 i e - L lliltjogrLrfie se]ectivb, . 1019
    I . r/ . { . liizi o p o t o l o g l e
    909 I,lj. Ateriosclcrozt!- rlliri3ca lfalorescu, Conrl
    I i,.5. Monilcst5d clilrce: senne F sirnptoqle la nra$omir l0l9
    ; ,,('. il;il; faracrinicc ?1t
    919 3.1.5,L!] jFtlipoproteinemiile . 1021
    ru.;, rii,ig'i;fi".li diterediai 3,15,2, Ia.ctbri de risc coronarinn t02{
    , ,),\. tfirtitrnc L 2?l) 3.15,3.Prolilaxia tt)27
    r.,r,). l,r'(4rrrostic 941
    942 1,1.t,4. 'ftatamentul lBedicanlerltos ; 10:19
    t.r).I{), orBarIrzare lJibliografie selcctiyi , t0l0
    t:!,
    llr l, liirgrx { i c sselectivt
    llrl,li.grx{ic electivt
    :llfllo tcr cu ' llitce r Sl arnnte ' ' ' l, 16. I:lipcLlonsiunea sistemicd - Mireoa lll:rioresplr, (;{}Irstaqta f]]ra{omif 1030
    ' llr. SrLr ) r l . . t d i r t r s p i i t r o r - [llr r o n ' W
    'l 16.1.Hjpcrtcnsiunea artedald de glarli'fa (la tineri) .. 103$
    . . t rr. l. t ; t i t a t o ; e n i c ; i d ia g n o sL i, clin ic ' / X ;i \
    aA
    i trl 1 Ir,r,,nr.nf
    ].lf),2, l{ipertcnsiunea neonatali 1039
    r n P l i c i l i i t i u n jr ir e :L r cs' r j' if:!r ' i
    .1,16.3.ltratnrnent
    lrr. . ] . (i
    |, , ,,, \ )w,r,l-r\,!lu ;l ; :1,16,{, Urgertele de liperle&siulre arteriallr Ja copii (oire}e de bipertensiuDe)
    I ilrlioglafio $clectlvi.
    10{6
    axticular acui - lll!ge!! llaiolesour lliltliogLlfie selectivx. . 10{9
    reumatlsmul
    949
    in boli Si sindroame cli'rerse - rl{ircoa &liri{lrcscu,
    949 10{9
    950
    951 1049,
    05ri 1049
    1050
    1050
    959 1050
    105r
    c@
    961
    r0r2
    1053
    1.Ll,2.l. )ipidomiologj. 963 JOJ3,
    964 1053
    964 t 0J3
    .r,ii.f,f. nvofutia ti prognosbicrlcorditei rerrnatismale' ' s 969 105{
    l. l1.2.6. (joroo& SYLloultam 970
    97r r05J
    11,2,7.lixomouo do lobor4tor
    :t.lt.z,'1, 972 1055
    J. 1!.2.7,1. Dovacl inlactiei stloptococico dnteflotr,e 973 rort
    r 112 t 2 Alto
    .1,t1,2,7.2, altA cxor$or1o
    ora.rnnnsde lo,borotor ' .
    ilo lLrborotor ,
    973 10r6
    t. I [,2,8, Dio8[astio
    ll.l[,2,8, l)oritiv {i drloro$Il{u
    ttiocnosirio loritiv diloro$li{d ' ' ' '
    971 l0r6
    t.11,2,0. Tfothmont 981
    ,1,11.!,10.Pro6lottic . I
    1. 11. 2.1 1,llro lll&xto . "lt
    982 1057
    " 10r9"
    984
    Itllrlloflollo roldolhln .
    1q,
    1B
    I'u8-.
    ' l/ ' . ll I r',1,,\,,riri r,:1, n r lr t,I{ r r ir ,,Ir Iir Ir |( livc,,r c t0 61
    l/ . 11. i . | , , | , t )| ,: | | i r , r (:' lr r L l .l,, f.r 1 iil( ) r { f,r ir o s( ,r i| xlD si :r si !1droarl r.i of pol i msl -
    l0 62
    . l/ . 1 r. S l r r r l r o u r r r c t r ) l i rL r llir lu r ;r tiv( ]
    , . l7. li, l i r ) r l , f i , ) l e 1 r , f a l i i i!, cx{ zi o lr r o scL ltX..
    1063
    i06,1
    I. INTRODUCERE
    iN GENETICA
    I r,L, li,)itf .r l ; . : s c l . ( t i r r i i064 CoNSTANIA |ACOB, MTRCEAMA|ORESCU
    1.l:i. li,lr i1l,r r;rrcl.rr -- ]Iiraea illaioreseu, lle]llilniita Oriiron r 106{
    , . lli. l- l l r i i L r i ' r l l o f l n i r t i/e a lc va se jo r 106.1
    l. ls . [ : . I r , r , r l . : , r . , r F 1064
    ^ ,- lo 3
    ; . 151. 1 . l ) i s p l l z i i x r g i ox) e t a se ve to xse ( h € r u to m u : sax hcmmgi ol rrl 1'encs) 1066
    i lf i 1 r . l l a l l o r i r a l i i l i n ]1 3 iice . 106E
    i. 11. 1.. 1 .l , i r r l a r g i o a m e - . . 1070
    I lfi.:1. lirlr ./:rsculare remrl{ormatj7e 1071
    I . ls . : 1.[ . , \ D e l ' r i s n e e or tice 1071
    i. lS.i.l. \'.isculite irnure (angeite recrozentei 1012
    i. I tl.'j..r.,llo:lla Ka$asalii (sindrol]} adenomncocqtanitl rc74
    l. liJ ;1.-1.ljolile vascrllare arteiosclelotice . 107-i
    l. I lJ..l.li. Sindromul oilostatic 107,-
    I llJ.:.i;. lschcmie acuti. a unlli rnen1brr.: . 107-i
    i. lti.:.i. .irlcbi'te1c rnembrelot t0?6 1.1.SCURTISTORIC
    iN GENEIICAUMANA
    l. lU. : . ! \ h r i c e l e m e n br e io r 701t-
    ,. lli.:i- i[1bu1tri vasomotorii a]e ertremitefiloi 1073 (ir.rr,liLrr rlofiniLiica stiinli" a eredititii provine
    de la cur.intul grcccsc
    i. I ll. : i 1 . , \ c r . r s i n d r o a m e l.a slq 1 a r e p e r m tn e ir te 1078 t ri)i,r), t'.\r. irscaurni a lta iagtere, den"miil foloiitJ pentru pnm.r tla.irr
    i.'fi. i.- :\orosindroame 1,:rscLrlareparodtic€ 1o'79 ,1, \\r. ll.rlL.sonla cca de a treia coaferin{ii internationili de iibridal,r
    I r l, li, , qr, r i r , s e l e c t i y i 1031 si
    ,rrrr'IrolrrI'r rLplantclor de 1a Londrain 19d6.
    t l, l(, : r, ' i,- ! r : f i . . 1052 f'r'irrrr"lr. lcgi alc ereditilii (cuvint provenit clin latinescul heretliIus,
    ,,,. irll: 1lr l i . 1081 ' rnoitonirc) au fosr descopcrltein Jg65 dn Greeor Mend,.l si
    .r,i.irrjr:'
    , ' , r. . i ,1,i .r.1,. concoffirenJ;i indcpcndcntir 1909 de irci boiani;ti:
    . llLg,,
    ' i' \ r rr.. r r ( )ialda, C. Correusin Germania si E. Tscherrnackin Austr_ia_
    | .1', .,r,r ri...r'opcririlofultcrioarojntcresinclg"n". cromo.omii. murrtiil,,
    ,",.r ,l,rrr.ril 5i sintcza-gcnelor p,rin proceseiehnologicecomplic-tc
    c!,1irr,
    I ttr, , r, / , rrr,lrci-r,au indreptilit afirma-tiadupi care genetica-este
    ,,,'lrrlrrr .rl XX-lca. Pinil ia'aceasti fbrmuiir", .".""ut"J[ -prodtrs[l
    valoai'casliirr
    lrlr, ,r , rrroyiin{c'lor modcrne despre geneza;i evolulia viefii, au {ost'insii
    . r. ir(lrrrrli.ri inense de obseivafii ccrietdri ..." =" Ji"id io
    ", 5i
    ,rril'1,.rr1,r1,., izvoriti: din dorinla gi nciiniitea omului dc:r iace lurnini ",i"n-ru.i
    in_
    t, ,rr ,L,r),.rirrlriutuit de conluzii qi inceititudini.
    lrr r,rr,.rilr, lrtrpoarelorvechi, ca egipterii, chinezii, indienii, asiricDij,
    ' ,, , ,r I r ,I.ii,,r,,.fac prccizi.riin lcgdru1i cu sclccfiala planr,, ,,,rim"1,..
    ,.r,
    tr r,rt"l',-r., l,rrrrlrr<.i 5i
    sL spunoaci unele tfici tu.ri omcrestj,ca loita si inlc_
    r, l,,rrrrr,.,,. r.r,.,lLtar.c. In Grccia anlici, platon rccomanducprodrc"i .,,
    .,1,.,r\',, rrr,.rlilulsilit l.osi,d^gLep-ti si curajo;i, idoc jnscrisi i'n cdrrc*ii.,
    i|,,r,'|i., .,, \l,i I,r' sus,tlnut pC
    .trrpoCratrcr..au bazr ob."rvetiilor.gcncair,3i,.,.
    ', .,r'rrrrr. t,,rt rfl In,rllonnJJiiumanu sinr crcditlr,.. AnaxaRoris,irr rrrrr,.,
    ' r 1r 'lr' .l rl0r)a'i, cxplici. in mod materialist fenomcnulereditirtii, rtrib.rir,l
    ir rrr',rrrii.rr.r r.rrr.rr<:tr.LcloL particulemater.iaic.1. 'falmucl'sc rncnfi.,rr
    | r' li rnr'r'ir'r*r' ;i-rL circLrmcis ''or primul
    '| {iu si cr a rnurit si ia {cl s-rrintiri4rJrrt
    , ,,.1 rl, . rloilr,l, nu rrrai lrrc voic sir_ciriLuncirlir. pi:
    'r 5i urrniLtor.ul. lrr tilul
    ,',.,1,rr,r.rl'lr(.,r() ulr"LSrtfi
    ltlevcniivir.,inlr-o lroitlii.It;.lrsll)isi.(,rc(lilar-
    l)rr1r,,- r ,,rrolcrL' stagrrilrc;i r,.piirnurc i! (:(.ri):(i-Lrii .
    r,-lrrr. r'\.Il|!t rrrr.rlirr, ;ii i i rr! i I,i I:r , <:iLr.ar:1.r,_
    i[,r.,r,rtlirlr.lL
    rnir:rrrscolrrllrri
    5i ,l,.sr;o1i,,r.ir.,"tr (.11.|l)(,nlr.lor
    i0
    :'.I
    ..1 ,,1 Lr lr r lL ur l Ir,,l ,,i ' rl ,rr r(l ri r, i tl ((r,i i l l l L), rl l i tl l l , l 1,tl l (, ri i l
    rt .rrlr . t llt r l t r , , lr rtrl ,rl , r,,l i l rl i i . , , r r/,,/ ' /,trl rtr i, 1111t 1, rti1: \ l , t . ltD, t t t t sl/ L( - ir iU, lr , r t r . r l . ,
    .r,, ,r ,i ri ,r.rrr r .t r r , - Lr t t r 'i. . qllglbill si r r sll. , , l
    L rr ' , r r r lr t l . r l \ \.1 l l .l c rr ;i rrl \l X J rri r s t fl rc l .' ri l rclc col rt;rti rri l ' :Ll o- i1r ( i( , ! ) : , llr li, Llt r. ., r, ist cnt c i. cr , r r si. r t uf ir L
    S_, i, t , , , 1; i( , ;
    ,i ,r,,, l ) ( nL r iD1, . l|p c rr' rr(' r\,(l i l i l i i , l )()r[j n d d c Ia obse1.val l ]a mi nuti oas' .i a ,r . i rl o l r l l r" ' .
    . ,,.Irr:l r' loI lr r Diljr r lr l | g i L l c rl c rtri L l fn rl n ,L l i i l , c orri rni tal c. J. A darns l tl i .ci - Il t L,.i rri r I 'r r t r r l sccnlr r t r r i: . 1 \ \ - i"a, ir r '; 9, 11,l; , , . t , _r r r :j r, |{.|.., ., , I I \ \ . . \ .
    ,
    . ,r ,. , 1r " ' ' , t i , , , n ..tr ri l i u r)r-, n -' .j j f.rr' \' . nr' oD i i J' l ornrl i J,' .. i n ' ,' l ' ..' ,l ,., . ', r r 1r r c. r , )iJ,
    , , r r , . r i.r r r en] iR, ir r d, . i, . r , , , . ; r . i|, , r , . 2 r . r
    r:r,
    ,' ' lr-r'(Jrirrr l l .l t,nt |ll (tr
    (.irr1.
    ., Iac lclcriri 1a hemo{ilic iiriltind',}-sc cir boirio. r:ste [(,t]Lun.r (l{,2\.oltarea carar__icrclorsi iriiusirilcrr.
    "r r|' ||rrLr(iiIi. irr t\t!"i ^a",il,r,ti.i.i,,i or.llr_
    ,,r,rrrillslil liL l,iLr-ba.li5i transmisir clc forrci biricfiior 1or. G. \V. lluntiregion ' ,1,;.rLfli
    in r:rornosolri.
    ,{ccastir.
    idce.a
    t'ostpi"t",iri
    c l c c i i ti L { i id o mi n L u t,',1 i ttc cr,,' a, c..r' .-i poarti nui nc-
    i.r,, ,' ,l r , s c r ic lcLr t r c r . i r' a . :r'r :,]:li I. [lorglLrr.:'c prn. irazr:leteoriei rt,r-o!ori.i*"r,
    'i.rrrr -r,,
    li,, rrr,rtinrl cir lxlirlir .!o nlarlifcst:r it uuul sau ini'.i nldti desccndcnti, L'ii:, )r].1 r)1'l:l'1"ohs,rrvariilc,i'
    _.!1( . r!1".,:itit
    iii 1,.r,,
    ,,,u,
    ,l,r,,r rrrrrrlr)ir col-riinu a-reseulne de LoaliL, anenintarea rlisparc, striLtrr'potii
    :l,ll
    .'r ,1,i,.,1:,.Yt:.:t::
    (r'triir.t(,r _(rj.?,)):. ""i".,
    st_.iu"lr txist,r. .chimL,riri r,co: I,in:lri,
    rl rrr])l tl (tLv
    -,n,1,,,,
    l

    , inr,.. Ir,;n,,,rr. i,
    ,rrrulrri l,olrlr. fiir.rrl r..,r)rrrrrlr',
    carc rcalizcazl tipuri.,dn ,r,)ruo5o1niail,,iiti- Jt, ct_,rparentali.
    'r -.igur siuriiiosi. ";
    t !)r(r')nritcrlt {::u ilcrr:i'!c obselr,'atii sc lac Primele cercetilri fundlr- ' ril' ,1, g, rrrrici prin rn"iojc ,.i,otogi, ., ,f,,, ,:.,i,..,
    rr, rrirlr' [r lrioiogit'. Sintctizinr.l datelc culcsc il]tr-o lrrngi. cxpeditic, Dri-rvin
    lr, ' r:1lill1i;:z,gi,'"i;ii.'nr.iisn,,
    l: ll :.i,'',r., B;.id".;,
    tttolc,cttca. rllorgarr, tsr.idgcs, i,;j";;,;;';irrii,::.'lJ,tii:L,jl
    Sirlrt.rilnt si tlliillcr. an rk,it:.,
    , {,r,r'i)r' in 13.59 tcolir. cr/olulionist:l, publicatiL in ,,Originca sPccii}or' ,
    1'r,ulrr,irrilo profunilir rcroi,.'.1i1,iniriologic, stiintii care a dc\:cltit de iriuilci
    \';l; ':l':i;lltliift .,qi".?!i 11iii,:,1?#',Ll,,1ll
    ri,i" ,1i:'\:.li,liiili;,1:ii,ill;
    , 1 , :;i rrl s iil it oar c . ' 1 ' ' l rrl ,' ,/.' .', 1; , 1; 11.
    i.tirr rrr, , rrrr rr I rrl nlsf, rii ,.i, gcnctica a {ost ir-rrpticati,riil nurncroasr.slcTc
    irr antrl 1E55, cir"ltgiLrul :rustr-iac Gr-cgorf{cndcl, ir intreprins 1r -,-lrsta , rir
    i r i1 ,i , sl i .inlif r-r r i. '1n
    i i ,i.t, ;l,iin{iric,iir ' p,11.1r 1, 1i111s1 deceniu al sr : colu'lt i. if i- iJ- "] , ." 0"."o1,,,.i,
    .aecgniu-;i';;..;i.','t"i;i'Xi-i,,'l n. , . . . . , , . , , , . ; l
    '1,,.10,l( iuri o so'ic dc I'xpcriilnlc care atl durat opt ani, rclrul.tatelc fiindl rtrl
    r r l l i 'i'Lrxilor s.ng'i.r,-'-
    " r l L l x i l o r sa Arlo
    n r ,r 'i f,' ,\ l l ( ) rdc.
    1 ^ .n r .^ r ..- ,r ,.+..:- ..- -
    ciLrrt - : ,
    t-.",rrt.ln,"r','.r".i.i*"i"
    - ".".i,.1',,,.,:
    l,ulrlir;rlc irr ,,.Jnrnalul socictirtii clc istolic n:rtura]ir" din Rrno, Mor':lvia. ,,r I l i . s, . lr ir , t {r r t il , l r pi l, . gilc
    m , . nr l 1i. . r . . .
    i',,,u,r1,,,r",, liii ]I,:ndci s . o*it pc transmiterezr crcCitari a divcrscloi la- irt 190r.),A. ij._ (i;rr.r.odiorcle"azi .f.,npt;;Lr;i;,
    r.rctr,rislir'i ir.lc boal;elol de mez,ir'. (as1-,qc,tt,t.a sru zbircit). Dupit irrr:ru* afcc.iiunc cr.cclitar.irlrr._
    , r,,,.,:' , , : r 1, , . 11,r , c. . . 1 ,. (L ) c n l rs ;1 l ,c l nz fi rc 1 ,, ,r,. :r oL,l i nrrt i n pri nr :' -
    rr'rrift,siafir I : r . iLoraozigofi
    ,.r,rrri [r. : i: Lt la.
    ii , r o: nuzigof i p.i,r
    pr iu cr , . r , 1; . . , , , , . : '. i. * ' * " : j icl ']r)u.,.,,,u-,,,,
    cx.ic!i,, !hornogcrr
    ::uY6r lr i
    rr' {rr ilIriit'llliL tLn( I r,itzLmc, lleCeSari| cOm.cr-tirii "ii..:r-'i".',.i.i 'L' ':
    r,,rir(i(, nurriri boabe ncltde (L). l'rin incrucigarca ?rcestoradin urrla't, ,,r-r)a- , r,, aCCStui acrq.
    ';;';;;i:i,], )rntczlL si
    r r , rtirr.ir
    r l , , l , , , , t,.zimci
    r z i m ^ i iiircriruinate
    '.- - i ,- ;- a fost .orr,,t"rnii, ',,i"i,.liri;i
    r.rri irlcnticc intrc clc, a oblinut in a doua generalie 75,0/oboabe netcdc {I-)
    l i ' rr'
    r'i 21i'li, ltalrc zbircitc (r). Din armestecul intirnpiirtor al caracterr:lor boab.:lor
    ,lc rrrrziLnr.ru rezultat, deci, forrne LL (nctcdr:), Lr (netcde), r-I- (nttcdc) ;i rt. eng1(:z
    lil ,l:lil:,,:l:illiill:lli"l:l:"1 G-.Ir. I1,,rdVsi mcrlictl.r
    gorn,,irr
    :,rrr1.inlclc z.l)ircitc,fitcarc in proporfic de 250i. l'rin acestc cxp,'rjcutc si prin )l "'llll]Ji:,"11:1*?:ll**l:::jtgli''.'"L"ii
    1rri,rir, rrxmuliL
    m,itcma -s"",";^ti'"p"!;i;:ii"::liii;li:
    ri,.,ir.r 'uiJi--iir.r,i[.".iil']iiii'
    .rltllr.(conbinatii de flori difcrit colorate), lfendel a adttat cir transrnitcr.ea. il|l ,,xl)iicitt t1c "ir"' p.Lt.,iog.iccr.rim]neconstantat
    ' I .llll. dc cc cc r."ci,cng',
    lrcclctrt*. g"iilio,-;,,;;i"si;
    gcnclor "i,llJt!, (l(.
    , rrlrrctcrclor crc,litarc sc {ace prin alernetile djsociabilc, numite ..:std.zigan'c, Il r ' I lt:'l:,rt
    r1,.rr,.r:ri ila
    r. a1t a. constarrtr.i rlr.
    lit'r:rrll clcrncnt deteuninind un caractel particular, Desi aceasti descqpc- l,'lirr.r illrni-riato a sccolulni al X-\lca
    rilr' ;Lvcu s[ rcvo]ntioreze intleaga gindirc biologicl din secolu] al XX-lea, se inchciiL crr cercctirrilc,furtdir.
    ri , r,;.:rl r' (l{ ! lt 'ur 'l ir r - . u; r cr r r l( r r n'r clniCt . . 1. .
    , rr rtn ir {ost intcleasf clc contem.poranii lui Mendel. ln", Dr , lpni) I gr l {) . Ar . , . r t . ,
    tl 1\lrrr rI. rfccarly sc ocupi- cu riesci{rarca .ot oi.ri
    ('rrnr in aceeasi pcrioadi, Virchorv qi aiti biologi au descoperit celulcle ,I.r'rl;i ,,"irii* ,ri _
    -ciar
    ,:, ,,.,,,, q"::"tl:l 1!,9..\tilkirs studiazii_
    ,,,,i,1;j.,,1.1 ,,"irii,.""r.;"ip,.i"iri_
    1rr, r'irlr. c|: dir.'iziuric, ltumai in 1875, botanistul german 13. Strasburger
    ', , , ,, rirl("X. Acesieccrce1j.ri
    ,'r r,, I,/ r i r'..t.iitr.c fu o.;._";;.ril; i.;i.
    ,r,l,.sclis lnitoza in celulelc r-eecta,lcsi lragmcntarea nucleului ln particule l. tr{.Crick;i J. "rtti"""r:
    .lt.l1-at-son;itUiii.",i'"i..,.t"rii
    -diviziulii ";J.faciclrrlrri
    , olorrbilc carc se impart in doui in tiinpul celularc. W. Flimrning.
    zorr)ogist gcrnan a observat acela$i fenomen in celulele dc broascd. 9i a dat ,, :,','ll;ll"J,l',i1,,(l'^il;..'llt:::':::::aub1e"riccconiiii"iir,.ii'
    r ,rr r,rtrir/.,,rzolrLi.c..dceasti.descoperirea stat 1a f.,iza-aczi.olt
    ,l, rrrrriir,:ri' dt: t:yom,al,|r.t,d. particd;]or colorate din nucleu Cromos6mii au , , ttitt, .Ltt.,:r:,laya io o do.rojumi.tatc;rscr:olul.i
    l.rl irl:ntjficati in spermatozoid;i ovtl de citre belgianul E. Benedin, dal r' /'i' rit'i g.'r:tice estc intereai;'L -;.i; ,,,
    "r..t'i--rnu,,i
    d" ot"""i "*_li".tlFlilll;i]i
    rrr Ji l;arr rr1.r'illrit cirlititi spcciaic lcgate de ereditate. rr,,r rl,, \|)\ (conplc.":ult1t'
    , , r,r 1,r, r,)r spLr:i{i<r,: tl'e prol cinc spec:ificc'niai:.r,r...
    i;i rl.r'i
    l.iL int:r'puirri sr:colului ll liXlt:a, \\r. B:rteston descoperl ci. iegile ficcin$"L:l;j1""'-
    0 r(rr(l (,lic r r { ' ailV llr r bi l i ta tc $ ii n l u rn o u trn i m a l i - q i tot el di , i n 1906, nurnel e
    ,l, t!ttr'/ir'ri 5liiu{ti lriologiic (:trtr' so ocup:L cu ire<liiatea. ,,11",,,,,'''l;],il tll4Seutar
    l,]f ;,ll,T,'#'1 iL{"i rJc'sti';p'--'t'i,
    c,,c,,,lrrr
    ui
    , ,,, ii,r,,,,',ii1i,ii, rrr. sisL''irtt-"or'
    in parlicttlirt
    it
    \\r. \'otransrrt rltr.'azl. nofitttrilr: tlc genoti/t, prin care se intclege baza ;;; ;;j|il'slilffiTatrcc
    .rr.rlilrrrii rr orlliulisnl(l ()I, forttt;rlii. rlin tolaiitatea elementelor ereditare 9i arrst,Lt,irii
    c,,L
    numiir.rrr
    'l' lrttofi,lt, l)r'in
    (li!11:sr: rlcscttttl,';tziLlotiriii:ltea caracterelor 9i insugirilor
    , 'rIt.r'i o llil ir lr . or A ir t t i s rrc l o r. Atl l i L Si rtrti rrr i tttro duce i n 1909 dol i unea de rr;r
    lll ,llii1l,,t{,,,,11,,,1,,1,ii:,.$,,,lltt1.,,Ll,-,
    ;i,,,,1iiilrilr,,'ririli,.,l,ir'firthlllliillli*:ir
    rriproi,t
    :iv,luuill"lir
    . :l rrri , ,,( ' iur ' r \ ; l) t ir lii ,rl )l l tl fri Irto 1 rfi trti i ,J i |(i| rf{i }ni snl l ui si nt conri i l i onate
    i,, i r:,, 1i;,r;i
    ; il*li;i _iiiilil ';lilli::li,nllil,illll
    'l. l

    :t;l
    1i,,,,1ii,,rrrrrlrctrliLriL.
    .\u a.piLr
    ut nurncroasepublical;ii,ill La1"ati str:riuLit.Lt(-
    ir''iii;1,', th:Iii
    l'l,!i'iililllil]i,lll,I::t
    1t,1,, ,l; ,rr.rrt,.rl,. grrnqrticicui
    r.omlni contcnpor-ani,refcritoilr-cla ecnclica nolc,
    rLrl ri si lrirtolo6liaitdusiL prenatal ($tefan Antohi, I. Caratzall, I. Covic,
    "i;'#**:il**x
    rr;i'ri,
    {;:il*;il",l,
    *litt***li*{$i*i*t';**l*
    Itrr, r Nlrrlincscrr,
    11.Geormineanu,C. Maximihan, $te{anMilcu, P. Raicri ctc.).

    1.2. FACTORII
    GENETICI
    ,,,,,1J,i,1,'11,'i,;i",'liil':'1:'H:i#",":,Tti*:;,ffi#;',*mtru1T:xlt l\IrLltilLrrlinca de celcetiiri in carc s-au angaiat numelor-e rliscinlinc
    -i;;;1"si;:-";1ig"""ii.j,1-i"0"".1"'--i"-
    i':lffii'iii,;:ill.*u o,xer'a(ie
    ,,,,,,11\ll"'lili.';:o:::?ff#'i'ili:Hi 1 ri ,lrrr1i,
    , i'r:<liciniL,ct'i-ie, Lice,
    l:i
    $,-.,i:"-.
    r"':illr"rilil"i'iJ:iil:##1;###.#i"'',}*ft
    n, lr i-r), l\('rrlm cunoasterea ercditltii nrnane. au rcusit sir dovedcasciL rohrl
    Lr, , ,rirlrir "rril ,g.rt, gr.nr.iic, in transmitcrea unui iiumi.r imprcsionant <l'
    t. r l ).' i ,, ,r:.co. 1'r i- r - , 1. , niSm ul nLr r . _'t inig, n, . ljcn ulicn snu pr : n abci, r {ii

    .q:#i#,ir;ifili:lig#t"&lili*iii
    l;''l,ilili*iiif',".'ffi
    r'rorros()n1irl('.S-au incLividualizat pcstc 3500 dc forme cliniccl dinirc cart
    r)rLrt(.ir.rr o o'olntie severir. Evidenlcle statistice arati. cii 40.-
    Lrl Ll rr.r.r,rl Lrriior iportane sint rlctcrminate de anornalii gcnetice':- 51,,nrlin
    -50)i din to-

    rilli,lr',:li'illil;rf
    ":li[1:ji#l1illi1#*L:#'":r:r*iu]:iir}; 'rr.,r
    rirs,r,tii dcc,.rlrri
    ((-1rru,11"r-,llEi)
    -i I5'o din niisculii vii prezinti. anomalii cromoso-
    l0oo dir] mirlformatiilc congenitaie sitlr cor.sccinta

    ,,i;r*i*L i*"ia*t*iJ##util#r;*
    I rl nrrLl.Lliilrnetice, 20o tn.Lnifestinclu-scde la nastere si 1fi fiinil conscr-
    r rrr r rrtror abcratii cromosomalc. Apro:<irnativ 60fi, dinire copiii cu h.ra,
    1,r,i,r',, mirrtaii scr,-,,.r-i s.int hanrlicapali genetic (Scr.ivcr si co1ab., citat dc

    -,.
    r' . tl i Lxi uri l i i rn).

    ;'i:.tl]';;,':$:ll:!
    ";*f
    Iu prcdur:crca rinor stiiri patoiogice sint incriminate uncor-i inai nultl
    l, llnli,;ml**'t*i:,-#**l"";*it
    ,,,
    i" " ii:llli.,'J'::;::ii;l gene-
    ,:rr r:fcct indir.iclual s1ab, dar cale sint- capabile si. rcalizczt. lr.in mutatii
    rrr riirLnLr o sumare caatitativiL d.enumiti. ereditate fol,igetlc,). ,\1t ori, ,r
    i ill iJTff3::'i!i.?'*,i!lr v'.: arornalii trlrrli {rn:'r anormtli estc in stat e si. se cxprinc prin apariii-t mri rnnllor
    ,rr , lrrlii (r.,{.r:lfleioiraf).

    il,:,'iili$t****1,"*'i,,f,#iiijii:ir;F.'.'i"#;*hxri'triirr:
    Il
    Irrriilirlul urrrilll lt1 cste il:ir prodLlsui exclusiv al flene1or. Eir:rlitatclL
    ,, r,lilionrazir un pr-ocr.sc1c dezr.olt-.Lrccaraci,,ristic, dar"acesta estc supus
    Lrrl rr,nflioL ,:rultor va;:iabile diu mcdiui inconiurltor. llcdiilc siai,rj- si nr..,
    l ' r: r' ,tri .,r,i l , , \ f . jt r 'L pr l. e: . nt ial in
    "iur r i . . , "f ir - , . . "u r ol - olr : li: r si, , ci, r .
    | , , roli rlirr ncdiul intr-auterin, in pcriorCa eirbrios.,nezci ..i^r

    ril*iri*,#$L#""J,'-ffi
    factc,ii diir i.n,.l-

    ih'+*'
    il*}i"?f.$"i,:$.1#*
    ,l rrl l , \t, ri . t..,1 ir az. ir p. r nt Jr 'r cn- r . . r ct ii I jzjco- chim ic d, schir nb . r :
    l) iLili-
    r' ,rrrl l n, lic. In auunitc conditii, factor.ii de medin sint capabili sii nro-

    iii:irlr:r'*"t1"""#3i,tii"i;.3;_-t.''5,"5J+?*mp****, lrr, , rrrrornalii complexe ale organismului. Importan{a factor-ilor ,t, rri.dirr
    rr ' rr, r r1,zvolti prodLrsrrlde colccplie este ilustraii de faptril cii acc5tia.
    I'r,t in,lr, unelc anomalii care sinuleaziL o maiformatie cl-editiLr;'r.,siar',:
    l.:'jl"'1"1"1"'#"1;'1ri.:+*"tsilqj*!",*r,,t_rezrr,tatele
    lr;,rilrli,; tttt t til i t .l. ttoropie necred.itari| a unei rnaladii ereditare.
    i rr paLologin uurirnii cxistf, tumcroase exemple prin carc .;v dul r:duit (.
    ilrll;ul,X;,';;i:ll,li:,Tf-$;iq1ili?rT-*$:i"t*:*t*r:;i:r?i: t,rrl lr,;r f:rr:tolilor dc mediu de a plocluce
    ;u tr:l irirornrLliiindLrsc gcnctic.
    -Microcejaiia modificiii fenotipicc, c,r.rc rnirnt,rizi
    poate Ii eipresii: honozigoliL

    jtl1j1,i,:1',;#U=.,;r$":l+:r.t::1
    ,,l,tillltlr,\,'1T$:',i:ii'i:
    r r,ri lrril: autosorull reccsive, dar pc.r.tefi produ;i si prin ir-adicri alc cn-
    l,r r' rtrlui srLrrprin crnbriopatic luL,ioUciL. Ri.tinobl.rsiomul es{.c condi{ioruLf
    ,l
    ' ttrtrl L{:i,ru.Lrtosornltldominantir- dirr po;rle {i o {r:nocopic, cintl sc ntnni-

    ], I liil r-
    ,ll ;lilh:#:l*rl Ht**:?:tle! l, i r.llilitr('lll. liocornc)i:r, conditionatI dc o rnut:rtic :r-utosortlal r.rc,.,siviL

    r;.ri;,:iillq-lilillli*,rmi:,{**ii::l#[
    jj:ij:,riIff -".T!ii:i
    ""''nffi'liil;iii;lil:,,::,,'"1""'#ilf-i?
    ,' , . ti i .r,LrL...d, , L r lidor nidi.
    I" t' tt,rr' ,rIIi i I r 'Potf i pclnanclt c ( incor nr : liir )sr LLrt nLnzil. or ii, r 'r Lin , , r r zLll
    r, Il rl nroi i l ol ri rrcrr ici ilin int oxicalir cr r nit r i; i.
    ( i ttrt ' i ,. srrrnr . ; r ziL
    "''r"r"ri,'
    till','iiiil:\ll',rl:"'i;ll;ii:*l:
    ( .ll*:1"zu
    ll
    ; Lr . {iLr r Lrr'a lr r {a[ ii] or g0t t ciir : , t( : t L ( t Llirit llr , : lr ; lil, r r , lin
    trr' l i rtl i rt,,' IIi IILiI r ) I, , ''r r ' r r . r liilr : r r , zr r lt r if , r ,ir r 4, . r r , , r 'lr lr r r r r ll, r r r r r , r iit,, r . , . r r li"
    o
    ; t llr'l r', srr c ut t : iit < : t lu 1)l l l l (1
    :::l
    :t,l
    ,'.1(l l)rl('t(r':rt tt\ttt')ti:\i)tttllilit.ittrittiti, \n crltcl 8I-arlrtl tlJ pirrticiJlillc i'' ":- ,
    r, r ,,r i i rlt ir r r it L, 1i r ' . i, g ;, i r 1 1 , l ' r, .i z ' 1 . ' ,r,I i f l , r r lt , r ir . Lt lt . lr r Dr r iLt icr |L' ii'i|Lusnlil{I lt r r L1; i,ri lit t 1r 't Lrt r r li, iI
    ' r1i ,.. (,)n t inr ill] l t l, AI ) , \ csi, , r 'iLliir lr il r lr 'la o specit lr a1ir L.I - : l r f r t r '. r t r
    l (,l l|llt it l( 1, : : r ' r i( l l i l i l c i n 1 -r z c rl ' I p a l o l c ' li r zi l otti l ui u]l l l l l l ' 1' l rl i g' l
    r ' , l otrri i iiL, . \ l) \ csli: dir lj, 6 I 101e dir lt oni ( ul dalt r - r l 1. et L'r inilir lll
    rr rrr,,rr llt liil,( r ' )(r r ro, : t)rui l o r- i i l c l u l o r (a 1 rc ' rl fi l rri ' ' !atri mol l i ul p' u' l i fi r])
    ,' o n c l i ti i l o r-d t l rri c i i u i n c o n i ur-i rtrx,carc si l t i l cl i sp' l ::- , rrl r1, rlrrlr.cttliLriL|italii cu rlasa atomuiui r1c hidlogcl]. Cilrrlr'lr' .L'
    ,,, 'l i , '
    . r. r',, ' , , r' 'tr, 'rrr:l',, t , ,,' ,1;i
    r .r" I-i : .i r' ." , m L ' ri o r' rr' ' ,r Lrr rLr; Lrjur
    - nr 'r . ilt t : clin clt r iit ilt cL de , '\ t lN : t ct lLr lcLol solr ir llr 'i, ll
    ' n rlillr:lri cu nrnl)irrnl de clotlosomi (formull"L1rtp1oirli. ru 23 (li' cr1)r1,,
    r'i, , ,,i ., ., tr.t ,i',-dj.l, r'iilica ciioto.qic:t, tle r:iLractentl rrtltiiactcli:r:
    ,, l,r1ii rlr, iot-tnuJu.diploidii, cu 46 t1c crollosolr'ri in ccLuln sorrrrrlic-r1. Orri
    ,L ',,,,1 i, , , r ; , , , , r , t, 1, , i1 " .,t" 1 "p l c i o tro p . d c r" l o t' gcnc, cl asi fi cal cl bol i l or;i '
    ; t , t at i r, I r1 rl i r (rr l) lar cir gaincliior t lobir dcst e doul sct t r i a cil. r 23 d( . ( r ) r ] r '
    , Ilt .l "r . . "t 1 :
    -r'P r 1 1 '1 {j i c 1 r ^ '. c : ,, tl rl rl rrn {r . r n si unr r l pat cm ) , r 'oalizi nr 1{or - m ula cliploit li cu - 16 cl. r 'r r '
    . tr', ,. tir .,1 . r r . - ir r i r r ' . r t , 1j, , l . t i" , ' n o r i n : u r '.
    . '.lr . r "l ,t : '. r ' , , r . t ni " il" l l l ' l n c 'd t l l
    , ,.1 ' . !',ri 'l 'r t t l
    '. ltirr lrrrnr:Ltli. r-ctlcrc chir c estc o tttacr)uolecttliL irolintt'r'ir',i,
    , ,,1, , , lrLl,il,. rrt-lr f1l'ii o1. lp. '1.I)\
    i:orrscci:'l'' . r,,i rrrrilrrlo (monomcnLl) c:;tr: ttttclcc'tidttl,format ilirr J rlcrnr'nlr.:
    1,1 ,\rr,rrrrrLiii ,lc lluurir sau (1il si.ructlu"'' a'lc crotlosor'li1ol'
    1r : r ls m is ilr ilc s a u l l r - r , t - 'r ; i r l ( 't r t i a l r i l Ll r i i i rr) o lrrrziLrLzotatir, pulinici sau pirimi{linicar; b) tr zahirl plrtl'zir'
    l, , f ,,t rr,<irLrlttcilrci r t s t r ilt t c illz t li,
    ' .ri ll lilxrziL) ;r:) :Lr:idLrlfosfolic.
    .rrrr,lrlr-
    !r- l\:ttcl<: f'u,riniL:csinl. reprrzel]tiltc dc lduistti (:\) s\ gurutiui {1,).
    , ) \rlr)llllllll llollgallLcc si rmrltilirti ol'illi', clctcltrljulrlt: rlc :rliltatii
    tncdiu 'll-iulsln1l-(irrlil i!ccsl rl-'L
    r | | lr l,,l r, 11, in ir5c(i riill cu {ilctol-i c1'.' Iirtt'lc f i.;'ittid it.ri:c sint c:onstituitc th cilo:;inti (C'1 ,st titn.iditui (11.
    '; , ,f, l,r,iiii;i"t, i-isr:rr1r"ctu,'n1ci crilcttlincl.-sr: tlrrp;-r'I'rltor1t I lrrpr:'1'r"r" \ r,.rr.rrllrzli azotirlt cu ilirso:iiriboze, pdnir-o 1r:gir.tutiLN-oxidicir, r'r'n-
    t' t' tn )tutlro,:ir1.-.\socicrt:a:tLtclcozirlt ui cu acidul {oslorir:, plintrrrr lcg;i
    1,2,1.FFOGRAMUL NORMAL
    GENETIC 1 ll irrslrrrslcr', loturcazir tttt ttttt:lcotil.. :\cr':asiiLit'giLluriL sc iircc la lttrtrlirr
    ( i)rrli)frlt t:ollc(ll)ti ui it.l1:rlalal lrtilitit{ii se adllliLc c'r ll iISnriLrr l ,1, I irr lrozilirL-5' a glucidului. P,;rl]trtl !i {orma {iiamcntul c1c
    '\fJN,
    urrr:ico
    at:i tl ul ui dr' ' oti i - rr,, , rrrrr.sr:alr:r-r.Luinr1 un lanl de polinuclcotir.ic, in carc lrrigilc <lc 1r'qri
    .,,.,,r,r: , 1l, , r . , j, ' - 1,o g t,n c ra l i i :1 ;rl l ra .s t frc c . p i i n rcP l i t:l i rt' rt
    rlltrttrttrlrtl rlivizirruii :''- irr{ rllrrr:irlul unui ruclcotirl $r {os{atui ttuckrotirlului adiaccnt (prirr
    ,i,,,',,,,l, i,, irf l ,.:iirt",rt iT nucicij rr'1uli'lor" it.r 'r
    :i l a rl tl i c a z r"r i tr structuri l i l l rl ncntt:' " :;r' r" ,,l,i,u,liu lxrz,itia3' a accstuiaj, Sc rr-'alizcazri iLstlr'l o lcgiLl.urii-1' -5' los
    ,L, ,1 , , ',f
    r i. , f , . t ' a, r , , ti c ' l tc j ra l - ',,
    " t',,',,llt"nni,"rizibilc Ilr micrtlsctD liitru'c t:t-oilrosotrlc()ntillc.o il' 1-l(] r' ., t,,r (l i g. l. l) . Nuclcot it li: le ir u o or "clin. ' aD{'r - i, ) t lica! {int inr lr liii<, lr ',
    ' ,,,,,',,
    , 'l 11" '
    : i ' t ' ' l l .{ttt ' ' t ' rrr' ' orrri l " t r' ; ' ,1,.rrrl ;, rl r ' , '\ l) N, cci: a cc ii conf er iL o
    'i',, '.. r r i, ' , , , ' , i, t f - " rli"ui ,t,' ,
    1 " ;i
    rrfi t" rpl o" i r' ' ' ' l t.rIl i rrr,pr rizr Llr iliL do inf t xniit ic t {lt }f t icir -
    l ;'- a .1 't '
    ,
    ' ; ;
    ,', -i ' 1 1 ' 1 ' ;' i r,i rr" 1 " . ' p
    (' 1 (r.): (;c n (' l { r s i rri 1r:gatr: si rcvcul i d {ol l :t" rrl 'l rd, l ut.r \l l \,,rl l l n-r' l rl ,l rr1' .' 1 ,11,,- 't,
    ,,'1 ,, , " t t r i" , , , " il t " nog l o l ru l i rrr' '
    l r,.,rl i z,r t <1. [ \ 'aucis l- 1. [ '. Cr icli ; i
    ' rrrp , l i gir it t r at r ' ilinl i rL i c i HrCs,u.
    11"L sJi ; l'1t t1 I I t. \\ rrlsrnr iD ltl.j.i, a.rc 12 car{ig..ulir-
    l:i(,(rirr()lrucl(11 (l.llltr-o cl ltlli! sotnlLlici eotrlinc uD -c1ul'lu 1,,,'t,I t rt ii,' I t.r 1rrryi r ti. I)i.(.,11
    pi tt{ rI1' t1' r (r -L! L'n iLri. {'.LL,Llt I
    .rr, ,:,i( . r ' r ' 1l1it : lnc r r s a i ti h i i l l ro \c n j t d i I s p { ' rl natozol dul . H l/
    , "\.r
    iccurrrll'tiL:i ruc-\irjc i':- , , \l )\ sc con) p1inr ( li[ ( loniL] anf u, 'i
    i,,ii,',, ,,,t,,, il,r or-ulirl itlai crii, irr lnotllrrntlrl: -{ml)clc
    .
    i
    r, 1 i ,, s ir ll c upr - ius ci l t A l )\.
    l , rfr rrl rrTr r lr t xr lir t ut : lcot it lc t : ilr c st 3":. ;
    , I l i , o ir Jir [ , s1r 'r ' t lr r : lpt iL, iu slr t st t i
    GENETICE
    AtE EXPRIMARII '
    1.2.?.. MOtECUtAfuE
    BAZELE ' I l , ,,;ro luic, uLr r r Lin jr r lLt l t : clulali. lf /
    (;(rl(1i(il st' ttllpit crr slrrdiul stl-ur:turii clc]Dent('lo! il':r(:' l rrl r, ,l i lr 'r ilr lr ' lr azi r Lzot at t : lr ll iar i
    lllolrculalir
    ,, . i,, ,i,,,,ii",r.iri,i Lrl*i rcnctic ;i j,lt ]ll:,.::lll:,,1:1,:.cirrc rlsigurira:.r',o- I , , l r,l rl ,,.p lir iicr . r '- r isiii ir n lr lr or t ct r u
    'rat,'riat
    , r,r' ,,,lrtr'r'rlrt tct'{to lll. l- il or t l( r o' r r r a { unos lillf r l ( t r t n '. c c s t
    rltltlcriu ltr: ,.r,rrlit lr lir ', cL, uLr nr it f lr l; l, r : lr 6r ir 1 /? --:, 12
    ..,, ,ur .(1us i.",'rr.iri csrLrtialc lla:
    rcft:rit.ur-L: ' ' | )i t,It,u i l tilt i bL[ . ilor t 7) lt la, ( i( is( iop. u]
    ,,i,i,:;i,,,ir],,,,.rr.ir,i'i,,r:i,itlt,u ,1
    s lI Lr ( r 1lr lirI r r( :r' ct i ri rr,Li ti ' .tfti f' l :t s p i tJ i r a ' \l ))i .;i
    e i D l ]]l i ci r 3r' :' i ' l t | , , r , 1, )r,, , . , ( , . r , r i I 'r ir r rif ir , r . ' 1r J .0. ft, /..,j
    c ll l rrcl anl sl tr l l l l 1l Lrtr' l )r{{ u- I ,,l r,l ( r,rr linir r r liLll"uiniLt ) f ut r iillll, ii Ch
    t t o, i, lt r l . illl ,' z l i rr' p l i l i l l i ' ' r'
    , ri i :1 r 'rr, i,
    ;L ' \D X ' r1
    " , r rtri , rrt r r t r r i, olir l r : or t ininr l iiir t ir liua, 4?l
    a lrrrii rt- l ,rrrL( r ', . lr r ( irrror ulr ict r t it r lr r iir , \ - 'll,
    , r ' r ilil, ' 1, , r )l )l .rt' i l nl(': riullli t,rt-tt'tic tlit buzir nolecuilrI i ,,l .rl l
    , r , t r . llr \ r l . . l r i l q - q ) . ,1,,1 r rrrrr rrrr rl, oiir lr . lL. ur n( ininr l r : ilozinil
    i r, i r,, r , i ' i r r ' ; Lr i rrl ,i l i ti i ri ' , l\ r .
    ri ri i i r l r i , , 1r ,r Lt r r 1r ItIt ] Lt iI I r lr r( ( - ( ii
    ..1,''.I, STRUCTURA ACI DUTUIDESO XI RI S O N U C T E {A
    t
    ICDN}
    'r t L c . i ] 5 i $ t l r i c o i }: ! r '-
    l ]a/(. I f|l ri r,l i i |, !
    \lr'\, l, rr[, r l lr t l liz i' r l ir r lot r r t r r { i' i g 'n c l i c 'r
    l) r ' r r t o t t s l l 'r r {i a . r : i i , '\ J ) \ rlsit: tt-itns
    ,.1, r, r,l,r,rrlrtl r',i : i , t "lr t lt r r lr r r it lot ,L It: l1 l ,r.,r,rrL ,
    ,rrrt rlor rl ,t'rlit,rltr 'L l, r ' lJ r Lr ' r t l' t it r r r ' lr l ' O s ''r " l i d , ir.l .,{1,1 (rl ,r.' ,rl L(I l rri r )Lr, Ll
    . '1 r 'r : r 'r l I t : ,l r' I\' , i ,l ,r.L,tj l !l I,, t, .r,l ||r,rj r,l ,r
    \\,r\ ll I I L , r ir r lr ' r lr
    ' ; "||t r r r
    \ lr \ ' r lr lr " "
    'L "l ',
    l l ,
    r 4
    l 4;r llr' l)r)rlllll(Xr()(r a' 'l
    I
    t1 ,r ,1 .' l rtl l |l \ 1,., i / \l
    I I ' l .l ,r li! i') l
    1 ,,1 , , r Lr r ii lilir rr. l (' rl ,, \l rN ' .rrrl rrrrrrl i n rri , i l ,tl ,,11t;.t' ;l ;,1' i ri l 1l .t;' r Lrr (' ttr '; r r i( 'lr ( or llilllislllr . Lr r r 11r r : lI t r : r , lullr r ) , , \ I ) N iDit . "L i: l r ', , 1r r {i, .
    t-
    'I Iri '1 r " 6'r r { ' r l" s " sr:rl ' i l ' :t ' t' r' ' r:I' rri | i r i rtt r " \' i ' ;i ,l ri rrri | i i r' rr 1r |t I I cir r cI ,r. lir r nuclr , U, cr i car e lcaliz- t ilt zirsi_r 't r ct ur lt nucl, , , , ; t r i,
    ,,r,t ii, r , r . , l' 1, . <' ,l"i,ir i i rr:,rl ' r)l ' l t.t r:rr l ' Sri l rl l i l' 3' -5;-Iosfotl i ' ' ' ' r' l l " u- r,.r,il ir fIr)rt|ozotlril()t. Sir.rtimpJir:atc douir tipuri cle pr-otcilit: his!.o,t,tlt:
    ' ,,r di nrr' " L z' :z tari lltr',,
    I;,'' '' ,l i r" z i I' ri i r rrrrs l ' i u l d " l 5r:trrri t, rrr, l,:rz-icr.)..i ttrrth.is!r)uclc(proleir.rc acide).- Nonhisiorelr: siui ;fqpl;n{, 'rlin
    ''',';.,tI:ii; l ,r l ol i pi rl r' , r lzir r r r : ( ir olint clr r za,r m clcaza) , pr ot cine de
    - qt r uct nr il i- i lt r . i, r , . ir r , .
    , r rrrl rrJl l l rlor '. I list onclc, im pr eunir - cu ionii de calcin au t o1 in uenii: r , t . , , , ,
    ;,,l,ll':.;illr*'tsi"T::li*:l.1"i!,'i'itig*r.,1.i,}l;:;li"#1"*
    ..:,;i)., timqtg"
    i,,i",ii'"1't:ir" slJcitj,:lJ.:'j"ll*,ut"tii:
    Ll ,i l , , Irrri i spr r t ir L) ci. r idim cu- sionir lca m oleculei de ADN. ln t im pul , 1i, i.
    rrrrrrir r' l rrl rr r t , , spir alar ca lilanent clor de AD\ pc m olcculel, : il, - :hi. , , r . i
    i:1 ;;Lr:l?'..,!l: \ t t | | ; t, | /,,I s(lu1_li tr(:i L c t' ol t-l os oml l or,
    jlll::1.'i,;,ll'i1,1 r0s.rpuri-,,Ja-
    siru're.sarc
    il{r1ll,ifii,"ir,' dc.rb0-') I rrrrcliilo ,,\l)N, rlcrir':rrr- din str-uctura sa ciriruici sir.tt:

    ;'lillli;,1,:.'(,'i.,li;Ig"1l"'l'J,1;";l'fl;:'f,i''l"olllit]:i:**::j^ii*1"1;
    .l tl,-. turi Jn-lridrogen),favorrbil' procns nlrrld^ rnpjlc
    i ,,rr , r\Irl i r
    lutt/i( l( ra.lliMrc sa:u funcria autocat alitic:r, irrin ca.rc s'.j asi,.trrri
    ; i iD lr r ; clasiiir lp r r . [ lsr nit cr ea it f o: : r n"r t ir i genet ict ;
    luut lit. ltt'|::iioc.rktlitit:ci. ptit transcrierca gcucriic irr .r\l{\
    .l '1,,
    ll,r. t.r,,,tr.lti.,-'iiu.rr," r-birLriciI A D)'l rlr''1r-i
    rtivel' .slvt 'ttv': .r" .r .i ,, r lilir . r r lla sint r : zci pr ot cinclor speciiice; -ntcsajului
    ' rr
    5:"t:i.,*iJ';:i:l'"-Jfi'..".:,1:""',]':il
    1;i,;11iqi1i'':ll;:;:,i:;,i:j:;:x:'x'i Itrtrt!il lt uariabi.litalt, 1llin rccombinlrilc fragmenleior dr ,\l)\
    trrl,rrl iliuur'l()rl(,trczcisi i:r pcr-ioadelc dc diriziune celular.i.
    lloplir.rrlr''rr I)N. PIin strnctura sa in dubll. elice qi complrmc|r rri.
    I 't
    trt .r l r:rzl l o r r r zollr . t c,, , \ DN eslc singur ir m olccuh capabili. de ir ir t or r lr ) i, . r r r , .
    i ''t ' cH'
    , rrtrirlr,,.r \':riivi, in fazelc ik: tcpr-otluceLe de rlultiplicare cetrulari. lj,rrr-
    5i
    rl l i l tl. , ) r '(l) licit f lr cupr ilt ir , , succesir r ncde r lai m ult e et apr , , ;; s) . 1yl1

    I
    ' r,rrrrl
    I
    o ?-""'y{,"
    ( ".I p.a'il--/
    ,r'.r prolrlsitr'i, pr-in despiralrrr.c, l cclor ciou;i c;r_tenecomplentrntait, irs,,.
    rrr.rrr,ri orrl r.sllr ir lr , r 'iir r r ur i f enuoar ) , pr - occslellizat pr in r uper ca I , : git r r r ilor
    o - P.C ' I l rr,l r,11,
    6' '.'.ni^i
    rr ir r 1r 11, 7, r 'nt craizjr ir . , i, r nclcnucicaza;r : ele- douii iLt c; lc su- r lt , - , r lr i, l
    o
    t.n
    /1.";.,.-
    illl ,,r4nr'
    doel7/na H
    1l l ,,rrr,r rl ( \ '; lr ) sir r lcz; runci noi t : r t r : nepcnt r u f iecar e m onocat cnii t lc . \ l) \
    prrrrrrr (r.r, i'r \ i\ i, r lr npr m ; it r : it ir ) ,{olosind nucleot idc lit r cl: t lin nr . , lir r .
    I
    K A/ 0"'//'/{.--1,
    \.rrrrl ' l ,rr,.r r r r r ,lloliilr lur -
    - ( ! . ilr cc in pr czit nt it enzinei _dDN polir r r r , :r zr r ;
    z.'..--/. 'n./ \ ' I l r\,rr,r Ir, , r ir r liI ol dc hidt ogclr it r t r c a. t olr ii bazelor pur inicc; i pir im ir jir i, . , .
    tr-4 tJ-u ,,rrl ,l , rrt,rl i rr ( t r ll: r 1r 'it 0 ( ) aL1( utr a - sint ct izlt t r - l;
    cchc si cat cna ; r ou
    7, i. I r.. ,,l or i |, I 11 r : ; r t t : ncconl_. lr r r ent ar c ( f ig. f . 3
    , I ) s; , ir , ,
    d :/toz!:t ; i li8. . i. ) .
    gr;*,/ ^u-l -' l )l l ,l ;r r . lir r . r r , \ l) N m i esLr rim obilir , ci supusil unor m iqci. li t lcit r ct , l, r 1, ,
    l ,,rrl , r,rprrI , . .r 'r r r . rsc ' p0t lcc iLr lr : r c{ir r ni dc t iir r p r t r , .or diuut a n. icor : , , rr.r,,r1, .
    , r t,,,,,,' ,r,,l ir I r r , ilior r ir n. . l. . , r r ilionir n- ( l! : . . . . ur r ( li) . lc. . , r . . , r li . , . ,
    6 !1, , rrr ,, ,l , . li) , . r lr u. {':ur r or lr . ( . it r uj iir lungui st r ucr ulii AI I N- I _; , nir , . ir r l
    1,,t,,l rtl ,,r ,l , l, , r z, ' , \ - 'l', ( iC se pr ochr c nisclLii nr ai lcnt c, i: t t inr |ul r . , r r lr ; r
    ' r, I l ,r,.r ' ,r , l, , sr 'lr it lcr isi inclr idcr i ait ' lcgiit ur ilor .
    l ,rl rrr' rr ir . lr ,r lc - '\ J) N lt r czilt ii dc ascm clloit i: ont r . llc{iiiir : : plcilrI , ir r r l
    ,,,1,r rr rIi Ir,|; r (t iI I I I ( . clt it isi( ) nr lii. in accst c c; r zur i sc pioclr , . , . i, , r r Pr , , t , , r
    r, ., IrI r r r r Ir,r l|lot , cu lr csilr ilit at ca schim bur ilr , i- int r c f [ l; r r r , , nir , 1, , 1,
    .,' .,r (
    \l r\, , IrI I rrrr.rI i i I r., si plicr - ilc iiu. r t r r r ilor clc _\ DN {; r , ; lxr . ilr il: ,
    ,,' rl ' .rr.,i r rrrrri : r llr r.iir 1or - sioniLiilc
    r nr ir r ir n. Scst icciLiucclnllr r lt c; r |ioiii; lr . r lcciillr r lcr \ l) \
    ,r' ,, rrrr,rl r r lr . 1x. slc r r r t r ut t r t r , r : n r ur cliit nr t , t lr r .,
    lr iniLJa ? rr Li j i ri r I i rrri , 1, .
    ' tt, l rrr l rrri rrr l : . i, r I l; r ( lc lllllir t l r : r - L uct lr : t l cclr r lir Lr ] 1i- r Solrt.:iL t , l ni|ir r i sulir r r ,
    ,,I ' l rtrrl rrrr,trrr. r r l ir r {r 'lcgt 'r t lr : r 'sil; lt c: inghcnt r uir ii f il; r r urLt lclor . r lL, . \ l) N.
    ri ',(,lirir,(le|lidj.ede Al'lN i l ' r' orrr lr ir r ir likrf l'ir gpnenit lol r le
    /.,, I -' \ . l t . l r r r i r " lr ir r r i i n r ,l | 1 liL1,l.1
    .. , , ,i i,,ric "':r?le$e]]ln-
    1!! 1)' "[ l) N st , r , . , , , lir : , , lzilir . ir r sr . i, ir r l, r r : . ,i 1, ,
    rriirrr' r ri r r l z . L , r r l T r ' l 1 , 1 i, ,,,","' ' li' i I rrtl,: rt. i:1e (ClauCellF1t:re, ,rt,1' U rl i :i r,r'li( i0lt ( ' f illt t r r L, Dt , . l,si: <: r onr ct sor r t;iit , . l, t ilr r r .r . , , lr Llr r r i,r : r r
    lr r , ,
    ' r,l ' r, .rrr ,;rrlr r l . Pr oc. sr r lr r ir t r , .r liviziur r o scxur Lli, ir r llr lr lr r t l g, r r r r ,r oqr . r , , z,r
    , 1' rr,,l rrr, ,, r r ', lisililr r r ir r . l, r ir r I ir r r 1r JiI r .irc r uiLlLlit r i r lli
    rrrr,l ,,,1ic iir ' , 1, 3r r 1r ' p l i rr p rrtrl i ,l ' I rir I r,,i ;r,tr, r, rrI izi I rLi r:,ii-.pozilie an:l1p1-elrle11- i1r . t r , . ir ,r.lr . , r r i. ir r , ,
    r r r r ' 1, , , ' ii, l,l< t r' , r.) ' t/rtrtl ttt,r / ' r ii, r t ; i, , l: t l: \ r l , r l r L i , l r i r '1 i r : c : ' n : o l e c : L r l e i 1' 11,rrl ,rl r ' ,rr, r ', r , r r llr t r i; lr : , z. 'i ilr (:r( )rl l1)|i ()|rri <l rt rr,I r,- i ( iat It ) r hnlt t , '! :ir ll. tit n)
    r ( '
    '.rr ' " ttrt,tl ,t) r r|| | rr )r r )|l I i i , r r r , r l, 'r 'i : ' : , r r r r r ii ir r , : , r r r li'r r r r i, , i; r ir r r lii. i; ir r r '
    ,1 , \l r N.
    ,',||
    :l tl
    I l ) i\' t tI i lt)t t)t I Lt,i ql.. Iti tr ,r l tr i r '1 ,'( l r l ti o tL .,
    1t l I it t gii AI ) \ r r r r rL; r r r lr r i
    , lrr i r,,rrrLI r l,it r g. r t r r 'li. l l tl ti l l l r:r :r,1 ,rrr' i Ii i , r.r' l rtr" l Ltr: l Ll l ' r' rrl orl l l ' i tri i ti dc
    \l ) N 1';r r 4':r iirrilocorrrlrici,
    rr oluarrit t ) cJt t l: iLcir r - rlr ' siglt I r . r . s1r ir r r I i, r
    "
    i,' i;l;,,:
    t,l l rrl 1 r1( r' ll. t l) N, , rr, r)II| | | i I)Ii ,,i rIi r, r:' i i IrIr' Irst rttcl rtti i gcncti t:t: 1rc' r;ol l t' -
    l)itti); itltr$ft)t)tt.)!iottldLa si\tt rrr'::sittt:''t'r) (tig L5) in {r:lrrl accsta ganre{ii

    Precusa,,;r,t@a"- .,i "

    {
    1\itr,'rr;att2 ----- ----

    ,l,ttt rnb-n
    Crarnatan i r ecs; ti,. ;e.1t

    ,/zn./yeci,i larzlmtt lazl"nu /anlrealt'


    {nci molecule (1"1
    , r,' I {i)i!lilturaiia lcljc.)i.i1li dcxtro.:ri.:l -pig. i.d. -Auto1_ePlicare.q
    I r(r1, i , , , l i r r o u i s e g m e n t d c - \IlN ( D. G. l]r a u , AlrN (ClrLtcte Hiltrrc, 1981)
    l rt t l)l ( l , 1 c s o \ i r ' i b o , , a : I' - = lo sfa t; in iliF
    ,., r l ci spir'.Lle oomPlcte =. -14 A;
    ri!! l r . , l , n r : r r r r c l c o iid e ^distarl3
    :,4 .\.
    -.

    irrl rrLrrliLtotiiurtui r:ciriparrcnt crcditar rulic, care irr nlonentuf fi:ctrndafi.'i


    ,1,.t,r'rrrirriial)ilritia und'indivitl rleoserr,itdt' gcnitori. -\ccst fclout:n sti la
    l,r'. , r ,rLl.i I i r : ' r i i it t p o p u l rL i c L ,i o l c ,g i c iI u tti sp" ci i '
    li, t:,,rnl,iuiLrilefi.r3montclor i1c AllN, t'fcctultc in gcnom (iutrt: cro' /r!. l .r. - i i errl l 1rt)j mr.ex .ri ,rnos .j 111i l orpri n..rr$s i 1,g or.r/
    rr,,*'rri tli{r'riti) sau in iadrlll accltia;i pcrcchi dr ctonrosorni, asigur'r- pe hr ti npul rl ,(.i ,,r(:i .
    cic adrp-
    t,l,'r, irr,liviilLLil', hctorogcnitaic'r Sclrciicir'.-crrprrcit.tler.di{er'.'n!iati- ( ,rrIIi 1iI I i\ . , . \ l) N'r it oco't lial
    r r m . 'r L, : ic ur uli, r . , i . r ic, ir r , i'd, , . , "i
    .rr. r,i i, ut t > t t i , lif r i r 1 :r i tc fi u n (a l a c i o l ri u r d u l n.dl rL'
    ' tt(rr rlr' l(r '569 rruclcoiide. El r'.''t, ,-1qp16vsniert,-rstrict rnrr;rJ'lir.
    \l ) ' \ . lilr r llr t hL .l i tt(l l t. i n a i :rn A D \ b i cat" rnri dcrtro;i t' ctl n;r r' - \ It\ r.ri tru' t, r r r lli. rpq-l s, "li pp61, 1ijls. isr , lr n, . , l . , ". , r "r , pii . i
    rirrrrr.li,rrrrl
    ,,r,.r.r:,. r 1r , r , , , l. . lr r,l1, , c ;i . i i r l 9 .r.l , s .r,,l , -c o 1 :c ' i . r .rr -\D \ :pi ral al spr' , .ti nga rl "l l ,
    l rrrl l l l ri : ,l ,l t l tU :l nf,,l tZ,.;l z i
    ii. , , 1, , , . , . , .,., , , , . . , ,
    l ortn
    ,l l rr, ;:1 . ! 11; 1, r t < l. ir ' .rti :rtrt:,,l " ' 2 ,' 1 , -" .t' 1 i s i n l .t-anj atc di i cr" r feti d" \Lt\ ,,i]r:lll':!nrotivsintc".qtaie l r;.OL,,i tt,.l " J ,,,arn ,rJ o l l ^v !,1,. Il l Itr,r.L)D
    f,tri ,,:1 i. ( i. r t r . l, C l l s i rt .c i t* i rl . 1 :r o \te d o r: ; g.upel e {osfat al ci tui esc o
    din dtopt".-i. ;"i;-;;i;nc (suusrrbLrirl:rti
    'l :
    lir,i, irr zig zrrg (tlc uutlt iii tlcmrmirr,iL<7t:ADN-Z ),- Realizarea lnui tur de 'r, rt,'strnir)l)cu1t:u carccodificnADN din mrclcu.
    (r ti P d" \fl N ntr
    1 ,i r.rl .. . , 1, r , , t lr t t t t , ti,tt S rtrp ttti l i rc i ;tt:rl t. F r-r nrfi i l caccstui 1.2,2.2. CODUTGENETIC
    rrrt r, r l, . Dlit r( r lll( r : tl l l ,. S , r' r' ,rl cr' i " lrrl i rt(i l ro l ui cl (' a S ctl vl soua punc InI' ' Irlr'.rrrr,li.,gr'nciic:i.cr-.<rliirLr-ii .stc inscr.isi-r(L,-itl.t)gul filarrr.'lrrlrrirl,,
    ,,,^
    ,, rr,', ,, g, lr li s ir r r llt l l ]tl tl ) rl r. g | rrr' . l l rz i { i rr (' x l o rn l i a grupu1} 1iC -G facc po- rr,.\ [ltr:|[ irrrrl,rLj r.orlificat,rlcIr:lminatdc o lnunrjtiL siicr:csiun,.;r 1,,rr,.1,,,.
    ,rl ,i l ', ', , ' r ir ' f i, r1r r , llir , i ' i ,i r tl t:i ' l tr s trl rs l l ttl l r'!i i rI I (r ' l i l {enc ca ni trozami na, a{ l a- 'r"r)lirlr"(ii',' alciitrrir:s<r ril.r'.r. rrl;rrx'r'rrrrri,
    Irhririn rqir ili,,nir,,r rrr, r,r,r, r
    (A ndrcl r'
    r,,ri rr, l , , , r r z , , lr ir r r qlir trtl 1 i , P ti tt l ttr' i trl l r, rrI i tl l ..tIi r zri tttcsaj trl gcnc' ti c r.rt,rrr rrrrrI ri rri rI i r. r,rir{.unosr,rrii,,, rrlrropin,t,. ,t,,,,i,
    ,,,iti,,,,ii,i.
    l l , \ , \\ ' r r r r r l' r i . lr li r ll l r" t \ ' l tl l l o tl l rr, l rl l i l l )

    :
    30
    I
    ilrmiiri*ll,* Iliir
    r,i,IIr,',iiri',"",i.t!|';"5i I
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    Ir,i
    ( orlor r ii slr r r r ilir . i r r r r r inr ilicizi
    ir r in int cr r lcdir r l ilr r r r . ilor t li( or . ilr , t l, .
    \l i t rl , l r' : r r r sf u ( AI lNt ) . ilolccula t 1c ARNI ar c o lr illct l nr L<; L: oi
    , rr, r rrr.r'r'r.t11i. (slc cornplcmcnta|iL ului codon, dcnurliir diu accst lollv
    ir lit : r i : r

    {t,''ru,'r''',;l;;lli':"li\'3i'i$i'J#iiiiri;iii',ir,".,",-,r", ,rrLr, orl orr (r 'r . zi sir r t r . zlLpr ot ciuclor ) .

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    IIIl$;i,lr$l}r'+l"#:
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    ."i'r*|;Jil;ii,l';;'u"1.i t-rco;lric:
    ,,,, ',;;l'li;'.r, cl
    o '!nor'
    rjlljii'i:1i*,rij'jgird:fi #trt1s"un.*q4ii,$ll,:il'i$;i*:i'
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    il
    t,,rrtL'r t r ili pr oleinc (i i g ' 1 ' 6 )'
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    consrituitdin o''.rlonarea {
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    (: dra.!t:rtl,( t.odttLui geneti'c t


    celor
    - (,odlll ge11el1cesre specific Speciiiciiatea rezid.iLin succesinnezL
    I I ,rz, cirlt alci.tuicsc un codon'
    .,,,..1,1_njl"rr,jl,t1,i,,;jJ.::i"i"*;,.i::1":i:..::H:
    _ E.ltrjunivers:1tr
    :tl:l:lii;'l;:ll:iii:'ffil:l l"Ti"#";;il:"*ii"r, ."a"'*rcuaspeci ficl
    metionina;i nu izolcucita;
    ,r,..t.o"in.; ,\LIA co,lificiL
    , , ,jil,ir,r.,A,li", r"onino'.i l :rl ,l ,nrl )rc s por,.Ic ntc i i ntrc grl l pc l e de :l D uc l eoti de (c od(rl i ) ar|ri l r(,,l .i z i i i .i ,, ,.
    I r, \ t:orlifir:irtripto{anul, in locul unur semn stop' 'r, ',r ,l ' .,,l l ri i c el ul :ui . N uc l c oi i dc l c s i nt rc l rerc rtate
    ii
    pri n l raz ee az otttc A , l r, (i , (..
    TIei din cele 64 delripiete (U'{G' UAA'

    ',";.rliirff:r
    "
    ll'rrlrtic ar': punctualii-
    (lo{hL ,.i i ri c i rrc j tl i "r i n s tmc tur.! pr.tei nc l or s rD i reprez c ni rl i pfi n s i mbol nri rl (. l r,.l
    -- l i r. l 'l r' l i,||i l i r,L:rni na; S c r.: S eri [,r. l ' y r' : Ti roz i [3...). i ]l c hc r[rrl r(,gfu s i ot l l ] r,

    fr***;'#;H: JIJ:,|,l":r
    :T:";,:i:*l.i
    , i ,l r ' , , r ; r ' " ir dr ui rl c ti(Ati
    r G -\ '
    ,
    |
    , I l,rfr-! clcctri(i:i poritiT:! (Hist ina, Arginin:r ii Lizhr)

    ( rrl rr., l ,i l rc i l 1
    , V al i ra..,).
    ii ncgari.Tn (0ri/it Ast):,f
    ,:l rrl .,rri , ) . l n (.hc nafl l l gfi ,qi t ani i oac i z i i c ei mai hi (trol obi (trei l al ani l a,,S rri rrrr.,
    ti i r,,.
    C orl onul A U C , c arc c odi l i c i i perffu ]\' totj oD i rti ll n,rv r..rt.
    i rrl r,r | 1,.1U ri i ros aj Lrl ui rj c nd:i c . C oi 1r' c i c odoni U A A , U A ( s i (](i A s c urrr;rti z r.rrz .i
    ,,, ,',,, ' i'trc'-'pc iotdeauira translalia (trarltcr"tea)' ,1, fit l u' rni rn|s i rj ti i rnprn opri re:r traduc eri i (C Iaudr: I{ i ti ne, l 9E .l ).
    d'eliniiarea dintte codoni nefiiud
    - Lloclul gcnetic t'o "'" "i'gita'
    lr| 1rl\1i (1,' 11nrntclsPa!1r1' r.2.2.3.GENA
    ai.l'ici' {iccare triplcti este itdepen-
    -- Coclul genetrc lt cste suprapus'
    :rr-1co1]11111 un nucleotid ( ) rr'.r'r'r'rrli.<lc ntai tlultc pcrcchi rlc 1)L\zcutotitl.a
    ,1, LriiL. Niciodatl rLoi codou ttLi"c""li nrr cal:j troilrtir corhrt rrrrci
    .-i"t"dcgenerat'u"':l:;1,lixl'l]'ll,iffi
    i:'i'il1}"Hjj';""'*11'.:nT;
    r ,r ,r.rl rr ;,1r , iliq:
    f"
    r , '. ( sir r t r z.r r r r ,i 1t r . or , 'ir r ,r.(). 1) r , , r ir r l.,tr q. r lr . li rI I rI i r: r| , . lr
    l r ' ,1rrr,lr r r ': r AI ) \ r lir r cnr nt osor li po; r r - 1;r'L
    l_r . r r ,
    l, , r r r t r r r iir . . t l, , qlt r ut .( lr , t n) llr l
    I)cgc[e]:ar
    ;rr' llt^silLtltilLoacicl. ,, ' | (r)r| 1i r r ( 'r : r r _1r loI r lI r iliir LLc
    s rr;l l l v i rrftri ri i o tl l l ttri iti l nl ui ' 50000 t lc {. lcllc[ ) r )( ] r or r osr ] r r iir 1r pr - ovcr r icr r lr i
    ,,,,t -ul.
    ''''-' - t iil. i, , s igt r , ,,,,:ti r' ' r rrr,r ' .,il . l . r lilr '. r lr ( . n,
    rr i rrt l :rl rnscri ' rfil r]c' -' ' :i -vcutcl or de 1) ( .( : f or nosot niif r ovclili r lr : lir t r lii. . I ) iir t ol: t lr r l r ] , ,
    - S , *, t u' it t,rl (' (r;(L ()rIi' l i rr A Ii N rrr
    (1 " l l r' ' ,l i l- r 'r . r ( . ir
    , . l) r r \ inr ir li\ . 5o 000 r : r xlif iciL 1x'r r lr , nsr r lczt I r r . oI r . ir r lI or . ,
    i \[t\' ' l l )o
    l ri l ilr l, LI ,' , , : iili| ' o tttt'l " " l i rl i l l rl i rr r, Lrl trrr l rrr r r . ( ii r lr . r . r '11lr Ln, .

    llll : J: I
    i.1' '.J.:'.Cdrrrlcrulscgnrcr)ifir
    {rl g€nei
    ( ; I , lr LL : iir r 1( r L rr).(rt, l rL r r.l ' !1 ,1 , 1 ,r' , r ri i r:i | t-i ti P l ol r,ri rl cl , l Li
    ' ,ur)i i r
    i ',trr r rr . it t lc z r r .. \ r r ' :rl c r l x rl l t ,tJ rt.i u .,, rL i rr:rttr:rl epi nd reacl i i l r: l ,i ot:hj trri ct: |, 1' )(r l): ii . t r r r ot r s{r , cir ltl.L! LcLr : t ii( pt ct calioLe) copicr i: l I r 0: ljt t lr Li q, t r . t i,
    '
    rrr,.;r r Llr x . u( , c onl( ,ri l i tto tl l rrtri :rrrr;1 t)l ,n l ti .n .cLetl asl rtrcl xtfd,c?\resi l \ttl crncl te]e Ll r\ l rL. \ li\ r r r r : slsL:cst l c conlir iul, ca pc bandl'Lr naiSt r : t ir : r -ln1. l( ) ?7 r . ,
    ,l, lr,frrirL( alr, tcsnlLLt'ilor';c) illuttt)!:lt)blLutdc,implicatc inproceselc de api.rlie ,,,ri ,l rl if t , r r . r L 1r 't r r l su|pr illzit loir r e ci- t1a cLr car iot e] ant r t l r lt , iir r I . I r , o{ir I ,
    rl, ,rr,rl;rrtisrnrrluijtI) lrotuttr:1t.17.i,1,; c) faclctri dt coogulare; cI) Ircr*toni ':tc. \t)\ rr( lt r r r r , slr ,nnr li r nt ilung decit lallu1 , llr
    \ rrr i rrlril i l rr.ict acestol 1)rotcjnc rlcturLrinir dcosebililr: dinire indivizi. - , \ RN m cs'a3r r . , \ <: r , : : t r
    ,, , ,. , l, r i lt oilt r snl r r nci copicr - iexact c : r gcnci. Celcct i. r 'jlr ', , llr . lr ll
    (lrDorLStcrcilfenomenului ,i, codi{icarc gcnetici r prcleinelot'si descope- rrr ,, l ,r r lr , r r r vir . Lrsis S\ r 40) apoi Ja soar ece,au conf ir llai. r : i. , \ l) \ r lir r
    ,,r, r rl,,fii:itirlui enzimatic deterrnjnat rl. o irutalie gerielic.t r condus 1a ior'- - <i
    ,,,,,r rr,. lr |r iiur r i r . - \ or dr [ 1. ar ode nucleot idc, nunit c illlr , , , i . . i 1ur r ir r
    r r1:r-r'l r:otcspondcntei: o Scni. * o enzimi, concept conforn cirruia o Saltir , irl 1r rrsi:r-isc i n AItl{ mcsagcl numitc ,?.f,oir7,i (\\rirlt(ir (;iil)( rt, l1)','ti;.
    , rrrrlr-,rlr;rzir sintcza unei sir.rgureenzirnc (I3eadle gi -la-tum, 1941). lJr:oare':: o I Lr ., 1o,1rlr':rrrlrur:iliitL ge1)ed.iverse,ca acck-.acar.c ct.rrliliciL pr.rrtrrr .\ l{ \r
    rrzirrr'rpoatc Ii constituiii clin mai multe moLecrle ploteicc, aceirs'tirrel:liie ,, , I . l()i,rlinir, ()r'{ralbilttina,lizozimul, hornroml de cr-.cslcr,:ri iu,-rtrlirl
    lrrsl r-r{olmu1;rti slb forma: o grni. - rrn lar.tt nolireotidic. StudiLrl im.:.uo- i ' ,' . . i L r r r r Lr o, , llolr r r lin,sir lc lt olt r onul de cr esLeLcunali. - , \ ,c; Ls1:lri , r ! . r r r'r , -
    1,, ,rrliriirlor il cortrib.dt 1o urgit:-"--;c".iei;];if." ii-iC.id {i"c".r,, dir. i,,,.t- I' l i r or r , r it l, r lr l) il: r..\ ; t lcl, ir r gcnelc calc codif iciLpcnt r u 1: r r lr ilil, r l,
    rril r1<r irnunoglobrdine are o regiunc corrsta.ntii,controlatl de o sirr3r.rrrg r;. ,, ,,1,.1r,,.r , , r i: r li iit 'i cxoni
    - r opar at i dc 2 ilt r oni. in gclclc, car c cor lilir . ,
    , r 1,1-;irrucr.ariabiiiL, forrnai.'r. djn I l2 aninoacizi, specificatiL de 2 gene. li'rle rl l, r r r lir u r Lllr usuluir b ol exist iL opt cxoli 9i ; apt e int r oni. ( , , r r :
    l,rr:r i|girrni, constarti si vari:Lbili. sint scpalatc pl.intr-o secven{ii de 1 l.:r0 ,,l i r ; , , , r r 1r rrr'ollLr L{rar r . :ur : r i r nult c zcci dc int r - oni. Cn c- , <ccpt irrir r r , , r
    r, llolirl'r tctranscrise. In acest caz, relatia de\ine: tr-ci gcne - un iln! , | ,,,( TLr , , r I ) l, r ) t r 1L lt ist onc ( plot cinc ca|c iLsignr iringhcniuir _ cl lir t r {r r l, l|
    . l, rr , r , 'r r r osor r i)si pr nt r - u uucle var ir : t iuli de int er l- cr oni,ot 'gir 1) ij; nr l, ,
    "rIi p , 1i1ii1ir : .
    O {,'oil oste compusii in uedie clin peste o mie de baze mrcleice. I-a or-qa- ,, .L 1rilr , r i. s( , illt cuiilt c. hr t r ouii sint uneor i m ici, I or m a{i r lir i r r 1, r , , , . r
    ,ii .Lrr,lc ilocariote (fiLr-irmrcleu) si lr virusuri nu existi d"cit o moleculi <1t: ' 1rr 1r r , r , I, ri r lc lr vc sar i 0, i kb ( 1 kL- = I kilobaziL. = i iX) 0 pr . r . , , r . lrr l'i
    , i,l rrtclr'it'. l-a brctcrii aceasti moL:culJ.a.rccitcvamii degenc carc sirrt sitl.r1r'j / I l i ,,l , r r r : r inr r r it r :oli ei au o lunginc nai m ale Llccit : r i: xonilot - . lr r lr , '
    i,' rnt sir)ltrr cromcsotn. Toat" scnclu sinL lt'g:Ite, ficincl plrte din ace'a;i r rrr lulurol r.-\onilor rr:prezinti1 a.l)rorinativ J 000 dc rluol(.r)iir11 .
    r!r,irrii. urol( cular:r, alcltuind o sing[ri grupi de legittr.i (linkage). ,,,1 i .r r , , . ilLlr {r nilor cst e cle or dinul a i 000- 20000 dL; uuclr , , , t ir l
    ItL olgrrnisn clc eucariote (cu nuclcu cclular) genclc sint legate in ca,lml ,l ,r \ . l. lor r ir r r sliil'. , l9E1) . SL r pr cciir , , - : r L r jiD '. , r tLiir : , - t t : g( lr '[ ! ! i) r r llr i
    ri,r rltoililor: cxistir tot atitea grupe de legS.turir cili crolroson-ri e-.:isti. ,, ,r1 ,, lL. l( , lco( lanf ( {onnat din int r oni) si iu lr lt alcnir - i, , iur r t il".

    Zrrrr d.c pe cronlosorlr pc care este localizatir. gena. se nuuregte j,:,itts t,r r ,1 . . 1r ', or r silt r - r . rsi a d, . . 1r 1- i15 t oir , luzil lr L pet lt lt a dit ijlr : ; ir r ir z. r
    ilrirrrrrJ,1orr.). O gcnlL dali ocupi totdcauna un locus sirecific pe ur:rnr--,lrit t' , ! rr , , jl( r i cii scgm cnt c clilcliic ( cxo, r i ; i int r oni) it slr 1r ', r l: r ( r 'i. , 1
    r{Jn)(rsour.(lind ambelc gene a1c unui lccersEenetic sint iderrbicepc perlclllra . i, Llr : iinlllliiJ, int r - o nr olt culiL dc. ARl{ pr +ilc- r agcr - 1) iu r r r , , rt , ,
    ,! i lorr,irsorri. indilidul este lnrltozigot. Cind o genn, reprezcntind L11rc:rracier I r | ,ulr ir i cxonii cnr - csc inliLn{uic iut r - o ior m it capal. 'iir isil. <'r xlilir , .
    .,.r1, irr.c,c.ristiLpe cc:idoi cromosorni sub doul fonne cLiferite(nu. sint idoniice | ,i , l rrLl l) r , s{l- inr li: r 'r :cxor t ilor si a5lzar ca lor in AliN r nlsir r lt . r 'ir l
    rinr (:r.r'a(l:cru1pc ciirc il expriml), aceste fome altemative se nutncsc rrirle. L rI r, r {) r nl o1. sccr Lonlr c cnzim at iii a {r agm t nt elor , 1l }, , r lr r lil, l , l
    " I ,,, rl rr r ir r , ir r ii: oLij; i c- xoui. Si: discr r t iLposibilit at ca i: xcizil, i ir r l r or r l, , r
    in rrr'(sl <--rrz ir ividul este lrcleroz|go| pentru car',rctcrrll respectiv (variabilillte
    | , , r r 'lir or .r 'or lil'icir r ,('is1( 'asit ur aiir dc int r onii in; i; i, lupl ol' r r . ri, r r
    '''Lr,lir'i). Iiir.carc indir-icl estc homoz,igot pentru uncic loct gcnctice ;,i heLeio-
    :i r o l pr . r r lr r rir lt r : 1c.
    ,, Li (,r', )t trI r'j;r1r' . S- r l r lcr r . ionst r ntposibiiit : r ic: LilLt t ocxcizi(i, r l( . ( , r lr ,
    \i i \ r 'il) ( ) s( ) nr ic ( 'l'lxr r las ll. Cr , ch, i982) . Ar : oast iLobst t r '; r lil t lr r r ,
    | , , i , ., , i, 1 t r Lr r icii:poalr . ct r clua o cr '. t aiizii. - f ipn1dc AI iN t : r r : r clivil, , t , .
    '.2.?.3.i.Struclurdgenei tl rl , , , l ,r , l |I t \ \ iI t if u) : : l', t.l
    1," ,,r I rrir or r ilot 'r 'slir ( : ( ) nlr ovcr sir1t . J) acii ar avclr o r t ilit lr f c lr iolr 4iir ', i,, "
    (;L llir (i:it{)ccnstituitir clirr urai rr]rtlte teciurli. c -'! iuuclii distir:ciLr:
    ' tr ' l rl l jir l( r l, sl lLr i: 1. r r lii) iulr , t nt iut lonar lr 'cllLisit duci. l it rrr rr rli l i' r r r r
    .') I)tt)iltolalLrLrstc o sccvent:r de ADN aflatii 1a cxtrcnitatea 5'. Eir , l rrl ,r, I r in ( \ l) cr it 'llt . ) ( lr . r r r inL, f iLr ct csi iur Lllii l. clt nicjlt ir ', t iir . inr r l,
    ,, trrrrrrci rri dr: acfiuue a erzirnei,\llN polimeraza, cirre iniliazir sint';za
    rr I rrrii, r r r r r r llir r lr , , 5- ;{pyr 1 ''I ii , . , pr ir r r r r r l: lii . r l, in1Louii i] ll. : ; : ; l; liii, ;
    r,,i , inr lot .
    ,,, lr r r r lr , ir r r .ll, . olr '1ic , : i : lr l) lr licil) ir . llL. r cglr t r . , r cxprL ilr if ii ll( lr l( , 1
    l,) l.i ti.L:r ui. rcprczilitl o secvet.t!u"]- c'leluclcotide care codi{ici e:t :emita.ea
    ,' ,r, I r r,ir r r ( ), r, r r r ii r r r r r : lr : ulr [ir , r r : t r r 'sr rr]Jilr r r lr nl. ir : rr::ii, l llr r . , r ciLr r . f r . ,r r , f , . ,
    \'lt\-rl-rnatrir- ln gcncle reglatoare existl la sfirsitul sccve:rtei l;{i,:r,
    Ll , J( nlr'rlL dc coni trrl numit atenu,atot, ca.re inten'ine in colttrolul tral- | ,r, r ,lr r r I r r . r ir r r r r l: r - i: iir t , r 'i, iii, , r . iJlt i, ; l'; 'r . (ki: . li. t ir \ t ) '. ir r lr r r r r . li, . , l,
    ,, rilriili <or1ulli gcnciic. I)acir cclula. are o cantit.rtc st Jtcrcnti d.c produs fi:rl, rl I ,l rlr r L. t r {ir . r r, ., , lr r lir r i r r r i ilLlt olr I n) ir l( , t lr 't ( r r i t loit ; i ir n', , |. , . lr , I
    i I ri r c r il) 1iirs r . opr c s i r' l r i i i r.c l u l l i :c ru a to ru l u i . ' 1, 1,,,l rz r r r lr r . lr rir r : . r r r pozit it r lr 'i o i. ilr lr r r . i il, lt il l) r 'it lr .r lilij: Lir r l, zr
    \ ' l , ' ; , t r , t uI t l s l ttl /l th tl t7 ,ri t\Lg Itl l t Irto ]rri n zi si . \cci l 51.li l l (:, 1)' I l l (:1)(l { \l l l l l ,, l ,r t, rrrl r lr lr . r ilr . . lr L r , pt ijir r r r llt r ', , 1r {rir , ilr , i lr lol{ t r r lt r ', ilr - or r , , I I r ( ; r rll r . , r t , r
    u rr l, r i ii, : r r r (I i( ) | ri 1 L '.ri i ,1 r'r' i Ii l ri r' ri ttlz, rr 1 rt,,I,i Lr,1,rr. l rl
    '
    ,.r' ,i i i i tl i r, (r i r.,l )i (l I.r' 1IJ rr|.IrIi rI, rorIi J i c r l i L l )r' l l l t I i IrI4IIL,rrr||,l r

    :l I
    i,llrnrtlir;rllrrIiloirIii, lir' pltrlrrr rr ttltrlopcpli dirin hipo{izi. J)c ir'(!ucn(a.s-a 1.2.2.3.4. genelor
    Metiloreo
    rrlrsl'rvirtr:ii () ljcrli rl( lrislrx:otrrprrlilriliiiLlc
    poatc si codificcpontru dot:a
    prrrir:irrr:rlilcrilc. Ar:csicirslrrr:lr:rlcsrlrirlircrspcctivenoi in inlelegercae:;pri- l)r";i gcnclc sint prczenteiu toate celulele,exprimarealor estc difcrcr-
    rrrirtii ;i .r'cgliLrii g^cuclor. Sc rrrnirrrr:azirelr:mentul de mobilitate a struc'i!,11ii 1i,rl.rin frrrtclicdc organ; de e:emplu numai ce]ulahepatici sintetizeaziralllr-.
    I)illlrI()nrullu gc.nc1rc. rrrrrrrr.Ar:r'irslrr
    pl'csupuneci diferite pi-rli ale genomului sint activc itr r;rorl
    r r r, . l r . r 'r 'nI i l r l .
    de repelqre9i
    i.2.2.3.3.Fenomenul genelor lixlrrtsivitatca celularl a unei gene,sau abscnlaacesteiaa fost lcgatir r}.'
    'mgbilitcleq" | ||i||rr(|l|I(' tli-' rnctilarc Ai demetilare, cunoscuteprin realizarcaunui norlr'l
    hr iutcriorul materialului genetic existl repetiri de secvenieatit pertrtt ''.l,rirr('nial(modclulluiRiggs$iDuartein1975),veri{icatiapoiprin mcrorl<:
    ,1, irrllirrlic gcncticir..Rezultatele cercet5.rilorarati. ci genelc sint mai prrfirr
    Sunclc coilificatoare cit gi pentru-ce1enecodificat6are.In acest{ei se realizeazi rrr,lil:rl. irt cclulclc carclc cxprimi. gi sint hipennetilateln celulelc carchu'1,.
    :,rrlo dc copii ale unei gene, grrpate in fatnilii multigenice. Un e:icrnplu penilu , ,1,rirrrii,l.)lr:nrentulmolccular carepoatefi metilai cstecitozina, sub actiutrr.ir.
    ;qnryrclccxioniceil conitituie" caZul genelol crre speii{ici antigeneleinajor,.' de lilrzli, irr sccr,enlade nucleotidc citozini.-guaninii(C-G) dnr .fDN. Ii, ,
    lrisi oconrpatibilitatc. Prin metode de inginerie geneticf, aceste secl'ente care 'rL,
    rrll,r rrsl[cl 5 rrclilcitozina (5 ]IeC). Cum srcventa C-G rru esle {rccvct)ti'r,
    r(. rlrp(itilau putut ft izolate si studiate.
    r, . rll rr r'ii.urunai 2 - ?_oiidin citozineletotale ale genornuluimamiferelorsill
    Sr:gmcntelenecodi{icatoarede ADN se repeti. cu o frecvenfi 5i rnai arare. r , lrl.rt,,,rliil in cirdrul sccvcntciC-G metilarea sc i:rtilncstcin proporlir, 11,.
    .\sllcl, lii om, 30 - 509/0din ADN aparline fainiliilor rnultigenice'din acestir l t)0,1"_
    r';rlcgoric. Uuele secvenle,nunite ,,Alu" cu lungime de 0,5 kb se repeti mai l)rrpiLipotrza lui Riggs, in perio:ida embriogcnczr:i sc ploducc o metillr',.
    rrrrrlldc 100000 de ori, reprezentind1 - zo,t &n genomuluman. rr1, rr,ir, r:tr rrni{ornizalea AD\ embrionar. Pe misura diferenticlii celulirr,' si
    Ilolrrl sccvenlelor de ADN care sc repetl nu este cunoscut. Pentrrr genele rr rrl,rrl sr' protltrcc o demctilare speci{ic:ra unor sil?is-xri din gcnorn, crr , r
    ruxlilir:atoarc,sau grrrpeleexonice,se presupuneun ro1 in realizareaproduscior l,r LrLr,rr,,r'r.lrrlrrr;'r fi)respunz:rtoafc. Experimental (prin inginerie gcncticiL) s-rr
    (| sinL(:zirlroteici in momeltul de mare solicitare (aspect cantitativ) ;r de ,1 lrl(lrfr,llll r;iLmctilarea iit,.oitro a Senclor purificf,ie si rcintr-odricereallor iu
    a-i-ur'.rn. :r Jivcrsilitii Ior. , I I.r,L. rurr r r r il, r 'r r l"lcr m in: , r hlocar na c. r pr inr ilr ii ; r 'r r - i.
    ()nclr: secvenle care se repeti" posedii o proprietate remarcabilS.,de a {i iilrrlii rlc mctilale globaliz au pus in evidenlir conpartimentarea gcrro
    ,,rrolrilc" in genom sat ,,iransportabile", de unde ;i denumirea lor de Jrcru's- rrrrrlrrr,irr zour: destul de intinse ale ADN care sitt rnetiiate 5i carc nu 5irt
    /'orrzrr'.Accstc elcmente mobiie igi schimbii"iocul in genom cu ocazia uiror ,l,r rr llr' (:{lul;}r, numite cromatinir puter-niccondcnsantir gi zonencmctilrrir
    iirluli crornosomicc.Reperarea lor se face prin obsen'alea efectetrorasnDrar .l , \l'rirlirr(' cch ar[. Conccptul de ,,domeniu" de metiiare face posilrilil
    I rurr:tiortirrii altor gene, | | | | | '.| | I i I r'i | ;;cuonului in zoni active si inactivc (Linda Sperling.- l9l3).
    lranspozoniiou lost de"cop.t'iti dn Barbara llcClinrocl: in re;rrul
    \'(.rlctal.Ei au lost bine studiali ii bacterii in perioada 1970- 1980. Tra'ns- 1.2,3.SINTEZAPROTEINETOR
    r,rfonii st:prezjnti. ca elementegcnctice cu luugimea de 2 000 - 25 000 perechi
    ,l, lrlzr:. Iii codilici nu numai pentru proteinelc care necesiti deplasarealoiin lliorin(r'za.
    protcincloreste{uncliagenelorsi reprezintiploccsulcornpllx
    irrr,'riorrrl (cnomului ltlanspoziria),dir 5i pcntru cnzimccare ion{ori r:zi"- ,1, tr,rrr l,,r'al inlormatici dclar\DN nuclcar la polipeptide, sub for-na cochrlri
    'rrrl;r l):tcicliilorlr airrihioiice.aiL la uri iompus toxic. Xilol,ilital, a ac--'ror ' rr trr Ar:r,stproccs sc facc etapizat, pol'nind dcla matrita existentl in Al)N,
    .,,.1qrrr,'r11ugcnetice explici rapiditatea cucare 6acteriile dobindesc caracl:rul ir , rrr,l pr irt r:lul entul intemcdiar care copiazi rncsajuJ,rcprezentat de Al{\rrr
    ,1,'rczisiin{ir la antibiotice. Tralspozitia in sinul genornuluise insote$iede .i rlrrl:rr(l la stlucturi capirbile sir.transforrnc mesajrl genetic inir-o scc\'('rrlii
    ,lrrPlir;rrlr:a.in{orrnaficigeneticecare limtnc prezenti.1a locul de oiigrne ;; se | ,rrrrrr'rrcizi,{oLrnatc dil -{RN ribosomal (-ARNr) gi Atr?N de transfer' (:\It\t).
    rr:ri.rir(invadoazir)9i alt sector genetic. 'i, lr(,nr;rtic,ilccastir succcsiur]cdc reactii cuplindc urnrirtoarcle sccvcll( :
    , t t,,ttr',trt:kl,il. sau treccrcr AI)N la copia sa in negativ, ,\RNm; b) ttgnsm,isi.rr,
    I)rin accla6imecanism, al asocreriivariabile a fragrnentelot de gene cilre rrr rrri l ' 1s111, 11.
    AllNm in r : it opl; lsm a cclular i; c) l, r uluc*t a sau sint i'zr ir r r li
    ,.ulhrlcuziLlim{ocitele, se explicl sintezaunei mari 'diversitili de anticolptp
    1' ,1,l r,l r' l oli n : ilxr sor t r ii cclular i, la cale par t icil>ii '\ t r lNr si AI ?\ t ; 11)r r glr l. r , r
    (,rr l oatc cii nccanismul transpozi{iei nu estebine cunoscutla organisn-le t tt 1,, plir inirrrncciiul {cui:Jor reglatolrr-'.
    ftv111,
    : ol)r|ioarc, similitudrnea aranjamentelor de sec\.ente1aextremitetile elemente-
    iir'-gcnciico mobilc lasi sii sc prcsnpunri.cir transpozilia fse efectu':a;rirca 1a r.2.3.r.TRANSCRIpIIA
    lrirr:irtii.
    \l )\ liiu( l r i r r r r I I , , cr r I l"r
    f oiuit : gr ca 11r lx) it lc l) iilir si t llu: l{lL11 ( , nciu, ol:
    I)cplllsxrcirt nursi:rozcxtilotlsli' tlirijuti ;i rL:glati genctic. Transl"rzi-
    1 ,rr,rl rl r' ,i lopllsr r r ir . plir r ur cr nlr r u; r inuclcar i) , i: r r t "r lr ilir lc; r nt ir r ', 'r ll. inlor . -
    (iiJr.r,.prr.ziniiL cltct o:iursiLpotr'rriiiriiutl:ortatttiLa variabiiitiL{iinuel s1rtclr. ,r!.rl r i ,, I, 1i( r ' l) ( , ( , lli. o ( t t 1>r it r <1rt l:',piLqclf 1't t |v0ilr , r l, ' nt ot ) l( , ll1.l) , . ir ( , t , l,
    irr rrc,lrr;i iinrll, lrlirr rr:;rltrttjrurlrlllr'(:forllosorll:
    o po gat<:lr: Jlrlt protillce,
    I' r,rrrr ,,rIi r 'I r r t lr r '' linllz' i llf olcic( j i) r t r - o cr 'lr r li , llr lii r . : lr . r r r r . , , : ; r r ii( : r r li
    l r:rt|,l r oz ot t iil) ( |l l) (' lIl tfl ri r ,' ;rl tti tttl tt' t' rt
    l l l l r)l o (:l )(' tl r' (:rsi l l _(r
    \ri (!1i i .
    ' , rri r) u nrir , r I lir t lr 'r lit t r r <r . iniil it t f or r r t ; r ! ir . .M r , l, lr r l , , , , nrlil ir r , llr r r ', r . r i lr l

    :t(i .t7
    ,) ( l tl i ir ,( v ( . n{ i, l ,ri rr ri ,l ,l i ' .rr(r (,rrl c l r' l rl o c l ur:cLca) A D N 5i f()tl rri rr' (' iiIl tl ci
    r r,'L ,r'r r lr . c l: lr i lr ir I Ii . rrro Il rrtIIrrr,i trrrritrri r:i i ,c a p ;rl l i i i Lsi r travcLsczc t)rcl ttl )rrl l l :t
    Sfir5,tu/1e,,;t
    rrrr l , rr r li s i s i I r iurs rl i l i i i rrl i rrrrrrr{ i rri rr r:i to p l asmi r, A R N mesa.ger.Iu { el c-
    rn,.r)rLl(lri rcl)lioirlt' ir AI)N, iiliLnttttl,rlc complementare a1e motreculei marni. ',',t!
    f, 1'l)i[iisi rrLr[i]lnrcttt lrt]clri sof\'fsi(' pentru sinteza und filament comple-
    /lt7/t'
    fi,.)l1rrr noLr. i)cschiclr:r'taclnblci clii:c a AD\,
    rl lr;rz,', sir f:Lcr:suir ac{iunea unor cnzime, l.&N
    uccesalii |ecopicrii lanlului
    tansuiftazrAL}N depet- fr €.{01 r €r4,4
    ,v? | ,4V
    r://
    ,7i?
    ,/,,',, srrrL.4DN !,olirrcrnzc. La inceputul replicirii se produc efl d.t[tl de
    l,L r( ttrl dc scparare a cclol douir lan{uri, risuciri a1e Jilamentelor care pot
    I
    ','/,'/,tup.t'/b
    .j
    /frDA,r
    i /z
    rrrr"i,'tliclr continLrareaoperadiei. Acr.l luclu esie evitat prin actiunea unor
    { r)/,ir(:, din carc {acc partr: Ei glrasa, care induc o detorsionare (desrisu-
    a' 0
    , i r, 1 rLliiancntclor la rir'-elu1 bif rcatici t1e replicarc. Gyrasa taie un filaneni
    r ,lrrlrir:i clicc, ilenfil: cxtron-ririlil,' aptoni"r. si 1e rrsudcazl, cu re{ilcerca
    l
    /'+
    rr rlrrlilrir. \lt:lunclic.,nareaacestui si:tun ruzimrtjc cotrpromite actititaiea
    ,,l ,L l l r / CliLr : dc 1' I 6 1 d rte1, 9 8 4 ) (fi g . i .7 ). rlikt
    ,t./.:.t;.J{:Jdgef
    [.a t.rrcaliote, r.plicarei],\Tl-\ drtermini intr-o primi fazir formarea
    rri,,ri Alti\i prcnrcsijgci in care sint tru.uLise iitle'gral lo;tt' scgncntele din
    l i ..:rr, r ' . r r i . , . . \ l) \ . \t\ p r' ,mc .rg c r , r;r' i r, 1 rsl fnl rri r ." :' m,.nfcl c c,:.'
    l
    ,r,,irliciL pr,nim plotrire, exonii, cit si {raglnenttle ,,iuactive", intronii. Sr'-h ,"JI
    :rr rirrrr.rL^rrurrisiitem cnzi.ilalic specific ..,- r'tltze;Lzl intr-un a1 rioilca tirnp ,.\"1)/lAn€red
    ,r ' r:IiorrrilL':L fragtnr:ntr:1or,la locurilc dc joncfiune dintre si exoni, (,A0n//ar
    ^introni
    r,, , lirrrirri intronii -<i sr: realipesc {ragtncntcle de exoni. Trr accastS-formi. , ,)'
    r,, rr,:rlil, rrzii ,\liNn - natur care cucrinde codul genctic pentru sinieza I /,,
    i ,r,ri r'i r r ,I , , r it ir . Ls). -\L o l c c u i a d c Al l l tm e ste stabi l i zi rti pri n acl i .ugarea ) is
    r l, p, ' ,,' d " rru z i n .l , [o rfl .l l ' l :r! .l ri .21]0 nu.l col i d,, l a crtrc' ri - / r\'.U
    'rr,'..- r ' , r r t ,
    l r l ir .i'. l-.r ccnlalti erircmir a moleculei de ,\RNm se afll c sec\renti /t/ (,iJ'dtref
    'l.
    r rr;rrrirlirriL 7 rncl.il, cu iol in inilier-cersintezri p:oteice. ARNat se p{ezinte,
    irr rinrl srrlr lorml monocatcnarii hclicoidald (un singur lanf c1enucieotide). rlt 7
    n exo/l€)'a{rexq,q
    34
    €x0/7
    Sl r rr:1,rr'.r1,:r' dcosr:be.cie cb ADN prin flpiul ci are ribozd. in loc dc dcs- ./ti{-/Ut:€/ti'
    tl
    {'
    , t.tt,/t'.tfie

    t t t i. S .i L. nri r s i nl ez ei l )rrnei ..."l rc .rri rrarde]a A D N s es nrerfar Fragl nertul d.r A D N , or(' s .
    | , 1,,r ri ri ,i i g(,r)f, ( rpl i l l Ll c !c grrItti r ac 1i ,-r, l ol ]Irai e di n :oi l ori c a:e s ptti l i c i r" s r.,tc r' r
    r ', r(1,,r i , \oni ) $i s c grrc nrc i r:ar-rr pr,rr"r,,. L, t,oc ."1rl ,l { rnl (z i P (i l ei ri rs c s u,(r.l ;l
    | ,|,rIII r,IrrI,(' ; a.) l ral rs c ri ur,a, s aru i ' { | ol i r' rc l l i nreS ral :r.r ger(i i nh-o mol ec ul :. dc
    -\1l N
    t r' ,, .r,:,r I l , ( \r i /i r. j ntroni l or i i i l nFei rl ,i i l ea ex oni l or; c ) pti r s l rdi l roa c x .r)i l r,f
    "tti nc rea
    , , ,'!,1, nc (1,) A l tN l } re!fi gd .rai c c or1.j r1el a i ul de ]ruc l rol j (Li i redrs arc Lo(i i l i c i i l ' i i l t()
    I R /t' netage. ,1,,, I ,I r | | / i i 1, / rr r' () gr' ,r(.i; d) tl adu.f.c ;r. nres aj ul ui gc rei j c j 1r1r-rr1l aD t dr atl l j nc ac i ?i ,;u,'
    [,i r])r( rz r"i pr' ,i .i r.a (]\. L)i l r1(:hi n,T' } . S l or:i l ]rs k i , 1984).
    r
    s,ore/radtteere
    jtii!. 1.7. -- Sirtczn Al(N rLreixtcr. r.2.3,2.IRANSMISTA
    ,{)
    1rrrrir . r lir t cir l( , r 'r ildc - \ ] t Nr n lolr r iat iL in }luclixr m iglc: r zt i.sull I olt r r r 'i
    rrri ri l r oz ii5i r r lr r c il ir r l r,r' 1 1 ,l i rrn ri tti r.I)c r:i l ,i rz ,i c tzotatc carc i utl l i nsl ;r:uctura 'i . ri rrrl l , , pr ir r lxlii llclni) r allei nr ir llcar c, in r : it olr lu: nr ir .
    \l i \rrr s ir r 1.ir r iL. ni n rr,i trra i ri n rLc, i i o z i rrrr q i rtra ci Lttl ,S ucccsi rtneabazcl or di n
    Al ,l \n r r ' ,llllt i s 11(r' r,r i !l (' i r l ,l rz l l o t rl i rr ,\i )N , t :tr compl crnctttari i ;Ltcstr:ri ci : 1,?.3.3,
    TRADUCEREA
    .\ I' N I l { r' 1 rl z ir r li l) r o( { slr l ( 11. - jnlr , ziiir 1liii1r , , 1: , 1ir I , ,Ir,', r 'lr r {' l) 11sul) iLlll{:
    ir r r , r '
    lt l ' rL(r.rrri ri r 'ir , lr t r r r ] , ' r r ) t , . f ilx, n( l( t r ili( ( r lll ( , ) i, r r , lr r l lr , r r r , li<.

    : i9
    lll)
    'l't ansfrrntl inlirrrrta(ioniLlcxprinr.irt prin rclaliir lrrrrd;rrnuri
    aliL Al)N-
    It,,sr:iltlrfllrrttr.srtjttltti irrlttsde ARNn 5i sintezaprr,l1lnr:ior,
    11r'rrr'lit \l i N ;urrtci ni r iL Iost nrrlnitir codiJ:imre(totalitatea lcrrcfiilor dc i lunscrillc
    r,,rirrr: r'ilxrsrrlrilorr:iloplrrstrrrtir:i, irr prczcn!:.1 ARI{ ribosomal'(,l liNr) ;i r l rrrl ttrl ro rlin carc rc'zultir sinlcz:r de lanturi polipcptidice).
    t .1fiN dt traus/tr (tl IiNr ).
    llilxrsornii rcprczintiL prttlir:ult' dc 5-20 microni, situate pe-:nP1.a:
    l:rlrr cxtcLnir a rcticulului cntloplasuraticdin citoplasmacelular[. Ei sint
    lirirrirLli din subunitiL{i cu constaritiLclc sedimentare aileritl. Aceste parlicule
    cr'| liu
    ' r>roteine si ;\trlNr-
    All\rc'tcsinletizat in nuclcolsi se prezir'1{.-t sub J tipuri :26S /Ste4-
    ,1/t L/eu
    AOI/
    W
    , /, fornrf din 55tr0 nrclcotidc. /8 S formal din 2 500 dF nuclcotrdc
    :.i 5 .9, constituit din i20 nucleotidc. I-a mami{ere, genele czrre specifici
    I tu8kfl
    iil rril' i I s si 2q : sint sirullc Pc l'tatelc 5(urlc-a1;cromosomiloracro-
    ,l.rrri,i. t,"rr. ppnln;5 S'srr si{uat;.Pccrornoomul lsi pc elfi cro^tnosomi'
    AR\ <le irans{er' (ARNI) este .format din ?5-90 mcleotide. Succcsiu-
    r, ir l)irzclorclcARlit csie identici 1a toatc speciile(bacterii, virusuli, plaut'"
    rri
    wT;e
    rrrLiruult\.Aceste seu'entc sint numite aniiJodoni,iiind stcreocornplcmcni €-*
    lr,liL clc irazcle ttansc:isi' pe ARNn: adenin:r peniru uracil, guanirfL pentrt
    -{unctional,
    qril',sinir si iuvers. -\R\t il {orrri <1etrefli- se realizeaziLdupl
    rrr',i nLulic rcma:rieri: seclioni.ri gi supiinentili dc nuclcotitle-(se elimjni
    s,, \ \ nli, liJi r \i j' r\ nla .{' si cc adilrs; rriplcitrl CCA). La eucrrtot
    ., ,',,,'i,1,r,.-.i c\;::. ,irnril su[, do6enc,.rt:rcoJilici pcnlru sintcza AR\t.
    Nrrrriu-Lrl clirARNI 1a eLrcarioteeste de 56, rnai apropiat de numirul codo-
    rril',r (6.1)qhrcitc1ci.1 arrinoacizilor(20) carc intr"i. in structura proteinelor.
    il o
    .h
    s n
    lrr l,'irrl' irr:r:slacriistir urai muiti AR,'r-i pentt., un aminoacid,situalic in
    r ,11. ..:l| ,l{ t|tntiL i , . o, r ; p blov t .
    Sirirczaplopliu-zisi i proteinelorcuplinde mai multe secvcl!e. l\[o1e-
    ,;rrlLrlr' ,\ trtNrir,iringiLr1e150-nanornicroni sefixcazi pe 4-5 ribosomi ia nive- lF// lrao,tfer
    lrrl srr1,rrrritr-Ll,ilor,ionstituind ul ansamblu denvmit pol'isotn A minoacizii
    rrr",rsalilortnl-Lriipolipeptidetolsint aclu;i1a ribosomi de c5'treARNi, dupi I tl. 1.1).- Diagrama c;ii dc transmitere a inlormatiei geneiice i!} sinteza ploteiDclor.
    o rrr<:rLlabiliL actirrare clzimatici.. ,I,2,3.4.
    ' REGIAREASINTEZEIPROTEICE
    I.zLrLpclul,\ItIn {ixat pe ribosomi,ARN|, in pfczenla enzimci amilo-
    rLr:irl .,\llNt sinteiaza, zLtiuci cu ani-icocionul complementar, amino:tcidul Sirttcz,aprotcinclol
    otcinclol se face sub actiunea
    acliunea geneloll de
    de structur.iL.
    structuliL. Iliccarc
    Iliccaro
    '.r', i[iL r.:r, r,t fi irl;':.,t .n protcitLrpc celc d,' .lnl"zi lJc nxemplu: p\'n- ,,'lrrlii corrlinc un echipament genetic capabil si. induci. sirteza tuturot.
    l||r o :,1 \'u,rl.irlU h:,zei..rd6ir1din AD\, r"Pr(z' nla-fi do triplct'i-gux.rrini-
    (GA.\r, ARNn sintetizat la 1ocu1decontact cu fractiunea rl i ;r,pri
    rr,rlirr, i
    rriirlclor.
    1r,rlr;rr'piirlclor. Cu toate
    toate acestea, sinteza proteinelor
    acestea, sinteza proteinelor se face
    face dife::cn{itt,
    dife::cn{itt,
    rr,l,rriri"L-aclcnini. ll,,.rrrri lilr dc ccluli. corespunzindu-io anumitS.sintezl-proteic5.,Acc;r.slrr
    r, . t,(cli\'.1,, \tJ\. 1':\it;ttt.crierriplira iT codon complemcntar:cilo5in.i-
    ',' ,.',yrlir:ir. prir: faptul ci gencle sint active in unele celulc si inactivc irr
    rrr,cil--iriacil {( L{-lt. .Fix,r pe ribosorni,.\RNm induccintervenlia antico- lrL urllarc i] controlului activitdlii genetice,efectuattot prin intcnn*
    io]nplcrncn,rr, C.AA, fixal p- ,\R){r, car" preir din ciloplasmi 'rll,ll
    'l',Irl[i 'hr.rl lt,.lclor'. _.,\ cffunea d9 rgglarg a sintezei proteice a fost.d6scr.islpor:tr.u
    rLrLrinoacidLrl ipeci{ic codonului respeclir' (acidul glttamic in-cazLrlexcmpli- rl;rtiL qi M
    ;' ri trr.r rl rl r-r.cl,
    dl:: .facob
    ] r cob gi Monod
    onod in 1960.
    1960.
    [ir:ri) si il aduce ]a iibosorni pintru a fi introdus in molecula proteicl (l,.lir lriri
    (,.lir lriri multe
    nrultc rnformatii
    informatii desprc
    despremecanismele
    mecanismele dede regJarc gcncticlL llr
    (fis. 1.e). l,l.,l tllrrizirlo rlc microorganisme, in.dpe,ciald.e Esc.hericlti a,cil; car8
    r\tnittr,ritcizii sirt codtficati de coiloni lrripicte) dispuse linear, {iecare 4i rnoctu-
    lrn,'.;r riit)tczir dc enzjme in funcfie de compozi{ia mcdiului in caie crt:$tr.
    llinlcti avind suecificitate pcrtru un aminoacid.Aminoacizii clin codul (, rr
    tt lilrrrrrzir.
    liltrrrzir. s;rrrcu lactozi.).
    sarr cu lactozi.). Operonul
    Operoiul lactozei a constituit
    cbnstituii unun modcl
    modcl tlo
    tlo strr-
    sirr-
    q,,ir',li<'s,, uumcsi coclonicispie a-i deosebi <1ea1!i aminoacizi din structtra rllrr rl rr'gli"rrii gcncticc.
    a'le catenci de
    lirtricitrclor'(bidroxiprolina,'hidroxilizina). Ccle patru baze .
    (l('rrr,lr.clLlc aclioneazi sau carc rcplirni. aciivitalca gcnclor struc{u-
    i\ lt Nrn { A , tl, C, Gi s..rDot courbina iu 6'i variantc sau secven}e de codoni. flllf .f. llrrll, s(r t;etrcrtglaloatt. Ccrlclcstructuralesilt lcqatc tJ,.,ugcnl'Lrlr:
    ItirrLrt:;ir:,i;lra.trl silt ipccilic;r: cclor 20 :Lminoacizicunosculi. Trei codoni r rrtrlrrrl, rrurrril:'roPtrthr. Ansttmblul gene de strilci:ur.ir,*oyx:ra [t.rr cstr..
    (tl.\ \. i .\(;. L(;n ) rr'.riirrrlil\\ili(ilirl, |r"trlru atninoacizisint dcurrmiti ttutntl /t(totr, 01tr:rottulintri'L iu rclatir: cu gena t-,.glrLloalc r:rrrcprxr"tt:li
    ,,,l l rri , r r l . \ i 5: , t r \ l ,t,ti tttl h ,rr' l .A(:,s l i i r s i rl i t,rl ,,.i 1i (' J S etnnL (l ( P ttnftuati c in vttittirlarlr:rraula rlisi:rn{i 11coltr,totr.(ir.n:rrigl;rloirrr:lr:.ct:uli-
    l rr l r r r t : t it r r t f r r t t t t n i i rrttt 1 ro Ii 1 Ir' 1 Iti Ii i cS. p ,' c iIi crrrcrtami no;rci zi l or 1i r:i ti Icl 'rllttjrlr'r
    lrllr,.r(ll ir irrtlrrcr.sinlczu trtrcit'nzinr,,in pr.r'zcn{ir
    rrrrrrirLrl,slt.trt
    cr: trt'l.,rrir:
    rI.rIIr r r iI < I1r r . . , ,l11r r. ru i ,l i r.,r.l i o rl rl ,
    4 .1
    40
    rllliLl){}liz,fl(nlt/,ltrt tlt.l)tttlttti), rirt[ (Lr'i.Lreprima sintczlLun(.i r:r)/.ilue I l ottro z, i; , r 1iilr . zll I r r t t
    iir :ir' lrrr:t:Iitr priu inhibareaunei enzirncsl)(:cificc,
    (,t/'.rftfurt ttgol.iitri), l({.1)r'i ' Lrl rl rritv;l r r r 'liz, r r li.
    trri lrril r\'ir(ii('invclsi //r'irl /r,rr'li),cind un prod.usJinal rezultat dittr-un P c i i tt ; qi. r r ucs{t :dalc , . lL'vcnii, r' L: }at ir ' , , clasice" it l) it r c un lou r i! ) r I ( , l) l
    plolls rrrclrrlrolit: irrlriiriLir<rtivilrrlt:a cttzinteicare a Seneratr€acfiamcta- r' i, r'ilor' lrr or-grrnizalet gcnonrulii, prin descopr:r'ilile din uitimii rni, (irr('
    , rrrliilrlirii lrrlirr rorfisnml gcnctic. Structura ADN nu rnai este privitir ,;lt rrrr
    l,olir';-1.I,l:iislit dtri un tlrrlrlrr (;i)ttrol al genelor de structuxe: tn control
    poziliv r:irrr1 produsrl genli rogl lorii iniJiazl transcriplia1a uivelul promoto- .rr lrl)lu ({)ltprrct c1cgcuc. I sc atribuie o conforrrralic imbuciri:itti1l.i.l)l-ill
    .
    rrrlui qi un conlrol reg:rli\:, cind transcripli:t e,stereprimati de piodusul ':rr,llllir dc portiuni corl-rficatoarc intrer:upte de zone carc nu sprrifilir
    :r','lLitsi gcnr:, 1a nivelul operatorului. l , lrl ur silll(,zir Protcinelol si carc ,:rctpL 800/1,dir:r genom. S-au descl is
    .1r;rIii ii irrt
    irrl'rr: 3r:nice,
    r.r,'nito, Iarn.ilii nultigerri
    I:rmilii nulrigcuice cu secvente de gene repetate. lt poli.
    [-a cucariote mecanisme]ede reglare sint mult mai courplese. Fcntru
    , Irr',r
    | ' , r IIir,Irr
    I r.,Ir I trrI stluctulal ar
    rI sIr'uctulal aL,\DN sint
    t\ r),t Slnt inse decr
    .int cupnnse genc auce,
    deci genc urice, Iatlllll mull i .
    fanilii muill
    i11,'llgcrr.rl lor ari {osL elaboratemodelc complicate care inc€arci se explice
    ' , rri(i,'.. !r('cvolllc
    s('cv(tltc lon-coilaltc
    llOn-COOalltC UDICe
    unice SI qi JrUj!
    AD)i non,codant
    non-coclant rl1 ill SCCVeD!e
    sccverrle ICrP0llll".
    rcrpotrl,
    iiri(fvcntia genelor reglatoare ia mai multe nivele ale sintezei proteice:
    S I r 'r , {. l r r ;i ' .\l ) N o .t" i r '[]u ^ r r r a ti . !n a [e r a r r r o i o z.i , d , d i t"r i tc ,.v r r i .
    I r rriyr:h ,{RN prcmcsager', in:momentullransporttlui ARNn in citoplasmi., ,,, rri, ,-;l: rr.mtatiilcpunctate in carc sc inlocuieStr:1rn nucleoticl
    r rr crusul traducerii. AltN poiimcraza nri iniliazi" fabricarea unui ARNn la ,1Lrr/,
    ".r
    .'.,,,i,.rlir Ll.r llagrricntJ iesite tlin crornosourirlfiriti, l'.imite recombinirri.
    irrliLnplarc.Aceastii enzirnd.are o afinitate ptrticuLari- peutr:,r prornotoi'r
    , rlir;lirg rcconlbiniiri ,,prin onologie" care sulvin inire doui seclrcllo (|,
    A I)N ceca ce ii per-mitesi. inccap:r sintcza ARNrn intt-un loc ptccis. l/iteza
    ( 1lciLLcsefor{reazi ARNrn dcpinde de secvenfa bazelor promotorului. -i\{ornen- \l)'rl orntiloagr:qi rccorlbili: i ,,riegitime'. prirr r':perca gi alipi:r:a rrrr,rr'
    ,'nriric putin sau deloc ornoloage,- cleplasarcaunor secvelte iitt'iutrrl\o
    Irri in crre ircepe transcriplia sc afli sub dependenla proteinelor de reglare,
    .,,,ri) ,liuir-un loc in altu].
    !irl)rlriotuc.Rcprcsoruirecunoastein mod speciticun segmentscurt al ADN,
    ,,lxrLirtorul sitriat 1a inceputui 'gerei. Cind -replesor:uleltc fixat pe opelator \,rcsrtr',,misciri" petrecute in structura ADN, deqi rr)lativ rar!.',li,rr
    ,i, li,rrrinir rlisconiilrutirli bruqte ln er.'olnlia,,muta{icraliy, a geuotnulrrir rL
    ,.1 irrrpicdici progresiaARN lolimerazei di-a lungui moleculei de. AD}I.
    { irrrl r:clrrl;rare ncvoie di: ploteine re?rcsorni se scpar':Lde operator gi AR]I ,;rrl,lirrrlii crrlc ikrpisescsfera fiziologicira polirnorfismriluigenetir:.
    Iurlirrrr.ruza iutrir in ac{iune.
    l)crrtrLrfiecare tip de ARli (nuc1ear,ribosomal, de transfer) existi o 1"2.s. PERMANENTAME5A.'UL[J|GENETTC
    r uzirrriLA{lN polirnerazi. speci{ici. l)'. lrt apariiia liclii pe pinriuL, singurul plenrrrt pL-rl]tanelllinl ,(i
    Oplir:ca sintezei proteice se face prin {ixarea unor ploteine, iu rnocl I l,('.rl( i1r(l{.st
    ructibil esie mc:irjll Sfnatic (Jer-ometr--ie-.rne). }Ie-rajrrl' r,
    r,rli,r:tiv,pc propriul ARNm, irnpiedicindastlel activitatea ribosottitrnr. ,lrt.rr, iu irpiu'eutij-contrarliclit, .[Jr il uniTatc dialcctic,i iu divrisii.rrt',,,
    1r,,l,,t,ir'iL
    1r,,lr,1,ir'iL irdirrizilor. cstc rcaiiz;rt plil
    ir irdirrizilor, reolicarcaADN cxistclt in rlrcl,'ii
    nlil replicarca
    " lrrl' lur- Iircale frasmcnt
    .mnrrt (1uAI]li
    ,l \D \ ccodrjici
    n,' l i fi r:i ccnstituentii
    rorr< ' :rrr. nl i i organisrlclor.
    nr, rni ,,r".l ,' r r.i
    .i
    1.2.4.FOUMOnFISMUI
    GENOMUIUI
    rt ,,,l rti ,l 0i :ianlur ilc pt ilipept ir i, cr ', cnzir neie Si t oat e Conponent elc n( , c( , r .r ,', .
    liiecale perechedc clomosomi este fomati dintr-un cromosont matern , rt lll

    ;i rruul patern ccca ce {ace ca genonul unui individ si conlini o stlucturi. I'rir comlrinatia dc genr: co{inute ir nrcleul celulelor salc, orjcc in,li
    13.ni:ticiJunicl. La heterogenitateagenomului contribuie ;i mutaliile genetice 'rrl ,r.ic rrnic. Prin unirea cclulelor sale sexualc cli celulele scxrtltli ol)]l
    ii rnai ales recombini.rild {raemenielor de ADN in cursul formitlii Celulelor ' 1 . , ,1,rIi rct r r , u"ir i int livi, i Jif cLir Cp, linsr r si si ir r t c, ul . iu, unic. \ r r i . . , r
    ;.1r,rminale a spematozoizilol gi or,'ulclot'.In timpul meiozei, ilistribulia I , r, l, r ul)riLvicluic:;cltccind rlc 1;,ro gcneralie la alta. linild. seama rlc r< ,rl
    ,,rtirnplitoalc a' cromosomilorin !am"ti oferi posibilirate^a trnui numir I, I1,.i,;il:,ii)Il,,l nt sc r"cpro-c1ucc,
    cr-p:S*:gaffi9**J*:gl*"*),
    irrfinit dc combina{ii care explicb.polimorfismul genomului. In acest proces, ,, I rirr pun''t (1r,r,:dr.rt.slrict r;enctic,inciividul repre:rlnt:rvectolul gcrr ,
    { rornosomii analogr schimbi. secvente genice (crossi.ng ozarJ determinind l,,r r.rr,. ir':rrrsnrit mcstjul ADN, cu constantir" ;i divcrsilateasa. Itcpclilrv
    rrplilia oe gene drlcrite pe un anumit locrs al unei perechi de cromosomi rr \,rri, ijrlL'il Lu ilparonlir,ADN-ul are puterca d.c Col']servare si d,: tr';rrrsrrri.
    (starc de he[erozigot pentrn un caracter anumit) . Ur I'ocus ocupat de aiele ||rr,., ri(:ncrcilzil llunlcroase mutalii Si prin accasta lcrmit( ad,rpliri l,l
    rli{critc se numeste locrzsbol,imovfi,c. rtrr,rliirlr: rnt:rlinviit<tar:c. Pr: plan populalionalacsstc aspectesc lrarlrrr
    Din srudiu[ variabiliiigiigeneticcsc $tic c; un individ are aproxima- rrr rrrritrrilrr 5i tlivcrsitatea indiviziior. Caracterul r-leunitatc este 1:onft,til
    liv 6 700 de gene sub formi.'het"erozigote.din totalul de > 100000.' Pentru ,l, 1rrr11r;rrrrtrl.gu)rlic carc cornandiidezvoltarca6i funclionare:r or]]rllisr|,'
    r:r:1r:23 de perechi de cromosomi :Li speciei umane existi 223de conbinalii l,,r li,li irr,liviziirrnci :fecii posed; aceiasibagaj gcnctic,lormat din ruritr,!i
    lxrsibif de llalizat in garnet. Probabilitatea ca un pirinte si aibe doi co$ii ,lt.lrrrrl,., 1r'ntlc. Uritatca dc structuriLir genclor|orm<:isz/a onogcliiallrr.
    "rlti:ct
    cr.l 1lr1sct cromosomic identic este de unu la 223 sau de unu Ia 8,4 mili- | ' ,||r' I i I )|rI rIi lnci pog1lr!1ii. Elcmt,ntul de divers--itatc;r indivjzilor r:sic r ri
    i'rr'. (cu L'Kccptil1;rrnenilorrnonozigoli). rr,rlrIl rrrrrIirIiiIr: 5cnclicc.Aceslea fac ca {iocarcindivid siLfir: uuic, p::czr:r:1irrI
    inrlivizii ir,'Lcrirzigofi rLuun cornii-oitiment roai bun ln condif ii de mediu rrl rrrr:irrrrrbIrr rlc r:aractcrccarc ii sint Trropriisi consiitrric{r:lritinul silu:
    it(nniurir.tor varirbil, dccli inrlivizii homozieoti. Ei rezistl rnai bine la , rtlrrrrlr rxlrilor',t pirrrlui, a piclii, forma iniiniir,r, irirrirlrrr:ilc folii, ilirlti".
    rtt o mai rnarc vitalitatc, au parametri
    .'ll.trsiirrril,'rnrrrlitrluiiucortjtrr:r"Ltor,
    Iizit;i stt;r,'r'iori.

    4"1,
    (rs rrl l ti al cal c fi i n!cl or' \' i i si l rl (l i vcr- tr;icLr[-o tininiL). Arx':tsti'r itbi]ratictlucela iulocuirca rttrtli rrtnilroacidcu alttrl
    I{ r ' z r t llii.r : ii t llc rL rtt.ir' :tti ttrl r" ti s l i rri
    ( i tl 1 r p
    [ttttttc l tr.ri o l rrL l n a t[fal e'
    l t!:i i l e ;;' ;.il.;l ]i'" r.f ptoi"i.i li dcci la modificur"r' Irr'srjului I 't dit"t'
    :ri l l L l cl L; i lt llilir l( ' il 'i"i,
    I..i.ctclc acc.tci stiri poi fi minimc in {unc{ia molcculci prolcrccsirrrl)of
    ,'rn.tr in sttprimarcatuturor luncgiilor acesleia' -
    "i;;";;l'^Giu
    1.2.6.ERORIAIE PROGRAMUTUIGENETIC mutatiile monogeniccs-a dn'cris fcnomcnnlde polialclir'
    (mtrtofiile genetice) pe u1l slngur
    ,l,:l"crminatde-mai multe mutalii gencticc,survemte succeslv-
    r,,,,"..- J" .ii" iJ p" ott locus' dit, situat pe cromosom,. exist5".o singuriL
    l\T.rrlrLfirLgcnctici sc rlcfirrcstcca o rnodificare:tabiliL in structura ADN, sinteza unei proteine modi{i-
    *"tJti", i""" noui. va codi{ici
    rr;,rr.rrri.iL,iii. crcditar. l\Iodi{ici!rcrproBrdmtrltri 8"n"tic norrnal(gcnotn]1la- .,-J.'p.i"*-"
    lirrl rtrrrcziltiu un evenimelt molecular intirnpiitor, apirut in curs[l drvulu- .-,,i,i.In ."^r,a gcn,-'noi:, mai poaie apar'.o mulatie Prin, rcpelarca muf 'r-
    ,,ii', , f J'tJ"i g"t-it.tale, deierminind,in {inal, o schimbare cantitativ:t sau ca-li- riil, I ." 'riune" i, o srrre potinl',:lica pn'acelaSi Iocus. P-ol-ialdia cxplici dih-
    ;i' ,,. tt" unei stlti patologi"c. Dc exemplu, delicirul de glucozo-(r-
    i ,,-r,L"i*in"isiniclizotc5;, prin accasra,boli orcdilar"rleprodusului de
    "rri'"Li: putin ioo d.. controlate de tot atitea
    'rit.r
    ,,rrrct:p{ici genetice din celntrclc somatice nu se transmrt lil des- t,.:nt-det iaroe"nazi are cel
    Muta{iile 'ariante'
    genelc at cel pufin douS' formc
    , ii'i,:. s"-.*iia"ia zo -soiL dintre toate
    r.D(lc[ti. ":'
    ' (;(it.Iomutafia poate interes:i. toatc categoriile de gene (dc structurir, rrl r.ii ct' .
    situate.pe loci dilr>
    loci,.drlc'
    r,,1|iltonrc,opera.toare). Llneori existi cloui sau mai multc rnutalii. genetice situate
    " iti. .op"frii" in pioduci un tablou patologic similar, deterrninitcl ereditsttn
    CnLrzele' mutaliilirr sint in mare parte necunoscute Foarte ral ele se
    rrr,.lrLti"r,ontan; de reg.rld.inL indrGc d' Iacro|i exicrni. Experitncn.lal, /"'l''{'ff;[oriitil" geneticit'
    .r l(,:t r)o:ibildproduccr'i"L lol sub acliuncr r.dialiiior ioniza'rre,(c:t Iurtgtmo di{erite c1egenomuta}iitealizeazi,keterogetaita'tea-
    f,, l.i.ii"i"i-ir"", ti*it" tiri|togice foarte largi, genomutaliile detcrrninir
    ,l' rrrr,l.icomp'a rr lrili cu distanfele inleratomiceale moleculejnucleico)' lal( :r
    gnnr-ticqt aslSrlriJdr pLaDLtl
    srLl,rtctiuncit virusuriior cu ADN si posibil cu ARN (prin asemenare structu- \',.r..rntecarc stau ia bdza polirl1or{isnrrrlui
    1,,cici in condilii noi de mediu exterior.
    ,,,1") ii s,it, ectiunea unor molicide chimice care perturbi lenonenul de
    ,,.y'li,:ir',,(r'.,loranl i dc acridini. azot'mttstar'rcidul nitros) '1.2.6.1.
    ' Ilrrzt',lt, ultraviolete cu lungimea db unda sub 300 nanometti, razele DEMUrAlll GENETICE
    TIPURI
    \ si r':tttuLra clelcrminialtnriri siructuralcale AD\. ln cazul razelortdira- Se realizeazicind o bazi azLt-
    . i,,i'.i,.. procluc legirturi chimice puternice intre- doud--baze A) f,I ttt ati'i brin' 4nlocui're.
    slebc cu -pirimidinice I rii J6 i"i.."iii io ita.'a."r.tu se poatc face prin ]nai.multe modalitiL{i:
    'rrr(fi\' " 1,,:accla5iiin1. Consecutiv, se rup 'c"lcgiturilc
    bazelc com- -L-i ptit
    triiii't'ie, c\td o bazd iurinicii sau pirimidinicf, este inlocuitir'
    rrl,.nr,.rtlrrle dl p"'larrtul al doilca, duce Ia dezorga nizarca dubloi
    "..a produc rupturi ale filamentclor r,,r ,,,i"1.- pilri"ici-';i respectil pirimidinici. De eiemplrr exrstentalegf,tun-
    i,u'r;Llcr ADN. Iiazeleion'zani. (zsi grmma) r,': ,lc ii..i c a), inioi de AIT (sao T-A); T-G (sat G*T), inloc cle
    ,i' ,tt-lN rrrin mecanismul indiieit i1 radio?ializci apei (radicali cle H;i t' ttrittll,"o;-Q;
    ()ll iorLrtcrcactivi). cu o baziL
    Di[r.rirc subsiarrtechinticc poi altcra ADN prin actiun"a dirccte a 'i"""t=.ersie, crnd o bazi. purinici este inlocuiti.
    , r, i',,i,ii*"i-.i D" exemplu: A-G (sau G-A) in loc de A-'I (sttt
    rrrr,,r'rrrct;rl,oliti rezult;1idin degradarca chimici in organism,care sc lcagi
    prez-enli.in cantitlJi r \) ; G- t (sru T-G) in loc de C -G (sau G -C)'
    tL. lrazclc guatti.tice a1eADN-ului. Benzopirenii, 'sub
    li:rl,il''il fuinulde ligarisint melabolizali formi de dioii cpoxizi, {oarlc
    "apre- B) f,Izt'tuIiL brin inaersi e, determinatede-ristulnarea untrt
    rt:uctivi. errrrbili modi{ice baze[c din ADN. Unele substanle chimico ,',,,r, i.--,"i l".i"ti'.u'in ."r.r. invers, situalie cind un aminoacid este inlo-
    ,ili'l,cscicsiidurile dintle 'i bazele purinice 5i desoxiribozi, cu pierderea, in final rrit ,;u iitrrl. I)c exemplu:
    .r l,;rzr.ipurinicc (A sau G). Ac"a"ti rcactiese poate prodtrce;i spontan' A- 1 r C_G
    5r. , orr'irlcri ci o cetuli umane pierdc jri medie 20 000 de l:aza pe z'. )[uta- (:-(; --- triptofarl C-G -- - Slicinl
    liilt: tutr:lice shontune se pot produce sub actiunea unor Jactori endogeni, (-;-L -4.-U
    .r v:Lrial.iil" icrmice ale- atomilor dil molecula de ADN, nerespectarea-
    ,.,rrplcrn.rrtrrititii bazelor,defectede ,,reparare"a unor secli€nlede ADN, t:) ,\l)LLttlii brin deleli e" produseprin pierdcreaunei pitrti
    r , ,,1;'i, lecrurii rr'iplctci (tr'l.otti tt."-tsrrs) Piotdcrt'iL
    lr<,,iuc"r..,." rLrrorrccombindriincgalc intrc genc ncrlele. ":ri "'r'i,.t:iijcotea 1a o parte dintr-tr
    Mcc:trri*rntlrnutalieigcnice"csteh"Letoten Poatc fi o ntuta[ic rr,orto- r, ,,,i,.ti,,f Bctu)ticsc poate limita la -cifive codoni, tlcci
    .,:,r,i,rri,lrr-in ab:rtcrce de'1a ,,uormele fixc" de imperechere a bazetrorpurinice ', r,, srrl lri.citcvlr.genc, De exempla:
    ...ipilinridiuir,ein {ilarnentclcde ADN. In mod normal, singureleirnperecheri '\-'f del{rlic
    iu,ril,il,.tirrt A-l'si irtvlr. si G.C ri irrvcti. Aceastd- spccificitatccste deter-
    rririrtiLr[r:1,.:1i.1rtrii,',1,'lridlogcn. l!l,rrli[icarcr acestor Icgituri intr-o molcculaL ir,[;
    ,[r, irtL:nirriL, i'iLcrposilrilir,,;n1il,,r,,,, ,,tt,rLtnrliL a accstciJ cu citoziua..In rcpli- it t {t - t t t t
    crtr(:ir. Llnliiloirr(',-lrrL'ninrr. si' r'rt itttlx:ttr;hrta cu tirninn, i;tr <:iitlzitla(c:rrtl l )) t ll t r 'L*lii I r 'ilLi t t \ t ] li"'. r '"r lizLlr "1'r ir t it t lL'r t lr r t : ct "ir '
    ,,,,,,I ,,i ,' ,,, , I i , , p, 'r , ',1, i r lr 'r r r r t : l'r , t ir I r : , lr l"iLir ; t r : "t l. clr r . ii lr i'l' 1r 'i
    irrlrxrrir.llclirrrirrL)l,: v;t <:ttlttrt ,,ti littrtttin;L;i tttt t:tt rttllttiltlt(r'ttrrt:rl [i 'r it "i 't ir i ': t r
    .l lr
    . l' l
    .,Lr i -,rl i ril r r , I r . r r r oylr 't r it r .t l, dcsccldcn[ i, asociat r . ir r lr ilr lit l, sc s( , 1) lu; r
    l | , r,r i, , r r t lr lr r : rrr ,,l rrl , i r' _r ',lr ', , lr r cir t our - ralc: lct : st r r ia, scl) ar ar ca.I iLt : ir r r lu- se
    la iniint Pllr r r ,
    1l ili rl Il i (: {', C (1, rr)nr(.ll tL. d ist:ontinui1lL1.c lL pirtrinoniului eredilal).
    rl *'ll lillrr-riri rlrrpi tt)rl0 (tlugo-dc Vries, Kar] Correris, Er-ich Tschcr.urtli),.
    c_G gr{ i . l r r i Nl, nr l'l r r [ r ; sL aplicat ir la st udiul r ecur ent elor unor boii cr lr li-
    " ,rr,,
    o rltrlrli rlrlrtirtic:inscr:tiapcrcc.hiiG- C $i trccerca
    llr !recr,ir'xclrpll Lr,risti-L lrr' (rrn;rlizrr;u lnr-i:lui gcucalogic), pornind de la ideea ci. modul <1irr:orrr,
    1,,' lor:ul 11 l pcrethii ,\-'f, 1,,,rIrI rL c iu'ilclr r olor cxpr im at e in f enot ip r ef lect i int ocm ai m odul ( 1( . ( r ) r r -
    l)rin dclctie si inscrlic sr. p'oduce o perturb:ire generalizati. a mes3ji1- tr .rri. : ij,'rrr.l,rl colrspirnzrtoare (devcnite unitii.fi {unclionale rncndolicri,.,).
    lrri gtrei:ir:. i'rotei;a sintbtizatit este rnodificatd. qi pioduce, Ia rrndul ei, l ' .I i , l ri l i l, . i r t lur liut I i, d ci, r r dir ic indir ecr , p: - inanalit ir c. t r lct , , t i: 1, ] l
    -r
    rr rl:viatic corcspondent:ra unor funclii ale organisnulti. Un exemplu i),-rs- r, ,l i ,1.ri r: 1 ast {el m af t er l) . l) jn acest c consider alii s- ar ( Tcspr il
    ,.( r lilclit c
    lrrtiv cstc rcplczentat dc ta.lasemie, in care se producc o mrtatie Ia uea ' ,,l rr l i l i i ti l l r L' t r . alsr nt t er c er cclit ar iL.
    <lirr r:cli: 438 de stbunitili ale betahemoglobinei. Accastil mutalie schirrli I'r.ntlrr iuit:legcrcl 1lansmiterii ereditare a bolilor gcnctice cstc n(!.,.
    ,rrliuca. l.,azclordin codonul lizinei. Astfel, succcsiuneanot'mail AAG r:Le r rlr'lirritcr r-i:1a_tiilor'
    ..t-.xistcrrtc iirtr.. gene si carectir-c1c cxprirlatc rl,.
    irrlorruilii cu lll-AG" Corlonul nu poate {i interpretat rle nici un ARNI, liziira ,, ,,ir, l)r(i{LLntsi a r-clafiilor Llinlr., gcire, ptln nolirinilc de genotip si fr. ,,.
    tru csti: ircorporatl ir lantui pr-oteic, sintezrr proteinci esteblocat[. Tot T]fin ,,t,
    inlor:rrirca unui aminoacid cu altul, dictatir de mutatia pdn inserlie a ulol tit;trliftll, lr|r-r'ziutiL totalitatea gr:nclor. cale determini. car:tr;lt,rr,l,.
    plrix*i clc baze din nucleotidul ADN, se explicir siciemia(hernoglobinozaS)in l rri ,' r' r rr r isnLir r , lil, r iL. clr pe a1c ont ogenezei. l- olosit 1a t nodLll ( x) 11( , r r , i,
    r'tr-c a.ejch{glutamic estc lnlocuit cu valina. S-au descris peste 300 hemoglo- I l l ,,, t| rri , 1, . r r r r , 't ip sc por t c r e{er i num ai I a genele cor cspunzi_t oar rttr r r r i
    lrint: anormale. Droduscpdn acest mecanisn. . r. , Jl r tl . r t .
    h.r alara stbstituirii unui singur a.minoaciclin rrolccula proteici, mrre- l;ltdi,fittl- r:uprir',detotalitatea caracterclor unui orgaaism, corcsl)llnzi
    ri ,.,r,' l , r inf lur . nt r lor dc m ediu, expr im at e, la nivci r nolccr r lr r r ,
    l iilr: rlrrtiic,r sLrrnai pot exprina. ii prin aite tipuri de anodalii moleculare 't i1Lr 1uisi
    , rrrr siirt: nJ absenlasitx{s-ttl,1{ireceltor le sulrafald so.r,in interiorul, celidti l rrr1,rr, ,l r. . e1. q; 11r slr u le sisLem e de or gane, vizibile dir cct sau pdn inir , r
    , rr irr lripr.r'rxrlcsterolcmiafamiliali. (defect de receptor peltru lipoproteitrle rr ,lirrl. rrriiloacclor dc investigatie. Aceste car:rctere dctcr.rninii.ii.divi<lrrLli.
    rrrr rlr'nsilirlrrjoasi"rr); b) d,eficitwl, iu, oct,ititdtetzunei en:.i.nte locah):alit ,itz t ,1 .r l ri ologicir .
    tttr ttormuL in lizozom,i,tnitocotdlit, sau, sfal ittl cxlyocelu,l,ay. Un exemplu lixplirrr;rrca {cnotipiciL cste conditionatir de relatia dintre genclc, rrlr.l,,
    il rrrrr:.iilrri'.Icrrilerlonuria,pr.indcficir dc dihidropt"rin rcductaz;,o lorrr; rluirl(' l)(' l<ri omologi ai utei pcrechi dc cromosomi, cAre contt-ol(,irzri
    rrrl ilrl.ilniiir, rezistenlS. 1a tratamentul clietetic; cl irbsenlafyodxtcerii t|e rr, Lrl.i r:intclcr (genr: aleiiforrrrc), de pror enicntiL rratcrni. si patcruiL. (iirrrl
    ftnltittr: sfttci.ficesaa de flateino-glotcide,ca in edemul angioneurotic ered.ir;ir ' ' rl ,rrrl rl r. lr l, l. '. : uc acccagi. . t nt ct uf i si inf or m at i. F. net ici, 'r nr t . spr r r r zir t r , . r r r
    prin dr:fcct dc biosintezi a inhibitorului C, esterazi. .f' l ' ri r;l ,xl) u r ilt r lcnot lplcc s, ' r pJlt ^azi 5r iI . ca d^ hot no2it ol a in( [ ivi( llt lI |t
    Jlupi cum falsiticarea mesajului ereditar intereseazd.forrnarea unor t,, rrlru-caracterul respectiv. Cind o persoani_ are gene a1c1ediferite, fi(xrr,,
    tuol(:culc, cliferenliereatisular5. sau organogeneza,genopatiile se in:lpart in: ,1,t, r rr:inind pcutru acela;i car-actei exprimiri fe"notipicc dilerite, sc :r,rrli.
    -' Getnpotii molecwlaye(chimiodisplazii) prin mutalie genetici unici, ' ' .l r,r sttt"cil dc hcler or iea! .
    (xnducind la rnodilicarea sintczei proteinelor. lu r:adrul sti.r'ii dc-heterozigot, putcr-ea de expl.inarc a urcla silll il
    -- Gcttopatii,tisulare ('nistorJisplazii)prin alterarea diferenlierii celule- .r,II,iu.<litrtrc ci:lc rlouir genc aJcJcinlegrturd cu car.actci-u]pe care il spccifir.r,
    Iol san tcsutului unuia sau mai multor organe. E{ectul genomutatiei afec- ,1,;rirrrlr,rle calactcrui dominant, receiiv sau codominant
    ir carc il ,,rc, g,.",,
    l,.rziL lxriliuni din genom care coriifici in aiela5i tirnp inluctori ai embrio- rl ,l rr.
    1l,.riczcri si molecule structu.rante peirtru viala postnatall (wzi capit. fl,isti- Oqtu:l,crul tlontin.ant confcrl genei capacitatea de a expr-ima f(irlotilri{'
    ,lis/,tazii,pag. 118). ,, ,rtrrrruiti" 1r"irslturi!, :Iascind alela pereclie.
    - ()ttto.pal,iinalJtrtnante (morfodisplazii) produse de mutalii genetice (:artcl, ,ul rcc$'ia al unei gcn,: Du afecteazi. aspectul fe[otipic, ircfiull,l.l
    r'rrle rl, lcmrirt pcrturbarea {olmei sau dezvoltarea rnot organe (uezi. capit" ,r liinrl inhilratiL dc prczenla unei :.1e1. di{erite irrrc o dominir..
    ,\l r.fonnalii., pa,g. 122). ()odntnittt.nla sr: referir la genele alele carc, in stare iretcrozigoliL, i1i
    , ,, tctlii ,:(,n(r)r iir.nt {unctia geneticiL, trisS.tura in cauzir avind. ilrrrlrr,l,.
    1.2.7.TRANSMtrTEREA
    EREDITARA
    A GENOPATIITOR ' .t' rrrtri i ti l, t t r r t ilr ir , : ( cir zul g; lpci sangLr ir r eAl3) .

    Vari:rbiliiatca si exprim.rrca caractcrelor oxganismulul a fost atribuitii r,2.7.1


    . ANOMAUTMONOGENTCE
    ;;, rrllrrr, inainlc c.r xccstca si fie cunoscute,pe baza stucliilorlui johann
    (hcgor McrrlcJ, cfccluale intri., anii 1856-1865, asupra hibrizilor vegctalj. lirlilt: llxxlrtsr: prin .lr:rnsni tcrca urcdititlii. a. rruci singur,: [i()lrc n)ttlirll,.
    l)in ilxrtczclt: ,:rnisc(r,cri{icatcintr[-totlr] mai tirziu), rezulti] ce clcmc'ntclc ,rr r',r rlcclrnisrrr llll.ogcuir: i.rci varianlc: a) I.runntil,arct r,t,ttl,osontal, rt)0r:si.nti;
    l' ) lrunsniltti uttloxtmnl, dam,in.uul,d; t:) lrousntilL:rt:a h:guld lt c.ronctson rl,
    I Vr,zi .1,1.:1, pag. ?46 711{
    ! Vczi vrrl, 3, po g. 6{ ) 1) - 021
    .\, rlrtt .Y-/r'llirrl,i,

    A$ 47
    Itt lIlrttsttrilIttrtctrrlillttrllr.ttttr'ttiitlr' ,,<loIninant" " ,'x1rrl,tlir.
    ;i ,,r.'ctlrsit :rt1osr. r ) ) irrl'( r : csiv(l): ( ) ir {r ir
    ) r lcr usl lont c lipr ililc r lr r |r 'olcillc ( dc st r r Lr . -
    rrriridr'(nllrii rrrorlttlrl,'trrll)i[(']rlirllrrr lxrlii in ?rrborele Scnealos^io ll 11tlul rr]llli ()ar(', c Zilnc).
    dccit dift'r't'ntcltttttLLtttt'trtate
    irrrliviil'rr{rr:irLt in rnecanismul genetic.. ft'rr'lc- lLr|ir frccvcrrt,uliolii ,rst,'clrnoscutir jtr populagie sc poate ca]cul;r ir.,"r:.
    nri dorrtirto.uL arLiii. ciLtnrtlrili:Lpoalc Ii clinic rnani{cstdcind individul rre \ nl i r \t:,ri i r l, ' l) ur liilor . du1 . ' I olm uia t t r ?djr \ \ '"iolr er ! :
    'I'crmcnul de zecosia
    o siui;uri. clozir ;r mutalici, cl liiri,l h,'terozigot. -implicl
    ,.risli:nta dozei dublc,' ambclt: gcnc fiind mutante pentru ca boala sir se p3+: pq+q, : 1
    rranilirstc clinic. In acest caz individul estehomozigot. Genelein sinc nu slnt , |
    'lr.:
    p:
    -'
    {r.lrr(]lrlrl bolii alitcs,r:nir1 reccsi.,/e in poplrlalie (trec../en1a sterjj dc borJn,Tr!,l
    rlrrninmrle .au rccesive, rumai etectele 1or determini st[i. patologice ce tr rl rl | i .l n. pat( rl os i dr rc s pc c ti r:); q!: i rec rerr-l a i r(l i rj z i l ur: s i neto;i , genotj ?,i c s i l ur,.i t)i ,,
    ,, |'l irr (: nsidcraro iroaLa,rrs?ecti/:!; 2 ?q: {rec.rerla indiviziior
    ,,. clasifici in dominantesau rccesive. , llr r rrrtlrrtr.
    sdn!.togi, dar l ittrt,,) L iLi
    LriBd cxerrplul n)ncc,r;isoidozei care 4re o lr.cvc:r.!;! de 112.100, ,\e ],(,ale Lllrol:,
    Accste boli, detenninate de o mutatie genetici unici se transmit dupi. 1
    nrxlrlnl mendelian. (lc rurtltoli : p' ,"-
    2 -500 '5 0
    Individul care manifest5. boala estc dcscmaat cu tcrmcnulide aa:zl
    inlrr,'p/ol>asitxts szu proband. t 49 49 11
    rt:
    ' 50
    I * ---' - :2 l c:l - - -- - j,92-11,.sau: -
    :0 ,- 5 0
    'i.2.7,1-1. oula:omol.ecetivd
    Trqnsmitereq
    .liste probabil ca {iecare om s5, aihir genc recesive. lntmcit eie rru 1xr1
    In accst tip de transmitere ercditari individul a{ectat de o lna1i gi:neral,l, rtestate
    ' r, ,rr gr.ncra prin
    eslai, . pr in rnetode
    m er ot le dc
    de laborator,
    la adultul afli-
    afli_ de exisl
    erislr,ir{r
    r,utir
    ir lnr)$tcnit citc o ieni patologici de la fiecare din pirinli. Manifestarea bolii rrrr,i Hcnc rccesive din genomul siu, dupi nasterea rrnui copil ?:omozigol.
    ., tai:c dtci rruliai in'stare"de lrcmol;got (dozii dlubl5) plrin{ii individrilui
    ,,ri,iirii fi;"a t""otipic slnlto;i 9i genotiplc prirtS"toripeniru-caraiteruI genctic a Caractereleered.'itiQiicr.ztiosonzal,recesit:e:
    irt t:arrzir,Ifctcrozigotul avind o'ge-nirecesivl responsabiii pentru o anom:trie rr) pirin{ii sint norma-liIa exarnenul clinic;
    rrrrlosornalilnu rnalnifesti boalalficcare celuli a-organisrnului s5.ufiind capa- lr) intcrcseaziLin mod egal an:bele sexe;
    lrili sir.producS.aproximativ 50oi, din numiruI de molecule proteice active-
    1r,r1r,'r,,ch,:c,1.sa cu un indivjd s!,n5.tos (fonotipic ;i genotipic), deci cn , ) estc un mod de transmitere rar intilnit, daci tara genetlc5.nu cslc
    rloriii.llclc nonnale pentru tr5,situra respectivi.,va ducela na5terea unor copll pirrtliii in populalic;
    sirriiii:5i, cliu care 5oo7n..ot fi ireteroZigo{i, purtltori ai gbnei afectate. rl) nu se constatl transn]itere difectf, piirintc-copil (pS.rintele {iind hctr:rir
    ,rl rnr rnanifcstirboala);
    .hnpcr:cchercacu o persoani. heterozigotl pentru trisltura r€spectr!-A
    (lirrorncn frecvent numai. in grrrpuli populationalc inchise, sau in caz de ,.) cletectarcatarei gLneticese poate face in unele cazuri prin mctorlr'
    coniangvinitate) duce 1a aparilia a I r,,,lrir)rice(majoritateabolilor moleculareavind un mod de transinitcreatrto-
    rrci caiegorii de descenden!i:75o/otor ,,rrr.rlrrtesiv), claci.boala nu s,a produs printr-o rnutatie spontani. (d,anora).
    fi lcnotipic si genotipic norrnali. 500/o Sr: cunosc pcste 800 de boli transmise prin acest mecanism. Plir,rlrc
    vor fi h6ter<izilo1i(purtitori sindiogi l, ( ,llr! se enumcrei tulasutlliamdiord, glicogenozele, galactozem,ia,fenilceto .nt,.ia,
    pcntru lara rcspectivi) 5i 25o/ovor fi rtrtr,,rutlt;t:itlo,td,
    alcaptor,turia,hifofosfafuz'itt,boalaNiemann-Pdclt, boal,all/il.sott,
    gcnotipic)
    ', Lolnavi (afectali {cnolipic qi ,lttlitt. (.rnauraticd.7'a3tSachs, boala Xt[orqu,,io, galgo'ili,smul,atrolig tnusculnri
    {fig. l.lci). Deci in ceea ce privesie I't,'t,t't.it' (lV erd,ing-Iloffmann, ) cond.rodistrofia osi,J.icantd.congen,itald,dis-
    genotipui,raportul mendelian 1adesccn- l'l I it candnectodermald,s'irubornul adtenogenital,,xeroderma pigmentosnnt,
    denti este de 1'.Z: 1 (un normal, ,'ltttltnttoliza bul,oas,i, ataxia slinocerebehasii Fr,iedreich, P&r(atrizid s|a.stici
    doi burtitori qi un afectai genetic) iar gu;d, baala Pamfc, sindromul,I{artageni:r,
    ' t"lilrrti, crclinismul fatnilial u,t.
    lenotipic rapoitul este 3: 1 (trei sf,ni--
    togi 1a un bolnav). qutosomqt
    Trqnsmitereq
    1.2.7.'1.2. dominqnli
    Riscul prosPectiv este acelagi
    .'.1-)( --rtortnh ; 25,/"-bo/nar/' . pentru fiecar; na{tere. Din cf,sitoria a lrrtlivir'lululcr:tiL1
    nro;tcnegteo geni-anormalii(alcli. rnutantir)delrr rrrrr:l
    €0 Z=pur/i7or iloi homozigoii ',or descinde numai ,ltrr1,,rrirrli,t:irrr.cslcqi cl rrfcctat.Alela percchcdc pe clomosomr mut omolog
    ltilt. 1,10, -- lf nsmitercl arltosomal lecesiv:r. lrohrevi (de cxcmplu surdomutitater. ' ,1' rr,rrirlit. I)cyi lrctcrr.rzil;oi(dozi simpll) individul rlanifestli boa-la,gcrriu
    r:rctlitarL). ,rr,r rrirlir r:otnportittdu-sc cu caractcr dorninant, Ajuns h vjrsta dc procrccftr
    .llr:lilr:
    utl:osomnl rcctrsivrr sr: matri[t'stfL pt-ccocc, diagnosticul fiind pus lr,rlrt,rt'ttlvir foltrr;r dotti 1.\ruri r1,:gun, li: unul 1:rrltiitoral :rlclci mutantr:
    i rr t,,gr il; ir i' . . lr r t r r rc i i , x i s t;i Ii s c ttl trt n ttttt l ti unttl rJi n patru copi i sh fi c 11,'rr,rp:rlolrl;ici) ri rrttttlpurlirtor d alclci nor:nalc(gcna :ronnlr.li).(icnil
    rrj ,'r:i tr i,s , ' t x r r r ic it rl i trtP l ;r r' :t i tt ttttl l r' frrn ri l i i b oi rl a si i nu apar5.,rn spccral r',rrlx,r'.;rl,ilil)(lrlIlr ,llr{)|lrirli:l
    arrIosornaldontinitlrl.iL cstt: l0rl izirtiL llr:
    i rr ,rc r ' l,r r , t t , t r t t rri L ti rri ' , ,1 ,' r:o 1 ri i ,,\l i rrtrtt' r ' al ,i or:l ri Lni clcatc
    'L sti r.Irr"baza ltttrl rlitr r:r.i22 lrttlosotrri.

    4 tl 4t)
    ,) . : lillr ; i. ji( r lr . lt ( r ( 1, ) nr ! r t iur t ii.
    " ir 1x) lr t , ', . : r iili" o g1r . rItr,] i'. {r : r r zr ||i, 1,

    l*rtl,l,'"i',,,
    rrllr:ljji,'1,:1i,,j;:i":jji;'':*#;;
    ;1,;l;l
    iil,il iil :'
    il:',;,r,
    ;;ll,';#;;:fit:l:,\t-::::i1u)"^.,,..,,
    , \,, l ,l r(,) i r! loLr ii. siir r r r "ii:
    t) ,ittitt ,:t'ftn:siitilth\t itt:!;i1';iir i-jtrrr.ri, ciltd ixrala -(ocxpr';nti"r, itlr'.o f,,rttt,'
    .til'"
    ,,,,,j1'll,i"ll La riniill 1o,..dcscendelfii norl.iali'
    ' r ,, rr.r, ,.rr r 'lr ilr r - uccvidc'nt i,; r r r iilLl f i d. epist at irdclar plin nr ct or lorlr jodt i r r i,, .
    ' r i tr rrrr,l . lolr r t c t lc ancr t r i, rJt er t , . rilici. i );
    1 nrr r'.!- l1-lilr'
    nrr Yor: 1ri l l tl a1]'i -
    hf f |1n "- - -.^ girnctici
    neavild t:rra ----+i -i '.)) i,rin 'l,ltctt'alic1 r't,{t'tsiiix :!.i'rei, cirtd, grn:r anonnalir r:ir 1r.,' l]r(r ,,
    l,i \- r"it c bo"',,. ,.. i r. rl , l i'ct lir ili ( dr im ic : : r r ubioiogpc) .
    / ' I ' c.le n'ai mrlte auom tlii doninante l'rrrrlr, r'r'l, aproxirl]:rt:i\' .l {l{l(} boli ereditarc cn trlr.rsn]i1:cL|r.r11Q,,rrLi
    i I in
    " ' o"zi"fi ootti c"ractcrislicircintiinitc l,, Lrrrrrrrll s,, jrscrirr: siclctrria.::ftrocitoza,eli,ptocito:o,tttlasctti,t ltt.tnrri, ,'rl,t
    ;(, lT A !i,'.';;;;"ti"&"' a\ u.irsta-trtnti;"ir.tt ,, t,rli lttl.ithisticti, nLlfrita erctiitr:t;i nt sut ti,itale, f:c,Iipoza fottili.lii mttiltl,l.,r.
    , rtl.t)l,lt:itt, oslt0gt:nczuiltt'tlitr:lti, tlistralia rtntsau.larti(fot:iastclulo ititittr
    "?\ t',r J, ittitt['ir.t t:ortgc,iLtlti, ti;i,tla ,ia tlistrof.icti, c.ni.ricl'ia,orb,irt,t ,lc, rtt',tf,/t,
    ' '.,,,'5 I ''lll',;;l;',xr.i#r;*''6,':"fii,,;i"#
    tiln;' t', '
    "'
    ' 'i
    ,.1a r.Pritit'ir"'tt',t li,',t tr,lt,'tt,rl, ,1[,tr./itrt.,boaia ; .:.:,.:J
    ,,;'t rr ,tir.hrrrtsii, l..ltt.ngic.ci.!t't
    sl,iri..,iii, hiperclasicza pielii, harato:,:t.i,tlittt,',rti.
    i.r iicrr'oregic'i, d.iat'ett.rlinsiliil, si tir trlrl. ll,,li
    r, ttr,..itttlturrr.rrl Xoonctn,,.;:uiict;zro.t'atia ltipertrc;ii..ti obstr',l!
    -"t-^hri ctai:,.i.
    di"tr-o" ramili-
    '' Tli''l-;""' ;' ,-,li'i ,,..,:,
    o''*
    U I 1:::'::^:
    -l
    Lil'I o' e" U :;".'"'.,'.,oll.l,ilii"li,l'.llli
    "il"i''",''"
    'l'l 9ra.o'ra1iischelctice
    atriai
    septatr
    de{ect
    l.?.7.-1.3.
    Tronsmirered
    recesivdiegoti de cromosomul
    X

    1a cxtremiiiLli1e superioarc, sau nun.lal fiirrrrLlsi scv.'ritatca i;r;lil lr I t;; itr..ctrscromosonLulXsini dijcriit lrr l,i, l,rt
    5li.; =.n 7rma/i prin de{rtr scpt'r1 alri'rl s:lL}Il'dn}al cu , rr, r,. |i, nt,:iir ;rvind doi c: i:,ltcs'rmi X poate irrezenta atit
    -c-rafr:a i.\: Irr. ,,r.
    , ,rt , ri ;:i r:crrc1chdrnozigct i:eirti:u gena muta.uti.. f,lind arc o sirillnir r,.r,!
    srl.z.lo,'nari Lon"tli schcllricc Accasti' dir''crslttrte
    i:,i1!
    ,,,,, 1 . ."'.*ea a,t.:I ,, ,rl r1,r,l rrr r r : iiilcci sint com r els?ii, l r 1cgcna-alciir r ic pc cr om osom '1lot l, , 1, ';
    " I t ,, , ' ;r Ir:nrria nu inanifes'ri l-.oah {vczi nai jos), clirr o tr:Lnsmiie, fiinrJ Irrr lrL
    *"*fm.,:l'".H::r,T".f^i,jLticdtnti r, ,r, r .rl l o| lit ] icl' gcucLicc.
    dc heterozigot
    rnutalia'lomLna'ri:r d-etennin'i L9i1i, ll-"t 11:'
    l )o<trtL,:'.:.- I'rirr irnpcrcchcrca rin,:j {orci -rcterozigorc r:r un intlirici cv'1|1{s<,il)1i,,
    l,r' ,l , rr<lrntii masculini'"'or pi!z!!,t.! boala, pril ntuStenirca oroil(|sot)rirlu1
    Ir1rl,.1i[itii:*#*ii::,:iit,xf
    ii--'*,p,",1
    i,'r,,t.
    3;.,'"'#i-:"..1n-:i'r:*$l'':"::;
    a"'"'"*t"'"o:/tli"t*:"tf*,:X1:i:":tt':iJlLXltil
    '
    . I' r| | 1.rt,| L; r I anom alici si
    - iilni "or I i
    s: r nit osi. F. L, 'le vor f i t oaie: . ; ir r iLlr , :,r
    l,r l,rr r.rl r1,rrlin e1cr.or Ii purtirtou'e ale genei rna"rcatr:(fig. 1.12).
    cu,nslri |
    ,r,, tecrrLurilo_r.
    r..ii. ":'",tll::::",'::'"']i,,,,,1""r"r.rri"
    pi9!:-'' tje indivizi ' ,, r , i, . t , loi^ lr , i r ^z; . . o1: L
    {pr : , 1
    o | 1, ri.r rrilr.tigcnc rcccriivc rnutantc
    iu oric,: boali. artosomal dominantl-' -airumtla

    l;rx*:tiim.rury*:;rlii":#fririi;l44iff
    d91nin.a.l ;;?i j*"'H$f l , rrrrrl,l i n cr om osonii X) s: c im per e-
    ,1,,.' i ,r r rr r r n par t encl lxt lnav ( ca. z
    6xa,,omoiiI
    ,.,ii ,,1;l6,' o1'['r1'":::""i:l,i]:::i]ifi"*:;+J:J*
    I r,'rtrriruilvititiltc) l<.ratc fctelc 'ror
    , , 1' ni l. r rr. ;;cnc{icii (50o,,i }:olnavc
    .,J",i:"Jii.t'l::".ii:it:i.';i;; l trin mut
    atic genctic
    kilill
    ,,r,r.,'iirnitiv 15%. corditia nt.l"J"a
    a"'. 1igns-e]a virsta adult iiaavea
    , ' r," ,, | )rrIi ii1oiur hcl . ol'ozir jot c)li 500. 1)
    1,,, l , r( l i r . or ii lr r lnavi. Sit uaf ia !,\
    t" 'deprin anomalia
    gu",l"'ra{i de normali, i r, rrr rl . rrt r i, r Llcnt cilor hor lcr ziUot c,
    ,i,,sr,urLdcnli e:te realusi. , ,, ,1,,.,,irl rr lr li plir r int r : r r : s; u- ea
    "p*iirJ,i" am bilor
    lrrlcliacir. ' ,,,,r, ' 1,rt,iX, r r [ osl dcr uunit i'rr ] c Polani
    a C avs.':terde erettitrilt atttosam'al'dontinattie'1 ' t' ! rt\1' tl.lt t t t ( lt " .
    " sexe; Lr , ,;rrl lrlir'lririrlr, o gr:rrii.anor-
    a) a{ectcazi ln mod egai ambele rl'rstiucte'
    it t.,t" ulor' <lupiranomaliile{e'otipice
    ,rr,l r r,r,i i ' ,.i r . . iilllli lll r : r or uosO r ntX tl
    ii ;t.:*; il-o' ,1,i , rrrr.r i rr I oI r lr r r ut r lr lr lxr r ir ilL 1_r oJii, 50,t dtn hi/e/i
    r r,z nial, r i l' ' : , ' o z i :o t: - ,l;o/r,,''trt
    r ,L .r .rrtr l :r ro .ri . g..nc-rti i l c prcccdcnt,., fl l rr:- , r.' rr,,(| trl l Y r r r '; r ', , i0ri-ll. no cor csl) 1ur - ..f0ii Ctn fblb ',, r.t.'rfi;tr,,."t'
    , ,'l ;lr]ll':lll'
    ,'i:",i,i,li..'irt':i'i:i" d'j'lrpirinte-la-cotl,l]':1"1';T
    .."'t'u''.."' ,l ' rr,. r' ror lor r r llr lui \ . i) it r ir lqlr -
    I l r, rr' r ( | | ( ' l) ; [ l( , nL't ;SiilliLlor
    l :i ,1. 1,12. ' . ' .|' r' Ins uri t,r' .i r, rr(,.rj i v :i l fi l i i l
    :,iii rt)
    , l i li ',) ti i l l i ,", \" '" 'ti'ztrril' rrin rL o I u ra I
    1)rir '
    i r Sil
    ', 'or , l .: \ ()rros .rul rl li.

    ('1ij lr'rriliiisirrilioli;
    tttttnrri | ,,,. 1,!ui i l rrr
    .i .L,rj |(, i {|( , r, I i I rIr I | | I I
    .i ttrtri irr'lrrirl l''!ttrrr"t''t 'rt.,':r ,,t",|i ,i rri rLl i r",rr Ii r(t tri !:/.I1a l rrrrr.rrtrrrti l r
    "''' 'li,i1'1,',,,,r'r'r:'li , ,,r"'Lrl ',l i l |r Ij I.I' II' ,/|IIIIIi .

    l,( i 5l
    tl rLri rrrorrrrrl i1rri , 1lt vr . r rr r lr r r r [ r r r ; r : Lr . ir liui( ii
    r,l l l l i ! I ( I ( I ) ! I ! { r || ()i l Ir.rl i l rrl l I,' l " rl .i rl , r l u l t)u-nrl i l uL\, provtttri l tl ' l :r 1l( ] scllt nif icr r t ivt r ,; or rlllr
    r libili r . r r r it r l, ,
    \ ,r' ,,' r' ,rl tr!():1 " rl i ri
    f ' - l r marni cl ottrt.' ' otu' -rl ! Jrr , rr.rrrl rir ril <: or r sl ilr r ir , Lr uhi. lt t l, ut t : it tclr, r - cir r 10Lr lllrI r r : t cjQ zigoli. (| r.I r,| |I I i II.;
    ';'i ,i ,l , ' ii. i, , ii, , . i f , t.u ,,,,' ,,,,,,,' l ;i
    ., l|rr rrr.ir( i lr,i rJi.l doul ft)lrug,-'rLi[rlcxului si haluccltd qi ilr forrnt hornozigol.i
    \ rl L iiL t r r l. r i. ) .
    l'riutr',r [,olilc qttrt]itar', (:111r'rrIIslDitclerecesif i legate de cromosonul X l,r,ulrrr;r,:rrrorrLirliiincornpatibili: crt viata. l)e asemcnca iclttio::a t:rttt,11t:tt,iIl| '
    ' i E tttt; t' pa!i -' ' hoti do' " al i .pII(f!u1tc,r.t." rr,,, r1rrrl i 1, i1,r :iu vi: Lt ala hom ozigof i est e iuapar er r t i.1a het er t _r zigof i.\ '{. Lr lr liil,
    rr, lior i' . , 1' ' c .,, l t;n t fi !;' tti l ' l
    i .tt.l; , ! ) |t ! !-.,. : ! t . t / , i l ,u g r' ,s ' ;.i I' f J )!t l t ' .1 , a . -Li t.r !1,' ttotl 4cJ,ctl 7tl ,,1,,' rr , \t)licir rnortaiitatea di{lJrit:! la bnicli (mai crescutiL)laf;i d,. lIl ,.t.,
    ' t' t' tru'
    , L,,t (1, {r I r Lr ( t abelul 1. 1}.
    ,1,r llr,iti.svttti.
    a Cat',.tctueJeered.ildiii l'ecesix)el{'gftte d': crottosomul X
    sc rnanifesti'
    - Pcnl:lu trlsltura recesllri i cfi.rtatde cin os'jntul X L'oa1a Itifjdlfrtltt hol;lor ilderlnlnrte ile o siranri !Jrni mfll Dlit (-\cjso , 19li:tj
    r', . ; 1, ' r , n" i ti n . \l o d u l d ' J tl a rs tn i tn r' '
    t' ' obl i " l ' oal l pri zcnl ;Ll a un
    - - i, ;
    ,,,,llri,L m,r...*lin se constatir si tra fratelc mar.nei llolnal'ului (rclatla uncht-
    rt l rot
    .-'-) . l]r_ec_ieita \r. dc i { l i "i z i
    ' {ln indivicl de sex ]|asculin ntLiransmite boala fiilor sii, iar {iiccle sale l aI n l i or! (i (

    r, rri l)luti.toarc
    '' a1e genei :rt-toLmalc.
    ndcrrl i l or' ,
    ?^li if " i u l r' :' ,,a r" i L tr.rrrj mi t g fno? x dr' " c' , ,.
    " ipi io a i c ma tti fe s t' b o ,' l a c tc e p l i on' l ' | ri
    de fdr; ci !]cl rezul l ol l ]
    - Lr i ir oic
    X normal cste
    i:rrrr,rcchi'rea unei purtirtoare culn bolnar', :si iiircl cromosornul
    1,,1rl;ilil;;i;, i";;l;t;;;p"."ulu1 cromosomactiv {iind ce1
    Ran', sing''r:Lrl ,,,,i ,. l i ,l ., I
    ' .1l l ,tc ui tal
    \11 , .|r, tri /1rrl r,i nc :l rri v
    15
    25
    , geneticir (ipoteza l-von).
    '111611a1ie \l l I r)r, l ri i ,,ri l ri r?ri l )0z i ti .r 25
    ', L r,,,1 l l l ,.(, rt j ti ps i l La,
    'l.?.7.1.4, Etedilll€o dsminonti legsli de cfomoromul X 1r1 S l I' i 240
    '/.1 600
    ()cmt anormall situati pe ctomosomul X se comporti' cu caractcl do- ,l , ,,tl ( l ri ,lr i { 9i, (US rliiri} 2;0 ( Ar bi)
    o femeie sini-
    ,,,i,,,,,r.t.-iliilrutot cu accasti tira va aveaprin imperechereacu 25
    ,",'.,'i,ii"', ::1nJ'oii(X mot.lin inderrli;i \- pa,r""n1;i {c1" bolnar'' 1X
    I i thl t, tI a .tni d) 8% (I-:.S.negril I 600 {tjS (.tj'il
    plt-- inor-"I, cu r:dominanl
    car'rr1'| l ln acesttip de
    ',
    ,r, ;'t';;;;*; ;i f ofcmeie i% (ij.S. l1egri) 1 2 0 0 ( L r S Ikl !!)
    ;;,;lii;;;6;i"'sini ii"ct.te d" doui ori ruai ircc'e't decit barbalii' au Hb A-C
    lo"ro r. i"'JiJ"-Ji" fiiceleei-;i la.jumltat'edin fiii ei' 1%(U.s. ncgri) 100 (tlS ncsri)
    ',i,,;'i;i;i;;;;;l;
    ni,,'''1'f sint'rnai pu!1n sel'ere la ldmeile heterozigote declt pine, la 16% ditr 400 (US ccli
    "tut;i"-i""Jipice italieni teDi dc ori-
    LL LiLrba{ii hcmizigoli. ginc rtr(\lit.rxI r.r,, , J
    Ilrintrt bo1ile clomrnarte legate dc cromusomul \' cLr.efccte letale la .,,,,"1| I r, j l rc ]l rc l .i c foutati c i r l5
    "izco'tlittcttlio ,', ,,,,r ttr,t,rr' (Lc l i c i t (i c al ta-i duf.f
    r'.,.t,.riii"'ir"n';isoti'sn in'criu: !tgtt"nt"^.hipaPIazia..r{et.tnald
    t, :,;i:,',;,r;/o";;f iio-Jo,io aigital, hiperatnottictuia friu deficitdc ort'ilitt tr'tn"' , r,,, r 5:rIri ,:rI j ),,
    25
    ',,';,:;:;,:';r;;;";;,-;;;;;,loiL/'a' o{rr',i' i corqx t4i cntci flexovitor' con'
    cH'sbtt's'}Lx'Lt 2A
    70 (al1,i)
    'i,rtLsi.is'i anotna!'ii carirtretitt t ene Ll ,,J,i ,l ,tr.l rr r :,;r,l 1s :t9! 4 0 0 ( i IS t l v,,i i ,\'1 ,1 .,
    rraz4
    '1.2.7.1.5. Y
    Ereditqleslegcli de cromosonruN
    100
    I)cnunrit.l ;i eretlitate halm'tdtitii, derermini' lliil:lt"::"19t:"::--"
    ul
    l rl r'

    i:' ;;;;;1:, ";*;";;;;:" ;,;'."ai' {au rro'r' L:L. irornosom ::l:


    (i
    ' nod de t r' e
    nsmilei fost dc'cris
    a "x-pj-' rt- t()
    .i r',..t,';ri:".rarid-scno";"ii"'At t"'
    rij.ir;i!:,*T.pt,*;+"*:,?#:;,");:l;
    ,.1,,,,'j 3 000
    II '),
    , l lrttt
    ji,ll'i"",::r"'*J.!Kr':{::':*"!3
    ,,' "",,l^ ri, rrirrni rl rrrratotoelclerceptiontlo: J"'rnlo o palmoplanloi t'i!
    l t 'l , r,'iclt't'io :n giald,
    1 'Cl L t't,o:,t hi'f "te.1'It'xcoxft
    i i LLULLTtLty'
    w
    , rl i U i i . 1 i $ , i , ): n i rp l , )i l u -

    gonadeimascu-
    H Y, curo1in di{erenlie'-ea
    ,,,,'if,,i';i;;i]i;t;.oiiii,"tillut.i"
    '
    50
    II (l ! i i )c c ,
    r'l llr l l c - r{l 000
    t5
    Muto!ii lelolc
    1.2.7.1.6.
    .l 0rxI
    , t t ". ' l " t r r t t , r i l ' L Lt ; r l ' , c : r I c 'l c l - 't t l : " 'r '
    llx is li' r i1,r t " ' ri rttt , . ,r rr | , i rr. ' I i i ' l
    rrl rtt ilir t t t t t ot 'ir l! r ) l l ri l l i iit ; . , , ; r ' l' , r lr l, il, ir r \ ir l. r I n l o r t n c l t l r i 'r 'r r ( 'z i l {o t t ' l ) ' c l "
    lllf irt-cslor
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    ',,
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    t , or ' {11g. l. l- l) . l) it r ir L: , r ,Li
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    i, l,;r':ii,,i;:lti,:ril,ut,ufu!LttttLtti,strctLozfl corugatxital,d,de J,'ihr, tru,ralio cottT;t trr/,r1.,
    lrrcc\clli:r \r. Ll , i l rdi .ti i i al ecl l i i' : /,t, srlt:ufratid, rt,n,tlchit'ulifiidemii, rutele t,t].fo/ma!i'icongenilitlr l, t' I
    l l o , r l , r : l l r r . lir ir rlli,tfr
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    'I.2.7.2.EREDITATEA 9I MULTIFACTORIATA
    POIIGE['IICA
    (..:rrctercle eledltare mostenite dc cirtrc un lr:rlivid pot Ii cletcrr;rnatt dtr +
    t;
    ,, i.r-rrrj. jL-u,i (ca iu rnodeh-.Iirausrniterii cleditarc de tip mendelierr-')sat'. de :..
    ', .,,,r ' r . , - , r Lin: . : . r :n ;l i r-:u o t :{ n { c rrd i 1 ' c pcl i q, :ri .i ).
    ' implicir, in determinarea tnei
    '1.sor:icrc:rsa-rr clisocierea lenelir
    r ii:r)i.irri,:sie tlictatir de legile hazaidului. ln Cazul asocierilor, modci""il melde-
    lirrr Ll,' tlursrnitele este foarte greu de recunoscut. Uneori, {actori genriici facbri de medtu altresrn'
    ,lit,fiii i)ot avea aceeagi exp;:inrr;r. {cuotipici. -l-t,cl' unelc polirnaiforn':!ii
    t!,t :i LU; : j jni: r r n ^ i rL .r' r' i i .ro mo " o m a l ^ ,r. I to i l l ,^l mui atj l ' j cn' co l j r i f.1:i - l l odel ul etl ol ogi ei l nul ti frl c tori al e' (€. C z ei z c l ., l 9i 7).
    ',Ir,-,.I)1i Iri Ii trl l ri l toi ral i ! pc ntru o anonal i e s p.c i { i dr are o di s tfi -
    ir:, rrii ,lonriuantir pleiotropi fetali) sau u:rei embrropatii de cauzi necunosclitd' , l ! rtornrl .r, i n ful l c l i e dc l 1nm:rtrl gene:l or c r ,,r' i s c " mi uof i ,r
    ' {,ind un caracter anormal cste sul) dcpcndenta -'lai nulrcl gene mutag':ne ,.,,1nrj rl l ni s i s i c nr pol i gc ti c , A rornal i a s e mani l es di c i r1..]pfopofl i r
    r,i , urtL L:,.rntributia Lor este di{criti- iu lapoit cu variarlilitatea totali a cararte- r".r' 1,)r' ,I ri s c ni nor' (]epi l te$Lc u11 anumi t prag. Mani l c s tarc a.
    rLrlrrii, s1,,ctiv, clistrihrfia crctliriLtii transmise sc iace- dxp5. o curb5. Gat:ss' r ., or s i :l ,.rr' pol i g,i ni c c urmeaz :L o l c €i e anc es tral i . z Lc rc di ti i l i i ;
    :, rl ' .1, ,1i !1(nj |; i l i /i 7i url i i r' c rl uc ti onal e i r gi unc Los eroz :r, prono.l i i l
    \rrtriiirii lencior implicite lu. r':'stccunoscut. In general este l'otbr de ,,gele r1r(.ri1o,:gcflc r,q in jrlmr"rti'rtcito cu Iiccafc gc)Lcrtl,tic.
    rrrirrorri'iLlcin rrrodindit'idual rlt sini capabile si.::prime condilia patoiogici-
    it t ' t . dit r . r t c : r p " l i ; r,i c i t ' s l ' ri l rt.' t r u u ,t ar-i ' i 3cn' f' ce c:r' i al ori z (" i l ' ,.rrl rr r , r ir r r u; , : r : r r ;llLr i nilir :sii: r par l un caz lt ot l sim ilal, r : l 1t , 'l, r r t , ', , ,
    .i ,.r.r'rr r r ili t . r , . r ' d, lii r rrr" ,l i u l ::' ,,i i o r.,,,r," ' ' rd ,,p r.-' ul d l r' c' ;l i ndi vi dLLur r : or I llr ir r r l. i(dr, ) ge[ {j, s; r r t unil {oar t c asL] n: r llir t ou r i1. lt r t ( i|1,
    ' | 1| ,{'| | ' .,| ' i ,|I . r r : , , r ir iii
    l r',ru r . r ; , u) i[ ' . , lir r , ,r.1 , ' l rl c l i v ;. l i rl to l i i d c , ri s,- ri ,c!i oncrzi a]i l uri J' | 1r,r,l rrl i rrlir ( lr r r ( i, r : opii) r r r r r iscr r l c, : l r uui cLr : scr 11. r : i, avinr l. jt t t ni. t r r lr : r lir r
    j1'rr,, siul vrrlirrliilc sr,'z,iui,:t ,;otrrlilii)c gcroglaficc, socio-economice,Iactori 1, rr,l ,. r' rrrrr r r '. l{r r r l,lt : r l. c gr r t r lr t l lLl t loilca ( t t t r t : lr i,r lt iLillSi,l) r t llioi) ( : ( ) r r 1iu
    ", ^
    i i rl n ,rrl lr ir r i, r r r r lJ , 'lr ru l i rrrl l rti l i !i r:rrl c i i tt d t: r asi r..l ' n accst caz se vorbe;te I I | , r\ | | | | i rI i v r ) P, il|ir r r , r iiD i1, 't t '11r '( : olr [ 1]slu
    ' , ] ( l/ 2) : t , ir r r t t Lr L, lt 'r l, 1. 1t r r . r lrr rtll
    rfr,rr r. r ' r ' r lil: r lrr:l. ! l' :i J tL l i ttttl i i ,,,,,t,' ' ,t,' r, r:o rrlp ortt:nii t 1;ol i gcrri t:i;i o compo- rl ,.r (r' ,,rr), r r r r r r i o r r Jr iir n'',sr ir r( 1, 12) r '. ( ir t r : il glr r lul r lc t t t r lct t ir . r l, ^r 'in, . r r r r i
    ' r,

    ir, l l,ll
    (Li:
    I )| I )I )II I )i I i { i I i I ' i I ( l t r , li\ ir llll s i 1r lof l01} '. 'a S C :atC e c a i i f ( }n l l ) i r l l l l l
    l l r, 1, tl. t irl.'',i,,i''i'i,ti.
    tl. cat'rrctL'-':1e
    ii,',,,,,,(( r.rrriii.rl g,'rdlc"'t"spotrsal.rile
    ;,'.';,f;'-i,' il ,,l j !t' :||el i { r tl l fi bui l c rl tdi l ;rl i i rrul ti i { ttori al i . (-\c l s t1L, 193,i )
    i)r|| rIr.rl lt - {(' s l( ' ) lr \ r t lno s c l l l , l i tt (r' l rr)i rl . L' l l c l 1 l l t c11P rcci zi c-ri scl r} rccul fntel
    , , , ,,,,i t . : . ' , , i, t , , li, , ii ,,,t' ti s t ' rrrl " i ri ' ' l c 5 l 0ro' l a trrdol e ' l o.S rrdul ' i i
    l i ] l al ' Jl e'
    ir , rrl Ir r r r r ' . r r Liji ilr - ic l i ri l o l rr,,rl ti l l , ro ri a l " v .tl i .rzi dc l r l al nl l l c
    , ii r['.i l rr, ut r ' i r lit - , c r i ,to p o rl .i o rri rl d ]l u rn i r-rrl p^r5s3ft-161 i r ' ri ^cta: i n
    ,' l
    , i ;1 , ., . t , . . t . , t it t ' i mi n i l c -t.ri l ,' r' l a c rz u l i n d :i l tal rel uJ Z\'
    a
    '\ Jraiiz:r st.atistici pe loturi mali de bc'li poligeiicc si multitractorial':
    r,' rt|:r.i (1,'spriilclcrca uno!- particul arit;.ti de grnp:
    jrr tntdie lc }- \l t, .irt,
    li:;ishi o /&td s;tnil{tl'i de lcctttttld, i0,ai' I
    'ptu:tur'
    rri j,.l!.
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    l ,l,jj.rlr:
    i
    , t,. | .., rii ll
    , i,,' copil si. fle.fectat este de 4l''o' I)ac:r un JcItria:!
    ii"!,, iir.oi." 0 ,2 .1 1'1
    l,r,I '.rr'n'titoit'l
    cle buze,;i palit, gansa ca Driinul copil s:I .ribir. ac{riraii , .r r\ i i L i l i a l 0. I ( jr l 001,] :1.-r
    ',.,1, ,i.*rr;iituri
    , ,,l.,,,',i l,
    o /0 . (p' i rj i ' r !)
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    I i i rl
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    I' i x' rnti rl c sol d i r,1 t' t !l j 1 j,9 :..\
    't l ,rl ,,r , - L ! , r ir i lr . c y c rl a i e b i i ' ri = i d j ' n l l z i a
    ,, r 1,,,, .:. . l ri . i i {) , l : I i i - :i i l l
    r(. \ t ) rc l I r . 1Dor.l l 1 l n e s o r,,, i ." i a .ru a a fc c re tr' Ll i i trLl Jo s.si l l 1r13il ' ttl n a 0 ,0 1
    ;l ' -,,, l' , ' . . ; . ; i. n i " i a ' p r' i .-. a i b i c o p i i a[" r" trl i f)" er" mP ]tt" rci -\ a,.7aj i,: t) ,:
    \i, ia:
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    j;;i* ' ' a ' ' r' o steruzir
    ,.:;';ii,1; {i .il ir;". i', ti-p cc c.lacitat:il a alut .l 0, c ,.1
    ,l,l l,il,rl"iii';;i
    riscrrl pcnti'u ";
    desccndenli estcde 4l{,. -\| :,,iLj1]:
    0, { t:i
    I'L '' I rl i (; (r. r' l . l 0. { ) l l l l !|' j )
    I 'ro/tdbil,itdteaca arnbii Bttttcui id'etiti'i si Jic al.rLali ut' ttcrca;d.ttul' .
    'r
    . j " l : l rl ] (),t2 l i i i i i l l ,j ) jr l*,
    t' ::
    ,;t,,'1 , , ! t t t , t i t t t i. t ,d , t0 Ao ,,,d o v tu ,rl l -ttto i . tn ,c d' c' 1 S ans' t,n:i t' ," t^:^:, i
    ' l ' l F' rL rcl P S r us ,,i i { r, j { 1l l z l rl 7
    i ,,1 'i ,' t . t i ' L rn c o rd a n t{ ' iPP nIru 3' mcn)r
    , t f €( l0li. F ra c \' ? n 1 .c 0,:
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    ' l l i muTJ -,i r" 'r ,'
    l, ' . rL i t ' i 0,0: i c l .;' i al
    ,,l ..,rr,,i , iil, , r r r inm od" g a l o tu l l ,u ra r.e tl c l c n tri rrl ti d cosi ttgrtri 5 i 4,j '
    1r-Llnl: (1,' i ( l i ,1.j r)l
    |iiscttl recztrenle'ipen'tru strcinile alm(itodre depinde de &un s-& l i -,,;rrLra)
    4,tl

    \ltt! ta savcin'ili aitcrioavc. De exemplu, riscul recurenl'i d":p"':i:.':t]


    l, t'i.stttl, (), l l tr
    -1O{ rLl l
    i;rl,i,r-prrlatinccste de 49,; pcntrt un cuplu cu un copil afectat ;r de 9'lr dllpa
    ' ' ,f i i , , r r c , - ; , r s t i na l { o rn e ri o . t. t, i
    aL st"lelitdtea \ 0,l l :'
    - Iiisctr'l anontaliilor la dcscc;ttlett!i€ste dirt(t plo|ofilnel
    .u' aganglionozi iongcnit'r1i- i nl eslilal;
    ut.tl t, t ttt,rr i, i. D^ cx'ntplu, 'inteitinal *:"iut 0, (i l i l ti 0r: -1 .
    , .' I .,i ,:i.lti segmint mai lung are o .;ans5' mai mare de a alrea (l .or:.l fa .r ,:1 .
    ' i, ,' .i".iuiaecii "o giionoia cupriirde un segnent iatestiaal (i,J- .l,:'\\
    unul la car" agat
    'ir, "i
    l| l i l i :,rt ui- t .
    ,LlL r l,i/i,j'.1
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    I
    1.2.8.EREDITATEA FltA
    $l SISTEMUL i. l
    t.. 6-12 'll r

    i rr t r l. ( c r , . a ^r c(j i l J l i i rn u i i i { a c ro ri a l e x fo sl u.ura1i . de Jcmonstrarca


    r,,,,r i i-i' ; i,;i;. d in locii g"n"lor adirposresc ale)e dife:ji e, vanabjl e
    'rr" "?it 'l!i"
    ;;"';,;";ii;: J" f,',ii"la.' C"i'iu t:,;"t #"*otouseg'clc 6ieverianrcale genelgr l )rfri rrrr!r, c \. rl (.r:l rLl i A .trrl l ,:l
    i',,,i,i,,i,i, .i cclc carc cxprimi grupcl,, sanguiri. L,a sistcrnulA, Br 9' AP' t' :' i , r' ,::l .. ..1."r, N ' ,;r..
    ,l, r,,,,rr"rlit dc Lantlstci'.i i' 1!00,'carca pirmis clrsi{icareainrlvizilor in
    .; ,,;,;;l;;'.-i ,,,ii;;*,ifa,,i."l.titi,,' il,, t'.,i .iit"-" <legrupesangvine:MN' P' I r , , 1 , , 1 r r r r i l i ,,r r l r ci r r .i Ii r ','r l i i i r u l i vi zi L o r ', r r :l l I r :r i,l ) r i t) i !l r l i ( :i r ,i , l r r l r r ',i
    fif],..i,tir,ii,.rl.Llrr','tqqori lr)-r) i-:r ,l'morr:rr',rt ,:"1cijtroci{"1. pos"di pe l 1 r '1 , , , l ,Ii L |,,||Ii ,.Ir ', l l ,'r ,r r ', i r r r l i vi r l l r ', p l o l 'r i r tl g l ttp :u r tt;l tti r r , 1 'r ,1 "r 1
    , , rl,t:rlrr tir st l4,l()ri t n' i: ' t t t ir i ' lr ' ; lt r r 1" { ir r r ' ' : J ( ii r : '- t t
    t t r t t t t i r t t J 't i t ( r " e l o r d ' ' ,, r , l , , r , l r tl ,r l c l r i o o ,;i r :
    li,,',,.,i,,'ir;.fii1"'i': Ilp' ()rr, (ic' t:.ttrltl rrmcntul' l r r r r r r 'l r l tt[,r r r ,,,,r ,, r l '"- r 'r r Pl t i ti ; r r r r l ,r l r ',,'r ti o r r r r l l r r !i , i r r 1 r r r r r i ],'
    "'',','''',,"\'',,"i';l's",,i' '''tit"'
    . , ' r, , ' ' 1t . ,, i,'r i u l rli, i ir r , r ir , it t l, l, , r illr x ilr lr l l, i | l l r : 'n r i '\ c t 'r l t Ll t : t t t t 't t l c
    atl'
    I 'r l L i , r , i , r ,,1r l ) r r i l r ,r ,r r r ', l r r r l i ( ,l ,r , 1 1 1 r l r r , ', , r r r l r l , i i r r r l j i , , r r "\ i r r , ,\

    5l
    | | | , ,rI r'r'( )r i rr lx r lr l, r ! i l ,rr ( | rl l l l )o l r rrrrl i l l rl r' ). l ), s, rtl l rl l r_t' l rrl l l (,r ' ,' l .rl Li ri
    rrl .L n ,r r r ' , r t t r lt r sl; r lrrttr' r' 1 rIttItl ' \tt\tt l tl tb tl i t l i ; f;r1,itlL c anumi tc l ,,i i . r\Lr' si ' .: l l l .\ "i Lol i l l .r' (i :rj (' l l r,
    q(,. I-., l r)l J l t
    l u l i rrrr r r r o , lilqit r , r' r' r' rl i l rrri rl i rrr i rrtl rl i c i Lu rl cocfi cl ' entgel l eti (' . S ul )sl l rrl ul !
    , rl l i : lis c , l) 1il) ililiri i , r r)ri l i i rl l i rl i tl i i ,,tc L ' :tt" ,:r Iost cunoscut stu' :l i utr
    , r',, rr iliilii c r lr t lt lot . -* r-i D ri,
    l)rrpi 1950, Jearn I)artssct ;ri apoi aifi biologi au der.r.ronst-r'.r,,txisttnl.
    ' ir L, nt,riLrr-tlc nti:mbranir celularar, particulere pentrt] fiecare inclii'ir1 sifaptul \l Lr :'
    'l
    l. L {il il
    ,.r rr) ( irrilcier clat cste acelasi, pentru un subiect, Pc ioate celulelt saie. Aceste rr, r ,r !,1, Lr ., I l i , )t , i ! t ; . . -i -\.1 ;6 l r ,l )\ , l
    , 1 nr rtc lriologic c'iiscrininitoiii pentru indivizii- rinei spccii ar', losr ni-,l:lite tt .i, ii
    il i i{1, l
    . , /,,,,r, rltr ltl::lr.'co;ttt'atibilitate satt. IILA (tltnntn Leucttctte :lri[3c;ts), t:.tttl- ,
    1,1,.,r : , i rl i i . i . l . ,i.i : . : . r: . . , j '
    ', r l, rcr,rciLar-iurmni (iiinrl tlor dctcctabili i:c it'ricocite). -{c,-.rstir ]r|dr- )i .i t
    , r it rrt Lr biologiciL e,.:pliiir de ce tr-ansfriziile de singe sint greu rit' .:iq{luai de,' i l i l ,,. l rl l ' ,z l ni i . 1 12 - 90 i.,l
    1 |:l -.\)
    ,rr, irrrlir-id.lir-iltul, in speci:rltrar.:{uziilc c1c1cucocitr';itrol'-bcr:il': 9i er:llic5" '.
    , rrLr lLr'
    1t 2'; il ,,4
    r,r"r)r t l ( 1c I c s ping e rci g l e { e l u r t1 c o r3 a | J , l , ri n l t.Lcti i -j uuue Je api tr:ue'
    ,r L rr ijri: il.ti:r.
    rl, ,r:irr I Li. ll:j -0 x.i, r
    r, rrr;r tLc{iL tolcr-.aliLcste {iLt,rl un.lr tirt g ;erj, sl biologic rtlrrezintrl un (\ , fi s7 t.t, l
    ,r, ir:lrlirirruamei (jumiitate din gene pr-oYinc1,.'lataiii). Acest tr-:iicnrenurlic I LiL r1, .", i i,irj:. 1r, t)tt -l 35
    , rr,, rlrlicat dar..s'i gtic cir optoiittttii..50g'u tlin femeile care ar.i nlscr.Lttle; l rl l )l .l :i
    ri ri 1., r,,l l )' i l i t : ;l
    ' ,,ii :iu1 irnunizatc la ar.rtigclelc IILI ale fc!i1c.'rpurtati. \l rir r.,l,t:,i.l D i i )l t a t9
    lirLcr-Ll)c plan {iziologic sistemul HLA asiguli, prin b,,'tl rgenriate, Lrr.l j l t i i; :1a,,1
    'rrrt,linr lir - iduali" l,p e p l a n p a to l o g i c s -a i :o ' .l s ta t:rtci uncl c:i r' -l :j rl eH ]-A l j l I)It:l .r6 ):,,2
    I),' ])n,i l.l .l l ,:
    llr lii, (lisl)r)zlntc fcuiru'anuirite bitli, Impiicalia. gcnotici ,.:r 1141..dc l )i ti t l .r0, ti
    l,LlrrLr ,ii. .,ist,rn.Lulsau coniplclril major: a1 listocompal ibiliti|rii iCHltI) este 1)i i )F l ii; t:i ,:
    . r'r;r''rl.t ,lc iirr gmp de gerr: situat pc cronrosonul 6. Gmpnl rte Sere esie li I 4 ,- 2"(:
    l )/l )l r . -i)
    rt r r,, .1Ioci - A, JJ, C 9i D, comportin,l ficcaL: lLtrllc;oilsL:i':l:]e. Accste :J
    :\,j
    'glicoprotoine Cc.uptr{a1a t','1u1ali s-i penirLl el r! l, l " ii r , \irl i. . a.- .:irri i _:ri i ti .l t1l l.l
    ' : ,,,,lificiL r-loui clasc de I t-'it : 5q : i ,i
    ,l;r ,r Ll, protcinc din sistemul courpJcruentului: ;) 3erlclt 40 clu'.sa I, care t), i l l i l l tr, r .,1
    "l 1 i r,:r ' r Llt igc nii s c ro l o g i c i d e fe rn i n :l i d e 1 l - urpi antul dt cxgal ' : sar, !e- rltlllt :,
    supr.',1a!il BiE
    'rruii: lr) gr:nclr: de clasa a II-a, c6r-c coJiJirA lcntlrr fLliglnii de I r .i r , r i i ); L : , 1 (i r' r r)l l )l i : IJ :il
    , Ir),rli implicati in ::eglaleaimuuitatii; c) g,'ucJc r', cla'a .r III-a care ir:tlud i , ,' i ti { )l t)l t I tt0 1t),2
    i , l i { rl rl , : L ^ r-
    : lrrolliric ali sistcrinlui com1lem, nluiiri; 1r(turul B. inipiicat in cJea ,i ,r . I ri ' i )i D l ' r .l .12. I l!.,
    It' lrr'r l irctiliLrii complementnlui; flctonl ( , si factorrLl C, ca:-: intiivin 1l rl l i t ,! l ' 1,:j
    _
    tr ,.i,r ciasicir-de actiiare a cotlplcm clltlrlui. Gettrl,' ca:t' ccdii'icf pclltru , r r ,, i ., r, , s l r l ri , ' i ri : l , , rr , . . l l rl l i i ,: ;.1 .1.i ,
    li , r ,,r r .t., i i r 1 1 , l l l i );.1 l l
    ( l l l l : 1' nr os ic ues cc a o u n i ta te (c o m p l o ti | 7
    1 \\hrt i tr' 1 A . S ., 195' l ). 1)l t)R r :i j, ,
    ; :'1;rcciu.ziLciL e:listir un nunri.r ile citi'r-a Iltii t1c gcl]c carl) specrlica ,,l r i , | , , . r' rL
    rrt:rr irrriigcirii p-r-czcntila stpralala reticul ocjt cl or'.,hcmatiilc,:, Trorrlrr''ci- .Lr r r l| I )' i )i t 5 riu l1;, .l
    1)i l )i i w 3 )?, 'i ,3
    i I I ,",,,oCite1oi;i celtleior tisularc. Ifoclalitii{iie clc c:primare rezu1'ratc
    ,iiri '',rui1i1rJulcposibiiit;L1ide cornbinarc an1:igelici, a{late sub c':.ur:iolll celor
    -l i,,,.i, rlrlr.rminir pcste xn triliard dc valiante antigenice La.s';rlr:iata relu-
    l,lor rrir:lc11c, cxplicind imposibilitatea jdsilti;:1i:ii cehlarc l:rr:'e inriivizi l -, .' :i l ur i! , ( , l1di: r '. Cit l( l gcnelc nut ant c sit . t t sit r t at c ir , ali<: r , i, r ', 'r l, '
    (, Lr, ;ir:rrp1 iu- i1r:rnenilor rr onozigo',ri). I l ' ,rrrrl lll, \ , |r r : r 'or nosom ul6, lcgiLt t r a dint lc ilcnir si I I LA |r r r v, , , r ,
    ( i ilL'scopcrir-cimportanl.:r a tr]timclor :ior.ri 'iecenii :r ic'.; lafir:l cli . r,,rr,rrri l l L r jir I ) |I I iilnii.a am belor . Est c cazul unor st iLf i pt Lt ologicccr r , 1,lt
    r,,sl, ririr rtttor aturmite alclr: dir:l sistemul IILA predispullL i: lrur:l:iru r ,l ' . l i lr i, lr 'oxilir ziL,cl, r f it ; iLt l de Ca, hcuocr or ir aloza ir lir 4r r r t ici. t ir r , l
    t',li .\,;1ILt, l,o1n;r'r'iicu spondilil iL rncliilozariir jrlr:zittl artigen;l B, irir-c I r I i i , r it , - i( uli si glr r pr r l I {I - A dct cr r nir - r atsr : I r oat r : pt i- . it r lr ir ) \ '( ul, r L. '
    , ,rp rrr i' ' t Lr : 5: i - { ) : i l n , fa l l d o 1 0 9 1 ,i l p o p u ) a1i a gcncral [- Ir ;]:aber' " ;lct rr l .rl i l L , pr in i1ti. ci't ninat c".alt L t igct r lllLli l- 11- Ala f r it , sil Lr r r l; i''r ', 1, , 'r Li
    ,r l ,rri ir r lr , r : il, ir s Ltl i ;l o -tl c l l rrl t)r' tl ls c a s o t:i a z i iai l ti 3:el trl I)l ?l ' 3, ;:r:' i n i ' o:al ;: ,r ,, I l r i! l) cc1 l) f , '! '( 'llt iv. I t r clr zLr lheO iocf O t r LlLlozL: ( Lcl,
    i, , ir r ilr r r I I 'i -
    li Lir , r r t t li11r u1 l )rv 3 i tl l rr' 1 rrl 1 .3 ). .r Il r.tl l rri lll, , \ l: r t j; s1r -tLit t ir r iL,lxr r - t t Lt r rt lt l , lr r , '- r islcr t llrlnlr li nr i r r l, r l
    ' , ( r r ( , ! , 1 r lr r rti .l i l tttri 1 ,ri rr,i 1 ,i ,1 r' ,l ol ,l l rt i l i tri ;r' I' i sl l ntrtl Ii l -A ! i r' 1:l i ,,, Lr.rvi tr rr r r ili, r r r r {1i, , \ r 't t r osr : t t l,cot t ilt t r : r 'ia ( l( [ ) islr t f ir l) r 'r '(( i, , . r i, Lr lr t
    rrr ,r.' r l, , r ir i, ; I ,fi i rrri l ,' ti , i ;,,' i ;r:(,(' . l i rl l tl l l ( i r' r l rL.\' .r lr r : , 'r r r lI i, r r I I I I ol lr lit r singclr ir i t , pr iir lr , ( it r p, i I r . r l, ill.

    l, l I t)J
    ( r r r r l l( sir r ir '1izr ': rrz 1i
    i l l \ :,,ii i , rl i r rrrtl l i tl tl " t-c l i sti Iegi Ll uri 1ar.-'4:1r
    { ir r r l ir r I r r ' ; 1t rr1 rrrI P i ' nni t ' 1" r' l rl l (l l l l r;i : t lr : iulr r t - ot plut r ir l'llot - si cuzim t : lol P( ' -
    ,(r)rl i )iniir i r lr ' ( r ' t t i , (r;u rs n ri l (ti r s i rrrtrl { a n l nu cste absol uti r. trn aceste ,rri.r..vio 1>r-ogmntindasi{c} rl.ifi:reu!eic individuale 1ralrsllrisilil c alr' llrr'i
    rlc probabilitate a bolilor. l f i rr.
    '.rzrrri nrl sc polLic frtcc o pt,rvJzittttc
    Is't:itt(it. grllftcr. lirrr:r't'tt(rr rurtti grup HLA poate ii rltt crescute tr,rr ont, ovulrLl {ccriodat ;i cclirlcle sorrra'tice rezultate ciin mitoz'l'
    r,1r'o lnpula.tic bol:ravr-riu rap{)rt cu o populalie mart_or. Se poate presu- ,1,,, riv,r r:otttiu 4(r ctomosomi sau d.ou5.seiii a 23 cromosoll.ri (celul'' ,li
    ,,rrrr, ..i , : r i. t , i o ; . n .i ' l , fr1 -c .P ti l ' j l j l .l l n c 1 1rc u l .i l a boal a rc" p ' i i ri ,I .-ai ; 1 l,,,lr,). I)in cli 46 clomoscni, 44 sint autosonali (transmititori ai cat.tcll
    ,!,, ,r slnir:r sisierrrului HLA, iurr se intimpl.i iLr *pondilita ar.rchiiozanti iil li I slnt sexuali (sat So osouti): X\ nintru '' \rrl
    l,,r rlcrrciicc sorlaticc)'sr:r:utr
    ,r,. *i intihrcste -tt"- frecvent autigenul ts 27. AceastiL genir nu actioneazii sin- t rrrirrirr si XY 1rr:ltru. masculin. Celdele soi.natice se tnnultc:r' l't ir r
    , trafismitere familialir. in" plus, r:u ioti ind-ilizii ;rrtt
    n"r,iiii- Ji 'lt,,tt.r ntti uti/.ol,ir:i,din care ri-zulti celulc cliploide ct 46 erc,i,;osomi
    ,r',,1III-'\-I:i 27 {ac spondiJita
    "xi"tl anchilozanti. Se presupunedeci cir. pe tringl ' ,1(' 2.1) (f ig. 1. 1a) .
    ' ' r.r (1,'susccptibiiititc aclioneazir;i alli factor-ii:r protlucer-e:r ioiii ({actor-i (ir'lrrlt:lc si:xuale, sper:lrtiriozoidul si ovulul (sau gametii; .r'ilrtjll
    -lr.rrrrr'Li
    ,l rrr,rrlirrsau-alti factori geneticil. l)e exernplu.in producclealupusululeri- 'lr, rr :i(,1 <Lr 23 cromoscurriicelnle hap(,oiile), t,ie rezultind dln diviziLtrr,r,
    r' rrrrrlr,simlus dc hidralazini este lcccsarir asociereaa '1 factoii: ingr'stia , ,lrrrlirrrt;rfir-s.Lrrlil.iotic;! a ceiulelor diploirl: alc gonadelor' In c'.list1tr:
    'lrri
    ,i lritlrrrlazinir., scxul feminin, o Scri carc cxplinir. o acctil:rreleirliL a hitlra- i ,,,, r, r'r)lnosornii on.rologi s,.-lipcsc in percchi, iipoi sc separi" ficcatc ,;t,,
    .iirrri si IILA-DR ,{. in spondilita anchilozarti"r: HLA-B 27, se"rul n.rascu- ,,rrr rlirrlr.o l)crcche ruer-gi]1tlcitre unril din cei doi poli ai cetruleiin tlili
    lir, ,, irifr'ctir:cu Salrnoncliasau Shigella. in diabciul juvenil, c' asocierea ' r,,
    ccluli nouir l':r r:ontine 23 i:lon:osomi.
    lil,,<r;tr.c
    i I | . \ t )Il .i ;i OF cu o *ndini.ii"1a ,autoimunitale (anticcr,'ri antiinsule llirr r:clulir diploidir a goraclci feminine rezuiti"r 2 cr:lule hepJoicl, (, rr
    'rr' ll . r r l i l -+ .i o l r l l ccL ic d L I tu \5 r cl{ l' lL . Up !o<, l Y dz)
    | , rr) rir,i rlr'23 cromosor''il ambeJc ar;ild citc ?2 aritosofili ;i .ite un r,rr.r,'
    It,,scnpci-ilcasistcnrului HL-\ a adirs liniuliri I,r:ivilr,alc 1: clistribulia , rrr \. l)in cclrrla diploietrir n:nscrilinc rczultir 2 celul':-h;i1'l"i'l'
    ,,, r''riicir-i lrolii, legatiL dc rispindirea unor tipuri de antigtr. a. t1t:schis' . r , it, rf i:ri)lltoso11ri, ^a.qonadei
    trnil ;rrillll tln gortosoltl X ;i nna un gono-sornY.
    l, rrrrrri ,roi irr getctica i:lcdicali si a pertris ir4elt'gJcreaitlaer:.c1iulii ':re-
    ,!i 1 i r1 i , r ir ( ( liu.
    ',/o,/I,.
    -\
    fr$", t./-"r-\v.
    IN INTERACTIUNEA
    1,2.9.GEMEIATOGIA EREDITATE.MEDIIJ
    i,ts:-I -. -?i
    "

    slririiul ger.reticii pr:in intcrnecliul comportamctllriui geni:lilol ll or.ro-' \@ ' t\\Y tl


    ' .' \O,/ /
    L ,1izi1u1i rr scos la ivEali unele aspcctc interesant. in Scnczn aaracterL:lof -...--/ \)!:--l

    ',,rr.rl' si t,.rrolollicc. S-arr putut stabili urmitoalelc relalir: .i/t tfdz; 46 Profazi+f ,i,/e/a/iza16 .4;/ela,Ez,i46 ::rechi
    , t t , : r r ; , , t ^L c o n J i l i o n ;t S ,n e ti c i -c ' a | l -' zt rl l J l nl i - l l ni i ;:r' ' ro- prec0ce ,tcrd///,i iaoiTosonl'
    r,.ir.tri si llL intilnit ia gerlt'nii dizigoli (roltil lactor:ului cleditari;
    un catactcr cr.r--nditionat muliifictolial :iptre mai i-ar.la molozi-
    ,'r. ir , , r r nP er c , i, t u -' rn " n i i J i z i i o l i : '- -.,,/----\,
    cLrr:ii un'caractcr- csre conditionat uozoio3ic lfaclcli tL: iuediu-r, el
    <----'-*\
    ,/- >\ \ *.\
    , r';r :rrurifcsta cu aceea5ifrecl'ent:f 11 temenii nlono- si dizigoli ,4*|) ffia.q
    enJr lI
    l)o|atl;r rolului eredit:rtii il] dezvoltar.'a Llnor caracte:c ililntitittive ;.t:< f>'t
    -;/
    '\'7

    iL )iloirrtt t.riclii, a ilisului, iniJlimea) a fost trdusi si prir.r {aptui ci gemenii _a--'
    '.,,r.rn t i . r u c alJ .l c J C ,d :ti ,' ' n p PS l c EC l,, r c.' zuri . 11| . 46
    . r r Ldiul q c trn n i l o t .o J o rc i ' r c i .re ui te -i c' i 1 1' 1j n-::r a1,.r,l ti a .7.'ofdz,j itrer,Szi
    l' ii .4,alitzi
    'r.rll,rrr:rtiilor cornune (rraladia luxanti. a ;oldului, picio:: strinb couge- l !l \li t,,z x rrr' ri rl ;i . I,rt,ri t17r1: s t.rrc dc tc l rr,:,,. l ' rohz e: C on(l l rrs ;r!!
    ,r t.Ir.' . r . r " ' r i! ir ' t ,s i l ro z l,o r, : tl i l b o rrtl u i z a h r r-1, .i .1 ,rl Lcr - -,l i - ,' oi -' cn. L ,,,.rri rrr.,i r.rrr(s ,r; i t; c r.rros orl i ..l l .l .rr' i l rr, 1l rroi Li l o al e.t:' 1r).!i rD rri i "r,rrr'
    ' r r r : , r ir r . r '; jr tr,' n i l o r tn o n o z i { o l i .rL ^ i -t L tl j ' ,rr i l ) ." r' l Ji .;: ,1. .: di r; ,,r'r r' . rrLrrl l az i i . Lr ,r' rl rul .(l rtl { ' i i r1 !i .i rr., l rl trori nl i s ti Iofrl ){ rl ,.l - l rr!L: l ' ' l '
    ,lil, ritr.rr rrr:irlirt cir. c]czvoltarea p?lrilmetrilor somaiici (greutatea, ir:i5llinea) ,,' ,,r,i r1 ,1ri ti l l rr, rl .. l ;)gr' r c ortl orrl el c l e l r. l ri .l r)i l oi i ri i -f,,/rr
    ' l rr,i
    , , r'l :i r' (' ,,,r' i (l 1:l c rrri gfc :rz a!l i c c ar. l u (11r' rrrr pol .l i Ll ,l l |i , rk / i ri I
    r i rrl , lilc r r lr l) r ( ' ii u l n l r]rti t c o rtfi c i r:n tg e n c ti c i ntporti l nt' ' i r,l ,i rz i rl
    r. ' t t t -. t ri rL : | , , r L ri i : i ri rr). (j o r)r. , s o l l )i i , r' rr1 , l rr I i i c r: { o f r] t L i -i rru (. 1 , r. 1 L r, l
    I i:
    J i r(rrr: r 5 c d i ' / i (l ri .

    sl ANoMAtllLE
    1.3.cRoMosoMII LoR t \r'l ),rrrrl r' ,1 , t , t t 'r , , . , ' il, , : r Lr r , r it 'giir r iir r r l, r r l 'lir izir lr r ii r r r "r r '1ir ' sr lr r r r '
    f lr lLr llliil f |lLlli[ i , i , , 'I r r I , I l l r , , ( , i ] . I i I I I i I i i ( l i l x I I I I I | | | | I i I I i , . { ' , . lll, , l, r , , ' ] l r l ir ': r r r r r '1jiir r r ir lr , izil , ', r llir l ir i'1l, I r t t t r t t t t , , l, r '
    'rrrro r,,rtii t. llt r ' : / illlir r1,1,'l or
    '
    ,l , r,,rl r,(1,,,' r i r' i l l , ,l ' i l l Il l i :l i l l l l i ' l l ()i l L, rl r:l l r' (i ,l l lI
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    ..rLr I rrI rI r I r. I r ri I r i rr ( 2. , ) , \ ) , r r ,,r(1,,i r' r)tl l s( ) t ) r i X : t i l, , r , , t r ( ir r ( '; l I t ] st inaclir , r 1, f r ) r ) r ir[ : . ] , ( . 1' ir ilr , ( l
    . i i' r r r r r r . t r r l r t l: Ls , 'r r l i t r , c i u . c ( l c t c l t | i r r r :,i sr,\!1i l L t , I , r1rt r' t trti i r' . I |I I lI I I I t ii, ; r t iI r r ] iln sir t ll. r r rcLot . t csor }r t lr 1r r - , ; : nli i: r . lr t lr r l
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    ,r l ,rr !l rl Lr l llit f r .
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    , , rL | l ,1],ll i t zi. n] 1nlit iut ) it r lr illolr oinX e- qt eact il- , celi. lal'i sc; ] ] ar t iv|ir zr '1: l,

    bbfif
    Lrrrr,r orrrri ( ! ) r l) lls( : ul.m r cleiil: .Scicct ar ca cr or - nclsot nului X car esi: . ilt acI r ( , ir zI
    | | rrr,.ir,r, lrrt:r: iu viala ,,lu,1trioua.r1,este intirlplirtoare (prr-)viltit (l l.l
    r.rrrrrl , . lir ir Lli) ; i ncidcniicii. de la o ccluli ia alt a. Pr jr i : . , - . iii u{ , r r ir Li
    ,l ,,r' i ,l rl l \ ll {cr r cic sc ; : : r ar lizr azir un ec}r ilibr u iLc clozit z z, si: , i *r . u, , lir .
    . Lr.rr()r.r)rlu.l X aprLl-iininrl rilui individ mascul trul \ .rl
    ii cl:o.,ltos,,
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    colpuscultl lJali estc pr, z1,lt la :,.\ul
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    f r (l 7, r r r il( 'Plllolr gice cll ( or iojt ot it oLlaiiir 1c r ipul X\ 5Y r , . ) r , or . : 1, , r


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    5TUDIUICROMOSOMILOR
    $N INTERFAZA Cue:pono'enia h/rr" cro/l7ot'tr.:,' /
    €/ L a,iJ L/,ecu//:/ Cd rl
    St: ;ru.il,: r-r.alizaltliii rloui"r rtrctoclc:
    L i .l ti . - C orr,rs (.l rl :l i ,r' r'
    \. ( , ' 1r ' , : L' ldr (u c o y k u s (u .I,i Io r ] ] rrIr i n froi .i ul bLrcal , Lne-
    lr,rlr ,:rrlr. Iru-niz-.irziL rllL' asrr]rr"rL s(:xullri iRdii-idu.iL.ri,lla.rr si Ilcrl_rlm au
    \l l Ji l | , t j i i t! l /l i )' . (' .( 1i u(l (.I.)i ,IL.LI1IILIIIIi Y
    ,l rr,)r! 1. r ' ir t lr ) . lil) ci r i rr rl rr;l r,i i r:r.l L rl rl o r rl i rr i nrrcoi Lstr j ugrrl i i tl ,, 1.., l crnei ,
    li
    ' ;,t,r,;t
    , \l :J I llI r ' ( lr i) i( ] t r l c x )rn tti l l i i Il l i rrr:l rj sl l L c rl l oi t.f,' ,l l .rot. fotu[j i i , si tuat pc i ,,,, (l r
    ri ul /rl l l Ltui ri tri j []rl rt-r.s i :tnl r. l r rrrr,.l ,,j l ot j l 1, ri ;rz i ri , rl trl rl i o
    1 'r r l . , l t l .r r',' l o11t|r' rrt ,l Li rl r, ri n ttrri ri r r. ( rt :rl r.:r:,1i 1111 t1' 1i ,q 1.1,y 1s 1i,,r11i
    , i
    l i rl i t l r lr . lt i I I |, ||I| )Ii IIIl I t!,l rtl r.l t!.. .\r.r..i 1ro t' l rLLi (j 1rlrr' pr.r,zi trl .irtrrrrl i l i n
    ,.' t r i, " , , 1", r . r l'r , , , r
    ti :1 ( iJ
    X,3,2,STUDIUL CROMOSOMILOR
    IN TIMPUTMITOZEI l i l :r r,ri ' i ,i r lislr r u( ii.t lr : cr t ir cii: lir< r 'o r r r tl i d i :l o r l i a l l t[ci {r r o r l l ( r so l n L l l ( 's{( ',l r ''
    (coriotipull rltortitlt t' :,J\r iitt:lLtuntrir. Cln<L tn zi ti r l r r .i o q L , :r p l u i r l ) i ' I,'r 'tn i n ,tl :i , ( t{) l l l ( ''
    (lrt.,mo.onrii
    pot fi l,irrr,sl.Lrtliati rrrlrru1sc rrlt',,:sta uclocentric. In ,- .r Ir l i n cg ,1 i L .'i i i l ,r a !"l ."r . s, tr o tl .i r z:L l ) r 'i r {r r l
    . in iirnpLrldir,'iziunii celulelor mito- , |l l tr :.1 (] :r Lr"rl l l l :c l l rl cu litcra p (!eli.t).
    litr, lrloc:rt.i in mcta{aziL, cLr ;Ljulorul coichic:iiiei. Cariotipul se studiazS.pe l ||rJ'

    " ttl . r i Ll li: r f oc it.. s i n Su i ,)r . p c ,,.1 u ., c rrtanar {Jibroblagti) , a duor dili-

    Bra/
    (
    I
    t' Sole/i/i
    Jcirl'
    t
    6raf
    /a,49

    -(.e//lfomel er
    - Ce,ry/ron * Cromosom
    ',,'tlibLeitlr/c; sub neC/ocent'ric; 6Crocenfr/c
    ' ' /i.///ICo,j 1/7 {*c.onc6cm
    ..'/(.'/.t('if///ic) .t0bmslacent''ic)
    F?g. i .16. - C ro os oui metni nz i c i .

    Irr frrttr:1;it:de pozitia ccntromerulu,i sc poatc calcula incliceltr t:t rtlt,r


    rrr,,rir', rlup;ilortuula:---L
    p+q
    !irt rl,rrrit:rtiic clornosonilot se ntrrr.rfsc trlrrrrli ; i at plopr : ii't i {i r l, '
    " 1""/]1."t,,',r,t,., cromosomilor miri pot tr obscrr.ate st languliLr i, d cr tt t lt t il, '
    r r' rr,l r i r' l i i scct t ndilr e.
    Fig. 1.li^ - Czclatiparc. ( rirrrt,rsomii acroccntrici prezintir, de obicei, 1a capirtrrl st:tttt ttillr'
    .l,.ll rlici, rtlrtitc satel,il:i,atafali de cromosolll prinLr-o constlicl;it^ slt"tttt
    zirrr ' cstc stimulatii cr1 ph3.rohenaglutininl,ie.r in cazuri specia,ic,pr" ce- ,l .rr.i . S l l ,.l iiii N1rr o1 im por t aut 'ir i or - ganizar ear uclcolului ( f ig. 1. 1|i) .
    lrrl,,l, miLdLrrrci(hernopatii) qi pe celulcle fetale t1t'scuarnateitr ticiriditl arrr- i.3.2.1.1,Clssi{icore
    rri,,'Lr(.
    ((.r,.ilopatii).Studiul cromosomiloi sr fac.: dupi dispersarea1ol in
    i Lrl r l l llIJlLt: onc.
    Drrl,.i. rlili'r'Lutclc modologice, cronosomii au {o-st clasificrLfi,.lrr trrrri
    rrrrrl i , ri ,rr lr , r 'in1cint er nalionalt i ( I ) cnver , 1960; Londr a, 1963; O l: lr lgr , ,
    Ctu'iot\;area sc fare piin fotogr-afirrca, d.'cnparca 5i lranjarca cromo- l ' )rrl r l ' ;,rir . l97l) . Cr it cr iilc clc clasif icar e au f ost : a) lalia L: r onasouilr t r ,
    sorrilor in p,,'rcchi.RezuitaiuJ car.iotipului se d.r cl,-rri c-.iaminareaa trS-40 de ,l | | r,,, i ,rr( r r r t hr sl it uDir t it i in lc: - echi. uunt ct ot aic in olr - linc t loscl( 'st r it t r li'i. ,
    (,,lulc prrltlLl ficcare inilind ({ig. 1.17).
    ,1, Lr l ,1' , r . , lr , r r , t 'e inai m at 'c, pir l: . \ . 7a72, pcr t chca cea m li nlicit ; l, r r r l/
    Studirrl clomosomilor in tlmpul meiozei sc poate pr.actica, pin; in ,l , rr trl nu r t t r i, ( t r Llr clul 1. 4) .
    1r|r.z'.nt,iir sr.-rulmasculin, prin biopsie tesiicular-i. Se pot pune in evidenln t,,,rr', , , r r r ji : r r r I ) if lr r L dcnt t r ir ir c, t r l, X si ) ".
    rrrr,l,' arrorrraXiicromosomalesi, in caz de sterilitate, anomalii speci{icC. I r rl l i[ ir ir t cr r m ur ] cr ici! s- . r adiLugatapbi ; i o clasif icar r ' lilt : r 'r t li r : r t t . '
    .I.3,2.I. | l ' | l ,i l t. ' rl, r r , r sor r r iiiu 7 g|ir 1r t , ,<le 1a A la G ( I ig. l . lq) .
    CARIOTIPUI.
    UMANNORMAI. ( ttttIt'st))irt: iutflrui.. Llhii clornosr,,lni prozintir. llncl(r vltl'i:rlii llro!1rr
    l ,rl i rr' , l ,rr,i r 'r |'r I r llilicir I jrpat i ologit : iL. Acclt iir . sc llt 1ll1cscc/ or r nsor t i r ut t l't t r '
    In statliul de mct:rf:Lzi-r
    clc,urosoruiir,irrt clivati gi constitnili din doui 1rrr ,,,rrrrrrr( i ) r;i ll rlilcltiul irLzir" LtyorcLupiiuni'1c soultl( t:tt hi.it tLi.llr'ili l'tt ttrlttli
    Litr)t.,ttil( (b:ate1ecrctnosonrtrlui)r'r'uuitr.l,:inti-c stluci.urir-ccirtmlii, d,r- t.L brul:t'l,ir i(i li LIl, sd.lt'lilihr, ii.ltrttt(,r t: ktlit ,r rr"
    rr\t) t tl at,ct,I tI t,a]nty, ltttrrltr, lr'littorl:isut,
    , ,
    ttrt ' , ttt tI I rrt \ in r t 'lnr l f 1, , 'r r sr l.A( : \ 's1(Pir r lt i( xliir r illi. li I r lor f ( r jogi( x'r i( r I lilll i
    Cc lt lt ' 0t Dt N" u c sl tc l r s tL l rtrg rtl l rtr. s rrrLo c lr[]l ri cl i c 1;r' i rrri tr;1, rtr.r:okl rtrl l i l l i rtrtl rl rtl ri rr t r r r lr 'lll at t losor t lt l r lolt t it t lLlt l; i 1; lr l scr vi llt lt xlit iizr lt llt t llt ol il( 'll{'
    PIi n c r : lollLir lii oll i ;u u i { i tri r| o rrri rIi rrr.i ,l ,l l s | r' r,t.i i r l rr, Ii xi rr.r' i rr:rr,rtl ori orni l or 1,,, ,rr,i rt,,", r r t ii r r slr t 'clivi. S- lt t t , 1, 's,t is . si r lll, r 'r r r ir t t r l,( lll 't t t r t tI oI o1I it : , r. :, lr s, 't
    l )ozi l i l L I r' I I i rr ,| |r(,I I | | | |i l )i ' i ri i r
    l tt l i t s nl t , lt t lt , t it t l i t\ l i rrrl rrrl rl i l i z i rrrri i r:r.l trl r rr' ,.. t tl l i rt r.rt i, r li1, t t l t t ot t llr t l, r 't t t ol, , t lt {i: l { I ) t t \ '(|I I iI ||) ir I ii t r r lr i ( 1l. ll( r f illllir '

    (i l ( il;
    sirll: .,) r/oiiq a/i,t t t t t t lt r l, t , t t t llnr i) t r i( t " LLljrc iui lilnt, ltt. u1," t, g, /A;
    lt) . \'lIt.Jit,tt \tut \ t t t t lnt t , ' , , t . , 1, ' lt t i lt I , t t t t hc , t , t r . l i . \ ', r - i r r i : u t r m i . r i r , . a u ,.,,,.,,t11:;:,';'.,',"i'1,,1ii,1,]'111,,;r,i
    :ii,li#i"i:il:iil]
    ,,,. ,,i,,,li,,.i,t.,i"Ilarit geneticiLcuprindc
    pestc 3'50getrr'l citr
    iosl drrscrisr: ltr lriltl ipi, lir (.irrr', \ist.r t cntlint.r dc picrtltre.r rl{rur cromosom
    irrrrlil sint 1ii'nccunoscute
    X lri Ior]lcilc pr:stc -5-5tl: :uri si ir cj:on'losonir ui i'la lriLrLlitii peste 65 ani. ' "" t'itt';,;l;; . cromoso'rilrx' trL'
    o'tioottt' pentr* analiza citog.lr'ticii
    r r r , i l rr t t t l l r : p r oce o ce :
    $
    fl flWuw a#
    1? . t
    9. li tr.f
    #i l l\.'1' t:.h tt,i c'i clt b an tl Ltl : {! t t a flos
    ',',,.ll',,i',,,,ii],
    ,f:l'i:l,ll,Jl''::, ,o,
    , .,',,,',
    :iliiii#,l,lll;j'-,'"'o-",1,1u".,
    i riijl
    "' rllJrir r!';ih'(;,

    rl,t
    l;"1,,i1fu ; ;1'"Iiili"1"ji;":iii't'
    ft
    fl]l
    .;-
    sr * ae$& s u$f e{ "i'y:,j3li1tj:T:"'fi ;l
    a 9 /6 ///?

    , r.rl .'
    ,:::r";$:Jll".";::ll*:,1*:t"'l
    .,;'il,ililn,is:xfr "lil
    i f(,l l l {) :otnl rl rt, \ ' ' x r^ are o i l ri ol l s c ' ' :Il (l r)i er{ i J
    c ct1 '51)r()-
    lt\ .ltthxla ,'tL i i)r0|1n'leo:;iuritlin 1i L1(/iiitr-aral:j ' Colorarea
    . r* ,sS* ir l .\{ S} &tr
    :l. :;llil: ,i;:.i.,,1;:il'"
    :ltili: ;"i,'i::";,;,i.ff1,,
    -\ ''rl.l'ii,,.i,i"l',1i1
    t? 14 S' 6t 7/ €
    a
    !_:

    li',tiiau-,tir,.t'.cromo'trmi'or in rcii'r'
    f ' ,,'i ,1,,,i,1 ( iit nr r r r color at ie
    G i. - a it t '^s,' t r [ 'r it
    il ;t

    t8A
    d! ,;
    i',li*
    :rlt;iuli*
    ',1
    l i .' [' th : r 'r t L

    :*itff'#"Wl:,ff",,*lrii;;T5il
    'r,:,,,rr,,.-ij 1i;,
    dc aat r ot at ':

    F:. 6 :oii,',i,,,r
    r,.fr*:_.::-T:.:^:),,.1"i5'1.:.S""ffiiil;:],,niJ-1'!;
    lll ,,:ill;i'ii:;.:i::it"i;*li.."i#':;;.i"'ie"...ii"i"i*'ii1orcromosom'or'
    , ,,;l;:,l'J'lJ;i'i,'.,t i'..:""i:*:"'l;l'l
    .i [i.ul;,,i'"J'1'.i'']'i"lil]l'"' ii'
    irlcn
    F ;t. 1 .1 i, - C*r ;ci:iir !!o r ll:1l : ;.6,
    -!:\.
    I i"fi ;i
    i;'i:"
    TabiltLtr1.4 1:ii"ii,iti:l*'?#i:ll'llll*r*::
    rl:'r,,,
    {ii$s;Iir:]rea .llrn{}iornllor
    ultrqsttwturolol ctomosornilor
    1 31 l 3 Exomenul
    Nr. tof.clrik,'- tlc r (ADN' lrtslt'tt'"'
    CaIaclcre ril,-,r-i.iiisr:! ()tl1rLrrizar,'rrntolccrtllltit ir cotr11)ir\11luiuL'-c1r'lro'"rc
    datoritir stuiliulrLi rl'
    estr: pirrti'11 cmo-sct'llir'
    1, ,,t,'irr,' ar'ith) i1,n cr-ornosonti

    L1
    1 ,2,3
    {, 5
    .ei ai rlrari: 1 si :l sillt 1re-:ii.cntri.i
    ilir,r;;rrn;li'ii:;:'m:t:f'tlnijL,'iiil'llJ,"
    6, 7, S, !r. trl,
    11 , 12 , \
    1i, 1.1, l-;
    rrrei;!c. tir:i si subr eiacerltrici

    llu*,.;;,1;i'"',1
    :jir:lltijllil"*i ll ;ll
    ;:l'::1;^li'T$'iiilll'
    j;ii,,i''llli:,;lil*u:':::t'1x,;:'::J:,:il
    .c]-o!.itr'ici 111a.i: pot a_./ea saldiii
    t6, 17 , iS
    I9, lO
    ,- flr | . r i. i:, l \ .,,r,:r., ,. : ,, .:
    rllctlcentrrci lnici (aspect dc liter:i ti,
    ill,l;, 'l
    l, ll Y
    -,1 .,,,i
    L t,
    ,.:1
    r t,[i i tu i ,r.ri ], I
    .
    l: ,.,no.
    illll; ;;llX;'i"ffli'J;":,',lll':'J"'.,1;]',:l::
    ::lil;'ljli r l \'{ o l ) r o 'o l l ) l '
    '1.3.2.,1.2. rrr .r \lr\ r l l l r i :, I'r tl l r i l l 'r 1 t' l i cl ti l "l lt
    Anolirq citogeneiiciis cronrosonrilor nrLcltoprotcic |erntii:t: ittglttrtltttlt'
    l'to(:( illl (l( ril tlflai:(r i! ctlmplcxrLhLi r r :i l i r ct"
    u r i t:to l i l
    Sitttt:ttrrt rr Lont os , lr r ilr , t - ir oit t , li ilt illi. / , , l 1 r i l r l , r r r r r t t l t t l tti ,l , ,\l t\ i r r tL - - u r r ti l a i i " t'- ti t"'tt tl l i n i r '.'\stfcl '
    |tirr riil,,r i, li( 1oilr,. l,il r ! i :l {l {) 1 ) {l ( 'ttti t:r o l ti st r ;L r r tt
    rll,,l'rrl ,,r lr lo.1 ' r t r , lL, r l 1' rir t r . r r l, r . r t , it ( )I I I r ,r .(,. I | ;j L ( I ( , I | | ( , . , ,I r I I r )I. r t i t j i , | l l
    , t t r , , ro t r t t t l t ti t.t, 'l ""r t
    ri ;jr;';ii;\ l
    r tr p l r r , t'"i tl '"n t' l L tn g i tr tl

    l, rl,.r,l,rii ,1 , , t r r r ir r r lir . , . lr i , . r r r l , r r r , , t i r r ; i ; r l r , , i I , r r r rrr,,r;rrIio1II;il.ir. ,.i;,',,r.,,,


    i,,.,,,,,"i,,:i,, 'l '
    lI;illl,'il;lll;ililii;'il;ilr1'l:t
    rrt lirrrirlirrri lrillL r , l, r r r ; , , , l, t , l, i, lr
    r.,r,
    . \ l) \ irr ,"lll, t, r,,, rr,.i,,rli lrrirr ,1, 'ii,,;'
    r,l ti ttti r l r,tti l rl tri l l l l l ( :l l (' ' 5 l l l l (f(' rrl i l r{ j \r' r" \

    ' Jrtl"'. r., t r , , . t .,.' ' . .,,.,.t.


    (;,a
    OA/V0A
    rtil Cft0l/ 0J0/t/A
    l$d'$r
    sp ss h\
    #s ffid
    /[

    ryq#\ t$
    \23
    ffffiru$ r,rt{r
    45
    S 6

    pgwtr
    u$ &&&$$kpe
    *&mg &$$s$e $ffiffiK
    6 7 I I ro u t2

    pw
    13 14 15 t6 17 l8
    $*S
    r I gF
    19 ffitrffi
    20
    {+as
    21

    l i(. 1,20. -. Cariotip r,rasculinnor$al. J-.\etr-ata1e


    22
    Fge--r
    cu ldpsi :!,
    $q ?
    Xy
    &
    R @ ( ;c
    ];ig. 1.21.,,.,txrcaj prin
    ,:.)li,;rtj€ cicnlsa.. Cronosonri idertjri..rl-i u .errilLr.tirc'atupi; be;zije g, R, r;, C. lOifrra
    bcnzile caracteristicc(Deb# R., tio\.r p. trli). n. Roy.:r I,., 19i?).

    I-a elcctrononicroscopie, nioleculelor rie ADN apare snb forraa


    rr(x- complcxe. dtspu^se -plierea
    numite nucl,eosotnlsau coipii ,,Nu,,. Un
    -p-tiodic, /q 32
    .",rtrle perecli de bazc, cnre se girsesc-infir;urate pe
    ii":-l:?::1,
    n ,140-200
    rlrolcculcde hrstona_

    '1,3,2.1.4.
    Hortqgenonrului

    ., RL.prczcnlar(a gra{i, , a poziriiiorocup.rfcd. gerrt.lnurrui cromosoln tr!!?


    /t.t:l,t rrprezrnl5rrna din pr,:ocup;rilo{undamcrrraJL,rle;cner.icii
    .!
    lrlr)1.{ f:t:.lt;4.)
    rtlja rc. llrlCrV alUl (J"
    O Cupaf iieC2r " t . , , - s e r r U m e s i t / O : , , , : r r - j . t d - a C e e a s i
    lx)zrtl.' rn lr-ul) cror no5or n. . d. r t s i in r r s 66. 6p1 i dcliv",i prirr :. ulicrre diir
    , lc' r:nir. In scrl.rl..r
    . nt o] hc i_\ jo. r S! npf t c i in c r om o s o m u l c a r c t l , . r i n , . I o . i c o r e s _
    wotRpr-ttor1c..1atr
    s. uurn...tes?r14?r.rRnnwicl;. r,r-,i. )Iarkedi
    ]l'11'r:l,l,,tl
    sl l l l ( llCl ; lu. lO . l pC a C .l J Src rOn tOS O In \-i. tC z a r.u c Lr. cC i nai ti 1r.r7:i rr cU noas_
    l "rr':t gCnc ll c ( c { J ,' i l rrs l r-a tl < l t, r,_ \c tnl )l r1lcromosol rrrrl rrif,,,,rc
    . lr : ! l1lt nri _
    ttti n r in. 19110, 35lo c i g c n c ti c i c ru ro s c rrl i fa , l i r-de rrnmai 9, i n l (,71j ,si rl c cr.o-
    rrro s or lr r l l, c r r 26 p o z i !i i l l rro s c u i c i n l g S0 , futi r (l o i 0 i ri l { )?S . ( r,' r|),rri rrl | -. l i []rl l |' (r jI 1r)(trrl rz t. l i fN l !r' i ; , L,
    1.) t) ' rl ' ' (,rri ' r;
    l , rrl l rrrrrl .
    'l
    t;l t
    I'r.rrlrrrsirrtlitrlg|rtrloI sttl' rrs;trr:tstrucLuralqi luuclional yi lrfntru
    rrrr,r;iziLrca.locr"^-uluiotltllitl rlo cttttrtosotnicstc neccsaririzolarcl lor'. Anr-
    irl,xu'r,adilicultirfilor telrrricr:tt,r:csrrt'r:accstui lucru (realizat in ultimii :rni
    riirirlrmrlf
    ilrill"r]#Hi,xtil'],;.+'**i
    i,r'irr in(irrr.ri,.gcucticir) cslr: tllliL <[o cxernplul ulei bacterii care contine (rrn'oso''i
    '() 1 * *:#:rf,i"1":'Tiiiri"..:il*'i:d*t.,';1i
    urirani
    .,1,r,,r,p'.I rmn dL' Al)N, r,'plczcntind api:oximativ 3 000 de gene Fari de
    rri:r:astac,i:lula umani cuprindc o cantitate de peste o mic de ori ulai mare.
    l'rolrlcma reperir:ii sediuhri genelor, in -genomul u la.!, a fosi. iniliatii ;i
    ) i,,ll*;':"Tiery
    iLi:nii;,','ffi r.i
    i:B*li$ir:::lt- ci(i,,r
    lrr oaLccarcmi.surir rezolvati, prin {olosirea rrnol metode in5lenioase9i mai
    rrrLlrncomplcxc suL,aspcct tehnic. Acestcas-au tiazat pe observareaatenti
    j$rji;l;"i'1j
    iili${l[1i"#:::h:":#"h;ii"i:":*'13i'"ff
    .' ,.'z'rrilor,linir-.( u,xprimalc gcncriciqi stcbililca urlorlcAituri frnrilialc
    irr : rlr,,rnicgr"ncalo6ic. Accrtr' ul-rc'rvatii atr pcrmis dcIinircl utror'{rulluvi i1,
    Iili*ry;;#$""=i-:il#i,i,i5ij,1
    ilj,
    ru3;i*l'i,r.i::
    ,1, ttta(lctc le,c:rlizatcpe acela;i cllomozoul(gcnclegatc - Iinhage). Studiind
    , r'rirrrosomiirespectivi s-a reusit dozare;i cantitativir a gcnelor (trisomii, rno-
    rr,,.rirrrii).iin, ro1 ple{ios l-a ir.ut in continuarehibriclaleamolccu1arl, care
    :'#.riift"i":${:i,,,?
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    iii' ,,.i,* ", slA-l? (l rrrrtrl ntl trtl rri rr D rrl l y IJCiIIP
    (SA l2l
    ,f,,rig.,,ul ,tn ir'lrrofol0 ':nlrllsttt I'rtri ,,l i t',nl n1 $l f ,,r.n-l i rnf,)i f ,n i l or&

    ?0
    ?4
    ( ftnl t!tnnr t tt'r l r l | .;t

    I ' , , , r 1 i t r 1 ,, I I I L . .i , , I i I :a I l i l , I I (fo) Ia-1


    L l 1 r , , , / , ) ,1 ,.1 l i| l r,,q frn ri L (1) ( }IJ}I
    i , L r r i t r tl l t,i r:,? rL l - l GnI{- 1+:
    Pep C
    A,[,f,,virrI l l , si l l r1 ci r : r ) r tr lilioar ( , r fr ,r ) !js.ir r r ]al (P ) Ad\r12-Ci\ts- iq
    1 i , j i r Al l N 5 S Rn 55
    l,,ilittll l rl ,l r:r|:r" zi t l - ]( S- II) F H - i +2

    CtomasoNi.rul 21

    f l l!)so n l a l f ITNA
    I^illirN, i I a rri (l -krsi o ri h .rzi l -si n teiaza GA1]S
    l ' 1 , , 1r . i t L l o !rtj \-i ra l :r (i n te r ler on I ece?tor ) .{vP
    l ' r l n r , , \ i 1 L (l i srn u to za SOD,S
    ,a€pi/dbz,i a'
    Cvonmosotnul 22
    4,4/! 5.t
    A li\ ril r r : , ' r t l x l r. I{NA fu/ndrtl ,t icrd,r.d
    (r) Ans-A .lr/ i c/eacc;or.,i:r.: i.?
    1i l)l | ( l i i r i i ) r i , , r x - i (r:r) Ilia' I (; L o t t..1 t,t'.i,ld:ti
    | .^, r, ( ori r ! u l i o i . r i d a c r o n icit (!') c}IL
    I i, l ir r. ll l l r . i , J Z j d a z a (po) P-cal
    , \ , , rrllz r l t ri 1r o n . l r i a 1 : : ACO- 1-i1,I .l.it,. i.:.1. * Ilayia crltfiasarx"iai. L Artosomul i tman cu o partc
    ^: {liir rnrrl(crii sintetici :si rartare iizic:i provizolie in ilnclie dc
    A llir I lrrl u l 0 r i r l l z a i l (F) cr-Ga1-1]
    rent{ ornc r i i l c l rz i l o dc ti p G (A rtol ri S , 193i ).
    Crontosomul Y
    l, r, | , , rt 1 l { 1 , . r (f r L r i ' d r i i t e stic- d la r e TDF
    A iliI , rl r l , l , l i s t . , c o m p a tib iiite lr e Y H ,Y <- ,fpczrd/boenezd/fdmord /9//)
    + Crerybrea" prou/ur /6i/r/er/97? 6e/mdn/9n)
    fle veuTea * o?.;vo//d,ea.i/ mdhr.dredrhstcu or
    ,\'/I d/0ma/u/' (S/epe.s- /37J ; Atn/er- /974)
    l, , rl, )t llir i cr i l k i n a z . r I,GK
    .:.. t /.t / urdre d,t chEy'&1J
    /a/
    A llr ' lt : )l a ( : ol z i d a z a ( b a r . 1 :rF a b r ) "] 4Ga] .r' t'.4?/ld red d/nft/or ( ,0;/trrn llel€a/athcvh/or ffeniunz.Jniltn /9N)
    * lF rtepriccr at cmmacamu/ir /9/J)
    . {Jiebe/$-
    I li t x , iiurl i r r - [ ' r r i n i n { o s { o tib czil tr a n sf e r ? za HGPRT '-tbbczlorns*/ /9n)
    I ?a;h,;p; /r'-,
    Ariit i( rr l r L , $ p r a f a t : r l .g a td e X SAX .-'- -:'.' tttithfe/ - /!78
    -c-d,p:i/ui-ii6((1'c
    I i lrf i )z (F ( ; l o s I r { . - d c h i d r o g e n a za
    t ill |rf l n i! r.,lcrii colorate (dcuteranopia, protanopia)
    G6P D
    ^- - Crefte,";" €/ F1sr /966)
    CB ,fpen7dt'l{eneld { ,}epo/o, loffardr'qt fmu: u
    I l, , l| r)I 1li a c l r l s i d l HEM A
    I r' | ' I I i, r, r I r | . n . 7 i . - : L r r i r o - 1 r o n .te r a zci TATR * Heleracroms//,oii
    1; r (| l)rt : ! r , r r ! 1 l l i rX Lg Xg

    Anomaliilc cromosomalepot fi d; numer sau dc structurf.


    l,nr:itleu.la.Pe baza unor studii cromosomice fi.cute sistematic la nori- I t(. 1.)l . Il .i r.rta c rorrtororl rul ti rLnran \ (Biilrter 1 . M., Stalder G. R, lt77)
    rr.is'rrii nlsclcctionati se xpreciazi cf, incidenla anomaliilor cromosomaleIa
    lf rslr.rr ('stc de 0,620/6din care 0,28o/osint gonosomice.O treime din cromo-
    ,rrrnopirtiisint de structuri, aparent echilibrate (f5.ri modificiri ale fenotipului) o7i,pentru trisomia 21, la 90'fit
    , .r.,.ullri$)tniilol' autosomalc variazi de 1a 70
    r,t,4Z"/o sc irrsolcscde anomaliifenolipicela nastere,dintre care 86o/i sint prin 1,'rrlrrr llis,rt:ti:r 13 5i 18 gi 100o,/o pentru trisomiile celorla{i cromosomi (solcc{ic
    rrrrrrlil'iciuicromosomal.e de numir Ei 140/oprin aheriri structurale. Dintre rr.' trrlrl i ) (r.r l, r 'lt r l 1. 8) .
    rrlcsicl dirr urmiL, 80/o sint ereditare ;i 20% sint doblndite, prin mutalii l)rtnii. r:rtii ctvLcticicni, lZ-14o4 'iin1r''' toti copiii eu sltr vor avc]r o
    /it'll(llicc/rr lrourr(schcma1.6). trrl l ,rrr,rrrl1j ' rr , r li: ii sar - rcar c ir nplici un cocf icient genct ic oar ccar t - '( C. M lr xi-
    f ilrrrliLc <Ic anoma-liicromosoma,leau o frecventi. varialtilf la naptere, rrr,lr,rr. lt)34). l'lxisliLtrosibilitatia ca irecvcnla anomaliilor gcrletice sit ctoas( ii
    l)r.ntnruurlo rliu clc liind binc stabiliti (tabclLtii.7). ,,' ,,, ru,,i'r'; , rrttz,l,,i t Irtagcttc diu rnediul inconjuriLtor 1i prin Lt:tlttr:r'ri'rL
    l,l cLonosonrpatiilcttt o frccvcotir de 15lo rnrrjolilrL(cl dc- i l rl ,,,,i ,l ,rr t r olt t t : r l r l, r s, lct : ! ic dt r t er m inat t l r lc pr ogr csclc r ecupct ir t or ii lll( '
    I r.r'rrri rri rrtI"rnlrL'ioni,
    ltvoltuli irt 1>rimclcsiiptirttrirtirlr:grsl.atic,I)intrt: cttr.lrliorrii rr,r,rrtati i[ via{iL a uDO r iI X] ivizi car c lLliir r la. t ir
    ,rr,l ti , i rr,,i . l \l, . r f ir l( r r ca. , ( r r r l1lrr rlr : vlt Jt t r ',
    t kr
    llli'){,ir rrrtrrrllirltrta{ii qtlc tkrlcttttitti cIitttitrrLIcrt Iot in Pr:itrrr'lL'.i liiiPllirnini. l ' ,.i :r l rt))i r'r r i ( : ( '1) 1'oilr air ( l lngla vlr st il llr ocr ccr ii 5il c] : ( r ilsci, {; p: t 1; r 'ncli. il
    .lrrrrriitrlr.,lirr rrlorlrlii rirtl 1r'is,rrrtii i rrrI r).i,)ltl i rIr'. l\'lollrrlilirlr.rrprr.rrrr
    l;rlii irr | | | r,I Ifl rl ri l l r isii lr lili ( l( 'l) r lf ir !lll dcsl: r lnr lct t li.

    7rl i7
    '! uhlul | \

    |i( ti A 1.6 [$ u(or'lruilt ll)l) 0iI7ur'i


    DlslltbuUrr {'rrtollP|ulltlr' {u{rrDralt
    t r l s l r t b u tkr llll,h r m r r t( r $ ) n r :r lG( S6gol i ne A ym6, 19S 0) (L'rtrrctst I.L:., Ti rerk { ' l s err A .J ., r977)
    ' r n ( ' lr
    It, , r ' r ii: i., ],( ,r n i"r scu ti:0 ,62i l o
    i Cariotipul a'rortoulrri
    .r+.i .i\]"to
    3{).); 6il ii 12
    A r, ' rnrd ; i 1 l e s t r l l c t ' i r i , An.:nalii rle mllrlr ,\rorq ii il{r structurl I rts j i oi di c 1,1 10
    l ri t)l odrc 40 29
    dezechrlibrate
    1
    ('i. rnrrli l c s t l l u t i n i__ l t is()fidc 2
    l, , , , , ril, ) .t, 'l fi srl rni e 4 ,
    701i, {0,42i|, din no1'ni-rcl1i) 3 2
    ]rtntd.i;; t.t!.t tisnmcta.snfr.t Jcn.tiPrnki l ri s(,rri e b 3 2
    '4 z
    l ri somi c 10
    + I
    'l \'i sorni e 13
    I
    z
    lnt n4tiil At xN,n tir i86a,',) A nunatrii t14%) 'l ri r{}nri e l { 1t
    'l trs()tr . 15
    )\ 15
    {r,s9i
    ,,
    zb,A
    .1, .r .t
    3./"
    + 'I ri sbrrrtu 16
    60}i, 1t% 'l ri sr,rrri <: l E
    l€:c1rtc!1;e :rliime peste l!]aEre srrb de noYo ereditare l ri rtr"!i c 2l
    i5 ard 35 a"ni I ri :r'rui c 22 2
    | )ri s()oti {j ]( I
    1,V \
    Tabetrul t,,l )L"Ltri soni i c I
    :l
    FrGcr'ont{ e}rcinirliila}, n}onoosonriee la Baltrr. (J. L. McizoiJ, 1980) 5

    7ab(l tt! 1' t


    'l risonia 21 1/660
    'l)isomia l8 xJ7000
    Ai0t1rnlil (r'omo3oini(e d€ llmilf,
    Ddtlii
    Si dromul 5p- 1/500oo- 1/100000 trilomtr 2l lrr 11 irliai
    Sindromul 4p- 1/300000 .t/, x\1, l- 2l -
    1 i s :r: l -' :' fr' j
    'J|anslo.alii 1/2800- 117500 {7 . X X , - F 1 3
    . t 1 . . \ . , ( 4 5 , X O) -- silrdrDrntll -i]lrlter
    .1/,xxv/46,,\Y ' ' i r1 l : Ii ' rr' i ' : r rn/ ' i :c
    ' n' ul
    11', \1:/45, -\ - lr:\ozaic c1l do!|r PoPL{aiiL
    XVY li 1000{a) .11,X/46, X-\i47, lxx - rno?3,i. cr tr-fi PoPnhti!
    xxY 1/700(d)
    \Y/XXY u 1400{6)
    xxx 1/1250( 9) estcn dcfect
    lrrisomia
    xo 1/2500(9) .*,31:*:.:t!1:,i:fftr'"J,"ff*:"i:ltl,li:i1li,
    ."
    trece'J!:i:n:illli,
    1.3.?.2.
    ANOMATII
    DENUSIAR
    ffi ;;p"cr,si
    ilff1;1"*ffil.ii'i,..!lri.fl;;; iiii
    ;l liil"ffi ii croruosonr
    n ?ff:'"#Lr,f;":1#"':?.:.#"""ffi
    . Cariotipul _nornral,conlinind 46 de cromosomi (2 n) este nvmit ettploid,. '" r$iffl[:]t i'f:3"]:'il]s',].':11T"!
    (_.
    )ricc anorrr:Lllg
    antru,ploid,ic.
    de mrmir', intereslnd unu_lsau mai mulfi lromosomi se nu;te;te
    Cind nurnirul lor este un multiplu mai mare de 2 se realizeaz5.
    i;,lil., fui':
    irirti,,','"tffi
    l;i.l^il;;i;i1111,r*l,
    o l>oliploidie, carc poate {i: 3n : 69 cromosomi, 4n : 92 cromosomi
    I t.rlnlul 1.9). l,ir. rcelali iutlivkl Pot coc o,,u).
    i;;g;,H";.,',:*i*J'i::(ils'"in?.1;,
    cu cariolilr 'l''
    Anoma-liilede numir cuprind; trisomia, monosomia, poiiploidia, mozai- lllorrosorni cste absenla unui ctonosorrr llr o pcrechc,
    i1. l- r f i t l"i' 1'rin Pit 'r dl'r r 'r t t nui t Lont ll- "t t t
    r:urilcsi himcrelc. n , ,,.,,,t,,.r ui, ii- lZ'r i'nt t it "t 'it t : 'Li s: r ll l) lllv. r lzar r "
    :lHsomitr cstc cea nhi lrrcventir anomalie de nnmiir irrtilnitii la om i rr 1," r' i rr:rl:(rl( 'nliAlir ll't lir t at t af lLzii,l) iill f uPillr l
    (0,.'2')/,tdin nou-nirsculi).Jtr:prczinlricxistenfa in cariotip ir urrrrj r:Lrrrr,rsom
    ' N'lunur,,rli,,l rrl.osotn r:stcloaltr' r:ari lrL s1x*'irL
    icr-r" t'ti:,i:,,Jtlt
    i
    gottrr:;olnit t slc ilttsttit rrji:,:il;;l
    snplimcltlar. A(:cs1ir fcariotip cu a? (Zit ] l) (.r.on
    poitic fi inrk.pr,nrlt.r'rt r(]s()rni
    l, ; r, ,,rr,j r,,ri i ,ii ii ,lit t'i,r1,,).
    Mouosomit
    s,r| irtlttts(irirnslor'rrl)
    ilr itll rl(,rTtos(r!(cariotipeu 4(rclorrrrrs(}rrri). '
    7$
    rM
    ,,, ,r,,(t,r,,
    ], ii; lll;1 , , 1 i i , i , 1 , ,,,*r.rrl1,rrrrl i i rIro t,l t,i1l ,r .iruour
    r lis.ir r rrr,rr r, ,,iir :ir L
    li,.
    |"in r:r C f'r

    frf-ilw
    tolilrloirtiillrsirri rrrrrrirrrrl,i
    r,rr,r.ptioualu
    Ia orn. O tripkrirli,,{.3rr-_ 69 Vlr tlll\ -il)
    illiii;,:;
    t;tr',.;li',1:T"J.l';:ll":it
    ii1:ipiil,l,,r!'i?i;llf ,1:11i,j::"lll-i*i V l \--
    tAl t
    llll r
    iln /
    l
    a
    " ,t
    ttl ri t), pr jr r I , . . r 1' 1 { ;1 1 ,..1
    r,r rrl rrl rri,l t. , ,:. 2 s p .r ,nni eTi ;r;.' {ju u s '.\ ut
    . Dt/filf
    - tf l'!tlJ t,ii lilt'tif

    ,r,mffiffi; ,ffiffiW}{;
    M:j/iEV
    - I,J!li!,att['v -

    w
    .,,,.ilil JI
    -frilw-\fran
    !=1J.J-rr-

    A yarfun' Captitlt somo


    @ lVorma/ .Capil
    ffi€o,??fc
    rtb l,rt-/'
    /,,,+?/1J
    / /f /ilJ1[X,4//f -

    v,/
    {[
    rl
    x

    f //r0frfrtf/ /t'ti/f
    Fig. 1.25. - Accidertele meiozei.
    sflft//t't/

    ..,,,...,YlSi..ql.i:,I-a.acelagi individ.segisesc.celpulin doui popula!ii cetulare


    ;rvrn{r cAnotlp drJent, provenite din accla;i zi6bt. Anomalia'sc produce
    zt6olul instgi, de,cidupd fecundare.I n. rip'pariicular in
    de mozaic ii constituie , Fig. 1.26, - Anornalii cromosomiale de stfqctuta.
    , r|(,rx,zrAonsxnuJ nelerocarrot. ex.empli{icat prin doi gemeni homozigoti cu
    cirliotip,diferit,.unutcu 46 Xy
    ;i afiul cu +jX. pi;rd"?;;;", cromoson y
    Jr lcl de al doilca. coincide cu'separarea oului pentm-iofiarea
    gemenilor. .llololia estc pierdereaunui segment de cromosom. Fragmentul poatc f i
    llimerele situaliil9 clnd celulele oiganismului ,1,.r'rl;rtnumai dacl are o anumitl lungime.
    . .definesc derivi din d.or
    !.rrr.rnai mu_l}izigoli. Carioiipurile confinutul lor.genefic iint
    9i diferite. Acesi (homosomii inelari, Se torrneaztaprin dubll delefie la capetele crotnrr
    :rt:cident poate rezuttafie ain .*.i.t"""i su"";"il"t;;;;i;G l;;;; ;-iB.A;
    tlitcriti, fie prin singamie (iecundalie). rnrtnilor, cu realipirea fragmentelor;i {ormarea unui inel.
    Irrvorsiu sru inversarea unor fragmente de cromosomi poalc fi lcri'
    tllrit:ii, rczl.ll|i:rrddin dubla rupturi a cromosomului de o partc gi alta t t:ctt-
    1.3.2,3.
    ANOMAUIDE STRUCTURA '
    I r',r r,.r'ului;i apoi rcalipirea lor dup5.ce segmentul intercalar s-a rotat r:tt | 8{)',
    '',rttltrttrtct:ttl,ricd,
    prin invcrsarca unui segment situat pi: unul rlin [:rir{cl: r:r'o-.
    Cuprind delefia, cromosomi_inelari,inversia, izocromosomii, nruriotttttlui.
    translocalia
    ;i i'sr:rfia. Toate tip.rile se prod'c pri" *ptori'soiu"iiiiJ*i'n' pu,,"r,, o,.,.rr.
    ir'r^cronreisomilor,tlc celc maimulr,. iri i,, ti'*pri lzocrornosomul cstc un clomosommetacentriccn bnrlclc rbsolut cgalc,
    r .r0). ifig. r,z0 ,i trbclul rr.irlizrrtprinir-o diviziunr:anormalil, ttansvcrsali"r. (rru l, 'lgilr.rrlirttlii) t ct'ttlL<t"
    -"i.irlf rrr'fullri,l)i,lrlrr(.irrttLrri cclttititrnrts.
    lrr';rl;i rluplic;r1i:r
    80
    0.1
    'Ii rhtl l t! l l (l
    t) j|'tlo xj/r4L/!t!!U ltruh
    Arrorrtrlll (t(turo|o rk'r d$ stlucXuri

    . t t, \ V ,5p-- - ddtilic :t btalultd s(xlrt a'l cromosomului 5


    Pafli:ll,
    al cromosomului lli
    i r' . \ \ , llt (l - - Par.tialt a llr'atr]l1.i l1lrg
    dr'lclic
    a L r o m/ronrul ui l cu punct i l e rupl u]'i
    1 , , ri[. (tcl(1 ) (q2 l) - d ' ' lctI L r n r ir l3 l:

    t;
    1-
    ;1 1 ,g i' r ,r ",2 b d n d a I a'Jrc!rrl i Iun8
    2 L'rud'r,l S i re8:un'J
    4 r ., \N dcl (1 ) (q 2lq lt) - d cle li, i,n ' r :iiL ;llA In r r" regi uoefl
    i l,a n ita t, r n b r u lr l It,nq rl (rofl 'bomul ur r

    . { , , \ \ 1, r (1 9) - cr:omos]{)m 19 ir inel
    2, rup!u,ri l or i n rcqi unP n
    .lr, \t, r(2) {p2tq31) - in tL a l cr o ,r ".o n r "lu i "D nsLcuri v
    2 , b .r n d r Ii b r u lu llr i j4nrt;i r'fl urr'3 J oal .da I a D t3-

    Il
    !,,lu i lu n F
    cu izocromosom pe bralol l11r1g
    r , , \, i(xq) - indivi(t ds se:r {eminin
    al cromosomului X
    prir fuziruc ,ti
    r,. \\. - 14, -21, i- t{1'k12h) - purt:rt''r "llsimptornatl:i1-:i:t,tilll:*tii
    r ( tr tr i' i, in lo ' u in d cfo n ru-ornrr l 'i fr z I
    sinalron! DOl\rN cr1 translocalie prin lrziu : certrici
    lti2 Lq 2 lqi

    fi!
    t,' ' r.\' , -2i, -
    inlocuind url cromosom 2l
    . in d ivr d d c s.t le m itir r cu Iru0sl o{tt!i e robcrtso'ri i ni Q fornarca frgarii guadlrld/a/c
    r ' ' . \\, t (tJ: 14 )(!lt: qti)
    p r in fr r ziu n c. n lr i t efl ul i l 'rut:| i n(t' 'rcmosom rL 'I
    ,^ l
    si clo m o \o m n l l4
    ri, ' i\ ' , r{l;5)(q 21 ;qll) - s ar r

    *
    - iTi:..:?:ll;;:ffi:ii:'$,'j,Xtf
    rr r,:,1.:;:r-ilr."r1l1lr1 iff'J"1.:fu:H"J,:i'i ]:ig. 1.27. - a) Recolnbi';|ri cromosoll1ale. b) Form:tren {igrrii quadriradialc_

    l' ;;1i: ,1i:,..


    ,,""1, 5
    il,iililiiii"i'ii,'lii^'rl"r'ii'r"i"i ruigacrcmcsom'rui
    Ta,bcL.tl l ll

    grtneipelele sinrholuti &dllzate Fenlr$ anomalli aromos$rr|iec

    'l'ran:loealia .stF lranslerul unui scgment dc ct-omosom- pe alt cromo-


    u" ti o simpld'
    ttattslocali.- ptin transferul unui segment \ (i - grupa dc cromosomr
    u, A;;;;';;;il;nt
    ' ""-" -""^-iii"t"n o',m' o t;nm;t;celi e rettprocd pri'. sdn\mbtt.l t, l l - p{]reihea de cromosoml
    i,:;,, prin clomosomi setuali
    "ttol..o- neomoiogi' ?3t o transhcalie
    -
    ;,',';iffid;t;1;;fi i"ft" aol cromosomi -- sspare doui populalii celulare la 11n snb;ect
    ,':,"i,,;,',:,.;.;;;"; t;obertsoniani). Aceasta din urml se intilnegte la aoocentrici' - bralul scurt al cron1osomullll
    l'' ii,:it;;-;fi,'oir." t t"pt".r *'"tromerici' la ambii cromosomi' cu formarea - brafuL hlng al cromlxo1nulrll

    Irruri <lomosommetacentrlc sau submetacentric-(prin fuziunea.br-afelor


    lungi) I - crorno'som suPranunlerat
    crorlosom pietdut
    cu sateligi care se pierde' Rimin astfel45 cromosoml' -
    crornosom i^ rr.el (Rin{ch(a4vsdw)
    ;i:;'i';i;ii;;s-;;iientric
    '
    ''-
    'I'r'ansiocatiapoate fi eck'it'ibratd(cind nu se constatS-modificS'ri feno- - izocroruosom
    deterrnini
    (ri"a prin moilificiri cantitativegenetice * satelit
    ri,,i,,,'s' I * transloca$e
    "Ziiiiitri;lioriii
    rrr.'tril.staLea clinic; a bolii).
    pozifie' pe
    Inscrlia cste trans{erul unui segment intercalar intr-o a'lt[ diccntric
    -
    .r,,ll1i cromosomsau altul. - cndoredirplicaiic
    Re-
    lindoreduulica!ia seleeli\d corespundeunei lacune "t6p6566ice' ll - constriclie sec[ndar5,
    .;j;,'ni ..1" se lacc asincroncu restu'lcromosomului' * dclclic
    ,,li,r";';;i
    a 4 cromatide (in loc de 2) pentru segrnentul re-
    *
    l""Jn.,-,tur"o"ro*o.o-i
    d\rplioollo
    :'i'i;Ai;i; - inserFc
    , ll(: (tlv .
    cxpusela agenli
    In sindroaurdc<lcrupturri a cromosomilor in celulcle
    .- ter$ri ral
    Accstca sint d.tcrminate . . rLrftur.|,
    quadritadi'rlt'
    ,,',,,.,"]i,'ii,i '\ coiIiE:!ttliil,t
    ,r;,1,;,'tv
    'ii",'loi"",i 'i
    ncomologi, cLr 1n
    r..plir::r{ic. . rl l ptnrar - rtl rU tue
    'u,i
    ll,:'lj.i,j,i,r^lrii.:"i"ii.'u ,un'ntngi sau ' t)i l l h l rt
    rrcfiind int:ii s':ltltiil'', sc rcrlizt';rzilutt ltt
    rtslrtrtrl: crucc
    ,,iii"i,tii,lck'
    "','t,,i,,ri''
    (li;r. 1.2,7) :;i lalx:lrrlI ll)'
    IIII -- l )rl l c rl r

    1i: i :l
    I ; : t 4 I T t O L OGt/rAN O MA L T O RC R O MOS OMILOn r l ) ! , i , r s ti r ',/'. I r t.l l r i l tl sr tr t- l ",l l r , r i I i j l l l l l r r r r r l r '1 r l r - i r r {cz' i '\l ) \
    i 1 ) 1 ) l r l so l tl l {- i 'l l tl l l l r '
    1 , r , , l r n i r r r l , 'i L 'r l l r L l Ir r l ) L L r i a lj r i l l i l r t r ' fi zr l l l '\r 'r r l ,r l r l i t
    l r r lr lor lr r rI r . {ir iu l r)n l i rl i i l r)ri .r.()l r()s rrj l ti l osri n l i ncri ni nati { actor-igttcti ci , , r , i n 1 , i ''f : i ' u ti n a tc ti c l czttti i i L L Iu sr r L u i , p r i r si st.l ,'l :i l r r L i cl co i i l o i : :i i r 'l l i l l l l i
    '| tt t ' lr , , , , , , ,,i r. l ,l l l ,r l ( :;1
    l r . i, r r r 1o r i. i :1c rt.r. 1 i , i l ro t fi re p r.ezentati de: 'l l l l ( ) l {avoriz;r :rpa.Lifin.lrtt'rtr
    Lt) tlin.rt. geneiic
    l)ttlil: i.iIiti1l1i.5:: {r1,:ri-t)tl -ar
    t ' , , t if , l f , i ,;ti ,t' )t! to :a n i , ri l ' c p o a te c1cl errni nao a.Lronal tccr.o_ irl., ( r1)rrofrL)rric,'.Fi'ltl-r aarastii. afirnatir plcdrazir plezr1l1a a:lti(l(r1l)il('i
    rr,,,,r,,, r t ' l ir , . 1, r . i 1 r' .rri , c i rri o ::i | u 1 p i L r.i n tii ori ri nd non:al . ,r1r i roi ' l i , 11iin lr isof lr ia 21, a ani: icoipilol'. ant iiir oidicd, allt iillsillilli r t r r li
    f t r t t t t t , t t t ; t ; il;' t.i ts l o i a l :: t.h ,i tl ,,.,tt,i rtrn r ani l t.tl fe i n fcl oti fi l l paren- L: Lr:,iLLsin,lrollr';f i'lirncr. |rezenta a nticol'pilor estc lnai mirrj irr l' irr' ilr'
    ri ;, r'r r r L po: r t r : r ir t e r:r' ri l t:il a tl ,,.n ,L .n L i rr.j
    -i fLrl ti i i rosi bi l c:
    .r) ;tr:r'1ii:ricarior,ip cn ccl ilaitr;t11, l) l'i)'\{.t. itcLttr;Lti.7n:.id,:.t!a trisoniei 21 f?"rc s:L creasr:r'tittlL rtr t rt
    l 1 r r r r iot i. p s i tc n o l i p l c l n ra l . I ljr l)ir1('r'n:i. frsti: 39 f,nj, cincl. m;rma este tiliri:..
    rlL j '
    r') crliol.iir 1i fcnotip alo::irril. itj 1 r,1",r,qiirrl;/J. iiiuinuar.:r raporturilor -scxuaie ilulri "'irsliL
    \,, ' t 1r , ' i1, Lli .r-.iJ..,p i n d d ,' l L i p n l rl c tra n sl ocal i c si de sc,:rulpr-rri ntc_ ,' ,, .,i ' ..rt,1i ,,, ,r t : 1ai: a dint r c t r isonia 2i si lilst a inainci ( im Lirir ilir : r : a s1"r
    r| l l'| lt i ttrii .jt ! l t , , t 1 l alle r j ., it tractLrl gtnital icnlcl sa'!i iml)1-rtiirirca-o',-ulul',riduPi'1.l)orrl l
    ' tliLi,'ic ztt{.er:ronrcsont,ir:c '.roirlirlLLi
    ,,, r rri ).
    : o aiJratic crourosolnal:rla unul rlil liLrir.rti '
    l ,\,)rir, irjli:. iipalitia. altci al,,-r.Lrii rrornosomicc la dr5ccltdetlti (trisoiric
    I lr copil, t irtr-rl zrvind o atrom:i1it:_\\y;. 'l.3.2.5.I]IAGNOSTiCUt
    ANOMrqlllLOllCROMOSOMlt9R
    l \. it , r L i, t ' r i. e c o l o g i c t. a ) I" i ,rs tan i u nei . l l rsta i ni i i ntat:' ra n:ri l ci
    l, rrrn'iirr;i rua.i alr:s cu cazurilc clc tr-isomit, (21, 13, 18) si cu rLrrclc | )i;ritno.iiicul abcr;rtiiloi cromosomilor tllcr: i--,ril trfi ctllpir:
    ,,,rr,1 ,r 1ii ( ] \ i) , 47 , { x X ). Sono_
    tr) lil:llnt tlrtnmnert lco-clillieii , cl-lprinzlnalc\a1ncn1ll clinic cr;ntIlr'' rri r
    li'irr'rrl ucotiiil {iccliei lirs:e matrn.i,: variazii. considcraLil rinp;-r cunr I Lr,,L rrrl roi rlui gclr {t aol{}gi{tPl: , ecizar daalllccedolt clor ginecologit r r . ; i. r r l'r l'
    , r.rirriri l),' baza studiilol lou-liLscutiior l,ii sau dupl rezultaiul iifttnos- r r, r, rl,'rrir.1ittii, r(:l:rtii ti..''spi',: tx'o1u{ia safcilii rii,r carc a reznltat ill'lirirlrrl
    .i
    r, , rli, t I)t,,i).Llill. l l) {)'(}ruatiriit f,o\rli (crJrPriscuiulBar-r). Cromatina sc'xtrali st: slrttlirrzr
    lrr rLllirrii ari sr cc'lstati. o cresi:erca incidentci auomaliilci- cromoso, ,, l r,,l i i rl l rnr : ; ll.r \ c, 'sir , r, ic c- , blincpr io r aclaic: i m ucoasci do pc f af : r . illlct r r ''
    trrt,' l;r grrrlrl rlc rintiL 3-i 39 <1c ali, 1a carc riscul trisoLliei a trccrrt ,,i ,r rzi ri Lti ,: r I ixcazr i incr lir it cu- aicool ct ilic 961; ; i - scr oior cir zii l) r r '1'r r
    I I r 2.,'14'1,, j)(,rltr'r pcricada 19,5-i 1969, la 5,59ori,pcntru pcrio;rdrr_1970- .i , l ,i n, rl i fc*nt ir it t : sl obf it r ilr iu color : r r e c11hcualauu. . lt l lur : lr : ii t '1r ll''
    l')i I (li\.,ll)rr si coiab., 1978). Paralei cu sc:rdcrca i'irstei irL:riii a materni_ 1,,, '1, ilrlcic ufliti ir.rilttri':rzir se g:tsclte crotlatilja scruali! sub forttlrr r.r'
    l. r rr Sl'ul'rai, s-u constatat gi o sciLdcrc a l.irstei rncciii i,, rnamclor- 1i1ril p'
    1,, , rlrLlri llirlr-, liipcrcrom, cu asp;ct iliungiriula.r sau p1.ul .co11xu\,
    , l | 1r'rsr ) |] 1(21. i Irl .r rrl (rrr,i ir lncr ; br r iiit i nucicului. Sc adnr iic {j: } un or gair lst r ( 's1r '( 11) lll'
    )/tctuti:;ltttl de aciitn.tc e,stc explicat prin mai muite fcnonene lcgatc de cc1 puliu 20?i, dint r c. cel, . r lelcslr r r iir t lr ' : r t r
    . ' rr 1" r;i l i r' (rI'r :sox f i: m inin) , daci'L
    r ir':.lrr rnrr.itlr'i(S. A-Vmd ;i colab., 1980) : rp] : ocent ul ost c nr ili [ ] ic, sir b 10') o, 'sc susl: r 'r r lt lz'r
    ' ,' r,ri i uri scr t Lr t lil. [ ) ilci-
    inr:r'tinirc:r disocierii acroccn'u:icilor in prclaziL, crescil].! riscul .r i, rrlrr urrui mozair: .'lt5,X/46, XX (trta,'limi1ian, 1982).
    rr,rrrrlrii r Lr r c iir . i.c r oino s o m i l o r (Pe n ro s c , 1 9 6 6 ); t ,,r1iir.ctiltLilllLrl l-cptcziniiLL1ncrorllosolll X inactilat, ctt.o cotttlt tltitt-t.t
    l,locrrr.L riliriLriji Senelor ce codifici pcntru ARlir in or-ocitele /, ri ri 1qrrrLliciL, {a!ir.tlc r:iiriotipul ni}sculifl caro :u'c ulI s;lsLlr (Il-r)II I 1}:I()I I I \'
    r'r",'r'i rr . r , . . \ , . , [ . n. ,rn . c .1 , , o rn 1 ,e ,,..I p ri n rnt, rrti l un,ri orH .Lr.i z,:.,r . ii l ir u cor Pr is{lulil: }ar r '. Calculul num c. i{l al cor PI l: icr lliI {||
    t,,' | ,.,ti i rrr,r 'r r r r r llt
    rrrrrl, olrLl iL.itLnLriaclocentric, ccclL cc ar far.oriza notdisjunctia (Salamanca- tl ' , l rl .r' ,it t Pi-Ir{r . r ur lt lir : lir . cr ounsot t t ,X i - / . Fr : m ci: r il! 'ir 'l 2 ( : r ol) r ( ) j( |llll
    t ,rrr,r,,:2,l97li) ; , \,r i rvl ' i r t l silr ilui ( x) r p[ SCul l] ir r r . in anom aliik: ilonO SO m alc- cU. r r r r i t r t t t lli
    rrirorrrliilc Iusului mctat.i:ric, prir: nodi{iciri c:itoplasmaticc (liche- ,,,rrr,,urrri \, sc pol iliisi illli lr t ult i cor pt sculi I Jar r r . in- ilo1r ost ) lllir L li( )
    1 rr l i r', rlis p: uit ia { ibr c l o r mc i o ti c c ) (l ' Ii ts c l i i , 1 9 69)j I r i ,rrrrl i r,rr l lsi r : ii t linin, coLpusculul 13alr 'lipsclt c ( t abclul 1. 17- ) .
    {) l orr:r( ilr r t ct l lt ( r r cilsi ser uDilt t . r t i ca si r 'lr - PLr scul- ul I illlf li( ' illiil
    (lili)iilLrirrLrat'r:cvcntei clLiasinclor, cu riscui pro<lucerii de garaeli
    ,' .t, i rr rtrrr 'l|ir l 1r o1ir : t ot I r lt uil,r r ll, t r , \ ur , I , ir n, t r l, , . l'il- t 1'. : t . olt ; iJ1( lr t t t
    rr,rr1rl.izi, lru rlt'l cu inaiitarua in virsie (futlartit,' fOl:;. ! rl j Lf l r, r , , il, 1 ( , t . r ir ir ) lr . l) lr c cu o hecl'cut il <[ r 3') . i.r, 'i'. it oulr ] lilr . l. ill
    1,,rrorrr, rrl rlc iirltirtrilire ar prtea li cfcctul cutnulat al rLno;:agenti i l ; r l , i i l r ll .
    1 ,ri i rI r tr lr , t ilr r r , t r lr l i rq r:i ti i .
    lll) \ r ur l ;r l r tn r r t'l r l i tl ttl l l i l tl i r l r sr 'r r l tr :l - tt,'l L zi i l r r ;,l zr tti i tl r l l tl t' r :Ir ti 'r II;'ttI
    ll .1,lltit,,t t',r.rlittl,iilarioli::,rnlt: cxorcitittii sur cumul:tlit nrai ales l , , l r r l , i l r r , r r r n r l i i l , ci i o g ctr r l i t:i t i ttl l l o si i r i l i i ..
    lr :rr.rrrL. l,i r r ' i: r r ir i : rr- | r.w rl i z r. frrr0 i l ru tr] t| : i roni i i sj rLncl i r, l ) L r r r r i|l l l l ,l , :,i ttl ,o r l sl i i r ti l I r l .i tl 'cr |r r {r , ( I) i 1 I,Ii IIi ( :( ) . i i l r r r r .'r r l r l I tl I
    r) lt t t , t , : ; t t lt ; lLt ttl it,l ttttti tt tt)' l )t,)/1 tt | rrl l i L rri si l -i rIr.LrIi l ' i i,,1trrt:ttrti l c , t, , i t r i . r r p r ' r r i ,l r ' l ,r r l p cl o t r l i ;l i i r r l r ', Ixr zi l i ;r i ti r r r ,l i r u ttl tti :r i r i r r i :r 1 l 'r r l r r r ' t
    , ir)r,r,rr)qlir' ( r t t r it t r 1 l ri ii.t1 rr, t I I;rI i r|, rI I rr, I I ) , l ,i rl 1:,i ri ;r rrrr,rrj rrrr,l rrr,, 1rr:i l i - | | i r t ) r 'r i . r 1 ,,1 "i 1 ,l ,r r r ir r ', r r l tr r l ttr ,l ti .
    , ,r rr,l rrrr : . r ' lr r , r ijr r l i rr,l trr.i i r' i,rt.,t,rl r,i ;rr r.r' rt 1, tl (.tl r' r()[l t]r,,rtr,,1,rl i i l < tf i , i ',, r r r l i i r i r ,r tl i r l ;r l ,r r i r r l , r r i l r r 'r i r r r \r r l 'l '."1 r l r i L l 1 r 'r 1 r
    r rrrLrr' t rl { (1, ,, , .li, r, r r , ,.rl r', r r r , . |, ] r , ' i . |) t , r . r | r , , r r l',, ,,'l r,lt,,l ,r i
    , |,1 i r L i r l l |,t.i r l Ir , .r I l ) L r r l r l l l l l r L , Ir ,l l r l |r r z,r r l r r r r r r "i r i r r 'l l " 'l '

    it . l illr
    lnrllrntlll0 r lr l$ f| lr iDi,,ll ( ]o r I tir r ( .i se xt]ftt e (l i ;ni er, ]J. ti ., 1975)
    Int)t tIt l . l 2
    ';t];'iHl':,1':11:\'Yiii$:;lili"'if;11'l
    ,,,,-,,.,,,,.,|i:,"'p!lillli
    l . r l r r r i r t t t : r t l st'cr s u n tc.
    , \ 1 r ) )l i ; t | , i rr t . s ( j xu \l:;
    i \ , l r a s n r n ( ' o J i o l al cu
    li( r ' d ( ,f. ( k.:ir r r
    ,)tsrtrtrl rrtx.i(.
    I _ i 1 ) r t c d c r na t c x t re xr ii:r ljto r
    l r l c n s p a r t i c r l l a r cu r n a t{ o r n r a .!ii d c tip ,fu r r e r
    l iir?iIre rint:ili
    '1:r.li{r rDrc;.. chiar ftri maiforn:tatii
    ilsr,riarc
    I , , n { . ' r r . , r n r i r , 3r .r . J!r ,) r . ,
    ( 1)irlctotic (te r.rrt:! I.r r r ,,*,;
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    h{),}rofilit|, d.rtt.,ris ul
    i{clnirr inguina.ll 2ila/ hantwt
    lraniilii cu lln rnale eri{.cs r_1cf.t. (e/ nint 1

    ,\rrrl);guilate scxrlal;l
    '\l;Lr:rsr1 nconatri cu pierdrire.tc sllre Prottny' hantras
    i l;rzierc rlintit!'l ( a/ caTurutl
    t l)sr]ntra
    arresteriitesticulare 1o putnrrtate cu sar t:rri ginrcomastirj
    ( ritlorhidie perdslelrll

    {5, rrt.lriradiusurile.int"rdisitel^,a si rl dr, la buzr inde:;ul,risi auricu}r_


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    miilocul palmei), Simiao
    sau
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    tx,ritirr 1' si cl,' d,' un un urrghi
    urrghi ,,r.d.r.'
    ,,r.d.r.' irrrre inrre 45"-56'.,'ii,,Jrori.iu
    45o-56b,-cirldfoziriai;;;d],1;ri,; iriradrriiu]rri
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    lii, r':rrr. irrrliIjrl ' .,
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    , '-li ltl. Llnscte. I_.1 .1._1:ulr[ascuiin . ,
    ,,.'.. se .r ,r,r)(l {rl i si r udi: lc colat cr alc pcnt r u pr ct 'cnir ca r jscului dr : a t t r r r sr r il, ,
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    s,upliment:Lr- clescrestc :tcestc l \. l tt I , r ioadq Jc. act i. t it &t e Ncnit ct lcZ car . iot ipt r l lsl, ,
    ct{ro cu irllilri in r:irzirl tulburirilor de pubcrtatc
    apfo_airmattv 30, i;rr un cronlosorn y ;i cind .::risti tulburiLri alrr r-r,plo
    ,l rr,, ri i crrl ; lr r lni.
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    'l ullttrtir'ile de pwberhic se suspccteaz!.
    cind ia un bi_iaf sc r.onslirl,i
    l l o d il i ci ri l e l i l i Io; i .r .
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    r,rr1,!)nri rsl i( si , t cst icr r li r nici f cst e posibil sindr om ul I ilinef eit er . , cu <: r r r . ir r
    i l :" ' ,!,1 :u i.r1,rl.l'i XX\'), saulaolati. cu oruetore,: prtrnatia(sc suspectcaziLun sinrllorrr
    J r I' l (l au Jo:l gl c5.t-i ..^,i n 11,| pj 11
    (r,' ,-t
    L ^ J -l rt., i n I rrrrrr.r' ,r' rr car iot ip 45 XO ) .
    " p,.i .rj l -r ,n6r11.1j .111.,.. lttll'trriLvilc rcpr.t'|trc,:'i cu,fluLu,ipot fi clescmnatc clc starla 11r,slirr'-
    t' o rr n d ^ , ,1c. I r , i r,.ri . r,rri rl ,i l ., c..
    /r/'// . I)unr;Lr-."r s,r11\c.uudari. La {i:mei poate {i vorba dc un sindr.onr lr.iplrr
    I)tru , L l cI 1,.\ruttn, I i g_rrr-a crninnrrtei l r,l ro \ (lrr X-\.\) sa.u.un sindrom 'l'ur.ner in mozaic. I-a birbati, nnclc ccl
    i t'll_.r. . Irozrt i.' "r iradiusului lrrilirr
    .rrill. fi Sur.ir ," ,
    c ' l u r d t a l doi l r.a dc.\,.1, j .r i rl cJ,ui ' l i r i rr{ ,, ) 51) , i pr r zinia o at _r er alie
    nni, a cr cnosom ilor scxuali, sc con'slr it , ,
    l

    V4 ' iii+:ii*;imj,j";l"i;tl":a
    J r rLr,rrl rrr' ,. , . r r 1( . t 7- tt lin cazLr r . i)un sindr om Klinef elt er , unr or i in r r ozr r ir .
    i, rilri 1,('oililn(liLcariotipul jn cazul ar-ortrLrilor spontanc r.epcllrlr
    1i irr
    , ,.rrrri ^ rl-,, ' i n siir lin! iir i
    ar t i{iciale.
    Itt unclc. imprcjuriLri rnedico-}cgalr: se inclicir efcctuarca cer.iolilrrrlrri:
    ' 1li'; j' i"'l,l'",;,,i,", o*tir'ii"t;"'.'JtJ,,", r) | ' ni I u a tlirnit.ra o cvcntuali. formrrii. 47, XII
    , :.llj:;.: u,,, ":;,;_ la. un narc rlclini:vlrrt ;
    " t'tt t ' 1'lrir'cqir
    l,) l,i nilL ir g:isi o irosilrili cxplica.lic a tulburiLrilor de p':rsonalilalc Ir,;irl,
    a,tFi rn srirar:r,
    1""":11X
    fiffi?:Tici. ei rlermato3lif* ,l ' :,, rrri l i l al o ; c) pur Lr u st abilir cii m or . f ologieicr onosom ului I , cl . Lr gr r r ir r , r r t
    II lIJu lr'( irn()asLcrcasau cxcluderca paternitifii.
    1.3.2.5.1. Indicofiilecqriotipulrri
    (',rlir r r ipr r l . " ef c c ru e a z i -.p ro b a rrd u l u i 1.4.PRINCIPALELE
    ANOMALIN
    ALECROMOSOMILOR
    r'ti i;li#l;,ti;iyiiiI:Sti:j*xI ffi ::qT*iJj
    s i rl npj ca7, p; AUTOsOMALI
    ll1'i,x,
    , l r. rrrai rrru ltc cirru ms lanl. : h:f; 4 r r 's r e i l q t,ru ltl! A: - llisomia cromosomului 3
    (t, 2, 3)
    .ir,,,rii; .1;'.f";!^rX"^l^i,,,1i,',i,i,{,'"il;h"?""',,.T"y",::,;r'l*i,:ij;.1:,.l,Tl
    - l)elcfla hrattrlui scurt :il
    (Sindromrrl .{ 'p-)
    l)rtrlttl l)
    (4,.5)
    croruosonului 4

    ::1'.'"T'TSf
    i rrIii_rrr ,lcficit statur.opond,.rai - 'l'risoml:r btatrrlLriscurt a.i crOmosomului4
    )'T.
    lffi 1,1;':T
    l;tll;:l :l' r: *'*1,,"iL"i,'"'; [ *xi.f:t (1 r'isomirL4 p)
    -- I)L:lc{ialrra{ulni scurt al r:r:ourosonrlld.j
    Ir1 qrimlle doui situalii se pot depista
    in general: fSindronrul 5 p-, sau smdroniu] ,,nrieunatuluirlc lrisir.ii',)
    ::i t"lj'."'""nri fiindr.isoiria
    , tu.,,"l,,n,,llii(;i{,i 2r.cu ;
    l r '.o t,,i r tl a i r tl u ,
    ( l 1 l \o l n l i r r l .)
    sr - r r r l r l , 'o r r r ,,,o m r r l L r i 5

    Jill,liil'i'"
    i'z'i'J1',)ff:T",*t"n,":?i1.diT{ix"-:ij,.'Jl}:'H:"ff::i:
    rii'cr
    translocat.
    ."it#r"':i:"*"#":l#*:*li::$#B
    ((!, 7, l t, 9
    - 'l'risouria. cr"rirnosomului E
    fr-isonil l.ri:;Lfuluiscurt ;tl clomosoruului 9
    l,jii,,li:"," ta. | , t ) ) ('l r"isorril 9 p)
    - - l lisonr iiL lr LalulLdlt r ng al clor nosor lt Llui 1r )
    1aambii ( l lisor nir r l{) cl)

    lll,,,liji:jilt,ffil'T;,i:lil?i"Jfr,',T:.,f"fjifJ;.d,:""::l'o,,'
    'J lj: r ( ) 1r r ilpar {i; t 1i
    a ir l: r t uiui scr r r l t l cr or lr osor r r r Llr rll} i
    llliiili',i',''lxli;l?i1[""p:yil?f,1"g;5;g*alt:it'""'1tr';fi:iY:;',"; ( I |. lso|1] r iL
    'l
    l0 l) )
    _ r i: ( ) lr ljl pt r llit r lil. ; L lr t 'it lulli I ut r L ; r l i. t or r r o. r , r r lr r luill
    ( l i l !r |l |l r ) Il ( ])
    ,".,,,.,?,,lJ,,'l;,1?li;:,,:l,,lljl;lll,l;,llil,i]il,;illi',lT$ir:i;ij;l;;l^llll::,llll: l r t.r r r r j ;r l r r i r l l l r r i
    ( !r r r r r r r r r i r r |2 p )
    r r :l tt ll ( r rrrI r| ) j n, rI I I I I i I i lj

    tllt
    i l rJ
    ':l /
    [\,lorrosrnrri;rIrllrlrrlrri sr;urt al crot:tosotrului 12 (illono-
    s ottti i t l 2 p ) 1j
    (;r 'ltisotttirr cronrosiJrllului 13 (Sindroniul Illtau)
    11r/ I): 6a/ate/h
    ( r 3 r . l ,r 5 ) I proS//7/ntxli
    .-.l)r:le!ia l-'rirluhli lung al crorllosorrrului i3 (Sindromul Slraitsnt
    13 q )
    - Trisomia cromosomului tr4
    ()rulul E: -'Irisomia cromosomului18 (Sindronul Edwards)
    ( r 6, 17 ,1 8 ) - D"ictir brarului lun-' nl , rorros4mulr'iJE (Sindrornrri Ndt
    18 q-)
    - Sindromul 181 fi/h!il

    t )rutbLtl [;: - frisomia cromosomului 19 (1risr-rtr:ia.i9 q)


    l te, 2( J ) - 'frisomia cromosornuliri 20 ( l'risoni:r 20 p)
    i )ttr,fu.l G.: - 'frisomia 21 (Sinclrornul Dor,vrr)
    (zt, zz) -- Deletia cromosomului 21, 22 ,4utr/rt'orrn q inc/ntrt
    ail/n ongo/o/d; d !cl//o/
    - Trisomia 22 (Sildloniul Schmidt-Fraccaro)

    1.4.1.PATOLOGIAGRUPUIUI A (cromosomii1,2,3)
    tlst /,:t
    ,\rromaliile cromosomilormari fiind in general incoruoatibilecu virta,
    I,.ll',1('!ijl:r,('stuigr ul erie r'.tr in,iInil,i. :.-j rl scri- n lrironii r ,)o|1asi'
    tttt.lui ,) crtactc'rizatir prin {acies pitrat cu hipertclorisn, gurir malc, comi:uli
    rolrolilr', olrlali rotunjiti. I)ertratoglifclc arati o fri:ct'cu1ircrcscuti l virte-
    irrlilor 1rcpulpa digitali.

    1.4.2.PATOIOGIAGRUPULUIE {cromosornii
    4, .5}
    't.4.2.',r.
    ANOMATI
    ALECROMOSOMUTIJI4 ff6 anarma/
    f,,/plo/.h/ y'/e
    1.4.2.1.,1. 4 p-}
    Deieliqbrolulvisrr.rrt{sindromul

    ItlcL.lati| de \\iolf in 1965, sc caracter-izcazi pritt:


    . - r r:La.rLlstatxi,ra-fondel el consid.a'abil ;
    ,l i smorli e cr an i o--[ar:ial ti : mt'croce{a1ie cu ilolicocr-f a] ic, :rlopecia velt e*
    ,.rtl ni , .[t t nr.teinaltii cu lit'ertoni a ridiccitctrilor t'leoat'elor, lipcrtelotisrn, retrac-
    I,it ltl,rat.J>tlor, strabivn. d.i.aergenl, sclcrocornce, colctlto.m,n iri,ond; nttrgil.iTe
    s\ Pa/al
    r?
    rrrsrrlui sint dlepte, in coutiluarea iircurilor sprinccnoase; t omisur,ilt bucalc
    '4.ri
    :;ittl Loltnrf/.1:,buza. supelioa.rl este sculti; inconstaat, }-ruziLc1e iepure, r/rs-
    I'i',ihrri l,qlatittri, retrognatisntI urechilc sint foartc cartilagiuoase cu anii- lory',tcl
    lririturi ir)v('r'saf, slab conturat, lobul trrcori :rbscnt; fistrilir preauricularri; d.Id/l//
    , r'tt,ltrtl ttrlili'L' r:xtcrn in,gusl:
    tttolif.ittit,i ttlc rutmbrclor: degete fuzifornc cu pliuli de flcxiune ngutl
    r'Il)r'illllI)r( r'irf(, irDillantare pro,rimalri. :r" dcgctului marl; rLghii c.ritvc-re
    r,i l ttci lor r r r ' ; hul. lt t u a l g rtsI
    - mnlfon l,il:: (:irraliol)alii cotrglttiirlo ;i ..riscL.rlir' (1r'.{ctc); coirste
    iIr| )| ,r IrrI rr)()r' ir l.(' , lr r : t tti v r,tl r.l ,r,.,
    l rl o rr l r,rl l l rl rl , sl ' i )i {t /,i .l i t(,t,l Lr,rrrfi cr:ougcni -
    t,rl r'r rl rr r r r lr l, lt ilx r s .h tl tts ;
    ir t l r , tr , s r r lt , irS. N (l : r,trr:,' IrrIo IrrrI
    i ' ' r.' .r' r,r' li rr t( ri u(l l , i l r)l t()i ot i rrrl > or-
    l rrrrl ; r ' r iz r . , r , r v r r lr iv l j rrl , rI i I j r'r' Ii i 1 ,.1 .-(, (l i ;1 . l ..l 11, S i rtrl r' ,rr ' 1 l ) ({ l i ri , rrl qv rrl n,,i .r, I r1i ' I l ,l t.l )
    '
    jl I
    irll
    1.4.?.1.?.
    Irironriqbrqfuluilcurt {trison}id4p-} [t/cy'tc /ttrr,'u/i

    S , lr it r lii r l< ' ( i u s i i rv s o r (1 9 6 .{ ), Sc l L i n z c ls i S chmi d (i 970), boal a a fost


    ,l, sr'ri:rii rlr' \\iilsrrn si col;Lb. (1972), cu urr.liltoarele ciiractere:
    - sindronL clistxtrlic: Dicrocncefalie, glabela procminentii care se conti-
    rrrri <rr ar-clcL'lc sprinccnoase, hipertelorism, ble{arofirnozi., microftalmie, colo-.
    lxrrtir, stralrisr.r.rj rddcicitta tnsului infundatiL, vir{ul nasului rotunjit (,,i1'[ fanle
    an//ricn!o/kre
    lirllt'); gtlti .ttr,dye,bollL palatinir" ogivali, birbie asculiti, rctrognatie; zrrr-
    ,/rilr' sin1.ios implantate, cu di{erite malformatii, hclix plicaturat, anteheli)r
    1r|rr,'ruinr-'nt; rilal cstc scurt ftintl capului cstc jos implantat; spati.ul inter-
    )ttrt ('loitar trstc mirit; penis tttic cu hiposparlias; se pot asocia :rr.rornalii geni*
    trrlI sj r'eltcbralc, deficii statural;
    ' l crntttogliftlc aratI" o cr:cstore a lirtr:jurilt r pc pulpclc clcgetelor;;
    /.,,ti tn a.ryccl.. de /ttni , Cc/cha hrnine/i a Jreht/rt
    . llrietl:pltt : ttisomie prin translocalic s:ru inversic periccntrici-1. mu' r att /i/tb, htp er/e.b rt,rm, ,il!//' n una/ fom$t/)/ !;
    t,trt,?/)11/i, uacr/ p8 /h4/dr-
    r.4.2.2.ANOMAr.ltAtE CROMOSOMUIUT
    5 ,'th ncda/t prtainru/an fprg/oli f/"'rci

    I 12.:.1. Dcleliq brqluluiscurt(sindromul5 p-) ilpap/rz4 hrnqc/ai


    squ mqlodiq,,mieunqtului de pisici') tt/elminA O it)1t//C

    (orzt roca/a apro.pts/c


    Ilonla, descrisii de I-cjcune in 1953, t:s'Lerar intilniti.
    ( li nic int leun e s te :
    s-rcutatc niiir ia nasterc; hipotro{ic st atur o-poncleraii; 0epo'r/ala - Totltttr
    -- l.isntot/ie craniofaciald caract.i,isti.cd'. microceJalie irnportanti., /aclas
    /rtrr,l', lrirloirr,; diafanii, suturii motopjcl proenineuti-, hifertelorism, ct apl,a-
    t:itt. riltirinii nas.u,hti; aficanttr,s, /ante lctlpcbrale cu imou.golier,e, strabisrn
    ,l i r,r " r r r ' . , r r . . / ir i :;i ttl t.n y .,,l i s n " rl i c ..; ru L , rcLrl i l .rtty.:Lt,ui : qoni onsi crs;
    - nnl.fornalii'. cerebralc, cartLiaecsi rar rc]rrli: n,tlJormalio (irnaturi-
    I trlctt) lo.ringcltti cste constantir - ,,lrtrurge rustic" - detcrminin.l un plils.
    rtscrtrirnirl or rnieunatului de pisici (setr-n rluasinatognomoiric),
    -- raiayd. fsilzotnotor sewr I
    - tlernaiogliJe cu pliu palmar transl:ers: triraclius axial iu irozitia t';
    t , r t i' , ' . t t t l: J ,l ,ti r b r" u l ' L i :(u rt.l \' rn r.ro5or-rr1u. = pl i n 1.111-,gr" l ati a
    Utr(,i1ri]]lslocirtii parenteralo cchilibratc sau prin inversie pcriccnlricir a cro*
    rrro sonr ului5: Loln a v i i p o t a ri n g c \.i rs ta a d ul t:r (fi g.. 1.32 A ;i .i l ).

    1.42.2.2.frisamiobrofuluiscurtttrisoniq5 p)

    .\ fost descrisi. dc Lcjeunc in 1964. Boala dctcrrrinl uu trspcct clinic


    in ( irr( s{} ttotea.zit: sttimlctrca sfatittlui. ittlttcat u.ncular, bdyttie tleztaltatii, stra-
    lttsnt liurfltrt.t; obezitate asocizttit cu ltipotolie st ii.ettil.itcLemintLtlii seueyii.-

    1.4.3.PATOIOGIA GRUP|.}|.U|C (eromosomiioutosomoli 6-12


    ;i crornosonrulX)
    r.{.3.
    r. TRISoM|A 7
    CROMOSOMUTU!
    l)( 1(r'tninii:
    , / is lt ir t lt t . l ' ,r,i ,tl ri rl i ttrtIri (i rrrtl r. 1 ,ro| rrri nr' ul i , :,i j l ri 'i rrl l l , l l ri 'C l l i l. s j r,1f' rr "i l , { rLri { ' i rrri l ri l ,, l ,i s i ,l ' ! ). l } l i l i f i i r| .' rtrri Irr :i rL,l ' "r I' t
    ttt;tIIo l- t t t lr I r ' )r,lls P i c i l ttrrr l r,l rrl rtl rri rrro l l r,, trr i crrqnt (i r' ; \ l , t' r 1i rl r, 1,1( l ,rri rr)rl i l \,' Lrri rl rrl i , (i i |"1i 1,;' 11i . \\ ' !l (l r) Lr rr
    '
    lr r ut t r l it t : , rt,:rr/,,rr .r,Ii tr,i trrri , r,;rl i z i rr,l i r,l rl r' l rrl ' rl ri i rl i '; ' 1, 11r) (l i . l ). l l , I rrrl rr , l Lrl \)
    ',

    I rl , lr J
    lt , Lt l. f ) ) { ut , t t r}
    l ur;(),1
    i r' ((r' rrl ,l ,rri rt, \' ( rtcl )ri Ll (:); car(l i i r(r' , r' r' tttLL'
    ' I'l ri i r ) ( lz llr i) ; r r r rl l l ri iIri Irrr1 rI;r,rr((. ,,.r1 i rl )s c &tc l edol i :rrti cul utr^; 1.4.3.3.
    DETETIA BRAIUIUILUNG A[ CFoMOSOMUIUIe
    tl t lili lu lt ut i ttI lli : {rindromul9 q -)
    d.utn,llotliJi' cu l)liu {11. t.rirrnc distal, triradius in t', cle;iert- r
    rrr rrrilrrlui (l(.ar(:rrri, l1'(lr!((1r(.ir ( r, stclor dcrmice; pliuri palmare si plantarc Sl t arrrctcrizqilzit. prir,: - ilLtir::iLlle mi tld; disn''a;'fi{ cltt}1ioJa{i'rli \'t.1
    rrl i rrr:i1c ; l'lirIi(:, irLclinari obiicir ir fanterlor palpebr-alc, niri ritsflintc, trrr" l r
    IIIr,,ILr(|r
    /";'r
    - (:twioli.Pxl iu'at:L o trisomi,-r,! in moz;ric (c[omosomul 8 estc cel mai 1,, rrrrl,lruriatt',irrl:rt inalt, niclognalit'; - {;l?rl cslc scull ;i palmat;
    rir.rr,.cfomosorn a cirr-ui trisomic esLe compatibiliL ctt. viala), , /, pr',,zilli tnirmcloane iildcPiirlatc i
    str.fLrtsislctliL:
    1.4.3.2.
    TR|SOMTA BRAIULUISCURTAt CROMO5OMUIU|9 lrrngi, llughii i'rilttate.
    'i'"gr'Ii'
    {trisoriis 9 p}
    DELEI|ABRAIUIUIscuRT At cRoMosoMul.ul 9
    1.r'.3.4.
    Iloala ll {o,ci tlcscris.ir de lltithoi-{ lI. O. si coleb., jn 198f,. {sindrornulI p-)
    (:linic s,: mani{cst:r prin:
    trlrirriltslr'Lr-ilc r:linicc cuprincl: -- tlislar,tfic r:ratiirti,t,itrlti: tl'igoloct lli;
    disnLorfic craltio-f.r; !1ld: micl-occlirlic cn bratriccfalic, hiperielorisrn.
    rrlr' palpcblaic :rltimongoiicne, erroftalmie, nas ciLrnos cu lrir-{ul glolxrlos, . rrl , 1r;rl P clr r ir l<' ' sus si in l{r il', ll. r s 1'1e1,"r ir i'- ll-r r az'lle olil'llliir '
    olr lit : t -in
    ' rrrl , ri r' ,r, l ru i: i. supclioar : l Jut lg' - - , / i. q, 1' jnr r 6i. t t L j', lieot lczo1lr l: r t r j'i'l
    r /rrs rrn il at_cral:,,o1)ra.ii pr:ooninenti, cornisuri bucale coborite; urechile sini
    ,1,rttt'tlrt1yl.i.[t (u rrcr's dc viltejuri.
    r' . rt r, r,(il:.Lpllugit :
    hroltitnc:t,falung it si clinoilactilia dcgctului ul cincelca;
    ANOMA|II AtE CRoMoSoMuL{Jl l0
    1.4.3.5.
    rtfunl lsilntnotct importani, cu tulburirr-i r1c vorbiro;
    lrltuotoglif. cu pliu palmar transvcrs, inegalitatea intrc plinrile de :r1 l ri ttt nit f ar ! ia|i t r lt oiit lt t . i. lr t t t g ( 1r - isor r iiai( ) ( li. llst f o iil( '( lir r r r
    ll '.irrrrr.:Llt'dcgltclor, a.bsentasau fuzirrnca triratlinsurilor subdigiL':LIcb si ,r., ri rrrrri llsllt iL pr iir niicr oct f ilic, llir s i'or ojr t , at r c'lnalii lninor c illo ( ) iir "
    , , { r'(sl( rLraficr:vcntti alcurilol tligitale; | | ,trl ,' t ,t r r ir ir zi t , l. ilr ot t t olor i, r r : , \ i.
    '(iriali[]ti: blirl-iri scurt al ctolnosomrrlni 9 in triplu exr,:rnplar'(fig. ar e u11colcslx) ll( 1,L
    l . i .i ). l ii, l tt1"'
    cratLi.ofaci.tr
    l.ir pilirrl : lianslccirti. r.r:hilillatir. sau moziiic. rxtlcur itiL{iJot ; 1:r:

    . r; / . i . i . l r r i i r r l ' r ) l,' ,,1 , r L 1 ,r r ,L r i) i,' ) I' I' ,iiL If;Ir sl,r ;rl i ,. (](.Tccl i i l rl 'i rl ;i . I,t ov el i !r ( l i l ( . l :r
    lr r, , , , | | rI I | . I ( t r , , I ! . , i l i r lr l) r itl. . ti i,fr t, 1 1 ,.\\,,1 ,,f ll:' ) , r (l rJ: l i J (,t l l r 1 l r ) 1,,r 1 ( r l t'r .
    '
    rLL ;.)i l,ir r , r ,ir ( 1 , I' ll r , lr ir r r ' .r ,,'l i rl ' , l rri l l ) LrL i 1,
    ,, L ir 1, ii , t,[lL,L
    ,
    l,lrll I t,r i)

    tr,l
    L'1.:J.6.
    ANOMAIII ALB CROMOSOMUTUI
    iI Ht/otrotentcfa/rt ct
    fuzinn /alt/or f,'o a/r
    i\) '1 ns,)tn.tn ftu.li.,rli rr lti,ttllli lt:tlg (trisorait 77 q). SL:rrurdfest:L sr alrc a lu/i,/or
    t ; r tu)s, . t.icrorttrognatic,glasaptozii,d,esfictiturii p,tla- o/fa"th//
    lrlirL /itcir:shrilri iL:ios,it,Lts ',,,,.
    i i ,,,i . t ' r t h. j, ' : it t l, l tttt.' 1 ..:i 1 a t,.: ttt , rc ts ,1 , pi cl e, rnombre i rde\r' a maIfor-
    rrr;rlr'..t artlirrlrrLiii-Irnotnlc. 'iiaard
    fs,ilnmotir sever. C ariotipul arattr 1z
    .rrrrrrirlin lriLrin!i o tlarisloca{:ic cchilibrati.

    'r.4.3.7.
    ANOMAU|AtE CROMOSOMUTUi
    t2

    . a) Xlr,iiosontict72 p rcalizezzir patru caractere somatice: occiput proe-


    nrr(r11, nas marc, aniehelix hipoplazic, nin5. strilrti. Biologic: sc:tdcrea
    l.l ) l l- l:i.
    n vatpu/ prck
    . |t),.ltrisonin 72 p reprt.zirrtir contntipul monosomici 12 p, prezentind: o3?/p//d/
    i rtlir:r.Ialic,nas scurt, ant&elix prcemineni mine lati. Biologii: cresterea
    ti ( r es/ ff ca dlaneh r'//!//
    t.t)|I-t).
    btparnia/
    o Att otttctll'ilecramoso?tl'ltlxri
    -\ (care face partc din grupui C) vor fi
    ,llsllisLrIrr golcsomoliatii (r'ezi mai jos).

    D (cromosomii
    1.4.4.FATOIOGIAGRUPUl"l.rl 13, r4, 151
    1.4.4.1.
    TRISOMIA
    13 {sindromul
    Piitou)
    i\lcr:tirrnea, descrisS-de P:itau irr i960, are o {recvenlil dc 1/,1000-
    l/7{)0{) dc na.stcri.Se caractc zcazi prin (vezi tabelul 1.12):
    - grt:uttrle rticd. la nasleye;
    .- dismorJie crawioJacialil,cuprinzind: microceJal,ie, frunle ---'
    Jrunte te1,itd,timple ncalili Julura meloPtti
    rtlrast, lti :ttoteloristn , u,as liilit, ttticroftolnie. disfla..ie yetinaand, colobow&
    rr'irttri sau coraidiand, ctfiar ctd.: sr poittc nota aplazia regiunii mediofaciale lr rconarc fa h, rezu/l/n/
    ,l, lr.rrnirirrtl cchocefalia, di h )derca precoct
    Jcspiudtwrahtzei g,i a y'alatului; in cazul asocierii a tu/u.// ner0l/ca
    rrr:rI li,r m a{iil or c.rCbraI c sor'.r. se noteaz6.ltol,opro:encefalia, ciclopie, cu orbiti.
    ,i rx:lriunic, trompi nazali.c1rnarin; unici, guri de"tup; ulcel;rii atrepielii
    ,t ltrtlui i.n,rcgi.utrcat)ertexul.uiyhc;nalgiom pe frunte gi-regrunile temporale;
    trnr hi jos i tt'lariate;
    - nt,rlforut,rliiruttltiflc: cardiace,digcsiive(malrotatia ansciirtestinale
    l,rirriilivc, tlitt rljcul llcckr.i), panclcatice,de ci"i bll\are, wrogenilale,osotse,
    .r1,. ur,'rrrl,r'lcr-(polirlaclilie. degete flectatc, unghii hipercinvexe, planti ?ttaciluri e buzet
    {orv(,iii, pir:inl strinb), helnii; purtrl strins, cu dcgetc suprapuse; v /a/alu/tti bi/alera/
    . -.d.trttittcr.ltt ttiologiac: Icbulalic ft artn&li. a y'ol,inu,cl.earelor , lrel,ungiri
    s,ti.lt tr.h'.rutrl.tilor neutrofilelor; lersistenla henoglob.ineifetale 9,i imbrioiare
    (l.llr ( ilrvcr' 2), carc clispal'e iir -moc1
    normal dipi luna a treia de gestalie
    (lir1.1.3.5-\ sii 1l);
    . .l.ntt,r!.'-l.tccLpliu1r.Llr:r:'r-r,rt:\'. s, i.,.;,| .r.rJialeti ar.c.rrrcrnscrrtt,,
    llrlj:i, ilr l lt,l. iil lr)titi L t ' jilL i ' . ( 1, r . r a, l i " . L , l u i cifrc rn:rriin, r r,t.li-
    Plir jJ i. .
    .t ril t! It)l ]l l l l j

    . t , t . ; t . , t lt / ' , t :l u .tl i i o rri " rrrtti r.Ii i Ir,I.." r,


    r:1 4 i X X (X Y ) li; i 1 cl zul
    ltl|' l 3 s . - A - Sinilromul Piitou (tri6omia l3), Ctillicll Symposin.CIBA'
    lq83)'
    l r,rl l l , x : ll , 1 : , r 1t ' 1 ,.t/i .r /. 1 ,1 l l rl ' .ri r.rr, r ( 1j ,1 l .l q).
    0l
    Il;
    LUNG {rindromul13 q-)
    DEtETIABRATULUI
    1.4.4.2.
    /'utttt,,t/r itt,t cu l )r' ;r' r' i sr'trlt L'icr t r r c ir t l( llr N lloala cupr inde:
    ot'p'/t,tup/d//tJ(
    ,ii'",i'rfi, ,rii;olarint,i (i/: rnirroc' falie importanti' craniostcnozl'
    \ antort. tonlrat/tl ]tosolvonlal ( profil de g/?c').'.mtcro-
    //7 t/|t/e lrrrr.rl' lrrrrsrrrcu prolmlnalca n#iarlui
    tt,' l rrri ,, ,,,l ol ,o r ni ir iani gi cor oidiar t a cu sau [ iTa calar act a: ur cchr I nir r l'
    ,l,.lonniric; ii sup&iori s61'It
    i.r,r,cisia jos ;i I'nainte.(i,?ytf i
    'rniini ",tl;,: .ay ,:;'!l
    rthtrrtl'): de{ormate, ct absenlapolicel,zl (patognomontc) 9t cllnodactlrlir
    ,l ,.r,r.l
    rrl rri uti t::
    /ti l>otonic gcneral,izaf'ii:
    Irteotnu genitalc, imperforalie ana1l sau fistulit rccto-
    . )i iitturirutlil, cartLiace,
    \.'lrrrlir:
    ' I i n,;,'faloiahie sever5.pini la stare de inerlie totall'
    fo//obch/tb
    po,tlaxn/l
    rRlSoMlAcRoMoSoMUlul14
    1.4.4.3.
    rr
    llt,ltlizcazirun tablou clinic cu microcefalie, {runte inalt5.,-hipertel orisr ,
    ,r'l,rzirrrrl,l:-rcitrii nasului,cpiclntusunilateral,asimetria-{antelor Palpcbrirlr'
    ,],r,i ,"i,, t'i"sl, ut".ti mici, jos implantate-;i foar-teconturatc' liil
    'i,,,,,t
    i, ;,''."i,,, ;xtrernitllilor; hipotrofiestaturopoldi-
    {lerburn u '',,;, '"altor-atilr
    pvarc ltpap/azce ,.r1.' ',1;r,,.

    1.4.5. PATOIOGIA GRUPUIUI E (cromosomii16, 17, t8l


    18 (rindromulEdword:l
    IRISOMIACROMOSOMUTUT
    1.4.5.1.
    Co/obomarehatr
    v urce/
    I t, sr:ri-ilI, litlrvard' in l960 arc-o Irecv'"n{i.d5,t/800.nou-nirscrrli
    rr,,,,r,','r:,I,, ,,-tfrit.i" foarte complexi (vezi tabelul 1'12):
    m'icti"ii"i.:,
    la na;tere I
    Lrrltl'a{:e
    itltpoicrtr rnintall gravi.;
    ,lis)nrf,ie craniofaci"al,iiaractcrizati prin micr-ocefaliediscretiL,sca/ir-
    ., t',t,,, l:tili.utc it;cd, n;p6plaz'fanvcadelov spvittcenoase' hi !.evtelotism'epic ntus'
    l.,rrl,.rr.rIrrr'Irr,rI(. incnst", microftalnie' rolobomo. opllcliitr cornccnc; /rdslru
    .r' i,)l ,,ali,:iLt Li tiitlr; "gttra osrt mitd' trittttghiularri, bolta palrtiltrr
    ' 'r in 20"i' din cuuri se consl.ate desprcil"')
    ,r't, 'lt, Dtitrtrllr(tllie: l.'ll'::
    .' 1,,'l,rlrrlrri; ttv,chllcsinl mari. jos inllanlsle, oblrce,detormat\:(ltrrtttt
    '
    ,1, l,ut)t" ); gilttl estcscl'Lvt, t'fthn&t;
    trttonruLiit'ot'aciae:|'orlcescurt,apendicexifoiclabsentsauhil)()P|lL-
    ..r, IrIiIIIl(' I ()iI II1' rtttlimcntare, ombilicate lateralizate-;
    tttilt.t itt h.,:i|,it |>atogxolnott' ir d:tLt.getein fIcxic pcr-rnancnl iL, irt.t[tt..
    ,,'"i",1"-,,r' ,,tir" ti",r'd"g"nrl mijloiiu 9i uncori inelarul' rurictrl;rt'rl
    'r"l'
    rl )r'l l )ttti I l l l ol l l l ;
    l )l
    '
    ,ti ' rl l ,, r t t t , t lii: r ': r r t lilcc cot t st lnt c. r enale ( r inichi ir r pot coaviL) . 5ir li11''.
    ( quLnl f t t t r t Ln
    ( l \' ' ;,), ' ). , r r r , ( r ', .r lcbr r lc) , r '1, ' nlom br ( 'lor ( lt ct or . . r dvus,
    fxpansTunr nuc/ecre ' ,," t,r, l i ,rl tr t it r r i', r ''r t t , sit t , l, t ililir ) , lr t xaf iu congcnt t ali dc iol( l lr r 'r 'r r ll
    //7,/Cac/c//€/t ," rrl l i l rl r' (l i g. 1. 3{r A; i t }) ; .
    '
    ll/n/chl po//rhth: ,i'rtttrtloLrlilt ,rtt trti,.l'ilcl irrcu.rilor digitalc, pliu ptltnlLr- tttnsvt'ts'
    ,1, rrl .r nl i ttl t t i , lii ll, xir r r t , ' t l. i- lr t l : t l t lcgel' lor :
    ' ,' !),,,tiht t l, 'lr '47 \ X ( X\ ') lli, ir t t r i: i"r nit r lil" r 'i lJO 'l' t lit t . r 'r t zt . t t t '
    , l' ig . I . . 3 5 , * ll * S j r r d r o m u l l) iii- n l| ( L r iso lr ia lj) . ( ( :till i (,at
    S yrrl x)si r, ( si lr r I t r r r ' ( ll lr i{ot l) ir i ls 1. r lr r 'liill;; i lt isot t t iir lll l) llll llir llil( llr r ll'"
    tA . l ,)ti j ). ' ' rrt,r' ,
    \,i 1., rr.,ri ri i , . t , it r r r ir t l, r lii ir r lor t t r ' lt ' lilr lr '.
    t)l l
    l)ll
    CROMOSOMUIUI18 lsindronrul l8 t)
    DELETIA
    1.4.5.2"
    se nani{estir iirtr-tur erLdruclinic

    tt,? [l I
    r n tr n )
    \U'
    tr
    I)cscrisi de Grouchy in 1964, boala

    [] Ll|il
    /nsonia t rononnt/ut
    \-'
    /6
    \-' t
    I
    L \
    \,N\'\)N'l\
    i \,i i '
    ,/\ I \\ I
    Caplugutil u )l :v a- /
    Ot'/tof rfoem/- / ""j-,1*"
    atnl ri laff .fra,,/-\
    rd/f l uf/! /.71a
    UreclrEt iw/an'
    $4. {
    rah. ,l1tbrugnalb. \.*=s \-*:-
    t , I zt, ,l t - I-c l i tr, nou-n;s ".r.r ,,r s i ndrom
    i ' i .' .' ,i " .:i ,i ' 1,r" l8 lider ) car ior r n4 \ s'r r N
    fur.zninc,/crlsl tt l97E)'
    -. nderu/;i leui/t / \.' lx. tr. na"t'mar"9i cola|''
    \ a/ F-/rc lritah pt,'.sle
    ') dea#e/i al 3'/ea
    -*1, i a/ 9'/ta.

    fl/pop/dz/d
    ll;ii1,.,1*:'.,"1":'"'$'ii:*::,::F;;;6:i;
    n!/////or
    J7'nddcl///e

    ,l

    l/tVer / t/o r rt n e,pcanlut


    //e/ut t' sturl ,l sr/ctta tlar,t l/t'thl
    A la/ulea,1,'irnntt/
    , l/ l i ,l i tJ ,l "' l rrrri ||r' |' ' ' ' I|)i ' l :rrri rrl i l
    - "r t
    tti8, ,,3d . - A - Sin r lr onr lr ll, : ( lwn. r lr( lr ir t , r t |io lN) , ( { l i I i r n t $ y r r ; r , r , i | , I t t L A , t , r f l ) , rt', \\.,1' l tl ,t t ' 1 """

    l( ) l
    0{)
    r ;r ',
    rx,rii
    {<,.,r,.ir.rr:pi1r-rarc, r'r.irro,rl,r
    ..,,,, ,llllxil,:l:
    ,,,,',. .,,,,lilll1,1l{li;ii:,:,,",1i,.,!i:.:,',:."',it:::,.i,
    i,:,;:l:if::,,,rn'nrcroanc i _l,,lll,Jl,,l,,:hi,ll",lrilirl"l,il,l"ji
    virsii,
    nt dllat n !i i l x rri l ri l r' : rrr' ri t.rt c l rc l i ace si renal c, ,,)j1i,f",,,:;):,;;j"j,,ll::','li,l'',1;'i'llli,,iiil,'r;ioiilLj"-"o.t,i"'.ricrib
    ri rl .;
    _ \ ' , n: , . , r , lsp ra r,ri g rr;i r:i s u l rl i l a tc
    u neori ;
    mai {r.ccv.rrt gcni -
    fiil"r'r**li?*
    qih'f*
    :;'"lrl.i*::lit":*:x!"il
    illi;ll rl:*ri:1,
    ?,y,li'lll;**:;.il*.1"i':oti,
    .tif"l.':*: ii';]"ffi,i;l; ill:'lijl
    , ) nc . ( . l. llo pr,,i l l s ,.r,.ri , c (l rrv u l s i :i
    . b! , , t oF , . . 5 cu o l c a z .i ,l ,,fi c i r
    - ttc.rnia.togl,ife.o
    rro-i. ."rescui
    de
    d ,. Ig A s e ri ci ,L
    si sal i r-ari i r tJ:r$l;T*tt iI.iI, fttsrtr
    s'arezczr:
    ti'i'i.'n: chirnici)

    l,:Iii,l'lllifk';m':'"*t:jlxll'r$#"?,i":#
    pot;l ,lll\ ',,1,i';li':;.,';;;;i;;''ii?i;ffi
    "rrt"ju;;"
    (X\) rBq:pirin,tii i.*I
    ,,,'t,,,,;iffliK,,!'":*if.X#" di carr;iip
    'rJrmar
    ;:,,,;;' ;'i;
    'il,'p,rtt"l 'pe ":''ffi',i{",::iil
    sexe-este de 3 birieli la 2 fete'
    1.4.5.3.
    S|NDROMUL
    t8 p_ r''.,,ai.'qi,1rr'.1,i"t'.1'1a;gg,:,:'*iJi._T"1*ili-,t
    i'iiil;
    .
    <:riri. cu sci.derea importanil
    .t;l:1!i";:,*i'sT#*#,tt#:liiin:i:*":m
    Dcscris-tot de Grouchy in 196i, intrunertc
    un sindrorn d.ismor:ficaso-

    ,i,
    ;{i;*1#;#if
    ,i;,,!";ril:{ir7:r'f
    ;':i:',:!;it:."Tff
    rfird*1";}#?"x
    ,,il'l***:,i:ii.'x"iltil",'i"i-'"tii;i;3;ii;"{
    .fomnd.tte ,,chibiw de iand.ayit,, ." u.;, i;idrp.iao"rifiir?,?..".t
    ,
    ',
    ,, irr,l ltlu'rrlcl crr imbirtrinirea'

    nlnrtla 1 git scwrt, prilm.at; ; conristtri


    iti',";'inicroceralie
    , ,',,;;;;,;'';;;,; ,,tr. bazu
    ':#i;,";;oe,Xio:,.',;J::rt,!;:'!ri"anrts,
    - torace in plinie, cu mameloane foarte indepi.rtatc; I .rtrl,lr ltulpebralasint. scurte,
    . - rlcgete
    luziforne cw t'ol,ica sas imbl,antat:
    - iniirzicrc staturoponderal;:
    - t:ariot'ipul,arati. 46 XI"
    ,,:11;i,,,,;ii1;,,t)ffi:*1*tlfffi
    jflitt*i*ii"I:;l:**
    liiiill"l,il}tli]i:iu'lnei
    (Xp 18 p_; pirintii pf,r avea ceriotipui
    d:letiidencrtoItoattcri'' ino"'ic 6.atcrnslu tran:Lo'
    ii;i,r**i''r*t"lt"'?'',':tril6
    r',,',,'it,i.f i", si ticformat.Gura"cstcmici,cu 6tz:c
    groase'l'
    1.4.5.4.
    S|NDROMUL
    l8 r, SAUCROMOSOM
    18 tNEtAR j:i;.r-..rl,*ll*y";yr;;.!iiL?i!{",{;'ili'i'1'"','"
    iil'i
    Sc calacterizeazd.prin oierderc de fragmente,
    rl,: , rr,rnatide. Sindromul asoiiazb_o malscgrcgatie ;i schimb ,l r, I rol i c, r' u, casant .
    (l't)nrncde 18 q-, sau 1g pJ. """"tuf8p"1l"-'*."lii
    ?o o"ti.it a" fga
    ,,,,,,,,,,',ilKo"Yr,";!W".ry!{:""hi'::J
    1.4.6. PATOIOG|A GRUPULUIF
    {cromosomii19, 20}
    S-au dcscristrisomia 19 q;i tr.isomia20 p, ambele
    cu patologie siraci._
    ,ii:ili;i;il[::;uiH?gfid;[ii*!r:*
    l:1, i:;)'
    fTi:i'':l'"."';t,:'l'
    lili,',!^"i,,'Wii,;n,T
    j.4.7. PATOLOGIA
    GR-UpUtUlG (cromosomiiqutosomdliAt, 22
    gi cromosomuly)
    rl,,:,:,:i,:,!;,:,i:,
    ,;,::,;'i:l':",(;,:,i:::'
    :i,;{;';,,it"
    ::,lili, illrl',t";l'{ ti:"
    il.,ll?rl:li,,,if
    tisom( tdr'i
    I)atologia cromosomului y estc descrisiLla
    capitolul goncsomopatiilor.
    ,,";ultu;,-ili*iTi:lr*:l;"r"1*T;*
    q,'
    i:1.471-TRISOM|A
    CROMOSOMUTUT
    2t (sindromut
    Down)
    l\tlcnlionai.ide Esquirol.in lSjg, boala a inrcgistrai.pnrna ii:l:' jl",':.:**:ln"'ir'ii:
    r]ljrH*]*I,t'#iit,'ilIij#Tl*;i::
    ,.. descr.icr-r.
    rrr lt)46, cird Segui' a-numit_o , icliolic f"rfrr;;;::'-i; ,lr r,,' ',.i :rctlrrl>tfllrrt.', rJrtmtlatlguttt" picior pktt'
    t,1ii#'',,,';ll"il,ill,ii..'',,,$ll,;",',
    lcc.aqr pcrioa.ii
    I)owrr-aplofunr)raziIirlrrririrriirzicr.iip.it,o,,,.,riuili,
    ' l,:l-:]l t;tsrillalr.c(lcsl(.tn:rti
    i,,,til.L si , I'l,,tllfl;ill'i*ilt'
    {, (.r)n..ri(.r.i,.iL
    l,oalir ,,irlioli,.rrrorr;y,rIiIrrr:i,,.
    .rl,,rrrrrn,..tr. lrr
    ,iiiili,l:'ii,t;1111',;,1.;'i'l,l',u:,1,llli11,lj,'s(:,,r.,ii:,1r,(,,i,ii;,,iii,iii,i.-,,,'i,ri;ii,,1,.,:ii,i,,",, rrd,u
    ,l,;ili::rr,:lllxiiili;""iut'i,','iiii'1tli'.,.;;"i"il,,,,i',1'11',.;
    vx,ir.i,
    t0 i l iu.l
    ohlQ 9,,. .\'
    ([,,)
    0S a;i_\
    "7.---\O

    Irrcamn crnosoma/tt 2/

    ;fut o^-^$
    in\/n\
    nJ
    vrft ) zz'J '-''
    lratzr/oqa/e
    ///22

    a, o" r) y1,r*t pitpat,att


    n70ngo/o/ o1, c// cJ, ///i
    ma.,:r0q/at/t

    Puncle 6n$rt e/d,tcti,ts

    I
    $, *1f*& .Se
    " ri' ' :.;')
    /;i ta.l .:l .9 l l i l :i i i rt tl c j i x ni
    lreclt nt; ,
    /.,/pal/az/ u i N ' i ,,tj 1i : ' l :, X !, F ' l L'

    c i L r vi r L !'L I o ci r i "u ;i 1 l l ;!r :l 'i ca lr :it ttl to r


    lrlr r r r r rrrrrrt i i t- t t I i <: tl c ca zIr 'l o i 'l l tr l r l u

    0atchddn /cni
    i,tn ltltthi/ / tt ? 4 ,,,,,,:ii,i'lit,'liilill'll,,l:i,.'ili'l'l':,lll'[';ii{r
    ;, il
    l;ig. I 3tt. - r\ SinrlrorrrrrlDo wD (tfi souri o .l l ).
    :,iiii,til,'l rl ;,;li;llliiitiliil
    :;,li'i;;;i;t, i.]i;i;l'lr,
    i lll,li'i,,
    :iiliii1i
    1 rl :rtri , l i lir lr r r {ii r r lr '<| r li : ir

    104 t05
    '!'&betr
    l l.12
    .l t t ot t . t lii. Lt L i tl u t,i tr: (l c s c ri s e l n si ndromul l )ow n si nt r.e_
    I'rr.zr tlirtrr rh r:r'r:51r:r'r.lL.llr.lr,t tll)Zi'to lcucocitare: fosfataze alca-line, fosfa_ ltei tisourii ]ai lrtove e (Ne1s<)', 1983)
    , ['rlu{.lp{k!lc urra(,lcrc rtl[i€c alc cclor
    t.r7r' .cl(lc, $:Ll;rctozo- |-f{)slirl- llr.i(liltrans{eraza, G"pD. ln eritrocite se
    con-
    'l :rl .:'( r ' { li. r , . ' r _s r r pe rn s i rl -,l i s rn L rl ,tz (S
    e i .O .D .), con" di i i onati de supradozai ul
    j i .n r(. |] t UI ilt ir ,c lr m rn c rc i l u n o r m n t,tb o l i ti a i tri pl ofanul ui cste rcdusd. 'I-dsomia 18
    C ai ta_
    .it.rr'-.r dc ap*ri'c c ritiin fectioasi. csre re.lusi. 'Riscul p"ntru {Sindrolrr Ed$'ards)
    teu-ccmi."[ie {SiDdior Down)
    rl ,. /o ( ) il t nal m alc d o c i i i r: p o p u l a i i e g e n e ra l i .

    , ..l )_" . ! 1r et ogli/ elc s e c a ra c te ri z e a z b .p ri n: pl i u pal mar transvers


    (rrnirr), bilateral in 260/o dht cazuri pi unitateralin iso/o alri cazuri; triradius
    ,l.llll Retard mintal 9i siaturo-
    p1lr!!,. ,.t,-,(i 5o/odin cazuri);bucll hipore"nari""l
    ll] oc f5o%t; t".i"
    Retard rnir1tal, biPerto-
    nic; retard statutopoB_
    poBdetal; hemangioone;
    r'l llrr | , rl(: marlmc mal-a_ i{b fetald pe$istefltl;
    dcral; greutate ici la
    ( r i.o l, i p u l esre nrodiiicat in includi h rucleii letcool'
    .. .o functie de csle 11s1posibilitili scne_
    I r,-': r'rsomrclrbera{9^4,%) telor neuttolile
    iu.care-carioiipuJ estc 47 XX (Xy) interval 2"11_;
    lrii,nr,. jn-Jnozaic(2o/o), trisomie cu tianslocatie 4o/0,inteicsind 2 Occilrt prooln1nent,_ Ilicrocclalie; b!zb, dc
    cromol Occiput plct; epj-
    .o'nrr| (iJ/o) St.crornosomii Zt,i j4 (34o/o) 1 cxcmplu: 46 XXt (ta,l). ln cartus; -t.r.nte PalPe nrjcrognalie; ureclu ]os iepure + Jantlr PalatiDi;
    si cu an(F irnomalii ale liniei rnediarttr
    c.rrnrcpoate li atcnuat dacd propor(ia celutelorcu caiiorip brrle oblicej iris PZLtai, implantale
    m.rtii de fot a pe pielea par€si a cr,ln-
    ::]:]1::::;"i.r^.i.ry.^I"1
    ||ofr ltJ cstc lnal mare_ fl:racroglosie, uechi
    l ui ; truc roftahni c , (0l r,l ' "
    lr]a1i $; delornr&te,
    ma; surditate aparerrt,!;
    pot {i mcgtenite_<auproduse dr nouo (55o/odin trans_ nas hrtit
    lrtecbn jos imPlatrtal{r lt
    ,rr),,rlIl(:
    ...'f'rrnsloratiile
    pe un cromosomdin grupul D;, mal{oInlat€
    Itc6u'en1s,familiali a trisomiei 21 este rar:. Ea se produce numai Cardiopaiii c ongeni l al (i :
    . ln Cardiopatii cotgeni- Cardiopatii 0o gedtale:
    .rzrl (:irr(l unul din parinti porrid. o transloca!ie echilibiat! sau _ CIV, canal atteial CIV, cadal utclial Pcr'
    Ioarte talc, in spccial de{ec- l)er-
    |irr irt rtltut mozatc cromosoma-|.. Recurenla esto de t00% pcntru trans_ ie septirlt) sistent; torace scult sistent
    lr'.tli,' Zt.l21 p,cnr11,
    celelalte translocatLi (DlZl siu' ZtlZZ), cind Ihrghiuri r|cctalnrlar'e :ltinichi in Poicoave; polichistic, rrtcr
    : {e,,t6l,
    rrr.r!r:r'.sti..purtiloare,dc. 5o/0.cind taiil. este purtritor (Duca Marinescu, l i mi frrec criptorhidie
    dil-inrate, Pcnis mic, rri l l orl i di e;
    ilrara rranslocaFrtortr mozaiculuiparental, riscul recurenfei este criptorlridie rhdr(ti ei c oaP s el or; her-
    1,.1":l
    rc I zll,, lie irtghinalS sau olrrbi-
    /u-pentru o temcrc car.e a avut un copil cu trisomie 21, lnainte de
    vlrsl.;rrlc 30 de ani. nnghii o.tr-
    f)eformar'ea deBe:telor il} I'o1idactilie,
    'li';rtamcntul se lliid latc ti scrlrtc; ni|
    axeazi pe factori educativi, de mediu familial si ln pliu palmar lmnsvers; {lexie; hahce Sros s1 ve:re, Pli! lalinat
    rt|rl rlt. dc recuperare neuropsihomotorie gi pe aplicarea unor trataniente hipoplazio {clangei sc rt in doNiflexiej Picior
    olt ro|lrcc{cnerale. rn;dii a desetuili 5l plat, picior valg
    dep:utarc intre haltcc
    $i degetul 2
    1.4.7.2.DELETTA
    UNU| CROMOiOMDtN GRUPAG l2r,n) Blze ('le icPu!€ --t {a ii, Delormar€a dcgct(t(t trl
    lloltz! palatita, og1-
    SAUMONOSOMIAG valir; strabism; g;t lalatir:,; aron1alii ocu_ fler.ie: adere olnbilicolii
    uflict; margini suP r._
    scrrx; dinli micl; Iare; pliu Palmar unlc;
    or.bitare turtrte; rurr 0_
    Intruuegte un tablou clinic format din: limba crr liinlurl; a- lipoplazia ungLiilor;
    ftlmeloane depAltate; gna!€; polim r'ci ro{lslrll ;
    .^l.isuorfie craniolaciald: microcefalie, fante palpebrale atrczic intestjnal;;
    git palmai; artedl ortl:i- picior val8.
    oblice ln io-s pcr{ora!ie ai,L1:L
    rr.irtrrl.,(,,antimongoliene.,),blefarofimozi, cataiacfd, persisten!a
    Ir me'nr_
    r,rirn(r puprlarc, hrpertelorism, ridd.cina nasului este proiminentb-,
    micro_
    /.ir.lIl'.,UreclIlJos tmptantate.cu cartilagiudUr;
    .-,tnulformalii: cardiace, digestive, renale, genitaie; tqu
    Schmidt-Frdccqro
    1.47.3. TRISOMIACROMOSOMULUI22 (sindromul
    -, k,i,potrofia stataro-ponderald, hipertonie muscularl; rindromul Colobomq 5i otrezio onoli)
    - biohgic: trombcpenic,eozinofilie,hipogammaglobulincrnir:;
    . . - dumatogl,tfa cn -creste derraicc foarte marcate, triradius axial ln
    lnzili;L t'; trirarlirrssubdigital foarte distal; lilil,::111"il;:'#;ll*,{'t1il"$"llili:1:')i
    ,,,,,,,,s';,,.'ir';il,i,1lfil, u"".'rrrrri)'rr'l' i
    l'lrr'rit':
    - aarior'iful poatc irrltir dcr.lia rcgiu'ilor juxtac,urrorru.rit:(f. *rrui
    cr(,nlosr)rn 2l srrrrrlclcfia unli cromosom ZZ,
    l jlmliiiin,inli.nl
    il;liil,l lii;li'.{t'ii'\li1;';'
    l0tl |07
    ' r l.,i ,t SEXUALI
    CROMOSOMILOR
    1,5, ANOMALIII.E
    t' , p iI. !, tE
    1,1
    1.5.1.CLASIFICARE
    5tF
    ,::5 !3e o l- ':l '1,Anomal'i'i' cleI'afonnul'a46 XX I'afamzie
    prin d'eaiapie
    ;.-r i a f.i
    A. Dc numir:
    :- : !q Y g "
    I. SinclromultriPlo X: XXX
    .:+ a._:.9E E ;t l( I ,: ;ii;;;ri.;;if X: a8XXXX: 4exxxxx
    3: Ni;;'!;"; 1+s k
    lqtlgt)-- xo; sindromul
    a ir €.ra! ; ni;;"i.;; xlxx; xixxx; x/xX/xxx
    '6 e .[]. De structuri:
    - Izocromosom X
    ? 9p; . r . 9 - Cromosom X in inel
    .J E - Delelie a bralului scurt
    \ 89F" !l : E :' E ;
    Ia bdrbat
    ! G i: = 3 &E :- Il. Anomalii Pri,n d'eaia,tied'e la fonnutra 46 XY
    o3;J E t r,E g de cromosomul X:
    'A. Lecate
    "sindromul KlineIelter ; 47 )()(Y
    t 1.
    i. Alte Polisomii: 48 XXXY; 49 XXXXY
    3. Birba{i XX
    .9 tE I lJ. Leeate de cromosomul Y
    x,E o --sindlomul XYY
    , i ** u,
    - Aitepolisomii il *l{-V, ?, LT&fi,
    . : f E: ; :
    9i anotnal"ii ale d'ifercnlierii'
    lII. Anomalii crotnosom'ice
    : ,J^;, - Formula XY/XX
    a + .io - - Eg - Formula X/XY
    5'!EE;ig; G
    t1 .9 42
    TY. TriPloidia : 69 XXY
    :: &Eg l{ a.i
    !3 s E e F " b " ..9.9; DEtA FORMUTA
    PRINDEVIATIE
    -ii!+
    !!.- q
    :p: fa l> i
    1.5.2.ANOMALII
    .i:it I 3 l; : -E 46 XX IA FEMEIE
    !'i :fB*i.de 5.i 46 XX
    (,
    9.: E o! i 9* dA 1.5,2.'I,ANOMATIIDE NUMARIN FORMUTA
    > 9 .:: i $ E H : P6 F
    g I p:.t
    A H; EE.
    1.5.21.1.sindromultriPlo X
    are o {recven!{ 1/1 000; ltt
    HE lrr oooulatia senerali. acest sindrom -{9
    ,'rr,ui,r. ioi"""iio r "menta1ise intilneqtemai frecve-nt(4/i greu
    iEd 000)'
    x - (I;M;.t: se manifestl oti" ;;;il;'; Jit;oui" ait"i"i' de lncarlrat
    - . 5: l cazuli' stcrili-
    E* i .,i i',,,i,,itiotit,toii"i-"iii ie gravitate variabili' ln unele
    oI 9 il :
    c iEl c o ""t r': 0 l 50-?5.
    ,,i"ti +l XXX' Dcscendcnlii arestor.{emoiau crtriotiPrrl
    t o. :
    i)iJiih zr'
    4/ \XX sl,i al KXY, uncoricu trisomta cromosomulur
    E i 3' : E€
    'I.5 2 '1.2.Alte polisomiide ripul 48 XXXX'49 XXXXX
    )t dcbilit:ri r:
    At:r:ste polisornii ;tu un corcspon'lcnt clinic carirctiriz .l'lrirr
    ji[ q; f i1, oDllcr l ln slls ll
    rrri rrl :rL'thrr' ;,;;'; i', "'. , i gr : r r l, ', hipcr t clor ism , f anLc Pit ll) cbI uI l'
    nr zr r le, m alf or m if ii dcr ) Lir 11) r t' t 'r 'c) t ijos it t r -
    ::,' ,;i ;,,;
    ': i, t ii. lnii ll; t 11lc'ilr llul) cr ) l- I
    i ,i ,rrrt:r1,.l {i t sct t r L,clir t 'r LLct ilicr L 'lcgelului 5' anot nilllt . li':
    lt r l [ lt ls {l( : Lr isol) ) i(2l ! ir soci; t tcll r l{'l) ll: t ilt c llllll] ill; l'
    i ,. ,,,,t,' ' ,r.i ' ;r . D, 'r

    t0t 109
    )r]stilt:t linJt,!em t|l''eX,t|(l]L'i|'.i|i|/, crr irdlncituri
    t ,tt, tut ) .14
    |,tl lttltt-ttilstlrrl S(|
    ' uaniolar:ialir':
    ll.dltl(itri'! ti\rollptro otuHo dtn trtNo'rl'r
    ft.nro.q\omlilc }:rrllalo ln nhchrl n.cnrtlrrrl lrnrl rro- i,'. piiiiiiiii' ,r" Ilcxiunc,btcrvsiutll'colll ;i clisrn'rL-lr'^ urcchijos
    ,,,,'t,,,i,i1,
    In o r o fir { t ( l ) r r L jl- V^ r in r jscu, 1983)
    cpicantus, bolti ogivalS''
    iialatiniL
    trirr.rlr:loristrt,
    t;'L;9*;:',i:S'JlJ""T##,i"Jl*"#r1;?",ll
    iiilri,';illi.;"1,i'.ri"'r.;. -t.toi:"tiogtinji",
    4 sc rcmorca o- rc^ducere
    l.a coPilulmie .t "tl:'_Y:-Y:,^']:I
    'rr\ n&t'tiswnt'
    4
    lrrrrrt , . 1 , l a t d . -' r - osocsi .intirziali !,.oSl"aiI' se.inslaleazd'
    -_
    fruntc proemir-rentl ,r,',',t,',itt,rlirsr;-L
    (1" lrlzt proeDiDcnte glabeli larg;,, ptati ,,r,,rr,'. , rru cstc nici hipofizar,nicl hlpottroldtan'
    rrt prooninclt, vld bulbos nas asculrt """"".sil,tin'tr, al rfismorfic'poJc' tuprit'd": ftozl p,alpebral[' epicantus'
    Ittrl)ic md-sivl, rotundI
    @lcroretrognali€ plerygtum..cot[1
    I il s c ut . t ,rr,rlri irrs impl:rntate.microretrognafie,
    ""' ":t'.tiit"itii ,
    8it lung fi subtire
    exces de arcuri iirt Ei pot" pr'ezenia niui figrnentari' Existl o tcn-
    "tii
    lirtir lL cicatricc cheloide. t:
    9 p-j- 9 p* '""''" ct tndepdtt*rea imfortantd d tnatneloanelor cat
    1, , : lri(.
    r la l i c i:,,,i,' rii' iit"
    tlrgonoce{alie "ititta.i",
    exoltalmie "" hixrlrlazice
    ,irrl "i't 5i uneori ombilicate'
    lrric palpol)rate obtice ln jos ;i in afarA fante palpebrale oblice ool ii delormate:cubitus
    ,')'it''rrt't ualgzs' miini 9i picioarc scrrti'r'
    '."r""'.!i"'"'
    in sus ii in aIari, i"""i' +r"^
    , , .,ilj,'11ilili*fi;.-p[" .(snrnnul Archiba'l).,
    .r'li-
    ',ii,.s"i"f
    {rili(:i; nazaleodentate in jos
    ras plat
    i,,,,i,',:iiir,''l" 5, itip*totitm digital' Uneori se noteazi pliuri inl't:t-
    ori{icii nazale o e late ai{erior
    l,r'zrr ruperioare scnfte u"" (ttt
    sint f recvcnte:urinare'in 50oodin cazuri ' t' r
    Duza snperoat{, lunse
    hirl)iD)i)zofalaI]gie dolicomazotalatrgie - ";:,|',ilr,lr^t?),r orsanice
    ,lr'fllri|,1ogli{e i numir tedns de ';i,r'i1:iri'i;";;r.Jlil rtipopr"rierenale)si cardiovasc ulare' in 27 /u 'litt
    e xce s d e vl rtei ur'i I iri I
    2l P t- ,'''",r,,ii i,r"t"""i.ili
    "'.t:.*iiiiil, inter-ventiic'uiare,clextrocardie',nff-i19nttat[)' -"
    2t q - l - ( q 2 2 )
    21- (moz3i c)
    2 1 q * (det 2t q 22) senzor,ial,e:miopie severa,cataractl congenital[, tulbrtt itr.t::t
    hilrol orrif 1i hipedaxitate
    hipertorde v.rl.tii pentru culori' Surditate
    lrA{ r' r(f lr rr i
    Minifestdri osoase.Virs t3"l$tln# t"o viatL in raport cu virstir
    l rrl(. t ) h ) l : 1 ) r a l e o b l i c e
    blefarocalazie e).1em6.
    ,,,,r,,irgi.i.'O.t"oporoza estefrecventl'La,genunchise poateconstaurpl'o-
    I'r ri| | ! t i i n a f a r : i
    larte palpebnle
    jos ti ln a{ara
    obiice ia .,,;i;',;;i;;"tgi"ii'interne a pratlurul tibial"(careare o. suplafali oblicit trt
    tnii0 llt us h l i c l ( t perslstenta memirranei papilare ,,"' si iil*t.ii asociati cu'atungire" verticali a condilului fem ral int(rnr
    lliperostozi frontrtli
    -i""i" dufii ui..t" de 6. ani).,
    rrrrr:hi orr p.r.vilion si corlcil mici
    $i condrct urechi cu pavilion mar{ & concd 1arg6 i ,,,i,,,ri Xo.o"i"z, manifestat
    ;i
    I'it x , t , t . r7 i r , , c . e t o f p f o p r i i ,r le n r su l,j
    conduct auditiy cxtern larg
    l,l'l:;;i[l f",voltate. hemivertebre' sindtom I(li';x:l'
    arc nazal Joarte dezvoltat
    r ! rt llriurill c , . t r b u l a r e ; i i ) i a r c m ici, iDo e x ilid c
    u n g h iu r i a, cta-l -'ul afeni i l i ace l ol rl e I ^;i;;"iriud"
    (frrziuncavertebrelorcL'rsicalc).
    J l" (n, , rr I 7 9 . ) mi rj . ''il '!:ttlburd'ri Hashirnotrr
    f rl[ rlol] l i f c : c r e s t e i r n a t ur e tr im d iu s in t,,
    r n o e x lla c 9t," end,ocrine:pelturbiri de glicoreglarc' tiroiditS'
    'l( ' /ih la : r r iradi us axi al i n 1, pl i uri pal mare
    iri l)liu palmaI tGnsvers fi (l iroirlitir cronic[ limfocitard.)
    tcndirt {rt
    la udolescent. Pe linge nanism 5i malformalii se remarcl
    roportiilui bitrohanterian biacromial' Sinclrotntrl
    l.r ol)i:zitatc, rllvcrsarea .-si
    prin,amenoree ptitttltri,
    1.5.2.'1.3,
    Sindromul
    Tvrnersqu monosomioX (45 Xl -i"tt"r" vlrsti se caracferizeaztr"
    ""i"l.iJi"i".Ia aceast$
    ,,,,,,.,.1i,,obse.Vat
    l;t,,"'.*i; iecundare. organele genitale intcrnc stnt hi
    (sindromul
    XO, mono:omioovcrion6)
    tn,t)l i l zl c0.

    Modificirile somatice au fost.. descli$ de Turner Iliololic sE constati- abscnla estrogenilor urinali, hipergonadotrolitrttrit:
    rn(xrlioneazi.ln tn 1938.,Aibright (1,u.itr: 100 U.S./24h).
    r.rrr:nfaovariani .1942cresterea va.lodlor f.Sff, c.ea ce-pted""ro p"o.r,, l)0bilitatca mintalii este prezentl tn 150/odin cazuri'
    9i nu hipofiza_ri,
    a llburlritor end;dil""]"" ig]i^.firfif#"
    "orr_ tt'tt.it
    :r.rlcmonstratabs6nlacor'pusc'tu]ui Bari ;-l; 6i6"d;A'a descriscario_ l).rm4toElifa:triradiusuLaxia-leste in pozilia t sau t"; figuril<t.
    decit Ia nonnrli Buclclc,;ri vit
    4s X, prin pierdcreaunui'cromosomsexJal(hipogonadism ,,,rl, ..i fii',"iin',.ticnc slnt mai lrecvente . (l(:rtr)r{r"
    ll,tilil,,11i:**"r" t,.irrlili,slui nr;rilnrLri pc pulpclc digitalc, cu numirr crcscut dc crostt:
    .[nciden]aeste dc 0,4/iO0 nou_aiscu]i vii. Numai 'l'L'sltt ! .Drrrrcsic ncgatLv.
    ,.
    rlrrr aproximativ 5_10% cazurilor' Crolnosornttl N
    pult)ilorii accsteianomalii.senasc-,
    r.csiultqOi (),triolihul cstt: dL: 45 XO in rnajoritatcrr
    Ss",;i'fij",trtim inu[i prin -iiiiti,',11 -Vit-lir tn;ttnri nrt irtllu*trJ'r:tzrr rtlt;t
    irv.rt spontan. ln sezonulmal-ocromlrrlcse nasc'- ,"t,, 111 11,rrr ,lcr:it plt' r'rr'
    2/3 di" .o;;;r:;-'ii;r;fi#i; I nt Llr r . '
    'l{)
    tl i : Z (J lti(t r'"1 ) . "t,ii r (
    rtti ;t .rrI rrtt t It I i r i Alr t 'r '; L1ilL'linnosolnicil ' at <llr t ot
    't llulldlslull( ; llul
    'l'rLbloulclinic t' rrrr cu t r Lir nif ost it rclinicc
    i t nr Li Pl4lr 1 l) n) nt lr llillr ''
    cstc parLicularln raport cu vfista. ' | l ,s,ri s r r r r zlir : t t t - i'XO / XX X' i(Xr1)(1rLb.lul l lli)'
    xx1,'. Kxq- 9i
    't;,,; r;i;i ,i,',u:,:i..','nriuti1'uii
    ll0
    l
    ' t ut\t It

    ( i rtl rt l l noru' l i i l o ft' nol i l rl l l ui fi (a]i oti pnl [i i rt s i drr} l nrtl 1\ ntr
    ',rD prr:r!l e L1\rz t6 J ., < ;a51 \1., 197' 1)

    tH ,.,,r{1,. rul (z/.li ari e

    , ,,r ri ,l r1, rL:i c rl i c j oas :! a pi rul ui


    lco%
    10a%
    100%
    i00%
    14'/.
    64'/"
    1C09/.
    2394
    {}%
    t 2%
    l0q9i
    6gyo
    65'/.
    1. A
    (x) ,l{,
    r00,ri,
    l0{)f1,
    (r{),]i,

    : l 'l i '
    ,t/0ucJ0hl/,,t Hf//r/f ,{0 1,,'r1r' 1l rti t 42% 519; l i t) ,1 ,
    20% 0% '6% 0 '';,
    h'0,t4|/lt/ala/ r 0./" 0 91, ,-%
    l l , l ; , ()nq.rri l al e dc c ord 0% a"1, c% ) t'.:
    \,,, Li rl rr (l c tr' (i t urrnar 3E% .1 ( l '
    5.1l;

    ( ind tabloul clinic de sindrom 'lulner se asociazi cu cariotip rlot rt:rl.


    l. :rrrrlrrlc -cr:xc,se vor-beste de fenotip Tumcr familial sau sindron pr.',r,1"
    I rrrrirr, sir.idrom Turner masculin, sindrom Noonan.
    'l'ratam.entul cu hormoni estrogeni dn substitulie se incepe l:r iir'lr
    , l .\ l 5 :r ni. Dr r pd apar it ia r . r "r st iur iini 'c r ocom anJ; "so, ^i'r .ir
    . l'' : '
    ,,r,rrrlui. 'l'ratamentul chirurgical se aclreseazi-uno;: malformalii (crrr''li;rr'
    ,, rr rl r' , or:l uar c) .

    Morcricurix/XX' X/XXX' XIXX/YXX


    1.5.2.'1.4.
    (llinic, {enotipul este dominat de clona. 45 X, clc lnde ;i rlranifr"l'rril'
    r', rrL.irriLtoar:e sindromrriui Turner, cu grad rnare ,-1evariabilitatc. Sr' rr(l
    ' ,,, ,, l ,r, , lispozilie [ r avot ir , t i.

    AiloMAtll DE STRUCTURA
    1.5.2.2.

    ( r'lo mai frecvente remanieri de structuri -ce obscrvir la bratrLl lrtrr;l


    ,rl t r,rrrrosornului X (izocromosom) 9i sub fonna cromosomulrri X ilt irtr'1,
    ,r' ' irl r;u cariotip 45 \. Rareori se c6nstat.l delclia bralului scurt srttt rrt'rz;tir"
    lr'lloul elinic cupriudc o dismorfie n ecatactelisticl firii trrllrrrr'iri rll
    sint inlocuit e de o bandelet i {ibr oasii, r r r "r r r : i
    ' r,,' .l ,rr' . l n dr 'I elie gonadcic 'furner.
    rr.il,r;rrr cn coa din sindromul

    PRI$\I
    1.5.3.AtrUOMAI"tl DE I"A FORMUI"A
    DEVIATIE
    46 XY tA BARBAT
    ANO^4AtllTEGATEDE CROMOSoMULX
    1.5.3.1.
    /ll ///
    A//fa,ei '1.5.3.1.1'
    Sindronrul
    Klinelelter{XXU
    l// t// lI-
    'l/ f Il h'f/ff
    l )l scti: r r ll lililr r 'f cllr lr , lr t I 942, siLr t lllr r t lllisl( rI 1I I i||I ( : iil(rr: t t o llr r l: vr t r f il
    ,l , l //(X ) tlt l t t or t r t iisr : t t t it t t lt sct t lit li hr |opr r l: r {i; r llr 't lr r t ; t lit|i ( ll r r lt r r r : v( 't t lli
    rr,,' i ' ,' ,,,(, lr l t : lt lr liol ilt r lr liI 'if lr I iI I r | r r r ilr lllli'
    Si' t( 1 ,' iL r l lIr icr ( \O) . ( ( li' ,i {r1l

    l13
    l l :l
    l 5.3.1.2Alto Polisonii
    'l 'u b lot t L t lit t i r' :i c c o ttti rl i t:i t c v l rsta'
    dc 'lltl)tl,(tlt ,\" r'ottstlLir dismorfie rltscret1"' creStetea
    lr',67111,1:
    st(,tureId Itlrmula 4{t XXXY detcmrini. un {enotip asemlD;rtot sindrornului'
    La pubertate om dismor{ic rnai accenturtc'
    tilin,,i"iict, aaicu debilitate mintalf, $ sindr-
    n'tittlllti, inttttttirlii ale orgauelor gerritale' supinaiiei 5i pronafici
    '1;,,lti;11uitii.dtbititofc s,''ix,ti,vii prezenta limitarea
    rarhocubitale,
    sinostozei
    , irsrxirLz-ir giltecomasti&, sc constatir ittt'Puberistn, lti!>ogonad'ism 9t stelil'ito'te.
    rrtttr:lrrafului.
    f'ornula /r9 XXXXY a fost d.cscriside Fraccaro in 1960. Tabloul clinir;
    ,.slr: rxrmplex, cuprinziud :
    sittdron clismorfictanio-facial: craniul mic 9i rorund' occiput-Plitl'
    r,,.i,* t.ti"il"iip";i;i;tifi, fante farpebralc ohlice in sus qi in afari' rirlicirriL
    rrrrsuluiturtitl. urechi mari, de{ormate, gur5.mare;
    * tardcec'ilindric, cl'inodactitrie a degetului al 5-1ea;
    '- s inostozd rad'iocttbital'd (caracteristici. gonosomopatiei);
    -- sindrom Ronadic: pelis mic, ectopic testiculari' scrot- hipoplazir:;
    f,i"r,.i. GiiiJ"rf-"i"ta .ia"."t"a diametnrlui tubilor seminifcri, ntttttirt
    r,.,lusrk' celulc Leydig, rare spcrmatogonii:
    - kipotoni e mttscul,atd Si inttr zi ere staturopond'erald ;
    -- ln cefalo hatie seaerd(Ql:38, in medie), iproporlionalf,cu crt:ltcrcrt
    rrrrrriruh dc crbmosomiX.

    BErbqti46 n
    1.5.3.1.3.

    Sindr:omul, descris in 1967, asociazi.in fenotiptrl masculin' modificlrill


    in sindromul Klincfcltrrr'
    rt,,',"Ai."llio|ogice ,side profil psihosexual cunoscute
    lixolicatia masculinizS.ni coexistente cu cariotipul XX ar fi dat1i7li'
    ,,,,,rrt,riJt""unor Benomasculinizantepe cromosomulX l.ltrpi alli il)'t('ri'
    ,.rrrlrlionul ar prcz"entaun cariotip XXY' ctt pierderr"a rrlterioarS' a o1)ltl('
    ',orrttlui Y.
    Klineielter la un t-'6iat de 16 a11i '1.5.3.2.
    Fig. 1 40 -Sindrom Y
    ANOMALIIAIE CROMOSoMUIUI
    S r " r u ri in a lla : c_ Iccr sr r ' o iL j: h ip o g e oi raJi srn,cari o
    lip \\Y { l( l) l' r ( lir n a r n ir ( ^ lar" r'r dr'
    XYY{disomiqV)
    Sindromul
    1.5.3.2.1.

    Musculatura .estehipotrofici' lesutul Sr:intilneste cu o frecvenll de 1,5/j 000 in populalia generall' de 2'3
    li:sliculii sint mici ln raport ""rotol- 11r urir iri medico-pedagog:ce;i de 12,3F 000 in rn ctliul Pcnitgt3gig
    "o gitloid' Diametrll bitrohanterian este merit'
    *ra"*-r" ,f"p"* i"pi modefi ()t,inic"nitiilie
    realizeaz\ o drsmor{ie nespecificl: acnee rebeli, modi{ici'ri rtclio
    mirrtal s'e poate manifesta comilialitatea clinicf,
    ?i," ,,""i"r'iJi"ituloi l,,lli',, ;;;;;";i; membrelor superioaie.La pubcrtate se remarcS't'rlia inaltli
    (tig. l.a0). .r llrtilitatca scirzutir.Descenclin{iipot pr'zcnta trisomie,2l Sc asociiLzi'r
    Itiologir, se Pune in cvitlcnli o scidere a 17 corticosteroizilor 9i i dc grade iariab c, merg.ind-pini ia acte dr: dt:lirrc
    ,, ,,n.ri,,r" t cinadotrof-inclor in ur:ini ln slnge se remarcl,o
    cregtere v.alo;
    1
    'li,'iilii'if"
    vr.rrlii, rrncori cir caracter sex'iral (agresiunesexuil:t, homose*ualitatc, pit.'
    "o-p"itament
    ;t;; ]:;;;i;tilparal"t. c,r rctlucercatcstosteronului) Bio,sia testic.lari ti l l l t( ') .

    iLraliL sctr:rohialinozat*Dllor ."-iriit."i gi hiperplazia celulelor Leydig. ln ()uriolihr'tl cstc XYY, cromosomul Y avintl t:xtrcmitatea distalh ir. brit
    rLlul B:rrr cstc flczcnt' 1rrI rri I rrng 1j;111 nlal (corptlscul:'lrilrrcilor)'
    1' ll11o1,'sr:t
    cu crtriotip -KKY, 'lLrlll)uif
    lirlrrrr:1,:
    ()triotiPttL pcrtc fi XXY, in 60lo din cazuri' sau ln mozaic' '1.5.3.2,2.
    a lnam{}i' frecvenlit Y
    Ahe Poliromii
    K\'/KXY. Andri:trLgoicticiLlrrlati:lriLt:r vitsta inaintatir
    ln 63o/t ititt cazuri cro-
    g"ri,'l,,tiii,lli gi ;r rnalttliilrl irlttttittttttrc in familic Acr:stcpolisorrriiY slnt tl: ordirtul {8 XVY)' 40 XYYYY' 48 XXYY'
    (|()iI)IIIIiIIiII [oudisjttrlcfio cst'cclt: nrtt(rrnil
    ct|igitrl:
    lrr,;,r;tt';ii- sriplirn,,nt'rr: 'lr: ,II' XXXYY.
    (lc lit lirlii'
    1i ln 21"1,rlitt crtztttiprrr\illr'
    ll5
    4
    1.5.4.ANOMALil GONOSOMICE5l ANOMAIII i rrrrl,Lli.: dorniumtiL rtrlosomcli, transmisS. ereditar, cu pcnetrarrli. rnafc $l
    ,xtrrcsivitale variabili. Purtitorii acestei mutatii pot face si alte tipuri thr
    ALE DIFERENTIERII
    SEXUAI.E X,,rrrr:rnii (Maximilian, 1982).
    . Leucerni,a acutd tuonli'mf ocitt"rd de nono'
    FORMUTA
    r.5.4.1. XY/XX \lrrris si colab. au sesit 17 categorii d.eschimburi genetice Gradul complc.ri-
    i.'iii acestorapoatd servi ca in-dicatoral tipuiui de.evolulie: a) inversia la
    Sr: rnani{esti. cu hema{roditism adev5.rat (ambele tipuri de gonade crirrncisomul16 determinii un prognostic bun; b) trisomia. 8 un prognostic
    1rr.z, rrlr'), dc celemai mu-lteori cu f enotip somatic{eminin. in1r::rmediar-;c) schimblriie coinplixe de fragmente ADN un prognosiir:
    s('vcI.
    1.s.4.2.FORMUIAXlfrt (45Xl46XYl GONADICA
    SAU DISGENEZIA c Leucemia veiul'tfltd din crbunerea l'fl ca/-
    MIXIA fn moaalc| t: i tt,o g c n e evol,teazl.cu schimburi cromosomice ipeci{ice. La indivizii in
    virstir ie remarci pierderea integrall sau parfiali. a cromosomutrui5 sau 7 iti
    l)r, nrultc ori crcmosomul Y este anormal, pierderea1ui explicind clona r:-'risLcntaunui extracromosom 8,
    .lrr \ Sr: rnanifestS.ca pseudohennafroditism,ctr asimetrie.i'' dtferenlierea i lrlewc er;ni'a cron'icd" l,imloci'tat d,ll.a:l T. ;i colab.
    ;','r,, I',, , r)fuportiunalicu momentulmanifestini mozaicului(plin picrderea (l9li4) au descoperit c[ trisomia 12 este relativ obignuitl Ei reprezint{. un
    r,,rr',",rr;rlrriYlinviai.d embrionari.Clinicse mani{esca.cu fenotipturneriart ,li, r,rrint de graiittt". qupi.J J. Yunis (1983), fiecare tip de leucemic tr
    Ltngonadic:r.
    :,, ,,',rl,i.:rrir de ilnomallecromosomata.
    't)lr1(ar avL'aun coresDondent
    c Twtnova- Burhi.tt a f.ost primu'llim{om identificatca nr:o'
    plrrsrn de celule B monoclonale, in 1967. Studii citogenetice au ari.tirt irl
    1.6.ANOMALIILE 5l CANCERUL
    GENETICE rrccrst5.boali- existenta translocatiei de la cromosomul 8 la cromosornul l4 itr
    "10',/"din cazrr|la ciomosomul 22 h 20fo din cazuri-;i la cromosomul 2 itr
    Tr l97q s-a fdcut descoperireacA in Senomul.tuturor speciilor auimale, t I din pacienli[t (8: 1a).t (S:22).t (8:2)1.indiferentde!prezenlasau abs.cnfrL
    irrr:lrrrirrorrrul, existS"o gen{ oncogendsituatl- pe cromosomul 8, sarr c-lnc virrr-uluiEbsiein-Barr(G. Kiein, l98l). I'rin cerceiin complcxernlerdrscr-
    t,,l,l,tr,'tt,,.,pin), dcnum"itiastfel-careplicd- Ia existen-tafragmenr"lotortco' l,lirrrr-.(bisl6giemolecLrlari, virusologie,imunologie,citogenetici)s-a putrrl
    (iiril ancopen) din genomul unor virusuri. Se crede ci. fracliunea i.r:rl'ilica clemenrul principalin producereaaccstuitip clecanceresie.p-urrlrr:;r
    ,",,,,,,,,,,,,
    ,i,. ,ttrN ,,o functie olcogenS.6xercitl funclii liziologice in timpul embrio- ;u (x)ntact, prin tran-slocalie,a g;nei oncogenesituatS"pe cromosomul 8, cxis-
    1,'.rr,r, i, irr r, (cnerureaceluiar6si cicatrizare.Participarea gen"i oncogene tlrrliL la toti indivizii, indifereit de specie,cu o altS- regiune crornosomirliL
    i:r lr,rccsLrl,-1.' iancerizare sc efectireaziccl putin prin doui mecanisme:a) prin ,:.rr'.conrineinformatii e'ncricc despri anticorpi (cromosomiiZ' la i zZ)
    ,l,.l t irr.rric.r doui.oncogcnediferite; b) imortafizareaunei celule,prinmeca- Fragruentclede AiN din crodosomii z,14 { 22 care spccilicd-pcnl rrr
    rrrrrr rrlerrioscuturmati de exprimareageneic-onc(CairnsJ., Logan J , 1983)' i iunogl obulinelor, sulcri remanieri profunde in timpu) diferentit lii
    ',ir,r,za
    lrt rrrlolo{ia umani relalia dintre anomaliile genetice9i rnalignitali
    litrf,)citelor B'(T. Honjo, 1983).O translocaliea genei oncogenein faza drr
    ,-.t,.vrrli,'l'itt'xlrimatii: a) exisrenga de anomaliigeneticP in cancer"lePelinie lr,rrrzitica celuLelorpt" B spre celula B ar gerlard.o mu.itiplicareclonelalr:tt
    lolxrir:ticir.lleucemii
    rrr jilimfoame), in care s-au constatat anomalii cromo- ,'r,.'r'iria lirn{omutui.'ftr inrjrpretarearelaiici dintre anomaliilegencticc li
    lr,.rr
    ,",r,,,,1,':l,) L,oli geneticecaracterizate 'prin remanieri cromosomale,in care ,,r,,,riiia leucemiilor sau lim{oimelor existi incir multe necunoscut€' Recc t
    irr.irl,.rrirrcanccrulirieste crescufi (sindromul BIoom, anemia Fanconi, xrzo- \ir,,ris,Le Beau si Rowley - 198'{,au emis ipoteza existenleiunor salas-uti
    fr,rrliic pe cromoiomi, caie fa.vorizeaz| apari!1a rearanjamertelor sub fortrtiL
    rltrttrt )pigmet'ttaswrn ) ; c) tisc cresiut de leucemie in sindromul Down (tri- I r,rrslo&tiilor.
    sorrrirr 2l),
    l) Anomalii genetieein boli hematopoietiee ll) Itoli genotieecar&cforizatoprin romanier; cromosomale ti itroidoull
    qcscuti a cftnoornlui
    o Lut,tce +nia t'tr'ietroid,d' cvonicd. ln majoritatea cazurilor
    {t,t}'1,} ,rristii un crornosomanornal, Phr sau ,,Philadetrphia" numit astfel dupi o .S'indrotnul' Bl'oom transmisautosomalrecesiv,caractcriztt
    'rlt.scoocririi
    i,u:rii sale. Studiile de bandareau demonstratci acestcromosom r'rirrlrrrxrt|rrfir.l;rLurr.lisi Lelangicctazii alc feIci, sensibile la soare,plczitrliu
    rr.rrrr.zirrtiriur schimb reciproc intre bralul lung a-l cromosomului 9 9i bralul
    -Cercetdri ,,.',,,,rri,:ri
    suLrIortnir.dc iromosomi quadriradiali, itl 0,5 - IJ"/o din c':lrLl".
    Irrir,,rl crornosotnului22. de recombinarea ADN au ari.tat ci prin l'r)(lrrccrcrrtlc clonc celularepornind aela remaniereacromosomalirar cxplica
    l,,.,rt r,:lrirnLr <lc fragmente cromosomale, oncogenaAbclson este transferati lrr'(v,'rlir crr'jculirir canuctului.
    (lr. r,r.(:r'i)llrosonrnl 9- pc crotnos,rrnul22 (pozilia trambdn, Ianl imunoglobulitt o' ,4n'emi a Ii anaoni, boalracu trattstnitctcatltosomalreccsivit,
    lrrrrirrr,,'). A<;r'.r.sl r'rt(' l'trs', rn cvidcnl;i in mi'tduvltosollsii.irt
    ir l|lrrtsl,tc:L{in rrrrrnifcsirrlir.t:u irplazictni:tlttlarit,tttomalii cardiacu,tcnalc i;i osnase,prezintlL
    rur',,rrrrI,,,"iI'. iricilo. Evolrrfir bolii cstc t ai scvcrl 1a
    itt,:tiltocil.: 1i riu:girt:iLI Irr r:xrr.rrrtrurl cil.<>gr:rurtit:ruptur-i ;i l,'lr'rrttljantente o' Actlstt:itlrt
    cI rJnlosorllill
    , i .,zrr,i l , ,. : r r lI t r c I r t ir ' ttti { l ()l (l i i (l ro l l i t;i r.fi ' rri rt:ro ttttl sotrtl ' h, A trol ni tl i l t cl onLt> :,t,rl :r lrrrzrr
    tttt'rttttrtIIi1lIir',1
    t i cr'l r'
    rrlrtr ;rtiPicc.
    l. r iil, t I oI r ir I r liiIi .l ,r l o " l l i ' l , rl i rr l x rl rtrrvi s(: cr(rrl c i l l si ' r ci l r:xi sti Lo
    ri l )rrri (i iL

    ll (l
    . , Y/'/{) it f ltt tL l. o li um " t r an s m i s S . a u t o s o l l l i r l ltr:r:stv 't'abtlul 1.lb
    lt l: t ) t t : t t
    rL{t' rLpiclii la. razeleultraviol.ctcti. l!f,i{ti3
    r. r'irli(rlcliz('ir/.irln'irltr-osirusilrilit
    modificlri sint leziuui]c A1)N-u1ui,
    (]l slllcItlett prtJrcil)trldor {Icropatii tisulare (Debr6, f977)
    ,1,,r'lrtt:r,rr:r:ttliLtrrrtc. SubstllLtrrlntrtrsl.or:
    ,rrl, ftrrrna tlc r'litrrcri pirinritlinir:i, (tirre nu se mai repari. in cazul bollarik.rr ^Ntr tt) r Ll 0& rmjzc Neurofibromatoza Recldinghause
    -indivizii Dor:mali).Acumularca dimerilor pirirnidinici
    t, rrrrr st: itttintDlir la Scieroza tuberoasa Bourneville
    i,,volizcir.zir.roiil" d" duplica{ic 5i rcmanierile cromosomale care au ca efect Xfalaclia von Hippel Lindan
    '
    .,i,,,riiiir tlon,:lol Dscudoaiploide (cu 46 de cromosomi, dar cu distribulie Meianoza neurocqtanatA
    Leatiginosia centro-{acia15, Touraine
    .,irolririrIr'L).(lanccnrl cutan-atapare mai frecvent ln acest tip de boali la unele NeYomatoza bazo-celularS,
    r,r,r)rrl:rlii xnrl)cdin nordul Africii.
    lil) irr trisomia 2l (sindromul Down), 1% din bolnavi fac leuccmie' Ichtioze Ichtioza vulgare
    r\r:,.s|ft riorncn cstc o exccptie, restul sindroamelor cromosomaleavind accca;i (i|llorlra,lii congenitale Ichtioza legata de ser.
    rl(l liolii ;i arexelor) Ichtioza congedtala receslvt
    Ircr:vcrrfl"a lcuccmiei ca in populalia generall.. - Ichtioza hystrix
    iiiiAi.,t s""etic in difJrit'e tutnori at: permis observarea unor abe-r'afii Eitrodermita congenital:r,ichtiozifol'lirl"!
    .rorrrr,somalc. "Ast{el in mcningioame s-a descbperit un cromosom-22cu dL:lefii'
    Keratomul Inalign
    5r' v(,rl)(stc clc o ccnir a rctinoblastomului situatd.pe cromosomul 13, cu trans- Sindromul Sj6gren kmson
    rrrilcr', duminanti 1c.rr".t." qi colab., 19S3)9i de o geni. a turnorii Wihns, pe
    Sindrornrl Rud
    , r,,rrr,rsour.ttl 1l (KouIos A. gi colab., 1984)'

    (histodisploziile)
    TISULARE
    1.7. GENOPATII Maladia Thost'Unna
    Maladia M€16da
    Polikerato za Touraine
    lrr iLtlst gmp sint incluse afecJiuni caracterjzateprin modi{ici.ri culnlare Sirldromul Yadassohn-Lewandowsky
    Diske€toza corgenitale
    .'i ,,rlri1,'rionici, ali: unor {esuttn sau grupuri de }esuturi, cu alteri'ri {unc!io-
    ir,rl,,,,,rrstr;u1ivc,rletcrminatcde mutllif geneticecu caracterdominant sau
    r,, r'r;ir' (lrLlr:lul1.16).
    (rlnomalii ale aparatului
    (ligcsliv gi respirator)
    DE PRODUCERE
    1.7.1.MECANISME
    r';
    l':rloi:, nie ltistoclisplaziilor ost'- incomplet cunoscul'-r' Sc presuputr' A,Iezailerrno2e Maladia trfarlan
    i rr l !mp Tes ut c ori j unc ti ?
    , \ i\ri r l rri v ir r iant c in f u n c fi e d e n i v e l u l d c d c z v o l ta re cmbri ogenctl ci ' , (.Lnomalii ale tesutului Ilaladia EhleN-Danlos
    ', i .,r,rrti rr ir , s t r t t c t ur ilor ti s u l a re , a s u p ra c d ro ra a c fi oneazd E ena mutrnl :i a \ionjunctiv cartilaginos, Pseudoxantomul elastic
    , , , ' ru r"i i ,'in p" r io, t da de c re s te rea n l c n a ta l a . Efe c te l e gonei mutanl c se ' xP ti tnl ,rso,s $i vascular)
    tcsu-
    i,ii,, ,,,.'lifj.^t,, o unor enzinrc q21c 6eqlieneazi org-anizarea5i-mi;ciril'
    irrri l ,rr, ri ,' z ' r r c a I or pe l o c u ri p ro g ra l n a l e g e n e l i c ' [n Iuncl tc.de momen!i ln Tesut c{rrtilagitros Condromat,rza multipl5,
    se vorbeqte de e{ect genic pnmar, Sindromul luaIfucci- Kast
    , ,, ni .,, ,,,lu.h.ir .".,u.1e ittflo"tt-ti u:itlmS.toare Maladia exostozant4
    ', . ( t| r)(l i u s i lc r t iar . Maladia 3llis van Creveld

    PRINEFECTGENICPRIMAR
    1.7.I.1.HISTODISPTAZII
    Tesut osos Maladia Albers Sch6nberg
    tlirtd cfccill unei gene mutante anormale se manifest;' precoce .si ,pcr- Osteogeleza imperfecte
    S pre
    t r rrl 'i r si sllt t t : t t iz ur e; reri b ri o l o g i c i . tra d u s i c l i n i c pl i n di scmbri opl aztt
    , f, ,,i,'f'lt" ,i. .fti*lodisplazii (genopatii moleculale),-care respect[.embriogtneza Tesut v"lscular Angiomatoza Sturge-'h'eber
    i droxi l azi cr' ' c pro-
    t , ,,,r,i i , t l, ' la r c c r s t i. re g u i i o i " c e d e fi c i ru l d .. 2l -betah Maladia IJonnet Blanc-Dechaulnc
    ]f,,.,, i,''f,lJ".niJic cong.n']rati a glandclor supra renale pi ltcrmalrodiiisr n la lhladia Rendu-Osler
    i't,.i ,ri'"1"r',ii"l'i*riii,'.. insot,:c"tlcmodiliciri str-ucturalc, rie
    mor{olosic.'' Sindromul Klippel I'r6larrlray
    , , , ' ,.i , ,r r l t , ' jr ilir r f t r if r' i , c m b ri o n a re (c n d o d e rm u l, i nezodcrmul , ectodFrul ul )' Sindromulllean
    ', *nezoder'
    spre exemplu, gencreazi
    ',,',,, i",,rir<1cn'ului,
    ti,"iiii,,iiiiji, Ilemangiomaloza disenrillotd,
    -a9a-numitele
    ,,,,,-,'f',',,,t,ti^;iiicilsi. t"t,tul',,1ustic dc Ia-t6atc niv'lclc lisular" rlc .nrbL'io-
    ,,l,i,ii ,i"il,,i'iu ii i,iil.,iiiriL,6o.1. Ii1l,.rs-Danlos, cu multiplc rnrrnil'siirti,
    A i ax i r\ l c l augi oc l rrz i { r L()ri i s -l } or'
    ,l,i 1,,ilirrtl"rilr't:ttlntratir pinit lir' artcrillc,
    irnr:vrismc san icslrllll (:ir:tllrrHrnos S i ndr0nrrl l l l c i )l |r
    A i rorni r! l l l l rr$l i r:ar I,{ uLu(,ri

    llrt
    I ll)
    r,r r lctttLrl tlrt'trt} drNithtl stywclural, ctt tlebut t'renaltl. Trr lccsl gtup sint
    (rlrrcxorulrlu,ir()rr(lrorlirli)zir rrrrrllilrlir),{csutul osos (de excmplu, IrriLlrrlia irrrlrrsr.: rr) dislrugeril,e',b) tleform,alii,l,e;
    c) tnalfurma!iilc congelritala.
    r\|lrr.r's-Sclriirrbcr'6i),
    1oslri.ulvrlit:rrlrrr'(tL:
    cxcrnplu,angiomatozaSturge-Wcber). l\rutru cele mai multe cazuri etiolosia este necunoscuti. sau sc rccr.r-
    l),r(:.'r ftrrr'tt:precoce,pot fi interesatetoate cele trei
    ({rn.rrrrrrtilrrti.acfionuiLzir, :r,,,.1,'(' r rcditatc mul t ifactoriali..
    l('ii,' r'nl)rjonare, cu pLodnccrcilrle arromaliicomplexe (polihistodisplazii).
    ,I.7.'I.2. GENICSECUNDAR
    HISTODISPIAZII
    CU EFECT 1.8.1.DISTRUGERITE
    t;(uole mutante anomale care au aclionat in tirnpul embriogenezeisint Siut defecte care apar in urma unor modificb.ri structurale, al r-.trtrci
    r,l)rirr:rii Ja sfirgitul perioadei embdonare. Jesuturile fonnate conlir:Linsi 1,,ir{irIinorganismulfltului, careinilial (in embriogeneza) s-a format nolmirl.
    ,' lrrl, 'lisplazicecare continu;. si se reprodud! sub formd.modificatl, toate ,\ r , .J fr:nomense poate realiza prin douir mecanisme:a) ruptura sau anpui l liir
    li,riir.(i:fc-l genic secundar),anomalia persistindln genornulcek elor patolo- rrrr,i 5tructuli, in general degete,brale, picioare, fiind determinate de blirll
    rlir'r'. ln acestcadru histodisplaziase perpetueazS" postnatal printr-un c1r,:fect rrrrrrriotici: care plutesc tn lichidul amniotic. Cind benzile amniotice int(:r'.
    ,irrrilrr cu cel din genopatia molecularl. Un exemplu este rePrezentti{de 1,,r,'lzir.cu secvenlele normale ale dezvoltlrii embriologice apar malformol;ii.
    ,rirrrllornul Mende in care, intr-un prim stadiu disembrioplazia deterrriinS. | )r' c-remplu, o band5.amniotici poate i4trerupe fusiunea proceselor {acialc ;i
    ,rllrirrisrupir-rtialgi surditate.Celulelealterate sint delicientein fenoloxidaz5., :r;,r,rcdespici.tura buzei sau este modificati. structura cranio-faciald; 6) lnlrc-
    ,,,,'rrt:,rditermini, ca efectgenicsecundar,un bloc metabolicir.rmetabolismul rulxrrca aportului de singe intr-o anumitS. zon5., cond.ucindla in{arctizirrc,
    lir,rzirrci(lzi nivelul tirozinS.-Dopa). ln acestfe1 o histodispiazieinclude prin r(\:r()zir si/sau resorbtia structurilor distale locului afectat- DacL accaslrr
    , 1,,r ,l rrn,laro chimiodisplazi, . rrrlvinc la inceputul sarcinii se constate in momentul nagterii o atrczic sir.rl
    :rl , "n11 1n"i ariumite pirfi. Acest mecanism explici dismdrlologii ca: gasllo .
    '1.7.'t
    ,3. H|STOD|SPIAZII GENICTERIIAR
    CU EFECT .,liisis, atrczia intestila.li, porencefalia. Factorii genetici nu sint implictli irr
    r' ' I til) d'. tlcfcctc srructura,lecu debut prcnatal.
    tirrolc histodisplaziirnanifesti. sporadic o tendirlii neoplazianti. tle-
    t',rrrirrrrli rk: instabilitateacromosomali. Aceastase manifestr-prin rupturi,
    ,lrrrl,rrri fi ].car:lnjamenteintre fragmentele cromosonilor ca in ;rni:t:ria 1.8.2.DEFORMATIItE
    I,rrr,rrrir iri in atarie-telangi.:cl?izle 2, sau prin configuralie cromosot'trlir
    1 ,rrr i i r' r I r iL
    r rL , cluadriraciiaiirreaiizatl prin rcaranjamcntul cromatidclor, c:L in Slnt anomalii structuraledeterminatcin ceamai marc parte priu rttotl,'
    irrrlr,rrrrulllloorls. lrrr,,inlrauterrini.,interesind cu precS.dere sistemul musculo-scheletic. l\{Lrr:rr
    llslabilitatea cromosomali este demonstratb.5i de sensibilitatea,;r'iu- rr rrrrrlilc producerearcla baz6.fie un dezechilibruneuromuscularal litill]rri
    l, l,rl rl.iqrl;rzice din siirdromulBloom gi ancmia Fanconi,Ia o cancerizarcplo- (1,r,ror-iintiinseci),fie exstenla unui spaJiuprca mic in carese dezvoltiLfilrtl,
    v,x:rrliLirr iiiutortl virusuriior oncogenecu ARN ;i ADN (virusul S\-.10). , Lr irrghcsuireaacestuiain uierul matern (factori extrinseci).Indifcrcnt tLr
    lrr rrlrrxirriolangicctirzieexistb"o predrspoziliepentru cancerelede pieie, stlri l',r1,'r{(rnie sc produce o reducerea dez\.olti.di sistemului musculo-scllclritic,
    rr rli'lrrcI inforeticuiare,ca maiadia i{odgkin, sarcor4,leucemie. rrr,rrrifr:statir prin diminuareamigcS"ilorfetale si deformarepozilional[.
    l'r:rrlr-rtcxolicareacimpului larg de actiunepre- si postnatal al gcr,Jlor f )cformi.rile de cauzd intrinsecii. se intilnesc in cazuJ degencrcsccnlt:lot'
    rrrrrl;rrlr:r'xprimate prin histodisplaziis, adnite existella unor defecto ale rrrrr;,:rtlarc, ca distrofiamiotonici-Steinelt,in cazul]eziunilor de neuronilt)otot i
    rrrr,rrp,nlirrni din genom care codiJicf,'concomitent pentru inductori utili in 1,'rrl.r'ici,ca in cazul maladieiWerdnig-I{offmanncu debut precoce,;i in citzrrl
    l,, ri,rrr,lrr rlc cmbriogenezir,pentrn molecule structurante in perioad;rnc.st- l,,,,.r1rrilolcleneuroni motori centrali, prin defectetimpurii in dczvoltarcr sir;-
    rrrri,Ll:r ri purtru r'..oleculercpresivecate regleazl cineticala virsta de adlrlt.',i |, ||tlrlui llrnios ccntral.
    Irrglresuircafirtului in uter pri[ factor'i extrinsecipoate fi colrs{)cilrlrl
    1.8.ENSMORFOI.OGIA rrrlri rruiiriLlnare cle circurnstanteca: a) descrestcrcavolumu,luilichidrrlirr
    rrrrrrrirrlic; 6) sr:irdcrea debitului urinar fr'ta1;c) scurgerictonicede licbi(l arrrrti
    |)isrroifologia reprezintS-un capitol de patologie foarte vast, care cu- .lir'; /) clclomrarc:Lcavititii annioticr prin anornaliide formi a uterullri, (:iril
    l,riLrrlctotalitatca .rnomaiiilorrnorfologicedetennir.ratede factori genetici;il r.rzrrlf<:filormrrliipli, cxistcn{atumoriior utcrine, implantare vicioasirt lilir
    irrr rL' rncciiulnconjurirtor,prezentela nastetesau depistateulterior, care au; c.rrlr'i, ltrorralii alc lxlvisuiui sau a1eorganelor abdominaledo vocilliriirl(:
    cD ?ancitopenie, absenta policclni, tadirs hipop]^zic,
    rr) lrrr'zcnirLliianornr;ric,r:a moclul lesclol care determini.imobilitatcir [ii.ltrlrrr
    ' A|l(!nit! Iranconi sc a"socia,zi intrc corpul fd.tului ;i perctclc utcrin. trl
    l r t " I t , illrr ' r L i l l l i o r n c l a u o U c Z L :L p ie lii, a n o tn a lii r e n a le $ 1sta tu ra nl i ci lirrrr fixrur.rirnctul.rrclr:r'iufcrioare
    : A lltrii!-lcl irrrgic(ilazia trsociar:L rr sindro tclangiectali.: cr1taneomucos, cu i"trxie .rrr',r,1rilrltrzctttrLlic sc irsociaziL rnultiplc deformiiri: gcnu'/ecxtrlatx(,lnirl l{10')1,
    , r 1{ 1' , r ' r ) t l ) r t g r t ' s i v i r , n i str $ n u s. ilo ln :L ' /ii n r a n ifPst:i o snsccl )ti |i l i tai c crcscutar l !" j nl ccl i i rlirr r::rzrrri, ot1.lrluiltrrnLualitr 50o/o,scoliozain 40fo, totii*rlis yt
    rlislor:rLlirr
    r , f , L , iL, r|| , i r l ( . l i r i LD( l l i l l , r ( , lr l:, ( 1 s.4 ) iii 1 r ( .( lir lfi o .lr r la r .
    ii s i l l i l r r r n l l r l l l l . ( J | r sc cr r a cto r i/,l| r lt
    t) ]i' r l.lcl| tn lc 1 l)i rI l i r fc Ia1?i rk vi rsl a i rt:l a- 1rr,i,,r'sllirrlr in 20'1, rllrr c;rzuli,(l:lc rrai frccycnlcdcfomirri protl.ttscrl,'
    ')rfltrl
    (l (,l i ()(r { i (, srrri l ri l i l :r1r' l;rrlrrrii r.xirinsrv:i sirt(pii:iorrrlstrirrrlrr:ottgr:ttilll dr:qolrl,
    ;i lttxil{irLcongr:uiiltliL
    l r(rr, , li'! , lr i t ! , l r , , l i . s i ; , 1 1 1 fo ' tn ,r d cr ' r llI,iir lt. r r r it:il fi itlr ir r r lii, Iri t,l i i
    ,rttrr,r{ii
    l , r f , , , r, lL : r ' l ; , r , , 1 , 1 ; r I s i e , r l r r ziir r r L r llittr r ,,r r ili r lr tr r (il| l I r t l,r r l(' i ri , ri ,1,,,l It'l i . r'!t,{||! r, l r' f{,rto. irr r:irr',', rlcfornrrr{iri
    crr,'x,:r.l4irr frit'ti ('si("ltornlrl.
    ttuir;r:,
    l, L. r, , L iii r l , , f i r r r r r .r r , , r r r lr | r r r ii | ,r | | ' r Ir ,I1IL i r r r r r ( i, L ir liT ir r r l{ , i rrLrrl rrl r rI l ,tl l r'.

    llll
    120
    1.8.3. MAtFORMAJIIIE (morfodisploziile) r(,,rlrr l)ot fi idcntificate tardiv;;i pot r€prczcnta, plirr rczistcrtliLsr:izrtlii,
    ItrlrczirrliL cl:{cctcstlrtri rrlirlt:cu rlcbut prenata},carerecrrnosc multiple ,rrlrrrlrrl pc care se greleazl afecliuni intercurente; alteori, maltorrr.aliilc con
    nr,\'irnisrn(' gcncticc dc protluccrc, dc I a muta!ii1e monogenicepinl la ereditatea ,,r'ri(rril sint depistate indirect, dupl complicafiile gerrerate dc anolnrtliilc
    ,,r1,r',i,r, (dc cximplu, rahitismul ienat qif sau in{c;liile urinarc sccrrn(l,rr(
    1",li1.,nicir si multifl ctoliulir. in {uncfie d.egradul de exprimare, rnalformaliile rrrr,,r,'l,siiuc{ii co;genitale ale tractului urinar); explorarcainsufit:icnlri irr
    1,1 [i najort' (crr anomalii structurale complexe care neccsiti intcrvenlie rr, r t, :ritualii f:rce ca unelemalformalii si rimlnS"multir vremc nccrtllros( (rir'"
    rrr,,r1it:rrliL,chirurgicaliL gi estetici.), m.inore,t disuete (sar neinsemnate), cti-
    r lrclrlr' ca variante anatomice normale. Dup5. cum este cunoscut sau nu
    rr(.r'irnismulde producere;i in functie de posibiJitateade incadrar:ca anomalii- r.8.3.r.FRECVENTA
    tI EPIDEMTOIOGIA
    MAIFORMATIILOR
    l,rr rrrotlologiceinti:-o entitate bine conturatS.,cxistd.mai multe nodalitirli de
    rlr'linirc r m.alformaliilorcongenitale (ve2i3,11.,pag. 1049) Sr: considcrir c:r aproximativ Zo/o din nou-nIsculi au o rnalforntit ltl
    o 5' ,i tt,d y o m rr l, , se referir.la tipul de malformatii in care cxistir o rrrrrj,,ri. l)aci. se includ gi malformalii1econstatatepostneolatal (malfonttr{ii
    r rrrrzi. rnicir 9i specifici, a;a cum sc intimple in mutalia monogenicil. {Jn rcnale, pulmonare1, de coloani.vertebrali) incidenla globalil ;ljulxr'
    ,.\(.url)lu il constituic sindromul Holt Oram, manifestat cu malformatii de cord ' rrrrlirr,rr',
    prrr,r la 5o/o.Malformaliile in{luenleazL mort:{itatea perinatali, :;i inf ,rrrlilri
    r;.i rrlri cxtrcmititilor superioare, produs prin mutalie genctici trarLstnisir prr, lt 20o/(,$i respectiv 250/o,in lirile ln care deceselepdn boli inltrcfirrrrsc
    .r rlosoni dominant.
    ,.r trrll,rrrii.rinutrifionale sint neglijabilc. Frccvenla mal{ormafiilol t:slrr itr '
    - Com'flexwlmodologic sur secaenle delinegteexistenla unei ma1{onnalii ll'l, .','li d,' f,tctorixrcgrd[ici.Astfel, in Ir]andr de Nord artnnccfrrli:L r''l ,
    lrrirrrrrt:,{iirir cauzi. specificL,din care derivi. alte anomalii stmcturale. Eroarea rrtrlrrrl,r(:u,r'{rccvenliL-de'4/I 000, in timp ce in Anglia de Sud-Est :[r(r:\'('tr{rl
    irri[iulir care se produce in stadii]e precoce ale embriogenezeipoate fi o mal- ,,.rrlr.lir l/l 000. Existl ;i in{luenle determinate de rusd. Polidzctilirl rLlc o
    lorrrrir{ir:,o de{ormatie sau o distrugere. Un astfel de complex morfologic se rr( irl(nti tlt: 12,80/nola rasa neagrl.ti de 1,40foo ttttt,t
    Ia rasa alb[. Preclispozi{iiL
    inlil)citc in sindromul Pierre Robin in care hipoplazia mandibulei, ca dc{ect rr,rllorlr llii in luncfie de sex estedemonstratede stenozahipertroficirtlt' pilolr
    lrrirrr:rrrrnic, dctcrrninl ca secven]eulterioare, glcsoptoza cu blocareainchiderii ' ,rt';u(' cu prr:tlilcclie la birieli gi displazia luxantl de gold, la {etc.
    lrollr.i palaline in regiuaea posterioarir si constituirea despiclturii palaiine in
    fir dctt:r'rninareaparticiplrii factorilor genetici qi in inlelcgcrr:a inLlrrr:rr{t'i
    li rrrrrii tlr u. l;rrl,,rilol dc rncdiu care intervin in producereamallbrmaliilor cu o rnutttilli
    o Asocia.lia, iudicid un tablou clinic plurimalformativ in care lr'r r.,rr{ir, rrrr lol important l-au jucat studiilc elcct[atc pa gr]nLuii utotttt
    rrrr s-rrdctcnninat o ctiologie specifici sau o inlf,nluire secvenliali.. Asocialiile
    rrr;rlIirlrnrrtivc apar sporadic in familii normale. Ilustrativir este asociafia
    lrrlilcrorrl tlc cauzacare ]c determin:i,sindroamelemalfounrrlivt' rr'gttr'.
    I rltrt. 'rrl., lJ,'rlrL pai:icn{i,familie ;i societateo povarii afectivit;i cr'otttttttir"r.
    Xn funclie de irnportanla mani{esti.rilor si dc momcntul exprirniLrii lrr ,,,, , rr. Ploblcmadepistirriilor cit rnai precoccgi elaboraret ullci slr',rl(llit
    rrrirlfiutlaliilor se disting mai multc cventualitlti.: ,1, 1,r,rlrilr', pcntru sciderea frecvcl!ei malformatiilor rcprczirrl.ii(t l)r.(()r'rl
    . malforma{ii congenitale maniiestate tn viala emlxiolari., extrem - pliruut ,;Sisl(rrl
    pe plar internalional. ln 1974a luat fiin,tr"r
    1,.'r' 'rr rrrili'striti'r-
    ,1,' 511'1'1,',incompatibile cu viala intrauterini!; acesteatlcterrninir moartca ;i rrrt,'rr.r{iorrrrltlc supr4rrcghere :r malformatiilor depistatc la nr;lctc" ", r'rtr'
    :rror(rrrcucmbrionului (sau a {irtului); rrl,r lLrrualpestedoui milioancdc nagteri.Priu acestsislctttr.rtrl
    ",11lrt.rz,ri
    .1,,',1'ril crrlrrctcre mirlformalii in [unc!it:clczonil gr.o-
    ' rnal{ormatii congenitale compatibile cE viala intrauterini, clar care ,,epidcmice'xlL.ur.Ior
    irrrpirrlir:iradaptarca {ltului la viala cxtrauterini, producind rnoartea in peri- r,,tr' (lrr.rvcrrlrLcrcscuti a apla"zieidc fcrnur intr-o regiunc dill l,'rrtt{rr) rlr
    orrrlr pcrinatalS.; se consideri cn 20 din caz-urile de dect's din al trcilea llrtr, rlrrrtrl rLniicpileptice (acidulvalproic) gi de{ectele <lcirtcltitlcr,irlr,sir
    trirr.sinr rlc sarcinir;i 15)'" din deccscle -0,/operioadeineonatalesint determinate i,r fil rr ||r'r'\'osftntral. A1 doilca sistemde supravcgherea. anomi iilol' (io|lll|
    , lr. rrrulionnaliile severe; rrrl,,l r lrrsi cli:at in 1978 dc cltrc Comunitatca licononicir Jitrrrlrcirtti, r'tt
    rnallormaliile congcnitalc compatibile cu viata, dar care sint inva- i r llrrrrr'lkrs(Eurocat).Accst sistemurmlr'clte prin mctodologicttrrili
    , ',lrrrl
    r1.,. , r rrrrirr dr:pcsle 160000 dc na,,stcri pe an, clin punct dc t,ctl.'tr'rtl lr',r
    lilatrlc (s,ttiu,abifida., desplcdttra palatului, luxalia congcnitalir de qold etc.);
    r, rrt,r rrrrrrrrrrIiiIrr:rnalformaLive, aI ctiologiei(cariot\r 5i auorn ii bior:Itittti,r')
    . malfonnalii congenitale care permit vietuirea pe tennene variabile
    rrl',"lrrlici (rrr,rniii.si,rripL't(rrncnhrng$icficacit;rlcamisurilor toriLpcttlirr',
    rlr, linrp, in lunclie dc importanta organului atins in economia organisrr'.ului
    s, 3, a; t'r, ', rlr\, :,i , urirliv,'),'Irrtr,' t978.- 1981 Butoclt ir constillrii o l,rttiri rl,
    lrrrilrLrlii rrrngt:nilaledc cord malforma{ii rcnalc digestilc unel, din
    r As o f i ' \' 1r i , ' l l . ( L t , i i (' l j rl l l , , l i L , j : L l ra rl l rrl rri | rs l ri rl l o t '
    l i : r , I i r l . ? ' ( ' n l) r in d . d cl{ r c1 { : r ( ti\ir r d c, a tr czic anal i r, {j stdi ou .)l tezi c i rahco- \, /r / , ' l 1 , l l , r{ i , l rl , : . 5 . -l . I ' i . u . ' 1 1 7 ' 1 4 . 1 .
    , , , l, rrii, nii , L i t , o l t r z i ( i ( l c r :r d iu s $ i r ! ,) IIr a lij ( lr la ]c ( vczi ? o g . 1062)
    j l r l ,,Ll | rr , r | (L . r| L I i I I | r, )1 | r(. l , , r l l i f l l r l )r' l (! : { rt Mo l l i l , ' f i u rl : i \ , L , l rL r, I rrl rj l , r l r): r' l ,r ,
    V ( 2 i 3 . : i . 1 r r r , l 5 57 - 5 !) 0 , / rl r, , rr, i
    1,,,.r , L r, I i , L l i i l , L f 1 l | r. , t f i i t l f l | I i l l x i rr: rr1 , ' t x rr(I r l l | l I , , u | l rl i i I r, , r' , 1 , , l ri i l r
    rL Vc z i v o l , l 1 l , , , r 1 r i l . 1 .5 ., p :\lt. l,a ft l5 5 ,.a p il. 1 .6 ., t)n'i . 156. 20'j 1, ," r l | ' l , , l r. , 1 , f r; r l , i l i rl rr, l rl , l , , , l rrl , . I ; rrrl i r | l : r" l ; rt j rri , l rrl , l i rl , rrl , i rl r z r r' 1 . 1 , 1 1 ' r
    . ' v .7 i / ( ' t . ',,
    , i l : r L 1 ,ir .2 .1 ,l) ir u . ,J( ) ii .ts0 ; ,l1 s 4 2 0 ; t2ti ; 4: ; .t.i :r,4.t'/. 44/. 15t,459, , l r ,. | . 1 r, , / r. r r, rrl i rl ri , rL l l " r, r 1il .i , . . . 1 r, rrL L 1 l , r, l L r 1LIli,l'i'l
    ' t i r, l rr.
    'I t , . l, (ll ( n 1 5 . l , " l l ( r 1 , 1

    I lr:: I :i i l
    (lirl (' ( rrl l illz iu( l lt o36 < | ' ;rtx rttrtl i i c o ttg c rti ta l ei n rcgi strate l a rtti tttttttri t i l -' uDtri orgln nLl so urlri Producc(lgcn..zic). DacL indu,lorttl csic iusLJiciottt,
    , l()5 ? l l u ait t or i. J ir l: v ttt{ rr tttrrl fo trtrrrl i i l o r c o n s t atate este menl i ol rati i o op"tottolui cs{.i:incomplet,i,organul estc schilat prirliai (hipoplezic)'
    "*p."ii,i
    Iixc,'srilirriluctoruiuidct*rmini o ltipcrplczie.
    ir rl ,r'l rtl L l7.
    Mrrtatiilesenelicesjmple pot-fi-transmisedupi moduJtecesiv(rrncl'
    -l abelul 1 17 rlicr,rcl frrlii), du"pi rnodul dornin;nt (focomelia) sau lcgat de sex (unele {ormrr
    c1chidrocefalie).
    lll\l1lh'!i:r rn:rllornraliilor colrgenilttle depislate dc ,,llurocat" ln prrioadd llr?$-1$Bl \n mattatriaplaiotropd sint implicali opeioni-inductori care controlcazir
    ,intcza nrotnicl ii embiioe"nezamai multor organe ;i lesutut'i Cons.'r'inl:r
    \L'llr)r rtL.!1ii intcresind extrenit:1ile 2 253
    l!ll,illtr.llii ale siste llui cardiovascular | 1t6 rrrutaliilor genelorpleiotropi sint polidisplazilleca: sindromuloro-facio-dir:ilal,
    I'l;rl k, rnr:llii ,rie sistemului nervos oentral r 28r rindromul" Wr ard'enburg-klein (manitn-tat prin iriperrelorism megi ;rll-'i
    l,lirl torrnalii musculo-scheletice 1105 frontall, surditate), sindromul Holt-Oram (manifestat prin hipoplazta Pou-
    NlirlL(,rur:ilii ale aparatului digestiv 689 cclui.aplazi, radrale,cardiopa l ie corrgenit
    aii).
    Ali r r l i l c r o m o s o m a l e 65{ aulosornalrncesiv autosomal
    1\,1'utatiil.genetice Dlciotropc sttrxnsjnil
    l,r Lri1{i ?al:Ltine ti labiale
    N1[1tu) na1ii crtarate s57 ,lominant sau legat de sex.
    lllrlformalii ale organelo. uogenitale intehe i59 II. Maltorfralii congenitnleprin alera(ii cl'omosomalo.Celc mai {tlc-
    ,\floruaLii nretabolice 194 vcltte mal{ormatii de natulir cromosomali se produc prin defect de seplrtaLrr
    rr 1r'rcchilorde autosomi.inrimpul mutiplicirii cclulare:lrisawiile (21' 7t'
    '1.8.3.2. CONGENITATE
    MALFORMATIItOR
    ETIOLOGIA ti t si uouosomiile(sindrcmul 'l uvner,sau XOr. Absenla rrnur lugnrcnt d(r
    crornosom .3u delclia.sc insotFsiette reguli de mallorma{ii(sindrorrrul 5 P-,
    Trrrncdicina umani, ancheta epidemiologici reprezinti principala metodA .1 p -,). Schimbul' de materiai gcnetii intle cromosomi, sau rccombiniililt:
    1x rrIlrr idcntificarea.factorilor etiologici gi a riscurilor asociate.Anomaliile con- (trossinp-oacr detetminao impirlirc ittcgali:r tn;t-
    0/60)estenecesarlurrnirrirea ), in tirupul meiozei-poate
    11r'rrilllcliirrclfcnomenerelativ rar intilniie (1,73 t' rirlulu"igencric.Cnl'prrlino parle din glmcti.au o anotnaiiccromo'')rrrtci
    ,.5:rrrliorLnclor mad pentru a ajunge la cifri statisiice acceptabile.Intr-un "nmbrionului, manifcsiald uncori pi in .rnaliorrnalii.
    lrrrrsrnj..-r
    rlurlirr r'lcctrL:rtde Holmes (1978)pe 30 681 nou-n[scu]i s-au men]ionat 81O
    (1,{,'/e) frrirlforrnalii majore din care 57o/oprtn anomalii genetice; 160/" dir, Aproximativ Z\ofo d\\ anomaliile cromosomale deterrninl avottttl
    lrrlrrlrrlrrtlrlfonnatiilor au avut drept cauzl factori teratogenisau de mediu. snotrlanin nrimelc3 - 6 saplamini de sarcina.Ele sint prezent'Ja naqtct':itr
    d':5/., rr
    \r :tll 75(t/e<lin'cazuri nu a fost'posibill detenninarea itiologiei precisc a. Iir.l'or{ic cle loo. Prin depistiri ul{erioarese ajungclr o proporti'
    i r:rl[c,rmatiilor Cong.nit aJc pri n cromosomopai ii'
    tocmai datoritl rnultitudinii de factoli ce pot actiona con-
    rrrirllolrrrrLfiilor,
    r orrilcrrt in producerealor. lntr-un studiu statistic efectuat pe 520 de avorturi spontaDr:,A' Jlorr(:
    Nurncroascle c tTze care pot deierrnina malformaliile congcnitale se (1978):r constatat prezen{a abera{iiloi- cromosomalcla 51,3}o de avotltrti
    in .factori ertdogeni {de na.tur[ geneticir) ;i factot'i r-ioged (de mediu
    rrlx'irz.iL (lrlrrlul J.18).
    11r
    irrllrrricr-in.,side nediu extern).
    I'abclul 1 13

    1.8.3,2.1.Corlze endogene r\|)erntii cromosomalc o]seriste ln 5r0 avortu]i s]]o lartc (A Eon6, l!17'!)

    l. ,llalfolnnalii corugenitaleprin rnrltalii gcnctiee. I?rin definilie o gcno-' 11,,f,,si -'mi c i 45, X O) 4 1 r :l ur r r i ( l i ,.f i l )
    lir. rr.rilonnanur esleo anomalieconstitulionall legati de rrrutaliaunei gene L,,r,rri c (C , D , E $i i tl s pc c i d (l ) 146 (;rrnri i :i l,lLil )
    l).r s c^ z'i ]i ( .) 'l i)
    | ) tLl nf tri sol ni i
    irr.r'r.srrlitr.mbriogenczei. Gena mutanti este sursa unei morfodisplazii care' a l ca zu r i ( l ( ) ,l ') 1 ,)
    l r Inoi (l i e (3 x 23 c romos orrri )
    irlr.r:lcrrziLcortfiguia{ia exterioar5"a individului sau numdlul, forma ori structtra 1, i fl l toi di e (4 X 23 c ronl os onri J 1 l co .r r i ( 1 ,l '1 ,)
    urliir siurmai multor organeinternt- (T. li. Robert, J. L. Laurant). Lri Lnsl ocati i , i nc l e, noz ai c uri 10 cazrrri(3,?91,)
    (ioropzLtiilemaHoinante r"prezittiL aproximativ 2% .lin maiformatiile
    r-' ' tidl anoul al i i c i togrl rr ti c c : 267 dc c i )z i i ri
    ((,tlAclliii c. lllc se transmit drpi modelul mendelian ceeace ar presupune
    .ri|rn|a unui dclicit enzimatic molccular, neprobat lnsd, cu exceplia-sin-
    ,lrorrrrrhriadrcr.rogenital in care se recunoalte deficitul de 2l-hidroxilazl. LIL Jllallormalii congelritale dcterminate do erodiiatrea poligc,lli(ir'i fl
    lrr rrrrr,lr: rrrlfolnralii se corstati o instabilitate a ADN, ca in progeiie,. rrIrrIIiluetori:lli. Maliormalii]c pot fi produse.de altcrarea.strttr:tulalli rt tttrti
    r,irrrIrrruruI liirLrconi,sindromul Bloom (Polani, 1979). ,rrrrfl,rlAcnc (rrrdilalr 1,ali gett i cii) I a carescadaugirfaclori din m'1iir11 n1rllr:'rrrl
    i\{uLaJiageneticl poa.tcIi simpll sau pkiotropl.. ,,rr,.rl,ilsiu ititt:tvi:tirin dotcrrninismul c i.
    ntbriogett,:zcIn actst trttl' 'ttltit
    ln nrutul'ia gcnetiiti sinltrri se produce o disfunclie a cupJului operon- Ir.ill,'rt|r:rt ii(:ir(l, s])ieitllriL
    lrllio-prlatirrit,Irrxaliacongcrtit;rlit tl{. i'.'ltl, 'rriltrr
    irrrlrrr:iol t:lrrircoutlolcazi, IoLtuirtca unui singur organ sau !rtsrrt,Absctlla l,il'i,lir, atrcucct{alia., slt:rtttzir hipcrtroficii tlt' pil<-,r, uD( [c Inalt(xlr]il11.l (l(j ( ol(l'
    irttluc:(rlr faccca opc romtl(cotnpJtrlrll tLrcisironi ctiololliii irnpiediciL
    frrctorilor.
    l'lrrliriilrrit:a pirsibililttcl cdculiLriiligLttorrsc rr
    rrrtLti llrn(cicrLlcmlxiogttnczci (i:L(lllolllilliilil('lr('litrll
    i.;nrll('nc(lr.s1r'llclll';i t;ttfttnt;{icrrglirloirtr')slL[irrreptcsrrl1i ct ttttttittcsr:ltita t<:cs1ornil|lfor.nt
    rrr0rrlrrirr,r:rrrr.nlr:i lr1ii. Sir r:onsirL.r'ir

    l114
    rliubc:ltrl zaharat (vlzi 2.11.8.2,pag. 357;i 3.17, pag. 100.1) tisl.arcad(:l)r('-
    ttttcitralfounali i determinati.rnultilactorial
    sir ittltrvirri.ir irl,rrri{irr
    r'.rt)irl'ili. tlirrlrcl la fcmeia gravidi" cresc dc doui ori riscul malfor.ruatiiior, fiind favoli-
    , .t, rlistlilrrriti l,r,zurnplit irrlr o lropulalicdup5.o curbd.GaussobiSnuitl.
    () rnirurtitatcilr. iutjivizi atr r:orrtl,irlLtiigcnicc cipabile si favorizezeriralfor- z:rl,' :uronaliile de sacru p.indromul de regresiecaudali ia f5.t. Unclc lul-
    l 'r rirli horlrlonalc maternc, in specialtiroidiene predispun la malforma{;ii.
    rrrirlirr.Accslccourbina[ii!]oli(:( sirrt nrri {recvcntcla rudcle de Sradul I ;i in
    .l)) Facl.ati y'zicz. Radialiile ioniozante reprezinti un pericol pcnl rrr
    jai sl Ia om. Sc rprociazJci 2oodin mal{or.maJiil,.
    ' rrrl,rion, vcrificri crporimen
    1 ^
    'f<_ rrdq , orrgonitalcsint produsede radialiile ionizan[c. Efecreie teiratogenesc mani,
    li'sii_in. spc,cial asupra sisternului ncn'os centml. in timpul investigafiilor
    i lirlio)ogice dozele de iradiere se inscriu in limite foarte largi, de 1a 10 1; 5 000
    r[r rr':ilirazi(1 rad:1 r: 1 000 milirazi). Efcctclc teratogeneaparla dozemai
    rrrrri dc 25 r, {apt observatin timpul bombardamentuluiatomic de ln Hiro.
    f,opu/alr-a slrirna,unde au det€rminat avorturi la 28ld din femeile gravide Ei malformafii
    fP,m/n/nd !_l\ Budc natca/ine .,r.vcrcalc sistemului nervos central (miirbcefalie, aneniefalie) 'qi a1c ochilor
    r--i\- a/a leneilorafec/ala l:t 25o/o clin dsculii vii.
    ft,pu/ay'a
    marcu/ni i:-:\ c) F actori ch,imici.(xetobioiice). Un numi.r important dc substarrfc rL.
    rrrrl.rrrir. chimicl, administrate sub form:| medicamentoasi.,sint implicatc irr
    ii(,r(.zir unor mal{ornalii congcnitale cxperimcntale. La om, dovadi r.ft'clclor
    I llll ogcnea fost ficute rctrospectiv plin ancheteepidemiologicccare arr pt.r.rnis
    (1,n.l;rlrr.a ci factorjj r"himicitransmi5i pe cirle pla.^ntari acoperi .1,y',rlirr
    ,.rrz.(l'. tnirlformaliilorcongeniralc(C. lambotr,', 1973). Prinilc cci,l l,li
    rrrx'ivc pcntru cmbriopatia malforrnativS"la orn se inscriu:
    o 'f alidomida (calmant si scdativ). A probat efectul tcratogr:n irr
    p,:r'ioada1958- 1961,cird in C'crmanias-au niscut pcsic 2 000 de cdpii urr
    ,rrorrriLliidc rnembre (ame1ie,focomelie) gi alte malformalii. Gradul dc sc,vcr.i
    lllc ir fost cu atlt mai mare cu cit medicamentula lost luat mai precocc(illlr,.
    ,l zirrr rr 2.5-a;i a 30-a de gravirlitate) (ve2i3.11, pag. 1063).
    i
    o/n
    r o Antimitoticelt. Au actiune malformartl" certi, prin t'feci:ul rlc irr
    lrilr,rrr:r rnuitiplicirii cclulare.
    o Deriaa!ii de t'rogesteron,. administrafi la inceputul sarcinii (inir',.
    fcmet birla.lt
    ,' l'.rli a160-azi c1cgraviditate)pot viriliza {itul feminin,cu ta'bloudcPsi:rrrl,r
    /ir1. 1.1i. ' lr rrx:r'cnla maltol matiilor determia,rte ]nu1li1actorial. Ple|and,e/etuld I raliei, cotNgeki-
    t,tlt tt, \,,11 lt scxul feminin.. (ll. Czcizel, 197?). Lu:rafia congenitale de sold arc o Jrecvente
    lrr rrrirIroditism.
    r'r,i rir/rlr'r li! l)ij.icti (lecit }a tete. (Prag!1 cle isc este mai inclcplrtat (le medje lntr-o popu- c liolicu.lina, administlatS. femeii gravidc determinir o prcdispozi{i,.
    lrlLi ,lrlri). Lfrccvclrla, bolii crette i1l grupud restdnse, legatc dc apa,ritia unui caz. Distributia 1r, rrIlrr :trlcnocarcinom vaginalIa fete, mani{estattardiv, inporioatl;rpuil:rtirrir.
    ,,. , I 'irlilil. L l i i ( s l c v i u i a b i l a in lu n clie d e g r a d u l d e flld e n ie, fi i nd mai puterni cb. l a ftdel e o Mdlormatiile sint mai frecventela gravidelc carc arL lolosit lrarrr.lr
    '
    .r' I ri' , 1' I l . l D r r . , s u l , F o fiu la iic se p o a te d e ci' co r lsta ta o creqtere a nr1meru1B ide bol na.ri
    ,r r;rlr,ri i r r)(f sc ol)scrvi la po?uiatia generali,. Dace alecliunea apare 1a sexul care in mod
    /t.trtt.lt,..(bcnzoazepincgi carbanati), arnJetaninii si as,firind, la incr.lrrrtrrl
    'r ,| | ( l l l l l .
    ,,,riirlrilr (!slr: luri prlin a{cd.!t risc rcctrenle a anonaiiei rospectiTe esle mai mare,
    -i:]e t .ll.reptctmicinaSl cltini,na actioncazl pe nervul acustic ir.rduciudsrrlli
    lrrlr'llLfrit.
    r,rrlirr. rl'scrcscindr-r.ia rnclelc de gradu12 qi 3 ale bolnavului; in raport cu N nmcroasealte medicamcntc au fost incriminate in producereaun(n'll'IrI .
    rrciirLlcrvariabilia pragului de sensibilitatc1a agenlii malformanti (fig. 1.41). lrrrrrrrr{ii,raportatc ireultimii ani. Se atribuie tetracicl,inelor
    anomaliilesrniLllrr
    ( ll' ;(.rvir.fo:r.
    accstor forrnc dc fralforrnalii pe mai multe generalii permit calcu- ltti rlctttar; ni/,&min&D, in dozc excesiveadministrateintramuscularfclrr,'ii
    l,rr,'rrrrnrrilisr: cmpiric ai rcculenlci, de 3-60/o. Clnd 1n aceea5i{amilie existi.
    ,l,ri colrii rl i!r:!:oir;i /llirvi{lr gcrlcrcaz!.stenozS. aorticl la {it. lrnl,froatul tle sod,iru(anticpiltlrtir.)
    1nnl{ortratic,riscul crestela 10](. rr rh,lrlminrt o rati crcscuti ahipoplazicigi aplazicifemurului {irtului. Iixjrr,ri
    ntcultl, r:rtrl,itnizit,procluc despicirturir palatini- la qoarccc. lJnclc sullslirl)1,.
    Couzeexogene
    1.8.3.2.2. (ilroolul l, ltil.untoina.,hcroina) talosite de femr:iagravidiLsint incrinrjrratrrirr
    lrrrxlttrlrrl lulllrrirdl.r ($nportamortirl c alo mpilullti (lttt,ulogtttitomlullt
    Iirr nrrniu tl,lirliv lnirro dl t:rLllornralii se datorcazl actitlnii tcratogcnc turttrl.i.) (lig. 1.42 A, )t, ('.\.
    r l rrr'l o rilor r L, r r r c r l. iLtt:i , rrc l ro l l i i rn p i L r' fi fii n rn a i mul .tc gru.pt::
    rt\ Iitclori. urn.h'nti, liiind itt lclrt(ic d.c sch i:trlrtrri 1)olll)illl('nf('t:Lttrrcdirtl. t l i rrrl rri rr l tr.l i ;r.rl (rool i c i \ ' l rni l rrr:rrri tr,s l arr (l i $r)orl i ,.i rrni (, hri j rl :r ,l (.r,:L(l r' (l i I..r' 1,
    , . rrryl rrirr l rrl c s ttl r' t' i s ttl r i r:ti ttn ,rl t.ttrto t rncl al xrl i fi nul , rtl i ctrcftri :
    rrr r r ir . r ' r r , lilr tpi
    l 'rl nrl Jtj l r,l l l l ||r rl ' r,rrl (.fIl i , l Il l , rl i ri ,1,. i rl l l x )r i l l tl l 1.
    r rrrl l i rl rrl r lir " , r lr c r ir r lr ' , i1
    i rr.rrrttP to rl tt' ;i ttl tc t' i o rrrl rtc trl rri ol l l ttcel i . S t' rttttrrt$l c t:l t

    I t,;
    l,ti
    l i ,rl rrl r' l r ir r iot cr aiog'u ll unol slr l) sLar ) t cincclr r : siL lic cut t oscLt l it t
    lr rrrii ,rrriplirr lolosirL:asistcrrului i):rncilor derdate care centralizcazi" rtlx)ur-
    l, lrrlrlit rrlc irr l itcratui':r t1t'sp(,cr ilr1iiat e desptc rneclicamcntcic adrnilisltltir'
    r ,1,l,r. [.rr :rcr:asta se arlaugir str.Ltlittl ntetabolisnuthtd stabst tNalor ch'int.i(t
    t) ,rt tlt \)t'att.t!.ist)Lul u|lldir (xL:l1obiolicclc)in rcialia organism niltcril-l:i i
    (,)r)r.lirlirl irslfcl, ci"r pc lingir rr.eiabolizarea medicancntelor in corPlrl
    ,1,i, ,,risiiL rurclc ,>r-occsrmetabolice carc sc petrcc in {icatul fiLtttltti.
    L,rr((l ( (:l rinlic( . induc il acest c cazlr r i sint cza ulor enzim e hcpa. t ict ' <1, '
    i r ilr)cr1)11rI)450 rnolooxidaza, capabile sl tlegradeze xenobioticr:lc itr
    ,, lrrrrir'rr r,frr;t loxic si tclatogen. S-a deceiat o reactie de N-dialliilarc rr
    , ,' .
    ' r, ' 1rt , r i rrLi ;i rr tliazeparrruiui'1a fr"Ltuluma11ln timpul trimestmlui al clojlr';'
    ,l ., rirril, (l('vansind lirogrtrmalea ontcsereticir a accstui tip dc rcaclic- Sr'
    ,, ,l,,rii r';i ft:nonr'lu1 de ir.rtlucfieenzimaticir ia fi.t prin substanlc chirrrir',
    '
    ,1,I rrrlr.rlr.gr.rrotip, r:xirlicincldrfcrcntelc ilc risc tentogc-n a1c nnui mcdicrt
    l |r | ( l i tl -

    I;tLkvi bioLoeici (*:u!i itfctlio;i ). Se aprcciazir cir aproximaiiv il''|,


    'l)
    ,1, rrrrllirlrnrrliilc rxrugenitaic sc dator-eazi in{ccliilor intrauterinc. Iirt lol
    t, ,,r'il itrrlrollarrt il ocupiLr-irusudle. Yirusul cale dett-.rminl boala'incltt::iilot
    ':t ',tt,t:ttlitt lrorrtc di:terurinir microce{alic qi intirzicre mintalra. Ilttltaolu,
    , ',rrrr, lrrlii la inccputul sarcinii reprezinti irl lisc de 20- l00ji pcnl lrr
    t,r.,l i r(r,r' i ' i rrrrrr 1lolm : r liilor , in f unc. f ie d. e per ioada de gest a! ie. I n t ilt ll) t r l
    , r, I i,r1;r'rrlzt,ivinrsul rubeolic produce nalformalii cardiacc, ocularc (ctiit
    , ) .,.irr.r'r'rrrsc (surditate, debilitate nintali). Riscul scade dupi. primit lrt ir
    ,1, .rrr irrii, o irrlir:(ic cn virus mbcolic dupi primui trimestlu dc vialiL intlrt-
    rIr, Iirr,I Il rirI( rL:fcrrninll tulbuliiri hcpaticc ti osoitsc.
    I t)\ol)ltts to"t,t,cl:tcrmin;rtir de palazitul c:ristent iu carnca dc lrut(l lillll
    'l r, r,.r' .1l it ..ii ir r , l, i' cr iil, t l, pi: ici, s( poat , m ani{r 'sli lcr iLr o"j,t t r t r llr ) r Li
    r,,
    trrrr,rl ;ri, . ', *ar , ir iii( plint r eicr eaplacir r - t ar it apar azit ulr r i) dciclr t r it r ir t r I
    l, l, t,,rtr rrrrrlliurrltliuc (mii-roce{a1ie,mairoce{alie, rciinitii pigliort:LliL, <:ttlr'i
    ri ' , rrrl r,ri ' ruri (. lr r ', cpilcpsic, r et ar dpsihom oior ) . l'r ecvcnt , boala c'st t asit r t lr -
    t ,, rl rr ,r l ,r l r.rr r cirtrr.avi<iii.

    I,8,3,3,PATOGENIAMATFORMATIIIOR

    I r,r,,.1, , rr l( , ! ( 'lt si/ : r t r r t . xogr : ncdct cr t r inir pcr t ur b[ r 'i int t Lut ct it r r ' lr r
    l rrl , l ri l r' i , t lr lr I ii, n, ui.r nu, lif i' ir r , l ! lllbr iog( n. zir pr iD r uei m t t ll, nt , Lr r t t ist t t ,
    url r
    llolotrl rfr, r.mlrio!rclezir: !r) Aguezit:: rrbserrtlr turri oryan siru ittl.
    l'ltt ,l, ot'i.lrnr' (tL' i'-tcnrpirr ano{talmie, aliazic r'('ntla{); b) 1)ii.s';'i'lr'lir':
    r, r rl ,, l r)rrrrr'( ' r r or jt r nol{r r ( r 1, rcxc[ r p] n llr icr ocef alic) .
    Ili1x'r'llolirr ttrrti sr:hite o tbliotrrr't: tl Gi gantiswt: y'arft:ah';b) l)r'r'ivrLli
    ,tt ,,trrtrn,r' ,ui ( r lr , r 'r r . t t r 1>lu: spliLr iL,r init lii sllpt ir uLr t r r cr ar i,polida( ] t ili( ') ,
    ( rrft.str'llr ttlot sthi{u rrrtbtiorrirlt: a) Absi'nflL<urlcst:clfci uttor s<:lri!,
    , ' , rr,,r,l . r' rrlr , ir r r nor l lolnlir l s( r r r t r csc( dc cxt lnplu: I isur i llibilr lc; i pir . lr r
    I t1 1. 1. 1 J t n l r . i t , f a l i a a l r Do licd . t\. ( ;r a clu l J: L a ia l c1 eg a ;; si aturtr l nai ri .I; sul )porde_ rrr l ,, :,l ,i ri r l ri lir lr ) : lr ) ( ir r lcs<: i, t t ! irt r lor 'PiLr 'I icr r t r 'it r nr or i t t ot 't t r r l sl sr 'pr r t 'r i
    r l' . . r, ( , l i " l i c . j ] . ( i r a d r l Il: r x,td l ( 1 ( . I r n ; h il) cr te to lj sm; epi cani U ri j rr'r.rti i ci na
    '. ,( ( . ( ;r a r lu i
    ri asul rri (' 1 , r,.rrrl ,l rr;r'ir lr , pir r , r 'iliclr iLr l in pol<. or vir ) .
    rrl! r! irllri sclrl, pllfat; r l,!:r ' r ) sl( ,si{ . Ilr : a ) f,l i u pol |t,ro rrr (.rr:fj sl i cc {1r
    ' r i l s
    ttl ,, r' , rrt t lt ri o t , o l i r : ; 1 , ) r ! , t t i l ( lf i) silt) liir r ir ij n r io r \,( r o lr li( .j r ri !r'ol tnl rri ci rrr,., rrL; r{(ti hci rl a llrxlitit,it'i ltt tttirytr-trift^ pt-trlilol' ornbriotrlr{.: ./) li( l{)l)ii (rlc lrr:tttpltt :
    ,,ls l i it| t0 ( tlr iir . r,,rl ri rl i ,.,l l rrsr iI ir 11; r r r 11ii)
    l) ;lr r lr r r liili r lc r r r ir r {i, . ( r l,r , r icr r r |lr r : silu: it it r ut $u. s) .
    ' rr
    I :l i r I : i1|
    ' l l t l , l rt l I I
    It.r'sislolllr iult r nt ir lt r \ l r ' r r , l r r r ilor . ent lr r i o l t r r e i : z.r) P tt si sll t rl , r tl c i ,,.i ' i rr
    ' ' trtIrltorrIIlr' (rIr, r.-rr . r r r llr r : , lr r . . l, , lr r r r lhial1, , t lir - t . i t i c u l Il eckel ); ,) l \' r-si :i , i r1r i. l9l.\j
    I'r r i r. l r. rl , i , , r' -t : . : r' r , r rI r, ' r t i t l t , t rr. l l l i -l . i t t rl )( l t
    rrrr0r rlisll0zilii.iurrr.l ol] r ir . r , 1. | | | | rI.i ( )I rII I.() ( dr : c x c r n P l u : rrperfor:rlia aDaliL, rr.';-
    I.l(' lttit o {)lDUDio ilrii ir r lI r . r r 1I i; t I r , ) .
    r ' a ur ir i r nar r ' P a rl r' rr n rL l l i rr.n rrrti i l o rc o u grni tal Lrsc consti i rri ci n pr.i rLcl e
    r .l rrri. (; r lr rr . ic t ji int r a rrtc ri n c (trrl x .l r 1 .1 9 t. l l al { ,,r' r1l A 1i r

    hciridcl.-o poslclioarir
    1.9.ANOMALIITE
    GENETICE
    iN BOtItE a tuLd:lli errai - 2i i z i l c
    CARDIOVASCUTARE -- lnchidere artcr:ioari
    a tublrlui erral - 26 n1< :

    Ilirlliluratiilc cardi:rcr ocul.,ii un loc irnport.urt in p.Ltologia cop.itrulLri" lil|rriii 1:rLriali" - luchiclc".e a buzelor - i0 zilc
    t rI isl ir:il . r''a.i :'r'irtind cir aproxi,r xt i\- b"/ JiLit.c copii eu'o anorialic clicnrr-t1i Lranl:i lahii1lal:l - l'uzilrnca lroccqrb.
    " j l ,.. r , lir . . : . o,, - 3-9 s
    rr lr : . oc i a z ii n -2 5 0 o ,l i n c a z u ri ii u rl r^ rni l [or.n,:rrj i U . pr,]pnrr' I.
    l{)"l,.,iin malJormarijlc,'rr.diace si alcc}iunitc vascularc siut coniiiit,rate (llj.raj a1 tanluhri - 3{ ) Zi l .
    - .. .\!r' c z i c d. .s ()i ag
    'l , l ,r, t , r r i ; , . n, . lic i , a n o rrr:,l i ic r,rrr1 9 5 s 6 1 1*,.i n rrrrrr' i i gcn.ri cn), r,.strrl ,,,.:.,.1n {rsolago'traheal
    ''rr,'1 , , ; i, , ' , r r J t if ; r c i o ri a l :..l l o ,l a l j i rro a d e l rl n s mi tnr,. ,.sI,. I,i nc r.l uro5cl l ,. !r -\l rez i c rc c i al i .u - LliiYaj il cloaca Pritniri\':.
    rr( l( (rr{itirti_ c1i'icc (<1c crenip}u cartliopatiir- cli. sidr-o'r'l pertN lor area rcctullu
    }Iada.n si iiin. li siutsrlui 11t(8cn'tai
    ''irrrlrrrrrrrl lihlcrs-l)anlos c;rlc ie transuii autosomal dominant) tiar ri,rninc
    ll.1lrolal-ic i r1test i r i:11:L - ltotalie rorlnalt
    irrci oI rsr:ulr-L in ntulte car:diopalii malfor-rnative. ,roflpk'tii _ l0
    iu lraLologilr nmirnl sc culosc pcste .50 cie boli ercditarc cirrtliovasr.it ar e
    l l.rrnspozilia -.,oselor' - lrcLidcfea aalccvrt: a
    'l l l r'l lr lt llill. , l' r ' t \ t t ll t.tl O l i C
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    l ( !: . i frrc hi !1t1i .o ru11
    .
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    \l :ri
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    L )o \rn. :Jl t l nuti tl i { . g(.n,.1i ,..,, I
    .irr,lrr,rrrrrllr_rrrIrr{rtsr) 1xc
    l).rrtc tri:n anontalii }nulti,s.t.sl,cmice, iL carc rL,ii:r-_ lnchidclc a salltnri
    ttttD.Lt . ir( . , r - r lr J c rric l )r,z ru ri ' ) p i u tc a ta b l o u l u i cl i ni c, ccl mai frccY cnt ,rfcc- - 1f s i i l ,l ri nr I
    i rrri .l t r ' , r r , lT . L.upa: i r, i ' c a rl r.l .' o r b o l i rtre di tarc gcncral i zatc al c tcsrri ;i i ri { fiptol]lidi. Co1)orirc a testif riclor
    , orrirrrrtiir:, crr ittcrcs:rrca fic lr elcmcntclor filrroasc (-elastina,col]SCnul) , .
    .l
    ,llrrrlrrlclrrL ncfibroasc lnrucopolizairar-ic1c, subst:r.nti furrrlarircnta'ii). '' ?i t\
    ,\plnzif rl e r: rL l i n . Ioi-mare e osutri t:l'li:rl
    I,)r'ollct:r', r:olitgr:nll, astin:r { i s ,rt,'
    .i1..11_ S c l afarc a d.l c l rl i ' :
    -simucopolizahariderlc sint colrponcnrc
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    ,
    tt:r1,. -cl
    rlL.ir'icrt'lorsi v:Llr.clor crrdiabe,r.utiliilc care a{ccteazi. accsto str..ritiri
    l,rxlrrr: irrrPlicit a'orlrlii cardior.irscuiar c (iabclul 1.20). Accstea s{j pot iii,,iri_ ( i c l ,)r,i r -. l ndLl c l i c tl :rc i i l :c
    l.slrrirrlrrint:ipa1,prit.. l) c.fcclarealr ndtNtn|& {tltolelarcorouurecarc ic ol,-.irrr_
    'irr,r lx|r i|cun]uliu:ca unui mctabolit, ca c1eexcmplu in alcaptonur.ic, lilrno_
    , rr.lirrrrrir', f& tkloronto.xta L,lcstiaun, silLdromrrl jluntcr, siridromul : ri f ( ri r-r. s i f f r! , i , 1 , l )c z /oi tar' : a x \ul L' l
    I-Iuilcr, s ! r(l f (, u L rl . r(q r' l f t t
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    , r'rrr r1,ri r,nlrc.'r s;u rnilrll."r, ca in siudronrul MatJan, sindromul de
    ilr,r_
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    ;, t\
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    | . , r r r l r l r r i l co r r sl i i r r i , r r l l ci i ttr tl r t i cg i r ti r . d r ' fto h ttn tItstttttl ttti i n tti /"r f) L tl tt'
    1.10.FARMACOGENETICA , 't , , u i , 1 , , r /.,f, ( l r '1 r 'ru l i l i i r L i l ( L l ! i i ( : si l r a l tstr ti s i tl tl .o sr :r tlI tl It'c,si v. I'ti tl l r r '' l t
    L l , r 1 L , L L l tl r ) r III{ ( |I( i IIII{ IIi l tl L 'i zo tr i l vi d a , sl l l fi l l l l ( l i l zi n i L , Iti tl tr tl r r zi ttr t r "
    i tt t l 'ztti
    Ii;rrrrrtlr llttr,1i r . ii, 1; r nt r ir r , or lr . r r ' 1ir . tsrr t < r r tr r l t i rr . i t t l t r r i J , , r L I L \ , t , . r I l . l i 1 ''I r I ri Ir I; Ir ':I tttl 'r t r r r '!i l ttr i l l tl r .'tst' l tl I r r r - L"l r r t stl l r stl ttt!r "
    . rr" (l( \'rr) ill)illr'|llI l] ut jt ir | : , 1, il( . 1t llllr , it |] |l( ) r : , r t l r s l : r r r l , , r 'l r i l r r i r , t r . r i r r L , , r l,r, , , , 1 , r , , 1 ,'f \'|i i ( . l ) l r | r , l l <l ttl i r ti slr r ;r l , I L |) ( |I) IIIi IItII r tt l r tr l t'r
    |\||i IL
    rt r t t rrtltri rrrrr:lr, i;rr \ { . 1) ( ) lr i( ) iir . , J | , , . r rI i , rrrrrI r t r l r r r r . r l . r r , . l r r r t , r r r r r , . r l I l , r , r i i r , i ; Lr r l ,,i tr ,i 1 l ,r tttr I,r 'l r t t i ttl 'r 'tr tl l ',, ( r r I|) i I1 ) ) 'i I') r r l l 'r l r l ttr r '
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    :" 1 i. ir r Ir' I r' r' rrri rrii . r i trrrri r,rrrrrrrrsrri ' p .rt,' n ,r' g' ,i ar;i ' ri i i ' l ' ,,.' ,i .,' r.r : r , li: r '; t t , , "t i,ulit i ilt t ' lu"'l' pr 'zr r t r r pr ir r\ ll' i: r ""r 'lr l 'l'
    , t Lu it lr . r ' or r s r r ulti r,,rc l l l r' l i rrrl ,,,,1 ,r.,,l i rPo )i fi c,. i .,i , ,r, ,rr,,i , in t ''zr r 1 cinil f ir r r r L'ir r
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    L ,,'/i , { , rl, , r l r i il. I r i,l L .ItIrrL i ((} ,r_ l )l )),tra n s m i s .. ,,,/.,' :.illul j. r n. lic nt i. i lu'r {" li . cl - lll. . c$pl. u ll l u lr ll trr
    l ccosi v pri n ctrmosorl ul I. 'l ^" l citati
    I. r, l[,I\']([rL pr,:s.tp...i, credilsri, ciud iLurbii soli iint rlr
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    i r'o , t llC' l. lnO lr l. . P ,n l fl l .rC (s r ti 0 rl n 1 1 1 a 1i ,.g,npcti r-,i sn r-rrnosCaproxr , i clti,t i,r fui,t-titi,r linuia exisl:r l1na sau urai mul1c boli irr\''li
    r riv tlO dc alclc diferite care afecteaz-r,peste 100'rniiioanc ',,,,,,'11,,
    I rl( r,irr , itril lu tl]iistnt avalrtun spontiule [cpetate'
    clc lndivizi. lnttr_
    . rt.rr hcmolizci pentr-u unele rnedicirnente
    est" ,.a.inbii!l c., .asa. 't:rpL rritLi prcvr:nti\r cu rc(luccrea lrccvctrlei bolilol gtlnetictl lr t:ilrir rl
    [. r L. l' ) t c r , m plu ,]" r.,,a c l i r-:rd v ,,r..l ,c u S ubS trJJ
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    ,. t i] . ii. l, 1a|r . frri n a p j i rrrc r d o c o rrj c o i z i
    i gl arrcom corri zo| l j c).l r
    ' unrri ,i:i l,t i,,r,, pr"iu,," ;t,diiglosricirlui in slrcir{lc cu r-isc ctcsr:ttl l)rltrltrrl
    i L \::lrzl i,. , . \ nO r r t jlt l. tS tr l rJ n s ml i ,. rrIo s O ma l ,, t ,l, i, lris ,lc stutliul citogcn;tic al lic.hic1uluiaruniotic (1966) S- ru 'r'1"'
    t]o rn i nant-
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    I abchd 1.21 ' " I.i ' ' l t' u i', r , , - , ', '( lclo'. ot i'" r ho5r ; r lia) Sir r bilir ' 'r t ir nl'r r r i' ' 'I i''r 't t ' . I
    \lrrllr:||xonlc
    ''1-
    ,t, ,,,,'tt,,r-,t!ii ini2orrantc, sau d;elar'a un.i afLcti.ni p'cifirnd irrr''li'
    apte sii t}loducii o hcroliz:r ',r,,, t
    r| |( r ,rrrI r,i I i I )i | ,r , ^'r 'r ir ll dulr ir {' c\ olllli oir r 'cir ! r ' im pt r lt t t t l t |r t t t u
    h indirizii ru rletictr dr c0_1,1, {l,i.rocr, lllTjl
    ' ,, '
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    .1!bI 't lt, /'r, .tfu l,'it).
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    t;,1 ('1('rlrll
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    I
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    , I rnur preparat Polrvltamlnlc'
    ' 1"'rr|rrD(.r'lrliollillir

    RETROSPECTIVA
    i.ll.1.l. coNSutTAllACENETICA

    l ' r , 'r r l .r I) ttl 'i r ,l l l L l l Ii sD u l l : r l p r '"b :r h i l i r a tc i 'l I'i i IIII r . ' l t.r i - r r l
    '', . n r r . | | I r r r,,,i In ,l i i l .t) cl i r '" l i r J'q co n tJcn l i :a u d a r i ' xr L 1 i Tl i cr tl "

    t: ,,,,rr,.rlr, ,r, rlilrrrir. sr-rsc'rcploduciL la mai rnulti iopii diu aceeagi {amilir' ' 'l'
    , , I , r , r l ) i r r '(l | l q cr fi r m a i m [1 to r cta p e :
    1l l- l iortlirntttrtl arlletrtioitll ii dirtglorticului biochinrir: ltl ttttzul palrrlo-
    ,tl'' \ltxli:tl. t)r:llt-ttrittarea clinici si hiologiciL lr mutatrtr.. Scl-rt'trccpresulrrrrrl'
    I lL631cl6r lill lit nt ': t u: i pr ir ir r l'
    1,11. PREVENIREA
    BdL[i.ORGENETICE ' .," ,' ,' f ' " ,' f., I 1't , , , r , , ; t , r , , , ir n,
    rrr,r.lirl 1,,r-.1" transmiicre.
    ' ,I , ' ' , , , ' r., r t i t , .,',lilicrrltirlr',
    , li, r t , , sil"t l- eci: '
    Aceasii. condilie reprezinti 1rr 'l''
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    l 'r , r ur r p. r ' . . 1r .1 ;r1 s 5 6 !d 1 ,1 ifr.r.r.rr.c
    .1 t L .rJ i.ur;,rr, ti c,.sr D ..r,1rrL ri l b.Lr , rrr,r,rr i tr r r st t : t - t ', t lt ' r t t r Lt at ii gcuclicc ( pest e 2000, dcsclisc il gr 't l. 'Lt r
    ' n - " r t ul r , , . u, in ' n i . c i n d i r,r' r._ ol L n ri l i ^ ;, o ,,ri onrai i ,. g,.rr,.i , r r r , , r l lr )
    , .1,r || l, r r : , lln , , l n (' , mrt. i l n p o rtJ o r. i .r i .r.r - p...i rr, r tl t ' ti
    hi :. ,rrA ,,rttrl ur ti , i ,totr_ l , r r ) {\ ( f r l l l l r 'i l ( l t'a l tvci l l tn l l l g a i i n fo r r n a ti v cn o r tn scr l l a i a r l l i l tg i t-
    I i" Srrlr li)frr)ir irolilor meta|oli, u (-mut,Ltiirloriogclict 'nli, r t r 'L l t r t i l , g r r l r 'r l cvr r ti i tl r i l i l l l tl a .cxl l r i l ;i i r r i i g c'u cti ctl l r t tttx:l e ca zti l :t, o .'r l ''
    t . 1, s'.ril.,ub 1or.nra
    i r' : ' r , , lir ; r r ^ p o l i g ,-rri c .i.i rn u l ri fa r-r,,ri ;i l ..7
    .(, .rcrsrrl r i .l .i i ,u,i ., ;,,...., i , t rr,,tili,]r .slc trt-rxltrsi tlc tlrai tlultc tipuli c1c mtLtirfii gcnt'ticc l)t: r'r' L'r
    | ,, ,llIt,.r ,rst|[rlutrti ca fr.,cYcntir, rcprczintii o gft.Lrlatt: r, 1 j c, Ir o .t]L l i I sr u - i .L 1 r (i 'u I l l i l ci l t( n l Il j i r ( r 'I
    1, riii, si iirdir-idul inten:sat si gencrcaziLpiobi"rrt rli 'or.rljn ;.1[r,r.t
    pr:ntru sor:i,,_ " , r , '. . , t , r , ;r [,"r ti IIr IIr IIi Ir ti 5 , r r l r sin ta 5 'L 1 l( l cl i L r r r r l
    ' trr. 'l trl r ', r t r r l l l i r :i 1 r tl r l t l 'r tti l i r l ;r l i n i r i tl r "xi l r r z:L )
    ' 'u
    t , t , l , r t r l i t r t , rl ttcl :tzi , sr r r t t:r t <l t'l i ci tu l tl l si u tczi L a b i ti p tcl i n ci 'r \l i o o l i ' '
    , , , i , f , . , , t , t i , r ':r r i r r r r r l i l l sl i i r i d i l 'r i l t:, l o i ti c: {i i r tr L cl tx;i t' p l r :i o l r - o p l i r l t r
    1.11.1. CONSUT.TATTA 'i
    GENETICA ( i r t r |i 'r z|r l r i r ' l l r l g i l l | S' I l"
    r , n r , r ', l l i l tl l l l ;l l l 1 1 . l l ( ' \r r l l r l ) l r r , 3 :r 1 " 1 'r tr r i L
    I) ( \) l l i l l l l i :" ( l ( i i l
    ,r.
    I ir iol c s c r r qilLill p rc v c n i r-c el ro l i l o r.g r.n r.i i r:r i l rLrLrr::rsrrl l ui i i l ,, ri L,gi .r, , '', ' 1 , , r t I r r IL ,t;i , It, Pl tl o ttl |g i tl i r " ,,,,1 ,1 ''t'r 1 r l i L ,.sr '|l i r 'r r .r i ''
    .. rl l ]lI t ( ' lnll) f ol) i1l .1s /i / g ]tr:| i ,.:,1 t,,u trUr:i i .!]l l i | i )t.(,:ai l l i 1 l :i l .l l , r L r l , r l ) ', i t l l , 'r 'r r l ,' ,l ,l r f i i r :i l 'r r l r r r r , i si tr ;l ttti r 'ttzi ttt' . ''' r i l i '':r li (11 () irrl()rr I '
    ' . , r , ) t t t lol' |t ir r l( . (j tl s (, 1,l i It i l l r '( r 'r i r \i r . l 'l r Pt, vi r r i l L l 'i l i i r t ttn o t g ( 'tto l 'r r l i i
    P o l l r. rl , j rt-rv .i ri i ,,l rrl rl rrl i rl r, ,,ttJr!rl ri rrr,,r.r,i r r , 1 r , , r , r l r l t ) r n r r D :r t "i vi l l L i |l t ( rl
    , r t r r r r , l , l , ,,l i I i t rrI r1I rt t t I r I rI | , ,1 i l , ,,i ti ' t' <l tt:l i ' r l l ttt l r r l r l o r tl r l i r r i r ' f'L 'i r ' '
    I /.\' t t t v ils ir L, r ' , rirrrrrrl .rl L .rl i (\' l i l i n s l tl u s q i r. i t pi us, nu ul i i .,, rL Lri i I.)i -i ...-
    , r.l s i gr r r Lr . { irli: . i i i .r,t,,ri ,1 ,..rrr,,rl i uc, a i 1 l { .rcti i ]csi srLl tstr.
    J Cr,ltli! t:uiu, le/)?/l,1, ''ri'l
    \-,r
    rrtr,1t. i ,r:rr,.r,
    . l r r r l s it t r t ilr I I l,,r:Ii rIrri | ,' r-' r.ttr.l rt:r' . /
    anzu' . anA,(,..?poJ' h dri fit;'i tt h'a .rr,., '
    l rr ' ir , s r : if r ir llr l l rl rl o rrl L rir l i tri < :, ' .l r ro i i tlportani i l j oaci i ncl i rhar+ ;r Jtftc:o) i-. .j-l-
    , r ,loqiL,l r.rrrial.rilcir riin)r lx)li r:r:nc{iceir.itr uu sitdronr sau o l.,oaliralu- z (1)
    rrr si slrrlriiircl noduhri dc tirLtrsltitere efeditarl. I)e cxemplu, hidroccfi
    lr. ,)1,..,.r vitli-rilr un copil rlc scx uresculitt crr ural{ornatii a1c polilclui srrg.cr-,.,azir jltnt T//a7t/ir//! !);
    ,' rri (l( 1(,inlirlati de agcuczir:a rcgi,-1niipostr:rioar-rr a apcclL'.ctuh,.i I rri ,Sr'1vits,
    T@ .{t'x
    I r -"\-)
    'r i r.i r Lr , o nut at ic ;rc c ro m o s o mu l X.
    Slirtrrl gcnltic plcs1.1pu1tc, ttzq!,,
    lc ling.i coutpctclia prof.sionalil a utrrlir:lluL t:2
    r ,,r :,rl l rr nt , ( r - \ is t { ' nt ail n o r I a b o l ..ri ,,.ri c I' i n c n ti l :rtc , ,:rprrbi l usi , r:fcctuczi :tl t,tt,r-
    r r li r:i1<rgluetice,cnzinogcn'.tic, , irlunodprrr.licc, Lt."ie ,lc coagfllrrf /.t.j.
    ftnct nr/ia/ aittali
    j^i) !tac/t/

    I',',LrLrrLn,k Lroli,c& miopittiil c ccDtroturclealr:,cstc ncccsaf c)i1lul(rtuL (lc rnictl- ;encti, tu


    , ',1ril llt't:trouicit; pcntrn dilcrelliet:ca unor mllcopolizahariclozc slltl ncc{,slltil d/Z/q'ito/ nasl!/tt'
    , rLltrrril, dl fil;r-oblasti; pcntru dia[inosticul rrcriroiipiclozclor.sc ir,liri l,iol,.r: I ?O
    ,,l ,r.rl rr. .tabEcl/Er;,'.-t, -,
    fl, Slrbilirelr lilitlici rys/ari tu cf'ct/dao"
    I rIrIrrl-rlr.stccunoasterea mai nultol clcnlcrlto:
    in boaln sludiatii. I'rtltr-<t ttqarn*ti

    s|&t't\t tl. sd dtate d.na.mbriior fanriliui, citzurilc dr. :l\.trt'tl1ri sp{J{ll.titrt,


    r-iguroirsir
    ;_9
    rr r rr{i i r r r or t i; / egaI ura - e/tg/, n,.t"'
    ,,irsl,t .;i ,tt[;cetlctttclLobstctrit:alcale nitrutL"i. inclilitlului lrolitar., rrrroln, flo/ c'tf,a/or/€
    t.i r,irrii in sptciai in primclc 12 siLptimini, cvcntrralii {rLctori ttr,atosLrni cSntan!4/na
    ,lr r ,rr'r,;r:li pil ioarliL: nr.cdicamcnii,'trcprimitr', irfcclii (r.nbtitila): f\1runnc Jdrci/ri in c/o/ul:6
    l, r,rzr' \ ; npr/ ne/igi/t'm
    tttltttltrtltlc l,atdlui, ttsta, cor.tsanguiniiir Ic posilriliL ur n:i:n:r;
    <lirr:i cxistir. in {amilic un caz idantic saLl cr1 ttirsi.itrlt'i sirnilart"; avotl
    rllci in familic cr:istir ir;cliriizi crr anomalii pc c;Lrc lir.obantlul r.:.r
    r,.,1 , ' r , . r r . i, s t i. .., l ,a r .rp r...i rr L ,n ;,l r r....lrcti r.:: rap/u ,tti' , .
    I
    Ll.rr'i ,-tisla ludL: eLr boli rccu'gosculc clt {iilri clctcrminal. gcuelic;
    rrr-('cstr otigirco ctnic:r a I:r-milici?(sc5tie c?i ranis{r}u1 \Iulibrcr. tslr:
    ? - -_l:
    Y
    j

    rr ..,rrl)lrL rLr lroaliL !rncticir intilnitii la firil:urdczi).


    I'r' lritzu"tlirteior obfinutc se alcr'Liuicsteua arborc getrcitlogic,in orr.iiut. .tornrt 1' 't
    e
    ''
    )
    , r',1',;i,.1, r irPr-inzrndirrLr.,.Lga listi'r i.! ff;ililor, sltlilriloi.si :L lrrturLrr iLrrir:l,rr, 't,\'
    figuahe
    I l rrrr, r t l: t l, I r t i S l lrrl , In i .
    Iit fra:ctllaycd {nhai tt genealogici sc {acc tiiipl o schelri] unii:ii, ri.s1:::r:-
    ', tnactu/.te,:cul r:!t i
    t rr'l 1 l rrr lir our olo pr in c i p i i :
    \ , r , ) ,r ' l) , . r : r r. ' :c ^ rr,l c rrti ci , i rL ..ii r,J I' i .,.,1i 1u1osc,Lti . Fi t, JI (as e.-t/ /a ti'in g; ,) in Ctli ! eotia.lla
    . s..r
    i tq r r r , ; . z i : r , , , :,s i l i n i , o i z ,rrt..,r rtl n t. " o ! i Ll i . , Lr r.i [i . rc,rrr,,r,, .,,,; .. / /.1 t;ty'tti .tttlt;ciL lea'slt
    , ,. , r,
    . lr , | /4/irl /i !,t^li
    I llll l . l t t s ( l l l l (
    0!.ruglr
    lr irlL'r'ir)1LrlIj,rc.ill:i Scn)ratii sc li.rfrazi:t cu sinboluii ildicafiil,r
    t .,r"rl i: r : , . : i, . r \ ( . t ' r t ri ..L d u P ti u rr ,t. ri i i tl , ,!,:.i ..l .r..rr l , .i 1... grri ,.rrrr.. i nrl . : t . t . )h o t i rrt . ,.1, tr :t ,11;l.t n1l . b,)
    t ..1.t. -- tL.l. t,i " '1 "1.::
    ,.
    ' r-,Ir rit.ur',. i:r liPrrrilc ,[r ]ogirturiL aii cupiului fciLsiLtoric,1Jg.;'r.t urri
    r , rlrllliri t . / . ,l ,.,l rrr,r (u l i p ul t lt boalir ( cr edit ar i, congenit alit , f enocopic) 9i cu t ipr r l 'l'
    Sr. lrlccizenzii inJcgcndi jniorm:ltiilc rr:Icrjtoalc 1a starir:L tli' siLrdLtui,: ,.,, | | ' i l , r" ' i , 'r lit lr l, ( t lot ninir r r t i', 1" r 'ir '"r ) '
    ,rrrLir r r ilclx r li. ,\. l trt r : ii t t . f r i t : ! i'ut t t 't ist t i t t t v t t tt t t 't t ' t l cl( o ! L: ] t t t '
    O r r z t t l t lis c ut a t (c a z u l i n d c ti s ;ttt fro ;5 asi htsl s,r dr,sl r,rLL..rr:r , rr ,
    ,t ( lir t . 1. 43 ii i .4 4 ). " ' ' , lr1;r-i:cicr.ca ris:culrri rcr:rrrrtn{r,i sc 1rr,,.
    \;, <.uy,ti!,rtnts tilrfii donti,tttu tf.c
    inr lividt r lt li:
    . l l i . , lpt t , c ir r t ' nrr i s o u l l ti l p l tri l i { i s l rrr l rtrrrr rrrtti l rol i i t;l rrrrN i r.r' l w " l l l itr
    r 1,,rrri trrl tIr l :t s1; t r clt t lc siit t it it lt : ir
    i Ii I r| | | | I rI r '|' j I olr it , ( r lir ii rr c rrp l l l l rri (' r)l ts u l l i rl .. Ar.,,l rl i i l l i rP .r , i ,.,.'rr,;,. ,i i rr r' , ":,.,i rtrl i vir lr r l r r lct llt l lt t t 'zit t iii r isr r r l <lo l lvr '; L 50'/ , t lit t t lcscct t r lL'lt (ri'r l
    . ,r ,rl r'l r ' olr lit f t i, , ir r r,l l rl ttl c rl i . r' r,r, .i l i . i rtl l (.ii oi ttr., ( i rtr, l )t1,,Ir rl ri r rr ' ' ,.rr,,i .rl r r {i t t t t r '
    ( lir lxni l: l) :

    t:i t; | .t7
    s tc l l . l tt.,ti , . 1/ r , : t iut Lcf t . slc det er nt "inaf i
    'l'
    o ar o't |t t ) -
    'r '. tt ut o b LtI i,.. u\ ltt ti:ul atnnt'aliilor ie nwmdr. Cel mai binc studiat
    t''lLr

    a,t ir JT'
    ,.,lril ,','c,rr"ntci i'u trisomia 21 1' afara t'anslocaliilor ;i
    ' 1,.
    nozaicurilor
    ,,,u" ai " ri , - i r iscul r r cur nlci pcnt r u [ t t r t t ilc car e uu at r t l r t t r t 't in
    ,,r,il cu tiisornie 2j, inainte de virste de 30 ani, cste de 1 -Zt)ir'
    par-'rrr-

    , ,i .
    5T+* tr-dNT ' t,l i,i- iurut, tyin slocali.ilor. pentru un individ purtitor al unci r-erna'iL, i
    C) t-'clilibrirtc (ienotip normal), riscul dc a aYea un copil cu o atr'>
    ',,,rr,,.<,male
    ,r.rl i ,.rl r z,i l ri l i l 'r r li ( elnr lat l d, Pindo dc : nai. t nulli I r c. t or i:
    '\, rlc {clul tralllocalici iinlre acroccrrtrici seu alli cromosomi)'
    ,l tl l i ar t or r t alia( sl' o in\ cf r ir .
    . dupi c Lonr osonr iiinlr - r '"af i
    -
    i)jn a'nchetele europene pt rcz-ultatell' diagnosticelor-prelatale se colt-
    / j i r ' . / . 1 . 1 S o h c r u a a r lr o lcllr i n cn r r to g ic iu lr ,r lr t:rz de l j .rrl :Ler()si .z:rul :t.
    t.rtii ci riscrrl rccurenlii ctrriotiptrlui dczcchilibrat ':stc dc -5,3,9/o ^in-tran-<lo-
    rrr lrirbat siniitos provenit dintr_o familic crr triLsiLtruiL jt t it t r "t '-
    dominanti .,l i i l r r)rrcj rl r.lc, r ln l. l, lo. , D, nt r u t r ansloca! iile r ccipr oce "i d' 9"o
    \ |.r\',.r |lulnal de5ccndenfi - siuitto;i: ' , q,.pl i .r , : uur osor iiului 0; ( CI r : r t r r J F. si colab. l980)
    ' 1 r,11 .
    . ,rl,l,i:_diyid lrovenit din familie cu trlsiturl clonrinantli.loatc fi nuurai l'r'irr r:onstilta{iilc genetice r(rtrosPcctilc. Procentul maxnn de cazurl
    rr, .,1):n-, ntir sani.los- foxprosivitatercdusi sau pelrcfranti scizrrti .r Acnei). clc rnf,ritrcalratrici, ctte de aproximativ 30-40')1,
    r'.;r(,sr i:rr,t pulind si frdnsrniti afectirrnelt ' ,,, r,,,i i,tt"urtti, in funclic reccsive auto-
    (dc cxcrnplri:Lroalarixosrt, ,,, rrr,1, t,tjill,, it^nsmis" dominant ;i de 20-30o7o lentru bolile
    zr,rilii si ictr:ru1 iremolitic cu microsferocitozir,caie pot {i icceratc ra :,,ru,,1,, 5i Jcgatc clc scx. in practici procentclc- sint mult mai mici pnltr\l
    i'divizi
    irpirr:(.rrl sarnirtosiprin deterrniniri rediologic.,si ilc laborator); ., rrri rrrrrl,ri z it r t r '- . - frr niilje lt u "1c ioldceuna diaBnost lcat pr nco( o sclt I ) 11
    tr rr', ii slatul gr:nctic nu estc urmat. Pentru anomajiile cromosonic" in :llirr il
    . irrrlividul provenit dintr-o familie cu trisiturri tlominanti poate
    1,r,z,,rrl:rIrr,:J:ri'cur-sul vicfii (nu de la na;tcr.e)caz in care transrnitercir.re- ,.u,.t,,,:"tiitor:'familiale si pertr-u nul{or-ma{iilc sisternului nctvos centt'rtl.
    ( P' Roy"r '- l9l- ) '
    tlrt.,rrir\( I;L(, iot in r:rport de .l: 1 (50o/odin dbscendentii,ca in ataxia
    cerc, 'r' ,' rr,rri i :r LI, ra zur i cc pot [ i pr r "\ . . nit c cslc f olr lc m ici
    r,r',,r\:r..ir11 5(. poaic rnarrifesttt ' ,1 l tu' n L t t , , l'r r s! ' t t t 't llif r t dor ial r iscul. r ncur cnlci dcpil '1"
    dupri \jrsla de J0 airi. 'ldt vt t t it t 't t ii ( {'r r -
    ,ll reces,i,tiiaprecreteariscului rccurenlei porrcstc ' ' ,,' ' r.i sr, n1l si : r , 1iun. r aiost or f r ct ot i : r supr a viiior ilor Pr o. \ lllsidr r
    ., . lr,r t(t(Iltltr..:rr(.r
    Ll:']]llll_ l:''lo,ti:
    !,.!o!,i.1 nt ' r - u r , t , iunc t ur Jf ogr : t li oxpt lncr c la r azc X) '
    'r" sllrn dc pllrtiior (heterozigoii). ' 1,i
    "
    i , l nr,,Ji crr ni,
    I)cpistarca purtir"torilor un-ei.gene recesir,ein populalic este in .\:,,,i ,r,:r r nr t i I t t t t ll. or hcloli ct iologici sau incor nplct a cunoast (r ' . : r
    'r'rr rlr rl'.lLr.ler 5;eneral ,,,slorr impicilic:-r forn:ularea unei probabilitl]i de rccurenii a anonl'rlr(r
    , chiar.prin.rcs.tiri itt.&nittE",
    liirindicdmo r.tcIaprrJ.i nr.ni_
    l , r:11ir {.nol)a'rcitn Ienoripulunui individ estecondilionatrldc impercchc. ' , rtttzi
    rrr ' l.
    rr
    , ,r rl ,)rl,r.t ror1a,rrt..t-, acesr{r.nomenpoate si. apari i u ,n ,rt" caz,uri sc pbatc cstima o cifrir de risc e'urpiric, cu atlt mai m;tt
    dun,i
    ', r' r':r(u(l(. puriiriori. Prin dozir.i biochirnicose pot'dcpislir do-iicxomolu
    mulr. ,r ,it"sirri a{cctrrlimai inulli membri dintr-o familic'Dc exeml}ut.i1,1l's,
    l l cL l ccta l l , fr - i i r 'l
    ,i, .il*oli r,r(,rtrrr.ir I,rilci. jn ,- a zr r l u n u i c,r p i l a fccta l ;i a iliirinlilor
    h.eqoglobi-rozei S, rata.cmi"i, maJadici Tey Saihs, : , ,,,,i,i,it"',i".r'l;;. cind sint'af''ctati2 copii,ri'cul.clcqt' la l0u'o' l)irt i
    ]j]:j]),i,::,
    ,i' I tt, ill-a.1-antitr.rpsini.,
    |',.rIrIIIII -r.! {enilcetonuriei,hipofosfatazrer,ntuco\rrsc1,
    , r,,. l, t ,'t( lrltlrr { r tSL c r j\ allar . ,,,' ,,,1r;i;i't.t.t lrltittt'" sint afcctali ristul rccurcntci tstc de 15o/o'
    lrctcrozigotepentru.loli legate de cror:osomulX pot fi iden- I{ iscul rccurr:nlt:i estc mult mai nrare cind boala intereseaziLsr-'xttl
    ,l,r,rrrr.il.r
    lrri irl(. ,.r r' irt mori obisruii csit atectat mai rar' Astfel, dacir stenozahiptttro{ici
    lx'nlr1r dclicitul de G"-PD, maladia Fabry, (deficit de ilfa_galacto_
    ., ri l, rz i l 'l'',., ,,i1,,ri,l,,r. ir{oactcuzir nrai llccvtnt blictii; st miinilesti Ia o lctit'.' lricul
    lrr riisirrrlia muscutrari progresivi Duchelne, deteuninarea indirecti. Li,,,,tJi ,*,.i,,1'ir"ii .r"lt" {oarte mult. Cu cit malformelia estemai mani-
    i,rrr rlozrrrr.rr cr rr rti n-Iosfolinazei..-perm-ite o depistare a heteroziSJolilornumai ,, ,iii ,:,i riscul cste niai mare la rudclc apropiate (tabelul 122)'
    "tit notranslltt'r
    I r ,'lirr:,(li. r:^z'ri, iar in hemofilie miisurarea' activitifii {actorihi:i
    VIII;i a rlt I),ttri I'o,i( rslt ,u;tgtuilalo (PICZcntiIa na;torc dar
    .r riigcrrrrlrri frLL:tolulrriVtrII, ln 80o/n din cazuri. r-iulati
    lit,'if,ri"t.tiilir trct'r"ric in {aciori in{cc!ioqi .satt '1"
    ',,fir,ri'r',:,,i').,, tnru'
    l ) r ! . " lf c \ ^n1. r u n o i B e n o a u to s o ma _rc l c c s i v c cstc cunoscuri , Irccvcntrr ,rt"',',,iutl',,-t:rtrt: ar irr:libnat in perioada embrionari (toxo'|lasrnozd'
    t ':'l i l ,'r il, , r lr , ' lc r oz i{ o 1 i s e p o a i c c i r.l r.u l rd u i t.- r forrnul r ][arrl v_W ci nhcrg. , tlt)t,tt!!tli., lttbaold).
    riscul r'capar:ifiti
    t\ I' t,ttrr,llrL|?nt{tolia rccesiud lagatd. tle u,ontosomul. X. lr rrr,,,st,:sittta{ii abscn{a{actorului creditar eliminir
    I iiirl,alul Pur-tiitor, ci.si.torit cu o fcmeio siLniutoasirva irv(i;r (lcsco.rclonti rnt ( irzlli s i l tti l a r c,
    '
    ,l Itt cl,Lna rLcirtrtlit, fittitlrJ st:amlr tlt: c|iteriilc r.ignroasc r:irrc statt lir bltzit
    "\ n r ir s iulir r . ; r jilo ;i l i d u j c \ l i ' rn i n i n D l n .t.i i (,i r,1:l tcrr.ri ,ri j l ()1,..
    Il i ri cti i trtt.i irrrrr-
    . , -,t., l i r lr li. lr ) iur ' v r ' r l )l (:z (.n ti lb o ;rl .r.;i j rrn r.-r.rl t ldi
    r' rr 1,,t,,V ,rrfi i rr,l ,.t.ozi ,.;r,i ,, r'',',r"j' il'''i ri' ,' urtitit.. i.lrnict' im|ust: tk rl l.tLrtitrittr'a
    'i" 'tirii I( n ) i l l l i |Tj l ( ) t cto n to r o u ta h " i ttfu tn t:'t'"t
    lr ' n l l 'l i ur { , r llliit glnr ' 1 i r.i i . r ': l i l , st tl r ' l l r '( l l l ) ( ;'ctl tfl (
    r , r , 'l i t r : r t',,t'lt,,r,i,t
    aspr'r:trtl cliltirr
    ,',,,ii"r,ii .,,1,rin,ltt ln s'rrial tlltttr rcf.titoarrr l*
    t :i tt
    . lJl)
    4 { i r r r t l r o r u r ( . l 0 l lI lr n lr lr r'|| r n l{ !r r !lltr !ii r fir $ ol i i t:rl ( col i l un{ (N c!{,
    t nl :, i tl

    1977)
    1.22
    Irl; :jliii'"lliirlrl
    r|u,jllll ftxiil;:iili:|ffi':1*lrt ll';
    x tinh"t,"
    ' ll'i::i;;oi,,ili'nlif,i,?l[,ri''!l];'i:,*:
    ;:;;:;)i"oif,ih
    "n,,
    j
    s
    l#*-":.n'
    ,,;it;l:*1in, m;i.';**:'lll"ll",;iix:rlil:i*'l
    'p
    ::,
    i,:l l:i""ll',...fi
    :i:;;l]:r';fii;J,i,
    ;;l[ln:iii.S". :lii ,'T'''i1ii:.5',iii
    E 'I "':
    ,,,,.,,,,*"i"" '',.,lllii'
    lfolf:l:" i"l,,r.:.1;l:,,;l; l,.,
    'i:,:J:'.,,*'u'l'",ioliilll
    *
    a E
    :irrrlr,r
    ;,iir ll_$,t"l; F:ri#{;p;,;;;;f
    +ftl,,i,,*,;
    |', :,,11,r iri troprlatie/1000
    li, , , rL L l ! . s t r r i m e s c u lin /Ie m iii!
    ;3',li,q I,
    0,31 5
    ,?i :1
    ) ''rrii:il:ii:Ili",ht'rl"i:i.**i*r*nit[]i*it
    I
    i rrrrrri r:qril d.up:'! u trutc a{cc
    LI , , ,
    lii
    pirfirli irormali
    .'.,. , , 1 , . u p : l r r n r ' n r ,, r ;i
    4
    t0
    ot I 1,1 l 3
    1.11.2,DIAGNOSTTCUL PRENATAL
    *99."1t^1:" ceamri irttlt"t
    ,ri lrrlii. SLrc\plici consccinlelemedicalc,baz.r,k.gt.nclicc f-isculrocul"rnlci,
    li i tt trt-ozcutdiagnosticulprenatalreprezirrtir
    irr r,r'rncni trior_dc in]elcs, folosiud nctode viiualc (glifice, schemc cti.).
    t rrt'l.rrlLr,l,ricsi ruooasci impactul potenlial po carc.iiala il poate avca ln
    lrr rilir.. t) lxr,rli letali la naStereeste claiific;tir ca foartc seicri., c1ai.iina
    ';rrr
    rlcto|Iriuii decesull:r i6'ani (de cxemplu) vJ. avF implicajii mz[
    1.rro
    l r)i!,lr'.1)rrinr lilmi]ie. Concluziilemedicalcrfor fi rnai pulin citegoricc, liLJincl
    ',:r,',*lmr':r'uilJ#;"d*:f$i**
    ;ll
    1i1;tk*i :t"i*j*:t*udui i.s-e
    inre50..cint1
    s-ariLcut icrtttitrrI
    crr-
    ricr
    cclurcl'l
    lrrrrrrr!ilrr'Posibilitateadecizieide a av(.aun copil si de ;r acct,uta-ribcuiils
    rrl,, iirrrri gcneticc, cle a intrerupc sarciaa, de a aclopla un'copil sau clc a
    ri\ rrrgc lir o ilsiLminlar.cartificiali (recomandatiiiri'toate cazirrile autoso-
    unei
    $T-'*:;xrixt:'r*s:-ul':l'te ]i
    r,,,.,:..*i:,"iit.;*br1,1t$-:.i::i.i,#l:.li::,:mr
    ll i:ilTr#i'ti'";#
    rrr.rlr.rccsirrc;i in bolile dominante severe).
    tl,l'I,lir,tlif,i",f *'":;ffi$llt*
    ii..{Tr:}iT#:1*#*1*;11tf
    1.11.',I.2.
    CONSUITAI|A
    GENE CA PROSPECTIVA ji**1.:
    i;iit.t,;t,tt!U*1"'i':,:3i.i.;$;*i1*lj.*xi:*
    l '11\,'r,iior prospcctivilr boLilo:SuncLi.ns.. rcf,.r.,Jr,,loui rnodrllriri , r\ irtr Pcrnlis vizualizari:a I
    , ,rrrllr
    ,lr rr.JrItrclalee condi]iei de hetcrozigot; DJ di:rglosticui artr:rataj. e ittlr''
    " il,"lt"til{ioc prenatalesc Pot eiecluaprin:r'-o.sl-rinsi colafuo'at
    1.'l1.1.2.'1.
    Dereoqreo
    hererozigl;ilor
    l)r'irr aceasti rnodalitate se urnirclte prevenir,"a bolilor metabolice
    :illrliilifu
    ;r"r,ffi*t**.:.:i,1,:'*l**H
    1, .'l rrr' |,irr :(.nomr.lf

    ,, 'r,.:r/r)i.rt:t[orpcr']Lru
    rtii carc specif.i.iun delect enzimaticcc poirlr. fi pus
    i ,r'irl,.rrti.5,. Po.rteadr"sa.intrcg;i poorrlatii .ceer ce
    'ste Breu d,. r.alilat
    rJndament,llsconfat,sau sc poJf(,aplici unor.glu_
    ,:,'i;liaiilift***ts'i"t"i#ti"Cl*:e$::'*i PRENATAT
    1 1l.2.l lNUlCATlltE DtAGNOSTICt',',LUI
    ;rrrl.i .1r<rprrlafionale cu risc crescut, prin metorla scriewing-uiui (depistirea
    i,,lir iz,ilor rLplrcnt,s,-rnito;i, purt_f,toiiai defectului.enzim"atic).penlru a .fi
    ,li, ilnti, rxr'todirde
    _so,rs).tizg trebuie si foloseasclteste de laborator sim_
    .:r,$":ii:
    i'1r'l'ili':iT.,
    ""5iilll":1l,llii,"i1;i,1.i;o:;T*i.it
    I l, . us()r (li. manil)ulat, cconornicr:, sensibile (sf, fie pozitive la un nrmijr
    ur.1f{r(l(, purt:rtol.i- daciLestc 1ro;ilrilla i00/o)
    l .'rlilr. lrr indivizii gcnotipi<r:;iLniLto.;i 9i speiifi"n (sii dca rczultatcr
    pcntru ifecliuuca iiLutatl). -',liiilx,l'lllt .li'.%'li:11:i1""
    l,lit,itl
    l)ct(ictororr_ hcterozigolilorcsIc rrtil.i in acord;ir-casIllrrlrri gcnctic ln
    illl;i:iili,Tl:'"'
    . iili':,lll,',"i';'illll r).wni
    rm''pir,r:rr"si'rrrom
    r,L',p prcvonilv,ln mai multc situafii:
    ;'lli rnrr
    r c
    ii'ln.i.'l
    ;
    ,. :
    l', r,,lrl)r{
    il cirzrl htl:tyozi,galilo.r f uttru r.,liuti m,wl,antrion nnttd, rrca{irctlr{i
    (l)r'ir)P.rrr' lr"r'firrr:drrsi.
    1""'
    ill'iJlltl;t:: ;i,llllllli
    i;i .xllrtrsivitirtr;v;rr,iirllili.
    srtt cirrrl rL,bur.ril
    l 4r
    l, l(l
    l i rl tl i ttntr l tl rl l l I i: t

    t rtttrt I ':';
    t t rt ort ' r r . x t | r t r r ' o T l l o l r n , \tn ,Ir o xr r ,l tn llo lilc dorniriarllc (Goklstein
    ,\i Jtrrr n, l9!1,)
    s r r!
    i\lr :io r l!j ( 1 ( r{ lciccta r e lisamen lrirrll, rrrogra-l l ' rev c ni r:e.L uc l rri i |i
    asuri terapeuticc posibiln {ie, :ulgiogra{ie ler6l.ll complicaliilor hilo orNr -
    l ..r ia Dr cn( .lin ic p.1a detcclare prcs)cr,
    Iiriantene dc laborator nl:{surarcatc $un! ar_l
    t.dal e

    ronil Ra"diogralie re11ale I'reTerirca a cidozci ' l.)slt! r'


    I r ( i r ( i " rrra 1 {)za ,\, r(1,r/N l rri ,tr1nr,r ltahitis$
    poroz ei , l i ti az ei rc rral c
    Sideremie Se. plevine ciroza. ill.iu, { nc h oczLlcinoziL)' Pl-i-
    1lclen1a cardiaci., dja|ctd 1rri ai , c a c c rna, c al _
    ciulja, lol1ogrr:Llrl.l se-
    1t/iilir ( ,rl l )crl ricir
    Bilirubirernie Diasnostic rtifere tial
    I)eterminarea rlropor- Iivilarea acutizrrilor- lrr I'
    cD Loli trcpatice ;evere tirinogei sirtelaze; cviiarea {11oI rnedicanr( l ll(l
    l'cte nrelcrd..: pe Radiosco?ie jntes- ca l)arbiLDricde
    r'. i/ Y al oare i n di aaD osti .rl r^ ]rema11l
    .J(g h crs buze, mucoasa i)ucali, tinal:r, (lilclendat al bemoragiiJor.
    degcle
    ' J ;abd l 1:l
    J!:r. colon; Ilrcvenirea
    colonosoopie Iletcrozisoulor aiccl:rll ((hrlrli
    {'nrrm ricc p rtinlr ilcno'r-ctate
    (ll strui sc!acc.) t)fri!(ioulc
    Ex. colon ;i tle :,il:::"":"r:,r?i""t"
    rrultjlte, lipoarne, lntestin sublirej colo-
    n Droane, osteoamel
    'fesut
    a n 0 m a lii d e a ta r c
    Cordii;ilr
    Xozimn
    l-ipoatlle rrntrilte Calcen]ia, gticelnia, I)rc"crire:r conrpticatiilt,;
    radiogralia de fa 'Iegunlcllt
    | | | rll it )lil rcalcemiei, hipergiicc T{istidaza
    rurceasca,,stonlac, Cist.,tion sintetaza tricat, limlocite
    , Ilcerului peptic,
    cancerului netaslatic ArgiDinsuccinaza Eritrccite
    \,,, L,r i rt ar'gi ni ffuc c i [i c i i Eritrocitc
    l r' lr, il,rrta dc hefoki[aza E[exokirraza
    Clalcemia, l]orrnonrrl Prevenirea complicatjilo! Eritrocite
    i | , , i, lis rDu l _ G.6.PI)
    paratiroidias hilercalcentci lr, ir, i, rria de glucozo-6-fos{at
    l , l 'r,l rl )gc,r:rzl Sibroblagti ir cuiitrri
    xa tl o a l i le, La1]telaslna Colesteroicln;a Galactokinaza
    Prevenilea bolilor colDrla- l r l i , i onl a gal &c tok i naz c r Eritrocite, lcucocitc,
    1, , ,rir l. r rr r i l i al i i . Acti.ri.atea recepto- Galactozo-1P-uddil
    fleae plecoce blalta
    rlrru.I lentrr tiponro- traflsleraza
    NADI{ dialoraza Dlitrocitc
    tclne cu de$itate \1,, l r,:rrogl obi rc mi a Ser
    joasl in crllturi de Iiosiataza alcaLtra
    I l rl r)(()sfatczi a Trombocito
    Jilrroblasti l nrrl i r V on Gi e l k c chcozo 6 -fosfatazs l ol i -
    }Iipoxantin-guanin-{os{ori- IibroblaFti tr cult[rii,
    rr,.,l ,' l ,csoL_NY har} culi piloti
    ABorlralii ale coryului, Ex. miini, e.raluale b;zi1 traflsleraza
    ll, r l l rll[1[ Preverdrea c.niplicatii,
    :!le policchi; sullu catdiaci Ior defectDldi .ardiac
    s i s t l l i c d r Je f( .c1 se p -
    tal rtrial

    llircrtelo srn, bjr.bie


    micr, urechi jos iDr-
    llraluare cardiacJ.. Prevenirea i rsufi ciedtei
    ltadi€rafii de schelet cardiace
    ,,,'ll'.:ljli-j':*;,ilfr1'J-ff*i'i'ffilx#TilH:litlli,l$'cil
    pla,ltate, ploze ltd-
    pcbralii, detormSri :tahc| 1 125
    sterrale, crjptorlidi€,
    stcnoz."t de aderi l l t i i u c n 'l tl h sl o l n l tr r o i l n a p a r i l i a r r r {r l l 0 r m a l i i l o l ( G.}Ia IZo u 'i co ]a b .,]9 1 t0 )
    Plrlnronara
    Nlal{ormatii majore
    Sl)l(:romegalic, ictet Irrotiu sargvin, rcti-
    ',.rlilrrI culocite, ircmoglobin5, .Plevenirea al:lenliei, cole- 1 000 nalted
    [uaze1
    l ezrstenti, globujare

    I,;c1oIJio il.i (:risl:rl; n llxamon ocular la, Sctrdcrcdr.js.nlrri onevris-


    S u i l u s isto li0 la,mp.L cu fantil, mu\ti d jK\xrnt, f rcvcniroa'
    r r r i l r l l ti a o r ti:, I,:x- rctacarI)ialr
    l r t ' r t I ' l i lr r u g i

    l1: t
    | 4'.1
    I.I I :).i,,MIIODII.I DI DIAGNOsTIC
    PRENATAI. tlltlti : 'l

    ,;ii:,,,.'il*.'r1i]llt,1i1; r;ir:'|i::
    ir;ii.,i,'ii-il,i$m*:'::':!";l:i/i
    r i 'l i ,r r ( ti ,r r + rlr n rri n l ! ' l i \ n ru h ri

    norl J
    ls\ib;l lic :r li d i rs , f i a i ri c l i r i rt ut o ro

    rr. r:. r-
    i (. 51,,|. i , r\ i ),

    ;i Irirr r.r,r-c.iii.ri
    ,,r,",ii,ii"i-i,,;::i:j:ltilri;,Ji;.':,
    r,,, r,ri.ziiiili c.r.iarr:. l
    l. lf t . t lr l. i trd i r.r,rtr.rtl ,ti :,,rrn .ri - I
    :lrliii,1iili,l?;il;'l:.:;,a;i:",,?!:;'i'.:,!:,:"r,,!:,::[:i:;:L?:,
    ;11:l1i:;1;i-,:,.:ili;iiiil:ll;
    ,, i,l( |lrio iso /.dcrici.
    ,, ,l , rri (: l l opi ori c i
    \, i ,l rrri c l fei ir i nos uc c i rl i c i r,
    i llchidr-o:.lcraz:r rlcid l i iso./atcric Co-\
    ])cficir clc profionit Co,\ carlD:iilaz:r
    -qreir]i osrccirraz:L

    ,*ri";i*ria*ir*d:ffi
    \, i ,l ,I i ,i ri rl IL)-lrx l 11oni .i l 1'1.1i}lralonic (lo,{ finli:.r7:.
    \,,rhrfi (i i l r)l i rr" r I ()r()1:i rti l i .-pi roi os l o.i l oz a.
    ;i or.ni rti ti c (1(..

    iii'li$[$l'ffi
    ,':ji1, iriii,f#;,;i.1,;ii:;1,i#:.:ru,i"1;.:l;,
    ,,,,,,,,,,
    s,n,
    ',,1r:ri r'
    r,rr,ti rr-r.
    lI
    \ t{r ti l ql i .osarri J rnrni
    , Lr!,i r'l tri rrrti tc nl ai
    ()i oti(iili. d(r:1rl)oriila;ia
    Hiilrolazir specilio:l
    l)i r/at drcarirorilnzi,

    s,
    i12,;,i
    ,,1,,,l cIi l ,.si .r {:,U Ir.t;rc nrc orl r ti d Colcstclil estcr lti(hol|'i
    ,rl ,l i r1i L,ri Sinictara aoj{lului rrgi]ril:ju..i jr
    :\cu]nriar. do cistir,l

    ,,,,,',ffi{ifu ir?#ill,r:
    *1i;ifu*$f{1,:"i;,'uL.#ffi
    ' , l i , i 1 i rrrrri l ar- c oi r)l i 1r.rt
    rl ,,, I)r!r1,)s 1i I f\'
    , I l , ri l )l 1(,s 1i p \' t
    ,\(l enoz i n (i oar)i naz i
    ('ol:|gerl 1ip llI
    (lrtagcn lisii hidrosilazr.

    ::r
    :,, irl"iijllj,ijl,ffi
    ;riil;rl
    ir; ll i, I,* t#i;,i,iil*ii,
    . l ,l , fl l );Lnl .)s ti p \' 1I
    ri v (l ')r ,r) (t-\)
    ' ,, ,f (l i o^l l )
    r, l , i l {11,{l rl l rLc l ok i x ri ' r
    I'rocolag.n pepti(ia.2a.
    {irra]llid tri}re:rosi(1aza
    Cq-andtlaza
    -\l Ia- 1-Iucosi rl e 2..
    (;:rla.ctokinazi'l

    ;l;lll,#-ffi ftfirryi
    Ii:lli,l f;fii*rxitxi,rrTi"htffil ',., rrl l i ('si ,i ozn Gl I, gLx r(j .a1;z atj1j
    ' ..,i ,,tli , )/i (l ()4 (;x l , j l rrr' l ri l i r i i p II
    ..,, ri l i ,rzi rl oza Gl I, l i p I ' l rl -S tl ol rs
    . t I
    Clnh.cl oz o- 1-Iosfa.t nridil
    ilcta-galaotozi(lazr rl, ll, C
    lleta-galactozi{iazi. it, C
    tr-ansieraz.r

    riiLr,:li;j;t$:i,
    I{ c aos auri ni daz a..\

    ;ll ;,lr l ir:'::;


    l[1;.;..*ri:i::'i':i
    ., |1i ,,/i ,l o/1 {l } { , tj p 1I S rn.U ro{ t
    .. ,,i l i ,.r (l !,l l r")
    .L , /1,(' l osl r( dc hi drogc naz a fti c { ;c i i ) { L\)
    tl c \os al )i ni (l al a,,{ ,
    (;l!cocembrozid:rz:l
    (;hrcozo-6-{oslrt deii(iragcnMir
    l :l

    il'ilJ;;"":,i-
    iiltit,1,,"'*l;,1,.i,i,1;,',u,i,,i3.:#,#:*1*.,::,W;,1:li;'
    .,,,,j 1, i ,,7i r 1i p l l P o pc
    '.1,, 'rt , l l ,'/a Lj p IIl
    .\l i:r- l-,i-ghcoziCrzir.
    -.'lrDito-l-(rglucozj(h,1tL

    ii-;iimirffiii+i-5:ll* lffi
    . .1,,011(.rrozi

    ,,;i
    i i pr. l I .i .mi l o l l -- 4, 1 - 6) trans gtuc .rTi dl |z rl

    ,i;,i
    Cistrtiolrirl sir1tctaza

    iff *$:l'+:'ffi i l 'tr'rl t!)|'r)i ci I|erni l r 1i p tI (-A D ) lleglaroa d.{cctrrc&si, :r. il-liclroxi-.1{r(,ru-
    Slularjl (lo,\ rcchcto?x, tdburars drf lLjgil
    inr.| ir li?oPoteiflclor dc cclule

    'ii,;rii,[];iitililir'ffi
    "1r':'h;1:,t--ffgiTili
    ,' | .,, . nri 5, ri r:,l i r( .ut' r.-,, , ,l :
    Lizin-ccrogirrtarnt
    2i-hidroxihra"
    rcductaza
    (IrccTcnt)

    jriiiiliiri#$r-*$*is;"'":il
    '
    lrostai:aze d.ralino
    r,, Ll ,, (l {).rl i t) {;alaci oc.rcbroridlx:to-galaclozi(lazir

    :ri:ili;lr;i,,ir fri.ffi
    | ,, 1,,,l , i )r'& )i doz a l.ac1osi1 ccranlidr zn
    r,.,1, N \i ,rL 0)f trl a) 0-X ) llito\artir gurri'Floslorjt)ozil-1m.rstcr ir,,rr
    1)ecarbor.ilaza
    r , ,r ,trU :i tr,,ti r n)(j i i rc ro ti ti i .ri r .\rilsrllataza A

    irffim*g;:,;",1*$itfiii;:ti rl , ,,1(i , (.ti o(1f(rn)


    \l ,,,,,l rt,i (1,),r 1i P I I
    '1,,,,'l 'r)i ,l (,i /l lti. | l l l (ps r,url o .tl url c rl
    xr,,,,,1,,,1i /i rl ,i rri ,l ol r| (l l nrl or ri S dr(i ' (,)
    -Alfa nrcnozilaza
    ,l onralic dc incor.p(;f;rro a clrDrului
    l hz i rnc l i z oz orrrrl r
    liirzimc lizozolr)!ic
    AUlr*L-idrll|on;rlaza

    ,,',*iilllil;'1fi-iii,,r,,ffi;r,ilr,ii,.h:.i,r,r:rr,, \1,,,,t,'rl i Ti rl r:flkl i )ra I l -' 1{ rutc r { 1,} i )


    \1,,,,'t',l ,,,rhrrri ,l )z o l l l .A ."S rnti l i ppo A
    111r,,,1',1'l Ll rrri (Il rz r l l I l l -S l |i l ti l i ux ) l I
    SuUGirlu(,ri.l snuar:lza
    Ilclrr'l1rr snlloi srjlltttz;r
    N -i ( { 1i 1' rLIl -l ),i tl rr,)r ri rj ni { tl z i ),

    iiiiitiili:ll:ri,r
    rTilffiilii*ililltlffi
    r 1,,,, t,',1i ,,:\l )rrrirl i )/iIr.\' -l l of(|ri o
    111,,'l !,1i ,,rl rrri ,l,,?r \' l
    [1r,,'tbl i /r |r'r
    '(1 ,
    )r;r Y l I
    r,r, rr,|,I L, l r (l !,i r l i r)
    l \l rui ' 1{ 1rn\ l .l l nry
    N -:r(:rli l l n' x oz l rrlrj - o. !!l fl 1 rrl l l otl ,.i l

    l l c l r LJ l |.rrr,rri i l ,r,:r
    S i i rtt, ri rl i rti :i r
    I t,l
    l1l'
    ( ttr uti uLt) tJ t,tl , l ttl L:ti
    ,) l ttl i slr r r t 't r , , t liogr t . [ it r i P, 't t . t lit cir lr i'gisill] r '(ir si ( liils- llost i( : ltltl t ll, r Li
    r rl or rl ' ti i l l car t liac
    [1 lti,tgt,o:li ttl ,,1t,,':Jaficnl ut tl[" ttolit/ir
    'Iirir,uliccrca.
    tchoglafic i in cerr:t'tarca gcncticir a uodificat strrrtltili<rrlir
    li, rl. irlr a a i , i ( l [ ( d ( ] I i c i t)
    Ornitin ccloa0id a irro-trar$Icroza r,,rsiIriI ii iL1ilc dc cliagnostic :rntenatal si r.aloarea sfatului genetic. Pcntrrr 'l, r,'
    !'osfat:rza acidr'L
    I , , I ' rr \ o , r l i s o n L e r a z a Gte licii:) Foslohexoza isomr:r-aza
    ,,rn:r nrallormtfiilor externc si intcrne ale fi.tului se {olosesc in tnod cot]rpl|rrltt
    Podibilirlogen deiminaza lrrl rloLri iipuri dc aparatc: aparat cu baleiaj manual, cu carc opcratorul t,\ ,trr
    l', , 1i, , r( . c r i t r o p o i c L i d L Uropodirinoge lll cosi[tetaza lilrric o inuLginc prrrcis:l, cu ajutorul cuperlor succesivc si aparatc zist, ttt t t ttI'
    li, , j-n, ,, ( l b l l l o )
    -l' \ t nrDl l c n r i n i z a n t ( I X )
    O-tidaza aciihlui Iitani c / .1r1clr! o iu atir rni5clrilc fiLtului gi pcrnlitr: obsen'alea modului cum accsta t ri i, )l , '
    Proteine de legr-{trrr"r:L a]rdrogenilof
    rr l tl 0l _-
    Valin transamirxz:l
    \ l ri , 1 r ( l x r a l a ) Lipazlr ccid.i .lirlrlcrrar,:a ccJroglrlficir dcpistcazi douii cateliodi dc sernnrl. tlurt,trtl, .'.'
    \ t t I tt 1 1 ( 1t i ! ) 7 t . t r h s u . ) ]1 ]]ndonocleaza specif idl ,,/rr'riflr:cctti: sir.tt asociatein general cu malformalii ca: anomirlii alc ljclrirlrrlrri
    rrrrrriotir:,ascilir fetaliL,cdcnul fetal, l:todi{icarca biometriei {etarli'.1i - anottt.tlti
    iir,r/rarrrl ulc r:rmiului ;i rahisului, viscerelor, extrcrnitirlilor ;i pcrcliIor corpt I1tri.
    r\l) : rufosomal domirallt, LX: lcgat de crolllosonrul \.
    ,lLrr i nrodul autosornal rccesi,..
    Ltel.laltr, a.lcctiuui sjrLtj trausrltisc
    l ' .l rtnctt t . ilr og; l't r , r , sr t t ciJi, t ( snnlr ' dt r pt l) :
    ,4uonttiiii ti chittultii aiunio,tlt. \irlumul norrnal al liclidrrluj anrrrj,,rl,
    , r(.s{r,Inrglosiy pinir ta 1 000 ml in sirptilrrina a 38-a dupiL carc scatlc 1:rirli l:r
    n iilll; clectroforczlr Slicosaminoglicanilor-pcutr.u. diaguostieul clifcreniial al
    ','r: r' Ior,l, rnu.opoliz.lltulidoz:,,d;zxrpi]gamn)i!-dluiamil )(tt) rrl lir tcnncu. Ilidraninios-ul in afirra diabetului, sarcinilor rnuJtiplr' qi izrr
    a dzaln .
    I l?nsf(.rrrz,.i, 40,o/odin cazuti cn malformalii tcn/o,$c (iLrr,rr
    r irlo:rlloL si izoenzimelor fosfatazei aiciine, in - cliagnosticnl mucoviscidozei. rrrrrrrriziriiso lsociazl"!in 30
    , lrrlir',nritl on-ir:nir.tgoccl), stcnozedigestive,hcrlrii dialragnlaticc ;i cl)isturi irrl rir
    |rt,:id.itrttelc
    am.nLocentei:ei. ln timpul c{ectuirii amnioccntczcisc pot pro- i,,rrrr'irrr'.Oligoarunios-ul, in a{a1a semnclor de insuficicntiL utero-plao(.rlrLrrr,
    ,lrrr, , rmrco . unclc incidentc.
    rrlilllrrziL cxistcn{a unci malfonnatii r.cnalc'(rinichiul :nind r..o1in lrrotlttr',r,.t
    , I)u.r,tclictltoate /i a!b( satt sanguinol,:ntri(prezenfa hcrnatiilor lmpiedicir_
    ,l ,.rr ril:rr, I r, l ri rl ul rriamniot ic) .
    rr , rdturilorcelrrlar-c). Risculccl mai imporllnt cstchnmor:giaInto_
    r r:,| ' rnr"L ,tscittt fetuld si-' dccclcazi" ca o zoniL int-L..nabtlotninalii11,('((,1{(lti rl
    (in l4o/otlin cazrrri), prin treceleahematiiloi fetale in circulatia rinternii. , ,x irrziLcu lroli hemolitice ale fitului, mal{orma{ii x:nalc, cligcstir.c;i carrlir,,
    Izoirnunizareapoate fi prcvenitiL prin administr":Lrea intr:rvi:no:rsi :r unci doze
    {lr' 5 miclograme de gamma-globtline alti-D. Avortur..ilespontancprin amnio_ Iidtut'u,l.fcl,al,,sub form[ dc cdcm subcutanat si dccclarca scalpului i, 1,rl,
    ( r'rrtfziLse noteazEla 0,5 ]'o din cazun. I u,.rI r' lL.r'syrrcsia unei lxrli hcmoliticc (izoirmrniz;rrc, talascnri r:) sarr :r itt u'i ttt rI
    I'l l ||ri rl l l (:i L]:(Il ac c .
    [). Prel,etarea-de si.nge.Jetal,.it utcro se practicS.din 1974.Se poate {ace in
    sripliLtrina.a_20-ade gcstafie prin.punctia.venci plicii cor-iale(plaientocentezi) Ilionr,L:lr'iafetaldpoate arita o intirzicrc c1ccrL-';tcrcintrautt:rinir, t:ittl itt
    ,1",,,r{rrruri ciluzc d.c naturi. gravidicir, sc corclcazi in proporlic tlc llo{, r'rt
    rrrlr t:ontro1u1{etoscopului,sau prin punctia tr;rniabdomina_triivaselor ombihl
    (lirl(l srrb control echogra{ic.Accasti metoLli permitc dia(nosticnl antenatal ,rr,rll'rrrrrfii fctirlc, ccl mai {rccvcnt intilnitc fiincl anomaiiilc cromosornllr', ttr ,l
    :rl,lrr.rnoglobinopatiilor(form"clegrave-dc talasgllie si drcpanicitoz;'r)si al herno_ l,rrrrrrr{iilc rcn'.rlc5i anoncefalia.
    Ii l, ur,rutteeclngrtrfice sPtcirtce:
    Irliiior plin determinarcadeficitului dc factor \rIII..
    1l nlfar.m,ali'i ak tubul,lLi neur*l.. H\drocal:,\ii:r t:stt-' dcpistabilii ptr', r,r','
    .t) Praleiir'i cletest,ttur.i Jetale.pentnl efectrarea biopsici
    -
    cutauate si hcpa_
    t,rrrr ,r|nr,rva.n:adilati.rii vcntriculilor Iatcrali. Spina }ifida sc co:rsta.l ir l)firi
    li, in scopul unor determinirli histoenzimologice.
    rr1.rirrchi<leriialcului ncural postcrior cu asp!.t r:lc U s;tu V, l)t'irst:trtlltr.'r,
    d) Iietoscot'ia si enbr'icscof'ia.Iieprczintl doul lchnici dc l-izualizare 'l',r
    rlirrd.iLa fi.tului. | ,rrt' ,, l r' { r' ;r[i e sr ' st lr hilcsrc diagr t osticul' l, ' anonc"f a]i, ,
    jrrtroducereain car,-itateaamnioticii.,pc .ll ulforrnali'i tligisthte, ca atrezia dtodcnali., atrczia dc ileon, omlalu , ltr I
    .lictoscopia consti. iq cale ab<1o-
    l n,r l r j rrrl l r.ct ainpr in cchogr a[ i, .
    rrriur ir 5i sub anestezieloca.l6,aunui sistem de fibre optice cu juririnl rece prin
    irrt, r'rncdiul uuui tiocar cu dia.metrrd _de2,2-3,3 mm.-Se cerceteazi.fragme'ntar l[ ulfurmalii rcn'&lt : Polichtstozi, ltidronefrozir, rrgcnezit.
    l'talform.al'ii alt: pcrtlilor dbdornilt,tl,i: unfa.locelttl sau ga.slrr.,.st ltisrs r
    lrrjrr lotoscopfiLtul, placenta, cordonul ombiiical, anniosui. prin fetoscJpiesiui ,l, lrr:1rrzi'L.r,,.'ur.r,,iir,in fui:r ibdorncnului carc cotilint' dileritc oiganr': slottt;rr',
    rlr'1;ir;talc'.fantclelabiale, artrogripozcle, malfolmatiile dc rnembre, focirnelia,
    l rr ,rl , r nri ('i nl cst inalc.
    rr rlirilctiiia.
    ,ltrtllintt.rliilt nu Ltiloil. Sc pot tliagnostica {ocoltlclia, irllll)uliIllil
    lirnbrioscopia const[ in introducerca prin co1ul uterin a. unui histeroscoo
    rl( ( o[tact, care se aplici.-direct.pe meinbralcle ovulare intacte. Se practich iir ,r,rrrrrrr,rrrl ' rrr ,r r plaz. irur r lr i , r s r r l auiclr r ajr , r luisir r gar nlx'i. O u r lif icullir lr :st : 1u, i
    , |,,I(| |rrir)il nur.llornliliilc rlt:1;ciclor,
    r.rail)irirnina it8-.r - a12-adesarcini. Scpot observapirti dil embr-ionsj insoecial
    ,\'uti.tti gtnt.rlt.tt tnulstrruoora- l.ipit.rrgr ntt:lilor tttottozigofilttlttoiil)Illiolili,
    rrrruilc. I-ipsa de transparentS"a rncmbranelor, aL.rundenta lichidulii am;iotic ,,,vr.rrl rrrrl i l r it lli. r ar lr , r r ir , sr 'Pr - , 'cizr ir zir t : r rt t st t r in! r 'rPlir r t n, lt t r l; l , 'clt ogr lt 1ilr r .
    lxrl in4>icdiciLlt:pcrarca-.crnbrionului. Fctoscopia si embrioscopin reprezinti"
    rrr,.r,"lr: irrr':rzivr., rr ri.c ,L. ilv(rftsponltlr. y' lllli t 'st t rDosilr iliillr t r liit t lr t l ir inl( 'slr r l , lc sit r r 'it t r t
    I)d$ t. i t t r t 't ts. : r '/ / / t / liiit
    Lrr,1 l ri i i ri l ri'r r r lr lo; r t cl t ut t t i lcl. 1nc( li( : ll,
    I'lii
    l't7
    i) l)irtirtoslitttLrd!ltolog|(: iu. mollornr'alii.inainte <1e18 siLpiiLrrrirriIiLtul
    rLr , r tr, r'izilril lrr cxpl(niu ( i].r-ailioiogicii,
    carede alt{el trebrie evitati. Il a 2-a
    ;,,, ,.rr sllcilii ladioglllia continutului uterin poate aduce inlormalii dcspre
    rrr,,rrrlliilc scircletuluigi ancncofalie.
    permite vizualizarea organelor gi coutururilor {etalc ,E
    h)
    . 'Lrun.iofel:ogta;fin
    rrj('clrr, rr intraamniolici de lipidol. Este o metodir irrvazivil si traurnatici
    l,r
    r 'rrf,c'io.,fupru"J do rn' inbrJ c, rrtstiri l)r,'matIlr.r], Se utiljzerzi irt r'r- a
    r,r li r',rtrcme, cind riscul malformaliei cstc foalte mare si echografianu a clc-
    I r)intt c11certitudine diaenosticul,
    f,{ultiLrrdineadc inv{istigalii care intri. incil in plotocolul diagnosticuiui + -l- +-r'-l I -- -l- 1-
    1r'rLtirl dovede;teci nici o metodi.nu estecapabiliLprin ea lnsrigisi depisteze -i- '; 1- -- --
    1,,; ilnomaliilc. Echografia ocupir-unloc privilegiat printrc cclclaitc cxplorln.
    l, ce.lesicompleteaz:r amnioccntcza precoce,prccode{ctoscopiasi pri:lev:rrca
    ,l rrr'j ,rlr1,,r,o;ipcrmitccvitrr.r rnrniofcr','1.:mfici (fi{. 1.4il.
    Politica sanitarir cea mai. e{icaceeste de a permitc populaliei c1c{crnci
    iLrsir.r'cinide si bencficiczcc1eo metodi clc dcpistare ll {irrtclie de {lccvcnta utot
    rn,,lionna.tiiit rapott cu zona geogra{icir(depistalea l.reta-t:riasemieiirt {iLri ca
    t,rr.r:ia5i llalia, a defeclelorde inchiderea tubului neural in Scotia ;i Jara F i:L i

    iirrlilor) si in rapott cu viLstainaintaiii.a mamci-

    , .'t,'l i.hll t ii! /,t/,t//ctf//rfld Al0,l/41//t/1/0/.4ff


    ",/./1!/,,

    r- -l !- -- -l -
    .tt:00fi,4f/t I 1/{h/D,1Arv//)//t' ,l,rt,na/i a/e :,- r-.1 -1'
    -- l&- ![ /?7/ I
    llit'/r/ nt//ad/',
    . i.
    I l/.!7,,!!4dl ;,tQ-r7lapr tna,( /!/2 )
    i
    MaIZtn;lt
    j
    I
    I t €l:/t r //, n lr r.'q (/ !/!) +
    I
    .,,lm,t tt.ltirn I M-aa4y''zaia n /a: e,t.796?
    )

    tlt:,ttiridra ( /!fJ)
    1- -!

    I J;;tmaii) 3
    ,..,tL!h.?t t!-a" tro/notomJ;b.(/t6/)
    -i I
    | /, ,tti,.i/e
    , t/u/ui) ,.,-.xfv/i 01/////
    nqfryln8/ 0f
    ti8/,41f
    ,tidlt
    entnanc, ( /868)
    tr. L i lknqr/olrniah)-
    I /!L//iti ,4t1': ( lSdr) .i
    I .t
    ':[?o,?/blirt ndt.. t
    \
    - (n/;' Ii A

    P,?f / f yt,tf
    !' :-'j
    ,t /0,t t0P/f ,lr,nofl/tb, ( /91!) ;i .,' ; g
    0i liv ftul
    l ?r.)rblfulbanl ?.
    L. .i;*11
    |: ,;l
    ,
    ,4/a/forn /t : .t ir ]] lt
    ( /s3/) ! , ! o e r: F. r-!
    j
    i Z i Y c :j''r -: c
    9 J a " rr: u ' . j i " t
    l:iI 1l), N l o l,i( lf r l. i0 vIstiA{ r { io ln t inr pr \ l v i ( : t i i l b l $ l c (4. l l ,,'14, l i )841. E
    , ft E e T, Li : .,. t:. Ii, El .'.I
    A tr a T .l ! I
    j ..,. ,- cti , .t ,e
    i, r, - '.)
    -.
    1 ,l .l ltl
    / ] J ( ; t ) t l t,r i r r L l ( x.ti i r l ' l r r i r r l i r r i ' " i n r p i l ,'l i ci l o l r r r 'r r ' ttttl i :- ttl ''l r 'tt{'
    l r "tr l l o n l l l IL - l ) r ''l l \
    1.12,TRATAMENII,,'T
    BOIILORGENEIICE l r r ! , r , , o r r . L i ( , .... l L .l r r r i n i sl r i :r z.i , i r r l r ;r r a m .n t ) l l l ,sl i tu ti \.
    i ii' ,,' iiii,,'i.iirjl,ii, r.-i"."i lormon clc crestcrtr'ltttrntott
    inineralocorticoizi,
    'l)ir1:lrnrrrirrl tnorlrliilol glnr'1ict, cstc incil linrirat. El cuplindc mr:l,rrJe rrr i ,l i ttte ti c).
    ,lir}r(utic(l r:onvc-nli(}naltcal, si: ldlcscazi fic plcvenirii unor a{r:ctiuni {in cJPrirrProceticc..ll'*8i911" i:-11:1I^'9,Y:+f"1\i,:'"s,T)l ,'.i,,111':.,i:
    ,', rtcr-rlnral{omatii) fic c{cctrlor dcicminatc dc o tulbula.r'cmctaboliciL prin ,', i'i;;oi,;i;"'"1,ori,,,"^ tt' glico."n'za |;i lll t'rin j ls'tl/r1. I)','I|(''II\'
    S L$ul tl r(l ucvoilt
    ',,ti,
    ,' alsorb.iti
    rllrr,,rza
    ''1 l -^'l;;{ i , ;' r intestin
    irr i nl .\ti l ) trccc
    l rtc c di fc ' l i tt marc;
    mrr' : circrlalie
    l i fc l l l i rtl c asigurintl l l "v (' l l i
    ,li'lr(:rl cnznnatlc.
    \llniptliLrilc genctice carc au intrat in placiica clc laborator ;i in l,io-
    l, lruologir', mcnitc sir corcctczc tlcfcctril Ia locul dc originc (in structura r\11\- (- i ,r,i t ', i) la) {, ' r r l'o'it Llt 'r t f r ''it t t : t ''t 1'
    'hi't t - '
    rrlrri), dcsch:irl.o pcrsp.ctiri, pliniL clo spcrat.ttc ir.rtr-o patologic considcmti{ pilri ,i ;' ,,' )ii' , 't . '' 1- , , "t " li"' it i sulr '1: r r r 1t 'i h'|'l3r oir r r " ( l
    'ii "1, "t "
    rrrrrlr'rurlt r'nabordal.rilisub aspl'ct tcrapcutic (r'czi capitolul ,,ingincria gcncLii;i."). ri ,' rri ,i l rrrrinlr , {r - , . losit iir r cir ozii' ir ' i}ilolr nliculf lr i'
    cJt t t t : lor st cunt lar e al{ unor holl
    I). I ralar""." ea -1ront"'tu.c
    pc calc chirurgicall: a) intcrverfic c1lirtrrgi
    PRENATAT
    1,12.1.TRATAMENTUL ,,, , t ,,'i ri t'1,',,
    la'bioprLlrtlirrii
    r.rlli rl(r (:{)roctie cil i caznl m'ilior*a1iilor clo3('ni1n1.:(Iantii
    in Prczi'nt accst 1r'a'r:amcntinbraci'r aspi-.ctrrlincii rnodest al ptcvenirii Lruor ,,,,. ,,' i .. t ; i, if , , , : iiii. c: jldi', p: , r ii, Lnom alii r ' nalc r ligcst ir ') : 0) , it t llt t lt t
    pclogct t r c c'r dt '( - \ ( llll'lll
    lr,rli rnrtl{ormaiivc dctcrminatc urulti{actodal. Din ciatelc pu}licatc pe act-Lst:1 i .' . rri rrrrri ' .t li, : , r , act ionclzl lsr t l't l m ccanislnului 'Lnion'cnLii. h. ' i'ur Sicaloct r ( ir r ': r lr
    r t 'r '
    i,,rrii s(' r'ctill l]-Iai multc rczultatc cu efect favonbil: ;' , .' ; i ,,i ;;, ii' ii. l'L. ir or o , r , dit , r r '. ; c
    ailministralea periconccptionaliL a nnui prcpar:at polivitamiiric a sizut ],:,' : ,r,' i r. ,. . , i" ii, , . 1, "*r i , : . r <1n, . rlr ur nor i oso: r 5( . r i r lc_pir gilor . . m oi, P"lilr i
    ' isrrrl (lc rccrrontir in spina bificla dc la 4,71.o1a 0,8']l (Snithells si colab., 1931); L , f,,,,,,f,'ii. . . , io, t , . 'o, ni. r pr , r ine r r r 'r liSnizar ir polipilor : '1) int clvcr r
    . r'rrluccrca pinilla clispadlic a dcfectelor de tlrll ncural prin tlatancui: cu- ', n, t " a" t a tirli'ur'rrii'ri- clinice' cit' in Ittalitrli;r
    i;i , i'irr"gl,l"r,, .l.i
    .rrirl folir: (l-aurincc si i:olab., 19El); ii,',,i,", riti"-tt^sp1:rntare "i".f a -"ii.''o'"
    unui fragmcni de piele 5i administrar(it srrlr{rr
    cil l1rn:lrc n tnirsrrilor cle ig-icnizarc a rncdiului incorrjuritor, l lgi n, i t ;''rrLli t1i' lii-'r-otr1a;ti.
    rrrr.rrliriclL viitoluci lrilrne, 5i tratancnt cr r-itaurina B, s-a redus riscul prittrrr
    r( { [rrJr|L fanlr:i prlatinr: dc Ia 1-5o,,i Ia fi,-5]'o(ascminirtor cu ccl din po|ul:i!ia.
    rrr, t )(t -llli r l . GENEIICA
    1.13.INGINERIA
    - ltr:zultatc asemr"rr:irtoare-s-lu obtimrt in prevcnirt a fardci prin 1r-Lta-
    rrrort rrr iLcitllolic (Talaror.ri lI.,1982). al unt'i liitrlr
    lzolrLrlr gcnelor, in stare puri, dir: patrimoniul er-editar
    R*:ent au fost inccrcatc cL1sL'lcccsinturr.r:ntii dc micir chimrgic inlra- L i"it-,'o aoutitit scop a condus' ln rlt rr.
    ' ', ;'l',1',,;; it;o.iiiiJ.t* 'ltintulck'cltnltt
    lr'tirliL (introriucerca unci sondc vezicale in unclc nalforma{ii obstnlctive d,) caf' ' jt,ttiiio vast clc cercetal-c , ittghrcr'ia g.ut'eticd'
    ,,, f , onui tlom"nio
    rrlinart:) ;i transluzii fctale in cazuri d.e incompatibiliiate Ilb. " collstii' lrl
    ,,,r<rrxrteirnisme. Esen{a acestui {ascilant cimp de activitatr:
    ',,
    ', de ADN cu ajut ot ul unei. cnzim c dc l'sit ir
    a unei
    1,12,2.TRAIAMENTUT
    POSTNATAL ' ' l .rr,,' 1,i. , 'cisi - olecule Boycr Stiurlcy Colicn (1972)' S-a d)1irr.lll
    1r, , Lt.,rtr.rlrcalizat cle Herbcrt ;i
    1 11gq;ilttiit'
    \urncroaseleproccclceterapeutic0iolositc in cilzul unor boli ercditarc , t ,1,l;,lri,lcrea ianlutui t1c ADN ;i scoatcrLa tnci .s('t'!'entc
    m ai m ult e gcnu s- a c- r cat posibilif at cr L insclir lii lt t
    llrrrlrrt:cfortul dc corcctarcpartia"li a unor anomalii transmisc reccsir',nauitlcs- r, ;' ,, r, trl i i r, l unzr sau ;i
    cu ajr r t or ul ct t zit t t t '
    lirll Inil dofcct enzjmatic cu tulbur:5.rimetabolicc secundare. .,,1t t,,, ,, rr lt r iigr up de ge, nc,s"cgiunile{iind lipit . apoi
    f iologic plirt lolo:ri
    ..1.llicrapia de substitu!ie folosesteenzime 5au pror'ine l,,r \rclrli clcscoperirea stlLt la baza unei ro'oluiii in
    ,,rfl' ;r(lnrinistrat; pc cale intravenoas:r,sint preluate si utilizate il celuGle dFili- ,, , .r ,lrrrri rnctodc recom,b,i,atL:a ,4DN 9i obfineret anticor'|i1tr tn'ttt't..
    r i, rrI r'. Prjn accastirmetodir sc tratcazir.:a) licntaJil,iaA., c1rconcentraredc Iactor 'oi,acestor:r ia problemcle' practicc meclicalc alc otttt'tritii
    1, rli. l'ritt aplicarea
    V l I I t'xtras din singele umau ; D)dg&lt4ilutgl,obnl,inemia, cu gamrnaglobuline spc- numit biotehttologia'
    (ilir.t': l) dtficitltl, rJccotrinesterazii., ll.llrl tlrl clltneniu nou,
    cu pla$ni rrmani] szrllcu extractc crvjrnatice l'r'itttt'lt ?trt:crcirride ilgincr:ie geneticil au{ost lt bandonatc
    pcLltlLl r) l)i'rt
    r : t ic' EI c s- t n axt t l) L'l) r 'r I
    1,,' 1, rl l l i rr r lr r lit r cat r zaunor llcer t it udini de or din
    l)ll1't llc ir t ( r .
    'pr
    !\. I r n t ' i r . t li c tr a e t.f c c te i a r b l o c tr.j u' l u i en::i m a i t c. t lt n incor por a in cr om osor niilor '' o Par t c' sit r t t oiit lilr r lcr r
    ,t, ., 1,,,,1 , 'l'iolr Lgilol
    lrr rrnclc lroli mctabolicc sl: poate acliona asupra fazelor neta}olicc care sint. i| slr u. odist nt g' lJlr r : lI t ir r -
    .f f ,l ,,t,' i rr r r , . <ri ''iuI tl, , act r : r it 'nt ',pc ''ar c apoi o piir : Lsir
    l.girlr' rlc rrrr tlt'licit cnzimatic. Existl mai multe eventualitifi: l'r t clLlici. c'r ', f i
    ,, ' r ,, , , , ' I , ,' , ,, I rt, r' i tt cr , nlint r t r t ' f olosinr i6cnel' "t ": ] ""1. l] . , : : ] . ''
    rr) ('irrtl substratul enzinrci in car.tzit pror.inc din tncxlirll exterior, ' r r r r f oil r lt r t ni{i t r t t t sr lt t cir r t i ljt ) ") iin( ] : r t r '; r sli l) ir llt ( lr
    ,l rrr,' rrt ii. 'A, , 'li l; r t li
    r| rrrlrrt.r's r sc irlitninir a.rhrinislr'a::eaacelLli produs, Astfel, in fcnilcctonu- i; r ar l izolr t i i1r 't r ;(r: r r r ' ( x) n.
    r l sr. irrllrilistlcirzii dielir ,.1111,.frir^'{iLrlt. {,:nilalaninir, ltt gitlrclo2cnlitt i .,' ,i ,i ,.; I, r , I , , i , ifIrII i I , i , , I ) Lll) t r l'': , I ler st : hr r rsi l't t t
    . 'ct t t t t t t l
    ri , (.:,i rllr ( l(lir lr lt lc r ii tt ;rI i II r{ r11i r1i r' , 1 n l ri P c r,o l t' s l crol crrri r'f:rrt:i l i rtl i istr l cducr: ,,, f ,,rf fi , "l, ', t , t 1i"'11t t r ci, li, <lr ii t t iisr 'lu' t lr ir t 'c'll 1t . r : r r 'r r: t u t t t t t r r il- o
    r,rrri i l i rilr r r l, , olls llt o l l tl i l n t' trl l tl :
    ll- 'l

    I tr{)
    I i ri dc :11)N t ;tt'/ttt:;t
    i,1 l ttli irtr r,' l, it,l i Lir gcit t rLtr:it'tt cttttthiit
    ttt"/..t l1r r 1, , 1, , : ill )L l rrrrr ,r, | ' Ii rl l l )l l , 'r' ri ' [:rri ' :rr' ,Jl \l .r' i : "t
    t,' l rl .t,, ' i ra; r' 1n1' ,1" \D \ ,l i rr E . I{i!lrizii r:xltrinrrr]tali rezuilati irr.birctcr.ii <lin l,]cot\il)i!r:-|Ii1,J t1..Ir'1
    1.i.lLg.trit.
    .r I'rr'.rL. \ t , . lr r l: r . iu .r,, I i z o " , ' ttr '! '
    l rr l r1 7l. l> r r r r Il ioq n i ttt;r' tr' i t1 ttto rIi Ii tl ri l c IIs tru c tu l :i i bacteri ci ' E . col i pri n I' ri l r- , .\l)N irrcziniir ullrirtoarclc particuialitlli :
    in<lislx'rrs;llrilli
    rrr,rr lrrr:lr.i:jofltgului.tnlr'rrci1 rl(liviiiri('21 l racicrio{irgiloi cste imprevizillitril-;i - sir.Ltincapi]>ilisir sinteliz,zr Dufirr;t sul.rstan{iclrimicir'
    lr, rr ,1,' r:orlrolat, l)irrrl l)r:rg ir irvuL iugclliozitatea dca folosi ca intcrm.:iiar sir' I, zci ADN, {ir:t .te c'i':e gt ru"nii.nn sinl r'jrtl r:nti;
    ": rilei
    'ill D:t;ti'din .
    ';;pabili sir falrricc rcicinl cliurinopimclic, inclispcns:rbil{ororr-rr
    rrlr'r,lrr<L|i"idfrrgsi cclttl:r ltacicrian:r, u11\'itus a-cilrui replicarc csic const;liiltar.
    \rrlrrlrrl t iolosii jtlrtru ircc:rstaYirLlsril S\r-40 (Simian virrs, clasat pclocli '10 1rrr'.
    '' I isulrri
    '- {r:rmr:nilor ;
    rrr ,r'r irr lirusulilor suscrplibilc cic a infccta naimllta si t product' c:mc"i 1a ii,it"ri..t:i 1a icinpcrat'ri 4i:37'C (in corpul aoimalelorcu-sittl;ccrrltl;:
    .rrrirrrrlr.).intr-o ldnr iL fazi, ATI-r-rrl cliu S\: 40 lr lost transfcrat in lractelloi:ig r.iurot triLi 1a tcrnperaturi sub 32"C, dcci it apir' acl"i so1;
    ,r irr rrI 2llcl finr p i racicrio{agul a fcst inttoilus in bactcrie. llultiplicirrca lracltrici . .,u por ft r'm.nlr ..irrlolosihi,lrrfi d, 'rrbon:
    1lc,:Jislrusi.l, lurrrirr zil' i;
    r' ,r lilrrl in coniimrar:c dut:ir morlclul AIl,\ din vitus, r::r urllal:c a vecotllbili,!tt'i.i -.ini r,.'iii,,tl 1r r'.2, ultnriol' 1^.
    tttt:,) trlt'l()r gurite. itt aceastii eitpi d,.: ccrcctare, I?obert llollaclr, a sili!:ii:it . - ,, 1 uol orinti irrformllii Soncli(I rl' l:r altc or{n'rt'mt:
    1u,r:i, r, infci:tirrii su5cid.cE. r;olt.carr-c tliLic;tc in colonul ullilrl, cu S\. 40, crnr:l- - .i"f i"ii*""!i la nuri ero;i fagi, tleci r"fractLri 1-r ttrnsrtitcLtrrL srrrt
    'lrrl tLt'tirnor-i 1a om. -{.cc:asti- ipol czri
    , i,,,,rrlir rrrtirtrrl si irtricolul clea iuducc for'ru:tletii r'(;r:.rrtionareade ADN 1a orn sau la virusun. (l(
    r rIrrlrursli o pirtelnicir rcactic a oamcnilor c1c;tiin{ir fafir rle:Lspectelede clicir ' iil;d-'eri' tl" scco.it.t" rirr start la baz;'Lrcluirtii t'tlcdmcntclot
    .,1,,irrgir'r'r'icigerrcticL:,cuindnind cu Conferiirta Asilotnar (Califomia, 197:1), rr,r ,r,fi, !,'ni'rici irl rritilnii l0 :rni
    , l rrrr.Lr'irr', rrlutinir:rrira. csDr:rimcntclor a {ost intclzisit.
    ( ontxx,r'r'sc1c iscirte din princlc rezuitate t1t: rt:cornbitriLrii gcllclor alr [Dit
    1.13.1.TEHNOIOGIA RECOMBINARIIADN
    | .r| |rrrfi I (' l))'irl ck:scopcrirea ;'n tinp a douiL {cironeue: a) rccombinir|ilc dc AilN
    tl'
    rrrrsirrl irirnnalrtl ingitrt:;:ieigcnr:iiic, clc producindr.r-s, sPontalr iu naturir, r:'r o Prt:z-rutat;i simtdificat, tehnicr recombinirii ''\l)N cste un-procct!'t'tt
    r illzrr rrlii rlc trr;trcinr:it su Po:lic colsiLlera Irui util c,l eic s.i {ic.controlatc pnn ,,,. .,,i*"i" Ai)N .lriir, intr-o ccluli gazdi (bactcrie sau alt rr icrootgrr
    rrrrrirruliiri <ll iirlxtrator, dccit sit fic lirsatc la voia intimplirii; l) ingineia rrr.-- .inlr-u"..i"tiiormi car( s-l pcrrnirr-r mcnlittctt''si r"prtt'l'rc'rta \D\-ului str';-rirr'
    rle lrotcctie biolo;icir ,';;; ,L,ruoifi.ii ;i multipli'',iriicclulcl"r Aiizdi' I'rin si'l(ctionirr'.;r srji
    1,,rr' lir rr lr|rt|liciaziL clc tclruici llif tle prtcisc si cl, misuri ;
    l,i lit i, i, irr rtDitiLtir1ccrrti:gorieslrccirli (P1),iucil pcl-icolul rattstrofelor urllrrrtt: i , :tf .f in.i,'""r. .r".itii-i o lnumiti prol.irri- irr'!sta,l)oatt' itrrl.rtr''irr
    l, t,', r, lrrs. irrrlir,intt viiusriluiS\t 4o lcaic {uscs- prczent in culturilc dc f.:iri ,l - . ,i"z. "i "li o sintnzi ;r Prol'inci in cattzi.Ittfrttcii tttt'tt'trt
    'liriia{:i.'rlnosclliL s' porrtr:<rirlttt'
    r, rrr,l ,l, nrrirrtri{iL,rrl.ilizatc si ar.Ltcriorpc s,rtrri Jaigi in {rLl'ricarct vaccitlllui ,-l,,ii" t"r" dc ctcitcrr ltltrl'i Inari.dintr--o' el'ri;i-g;rzdr-L
    .rrrlipoliottticlitic -- prizcnlit rlecuno-ct1riI il lr(nlca rcsPrclr\-ii)' c(-'rcetirt rcirr)- "u
    ,,.l , .iiit.ir!,. urr n*m1- riarc 6c cclule idcnticc urunitc celulc monocL'tt,rlt ltlrtl' '
    ,1r,.r'{ir',r
    '
    lrr iu{iunat cfcctul siu cancerigcn1a om. l , , .ia".ri ,1" or" utilizat). in acc.t fc1 st lxra.ic rcaliza sinteza cconoLIll{ il ,
    tr.\ lltcomb'iu,irtila shorttarrc rte ADi.l{eprczintir ul {cnomen o|i;nuit in "lor
    ;, ,]rt:r';it,,;;d";iibi1,', t .rttit suLstarl( tlc pr:otticir'in c.ttitl{i ltrrrtt'
    ahii 'iLtutiL
    naturir'
    rrrrluli. [Jn cxcn,phl il constituic sugcle c1cE. coli, a c:rror virulenii a cvo]urt ,,,,,,nt,iminate
    -i,"iiorn"u,'t de agcnfi virali sau dc
    I'ri tr rrr, r ' : r r i. m r t lr ( . ot n b i n i ri l o f J ' -{ | )\. .l""r, iom l ,inar' rr '\lr\ tr Pr-rrtl'rrt:rirnullr'^cLrp":.
    l r r lDir r iJ c , nt lo frr' o s ' rri c c ' l ' l . -" p r' 'zi nt" r ' :rIV i i nl l )orti ni " : ,r) l r., *m , niar . a Al) \ izollL' r iin l nolnul lLn( lc lr ll" ' ln lor ull 5l) r r 'r lr l
    r"rl i l ,rr , I i; r r ' i, : . I r r c ' , p i i . I' ,)c:. n u rn .-rr.'p",ri ' 1t"i rn fa ctori i cat,' tl t.cmi ni tt:or' ;' I' , ,, ;,ti.lon,littor cnzirnc <1ercstrictie satt cntlonuclcazt' Sc cunoso aprc'lillillrlr\
    irr sr,lrlic:r:utii, in stiirilc cic imunode lic!,:n!:"1 ;i clupl
    -iutc'rvcnliile
    chirurgicale. t'i, llr, enzirnt de rcstrictie, dc oliSirrc bacterianl'r;
    l'irrii irr rrruri"rcu 20 dc a erau mai ptuin rispinditt, ial plasnirielc (forrnafiuni t,) dctcrminarea sccvL'rllclot dc luclcotirlc din Irag.'mcnlLrl
    tL: AI)N scl'r
    (l( ,\ | )N L'xtracromosr:nal) ,rrau rarel in ptez&t .i0 - 507! din toatc varictirfile (t,' 1,11,
    ,1 " l i .:o l i Lor r t ir rnlr r . rr' i d t. i n m,J i ( tr,i ti p u ri p cnL' ' u Ii ecl r. r' ,tti etal t- P l a" - cirl-(cstc rirrr'l'i' ' t
    rrrirlllc ir-ccrlt'ie.ib.Lltcriela +ltt, prinir-o dodalitate cu totul padiculagl: umxl c) iltroducerea fr.rgLncutuluidc '\DN in cclula-gazctri' (:rl ltrr'rir'll
    il' f.'.ofi.-,q...'ipL,,"cslcrcrlizrl "ralLlorLll 'tLttri r'ctor"
    ,lirr fjlrrnrrltclt-. dc ADN sc desprinde din intcriorul urrei cclule (masculiniL) si f
    Ccl rnai frt:'-e't' ivl'sit'L c'lc plasmitlrr t rrrr''tL
    jn ;,;.,. ,;iii,;.;';;ilti,lt,sol
    lrrrinrrrlc in a.ltii ccluliL(feminini), cil c.rrL'1-jnc contacf qi in care reconstituie, ir"1"p";i.i;;t i1cADN-..1] r:c].lti gazdiLsi poatr: c.clificir si'1.2,
    i', irr r','lrliclrc, cchivaleritd rirrna; in c':lula rrascutrinii. Rt producerea plasmid.ei i,,r,,,,"i"pr]..
    L l , . , {) i . , 'i t c ;
    ,, lir,:,: jnrlcpcur.lr,nt de rcproducerea bacterjei' Iiolul plasrridelor este varialil- t' r i i :'];r zr l i 1 'tr tl '
    l'.1r, 1rr1 ,,invir{ir" o cclultt de t fabric:r. cnzine de rezistcnlir la antibioticcl 1 t s | l ,tt;r Il l !l tl ( ) ;l ' r' ( : t l rt t ' l /'{ :rl 1 "'1 :r L I:r r i I''I .t"r ' I
    I ( i r i i r n r L l r i Pl i " l t i ^ r tti ( ,l l l tr "1 : l l r "l
    --.ri,",-ffiili,i 1a virusuri 1,.. , ' l , , ,,,l l i i g , tt,,',, i l
    iiii,l srr,,ntanc<1cAtr)N sint dove<iitc de asemeuc2r
    i r : i r t r r i r tl fi l i !t ttu tr t.
    r,r lrr rrrrirrll,. l)irr rl,rLLiivirusuri difcrite Prin rccombiniLricie A1)N, poatc I 'r '
    ( l ' 1 l r i ) .t l r .r i 'r 1 r 'ri l l r "r
    ir,zrrl{rrrrrrr"itttstrorr.Arx'astir. errcnttrirlitattla {ost (icmonstratirprin ()xl)crien!;r i r r l r 'r r ci l i zo l r r t|l t <l i l t S( i l l o l l l l l L l r r r iIm g ttr tr tl r l L ''\l ) N ( l {) 1 i l . n |'r i r l ( '
    ,litt l(,7(), lrL :ian-liratrr:isco, in unui vilus inoli:nsir"ltl bab[i-
    ctrrt'rurtnt l.ritliu'ca ,,, , , i , , , , ,,u n ,i t,', l l r r r l |i n i i 'sl ' Sr tIr ( l t l i 'r l i l r ' r r l 'l i tr ' r t 'r i l '.r r ( 'i
    'rrrr t u , t t t i , ',1 ,l ( , l i t'tr 'p l i tl l t l i i |sl i i i r , \l i N 'I r "r r l t\l t 'l n r 'i l l t l l ( r l r l r l i r l ( l r r "r r l r i
    rrrrlnir.rr vit'lrsinof('1rsiv al Eolrrr,r'lttiir dltsll lortIl:rl(ritlltllti 1)il)fi(l{]llrc{i1i- L
    r lrrlr
    \ l f ', 'i i , i 5 i tr r t, i r ,l i tr ', tr r |r 'i r j ttl 3 'tt'l i r , i ttcL Ir tl l ) l i ) !l :r l l l l r l i l r l r l r r r
    ,:lirrr..r,i r.rl (.(.rl lrrl rlrrrririliLlrirlrrritri
    1i |[rltr:i rliLr1i la r:iirri,citnlrrrtrzci 5i itr r l l Ir r ( l ( 'r 'l l l i \s' l l r l r !l r 'r I'r r l ')
    ,r
    (l, 1 , , l i r r | t l ,i , ,'r , r r r 1 ,l r r ,,\t{\l r r 1 r |r r 1 1 ;i 'r 'r 1 '
    Illrlril', ,, lrrl,' tttitltr'.
    '
    t li;t
    lir-i
    1.13.2.1.
    SINTEZADE MEDICAMENIE '1.281
    (ldheiarl
    I rr rrj rrir r r r r lr r r t r . ir nz i rrrl tt:tl t l t,u rr.ri fl t:l h ftel sai (ret:crstranst:ri l fu:,.) ,,-,
    rr,rl i zrr z i lr ' lr r r r s lor r ri l .r,rr.\l l \rrr i trl l o i rrl ri c a A D N -ul ui , t)umi ti r A D N l torr.- Sint ezoinsulineiur none
    l . 13. 2. '] . l.
    l )l ( rtrr,r) 1r r ' ( A l) Nt : ) ,. \u c s 1 rr,rrrl l l rrri ris l a l ri l d e c i t A R N n, este i nserat i n pi n:;-
    rrrirlr'rsirrti'irsla incorporr1iLupoi iu llLcterie. l)]asmidclc utilizatc in laboraiuai-c in siulcza insuiilci tmane sc folosesc clouiL tehnici tltr recolrrl'irt,rt,
    prot irr tlin plasttiicl natltrirl(' firrc conscrv:1gencle dc lezistenti- la nrlclL' anli-
    lri,rtir:r'(lrrrricilinii, tctracicliniL). Acesi ut.oyh,eri de rezistente sc folosesc ii! .1. Sitrtr:za indcpcntlentiL a cclcir douir-1anluli alc insuiitl:i (A ;i ll) I'i
    ,,llr'liotnLct btctcriilor cirr.) g:Lzduiescpiirsrdda hibridatir, si la rcperrricit fll r.'r c[plarci! lor (rnctoda dcsclisr-L tl.o GocddcJ ;i co1ab., 197()).
    /3. Sit.ttc-'za proinsuiinci 1)rin l.rfrri.rr dt:trtnstricrL'. i.tn:usti ,:t .t irrri ' r.,tulr i r
    ' l o rrr,l orr : aLcau inc o rp o ra t AD N c .
    Iiirzrr unniltoarc., eiitrcru cle dificill, constl iq izo]ar:ca din zccilc tle nri rlr: r . iusrriiniL (\,'illalionaro{{ l97li).
    l ..\' ttt t t : a i, n: st t lt nt i n! t t : l. t tr al/ t t ; it t t or ul l'.
    , ,,lorii llrctc'ricnc, acoa colonic care contiDe Al)N-ul spccific pcDtm o i)r'ololuii ': ol'
    .rrrrrrrilir. Ilxistir numcrosc mctcxle cle triai carc neccsitir per{cctirni-rIi. lrirr ' l r. 1.32).
    ,lirr clr'lolost'ite sonde dcAl)N produst prin sinttzir chirnicr"r,-
    lir ir srnr lpropiatir. cu t;cn a unt:i por{iuni din ADNc ciutat. Scxrda,r;rr:i,atir
    cu sccv{:llar i,r'n-

    ,;rrl i o rt: liv s ev alil: r idc A L )N c c tc a rc s e a m i rn :rs tr:u ctural ;i dt" r.cokl ri ci r-,,r.ptc-.
    iachr,:'tt ).
    .4i'iA (! Q!.',
    i yp))
    lr\{. iunprcnta de radioactir.itate. Aceast}. colonie, izolatl, \'a lcprr.rL'iili].
    ;rrrrrclrrJdc plecare al culilrii nonoclorra]e calc va sintctiz,a protcinir pf{r{ra- :.' - i
    rrr;rti rlr'-\l)Nr'-. (lu a.ccastirtclniciL au fost clonatc protcini: urnar.it:ca {aliorul ,r'0,!t;i \ ',/
    ,1,,r'orrLrrl;rrllX, al{ar-antiiripsina, insulina (Iig. l. O I ;i LI). d; dt7.fr/.r;'7:i
    \.,t,,,,

    ,rr'
    =_)

    ;.1,,,,,,
    It
    ,'/e// bethl ,/ar !! r'ilE,r 4 |f/t? .
    I
    I
    I
    @ /
    /--:..
    f ri'" /i#i,'."L2
    :
    i --
    /ffi\ ,Jtt le
    li trl,ti
    l,n\ I
    +
    fo!!/el/t d.
    v +
    i
    xt,rirro4c!1

    ('i|',! tv
    [L'i.u.

    a=
    /L\\
    nl
    .0,,)I
    'l,r,i,.ot '

    til -.-r
    : 1t l . l ' f . , t L t l i rc rc x ] , , )l c i rrN i u rr: i l { j i : ' J L a l -rn l i 1 1 i P s i 1 L ! ) ru rj t t t ! rf L rl l ' rrrl | ri i l r' r '\) ,'ll'
    , ' r Lr ,. i rrl l s n ri (t c l i . rc rrl i c 1 r. !apai;ic s a ! s i l rl . l i z rz f l i r. , t (i u a i rI rrL t rl i l : r1 i rrrrrl r, l ' rrl
    ,',,, 1, , , , i (l n . a , " l , i , h t r-r, \ T)\ i a l a l ra 1 a rt l : 1 ri l )s rrf i ) i I l I t rs D rj ! l x l )' l l i , i : ' i l ' r rr!
    t ri. : . lt , . l l t i r t c l ( i s i D t ezci tr o tcio e i- ' j- ilr;n g jr .r - ic g cn eti ci , 1. Izol ar:ca(cl r.naj ul ) .A ])l i care
    , !,/ Lr iu r { ri 1 r(l ( re g l a f e , . a r. 1 )c f ri i l ro f ! (i i t i i i r-r(1 e (l l i i (( rri l s rri t rL ' i ' rr' 1 L '
    t i, . iliI r'i ( ' t ) r ( ) t c i r r i , - . \ ) l zo ia r .a ,\ll\r r lo til r lin fi.a i. ll) (opi crca A l l N nr i n -\D N cori pi e. ' \ 1 )\ , (l e t L 1'
    ,, s i g c i rrr. ( r i i (i i ] i . r-! i rc i t i L rr p rr, rr: i rri r ' \ (l i n l ' t l t l c f i o l i rs : l rrrrj rrr'
    ,, i t rljI l.\ l ) \ c ) r r : r i u l i , f r l r cr e r slr :!r sc.r ilta z.j. ( l - A.I) \c cstc gre{a1 i nl r-o P l osl rl i di i ri ..i e- ' .l r r r n rt i l (, r"
    rrr ! l ri L l rr r
    '
    l , ' 1 , ' : i r{ 1 5 / l rr. * r, 1 L ri (] c l . g : ru t rri a ri l rc z o l l rl i rr l l r i ' i ' l l . l ' 1 1 ' / ' rri t ri
    , , , , il . ,( , 1 i ) , c , , r , n , l c / c.1 ,' r . J) ) lr la sn r id clc,.g r cl:r .tc" sinl i ni l i ,dl rse i n col i !acj l i . E ; i 'opr- t,Ir
    , ti l t'1l L . L rr; , L r rl s l l (1 t c l i | . l 1 : i 1 : i 1 f rf i l r' n h rs a t rrr i ' . r rt rn . i I 1 n a rrrrrI i t r rr' 1 rr I
    , i, l, , 1, l , f i o l l ( r i | | i i r l l { ' f r i ilii.fiio r n ctcd c, DiI:, cc se i zol .azi r cl .:rna car( f.n1i c r.l )\_.. 'r
    , , ,LLl | r .\ t , l i , : i i i L i i l rt ! ' rrl , ri n r; -r rl i n i rl t rrrrrl (rr1 a I , s i rrl . l i TL rri o (l t L ri i 1 rL t rrrrl l i I l i (rrL . i l'
    ' rx , ii j , , ( i l | ' i , r 1 i i , i i!r lr n r , ir r n n r iia L tr o io .:r l( lc.\(nrtl n al l a 1-ari l j l rj l i sj ral .
    (i (, , , r, 1 t , l )1 1 ' l . i rr: ' r ra i , ' ri t a f : i r rrL t r(ri { i L rI s rrt l )) \ t ' - l rI L '
    ,r !l (' 1 ((l r(, i t )f , L i l t j i L 1 , I I I , i rrr' | , , r' 1 I r, , I rI I I , l I ri ' l i l ' a L i l i rL rrl ri r' rrl r \ll
    t , i i rrri rl i / r1
    1 , 1 ' r' l i r/ j ' l " ' i rr l )\ l l
    APilCATIttE
    1.13.2. tNGINEn|EI
    GENETTCE \i l , r t ' r, / ( rrt rL \ l )\ ; , i , t ' 1 , ; L i r l l r' { 1 .1.

    Nrrrlrrrrt rir Iri,rl''II r r oI oljlt - r lr lr , il I r lz c lI pr r l r 'r 'l i l i n r p l i c l l i i r r : i r t t r '; r r r l r - , , / ) S l I'r ) r l l i sl r 'r l " l l t :l i ttt,'z; L i l l tl ti r ',i r t l l i l L l l l i i l r r r Ito l Itr r ' \ ii, ri'
    "t
    ' r1, rI i(i| |rIt IlIl rl,'r'rrrrit lt r i in ' li; r , ' t t , r , lilt t l r r t t r i r ; r l c r t i u n i , i t r l t r l , r i r t r l r , r r r j i - ,., r l i t r , i L l {) l ) r r r trl l o l i r l L ;

    I lilr
    ll, I
    '/ nb,l t,: I.:\:
    irr,livizi. ltcztLltattrlcolrlinu1cati:s{ir calitateafoartc lrutrir'rr accst()iilrslrlilr(l
    in nasir tlii spcranla rc.ftlcerii costtllui m eclicam.crrtcluiln gt'n',al
    l l \ . r" t 'lr d r t r r o d u . ( o i r l l x u lr ' tr r ' l' r .lr t!' l0 r r h d e r o lI) r r r b ir ln r o a l I)N fl c:rre pot Ii uri l i fi ?l d-ri -
    r tr r ' ' t1 ,, ( l' , llii,,Ir ] D..]j_ , l9 l J4) lr,,i,ricLu.,ra
    1a forn' il{
    i,'.,"i,n.'l ,."iiu"""zd mai iepecledccit insulina porcins Administrati
    I,,(xl,rs,,l i ,r1,lcaU b Stadiul ,le dez.,(rtare f,t t'Ht niti/)l tltl t
    -i I t.t t t/f ,l/ r://i/4 x0t /
    le/7aPer/ru ,taiai,,5
    I) ir !]) o t incerciri clinicc cfcrt[ale
    S.U.,i., Distributia tx., Dlat
    irl {,r.za
    nrordial planifica.ti, pentlu 'i6*t , t ':'
    6rrJ
    decembrie 1983 ,l . I <t r1,4Jt'/1Ul
    Ncsiglr; posibi] sir, {ie un FoL|/:i
    '1FnrnI
    agent clicieui inrpotfva oefa-
    Bt/e- \- _'
    a'l rftor intcotrii cu ..7iru6j.
    { a/!:/a1tl tri
    Incercar.ile inilial€ indici eli-
    cicrti inpotriva anuhitor
    {orlrc de cancer (limlorr, I
    snrcoll] Kaposi) l a,t/,3
    I l, t r ) ( k cre sl ('c [ru i L n Unlic ca^ri dc nrr.nisln hi- Primclc inccrcid clinice
    'rrtr
    (l ( ; l l $ , r r n Ir)a tL n .ro ]]i n i )
    Polr/,ar terrrfnaie cu suc0cs irr
    s.u.n.
    i_ _:-.r
    Diabot lncercirr'i clir)ice, in curs
    4ll,rr1';rLr ti i r.r. rl l l r! S.rcuri, tranDc, inier"eri.ii
    chr-u 4lic-rnr G!1r ncccsitil i n cl rrs (l c dczY ol l .;l l r'
    irlrrcuirea rrrni ,ohulr .lc
    siflqe (poatc {i ol,tirot 1;.rI
    Yi.u$i)
    ri) Urrle {(,.lr}e dc canccr {;en:l csi c i j l ona*L !i ci pedi otb
    tWr C/iral ta ffl6r
    (determirii .listlugerca d0 1 ttira"' ra
    ci-rtrc .clula T stinulatiL, a Sirlt plani{iutto rccrci,ri I
    .elulel(rI cariccroa.seJ
    ,) Poatc da l11ll.la.liidr ldrl
    cl i ni cr
    il,__ -)
    tan1,,t mzzruZ7k,/,,6
    prei la. ciuo sislerrn:l iLrrrrriiar

    I .r' r, , | '' , r o r r g r l a r c 1 , J l l llexroJilnl in crus dc rkizTol{;rrc, ceui


    clonrrlir 9i e\p{:L}iatii \- ,'"
    \, 1rl. rLrrI I ) l l ' s t u ; n o g o r i { i c l)izol/ir chcrgr b dc sirrge l]l prczert se p1r ljc6, din ,/
    I I l'rl $rr ilcti'/n- in tronrllzl, o.luzii! ar'tc- surse lraturalc, procedcul rle
    1 ,, rr t t',rs
    , , t { iIi t ? c i
    rri o ( c i ( l . i t i p r l r-clor Fi irltrrct n)io{)ardic jccornbinarc a ADN in curs .-:
    Ihr.f; .roiii.. s!.n cit lln.s- I r] curs (le lrccrcarc
    t{ izic P 1 .r m c]r scr r - t i€ slo
    anat()S r':tlnrai re :rr.oiic
    1 :i !. l .' 17. - Ins ul i nc urnani bi os i rtc ti c :r (duI:L W l" n' l i l l c t)'
    a l d r o r jiii.i)

    ,) i{,r:rr{rg(xrir sirtcticii i:st c I cgatii dc gcrlr car.ccodilicii bct:L-galactozidrza, , r,rr irlr' it t1rrsla scirclcreaavortudlof. Ll tinc|i, a pcrlllis rcdtlcilrfa scrrlr\tll
    . I I
    ,,rr,, l,r lirrrlui , i ir fosi clonatl iir-irl.rsmiJJp Ijtt 3ZZ; c) plasmidile purti].rJlrc. I ., r i ,,,i ,, ,for,--fn.. Arc int-licatii prccise la copitul diabctic in cazul r.zisl c' I ' t rt
    ,rlr'y1r'rrr,i liru(rlui -\ slrr lJ si genei lr ta g.rlaclozid.rz,i sint introduse in bartcria si iu clzul a1cryir:iIa insulina porcinr'r'
    ',r',rrlitr;rlxrt'cinir
    l . r'li ,.,1\ cl( sl, r, ,( Ii, ;uli ir plezelta galactozei neccsiti sinteza.cr:escuiil.de
    lr t.r.i .rl ; r r ' t oz , ir l: r , r,:,i 1 n n i r,, n r' ta L u l i l a rn .r g l u ci Jul rri ; c) hr,-rtr.i ;rv. i rr- 2. Sintezahormonuluide
    1 13.2.1
    'retlere
    r!,lrrir o l)ro1('ir:r Irillid c'lt:I004 anrinoacizi, for-rrrti_ din beta-galactozidazd.
    l,;.i;rIi rlt.Iirrr{ul I srirrl}a.liusr inr:i, printr-un radical metionini;f) prin cl:varc t
    I| l ' l ,rtt r , t t t t t l ;r t t t i . t t t t t I rt i lr oTlnor l JI cr ' sr ( 1 ! C ! l I *' f 'r l'r s|l' 'll.
    'r ] ( 1"1o'll"tl) lil'r r r ll
    I rrr(rtl i i r' . \ s i ll s ili. i' li| c l l tc d r, I r.1 ;1 -.q 1 l 1 p 1 r;T i dri zi L rccornhi i ri i c pri n,rxi -
    rLpoi r" .t' 15;rtti . Sir t t , 'zltr : lr it t t ir : r -r L. t c, : '1uilt ot r t t on ''r r ' 'l [ ( ] -
    1,,,i ,, i , i ,) r ; , ', 'i; r , , . . i; i. I l'r - r r r onr r l olilir r ut r l'la t : . t la. vr t :t : st t ,Jo, ' r '1t 'r 'r , sli
    i g rr r pr , l. r . < r Ll[ ] ri rl r"f('i l i,tl )i ,rri rr ,.i s 1i,rr,' i /tt,i rn i r-ri { rl osi t:irl r: c0ui l i rni 1D 1i
    '. l ,r.r.r'rr
    lill V S.l . , \ . ) ( t ig. t . l7 ).
    " i ,
    rl 0r t,, l rl trt ( i . - it ll lr , ( t sr t li: 5r ) r l, lli1x, f iz" 'r r lr 'r : lr r lr ', l"
    llllr r lr "l'lir lc t ' ll'
    l ,i rl. : , ir , , r rit r c lir r i.i -ri t i r)s l tl i ,( i rl r(i rrrr(cp r-i trr;r,rIrIri ' i rl .r,rrg.l t(,ti (.i .ii t l osi t., l tri t ll I r'lr I i I I t | , . I I 1 rl , tttt i tl t (.1 l )l X ) l l ){ nl { ),l r' rl ol rl fl ).
    iz''l I t
    I II,II Ir' rIr ,| 1i I i l( ) X { }/ ll, } i r" .rr). l i r' ,rt | l ( i ,r l i )s l , rrl rrri ni sl r.rrllirr yri.tr. | 0()0
    ' S i ,rr' 2 , : rI r , , r 'r I ', r r lr I rrtli ' r r , ''t ' ' I r' ( t | '] r r l') r lll / i 'r r li, lxr lr r ir r 'l'l' i i
    ( , . ll. , lir i t , , r r t r r l I I rrr, I rrI : r r , r l lr ilr , r f i
    iz, |, , r 'r l( , r lr ir r '
    \l .l N rr, ,,,i ,. r . or I iI i|r . i i. t
    I 1,0 I Ii'i
    llli;lllr,'lli,il r,Li,n,:i
    ;,,','i;ili'lJ,l,lllll,ll;l,ill;i:'l;'l,i.u;l;.,uriiii-;it,:'.,rri,iL l rrl , rl Irr r r r r l r ut ' : 1r <r : ilit : ilr t ir ' it r silr : cic.I - r r ct t t l st 'ct r uosc iiLi lillr Ll r 1, -
    Is,',,,
    ir",,u rl;rIil'.,it...ii;;;;s;.,.;1"':";ii:tJ'lil"iiitl"n rl r' ror:,r) ir lcr - {clolt ul Jct Lt : ocit iit0)- ; iut cr lcr onul clin iilr r obla; t i, st '( ] r 1l r ' , 1,
    1,i,,r','r , rl L
    l',11ii,i."
    "' '' lrrl, rrr, lirlirtirazir-fibrinir; o) intt:rtt:r'omrl itnunit:rr', si:cr-etatde cclult ' rr',
    r.l r' , rrl ,, l i rr kr t nulni llur kit t .
    ',
    J".r "u lrr l( r'irl\lltica :r.ltica.uccroasS. (extrem r1c costisitoare) {olosir|a jtll i,
    /\ -A ,,rrrrlri izolrrl rlin loucocitc;i fiblobli;ti a clat lezultatc interplcttbilr'. .\ i,r'i
    V ltutt
    ,,,1,,il irr r',Lrrr:rmlrlc sin, caircerul osos, lcucctria limfoblasticiL itclltit, 1r1i('l,,rrrrll
    -- 7--- -l
    // fen, rrrIIi ;rl rr,rrrr'I luor r r u<:c: , Lncer uldc plir r niu, lim f oam e.
    lnlr.r'li'r-ortulobliuut prin recornbinarc de AIIN sub forrniLdcr gtlliL trl,,it '1,
    rrr l rrr' l l ri l cs lt , r nr r lt m ir i ief t in. Un iit lu t le cult ur ir r lc b; r ct er ii pt - or lir t : r ': t t', 1: r i
    ,.--\ ':
    f ,.rrrl i l rri ,,l , int r r r f uLonca si cit cva sut c clelit li dc cclulc ur naur : .
    :' l/"'a'?;
    t'.--,-''

    5intezode {qctori ontihemo{ilici


    1.13.?.1.4.

    l'rirr lvolrrtia consiclerabilii a biotchnologir:i -.LrsPet.ir-obii rtt tt rt ,rrr,,t


    rrrr rrri 1r'r'irpt'rr1ir:c cficicnte in anomaliile factorilor, sangnini. h.rccputttl rr t.rl
    I r( rl l)rirr izolrrrca lactomlui IX (dtficirnt sau abscnt in hcrnofilit l.l), lirl irr,l
    ;,1,,r,rl crrl rc r r or t rt lir f Lr ilor de ADN. Jnt r ut it conccnlr at ia sangllinil a l'ii( : I t r IiI I ||
    l\ i ,|I,|)iIr'{rrr rlc rnic;-L(4 micrograrne/rnl), izolarcn AllNm corespllllz;"t I r, | ,lirl
    J'1 I
    l rr,rl | r,1r'l rr ir |iir : ir nposibili. . li. Llavie si , olaL. r lr pr o|us ir t 1979 r ; a llr ; r lt i( : r
    t,,,rrtrrrr,i utr, zirr \ l) \ o sccl'ent a'L dc ar ninoacizidin f act or ul I X 1xx'in ( t r r t r l r lt r
    _{
    a/71/y/rak' ,rt Irrr,r rrpropiiriirrlc cca a lerctomlui uman). Cu o astfel clc sondi, marrcalit I r.1i,'
    hrut ,, t ir', ,rl, lit rrilr"rr liu .i2 nucleotitle s-a rcugit prodncereaunui AI)N cotrplt:rrt, rrtrrr
    \l)\ rrlrri Irrr'1onrIuiIX. ])rin hililiclare'ln iclrrle bactr:r'icncs-it lcllliT,:rl ilr ,li-'
    ,l ,,(rori rr,i r r lir r cr r l r r r i a b: r ct cr iilor con{iniud gena cor espunzir t t xt r cI ltt l o t t lr t i
    it, t\
    \r{rrir{iir (,sl( nrai dificilii pclrtru factorul VIII, a cilui absc;r{ir.r'sll
    'tl:t, ,.,!,1,;l:" .li"l;,l wirus
    1u,rr,,rl ' rlrl ,r, lr nr of ilia. \ . Concr : nt r : r {iasa il siugc est c ( 'xt r cm ( 1(lr r li( lir( ll) 1i

    i,tli,
    l; :l,11i::it tiii:':;,.,li 2 ,,nirLc.
    ilLl1l"i"i.;:illl,:il""ir ' | rxtr.rrr,' r]r ,r , '/ nr l1. 'r t r uct ur . r sa( o pr ot cini f oar t r : lr lugir ) nu, : : st t : I r iI t t ' r 'I t t t , , ,
    l'):: ;,1-
    l,l l;:il:
    .;;,'ii',:;.i,'t,t,,r,,:' i ll l:l;1;1,:lJli,lii:iJ ,rl | | rr' r, sii, I r icii, r , 'nl . r lct clc sint czitla om . Pr ir nclc r t 'znlt lt c ir r vr ll l't l'
    I r l ,' ri rr, .r lr 'r ct or ului VI I t pr in ilgint 'r ic gcucf icir ar . t{ost scm llalir i( 'ill l'r 'i\
    t rr'r'.. .". ir n. . J - . , i, . -
    , .. :,r. .,i,r,.1,l r,...;,.,,.,:",,,,,;,p..,,,
    I, l,'r;.illj'.,
    .. :; l. ::l;:,,1,.,, ;:i;,,
    l,l,lr:i,'; i:;1,;l
    : :i,li,,ll Sinte:o de {aclori ce inlervin in sistenrul{ibrinolitic
    1.13.2.'l-5.
    1 ]3.2.1.3.
    Sinteza
    de irlerleron
    l'r1)1,\.fiiL
    I 'r l l l rr n r ( {l r t r l r 'i r tg i n r ti c g cn r :ti ci L s a r cr r si t p r o cl r tccr ci t tl c r ttr l l i i ttr tz '.t
    fat:i dc o,,,r,,,,,1,1.11:f]t:l
    il cadrul allei. stiLripatologicea tbst l r L r \ r l ( ) r 'l i sL r l l l l L l l tl a sm i u o g o r u i u i , su b sl a n te ca fr .ri n tl o cl tto tttl :tl i ttl |,l tr
    , r r r I , r r r r r l r l r , fi l r l i r r o l i zi , i r n p i r :cl i ci n d {o r m a tca cl : l n r n r l u si ( a r :i i vl i r zi 1 'l ,r
    ril;ii)ilrir]i,lrtii;,1iix"t!111::iilll'{rl.il,:i,;,llfii#:fu;:ti:t"".xr
    'r'' iil'"
    ; ,'l,]ilil,l,'l'ii,;li,lll.,;'i;!"'i'i""t a";t;;-
    I i r r , , r " , r r r r l ( i r r ( . l ) l xl l r c( ' p ) ttstu i u i r , t'n zi m i r ct'd cg r i r d ca zi i fi b r i tr a ) . \r tttt, t,,,',
    l r l r r r r r l o ; r r l st'o l i t'n 1 t:l tzi sp r c i zi .,l :r r ct g cu t:i t:a l c r :o d i l i ci i l xttttt'tl l tr 'l i vl r t,'r ttl
    'iit "'.,',pilii""*";r,, ', t l , t t , r l
    I i l lr sttti tl o g cu ttl tti cl t'i ', sp r c d co scfr i r t' r i c ttt o l i i u r tzi i ., r r cl i vt'i r zi l tr tl tr r t

    ::; ,lL:l;i";lt,lt;iurillii,",)xilxlii:ilJ:it:*:,19,il#*
    ::i,r:r,i::r,iiii
    l,l.r r r r i r r, r ,
    i i , rrI rI irrr'orlxrlitl in tr-onlrtts, fiLriL lL stitttLrl;L pl asttrit-tttgtrttr t I t ilr rtl, trt
    r , r l l , ' , r r z i r rr ,,,:i 1 l t'i tt r r r :r 'r r sl i rsci zi i ttl r i st:r tl l r ,'ttto t- i r g i i l <l to l r st'L tr l ttt'i r t l i r l r ,.tr ,,r
    ]i, ],i 1,,, 'rrLllil,trr,irii
    ,l]],,],,',,r niiliri*iJ;;;itili;;,",1.,,-rdra
    I rn,r r r , , l ,t t t , r z r , i .
    'ir.,,1,,'1r \ l , r r t tl , rl rI(' rI r r' l I f i L ( r l ( ) l l r l i si L 'r l tt i ttl i tti !"( l ) l r l ) r l ) i fl l I rI I I i I I , rt rI I ri t tI r l l l
    ',ll,jJ"il
    , ,,1', i/;.,,ii, 'il ill,l;,,i1;t.ltl
    il,fil,l il ,;1j,1;,i,,1i,1,,,1,1,,,11,',ll,.lll,,,i;
    ;;;ll:,,:iillli r ' r t t l r i l r , r , xl j ttr l l tl r r i r g tcg i r l ,'l <,t rl r' I i l ' r' i rri r.
    I t t r r r ' ,'r .1 , r ,,.r l i z,i ti :r ';r L t i l l r ,c) r i :r r to i L ) ,,:i Ir i Ii I i Ii i tt Itr r l r r r r t' Ir ti tl I rl

    l lr,i
    I r1)
    L t-1.2.
    L6 Si,rhra (t,, at[(,1_o,rriir;psind pROBEDE ADN PENTRU
    1.13.2.3. pRE_5t pOStNATAt
    D|AGNOST|C{.'I
    () i iulzai g(,u ljli( : ij
    ir . r r liz i, r lr Lllli Pt r llnol. r i l r , c u i u s u t i c i e n t : ! l . r , i', i ri ltL irlcirtiiicarea stlucturii uormalc sa.ucu aberatii eeneticea Al) N-trlrri
    ri. i s . r . r ' r ' i. . s r . d i rl i r:i rri lrirntofie ,, lrri, lr,r uiiriutir 1.,.1
    ': J ' r, rr1 1 rr-r-l L ri ri tripsi niAL.
    ccastarcrrzi mi L Iacc partc {osL sir:rtetiz+tc irroL,c c1e-A.DN spet:ilice, corespunziilol ri
    'lr qrrq)lr1 irrrtiprotclLzL'i.r'tir', rrl.rLlt u. r, prultjci,z.r ,l.irii rror.itr;r1t: sau patologicc pentiu unele afectiunii mi:tabolicc 'cLrlrosct rl, .
    t"sor,r. ., si protciincl., l'ri rl.Lrlrj;r probe c1cADN pentiu mai mult de 10d de gcne umanc. (jiltl cirrrzr,
    ] . : l lr ll- , ' , , " '
    ,,1 , 1 ,.ry i 1 1 11,. , ,1 ,1 a ,,. i ;.;,-i ; j ;;.i a,. .,,r, 5,..,...rd,, rrr,I.r rLl.r'l-ru unei Loli geneticeeste o rnutatie unicl, segmentul dc AI)]l analizrrr
    ' i- '.rrcLulrrorpro1...i,r(Lj, sutwilc, in spccial ', lril,rirlr.irzi, r:t ADN-u1 nutant clruia ii este r:omplernental.
    plirmirrril, impotrrr.a e m{izcmulrri )ilrrrlirrl pcntm diagnostictrl ulci Loli gencticr se foaie etcctuil, (.r1
    carc desradcazir clastina). i.r""r,""t; '\UN
    Lt,ll.:]. nllr ..
    .:]":,::ll lrr"lt"1i"i gonctic,: carr:: v rl ,r-rr.,.1,' c, u. u11; t ie geLrLici t pr ospcct ivi, in peiioada pr et at al: r , in cllr LI t , l, .
    ,r ir ut (1 . l l l a _ l rrri i rr:p s i n a ,,s t,, ul ,ro-\i nr
    ' lr ' lt , L,i r l TS OU rri l _._rrri ,1,. l l ' ' r,l rrl rr i l . ] or r c in 5apiir nina a I 6_a_a j7_a dc sar cir . t iu sar L iir cclt r lcl, ,
    ' i' \.r'r1 (]cr. a.cestric'zirnc a fosi cro'ati in r'srt;r"r,ini lr |,rziI :i I ilol t oli:rlc, in si"ptimina a 8 a - a l0-a.
    rr r l' r : in . r r r f jz r . n rrri ni.'r.,iritatr,;r tr.afa-
    p ro J ,rs J .,r,rt.,mrl i ;rg , n , ti c;. .\l)N-irl {ctal, purtltor al unei genc nrutantc, izolai prir.i tei.rnici dc irrsi
    r, rL1 .,, r.li,llcri,rstc segneutat cu ajutolul endonucleazeior in iragrnenlir clrr',.
    1.13.2.2.
    TUsORAREADE VACCINURI 'rrri ..p,,i .s 1r Lratc prin cltr trofolezti. Fragmentele care colr{il gcra lrrlniurl
    rrrl r,l , r{i i i rrlr cn osunJiLr adioact ivir dcAl) Nc. obt inut iL it r in sint cziLchir r r i,
    l\,r dut-trea r.rc.inulilor. pril tletode clc rccornbinarc .rrr lrrirr rnclorl;r recombirir i. {luaceastir tchlici cite puribii ir. pr-ezcni rlir
    a AI)i\ sc iritz{razii ;1
    . , r rlnrr \Ln[cze) r,, lr,rrl Plc- si postnatal in ar.remiafaciiormh, talaseijo, deficiiul clc lllrr I
    lr u]tor |ro1! inc, in cantitatL. rtrar.c, ptir.r clonarca gcncior.
    r rr r:Lrri si lracterrii. Protcinr:li: obiinrrtc. ilirr 'rrl i l || !, r , r.
    sltrt tcstatc pe ooi*ot", fiirtl re{inufe i ' ol L.rl i ir hr l im cns a1 m ct odc. i cu pr obc de AI ) \ const ir in pos. ilr i) ii,r , . r
    ,rr, I i, .I11. r.d,c titruri eticienl.c d. .l t, Lr l i r:i ri i pr r rlir r or ilor si I inciivizilor -a{ect at i de o boali gr nct ici. l, iir , ,
    anticrrrpi, c.pabiic si. leutr.alizezr. ailontul
    I r1.,,lrrli. (.rr trr:csttip r1c r.accilnui. rr l ,ri .,rLl , rlilt . r 'lr apr o. \ r m alr v 2 000 dr . anom alii genet icc ut lanc ciln( r sollL, ,
    sc eliminiL ncajunsurile legatc <lc vacci_
    Lr;rl, rrrrr't,rrlionaic si uumc prirblcma rrr 1,,.t r,[,rrlificatc sub raporlul tleficituiui euziilatii circa 140 dc bo]i.
    i"""tir,,,rii :;;r]rlitc sa'
    I {1rL trrrrlzil{Jiul i! .rL(('ittult1i 'ti:nuai'i
    inf|ctzurt si colfiuriuai.{ja cu .ilti ag-e|ti iLrh,c{ios,;i l), llrr)l)L.rircirulol secventc polimor{c ilc ADli in genomul umar.r (r.:rzrl
    . '.\ l )
    . l l |) t ) / . \ l r\
    '-r,l ripullzi"rtolfactorului IX) carr: pot 1i evaluatc- pdn probc dc l,l
    I)irrr'r' r'iLrci*urilt' st.criaic nu'riii r.accin.r ,1, l,i,l . rLri pctslectivc acestci rnbtode dr: analizii g.rreti;i-l.
    hcpatitci Ii sc ariiL irr frrzr-r '
    rr' r'(: r ' , . r J iuic aL. r.c
    1.13,2.4,
    PROBEDE ADN PENTRU DTAGNOSTICAREA
    I \r,||l,l( 'j tr)(i )1t 1.!, AGENItTORtNFEcTloSt
    ri. t)rlxlql{r 0$liJrjll+ piin ft{\}nrb|Il$r.ta Alt.s
    e re Itoi ii uliiizr{tr ttr 11r{.rijtnri
    { ? e 1 1 ii,) h r I) .Il., r r u /r } I 'r, ,i rl srxrrificc de ADN, r.irale sau bacterienc sint experincntatt irr si,l.r Li
    .l r ' I,rr, r" . r "iilur ir r i, cr iosi , i, ", . jii'i , lir L jlr t iJ", . or lar ii. nr L, t r i. >\ . i, . sr , . r r .
    {'r'r!lusrl I ;\r ,lic.1 b il h l r' rl . t" r,l rr r di: 'qnosr lc'r l . iI ilisr r lui. . Bunor c. i. loiii- t r or pcr ic. . i, , t , , , . ! i,i , , .
    l S l rl ti rj de r1r:z|othi c

    I ( ) i ( t I ( : y i r o l f ( i: sti-
    --+- r t,l ' ,ttt,i t,r (r onr palia Celus S. t . A. ) . in ac, , st
    l ,i. , , l' t t,,l,,r tcraJ:eulice altir-ir-ale (vir.usur.i "adr u
    . , , -cr ilor eazr - Lsi Dosilr ili
    ARN), priir metocla cli, fir,,r,
    \'ardna..:a lirfoi.ri /r. 1r (l l rs d. i rccr.r"Ll i (ti i i .e
    ,. ,. ,I , ,. rjriil()c . r l tl rl rl ,,,
    r 1 t 4 /ifn sL L _ (ff0l ci i rc dc r)ri i i oc rot l i
    r I I ll
    i r1 (l rri ri t di spori bi j e
    t.fl i rN
    (llllgrr.,st1c:Lrea (lc r trrioi. r. i.13.3,TEt-tNOLOGtA
    ANT|CORP|LOR
    MONOCION|AL|
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    l,,Ul { (li ,sir(r..r',rril rlr'l.r Pl,,rDirri
    Prirr\,.n(lr.plrlmonarc,1tcc,.irrvrrtlr.iculul
    irt rinrPUlvielii intrsr'lerine
    :rtrt( St.(l(.irr,.t , r ' r . r r r l, . r r li. lt t lc CSt f r . l . s i n t C l , . C U c c a m i {i m J r C ( . O n _ : i 'r ' Ir r c i r r ' tttsr tl
    't.')rvir
    l: r : r n x " l 'i r r 'l tl ;r I p "r 'i o r tl r d 'zr o l tr r - \'( "
    r'(.ntlatio (lr. oxiAr'rr irigrr lr.r.iior.irrlccrebral. Sin.gelc iosit la corrl pc calca venei ') ' i j i r - tr r r l j r '
    ' '';li::",i;ll
    ,l'J,llii:'i"illj'::1"'i''il1'lil:llil:o"1'lT''J , r,,,,,rii si
    r jir n t li{"Lit \ lul'illic'r ' r t r nr r or ilot '1'l"p' t r r l' t t l: i
    , r l , , fi .' i ' ' .'. i, . r "ol'i- i, t ( 1x''
    ,' ,, , r r , u. , . . , , , f act or ul r - '] nct - r sr - r ' n' r \ ouc; ) : c Pr o'll1( ' l) f
    geitalie iD aces'i mom(r1lt toirtc s1r'tr(
    ' r ' i''r ' ," ,,., ,iup: 2O clc siptiirnini de
    c' nusii Pr ^[ r lr r ( l') 'ilr l
    .rr.rl , " flrr r'',,iti,r.l
    ' l ,rrr l, r nlpor 'r 'anl"( scolf ! r li [ o"r lr r t iunilc r ) : r rr l
    t,,rr' .' t, . l .sr-lr l ilr s i, sub cpcndim o zolli iclnr ilr lf l\ . iL. ul] ( 1c\ ' I ' r ': r r nJz: l
    ' ' '',li"llil,i,,\,ll,1tln;;:3i,1f.lf'sii. intreirri'.'c{ii:
    #;i:ff*"1ll;"'ren
    ',,,',,iti:fi-t.r,,i
    "' t:.t.
    rt..cott':xituticelttlsrcinlrc ueuroni (sinapsogc'cz.)'
    ''"" ^" ')i,",),,tiiiiilii' gLtot".carcsepretungc;1e pini la virstaclcz
    ',i,;,'i:;;i;';;;:,,;;;;;;i:''tii
    "rtrrtrto, ^ni:
    4 ani tr''|ii
    r0 saitjmini ilc scstefic^qi
    . ,,;' ,,;t , ; t . 'nioi * r 'tilr - '-i'"
    ului ir ' pr 't ilr i in ir t m i- t al. . r il 2- ir : r sar clnlr sl
    '
    ,l t l', t l - . Jr ior , 't , " , nt ; elc. t c- it ot - t t lt it t r ' l- n r 'r t c: r cr l. ' 'l' z
    " ,' t;i ' )' i ,ti ', i,
    ' ' ' ' ' ' t.r r
    ' ti ts t.tr .dt 2E,s ,i b!dnti 'ti J c ges tal i e.]* " 11:o" t;;]i ,l ;l ';l 'i l l i
    ,.' , .;' ,,,,,it,u'lt (l' l/10 din sr('ulaLesr'o'1''rali Emisf'r
    '; t,,it.,,trrt;,ri"1l
    i"i ,ii puline" santuri' Substan{a cerebralit'cstc 1'ralitli
    ,1,',ii,',.
    l,;ir:ilrillil;:*rr;,lL"i"r*A!1ffir:il
    $L:''1*di"iti;rft1ii
    r r,,r' r,l .rti ,r,' r r t r ir 'ular i, car e po:
    pcr iolr li'
    .t,
    ''' ,,
    ' 1,,'
    'i 1, , ' :l , l: r r uleclal it t r cer st ir
    ,i .i.t s i,btiwini, cu toaie cir aspectul exterior ai emisfcLclor r:(,r'r'..
    ; llil
    ;li::lii:;i,ili'iill"lil
    7.t'
    /9
    ;;I l;,1:: lll,;ijll".l"* ll':lilL'"lT,*lffi
    ' ' ;','l',ll:
    ';f:l::l; Ltr.sdrtd.nrtnremisrerele.9.'"1l:,;,'ji",:ili
    26
    lsingr: Deaxlgerlo! 4
    | 15tnqt cyiqen?:
    80
    .to
    4C b ;:ill':;tli s.,b"t,,.'1*.
    illl,"l::1'tfl.',:,:ili:it'"'"9""o?:?j',ffiiu*:ii:'*1 itr
    ::,'::." aiip"i' ltcmotagiarentriculari [iind t'rctpli'rwrl:i
    Fig. 2.1.b..-Ilustiarca disrr.ibuirii singetui . 'i.,'::',i,,1ilJ*"il
    :;]:':; ,; lji. .""i'ri, pc' misuriri' ilift'r^nlierca
    conicali
    11"{'l'll':11::li
    rcnos omhilical_ta ,ril ij .€turalia
    Il,.n.cnruatJ
    )r oxrs.n rr drlcnlF \., loarc rie iirr rrtafic. rllil';ll:;,:ii:
    ',,;i:;,,1i;.
    ; ;ll;: llln";;;:il:j'li:::""11:;'.:jiiliTJ
    il :iililri: triunclfulul t:trrt'
    carc'inccpc la nivelu] rni'duvei-spinirrii ;i. a
    'llttlitti:tarca r r sislt m ului xLnpir am idlr l in t it l': t r lr r
    l ' r,,1.t' r()l l ti 's( ir zila Lir za ' nr isf cr cl- or
    5i '
    , (:,supcrioatc, ajuns in atriul drept trece prin val.vula
    ,;rv tricuspidl in r.cntriculrrl "' 'ii\,,'',1;:,,:tllli"T r.rrrcxisr'i
    i:,Tiii'ii#?iiX"fl':iii'i'i,.t. (,(or(:'rn,,
    rrIl.PI sirO' irrclrn art-r.r p'Jlmonari.Din aricra pulmonari o inici parlc (lin sit)l-l(: 'i, gract'ttlc rnaturar.m'rl'l t'11i.,i hipoxiei;i
    rrr'(r:s Prclrirlntnl, ral Coilmar mare paric trt'Cepritr c.rnllnl ,1, ., ,1't;;,,;ili" i.:ri;;;;;;;a.tt
    ari.r.ilrlin;r,triL ',, 'i '
    (l(',s(xrndcntii..Dc acestslaunt dteapta_itinga,prin'canaiul iiierial, cste resnon_
    ';,rl,iliL 2,1 2.1 4. Dezvoltoreo {uncliei renslel
    rczisicnt.ivrscular; pulmonari cre56'x1;. Lr fif, n,rrnrl i'"_'lf;;:,;i;
    rl:xur.sang,untot lt trcc^_pfinplinrini: acestlu.ru sc (lilorlst(.
    ultei vrs;con. llruir:lrii irxrr'P rliJcrcntir-:zc tlinhma:r2*arlcviirli.intt'rlii:l,lill,'fill,
    \rlr.:[r u]al-.jlfr:it ntvclul xrtcriolclorpu]monarr.. "sii...sr: ir ) cli
    ,,,' i ,' ,1 ,l i ,t ,. 't , r r ' . . iif , r 'il, ',, , t t r 11t t r i: lturt ct r al ( m cr zot t t : f i'r 'r i
    (rrr.,,t.r., s.,1.zvr,llii
    ili,rnrt:r''rlirl
    . ^ [)c i;r vlrrta d. 5 lu'i si pinir.i' rnoinc'tul na;tcrii, fn:r:vrrrlrr(r)r(l.ltri {0tai
    .sl.ini'.
    ,,rt,rtr,.rrr
    I35 fi 15.5c'rrrr';ir:{ii/rrrirr,.rr
    o v.rialrilir..rr:
    ilr,-I tir rririli .r'.rli.cc/ 'rlvis,.,,,,',,r""""ii.,:,,i"i,ii,i,,"i,,.i,,ti1;
    rl t_

    t't I
    tl tl
    'lt t r nr, / - ' , I | , n r , t ,. , 1 .,, | .,r ,. ,, ( J l It,, r ,.) j ., ,l formai : l a r1,, l ul i .
    /rt(r'{i rr.r' r'' I ri ' r'i rtilr -.i r.:,l rr 3 Tdl al ul :.1
    lii 'l] :, ], i ; i ; l 'r'' fiinrl atins.ln vir.sl:r cle fi
    ' "'r r . r , ;iilrrl Se(:1e!i:r hor'ruonnlir ir periolldtl lrliilir Si neonalnlii
    . .. J . ) r z r oll; r rri y ,,;

    l,::,m" ;i;jr;:rl;ll# g;r


    rl;;,i*i: .::j:"li*
    ilit.,i;ffjltt'*i,;;.:.:,l Data 'Ietrl: Pasaj

    il'i'lixli:ilrulr l{ol irr fefioa.la l Iodi fr..' 11 l tc rni t!t.!1,'

    iii
    il,_ lii:ri.
    r,ri,i
    ll,:li:liil::i
    I *":mi:",r J*fir*:i*.l;:;
    ; ,;"i"le.""p.o.i.,.,,
    n .iqi.,"
    ll
    atariliei placenlar

    ?J:i':i:',i,'#'!1il1;.,",rr, Sintez:L glicogenulni Virl postnatali aloi


    scedere pinir. in ziua ;r
    rlt'zloltitr'ii
    riniciritor.inperioa.da
    1etalipoi produr;crrmi+
    hc l ati c ; ues tc re
    10-a; stimrlare cr'( (
    ,,,,,,.,.,,i,t.',,,;,jirll1,l,,' sivi: hipergliccmic
    ' pcrsistenta:aesonefrosului dctcrminiLurctcre abcrante;
    ,, ,,,,n,1N',i"'"i,,1i,ilhf: uretcral
    *il#:TJ",:ff"J:t*-m:,,r,,*iurcrui dr- 1l siipt. Virl Ia
    s c dderc
    0,5 orc alxn
    l a 3 or0i rl rl

    , ,,,,rr,,..l'lili'..i,iilt""d;i;: :::""r'"'.'i"ipii .r"ii,'.i'* I,p* crL:z'rilt"irrii nou virl la 24 ore, ap,n


    pinir. ifl Tinir
    ri,,,,,,,t*,i" Jii:iil*JT]l'ii,.11|.]:li:i
    ";oHfii.:ii,T'fl#:?"ii:ifi tL l.l s:Lpt.
    scedere
    a {-zr

    ,.,'l;;ili;,li;:ll n,ir,,li".i*
    ,i,ffi,ijilli",T,1{,"1r':i,#":'#::';:i,;;J;;;;,, StimLrlar_e cortil.r'
    ii
    ',r I
    2.1.2.1.5.
    Metqbolisinul llczer?c de gl"rcg.rrt N i v el c res c ut i n Ifi l rri
    ferol 16 s:rpt.
    zi apoi scadc
    Datrrare enzirDaticl-r

    1,,i,,i,lllp
    16iry,:!{i*,::ll,$,il,".iffij:,ji:x.J.T,l*olx..",,';.,1
    rrrr rrivr'lscr'rznlfatit"dc cel matr il,fi[";J 5ec tLtre s c a/uIr; Il l r'

    ,i,:ili,,l;rii #iiiii.*iiilh';;,f;":.i,0""::i"Ti;",:if1"1;:trfi;
    fll;\:i.',",ii
    circulator crcsLrrrl:
    Nivel crescrt irl f rIrl
    se?tamin.I
    Ni./el crescrrt in pritrrir

    lr;:;,rl
    it,llriii"ii.:fili: * J.1*i,#.t3i",l,ffili:1i
    "*T[i.1?",#
    s5ptdminir, apoi s(o!l('

    jliri:i6**l,ir.rff.ut:nl*l,.'';.l;l*,lil"ru.H,tt#
    :::
    "l:.* g?;J;'.illf
    i :*i i olLii'
    q'"n'i"'^ Rezerve
    creiterc
    liPidice
    letala [uca
    I l'1li:r;
    jii,li;li i:ll1i i.*
    sinteii,"t';i-!i'pJzt*'i;
    Ileglarc eiergeiicri- 0 \rirfla 2 ore, apoi s.ir(i(i

    ri:'Jihl,ir::ldli
    1l;:lill5:!"":ifj'.:$i:,.ste
    irductic erzi[atidr

    ;;ll;l;*,*filii#; *,,*'1"",1T,"':o;u"i:1",.#.*T,
    ff ?illll#:i.#i 13 salpt. Cregte pirit
    a 3-a
    trr znrir

    Nivel crescut I rillil ;lr


    , ,' "::; .l;l;:1.:n( rntif'''ri
    ctiscindcia rimpu!uiri'n'ijumi' ziua a 5.a
    ',:il1,l#i,{.,-{ill;]
    .,,r' lr.*'rirr{c(incr*firarc Nu sn '':"'dac'i N i v €l ul di r c or{ l t)rl
    .,,"Tlr:i,:'fl,',',1i,1;ill'"'.,i"t' nivelrl flatcrrr
    singcl'ti ral;'.;;*;i nrrcrrcir in,-ins,.i,'
    ,,,,,,',;"'r:''!'1.!;,.',7r-r':::,ii'i;':'r':
    ,r.,;,;il,;
    i;.ilii:1,i'",:::#',fi11'i,,'#],ri'i'll
    ,]fil*t'\,o"o,l:il?ruil,fl;il EvALuAREA
    2.',1.2.2. iN TIMPUIVlETllINTRAUTERINE
    FATULUI
    (iirrsr:r;infa
    . rrutdfr'onaliL
    :i si si rnaturi'lii fctale sc foloscsc.o .st:t'icdc tcllttir'i
    ' ltt slrtirilirt:a crcstctii
    l'r'rtl
    cliuicsi nttrttiri
    ,i,;qiiilillririixlilTttiiin,irr,;rr,il1,ri:iljj,ii:i
    li',,,,i1',1';l:'l;l',;li';,li'l''; ll',',lll, ,
    ,ll
    ut,,rlr;i;ljrt
    ,,r ,,rr,rrr
    iiiii",'i,',,,'
    ,,,,1 '.1a
    I rrl rrt < rrttttl t t t ili.vil'siiL
    gcsl: r lionalir '
    cxain('nLrlui
    ii,,,,f,.',,,i'i"r""iiiii.gh".ticiLirr tnntcxtL'.'
    .1. t i / | r tt s o t t o ( | a . l 'Ld' i) r oicct int l un f llst : i<: t ll. . . ) : lz( '
    ( 11 lllllils( jll] l( '
    I'l;;,,'Jliii
    11, ,ll1;t;ti'ij,li';1, '' ,, " , ' ,,' ,,,,,
    t, , , t , , i, , - , i i'i', , , ilit i'it t t l ct : ot t t 'ilr '
    l) t r t vt 'lt ilc
    l) r it r t t
    t
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    I i' '.1
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    t n. :1.2. \ ) r :,r \r 1
    ]liili;li",lil]];lil',.i;'11;,' r"':(';
    1c,r fiiuruisi rituiirsiLu,r,
    r:rc;tcre.
    tn I r i l | 'i I'i | ,r 'i , tI| I x ( x h u
    ,,],'j11,,",""'.".' ,fl I'r r {:l i ( i ( 1, /i f rt i i l

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    l ( l r ( ts , .\. l r a l l . l . -

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    t:!t, ili,j
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    a (lj,rluer.rrhd
    c,:cstcrf ra"""i"i'rifl"r,l r.rinrirzicrc
    ferati.
    ;]l;.ll]ilii,J..ji.it" e
    , ,,' ,r'lt.lifii:'j:,i";"il:";.ll;e: scpotclctccta
    clinsirl''Luinr
    -J

    ;1ffi{"{:,.j.l*i
    ll;iil"::il:11,uirTtfjil{l#*i,j,jtili'sl*Tf;i:i:., L /U
    x
    ca

    ii.
    jii:i.!ii#'.;;;1!:;'li'iiiiiill?""x,1.?..3'];ffi,}i.ii"'T:i;H',;*;::"f;?3:,1
    l
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    -i-t;;iitii,r3;,,,ii,;tl.'|r:1;i;,t"-#i#.;*':i,1ru
    c, coniractia
    ,,,',,,,'';,'li','3li?f:1"1#:?'i:r:i,"co'";tentl utc;-inf,,
    estcprodusi.
    40
    . brcr.dicortlieirltiyzj alti, czre apar.t: clupii ce
    contractia
    ;;ll;:H;lnil*,t".,#L?l"f:l:.*ff H:iil;}:l:fi
    i,${:*#*:..i#liii
    ;:i;,ili;li.,T,ff:i:tl,u?f,l;iti"'i'gct.:ic.Jiaif,ii',**ri,"'i"ai.i,,".".rtut""
    ,f'triiffi[#:,1,:"#3f
    -, dcceleyiyik t:ariabilc. ,

    :;ll,lltt.:f[ift#..:*hiiiii:*d,:]i1,::if "": n za zz 21. 26 E n 32 31.36 38 /,o

    ('. D I c c I r o c a r ,l
    in
    iittii,nyl$?.::r,1*';:;:*i*:t#fl$i1frl*i*triilil
    i o g ,/.tzJ i n J(t,tld
    io
    vinsrt atsrarpwaLAtin stptaninil

    . oi.lj^orr1' Plp
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    m:*i:i'll'".,;;:[i"'i?li3",T':ffiil* :.1tr /.)
    ct x

    ff"'l#'t".":J#,!:,j;{fi 8H -
    "",,li;,,fl
    ,',25irrdiciro -buni J,,'i:l,s.l*,i,,,];1*,ii,!!"Jr{'J"!r1,
    circrrlatiefl o oxgenarc corespunzitoar,,. €ls.
    - F l s.^
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    ii,T.!li. e l B/ 2
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    " 1,1
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    ,,o,",[u.f.il,j!.11';&{,ki" ii|,i l;l;:;:ll;t,,;;lllf:"?..i:e,orafici s,;i
    r:on-
    ,,,,,,.,,rii"lii . 1u,"t,,
    ,iriJ,ii,,i"i,r,",rli,ii r,.l)*rz(x.ria
    1rnscnn,r.tli?::,,r,:,j,llli:llf:
    Rro
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    ,',,,r. r riri, r, .
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    ill;ll
    :ii-lll'r;i:"i''ill';"i;1;lr;*rs:x;Ji,il,r*{,,
    I rftrilu|.l! dirlrc dimenriutcd Icttllir tr;tluti&rtea lclRli! cr,estclca li sinilalea
    Drcto(le ile evirluaro f{tati (dqpi M. L. ChisNick)
    liit lrl ti $n(!lo

    ,|{1iir,,1;1;
    l,)"1;;; 'l: ri:li;";,,i1,:i"\dili,iII1,,,,,
    ii;,',,;;l,j,li:;:i,"ilil rrri ,,is,roria
    Semne clinice .le
    .suJerinl5
    Jctali

    j S;r11iltatea J;iului j
    Ciraii(itocosralia <- !H-nl sailguin letal

    ,,,"***ti{ili,,.,,"1i;::ii?.;;'.l!"::i:it"1il:il'iT'-.""' rr-itlar-- Misctrrile respiraiorii jetalc

    itii,#,rt*qi*;;-*il:+*:it**+i$[f+:ffi
    ,,,,,",,,{!!!,!#i{{"ff.rr*tft
    i ),.1,\1i t!
    ^nomal
    ,i rr r'\:,r)rcrl ul l i ohi
    c orrgeni tde
    .l ul ui amni oti c ^
    i i l or
    I
    ,t
    +
    I

    Silirubina ir lichidul aDuiotic


    (in iniompatibilitatb Rh)

    **'{ffiT;!.*^.de
    Ul;;,;;f:i;r;i*f::#:; j:";
    z ns/r00ml corespunzi'rr
    -i-Exameio

    .,
    abdominale repctatc

    ,,,,1"ni*' unei
    ",ir"te +
    }I;.surtrri rep€tate cu ullfl[$n -
    ,* r r,', {,'iil;#J{{.tfi, 1!J{'i r u/tttattotc IctaIo p'in studi ,i porl l er:a l i . 1naternb,-> Cre$tere
    ' r'.r, nete ale .ldmetruhi bjDoridrl

    -,i'i * {illili:{i
    H:ffi *,;iffi
    "'i.i
    " Calcul de la, prima zi a ultimci

    -r*ti#i## 2.1.2.3.EVAIUAREA FUNCIIE|ptACENIARE


    llvaluarea functici placr
    tl
    ] I)imensiuri L
    -T_- i
    j rnenstrualii
    Biochiroia $ citologia li{:lri-
    dului antriotic
    + Radiologie teta'ln (afftritri'l

    )*:'ti:"l1ffi i;f*r"lffi,i::r,yi!
    '##i,ik'i'tfu
    E)iame]1 abdominal
    flate 1Tr
    cen{rilor Je osilicilc)
    trIxsrrarea cu ultrasunete a diametrlloi
    biparietal lntre 20 - 30 slPtemlni

    2.1.2.4.EVATUAREA '1'cstul l.t oxytocimti (Otytociuclnllenge sebazciuir


    lesfJ..Testul
    UNtTAlrtFETO.PIACENTARE
    r" lrrrrlulc.t.in rimpul ulcrin;,
    c"ontractiei scadcflu-rul sanguinin spaliul inlcr"

    :lri'ii,r,;:,.,,,*f
    lt,+itti# j*rn#fd"xi#iiri:tXtH 'r|,,:.'r,i
    ,rrr,
    lcsrrectiv dxigen"rea fetali; scS.dereaPO, fetal produce bradicardit:"
    ii tluj l" n*vtoci-neprobcazicrpacitateafelaliLdc a suportacontrecliilc rrlr'-
    ,iitt tiuroultrivaliul.ui.Teslul poz-itiv,rcpr"zentatprintr-o decclerarc(lrrrrrli-

    j,,1
    jir i$:,'lxTtt:;.l,ii,*"thmr*#,H::i
    *vdli"lf
    j,liii,rit;'.:ti,triiiil,f
    ,,rr,li' ) rrr.ristenr5.si ritm invariabil,secundaiecontra4iei utprine, in condiliil''
    ,,:lrl.ii' cstrioluh-rj urinar matern, reprezinti o indicalie pentru tenninatt:rr

    *,m#,,i#i*ta[1"ia,{ry:;r1*ii*; rr,rlirlii prinoperalie cezariauS.-

    ri.i:,',nr'librl"xf
    lf,ifffit*{fiiii':;:;*1,*r":i:;i:ir LA VIATA
    NOU-NASCUTULUI
    2.2. ADAPTAREA

    rgir$ri
    1,;i, #,tffi 'fl"Jf"tr;;
    r;#ffifliitr|:,:iiffi EXIRAUTENINA
    2.2.1.FUNCTIARESFIRATORIE

    ilil-,;;irl;;.prrt*iirf*i*1r,,;
    li;T,t,ffi ffi ,"jffi tl11fL,a..'qq$g" l]".t,liln usteirlin cu un liciricl sccrctatla acr:stnivt'l'
    ,r ci-r co rDozltlc osre cucrrra clc C0a^alichiului ltlniolic. iu tirtrpul 1r'r](',(:r'ii
    rrrirr t:artirlttl'pt:lvircnjtll, o trtic;i.irlrlc tlin lichitlul pldnioniLr fciill tlstc clirniniri
    i',i,r ,,,rrrf,r"s'ion,';i'torac,ilui,cca inrLi tnarr' lrartc it srt l'iinclabsorbilir 1.)rittvrtsclt:
    t7ti
    fl7
    \,rr)glrin(:5i lirrrfrrtir',, iu ltrirut'lcminute dupi naStcre.Al'sorbtia
    l)lllr)lUllrrr(
    cregtnriirapidc a fluxuJui sanguin
    tir'lritluluiintraprrlmonarsr: [:1 ,' itr r.rrnditriilc
    lrlin scirdercarezislcnfci vasct trllrt accs[nivel. CrcqtereaPaOr,sci.dereaPCO,
    ,;i r:rc5tcrcapll-ului {avoriz,'rtzit sciLd,'rcapresiunii irr circuiajia pulmonari.gi
    i"strx'ctivcrcgtercirlluxului san51uin.in conditiile hipoxiei la nagtere,acestmeca-
    rrismesteinhibat (fig. 2.4).

    '7.30
    'I
    A.
    '7 2 0 minut (tabelul 2.4). 'Iabclul )4

    r"tpilatt$tl la nolt-ui\r tul tlc :I lt!


    normele ale peramelrllor
    V:rlorile
    "i"i']p-l'iii,gh
    " trn RorsreTG)
    ;: ni*"vro'i"'i"i rruarci$e'H:rrper
    q)
    60
    r-^ respirator
    rritm,',l [ ;3: i!/Ji''
    V ol umul rcsPi rator c ul ent 6-8fi 1
    E l l orr ti
    i pa.U ul n1ort
    SDatiul {iziologic
    ri ol ogrc t60 r)t
    r,0 V ol umLrl D ul monar tol ar
    "d Capacitatea
    C i n timpuL
    vi tx l i , in
    aoaci tatna vitxlr, ti mpul PrrnsuLrl
    P l i ns ul rri II
    -SaJ
    ' ;; ;i
    nrr
    ,fI .^ VohrrnLll insPjrator _totrr i S0 r,rl
    j
    ( apac tatea ;ez i dual ., tutc ti onal i r
    surfactantsint
    Tltty" dg
    In mod wual, imediat dupe naqtere'ca4titilit"l:I!,t:1f:*l:"Htl,ti:
    inciile aclre[e
    riltbcraterncaue
    tlibcrate (din incIliilJi;l't;1"*
    aeriene(u'.:ffi;i. J;
    Lll '" t;il6i bun stimut p€ntru aceastls]i-
    fl::i"::L
    ir,lt*t" l.i- T"T*9T.::"1ii"
    *t"tia ah'eolarf,,il"t stabilireaunfui
    decistabilirea *'/";;il,-;;;; ;i1-
    interre{e
    ,riisir"" ;t"6ifitii-Iorfelor tensiunii stiletfili
    O lA
    (J '"

    \uflirctant.
    Maturarea pulmonari fetall se poatc
    - {eqeii . cste ameninfatd" du
    95 tiot"iii - betanrethazon
    ",ttri"oiJ >u{in cu 2 zile lndinto
    relpiratorii idioPatico
    q'l d\
    T -. I)Rl (Lrg$ns $r ttowle' tv t L)',
    "LU6'L
    ,i'nci 'te$l"stbilh de sinteza lecitinei in
    E
    -- i",itlcoiziior a"pa naqterela copilul cu DJ
    c.r65
    o
    CARDlovAscuLtRA
    2,2.2.FUNCTIA
    polnentgl corisonului
    Densarea
    . .11 ""tt:'ii,..P.ln "'"0'l"T"ll,f;:l'i'lt;:::l
    r,?,r$T*:lJ*itffii;r-q':*l*itll'1":l'1".r:F
    r:ircuhJieiPlacentarc,

    I ta. 2,1,- Mn rlili(illllo I' aor , lr ( i( ) s ,llC( ) r + i Phr - ln s lr 8 t l o a t t c t i q l l o n o u 't r d x o u,ln P l i n r c t o


    r'rr 1r z ilc r lr r lf r r r r r t t ( . r '(rlihr
    ' r r r l\ l : r l r l r r r t r ,I A ) '
    rlr*lh,6rti'#Ji1ttrfr
    llst,'ffi '*]*$Jit*lii.'*.tmn l7$
    rTrl
    ,' ,,i i ti i r i r, ,:' r ir ) l) r 'r r r'l J 'r L : ll' r r r : r 'i'i i'l' : \ lr ' r r l'r r 'r '' ' lr r 'r r lr 'r r r r
    Irrrlrlirrl rlrril-Ln;Lstr:r-r: rczisl, rr1.Lrlin circr:1atiapulnonirli dclit.Leaproapc - - i lr , I 'r cL, 'i, , 'lislr li l'. lr r r : r ''l'r c'r : 'aPidi: : 1''li'r lr , r i . r lt ,
    I i r' , l i f i,
    ,.1irrl:icrr tr':r cliu r:irculalia sistcrnici (cca c1i:ttrmi ccr.a llai clescttl"r). ltr acest ' .t,
    I. r' ' t.,. .. .' r '. . in. r i; r ii o. t 't or i. 1'r 1 31lt r 1nr : - i ' L- r nou- ll: : ulr ll l) r nllr ir l
    l' l. rlt slnr.;t.lmic stinga-clreapta st produce prin canaiul arterial. Pe lnirsull"r cr: cr-cqtr d"Li.o al),,r'irii crcscut cie tlcclloliii; itr
    . r,tli'i,,r,li ;j,l;;;;;;;ir.;
    .Lr',.:1;r si: inchidc (cle obicei, in 2.1 d,: ore canalul artcrial -scirchiclc comillet), ".ina
    irnatul nu c:jI " c'rp''hil i'L mutl;in"L honteoslaztl ot{{rL
    Iinicliul
    ,,/rirrl rrl slinga-tlrcilpta diminuir
    ;i dispare. h cursul primci zilc clupiL nastere ' "rirlilii Il" ilr':s'r
    ,,. ,,ri i ,r; ,, r,,,, I 2. . ir : . : , 2. 1) ,
    r,zislcrrliL din circulatja pulmonaliL scadc 1a jurnitate, ajmgincl la valoarc;L rrrl,
    i.', i,i.,"o,"r r-Jlorilt, criatini.rci in sirrge silt -rfe1,23-1,31 1g/100
    .r,lrrliniLrila slirsitul priurci si.ptiimini. llrmirtoarelc cauzc pot iinpicdica sci,L- ',,r"^r",*.-.1e"if i. rn.,-nii.cutul 1a tc.irc*; l'alorilc iiL rl.rttr:tl
    ,,,,,1' ,,,,,; 'cv,:trinrl
    ,l' r,rr r.lsoconstrictici artcriolare li';lnonare irrediat dupir u:r-sLt:rc: a) crestereil
    /r)rh 11,65 nlg/ 100 m l) la vir sla c1cI lunir .
    1'r, rirrnii iir vcnele pulmona.re; &) tr:ursrnitcrca prcsiurrii sistenJct in circrdatia
    l,rrrrrrrrrrrir;c) cantitatca cicscuti dr singc in cilcuiaJia puhnoir:rri-L/slzrll slillqa- 1(b.l 1tl : i
    ''r '1 ,r.\' , lr . r j, 1, , . T ' 4 0 .
    lDratru itllt{r',r {rmtlie i ro al r) l n r{ ]i l ' D i s eul
    2.2,3.FUNCTTA GASTROTNTESTItIAT"A i rf i r'
    E1e.te ; i rl i l s i t l c l l l l i i
    | r!,ri iir. irlrcti|lar
    I-rrr:ilstade 28 - 30 de siltiLmiui tractu] gastrointestinal
    estesuficicntdc ' i?uLicc

    lr zlrrllrLI ptntru a pcnlitc absoii,ti.t :i utiliz"rrri :,ubstant(]or llutr-itive si, c|..ci,


    rrr1,r'rrvilruirc;r cxtliuterinir. Cu to'irte'acestca,fuuctia dig;:stiviLcsic insirl-icicnt
    rrr.rI rrlrrliL ir rnomentul nastcrii, urmind sii sc pcr{eclionezcultcrir-,r. ln.,,ii i , lL|lr.l:1t! Iiczis,.erlia crcscril itl afic- S c :rdc rc a .:rc rc l i c i { l (r 1l )r1rl r'
    l)tsi rcglarca cantitirii c1elichirl arruriotic cslc rcaliz:itir. prin ingiritirca riolo alercnt:. ca' r-a!:111ts api r, mc !1i ,-1i rrl |11: (r' tLli 1' r'
    la secrc,lia (le 1elliii sar ti c c , ami ros l l L.rz i (l (, .1, l rl rr
    .rr, r;lrrirrrLccitre {art,coordonareadeglutilici si a pt-.r'isLaltism.rlui cso{agian cstL: "
    /i l . 11,,,
    epirLe{rinir { eri c ol , pef i ( i 1i r1.r;
    rrrsrrlilir,ntrlczvoltatl la na5terechiar-la. nou-liLscutul noln]opondcral. -{ccasta, c l i gox i rr' r. .l i u r{ rl i c c , s ti (l i rl r?'
    ,1.,xirrii cLrun s{inctcr csof;gian si::.b,predispune rou-niscuiul la rcgurgitatir.. salioile.t si 111rr {r}( r'rr)
    lr:rinlt'rlc 31 - 33 de siLptinlini, in condiliile incoordoni'Lriidcglutiliei cu res- I l r , L,,,,Lr.r t).,i i i .rl ' i)e{.ict si:rui riral
    l,irrrlil, riscui cle aspiratie pulmonaliL a alimr:ntclor este prezflrt. In raomentul ,l r L i , ,|,I)rI|!ri | i ,a/rl al
    rr;rsicriiirII-r , gastric cste neutru (prin inghitirea delichid amniotic) dc;i sccretia a S c :(l c rea ri rs P trns rrl ni Ir I
    | , ,. ,1, ( rl ar trLrta- liel-lrra1L].r ccntritu8:i
    c i rfi u-ei ! c 1l apar ;i s (rl i rr i ri
    1il;rrtrir arir uci<liLcste prezcntiLdc la 28 - 30 t1csirptirnini clcgcstalic. ',ic:rrhlhri rclral
    v or c v j i .r al i mc nl c l c (rrri rrr:rl
    l..t1ls::q.,prlncipalul lridrocarborrat clin laptele mirtern, poate fi hidrolizatii c nrc nrarc c l !c tf()l i ti (:t i l i rl '
    ,l, lrr<iaziLdo li virsta de 28 r1esiptirmini, nivciul acestci enzimc crcscind rapiti tel e dc ' /.rc :t' 10 nrOs rrr/ l (X ) (:' rl
    rlrriri rrt:r:irsti"r. r'irstir. Sucroza si glucoza sint absorbite si rnctatrolizate binc chiar' hptelc adaPlilt llJ lrrl
    Os m/ 100 c al ,l ,rpl c l (r Ll
    l:, l u r.rniiLr r (r v ez i r - o1 .2 , p a g --.1 -5 9 -1 6 1 ). ' rrl Ir
    'I ri.ltsinct - cca mai importantir elzinrir protcoliticiL - si lipaza 1' { Irros l l r/100 oal ; l :rc fl ( rd'
    '_ esen- rel c ni i .i (l c s otl i tt ;i l |trrt tr'
    {i,rlii pr.ntm lipoliza trigiiceridelor din dicti inccp sJrii.- secrctatc de Ja 30 ti ei dc P ol as i u;
    j rr(atr' (ri rr(:rrI rl
    r,ipl;irrrini, nivelul lor crescind rapid in plimclr slptimilri dupi nagterc, in urma s odi u v :! i i i i ni tal i l
    .,I i rrrrrI rrI rLi rcprezentat de alimentalie. Cgncr:ntraliile lor sint corespunz-ltoare
    1',,rrlrtrplotcolizir silipoliziL (vezi voI. 2,pag. 159).
    (irrttlrarativ cu nou-niscutul lormoponcleral, dbsorblia grdsilnilol, Ta pta-
    Lrrrrirrrcstc delicitar-ri. Datoriti. rrnei cantitir.ti insuficiente dc siruri biliarc, nu se
    l,r,r,ltrr','o bnnir solubilizare a gresimilor in lumenul intcstinal. Acizii grasi cu
    lrrrr{rrriscurtc se pot absorbi direct in circulalia porti- chiar in condi}iile unei
    iu;rLlicitntc biliare. Administrarea unei cantitili prea mari de lipide poatc It:rla, dc filil"rc se ;rjilstca,1ar
    rnnl.irnii t )ilor Si c:rp:rciLii.1I'
    l,rrrrlrrclia prematur malabsorbtie, co pierderc de grisimi ti calciu (vezi lo1. 2, l or i 1otraus P ort () d:r1i r' I rk 7_
    lrL rn r'l tt2. l 1, pag. i55) . v ol trrc t! ri i c l ri tl l ui
    ,\l rs or bt iaint es t in a l i . a i .n rrrIi o b rl i n :1 o r, fi riui ui -ri a r.,i arni n:i B ' cstc | 11,,,,,,, l r L, r ri (L i l rL i Itctcrllia lrol tc fi s(,u11irLLrrl't i l c i Lrc rLL,rL s (!1i ,1 r,,i
    (,,1 rrl ,ri /,1
    lr rrr;i llL nr:n-nirsr:Lrt. (L(rv ol ti rfi i i rrs rrti c i r' 1r1r i r s -1,' l i l i rrri i rtlri
    rr(.{ rl i l ()l ri )r1i fi rl i .
    (' l l pi r{ i l rt( i .f|nrrri r"ra i 1rl ,i l ' )I l rrc i r' ,:rrr,,r l r s rrl i rL ;t rtl ' rt
    2.2.4.FUNCTIA
    RENALAl l i ,,1,.,,!l ,1r i r : r' , , l i | | l u i
    (l i s l l l i i l I ri :rl )N )rl )l r(i n 51r \:r i 1i l l ri l l l .i i
    t,l rll
    {rr I inr pr r l v ic f ii i n tra u tc l i ttL rh o rn c o s l u z i l :rp i :i ;i i :l c,r:trol i fi l olcstc rttcl t- rl i rrl rri : rri v ,,l (rrc s (rtrl,l r: rl rrrrri i
    lrrrrrl rirl L' pllr : r ' r r lir . lr rl rrl i i L ttl u p l i n i rs t(' f(' ,l l rL x u l s i rrr.Ll uircul rr l l i i rri l tl r. Ii l - i rr,i ,r,rr' ,r ," r,,,,l i Lr ;Li r' 1rt
    I L, i r r l i s rIrrrrrl r, rri r l i i [V 1i r,l IL|r]ri ri
    i, . I rr, ; I I , rrrr, ' r rtI rrt r i r t , , s r ti r;i i tl . l ' rtrtr:i ir rl ,' r,,iI r,.l i r: I r,l r' 1r| r.l Ltri lrl
    i L. r' i tti r:l ti i tr
    r L,L l rrrrr, l rt
    i rl ,l ,,:,l r' f,ri Lri , t,(' i rl i f i rl ti l ' I
    \, \,'l li l ',r l' ', ) li

    tl
    I l l r)
    ( .nni i r ni a !ntt i l ,: ) .5.,

    l'alofllc l|or$rrlo [i. t ]rallici rf alc !A ro - irscut


    I
    2 t3
    i

    l. : \ (, .1 . i r s ( ^ 1 i r n i , ; , c . | lciu - S{r ).rr Ioiitoriza cll}cill Si,


    lui si rnrg i,ziuini silril rnagn.zn irr conditiile e\cre-
    l i ei crfscni (i .l ( so(l i u
    I I | rirlI r i i a i c o i z i f i r a t i c i : | \l l ',r,(,1 i tl (rrr { frrrl .l rar
    2\J t5 l l (t
    | tr,rj ,',r,./ 1,7.1,' I:)
    . , ) s ,{ l i n - t o l a s j n : r d e no - tlcso rl,i:r so(llului oste sor-!- i00 .115
    ?)rtii: , i ,'Il ("'l /nrnt'1 1) 120
    scir,:ler1,ile\!rc.ti.i i.rrilor {le
    h1(l rogs! j 1200 l ,l l ){ l
    .135 800 90{)
    L, ) lrr c l o z , . i - i o s { a t a h iD- s.i -r1 er'i l a r'rl cr'ucarfa cu,
    Inlc'iozil t {, ,.1i i r zi h,n ti
    S f ii, l r : r tf i l r a j r 3 p o r t u l u i 250-400 5{ )0 ()l l l )
    t - I ml/i.g 15- 60 250 -,100
    i, ) f 0 r 1 r i ) r i t j l o r o r g a D ici Cnrl!! cstc .:chi?alcrlt cu
    I'r\ l-t fi a substanlelof Jlrf,ul sanguin rc al; sca.le
    Yiz aiizarca rinichilor la
    piclogn{ia intra?enoftsi: I r!l !,s di r c \al ns uul tri d{: nritfi !11 nor:-nI$(ut ktlrp:r liotcr)
    lransporiul tnbular crc$te
    lent iD pri lele 2 sS.prii,rnini
    0,10 --0,70 ii pri mel e zijc
    si rapid iD ur.mirt(xlrelc 2
    rno{lcrati. in primcle ,ilc
    sirlt:'rrrini
    -l--l' l- in ])rimclc zilc
    l, l' ricjlinc Doze scrizutc clc peui{i}inar
    mictoscopici (la 1 i?/" dh norr-nii:il rr! )
    v.rr da l1i7e1e sarguine adec-
    vate in crrsrl pdmei silptat- tE- 6 0
    rini ile /iaii | ,,i ,, ( ! r ' l ;,l / l ) 10-40
    ',, 1,7--8,5
    .) (;lucoza;i J a tu r ita tca tr ln r lDi .Prin sc;dcrec resorbiici ioats
    proriimal apirrea glicoznria il1 eordi i ,l , 'r ''l ( r r l r, l / l )
    liile supr&rlimeDtatiei
    'r r , 2 me/ks/l
    lr. A , i(li i i o r e : 1 , , , , , r , , 'r r , r ( [ r r ]i L Il /1 1o r e ) U ,j : L n ;l r r rI'r ( L n a t r i i t0 l s,5 l i r
    L Aciditatea titrabil6, Scldercir ercrctiei de l.Jslat Se ra e?ita incircarea cr} la terlrcn
    scizltl tunclional crcscutd. in Prirnele septilnilLi
    2. Scirderca excreliei Scildcrea numiiruhi dc nc- Se 'ra e,/ita inc:,rcarcc cr ac;zi
    i l(1 Al1IOI}IU frod Iulctionali
    1. Ilrag sdrzut peitru Imatrritatc tnbularil Iste preuent:l o acidozir. rc- HEMATOTOGICA
    2,2.5,ADAPTAREA
    l,icarbonat lativ,, inso-litir de lipsa de
    : r r t ( 'r r
    (i
    &lspuns la inciLrcarc cu aeizi
    l , , ,I II I )it I .1| i , cu vialc int t aut cr ini, ir dir pt it r ( r . lt ! 'm at ologir 'i
    l)r:Iicjt de concertra.re; .{nsa lui Herle esic iclativ Aliment:ltia cu Proteine lr cm ogiobin'i' m orlilir "r 11 ; r
    ,,,,,,rtrrl rri . , , it 'i f ii seidor . . L cot t c. nl*lici .
    .rDcentrarca maxilni scurti! 1a rEstere; ureea di! este rccesarl pentru a stabili '. lt r
    r:stc de 700-800 Inosml zona nredr ar;r .],re ur1 tol gradientll de corcentr.ue; ln ,,,,,1rr, ll,,t,g,,in,nodific6ri funclionalc f morfologicc alc cc'lulelor slrrgrrjtr( rii
    liiru major in concentrarea uri- condilii de srlrss se?er t/drsi_ rr rl rr,rr' rt fr t <1ot : ilordc coagular c.
    ji
    {in condilii ale anabo- trri, diaree, in{ectii) con-
    l ,tlorik' harnoglobir?ci sint infhcnlatc de volumul transfuzici lta(:crrlirIr':
    lism ureea are -/elori sci- ccnt.alia udnii cste mariima
    tr rrrrrrrriscrrtii l;r carc pcnsarca con'lonului ornbilical sc lacc ,,tarr<liv"rriv.lrtl
    znle); ADH3 Si r:ispunsul
    tobular rcnal sint scizuie t', ,r,,,;'lrrlrirrci;i lrt'rnatociitului estc mai crescut rlecit l'r ceila care pt ns:Il ir,:" lirr.'
    r' a{ ,,,.,_ l) r . l, , , r r l, . r ) , . r , ; 1( . t . slc\ ir loLillr czir r ttir loJilicir r i f iziol, 'pi, , it t lr r t r r lt '
    rCln/C glucozii rlport l clearance'lui la indinS $i la glucozi ' 1. r' r, rrt:rl r', l: r r r r ir . l{r , li ( l\ 'vir slir I ol) ilr r lui. ( t I l"l"l' 28si. 2q) '
    -- - r'rtt irtz'i ittlt.
    2Cl]rlr cl€arance-ul l.L rci{1ul paraalnino-liluric I trivilt ,',,ltlutvttl,tiisarrgltin, irnccliit (luPi-t rli*tcro'
    rrAl ) l I - h o l r n o r r l Dlid ir n .tic ,,, i tttr ,, ii7l. g( r ) r 'l) ( u) . ( dilr d, i8. 5m l1kg cor p) , Pont r u uot r - nit sct rt tl l lr r lt 'r t r t . t t
    '
    | ,l ,r, Lrr.rlr rl,r , i, lr r , J', i. t i sinl lr u, ir r r llLi cr r : scuL, 11, , , . , s, ', t t volt
    t t r , t ut nlt li l) lilslllllllr '
    l ,,rtl n , ti. lt l, li\ llot t - lliLsct iilit r <liar nt : i: r Lrt tlt t ii t t t "t '' 1{ li, 5 1r ' r t l) iz( ) ( 'ilo/ il
    i l frl l l (.r,! , r , |l il|lilr ) i1i. \ 'ir l( , ) . il( ' r t l|t : uLor : il, lo r sit r l t r lt i ( : l( s( : lt l( ' t r l l) r lllr r 'll'
    Vi r lot ilc liolr r r orri l o rc l i ri ri l l i r(i l rl i rt rrri tti Li u l l ri o:rrl i r (l (' r)ou-ri i suut si tri l
    u rl i i r)i rr r r l( : l7- r ' r ' los l l r' ,ri z i 0 ,5 2 ,j i n rl i /l i l 7 -l ri rl t rr:i i ,r,rl i r:oi zi o,{ )5 {),3 urg/l ; t tl , ,l rtt,,rt t . r r l, r , {! 5r ', , ) .s' 'r : r l) ili, 'r 'r ziI r r 'r lr 'r i'1" l"; , lr jir r 'l't l l'r ir r r 'r
    r ) l ( r lr ll ll
    p rrl l n i rrr lr iolr l ( 1. 01rI t l l /1 . ,r,t.rrrrl i r \ 't ir ', , r 'r l '1, 'lilr , uit , lr r lrlr ': ll" r ': l' r l' r t lr ) / r r r t r t : r lr t r 'r r r

    I 8: r
    l l l :l
    I nrr!d 2.5
    lirtlirdL sttlirnatlttt'l lr r:ritt-ocilcloi estc i1r:6 'nlnih i;r prirtrt'il i zilc rll virrl i
    t.l,r'ilr. ltrnrolrlitdrlci,ltrrrla!,rr,r'ittdui!!i
    reti(rrftteiUlior.inpfi t.5iiltilmini dc r iatri i | | 1.! | )tr,' r / l!, l, r ; , . t ) 'im . r . : l, liinin-
    ' I' ,,u,t,.Litii,,,i,rr.t:,J.., i,t p',tic,^da ncolliltirl:i':c prodirc lad:rf ii h'auzii or ii ir| '
    '
    Cordon Ir.imele l)r'i11ra l i l ,' ri l i l rrr'[rtL lir i ar coa! t 1ld/ ii. ( t abe1u12 11. )
    ,rnLilical 24 ore sarplalmin,r
    . r. )it,,
    | 1, , | l1' x lol ) i | : r ( g l l i l { } n l ) 17, lE 13- . i 9 \1
    l, r f t loc ri ! { 9 / o ) 50--55 55- 6 0 i0- 5i a0
    i i , i(rloc it e i o 1 , ) j- - i 35 1- -: 0. 1'
    l'N]'tr'n acilte .r:rlori rccoit11r..a s-:r larcut dir s;..tele velos .', :,:
    r0

    1'abelui.2.1,
    /,rd, a ,(cfl/?
    l l o d i J i c i r itc r r lo lii h e n r o $ lo l,ir ) !' j in ) lr i' trU t '. r)i)0
    n dr ri r!i

    N o'.r{irscu t Irrenla"tur nlai rnic (Lc !n/ia'r'e


    ,, , :,.,.
    ( 1200- 2 4 0 0 ) i 2t)0 g
    /xrtrr)iuc/ea/ |
    0 17, 3 1 7 ,0 15,6
    J is , E i4,E
    MoN.rle
    3 15, 9 13,2 l2:0
    5 12,7 t) 7 /4 28 z/,/e
    9 ,6 8,2
    1r.) 11.-1 9 ,8 8, 1 , ri r:, Lrurl i rrrl ui rl c l .u.oc i i c i :ti rl rl e :' c ri rt' ti r drl i r l e..l .rI i l i rt trr'
    -l
    2(l l: , 0 9 ,E 9,0
    50 12,0 i 1 ,0 i 1.0
    1(hl l tt : tI
    l, rl r),1 1si dn_|5. 00/ r nm ! i r p r, m a l rrr. L ). a i a rn .l ra a, cri fro{i i cl c i n acedsti
    l .- rl s l ti )
    rr,rirrl:i :ru u Iragilitate lur..c.1rici crescutir, durata vic{ii scurtatd. si o actinititl- \rl i ,ri tr n{ } } i rtal c al c i l rtl ori !1rl r.{ ' 41!!l l :i ri i1a !rou_Ii :tut k h+ ):l
    rrrr'1abolicilcrescuti.
    zile de viafl nuniintl { frtrnulaleucocitayd
    semoclificir
    rapid I
    I
    .
    .\ ,.1.
    1
    :\ou-ni s c ut,]a
    tef,.l rn (c ^r,l .n
    i S n,r-,r,-,",,,r,
    ,,,,,',,,1,i
    flitfii," ; on' ""' rrr
    nfr..r,.r
    Activitatea metabolic! a lcucocitelor, {unctia de fagocitaresi incorporare i}
    tril lolrlrLutetrozolineisint crescute(fig. 2.5). 2{J0- -r00 :00 250 2 0 0 ,- ? 5 0
    , .'l'ycmbociklelu dupi pr, na;tere valod intre 150000 *- 300000/mm3, aceste .i0,, 1ill {o 25
    \'.rl()r'rll)nLltnxl scizrrfela rnalurj. 90 6 0 .7 5
    15- 12:l .t0 35
    Xliuluua csoasdla nou--niscuteste initial hipercelularS.cu un raport intre 5 0- 1 i 0 i00 N0 lorl
    :ir.'r'irr
    rnicloidSl seria edtrocitari de 1,5/1. Aceastl. hiperceiularitate scade spre .50 - 150 25-40 25--40
    rlir';il.ul primei sipti.mini, raportul mai susmentionat ajungindla 6/1. 50 15'i .t0 - 6 ( ) l5--40
    7.i 12i :10-40
    50, 100 50 . . I(lrl
    ?abetut 2.10 I ; ir; r ;n I llt
    :0 - 5 1 ) t0 s0 ') ( r
    Valodle lcrleocitelor si fottrrula loucoellrli l?r nou-niscut 1 0 .- l l 1 2 . tE l { .l i )
    i 0 - 1 .3 tl - l ( ) t.1 .)0

    NMUhIOI"OGICA
    ADAPTAREA
    l ,',t' c ()i)ilc 0 i u r l r ) 18000 - 20 000 12 000 'I.2.6,
    Il ,l i)uorlort u c l c a r c (1") 5J - d0 \ 1 , r i l ir r i l r r r r i r r l i r l r ';r l ) l 1 r ;r r i sl l tl l o l i r m r tt,,i r ,g i ,, l l ( 'i l l ) i i r l r ti l r r l l i i ttl r r r {i o i r ,,r
    45 - .t0
    l ,i 'r'looit e (? / o ) 30 {0 ; , , l r , , r z .r l n , r 'o ( r ' i r l l i i t( r r i ttl tr t L l ,'r 'i l ti . I'i .tr tl r .i l to tt'ttr 'i r .rttr r i l l r o l <l r t tttt
    l 'l rn o(: ilr: (r l , ) t0 5 t0 , r t , u r i l | l | |r r ,l r r j i i , ,l i r i ' r l I'r i r r l i .,tttl l tt l l ,1 , IIi IL i tt) | |) i A( ' r l l i i l ) tl l l \ 1 l'
    l ,l o ri, ', )lik . (r l ' " ) i tIL IIi 'r l i , i :;i i r n r r l i i ; ttl i g l tti r t ''r
    t , , , r 't , r r r r ,,l i r l 1 't',{,', l ,,t i tt tr ,tr l l i r L r II,
    , , l ''r , ( r t I' r 1 ,i r , l r r tl ,, i i r 'l r ''i l 'l r r .ttt',r i l ,L r t 1 ,,1 r 'r tl i r r l i I rI ' t t t rrI ' ri .'i t r tl 'r r
    llr,l
    llt t
    it l2 ;r
    irr r i rrrrl : r ( i, ir s ; il) li! li ru r rr l 2 -;Lrl r.g ,.s trr(i ,..i.i n rczl tJ,.i ;G;i I.,l l r srl posi l ri l :i l,irrrlix'ii:irlt'tinticl ritspuncllrr phytohcmzrglutininiL rlin si1ptiiutina
    r rr c:i l ,l i r r illir r r 2t ) - ; rr lt. l Is t;rti r' , IrI iI i )r i I i I I , .i r J Ir i | o r pi l .rf (l i n i i ni .t" f,.rai ,j nt ,1," l , ,..,1i i D l r.,lll''r illi.
    i lir ttLlx'rr:uliltii
    pr-ovcniru!ir nraternl si sint rcprczcrii.a!i dc I;iG.
    -{cciti aniicorpi ric origine rnater- li i,,;,;:r;,DJrilitatca intirziatir" este evidentiati- de reaclia
    r i l l 1 l {;) r r i. ( . l, r inpla, .,n ri j n ti l ri rrru l rri rn t.s i ruL l ,srrci nri : ni i . i Lrl l orl i n:i nge} c ;";"ar-ca BCG' Lapfematur act'astirlr':at:tit't'siL'
    ,, ,,',i' i'i,,'lil'tiri:;i;i;6;, sl sc cfccttttrzc l;r tttttt
    l, lirl viur:tz."r, u virsta gcst.rtiorr".rlir,{iincl scirzut in nrimr:le 2 trimcstre dc viatii .lrrlrii (lc ac{xrasc recomand:l ca vaccinatea IICG
    t tti t.rtrl 'r ' io) ir Lrlr l" r n rc n 'r,ri g'
    l ,u ti n d rl ,' p i .i n i r., l rrl rn r i nrn (l Jl ,, l i !l 2.12J. r r"i utii (:u grc[tate mai mare de 2 500

    Tahtl tLl 2.12 ENDOCNINA


    2.2.7.ADAPTAREA
    l lorile I$G h sil| g € lc lc( n l tD lu r c!ir ltc l' lrst{ $est{l i $nxti i \i r.zi ti L lr clnl 2. 3, pag. 173.

    \, I sl r ijcst.r'tiolel:r. in snln;lmnri
    TERMICA
    2 2.8, ADAPTAREA
    Ni i fl ul rn.i l nr j D nrc_l ;
    cu tetllx rrt
    N ott-tri sctltltl normoponcleral 9i sluirtos ili rnoltilc -u5urinliL 36'5
    , l{)
    l03ti , ,l'l;;;,';iL;i, 3;,i;a i" nivcl'l' tegumerlelorabdornimlesau dc in'l t'rr1i
    n) .t9 935 i if i' , , , ,i".e pi"tot i"filt'' inir-o cameri incirlziti l e z5'C' ln
    u .15 It50 "l
    , , ', , i r r i r ':,,'l "l.if
    r ) r ( l r t.r ttttr r l n u e stc a * p .'tti l ti - ;i m e n l i l ) i o i e m Pl r l tr l r i l Io tl sl l l l lli
    -ts :tI 595 ,,,,.,,,,f,,i,f.ri.rriil,,r,n-r,,"r"lorc"ractcristici: prczinti o supraf,rtilrarl':r lr'!rl
    .1:t0 gras subcutan:r-t cste slab t'r'p|r'
    'niii lufir ;',','l',',;"i;;,r,,i;t;t'^-'. .; Ercutatea;lesutul
    ',, scirzutirdc rnolrili
    . , ,r ur:isilr('r;.,lruni-" eit,, in cantiiatemi*; capacitatea
    'r i'pot t calor ic scizul pr in alim lt t t at ir - r - ar o acoPcr i nllt llir l I t ir t
    in lirrpul victii intrauterine trec prin Dlacentir, iu titnr narc, anticoltii ..,rr .' ,
    ' l i .lt,,,'rlif| , r, .. 'r l,si'cn 5i t cr |r ogcn^zi; cr paci{at , r r 'dusi dc cr csi|r e ir ( r 't lst t
    ,..,f l'r,l',,ri,,'.."
    :,,i
    .rrri il .t;r'it:i,tantidiftcrici, antipoliomielitici, antitoxoplasmozir si a'ticorpii iih
    i,,,i,. ru'amcntin'lr minirnumPicnlililr"l'
    i"'"*li. .""Aiti;.1en1
    l'l,x rrrrfi. Nu trec prin piaccnti anticorpii antisalmonella, anir-ll coli, reqr-inelc l l ( 'l l l l tl ' i "l - l n tt:
    , , t , t , , . ' , , 1 , t ',l , r r r r l r r r u l u i , a c{'sl d r r ch u i ' p l a sa t i n l r - u n .m cd l l l
    ri rrrrlirrlpii compleli anti-Ith. IgG de originc nraterni scad in prirnele 3 luni Pst!' r 'p r 'z\'n l a l i ( l c i n l e r va l u l i n ( 'r r " r -l t rrt i l i t l (' i t r l t
    , , ', " . ,,u , * , l t
    rlrrpi nastlr-c, cleterminind aparitia unei ,,lripogamnraglobulineruii {izio.iogice,, ",i,1' col}Stantc a corptlllll
    .'nrll' ll ({)lll'illllliriir pcltru mcr]lincrca unei tcmpcratur:r
    ( irr(, ('stc cca mai scizutir in jurul I'irstci clc 3luni.
    , ,l ' l l l l l l l l l \i l ,
    Sirrtcza (lc IgI{ inccpe in sirptrimina a 20-a de gestatie. Nivclu} lor crcste \|{'rIIirt(11 iI Prcnlatudlor intr-un mediu termic ncutru, cltll:.."]'t'1..:]],
    llrrt, rrjrrngirrdlavalori de 8 rng/100 rnl in singcle cordonuhii ombilical la r.rasteie; a l t. p r i tt :'r i d cr ca - c- o n su tn u h i o \i A( tt A( "{l
    . I | | 'r . 'r '| . t I | I I I i r i l r ,.'l o l i t,:n l r ^d(
    vrrlrili r:rai nr:rri dc 20 mg/l00 ml puu prtiblcrna unci infectii ictalc cronicc. l.ln , .*a"n' in pr' z' nia hipoxi' i frmlcnt intilniti,in patologirr
    t;;l;.;
    lil r rr si izrrt clc IgM la nastcre nu exclucle insiL o fetopatie ; Igl{ rle origine nrerernr-r ,,, .rrrrr,rrrD, ', ', ',iii "'ni
    l, t t olr 'nisculi. I ) cas"t t t on"l'lpor t t cner t ct lcscizt lt lapr ( lllir lllll
    m al br nc f l nt r u ( : r ( : llt 'r - "
    rrrr lllr: ltriu placentir. , , ,rr, | . 1r, ,rt:rl ' . I , , I , . r p: t ciir lc gast r icZ m ic- i, t 'sf " ulilizlt
    Nivrlul scir.zut a1 irnunoglobulinclor 1{ (Igtr{ 19 S) in pcr.ioada neouatali_ l. l't'orlrturna ile eikluri' Caprciiatca nou-r"rscutului dc ?r pl'odtl('1'
    ,.,t,1' ,,.' i rri rr 'or r".t riciiii, t nuscullt ur ii ( f lison) ( 5t c nuli Cant it at ( r r t ot alii 'il
    ct iir- uf
    lrlrr'(xl(' ir fost considerat cb'cpt factor. "fa'"-orizant al procluccrii infectiilor cu. -
    jt,'rr( ri (;rirm-negatir.i. Acest lucru nu a fost insd. dovedit. ,' . ,i' ",i,',,," , ,1,' ,i ,1. , , , I ; i ui ( . t c I ur nizar e p. cale m ct abolici. li't m r r gr 't t 'z'r
    ' i ' r,:.,rn, 6""
    t , t , , i , i. , f * nit , f qr ; . inr ii , l'r r inc" A. cast a r cpr czint i 2
    I)ir zina a 4-a de vialir, stimulul autigenic reprezentat rie {lora {iran.r- r "r r iizat i inzonr git ului' st Lb: capular ' ir t t ncr lir r
    cpr
    ,i ,,,,' ' ,,r,,i l ,, i, lr P, , t *i ii ': 't '
    rtr'11lriivii, r:tuc colonizeazi in mod fiziologic intestimrl nou-niscrxtuiuj, protiuce o r lin Ar iisir r r ''; r
    Irr t rr, ti tr r t : r l. ( . 'lt r l, l" , r t , . 'iui t ii- r LI St isir n( dit cr i. dc cclc
    ( rt fl(,I(' rlrl)idir a IgI{. ' 1,ri rr li'l) llr l c: - r. in' I 'oijct c ir r m it ocondr ii il co. nt ln nt r nt r 'r t ) as( 'v; t ( : t r or {'
    ..rl l ' .
    lgA siut absente in scrul copilului la naslere. IgA sccrcto: rpar 1.r :curt ,|, ,,r,1rirrrr,-r\cr.asLiL zonii cste Ic,arln trsculelizati ;i bogati in filcttl ncrvoltsl
    int cr m c, lit t l . t lt , P
    lirrl) (lltllit n:rsterc in secrctia lacr:imaii. ,;,,,,.,i ,;;..,t, , , , , , li, ii, i i'1o, * iii. . "', 't csr ! . supusll lr ig, . piin
    l:;;i;l',',1,1i,,,";ii'-,,.,i,,i,,i,,,),, ."*,,.ri,Ldcnor,pinL'Irini;ii'lit,.rr,na,l, rr.izig.rrli
    I)r,si nuriiLrul dc polinorfonuclcare oste crcscLLtin primele 7 zile si:Lctivi-. dc ] il'r 't '; t t '' r l'
    \' ' l i si rrt r r xi, [ . r t t sir t t r r "''r 'iit ic"1i, r clLcliit 'r t iir r {l iDs{) lilL '
    lrrllrr iol rrrz-irnlliciLpoate 1i pusir in evidentir prin dcgi.adzrrca\B-ll-uiui, ri.s- 'iil, ii. t"imr6L.czicrr'il' rapi(l (luPi tr.il.rt (lrr'Isr'
    ir anra,tor si firgocitiLrt:stc dciicital. Valorilc scizutc alc conpouentei ,',i"',
    Jrrrrrsrrl "",,,";i;'t;;ii';.
    rrrrprlcr:l ,llzt'olllltiLlir 1;rLrmitturi
    ( \ ir r:otuplcnrcui ului (7i) mg/100 r)l in r:orcltnul onrbilicriLl)
    5i al propcnlinci rkr rirklurri' tr. I)itrrltrilt LLt cil'dtrti ditt
    (l/2 <l i n r . r r lr ' il. t r c l. lttl ' i ) i rL rtr.u c .z l i L rl rl .fi c j t ti L:.P sorrj zrr' r,,I)(,fi ri ful di ) ll. I'ir,rrfr.r'ik.
    tiri cir'trtr (''gladicrrlrrI
    trctrstuit,.
    rttl,l r ii,-r rrt t,tgtlttisni'|l -sttptrtlafa
    l,sr)l ri zilr {lr' r I r i. . li r : 0r ' rr:lP | i rr rrrl tl ri n i s|lrrrr,l rrl r' l rJl rsrrril )rol sl )i i 1i .rl i ' l i r arl nl 1. I't'trLrttstalriliri'rrlon.i tlt: (1)nlortlcr.rrriclir
    tii'r' rlillrr.lr:r'asonroirrr.
    ,,ri',i'i,':1
    l ttu r r ' , \ l, li( i unl tl rl i l l l l r,l rr.i r.l ,,IIrl o l IIri Ir, l rl l l r" :l rrrsrri rrr,l ( 'sl l ' i r l sttl i ti l tr l Al x'5 ti l l l I) l l l
    '\ r'r,rJ l trrsl u;.:i l iur. r o u D , i r n r t t,l { o r \i 1 !) l l l l l Itl t1 x't'l L l ttti i ti r :i i r l tr tr stt'
    r ittp q r'p l o r r rlr r r l ir r s r , lr l i r.r,trrilrr
    (,rri ri i rl i , ,;,n l i ,',.i tr ttttr r ti r t'l ttttr :i ti tt<l ta P^ r r i l r tl .r r r l t r ttl r tl tl r tt'r '
    , i , , ', 'i ; ; ; " ; , ; ; ; . ; 'i i ;
    ',," ''
    i ri fir7
    l, rr| | (ir ll ( )I ].I, | | I | : .| ))I I I I I i ir I r) s l ( lr , lJ ar s ilii.
    SLr rlr r . ir ir l c l c : r c l o r - L u l u i
    ;,,,1i;Tl'll;
    i;ii,,,i;r,ii'j"i'r,1lllt;;i;lill,ji;lii;jll,l*j|:,"11:?J#liliil;'; \ l' 1 i ' r. L i J rL rn : l lllectclo nsrp1.a {:ilnlrri
    la. / ' . , J t t ilc . 1 , .J l .l t,r,: tt, 1 .,,r .:,l ul

    sc.*,,;;:ilj,,:iif;id**:**;*L!':,) 'f,!'l':{:iil"
    , ,t r f u, I tt r: r:ilrc rlediul inr
    r ci,rrrrrrii
    l,i.rri,,rc i ,i //- rurr.' r. fi z i c i l g..j a, nc l .!-i -
    -r vf/ \r c l roporar
    I-i ps a ur i ri di . medi c al c a. s arc i l i i , i ns ul i , i l rl rl
    tu) li1iia!it. , pl -, r.rr' J , r,nn.ul i rr' i U ' l i mnr.l ":r :, r. r' ,
    Pierdcrea cirlclurii prin.radiatie este irnporranti
    aiunci cincl naturitaie, distrofic intralterini.
    tri ,l ,th l ;, i : obc ri tatc , di rLc t z aharal t Irrenaturitate, mortalitate intrauttrinli ti trr,)f

    i1'ffi-lr$*-iJlr,;;*+*q*
    ";ijii no'ii''t
    i,''n",.-
    il,il);,,'11;lll,iii."ilTJ:tiji.dl-I.j;ll[,.1;11;:1#lt,'".i;"i" irilcrFf atirontisin !rnutu
    taliLrtc pelinatel:r.crescuti, mauonutl,tii c(,l 1('
    nitalc, macrosomic, DRI, hlperbilirubnrcr)ri.,
    pogiicenic, tronboza ae:deircnale, hidhf \ h tnlt
    ljrcmaturitat€, riistro{ic irtr^uted
    l l i poc al c emi c , l c tani l r neonatal i , l
    ir.
    ponr:rtl
    Ir
    "
    Lr,'
    l\ (lon-ltrclin. Accst mocl cle piercrcrea clrdurii
    r,)r nir.scutu]rstr asczaltp".., sr,prif"ti, ,,,a" st_,reariztazi atu'ci cintl J -, n .r' rrr;r:l r, i ,rr: r.F.' rJ ri l l :, t' r, t,,' i , ..t
    1x,uf.ja",_"r,i',,1"."orrIr-l"r,.;. P rem:rtudtai c , l rl auormati i c onB c rl i l i rl t, I

    ,,,,,,:1..,1',.'il',it';il;,.1Hi:Tx,;hilillxl;t;;::ilii.Jii::l';Ii:il';i"t,iil,$.li:11 . ) ) r ,,t) ,l t,,r \t:, titii.


    tar.l psihonlotor irrtlaitcri
    h Totiroklism.
    , dcfccilr rtl(: SN(

    Ilr::
    ;1, ji'Jt*,i,i;ii,l"';i;
    i{;{Xliffi,'mr"*lr::'{*.:llii{i +:m
    , ,, L' i i r l ar ( i r fr l i i L c a l

    tt 'r l tl t ,,,dtt r nstln i )ro n f n r, h i p o rt . ;r


    B'crlaturitatc,
    !'rr:maturitatc,
    ]ripo\ic.
    lListroiic inlrlulcrinir.
    H i pori i c , prematrri tatc , c l i s l rol i e i ntrur 1, ri r' L

    1,,i1111.1,]i,i.iiie,I,ffi;i;llfl'i;:[f,i:!,1:]"]::lT'_fitl'"1i;ii:JJl#,'l : I l t t, ti t, il ( i i r" r . c s i . i n a l i i

    l,,i'ililiiliJriill.H:ffi?,ftf
    i.1};iff{;:;lT",,iili"iiii.lll",l"'"u:*::i*t,lli rt i ) t,i ) ,,1,,!:t I, )rri : ri l c n i e l l i os tefl i e i :rrnz i i .rri c , hi for{ i c .

    tit:ililj',I,.|:iiil
    iT:,|j:;:"::":x'lJj.1Tjilif:t,,;;.].9J'l#;fiTl*t.fi;,T::g;.,* I i 1 h t) t,tttl t,L:t t , :

    i' iompa'atie .,, p,'i'a""ii"


    p-iioililil;1#;' ;,,",.r,"toi
    ,,ii
    | , ,j j | ,i r I i I )i I i I i r 1(j I i h si ,\BO l ' l ri tfoLl as toz i i , anc mi c , hi pc r bi l i t LtJri rt,trti r,
    lripoglicenrie, asli:ric,
    i,}'Ylifo""
    ,]'11, Iu' Iur. t-ur' I rrt.f rr.i t-J Ir" r' .
    o Prematuritate, .tistrofic inlr:rot.r'inii.
    /o l-ibrozt'r chisticr-r dri r rcr.ns, -I':r! Si! lr! r'l

    2.a Nou-NAscu/ur.
    cu RrscLANA$TERE rrai nri Lre (l e "1(] ri i i .\' /or1, nral l orn1al i i , c r' rs r ru.,ft;rl i i i i I(i i t! i I
    l fi i uri , pri ui pal c ntai i l
    i i rri , trl i t\]art rn Ll ri i rnul t

    r:rr:|r:1ll:lli!1,1;:1:::;:1il#*,iffi'*r,L';1,11!tiij".,1t31tii;flti,ri,,*lt l i .f:. /' Ir, r" l 1- ,r, r' rr,r 1. . i ,

    ;;1,,
    I
    ;i";,:':i,f.:;,ti,:';:;iff
    iJ:i;,5j;:"ift *f*?f :* jfri
    ffi?;Jl:*:'
    trirl, \"itl)lln o oblernc de reanirnarc.
    ' :' l ' 'l

    I:'r

    2,3.1,FACTORI
    DE RISCCE PRECEDA
    SARCINA ' t ttr i tri ).l l

    Vczi tabelul2.13.
    ' l ' ox opl as rur' i r c .)rIIc ri i []i L
    2.3.2.FACTORiDE RISCPREZENT|
    lN TlMput SARC!N|[ (;rrrrul oLnai , s , i )ri t i l
    ' r;r
    1l i , f,)r( ItLl i (,, , rl , i l i ( i ri (, i ,l ,rl l (.
    l ri ,l r,tr,l i Ii ,,
    \i L, z i t : r l, r ' lui 2. 1 ,1 . i , r, , l ! l )r1,,
    , r(x hrl i l ri .ori ,,r,1i rLi ri . h(,I)r1i 1ar,
    i tn(.Lri nrrrgi rl i r, rfri rI!r' ILi I!|||,, l i i rl i l rf r,

    2 3.3,FACTORT
    DERtsc cE AcItoNEAZAtN TtMpUrNASTERil l l rl |l ,ri ,)l )r{ i ( r rl !.,l i r i .
    \/' r1 fi l i l i rl r [rrrt{ rtl ,
    Vl z i t r L: ' ,I r r l 2. 1 5 . lIl r |1,,, 1 I i l ,, l i , r' ,' r ;ri rl i (i /,rl i ri J

    I rrii I l tl I
    (t1' !tti l l ttrt l ttl )tl I t: )
    ( (anti j tttatu t,tl ,tt 3.1'l )
    L ur!rJ l l rn^\i ' (j i s rrori ' i nrr' Lrr' -ri rrJ
    I '\ . . . t r i ll Mcdngocnceialiti, riiocarditi, ictcr, tromlro_ ".i ',,,,i ,, tl r,l c rc ' s tc rc i r n)' )fri trl
    rr, , r1r' rl l rJrrcrrtoas :Ldc c ordon H i po:ri F, henl orauj e l etx l i '
    citopcnic, hepatitir.
    titii De.ilatale,
    t l, r l' t s s i t l f ) t . ! Eruplie herpeti{onn:i, microceialie, calciticilri
    | ,' l ,l ri rl Ial c c l i e bac teri arS ' hi pox i e' i ronrboz a v "ru
    ccrebftile, ictel, hepatid!, trombocitol]errie,
    orlbilicale
    arrenie, coagulolatie, kcratocorjunctivit.|,
    l ',1.| | !.i ,l ( . {:r 'r l or } l:liDor'ic
    choliolctiniUr. li!olrolio intraui( f r')ir
    I r' .r "rrrl i l i ' r'l i ,' ri J ,q.;orralii congodtale,
    , , . , r. 1i, 1z,i St.rmatit:1.
    ',il: T{ipoxie
    ' '' 'l I cl r i t ] " r ! Prel1laturitzlte, infcc.tic bactcriani"r ,,, | .rl ( /l 'rri rl i l c c ordon
    \,,, ,,,.,',, rrt)turi r l l c .orLl on l l .nrori Lqre l rta l i l ,
    / , . , i)1r. c n t e f o p a t o q . r \r:rrs:rturi, dia.lce ictalc, sirr(llom de asl)i'
    l ',,l i i ,rl l rrl :rl ( Creflcre; mortaliti!1ii
    lril( rt i( i b a o t e f i * n i r . t c b r l . Scpiiccmnr, lnelljngit:r
    ratie de Deconiu
    t, Prcnatrritzttc, iripoxic, distlclic intraul(jfr":
    llt t lt . (t n ( t r t t : :
    I .1...1' t ll Tesi Coonlbs (lirect ?ozitiv
    , l, . irrrli r) i c o l Sirdrom cenrLtitr
    ,, i 1. ' r '1, u r . j r t c z r . Hipc|m:Lgneznrnk:
    rr rt irrir ,\dirauric, ol)structie rzalar FEIALAACUIA iN TIMPUL
    2.4. SUFERINTA
    ., . , r / . r '. i /xL .tr
    \l . , l r ) g u r i e T e ri {j .:rte
    I L .' , td r i^ L rdrrrr"i , .' .:r 1.. n, l r.r',or',r-
    l)otcrtial rnallorntatiY - ASFIXIALA NA$IERE
    TRAVALIULUI

    \'/ l l u rri " Hipotro{ic irttral1r,orrfli


    HlPoxlEI
    2.4.1.ETlotoGlA5l FIZIoPATOLOGIA
    \ i i l , L a l co o l Sindrom secu dar aluzulti de alcool
    Irsrficicntar placentari t' p r , r i n l i 'r cd l l za cn a m r i l r ccr ' ttti cl tc p to 'l r r " l ' zi r r r ti ,'
    '. | | i ' : ' { ,.1 r: 'l cfl L ;ci l l t t 'r 't i 'r
    | | I . r |, |r . I L |, i i i :i 1'cfiool perrtru tat 't', ,i,,.',f,'' pcrinata1,,. Din totaiul deceselor la- nou-nirscu{i 75')i' sittt
    " '., ''' \ e d: t l'r r " I
    '' rrrr,l .rr, l ri tu, sl, t . \ ccst , lr opism ' : r ) lr ipor it 'i Pt nlr u- 5\ l
    ii'iol"qit l sl'cif i'a; cPsici per ioade dc \ ir st i ( r "'
    'fabel u! 2.15 " " ;; " ;;i " " 'i'"t i
    ,,,t ,,l i r,i , ir , t t ui, car c cint ir elt c 10: . din gr eut at ea cor por al: r ( 350. ii) '
    , ti(),l.,.tliu cantitatea totall <lc r-t. primiti de organismul {ctal, lrrf,'
    ,,, ,|' ,,i r;r
    ' . 'r i[ ] r s - . ( ! r r l i r r a l Premal ritate, trans{uzic {{:toletatl, hipotrolic
    intrarlcrin:r, hipolie (at 2-1ea Seam:Lr), hipo- ' l .'1r". r il ( olrslrrriil un creier de adult
    mortalitrtc rl'
    l'(),, ir {(slrtul cerebral al nou*n:rscutului cste de 20 mrn lig' lrr{ii
    gliccnie (gearnlnul hipotolic),
    pcrinrltal:r crcscrti. nou- r l's( : r llr r
    r,tt rrrrr, l i 1' l : r : r r lr r lt .Cant it at ea r elat iv m ar e de O , in slngele
    \ rj l( | . (' ; rf r r c i P i l r t t l i Hipc,xi., rupturi tentoriale
    este determinatii de amrmitc proput'i rll
    \. , , 1r: f . i! p r c l r n g i r : L ltipoxic, cnccfatopatic lraum?Ltic:r. lrsc Ifl_ t,,,, ,', ,,,,l,l1iil, tLIIci .PO2 scizute,
    f et ale
    {! liii. ii i .rl0 ritnlrlui cardiac {€ta.l Hiporic, tahicar(lic paro:iistic:l 1,, rl rrr ,rl , lr r r r t t at iilor; i henoglobinci
    Prematuritate, iniectie rconataul (
    l . rrttzok' pr incipr t lo r it t 'c det et m inir hipor . ic i. r r , lt elio dil llr 'r r lllt l: llir '
    Pd /iar1:l llip ,,\i,. h - r ) r,'rf,si ( ', r. 1'r. l J. l )crrr.,raS i r \ 1t ,) , 1 il'i t avi nl. I 'O , t v n l' r 'a ai Hipoxir l'ipor ici: lr oJilr r r lr r r "
    suprarenaliL, leziuti spinalc 9i ale oerviltl peri_
    r i r , ,rrr,:,l .ziit gor cr al: r ( NO 2)
    fdici.
    I / , , r, '! i l.r,i.rli Edeme 9i cchinoze alo ictei, lliporie l ,l l l i rxrr ir t anclnicat .
    '
    l ', , z r'rlriic t r a n s r e i r : ! I{ipoxie, trarnatis r IetflI ,j , rlcscut alc Or: convulsii (cclampsitN sau travaliu lrtl)ori{r'
    l , . l, | lri(: s i | t 1 r r p t t ' i i u l e d l r :t EIipo\ie ',,'.,,,tt
    Ilr p o r r e , 1 :r r al i z', D I,'\ Lfrl l i j tl , rrrruri ri l l i 'rn l l ' 1/ rrr l i. licr ir i. ir t lt ot t slat lt t . l t r a. n s- pl ( t 'ct t t lt 4( '/ dl'( )
    \, . iu r' i f l l ( . r I i . rlisglrrv irli,'
    sDi[al ,, ) ( i t:,;;l;ii i.,:ut./a- fl&c. ta fi lelicii n rii r in srr{icienJiicrrdiacir,
    hel1lotagie ccrefurald \ - r t scnlar c ( ioxclnic) ' ( ( nlllir L ( r l
    tiipoxic, ce{alhematon, 1,r1,, rt,rr:,rvi ( s( ll( : r ozil r iasct lar ir l, sPasm c
    ,'r.'L,iirj: In{eclie bacterianil cpilcpsic.
    ,rt, rrrr, 1rr,Ir r r i1iiI t , dialr r lt ,
    ri , , t n . f ( i , Jl l cn u l i rf:r l ]' :nclnbr .anelor
    , ' . ' 4 ,,f. l I{Iectie bdcteriarii, prcnaturitate, prolapstl l,) tltrtii.littiri lt ii/u,:iuni trans!-lat'aftuti ;, dfgcnorarua lilrlirroirl L '
    ,,1r1,,,' i r, l ,,r it t r ii', slt cit r iL pr r : lungit i, iliabct , r 't 't lr r <: t icasupr alcf ci r ll r lilt '
    ' hipoxie, aspiratie <le
    cordorului onbilical,

    l'ost aturiltltc, agcnczie rcndit, rinichi poli-


    ,,rrr, (rl , rl i pilr ' lr t t t t t : t lt t r it dc pllccnt l- L)
    ' '.'[,,i,rI i, . .
    chistic, obstruclic uretral:r, {it nort t ir ct t lulir : i . f r 'l'o- / t / uLt t t lur' tl) ( r r sir r iL ( r't tI rI rII I t t I t I i r r t t t l'Ll
    ' ) \l tttlilt t iit i llt r'
    r r' lilri, t f ; ll r r i { , c Pr e zcn ta lie a o|rrri rl ar,r'uper1-'apretnatur:i a , rl , , 1, r ', r s,l<, t , , t r r l, ilic. it ' ( st t lt lt t iir t t r t llt t t llil. t t t lr r li. lr t t t . lt lt ) '
    nrenlbrancl()1, 1)r'oluPsul (rrr(lonLrltri ombilical. ' ,1,' ,,,, ( s( il( l( (
    'l : r sr lllilLlillt lf iillr "
    (l c cs()l tLg' i rrrdforml |l i i ,t , , ., t l , . , , 1, rt : rt ttl t t i l t lt lt l- lr lit t l) lllr , l) r ( 'r 'iilllr ii
    t) r ' ( lr r r ttr r ilr L tc, l rtfcz;(, ' ( ) t l'r . lir l
    :r 1 ,.SN( 1 , i' r i,l/ .,1'si i l (rl tr. t l l ,, lil) , , ir i , r 'l , lr , r t t : t lor lt r lt t i 1i t r t ' t t
    l' ,r r llllfil' r lc, l ri tn)\i r', l rrrr(,fi ti {i , l ' l rrl i r ,) ,' r ) . lt t , t t t i' ; r t ilt : lt |r r t r r liz'r ' ir llr 'r '1ir " l'r r t t t llr ' : r I |( I I ) ( ) I I |1I I I '
    1 ,,, t )tl t
    .t Itt
    r1,t uI
    r r, , lrt , r, , 1 , t,liri,, 1., l' r { ,,r r l1 r fitr l( , trl r,\i 1 , l r, rrr,'rrrl i i , l { l rrti i
    llItr n r :r 1 1 ir ' l, i rl .i , l rrl r,\','
    t1 l l ,rll, , '"t l', ' l''r , ,
    li , lrj/!, 1|lr, lri rL,1| l "

    l :l I
    I1[ )
    ( ( ) l ( l l i - 'tl l r ',fl r r ,r ". { u l l , 'i r r r i l ' l l l ' l 'l '
    lt.,1l odi.l i.iiri. r L r l r r o , l l r t r 'l ,t' ttl i i L l i l ) r \'( :r {i t l _ '
    ,! lr ./ tr.tt( r.i L:i rcsririt,torii lt tL(ju- ( l sr l l ( l l l l :l t1 r D L l 1 tl digcstil
    l strvr:ni1li ilt ltt:r'stl ct'rt
    , r i L r r i 1 'l i i s i sl l l i r tr L In cl o l r ) 'r 'r l l l l l r l "
    rt ti s I tr /.. a")Iuhibtt.id. tttt/rttl.t,ri !.s{,it'Ltlot frin h.ipoxr,:; ,,sindron as{ixic 'i u !L \r :.r r 'l i l l i .i 'l l ,.l
    i , i , , , . , . f 1 ,, , , r n i i t ,i r i r ti r i r n l i ttl tr l i r r r i r o i ttu t
    l)r1(\)('(f' si efectul inhibitor produs dc morlinir, barbituricc sau alte clrogtri. 1 , , r ! l r i l 1 I l i i s( l l l 1 L 1uli ) .
    . l>\,L)eztohareainst{id eilti a gevtltrlu.iittLltttol.tr.rlanou-nilscut pt",rritot
    , :,irrllorr.rasfixic tardiv.'.
    <:) I)ulburdl'i t|e tuttilotie I membrauir hiaiinir, aspir-alie mal{orma{ii_
    ll. Inteusitateahiporiei. A. flif o:;.itr. Ju.nc!.iolt t 1ri. Organis-
    .11;/r///.1
    rul rluseste sii rrcnlinii o PO" corespunzirtoarre prin crestcrea clcbltului
    ,;rrilirLc,plil redistribulic srlnguini{si prirr clestcrca secrctieiglandoi supra- rt )u - ira/ra
    j '/ | /,,l l 1 i . r l.r
    l( llill,'. ' , u i 1 r1rc
    l ! 's, ul l1f a. l re L
    ,r :L i l l i l i .i l l l c c rc ! i a
    B. IIi:lroxia m.ctaboli cri. Cairtitateadc O. ajuuir la nilclul i'l . ll | , f ' r" ' r ' r ' " '
    1,r rtlrrrilot cstc scizuti. Se produr:modificiLrimetaboliccla nivelul S\C dar '' 1 ' r '' ':r t '.;tcr':iat diatd-
    rr,irsolitc cle uodificiLri structuralc. Aceste rnod:ificiLri
    siut rer.elsibilc. , 1, r r , l i r r r :( l ) r i $ cs) . l l r i n r a l cr i ( 'a 'l ti
    I
    " t I ,1i " . r' : rrr' ii tl 'l'
    t'. Hi,po xi a slyrL c:tur ctl ii.. Este ceamai severiL forrnirdc hipo- '
    . ' :"" r ' i ,l ' l' ''r 'i ':
    '.ir'. \lridi{iciLrile structur;rlc sih+ nrF,onr,, <i irarrarcih;ta rliferite stmctur-i l ,,,l l l . r L ,l , , l t a l { ri o a (l i r
    (i c afnoc'
    .,r,, ( r(,i(nrtBi sint afectate .rif",:ii, j" Jr*ii"';;';;;,;i;;;.,rrcteristici meta-
    l,olicc rlifclitc. Timpul scut's pinit la npar-ifil leziunilor poate \-aria intre
    , i l (,\'l nlinr lt c s i c it e v a o rc .
    l). ,7 tt o t i a. Se caractelizeazirprirr ;rbsenta totaliL a O". llodificirile
    ittrrrlionrilt', r'lctabolice si structurf,ie apaf 1oafte rapid, si tot cleierul este
    rrlrr lrrl rurilonn. Efectul anoxici se instaleazir.in citcva minute.
    lll. l)rlrala hipoxiei. Ct cit hipoxia la actiorra pe o perioadii r1r: ti.l:o I t',' " "' 111 {.'1':i:illil}iill.i:Jl:::il*'*"lli;"ilii,
    :ll'l'lill
    trrrri lLurgir, crr atit mai seyore vor {i leziulilc cle la livelul SNC. Hipoxia
    lrrru {iorrlli, acfionin<l pe pcrioacla rrrai lungiL d.e timp, \ra produce modilliciri
    iR't''i.,],:,",,1
    ,, ",ul,l'1,',',',',',';,1.i',,,';,1,fi;liiil:;;."'J,.i,ii,ii"i-;
    ''ll,: ;,,lllll'it'l,l;ili;:l:iii:l?:
    lr;:ili;\"llll'i".l.l'i,'o"il',i
    r :,i:;iI,'iI j,ii*itrinist'm'#:li.j,,:ili#
    iLrrr'li,,nrrles.LrL rnetabc,lic,;p. cind hipoxia nctabolici, pr'elungiti, va produce
    rrr,.i i l r rir i i i. r oloS ic, i i rr, rs i b i l n . "i,,.'iri'i.'';l
    lr t f un, - ii d. t im | u l s c rn s d " l a ,l .rl .rn ..n ' a r.fi ri i . . n-l rta r:rodi ri -
    ,,iril,rL r lsfirarorii este urmitoarea: inifial, lri;ciri rapide de gr;slllg ilLsolite
    (i( rriscr-ffi bru;tc a1e membrelor (prim:L perioadiL de gasi>ir.tg), urmate dtrpi|
    r wiirri ri
    :il
    I 2 nriuute, de apnee. Aceasta estc ,,apneca primare',, dureaz:t 1 min[t
    ,t ins()l.citc de lrrarlicardie rnoderatl (pin:r ia 100 bitii/minutl, jrl stirnnlii
    $i
    i
    *ii:lniliitilll','*ffiljy*;11*'i,
    'II''llijjijrilri,'ill* 1,,* clcbit ului car r diacar c ct c{cct c st '( - r r ll( lar ( 'll( llLlr r 1r
    ,, ,,i ,ri i ril, ir t ir r r : cnt r aliL. a
    lillrrri pot decian;a o respiratie spontani. Llrrneazir apoi, o perioadi de 4*
    r trirr. in carc sc produc migciti si.mple de gasfi,ng (a <1oua perioadir dc ; :1, 10r'ir'rrl(r
    primcrt'
    ,lii,l1'll'll:'ll'iliili]i]'"iilif"'l,l',ii.="n,nr1ir.in
    'lll'l
    ':,tsf)ut!,) cc scad treptat i1) intensitate fiind urmate de,,apneea secundari"
    (l.r il trrirr. cler la deglant.rca hipoxiei). in aceastl perioadir. stimulii externi Ir';;',i'rr,jiikrhlli"j;.*:lil-'i,",j:':;ii'
    rttt trL:ri1,ot LleclauSao respir-:tliespontan:1.9iin lipsa-unei I'entilalii coresptln-
    rii,' rr, stoFrl cardiac aplre in clteva minutc. Cu cit yentilatia artificiali.
    llll;l;liiliiii-'ll,:11,1'!:Hlirgruc,,zei-s,,hct1'rir3iir:'
    'Ir''|('r.rri
    ' ',J'l i,i m : r i r ir z iu in ,,a p n " ;a s o c u n d e r.' ..,c u a tir nt.,i l trns.' . \' l fi peri or.l i ,
    ,I,rr.r ,.r f , . . . . r eiau n i s u i l i l , re s p i :rL to ri si p o n ,rn ,. (i i g 2.0/. il,,,1||irri.rlilililili**jiirll*,,,*;;li*l;,1;':y
    :ili;it::ill
    llilili
    l:lisl,'L uncle sL.nlnecarc difclcn{iazir apneea primarl cie apncca sccundali
    ( I ,,rrrrilr LliL) .
    .\sifci, in & b lL (. e tL h r.i n ar d. alurl cordLrlni esle rnai rnarc <lc 100/
    ':i;il:;lilllliiiil;il"ili'fiT.li:.",ln:llilillJ;li'il
    irl;'ll -.,,irlit,-,t.,,t,'l',i r'sl' itrrrlil"
    ,,tLiri1x,si''
    , ,,, ., 1r1,,ri,rri, i i. ti,,,1urt..,ri,ri-:i.ii
    r'iirrLi si <| oiricci sc acccl&eazir.il contiuuarc; pLr:sitnca irrtr.rialii c normali.
    l rf ll l
    r Lrr{:r'(\(:utir; r:uloirrca trunchiului cstc nai rl.'grabiLciauoticiLtlccit albiL; scvlirl 'rl
    rrrir:itl isciin spontltnc (c,r., lruzc, 1:lcoirlx') ; r's llullL.-Liil,. sint irr rry,riu-t"L llr.rir ;i I rr
    r )l l r)rl l t ( r' l f i l c lr ir ' 1r ' l ttl rriu l rz :rl l ri s i i l l l r L i ' fi Il l ))j r' ,,1' l cx(rni s,tl ti r' ,' sIi ri ri ol i i t'.,1.,'. HlPoxlEl
    D|AGNoSTlcuL
    ,r(l i rr(r (r/!y' s lr r rl u s r.). l t t Lr l l t l t i :rl S \' ( r r.t l rl i l l ol r r' rtrl ' r l ot
    ( !r r rl l rl l l rl ,l i i I I I I | 1 | I I ! ' I I t I t t t I I i I r ' ' '
    \I , r ) ii|||' r ' r ' r(I|ir r' L tl rr!i r.t rrr r' ,,rr,l i l i irl r' l ri Prrx i,.r' .t.. i rt 1r;rr' ,, rl rl ori l i r (' r.
    r lrrllrr{ili trrrti ,l, 11 lilo; I r r r r r li. r r r l! , r i, llr ) i ) t l . L r i r l r l iltllillirl lr.llli
    , 1Ji,, ' liz, .rrr,r'roi,,r ( ) i' , r ' r r z r . , j, . , r , , r r L, r r , . r . r r r r , r r . . r r l t '. r , , l r l r i l , r r l i r , r r i r r
    l l l :l
    ltr:l
    ttr r to tl c tl r ' t1
    tii;rgn,siicui rrcstacriu
    rczi
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    i':,
    :iili i*r
    tqri;
    E
    [srnd]omul postcsfiricl
    Vczi tabelui 2.18.

    Slnr&orNrt tosl st;xir (dui)i O,)tadeD !u.-difir:r{:)


    l abt!ul 2.18

    ,:rrf
    liriiEffii*1i;a$iffi54*ii,i
    f,r:,4r.6p1
    C oinplicalii. plthilonarc ;
    (lct':esar respinrtorie tr. rzit.rrie
    , ,rtl cs.,_r,
    rcqliratoie icliopatic:'i :
    sjndromul c1e aspiraiie puhnorr:lr.ri
    ;
    i'iiHttilttt-iffi
    :rli,fi l**;*;b:i**f il
    lt . C I ail?licalii cd.(diaudsa&lal e ;
    r:*,1;lit*:ltl":i'r
    lii,;r:imiilt*ig{tttl;";ft :
    '' f i s r e n l c , i f . r l a f i ci d c .ip Icr ..l. b fa d i,.a r Ji.:
    . . ' r . l i n n r c 8 a l i e L m n z ilo r ie , ;n :u [i,.i.n li
    cir rJr :r c.r;

    II*:i';riiir, i
    'iii:
    Falo.-lre/hipoperfu zie peri{cridr.
    (:|r
    fli.aiii mctabatice :
    & i(lozii metal]olici;
    rri|(lglicemic;
    l**en*i*if-ri:**'li:ru;:
    .lriF,rLrili.ubiremic 2.5. TnAuMATISMEIE tA NAgTERE
    MECANICE
    ;
    rrtlburi,ri de termoreglare ;
    , tt ftcrea cotrsumuld de O,, ; tli! tottlrlirl|rl
    ttrtttt,l,'rk-lcziuui trauulaiicr olrstctricalr'
    , r (isl erea secretiei de ADIi.
    j,l,ijiii"r i"l'l'i'ii
    ::r;li::lil,l'll,,iiil,.'l,ii;',i*ilil*1,*rui*._:'..[H]::,Xi1
    "rrl,
    ;i;i lli::i#ill;1h.til't$:?"":fi
    !:fiffl1+lll:#'
    *:":"""

    'tt',";'ll,li; r'rrs1n'sabili macr-osomia clisproporli1,.,


    ;i :ru ",iilll.iiliiiii:
    ,sint: Prc(rPrt:rl
    ' 't"';,,;i' . 'i.'*i"tit"
    ',j',,,,',.'1. 'lisiocicr".prclurtgitr'
    tonrarcia
    ,' ;.r' rrr,','t,*l'rri"rli 'l,.fi'itrri'
    artcrioar.I suL! tensi$(ie. mi({ti.riri, lxlli r al.e{ijrt;,rc;

    MOI
    PARTILoR
    2.5.1.[EZtuNlLE

    ril,i:i;,"lii.r;
    1,1i,ii,1
    , ," i;,'.' .,1;,
    ,'l'l'i;lJi i ii
    ii:l:llii'i:*i1'll'ili
    |.. ( r) n f l i . a t i i renak; ' l i r ''r 'J ctr |r 'r r n l c( !r r'
    : ; ; ', ',ti ,:i 1 ',r ""t;'l o ':r l i p ':n tr t
    ir'(irozir tulular:l acuti;
    ( , f.7:'! meddftrrr acut;
    e ,,/ ';;l
    rrt'l.li:lfJ,,i].jiiti*,i:li:il,,ll;l,l,ll,il
    't l' r,I t;,,r',,rrxr;rriziri:i
    ;
    : t rsD J i c i c ] l 1 j il ie n a l r " ia cu l:i. /
    ../ u
    , i I!lrlJi;"t 'il;l':t':lii, l\,';I;iriirJi*Ii
    tr,.*[t;ill,,r',ll'lLl1
    ,i,l]illlil:
    zi lr ', ir r r r lr sclt ! rol'iciir
    t
    2.4.5.gOCUt NEONATA|" ,.,r ' lir l l ,'l r 'l l l t "
    ll'ltllillill' '

    i i' c r r l *r : o' ir t . l s . r,l r' i l i :s l l ' r Ir' i , l r,rl o i tf(i ,l ;rl ri t.rrr.rl i(l
    i : l t0 l ri i t:i i /rrri rrrrl ),
    l .l ,L l ,l ' , ' lP r r ls lilif or nrs ri rri rl rs l rL l .,\rr(,;l (.s r:tn l tr .r.l i rri r:,r;r,i i r;p1,.,,,r1,j ,r,.i ,1,,21,, 'l t':'|tiu' 'lt'r""'l;i;,iilll,ii,l,l;ill'llii'll;:1i
    i'.
    | *''''tr'iri'rr''
    il:
    ,il'ililli;ii'i;,\ii'i
    l rl l , I'o lir . , 1, lr ipox i, s i { .1 ).1 .(v ,.z i s i i .r. 1 rrrl S tl t} l;:ill'';'il
    , Lll;',',1,{,111'; ll;,i,;i,',';:''';';r,;;;i"',
    ,,lil,ll"' 'r ":ir'
    l l ,rl .l l rl ( llt
    'r
    lul 1 |1 1
    r, ,r' l ,r1rrl rtri rr <lr ' : , r t lr r t r r ,r 'sil l'ir r "l'lilr it r l r lt lil' lir 'l'. r r l) {) r ( lllt ir 'l) l( nlli
    '1.11.'i.1,1,1
    , ,,1i,,,1 ill,,i,.iL,rli
    l:,,,.,:,,,i:i.,n,!,,t,i,,,,i,jfi,i.li;i,".,,,1:l;l;,,ii:io[] , rrt.r.rrl rrl i z,; r 1r
    ,rl rrrr' l ;trr'
    t
    lr tlir l , r lil: t r t izllt 'lilnt "Ls'1, '" 't 'lt
    11111"'1i" f ilsi ilr t ll- r 'si"i'

    '' rr t rtlotc: i.
    srrr cttc.'fal,r ' l tl
    i ;i',t;";.ii;t"i r1if,:r-cntiaitlcbuitr fir:ut r:u mcningoccld

    iilli:,'ilI.
    il*ffi:l"' xtil ifrrl#*#:iffiiili:':H#
    fiii'li;::::TJi,l,Tji,ji." in.puseuri,
    t.i,.ii'iii..,.t.i,l:,irior.gi,ii.,iii_
    , , r'r, zirr(li |ulsittii, se licccntui:azir
    " ,,
    ,l
    ' ," : ', zir "'
    r : 'r liulo; ic) .
    ir ,,,','i,iti' r,,'ttr"toi""illi'oic
    cu plilisul nou-uirscui ldui'

    loc lcnt, lirtr-uu rnter\al ilc 2-siiplirrrr' i


    iar-osrtl l':

    ,i ,,;,,,i
    .""pi5i;;;'rilff"':ilt:l];::::,."1iili::li,Tft,::
    :1,;li;;;lll*; '
    rl .r ;i rrri ,i tt f t t nr : f ic cli:I 'olt m ul accst uia Cr i r : r r e except ii
    t I Lr l ri l i rti lr it r irlilr r r ir ) nu silt ncccsar e ni'lsur i t er apcut t cc
    ( : o' lr t llr or 'r - i'
    l'lr r r r 'lr r 'r rl |r
    ,i, .iijlli;lli lii}i,iilltfJii]li' Llnorzolr.cli:atrorir:
    ctltarlati,,
    iLrtr--,'intc.-;ri r " rrtt:' i tr' l i, , r ' 'i' , i . r r f ""li")
    ft;L'
    rr1,,r,r-i. int. g"i,iiiioiii I rtt,ltrrilt,l ut.,)lri(.sociaic *,r.,o'i c,r c.l.tlohclnstolr,rlll rlat:ir sitlL
    r.urr:actie,,rlc.,.!,.,i;i',:']',(,.f
    i;:.,:T::|3:ff:1.r,-, "', l rrrrlrl, lirttirr-e, il-iriL inftlnt]al-i:, nt ncccsitir tratiurenl'

    2.s,2.rEZtUNtrE gt cRANlocgREsEAt
    CRAN|ENE E MASTVASUBAPONEVROTIC'{
    2 5.2.4.HEMORAGTA
    2.5,2.i. ENCEFAI.OPAIIA
    TRAUMATTCA
    OSSTETRICALA l l Inr,)ri l i t iit slll) ipone\ : r ozr r l- it r Lliieu'ii- lt esulr lr il'ar "oiar calcsclllllr r l'li
    ,.,, | ,(11trl l rcnr . u1111! inculos, : r Lr - i, . lai'lpoat cI iuasir - i; i: - lpi: 1iL' llr Llill I
    \ ic z i punc t ul Z .l J .1 3 .1 . nr')rtrlit:tLLr-rcL'ru,litl:i Sc intllucltt rrr''
    i,,,1,,uL,rntii{ci,::Si rill.1)
    | .l ,').,i rr'rs(:uti t'\r i..l(ruI{,'tlx "" alt'r' Intlrr''it it'stcit''lc coilgLliarc r1l l( 1
    a.1.[]
    2.5.2.2.BOSASEROSANGUINA
    t,, , ,t,1 i rL r, , . , , s1( ,( . ^zud, lr oala f i considcr at h gi ca o f o''lir r - r r li r l'
    irr li)fnla sa cea rnai bite cuuoscutiL tr,altzt.ttzit
    ,, l.r lr, rrrot.rr!,icii a norr-rriisc'rtul i
    ', (J
    oat e -{'' Iluichison) , prczintir tru
    aspcctul L:ultoscut sub l)'l,r ,,vac..ruln criractor" nou-*irscutul lrr ,
    li'sir d in loc t r t lr ilr r t l
    rrijr:irillfiJ{$i,"1ii:gif;::Tn?t,,*,lnii'i.,1:ijrlr.,,,,,1ffi:i:,,.:,r
    'irsl(.t.(.cll
    i ;1,, ., iiiii, , i. , 1 . ca ut t , , coc" Accsiir <lispar e
    i:rf ,:::",ii;1,1,:':!i1*;i;:'*,,;:,i..lxf ,,, ,1,,, ,' ,,,,., , i , , . , t i, ' ir cular i r lc ccbim oze Hem olagia subapt r lt cvt tL r
    - o1
    ll,,';.ll;ll
    !lii.r'r"tl 1f;l;friHli . ' l i rl . ' ' r z, r r 2 'l r ;
    'r ") ^ '
    r r '" t : 'I i" it 't t eer t lr , t j
    ' 111 1, r ' ] 1"1
    I ,.r' .\1 r ' , r 'it r ' z in - ' : r r n': r f r r r nlali, , . ci'r ] l- 'r i: iP. t ' 'li lr r 'i'r r r r r l'
    *11t

    .r'' 'irrr'tir inrr.nterinircarizincl Jl ,rrl.,iiiii"" rii.iir"i iri"l ;;i";,, r r, r' \,. Jr , 'r r r ol- lglir cpr t t . r r 'ipit lit . p. nir L1r lisir t ir nplu, ut r u hL'r r ulilr t l i''
    l, ..rr,lul
    I'r', z, rr: ""-.t".t
    ,l.r..rminin.lnri,i,.,,.,.,',',.l;.",-; trt:rr'''
    ,i,, ,,,, Ii.isi ,l_.,'li
    ';)l'l,l;11.j, r 1,',.rl, r'olrisit t:ii ril nii't'] i u;c'litt't- d.c-hcnrt'globirit (nir-cl
    ,,, i:: ,il',,; .:,1,^',1',?l
    f l vi,,nn lill :;:. :;1..:i:li : ,,1,,,;
    ll:,,,,,, | ,, L I pi,1 li rrrLtrLi,rst-vL.rj 5i ultcrior ictcrul''l ratamctlul cottstir in ltrttt
    rri tn i ..i rt" :.tiz,:tz',li'
    , i r lrr u.r nar ' ., t i' l( r '2 inl I r t t olt lr lliz. 'r "
    i. r, i:l l , l , i i ", j,l ? l i ,,," Y i " ',';*i l '. " '
    , l. ,,'
    'r r , it
    ; 'i'r ' 'i
    i' - f I (1'ninistrtrca' \'rl r
    - ( ', tduP:t
    ,, ,, i,, r1,,r rl ,,,,,gi,I,,r,, (,r::c surr-il.' Li eittv'r orc
    l :lil.:rirLiire
    tr,:sutu,i.L,"
    "',,1iiiTi1;iJ,T:.,t:,lt,1;:iu,T,i:lt:,i,ii":ii:ii;,.i: ; ; i.; 1, , ,i,..-t,t nt.,i,-iperfuz:ic cu pla-sr.tir- proaspirtir insllclatil (li) ntl/li"i
    | ,,j',lr,'1i,,:lili:x11";:1;J:1j:j:J.iil:::;,::,1",';nJ]#:'i,i,;,
    rl ,rri r r lr r iit r i.
    jl,:i:j#l FACIALE
    5. PARAI.IZIIlE
    :,1;,1]

    , ," fiz1,,1
    .\-
    1;l'ill'llr;;li;',11i',,"""j,1[iff'*:J,1,ii:i#ii,{,.";i:"'.;1,1",]li
    ';,ii;;r;;:li;.;:.il..]ii,r,.:,{rlillili;l;:fii:: '' l, : : 'li Ir I l|r l ni|r "r l I 'o'r ' f i '''r r i"ir r Lil: r lll i 'A' lr r / ll
    ,,,i ,r,rri,,,r'
    ,,,i,i,,oi:;;;;;;,i';;s":'d' . t ' (...lr'tz
    rlr' . , t r \ lt il it t 'l: r r r ' i lnzi lt ' nt r ''t ' ilt c'lr 'r ll un' i lt "r t r "t : j '
    ' it r t t 't t r sit tI'
    rr L, ,u,n1' r r r lr '. it r it t r ir clt 'r : llzr ir i, ilr r t alizia cst e dc t ip, 'cilut lal"
    , rl rlrrrrr irrfcri<rluii :L itctli{t'!ci- contralal erlLl L" lt:rralizia i}ri) citt.il(]l I
    2.5.2.3.CEFAIHEMATOMUT. ',r
    ttt
    l rr ;rl i r'{r izt llj, , st c 1'clll, a ( 1u p. r r alizii I acialc Pcr if er icc t calizat t r ; r t

    i,,r'i,ri,:
    til:t*j+:::i,i#"ril"pii:.,i';'l!;,1,i11.iff:lllllll,,ite
    l:i:u,.i,orui,
    f.:ili ,,' ,' , ,i i ,,t l l . , gr li r r lulr r i pr d{''r ic "l
    ',, ',
    .", ,,,,,,,,,]ii lr^:) pri'
    Lr cr vLr
    co'rprcsii:
    lui
    11: r . nir - r lu}
    itt' t'tlero
    glLulii
    s"tu ill
    st ilot t t r
    lllolll('llllrl
    lc lr r ( ) r 1r ( t lloii; l s; r cr at iat r pr in : r llliclLt icdt : {or r ; r 'ps) lt t
    r sl, t

    r,i,ir,creii;ii,ur"Ji.;.iiii'.,1iii..t1tili,;,Jllli'i ,,rrl ri r l rcrrlt zr r lr r('u,rrt,lil.,i,l


    rr :ljiiTii:l
    j,ir;-,iii'"''""1,ii:,..iili",.ii""ili');,:,"11',; ,1.' ,., ,l ' rr I t t : 'I it r t , , i, r 'r '''iizia i'st c hot uolat er lt lir , it t t cr cscaziLit r lr clr gr t lir li
    l,:ll;l'll:illllii;l; ,
    ;;f.'.ff;ilf r, r,,,ti r,t si It t <' r' ItI It t t t ' I I las<: .
    rr,., ir,rr.rrii crr\,. .r';rrri.nr'
    {.,,r',rrizrrriii
    ,, ,, ' ,,,i trri fl, , 'ii liI I . r 'r r I I t I t iI ilt lr 'r r lr ''t 'L[ t cJ't r i . lr t r t {. r r lr t r t so- ) abilt l' ; l, 't ''
    (,i;,.",l,,li"iii]:ll,l]iiiii
    r)*,:rcrirri, ,,,, i , , I r ir r l ir t , 'lr i'l' t . , lllt t ( l't ! ! t l! 't lt at iJ 1i t t it i l r r r r r ' '
    :r. l.rtl' r'rr 1 ' rilt rrt t t rt t rrt
    p .irt t l rl" r. rr ', r " 1", , r t , l: r l i. ( ir ) r l r ll, r l lr ir srr t lr r l
    , , , , . , ,) 'i ',',',',',1 1 "11,:: rrlr ' " ,,,' r,,J.
    ;' , ;,," i ir r , r , t i'1, , ': r t i"; t : r r 'r 'r 1'lilr ; 'r r ''- l' r r r ''
    ll', ;li'i',r,1'il'"lrt ,'
    , r , , ( , r ', i. ,(i,i
    ,,,r
    ( ,r,,,,:,,,,1 ,,] l'l] , ', 'i, , , , i, 1, "
    , ', 'i'llliii', 1, 11', "J1 ,']'l i l l l ':, f,f' ,,,' i ,,, , ' t rt i t ' .t r ' ( 1'r r t : rcslI llr t sr 'ir lr '] ) it r lr 'r tsiir r ilr r ir si)
    '] ' '
    illr I
    ; ll l{ I
    ,.,., lllliJ.,l_.11.].1llic:rP:ir,rl (t * 2 silprimini,trurt)in crfe sur,
    rtr.usciciure DE PTEXBRAHIAT
    PAftAIIZIII.E
    2,5.3.2.
    ;tlt ;i: :i:':ii :iilI:Ii'I ;i:ill;ll'lnju:::1,1, jfi,i.ff:t"lj sl*l
    il "r*?h: (', 1 trld clcs sint consccintl irrtct iuuil orl atct c:crcitatc asupla ciLllrlrti
    rrislr-r'trziu la 4 or-e) . -a1c
    .tuoi.tt., in c{ortul dc degriare ruuncrilor) 'sart'
    I)c obicei tratarnelrtul nu cstc necesar. Dacii insi. , rr,,r,,i ii" 'tt-
    dnp:l 7 _ l0 zil.c tlc "*r"iilodil"
    excrcitate asupra ttmcrilor (pcutr-u dcgaSarea cirPlrlrlr rrr
    vr.Lt.1espt ctul stc_stationar, deyine nccesar , irrt,r Ir)rctiuniior
    etcctiocliagno;iicul. Cinrl acesta '
    : r', . . n ls f r ( r d- d _ e g c n c r.l rec a u T m J l i , I i n i L .cr.rrpcr.i 1,r,z, tr1rrl i i l i P
    : rllviclr t ') .
    i l orni cc :r l trrl l chi ul ui
    :,nl
    rvrl'os_ tratamentul impune (cl.cclniprcsic, ueuroplnstic anas- 2.5.3.21. Porolirio de plex brohiol superior{Erb-DuchEnne)
    r - u per c q b n 2"!rjytgr""]_11
    l ,'rr,r ' 2. - L- XI s e u X l [). { o rl i c o t. ' ]-l pi r i trr .rrr vr,!trr,.. A l .stnte r : 1"r r 1'
    |,r.uljl'r-.ltr poatc sllccra trp-a Congcnitali! a mrclcului
    ncrvului cratiofaciil. \. ri r-,, Dar ', r liz, (. . 1. cor ) s, cint r l^zi|ii I id': cinilor n'r ! or ': t "\ "
    ,,, ,i ,. i : .i , t " J"- t . t , r t '. . peailil m 1'r ului r loct at c'r o at r cl'r i'r i' i:
    'n' '
    r r ir lr i lir ' in r hciuclie 1i t ot '1i' in1^r ni cr r 'r '1'-
    , .
    ' ,' .,,t or l. , L, t "t i't
    2.5.2.6.FRACTURILE
    OASETORFE!Ei (mondibul&,oose no:ole, nroxitcr) ' ,i ' ," ,,' f i'i o'r i. ut "t i" colr r lui llo: r / / d dc ui"la ) 'i. cu palm a ir r 1r "'
    ' ,,,f ' r,-t " tl- l Jlor o ost i. abs nt d, . n31leo al' cl?t i i- r r - ) lr r r r '
    rr, l (, I1, \1 ll
    I',',',,i,, . {bLt t r cir 'r
    Sint oosibile nncor-i dupir aplicafii rlc forcr:ps sau lixtcnsirL :rrttr'-
    ." conscculi\r rnaucvrci ,*i-iri a anleblalului si s[pilalia niinii sint aLo]it''
    l\lrrrrric;cauin prezentaliile p^olvicn-c,ia .xpotsii t'r rlrrlrri si nriscaLcat1c apucalc sint pilstrate'
    ir.,,niutui i-1"io.",,,"o si rnohili_
    '/'iu(';rprecocc sint necesarc.rn abscntatratamentul ni ilpar corls{rri(riri vicioasp, 5' h'^ cr r o I 'scuJof 'r r r lizie dr t r nr or - j ' l't r '
    ' f i ,,,,., i. ur c'lil"r t lr ir l
    ri
    rrrtr:lril ozc. ' ; ; t , . , t i'. 'i. 'f ; , , r t m ar ult t i t 'P; ( jzi; lizi hr 'nr cr ali sar t ost oocr 'r 'r lr i'i
    " i ,i " ,
    ,l r ' ,.rrrl ri rl i tt lncsul congcnit al ( pscudopar allzll valr ot ) '
    sc as{)(lirzir
    2.5.2.7.t EZtUNfi.EOCUTARE irlr ttrr tttuliir clc iazrrli, liiraliz'if tle plcr blahial superior
    , I DirirliziiL ,1,' tt,'1v frgnic (homolateral).
    constil itr ttrro'
    i' ,t,tt,,j;ri. ,t., pi"x biahiai supcdor, tratamintul prccocc
    . .Sint reprezentate de eileme seu cchimoze p.rlpcbrale, hcmor.agii sulcon_ ,r , r' ,.,,','f r,' ', ', i, , ,i 'f "it "ip. ^t * pcr ioar l"t e 2 - 3 or n' alt er nind cu l) r 't i( r ''I I {'
    jrrrr'liv.lc, leziuni corneenc. {racrLrri .r,, prin ..brlutrli;r
    (rrllirncl:realizate
    oLliti'..io ri"i"o.ugi" in*traocurir-'
    mai alesprin apll."1i"a" i"i..,p"ll. *.'ili.ion" t"rip"irti." ,,', .,,,,"f,r"i;i^,,rt,
    ','r'ri, ilr.i iiir"i. l oiliir"r"n se frcc p'eLoracic
    icul sinr v.rriabile
    ..i 1'r',,xrro.t c,,'tin,,ilcri.-"i
    i., i if,:ii,, l" 90;, *ttt"bra1ul"ipc liDgd.corp,cu pahna orientatititr srts
    it l iin''
    I' rr' rr" r,, r r r t r lscl, il{, rpJf : t lizili in pozili" dn r cpaus sr ' Dt ill. Pf
    ,,,,,1' rl rzl r,ll ,r r lr t l . u( ar ulr t i J"ast t lna capuiui p" salt o3uir .Pi't r ul- 'l- 1l'i': t l'
    pl. r r r 'r 1'l
    2.5.3.LEZIUNIIE
    TRAIJMATICE
    CER1I!CAtE l , ,rl ' l ' r' ti ' . r 'r , 1ir ii" ''- r inr ni si suf inut ic ( cu aot cl) r a1ul ln ll'xlc
    i r;, | ; ;;;' r , i. , i'; "i t - r it , " ploxdui c"n'icel pr in pr csiun"a ccnt ur ii. scr ir t t l: 't '
    st AtECENTURn
    SCAPULAnE ,,r. r .' ,.r ..i r i,
    int in, . l, 'r , 'ir . . licini] or ncr loaso. Pr in aJt er nct t ! a. pcnoa( loI 'lr
    l(
    j' i i r r hr alul f , I cct xt llr r l) r l
    I ' , f ', t , , ,; , ' ' , r r r m iir ,f l. p; sr r r r cir m obilit it ii. aI t icule: r 'Ja
    2.5.3.'I,FRACiURA
    DE C|.AVICUI.A ' ' ' program dc nrobilizare pasivi' a braltLlrri ilr
    ' Ill zrlr' .,' r'a nuttia iircepc un
    rnrrsculaturii anl a-Sonisl c (mobrllzarca preco;(' rrrr
    ,,,1rrl r.riliLt-ii ri:tracliilor
    I)i^l.c fracturile traumaticc obstc,ttica1.., fractura dc cir*,icur.i cste ccrL , li , , , , rrrt rt rttlrllir : riic tlc agravare a leziuni.lor nervoase)'
    rrr.:ilri, ri rl r.,i'nbraciud_d" ccl,,rnai'mrrlrrori a.,pc,irrldc fra.turii lnconDlr]t:i de 6 luni ziua 9i noaptea cu intcrnlitl'rr1;l
    Iru,rlrilizarca ,, t"."s,ri'ii*p
    |..rr r'||l.t \.:d-. ). LqtDlt.(.vc[t con-"cinl.a uRpii.\pulrii lahcriolsca urnirilol mrmal pc trllpul no?!u'
    r ,rrr,,,ri iltcr"t6 htni
    rn,pr,rzcnLafi:r.cri-niani,altcori apare in prezentatiii" p;l;;;,
    ,,xI,,rrsici in cazut hipcr__
    mcmbr.elor- de nerv brqhiol inlerior (de tip Klumpke)
    2,5.3.2.2.Pa'r.crlizia
    . I)iu puuct _ciel'edcre clinic, fracturile ,,rn lcnrn verdc.. sint dc obicei ;i.t'o :ti '
    .r,ir,rpin:leticc,d5lqnind aparentc _ iO ,i1", p.i,i li('zulliL (hn aicctarca rirclicinilor anterioarc alc ncrvilor-C'
    $uqi u
    , \1r".r.rl!tli, ni,i lul tinicidcfr,i.tu.:. unui iilu_s
    ,' r,,,,,rl ri It, t v 1{, r xc; r ldl' acccaqipar lc: cst ( m ult n- t aj r ar i ( 2- 37r , dt t t lt : t r 't
    "p.ri1ia
    Ff,icturii..ornpi"i.r-"",r,,ar.p.;nil*i_ dc. l) r ir lllir r 'niln
    rr.r-\'rl s,*r abolirca motricitirtii spoofane.ie-braful rr rrl , I,r;rl tir r lr ') ,r llr r t nuit nt ai scr ioasi decil |at alt z't a lior
    dr: :riecagrparte, rcflexul
    ;r.irn,lric. tJisp_r.ii
    i;r Iosci s,iprrclavicrtrr. nlrJ".Li'*,",ldcm al nir.r.iil,rr r,,r rrr nnrll( { it zt lr i ljndcr r r cl r : om plcli nu 5c loaf c- obt lno) '
    ''lt'rrrcr"l)ir:r' s,:.drfo:.mrtalc-
    ||r'r, jn zon.r linici d, Ir.Lr:rur.i. l ' ,rr;rl izi: rit t t ct ',snlzir cslr cm ilat r "l di"t ali r r m unlbTullll : up{'llol 1l' ir ( }
    i \| l (Ll]l-.-li).rs:1.
    Mr.rl,iliz.rr.cr,
    rra.siv.r , l, a[ cr - t aii) llir t l at ilt iL iur 'r 1: -in
    L Pozili( ' ( l( . I ] ' r ir .
    t:xilt r lljnul r ; t ( lr O loFi{ . pCr r r : if , , a l i , r , r l l <. r ,l ' ,r' r(,rl r' :rl, ilt t ( lut lclL
    ;,'ir'rclurlc.rr.vc:rl*aliiparalizi..rii pti" ri"rriai, "";';il..,ii;i;i;" r l c r : l u r . i C r r l l i
    IrJr.lUrii nr r . r
    ,' 111,1,r ,lrr tr r ir r i. r l'i [ , 'ci) 5i nici o t Dilt ar ': djll i] r t lcuiall: l. pun) nlulll
    ilt 1' s
    cli'ic .st. irr '',
    ,,,,t,i 1,,. \l i s, lir il, , c( , r l i s; r im iir ulr I i
    , , inl pislr alr '. Pozr lr ir d" r cl) ill] s '"t r "r ; l
    t) D1lal..
    f t "t i' r oiir li" int inr i : L ; t t t l' l'r r {r t lt t i' 1: r t lnr : it t "t l r '
    t
    ' li: ir t ar r Lutrrrtl i ' , .,r' ,i ,' ,i ' .,t i", , , , i, 'i, 1i
    c o ' s ti r. i tr s .tL rrr,:r tl u t.t,r.i i iuIi
    , srrr;rrr.rrri iri rr:ri i .l r bra.tul rri
    ,^
    i. , r , r |J r lilnut , .\' t..rri .,r< :rrl ,l i rrrl ,.l r.:L l .,r_ l ri :rcrrti l il ,,,,,1,i ' r r i' t l, cr z*r 'i. t r t
    i ,,,.,i ;;;, l i ,. l, l, i'f , , , t ii, , t i'f , , r . r i'. s, . : r i, r ci: r zir . ir r t r . r r *r
    1 a ,i i tt. 1 lij 1;;;;,.,, prirt plozii' ntiozr"tsi .n.'fial-
    ,,;;,;;;;i ,;; i,r,,, ,ri,i'i"fil:t'f ii r:r'r'vit:rLl lr,I'ol nI t:r'rrl , irathrsiL '; , t ir '
    ,.r D |l lt I I ill' , r t it l l ]l l ti ,.tl rrrr| l i l r. rr,r.,,,,tr.,i -
    ( : lillr ( l( '
    rrrr' { r,i tl ri tot t t lilr t llt lll- llor l) cr ) '
    t.rJt' .rtt)j
    l ( r r r , or i lr r r r liz i rr rl r' p 1 ,,r I' t;rl ri l i p o rL i c l i courpl ct:i fsu1x.' .L,rrri;i i i rl ,:- ,rI,.o I.Ir.;ri | rr.r,t . ( . t r it l. f r(li,
    . t l silLlr . liit i,llulsl:
    il lrit Lillisi Lor t icoli. f {r sl) t l( r t ir '.l'lli( ,
    ,,,r,r). ,, Lr lr.ilrl||lali(]i.(,slc ti;trlsi rlisL:tLtatl-L (toIticoiisr-ri lI]uscnlar .poalc, ryliLlrr. si
    lrrroL,ilizirr.:al)r'rrilrllri in l)afalizia tL' p1c:; bi-liiri:i infr:rio; sr: {acl. i-L lur, I rirsl( ri l)fiu ()lli.ilalis LL'zrLani), intr-utr ]1u1n:1rdc crzuli fiintl plolr:r1ri1
    .,' ,l , t,,.tl ,,i 1, ', , . ', ili. I r i. '' 'r r 'r LiI : -' - l J- : r : 'nr 'nt J' \ isLr 'llr 'cLr 11'1t l1' r t r r
    1 ,,ii;r rl, rrrltiliLnL nnrsurllir (pozilie r;r:utri). l,lina si mil]rratu] sir lritgir ri,. iseheuricir altii srxrr
    ,, ..r1lii l)lriti l)c carc pnlma estc pus:! in axui anteirr;L',LLi!rri lir;rpii.llicindu s,. I " rLt'rttlrlust:i:tl.L'lnii arrtori arr Sisil o zol]al Je nccrozi-r 9i
    r, si{rr'llocliliclonl;toidi;rrrii. ca o clisplazie (tlLlburarr: clc crcsilrr')
    il .r,Lsl Dr rurtcbrat si contractalr)a dcg<,tclor). ,,ltttttortri.lL"
    ''t,'i,,',lilt
    \{asrrjr'1r,:uriscirrilcpasir.c sc incep rrrai dcrrlrnl ri,'cli irr prralizii1r: iic rlupiL la;tt'r'c, cl r cb celc nral urulte ,oii. aLlO:-L ql iotcrvtrl 'l'
    '
    .. ( r)r'\'ical srlpcljoi. t.t z;t,,, in c.itr.ali', a nultlriLrlui stornoclcitlomastoidiansr'
    lodu.laiiL, durir-,imobiliL diarl:retrul
    l)in puuarttle i'ecicrc{rvolutil', daciLtmncLiLrrill ii!r'\-{!iLi,'Pirsir,'tizr"L cotrli- 1,', ,, l,,i:rrririiuric
    'or.tiLLn"a 'lll zil. s,' *" 1-' pr-in i't]: '.rrl,
    ,
    14.1r-
    r, fl|| ltraioLliciL, motiiitatea sponlani,Llc:rpaLtr-r fi,:ri,,,,ii.iii-A,riirc ,,vicl"ntiirr.l tlin lrriurr'1,' -i tr.rducc
    Jjrogi-r.-rii'.r'ilrrLrr]aL0lcorn-
    ' ,r r,Irij linclrr-sc dupir ln intr:r'vtl cupdns inj-r'r:cil.'vu sipLiLnini, piniL 1;L , rl' rirr crtpttltti(lc ParL(1aicctltrt,il lirirp ct b rt'i'L ' rlc ridicat':i;i olitrr
    , {, l|llli. l):Lcirfiii:t.ltr l]crvoirse sini; ratomir: iriti-c|ilptr sr poi!ff .LritiriPu o ,. 1,r',rrrrtiit-tLl op.r.. inc.,r".ret dc ilcluccrca-caprrluiin pozilia,nortnrLl rr'
    ' .rl i ri, , t ) c lm anc ni: t. ,, ,, ,i,,.,i.,. tislc vi]rba ir ir.ceastiprimii. ctilpi't, dc .', totticolis rcalizat ,r'irr
    ( lr '
    {)rci palalizia pcrsistiL li'rrir-a.urr:liorLrt' iir:ip rL'3 {r iuli, rlir caur,.ir 1 ri ' rt s|Lr lar itsi car e r f t r oc( JciLZ: L\ lr r t r f ir r l r nt r llll. llLLll- lt ll cillLl! 1
    ' .rri Li
    . r;r|ii lil-'lclol lcrr.oasc, r't,.rttioplas1i:i , rr,rl !)rrrrl,;' rl, f lscialdr spalcdeoi'icr it lLr p, ; - - 5 | r i - '\ 11|or i iusiL' t or t iur li: r r l
    ofcr:'r sp:'r.rr!,Lrl)rrlltrir !r iii(:irr.irir':rir ',
    I I llrLlll. r.l l i i ri rl r Lc r ccast ii dat e c( ) r
    lls, illir t . cLiL- liir ii
    'alu't dr Lr Lj' llr . ar i( ] sf . cil7
    picxulrLi lrrabiai snll'.,'ior-lu-, ,-rir lir(liinoslrc ru;ii LriLt
    ir 11,t,trj, pirr:ai,lizi2r- ,,Lrrilril l)rogr-(isivua aspect caraciedstic, tra'c1tsplin plagiocofalii' (ftorr
    I r prri:rlizia.plexului brairirl iu{rrior. r ,i, I t'rlit ,1. afectaiiL,bombeazir coirtrolatcr-aliu timp ce.ou:ipilitlttl
    lui si clavicdei clc Ir;rtlLr'
    I
    'l 'iir.tel homolatelal), ridiquca Dm:Lr.
    rii.r, l,,,iirlriaziL
    PARAIIZIADE NERVFRENIC
    2-5.3.3. I rl, , rrrri rrr, ' i t'iLr tacialir, scolio/,ii ccrf ico-{lorsiii:"1cl1 collcavitiliu orit lriir{ir
    rrl ,,r l rol tt : r r 'i,
    \t, il:iocjirzi uncori paraliziei cJ.eplcx brairi:r1 sup,,'rior ilomol:rror3l (r:ri.. it'
    | | t,t\it tt, ir.lticolisul {acr: nccesai:i-r':lclr-(1crcasindiomtll ui 1(lilrpL i - I i I
    ,, irl)irr( izolat). 5r: datorestir tiaurnatismului eLsupf,;r tcrviloL 3, ,1 9i -5 clli- dc Vi:rfclrt
    , ,ii L,rrlizlLit;trl nliii des cle traciiune:r lateiali si hipi:rcxtrnsia gituliii in ati'- r l ,t, rLrl|( l )icf Lt n_tsl it unol eventuale disloci.ri traum:rtir;c
    ,rr' .rl '
    ,,trl i i l t pLlv ir , . ne
    .
    (l l. i r. i t: se constata! dispnec, cianozir (naerri iir cuzc), rcqriratii tlc tiir l t ,r,1,11111r/1t,/rj, torticotrisnlmuscrla1.:rr1l]ccin disculic i ti] cauz-c-l){)si
    l,r1 ,1, 1r'rI ir',rlir r:rlm sint: strabisiuul, tumoril'- med'uiarcsau de fosiLpostcriolrli L
    L ,,rrirl (:11zrbscn!a expansirinii peletcllri abdornil:rl iri inspiralie, (:\'clrtlliti
    , ,r i rr r, rrl , r( l( r ) oiJienc ( silclr om ui G r is'1) , - r niozit i. o'i{iair t iL' int o"iit r r t I r t
    ,.irrlrr:a murrnurului vczicular. de pariea afcctatiL si uncc,ri tip.,Ll.slab.
    l '. : r t t r nc nul, rftd i o l o g i . c c d d e l ti Mi " r- absel l a cxr:ursi i l or rcspi i a-
    , , i rrlr' lrcrnidiafrasnnlui dc Dartea a{ectatir,deplasarcr r:lediasiinului contrr.- ,,rl 1' ,r.Li rziil'rirr ( 'r t br a1o, r nielor lisplaziccin ic't 1: ',ocr ipit illizar c r k' iLt lasr '
    ,i rr1 {tnisr:atcaparadoxaliLa C.ia{'agmrrlui)r.Lr.lli7--,t) t t I tt tti t.tL[rLI lrcbt.lic insi'ltnil precoce ;i constiL iir mobiiiza|t .1'r"
    :i i1n'.nrirolur ric lt,:l t:c-
    .r, l ,ii: r 1r ' r ai. . r\ ,. lrrrirri pinir.la supcillrcctie, con{om uirui progtan zildc,srsfirrrr.i'
    | , rr rl ,,,, , ', , t li. i, sugar ii cst t iiLlcr i i't pr it e'i c{t ct li'i ; i ir nol'ilizir i it r
    I rrLcr.trt,enlnI catstir in aCninistrarc:L iir-' ,:rigcl, (iec[bii- l:rlel!] . , f., 1" ,,i 1i, . 1) lit 'iLcu t r aLaint Rl cousr lvillol nlL sc t ) bt lnc col'ecllr llt llr il
    l)if i(ir l)olirrlYi!, eventual (iIi caz de dispnco inar-r:i."ti)cYitarca t|anziLori,'
    , lrrrr,rit;rliLrioraic si asiguiare:r nevoilor miirrm.c clc calor-ii, alir tr ,l .l ;rrri :jrr po.ttc far:r interi'crrlic cLirLrrgi'"tlit-(t'iongarc chinlrgitrrlrr
    ;i c]-ectn,- ,,,,,.,' t,,' ;i,i ) , ii ii, ioit ilir nt " ult , , r ioaiir in poiit ia '1r hipcr cor ccf ic. ini! ir r l'
    r irr
    i rr lrL'frrzir
    1r'L'frrzir cnrior-cnoasi.
    cnrior-cnoasi. Supiainlectia
    Supiainlectia pulmolrar-ii {ecc receslr,r tratatrcl i t clr t ir lc si ir r t lt
    r t r : 1iviL( lxnilu cl- it a- r cascolioz'ii cololr 'ulrlcr
    ,lr iLritri)rot1cc.
    I , r'lr iLritil)ioticc.ln In ccle rlai j:r]ull{r
    ccle lllal irrul : cazu[ lindtcarea are
    cazud 1'.1]ldtcaiea loc intle
    are _ioc intre 6 sitot:.-
    si"rot:.- ' ,' ,1,l j .,,,,
    , .rLi si , ,rrl ,' , 1.r,i :r lr ') .
    lLrni d,.ipir naslerc. Ilacii irnd.rirea clilict-Liolcgicj ,r.r eritien-
    .r'itL,va
    I 'r lri(ii <,'arnciiorarc, se poatc lua in considclarc intc:r'ent-, clLir'ugicali,
    ,,/, (\)usii'i
    rrrrtsii'i itr irr r:-rcizia unei piLrti a di:Lftagrnului al.cl rl ;i lefacerca apoi a COI.OANEIVERTEBRALE
    2,5,4.TRAUMATISMETE
    'i r rr i' , , r . . s . l . [ r if o ;n i .. Pr.' r ;t,.a .rj u p . r-l i. e ..,r1rni
    q-roia rdiafragmatiai -i ,-
    Ji al ragmari c.Lrcs.-
    I ' I ilr"L cslr:
    csLr: coboritir perrnilind rel'elirea mediastiuului iruld in pozifie
    Dozitie nororalii.
    nornral ii. I r,rr, ir l l) l1z1r ll1. ilinC 'Llar ', sint t '. 'lr scL'irLr i1r 'r cJi"r nilolir r t r gil. t t r lilt r r l"
    , i I lr {:ulill lrrsirlilor., iri l.,rrz,,.nt.,l i., pL)r'i.rtr;-L (ctL eLtslot:iirrLttttlilotl.
    I ll'n ntir trL|lnreirtului chirurgical, cazu:i\e calc rru au au evolitiic
    evolutir: s1)otrial]
    spoti-iau
    ., ,f ,i ',lli,ttrii, silcliur'i liil tr''' [r-'rcttrt i rirnr di:l rrritt
    ,,rrrrl r ilii.dc , c c t li: lz i , c l c o b i c e i , i ta i n te a v i rs to i r l c 31uni . r t,,,,11,,t ' 'r1 "rin.
    l, l , rrtl, 11111i l1r 1; l'r 't,t f( r : jLo it
    r lor l: l dc I t t : wr t t I t r li'r l : t li t r clct nt
    n t l'lt t lit L l- o': r t -
    r | .j r, rl i l o( lot sr t li t sir ' ( loil nlit i lr ( lcv( r nLi"l-
    2.5.3.4.tEZtUN.E MUtCHtUtUISTERNOCLEtDOMASTOtDIAN
    (torfi.olirul musculor) I l t u t t : it 'f ! r 'llllos( 1R'i 1- llir t ll:t L: s( ) \ "llililt r ':
    ( fi l l ( ' n r ) l l - l l i !s( tl l l l [ ( 'sl ( s( r tl i tl ' l ) tczi tl l i t <l r : l i L
    l l il: ot r lx ir t t s iltnt u ;c l i i trl ttis [i ' r' n ,r]r' i ,l o trri rs l o trl i :rrr
    i rrr:rrrr;rrlrur;i Ir,r' i Iol IIrIro. I I 't , t t t ) ( tt( 'l tl l t Il /1 /r J( ' il) |'r i I sl 'r l r ( : l l r r [L 'l i r l i 'r r i l 'v1r
    I , ilijr' , l'o irl(' iilllrl ltl r ll) 1ll|il nI l! : ulijr ' , 1 I ) , I I I iI r I ii : i i I .r)| r: rI i I I I i | { .I I l l | | i I r . j I i l , , i t , 'l , t t , , r , t , t r , 'r l ,'i i r 'l r r fi ( .i "r r t.i l \'sl ) i l i r {L }l i {,IIi I) I) I( 'I '
    I' rrt ,rtl'l;|ir irrl I'ritr o r r llr r iz r r r , , it lilr r ' r r r r I i|r ' iolr r I i i t I r , | | I i I i | )| | | I I I I ri , i ( ( 1 r 0 r i i i , l i r r l , I r i I , o Itr r ti ,. l i t',r l r tl i r r l r l c ti r p i r I l r r l r l l i '

    ::Ul )
    i.t0l
    2.5.6.I.EZIUNIIEMEMBREION
    r 'pi-
    Iti Lr' ,,,r' i rt Lilniit : iu pr act ir : i, 1r : r r Lr t lil' d''' or r st luugi. . sir u dislociLt i
    t' ,.rr. r' tr ul ,, , , , lini, . 1, r in al, olit ' it sr lL Jim inLr ar '. ''rnr olilit ir r ii sP') t r lr r . llr ', lr
    altr:lat, lc[lcxul l{oro iLsirni:tric,turnofac}ie, c]iforrnilatt,'flra'ltunrn!trI
    rrr,.rrr(,r.rLl cli l)tlir{rl
    ,trrr,r'. (lipr'Lt)lr rirobilizarc. Did!:tlosticttl sclace clinic si radiologio.
    ,. l { ,trtol f l c.

    D 'i a g roo s t i c rr I, d.if crcnli.al face ucccsarirconsideriircircntitl* CLINICAL I.IOU-NASCUTUI.L,I


    tilol responiabilc de hipotonic la nou-niiscut (the Jtofll>y ,infarn synd:romc 2.6. EXAMENUL
    ) ;i
    r n spcclal arnlotonla congcnitali..
    'l'ratqmttttttl e-stcsimptomatic, rarcori neurochirurgical (fracturi r-r:'rte- i coprr' Ir r ir nr r lr t i , xir m . 11al t lL'u n'i''lllului csl' :
    . -
    ir';r1c). - cl,: a stabili plezeirla unor elrent11alcmalformatii congcnitalu;
    -- dc a iucadra lou-nescu.tul irl fuuclie de virst:r1ui gestalionaiiL: prt)rrirtrt-
    ,
    , . ., di rrnr" t t t r ilsi( . po. ilnlxt ur if xt c:
    2.5.5,I.EZIUNII.E
    ORGANETOR
    ABDOMINATE
    - c1ca cvi<len{ia prezenla uuor modificiLri p.atologitl carc ar 1)[t(]l irrflrr-
    2.5.5.1.
    tEZrUNtr.E
    HEPATTCE , nli ()volutia pedratalit sau ultcrioariL a copilului.
    onarte< l inm odilicZir ilcpaioiogicealenot r - n: iscLr t r t lr r isccvi<lct t ! ilr zli
    Ccl rnai fi'ecvcnt estc vorba dc un hematon subcapsular (rarcori vcri- . r ri,uriitiL. elc {iinil semnalate ihiar di ob,Lctrician (hidrocefaiie, dcspit:ii{ttt:i
    r:rl.il.r.rupturi ,1" ficrr)^asimpfomaticin prirrr"l^ zil" d,: rrrli .-au tradus t, i,Llat'siu irnperloralie anatii). Anomaliiie vizibilc produc tull)tuirri lrrrr('
    prirt scnrnc ncsp,ciiice. ln -r-olu{ic pot aplrca: anemie, icter, tahipnee, tahi-
    r:lldic, .Palpareahipocondrului drept poatc evidenlia o formatiunC turnorali. 1r,)r,ale scfioasc.
    Ittrpcrca hcmatomului in cavitatea peritoneall csie posibil:Lsi anircneazi. stare Este in:Lporlatt de a se urnl:tri sustinut stal'ea nuu-nisclLtuh in ptitttr'l('
    l ,f. dut)i Lri . r slcr c.lt t r t t t t il, 't lr r dif ic5r i nor jnalo s. Lupr t ologic" I iir r 'l - p" i1r "'
    rir: ;oc, abdomcn clcstins,<lal cr-r,,natitatc deplasabiif,". E-ranrcnu-lradioscopic scorultli APAirr .lrr
    :rl ,rhdourcuului,,pc gol" si par-acenteza confinnir,un hernoperitonerr.trratanen: 1',,',r',r {ibearc'intcrval in parte. lncepind cu evalualea (:rttt1i,
    lrti I onstir irr arl.ntirr.r.rrlre ] ,',iint sitra 5 Irinute (care riprezint1 ev;luarea ,,instantance" a stitlii
    dc singn5l i:ircrvcrrtin.hirurgiirlir. ,,rrrul l i l rc si nlur ologicn im , 'dir t dr Lp. r I la; lcr ' si l cal) r lcit i- ilii
    r e{: llli: r . r . l'
    ,,,,rr. l ,r viala , xt r aut "lini) , sc conlinlli supr lvegh( r ea nor t - l) iLscttllt llll r r r
    2.5.5.2.
    RUPIURA ',
    DE SPI.INA ,' l,rurmeto3re, in care se poatc instalao eventualir.dettesil.respiratot'ic sct;tttt
    ,l,rr.L pnenmoniei c[ membnn;. hialinii. De asemenca, dupi" 24 ort) ril' l)(]1
    Este mai pulin frecvcntS. ca ruDtura dc fisrt si recunoastein ecneral (:orr'
    :r,r.lcasicluz.r.:nacrosomic,eritrohlasto)i,sifilis cong,nilrl {friebiiitar^clrescull rrr.trr"ii.icterul, cefalhematomul, sindromttl hemoragic, crizelc c1eapn(]c,
    !r,'prri
    osplenici). prezeliarii pol.r'icncq.a.Clinic, so mnstat,i: :rncmie,prczcnta r rl,riile, ocluzia intestinalil ete.
    (rrn,'oliiarrrrcifonnrliuni rumorrt. iI Lipocondrulsting;i semnnd" itcmopnri- Spre deose.birc de tehnica e,{aminerii clinice a copilului nrtti rrrirn" "lr('
    lon<x. l?arliol.ogicse constatl deplasirei fomlxulrri gaiti'ic sprc dreapta' T-rata- ,1',,r-;LtJsi sisteme", examinarca nou-n:Lscutului 9i in special pritnul ."rltu.tt'
    itfittul aonstiLin administrarea de singc Ei splcr}e|ctomie. .1 , .rnurnite particularitlli: prin observarea no[-ulscutulu.i dczbliLcal, st' olrlitt
    rrr ri rnulte inlormalii decit prin examinarca ficciirui organ in pi!r't('. '\rllrtrri-
    2.5.5.3.
    HE'I,IORAGIA
    SUPRARENATA t, r{rsturi spccificc examini'rii c1c ,,rutini" sint cl.riar itrutilc, ctttrt rlt Ii
    l' i r:utare& toraci:lui,
    Sc traducc prin fcbri, tahipnee, cianoze,paloare qi prezcnta.unei forma- 'I-otdeeruna. nou-nliscutul r'a {i e,raminat <lczbriLcat,plasat sulr ritrli;rtll'
    liuni trrmora-leintr-ulul din flancuri (poate sugera o tumoare Wilms sau un
    ttr'uroblastom). Scnrncle carc sugereaz5.o insuficierrll suprarenalirsint: stare lrr til;s:L ;rccstrtia, lltl sc va !ini: descopcrit uu inton't1 mai tnlr'l't:tL' | 2
    (l_e rrrl ,rLrl .c (ri sc dc hilnt cr m iel) .
    _collps, con\,Tlsii (hipoglicerniie), virnirtud, diar6e, elijshidratarc,distensie
    ;rbdominali. Examenul radiologic csidnnriazi lirgirea spa!iuJuirctropcri,-o- Il;xarttcuul rlou-niLsc[tului (rccomandai (1(i M. T,. Chiswick) st: irrrr''1:''
    ncal-cu impingcrea anterioari. a iiomacului. I:r evolirlic apar' calcificlri supra- | ,, obsctvafic gctt,rra.lii.: rl) fclul ri:spiralici; b) comPoltatncntul nctttoloiiirr;
    '
    r()nillrenc. r) i (gurncnt{) . Sc cout inu. [ . c( r : bDit a cr aniu] ui, {[ f ; 1, lr r r r f t 'lc, r t bt |) t r t t r nt t l,
    T'reratnentulconstir in adrninislrarq dc singc 5i, in caz rlc insrr{icicnfii ,,;1,r1i r:i ri l guir r ; r lir . 1i gr : 1iLlliL, ullor u: r v. Lt t r 5L; t lr i,I n'ir ) r l) r cl09i sc i''t r r r it r r 'r
    suprarenrli, corticotcrapiesi rccchililrrart.hitlroeii.ctroljticirliu,.llt(.nrli. I)L.ci- l ri l ri i sLl i i l rrr i al, . r : ur pr Llli ( gr r l1liir ir .lnnginr
    , lr . r r iLcit ; 1,
    r ',cilt : ur nf r : r 'in{iicllt t ir Llt l'1,
    ziiL intorvcntici chinrrgicalc rlcpindc dc volumul si l<tcalizart ir lrcmomgiei, :rl r !onri tti tli i ).
    ('v(,nllnl un lrcntoJrcrilorr0tr.
    207
    :l0ri
    26 1. OBSERVAITA
    GENERAIA
    2,6.1,1.
    TIPUTRESPTRATIEI l l i r:t'urst| l rl ol Fl |i rs {t!l i tl ui Irt tti D rul i i o\1(' Ini i l i i orl t!i ( dc s l trdi rl do r$Il c l i r i l rrl r'

    r,rrr',-Lscurutui.
    :i;l,i,i,ii'::''*j'i'.Hlll'i:':l'linist,.Lle S. r.oi-obscr'a l i ri fl i l
    "',l,il
    lt';l;ii":,:;;r,x"fr
    jrrirr,,r1, iiJt#'L,t*iijj:1:li:"ljr:'1i:"*i1i;'1,1,Liixj-
    2_:r;j,;;;;f,a iiij:r,T'li.-"*i,l)u;_.,p;;;r,,;1",.;';,r,,-tf
    aii;e
    2,6,1.2.
    COMPORTAMENTUI
    NEUROI.OGIC
    -i l

    : , :ijf]'|. ,ir;.'l?l?.:,,1?,.:1il*":i:.:1
    *:#,,:i'i";i.lj"j"'i:ji?i;ii:,,::
    rl. rilr-L:Precirtl \Volff cinci
    ;i stadii a"r.J".ti,,it"i.'ii"i,.io,, Z tO1.
    !al rr'

    r' I'l
    J trti i l a. i 1l rttortitt)tizalt:r, caloterizarca si coltlctiLtea lou nitscutul ui llr
    I
    LL,r Ii,,(',unco'i, aploape irnposibil5. cvi'-luarL:astilrll ucurologlcl{lll llttsll
    l'l!io d c l e dc r e a ctivitr ( c :tlc llo _ r iiisttr r u tui
    l x terrD cn 1d p,-! l 11..i ru
    ,j 1\',,ti f) -ncirrol t':t tinc scrrlnli dr' tttrrr'
    , ., ,, itr exirmiirarca ogir:i & il.l'I, sc
    ',l,n "", nl' dc diagnosiic ( Chiswick) ; .
    tt*rUU i)ntir Preclrfl J] ' ,r,1( ( i rpc.
    I Srr,llin I spon"filr.]c si irr-czcn!alcillr.Lor
    J l)ut):r Wollf Jt,iril,ao, totltlsul"muscuitrr, ni;ci.rile
    r ,1 li in[]ltcntrtc c1e virsta gcstalionirlir;
    ttli'rit I t r
    t. Soi1lr IroI nd : ochii iDchi$i, r.(,s_
    t. in iittti,"t cx:Lminirrii n"euroio5licca u rr. sir va llsigtu'lt1:ozi{ilr
    prra.Fe resutal:, hfsc rnisc.-LriLuf -\cclaii falsi';
    I
    ,
    , rlrrrlui, iLlifi'l sr: fot obline rczultate
    s o m a ctlr : o .b ii r ft.h isi, r cs_ rllt
    l x r a r r c .fflcg u h 1 j, m isc) u i r n j.r
    2 Acclasi in conditiilc in care nu sc poatc oblint uu si:nn ucuroltlgic jtt ttt rr'r 'r
    3. rrcaT ,, ,,,t ,lot,i, irrrierclri se preferiL incltrtituclil.ri::r, trnui lezultat irrls
    F i tilr istjr : ,ch ii .t.s_
    - (r ie r .ll {ru csl c pfcz.nl ta rr' r i rr.i :l ' r 1r 1'I ) r elt t nAit L';
    Prechll) r
    , i'',,,i,o,it n"otifugi. cfectuirt dtpi o crizii couvr-rlsivil nr1 nr(" \rirl('
    4. lre:rz si actiT: ochii deschisi.
    Stadiul 3 l)rech11
    *11:rriri *cli.rc, .r.rr..i 5t ptLnsa
    r r r n g . , lr F :r ' l t,r' r trrsli r:i i.
    .5. Stadiul 4 Pr.ccir \(nFrlirscutul lor;nal la tcrrul u, rrr-.:.il lt sy'"1'".sti-ct1 ntcttrirtr'1r' l)'rL
    o. r ll
    Stadirl 5 Pjcctrll Lr' rl l l rrl l rtc, in vr enc ce I n' hlpot on ir 'lol) r : Lo. pozit it dt I il'oir sc'Lit lll!
    : ' ir lllt ul r r ull'lr lulul
    Xirnusuloposturtr .i ' " 1,,r tttl ' l i', : t t c l- u Lr I at "l, ' it t t ir r '"1
    ate ltt)tstttttt)l
    ^ilTliJ_l ,;nfTrrn1lle nou_niscutuluivor {i cya_
    liill;''?".',iX';i.11i,1*,"**f;$:_\l*"*1,.:#fulfi hf
    lrr tirnpul dcs{irsatului sc va acoLda o 111q}e
    1 r r,, r lrlirauevr:L:'n.n. hipotol m ofcLir aproapc uici o rc"1s1('rrlii '
    . ,,D
    atett'lie.rcztstan'!e'\.
    (

    '''',r' ,.rt., ( - ir , , , , 1\ Jnr r f . rJ. "ir pi") -


    ,,,,. lf jilLl,,ll";";"lj:,.,?r.:;,"liirJii:: i. H;*.J,"J*'"*,,u,,-,,isc,,t,,rui \;;,' ti.,r"t"r'"ittior
    ' dingnost ict l dc hipclt onit .
    t" o1r'rltt,,'accstci urancvLc, cocir ct l)ll 1rt'l)rll'
    ., ,l rr,,r Irr
    i"i"".,,i,'".t"'t,'.i'ii"o
    ,,,,,,,,,i.,.llio,iloi|T:}|:'"Tfflt.q; a" alcrtir,
    pasivii '', t'rt obletwa 3i19!:lv'i&
    -iL-LilciatlIor
    mcni 'rr'lur; iu c'rz dtr lrslllrr'llri '
    ,,,r2,, 1ur,,t" fi til""ie in afara sis'temului nervos (<lc cxcrnpLr lrilclurii I'irrl
    ,, 1,,rrrri l l i tir ) .
    ,,,',,.;#*?*i$tillii;*'il::$i:"i;::l'u''?"i'i''?#ii;potinrlu- S,' \'{r acorcla atcnlie cotlpoftarDr'rrttdxi ;i, !ilritLrlui rtn (itt
    publiti-t l'uvl\la sa
    pt'z' ttt
    pr('i)rl(
    ' 'r,l,r ., societate ittcriialionali - e;rre isi -
    a nou-ni.scut'lui
    ,"",,,, ntli,rLtTiji" "ff f.:f;:r'"iterc .starea'eurologica r" rrl rtt ,' i ut linl I init ulr li: '|, , t , nu] t "'' ir x'ur 'li; t r ' ir lr lllic r lLosi: lr ir ir1i|il't
    , -_ rxpr.natu,,
    ,n",,ir.,,,#1,iillj,li,,:i:i;J:1i.,q"11f,,""
    p,,iri a,_ i " r ,,,1,i trrhr i r t ost . iohr i i- it r d) .

    ;llli'llii:-,::;l',,u;,iil;l, ;::.'fi;;i0'..
    jir;l"i;;;i;1,:ilf ,,rra,,,,1nio, l )j \r)i r ( ) xar lt cnLllnu s- a f ir clLLjlr r [ ') nl( r 11r ' r ] |'1, r \ . or it l, il( '. ( illilir lo
    ,1,r1,,rl l i ri i ur t a{: it : ) vor lr czi sr r spicit t lt Lr t
    iLur ci ar t ot lt lt lii llr t llilloilt ll( r :
    sr I ll

    it t lillt PLt l ( - \ r r 'lr ) ollt lllll:


    1i nu {ipir dr lor r
    Lrl l 1) . o. cir r ( 'r : lr l lt t '1. Jic
    lllfi,Tt,,,i:il,li'il1,il,,ll:fi1
    i;:,.i;1,,',.',l.1::l:;ilH::';flf',iJ':,",'lilil1il:}':i::1,;:t - utl ll. I l. <llt t r '{i1lit llr lit ll'ir t I llli! lll'vr i ll i \ llt llit lit lot llllli ; i r 'it t t ' r r t '
    rrrr (i pi i l a sct t lil.
    ?08 :1011
    l lt r r r r t r . t t r r l r t r . l i ,l r)rl l ( l .r ttr)1 1
    rrri s r.u lrtrr r l t.curgc cl upi L ,,1i Ii r tl 1,, rl c l l r
    \,r'ri l( ( r i r r r ir r i. I{ r,l l r,rIl i ' r' .l i .r)l (' rr(l i 0 (]i tsp0ot fi abst:rrtei tr rrrorl u()rttti ri ; l i , r r r i i r l r r r l r r l r r r i l r t l ttr r r i r r i , ( t i r l ) i r 1 ( 1 l i 2 !]- 3 .i d l si 1 :l i r r l L i n i ;1 'l L L '
    p rrrrt' r ' x is l: r r ' lor r u s ri r' s r.rrrtri rl rrrr.{ i L(n u u ra i cl onusul i ucpui zarbi l sau :rsi - , ".rl l r : r " , rl l :l r i ' 1 .- l ,Ii :r I r " i r r l r : ;.l r ' " l l i i ''- 1 .
    rrrr'lr I iurli(.r'i o a1r()tnlli(.). I )csi st' pot obtinc rirspu$uri Ilormalq la nor- ( iril(l ,)l)ti(-(l pot {i cYahnl,r, Ir'iir cap:rcitttca nou-rlatscrllrnl{lj tLr' .t I ::
    '
    niiri,rrlii (rL bsli nusculnrc, l)rczc[t:r unor rc{lcxa tendinoase rlormalc la r r r r r r r i i t i t t t t o l r i cct u ti sci L to r ( cl r l c:i cttr p l u , o u i n g e m i ci r o si r " l j tr ttl r r l r r "
    rrrr,rrri'r., lr. in{ciio:rr..calc rrnui n.n. ltipoton face improbabil tliaglosticui rlr , l i l ; r r r l i l r l r ' 3 0 t:r tt r l c o ch i ) , ci !1 .c r - t- 'p r tzi n ti r . u n i n d i c:r tr :r t- r r l i l ;r l l r r i r ' l i ' l
    1 ,'lr rnuscullr:r spinali. Iixamcnnl lclier-rr:lol poate sprijini tliagnosticLil , , , r l i r '; r 1 r ' ( \ i . L . ( i h i sr vi ck) .
    rr, , l.,rzlrrrri ltcurologicc asirnctricc ipus si ltrin alte seinnr:), precnlu si l il,srr lltor- lc{lr':tc neonatl"1,r, cc sc rilitiizeaz:i. ptl r:;r}L'e l1('tvil()i L rr
    r r r , r r i i r r . i i c i utr r i r i L :g r a b i o ,,d l l l l fr "r i o " cr r cl l l l i l I cl tti i o a l o n a l i 'l ]1 r 'r \r l t]l
    r', l r,l r r r r r r ilr ic lom o l i n g o c c i .
    L,l | | t( t_
    I't,!ltirta st:,utuht l|abi:.tslti estc irrlporiantil in cxarncxrd :rdultnl i. I\'czcrla lui 1:l
    ' ,: . ', )ri c vl|loaie parololiicir {dar nioi absenla lui :ru are .raloar.e iizknoijidl zrbsoluti,l) ?,6.I.3.TEGUMENTEI.E
    , , l : i l l i 'Lr
    s l i r c c . ) r r a n d :! sir se r cn u n lr la t.o d n ce r ca tu i (N I. 1,. C hl s\yi otr).
    I. (irftrlalia. A. 7) al,o q r.. 11. 1t rnotl lormal, n.n. Irornoporrilr'rrrl
    St'rsihilital.ea nu are rost sir lie testatir prin producercaunor .scnzatii
    rr,fiir'lli{) llcntru nou-niiscut (iu alarir dr cazulilc iu cilrc cstc ilccesar:l tu).11 l)f('zr'r)1irilt'gumt'nlr: palid-rozatt itr tinlpul scmtl. lri. l'rt'maitirr I I,t
    ,r' ,r j ri rnui l rl iir t cnuen in st lr c dc vcglre pot pr czclt a paioar c in r r r t lt , l'r , r
    ,
    'r r,,r'cilrrir,lluhd unui nielorrrcnitreooel). I rrrlrr',juriti: encmie, |iPoYolcnlie, soc ncnroiogic (asfixie siLlt tLrrrrrrrr-
    Ilclle-rele arhaice sint speci{ice nou-nlscutului; ele sin1. tranzitorii,
    rrr Ir rtrr.5{r'rr'), ar:idoziL(;i iripoxenri{, lripertcrtnitr.
    lr .l,,Liit.ulcJupr-r
    o sccr.enfiL
    variabilirir pritnelc 6luni dc viiiti"r.Ilintr.e accsLc:r '
    , r liri irni"-r.l:rnl I . s inl :
    lrr rrr',st'' i tttltltriuliri sc vit contlolt tolnpcraturil incubatcll'rrilri. " I
    ,
    rrrr" rri .ri r t lit , llcr noglobiua, hem er oclit ir l siechilil'r Lr l 'Lci'lobazicsi '' r , '
    - rtll|ul. illora: \t oxcitrtii dilclite ([rarcrr.r lrru.cir a scutccului, ,, rl ;r rr Ir-r' rr lt r all-hcnor L agie ( hcnr or agi. tint m '. r . r ui Ln"r l lJllci pl or Lt tlL " 1r
    I rr,1.rr) rrrr l,,c inlr ,rn l)r;nt iimp cxtcrr.ia;i .rl,dtriljr br:r{,lor crL11, lj, ,l ,,i ,rri l .i rrrr r . uit j bcuot aglci: , se lr sociilzit r ; r lr icar dic. I laci ancnlia r r lo'l
    i,l, rli:JilLtr',crLintr-un al doilea tirnp brale1csi se aprnpic pt linia nr',1i-
    r r irrlr-o nriscarcdc imbriLlisarc,cl1 pumnii striqi; ; ',,111,;illl lrcirolr'zir, sc asociazi. icter ;i hcprLtosplcnolrcgalic.
    l i . l i rrs i a- ir Lt cns. ln nocl nolm ir l, nou- r li- lscnt nlpoit l( l) r lr ' r r lir
    rlhrtr,l lc .Lgdl&ye:?\ti\gerca paLnelor sau plant{rlol cu dcgetul cxa- , ,r lrL rroJor-irticin priml zi dupir" 1]astcr(l' llr tllc,conrli{ii- clL lroi'l li
    r Lr,ilor-ului dctcrmini. flexia degetelor;i ngitare;
    .- r'cflctttitotticctyuical:rotalia latera1l a capului 11.n.de cirtre cxami- l, rrrrirrrlr-rrlc: supriincirlzirca irrcubatoi'utui, llipcruolcnit: pius ltcttt Lt"
    ,1 , rr' :.,l l i , ] lipcr oxem r e.
    r.r , i, d.ctcrnlinirilcxia braluiti occipital si extcnsia cu r-otalieintcrni qi
    | . t i (t. it o: a. Cialoza dc t ip pcr i{er ic, la nivelul ur iinilor si ] lir i. 'r t '
    ri,,lr tic a }ratulni laciai;
    1,,r, , iit(, lrfc\-cnt intilnitl la nou-lliscutul nonnal in primelc or,.: <luirii rt,',
    rcfl"':xlr.ld.ectptitttriineslaflcri.' suslinin.J ri.n. daciL,qcpunc in contact 1,,, ( iirn()zir dr: la nivclul mucoasti bucalc' 5i cia.noza poriorali pot Ii 1;r'r
    irt:r (lo[sali a piciorului cu rnarginea mesei, acesta va aduce fala plan- ,1,, , ,1, : cirrrliopatii congenitale cianogene, cdzclc dc apnec, bolilo.lmlrr.rrtrrrr(
    i rr :r. Iriciolului pc masi. si va extinde piciorul; ,rr,rl l rqruh ir nar c ( ; em br ar : r hialinl, pr cum ot or ar , hcr nit ' t li; r lr r r lr '
    ' .rt-lleru,l,de rters owlctm.at:sustinind n.n. in ortosiatisn pe o soprafafii ,r'lr,.r). 1ri:rsistcnla ciiculaliei dn tip f,tal, sindrom-ul .1c hipcrcolc' rrl.r'r
    1,1 r;r si pt'opulsindu-lpulin antedoi, acesta va peii automat; .rir; riinir., ircrioragii cercl.,ralc, rnodificirti trretalrolicc (hiptlgiirr''rrri'')
    1r,
    rtfleru,l de Prc.pulsie n lim,bii se obline ia iniroduccrea ului corp , , , , ,, r, rr,liL cfectuaria unnittoarL'lor cxploriri pirraciilice: testul liI llilt|r
    '
    ',1'r ir) !-urit I.n. si pcrrnite e:<prllsarca acestuia; ,, r, r.,', li,,qla{iir.puJmonari, herrratocritul .'\strrp, glicLrn]ic, 1v111f1111 lrrtttr
    - rtflcx,ul puttcl,eloycar,l,iualc: atil11.rca tesumrntclor p e:.ibrca.le antrc- I' l , ,rtl 1,,r t] i.
    '' '' rl vi, r^.r J ,Lc'a p.rrir a gurii )inr\ii si-caaului migcariilt: supl; l t t tt lo6/ ea 'p a l i t t - c i, r t t t o l i a i ( 'g- r . cy) Polt 'c {i ( l( 'l. 'r r r r i
    ,-i (cel mai frccvcnt), crrdiopa.tic congcrlil'irlir, 'rrl)li
    - refleru,l Babhin, da,c.-:- degetele e.xaninatorulur compr.imi p-rhrclc ,r,r.r ,1,. ,()u 1- hipoxie
    r i irccsti)rlspunde prin flexia caldlui, deschideleagurii ,' | | rL ..ru lr cr nor agiL'ir t r acr , r nianf , . ln cazur i nt : r i t ar : c poat c r t pir t ''r t it r
    ;i piotruzit limbii. to,?r' Pritr :'rrlr r'r
    1,rr,rrrrr,rlor.:rx,hcmalom subcapsular hcpalic;i gra tt-hab1t-s3tni
    l|flit$Jcopi& Du a,i ido rrofii la, virstl nou,tiscutului (mai ales comparaiiv cu dilicul. (
    ' 1,.:.rr, rl , lor r t ni' nic, 'l ( r 'xct 'plior r al; .
    i.rr ) , 'r uu{) ului). Ifuncf.rgiile retinie e !o: ij .,,:rzute Ia nou-nisculii normali;i edernul
    !ftpilaf l ' . Ir:t cr 't r 'T. I n f iincf i, i dc vii. ie t lt vi: t t iL ir t 'r r - c t ) cl) t r {'r
    t r 7'ii'
    ir 'l't r r l
    r, r , . 1, r , L f : t q i i t r i . ' rc o o s t;llL ti a p r - e si{ n ii in llr | r .I ie lr 0 cr r iscut€ t,r nou-ntl s.st.
    r,, r,l , rrl rl i Dic l: r valor i ale i: ilir ubinci : '- 5 m gl) i) , ct iLr logiapoili{' li lLr r t t ir
    Ntrvii r:rirnieni. lixamcnul tradilional al iieciLrui,r.rr, .r*r,ion;tifi],
    L' i rr:r.irr tLrru'ologiaco1lilniui nlLi nrarc sac adultului, lu cstr_.util Ia nou- l i ' .:t : lr or r ll lt cr r r oljt jci'La n r t ( Rl) ' AI I O , r t lic in( nr npaliJ) ilit ili)
    ttrr,. rtt, in a[rrt'ii d,r cazuLilr:<rirr] .sic suspccttrtli.o artoLrtllic lr rutui llnumit | .i -r ii:
    r, r\, (: f x r r ii! n ( r l( r c x r)i l rl )l q , y ri o ;rr 1 rL i 1 r,:b ri Lsi ;ii rrr pi l ral i zi i u Ii rr:i ;Ll i L). lrorrlit I t c nro.lii.ir:ii. I trt)ll-DiIlcr1lll11i.
    [,]i sci rr:i l c
    ,rr'rri rr r rP. r r l I i |1r l. . ii L l | 1 rr-j rr| rrl i | r,.rr.rr.i rl i rrL l L r{lr, r;:rP trl rrirr.rr. < l i i rl r.-ti ' prt| 1,: l rr. lt t r r lizr tlr r ir t t lt I , r : 1. r 'r ilr or : ilr r r ( . 'lt zit r t olr lt lt)t ,
    i n ,l l r, r r o|r r r r i r , , lri i i r,,l rrri ,.r.i rll ).ri l r,.2 ,,o y r0 zi l i ,. r.ri rrrrrrl r.i i n sP rr{i rr, i trlt 'r : {ii,
    rl r lt l 't ir r lt t 't t t rl tr rilijL r t ',
    :l t0
    ,|l
    lL t () c \ ol ufj L) s l )r)l rLl l l ri i S P Lf I{ ' i n)l l )l l r
    ,r ,) t .t : , ,i tr / ,t IL;t:,:ttt:tttLtt tt' |, L | | i : t )'t t t )| I :;| ' 1l l I l Ltl
    ir Lr , r ' liz iolo -i r rrl rrr,' Lrr.i s rrL tL rl L ri , ., ,,,,,,trfu ri L !1i l f()l l i l r/rz (" c{ i r ) do c ol ]s ul n ;1 .ui c c fi tl l { '
    '",, ' i !i i l 11ol )at i" r;"rl r' I
    lr ' 1r lir : t t it , , f ,' ,,,.r,i r,i ' \' '. t,r"l ri ' Il -' ::i 11 'lJxll ,l
    I l r "Ii l i J ol ' l Tl l rr' l
    r lr ' l, . , c f ct r - iir.rx :i l l r.(,ir II )LI r II r| I , . (s f,.roci l uzL) ,, 1;i i rn?rl i c! (;_6-pl _t] 'l l l .;, r. r_' i :,r' r * l r":!rr' ' J
    . i . r 1, , ' r r o g l o i i rr, i -_ f hiptrrpigtn cttlrtt ' .
    ,. ' , ,, ll.' r , c,i;t;* '.:iot: pat,t tftott!)k)itlti' sPcci{icl rtlsclor
    rIsor-btia hernoriigii1or, ' iri picle. .ir1)irl*i rilLl,
    tlt. )\l*ur;, rut*;l*i1it, .'st i.tilr,::s-,c 1L.ci,..t s ttl tl l '
    - sindrolrul l,uccr-Drisco]l. , ,r LIII L /'{)i 1( 1l i ac fi tl .t, ai i l c mi Ll oi l s i , l rJ :rc opr.' ri ti l l L! l )i -l i - s i Ii rt i i
    l- t
    l t lt 1 -. .. .! / o 7t:
    ttl l tor'r:.
    il,'flcllc cliilo c it ar r : , llL ; , - t ot in; 11i, r:) tr-alicciir; l1 l tLLrtit'
    scpticemic, Vl li. l ezfurricjE: a) -\liiiarla cL'istaliLu:ir) ilerl:cs;
    '' ti 4 hi y'11i ;1 1!i .rr l l rl .i Lt:tv l c L ?i .gl i l (l ti os tt.
    ' iuhibitoli din irl)t.r1.r nt:rir.rn. ticgcLtlc' trliilri'
    gaJirctozcmic, l.l. llfodiI!ciri ale uN4Jliiilo;' l-in;iLiii' :''ri liirzruLL'1rL l rl l r'
    n|i :t p rL i "i i r' ' r"' : \i rt' l i ' :.l ut s rl tr
    . r.: ,1 ',1. ".c-',t-",,1i " l ,
    - hipotiroidism. cclo'.icirrrirll
    ric r'ruririiI Iitilr'" iii: displaz'ic
    ittt.ki o siiltimiti. le a,ia!ii: ' ,,t:" ,,' ,,'i, r , i'. t iit liiii 'Lr
    '..r;.,;.,i.,
    , i. li, , r , 1, . , l i J -l : n ri r::,,..i r . ,..,..rr... ..r ..,i i ,, t i, r I r nir lll 1a 11: [ liii i11 iim pul s'iiir r ii
    .:i .l | ,.
    artezie bili;rrir congenilal ii.
    l '. ( ' ol, o t ' . 1! . i l te rd e t i tL t:L l rl t)i . Inpi cgnl Lr-.I Lcru- 2.6.2.EXAMINAREA $l A GlTUtUt
    CAPULUI
    rllilor crL rleconiLl sc indlnestc fllclcirt -l e l :i l
    ia nou_liLscLitrrli:n lirstl-r g.,stte_
    r,,ririi ntlri 1'tltLc dl) -,12s:Lptilrninl. 2.6.2.I, CRAN|UI MARE
    l ;. . 1 s / c t : t t t l b i ra n " ,a l ,1 t[' B ]l rn tu rr' l i )r:, i i l i l n,stc j l noLrni Lscu-
    ' ' mALc' (Lilf Lllil:r'l1-
    I ' illr r l. ir r , r,.J L ri .r c ,r!.a Io rl ..\:),ri l , i ,rot. r.,,ri ... l,,i l. u. ctr llislt-rl{ic iirtraLltcrili'l. claliul e:-ilf -,,llP;Lrcllt"
    'Jr..,; r '( 'n ti l i fr 'ti r 'u l
    l l .' lt r ni- r r r l ( ' s tc p re z c l ]l i )f te g u mc n tc l c l .n. nt:ri nti c t| ,40 si Li rti L- . , , t , , , , i . , t t i i l tr l l e 1 r u si i b - i 0 |f l x:l i L .ti r n a i r - i tL 1 l l l u r - L l ( ) i r
    ' , ' ,l ' : , - : ' r i, r ' , .: l i c u l u r,rr ' l ,r' .,r,Iti .. i',,irt',,i*Lt,'il;rirocetatlr, lrirLieu:n.'ci'''lil, lalrili;r1' LlIaclrlcnccli!lir) ir!r
    lll. lltlernolt l.r nolr-1ll'r,rcr1t p{)t fl inlilnite irr Lrrntl'itoarcloirlpr"i,juriri: . (rL t:('t'i!iC ;;sillic ira-i;-
    . 1. . pr , , ' , r r , r - :rl to . rr li,
    (:fitrirli:1 pr',nllabilirlilii (pr:in lezirri diilc rli: iripoxir,, frig), cRANluLMIC
    2.6.2.2.
    arltrinislralca ercesi\r:r.(lrr -capil.r.c
    lichidc in pi,rfuzir',
    'h,iJtot's iu incctlpatibilit:Ltca ric llh, I ,r ii.lr. rlirr 1na1]1i.. didletir.L crdLiul esi - . iP.'-rLr'LJ.rrric'. , dar cilctttttl'
    -letaiis l.Lntli'lllL ;i.rttr t'l;tr. itt:1.,
    . - sinCronr { ulner {la livclul niinilor., si picioar.clor, sr_.rf cniuin). I||i (,Stci1] linitC norglali]. ]\i'rctoce{lli'r l'u.ii.'-ij
    .\ r:i r r td,.n,tttl. gcneralizirr 'in \ li, , o: jh r l: cur '( l- : lif n : t 1. or ' lor ' 't lr 'r r r : r lr '
    . . _:L: iltilncgtc stadiul ;rvarsai de Liporii. ' r' r' ,r. rJ 'il ,ir .
    r i";
    ' j ,i'". ^"1llr '
    ir r r r " r : lr l
    r lrjrotr:rmic. ,-iclereck'rrrullocalizr.t si: poatc intilur ta iocu{lc iii carr: ,,' i ,; i; ; r ; , '; incl. r r i; , i, um . . 1: , io: 'ul'l ' 'r or 'i'
    r, irril(. itrl s11[,.'fitu11ilauln.rlis{n. (lorcrps, uotl..rli tic imluatic pj:j1].corrl- ,r, ,, rri Li c .
    '
    iLLrrt'd:r1.ri dc grcul.aiitir corruiuil, ,
    l\'. llcst'rrarnart";rtFquritrnt{'iot: sr. illilnLrste in: tlisnaturitatr, iclttir;ziL AI.E CRAT'IIUIUI
    ? 6.2.3,DEFORMARI
    . ,,.rrii:r1iL,i:pirlorrnrliziL b'.rioasi'r.,slafilocoiic blloasil pcllfigriil;, sililis ; 'r r l l' r r r "r 'l
    I i r . . t r , 1 1 . i o l r,.:" ,. l l ' ' .r str*sanut t ina {Caf ul sk'cid t "t t 'Lt "" pt " "J : ''
    olr t c i ''iuir iir z'n r lr r ' I 't r 'r '' 1"1'
    \'. Ihitemul alctlJit; al uo lt-llisrjutuiui (et ituria toxicnm rreatltltct,tun) . l';
    ' ; ' ;;;; J; jp"r "t , . , ' 'Pit
    . r'rrrri:tcrizcaziLpdntr-o clrltie nicropapuloas:j_, eritemirtoas[, centraiir_ Lr .rlrrlilor'. Itesirrbfia se face rapid^
    , (r rnioroveziculi-r cali: sr poatc conlunrl.a cu o pusiulit. .[_a cxalrenul ( i^ftrllr0rnatomul esl-eo tumefactic {luctucntiL riiltir c1c-hoilrotrrlllirs]ll'lr"
    (:ilfl sc {.r'tn.irzi.. irr. ,r itrr',
    Lr, '()s(r)i)ic al cor]1.i1Liltuir1i accstor- r'cziculc sc g:rscsc ii.rt n.L1ili.rcresc t de r r;r,,, il"{i'iti, t1e sut'ra. oascior crariului,
    volum iuos, se po. t c ir r so. ii r l, r : r r r "r r r r , '
    ,,.rroiiltr. :\ccastii crup',iir cstr fo:rrte frcc.ierii intiinit;, esi:ciocaliz:riir, rnai r,,,. t , , . . t t "nci r : i. t l , : t e {oar t c
    _J,
    ( i1'\ ir lr r r r l
    , i)(, l{)r:l.c.c;i rbdomcu, ,si t:sic, lL; Iapt, o u;ticaril nconatali. tra.lzi,ioric. ;l ; , i, . . , t ii, l L. ln. L. , kr . Cclallt cnat ot r t ul 1: D3t cpcr sisr : t
    , " , ia calcif ica. r c
    VL ,\rvii. .lbi- fi vasculaii, pigmcntaii sau scbacerj. ' l Lrrlr,r'i lt r t r clit r {iL
    1't t 1; i t lt iir r ' 1r r
    II ndlt!:io Ntti t)e.ItlLI]'klutr (u,tritts flatnttcttr, ,'sli frccvixlt inijiiltit, l \tl tl l l ttt r lit ht ll; ii. ll'ot r t at r r '1ritt r lLr '] i'r it rt . 1'or 1' r . Lr r : Lr l, ' ( l "i l l r " '
    1,,.rl i zrrl liL it i\ ' { llr Ll t ( g l l me r!' 1 ' 1 1 ,1 ,:,r:q rri c rr,.ll ,l .rz-:rnrsrrl ui si i :cai i L,r\r;r:si , r ', 'r . : . , 1 i l ,' r , i l l r ' i L . I;'r ttl .Itt IIt l r '' t|l i r :r l " 'l 'L " l i tl " l '
    ' l ' l 'i l o l r l i " l l tl l l "i
    ,1, ,, rL viISlrttliIt l)iilr':,it(rli tlisp;Ltl rlottrltlct clup:'Lcitcr.a lt1ti" I r r r t t r l i sl Il i i " i l l { t i LLt l t :t i t t .-,t l r r ti 'tttr 'l r 'r ttl r 'l t'r :tl t I'o 'r
    Al r r r r r :i ti tt'l i r tttl r "l r ' l r r r r l :tr tL l r sl t) l l i ) i tfl I'l :r r l l l
    llrrtttttgiQttLttl i) s.ttl\t)' f))'ulttiltr1ll l)oftio Ii lrrr:zInl iir llitlir,r('. I,ll r:orrti* ', , , , , , , 1 i i i ,,1 ,itIl Ir i r IcI tIi i i .
    , i r''',
    r rrr r,i i r: t lt 1, r ' i-lil, r r ' lr l tL rti l )(l l i lrl L r' ,r trl ro i r.rr' 1 i .Ji ri :i r.;l r.ti l ' ot)1.irl1tr1,;11i 1511q I r l r r r l i t'r tr i j ''tti l 'l r r r l " r r l r i ( o r r i l r r r i i i tl 'i i 'i r L r
    ;;, 1 ; '; ,i i .';i .l r i l ) r 'fl i r r ) i r l i sttt
    il | ) r r t t i , t.r l t( . t t0ltl( r iollIil lil,

    , \ ' ,1 \
    ','| ,: : l l. '

    /\'
    rr' l| i
    lio nllu lr,Iil rrrh lt r r r iur l. , t \ r .
    l{ili,
    I ) ) : 11, ,iui.il ni in 11r'rni.toaral
    lrr'rrrr)r.li! i, r r . r . lr , lr r , t lir , ( r lt . ! 11 c()rl)r:rl,
    (, irrr1rr.ci
    -i-.LrL; ,..Ap'*,,**:r",,:11'l::l:1,111,,'lii,iil"',-:i:lii.i"t
    .l( l-1 -20 s({ 5 r 'l n ) ;1 1 r 'l l l l l 1 r l l l

    Ijjl;"lillil:;lnn:;t";::*1,,i,ff
    hidroccfalic, in.sufici,.:n1l
    ,"Jr"'i,T:t?J,lHi
    iJ:::fr
    2.6.2.4.
    TUMEFACI
    TEGirutUr ,, ;.. . ,.,nvttl,'ii5i 'l i',i'n.,"':"':"pilrtori' nlin ' lr"i'1rriil-t:]']::ll.i';, .l]'
    ., ', ,rrii'ii uiui,,i-ilu"ii
    ,tj:;.'nosri,
    I'or li situa"teiatcral sau cenlr-al. ', , *,11.,,1,?l''ii1i,,..tiT,l'ij
    rraisr:rriuLrrisi r ircublLtorultt,
    ... ._,.Jrr1lrctnctia
    eeltrali_poatc fi, dr:tci-minatidc: gdsa conseritali,
    i i.r.ia_ \sirrt1r, u-tocul'tuL:r
    hi:r.riocllluLir, 1i rurclrilonrbrr11l.l-'j:1,'.:l^lt
    l#'lli:lilili
    ' .]l ".,. :ll'ttt
    Irr.,,,t,. ,\l ,:
    rttiiiroi'lirn..rr,rlrrn,rrluj rn;r,')-n, r ioiuii, .rr,,ri..
    ' , . , . 6ngnnj1 ; jn
    ;t.d ^ . r.re . r 1, ,,t:llll"*.u]i;;l[:,*i]'L*lil;i.,;ii::
    ,..-
    r r lr olis m u l , r i
    i;i:l"illli-$jlilli'ili;,'';;,,''
    t . i r o >: i n L . i .
    ,,,,,,,,,lj;l']"ii:;fi,j*"'.i',1"i:i",:i.,*:1":l:;,1"#x':l"Jli,,!,ilii:$',?,'ji,rrll
    ,l rrsl rr r i iir anhialc ( i n z o n a s u p c ri o a ri ).
    ''j: '
    "' "i;:-,,:,1;i:i:i1,tnai nici
    'm
    iic 32 rlt': sitptirlTrinisint ce] i'i. {r.cvt'nt
    rcsPlrato'l'
    c("ntruiu1.
    pr(r{lis-
    ;i:i {a(:r |rizt: <le:rpneeprin inurtluittrtcir l)llit
    2.6.2.5.
    A":3'r1't
    Bisp,rt',,,i' 'll'l:it:i,:il:,.
    OCH|I
    "":"itli:ii,Jlfii1":il:f:lJi'iill,l:lli
    r . , i , r i r L o l r r l 1 .o l i tc ci Sc p o l l tL )
    r.l.l)
    i nr:ori c'larninarcl ior- sc firce- cu clificu-ltatr drr.toritii.
    r.,,1 si, r lr r l( : r . r r lr r r i ' ri i ,r..,ri i cdr:qrului ,_t:iDc- 'flhipuecit (ritmn1..rcsi>ir
    lior 60,rn:imrt)'Sc po:ric ilsooiacu di'lr'('sir
    rri rra rrrl u i J .,, ;.i ,l irrr. ''
    -'
    , .1,'iritorit s:rLr Poate ll aulolloll1ir'
    . O J ) , ! r ait *t a n . t-..o ruc ,t.i . S" l ro .,tJ ui trt,i i n: r upcrca rncrl bra._ 'f ir; n6iale;1 111st1lx' I ilil '
    r ,,.\.
    l)(iscclnct sccundar anlicirii Lj.fcctriois, rci;pita'toric sc poat c iltihi
    alripni:r:a {irriL.cietresS-
    ', for."psoiu,l gloo"o* congcnl_ liclri<lrtlttt
    t.rl, nrbcoliL congenitaliii " 1 rlir;lncea hi.rrzrlroflc ,r, t'ot'-'itt-oiii*i"i- iittt'it'i"tlt ..il .-rcs.?r1r!i1
    , . ,,,\._C, : : ! , !
    ,,,irurrir
    , . , i, t ' tu c o rt,g e n ,i ta l i i
    {rltulstl)ili ic ttoutrnanti.), r-u}:eola congenii:ali
    (rrp .r' t' it r ai t ir z iu) .
    p o a te f i i nti tni ti r i n boal a ercrtrrt;Lrt
    ;i in galactozlmit:
    ll|tr:h;:*:ll'.;x:ff1',,;1ffi1il;:'*.1,T:,:",,1,"
    l,, l,'l' i.rl.i:.
    .
    hcrritiiagi':)'
    ltncningii:iL,
    tor ilr' <il'icli
    i tt o ;r,j ,n c ti Stljilorul. Siiickrru.t poate fi iniermitent . inspi,ra ; rtt'trt'stlr'
    oiganict si
    . ...,..'., ! , , . . : . , , , , . : : , t ,i j ,. " -a t.ti . E ste { rccvcnt i nri l ni ti r; se rurrirn. lii,ritloltLl coiiltnuu o"- Autot"gtt unor 'ri'/srtL
    i''ziurri
    ,',,,i11"1,:'j;11';,."1"-'*j#i:iiii';:lji:i;;,1":;i'::,'j;,"J;,'J::ifflj;i
    :;',,i'il:;
    ,,rrlx:oujunctiviilll se rcsorb spontar, tii.r
    rr,,..1igaliisuplimcntarc (tabelul 2 22)'

    "t""t"=i".i"b"i". 2.6.4,EXAMENUI. CARDIOVASCULAN


    APARATUTUI
    2.6.2.6. gt NASU!
    URECH&E nou-ni':cut atit clirrir: t:ll r't
    cu d'ificu]tatcia
    -\ria cardi.aclse st:rbiic5te
    , ,
    ,rlrlrrr
    Lrr r:ltslerccond.rrclrrl
    ,,rrr)rn.rlii
    ruciirir c\tern pottc Ii un:plut ru v\rrux, S. pot
    rl,' fLrrm., ,i alc poziri^i' ur,.chii. irrlpia,ri:ilf"'i"i., i#*,iffilliiilll,
    trlr'liii:ilili'i'+,-t:l."]*lll,y*lii'::fi;3'ffi lr r Jir e. "'i''. ,
    .r'l{."ir, irsuci:ltc, u trnomaliicromosom.ite ",'",, ,' .l l ,r.r o: [ a l2c l4u/ : r r ; nul' Rit m r 'l
    sr rcnalr..
    r ,,1;rnornliii:t. Asl[rzxre& carc'"iace po'r-'e inlilni ilr urrnittolrt'tlr'
    ,Ir:"r{." Sc,va controla permeabilitatea cana_lelornazalc 'go"iini"to' -sc
    . ,, pnn inc}dderea | )li lnounotorax, pleumomcdiastin ;i insuficitrni''l-cilrdiacir'
    luirr, nou-rlscutuJui, iu scopul depisfirii precoce a unei airezii choanale prinr'i zi (ste bcnigni f'Ll(///'
    r l(.nrln lDoltso sau osoase(urgengirciirurgicili :iutluri oar iaee. I'rezenli' unui suilu il
    ll. r'"'""!o ii'.'uisuti"i" ''t:l:,,''''l'*:,:;[']ill[li;,'ll;,1:
    2.6,3. EXA,MENUI.APARATUIUI RESPINATOR
    ',,"^-p"*i""r,iij.
    srqrlimcntare;
    I , invesiisatii i";;t';,;;,',,i"i
    , .t1:"1"i:1,::';l:l,lii.-,'i Ji.,gu.srir
    1.,r.,,,.,,,;t,rt.ii'r ".,,.,,
    semnificativ.
    ' llift,iift:l",liil";!iliL'"r rlri
    ,,...,lt,'.:lri.,,1i.,I'r.riodici estc specilici. perioa<ieineonataie, acest lucr"u ir'
    L, I );t,ii, i",t,rizrLr:casullului nu c'stcscmniiicttil
    ,"r" pren]atur. In timpul plinsului, prematunl poate prezr:nta i <l r ' :r l l l r tt{t'r
    illl:llii'J,] i':lt,-i - ;,.pcitul It , , 1,'l 1 1 tttl tr l i c l tl czi u i i t o a {- cc- fi u n tl fL l l L l - ( 'l L ;l t tr L r n a ti i
    drrr-i 61^Lir.1rn'r_s, insorcstciu gcamirt,
    ,,,.'.]..ll.it,rl.,,l,f',,ii,
    Ir'rr'rrlilr, .lr)g|n,.r'irl,l.r llorr-rliisr.rrtrrl
    cste
    l,in. color..rtli lii.i" Jetr(:Si"rrspirarorit,, ,, ,,,ri,,','t:,' ,',lr',til'i'i'tiittit 'lt ltontil ' s" r'i rnrrisistoiit:)'
    ,',,rt,,it,i
    ltcr(:ulilr'(:a. ioracclui ntt cste ncccsarir..Daci"totrigi se facc, yrcrt;rrti;l va l !rrtrXicr lr dir rAV ^ f i t r t 't 't r r t li I t t t t t ii t t oLt t t ilr ; t' t lt
    " 100/ r ir inr r l ir 'r 'r t '
    rrsoirrir,arintl grij:i sir pozifioniirngitrrl cnpul pd fi. r llot r lt il c'
    5i linia-;;cllianir. 1,r l i r' l i l rll r , r 'r 'i, r : r r Jli
    lt t t f ii" r ) 'lr |r r || lli lr i|t t x t r '
    It r:spil-iLi
    iiJ,: fiind suP,:r'Iicial.,rrrrrrnrrnrrvr-zicurius(i .scullrr cu dilicul- l )r' rrlr i( . r 'i,I 'r Itt I ir::t I t Ii Ir sr i lt s'r r : iit ziLlct' tr:iz' I 'r '
    '
    I I I I ( 'I |||Is"\
    r / r 'lilt
    rrrr,';l'(lllrrt, rlrlrc,lrl,sri iifl,'irl)liir.rinsl.rirltlic ,,1,, ,,,,,,' , rr iI I r | ; r ! , r |ir r l r r t l r r r llli'r 'r n'r ( ii r ': t I r li't t l r ll r 'r l ||iI ) I ) I
    lrrolrrrrdir,.ltr lrrirrrirzi tlr: viirIi, t lt t zt t ( r r r ir lr r r l
    .lt|.,|I|||.Irr'.|:rn'lt r.rl ||l.ir.ri,Irii,rrriIl,,Pt.r,zi
    l:i-rtn irsllccttrirr.trttl. t,l , . ' ,' l i l lir ' r t t . I 't r lr : [ . '\ ( ) lir l'il llr 1"
    !,
    l.11
    :I4
    | ,,t ,.!tl i : 2L
    L r i,,t,,r tii ( ti.l,t| r r .i l:r r la ir -rfti i .Il t . .r li\
    ,t
    | rI I i i . rrt I i rr. ( ) cffsl r l .t, l l l ( ) i l ( [\i i i i l {ft]c\'( 'l r ta i ( :i l fl l j i i i - f ( l ) l l l i 'l o {) i
    :. t l, t t t i l t ) I ) | \ l ) . ; 1 tt, ) sirrl f1'br'i si f
    iit.rrir',liriitlc sLrpLirincirlzirc iirrrptrI
    ,i",ri:'1".,''i,"r.11'tl
    ) t t , t , l , i t t i ) t t t L :l . r i n ta t.
    r I l l rl l .
    , t ' . i L s i i r c s p i r i t t o r . icid io p r r r ( .ii a tt'cu l l l r h i l ' i r t r l r ta p l a ' S.' I'o t i r r ti l r 'i i 'r : 'l ' .'r t"
    2 i , , r , , , r " 1 ,' to l r l ttl tti
    stirr
    j' r ! o r L ) o r ) r c ;:':i;i:',';;, ,;. i;;;;Ll,n01o;-.\I rrLi' Jirlirqnrrtir , .i rrcl",":'zi' '
    lL ( . r ' ) o f l g i l l -t n r I m o ,r ir ,r :i
    k l l l i p ! l l r r r D r , | l i . lo n i( ]a l rlrttorttlui tlrcpi (t:oair--ar). lt't
    . t, Alrrnci cinrl (lcrtroc:lrdlanu cste asociatiruI silrLS illt)trslrsal
    l.i. r': "or"qlLttt
    intrrLcrLr1irc t cstc rnai If( c\'1'rlii
    , rI . r ,1,,,iiir,'i;', i-,.,r,,i,j." crr ma1{ormrLi,iil'' '
    "r(!rritr!.
    ' 1 i: t t I t i i . u l t r t i ; i . r . . ! t t . i ' ].tr iiilil;i #;;;'il';to*""iii.oniut'gie' scm'c clini< in 1'r'z'tr.. u1tor. '
    ....'..,'*,.r,.-l^-"^..^r+ointtlrri iiisufici.nia cardilrcit, miocrLr<litl'1,
    in itsuficicnfa pi'rt
    ., iirt<:c lratologicc sc poate intllni in:
    ;, 1rr,zic droanrl'r, lar:irrgi:|ni ' glictigcrLoziL rLlil lr,lt
    I'r ( i c r r s p i € t i e h r lco o n ;1 r ,si,]g ' r , ta t1 ,) til.i, iltrtu,,t i ttozi
    , ]irii cldocardicir, hlpo<licclni'
    hlpo<lici'nie, ;i
    Ll i L I'rr{),r{ul o s i c , s i n d r o tn lJicr r ._ lto t) in n t , '*l on ,. , "."Jo.niai.:t,
    o l o l l ,r l i " r l " r r l ttti ,'
    i,,,f -lingi
    . r i l r z . r r r . o l l 9 1 ] r i 1 at ir ) b a r
    | \ ir ), r ' ,t ; i t ! ) r t :I x i r . t ' l t r n\u .) ti
    ABDOMENUTUI
    2.6.5.EXAMENUT
    I i, r j r i ( , l i i r l f a i r r i r r j c : ',
    iI r i I ' t ) r( l f : r \ , p x . r i r n o r n .r tir islir ! iL-tlt' I 'll'
    o f L-cc:'crrf
    c n 1 ( . ( i [ r s 1Jilr til ,,trlera ortrhiliealir unici, -\nomaiia sc^inliJneg|e.cLr altt'rrtitl
    ur:iri.s lor ciiut:r
    i| , .' 1
    1 rr(a) rsrr r l l : r r . l', i,".i ttirsintilnitir la genteni.ltt acestc.imprcj
    (\1rzi 1()1 2
    , lil i r L l t ) c o g c i u r l ir a lim la tjci:lo r - p n ln liijitr c '
    li.r,rnlii t)osil)iIc,iisoclcrta cll acusteilncfiincl-,insi' ol'liSaioric
    1: . ii l; d l t \ i s t t j i t i r i r i , t]r ,.s ..]itr a l
    Lr i ( f 1 i i r, .Iilr).
    lrr ) r L ) f l , . i i /\.t),iLlstalisrlct'iaipcrcteluiabJomirralrcprczintiluLlit.sl){t.| tllll':l:
    , ir , r { r r L i ,, ,i. f',",l,f, f",i"tolri." r'izibilosc pot rlrtori rtnor ol.'qtructii-il]'l

    ,
    t , it f l l i T i ( . ( l c n ( r r i r (r Iil
    ): , t , I t r ' t t . i t , . i a j . t 1 l a ? c. :i sr r n sn i;r ,.
    f,,,;;,i,,t,ir,;
    :i;*ll,ll,lrii't';":'i:l'li;lfil'11'Tg*#:tiii'lt';,i1 t1ilir:rrIIIrI'
    cu oaier:aic
    ii."i,ir"i." p,trrr"i,i{-ili'z t"t' rctro'.cl' "* lr l i
    , , | 1 l n r | . r 1 i i c : n r g e t l i ia tc ., ri l i (,,trsisl"nlcLscizur " s' '. 'i'r njim ii or g'r uulr t i l'olu) . int c'ior 'Plir r '
    n. r m r ] \ - ( zicir t t r illir r : s( l'r l
    i ,,' , ,f, ,, . t . 't ". n, '. i,p. f p" l. r uou- llr 5culu[
    riiD ' l f o r r r t r l d c h i p . r co n c( r lllf a ljc simfizei(r'czi
    ;, ,,i,,",i'.itJ ,,;i; il,rii, i., 1 -+ c'n rleasupr':r 2' ,rtll
    'ol
    t t . | | | \ lt ::it ttlni.olniNet.t
    ':I l l ts).
    i r';if i r , [ $ 1 o z : r f c t : r l i l \. l ' i vst ilnr ilr , . \ iir . r siLlur ilc ocez- ionale sint . f r ecvcul it t t ilr t , t lr
    oropcl nr ol)strnfri.i. ,,,f,2' i , . f or l' . L, pr - r, r , si' \ r 'lilci r ^ir nl( ulll- illt t t lr l vir sit r r lii 's" I 'il"'
    "
    ,;, ;,,,-,. . ; , : ; ', i, u, 'if , , r 'i"r , : r , . {or r t ' plc, t r al, ilr , r r l, : ', J' o i, r lr r r ir ' it r l' ll
    ' 'i insotitudc 'li:1ensi't
    .rrir.igi,'.r1ii
    ,,l,,riit'ii""a,' ,.'111:"n
    1'.':l.ll:
    ,r, i,lozii scnndar:r iri.rcliei, !o0 prin far,cir.3cijr. lrl,,L r unof ocltzii "tioiugil
    intesfir.ral' si trcct'-riti' ''\|lori]1 ri|([l{)logl(t' (\r'zl
    2 ll; f il. i lls: I 'r r r ) 'I l
    ' . r' . . 2 lt r : nur lclr l, l. 1. 2. 5. ' l 2 l. 2. 1 Z l'l'
    '] aLt.ii 2.zii r ' r ' ,. t '1.t . 2 4. l. i 4- l. 'l Pir q 220 lf ir r ' : ' l' r 'l l'
    liti{roo;r
    -.lriilor{hli la $orr-rlii\t]{l I t.l i ologt"z"zo,tt sc4ut t ( l( ) t 'r l i t r 't ci( ( : l! ! t l ( t t t 4. 1isat t l' \ '\ '/ l
    2.10,ptg 236: trLbchrl218' l)ag z4() :rl
    .' r,ril. -iijd, --'zz7 (t,,b"1.t1
    r.tl r l tl 2. 2. 2.
    I iri. ) b r - a n I t i ' r . j I 1 S i a rl 1
    rl'i1|ozar lrrirrgiltlril l t !)i slct r sia t t bt lot t t 'it t ol'i [ ) csi . ilist . t r : i r : t l't lot nir lr L]
    , ,l rLtor.lr , r nci obst r - ucgiiiu r "giut ", , init r iuiLr r t : L inlt r slit t t t lt t t
    I '1r ' ; r l i r i u c o r . z i l o r v q r o lc i t : cvr - t nL
    , lris { : t i u : i g j t n ir npr ciur iLli ( it t spcct al ill r l lr ' 1) r 1'lllr r llr lJ
    t ' 1r ) r ( l l r f l r r i r L g i a i (h fr r l| r g io n r , l ,,rrrl l i rt t ilni si in lLr m l- r loar cle
    tl,p ilo r ) t)
    ;)/r/r' /rs/ ,a( t , li, nt it t , irf' t r it t , t iut lit ult t t 't sct Lli t l. r lr : ( r l) 1. i! : ( r r ) i( '/ lI l. . r ) i1) ililii
    r
    ' r( r t ! l i l l , i l H l a r l
    ') " \ 'l- l(I I 'r
    ,u,ri i l r' t t t lt r t 't r lt t t 'r lr olit : iL' t t lr : us ir t it L lt ipt lxit , l) \ 'r l{) lllllil llLlt ll
    ( iPAl''
    rrrl l l ri l i l ir r lir r r l) r 1l i r il lr r ll( '1] h111lgil
    ' 1, r , r / , r i r . r l r c r l : 1 ( t I,o jr tu zi,.)
    l )t::1,tt' , i, t , r lulot t t t t t r t Li r lt t li dt r t t gt t t t LlL t h't t t ii: 't l" iil llr 'l) ll1'r r "r ir t li';
    ' 'r l ) r ( - j , : l r ; , l x . r ' l : r r.l1 l iI| I
    ./j.s. Ul:L r . /ir \c
    .r i" I.i r tc 'it t t t t ll si'r t lr i'r r r ; ir'lt r sr llirit 'u{i r r r t t r Ll; t 'r i:l') r ilr i'lr 1 ;
    llrrfl t i i f l i i d i l ) , i r o .L r { n ) ir liir r L li Il i ,,,,, ,,,it "i, , i, 'i, , t , , j. llr jt lr r jll
    lii( r o / . r 1r , ! r l , r i l i ) l rI( r (f( xr n ( lir r iii,r t[1 , ,,,,, f,,,r., ', jr olit : lr ist ir ', t t t 'lt 'ol') ir sL"t lt ;( l : it I I ) I I 1t I I ! l I
    1 i( ,i
    ,.r,1. " rrr ; 'i,, l)ii, : L, i
    I , lir r . l t , '; . , , |l: ''t t lr r '
    :tt(;
    ilr?
    lt lir r { 1 I I I I ) {) I I ) iI {I LI '
    i rtzi tl r,' t r t t r lir r t ir r: r I lLlr iillr l' si r t u I i"LLt lt t t c* t t l"t t '
    li. . l. . , i / , t ( v r:z i v ,rl . ulIt-LlL] irsri:nii:, . l r.i rrir ; lor lr kli, .
    si peril xitir ii trl.rrrilr)ir
    rl i l i ., , r r t iilr ' r r i1: ii,r rro p i rI i , :,,,,.;ti:; i;ti;r;;i ,,, .,r" '" rtr:.ruarrciir clectnarca ir:redi:rti *)'
    (rrrl co rl iirl: ")r. I'i,,.iig'lili,--ir'"Jiii
    " (dupiL zitr:i
    r r,lt.^t lonirr crornatinir sexualir. -r1"3
    li. I I L: ut of t t,i to rt, f ? , I s c ma n i { e s ti c l i ni c pri n di stensi e a} cmi - prcglantriol' dil uriru r.r'col1lrli irr '2"!
    l,r in,,t.'r, ie 1?-ceiosti:roizi ;i
    rr,rl:'iirrso{itr-idc colorzrtia.albirstmie a perotelui acestuia. Acclergi aspect sc p:iclogt-alit t t
    ,i, ti.i,,'1t;i clcctrolili, radi;Sr;{ic:- rrretrovirginograrnr'L'
    lxrrrlc irrlilni in oLrstmctia vr:nei cave infcrioare. I{emoragia abdoninali- -sc I r()l 1l ).
    dr: ilsltfi('it lilI'
    lr,rrll rlirlori porloraiiei unui organ abdominal (storna{, hcmoragie subc;r?- >(' \'r)r iLrlrri-!rl in scopul plcr-irtrtii conplit at iilor .lcg'LL':
    Lll gf('rr
    rrl ;rrii l I ' ic at r r lt r i; i E t.rN . tj , rj:..i)r.iu(,rt..lii:pici-,1cli1edi s,liirri, .l..hiJrat.-rrea sl stallol]ai-(rit
    t, . t ) t f c L: ! t " ttl e f rre te tru ' i a b ttro nt.i tt, al ' :,t) Onr' fcl acetru! (v,::n
    '
    r.l.2. 1.rrrg. 18a ;i
    .{16), pltrtlnderoa conlinutului abilominill in cottiotrul tll (){},1..(iin cazurr, lou-nirscttul cste ck: scx {ctl]irti ct1lip':rPlazic t:otr
    ,,rrrl ri lir : ir l. rnli ,rles dacir csistil urteccdet.itc in accst scns sirrl
    ,,,,, l,, ,l .rt]rt
    s c z i v o l . 2 , p a g . 1 8 2 , 1 8 a;i ' 176) t:xttrri oti z.rt, r ,;r.
    1 , \ r . , t t : ; ! r os c lt i :i(v , , <r'-, fot:ilc lntcxplicabile
    ^rena1i, 1l naqteriic antcl'1o1rru'
    dc psettdoltLrtm:r
    :r, l.r' rrlxlrinrina.lc printr-un dc{ect la peretele Piu aon}l)ilical, r,, riiil,. .llr't i"rllri, tliaguosticul poate fi: altc foune
    c) ,4ltsut.ltt uitsctt,Iatttrii. abrlotttinale, se asociilzir cu maltor:rtitlii lllirlrr rncl'.ri
    adcr,i[at,1)i].iatcn hiposparlins,
    t,,",,'";,"ilii,i;;,"t,"ii.r.*ioiiiti.*
    i' r', zi r r r l. 2, pag. 1,,r r, , rlli ;i scrot bifid iu lips:rtcsticulelor'
    lttz 5 i 1 a g . 3 3 2 ).
    'p
    ll. L o - , i i o , t tt'1 ' I ti g i i o mb i ' ti c u l e sc pot i nti l ni : !i ' :r-ri :< l e-
    ; I r rrrrrrI rr! i r' , inirciie stafiiococici-, persistenla canalului omftlo:mezenl.ttic
    ((,)rrrrrrri('ill'(] cu intcstinui) ti persistelrla uracei (com[nicare cu vezical. 2,6,7. SIMPTOMENESPECIFICE
    f ri ml !Itri scrl ul t , rr' o' sc alimcnteazi crt rlili
    l. l nt ir : r it r c i n e l i n ti i L s re & l)iutrt accstciLamintin: a) nou-niscutul c'rr(:
    ri i ,r /. llrrjot'itritt::r nou-ur'rscufilor climini plirnul scaun rreconial in primclil . ,ll ,1; :"it)' .i;;-;scutnl carc ,,riu alat:t bine"' i:; dotcrior:tr'€rit bLusr:r-t r'
    'tlrrpiL
    .14 rl(' or1 na;tue- Nou-nirscutttl cu distrofic intrauterinit prtzi:tir o i.!r r i{oncr;tlo (tabclul 2-23).
    -,ut*t,,'lmpleiur':iri'sc
    irrlilzirtc ir r:limin;rrea mcconinlui. lntirzit-rca climiniirii mcconiului ;resLe iir vor avea ir Yldct9 \rt-qit( )are1c rfc{ti[ri
    l(r 4l ,rr-r', lir n.n. lir t(]i'fllcn, poittc {i secunc]arii urtlliltoa.rilloll afcrlluni: ' , , , , 1 , ii, , . . , i r , i r - * i i i l t i i " , r t i p " . " r t e ' r n i e e t i ' ) , i r r f e c { i i ; i h e i n o r - a g i c l a n i r " l t t
    ,rtrlzic siru obsiluctir: intcstinalii, r:tt.g:lt:oloncougcrlital, {ibrozli chisticir de t 2 2i)'
    lrirr{ ri ls 5i }riynm agnczicaric,
    'j-r, ' , 1 . ' 1 i r ' r i n : 1
    q, ,,"ir.,ir"liL r lvi ir : z i ' r l ' o l r r l
    cfictuirrr:a urm;Ltoi,;clor se 1:a colll.rlrlir
    i*vesiig;rjii:
    l-;r '1r'rnratur cst{r posibilir o irttirziorc rr1:rinlrrc in clittlinru',-'l mci oelLl- , r lxrli;u <1iabet,ingestic de droguticti:; a) hc.rnolcucogralrri' ll(itrrirl{t
    lrri rlirlrir-iii alinrr.ltit'ji nr:li trariivc sau unui ilcus irarlial prin hipoxi :ru
    '
    ,,, r,j-gii.lr"i,,,' l*to?ttftttre" urixrulturi' crilttri. dr: I.rll{:
    :rfl t !i t ' . ,l i l ,rl rol i i L : ( ) 1)"oi."fii"; "i' pent r t l llr r r lt r t l
    [ - pdnt r u r uii: ciic sau hem or : r gii; {) r ^c/ r e'??'r g
    it t . lir : ir it t .t l T ri m ti rtti t !i tn t rl . P r:i tna.ni cl i ttne sr: pr-o- ' ,' ., .' i i :,i Puncli" Sr Ll'dur al; r -
    - 1.
    ,lrr,,, irr 9()(l'r,rlin r::rztrriin plim,rlc 24 tii: tuc dupir nastcrc. I ntil:zier,-',iPri- "1! r lf 'Lai ' l ttt),l ' 11 l ' l
    rrr,i rrjr:tiuni pcstc 4,! dq orc se po:rl.c datori urnlitoarcior cauzc; ,Lrtort
    lr!rli(i(lt dc liclrjde, :iglrlr'zio rcllirli-r bilatcralii, obstnrc!ir: urctrlll il"{",uicin l l { ri tri ottrrtd fi l tl s r{ i a tl i l i i { 1tu€rj rl f l x N rorl ' ui s trtl
    ul, 1r'rrsir:rr'1si nr:ct-ozr-r. renalir sccun<larirfoculri s?.u hiposici.
    ''! ' ::' ' ;
    "l :rti
    (l c tri ;i ' rrrla hr"
    2.6.6,EXAME},IUt GENITAI.E
    ORGANETOR rr1,1,l f oc .rroi i r1l 1l z i Ll oafc ;i tl frtrrl l .|f1]||l i ti { ' l t' i '
    I ,,,, .l r[.a (l e ]r ' /{ rtl ti i ' ttof; l )l c Ll ol ori l -{
    rr. \ r r?r I .lt r.r. s t, ir, /.i. rt . Firtloza estc fiziologici la norr-ltirscui l)e 1,,i ,r,,frr!1. c c rc b|1!l ' r { /c di ri c ttl i r{ i )
    , I' i ,, rrrL<; rl rr:l i ttgi t.i
    .|,r ||r(.|lrir, s,. nrlprrazir lrec\1'nt tcstictllfl] itr caualul inguinal ;i hiclrocri irni-
    .rr l , il; r 1r ' r r l ( r ' c z i r-o l . 3 , Z .6 .l l , p a g . 4 8 -5 s i i 2.6.2.2., pag. 491). , tt' N ttti l ni tt r,s j ' i /n s fol i !r/l
    Ii. ,s . .1:/f !. .l' ,. lt i ;r' ri ri.. I-a-lriile mir:i ;rp:rt rqlativ lDai Cezvoll'.:lL:lrl 1,.,!i .
    l r l l l ,n l ! l rI I rLi rrrL ta) l l i -
    |{)]|.r)isful. Sc inliltlr:str'. l'icc\"r]ilt,o sccrclie VagruaiiLmllcoasi-r, albirlO;rsii (' ,1r1.1(rrrl rrLtr
    iul :".rDlilriil()l('D1ir sccLrn(llrl hipefeslrogcnici 1r'ansi>jacen LarL c {r'ezi '',il- 3, '| | rl i ,,t,rrI i r'
    rrl rr(f0 i !r\-r:' ' i rL::r
    ' ,,1,'.,,,,1i 1I
    .'.{r.1 . 1. , 1r r r q.4E N ti 2 .(} .2 .1 .,p rtg . 4 E9 ).
    iu lr r iz r r r lir lii rp r' l r,i a i tri ,rrti l .l l s c x u l tl rrt:rcttl i tlci , l i i I{ i ni l ri )r, sc l rf.l \i rl c
    l l 1 (\,l l1, in z { r [ il (tS,| | ](' l ()rg | l ri l rrl c r' -\1 (!l l (' , c(l r' l l l { l i i tl tl ti ttl trzt (ttrtcrrri r:tt
    2.6.4,COTOANAVERTEBRAIA
    i ,rrl r lr Lr lr lr t lr , . ljr ' r ' ) . tl l i |l ri r Ll
    '\r' \.' { \:tl l l i l l ;l ,11(rl l l l )r' l )l fl l i r rl r' :t:ol t' ti tl l l (' v r' 1l 11ti l l tl tt"tri ttl l r'
    rt (ol oi l l l { rl \c l l r' l ' l ;l l r
    \ . I ) , |, t , t . I i i tIt ,tt .1 ,' l , r l i t t,t \t\ui ttt r" r ,t tt i trt' . ,1,i u, , ttl hl trtIL l t' r' l ri | l rl z i tttt|
    .t:rl ' \rl l i l l l 1l r! !' r"l l \"l l (' l )l ,'
    t r l tl r r r i ] r , r , , lr t i ' l l l rri g rtrrl ' l rtt:t , ,IrI| r' ,IIti | Ii i ' r' ' :ttrrl I i r 1r, Lr' r I rl ri .,' \ | | t.tttl l |^t \t "t:1i
    I ',1'
    1 l,.,'
    l rl l,l l l l l l tl rtri tItI|' i trrI i ,r :rt' l r|l tl l rl
    '
    l L l l ti r ) ilL, 1, 1, ' 1' ,1, 1 .r ' r,,,,r ,rr:l rl r,l r" rrtl ,trr,rrrrl ' , Il l rl l r. i t,rl t' rl ri ol rrttttr
    : t 111
    :r l
    llol lr 'rlt
    | ,,i S,. I ' i, , lr : r t J c LI,rrr,rrIrrrr l )()l rt('i r\.(.i ru l l s rrto cdc pi r sau o masi . (l c tl ;i l t :rll'r r'rr trascii ctc.). ltl incadlatcir crr per5(irlrlliIsccliti d rou.Diisclllr
    ' ',,';;;ft;;i'p,lti.t
    rr'. l) r . r ' r ' lr ' lt it i ll rl l r. o .tt s .ft[n a l ti fi c l a o c u Ltttni r ar,r i nri t,rrtan!i cl i r; . u rotit Ptntr; b patrrri Dc aselLrLnca in cadnll sl! rr.r
    '
    in carc st'
    lrli-r) l(rarlc uricir l)t'ol)or:1.ic tlc cazuri sc lnsolestc de tnilrur.lLri notorii ralr f u,r,r-"ils""tl nirmali tr:ebule sl cxiste sectoare scparate. 1'l;r
    cu Pci ''rrI i;rI
    r rrzililc lrlir rrlcnlbrclof inii:rioare (ulri sau bilateral), ulccic trofice,
    ifcsca- , ,,.,i iriscuti prir opclatie cezadanir, nilsculi Ia dorrriciliu si cei
    .,rs, lrrlltrrirri ale lnnctici vcyicii urinare. ',ri li"l" r' ' r
    ,u;.,,i , ' ' i ,f i3'ni, ; "i: t ; "i', 24, 1' or "1. L) ' r ''nr t r cn'r ' in ot ic' "
    st lot t 'r m l) or r " I l'I '
    I) iit s t . lt . u. lot n i e Ii d c o { o rm i r d e s p i Lrl l i fi d,-Lorul ti (i n rcgi unca ,r \,rl i \' ,r i j , ii- Ponihilc: ir t t s- r lon '1" ilolan. ; i ult
    i.nrl)iu:r (lc obici:i) in care tn spicul osos sau urr scpt fiLros pr: iiriia mc<liani., .rrliLrriilor- clc igienizare pcriodice a serviciului'
    'rrprrlir. coio:rua vcrtcbrali,L t:rt tltt
    in douiL compartiminlc trccincl prin nirrliri.; \ou-rriiscutii sc cxarrinoJzi rilPi'l ir 5alit {- nrstO-i t1l-lllind
    seIr'icru lvezl cxirullllrrl' r
    lrjrrilii iirir|icciiclL asceiniur.rcanomaliL a rrridli.rri irr canalrrl- \'crti,l)ral ir) \illlr(']t col-llDlei si. se efectu(/''r 1l prillrir-o't in
    i:rrlrul clr';1crii) 5i clucL,1a tulburirri ncurologicc ale mcinbrclor ir.rfcrioaic. r{)lr-rliscutLili), (r.-czipunctele 2.6. iriui. )a Z'6'9)'
    flrscri.) ;i ak:.-sfinct t-.rului anal si vczical (r'czici neurogcnii). Itiag r.rlrrt't'rti
    lr,rrrrliz.ir: LiL l.raza tuturol telinicilol Jc ingr-ijire al c ,nuu-D:lscLltul ui in
    Lr(,li( ul so facc prirt ra<iiografic(spi, uJ ,*e5 in i.Ll.rlrrl sf inal; snu -miclogr-rl Le. pievcnirii ir{ccfiil ur' iutraspiteljccs ti carc.-cons1'L ir slrllrr
    ,'','.ii, ,,tii."irtiot
    o Sropilir dr: citivrL rnilimrtri aclincim,- in rcgiutca s.rcrococcigiir:t c
    ;.:, l" t"to", ineintc;i dupnfi.-circcoPilexaminall'' /i
    r,)l]|irli; |rjD tr:rcliunt-.a piciii dilrprcjur sc poate vcdca funiltil 'i'ii;,li;;i,r'i"ttito pas' 362 si \'()l :i
    rrr, r ' inc his .
    S,ro])tt(ji, t,I \', ;ii,;;;l;i;-iiio' i'' s".tia de '.n puiictclcz'tt'7'4',
    r1 ril.I l, p : r g .6 3 3 - 6 4 4 ) .
    {) gr:opi!ir (lcasuprir lcr-ti:brei S, (iocalizati ,1o olricci ,i,-,:ipi1;11 sl11 Lr[i.t-' pcrtrrl( lrrrl
    ,rrr) lxratrr fi ru.L-sinusdcrmal congenital; in {nr.rdul sr-ruse inscrir un tl,Lct l.r iltt'ruaLea in seclic sc Ya lota: greutatea,- lunginca'
    se vor cornpara cu datelc coresPrlnziLl (' l '
    , ,.,r'i,,rr rr,rrirrt:trul toracic carc '
    lil,r,,. 'lr l-rrri( , ' :( pr,iunueste pinL la tlztrt uttr,ler. Accttslit l)roFri o)r:1o- cor;ctc a nou-nitscutului si rllrlri L
    ,, i,li ,,,jtt.,ilon.r'lc il veclcr-, iL iucaclriuii
    l l r,rl i l, , r nilu lr , , c i ro r i r, rrn tn i l o t d c p e p i c l c i n l _C l l , l trocl uci i rd nrcni tgi te. disn- iat ur it at e m t r cr osollllt l r
    rrr, i ,rl, ulualr ' nar ologii lcgat c r 1e - sausta't'lirttl ittrrt L t
    l rrl rrl rr r r r , , , < : t tr c f c t i ti c " r,d e o b i c e i c rr b . c o l i .;. ' ,' rri ]r. n. va" fi rn;nitorizatl zilnic in condilii
    ,,,,' ;,u ,,r, , gt-,,il.tea '
    Si rrrrsul dcrnt al i r cbriic crtirpat chiltrrg ir::rl. l , ,rl i trt crti :r!t c.
    o Lrr inlrtrca in seclia tle nou-u.iscu1i sc va 'onlroli! I'a)nftt",tl 't,'l
    tnel (r\:('nlrriir
    2,6.9.EXAMENUIMEMERETOR ,/,r/,r irr s.r,l)t:l t:r'altrirt'iin-i1apl:Lriitcrmicc si r ''r'iclcDticrir
    rrrl ' ,rl ,rLrr l i i r rt r lLlr '.
    St' r,;r.r:iuta picio_nlli,dnts li rlllg1/s $i Ltu'us t q trin car.clcccsili cor. :ttic. i('
    , \'rl tlr'|lliri cLilltt]tor(a brintl,ai sLauIl J taonial (nrlt-nal -Pitlii lrr
    , iopr.<lici irrcrpincl din pcf ioadir niron{rtal:i.. piniLla 4li deor lr dcla nir ll" )
    'r l ' ,' r ,1, l rr rr r ; t , ir r ) ; i a plr ir zt i it t iclit m i r lor t nal
    \l r:m'btclc infcririarc rror fi c:iarniluic ircntr:u iu:ratia congcltititl; ,.le cstri r)(r(( L]
    . ',/\tlt!t'ttt. ttott-ttdstttttthr'i ifl]ediat dupil nastero nu
    ;olrJ. Alxluctia cstclni! a r:o:Lpsrillcctatc c lirnitati. Un clic poaic fi priipat l
    irtd lrpul lcmural cstc ch.1i1:rsat ilrapoia lnarainji postcrioare a c:ir.iliilii , , ' ,' aninati in couditiile unci t{l}di14e la instabiliirrl'
    t'
    , rrril0irlI silu c,rte itnpirs 1a lrx. (ruttcrior) iD car-iiatca. coliloidir (rrranr-i..ra, ,,," r ,1,r, , irr st rvicit nu siut {r'ecventc ir.rfecliilc stalilococicc alc iirgtrttr'
    'i',,f,:,"in1L
    ' ,r l ' .rl .ri i r t r or t - t t iLscut ului se p( nt r ' {dci t u 'r pi dc I a r of ir r ct ( a1r 'r it t t t t t r '
    ' tr l ,rl l n i) .
    ' " ,,tr.,1. ' r , l, , . Lllr r , . 1', i - r i't ir r d p' r ir 'ol d" ar 'ur i
    t lttL,riiirtt (t)rdoi;l.th.ti ombi!,ical':imecliat clupiL lraitcrc ilc(s1ir sl ir I
    2,7, INGRIJIREA , , ., l i g,r t ir r ', 'r r zrsi'Lsc sec{io: r eaziLla o dist an! ': r r lr : . 1, 5 2 ( illl d( lr ir zir r '
    NOU,!$ASCUTULUI
    NQRMAL Dlieu- oaunor subst an! c aut iscpf icl: 11raccsl r r r \ I
    ri r' l LLl .rrr'. r lr Ll, r r niLr , L-r]ti:
    ,r' ' ,' 1,rrl 1,r , 'r 'r 'nir ii r r r r Li ir i{1'ct iicu pu11ctdc plit ir le om hilical, nt l csl r 'r r '
    2,?,1,IN MATERNITATE l ' ,,,ri i rl , r r r lr iiical s( '\ : a.piulsa de 2 or i pe zi c[ alcool70o'|, ill
    ( : r r r t ( ( 'r ] r l) lr i
    ', ,
    , rrrrrrrili,l si , l, 1r r 1lrini- 10 zilc <lcllL nast r : r e( la plct nat ur i. 1i l: r l LI
    Itr srtiia clc lou-niscuti norntaii sc t1uti1 uotr-niiscutii cn .1t,.: --LL ' botrlrLlui oltllriljr:ltl :it I
    l | rr(, ] 5l) 0 ir , l { X lo g s i c u l .i i s trL 1 , j rrtrr , ,rr , rtclciizlll \'ilsolc olu}ilicirltr, t1t-.titsar:ca
    -\J si dc si ryi ti rn,i ni , l
    r,rr:r :r' lr r { ' r ' linic c i 1 ,,.l x x rl i ' L r,.z L rl " ta ti o n :l .r -11 tr.' l n);prr sr . i, t r t r r r Lnr : ist r cr t 't iiom lr iiicali: dupilaccst ir llcl'vir ls( '( lir l( ) l
    si l a ti ,l ,n s r rci ni ri l r;1el i ci u.c i i i l i :!,' ut , , I Lr;li, t r r , r i, lr i, , l i, r cicat t - ict li s( ' r f col'411d: LiI i- it 11''t 'I I' r " t
    .,..,t ol.rrtir'_ liziologicl-1.Salo:Lnclcric nou-n:iscuti trolmali sLi vor l)LJsa in i_rcc- 'ivr : iul r I
    r lc I t t lir r ut , la 2 zilc ir r i'
    liilc rlc olrstrrtrir:il.in o,1,.ropicrcu. saloanclor dc mame. Nou-nfscutii r. .i ii ,, i ' ,, , , , r lr r { r ( ior l ( l( ' uit r ilt clc lt gint t it t t p '
    1 ,rr1 ri r r pir lr r r - iplr ir - rt r:l rr, ::c \:a tl o c i r" o ,s u i t ra[atl ' dc L ccl puti n 2 m: qrl t I' r|lt lr t t ir r t ) l! ( t lt lt it t {t t lt r t 'oLiccse f r t c'r it t lct lir t t r it t l>i' r lir : lr 'r r ' l' I i
    l i ,i rrr iir r jir llr ' r lr . r' l l i rl L , (r1 ) c u r. rrr l rl ,rr r rr t , ur ,t t l , oiljt t t lllilI r I . r t t llr 'i 't 'lr r Jii 'll llt t J: r l 'l( . : lf sillt 1", , ; r r 'lt
    ( r l l :r l l ) ) l ( 'l R ( 'l l i ) ( r r r i i '
    I' l. l< . r ' . , or r r , r r t rl rl ' i il i r i l p ri n rl r' 2 ,' } rl ,' o r' , l l or1-rri i .scl rfj ' , r , {, 1 ,( l,l I i l ( l ( Sl r 'i ttr t'i o ,l ' r l ' l r r 'l tr i tt L ' ) IIII| ||I'i |
    sii L [i r, l rJl r-rri L t t'
    rl r L r i : r jr l( J rrt l, , 1r ' ;rrrz i l i lI ..tri ,' rr,1 ,,6 o rr.,) tl c sri t> nrvl ql r,,rl rrl )i ,(.i i tl i i , l l r r L l 1 , | , r l r i l r fl t,r ( tti r l I i i l j {i l l l csl r ' r 'r 'r 'l ti sl ttt l ti tttl r :i t i tl l l s'r sl l r tl i o r 'l l i .i '
    Irlt,,l, r 'r l l zi r r l o l l i i l i r i scr r l r r r l 1 t'i "r l i r i i r r l r i l r i l i l i l i l i l ' i '1 i r r r r ' '
    ,, l l )l r.r 1, , r 1 r r i; r .s i l i r' i l l rr,r' rrrrtrl tr{ irrrrrri l i l i r l r.r:i i i r.r,srrrol j I,i u(.i l sl r.,1, "'r r i r r tr '( ( i r r l 'r r r l
    , r r r r l , r I , ) r ., [r ,u l r i , , i ttl [r ,', i |i tr ,1 'l ' r 'l o i r r r ;r 'l '" ;r tJ]ttr l r r L l ]
    l ,r'rl l l u , r . Lr ir z ; r, , , 1 rrr,ri rj i r' ,,| ti t ' 1 ,, l rr' ,l ;r ,i , rrl rt rl ' i 1, , r rr tr: i , L| , .,.r. ,t.
    i ' l i l r r ll r lr r t . l l. \ ru rr, :l rrr /.r l i r l i .r r t r' rr,l i i l l t , ,, rl tl .rl r ,l ri I ', , ' , r r r , r r r ,l , 1 ,l ' r l r r '1 ,,.
    'li,
    :':/|
    'i tl
    c 1' n, it lr t r it t . s rttl )i tr/tl tn l tt tl tt)r' ,t r' , zr I r11.229-
    :i t d .I o r,t-tLi ,sctLl l tl rti . , , l , " r r r , i l i r r : . i tr l r tL co ttl sp r tttzi i l l r i r tL :. l l tl r i tti r : <i l cr l l i l tl r tl tt- r 'l u i l l l l i r
    lil ll lll llll
    . . llu] t ( t t li t u ,)rr i t i ts trrlrrl ' ri , r, z i c a p .2 .3 p ag. 22' l si vol . 2, prLg.04- -71j . , t | , 1 , , , i i r , ' r r ) r r l i ( :l 1 l ;i si r r a r tr sp r r '1 i vr 'Li n l cg i L tu r i r cu i r l g r i j i r ca 1 i a l i m cr r l r r l i ;
    e '1'*[uL (iu.llttt,:, l,tl,':,il irr srrr|ul cvidenticrii J,-rnilcetonuri{i :c c\e- , r , , r r r i t r r t r r l r r i l i r r l o u ti t:i l i r t.
    rrl, 1r irL :r'cnltarca pc l'iiflic rli liltru a lr ci picltrd dc siirge obtinutir pritt t t t ) 1 t ' ( t tl t) !t- 1 [i r 'sctt ttt /7 1 7 r - a fi l u m i u o a si t te m fcr i l u r i r , \'r .l r
    rnl lr.u-i,l Lcgrunclttelotla riir:lrrl ciLlciiuhi (sc vor respecta liguros uiiLsurile i r , I r n n l i l ) :i 2 Z | . i l r t p r tttl v r l i l ;n z:r l l a ( l e i u r s:r 'l ' irl
    'i
    ', "i t.'r 'l i 'l l r r ti
    '1,, rrrtisopsic, a.t:ste rc.coltiiri fi.iml, inacim.isibil r1c {r'ccvcut, iuplicate in , , ' , , 'f l r r 1 '' fi ',';s si PI,;i
    'l u p i . 'i Ii ti l ,.d c,2 - l l l l '.l o o l o l o ;l l ( f
    n r i n i i r r 'l i l r ' r 'l
    llr():rLr(rur,:r ostcorniclitri la nou-nlscut). Itczultatul pozitiv corcspunde unei ',f
    . 1 , . . | | , , r i n r l , . I'i r r , i r r I''I' , l i r l i n J"r ': r o n t ( l ^ - '.l n d 'l l r l F
    lrr1,,,I,,rtilal:.Lninerriirlai marc t1c .l mg/100 ml. 'fcstul cliL lezult:rtc falsc t:,r,,t ,t t,t:t';!\',t l l t'i s' i l l c'l o in lnomolllul tn :r 'r '':r
    ':r 1 1
    rtrrri,i r:ind sc {ac urlrrirtoarelc 2 cror-i di'rccoltalc: prea prococc, innintc dt' , , r r r l , r l r r, r l r r r t < i .l L tr tza t; tc;n p r r r r tu r ;l t n Ii d c 2 2 2 4 "C ' i i i r - l ' tr l 1 r '
    :r,ll Ltistrarr:a unci cantiti.!:i sullcicntc dc lapte (se recomandi! rccoltarca ln tl u r i tt b i i i i n ccl e p i L"'"tt"ti
    ;i n d 5i m i n u i c i n p r i m a h :n i l d t l i r tl r r '
    , , ', , y , , 1 r l , ' 3 ( "( ,
    rirr, r'stcLnirrii clir rnaternitatc, lr 4---5 zile clupi nagtcre), s;rt in cutsul rr" t r :{i l
    '', ', , , , , , ', 1 I r l i si n tttr i t "'t t't: sti p ttt tl c r o Pi i ' i r i th r p l - 1 r 'r i t
    rrrrt llrtrLuront cu aniibioticc carLr pot iuhiba clegtcrea bacilului subtilis. ; 1, , 'it ii, ', t 't . , r r ir 'lul plicilor . r '' r cior nat r di slr il''r t '' piclii r 1'r t
    " ' ;; 'e vr 'r 'lt "r
    o in cursul intcr-niLr-ii in rnirtcrnitalc sc ddJni ,istleil;.i inlrantttst:tiar; l, l, " ,,;
    ',,;;' ,i
    ' ,,, i t in'', t , 'ini: ir l Pr 'znnf ei ( 1t t <t 'lor 'bor 'r "
    'ilr ul baic un t t r r gt r 'nr ' . r i'l
    ! tt i/1.e, .1-a de la naltLrc, 200 000 u,.i. ril.Ltltitta I),, satr. f)" in scopul prolila- i " , i'i, ii': , ' . , , '"ii- 1, 'i. " iniint ' do
    ., , r r,rlr if is r nulr d. " ' . - pr olr - j 'r zii dc conlr t cf t r l ir it ; r nt ct t 't it r 'r 't
    'I' . l L. tl i .. ll, .'tr iir r . cr f r sicr i pont ; t r l: "r l lt : '
    i, 't r , lt r ngiiT pr iir ilr r n sllr 'r t . subt ir e dc
    t l'ncr:inureo BCG. \rar:cinul I'iC{i pcutru itroculnrc intrutlcnnicir. ' , I i ,i i ," ,; 1, r ',
    disp"nsar' : pcntrtt ir Pt Urrtt
    ,ri, ),r,..1)?rrat din ctlttr-i lii alc becilului Calmctc-Gu6rin suspcndatc irtr-o 'l,Lr1 .rrr ,rllil li,r'rurrliLrccomanditi di pcdiaLrul de
    .r,lriii,r ilr g]utarrat tlc sotlirr. Se r.or laccina toli nou-nirscutii inccpilcl cu | ' ,,;,j ,,,' ' ,,r,ri l, 'r r t t r luiicsicr scr ccom an'J: r schir lbar clnot t - niisct rt tt uluidciil'. tt
    ,,,,,,. | .. r ,r'! . r r . c: r " ir slJr ', de vcshc ii sl. 'Jar c't cu siPunr giur lii I . 1"'
    r ir-.i,r tlc '1 zilc gi cu grcuiale (ie 2 500 g iu rbsenl,a unr:r infcclii acutt: sat
    , , ' i , , , 1 ', , , , , , t , Tr . 't am cnLul t r il'ut r 'lui / 'sir l cot t st r j in s1 : i t r
    rlr,rrlrr lologir:r:. fiola rie vaccin llCG rxrnqir:rc o pulberc albi carc nu trcbuic ,t
    ,,, .,lllr:1iL pllarti si carri cstc ccllivlltnlul il 2 g masi b;rcterianii. l)rin sus-
    'r
    ,,,,, ,,' ',,,; ,1,'itru;clcJs;rr Pennlnganat o solulie slabl dc p-1111:"1.
    iu solufic Souton tliluatir (se r.a barbota continutul {io1ei dc:2--3
    '
    , ',,,,,,rtr.,1r,l/l{)(XXi, {'rt uR scutec:l:
    lrsciucaplin tamponarca il 1lx,P-:lli'
    ].ll
    ]t,:l
    1,r'rliir-r'rr. r lr cpt r unul r ll( llilr l1: lr '
    ,rri) :.r ob{inr: o suspcnsic incolori, imogcni ;i u;or opalesccntl. lraccinul | , ,t rr.r lir t , 1,la acr ul din clm cr i, €\ 'cllt ual in
    ' ,' ,r li, t , , , , ', t, ir
    ,rrr,l , ,.r;rrr ic cu slillir r r lr l: l
    r nt li {olosir ea un i unguent ir - nt ill}icoi
    .r.,tt l r(lillripcn(l.rt sc va {cri d.. l umilir ji ta ti folosit in urtnitoalclc 30 de
    rri rrj t(,pi: uLluas c ov i ta ri s c l l l u D e i r^ o n ta rn i n i tj a cei dcni .rl " ;i sci rLi ctci tntmi - r 'r r r 'l .i 1l l l
    ) ) lr li'i) r t
    rrrl rri r I r bit c iii v ii. i ' , ,,,,,, f if if " r t nt : i a) ir t cr r t ; r 1ii f r ccoc" sci{I cr ( 'a iu ( r r u{ir t {'
    t l'' 1a naSt cr " in pr iur t r ll ilt r r l'
    ltjrrtatr:a sc va c{cctua cLr o scrinsii de 1 ml gi ac intratlr:rmic il l/3 ' l r| ' ,, r( , r r r r ; r sr r t iulalnngint l it gr cut at '- ; L 2 ! :l l
    ii"',, ,'t,,ti,r [atui'alii'a nou-niscutu] ui uorm'rl; r'r'u i Pnrx'tul
    rrr,.ii,, porf ero-r'-xtclni'ra lrratului sting, priD intrtrtluccrca. strici intliidcr'- .l { r ,,\ , ) , lir 'r ir , : r . stvolun1
    rr!, .i, rL rruri cairliti-rti de 0,1 ml var,:in. S,, ol,;inu o papuliL (calc sc miLsoarir li lcr l. 2, pag. {r 4- - 78.
    irrr',tirrl t rr un ccntimttru) cu un cliirmcLru (1c 6'-8 rn{n. Papula dispalr: in l r' r,l, t Llr 'r 'ilr L) sur 1: ( l i' I lt Ll"r t t i
    lllirt lt lpir cxt t : r nar ca n') 'l- n: r scr rt ll't
    l) or
    , il r r nriurtc in locrrl r:i fonniltlu-sc, dupiL un intcwal c1e2--5 silPii'ltrrini, ,rt,,
    c ( 'l trt:,i I11(r\'(rrl, ii:l,r:rtr'l dlrpiL l0 ;rtl tl'
    r r rirrtlrLltrsr'triudunt irco])erit de tcgLlmelto ro;ii, lucioasc ct1'c abccdcaz:i .fi::iologit: disp:rrr: complct
    i, tc iLrlrx:uit clc o cnrstiL iucotriur+tiL dc o zr-,ni critclratoasit; lrncon se l l .l ' L rr r . r r . r r I i( ijlL'ir t t lllr r l nou- t ] it scut ul a ] ] f czt 'nt at , lln l( . 1( 'riii'( 'L li||. I l
    lor r,rr';rziLoulr,:cra{ii:superliciaiir caic pr'r-isti fin'il.r tirstsde 4--6 luni.,\pli ,r ,rrr,l .1 , \ , ) r l, ir r j( r r n l) r ( \ r at ui, ict em l nt oilcnr t -1) ollic l) 1'r sist illir 'iL' r r l
    ,.rr,I illror tratal[tcntc silu pa[sar]iclttc la JocLri ri:acfici trlostYaccin{rlcrru .,l L,r ' r,.1 1.,r ir 'lr r r lr ' 2 3 si- ll) ii- r m iDi f iLr i. a st ' it lc: xha' inlt - - lr plt lolo; lt r l) r
    , rI' Lr"(:osara!, cle pttind agr;var sa.u prululgi ulccrafia. Elicienla \-accirlrii trl
    li( (, irr rnltcrnitite st: tcii'Lclzti pr-id rui.sul'alea cjcatricei posivacciualc lir c \litiril' r fi L i r t,tr tl t ttu L t'- ) i ti st:ttlL l l i Po t a yr 'i l i t ttl r tr tl i i r 1 't 'tt t"
    rir'r.r rlr,rr luni; se apreciazi. po;itiv oblincrea unei cicalricc cu (liirmetrul , ,r r ,, i ti r r i ' r [r ,t.:r r r l r r ]tc si q r ti r m i n i ; l l c( '.st fi tl .) t s( ' ( i i l l o l ( s{( Ll l 1 l l
    L rr i ir ( lirr1(.nsirrlrcr,, pultc 3 mm iu propo{ie dc 95 - 100,D./o din tot:Llul coPiilor 'l r r r {i i r tr i j r tr l l i l :r i n r 'i i 1 I '
    L|, i rr , r r r , ,l r f ;!r ', r ,:,,:r n n i l i ci r ti e l r a to l o g i ci L ''
    rrrr r':.1Lglr t t . , ,l , I t , (rt t , . , . t \,, t ll i l rt c i ,
    'r ,
    , l ) t , t ) , I t I,t r ttr i ttt|,l l |sl c ft tl cr ',r r t i l l l i l l l i i i r i n i :tttstr ) |i tl tl ' l 'r t i" I
    ( :o n sl i ill .'l l l i l r 'l i i r r 'l ,,L
    2.7.2.LA DOMICILIU . , , 1 , r 1 , r ',r ,l , i , l r t :'l tg l t|ttl r r i i l tttl tl i ;r f l l i l l tl r i tl si
    , , , , , l , ', ', r ,,,, ,, , Ii , l r i .i i ', 1 ,'1 - 7 j 5 i ;i ci tl t', i r <:L ttstl l si r L l i a sl i r fi l l r ) :'tr 1 '1 rllrrl
    itt r':rzlll tt0[ rri-rsr;u!ilor slitriio)i tttr cslI t qco trta trtlill lii cn cxtcrtta|t'a , r r , , l I , , , , l r r r I , 1 i i , l r ) 1 ( ':i ( r r . i l l r ',,tr ,l i i i i l ' i tl cr r t' tt'r r t'tti r s|r r l ttl ':( r ' r l t r r tL
    rr rrr :rlr,u tiiatL . sir s c f ar : r ' r it ur it t l, r l, ' { z il, , < 1 , 'l r t u a ; L e r c t i t l o l t t 'c c t l , i *i i r t i t ' ,, , , 1 r , , , I r .tr t r ti ct,'sl ,: i l I i l l ( 'l l l i l l i r l i l ttl l r t p tl tttr l l i tl i l l l l :i ( 'l 1 i r 1 r 'i r r .' r I
    , lr , ( "sl i lr'rvrr.1 {xr l lt lr r it |r t r lI t I lr r I r || : iI r t i llr r l t t l O g i l i l , t l t t r r l l t - i i i c t l l r t t l s i t t l r t r r I r , l t t t t t t t t r, t t rl ,l ,tr |i l ( l i ' r r l i r i ,'1 r r 1 ' l t l n r r l l t"r ( \l ) l i { i l l ( l i l i r r i r i l r .t1 Ir 'r 1 ' i r
    , I | r,11,,1 lllllIr, ttrr,r'rri: ir : .l) i ir s r lt l( t l, r . ( \ lI lt lilf ( ' ii s ( ' \ 'i l : L l l l i t l i L i l r c o r t t l i {i i l L r i t L , r r r , r 'l r , r r ,r tr r , t,,l ttti l t l to ttr tl tl i .
    rirr' .lirrr', rr,liltirrl r )r ' r' rr r t l r ' . r r r I lr r ' t r t ( it t t t r r s l r r t t l t l t t i t r o l r l t l l i ; i t : c r 'z l t ' \' r ' l r ) r r r tr ( l
    l r l r r I r r l r l i fr i l r 'r i l i r l r , r r tr 'i l i i l l ,r 1 r fi l " l r 'r r r r r i r r rl l i l l l l ) ( 'i l l '
    rir). ( \1, rr.rr'!r l l. r r ir r z ir r . r r I ' r ' r lo r r ) : . l t t i l t l t t l t r i , i r r '1 , r r r r t l i l i i l , r l ' . , , ,,' ,.,,, ( l l r '.) , .'.r l i ) r l " 'r 'l r r '1 r 'l l 1 ;r 'r ( i zl l l i t i r r 'r r tr l r l :r L

    .t:tir
    ri ,,rsii/rlsd tarls|i.l\ftli,cnu s{) llrtcari i)uti|du-st illucliora })Iirr 1||(xiili.ilr., '
    iiit"'l, j::**1#".11il:'1:it";:;l:"ffiJl"
    ,i,"i,illi,illil"',til::flcff
    r, .iirnulni alimentar matcln (mai mrilte 1ir:hitlc,1i'grurc, {mcf o;.
    r , r rrr;r.
    ri 'r':n
    in concliliilc alimcntatici cl1 lxP1r' l)r'rL rrrl.Lpt.Li,cc,Lr'1ip.r.lia -poltL'
    apat-
    ynntt fetatir'sc accelerea'zi f1 *iT,:l" 6 luni de gestalie9i sprs sfir-
    r,l fl cc v c nt ; adm in i s tra rc a c i 1 ,' r' ' .r i i o " a l j t" tl , ' rrt rl ,' l i LrLri i l ' (cl upi Lvi l sta ,"r''i:;'iJ';:;;:,"apond.r,Jie de J5 g/zi'
    , I,' I sipiiLmili) rrzolviL a(xrasliL probJ cnit. .\tunci rlilLl noLt uilscLttuL r!r( un
    ,, ,,nn ii intervil dc 2 zilr: si csto cxtrcln dc agitat, cstc pclmisir.Iolosil-i'lLsultr
    ' i',
    'rI iL
    l{ rr
    .- ;inliriiiliii:i'.::li":l,r::(*:Tti",?
    ,,iii scadcla 30 g/zi pinf,Ia vir
    ,,'r:r-t:;tcrii
    ,
    ''..1 ilffi;';l" p"J;;ld"id"'og"'' ln ciuda tii
    r'i l'l,li[li:ii:,
    ,r .,;rrlui c u glic c ni r.
    - colicilc abdotttinal'c sint fi-cl'cuLc iu prirncle 'qiPtiimini dc vialiL'
    ili ::i:IililI il.::{j
    r"X'i::at""U*:,1
    .,I'r.'|,ri rri, Iri 1r,iru-;rcrec;,in .uq131e ?':i&lT;l''
    *:Llli
    ,| ' r.rI ,.i r:r'rstcrir,un sugarttotm"i "t";t" "t;:-*"t
    -acestor
    .gi:it-tll"r:il
    siptf,mini inainte de naitere'
    in greutatere in primele 4 zile. dupS nagl.ct'':
    La scctia clc nou-riLscuJi a ]IatcrnitiLtii Gi'.llc;ti tlin iltrt:utc;ii sc {o1o- i,,',
    ' ,riicut ul' normal pierde pierderi de aP:1.$r sc
    .,tr' fisa cle legirturiL din tabclul 2.24. . ,,,.
    ,l i tr' .....,,u-i-
    :ti ' t t t at e, m axim um l0o/^. "a reprizinti
    t 0o/ o'Ac"st"a
    ''
    d9 L .ia"'i -"*i-lrm l- eliminare de mecontu, altrn' n-
    1,ri,l
    1'r,'.'i, 1,i'rdcrid9
    iri 1,t !.^C'te"l=pi3trY):
    L !.^c' (qcls
    recrpercitzi''
    normal
    'I t:tt'tlul 2.21 i ;lii:1,,
    ii illrli':{"ffifi'i;io:;x"a"J"ifi'i'*-"e="otul
    ,,,., t., Pi|lrlurePonderali'
    S p i { n l u i { I ; n ir ilc o t,' ld r i( ir lli t{ { ilo l:e ..( ilr ltl l i " S {'tl l u norr_i rri l '1ul i
    2.8.1,NEVOIIENUTRITIVE
    NEVOITEENERGEIICE
    2.S.1,1.
    llitd de l,Edtu|ti
    esic crescuti in conditii de lLipotctrtrt.'
    l, , . aL : r ' L L l u: l , \ u r t c Il rrnrrnc (,rnl ilirl(rr!cli:caloriinecesare
    de caloriipot fi sc1zul"
    . Sr a:to|ui .1)i-1iJc1$nrut
    ,,rr I rir ,lrirrrrgic'lcs:u infcclii i*"ii, ""uoit" binc rcglit
    .i
    .. ,iri l l rl :ri l l lig - .!, . .,\18:t1'
    , ,, t,r ' ,'1. r,l.r*irrdnou-nascutuli.tr-r^ 'i;l.ii;;t i".-lti"r 9i adrniuis
    . '.,ri rr- i de
    pierderilc caloriiprin absorl-
    '
    | ..
    .r.' r,,r,I r ' ,, I rr',r' Irr| ., t i ' p.r,renr
    :rali (se
    '
    li, |(\r, , Lrl,r'lrrl2 25).
    Ta.betrul2 L5
    ll , r1l{ L
    'rL rl ,i l tcu
    N ec os rrrul de ral ori i a[ rrou-ni ' c ul ul rti

    ! , , , i s r!|:rri l l ] .ltlr
    l , L . n ( r l ln .
    ' r r r , r l o b i 1 ]a !
    l ,l i -,i '
    i r , { r-rra rrcu t
    \,. , 0 l l ( (i -.:l ci ,1 l ri l l l 1 1.l t:r . ( Lc
    \ l ) i I 1 l (l (l tl L l 0 1 1 . i .; iL{ itlr inislnli l:t ( hltt A. 0
    ( i i Li l r! i ! (.fc.l (rrt ]n (l it,:r .l- - t2 22
    50 50
    30 60
    15 l0
    I , L r i rl r. xtL L Ia .-!
    rli
    .rl tr.,;i l i c l l ! l l ti nrc rl tel or
    \ , . f i l |1 i ( i r i \1 r-r
    \, , . i r 1 r 1 i r. r{ri i ti ci :rl l
    ' . , , . irrr, r L , , r n l , i l i u : r t : . l . f il( . a L co .n :0 ' ll
    I i 1, ir l i i f t r ( . 1 (i , i ( l l r i L lir tL l( ,
    dc 60-75 rrrl/lr1i
    in prirn:le zile dupf, naltcrc est-c
    .1,r, rrrtl ,1,'lir;ltirlrr t)r\''
    aer uscat li fo-totcrtPriL
    , , ',,;,', ,i"' ,i' i oiirirl,''n.'riorinconiurirlor-cu tirtnp"ost' '
    Pic'r<lL'r'tl
    ,r , r ,lr r 1r rr','r(rrrrLiLitlii
    trt i tt"itirpr:'rtru
    NOU-NASCUTUtUI
    2.S,AHMENTATIA ^f "til"i"it 't
    ' 'il:ll;,1' c-stc
    *rurn .3iril'lii,tlrl'li'm
    , l:li,ll,;ili",f'1,i,?li;,'
    *,,:.f:::'.1:l:!i:,j'J,lL
    \,i,rPi,Lt|r lr()t r - lr r is llllLllll
    ( i. r lit t t , it lr r ii, r 1 - \ l l l l t l l ( 'l i l l i 'r ' f ( l ) f r ', t Ll t t i l l i i ( 1 1
    ;,
    ,i,r',, rri;i
    lir,irjl',ir
    i

    i
    l,.rrrlrlr,rtr I I r I rr ri I is I r I r I llt t r , ||r r it , J . , , lt r r . r 'r . r L t , , l l L l t r l i l t s r r l i l l l i l i t l L l l l ,

    rliil.r
    r,'t l,rL ,lr'll( ) ll Llr ' ( lll( ll
    ",r lr,ritrlr ' . lir t , r lr
    I |I r ) |) , |||I I (I I I | . l : r | t | t t t l l l l
    1r , , 1
    . t z t t t t lt , ' | . r r \ r ' r r l r r t i i
    I | | | r I I I |' I I i I I ' '
    l r r l r r l r l l l r l ' l r r t r 'l ) t l i L l
    rrir;illl11
    liitliill
    "i,"",",' ,iil ,i l " ,\" ''l :,1,,i ':i l-i''i
    " "ll)lr r \r /l i i /zN
    i 'r tL i ;rl iPr r l r '
    tti ':tl r tr r tr r " r r tr
    r, rrL r r ,lr',rlrrtt Lir l r , r L , 1 , , . 1 l' Llr r ' r r r i r , r l i r t t 'l r l t r ' \lttrlttlrill ''

    Il
    ,,,1,r, 1i r:()lt t pozililrr lif t : r : it ir 1 . ( lczilvdt r t a1( ) i! s'iit , llt r r l'r r r r lor llLplr : lt r i. r I r
    . ,, , 1,,i'l{, ,rllrrinirii. si liOo/dcaznini, fa!:"rd'' 60% albrrtrtitrr ;i 40/o crzcittir
    ttbt:l Ll 2.2t;
    'r' r l .,1rtr.l I rl r' t t ut nt r "L) -
    Norr, ll(f r l o U ( r r t d o r l e
    l,r'tnnnt lutut t rin(,lfllic clr neioile calorifc r:rporfate Ia qlrerrlato ' r .rnti t;rl ' r r lr : pt oleit t " nt : c"sr r i pr em Jt ur ut ui, in^condif iile uuLi I I t {ii
    li
    (dnp,-r Sincter) l z {t r ': r l/ kg/ 24 or o '|st e d" 3 S/ kS/ 24 or e u r at r e pr ot cr cJ. r lr : r r
    ' 1" ,r" ' l '
    ,r ., ,i f clir ', , i" im pi, dic, - L cr cst or ci. ; i. pr oduce hipopr oieincr nic . o
    " ,, 'ote- produce letargie' acidozi' nivL luli
    , 1r' " rl,rli,:::ri,r''i dt 4glkglz4 -in
    Modul de pierdere 'r':'rt plasmi cu posibili' toxicitrtrr
    ,',,',,,,.,1 ,1,' t:tt'scutc a1e unor-'ariinoacizi
    rnl/ 100CrLl/24
    ore ml/kg/24 ote .\( cr cs( dt i de am inoacizi de azot pr in ur in5'
    ," r' \( 111i, ' Ei
    ' i ' ' ,,' , i ' ' , I , ', t i''- r "f i. f " m at er n' m ai b6gat e in. aJ6um ine, sinl m ai l'in''
    I'ii r.lcri insensibile
    43 , l ' r r. i rr ol i rr r . l. : 5 slpt im ini de viat i, d. eciipr ot einele din lapt elc de. v; r cir
    13 8- 10 .,' ' , r,' ,11,, , , , i, r ,cazcina. -r Aceast e t oler ant l slabi- se dat or e; t e dellcr l|lor '
    lrriri, (la :00 mosm/l) 30
    " ' ,' ,' ,' ,,' .rl Ltrr ct abolism uluif enilalanini- t ir ozr ne- acr dhcm oS( llr r zr -
    | ,r'i,lrf
    50* 100 30-20 ,,,, , ,,1,.rrrLitbolismufui metioninei - cisteinS..Administrarea la_ premlttttt:
    5
    98, 148
    .5
    , ,rrr,,r t,rolcittc bogatc in fenilaminS- 9i metionini (prezente.in cantitate malt'
    59-i { j,
    ,i,,i).,1,i','iri cantitE!imici (2,25gl.kgl?\ore),determinlapariliaacido-
    devaloarea lcrtilrrlrLrtincmiei9i hiperamomemler.
    ' r l,r1u,r
    llll;|ij\lliiirt":lgi"1ffi;i.l:s"1,.t'..i1,tunelie sacalorjci:
    :1ii;irirx*il,rlfiriiih*iiH:k;rXifu
    'ililliil i"'-""
    :#,h."ri*:ir:
    {ir.-""i,l"i.scur'r
    pre'ratur
    DEGRASIM€
    NECESARUL
    1),i].].3.

    I rpir| lc rlin lapte se gisescin mod principal sub forrnir dc trigliccridr'


    l];; iill:Ti'"ffi,i l!,'#scutulli cIr:-oocRr
    l)l(:lnahffttl mic are mai multe dezavantaje in privinta I
    balantei calorice.. cI{ -oocRr
    f,ru:,lxi'y#;*:,li"r"'ff
    l;i;:iili:]_:rhi?*:,i",*";:,:"tx.ffi
    ji'i":,.?*f, ff
    ; cr-rs-oocR3
    illiil;" :",'"?:,:T.:J?::",':,1$ffi
    rrrrr (srrb lonni de lipide).
    #,liJ;l*"":*:r'*lif$'A:l Irr .l rrr,lrtlrr rtnui triglicerid Rr, &, \, rcprezintl. radicalii de irr;izi
    sau scuit qi- poi fi saturrii sau nesirlrrr:r1i'
    i, ' ,,, rr'r l, ,rr l:rrrr:lung,inediu
    tr l.tr'., 1'rt
    .'' i,l gra!'al trigliceriduluipoic {i cu Ian! lung, mcdin s:rrr
    ,,'r rr lrrr li,: dc "numirul ?e atomi di carbon ce formeazi lanful l''t
    ,,,,,,,,111;lt"l:':l,i:i,",f:l,"aT;:l"i;:';",'q*mif:i\*"r'"lfu:?:u,i:?::
    .o,iJui '., rt",l lr .. 'r'rrrrrli/[ari dublcieg5turiintrerlomii J-. c:rbon),silrl"ttr'\il
    l:l';,1,'$x'"r;:x,'::
    l:l ,l?:"*.1r J-illt,3"xl'f,"lr,",.Tl;T:lltJo-#or" " ',
    ,1, {' , .,.t rt,rnumir variabildc dublelegliuri intle atomll clc ciir'l)t)rr)
    nr''irLrl-firl)
    .,:!1"."a aoiviflii
    rizice r.
    a pr.rrnaruru,",ijlillT'.ttli]. l"lrrrrti' ((:r ldnt lung, saturJt)si aciduloleic (cu1anl lung "t,rl
    1.,l'].11
    i'( : ceea *f
    IrrearL'ce' lotalu dc lcizi grasi din lapLelcutttrrtrsi rl'
    ':''rrrrL suplimentar{' "," ','.' r, tt',,',lirtc:rnlifxrr-a
    '" i'"'Ti;*"irl,"rt';T#i"0".":1;1"
    1,,,,, gT:t
    1il3tt""#:::::'"T determ
    oneutrari
    ratc)ra1"n,#
    '
    1|'| ,,,',,rti.iculii lrL o rcrivilate lipazici. reiriiv scizul-i ti rrrrrtitrili
    ' , ,rl rrr nou- ni\ c uf ii lr. te rmc n .
    i,{llir,|tf I , r,, | . r,rri l,ilirrr',, in intnstin, ei pot-absorbi90"/orlin lipitlnlc I:r1'l'ltrt
    '| ,"",,, rrr'"r;rl (1i rrrtrnrri e lalfclui dc vaci irrA'r'rl.)'
    60-65% din t ipit.tcl
    r ,,,t, iiirr ,,riirrnilcaccslcidifiicnlc sint expuseil trbclul 2'2"7(Nl' l '
    2,8.1.2.
    NECESARU!
    DE PROTEINE i II\i r'I)

    Ncvoia di: proteine r:entru un su€ar normal ia primclr:6 :ti tLrl trt ' t'
    sipiirmirr
    1:.l]"{cc ::-1: q".-r..s*c/il
    .Q\o/o.din feniu cr"sre,";. un { ti n hl rl c l e ttrl ru,r fi l ul t{ !l o d(: v nc ri (N t l "
    ( l tr"ar' 1l
    .rr1'.rr. pumcste 180 ml/kg7zi lapte "r?.r"il"l*ii.
    de mami. are adguraie ac6steircvoi 1,',,,,,'fl r,l 'i i i rl ,t l i nl ' qi l r' l r!i tr l \' i dc k l t
    1'rr,l,ir,: (2 g/Jrg/zi). Acirii grlti A c i { l n1 p,r1,,,,1,,
    l;.li)-t(.J,:_ raci. continc 1\l )s orbl .i i r i l l to zi tr i i r:l ( l ,r ( r , r tr '
    -d_.c hji, dc ^de ,3 -ori -rnai multe protcirrc rtccit laptclr; l i l )i (l (tor .l i r t t0 tr r l r tlx( ti l r r l r r L
    Ir.rr,
    ll,l'l(t,11:1.,911119 1,2 mi). Alimcrraiiar 6iJ00 cU crrniitiili.iin,i, t,d l r r r i(lr )
    t i, lr t ( . r t ( . _ll]l
    v lc i i rl
    d u c r. l u rrrr rr1 r,r.L1 rro t,i r. (1, (,
    toti i hrL Ii i )i { l )
    rriuti lrrt sc irsociarzir. $/l i j r/zi . \,,.r. :r1,,rrl
    cu o crcslcr.,,,r r1,r.tiriti,r, ,,j ,,rr niv(iirli'i,r.,,r.jcut(,ucllr(,c
    , lll. , l, .l l l l , l : ' 1 r , y , : r r,,' r ,
    ; ,l j l 1 : : : ii1i. , ii l |lrl .liii t , r ' rir:..i,., .r, j,i ,s r t:, 't 2, j,i,.r .;rr;,,.r
    l lrrflirrnrirl(,). rlr
    r;:r r . ,r :r rr,,:
    |lj. ..,,.
    .10
    '.,' '' I,r ! , l t t | ') r,r :,,,.;r rr.
    1 ':',
    ) .|;
    'Lrh(l I ),23
    I.:rIlclr'"11x)11;,.r,tr(irr,,
    rrrr Iu-oc(tt mai marc de acjzi Arir\l l(.5:lllu.ati.
    r':r,rr.snrl.,ludr(,lrzirli Iriri rr;r,r dc lipa_zapancrcalici.Acidul 1r:rlrrrilic, nrolrrtl$r
    care ''rttile
    surltr'ril;l;:llff/;,Jr%.:#"trll.'.,t'""onu"
    ,nr. ,r$'r,un.k,r$. rrcrrlcrrlr
    , rr,. ctlllrlallv ccl"mirr i tl'ot.iatriaciclgras saiurat, esiemai-binc absorbit
    lu,(:t,acrd gras lrber, (-rlcgat.de glicr"rolin pozilir a 2_a ca monogliccrid.
    .ln laltelc uman 75% din acidul palmitic estein poziria2, in vrem"ece in
    de
    Iifl('lo.dc,vacd.,numai 401, din acidul_palmiceslc iu pozi\ia 2. Sc paro ci 30 t? 3{i
    24 26 z8
    .rt,sorblra, ]rpldelor estc perfurbali si )a premarur qi la dismarur(ceeace
    r'"I)rczrnta.o pterderecaloflci rmportanfila n.n, cu greutatemici. la naEtere). 311 345 350
    25 24
    Grlsimi]e din a.limeniaiiaprematuruld trebuic sb t"rnizcre 50i" di; ', , , r ( r r l 1 ) 24
    30
    ', , 1 i , ' ( ', , s ) 30 29
    lotalul caloriilor necesare. Caniitili mai mici de grisimi inclini baianta 145 l5l
    t40
    I'r'incipiilor a.limcnrarespre proteinc si hidrafi de caibon, avind drcpt coi_ , (r"() 80 84 E6

    t\a\e\a
    sccinfi hi perosmol ariratea; ,o. dietd mai hogati in lipide produce'cetozi. | ',!11,,,,,rr ( 'o g ) 3, E 3, 7 3, 7
    ' l, 9
    r'ourru acoperlrea eccsarutut dc acjzr gragi esentiali acidul Iinolejc tre_ N l i r t l | rl i r t {t r r g) 1, 9
    I r,| (r"() 89 t)
    t)'lrc si lurnizeze 3% din cantitatea totali de calorii (300 mg/100 , (us) 282 x'72
    [cal). "r,,r(l '11) x93'
    1. 7 2, 4 :t,.,,
    .HIDBATI '," 14,'l
    2.8.'I.4.NECESARUL DE DE CARBON ' il
    ,, ,l ',,1 (r1) i5 15.1
    I,r, (l i )

    ,
    I{idrocarbonafii- sint..prezenli in" lapte sub forma lactozei (7 g Ia 100
    ttll, ,,,".lipls
    ^

    t::l (i:'"""ils/i:3:,|o*
    ;';i
    d:
    .stc hr(rrorrzaliTrp5,
    Ialn de 4,8 g la l0o.ml de trplc de vac;). 'Lacroza
    de ractazi la nivel'l marginii in pcrie a inresti'uiui subtire
    lr
    :,::ll' l:;'l'I':#6d11-'/#il
    (90 mg/ml)
    .,,l ,,rr1i ir'r :rlt : ilr glt conic
    fr'T#
    ?iff
    ;i irlnsformaii in glucozi.si g.alaclozi,care sint apoi absorbiteprintr_un 1"
    nrfcirnrsm de transport activ. Un delicit relativ de lactazi intesiinaj;. in Administrareanl;
    .,) t,,,,t,,rut
    l)r'rrncl'-,
    -
    saptamrnl dc.yrate poate explica scauaelerelativ lichide ale nou_
    rits.lltutur nomal, alimeniat la sin.
    Intrucit sucraza intestinali e pr?ent6.de la nastere, suctoza (zah5.rul),
    i jill':iiil*#t*,s-";,,'*';Tli*i'"i
    "Tl:1Xt;':.'oJ:'T:.1i:ltl:i"'1,,:;;

    1r,rrl. fl xd1ug31ila lapielc de vaci de Ia inccnut.


    Caltitatia de hidiali de carbon necesari.ientru o buni dezvoltare a
    lrr_r'rn:rlulioi cstc de l1-16 gll<glzi.Lactoza,sucroza5i maltoza sint bine
    "' ''",:)i,'',i,'iiiii,'i:i't[tm""r'*'":..'#Jit]i:{l}
    lolcratc Jupe citeva zile dc viati. Glucozaest,.bine iolirat!. in alimentatia
    _
    pirrenterali.,, exceplie ficind, pentru cantitiiti mai mari, prematurul ni.ai
    ,:i:,i'.i',:l,,v:#t'iikr*illit::1,:+ltli"
    r,;:
    rnic de 1 000 s.

    2.8.1.5.
    SARURT gt OUGOETEMENIE
    MTNERAIE
    iiiiiii,:i,ii,,, *ru'*':*'t:
    i*i+:-*S:l*{$r iiiii
    irs*-rii
    Cantitilile de s5.ruri minerale necesares-au stabilit pe baza ratei de lt,rti r i , r ,l r : 2 0 0 0 $ '
    lc.umulare a acestor substanle la feli de dilerite virste gesAlionale (tabelul
    2.28\. vlrAMlNE
    2.8.1.6.
    Deoarcce 2/3 din totatul si.rurilor minemle continute de nou-n5scutul
    l:r [clmcn se acumu]eazein uitimui trimestru de sarcinf,, nou-rescutul pre-
    rnatur va avea o carenti imxortanli. a acestor substante.
    Nccesarul de sS.ruriminiralesint urm5toarele: Na+ :3 mEai ks/zi. K+ :
    ._. 2 nrEqTKg/zigi Ca++ : 2 mEqykgTzi.Avind in vedcreci raia "dcilrsorb-
    r;iri;ililr|;p,:i114[+$$ii tlf'li
    i,,,jiii,i,,"it'o""^'"i:till,i,Ji:'i".ll,t?l:i{iiil
    ,,,;;;i,;;,',
    ll('a acestor sdruri cste dc 50%, cantiialeadr. sodiu {urnizatddc Iaptele
    Irltcrn gi
    .de preparatele de lapte adaptat este insu{icienti. Tendin]a la
    -io1i lllll
    1"'''ii'rr
    .lupolatremle.a
    I ir d mlq/kg/z\.
    prcmatumlui poate fi prevcniti prin suplimentare.Na+ pinl lit,ilil:lri,ll;lillrii:,l,flii}i"t:;',il'*#l'.3J.'rf',:
    ,i;ii;ill.l*;Slil1lii,;illflil:ll"'"lfi;il"il
    i ,ll;1,,'ll .,,,
    Raia dc acumu]arcintrarrl.,rrirrir a Clr'r+. dc 150rnciJrc/zi.uu noatc
    fi a lirrsii.d c pr(malurul cuoKrrriiri,.rrrli rrricirrlc I .500gilibniiiliilr, alirucn- Iliinri
    i'
    I:liiii;lilli,ilIi'i;1iiii{
    liirii cu l.ptr; malc'n Iirr-irsrrDli:rrr,lriar..acr:si.i srrbsiairtc.O crrirlit.tc insu-
    Iir:ir.n1ir,<le Ca++ tlctcrmirrii si:rlion{rr('it<rut.bcipotrrlriralt,qi orirr rlrorozi'r. ',, ,it11,,t*i,,I*,",i*i'i*
    1t:tu
    "',1 lr:ll)
    iir'(l o l ,\1) llii f r r lr r iz . r r z i ir, rrrrrri l ^ t. s rl fi c i c n ti l d c vi t. ri - L:r l r r tl tr sl :r r l :r {l tr i i u tcn l t' Dr-il r,'IiLlI Iii-r'it.'lr' o'rilrilirtii
    l rr.rrr:rrrrri icar.r' , , l , r r t r , r , o r r I t I tl Ii Ii i 'Itl (l('
    prirncr.i<:.alirnrrttlrticprrl'rrllr.rrlll iot llir sc va administta, sirpttrinirlrI, | _2 rlg - va {i p u s l l r si i i 1 1 1L l I i ]) t( 'r vi l [
    , , , 1 , , ; , , ', , , . l t t ( ()! I I i I I I I ;i I (:, tr o u _ n i tscl i ttr l
    r.rrt. r'i l. li
    . , , r , . I r l i l , , 1 ) i i l l zl "r( 1 c n o zr p tc'

    2.8.2.ATIMENTATIA
    ENTERATA
    Molod:r :r1easi.in alimcntarea unui nou-nirscut este in functic dc vir:ta
    lrri ll, stalionalii si de starea lui clinici imediat dupi. nasterc. I)ac-i alimen-
    lrr{irrlrL sin este metoda de eleclie pentru alimentaiea noir-niscutului normo_
    lr,rri,lcnl ,si- a prematurilor mari, prematurii mici necesitir suplimentarea
    lrrrri.rrtcraliin pliinele 24*12 d,eore dupd nasterc, i.rr prematuriiiub I 000 g
    rlirrlrrrt;rticexclusiv parenterai.iin pr iinclc slpti]nini-,ie viati.

    2.8.2.r.AUMENTATTA
    tA stN

    ,,Co'i.lt 1)tr fi alijir.trtdt la sin. d.e cdtre


    de 2 ukd Lrttegi."
    CORdN

    .. Llqrtclc rnatern este alimentul natural a1 nou-niscutului, care si-a. dove_


    i tr trr)l ' rr
    ,lii r'ficir:nJa intr un num5.r infinit de cazuri, Alimentalia ia sil prezintir Fit 2 7.6. - l l as aj rl s l nd1l i
    nrlrlgetii acestLu:t
    rrlrrrilo:rT,ltavllttajr' , atit pentru slLgar.citsi pentru mami: (.ste{urnitar
    J,.ril ji rrsordc adminisjrat: cste usor digolli ,i binc asimilat;
    intretin,.
    ,' ll,,r.rirrtr.tinal:ifiziologici;crestcrezisrnnlaimunoloricri. a nou,niscuiului
    rrrrp.lriv.r infcciiilor rcspirrrorii si digcslivc; iucidenia crnccrului rrLamar in
    , l' ::r-.rz|lri, , l 'r,! rrr;trr|' r mamel ol l l hi
    prirrtrclcrrteiJccare au aJJp,aLla sin. ,, ,' l rrrrri l i l r' i i Inanrai e-
    ',
    (Il numi.r inadmisibil de mare de sugari sint privali cleaceste
    avantaie.
    \, r::,1I ucru sc datore.;tc, ia cea m.ai mare parte, faptului cl alimentaiia
    r.rlrr.Lli mr (si,. incurdinr-sulicienldc mcdiculpcdi;rtruinccnind t]in mater
    rril,rl".Srrcc,'sul alimenraticinaturaledepindcd,. urmii.torri'{actori:dorintir
    rrurrr.i (;i a tatilui) de a ilimenta sugarul"la.t"; - -;f;;;.;;:;
    .osoi
    riultii vigur:os;-* incurajarca aiimeniatiei naturale de "" ciTrc meciic.
    l)r'rizia de a aliinenla suga:ul la sin va {i luati. de ci.tre mama cu ccr
    1'rrlrrr2 Luni inainte dc nasiere. Cu ocazia consultatiilor prenatale se vor
    ,lr "\l)lrci){l^aiupraanrtomicisi liziolo<i,.igiaud,i mamar.c.,ise r..r cxlmirr,,
    rri.rrr'.lr),lul.lrr irnlri'jurjrjlc in car,.nam. lottul nu prnem:ni in lrLllr;tstimu_
    l,rr,r ulanuitle, ,,inarneloirornbilicai" ltrczent ia i73 din {ernu, se va reco_
    rrrirrrrlir.
    stinrulareaprotractiliti.tii acestuiade.dou['ori pe zi timp de citeva.
    rrrr.r'rrl".N,umai un mam;lon proerninent asigur5_o buniL apucarc a sa clc
    , ,trr cr. r P ll o .iu clJ'ir r . r ledur c f oa- ; " pent r . r i r nam i .
    l)co.rrre,' mrrlte ritxtrr(' prezinli de tmrlgerca sinului,
    "
    ir.r':rtcs (:urrl rrcc-staestc ,,aDgorjat" si_aver.siune.f.r!i. dureros, femeia va {i instruitl curn
    ',,r rr rn:r..,zr lrarnela, tiinp de clteva milute zilnic, cir J *2 luni
    inaintc clc
    rrrr;l ,rr, (l ig. 2. 7. ; i iig. 2 .8 ). ' ', \l ,r .rt l n rrl rrr l ' r' Lrrl ' u' |l | l )r(i -
    lrr mod fiziologic, siec-rcfja lactrLi:i'L L,', 1,l i 1.t1i r trri rrrrc Ll )rrrri ul
    , sc instaleazii i[tr-r: l2-a si rr. 4_rLzi
    ,lrl),r lr$tct:o. Nou*nlscutul alimcntrrt lrr sin aLr,:in nrotl nolut;rr, irslx{t d(, ui i l (' l l l l i ttl l ( (l L(ri l l tfi i l l l i i ;l r'
    'l orr rrl i r:r' tti ti ttz l tl i l tl ri i ti i r o tti l rtui l )l l l l Ll l
    , , rrrl .rrrr.1al ' , plinginr 1 p u i c rn i c q i Ir.r:v r.L rl f' { o rr-r ri rsr:rrtrl l l rrr,l rr i rrt i rrr,.
    ost. i ri l c l l l (l l l ( 1, l l l l l i ( \rl ' l
    , lirr1 rl rrl r i r t r r t ir r : r c ,s u l l h rn c i r:i rrrl rrti l n l . i l :(i r.i )l i i .rrr:r" sll ucl tr. A r:r,rrstri " ," ,r r 'r r r , r " { ir t lr r ir . r t 'l' "il ', lr 11r : r . : 'lli''] . '.',.L' , i i tr I rl l tr' , l rt :;r"t
    l
    ,'l ||,rr,l .l t r ' ' rl rl l \" rrl i rl l r"i . rl l t l l l ' rl l ' l trl l ' ' r' ' ' I ' rr
    'ir tr ri i l fi , , r lt l. t P t r r : r x : 1 " , rtrl rrri rti s l r' l rl rr
    ,l ri u r i tt s l rl ;r tl . rtal l .rr., l trr,ttr-i z,cl t,,t
    ,l ' r r ,r rr l i , i :.l i r|tr' 11' l l i rrl l i l l ("
    '

    t , .t(l ll,i I
    .. l)r'oglamrrl fix dc alirrLcuta[ie irnpus <le maternitate, nu est(. totdcauna
    lL::.,r"]l:l!,.
    z,.rz.r,
    t{'lii suga,r.i
    {liirninlesc niai repecteiar plinsui'puternic ii epui_
    . alunjr ndI a ora d " a l i rn e n ta fi r s o mn o l -e n fisi ,^r:l i psi
    ?t'"'"H:frt",1'i
    Y,:1trf;:
    ll'.,'ii1*:.L#11
    ll:'i,ll' il;:I,,11,,;lT.',.l ;Tilf1l
    :1,'l.ll j:*ll::tll
    :r iurpra.
    influenteazd..in mod ncgativ o mami prea anxioasdpcnrnr
    nccesar,atit din puncr de veder. Iiziologic (stomacul nou-
    db i nt" re5 pengp.l

    ,j:illli,rlll"i:Hf j:1'i",:t:":il
    l,,l,iii,,i*irllil"*:l'n";',3:l*.ii:';':fiHT.L
    triscutulur. -.usre
    so go)e;te dupi 3 ore), cit gi psihologicii Soaiimentez"
    niisculul.cit rnai precocegi cit mai frecvent.ln iniirzierea
    |nrr)trrJe_rnaturale rohd personaluJui medical este preponderent.
    nou_
    administrrrii ali_ I,r,',,i',ri'i *'JiG*,it",*':t.l"rr;..*'i".Hl'tl
    '"""'talcloilea
    =tn
    l.hnica alimenlalieinaluyale.Se vor da e_xplicirrii 'ffi:i"lf1i;l"lf i.',",#"'::i;;i&,t;3;l;li
    ..
    lrir rn care se line sugard in timpul aleptirii pentm . se odqinemaximum
    or. (:onlorr.sl
    in lesitrrrd cu Dozi_

    _retaxaredln partet mamei. Se atinge gura nou_niscutUluicu


    :ll),;ir,l,f
    ii;ffi :ff#'f"f *.:*;*#i*i:ru:**tl;
    ;r:l",,itf
    ln:rlltclonul,.taroflzind- apucarea acestuia prin peniar.a sinului
    cu doui. r,,.rrl,itrr la al 2-lea sin")'
    u(ri,'rc ril ruvetul areotel malnare, avind grijd ca nasul nou-niscutului
    sii
    riirninir, neacoperit.
    -Tra
    nou-ni.scutul ,,somnJros, gi necooperant, se storc in
    pici.turi deJapte. SuccesulalimcntatieiIa sin se obline in condi_
    ,,1,il,.,1l*l:l;:l#t"'illl',i:'il"ii"#:J1"11'?.T
    ,l] caLesugeprost secundar efectcl't'
    f,',','),_:il:yl "oo-Jtt"i"t
    !rl
    -rncntrncm
    carrrlele
    unui echilibru intre secretia[aptelrri gi drcnajul'acestuiadin
    galactofore. Acumularea laptelui la acest nivel, prin cregtereapro
    ,,,,:ii,,,,,r;ii:-.,,]i'"1i.i'p.taogi,l;.J",$:iff;,il1*i"'.
    ''.,,i",,.;',i;";;.i.;i;
    sirrnii in[ramamare, producc stazi venoasi
    r onsccrn!aaccstcl staze este.o. atrofie a_celrrlelor ;i li mfatici' in t racairalicul
    gJandularegi mioepite-
    are.
    ",i,'
    ,rJi;"::tt*ii'i;'#i#;*1,*i,.nt,*;:l
    'i'ill,l,',lllif ii;
    lilt1 ti : inhibare a mecanismul
    5r:rz:rr{vonzeazi
    ui hormonalae de"ian'gar.. , .".."1i.i l.ci"r".
    apantia unui proces inflamator 5i a inlectiei (masliti).
    itlltl';ill'i;llllilllii1l1i"?,i*ru*i,ii:l*""1;fli'fl;tl,
    i;"|i;llil
    .]'r:slc nlotlve,seva impiedica, prin toate rnijloacelc,
    ,,angorjar'ca,sinu_
    to"ii'iitot""iii"'
    o'or".
    ; ,'; illll''':i:i,,ls,ffitJt;g;r:;?;;;"r;';1;;;aoio,ii
    llir,
    lrr. n,\.slir va irebui si lie tot timpul.rnoale.Daci sirrul,t;tu;j,
    se tumc. timp.lpru''tr.r
    fi;rz;Lrru.s,. va intrerupe ali.ptarea, cl din contriL, a" ,o p..r.,."nou,ni.scutul sj. mamelom:rui.in
    "' "li;,,Ii,'ll1;;Tt*!$t'j?"::3"i:"-*e1u1
    :l li.r,.tnarlr'.c-vcnt.;io perioadd. mai lungd do timp (i5 minute Ia ficcare Acestdiscon{crttt
    ia sin. ln con(rrlrrrt'
    r r, ',1i"', iijil-X:11"^it::lent
    ,r,,r;r J-a dela na;tero).Daci. n.n. esrr,,,somnoros, sc va mulge sinul 'ii'.1i"
    :i1,.:1]l1
    liir[nill cu
    "sau qi.o
    r:1" U),.llclLrnti
    pompi mulgeloare m"carricd (pompa manuaii dc muls
    _producedurere si lcziuni la nivclul unui sin co[gnstionat).
    iiilil:lrii;iriiii",lh;;*i:::,t1"t:il1J.,i#?il:
    rl rr ,,r l l l
    nrlr, pc|loadelcdc aliptare glanda mamariLs,crcii. prin dializilun lapr'c t: sin"' nou-rrirs(rr
    l ,,r ||' , ,rrxtiliile unui sin neclrenat se produce 'l]Yft:
    scizurir de gresimi (2!/o).gicu o canritato snitzutatlc pror:eiir.. rll r, lrlrlrr(l r',,spirabine, nasul fiind pr-esat cle glanda trime{iatir'
    l'1. "..1-ll,-tnt"
    \c,:.. lirpfe umple canalelegi sinusurilegaLacfolorn,si rePrczinrlr,in mod frtrcvcniclor
    Ii;f;i:**:;";l:p;:
    ll lrirrrclrr zilc duDir externarea din maternitate' datoritir

    Ij,
    l/J dtn carrfrtatca torali supii de copil. prin
    ,r),,rrlrl.,.
    rrrr rr.ltlmptrl sucllunrl sc produce,pe cai proprioceptive,
    Jrllr)lrlcl-rrr zonaanlerioarisc declanseazi
    "rimularea
    mamelonu-
    o dub]iistimularc a
    sccrcliad^ prolactini, iar in zona
    r
    : : iil
    i,t iii*i*l,llu
    "?I-:ifi::r*'.r'"e,
    ^il;:ll::l'lll,lli,,+;3,'"#,",*"*::iii'i{-
    lrl''1:.ii?:llisccre{iadc,oxyrocind..
    l',,
    ,l"1.'-,1',
    l.lv9olctor
    J,:l"".rruoeprtellalc,
    Proiactinava srimulaproduceieadc )apt,.
    glandeimamarc,_iaroxyrocina, piin contrectir cnlu_ .}d1,**ffi{i
    i t':
    _rupind membran^lccelulclor secietoare,d.rcimin;, o
    .,, \lirozrc dc globulede grisime gi de prorein.in crnricle galacrolore.Accsr
    ,,rl)r,.(tL\,,cJccfle'a cirui sccre!ieesLcdeclansaLe prin mecaijsmncurohormo_
    ,, :Iiilll'i #l'"H"h1"ffi'f.9,?J"li"1
    :l;" lfilHi""i" r
    si'':r'l
    ,l:11,,1!:1,
    /{r;rsrmr)"i.1."
    sucfiu:rea rou-nd.scutu1ui,are b valb:rre calorici mare (4-7.go/u
    lr reprezintl 2/J din volumul total. Femeia cu o buni. dbclanirit-r
    l,,,rijllil;l; m';:-"14
    ll.ll,Ii ,,:
    rr.rlrl(.sfi-Lri,
    sccrefieilactate, prezinti_in momentrl ai.i.ptlrii un complcx cl,_.
    rrunrit de liter.rlura de limb,i ongIcziL,.drJllAl,r ,,cur,.ni.,. ,, l,lt;ll
    ;lllilliii',.:::ff$""lfi ;l,lil'iil
    1l'"',:*".:#?''li'*i;:i;,1,l^i
    "'".t-,1.:'iil"i:-:'$;::-ll'i"-"t'"
    Ac,:,,, rnrrlifcsi;fi si nt reprezcntafcdc o scnz"atie ;l; ,;,1;i;;i;'i,''ii;'iiili-".,s;^r.'i. ."";,lll'.i:
    al,clomiuale,
    coti"il"
    ,.j- i"ns nc sr dc..inte . i,llli',"'';,
    l),rrrr, lJ nivclul. sinilor,.i;_rr:
    I J)|l]l)r'lnrclorsipiirnini dc alaptar.c,
    in timprrl suc[iunii,in spccirl la lilirniprLrcirr
    ,,ri,lillilii,ll;lll .',
    llii'uh:l,,il'l-:::,-'*q:""llifii:li']:]il# ii ,i''
    u,,,
    iliiIi',,i[
    l.rptclcse scuric 5i clirrsirlrrlcor r.;r_
    l.rl,'l.rl..Urluol'l,ln ma pcrccp0ac('ir:iliis,.[zitic |1rrrn:ri airzin,lPlirrsrrlrrrg:r-
    r'urlr )t,rlL po.rtc l-cgill..rcusi-,,crrrcnt,,iu fnrrcfic tlr: inLr:rv;rlrrl
    ir(:,.,1 r dr-!''[('infornctll:.Act:rr$i.ii
    lrt ,,t:r'rl'r.",l,rv,rizr:;rzir
    corr:lareintr.r:rtrirrnii;i srr11irr.,
    rlrrpii.crir.c
    rrlirrioLrtiL!i,r
    iilnr
    i'lriiilr'fu
    rir*t ;i]iii:iifri;
    l:lr ri;
    Iiru;rr
    , .' ,. r, ,r rrr' , rrl rr r : 't r l'1llr r li( it i : - 1t ' r 'ir sl'r t l' J- I llt r r l
    <l r;r'r:r.r'|i.
    Irrr;IirIr'i
    r:rrvirlr,,rr,,,lri.ti,.i'r.,.r,ri(.'t;l
    $r
    ''
    , l: llt
    :t't."
    Anlilttolitrl.L, (tsftl nt,. .,t rrrt/ilrit;/umiyrictlcsc pot adnrili5trlr rramci ALIMENTAIIACU BIBERONUI
    2.8.2.2.
    crro i ;rpl.cazit{iu iL r,l,c1r' r lirrir:r' r,r,rlnificativc a.supia sucarului.
    An,ticor/ii an.li,Ilh.. ttrlL:trii prin laptelc rni.terl 'sini inactir.afi in
    inicst.inul_sugarului.ncliinrl ircccsall intrcruperca alimeltatjci nalurajc lr
    clzrrlilc rle izoiniunizarc.
    :liiilli:il;],'ilJ.l;ri#'{i,:;,il,t!:i!{Si*
    lll;ll
    li'i',i'",,i'1;T;:i',ii'i,1'*"j,xsi:'?j';'11$'ii$1""-
    , i,;,lt i ',,.rl,"itd- -r';i-
    9rh*; j1,*; :1HTJ",1 tl,ilili
    f,i,ift'1.,
    ,i""o"-"r**jJ:i:""J;i/;l]l;
    i ;ll;.::':,l,iii'Ji:l'[liii"3"'i$;"1;i"i'ii
    ;i ;i;'iri; l:,'?:1'[!il"{1"'
    i;i*:"'*'jiaL _i'J'ii:.,:i|Ji
    l',lil;l
    fi'Ja.'"rna
    lir,.. L:lll:l:*l'i';'::'*L':1""j;xj'.:',ltliiiill";'i1.i#tl
    """t"*'i
    i ,, i vol. l, pag. ?6 - 80 .
    "

    ?.8.2'3.AUMENTATIAPRIN GAVAJ

    ', \',,,,ri,ne1ia
    on"*,Tll#i,lJ;i,'li"i:fi.8 J:'Ij""{il''L';li;ll:
    ilri.*il;;;r,'il""i-u'" d"ceaie'ta""ltsrtgtr rritr'"
    ;i:,11,,;:";liiit:,1lillf ; ; ; . ; n) , . t t nt '1i. ii,
    ,.,, rrrr.r ,l ,1r . r , si-r espr
    L r at or e d": T; ; ; "'c. f alopaiie
    ot ''
    ' ., .' ,r" | l l ||ir l, , r |diopat i. ' congc'nr f 'lli
    l:;lit;ri;#f:"";"mtt*:;:l#ffi ji
    :::,llit*'li;1:!i::t
    lill
    I'',', 1rlliii*it :*t";t.::'i::*",'"":i:'i'':"'11*J
    , I : :ilt;,:
    tri,;,J ti;1":;i
    *irlh*,*:i:{a:'li:;,lj:},.'..?10"' sr v'r evit ir t Uslor ': r tr' t

    Fig. 2.9. glrctriurii la


    ;r: r,rlri,,;rur$r45f;;1.qffi
    l ' | ' .,r,

    ij*+**";Li*'
    de. gavaj t '" i; ""t "- '- t cu leucop) ast 5i
    ', ( ) t r ( 11r

    :'
    :lli
    pri'a"'r"'1".:l::'ttil:u1
    ffi .!;;,;'*i
    :II iI;'lll;lll,il
    I t:terwl,neonatal secundar pregnandiolului excretat prin laptele matern
    r.:;lccxccplional de rar, este benign gi cedeazeduDil 3-4 zile de la lntre-
    rrrpr:rt:aal5.ptd.rii.
    :rlirrrqntatianaturali-
    $farifia accstui tip de icter nir justificl renuntareala ;*tilln",,liil
    I' liii;,jlli,1;;liul'"iJi.i1's3ili:iii:illl rl '1 ";' Jt- tl r l ,':u
    r r f' 1 'I,.i ,t"' l l stl i c

    I ;l;I ;,i:l;ll,;r,Fl:,,',5;l"tllll'lll,:'lll,:;tlll'l::;
    '' ,
    Adcsea rnedicul este chestionat asupra efectelor anumitor droguri pri-
    rrrilr' ,1,:..rnarn;'r
    rrrv'',r'i.
    asupra lacrariei si asupia nou-niscutului. Rispun'sul estc X:l;illll'
    'li;ll;'
    "2 i 'l tr t)

    dificil .dc formulat (vezi dapitolul Farmacologie,punctu'l 2.iZ.Z.


    ri , l r . 'i , r ' r 't r .i tl i ,i r .
    la lnl rrl 2.117).
    . Co raindiculiil,e alin entaliei natwrale slnt: tuberculoza activl maternir,
    pirl.rLi
    oskizis-ul, t ratirme{rt anticanceros gi antitiroidian administrat mamei,
    'l:lll,;l ll-liiiiil
    lll,l'lil,l:Iil";:,;*ll'lilll: i::'rr':,i'
    irliLiii i i" r r r 'lur inir llr r lr r ( r l'r \ "1
    , , r,l .rr r , l r l' l r z t 'r r t l'. . it ilt '-t t t i; it t t ; i ", r it t
    l,\rlr"z:rD.rt(.rni LL:l:rc1,Lti.. (r,:rnpcrar)9i infeclia gravL materni. (temporar).
    r )rll l)li"i'
    l'rcrn_illunt,i.f,.iL 0.r rjpr,:lrul.L o Contraindica;iepentru alimenla!ia
    ttrrtr'rrlir.Mirrnirsr vrr mrrlgcpi',1 i' rn'rncntul in carc'sugarulrlcvirrcsuficicirl tl, ill 'i'll'':l:'ill1'ui',il,ll.l;'ll:,,'llll,l:':llr.1
    ,t,r ,rr,rr ,r r r ( l: r lt r 'lt r i 2 2( ) ) .
    tl c vr:l rlr , ) sl) , . t I n- llit I )l l r,:.rfi J rrrsL r .i rr. l i r(.C V r )l l l aC
    , t.gl i P rr.rrri rtrrrirni ci pol , , r r jt r li, , . lt r . lr ir . r . r , ,
    { r .rI i rrr' .rrt ,rI i rr,rr Lrl rrI rJrrP .r.-r,
    .
    rl ' i rrrrP r r r ir i Lr I t r l rl rr o Irrrl i ).
    P,.ri r,.rr
    l i Irrn g ;i rl r. g:rvaj (i rrr,rrridrrP .-rrru i [l r,rw ilr
    l;i,'':l:l;ii,'1,,i;ll,ll,1'1,;li'li;ll,'i';l,l'iilli ',' r "r 'trr'r.'
    ir t it r xit t r lr ( r lr lr ll t """t ' ', j, ; , 1
    ,,, t t t i i"f
    r t r ', t r t t t lLllt l'r t ' '
    ' " ,' i ,' ,' "t
    :t3,N
    it
    'l'abelul 2.29 Aliru()ntatia continud.,atit cca gastrici, cit 9i cea .duodeno-jcjunal lilts r
    '.Cohnic.r-coriplica[i de adrninistra.re' cit 5i
    Schern:rde allmenlatie lrin {lavtri ln lunctio dc .tre{falea la natl€le i"
    ',i,,,f,, "xccptie, nu pr&inte un avantaj evidcnt in cornl)r
    i f,,'"l-"...td ineroi'si.
    'r,;'
    crcutate t,,"r' ,o o," Cartitate/mase !. rr, ,:tr .tlirr)"nlatiaprin gavai intermitent'
    I
    in ml i':,,i'i' p.in"iirJJ ? p"t*^tur'lui foarte Inic alimeniat.prin ;rrv'ri
    gastrrii
    r' ,ih"tiar"t"' aintie neceiiti",tilemc'ri de..lichide 9i toleranJa- ptintcl r:
    ""
    4 -1 2 t-2 ap:r stcrilir + ,. 1 i,i.itii",j t"orizeazd" aspirilia pulmolari .ln aceite
    -condilli',in
    glucozl 5% ,',i,i',ri'ii a" alimentaiia enterali' se suplimenteazl sad este comPl(rl
    glucozh,5o/o "iote,
    rri.r'rtiliL cu aliirentalia parenterali'
    24* 48 3 -6 glucoza5% +1ln 1/2
    46-72 4 -8 glucoz5. 5% -l-1m 1i2
    > ' tz 5- 10 lm PREPARATE
    2.8.2.6. DETAPIE'FOTOS|TE IN ATIMEN1AIIA PREMATURUTUI
    I l'
    cur.nfi. penfru alimenlatiaPrematurilorse folo'c.5fc rl)l'
    lrr r,frtclic.r
    4 - t2 api sterili + Blu- nutritivc 5i comPonenfa clccll()llll(r
    in aflri cl^-substantele
    'ii'-i,rr*"ogrou,tti
    cozd5ok ",",r' 'i.,n', n". ;ttr1o'ri'.teccnlut,lor :irrl
    12-24 4- 6 glucoze5% +lm1/2 ,,t,, r..rt.r,:..iebosacin ." L*r. l '
    n 5i J \t[3r-rr;f:r'1'
    24 -4 E 6- 9 glucozi.5%+ lml /2 ' , ' ,,,,i ," ,f, Ei lim{ocite iriunocornpetent .3. t
    43 - '/2 a- t2 2-3 glucozd5% + lm i/2 ^?.i"f"S"
    ,,,' ,,.iivitrrt. facocitard.iniensd secreti lizozkn, e3, c4 si lactofirinir", frLt:l,t
    ;' pi":u""tii cnterocoliteiulclro-n crotir'" 1l')[TN)
    >72 2-3 1m 1/1 ',, , i,,, i",i"i"'iil"ui nou-niscutulimpotrlvil rrtr":lrrlt'l
    i ,'',r,,,ir,I,' ti secretiIgA &re protejeazf,
    4- t2 api. sterill -l- l'r'rrllt a-5i pestra acesteavantaje, ]apt-e1e..de. mami' trebuic rer:trllirl
    glicoz\,5ok
    ," ' din
    ,tl'i nj"t"ri"t plasticsleriLe-(celulcle )apre se lipc'c P" 1t,'t'
    glocoz; 5 % +
    i, ',',,,'i,
    , i,'i l,'i"L,,i iinediaL
    ,-l.'ttl"tit, administrat sau dupd cn I losf ("rlr"lirl
    + 1m 1/2 (r'r'r:'rl
    bactcriologici:
    24* 48 3,4 gtucoz5,5%+ l" ;', ,i;' ;;;,, ;&;f i;";;re:'vem rezultatul culturiloi
    lm 112 I rl, , l r r r l r r lr l r ') .
    4E*72 IJ_J) lmlrll lr rni lc scrvlcll, loloslnd lapte matern fiert' datoriti
    risctrlui t:r'es' rrl
    >'t2 20-45 3-4 lm 1/l necorespurtzi l'rtl
    .l rrl,! t,r. rr ilcestuia prin condilii locale de recoltar'' "
    ' r , r l l | r ,r :( s c a va n ta i e Se p tPr d .
    ,' , r . U
    r,,,lr,;;;;;" ;.,;;' ,, , ' iapielui m at er n conlinind un r r nor l t : |. '/ ''iI I |/
    'r 'B-
    . i, , lact oglobulin'*
    "- t *iii'" de lO o1o,cu cant it : Lli cr escut c do cr sll'r r r 'l
    1,,
    ' ; t,l l ,,ruri rr . ' I "J. t vr r r r ''i
    l.iil\'ti, pinl in momentul in care staza gastrice dep5lelte 25o/odin volumul : , ;;.,;; l*it at ""ini si lir ozini' r cpr ( zint ; L un
    '', , 1"t ; i; ; i; ar c Jef icicnle'er r ziLnat ic' in m t t l'r liz: t r ' r :"
    1ol;rl ll unei mese. Scopul este de a tiurge in 1-2 siptlmini la o cantitate ,,,' l ', , . 't "r , U"i"i. . ui.
    " ' ' '
    iolrrlr"rclc 120-150 mi/kg/zi sau la 100-120 callkglzi, I ., ,,rrrrrr; r . izi. ( lozvoliiLr r l
    r1,,r, , , , , obline o cur - bi cle cr e; t cr e.a, pr t 'm r t ur ului siLnilar ir
    ,' | ' |I r| ,| ' IrIr ' . ||I | . I ! c sir r "'cant i[ . 1i r nar i d. t r p'c r n r r er t r ' l5U - , 1 / ') r l/ ll'1 zi
    2.8.2.4.
    AUMENTAITA pRtNSONDANASOGASTRTCA
    CONTINUA '
    r 'lr r r l
    : r r ) I I nlilt l L'llll'L
    \l " rrl ,rl ,.r I 'r 't t t . r iur ilor var si sau pr ezin: i dist cnst
    ,,, t" ,' ,,, ,, r ', islol r : anlit ir . t i.Pent r u icest e m ot ivc sc pr cconizc; t 'zl-sr t lPlt
    ' r ) I {'r r lr r
    Acr'sf tip de alimentatiese {oloseEte1a prematurul mai mic de 1 000 g
    cirf('rrLl lolerczLzialirnentalia intermitcnra. Se folosegteo sonde Ch6 gi un , , ' ' l " r r' , r . li I ! r ot , r ci I I r pt clui m ar sr n'
    I ;' ; , ll, r ir i, , t . it , t r t 'cit or icisclolos"; cpr "pulr '. . iir lt 'r i r l' Lr r \ "r ' l
    tilrr (iorstantcic0,5- I mi/ori. administrat cu ajutorul unei pompe de perfu- acosLoLl) r "] ) r
    zi,'. I'rrbulaturapompeiseichimbila8-12 ole,iubul nasoga-strii , rr,r l tr,r , , , , , . t , ',iut . t c 81- 91 cll/ i00 11r l Pr in 'L'lt lr inisir 't |ca
    se schimbl 1r ) Lr L'lr l" vlll l' r , l
    ,,r' . ' .rr' r r r , r , . r r r lit : r t , - r clr li\ - Sc'izulr i J iif r ll- i " l, r ll
    lu l2 -2'l dt: orc iar laptele administrat se inlocuie5tecu o prizb.proaspiti lr ) r r r r r t
    , I ( r ll
    ili
    ,,r ., ,, rrrr r lir r i ; L linii: hiului, diar eea osr nol- icii; i r lisleusir r ". r i'
    lr li{x:irro3 -4 orc. Rcziduul ga;tric sc'controleazi1a liecare2-4 ore- l! lt iclr ) ll1r ll
    r ,rl .rl trr lr i|lLr t t t st t t olilr cst ii e uu f act r - r rlavor iz I 'nL lr l cul lr ilr ll
    , ,,'l ' )
    2.8.2.5.AUMENTAITA
    CONTTNUANASOJEJUNATA i tL i \l t"f (tn' :J i uttt-:h' tri ' i t l ti
    .\. 'i rr, l l i ttt' , tt' Lurt' ,! tt' t' i t
    l ) lllf r r ac r ) s t t il l rl L ra l i rn rrrrl :r(i r:rr.M o s c q tc tnr tnb si l i coni rl crr o l rru- 't r r , , , i t r r )
    ' t r i | i r:r:r' i , I , : l o t Itt'r |' r l i r L l 'r L r l r tr i r r t 1 'r ''r i r { i !r 'i L ( r r "
    11 "l ti .ttr :l l tti Jo t l 'l i r r .'"i
    , , . , t r l l ( r r l l l ,( ) l l i i l l ) so r l ) l l f i r r I1 1 r ''l i L l l i l r ' i 'r l 'r r "r r l i r
    li rrl r'()Hir lii r : r t r lis lir l l i r n ,l s .-i 1 r:n u rtc l rrrrrr-rrl
    ri . " rscrri
    nl fi i nt) a;r:z,al i tr tl ccnl l i l tr t I r l l L ' l l l r l 'r r l rrll
    l i rl l rrrl r lr ' ,P l lr c r t lr t t l frrv o l i z i r l l rrrr.l .rr s o n rL r:il )r' i l t pi l or i n rl rrrxl rrrr.I\tzi fi a , 1 , , , , ', r'1, , 1r ,zi i i tt r :;ttl l j l r tl t: r Ir 1 l ' r r r l /l l g l r r l r r l l r 'r :tl i r/
    r i L l o ti tr i r t.l ]l L IIIi ||IIIIIL III r 'r l t '
    sttrtrl r,is r ' ( : r ) nl11, lr . , r zrrrl l i ,i l o l l i r: L l l p ri rr p l l (r:rrr.r. rl rrl ol i l l i l rl l zrrrrl ci l ri l ci I l 'r r r l i ) r i . r ttIr |tttt|ttIi r tr I r l :i {l ' l r l l l i r r '
    ri rri (r"r'ir'l rr.'lI l' lr rr"'
    (r,l ( rl lilr r r r r t ( . r l( 5 ) ;;;. 1j,,;1,,;'ii;,i,-,,1,,ii i,r,'iz.i,t
    " lrrirt 1ir'i
    ',t,1 I
    2 3 ti
    c(]rr(:('rr"
    'luhteru'l'd sirri: gltrcozaill
    l)cntrn'dLinLt:)Italiu
    .\rl,trliil,,'.li osiLc
    l r ; r f i c t f t : l i - f 2 /o p a l n r n o a cl zu
    (lrr{iL-rlr: 4-5*50(/u,irr prc1r;rlrIlI,,,lriyrruite de lapte). ln morucntuJaparitiei rli""t"r"'"t?,:i:'T::*:,1".i,;1.,Tf
    .iii,,iri,,'ir''.i.0,i"^,,',"
    """
    .. !- .- ^ ^ - .:+:+i A^ ) ' 1 , ,r t.t!!,t./.1

    'rrrpilor Setoni4,in urinlL sc st.rrd,' caltitatea di grisimi c[ trigliceiide'or (lc


    sr)lrrlrrl(r
    s,,lrrliilt,l,' ;',;'ili
    an]r'oacrzr' il;"6;."ii'ui".'::::ili
    oYr",rt.'
    i tn l i r l o a ci zi :1:
    de ::';',:::1,,)'

    :,i;:lr,li"'.::i"i,i:f"
    lln! mcdiu (I{CToil) administrat. La unii prematiri preparatui este prost "" pi"'toiorit"u solutiilor
    r,irci ttivrri csf(rscizut la prer ,aminorrcizi
    rrrllrat, producind diarcc grisoasJ.
    , ,1). Suf Iimentareq cu kid.rati de carbon, PolimeriT
    .',( r'vilit
    ,-,iti (:ro;tcrcar
    ir :i"
    ,.r,'c1.r,..a1]1o
    l;;i:;"1'
    .1r1oru.emrer,
    :,*i'L'l'liq**if
    hiperaminoaciduria
    -i't'"*":::^"
    ' ,ii'i?j;liii ri
    aciaoza.:t ct9it:1"j1
    ,ll:t''-l
    rk: glucoz5. (Polycose) siut bine tolerali, creicind osrnolaritatea intestinall
    l?i"i"j.il.r t i'lTT:t
    i rl,ritr,i.. 1u tillrpul adminlstr;r :" ::*?::i'"l:i fi?:tJ,;i;,,iI
    f t j#:,,"littixit;;;:L,rf H:t'i#i:r;:?::' l.l
    "i:hl*',llr:il
    rtttrnai cu 500/o,in comparalie cu glucoza la o valoare ca1oric5,echivalent5..
    S. adaugi. I g de Polycose la 30 ml larrte matern. crescind astfel valoarea
    ,.rloricii 100 ml la 6t cat. In unele -cazuri dupl administrarea prepara- iililiit
    I i, r,,rr,.ii,, l',rr,,,ii.cirmanifestatS"

    lrrlrri apare diareea. ulei tl" s.'i,


    '"' ").ji'lrr.. tntrutilid (cutkr) co..t'in.e."l1T":J,:-je,
    C. S u b I,i m e n t d,r e a, cu b/oleine. Preparatele industriale
    *t,, Y6 ;rl : ;!iit ll);i
    r':'i"l
    rlr. proteine ie administreazS.prematuirilor care, cu toat; ci. prinr.esco ralie
    r':rlolicirmare, nu cresc.Cantitatea recomandat5.este de 1-1,jg/kgizi. Atunci
    , irrrl ,:rntitaica lotali de profcine estemai mare d" 3,5 g/kglzi, rilimul este
    IIll'iriiJ:l
    ii,r,.irr
    1*
    "iii'i"ir.
    i, vt:nclc'
    ;1[] ii' ".."i.]'iii'
    -r.i':*i::n*;"'i,f""11;'o?,XTi3"ii"
    rli,'a'i^io,ie ilillil
    lrilrurcal.oricgi cantitatea -de lichide este mici, pot apiibaiilburiri electro- Periferice, liri" si
    litir:r:insolitc de creqtereaureel sence. ,,, .rr.rl i | stc d, ' 0, 4- 4 g/ kg/ zr '
    l). Pret'arate sbeciale bentru, brematuri. Ia afarS compti.catiiteytlt(?:n;!*!{,r:!*:::i::1tr!,n{{{!!.!{lr;
    rkr lccstc supiimentiri a1e laptelui mltem, se foiosesc preparate riietetice uiti'it'r"o
    qrcciale pentiu prematuri, sub-di{erite denumiri industriali. Aces.e preparare l',lll'lll ".rli,l3#.:5 ii interrerare,cu
    plach'etare
    l'a"J,tl''iitt --
    rlc laptc au o valoare ca,iorici de 81 cal/100 rnl, proteinele slnt extrase din iclur"lt"n"tnl.'it"""t""Ji".*"uX1',,*1it'.:lu1"if
    r[irrLlf il:,ili;#;]
    l:rpl,.ll dc vec!.,iar raportul albuminl/cazeinl este ae 18/82. Aceste preparate
    .,sPccia)tr"sc dcosebescde preparatele ,,cu conlinut
    'caloric
    cresiutt prin i;,1:ll",,i;li'i':":'J'1"*lllili4r:#f,,jf
    flrt rlttl r:i.: nr:rzirIntralipid atun
    .rrl rrrtrtisi "tuv#ffi;t;;.y#rl7-Ji
    qff",'"ii'iiFilT#
    <^r)/ J.- - -
    !r,r/o u'r ..,.,-,. .*,-izate de grd.simi sint furnizate de trigliceride

    1;iii1i:,ii$fff;r:1iJ"ffi
    -l l- ^^ r^- ::i- .
    r:rr lrrul rncdirr.
    -- 50o/odin caloriile furnizate de hidrocarbonate provin din altl" sursl
    :, " 1xr'."
    rir)'
    rknit lactoza: fie sucrozi",{ie polimeri de glucoz5'
    Accstc prepamte se suplimenteazi cu cantitilile necesarede vitamine ili,iili;lil lli..*}l";L ;"l"ilYk/
    **;*"i'#ffi'n'',i#"1"u".1ry'
    si tlcctroliti.
    Sc c'xperimenteazi prcparate ,,specia.le"noi in care predominE-protei-
    It, ll din zer, la carc' sc adilioneazf, trigliceride cu lanl mediu, alte hidro-
    ill,illu*trr**:::Jl::;l::it:];'
    ,,,,,
    ', "il:":15:;.i:xfril"
    in acesteimprejurirri se inlretup.e admlnlstrarea'
    1t, rrl,rrr,rt;"r;
    r';rrl.rorrrtcdecit lacloza, vitamine si electroliti.
    ,r.'i Intralipid.ul"
    are"x*.il:ill: ::i,;'ll:l;Jlllli
    2.8.3.ATIMENTATIA
    PARENTERATA trr v, ,l,"tr'rnultipleleefectese
    2'30)'
    ;:il'iL:;,k?,xfi
    .',r,1.r!(' t('z(r'vl in folosireasa la nou-niscut (tabelll
    Administrarea pe cale intravenoasi. a lichidelor, si.rurilor mincrale
    r;i n vitaminelor necesare nutriliei nou-niscutului este obiigatorie 'l dbdrl ) tll
    itt listuJa traheoesofagiani, omfalocelul gigant, gastroschizis etc.
    do vkrl[
    La preinaturul cu greutatea sub 1 250 g, sau cu detresir.respiratorie" solronrnde I crluzio totalS ln primclc 7 zlle
    rrlirrrr:ntaliir parelterali. reprezinti. o metodS.suplimentar;. care se foloseste
    lrittir cind gai'ajul poate aiigura necesarul de caforii si o caatitate de tichide l /l i t(
    rrr:rj rurrrcdc 100 mli kg/zi. Iti(lrrti de carboo
    Aclministrarea alimentaliei parenterale se poate {ace pdn plasarea unui
    (irl(lor intr-o veni. (sau arteri) centmle, sau pe calea venclor periferice, (r5 rnl/kg .l()
    I ilL'r$ri l0r'1,
    (;lln,ozi I07. N ef l i f ti0
    1 ,5 - 2 $ ,1 It)o-. 115 4f lnr
    rolulitf ,!(j $l;ntcrltillnf N trl l i l
    100 rr)l
    J l l l r (i t l l t j f t l l l l . f i r S l L rc o z ' . |
    to'i,, Li{i lTll
    ,.1s/l(X) trtl

    : 1311

    :1JIJ
    'L'abchl 2.32

    il1**"*''':ri,ilx:i,,;tffif
    iliiil+qfl*i'$tfir''j'";r*?l;#
    d$tr#'if
    fid;'if
    Solu!le do Poltvllan)incpcniru flalmiDistrd,fn
    aceuucl
    lcrfilzie (dup:i U S Phat-

    liiryL'?;fr:?r"*t**;ri**iif',i:ffi Componettul
    Cantitatea /5 ml

    250 mg
    Tebelut 2,31 vi1. c 5000 tt. i.
    Sol[til de pertuaat (dripd Boston l-Iospital for lvonren) 500 u,i,
    25 mg
    !i l . l ]1 5m g
    \ i 1. l l , 7, 5 m g
    Componetrt Cantitate Ia 100 ml 1 r i - Il . 50 mg
    N i:rcillrnidl
    ',Solufia-5"
    2,5 u. i.
    | ).rrlroz:l rg 2A
    5g l og 'l'abcL1 2 'i'l
    5, x liu I mEq I mEq
    MiLgnc z i D 2 InDq (dx pi i C hi l l tc ' r s l l oc pj rnl N I' !i i ' ' tl C c r' r'
    0,25 mEq S ol u!i e rl nD derd de ol l gp.l { rnenl e '
    o, z.l titi,1 Uosrnn)
    Clor 0,6 mEq 1,2 mlq
    A . irl f o l i c 3, { mEq 3,8 mE q
    \ / it t m in a l l , " 50 Pc, JU lrg Cantitatea/ml
    ElemenfirI
    Sol'rlie dc iiicroelemenle 0,6 pg 0,6 pg
    Solutio dc mullivitaoine 0,2 tul 0,2 ml
    0,25 ml 0,25 nI 400 pg
    200 pg
    10t g
    59t g
    :l:,,,.,.,:lj:li?.i(e":,9'i:",',ii.'!i:,il:iiilliii;i:'fii.'',.;?,fI"Hj.,"ff#1. 200 pg
    ;l;,lt:;j'Ji.:i:itlii',flfiilx:
    f,lts;;lji3;i:i,t,Jfti,,?";"'rt','p,",a",?i mgislpt' pc loatir lrt:rr'
    q-jnisr
    ,,,,."{yil"f,,ji*",.iid:#t,,rari csr
    e,,"i,, *ri6o'"1,11
    ?;i3f- \ril. I{ se va administrai.m. in rlozi dc 0'5-1

    jf]i-ii",;,x':ili':':HY,'",i'S:.:
    ;ir;li[:::**it1?*,"j::"iiili
    t;rn tilaie t f;rlr
    ,,,'ii:l**$p:*i**li-$*"'Hi:u!i.{' it:r:,.,{$
    i:,':iriir';*:*:r4':li:;4.t$ffi;st$
    do c lc r ir olit i nt c e: ar l c s ir u,nie,orr"r,
    Na+ 21_3 mEq&e/zi
    r<+
    clor
    z rl.Es6lj,i
    z mlci'.gi,i 'i';,'t',';;il;qii$,1!_Til'1,,q:f"*lt?".lit
    ,,,',,i.i,ilitt"JT.llliit::"*:::"ttt'
    potri maimarila prenraturur
    subI 000s: j1rpj,"L{'::r;:;u:Jg6a#tyri
    iir;r
    11,,elf ;,1':r,;:E ;:,?"*tj
    rrrl Iiclrirl lrcrfuzat.
    ::,fiTiaxe?'jt'Jfi
    i::":i:S:i-:,a:,.H?/,H:
    "*l;,li1l#'li?
    ,,,,,,,f j'.Iil::.;s;iloJ/,#"*.g"#l:"":1lif ::rut'?ii"t#lfiiil':',f0,}1
    l,',],{iilil*?i';,,",afl
    i:Tf';,iililf
    Iiillill,li":l;;:n'""i,fi
    liI11 1tg*f
    ',l ,nij,,i:hk);
    *i :i "m,llff '""il'1li,,ll;lli'llltTiilrilllili';,lli:lrtt..:,:1",
    lirir
    ir
    ;itlliil ":
    l,l',l:iiil'li,:ifflii11i;:;:l;:;l,i'i;llilg,:l';,inlllF;i,#iill
    ii,',i, iiiirrrili'riil
    [$iiiri;,ffiiili,
    :1fliir;ii
    t.t0 241
    l dhcl ul 2.31 ' nl bLl 2l A (u' )l rnudtt )
    s(lonlit de )areDterali
    "limoutatio
    | )' l {rnr!i o l rttl o(ri rs rJ !
    Component Propoltia /\,,, l i )zi i rrx)t.rl nl i c r' !
    Lal/kg din
    total calorii I i]"'].i;lll]i"iiilii',"" deFoteine
    a.lminisiririilritlroli2ate10,
    ( ,,,rrL i z(r)s ol a ri , "ecunctare
    12, 5 50 t25
    i0 r0% 25,30 | )r' l r x:1i (i l l cP aUc ar
    4, 0 1'1 1A r), t',:i , .1:t do l c i z i grai i
    l , l i fi l (l c mi croel c tl ente
    tt I l tx:ti .i
    ( ., L,,li(lrr (cca nlai pcriculoasi)
    Tabelul 2.35 , |,li(rrrrric (se intrerupe pcrfuzia'rerei rcsPec{:Ye)
    llfoditorlznr&l Dou-ftisctrtuhrl alimellat Fnr€nteral ttl. (tt'nfli.tt!'ii l€latc dt ,:at!.lcr

    l L,'rnl xrz.tl(Le ve ni , c av :r s upe oati


    I rr li,l;(! pulmonarar
    r , rl : r!i ( l (xral :r.
    {;rculatca
    zilnic
    l-ungimca
    Circum{crir}a craniand
    sApteminal
    2.e. TULBURARI $l DEZVOLTARE
    DE CRE9TERE
    Glucoza
    11l.ctroliti
    zilnic 4 zile, apoi de 2 ori/siDu,rDini GESTATIONATE
    VIRSTEI
    2.9.1.STABILIREA
    ziln ic p r im e le 4 zi te, apoi 2 or;/si ptj rni i
    Ilrcea, amoniemia
    pfhrl ,':' \l rri rxit n: r liv lo. - lO a/ o din t ot i nou-niscut ii ciniilcsc lr t ir i l'r r lir r .'l'
    na51ct t "" ( it ': '
    Calciul Si {osIorul la 2 zile ln I-a septemind, apoi o (latnl
    snpt,
    ' ,,,' ; . i linL di'"num iii . , copii 'u gr eulaic nici la
    M agneziul
    I{enratocritul
    -' i ,,sti' ;;eS-
    ' ,' Ii rr:rrt' ; i; ; r, udovcdit af iniscu! jinaint edel^J'm cn( llla|r ll( . 'lI l''1/
    l( r 'slr r l
    l rarrsamiraza oxalacetici 'l ,rr,l .i r\i r ii) si avind gr eut at ea cor espunzit oar c vir st ''I gesLat lonillr ''
    slpte;lnaI cu un gr ad var iat dc lnaiur 'lr c. $l car c at l r ir ! r r
    Ililirubiremia sAptlminal ' t. tt.i i rr,l rr r i r iuu- n; sculii ( m iei
    "
    Proteine totalc , ' , ,,i ,' , i'', - r,"iccit cea cor esP;nzi t oar r ' t ir st 'i gcsla[ iot t alc lur r lr r t
    sAptS,mhal
    ' Urihd ,1.,r.' ,,,'" ,li.tntt..ti). Ca o dovaii a insuficicnlci clasificiirii, un not:rris(rrl
    Deusitatea Iie ca r e p r o b ; de uri ni t Lr pri ma si ,pr;mi n5.
    cpor , ,r, ( inliir(:$tc rnai mult de 2 500 g poate fi, totugi plcnlatur sau mlc lxrrrl.trl
    Glucoza
    ia lJ ore
    .r., ,',lrl^iion.1a. Pc scurt, se p;;te spunc cir intrebrr'inlarc:r unor atrurrrrl.
    fie ca r e p r o b l dc uri l r.j t i n pri ma <;p.i mi ne, ',
    la 6 orc
    rpoi , rt, rri rlnt:tl Ia urmd"toarele definitii:
    Volumul total
    Corpi cetonici ,r) l)rrcir. se foloseqte drept unic crTtcrit gretrlal.ea lanasterc nolt-t.riir-i'
    Jie ca r e p r o lr a de uri tr5 j rr prj m3 s;rpri mi nl
    apoi , ,,1,r , ,i' , ,'intiresc mai. puliri de 2 500 g la ua;tcrc sint dcnumif i "t:ol>i'i t tt'
    la U ore
    ' ,r, trl ,tt, ttti rr i la nagt er e".
    (rirrr
    .I'.ntr ttou-ndscLatulcele prituerte Int/alipid i ) I ),rc:r sc foloseste drept $Lic crite:!i.|-tl'ur&te gcst&liei' nou-triscul'1rl
    ,,, a" SZ sipt:tmini este denumit lnu-ll dscut firenatw'r (in<lilirrrrrt
    l,ipcmia zilic ,l
    ',,,r l,rLl.in
    Herlrograrnacu tromtrocite sE'pt;minat l ,rr!tl ;tl It).
    'l-ipidogrami! sApttrmtnal t ;, i,, r/iistii gestalionalir se inlelege intervalul scurs rlin prim'r zi rt tlli irrr.i
    atunci clrr(l ril
    1",,',.,,1, rnctrstru"alon;malc li pirii ii momentul nr;terii sau,
    , r' rrr r r r : : rrilallr concept ici, sc adau3i I r aceJslir l4 zt lc'
    ' | | | ,' ,
    'IatuluL 2.i6 | ,rilr rrrut.ufirft,. :;eiulr{cgc un arrumi.tgrrtd .lc d, zv<rltalc n notl-niscllI ltllli
    fttnrplicntiile Nlirilcntariol prrreutornl€ ,' .' rrl l rl rl i rr lt 'o sir r cinit .nor m alA, car - cii P'r illit {r r r l- 'r r t r irlr cla'pt ar tlr : r vilt {r r
    , I r ,rrri rrt i t t l'r.
    llho, $j hiporglicornie l rr l ttr t r : {iLtt lc vir s[ ; r gr r st t lioniLlitnou- l] ir scut r iit i'r it lt pllll iu lr r t r t iilor t t r : lr '
    l)ls (t c c l r o l i t o I l | i e , t l , l '( ) l r l :
    llipo- t i h i t ) ( x . c i r t ( x r n i c 'l'(r0ziltr ( 37 sitl)lirullrli)
    1k)'tttttirl ttl,lrtttrul'tt'r, c11 virsl il Acstlltiollrl]i!
    ll i | ){)t j ,I :r t . ,I i I i :
    ' lt)3 z'ilc
    '' ' ttttu ltirr( ttl ltt l'(rut(')x, ( lL virstil gcstrtliottltlii irlttrr ?(r0
    linlr' l/ .1 .1 ,:r i i 1 i,li r r r i r r i )
    2't2
    : l, l. t
    (marc f'tttlru'
    ,rr,rt-'odtutI ftt)sl,tilur, cu virsta gestalionali > 293 zile (> 42 sip- - cu gveututenlava.pell]ll1vlrsta gestalionalL
    lxoN[-ndsct,tt,
    1j,rrr.,irrl1. i,r/ri'J ;i cu Arcutate t97 peccntile)'
    I)acir se folosescrlou,i critcrii.asociate, dulata gestaliei -. acelagitimp'
    ttoslrye, 1i greutatea l,a dc tnlet"ge cl un prematur poate fi ti dismatur in
    sc ajungela ut.nt;it,r,roa clasificare:

    /,754

    {;g)
    /,2!n

    /,00(l

    |/5C

    .:tli&)

    3250 ERAAREIN AL
    V G,
    30D0 PRINSINGERARI
    A-
    PASTCANCEPI-l
    2750 MLE'
    tt5a0
    .,254
    2Aqi
    t75a)
    1!-tT)
    1250
    | ( itt:)

    ')':,0

    j[)
    '

    al, 25 26 27 ?3 n fi 3i 3? g 3/- 6 35 37 3A 39 e Lt. 1-21"34a 15 1,i


    S/:PT")NI IIi i DE AESTATIL
    iminle .j€ termen I tnrne, I i:ost ternen lrl
    | , .'. tl. - ticlalis (li tlc lnorbiclitatea neonatalt' vlrsta' gests'tionq,lx 9i Sreuiateo
    SAPTAI,IiI,iI!)E GESIATi\ (J uP r- Lul ' c benc o fi c ol ar' )'
    rral terc
    "l l0 - l t c r l a l i a d i n tr e n r o r la liia te a _ n co n llfn t_ r ,
    sr :rL.i estal ! LratL si A rctri atea ta na.$tcfe
    ( tu lr t l.,r t" .vir gestationaledifcriL0'
    Nou-ttirscufiicu aceeagigreutate, dar cu. virste
    L cu cu . )

    oi]sictticate, patologie peiinatall difcrit:tli'


    ,,,,.,',',t'ri",rii,'iii,i'i',rmrilic,Ltii
    ' ,otGntis tl t:tL qr.ttld.lt ltrt'tftturilourt zlzslcl gcstlL{ionilc {ir t [q) ]i,', ' r:i,,;'i",.il,it ti irrrlepirtti dif'lrit ltckrtin (lintrc mortirlilirl':;l
    . .
    ' ','',' t:sir'
    .orcl'tLefi cu vifslit,Acit'tlion;tlr-L'
    l rrrr:r' t r t iI lr . 1 6i ' ) / d rrp i Lrrrrr' l rrr I Ir:i i l i, i i r i , i n tl r 1,,' r,.,,r' r1i ,'l t) I'i,'ti ,ir",,i.'L"i'
    , 1i !)0, (I l)lt 'l',l; "",1 "it.-'irtrlrti
    i rl l ,'l i r)
    lt iu t it r hl tu t:tl tl ttl r /r/{ ,i l )(. l I]l V i r.r;i rr 13,II;I:rIi rIrIIrLi /l rr.r.
    ii:l;rlil,'i;r;j;llllil,'i,ll;i'ill';rl;rJ,'lj'ri;lliiil"
    i:',1,.ul, ,t,ii , l'r ttir;lr:t"'
    , i'l"ri"r v:rl"ril"r'gr'.'rrt:ilii
    ,r/rrl ,l,rli: , , r r lr lr r r )( 1; r .r,rrl ,rl ,, i 1 i rrr r,rrl i l rJ i,,.,i,., ''
    i"4li
    :t.t,l
    ffil vtRsrElGEsrAlloNA'E
    rEHNlcASrABlLl*ll
    2.9.1.1.
    Iii
    Y
    1.r,,
    .9 l: ia"i,BtT"t'Till
    dc anem-nezi'"
    &
    1)esireprezinti un elementimportant
    t!
    d iFs
    ,f;-.,r*irli"?'ll'il::1,t.*:lt":+:'**:i:;!3
    t-
    l.sv
    E j-
    Eq
    [i$kl*i::[ltti"'ml*,1#;',*"'l##J'i'"'l*:J"
    i9 :* l gE $
    E e lS Se
    $T"*,:::.ris*itf
    T$"'H,H:I;:'i,tr"lilxH*
    c) folosirea unui scor care
    coI
    a"^ott'*"il:::T:tn"*e seva line contdtr
    E
    iH t"5l.iu;;.
    $elit 'h""'lt a vlrsteigestalionale
    t
    ee
    **tt:-':i"-:tH":Tncordante rle urmirire a dcz-
    cu criteriilegP'!9lli:-11",
    'd
    EllleEeE diametruluibiparietal);
    : i!16.e Elt voitirii intrauterin" i-xo'"'"li'it*'""so;G-; traum atizarrtr )
    l ,c Q te.9
    l9 tr
    JiiJx":#i-'f*s#*:*"ru i"
    independent!' ti"*J
    :""""::a" nou-niscutului
    a; s5'nltate ":":e 9i str'st:
    .E - - ;'9
    lE c
    loE - .a fi"
    J:] bau:zePe criterii Precis"'
    Es= l9 e lB 8.
    Crr
    qe E t3I
    t.,*
    a MORFOI'OGICE
    DUPACRIIERIT
    6 l :5 APRECIEREA GESIATIONATE
    VIRSTEI
    2.9.1.2.
    I
    I tl ll-ic,ii; Aceste "t,'
    * b*:"i:1*3,{}11,'*1i";si:i,:lii*:iltT:JfJrosi',
    criterii prog
    l€ 'a:.'a E* E lE ' l l" - : i! ' rron-nlscutului se dezvolta
    E € = 5 E lF !-'. : l=
    ts lP (-ffi

    ;
    l:'
    .,,1n -:fr
    EEo
    ;tilg:
    lai;i1: { -1i-/
    t.F
    B;;ls;,
    lrEEl!; ANTEHELIX | ':{
    US \,Y}
    .- . l
    E ITRAGUS
    g
    ) dtr
    A I
    u.'i: E liY .3 E 5A T
    u ;J .9
    P
    ! lr t.* t,tr 2.12.- t. Dcz!'ollrarea cadilajrlui
    f,lf:j;13;
    l';"'i,lJ.:i'"'l:" ll
    u
    t
    arrricular
    tiJ!,1".*i.'J;t;jiil"
    tduo:l Harlncx'
    ",!.:."llllJi'H
    ***u" -n
    ]

    F
    ii a
    i =.
    lb
    br..-
    t6 lla o ni,,;".
    u"*"tt"
    ?
    'd s. r,i"i.,,'rii'o,,uLi*:,**,.iil1il1'
    b
    q! l qr !
    l" c
    |
    l.B !
    t
    u, lt *" iE l;c *'lto"'
    tr1 .- t' ;]l
    lr lfi g c.pi"r",'r(.''*'*"|1*"i.1i1|'
    J,11$-
    !i If' I ld q
    IF E 8,s,
    :
    .r,
    t:.i Fr i
    i." "
    t
    le"l [f]
    lfl l:1 ti q Jil
    .!.lJ 217
    il
    ln apnrcicr.crr vlr.sl.r:i gr:stalionale- dupd. caractere morjbiogice,
    .
    plrrnr virst,r-Ucst;tionate(shalor iitisl apropiit c)e
    :11":,lir.^"j'I_llll:
    Iclmcn, cste subaprcciat, Accst lucru se datorefte fapiuiui ce la aceastilcate_
    loDc de nou_-nescuti, cartilagiui urechii este moale, tesutuj mamar iinscste
    :r tcgumentele.sint subliri (prin Iipsa tesutului subcuianat); celelaltcs^mne
    D).)rrorogrce
    lndrci, ins5, o maturitate apropiatl de tcremejr,
    semne 4 5
    neuro - 0 I z 3

    2.9.I.3.APNECIEREA
    VIRSIEIGEsTATIONAI,E
    DE DEZVOITANE
    NEUROTOCICA
    DUPACRIIERII
    <d # ,H
    exla
    niinii P
    ct)tebnt n
    | 90"
    h'r
    lr
    | 60" h h ll,.
    ' l5o
    . Scoru.l neurologic-se rcalizeazi prin evaluare posturii, a unor misciri Corso.lle
    I'i'srvc-la.nivelul.artieuhlisi pumnului,i Ia nivelul articulatiei piciorr.,iui'ii a xlo
    corccTanlpozltrel dc tlexje a membrelorin urma cxtensieipasiirea acr,stora. --rJ
    900
    -4 ---a
    \rfllontalca acestorsemne,cu excepliaflex,Simlinii pc antebrat;i a
    1>iciorului o o
    1x' garnbi, 6azeaz5, .pe faptul ci'tonusul musculir crcste o riiti cu virsta t'(:ltact'io @
    {csrrlronara -sea nou-nascutului. In cvaluarca criteriilor ncurologicr nou- bftttelor ?rh !t-y
    rriscutul trcbuie s[ fie iini;tit gi ia stare de repaus. Din aceste 'tn" qi*:p,o ifuo
    rro-tile, eva-
    tu;rrca.neurologrca a nou-nf,scutului m se poate face imediat dup ir nargtere,
    relracti,J
    in pclioada de reactivitate crescut[. De ademenea,nou-nlscutul'cu
    hifoxie OG 06
    I:r uattere, cu leziuni cerebrale sau sub influenla drog.urilor anestezicc,admi_ EJo4&r <qo
    r)istrate mamei ln timpul travaliului, nu poate fi evaluat cu a.iutorul scorului
    ncurologig. Un alt dezavantaj aJ testului neurologic este acei; ci nrr
    apJicatnou-niscutul foarte tragrtizat, la care aceste manevre suplimelltare ar
    loate fi oa
    fie
    e 16e "b
    Ana: 6c:) 1,
    alla
    od
    -90'
    putca accentua hipoxia. t:tilcii
    Dubowitz a combinat 10 semne neurologicesimilare cu cele descrisede tr) & ob ^l.-
    Arrricl-'I'ison(1969) cu 11 oiterii rnorfologice-descrisede Farr (1966). Scorul
    olrlinut prin evaluarea celor 10 semhe neurologice se aduni cu cei'obtinut
    o
    I'rirl cvaluareacelor 11 criterii mor{ologice.(tabelul 2.37 gi fig. 2.13.) '
    Virsta Restationali in siptimlni -- 0,2 642 X (suma scorului r,ruro- &' (}'
    L, B"
    l,'l1ic-l- sr1ruascorului mor{ologic)+ 24,595
    Dac[ difercn]a dintre scorul mor{ologic qi cel neuroJogicustenrai mare de
    tl/rnoftx) w \a
    {, l)ulcte, cste recomandabilsi. se ia in considerafienumai elementelede rlez- vN w,
    r'oltarc norfologicl ;i sl sedublezc valoareaacestorala introducerea in lormull
    a
    Cu ajutorul s.corutrui.Dubowi.lz
    .rptoximaliede 2 siptiLmini.
    sc poate estima virsta gestalionalircn
    cf'fi af? r1-'r--t ar*( ,E

    l)iu necesitat€adea exprim;r virst gcsta{ionali imediat dupi riastero


    rrr 1rc:rtrua rcducc la tninimunr..rrrunipularcl nou-niscutului lrigitizai, sc r i t. ' .1.!I (l fi l c ri i rl c rf.,l ol l i c c (l c c v i l al c a s |r' rrrl Lri l )rrl ' otti r;l
    (l rrl i i " r\rrri c } ' l i r;otr)
    r,rr:irrgc lu practicirla scorurisirrrpliIit:;rlc,
    rrnclcdintrc elc bazlndu-so'nunii pc i rtrl i rt)l a1(\{ l o l )rrl n)\v i l rz
    (: r:r(:t( r'1
    lc dc dczvoltarc tllorfolo11icit.
    .\(:orul,I;ut.nrlrii cvalucaz.ii'r,lrslir gcstaliorralii nunrai rJul.rr'icril.crii
    ,torr-niiscut
    rrr.rl.irllicr:,irlrlilcluntdo[crrctivi{:tlt'lt ulrri sau tk: grl.litl ric nfcc-

    :t4ll : l t 1l
    '1'alnlul 2 3il

    I arc plin hipoxic al acestuia. Acost scollse poate]e{ectualimcdiat tlupir nrstcrc (l ri l ol l l ov{luaro vlastel $cstalloflalei soor l lfunstr0nl
    (talx:lelc"?.38 si 2.39)
    Li , , rrL (l i ni c
    citeva vasc rul|,fl
    It,l , i l ,,l ( ,0, tegr - numeloase vene lra,ti pe ab- se vial cu dili-
    tributa,te vrzr_
    ii venule vizibile domen cultate Pc o tr_
    clar mai ales Pe bile domen salr s' ll
    abdometl

    prezent comPl(rt
    r i frl ;rtr)l urechi i absent ln a[ti_ in hclir.
    tragus
    y= 0.2642X+24,595 toati, Pla(rtlL

    t)'ror!i l rrrl ori zon'

    {abia vizibil, bine delinit,


    :IirrnelomdRi
    :{i,ri areole areola p1at6,

    lLu ajung la ajunglavidul l


    {u1 degetelor degetelor

    fin, incilcit, Jirul gros ri8id,


    volollea, , " aspect linos erl aspect de
    --1 aSSrUlU/ tuvile
    i0 :0 n 40 n ffi 7A lubowits ' l ' ubtl rl 2 i \t
    tlri llinnlttrii r
    I it . 1 . 1 4 . - l ) i a g r a r n a le r ]ir u ca cr la ie a - r ir sie i g csia -1i ol ral e(u aj rl ctr.: :ft]rrl ui Il L.Li ,ni tr.l (hlcnlarct rlrstci gestalio nle duP':Icele ?I(rilerli als

    CUREIIE
    2.9.1,r. DE CRETERE
    tNrRAt'rERlNA 21 4-2
    191
    198 28j Z
    It 2()1' 1
    Peutru a diferenlia ,,nou-ni.scutul mic pentfll virsta gestalionalir" do 201
    301-L
    rriir,rcategorii rle nou-n5sculi cu greutate mice la nagtere se folosesccurl:elo l (l 2 \1
    217 -11
    ilc crr,'steri:intrauterini. (fig. 2.15.,{tg. 2.16.,fig. 2.1'7). ll 32
    224
    ,\cestecurbe de crestere.lcrrtruBtcutatc,lungime ;i perimetrul cranian 321-tl
    t:l 33 l6
    rr: inlocmcsc pe baza nrlsurilorilor- clcctnatc pe grupe mari de nou-nlscuti t4 237
    5 4 t5
    ;Lciilor virstiL gcstafionalirs-a putut stalili cu singuranJi pe baza datei ultimei 24:l
    25a 3 5- 1 .5
    I)in acestegrupc tkr rtrliTirr{irau lost excluginou-ndscu}iicart:
    rrrtrr::tr-rraJii. 256 :l(' 1"4
    tl J7 r -4
    .rrr plczrrtlt o pxtoloti(: r, irr li prrlut inlluen{a grosolal curba crcsterii IN 263
    :i8-1..:i
    i/r( r((lirlia, nttu*niscutultlin nrlmir clialrrrticii).
    irrlr';rrrlclirrr'(hidrcc.fuiirr, !69
    3 9 I:i
    21h
    I)upii curbclclui IJslrr:rr;i Nlc Lcli:t, so considL'r'itrolt uitscutul ( u {l0z- :llr : 4t) I ;l
    ,'I .i l I
    \'oltiuo rorosl)rrr)ziiioirrc 3 si 97 ltctc<'ntil,'trlupi-t
    vitrlr i lqlrlrrJirutrtlr'inlt.r: -l
    jrrltr' l0 r;j 110du 4 1 rl l
    : Lrr'lrr r;tlr till trotlttltltr
    ll lrrj l.trl,clr,ncrr, littl consitlt'tlrlrr
    p l rc c t t t iI r ' .
    !r i t
    l.llt{)
    / , . 1X )
    /,un 9)4,/"
    I
    -)B1a I
    '/59/.
    36C0 759/o I
    5A/.
    3404 54"/"
    324) 25','.
    3dn 25%
    2WA |09/,
    26AJ
    21"@
    2204
    2gla
    1W
    16{p 28
    71,9j 27
    i2a0 26
    TgJC I'i g. 2.17 . - C:lrbe 25
    8A) (Le crc9tere r nrra-
    6rc utedfle ?en1ru
    21.
    LA0 pedmetrr cra 23
    0 sciptqmini nian e)iprlmat 1! 22 L-r
    (duP6 or'6i"'itt'
    N RK \ R R 86$ E dE E h Eg S \ $ Q e Wblie l,erceltile
    l .r)l )chenco i l co- o V-:, za 'n 3' 29 -{)3i szp l r36 ln4 nLl l? E tb qP-':,t.lu
    l ; i g . 2.1,{. * CurLre de crcttere intraltelin;, pentrt greutale, eil nai;i l ab.)
    il] percentile (drli, Lrbchcnco Si colab.).

    lunqine 2.9.2.PREMATURITATEA

    ::,1:ili.ii,ii",o;.ilig%y""lil,",;
    '.,, deoc'ece'/" YlT"
    , ,.erisf!,citoart', illi.'j*
    i"'n"i
    Z-ot
    "t" T."i ll-"1:_.9: {i adin;rrrri,:i,
    I t. J!l;Xl',Lji,
    i i^,1lL * f ".:-.:*f ;u,,'',
    l#xi..,ii-,,
    mlI i*n;i*
    t"f'f*i'Hiilli:'i't"i"i' i'l;:: t 1'"'
    unui,nou-ni'cu
    a-1.
    II lllif: iHil "ii*
    !:iilirli.*t:,l il*{ ;'|.li4y
    r*;:l tJil'uulH:1 t* :rilil
    ;ihi;'T;f 1,".'i:;T'i.*l'{*m:"#1Ji''ilr'"
    ''l':t,Tf
    ""'"'U'r,rn'i!*:,y:{:KP#y:i:&xt"#i'fremato'ltes'lm
    - boii acute materne
    - diabet matern
    -' malformalii uterne
    1r'r :cutr
    _ i*illr'"$i:'lxiii intcrvar
    l Pl 'l
    - <a r c i n a m l l l l
    i'lcc!ici;rtnrri.iicrrr
    sccutrrl..rir
    sapkimint
    il:fi':f'lliliililluii '' t{:ll7'111"
    'n"-t"oncl:r
    ' oii"t
    \ Ktilrl hSqs\ tt
    I t ) ' . , ' .ttt. ( r 1 r lr ' ,1 , ,: , r r i rrI r': rI r1r,r i I Ii i pr:rrl rl tr rl yi rrrr.,
    ,,',,,':,t,,,,i,l,tlilii.ll::i*,ii'illlliil;lliil'i:'
    Nou-niscu,.,rr
    "oi'itu'tt)lrotlri.
    l i l v i rl l i l { l \l l i l l l l (i
    .,,l l Lpl l ttr
    ( t IL ,;1 i,. r r l,r ,,L ,l ( ir tr ,r l l\l x.rI.(, i i i |,tl t)). '1,
    ' l ti )l l

    ill,ll
    l r i l 'r 'r i ' i rt i t t. t t t t I t I t
    aJ A.[atolul res])r'htlt'r.(lrrrza rnajot-r care deteminii crr,;lt:rca tatei , , 1 , ! , t : , f , r r r r l L i o l r r tr : a p l r i {i :r
    -r tr i i sr r s. Sc va i l n |i cd i c;r esfe i .
    rrrorlalitiLlii la prcmatur'<rsi.c , l;l:,;,:,,i,,,,r'ii r6r-'"ri"rial 9i,-<1acir -nicr:srtr'. sc v'a.aplicir^':t
    inc;rpacitateapuln:onari a acestuiadc a secreta
    o <:rrrtitate suficientii dc sdrfactant. Consecintaeste Droducereasindromului "
    ""iiu asistat'a
    .i; ;,; ;1,'';dililic (C.l'A.P.; intubafie),in 199lul prevonlnroonr-
    rkr tl:tresii respiratorie idiopatici cauz5.principalS"de- deces. Incidenla SDR ' ,'ilii,,t."i".itJi*"1t
    ,]',, ventriculari)'Morlalitateaesteintrc 30--
    (sinrlrom cledetresi. respiratorie) la prematuri este de 10o/o(ceamai mare fiind Itl ,l "
    "-or'agia
    ,
    l;L prcrnaturii intre 1 000 * 1 500 g). La supravie{uitori, oxigenarea cere- g] Plevemreatnctrt-
    I l. l)romaturul de 30,-34 siptamini (1 250-2 000
    lrrrli insuficientir induce lntlrziere ln dezvoltarea neuroDsihomotorie ulte- respiratorii"prevcnirea hipl)
    I'r ,rr|r lrirtlinc,prevemreanrpoxiei, plotuzarea
    riorrri. Clizele de apnee ale prematurului se datoresc iriaturlrii ceatrului
    r(,st)lrirtor.
    jl;;li,l'"1il.*'ty"xll"*'"lruffiLTii,1t*i?:i:"3*
    ,:,lil
    b) Hemoragia intratentriculard qi subarahnoid,iandslnt adeseaasociate \1" ;{.,l i rr;t" tr,' s t c int r u l0 - 400; .
    , rr rlrisoade precedente de hipoxie (de exernplu crize de apnee). Hemoragia
    ttrit.rcr';rnianf,se gd.segtefrecient Ia- nou-nisiufii ce au deiedai cu SDR- gi til. l,rcrnaturutde 34-37 slptlmini (2000-2s00 rl;r$*:,;,Hl
    , r, ,,: , .rrii i" ,rr,reazirfavorabil, nefiind necesarS'internarea
    ;rlirctui cle apnee repetate. Semneleclinice slnt de qoc circulator cn semne
    rrcttrrlogice(convulsii, strabism, ochi ln apus de soare). Temperatura corpului, r',,l:,', j;;:i,:#"i:";*ilTJ'3iii"ill;
    rli.''i"i"'i.;"i.-i"r'"i"'r"-.i""*fl'j,lT
    pll-ul :unguin qi tensiuncaoxigenului artelial scad-
    in scopuloblineriiut
    rrr,rrl.rlici
    ,,, ,,,i,i,,i,iir-llirtalititeaesteintre 5 $i 10%'
    t) Cardiotasur,l,ar.Prematurul prezintl o tendinli la hipotensiune,
    lript,rol,.qlilgi sindrom de persistcnli a canalului artelial.
    ,.1)Digestiu. Inainte de 33 * 34 de siptimlni lipsqte reflexul de supt
    ,iI'il;,
    ,,'.lll'lj'I t,';'lllt,';:i;r''ir'X'l,i"ii"T"'1"iilffo:l":ll''.;
    ,' t,, t p": , nnlile chiar la vir sf a icolar t '
    i;i rlc rlegiutilie. Acest fenomen, impreuni cu capacitatea gastrici limitatl, ' ,,,i ' r' 1,
    oblig:i la alimentalia prin gavaj, coinpletati ln primele zile cu alimentalia
    pirrcr:trrraIi.. 9l CAUZEDE DECEStA PREMATUR
    pRoGNOSXIC
    2.9.2.2.
    ' 1 lmalurilalea fuuc{iilor hepalite prcdi,spttne la prodrrcereahipcrbili-
    rrrlrirr,.rrrici(princantirateredusideglucuronil-transferazi) gi Ia prcdispozifia l'r olirrosticulla nou-nf,scuiulprematur este proportional.T.51'l::i l]i
    rk: ;u:urnulare (cu efecte toxice) a unor drog:rri (clorarnfenicolul). Icterul
    nrr<rl:irrapare la nivele mai mici ale bilirubinemiei serice. Imaturitatea he- r ,i li.,ii'1,,i'lli ii"'i.-i;ip.ti't" liii inl'riorrr.l;r1i'l'
    1ou,'5tt"ut"tca
    p.rticrLst.rnai traduce prin hipoproteinemie (edeme) ;i hipoprotrombinemie ,,l rii,, ili'iiiill?iJ i;;#J ;;'s"'t"tie'ca1 Juratir)'
    1lcrrrtinlit ca hcmoragii). 1,, ,',,l,,g,uiil"t1cprematuri cu.cea. ntai q:1li1','-t"i.,.:1;,1il','-f
    ii
    "l ' multe
    m ul t e la
    ) a suPr"ttl",
    supraviutuitori
    avt l'runtrlttt ii;tl.ir
    I) .Irnaturitatea vemalddeterrnind dezechilibru. ln eliminarea ureei, clo- rl l {ll , i l l rl l rl l { ' lJ"
    ,. r 'r l ri;,;iii;;;;;;t.ik c c l I rrrdr
    -.i mortalitatc nionatala' Sint
    l1e (urr('n(rrIr'It( i
    lunlor si fosfafilor precum si inci.rcarea cu radicali acizi, ;,'.:;;"';iliitit
    g) Hipocalcewiagi lti.poglicemia(nivel sangirin al glucozeisub 20 mgo/o) , rrlrtrr r l r ' rrrori:rlitatc:
    |) I:Iifotennia determinati de dificultnli atlt itr producerca cit qi ln r...lltrairnarcr,idinPrirnele24dcoreprinirrsulicien{irc.Spi].;|i()lil''
    ((Jrsclvarca cildurii (suprafall corporalS.mare ln raport cu greutatea). rrrr vilf urai r:cclus in urmitoarelc 24 cle o::ein urma bolilor PtLltttrr
    i) I'redispozitia la infec[ii line ?tit de o imaturitate irnunologicl (acti- lr, rrr('lir.tiirv, rririculnri:
    ir.rfcclii'
    lilllL lxrctcriostatici ;i bactericidi a sr'ngelui;i activitate fagocilarl a leuco- ,,1 i.,,i1"" virf mai mic ;i mai tarcliv dat dc
    cii(,1{)rrcdusc, nivcl de IgG dimimrat cit 9i de prezen!;r-amrmitor handi- ',rr rle mulie.o'j nu exjsti
    t., ,,)i.rn(:nr nr:cloptic ll-ii"jl jnlallrriflllir.;l
    ,:Y]fl,]]]1,,111
    ( ? r "a r P- u 'F'I:' ',"i "" de
    r:;rlrrrli ncspecificc: dificultili in alimentalie cu tcndinlir la aspira{ie pr,lmo- ,, '
    | 'r " , 'r l ' ( l : r l , r L'l n :r tl l r i ) , tr a .t C c Su Acr ( 'a Zi I ."i"
    ir,''iillii'ii"i""1".;i;';"".il;;'i :'p:1i: il\orba'
    rrr','r, rrnnevriri ;i explor-iri multiple, cateteriz"iri si perluzii prelungite, apa i,,',,i,, ,1,ri,i,,r"gl.::"::]:,,T0"*,li'i
    jl.,",i.l,tf
    ,i:';','l1t'"",i:
    iHfi' ji:.''l:]il;l
    (lll,"r:::..i:ll::'
    intracriui:'ni
    ,lirr inL:ul,rior ttc. Dc;i in{cclia severi" ameninfi- piematurul (septicemie,
    ',';;,i ",
    ill'l''1" i,l',,'{i;'i,1"';iJ#i;'.;h");;"ioor"gr'
    -Siiit, congeritllt dlfcrazrrsarlArrrlrt'
    cong
    rrrr.rrirrgiila.)
    utilizarca profilacticl de rutini. a antibioticelor este netecoman- ,, ,',1
    rrliirr, ;i trrl{onna}ir
    infcctii si
    i,',i ),SI)l{, itrfcctii ural{orrualri
    rlrLbilir.Sr: indicir rnaro atenlie in depistarea foarte pr-ecocea unor sernne de 'rtr,,
    rttJcr'!ir'(vczi punctele 2.1,1.7.p",g. 36I).
    '/,9,:I.3. PREMATURIIATII
    PREVENIREA
    I)irl 1)r!nc1.t1c vcdelc practic si al mi.surilor de ingrijire care trrbuic
    l irl.(, rn)lr-nirsclrlii prcmatuli sc impart in urrn:rtoarele3 catcgorii. c{)trs{iiui('-('
    rl,' ltlltrttirt' rr'prtrnraturili!ii lli:'l:1:.il]::,1]:'
    ,,;i' ,l:'.,",,l:li; ir;i,:,ii
    \l,ir,rttiiL llli',1;;
    ;\ii,l'
    DE PREMAIURI
    2.9.2.i.CATEGORII
    ,. ]l' l 1 i, i l ,','i,,i ,"::l;:llli,l
    i .,i i ,i "1 '' i rrrlf'1,j,;liiii,'';i,,,;lll,,,i)
    ' ;Ai"*"'t'. ui'i:r
    .)l i ci ,c.*'i
    :"l ii li i":'l
    i 't:
    l .l i l :l ':i tl ;
    l. |)r'r'rrrllIrrlult]c 2fr l]0 rri'ilriiLtuiDi
    ', r,,'r,lirijrrsl)r'o() Iniri('nriiillr'r;rrtr'
    (E50- I2:i0 g). ,\t:cslrr nagtt'It :i: l' ll'lli;i' liiii'ri:i"i',r"".,,,urilir J::11'.':'.!il, :':ll'i':l:,il,il
    , 1 , ' i ' i " i i t r1i ii i r ^ l i r r i i . t i . r i t t t i i r t . i r l . t r l
    ,lispttrtr: tlc o scc!ic d,' lctrtllit' intcirsivji ,','t,i',iii,'i,t't,lj,,,li
    S, r,r jrrllrr,lri Itr,r,,,,,.l,,.rti''rt,, t"i,'r:ctt.,tjir,
    rr,rrrrrrirrlii. tltr
    lrrtlc rlr'lirtit'nft'lc ,' ,, i ; ] l ; , lt|ri
    i ' ll r'; :r r;l l t v r' l Il ,
    'r

    ]5 | : lir r )
    ttr ) tl Itr i I'' tt1 tt
    ,, tttt r o l tkcl vl v i Il r l tPi sl :r tL 'l l l ) fc( l o c{l i l 'l - 'o L i i l r r
    2,9.2.4. PROFIIACIIC
    TRATAMENIUI. At PREMATURITOR '1 r r , , , 1 , , r l r t ,

    venit c1ela obscn"r r !iilt : lt t i


    Este ncces:rri.o pcrfccti"rcolaborare cu obstetricianul pentru prevenirea l ' r,,1 . , rplt it ut ut lLlr - La r olr t lui oxigcnr 't 1uia
    lrilxrxici nconatale, a hemoragiilor, asigrrarea ci-ldurii necesarein timpul i;ll :,1;;':ll;l':
    r,'l'l:ll,,l l,l;'::l:ll llll,:,;l
    3';r.'il;'
    :ii:::1ulil:',
    I uLnsportului, pentru o manipulare minimS. a prematuralui gi anume numai
    pi .i ,::, r";;'i -i , -i 'i ' "Ipl i i
    dc cirtre un personal bine instruit. ' ' ' ' ,.',1:'-li'ti t : Ll[ . r i o it lnn"r ' r 'J'ocnlt:?:i
    'lr lcr .,1,',i
    l' 1, ":.';;i ;l ,i l r
    A. M en,pinerea cdl,d,uri i; aJ prematurul esteplasat in incu- . ,' ' . ., l , l , r ' t nt it
    otigeuului din aelul atmoslL'tli
    l)rtor (de unde este scosnumai cind este necesar)la o temperaturS"de 32,5-
    35,-5'C;DJ controlul repetat al temperaturii incubatorului qi a temperaturii
    prcmaturului (pin[ la stabilizarea ei la 36,7"C); c) controlul umiditi.fii (50-
    :, II:rilil.lt'n'i:"l"l*:n::"*#Ti::;'u'r{l*'l:""
    ' r L, sitil r'.'ilrtrsc1a co""Jntl'olia

    '.i;' i; rr,1nii"dit"iti cu graclul imaturitZLlii' tensrlurciL oxr"


    6s9i).
    :.;'1,:l,il
    ,'' ,;'
    ;r'r',, 3,;ilg:l'::ll ."1il11iJll, i,'
    :lill'
    li ,i ,, :l l.ii li, :'ll*i*,i:1,'",*:J {.,.re"sci,"
    B. l[enpinerea res!i/dliei: a) echipamentde reanimare ',i,";;;;;,',;ii" io u ,oirt,
    in sensanterior
    rLtlccvatin sala de travaliu gi seclia de nou-nascufi, incadrat cu personal bine i";ef"s:'
    e dcr tlct:rlrt t ' r'
    inslrlit care s[ gtie si-l foloseasci.;6) metode corecte de reanimare in caz de i l r ,' r:r'i:rinlin. Ap:rrc erlcm'retinian' care ste.tunat (lollll;ll'.'il
    ]inal,
    lripoxie (vezi punctul 2.4.3.1); c) oxigenoterapie,in caz de cianozE; d) obser- ' , i'''.]i' cin.l boala e ireversibiiil,. in stadiui.
    vorc;r a"tenti.a prematurului in primele zile, pentru depistarea SDR., crizelor : ;I ,1.,,,1l rLL ,,",,r,i."ii,,
    ' "" po,topo't.:iu1l,1,.::t:.1:t:::lll..;l:,,,',1]:l't
    r ''t Lr ^r L'. r ' .i" ( 11'
    asit r ( it {o1{r r r r lir lii
    (lc apnee, a cianozei, stridorului, convulsiilor. ,, | | | , i l t i {ri. Acr m t sc lioat e'?; i; ; iu c'chiul libclo
    C. Preueni.rea l rl ,. (i rr sPllcl': linui cr ist alin clar ) '
    infecli(lor: a) seclie separatS", cu spalii m icr oJt alnic' ciullt r i ir 't
    ttrr"i nrlri pcntru fiecare prematur; 6J personal separat de restul secliei de l . , r/rLi s, lt ', , 1c,l, oa1a est c bilat cr ali', cu
    ' i'
    rtou-uiLscuti;c) spilarea frecventi. a miinil or (inainte qi dup5. rnanipularea
    ' ;,,1';;,'iri, l'riii:, miJ 5i 'r.reg"1:'ti .,'!.p.icldrlr' . inlpollrrrrIii
    n t ' i ( r r l'
    L
    , , .r r r . r r:lr ' . , r , r c o n r i r. li n i r t ' i . v l - t r ' , . r i ' : ' . . i n c i ' . l ' 'r\
    ])f()uraturului); d) posibilitlfi de izolare in cadml secliei; e) dezinfeclia
    i nculntoarelor, chiuvetelor, sterilizarea incubatoareloq schirnbarea iiltn:lui, :' -' , , r ' . 't : r ; i P, , . . , iizi'c lbr r la, la 'r c^ili coPii'
    ' ttlltjlil:ttll'.1i',1]];l-
    l izolcteler, a instmmertarului, tubulaturii, controlul bacteriologic al eficien- lr,r , .i: lrr rri(:i un tratancnt eficicnt in fibroplazia lt l ) :r ( t'
    str i cti
    fci rLccstorm;rsud, sp:ilarea perelilor inciperii, sterilizarea rufi.riei. r , l',r r i r tr r i l tl ttl i ) fe vc1 - l tl v to t'n t:t l tt m o n i i o r i za r cl r tti' tt
    carcllrlrttt'
    D. Alitnentaiia carectd esteposibili numai cu ajutorul unui ' , ,, r,,, lriIr11, ittiircubator.sau;iii
    r ri ti'l irrilcubator sau7';i velt ilat
    ",i,lii",iir,,,,,
    , ,. .ar:tilicial)
    l)(irsonalcu experienli. Se vor evita obosea1aprematurului, precum ;i aspira- | | ,r ,, r ( )
    ( ) l) t or r ' ( m m l1g/ ' l.ei#!;i";ii"'iil i
    at lm inist r caziL la lol 1r r '
    fia (cu prilejul alimentaliei). Se accepti, in general, o alimentatie precoce, rr, , r, r,, t r it r ': r sir n ar nehoLar ca bolii: ea sc
    Iit 4-8 ore dc la na;tere, care ar sci.deahipoglicemia, hipcrbilinrbinemia qi not
    l ,t t t r r ,r ', , :o- . ; i8. e eLaPic'
    c1l bilir r r lr inir rrr rl I
    ciLtabolismul excesiv. | | | rl r l, i I i t u 1, i n c m i a r' I
    ', 20r t lr 0 r r . 's { u 1- . - r 'ir '')'l'
    l
    l'rematurii mai mari de 2 250 S care nu au dificuliili respiratorii se , l. ; ', , ' , 'i i, , ', nir ' lt 'i' d' ir 'lt : r t t t lllr ': r r
    I ici'lcl! a
    vor alimenta la sin. La cei md mici, se practicl gavaj cu sonda introdusir r' r rl , ,r.t r t r lt t t t r c", r n sr Lpr auiet uitt r I 'I I H ) - "'
    si : r or , lr ir r t ir r 'r '
    I,, r).r{(vczi punctul 2.8.). " rt r lr t it r r tt llllint sr , u"t " o"- '"iin- i"iL I i' slr lf am iit c
    ' r,

    2.9.2.5.
    COMP CA! tE PREMAIURtTATtt ,1 I i;;,;i,"i,i,j:,,,,l|,1,,ii,?,ii,"n'n"f,
    i:'':^?:
    #,::1,1&fur ilr'''
    .'lli;]'ili"' ;'i
    i, '. a t r j'r i {cc'r sr |''t t t r i" ir r 'lr r 'i ' l) r i r
    r r
    ' ' '', 't r r r '''1'l
    Ccle rnai inpor-tante cornplicafii ale prematuritilii sint: ' i : i: ''''i'i , - i" t " l1r 'cr ) '' r '1"'r , ' I i Pcv r r il - ir r r
    t oiiont t lr r i r r . Lr r liistr t l r r l l; r
    A. Sindramul d.e LJetrasd respiratori,e idia.Pdtic,i. r) ' ' Lr,lr r l lllr t lin singclr ' t ct t i"'l ''t it
    "lr l"!i !r.rr
    i'ttrrlrrrliamembraneihialine, \{lIH) (vezi punctul 2.1,1.1.1.J; , , r l,'-1,r,',,,',tii,,',1*,, tooit.-i""tt ( 1,? -^ ?t J.l:l;..,1,.::'
    'i , ' i l, (, rj(rr'L(lt -
    lt lalitri iri'pr-iitt'-it. siirt"tmini
    J rirl'i.:
    'lirt
    t rtttr''
    B. H e rn o r a g i a i;1t,t.r a.t a n;'"tr'i c u L a r d (v ezt punciul 2.11.13.1.) ; 'r'
    ,'li',,', ,;"iiilii
    ,l';",;'*i;,"r
    ;1,',',li ii,, o {"t:'!i'l,,il"'lll]1,'l'ii
    C. Iletinol:;at'ie ! | e m fl.t u r i t d.| 'i i (fibroplazia retroientalir) "uu-":'it"ttl1 "Lr o rcliLtl
    c:isLl.
    i,'i , ,lii',,r"ii,'ti'r,,iscilLtlc(;i in rnirdrLviL.
    r:slc o rctinopatie a prematurului cintlriud mai putin de 1200 g, care estc '," 1i1l' in liLrclrc z'i itt"ii' r'rl;'
    riiscrrtinrintc clc34 do sirpti.rniui<[rgcstafic. Abia in a 6-a decadi.a secolulni ',1,'
    ,,rlr,,r,'ir'lirr;i).lll' ,'ilcr arrti'\'st;tit'l';
    i'r,"",li"i,iii"i,,l",l,,,lt;,11,:li,
    llll;,t,:,;i;;,ii
    norilr'rrs-ir de:;copclitcir boala c sr:crrrrrluLi clcctelor toxice alc oxigenotelapici "1,,:t',1
    fil,j;]l'l,llil",,
    t r 1 r , \ i l l zi r ( tr 'r ;i l ( 'fi i l l l l ) l r )
    ll pllrrratrrlii cu rnrLladirmcrnlrnrlr:i lriiLliue.Ultelior s-au descrisli cazuri llr ( 'l r l r ( 'l r ( ) l ' l L r r i
    , , , . , , , ,,,,,, i r r l r l r r ( i L 'i l l cl i l o i l l o l r i tr l i l ) r ' l i tr g i i :r r :i L r l r 'tr 'l L .
    rrorr.niisctrli [irriLcxprrur:rcdr: o.ri'],rr snplirncnlar. ln prr:zcnt sc admitc cii, l l vl ) l l l tl l l tl r L l fi tl l [Jl l l l l '
    (irl,
    rist:ulr.str:crt:sr;li. o rlnLir. crt rlrrlrrlrrr.xPuut:r-ii lir oxigcu. lntii aPltrcspasmrtl 'r r t , Ir l i v, i l l i l r , 1 1 ,\i i ') , t'xi r :l L o t:tr r i {t'tl .
    l l l i r l l ( r tl l ) tl i l r tl i ''
    rrrlr.r,'lrrr rclirictrc,lpoi <lillLt:r{iir, lor'lru.rzitrr.iclr
    lor', cd.orn si ( :r l L , i l l i l l 'r l ': r '"r ttl i l i i ' r l ttr :r r
    5i lrr.'rrroragic,detl- I 'r r r l l L (r l i i l ,l l l i l l 'i i
    rlrrrl r rllittli rii itt slir'qil1rloIiIi'rrrr', rr lilrrovilsr:rrl;rriit:rr rr:luzil prlrilli lrrin{r-o
    ttr,r,.r,r| | ,irrirrrrIIii :;i 1,rlrrl, r,;r vr'rl(li,. I'r intrlr:rrr,ntttr: rrlll r lrr .l .l :riiPltirnirti.

    :lri{;
    accsLc iulPr l'jr uir i' r lczr '01l: r r |. r
    ,,,rrrL ,i ror , lr r l \ '( r l li ill( \ '1ill( lr Lt r lir " iir
    ,,,1i ,r,,1' ,' ' :, r r i, , t t , , , t . ', ' 1i it t llit . 't at iL' clist r o{ia se llum cst ( ', "'1'?r 1( i r iir r !
    llct r oPslhlc llllr L l) lllr '
    1t). 1t' tt l\ \ r r il\ - r 'il lln |r - ogt xr st iQr lc dt 'zyolt ar c

    '/.9.1J.l. coMPozlIlA CoRPULUIDISMAIURULUI


    or ianc i t . rcr r lst t l ct '''
    r' l , r) ir ,rfLi;vr r r ir t t icili gt at lr r l a{cct ir 'r iidi{': : r it clor
    rrr,lt
    " ,,,i ni s( r t llr r l lr i
    ,1, , , io, lit t ', it t t t t t "i r lar i ( in com par a{ie cLl. nou- : i 'l r ii"r ' l'
    t ot ''p't t t z" t o': : \ ir r l
    ' r i l ,t 1' | '1'I I
    r 'it '; : 'i r i' - ' 'i"tint
    uiu]
    'll
    't . t - dll5t
    r l\ 'r olr lr lr '

    Iliiiill;ll;llilll i;ilix,'sg'"',i;:5'::f];#;;:"
    ,, ' | ' 1,, 1, 1 , 'n: ' I
    ";li
    li'1
    i' .'"Tl)l' cinsum:l aprotlpc cx<1tr:iv
    , i ,litr lllrl Lrl .,', t n. tt'*- "i"i"t"f di'm:L1urrtlrti l )' I
    'r:riitii't 1ri1-'c''tslic':initi
    g'otii"i*
    2.e.2.0.
    CRtTERtt
    PENTRU l, , /,rrllai lrr'( vr'n!ir ;t
    EXTERNARE pli' ( lcPozit cl( ' si: it zr trl ' 'l'
    r .ri.i .rt lr r lir r r sf isi; ruco'at alt t st c scr iut i
    ' ri I ,l ,ri l i ( ; i r : it r r liilt r . , . nct och sof il{ ir r r t '
    ( r' ti rl l) ir l1'( r llllLt ( lt r llr r r zicr i'a cr c; t cr ii f ct alc; cu
    '. tuf.ri tloui pclioldc rL' rr.r l'
    ,' i,".l, ri,',' ,,i,,iii i'i':t tt:tr" n"l,'tt"ii'tui
    la 30 ciesir pliilinL l) r {r t r ir t r r l1) r r r '1
    l ,,i i l , i, it r - ; ir L20 siq; lim ini si de
    l . rr (ti r' ti l"ll it i: 111. ']. ]. , ', ( lt r : r ': 1' r '
    r '. ilncr : ibiliL ir r lxr r i. it lclt
    ,rvt'a
    iet'1.priarc rl,iri'
    r' r',,1 'ir i
    ,,i,liT,i"ji"t,i]',)t",;'"i.,;t..iii
    i'i,),ilil:il,',ll
    ,; rr,,.li | rL1lt lr lr : - Licillt u] t ualt , t t l. ozvolt r ir r
    st poatorPlo(luci"t;r;,l;!,,if;i:itg"l,t^1i,.,
    i,, .r ,lisrrrirlrrrilrLl(a ,,,,'1,,
    I r l " ri i r '1i'r Lr gici
    r 93 "t t it "t 't - it ] ll- it i" o f iLst : r scslat lo'i : t : r 1) ! {) r r l'r
    .r , rrt ttl r sr 'r llilorcLl nlalnlLt - l, I . : t a1iLir Lr
    vrRsTA
    s8ilhtfbigfrpFNTRu GEsrArroNAr^,
    ).e.3.2.ET|OtoclA DISMATURITATIi
    I. ' r lism aLr Llit iLliisillt ( t 'llJcilll
    1,' ri i r '(slx) r islr lr ilit lt 'pr - oilLr ct r r cir
    'l'l( ) i
    t1/.t1r1, lt 1: d. ) slar r r r , , Lt lt ici, ; . : 153, cnr ; l) sr Llllr r r t r i{il'. . . ) lt t lt t t r . t '. r"' r' ri
    ii,,,,,,_sii.r,."p..,i,_.ii,,.ry"liji.ti"lir!! r1) r-rLs ' tl l ' rri (to-tttl ri o' l rl l )rrLLl IS l l !l l (' 1r
    l ' ,, , r,LL l rtL,l ttl ' rl -l ; l i tl t:nri c );
    l \rl rl :rl : ) dro; ttl t.I' tr"t' '
    f.,'i l | t,.,l ;:,1, rr' r' l l ' rl
    .l!:;t.#-.f:t'T,,,*"?:i,jijl
    ',:';:,';;,',;i:i):,:{,;,,::i*::,::.::i;,"^,a,iri,iiihi,,
    lllil,lilili;ii t i ' -i ' ' 1i t rrh' l rnr' r1i rj 1' ) i rrl ri r l r' ; r) rrrtoLrt
    l rt

    ,:;i;:ll;;liil;1 j;i'";l::,
    :i,i"lf'
    1.;ll!,i,:,",;.i:,"i:::!ii .)':;",,u:';:;pcn,r'.,.;,: l l 'l ,tt t ]1 l l L]' t
    ' ' 1 ""f

    it"' ;ti
    ','
    :i",:,'
    .'""'. 'rj'ri'' '
    .i
    '
    r, l , 5i l ftl l tt;tl ottl tl tr
    i '"i',:,i ; ,"',:,,i ,'ut''tt"liior-o'rosor'alc (L.isotrric
    ti l :r ' '
    :'t:tt
    t)l
    ll.
    r1l1,,,iili'l,l
    "."'',';
    :::,:filiji;il ", ","ll"u]]"' '*"r"r '; 'r , '', '. u 'u ., i ,,,,1 '"t" ti ttt ( l ttl i t'l l l ;.'1 ; 'tr t l :

    j,tt:ri1r#ii[1i:;,{li:ili;,,1l:l:1ri"r}*i:[x,.*
    ( ( 'r r i {l r L cr '' 1 ' !l 'i l r '/
    , | ,) l ) l tl to l l tl r l i i r :o tr g ..tl i l 'L l t .t

    :,i,; f||rl orl k ,r' ttl 0l (,1' i r; l n Iro(l ortl o' r


    ( l i , / , , (, l u t )r] l )r' r' f s )
    rl i s nrnl trri l ;rl i i
    r t,ti t)

    l ' r (r c l rl '

    ""tlr; J,H*Tft
    ;llltii;!i1..,*..l*li:,;i*"lli,'.T1i,",# :i#i ,1,,,r1,'
    l (l
    t(l

    ir,,,r:
    : "; l ;:;;,1;jj';liiiiliiil
    r,if i;lfiillll',it,lilr
    ;r r,,,,,i,,r'i,,,,,,,.,,i,,.,,,,r,,1i
    ii:, il:;'j;;llmi:1i.,:j;
    ;;;'lilllllllll],i.;it;llili,.'J1i3,l]illiii,.,illil;;';,.i
    t'
    l',
    , !,r
    ,l
    ',,'11,,
    , rrr,rl,
    |1 L l|rtrirLrL,.rr
    L,l'r LLl
    r rrlt|
    L
    irtr'rlrjrltr
    "'rrl!llLrrr1 ,t )

    ,;:'i;':;:i;1
    "l;il;l:i;l"l,il,'i,:;,;tj,1;ii;1,;;ii'li:l;:ilr,,1il1l1 ,,, .,1i,',,rlr1r'r,r rl' r"
    r' t' ' ' t' r'
    'l"rrrrlrt' "rtrl'tli'rtl
    r|l L' r1' r' { rr' rl i r1;rrrz i rl i r'l rrl |Lrr r"i / )
    ,,,,:,1i,11,,,,,i: , ,"',. ,,,,,,,,'
    , l r,,rrrr l l l ri rr' ri
    '

    . ' lr ir
    l l ,,r t
    u1t"1tl' sinl Ilr'11i' 1'rirr
    N(nl-uirscu(ii ( lr 1'r.llirr( rl( i (lr.tcr:nt
    inttir gcncticsint ilcln,..i,pc irlrz:r l'.irttl ,::rlnltLitrsit sttlr!tt" irrr suttrdlc 1-:llll:'ll-f,
    presiunii rnl LiL(irr)r"rr{'
    ,.,,r;i m prin crc|tcrc:r
    r:rrlltr.lor-dc crcgtcLr: irrtIrrrII(
    rirriiilr rtrodartificial printre disnraturi.Ei nr rrt , ,, _i' ;:,1:",. utul
    ; ,,;i|.;rii^1"iut
    scrrurcclirfce de malrrrrilifirr i;i nici nl1 pun problcmc de patologie speci{ir:{ ()1r:tltt ilitrrlismaturisintlig"ro5i9iactivirlupi"'U**"$:ltlil;;?'f'l');;:
    rlist uaitrt'ititii. Aceasti. alilrnatic estc valabili., si in sensinvcrs, pentm rrcu-
    rri.scutii cu Srcutate mare detenninatl genetic, dar care prezint5. scmnr,
    ,I
    n,l":'Ui:ltuT$[tr*#$$:i:*'s:'
    III ;triil,'1, r ' ' r r r ,t .
    cl inicc de dismaturitate. , D i ' t - i : : ' r , ? c .d s r i u l r i m i r a r , . s o r r,ei " i ' i , i r , . l,', r i . , , , .
    ln general, proporlia de disn:raturi prin cauze intrinseci tmalfolxr,4ii r,tl,:l ;l',,'",I..';ii;
    ' , , 1 , i, , r, i. , I
    ;i'p:,i;;i; ;;;;*l.ipn.'
    lrr:ditare, infectii cronice intratterine) este foarte mici, din punci d.e vidcrc : il;;,;;;;
    .l ioLogicpredominind cauzele extrinseci.
    S-a demonstlat ci um;rtodi patm factori au o leg;"turir directii cu dis-
    ri.,,,,,,,.i,t,,,',,
    "1r,..'yl1:*i*1"$,.:.:i,iqqg:,i
    trrLluritatea:a) furra.tui(fi'ccvcntadismaturitiilii dr-Z I 3 ori mai rnare ticcii
    lrr rtr:Iurnirtoare); D) {emeia care a avLrt un copil disrnatur' (sugclitrd factoli
    i'lili:'iilri'1,,:ui.r:;iillu*i,',i:1-?"."i"J":i:ii:i:"
    . lips: r edcunlu
    1r rt,rl rtl i l or-lu
    l, uLlici). Nu oxisti. o legituri. eddentii intrc iniltimca piriulilor si plrrhr- problene:
    l)jstlrtttlnrl pune la nasterc urrnltoarele -
    r:,'tcir tlismaturitiilii; c) ferneia mai gracili" estc predispusi. si. nascir ul dis-
    r)rrtru-, acest lucru lefiind legat de factorii socioeconomici,dieti .au furir,rt;
    ,l) rliutrc infectiile clonice congenitale carc produc disnaturitare, nai ;1cs,
    jfuix
    x;"r1,
    ,l'';, jt,,.:l1i;$+*J1j r
    :;il1.
    i.j::l#:|
    , it ornc'galiar si rubeola.
    Ilolile'cronice materne, nivelul socioeconomicscizut si nalnutrit::r (il
    ,rlrLrLrnalnutritiei severedin ultimele luni de sarcini) lu au o relatie evi,-I.rii,i
    iis*T.",""'I1.,:::#i,",
    I liiiiii.ii:ii:lilii'};: e pitIi;to,r,an,i ilicttid ttli."-li:1"tn
    in rriLil.t :
    , rr rlismrLturitatea. I)e asemene:r,toxemiargravidici (in afara for':nc1orsrlLr " t\. lI t Dtor Lt.g,L 1ttnr I:rr'rl"' l''i'
    ,,:i). ltr,r:l.r''1'rt''irt tr''"i "1i'
    .1"1,r''<:l,rrrr1'.io;i ,'clampsi^) jox.i rrn rol prrrinimpo:rrnr. .",;n<,;.;l:",u,.j:;il1.,,!l,,ll,l?
    ".,,r;_1i
    ,,, i, i,,,.,,ri,.i",,r
    '. "'i""=i "'dtpto'p"
    Ntt cxisti. intotdeauna o concordant5.iltre leziunile placentare si tlis- l,. rr( ::rr.' r\ ur t' ' ^ -
    lrirli;r intrauti:rinir; adesca,infarct" mari placcntare nu p-roduco diit:olic i : i " rr" l :l l l r' tl nl -Ltl l i l l ' --
    ' ;-' ,i '., fi,,ri, J l:"hi i rtlni"'i' )'
    ' 't,t
    .,,r,r'rri,.,siiuvcrs. Placenta].Iuesteun factor frecvent asociat,pisrr-:ndu--. - rl(:
    olrir:r'i,o pr-opoftiefit/placentl normalS.de 6:1.
    'loxoplasrnoza, luesul
    ;i inlccliile bacteriene naterne produc na,<tcli il:i:l*'*iu::i
    ',l,i,:l;irlii i*J.;:#
    tt#i#4iffii ;',;
    il;ii;,,
    r'''.;
    L)r't'lrla1.urc.
    In ca.dmlsarcinii gemelare,mai a-1es dupd 34 de si.ptimini dy gesirti,.,
    lrorrti-'criista. o cauzii evidcnti. de clismaturitate: trans{uzia Jeto-t'etaliL-,\- ,, r,ri nr+i s+*'=:# ;lr'iiir;'
    i sce':1cro1;lilfcffitn*il
    iFi: rs$.t,.,
    ,:L'rrsii cauzir de clisnaturitatc este, insi, extretr de rar5. si se inso{egi-' tlc
    ,rr, nli,r Ur:alu.inuluidismarur (in contrast cu policitemia caie estetiricl).
    , ' ,,i',iip-',, -:*"ilijill: l,!"'''i,;',
    ll1:'
    ,iltli,,'ii"l,i
    .'\lt qrup dc dismaturitare cu etiologic evidenti. este cel intr'idt la lorr- t' \il,,ui,?,i,',i,ll#J1ltl!l'$.#;it*iii;t:li*,ll.::
    .,:,.,1,*:":ii;'i'i,'i."r"il'11.i,,ril.1.,'liJi.",f,
    t;
    rr;rsr:rrittlcu ar:ierirombilicali. rnici ({rccvcnlado 1lo din totalul raster-ii,lr).
    I l' iri'rrrrir,,i
    .u
    '.1':{,fin':eniaJi''i
    sc,i'.,.,t1..rr.::,J|,::i.:]l]],qiic.*ria,
    , 1,rirr
    31.'r.lar.i1ari, ,,;ri ,rl, I r
    2,9,3,3.
    ASPECTUI
    CIINIC A! DISMAIURUIUI liip,"ttrrtLr
    rliLtot'r;tt:
    il:ri i.\:,::':'!':';"'fip.:iicIa naqterc''isc
    ,,,,1,';','fi
    'r
    . 1' , . . , r l t r i tr ':r l r zi tr r l _ . Lrl
    I-r jnuiLtatc din cazurile de dismaturitate este evicientl o ,lir;rinuiL:L rc I) a '1 i - r r i l i Lsci r d cr i i !csr L tL L l u i :'ttl r tr tl i ttti r t
    sr
    'tt
    t . t t i i tr tl L r ttt'.i
    !r'r.rriluilol rnoi conconitenti cu sciLelerca
    rrri'l;i,ri1ulil':lltrl+:ffi
    li;,
    in greutatc. llismatur-iil ';tcIr.,g-il 't
    si cLr rslxrct cmaciat.
    Lt clism:rturii care rr pr-ezintira(;cst irspcct cn:aciat reduccLr.:alcsrtirlui
    r1 rrrss r r bc uiiLnlt e s tc to td c u u ra . 1 rrc ' z c n 1 i L .
    ,iiij:iiTtll ll,,:;
    lr,ii;
    lli,r[:r'
    'i,:,..,, cci.t.bral).
    l.i'J,;' t){,i,,,1 ii ,,vil,rl, ,.rLrr
    rLr\.i}( L rL,
    musr:nlar,i cstc scizlrli pc ol-r-iLji,tncmble si fese. In cazul ,lis-
    ',,i'"
    : il ] l: ;tl,l",il:'lll ",r.i,
    '11usl i l tr 't'|t si sr r 'fo l tl t' z'r l l l vi l ':i i l r r l ' 'l ( ) 'l ]
    ( r 'i r r l
    r rrrl r r r ili. f ii < lis itnro r-u i c i i: :l l rrtj rrltr.,l crrri rin L tL tl ,i n contrast cl r restLl l corl :i i 1ui , , , , r r r . , r 'r , tl , i l l .r r i i l l l ( l n l l l l i t 'l t
    I1 '
    i ;rt r ' ir r l t : r ' r ' 51c lcirr
    n l u n g i r:rr' 1 l r l ,l r.i rl (' c i l rL i r, :rspcctulcstcdc,,copi i dcti fi 11" , r ,'i r ttt l o tl tl l t't"i i t'l "l l a l Il l xo l i l o r i i 1 l !Ii |IIi IIIIIIi l i I r r l l ) l i
    l, lrl.rlrrirli), ' r r r r r i 'r l r l
    l
    | | 1 t ! / , t : nlc lt s ir r i s rrl rl i | i , rrs r:rrl ,, l i .;rrL ri i .t't:n rl ,' s< :nurtatr: i l l ]i rml ,,ttti
    l, ,r,rrl,r' ( r l r 'r l {:i ) (I i f I I I i rI I I I | | I r l " ( r f( 'Zi s( r 'l r l r ' l ' Ii II''I''tr IIi '
    l r, lr lr r t t lr ' . lit ) y / ! tL t)r)rl )i l i rd l tr,1
    . r' r.rrl rti r-r'i,rttl rrL' r:-rl rlctt tttr.r' oi ti u,l tvi tt,L o l t rrri rrrr; r l r'rr 1 r "l i r I I 'l r
    | , , r 'l lr i r l r l i r l l i r r to r i 'l i i i i l Ii Ir ''IIi i cI r IIi ' I' i i 'ti r r
    ,rrl rrt ; r f i| li; r ll) ( , nl ,t l ri i s i ,,, rr,rr,,t t,tp i rl " ()ol .sl tl L i i rl (.vi rl ,' rl ,' 1rr' Lrl ri l ' l r i l "l 'r r r r i ' riL lrrlril Ll
    l ttl 'r lt t , , r lt ' t I I,,I, ,ttt , t t t t / , l ' ,,rrrl (' ,rtr;Iri ci tttt,, l r,rtri l rl i r I,rrrrl rl rr). 'l r l I lrl l L r ':t" r r r r l r r .i ' '1 ,'r 'l l '1 't""'
    ' J,
    : L rl
    :l i t)
    lr r
    t t {it t I ) r ( ) llr ll}t i}1('itspr
    ,1, ( | l l ]rr)ti lt l) \ 'ilst : ullrllr ' Jt t '- '''1'r r '
    l' . . \ it t I t olt ""t elc sint subf - - d- ir
    c- l)i ot lr s(
    t lrl-lt1lit ir tlr
    t ' lllll
    'r t l
    u I tl , l t t l ,, rt' i s to z ttd le sdl tgu,i nci . { IIi < tt, r, rr( n, (rt ( l( s( r lr 1) r lllr onar r t "'""t i't i)
    h,urtlrnril sttulront).,'\((.s1 sir)(ll()ut sr: <iatoregtcpolicitemiei secutrclare'liipo_
    i'
    \l('r ( r()n1c( ri]il.iutlc1.1n(: si rrntri \'olun rclativ mai mar.e al hcnatiilor. -ln " "'i',,,,1u,,i1i,,
    trtactst,e
    'orlt{icr-ui'
    ;:J:.':lr","ij;:il1rt:;Til:i;i,,T,llii;lll'
    ' ;'l';IIillii i:1,('ll':lil#:i'illlm;
    ,rrrrrl i f iiic il c ar c h c n a l o c ri tu l a j u D 3 e 1 a 7 0 !d apar semne cl i ni cc cl e sufe-
    rjrl:r r)rar!{cstatc p1-in gcarn:11,tahicardic, iniu{iiicnle cardiaciL, crize cot_
    \ LtI s t \ ' 1 ,
    roRCH)
    t , . ) t , t lJ o t ttt.t tt i t o tt g e rti .ta l e . ll al fonnati i si rt mai fl eu,cnt Dlsi'tATURlIATtl
    2.?34 IRATAMENTUI'
    L l |ti l rLit r lii nor naL 5 c u tu lc u rl i s n ra tu ri ta te ,,a rrrtoni c:r,..' R i sculma.l l or-nati y
    :i ;r:cstli lrup,de copii crcscirrd pinai ta j0-20 dc ori i:omparratn, cr1 l]ou- r-1cstc tcctutrl:lt:t' iluu rfiscu{ui llll l'llrl(
    r" ' rr , r r l r r , ' rr nr l 1d, n ro n ri J \lttrtr:i t irltl clismat uritatt:'
    ' -rr.J i o 1 :a l i ri r.o n Rol l i l rl ..c;nti l n, j ( cu o Ir!c_
    . r.t. , l li' . no ] . r a. , Sti l c .. ,.R
    l! riJ o di.l ittiri
    O ri ,,l .d j -l l rn u :i ).
    l.t.i.r.tI c.t3i t c. in air,;ij tlc hil,oglicenic
    ll':.'*l::jl;lli::'lfiiif;:ii:li
    IIlIllt,rirlr;:i;lIll*j;,1t1'.
    ,.rl, ,.rri.'- !lismaludtaie.'rai ;i }ripo- rrri rrl r' .
    eslt ins,,!it:Lrlt ur m rLto.rrclc bi6logiie: sc prorhicr:ry"l- :1,).,i. i]]:ll]t:,,11:
    gra1.ii,
    r,,',tisn,ltuLitarca .'ij:lli,ll,
    , , ..,t:
    ili,heth.i,tr.rli;r,r. Ircii aspcclll clinic al nou-niscutului 'roili{i:iri
    sugcrcaziL o ,,, ( | l r n l r l v& r ccu u o a l tu i"
    ) 1 " l ! 1l;i,lli:li,l'ii,'lll.iii";u;L::"':,.:.;;;i, 't"'1.d111"1:
    ,- . l::.1.:ll:'i';:l',
    ,tcsl ,,.i 5 r l t "),il
    ,L 1 ,
    '1, lrrrJr.r.n,, rlrsntalL'.rllirlr'lt5e clractcrizariizirp1.in cxccs al apei tolaic a olqa- irLo f irsti g";|.tii:tt:11\l]i-5,,; ,.,,,\{tiirr
    ,, , ut.i,,lulr,inLinar-matctn :,'l'l
    rrr rrrlIj,;i irnume, i! spatiului cxL&lcclu]ar. Grarlul c1ehii.>crhr<lratarctste 't,,i, i,'il:,',llillln l':'li:l','"i' i:i.'"'.'i' Ruiut :,
    i l,!':i'l::I ':i",11;:
    'i'r'r' l,' '
    l,r(,l,orllimiti iio sclerliilicil nriilnutri;ii:i. Corrcomitcnt se proriLrcco iliruiluar,:
    I i';
    I I l;i,,1i:lJ:1,'ii.
    lrrln'rlrL.r'rrrrrj .:;:i";l
    !rL!'ruzar t, ii.l"li i. -a.',,i'.,r
    , r,rlrrrrrilui t-cluiar-. atit llc scama apr:i iltr:rlct_,1ular",iit
    ;i ,, substantcior
    "r'
    , , rrI rr , I i r : | , I , r | ; .fo n l {i
    1;;;i;i;t'r",., sr ''"'
    Il ,'.- 'l T l l l :J \ ' ar.ul-,ralir: "il1:,;;;.:i
    cr,riiL:nii,'li
    r,(,1 'rlr .
    1i\ ,,1tida.:d ;llrtri. I)at:ir djsnraturit.,tca nu este Joartc :tcccjrtLlate, ;;ii"'.-, .."
    i,i,,l,''';,,1",i;n;'., til,iJjur"""'1",': o'.'.i,i p.l:yl?*". : ....
    il:ll,"''ll"i:Jl,l,l 11,
    ., r'l,,z.r I,rr.z,rLt.-ri,rr--,li.tlJup:i na,strre esic colnpL.nsat:r,il pri'rcle 2,1 cie ;";ll,r''":'
    i1,,,'ii-ilii]';l ::].;ll,','
    ,i',i,,'llli'),i
    (rc'('rrtr'l'i'
    i; con'litic
    ,r t, .rt1 r l(/r.r rc..prritorrr (nu sc r':r arlninislrn, de mtinii bicar.borrat,
    _
    I l''lll,li'll''llll;'ll:''J;l::'l;ii.lfr;;.'i;'r"i
    , l ,' 11 trt
    r i, , , inl r , , l _\ s lru p ). 1 .1 :i s tc n ta a c i d o z ri l a 12 orc tl c l a uasterr:(i n cadi .ul {r tt:tt'i-ttttl'l'-..:1..-tl':rr'lttrirtr I'
    I | | | | 1r ,1
    rr,Jro r r Ltt L lr os t ar t ,j o tl f) e \rr 1 .!1s1c mn d .: p i o g r-rosti cuefal orabi l . I ,r lrr{i rrou irr'rscnfrtc'll.liisrtixt ruiiilt ur d ir r ilir r l''
    : . t Lt , r .f .L t ' , rl rvi r' ' lr r r ', t zr -101'i,r , ull/ lr g, i: Lr aa lur e- coLr i. 'le ''r lr ! . glit : r : t trli'
    60 t ir 'i S' r'rt
    l
    .1 . li, : t l !u l u t.a u a rti ef i .l cnti azi i rtr.o{ i a l i mu- r, ,r, r'rl, li rrorutalil"),." tttliipt't* tt'tt*eloL 'irnic'- ' *1i:p"glilr
    rr. ,r: t)rrli tl]ul i-.:sc,11.usriLttiat rlr\ Llrr I irr: toltt:tti'
    ;i hipcrtr-anspllrentiL pulmonarii cu I I , '," ii ll,,r.'l','pi"i-ii"ti tlin"irt:L1ii P'o
    , Yi'
    la2 or e dct r a t lir f i. r ( ' i
    l ,,,,r, , lit iil, : pcr sist culi: iacit lozei'pll'<i'25 r ic s<t t ii*'r . lLili" : 't t t t
    T&b.lu| 2.!1
    ,1 rr , r' , r lr t zi. i cu sor ulr t r t "'gii; ; ; ; ; i'i- r ii"i't 'ot t "
    ftl ir!ol,lelnelr p * d{r prrDrtrtlll. fi dis{u1u{* kLuf; llhrN) ,,,,r ,,, i ,' r Lr z. r 'r r L: 2r uliq/ kgi24 or c'
    s( 't - r t nclaL': r 'r 't llr r r l' I t 'r
    Ir t' 1iz( a iulbt r t ir t illr i r : 'r uologicc
    r r (
    j\ dm iuist r ir iL a lr r r licir llr r 'r r l t t 'l ir r r ll
    "1yl', 1] ]
    Fre a ir i I)isu13t r ,,l rrrrrr .l r. ' t t t r r r t iit t l,sol. l0iL, i glkg ir r '( 'n( lir r il'
    1"r ) "1': 'li't i. Li)
    ,,r' ' ,,'
    .rrt,| |rr,rt t lr ' ( t lir r zLpanr , "; i; . it lllir 11rit : - , : :r*''l"t
    llr : r '
    |l1, , i' . l' I 'ii'n' pr iL: ) "i'r \ ' ' r ^r r i( : "r 'r r l
    .'
    (,r, iliL! l i r l i rsi r.r-f t)fn i rr .Lce.asi
    , r L . L i t , r,l , 1 k)![rl a L illli''.li','.',ll:,.:,;tJ
    i"".''i,r': ,l:til',Tll1, t'i;ll,','*1].'i],ijl,;i,'l: )il I'
    : \ r r , , r |i r 1 , .'ti .u ta l r. 5- 11)
    'ti
    rccu?r:i-ar. ie]li:r-l
    sdrzul
    0 ti -59/o
    reclpcrare ri|pid.i-
    '-" t , lr r - l1r 'p'"t it t t ''; t i"f ii'i"'lc lt t t t i
    r r t
    . saLt lilt r - r
    t t it t lit r r lr rtl
    rr,rrr,l,1, l , zir r r r iicr ', 'lr ' r ttttt
    ll1embratlirhlalLl:r aspilatic mecoxiu
    , ,,.,l rrrl rr i, {I , , I I I I ) I I I I , '''t 't u- t 'i, 't it clizct lc' ; i' Llr ' }lilxr glr L
    t xLnt 'Lt lsit 'r
    t nor r ni ( '{5 i't r : r r r : rir I I
    Itr tr r , lt t lr t l r r t l o t r t par : ilr f c 3- asir - iciu
    lrlr,lji (,,,i ! r rL i l a h )
    l l , t , r l , i l r1 rl r r{i ru i r
    - + i-
    '..1
    .- .ili;l:,:[j",ill
    1,,:ti,t:lilli;;,,,i,,i;,1,:i,:'; ,i ,,;ll,li;
    ,'J:,1,".,:1,],illlill
    iilil] . 1: t t f

    , t l
    ll t , c ( l [i 1 lrrrrll tr'lrirlr'r r. ri
    ,,rI,IIj.ii ti 7q1 '',11"'i1']
    i'''iiiii '':'"t "
    '.i t'r{rr
    1 1 . , 1 1 ,r ' l rl i |o rl .tL j L i trl l
    , ' , r , , ur r r / 1r
    ' " , ,I"
    i- t,lirl,l;
    1,,;,i'llillil;l,illillil;ll;';
    "ittlisi
    i,'i:i"lill,;'i,l:,;ll;, li'ii':,ill'J" 'il'i" i"l
    l l ) , , f I A |, 1 (l i rrl .i
    l1 . l r ' I l r i i i .r'l i rti r'i
    i i rr r lr 'r
    l , r, ,r,
    t "'
    lt iLli, , '1u": i"f i' l. lLr 'ir r ill 11r 'r 1: r , ( iot r r r l: i: . ) 'l' 'l' 1'r 1i
    lr r r r l
    t r t 'I
    sr : r 'ir ill' lr \ it t ' ' lt ir r t lr r ! it r ll 'r ; 'r r or 'r r 't
    l , i ,,i
    l r . , ! r l l lr, |l l r'fi r,r f,l f( !i u| or i r f. i. ll I' l r i IL/ l 1l , l (l l) r lt , llllll \ t |ir 'r 't 1""1u, lf it
    Ii r |. I ' rl i r l "r"r
    r]1rrir(rrir: llll ill( t"'
    ' l rttl ti r i l t;1tr l l l l l l t l ' ()i l i L' :t V r
    I I r' , t r r ; r I r r t r t I r' i l l l ' ;i ' :' ' '
    , ,rr,,, 1,,r',,, ,l, lri(;rrlr,'rrrl
    I
    l/i ri ,1rLr ,il , trl,,,l'., l.rr,lir,i ,,, ,, , ,, , . ;, , , i , 1 , i ,, ,,,t,r,il|i
    ::L'.;

    ll, l
    ,,1 ,1 ,2' ] i, , 2 - 3 r r r i i i ;i z i . II,,,| | rr.rr|rr(.i
    ( | ,i n :rc c stci mpr.ej ri ri r-l s! \r:r ci rura o ,\ !,ct,liul I l, sc adaugirlir scnnele dir r st aCiil I ur r r ilt olr ( '] t it ) ur r r ( .
    r \' Il l l ,lli. t lI r llO Lt iI L ,i c t:0 tl g c rri l trl l irtr.u r.i d c n ti cl i ni c. t {t t r r l' lt t cl' it n|r , gn r t 't Ll m ! conir l
    Arrturia sccrrnclaricr.r'slcr.iir.rLpiclc se p{late prcveti prin aclm,,nistrarede rlncori asfirie lar na;tcrc
    l lijcLrLl--s,\..r lrltninisLr-ul1.r os in caltitatc de I rng FeE actit,/kg/24 ore- .\ l;r il i itl' I l I. I-.;tscmnclc indicate la stadiilc i ;i II se aciairgr'i:
    r, ,, rlir picitrfi/24 ore diu true.:r:oar.eleprcpai:ate: po1l,,\'ilSoi_Iron - l;olttl ombilical ;i uaghiile inpregnatc cu mec')lllu
    t I r r', -citt.5 J ; ,r - in- . - ol, F ' , .l o -: . r!, . 5 . LI ir i ; i . l"onr r al.
    '
    Ii'c ascmcnea sr p.oaluc dcmiaeraliziir: osoasc cu fractur.i spontane la
    r i r l :r r l. c 1 luuL 2.9.5.2.TRATAMENI
    ( )ourparativ cu ccilal1i nou-ni"lscl1ti, dismatlL,:ul
    nu prezillti-r c rat:j. c1.cs_
    , Lrr rlL,inleclii in pcdoad:r nconaiali.
    l)rtii,ti*L Slabilirca cu e;lactitatc a virstei gcstationale, pc l)lrzr ullirrr.'i
    I rr rLlaraasocicrii mirl{orrnafiiior- congruiL.ilc, 5au a idectici cronice intr.a ' r sl tttrLi i , i p|in |'lt : a'. r t , li; ii", pt t r ut n ; i m ; 'r : t l't r I r lor il. 'l ''lt i( r l ' 'r t
    J ritr,- rrrortalitatr;r pr-.rinatalii a dism:rtLrruhri o;te <l- 0,211, reoiczentinct ( 'l) ! l' r '
    ' ' rr.,r, :rn-. r ioscopi, ,r '"sr t r l : J 4: ': : o; i : . l'it t nit r nt oa 'iliinij. Pr ir l
    L , rlin totaiul nou-rdrscrtilor niscufi ru.rrli si tlecut de cle sirptiimirti ]]ou nii ' tr.
    -5',1 din dcielele r.reonatale. ' ' ,,rtirlu,'r, tlaci-r r'ir:sta Eestaliora]:i a 42 $i
    \ {)Lr-ltii.scLltul {tis1n:rtur ayinrl o tolerrnti .1igts1ir.i mai cresc11t!. decit a rrrl Pr.czintir semne de suferil]lil irlitra1',lerinir.trlonitorizarca fctalr-Lirr lirrrl,ttl
    I'r rrrrrlulLrlui,:1eacecai ijr:cutatc sc poate lrterla mai devr.cme dccit acrsta. r r.rr,rlinlui fstc Lrbligatorie.
    l. , loniciliu dismaturul teccsitir o supravcghcr.c spcciali. din p.rrtrrt autuh_ p::eveni. iih l lr tr'' t" r
    lbsttL.!lit.l. -{spira{ia rncco:ritrlui Cin trahee perrtr]l
    lrrl,ri, uroriitea sr-rbili.survenincl , inpriirrric o iLLni Jc \.iat;, inuit m?ri frccvent 'r
    l,r,,rLlrr,rncutttoni,:i dL: aspilatie. :llimcnta{ii: pl'ccoce, I'vtntull l'l \' 'tr
    ,l', it la no'.r.nlscutul rolmai. Sr plre ci tccasla se uoduce nrin tulburi.ri tle - ; i t r at : r ncnt ul sindlr or ut r luit l' lr il' r
    .l rr' rrzi l t)', , nr , r - et r ir eahio, , glicer rici
    r ' . , rr' . li:, r - . . s uf v j:. 1 .. i o rrJ L rt.u n .i .n ri r ;,l o z crorl i c^ pt.oJ.l j r l n p,.r.i oal a r r,,,rzi tl tc sal] guin5.
    rr .,l l ' r ' t , , . :, i, t i. t o" . !i :..' -ra { .rri z rrr:i .

    2.e.4.copri"t".il.
    MAREPENTRU
    lttRSTA
    GESTATTONALA 2.9.6,PROGNOSTICUL!'IOTJ.NASCUTUEUI
    CU MICA
    GREUTATE
    ,\r r';li rnu,a:1sc11iiau o greut:,rtc1a nast,:rl' irlstc 90 pertentiie pcntni
    \i r lr ) r e( s t at ionlt l :l . (ll stl1)rir\i.
    in ,:untt-c binc Cotate tehlic se noteazi crc;tcrtir ratoi
    .liiiololir,: ;r) trn:titi:tio;ra1, b) rrrarni riiabctici, (stadiLri,{-C), c) trans- l rl l l i ,L Ir lLnr alur ilor ior r l'r : nici ( < 1500 g) car c vat iazl azj ir t lt ': 5( i
    l)Lr.aliii ,niirilor vase, c1"1 critroblastoza {etalii, ti iransluzie intrauterinX. ,' ,,. Irr' cundif ii de ingr ijir c cur enii', insi, pr ezent ii in r cajor iir r lt : r t I r t r r l' t t
    "r
    r\ r'...rs1;"r {ic nou ni'rsc[ti pun 1:].tastere urrrli.toarele proillt: nle: l ' l ri ' r' < :r lr u dispun cli cclt r c s''r pr aspecializal c' r uor t aiilat ca : r c. r lot r . lr t L
    .ciltcgot:i.
    {r rirrrLlisrn obstqtrical la nivelul S\C sau ill- re /iior peri{edci, fiacturi. de ,.i , tu,t., , t <'. t r ca?f t din r at a r r or laiit dlii inf ant ilc esr ' dat ir dt : pt 't r t r t lr Lr r '
    ,1. r icrrlr'.,biporlicr:nric si policitcmie. , l,r.rr irr il1i:lr-' liui dczvoitarc).
    {loruLuiiiLgcnuri.:,1.'!: se la institui o alicrcltatic prec.Jce:eyentuai PEV
    , , r(.()zi l{l(l;, b0 lxilkglz{ ore (\'rzi CoriLrC niiscu.i din mami. diabetic.,i), grrqrr N l rrrr"l ' )
    [r S . I].A . 1rrA terdti l i l e s e ItD t31; di n a' r' t trLn' t J t l tr' r:rn.3
    , ,,'!t,i 1i (k ti \,c l 3 { c tre:ruur' i t.rl i .} :-c rrl j ,atL i Lnl rurc ri l ' i urn1' .r:-;l j i l r 11'rr' rL:i :rrrl \ ' l '
    l'rr . .i l i, . , c 1c i ag:r1i re l enrru n.,j c ri r' l tLa P ' ' nLrturjj 'l r) 1i Ll t tti ' t I | 1' ' r"
    ', t -l 1,,,t,, :rn i r,,:ti l ,i l i t:rl i
    rr.,ri ,r' i ,' J , 1(r.l r' Ln l r).,' ilr trurut) \Lr ' i ' r' :i ni \' l I ir
    ' rr"l
    'l
    2.9.5.FOSTI'IATURITATEA ','.',r' r.1' ' 1i r lJ r:l r' l n ' r' I -' : .' i l u: r' "1 rr' i t' r N l ' r' ' l l t"
    i ., r,,u rr. . j tr' na r"ri .' -J j :i .ru i m.' oi i .,:(rLIni ili rrr:r\l i :rl ,
    '
    \,,r1-rr.L"cLLlii !'r .,-irrL,L Sestaliotr.ild.inai rlare de 42 s;.pt:rmini sc co1]- , i .,', rI. i n.-.' r .".,1r.,1".. rn(r' rrc
    ' ' E (rr
    ' rr.J ts rj r r::i J .,l ' l "rl ) r\l ' r' r"
    rrl r.r p,rsrrr.truri. In tn.rjnrit,ltea cazurilof, eiioiogia este necnnoscrltl. Pos,L- ,,,1 ,.,1.rrrsrLtr' l rj ds i i ti r:tr-i i t.rdl i ti i ui c l rs i !e l a l r' i nl atuj j s ub l i o0 s
    or |ririrl|ii Poaic Ii r:auzi,-tirrie:rl}cncefalie sau se poate ir.sociacu trisomi.-t
    Ir. l)irr rrLrrr:1- r1r:r'cileL-..:
    clinic, iungimea si pcrjmltf.1i cranian nu sint modili- urtl r, lr 'lc it cur oJogicesi livelul dc int eligenliL a1 acesiot 'r r r lr ii r r l' I
    (ir , (lirr ri,.[ir:itnl pondr:ral este er-ident. Sc ii,:osobescde dismatnri prin l rr,l i .rl rl, '. 1) lwicsr li St iwalt '( l975) , iar la noi in {ar : "1dc pr of r lr " t i t ir r l lr r '
    LrI Lrl i:,i lriuiL 1a lir-strLde 42 dc sir.pti1miniaLi o e rolulic rormali irtr.rrt{! r :i l r,l rr Jlslict t azy. licr lll"n llt t t g- : r l) ; r lr lr "r
    i rr Iri, ' Lr I|tL; i iu gli- ..L i .l trs u rv c n i n c l tl i tp l " Ll L : rt i Lri -crv1l , Iti rlr si iat : t ili c, r ulr ilir t r , lu pr oinosLir ul p( '
    l ,ri i i ri i ; / , ) r r llr r r "iLcom pt it . r ! ii ior r pi'r inlLale ; i- nr r 'r r r lr lo; r 'J : t ivr lr r l 'l'
    2.9.5.1.CTASIFjCAREA
    POSTMAIURIIATI|
    (dupi Cli{fordl ,,,1,ri i i ri 1, I ir lr il. '; . i) gr adul( j. {oni- act r r llr nl. i/ r 'olr ililr llt . '! . ilc|r . 11( ) 11. 1|i|'( |lI i
    , t l ,,l l ,,,lii ( l{'r r r r '( lit l cr : oTr llr : t z. - dlt r pi ' '' 1r 'tt r 'r r '. 'r'lir t r 'if iit i
    ,\I, r L( ir t l, i:
    I lilt t t nr . r l{ r ' ir r c rr' fi i ,' , tl c l c rrttrt rl ,. 1 l .rL r-;Li { (i r t r r ir i I I r r '',cr r ii f or t t r ii r ll l'r r r - aljr , j''r : ' r ' lr t r r lii l: r t r lr t r - r t iisr 'r r {ir t lit ' '
    :
    l ,rl , lil r llr r l|r r ' , r , {t l t lilll|i'iir slr asli<r i lt r <ir l( , r l{lr. 'slt ir t vr t s r ''r t ' l'r l r
    s lil, llt , , lr ! , . r t tl rL l rt s i rl )ll rl i rr rt ' | ri rii
    .l tl ||l l l rl i l 'l |lr{ i rrrl l rl i i ,(|(\' |l t-l ' |||i { )l l l i l Zi i rl i i l ,t.r' rtl l r.i rrri l ;Il i .i l (..I(IL|||' i l (.1.Il
    I , ,r , r r I t l r ' r I I ( . j I . ,,lilli",
    , f,,,i ,11i , iii, 1 , r r ir r r r l, $i ir r , ir l, r r r ! r rr r r . r , r . it r . it r r lr li. r t t ii r t . t t 'ilt t 'l t . t trrirl . r;rl ,i l
    I l lill( l tl
    r r , 1 r i l ; 1 1 1 . q , r lr tir ir ,, r ' r '

    ' rl t
    .rl
    r . tr l l r
    , r 'r 'r ; r , l , l l rl i :.l r o l i l i ttl l r tl tl t ttttr t. { , r' r' t t I i r 1r' rt r ttr ',1 i , ;r tttr r ti fi r l u r r i i tt l r t i
    ill' )
    ir rl l i r!ir l. i r r r r i, r . L l rl r,r,L r l )' i )i { r.,.s (i i {i)r l tel api :r i ntensi vi r.(i n pr-r' zcnt i 1 t r Ir' ' ' i I rI rr rr r i rI i ( \'i l sl i r l ) l l r l l ' l i l . i r r r , \{r l ) Io ( l 1 l C r 'l ) i r \1 { l r ',1 i r g r 'n r , l r r r i l
    i ru i rl Il l l r r s Lr l, 4' ll, [ l{ r tl r, l { t i O,' 1 ,(u r 1 .1a n i i nai ute). $i i nci dcnta al tor t , , 1 , , ) ,{}l ) 0 j .t.
    lrrrrrrr.r lr . pr r t r r liz ir .r ' t l r.IrrIrI:i :r s c .i z rrl ( L rr:r.n i pl cg.itetrl
    :r, pl egi a).S e rcmarcri ,
    l('lu:ii, ilrll)1rr:iri rninoLLialc liux:{.ili ct:r:cbrale(,,rtr:imlemilarc" ,,stingicie").
    Itr'( unr)i!stcrea rolulLri loxjt:ii:'itii o{genuhri in ct.ologia {ibroplaziei
    r ,.1rolcl I ;11,, a dus la reduccrea accstui lerios iiandicap vizual (dc 1a 10* t0 7d la
    I l'li,). 1llcjd surditllii a sc:izut de la 109i la I - 7o/oin ultirnii 20 de ani.
    '., rlrilrrri , accst 'rnta
    fezultat imbunr'Lt:aliriitratamentului hiperbilirubinemiei.
    l)rrlcli prir:itoarc 1:r coeficirrntul <1c intcligenfi (QI) a acestor copii
    t u ,UA ,.t l\" ttE
    rr, lrrril int,.'rpri:tate cu trudontiL {Lln r"o1important arc QI nl pirinlilor ;i | | tt,ltiL..,N/\J:1,, , ". ir,
    '1r rlrrl rlt: stim trareiatelr:ctuali dirr iarnilic). Se consiCerir ciL si coeficientrrl
    thttt r.tN -.,- "ft_* sr t- ._,;-l
    'l, iricliqcuti'r nediu al coniiloi c:.rlr',.utetc miciL la nas,tclc s-a ameliorat iB \_/ A, .. s,:64
    -,tNG[tR
    tl A::,1'OC|r t'iiJDlUFl'l'f Dt
    ' rl l i rrri i 15 : r r . r i. o
    '/a /' L 9 zile Gi:AMAN
    3EL1!.!t SiAMEZi

    2.x0. SARCtntA
    MIJITIPLA

    ,r,r:;1
    '
    Irrcirl,,rr{lsarcinilor-multiplc cste uiitri,.toarea:sarcinir gcmelari 1: 90
    ti,srLlr inri cn it'ip1efitr: 90 :l 00 iar s:rrcirlacu qadruplcli 1 : 90 X q0 ><90
    ( lcirr, rrii iroi rezLrltar,trintr-o
    singu{ ot-irlalie{iind tnonariEt!i(,,identici"}
    ,livizirrrct onlui producitdu-sein primele dori siiptiimini. Frecl'cnta gcm.-
    "o-;*)
    rrilll rnottrrzigoti t.'
    estcdc i:200 nasteri. -
    :1,-...-
    +f )-ts.^r"t
    (;crn{llrii l}ot rczulta dintr-o ovulatie dubli, liincl d,itigali (,,{ra!i"), frec- ^l\---l .:5ti'7.1
    vrrriir lol rlcpit.tzind de ereditate(transmisicafltosorrralicu e\prirnare numai
    l;r nrrr.rnir),tasi'1, t'irsta mamei (frecventa cregtc cu virsta), medicamente care
    lrot iuclucr:o ovLrlalie rnultipli. Din totalul S-cnenilor 2/3 slnt dizigoli.
    ..'-...1
    Iixistd o legf,turi, nu totdeanna certi., intre zigotism;i aspectul placentei
    G EAit 4ll ir - Lt t 'I iit li. ', 1
    {urormorial;-Lsau dicoriali), numlrul cavititilor amniotice si sexul gemeniior. - , . 'r '
    { r lo;ttc iicestea,se poate afima ci gemenii de sexe di{erite (30lzo)sint sigur 'di:ittt
    ,lizigoti. (icmcnii de acelasisex pot fi nurnai monozigoli atunci ctnd placenta ln',t) {,i\,lBRl-
    lrtc rrrotrocorialirsi monoamniotici (25o/), sar in cazul in care placeuta este ttl"l,r,,ll Dl- -+
    7,-.,.-\\-.
    lritrrli;rli, biarnnioticf,(a5ld) sint monozigoli in 8o/odin caz{ri sl bizigoli in lr,-.ttt::tN4EZ|
    t /'){, rlin cazuri. :;AL) i(.- ))"i: cEt
    lmportanta stabilirii mono- sau bizigotismului este legati de o a.numitii
    lt4lll)A U''-l 'zlJffi/:
    t'titMiTtvA. -* \ |
    l,rrlologicirr pcrioadade nou-niscut: sindromuidetransfuzie intre {efi lntil- ' ^ ,Itt " o R | . v1 :y'
    rrirrrlrr-sc rtumai in placentamonocofial[. De asernenea, acestltrm[ este im-
    t\inqg -
    lrolttnt atunci cind sepune problema unui transplant de tegumentesau organe. prtrnt vo
    SiLrciru gemelari estc o sarcini cu risc la naitere. Recilnoatterea ei din
    lirnp cstc irnportantir.deoarecesc poatc asociacu preeciampsie,iridt-amnios, i j l l l ' l i "' l i ' l ,i rr.' ' rri rri \ l l
    t .' l ' i . D i l l l rrrrrrr l ti ri rrri ' l i I' ri r"rs 1"L
    r,j ttrr.yir:ru promaturl. Nlortalitatea perinata]ii,ln sarcina gemclarf,, estc dc ', r"l r' ,l l \' - l l rtrl "' i I rri ' r' : r' | 1l ' l * r!
    l,l'j{, in cornpata}teatZ - 3o/oin sarciruruorrnalir(accastircrcitere datorirr- '
    ,ltt.sc,rnai a[cs, premat[rit:!!iii. Diaglo.;LiL:ul Lle sarcinii gemela[i sq punc t ; t lr r r r t r r t lr r '
    l rr,rl : r lii t lr 'pl, 'r t t : t lr t t ilit it '; i sir r cl; onlr r rl lc illt r r sf it zi" lr '1r t li'
    lrrirt palpart:,uuscultareaBCF in dorti"L lur;,rrcdiferitc, radiogra{ic ;i u.Ltur-
    t,' ,1,, i ,,,;;, . jr '; ; r 11. 1*. lar nr
    iL 'i po: r t . ii ( r ns( : r r t i ( 1, r 1( r f il r I I I I , ) iiI I ) I - iI r lr
    11t <: ir t t i:
    ,rrrog|alic. \ alst ll( , f 'I 'r r r lir llir r ii t lr "ot r lr r t t
    l rr '{ \ ; i'r t lil t t t ili m illll; r 't r lll, r ii / r / ', r r , 'ir ,
    llittiLlir vilsLa dr:28 dc siilrtiLrnirrirll gt:staNicdczvoltarca itrtrauter-itri-u ,, rl ,tl t, tl r ; i ir r iisr r cilii ; i n<xlr liilor - cl| t : t it t lt lt t it t : r : r t 'ir lr r j1{! ll( 'lit lil ll) ot l'r
    .rlirrr:lirtril;crrtni.tritrprtttccstr:aslurlini'rlorllr:r:Lrci:rtrrunuifiltdinsal:cirLirruricii.
    ,trrtrtol i rl i ;
    .\1roititrrrrtl(lr'(;rc;ilcro irl 6cttt,:rtiklr lit rta;tcrr,,
    ci ptcz.ctttltrcl,
    sc irrr:clirLulLr:,

    t.t{;(i "ttl'i
    . Itccvur!a dulrlri lr rrrrrI{ormafiilox congenitale,ln cottpllt:afic cu
    s{{}l.rrl Silrcr laD
    :rittcinl urrici-r;
    -- r'iscul crcscut pentru al doilca gearnin, prin asfixie {nrai ales atunci
    r:inrl sc nastc dupiL ul intelr.al rnai mare cle 30 dc rnirute de la. eri"pulsiapri-
    inului copil), prcdileclieide nastereil prezentatiepelviar:i;i riscului crcscut
    rlc rncmbralS. hialini.
    torace ilnobil, respiralie prri ],(l a,s l rl rl
    Sinth'omul trnnsluziei intrauterile sr:intllneste la scmenii rrrorlocorionici I i ( n i l ,.i \.;r l tr l ()mi n a l in
    absent abdorucn!1 boirbeazi
    irr crLt-e existi conexiunivasculareintrc cclc 2 silteme cii:culatorii fetale. Cind inter.costal
    r rrirstomoza este ader:io,artedali. nu infLuenteazi. dezvoltarea intrauierin'; ,, l .Lr c :.i toi Ll i r u i . i
    .r Iliilor', dar poate producc moarte.Lcclui de al doilc.r gearni.n,in monertul | .r | r r i | i l D r : rs o l ! 1 ! moderat
    rlrsLcrii prin exsanguinare.Anastomoza arterio-venoasi. st produce la nivelul
    pct ce]rtibil cl]
    rrlilcdoanelorplacentaregi influenleazl dezvoltareaintlauterini a {etilor.
    '
    (icarniLnul,,donator" prezinti o distro{ie intrauterini accentuate,
    rlillttuta de greuta.tedintrc cei doi gcmeni putind fi mai marc de 1000 g.
    ir ,lczvoltarea rltelioarii geaminul distloiic prezinti un handicap in ceea ce 'l'&t)tl ul : t i
    pt itrrste clezvoltareamorfoiogici si iutclcctualir.
    'Geamrinul la uon-Dirseut (dupn }JarsL:tll)
    primitor (,,tiansfrlzat") poate prezenta policitemic (cr-ricter I l i r.tuo.ti trrl di l { r tnl i :rl ai ilelrcs€i lespir:tlorii
    .r<crrutuatdupi na;tere), cardiomegalie,hipertensiunearteriall, lngrosarea
    rrlrlici zLrlcrelor puhnonare ;i hidramnios.
    A. AJcclilui fie&':nte;
    Anomaliilc congenitale se intllnesc de dou[ ori mai frecvent ln sarcina Detresa respiratorie idiotatice
    -
    lir:rnc1ald.Peutru anbmalii ca anence{alia sau hidrocefalia e-\ista o .discor- Tahipncca trairzltorle
    ,i:rtr chiar k gcmcnii monozigofi.ln cardiopariilecongcnitalcconcordan[a - s rn,j i ooul l . as P i ' r l r
    ,. 1",1,25% la monozigo-ti;ide ri p l :l c ]..
    5o/ola dizigofi.In d"spicitu_rr.le patat acPaste - P prs i s Lenl i c i rc ul * :;c i d'
    rtrIimr '/:i
    rrrLrcordanli crcste la 40ld la monozigoti;i la 8u/6la dizigofi. Gemanii siamezi - I{ipertersiune:L Pdmonofl
    rl intllnesccu o {rccrentS.de l: 33 000 de nasteri. t3. AJecliuni |tr.ti r 6/e:
    - Pneumonla
    - Hemoiagia Pulmonartl
    2.11. PAIOLOGIENEONATALA - Pnerunotoraxul
    - Dismatluitaiea Pulmonala

    2.11.1. BOIILF APARATUTUIRESPIRATOR C. AJecliulri Jaarte rale;


    (atrezia choarl'lli' silrrlr"lrrrrl
    - Ofsiroclia caifor aeriene.superioarc
    Picrre Robin, nlacrogroslaJ
    e ptimclcauTi!de morbi- extrap-ulmonaril (hcrnia dia{ragnr al irrl ' rLrr"'rr
    - a;;;;;t*'.'
    .i,lfili'ii"filiii:'.-ie mecliastiaalc, chist Pulmotar)
    I)ificultatea in respiratie (,,detlesa respiratarie") estc cea mai freclenti" t\ i tt , l t,t t.:! l u t t )n a ] ' t , A . C dttl i a.c :
    rrrni{cstare patoiogice- intiiniii la lou-r]ascut. Ea reure;te urToetoarelc Cardiopatii congenitaie
    -
    :l' tttlrc clinice: talripnec,geamlt expirator, retractie stemali s: intclcostalir
    ;i t,iLlii eic aripiloi nasuliii. La ace,"ste selnne se isociazl frecvent cianoza. L l l .Labal i .?;
    Sr:mnclede retiactie toracici au {ost glupatc de Silvcrman pertru a codi{ica - Acidoz:r irctabolici
    -- Ilitrosliccmi:t
    ilravitatea rtretreseirespiratorii (tabelul-2.42). in absen{a detresei, scorul ' - Iti potc rrni a
    Silvcrnan cstc 0: in oiezenta ddtreseirnaximc valoarea scorului va fi 10.
    \cor ul cstc influenlat ic t-i.st. gcstaiionxiir a notL,n:rscutuluisi cle starea dc (1. 5' .i rrrtrl tl uftos c c tLl f.l t,
    '1.rciivitrlc n(. roluei.^:l ir acesIuia. I I( mofnilin cc1..drrll:l
    - lilcrnrll ct.1cbrd
    i\Tociiliclriiepuimonaresi hcmorlinrinicccarc sc produc dupi:. nasterr', Itf{ )l i Ltri a[c s L( z i c c
    irr <:onditiilcrrnor g.radeilifer-itcdc urirtularc mor:fologicl, ir.rgreulazi"stabi-
    IttriL r.liagnosticului ctiologic:rl rlctrr:sr:ilr:spiratoriila nou-nirscut. l) S i s l tt)11!lt i t/ttl ' 1h)t;

    . I)cyl dctrosir rt'spiratoric irllrLlir,irti nti:r ilslU)riLa1;:rrattlui t:cspiratr)f, I I i I I . ) ./I I I "| I I I


    ' ''
    si lrt rnljolilatca ci rziltil(,r' r.slr' ;rio,lrri;rtir boli pr:irnitir'puhrronhLr',,rr \ r,' rrri .r ' r' r"'
    r rrr' l rrrI
    S i rr(tl ,rrrrrl (l f l ri l ! rri
    lrolir: rrvcr llr rrorrrriiscrrlrrrtrlliplr'
    :rll, ,.;rrrzr. (l:rlltlrrl2,.,13). "' ri t111i

    1t ; ll
    I l(;l,
    l) jr r lll T ur lik ' (' \l ri rIrrl rro n i rt(' (i rrl : | tl Il , ccl rnl i frcr:l tl l tt, Il ol r!:tl l rl tr
    rl i rrg tt os li<r :lif <r ' r ' nlirtl r rr rrl l t (i rtrri l rrl l s p i ra to l i i i tr pcri oada tl (\)l l rl { i rl i l . ' i rl t :lls,li:$,iil"".'.*{:till!rT\""}:
    illil,rllfilff"l'J"lili"::'ff
    2.'I'],'].1. DETRESARESPIRATONIEIDIOPAIICA
    r c z i p uuctel e 2.Il .2,7 | i .5.1 fi -r i )
    < : r it r gc tti ltit't l i i rl l rttti i r.i rc r,tti (r'
    r'rrrrl i < r lr ir iiilr
    jj; j*:
    l;.,rilnl*lil*ljll*".1,*:ii:":"x:;t'J.x"?3,T:"'
    hioline- MMH)
    (Boolomernbronei ,, zrrli l. i,r c,ucuou-nirscutul,:[9:%!l;ii:1*i1:'x:3"i3."",i i;i funclia
    lr- ,' ,l ,l )l rl l uonarc s0 lcsoar be, s
    -\r:cast.-Lboall rcprczinti. cca mai importanti calrzi dc dcces la t',i
    u,is(ril. l-rccvcnla qi grar.it:rtca erfecliunii cregte cu sciderea virstci gestatio- l,,rl rol iLrir sc itntttlioreazii.
    rriLl,, putiud Ii intilnitn in 20|i, rlin cazurila grupul dc prcmaiuri cu greutallir
    morfgi-o-qi1-'L
    llit:l,ht:itna datdescricrca 'lisi:*1-l.u$T"ffrir? il;*il
    irrllt l000--1 500 g. Rata mortalitllii prin dctt-esd-respilatorie idiopa,:ci
    ;r,,;'j'ili:ii,lT:;l;ji:l*'l',ll;:,":lT r,lriui'r
    "iJ:::triu#';;u;l
    , :1r' rlt' 30-60oi,, ci fiincl mult inbunl.tiLlitl de Jol"sirea tehnicilor modcin<:
    rlt lcsDilatic si i1e rnonitorizarc.
    l)etr,:sa rcspiratorie idiopatici (DRI) sc intilncqte n.raiI'ecvent la sfri'l lin* jlji:il";t*l*,*:*:n"*1.',",iln,ili"'ifl.*
    rrlrsculiu si aDariiia ei este favorizatir dc rnai mulfi {actori cum ar fi: fen-,eial
    ,, rli,i :u'rit rrn copil cu DRI, pr-curatur, estc diabcticd. sat a rnai P:czcr ; t
    lrrlrrrriL si txrJozi itttrupurlum, naslcra Prir operatic cczadanii, hiporic,
    i':ltUl*ii*...1;
    ,,lrulliqt ***':1::*#l;#i,yiir
    ' ,r .lilicrr)tiL{i iir i -stalarl'artlsl
    '', i.l,rzi, si hipotertrje dup; naltere. Iiste t1crcm;Lrcat flccvenla cu citrc al',i10 '' t, ti, uitcrior. L',tati,',1o-se ut"1
    .ou-"lsl' l
    i;31,:il:lr:",i1;H.;n:llXtffi,]i
    "i"ir"rr:'::"tli
    #""|!Flb% xliil'i"-,i"["r
    l)l{I l.L lirc niaturLrl rr.rscut prin opcr:r{ic cczvr.:;iL (efecttati. adesea pcl,rtl
    Lltrt)tttt htLtcui,Lcu sin(eralc) sau la al 2-1ea nou-nirscut dintl-o sarcinf
    'rrrrrtl:rl.r
    ' I l.i'h..iili l;;
    ::"",::
    r.Lrt' a avirf loclnairlte dc termcn. I)RI estc rar intilnitit ia disna-
    t rrr'. irrI rr ri u i Drotector :r rupeLii prcrl ature a membrant'lor ;tu a f ost demonst: al' , rii,l;:llii,:i:?,lli'.fiiJ.ii'Y'1,j".:*Hlj"?,"':11*o"on
    rcspiratorieidiopatici'
    '"-'',,
    I,'iziolraiolooia DRI.-il adapt.rrea rL'spiratoric .r nou-niscutului cu r, rlirLlcsiL
    irrr:rlrrliilti ln d'ezvoltarea pnlmonari, doi factori pduciPali actioncazii ln (i,,,miLtuleipirator,*p,"j;Xth;I3]:ii"3;itl*,*::liu;,","f
    t,r,'rl rr , , r , , ' . l' l' , t r , /.i p ro g r, h i p o p c rl u z i a puftno:' i rr' r si l i p' a -i ntL,' i se"""'
    ' s u d c i "' irrtc
    ]i;1,f9i111x^-"'.-atour61e
    v .:
    , ' , , , ' , i . - nt il:l ti J n s u ;fr.trn t. ' i u c" rdi l i i l " si l tt zei i n' rr- ; ,'ll''l'"r:'?fi!,"'l"J,Te:K";-';T:'";;
    ".'r,i ,1 ,rlc
    Ii,jicrrl. .
    rapiclc a cantiti{ii neccsare de
    siirsitrrl c-rpira{ici, fiind lecesari reexpansionarea.unui pliLmin alclcclatic
    lccitini,

    , rr or:rviiLficcirrui ciclu respirator. Compliaula pulmonari scizuti creste foarto'


    aiveolele se colabeazl ]a
    r,l;:i;';,,;*'**;;itl':",x"*h'""';'t"l':..n1:i'j?:
    l,r;' t,'irsirurc
    a.rterialiL.
    rrrrrl t , . i. r t r r l r ^5pir J l o r; rl z u l ta ru l fi n a l c s r^ p r ,r,Juc" r" n c{ l cctr,zl ci progro-
    'i v,.. l, r r r ' r r r er i' Lr u l tn o ra rc
    fi i n d p c rfu z a L " ,l a r ner' ,nti l l i n drrarmi nA sci - ,, :i;u:* ^'i"":J;tirT,:'::::#i:'i",1$ix'"''IJ"#:g
    i " scaccentueazi.
    ,',,,,,t,,'
    rl tri ,u l' , r { ) , , r pr r it ia .-rs fi x i e5i i a J c i d o z " i m e ta b o} i ce' H i poxi c ' i aci doza. i a
    rirr<lrri lor, plin cfectul r.'asoconstrictor la dvelul circulaliei puhnonare sczLd
    t:"f*X;lU'+*111.11#) ,;l
    :'i,,t$Tidl$I"ffi
    r' ;rrr1i1.i rt rrit <io singe care pefilrzeaze alveole'le (fig.2' 19). ::l',,'1",'11il;y*1;(rq,'""u1?i"1;"t"t moarteanorr-
    ciriulatorpcrirericarun',ti
    ,' in or ele cc ur m caziL'
    GuRrAcrANr ' ,rrrr;,Lznrilc
    ' rti rl rri
    evorueazrrtXyf*,,f:A,THi:l$kj-$:Xrtlt;
    in care
    I 1l-
    I
    rrr.t'r',;\IloLrstI
    t,trL\to-\_.\]t
    cor.PLrANTAI
    PUL\IONARA O ,lii,ll,l;l*;}1ilr*iiffi T"'#"il?,,'T:l'
    ;*:ll,t-tn1)",1-Tf
    trrr,r| j rk' s{ rf act anl)
    cster:*':"i h1']']1L,.,*l,l;
    t
    I
    I
    l
    v I
    ;;' l l', ili';;;ir }"i boliiliperbilirubinemia
    ,,,;,rl i,.lr:rrrluinrlclqar cste prerent 1a aceFti
    prematuri cu hipoxic aci<lozi'r 5i
    Ii1-UX S.q.Na;UlN
    l'{lL}toNAIt tl
    1;ig. 2.19. - riziopalologiit
    \:]]NTII,..\TiE I
    ..!r-\-EoLAltA l
    dctfr:se'i rcspiratorii idropaticc'
    r' , ttlttltlii.
    lrl(r:1iir s0plicomlc:-r,sccuntlari {olosirii ventilaliei
    l,r ,llrtrvrrtr'rltstiit'ii 1.1trtrcralc a nou-niscutului ln momcntul
    asistate' poatc clntrrt
    in carc detttrsir
    { loncomitct.ttcu :rtelectazil l)rogr{)sivirpulmonarl, si detcrminat rJch\ru ,, ;,f,, ,,,,i ,' l xr, 1l' sit sr : ; r nr clior cze'
    rir: si irr:irIrzir,
    sL:rrroclucmodificiir:iri.l;r. nivilul altor or',ganccarepot amcnilrtit ' rlirs':ttlttlu i t:Ll-DRI ln tinrpul
    itricriovrnos artclial (carrr
    unalul i ,,,,r,'1,'r II Ii , ' r II I r i.r' i i slirt'ii gt:trLtal': a nou-
    r i,rllrrrrrrr-rtitsr:tttiLlrri,
    cum trti shrtnr tll Prin, '
    lDolol ilx' pt r r : ut noni'r 'lt ct r xr t 'gic int t lt -
    sr rircrr(irr<: rl(:sciristn con(litiilc etr'llcrii prt:siunii ln circnlntia pulmonaril)' t,,r,,,,,I,rt,rI,ri 1xr l, I i r *uLt illlc:
    ii lronriorrogiavcntl'iculalii,pril) ( t(t\ltrfia {luxului v(:rlosc''rr'ln:1. l)|rPd.6 or(l r, trIti r ttl l ttl t, t ollt 1r s,1r i1xl51lit 'll( : t r nt
    'll t c'

    :t'i I
    270
    viir i: r ' r '(ir I I
    l; olos ilt ir l o rrc rrr(rrrIi i Irr rrrn i tl tr o x i g en h r:npi i i protrzi rl i r-,:l ri ral ol ' i rl \i r,' h t l pLilasir r lujslt i, . t ''"', " int r {r 12 5i- 60 - or e dc
    i ,,.i ,i ,,,, , , lit i, , auilllC( i ca: lr Lr i- lir - tilt ; r ' Lvr 'lului I 'lt , a cor n|1t : : ': it lr r (! t Li , '
    li1rsa moni t<.rriziirlilxruurrrrlrrlr it l)rO2, poatc avtr:r efccte toxicl la nir', lttl
    lttinr.i, !r'srrtuirti ccrcbrll fi al lcsutului pulmonar. : l ,| | r i ,,:r i111. lr . , lr r lr r i ( ) ! '- i I l\ , nJ"l nt I r 'r . lr j'ulr r i: 'illA- '
    ttl t
    fn pelioarla ch: ;rnclioralc a cletresei respirator:ii, c-,datiLcu scirdelea ;,r, . l(irri,:hji rrLrsitrt iu srari: si conscrve bazele {probabiJ ditl cjlirr;rrt '
    . rr,rl i i ,l r: ir r 't ; t : t ct af ost at , cer : : icc le- al pcr m it e si aclr oncze c'l llr x i'lllllr ' r)
    siunii in cir:culalia pulmonarir si in colditiile pclsistonfci c'tnerlului artt'"1-l.rrl,
    l' l"
    gradicrrtul dc plcsiune cate se rocheseazir poatc producc un .sr?lrul stirqit I'tczttnirr unui catalloli:lm i:lcscnt ducc la eiihcralea-de Ji' ;lzrrt si
    clreapta. Clinic accst sltunl se tnarilestl printr-un snfhr sistolic acc.rtuat crrr'rl l i ,,,,i l ul i r. G r nr : ir r ichii nu pr it iciie osm olar il; 'r '^a Lr .inli
    r ( 't 3 cr ciiir l( i1ir 1 'l'
    ,iisnrr: odatl cu inchiclere:r calalului alterial. r(r'r,trlll1l ]-c(lusi), accsto sullst.lnte JtIDg Dll fll lnfltt' ln \rlJilo'
    ' ',
    S-a consiciela.t cir existl si forme clinice u;oarc de DRI. in rea1it:11, : r t viJenli o r ' 'l: r c 'liI r z I '
    1,.' rr li'r t nli. t r t t lt nn:t : - , r :
    ;r{rcirst:Lboali redutabil:r sc poate conftlnda, iu primelt: 24 orc de Ia <lebui. r'rt pr , 'j115. ' i , r ' l- , 1'zilL iol ' lai'z'r ii l'r r j t
    ': r,,,, t, 'r it r llt . l" rl
    {rl)ipnee tr:a z,itorie a nou-rtiiscLrtLrlui. Aceasta csic o entit:rte cliricir frecvlrtl , ,t:,"',I(."t t"tiiL inpiedit',-i. C':Jinritartr nrr;irtii crrdia''"; ris'1r''lrti
    iril-ilnitir. produsi, plobabil, rlc rcsor-blia intlrziatir :r lichidului pulntonar {"lrrl , , 'frrr:irir-itorcu ccl <lin her:ioregie pulmorrrr'i, c1ccarc 'e di{er'-n'ri:L;'-r i |r irr "
    si sc manifestii clinir: prin detrcsir respiratorie motleratiL, {ir[ morii{icld rilc , br.rttl,ogramci aericnc {ar}'"r '1t 1'r'on9r''1]in
    rt sj (oui'r'll'{irl'ii rr lrr
    ',l,, 'LCr
    iirzelor sanguine si ale radiogll{ici pulmonarc ; evolulia cstc {avorai-.iil (unc,rri 1,1i rrri nul t r t r : lcct at ic) .
    in citev:r orc, altcori in 24 - 36 do orc)- "flft(anrcntu:l dellesei relpiriltotii idiopatito' itr pt"iqit] r"i:ril' '' rttrl "'
    l}aluale:r liseului prodnccrii Dlllt irraiutc do nag{erc. A\rixl in vei, Lr trr ., :r , r ci,r ii , , , , i'l: : lulc 'i: ', ot 'er ''t i i' zt r jat t : r ' llnr in lt "t r l'lr r l
    ilar..itatcir 1)RI, tstc obligatorie cvaluarea ntaturirii pulmonarc fetalc lnairt,'rr ri i l r' ,i in''r r Lt . ir i pulillo. t . : ' t 'l^ cor spr t r zit ( r l - pr eclllr r '' r r 'l'
    rlr:clarr5iLlii uriei naqteri prematuic (in izoimunizarc, t'laceuNa.praettit, inft,. i,i,, 'l
    .r ;,' ,\" ', i : : : , . i^r er iPolt , ' : ' . r '1'lI lJlilr : pr i ir r "P'r 't - i- '" 6oJit i' lr "L 'r r r ' I
    lrn:ririicir). Accst itcru se {acc indircct (curoscind fiptul ci secretia puir:ro : '. ii d^: 'ir lacl: r t lt r r r ir t''lnt inis'r : r r ' 'r l' l'l l
    ' ' J' ,
    rrriLcor:rtribuie partial la formarca LA) rnirsurind cantitatea rJc foslolipide dirl r.r,/()l"r1 ,, llr
    , ; =,
    ! iiiinuit
    llil\tir"r, '1, "o':r n": ; 'J: "t ' ( i': nut l' r L I r : l"Luii' ' r t 1l lf i I
    ! \ , , l, r ir . r r r I ' r i i r ti u rrc l i c x 1 1 ,1 1 i 6 fj c ,'i r,trc
    . vrl orj l c rap.r:tul ui Jcci ' u.r/sfi r " l' llo'r r ''. Ligeir r s luT'lr ' l) cdr r "cr ' 'i t
    ; , ,,., . " t ' 5, '
    'r r i, . lir : r: i poz iti ri ,r' t t s tu l u i l ri i C l rro n i - (de l ornrar' r spu' ]l ci Jn prcz l .l 'i' '; b, ' j- loala s- a i'l jllccalci s'i 'r r rir r r r r lr r r r l
    I rl i rrncut ct iologic, at unci cilci 'leclal; at '
    ,'trnolirlirit qi riscui dc prodrcerc a DRI existi- rclatiil prezentati in tab,:hrl ,,,,r',,t'i,"r;" nt'gitrisrrului fe'ral si 'i se iml,,un'i1it t"i. 5'lrirrrbl1r'ili:r';ru" ' '
    ,t. 44.
    r' r,,.ri ,L ' r 'or n.- lllul in r Jl - 'll) '. iJ I dll lollllr sc'r i lr r 'liot L\ t ot 't ' l'r i|l
    .\cr.:tr: corrla{ii sint |alabile in marca m.ajodtatc a cazuritror, toitlli , ;' ; "1 l- \ d . - f - 't t 'r ' Pr olr ''"1' t l r ll^. ir l : r pli '' r r r ''
    (')ircDlii sirrt Dosibile. '17; r t nr r ^ , 1 . ': pr "si't : 'o 1"- ri: : ' : t i ir r t l'! r'l '
    r' ,,,r ,l , r , . oi- ar in ir t t r - ut t . - i - 'r t t ir r ui"
    r ,r,ri ,.ti-.ol.i lir sfir'5itul i.rpira-,tiei, at ilus la irnbutrirtii{irrrr rrrlci 'l'
    la ercsturc.{.:1it:itii ireu'ologice ;r actrstorcopii' '\r;' si rL'
    'Iab€Iul : t4 i'ti.t.ii.,
    .,' ,' l l " . lizr "i l r ( t t 't t s h'sil f r "r t t
    't' I
    ir in . - r nli''f - '- \ '. ' ^t : li, ' 't iv?'. 't 't 't '
    IJilr$roslieul a)1l€Da1al *l DffI (rl!p:r Eiars) t nlsci ) J- r \ 'r ir ll] i nczal'r '( cu cor lLlll! : rr 'r l lr "ll r r 'r 'r" I
    ' ,,,1' .' ,;' cncJot r r lr cal': , t:irrclsr:lirIr" L
    ',,i,itcipo"ta"),sauI'liEI?(loltili-'teutde'upitcttot'ylvessurt)
    iIltia arti{icialir.
    Iiiscul de procrucere 'ri
    1./s
    rtairorr I .*,,,,,3::r",0:0',",., a DRI lnitial se va ince::ciL;ucnfiltci, e I'aO, i;rlle u0 -ll0 NtnIIA lttitt.:t'll
    r
    ] o m r r e sub c{) 't '. 1) r 'i I 't L] ' : l" lr r 'r l, '
    l , l r.rf,. ' d" o: <igen. i'r , 1, 11( ^'1;
    [ 1: 1r
    I
    t,tr rr t "r llR, ir i cont lliilu l'iO 1 d' 6Uue' c'f e r ndr ' at J lolo: ir 1 | r '' l'r "r l1'
    Pt ici' nt r n : r r it nt lt 2 i r r t ' t l' { }
    S,rir 1,0 . regatr7 . prezeDi i009/o; se.rcr , .,' rrrrr l, 1, 'i- P. \ i'. Da, : , Cl'- \ l) r r u ccr '-
    1,0 - 1 ,49 , l1egatr./ . rle obicei prezeotj forma ,.',f,.l,rLt -iO--lrlt151;i atunci cind apar crizcle clc atrrrc, tstc irtrlicrr'iiil'r|' rr' '
    rrcdie de boali! 'pr in -tr
    rrl i l rr{it r i r r t cca. nici: inillbaf ir : aheal: r ' pr oxit r ] I t t iv 30i{, r lit t ' 'r zr t r t l'
    1 ,5- i,9 9 -A
    lclnll lfoaliL ,r, l rl i i : r c, , . it i CI 'Al' slu vt ; r t ilr ! ic Lr f if iciaii'
    It:ilc :,0 . poziii.. Irr ;rfllra nrlrnillistirrii tic origen;i a l espii'a{ici asisiatt: rrc v"r ir
    Ir| | | LIII)it i(I ( ) lnit sllr r t t l) llf cut lce:
    Idortiiiciiti paraelixice" Sc cr.rnstai.iLo scldere a tsaO. (chiar la conccntralii r t lr iolillclcil( or lst an't i. a. t l: r upcr - - lt ur iii'or 'pr r l"t i( inl: lu: iiv: r ( 'r iill'lllr lr Li
    l'
    i r i' i, r L1 dr o- s r' ,.| i rrrj . l , i ,l o z :i r' l i r;r,,'r;c si m,fJl )nl i r' i , Jri pop" ul oi rt.'nir " , r L, lr 'ir islr . ir r t lr r r lilt lr , t : r lir i l. . iilt t {r r lr l: ; hr , , . , 2, - L. l{) 'ii, 1r r ; r r r r r r '
    ( li; i ( 'r t , t r t r r i r r r t N t )
    scii<lr:rrr alfir l-rLntil:r'ipsilr,i,s, iiri"t,rrt t-rr1:orlului I-/S ir aspilltul 1r'ah'r.rl'i ' i l ,:.,lr r r r ii r r lr 's( ir t ll't vr t l : r , , r 'i, ', l ir g, ': i 'l, r lr "lili
    ,
    ir ] , li1r ir l, , I, i I ;' trri II ' ( ' r r t r r r l/ l; * li' lr i'l' ir r I 'r ir r r : r'i'l': vir r ! r 'i' r r '. '
    l rilx r li; r 1ic m lc. , 'r r r ''
    ' ,,,,,,, r lr
    l) r ' olr L: l rrttrfi o rl l l c Irtti trt,rtt rI,r trvLl r:tti i l tr,i i : rtt:i i < i cutl r totl l l rl i l ttti ' i ,, r L. f r i , , it 71, t i1, , , ,i, , , r i) . Nt lr r iir ) ll : r o lx) : r 1( r r ': . t li: ':r r' rr t lt lr if ir 'lr r r t . 't r L. . t
    t t t 'r i. t r r ir r r 'r 'r 't t r r r r trl. r r
    i , i ,, ,,., , ' , , l, ii1i, ', r' I i I I I' ' ri i I r! i ;r r t t 1; ipil l1'r 1i; r v'r j) '
    I rI r I rrrrrrr;rr r, , : r ' ,rrl rrtrrtl l i t, ri l ri rrri o r l t)l i tl , r j ci i (l (j l (rir'l .l Lpa,:i i i l fi i Ir:zi l l tl rri : l j ttt, ' '. ', , (
    i' 1 | | ( I ) \ I I I I I I )' I I ' i L
    ii, , , ' , r |, , , r r , , , l r .r rP,ri i rtl trir r,,rl rrr,,,l l i r' rrtl rttrr| rrrl ttl rri t' r' rrl i l rr{i ,/ru,l , rrzr" ',r',r1, rri r rr 1,, rl rrt
    I lrlllll rr
    , . r . r l r r l . r r l ( l t i r l {( ( r 'i l 1 r ' i r r t \ l )l i r 'it l l ( ( \'( 'l l ti t ttl i tl - L t) r 'tl r ztl r i ,'l r 'p
    I)r- illc onr r : lt r r : lr rL rz l rl ri l i l rrrrl rri i r(i (l o l l a z i c sci nccarci " rmcnti trcll cl
    rl lr.-ul ui r r , r lr t l r t i . r t l L r i r r l ( t r rl ) r r l - ( i tl l ) i r p l i t::tr ca i l cl s1 1 l 11 l :i l ta l n t'l l l ) '
    nlLi nuLr c dr 7 ,2 i , ri rrl l rr l i rri l rL rc a c a n ti ti rti i dc N aH C O, l rr t nrLq/ t i t t t | | , i t 1tl ,|],1 ||||]t|.l t|'tt,l .tti .S- a r r 'r a p o r tr r t].i ( '( j ( 'sl l j [],|-
    'rr:rL i n II,j'i, , , i, : , , o1I iicr t t lt f I ', 1'I , , , 't t t ct "t iiat vcnt ilaiieasist ir lir ' ( ir r r ir Lll
    l.t.i r.: ,,.,,i
    '',,,,,,,,f,
    ,,r i,',',1til'i s,',,itcaz,-u firlrttrlciL ..,i sL:chclelc n rrolosicc'la/snll-1t)l,li'i
    nt,urologicc lir suptrtvit'ltt "tt
    )lL i,rdicr-Lfic transfirzi,' tL' nr:rsir elitrocitari, daci lli cste n-railr.ric de , , ",,,it"i,,l"
    r r : : r f :
    i r
    l ccr
    cca st
    sti ir
    L lr oalir (( tldacit
    a ci r si .lir r
    L'r
    sirtrlll I{ ,.'ttt
    irrl i l l i r i l i r
    1 1 1 1 :r '1 'n i : fr ( 'n i i i i l r r i i {j ( ) i l
    "r ru a Yu l
    tt daci arar tulbu-
    .lir: irrsauguinot.anstizic cr1sir.lg,jproaspit (E0 mlikg) 'l
    l::i,ii,'i;i',li'',r,';i"i;';.'i;t;;;iirir,,"r''''.i""ri::1".i:li:l.li
    i 1r; (l(: c { - J a i g t 1 l : t 1 ' c .
    l:' ' il, ;i;', i,,ii,'l ,il:"ii,""t'.1.t"t"
    : ':i 'L r ! u rL U ! , , \!
    ll
    ""o"uiost:::'LlL.':::1':].:l'.ll .i.L
    . ,, , ,,'l,l
    | l l LI Li r L r 'r i r 5 rrl , L d r
    l'inir la o btinelea rezllltatelor culturilor din singc gi lichidul gastri,' se t:irel rrn':i tiisplazii bronhoi)tl monarc
    l',,tu,.1,,{t l|zr''tll
    I o l l -l l i rs r illii

    i r, ;rrlrniristraart:ibioticc(wniciliniL I gcntamicinir).
    iu tir.r.ipul tratain':ntulni nou-nirscutril r'a li :loniiorizat cortinuu
    , ,,;,','ll.;liilii'"li',li;,;i'#ijLi:;T#;';;itt'i;l'ii,, 'airtttrl'r'
    "iie",',
    ' t '. , i l , .
    ,l,r .r vr':rtliiularir, ritmul rcspirator si tempcratura-- si sc vor facc urmir- {
    r,, rr, lc lriplorird paraclinice:ltl, I']t.{Jr,1'a0", si I{tiO., lt fir:carc4 olc {cstc |NTIRZIATA
    slNDRoMUtDg REsOREIIE
    ?.11.1.2.
    , 1,.' ,i,'lcrilr tnii-surirrca
    trait,\crltantar cot.ttiluiia I'a0,), .gliccni;r;i lIt la {iccar-e FEIAI
    PIJTMONAR
    A UCHIDULI.,'I
    ,,r,.,Nir Ii,Cl1a2,1-.1Edeore;p[1urinar',o,snroiaritate tt, .Llesi
    r.],pr-oteinr'l,
    L \. zilnir'.
    Sr tor r.nai electua hr:moc,-rlturi, railiogreiie toracoabdomiuelliLpentr-.u :,
    ,,,,,11'Jililli,,ll,;\:ii:,i:,1|;,lilioll^'JTx1l$
    ,rrtr,rlrrl sondcidc intubatie sj a1catctelului clin artcr-aourbilicaliL.
    ;"'t' )+,,"':;'ll,l:*l*T::::;li-:-''i;:lilif r, ("'|" ",
    ii"Ji:ld"or,i""i,
    SLrccrsnltratamentului in DRI depinde ile cxisten!a ruei cchipe (mcclici,
    .rrrrrli)suficient dc nuneroasi.;i dc antrcnat:r in ingrijirea lou-liscutului
    '' [ "i,:'l;;,'';';"r,ii-tti aiirtr,, ,." tr,rirliu rtl-ar'ntllor]rrirlr:r "'
    l;r.t,zlrt r-cs|ir:rtor.Esic cle sLrbliniatpreiedn{a pentru nietode neagresilc, , , r . r L r i l '. 1 : i r i i : r tu m a r p r r tt ,,a "l t
    ",.1i.t"
    i "'r r u l ti r ' sfi l o r i i . ( r l n t:o r i l ) t'sl ( l x)
    clir ' -l
    t.1,,:ircr irrifialir a CPAP-tlui qi numai ix txtremis a ventilatiei rnecanice.In "...,"-

    ',,rr,li(iilr, nronitoriz.irdleLectronice,se
    l:a renurta 1a rnatipulati inutile ale s''.'"'
    '' "llllill:i);llii',"i.l'"n11,,?lT']:'i::#:;:j:Yji:jf,tl':;
    {r!r(ror)rr!
    rrlrr rriiscrrlrui qi sc \.or pistra crr meticulozitaiem:rsuri]c de prevenirc ale ciec1i{crcnliat
    gi:cu 'l
    rrrl,r l ici slr:rmdarc. I l;ll.llll:,],l.il;|':':;;'rffi.i;J; "''i" "'t" riJuhLil)ulfl]()lrtrlll rl
    irr rlorneninlfrez'mirii boli.i, s.att obtinut progres€semuificalilr'. In '',..t lortne dt'resorltic il]iirziJl:r ' -licl
    lrr .rtttlrt'1c srr irts(){Lrli'
    i rzrtl unfi na5tcri prein:ltureiminentc, sc recornanclir- intirzierea na;tedi pdn ,,',,,',, , ,.i, t.i-iai'olabil i in primric-2a ln
    :11, 'I-.;jlrtttt
    :r,lrr irrist r:Lrca'intrar.enoasi.de agenti stimulanli beta adrelergici ( Saibut amol). Li,,iipu-urui'.:
    | ,,,riir. JiHiS',li::l:*ll ,l'll,:i,ll
    i'.,JSYt.t;;,
    l)rrrli rurstclca D]-cmatu{i poilte fi arninati celputin 2 - 3 zile se lac eforturi iili linear c per ilr
    ,,r,1' rrr.,,,1,, r r 'il
    irr irrt,st'tirnp icntru acceierareamaturaliei pulmonale. ln 1917, Liggins qi ,,r r,' r,l i orrrlilnlie. tItIttltttI'I t
    llo\\'ir.iru raportat sclderca semni{icatiYea incidcnlei M IIla nou-nlscufi, lr'itttor,Lit:rrl sc ptnc dc obicci retrospcctir" inilial)utindu-str r' rtr
    acidoza rnctalnlit:ri
    ,lrrprio gcstalic .le mai ptttin de 32 de siPt:,mini, dacir gravidelorli sc iniec- , lrl{1, .i,t{lforn.rl a.,, ttrp"r.Jii""otialie Lng"i"i'
    |,.irzi l\'tirlret2rzon(cel pulin cu 2 zile inainteana;terii). S-a dovedit ;i experi- '
    ' ' ili,'l c1e
    gi ac'ninistrarea l,'li'
    glucozir
    rrrrrr rl accc,lcrarcalnaturatiei pulmonare sub infiuenfa glucocodicoizilor; o,, confo:tuli ermic.
    rrri,rrrrrisrnulintim e necunoscut, efectulinedicaficiestemai pulin activ 1a copiii r 1',,,,lrr, i t nt t'liotarr:lr r--apidi
    a simptomelor'
    il(, I Ix r[asculiu. DupA nagtere,tratamentul cu betametazon al nou-nS.scutului ",,l,ii::':liuu"
    r r \lMll cstc iueficacc (se consideri c5-srlrss-u1nagterii elibereazi cantitili PUTMOI.IARA
    ,,.I1.I.3-SINDROMUtDE ASPIRATIE
    rrrrrli rlc' stcroizi endogeni)-T. Fujivara a utiliza"t primul cu rezultate brrne
    .'rrlr{lrrntul in tratairentul l{MIi la nou-nescut (1980) prin instalarca in
    ir.rlr,t.(pc.tub endotraheal)a unei cantitlfi de 25 mg de surfactantsusPendat
    lli,l,
    tlli;i;liLjttL:i',liii:;i'i:',:f,,iil]]i:'JU
    ,:ll'',i;
    , ;,:,,;;,i;;l;
    ,iii*;{,;*U:i;
    rrr .,'lufit sllirri, irr dt curs de 20 secunde(4-6 ml suspensie/kg).ViTta
    rrrr'.lir:i'ccornandatr.peDtru acest tratamcnt a fost i2 orc (deci, nu imediat
    ,
    ,i,,,,.,t,
    itr;:ii;,,",,1::ili.J,i.1''{,f,J
    ,lLrl)i rlilitcrc); pina rtunci sc foloseftc ventilalia artificiali pentru menli-
    ' r,.rir alvcolclor dcschise-Sur{acfantulutilizat cste adificial (lipide liofilizatc
    '
    ji,
    ji
    i,iiiiii't'iitlitj[,ill]lt'l.',
    ' 'i i ll',',']l.rrtr'i'1ic r)u ndcin rnocl c t ra'rol,r"orrr;ir '
    irrl'or^ci

    rI$rii'*l:]ulil
    'ortrtirl-in

    1,
    ,.r.1rrisc din plllmin dc bovine la c:Lrc s-l adingat dipalmitoil-{osfatidil-colina 'ittr
    {l).1'.P.C.)5i lostaticlil-gliccrol(I).G.) (rrrt fosfolipirlstabiiizator). Acestaeste
    rrrrriIrrrn tlr;it col natural (oirlintrl l)r'ilr sPilltura puhnonard"a icptrctrLri lrrriugirrusc.rt'll)icirzii)r"11
    r,lrrll),tlrLllir.ri(l{rrl, l}{'rltlu (.1.iLt\:2"f,.);rlotciuc(inclr:zirabiie, pcntru ciLpot fi ,',lii ,1,r",,i.r;tl,',rlr0rrr),sfirrr:tt'rrtl sirr'
    ( r'ir trririIr{'(:v('rttttii"'ii' ti"'lttili':"1ii'fiitit"""'?it ir r;o.sliirtitr
    ,,Lrlirpnit;t:). (lrr sut[rr:lrrtrticlcal:rt li t:cl ob{inut sintctic. Ali. irxxrtwctritrli; t't l,t t:.
    rl lrIrrrllrrIrrilrri lirrj it'irrrc;tc IirIltrI c;i rtt.rxttt{ittcpt'osi:tglirtttlittt'
    r:t tlilrLl:i ! 7i;

    :i4
    Ii f Il r \t.Al l l l l ) l : l tl r \) l l t
    ,lrorrul 11 li-.Dir-.Ltit t t t , t :, , t ri . r l . r . Mtr:ottiu[ esL,] pl'fzc111- ir-r liclrirltrl rturllioti(i
    .rr irl' ,, rii:: rl,l:rlrrl r : r il, r r . , ' r { : r llz ir lr r in' iPalii L climinirii ttrttuitittlui itt
    'r1
    I
    .l l (l l ( l l I
    .t
    l l l i ()N I l 1( )L \l i ' \
    .t
    Ii
    ii< lrir'lui amraiotic este hilxrxirL (sr idcrea PaO, ctr 30oo1 (fig. 2.20). I
    ,)l )s tfn(,ti f P rul i .i l ' " +
    l. .t.
    TabetI2.15 t,:rtr,lzt'it oll'Jf trltcTl\r ,,PNEUMONIE Ctitl'lltlri'
    \rl I('l ,\/l l
    \r:rlori nrdii al{ dllrrttclor com}oreDte rlc lichidutut Pitlmirrur ii alc lichi(lultli :rnurioli' I .t
    la iF ii do oaie, Ctl Rraiiorllatii alc nlamrtului ]eipirrtor (du?l Adams)l 1' )i,lltno s.liastii

    ,tt,'O.atI i- ACrllOzA
    .t1
    I,(.fs i s l c t;i c i fc i al i c i dc tip {etal

    de aspiral]e r:r'coniau (dup:L llaczrltl


    I tli '. ; l izirll)li'r1o:li^ sildromLriui

    ,, r, .,1:u,, prirnt:ircspiralii.,Nou-ni.scu''u1 aelile.,1Lf-if.-lolipnci'' r'i '


    diamctrui anterop-ostcriota.1toracclui crr'5{ril
    ,,,,lrr. , u I il,rrtic lorlcLcir,cu. produce o l)itl()l1r"r'
    si rl,.jxr.rlc't c1eoxigen.Anoxia Jetalh.poat-c
    ' ,,,1,.,.,r,)
    ' i
    '"".ai"i""gttie,
    pcrsistendacirculaliei dc til l'l rl '
    i'J, lil ;;,i;,,i,,ti'
    ,I 1, ,, I' r ;' tr r' - '
    irc ru.t/L
    l",,1i,"'!:rli:t truLnonaLir pune in eviden!6' opacitiLli bilatelalc. rrlt' trtirr'l
    '' , ,, . , . . : . - , 1; ", nlt f r r lr r i :anteropost
    nt er onost et r ol t or aclc
    c i$r l) n(
    r |n ( 'l l'lll)
    r ) l l 'll,
    f,i ^- ^- +- - . .
    , ;;,,11r,,'i,,crc5terea-diametrului
    St' FL ill l{T-r\ !'E l-\Ld ,.,,,1r
    ' lirr r rril,i) pr:
    vizil,i) pozilia de pro{il'
    p, pozilia Profil. i
    ri,,,,r, favortlil, in 3 - 4 zile' sau (in condifiii.r rrr\r
    ,,,,crtu'o
    COIIPR[SI{1r\E (t)ln,'rI
    l S( lIElIlE
    (r(:l:r\x!.
    I'\TESTI\ALI\
    .1c siincter)
    DEFEC-\'III
    " Pr coltDor'i , r,,,,tr rrrtsivt r lc m econiu) nor t alit at ea poat e 11 foarte crescut:-
    ",,,,ti' '
    ,,IIZIOI-OGIC,q
    + \-AGA{, t,,l ' ,, 1,r1,,,l i rrg l'. ; i llr ac\ J. )

    :
    i
    a' r
    I STIIUL
    .t
    l
    ttcbuieinceputimediatdupi naglere
    lr,ri,rrrr,rtlrtl
    1 .- ^ ;- .r .- ^
    Ji"civ,,msi
    1,1,i],llii',1'],ii,Iliiri"iu.*i.."i"r"i
    +Fn l .ti vc
    ; iiraintea ^oricir"rei
    r,' i ri',,,,','1',,f r ;^ ) i r - i
    9ir:onsti)]l,llii'li.ll':"
    tentative
    (vizrr:r1iz:,i
    din rraht'c
    veniila!
    d e ve n ti l n ti cic
    ,
    ( iii, . l..l
    i ( .{. .l . r.l. lt
    - D f lL l c o _\ l l 1

    l.:0. l)iieritele uccaiiisnle care dcterruin;. pasiLjul rrl.conirlui ilr lichidtl adrlllot1c
    -
    ( d r Pi M ille r i.
    , -, Ai,mo/ondhc
    [Ii] Delresares!rnlan e
    ,J0' { frsgssg
    Sirrrpl;Lprezen{i a meconiului in lichidul arrnniotic ru este suficielit5.
    1,,,r,1 rn r prornicesildromtl de aspiraliede meconiu,deoarecenmai in l0o/o .,-, r l
    l./' -
    boala. Nici prezenla
    'lin , rLzui:iiecu meconiu in lichidul amniotic apale
    rrri:,r,rrilortle grrsfingintrauteriae, sccundarehipo:riei, nu pot explica pre-
    . '|ll,r rnccl,niullui-pini ill periferla pulmonul'.d. ,lcest luclu se pare c: se .,:.)
    numai cu ocazia producerii pdmei respiralii dupl na;tere, noliunc
    | ' i\li7,t:J\z:.r
    , r,r'nlirli care obligi. la aipiralie precocc ;i insisienti. Meconitl aspirat
    ,J,rfii ua5teremigreiziL in perif6ria-pulmo tlui, producilld 1a acest uivel
    ,,l,,itrncti'et ot:rli jat eleciazii), obstruilie par'liail (iu hiperinflalie prin efcct
    '1" r:rlvr) fi l,ncurrrou".r Llri.nicr,lp iri,,rfi, i{ig. 2.ltt.
    .\piritii sindrornuluidc aspiraliemeconiall poate fi anticipati"in prc- .4,ytua/r ltpn
    z .rrlrrrriui iratalir.r cu insu{icienjirplaccntarir(virstiL gesta!iona1:1. pestc,42 /,,,t,1r:.
    i/,i,tqrnhei
    ,l, sriLpi feial pi a ixistenlci mcconiului
    dc iitri car-ciliac
    r-Ln:ini),r nir.,dificr'Lrilor.
    r rr t,A. Iistc yrrr'barlr obicci ck:rltl noll-l]i-lscui c'.1sclnnc dc llipoxic crt'111, -l.,'ti //'//// .,,16'
    ti.t :utl
    , ' gt lllt c nlr ' ( iir r t ) s ( ( l. t s c $ l n r i ! ) s a t r t l c l l I l P o s t m l l l l l f ,
    rrrilrrrr(r'ril'-r (rlisrllLl- r Lr ' 1r " l L , , l rrl i r l i r: L l rr' i l rrrl ri rrl ' rr,rt L.r ! ' ri ' i ,l i l i i l Lr rr rr(' rr;r'
    rrr' rrrr' ,,' rL,,r(rLrr1,:r ,\t' f:l rrr!l l \ )
    , rrr. rrt ,, I, r1 rittr,t)|r'Il it l) I t t ' { ' 1. 1I |ir Iltl t t t t , r ' r llt ir i, t 's r l l t i l l o l o t t 1 i l i r r ' <l i [ i <: t L l l l i i l 1,1 ,ii l i,,'1 ,i, l , ' r. rl i r

    ' .ti I
    't ;t,
    .T
    l: r r : r 1r r l lr r onr,i r,,l ,rt ,rl n r r,,o l rrrl l n l i ti Di r.i i tLn| i Ii i rrti l :rri r.i l | ,
    rr.rl r r i. r r t r r r ) r ) iI , l , (:Ir' rIIrIi (i IL l tr s c ]ri | tl r, rl rr;ri r l cl ul r.r,l r f(,-\i ri tl rtti - ? . I I . 1 , 5, ED EM U L PU L M ON AN H EM OR AGIC
    (hernotogioPulmonordl
    .i i l )rl i r ir ; r rl rL,{r()l I i II I rI i rl i rr :,l o rrr;rr:, s tr. o i rl i g a to r -i ,-,.
    Ii rrl osi r.e:r(l trr\l r,ul ui .: .r
    L i rrIi Ii r . iir , iils is ilLLlr0 s 1 { i rrrl i r' i L i i i u l o ru e l c si .L| l tl , c toi Ltc ci ' ! L] :l cl i r) cu ilipoxit inttlrtLLtrritt;''
    l. r 1r{)lr-DirscLLlulclL EfcrltitLt lnici'r 1it lla;icr',
    , irr rlrrlir l)linriliului ltti,(lisl)unc lir apnr'l!iiL 1tncunotor turLlui si lrnr:Lu,u- dismatud cr1 evo]utie aPlrr|rrl
    .rr I li, : |lr Iritrotil-ui,.l, lx"cum si la luii
    rrrl rl i as iiur r lr r i., \ i: r t ste rrc c i d c u trjs c p ro (l u c i n l 1 )' i o rl i n cazrrri si sc-i nsoi .i r. ',l,iiii,,,"ti-,,1titi.l"it,ip:t i"i'rr\-al r1cz - 3 zire dela lLastcr"lL,.'t"'
    rl,. rlr'1r'r'jor-a-rr:lr brriscir.a stiLrii gclcr.llc I irou-ndscirtrilrri. ""
    ' l )l rLr))r)trl Lfar .
    in lolrtc cazrrilc rle siirdlorn dc tispiratie mr:coniali-r.r,str: ilcijr:ai i ct,r-
    lli
    ',,',i,1 rol.irgiir1)t1llxon:rrilse rnalifesti ciinic prin sputl acrati cL1uilrilrLr'r'
    ir rrrir.r Lt'uocrdtulii si iustituirca lllccocr. ir Lr.!lanlrrtrihli c.ri ;rliiltio::r-l {
    i,,ii li 'ittutngic airulrlcrii pulrn'xitti insr-'!1t: dr crize dt 2rprrl li
    Ir', rricilinii hanarnicini). .\ccastiL iltirurlini: cs1.ejustificatir c1c fautul , il: pcr i{ir ic. Est c, . l. 't ip'1, un edem m onar ac, , t ' ct 1 i. t illr rrl
    . i l l ,,,rtl utor lL
    ,l .,(,rij)ilsirjui clc .rrrcconirL cstc tl.ctcr-ruilllLtclc inleclie, i]}ec()Dil cstc url i ..:rr ' ,', il, i"i,,l i'n lr,:.rrtii, sec.ndd f- crr ct erii 5ir,1qLli11c jrr
    ,,,lirrrlr.r:nlturiL pitltru /i. aoli si cxilniltltl alllttolrlol)at ()iOflic pultr, IICC1, 'ir-.lrrl
    , . r' i < ,1D i i hnounli: . i\ ccsl clicur r epr ezinli m uJul de m r ni{t st ar c ir l r lr sr r '
    'r-e..iu'ii
    r r r rrirlcnlr'Llczirrni cli: brcrnhopncrrnroni,.-..,tr d rtrirrist r.ar.r'lr rlc cortizo:r s-r 'il r 'r r
    ,i , ,..1r-;.. . , ,r,. r , . , r i, r '; , . , 1ur . L- r , Lipo', i, id, Jiie- it 'r r r z, . l ,
    'i "r,,l i t ir r r ' f ic ic nt i, rc s o :-b ri l ts l )o n fi tl l i :t i l ri ' c oni ul ui produci ndn _.r rei . .i ," '' J" r ului I r . r t or t - 't t ' i' '
    ,. f,' i u' lr , . : , . p. o{l r c. r "om or : gi"cu licbid traltsllril:rl' ''
    : r1 ,i rliiu 1, ! or - c ) . incircaica vascularir
    ' ,,.(,nlrli tlr hipoprotcilemie,
    i i ,, l ,Lrl rtrou ar iLi I iRl, ver t ilalia af if iciaii" 9i cf cct ul t oxic pulm oniLr ir l( ) ''
    : T],? I, FNEUMONIACONGENTTATA lrrllrrLriLrilcrLi'-coagularc nu sint in mcd obligatoriu prezente, iilr illtltrr i
    , , ,,i.,i.. ia'oriz"az:, ir'oclLcert.:rhcmoragiilo]'1a nivclul caPitrarclor-
    ( 11) l' 1r r rr' r '
    lrr r:onditiilc ruui trirlalitr cu nrcinl-rLnitql r: r-uptc cLr pcstt'24 dc or,, si fl r), l l cl rlr , l: r ( i": Dr dm onar : rncedelnaioasi se p{oduce ir . L 'ttlrrr"
    ,r l)r, r, rila al1or scmnc dc inlcctic artrlr.riotir:i., sr) r'; anticipa Lrlrntualit.. ,l.r , ,, rrr rtrnrrt t r'.,Lrutalismclor plodusc de sonda de iniubafic'
    rp,uiti, j pntntnolici cougeiiit:rle. 1)iagnoslicul cstc foitrtc p;:ob;r1ri1in cazul "l',, li
    I rrrlrtnt:utu1 c(1cnu1ui hemoragic Pulmonar se facc prill 1'cntilati( .lrr
    | |li rr,ri.r)iscut prcnaiur r:u rlctlcsi rcspiratodc ctrrc delntcazir in prirntlr ,,, , t , ,.i t rlanslnzic clc singc proasp:ri, 1a carc sc adaugl tratamcntrtl irolii r l.
    I | ,1, r)r'LrlulJirlrasterc si cstc apl:oape sigur atunci cincl la uit not:rnopon(1,
    f.irl ' ,.,l l cl rrtt;:rtoarc.
    '1, rr..,r r, spiratoric sc inslalcazir dupir i? cle r1evialil. -{dcsca,la nou-niscr,itii
    L r,,rii, r'xrurrcnul anatonopatologic puilu in cr.'iclclrtl lczirui de bronl,l- ?.1I.1.6-CRIZELE DE APNE€ALE PREMAIURULUI
    I r( | l1 )]r )Di( t ( : 0! 3c nlt a 1 i , [opneeo idiopotici o nou-nisct'rlului)
    l:lcfortiJ etiologic cel rnai frec\'(,,- este fstleptococul s-rup ll beta.
    iil
    l', rrroliiiL:,rlorlul dc corltarninarc iiild ascclclclL prin aspiralia IiclidllrLi \l rr, r ,:l , . dr 'linit i c: opr ir er le'pit ali'i llc o Pcr io, a'ii '1" li
    .rrrrrriolir:in{cct:rt. iir prczenta polimolfouuclear-cloi si :L gelreniior {;ra{ir* ' ,,t,i . ,,,,,,ri i .', r l, ' Lr idicar Jic, cilnozf , lr iPolonic ; i acidozi' r : r . l: r lr r 'lir '
    ;,rrzi{ili 1rr.flotiuL dit sucul gastric, sc impuDc inci:rcarea cle ar izola strepi,,- \,, r' r r ),l i [i ;i ' Lr .i r pi] . ila pl em at ut ul m ic daci dur at a cr izci 'lc apnoo cslt t t t ; t r
    ,,, rrl li in ltcn..oculturi, ulo{rulturi'Lsi LC1?.
    .bronhopncumonic
    ,.,, ,l , l 1l s,:cut r d'c.Cr - iic1e dt llpner : r u t r ebuit conlundat e ct t r cspit r r lir
    \ orr.-ni-rscrrtulcu colgcnitalir poirtc prezent:r a-sfirii, I , ' rr.r l (i l rL:1,ne- St olie-ccapar
    l r) cinm od nor m al 1l'10 - - 50'] ldiupt t r t r r r lt t t t
    L r rr.r.., r ' . . ' . it t r l : t . " o r.\p g l rn i c < a rrd ,rr,..,r r spi r,rtofi i nsori t.' . I -..ar.:.rl , , . , ,r'r ,,,'irisoles; de bradicardie.
    \l )i ri L l ( ) r ' ,! t e s o poate i rs ta l a i n o re l e i ru ri .to a l c. l n cuul prematuml ui ctr I rrt, Ir: <ir ?rDnceput insofi afecfiuni severe ale nou-1.ii'rscutului' cunr ilr li:
    l,r,rrrlroprr,rrnonie congcnitali"r, cii{erentierca de DRI cste {orute gr-r::udr. t' l l I' , rrIrt,r-i ; r ' cer clbr Jlr ', ,scpt icem ia, r ncningit a pur ulcnt i, ir r lbr r r : ir ilr '
    l,r rl llilj(:. Pr:ezetifa;ocului, a crjzelor de apnee precoce (in priileie 24 ric ,' , , .l ' ,,1i ,,1tLri o or lic'ini. ') ; apr r r ilia cr izclor de apnci' it t ac. slc t l"t lir r r r i
    ,,rr'1si r lripotennici, intilnite rrlai {recvent in infeclia pulmonarl, orientci.rji par t c, ( 'sr r
    ' ' | ,rt,| | , ,rr! sl rnn, l, , volulie nclsvor abilr i Pe d' ir lr : - ir Plr |r itpnlr
    'i
    l,r'( itr:r'st rliagnostic,.'tparilia sernnelor chnjcc dt l,';onhopncumonie clrurir r", ,, rrl irrliltritir la. irnaturii carc rru au boli organice Acr:stc crizr: rlc
    l.l ,l( (,r,i (Lc f iatir cste detcrminat:L Ce infecfia securdari prin aspiratie 1i{l , l ' . r' rl r i ) uol . iLlr . r t - r rlu . L plt nclc douiL sipt lm ini clc vialiL la 30( f ; ' r lit r lt t '
    i,r1r1cstu dc rcilurul g'-ilstl-ic in clz'Jl rnei fistule cso-tiaheale. . . ., ,r,, ; , , ., , , ir r li | 750 S. Cr iz' lc , J' alr r " r Lpat I nr i f r ct r '' t l l r
    'l
    l,l-.;:rncnul radiologic puhionar stabile;te, ric obicei, cliagnosticul lr ,,' I i i i r L,'itl,,r, lt
    ', t tilL
    ' sor r ur ; i t lup'1 at lm inist r 't t t 'r r 'r lir nt : ut alioi. s: r r r. ir r
    ,' ,.,,"',,,t' ' t,rl,11u,r -
    ir(, l]irscutul nonnopouclcral; 1a prematul exarncllill rtdiologic foiltr-' F|,, ' r' rrri tr tii r r t : r t r t r t t t lt Ar : ize de ; Ll) nuc alc
    t i. . : cst r ir Pr ct nir t ur ilor ' |iir r i
    / { rlir inrlgini similat'c cu ccle dir.r DllI. r,1rti rl c l ,r,rrlicr Lt 't lio ( sub t 00 blLt ir i/ m in. ) ; i dr : a<: ir lozrt-nct r abolicir " ( loi; r
    ' ,,, I I,rrti :rl ,r.rr cr t lit r i i11111'qi<; ir r tr inr
    : l'u1 sot lt t r t t ht i |r 'r 1r ' dct t : r nr iuir ' llr 1t t .
    lrtnrcii I Jrollhopi]cruJnc'niiLcolrg0nitali'r cvolrrcazii adcsra spr-r lllllr, (
    ., ." ,,1,t,' ' r , r lr t t r t t lr t i . u . l') ) / u. f 11 ; 11'; - l' I'
    ' i ri ,rrrL lt nr i:ri' it Lr llt o;rl rtrs trrn u rn asi ttg c ra ti i rl c u n artumi t col ]l -o\l oi i ]l i c, st 1/:r l) r t llnr r llir ll "'l( lif ii, , I r illlz'
    i rr, , 1rr. i rrrr:r I irrI t lt 4r i1tri . rl l i :rc o rrtri i l ,i o l c r:i tl ri oa g rcsi f i r (l )cni oi i i rri r | (i errl .r ,"' " .' rrr t' i tri t r t i" r t r t t r r l li r "r r I r : r - r l" si ill) ilt ': lr iPr 'si t SPt ': 'lr r ' r 'l) r r r '
    rrri l i rri i) , s r , r ' r r r r r lt r ir i s l L rr O ,, r' o ttfo tl l r.r' n ri c , |rr' {ttz,i ,l r;rr l l l rrrrozi 10' )1, 1i I r' l rrl l l ' ,' I' 1, r , , 'I t t , 1,lr ilx, r vr : r r lilr r ! 'i, r ,lr ipoxir r <lt :I rIr t t li t t it ' |r lr t ct lr r r {t t t
    r, r,r'l ri lilr lir ll llr r l I r r l i l i l i . l r l ' ,1 rr{ rl ,rl i r' ' i r 'l izl r l( : ill) l) ( r . .

    :.1 7 1 )
    ',r.
    in
    I t:) t:ttr

    \,.. r . n, , , r-l ,l ,r ,ri z ' l ,rr rl r' ;' 1 ttr," l a


    ,r pl
    l ,lcl
    ! rnri
    natur
    ur si l i psLt 1r.' trunol i ul ul
    i t;i (l l i rl s hl l i )
    { (if( r|uirzr'rt0r:
    )rlirzritor: poato imtrrrra irutrcua aparilia i!ia clc dc scchclc ncurologirL'
    scchclc nculologic,-'
    dc scchclc ncn ircver'.sibill,
    ircver'.sibill, l . ti t;rti (l r i x -rrl :l ' i rtr!i r I' trl Ir' r' rrnIh ' rro
    buD:! dcpisla:-c
    l1 o liriniL
    lllolrtrll dcDisla:-c a crizelor tdc ipnc n ,cste
    J , ' a.pnee il neces.
    n.cn\ari n.nilorizat. ,r'
    .Jririfii,riea prematurului pe toxtir perioada prinrclor 1Z - L4 zrle dc vrlfii, tisDiazia 1)ronhoPulnrorlilii
    j ri ri ,rr.{
    rrri l i |L{ ra1l ul l norl ar:! '
    {ele!tr'.I toxio al Or)
    ll'r'ata.meltul erizelor dc apnee idiopatiei la prcrnatnr (d'-rpir ]Iarshall (\l i lti i \' \[i l s on)
    Xiirrrrs).-{c}:cmatizind, tratanentul ct'izelor de apnee consti i}r rrmitorrdc:
    - cliagnosticul;i tratamentul spcci{ic cauzal (de exemplu hipoglicemin); a) lrcEatur ;i lrcrnloPordcral
    r'i:stibuiari, proprioceptivir; | )1r! tt t i ,! )].ti :L.Y t; ! 1 00 g
    -- stinularea permancrtl: cutarati, ir t,r' o;.",1, : o n .o' c r rt:i i I
    I I i i )lt)!:t, r'..trlts c utd " :,:l ' i i ",i "-,' .. r'
    - C.P.A.P. cr canulir n:rzali"rcu presirurc nlici,L{2 -- 4 cn:rapi); . ' ,' .. i i ,.D 1r' c "'
    alir
    - niofilin ip.o. sau i. v.) ir.tdozirclc atac cu 5 mg/kg umaii de o dozll l u i os i .l c -LrL' e 4 s tadi i :
    nor]1]al:t i!1 ) .,
    '). rrtrc:{incre de 1 ng/lig/rloziLla 4 - 8 ore; !|inond|i
    - rr.ne,t .l c q(' m nrx t -,
    ,k /i:Ltr.j ll]"):tr'. .le j .. .LrrrJ r nl :r,l ' l f
    - cre5ter-caFiO, piniL la obtinerca PaO, cle 50 * 60 mmHg; l ri tLofi n:i .i si inlilt '.e ;r r:!ea ri1 -n.
    ;' i .rr '
    l oar' hi r' L l ul r' r"r' ;" '
    - ,l r ' rLr ' 1: f
    ..- ..cltilalia artificialiL pt l.rrsc--r,Iirii intubrrie. pcntru scurt tiup, - s. trL'r?rtlrrrlelrtinc olacitaic?L ?u"rt'trt'r'LI
    p' oduc r (:i i rrr!rr' ' L
    i i i r,i ' :, u^,, -l oate
    X'rcl enirea crizelor de p&ce idiop:rtiol, S-a alitat ci mentlnerea tctlt-
    1r,rrli.,rriicutaliate cu 1'C sub rormal rcduce semnificativ numii-u1 crizelot cG d) Ituc'oasa brouhiolarl rr'cr(rritl1 ' I l'
    b ro rh i o i ' l c : nr' ' .l
    Ll,r lpr'rt.: la prcmirtur (Dailel', I 969). Aceasta sugereazi cri rou-ni.scuJil | ) l nt.ni l t!:'l t E i c d ;
    c n l n o rl c -
    , "-" , ' ;,
    .,,c r t r r ,,.;naL s i i i { i l t ro . t I" r ';
    lu .:rize dc tpnee tlebuic ntenlinuli la lirrita in{erioarir a zonei dc termo. , loiLfe ,:l irucols:! i'. i""i 'lJ'r ''r i
    ziLloiil;c
    rI ttltIi-llltirtal. lii il" L "
    ' ct: ! \ ' u ' r' j i " "
    i l r t,,l r l r : t.e a i s p e c t i o i t l a ri ].:'r
    lr)t. buirtrre.r ernino{iliLrei (Kuzi:mi<o ;i Paala, 1973) re(iuce liecven{a . 1 r. o l . rl
    izii |r,,r Ie ratit" , l l j i | t r] h i -;
    .ti,i(:ririlol:cic :rpnee. Se admini:tle.,zir per os I ,5 - 2 rng de miolilin la ficcar'(l . : 1 rr -! L l ,
    .l h ,rri:, .1..irsta act'on'nd prin cresterea rispunsuhii Yentilator Ia crestr:rcLt iri'ti o''ite
    ,1{lj. lllrri. So va ajusta rloza de miofilin controlind nivclul seric aI acestuilt
    , rr, f,: vr!. rrenline-,intre 7 - 13 niicrogramc/ml; doza se va i.duce atultri 5t PNEUMOMEDIASTINUL
    2.r1.1.8. PFIEUMOToRAXUL
    t lll' l l ' l ) i l ] - e t : i l - l l c a r o la . fll lt'
    \ro irr'.:n pncullotot-axulrti clr Itn' lrrl'tr' ''li: -'tintl^ 'str' ,ll'1'ri
    Frc*'e'iap"t"#i;;;";i;i."'1f.
    , l , rr,iruiricut. -"'.ei'^ti" ', ll.il
    EOAIA,PUTMONARA
    ?.I1.1.7. CRONICA A PREiAATURUI.UI d:l11^9:1..:
    hr r,"r' i"ii
    iiliir
    ' , ',i,'nni''ii'|i6':il'-1"''rl'"i"'J'i'' lll::.:lli"
    pulmonordcronicdq premalurului)
    {lnsulicienlc
    ,, ll;l,ii"i, I'
    ",1 l'i;.
    &"iil,)"lli",ll
    i::i:,.-X1,1;,,iil;l,;l'l,J';;;
    l)rcrlatrrji foar-te :r.rici (sub i 500 g) pot prczenta in intr:rvalul dintro
    I -- 8 siLptimini dupi na;terr:, o insu{icienli. respiratorie cronic5, manifestallt
    lrr irr: tahipnec, detresl respiratoiie moderati, crize de apnee si cianozil,
    Iulrrrm si crestereaPCO' pinii la't0 mnHg.
    ",r--
    Iii;,,itil?i{:ffi**i'j..;":
    "i'j,:,l'liJ*
    ii,
    I Lrlr lrl(l {:rLsruLt: (N' P!v''u'r''
    ,'iit,',,"t"" aerul.i <h-it. 1.ng'1 .l'asrllrrt-slltl'l11lll.
    Sinrir-omul de insuficicnll pulmonarl cron;c5. se insote;te de umrl"
    1oir.t,l,.l modiliciri radiologice: accentuarea desenului interstiliatr pulmonat',
    ll: ,i,llli';:Ti'r*Hiqiii#*Tii.:1,'m lil;;;ll';t;
    :;;,i:*"l1};,"t
    voalale difuzi.. asDectmicronodular sau in retea,
    ln conditiile administirrii oxigenulrri simptomele se amelioreaz5. ltl
    ,'l,Il i'IrIill'il3i,iiifitiilii,1ft**:H11l llil,fl l'ill
    .':l*';':;lg';ll
    lirnnclc uioare sc rccomandd. un
    lc rnai u$oa{e
    parenteraii.)si iratament
    parenteraii")
    rin tratament
    trzLtamenl de susjinere
    ent tonicardiac si diuretic in conditiile
    sustinere (alimentatio
    {alimentatiu
    condi!ii16apariliei semneior
    l, iitll'i,\;1.,1';1,',]:li;iil,'i::'':ii"l',.i':ffi.jl*t:
    , ,t,ii r-, r:lrx:ttr:nzir clulliL
    t'
    :lirrice de cord puhnonar. I)aciL sugarul supravietuieste acestui interval drt , rl Sl
    ,,IIIi 1 Ir .i l s l J . , 1,
    '1 - 8 siiptirmini, evolulia ultcrioariL cstc {avorabili. r.l 1rsuslircral
    r,ncrrrii,i,,rl)iLrl li,',',l
    .r,,:,ti..,]l:l:l.l]::;:ll/;,i,'1",,,''llfl.i
    'fcsutul pulmonar al prcnrrtumlui
    1oatr: reacticna prin apa:ilia insur ,1"l;'1;'1,1,1,,
    , , ,'""l;il:lll',1'']i.1'ilqi',il,,il',-,,r,i"i'"".i,'q,t",i"t,"
    '"'lllil:llilll
    t'icii:ntcipulmonarc ctouicc la tliirilc roxc: aspiratiarepctatirde lapte, lolo1 -
    lll'iilIl""il,i,ilill,i'll,iiliiii,;il'l'i::".1i'iili:1t:lllli
    ,i,i:',.,:'', i:,.:t,
    I,l"ll,llj::1,';: 1r)i : r
    l:1i,,1],1,,",,;,;'illl
    t;ir-clrrLnor conccntra.fiicrrsr:utc rlr'^origcl, vcntilatia artificialiLcu prcsiurls.
    I'r'zilivi :,riitrtrtlrr!i:t,:trdott;'lrr'rl.r.
    lrt ttt:tcljcdc {rclorul ctioJr,,;ic irrcrimitrat,
    '',;l,l,ll',li:'l'll;,,l,liiiil
    ,lli lr' ltlt:
    :lll,:lllil.'r"i '
    ilii'1'''1',':i,i'i"i".,'.'
    \Vil';r,rsi i\4ikily(t96rt)si Notllntrrl' (l9ir7) pc dc aliir partc aiLclcscris doulj. ' l I irr1r,'z,"tr( " '1r"'1i.1.]il,lil],'l
    , 1,,','',u'"'""''''l"l1i
    ],1 , " ' ,' .1" ' ,Ilii,l i " ,]' 1" l:llll':'1,,l'l
    i:"']t:i;'i,liil
    ' " ' l"i '"i1,l ' l ri rtl
    ,.rriiI;i1itIi{rrli1rr
    clcinsuficictt{i1rttlttrorlttri. r'rortjcir:tlisrrr:rtnljtlrtr.l
    l)ulmorlaffl,
    i lil],,11'
    ,' ,"r.l ,:' i;,i
    1r,,l ' l l l l i l i l ,;' )i '
    '"" 'i ''i"'il)rr':Lrrrr('1'''(lii)
    il'ii'i,,';;''';".,'
    r,ri,lir1'lrrzirt (lrrlrr'lrlll.'16;.
    IrtottIrrrIrtr)tttrrtrrttii
    ',,'r:ll:li :l' i r
    '' lll
    "i]i'
    (.1 )r' r il r ! lioloili( , fi r,r rrr ;r(r' r.r. ri l i 1 5 u l )
    r)l )sr r ' \ f ilii. s i : r ll) r' { rl r' r' rrri rri { (r' (s (rrti l c l li )l .csi uD c,se ti no nou-ni i sautul :ul l .
    i ' r i gr:' (cu 2.r.r.10. vENrltATlA PE MASCACU POMPAMANUATADE TIPAMEU
    raoni tori zi r* a I).()..
    ,1 1 ,' i ' . , , |r ' r . r r lur ) rJ rrr1 ,,i , l 2 -2 4 d e o rc ..Ori ge' ul
    rl i zl oci razotul cl i n:,:r.rrT i
    rr,I)rlurlntor.r\ sl .rpr,i.s,..lltsoarbc cu usr.Lrinii-rprin singe. Cincl ,-,:.rLr. l,!l, o tnt'todiL sirnpliL t1c rtntilalic folositii cu succes irr rcsuscitirli
    rr||l')r.r\irl c Srl-.peciarcluric si. r'adiografia toraiicii autero_posterioarl sl|lii iLr tinrDul tr:LD.sportului $i illaintea sau ltltrc t!'ntatil'cle drr i111lr-
    s1r.
    i l)ir.nt 1rorn.]ali, sc {acc o radiografie in iltcubit lati:ral
    cuiu bernitor:,:t,1, . l'orrD.L,\ml'rr,r sc;lo.,t, folosi in inteliolul incub:rtorului utilizincl cotl
    l 'l ts, . r inl rrii;r cii O" tlc 1a accst nile1, sal ba1ol.ru1 dc cauciuc al pompci sc l)oittl
    . inqu.s r' 1 ,ri n ,rt;i i :r..n .1 I..l :o l ro.rr,l ,.i t,l ecri i ,tn,, oI .:rl . stabiliti O! din interiorrrl b:rl''
    .1 ". . r lot l. r - \ r . ,.r ti ,i ^ l l r1 ,,l ((' l ri " s ), 1 i 7 . \1..1.i 1j 3 r,rnor.,_,1i .,.r: r , lr: rlr: la o'sursr-r c1e 02 cu concentralic
    t-,rr. i ul ., .,,
    ..r .,r r r ' rr pJ . r ' f o..L . . ,z rrri l c d ,. .i tr,l ro :tr ,' i sc irsulliL printr'-o inasciL aplicatiL pc {a{:r nou-nirscutului acopc'ritrri
    d ,. a.pi rx.i ..,l " m.{oni ,:. } 1. ,,.!
    I rr , r r . r l r 1 i: r . ro ,i o -t r.i o r ,1 1 ,.r,,,..1 u ' ., ," ,,i ' ri rl . .gomor,.t^r . ,r ..,,. I l ,i :i r' i rl l Lr uc:L Pom 1r , , '1 pr ' r r zr t r "u sr ll) 'r r ir dc 'idLt r r 'i' 'r '
    : |l r!rlr, l. r':r.lroiostL.-L , r n' t, ol l : t . r ir t ''lt l: Li i l t i"'i nt o'ir 't 'i I n2i l'''r l 'l' ir l
    ,,in fluturc,, a tjniusului sr-tstrcazi dir:,,nor.:u.rrl 'r ' 'ir nl'r l
    i l|1 ri )(rnedia,\tinull'.i. dac:r sc oblinc o rlisLttrsit
    ',li ftr::. \tlti1:rtia Dc maicl cste satis{irci.toare
    t,, .rrr
    ll.,, rar L. dar posibil-1, rL lL:ntilatici {il.tificiale estc pro.iuc,,.i,it ,,l*fi"i iorii.i.i .o {iecar.cinsLrflatic 5i clacir culoarca nou-rrirscul.rrLoi
    .ll l,L1t
    )llllo; \ ' l r , f J l,tic
    llu ..to ..o 1 J t d , ta n r1 ,r..trr ,,rr.,l l rr .j ,OI r| s j -" uj ,,r. 'rrr,liltcir.zir.Cu accastiLlr.retod:lsc'pot obfitLc :-t'ztltati' {alorabilc irt p' '1
    ,r)i | ,l i , zrrri lc, t . r nit l: r l. r - l r
    'i ,,t r , r t il r , ' a- J r .l .i .c o r,Ij rrn rr.;, . r., l j o l .,-i . . r .,,.-t.i ,.ornpl i , :i ;i p r l i
    rl\ rt,, r, d.rcr dr',najnl pneumopericarclului si: instiirric imccliat.
    I. VENTIIAJIAASISIATA
    2.11.1.l

    {'i:','.i instr{icir:rl!:t llriPitator ic rle'ttnr'iniL o rrcftrre,a- i'Llo: ttr:ti tt';rt'


    2.1I.I,9. OXIGENOTERAPIA
    I.A NOU.N]AsCUT
    ' ,,o !l 1r 11g (la pr i: r r at ur ul suir t 500 g, , io nI lS) ' PF. t r {r 7, 25 si {'r r lt '
    U ,ll]l',r..r1;".: ,le {}. iu l,olile pnimorar.c ale nou_rriscutulti cri,:tc pl( ,t) rrrrr lI.(, noir-tirsctitul respirlntL infl" o conccntr;ltii' {le 0" (lt li(l'
    . ., )r .i ir ]ll,rlisit:t r-tlrtii:r-tio asrstatl"i.
    ,/ttl l,nn lulLurj[j]e tlc tliiuziune si r.le rurtiJaf:ir: si irnbuniLtiLl,:ste oriii
    i rr.||('ir t('sutudlor. Cu toate ilcr-stca, .]clr]tiuist,:.,renii. (.r,
    ir.r con<xntriti,, POZIIIVA€ONTINUA CPAP'
    2,II.1.']2.PRESIUNEA
    r', r , l. r r r ' , r q. r r rrtrrlc L ,j r:t:. 1 ,..r.,r.,,.,.rJ
    r .ruh.l b,1.:,i 1r1-i rn;n ..,.,." ,,,
    l L! l { r o\i.c ocula|c -si pu}mor-tarc./o-sigelrrl t,stc un me.rlicamcnt l ,,l o" i t' cr C lr , i i: ' lipr lziuLir 111cLo( lli dt chclio 1r 1t r ei'lLlllr l) t t ll l) r ir li
    l i.
    lri r:u DR1, aturri clncl acestlt irrczilliL rni;citti ttl-spiratoLiislrortlr tt'
    j'
    rl i rj l Ll tnai o; - al nct or lci r ol- ! t : r 1n cvit ar - ce int r t ba{ici ir ': r hr ; 11",t 'r r '
    2.'l1.1.9.'1.
    Fibrople:iq reftolenrq16
    I rllirrnl rnic poate a1'ca el(lcto :iccundarc catastrofalc.
    \ori niLsr:utirlrrlsDiririntr-mr sisttrl in carc sc rncntiuo o pr-r'silttl" 1"'zt
    irr r:orrditiile aclntinistriir-ii^uneicouccntratii c:rr::scutc clc Os la lreln?-ttu., ,,)1rli1111icatc, ii ansmi{incl'.r-sott-ansprdtnorrar, irnpic:tlicir l)l!)iirr({ rt '
    r , l r r r r r ir r i o- c1 1:r. -r a l ,;rO - p r.:n o n \O trr,tl l -. t,r.o,i u,, \a-, ..{,tl ,il'liii idvL-olirrla sfilsitut r[jsl)if itlici. .\nlcstccul dc aer si o\ig{ t], lr'' r rrl
    ri r, l t ' r , \ " 1 . ' 1, ' li \ r:,.J O t .l i n ,, n -. i ,, .t r rl i rrJ trrm," ,o:, \.,r_, ,,. n,. i ,rl , ii, ii, , t - pr , r ( i, r \ 'r l , r r
    rrLrI r,i .lir i, . r lg, . i . . , r r r |, . : . : : , I nr', . ' I
    rr;rli,. pirltrrml in umoarca litroasii la livi:lni c:iii:ia se pioduc
    hemolrqil; r lrr lriutor',il unor' lclzi ola-ctirl iD ilatnl norr-n'rt' utttJrLi [-rtttgitllclr ltr
    'r*'rttrizrrr.ii filtr-oasiLcu retrar]tie si'clcziipirca clc r-ciiriir ietcmrnir orl,l,i.rr, ,,r' aiLr( Di-Ltru[d ilt nasul nou nl-rscutului milsoarir intrc 6 mnl (lrr 1'r'
    l', rirrr rLcL'simotir-, in con-ditiiie it care ie adntinistreazl
    i )in rr:i11:rlc 40t),o,i\tr' obligatolit ,letlr.ininar, . r pr0"J.t jutirval
    0, in r:olc,:ntla1ii. ,' rrj ,.:i r l i ' cut : r t ca int r t 1000 I - i00! ) ) i l0m t r t ( 1'r r t r r t t - t t isrt t lt ll
    c,ic,
    "1or,., lrr l ' r. r' ' " 1. r. t 00t f - i if lt r lr r 'li'r , r "llr l , l' 2m m \ 'c: : t c: r r r r l' 'l'r ' 'l '
    'ro | r1 l ql| lr nu s o d e p i l i v a l o r-i l " c l c .6 0
    | ir'rzirl'.r u rlrcollar:eatrauscrlt'uatil a sir4r:rui dir artcia r:ad.ialil
    'I
    q 0 ]]tutH .-. \crst l ucru sc;' l rt(|
    sa. rcrl;i,: iirrr'1
    ,il ,1, :' ,i i tl .L, 'n, i, t t , it , '', li 1, LLo lungir nc de 10 cr . t tsi r Lndiar nct lLtt lc 2''1t r r t r r l
    r l.zistL:nfiL <li 7 ori tral rniciL lir Jlurul do giiz I'n^siulca.pozili"i
    'rrtt frtit .lLl r,t Lrriz;l] ea r rei artere onrLiiir.alc. S_a constatat cii crtsi:r rt, (:l),. t; -
    r,lirlil slr'irr:;iihtre valorile obtinutc prin mirsrrr.art,a ajutorul 'lrtlrLi sistill sL ttglcaziL pl'in illtrodlLccrea tubului dc sticlii A ir)11 Lrrl
    cu nnui elcr:tlorl 2l- 11
    i r)(i l z il ii. ( i! r ' r ' dif u z r:a z i tl a n s .rrt;ri u t,1 ,, t.r n i vchri ' ,.1..r ;r.r'l. r l 1, ir "' l: , , 'ir : , I r r l . lur il 1r 'ui t ig. 2. 2i - i
    i a.j i l i u el or,11si ' i -1.r.
    ;.11,. lr ' rLrui ,JiI i(
    ir 1, ', iL|(l, r L,ilLLll. , iociir uic. sc dezvolt iL cu m ar r ' t llllr ir ll l ( t
    r , , t r iS t c r r iLlui t l a n s c u ti u ra l s i l ).r{ )" ) i )..j ,..,l ori i , r, i ;i r, pot i i i ni l .,ri ::i ,rt,,
    ',i rttt, ,, ri l i r rl cz, ir t li:t<ir r Jor plr iir cli'. r ( r si I int r 'iii lr r lr Lr lr r ir r r iI olr ': r il' iLr
    'l ' trr' t r r lili. ir ' ll.r it : |c r{ rz i c a l ri t(' !t' r.)r,Irrr' (c o l n| s, hi | oi ci -ri ri rJl rLr' ro(Ji,r.ri .
    ,,rJo or r s i, liir r r l nll ,q rc s i v i -i
    i rti . ' .trr' ' ,, 5i; , r t t t ir r i i r Lr l it Lt 't r . r l r l' 2f it "t ' '
    s i P c rrri l i rr,i ,, u r,,,,i 1or-i rri r.,, corrti ruri ,i I' r l )r, ( t "1 l'. at I 't t it t t lt , ' ir r lr li r l r lt t lr i t r 't , 'lt t ''
    ' \. !ttl i t,r ! it lt
    I ' r ' lr l ll ; i I r r lt ' e r:rl r1 i ]l rt
    o ,r)II(,,I)IIi ri i (. (.o l tS Ll tIti .iti. c O, D t;ri t!l i l t1 rl r. or;t rl , l tl sci t cr t r iI r r I ot ii t t t sr 't , pLllr lr : , L ir t r 1I it r I ir 'Lill'l: llir lr 'ir r r {r 'lr ''lr r zir r
    ;{,",,, . r ! ( s lir s r v jl i l (l u l i )l i s l i l l o l ,,ri rr,l r, (u (i { , l ri tti sl );urnti r
    r.rrr ,. .n ;r,1i ,rr ttri Ittl ttl t t t r jit r li 11r 'sil{iot l: r l,'t r l' \ 2 r l. . ': iI 'I : Lt t I it r i,I ; r. " i . r t i: t r 'r t l: r l'
    rl rl r ' r ' r t ri s r' I ri rr lrri . l l (.{ rl (l i (i i | . i u tl r.r. rrrl nti l i s(rtr.r,rr,l Lt O" :rtl , rl ..u r r l, . r r l" | ''t lr : i l' , 'ir r r lt iPl, r i' it r t t 'r : 'lt t '
    ;tri rr
    r',,1 ,i r r r r , lr r r t r r I rIi rr. r' IrIrrr i rrrrri L rr,rri ri r,,i i ) ,10,,,;r1,,l ,.i (),,,l ri l ,, l r,_l,.,rrt
    || r,l I , |' / I I LI , , i \ .rJ ,,Il ],r. l .r trrrl i l ,rl i r ;1 ,i ,t rrl .

    ,ti ,
    r :i l l
    dck'esei"res.birclorii'
    It) In .'pruenla O"t!"UO
    cutahipnee
    NA5
    rlT1f"?tt#lil;
    *f**'#$n:-';.,:l'l':;r:'l!Si:i3''i"Ttr$:"$
    :Iltffi ,:fujiil*
    r 13;;t'
    ;e$.1.i:iilfii?#xrrl'*1?
    riinirl;*lft
    ,,''',0,'llJ.',.:ff '
    :il'*ftf
    ' ia2
    "+E
    lil r- r ":',:ili:tlf in s"
    nxpiralie po'tui
    "rirrtrurirti
    "#ii;:",.ti,::i:,;ll.:*il Irr''
    li'i;i':il,;i"j'i':l,,Lllt',i,1'"',i.".u6'
    i,i,,ii,iii'.,5,:;.1,
    i,', "" *q.r
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    C'NDENS,ATOR
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    sarr
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    .' r, i l ri ui i n r '.
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    l rl , i:
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    Cu
    $"::,)jl:';;,.,)ll"i
    corstirnt
    , .',rlr, irtul.r;rti:r ir-ahcalir este rnai e.ficieutl.
    di: Saz {urnizft iutcr-ntitcnt in tirnpul inspiratii,i
    o[,]ftrr-ca -,.o1urii unui Pistr,D. Diu accstt tipru.r ric rcspiratoarc amlntirn:
    l':l
    . l l ,r . r r . , . i S t u- t - t -1 0 ,,, ..)r(.rl { n s l i 1 n ra .., ,,1 i ' i rl i cr-..1, -i ,i " " i t.nr.,- 4. INTUBATIA
    2.1',r.1.r TRAHEALA
    .i
    l'(iir'.r'urt clc tip- r-i:rrii.1alorut Lr.er^r:ics,i tui-'i"rzc'u'
    fr,.\ su{icieal
    :r rtailza sio;r1ui, rlirtrnarcr LO, l nl rrbafia const i in int r o. lucer ca pr in or if iciul glot ic a r t nui ir r l', 1,
    i1, , "
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    ' r , , , :t .rl r.,r:,r.r,L l i it,r. r.,,,1;r:: unr
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    ;r pie.rdelilc r1c.gaz din sistcn (la rrivclrrl son,:lci
    , lttrlrri.r,.),_rJrite 1iP d. r-, |tilator prozintil rrrrritoar-cltl I l )r{ rruatur ul m ai m ic dc I 250 . q) si 3, 5 m n ( }a r . t ou- n5. scLr t1ur 1 r i ! 1r r ,
    clispoziiivo;
    \ ii\ , r . 1 . l rz ..,1 . ])rrl l ri tc u i i i -l L u xc rr o proporti c 1,. .l {xX)g). Soncla dc intu}ratie sc Poirte introdu(:t'pc gur5. satt pi' t;arr itrrrl
    ti r,,, .
    dc O, i nl rc 2l _
    l rrrl rrl i i ru <; lr cr si, in conr iiliilL- -r 'izualizir ii or i{iciului glot ic . l it jli', , r 'r r l
    dr' lcqlaif a iilot'rLdri diu!r{, insfiraii..rtcrpir;rtic ir L rIrr,oscclpului r'.n lamiL drcapti., .tr)istanlala cale trebuic sil ajungil \irlLrl
    . t ..
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    ilc rc''-{arr :r prcsiui'.ii rttrir':irrr'-r
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    i, , , ,;,.,,, i 1,1]"t"t
    L1ir,isc controlcaz:r totdoauna r:rctriologic.Inaintt't ;i intrc incr':r:i.tii ,1,
    lrniriiiicaior at flurulr,ri ctc saz (32_31.C).
    lii.i,.t:l1,ll ;i rtrrxi uccrca sondci t r ir ht alc ( t enlat ila dc it r ubali- 'nu va dcPiLSi30 r l, r , ,
    .,,',,,ri,ii"i1]1'',:'l;l'|1.':1,'"',t," crpiiatorii
    "it,ti!.,oi]"' poziiirre
    ia siirlirul ,l ,,rrrLr:c pto( lucc br aclicer - r ct ic) sc la vcnt ila copilul cn O , 1001; ir r lt r r r r r '
    Iri:1ty_j1i1. r-,..q]:Lili vcllumr rli r.,.:piraror. cvtcnL (tidal. uoiuut, ,,rl pc inascir. in condilii rlc trgculir, in apneca la ru;terc, sc \:l l)r'lL lr
    l\,. rzirr , i I ttLt0l -d, i,1,,/,rrr(on_stant ).
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    ri , r rl, lrz tlc la nir.elul sondci dc intul.,atie
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    Sr poatcpr,tittt:urt'tii!i/Jr,,i-.oirr,n". " c* 1.cspr_
    ,,,,
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    { )r;1nzitiv cal.u p.imite t-cglar.,:;r riiruuhii rrspirator. rr,r'nrite picrrlct'i clc ga:: la o ptr,sitne pozitiviL,:'le I0 ctn l].0.
    l'(rn1ru ir Pr-c\:(rniohstruarL'e sonrlei cle in.iubatic -(c Pt:acii.jr-!asPli lil}
    ., , {)i:ipozitir car._. pcr[ritc declansarca ritmului respirator_ clr cit r.c
    ttlr) (lti!.\ti'). Acest dispozitiv mr poati {i declimsat dc citre copilul rric, , ',r'Lirulului sin tlupiL cc s-au itttrodns 0,5 ml clintr-*osolulir: c1csrrt-fi;'io1, iir',
    rirrrrrl r.r,srrir.:rr.L tiind cbntr.ol;rt d.i iner.lia ;;;;r;-"p;;;iui . ,,,ljcinir ;i alfa-chcnol r-ipsinir. l)acir cantitatca tlc scclctic rorort;irri r.t,
    de respir.at
    1 r, ,1 rr r . i. r l1t , , I . oo s c < t,.).
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    . \ . . / jolos l r c L t r c s f i ra to ru l n ,.i : ( T( '2 t nint r t L' cir . ( ) , ll) ll',
    ' ri rl rr sorrr llj . q( ' \ il lLnlila illt - r - t ir sclr t ul t jt r P
    de .1 c u p J a ,a p a m tu l l i l c o p il se va contr-ol a et:rnsei tatcl r
    .,, ,,,, . . , . 11, : l|. , , .s ,
    ' ' rlllll|lr fi )'..\'a rfglir rrryt,lL supcrior a] pr.r.siLrniitlolitc, astupincl 6rificiui
    l )r' l ol ttii 1>r , t ior r r YLlir ir iila{i|i 1r r ! l1licr ', r t t ct licLr li5i asur nit l'c: il) ol) s. , l, il
    r rl ' n r r r l t ululLr i cr < l c 3 c tu l , i l t i r l ol i l l i ir s<t lr ir r r lr r Lr il<lt - i: it z')i'- a!lc
    ; (nor ll r i. l) c acclil, , 'sil r r ,
    , . , - nir sf rulr
    . S,"r,;rrlu1rcl il lLlnp(.r.ir tlrl! l:lltxnlui-dt gaz. \intilatolLrl <1r. Lrr (r r |r 'r zr 'loL ; r r r 11it ilt ,5i r r plr iLr lli'tr ii, r l r ilr lr
    | l rl ,l rii( JI izr r l. L( ) ] lliDr Ll"L
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    i ,i tr,1 " rrn , Il u i < l c g rL z rr,,i n c l -L l zi t)accst Irrcrri \, :,l c Ll .zri r i r , t ot l, 'r 'ir t r tlr r t t r r int , Lvr t l r iL 4 ot " si ot 'i ( l( ' ( f i1L , , t i sl iir l
    . lr r lr r iz r , r r z ir
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    | r.trl xrt-i i trr.rl r,
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    | ' rr' r ' lr ir , r l{r)r lI i, ir rrl o rIrrc i rrrl rr 1 ,.ri t rrrri rrrL rl l i u i ' ni cr.i < ,r.rrii , ,,',., t ,., r, , ,., i I ,, I L I rl i D (.i ' ,r( ) , i, lr ': r 0 f i ', {) r r r llr . : , I 'l( ) , i: Ltr i5 ii. i5 r | r ' ll si r , ll
    I r t lir r t l rrr' :rj tttt| i rIx rz i l i t l ;r 2 i tu r l l ,.() r.i | i l rrrrri rr,r;P i rrr]r,r
    ,l l ) [o ll rl r ,/,l (| r,, r/ , li\ ,
    '

    "l tl ;
    I
    ( L 'r l :r I- tr l r :L d I l tl ) r l l l -
    A.1- lnterptelsredrezolldlelordo:irilor rlc'goze
    2.i1.1.1 tO ], dinl,rt:rlrrl r l L c"sci o r .l l tl o tl 'l l 'i st r l fi ' r ' 1 .'1z1
    1 ]n ti l l L l l
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    a ,.,*i""r.-,'1'l
    | estc dlterlti
    con(enitalc
    ( ) j,i.-,i.rc l)rrsc:r a laO, 9i o crcitcre-r PllCr" lnsotitii dc dctt't'iotrrI ' 'atii '2.4: 2.48,2 49)
    ir.b"l"tr" ,
    i rii r:iirricLr a nou-ni"rscutnluit
    colICirrll'ir
    '1',1.11-factori care tin { J"..pt"*1,1"..1t1'':f,1i1tto'' t"b't1"'"t 1'dbetrl' 2 47
    ga,os, dc{cc}irrri 1ne6'rnice oirstltLr'-
    li, ,lr'(1.,, itiLicl,,rea c1c ilui , -di:locarca'
    ' ",r ,,]'ij,'"i.;"1;..
    :;i li:]',:i"il;,,'l"Ji, {, ,
    : p1,,1r:,o
    o",ll"i;, ln lrtunul xr de via-li' 0*305
    l'recreD!a lrolilor ca liaoo con$cnilalc L.I'., modificai)
    zile

    ' ",,', ' - . il;;'ll il:',j: li:l:j 'l[i]:";,pill"'lill


    (drPi ISucleY

    ':;i, " ProceDtajld


    ,,.' '
    ',',,,'l,ii-
    ''it":
    ir,"*"rpirnzitcri t1e'vJntilafic PaO, cste datir clc crcltr'
    scititr''::i.
    prir' iLel''c1 zie plogresivi A'ccst jrarl-
    l)iagtrosticul

    :Il:lil;.,iil ;:i,.!,:i
    i, ,,rri,,r'ii'.""it'in.intrapuh.rot,'al

    i.l":";r.'g, ::..r":,*..lnl u i .iilliii:


    '.,ipiirturie yrzitii-iL-IEEP ::,..l.ii.
    ettl
    (fositi.rt.
    1i,5i1\11
    c:rfiru tr'"
    t'r'ir .ele 5 cardiopatid iat ardillea Jrecl]eklei
    I )ofcct sePtal vetrtricrtar
    (49't;)
    16,1
    9, 2
    lr;'pr:.ri i""o 'l,rtraloBie Faliot
    -
    9, 1
    '1 ,rnspozifia, artelelor m:trl '7,8
    '"' "']''.i1...',,r,.,a pcoo i1r:l rlodi{icirri i1]trirr''rtaltcale Pao, estc Pr1}rrsi ( irlrctala aorter
    stilg
    7, 0
    r,,sl, iila'spritiului dort
    l, venlilai:e rlar nepeduzatc) ; se c{rLcft(rlziL
    iallcole
    llipoplazie de ventrictl

    ' I'i't1';1;,,",.', sr.)"!


    hiper',enti1af,;.. I l tttlitoafele 5 ca','d'ial)at;'i''itt ovtlitea
    fredefllLi (21%)
    6, 3
    ,']id":li:1"1i;u"3fri"1;ji:"'ii,,. r..l erea r, zi steotc i v a"c ui ' rrc
    pul rrona:"* 5'7

    ,,',,luliilii'l,l'ili.;:
    . , : l , ii",,l',1 'i i,'
    I ll:li;:l,"Jli1i,,i
    '
    l! r'.istcBfa canalului arte ar
    l ,, l .cte eB docardi c e aurl c urarc
    5, 0
    3'E
    , 1, t . r 1' I- l o ' r l z l 'l rll i l l - ': : " 1 1'Llpozitie _ 3, 8
    r. rri r..:.'t:r..i'h i-lir r in. ur jlJ . : '1 .
    'i , Tr,," ,^t'' nii.ll' - 'r:'i'r r'r- {l:io- 70" ') ,ir' ozi Pulmonari'
    \' '' Y. -u]
    ', tl tr oatrfotmali'd (26'7aio)
    '' ' ; , , , i, l'. . r i ' :"l i . ,: , 1 1 1 ] i . l ' ,-, i ,' ' r ' r " r r r ir r ii
    fr ,cio n rcr
    hidine, aspiraJiei de mccorrirr'
    * Se ioclual aici Ei lormele secundare 1nembrarci
    ,,,
    1:',:.,;;il'1''1" l,\'T.i?'.,*
    ,:;';il":l;1":;ii:i':i:"':::'fl
    rtu" ','..n'""'
    *:f,'r:,1i1'_,X'l;::ll
    de hiPeoonceotralie etc'
    , ,ri.t,i,ii,.p"r19*1 l*f ia s0-f0 cn lr"o, ',,lromului

    ji*i1li'l$T,xri
    l;l ll,ll;r:;.:,'* i"""#,,".?:1,3"";;;'*.;, ."1,i
    '" attllil prc c ote,0-7
    Tabel d

    zlle r
    ) l\

    rfl u{ ' t' i l al c l rr I rrioaitu *co


    ;l ,l#;;i: ,,.,;liil,\'1,,.",,,!
    '(,1,iiixli:l*,I:.".,,:,:i.ii j:1lllli,
    t-""r,1..1. l rccr co!a tardi Ip$l i i l or
    (duf i Ltuc rc 5 L. !., odi fl c ai )

    ,, Lril ,rir,r.iari: a no'o-r.risc*tu1ui,'co1t:?ft":i'$:.i',;tii;':ilrii,T|:,i)liil Procerltaiul

    'll ,,r',i -1"5":'f;'"111liil'1 ms .le r,fri.1n1,,ri,.,-iru. 1.\..pcntrui-a tr)rc\''r'|r


    1'3 rislll:l orrpclrolt(l'l (r1 trL"1r
    , ,l I 'lll ',;1'
    1l.iiit.,iil.llupil deirl)arc nou-lirscutul su t4,6
    j":iljl3:ii,T,:iillii,lli
    ,,'r,t:i,.li;.,.iicJnur:'nazati,"r:,"'"1.,;1l,.lli,ll",i. | ,r rr)ozitia arlerelor' n1ari tz,o
    '"', r''
    ooo-'i'"iii''r"i
    , r, . ,,t,'z '" d, v .n l r i c u l s | j n g
    ' i c s c rl t J
    1 0 ,4

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    i, ,;.,ii;,,'];rit"$il; i':.';':'lia
    ..;;; 'J,i,ni,,, '
    '
    r r r l J /* \ u l . l f ! f I L ' rro n l rJ 3 ,4
    p"
    i; .;;,i',i,,"-i,li"i,i".
    i"iln"il:i;;i,ii,l;l]l,llnl,,,.,l,i:;iiT:i;li,,l,),il,l"',"'' ,
    r,

    '
    i .r l ogi e l 'al l ot
    L,i i i l 1l i l c or tel
    6 ,6
    6 ,6
    I l ,!r t s ePtc r v er l t l ro l l l i l r 5 ,'7
    ,r rnl){r;Li-ir';.i constant:. ii 5 ,5
    \ l .,l LnJ r l i (
    tr' ' r r' rtrr' 1.' :r' i I' It, -1
    '',':,i "'"',r',"
    BOIILECARDIACE
    2.X1.2, L
    ',.'
    l rtl otrta cartl l .i rtl rrirtf1' rrj rI 3 ,O
    2 2 ,\)
    I ' r rlr , 1' , . ir r
    , l ;,,,1 1 1 ,' l ,,i,ll i' ,: , , ', , '', : , 1i: , 1',
    : :' ,' i'lrl '] ' ll, lijl; : ] , ' \l rrrr.l t(nrrri r l ri

    ni
    |0 l l , r : r lt { r r r r ,,', r ti ltr r l t 2 J",u'.l )rrrl l l l i r
    rl l l l \l
    1 0 0 ,0 ( J

    t t ( u ) ,,.,' , ,,.,..,.ti 'i '


    ',,1 ,1 , . r ' 1' , 1 ll i,lt:l | t. rl \r"l l 'r'l r r''' l ' l "\' I
    l !)(;' \ ' - l \7' / '
    , Lr ] i, r l l , l i r 1 , r i,,,r ,I ' ' l i c i l i tr' rl Ll ' rr' l i ;ri ; l ' r' ' r11r' ' 1"'
    ":t l '2'/"" t|r 1t't1tt I t r) I I i| ,l l r| )1, \\ l l Lti tl t !r1
    r t ' , r Iili ,r lr tlL r r ' r r li"lr r r lir ', )t,i i
    '"rtr"tri 1'rl L'
    , rl. r' , , r l r l '
    : I i1)

    Ir
    'lul)elnl 2 xl
    'Iab.lkl 2 4t) ltl rt0u-nlsort' ( Lr'l)'l
    I I fr v .| | l l r ( 1r r r '!l I o s o i ul l l l (|tl r' ei { rl oz i r Itrr(hol l l o.c l rl i roe c on{ l c ni fi tIc '
    Ireclcjl( eardiop{llilor congcDltalc h perioada lreonalrli t l di l i de 8-30 de zi l o r
    (dupe Brcley L. P.) Procetrtaj

    l)iatnosticrl Procentajul
    t,ttr,'11nc(36a, tu
    )
    9 ,2
    r, l !. l 0l ti i t [al l ot 9 ,1
    l)r,1ect septal vertriculAr 16,8
    (ioarctatia aortei l ' r'r')zi ti ar artc rc l or marl '7,O
    15,9 '
    rt,,,',trrzi
    'i ii, ri dc ve tri c ul s ti D g 2 ,9
    :lianspozitia arterclor mari 3,4 i ntac t
    ]',',i , r*1"- "oti r, c u s ept i nterv entri c al ar 2 ,E
    llctralogia liallot .l ,4 2 ,4
    |)c{ecto erldocardice arr culare 6,0 veooase pulmonale
    ,',,"",,1i,, lotnte a lntoarcerii 2 ,3
    I lipoplazie de ventdcul sting 5,3 \ 1,, , ri . (l (: tti cu s pi dl
    llczistenta vasculara pllmonarir, crescut:l 5,3
    Ililsiste[]a canalului arterial 4,8 ! t, t! t ai anagtna (39o/o) 7 ,8
    r\nornalii tolale ale irltoarcerii venoase pulnlorare 4,7
    Vcntricul u ic
    , ,,'i ,l ,rl i c aorta .5,r)
    3;2 I r, l,', lr' cldocoldicc aurcutare 3, lr
    Total 100,00 3, 2
    ^ll'l',i,iii nurrnonar:! 6, 3
    13U-5copii ?n ,, The New England Regional Cardiac program, 1968 * L9' 77," ,,, , ,i,u,,ttii,ri"r*o"tt:l '/.rscuiad crescutir 2, 2
    \l L,t ,!'l i ti "l 11,r

    2.,]I.2.1.DIAGNOSTICUI
    CARDIOPATIII.OR
    CONGENITAI,E t.. t,rt(,1i t (2 5' h) 16,1
    I| 1,, L r|rJLal veB tri c ul a"r 5,'l
    Ilolile structurale de cord pot simula boli puimonare ;i bolile pulmo,. r!, i, r'irr cr.ualului arterial 3, l
    '
    r r r, , :i .t'i r atri al
    rnlr:1mt sirnula boli cardiace.Adesea,boala cardiaci cocxisti cu c"a iul-u-
    arlir (tabelul 2.50),fiecaredin c1econtribuindl a tabloul clinic. CeIemaifiecvcr:- I .t627 c o|i i N ew Englald Regiolrl lnl:rnt Cardiac Ptogi{m' 196E -l"l// "
    i n,,The
    1csenrtr"4" Ot"r"ntare sint: cianaza(213 din cazuli), insuficienta cardiaci (1lZ
    'I'abttrull ':
    rlin cazuri). eritmiile ;i ;ocul cardiogen(ta.belele2.50, 2.51, Z.5Z). I,Iai rar, btili
    ,.rudiovasculare serioirse_ pot fi suspectateprin descoperireaaritmiei, tahip- eu altc alccliuni care so lot r[rrrllsrln
    rrcci, hepatomegaliei, edemelor peri{erice, hipertensiunii sistemice, r-itmulii |,,,,'tro\11.,ur,rrrcrcriirr
    ",,fi,1t:$:1llT"":,:1,:l1tJ"[, (du?ii Ulmer H. E')
    (le galdp sau a tnui examen paraclinic anormal (raOiografie toracicS. sarr
    S e Iac e di :!8l rori l i '
    Semne clinice
    l )i rgf l os i i c nl
    inseUltoare
    dilerertial l)rirr :
    ,l(" bazar,
    1'abel l 2 5$
    llia.qDosli{rul ililer€rttial lntre eiaroza de etiologie FulmoDar,ii Si eardiace nCG ICG fr,ri. lll(xlili(rirn
    cianozilltahidisPnee
    testul la liperoxie; crl or( :JIr:r
    '
    marcatir a Pao!
    Cardiace .L)CG aspcct de cardio_
    hemocultur:r ('1-), 1'r)rrrrr'{l
    nriopatic
    peoie
    tahiiardie, insulicientd llb < i0 S%, amcrtofilr(
    L, irnic p!'r&aturitate, cezariani, mam:, copil ]a termen, mami! diabeticir cardiac:l
    dupe tra]rs{uzae
    diabctic:l P aO" normi r,l , s i l Ll l r:l II
    \r Ll ' 1,,,'t1l ()1i i rr(rrr;i , ci&noz:! ti hiPoxie /r' l '
    {lliirirl detrese rcspiratorie, disprce, mai mrrlt cionotic decit dispncic, ri ter-i eu s Ll z ul ' !' . ' "
    r
    geamtt, tjr-aj sutlu, puls anormal, Iicat rnare tierca rrrcilrcirlotjlot)rnrrllrr(
    l(r cardio- cor'd rormal, anonrdii 1)Dlnxrrnr. cold de volurr Irormal sau n]illit, crr'a1io!ncliairc ;tc eni a (} l i pogl i c rrl i ' l L l
    ano$iilii a.le vascula zaliei pulmo- s ! toatc as oc i J rl rs rl l l "Ll
    -< i i ac cs ev c rc , |]s P e(:l Ll l rrL'
    rrarc sar corgcstjc ./cnoasi pDlmo- "
    ' fs l t, l l i /]]t, i urP c c l ' I i rr'
    1, 1(; n . r r n x!1 sa u iljp { ]r lr o li( ,r .r r ir i(u lr :l posil)il anornral T{VS) fru' Irl rni rfdi c , s rtfl , c ru
    (l i c ' '
    dlcrLfl:i Irc l l ;rl r('
    \r iffll) l ' r ( ) !.- :1 0 0 , sc r l| r ( li,Ii;r /;1 ,r ( ], I'rO" -::100, nu |{r nnrol i or'(i )/i i l |}, i :a l k ,l |r(i i i rl i (, $' l Lrl
    1(sl do hi t)('ro""i (, rurrr:rrl i r{ i a tr;rrri rntri!
    l , c o .,! - 4 { ) ',1
    I'( O,,. a,10 rl l r,i rri t1!, l l l rou(:
    l ! ( ) ,; r i r r , lio r i r .,,ii ,l r t,l, ( | AI) , t,,:rlul |' ' l ()1n/r,l i rri i
    f i r r I lr lit| ,l. r r ir l,!1 1 1
    ' ,r tir ir l,!i,
    :l l l l
    t:1 ){ }
    jill{*"nj*qi*rJlil
    fi,q:,iliif#'.l;sllr::iuti+l.nL"'i
    stluctural6 (LiebmanJ., iorkat G., Hirschfel<lS.),
    t;i ,ul t, ilt t L, . , "l, ir ol, , rc t il) ic l) cr ) llt t l, oli pult r r or t r r ' ; r jt Lr r r c( - \ ll\ l ll- 1'r r ''r
    ' ' ,,,,i ,.i . l i i r r r {r r ) r ilir l t . o ini( . r ',
    r r c d, : ; t pr clut r gi pr c. ir t t t e; tpozir ir i 'lir r r r lr ' ' 'l' '
    .\'lr'i,[.rrtt,l,'"ttgateaziro interfcrcnii tnecanici"- cu funclia,pullr)rnrirrli
    .i"O-."-"f ventricululrri r ,',,r,:ii,ii .,i Ltttprim:n traheea).'Se mai intilnegte itr traheonl11rr:ir"
    :,',ril|,t'iig'tri:JJ
    ;3i':,'#fi,$,..?$li.,U*lli ft,,J6:l"f*fi
    "j
    ,t+lll:
    Exan,enwluxui nott-ndscutsnsjerni ai a UaU'seiio)ia tte cord,.
    ' rl l l l|ll ))tt (oI) l iar ,x\ , a'o'ralii ale cutiei toiacice, chist bro.hogenic, masc lll(\li,lr'
    ,,,r,,r'r)tor.Ax.
    "
    rr'r
    l '1r r 'r
    t',,,,1, . Nuuriiorul comun este obstruciia ciilor aerienein timpul inspir'r{ici'
    't:ii;::,'.1.c
    Se vor ,ta alnee, Ia nou-n5.sclt-1a termen, sugereaziro boaliL rr' SN(l'
    grico-
    ii1}]l?r:i,T:ff#,i"1i"'*i*"u"u","5!t;,3i,1!ir',i:;:t.rui'conjunctiv, |i tl )i tr$1:i nti az ii,ade€puE
    tiiu,.lc cpuizare
    aIeaD a bolilr'
    ol l l ol P u!r1or1drE pulmonari.;i
    .i t!drul dLc '
    ,^ardirc'
    ..\prtt 'i
    itr
    ,.,,. ,ii' t,ifogticemie ogliccmic(mui1i (lnulli n.n. n'n cu sindrorn
    sindrotn t]"
    de hipoplvr.'
    hipopiazr''a lnlrrrrl
    initlii :lrlr'rr
    siinlli rrtt
    'rrl
    ra:mbeoli, inreciia
    ,,,,"r,lt'lll"":i:u:g:':ifr,tr"fi.t1".il-,",i":,jffj;1ft:ltor r,| | ' ,, 1i ,:,ri ri. ,scv. r ii si de asem enea cr ize de Jlllce) '
    ft,'f,iiit" ttt apar )a nou-niscufi cu boli cardiace' J)e obicci clc rlr1lr'
    ,,,,,,,iil#i:'il"'[.J'ii'""1i,Jl'.lli." si starea
    n.n. rana;-
    i#:i S,'.1:t'"''"rd
    r)-Comlo qmc lul ttuu-ndsctrltiltQ..
    ' ,.,., ,l
    ,r Lro alr iPr im ar i Pulm onar i.
    i ' , t i, t t , , t 'nr t r r ial' 5i nxdsuvar ( a Pr csiunii r : vl t 't 't l'' l : t nr ) r l- r r 'r'
    r r lii
    a,^li;iIciea sponta. pulsul iadial, t ibial posicr ior ; ila p"dioir s: i Cjr r t l s" it r r l'
    ,,
    prrrrsulIa stimuli ofer5 inforu ' r' r.' l i s' r im r c
    iis.,
    arde"*ig.;
    i"d;,'ii"#l#i*i T:'K?+#;i*y&,li;;":fl# .,,. t,r,l . l )rlcr r t ic li picior . sincr on cu pulsul r adia) ' 5r Poilc o\ ch] ( lr '"
    r' r,, ru,l r,lr ict r r li, de t ip adult . E neccsar si se palpezc ct nbcl'' 1't t l't
    ( i' r r r
    tri r:r
    de ls[ ll] ir ( lr lr ' 'r l

    .kltrt:S:#;:t*ffi
    aor t ici, sr cnoza

    +it:,.'ff
    cir st enozr . supr avalvular d

    iiE"l,l.tl:"itq"lfht"##T"ft
    ;i':ii*l$fi? ;"-i;T,?lt'
    si flascihipoton)
    li ""
    ""o-p"'""ta
    ipioapc
    ' rr.rl ,, t)crrlr r r
    ' ' " ' ,i ,i rl ,, ir r r lr Lduct ali - t oat e duc la o pr esiune ct - esculi
    , ,,,,rrj ,,,r , i1icen br at ul
    " ,.
    st ing. Dispar if
    1' ti sr r ; ir ili: Lpr r lsului la"t oat e ar t cr "le scr nni{ici colr psul
    ia
    - pulsului-
    r cm ur el
    in lr r ': r ( r r l'lr '1't
    'ct t r t t if i'
    l
    "'r r '
    r l'i
    t,,,,:, i', r, i, i , , ', r r ct ar ic ceam ai Jr ccvcnt J la nou- nd"ct t t c cer jt t xlir 'lt r ' l
    ,,,,
    ,,nl'1,f
    1"1j',f j.i:",,
    i,,'g,.i{ii,i;J*'iT-Tr/;,Jf,
    X":f*.JJ,:f,J-J,:l ' ,r 1,r,.Irr ,
    |: r l: i, in car e lf Z jnler ioar a r cor p[ lui c. per lt t zat i cu sir t H" 'lr r r
    t t,i ,,,i ,r , ir r r r r i, r ] : , r t er iclj si in r ceast i siiua! ic, pLr lsul f ct r lr r r al : i: r l l'icir '

    :*:"'""'*;
    irixxxl;;ix,H'{+iji:Hi":lr';:::']rJ'i:ir'r*$'::iii:ff ..t r rt illlc\ o: r nor m aie si m em lr ele inf er joar " por [ i r ir , nolict t l ilt c( , lr ll', 1
    i .rrl , r ff riir f il{) ( vezi ?. 11. 2. 4- 2,pag. 304. ) .
    '
    It;rcii r;ittl luspectate pulsuii liperactive, cr iu caz dtr I)CA
    ltr'lrrti'
    r lr, r,'r ilir:iil pulsril palmai sau digiAl, care ru sint nornral palprtlrilt

    \",!,f
    :,f:irri;:i${\x"3tlf!i,tiil;.,,itiiffrJ",'"il:*:;':i,#,:,:
    ?11h*:t"3""Ti.iiri3;5.i
    I'rcrirrrr,,ir'sistoliif, a bralului poate fi misuratir c11o manl('i'i
    arterial' Prcsiunea diasitolicii' ltorrl'' lt
    (lr' 'l. )

    #rsi#[f,:tLjil*ffi:ittlffi?]t:ffi , rrr r ri rlcltr:{it; Doppler a iingelui


    rr,,.rr.rlii ,,,'
    '.ito.iot6ido
    , t,rrl i l :rl cir singelui) .
    (care
    "cletccteazi
    miscarca. peretehii ttlctiitl, t r 1't

    u,i u,lui rcsy'i


    ratot,cah ttt. Sc intilnc$lcla nou-niscu c1 .lnru_ ' 'r.tettousd e dt utilitate di1S11o,1ti5:t- rcdusi lrL r)orr-trjirrirrrl
    ,, ., ..f.rd!:::! ^l?l !u 'l\ t 'r rsiriltea
    cardiogcn'
    i";,ili'i;i'.'"!11,'*rIl%iiilf:;oc Jtcmorasie
    intraccrebrald'
    hc- ' ,, ,,.' t,, ( ihe cr escut c, din cauza dist ensibilit n! ii hcpat icc la r r t ) r l r r ir r '(t r l

    .,,n."..*,,J1*ffiXl1ii;:t:ri:i:?,'#l: J,iiillil'f,,,T?,i, rtr, , ' ,Lrrrr,rr ,I I i tr err complianta lui mai sci,zutir 1:1virsl'l rnd rDari)
    ()(:rLZlr)rrirl

    l:11,1:, l":ji:F:t
    l)ri,n|ltrr Irglzt (cu compl.la]tfi sc:zut;), fie prin interfer.enle cu servomeca_
    ' ,," '
    ,' ' " i '
    'l', ' v, nolc
    git r r lui dcst inse 1la copihr l- lir r r r t v, . 'ni''i'l) ; i. , r ; r r il'r r ' r ,
    ., 1, r ', ,m it t , nr r i, : r r 3cr ind obst r uclja golir - ii r r t ia- 1" ( r lr "r r 'r 1r 't (r r 'l'l
    prrn carc anornrtiilcgazelorsansuine pH.ul LCR re- r 'lt r r lr ''
    ]]1.1,]]1..,". ;i ' t." " rrr , r r r r ; r lic l', bslL'inu r alv"i t r icu; pide) . ( - r nd lr "'it t t t 'it vr 'r l( 'ir r: r
    r,t{)iIZit, ^llllll]"
    lcsDllatta. \' , r,l( ' scalpului pot aplr ea dest inse.
    r,,.r,' .
    Itxi4 i",i,ntercostalesi: ,1 ltitn,:ttsirinile ficaluliti. Normal {icatul se-ltalpctziL h 2 l "tt' "l'
    rrnari (AJ
    1'r MH, pneumonie),
    1t",;ilT'51'l*""ul,T"l?'.'-tu lll ";"'J.11: ,, ,rrrj ,r loslr r lij , ir capil, pe o linie cc une; t e r nar nclom r l dr cpt , ( ] r r 'r r r t lr ili'r r , l
    1"
    (pneumotorax_
    lremic diaJrasnrriici).Aper gi in JC scrrer.;i,
    ciird \t rrrrrr,.,rlir.llrrlui ,, rrn ir.rcliceal severitltii insuficien! ci cr t'r1irce rhclrlr'(r Irrr ', '
    l1l]T,*T1
    ,.*1::,]^ t:.lti:il" brontrci.produsidc r'ranssudatul alveolar.Rerracriiinrcr- ,,,rl ,,r' l i r' \ cn0ir sir . jiijlclnicl"t ) , inacest ciz, f icat r r lcst cI e5- - 6r : t r st r lr t 'lr "r 'lt t l
    su-bcostalesusereazi obstruclia ciilor aeriencsau pllinini cu pot plt zeir t a <: t rlical nar <: lr r r r r r r lr r I I t r l
    ' , i ,,l l )rr l sir r l r t i ; r lt t : boU'car c se
    l.:::lifjiJ l \ l ,. r lt t t t t hlr : r i. l't 't ir : r . O r : azional Do[ llplt r cl ( dolll( '( cc ] asii t t t t r t 'i l'r ''lt 't
    r 'I t l'
    'r t r,r' ,1, , r r
    ' 1,t, . ', '1, ,
    l ir r iir 'r il, rrr- i lr it it llt lr lor . - l( : r t cot i. it t t I ( lr '1r ) rI'I I : 'i ir r lit t "
    , . . . . . . .,!d,tf!:,r ::!jloritqsutuisointjilcsclip ic t a n o u -n d s c u lic u i\1I,1n4ctrr_
    {, r t , , t . lt ' g, 'lr ,r i, li1: ) slr<lr ir St cl: ii l) V( l in l( l lir r lolL- lliis( r r l I t I ||) |I'I || |
    liil,l;;'"3:il',:;;i',111,'",i'?ilili";t";,,,lillil':';;.l;ililnx:;ll,i,l
    i"illlliilll:: r ,1,.,r,,l l :r t r '; t lt l) r 'r ' r '( l( lllla ln; t r r : lt lt '.
    i r r or r 0iisc: t r lr rllr l 1r 't t t t |t t ( '. l. l0/ r r lilr r ll f lir lr ilr ' ; |o
    r'czislcDlir
    riikrr',rcrjIrro
    rli ununrcar:ct,a
    a iriilor;rr.riIrrr.sirirntr, i ,.l llt r t , r r r t r , lt t l. t t ,lit
    Jii,,;1,i,Ii],,", tttrr | ,,r | . i i / rrri rrrrI ir r lr t it t llt siilr liir r lir li , 111vi: r {i) , ll( l( ' polir r r ''\ 1r 'lirir lr lr r r r l
    | , rrr,rr,. 1rlir t ir r r r ',t 'ir I r 'r I I r ') .
    ]]t:t :i :!:l
    1t) S:ttfluiLe cartlirct. l,tii t:rtlriilce serioase pot exista firri su{:luri si
    I::i'il'Jii{ilii"':itit###;";,1
    : IIll,':,,1' x ; :l
    i'I
    irrv'rs;.urr su u intcu. Ps:tf,::r1r;-1rt.3
    rrc). Nou-n:.cu.tiicianotici o
    intr._oentitjtc bcnignd icx.
    rnal{ormatie cardiacl au- (in ""
    genercl
    llSi,
    utr l.'r;iii, o aortir larfle, sau un trt unic 11,;,1
    ) ''
    lncdcdrrrrrII
    _cu
    l,rrrrrloslic mai bun cind suflul cate se aude e mai inteni. Ci cit boala
    r:ardiaci.e nai s6veri., suflul e mai mic. Sau, altfei spus,.ctnd suflul este pro*
    I'i"rrt;rprincipali, .iiualia-e dc obicci benignii.Nou_hasculiitrebuieascuira!i
    "
    r':iriirf,i*,y1"3
    ;'.:*i'*xil'll";**:t"ru.
    rutrlrrrsuflr,ritln rnai multc ori, pen[ru ci suflul poare{iintermircrlt(dc c\. PARACIINICE
    2.1L22 EXPtoRaRl
    r{ rA ). lo*x'r"r
    eramcnur
    cd..Este<reprereral
    i) cad,,iaceIa nou-niscuti cu o MCC serioasi. sint de obicci ,J"irit
    -Zgomolele
    ,'ttotrnale-.Un singur zgornotII, dupi primele l2 ore dc viat;, araii clc obicei ,,,,,,,,11".if {Jx:rrr"!r{aci
    ,' l)o.rlacle cord. Un
    tttottarii"(de|i poate fi-zgomot
    lI.net-dedublat sugereazdde obicei o boali pui_
    prezent in transpozit,ia riarilor arterc cu sept intdct). tl:,r:i.otu*n:*,u*k*1#":$fi,llf
    -fr{ll,il:ll ' l ' b(l l : t|

    (dupA Uhnet H' E )


    ., .rrrltonrttlolo$ic scvcl:l tr lrorioaila tr€oratalil
    Dtagrrosticut dllereDqat al pritrcip{Ielor eattttopatti congenifule caro prezirltrl
    FC G reooat:rl ,
    Defcctul Simptome Forma si m6,rimea Vascularizo,tia
    cordului la Rx pulmonari
    ri0
    caieterism, mgiocarliogra Lirr' rt
    l ri|]spoziiie, ,1..,)l ,i (xi i e s P ec i l i c septosto}llie, balonatti'scPlr'r'l "rrrrt
    --,fi ciatrozi, hipoxie, ,,contur de od culcat de obicei ++
    , i t lI nii acidozS, h ziua a pe o parte", media-
    3-4-a de viatii stln st mla I )rrl"rl
    de obicei suflu mezosis_ cateterism, .llgiocardioFlalic,
    (lr' rrr
    totali a cianozi, insuficir tolic dedublarea Z, atrioseptostomie, chirul:lic
    ,,siiuet:r de om de de obicei l, -1,
    ca r d ia ci zlpad.Y,t""
    (l , l
    b $ rd a re l , r' l rrI r! i rl
    de obicei s1rflu halosistolic
    ! rr.t()t sep
    sefL,ri insrf. cardiaca, difi- cardiomegalie dedublarea Z,
    -t- -f
    c^rtteti in alimetltaiie
    liliatiri preco(xr (,l rrc i l ,s t(, ' (, r "rr)
    ( irrIr1 rlrterial
    frec?e t, Du mai mult
    insu{. cardiacd, cariliomeSxlic 1-+ declt sullu halosistolic Z:
    l a. rrrrrabil debesi respiratorie
    hecYent, nu mai mult rezectie Preductllli
    c dc aor ti puls de obicei cardionegali€ rormal/ -l- clccit suflu halosistolic

    rlc obicei suflu halosistolic


    l) olmorrarir cianoz;i, Soc de obicei cardio,
    (liBi1 rrli''
    {rec\,ent suflu u se |IdlniDisLrcaT-:!
    l, . ri, , lDt gc I, allo t cianoz6, Ji.!e insu{i- terism nr:ii tirziu
    miccu Yirful . ridicat lj
    cienf; cardiace r -) {r' rvent suflu mezosistolic catcter.isr)), dngiocllrd
    joilrjlf ill, r1rr''

    ciarozb fare iruufi- stomozc ((lacri csl.l' rrq;{r:':rr)


    mic cu nrediaslil su- (-)
    ciedte cardiaci (
    Jr-cc'rct su1lu mezosistolic banrtilr:e (da,ci, cslc rr{1 1;'rr)
    arr:rs tonroz i l (rl
    , scii' rr' r i rr I
    insdJ. cardiaci, ctlrdiomcgalic nonual/ L--l ii s Ilu ]rroiodiastolic__-_ 'sl(
    posibil cianozi.
    Irccactr I srr{lr h.r.losistolrl
    dui tricrspidi cianozi, posibil illsul. {1(j obicoi (- )/normol
    g"'jlj,!".'___ 1!i9i':$qq11 _
    or d n h i sti1rfi iio c, o lil{ u fic, ( !l r r r i r)firdiotncgalic ( , r' r'I l lV l )i i rl fr' r' l rr
    ), nol rra!/
    !i.
    ",r',Pr1lli.c lr c.r ' v( xr irltl I- :l- ll 7 , .l ' /,l i ]l i ' | , ' | | | I I t : | |I i | | I ;l l i

    (1,, i ,l ,i ti r rr' r r( rrrxrrl i l l

    'I1lI :l l i l '
    p, ,lr.rr:crcze
    afecrirrnilc
    cepotsirnura .,'r,lirl , irr vcdclrrr c-rclutlcriiunci intcrvcnfii chirurgicalc. ln prirnc-lezilc
    ll 'fil::i,tlfi!,,l;iilj;J;:liili ',, o r,orrrii
    .fi,,,\'ii-';,,"n;;'i;;i;;.i,,,.,;l;ij"::,.,"xff:xlJ%ffiJli#t.rt$:x-"llTilii.
    ,l, ri;rlri :r'Prxrlc r:nit"tcrizaatriul drept prin vena ornbilicaliL,in condil;iilr:
    t| | )tr i t:ltt,sz)lrlr().sl^i
    firll)inc pcrufeaoil.
    i;tiiti;l:ll*"rT':llH-'"J$irH;1#:"ff
    3g":*lf11".'r'*e;t;;o;;: 2,1I.2.3.
    CIANOZANEONATAIA
    ,,,(,,on7csea'.ier(dina,.ffi 'ffY;i;
    lr)fi(.si a unui canal artelia
    \lolivrrl pentru cale e suspectatl o boall de cord serioas].in prirrrclc
    .l.i:i:,,ili$.d{t}qilritti'#rif
    r,u.ita4",ili'i.i,it r.*li
    i ir.i*, ii' ..im1:,,"r
    .rl. rlc viirtir csitccianoza,cu sau fi.rE fC. Cianoza centrali (prin satur&tjc
    1;,
    111y1,"i, "fi:i'.i:llr"
    :,A?ii ,'r,,rrrr:rltlr: jolrsir a singelui arterial cu origen) se poate recunoaqtela lrr.xr-
    .,,T*o'acentei..sdi
    :ii:i,:ri,i},i'i:?i:Ti,,ilil:,:lir._ri.1'jt"i;51*iliu,,;if ,,.r,rrrl cirrrl:l g situ mai mult de Ilb redusl esteprezent5.ln singeleartclial.
    lrl|r rtlr)tivc insuficiurt dc clare, cianoza e mai greu de recunoscutla rrorr-
    ',r.r
    i,.i.(Na,.I{,Ca1;:1 inrerp
    ;,,uro
    o,
    c.*.,* #::, i$fi;i "r,r'.'.:l1 rr.r'r nl rlrr:il Ju r:opilul mai mare (cind cianoza central.i. este net vizibilir, crL
    rir,,,,,ir; }fffij."t?{i:{Hl',; .,'r, rPrrrrrlc r:rro tcnsiune loarte scizutir de oxigcn arterial). DacL norr-uiis-
    'rlrl c irur)nric(8gHb%) saturatia cu oxigen la care cianoza e vizibiliL c
    ,,,,,',,,f a' Metod"l-
    esteneinvazivil
    ;i utili in perioada l" rrll r,r'iiznliL(630/o);invers il caz de policitemie Qe gWDA) satnrafia crr
    ,,;:r!'
    ; :,LLuJ:r:"{J! : .'\r/',rt lx)irili fi destul de inalti (88o/o).Cianoza perifericl (acrociauozl) r.
    i,,
    1,r,,, :.:l#t*:.f'",fl1T,?f
    ,$irj; ,1,l rrr l ;r crr o coloratie vinirti limitati nurnai la pielea extremitS.tilor (in v r.1,rnr:
    -,,o't,ic-uiJ,n";;ff;',S},U#,?fjn:fr
    ilIHT'i":Tf :ni::",1f#i,H??i#,H*lliii'"1;fJ
    $TT:31*,':##:
    ,, rrl'r'l(. rrr'lcrial c lornal saturat). In general, este un fenonrcntrorrrrrl.
    lli:rlirrclia intri: cianoza centralS.9i perifericS.nu este insii al:sollti
    Tcstul, cle hibet ,rtrlr,Lrrrrrr si rrlrrciclat'calecesiti misuralea saturatiei :riicrialc in oxiilr'rr
    rnrilt,:rl9#1yi"'t#,?:.r;.#r*iii{1*-*#iii#:if#{?
    j ' r r t, rr',rrrliio:iigenului1p2gr;.
    Iir IllirrrIrr nc la accste criterii, desaturafia arterialiL scrnrrifit:rrIivii
    ,,rrrr,,z,rr'r.rilllii) c consider:t5a {i prezentii,daci.PaO, estcsub60rurrrllli
    ili;iiit,'',,:,i:i?Ji'i1*' jl"H:,ifi: iip1-l;fln T"*,,iil-H,".;3,"",f ?i;, rr rrr.lrr rlr,24 ore sau dacii saturajiaarteriali a oxigcnulli e sub 9.lli,. lllr
    ramJls'-duPi t"'t"r r" r'lp"io',i.l;i;d",.* pentru
    o t'an,.-
    1,I rl,r ,rr. o srrltrr:rliccu oxigenmai malc la presiud aic oxigenulrriruli rrrir:i
    ;li);11,1',I"i?i"Ii"t rl,l r ,l, lllr rrrlnllului).
    lctalir are cu ,109;mai pufinl a{initate pcntrrL2,i}-rlilo:,
    ,,,1i,,'!1:$$f,1";r"";.91: .fiii::?:Tili":#!fi ;ld::**:giti",ii",,?,rxi
    IIr.rrroriLrIrirrIL
    r,4lrr,r,rl (f,.t l)l'(;) declt Hb atlult5..Aceastaface ca IIb fctirlir-siLsr.r.orrr

    t:;tl'i,t';f;,f ,l,"""'.lilTj;Jl*fl*m,*"l;'; j:;::li":"j;***]1ci: 1,,r1,,.r ',,i,irrrl rrivt-.lele2,3-DPG ar fi scizute,cu devieresprestingrrir r:rrr'lrli


    'l ,lr.,',r,r, ;r lll> si o saturatiecrescuti,cu oxigeira hemoglobinciJrrorur,'
    l'rrl rl,rt,r(r,rir,libertreredusl de oxigeniesuturilor).Aceasta:lrj lrr llr\:l

    ,,,,i i;tiri; li J"i,l"';;;, ;;,!k *"3?".'*i"1f


    rr' ' ,r<'trriitilorci pentruci.insufi.i*t .irpt".*"ll ;:*:?""111#tr$i i ,1, tr,r'r,rrr,'' rr unei situatii serioase(ingreuneazi,lecunoagterr.lr:iuroe,.i)
    rrrrr rr,,rrrrrscrrLcLr o cianoziLabia <lstcctabilir poate avea PlO, dc rrrrrlri
    p""i"iitiito cardiopatic. I , lil r I r l l A) .
    " saudobindilil"
    r|,i!":n::rf i a (uonienirali
    , ,,, ,Y,1,1,r,,o.,,
    ! .poarcsimut. l'r' rlr' ;rltiL uartc. hematocritul relativ inalt ai nou-nirscutrrlrri lirrrll

    tr:r;;d;ilr,r#.iffi *":ifr1i?;:{,$kti;l:#i
    ,t*{aT;;lff
    tr' rlrt.zl rr'(:rriro.l ttcrea cianozei. Din aceste motivc, ll:titsulirlcll l,;rO.
    I ll rr|,r| . rI ' rrr.-Ltl,:cil ilspeclie sau tlecit saturalea cu oxigcn. In nrotl rrolrrul,
    ,r,r r,r' r' rl ul ; r iingcPa0, de4. 5m m Hgla r ''ir st a dcoor isiPaO r dc00r nr r r l11"
    :l:,t;r':,:';!.Tl"Ji::i"f
    l;,.ipf1,-li;',t*":,,1;,9,,+,1"i$p:::llll l r rr .l .r tl r: o zi.
    ''r, r'rr tviln r',rcoltarea in tirnpul plinsului (care produce
    5i hilx:rvln
    explor.iri cald.iace,cum ar. Ii c ateteri trl r' l rr ,rl l r,ol .uii. gi slt unt a. t r ial D - ' S) . Sht dc m t i r nar r : \ 'aloar ( r r nii: , ur ir
    ,.,, ..,41]lr,"it: smul cordului
    lillii'1,;:,1'i'X",15){?,1i,"f#,#,'.'#et!;r::4"^L{r,;r$i::"1i"#;}';jffT; I',l l l r lll :l tj l l ( , .

    :tii'il','ffiii.?i:,l.
    iffiy#l'* a;,,*nxi:rll*:,li:'i::lii
    #ii#3;;,
    l) Alxl([rrroir rliaqlnostieului oianozai eentrtr]e. Cianozar ccnilillli irl
    ,1r,,, . .rl rrrrr lir , st : ir zr r liiar t cr iali. cu 0, 5i poat c f i pr odr r s5.f ie pr ir r r lr r r r r t
    rr' l rrr, l i r, I'r 'in : r lr r r ntir t t t . npt t lnt onat I ) - > S.
    r n | | )r'r.illr:rt i:
    I t r, I : rr, ,rrI i r;rrI sl firt:r' ptin olrst:rvalirr clinir:ii, r;rrliog.taliet<it;i.cit:i,r'rrlo
    '
    9i posibil'r, a cavcaticcl'tiru,rgi
    calii dr: rl.qi:ulii iu l l r 7' ,r,1, l nr r ; r t t lir t ir r r r liC(
    , i. Cr k: lcr - isnul r : ar t liit r :: ii ; r t t giocar di<gr llit r r iir l
    ,, , ,,i,liitui,t|;ircsarir, r,,, ,rt, ,rl ,roir l) ( ioI r I r , ; r t ut I rp( r r lnr lnl t liagr t ost ic r t t lr lonr ir : 1>r 'r 'r : is; r l\ l l( l( i.
    '
    ,,,,,,,,iilll"l;l,i;l,iii,itiili':rllil',iil;11,,1.1l":,:;llil,,iilll,"ililii.;ilil1,i:lll
    ll
    ,\l .l ' rl ,.l l rrrvr r zir , , r ir . ir vt : , ii11ir {ic slr r i jt t siilir ; ; r lr : t ir xl r ', r islii lr , r silr ililli{i
    | ,rIr| ,rr/., Irr; r t c r lr ' I t . r lir t t lclll rrl ri tr t t lgi r;l rl .

    '1l l ;
    2i't
    5.,,lllalostt,deluborator'Scvaci'rutahipogliccrrriu'crtutt{aclrttt:t'
    cianotic trebuirrsji'{ic irltr-rr
    ln tinrpul oxautcuttlttir'lirrit:, rrott-trirscutul ,.,,'tril'ri,, la cianozaccntnla. Mclhcmoglobinemiava {-i_suspcctai I" pe lipsir
    crrnrcLir. ca1di, linisiit sau irr lirttprrLsomnului Fi s5. respire arcr de carncri ',iil,.ii'; ,1" Jilu"ni tor" . cind c expus ia-aer. Anornalijle eLecir.olitilor v.'r
    / r( ir))lJosifit cu oxjscn), .'i'ii,i r" i.r.',riricrroa itipcrplazi' i ionicrlei suprarcnale 5i :r insrrfici.rr{r'i
    l.'l'ihttt r,:sfirilor'r"a Ii observat privitor la frccvenla, adincimearcs- .J,i,r,i,."ii"t,,. Utilma poat'c i;ita MCC. M1surarea.hematocritului va pr:rttril rr
    1,rrrrli, i, p r'rzcn{;' retracliilor costa-lesau a geam5"tri1ui, prezenla bitlilor
    ,i,'i".ii. ,irr.t-*ului'de hipen'lscozitate. Leucocitoza va indica septic.ttrir:.
    '(t.
    .rril'il(Jr nasului.
    ' Z. Xf'i;cdrite sianttne vor fi observate. Leta-rgi1 sau ]ipsa. mi;c trilnr' Iiadioprafia
    ' bulminard arati mlrimea cordului 9i vasculariz'n{ia
    ,,,au,nn"ii,. SE inr ind"ntifica M-\IH, hipoplazia bronhopulmonari' littt'
    .1u'rrlrn,rd.cvrte sugereazd ;oc, septjcemicsau boli inlracranjen'. Insi i,,;t;;i;';i; .""u,rtitria, hernia diafragmaiici,chist"le pulmonare,plirrrirrtrl
    rorr ' niiscutul cu ciano2e avansati (de orice cauz5) poate doveni acidotic, r,i"inf^.iii. agrirezia pulmonari', emfizern iobar congenital, Pncunlt)rric'
    lrirr'ron si fari ri"oun" La sfirnu-liidurerosi. 1,'in,irnotoraxul" 5i clriloioraxd (torle asociatec-ucianozi)'--
    ' j. ilisbansul r[attozeila rcsPirc{iaie oxigen | 00o/o(FiOz 1000o)'Sim- ^*1. 't,l"t.u de un ridus ajutor in.diagnostic' Uneori e dc trtrttt'
    ' iCC
    Dtiti,irr,l forhc mult lucruril( se' poato spunc ca dacd un n.n. cianoticsc .,i"tnt, DiA " cu T{VS sugcreazd aireiie dc t ricuspidi ln alte cazuri':'r'ir1ii
    sutr oxigcn,hipoxemiai de origine pulmonara,in vreme ce dacir
    i'rrr,,ti.r,''rzr"r, iivlj. .oi" .=".iati cu iulte forme <leboli pulmorare si cardiace (inclttsiv
    r;,rrrir t.ulhrslru, cie'noza" dc originecardiaca.*- "
    '' ' '" fizioloeici la aceasii virsti)
    llVl)
    lr r r' clirate,lucr-ulilcsinl, inS;, mai complicaie: s".-;;;r7*diigrafia (modwl li) e o mctodd nou inwazivir' {oartc vrtltr"
    - intii,la nou-niscutul cubolipulmonare (mai ales Ml{H) 9i cjt *q"i"i ,,,,,ri,irl. ,r"ot.tolofi.." C.t .lotntn1 ci se pot determinami;cirilc valvci' [tttr'r-
    rrrrri I) -r S intrapulomnare gi prin gaura ovali. - nu cre':te PaO, cind ,rrr VS- precum si prcsiunia diastolicjin arlcra Puhnonar' qi rla{i:r 'i. t'tt
    ,lt:tl''
    rr''fir;i oxigen I009o:
    ' -a1 ?o ea,uri.nou-nlscut cu PCA izolatf, poate fi cianotic prin IC, ,,.ziJ.ntl vrcculari pulmonari, l-rhog'afia poatc face urmS"toat.lr'
    d. hipoplazica VS (evirind cateterismul) si a Vl)' I' tt;r
    1r:rnssuclat:rlveolar si c5.iaerieneobstruirte. EI devine roz in O, l00o/opentrtt '',,tii"n,'iinatotn
    l,,li.r Fallot, transpozilia marilor artore inioarc''rea vcnorsil Pltllllr)ltrrtil
    ,,i n,,.',nism,tl hipoxemiei este hipoventila.!iealveolari, dar boa-lade cortl .,,irirnJ,i rotali, truncus arieriosus.Proba unor cavillti ;i 'asc i' rllr(rl
    r', rir'
    r.rrlr,l,lcruaIui dr' {ond:
    ' ,iiirriJ"-rront" aiuta ia di{erentierea unei. boli cardiace de simptonrclrr
    -. in fine, daci nou-niscutul cu transpozilie este foarte cianotic in ,;;i i; hipr:glicemii. Daci echografia. c absolut norntalir' r'rr
    rrr.r'rrlrlin dt. devine mai pulin cianotic in oxigen l00o/o, ex-plicatr]a ,,g,'t"lrd? -;1i;;-i", rrnita piirtiipale e pulmonar:! 9i, dcci, cateterisrnul o irulil'
    "r-"i';.,
    nrr sliL in {aptul c5"o boall pulmonare e cauza cianozei, ci oxigenul 10010
    rezistenla
    -vasculard.
    pulmonari, permitri:d un amestec Echocardiosrarna mi.soari dimensiunite VS ;i AS, ceea cr: rr ttlil irr
    irrspirat a siS,zut r; .u PCA 5i MNIH. Prezcnti canalului ;trl"tirtl ,L:
    , ,,,i,,r"-"-",iii
    ,rr,,i brln or\n fovatnenoudle. carlalul arterial sau ambele. El poate apirea '|,i. a-." i"'slirrrt "i,I'iuiu.or S D cu matiticaAS 5i a VS' In prczrnlit :tr-t:'lot'l:tl'
    clirric roz,'dar"PO"+'nu va atinge niciodati 150mm Hg. In cazurile in care -
    ,l iu'at, ,li".ia" Jigarura ca':rJuJui 1m'dicali rru chjrurgicf,li)'1|r'ItIilir:rt.Ir
    l'r(r-x crcste peste 150mm Hg aceastainseamna cd nou-niscutul nu are un , r'i,,.'i.-.i nulmo'nat"permitc miiurarea fazci d' pr"ejcc1in.;i'l:' 'i'' ti'
    strrrdt majbr b -- S. Masotat:ea plI-ului arterial va estima severitatea acesl''aro{lccti p|csiuncadiastolici tlirr "rl"til
    (f it z lllt ll.
    ' ',i'rni"l VO. Raportr.rJ'intr"
    ajutor in 'lirrli
    Pentru misurarea rd.spunsului gazelor din singe, n'n. trebuie sL res- t,rrlrrronaLir 5i rczi.stenlavasculrri pulmonarS-;.ele de,rnerc
    ,r,,slirrr1sindromului de persisiemi a circulafiet lctale (raport cr'('scul)'
    lrirr: oxigcn 1a un FiO, maimare de 90 o/" (timp de cel pulin-10 minute, pentru unui shttrt'l l) > \
    llchocarclioeraJia de contrast poate dctenniuL sediul
    i s1,ilue,:,rrnai mare parte a azotului"dinzonelefoarte slab ventilate). '
    intr-o vcni ir:i, trti
    pr:r'ift't
    ' , ,,f ,,.,] iJi.. (i"iSctare de solulie ialini izotonir
    4. Povfuzia de totrazol'ind.folazolina (priscolina) e un puternic vasodi- up;rrili'r lrt
    lrrt:rl<,rpcriicric, cu proprietiii adrenoliticd-gi colinergice.. Doza e de 0,5- .'f''rf.l" ii.la""e rlc accasti injecfic sini rcc"p(ir':nar " -;i ,"r'r.
    r'r'll
    -
    I rrrg/kg irrtravcnos. Rispunsul pozitiv esti-'sciderearezistenfei.ylsc.ul11c ''rrti: i ili difcritc caviliti arati dirocliashlrnrulur) l"clrocJr(lruHlirlrit
    ','i'i,,nali reproduc,:,,angiograrna" intracavitatJ'
    prrlrnonatecu o cresrcremarcati in PaOr** in singeleartcria.lombilical. Un
    iirsprrnspozitiv e sugcstiv,nu conclusiv,pentru un cord fird anomalii struc- tlt Carcqoriilcdt boli ce produecianoza-ceult:rltrlir notl-nilsrrrrf/i//ty'''
    i.ur:rlc. ii.'M.;;"';,;;,irii, ra <tc.t't t' fICC 'w .shunt l,r -' s ii iri(r(i:L
    t", ,, 'i,,jii-:;" l'rlor'
    De cxemplu, o coarctalie juxtaductali. cu hipedensiune pulmonarii ,,., tt,lr,:,,in}lir, Fallot, atrozic pulmonrrir, irlr,rzi( (l{r trir:rtr1rirl.r,
    -iiitittt,',t',,ri
    r\)irlc Drczcnla un respuns simiiar' ,,persistenfcicirculaliei fetale"' Insl, trir' rni). Nrlccanisnirrl tiatr"zci " shtru/rtr'r :'i'ti lrtr
    in c,,arctaEiajuxtaductali, pulsul fcrnural poate scddeasau dispi.rea cirrd l)
    ',,",rr, :1.
    ' r- dc olrir''ri Ntr r"'
    prcsiunea scaiie in a.rterapulmonari fi VD. Ii.,rsrrirltiilr:sirti adinci ,,o{trtc"' Su{luri - -p-tzc
    l00io t [i trtrtti "trt rrrir'
    ',,'' r,,ii i'ii i',iit ,""i,,,t',,,hr1.'it'r'xig.'n 'rrtl'rl--po;tt.'
    ,,ii ,. ii,,r't,t,'f *,,,i Id(i,
    ,r,:i,1,',iic. crl(trrri\rrrrrl'
    rch'rclrrlir)flr''rlirr, 'rrr'r"
    j,'j t r l i',i
    * I'h.Or (ujrul lcspiral din calncril) o{orit o cstima,re a. scvcritltii cazului, Un ItaCO, t:r'os"
    solnnl_ ir s r i nt l r l i l ( r ,
    otl[ (uorul catlroroi) itrrplici, bipovontiillllic ol'r(,oln11, iar llePutilrta l'aor dc .L crlfllc iL (rurorrrirlirr
    r.rr:scLri
    t l rriv lu O " l 0 { ) n l . a r i l i t sh lllr i I) S. 2. ilcc (, sluutl,i) _>,s |i irigrrlic prrlrrr(lr[Lrii
    ir l ' , r t r ( . i . r ( : t l o I ' r u r ' '1r ,.
    ' rlo n l ir ' rrrirrilor :r,tlit:, jllloiLlctr('ir vtrtrttsiL It1tIIIt.ttiIIii illl()f'
    "r r .t
    r lr th u ) tl I) + S lia rI (l c si ncrotri !rrr vorr{i to1rc/B !rl url o. l,l,,,tt,ir, i'l,ri,s1u,ri1i,r
    (lo(11lripr f r v c l l t i | l l l i l r t r o r r rPo ' l$ lllo r irti lr ir r r il,!r vn lll.
    900
    208
    iln-x1**lt":"",,*g;1
    ffi $;
    fr#;x:l'niii';[:3s
    f{
    \l ,ri rrr t ( r lir r llr r oslicrl i I rrr',' rr( i rr l ) : sLi'lt ozit lt or t icir , t : t t lr r r lll, ir t r lt r r r ot lii

    ' ,, rri rn iilsli lt t r r r : , : lcr t si


    t : r t . Llr t : t r rcllt l ; i boiile din gr upa I I I ur m iuloit t r 'lo

    (::f
    ,,,,",1;,frrJi.,ff
    :;?g,tiifu l ,,,l r r. l tttr I t t lr lr ':
    l l ' l i V; ' lr lr x; r LlAV ct . r r lt plct ,congenit al;

    *:li,tii.,":^*nfui:"
    i*tr ',r'1riiclrrrir, ;i Irilnglitxrnic; - copii din rname diabetict:' -- tttio'

    j$f**:lrr*#q;i:-:q**.,p'*r-.tlr
    ;5$bfr-g*frgffi
    t#:il'"fr
    I l]tl.i 'f)uLrnairurt'rbrimare (1\IMH, atclcctazic, aspir.rlic dc mt'cottitt,
    t',rr,,r,rr rr. ;rrrirrron;rtr-L, pncumonic', displazie bronhopulmonar5, lirnfangirr'
    I,i r,,,rl 1' l (:z ic pt t lt t r onar ir ) .

    It:;'ffi sl;';l*""l;
    t$,lt[:':;.*,tJ"":';';:u:1ffi
    1' l
    N,., rrrrisnrirl <:iirtozci e complcx: hipovcntilalie alveolari. (lltrliurri rl,'
    ,,,r' l r uat c) ; shunt D - - >S ( zonc dc plim ln com plct obsiir r it t c) ;
    rrr1r.Lr '! iirolist
    r rr, ri ,ri i ;nr vl ni il : r tir : / pcr f uzic ( Y/ 0) ,
    ,,,rrrrrllc clinicc lint : dctieiii-i'espiratorie (retraclii intercostalr, lriliii

    :q:3d-#tTrfr
    LT#j,-jliii,Tii,f,ffiritrilirr-r'ihsl',::":'fl:i ,,r1,r1,'rl,,r rrrrsrrltri,
    l i , r ',,lrrrnrrtl
    1 )rl n !u l l1a.
    gcarlirt cxpirator), plus tahipnec ;i
    oxigen
    it o xi 100o/oc variabil:
    si lipoxcmic.
    lipoxcmtc.

    l)nr (in crLLdc hipoventilalic gi asincronismventilalic/Pcrfttzir'):

    ,*T.itiffii;
    :n#ttil,*r"liij#li:##t1,i;J?i"i3x,rrirft
    1,.,rr l ' n) l|t n I I g;
    ,l ;rl r ( , l. r c; i t xist ; "rs/
    " r xnl ir t t r upulm onar D - > S) .
    li,',li,y'r.itiiL ptrlmonarir e foarte utilir pentru diagnostic. AcirlL:rrrir'1i
    l rl'l ' r.,r1' rri ' it t , , 'l, lt t : r i m ult , ' cazur i.
    l,i,.r'llrli{ii sctttlui, aspiratul traheal, hemocultura, perfuzia dt: tolir-

    IrnT';;t"gfffi
    *1 F,e,$i$'{*tf[ti"i'.iTrH
    :tu#?nH'iH:i#**#lrn"di}
    r,,l,r' ,,,rrrrlt'teristnul cardiac pot fi necesarepentru diagnostic-
    ', lttl.t rllran[ir. mccsnicd' ctt' lwttclia lulmonard (hernic dia{ragnr:r I it'ii,
    1,rr' ,' ,,r,,l ,rrr r x, r : r r r {izt 'r tlobar
    r , at r ezie choanal[ ) .

    ;jT$-i#:*tlfl '
    l l ,,,rrri sr nul r ; iir nozci: com pr esia plf , m inului nor m al san olr sl t t t r t l;
    htr,,,,,rrli l i rt i r . ir lvcolat ir .
    ' ,,,,,,,i 'r lr : t lct r csir r cspir at or ie ( vczi pag' 271) . Uneor i sct nt r t cP|t i
    l l ' | ,' /,l l 1't |r oicint cst it nlc it l t or acc.

    'ffiH":T':rn?
    ;*#':*i{tl-a"",-ti}#;:triTi1?",x.:l'"fi l i .,.l )rn\ I 'ur I lr r r xigen lor ) % ( l'. t O ?> 150 m r t r [ I g) . -
    li.r,lio11r'rLlirr, pulrronaiiL punc tLiagnosticul dc multe ori' l?CO, c ctr'$r:ttl.

    ^'"'?x!&{:':*s:t":T'q}fi"*fi+*li$ff##t*{dff*l
    Irt1,, rl
    r, ,\'iulronr.ttL ,,l>usistat'fai circulaliei fttall'
    ' r' i rrrrr . Pr r l r r r ont r iL,slt unl l) - - >S cor d cu st
    (PCt):
    r uct ur ii
    cornbinrLlit' rlt'
    nor t Dlr li.
    ,rrr,Ir'or r r irl)I 0li por lt c f i pr im ar la'i nou- niscut ul la t cr m cn. slt t t Por l
    r!r' rt,r, l .i ri i ilr r ( ccct lt r iit : it pir r cnle sau secundar hiper viscozit iL] ii lilt 11, 'lr r i,

    $;iiffi'g;i3*irg11i,,g;i{'ffi 'i":?"r,":,?:,
    :t;
    Il
    ' r' ,rrrr,,rri ci
    r l, ' lr spir ir f it r ,hilr cgliccr nici, bolii pulm onar t : lconat alt ',
    1,I i ,,l r11ir r sinr lr ot t t t 'lt t i nt r r ' cur r oscut i, cl apar c - t cor ct it ; - r r it t r l
    tr,' |ll|.,r|| l(,, r:lrt'csclttl rrrzistulta v;rsculari. pulmottariL gi rluc 1n int:lrirl, tl'rr

    ;n:*:,;:.*'iit''i:iJ*?idh:.*1i'"*#*:lt:3::"H"'l'ff
    t4l rl rrl rrr ru lr , t ir t l, r t t t iut loc.

    I l ,,rl t
    \' .' (r,.r 'r , iLlt li r ; r t ; xlst t nat ur it t t ca sugcr eazir lxlsibiliiat ca uuL'i it t r r t t lr
    l ,l .r r, nl i rti ' .

    *r:::!"!!w,f
    &3":f i.iT.u1"3':.*ffi
    i$:'::'#iii"tf 1':x1?:.g,:::: N , , r ', rr r i:i r ttttl ci r r r ttl zt'i : a r tcr i o l cl c l l u l tn o n a r c r :r m i tr i
    l r , r i r f r l r { r l 'r .Ir r Il "r ) ,,u r tt[|ttI a r tL r t'i i r l r i r n i r x: d t:sd l i s ;i i t:xi s;ti r sl tttttl l l
    v;tsr x:o r l 'l ti ( l tr '
    '

    itiil;rt;il;
    #$1' y*5",:"r*m.x*ll:;"tTn:;
    li:#lj$y*I l , r l r , , ru , r l u l i r r l ( 'l i i tl .
    . l '\ r 'r l i ! I rr I r i 1'rI t t ' r' , <:i l ttr o zi t r l i fl tt'ttti r L l i t ( l /2 i ttfr l ti o l tr r i r l r l r r tl tttl tti r r tr tt
    "

    iiu*iti,
    *l#1il;;H*';1fl ;i*
    ti1h#;xffi
    r l , r r r 'l t ', i ) Zl i o r r r r r l tr l r Ir i t tt : I t i t I t ' t r: : t 1 l ttl tr to tta L l l i c l l ( xl ( o ttl tl . N tt si ttl r l ttl l r tr i .
    I rr,, t I rr, ,:,I i r:r rI r .,;l l , l r l l t l f g r ',r t t:u l \4 .O( )ci l tl t4 l t:tr r : s( '\r ( 'r ,', r l l 'l i i l l , r i r l l
    , " , t t ' L r l r r 1rt r,r I t t r: I rt | . i t tt tl i ttt' s|l tttti i tt;i .
    l i , r 'l , r l | l ],r r l l i r ( ,xl 1 l |l l l t) 0 ']i , r ' vr r r i r r l r i l .
    il0 (J
    ' jt ) I
    Rldiograiia prrlutonirr.ri:rl,pr,rI tlc gealr nla"t, cord rnodorat nriilil. iil"lill"i;l'l"l:
    ll,,r'lli,,li.li{:llilii':,1:lilll,i':lli),li';i..,1,:i',ili
    rr:itlcnric(plin mctabolislr rrlrrcrrrlric);iPCO, croscut (multc zone alvcolar.e
    sittt hipelventil ate, dar subpcrrfuzate).ECG: hipertrofie moderati a VI).
    Cateteri.smul cardiac e uncori uecesar pentru cxcluderea unei MC(l
    ' ";'1li;,,1,"''1":lil,,Tl,,'i,,i1"1$llll:i"1"*:?:* '''','.',,.,
    ,Iirril'i
    jriii,:llilr,im:'*:*;
    (I ri r1r| r' frIzir r ) , h4r ot cusr r t nc'

    "tl'll''r,
    slr jor-sc(.orrcratie preduclrli). 1r,
    Cu in cateter i-ntrodusin'artera ombilicall se poate face o aortograrnii,
    ccr opacifiazb. toati. aorta toracici" (pentru excluderca coarctafiei).
    1i11""1,i3.'*
    l?"
    I}.;;gruFL
    irili r :.'.t) 1 r c,r n l ''. l ( r sl ) u r r \ u u 'r r d e ^ 'S " :"" q \'.
    l l :r ,l i ,'l |r r [i ;r to r l r ci ci a r a ti :,co r d
    ;
    m l r o i n scp n l cp m l ' tl r n l r '
    ,' l rt , rr,ri l t r t ic ir r it r slllicil'nf J supr ar . 'nalS'
    Rb.spunsulia tolazolinl e bun (perfuzie prin veni. a icaipului dc l ' :ri rl i r rr r r it [ t : lniccu pCO a cr esct t '
    /- mg/kg/ori). Vasodilatalia sistemici gi puimonard. dat5. de tolazolinl <r
    ir;rLrnare, c5.uneori e neyoie s[ combatem hipotensiunea sistemicd.,ce aparc ' \l l l l csi cut ilr : clclabor at or : hem ocult ur i( sept icem ie) 'ECG 'elcct r o-
    r1r, ri r i (i rrsr r iit : icr . r tsupr iL ar enali) '
    tliqriL administrarea ei, cu alburninS. sau singe. l .t. l )i u r s(
    dir ciauozit
    7_.Bol,i ale SNC.(hemoragii intracraniene, boli conrrlsivante). Meca- , l, lrltsirt rcspiratone prin drcguri ..administrate..mamei
    nu r ispunde I a st im uli' Risl' t t t s I 'r t t r
    rtisnul cianozei este hipoventilalia alveolari. ,,,| ' , f' ,1' ,' " ' i ,' rif , , 1i, : iopilul t apar ic.
    ' , , ,;' : ri ,p:X, 'it i, , or '- I som '[ t ( 1 Radi6gr af ie pulm onar '"1nolm ali s: r r t
    - _ Crize de_cianoz5",hipoventilatia p€rmanenti. sau respiralie periodicli: '
    itt _plusconvulsii sau lip{i de rispuns la stimuli. Rispunsul la oxigen 100/n , , ' nrl ' rr' .rtr' ;
    hipoventilLlir:
    r: bun (PaO, > 150 mm Hg). Radiografia pulmonarS. poate fi normall siir lrtllrttt-iLli ncuromusculare duc la cianoz5' prin -(irt
    irr;rlI pncumoniesau/si atclectazie,pl-l-rrl c coborit. pCO" crcscut. inoscdtre,diJ"gie' Ritpu"s. bun-Iaoxigen 100/' (l'rtt)'
    ,,rl,'l.,,, 1;;,;;;i;;;i" condensare;)
    Invr.stigareaSNC (Pi., ECG, tomosrafia compuieriziti a-riali1. ' i.,ii ,,,,,'rrg).Racliogralie gulmonari normali sau shunta + S. lrr
    8. nfetheutoglobinemi tltrrtrltttiv,'norrlctiJlo ce dau cianozdPfin
    a (prin deficit congenital enzimatic sau dobll-
    Niti un tispuls Ig.91ig"" 100o/o't''is
    dii i'L- ex., nitriai). 1,l,rrrrr' r. rr(l zgomote uttot',rrJ"'
    Mccanismul cianozei: Hb anonnall cu capacitate de legarea oxigc- trl,l, .rrl(,'() u,,,ruur"p-*o.uii ie obicei se vid radiologic. Diagtr.siit:rtl
    ',," arteriovenorrs'r(rsl('
    rtului mult redusi. :, ,,',;;'' I,,'i"'-,ritetiogr.tie pulmonari'
    -- . A1il. "{istuli suflrr sistoli('
    ,l inultiiod,lari*-n iit"t"t"i (ficat mare'
    In afari de cianozi. intensS-,nu sint alte semne. ',,.,,],;',,,,,,'i,,r,,
    .,,,,,,'i i,,',,,,. rrtt;1iomatozS" cutanatir)'
    In cazuri severe, hipoxemia pune viata in pericol. Nici un rispuns
    la oxigcu l00o/0. Radiografie pulmonai'i nolma15.,pH-ul normal, pCOz nor- NEONATAIE
    SPECIFICE
    :, I1.2,4,CARDIOPATII PERIOADEI
    mal sau sc6zut. DE URGENTA
    Singele ciocolatiu nu se inrogestela expunereala oxigen. Singele sc n' CARENECESITA DIAGNOSTIC
    col- oreazl. dupi .albastru de metilen intravenos (1 mg/kg). Speltroscopil
    rLsigurirdiagnosticul. LI |.2.4.1.Trqnspoziliqqrlerelor mqri
    t). Hipoglicenic (copiii foartc mrri - din marnc diabetice- si coplIl rllrrl
    foartc mici - t'x., miii pentru dati). l,'' lr'rrr r'(tzitiir
    : simpl;"ra arlerelor mari aorta porncql" din vi'rltrit
    .' ,, ' :i;.;cl.'; ;,,. inapoiin circuialiasistomici'iar arlr'rir lrtrlrtr"
    Mccanismujcianozcj: - insulicienti \?D 5ncu1d11[hip6gii6nnriei;- pr(:-
    'irrln crcscuti in AD ducc Ia slurnt ll -' S (ta nivcl atlialt--
    ' ,iil,: l'.-::i:i"*:::'',fit*'t$"'ll5;:;r"il1li:,:11
    ,li,i; ':',:,
    "';til'l,i
    lT"lli.
    Semne de IC: tahipuee. fica"t mare.
    )umne de hipoglicemie: trcmuriluri, aprfic.
    ;:;r1
    ;ili.,,ii;: ir",rr,i[ii
    o;:$i fi*';il$#f'ilti, irrl ;1.;*',;r:
    .. \i9i un rl.spuus1a oxigen-100?;. Coidul mare la radiografie. Dozarcir
    illia:mici, respunsul bun 1a perluzia de glucozl. ':i
    ;l'
    :i' ;l
    l;'
    l''
    '' /':;li"ll i''';l';ill'..'lli l;x;"li;' ;;'triszzir
    l':';i;'x:::';ifJ
    -
    risrnul
    1,,0..S,ind,romutr, de ki.peraisco::itafe(Hb gi hematocrit crescute). Mct;:r-
    cianozei: I{b totali crescute (25g/100rnl) (transfuziedc la un gc- " "'ll,jll'u,:.,iili:e,j"';;:'lii;il;ll'i,o][i'l
    I
    rrrr'nlarllu)). Nou-n;scutulestcexlr,.nrde plctorii: i{b redusi cu I g (atliif ,,, ',",.,r.' l,i llSV, sitnptonlnleapar dupir ft-l'1.zile) ,l.
    s:rlrrra{ic88/o) inrprcunl cu cr!ii,rra r iscozititii si crostereaditerengciar- ptit-tttovirsta gcstir!ion.lii";s. rt,
    ,,titot"
    ,, ,':r:,'','i,t;:';;ili;i-;tt"
    lt:riovenoase in oxigcn; prcduc o ciarc,zi ct'ntral) uloari ;i o cianozi.pcri- ,'l,,,iiii
    r . r x r 'r i ',r ctt r l i l tl r t:{ttl r a tcr n
    lllir:i marcati. (cx., in intirzielca crt:;tcrii intrauteiine). " ' ' ,,"i,,',',,',,'i),.' tn,'l"trrl
    i. ,' ;..;;iiilt;ii;t-;'tiilit'prtltnon"ri s. vcd. urt c'rtl l:l'.1:],11.
    i\celti nou-nisculi fac insr.riicir:nfii cardicii. prin ircsterea viscoziiiifii r'r'l ,l, v,lt1l r:trrlrtl)liLt11(\iii;siirraliL It$tt"tlli:.
    supc::iorLr-ir lll":J
    :ringclui.Nici un rirspurisl:r oxig,.rLlrrt),1,,. ,l;'t;ii': lr.gatii'i"rr-ci.tI s. its'r'irtzrr
    Cu diorncialiclrr ridiogra{ia pulrrro" :l:1,:':,.," 1"iiIr"'n"ti'cs1.
    Ir:rti. ll(.nr;{tocrilul(lll) P' str:0.'i'j,,(rrrrr,,r'i .,r t'r,,/.r ",,';,:;i';i:iri'1i,t'
    pttlrt,rrttr'r, t.:11..,:.'.tj':tirrl''l]1,'ll
    pulrrt'rrrr,r'i-r'
    Pitr:-il:r S5',,). '.,l: ';,li;;'i";;i,' "',,r,,,,i,,ifu,it1i,, s| asrx:irtzit ,1,'
    r)SV'r'rrorir''
    l)irr;ii.
    itl)ilr .s(.tJrlt{).
    t:rttcliov;rscttl;rt,,
    s1u ncnrol69ict.,sc ildiciL vglcstx:lic il;',,;;,:'l:: l;;;i;;'"ii iiii"ir,s(<:itt'lr
    . {l r ' .i l ) Itl l l l l l ( )
    Ilus inlrx:ttirt'urh, lichitl. 1 , , , t l t , , , . , , l tl i r l i
    ii0t l
    :i0tl
    Tratamentr. Suspiciunca tLc i ltnspozilie a artelelor mari este o indi, 1' r t l,d tn c n' t, T)ac\ sc suspecicazittipul prt'thtclrrl dc coalctalir',
    crrtic irbsoluti de catcterism cardiac, diagnosticul fiiud conlirmat de angio- sr' lacc cirlctcrisrn c:rrdiac ;i angioiardiografit'pcrltru localizarca strictrrrii
    r;itrdiografie.Se practicS.atrioseptostomie cu ajutorul unui cateter, previzul qi pcntru icientificarea eventiralclSr rnalloiina!ii asocirte inainte de opcraJic.
    ctl un balon, care prin retngere pr:ate rea.liza un defect septal atrial irir:rvcntia consG. in rezeclia coarctalici cu iortoplastie, ligatura canxluhri
    :rrlcrirl qi bandareapulmonarei.Mortalitatea dupl operalie estc de 35*'60'){,
    (vczi fig. 8.98).
    Itr.irrtcrvon!irtardivd esle n"cesari in l'4 din .azuri.

    2-11-2.4,2.Cosr('aliq de qorld 2.'l'1.2.4.3. corduluislinghipoploric


    Sindtomul
    VC

    )Y+
    AD I\
    l--
    lu funclie de loczLlizareacoarctaliei, fafr'r
    de canalul arterial, se descriu urmltoarelc
    tipuri (vezi $i 3.3.8.1):
    o Preiluetal (,,infanti1") (vezi fig.3.147).
    Asociereaaltor malfonnatii cardiace esteobli-
    Acest sindrom inglobeazi urmi.toarele anomalii cardia.ce(vezi fi 3.3.6.S):
    - hipoplazia sau atrezia valvulei mitrale siruf;i valvulei aortice;
    * hifoflazia ventriculului sting, aortci ascendc'n1esi arcului aottt'i-
    Asocier-eadintre atrezia aortici, hipoplazia mitralei 9i hipoplaz,ia vrrn-
    lrir:ulului sting cste cca mai des lntilnitS" (vezi fig. 3.116).
    I
    gatorie (canal arterial larg, stenozi. de aortir,
    Fiziobatola!i c. Modi{icareaprincipali"consti in scir.tlclt:l[ltr-
    ventricnl sting hipoplazic, DSV). Dezvoltarea
    / \rlui artcdal sprc circulalia perifericii. Amestecul c1esinge arterial t:rt sitrlit:
    intralterinS. a vaselor colaterale pentru iu-
    /l vcnos are loc in atliul drept, prin sktmt-'al complet sting-drcpt, rrrllizlt
    ,l mi-!tateair)fcrioarii a corpului cste miniriri.
    o Juxtaduetal. Se asociazl cu a,lte mal-
    prhforancn oualc.Circulalia periferici. sc alimenteazirct acestsingt'rrtttcs
    i r,,:'l fc caloa canalului arterial larg.
    iolmafii. Colateralele sint slab dezvoltate.
    C li ni c. Nou-niscutul prczinti, din prima z.i clc viafi, sernne t;littir:r'
    16l r Postduotal (,,adult"). Asocierea altor
    malformalii cardiace este rard,.Vasele colatc- ,l, insu{icienli. cardiacir.cu qoc cardiogen, inso{itc dc cianozi. rlotlltirti-
    rale pentru jumiitatea inferioari. a corpului I'rrlsrrleste siab, atit la me#rbrele superioalc,cit Si la menbrcle infct iortrl
    [- lrrsrtficienlacardiacS" se insolette dc anurie prin hipopcr{ttziercnalit.
    sint bine dezr.oltate din timpul vielii intra-
    YP uterine (vezi {ig. 3.I a8). D'i a ng o s ti c. Rad,iografia cartlio-pttlmonarii evidenliar,vito t;atrlio-
    Tipul de coarctalie preductal qi juxtaductnl rrrcgalic aCcentuati., in ciuda hipoplaziei ventricular-e stingi. Vitsr:ulrrri
    lti11.:J.15.-'l'ranspoz;$a Ce va-se clucla decesin primele zile dupi nastere.Prirr err{ir puhnonari este foarte accentuati, rea.lizind,aproapeaspectultlt' r'rl trr
    rrrirri -- liziopatologie, AD -
    .tlrill(lr(Dt, Vl) - vertdcul drept, inchiderea canalului arterial se produce o ;,rrlrrronarECG.'hipertrofia de ventricul drept si aspecttipic pentrtt rrr:rrrrslii
    .^o --,aolt:r, AP * artera pulmo-
    jncilcar. aclrrd a ventriculului sring asocirii. .r[,.t'{iunc,abselfa activitElii ventricu]are in precordialclc stingi. J;(.r,: tli
    rrarll,VS - ventdml stitg, AS - cu hipoper{uzia jumitllii jnfe-rioare .r rnirrrrarr',rslu lipsa zgomotului al ll-lea priu atrezia valvulei aortir:t'. /lrr,/i',
    l| trir| s1 irg, VP* ve ne pulm o- corpului. Asocierea altor rralformafii aglr- yrrlio cvidenliizii hifoplazia ventricr ului sting Eilipsa mi5ci.rilor vrtlvttlr'lot
    uirle, \rC - vene ca"e. rrriiralcqi aorticc. Zcsh.illa hiperorie: PaO, poatc {i <50 mm I'Ig, Ii.r'ii <lilc
    veazi. si mai mult conditiile circulatorii.
    trnsuficienla cardiaci severi se instaLeazirin |r.rrlc intre zonele pre - qi postductale ale circulafici,
    prima" siptiLmini de viali, insoliti de absenfrr, T r atament, Chiar daci diagnosticul sr: stabilcgte prin irtvtsli
    pulsului la femurale. Tratamentul conscr- ncinvazivemai sus citate, se va efectuacatctcrismul cardiac9i arrgio
    1i.r(iilL:
    r.ator poate ameliora semnele clinice pentn.r ,,rrrliol;ra{ic.Acestea sint necesarepent111a exclude altc mr forrnar}iittrttr
    o perioadS.de 1*2 zile, dupi care se reinsta- ;rr fi: coarctalia aoriicS.preductall sau atrezia izo]ati de arc ;rorfit: itt
    leazir o insuficicnl;. cardiacS.severe. (,rr' cventuala intervenlie chirurgicalii pateativiL cstc eficimtir. lnttrr,,,tr,''t
    D i a g n o s l i c. I cnsiuneaarltrial'd (da- tlr.rl)crafie in hipoplazia cordului sting este firi succes(dccesr'n plinut lrtrri
    i crminat "r ul trrsonic) le mcmbrele superioar',' ,|, 100%).
    poate fi norrnall (sau ugor crescuti) (70 -
    90 mm I{g). 'I'.A. la membrele inferioa rc n Boli primoremiocordice
    2.11.2.4.4.
    depigegte 50 min Hg. Radiografin aartlio-
    .bulmanard: coldul estc mult miidt de volurtt lirlilc prirnalo rni<rarclicer..eunesc ull gru.pdc ir <rli ci:Lrdiacc nc'slt ttcltttrtl,
    / i/r. j.26. -'l'r,rnspozili;r dc.rasc 5i sc asociirziLcu congestic pulnonarir. 7lC'(i,' irr r:rur:miocardrrlcstt:lt:zat la nivol cclular.
    rL)r!ri-- nspcct r-raliologjc, hipurtrotic biveutlicularl (irr {orrna,,odtIl1".. l. (hmctrrislirrilo mr\ioltiuhri mioftrrdic in Jxrrio:ttlittln ltotr"rrilstrttl.
    IIVS). f(.lC; sul'lusistolicacopclindzgotnoittl l\lior:rrrrlrrl{r:1alcslc t:onsliluil.tlirr lclrrliv trtiriprt{inr:<:clulc (iilrrorrtttr;r:I tI rrrr')
    rrl ll-lca, sart sttflu sisiolic rxrnlirtrttt.ll eslu.I do hi..ltu.oxi.r di[rlrnfiiLl r'r'i. O r:ousccio{.i
    r,.rrrurirnrrll (r'srriirriclr,i.ilial, l rtrt'rlcil. t r r:l cListir:islrrtt:ltttlLlr
    tlcliilziL o sitltttltrc inr . : gir lit , txrrrr|urrliv ttlri r:rcst:u1i Iir rtLltttlrL,
    lt' sttlr:. Irlrrl irlr'o {oltiL rlr: rxltlmc{it: trrrisciietrlir
    ,.r,il rr'i trrior:irrrlLLl incottt ltirltlic
    li,rrrlc rlrr;ii lir r:r'lt'i lt f c r t ir t ; t l' , r lr rrilx:irrlul .rrlttllrtltti.V('tliri(:rrltllli'lrrl rrti' tt r rtlrrrt rli t:tr';..
    illtt,' t.ciizttliL

    : i04 tl0r,

    ,i{
    Iclr t voltlnttlrri stnsllill i!r r:rr rrl rrttcicontraclii, crcltcrca dclritrrlttic:rrlilLc 'l r u l t .tn , r ttl . l ) i L t;i L r l i i r g r t'r si i cr l l r 1 '' l r o a l i r tl i u ' r r tr .l i ci r Pl i l r l i l r i r s(
    l'iirtrl rli:pcnrl:ntil corlplcl rll li{nrtl contracliilor: (tahicardic). l)ttoliiii. t , r l 'i l r l : l r ' , , t ir t r '( :l r ( x:i r n l i c,{l r r l i r ''i l "st".cl o l o g i 'r ', Itr r ":l r ' i l ttl i ca t cu t'l .'ti r
    .,r:,:s{uiiipt, 1a non-nirscrLt (tttarc t;ousumatorde oxigcn) muqchiul carditc , , , ', 1 . , r i l i r r c itt p l r i o a r l r ,l c l r o u - r i i r scu {. Fi b r o e l a sto za :r l ['cn d o cu r d i r r i ' :r l tttt' i
    lrrcrclzir tot timoul la caDacit&tea" lui maximi. rt| rl (l{rl)ulcilzir
    , rrrrl (l { rl )ul cilzirin
    rlr:ltrtlcivlJu pcrioada nt
    iI pcrioatla ca.stadiu final irl ttlrli
    ner-,nlta1i(considcrat6"
    ' rt|rl
    II. Clasilieareaboliloi plirnare mioeardieo din punct de vedereetiol-qgic' ,,i,,,,,ri
    rrr intrautorine), arc
    lit. intrautorine),
    i.r:rrrrlitc un proguosticmai prost decit o miocarditir'a(:rlUi
    arc un
    |t. Pvoces 'inf Lamator: mtocardita acutd- (CoxsachiuB).- rrrlotic, rrou-nirscutul
    ,,,ll,,,rrrrioiic, ln prima
    deccaincl-in
    deccdind
    t oo-n:l'scuiut prima luni.d' (dupi r(owc.lt
    viati (dupi
    iun5"de vlati l )')'
    Rowc.ll l]')
    l',. Pvoces degenela'tia: miopatii primare sau secundaredc l't:nl:rn diagnosticul' diferen!,ial' al cardiopatiilor cu sintll{o
    .congclitale
    Iip congestiv sau hipertrofic. rrr,rlologicscvcrii'in perioadi nconatall vezi tabelul 2.53.
    iopaiii congestiati -frimard: {ibroelastoza endocardiaci;
    a)"cartli.out
    ltj cardiomiit'atia congest'ia d. secundard : boli neuromuscqlare; CARD|OloclcE
    URGENIETE
    2.11.2.5.
    cj cardiomiaipatia hi.pirtroficd. primard : stenoza subaorticd" hipertro-
    lit ; iL; 2.11.2.5.1Insuficienlq.qfdiqcd
    rl) card,iow'iop : glicogenoza.
    atia hif ertroJ'icdsecund'ard
    C. Status posthi'poxic: estedeterminatde o asfixieperinataliL Insu{icienta carcliacirla nou-nescut se mani{estl, initial, Prin cr('il|rt''l
    rr<rccntuatide origine pulmonari. sau, in formele severe, de persistenla circu- r,rl,itlii irr grcutite, 80-100- g/zi, cu toate cf, acesta .: ,"li*:1i""_1ii :.'l lllli
    ,rril:rlc. Apoi, asociazi.
    sn asociaz6.
    sc tahiineca(> 60 rcsp./min.),tahicardia,ptrlsttlsl:rl'
    lrr{iiri de tip fetal. ',itlrc. -\noi. lahlpneea
    lr, p:rr,rrnlgrlio,edcmc palpebrale, trarrspiraliela nivclul lclni S,iIt i It' ' | ' rt ri' ' '
    Diagnosticul acestor diferite tipuri de boli endocrrdiace se face, adesea, 1.,'l,i,li*rrn'"e.cu bronh-osp-asm, ralurile pulnionare de 1a sfir;itul cxpilalici,
    nurnar lJ examenul anatomopatologic. Acest diagnostic nu este lipsit,.dc ,.' ,,t 1: rnitiLtile
    l:rnitiLlile reci,
    reci, cdemele periferice, oliguria 9i anurh sint scmnc d(' ilrr'rl
    irrl.nresnici postntofte1n,avind-in vedere faptul ci anumite forme de cardio- ',I cord.l esttrtrriitili
    lr, i,'rr(irr::ircliacir avansatl. Li radiografiaCardio-prtlmonar!"
    prr.tii primare au un risc crescut de recurenlS.familiali. ,l, v,jhun. Contractibilitatea cardiac5' nu poate fi evaluatl prin IIC(i srrrr
    F i z 'i o b a t o I o s i e. Insuficienta cardiacS.in miocardita acuti. 1a l,rrn liCG, ci numai prin echocard iografie
    rr',rr-nirscutsr-insoteste-de dilatarea veritriculilor, dar cu sci.dereavolumului 'I rularlr lul insuficirn!ri cardiacela tlou-nds( l'. [-a un n)arc tttttrt:tt
    pc r:orrlraclic qi cu sclderea debitului cardiac. ,1, llorr-Discuti. si'mbta ved'aierea lich.'idelorad'm,'inislrata asociatdctt' d'i11i[Ltli
    I'rcsiunea ln atrii qi ln capilarele pulmonare este crescuti. Cauza acestor ,r,, ,irrl su{icicntepdntruameliorareasemqelorclinicede insuficien}iL carrlirtt:it.
    rrrrxlificirri hemodinamice este-alterarei calitdfilor contractile ale mugchiului lLr,,i, in anumitc iorme de insuficienll cardiaci. conScsiivd curn ar Ii tr''rt
    crrdiac prin edemalierea,umflarea gi ruperea fibrelor miocardice. ,.,rrruliuirpersistenteicanalului arterial pclmeabil, la prt'matuml frxrr{trtttir',
    Clinic. Nou-nlsculii cu cardiomiopatii prezintl semne progresive r.,,r'Uusul6stc ncfavorabildupi administrarcade Digoxin'
    'Avirr<iinvcdereabsorblianeconLrolabili.r-l)igoxinulrtirtrlttrirri:'lttl
    tkr insrrficienfS-cardiacS.,insotite de dificuitili in alimentalie, care se accen- rir'
    tuerzh sore sfirsitul oerioadei neonatale. ln miocardita cu CoxsackieB sem- /,,/ ,'r.iu insulicicntacardjacila nou-nlscut'doza dc arrc sc vir il(lrlrilli::l
    il, ,,'riuii.-r:arcntera]. Intervalul in care se administreaziL doza de atac vir li
    ru:l,: cliriice opui io p'.i*" siptimirLl ile viald, evolulia este mpidl 9i se inso- 'l''
    l.' lr, orJ (ll2 dozta.initial, 1/4 dupiL un interval de 4-8 orc, iar' l/'l rlirr
    {c;t.r: frecvcni de convulsii gi alte sernnede suferinll neurologicl. Miocardita (lLr)i un'intervaldc 4-8 orc). Sc vr. cfectuaF"Ct'inairrt.'tlc :tdtttilti't t r
    scluntlrrS. hipoxiei accentuate se manifestS.clinic tot in perioada de nou- '1"/.r
    D is( rll. r, , 1i,,,;iilcitloze dc Digoxin' Daci apar scmne de toxicitate (PR'0,1(r rrlr"
    .,rrr lrrllruri.ri de rihn)i se intrerupe digitaliz-area.I)ac.i t'Icci:ulrlorit tttt r;r'
    l) i a g n o stic. Radiogra{ia cardiopulmonarS. evidenliazi o dilatare
    ,,l,trrrr si nu sint scrnnr:de intoxicalie digitalicl, sc poate adtninistrit itrr:rr
    glol,rirlir.rL cordului cu contractilitate redusi (evidentl mai ales echocardio-
    1,i ,lirr'rloza de atac supliment:rr,dupiL 4-6 orc 6c la ulti*rr arlmit'tisltrr'r'
    '' t(;,1.
    Kfi ri,,l',lul z-54).
    In Jibroelaslozasubendocardic5,electrocardiogra{ic se intilnegte HVS '
    l)ur)h 6btio.."u cfcctului dorit prin administrarct dozci rlc irl;tc rll
    irrsotiti! dc subdenivelarea segmentului ST gi negativarea undei T, 9i un
    ftr'rrriirr.se coritinuirc' 6oza de intrcJinere'p.o.diviz.tir i.nZ priza,la l2 .r','
    lrilxlvoltaj rar lntilnit in cardiopatiile structurale.
    trrl,lrvrrl_l)c ascmcnca,dacir.scmnc'iedc insulicicnliucar,-liaclmt sittl ;ttr',r
    Ln miocardita 'inflam*tor'ie se intiinegte, mai frecvent, un voltai scizut ,rrr,.rrlrr:rlcstt1loal.e adrninistra, deIainceput,dozadc i[trr:lincLca'irtngittrlrt 'r'
    irrsotil dc tulburi"ri de conducerc yi tulburdri de ritm, ECG_.fiind,ir.general, 1,, ,lr,.rt:rlizar.ei lotilli'r d'l)i () sipfiminiL. [,cnlru ca dozil (lc intl('fitr( r,'r,;' li,
    rrrx:iirir.ctcristicir,cu valoare diagnostici numai in zao/o din cazuri (Nadrs , tr,r-irri tlclruir:si rrtcrtllrl.i nivilttl sattgttin'l Iti{orirrniIlr l--2 ttl;/tttl.
    ri lrvtcr). I.r fonocardiogr:rmi,dc obicei sullu[ cardiac estc absent, iar zgo- lrilrcticc. S() adIlri rristrcazl furoscntid in doziL dc l-2 tn11/kg;rl'tr'ii
    rrrot,lc cortl.ului srnt asuizite (,.,cordulmare gi mut 1a copil"), ,lrrr,,rrrrrirrlr:twillrkr(r0mitrutctrrrsc ob]inc rru , I.,:i tlirrrr'ticsc atltttittisi tr';tzlr
    lrr suspiciunea:i':lteibol'imiocardiceprhnazz se indicd. e{ectuarca testclor ,, r|,,,;.irlrizlL <lr,2 .4 rng/kg.ln ,r,rrr,lifiilc rr,]rrrinisl r;'uiiPrclungitctlr:rlitttr'litrr'
    scrrrlogicela mamir Ei 1a.norr-nilscttt,pontru punerca in eviden!_iia unei t:vt:tt- (lt:.t - lrrr!)'1/;ri\lrnlit':rtt t hiltl'ttrltri
    '' ',' .rrI ,I i rrr, ttI rt ti 1';riitri (:irttlil:rl(ii
    trrrLl,intcc(ii cr CoxsackicR, parotitlitir, griPit, hcrPcs, rubcoll, citomcgrrlo- ,nt,l,,lt,r;it i r ti l xr r l r tr l l i i ,
    t:s( t' tl t:r ti l L t) t:t: i tci <l o zi l l :r vr l ti ztl i L zi "t l l r l r tl l l ctl ttl i t
    vitns sirrri oxotrllsur<lzii. r 'r '. {r t o l l : i l t i ( i( i ( :i l tttl tttttl tl r l c'

    300 307
    Tulburiirilodo rilnr curdioc
    ir.11.2.5,2

    (:i'ir lriri frrcvolrtii 1.u11;nrrrr',' clc ritrn 1tr nou-n5.scut cste er:tlasistolit,
    GIid de lratfl, c||t :rl insuliricDtci cardlacc l1r uou-ualsctlt
    ,r rlr,olrir;ci, nu si: tlrLcazir. t\trmci cintl se asociazi. cu tahicardia, cxlllr-
    '1'ratamentul adjuvont, r.l,,iir Po'rlL |cPrczr,:rttaLL1I scrlrn pr:ecocede suferinli. cardiaci care clisPrr|r'
    l'ratamertql de bazi, a.l
    t)r iI1cipiu cdem pulmolrar, i ' 1., .' rl rrri rr.rt r , r r ', . . rd'. , ligilr 'li.
    insqf icienlei c:r.rdiace
    $oc cardiogen lllorrrrl irI rio-vcrttliculsr de ({r. I !i II reprezinti frecvent cfccttl triila-
    Dopamina ln peduzie ,rr, ,lrrlrri r:rL tligitirlir. .lntirzierea conLlilccrii A-V (daci prin monitorizirrc
    Cfelterea contractibi- Digoxin, B-acet!'1digo,-iin
    lii:Llii miocardice 0,25-0,50 mg/kg/orn rrrr '.,, r,virlcrrlirrzirrrn grad mai mare de bloc) nu trebuie sir duci ncapirrrr.l
    D,\; 0,03 mg/kg IvlIlI . ,.irlclrrr rlozt:i dc digitalir dacl efectul inotrop pozitiv estc necesar clinic
    DT; 0, 005- 0, 01 m g/ k g/ z l Glucagon in perfuzie ' r.r ' l r rl 2.55).
    N. N. la tcrqclN 0,05*0,1 mg/kglorn
    DA; 0,03-0,04 ms/Lg/Iv, IM
    DI; 0,005-0,01 mg/kg/zi Tabelrd 2.:;:i
    0,005 kg/zi sub vi$ta de 14 zile,
    0,010 mg/kg/zi dupi 14 zile; 'll hrnrr trrl rrilrrlilcr (d $menlnlri alala fu ]elioada d0 rron-ndsctrl
    doza de atac (DA) totdeauna
    rareBteral ! a) nasa] cardiac c-.ctelll
    iaci doza de tntrelinere (DI) se ad- b) vcntilatio cu Or 1009/o
    i'nidstreaz, oral, se va calcula cres- c) coreotarea acidozei
    cind DI ce se admrnistreazi, patel1_ (bicarborrat de sodiu 2,5-5 111nq/kg)
    teral, cu 20%. d) ronitorizarea ECG
    I l. Diu r e z i Furosemid Spironolactole
    1-5 mg/kg la liecare 4-6 ore 4 ntgllK9lzi IV, inilial
    2 mg/kg/zi p. o., intre- t t l\tl d. .ffih,ric I'rataneiLtll, de Tratatnenl l de Lurdld
    Fnere
    t t l. A(lministrarea de cantitatea totald, rlo iapte va re- aumentatra parcnterali!
    liclide prczenta-naximum de Ulo dil1 60-80 mr/k8/zi
    grcutatea corporalS, divizate in Adrcna.Iin:r, sol U10.000, Dopanina il1 pcrlrrzi(j
    8- 12 mese, prii gavaj; sc va con- 0,1 ml/kg i. '/. sau intiacaldiac 0,25 m8 kg/ofit i.v.
    trola greutatea n. a. de 2 ori Pe zi - Orciprenalina (Izolropil -
    i v. Me'rlinerea echiliblo acidobazic
    homeostaziei electroliti -Alupent) 0, 1-0,25m9 iotracardi-
    glucoza ac Si/sau Calciu gluconio sol, 10%
    trars{uzie cu masa 1-2 I intracardiac
    eritrocitar5, 10 ml/kg a) compresiune oculartr
    S1rllat de morfind t at,t, r t,ttr l \ rxititit:d
    Limilarea eloltului pozilie irclitatd, 30-450 b) digitalizare r&!idft.
    0, 1-0,2 mg/kg s. c.; ,,1.t,1,/t,',r l r ti t
    Fenobarbital 5 mg/kg1zi (2 x 50% DA intr-o ora)
    intubarie ti ventilafie c) Vcrapanril (Izoptil liole 5 mg/ml,
    artiliciald cu PEEP irhil)itor td Ca la Di-relr1lmutchiului
    4-6 cm HeO cardiirc, cu pr oprictl,li antiaritmice)
    0,3 ruti/kg, c:Ldozt maximd, urticd,,
    {LizolvaLilr 5 rnl glucozr'r5%, i. v.
    lont, I rl/miuut, pirtr, cind ritmul
    Clizele cle cianozl paroxistici, produse dc constricfia zonei infundibulare corCi.Loinccpc sL scad,
    .r v"rrtlicrrlului drepL favorizati de icidozi fi hipoxie,.se-trateazdprin adrni-
    tralamentut a t,tt,tr t \i Digit.rlizarc rapidl. D i gi tal i z afc c 1c i rttfr' l i rft,1
    uisltrrtn I'nld de morfind i.v. (0,1-0,2 mg/kg), conLrnutndu-se 'ttttnl l i h ri -
    t r t,.' , t,
    'tt'r r tr l tr tit V,ir{p&nril (ca, mai $us}
    ,:rrIrr',['r.rnolo]p.o. (5 mg/kg/zi, divizat in .t dozc.1. l)olil)rilotie clectrictr ( 10*25 $/s)
    Daci. valoarca Hb este mai micir dc 14 g% (Ht <40) se considerl cir I tr t,,, t.htt t' r l \r r I)cfil)rilarc clcotdcl l,idocaina in l{it f('7i,,
    0, 1-0,2 nr8/l trr,D ' ,,,' l
    ,:stc vorba d.e anemie care se corecteaz'act tnaid' elitrocitl'(d 70 ml'lhg' I)r' (5 ,nu/kg) i i:r&car.liac
    l,itl<)c:rinrr"
    irsculcnca, atunci cind hcmatocritul csic rnai rnare de 70% se corecteaza
    lrrin inlocuirea singelui cu l)cxtrarl, I0 rrrlikg'
    Atlninistrareade Orittr-o cotr(:e[lfrtiicrnd n'Lre dc'10'/o-ta nou-niiseu-
    numai (liloit ircosta:rfc cdem Pullnollilr (ln(cl- !l !rr,rrl i\ I cr r f {r
    11111111'r
    t t r Plr t (l,r il. ur
    r 1,
    r vr 'l{r
    'r r {licult
    'icr r liLr it rruu ir l. li: r l - lo( l/
    r '{i0/ r r r ir r . ; r 'it
    lrrl crr ciarnozlcstc Docesari"r
    ,rll Urrl
    rr l i r ir
    l |r', ||lt(lr l r ; r 'ir r io{r '; lr ' <lc ir sr r I i<: it : t r ] cir 'i dir ior r ; 1r ', ir r iil) ') i,
    ir . r <liir crsc
    Iirrir tlifuziuncl pulrlronar;t). l l rl l rrl
    tsis- rll . i .:rr,
    ' | l r , nu r lt ; r r r r r r r r , r lii slLr r clr r lr lr '. I ) ( . ir s( r ) r ollcir bkxlr
    , r l A^- Vdolyr 11.'. lll rsrr ''
    plirl intttlrllir'l;i rtrsllirlrliL'
    ilrtttifi:sl'il ltrt.l'lltzit
    lidcmul ltttltrtottar
    llr(i, l r . l r l , r l ) r r :i l l a tr tt r to r r ttj i r ,r :r r l, tt Ir i l 'r r r r , s, v"r ':'i yi i r r r tr i tx:l r r d i l :r r L ttl tl i i
    lrLtii r:rr I'l,ll,ll'.
    3( , ll
    :t0ll
    Iiintl rrn scrln tlc proguosl.ic :leIlLvorabil. Atunci cind ritmul cardiac s|lrtls tt'lt) n):itrs sii liiminir pcnncabii csic pr-crporfional.cu prem;rturitatelt : s[l)
    .rrL 50A'in. sc adiniiistrr:aziLt,rciprcnalina(Izop'opilaini'oetanol-Alrr'r'tt{) t il,0 | f ,,t,tl artr:riai riimine ptrmu;rlJii in 701( din caiuri' Daci sc lr'sociazri'
    "t rlc tlctlcsl. respiratoiic accst proceni est-emai mare.' fn 1/3 dirr
    in ,lozi <1e0,05-0,1 mg SC,sau solutie 2%, 2 picituri Ia intervalu-1d'c 'i olrN' ',ir,,lloirrrrl
    ln stopul cardiac se injecteazl orciprenalinaintrrcardiac in tlozi' dt 0'l - :rzrrrih:tlc irrrrsistcnti a ianalului arterial permeabil,acestaseinchidc spon-
    r).25mg in]prerni cu 5;d de NaHCO" 4,29o, unnitS. de masaj |rrrlirtrr ,',,'it.,^'],.rit". Itit-o alt.r treime diu cizuri canalul ri'minr: pcrrn.rLlril
    ,riern(caiecoiaminolesintinoficienteinmedirrrcid!).Dupircluarcacunttrtt' '.,,, ,, 1x:rioatll mai lungi de timp {irrl sl se inso{easci-de modi{icitli
    1,,
    ',i.Lr
    liilor cirdiace se continu5.tratamentul cu dopaminS",in dozi. de 0,25 mg/kg/r)t'i"r' llrrrir:L: rr"Lric.ln 1/3 din cazuri, de obicei asociat cu membrani! lialiniL, st"
    ' 'ir.'modirrrmiceimporlante.cu slrrzl stingl-tJrcapta..5ihip' t-
    Folosirea masaiului cardiac f5.rd. vintilalie pulmonari- este inutil I ru,,,l,rc"rrrotliij"ili
    /ri tibrilalia sau 1luttciul vcntrioular seinstituie i'rediat masajul cardiac cxtcrn i,,, ,,'n, puimonrl.i, punind in pericolviata nou-n;scululurlvozi tig 3 l36
    ,i vcntiiitia ariificiali. Se poate {olosi defibrilarea tralstoracici foloslld ttll ''i
    '
    3.r37).
    -C
    , rrllnt de 10-25 \nt. ln lipsa delibrilatorului se practic[ defibrilarea rnrxli" i'; c. Prematur-ul, cu imagine radiologicS'.de membrani" hialiniL'
    -intracardiac sau intr'-o veni centrali. Lidocairtn r'r,rirr1:r cletresir respiratode accent"uati.asociati ;i insuficien!f, cardiaciL'
    "';
    r:ir.rncntoasi:se iniecteazl
    (XiliniL) (fiole ile 2 ini conlinind 0,2 g clorhidrat de lidocainl in solulie apoasil) ,rr ,rr'saallor snmneil" malformaliestructurali.cardiaci.
    in tlozi dc 5 ms/ks.
    ' ["..a.t"^ sindiomu]ui de insuficienia rcspiratoric dupi o pcriorLli
    Daci fibrililia ventricularS. persisti, se opresc contracliile cartlitco ,1, :rncliorarc,in ziua a 5-a dupi naltere,;i aparitia crizelor de apnci: csli'
    rrlin iniectarea iniracardiaci. de KtI (2 rnEq/kg) urmat:-uiLnediat dc rL:sti' rili,,i, pentru'aceasti boall. Hepetomegalii se asocia',1cu.puls ,,slltiut-t'{"
    urularci cordului prin iniectarea. intracardiaci de orciprenalinS..In printr:lo t ,l. T.A. divergenti,ridicati.in sistoli;i scezuta.indirslola'
    'r c. Electrocardiogramanu prezinti modificlri carirclrr-
    s or-. dupf, clefibiilare se administreazl plofilactic ldocaini. in pcriuzir Di,apnosii
    o,1--0,2 urcil;g/minut. Lidocaina are un important e{ectizotrop 9i crorrr.rtroll ,i ,li,rc.Fon?cardiogra{ia evidenliazi"unsuflu sislolic inso}it in 3/4 diu cazttti
    ulc:rliv ! , r rnr.lrmur diastolic.
    '
    'l'ahicrrnlil paroristiel suprarenllieula|{ poaic ameninta.via\a rr'rtt' Radioprafiacardiopulmonari aratl uncori cardiomcgalie9i crt5tclr':t
    rr.r.r,rr lrrlui.Uneori, accrsli tulburrr" de riim "e Poatc cvrdenflaprrn:ttll' , rrlarizailci"pulmonare, greu de diferen{iat-de modifictrile produs" .tl''
    '., Diagnoiti"ui ." pune Pe baza examenttlui crhoar'li"-
    lrri{i:rls, facc comlresiuncapcglol,ii oculari (5 .^cundc) 9i digitrlizarca ':'ltirlll ,",
    orrllnhcraliL. Dac[ inima nu riintr:l, in ritmul sinusal dupi pdma dozl'r (lo "ti,i,n.'hialini.
    .,'r,/lir. RaDortul dintre diametrui atriuJui stihg/ridicina aortei> 1, 3' Catctc-
    lliuil,,l:,, r" aclministrcazi, sub conlrol ECG, Verapamil (Inhibitor al ionilot' ,i.'irr'i .oiai"" ;i angiocardiografia, pentru demonstrarea sfuanl-ului sting-
    ,1,1(-,r la nivelul muschiu.lui cardiac cu importante proplietlli antiarittttit:n 'lr, rrl nu sint necesare.
    in doii ile 0,3.mg/kg dilrrrrl: ' 'l- , a t o n, e n t. Dacd. pentru menlinerea unei PaO, satisfec:r'toarc rur
    s,r,,r,rv"utricul.re:Izbptil {iole 1 ml: S
    jntr-un n n' nu prezintiLrLt;it loui
    irr'.5 .rnl s]ucoz5"59L, ritn de 1 ml/miuut.
    -g) Injectarea se coutinul i)illll '.i' r,'cesaricontinuareaveniila!iei artiticiale;i daci
    ,:iltl,ritdul cardiaiscade cr 10% (contrcl ECG), comutarea pe titmul sinrtsfll r.rrrinsuficienli.cardiaci"congestivS. decompensate, nu este rndlcatirlIl( ll'-
    ',rl permeabil' At rnrt:i
    rrrmincl sir se produci. in secundele [rmitoare. Se continuir tntamenitl] (:tl lil.'; ,;'itiiJi"i!"t*
    ;;i;;i;;]e .^u i"t-""oTogicl a canal'uluiarterial
    ,lir:ifrrl,r, in dozi d" intrelincrctimp de I an (dupl G"lbrnd Si Rosert)' , ,,,,t cardiaci nu r5'ipunde la tratamentul medicai dupl 24.rlt'
    l'luttordl si iibri]aliaalliall sint mai rar intilniic la nn, dar slrrrx:l , ,t, la ingoputul acestuia,sau7giventilalia artificialS'trebuie.Prclungiti'
    ,.i.,[ :L'ar-pun iir pericoi via]a nou-ni.sc[tu1ui_gisint rezistentcIa tfatar'rjlll. ' rrr,licAinchidcrea chirurgicall sau cu Indometacin a canalulur artcllrtl'
    'contracliilor '
    ln lluitcrril atriai {recvenla cardiace este de-350/minut cu ull li.rirr rnortalitllii, atit in pr6cedeul chirurgical cit 9i in ce] farmacologic, cstc
    lrlor:A/V de 4: 1 sau 2: 1. Atunci cind b1oculse comuteazi la' 1: 1, apar scnt' .1, r o.- 15%.
    rr'.l,.rtri insuficicnt; card.iace.. Se inccarcd.cregtereabloculul prin adminis(rirr'l t)esi'insuccesul
    -ioid""uttu I tgrytylgi. arterial este de
    lnchideriifarmacologice
    ,l,
    ' Vr'r.ruarnil (0,3 me/ks), urmafe de cardiovorsiune. t,,' *''i"."o" cu acesta.lndoietacinul (inhibitor al sintezt'i dc
    in
    i'se produceo in;u{icienll in irigalia sanStini. 1'uliirr
    In'tir,.itr'rl, atrl-r.l t",,1]'.,*i""aiti.l se administreazep'o. prin gavaj, in dozi de 0,2 mg./kg
    r i, .i. I )o obicci, rispundc Ia.tratamcntul cu digitali. Tnlipsa acestui rispunx, i,,t',,i,I-"io.or"il5o/^, in concentrafieac o,z mg/ril ; acceagidozi' sc mai porrlr'
    ., rLdrnitrist rcaziL Vetapamil, in po{uzie, in dozi de u,3 mg/kg.in tilrrp do ,, s,,i,,'tJ"doui orilll interval de l2 orc. Rdipunsul-Iavorabilla' fratam{'ttl
    ,, r,r'ri.I)rci nu sc oblinc rczultr'uI dorit se practrce caldlo\ crsiuneir'I'rt)qr' ,,,.'t1u1.,." prin irnbunltitirea condiliilor respiratorii ;i posibilitatczr-inll'r
    rrosticul flutter-ului si fibrilatiei atriaLe este sever dar mal pu1rn ncll!or':rr)ll ,,,'".rii u..n,it"ti"i i.titiii"l" la 24 de orc deli ultima dozi de fndomctat:irr'
    i,'irl"i tiitnii.',fitpit., t;"utoi
    ,l,. ir la copilrrlm ai marc. Ei corclul revin la dimensiunilc nortnrLl"'
    riLportuldintre atiiui sting/ridtcina aortei <l' E[cctelc n':rl't-
    ,.,, ,,1r,r,tir,fi''t
    conoluluiqrteriollo premolurul
    Persistentq
    2.'11.2.5.3.
    idiopoticd(membrond
    cu detresireepirolorie hiolinir) rlrr,rlc,(:tt crc$torcilrctentiei dc aplt li crcttcreaurcei sanguine'Restrictia tle
    "i,,l,l?-ii,,",''ii,iui."inoo,""to"inconltauinatectarcatranzirorieafrrncfici
    fi' tt:mlx)rirr'
    (
    t',11|l'1,i. 5i Pcrfuzia cu'rloiramini in dozi. tnici-i Pot
    ,t;,i''.,r'i,"'1,'
    IrnetliiLtdupi lI.t$tqrc,cirluitll iIrtcliaI co]llr:rcti.srlb irrlllictllrr r('t' lrrrlir',rl',Aturrci cinrl ianalul artclirll sc redeschidc;i re;rpar semuele clrnl(c
    (vuzi^si ltt itrtutrtiic -(r
    coudilii, :x:tivillrlll
    r:rr'lit:Lr';t tloz;r tlt: Itrdourctacin, d r numai Ia 3 zilc dupft-trltirnrrprizit
    ttrii I)r0" J.i.7.4) ,"i iu,,,r,l
    llisrrrl |i\ lltrllll
    1..,r.l r:irrriut:Irrrlrrrt.IrIriI.
    locirl,.,L liLt_r..t;rgl.irr,lirrulor'r1,.tiP 'rin ',,p,'rt, I)rtr:itrlrtpit?4 tlu
    rtrltnitrislrittt:.
    l,,,,iiii,, t,r"iit,,, rlt:ltr irtccput'l ttitt^lrlolrlll-
    'tc
    8ll
    3I0
    l rri r:rr I t r r k lr r , , I ir r it t Itt s r: < tL s e rv i in j r:i o rrrrrr,Ii or.rr,,l i rti r:i i , srr rc L' fl r:1tt rrri , l i rrrr.i ,r1 r oi r : r r l0lr r zolir r : r r lr r r lr r isll1Ll: _it r - lxr r 'f t t zi, 2 r ll3- / lig/ t t t it t t t l,
    .l
    ,iirrt Ii1;rLirrrrL clriltrgicali a.can:rh ui \rlr'lii\f. ,lttitrJ. t:tt i)tlrt't'.t:!i.at{a.iur.titti't,l ,, , ' r\' :rl rl , r: ilr : v; r, , . , '1, , , r , ', r rri : ii, lvl zilr : ) . l'cr f t lzia sc iliI t 'r 'u1lclLl'uDt :ti: it t r l
    ,i, IrrIorn,"/,uL:intLtl tel)re:int.i, i|lad, xul tl'a.[,a]qtl. rottitt tt!iott,Ltl,:;i lt a:;1..l, f;stl rrrl i ,r rl r'O , , t t lt : i sr r . r iisc; r . t icsulr ( r 0o7|, ;i pr esiunea inspiLat or ic ncccsr t t 't
    ,r, /i.r(, sr t't:cou,urtclei folos,irra lui J.LLtrtsiiJL ccJltt'LIi tb cadiologia Jtr!,:)diltl ,1, rr' ,.r,i 11,,0. iir tirrrtrLl pr:rfirziirii tutizoiinirlui sc va. cortlola Porrrirrlcr)l
    pLasm'Lt'\l':rrl
    ,.,Ir iI sttliil. tle \trcnatologic,
    fvcadzu,te cu Lut u?odcnt iulLct dc t.1'sli( ili.;t{,'i. | ' rr,litr{r,l,1,'sr:iLrlt,rtr a t t usiunii :rttcliale -seI'a corecta cuull
    (l' L.l l
    , ]l ( 1l iitr Paiotrtirnrrlico.0 alti. complicafie clupir adrninislli]rca
    2.11.2.5.4.Sinrhomulpefsistentei.ir.uloliei felole ''' i ,' l i ,'ii. ' '; : iI r r '' t : . I . r qr st r oinl'- "t i'r lr il. .
    , rrr. i r,,ii, , iiil, , , , lr niniir : , lr ii '1, 'l obzolin l'r 9z - 6{t t t t i. r r llr :
    "; nt : colg"st tv t
    I (... lipsir- clc inclicrrfie), insu{icicnla.cndi:rciL
    Sindromul pcr.isipn1(i circul aliei {etalc aparc atunci cird reziitcrrlir ' liti rlc lLilrlLoxir: r ': r l, il'
    r,rsr:ularir pul;nonari. se mentine cr:escutirdupir nagterc. Consccir:fa rr*strri I i \trrl ( , inr l: r loinr nr , . rico li t A {r '0 . 'nm HA . llr L, r r or m opond'
    : ( r 'r r r r J: lr l : r dnr ini't r , r ii dc lol izolin F5l' ( lt lr r ""'
    l:rlrl cste o scidere a fluxului de silgc spre plirmini 1r rtlr sin&t ilnt]ori.lr rl ' .' .,r.' ' ,r" ', '1il, , lir
    tj.. t /!lr' ,t.littc, rtri.tnitisl,t'ortd de T'olaxol"i l'veln'tie con'siderat ltn l"]'dtamt:)tl
    ,lrrlrl-sting prin canalul arteriaT si Jora.mett,otale.
    ctrtl'iolog'ie coltLtldlti'
    Sc descriu urmetoarele forme de persistenli. a cilcula.,tiei fctale: ' ', t[irtttt.tl, (:drt: sc 'ttL apliL:lr,niutttt'i'ht aentrtk' de
    [\ Iiarrn& irimo/(i (id.'iopaticii) in carc cxisti nodi{ici.ri rn{.,rr(l
    l,,r1ir', rLIc nusculaturii vaselor pnlmonarc, $ocul cordiogen
    2.i 1.2.5.5.
    Ll) I ior m t L sc c u t? ,d a rd i t c a rc v a s o corstri cti a \,ascl or pul rl onarc
    ,:,1r: r'cactir'tr unci hipoxii gi/sau acidoze asociatc cu urmitoarelc) boli: rLs{ixi, lcltrtrttti irrrpliciLo irrsnficirulir primarir. acuti a
    -corclului'
    sevcli t'slc lrtlri
    lr.riurLtaliL, aspila{io de r:reconftr, policitemie, infec}ii severe birctelicri.' srrt l)is(ilx:|il inilc sot, cardioqcn siinsrriicienlit carc.liacS-
    \ ' lf oLl{l o - Ll :,,l ttl l i: , luza'c0[ m ai im poii ar ] l. ira locult r i car diogen est c it t llLt . t lt t l
    () li ot ' jna ca n tp l e x d a s o c i a ti i c u i s cheni c l ri ocardi ci r" ,cn ,rrl Lr ,,' L,lit:. l,rr nou-r'tirscut, cituzel; cele mari {recvcntc sint: liocar(lita' s( l)l i'
    ir( i{ f il . \ ' i r .
    , (rrrl i l tl tt s r t t cningococem ieI , or iginea allor nali- . a. at t er ci color lir lr '
    lrr concluzie, sindromul. r1e pcrsistr:nlL a circulatici fetalr: se ilsoft'sl, . ., r, I rr r . r i li', v, lt t l. : t : , , lr ot t : t r l ca'4ult t i sr . t t t l hipolla: ic'
    ,l, o hilxrxcrnic artcriali ihlort:inti. cu cianozir ii s/xlrrl drept-sting. , tbl art L c l, ir t , i t : . I lr r lsnl ar t cr ial est e apr oapc nepalpabil; r r r 't t
    , ,'rl r,s{r' lrratli<:iilclit: si lahiPnoic l'io1ea cste narrnoratiL- Ii'recvent r'rislr'
    t l, i n, i c. llc obicci, esic volba dc un nou-ni.scut 1a tc::rr cn c:rtc irr
    , Isi rl r4t ir r r pi, t i. n. 'ir r cliir lt m ar c'r alur ipuim onar o, I >r esiu'ncl'it r t t t ) t t \ t '
    ,,.rrrIiir:ianozir accentul.ti aleI a nast ere, dispnce ;i suflu sistolic. Lr {orrn e i ipicr'. , ,,,,, r' sl c r : t , scul. i ll l0- - 15 cm : r pii ( in collt r ast cu ?r cslul. Lcit\ '( llt ) ir : r
    lr,\ or)]plica|l-i, rru se asociazl. sc;r1]cic de insu{icientir. carcl..iaci. ln l,'rrtr:' , rlirr so' ttl i'irdotc'xic si hc oragi{)).
    corrrplicrtiL (insuficien{a cardiacl cste prezent5.) boaia^ se ase.ulir.: (rr ,!
    ir/i,t:irrltt tot'ttcicti:rrtttit o caralior;1clialic;i ECG.ar:atir sctntr' rl' itr
    Lrrurliopuiic structuralir. congeniialir cianogenI severi. In i]ces1.c{oirr!1r, (:lr
    sriLt cltr rnior:ltlitii. Ii{ccl'c11t sc inlilrle$tc o acicloziLs' v.r''
    lul. ir-atarncntrrl iltcnsiv apiicat, in 10--200/o clitr cazuri sc produ.c iicr),rsrrl "i,u,',,1i,,
    '. I abloul clinic est c dom inat lt r'l'rrl'l"rri r r i t r t r r ll
    , ri i . l rLt lt Lzici iisLr lai- rloclilsrr
    irr prirna zi dc vialir ca o consecinle a hipoxemiei acccniuatc. t .,ru ri'rziir lisrrla.rir tlircit tle insulicicnliL c-ardiacr-r traditionalir'
    l)i,:t.gn oslzc. Iladiogra{ia cardiopulmonalt aratir in {o|ma :iLIrplir , ,, t s,, rti t l cucloior lir : ; i : ulr 'r r lr ainbill 't lcli coe\ ist ii' ( dc t r llt 'r 'r plr t il
    , ,i irrirra rstr: dc volum norrnal, vascularizatia pulmonari este sciizutir 5r 11us. l ,:Il ;' ' r "' '''l: ) .
    rrr,,oIr,slt'rl: modilicirri ale larenchimthd Dulmonar. llCG estc ncconc.lii,lrnlir. ,, r' l l rri, lr illslilr iliii lt r r i ir ', 'r r r ' ni t ir uf gculii Li' 11ll lr oll llir ) i(llr
    i 'r l(,',l,itlL:nliaziLul) su{lu sisiolic <1,:iasuficien{!. tranzitonie a valvtdei nitrlr,l' rrl i r, l ripoit , , r , r t r r iilr t : iil. iir ipit t licii invcsLiglt iilr : lf c'r r 'r iir 'r slr {) r l) ililil
    :,rrr irit:rrslritlc. liclllaaldiogv.Lfia arati o sci.clcre a corrtmciibilir ilii -' :rtli , .' :rrl rl ir : t - ot t r lllr '1.
    , rlrrlrri tlrcpt, iar in {ormele compliriats qi rnodiliciLri alc ventlictJuiui :rL.ittli ,i ' .i ' ' ,, , l, lr oii t r , r l sir n'lil t r lt : lt i t : ir i'r lioiiurlil noLl- lli'r scut pt : ] {r llr ) ( ) 11
    I r ::t.tt/.lu lr,if eroxie denonstreazir prezenlil :nn.aiskLtnt important drcpl -sllttg; rr '
    ' :i rl t ri r l r nr iizr t t llt 1t , l, , iLi<; l, t lgL: r - r it ai, ; om l hcnc'r 'agic t : t r : lit lgt 'l
    ;, lxrxlucc o salurare ciiferenlialiL a singelui, PaO, in zona irrociu-ctalii. iiitrrl 1,1,,,r,. r r lr lLt r llr it t lr Lt it ; tspt
    . ir r ii) , hlr c: r i clt r cliaccor r r plcf , it r st t licilr ri'
    rrrLi rr:rrc dccit Pa0, in zona posttiucteriir.
    '1'ra,tamen, rl. .r.rtt tl u l i l r ttl i ti , cu r l i ;r r 1 tt" l r
    -dtuaci cin<l o r:ai:<liopatit congenitalir ti.no;:,-, r l ) ,'r 1 i l l r o i l - l l i l i c1 i i .!L
    r:rrrrrcl.llie dc aor:tii predu.cLtrlii nu poate {i cxclrr:;ir, pritt cxar:nenc:lt' l;arlL
    " p cr ti L i l l l ( r i r l l r 'l '
    r:Lirrirr.Lr rnli sus ucrlioraLc, si: rccottLlttrdirctteterismul cardiac cu an1;i.rr,rr-dir' r r ,,,i r r L r r r ;r i i .o r :i z:r t,r a tL l r r ti i ;i
    ; lLlir, 1i aortogtalie asccutiertliL.I)rtlr;'t.t:riclutlcrca posibilit:tiii uncir:artiiL;,1,rtlir
    , r,ru;(rriil rrl c si a al f{)r cu.uzctl(rr:il.turz.i.L:r:rti i:lLli(rcspiratorit, ht mirtoJogi{ri :rii{i ll(r ,,r i i l t 'r 'i tr ,: r ,::i ttl i n r ,'r r r r ,'Ir f i Ii r :IL i Ii r 'l r L ri tt:l 'l l r r r
    rrr',rl o ; lic i) , s c ir t c c ir.tc i i u rl trti u i s tr:tL r' ;rd t' ' l i rl i rztl n. j m rsi ,:ri ri vi !:i i ,(l i l i !l :l
    foli iazol I l i tr i tl r ,r tr t:r r ,r r l ) \;{.
    l ,rr r.r' r c iior r er r z iilr rl i v r' l L r1 a l frL ..r' ,r,,Ii o l i l o r,tl u unrr:ai .l utti vci tti i ,i tcttl ;tl i (i l tl ,i rl rr) ,.,.r 'i u l r l tr t "l i t., tr ti l si ci r r l r ,,i i i r r r l r i t:i
    rr;r,r',r : i r r i i: r t t iv lit ti t:i rc rtl l L l i r'I.i i :,Il Itri ()(). .l n i !i ll , st:1l t.t:tl tttl Icrrl (:l l l ri i r.' (rl l l l i ) r L tl t) tttt, l tt) i 'tttl i 'ttt;ta !,ttt't. l 'l l ' l '( ( !',
    rr,j l ci i r r l I r r r 1l/ lig rl rl tl i i rr.r(, i .v ., i tri r rttL i :tl t' t v ttI (l ,r -]{) st.l rr.(l t,.i r' t,' :t l ' rr(J' lt,\t l ! | !
    ' r r tl , , r r t: p r r . l r r r l ,:r i 'i l
    r r r r ( r l 1 r :r x'
    i rr rr'lqit t r r ' . rI r or r I r I t tl I:tIrirttr i i i rrrtrtl l l l r' s l r' j l L l { rl )l i l i rl i L tl t. ttLt i rr ,p l l l r' l ,(' 7l 1l v ,, t,,tti t ti l ,l tt t)ttt
    1r' rrl rrt rr rrrrri l ,' r,r

    :l l i l ::t.i

    rll
    . tl i . rIr:t' . r. r' rrzriI , rrr. l'lli: lpt t nsLrI llt vor lr l'ii llr ' pt lt it : f ilLllt lt ict t t lit ii. ( : ollsli ilr lllt l( lit '-
    i i trr(,s iLll\ . 1t . r lf lr iD i .s i i s i (l i (.:i . i n l l o c u l c rrd 0 i 0 ri ,: :rrtt hernol l ti 3i Csi
    S ir pi: I I ( i( i'
    . ,, a si't t t Lt clor . d, t ; r 'xr ; ili t t 'vct r ir ii volt ajr r lui ulr m al
    r rrrl, volurrc n.tzi.ii ,1,, plrtstntxrxpandct (pilir irr 'llt rlll/kg) llcninr rr cl'r'r;lr '
    Lr.rrIi l rrtrIi r r i,
    (:it( nt it L-ui'scLrtrll iiind' iil contiD alc sr'tl) v(rl!
    ,l , l ,i trrl c . r r djr c ; i prc s i ttn l i r v " n o a s i , I ,r r:rtlclt tttl 1)(:loo vir z'ilrl,
    f) J)aciLoresiunea Ycnoasd:este pestc 12 c lrp.i la un nou-ltilscut, r'rrll ' I rtr, ;rl l i l i ci rl i .
    ,rr,Liprlobabileiauze sint ;octl cardiogcn sau tampotra.Jr pcricardici
    TA NOU'NASCUT
    CARDIACA
    'l ) Dr c r es r " pr " z c n r $ o c u l c a rd i o g e l ).n .n . l r(bui e di gi l al i :ai ' S c i r' 1" 2,I I.2.6-CHIRURGIA
    ,,, ,, r.,crluz-iedc istiprotorenol: se amestecl 1 mg de isoproterenol in i0{) ttrl
    gg rlc isoproi "r'enol). Soiu{ia se inj,cctcaz'r' ' tt iu pljma lnrir' cle vialii' numai atunci cind existil
    \r' ittllt vitttr cirir:Lrrgic:r1,
    'r^)rL L n ir5"/6 (l rnl conlino l0
    -lrr,rzi perioadlsc'folos(:sc
    ' le; t ljc i , u tl l e z l d c
    l i to rn l /mi n rrt l tari i gg,' mi nut\. l Jn ri rsl ' rrrtr , ,r,'r',i,,',1"",,t iril" iiitai.p"ii. cot'g''rtjtalih accasti Ir.iotttial;. b) .rt::eclitr'.
    *i ligaru'a ca al'I
    i,rrl i:ste probat de sclderea P'V-C. qi cre;ter-ca alulii cordului 1a 100-140/ " 'i;;;;,,t, ;;;,"irtri chirur"liciic':ju:iiductct: c)-atrios.tptototnie;
    ;,;' (r) shtntr
    rl i rru L ( c lun1 c r r n sp a s o c i 3 z dS i d i g o x i n ). .' ir,'i:))i')riiiii;,ii tti',f"f'1,:,- ;i. d'efectstplal
    nl''i'ii 'lc t'ulmonard cu sa.tiJdrii
    '
    Ilobakino :q inflebuin!c.\zi ir: locui ''rrtlioger; dl ogul '", dilu.cilzi ,,"' l,ulrt.t)ud.t:itl s,i)tLt)::Lt,n,,
    coredll)Ii
    ,,r rlrrcoii 5o/^ si sr: perfrzeazi' cu viteza dc 1*10 micrograme/kg/minu1' ' ,, ,,,1)xttl'aulo['onit 'i.tt stenoza ie ful'nc'nard; ^f) at'eralie
    .r aenclor'ftrl'ttton'are Morta-litatca iIr.urma accstot'o1.rt
    I )' ( resie'debitul cardiac, presiunca sanguini ;i iluxul uril:ar la paci ,,i,rliu lL drruaj
    ';).or1ina ' ",',,i,,i; arterial).chitr in (r('rrlrr"
    , rrlii (ie nu rlspund 1a :r-ltecatecolanine r,rrr ,'J. r'rlsctttir- (t:u cxceplia" tigaturii de canal
    o trcitnc rlitr li
    '
    lr) Dac5.'glicemia este scezuti', se instjiuie perluzia cu glucozl l0ol'; .,, , r,r'tilti{rt rtt chirrrrgra carcliacii' Itata uortaliti{ii scade 1a
    vif 'l: ' dc 3 luni'
    i) Yalori'ctescute ale potasiulti seric lnsolite dc valori sclzute alc , ' ,. i i .' ," l ' ,:rt r t t t t in: rdllpi
    ,,,tliuJtri sugereazi o insuficicilii suprarernlS., care nccesiti rehidratare, adrui"
    l i .fr;rr - o dJ s lr " ; i d e c o rti ,' o i z i * u P ra tc n a l j . 2.11.3.BOLINEONATATE DIGESTIV
    ALETRACTUTUI
    i\ l(atliorralia lzulmattotri si abdomitaji v.r "rciude rJiagnusticul' rl'' viir
    1,n,,,rii,rturax'sai peiitoniti eu ier liber in cavitatea
    peritoneal i' ',, rrrtr,l, si simptolllelc ce pot fi obsiirvatc la nox-niscut cul)rind.
    de meconilr in prinrt'lr'
    ' uj Puncli,a lombavd este indicatl in caz de- suspiciure dc n:reningitii f,. ,jiri,,,,ii" oiriominnl,-., ,iirreea,lipsa elirninlrii
    I t L' ut ?t lo/ c J a ri d o ,-c ;n ttl a b o l i c e S . l .rC ' r u bi cl :bonat. '| nagtere ,qiscilun{: cl1 singc'
    I 'l ,)r( rlrrpii.
    ti) - V io, ar dit s , c l a c i t c s tc p t z o n i i , ' :' r" L l ^ orj gi no i ' i ra1a; rr' ru' i , fi tti
    lri r', zr iatr culturilor, se admidistrcazii antibiotice (per.riciliniLsi kanamicini) ,.,,1
    1.3.],VARSATIJRIIE
    1 ,,rrrrr r , v t n{ ua) iliLlp a (ra re / u n n i r.l i o )o g i i L a c;t:j , tt" . r t l'i
    r r l lt l, a n. r I . , s l c m u ri u u n d , p c ' l [i j n c ^ rc;Lti ' o !i a::i i I ttt ' tl ttti lt ( vczi s. rvo1. i 2, pag 209- 22t ) liPr czint i cea nai I t lt : r ''
    ' " " ." " ' i; nnf , inr lLni': ' 1'' nqt r - liscut ( t abclul 2 5b)
    oj Dacl alura ventricutrari, estc rari, sc va intrtldtcc rtt" !>acewahu ' ' ' ,,,', ', ,
    I t t 'l [ 0t ] L; / r p1r "r ii cpr cct at cll, at cnll' . pcnt lll '- r lr r r "1'
    ll iIts\rcnos.
    p) liacl sint ser:rlLcECG dc i:rfarct, orig.'iur:aanornali ir coronalei stitrlii ,,,,,,' " f,,,1,,' ,' ,:,i, 't i't t : . "t lt l. t i3. '"t . ioil1est inal; idcLolim ct aboliccscit r t r r sr t t t l
    ,l rl ,t
    , r lr' lxisilrilr'L;i trcbuie luatir in disculie a aartogramti dc 1 'gritld'
    l i ,' l i ttrLtl t : lt ''it ll'&?t 11L'ioscst cpr czcnt la50llclir r nou- llisr : r r lii
    ' ,'lr r i, r luor l,t r slr t t i' j r Lr .
    2.'11.2.5.6.Pneumopericqrdul ' l ,t' ,t' ,1111 111s1'ai'ir "\ siir : r al: |n'r lt cr eiit r - aum at ism ulccLt r lt l: r l
    \rii.rslturilc pol tltr
    , | ,,,' ,t, ,,t,i,t, r,,ir','l,rulti tlL hemoriinic intracranian'-i
    l'rrcumooericartlul sc procltctl plin pirtrundcrca aclLrltri lt acest rrivr'l ,rrr' 1, rr i r l[ ( ) ] ogr ct ', t t , t 'r in'Jc; i r qr ir ir nct liat . dupii llit : t cr c sa111a24 'ls
    prcsiure pozitivi.s:rtt ' rr ' nim ent elo: : as[ i; iir : '
    1,, ,rr1,, rnediJstit:all, dc obicei sccuiiciar ilespirc.lici cu I r' ' l rrr,,r rtt,, ir . St r l'r r ct lt r Sr lai"r '1t t 1g 1f 1ihui- t 'v'
    l'lil,;t' fconcomitent se poat{l :rsocia cn{izcmul pulrnonar, pneuinomcdri$'
    rrrrrrl ii t , n' ut noior u ru l ).' \( rrrl ,l j r' :i u l p ' :i cl r,J rotnrl r.tni vpn" l s tJ' : l t r ldilr t r : poi ll pr ezi llr c lil I r r ) "
    ' rl r. 1r 'L r t t t i : r r l l" lil' lr l' t 'l'ol: {'
    ..,'r,, , , , ' it , , jui s , , ' , p o l r,: 1 ' 1 ,,,l rtr',l, ri .,r r.trl x l l '.rr' -:l ,,.' r!l !:rc.\t i i .l ' L s( ri !' rrrl r Ll rr,. i i rl l illl( f ll t t t r llt lt t l t l. aslir ic sa[ r t r ar 'r r nat ist n( *r cbr al'
    tr,sliLr:lir.ricpril init:rlarda bru:c.i rr.,:irrn,rz,i,pr-iDtrr.rJic.rdic;i hipote'rrirrnr'. \' rl ' r,,ri ' i i t : : t ilt t t ilot ': pr f zcllt ir t r ilciin- viir sit ur : r scr nr llll( '
    rJriiscuniol'o
    4r,.rn.L.1c rtrclului devin .sur z j1r, irL'lli .l!( G sr:i rlr'egisiie.v:.r uD r. r ,, ' r ,,r, i ,,, , 1, , :i, , ', 'r , r i, t , la, '- dlL|lr - lisi: nt aLilcj. r r t r r lxclr r clr :
    obst r ucJia' c'r r r ''
    r,ilt tt. Ii^tti,,eralia i:irrdioDultrt,,irrrtii pLrttc iir trn corcl rnic;i s'L':rtl r - r r ilroxplozivc
    : ( in. jet ) 'lr r t \ ir '
    ''itlcir!i I ttr' , ,,,,' , .' , r ' ,t,,, , i, 1, , , ,. , , ', 1, ', i'i'it 'i Valcr - iiLlsiii
    1r.r.ir:ILr.tIir,_ c,L ,,r,r. ln 30,1,, ,li,r ,.:rlrLri rlirrq,osr-,ru1 Je prteuinopcriclL'r
    | r s1r 'ur liic int r r st jt t a[ ir '
    l | r , !! r r r lir r r 1. r t l'r r r rtr'lr \ 'l- r r - sit r r lilcint ( r lr il] ( lll'
    , t l, , t , i. i lil i' xa rttc ' ttl rrl l ri r,rt' r' :rl r,l o ' l i ' j l ttl l asti ttt.l ' l l oi i i .stc rr' vrrt' " , r | lilt t il olr slt t t cf ir t l5( r ' ( in|'slin 11lr t : r t
    i ,',,,,, 'lir:i 1., ,' l tr,r , ,,i ' |'1I r I I 1 L||i( |lr ) illr r iii io: r sr "t
    (l i i i ol r,
    r,rl l r.nr or . lit lilit ii lii n rl rl t: 7 5 (,,,. l { r)l rrl l l i rj ( ll | ].ro(J]-tl 1(l (l Ll st' l l l ]l c ' ,,'
    ,' ., ..,, rl r r r r l, 'r l 1"': ii' li ir r iilzi r t i ( ir i ?'1 ( it r ( ) r (
    /ya./ ] t:lt1.r:arc lxtalr, :,;rlr rr Iitr!a llo11:lri||()n11llr).i (lsl (' l)llll(liliil ii '.il!'
    itl!!.I.nt,L ,)i :. ,' t|r' !,,t tl i tt t' t: i t' (: i t( tt.!oti tl i .(.,1.' .t!,,]i ' ..tt,t1
    ,r,ri i rl t ,r,r i r:Irr. <| i ,.. l, r.1 l 1 r i l r.r:rrlj r:i ( l r)l (rs (s to u l l r' rri ttr' r(l l tl ttj l r' l ' l l tt tr' :l c i t,:;r'rr t t,t, i ,t

    i ,r i rrir ll, ir r lr lir r lr r , ; r l r,rtrl i r:r,l r,x i l .i rl,rir..l r.rrl rrl ..ql i i l r.ti tl ri , S ,' rl \ri rl ts(i l ,,i itr'
    . l to 'ttIrl rLrt,Ii r,|,l l l l /:j |)l ' ]l i .ttl rl 1l .' .t1r' l i r,rrtl rl rrl ,l } i l i l s l !l )l l l l l ' ||||
    r' i r1l (l ( l ' l rr)i l l i i r' l '
    ,l , , rrrl , rrrr' i rj tl r' toz rtttl :t i l ' o rr' 1rl i rl ' l l l l (
    l ,,rrr, il r : 1r r ,r, r r r r , r f i l ,l r,,Pl ,l !,rri rl rrl )i rr' ;rtr' ' r' rl rri t' trtrrt,II,ttrt| :l i l | tttl ri ',r 1r,,,

    illlt
    : 4
    ' .l,rbtl tLl ),!' ,'
    'L ( t b, :tti
    lrbilomirrali la uor-trisc[t (M L' c]risNick)
    C{tlzo rnal trecvcntc de ilistoNio
    {lirrrze frecYenle dc lilsituri ln tto]ioaila nc$nstflLi l{li}rir 1I. I-. Chis\ic}r, morlilicai;
    ( )l,s1ru0iia tractl ui alimentai
    l l (rrs Iunc!i ona1
    \rjilsitld lenigre l,l|l(crocolitil necrozaDti
    | )l)slruolia tractuki alimentar l'(:ritonit.,
    l)istcnsia stomacului ir tirnprl vertilaiiei asistaie
    ll(\rs funclional
    l'lrlcrocoliti, nccrozarli I'rx\rmotorax masrv
    i )rgane abdominale marite
    l!l, rrric ]riatali. 'l rLr ori Si chisturi
    'l,,ln iccmie, inclusiv gastroenleriti A scit:i
    I Inolcrantb, la dizaharidc
    I l.rrroragie jutracraldane
    ll()li frcdilare de netabolism
    prematuri sau mici
    I rLr,lrli(:icnFrrcnalar Peyistatrticntiz,ibild' e adeseaprezerrtir'la nou.n:|Sctltii
    Dac'f ins[' pr:ris"-
    I iit.tilwi. cc Nt canl,in t'ild p.rrt i iJi, rorrulli, care au-un perete abdominal srbfire '
    distensie ibdominalir' sugcr(rirzii
    1) supdalinentatie i,,iii"" .l insole;te de vlrsituri 9i
    l)) intoleraul?! 1a alimertatia ari:ificiau, "ir$ifJ
    ,'bstruclia tractului digestiv
    .i) septiccmie cre$teriivolrrrrrlrlrti
    , L ) l e z t u n i a i e S . N .C. Pal'fatea gl pcrrulia. Se va acorciao marc atenlie
    rinichi. v'z'ici), r"r ;i Pr"zen(ciunur rnai":rrrr)l
    c) krzirni deasnpra ampulei 1ui lIal'er:
    * stenoza pilorioi'!,
    'i;:"'.1;"tli'.ai. splini,
    ,,',,,, iir*."
    wilms, nerlrol'l a"tonrl Liclri'lrrl irr
    - stenoza duodeDatr sl1le.b:Ltri (sa'r at:ozic), 'l;]:ij "i;"',i'i,-'ru*oa,,'"
    prin r:retocleieconvcnlionale (scmnul vtl rrIrti)'
    , ;rvii.ateaperitoneall se va cauJ
    '- Pancleas i,]elar (rar)
    i ll;:: fi*"i"tt Ja"-i"^ia'poalelipsita nou-nrsiufii foaitegravbotr:'vi
    J'l rrrl
    I iit :iilt.ri r t .or1liri bili.
    '; E xamcrl'xtl /e ctal. Se va confirmapermeabilit€teaanalit' rlisti:rtsili
    ,,,,,,-n;ir"rt ."r" .r" virsettld 9i distetrsie abdbminall, _dispa,ri]ia
    ,,) iiirczi;| duodemld
    r|l,1oza duo.lena1i., i6trinse.i'r sau securrliafi; ct-'illPresiei lrrlui Fa .teas ir1cla-r
    l,)
    ' l lrrirlc lrcritolroalc cr sau li"rrir,nlaltot:llic Si rol'/l11us i'*ip"tti""i a"
    ,i li riiir"":.,'*" a s:rzctor(;i11.{15ct'1exa'ritt;tl.t tt
    ,l) ;r cr:! mczsnterici, superioare aberangl -iio:iu.li
    l rri csic retras) poate sugera maladia liirsihprung (vezi r-oJ 2 pag' J1;'l 2'l,t,t
    (1111cr1)(lr)lrril
    t,i, .;;ii.'U; rict stririt 9i go1se glsegtein bo:r1aHirschp^runs' pt'ril,rrii i
    r.) vorrir. port,, predlodenald .

    ,,. r.zant;. (vezi vot. 2, p""J;i)i.i:l pq+ zll;i 244-:2$)'';i


    intiizic pesre 24 d'.' ot . 4b9"1/L)'
    ' lilrLli clc mctaboiisn). I)aci climinarca utconiului r' , zi vol. 2, pct. 2.1'6, 1'rg.217 ;i pas
    lir urt trou-nirscut cll l'rirsiiiufi, poate fi vcrba de o obsr|uc!:ic intcstilalir; drrt' ;
    Observareaalimentaliei nou-niscutului lace paltldil,tx;6pi'11111r'r'rtr'l
    ,lrrr:fLolrstruclia este inalti. sau pariiali, trlccouiul s(' clirnirr:r iin prirna" zi, si in caz de gf^sr'tl\.i 1'llrrirl'
    ).i rrrruclc,rlaci sint prezente, vc.,ri{i .xan-rinalr, t.iutjndu-st I rezenla singtltli, 'rr Lr (virsitul:lc pot survcni "
    )- L, , , ti g ali' i. Valarilt ck.ctrolili.lor'
    lHl tti li lrrcc'isutt!:ttitt'
    -
    I'rrrrrlxrrlrrlncntul i,t,nrrllagic sugerdilzi uneori o cauzi sc!r r:t de vi$il1 lll i i tl r l tr ti tr tn .tr l i r i ' r l ,r t
    l r ', ( , l l ( l i t i i . l r u n l l l D r cm Jl u r |i l r c p r czi n l i L v'l r si r u r i
    t, irr<i rr.rr. rcluzii alimcnt-lia, este lctorijic sau liptrc)icit abil ) . ,) |l t''.|t,.'l |]l I||
    | , , '' l ) ''| i o a d i r n l i l u r r l :; ( l t 1 j Il ID ' i ]o a l o l ID i t.e l ]ti p o n l l l l .n l ''l
    l'llrrrlcnul gcrteral se r-a f:rce inaintc dc a st: r:cncentrrr a.tentia, 'lrillltlt boeli t rr:clit aLit cl| trt r'1rt
    i,,,/,, ,! licvcr.ir,la un nou-nirscut .it,i -,a.si, iuger' azi o
    rrrlrrliutrlui, se \,or cArrta semnelc de dc-.hitiralarr: : sci.Ltlercaporticr:rlri ri" I'rt rprrc in lriP'tPl:rzi:r
    t.rlrili crr irrecizie prin cint;.riri rcpetater,ie vi{ urllliiri oiigu'i:r, picrdertre lrtl
    '','li,,,. lir),irotrenia ,, n,riJ;iiii''ri cu lriicrkrJi"mi''
    d''srr' ' Lult.(uln(i41t'ctistt]tL'ttit
    rIrri. tlcprimare;i font:r.neleiufctioa;:c, in{undarca g'.lobiior-oculari. ' u' ' '''i'.i',ti""t"oi"i""'i':' ttt picrtl.'r' i1eingestia rlep^roteine
    '
    ;i rt:ll.rriir
    ',,r i , ,i., iniluerr{ati
    J , a i x ant en u i trl )d o mt' .tt :t,l rti s c vor ci i uti t l trl rl :rtoarcl c (i l l l o " r , '-,r"'-"Ti"f;i;;;;l.,lt ( J ctci l cr o ttt;r t' tl
    (ihisrvick): , r ( i ', t i , l n l, t;r ti r l l Ii r '.tr i 1 5 r r g .r t':l cr 'cu d n l ti e l t:'l r L '
    1 \1. i.. " , ', r c' sl r l "r r 'i r z r I'
    | | , 1 , i . , , r r g 'ri n ,. i r t tl i tl r |u l r u r ti .' ( L l '' Il l n ''l c 'i n r l 'l r l ( l r '1 1 '
    Lti:;tusia abclominal'i.Cirtrl tlisl lttr;irrabtlollr:riulni cste irso.:iai5.c11vii fsi '
    l , , r , r l r t t t r u a l i pr i r r r l i l i t ( r l c ( i x( l r .r Ir 1 u r i n i ch i i r i p tp l :L zi r 'i ' f i l |r n e f;:i tc' ttr r r l r r tl tt'
    1rrri, .rc,:stcitciinrirn,:l nu au o cirrtzi!l)r'lriSr)ii..l)at:i eristir dubill itsupra pl. zr:ll"
    , , 1 , , l rI t : L i v i r - ) .
    iIi rroostui scrrnn, protuzia btitrtttlLli r-rlittIica.ilicci olrbi]icalo r.-'prezilrll'r.lltl <lllL ttt:ri rtlr'
    :, rrtrt firLcl. Se r,;r r;crcett da.cii ilislt'rtsiiLtrrttr $cut:ralizalit sau iocaiizeltii rri s(! t )l.ittttni rt.. l lipr lglirlr:lrria lllitt-tr 1a otic:ir nc:u-tlitscltt Irolttav'
    r l cl a l l tr " \'r r r r "r
    \';r n r i' t : nr r itin iLt or l l r' p c ta t t:i tt:rri ttl l ti trtl ri rl rti tl tt' ti l tai r-t l l t ni r' ,rl rti otnf i l :' tl l ttl l , r r t t o l l - l l i L S( l l l l ,,,'r ',i u l ,r 'si i ;i l i cl r ( s( a l i j i j u l ':Ll l l t r tp r l r l l t'r l tts
    si r r l l o t l l r l r
    (l rrl rl r r l 2. 57) . t r r r r l r '; i l r i l x r g li r :r 'ttr i l r r ;i ttl l ti r - i i tr tt'i t;ttr t<:1 r 'ti s{i cr ' 1 :,r tl :tt:l o zl tl l i ci
    ( 1 l \'( ( l ( \r ( 'i l /'
    I ' it lr t t ult lot t r ;ttth rr. i l rl r ,r :,, ri r' < l c 1 .| l (1rzr| l i rl ,, l ),,ri i {,r\i l i r trr:. Li rrl 11, , , ', , 1 ', t l t' tr tIl :r l xr l i sttt ( tl l tt.' tl tt l t' l r tti L l l - r 'r :tt1 '
    l /i ' r' rt t' l t' 'i i I r r I , tti i tr tr r i r l r t'l l l l l l l ' l ,o l L i ( ' l i vtr tl ':r r l r
    ,rrrxl ilir : ir r t rt.: r r lt t lii l ri c l i i 1 i rr,l r,rttrtll r, rl rrl tri rtl x l rrrrti trrrl s :r.1;rLsi .l 1rr l '. t , r t t t r t t ttl r l r ttr i ttr i . l l l t|j i l tti ttl r l tr | tl tt
    (l (i r:l l llr r r lr ll : r l l( )(r9 ).(l i tttl rrl rrl o rtl
    trt' rl I' s l t' IrtIIti r' III IIIIIIi ' trr{ ' l r" l : l rrrl ;l ,, l o t r 1 i l tti IItIIi r l ' tttl i r r l r o l i r ttt.
    ' "r,rl,i
    r,ttl rr r r ll' it r lit r , r , I, i I t tr-i rrlt rli r , r:rt r' i rr rrl l rl i rr \1 l l ()rtri .l( r' l i ' r' i rl | rr ' ' '
    r!| ,
    : li
    Iltt Cl irti.lcst1>ttzitiv,cn Clinisti-rucgatir'- ln)it|( tPitreain galactozcmic' Lir lrirlr.lr'pltfuzrrlc l.rclxticsit t;onlinil rnaxinluru 20-30 tttlil Nrt/l
    lir'l,rrlrrria (,1, I,'r-tir (u.\cctcsr)
    ri {l vulurndcsolulicsflluralit
    cu kctt-ar-idrrri, (,,,ir ,{ r,,1)r1zir)l\ l15 116din so.irr{ia izotoni.de NaCl). Clorura dc I( sl
    ,1, 2,4 tliniilol, nolhidrazin!. in':Lcid clorhidric se adaugi picittrl cu picir- r,l,rrr1lii irr crr.riilrricdc 2 rnEq/lig/Z4orc. Sc adaugilicltidelcneccsarclrirtttrtr
    t rtl.i unei iumiLtiLti de volurn t1curini apare j un precipitat in 4-5 minute) sc rrrlr frrr,rr'(rrr{ia.tb intre{incic)-cercrcprczinti airca l0o ml/kg/zi.
    irrlilncscin acidemii organice. |), rlrirlrir{iLlilt: sc vor trata prourpt. Controlul rcechilibrlrii lri<llrr
    ,I,.,iroIiIicr, sr. :[ircc plin cintirrirc repetatl, determinarcahematrx:rilttlrli,
    '| cr cenir'gpentruinfeqii bockriene.Scpticemia..dreptcauzir de virr-
    'clirninati
    \.iiufi u,.onalrlctti po',t" fi prin examenclinic' r , l'r ir,li{ilor' <lin scr'-(in special Na) ;i aprcciereacantrlllii de ulilri trli
    rrrrrr,rl.r. (irrrclrr(r'a1irrsoiliului plasmatic cste un bun ghid pentru stalrilillrr
    Cintl, aparc ileus {unctional asociat cu o septicemie, tabloul clinic poatc , ',u,r'rl r;rlioi solrrfiilol salineperfuzate(cc seva mocli{icain {unclie dc slirrcit
    li txrnfundat'cLro obstruclie intestinali congenitali.. S-epticemia.poate.apirea , lrrrr'.r;i ,1, ,l:rl,lc dc lal,,orator).
    itt cursul unei peritonite sau enterocolite lecrozante.,Investigaliile. t-rcbuic.si l',rrrlrrrhipo- ;i hipcrnatrcmic- vczi punctelc 2.11.94., pag. 401 1i
    r:rrDrinrll hem6eram;., hemoculturi, uroculturS., culturi superficiale (pielc, .' l l ') 5., Plg. 401i.
    na-s,git), cuituii din L.C.R. tldir ttl trl i -
    i ,r ,,rLzr1,rvi rsiLturi1rilioasecrr distensicabdominal S-se r-ecorna
    Radiaprafiaab'lonitali' fu eal- in pozi!ie culcat6.qi ridicati poalo t,,.rrr',r r otttittitit":
    . virlcn(iapicz'"nqaunei obstnicEiidigcstivc,a perforatici intestina-le,a unci L Aspirrr{ic gastricir.pcntru impiedicareapneumoniei de aspilLrlir';
    :rscii:o,'a Jnterocllitei ulceronecrbticc Acrul inghilit ajunge in intestin ]a o ,t.'l'ritrrrricu[irlgocului,deshidratS.riisantulburl-riie]ectroliticc(plasrrri'
    orii tlup6 nagteregi ln anusin 3* 12 ore.Observarea,distribuliei-nivelelorhidro' ,ll,rrrr irii rrrtrurrir,lichidc, electrolili).
    acriccintestinale poate sugeranu numai prezenla obstrucliei, ci sediul 9i gradul t. Arrlilrioticc- cind cxisti suspiciune.le volnrlus sat dr: .li1rsii.'l''
    siLu (parJialii sar compieti.). 'fralzitul cu substan-fl de contrast este uneorl rrrl, l, ri l r i l r intcstinului (ampicilini sf gentamicini, de pleferin![).
    u,"r,,r?rti" nor.L-ndscu{pentnr investigarea vd.rslturilor.
    Dintre tipurile de I'irs5.turi, cele mai {recvente sint a9a-ziselezdrsd-. DE ESOFAG
    ATREZfA
    2.11.3.2.
    lnri haoipnt. I'ermenril clcsi nu este {oarte nimerit, se aplici la nou-nf,scu}ii
    ;rirLiloti."calcvarsi.din cind in cind, nu au xltc semnc9i nu pierd in gretltati" Alr,zirr congcnitali.de esofag este leprezentati de intreruptrrcacotti
    (:rrrz,lt sint multiple: inghilire de mucus in timpul, expulziei.care irit5. sto- 1,1,1,,rr r.sofrrguliiin traiectul siu tolacic. Atrezia purir cste foar'lc Iitrii:
    rrr;u:nl, rlefccte dc iehnici jlimentaliei, modificlii de pozilie inutile in tim- ,, I rrrrri;r<ics|otica se insole;te dc o comunicarccu traiectul aerian (r'r:zi;i
    migclrilor l',,lr,rlrir',\,{,1.2, pag. 169-1'70, 423-427).
    1ul aiimentaliei, intirzierea golirii stomacului, incoordonarea
    .sofaguJui etc. l,,rrrr clil mai irecvent!,(90|" din cazuri) estc :rcecain c:rrc lxrrliltrl' rr
    rr , so{irguluise terminir in fund de sac in drcptul bifur-crrti<'i
    rr1',rrrr.rr,i lrrr
    Tratamentul, t;drsdtuvilor persistente, cu t"rlburlri electrolitice saq ,.,r un traiect {istulos intre stomac;i lrrt.l.l.r',
    -rn intrerupcrea temporari a, alimentalici lr,, r, ,,,llrrr|rlrr1lnferior formeaz;i
    strnrle de cleshidratare consti
    ocr orale si aclministrarealichidelor in perfuzie endovenoasi. Se va acorda 1l,r l,rirrr,rrlir:sou aproapede ea), ce permitc ar:rului si. intre in stouriir' (li'
    prc- trrlr tr.rlr.rrr'..o[agjan) inferioari).
    I',i,,ril,rt" traramearului insuficicnIei ciiculaior-ii pe-riferice(dac,li.este lrr rrl tkrilcitip, ambcle segrnerltese terjnin.,'in Juntl de sac (nrt cxi:rl r
    r, [l:l) ti apoi inlerruirii pierdcrilor clectrolitice. Corcctarca hipovolemici
    lr Irrl.r , soIltJreal!,).
    ;,, fru:c prin-pcrfuzie de plasmi, dextran sau solulie de NaCI 0,9"/o (30 ml/kg lrr rrl i.rcilea tip, segmentul superior comuniciLcu trahcriL ;i 1rtttt11'L
    in liiup dc 30-60 min.). , ,t |l',.||,r" ,,oalhii."(iislr e tl.rh,ocsolaAicri;. sup"rio.rri-).
    -
    Volumul total neccsar pcntru coreclarea pierderilor electrolitice sc lrr ;rl patrulea tip, gi segmcntrrlsupcr-ior;i ce1 in{erior comunirrii'r'rt
    rr1r'cciazf dup[ pierdcrile ponderale sau dup;- gradul deshidratlrii (alit' rr.'1,, (tislrlu t rahco.;tofagiin.iduhli)'(fjg.- 2.27r.
    ",r
    rriatic valabill Fi pentru tritarnentul bolilor diareice acute cu deshidmtare)' { orisrr:infclc pulmonarc alc m.al{ormaliei sint grave:
    Siril necesali 1b0 ml per.rtnr {iecarc 100 g pierdere ponderalir' slliva'acurnulatiLin scgmcntul esofa5Jian inchis (orb) supcrior itrvir
    ,1,,r,'.,r
    rrllxlrrl c ltrolrsic;
    con{inuiul iasfr-ic rcflucirzir in tiirccfia tlahcci prin jntctttt':rlirtl
    loluru[l de lictrriilo[eeesruope .:rle irtr&relroasd pelllru eorectareaales]riilralirii (M.L. Cllisv.ick) l r l | | l ' r l ri ,lr ( r x's{) lilgi! l) ( ii) f cr ioaI ^.
    I'titt rrtttlx'lc tricctrnisrnc,lliLminii sint {rurcninlati clc oirstruc!ic li irr[' r
    (;f.rdul chlic eL desl'iCratirii Ir,
    I ri sl i i , l' ( ) 1, : t :i (islo'ic, l' l, olilr i, lt ; t r r r r r io;
    l ,ol .ihi rlr ut nt t it t st t l.cst c <kr liir it , r r r ', r lur t : r l I i, lr r . JLI ir .;rt ir r t lliolit :lt t r t i t t t r t t ,
    l'i{rrrlcrc pon(leralir hr.occrltuali!J 5 ,1, ,r l )(xl nrt . ( lr t t zit r : r 'lrt t t lt i {r r t vclliii r : st c olr slr t lt : ( ir tilllslt oiulr : liinali it t lr lir r
    \ (, luniu l l l o c c s a . rd c i i r l r icL i) ( tr 1 lkli d c ( r cu tir 1 . r r t : izilorl. , iliali ilr I ir : lr i'
    l t11l l 1.,i v ;rl; r . ziir r lr , r , solir g) . l\ 4ir sur ir t t t ( I ( ) I I ( : ( . I I I r ir 1ici
    , n t ). r L i r(,Lnrnlii) 50 r r r r r pr r lr .Vul,
    i t ( ir l ( ) r |) \ '. I ri,( 1ii
    ,11! rrrrrrri r, lirlr. or r lcr lilr , r cr i'{ilto lczir r r r t ', 1, 'ir r ir r plir
    N . l t . l i , , l r , l t 1 r l i r r ( :r lfr l) | i, Jr , i( r ( r r r iir r r tl r ir i .l l rl (i r'r lr lr
    l ,i l ri rl 1i 1i i rlr . i, 'r r li)t lr . l lr , zir r r r r '", iir r lr ijr r r nr lr ulr r\ / ir icr '( ir r r 'r r ll r r r lizii lr ili

    il I ! i
    !tl
    I rrr,l ' ' r ir lil r , li. lt r li lr ir lr , r , , . , , 1: r . i, Llr , iit lf lt io: r t r , slr r llliL( r l1l : ; i r r lr '' i'-
    l r rrl rti . t t lr lir l slr r l plit t r ' , : r r r '( t - '*i'Li ! i r lisl'- r ; i. r r , l't k'r ur ir r ir lr i) '. . ( 'ir t r l
    .rr'Lsi rt( l) r qz ot t ( i) . A l l r: trrrrz r.(l (. l x ]l i l ri (l ra u rn ios si ut; aucncclitliiL, itx;ltplt- " lir lir ; lr t l '
    ,.rr, rrl , <r , r r r 1, 1r ,'1 , 1i, , t : , ' r ', , , 1', ,n: Li r 1t 'gi: abi d'c r . l at llzlt f i
    r'i l rr| rr: rI iLt ult r i t lc a i n l i l ri { i , i rrr' :r1 ru :i trrtcfS.tul
    iu rtidr: a concentra urina, <lilt -
    1,r'ir rnatclu, mo:irtca IiLl.rrltri irr rri.cr. '' ',1,,r,,,lr,
    ,'', Lrrt-,:tlc {istulii. t':;o-1;raltcalir {iLti atrczic- c1ceso{ag' rliltirr'r:r
    d r ' ,,,,,i ,iiii,,it, .irr4rtornclc .sint rr:prczcntatc numai dc insrr{icicrrla
    lL r'f i

    flilnE
    wa
    ,t,,j,i ,t,,'.i . C,'it it
    ''r.i Ii ronr sloPir L.
    n,li t.t"..,o

    r,r:ri : r'r r li. l t l. - . . - o- lI il , "li


    ofiriL cxarrer.tul cu su1)stanli'

    r r : r Jcs'or i g: r u1: r '- m i' i


    trtlio"l'rr'

    r r ": - l't ''


    i j u I r r ' Pr ' r i r idti' :3 .o fil "' ' l ;:l i ;i ,,1
    , r .I : . i i ' , 1 ,' ,,,,,r r ' i ri L

    ffi ' ' ' ,. Irrl I'r i, i 1' t 'lt t t dr r t i ( t lL 8 or i it r cid' nt 't lt or m 'r li) \ no
    ,;l l l i :i i ' l
    (r"rtei,,r-al Jcfcct' anal lLlltsla'
    , ,l,,,rirrltit.l(i llllrol'l sLlD rttiti"-l' tc 1'atcr
    a[rcsia' radial dvsplasia aII(l r(rrirl
    r ,,, ,l ,3i,,rt fis'.trir rvittr csopl:gtll

    P'
    '' '',1
    ,,,'',,,rt,,r1 cliirr'gica1 co'sti. itt suprimare. {istrrlci tralLr:orist'I:r11ilrr'

    ,fi- ,N' .rI iz:rr',;r. rtttci allastomoze csofagienc termlno-telmlnalc'


    l r' , ,, 'r r 'lir iilI qr t lcr r l' . int gr r lc Sr cul3l' 'r I '- r nr lt '
    l l rl ' ri L [ 'r t lm o] r ir l. i n q'\ '|r : 'iI ' Lezr Jcsof agian! .'
    r ' llr : r r ) r r ( r r I
    ! ' 'l'( "'. '
    1.
    Fig. 2.27, - Dilerite tipuri de atrczie de esolag: a) atrezie cu {istule ( iit . |'t \ ') -t Jll,
    m {: l]r ln'
    1 ||I lr I r 'r.r
    tr;bcoesofasianit inlerioirS, (909;), b) atrezie {5rd listdt (7%), c) fistrll!' ,rr,.r,ri ,.r r i r : , 'r ibilit
    ' " ' paler i " tii "t.nr
    i * t i "r'Ln' i " :n'or
    " n^zc
    c u ni r u i i ' n p i e d i c i t t t r r " ' r : : ' l r r ' '
    tr':rhcoesoiagian:rs lcrioare il9/u), d) dl1bld,Iistrle traheoesolagiad (2%)' i',i[i''i'
    ' 1 " ' ' , i
    ,il, rr,ricrrc: sc lacc apol gtittoito-t" 6i ultciior sc leagiL {istr rL t:lrl r:'
    ' ' lav.rrrlrii
    L, r,i'r,,:i- cxisti). Priir nitiie' *lt"ti tt a;teapti mort:ntr
    '\' r' ilLtL c c l i tr'i c e. Se obsen'L imcdiat dupl nagtere cL sugarr:l nccr'
    r'ilii rLspiratii freciente, clin cauza unei cantiliili excesive.de- mtcozitiLti r,r,irii irlastouozei csofagicne definitivc'
    ,,1,t,,t,,,'1r,, cc sc acurnuleaziin gurir.;i cu tirnpui, in faringe (unde sint ,,gat' DIGESTIV
    'r,,r'isit,."t. introdu- p, esoiaAnu poalc intra in stomac.I-a prirnrr
    (lirlr:1,'rrrl ORSTRUCIII
    2.11.3,4. CoNGENITAIEAIE TRACTUIUI
    .,1i,,,,,,','i-,' copilrr)inql'i1 tl,'citcva oii gi apoi se sufoci, varsi, dcvine cil obsirucl:lr lrorrl" li
    !1rl aYca clifcrite sedii, de 1zLcluoclenpiai la colon
    rroli<;;i clispncic. 459--411
    I i i,;; lveri "'ol. 2, pag'2z2,4.t8,151"
    Iiiagnoiticul se lacc prin introducerea de srrb*stanli.de contrast (rkr ' ";,qnci:,
    r',iL,titc tii:uri cie obstruclii iot apir-ca; rrtr.:z.il' st(rrozi-r'ollslrrr(lr'
    pLcferiuqiilipidol, nu bariu-, care dupl examenul Rx. tlebuie aspirat ditt 'ccrnprcsic Jin f,{arir (,,r:..l,t,r,
    t;,,,i,,;.ii1,,'i"t.ii""f"i cu mrioniu, "l,'
    frLtrcti'rtr
    ' ' csofagianl).
    l)r1nga
    Lri ',, 1,; ;, . ri.,^iat' .,, *.,1rltlt 'l i'rtc'-rinalf);i anomalii '1"1"
    i-ipsa ii"rutiri ain siornac aratit c!. segmeutul inferior al- e-sofagu'l
    nrr r:orurrnicirnici cu tt'aheea,nici cu segmentuLsuperior a1 esofagului.
    r ' lr i irticstinuirri1cx. b.':'ir [[ilscitptun:" tlt"
    'l r tr.l aut entul \' ,ilsr-r"turilc,distcnsra uutfn-iiit'ii-;i iiirirzicrea 'lir'.riririi "11i1rlrtr
    este ctrirurgidal (anastomoza directi esofagiarrlL l ^ :L rnn
    ' r" l l " '
    r 'r'rrrirrrr.t, r'rnirulircstc Irocpclculdr.'-e)ec1ie. daci e posibil).
    l) r o g rLo stictti c maihuniucil diagnosticul emai precoce.Alimcrt-' 2.11.3.5. A'REZIAtl STENOZA lNrEsTiNALn
    l;r(irr1r.r' orili- tlebuic stopati clnd suspectimaceastdboall' Preparareaprctt"
    ; eapuJ ridic:rll L 45" p^n1nia impiedi,a .rspiralia,aspiratii corli- ( )hsll,)tcl,ia nplrrc dc obicei in tcgituea ar]]pdci ltLi \/:rlIr'
    tlttt:tdctralti
    1" r,Ll,,ri, ca sindro'rul .I)orvn' malrota{it: inl.ilt
    re o-ri g" n, antl brol l ce. P erl l l '
    rrrr,.pr or ir nll l: r 1i,l c o L i l ru c !i r' 3 l r1 1 i ;1 1 5 i 1 3 de ,,,,1,iri, l.t olir' :L'omalii-merioLc
    polihidrirtrrrtio'r'
    zr' , r r gluc oz J , s . .1 " . :o l i l i . 'r,riil,, .o:rgr'ni1alcrlc'.cori' La un n'n' cLri'storic cb
    ',',,l,iAii cste desti's in porlrurcil srr'('rr.irr'
    , sini: 5iiioasr.qi abdomcntl
    -Jistal
    rI situate cle drloclcn csic mai. prrtin J lr.' r'.'rrt
    2,Ii ,3.3.FISTUIAE5C.IRAHEAI.A rclirt inlcslirrrtlni
    clar probab'il comporti!. ttn llsc )ar lniil'r (l( lrr Ir"
    I ,rlir cr.r all0 anorl:tlii'
    (ir1c m:ri multc cazuri cle atrczic csofagialrl sint asociate cu o comrLl)t- (lLr.cii oL"fto<:tioest''.siturli !'L u11r-.vc1 ntlti ittrtli' t rr
    ii'i,*il',.rii:i tttr tt l tttl ttr
    r'lr'c (pril1 iist':lir) intre trahce;i scgncnttrl disLal al esofagului atreziat. Atto t r , l c b r L l . . r l \:i i fr i i i l l l fl l o l r l r n a i p r cco c' l i d i sl r 'r r si 'r .:r l 'r l o l l t:i ttl tl i lrri
    'asocial.c lriliu,rscln|iJ-o ciUstrucli,' sitrltti-r. s.'l) :rttt,rttlrr
    rrrrlii (dc obicci malf6nrr4ii vcrtcrbrale, ccrvicale sau dorsirlc, rtrto' ,,r rl:i. ViL|srtltL,.il,.
    r,,rirrlr') sin1.prr:zeutc 1a 501/odin rrr:,rslicopii (vezi vo1. Z, pJg. 423-421\.' \ , Ll(\',,2i vol. 2, qrrrg. Zl4,- 215,449-451)'
    t lr : ( ) lt
    lx) illr ' I
    lr r \ '1'
    l,rr sctnnul calar:teristic al alt'rrzici csolagicne (o cantitetc tlt srrlivi l ttr:tl -t : lr t t llor t r t ltt l: nlllr t it f i <ic t lt 'couiLr 'it t - llr ir r r(r,'lr
    )
    '. 2'1
    l) slr lli: f llL I I I ( ( ) I I I I ) I i'II
    ,l rtrrtt o; r scirur gr : t oi ti m p u l tl i rr l i rrr;r r:' rp i l trl tri )sc rsoci l zi t cpi soarl t:< l tr,,i ttrtr" r,,, ,,1,i ' ,i -,'i, t , l ol, r , Llt t t r in( t .ctrrlri,.ir,.v;,
    lili r s( iluLlitcst c cot t t pit 'Li.
    ',:"ii',ii,;',',,;.r vrr'iirl,ililrr!it
    ,li* cuuz.rr
    siil){iirrri.i
    ,,,1 "' ( s r Lf oc lr l' ) , ttts c , i rts u l i ti l rt! r rl s l )i ri t1 ori c, ci rtnozi L (cnt" r: (:oi l l ci (l rl l l ;,',. i,.,,iii,i",,i,,i
    r,,.ri olr I i' I r . t I r r r r lit tt,' ttl rrr' rt ru rP i l ttl tri c i trtl l xtl sttrvt' tti 1tttt' tttItotti i rl r' ,, L l \'l ()l r;i r'ii I I I I )I 1)I I I ' I I ) I
    .r rp i r r!rir , ) .
    :j::r
    :i 1 t{)
    , ,,;,,,'i:J,i,:,i,',i;',i',:,,,:,',':!,:i:i,'*,1:'
    !:^iiliiJ,il;il1l,
    ,)l,,:l;
    ll,;:i,'li,ill:J,;;,,,;,i,,;,,llil
    . t .rll;r rn ;ri jt,s.,i rn . r il. L r her pt l
    r, ' L rl lr r lr '; r r r i r r r |r 'lt r Jr r l l; r v|zir : i, t r r - f Lt - it slt r rt lt gir r .Sr 'l] t t t r 'l| r lr 'ol, : . 1r r r r
    rr r1\,. llj coI r nr r lr r i lr P: r rr kr lr r '<lr LciL I ist ula qst c nr iciL slLr rir r r ; lr isi. lr r , , ', r r r

    lli,-;,lrl,,r*lf ,,,,,,xi;;e,:1":#r*,t,*:m*:l:[ ji,;li ,


    ,
    .l ,r' r1", r llsr 'lr ir k, t - l: lr . r liL csLr :at t scut i ; i o lisit r liL r r t r . r {c r lir r lr r r r r lr r l
    lilr
    r r' . , llir r sir r ir ) ir '( 'lr cnr r l Pr , Pr r t i: Llsi p, r iucr r ( ia Jr ii. Li) . I inllr i lir , lr r l, '
    ;;ii,',"r.ls"n,'in,,,r,,,
    'jllil 'lii,,il",'ii;1;]i,";:,iiliit';l
    fl"1:,lJ ,,,, ,, I
    ' l rr,l, in r lr lilli- r( LL bir i: Li: ) .I n lir r . r anllul alul l. or Lt l ii t Lr r r r r r r , 'lx r r 1
    rrr,rr r l, rr r r "rl: r r r ir - clr r 1oli{it ir r lLr i, r ut l ( im per f or at ia lnir l. r ) . .
    I r ,li, rlirr irtlxrtlurtiL tcr':lpcutici si c'lr:progr.rr.rsticcsti: sii rli:r1irr11, r,.
    2.11.3.6.
    MATROTATIA
    tNTESltNUtut , .,rr,, r r . r liil, , , in; r llc'. ccir nplicir lcct ulsileziur . r ile, , joasi: . , ( an: L! J( lir i. . l . , 1, r

    :;I;,:l;i;i*:lri, jt
    in tipul cel rnai {r-ecve

    ;ruiiitt'iff
    +$lti, i:1*i,I r#j:I vo. 2' Pas'214si 44s--45i)'
    ,,,,,r;;;;r:il.r
    . \ l' J r c I a unii n o u _ ru ...,.rti '
    ,*p;mi$il'*1""'
    $)
    """'r"i,ii,z'iiii;ijtf
    t:Hid:Fii,:'ll'ffi
    ;:ni'"H
    :ixifiX{li:iill1iu*fu..':'':i'il"#lii*J::iliJ:
    33'::;
    ,,,,,,P11,i;:mi?:ff/#ti#j::"':.iii'*.,'1,^i!3::i,"1i'*?,ff"11il'r*,",,,,
    l,,l';l';:',X{l;il;,",;"1;;"llJ'.J"oliJlJ;'[lill'#:l",'i;::,1';,,i
    ,:',:;. ; I t f istu.l-e
    9
    ,J
    2.1].3.8.MATADIAHIRSCHSPRUNG

    i:;,1.',!?:',i
    r::::l';li'i,.nl'i':,ili:li ffTi,f"'l1.,.rtj"&,"o,il,,"li:','J,li'iil"; recto penneal
    o,ungimc
    ,,,i
    l,:::ilii#:";.:',::;***,::,:;i:,.,',:?"
    ll,,l,l::11,1.ii'x1,t
    :Ii,,,, ; il.t,.y
    ;iiill,1 F ;;:,.ii'-ii
    i,{"ii;:, 1l
    ;Til"'#;;""'i,"}tjilij,"t;;'
    11
    ',,','i,',:",)::;;:;)i#n'{i}*'ffi,ftrT#ijtil,,{r}rjt"",,;.,H51*iii
    . l,;,riiogra/rt abdonrittald BB%

    ,,.,,,,,,i11i::'i::'#(;y:,::ll;:fij:'{i},"i,X?,:ll:,T*fl: al miltcrii i rrlrri


    1.1.2.l . si
    -(ad\
    \,tr/
    4)tl 467). " ;rt. rectavoginol
    Ianlcr.ocolita e o complicatic
    '(
    '/"iU\
    l.rirrr: cuuoscn|i a boiii.
    2.II.3.9.MAI.FORMATITI.E
    ANORECIAT.E
    r , U\
    Il , l J i- r r r r r r r , , r , r,,r,
    1 t,.z i )' ,:,l i ;rrri ,, r,,1 .2 ,1 ,;rg ...1r,;
    .r t . . t t t I t t lt t lt i , .;, ,r ,rrrrrrr:rl i ,.i z ,,l :rt;,,,s i ,.
    _ .{ bS ,
    l ,l ri r rr.r " .5. . : \/
    ) ', t
    .|rJ
    )

    furcilt,,lrtlc
    w)
    r .,rr.t.1r,,,,1,;1.,,i ,r,rri ,1, \ r,l
    Ittl .rtrrl s i lx r r ' lir r r r lr ri rl i .r.j o ;rri ;r r,,,
    tl l s i n i i ,i ,,f ,r,,i i r,.' i l ' ,, Ii si rrl ,.irrr,r.l t,.,l i rr

    :i:lll
    :l:r:r
    '! It,tl
    ' ,tlttl
    (.irrir(:i(x.izatc
    priu irrtrcr-upcreatubului 11i.g,,s_
    ,.-- ,- 'llalllrtlru!iile.inaltr..sirrl
    1rv ,lcilsupr:r..ltnrsclfior.r'jdi,.liiori;ruaii; cstel.orbir <lco agenczicanorcttrL]i, (l:trlze do h$!!r i{'lllt'lil t(i
    gearrlre e& sl"!t(i
    utttrga rcctali e oarbi, sau sc contirrnir cL1o fistuliL cleschisirin uretri (mr,co_.
    ri 11.i I ul D i 5i ui c er C B s hi ng' R ol i t' nN l ty (h o l i i . : l c S \ ' ("
    rrittric) sau in vagin. Anusul estc absent. In atr.czia rectali., rectul cstc I ,.
    'i .,r.rr,
    , r.i i l uo(l c rrdc drto:i t;
    . r r 1r r .r , i , ( , I L r)t l f rr ctc.)
    ,,r)rl)", dar anusul ;i canalul rectal sint normal constituite si la locul lor. ,r , ,1, l !., I r ,, r , r i ,i i i 1

    . .. Jn_.formeleinalte, operalia cor.rsti intr-o colostomie (efectuati pc, sig,


    ,ti :, ,rri t i L 1 ; i ; . l f i ! . ' I i L s o u l a f ! {,C.ll i )
    | ,l ,r ," l ':'i ' l i r
    ,tr.trrlJ.Prognostiutl vital este lezervat clin cauza asocierii cd aite arional-ii , L' ,,1 l l ,r l . r. l
    tri1r Vater (urinare, cardiovasculare, vertebrale, atrezic de esofag). Irzo6.l.o.s- , IL' .\l ,r r : , 1 , : i i l ri l n i s u b l i re
    trirrl fnnctional cste mai rezervat: continenla
    anali. se stabilesie tirr_i; l.
    It) 12 ani). Ilortaiitatea esteZ0*30!/n. l r , l ! r 'r ,r " r tr{ )i l u r(i
    joase intri in cadrul ma-lformatiilor anale; arnnnla rectali ,, , u!.tr ddi l r :
    s c a u n e c u s rrrg c l ri l r I
    '\nornaliile ,,' ,,r ,r ., ,u", , ' r, r, r. : . . $ L c c ! ' i r! : r. j i i e i ? c l rl ] i c t t rz e d e h e ] x a ! ' rn x : r: t i
    i";{rrbinc dezvoltatiLsi traverseazl-nlanul ridicitorilor anali. Foarte rar amr,urir
    (j|clrrrrr lr
    r, (rialil este oarbl (diafragrn anal); de obicei ea se continui cu u1.!trillL,ct . ' ,i, iri( r,rlcf,r irr lirir?ul
    etP',lsiai ''c I' rle- tlic3rostira +:ii t::'l"l '\irt
    ljsiul(rs lars dcschis Ia perineu. Formele joase cu fistull Ia perineu pot fi . ,r,,, r,^,,u',,1I. n. 1c,:.reiraln hin'L!1{r1r!i rduilir, !erezisten'irlt' irlca}i)'
    '', " . 1 I t .l r " Ir r u ,r 'r .'" u r r ":i
    lrl.rlate sau tratate chirr;rgical (ano-plastic).Malformaliile auorectale ric-
    lrrtic rt:cunoscute de la nastere, inainte de a apare distensie abriominati si C e fs i ' a' ) i e:' ' tl J nus r:1(' :rl ' :' l l rr :
    ,,!l r.i l i r (' l c (rs 1e fl l rl l ai c i B el at i ,,.r:fe' rt
    '\, ' l e:al
    t iilsitrrriie. Prognostiull, este foartc bun il formele joase (atit lital cir si , r1l )f,, IeD |rr ..l i agrl os ti .:.
    , firnclionai - coirtinenti rectal5.).
    ''1
    UPSAEtlf'ltNARltMECONULUI
    :.111.3.10.

    Ti i tel l 'l :.i \ ' ., i rrt illi, : . 1{llr r : r or - 1, ! sclr }ii br : 'ht r li cll. - t r xllzit incet iliit ' 1) r (lr r ir lllr l
    | ,r^,rrrrr:,cltlii t ti 1;oala-IIir':chsprnr--gsau cu ileus nlr.comal
    Cauzo de ultFe abdomiqalc
    SCAUNEIORDE IRANZITIE
    " i l. [lPsA ELIMINARII
    :' l1 .3.
    {dup6 ce o trecul meconiul)
    ii n-sceuNEton FECATE
    A. ,lll(ffalii genitouriiare {se suspecteazi ia caz de distensie abdol}1ina1I, xsci.ir, mes( iD
    ilrLr, rrri, rczicl. dilatlii ir mod pcrsist€nt, i_utburnri de nicfiune, bacteriemie, piurie): i caz cle loh". r lus ; i lt r alr ot alie'
    ' r 1r,r r : . 1ir t ilt
    o) \rahe uletrdlc postclioare (ce produc obstruciia)
    Irnc nrrlnredidstinut satl p eumotoraj(d spontan (I1u acela aare apare ddp; -rentiltiti(,
    . .1,
    , rl, i) , 1 . 1r 5 0 , j a r c r r I or lj u l stL Ucli /J ir tr a , r u lu j u r ir a r
    :,,II.3.I?, CAUZEDE ABDOMENSCAFOID
    I l. 'l ronrbozc ..'enei r€nnte {tlematrric + n1ast patpab{n in ftanc) t i l" rrriLifi{'(lYcr}to ca.lz) :il}t: ilcrnia t}iilh iigtlilrticl gi ill; r:zic tlc cstrlrrli
    t : . t t ' Dn f i . : r , l| i li.

    Norrroblast.m {.ea nlai frecrert.:L l11n1oatecongenitale_dozare de caiecolariinc) (E'N')


    ITA l'IECROZANIA
    :l.l1.3.13.ENTEROCOT
    ' 'l Dmo.rrc Wiims (palpare blnld:r, spfe a e?ita ruptur:r)
    lili; r lr '
    - l.ri|toa,r,e (sacrococcigiat $i ]:etroperitoneal) !,' t" t t it l. lir r i. ( 'f ocr ) I it ar f 'r ozilnt il est eo boaii - sc1- cr' i lr cl st 'r
    Crlllt::erclifr-ritc ilLt rapot-tal incirlrll!iL rl
    r\ltc tunnrri {bernangioame, hepatob}astoame etc.). ' :,.ri I |r't'cttt llr r)rollliLtrll-1. -.lrt
    1,,.ri n'etliatric,
    ,ii',,,li'l i",.",',l.,,'ii vol. 2, pas 2l? -qi pag-.244.] l'l)
    r 'i r 1 1 1 l l .r i t r l t! tL r ] tl
    ll,,.,l.r ,r r r r l i l r 'i t i i Ir ;1 'r 1 ;- 1 ;t,l :t 'r ) Pl t,. ,D r r r l
    T,rbetxl 2.it, r a 1 6 .1 'r 7 - xJ"'l 'r i r {cr l llmlri \l r '
    'i I ' r ,l r :,i h ''r ,:.ti n zi "l
    C i l u ze m n i lr e cr cn te ('hi sx;cl :) ' ,, ,,.,, , , ,, , - . iii r , ) . \ lr : , r t llif , Lt , 'r rt : st c . 50- 70'] / oit copiii m ai r ni'- i
    d c d i.r lco ( .U.L.
    I!,' / trr , 'i't , ' l, i, l, ' cllllo: - c. lt ii. I 'r int t int m or '; t is p: uc r r l'i D l( : zir t r r r
    "r L I r ilu'
    ':, ll1i.{,nric (irrclnsi-.' Slastroenterit.r.) ,r' ,,,.r i i t 1,slir r . r l, ( hir l( iar t t ll r ir t '- r r : ; lllzt : ( iscL''r r i", t t lt n] 'oi''ii '
    ,
    I rl, 1{ rx )l i l r t r x r l : r o z a t l , rl ri , i r t . i' , r , / l, ss iu'r 'rr _1.
    r l'r
    I r i, , 1(. )llr i l i rl r ( l i z o l l a r i d e 1 ,' ' i ,l, r r l, r , , t r r s|t t li lit t r 't : . r ilot ll li s': i'r r l' l. 't l: r "r r zii r I I r : l: t ''t t t ] I iI ir
    L lu , , ! , rrr i r l , ) z l i , , l. ,.r r,, , ;, ;11 , 11i 11' r 1t ; r t t s l l t l . ; , ,
    '! , ir, / , , t . l i i \ a l i y ( l ( n . r u . t l ( r.r l( jin Ia p lc 11,,1|: (:l ;ttt. l rrl ttl i tLi r' 1 t' rr".(l r) rt]IIIIi I i II||1 IIl I
    \IrIIt, I)|i IIIi r ( I) l )tr' l ri l i l l (: l ri |,
    i t''r''' rriir'l 'r 1'r"iis1r''ri{ir
    I I il{ , , t , lrz i | . s r p l l l l , ] r r l a r , .o llq (llili!lir
    'I i, , ' )1, , \ iL , , / L ( , ' ) J i I . | | i t I i l li ' r'"'I 1"'i i'''''t'i''''L 'i'rI'i ll"'''tt ']'''''
    rrl ,'r l rr. l r

    :It I i l .l l r
    lt t t ! t t as lt t t t / l rr,l rrrrr I,rr 1 rr.r
    L rl l ;r t)ri 0 (j l l rrr,rni fi i .tjl .rl
    m'1l l,, rLq( <lisLcrsiorLrxr,,rrrrr:'r,L t, _i laar{
    r t } )fozi tl l i i i u
    sr4r i11115-, n,r"ai,,i ,,iorol*i o,rr r.ausar.*L,sarr
    r:l ri nr t gas t r . iclr il o s s a u (.(! s u rl t(.. NEONATATA
    2,11.4, HIPERBIIINUBINEMIA
    ili;Lltca t:u,,sau..{ir-i sirr;rJ .rp,irc {tectr.t (tlar poatl: fi inaparcntii
    tltn crLLrzailcusului). Sc nai rern.ucaLinstrlilitatc
    t.:rnrij ,si cr-izc <k:.aptr,,,,.
    ri Lunx1oz(,i intcstin;Lte la radiogta{ii alSctominaie , ,,,',ii,,,i,. lr' rloua c'.zi.t- clc mo'biditate neonatalii '\proxinlilt iv )(1""
    I, I,,,.lt,,,,|]1,;'r:]]l.:..
    p,i g,,l
    L f l l t l r d 1 : r g l l u]lr
    s t tct1 1 . .1,,i ,,,,i, nornoponderali ;i 80fro din- pr-ematrd ?rczinti itt ptitr ' l'
    Prezcnta clc acr lilrer. in pcritoncu sau ill ,r,' r,.r'iilo,ilii t , i( l( r , colnspunzind r r r lo: - I 'alor i al" bilir ul'illl l) r i"i lr r ir i 'r ' r t
    sis.tc,rlul l-ulos portatr cs1r, r r t sl,
    l1r scmlt clc prognostic sevcr.. ' l
    .' r " ,. ( t , zi l', 'lir ir ic. \ - ol. 2, 1r ag 60S bZZ) .
    "j
    y:::,.'1 j d.,trirtrccar.Lonatc esicrirl senn ce apareprecocr,. \i.rlil tniti,rritatc ir cazurilor rlc-icter']a nou-nlscut cu valoli rrtici 'rrt
    .- . ..l{^T]l
    . . t r - ' r L- r I n:]l-.:!ti.
    l , ..rl l ,..o i l .. i l :,.r1 -:.1,r,1 , li , liDrin n(investigate si sc considcrir ,,ictcr-c 1iz'iologi' '
    | ),,2!ri r.i , rr l rl ,j cl ,. { .' / ,...1,.,/ ) ",,lrr .rlr l,iliruirinci cilrc ilrl \rillorl llr;rl
    tLL l-{-zilc lnainte dc apali{ia srmploru.,lr. 1,. ib t[n 11 ,,.r. .,nr..,,,,, t' 1 r, t( | irr( .ru.tr-iu rlrimclt 36 dc ore de lil llilitero
    r ,r: , Lr r inr loal, rl l o o l ,r. l )o rr 4 7 u o ,1 i ,, ,,. . n:,-.ui ;iiTfori) ,1, lZ nrgi'., u, e,i.iti urnla'ttoarcle investigaiii paraclinicc: bilirrrlritt.rrtt''
    si -rrri to:r j LLrrLL(:l ' rrr '' I
    1t t , : , i, l , u l i i i z .' r 1 ..rrtr1 1,j . t,i .l .L rir l r,coc ., .ofi i to.. ,.r ri ., i - r,' , r,, yi in,li'rll,:iir, grupul sanguin ;i RI (nr,arnj ;i.Iit) ltsrul Crxliilrs tlir
    pozit iv: c lit id( 'lllililr r 1J'r rl
    '!r:.t.ls:ncnluL.
    metlicctl.l[dstui it:tli,tlt. Sc I r,,u tti is( : r r t{ir . r Dr czcnt a unili t c; t Coom l''s
    .
    .i . r ' r . o ir l , r lj r' .i -o { :rj tri r- :r,.n rru ,J ,., j. "uprlmi aliricntafia pr grrr;i ' Lrrrl i ,orl r i) , licm olcucogr am ircu I {t ; i {r ot iu. de- singc pedf cr r ( r lnr r lr r r r r r 'r l
    rL :,^ ,,.l rni rri _r
    r,,l z:-r ..ti i ,i ,rLi ,. I
    . r t t r lot . J . ( i. ., 1 -1 ,r ,1 . 5 ,.1 ri i ,.rn i i l rro c i ,, r i n,.^l ,ui rrrrre.,tntrj .i oJi ,.,l r,r r,,l ' ,,r,r , r ilr ixit clor si ir t r om bocit eior , r ct iculocit c, vi oar t it ; r ll't t t t r t t ] ,
    t cst c f r 'r r l( ll
    '' r 'l rfl)..I at, a I,.tz.:. r ,o r r ,r ie ..,[r ..lr t. ,.r ' ' ,,, r, f, , f , , t cit c dc'k'gar e r 1e albunini a bilir ubinci, liot r ir lr '
    uoi )., s;. l par.t l )..(,-...1,.,: 'l-4 in icterelc p]^clutil-.it( lx sl'- s, 'r1'
    ,',, " 1ir;titi, fosiatazi ak:alinir) si
    ^-l n
    "'',,,f ' l, : . c ' nri ;rri r,,rrr,fi ,.r,i 1 :,-o .; 1 ,,1n J ;r j bct ,l ,,l " U j r,:. ;.,.i a ri rr, , , l, l, , , r ll
    .., t : r , . jr t i, . i, r i(' l ,,i n t .ti ,r" i ,.a ri :,1 -.,r..r," ,,,., i , ,, ,,. , , , , , , , , , , nt aior it at c a cazur ilof de ict cr gr av sint plor lr r s, ,
    1,1: 1,.i n r ,nl ..r l ,.r:,r:l
    L, rL,,,l i l i ciil) f iu inJom pat ibilit at c llh sir u. A. RO , iar ict t r clc. usoir (
    t ! li ( lr '
    \r.t,l i, . , r ' r . : : o rrrl s .rrn , a r ::..o h i i ,L , t, ,.,.," ,n;-' i ,,,,ii ,ol i i , rr.,rl ,r,,,,rr
    J, ' ri l L ,l ,, t, rrrl l izi. kr gi<r ". ( lu t oat c it ; it " t "t " t ! " lt ipr lr 'bilir r t lr it rr'r r r '
    i , . r r l r ' , ,lll /vl I /- i r .. l,_ Il or. {: o,t_rl i .,.l l l
    "rt r-
    r nult iplc af "; ; ; ; ; ; ; ;(;t;abclul 2. 61) '
    ecliuni
    llasuiL-cxpandciii (dextrantl, plasna .d, singele) pot fi ttilizalo, r,,l l r I' r()r lus( 'ii, 'prrtru
    IiiIilrtIritt:L Iill(rrii cste to-\iciL cclui:i ;i or';::ulitnlc :tt'r'sltirt lli
    ttr{,itttri rtlleriadrc. Sr: r'or-. rcpcta radiogpiifiile abdorninele lii d-_6 or , r,, r..r r,ri, ' *r , . r r ll, r r ': r , . ' lr r lr . i. l, iiir ubir r , ' p, it 'ur r , l' in t r r il'x, , r r , lr ii r , 1'r" 'l
    l rrtrn ,1.r, cr. ri-r, prlc,,r . a pcr-{or;r,!iciirtestiuile (poziti:r optimit pclirr rt'l
    , i f',.liuii"t.. o-nlntit'iL, scirzirti iintczir tlc protr:irrt' ;i rtrcr'l.r
    L rlrLrul(),!-lct, r':tt ,.ulcat-pc_spate si in clecublt laieral itirgl. 'lntr.r, ','",
    lr, ' lr,.rr: r.zrtllrrltrl final cste urnlliuc:r rtritocondriilor'
    ...1t';l]
    1i I IJi -r-,l.rrcLitziL11rr\- nt ,.u lxtlLilr, sc r"ol iace -
    ,'j r. clcter.miniir.isu(ii,sir,,: ,,1i.
    rlt r , r . l, i . t i' .,. .., i O i ..l ,/r,1 . , o ri l u l ,,n ..
    ICTFRUINUCIEAR
    H|PERBITIRU8INEMICA,
    :.II.4.I, ENCEFAI"OPAIIA
    ;,futt:.t;!ttl 1car,
    . ,'i
    ,ir rrlr, .li n, ecsar la u.oii -cop!i._ Durata tr:rtarneni:lini polr,r
    ;-1t, zlJt icopiii calc stnt tr.ccali Ia llirnent:r{ie per: orai[ inainlc ,1,. ( | rt triri ilil.vi lL{ccfiimr' Pr-oclusit ..lc }iipt ILilir-ul'inr'rli' l'r' rr()rtrr:r ' rrl
    , .t rnr:'l \-:rl prtzirrir-firrvclt . -
    I', rc'ciclir.e, alc bclii). Din cauza pcri.o:ldei irlr,qi , i ,,', 'i ( , I icr nihn r is, 1. 561i5 er - c; t clt iL.i'ilir r r l r Lrr
    r'rl r.uLnluiL\1r.nrj Cf illurrntlr ', - ie. - S'. ] r uoll) '. t t t t t ' t 't
    P.r os, se r.a adninistra alirncnilatie ittxrri(.- ' " ,,rr" . r l, 1r "l,
    't ', if , ''rr,ttt l ; t t t r t t lt il r ir ' I r r r
    '- or llit iile
    r t 'i . it ii r I
    -'.:It1I I t tIt'rt t"t I t I r r I r ll
    r ro;rsi {rru Iiirllocarbonatr, proteiLrc,'J,ipido). lr / 'ir lr lj : ) - "r
    ,, , , 1i, r r r r r , rl.' r , t , , r i lr r t t , t iz; r t r li l'r u- 'lut'
    I rLtlttt,L:utrtl chiruryiud..lndicalii]c ' " l 'l jlr r 'I 'r l"L: ll"i\ 1) ir " r r r l
    se r-or-stabili impreuirir-i rcu chir-ur3Lrl; ' ' l rr' r rr rit r i, r t t i, t : L lr "t t t , t l, , - n'r l; r lir i ii lir 'lr "; l 'i r 'r '
    ., t r i'i lllt r 'jl lr iiljL\ lini<' - \ r ijl. ' r '(l. t llir i : r l'( l: r l'
    . inrloratia cste o inilicatie aixoiuti (dr,r stabilirer, acrst[i momont ' t Ir' rr r r ''t t t 'r I r Drilr : r ut l'r r 1 ; r l lr r lu'
    .sl' rliliciliL, pc'tiu cii nu totdradna nerul liber in pelitorclir os{e'r,izibil rxlrt,i l ' t:,, ),, , ii; , i; , i; , '"': r r Lr litlt'rliicqliir l , cur Pul slr ir l, 't t bt alr t t t r ir '
    I - l accst r liv( 'l so t 't t lbr t r ir i r lr 1" rt
    ( u ])orli) rli.r si slnt cazuri in carc se poate dtzyolt:L ,' ,;,,' ,i ,; ; , . i , , r r ,l, iii , , t , l, . . , 1, r l, Li. Pr or lllc
    un alrci;rsta paciclrlii lrr 1) t lcll'lr t ir ir lr ' lr '
    rruc ltlrfor-:rlia nu s-a tli:rgnosticat); ,,," ' , i, , , , 1, , 1, 1, ,. , st , r i, t t t t ', nlanif cst at c pt - in |icuoziL ir
    ' ,' ,1, i
    .,,,r' ,r.,l i r . iic Lot r sir L't i t lr - LvlLlol- i ah llilinr bir ici ll{) conjugilt lrp( slr ' 'r l) t r r ', "'
    - chrd socui ;i CD{ nu poi fi stirpinitr prin tratanncnt ltcrlical; clczvolt r r r cl llclll1) logi( i ; r ( r ) l) lr l. l
    ,,,i 1,,,i, , 1xr r lr r r S. N. ( i. I it : r I it r indu- sc
    .
    - gladul pncumatozci (1:,rcxancnul racliologi,c) n1.ase colcl xLzir r LrL , 1,r1"r|, it ir 'r r I , ir r , 'I I t illr t t r it . llcr t ', I iLl'irst r m t . r rclilt r it : t : t lc, ict t 't - t r r t ' l'r r r ' l' "
    ltrallt:tt'ii1 bolii (si nu constituic o inriicrtiL: llcntr-u chirr,rrrgir); if l, , t , t 1, , l, lir r r pl s; l cot lst ilt at ciL vr t loli lt r t t lt t r t lt i t r t i' i r r lr ' l'r lr
    '- lrocori, la lt.n. trittati mttlir.ltl sau/si chiltLlg,icll, sc constiiirlic s{rtr;- l ' ,," ' ,," " ,' ', . , t
    . , , , , i, t , r , , 'i', , , 1' it t lir - z, ilr - il
    c r lr 'zr 'oliiLn'; lpsilt ot nolotir " I t t 11t r 1'
    l ttti r r . lr t: r r lx r lt r i r lig c s ti r., c c n L ' < :r' s i l .i
    r.r' i l l tr,l vc[1i i . ' ' r r ' ,r "r r r l lr r {r - rt lt t lcct r t l llr xir ' : r l I 'iI iI . r r I I ir I li il lr lr nv'ill1i lr lr 'r r r ; r lr lr l
    | | | l ,r , r , , lli t t , r t t - t r iis<: t l{i r '; t loti it l' I r ililr r I I ir I Ii r r llr l2 t lt g'] {' lx) l l) r r }( lir l
    I ' r i, i' t r t ,i. t ' c . u l ta l i i . N rr l x i s l i o tl r(){i l axi c spt.r;i fi rrri .[,;ru{rl r:
    rri rl l tl s iL r lr t r . r , tl i t rrIi l ; s ,i tn n rrrrrrrrrrrl rrtrJr:-;1.1.1111,111.,g I ,, , , r r , , LLiI i, , - l) l{xlll( : r 't , : t icit t t t llli t llt t lllt t ' l; t - lr t lt r t r t lt t t i lsl' llt r 't t
    ,,u:rl ,-' .
    i i rrLi l ,i r-,l .i r;,. " ,,,, : r lizi 11tl't
    Si l l l u \ ' ( : iilr ( ir r s i. s l rrrl i i i rt r:o rtti u rl rrl .i j .r:l i tl n;t r,i i cl tr:i tl r.l r^a r ,1, lr it r ot r r oirillr 'lt ) lr ', s/ l'lsl t r l I ri 1' ' '' ;rI rrI i ' |t ill 'lil'r 'r lt lr "t <k'
    i )(.n tfl l l tr( 'r lr i r lir r : ' iI I I iI / ir '1, ( ,
    , ,,, ,f , , ', ' i, f , , r , ' , , u, , i, , f i , r r ir r l" ii', t 't ' 't '|'t ''I I ' . i; i , lr l
    ,r' r rr' r,i. r r r r ', , r t t i . t r t l|'t I ir '. io|oI : ir ' r l' r t t ' lr t lxr lizr t t ' ; r lr ilir r t lr ir l't ( l'r l'
    :i :,r; r,l ' r,' )
    .'|.,''.i
    ' I rh l l ') ttl
    T.tbelai ).(t
    llixl,nusli(lll rll{,lo,lif fl I h il' r .r h illr u tln .I| r ir ; r ' 0 u n tfi l e \ tu .; C 'oh:Lr\. ::" -:,;.i rt.) ll iitrrori dc ris{i ill i.t'{trtllti r lclear {rir]pt llro1lrr, fl}odilicr!t)
    Irotlu(tr'('i!
    I ticr clirti.
    f)ozarea irilirr:l)i4e:11i.ii Conpetitie pe C rotterc :L I o\i ( l l i i l i l
    |j apac j thl i i leglta le cu
    {_ cle legar'e a c c l l rl arc l ! l ,i l i rtrl ' i rrri
    J l al1jun,ina
    ]]ili111biirciria > 12 mgo( r.iburrinci
    Si E i j i bi na < 12 l nsi : si
    c o p i l u l < 2 l o fe celild > 2+ are
    I
    T.:t Coolnbs
    J ,,,,rl 1,r r,'t
    i, !r C o r;l 1 1 l rs D .rzi 1 i ,j
    .F
    Trs'r Coombs negatir
    'j
    t ' : / j d c n l L c:r':r
    I rr, r.,rrl l I I LI!
    ti c.!.-,)i l ci : ililir,rbina direct:L rri l
    Jlll
    -\n(r {irli ct.. I
    ,L
    llilirrbi]l:r .iir;rdr > 1,5 mg-!l Bilirubina iiifecii
    . Hcp:lriiri
    < 1,-5trgo.l
    -- 'llOItCH sir:Lioar
    - Ol)structic hiliar.:r lrr :t.ri,ilirr'rrurci :rtitutliniterapeuticelezultatelc- accstortcslc lttlrrti
    - Septicc ric I , ,r, t,.., rr,r 'l\, {,r ,li tr, cu ctih}fi lactori de risc care crcsc to:icitatcrr lrilirrrlrirr,r"
    - Caiaclozerrie
    \, 1, 1,.1,'rtrt iur intrat iir rutina ctinicl ;i nu au o:'crificalc itt litrtlr 't
    I
    -- Dcficit ellr.-l-anirirr:p3inal ! I
    'v
    I{orrt3': Crcscrt
    'i i , r,'ll rrii rr,{1r(,I)shicc a coDiilortrata}i dupl accsterczultatc'
    Fit,f(':a, cilisii.l a- (!lLicitec.ieJ tr',';rr,{r' lrilirrrbinalil:eri t'-stcelininati prin Placcntit,ictr'tttl tttrr:1,' r'
    i apirre irrtrc zina rr 2 r'
    v ,; ,' 1rr'lllrccirr timpul vietii intrautedne' lloaia 'i
    it{rrjolq;a, e! i!;acitriL7
    t .r ,'l' r irrlii. 1.,' t]n. c* hipcrbilirubinemienecoljugati-t-persist('rr l;i ({ r i
    Nunri.!:itoa:'i dF leticrlio.ite
    once vlrsta' rcr
    debuta la orice..vilsti.' Ictcrnl nlc[':tt
    )i,rtirr) i, l|t
    l,, )i,rlirr) llt Ltl nuclear- iroate deb[ta
    nuclear-iloate
    I ,,'r,t,,, .il. iri 1,r,i,l.ici, mai lit's'cnt la nou-niscuJii.cu boalir lrlnroiiiiLii pr'r
    Norrrlal
    t,, , ,i, i,,,,,r',r1,;Liibilitatea ri,: grup Fi de Rh,- daciLnll.s-a int{)volril lr r'
    liljliir.it0z;i
    - Ilcnorr.gii inciar-];t.
    ,rlr, .tr ,' .', .irlct,ra ciesiute ale bilirubinei ner:oltjt riialr N"rr
    .{nticorpi dii lap:* ri1:|iefi1 ', t' Li': rlcvin hipofon.'aloriloi rtlincnric si su5" ru "
    l I r r o f a t i b i l i t a ! e - \iO - SindroEl I-rceFtrisioll ' ',||,,r ,, 'liJic.ultal'' IIil'rrt"'t-r
    1):lrci.r!: dc c.]?ir:: eritrocita;e - L1rfotrrororsln ,, ,,,l,- r',,1iil-l ri$ditatc, pozilia dc fiinrl f i't:vrrrl Irlil
    - Crigler-Najjar ',iri ",t c:icrrri
    otulomotoii c..;tcrrri -opiitotonus
    dctcrn-rini
    detcrmin:i clcvia!i:r
    clcviali1 g-l.lril't..,r
    gl.lrilrtt.. ttr tr
    r.r l',rr,,lizi:r
    rrr.r l,,rr,,lizi:rrri,,:r'ilor
    rri,r:r,iloroculomotoii .''t
    1 l.)rii,ii n i-'r zr a. til].i.r"
    r:lai i$Lrtr- ar 6 9i :eiii-ujo.i,Le
    r r rr ,,,r[,lr ,h: stiarc", insotit:i Ce spasme oculogirc ,f rjzc]c t:ottvtrlr;it'r
    ,1,,rr1r' 1,irio; r ( l{'}ordc aplcc anul! ; i r ioar t c. a nou- ; is'nt uhli' t lt '. '
    "' ! ll. t l'lli
    rrl'.I
    r i,',i; ,,fii, tiil,"l,rl.ir,..ltot clc'ictern*clearcu nroditiciriclitici)ovi(l(
    ll,nti-n ci miii blLna evaluare a riscLniuirie afectarc cererbrat;l_ lrin hiDer- 1r,,, r r r.rl.irr|trlul :r(lccva.trru cste instituit inaintc dc aparii;ias<:mn.'lrr' l.r
    lrili rLlrirrcrnir:, pcntr:u o arumit[ concentfaiie si pertru o ammiti.vlistf," ,. , ' lr' lll' Ir.'urologicese vor instala, prognosticul fiiud.jrrcert in pcrittrll'r
    r. lrrlorLrscdifcritc- tchrrici care testcaz:; cap:Lciiateade legare a bilirubinci ,,rrrt.'1. l.rr tt.r. la icnrlcn icterul nuciear-sc poatc miln;Icsta, ;11ic:5r';t'tttt
    rlr, r ;"rl.r'' irll.rumini:
    l|r rrlinirntic,cliagnosticulpunindu-scultcrior o(lati cu nplri{iir ''
    .. lrulr:sircagelu.iui ilc s{ad.ex 25-C care {i:<eazi bilirubina nclegatiL dc '||,,r l,r
    , 1 , ,l ' l , ', r '' r r u r Ii 'r 'tt, .
    iLllrurrilii rlin scr. Cautitatea dc bitirirbiniL librriL pusir ln evidenli. prinirccasti
    rri,.llr:r rst( repre:zcntati de :'a1ori fcarte atici c:rre slnt greir -cle calcul;rt apar I i- Lsugar ; i st : nr ani[ c- 't i. pr ilr : lr il) ( 'l( nr r
    " l r , ll! : t r , 'r t r ologicc ( 'r 'l'r ''l
    ( rr r.Iatctltati'. rrrr,rr ( l r , , r , , 'r r ( r 't ozicc, 'r jgidiiat c ; i sur dit it c; r ct r r r dul niut lll i- r o'r i
    -- ,Tsocierencfu sefades 25-G cu cro;tLaiogrtfia,. f I i r r' rrl
    - iiolosi.rea rrid.ttltr,i l.ticlroxlttenzazoben,zoic (tIABA ) care mirsoa i
    r rrp Lcitr,"lraleziduali'- de li:gare a bilirubilei rie c5.tri alburninl- O capacitatn ?.rr.4.?.BOAIAHEMotlrlca
    ,I lr.galr a IIATIA sLrb
    -50i1 estc irsolit:i cle prczcnta ncurotoxicitiriii. lo {istc,
    .. - ,1'[isu,rarta:;.pcch,cJblomclricri a bilirubinei dis]ocate din lc6ittui.:r c:u
    rrIIruutitrlitlupiL arJrlitristlarr':iclr: slllicilat punc in evidcn!iLci'r r.a.tIr
    1.urt:itrLi , l l ('
    ( D )l l .(l l nl l ,
    riirlLuruliL lLIIrItrrrirrli rir. Llu inrlicr:(ll srLtnr:rrc
    r:tr lriiir.rrbir i:rr slrlir.ill{irrr;ri c t,i l 1 'rr ', 1 1 1 1 ,i
    Irr Lt , : ri,, li"ir rr li,lrl : r . oiilr l r , r r lt . z ir t t r i t t |t r lolo, llir . r , . rrl i "r ir r lir t r lr t t l rrrrcirrii..Att';1i l r p ,r :i Ii ci tttto t' r tttl i 1 :;t'tt,'
    '

    : Jit 1)
    :I ll
    , rj t.'r i 1, , , r ,l,. l, r lr ' . ; i : ..
    l rr,,,l rr,.rtrrrr,i rrrrrl,,s i .r i o i rrcorrrp.rti bi l i t;rl ,.s.rndui n.,.
    l,l '. ti ,l, ii) i. l) ir r , . l, . I.t .i .r, n r, l ,.rr,rti [i c ..d .a r rl i ,l .nC r.ri r,.o,.rL,]rc t n j .t,,
    ( l rr I)rrr r t r h: r , r l r r r r r : 1 , :r i ,r ,'i a { i l r 'r ,;r r t.,'r ' i ;Jr r i l ti ti cr l r l t'si r l g c i r ta l i n tta 1 .. i r r ti l ,ttl r ti i r r
    . r r r t J . t r .l ,l .r(.l i (, (l o rri s i rrt l c s p o n s a bi l c dc boal a he.mei l i ti ci L
    a , , , t ' r r r , L , P : ti 'r 'r tr r i r i ,u i si r r <i l i l i i l r l l i .cl l tl r r ci l l l l cstc l l cr l l ca b i l Ia r Ti l r 'r r 1 :i t",
    rr)L rrri i s . uf r r lui: s is t c rn u l l tl r s i s i s l r.m u l AB b .
    r, rrr..rrli,i,:Lriii rlx ]]rir,u :t,tIi r;I.tIr{r:tlrlt ril:-l ftlilrs antiEtnic. Accst I'irsllltlls 1ro,r1,
    rr .r irri(rrr{ in 'l iri'npul,tit'livrcn{ti (r:xpu}siei) sau a unti ttvort (.illrlii{ rrrrl
    2.11.4.?.'1.
    Boslu hemolirici prih in.orrlporibitildteRh

    lufi{cgelr:a, tratanentul si
    ,.,.
    til,ilitrrtr' Rh a avLrt loc in ultirr.rii .pro{ilaxia bolii hemolitice prm' rr}cornpa-
    25 dr. ari rcprczc-utind un matt succcs
    :'l rrconalologici. {-cvinc, Lantlstcinrr- qi_l\"i.]llcr pur.rin .:viden.,tiL
    hr 1940 ,' rrrvirr iar ri'itrrlnl ui'li'i illtervcntii o}stet::ic:ric,
    l;rr lonrl Ith, iar l;rcda, (iorm:Lu si pollacii r.accilJazir mana cu'irnunogto_
    I 'rrl i u i Lant i- D ln anu l 1 9 6 -5 . t,,, I l ,r{,},,r}r li( r Lr,lr 'r lnivllul aacst or '}t om or at ii. f : nunizar ca pr ir t lilr : t ( : ili'
    i. r n: r , r lnrol. r r i : r ..tnJnir
    l r n rnr ta lr:i; r 'li
    d'
    d ( . I:'l
    '1n,n L ,( 'r
    'tltt.l
    r i,. . r( 'n l l ',l
    , 'nt r ,r'l',
    tl
    i I s is 1,1Dul R] r , cst{l al ltl1 ' -!anq
    I. .1r.lorc.lls )l .tnl Jnluro!cn1c7J.
    l l l oe c n1c 7i .t.

    .';, #*fr*1".;';Il:i,;j",1?t*#*
    '! l)r.zc.r ,ur'.al ru c'1tfocltclc - *manc s. rstc abscrit inllcditrl
    -\cest
    ambiant
    a-rrtiS i o : . a, t ir ir : r t '- iinunologici l\ ?r ljr 'ul: r r i lr : , t r t i
    i I i 'r,i. r iz ii Rn r n11 1 i y ;. \rr^ o x i _ 1 ;" 1 n 1 ;6 U rH qt.l .i _f nl j ' R .l ,. R ,i .t,un.,rl
    , rrrt l rl ,,l i. | 1l datoliliL plczlr r{, r
    pf oilL ;:, o ,,1 fo T ro rru ,l J ..trr.\-p J n o r.{.i trn,l rr.rdul rrr[{h rr,.ari r.
    r. ,|ltr6fnLrl ,c.J.
    t(i1. idisillln.ul imunologic complet coDst:"tin r-iisputsul nr]mar-
    l. o t ' rn r n o r - a ini+ial; t" .- 1 i- - - /i,,- ."r - .- - ^ r,: ,-\ d*--':r-+i -=-'-
    t inr pr r l pr ir r r ,r
    - - - ^i 1
    ,.. ri, Tii i"iliffr r,;ffi irs;i.: r.ii.ii l,:"'n"i#,i:: )li-un--j$p-ns
    tir
    ,,,,rrLr.rrrr
    ., rr.iLilizrnrc
    slilrsrnlt1zanlc
    'riirii hemariil. Kh+
    nematute p:fr:un.^ iri.tirculalii
    Rh- Ititl.uiisc "l:,l"'rf,+#il
    i^ .i:culaiia. intiir.idrilui
    l"iii.i,i-l" cin, l r clct ilit al, 'a ir r r r r r r oLr ; ;.i, r
    lilr n(AiLti| sc hcmolizcazir,clibereazi aniigenul care este caDtat
    de celulele acest m ot L r iscul <L: illr r r r r iz; r r ,
    rri, roiirtlr si transmis lim{ocitelor.rStimuiarca declalsati i,a ptoduce, la .-..-?.+--
    r r, ,l lrr {).1 l:r l'7j1,,dil:tot:ilul sarcinilor irr.compatibiltl\r-'fxsl
    ';Ii-+,l-.'"':': r a o m n j i r h l 1 ,,. \a r ',r \l iiL rl)rotr'(
    ) r 'r 'l {, lir'
    irL.
    11r ,r,q..isrn scnsibiiizat,trausfor-mareablasticL a lim{ociteloi -l :-. -:--,-.-:-,,y
    , ,, informatc : . r ..l _r ,.lr-
    r,,,rlr.,|'r,.r,.r
    ' ,l.rlli ^* r- .,.-r-.i
    osic
    r,irrici!.iir rrl l ; *numai
    valaiblli. ,,* ^: .l -,^)l organismul
    dacz-L ^,.--.,i ^-,,r ..,,,r..,,,
    ttr;rl,rtr
    :ir produci nrticoryi. Pentru ca acestrarsp[nsi,no"ologic iomp
    ,],i t,,{
    r rt,.r ;!, sinl ul-ctsaLc antrr,llrr ia.ir tigcnul i[?h pozitir'. Ritspunsrtl st't ttrtlrrr.
    t.,, r,r'rr.il,iliz;r1.
    citcla 1uni. Acegti anticorpi auti_Rh si.nt.de d;ui , , | ,i i(' runrill;rr,t',iL.sarciin.ii
    i1, i;,i rruroAlt,L,ut.rr^ fiflr.pozi'ai\t estc promPt iit cantititi rrrirrirr,
    G (ripul.7S) ;i i.nunoglobul'inc Il 1l9S). {gC arr o I ,,r,rr:,r,, ( ri r-11.r':rtitml r dc irtar:icoroiapiLrlnd imccli:tt in pliniL cr,olrr{r,
    rr,)r ('lrr:rItr..r-crr', lrcc, cu rr.urrnt,-! prin pl.icenri[iirr I rn.pon.rbil;id" bor]a
    l,"r||,lrlr r ,. litr1l,1isi |l r.t-n:rs.,lLulu.. Al .i tip d, arrricorpisinl pr:;i rn
    .' '1.ril., I)nn 1".Lul Coornb.:in.direcr It., , tr rrr,i;r ltlr ncg:tilir a trost .adcriol sotsibilizatir (r-li o s;rt',irr,,
    , cjrids.u-irrjn-"rid nri arrticor:pii din l,ilr poz-ilir,ir;i cstc grav'i<Jircu o sarcitt?iRh pozitivri, ur) Lr ,lirl
    I ',t,,..ll,ll iarurrizrr.si dirccr r.rrd , r,iJ n,1.,,i nn,i.s-p;1fii,r!i p- ',.,r '
    r ,
    I l:l
    r. r . t| . ' lflt po ztl!\-- ale nor t |. ' L. CUt uldi.
    l ' , ' . , , . i r r It,- ti t r .r r u r r .t].r '".r J- cl Jn .a n r i , Tr <;i ,l , Ji ) i r r J l r i :r l i r r I t' '
    'r r 'l r . r 'r .i l l r r .'t Ir l l n l r l ..r n l l r - ''i IOa Jr . U l 1 .l !l o .rcritrocitc
    r l r O( r l ^ i'tal'. .\lr lr i
    I 1 :r 1 ,. "\
    Slit'rrrl:rn .r arli; . rici la.o f, rn i" R'r n.gativ,i pL.-cpunule ;lrrrnJ.r,d
    .l, ,lr'.r1,)'. irr org,rr:i-,nI .ri{rocircjor f rrt-rlilr ;rsli'l prrdusi, r''o| t4,a" p!
    -t,r.- , i, r (,
    tiL in circulati;r lrfi,r
    fth pozirive. .\l,.sr Iu.ru sn po:rrc '' lr , r r olizr u . r it r ', cit
    l . r' , 1)1,.i (.r'!i.
    l. , rjr
    l r r l, ' al ir i lr . i,
    . - lr: {irapul vie,tji fetale prin trccsreade eritrocite Rh pozitir.,edc la \'{, r lir ( I ' r ':,{,
    rrrrrr..srrr_rl, lx g..r1narn RiL pozitiv Ia fitul Rh n3gativ.posibilitateacste
    . ., l,l rirll-rllsr e. osplic-r.im.un.izare,r ,l,tor.{..mci nolit ,rt", care rr -rL I I ,
    ' z l 1r\' .
    tcz,ulta {ll1]
    , i { irr ,rrrl,c rl tr{no ti.lils[,rzi-in omp,,tiUiliRh. 1ri_ r" ri rl l
    'i r . , r . luZ i^
    s r u h ..tn o tc rd p i c c l i .i n s e R rr D ,rzi ri i . reprezintiro posi-
    i, ili ;rl ,, r . r i r , ) pr . r c r i. i . l n a c ^ s r' ,,i mp r.,i u i i ri i rn u ni z:rc.r esie
    puternic:1,sc !\'r 'n 1 .1
    lrrl rlLrpr-L 1t1tcontact rinic antigenic,^cLLtitru ridicat de antlcofpi si intr-o
    r,tolxr|tir, cle 90orl din cazuri. i,'201) t ilir r lr t l'r r ,
    - l)rilt micr{rtLalsfuzic de laun lirt Illi pozitiv ln singele unci grav.itli:
    rilr rrr1.;rtivr. \ l , r l r l li
    Accasra
    cstr:cca.ryrai.{51,J;l:1.lf.q rr+f.;ntF"iUtaHq.q",jnn+i}air, .;i illlll
    Lr t, | | | l . I I I I rI I I I j t I L . I l i \ l r.t. (i l.r/.i
    z ' (] 1rl (1 1 1 1 l)l 1lr
    .l rtl l l ( . (rl
    lrrl r Il )1I, -i, l 1l rl1 l )l l l1l lliiI'Irtl f"ii ll t !
    . , | .u i , t' t i, , . ui i i i rt i i " ,:l ,..u ,i jl o l i j ..ri rri ui i ri rl rrgcnrcr
    t ,L g ,l rri .l :.i '
    I I I l, I Irr.
    , pr ir r t).1 TT'i .t".'rt
    r ,l l l ,1, l; iil,'fiiii:i:lTfi:'li,li]i f r',.,., '.(o(l l li(\r.1.
    ' (' ; l l l l l ( ,, ri,,'r Irr, I l I Iti
    l . l |r'.
    | r I I{,
    r ' I||I I Ii.
    I rI I I I | | I / ; rI I | l -I ( lIllll ' z l (l ()l l )l l
    1.rr
    l I r ir -\r'l)r(,,lucc lrorla lrr:molitici a fil.rrlrri. Cr;lc douir.stimuliLri ,
    sin"t r,:ptel.n* \ | , r l r l l .r ;q l r r i i tr , .r zi r r l r l r .l r r l r r r r r |i r l Ir i i r ,r |i i r '|, I, i Ir I!. r 'Ir ti ' IItr r i ttr r t
    s , r . r i: ir r:i
    l th P rz ,i ri v i i .i i r1 .s ..1 1 j i i bi l i z,,..rz;i , u do[:r s:rr.ci 11i
    1.
    i\ ir, ,,,I.'1r'j
    ",,Pr ir r r : r ;i ;r , , r i | . 1 l l r 1 r l ,r l r r r r r ttl i i i r r r i r r i l i [...] , r r .p 1 1 Jl r ,l _ l l - :,,tu '- r r tfl ,r .r tr ,1 ;,- j r r r r r r to
    tr( . r . s 1,l). t ir s:rrc r[i i rl (..l .i tl i . l rr l i rn Iu l Pri rn,i i Lri i rri l r
    l xrzi fi vr. 1 l r , r l i 1 ,r:r r l | i r tl l r tttr r tr I r r l tl r l ( l r .r l r l r r tl r t l i l r l L , !l j r n 'l t1 ,'
    "r Jt\"
    , , , l {l r 1 - ,'zr i i i , . l ,r ttl tr r r r tttl , yr i ,Jr r l , i l r 1 'l i l i i ,1 , "' 1 r r ,zr r r l ,t i L t tr r ,
    It : ! 0 F---_ --.
    ..-i-*' ."*

    iilr I
    l;,1',',":' llir",i,]
    , 1],;,1',
    ,'',...:;,,1 ,.1:i',iJ,,:l;,ll;lj'j
    ;,,,,i;,ll,:l i,ri,J:"r'; i,il,ii ,2s,'r,r,'r,i'
    "t:l', I Il l;l;'',llj.;,,1: i
    i ; ' i i ' . , :, i i. , r ' ' i ' ' i ' - i '
    r r { 3 1 I: i: l , i ' l i ,l ', , l ,
    ,| ; :, l " ,i : fr,rczcula
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    tranfuzia intrautcrinl trsti itilr''


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    tj st: chr i ci er ut< ri ' I
    tltl Jl.I. ant,, 1111.rlr'
    :lil',;n*"til:iti=.,",1't.i:T"f
    1 :' llLlcle:ir.
    ',
    r.l,il,,,rtpri,, tiemolizi (hcrnat6clitul estc nonrral). ExisliL sindr-ourn1firig3: r'
    \.;ii.rr 1jt, -\rias I, il cuc cxisti alscnta totaiir. dc gl rtcuronil-t i';itrsfelr,zii, Flzlotoclc
    ICTERUt
    ?.11.4.4.
    ti1, --\rias II, crr trausmiterc .rutosonill ilol.titlrLntiL,clator:it <1':li-
    ',.'ii,
    itnlrri ',,r.iprLrfiat de glucum:ii1-tr:rtts{u itzil, t:u cvolufit favora}il:i. in urrlrr
    I'i rl i u u c nt ulr i c u f c lo b a rb i ta l (r,e z i v o l . 2 , p a g. 619). ,l,iii;,:iiT3,i'Jt .
    *:q;:"f; tiill
    l':'"'*;mllr.*T#:*5'llJi::1'"i';
    ::\ (:tLx!:( tllcd.icd1rl 1t0asc- l'ilamitttt 1i adnrinisl rirliL in dozc ruari pr''-':1r' ;il;'. :,i?""
    iiii;;i;' "ioi,"'-'ti{i
    tft"l?iT.lifi'
    ill . i;,';
    .i#i :i.il i,'ll.'-i,",t
    -i,iri,or,i""i,
    hcmol:iziL(in spcciat lir pre'nratrtri) ;i ictcr-.(nt numai )a iron-nlslitlii
    o*r" ";;j in
    aitins. .,
    l, ;."i.:','lrn
    :,il,1iIIiI;I
    ',r,xlrrr:ir
    , rr ,l, licit tlc G-6-Pi).
    rr rl o zc t lc 1- . 5 m g /z i .
    Sc rcion:arrcii nrimai vitantiua Ii. (Ii'lomrnatir' l)

    .\'ul,fLtvr,idele nn sc intrcbuir.rfi:azi la nou-::irscuti din cauzii c; dciris-


    I,'riIliii::iiUi5iru#t:,mli;*1i:;'61;'-:"tl
    , ,,zri lrilirubina din lcgirturilc crr albumint, clcscild riscul de jctcl nucl':iLr.
    l)c ascmcnea, adruilistrat-ca da uoaobiocittiiinterfcreazir. cu glucuro;lil- ii ::l";i;:ii;;l;,";,11.,ii':,"t1;l[l;r':,::J,'- rn'lL*i :r'
    rrrusferaza crcscind riscul dr: ictel nuclcar. S-a observat ictcr prelunqit
    !rr srrgrLrii ctt slcno.tdfiloricri- S-a sugcrat o tulbura-rc in- lretabolismul hi'lrr.r- rIiilri. ir:L',:.'iim*ii1l;:l"lll?s'*ai
    ,,,rlxiiuitc1or, carc duce la o ploducere insuficicnti. de UDPGA. Icterd elisp::r't pr.o.1rrc!i,r d,,g!':il:r:,::;: lhfi-.iil 1".':lfi:i,.!i:iit;
    cfescrltiL i
    l ,rt,.r l r,r lllI n, r ll c hir u rg i c 3 l a l :l r n o z c i tl t. p i l o r.
    l)ilt.ittll Je gl u, r,:a-6 fosfat-delidrogtta:tti (r'r'zi vo]. 7, licr.n:rtologie)' , 1,{fi li:i,l!Lllil':t':&ll, {**i; ""'
    i..'1;'fil3;'i',1',',1,il:i;,ilt
    '',iJ{ffi,,:,i.iti{+*:*ili,"',':$}:s)ilf
    :t, , , , ilo: o , ot ' g( i l o l ,i { v , z i l rc tn a l o l o g i ,),

    -irr
    l \. li: ic r c i- t, b i .ti /l tb ' i n ' ti c o tt j tt' g rrrd. Ictcml obstructi l ' ,
    <rrrc IJI) crefte pestc 2 mgoli, apale de obicci dupi pcrioacla :reonatalir,
    l , r r"':r li nr , z nt rJ i :r s i p i i m i tra c .i -l l .
    li{ ( i)[in YaloLi ]nai rnrcr
    i,:,,,1*":l;l
    'l l .r t rr
    S-a (hrr'r)rr'r{
    ' i, , ar t , gr ' ,u rl J o o s n h i r ' l g l l e p a ti ' .r n | onrt.tl i . i: in coniug:uca1i cxcrcfiabilirubinci'-,
    ''' ", iill'lirir.-rr,l i
    j,ii uLjerffi
    ,r:.;,:"r,ii;i., jlr
    - :ltre ct biiia,rii intruhepttticti (vtzi lol. 2, pag. 605) ar fi {ilupiL t'rii
    rrr{or'1)sradiul fir.ral a1 ultci hepatite infcclioasc intrautcrine (vczi vol '1, **,,f;;?::;li " il:lijllil, ll III
    t
    1 ,rr;'.3
    ' 9|i t i pag. 400 ).
    ili in::lul cttiitnlrti de coledoc so poa.tc sinli o Jomaliune solid:r in ,ii ;i''
    Ii li;:il'li:ilh*iTi III
    l*rlrl''ll'
    ]iJilrli{'.'f':jj;:j:ln ;
    lri '",r,,r,, l r r l ' lr ' pt r v " z i r' ,1 . 2 ,_ p g . rr0 l - tro 4 ii prl b22).
    '
    ) I ucottiicido:,a cste o alli cauz:r de icrcr obstructi\' ('i'czi vo1 2,
    " ln noa-niisurt (rlrr1.li'r'l l'.
    "i',1,',i,,r, tttrr tt)ttftil)lticLrritterttl 'fi:iotogic
    (r2 4) ,
    1 ,;r' . 'l)Lfitihrl ' " "'1,,
    d'c.al;fat-at titr ipsitr'i in ser se asotiazi ctr bo'l:t p'imon'rri vir{ii rriLrocittlolr,,llLr"ifih,,rn.mo3lr}rin,.r,s1.
    i,r,,r,',, r.
    srrr,;l
    , r,rrri ci ila adolc s c ent E i a d u l t.
    I-rr nou-rirscut, iroala -'e ascciazi. cr icter obsimctiv (pritt hcpaiiti)' ,, Lrl,' 'r:i;
    \',11,",'',lli'lf lt,,t-:li,:i"1,1..
    ii':liii::,;i;ii1;;;',r.;'Li;.'rti{'
    i,'1i'iilr;i; ,
    t., r iil olir bolii hepatice cu boJlir pulmonari nu r'sli cuno-(cuti'
    ('. / , ; t t r c ^c u b i ti ,tL b -i r' i rn i :/i )) S ' l ti cel ti i t! j :i l uatnl i i
    i,')i,r,,'1,', li,il'.1 l;ill
    *,:"ilif],ll;illlil
    2 l ' .1 .6 8 1 . ',,l],]'lll;i,';:lll;i,,'1,i,1",,',n,i,,,,,r,,. impll,:at,:'i'r lrilirrrl'i
    cxrtrjLrgrLrcrt
    r r .i . r r . r .lr , l' c ii r ' ,:r' t' i ,1 L rn L ttrl
    1 ' \ ' ! t f . r lilo t a tt rl t' !r l .' r tr' 1 o ' 1 ' l ' tl tt r' ;-; Ii l r' r : i l ' ul fu :'
    ti'rlttr'
    (t:'lotriz.rc liiLctcriattr-r.
    irr rrfrrr i.dr : ic t c r ) . Carz c s p c c i l i ,-t i rrfrtl i " .' .' (T r)(JJ). R t-H :i
    ' l r-on),
    i ur:sl l coi :gt- ' ;'l l'",' ,' ' ,'lii,llll,\lli,llii,,.i
    ':t
    litiL.*lini:i (:ir'tIlil]Il'
    rr:;tr:,r'r'11ttsr"t-'
    ,ri :,1 tt. Lz i \ ol. 4, 1 ..:. :J l a . \,1 ,r. \1 .1 , I.' .1 : , ,, r'it','ii'il''li 1';' t;;;;itiiiti"g'''t
    ,t' Lr.rrr '1, ,t ,,r rt
    ti,,,r.r-iuL.i iisr,riu.ut Iir:ltitllrti tlott-rlr't:r:ulului llr o tariclitl c ic agcrlli
    ,r,,,iri i l'r:c1io1isau d'oaltir niltu''.'i (rlr',,s,'rn|1rLdclir:itul ti,r alla-i-rntitripsin:)
    ,,,,,, ,, ,,i,,i ,iii;;l;jjiy;,'
    (,rl i l l rl )
    *1,,.;illli',;i,,l,i:;l;lll,
    l l ol rrt' i . (l
    ,, i trrrl r,
    \ ,.ri rrr l. 2, plg. . 56 1 - J 6 3 . t 'o rii",.illil,l'lil''l'lli',ii,till.;,1;,,.,,,-r,i(,i.r),
    ,,,,i,,,,,,(Lrrrrrr'r rrir.,,l,rrri
    2.II,4,3.iNGRIJIREA
    l oli r r , r r rr r iis r :{ i i ,U
    GENERAIA.
    i < 1 r' rI' rrr' fi
    A NOU-NASCUIUI'UI
    rrrI l i rrrri i in.(l or),l i l
    ICTERIC
    i i ,(.11r i ,' 1t}l (}l l (' l 11rl i r-r
    l tlrliii'iililfll,,'::;iijl' """
    illilliirji,;;l,li',lll',;i,,':i"i,,lillJ
    )
    1 .rt,,. | | i 1 I r lr , , rI r i I r , l|1, r tl l i l l ri r:r| r l r.rr,rr rrIi z i l o r-1 1 rl r| t
    i rr' r' sl r' i r
    l i rrl tl i , l i l r| l i , r' l rt,'
    i rttl r 1' r' r.r' ' l t l rl i : l. l: l
    , l i r.l ru ,r l ' , ilir r r l, ir r r r , lit tl ,r' r,l l tr,r ,i i (l l i I I I II | | | | i II iI . , \rl l tri ttj :' t'

    Il
    lr urrrirtoarele imprejtriri, icterul nn trcbuie acceptat in uici 111-I,i;lZ\ on'n?isN{rt
    l'r
    rii fizioiogic ;i se vor face investigalii pcntiu clucidarea cauzei sale (M i.. Ii{iolotlitr rlrtlrriei

    t'.Lisrvicir):
    - nou-r]iscutnl nu are o stare bunl; l ,) tr d! t l , t ). r: ! . : trans{uzic lcto_t11atern:!;
    (in sarcini gcmciatel;
    -- iclerul vizibi] este prezent in primele 24 cle ore dll vir"ri;"'; i':n."i"ri" f.t*l"t"il
    traurrlatisru pr_il an]nroceniezir';
    - icieiul persistS.pcste 10 ziie de viatil.; versiunca e-;iern!' a {itulti
    -:-caparifia icterului dup5. o ami:liorare idliaii; l .en J roan, .tc p.."1,1;. ' r' ^frrc . ' L
    I nc ' ro r "1 '
    / '
    - n;v.i1ul i:ilirubinei totale-> 12 mgc)i,silr a frailiei cor.rjugate> 2mgi'1,. I tx ;. t,1i t:i d i .!1t!:.i rr ' /i \' c urrr' 1 t r' r
    . 1"' ;-.' ," ;1, n murl i ol J r" '!
    / r' (
    "
    i ,' r.i r.;: o: ' n' i i |i ' r Lrul oo f r"' i ;1l i ' :r'
    I 1c ri ], ' ' 71;?i r^ ' r^ l i "en' i i .
    HIPERBITIRUSINEMIA
    2.?'1,!,5. MATERN
    DtN IAPTEI.E
    PRININHIBIIORI ( J J ' h r" r' -"rl l
    r i L :drr(""
    i ,"-, ,' " r;rri
    "' ' ,.i .
    " j
    ;' . . i. ; p : . . . . it . r , , , LJ r o : . 'r - ( r ' nl r "r '
    lralorile bilirrrbincmiei sirrt tnai clescute la nou-nirscufii aliffentati i; . . ; . ; . : "li-
    rrox p\rri i r l r' o "
    rrilrrlal ckcit la cei alimcntafi artificiai. La unii din nou-nlscu{ii alimenia{ir ".Irn' r' ' l r' 1
    ,' ",,' i o: :l ' oL nr- Lrlul u; ul :
    : " i'
    l:r sin acestevaloli ajungla 15-25 mg/100ml inziua a 10-a_de viale' Acei:ili! "'( ".t","
    ateteuz i rc a i r' c l or umtrrhc rrr' l
    {rirsi r.ire a bilirubinii nu este inso}iti. dc hemolizi sau rle 1m1ihepatict 5i |,1ni 1' .||].oi ],,,!|i |!i |u!trac ol do|l l l ui ol nbi l i c al (.rari c e,a1re' j l i .]]r|' i L|j l l l i l ' |-
    ]^,irir' tljr 5t.r rnai ml}lie siptiLmini. Daci. a1:'tptareaest!: intrerupti ti nou- dciitrenl:i' Prccipitatli ;
    -biberor.rul, bilirudina scarde.Acest tip rle ictcr
    i,.rscutill estr alinentat cu si tt ,:i l l |r' rtl i ;ee.ntl l :,ri a' l ;t:i ti mari .l t,s i ngc (]J c l l tl uc { c c tl ra|c ac 7:i ]]l l .' ||' 1.11'
    !.irr llutca datori prezcnlei in leptcle D]atern, iIL prinelc zile _dupii.nagtt'ri:,
    rr uncr fac'coti irhibitori ai coniugt'fii Lrilirubinci. Ace;1ia. at {i reprezenr:rfi 'iti i'

    rl, lronrxrni stcioizi (3 alfa-Z0bita-prngnaurliol),lar-la 30! din femeile *rt',r


    .L1ii1rtr:az"i s-alr pus in evidenfi ii l.rpte celrritiLJi cr'^scute de acizi graiil
    l J , ( : l r'i l Il C i l l l .
    ililcr|]D.{i1ll :rl rntniei ln rrou-Iislul
    ilii autori ncagi. prezenfa ;rcestor inhibitori ;i prrn aparilia acesrui lliufinosllcul
    r,: ,,r' ]ri; searna tnei iubiiimenialii a nou-niscutului {a}irnentat raturai itr
    1r;Ln,riczile dupi na;tere) sau pe s.'amaunei perisialtici reduse.(ia copjiul : :1rIr .,t\ i l r hi nri ai or
    + D i agrbs l i oul !roi ' .i Li L
    rlir'.ntat la si;), carc duce la cregteleacirculaliei enterohcpatice'

    ?.i1.4.6.StNDROMUtTUCEY-DRISCO',I "(
    Llnele femei au in ser cantitlti c].esctte de steroizi progestativi carc
    :urt rvea un eiect inldbitor asupra coniuglrii bilirubincila nou-r.riscut. Sindrr'
    L l r r,,rr)rr\ :1.-o!r1c ' l r]oc i tc
    l roI
    i,rr s,: m:ri numeste hiper-biiirubinciuic ueonatali tranzitorre. 111Ir ,r'.r ' )rrLr)l rri rroc i ti l
    l -!nr()r-rl i l .l orrrt: I' tr nrri e"
    !
    ' r!ri
    l )i l i rl l f i na, C o()rrrl )' ! .,,.,i . ri ' t' -' ' r fr; |;' orr Ir"i /i r
    1,,
    'rl ,),ri 1 { ' , i riratcrne sr'' s.:!uiriir!fr' /li '
    iil.-'lr.,li
    2.x1.5. sl coAGUtAREA
    si[rlGELE Surilcr-
    """.

    ,,',,',,.,,,, l ,i l i rrt' i :rr:,


    2.',n.5.',1.
    AhlEMlA ' ,. ,r 'ri l i /, (rr
    iilcrocitozi co gc1lit?r'Lil
    Valorrrea h.'r:rogiobinei la nou-nirscut prezint:L modiJiclri fizioiogj'cein eliptocitozar congcLrilal.| -
    irr.liic d.egr""."ro"I" nrS"crc:i,le rirsre gcsia-ti,.i (v.zi nou-n;icurul !or- al ft -tal as emi c , garn' Ftal as c i j rr'
    ':',,rlt.S,.cois:d"ri c; esloi'o"ba d^:incini" cfn,]hernogiobina scado.'uburrnir- .lcficit dc ti!u'/at lrr1]dzil
    C Il l s i l l dr' ofl hc mol i tl ' ]-111-' 1ri !'
    loai-ele r,'alori: 0-48 ore: Hh< 16 s%; 49 ore -7 zile lfb < 14,5 8-o1o;
    dei i c i t rl c G-6Tl l )
    ,lupi nrima c,1D";mjnidc vi.r{i Hta l0 go/o. \'alorile rie mai sus siut i u{ ec l i i , c c { rl heml !Iorl l
    ..1,'tc'niinate din singclc calil,rrral notL-niscuruluimai marc dl 3r sdpti-
    :rini de Aestalic(rt'zi r.rL^lclc2'1,2.8 \,i 2.9,pcg. l53-181). il 1 i ' l r' l
    pentlu (ri . rI " (] i n l f
    -t. b r; a'g n"o s I i c- lnaintc dc adminislrarea unei trans{uzii, | , 1 !tl , ri l D rl ,rl ' ri L' i ri c :rfx l i l rr nr{ l tc . 1 i n a l c (: 1 i r' rl l i l e
    ir rlu Dierde dlasnosticr ciiologic al unei anemii se rror recoltir probe dc r r' ,L, ,ri 1L l ' 1 r;ti :rj trrtl tr|l )l x :i l i '
    ..in,:ciiimolu si u"ecitrai) in scopiil cvidcntierii unor eventua.leboli hemoragicil
    r.,,o-nis".'t,,itri, infc;trii co'gcnitalc, h.cmoglobinopatii, defcctc c:uzirratlctt i l i L Ll f l l ti i I 0i l f(' l !: r' l i 1 rl oL' i r i i) li {
    'l,i l l 1. ,, t l lt ll( i illl( r llii lir r r 'Lr ': i( ' v ()l t c []ol
    ,,riirocitarc ci.c. lir frccventc cazuli, tlupl efcctttarca unci trirus{uzii sau a i l l ,, lll, r r r '.'t i r r r r : if r ''lr ol it t ,ii' t111g,,, rlr' r( li{ rrl.rit(', llrLr' (i'' .,l l :l

    rl(i cxsirnguirotlauslrrzii,11ia51t:ost ir:ul itiologic al rrnci anclnii nLr sc mai ( r , , , t t t lr 'r ,I 'iI iI r t I I it I tt t t i' , 1('rilll)l , t, rt Iilr:iltrLrt' r'
    (l( (llLrclr'lc2.65i;i 2.fi6). t:l |
    l,orlcslrrbiii tl,cii irt p,tio:rd:t iirt(itr
    il llt
    :t,| |
    I , ,l rr.rr ; r '1 allr Lit nht r 'l[ r nanit 5'] o; d) dc- r t r : ar r il) ' 31, Br adit ut 'r lt 't ( : 't t l'
    i (' r,i i rr.): ()r cil) r 'onalinii0, i t r r g ( 0, 2 nl) / dozii i. r '. sau claci cst t ' t t t t t : "t t '
    ,]j" (1i ir trenroragiei
    transplacenrare
    se po;le oirtinr. dl'ottr"t lll'
    ,.,.._,
    ti rn(L1ll]:t.:l*L:^.llr:li:l
    nLnloragra leto_tnatcrrir a fost suficient de mare) pril cre;ter.-a ,ri rt irlilirrr: ,:l) llcf.rtLocuirctt ioLinttlui, sanguirt it't,.-ftrtr'cliedt
    nir.rlu- r i I li, irr cottcor-da-nfiL cu gr-upu1 sanguin, testul Coombs (se va ciLrttlLt<-r1rl<'rtttttrt
    Ji F in,:ingele mamei,pestenivelul nornai de z]; de Ia r..JiJt sanguinir)., clltpir 1r'tIrrtrlr
    ll,i
    { L s trll -i1!,
    Srng er - 195i) . < .L,u{llirlir izoirnunizare prin in-ompatibilitatc
    , ii ri rrrr'r strs; 5) Cortctarit acldo:ri'ri(.\a 1HCO" 4'2t:;' 6 ml/irg i r")
    .. . l.esiyl dc eiulie acidi lilcjhaucr (1957)sc hazeazl pc faprul .;j. erir,ro-
    ci1r')c ietal-e.pii.trunsc'in circ'ra{ia mateini. sir.rt rezistente'ra
    sl)rc..dcosebiredc eritrocitelenratcrnc care apar-(dupi tratare ;i iu-.,..iri,
    "rdaicu'aicali
    SANGUINA
    2 I1.5.3.POtlclrEMlA- SINDROMUIDE HIPERCONCENTRAJIE
    sarr
    acizi) ca nistc',,fantomc". i Lt t ] cr r l''
    l t r' .' it t it i c. ' Sc consir ler iLpolicit em ie la n. n. cir d: - hc"n. r at oct
    d. {ixat cu mct}anol este tratat cu un rampon iaidr 22 sL'lr t r ir r
    ,r.r
    . 1)U
    -__,F1o.ti:l ,-rnge,
    llntp .1, r I 6.; ,,;i c<it icent t - : Lthr ia r n, r gl"bir r ''i Jt pise: lc 3"/ o
    - I ) oziLlil:
    5/, la lt.mpcrrliryad,. 3: C, dupa , at.. csi,. . , torrt. Eri_ ,, ,,, t.' 1,- . s5iI 'alor ileliincllr l, r l, ilcpcnt r nl, r im t sif t ir lisiclcr : illr i.
    llocitclc -J,J
    cc
    rclt cc confin :o"!iT qb A apar dccoior-altl (HL A aLiost clcnatrrataL ;i eluat:Lj,
    Hb F rezistii la liza prin solutia tampon sc coloreazi c1l ' j ,!r ttti t
    Ft
    r:oloran{ii. herroglobinei. Prin aceastii tchnici i,stc p'oiibit .,i si, detecirzr:
    C|tu7flc polioifetDi€i I|r lto{r- i5tlt1
    lr( lrloragii fcto-materne foartc nrici (0,2 ml singcj tlozir car-eestc
    - imuni-
    zrlrtir_jn inconpatibilitatca Rh).
    ttj t) ti ::. ,t,:i a l Lt..rtur:
    '.['cst'l Kleiha'er este rapid ) I r:,rr i , r{ ,a i rr u:nrare:r c ofrl oi l ohi onr} i l i c al
    qi n.rai st nsibil ca tcstu] Singer. r .) c i rrtl c ordorLl i s o f.ns c rz :r i c .l i ai du?i r .r:l !1"i e, 7{ )tr1nl ul :l rr1]'l ' Lr l ' rl
    rnrnr in rlidcnfit si erjtrocitelc cu un continut mic dc Hb F. lient.r cir
    i l c 33, + l nl i k c
    1' ) fi rl rl l i of(i otl ri i c s te P c rl s ]rt 1:r I rl b111c c L!.ri er:P ' l z i c ' r!l rrrrrrrl I I L I
    lltr!-ro.t,t r,11l.;s^ in.ol.(.\1..d":I,rloar,.,r:''pn.,.,-",,
    . ,.ltPr,,ty,l,,,t'ytt,.
    './s/rr lr { r , , I ) lr ( ll. r rd r' .. p u l s \l 2 l ! .s l . \l c 9-l ml l Ls
    5 x u n | " p a l l - rl l l } i l ,l .\ :cazul i , l ,\,' .ci ,r;l i , rrr)rFni l nrtrtoLi i|e rLn l )l an rnni j (,.,i dc c i t nra ra i dedi ' "t rl ti fi rr rrr' I
    .(x r, lr r lr , pJ lom e ;.rtl (, .o p l l In o rl I l r:.r
    P l .i n J r.rn ol l qi c i nttrl rtcti rrt. t.. 1,,,,,,..r.,_ ,) | , ,, .i rz i c l rarc mo_Ic l al :r s au { ei r_{ c tal ?' ir]l c aTui rrc i s erc i rti gc tnc hr' Ll
    "ttt I t.,nuttJ; palo.trc, adrnamrc, iusuficientir cardiach cu bclirto-
    rrr,,grrlir',hipoclomic, microcitozir. ouncori ln caz de - hutoralit, ',t .ul t ti U x ,:t)tt!r.i (.r;:i ' 1.i ,.:d J c l :ti .i c tt:;..Lt,i )
    itttcnta an,-.nnl' atar..:
    ttr,;t"r"cu,scid,r,;r rh.priI . i il lri: r. , rt o i, in , . i , . , . r" ii. i, , ) r,i 'r-r.is .r1 c r di s trol i e i rl l rauf.ri l i i
    l l rl, .rr\
    ri l ,ii',':'
    i. r - r !'
    s o(1^ulul
    1 1 111
    { t-u l rl u ra d ,.
    ;; I \., r .r\rr1 rc ^111ai (1i 11tnal i r:! c n totc mi t (ri t /i i 1i .:l
    l i l .X r).
    ) "\,, -,,.!L IL pos l l l l arur
    lJ. ll' r q I t nt. c it t tt, l. Depindc dc graclul cle ancmic
    .iugcliLr-ii: ;i clc gra.vitatca:
    ) f.i , i l i nrr.ri c i
    - - f oc ul; v e z i p u n c tu l 2 .1 1 .5 .2 . ' :,Li rtz rl i l al i l i r t1:.i ni j rrri |l :| l )l ' (rL I Ir!1 r\ i
    ) I . , ' i ,r/), (i l nr3.1l i tal :rd-" s utrri Lrfi rnl i s i l l dro1nul R .c l i l v i i h, '
    -- -\ncmia modelall f:i.r.iisenrne ciitricc; tr.tnsl,uzia nu c,st.: leoeslrli; , ,, 1,, I L , I ri s orri a 1l
    .. ' . r . . ' lm ir r i. ' r a. F c d u p i r 6 s i p l a rrn i rrj ,1 ,. v i i r!i .
    -. ,\ni mla _latroscni pr-iir r.epctiuri frecr-clte dc probr: rir" sinpe. s{r trr r,rr r lit iilc unui lt or naioclit m ai n: ; r r e de 6. 51l sc. pr or hl( ( ' o ( r ( slr I
    ' .r., iJr.rt.r (nlar_a.lrs.iasugarul c' menbrirni hia)iuir) " ,l .r' .r1 , ilriii viscozit iLt iisanguinc, ur m at iL r lc sca'r t lcr crilig: ir ii ; i ', \ i1ir r r 'r r il
    atunci cinrl ]llb ie_adc
    - lt' th r" , sr Ht cstc mzri mic de J5|i. Administrrrr-ca a 3 nrl cic lrasiL ttii- I rrilor ;i rio tcnclin{iLla mict-olromboze. l-:L lrinrlul 1or hiptrsiir :;i rtr i'lo' '
    irocilali'r (:1" dc singL:integr.ri),lri, crtst,., (D(enrr.ritia cl: Ili., a r:o::ilu_ , r' i r, ozit at ca sanguiniL( t abclul 2. 67) .
    Itri ,tr l. gon. 9-tll J t c [i , i r J ' .l l l , rg o ,,r ..t./m l ) ,l :r u.l r(r , opi ],rl I l ,,g1 _ n;1 ' , t t:t lt I p u'tu, I o I o g i L: c lir t zlcr i. l{ajor it alt r iL cazlt r ilot 'sit t { r r 'r it t
    trirsi-! ('r-ltroci:ririrneces;lrii. S. r'or allnrini:tra r, deri ' t, rl i rr' . in f unclic t lt : t elit or iul af ect at dc hipoxit - 'si lr ont bozt : lc s1r lllr ( r lr lr
    r0 n.ri :nisi, eri-
    r',,it ; r r ll: : dJ C i i tn ,rc \Oi , .. 1 .fl t-,fn i . r ,:l n.{uzi r.
    'r-ai lr ' i .' r,zi l. iit ii sanguinc, sc pot ir . r t ilni lLt m it oar elo sct nnc cliLt it : c: r lr : 1t , r ',
    ' r rlor ir', itrsnficit:utiL carrli:rciLcougcstivii, cianoziL lrtitt nt:srtl:ttrlttllt t rrtrr
    2.1',t.5.2. 1,1 r i rtr r r oglobinci, scm ne t 1e suf or int iL t lin par t ca S. N. C. ( cor lvr llsii, l''
    tOCUt HIPOVOLEMTC J lr l
    r, ri :rl ir it al) ilit at c) , t r om boz; r vt : uei Lcur lc, lt ipo. i- lir : r r r lic, ir 'llt 1, 1
    Dt i
    , Lri. r'r'('s{rllir (lc bilirulriniL sccLrndaliLhemolizci (pcricol (l() i(r{r'r Irrl( li 1r)
    oI c t i a .. h c mo l a g i a a c u ti i n p rr i oacl a peri natal l .
    .11,' ,/ i. lir r ir i 'lt t r t t : l, i r . rr icc. ' liiper bilir Lr bincm ic, hipolr t lr lt t t r ' ,
    rr--r Ilimora$a,la not-niscut estc rotdc:runa o i,:r;entri i S": l i rl l r,,,rrLr r ',t r - or nlxr r il: opt :I r ic, lLcir loziL, hipoxic.
    .......,_!^_1:prtn
    nrrl)llcsti 1, paloarc,
    laLipnce, cia1lozil, re,rpiralie ner.eguiaiii atickziu l t ,t / i Dt ,r 'l/ / / r / cor lst ir it 't ; t : <lnbir t cr ct ( 1t r in llr i: t odr : lllr sl) r i(ilir , )
    Irir'lrrboJir:iL,lrradicardir:, sarr iahicarclie, p\iC scizuti inifiaf '1'r ir t . 'r t nt : t t l.spr
    t t l r lilt r
    pri:r'"."tir,l;- l rrl l i r, rrrili, I r i1r or : r t L'r 'lt ioi ; i it l lr ipr , r 'bilir t Llr incr nici. ""
    zrrlcrr,.circulalitrianimia poalc Ii putin importantir, dar- glr r t or lr l, lr L lt lt lt I t : t I r r It t I
    |I
    devinc eljci,nlii uitt,- 1,, rrrtrrl r t lt r r t ii cit t r i sir t r lt ir r t ur r l"t t lir t icr :lpllt - ( in
    u o r'.-
    - \ r ' r l m onilori z a : H b , IJ t, l ' .,\ , p VC , ri iuml rl spi tator, ri rnrri < .nr,l i :rt., ,1, r)' ' i ,) \{isl if lr lr luonI cot t si. ii.it t cf ( xr l. lliLr oltt.t t r , 'i cxlt lt gt r it t olt lt t t slt t zil
    ,l5lIlll).
    ( sr r ll ( it l iillr t t lt t it t i Lll) liLl) iii , , .
    ' rr i .r ,rrr,,lr lr r r r r ill) iii( r ll ir r : r 'Lr yiSlll) lt t t . l) . ) ,
    .,-t , , ^l t t nt t l. l : l ) r)" ; 3 ) i rtl u ,tri ri t. i o l rtttnt/tri stn{ ,unt: i r:,1,:1t17:i rl .(,i r ,,,.rrl .r I r i lr ir linlr . ! li lllt 'r ll r t slir lLt t I t r I t t I I t I I r ct iir r I lr 00", , .
    I tl rrrr, r ,:Dr L\ n r| l rl r: ;, rrrrl ' ir.l n l i i i rl i rl r.2 0 rrr] rl i n (i n ot.< l i rtr,;r tr.r.i trl ,,i );
    1r:r
    ( ,,ri l r.r' i i . (), l i l r rr,l rl rrl i r ,,n,i .y,,' ,,,),,1,,
    .) si ttg. is r r ir ' , . r s , rrl i ,, ;,f,,.,:! ,\i ;,\i ; il l'l
    :l tr;
    ' 2.11.5.4.1.Cocguloporiicongonhole
    Ciintitatca de plasrni ln ml Jolositi : I'll ::'l'1,!ll-l l5! ':1'"LI111'-'$)
    llt actual
    Voltmul sallguin aJ nou-niscutului este d.e85 - 100 ml/kg.
    Nonnalizarea hematocritului si a viscozititii salguine determini re. ,,,.,,,1*{,'"'#'.:l;::?fl:1T:#\:'l;:x'i}xf!!l!1;?
    5'lcsiuneasimptomelor intr-un i:rterval de la 8 oi.e la i zile. Administrar.ea
    i,r lfil:
    <lelichide perfuzate nu are nici un efect, atit clinic, cir si asupra viscozitl.,
    lll sangulne.
    "-,"1**;'*[*ru;':'ll:'r:*.::*:;:"'Hfi'J;,:Tffi'3
    i,, i,i',r'i"titi"i"t;"*usculaie (exceplional (tabeiul
    hemartrozd) 2'69)
    Tabelul .1.6iJ
    2.1r.5.4. .E DE COAGUTARE
    TU!.BURAR tt BOUTE
    HEMORAGI€E
    Cclattllopatrii congenitde
    Diferite. tipuri de hemoragii apar la n. r. cu o frecvenfd de 3_o/o; dintre
    rr(fstea 1,13sint determinate de tulburiri de coagulare. Unii lactori ai coa. ::|);-!i tul t [ccsitue
    tullrii sint prezenti tn cantitate suficientS.lu singele cordonului ombilical I l i rnoti l i l l , ,\
    ,'ird alfii, sint deficitari,(tabeiul 2.11,pag. 185).- I l , |l rol i l i a ]]
    fii evaluarea lnei h'ernoragiila n.i.i".,n iir.r"."r-u de urmitorii factor! .l ut'so% tr a oni tgti e
    ;rrtcccdenfi p.tdigrce-ul tendinla la. slngerare, defecte ereditarol
    ^familial l )r'l i ( i t tl e f ac tor X I
    r:unoscute,boli materne in timpul-sau
    sarcinii, administrirea de droguri la t l, )rrli! v(tl \{illebrard
    sirLl.n.11.;i daci" acesta a pdmit vit. K dupi- na;tere. Din punct de
    .l uk)sotn(tlr.atsite
    rlinic se pot intllni urmitoarele 3 aspecte:a)- N. n. cu stare ginerali proastXl
    ;rciclozir,hipoxie, hipotermie, septicemie: probabil CDI: b) li. n. cu o-afectarc |)i l i .i h (l c I ' r' ottonrbi ri
    l t( l i Li t ([i itrc tol i Y (prox c c el eri ri l
    lx.lnticiL : hepatomegalie,transaminaze cresiute, bilirubina. directi crescuti. : l)r'ticilr (l(i :[!ctor VlI (proconYe! rri.l
    ,lrlicit,ric factori de.coagulare;c) N, n. cu stare general5. buni: deficit dO |)r'l i , i | (1.)Irotor X
    lit. li, coagulopatii congenitale, trombocitopJnie sau l r'l i ci t (l c i otor X II
    (talxlui 2,6li). l ), l i ( i t dc l i rc i or X III
    \ llhfitroli(xr( ia, co genitalS,

    -at,"tut i- I
    Dircaostic{l dilcrentialnl sln$erlhiila nou-nlserf ldup; Glader) 2 11,54.2.Coogulopdliidqbin'lile

    Sen1rte de lftborator Sr'i"rrltrtcrt.potentialului de coaguiare a siugelui se poate datori t trtt:i


    "4sD0ct clinic Diagaosticul probabil dp cuagr l] ar e - : lu r lr lul 6onsunrcrcscnr rrl
    'Trombocite l ttrttl ttrtri i nsl lf i; icnle a f acior jlor
    i r r,rl ,rr:r (fi g. 2. 32) .
    I T
    1 N N conM de trombocite ii!{ec!i€, eor, frodu:e,'e i 7i.t'4cie,'t;
    terocoliti necrotic6, trcr"rbozS v€qt,

    N T boa$, hepaticil.
    N patologie rascularS, - -i tl ' - - \')/-
    -;;,L, hn,"i/d
    alatldtate, acidozS,
    tate) ..:':'-''-''''
    , , r\ rf , c ct s : i I r r t c . " tronrbocitopenie imuna,
    \-''- -'
    subclinice, tromboze, hipoplazie !n!
    ddare {rare) (;O//JU//a
    1rc.\JY/t
    'li .i
    N boala hemotagicE a tor-nZrsoutulul, (rtt' tl ttt
    ( Jicit de vit. K) .r t,', .l rrnn fi ,i rri l tl l { c tofi i or d{ j c (agnl are pri n deJ i c i l (l r: l toduc el e s ar l ti rr
    ti 1 delicit coagenital de iactori at
    coagulidi
    N NN slngemrea este detemlitatli de I
    tori locali (baumatisrno, om
    anato{ice), aromalii calitative olg
    trombocitelor (rar6), (lelioit ilc llactq
    XIII (rar)
    l"l-.IillrD (le p rr t on' biui
    l"l :l','-1il|rt) |0r1 i l (lo I r(,nrl,r)plrlstj'rf,

    340 ,t 1!J
    '1 , , , r l r ' 1 '1 1 ;1 1 1 1 i 1l i1 ;ri tt str r r r '1 .n r .rJr i . r n l r r l u i 1 .l o l i p L p i i d i r : a l p r ','i tr o r r r l i n , i ,.:i ,
    , t , r r {r . r r t r r,'i j l l r l ) i "i r i i cr - 1 r 'ti n i r Lr:l i r :;tr l r o - r i li cc ( C OO e ( X) ) a a r :i r l L r l r r i i tl r r i , i r i ,
    ', r r l r r l o r r r l r n ci cr l l xt- r i l a zc, f.i ti u n j tr a Ii tr i r n sfo r tn i L g r u l l i l i ;l 1 ,.tr l r r l .
    I t rrrrl i'rr :rr:icl glrl a-cltrboriisl 111ta rt-rjc.

    z- - CIl, r"- CH"

    ':" 1 'tt" TI"l - (H,


    '
    .i,. ( oorr 'y.*lit
    ''''rrlro:{ilarr'! t'li];i,l]lii''

    1T
    -J TO(l C C O( r !:X -

    ( )lrit:r. ai t.

    \1,,ri( ir r r ^r rir f l, st lf l a. ? sar cini elcct r o- negat ivc pcn) lit {) l, i, , t r ) nr , r r r I


    I , ,.rlr ir r l, r 'r l. o ilr 'c o dir - al"l{ii dcct r opozit i! 'ir . liir i: r r ca r lc r 'r 1,ir r 1, r r r , ,
    t l l ,l , l rr {) lr or r r lr ir ] ii.
    P|r r t r it c acest ciasiLSclcgo de f osiolipiclr : l:, t r ' : l, . r , r . |lr
    , I tl , | .' lil r r r r il, ir r cir lilcut odlr {; t ct or 'lt l\ ( St uar t ) , 1r i: lim ; lliir llr r ir or r lir r . ,
    It,r | ' roIr'ir r lI , . r r riir ': r lc t ll: r , it ir nt ina J{ ( cali: ast iill 1( 'aliicalcir r l) : ini l) r , 1, r r ,
    ,rl ' ,' rl .rl , : , , i 1, r 'o1r r ir r clr
    inir ct ivilt lr ( bir nogic) sint cunoscut l) 1; 1 111 , ; '1 , , , . , 1
    ,,' t' ,,r l r r r czur r Lir tvit am ina I i cst c co{: r ct or ul car lr or jliir ij I r r r r r ir r r , llr , 1,

    l rr l rl'r . ; rvilr r r r r it r ciI i, pr r r t lonbiDa . s[ o biologic ilr t ( ] iivi, : r , liL. ir r r r I , , , r i .


    t, , rl r rrr l ( r 'r lr ' o ( l( [ iu l) o, \ ilt tot r om I r inl'i) . Sc ] r r , : sunr t r ir r t olr r lii . ; il l. r ,
    ,
    " rrrr .r, l r viir r ir '; r ( l( . lir t lloasil: L Jact or ilor YI I , JX; i X, r : ir r r , : r r r lr , ur , , r l
    1' r' ,l r.rrrl rir r ;(r1ir (l{) rlll I l) , sint vit ; ulino I i- clcpL: nclr r t f i,
    It' i r,r{r r l ir r lillulr ir r a f i lr r ; r or r - r : lisr : utcst ( j collr ovcr sit l. I r r ii r r . r r , . i r
    I 1, ,r '":.r,il igonr plot lonr lr ir ir : ( r , r 'i, l,rr! ir r| ; , r r l
    ? ;. i; at llilt - 11 ! u. i bot i, i. i!r J n o r t l liL:a u 1!t)It_it,1 sr , ' ,r .r, it r '; r r r r lr r tlllll iuirroc nivcJr il r I : ;ant
    l nl ini ur tig0t
    t tLi it,i . P;,tfiltrclzo.Se v;r administraI,iL. Ii, (plii-tomcnadion) t rne intr.ir. ,,,,r,, i , r r r lir r ir r r r tr rt oloqir
    r olo|ir::tr::)si ) r ir r ir. r. rhr
    lr rl act
    r r cliviii
    ivit iL! ii 1u- ot r r nrrl irr icr ' ' r . r , r r l, r l,
    ro{i rrr'rr-li.eulii prcmattri saLil;L iei ilirr rnamc nt,,,r1 , r ' I1, , inilr cir r r llt ur lnj ll1j li\ - ( 1 t lr tr pr ot lonr lr ilr il] ri i ( in silg,
    si|g, ) " , rr,,r rIIor rI rrrIrrIrr r r
    lli:ifll.l,,f car-c ar,iprinrit ' ,t,,,' 1( , ,
    .lrt '--Jh!,'.r
    N'n.rri (-\clmiLri-tr.rrea.r,it.li_ma'r.i ru arc cfcct prolilaciic icntrI rr Irl r, r' rrrl ) r rr' r|l
    r , )rr'
    pllzinli.
    l .1|t,L 5(.rrr'
    ) \ lu
    ,l j {rilil
    1rL t} nir i r(rut ( lc lli:
    't r iul uLr ar0t1i
    i a :l lr rt.lt . i,\(-(i
    \ ccsl , r ) i," I|, I, II
    )t t ;; r r '::..r)i
    s t ll;;tlt l)
    lori'iisrutr. l).ci r i .r ,rlr 1r , r ir lc vit ; r lt ir r i. 1; rnor r niscr r t si unji lr r r L<t lilr u( '{) lt Llt ; srllilr 'r , lr r , ,
    nl c.1erlimLniar |rr..rcr-11 siu ttaci. a prinif , , 'l 'r r I r r r r ,r r ( ) l l :r l i tl i i fsIr tl a tt:,r i ti i tu i l i ( l ( j g r a l ) i r r - l tl l l i ( i ( l fi ( .i i r l ":i r r l r ,,,r
    'cr'-'irscut
    rin i.iatarnilrt proll'lgit c11arltiliotir., s. .-i, a,hirirri:ir-ar.it Iir_0,5'iglsiip" .r
    tilrilir irrtian-rusr:ul;rl. '' I r , r 1 l ) r u l r o r r r l r i r r ;L )r Jr :ci t r r n r r i r l tl i ci t d c a r :1 i t'l r - i ' l r l i p l i n l i i ;l r r r i r r .r lr
    l ' , r, rrl, , lilir ijr ', ir r sii, it . {'st 1a. l) o'i:st : lL<kt Li 0 75. l) r 'r . i, o|ir , , , , lr li|r r lt ,
    .itt.,-,r,rr.r.,,s1, t'.r.erfti sc adrninistrcazi vit. Ii in clozirckr Z _ j mfl
    , " l::,, I t i rr,.rl . r l1. r
    .rr' ,
    r
    r' 'sij
    'rsii
    l '
    .i r il)
    ;
    i 11y;
    rl ilii
    )i l i i r 1;
    r i
    r r r r
    (l
    , llf
    l, i<
    r' 'I
    11(' l t.i1.
    i1.
    i<: in vit
    \.i I.-
    . li. I u tIIl
    iu I ir ('t rc, ', 1|t('
    r lr r r;t';
    'i -ssiut
    sinlr
    L |z 'zit
    lzir
    it tr ,' lrl lrj)
    rlt)l) r(llolr
    'olr
    - .,ri evit.r Jdmir strarca intr-amusculali). Dacii singcr-area estiL
    l l l t ]l l l \, u1
    ;rltr,\'eiroi ',||,r
    l l rrrri l ;ri ri I:r u()l t-ni i s (11,(:1ti l ti i . l l l i l i l oc (s ;u r' .,i c s i i rs i grrl i Lrrr' .r( tt\.rrl
    : \'. i .- . ; rtl mi rri .rr.r..i n q o p ro i r.p ,tr, in Joz; d.. l 0 rnl I;g, l a ul ) i orr" i .\i rl yi t- Ii . C i r r cttL r i cl r tl i vi
    , tc I- or.., pirrr 1ar.ortrolul ac,.:tcja.protrombila sc norrnaliz6aiir in lZ _ r t r r , r r l r . r , r ,.l r i l ) r ( ) t( 'i n ( 'l r ti r r i r r o l .l i i :( u tl l r r r l l
    24 ott: r r 'r L 1 , ,r l \ r u r ,r r ', l tsi l r l r u , r l r :n to r r sl l i r i i ;i n r r n i r i <l o zi i i l t'sr r r r l i L r i l , r r l 1 ,,l ,, ,
    s1 srrgerarle se opfti;tc l,:. 6 * tr2 ore dupi trnt.rucntul crr vit. Ii. Eristi,l r l , | | i ', r ,l ,r l l i ( i r i r r '( i l sl i Pto l r l |n ti i . l ) o r L ( :( '( :rr , t,cr i r l r tt,l i rrr i I l l i : r I:,It . r ,
    Lureil prosr s, 1ll cLrnoa\ter-ri mecanismului (lc cliun€ .t. z)itdnxi ei K, \ritamin;r ' '
    1 , , , i r , . r r J, r r l 1 ,, l ;t n o r r - tti .r 1 :l ) i r S,r l : i ,r * , 1 :L I , |l r ' ri i r , ] ' r I 'r i
    rol capital rl} co_aguiarc. ln acti\'area corDplcxului pr.o-
    :) Si , ,l ' .r, lr r r r t r i: , lr r r r ) r r lii ( '\ L r r lr t r r ir i - \ r r r tr - iclr r r iLj, . I 'r : <I iI r I r ilr .
    J u,]:,1:_1 l: ; r .,,;,
    ' . 1j: p r^ z ,n f s ,' :L i . r.i r,rc o i r)fl_anume u^I]l .i i mpr,rral l ti , i rr gnrrcr.rl ,3sq1p1. 1
    ',
    L|r r l , nr i : - r rrn i r d ' .^ p r1 r1i n , c 6 c [i 1 n ;1 7 ,icl rl ci rrl . \ i i :rnri rra K l l l Io: r lluhr pr lir pliu ( l( 'li( , il r l'pnxll( {'r 'r 'r r ir r r . loliLr l r . o: lt r r r lar ii.\ , t
    t, sl i ,t,ttl c,ts,i
    \|tt::,t lltrtlht)tt I.r. L. (tu\-.tdi"este invocat faptul ciu acltninistrzrrca I rri r , r t r I int ilr t r ': - li.il] r lr clilllli lr cDr r lir| . ' \ "lr ', lr ( 'l) r 1r ) |l(r 'ir ll. r lir r , l,
    dc factor.i ,,,,
    irLltirita-rriu:i li nu.irni)ir:c1iciapar:itia ln ilcat ir ', r 'r r / :r r r r l r . t rr t t , I i t ri r' i t t i ] i i rI i t tsr ,1 i 1;r 1 xr i r l l i , l , r , i l r r i i r n u r ; ;., r r r ',r r r l "
    pr:oteinc cc lr.sotLi trrL1.
    ..,1r'rr,;rrLrI ;11,:.l)r{,Lro'll)irnrij r!c'.star 'rcipr;tcinir pr.otio r'l ri, ii;;-i t, i l , r 'l r r r r r r l r r r r r o r ,r l i i , l i r ,r r r '|r l i zr tt ( i ||1 |l l l i r ,|]IIr ) ( |, l r l ti r l i |l t1 r l l t L \ L t \ | l\
    rJ , ' / ri, ^.,Lt1ig,,rrit.t:
    |] r sl f,' l i .l 0 ,i l \.l z ri r)r c r: l )l l n l c S C;Ltl ti _r,i tami n0 I t r r , l , 1 , l . r l t l ttr Il n l ;ti 'l :r i l r ti r r ,r JI l r r r 'l o t i ) .
    ' Lf t Ii . I)cci , r,i ti rrni rl i r Ii
    a t t lt , t t li t ) , , it , l ;i 1 1 1 i1 1 v ,i s l , s i trl tl i :r/ri i trth k ttl t:( r| -' l rr.Ii rrrrorr
    srr. l \lorj i l i t:l rr.orr u l i tl .l ,l ;t'tr ,. r j r i .i n j f( l r o i :1 ,,r 1 i r r , r r r l i l r r l r ,J, L ) r l i Ii .
    " , , i 't j t
    lll r { ) ti i r l
    . -[r {iruurdoulltiit dc consunt. -{ceasii tLtll,ttlirlt cltl coagulalc l;olrltr ii ( /////, lr l, r ll) r xil{r it t t t ir t sc t t t r t t t if t r sii-lllr t t t lt L- t lii-rrttl ir rilt pt t r : sii, lt t r t - Pr t t 't
    , :rrri.r - o"i1'liciolilorobstctricale(dezlipirL:rlc plxrcutir, geam;1rlrort iil ,,rr,r.rIi zrI,1r ';rlr ^ poat r :zipalt in : t : iclt lr i st lccesivciu pr inr i'lt ' ziL' clt rvil! it Alr t t l' t
    '
    rr; ,-:r-atinttauierinj, in{ectiilor, acidizei, hiporiei, socul aeonatal sau tttttti .r' r,l rtLrtrL it t t llt ot t t l, c- , ciiclorst : ir <li:slr ll 30000m m j poat ' ilPalo sit t lit t lt t i. I
    lr,,ru:rgiomgigant. 1l rl ,,l rrl 2.70) .
    t1 s!c-ctrti clittic. Boala se poate mallilestasub forma siugL' ' .r' rl l sr r iLr r it i yr cnt it i- r t i m ai f r cc\ 'out e:
    r rrlrlor generalizate (CDi), sau unor troint:oze localizate (tromboza vcrtci
    r1.1rrle,;indrorlrulheiroliiic urernic, enteriti recrotici). La sennele clil)i('' \ I' tr 'nr L o t : i I ' o t ' e n,i, t t a<ociat i t : lt t : o! llt r t 't t t 1: t t t i
    rrl, boiii cleclanlatoar e (inlectie, asfirie, socl, se aclaugi petesii, echimoz", ' I t l tr //r i'r ; I 's{( )sim ilir ii cu r necanism ul lespon- sabil pr 'lit t u iz'r it t r ur iz t r t r '''
    r' ,lr'arc si olisurie. l i l , I r,i nl r r ir ir r 'r 'L lp; uc cincl t ipul ir nm bociiar al r 'n t lil': lit llt : it t ; r r lr rlr l
    l ; tt o ut t u f. i't lilg.i cornbatercr. Lolii cleclansatoare se {acc tratlr ,,r,rr' ,rr,i , - ir t r l r Lt t n'r r t nir sem nif icat iv de t t om bot 'it , : t r - . . i) r in placr r uli. r lir r
    nrrntrrl soeci{ic,dr: inlocnirc a Jactorik,t-cc'lt:umati, care collstl in ad5'ugallrr ' ,' ,,,1.,1i ; l i l: r li. iu cir culalia m at er nir . Ant icor pii ant ir r om lD( r it ar i l. nll . 11
    ,l, plrsrn'i p'.o.rspiLti, '"1loLi de 10 - 15 mlll;g la intcrval de 8 - 12 orc sirtt ,1,rrr,,n,l rrr{il) f i1r r r ) }I nicadc- I ixar e a cot lplcm ent nlui sali pr in t chnit : a t lr I lr
    , .. rnt ui.ro'trars'Iuz i . Adrninistral:eaaccstor f;ictori nu agraveazi CDI-tl, rlrt l ,,r,r, ,r 1;11 i1vlql1t r i. 3plachct ar . Pet cgiilc apar la scur i t inir t lupi t t r t lit t . '
    tl, r-rlacr-r:riideclalsatot'i persisti, acc:r 'l':atamtlllt va produce numili o anll rr
    ' l rrr.r
    o:ir r ; r : r ir Lt , rul r r r r m ir r nor m ai sau cr cscut dc ilt sacar iot : it L'. llo; r lr r
    li,' ,rre'cliricir tranzitoric. , l , ,rrrIuIi rr r iI r r I l-: LnuiniLlLr lt r onbocit clol cr e; t c sPont l|n ilr llllct lr s r lr ' 2 : "r 1t
    ,1ti;titz istrat'eainp ar'inei la lrou-nirscrrl cstc tlisputati, .risunsul la tlrr i ,,,,rr. I rr r ir t , I , 'r '; t tI'Lcor nplct : tpinir ia 4 6 sipt iit nini.
    ii,rrierlii si tlozare:Le.i Jiinti ereu de coirtrolat' Frccvent, administrarca de lrl li rtlor i, .rplu )LttroriLgii sevcrc (intracranicirc).
    ,. 'l: ''t: eoa.c inllrr'.'i,r ivoluti:r CLll Ir :.o,,-ti.cut :' t t t u, 1, ", . ': ',
    ' -J"odrc'c.P":occsul l i I r l lt / , r ' i i I c.'ft unia Lr it a. iot t i ! 1! l't t r f
    11,.,lans, z : Lrint, dL -t,,rctcr,
    . j'. x i11i'r1:::r,2;1 ttur:rli
    lrcp'..,r'itr.L irr forut"l' \ r t l. l i ( ll l'll
    ' ,' ,,/,, 'it i( ; t , at ioi o nt t t t t t el. Cind ulilina
    l ,, t r ir , i
    ,l,,CDi in care plcdomi:ri trorrbozck:. I)cza ir.rifialircste-dc 50 ^uflig' i' v, rl l ' l )l )r)i rl( , \ isiiiuut iansf er pasir - cleant icor pi<1cl: im ilur iLlat r 't t , lr vit ll
    rrrrratij.rjr aclmiiristrare:L in perfuziein dozl de 350 mglkg/zi. se la rnotri' lt . n. Evaluar ea num iir uiui llonr bt x: it t 'lo' t r t r t lr 't t r ''
    1r,rizl rilrt:11 dc trombi:iii, care se va rxentinDlt1ue 50 - 60 scc. ' , ,rl i ,ri lr or r lr r xilc. r l>cnia
    ,
    , I' rrl l ti rrl : r l: r or it l t i. n. cu t lom locit opcnic. I 'cr sist r r n{r illt t icor l) il( t l it r I ll
    Lrl ,l rr rror rir r . . r 'r r lr r JLr csti c t cm por ar il, t lr nat i! dc t 'ilt ilt t : lt t illl sl) olllr r llir '
    ?.1I .5.4.3.'Irombo.iloperi! I lt , |t h, , t it ohanict t r : ngen, 'it t t l ti i{i) 1 )tt)
    / I r . \ l, , , , r r lt rcongcnit ali: r m ogacar - iocit clof ilslt ir . r o{'iat i. cll''A( ^t t ( ) (r l, l
    llollll)
    l-ic:,itr.iL trombocitelol suL | 00 0UU, illL.j s: consitlerl tronrbocitoperrir'
    1 ' rrL,, r,rrtir ', s, r t ', r ii. r iir act ar iL la t r a1am cr r t ,c* dt lllut in p. r 'ir lir t lltt t . t t t t : t I r I r
    i' lilii nriltc cazuri clc trombocitopenii: la nou-niscut siint de ctiologi"
    (-1,
    , ' .,,, r,r/.r lr . , \ , 't ) 1 ( : il ait c anom alii congclit alc ( lr lr s. 't r t ar lLdit t sr t lr r i) ll'r 't l't
    inl,.r;1jo::-:nunoio3iirir.irr iipsa unoi i,:st.' 'it ruiini pcntlu. e-videnlier'(:t olr ir r t r ilr r l'pilr t l
    , i ,,,,r:i i ,l ,r ir l r 1'clr it . r t l, . r Lrsinclr iul om ului li'anconi ( cc ap: r 'r 'i't Lt
    u,,,n,:ii ir.,.',nologiiea ti'c'rbipcniei, ioart. Lbs.tlrr se poatc siai;ili diagnosticrrl
    r" ,r or,| l r' ) . ll: r 1. t t r r |t t {ul lt oat l: si"rnu . lie necesir r ; it r t : lr zt t r i s( \ ( 'l( f r 'lx) r lr '
    cl: ,lr_ r,.j::- : ^ -t, i. . .
    l r' , r' Ii i r.I|) r iI t I r ) I I ( ! 1 sllu f ilr 'aL cor t icoizi l) r ognost icul t : t t r Lt r zt t vit l
    Tattetrti 2.74
    It l i t , )I h o r i t o f t L' t t ,i t t asot iqld t lt l'at lt i h'r t t t
    ( r oll) lr "
    lil'ir {l(
    llixlD$!tjrul dittrctlinl .I lloDt}ociloilcri:iti lrt r1o[-*iricut (drrpiL Os]<i] !t 11, ' t D t t t t I 4li ir act : st caz t r om bocit opcn i: " ost t ) o r
    ,,rtr,,l rLrrril'r , , is{. \ 1l1' ii Poir t t r r t lr r , zt nt : t I i| un ll'll( r lllr 'n '1| l'l I
    'j-ra LLo.ite - c( usllm l) ll( r
    'ni;!tn.
    I
    ,1" ,,, l r' ', ; , r "lr r , li, : "r zr t ii a. ur i; r l' , r r o I 'or ll lr 'I r t ir 'i
    ___l I l ;t 'r t r i, t , Lilr t f t t : uit t 11( ot Lllclt i t 't t ttt
    v 't sr t t t t t lt i
    , / / / (;r r lr r r ir t l ct t r Lr lr r Lr r r ct ii ct : sc dczvolt i it r t Llcr l' Vr r gr t tr r lir r lilr 'lr '
    iult
    '
    lr i :r rir.?fl i',,:.j ,,,r ,.' ,,,i t , r , i ir t t ; Llt t r tli slt cnolncgxliit c iic obict r i pr "z. 'nl; - i'
    ,l ,1,.D ,l
    tttl cL t si tt'l r o ttt't'r tl I
    I l t o i tt ,' i , , r ! tt l t t tt, i tt ttsctc
    .i3:.cctuL cIiYi.a Ql' t'-. lt- !,i st:''i:!!:1!i , t tl,t), ) l ! ) tL i , tt s t: tt,/, a r r i , ca tl c ( r \,r l l l l ) l l r : r t) si tttl to ttt 'l '
    I ttt'r r t
    ,,,r1 r r i rt t l r , rr , r:r l l Ll l t t r i r l i sctr ti u l r ti L ; b ) tr o r n b o zl - L L tr r :r l l i zl L l l ii 1 1 1 ;l r l l l
    'l l 'l r scl tl L o r l r l r i l i r r r [ ; ' 1
    a'amdl i i congerri l al ( t
    r , 't 1 , . , , , r r .r l .r ,i r ', r ;r l r ti r l r - r )scl cr ttr r l l l t'l 'r ca tr :ttl ti zi l ti i
    h cp a ir tsfit:n a ;n 4ti i t ( I I II
    ' , l' " r " t r r r r ' r , , I r , ' rrr I r ,,,, r l i l tt,t, , l tsttti l ti tr i ttl cstl t i :tt si tr tl t- o ttr ttL( l ( r r l ( r tr ( 'si t I ' ! II )i | ; I I '
    - l ) u f p u i ; j z r , i n r L !r r ., in1001ij h.nlangior't1 iiiiiirrrl
    'l ) r , , r , , . , ,1 , r 'r r i r r t ( ( \( l l l l ) l l l , ( 'l r 1 (r o ( x) l i l i l l l t\'l o zi r l ) ti ) .
    r hi:rzidi., ioll:rLi.l!ni l.:r, ( s( ' J) iic/,r t;c i) :r ci .i i anl , rubeolir
    , l d c l r ; r r u c g e tclica t siliL is ( !) r r ( ( :Ir tiu, aplnzie rildi..lir, 'i r t i ! st) ti tl ti 111 /t t Jtl tt ]t 1' 1 tt tl ltt t
    I( ,r t) Qf ( i( r r llllr ' t:nI l ri so i r D . l i ',i i 0 f,tr r
    ,r tloirlx,irclici , , Ir ( sIIi l If i L l r {) r l l l x) ( i 1 ( l r }l i l l l l l l l l r ) ,r i ', r r t tr r r r l i tl l r i r l r l r '!r ,
    - i u r ) 1 ) i i ; r i r l r r r l i .i. o il ( ' lr L Sr r L 0 vir :0i :,i ,
    r r l!",iii, 1 7 ) r r ) i )l 15rl r')i r,i l r rr r l .i o r r r l Llttr l i l r i l x r |l , r zi l r r L r r ',Ir tcr tti oirl l !, t l tr
    ,.or.,t,;rii:rti.!
    . l J l r ! j r ,1 'r i r rr ' rr r ' r r r l,,rr1 r ' rr ii,. L r :t, rri j rl :! t,',r ..\' , l , , . l rl ,' ' , , l , rr ,' l r l " l r r "r " It .r .o r i :r l tr I r L { l }l
    l t,tr l tt'r ( ;r I l r r l i r t|r I|r r i |I||t|{) | l ) ') l r l '' l l i r r ,l i l r l i r tr r cr r tr

    : i)' :i l ,:i
    l;jrli*"
    ilirll,:iir
    ;l;ir.i:I,
    ij:ljx..i;lir,i,r*,,,i*',,:jr::'ii::1,,:j"'; ' ,l ,
    l l r' /r 'r r r r r , r lr r t t scr i. it I r r t lct iiior :r ot llll, s, i) i1) ci: r zii
    rl r' ,r r , ) lir t . r 1i t ir zcclt iliblLr 'lLith'r x'lr :tc|oli t ir . : ; i r r : i, 1ol- , , 1; r it
    ,.' r,l .r I.r r r . r l. : I . i r '; r t : r ct't iu , 't i 1, : i't :
    r ) li; ( lr ir ': ; t t t r r t r t r t t ,
    i. : 11
    lt :Lsr
    . llir : ir . r r lr

    2.1i.5.d.4. Tr"ombocirop*iile rli, rr ,:,, i-r illllig/zi


    : ljlt oinii> 40 l gi/ 100 r r l
    'ir .
    r ', r '. r iir r inlr r iLr- '- i, li m g/ 100 t nl

    t?.*st"""#i#'
    l ii'r'rh'"#;t'tffi
    Numirul
    $i+sjl""tTfi
    t relrihocitclor
    '',
    1,'rtrt rli rlitosticul tlc:insuficicnf:1r|1lil,li-rdilcir il
    l. tttL utitlt:;rzii tlttlr''
    1,,t,,' ,,,l , , lr r it sf , 'r c- sr , . udacioligoanuliaap; r r oiniir nl, r r lt lll. iolulcint : ot t r r lr r l'
    I t , t , , ! r , ", , , . iii, \ ili: ct iologic pr cr cr r alir r : st ir pur ir - r ncliot r ali t r r . t r '
    ^ rl i .rl lr iu, 'r , r t zir 'i r ixr ale; ea sc poat c r r . lt nl: clilr
    ,i in: et lir r tpr iLr iur 'br ut iilr i! it lr r
    ,' 1,, Lrrl rr, ir , , r I r : t . . I n r : ondil- ii1c in cale llipopclf r t zi: r l': ir di sl llt llt t t t lir '; l' '

    -,,a##r*-*j*;ir;*###ill,'ifi*il$,J,
    sIrl cll''
    t.r rl).rr'r l' zirrti olganicc. Cirttzclc reulilc'uai 1rr:cr"':rltintilnitc
    i) lr at J nr ' r :r1 ,,,,l i ,,r r,r, r it , , lL[ r : r dr Lr lt not sinclr oaDr ollaicolt ] llcxl. il r zdt lir osl: t llt t it l''r '
    i ,n l i i p ri rrr" r.,,,,i .c l rn " ,,r.o.' ,..
    ,1,r,' r, 1 r "l r LiLiit lxl'l- '111 unol' r nalf onnaf ii obsLluciivc liLi: r lc; r llt t r t t lt t i t t t ir r 'r r
    ,,T",1
    ;,i,l",J,iliili,i",i;"?l',11''li,i,;',
    ir:il:;l:-i;,1;",- .:ili
    ,:'",,1;:i,ii
    'I'
    .l
    rr.rril, rl.l rn:ri r-:rr in pt:rioatla c1cnou-ni.sctt iirllr:lclc 272 ;i 2- /l)
    ' I : t i c / ii li r ; . Scm nclc clinicc sint
    r t 'r soccilicr( r lilicr I I I : iI i ir r
    ( oligur ilc sat 1anlt |ic, liiPr : r 'lr ir lt r t l't t '

    :ll*1;if*l*i*5f,f*'f,}?
    ,',"*ilt;,"f,1i,;1i1il::it;1vffi
    ,l rrrr'rri rrlr t ) . i, ) it l1, puls slab) 5isllccif icc
    rr ,l ' rrr,i. r r ir 1, . ilr ouclcliiiiL bm ic
    l ,Lt' , l , r' i ir lt ir r . , Lf icicl] licar cliacircdcm
    l .:r I ir r t r I , r i1Iobicct
    asceudt
    ,
    lt . t t l) .Hipcr hidl: it ar e lr Pt r ir i. t lr r r', l l
    pulur onar , cdcut I r {jbnr [ ) r r 'r 'r r vr r l'r r
    ir al nou- niscut ului sc pot r : r 'idcll! iar init : lr i r r r iit ilt t l'
    rI
    t e sclnt t cclinice cut l ar {i: lacii: - sr : r r ; t l l. t t islir : ( sit t r lr or r r r r l
    ,r",,,,11,1.1.,1iiiil?X:.lii#:]},
    11i:1j",f:,:#fu., ." ,1,rrr,,,t . r "r 'iir 'i. r r r t alt
    l ' ,,tl , r). rr I r 'lr ijr , : it r r liit nt alc, m cningot nii'locr : Ipolidact , ili. : . ar t ilr - iLI r t t t I r iI i'I r |'

    2,11,6,I"{JI"EURARI
    ^,,r/ff!l';,,,,,,,ou,u,0, , r,, .r (, rrr L . , . r . r xi; l7l'L f r ecvcnt cu m alf om r af iilL: r cur Lli';
    l i t t r i; t , t , , I t . r t t a/ ' it t , l c r . . ' Sc lor Lloza ir l s. 'l- t t lsr r lqt lit t : r t t t '
    AtE APARATUTUI
    UROGFhIITA!. ' r' rl rrri rrr r li . { r ir . i, iosf alii, , \ {. g++ , '\ a+. Exaul': t lr r l r i': t lt i'i: II.ttt;rItttt'
    2.1t.6..t.t!,i$[JF|C|ENIA i rrrr ir '. r iiir r r lr t Lt iLr r,. lcnsit at q pcslc 1 010, pLI b. r 'ir : r . 't r - oli! ri,'I t : t I I t t t r tr
    RENATAACUTa 11911* l ,r,,l ,
    i l rl ,, l rrl 2 . 74i-

    r::;::i;'3;1;
    ;1'
    i:itfir$fl*;1il1i*:;*'-?'dffi
    ,l t , , , / ; I r c i ; i I c I l C G st t lat on, sc h ipcr lir t li'r t r t i': uur
    I rll lliliti! , irrtLtvaltl 'lll prclungit, Sf subrlitirarl;rI, urriiiL'l' iLstrr{ilri
    '
    i lL I ) r r Plr r lizr Llr '

    l l r o : 1; t r . i i t r , ( pr iu aclm inist r lr ca ir t pcr f r : zir - 'r ' suLr slir t t f clr t 'l'
    .,,rl r.r,l ) , t ', , , , i t , , l, , "ic diagnost iciLiu sl; r diul'r Lnur ii:r ii iiu t lt t t : r rr lcr '11lr r "

    I
    :lr'ltrli;::",T,,i:,.;*r,i;:**$lti{mi#ntliili,:,;. r
    rrr,,rr,,rrilsr r olr Lr '.uLr
    r rIr' , r ,
    r , lor it iL.
    rrluir r r r I i, ' t r ogr aclir
    Sc r nai pot t f cr : t ua in scol>t liagit t : r t ic: t t lllr t st r r l
    sau cist osccr pir - ',
    -:rF:'#Ht Iabelul.2.71 l l : { 1 / i ' { P i n rrr{ i (l c n l t l Icnltle cnlo l rrorr-ni[.col tdulti .I:{i]r Il')
    ' I tthl ttl :
    "1

    l:|!6cti:i rert{lti lll Iloir-ri:rscut


    lilll l i l l r i r i i g k n n e r J a r .j l rc ri l r)ragi o,(L|s l ri i i t.|l rr|r:,rl l rLr-,r'i ,rrt.:1/c rrl i i I hi r rrrti i { i rl "
    l. rr\ 1 p t a s m t L l i c f e i a :l 1 5:i : 1,7 mttrl i i ;r. l | ,.!l r ' r' i !" r, , 1 . ! , i (:.uri i ol al i i ( ():i g{lfri l al { r
    ( rstnohritltea S3 + 4,2 ml ,nri rr. l r,.rrofi ' 8i " j l r:,rrr; . II: ",i r||:I
    urinari'! ' 1 :10- 700 m(i :j r.i l r 1
    Liu;rLrsorbtia l)icaIb.l.!.:ii)i:; :rs i i )' i r), i n(' trrl )fl l l i l Li rLl i ]r:r,IfortLr()i ' r! rrrrr(' rrl ' '
    I i 22 11l0s;loi, I
    .l( 1,300 mti zi
    rrt,.rLr' l i { , h l )' j ,l rr/1,, l x ,rrl ri Il r1(tri :rl i t.i , \i rr(l r' rrr rr(
    l fi )1i , . rr.l r-i 1i l
    , \ c c as t i inc r D .l !i a ,," ,," " :T l l l .i :,, 1 e ,r;a i i L
    cl c,vi r.sti ,i i rri r,:i Lz,:po.i bi i i ti rti l r: l rL,rrl !)rr ' /' r,,i rrtrL rrrLc |ri t, ' r,!1{ rL ,fr' :' i rr' rtl l rl rr' l
    I i rri c hiuluit l, - -uoLr -n i s e i l :,l { ,.r!c l (l i rl )l i r r' .:i l . l l ,l ' ., ' l r' r' r"l ' rt"r' l t
    f,i V,,." , 1tti 1,.rri i ..,,, ,
    -;;;; '
    )\,r. rj r 3 7 i . r F l tr r l i , ,l , r, t , l , ' l : l rrl rl , . L rrr1 1 f . rl , . / . , 1 / , i r r i , t i r l i , : ,1r rr r ) i
    "
    rrrrl rl , l r,
    L 1 , , , 1 L rr, r' I i l 1 . l rrri (r I l rl , r,

    :i t,l
    ill, r
    I'abthtt 2.13 'l ahl 2 75
    !'ltlolrnlolo{lfui inrullclc,t|lcl renale
    ocdto la ou-llls(ut (dupl Jaln)
    llh!fi!l|r{llrul illhrc.llliol !rl lBsrllclcnlet rctratc (dupir Heller D t: ,qi cd'rlr')
    }i[ipor/olemia
    Ilipoten siruea Insulicienlir rcnala__--
    Hipoxia .1.
    t)l i 1:ttti , fal i nti (
    I
    .l, Per{uzie lenalA arornalii
    I
    congeniLzllc, inlccli0
    tr||.rr,rri rl()l
    . )!i li urti ' .r,l c nol I
    J, Flur. sanguin ienal
    ,..--='-'--l
    ., Co sunr de O, I
    .r. rr,lrrrirrislrcrrzir solu!je I
    r / , , 1 ,) r Lfii,, 2 0 r 1 /L g x2 Urin5. stelili, pinri('
    ,f Realxorblie t I
    I
    l
    proximalS I I
    I I
    tobular:i. de 6odir )rr r:!spun{le 111(r.liIic:iri
    il/c 1 lr1
    n)o(l l l k l l r i
    II
    s r!l ) l nonl torrz J ,tea 1.v L
    \{, - d rrlinistrca.zt'L
    r)rarjtol 1 g/kg
    roroscruid 2 mgllrg

    ]J
    1 Acti'r'itate plas- fiislnllrs nn r?ispsnde
    matici a rcninei r' n |l 1' In-r1r
    I nfi ' z i .l I
    sc 1c?etx furosemidul

    It
    f.' s pu,rs rru t i s P utr,l c

    .l .L
    Ilrlt sarlgulD boalt 1ena1t
    pareflchirl1atoasl .

    I
    t VC : J trdtameDt prir bidrAtare
    ?VC : 1 administrare de vasoFesqare
    J I
    rrl rrt{l l |frnr (l i rrrrrei boa15,reDal5, pare[chi@atoasd ;
    obstruclje Illecanici, ln
    calea Jluxului nrinflr

    ", h:/ifr,'i':: T;0, unli ! ,.,; o


    bjca
    rbon
    fl,T}'j,:[i ,i,,*|,,"i'g):-.
    gj{,iul slai"1."
    inscnsibilir.
    {picrdnrea
    19"":l/^\{:'
    !,
    at, iir 1o.anr;12is.s"il ;,, l;ffi ;,;
    ;]! It
    llltl!:",?*,ln::::f *$';** de
    ll. 'l' t a t,(l n ent"l
    n nnlklllt'l'
    ki ! o c a.l.ce lttliei;. .Ca gluconicrol' l0){,
    l;' ;iT:Yi.i:3. j: I q1,1:rt t r l i , l a r e n t e r a l, d cu glucozi 5010.L arninonclrl,
    rdmiDisrrar.ea
    :::r_"^!:^11
    tratament: "1
    K" I in hipefka["ri"
    'O
    mEq/l
    '*l'r,"n :a- c) }(e-
    *e",i se {ace urmdtorul
    ,,, lntnrlfpirf'
    r 6| rr.nrt,n tut' k d p e r t e n s i u r'ti i arteri'atra. (ltrltolttl
    sol tTo/o,0,5-- I ml/kg, ta intervat tie _ l,?7),
    .o,lt$l $ld;onic Z { minute, - ' l.u u,, clnli'rri copilul la un interval de 6 orci(seconsiderhca {izlologiclto
    "uU _
    corcciarcaacidozei:Z^l 3 mpq NaHCOT/kg; lfq'11f.r'r,lrr,.ir'ttatc tk:2o/o I zi),
    - 5Jlucozi t' iucvitabill ]a. nou-nllscutul anurlc,cltirr
    ZOf,.4 vnftg, llip.riii.lrrtar,'a ,:s[c;,adesea,
    _ Resonium
    A0,s_ r;i?iri;rl,,lTtlli*i3Ti:#, ln conrl[1iil,' unui tI;rtanrcnt.strict, con{orm scllcmct a4torlor,',lu
    dt]$crlse
    [ioii,i tiiiii"'iu.niii s', va pr*cticrr,dializn peliloncallt, Indicatiile elirlizoi pod'
    .).ro
    8[?
    Tqbclsl
    I ab(lul 2,7$
    llalarocntul l n str llcl€ n l0 l r o tllr lo {cl|l,o h nourti-{3r|rt (dupi $iiue si
    i.','FP') Sinrlrontrto etr toDrlonel|le rcntrlc (o sht klendliealrllo
    ln pello ilu $couttaltr (J. P. Cloherty) 1
    Oligu|i(, flelanatrd
    (cdcmelc Si insu{icierta Oliguti! rtlr{tld
    cardiacA lipsesc) Trisituri gerelale
    .i
    irdrni n i \ i r a r e d e s l b l l -
    nri, l:r 2 0 I n t / k g l \ '
    I d i d r e z l a ] . s- tj ir j0 Jd n u tc M,ttI'n t(l i i tt h tl tt i ' :tl
    2 0 % , 0 , 5 q i t r SI\. menirgomielocel ureter dllbln, rilliclli
    'rr| it o }
    . l diurez6, absenti, chpi 30 mirut0 in ?otcoavt! neJLozI
    itloscmid 4 Dg/kgIV tr oare l trj l 1r$, l ti J x )s prri l i l r' {
    l l r,',rl nl ( rIrol i l' hemihipertro{ic
    I d i u r e ? i a b . ^ n r J .tu p ,r J0 m .n u 1 e iacies alrormal, anomalii agenezie rennlf[
    rr'r1\ s c | 1 1 i d1 g
    / n l r / 6 h I \- r pult11onar-.e,cardiace Fi
    (l(,prnin; 2 gana/ in. I\I sdreletice
    J diu}.z:i absenti. nl r.l r,,r', M,1krl ciae{aloccl, polidaclilie ri ni c hi pol i c hi s i i ri
    rl ializir" peritoneaul,
    Itti ,,l r,,||r /-fl l w (|r' 1' hc?atomegalie, gla!cofi , ri ni c hi po)i thi s l i (i
    lnailrte de 2{ ore
    {r I r. I r, l |l l rrl o rr ul ) anomalii celgb!-ale, con-
    {k! ln. instalarea anuriei
    .lrodistlofio
    l l r"l ,r'r' disu.olie toraoici. as{i:ia[li rl l , Irrol l ' l l rrl r In
    rc c ):oz i l rnc rl|1)rf
    .l r,'"i

    l t,t tl tt ti t r t rl t
    Tabct!.1
    l \v, t'tl t \' ))!l tt' n. hipollazia mutchilor di s pl az i a trac l rrl ui ul i l rf r'
    Meilicaimonle lolosllo ln {}aiamclrtul hilc_r{oasi$ abdominali, cdptorhidie
    .ii
    arlcrlale Ia rrou-risc{( (dup:l Adeiman 1t.) hi l , r,,;rr r r' 1r,,,, ' ri scleroza, tuberoase, adenoane ri D i c hi c l ri s l i Li , l utrr.rti Itl l i rl n
    | )ihnhalazi{a rol ' l r!rl r,rlt
    1-9 mglkg/zi i.1'.,p.o l l r,l ,, ', I l 1f,l r v ,tl ) hipoSlice ig,rDactoslosie di s pl a?i c r$ral fr,
    l'lc+Jt.lop:L ' rc l
    5-50 lrjtgl\<g{zii.v., 1,.!,. l .r, trtl rt ,r tth ttr
    I ' r' op1 n n o l 0 1 l l tr,l r!rrr I rrrvr' (,, rrl i r ciiaracttr, mhiiis41, del ec tc tubul ar(!, pl orj Irrl o
    0,5*2,0 rnglkgizt i.v., p.a.
    I)i42oxic1 I'tl l 'l rr | | rrl |l ) irtrr?iere nlelrtal5
    5 nlg/lrgldozir i.\,. '
    Nitropr.usiar A tnth,.'l || ttttl rL,' ,11' t
    de sodiu ?,5-5 pgllrg/rnin. i. r,.
    l l ttl r l ,'/i 'r'r'rl calaract:1,, leziuue IrePaticlr, dis{u!ctis tubulot[ rrtl$llt
    cetebralS
    1 o r)c alcs iLlt ilnn i t o ^ rrl c : l fl l l ' rr t,, ,1, | (/,,)' (;i (' fl l c ) hi poS l i c c rni c , bepatc rnegal i e disluDctic tubrl rh r{ru il

    - ar r ur io inlra r-l a b i l i d u p i 2 4 o rc d c tr; rtam,.ni 1tt"', r'i ' r'r't t r,,i i Lrrri i {1jst} olicrc, tebrl, hepatoNe- dislurlctie tui)lrIrrll rf l1tllA
    - hipcrl<aliemin ilalie
    .- -' 6,5 mEqil
    sanguini> 100 rng/l-00 ml l al .' i r, ' n1:,tti t.rl rL
    -uree
    - hipcrhidratare, fi ttl ',,l i r rrrr l ;' l cal0raclil, anomalij cardiace, alroulalli r(narlc varltl{r.,
    hipcrtinsiunc, insuficierfj cardiaci:i ' 'r"'3
    s ur' z c |l i c , rD i c roc el al i e $tcDozaafttrrci ictutlo,
    - ac r dor a n e c o n tro l a b i l i (v e z i p e Ii a tri,:, vol . S . nrl n.Lel c cu llipcrtellsi rc ttu(liviL
    t.16.12.1,
    | 'a H . . 371 - 374) . l tw ''t,l ,r r nnl,' n' tl a
    Jlrricli or'lorfdol, litlichi chi$tia ii olto olloDmlll
    l Fl rl r',rr I r,,,vt'
    Of hr l l " ,i l ) Llohiccfalic (cardiopatie) rer1aleln 7%
    (:i (i ) siut ].i, )rici, ca,xdiopatie, riflicld ill pqtcoov[
    2.II,6.2.AMEIGUIIATEA
    GENITAI.A
    TA NOU.NASCUT l |{''1""'r l ,','t, (luplical,ii ti m0lrolttlll oh!
    sisienrului uolcctor rctrnl In
    Sexul cromosomic,sexul gonadic scyul orlJnclo-:.1,n;ralc 60%
    . Si cxternc slrt r|,treziouretrolll,
    ln nrod normal .oncordantc- iie feminin,fi" ,ri"utin.'CinJ'ii"t ol..ora"rrld, Itlnn',r, i foci0s anormal,
    displdzlc chltucl
    {1e$picl.tur6, pdiatii6,
    sc'r:orbette de intersexualitate (vezi fig. 2.33).
    - riDichi chisticl $i
    ftrll'rt,t,' l t nll()1Il01ii articular'o
    oltc {rnonulii rlr0lo
    Prczenta .ambiguitltii genitalc. este mauifGstarca cca 0$llrnr l 'i r l 'r r ) J i rc i c Ea1rol r)ol ,
    mai comun[ a (lospicltLura l)uzci Fi .i h 60%
    intclscxualitir!ji in perioadaiconatali.
    0 pol otul i , c ordi opati c
    rinjchi'ihi$1i(1, lrr Pai'lrJevll
    . Ocar,ional, intersexualitatea se poatomitnifelta la non-ntrsc
    ';au ut prin pte- lltdirrls li l [(j i og !,rn)rnul , r]l uc hi
    $rr! dutrlicoljo {irr 70% dln
    gonade tn regirrnea
    i,rgul,1,rii rn regt$noa fl ltt,rttInltr,tttlt)
    l |norl nul c , c ol l l i ol nti c
    i:ltjl .ltll
    l l)lrlor, ,palpabite
    la lrnn. n. d\t .ltesticui) q$rlltr)
    s$i lcmiuirrapartntnoimrt. |-.* . :--*-
    I V l '4i fr l ' r(l rl ti rl tr, vt,l , 3 , p o g i r n 1 1 7 - '4 1 5
    368
    309
    NEONATATA
    2.11,7.INFECTIA

    ir npolt ant iL cle nor bidit at o 1i I r t t I I - I ; r . I iiI r I l'


    o ciLr r z, iL
    l ,rl rrl ir L r - r , lr r cz, iut iL
    6c, d./t: D t,ttrti :sl tc
    la nou*niscut cstc (lc I'l;,, i'rr
    l///a:/e/ ceh/dN , rr,rl;rlir. iir ccr,',rtrttr i3cncr:rlit. ir inlectiilol
    '
    r, ' \' i rl rL i r r lL, r 'liciscpt icelr icc cslt t lt l'i, n. , \ ct st e pr occnt c - - : intclt r4 lr l i r t r r r t
    C{ Hermdf/od/,rr/ ty'.'/;r." ' , , ,ri,i ll tr. r'. .:tt gir:utzrtc u'lici lrr Irlltcrc, la ct'i din serviciilc de tcr';r1ri' irr
    , r, ri si ll r, i <li;r'sccfiilr:aglomcratc ;i {iriL circuite funcfiolrle cor('sl)rrrr/
    r.:...\ Ps€uy'oh e.n dl/ c L',i in l.n./ /i /, lirr 1o,ls rcr:qs:rrJxxttru sinteza imuuoglobulinei se lLfliLpl: cl1)lllosolrllll
    t. ..1 ,t/h/rDm adaereqar/ ld/ conttl/l7d/ , , ' ,r cr' , r lr iici. in l) lr io susccPt ibilit at t : acr cscut ir1; rin{oclie a nor r lr isr 'r r lil{'l
    \J {
    a l/7-t''r) , !r | l Li i s (L t i l l l ,
    l// a///Zaae pr//t /n,7a e,r/? d, d.0' l rrl i c1i; i L'lr r t zint iL * . iup. r r n't l{orlnat iilF connunit al( '- si( L|t lcsii r r 'slr r'l
    aen/,1:. Jdo aEi/tocr:/L/' e tuot"e
    f,itutu;. t-:1; ,, i < l i op alicil- , L 3- a car izi . lt . lr cns lr nou niscu1, i- .1) r r 'St cst r lrt r'r r 'r 't r l'
    Bd.. t) ' -, l .'.rl, in r{l(LDi{: iru lu scizut scnnilicativ mortalitatcir l)r'ill irrl( ( lrr
    (xx, t.t r) a d J/ n dron K/n efe/.1e. (.(,1 4, ' rr t,' l .r \ Lr ''i'lu'r u s, t l; Lt or cst r :di{icult : r t ilor ln st abilir ca l) r 1'( r o( r ' I
    ,t Lr.r11ir:nIui,unor fitctori ctiologici rozistenli la antibioterapia (II I | (I1| I || . r,I
    ie rm dfrod/f/im adei'a.c/ i; r npr ont it t olo8ia clinic: r ir s. l'lit ' r r r r 'l
    { ' l r' r' i l tpir l 't 't - "n r ; 'lizar ^.
    Pse odo/teamdlaodiim //7d6cu/tn ' ' ,.,..,, ', ] . , r i. r ii : , ; i; r , 'r r <J , I ii' I inr I |1 ( 1 ": r 'iin l'oiiic r r 'ir r lr r t i"r
    {\ { /t u/tr,/
    /ns unb/ e,7/d',/e,5:/ r" r,rl;r]r'. l'rLlticrrla:-itiLtileiii{ccliei fctale ii nt-.onatalc sint delr'r-nrittrt{r''l'
    \7 c Htb osPad)?.tPe', ao-sc'o'r'
    ct c ''blofL€L
    H/pero/dzb //bc,'d/.
    -.,-
    r, rvlrriirt u!rn lactori pxiogenici carirctcristici care :Iclioneirzir itt irr ' rrrl r
    r,,.rrl i i rl c lir t r i.
    d_ao/.1 cos,/p,.d -e..
    a
    (t' r, .Y0) /r'd/,erenild/ Snd.cm tur,"a^ / r'0) 2.ll.7.1.Ro JL COtoSrRUtul5l AL LAPTELUIMAIERN
    REZISTENIEI
    iht CRE$TEREA rA rNFEClll
    IN PERIOADA NEONATATA
    / r. r . l l . l . S r r . n l ! , i r o xr .) .o l1 ]ll,sr - .,r 1 g o ir a r lic si s.\n 1 grni l rl 1c)rt{:rn; i )r .Li i !]i i L.l . 1(rrrrf ,l t
    ir licr sf\r a lita lc ( a iu li.l, llicicb, J. .tt.).
    lrrrl.tr liirtti-ilc tL: im unoglobuline so gilsoscin colostru, polxlor{riL ((ir rrr'ri
    \ou nirscLrtii cu organe Sonitaic ambigue pot {i clasificaii in li gtrtlr" ,,,r :rvi u r l- o lgA dt t ip seciet or . I gA diu lapt ele nlat er n nu st : r r hsot lr lr r r r r
    ( 11. i-. Chiswicli) : ,,,,,,,,r,,ir',1,'stiiirtlir;irru conferir in;ccst rlrod o imunita-tc pasivi lll'rrrrillrtrrr
    '
    . ' r,,l l r' (i c lr cir lii inicst inali im Pot r ivit E' coli dc t ip Kr ( vezi voi l, lr r lr llr r l
    - l.rscudoherma{roditism fcninin I ' r). i )i r;1 .5l ; i 1r ag.7l
    pscurlohcrmafroditi,crn masculiD [ 75) .
    - copii dc se:i masculiu sall feninin cu anomaiii a1e diffrctititrii il(,
    rti r<
    lir : r ' .
    Irrlrllori d.: rerisltlrl,:l ltltimirrobilmit din lnPlelc lnlorn
    2.11.5.2.1.Pseudohermq{rodilismul
    {eminin
    Itolul dc ;rcliuflc
    \'cz-i Pcdiatria, 1'cl1. 3, pag. 489.

    l.l i.C.2.2.Pseudohermofroditismul
    mosculin I ,', ,1, ( r -rrrj l ( f . ill .t. bi l tl i l s i l ]rpi c .l i c :L c ol ol ri z ar.a i l Ltc s l i rrrrl i r, rl
    '
    coli latogcn
    Vczi Pediat.ia, Yol. 3, pag. 491. I r, .r r l i s l rJ i l , n , , ri r inhit):r doz'l{)11arca. st11iildrocllhri
    ani i c orpi i protc c trti tl i j r(( s ti rnrl r!i r:i i rrl !' r' l rrl
    ','l

    2.11.6.2.3.Anoitdlii ole diferenlierii gonodelor (1" or rd ;1r ops oni ni z rr(, c l k rrrol l l di .
    ti z el |l i , I,r' rc tc l o l )^c i (ti l |rr
    \rtzi I'cdiatria, 1'o1. 3, pag. 429 441 si llag. 44-5. I r ,,l ,,,,\1,t, , / | .fc rt l )rc l .c ri c i i l a l i s tr' ft)1o(i ooi (i
    ,... I I' r' r,fi i l I ri i ' l r' l . ,1, J ,
    i nrr)i i al c c (l rrl l ri l , i )nrl 111\,r1i ,l (:l g]\, t,i (;, Li 7"/rr I
    2.11.6.2.4.€riplorhisrnul

    \ r'zi I',,rIirrLlir L,r , ol. . 3, l> ag. . l. lli.


    l r r r ; r l ttti l r l " ir r rr irr olol ir ii i r Io \ I i :](| r t I I r I l r i i l rrrrtIl l i rl { i i l rt ttt:ti ttrttl i t"

    cu orsqne genilolc ( lbiguc


    1) ll 6.i?5. Trotdnrortul nou-rr<irculului , l ' ( r , r ' zi l :r l ,r 'l r r l . . l t)):

    \ r..,r l'r"ir.rlrr r , r ol. l, l) . r ll lr ) lj.


    :tl I
    '
    j' ; r)
    i, r r r it , r ' l u l ! I rrttto l ts c l ()r,
    l )fi l r i tl )s c t){ ,rl t.\ r,L,r.r.r,l r.Li
    { q;y.," l:rt. r.._yr! r" , r , r l , , , , r r l r ,l l ' l r r ,r r l |r r :,i i r L {,' ttti cl o b i l u r i r l u a i l l l i o i r i r ' l r 0 r l r IIr ,r r i i '/r r r i
    l rxr{' nlr ir ir L[ c r . lii ]o r. r' c s P i ra to ri is i d i g c s ti v (,); l rrj i t,,l ,,111;q11y111
    ,l i 1 ',.11t1' , l ti l l r:tr.i rmucoi t:.i l t t i i , t , ti ,';t 1 .r . l i l tr i l . sl l r l r i l i l r l n d i a g n o sti cu l u i tl c n r r r ti tl g i l i . 1 'r r r r r
    "
    ' r l6A .,r.ro 1 o r; r r , . . l r r ; r r i l l i u r r r r tL r ';tcr i i l r r tn i i n th ti Itu co ci tcl o r , d t:o a r ccc l r l r l i .r 'r - i i l , r r i r r l
    la. nirrcl sd-ic,prin dcficii. de comlrlrnl.nl (( (, ,r1.., llir.r.lrri , , , , r t , i r r , r ,r t, ;i u ,r xl i l i ci n i l o r i r tl l a u r a to r i i . C o l o r a r c;r c'u :tl b a sl r 'tt d c r r tr '1i l .r r
    . r) a ac1_ir.iirii
    ',,rrrl, l r r r ,r ir , . J r r ,i :r,.d ;fi c i r.rr.' r)s i p ri j l ,)i \,Ir,, .l ,r.r,i Ig\l ; r " i r r r r r i , i i r l .( l .i l l tr r r ; i r r r :vi d r r l t!r - L}r r ctr - 'r i i 1 cl a o d cn si ta tc m l i n l i ( r i ( 1 0 i r l r l )
    zet,. care cuprindechimi6tai:ii;r:rrit.iugtotiar.ca , r , , , i , 'r : , l i ,L ( ;r l l )
    , ,.,,........,1.1
    i.'.r'rnrrir _i il.:Tl.,11q9.ilg
    sr t|'rctLrcidi:r.
    sc acrmitc.ci.
    ( l 0 r t/r r l ) .
    existir'n deficitglobalal {agicito;rr:i, I t , ', : , i l t, r /, ,'i r r l l a tr : cu l r l i n - .r l ) r l l tl r l r .co l tJr r '.r r L ti l i i ,l r ttt /l l L i 'r r l
    (scpostulerzir
    il11],:fi;:;.,;;11.;;1i.adultii "'i.i""1' ""o!'t,.i,:tor,seiicinrli,,, , l r r l r r l l r o zi 1 i r ,. Si r l g u r - a ;i n ,'L o r 1L - fIj 1 r 'r r ( :
    , ' , , ' ! J l i r:i l .r j ,r r o - l l i r s( :i l t cste p l n ci i l L vczi t:a l i t
    f i r i o l 'ti n '. tcz'r tl tl r i r 'r r "r l r
    i u l r l :l i r u b i i r t tr i l l l ' r r tr r
    r . r , . i r ,;i - i i l r :i o cl i l r l c l r :co l ta r c p r l a te Ii u l n a ti 'i r l ,.l ]l l 'tl t;r i l tti r ' l t;ttr
    2.11.7.?.
    FACTORIT
    ETtOtOGtCt
    At tNFEClrEr
    NEOi{ATAr.r
    F:ictorji ::ivdogici cu frecr.'t_-ngli cea::rai urar-r:in sr:ptir;lrrtrilritci:irar|,i l r l i , u , r r i , i ttti i ti i vt.tLt : l t"l /r u ,r l , r l i r l I'r r i l cl i e r r l t 1 'n a t' {i l r u t i tt "'r "i
    rrconrrtaic sini ii. roll si str.cotoco,rul r , r r r r . l.r ,i i i r tr r r l i i L g n o sti r :r r i u i d ,, n r i ,' D , o 1 1 r r r .i l i . \- i r l o t.i tr ti r i tr tl r i
    grup E. fiiruril, I !i ii 4,r ,fr.piof,r,: - ,1 ,i i ',
    ,l r n,.ti.l,l Bi urodu..i,,.l,.,nn r l r l l l L o Li t,i l r n ) i r i Jl i .,r 'i r ttcl e 2 4 o r cd cvi i L ti r "Po tfi co l si r l l tl L l r r l ttto t'ttl r tl '
    p-,,j.,,lf, i".r i ., j,ij\,.riri.. , r
    '.'r"l'.l],-r:].,
    l" lonr ' r ) r ' :
    I r r r . lt n n /rr.i n tl mp c . ti t' L tl Il l d ,.l " rrr i n; ,p;,:-11:,,r:.. rt,.l ri trci l ,. , '' r r l , r , .' r t ,i '' p ,r l i r n o i l r tr l l cl ca l tl l l o n r c a l 'ca scm u i l i ca !i tl tl l tl tl l ti r i ttp ;r
    1.r1t rrl'ntc. .-\cerrtl.cru r:str far-orizrr rlc ab_sc'.!a1r,.,riii p:,.rr.,, ' i r , '1 , 'r , 1 :- r 1 .,'u co p ti r i l r su b .5 0 0 0 cl c l e u co ci tc/m n l r l to a i t' t rI1 It r'" r tI r
    pil::Lr:rl,i
    ''',, ic otI ' i. , r , t r . ,i i i :ti i i n ,p " tri v , ;. i i .:n n u j u i pr,l ,z,l ,rr.i ,l t, :i irrirr , , , l ' r r r l r ,r r 1 ,,,r l ,r r ,i .i tl - r i i l i g tttl sti ca r e a i n ftr :fi e i n e o l a ta k: ( i r r .sp r 'r 'i 'r l ' r r
    ,l ,r.r,.,, r,r,.r ( l ( :j 0 ( ) 1 r ) r r r l
    . ! ' t ' t ..,tf' .' l o , 1 \r l l rn d u C . i n I r.r:i r,o,r:.,;.. ,,..:.. \c,,,.. r r , , , . r l r r .i r : ,1 " r r l i r r cl l r 'i t r l l r n u n ti i r d r : tttct;l m i cl o ci te i n i ti l r l tr ''
    :
    r, L. .-.r-r-,irriazii |rin rezistenta 1a fagocitoziLsi l:r cirritii , . ', , r i , r r r r i l i cr r l i r'
    lllll ccnplr::m|rr
    i rrl l,,.r
    r. I t,,lirrl. .t ,rliittil,, t.[ct:!uaLeditr asfiralttl gqstfic, it\ pr1'rt:lc 'r'r" 'lrr1"
    , , r ', , '', , ,,r ,,,1 ,l i .r r r tr .,sd ci L r i tu u ci i n i e cfi i m a tcr n o - {e ta 1 e ,si n ti l ) l r '- 1 1 !r r r r r r r r 'r l
    2.|.7.3. ROtUt FACTORI| OR MATERNTtN. tNfECItA NgO$,{ArA!"d, ,,,,,. ,t, , ,r . ''ii t , , t . r , r , ziliv,. t lhiar la nou- r : iscut ul {iLr ir inf cclic, sr : iz'r l. '; r zr r
    .
    . . . r : , :,fl .-,,l i s g -a .v i d i rl p ri rr ,n l .l r rrrri ri , tc,.l . ,i . ..i i ., ,.j .1 '| .l rll ,l lilrlLLl rristrir: E coli, ,s^t'reptocacc'tLs efidcl'ttt"iclis st]cpt(xlo(riilrll) ll
    ri '
    , | \| | ||ll
    r/| , lul'\:trit \l ,t lil, t 'r , t Lr t' ( il1, i/ / J. Dc ascr ncnea,num ilr ul cile polint or lot t t t rl' r 'r '
    l0 flJ c l. ! t Lar J . dlc hnl, t l m , r t . t n; j : tp ,.. ,I,. i,,,,.(1,... I t.r,.J.:r,...1 r i ( [ sr ul it ' I 'l nlr ' r r r r "i ir r lr ''1i ll|
    n' 1, : , r'(.t.'r.7 t!'1.'.l. c ior i . ar , [ dv ot i/ l. . r z , l t p. ir i 1 i . , i , r r . , , : ,,' f ,, ", . 1, r . : . tr l , : r . t r i, 't poil',
    r - om Lo' '
    t,..i,.i..i ,.c,....r ' ,.,
    :!]lrL1 1rr.,r ,,1' , rrrl , i i' r ', ii' il'r l a|ir r ca: it ol- 'cnie ; i iilr cm ir hct lr olit i( : i ( l) rr r l
    a . r m nailo, . c pr . odr r c , io, ir in r . r . i , J . , r , , i . r
    l, :,:-tl , lllrn,lir r
    r" ,. 1 . . . . , " , . : r ; . ,, r i . . I i rrr' 1 , , , 1. r " 'l r lr " i( l'. r ' t ' r ii)
    l,rf,.in iL a [ o: r dor . . Llit . r r r um . r i p r , . ! t t u l - 1 , ! , . t : , ; , 1 , , . 1 u 1 . {t 1 , , . , , . .
    ( .tt , , , ,,.1,i, ', 1, , t liii; , : i.( l- t t : t cll; r r llo. r t ' [ i concidcr ir ii. sclt ln d( ' ir r lir '! il I r "
    /))/th,,t..1t'. 1r l. ; c . f o, ' a1a6 l, ql/ il. r ] . , . lnk . t ii c.,r,J. :rr .)),1;l r.:i r,. r llt u. 'l'cst ul poat c I i pozit iv si ll r t ot t - t ) r r "'r t it t J
    \1'nrir, rc:ltlzcazJ srndiomui dc tnfcclic, aranjotili.; de asi:ucra,
    fiitirl {jc lloxt,, " " ,,,,' ,l ,l r' , r r r r ', 1t t r i t t t r t t r :cL 2
    i. 11."."I'i.
    g1i1canjli:1.genitai.lixisti o ,:n,.,to;;,,
    inrrriflor r
    lll'.,...t:lii ;,"].:,uldur lichidul
    t,riirt.rt;r, (utLt:.lL ' .rl ,,r r l, r '', t r r t r r L'i'I \ '. S. t l. la nor t - nir scutsint dc 1 r llm / l ll, ll l2 r 'r ' 'l'
    amniotic ;i culturile rccr.ritatri clt l.
    ' L r . , q 1 t1 1 l r.-.',1 1 .. , ,, , l " r r 'r r t lr , lr llr il . \ . > ll. DoJr 't i lxlsr 1'. - cut irin: r r r 'r r r i'r lr 'r r r "
    'r't \ lo'lif ic"r 'ilc ir r r r r r r ': ll"
    ', , . r l ' ' " 'r r l 1"'zir it ; i t . 'ls , izr . t in uDI .
    :
    2.11.7.d.Atlt FACTORT L,' l rrr l .,r rrr r . , r i, r l, r lLt , , r lilLgloslicirir r inf cclia nconalaliL acut il' ( ) ( : l15lt r l il
    FAVORTZANTT At TNFECIARntEOt{ATAr.E
    t, Ll r" l ' l{) r r lir l( X) r r r l r 'n silg'lc din cor d''r ul olnLili' ir l 1'l t r r t ; t ur " r Lr lr 'r
    . Ar:csl.i {a:iori slnt, reprezentati de echipamentul conl.alniliat{olosit l;r rr., rIr , r l, ir 4r ir t ii ( 1r c|r r i, , - r , lusi pr - r , i1- r ilit a
    at e . olr t : 'Lt lll! r r|r r'r r
    r,,lnllliu(,r" noLt-ni.scutului 1,,,,t,1, - r r r lci
    1a na;tere ;i ia protczarear..lspire-tcrit,ultt ,lirr ,' rrrrl i r,, 1. 'l- r Lr l, : , , r 1! lr lt t : r 'sieicr |st t r illllst L'x( lr r dcillsir r , inf r l<1icr r L'r r r r ''i
    rr/ (rl)ttoar{', adcs.a contaminati cu. 'gerg",:ni Grarn_ncgativi
    (il iPct:i,rl
    l'. i'i'rcienic);i alimentatir parenteraiir,iare constir.uic- l) r ill lr r i. r
    rlc irr l ' rr ' , r r t l. r ( lii, r r l t llr liil{) ( ) lt t t r olor czirst l pun in t 'r 'idcnt i
    ]rccrrJlal.isecl-mdar;.Fol0rirea catetcrului intrautc]:ii]
    ",i'i.at".silu r; clcctl,,
    'isc ,, l , I l l rl r : . ,r r t r Lr t ir r r lx: lii. , '; r1i- . t : oli L\ ; i r r polizt lr ar idului cir l'r ''r r lL
    ''||11-.1r1
    ,lrthri fixat pe craniul fetal cr.este{oarte rnult riscul 'r r'lr r
    de i,rii"ti" ,' , ,, rlr r i li l) r , t li lllir r ( r cst or gcr nlcni in I t lr li1ilr g'. it a
    . r I |t I t t I I I I r I ; r
    , , rrJptrluilr:tirl apar Ia 5orl din riou-ni.scu{iia.stfeimonitoriziLl.,. 1at;c"sr-,,f,. ,1,1, r,L r r r r i ; t r l t r it t ir r lt r t l lr r llilr iolicc indt ll't r lL s{iLlr ilir ii rI i Itt] rtI rII i i ' r t lt r r
    '. r r '
    ,, l , r, \l ' 1, , 'l r r ': 'l' r r iilir r ; i ir r slit lr ilir - r 'adiagr lr t siicnlni dif clt 'r t lir r l r r l l'r r ' 'r
    2.i 1.7.5.EVATUAREA M.E_Lq?E!g! , ,i i ,r , , '1, i1r , ii r r i r lr 'lr t sr r r cspiliir t r ic iclioir r r liciL, ( t r ) it l)
    PARACT|NICE DE DlAchlosrNc l
    IN INFECIIA NEONAIAI.A | ,.rI,rr. r I r , r r , , , ,r t I I r t t iI ot l"i"lr llr lilir ' 1"t t lt Lt t ") : '- i ll( '1nl( 'l) r' lr r r 'r 'l
    , I "'i: r i l ,
    i .' ' r , , i rr l \ '' r l r r "l lr "'
    , , ,, , i,:rrljrrfcc,r.i .i nnol,,jirl,.(. l rniriirrl,.,rl.r,r , ' , r" .rl. , 1, ' ' ' " I 'r i'r r r r i"-
    ,,., I I .,,.II: -.r',
    ' r'rrI,.rriI,r i..rr,rrl il r,.l,rr. 1 , ,'r ',r r !r ,, .r L l l r l !r ,r .r IIIr r i i l r 'r ', l l l l l l l l l l ) i l l l l i r i r j r l l r ]1 1r r 'r r r r l l
    rrrl,r rliD.-in;i,,,l. ll .:rrrrrr.irr s,
    'r') 'r', r.
    J )r)lljfrt (I I r.I ri I ;r t . ()i I noli ht nli, : ulllt ir . ' jlr . | .,r l r l ,r ,) l l r 1 i ,I ;r l r r Ii r i tr l t' l l r r l l r l r l r ttl " l t '
    ' r t r : r : r , s , r t .l-.LrI I Lr,. i r., ,I I r l r l i , r , 1 ,,. r ,,, i ,r 1 ",l i , r ' I 'l i '.r ,,r 'r . l r i l r ' r L i Ii r IIr |'i r l r r r i :' i ' r r i 'i l i r r r l 'i r r r 'l i r " l )
    , l' l rrtl :rirl1,'/1 0 irrl lr r r lior : ; ; t c uil ; li ( . illlil. r l, , r : : ; lr : llljrl)r)r ltr
    r t r r l . i , . i i , : r il l r , . r r l r r 1 , r o l r J i r i . ,' , " , , , , 1',r ' 1 'r r r ",'l 'r r "r r r r 'tr r i
    li,
    .11
    ;l l l l ,.i
    ?.t 1.7.6.tNFECT|ATNIRAUTERTNA

    cirl Lrlri iuloriii .L.rrpr.iL I ' rl o rl t i lfo"i' l ' i n l f | rt l ri l i r('


    . .I,-li plodusului de corrr:r,ptir_ rn trmltil ldrno-
    rrr.r'rlt'r manrfr crl un anLrnit agL:nt i'fcclios - dcpir.rilcdr,:rnai'rriiti
    {i.ctr:ri:
    tipul;i agresivitatcaagentuluiinfecfios,,:"ri.t""io' ,.,,rrrr.:,.i, i A-"Jcz_"i-
    tarc a cooihrhi. -.t.Aii
    A . f lt i, .ti c tl e s td d i -u . I e rubri ona.t,, i nl ccl ;a. errcl ueazi .
    dupii tipul ,, toi.ul -caunimic,,;, produsul O" moare 1;r cste resorbit
    . . , - rp f:t\i " l u i ,:rc fl ,r.l n i ri o -.onc"p1i.
    l cri un,' .
    - . lt i. \ ' or ia, l . , 1 1 a ri r. l a i . q L i L rL L ro l u ,
    o f c .ri .o ' r./ c i o1l ,ni o..t.t;r
    ,^ !\. r' -ell,
    . , , ,,r ' tt ,\' 1 . (-:i pi i ni ,ra d ,l -a- r(, t i rI i l a r, ri i o ro
    rl c 8ai i (, l rri )i ,.' r,
    i r:i L l l c rr' ,( i ,rrj rrr l o | ,rS;r r)oA i .nr,/.ranun i l ,. i rr[e,.ri i r.i ra]e
    ;r- _lJ J ' : , ' i ! /L
    truneot a, 1n, . ,ri | . tl o mn i .,J Irc i )s rrrt fo o n o acl i r,. i :r mct.ahoti " mtrlD [oc]rrsui rri
    ( ( l a l i i , c rL r(l i { )l )a i i i l i)Llc111l1.nrtt,
    l rl ri .rs 0ri :a, .rru-
    l rl i fi i . (11:ri l i !1!' .1
    :" - : 11: , lP f l i. r ' -u d ,r.d " z o rE rn i z i ri a l c d i r" rir,t.,-crat,,dr.t,zr,,l i ar.,.{ mal _
    estcloarte sevcrir,cmbriorrul-
    noar_c(urrrat dc re-
    lliiiltl;"";i,:i,irr(.!tra r! i f f o - f i h i (l r, , c rx r( i i rl i i i . ri ri ,
    rrt.rr([l rl i l l l .
    i t l a l r' , t : a l c i l i c r-t t i .);r1rl i 1ri ,]x nr;l ' '
    t[]\l , i ! .

    :g:,x3:e1r:1-q'l'i;u'{j,rl,;;,',:*ii"tJi.i.1.l,i,i*:*ii;:!T"!L::l$:
    viralii e foarlc lariat (L. S. proci,hom):'
    f i ' l . L i > t a l t : , c o ri t , L -
    Iilliii,
    rri r: t rn rl a l i t , r. t L t r L! l rl rtr c .l l ri ' L'
    l i ti t i

    prr,tl[sului de conccplie (ar,or-tsan nirscut mort) { i (: : ' u i c . rt l )f i rl f ,


    ;
    ,fJ
    ) 11:,"r!..,
    nJ . : t , r , p rc m J l u ri I rrn u i fa r. i rrs ra ,j i ul d,.i rrl ncri _.rrut. (j ..nri {cmi i l .
    r) r lir.v i n d c c a ti . c u d , tp c r,.d ,." . ronrl ,l rrn^.roz^j .p.rj ;#" f" ;
    , inf r prJi
    r'oc alc de [ . 1ep l 1 ;rn rr7 ;1i n z o tra a p c d u .l u l ui S i tr i u* po, -,1-,1.. r( ri ! r1 t , , ' l f ; , rt L ! { r' rr
    i l i i ,,,'
    l r :l ,.qozarei t
    l 'IL c u apa' t t t : r 5 c .u n d a rj r u rr, i l ri d ro c c l c ] i i (l s,.udom;l l i ,rmati o):
    infectieri in formiL cronicir cc s'epoatc preiungipirir-, ir p.,rioada l c l i 1 1 ' , r . rrl r, ' r: L ri I( i 1i ' rrl
    ,^ susal:
    oe ^.-{l*1..."r"" I

    vindecarr:ir {iriL cicatricc, in care crester.ta i,'tra.utcrt a


    ^ C C..a), cste uncori
    1ll Itllltir.
    rru l n , f rrl rf i i r' rD t ! l c
    . Uneori inicclia intrauterini. se poate evidcnlia c1cla naptcre, sub lorma tl l r, i rr I a t rrt ,
    (: 1 r(l i o l ra t i t ,
    unei septicernii, survcnite la un n. n.'dismat"., ." t"noiiriile mor;rgrcc s i ( 1 1 L )z a t
    cuta- S . N . (. ,
    icter-, choriorctinii:1, anernie, t.ornlrope?i., gl ic_
    :,1-t_:i
    -hjpltorpl*nomegalie,
    zlUnl OSOasfi, ()s tu., (,r!l Ii i L. \ l ) ti l .t
    ' tl , l ,' l A A l l
    (i , l l l t f ( , rrd i ( u l l f ( hc l )l i t ().P h rr(!r"
    plt: jl p'gdy.: de toxoplasmozi,L, rubeotiL,citomegalor.irozii s. N. ( . (al i ,,, l i !rl ti t,l ' ,n.) ' r' l ,l r
    .., , "..1"':11.:lll-1
    ,:..,:it:: ,j{t; rnlecfiic-r.orricn
    irrtraurerincau losrqnrprric subcl,- 1/(n:' r( rLrrr Lrrl
    nrlmlrca(1, -j, t U l<t t'l st dyom(.dupJ.irritial,,
    aperrf
    ilor cliolo6ici.ci pof aclionrL s L' t)ii Lr.,ni t, rrn -
    pc iot '"..ti /Zoxopla"moz;, .l?ubcolt,Cir.6mecaUcl.
    ni rrrri l i , l t( l )rri Li J ,
    ,parcu'sul-sarcinii /{crocJ.
    Tn a[ara rubcoleiir car" ,rfnrrarnafciari rpari,
    ]']::ll?.1:'',1:'ll llll'lT":l''1,
    rordeauna.rrccventr alectirrl estevariabili (tabe1e1c 2.g0 ;i 2.S1). | \ l ' l rl \, r),,:tl r)i ,r(x rf l i c s (trfc l l IrborN i :i :rr-\'
    ,r | \ \11:; trl rL(,f,,nr{ i nt. 1r( l )r)rr(i rrLtlanti l )odv rl l )s t)rl rl i (t! l trl
    'Iabtlut 2.80
    , ll l I r, 1,"rr,,u:rl i l rrrti )l )i l i z rl i orr
    Ilrcctenia infecliei r'ilale mater.nc in timpul slrrcinii si a i[fuctlci riral€ l& nouarilsc&t
    O"elail)
    khrpi,
    Itr ri'rrr',lirrrl ,li,rIrgic in inll'c{iil' inirirttteiirtt" ,f'}t"',]",l]]..1];','l1.',1.
    Feht idectici Matcru:L Nor rlii,scrt: I ,i, ' i ; ;,l,il,"
    , :,,r,,',i i'i .,",,r,1*,.,'
    t,, I rl l ' , .
    ':".,1!
    \"_
    ),lilllll'i-ilJi'.lli,tlll'i,l
    l{ l r' i l ( lll
    , :)' \ r' l o I rx t ( '1 " " 1
    i,,i,,,,i "
    ' ' i l cf'l rrl :rt''si
    ,,,,'ti ,,,r'1,i "r''(JF",t",:l
    li 1:-111.,:i l l ].,1".. I',i lt'i l
    ( litomcgalovjr us^
    i:' ],1,,' 1,:',,. " :;i ; ,;;l' '
    'i',,' s,,r'tri[i|illiNl ''t '
    'l - i r r r tr r r r r ;t" l 'r r l i '1,'',1'
    i i ,i " :r 'i l '"i '': l " r r 'i l i .' "i
    30 5 0 6 -..t5 : ftr ll's"ttl'a'rrttlirrrtPilot
    ;,,',;i',',,;'l;;'li';,,;...;:,'';ir:
    lJ c T ) c s o, 5- 25 ( ( ) t||'I( |I |'I | |
    j tl i l tsttti sl t.l l l :r l n l l tr ti ' ti ( '
    I t nl x x t i i r , , , . , i , , ,',' ,, ,,- i i ,,1 'r r ,,t,l i ,l r l l r i p ti r l l ;1 ( l
    (: ox s l c k i . I !
    t 22 t).7 7
    l , ', ; ;lt , ; , ; r ,, i'. lrir r r ,'r i' rl tll\t 't ,,,',r.'r'
    'N 'lli,, r '' r rinr
    i tti tttr ti (I r.ir'rrr"l"iit
    Irr'ri t.st tt{r '( L 'ci l /'0 'l) rtrt11/ltttrtr
    r r l l /l ( Jtl r r

    ; ;l;; ; :i;''. 'i,:,


    l l ' t ,,,;, ;,:. ;, i,;i i ,, r,"ii,, ',
    'r ' .
    ,,r ,,r r , ', l i i r i i , , , , i i ., "i 'r
    'i r r l l t
    , 'i r l r ( l
    t " i " ' l r ( 1 ' ' ; " l l l l i i , 'ii .r rll'l
    . r{',
    i r lr ll'll]r ;r l,' r;
    l' ; rr o l i ( l i t r " l I

    I i, ri ( . , , l i l
    i' l" ;;' l ii i ' i " i 'l' ' '.rtrritl"tri
    I'r,,l l ",,,
    : l( i l iilll r
    l. ic r liilt i: . rL .rr.r,rr\L t, r l i r i l fr,r:l i rri rrl _l l l ':1 l r r I , r 'r i ,',l 1 l ;r t t t ' l rtr rr l ; t l l "rsc tL r 'scr i trl n l L i l l l l l l tr l r ) fl r i l :
    i') l':.[t!'ltl,t 1 ,, ;,it, ,,;, t,1 t i, i .,,iralt (N{. I_. CJr:-s.,r ic,.:}: ayort, niscut l 't 1 1 1 t1 '1 'ttt'i tIi .:L r l ti ctt si tt<[r 'o n t
    r l '' tt|l tr s'L r t';'i '; l o i i '. ( 1rt r t I t t t t t Ir 1I Ir I i -
    '
    | rr1) r ' 1, nlls t c r l] ] ) t (!Ii i i tn r,i , i U l i rz i L ,rr' l cr te ;te ri i fetal c, ti tl l i orl i l :rri i , o;rgeni tal e, l r f r r l L l r r l i r ,' l r |i l i l i L , h cl l l L to sPl cr t( 'l l ii3 lliL' pllLlllil- l l r /u IL r i cl l o l ) cl l l ( 'r 1 l
    i.:1.u1rcsi sirnptou.tr: ir:.;:cui,r Ir ulsLcrrr,, irolmalital.c r:linicii. il ne.-.te:,:, inorna-iii
    llll('rlo;rrc, mcl u1t clfcl a]liii(tut. a''lir r LloliL:lL t xr lr illt '
    f;,)t r t , ) t t t t t it t ! ( N) t ccf alilk'i,ct t ir t inr r lL'- x. : r li. r r r ) '
    b) Efeclclc i,:.i::!ici-.ictllt ltlcttyicj,l.e (M. L. Chi:rr,iri:) : :.\.:.Jrr, 1.ta,scl1t , 1,' .rl " .rl l r r i' r , , r 1ii: r rint : i'i in sr aJiul ar - L] r{sim - pt ir nl ( L'' if it llt ic cot l'l) r 'ir lr L
    Drorl, nastelc pfctlitlul:i. t,,' l ;., ,l ,1i ,., r llir , , , r lilt ic albur r linocit ologicirin l, . C. I t 1;
    r ) . \ c t , t . ' , r ., .j ,c " . ,,,,,:f:.t.' l ,r tta l l ere s0u .. t. . . : ..i .. 1111 lriitda (:lilr'i' r:
    .1 .' , ; . 1. s, npijc . r p: . :. .ri r:ti t,i , p i ..i o n ,.tl .i r.i , l ,n.,u- Irthtt,t,tr it:[,:cliL:ttldi nlL[lt s.,rt tdl'i tt!i]1riJI'l€t:ttl'i '
    S asfrocnf. i :. -,.: i :r, u.'tri ; ti i | ,' l t ,l .rl i (, , , r I , iI i. r 'r . r subcpcndir
    -i nar c sir ncit lcL: qi cir or - iuit t LniLiL'
    l ,lr ' , r . ut t l. - . ' : , ( j ,. J r,,Il ti ' i r.., c rrc c f.rl i ta ,,i nf^crj . ,ul : r. ,..:.
    I I rrl:Lr : ,rl ll r:opil mic diagnosi-iculsc punrr irr pir'r'li1t'l col)vlllsijl{)r'
    . . t ] il.iit l: i r,.tl fr.r,rl i i t!l n o -ti r.u l i rr.fe e r i r,ii nrraurr.r,i n,. rl . t.. ( l ri :: i ck;: ( lir l r
    t I) ,Loal: l . ' 1 -1 -^ ' p l i c .L l i . i rr ti m p u l :arci nj i . nl a:... ,' 4tzrrfa febrei .. ,,l l .rri i i r r '',1ir iil. , si r i t ulbur f r f il; r oculat c l- r Lof icc copil lr lic pcr r lnr
    j ( rrati:rttir tl.t Lttll''
    s.lliLlt. unel clup!1r; ' , t ,i ,I iI r,, ;,i irr lL,!r:lLsti'L clircctie cliologiti l)rimoitr lr l,i' t.
    ' s' r 'lr t a {ct alil in 15 20'l. '
    L) inl cli air:i ir..t ,'. r-upcl.ea-menlbr:rnclor , , , ,, I ,i , ,rrrrrI i r - iit : r ct 'sic ciizur j se poat c 1r '') : Llr i" r n
    ;i expnlsie, nili m ar.e de 24 ore; .l r,, r rri (ir r r r t r r l. it at ; r nt r l. t t i'iiL, aLlnir r , 't '. 1! 'lr - r 'I . '"i t int lt t t l sr r t r ir r it
    c ) | t ' - . 1p, . 1 ;:' .. l t" trc (l i a t i q :ri n rn . i n ri ntpul s.ru j Irrc,-Jr^, ,l rrp;-inasl ere):
    d) s:crefii va:;inale lrraterrle anomralc iinctliat inainte, i,r'timpui ,,,' r,1 rr{ ,rl ,:1. , 1 1, , , , 1tii sciLzut ir la5li, ) .
    , _ sJu
    rlllpir naftCre; l , rrrl i , 11r '. li, lr 'i<liagnost icat ir cu plim oit l! ': cf i': isl: r olc: t clit ' poz. ilir 'L'
    e) scmne si sii::r,'r-otriede infcclie la copil (prezcnte la las|crc in primele t,,' ,1"'r li' L r t Lor oplasniniL) sc Lt : Llc: r z'-cLr L spir anicinl- r .( lir vr lr r r ir ir r 'r )
    , ., ' ' i- - 45 zilr ) . sa11 ir ir iinr : it t ilir t i ( ( Lr r r r l) r r r r r )
    J j-.l r c ) ; ,,t| ,, rl r, rl, I r r : ir , L ', . i t im p dl 30
    f) copii mici l.,lntru r-irsta gestalional:r; rnalfor.rn:r!ie congenitali. , ;,;.' i '; lr , ', ii, t r inr . ir r i)iau sulf aciiaz. inili g, 2't r or : r '( 6'siqr t iLr nir r i) . 1'r r r
    'sc
    ,,,,' i ,,1 , , . 1, i|irr iuiciniL lt or Lc st id': t t r r r r l l"l: t 1lt r : z'r r ilo| t lc ir r l" {i'
    2.11,7.5.1.ln{ecfio cu virosul cifomegolic , , r ' r r r i , r l . L l i , :i {) 'r ,i .,,.
    I)oltc plotiu,.. "tnbrioprtii si {etopatii. Riscril ilfec_ticifetale este ma I I u 1 |! l i i 'r r ttl , l l tl p i L zi u ;t a ? - l L r i c vi l l ::- t s. i ;i ':'' tr L ta n r tl r l - r :tt l l i l i r r r ' 1 r
    ||).rrr un(t iutcclla DiJmari a mamei surtine in prirna jumtitafe a sarcinii. In t r r r l i / l ir 'r l t.'r ''sr L u 'su l fa cl i ;r 7 'i l i ( ) '1 g 'r l i s,l z'l tr tc i tl i l ': d r l 2 0 zi i c) '
    rscrn.nca,.imprciur.iri. pot. apirrea la nou-niscirt mai{orrueiii (microltalmie,
    rrricrr't,"Ia,lie).
    sau o irrupatie g_eneralizatir, mani{estatl prin purpura trornbo_ :' I I i'6 .1.lrrlc{id herpcticd (herpex simpiex virus - ilSV]
    , rl,,rlcnicir. ir.p:rtcsplFnorneHet;",_ hiperbilirubinemie iu liiir-ubin e directi,
    ,l, llcs:L rcspiraro-:i;, .q111ede^irita{ie ccrebrali. gi modilicirri osoase (zone r n r r i r lr r 'f c!"
    - l IS1 : - l sr r r r i i l r r r l l )
    ci 1 , , 1 , , tr '' ,r ,;i i r r 'L i cr t ti p u l l I ( Il S1 - - ? ,
    rJd rotransparcnta il r:r,olu!ie, se poate dezrolta o trepatiti de l. -[11i,atiil I t t ' t' 1I r' I t r' I i
    :liaiize)..In , I t i:l l jrir)t..j ,iL, cotrliuutDitrL: pcntr'Li [o rr-t-riLsr'rl
    ' I'r_r]rc
    grgalttc. \ lru.ul i!' chminl prin sccrefii ;i urini.. La llD rxamen atent al
    l ', , 't , r r r r r i i r ';l ;r tr, tto u - r r i i scu t su b i i o r n t i d i * ' r tr i tl r l ;'i r 'i r r r Io t i r l i zr r l i
    (' rr
    -,,limcntului urinri :u.pot vcdea_ieiuleiribirlare dcscuamate, ce prezinti-r,in_ , ri, rlil,"ri q.'',zi;il)crliallic,\'oi. 4, prr,:;.5!)'1)'
    ( Iuzrlc,nuclearetipice (in ochi de bufni![). Ig$ sint crescute in i'
    siigele cordo- ir irrplic:n-,.,iNl
    fl"Lr
    l,rrr ir rlli.r,nlrinlr{r'r |rt'rirt'n r'. r rttIt-1IrIi | :rI ' 'l'
    r'|lr||r, L.L.l(- arL-atrbumnorehiecrescut5.gi pleiocitozi. Diagnoiticul este
    .r'r,lrrrxl l)r^Lcnr.1 p-rrri.orpilor.pecilici. \u existi i"rrpi^ c.i"r;rii. Supra- ,,..,,, ,,1
    ,, l. , r t , r yi r i', , r i. , : r Ll' -lr '. i r , t ; , t t . j. t c, t t r 't t ir r r l, lt
    .dn 'r p'. Lvi, : 1
    \,r,,lritorii p.rczin:. rd*.,'a ]-ziuni cercbralc: micro"efaji. L calcifjeri fine, .' ,, ' ,,r ||, . r ', : r , : l, ll') ', . t i'r 'cci, ' l l' si r L l: ''i{r ll"'
    ', t ; r
    ,lrlrzr'tr cu lenornl'le neurologicesevere(ex. sirdromul Wcst, spasticitatc r,,r ,rr . r , ii , f it it t : t li r lc inf r : c! i| cr . LT{S1: a{ccier r i inl. ii {icat t r l' 111: r t t 'lr r
    r.rrtrhipotonie sever'5) ,,' ," ,,.,1. ,. , it , r r 'r li, , lir r si alt c or 6', anL'. DcLuiul |olii cst r :ll 6- - 2l zilc r l' l'
    "
    Copiii in{cctali care rru prezintr'rsemneciinice de hoalir.excretj. virusul in
    rrtrrri mai nulli.aui, j:ind sursirde inleclie (mai ales prntrn graliidele car{r l r, t| ||) , . r r . . , , , , r , oir r , , liii1, , SNC"( cou. r , . Ll1sii) 1ir. , r ilu1; ia io|nci rIi I;, .rI ri rr, I , '
    '
    ' ( , st lir ii g' uir r lr . ic' :si Cl) l ( ilr lir r 'r l'
    sor
    I uclcazi in secliile "Jecr.lpii). " ,,,,,, 1, , , ', , , , r r I I , icr - ir >r lt t r 'r 'r llliilir 'lr '
    l i rt.rt t r rlol'ir iizir lii 1r o; L1ritrnpLica; i i'a SliO si iLl r r Llosls''7
    1n111 1'1l1ir r lrr
    2.'l1.7.6.2.
    In{ec!iorubeolici , r I l r, L, r i1, l, , l, l, ' sir t i l't r r lr t r nlLl.
    Vczi PediatrievDl. "1,DaS..180*185, i88- tgl. i ,| | |lii, , , ] r r lir r '( r ll s[ r t : r sr , 'r 'ilt icr - : t illlor ixlit i! t ( ', r llLr : 11) 'i'lt llt r t : 'r 'r lt 'l''
    /,r.*\' l rr I l rrrrl , lo, t lr lr r {'" l; r l) i( 'l( rlllor l illit lilcr t lsit r sr r lr l{) "t / oo'
    ( r r,
    V,l 16.? Toxoplosmozocohgenirqld \trrr, , . r , r r , , r r l, it . ii|r , ir t l li uli. sr r l lr ilr r i, r 'r r lii((:()II j rl Il t i \ i | ;i , I i( r r r lr l
    (: l l ()l i i t l (' l l rl l l ' r
    ' i' t l; < oplas nl I' ,1,,i tr r l .r I r, . l r, l r' 1 " : i (( I I I I L I I I I i rt rI t rI I i ' rri t i r' ' ' ri )l -rl l t ' l l ('
    . ; 1 r:,r' i tii rs
    i i tcu n T D 1 | i o z o l u m i c(2 - 71Lrp)rrr ti i ri l r.i l ,ul i r.,,l j l l i r '
    i ;r l r;r lii lt r r r r r lr . itr,z r_ ri rrtrt'l1rn i rl l tl r.s i r' rl ,p rczcnl l rl tl r,' f,,r.l l .| . tl ,. , i i rri , ,r r '1 l ,r r , ,l r' , l l ; rl . l i lil.
    ;i llll)iil' l)rlllirlrl
    1 ri,i ,i i, t llr r it l II I I{' Ir. ,,' )I), ' r:i l j r' url c ' l r;rrrs rn i l r,r-icsl i i t r:orrsrr rrrl l ,i i r.,ri i i rr:IrIIi ,.Ir,ri I l r , , r r rr r tl , l ,l ( ,1 1 ":r l I i 'i , l i i l i r r i r ':l l t ttl r l r '' :r 'l ' r r ' ttl l ctcr r zi i
    f t tI t I r' ( | ri | | r'r' l rrr l .rr ) . i i ,; l ' ' ,l i rl ri ,. r' ,,1 .ti , l r I.l . l l {i ri r,t. . r r r , i| .Ir r t't, l t,'. l .r.z i rt r ri | . . i ii I l i l l l ]|i i f|.l .fl .l l |,.i l r t''']i L tttr .l rl ) ,'|i |tl l l l ,l ( |||
    1.1,,|

    ir1;i'
    .i ti t;
    i
    ;'llll:l
    :,ll.ili. llll.r,ll,lli,
    jr , r l- l r ' ulllr
    (irr prlzr,nlrr{irr
    1,,h;u:i).q:ru_i)(rcirp
    , [ 1, \rl rl r]l )rL Z (,l tl .rtc d c u n c ri l l li (j | | r r.ctr1l rr.,:
    {.riir}i,liaL).,,\llc rlrrnit.r. ;;;l;,1"i;i:,,,lliii,i"l,llli:lilJl';l::]"
    ll;ll;
    ll ,lilii,' ij:,i'':l;;'' ''ill'llli'''
    t:rrsicrr:si tlc pr:tt:sii (Ia nou-niscutii cu lcziulti dis,irliu,,tc\'
    i u pri mel c 24 or.0rl rrl ti r,
    ' l'l'i.'','jll:lll, '1"' !ll'ii'l ' 'i
    .z.t,,.r,r r.^,
    1,r,.s] j:ic^' :pi
    ri ,,
    ll lL ,t,j{ ,rt :]'
    a rncmbranclor- Dacii sc consrati microccfalic *"
    , l .r i ,n u -ri rrrL i
    P 1.i qn,,;,.24 oi trrpj rrasrcre,tt-
    l ,l u l i a tu l i o f| c ri c i a s.r-Idcni e,l u1,.; ,,,u;,-" , pi cl rrrgi ti lili 'li'i',:il'l;l
    i',j,rr i;'rii\ tii,*ffi1,li[i;.iiri
    rii:rrir';ii..l
    ril'iri
    .r,,jrtoi"ii,riti ir primckr
    zile de vialir, clc srigrrcezir o infectie transmisi. tionrpi"."r,.,.
    r ] l^t . , l 'l ll 'j;i1l,,jl't;ll',ij',1'j,r,ti.il'::,"1i,'; l,':'
    l'."il'lij.,';l:illl'
    ...1 s u -p ,.re J ri dd..r rnarn; a c\.,r. ' i .fpcs i , ui i al
    ,. ^. . t"? ": " !,,,
    ,l l ..i .i rri i :c l s o a -i 9 1 111 pri rr gi 5i r.r;rdc i rr..l uzi i,i ,.,,.i i corpi ; ,,l]i,'l'l
    ri'ii;' ,"1,1'li', ' '1,'l'
    *,,1'll-):;' ';,1i",
    lrillll]
    no' ns t : .ct ". _:
    nt ,rt : rl r l 1 ,:,.,2 rp r^ l ^ l ^ c o l l r,. d i n l ^zi u' i l e { .ul J.i rte.
    ;:'l; .;1:
    i,,i,,r,"1il:',.lll ,,'i
    ,,1,','',,1'
    ,,." "iiit,:,..*ii:iiili;,,
    1.!" r.rrli nti corpi l or
    crcstc la copil.- -
    , i,,,,',,,,.ii, l,',,,
    .o.
    , ^,
    r .^.11
    ! ' pp:
    : ^: ^!S:ojr :-,-l
    ( ri,t_
    : : : .rtrtt 1 ,.i
    z l,l .n ,r,rru IIz r
    consft i n o-i tare:r contactutui gravi -
    n L l ..rp n L i 1 -^ ;i r rasfr.repri rr co7p1;.r,uIa.gravi ' dr C U
    lr . r pes genit al i r, ,ru n ro :rr' tl,rp u l s i c i .' ,,,',;,:li;liii;iljli^-l,i",llii.'1,;ltlili-i-;:;li ,,1\,
    -1,,,,*,,,i"
    'Iratamentril curar:ir':
    I.D.U. : icloxuridinl 50 _ 100 mg/kg/zi tbap de
    (,ara-C) in iormslc 5gys1e.\ritlarabiiia (ara_A) ^estc 'lrllr;i,l,ii;l',ll,l li,ili li,
    l',i,,,.'i',"i,., :l''i;i i
    l^rjl::-t.-.il:1it]:iLlabilozirl
    T"t,llll.ln,
    ro,xrci '15
    r lc - r u z lt el. t n d i n tc (t^ .ng/k_g/zi-. inrr-avenosintr._op^1i63,;" d^ r2 ore, rimlr
    r^ l tl c i l r.d a c n c ru i lratanreni S c l a(.^ hi opsi c cerebrul i ,
    dac:t nu se giiscst. \.ills in creicr, tratarnentul se opreste dupiL S'zile.
    :i * :i,*i,;l;t,l
    ri,: rr,ii'liilrtiin"'*
    ru'l r":':,..*rlr"*i,i;li;,,1
    ii;r'
    2.'11.7.6.5.
    !i*ilisulcongenitol lll
    :;,:,'lll,,li,,l',:',',lil'ii,li,1',1.;;..;;lij$**l:
    Vr:zi llediatrie i.ol. .i, pag. E30 - 840; pag. 844; pag. 853 _ I : 1,,', ,i,ill"l;'ll,ll','1"
    l'l';:]','
    irag. 8.56 866).
    855;
    ,,,,,,1',i'i;'l'11,1J,1''1,ii'l
    ,illtiriliiili:':$ll;ll;lt::';'ll'1 1'|)'|tI'
    2.'11.7.7.
    Riseulin+ectieimqlerno_letqle
    cu virusul heuqrileiB
    ' i' rr;l'
    ' 1 , ' 1, ' , t , t , " , t i t " r "t ' l'rttliLuL:tiL:
    n^''': :-!'''
    '''""

    .,tali
    """,,,t:"1*-i: ::*,i",1^gl"l
    anhge)tI.\\r
    ci. lunerea.in evidenli a I{BcAg (kefatitis n
    H\.4 q-(hepalit;sA antigen,
    ) nu reprezinteo rnetodi curentil
    {rc oragnosnc.dln pllnr1 d+ \ Ldere procric, infectia mal erno_i,t
    ah estedominat iL
    ii'l+t*'iiul't'ru;i;"l.
    ,,,i,,i,ilit,*;lt*l,i
    rJ. pr^zcniarlBsAg (hepo/iris
    B .s t,fo,d'aatisp,tl
    i:'l:l.yr,yl,::f.1l1r'l 5ituJl:upurritorului f,simpiomatic.
    rn sorul DotnJVultLl
    'I'coretic, ar: irebui investigate
    toate femeile .gralicie pentru HI3sAg
    ';iii:1'lnil";:.11'';
    , ilr,ljl'iir:;il,l'llll:l:lllll.*',',':ll;ll'1";
    si la nou-niisculii dl" m."T:" antigen B po)ltiu"ii ,ri,,r cri*ic'r'l:,,,l,ll,ti'l,i
    'i,;l],:li'll;1,,i',lll,,lll'l:;
    .r-ezultati_ se faci dozirtj
    r)lxitatc in priurek: 6 luni de viali. 'ruri,'ti:r.
    ln practica clinici se intilnesi 2 posibiiitlti:
    Iirri;;liil
    I j,1;ri"1 ;l;l'11: rl'.:l;
    e).,:!l5lii'1ii*:il:Ji
    -
    a) Atur:ci cinJ m;.ma a avur o.inlcctic acutj eu r.irusul hepatitei
    in rrltima perioadi. a sarcinii sau imedjal p:ost_parttutila Z/:-djn n;;-;i;cr;l;
    R,
    l;r 'i:lll.''ll'lll
    lrn',lr
    i ;,/iliiii,* Iiil.I;1,#!,
    ;'*:;;;:,,,
    :r'ircriapcnLlu HlisAg tlcrine poziriv.rin'pririOc i- O t.ini
    l. iltLTllil!:.,1""
    30r"^ltmatcrule.lcca{r
    I.tc. probabiJiI morn, lul nasrerii
    Lnri(.r^. I\..,r}i,mcnca
    dc ta nastcr(:.
    t)u rat,. orali prin sir:_ rl,illi;;l:l;,.
    l',
    :l: li,li,lir,l i,;11"r1i,'1;
    ilJi"r*il;,:ll, l;.ll
    l_lBsAgse climini si prirrlapfr:.
    .;l 'i',
    t:'1,1c:,s,rt sugarliint I'r' z nt,.nrotlificiri biochimic"(tnrlt:.rmlnitzc
    sl nrsroro Elc, , d (
    .j.c,cul(,)
    ^t , lc , 1 r nodc r . it ln. in, l lr c p l t i t a acutiL tnalct ni
    l)ror,ll(:; sr.
    ,i
    i ',;llll,,il ' ,l",ll;ii ',ti,,,'"'
    ,,.,'',iii,..
    :i; ,),ll;l,i,"ll;i,,lii
    iu prima..partea sarcitil, lll3sAg s,. r,virlrirtiaziiintr_o proforlrc r ci l i i ]i r {l r ) l l l l ( l l l r r
    mli mrr:i.r !,!rri
    irr nou*niiscut.
    '*,
    r .r ( 1 , :.l |i ].r r l :,;r l ,,:r ti t.i '|.l 'i l i r l

    . b) Atunci c:ilri grar'.idacslo l)n .irtor asimptouraticckr LIllsAg, lrirrrs-


    tttiictrtit vjrrrsnlui i;r rrori-nirscrrl.
    (l('5 .15'i1,
    sriJrr.i, rn:ri put'iu h.t:cr,<r11.,
    ini.r<riir-olxrrlic
    \,;i'1,]il,il;llilii,.'il'ii,lli:,lilll'l;;,,:
    ;,11,,'
    ((i,'r'r'rl Il..f., sclrrr.ir.z.rL J-.)" Ariirrrl irr r,,,l,.ri,;r(r:fir(.
    (:.r-

    l, t;lJ
    ?_ll.'-l.l. 5indronruldo ;nfe.lieqmnioti.d NEONATATA
    ?.1I,7.3.SEPTICEMIA

    i .rl r , i
    1l conditiilc rurrri i r.rry:rlirr
    1)ii,lurgit, cu lulrnrlrrrari(-.
    'i'.2.1 ctc,lir.lijrlarnniotic1L,tkl.i *n,,it i"friiii,,
    rLlpte dc nrai lnull
    infectarcaI.i. f
    ,;;1';rl:li",{li,llf lti"i"illlif
    fi ititr:iii".-*qifi
    til,tftii?ii).:
    ror:-nii.scu!i^1i'^":iI:1,T
    t la 1-000
    ,-" i ".i""i"rib'ita
    I ' r f c r 1i. , I , r l i s " .rn ,rrri [.." r.',,,1 , fn r-"
    . p" i f" .l i i al a qn^r 1)i .. ,],:i," i,',ri,j"tiJcsic, rl 2
    tt r,re 5{ro.,
    7 500 ,r(),1
    ,)]l:lJl;;;""lii'l'$i;'i n'''ri'i'i ""n'';it"li"csie
    l]l]l:r* ],lJ:1"]rt,,,
    n|rinart1l
    in priurcle4 zilr ttrrpi nilstcrc.N1i c_ir-sti.
    dc orr. scursdc la ruperetr
    o corctalieintr.,,
    mcmbr;nelor si creptereariscului in{cc.
    ':li ri,l',' voi.
    (r' r' i ri I'r 'iI ilt I - iLr , : , pag - i i'i ; 1 s'ir 1
    L't dlit c[ t 't
    .' -ta
    inoi! ] ir r r r l'
    ' ca in l I r 'lot t
    lirii , fctalc. S-:r constatrt, pr-in.puncfia amnioticj, p."')".t" bacteriilor Lr rr,' rt-r t ; ist t i( ii. , o t t t pt "et oi" lZu- ': ; 1' ii ''- n"r l1t t nl
    lr<:'iclrrlarnniotir: ra muitc fimei .r ,".-tr..n"-i"i..ti. lrr
    ir.i; p.or.,ot,,it.n i,,- , ,, tli,:,,, crr liandicapuri neurologice'
    l\rii:l amnioiict'!ocnltiLsiL det._rnrinetuperca membranelor.;i ', ,,,,,,,,, X, ;i :tL.rltococr:i.;rup ' piczinti-r agcr{ii
    irli)ccit.ta travaljului.
    dctlan;anr;r ,i r, . li' li' i9rn, E. coti t\1t s t r ir ' pii' -Li
    n-'r r ' i ' r '" t r : ' t I ' '
    I l: , , ' : , i i , , . ,' . , . r ' 'r n , i i ' ' ' , i i i ' ' i , , '
    r i "l u i i a Fi St'r r r o - l ' 3 l r '
    I)r-ezerrta
    modificiiriro. i'frarr.r:Ltorii.
    Ia nivclul chorionului si al corcr,r. ' "' ',,,),,,,',,,,
    , r ', , , 'l ,,,, 1
    o"pi'to."u"s,,,:-
    '
    "i,ti,is,i,l't't
    ",l,"'1,'l I ".'1," 1-1',::"f'11".i:".1)i:,,ij']':'"ll
    :ill;llli:1,
    ,l],,,"1,,:'1f'11
    , . |lrt{.)rsr ri ll,.:;::11'.:..1.c-trrLurilot'dintichidul
    "^;1"11;, 1lt,ll1 , ll;]i;l;i*;;;;;,1_lllil"i"iil
    'tit,tj;it'ili,,j,i i,Jl*tJ?i:J'il [:];:,11::i:i;,
    [.ucucii.,-1orpe irotiu] aspiratul gastr.ic {etat nu clcmon-
    prczc'fa i'{,rctieiuco'ata',, ci.clin
    ,1t cr,;rir. numait"pt"t ii t:iiut . ,t"i.ir"' ,".#ii t,,,i I' r, tlti "]i,il",,']li,,t,
    ( ;t1 t1 i t'1 t.N !'d l i r '1
    t''l' 't
    i r!irl) iltr-ll11 me:rliu infcctat.
    l)ialncsticul tle in{cctic 1r!:ouatalirrin cadr_ul sindromului
    c1c inlecli,,
    lnl U$" i{d:i{i?iri:r j1,
    l'rntl.t.rt
    ll,l
    r;'r1'
    ',lnrotici, :r. {ar:,' nutnai in pr.ezcnta ,il], etiololic
    ,,iro Du l)ot il i:xplicate de er.oht1Lia
    unr:r trorlifici.ri ctinice, patolt_,gic,., '"atcrno-fetir1i.'
    "f,1ln",illit.'".pii.."';"'ir"nconatalirtstc ruar
    , ,,, , , ,,",f,,,,, fu riorlalitatca l]]::l;...,::t"i],'''.:,
    ,:l:,,,'
    rrrirrio
    fciffnii 't" -p;trrltrczi-'n{i r;L
    tr.avaliului si in prezenta unei hr:mocnl
    I rrri pozi'rivc. ";" ' ;i,l,liii:'li.;,,'l,iiiil;;;;';'i
    \iirnir.ui cle ro.-ni'.sc'!i
    c'r-r-ciac iufeclic in coLrditiilc ruperii prematur.
    ;l,lllil,i'',,;1,'l:l,i:,..,.'l::ffii. 1,,,,,,'|i'
    t:i::,1:i,l,l:,p
    rri .rlrraDclor cL; lictrid.,rl ar.niotic infectat estc re]aiiv
    nic. Numai 7,3,,;, "'.,111'll];,,ra,,
    l,ll.]]]l]
    zutt.iti ,lin nrsteri cu ncnbr.;rnerupte de pestezl'orll
    _-..1,:',ll"l
    "7rIr,r nl1!J1tl,.,rl pitfoJo.rc| dupl-Lnastere. Ilata decesului la acecasi catt,
    'orl,i ,l(r cop11osl.r cie 4,291,,iar clin totalul decesclor numai r,
    II::'ir,;,,
    iLli:ir;r
    ruJ*trqn*l;f!i!!
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    11,1',,'rrirr.lril''xi.
    , r r ( , r , l l rl t * t<:ttl i i l a u o u - n i s
    rl., ini.ctii:. ,\ccs.c date d;nonsrr,.rzt ci.r-iscul
    apar-iiiei
    Z0o/o siiit clat,. ,otjji.iot,,.
    ,r , r,,r ,,rr,irit,,l,,,.,,,,,"sprrli"i"- 1l:".11.1}:l::]':'.1]:i1.".i,\l','
    int"ilii fu i.,,r,, norl-niLscut sc,cx]ftir' in |rrr'1r" 'ri lrrirr
    ) iirri.rt'l pri:inaiur dinLr-o saLci:r- crr inl"cfic iu''uollci "n.i r.,o-,lt'glrttui-io
    fri" rnic dcclr ',1' r , . r'( r trr(!ti <; accst or nicr oLr i) t r t t lr " lt r t r t
    :r,r'rrl aparirii:i DIiI (D,:tresi., rcspiratorie idiop:rticir). -n, r,t,r rl ,,r l I11 ( sr Ll, ( , r lulaDt r cot pilor im pot r iva
    rri .r rl r lr l rr' rtl l i r ,_,t
    . \ umiLrul mir: rie infccJ:ii tconatale ascciat cu sincir-onul dc infer:lir. 11,
    ' ' t.- .
    ,rrrLriotici
    _'.llteaexplica,pertiai, pri" pi"r"r1n l"'l;;,ii;;i ;ili;il,'.; \r, li, rti u(()il.1aron.''lcctioasc,:t *ll';,^11]"T1; iiii
    f:'ilL1'.1:1,. .,1,;i:
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    .r-i-i!r fnr'.^1i..
    , 'll,i l:l lli,,;i;i;;i:'l'1,'"..,;'f;ii prici'rjL.1'
    .i)foL frrr .l ,.'i,! ( t St o{ ( iit | jr lt f lax " ) , c u c {e c t l n t i b a c t e r i a n . rr-tilizlr-L'a'11:'];]'li'l:::ll;l
    ;i it't.tiitotii l:tctoti:
    Acest eft:r:l
    ,,1]iiii:rrlir.]r f/enta lncr'oiriului in lichidutaianiotics:iu tle o virutenfri ,,,r rl, L rr,lirr(',,t,ti t
    l l l l r l i l l ('
    , "rr "Lttrrburt'
    in'
    , ,,rrl ' ,,,1,r,r1'ili lr r cI ilat lii: r ', ttziiI rtrrt
    . l"r,r, r rlr, .i lil):irr ritror' t""t u"it itittlio"aic)' stcr-ilizarca nl'cott's1ltr
    .r proflir,^trc:a d: antibio.ticel:r toli nou,nisculii rczrrt
    ,, ]:,l5il-.1
    :rr rLn s,rrclnr rlt membr.,n(- rupte de mai mult tirno estc , ' ,l ,,g" ,i r' , rilr r lir i 1i lt r lir it i
    irrltilii qi pr:ri
    , lll)lli: t .
    I n[ ' c i: , 1 1n , . d ,- o ri g i n .. u ,n n i oti r-.. , .tn rar.a. i tr. { o]osi r.,.;r 'i 'iii;11
    ii;,",1.1i' ll
    ,,ll,i,i,:',,,''"-,.:i'tl,';',iiji;rili""iil:
    'l"llll
    " ', ',',',','''""f l r r l l ) r r r "r r r
    " o .f,ta t., profilactice intr_un scr-.,iciu de nou_niLscrr(i i ,l:i; l l r 'r t l i tc r r [ccti tr n i i t'r o r r a t:r ]c It:i n [t'r ':ti tta sr "
    ,....1.;ll1_llii.: ,".:ntil,iot^r-epici .,\r l cst'n ', i n i l l ( I'
    'r' '.1,r .rc:1, rUa t.azurilor ,j. infectie secundarii, ca.rc estc redutabili. r l , ', 1 r , , ,q 1 1l 1 r '1 1 1 r r tl t1 1r tl l cr
    L r i r i g r l t:r 'r i l r r l r l i r
    1 ' l l L i ti r r'r n o u l cl l tu l t'
    simptomatoiogii clinico care-nu poate fi or. . ,, l' ,lrrr,' 'j ttl l r tttr 'ttu tttt"ti i tt,'l i l L g n o - ti t:L r l .t 'r r r 1 i I'i ''I'
    ,_..,)'ll:r:li l,.,l.,r.zcnta.,r1rci l t r l r r L 'l i r :1 r r ' 'l r l 'r t1 'i l r r i l l ;r l ) i r r l r r l I
    l,r!c.rt. ,.tl].i r-i)iritrJ.trilt.{ruhLi ;i.piniL la ob!i1ler:ca]:czultatului liemocultur.ii, r l r r r ttt' l '' i "t1 t":i 't'l 'i t i 'r r i r
    , r' , ,lminlslrri. r-itrv.r, zii" p.iniiilinn ' i,, 1,,r,rrl ()l _(
    G. Acest tratamr:rrt arc ctcct {trror.rr.lril ' '1,, i .rr I rr(rrl l i l i r' i l r' \ri l
    i, . r I l , r . r ,
    I l . r . t , I . r rl ,i. .lr lu r r n,. -,1.11,, ( l ( 's( l ) l i 'r ( tr l i ( ' ( s1 " stl i + r ;r l r r r r r r ttt
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    ,l i ,r 1 l r r r r :i l r r l
    l r , r ', r r i 1 1 1 :,tl tl rrlLi lli;Il ti ilrtli ttl
    irr corrililiiir. s'rci'ii l l l l l ) l ( 'r g tl 'r tr
    c. rrernlr*rrr r.uptLt tk: t*iLi riLrrlt clc. Z,l ort, I.isr.rrl ,, t r , l t r r .tl ,t.rr 'o t' r ';'.,'ttr r l t- l r i i :l l ttl ttl - l ) i l l ( "' ^ tr 't
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    p|ornal.rrr1, si lir irl,il ( l j r r i ( r "' I'l i r l l i lrrl
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    . s,i
    r r : ; |i|r , lor - ir ir lioPr L L i t ; t i . I ) t L r : r i s r t I
    "
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    :i tt Il 1 ' "l 'r r l l r '
    .
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    "'l f'r i l " 'r l tr {i l t r tsr t1 rrt t r ':ti 'r tl ttr
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    l, .r ,l! l;Ut,i.r|r.,r r) it , , l( , lii.

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    , , 1 , ; , ,,'t; , ( ,i r r i l ,', ,'i i tl l , l ,t.l 1 l i L r L l 'r 'l l l 2 l i 3 ) ' si o n r r r t:'
    s ( ' x r n 1 ( li ie 0 ir sr lti( tllr ir r t' o r a 1 $ tir (l l r(,,tj j ,i :t ,l r|:! L : tr l l tr l r l rlr'
    J]el Lrr..r.r)
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    t,

    S i st. hfn)atopoi eti c


    I',;'i
    m'tfl;*.1,t'j,.[*:i,'1il:iii:';]Llr,,
    r r r Ii l ,i o l r r 't l t so o Pr cs{r - t'
    Icter (cu
    bact c'r iologicc sat r . ellc r r r iilr '
    Singerare '. ' I i 1 1 ,ti 1i " r /o i r r 'r l i l r i ( ci u ci cuit r r t iL conr lif iot r lr l pt t t'
    L : , sp i fa l rc n (x1 ,:l u L a t:- l
    |urplui/echirn.ze t at ogcD silu
    , , , , ' i , , ,,,, p tr s i r r cvi d cr r {i L , , 'r , g, , at - t t t ,l)
    j r r l r i t,l (r'i a p o .f Spienorregaiie
    r 'r li incep'r t . . {it . t ''. t : : t 't ] l: '
    I t ,r I t / it i iI I t t . l r r t Lanl. ibioliL: t i1l] ] : l
    \ i |l l ri ri l {l j t( sri /
    i l:iril,,"
    1,,:i,, stei..L
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    .1i.l, ,'"|ll.'li]::ti:.].li
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    ,,', ll ;:iill', illlll"l::il';:iiiiiilii" J:,::l:::i. ,:';,,:
    r,.ii"'i.ia"',
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    ''"n'it'ii:iteqii :i*lilil, ljli'';
    (biliorsc) lee[mcnte rcci/ unlede
    i )i5l o I s i c : r . l ) d o l r L r l L:!1 :i
    'fahicadie/ artimi.:
    H i poto si ul 1l ]
    iir'' :" 'l
    ti"1l""'l'11.'.li.r't'slxr
    ll, l, n r . a l c p f . o t . r t t l i a 1 ) .io r n iD:r i
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    .r, .._ _lll]:jp1""
    monltonzarca
    posibilitirlii unei infec{ii va avea ca rezultat supraveghclfir
    nou-n5.scu1:uluic-a-;i efectuarca unor "parr.a 'l'|rr'r ! lr'rl'rrrrlrrl"ll'l :.:t:-,:]i.'i
    i'Hiil;ti:j''1il',:'*j,,1'li;i
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    ,l i tri, r . P o11111 ir -r I)u L c ao [,i -c ri r,r d n b u trri u n-i ,.P l ;c.mi i . .explori.ri ;::;ti; siPriirrri
    ln
    " -o.rn
    .,r,,,,.,. l':.'ll : 'l ,l],i']''lli;:'ii'lliiii:',Hi 'no f't"t"u"i'itri-6
    trrr. r r l. -J r l, i" . il, , " l i n i c : fi ' L m i n " .i ,t8 u ru l .riLnri u r.al abi l i rr i :ri ri crt.:r trel ,, r r X:' u r ttti l o i tt'l ' tn t- '.tl - t
    rrrlrtului cu antibiotice. , , r '| | "tl
    ',1 '1 1 1 i i 1 r l 'r l i "'s' i n sti tu i r ( r i l u 1 1 {- i j ) "r l 1 l zi i :
    ln.lipsa. hcmoculturilor pozitive (de preferat repetate sl cu acolasl i r l , r 'r r l ,r 'l ..i r i r l i r tr | r t La ti t'i o r :i l c |;i
    r ['tr L t'n l c"si i :i L g r r l i tL :t r l tt
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    .'l tU{ r ) , r l r '''tr si l l tr t i i tt ' r r l
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    r0 :r t . i ul j in c a p i l o l u l J n l .ri o r) l ra b .l u l 2.E t,. "u p u
    ' l '''i ''r r , I : |,Ii L , t,;r r r r t.i tt'L ttP'tl L l u r i r ':o u sta n ti ' a In t:i l i r th L i . ;tr l tl r i r tttl ;
    r l ' Ir i l "' t'
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    1'dbel ul 2.5I ', , l tr r i tl r I :r tl r r 'l t'
    /'r r ( ) ''
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    cilir n iij:r u lei LU R h rou-lrir.r(j|t (dup n StlrII) "' r n tl r ti r ttr t'c;r t't:l r i l i l ':r r l r r i l r i 'l r "
    , , , r, , I r r r r r ttci r l ,l zci tl ti r ti tl to l i r :t' si
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    t"
    ?.11.7.9.l\itEF,tiNotTA
    FUnU[EN1A 1r1i L n r l( r t ilr i ci r t t Lr r t jt t ist lit r cailt r at 'ahkli; lni . lll : l] l: l
    p ti :zi tl i i r ' :tr l t,t
    l ', , , , , . r 1 q, r r tr i r i ttr r i ( l l r tr t'r l ti n g i l l r ( :i r g cl - o - i |) l l icn tcr i cj ) - n r l
    r tl r l i l r i o l i r tr '.:1
    '.rrbuie suspectat[ r,r L r r r l r , l r i . ,, r ( l r r r r i r l str 'r l l ' t i , i i r - ttt"n ti :i tt ttl t'r i i r r tco sl 'tr i
    ]r r;r!r:i:
    nou-i:i:_.cutcr s.i,li
    . int . ' r V r ' .I l. , .11,!r]1t'--rt';
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    'i r L ( tr i cr t I
    I ; tt | , n r, n i rrg i ri i p rtru l ,,u . . Ir r, ,.r.,.rr r.i i . t.r.rr,.. ri r, r , r 1 l /.i r J, ( I) I!1{II1 Ii Ii r i II r u a r tl :r :i tr l i l r i o ti cr l l r ''r
    .,' 1,. ,,l rrlrr, : r r r r lr |lI r 't t i'f Lr r : ii'slcr t t t t lar e nt 'do1'l1o:
    'l l r r . : v , , i, lr L t o tJ l u f n i .!s l rri l o r s i d c l ,5 o l o nl rrpr.L.rn:rtul .i . 1i 3
    in 6;1 a,,,,,,,L ] lr r 1r ( r ' lr r r i'r '
    lj)Ti..,rr J qf oirrrrali"r:c jr:ociazi cu meningitri puflrir:ntii"
    Clioi:r. diaelD:rlj. \i i ir r i ll, r r , r ir ir t ilr t t : r llir 'ii; m ira alt ibiot ict lor car c r ; 411111; 111
    L trlr:i in ;l,.,ririciiit r cf ] czclll'r t dc cf r ) cLr r l 16] ( is ; r 't i'
    .Dr:r'ulrnt
    ( ',L nr r l 1lt . i 5 1 1 -.p i < .i rrn e .
    r o cor.tstjtuia ,:lccirrirrr:a punctici lomlt:ti..r ll ,' , '1. r , r i: , , : r r l [ iinr l
    1"1i"
    r r\ ' , ' t '1. ., , ; , ' '. c'
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    il r '' r l"r '
    ';irtt ;rscm:"rniitoaro c1.1citlc din septic,,tliitr ncouatali. Sple' rlcosebir.c ti... ,:r,.. | | f f' , , i, ', 1, , lr , t : a'r lit t r t it'i''lni : L {r . r st r r " r 'lt lur t tl.
    l: L llot t - t r : r l r Ll
    ,,ilril trart-, in menirgita ri."onal ail-r Ir.br-a si bo'liaria fontanelel st c(nl ,, r ii I r I . r I t iI I Lt r ',1. 1llt illllt : ttrli1 r r t clr r 'r m f clr ic'r l "\ ''inr l
    'rai ' rl rl , trtrcistrictc1:l:13:]'il,l ', :i:i",:ll
    'trlrl{i:r f(ri )ipsi, ier rcdoruea cefr:i cstc inlocuitl uneori cu hilntoirir. irr I r' 1rr' r;rxlitiilc
    ,l',,, ; .'.r1"si ilri'rtrr'i
    -( rttrl, Irir,orl,.-te. par,Lliziilc ocu1ar.c,sp:rsmele I i l;',; L'LeLcriurlrttic r"'L
    1i 'Ls'r.ti' ',tri'l.trlrrrrrr
    clobiior oculari- si rlisiilrri ' 'slc
    1r.t tr'll, r, l,r| neonattlr c,.csc suspicirnea de meniagiti. llxarrrdrrul i_t.lt , 'l;l;,1i,,e11i
    , ,,, ' ,,",i, f,iii 1ri cu
    irrlrrr:fiilt L c('Lilonni l{L:mo'rrltttlil' '
    , sii: irrdjc:it la nrile prernatrr caic iu cvolueazi
    rrllLui|::i,, r(iP(:i:t(lup:!24-3.6 (1") t1'1.1'l,ltt',1,]]"11
    favo.iiril, 5i cste obligator.itr | ( li, rLrr,r 9l'l ai'at i 1i" t : ll''rl
    rri lrrczf'tta rlodificirilor cic tonus, a crizer<tr convulsivc si a fo.taireiei srrl, tr' ,,' .rl rr l) , r r i ' Lr ! t ir l, ', , t t , '- . l"t t iir r qt lLur ii poTit ivii -
    l( t ( lir r ' ( l' r 'i
    11r ) S l u r ] t - . .
    , .1, r , . i r l , 'l 1, , LLI , , i. ir lt 'Iat ' lr ninist lat i:' {i''r ciL sinl
    r r r , r r l. u Jr..rn ti rri J c j r.-n o -ri c ,.\l c D l nerca i n ,.vi rj rri j r ,i l rrr ''i, 1 '
    .'I ,! . r !rnrr. 'I ', l r ,, r 1 (ci :i i tr - t tl r r :u l r j ch i t u tg i c;r l
    l tr r l
    l( -, ll r nor rrh u ra ,.-i
    - I lJ t n L 'i i n [ '.'c ,! i r t :; :'t r 'i l r r
    l .,7 i l i \-i i 4 1 0 .; ,l i n cazuri l c d,.m,.rrj rr,;i ti p,,,,, I ttl tt ttt l ) 'It! 1 1 ]]L 'i i l tL L i'
    i' trti. lu crzrrl in care i'i. r" cfectueazi dnp;, on tratane,nt anterior si Ii l t. r r l ttl
    cu intti , , , ,, .'i r r l { l }i ( 1 ( 'sl !:r Ji l l {r l 1 t l r i n cJi i l n r "i i :r l r '1 ".':o r cr '
    i,loljc(:, si c?t.rdrata dr: izojare a gelxtcnilor'csle micit, Jtl t'1 :i r l tl l tti tL l ' t'
    detectarea antige llui i , r , , , l 'r r u l',r l i i ,l i cr ', l l l i cl ) l l l l 'i 1 l - 'l l t:tr t:"1 tl i l :o p l i ":r u i '
    )ii111'rIro prln contrirci : ._'Nt-inunoclcctl:oforezir poatt; r 1 l ;!r s:r 1 r l ' r r l r 1
    stabili diagni:s-Ltcrrl t, , , , , , ' ,,t.r r , , l ( :r r ( ) l ) i r Ib i fi r l 1 ( .rl o .i i l ;g /cl o z- r i [L i 'tr cr t*
    I llo l o g l c . u l i :i i i tl r i l r i l i i t' 1 't
    , , , ( r .,,;l r o i i r l l r l i :1 ;i i i :i t 1 ) t'tl trL r i n i u b i r r l i i u r :a zr r 1
    . ,.1n pr'uele_- n zile clupir na;tere, rnL,nirgita purulentiL este pr.orlrrsl'r
    .lrr-lf,ll' , , ', , ' , 1 ,'.,, i ,t,l r i i t r cl cti r
    ( L tl i ) :- i3 - - 1 2 o r |'
    c\ent ft l,..oli t;y' Ki 1i clo.rr"piococul"grupR ri|uJ IlI. )lcui,r.1iur n':vrlllll.r.i,
    || 1. ' : t r / t , t t ut t ! ..l o o t .t n \l t, 1t,t li",r/irrr in rr0irirrgitaPtlruk)rtir a n?Ll. l.l ] .'ll
    d i .ti n g n p ri n r i spun.ul m,ynsnL,cl c:rr i rr L.l ..l i . insi: it uir ii t - f iLlir t it l: t t lr t lr t t
    '
    rrr . ( r , r , 1. r ir : tc ir p l u d o mi F .n ta p o l i ' n o ri o rrrrcl nrrcl or
    dj n ,nnni rrgi tcl e rl ,rl l r.
    ,1, r r 1lrr r lr r l t l: iologic ; t
    'i|:r'rltLlilu
    t t ''JJ"t "t t
    ct l, gcr ln( - '1r(iir illll r'l
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    i r,, i\ I . r I r r I i1lr Lr : : L m lLL in m cr r ingit olc
    tra vJ nci nfFcIi oaqi . t' pi i (cmj ,, sr.. aio
    (rL:uill Lir.t,',;cLrtc-
    t ttrtrl;rri sr: poate asocia cu rneriinfuitipuirlenti.
    ln aceste impr 6jui iiri aqcrr,
    , r r,,r,l,rrzi -'rlirunriuor:ahi"l: ,1.",.,1]',1,1i]lj
    <1ir i LCR ; i o lr l' i. r il"'"'
    litl trtiologis cste_reprezentat mai frecyent de b. piocianic, izoiat' adestit <lirr rl i t, i, t u r si, 'l. r r i; L r r licr ol; il; f i; ; j; lt iir ilc
    , l, lr l {) 00 l- 1( xt 0/ m l.
    't t',r inc uL: t o^r " l o r. c"t '' r r Lt t t ilr t r 't r "r
    Atunci clnd meningita pumlenti. Iii nou-niLscut recidiveazir, acest luctin l i rl L rrr, rr t rrI i I Ii ! i i it r f Lt t . t clit rr lL: 'r 6Lllul r 'liL'l?. ili''
    I c J)o;Itc datora: prezenfei unei anon.ralii anatornice a ctaniuLui s:Lu la nivr:lr t it t t "'1, t ". t oLi ( t 0'i', 1, 13 z0f a'. f r 'r ir t r r |lt ul i) r '( '( ( ) r t r r l
    ,. ' ,,,, ''t '"1'l''cni vir r r l' r r r '
    i"'t ii' *r " t t t o'tt f 1'- ' '. ; . : l: : , ""
    t,.rloanci vettcbrale (sinus dermal); unor depozitc dr: {ibrini la berza rrrr" 1,,t, I ' l ,,r r . r , 'il, r ! l: r , l, , l, t t Lt t L csir : l''Lr cliv i[ 'r nir r 3'il: L l) 1llllltll1 |
    trtttltti r-cziduale de la treningita originarii; unei colectii sultCur.alesuri rlr I I 1u 1' : r , , r r l i, , l"r v't t t 'r 'l 'ir t nt 'I t uL
    ,,' , ni, ^i. , r c r in rl .c rl s c n r.n 0 l n 1 . l . ,, it ll't; acliit slc cr 0lt c t ". 1. : . l. ll;, "i. : ',
    r , r r i . 'r , r lt t r ': t z; ,r', , , ', "''- t t t \ '. nt i: ic'JI ( l u Pl 'r '1 1 IIII) i IIfIIII lrlr
    , ,,,,I', I,,],,,. L l t to p i i i tl i r l c su p r l l vi c fr 'ti rr :i ( l
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    izoi:r1i si do scr.rsibiliLatca. .r.ccstor:a.ln ileningita ut lj.coli: ;urrpicilirr;i 1
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    li h i r l r L r r :':l ;L l i L r ' Stl r d i i
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    '
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    ,u ,li
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    f,i cir r i.
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    :::' ; ,;'; 1,",i;;,; cot t vt t i; ii' l) r r ii t . pt t r 'r r r r r lr ( 1r
    , r : ', , , , , , , , , ', , t "ir ii liii( : . 'r ' li"t t f it r i
    .l rl r ' L li ( 1r ' r i ( ii l ri tr,),r c l i rrri ;rr.l i v ) rl c L i l: rtsi or;i l Ll < i i l r Il r1j l ri oIi < ,' . .\ tl r' 1, ,,,,
    rr r , ir lir , r , : ir r lr r t i , r' :,1 , ,,,' trr r,l ;rl ' i l ril L r i rrl ,,r.i i i l r,, r Ii ,1,,j rr ,| r' ni r,)r.Lrr.

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    fiL ri/r/'A ' ^P l i c ^1nl !-ii 'i
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    l t)it ) t ( it s t { . lilr . t io c , c l r{ o Ii L i l i L ' r' ri ' s tc ri i rcal c l L Inrmi uul ui dc i nftrci i i , l i o
    lr:r Irclioniirii tehnicilor dr: jzollrc alc acestui mictolr. listc 1'e1121 {i,'11tts1tr'1t" , ;irl,il
    ,,rr,,l i.:'r
    . 77 ti P rrl

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    r l 'r .l , l'
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    loclr: p-hcrrolilic Lancc{ic1d grup 13. Grupul de stroptococi }l a lost ,Lii ia;rt
    il,l, lllli], ir r"':0"2.
    i,;llllir"(rrlpli no.-nLcu!i
    iir.r '^ n /
    r i r r n ^ 'r - n :r 'cr r ti i o l o n i za t"a ',',
    in 5 tiplr:i, tcaic avind un poiizabaricl care continc t-:trnnozi si altc r',rJizit.
    l,r riricipecilicr: t'lc grup" Acitiul siaiic estc plezcrt il g-r:rqrul'Ia, 1l) ..i lll, zir(
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    i'iip':'''i"il'il:t,
    : j);?.,";:i: r'u i,il,:l:,:
    ,':,:,,i'li'
    'trirrt"rt fr"i'*i'
    \r'irlrrl sialic -co
    1r'opisnr sprcilLl-qiscste
    ;i in capsula li. coli Ii1 , ambii uiclobi prezcnlirrrl tttt
    pe ntm m.:1in5ic. It:rl.a cle purtetori rnaterr.ri ,.lslt-'d'.' 3t) );,; l' ' :,;lli','i1':1,','1,,1')
    i.
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    ,rlrilizarea rtou-niscutului rlc la marlir cste frccycnti, concor.lan!a ilirrllt'
    i)i r(\'h.]a marn:-r-nori-rtiiscutfiirrrl rir ?0-o,./,,.
    I 'rr.solralu1u i dt-- irgriji,-c csti: tot ric 30'),i.
    Iirecvcti{a. purtitorilor in iirrrlttl
    rlil,il,;ll'lti::di:':fi:!,i:::,
    'l;i:lil,iiii'l'ii,i}*rl *jlt15ltt,,:'1,'ll,-*':
    'iliil {x!.i:#",;ili::lii;lli
    lli,,
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    ,-\trcptalcocul I3 pr-otluce 1:r nou-niLscut douiL sinclroame clinice rleosr'lril'' opst >m z: r r - c
    i r r,,'r 1'r r irIriL llr gocit ozir; i
    ,
    , 1t , .F oy ut d p rt:c Oc rr, l )r-o c l u \.'pr l i i r i uf,-c1i c tr:rtrl tto-fct al i t, ,' sl I
    ,lritii dr: tipui I .,.iII. lloala po11,; avca aspcetr.rlunei srpticeniii sau blottlttt CU tlsTERlAM0NOCYTOGENE5',
    :').I I / l2 II'IFECJIA
    l)n{l1DroniacoDgenitalc. Rata mortltitiJii infantile esto clo ?0o{,- L-neori tli:rll
    rrosiicul diferenlial cu dctrersi respiratorie idiopaticir csie {oarte dificil ,lr' l'r""
    l ic.it (tabelu.l 2.84).
    ,, ',li',,ll'l',,1,'"ll.lli'l,il;liJl'1iJ:frli:ir";,i;t1if
    ;,,,, ,,,r.,, t.",,,",
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    '
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    idetresr rospiratorie nlioPrticl)
    (ciuPt -{ll)o\!l
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    II i;iiii"lii llr'
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    Ix{eclie cn ji'il,l'
    l'i"ii.$ri"'j;ili.;l';;',111'.ll'l;:ii11
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    50'i.
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    ( . n i i r L i i s p i r - a t n l g a str ic l00g,i, 0 ,.ii,,,lrj,iliill',illl;li
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    ; r i, r''
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    ( r . r . r r .^ . e09'" i; i"
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    \ lr" , u l , , r r i
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    rlitPir 10--.50 zile de la nastcrc si t'ste proclusiLde tipul III. ilo rl'r c(' rrl,rrti , , II,/.I3 . IN FEC TIAU R IN AR A
    lcsli srrb lorrna unci mcni[git(] purrriortc, cu ratir rnicir dt-' njo'talitiiil lrl
    3 , |r r "l 2 t;0 7 - t) l '
    lrruiilii (20ii,). In{ccti:r strcpto( o.icir poatc prczcnta ;i altc fonnir c}irritt' i,zr l ' ,r l i r r l r i ,,Io l
    irr pr-.:-ioarl:r neonai:alir: osti:ontiriit )i, cclnlitit, ctrnoiriitir,
    'l tt.tltu|tt:ttl,u l att,liin.[tt:(iosin ri|i)1]ic(r)liacu strcyrtocc.rc li sr' lltct' r'it itt' ., l l / l i l OSTEOM IEL ITA
    rri r:ilir t i ( i, ( llr lr t i r i r:rl i u n rn l l l l u j fi i n (l rL ' 2 si ;ri i rtri ni . l rt fo:ri rch: t.czi sl r' rri r' ,
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    l tl { i r rttrti
    l rrrl l rrl r' .
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    , ,, l ' i ]l i r ':r i'l i r r i ' 1'r i "
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    ii, i ; 3r t r cr cocLr lui' Cult ur i|: ; i {uilir t l 1u't t lr t r
    ' , ,,,i ,,' ,u,,, 1, 1u, , it , .ii t lr LLot in crLtrrrr
    , , r , r'r'r,r( nitol ;int obligatorii. Inlcr:fia {ctall sc poatc ptoclrrcl
    L'i, l,li' tuii,' ,,,rt,ult,lgcnii.al irricct'rt sru djn lich'itiui. 'i,ttl]:]]:' . ]']li'';1::l
    cstc dificil putindrr-s,. lri"'
    ,;;
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    I ,i';i',1'i;,:';,',it:i"iri'"i)iiii.',i'Mi'n"'n sru ?tlro
    J)7ti)notJ)h'r N\i:'s'rii
    rr r'll1
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    t il'( cLt
    conjLr nct ivit ci gonococi 1' s' facr: Lr .p'
    -.-.
    1r'trit ilit I ri
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    l r trtarn.e ntul, anttin{e.cJios facr: cu y;niciliniL sqrrisintcr I rr,rl
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    t L, I lcral
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    ru. '!cnt
    ,1.,"},rimini. S,-.qmr:ntclc ^se rr | r)) rr/l
    ||/l i i i lr,/zi
    rr i:tl ml
    im\ r r ide i rrLi
    ll] :-11]_.t. afcctar"c se irtr;bilizcaz:i.i1l lLi)iu.atrrl)r,r([
    r ' t"ir1 L ,lurrlrr t'rLlrrnrcrtulrri antiinfirctios.cind artr.ita ,.cptici. r:st,, j,rr,', il," iiliii"& 1,lr'l
    rrcgon't'ccir:'':
    .
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    2. 11. 7.1 5 .' N F E CCIIU T AN AIE ?.I I .7.1/.MONI|IAZA {mugue$

    lnlp.tigo hulos al rrou-niscutulni (Drr-n,,ati1.apcn{igoirliL). | " r , r ' t t , l. . r ' , , lhi': r i, 1) ^r l' ii ''ol i', li; - ir ' ': 'ipul, ' pr r lzi i, , ', 1
    . Esli o irr t , cr / ' ir 'r r lr r lr r L"
    t,(lif sccun{iari a nou-riscutului cu stalilococ auiiu hri_-rrrolitic. ,. , ;,i .r1.. li r r '- ii r '' r ; par , l) : , r cnLi it r , r it : r l" .l
    llo..,.l.r r,r, ' clt lr 'cLr t rr '' '
    rltrrilia uuor bute rle c.tirnensiru.ri iir.iabiic , r. \,rrt-r r it s", iiul p, , ni" f i 1'r ir Lt r - " igieuir
    il]]jll.:11 pt rorrrii ', ' 'iuiam iuf
    ri rr ir l, r l. r ,:lltli,
    . ( , r - pr iL!'i'l
    1Lr.o u ti n u t1 1 i rL rc i b u l e c ,c t ..r
    l a i r.l ccput dar-si deri i i l , :rrrrrr ,, , rrl rrl i L.i.
    o-sofag-;istotrr'r'
    l u L:r,rnl rnri, \. ruTj, cu u;rlrln-failirsind ir loc o i{ceratic si;pr,r:fir:ial ir t 1,,;1rr r ,i,ri,if,' s(i Siiscscin gurli, 'l'rr uneoli sc,r'lspi r1'lesc i r.r
    trrLn 1. r ' lorr lL, , ' nlor rt ro ,.i r' . B o a l a p o a tc a p i rrr a cl i n zi ri a a j _a L , r,riu,tt,,ttii,l,, p,,ri,rnnlc sinL inva'l'ltt: .ie caldidr' tlrrcori' bolilrL .rl''
    r1c l a i :i rsl ,.r,,
    ,Il r',r t , r 1, , 1i1: in r p u s e e ,J c e ru p ti e s u c c e s i v cp i ni l l a 4 si ptl mi ni . .I.otrl ,.rrrrrl cc al)atr: llnl {rfl
    l' , ,'',
    ' ,irr t, rit,tti i" cltlir:r si rilir Lri.lloniliaza pulmonnr:t
    r-rillt i('lctillii a nou-niLscutului se men{inci bunir. - 'ii, r 11sP'ct r u lar s- , est " r - t r . i l: r r lr) i1- niLScI li '
    ' ,l ti i r;rl rr ] i ( lLlar ) Lillioi: ico
    l r c I t.tnt e 1rI u l. estc nrinlai loc:ll crr puclrr: ccltjnind artit.,rr,tirl l ,r^zi tttti lr lr
    ' ( ! ( lit lt const ar l in r icpozit c m ici a] bi. ior sc" vt r r zui p( r lilt ll) i
    ( ; a It I ( ! i o : i i c I e ct cste foartc marc.- ''itt,.',11,'giilqlii hit'': <1c<:hcrtgrrtil"
    Pot- 1:i..'1co-s'
    lfodul dc tralsurit.:... ,,rll ;i ,,"gi,tn..'.l,p'"l"titti t at ulxr t r 'l'
    ,iir-r,r'i..prin;r'.iirrile pcrsonalului de ingrijire si prin sr:utecc.:!pariti:L
    ..,slr l rt 11 r)i i n.' , , , 1". - ; t t r t nui. li l; r f i: l dc uf or indep: ir t at c ( cu un
    '
    i'1,'r'fii crrtaratc intr-o secliL'dc'ou-nlsr:rrii coricorclirc. crrstir.a iru,rrirrlrti ,',, ''i ,rr,,,:ntin atliastrut1i'metilcn arat:r r'1
    ti,'',j,,it,)r,,',t'ii:r',i 'Ii(:('lii(1''
    r"1r'rrli;rlclc infeclii sia{ilocor:ice djn scctia dc Iiruzic_ l/rtt'rt,1-rrl rru cstc o ilii'Li tttt""rl tlcterminind nunrai dilictrltii(i
    pi r' l i i rrp i r.i tr..t...,tl J .,l ,,,,. , tt,/., tt! t J, . ri .,l o6i c ..l ,kr rno;trtclt'
    . l' , , ,, , ,lr', iir rr:crrtrrtrrt'isiru sugafii dcbilitafi poilte ?rol'oca
    ,,,r'r' .. l( indr
    r n. lronrr r l,r rlrl ] s | r' rt1 .,1 . i ro l i , " atingerea mucoaicri b-ucalc dr: mai rrtI rll "
    i tro d u s d c r nrri ntui te tul pi ' i ci ri stal i i .r..r i i ,',','r' ,i ,,,''r',;; ;;; ;""i;* iirin
    4')'i' :r'r'tt
    ,';rlrrl'zopoziti'i (nu ru'rai de tiprrl {.rgic I si 2, , rr'r .-J cr.cic:r i':,.irr1,,), iir tolu]:i" tlc bicarbonat de sodiu
    .',i, r:tr o valii irriribirtaL ( l''
    ,:irr'r'clabor('itzi-ro toxin:r c:{oli:rtiri.i. I.-e,r-.t giup r'1. boli, l,, lroar-u,,.,.,,i" u{i. . : a1[ asi 0, 5'] ; - lr oaspit i1lcp1l'r t li'
    ,,,,,,' ,' ,,' i t,,,,:, ,ir t gur ': , r r I r ni. 1i 'ol t 1'; I zil', ( J I I t sllilsr ) r r)'
    ':'1r itrr:lrrsr-r lnt.lcr.Ilitl.ey (den.n?titc e.:fol,,:ti,i t,t,.rili.,,,t,t - t:are tst. t) ,,itittl 1 ,,,, ,t, ,,, ri 1ir ilr i 0, - 5') u - r . l. f or i pt - z]
    . t ir nq
    tttrri siiiri dc..ir1:ftc{ic ctltlnat.i).. I)upi un dcl-_rttltrusc cl cl'tcm r-rt:rrlg(r l'r starnicin (nistaiint ir lormir lichidiL (prrll"'t''
    ltri.l s.pcrficiai al .pidcrnci sc zbircc;l. si s'tlctilscnz.ri la celi ;;clt,i,lizirl, ',, ' Lrilr'r'(zirit(lt() sc
    lr,
    ot't',tinip de ? - to zilc (J llulchirt::r)'
    n.rei lrrirI , ,i'ii i',",'l:,ifIoooooi; l'''t 'rt
    ,r1,.rriri_(slrrrnulNikol.rl-1J. apoi apar bulc ntari, coniJucnte, {lastc, p}irrr. r.rr
    lr, lrLl..Irr, ,:,re, s! spatg. Lambouri mari cli: epid,:rurirse dc,scuajneazi,lisirul
    (lr D'(iirtL'
    2,1i.7.18.oMFAllrA
    -riLpr-afeteinti:rsc a.lc trgunclrtclor (r-osii-str:iilucitoa r c, zcnrr..rrLl(,),
    \r1r,rl|ll ('li,rlrgtr'('st(:r(rpr'1rz('111ilt rh: sta{ilococli, 1tl:l-l:,,11:l']t:'l.:1i., ]l'
    ;';;'1";; ;--i, n,1',ti,ti'1n rir-'scc!iunea bontuhri-omirilii:a1srttt.itt ''
    I rr, :, rrr:r'ri.ri,-,' rr{r ic_ililr.r/-o_l-cziste'tr: rl:'t ltlirl
    csitrlrl:'t (
    ltrirt( llr r
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    ri rri ',il;,t:
    , r, l, t , r,' it
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    t vlt st r l: ot lr lr ilicir lc'Iiiscnl <lc omlalititcsltl
    <lc omlalitit
    : ' ir { , , t ir i , l :t:rl i l c ,t, c i p r.e rd u c i ' r1 odici to.ri r-,i l < .rLn.
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    '; ,; ;;; , ', t t , i or r I 1r iI '''
    iclr Iir. isr : uL
    ;, yrir ' ) r.' r : i, iin ir li(.z o L .]c ). 'tfii tt-t"'tn""ifcsliL clinic prin hipcrcnrirr ;i lrl' rrr
    ' .rrl , tti ot it I r ili<I : r lr '){) lt t l; . . . . ! . .! ^r . r , , , . . , , , . ,ittlt
    ,,r,.,
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    i ,,, , i ,i i i , ,,i, ] tl,,',t'it otrtlrilit:ir1 zcnuitLti nu t'stctotilc:Lttnrt '
    .l r 716 coNJuNcTtvtTA 'il ' rrtr' ,',,1; '',;,;ii,; teprczinti ,o porLtliL
    (ur; tl" t'rrltulitsi tepr.ziutiL liL "rr;1)rtrii"
    ( ,t ,l,l
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    'li lr'rr11rr(
    t'ir'(i;'lri lli;ll;ll.:l
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    '1"'",'tto'i'
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    '
    r . I ', 1 . r l I '| r l | | 1 ,1 1 ) .

    :i i l l
    : li il
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    '',',i,',,',,,!,',','1',','',,l1"iliilli,iiill
    l,)r'ril r1)nsti:iin aplicart-.asolutit:i clc ltir-auol lIr,,,,.
    l:lxt.indci-rainfecticrj in r.asc-kombilicalc cl,1r'nrilir plogr.rosticul(tlo:uixr, l; ;lli,'j1,,i;**'* ;,1',j.il:'l;,1','il
    ll*lil'il,'T,ll
    li.'i,iirL si irtir:ir poai c duce la altccschcpatice, septiceujc, t ioruboza r.cnci i,r)rlr.),
    ,;;,;: "1",:.liii,'iil':
    (ii"Il'lii:Jnlif;.i
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    :Ii;,l,
    2.,],].7.19.
    DIARFEAEPIDEMtCA
    A NOU-NaSCUTUIUI
    (Enrerilq)

    {-onstituic un grup hc'tcrogcn cle boli transtnisibiic, ct rJi:rr.r:c ca sirrrlr


    :IIi;,iii;lii,,::'lill*'lll;.1.,iil#:'lil.'?;fi,i' ; g) ' '
    , ,il , ,:",,tr, t',li iio.. ltlt""1'l trcbuicsr-r.{ic.autoclivatiL
    l.'
    tln priucipal, cu rtare infectiozitatc pcntlu notr-nirscutL]ldin lnatfrlilirl ri
    :l ari n}.)rtaiitai.e crescutir.
    'l,,,,,1,,,
    , '',
    1Lri,amc
    r,i,,ri,gic
    |',,,, uln:;:llij:l*:iiliil:i:$::*:i:?;t:;,fi 1;'l
    llt iolog?d
    .r'/rig.'11c,
    !:,s tcl ' a ri a b j l i L ; a L Ll o st i ncri mi nati : l i . ol i , S ,tl trl tt:l l l ', Il;:l li,'ii;,::tlli.l|lllliil':|il"*.'i,',.t"ii,iri,r''r'3 .:11,lllj*1i,,',lilll
    sti.rlilococi rczisternti, strcptococi lt lrcta-hernolitici, Psautluttou n l r ' '' l i " J^ r r r 'r l r '- ': r :i r sr
    , r r r , ,l r i r r r l i l ' i r t"r r r i 'ti i
    I i
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    ,it'tttlilasd., 0
    ,tcrttginostr, ttt.elid.ri.
    0tnelid.ri tlbi.cruts, acl,-.novir
    tl,hi.crt,ns, ac],-.novir usu|i, r:cho.1'imsuri.
    r:cholimsuri. in unelc efi,il(
    !)Lrs-a cisit rlici uo irgcnt cauzal. Sc lor- cft'ctu:r mai multe conrocultul itl
    epitl rril
    rr
    ll;
    li':i"'il;l
    l;;ilili,l.iiii'
    sr'opu1 cliritnticrii agcntului rcsponsalrii.
    l Ltctort .frdi:^ fto:.drl?.' a) si-lpraaglomcrlrrcalcrviciului dc nou-lirscirii;
    ' i , ,lliil,ll'll,i'liil,. o','""*:.:jli:,:..:li
    zii",i',,r,..,t1
    ,lii;r "i"ii'a,, r ' rl
    cl i a l ci cc' tr r 'l l u i c i u a tl L i n co D Sl 'l r i tl r . l v'
    l,) lipsr di 'ur.it.:riu in inirijirca copiilor (lipsa spilli-Lriicorecte a nriinikrr)i
    | 1 , r r r . r l , r i i " l tr ,zi r r i i r ,sta l tttc
    ' ; liPs.L telLrir i|,1 .rs,ftic iu prcparart:a alimerl.atiei (in si:ctiile de p;t,;rlr "r ir l 'rrl'
    hitlrockr:trolitii
    rtt in rcccltililrarca
    ;l]l ,;l'i;ili',,';'ll'1"'l'',ll
    lrrli); d)ei) n.ranipularcil oxccsivii :t 11ou-lliiscutilor ii cxpunerL'a lor itr su.{ii
    bisc": : L) pun.irtoli
    ,.'lr:sr:ltisc" pun.ittoli dcdr: gr:rntcni patoscni printr-c pcrsonal.
    ('li t: ic (. \-a azi\ dc la o izb'lcltre la alta. 'l'r:!sa'rtut'ilc gcnerait sirri
    "'']1'.ilil
    l, ;",,,,:'l':',lli;.i.,nl;.1,'l]l;;xJrl,x:i"]ii"
    ftrioLrtlt lc incubalie de 1 -4 zilc, dar foate
    (sirgarii cc :rii icsit din matcrnitatc sL' itterncazi in sectia cl.. pediairi. r rr
    fi de Z 3 si4rtirarirri lr rl'i, i,l irij]:,i1.{,ft:r,.]ll:]*ili:J?l:
    ',,,r;ii,:, ii"*ltlrli,ti',
    , t ti i r ( ( . ) :
    ;,i;: i'ir,r"
    ,' , ;i,;, r6r-i:lpl''Lil$l1,T^?{5i)i,iif,.. ,llill'l;:
    feriottla dt inttnic p<:zrtcfi de citela orc sau zilc si se cal:..rctcrit:,..ilri rl ' , , r l , l / l . Ji ) . l r r r r |r l l i r to i l r :cl (
    lrtin: ai-ror-cric,r'cfuzul alimcnl.rtj-i s..id, 1,:? in !rcuLrLte, r-drsiLturi, rlirtr,rr
    sit irlrclon.rinalii, schimirarc in car-acterul scaunelor;
    --.ptririadrt ta:;icd: iz-1lacntrca diareci la mai nulti nou-nilscu(i rlirt
    srr'iic, cu ,sc.runcitpoase lrccvcntt, r\I)lozic, crr dtshidrutart r-apidf,, acitlozi,
    !o{r; oiigufie, {ebri raicii sau hipotermi<:. Scaunelc la inccput sint gallrrnc r;i i, in{t',ii'r"'. li.'llli^"'l]]'llli]]:'(:l]l]
    1ttttlttit)ioliL'.
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    scnrilicl,ide, apoi dcvin apoase, vctzi, cli lrucus si cresc ca {rccvclli. ,,r,
    r,',',r,rr,,it,rlrr.t irr -1P'i2" 1't'.zi)
    '.'"titpri.'L1lt'
    ', .1'rr1"]: 'jt' ,lll.], i:ll.:,:l;l,ll
    J'lticir"7si' aclaugiLrtmpi'ilirrii
    Hiperpneca este irbscntir iir ciud:r acidozci scr.trc. Uncori, in r.iti:r'ir ,i ' ,,'l i,,l,i '.t '
    'i"" '''''''''
    , j
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    k ; u i ' ittitrtrlrist.ttlrrr
    i ' ; rlg/ks/zi)
    orc rl: la debut se dczvoltir tablbui clinic de toricoziL alimcutari, cu drslii. lil, , I' , i t ] ,' i)';r' ' ."'' ,rri:rrrri':inir
    , ; '',,"ti." 'i'.'
    rlrirtar-eser.tlii, ochii infuntlati in orbite, fontanela deprimati., sutnri incirlr.. ', "'i'
    r;rlr', :rbdomcn e\cavat, cornee opacifiatii -sicom;r. ilxtrcmitililc, buzclc $i I l , r r l r ( ,r 1 l l i l l l l l l l ( l l i u l cl t t:o l i tti i ci u i t;i l t p u r l i r 'to r i i r l L '/l l r r l r l r r i ''
    p ( r l l r '1 1 i r l l i r r ( 'l
    rrlcchilc pot Ii rcci -.i cirnozatc datoritii insuficicntci cilculatorii pcrif,rri((.. , ' , , '. 1 ":,,r ,r r r i i t'i p o l r '(l t- ( 'z( ,tr ti r o sr u si r ' i l c- i n l ct:!i ( '
    lixistri h etnoccttccnl.rulic. J'"d hipor olemic p,,atc.ipirea la prr.11iirrri
    inrriutc r{e al-.rritia diareei (ilcus Jinamic !). in unclt cuzrtri s, aruelc silt aprxrsc
    si iii;sitr: dr: matcrii fcc:rlc, incit pot fi absorbitc dc scutcr:c ;i corl'.urrlrr1r. 'I ] / , , '( ] . PNEUM O NI A
    i l l )i l r' i l Ll
    r' 11 L l l - 1 n : I . ll l t1:l l :t l l as t(l rc silll l l oi l Lt l x ))l l ,rl ' l l
    l ',r |l |l rr' l l i i r l )l ( ' z (
    'l r u n s rn t s i r.trt e a itgrntului patogen sc facc pt crlc |()i l 1('
    l't i I ' s i . s t t , t l ' 1 1 ' L t 't1. r. ., ,l '
    ii'ca1..()1ltli, ||'tt,'1,',',.l l | | l | l l Il l \'1 l l l i l l l l i l l j,l |,x '',"
    t ' ti ' ' , 1 , ' " t t t u . . l i i iprl litttn
    i to l l i r ';r i sr '1 'l i " r r r t
    (;r'lrvitirt( iL rru dcpin<lc aliL cL' un :inunit gcr-men,cit dc f:Lctori <:c1iu ,ll vir ' , ' ' , ' i , ' u , t t u l t "
    , ' , ' l: l' , " ' ,
    ', , , , , , ', , ',' r l /,,r ,r t,'.r ' ,\r r r l r i i
    1 1 ''"i "t'i 1 "'l |to tl tL cc
    r1i r D( ' , ) liir t : r l: t ;i rrrrn i tl i te ;Ls l a b i L ,rc z c rv c n tici dc:rpi L si cl ' ctr-ol i fi , u| ' (.i rrri sl rl r.
    l r,r or ir r s l: r lir : r ' sl :rldr c z ,v o l ta tc(< l cc ru rl l rr l i psa l ti pcr-pneci ,i n pr-r,zrrr1rrrr.i rkr
    r, i r r t r ' 1; r lx r irr ,r).
    t lr t t ii hli( ,t1 i ,i .: o l -i i .i l tc rl i r., l rrotrl roi l tl ur:roui r., sr' 1rl i r.r' rl i , (i rr
    i L r lli t iil, r Lr \ r r ll tttu l l t :;i l i . r' rl i ' 1 , rrrl rri rr; i l i i l )l nrl ( nl i i , l )( fi t()r)i i i t.
    i' i ' t , , , \//,., r1 l r(,r' \'Ii (n t,rrl rl i l tL lr, rrrrr, i 0,' ,, l i ,,,
    lrili
    ,;l rl
    r ':tl tr ti r i ti i d ttt tttr tr n i l a i L ' C l ti a r ttL c ttttti
    l t o t u t t t lttL - "i l {i l r st:l l l tttl r '
    FACTORI
    2,1].7.21- FAVORIZANII9I MIJTOACEDE COMEATERE A 'r (b;"oltt(t& t:ttpiLttlrri
    ; ; l,:'))"'1:r,1',,),l1il ;i L:onstitttieo 'ildicttli'e
    '1,ri)irtttoo""
    TNFECTTOR SECUNDARE tN SERVICIE DE NOU-NASCUTI pr tL;il''
    , .'. ,i ,rr1,r1r,!,rit:it izbucnirila tpid'emicush'tl'lreccrhle de.o 'sr'r ':t
    rlc o su'lr,tixcirccre d (l;tiaildlii 111ttli'l
    ', ,, r,).,it.,lininilii. 9i, irLtc.mdrile utx 'or!)tlui
    .tnwnit fLunt (ii' ,,il'
    Trltcliil,' secLlndirrein srr-r-iciiiede nou-nirsculi sint produsc mai fr|r' , ,, 1,,,1,, rl.Q truulittitrsd se nite feste
    ',r'nl rle urnitolii germeni: stafilococul auliu, streptococul LlFupA, liscrl'rt.
    .hid coli (enteropatogen),Kl,ebsiellnplt eunLonitte,Pyateu,snziyaltil,is,I'sutlu u ar It'tl'littt
    It .lttttl'iLtlirtlt'. l,ribttit: utilizal'e itt ntcd' ra!'iot'tal' AP&rili6
    :|rnds aeyttgixosu.,specii de ,Sahnoneltra., Seft tiu ntarcescfirs.Ilintre ce:l!u!irt'' di ittlrebuittlaret.rlcr&liol(tli 'l
    rurrilrLirn: adenovirusurile, \'irusuri paragripalc, virusul svncitial respirrrlol' ' t')tl' ttt :\'ttttttti, lillr' lltttlial'
    rttt' ,tt' tl ttt,1,, r r t r r t t t ". [ t t : liuit 'it t t it t o't 'ecisi"''ir t t iecdslont an'Just if icar eat t t ccsl'
    lir'hc- Este de remarcat cir germcni cu rnod dc transmiterc rec noscut aclr41'[ echi'lJa'i'
    ,,' ;, ,,, ,,,ri ,1. 'i, , , , , r it t it t t ibiot icelol f vLi'! lt r t r t t nr i. l. it t ' f n'ht ul cr i
    r . [r iu- fi pneumococtLl,ITcmopltil,.us si menin8ococulsint rar iur;rl
    in.fl,u,cn::ac iiir ; 'i'r 'r lc t im t ' t t r 't t t r t r
    j i' ., ,' ,rr, , , r ic r lt lt isilii d. cnt r m dr t i t lt inlcr nit t i1i
    r ri irrfe, 'iil r , ' lr r r ou t r i. , . r r t . " '
    - oer r nr l risc'^.'4t't'ti'bictLixk
    cr't nu st ttl'
    '', ,1t,littitt t! f);Lutr:alt:11ou-ni'scul'ului
    Irr declarqarea infccliilor cu cilracter epidcr:ric in rn:Lternitate motlul rltl I.|tili:at( (:|t,iln inlocttiIt'r -:.::',/.'.i'".',
    Antibiaticalc l.ttt,,i,tlr.[i 'tI
    rrtlrslnitere directi a germenilor prin intermcdiul rniinilor personahrhri rlrt '| ,]t|'l'l|I!|. ,{t ltrboratay,
    ,,,1',t ,lt ts, fts'i, lt rulittil (J. Iltttchison )
    ingr-ijirr:, al rnamelor infectate si a cchipamentului contaminiLt joaciL ttrr trtl
    la trkrttart-
    r,rLLltrl:ri important dccit transmitere:r indircctir prin iuierurcdiul altui tr.tl' l .'it itt)]' i zol.tt (oii.t6L!'ii baLnattilor tlt'tttct'i sus lind .
    r 'iscut bolnar- sau trarsmiterea ar:rogJcui" I t)t.1(t t,rltif,uljtLnt t:arc titrc-,irr tutLl,:t.l Lt! 1to1!t:,istljti.i^:,t:'::,f:^1,:.!
    C ntoiLtiti'itt ,",",i,:,'
    Ilactcriiic care sint inplicate in in{eclia epiclcmicirin secliile tlc ttrttt. , ,,,",,',",.1i,',,,',ii',',;ii;';;i;,'i;;;;7;;iii'iito"il'(fi.rtfot.'sit
    snficcc tsti dlLlocl(!itit I
    rriscuti aLr alunite caracteListici: posedii capacitatea de a s'"lpraviet1i gi d(' il ,"',1" ,1, sar'ingi,nrdnuli, h'ihuotna-;i
    "1,rlli,,:,tt,.ltittvu, 1i' fltrstit sl r";
    sr' ;urlt\rlica in nediul inconjuritor, capacitatea t1e a coloriza tegumcrtllltl t t't tlt,,tttlt ri ,, ltipuutttttul- cat'e cott[itrc 1!icse tlc cct'Ltcittc
    si rlc a plorLucc 1--olidigestive. tt .t ,)t tt t l/ t \ lt t t 'r t xicl sau f or m 'alit lt 'ili'
    Orcltrlca colccntraliei bactcrienc l.r probele dc,,autocontrol" btctll io. ('tt st)l1tti1
    t, l)tttt,l)ttlt)nrtl,tt ttor J'i sfdtratezih|ic eu' dttygcnli;i aPa'i.;tcrst:
    l,rri, r'rr:oltar.eciin selr.iciu nu concordi-ladesea cu aparalia infecliilor ia tl{,lt! '. 1'cgo
    , 1tr,, (,lt t t , t lt it t r i, ).
    rrL,r'rrti. (lcl mrrlt, :rc,.lst,,.rutocontroi" bacteriologic reprezintir un test in(lir',1. i:or -f:i ::l' ttt'
    ior r,l ncrcspcciiuii alumitor miisuli c1cprcvenirc a infecliei, cum ar fi sl)i, ll I tr/,trrilt t{, tu.trL:iuc;i utttitliJicolontek 'lettlrtt origert
    1:rlr':Lmiirrilor. Se reconandir recoltarea obligatorie de probe bactcriologilrt '' . l ttt,t lt . , lt , : t , l'i : 4 r t ( 'lc f olo'; "'
    pcr-ioilicurrmai din aparatcle d.erespirat, preparirte dictetice si de verificlrrr'{ | .l l ,tt li) t it r , t r lt t t f ut nvct t aJist it il'i; i st ia sr hint l''nla ] . l a; 'a'
    st.crilitilii. 1n condiliile ln care in scrviciu apar infeclii cu caracter epid('nrr,, ot' mi'rtecdscurtti purlt'tr' tt' st 1'11;'"
    | ,lL l'ir ii ;i sttrrtrila nr lttrta hal&tc
    irrrlicatiile dc rccoltare a probclor bacteriologicc sc extinrl. ax{-ndscxftul, ditt' in'tt'tlulot Iit
    i ,tl,t I't)t't ltt rtt li 'f)crllrt.tu lttt'tlcamani'ftl(t
    Dc pe miildle persollalului se poate izola o florir l.niclobiani pel rD al t('l tl i ri , ',t i,t'rtttl'trliiri.t rt,tnr-rt,is'.t ltriui iu.lccltttsa r'( schimba .halat'ul t'enl't'rt'lrL ' 'tt
    prin spl]arc ;i o flor5, tr:rrtri. dintl o fctlsii sllt"ttltt tl'
    lrr virulcntir scirzutii, carc nu se indepirtcazi , l",jlttl urltt/ti .si trl. rutiyLi'iLlt l'tnrbaa sirtt ittut'ile
    lolii:, achizitionati pdn contact, care de obicei cste patogenii;i care sc i rl', Lrhi
    ,,, 't ttt l't llt'tt (tt o llt(tsLtLs,) Jit cfiticnt't lt'ltuie si Jit ' tntJrt:liott '/ttt
    p,iltt rzi prin spiiare. s'l'int bat 'iloar lt ( ": , I "
    t" ' ' l ' " l trl rt ii, st iI t t ol', : / r "nt , , 't tii "; 1ie ! n*! 1", : '", "':
    Aplorinativ 15-Z}aio din pelsonalul de ingrijire {"'stcpurtitol'_ (lilll' Nnmi.tfic.i.i.rrLctt!'"t:":l::!,:!:
    ,i ,,tr'tl ttt,ti:,ttiitst,ltt boliactrtar6t'1t(t(ttt'
    zit uriu ilc stafilococ auliu in rras.-r\urnai un mic procent de purtitori rispintlr'rtr l t: l d i g ti j i r r tt ]ta tt- l ta stu [u L ,tI1 "
    t t t , l ,l , , r tl L r l l ttttIu tl t
    sir{ilococul, iar tlintre ace;tia, numirul de ,,tulpini virnlente". (depislrtlt' " -
    lrliu tipizare bacttriologici) estc foarte mic. Vor fi tratali nurnai purtirtrt l | ' ' .' ' | ,,t |'t t , . t t t t , i. it r ikt r , inaint , : dam olt u, r t t eaf icciir t l, i''t t olt - lt it sLt t / , 't
    (t' illfcc{ici la nou-rtrisctrt'
    il,r poten{ial mare de discmirarc a trripinilor virul('ll1r', ,,,t ttttl,r,tlrrttli rtttisttri L/cfrtttuirr
    .l stalilococ luriu cn
    ,
    t't lt:gztlolttlot t ttttt-tt'd"sctttt't'h'ti j cu slth:;toltlt '!tilL
    ratlurcntLrlcrLaniibioticcpe calr-generall a acestorpurti"rtoriestc incfi(:i('llli 'l',tl it,,r tttiittihtt' li
    i rirtamcntllllr:cai,pritr apliiarca zilnicl intranazi:.lde unguent cu Nc5Jalrrirrittil ( t 'J) ; f it t4i) ct ' t oxicc f r in ahsor b!u' 'i lr t 't r
    ' t' ,i tr,' J t lt t t t st t t '( '(t t, t t r : or 't 'f t t t {ir r i
    '',. , r'rlt,'r, i,,rr1,;" 66', dirt cezuri. ,., r t r l , l ,:ttl ,i ( l t' tu l r w tfttt) '
    1.'cnttlt prcrtnirca ;i combatereainfeciiilor"in scc!ia cL: nou-ttiis|rtll I l l t ttt tti 'r l i tr \tt l tt ftl t tttl tttl l I'to fl :i ''1 l
    t't't" o t't tn r tl l ' i ';o l r i r t'i l i 'r ttl t
    ,,,rrt.rt .l:i:t L .1 . ' 11. r ' ' ' ' r t , lc m . r : t . t t i:
    ,,1. I'tt i'or i'ttti in ctnt,lqet cLt rtott-ttcisctr'li'ir!vtttil0drilL' (tt!,tgotii (lr ltttttttt'
    ',r f'tr*ttt.,rl.: J','LrilL, ctr,inft'tyii rtslir htii, r:'tr'gus!,nontu'itt ;i ittftclii crlttttlt, NASCUTUTUI
    ' I i / . : , I RI \ lAM ENTUII .NFECTI I LOI 'IRO U
    ll. .\',r rIr' it , lt . ' i, r t , c o. ' r . , : r t r if ) i] t lt : r t r m i t o J i i t u t r t - i t r i s r : t t l i i : t) t i t t l r 'l t t
    . lt4tli,t ttr l:. r, ' li; l' ) Lt t t ) t . l; . lu , t r ' r lt : r ) ( 1 r s t t f t t r t ! 1 i . l ', t t l . t t I t , i l i l ( ) ( l t t t l l , L
    I l , I' r t r r 'I t r I r lr r lr r l ') ll t
    I t,l,'r i1 ',,,,,,:'i lt t t it r r ' : t liLr r [ ' , r lt r il lr ti l t t ', c a r . l : : t ) l t t ) 't t t s t r u l 'i ! l l
    :i i l i
    . iil:l
    ( louir luc( 'it uist n( rpL'it t r : ipr r:l'
    l lrr ct i 1t Iill
    l l rrrrrl i r,r i, iist t r Lt( (l |I Il((:t I t t iI I st : 1) o(
    tt' l ' ti ,t ii in Jcauoll, t t 't ttLu t Yiologic'i't gl&t t dit lt lot t t ( :
    Utlllza-.ea antilrlolicclol lR rlfir" ticut 'r t t ut ut
    lilrrrr trriitlir ir (lJl(lci t'itt'i<l': (othyteosis )
    Doza ]a prematur ;i i,ii*,:lii,ru,,t,u'ii"irlc tcsutuluitir;idian-( cryl.Ptotivoidisltx
    mai
    )'
    ales la b^zit
    Antibioticul ]a termer , ','.,i,'
    rli,ilili ,i.iiti,,iii l1"t"tui tiioiJit' Jiind locaiizat
    plima sdptimintr. ,rr,r' ,i"'i ,,ili'rit,iiii ,"t Acestfcsutglaudtrlat'
    rntiiuitdecit,atiroidia
    i' ;i il;,il'; ; ;:':,#,!;'tr;;*;,ffiT;',i
    "ttt
    n*- 8.::1i,,:
    I 'rt l i c i l i n a G 50 000- i00 000
    ulkg/zi,i.ln.li.v. la 12
    100000-200 000 u/Lg/
    /zi i.rn./i.j'. la 6 or€
    ru prezintft ",:,,];ll;;;: i"'a
    ,ii,iillJ'lli'lli:l#1#;"";;"pli""J ali ei se i,stre'it
    lnsofide
    poate ;,il';
    Aurpicilina 50- 100mg/kg/zi 150-200 ms/kg/zi
    i.n.li.'/. le 12 are ""'i,l'iil:]],' se'proclucittlbtt-
    i. rn.li,.'. la 12 ore
    eozinolile,
    ,'''t,i cantititi sttlicicnrerlc ltornotr tiroidia'
    iU.) t iciliua 100ms/kglzi 200 mg/kg/zi i.m./i.?. !e:[rita cu II lrr rr(lirlx,lisrrrtrl crtsturcltil"Lil"t"lu'iro'-:fL"l1"Il-^S.f,C:j,tLrlllil
    tI Lrltuurvo
    lr lrr('rirrxrrrsrrrr'rr
    lr 'i"i""";"li;t]
    ()x a c i l i n a cu atrofie cerolralfL
    lttticali
    i.m./i.v. lzr 8 or-.e ]a 6 ore rtltrli, sc lrjttrtgc la dcgcuelirrc
    Nrtcillira
    Ittl l rrtrl l i t lr t nit : liuizar c. ^^"^ - ^^- - . , . *nr i( -
    ( nfl)enicilin

    ( (]phaloti11
    250 mgl\glz:L
    i.m./:.v. ra E ore
    -50 mg/ks/zi
    300 mg/kg/zi i.r1}./i.7.
    la 6 ore
    i00 ms/ks/zi i.1n.li.1'.
    ,,,:ult:liii;lrlilrillti;;l;l'rlr;4:xi11u
    '#fi'rii
    iiiril;;il;iilii,1jt:lxi'i';l?"'1*xqriizt
    (lcphalosporine i.m./i.v, 1a,8 ore Ia 6 ore 4g,ratea"za
    rena:H, test
    poziti./
    l(i|oanricin;L 15 n8/kg/zi i.m. 15 mg/kg/zi i.ni. potential refioto*! 'lrd)ctrral 2 8b
    la 12 orc kr 8 ore ototoxic j ,r11se vd
    midstra mai
    de 12 zlle rl|| .o[rll.lor dhl(o lroooce tl'lrtpott{tftffsNl conganilal l lrlmeb luDt ile lltll{ Oup[
    ( ir . I t & r n i c i D a 5 nlglkg/zi i. n1. la 7,5 mg/lis/zi i.n). la potenlial ello' I"owery)
    12 ore 8 ore ototonicitate ln
    man qr Prczeltc la Prczcnlc k!
    prelungit t huzt (%) :l lu'ri (%,)
    'Iirbfarnicina a ll1s/kslzii.m./i.?. 5 ms/kglzi i.1D.li.v. reflo- 9i
    la 12 or.e la E ore
    7,5 mg/kg/zi i.rll.l 7,5 mslkslzi neko- $ 62 7{\
    tl l l l l l l l ttu,r)l trl i 0 6ti
    i. 7. la 12 ore i.m./i.v. la E ore 5E
    Il l n l l r'f8flrrl,lr{i : 45
    S treptomicina 20 mg/hs/zi i.m. 20 mgllg/zi i.m. ncl ro- qi l (l 1' rl rrl r' rrc s al i s J i rc i ,toar(l 61
    colaps la- doaq, 34 1t
    Cbramlcnicol 25 me/kg/zi i. ''.. la 50 msikslzi i. v. irhibitie a lni {0
    6 orc la 6 ore hematogene,
    ,,cenugiu" (se

    (i'lirnicirl sulfat 1C0000 !./kg/,i 100 000 r./lrs/zi p.o.


    toriza lirclul
    intrc 10-20
    nu prezint:t,
    x'liH!il1:frq#L:iiil,x;$
    ;li,,ir;lilllirlin"iillfi
    p. o . la 6 o ic lzl 6 ore
    lrl#:lLliiLll;f ,,."$*mtlillit1ffi"'Exii"l'';
    iii'irdlii*rai"^tai*, p\t'L.chiswich)'
    hipotennie . .-l
    Ni $ l a t i n 200000- 400 r
    400 000
    p. o. lzr 6 or.e
    r./zi 200 000-400 000 u./zi
    p. o. 1a 6 ore
    flu prezintl

    li;:l'ii',.;l#ffp;H$ill:ruxii'T';;'T:'#i#5 mintarIa acoiri


    2.11,8.TULBURARI
    ENDOCRINE i"il, fffi ;;;";i'A ieti'dutul
    l,il;1"111;;"i'$iiir'lir
    2.ll.8.1.MODTFTCAR| HORMONUIUITIROIDIAN
    AtE sECRET|Et sc punu p^r'inclozttt'tltt
    l)t,r!tt,tslirnll,: ttifotiroittisn cangcnilal,lana;tcrc,.
    LA FEMEIAGRAVIDA5I tA NOU-NASCUT
    2.i1.8.1.1.
    Hiporiroidiimulc6ngeniiql r!ri"ii,i: r{:r i*;,iii*,'i:1i
    i
    'vl,i;'i':ili;'ii tj*ti;'
    ].or-sindi'''l-ei
    ;alc't'sH->-2op
    i
    k'iHyiE ",\'ff:#
    U/mlslnti''3:?,t"
    cvocatourr
    liliii
    Este o boali grav6. a nou-niiscutului
    I)r'ococecll hormon tiroidian sc produc leziuni ireversibile alc SNC.
    deoarece, in lipsa tra
    -rcst
    li'ii.ri"ii.-rn.
    i i,iit'' itriicf
    ii,itJ"t*"1ii
    rltu lrlrrrrti''irlisnr,Iliurrlutrrlcs, fSI{ -!
    i.cltc-ln sc' dacI hi'o'
    i
    iiiuidismul congenital este muit riiai fiecvent lntllnit clcclt alte bolii n |0ittl.'r'lrfrtlli|l'l'SlI ii
    'l-e.slttt c fftif
    11'"1'J:
    -{l ,l,::li-Tttl: 3i:H:ti,i-11;
    lir:c congenitalc, cLunar {i fcnilcctonuria, pcnttu cirLedcja se folosegteun l{; t'ttt""ii"ii" sct trogte rnai lont duP[
    lu
    IB10 il co[contralra
    'lo.
    scr:cening lit naqterc. Irrccvcnta hipotiroidismr ui congcnital variiul. I rl'r'tt rr
    l/3 000- l/6 000 rlin n1nrl1rullolnl rlc ntgtori.
    30.s
    3{t4
    II( i r ,l ti i t I) ,) .!l ( l l r r :i l r ' 1 ( ) l 'r r
    l) r t 1r ii.1> lu rc rc r < i i a S n o s ti c u l rri ,l t,ttl u tt trrtl trl r,r i i i l ccyxrl . i nrLrrl i . ,,I \ l , t ) | t t ' tt i tt fttl tr ,'i ,l i :;ttt.7 tti 'r r ti 'l tti tl l L l sl L l t
    - [o tu si r a tl L cl t tl i sm i r ttl l r l l tl r r l i r i l ( t '1 i l '
    .1 5 1r g lir or inii/ z i; ti o z -l sr ,.lv a c r{ s tc 1 r-e p ta tp irri l .r ol ri i ncre.Lul tc)r\.ti ofi ., rl ( r, r , , l l : r t , tto r ttti tl i L ttr r ttl ttL 1 3 i l i '
    'l rl ilor ini1nt r c 9- - l 2 i rg /ml .D o z a o p i i m i i s ttt.t,;r , , r , ( 1 . l r i ) 1 1 - tl i sL r ttl i( 's1 o tl l i l i ( l l scu ti i '
    nrrrirni crLri ozi r rl c 1i r,, LrrJ
    r'r' rurrrtinc nir,clll ll'SH ln limi1e uoirnalc. )larna lrr,Lrric :i. pistr:cz,eo . rrrr
    i'r';rfic lr copilului irtaintc <]r' tratarnunl. jiuslrincl stilrnarclr Tiroidirq mqterni
    12.11.8.1.6.
    1 rri,,
    lll?Itcflli. illlIlttl r)l
    I r r , , i , l i I r r l tr L vi r i ci ]1 1 1i i fl j ctci l zi l fi r tu i , d c;i anticorPii
    I-ar aceasta! catcgorl(: (lc llrrll
    'l dfr .i .I I\'
    r , r 'i .r l ,l :r t'l l tr ti r "'r r ti l r l "l 'r ti '
    " 'l SII:- i anticorpi alrtititoid icrr i.
    {itr.licirnllll lrtlclcrlutll Slr]roral llixr,l (QI) tD htpoliroi{tisrnrrl c0n(enil:rl irl fl|ncti(, d+ \itr.itn . , ' " , ( ,1 ,'1 ,,:,r i i r zi ;' ' t- :, l ,
    i'l(lcpcrii lralemerrluhri (dupir Dlar]8e)
    ?.11.8.'l7. Hiperliroidismulmqlern
    Nr. L..zr.ri I l"t)
    _-,_).r..
    'fi:atiuletrtultLt
    lr(,( \r(rlir lxrlii cstrrtlc 1/2000dc sarcirli
    39jr r4
    1Ajzll
    64- r07
    34- 91
    7(76"/i,
    )
    :r(19% ) I ; ,,n.,
    'liillillil|.::l,
    l;,lll:,1,;ill,,'l'l'irlli.l:;,i,i';1'1,1i1;:"1lTi':
    2.r. 80 olo.|,) ,,. .r rrrr r t t r titl 1ir .
    matoril, po;rl. ttttlttt t
    I'r olt rrtrololttl, tr]rninistrat ln hipertiroidisnul
    i , l i ,rrrrrrl t tiir t Lc, br ldicalclic ;i liipogliccrnie.
    2.11.8.1.2.
    Hiporifoidismul
    ercditor
    neonEtoldtronzitoricl
    ?.1i.8 1.8. Hipcniroidistnulneonokl (tireotoxicozo
    -'.cconsiclclirciLcstc I'orba de hipotiroidisrn ereditar atunci cind rrt r rrr,r
    ,r nr:ri rrt'ut un copii cu hipotiroi,lisrii sau cind cxistiLantececlentcfanrlr:r1,,
    '..,,rrrris|ttltrl rlin rnamir cu hil)crtirc'iclisn nctratal ' p1(r/-inti la lrlrlllrtl
    irr rrccstsrns. IJoala sc datorestctrrlburirrilorin sintczahornonului tirol,iilrr carc trucc prin plite(xrti (l'A'l's-/trttl
    rit\t tr l.h.\t'oidbindirtgglolntl'in,(TBG) -- globulina .scricl pc carc sc lir,.,/,i ' ,,,'):i i',,iiiti tli: I-Al-S-matcin, ri
    rmunogloL-'ulin-' G)
    ijrorina. I)r: ol:riccilnala se inso{c5terJcgu5i ne-onataiir.- (ltt'tiirl sl.ittttrlLrLor cste
    t l. .
    ,$i .rrlti ,irnl.nogkrlrttlitt
    boir lr - r {f l'1. : l lt lt t ''r t
    , ,, r , rit r r , t . , {"r r lr r po: t t ( r il'l't r onsabit i I ii"r "t zt t '
    i ', ' lio: r la ir or t " : "- t al'ir : j r lup; i (:()rri'('rrrl
    ,' ;,,,i ,; i , t i, ) : : , ; ', i, , j,':j,'t nt ', it
    2.11.8.1,3.
    Gugs ncondlqli ' {-xit3(irilt,
    , .i,,,,.. i ,,,ll,,,f,iiini'dc t o.t:r acutiL: a.qlitalic,apctit
    diuct : , t ahicar dit , - ' seDlllc dc it t sr r lir : ilr r l'
    (irr;a nt:onatalir se poaiie datori hiirot;rr:idismului oreditai., tratirnlrrntu ' ,,' l ,p' ,' , , . - t , '. ii lxr ndcr alc,
    glanclt i t ir oit lc' l{r r r i: alilr r itr r r r r "'
    lrti rttattr':t 1ru cornprlli ioda.li sau cu propiltiouracil, hipcrtirr:idismului nrirt, ||r , ., t1u, 1i1, , t , , , 1, ; , r , , ir ozi, l,si m iu- ir ca
    Ircnrxngioarrclof sat linlfangioamelol (lc la acest nivel. f) gugl marc I rr . r i lr r sli I x. r t li cst c 20( ] i, '
    lr,rrlr
    dificultiLfi in travaliu sarr "onpi.csir 1tu cirilc r-espit:at( calot ii : lr t lr r lt r '''
    1'rrrrlut:r:
    'lt;tlrtrrrt:n1.trlcstc spccilic -liornrl )r:ii l;.irll I t ,t I t t ut { 1/ l?, 1col}st i1in ilpor l lr csclt t t r c licliidc; i
    ficr:iirli Loii in p;r11'-'. sr'cuidarir lrirlrl r rr inr lr t t - iL( l( ' lnr lir r 'r r r
    rrrlri cu io(l sc r-cnilrr spontln ilr,priraele 3 luni rlup.l nasterc. ,r,l rr,, . lr r opillk) r nt cil ( P'l't l 5 'i0 m g/ kg/ zi) ; i
    ( 2'5 r ug lr t S t t t ''
    t,:,,,r, j llr : r i, : li lr ( r ccsalii t r at anent c1l car bit r azol
    indaliL cr l sit llplot t r ''l'
    Tulburdri qle secreticiiiroidiene moterne
    2.11.8.'1.4. rl r lr L t t lit i|t t lr t car t lia. cirlcct : sit ir t ligoxilt l) t :
    sc scad 1r : ept al: r : lr cor i ir . llt lllll( r r lr ll
    ,' rtrrl .r lr ' , 1, 1, 'r : r r 1r i,t r,t t : r lic: r t ncuLclc
    ln timpui.surcinii normalc, calltitittca crcscut:L dc cstrog('lli l'r,,,1r, l) l( 'r'r t r l
    2 luni' t leccnt ' Pr opr alloloit ll ( ogcr lt
    rr()(IrIr(r
    rr<rrlilicirri
    cirri alt: (h{r):rteior
    i-u'l al(i
    alt: rli{tlliteior conp,orrentc
    rli{tlliteior comrronentc alc secretici
    conp,orrentc secrefici glar.rdci
    glar.rdci l)ril .'r,.1,
    glandci tireiidr:. l)r.ol ' , t,,r l) , slt r viist r r r lt r ll( 'ot liil'r lil ( l'l / 'l)
    :,1icf 1r:ursportoare
    1r:lnsDortoare de tir'rxini til']xini (TliG),
    fl'BG). radiocaptarca
    rarliocanfarea iodului
    ir:r .li rnr'1;,",1r, ,,t, ,,, , 1i, ,) r r lr t sl ir r t r or lr t sc; l t f it t am cllt iu t ir ct oxir : ozli
    Lnrrl lrazirl -qint cr{rscutc.'"f I'SII
    SII nu trccc prir placent:rj Ta To (tiloxina),
    (tir-oxinii), l'lr 1 'rrrr
    ,l,ililirrririi) ;i I-,{1'S (l.ang-actt.tt.g lh1,toid,st/.rntr.lc.foy DIN MAMA DIABEII€A
    ) II fJ?. NOU-NASCUTUT
    ) pc)t tL-ecc1>rin pl rr, trl
    pIr, rrl..r
    i i r t inr lx r l . . . r - ,ir ii .
    lli'r bet it : r ' ir lil( r r l
    l ri ,lr r , r , ': r it t st t ljllci in 1'r 'lt ar nollLdlgr t vidr : ir r r
    [ ii ilc( st {'f slr t t lit t i l{r r l '
    2.11.8.1.5.llipoliroidirrnul nrolern , t , , ; r t ir cr 'r r lr , 'lr t ilr lr il) t, lt t cct - i: ltlit l{xlll1
    ' l t' ,, t r ll l; Llr r lir t l
    t r ot t - lt lir ': t t lit Lr '1r it t r 1'
    l rl l t 1, ,r i, , , , llr l' l, L lt t lilst ll t lLlt lyr t it 'r Lr :
    r : t , , 'i
    l;ltt, t,t. rtt tyilut is ; t t , s a. lt l) t ix c ( l( ' t ) t llr t r ala t l x ) t t ( ' r l r t r : r : s i r : l j r r r l r r l , r i ', r r
    ,,IrrIr . .. . r Ii ,l I rr.l rt l tt i t t t lr I r 't t t ( <. Jlr sil'icat .lr r .rlri ,\ \ lr it r '; llt r . lr i. t 's . r sr r '
    lLr50 'li,rlirr r'rzrrli : r r or lr r lit lr ic l lilr r li s i 1r ' r ir r i r t t r l i i [ i i r r r l r r r ; r i ( . T c s {r t ; r l r i r ( , ,t,i ' r |: 'r t is. r l' 1" ( l( f '' ll ( l'r l) ' l' 1"
    , t Lill'o tic rlc t:o 1r it . \ ' lt - lis c t r lii r r ' z ulllr ii r l i r r i r { ( . s 1 i s ; r r ( i l l i r l , r,.riltl , , 1 , , , , , ,,, , ,, , l' 1't r r gt t or llirt lr lr r lot it l'il
    it ot,li;rrrr rrrr lrrrlr i. ., ',,r tJ l')l
    '

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    '
    ltrl \'\ , l , 1 , r ''" , , , r ,zr r l {i r l r i Pr :r g l i r cr r r i l l |l i tl i ' i tt cr ttr i i ttr ti L tr " sr '.l r i |r 't l r 0 l i r t r
    r tso <i i r 1 i r 'tt r r l r . I
    , r , t , , , . , , , , 'i ,,,ti , ,i i 1 ',1 ,1 .fti ,,5 1 ,'r ',,, '1 1 ) l i ( i 'l c i n sttl i r r i '
    s(
    l l l t t s ii i o ;r r u r !lkr lr r lr lr i r r r lr n r ( ( lr | a L \\jlr i1 (,i r:,1,1,,(1,,1r('1.,
    . , , ,r, , , , , r , , tl ,1 ,, a ,:,t1 ,1 ,, g l ttl r i zi l l cl :cl t:r ci L zi r l i l ta d c ctcsttr L r : si 'l ' p l tl t l " r
    ' '
    . r: r, lirr l . \ ; , l i a l x ) t . h i r r i( :; 1 r ' s1 i.l( ,1 i. 1 ,,l,r iu r 1 :i la g - lL rfc,r-r( l ) i ri ti j l |to fi i r 1i rrr1:rrls: ' ' ' ' g 's1 r L 'i t) o r r l i //'/' '
    l ) r e d i : L b c t ; c o p ii n r ' L s( lt r r o r li ( i1 t a llcce d e r rl c) cr ri rs{i i i l l sl al i orri rl rr'r1, '\ l , , . I I i , , , ., , t , ' ,,r tr i l tl l r r sttr kr r tl t. r l t'u tl l ) d r l r r L L \- i r sti r
    "
    s i r p t i r n l i n i sa r clr o g r cn ta le ]a n r $ le r e le slc 4l {g , r , , \ s r l r 'l r r l 'r 'l i l i c csto a s.r 'l t ti p i c i r r r i i d i 'r g n "sti 'L r l s( l n ) i l l { l ) r ) l r '
    \ 1r, li[ l l ] ; i u s u l l ' i o - . l e pe n d c t cn ilcb n t d r p ir 2 0 tlc a r i ii fr o.r(,11i !i { dc nrni trl ].l tri(1i l (r ' ,1 \" r \l i r l \1 r ' ' \r ' l \ |
    .,,,r. , r : 1 ,,'.r :i :i i - r r l :r r r t'r . i tr b o i r l i t Ir '\\'l l
    ! rr1(lill l ( l ; c l d c L J r l ti n l te 1 0 fi l9 r | n i 'r '
    i , ' , ', , , 'r . ' 1 u ,,'r ,: .'t,i i ' ,l r , p r ' o r r .':r i r l ta . o n fl r l l 'l :r r '- :' r r 'r r l i Ir l i r r 'r l r 'r ' r r : r r j
    f 2 e / o i n f i c d e l0 - - 1 9 lln i '
    \ r ' . ,1 i , ; l l , r . r ' n, i' .r ' ' , l( ' ,,r .i ( l t lllr n ( ) tr - l l .r SC l r t h tu l m cn . ( ,r ( r U ti L tti L r l ( n l t) i S( l l l IIl l l l
    , r r r r r , r r I i I r Ir , Ir r .Ii ,
    .11 c'rolufi (lc 20 (Lc ari ' tr" ,r{ ti L l , l \t, r tt'o l i 'l r i :r r P':l ' 5 I:;; l l i l ' l tr '"ti :r . t' 'r tt- r l r ti
    (13 calcijiciiri ill '/asclc pici()nrcl.rr lllllrl l
    (l{ r'e+i olatjc bcnignar . r l ' r r t , r t t : rl ,l :r r ) "l l ;t;t:- ' IIIIIIIr i tttr l 'p ccl 'l o l {r i 'r " 'r l l 'l r l 'i
    i r L p r i m e l ' 2 '{ d c o t- t n i l i ti :r 'f lrlrl
    d5 hipcr'lensime , , ', , ', , :'i,1', r,,r l :r r :i l sr tl o u sh i D g o i ( j . .i i u fi j
    s lr! , 1i[ l l i : a s c n l i n : L t o r cr 1 D - i- c.r lcilicir r ' ii ' r a sr ]. fclvisrl ni ,,,,r r , ii, , , r , , ', si zlit ' Pc sp: t t c t u pi''i'udt : sLr t t t illt r '1't l'
    r ir r il
    \ ir{ lir l l , ' i r r o { r _ o p a t i c i ,,.| ,,,ti , lJ'-, r f , , in"t "t "t t pr ( / t lr inint , suslinin'l inf t r r niieni: ( "( 'r r - si
    ", t i"iir ni. ,
    s lir(lirr 1 I t : r c t i n o p a t i e r a lig ]r il ' l; lr iqullar t t ; t r ' r '"1r ilr r l 1r ' t
    Sl| (lirtl U : r . p e t a , t c a ? o r tu r i ,, i ,,,,, ,, -;r, , , '. , ' 1, r r '. ,lu, g: 't i, J, r lr : . . \ l; r i
    , 1, ; r silir li( cll Plinj pul' lnii si lJulr lulilllr t '' ' lt lr 'lr l'
    ' ilr, lirL l ' 1 : r . r r d i o n r i . ! pa tje , r,r.r , rrr' 1ur i', , t r , 1,
    copilul n'is( : r r it lli ( ) r r r 'r r r r 'l
    ,, " r' ' ,, I 'i', ii, 't it , r "t o' pt linil, r r lc pciar c il punt
    j (i ,tl u! .: \'t
    " ,i ,' i
    , ,1" l r,,. :,i trl r r r llr ilollr r 'lr ':
    ,r l l i l ,r); llr ,' t lr lr r . : r 11 ( 5lc li pli z"l) lll; d' r ': r l"r i- : r l' Xlt t "'z"i 'r r ir 'r '
    li rlori dr lrr.o0noilie nel$rorebil al diahelullti arffixtr ru sar.!in{ {drp;r ])cders(ir). (rillll ,l 'iit , l , r r t . , 1li|u; ; li"r ni: r scr t t t r t lar ihil'r it r sulin'r r r ili l't r l" 'lr ''l''
    ' ' , ,t,,' ,' i .'
    \ 'ir l') r I
    r' ,| , ,Ir:rIrcI r 1| t ) lili( ! o, at c anur r it t : car act clist ici l) esi' t ulcor i lllilli{(
    ,,1' " ... t t t t r r t : 't it t l{) 10", ' lzt t r i sim Pt ot nll. ili '|t r t rl i
    ' l r) rrl '
    'lin r 'il ''t '
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    "41i' ' ri' l '
    r r
    I ' i c l ( ) r l c l d t i n r rn i{ csti, .r lin ic , ,' .' .l : ,;' , i', i, r ' t , 'gi"L Pr ir r
    'i"'l"il, , , lialr , r ' t sl! : r lll( ) lin) it lli ir iungind i r lir ir 'r t lr orr r "r r '
    I\1!o rI sau aci(bzl scvclii ' I ' t' ,1 ,1i ,, rr r : r r r r : r t i'
    l ,r r r ; 'sl,t r ' : i ; r t r ' 1't r r . t r r 'slir I' 't t n'
    ' ,,,r' ,l , ' ir i lr '( ic\ 1: r r tir ) lillr r l '
    i r i , i ,, t , , , '. |i1- r t t ort-i i it iiopalit "r 'st e r lt 6 or i
    ,1. li. nll'i:r nu coop.rteazr'Lin aplictrea irrdairentrlt]i
    '
    ' ,, , ,l rrt rrr: r r t r rrilialr r it ii: ir ,t 'ont lilr ; 't ir - cu
    ct ilal{i n( ) u- lr : LScuF' P( llr t r ll l( r 'r 'r "l
    :l'.tbrtul ' 'ttt ! I I iti : l rr l i ( , l l i l l :i .
    tr anomaliilor congtlrlitaIr lrr lrIr 'L l t
    ,I :-' ii r t)tls1:ilitt lrt'(lvL:l)la rn:ii tlarc
    t,li: iu slxrcialcartliopatii'dcfcctc alc SN(l si rrrrrll"t
    lllorl:rlilal.rxr perltaltali irt t[ntric de sfndiilc dc crolutic lvhilo fl de fisocioro.a fa{,lotilor dt lr'o1l
    ,l ,,,,,i-,i;'t'
    n$s1ic Pederscn itl dialretnl Eratcrn '
    'l | | " . r '. r r , r ' .
    i t I I i 1 r l r 'Ir i Ii r - r tIIi tl tIItIi Ir '
    ( lr!rlr,,rr, \ \ h i t ,l Factori i l c{l cl s( nl ,i r.I
    1 | 1 i 1 ,r, r r r I r 'r r r i r r '
    1 - ( r o i l l ( l si :ctttr r l a l i r p o l i ci tr :m i ci , fr ccr r cn i i tl ( i l ttl t'
    r I l r r r r l r o zl r l l l l ci
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    11, 1. , 1 l;'li l ) , t l 't t t t tttl ttl ttr ttt'ttti sr :tt'L ttl tt"i /tl i JL l l 'l i ttttttJtt'l
    t tt i r L tt
    L
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    ;t i t tt"t."'1 ,''1 't
    t) ', , , , , , t ', , i , , ,1 vr tl o r tl ci t i l l i ttr z,r l ti ' i l 'r 2 U g ''zi l l r r r l i l i r "tr - '
    ;.", a a d o l r r - r {i rrl 'l t- r r si ir lrl\
    l' 30.si , , l , , r r l r 'r , tti r tIItItti l tr i r l l r t- n tl r Ir n 5on ''l to L to n tr :tl
    r 'tr l i r r r t'l i czi n ti L l l u i r l ( l j r .i r L l r r ( :l ( ' 1 ) l r ) i i l r ( ' l r '
    r 1 , , ' r r r r r l rl r ti l l r tl o ;Jcl t l l l a '
    ti i i ' i ,i ,r ,'r tt' i r n l i r - cj .r 'i 'i , r ' cr ) r l d i 1 i i l . 1 r r r .i r r r r r l r r r tt
    l\loa.r'totirtr lutcriniL :l lirtului sc poale lrroclucc il.r al Z-lcll sttt itl 3 l' rt , , i , 'l ,r l ,,r ,,t
    , 1 ,1 1 .,1,l. ,,r , r ,l u r ,r r ,- ,1 1 1 ,';- ( r,,r p o r - t i i i i r r l i cl r i ,l tl l ,a r l ,l ti o ti c:1 , sc i tr r l tr '
    Ilirlr:stnr <icrsitlcinir si cste ir,sotitX t1e acidocctozil matcruh sau pl-clr:l;tltll' t' I ,
    l'
    i)olilritlrrrnniosr-tl r:ric se intilncFtc la gr-avida.-rrt diabct, l)oato (l(rtcl-!rrrrril , ,,' ,
    ,, , , ' , , , , , , t i i 'l 'r 'r 'l r r ti , sr r l 'l i r l i i t l l p tl r l ( i r - :'p 'r r l r tl l '7 S d e .2 'l .1 r r r t '
    ' , ' ' ri r
    : i t 'r t.I' i tttPt'i "t"ti , r r r . r r
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    1t)r'r(ir Drcn)aturit a rncnblaui:lor si na;tcrca 1)ro lilttlr:t. ln stlrrlirrl ,\ ll '',, i ,,r '
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    . ' t . " 1 ''', 'i ,,'.' t, I:'l l ','1 r r r r tr r 'r r Ir ,r r r r r 'r l x) r '1
    si i l,lrriintrr si cordonul onrbilical sint loltrtrinorsc iar in starliul l)' l') i l' .'i ''r r ', r l l i l r r l r 'i ' ']: l .t.'..'.".''..
    I llr, r . , l i .' | .II|I',II/i r l " l "i r i tti 'i l l l :l r r 'l l l \i r r l l l ' l 'r r '
    ll;rr','r1rr cstt: nrici. ;i inletctizatit '
    l 2 \'r 'l 'i 2 - l l :'r ''1 1 )
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    I ) ir t t lr r r c i. t l L r Il d rtr' fi z ,i o p rtto l o g i c ,s trl rtrl i t si ul P l i l i ci tLi i rt l i r< l ' rtl l nt '1 ""'t
    i r r p ti r r r r '.1 ' /- -l - - i-l r
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    rrr, r , { i< r r ilr r z i ir s rrl )l i ll i i l l l l tl i r:s l l tttttti i ttti ttt ' l:t rl rl rj ori irttc:t ttti rtl tcJrrtrl i rrl l .'r r 1
    r 1 l ' l " r l r vi ' ( r '\l r l l i r l l ( r 'tcr r r Jr ;r l r r i tr l r tl
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    l i r',, , ir r l lr iplr lllir ' , i rri r' r' . r' r:I,Ii l rr1 ttI rl i ttro z c i i rrrl l l rl i r)r' l rr rl i t' l rl l I' l rrr' 'tri ' t '''r r , , l
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    r,{ r{ i .r,1( 'r Dit ir lt uilsit r lr : ( l . 500 g) i c) nou- nisculii din t t r r r t t t "t "t
    rtr r,,1r1 1i|r'rvrn irii llrriil'l ',,,,1 r i|i.. l ,,r"r r.r.
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    rLl)t.,i il,rr ,, nIto.jr. tl r ' t f .ll. ( acid-citrat-dc-r.iloz.ir) r'1
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    i.lrip,rr.to'iciise rla acir'iriistrLiiili,r,cniiat. S,, r,,r ; /) maladia urlml 'ranci liitlitrt,'
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    ti ,rr,lncr
    pr
    1,rr'.ir1, r. hipet-gliccnic,
    ,, :,p," i,,.
    rxlL . Lipurirsulir
    .'.1, .1Lrpr;r-qlincmie lrPrr LrrsLlltlnll'r\c
    t>mrcsr .\r yel,tound.
    y(uol ltt. Glucoza
    GlllCOZai10r,6,
    l0r"/o,in ciruiillrl,,
    Cit.tllt(irl,, t) Q
    ,l (,(l
    ,i, {,o al

    ll
    nrl/lig Sr pc 24 or-
    si p1.24 r .,rLsigirrintluu dr:bit constant de 4_g rng7ligirrrirrrrt
    tll, rLituc gllc{.mta pi:slc a0 mgr)i. rnCrl..;,.I-a I_a nou-uirscutul
    nou_uirsctrtril sirnptomati
    sitir)torn;rti i:
    r. sr:
    ,rr rr,:rt,
    ln)rll l'-
    .r,i r. . is t , r r init ial rn .;i ' 1 ,,,7 .1hipcr.tonici
    ,J glncozri
    .rrn 2 u ,l dc
    fush
    ,l' ' rrrl/kg, cr,rrctitd-u-s,..il :r.
    Iri p ,. rtoni r.i 1t.i .' 26" . in cauiilrrl,,
    (t-5 -20_!.1)
    glic"1tio pinir la'r,a1od dc'-j0 11rg,]1,, lrifri ri E
    1 ": ' , 1. d, r elot t . td . I\,tc l , ::l i c "ni-f"l
    c r1 i , .,-' n ,t," :r-i zut:' , p,..r,. ,l \ ,i - r,r,., trr l ,rrr,
    r;r1i.rtii o altar cauzit dccii Jrip,.rinsulinjsrnul sccuirdrr
    tliabrttrlui tn;rlr,rrr
    ,li e
    (l,
    ( '.--x Nou-nascut' normol
    i, . , .
    2:
    (ntir r:!ic, tumori dt: paltcreas cta.). 'It:atitnrerrtul cu cnr.tizorr glucagurt r,.lr,
    ;i
    ir l {
    o ! l''lano ctiobeticct 2t '
    r)) 1r::rtarrl,ntc1ccxcel;lio in ;rcest tip dc iripogliceinic.. q
    o---{r lnsutinocle7encient 1l
    2.11.9.TUTBURARI
    METABOLICE
    IA NOU.NASCI,,'T
    2.',11.9.1. 1
    HIPOGUCEMTA

    [n timpLrl victii intrauterine placent:r fitr-tizc:rzl'io c:ihhtaijr cotrslotrl,i


    il -irrr - oziL,.('a++
    si ltg++. In acesf fcl sc mcnfinc un ni1,elcr.rscul al at.r,slor
    ,lir/lrn-i in siugelc fetal. fntrerupcrea bruscir a iiportrrhri lnatertr pro(hc(: inlr.
    ,l i : r J r r |, r r r ; r c r en mo d i fi c . ri i i n p o r.trn r,. rl ,, n i i ,l rrl rri ' :i
    tl i ,-,.1n1.,; , .., | ,., .rrri ,.r
    ,'..I l; , 11q11- 11 i ;r' unl uoim l o J rrn d ,.ra l (fi g . 2 .141.
    I litirrrcar:bonatcle t-epr.czint:trur.qr frilcifal.i ,1l.{,r},.f,qi{:llcntrrr I:il l
    ; l rr,. r : r , . 1r .lr : ' t r . p o rta l ;" r.u n L i rl u l L ,l i n r-i rc rl :r ' i l r l r.rt,.trri t,,i r r.l :r,.,rrti ,:i ti , ,\. 'l.r
    \tr.. *
    ;rr:,si:4. Nivclul glucozci salguinc la firt cstt: iu gencral .5O...80h,,clirr rrir,,.lrrl
    rrrrt.rr. Insulina e,stc prozcntit i' pancrcasul f.t.1 Utrr sitDti'rlltinir lL ll.rL.,r c,
    irrrr,,ltr:rtja.r.i.clrst,' c-u \-irsta 'l'otu;i, irrr:l-Lr.crrr::r gln,.r,zl,
    Sc-stationall"L. cLt o.,i.Q.
    l rr i. ' t i 11- r ' ilinr .,rl rr,,i i u l 1 rlr,.c n L -i , rr:rrrif: ,1,,!l .l l
    - i l l i ,ui i l i l rr p,r,, o',e.. a'
    rlr,, s:r:t'ctic srrplimcntar-i d.cin;uiiu.r. CLiar l.r rnirnr:n, r.Lritrrnsrrlinsrriirr,r ':d
    ..0
    l , l rl , la inc iLr c ar cac u g l u c o z i Ll .r rru rn .,, c s te rc.,i us si l r:ni . pl rLr:cul rrl r,l ,
    r. r r r r r lt s ; r r r m . , i l ru fi n i m o ^ -rn ,.rb i l .l L r i rr"ul i n,.. l rr ti nrrrrl r r..rr .:rI i rI I rrr 1t t
    ., tr -
    i rrr',li; r l t lr r pi r ; r ) lr ' c ,.d .p o z i te l c d e g l i c o g c ' h epati c' si cai tl i aL:csi rri . srrr,,,
    rli , rr'rt-,i. 1,Lrsi.la iiispozili.. pcnti.u suprar.ietuir.r. l)cpozitel, ht,pirti<r. rl,
    11lr'r;'r u -.111rapid golite priu glicogenoliziLqi scir,clerc:r i'lipidir a <xrrrr:crrlrrrlr,.r
    "lrri,'zr.i il prirlelc rlouiL ore Llt; vi"t"r estc uormali, In tifinr,rk, 2 -i zilr,rl, ilz 71
    'irLii
    iLr-r: l'c o,,cornutaLe" a met:,rbolismului spre ltilizaii:a lipitlr.1'r r.ir :;rLr,, Are Cui,n r:cstere
    ,1 , ,r1, r iin: t ons er u t-r-. L r,:s ren i \i o l u l p l a s m a t i c al aci zi l or gt:asi Ii i x,r.i (rrrr,
    ri l , illr p. r r us t r r c ) . 1 !s tc p | tz c n ti L l r0l i r.i r sl )l r, { .. ( ( rni:r
    r lL
    ;i O a l ti r,,c O OrLl i i rtt:'rtrctl , i l iriirl r ri i)(u r- )r fr
    "','r r l r r l r !r l i 'r r r r i lI'l r :L
    r l sfr l i \l
    ) l r rrttr l r l ) rfii x'[l r )Ir ]r cl L r r l 'r r L r i :L !
    l ": n, :z c i d i n u rn i n ,,.c i z i .
    - llt r r , t i' . u, ,
    (lrciclul ucccsitl"rglucozir poltlu metabolisrnuI sirrrj
    irr r.i. nriisllr.irir(.r,,1.r \ l r r . I i i tr l i l r tl s:r ; ,r ) l ,o l i i l tl r i sctr tr l tl tl :r l r i l tl r o l i sl l l ;.1 ) si l l r l r 'r r r r r r l 1 i "
    rrr.ilr,rlolos i s i alt c s u l > s ta n tcr1 l -p t s u rs r-L c l c ,.:n r ;tgi c(tl c' c:i r:rnl tl rr< .orpici .i orri rr1 i r l sl l l i ci cr l l i sl l l t- ;r l L r r I'
    ( iitgLlr. ,rtr t\| , r ,,r r r ,i I:r Ii r ', tr tr r t i r r l i l o si r ', r :x<'tttl i r l tl o s) ;
    |st, ')
    S il. uir t iii( ir r t a i h l c v o n tc i rl .rrL r' p .i tt. l l l ti rt..tr l ri 1r.gl i r.r,rrri ,r L ,'i| l r ,r r ,l r r l ,L r r i r r .r r l ' l o l l ,l tt:j ]t't l t:tl l s'
    rI.rIrr,rLrI,r ', , r
    , , ', , ,,,r ,,,,'f tr tr tl tl r r l ti l i r l l l l l tl cti n , l r i l xr r i r '' Ir i Ir o 1 r 'tIIIi r ' :r r r tt tl z l ( 'r l
    :i L ,l , t ) t t or r , DiLs (i rfi tn i i c i p ttrl trrL r.i r.s tl l g c sl :rl i onIl i ; 1,) rrorr,r,i srrl {i i ,rr '
    r r r r . ! , l r ,r l ,r 'l i r r r Ir i 1 r o 1 IIi r 'r 'r r r i ;r1',i 1 ti IIr l t:i IIttttti Ir ' r r r t. l r i r ...i tr sl ;tl l r L r r Ll ttl tr t
    r rrrt .r r l i .,.r .r r1 ,,r r i ,l ,,, ( r , I I r r r r r r I r r I i 'i .tt:t:i i I'r r '( .' r ' l i i r r , | ,r l r i i l i r r t''r tr t
    ' i tt i 'r r r r l r l i l i r i r l r 'r l {r r r ' r r i
    \, . I',1 1 ,,r1 ,i , \,L ir ,, l r , , , t r r l r I rr I ,, ,I ; I i , , rrri , i r ' r Il i r r i r r l "l i l l r i l r i
    l) ll]t
    ( ,l r r 1 ,, r l ) I
    ! i . , r l r 1r r ,l r 'r {r ' l l l l 'r 'r l '
    .i
    trl
    Toh(lt!l 2,(t:l

    - nou-llsor1trii lit 1o |lr!t| I Vlrslrr dtdnrlullrl sintptotnclor (in or.c)


    - l)r'cnli,txrt 1 5 ,60/00
    - critroblastozr, 1 7 ,60l fu,
    - drsruatudt-!te 20% 48-72
    2{ -4S

    . ,Atunci.cind sint asilnptomatrce, o rlare partc din cazur.ilcde hi ll( 13


    ur(. trcc rlcobservate-Avind in vcdere incidcnfa foartc crcscutir
    a Lri
    ruit,i.h catcgor.iidc nou.niscuri,,oii"iprr.,i ii-Ji"u.,,,.n,,
    -111um11.
    ,n amcr)t pr.ecocc csie obJigrroric.Se con.idcri hipo
    'Jab€lLll 2tt::
    ll-l!,lil:dJl,lu
    urmiltoarele yalori ,trat
    ale glucozei serice: i la nou-n{scuhrl ltipo$liccml( (llrl):1
    !.||l rlilrrorrlhrt &l s0lrlrroloreliniec cc sepot lliil
    lrou-nAscut Ia tOrmen; Iilaus ii Fanaro{i)
    < i0 m g o o in p r im e tL 7 2 J. i ,rc
    \{ 0 m Jd ; .lu p i 7 j d o orc
    rl.)rr-nh.scrtprcmatur; in p r im n .ip ri i mi ,ri .1,. /,at.i
    :*
    < .r r u |^rs:l
    g o ; d u p ; p r in r a si l p(i nri ni ,t. ./i ^l i l ,trl ,tt t tvr . rrtl Y 4l .

    ,1,l ,r l " {,,' rrA (rIr;1tt10


    _ Definirea biporglicemiei prin aceste valori nu llseamnir ci rrrr\l ', l r r I I i l !iI l rr(l
    oricc ni
    al glicemiei peste.iifrele de mailus este totdeauua .igo.. 'OJfloiti"
    (lc rnai
    rnai sus permite ,,A" lrcr
    uermite clinicianului
    clinirirn'r'l'Jisii
    "3 ,A+d-+-.- --r- *'1,^-r^
    detecteze prin mitnd. *,^*,,., , ctri, .
    binchimicc I
    l],lllli.l-"^"-"d:..ylita careexistf,(sa* in*fi"t""fa a glucozei
    c9rulalc cereb-rale_ame1in1"iy
    (M.L. " Accstevalori'alr: gl
    _,"j1:rfl_t: Chiswick).
    -r]:,I9rleatunci cind dozarla s_aA;i;;ilr;ila
    nri.i sint valabile grocozc
    , metoda,ca si ce,acu orto_toluidini. ln sc|viciul
    ",1,-111":tonumai hexola,
    sr:.clozcazl lfolositl ,||l l ||ri i
    ficlndu.-se aitererrliii"a ..ic' a"titott" ,r,
    rtrlucirtoarr:,al cii.rofnivel este.crescutin plaJma nou_niis-Jutulrri. (
    tloz.atiLin.si'gele capila.estemai scazuin-deiiii"^.r"g"i" At''cil
    I|marocrttul estefoarte crcscut,niyelu"lgliceniei csti mai "l"tt*t.
    crescutin nlr
    ,l r',{||r i r ,l rtri l ri s l rrl l (, nrn r(,
    declt ln singele total cu peste 15o/o.
    al i r, rl tt r* tnnl d

    9{)";,din toialul nou-niLscufilor


    :,6X"'gi;ttl#1li;'}ri:fi,:
    l:l,ir".lrji.{i:,."T.',)lj:T"l,l""if
    clrc prJri"ll
    lli:i,:-,-1i1.:":.l"en
    (rr'i{ r ag[ os lr c dr lc r.c n fi .r],a s c
    mici""rli-*";;i;;tJ;;;
    tionatesint normoglice ;i pun umi.roareld p(
    c u m r.,tu l tj J i i l ti bcl ut 2.93.
    l rl [r,r l rl I n.D ri a
    1.d.L 'i , l x.'r(k,' r1i l ,l f l )i ri (hx i ri r
    ,l rl l i l j rl r rrrtl x rr(,z i n
    ll\)o$licemia neonalall simptotlrlrticii lir bG ale eazuli (dupi, KlaEs
    Fi l.anarotlJ
    Itl'rryli(] rjttli(' llo(rrlatnli, sirlplroll1aticir,

    Semne clinice

    'l rrrnrfahrri (jitterin ass


    ) 42 20
    Cionoz, 43
    (loD,/ulsii Iq
    .29 I
    Al)n(,c, respiratici Ecregulati, (i
    ll.ipilt stridort, slr,lr
    i0
    l0 I
    A(lill lDio t3
    li.l rzul olil erltdrlici .t I
    ,\fiv ii fi ocrtlorc.tLltoI.lnolc
    2
    39S
    ,l)!lg
    r ir L ri lirrrl Itl()llit { ) r iz llllr ir Slic ( r r t t ioi : i. i! lll( l || t|lili s ( . r i , (t t i r r i j . I l I l \"tt- r t;'' ttl t t t: ' ttl '! ""
    l)lill r l l l i l r | r l l i ttl tl i :r n r l i l r Iti 1 r |.r i r r 'ttIi Ir i 'ttt:
    I t r. rro slir-: lu: lz il c r.o r fi p ro a s p o te , p i t:i i .l rtrrri l r. si rrgr. srrfi ci tnt tIr. , , ( \ , I l l r tr r ' l r r l l .l l .l i .2 ) '
    i:r ' I t:url citcstc lozultatele si fie experiincrrtrrL l)irr trccstc uotivr., 1rr,, , i i r co r r r Il r ti i 'r l i
    ,l i n . L ,r tl .t0 l tl u sl o :.:ti .l n e l i tl o b l a sto zi r i ,- i l t
    ', ) h t ) !,l i t.tl i tt :'l i l I' r r 'l i r r L :- l r Ir i l ''i '
    rliirrl' utrci srrspiciuni de hipogoliccmie, este ol)ligaiorie ,';',;"i , r" ; i r r r l r 'fl r n l i
    li olcctr.riril.il I '' 'r r ( rlll
    ilr,,; ri cantitatirrc. in tabclul 2.94 sc lrczinte o clasific.rrc rL iripoglii.r.rrrir{
    '; i ,
    ,'', l , i r , , , , i ir ( c( :n i :r 1 ;Il i l . i tr a ttr sl ' i r tr l l ci n t'tl - - i '.,Jr i i - r u q l l 't l l r l l csl r r |
    cl j b i 'r :i l i i r r n ' i rt
    l l rr () lr - nils Cut . {'i ,ti l l sl l '( 'l o r i ) i tn ( l l 'o i l i i 'c d 'i i o i :j tr t
    l i r ! r r ) l i r',/ i','l '- r r r l i i i i {t 'r t
    , , , ' l ', i " l tl ,u j , a ,, h L r m o l i zi L ' D c a scm cn ca ' h i p o g l i cr r r tr i a 1 "' r "
    li,''. i;;"1,;'i,', - i >in;"1' {ulo'it P' nlrlr '.\' '|rrr'rir"nl
    ",'t'.tu,i';
    Ar Ir1,ci,l,'.itr:rl-rlr'ffnzi] ;i conlirirlllrril rrr: 'r'r'" '
    ', r,,',i,'..tr.,f 1r,,, i, , ';.t, ; tlc irr"'tlirt:r cJr'| irrrir'r"rrr Iril'';;ri' Iri"
    [llasiJicarcr ]ripogliremlci li] ro[-nir${r{[l (utp:r ]nrs;i)
    ;',' 1 ,i, ' :;,:i'l;t,i', r
    , .',,,,, f I ,)r, 'lrrl'.1'lrlr'r'rulr'i:' 'Jn irri"tr:rii
    '\)(a j l l ri j r
    {i zi o p a tologic , t)itll)l!t..tttttluhlrtr ittt ir.tsritl,,.]t,tIt.rtusi{,,1.-,
    i".accentuit{i' sirrjr'r()
    ll.:::1l..,lll'l':i;1"',:,1',',
    i;:,.]l;1ii,:'; cstc iii"tri"l- Hifogliccmia
    ' r "'t,'l,ji.'i,, cslr : r 'tlr t ' r r r
    al nrr(atni i o 1i Ifzi fl tr'l ,, rr! l l rrir lr ist r lns la t l it t ar nt lnt t ''l nicciical l- r at am cut t ll
    '-r,1 a
    del i ci L S l i roi f ri si Itoi r'zl i , , 1 1,,, cJ,lrrtlgiL:aliL,Pal'lial:r Pancreaslllui' -.
    l)l lr r i x L r n c i a i . o l i s n } u 1 lr i gl i cog.trl w r ti p T. (kk!,11 ,l f Il t1 r .,
    Jr i p cr - 1 'l ;t( i r .i ) .
    | \ l ) ] '| l '| ttl l t!l J}ct:h i u i t|l ( vi s( l 'r o f8 a l i c fcr l ]i .
    Slicorr..,lcr rz:r, galalrtozr'II, h cm t'' o m l tl l cr l s
    i ntol cranl :! Ia 1!ucti '7:r, (l (.l i rl 1 r 'i ;'z:' r tt ttt:r cr r ,3 l "si ' 1 i
    dc.f cttrzi !. (l ol i ci t (1,, l rr, Jl i p o 3 l i tttr i ;r :r r ' 'l 't '
    lll. S i r t( l r ( tr l r ttl d r ". h i p cr l i scu zi L r r tt' ftl l r l tr l i n i '
    tozo 1,6 di {osl l l i Lzi . i l 'i ( l o ,r tn r ,tti u L i t';tu to '"i ti tti ti si '.i st'r 'i tzr : r 'tt l i tr r I
    1rc|i i l :r, sci L70ti r, (]()fl i l n,1| r ' r r r r , r t . r l f ( r ( 'r i ( '1 1 1 r !
    lcm alocr it r t hr i
    gl ucagc'1r.l, horl nor ,1,, ' rrl rrr.rrrrl . ili) 1lr nl( 'l111 const it in '- cclucer ca l tt"
    l tttl tttl ttt t I t [ L lt lpoglicct t t ici I I L nou- nt ist ul
    - il
    ,
    L l, n . r r ( . s L r n r u l u i ir p e r i- dialct matcr[, rnat rosoill) :l ,(l cl (nrr j t1sl r1ar, L\)ol )1,(,,,
    /,, // tr,rl :r r r t ) r t r t l const ir i- lf cct uar cascr ecning- ului la t o, i 11t l11- r lislr r lr l
    r r, r d p ( . rI I s r r t r n r s l n eritroblastorti Jlh ( r r ) t ct r ( ) 1r 'l( 'r l
    '.r cchl c treta, si D i l ro rL,l
    ; ;' ,:; , l, i lr ilnglic, : m ir , , : Llim cnt alic pr ccocc' t r at a
    1f i('.Lcm:rrn-.9f ck\{i th
    "1 1 1 6 pag- 279) ir L r r : r r t 'r ''
    C om|s, hi pogl i ccrri a i n(l r (r ,' ,,,, ,,r,," ' ' ,i , l, . , , , lir r '. i'ir sf ixici'( vc'zj punit uli'1 '
    r:ie k.rrcirLit l i :u tr tr a unui h e n tto cr i t onllill 1 1 ;l l x
    , r l r r r ' r , r r r tttti tl l t r l l l l t{'r l l l l c ;i
    l'rr, lL r i . r j ) ( : rr l L a e r o b : r d e ilipo:iie, insr{icir!11ii ce1.tlj.rf ir, 1!oa1acu rl r'i ni co \i r,,. ,t,
    . fr rlsir: ;i cirLd r'i"r,dc{cctc hipo'tenric , rt,)
    sirop .le .rr!ar, il.ci(l(lllir t,r,
    , ,,,rlrrrilaL alc metrloiisruu- pi oui c.i , aci drfl i a n( l i l , rr'
    i, ri , I i o a ( i z i l o r lo ic:r, Lirozinoz:1
    I r, , ' r . r l i { . r ( . l a r : l Irolicitc ie carrl i omegal i c ctn(r:l i ri i -r,1,' rrrl tt' tt
    frl ro rrorrc s i l i l rl otri k rri z :rrti r gl i (orrti ei d$l i t
    gi cozir

    i. { liprllliocmia ne{}natali trarrzitorie rcpreziirti {ornra dr: hipc_'*licirrri,,


    ,,ir rnai fiocvent lntilnitiL la noir-niiscut. .Estc caractcri:;Licit. llou,ulis(.1
    trlrti crr ilislro{ie intrattcdnir. Incidenla este crescutf atunci cincl disrrr,r l r! 6 orc (pdrl ]c l o ?2 d< r ott' )'
    alxri zilnn: pinl la ? zilt:
    lrrrlittr.ii sc asociaziLcr h;poxie, hipctermie sau detresii rcspir:rtor.it..lrr h l , 3, 12, 2{ ortr
    ,r:,riL:irnplejulirri, lipoglicernia este favodzativrde urmitorii f:rctoLi: r-rrzr:r.r,,. ,tl t .I t ! t )t t t t t t lttitii l ' 4 n a i l ' rL :
    L\ t2,24, 43, ;2 t.:tr.
    ll
    ,rrir'i c1oglicogen ln ficat, gliconcogenezl ineficicntir, rlcvoi cflergcl.icc cll ,., i rlt t ll:, l "i '
    'ttt i nl r{ l i at { hrpi l l c l ni nri rrc , rtP { )i Lr ' l l '
    l rrl(r s: irnatufitatca rnecanisrnelorde reglare a rnctalrolismulrrilrirlrrr l, I i ' r ,,'r l i l , rl i t
    l a 6 o!(i i tl P ri )n:r 2i ; J 0 1,
    j , 0 rtrr:
    L, 1,, i , (' 1 , 1 1 , ' l rrl )i i ' ' ' rl
    , jr:i ,r)niltcjor'tranivelul SNC. Debutul manifestirilor.clilicc estc il.
    |r-irrr,,l,, i i r; rl e i :i i c ori s c ,h.r' r'rrr:rs l rffl frrri ri rl r' l i ' r ' l ' rr
    L .i zilc iliipiL nastere(tabelrrl2.92)-Acest tip dc hipo5llici_,rr.riL: .r: .tsrri.i,r,,,.r, 'l \l l l
    silrEo
    lirrlvtrnt, cu hipocalceruie.Alimentalia precocc, sa11admirist iiLr.rlr<l: ;,11u d,: rrr:ri nuIl r, ori , l )i rr;r oi tr(l l c nrTnrrLl ' rrIr' " l ' rl
    llli osto 36!(l
    4(,j',ii.v., intr-un ritm de 5-8 mg/kg/min (rata fiziolrgicri filrnil:r.ti tlo iir.rr --'
    I'l l , rrrr, r, t
    ','
    Lul tr:uli nou-iriiscuinormal, la ti:rinirn),lrr pr.imdc 2 -3 orr: <lrrlriirr;ryllr.r.,
    pr,.r1cp:r.r'Lrniaprritiir bipoglicr:in.ir:i iiirll
    sirnptomaticcl:r rcr:st 1;rlp rl: rrorl t r 'ttt,r lt , , l l t rt l t r r cr r r r l :l t; r :l i tti r :t: r l : l ti l tl r g l i r :t'r l ti ': 5 i l ]t l ) l ( r z( r r tl ( :'
    ,)rirr:lrli . r l i r l l tr - r 1 r 'o sl i - r ) rt
    1,,, i . r l , r r t l, I Ir l r l r .r t r "i l r l ,.: 2 5 r r r l l /1 0 0 tr r l ( i tttl i tr r r i r r

    :Jl),1 :( ) l )
    ' I I T.'/ H IFER GL IC EM IA

    l . r l , , l r r l .) ..( ) (')

    l rr f i i )u -r; r! (d l ((h rP i i \\:il l( )


    l l i t' r.Itl 1{ .uri t'

    \ i rrL f { )rl l ] r, , s l l i rl i \ i , r, l ri t l i L f l { . r L lrl l rr' rrr1 ' i rr I


    r, l l , L , ri ri i i rr ! rrr. rr L L i : '
    (: { 1 1 l ' rl | l i ' r
    ; t l q l rt l rf n ro f l s i c
    .. iu ;rcestecazut'i, Chis$'icli nu r-ccomandit tcrapic cu glucoza lnrriLl.r,noll
    , L r i l , l r' 1 , ! l l rt
    litrrlrL.rtia.u i.qrt. si unnirirca atenti. C?nd:Lcistt cr-iicr-il lLr ,.i:rt ririir,
    I ' irli , L llr!\\ rck l-ccoD.uL,li tcrapia cu ghicozli i1]tt.a-i.c1r<tl. o s r' ro - ri s i (| s , 1 , , . 1, ( i r I ' rl
    liil iri.oPr r,r i , l l , L,, , , 1, 11 Li L 1 ), L n r)1 ( - d c s h i , l f i l ra . (
    i l i rl t t ; s ' s L : L L , rrr rrL L I
    l,l,,lli]:'l),1 itt,!rrpl.,,r ptttttt trolornetitnl ,intravtcnosal lti.tba!:li.i ticN: o injrr lrr, r; rl ; i ; l l rrr: o z i i i rr r rt rt i i l rri l rL t (' , S l i ro rrrri (
    , l i t ! rl ri / i ,
    ,[rrr.rl;r {(lac.-r.si:rtpr','zcrtr .irnptotne compatibile cs aliagnosLicrlli di]'.5 rll r. , 1 , . , , , i i , / r" rr" ri

    'i J ' lI i Ll^ )' \l | o z i (^ l u c o z ,i ) 2 a ' o i:Il r o r, | l .r rl ' rl n rl i i r ,Lr


    .l l ' ,.ri l ..ri ,.i Ini ,/,.,r, ,r I i c n l { n , i rr S r' (' t L l r! 1 1 'lr
    r'r LrLr.o,ri r-.ipla du iDtrct|rcre iA*90 mllkgl?4 oj1r din rr:lufit l0'],1,(jr,,. , L (s l i i d f a i t | rc , P o l n L r| _
    i rts rrl i ri Li ,,.i .i r lil r
    I;,r/ r. 1,lc. lolcrce/:r, rrou-niscutti 1-a fi alimcttat s n r, t o l i u ri (' , lLiPd-
    /ri os cu 60 _g0 ,li l;rlrlrJ l .r(X ) rt { j ' i ' .. r' r]l i (Lri ti rrrl i rr4s " L'
    l l ' 21 or c . s i i .c nri (i :
    (\r l i "1 ri I ri r I' rrL'
    i rc to|rri c ; s i i rt ri ft.M1r
    l)rt:t7 iLorlnogii,ccjlri& 1Lt.t.zslr lt,)tli/ut!(j.. al sL,r.i, coitit,l:r locul disl foiicii (rl (l i r)rL L 5/t \rrl l ( (),i , ' '
    ir{_.rlLrzi,.l ,l i l ri rrr r' s l ( r' r' rrL
    r lrilx'gJiclmirL lczistentri ') .lcoartrti perfuzia poate Ji paravenoasii i n i r{ ' 1 -5 s i f l a . rn l r' 1
    :L(l :rui r,i iIi ( l l ' (| r(l
    \ r,||l. r . r ) : h) sL v tL c rr' \tc p e d u z i a l a l j O ml /kl l /Z4,6r.r: {crlrir (rL o.l )i i I
    si si :1.:r t1\l t(i nrl i l l l l
    :'l t.. , nt , ' lir ur J .i i n mo ,l c o i c s p u ' rz i to r ..rl s. !..r
    fr.r,rz.r :_l uc,,z.11.i ,,
    .i s(j va cor'ltrolaglicctrria ia fiecaro ori, in prim.ele 6 orr':cu
    dcxtiost:ix, ptrrii,r s r (l i l ( f ( ! i l i rL Tl i ' l ' ' r ' l
    : l )o111 fs l t IrLri r:
    "r'ita hiPcrtiicemiii, giicozuria ;i poliurii (cu tulbur-r-Lrit,rcctroriticr: srr.rrrr ! l i ri o x !rLIi rrl i i tr)r c u 1 ! l t rl l f i rL r, l i i | r l ' rr
    r l ;:i_LJ . (l i rr1,(.1rrli rl rrTi l o!' h p 1 r1 l ( I rr l i rr / rL L r !
    (l i s i f (, l i , ' r.
    i rrl I rr! rrr rL '
    lnjL:ctarea repctat[ dc calrtit:rti mari a]eglucozil odat.;r(,,boXus,,)trtlrrrir, c r, { ()7 t r' , s l { rrl rr, rrl L : '
    .
    , r irriiir, intrucit duce la hipcrinsdidsrn si liipogliccmie <1i' t.ti,ot.tnd. i r( / o i l l (1 r ! i . ri rrrL
    '
    slltl , u , , t t rl , : t ' r'
    I)acd ;i cu qces[e Ltis ,ri, torxtogliccitti,t jt.I ;st. ].,t:!itl.t!.ki..a) sr, r,r r' I
    '
    t n rx l r(. 'i11Lr '
    ,.',rirola sr:riiul per-luziei(r'ezi mri sus) ; 1;) sc rdaugi hr,.iro,,,rtizor.r s P \ )l L l l | rri ' ' ; l rri l ' rr' ! rr,
    5 rngil.;1
    lr lichirlul dc perfrzie (la fiecarc 12 orc) .sau AC-I-]I 1 I l o l l ( s rl r' rrr I I i L r I
    4 un.it:itiiJrg irL {i<r.,,r,, (l i ri ilI,l{ l,'l 1 r. ' L / rr' '
    l.l rr-c (sau prednison 1 ing/k* 1;r ficoa;.e 6 ore, apoi
    sciLz?nc1 pinri la i rng zi)
    T rdttuncttttl l.t,ipcglicernici rsbeic la tr.ttamuLt. ln accastn
    lornlii (1,.
    r,ir,,ulliccmic sc adninistreazil_ Glugagon ,|,.)l
    in cantitatc de 0,03_0,1 mg/|i11 HlPocA[cEMlA
    lr iiccarc 4-6 ore (in afara distrofici intrauterinrf. D.cii
    rispLrnsrrl l:r ..r,,i
    liiitatn(.nt irt cstc satisficiLtor, sc poate incerca admini-<t.r1r,:,.
    , l: i, , - l ; 5 . .2 0 mg k q z i .,C m i n :r;rr
    ci,, l)iirzoxirlr,,
    pL.:o-;rl:i i murr-!i t ,r .1 ,l ,rz,, Ii lit,tit il',','i':#niiii,,i;lilli.iil
    ,,,1i"'l';il'll,,,l'; il,ii',lil,itll,
    ...",- , ' il^F m r " r . . . rs i . rt.l n :^ ..i ;i i rv ,L l i J ri i i
    ' :L clilclosticdui etioiogic.
    (dpi rn^,l t;rr,. p.:,r1,,1 .r,,t,i l i ';l;
    I ' ,:t;ll,'ll;li'il,lilli'ii:','iil,,jnii,,ii;;,j,jY ll r'
    .
    t , i. gI ' aqI i. t ! I h , j \o g l i c e rn ,i . e i . fnci cl ei rta.srtchcl t:i or j l ( !l l tt) i ''i
    l1 ;;l i ,l,"1''''
    ',, l l l :],,1:l (:{'s1c,
    ,l ]l ,l iAi .1,oi tti vr:r'trLi Y
    rr)rr rr'ri r'r'',1
    l {',r , ( . \ f v c r c ( inli rz i L -.. mi .n L :i i r.,c o n v u l s i i , paral i zi c
    cr:rcbl Ll i i ), r:;L l l l l l l i l r r ' , r rr tr r 'i Io ;tt, |' ,l 3 zi |"
    ,r. l:ipog-licemieisirnp,;omaticc tniatc ii.rsuficicnt 'l l v:r l o l i l '' <l l l ti l tl tti - sr r it < r l r r ;tr l r l ttl '
    csic it_rartcrnarir (.3t) 50'li,), llrl!! r l ( ( tl l i i r r i ( l ) 1 1 ) {l l l ( r ' i ttttttt i <:i tttl r r r l ''r 1 /l
    I'ror inos lic ni c s t e i n i rl t n a i b u n ..1 r:l trL r l o tr ,l i sci i ti i
    si mptorrrrrl i r.i , lrrrlrrli t:r r l r i tt i o r r i zr r i ) ' sr tl t: :t) sttl r '1
    1 r , , 'l ( l l t r r r t ( 1 ttr l l /l {X) l u ti i 't'
    r'..,r"1. , Nou r r is c L r{ i i c u h i p o g i i c c rri c a s i mptorrri i l i r:i .i "t'
    {ci r rl c ( .r( 0l l )l 1 r,l
    ' , r r ' r r I j, . , li. r l, ,t j , ), ,.v ,r1 tr,,.r,,. i ,i rr,. i ,r ,-,,.rr,.r.rj
    (t l ri ui ,.l i ).

    : i1I ; lt 1) 'i
    si 1n' t
    I)r'n lnt l( ) t r lar s c u l l rl l (x n ' to p o u d c :r' l r}Ir)
    ') s r r l; . 1, 25 r r r liq /l 1 rr.n 1 .r'irr
    ; r.r rl r I,r rrrl ,i rl ,/ll xrl l t.l trrl r
    ro tl -n :rs c u tu l l n r si r' .t rrLt)i i mi ni .
    tl ','i "l,lill, li',.ililllililli'li
    l't'lilll,;;1"';'l',' iiil"illilill tzoirzrl
    (1f[irvol r
    ( i r l ( l ( l l l r :l
    'l i Ir ct l ttr ',t
    sl:ttrrrrlti pc'r[osfirLu]lici-r
    1u:rtlr:rt
    t",,,1;,,i';i
    l)cSi.ltipocalcctnia cstc rlerfiniti. in rnoil rxlrvr,n{.iona1ca o con(.(ini rl
    .r r'irlrjrLhri urni micir
    de 7,5 nlgor,r,calciul scric tolal -- carc csto llir.ir ";ll
    I 1,;i'll,l";:.i,,,,'r'i l-rLl1livc ':r
    i a scizrtt oci.alir
    ttotr-rirscrtl.ttl
    conti!rrrLrrliir r.rc
    t:rt
    tl I
    i ttl to
    l o ,l .r 1
    Lrn
    ,'('ol)rccr) ru
    'lr'obicci)
    rru rol-lectii
    lcllectir in 1nocl
    raocl adccviit cotcentratia
    colcentratia calciulrti ionizlLt, sitr, ir ,''l;;l;l',,li,i;;;:"1,,,:i'ii""t"t't''t"' cr
    r'.rrro arc irnportal{ir fiziologicir. Sciiderca calciuldi din singe este lruoi
    Ll '(tti )-
    Ic nlnirtoarclc condifii.care se intilnesc in primele zilc dupir-n agtcrr_-:rL) : r
    ii;L rizutii a paratiroidelor,in spccial in primelc dorii zilc'dupiL rirL,rr
    lr) calcitonina (idribitor al mobiliz.vrii calcirrlui) estc cr:escutl, ilrLi rri,
    r:onrlitiiclchipoxie; c) deficit de hidroxilare al vitaminei I) 25 bidroxl,-i;r (n dl } hr{ l ht\l i !i (l - I s trpi :tnrtoi (l nl )r' rrrtrfttl e}
    I I i l ,r)(:rl {c ,rri n n(\)n:rl nl tl
    il;r uirrchl ficatulrri) $ 1,25 dehidroxir-vit. D (in r-inichi).
    hi !)o.c l ( t11it' \t:' )' " tl drti
    l) , i f lg os ti t;u , I e ti o l o g i c a l hi .f ac& l r.rri ei Ltt t, tt,
    ti ti s (: u, t (tabdnl 2.9?). Ilipocalcemia cu tlcbut frecocc aparc in primcl, 4l
    ,lr.orc dc vi alir la nnii irou-rr.=rscufivuiner-abili (t;behll 2.Si) si csto 0 r' r ' r!
    rrrc a scirderii nonnale al c;rlciului scric ce sun-ine curiird dupir ttas1,r r,, d, i.,, t)

    :t eb, t Lti 't l

    lliforui{rciniilc eu dcl}tt Ir e e r r f { tr 3 ,/i l e dufti .'.!rfe)

    l . '.1'nt t ent i siltu l t b sl.tri cal


    i . ^lsfiri.a ?.Iilttldld
    : r 'i'l'r i t '; t lr it llt i r 'r r r ir 'r '
    .,,, t,'l , l: t t i, '. sllll. t lcl'r 'm it l; r t u r lr r r ': r i I '
    lr om llr : it r t r i m in' lor r i it lr lln
    4 . I \'tt'.sa r€sp il atol ie id iopd t i.ti
    5, ' . ' ,' ,' ,, r , ' 1, 'ir r I ir ''t . '- r cir : Ll'iljl, alc
    .0 'l ratomcnt cr bicarborat tlii ('\1.1rru.
    | , ,rirrr \'llwo"i9\P"i,qil ry::"::.i:i"]1'"llli.'
    )(:1nr1lu. '],i;'ll
    It lixsrrnguinotrarshrzia cu singc recorlat po -{Cl) l)iil'l'y'i:ii: i':t(ili :"ll*:,':ll,.i'lli':l',''i,,
    1,',ll'"il;llilli'lli',ilJii"',,L,':iii'-;i
    ';1,1.^ll'i :,,
    itrs,{r's.
    'tu"'i "i'l,.f,:'l';.': 'lr'
    (J Crcficrea acirilor Sr.rsili'b.:ri (Irtt:rlipid)
    (. \ou-ri-rscut i din marn:r,diabrtid! ,
    'i;,lliriii
    i;l':,, 'rl'
    ;inl$":fir'til";::xll':i1'g,filiiii ''ili
    lu {ost propusi multi factoli ctiologici: srrpriruarealr.iuzittiric rr furu
    , r ztti rrrirrtt'ntati.i, .llT].fl1i;
    ll;fili;'l;l:,lll
    tici gJandclofparatiroide, aport redl5 de cclciLr,scddr.rc.rdisocicrii i.rrr.
    .r (;llolrlhu rezultat al admlntstriiil
    i;rk:iului ca rezr.dtat administrlrii de bica.rbonat hi
    brca.rbonatsi hiperfos{atcrnia (1r,,r ,, llilll,lililyltj,l;
    'li'i;*'i"'";;;;;il;:1i
    '',t,H*::,,tglXiti.Jil:l';,,,ll liitl;llr
    lril t:rr:-5.spuns la sr:crelia suprarcnalit cresc[tir -
    {'rr r'ozultat al stirii catabolice lir. nou-niscutii ce au sulcrit trarrrralisrrr l.r
    rnatcfliii sau fetali1 ]' .,,
    ' i' ,i ',i ':l ';"'i i ';;';'t'1 rl i ri :"rr'l i "rrr""'l i '
    L],:,,11,''
    ' "ri ,11,,, ' .'ord
    lirlh)r(-' sarr a] ciror aport caloric,estoslab). lnsi nunai o micii partr, ,lirr , ,,,,,.'i ,i .;:
    ,,r , rrrrri ,:',.rrr .,:,,,t,t.,t,,.,,
    ) i l ,i l'.;'1i
    ";l i ,)l l ,,,,,.,,,.,t,,u
    oou-niLscntii.cu bipocalcemie-precoce slnt hiperfoslatcmici. CalcitoniniL (lrr,r
    rnon. c;u.acliune antiosteoiitici, hipocalcemiantr'i.)cstc clibet:atir ca rirsprrrl,
    " giiologie.l{ipocalccmia
    , '',',1
    ',1,",',"'
    ,l',1'i,1il
    !,f!'tltt,'1t1r;,'y;it:r:ii,':i;,,i:, tr t
    lrr lripoxic gi i:oate juca un rol in
    rrgrarc la nou-nlscufii,ceau
    irotivc. Cocxistcnla hipr:glicemiei-semne
    cu dcbut pr.r:r.rr.
    ciinicc si simptorneanolmalc p,,ntirr .rltr, , ,,,, t t t r ' l tt ttl l ti l 'o ttl ttn ti u 'i

    ,,,,,,,:,:,,,,::,ii'l!i,,ij,:::,,\!,,,,,,,,3"]
    cu hipocaice.mia mr cstc r:liir la rrr:r,,rli
    ro -nirscuti.
    i t) (')'r')
    r t'rrr rrrrr r l'' '1"'.-liliiiiiiT),]"i'iiir. sirr,lri
    s'i' i ' 'irLr"gir""
    0 tctalfc scveri, cu debut prccocc si prclrrngitri 1:oatc Ii scrrrrrrrl, r, I ' ll]],l,"l",ll]'l]ll,;li'll,llil;iii;;;,,,i',,,.ii. 1iif,,,1'l r)"'".'''ui*'i:rr.,1];1r
    ..i',,,,t.,u,,11i,,,,,11',.'.1,..,i11 'il]]i';'
    rlur:c rc mcdic ia dcscopcrircaunui adenom paratiroidian lit nlrrni.
    'l-elania.naonatalii cl,asiciiarc- dcbutul tipic.intre S--i zile;i
    i ],,;i,:,,iii,,,'
    () tl
    'i,1111,,..1,r.;,,li1l
    ,n,,i,,,,,,,
    sirrrplo r, I ,,co ',;r r t
    rrrrilc pot dura mai rnulte zile piniL la douir siLptiunini. Sindr-onnrl rrprrrL,il , Ii l r r ,,r 1 t'ti - r i l tl ) 0 ,'l ( ) ) ;

    ' if;::i:ti
    |
    ;rsocicrccu hipcrfos{akmit (praclic nurnai Ja rrou*niLscufii alinr(,niirti , n
    l)r{)plrirLc tkr lapl.c tic vacir). J)ttgi coniimttul in calcirt ltl lapfolui rlrr rrr,i
    !l 'l ,
    ,:slc rtlri llrrc tk 'cii rrl lapttlrti tlr tttarnii,raporitrlr:;Llr:irr/losior ('ril(,ll,li ll
    s ttl l Ltl tt(tt
    i i rr:' r' ttl i tl i ' 1i
    rrlri scir:rrtt. ('lntilrrlr'a )r:lati\r ln u(' rIr iosl:rt,nl l)oitir'/i r.;ir.rclrrt,irl,r '
    ) l ttl , ' trrt' l ' l i
    : l l) rI
    :Irll
    ln vcd.creapnucrii diagrrosticului prccocc, sc vor efectrJa tloterm rlr, ll) rrl (:irlciu gluccmio 101)'1) arc 519 ir( calciu tnt:talic: srtltlnlrtlit
    ale calccmieiin unndtoarelesccvcnte: rlrl lir nort-ulisctlt : 0,2.50 lnr). t'alcirll in perfuzic s(' v:L iln']051{\:iI
    -nu nr t sr ' ir ( lr llr '
    dJ nou-niscdtul din mami diabeticl: 6, !2,24 si 48 ore dupZr r' l u,i r, 't r l ( plct ipit it l. l', r os si d; r u dt t z" m ai I nar i Calciul
    bl nou-nis,rrrulcu asfiric la nastcrc: I,3, {i'ri 12 orc dubi 'i'rrLraicnos sa y'cr os (nioiodati i tttramttscnl;Lt')'
    iu ,1,',,ir
    . ) prematurul: t2, 24 si 4E ore dup.i nastcr... l r l / r i r 'r t; l t l ti h o tr r r m i ' [,i r r i sa n u c cl i tti cc sa u Jl !p i l Y4 l i 1 ]1 ( ttl 1 !l tl ti
    .'.' ."i.iu git,.onicsoluIi^lo% 5 mUkg/zi1n,pclfrtzi'.
    Q2a solnti. lrrclrrt
    ,,,i *ui, ,.ror^1. l?ar 6s se pot da 2-3 glzi dirr
    "i,rrii'irii',,tti,
    il',iiir,/,.,'t.i');1oz,+ q,,ry:..,1o::*l.ctll..ili.:111.l:
    'iri "dr:
    ';' );:''ir,'',;t;lilt,tti-.,' ,'u .J,ttiir',, 2-13 zilc cl.pir cc nivrlrtl cirl iLr'
    f i;'
    l l rl l r ,r tl v r' l l l 1. l i L 11C )Iml l .
    l1) i'
    r 1 lt ltiltottrInmia ,bersistutlci so. admini;lreazit, calciu glt:corit:,
    crrr-i"r:tl'
    ,i',.i'li ,,,ii,liii.ilrit o,s-z elr;1cr os(hipcrclorcuric rtci-
    u-c I rntervo[ , , t Ir. r, r) I i I , .I I 1 sc \':r i l r l o ( u i ) r p tcl c d n vJci ctr h p tc m r tcr l l '
    r1llt nt < . r cLr t t t gil
    t r t lt ilt t '''
    il usociat i cu hit 'onnSnc: it n t a, - s,
    rf) (' i rrr l li / >or r r lr , r 'ntso
    iui ,, i,ii,i,i5r,iI -t5 (OH)3-r'it..ri in tiatatrt;ntul
    lif:ll'!t;I:.i.
    cstcl Sgnr* r'rrl1:l
    irt
    !r"tlt..r1g dc sribstauliu
    I
    ii,'',ii'ii,i,'r,l"
    ", 'r. ""i"il.
    I'lou t'ott, oxcch:ttl,
    nAscut lo
    termen dobut. prcctx't',
    ci r : l r l l o xl i l lil
    ctt:.
    Q,i0
    60 1J0 EA 269 ouls ?,II.?./. HIPONAIREMIA
    Fig. 2.35. - \/'aloril.e.normale a.ie 9-cT 1a lrqrl}ropqndelat
    ;i prematur, in frnclje cLeJrecyenta cardjac:! (dupir Collriiti
    $ i co la b .).

    = este ega/ €au ndi mare de 0!50

    ,'xll,l'iliii';,i'ili'il;TiJl"i:;]l';?:slil-,,ffT
    ; i;ii i'i;iiii,. A,,*astr<lifercnliere.'"^q91i'^i"::.-tti:.i:
    :,tt..*T:],.,,.,,,,,,,
    iiFn,li,y:i'll*i":i:*lru $rlg'"T $ltx"lJJ,rl Jl'Jillll il,llilil;
    t$tlllt' Fi nc tldridrlteazii.
    iiir,tn,'it,tt ntJrcr:ogonital,<lcficitll tlc aldosteron 9i insuficienfn suprtt'
    Irig. 2.36. -- Scmre eleat$cardiografice de hipocalcfnlie n€oratalJ,. "tar lntllnite la nou-n'tscut'
    i'iirlr turii ft)rrtc
    Concomitent cu dozarea calcamioi sc vor face rmitoarcle
    paraclinice: prolcinakie totald Si ECG pcntru
    ''il
    ;;;';:i,;i;;i ri.'i^ilJiii',i,i n", r' tl' &':,i,!:,o,It:^,T:!:!:,
    l:"!,;:#::;:l:',i,',il!,llL"!i,liTi'#','i... osmolnritrtrr'
    rrric't:rcaiininir'
    urlnaJ'
    -[osforcmit,-nagnftiemi(,
    Tyalamcnt. Irc frezenla scnnchy dirr,ice,sc administreazl c ill r:)onrnolrriltattr'N"a, K, Cll,ct'(latlmnir .(trr
    gluconic 10o/o,2 ml/kg intravenos, ln timp de 10 minute sub conttol I i't,trptour(t',,kil.'on'ctu4,ui'o,r!,.t13*il!":!,/,if,1
    i,"i'Ju3r,ilr'i;tlt
    (bradicardie, stop cardiac). Faptul clr administrarea piirentcr.ali dc cr *lllot- rkt nott-ttitsculiPrcmfltu
    gluconic controleazi criza de clonvrrlsii ntt cstc o rxibh de diasnostic: ln.,aty1 |c1131^o1
    fiiliiui niitiuli,.lc'hiponntrcmic' :l:l':::.d:f,l*'-
    sopot lntilni Irecvont
    t"ili;H-",:f';iliJ";t"[;;;;rscrrli I hlpo'
    poate controla $iqi convulsiilc hipogliccmicc. (lalculul
    convulsiile iripogliccmicc. Colculirl dozci
    dozoi intra'vcnoaie
    irltra'vcnoai crlzc dc iLp[rr'("
    poate facc dup[ suprafa]a corporalll. Sc dll I g calciu mctalic/mf24 r iirii,f-Htp"ruxcitihilitnttt, lrcmlrrllturi,corrvulsir$l
    401
    400
    cllnlcc dc hllrunrtr$rnlo hrl,lhrlto lr ort'uiri(ul

    Iiatt)3r'|lic lltiologie Scrullc clirice si dc

    Si'),] r , r n S c h 1 1 ' a f i . : - secrclie inadcc./ati" de l|DlI crcstere io grerlate r apidi,


    (asji\ie, hefioragie, hidro- liai {ir.ri c,lcme) Nc i Frsisl,
    ceJalie, septicemie, .''cnti- Cl l, 6,ica1ozi mctaboliclr,
    lalie cu Fes.iure pozitiv:. osl1lolaritate sericirl,
    Itt l rt;rrpl tt t:ilr cm ic.
    osJrc
    ritate urinar5, 1' , natriuria 1,
    2.']1.9'5'HIPERNATREMIA
    a) rcsolblie dc Na J pdn prematuii Joartc nici, pial.d
    imaturitatea sistemdui an- ln gr.eutatc, Nal i1r $cr, Ht '. (:ollsi(l'lir hipornatrcmQ la nou-nirsctt valori scricr' alc soditllni
    giotensint renine-aldosteron ; pierderi lrinare de Na 1 ; son
    disociete intre :natrrarea de cleshldratar-e, sciderc ill Rrc Irrr,rti t l r' 1 . 50 m Eq/ t .
    ta,te pot fi prezerte tl c ! nor | | ,t tt i ' | tst ', ir i cI it t lt r . FI . cV^I lt , . ir r - lip. s. r , unut . . i. . t ct . t lt it t it . i
    SloBeruiari 9i matularea
    tubdare l I ',,litir'', hipt:r:rrrtr'|:mra. r i asimPtomaligi'-P:'h]**:'l'l:litilii"ll'll-
    l'o(Ltc

    ,ii,"i"i:'iilh++*-i"*--nf
    b) pserdohipoaldoste:orism ;

    .\|or1 sci'rznt dc Na
    sciderea *islunsului firbuhi
    renal la aldc'steron

    p. o.
    sc;derc in grertate, Na,l ln
    deshidralare, Ht 1
    $rqqu;,1,'.
    llt,ll,rLiiliiiilm,rll*:,r;i*r*l*'"-:l*-semncdc
    b) in nu Ii ia parenternlr-l

    l j *.ll'^,,ii "i,1"ol"riffi''{^to.i*"f"':,f"0 ; s' v'tt


    ;;pr nastc^':
    ,\_(,rr'i cr_{jscute dc Na Cepuned in cantitate mare
    in osril nou forrnat imprerne
    cu Ca
    in greutatc, dcshidratarc, NOI
    lft scr, II.' I
    ,, :.i ;;';;t'ii;t,
    ''',l, .f:,.i.13ift
    #;*tt;*,n,'."",1**"!,,T.l
    lifj,
    I Iil! rniltl.cmic matern:r, etect de dilulie aI
    fetaie

    Sindr{rll 1 adrerogeoital d€Iect de 21-Hidroxiiare, a) sex masculid: organe


    (n
    lierdere dc sare 3-hidroxisteroid-dehidrogetra- hiperpigmentate, norma,I soul
    zel,, 20, z2-des$olazei hipospadia,!, Dtiptorhidrie
    b) sex Jemidn; hiperyigrdcltrr
    hipertrofie clitoridianA, furio.
    n&re medialS, a labiilor,
    hermafroditism ; .
    - pentru ambels sexe; v[$&
    turi, pierdsre in greutato,
    exicozi!, NaJ ti Kt 1r
    t)ctir it dc aldostelon deJect .te l8-Dehidrogenazi scid€re in greutate,

    I n iUlicienta srprrrenal;, trauinatisrn, deiicit de sin-


    K I in ser, FIt

    qoc, hipo?erluzie pedfeicI, Ioh


    ;'ili.il;J:;.f#..;'f
    ,i'l I mg/kg/zi; ca.
    qi-lill*,t'y ""^':l#y#T-'.:l}i$:;
    tretanlent
    nzidft iar apoi 1'25-'
    teze a steroiziior hipoglii)emie,Nat, Kf , Cl in cantrtateo" iOo-zio ttg' in 2 doze'
    .nln.vasonrcsinii,
    in ser
    Itil)rozl chisbiol Mod iceri intesiinale gi
    naF, hiporatremio 2.11,e.6, HIPOKALIEMIA
    T r at am entw tr. a) Hifonatremiamanifesl,d:se calculeaztr va-lori ale potasirrlui seric rna!
    - !{c t'rrr*ridcrii liipokaliertrie lir nou-n[scut
    citul dc Na dupl formuld:

    402 40s
    'l l 2 l0l
    'tb i
    I ll k,!r I oll$trlo ll rlrtUlortllllolot,ltt hllterL liotnlci lrI
    lillttptll4yor,ir, hipokalismlci la (nl-ullx(lrt (d|lprl SWn{ar)

    Patogenie Etiologie

    | ., r | | , I r I i I r( t I r r| | rI l t rl i (i f l l n.1irc:t Ii uirla T asculi*i, S'.ll(l(rpliIrrrrI ,


    nesalisfacelea ner/oilor zildce
    ')i; , "t ' "t ". * ,I| | !,!,,l l l l /\( l)
    lirrgirea complcx lllis' pr1'
    Lri ii( Z..!ie cxtinsii r r ,r l /,,r l r i ( k 4 z i l ( l a
    lorgirca irltcNol lui It ll
    clc intestin srblire

    ( ) | 's(\rdohiperaldosteronisrn.Sindrom
    lrnllrr f:r I i i |l s i ri eTa s l c mi - v:rlsitud, disteNi(r olxlofl i'
    li,l(llc greuLlrlc,
    Ti l or rralir, pierdelc h
    ,') diarec, apatjc, liPolon$irlDa'
    ei hiporhasneziemie i ahicardie, citlnoz?l, dirPn0c
    ],1]lli,,lXl""" K i , N aI , mo(l i fi orri l i c (;'
    , ,ons.nit.r.- trc c f, !1t 1
    ,,, pier,rcre
    de
    'i;li:1,, (i i goanuri c , c dc ,n( "l l rl (l c n-
    |l |!r1,, r, rl l i ri [i rl i l i |l s l l ti (:i c ri fi r torral ;Lac uti l
    rc l l c l i ) hiriratarc, nrce t , (irc&tirrirrll t
    l) Sinclrolllul Schwarlz-Baitter

    | (|1l l i l ,rrl i r' (:rnU.rilalir, nrodilidu i de ?crrncaLili- flou-nilscut oianoLic, cu o(il


    Al I')i{r cr.i g.r"strointestinale(drenaj) doz:r rczistent[ (lll< 7, ]0)
    tiltll ruenlbranelor colu]arc
    lr) l)i l r r r f t i c l .

    , ) S i,, . l r { , , , L ( . perllrzic pareitcml,l rnonitodzarca olcoirolil il(n


    n ( h i t,,:r ld o sr .r o r ,i"n r / s.L im b uri .rei cutc i n re N c ); f( l r lmlrirea mo(lilicilrilor I':C(;
    tubdui distal

    lftrrlificirilc ECC: ST dcprimar,undr T aDlatizatisau ncsativir.


    [ 1''onmincnt:'.prc]unsiroa intn,,valuluipR,'und;r p ampt;."ln ci
    s(lvcrc se pot lntllni extrasistole vcntdculare si fibrilatic. '
    l'-r a t a nt e ri L Se asigur:r nevoile zilnice de K, de 2 ml
    sU suphntentiazi deficjt ul de K dup[ fo.r.mula: de{icit de K
    glcutatca ln lig x 0,5 : mEqK/zi; sau s-evor'i!.ministra zilnic 4_6

    2.1'].9,2
    HIPERI(AIIEMIA
    l.
    Sc consideri hiperkaljemie la nou-niscut valori ale potasiului ll, ,\1xrrt.oxu)siv: sc corcctcirz:taportul de potasiu'
    rnai rnari de 7 mEqll .
    ll' r a t a m e n iu t, hiperkaliemiei se {ace in funcJie de 2,I1.9.8.HIPOMAGNEZIEMIA
    ni,' ( rabelul 2.101).
    A. .Exanguinotr-errsfuzie: se intrcrupo c Sl rorrsiclurirhipomagneziemic la nou-niscut valori serice alc IvIg sub
    st. :r dminisLreazi Cr gluconic l0%, I mlike/k -1,2-2,1 mEq/l). Hiporragnezicmia va Ii c:tutftlil
    trrl4rri I (vrLlorinorinale
    v,l. l0/o, in cantirar.:de 5 mt/kg/zi, in rjcrluz ,l'i uit nou-nirscutnu rispundc ii traiamcnlul adecvat cu calcitt'
    pc.fuzia de glucozi, chiar daci p1f. csre norms 'itii;ri',;
    i'rili.rriv-sii/, iLinrrctrr-nitscul ii'c u hipocalcemicau Ei hipomagnczicmic;
    B. Sindromul adrenosenita-lcr nierdere dr t'r alrstuta
    ,,,,,i"rr,'rir,ttri,i ilipo;alccmiei estecxccplionalit(tal-'clttl2 l0Z)'
    ;llil,,1rrisrnul liziologicdc icglarc a rnagnczicmicilrt1 cstc binc cutlos(ul'
    iint implicaligiT.! i:lY{i*f..1ll
    t,,'i; ,'i;'i;;ili;;,i''oriui ql atiostoonul
    l;1, l,i-iri;;"iiil ici.olbildi
    tubularc renale.I)d ascrneneaeste cunoscut[
    trtirr strtnstr ltttlc mitabolismul ionilor dc Mg ;i Ca'
    ,\ nr,,r (, r:Iitticc si h.traclin'ic o sJ supraprtnpeste ccle do
    ttn,rori, cdcm;lc fot
    ,rlr'oriiiri, fi prczcntc. liC(i: unda 'l' cstc itlvorsatf,,
    (lnplhnqt cu illtcrval Q'l' norrnal.

    405
    L ', | , , . l i r n r r l l ( ( l l tl l ( r 'r n r In r r l l l i i l l l l l r ( r ( \'r 'l ) l i l l I l r r l Ittl ;r l l L i l r l r l o l r r l ;r
    r L r r ( :i r r r ,r r r l
    l:lh' 1,tr ,lr r lr tl/' tr [Ir itl,./ir nti( .i I t , , , . , {l i , i ,i 1 u r r i ,, i .r r l l ,r i r ,,r 'i L Ir r 'l r r r l i l i r :i ) l xr si l r i l i L a i r ';r
    t) 1 r ':
    , L t l , r i r r i Ir Ir i ,Ii Ii 1 Io IIL r I l i 1 r 1 1 1 l tr r l i tir h ' r tttn i r to a ttl .tr ci {r l n (
    L

    n co L r ;tta i i r cl !l l l l L t l r l l i l \'1 l l t'


    l ' , r . , 1 {r rr r ti o t r Ir t:ci r : l r r r r ti i i l r l ci tr l xr r i o l L ti l L
    i l i l , , ' I ) . l l a r i f | i ( t j s ,r r i L C r sL o f l x) l i st l l l ( ) s[( 'l l ( ]\r ' l l L r l "
    , r . I r 1 , r f t ) r r , r l i f o i ( l i sir r t tr tl o ttt,r - l r r r l tl l tl g i r l i i l l l ]r l L - i ta ttl l L
    r n { i( .f) l
    /r.
    ' p o
    . it,l rir-- t ir. f p : , : c t i r o i ( i i sn 1 h llr ;tir r l I rpsaenzmer
    ,
    tilr'1
    t r , u J tjr .i l,
    rtri.r .ipec/rce
    '-liri
    l ) i a b . , t z a k r . m t r n a tu r r
    )1 " ':' .' r ., ,,.,..1 .
    ; ' ' 1 ' . ] ' , , ' : : ] ' . ' ; , r r ' r . .,' .lr ,r ir '
    | | ip.rna-qrloziornia matcrD;i
    I)ul)ir .\sa girlrlorranslLlrj.j
    l l , ' t r l i t i r n c o l r a t r t:L j a t( ,zio ,j( .
    cJr i t) itixI. { :o n g cDr iatr-l
    f.'.ll': :. ,',;" . r .i ,.r ,_ :,,,r i .r .u r i i r ,r ( . ( t. ir - ,,
    . ,,:", ,r,. ,i ., ,.i .,....,,,ri
    ru"" i r' i J:' r'i r"','
    r' ,
    i,;".1,: 1:;.',.'

    tl*, sot.
    ';-;, 0,r . i,lli:
    r,/Lv,
    l:;,,l'L,:.,1i.;,-
    .,;j.":J:
    ;"i1",.';";,d11i1;1li?i?
    ':1"i.,;
    ,,'iLll il.
    ^:*I'*.^d:,
    i1i;;;;;;";:. 'u',;
    ii",,,'.1,,i
    -25'r,
    ,11'"1 ,1,',ij ",1::;,;i, '**r..rill.,l''i','lu.ilul"ill.,iil:i
    :':Fll,"r
    .1'.,,i,,i,i',i:';;.;::ll:,'1,,',,;,r,1i,1 ;;lil;
    :.iX',,iilr:'#;li''i'll;l;;l l.:l: l )(i i . ; L i rl . rL ri l i!1i' i rr' t l t l l 1 ' . l i s r' rL : l i ri t (i rrn c d i a r-

    :;,;';,q;l;ii.,:j," "1r,'":,i:''"i,;
    rii"'il;";l"l'ir'*l:ir;;l:":::" ,) i'l"li
    "ii.
    ,.,,ri ,, r 'r r t t t r r isc r lt : r f lt lr "llt '1' 2- i'o lr L'- : / \ Lc't Llr l dcclr s ll( 'l\ l'll'

    ' Il;)',i',1:':*1:;r:u
    t,/.t tl.t' ( jtr\azi).
    i:,;Jr.i,,ii'if'l,1?'uI,, , r l :rrrri l i r '
    tripotoni.--u,iurori-",o.Joi;";;-t"p,":i#i:Li;:1,ili^:il 1r r ut r sr lilit r in vir st 't m iciL lit licr r sur piciuni it r lLt cr r slr
    '"
    l'r,tltnttttttu l , lt lt t n r , i ,!.,' al..i.
    " I,t c tr,: i u ]j t ls-.a!l)i ( I I t,t .oi, :0,, ,, l,r i'l sirur)1.()nr{ L,r-tlrtpit rtu intr:rn':i1,ilc cilcvrL oll pini lrL cilr'r'r
    \lr','rul).
    Ir)- 20 nrg,,k5/zr ln lr r , r-)
    p' r l o (65 rrr4 ,r , r,' l ' ,ti , ilir \ 1) r ; r liii ( t l br Lt ui lr at c {i pt ecipit ar tt ic alim cnt af iir lr t t lr t li) '
    . " ilc 1io. 1. , ( : , nr , .n t u J r r i s , , \ . i l l 1 , n r i t , n . j Z ; j l rl - A. r 'ii
    itt \ii. r/ l nO r m op, |! , , 1C. . 11. illii'r vr l. nL1 r r st c t cit t k'lr t t t r ',
    r., i ;rl l rt rrn Dor r , nir SCUt
    l,;:,,1 ;i, ,'.,'-1t,,r". alimerrt.rfici, rmrlte' l'uli Lit'trrlolicc manilcslirr<lrt '
    2,1I,10.BOI.IMETABOTICE tr t lr r '<luc,t i r r , ' 'l' i: r .
    CONGENITAIE t',rcltttiixe:r boiilol in{cclioasc, hcrloragici lr elljnSoccl'ol)tirl liirrl '
    c
    rNpERIoADA J
    or Nou-r.rAscur I lxrli cottgtnitalc rtrtllt:tallolict:.
    A,,,,r:i,'i'ir:r- acicloztrirnetabolico, lulr:rar''lo tl ictllici (in iogi'trrtiL<:ttittiir..tt'

    ji:;ilii,lii;
    ;;ti;ii1ril*,J]ih"i:t+,t:iri[:"hxiry.".J,liidi,.Trj,i
    ,,r,l r,r' ), ir iPogiiccnt ici si pr - czenJaior pilor t : r r ior r iciin ur iuiL: lr r ) ( r ) r i ''
    z,i ;rlr:lrkrz,iil cspirlltolir: discrtrtir'
    rtt'llti rrrir-osncobistrrrit a1.no u-niLscutului,ilr spt:cilii irl tLt
    i
    rrr.r:r,,cruirii acestor
    boli,, ir ;i l\.lr r:irlt'clr-
    ",,,,i'i',i*oi'aLill;lr:;:l1lt:il:iL.,,gort;" r' ri)ir il)i lLr. cons{)1'vi!tl'sau a scutcci ur l1scat)'
    l ,l t , , xam cr t ul clioic, sir lt slt gcst ir 'r l: i( 1'1u; lr i plt ospl( ! olr lr r llir lr 'r '
    ,ongcnir:rrr'
    1,]'l:iili"'i,i.'i'illl*,0.i.:11;1r;;'';1'Lc'ric' (rtr| , , r' l r l i rr, r lisllr Lzia ir clt clct ic: i ir gr osar oa ir i' lii , ; i licr r lr : r 'ca cI iI : I I |(||i|1|I
    '
    , rr.,r,
    L11rnie1..m;qi
    ',''lii:' r."'";i;;;;ii:i,:Jfr:,,J.i;lilll:il,,:'; ,J,i,i , r r ul t t ' ( , r r t nc,. cl lsf ir , ilr s; u r ' llllr l-
    br dcloz-ii,..rno,lmd_te.
    de mirrcriat;" .;j;i;
    li::l:,;:,; li,;l ," .
    ' ,,.' 11i t i l r j l ;' i c rd
    lL t . rs t r L ' rt t (l l ' l ' :l l l mj i l i nl ' l i n i l i i '
    lij.1l:ll,,;^rd: Li t, i l j fl
    "";';;il;.'li,tral,,f:l;i',";i"1.*
    ,ll::;1;i;1,t' Jii:i;l;r:li:i,;:lil;"';i \t,,i ' .
    '
    i,,li,ti,tiii:,-ili.",,spcctaculoisiastiriirou-rri''Lilirlrri''hrpicxsritttgtrirtr
    Sccvonlafernc,mL:nolor'
    c1nd,., \l ur,( i (lt ll( l r ': list ii suslr icinncaunci boli r net abolict : ,sr t :cjcct r lt : azli lr r t r r 'r
    r' 'u.','i
    ;,1q1t"!id? 1i*, L,rrrpt" rrn ;rnino,r,,rl)
    :l;i'1il:ilr;
    :ii:li'illl'"i" ii'i*;:'i): 'rinl'p'i "#iil"'1""ii."'i,',,,i r I l rl ' l ot iit i l, lt t r t clit lir : r r ;
    tl ,rt,' ti rl, t : ir ) 'AsLnr p; li) gli'. r r r it ; c. ; hililur lir - Lt r I r ( l ot alii 1i ( iin'( lr r ) :
    t -"r ' t 'lor , i\ l1; ' hr slr r {i) ;
    ,,,,1;),l"t,li,)')ij,i1Il,i:"?#li:i:i)ii;:,ywi,|,H,"*,,lillli,7l),:,t;li:i
    't't's
    l , , ,' rr,11' , , ', t ii, i, 1, r , r nl', , , t , iiit ; ''J'
    'Irrr ,' , r' r,r':rI i t ri trri ; 11)luit olr t cnt lt :
    lt clr oli! i ( Nr ' I i

    I'ir( b/i.; r:) diwtc; f) I csh.iclrnt


    art,; g7 ,.in Ai',i1"r')i;'irj,",iinuut, .:1,r,:i , r l":: , ) r l, lilr lr r r ir r at r r ir r : r ot t l: t t oglir lit : r icr t ui: it lLlivi r r lr t t t it t r r lt cizilot
    ii ,r ,,,rn,t,
    ,,, f, i ,,,i r;i r i, i'ii ; lr ) r I . I r . r . r r r I r r I *ur<:r r r r r t iiI I ivli; r .r r t izilot t t t ilr t r t iciit t 1; 1t : ir t t r i
    - a, r ' , , , ' ' , , u, ' ,.\o l . .1 ,tn ,l j ,r,, ,r)r,i :rtx )ti !,,,
    (fu ri .j l l .. ssx) I r I l l r ,l .

    101i 407
    .
    ,n,.,,,,'ill%"1?til"*"ig',"*litj:Jltlll,,i,*ll'T,',1,,i#ll";i;.'"o,np ll i | ! k)h t|'l!,tt't I
    mucopolizlltaritlozc' tnrtcolipitlozt''
    . Asfixia severiLla nastere poate minia o boalir rnetabtiic?i conEei l,r,li rrtt tlclxrzilittt: lisozotnt iL;
    l)nn crcttcrea excreliei de aminoacizj si de acizi orgrrlici prin urin)l. I Irrl
    ' l i l r( fi
    g ar t gliozit lozc
    ))r,n('ir, o hiperlactacidem
    i" so poain in!ilni jn h^mor.rgia''.,.1n r l'icll
    rricirlari, ti i tl ,f,,r,," ( iiir r clr cr , Ni': t t t : 't r r : Salactozcll'Iie' iut{)lr''
    | rit Z ril
    (lL- cL,rct Sftng Sl \Cp fl.Cm le . lrtllrttli'rri ln mctabohsmul rllaii"nttlo"ut"tof
    AtrLnci c.lnd semnele clinice ale uuei boli rnetabolicc sint prezente, 1,, iiir,lt,,rti,thrpozitarctde glicogcn
    vor cfcctua urmltoarc]e teste tapide: l i t r t z i t t t r tl i r t
    - J.tcrrninalea cu,pi.lor.r-cionici irr rrrini ,l, licit ul (lc a1fa,-ar.rtitlipsinir
    - test pcntnr evidentierea acidului metil-malonic ('rttn't.tl'sii
    - tcstul cu DNPI{ (Dinitrofenil hidrazinii) l,oli <tt dcpozittLrc dc glicogcn
    - tcstul la clorurir- {ericri (IieCi") l: rlircl tlztrtlti<l
    .- s t . p" nI ru ,;u b s i .rn r" rc J rrc to J rc (gl u,-ozi , gal actozi ;. rirt rrhrrantiL la lructoziL
    - r ( d. pf c lc r" I c r rl .z u j ta tu ] J c c c to r
    i e sl n sj ne par.vi rri i n pri r i ,,,' ,1,' .cu ur ini cu m it - os. 'lc ar I at '
    .- ^lt *ln
    t.t t4 ' t t ' or c , n. f f ^ t i n c i f. p u n o r,.a d i o g o s ti c ul ui unni bol i
    motabol i cc str rrcitloziLlar:ticir con6lcultata
    ,,, l )i s ( ' ; r c c : r I i or c .l , i a n rf1 , r,, (fi s . 2 .1 8 ). r';rhitism vitamino-rczistcnt .
    rtcttttttllitt l, clc acizi or gant ct .
    urccl
    rrroriilir.iiri mctal'olic,. in clcltrl
    tLa.a auiJ HEIiO!.-UCACF;WA" itAyEOCITE
    ait-UCQZA
    t't SINGE
    sLtRiNA HEIiACULTVRA
    r lrrticit dc PiridoxinI
    aORP/C:IO![i / t.]Fr:sil EiLiF.uBiii. ! TottLA, ut?EcrA) ccmit
    I Ii,fogl,i
    -IAZE StticutltE
    Rx.AmO EN, Pi,"liloti AIll(:loz0mlit
    "!cG l l !t( l (,2 |nllil
    l',rli r'tt r'lctrozitatc (ltj gllcoBcn
    fI.n.--_l [-l tr;-t E-;t
    . ." I lcpil .. i1 . . p", "aI F. . . . / iI
    , r j.-
    l ,oi rl i t t t t r t iini cr r t lt it os 'lc ar '[ 't r
    rrcitlttnriit Dlopionicd'
    ll-' rl irlith'tttia inctllmalonici
    t il".'"i l i tozi ttt 't t t ir t
    /l Litlozu' ma{abalit ti
    ti l l i l ( l ,o z t' l l l l i l
    'it,
    tt liL Ia Irttctt''zl-r,-
    t.,,l,rrir
    lxrli ctt rlcDozitarc dc Elrcoflcil
    rrti rl rr z; r l; t r ilit iL ct t lt ipcr lt lonit t cnt t ':
    ar lar
    i ' ,u,i ,, , , t t t r it li cu m ir o" r lt
    rrclrlctrriilt,ctt ilcizi orgalllci
    l;i11. 2.33. - I)ia\qnosticrrl difcrenfal ln snspiciunca de bgali meta,bolic:'!colgerliiola
    Duran), (ltNoztt,
    4;tlitctozottri:t
    ln lipsa unui laborator spccializat, se va pistra la congelatof
    ,.
    din pdnrele.24 de or.e,5 ml de plasmd reroltatl lnainte de inceoefea iutol() tnl!l la fructozii
    rncnttrlui, iar dacir nou-nb.scutul a decedat, se vor r-ecolfa 2-3 ftal boiLlncu ulini cu miros do arlar
    rlc ficat, cu u1xvolunr de 1-2 cms finuto ln colrgel4torla -25"C ,rlirlctuiilt' ctl acizi orgalici
    rccipieirt de material plastic. IIi f urtnutticntrt
    ,\. Sem,neal,inice asodate nu bol,,imetabol,ibeconrenlitdl.e trt'irlctniih: cu tcizi qtgnrtrt:t
    Di/'icttl,t:dfi 6n al,irnantd.ideSi Mrsd,turi : rittr.ltontttlltipcritrnotricntit'
    '- acidcmiiic organicc congcrritale gi sindroarncle cu trtiltts unonnal ql urhi t
    .- galactozemie gi intoloranfa congcnitalfl la {ructozI" (l(r acl:toul
    ,,'t'n^, ' lifoi cic su<Iontt'cltt
    ' - sindromul odrcnoscnital lro(htj' rLr'fenilactttnt
    i"niiautrur,,rlu - tnilrrs dc $o1lr00c
    {08 40t,
    irlL' 1ll l 'r l ) 1 1 1 r 1
    I r , lr ir r r r r iti l rr ( r ,rr,)r ,l , r.rr.1 rrl a i ..ri i r p,.,rl r,;1,. ,.1.1,rr ,/.,i rltl,, 1.1 o l - t st l L r l l tu g i i l '1 :i i r l l i stl l ) l j i tl n i L ci r ' l l i ;l i t:l 'l
    rrr i r r r nilir : ir t c r..i
    Ir 'l :l r '' r ' !
    'l
    I t c ir lc m iit. i z o r,;rl l l i r.i rrri ro s rl c l ti r:i otrr,r 1r-l rri sl ri r.l tr,i _,rori l , ,l r, , , ', i r l L L r ,. r '\ ,i o r ", r ' 'l '1 1 ''n 1 r u 'l 'p i sl ;i ';'
    r '' r r l
    ,,'.'.r l |1. , l, ut ir r r .i 1 ,,.\,, { , , l i r . . ,l i r r r ,o , r ' l r o r , i :'. 'r r ., [',l r I]: r i , l r ttl ' '
    r |'l i r l ) i 'r r r l tr ;
    .-_ t tr()i/-lncn I lit - nlros dc unt rinccd , i , , , , 1 , 'll l a ,, .r :* ; a J cl i r :t.1 . - cc r ,p ( ,ti r _ 1 'si , i l
    l r..
    I tl l r : t,- l)fo(ills (lf idilr (.,1ft, r,,|r , rl I tlc riti-abolisnr. artritr.r.izt
    rrll
    1 r, .i,"i ,t,,""tit,' ti" ll.r ilirr tirltxrriLriie 'r u l u i c.r ||Ii|1i
    illiIII(
    rlcficit tlc ireta-tnetilcrotciuil,cocnziura- :r, .ilil'os
    r., rrr.rr ,i(, ;,i, ;;,i 1i' tr,-.,i;', ;i i" o."nt" irupt:jurr-ili)s(r coltir)rL:L
    1rirrt'rLltroclus d0 ltcta_hi<lroxisoval;rtLt , lr' srllr tillP|lr\'( !;hcrt"
    sctr tttci i ( l i i L i ( ' ttttti 1 'tl i ttt't"
    ,St rbstttr.i;e / nl u ctoa./c,fr ezen / e in, u r i.i t,:i l , i . i i , , , , , , tl i tt{ ti i tt'- n ,i stttt'r tL 't'r c:i n i i 'tl t
    rlialrt zahar.at - glucoziL
    s( 1of olcctna icsiclc clc lalltltatol ilai sas n]en"LrouilL(.;
    tructozurra esentia]i. __ fi-uctozi-r i'lc(.tr-olilir'';
    .r' .,ni,,t".rit acidozir, hipogiic'rmi:r si tolbuiirrilc
    sin<lrcmul Iianqoli __ glucozr-r cl-izille convulsiYc i
    sc tratcazit
    dcficit dc galactokinaz:-r _ ,1,.:l I lc\ oi' j( ; r - 3c icr l I c5Pil 't i'. ; L i'l' 1"t .
    Eal.r.ctozil ': 1"
    galactozernio,- galactozi \ 'ir niililt c 'l' lll{' nlli l: A/ / l:
    1r t ttr 'zi, cu ; lr r ', 'zi lir o" I t ) (
    rntolcfalta creditariL ]a. lructoz_iL lructozir i i ,,o.r_r.r:,0..,t.,1 a{i:clat .st'cr, inlocuirc;r :lli lnrntatici ,pi ot( ii( (iirl){L)
    . pOntozltrti] _* xiluloziL 10'io, rtrprtztnti rr trtiLsttt'i r.
    ,'fi;i.:*;,;;;li;,i"ie a,, glucoT.:r r-'atu
    glic oz r lt i; r ri rr;rl :r- r' rt'nrplctrL irrtr'-Ltrr ((rrlrrr
    Sl trl r,z l ' , i:'" t'i"f,i .i,pift1h1i (inainic d' invc'ti- tr'
    lxrli hq;atic. st'r:r_.ri: c* i'tolcranti. l. S'lilctrrzir sccu'ilarr _ gitlii.-t{)rii
    t- , ri rl i zi tt):
    '":",i;J"i ( se pralrticir ('rsirtrllrrr
    Raar:lia t'oz.ititti la dorurti modi{icirdlc biochinr:icc1ru s{r aurcliol ajzii
    .ftricci
    ii'nilact(lnuria - r.(r.(l{) ' ,, rr.l rtzi rt;
    t it r , z ilr 'r r ri :r r,r,l ,. (s , ,l ,c o l e 1 ,.;,7 ;
    ," rr1,;,
    sc itistituie tlit:lrLs1x't:ificiictt ;trLto'r
    I ' r , . r jirI i rrri l rj ,.l t l ri r{ ,q ,1 ,.-i ro 1 , rl ,. ;n tri .
    1r.i ,,,.,.r,1,. ,,,lttll;oit::i1,tlr";trtttu*"uttu'"1ui
    lr is r i, lin, r n i ;r h l ,u -r,.rd ,
    rillraptoiluria ltrun inr:his
    , ' . 1, , , r r ido z i rrj i :1 1
    ,, ti ri _ l')sL' :lpfllls 2.X1.11. IULBURAR|DE TERMORE{3LARE
    ll ranonr - nagfr]
    {rocronociton} -- blcri_r-rr-dr: 2.1 1. 11. HI
    1. poTERM I A
    . rir.ficit dc ionrintilrtr,tlsli.razi , !:ri_vcri|) rLtunci. tcntpcr-;itrLtl
    \ott-rir-rsr:rrtlil csto hipolcrlrric -ciirrl . :tl 1.:'11l :'
    lt i"L cst ( r lllllJl( 'l'r r l
    Iriiror-|ilimbirtcrlilr colljng;ltli _ \,o:dr] Pt r nlr r r pit ucr iLr i'l' t ''f i r r
    'i,,i.,.,,,,,..,1rului
    ' ti , .l ' . l, ''l'(
    i:,a!i,nrrl
    l "r '''
    ,.'""1,,i_,li,rillli,ll , hi|ot t
    lltiLi r.tclttbol.ict tottt{ttit&lc.Llr.
    ?ot dut:t: lu. Lltt:rsitr perioal,:,,
    ,,,, ,,1, ^r,i:i:*,ii;li;,llr'i.r,,.,.i"1
    .;tt ltt qlctlti , Sir t-ircoturrni|i ['
    .i4,1'(1.
    gillactozcnliir , l , rL .l. ', , 8'I . .
    irtoJcranfl cr{tdit.iratlrr frrrctoz,i1
    iroal;r cu urini cu rrifos aie artar
    ,,
    il;l:',1r,n.,il,:'iilr:,illl'ill',"llil,,l;:r;",
    'ii:ilt. i:,,nr,. .,,u tnai lrccvr:ntiL.dc ltt irritr hilx''tr'rttut:
    ' ' . i.l. ' ' ' , , . r:r,i ,l o tl t.j , ' .rt,ti l rrr ;.1,'.rr-. ,rci ,,,:.r1.' ,.,rf.lr,,rr' .i ,
    ,.,.,I. ..t i |. . / , , \ : I . t ..:"Iirlr i.rrr' : ,,l ru
    I'1 I , .l i i r' si :| int ilnost r : r r ai t lcs lir Pr cr naLt lr l'
    :i rr.i rl ,.rr,i io t._ :rtri1 , colxiif iilc lLn''i : 'r 'r r r l'r '
    si;tdr-irmulhipcramonicmic; hipcriizinerrri:i :.,rrrrrrlli,r 'linicr . ,pol lipsi llL inccput ' chiaiil
    r t t t Lllr :or i t a] ; - t ot r iclir r ir r ' t
    rillt(.r.eltctncn]l1rt u cctolii si i:u-i-i ci-]tozi," ,l rrl t i t L(llll) ( r [ ilt l, "' t t ''; "'] i'i' l) c c': lt :t lllt i

    ;ii'r*i:f#iit'ilrur;l;liliii
    r:orrvr:lsiilc prir iipsir tlc pir.idorinii
    lil)rozii (.Lristici. riri palcrciLs
    :rirrrllonrrrl ;ltlrcnogciital ,,,i
    i',:'
    i:ii' i,lii*i*f
    r,'r lillo:rrr' si
    r,, rlri, t irtrtozl-L llcsl;itlLtirr
    ':st';
    suPL'dicirrli,ii,1.l:"tl:l:]i
    l',. I t u,i.jirttr tt0rt-rt tl:;t lirltii strsftrl ' i . . , 1 , ; , '! l l , . , t : . , .rt, . , . 1t I .,1'
    ' rr"l;'il,l ,'i
    i
    ,'i''r'
    lil;,.i;:lll,':llll',\::l,,lili'.:ji::;tl,lii"l:
    .,t .llttttri Litt,i t . t is li it t r t t t r , t r , t , t t
    ,t., i,' trrl i r,i r,,:t ::, t t t /.r r l, i, : r . ir r : iit r r i, , ir r
    tt ,t./ .i :,1.:t. .t!
    1 , , .I t , .:l
    , 'l '
    "'
    L ) r r . i l r l r :r r r l ,l 1l ( ) f-
    l r r lJ c . l\ ( l ' I l , l . , t | 't r , . '
    , l, lrl; r l |r I j lr. rr rrI rI i I i r Il i r I i t i I ' ' )I i i I I I I ' \ ' !)
    'l l ) i l r I r l ll ( t r i r ' \'r '{l i l ( r r l ' i l r l "r l i r ' i ' .1 ) l ( '1 i L Ii :, , .l
    ,,, 'i 'r ' i r l ( l i r ,1 r l r l .r r r r i r r 'L ' I I I r : t i i rI r i | | I t'Ii |IIIi ( i I 'r {\'l l l r tl i r r 'L ' t r r i l r 'l
    I
    | | l l | l | | l l l | l ' . , , l ( l r.l,]i' .r ' jtttir tl,it.' ;r lllr jilr tr .r r z' .' "il{ ) .) L ,t i ' ''
    ,l l l
    I J
    t l ) l t);
    ' l r' l
    i,rr.rilllir irr lilr trlirii;r lr lllr , r , l, r r r r . , / iilr l t ir r : ir lr l i r . , s t i r r g i rc i u . r r , l r r
    rrt lrirJ r. , iclrrl lrlin lr ilx r r r r r r r , . , r r r , l, r lx r lis lr anr lc r . o l r s i r r r . i r l o z i r .
    terl rri o l rtrrl rrr l rt { urr(!i o d+
    l l n l $!r'r l rrr'trbrtl ol ul tl i I erl l r' r rl l c ttl l trol ttr rr rIi mc i l i tl
    (lup' Scope adaPlat rlc lilltus)
    !tr$lllirlo:t l:t lralter€ + rirstl oopit[lui
    tiltJ ( ;
    l
    Norcfn,rfi :i ("C ) llempcrirtllr'^ rrc(l'c ("( l
    Ic j l rl ,' r:!tnrr! i ni l i al i
    lx r'i lrricii

    ]\cid;zi t I

    rl l ' l
    I f l'r'tsilni: n, ,rrrcL:r. 3 5 ,0 .14,0- 35.4
    I I lrlnrorrrr.| crcscutil
    lI'Ietabolism I ',r)r) { a ) 3 ,9 ,3 4.4
    1rd | 5l i 0 g 32,It- 3i.li
    IT t|r .i l t00 i { 3 3 ,4
    f l:-/rrri:r <ircopr.asring.r I lliposie , rl i ) ,t 3 2 .0- :i 3 , s
    fi t-. 36 sr-rpt.
    rr' -. lr/ . ( i . l r r l r n o ( Llji (ir ' l.r
    jl o r r .fiL lx) licc ca r e a ? a r - in tin llut crprneri i nor,n:rso.i ul l ri I 1ri r.
    3 5 ,0 3 4 ,0 - 3 - 5 ,4
    l 'l X ) g
    ,\ct'str-'rrodificilri mci:rixrlice sc asor.iirzi.cu hipoglicL.mic, hipol<alicnri,,. 3,1,tl :i 3 ,5 - 3 {,4
    ||0 l 5(X ) g 12,2 - 3:l,li
    rr,! siu)g inii crcscutir. $ocul le frig se 3:tJ1
    folte ;rsocla-cll hcmorabia pulhro. 'i l l
    .' 5{)0 l I 3 1 ,1- - 3 3 .fi
    ' 11)l )| fi :. i 6 s r_rpt
    Ilri i'i:cvi:lt intillitii tlccit Socui hipotcrrnic acut estc oicrcler:ct cr,nir.i1
    I, tiilillii, uucori Srcu rlc lecuno--cut ii tlctcrminfn<l ,:rc5i,,.rcar:orrsuutrrlrn 3 4 ,0 3 1 ,0- 3 5 ,4
    {l( (), si stiitionarca it} grtrltilto it. l1ou ltirsclltului pt.cnliltur, | 'lX, 3 3 ,3 - 3 4 ,:i
    | | r r l 5 {t'.1
    0$ :13JE
    3 1 1 8 - 3 3 ,!;
    f . ' f ' f ir t x ox , nlul h i l mtr.rmi e i . l r,rl t tc / f ,,r t,.. Il i ,.. l . .//rl r |500 32,lj
    3 1 :0 - 3 3 ,7
    ,1, tt,.rs/t,,i.ll.ntru a inrpi, dica picrderiii: rjc cildrri in rnomcntul nastudi, {ivo.. :,. .i6 silpt.
    uz;rlo (lc trou,niscutul ud si tdnpcratur-:r rclatir- sciizut:! a mcdiului, sl
    -usuarea
    urm:'ttoarclc miLsuri: a) tuBl[r]cntclor. gi inlit;urareli irr 3 4 ,0 '1 4 ,0 - 3 5 .O
    '.<.rrr;rnrlii
    sr r,r':rhJc | ' t) {, !: 3 3 , 1 * 3 4 .l
    rrl.r imcdiat dupi iraSttr', ; 1,) clnzol,sfr-uar1.x, cxaminarca Si'cintirrirr,rt 3 3 ,6
    rrorr-rli sr:uttrlui si: r"o;: ofcctua suL un racliant capabil sit meDiinl tar:,rx
    '| l r | I 5( l t) g
    32,6 3 I, ft* 3 i , ( i
    'i r l I ) {l O g
    32, 1 ..,0 ,7 - l l l .i
    rrrlrrt;r .utrLuatiL la ni'.lnl rrLdo.i,r'l'i Ll 36,-idC;ii plasarca riou-nisc.tr.ilrri ' ,r r l ) i ; s i - 16 s r' rp 1
    irrli.s;rt lingi ,otpul rtirlIrn lioatc plc\:cni, destul clc irinc, picrclerikr clc r.iil-
    ,t r,r l |ll( ' ( lr , r 1 ( lllDil u i rs fe r(_ 3 4 ,0- ' 3 - t,0
    f ,t, ()
    Z. StL:Lia d[ nou-i1risctt.li- I]tmb.ttt.nt!. pri;r plasarea nou_niLscriflrlui 3 3 ,0 - 3 4 .1
    Ir ioo :i I,4 - 3 3 .5
    irr iur:rrLir.ior- sc urrniircstc nrt'nfirrr:tc:raccstuia irltt--ui lllcdiu tcrmic nellill, r l |l , 500
    - . i 6 siiln . 3 i ,9 3 0 ,5 - 3 1 ,l
    irr rrcr'si fci sciLzilrlu-sc la rniriim cfortul rlc termogcnczir, ionsumtl ci . O,
    :t llr'\roil0 nLrtdtivC treCcsarc crr:stcr-il.
    .\tuuci ciud tcntpcratura r:ilrncrci cstc scir"zutl, sub 24oC, sau incut,.,i,r 3 1 ,0 :1 4 ,0 * 3 - t.l l
    I '( ) l ) 1] 1 3 ,0 :4 .0
    rrl ls(r) l)la-(at.linEii o. folelrstri .sit11 un pcretc rccc, cste imposibiliL nr ;r{i" t :0()
    rrcLca.urrLrinrcdiu tennic neutru..in accstc couciilii nou-niscuiul pierdc prin rl , iO(l 32, j 3 1 .2 ,- :i :i .4
    3 1 ,7 i 0 , I - l 'i .l
    rrrriilrlit't'itrc ltcr-ctclc Lcce al incubatolului, o cantitatc marc dc ciriciiri. rlll) si . sij )1.
    I)r: ;rcccr, lirrfurd cont (le aceste i>icrtlcri, tenpcrittura nreclic r.calii scatl, crr
    I (l p(xrtru ficL-arc 7'C cu caLc acnrl <]iu incubator depl"r;c;tetetnpcr: lrl.i[ 3 {,0 i .],0 - .1 5 . o
    | 1(t(, l l .1 3 .0 - i {.{)
    ;rrt'ulni i.liu carur:rir |'i 0{) 3 3 ,5
    3 1 ,l - 3 .l
    ;\('cstc piclclcri tlc ciLiduriL1>rinir':rdiatic sc pot lniitrrra incirlziud p .r.c- I 1rX ) 2 9 .S- 3 1 .S
    . ',1ri i t.i
    iii irtcubaiolului, folosintl un scut tlr: rnaterial- plastic stic plasat in iutcLi ,rrrl | ,1 fi .:,li{.

    rrr:rlrirtomlrri(ptfctii rrct'stuiscrrti['irrrl lompefelrua aeruiui aerului din interior'1


    interioll s;rrrr
    s;nl
    lrrlliinrI.norr-r;llsr:ntul
    rrl r.i i n rI nr t r r - n; lls r : n tu(i
    (in
    l n ti
    titnprrl t rarr
    tn p rrl tra rrspor-tul
    rri) irltl--ofolio transparcntii srrrr 1 3 ,5 :i 1 ,0 .:i 4 .( l
    | ,l ) {) Ll l, 1.0 r'l l
    ,l I i l rl i z ; ur liL { f ig. 2 . 4 { } ., p a s , I1 .5 ). .12.l
    \l o r lilic iir i rnr nitit : i i rl i : L c trrp
    trrrrcc ririLrrl
    Llil ii i i rrc u b l rtor.Lrl ui
    rl (1" {)), uncori i rr r,,rI rrl 1l l r l l t \r t' 5il'l
    i;rIrri l o l r r t r , r liir r r ir r iu rci rrrl i c l rtoi n l rrl x l , l to t s c rxrl c rurLr-rri sr:rrj _rrl ,,) .5 l l .l '
    rl i rr trrr ri rrl i t.0
    .rn ti r: r . I lf ll, . \ ( r ' s l l 0 r' l l l l rrrtrl ,rl i ri L rr.l rtl ts lnl n);l i ]rr.i trP r' r.r.l :rrr,i t l 0r

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    ,
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    \,\

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    rr itlJ)'nt'otit.
    'r\tr"st 1:',]'il]]
    rlilrrzilir,'l--l:lll:',::i:,,
    ti,t,li,t)ttrl ]," :lll
    1i"','1i,'1"';'",
    I 11,:i;lliiiii' ' "''i'';'iii''", e"'.1'lll:.:1..]::..,f
    r . r r I I i I i I I I I I I I|1 i t l u tr r r r yu r
    t"r a i - i ':tt
    il; .;ll
    c]c tcn ]p e ]'a l L u i t tl i tr t:r r l :t' l r r
    illl
    {)rp.ri'r'rrrii
    t'rnic nc'trupentr.u
    , , r i , : r s r x i l r cu scl _ \'o co n tfo"- l , :"a
    ,.r r , ti 'r ,r r l i i
    ), l( l r i i
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    lil',:i,11:11:l'::-,*"#fl*#fl|:"';3;x1j:l.jtr*"fi?,ili:*;tr:j
    ""'"""
    ii;,":.l:l;,il:li:'*:'"'litfiliL!""o
    lii;;ri:lir,l',1,?'.ffil;']i]*i:t
    lu afara incizici mcmbranei
    l)racticrtcin anomaliilerLno_rcctait-anale,
    l]1]1;1i91
    a""
    4cg*inenf iL anali. Din-t1c
    celclaltc intcr\rntii chirurgicalc
    tipil U .t;;;;i;;;pi",,,:
    ;Lcesrernotive, iu ..".iii-io._.,
    ()lx:r'atr;rl)irli-rl:1 .!,irsta de 1 an, practici"Au-r",
    .r seinsoles,:
    sc amtnir
    rr;
    ri;irri**ru*:+l+4*i-*; p5iif
    J"'r;;:,,, i*i1ifil$lilii,
    p'
    ri'.,'"u
    i .o,oi,r.
    i_.a;ni-jrip.il ,,n..".*, auur.
    st{)rnicir scoppro{ilactic,rlea lmpicai*-i*ri1i"'*l",ili","iT,ipnrn,olni ;il;iiil,:li::ill"l",'',:
    I:';1
    rcn.rl. il;j'ill:lllt:*jl*,:'.11:;:ti:Tlil':1',"1:;,uricori rrsirttri
    ri clr<ririr'
    poatr:
    2.1i.t 2.4.OMFAtOCErut,
    ,',,',,,ittilt ." it,r ttttr" ;i sub tensiune' trtr{ Ir.
    cr:rtrir
    . . Orrr{alocelulconst:t in hernrerea_viscereloi- abJominale iir LrazacoLrlu-
    | ) i, r i! tt,as t i cu,r .t.ll.*:l*;l.l],tif:i"";. "u"
    rrrrl'i omtrilic:rl, fiirl moclifica.eavaselor acestrda.
    il(1)lxrritenumai de peritoncu
    oi-g"";ii'orrao*irale {iinrr
    ;i dc- membl.ancl" nln"lrtl.,i Jnt vrzibile prin
    '
    , ,,,t,,,
    ' ,1,
    t .".',,i
    tr,,,
    ,' ),,gi l ' rli"( ; i Lngioglaf it
    n,c,, * t:iil.!t,iit!::$:tH*T*i,iii
    lit
    liijl[il,.li"':JF:::k
    i;"'::ffiTg1" ;;#:,1,']',:
    ;.H::,'jiti*t'i;;'i;;ii
    ],rnlalocclul.va
    fi acoperit
    cucomprcse
    ster'cinmuiatern sertirtiriltl, lli,ltlili ,,'l :ili:' #*:-ili",111T't,"itll*i
    i;m;i:liJi,"ffi ""'
    ":"'it'i"
    :iiiii,.,i:,1,1: *l;l,i:,*j1i;,iil. irir:1:,
    !y"J',llt"i::itT[1',*:H$::*;*nrt
    rrr.{ii la nivc. alror orsane.Aru"ci cinJ
    ltiiii:'i:lllijii,iir;ru';l':rrlil,r""1}s
    lririiin r!r,rr.i l l ol nl i l l i i .
    t"rno",iJ;;i;;;;; .","co pcr,,tclr} 'rl l ,
    ' r| ,, |, ,11I 111;1i in str.rturiinaromicc. Tn c:rzul omfr lo.:"tui."lifr,rt,
    rrcuPcrtnLrmaicu lambour:ide tegumelte ucc5ta 5(:
    rea.lizintln_se i'i1iat%ir,:r-'ie , vcntr.tii ?.1I.1?.7.MENINGOCELUL
    liuBir; sau sc f'losc;tc, in scop piotetic, pi;;;
    J."a;;;.-'"'
    " il.llijllll;:lilri.t'l'lllll
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    ,.,,,, 1,rrrr,,
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    it si ;soldlrl ir tt . 'LJou.
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    ooudi sl; r r lii
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    rliiil**1i1ii;;l' ,
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    -, i ti tri i r' ' "- i, '1"1
    1ir r n of r ( t l) " 1'
    'clise

    2.11.12.8.
    MENtNcoMtEr.ocEt
    ut

    rle lnchitterc
    at tLrtrut[infura],intitdill(lu"s6
    r",i"l,",
    lill.:;"rftTf 1..-:jl,j*".j
    .i".tr''li
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    '' 'ri' ri'r'"riiir
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    i' :ljil;iliiliJ.lil#l,n'.:i";:l::,*"::;.1,;lt;t,i;,r.;ifi:'.
    -i'l;l;r'rll
    : i 'rl,l
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    -: li:'1,
    I.ocrrtiz:rr.oa
    ceamiLi
    fr{.c'enti;;i., Li rr;.;",,'#;ii.iliil' .i".J;ll;illii,ii rilllil.
    llrrll1yr1,atr,r.Sacul lrcrni;rr
    f,",.niar.tstc,.nrurar
    ,r! ukd rsr.cr.llu[lJt
    cstc
    i,ii,l:ll..:ii:-ll partrar
    nrural plr acoperit
    tr r_l rc,rp,,r.it cu tc!.rrn|n1,,liinrl
    cu t,,gLrru,nt,,, iiin,l rrr ' ' 1"r1!' "r
    ' 1, r--,lil"-t rn - :rIl,r.,r r j, , j. f . I inO i, r r . . t r . , r. ' .ri ' P rr|r' r "I
    5t I r ' c lt t I l rn,,lttl:r. t ' t). - 1r1 ti rr|ul abdurtj c i
    c ' raps c l or' 'r
    r' r; ;rc 1i " : r l f i l { :rr ,:' (l ' rt' r
    scasociazir
    r,i:.i.,,,.ri'.tl,.,1)i,"'/,r/i,r,r
    si att" rnonlrki , ,, rri i si ufa t,e rrl :url c troharrl c r'
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    l U\:ri , i i rcel al )Il ' rnr (Ofol arr) rrLLtol rul nrrr ti l c l r' 1\ r'

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    """' lil;rt;.iii'.xt{{t:r1l';jl*:_*.:1":1'tx;
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    ph-OBt
    2.11.12.9. EME ORTOpEDTCE
    {parioodoneondtqldl
    2.11.12.9.1. sau nuo clislrtaz'it'i'rri
    er-icJer.rliazi"L
    hlxoliq congenirql;.l€ ,ol.l i ',llil]"li,litlilli,.l'Lnj,f#l-i,t'',,,,i.logic
    \{rxlificarca consti-!il t" ,r,l i /fi g.2.41).
    lu.rarca caprrlui lemul:Ll din .rct,turtlJu1t,t,
    Lit,..t.,
    ll;ll,1,,i'll:tI"J: rroLr-'iicufi,
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    rrr llrrir:ltr-L a unui sold dcja lu:
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    I'r'1i11c;rr', rn.nrir crapselesugaruiui irr abclrrclil.-rr,i."i irrr(rrDlrrl
    tr.atarncnt (;ttttuofrue ltol delrr,,iila {rr ront,,orl:rnr{lrl.trtrolo$i( "t "t"'"ln]ttl"'
    ot
    ' rl tolcrlir:
    t {rl}Yllc r:str:
    |stt aplicat vi':rfiu'
    tr*cazir
    .,
    ltDlrc at t hn or im : r s i. of im ini
    ;'i'"'l'll''ilil;'{',li:*,,:llt"rii1:l-1;;'#:"f"x'
    II 1,1siLntr'Lrnlni,
    tro
    . 1. \ / i r 't i , t , , r ^ . ."ira
    i .. ,-rri.,-.i)l
    rcr 1,,.,,
    ':cri'arlir 1i,,,,,,,.,.,r,,,",j:,t,9_lTl,,lri1r,;",,11;:,;i-,,i,J_rb
    r%1a.u-.ri)
    2,11.12.9.2.
    Piciorulsrdmbcongenitol i iirir ii sHu;,
    Tr,'"
    l,l-=i',t"ru;;.'ii:r11;'lt*:
    Piciottl nori-niLscutuluicstc ln mod norrn; firtr._o
    irozific nodcrati. rln
    -',ri,iitl":l tralrclririza'1.
    ',r'rrs (inlors iniiuf.rr. \coJsti pozirion51^pcrfect redulribiri {prirr miscirr.l l;lr;ili[,j';:3ffi-,.i*1.1*::li:m:llll":#1'J::'.*':'j*'j'"']""*""n'"'
    l)irstvusllr spontitr)e so corljr.azitoial pozirir aparenrvicio:s,i;:'casn dato. .',1'i ri rri strl tc rl ri rnrc i ;I1 tra)a!r!'
    ,r:il,: rnci lril)otonii tiziologic,.a nrus,.'hiloip"ionicri
    ceic i" r"m..tiazi tn
    Acccsti pozitie nu rcprezintir_un picior str.lmb congenital pelvia'i, co Plod|ce'eir bljlll ,.
    jnalt, .]isplolorlre ceialo'pelvin', Prezentatie
    ::llj.l.'l-.ypliTur. .jcrecteaza [1. ..|lllice | {olceps
    spoltan cr ajutorut unor benzi de lcucoplasifixatu
    .i1i',)..li:Ic\t,"lllu
    I' r' Iirrit
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    ,.,...,.1..,1l Drcrorulur
    irnror-ro,r1'.1 lal3irs vcmnd (l'
    in, contact cu gamba, Aceasti defonnare, chiir acceatrate: detres:! resPiratorie idioPaticit' cdze ?rchDAilc
    Irr(,iir'fatir, se col.cctcoz:l incorrrplet prin lblosirca atclelor, r.irminir.rd It"li tr.itc iatotile de hipoxre'
    iueori .,, , '.. LrJdi crr' l i c s top c al errj ' c
    'ri'
    rrr ;ri c iot l' t lt t , s 1r ' ' " tx l l n tn c n t.

    Ir);rtt
    I)a,.i de{or.marci de ttp tal;Ltst)dlgLLSsa asociazii cu abciuctia 1/Z
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    i ncnrn , hi pL Lr' ' r(rrs ' l r'
    . ; r J lr c t onilul,s o r(.a i j l r' tz i .,p i c i o ru l c o n r. ex,, pri n v,.r.ri cal i zarFat\fri l . l ',r" rl ri l rrr]i
    ;irrlrrltri. Accasta este {orma de pjc.ior str-imbc*cvohrliacca rn;i
    ,l :l :,l i l ll" lill , at l fi i n d i rn p o s i b i l i s o re c o m a nd,i proc,.d,,,,1l 1i ""tol.orot
    iii;
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    L'q,,titttClttbfoot). Piciorul este intors lni.untru si in jos. Cilciiul
    iur . l/ 2. .rn rc ri o ,i ri ' , a
    _ p i c i o rrrl u i c src ri suc;ri ;i ti qi ri . l f al ,oi ri
    t , . pr o, n' )l n c n t;. i a r. m rl e o l l i n t,,rni ..si r" i nl rrrrrl rti i rL ul rghi rrl
    pc r:rrro-l.facc.piciorul la acest livel. lfratamentul constl in .or"c1i*
    i,',i.i:;ilil*lliiff{H,!:'fih1:'
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    ji de suf er in! i; ; ) sem ne de hr pt

    I Ix,/.ilir i pi, - jo , lli p ri r, rtc l c s c h j rn b a te s i p i i irni nbl

    l l :,, 1 i'
    ticiiliili
    i n p:i rnctc 2l ruri i ,rr
    . s llr l, , , n ) r D ' o p ^ ' l o a d d .d c ti mp ,.^ :c poatc i nti nd" pi .i I., r _
    2
    ,,1,iIi*il,';',,*3rJ*:*eilf#;ii:ill*":':ll"'n'Jl
    ,l"r
    ud d^ sratluld" accclrrLrra
    ;]l I l:1.,:lil'il:'l
    ,11,]:l,]lf'
    '.i)"t,dj picror,5i
    al dilofmiL"riipiciorului_
    fiinb, in 50o"din cazuricorecri"sr.poa{,.1c,)
    .'rto p c dr e, _pr r n it lc t ,. s c h l n tb a f,. s u .c .)i \' : tu 5 0" o rJi n ctzur, :.l D L tr\,c,.si rrt.
    !',',".j#ii:t"':":ffiil:'#;#
    ,,,,, ;;l;:'i":ffi:#:i,1:;#:'xt':
    r olcctii chirurgicale. ' 'u''illl::;.-ii.Y#lu?,"&a i" tl:-):ttYi:^:il.1ti*"#tJillillli
    seinsole;te.
    [?T'p"i"
    ,:,:iir,itji:':"',i*"I;ff:'.:";lii::i?i!$ii;*: putti
    u'"'to'o
    2.11.13.TULBT'RARI
    CERE;RA$
    cauzcp1ltiplq pot produce disfunclii ale S.N.C.in
    j;'I;';;;"*:,uii{:ih#t*:|'11ii',r$n,:"l
    l;;r'ii
    , ,_ll"l lxrrioitla nro-
    108).
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    t. X":iJ
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    ,:,,,i,'
    ill,ir-*':#*'l;it':,r*+luiTi* ffi
    sufcrinliL ccrcbralir. sc yrt
    riis(cmatiza
    ln ur:miltoarele
    doui grupe:

    .!tt!iir.; al 'i 1:::;lii;"i ;;;"i uriri simptom poatcrl :;: :li: i:l
    atolog-ia
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    sl:tbi,.incoorrlonarc.
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    I)t I l /l l n l r'l 'rl l h ni l rs l ' ' (l rl F tl i x i m
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    norr-niiscrrl.l poatc prez..t. nllJ)tiri
    .s.pticc.rici"t
    rl i l r'liv it it t f .
    t11li;'riri tlc t.rrus'1i ] ",un"r,"
    1,.C -l { .
    Upirt slr-r{tcrrr,
    I ll'ttlhurtiyilt utrlol)olil t'. ;i clcdrol,itice sc ?ot lnalrifcstil prln c'rrr.Lrlsil ilit.rbilitatc,
    .i 'i 1 rr. , ; , lin, . r ni:
    I ,.r.iporl' c ,.m i a . l ,i l r1 trn rl .n c z i o m i r,l ri po-,i Li ;,orn..ri " 61i ;,; 31.,.* sn
    rrrrl i li,ir i liin, l r n ,i l i ,' c r' , n t i rrti l rri t,. J ,r .n L i ni l s{^q111i
    i rr{| l r\ ' 1] noas c . " .rr, l ri rr.,.c, l ,(.rI,l zi l tc s ori . c orl Tnl _

    O I ) Llc c lr lc t e rtb y a l ..s tn ,h tu r,r/r' | o tfi :ri i r..rn,rtt.i nD rczcul aunui rczrri l i rt
    irl('r fnirl ia ttansihrminarca claljului s.rt iiL prtznntl itl,,r Lirornaliilnrjotr, iritlLLilit.!i c, t_ .c.l i .
    sirgt
    rril cirpului sau fc!ii.
    a. ,.1na1nt.ltilc tal:,gctihllt t1tu rarnts.,Ltla rc siut r.iur)j - hipotoniil cst(l
    { r'l nriri frecvcntiL: 2-5o,i,din ltou-li-Lscutii rr-ramckl. cu tttittsteulu g/.r/i rs, ilu Lc targn. ]l i !o
    1 ,.( .1 t
    l !u\ s ang nL
    rrririsli:.ir tranzitoric ia nastr:1. s?l!rscurt tinp dupr-Laceea, nt:inife;t.ti (|lcbral sc.|zut
    , 'li)rt irin
    li )rt rcsfirat.ol'
    lr)rt fcsfiratol' diminuat,
    fcsfirat.ol' diminuat,' lipiLt d;rL, slaL, ,lific[]titi
    rliticiilt:iti'lala supt, rniscirri
    rni;ciu.i ,rctilar.,,
    i[l(]rrrirl|
    irnrrrirl| sl. si hipotonic. Scmtelc Scnurefuclispar
    ,lispar. pt-oinpt
    prirnpt clupiL
    clupri I DrgDrg-- cloi.urii
    elorlurii de cdr.o. tricdt|fc
    ''fratan.LcntLrl
    I ra ta n rc n tL rld tcri/c
    lrlrouirLnr
    'l ri ,n rr r n ( t s r 1s
    ('l'etnsilon)
    I lJ n rt)
    intravenos.
    l n tra \ e n o s . dcc ntrcl i nrrc cu 1_5
    iii.rtrctinr:rc l-5 69 mg pa,r-
    orrr-
    .lrjtrrni lx)aLc
    r{ri-lrllnl l ..c.l t.
    l)r'rrt( 111i ncccsar
    nc,e:rr pinapini la ia 6 siptitr}inl.
    siptlulini. t,'nele [_inelemiopatii congenitirld
    congenilaltr anoriie, h\r.r- sLlr8e,
    51._ lr()strrrcsc iiutosomnl dominant, in vLclnc ce ltoala \\rer-dnig-I{oflmariu yi EIIG
    rqiirrrgcrozt,lc tluscirlare sc nrostcncsc autosornal rcccsir-. ln boala \\lci. sci(tcrcI'n()r '/irtu' i
    rlttig. llolfntann po,atc e\ista rLn i-qtotic tlc nrisciiri fetalc r-crluscsi rcllcxck: ti Ht
    lr,rrrlirrorrscsint abscnto. lnsiL, cu cxceptia miastcnici gr.avc iranzitor.ii, fu1)1urr't 1r
    rlirrgrrosli<ll lxccis in accst Srup de boli sc bazcazit
    1>obiopsia nusculari-r ;i
    , I r'1r'onrioSr-a1ir'.
    r lllretr.lr. lriporiri tsuprt SN{l la nou-niiscnl.. Se.liul lLrziuuiior. hipo- lt ti c;
    il1rr. c( 1clrrlrl
    rr,, L;Lriltlul sistrrlului lerr.os central cstc diferit in functic de r.ir-sta gcs_ hi totrtri e,

    lirlbLlalir a nou,niiscutului. AccastiL di{ercnticrc c.stedctcrrnin:itiL dr: stadiLrl l ;.i rs . Ir-\


    il( (l(zvoltalc anntomicir ;r crcicrului in funclic d.c vir-sta nou_niscutului, , ||l )
    l)irriLl:r virsta dc 33 dc siptir_mini dc gestatie zona matricei gerrnina|.
    ..rrlrrrlxlxliurarc este bogat vascular.iz;rLi.Condi!iiL: localc dc ciriulafitr 1e1:rrgi!), 1.:li (;
    5i i r l l aLi l i tatt,
    1rr.rf{ii flagili .{i accstor r.ase iavolizcazir. producolca hell}oragiilor. la'accst l frl ei
    trivll si lupereir lor cu inundalic ventricul:iri-r.
    l ri l erl otri e, l r.\
    [,:r nou-n.lscutul la termen zonz cea rnai vulncrabili" la iripoxie t:stc r 1 l , i 1 r |1 r r '
    roi l.r'xnl. Leziunilc Decrotice corticalo sc pro(luc rnai frecvont ln regiutrr:a i i l ,: (;
    i ri l a|i l i l ^tc ,
    1,,rrrs.r;ital:i,postcrjoal:{ (prin comprcsiunc pc planurilc dure osoase si.tcn-
    ,lin l,t la-ischcmie
    .in_condi!ii de hipoieusirLnc).--{.diseasc poatc Iace o coielafio pcl'riL:it,
    i ;Fi t s tri rtc rl t
    irr{r'c.{elul ;i scdiul hemoragici cerebrale, r-irsta gestatlonalir, cvolutia tr:a-
    rrrliului si sirlptomatologia cliniciL (tabelcle 2.109 sl 2. I l0). 'l t
    { l i i i c l tl l i !1
    . -lnrrstiga!iik: neees?lr.e in rirzul unrri nou-tr[\rut tu coulporlirnrenl trtlt-
    t'okrr;ir. anonnll_8, l)cntru toti nou-trrscutii : ,rl ,;licr'mir,;-0l uatrcmio ;
    ,)l rl l trL pilir r , pC0, ( A s trn p );d )h e m o c u l tru i ,u ro c u l tur.i ,cul trri cl i nl ,.C .tt.;
    , )...lLi'n urgr-iirni;./') clarncn clo urinir fentrLl ltliros
    ;i substan!c t.('(lrx,tolri:
    (( l i n i st ix ; i Clir r it c s t ).
    r; \ l ' l l r i l ortrrl i orr l i i .
    ,,,)rr.r.r' ' rr"rrl . rri )rL)rol ni ' rrir r!
    * ( t .tr i LI'
    l )q ,,i r,)r r rri l i r r11'l r' r Irrl l l rrI
    ,l llll
    i r:i J
    lLilrololli(' ii r ( r ]:r l l 'l \l l
    c.l l i tr tttzr :' l r P:tl i r "
    I t t l , tI I 2 . 1l r , , r r l l , r 1 ( f l [ ( : l l , ( i i l l l ( ) l i ( ' cL l
    , , 1 'r , l , 1 i t t c l g t tl l t tr '. lx'l!iirrr:l
    'S.Drnri rlinirie r'ct|rologi(c ru yirlrgtrosrtc
    cf rrlr.rtrij (,t,irr,, Zitqtr) rrri"tur"'i -,1,, i,rrlr',1'-\Pulsi(prtrrLrizir'
    col'\-i\'ll(Port(irfir('iL
    '"'
    'llsi'iil,lltillLili ,ilri,rt rLip.l:ouit"
    prrrLrizirr,
    rripuronir.,
    .{lrn,l,
    ! lrI rx i
    irirdi.r.t llu.pl.i
    ncr:ca(.11'/c
    nastclc si prelurgii; lcste lO mirutc ,1'.i"1:'t,\llllilllli'illl'ii""L'l\ilii'lr""i"''i.'"'p"ti"
    ir,L
    1rrr, s(, lx)rrtcnanifesta ,"',r",.,
    dc volum)
    volum ) '
    "p"ti,,.
    r ilit r l si dc
    1l'! ir n 1 a t o l a l i ! a r c l i e re lo r p r in n r e
    \ ' t D c o l l l o l o s i c c a s ir n e ir i,c
    ' ,,":l ,,,i ,r,t,,l(rt
    i i ,,,;,''',,J
    i)';ll;: 1,uitit.",;i
    i;ll:)ilioll,,1,,,)iiil ll:1:
    / . . . . , . r . , ii- , ^"- r 'l, , , , zitr l r x) t ( lr r (( li
    t.,^11;,:l:,,,,r,iill;l:irli,,l: illl,;t,l;
    | [ ll] si l u n ] i n a r c c { ) r . t ) rftUra s;n .j.j.r i
    \, rrr'rlr xear-ologi|c nsimetlice
    ,,1,1,,11'.,1l'lililil:ri"fi11'11iil:l'i,,i;i'ii''.'Iiqi'i"l'gtritii
    fi (ti{icutli-rii irt atimculafie t,,rr,, l ri l l oi oni t.
    5, rlrrc n.rrrolog;ce asnletfice
    ii cfize (lc rpr|rj ,ll'lllillii';,,,,.
    ,,,'l',l' !::;;"s"Lt"
    *:*i,"",.i1i1i1'x
    11li;,liri;l',:i lil.,ii,,;lli",l\l'o.lllllii,,"
    :il;,'ii,,,,;:,,
    ,\tltic irrnr:r1ar{le hjFsre\ciia.lrilit:L1o
    ;i tripcrrorda mn$llilor exrerDs.,1.i
    rryql.FXl*i:llli:'l,i';ill
    ,ll)1,""':'Jil,,,'il'll.lfil;li':;;:f;;
    llll':11' i 'll,l)11",'i'
    p"racticl transiltrniuarca craniulni car.t poate evi_
    ilr:'ji:1,:liili,
    ilpso'gisr'ii
    ll,li-,1.*),ili'i"'l''lll'f":ii":ii;""ili'';'a,.'
    :tr'
    alt.r.rtrtzt
    , ..,,
    ,t, rnotrl.rirr cunt 'e
    nit.r]a--lt]ll::.S.,:tr-r tr fi:chistul subarahnoidian, hetratomu irrlrrlural;
    1 ri ,1 r , , ,f ,: r lia, l: idr . rn c n , t.rl i r, tl ,i .rrrr u u ri rr., Ii rl i ,,.si rrl ofi a cl .r,,l rrl ;. st'r'"r''i
    ""t "llll"il;,',-,,irscrrtapttic, liipoion poatrravclLo infcctic br''ctrLirLrir
    ,l i rrr t t n. t i : t n. r : . l r.rl o ,i e i l L rrn i rr.'i n rn s , . x ti rrd,,.u l ni l i rnul r - pot
    \'a(lrul srrrsei lrrmi'.asc - in
    r.(Jjj11rIC.] ocr:ip-italir.,\cc.astii 't
    gitnn. f'outali -- ;i cn mai rn.lt trtr r cmln
    A l l a ,,rr' .i .,
    ' ,ii,,il,ii,!lii::.:ii:;,:",(::ii:i1,fi":,:;';t'
    ' .ll,'
    ri'ci a'o*ralii intracr';rnic'c din -.inr.csiiga !ir- e5fs iniportaniiL intncit gisirr.a
    c, lr drj rnai sus nJ scrrtc5tc dc iltc invcsti- .l'1,l,'']'i:.|'';..ii:l]]!:i'j:il];.i1'"iii..,5'"^-_
    tigalii. zr'rrlt Itr
    it.tt'"t-"noese ;ru liscLll il'
    I : , :, , 1: , , t:.t 2 a tt,.,u t:.Iy \lc ,..ri c ,.,i utrrrri
    ,i rrl c i I.ri rrr,, ,i i :.j nu), \r,tt'rrirsctlt,ii ce Ptltl']csc pttlo'ii
    ,
    sf lf)l()tr-r,. , : 4, : : . ,' ,i ;,
    ra!l.o(ralle (r tian.-1,lt nlttt ltrlbur,iri , tcloLalicclelt,.lyoli,r,.., iricirii l l l l l )l'i',,i,-,'"an,Llc
    l l i trL

    ;:i r'agncziul plasmatic; cfornJrogralia rninoacizilor; cromatogr;fia acizilor \t,,11(.r' oll( , r - ( ll1. r , !rlt
    ,, . . , . '"'"j. . ii"l. , . r i t" lll I']"ll'']l^]it r.t;,lt'l cl tl r i l , ,l r r l
    or(rnici ; anroniul. plasmatic; per.firzic.. intravenoasir. (pentri diagr:ostic) l ri l xr t onic san 'rctabolism
    t lt iLlt 'u cr ipir . - 2. i; . t ) . ; i . o1. 3,
    . r 1,rl i ,,
    a 25 rng de piridoxin5. in caz de convulsii intratabile. | ,,,1i , l"ii,rrrot r t l, olism)"
    I)cttlru hetuorag,ii inlracraniene fi,etra.umdticese va nota dacir estc
    : ntr{uinolent lcincl este luat pentru culturi); teste de coagular-c. -.C.Il. 2,1I'I3.I . HEMORAGIIINTRACRANIENE
    l),ntyu Lrli it(t!roinusLulqrc va injccta intranuicular I n5J clc ten-
    _se
    I.r copii h4)otnni (pentru diagnostii); irir'lpsic muscularii; ,l.'ectrornio-. i {;''1:'.,;l'.1:iili:l,,tj,;'L,l",i
    | ,.,,,, i f,,,., '''
    '",111",1.,';il'l
    ,;i';,'
    -ilont' c r r ' a1t n- los l o l i rn :l l a
    :
    Frr tl J s n ta l i .;.
    Penttu boli cyotnasomrtlt: culturi de litn{ocitc li L.r:tminarcl crotrtoso_
    rnilor; rolul l-EG. nu este eserrtial, dar poatt fi jt ljutor pentn stabilirea_
    ii l".,titlli:,il;l*lli:j,il"*li*
    lr irt,'iit,
    f;:|i",,;i, ;ll\l
    ,:l::',1:r
    prognosticului. t, r . rrr., lrtiot itir rut'rnllrar.Lciltialrllc'
    Inaestigalii. ra.reori indicate: punctie vcnti-icularl, punctie ;ubdrral;r,
    pncumoencefalografie gazoasS.
    ,,,ll,,ijjill,l i;l'l,
    lltl"*,illl
    r,tru""*f,:;:l'$'.i:.'*','^;xi, *- sir r l lr r t lor r
    Se.prezinti mai jos citeva L:oute, rflai lrecvente, ale comporanituttth,ti pi"t af Hi' aLLr zul t lc 61i1"t icc
    ,r,r, l ,r' l l i :ttl slt it nt , t r aviunu
    rrttwologic noyJ'n&I,ld nou-rtdscttt :
    tt) Hi.t'ot;,ia. De obicei apatia se insoleple de hipotonic iar hpertxcita_
    .''i,,,1;;:;:l,ll'liiiilLili"/;,*.'a,ria'ir irrlirrir''
    /zr.,'uvrcrI.,:'1:1.j:::'."t
    ': :lil""l'i'l:
    . ,".
    rt,
    ]lllill]:1, Uneon
    rrrrrrrom,l. i"""{siile
    cn l,ipcnonie.Lrr"ori,semnele
    iinr unilarerile
    themi.
    raUloulo schlmbirlor(apa[ieurmati dc hipcr"crci3l_rilj1x1s;.
    i,l:lililifrili::il.nlllll;i;'li,
    I,lll;i,lif l,)li;l
    ;,r,,1. j lt r t "t '''t '
    Cjrcumstantcle. sugestivepcntru aparifia'hipoxiei trebuie c.iutatc u at.,ntia r i" : 'iii'p'"nt lr t t t t i ir t liln"il"
    i"
    ln antecedL.[tc.]epi(,, intra- sau postnatale ale nor_ni.scutului. ,,, \, r.n, nl i i r r r ui - '- Lt t r , , , ^t . ''
    ) i l l i l l l l t L )l d l i l l l i r'
    sLrbarahnoiclicntlllill plrlrrl
    ,r I l \.''l
    't l l
    . Un. nou-niscut care a prezealat risc de hipoxie nu este exchs si. aibir prrrcluc singeriri
    rusir.lr atta cauza d!^ comportament neurologic anormal (de exenplu sept! , ,t,,,,-,'f-tu1ii rnattlri'^se
    r'(.oric,tullrurare metabolicii-
    b1 Probaltititatealrawn'atisnwlui la na5terceste rnai usor de letlus din 'i;'iiii'l;ill"
    :l;;,,ti:ii'.illili:m;:Tlf$$'""'""i1**,:i'l'itilll
    {cJui cxpulsiei decit probabilitatea i poxiei.' rl'ir,
    nPirli'| slli:ralurt
    I Iemoragia subdural5.este de.multe ori fataliL rezultiLdin rultura unei
    ' '
    ,,,,'','
    ,r,i;",,,.,.
    ,,,,,,,,,,,'ir,i (i,iill'ill
    subrlulaLiL
    l:ll;,;')l::'"'i:l,ur,,ncstc totdcrurlrl
    vrr,r ccrcbralemad sau din sflgiorenunui sinus'dural. ;i
    Tabloui clinic a1 ,lllii?ll'lll'
    * t* illil;',:*',t'i,,iT:,1':.i]
    rrrlrturii rlc tcntoriu (cort al cr'rci:r:lLrlui) - care csts u5ordc confnr(lirt cu o
    l,.'irlir r'l'.aiJrilirlir rl, t.r,l sa. o tLrlrrrrrarcrcspiratorib- co'stiL rin: norr-
    |ort. llrtrt'rtittl;
    l;,1;ll,'1111;l"lr,,ll"iiiij:]f*J:iiiiii*ir.i^"'t'..'"r,11:ntoriari
    , lill
    43t)
    r ll lLt llt 't lt llr li\ lot lt r t \ pt r r r t
    r, rrlrii \ilirli rlil lrr illr . , \ lt c or i r ' : r s ( . t . l' ls l) ir ) ( ll s t ! s u l ) r . l l ( l l l r : l l ,
    l)r. 1,nli.l,,r , r, l r rri l l l rtl clr lr t t lt r illt t t lL't t ) t t ir ''lt lr lr r i. ; i . f r ll r r r l) lr r r r LI l) r 'r r ( lr
    . , r, l,r :,1 , /rlri I , il: ' , r . I t . ,,,l , i i ," ,, ,i i ' , ,,,2i , l" t t ''"t ""git '- lt t t it : ''r lt '- i( ulir r ii' l) r 'ir )
    ...,r 'iil,
    Ilt,nrolrrgia il t ritlcn tlicglariL si lrcnror.ag.ia sLLl)ilralrrro jdianir s( inlil
    ,r,,racio,'j cr'1,ri'r'sc rristrirrLr{i':r ;'i
    ,,, sc l r r P lc r : ir c lc r 'ltcL l )re tra tu fi i c rr
    -\I.U .l I. s a L i cu cri rc taIrrti l tLj (l l i rl )11r.r,, ,,':ijil i'll,ji ,,"''i,Li',,liil";,i,'Jil' , lt vlt
    plcsiullr 'r : t - - ^int l scr t llti'
    l I nl{r lr llir l"r
    '\l rtl i rr s i hipot onia s i n t s c m n e { r-e c v c n tcc c a p i tr i rl i ri ntea si nser.i rLi ,rrA r,.l l ,r.,,' ,' " i r,ti t,f,,i s, , r r gr t it
    ,ri ttrl rr r r lt diagnos t i t:u lc l i u i c . S rrn rl c l o a c o s tu i t i l ) tl o henroragi ii utl rcr.r rri ,,u,
    .rlrrr:i constau ilin conr-ulsii si hipcrc tcital rili t:itc ; ccl rrrai des sinl r,.l,r,
    i:');'1,;t,i";l);1.;;l;l;;;::.'i:ll;il1nlii"'.;*l'l'1"'1i11'!
    "et "i'r t t ) '
    s(si,,,i'
    ,rl rrl l r lr ap; r r i{ ia l x u s c i i . a ri l i :i i c ri d rrri a rtr cti i i or l a i ti mul i i crtr,,rri , l rr
    r.rtl i ct r ' . c u o l) r r ls c :rs i i n t:rp l i c a 1 -i sL c i L < l c rc a I)aO" , :L pIl -uhLr si ur!Ll l ri :r rl l
    ,,,,r',,,,'iurut.rrisirir,.it."t#tlt:.:ll;,i:::ill:,.il,tii::
    ,, rrrrrl rhr insu{icicntir. circrrlirtoric pcrifcriciL. Cinc[ tuli.ruriu.iic clc sarguin irr'li'..:rrr"ii
    ccrclritr,irrtiir
    corr-,r'rl,rt, , ]ill']l,l,,];i'l,lli'11\ilii:,:lllii'ittu.''t flr'rx.lui,.sarritritttt r' ltrr i
    ;,r.rr;i rrrr lo) in ctiologii', singcliLriir. din bolrtul ourl_rilicalSi la krcrrriir, ,1,, rrr . iiii,l" to,lt,rri ,'"i. 1,,.na"t':r-e;tcrea
    ',1;'i ;; l''i;'it. rt'gitttt';r
    *'"1'- in lrlod prclcrL:tl1il1
    1 ,r'l i r' lx r t / i s ugc s t i v o i )c rtru d i a g n o s ti c ,
    I 'r;rirlrrl 11ri. au tcn(lirlti!tr it;i"'i1":':l
    .\r-r'stc sL'ntncr:rpat- la nou-uirscutii cc aLr avut hipo:iic sau ill)l(r, l,l i, rrlli.
    ' "1 si tttg ttr r t
    r.L r,l 'r r ' .I is t r - ' S r - r 'de
    u s ta b i l i t { l a c .i s c n l c l c l l l c z cl tatc rl c rrou-utscut rrl i l r r,' r lrr lrrz tll l l i p o xl tl p cttL r l ti r l ;1 1 1 9 1 {e r a t:- L.1 i r 1 l n 'r l r a tr tt- ,.fl r t:l L tl
    i rrt ,l r r ior - it cur ic r D u l u ic c rfb r-i l 1te mp o r:a r s i c o ns.csti cisau estc \.orl r;l ,l r,,l
    , rlirlrilli
    iIrrIrili horlorr3ic
    hcntolr3ic intlacran intlircr:iriana-r.
    r tirnin rrpoi it:targici, incirpalrili si sLrgi-L
    ian:'r. (i4riii cc s-au nlrscLtt asfixiafi si :rr,rlr i;:*ll;;'ru",'ll"1:i.,'l:::*;:1"'ill"llil
    ll;ii,'';lllll,,li'l* {
    pr csiunii singclui : Lt t |r - ir Ll t ': r
    cu r.-espit-ltiinr:rcgulatr', , ccu i r '" rrr(
    r t l1i,," t(,r i ,,r.ir r cs. nsibil l"'*uait ii: iiit r . ,
    . I r, fl l i Lr.i rl itr r r itI trI I
    r,,llll,r ru lui J lolo ir n: ri t-a r' .s i n t liipt:r'iritrLbili,
    l i i p t:r' i ri trL b i l i .cu nu t"itti' 'i"ttguin r:r.'r bral a'{ost.ltrst'
    c u ti r-nrririrturi
    t.L-nrl i ral turicc
    ct nor
    1)o1 s,. l,1l ,
    s,.r,,rr , ; ,'i;,',ii ,,,:i,";"t,i li
    " act ivit at ca r 'lo1or . i( '51) ( 'r r lir r r ir
    , it )ll\' 1 r l s i i l . ,,rnl l , rrri rri ri( ', t upi t t "it "'t : , ii' lc'g: t ir t r itt : u
    l'orilu('ll antcr-io:rrirPrilttc boltl)a (clar accst -scnrnpoatc till lLr 1,,
    :, r'(l {ir lr l c ( r ' (l) r it l) .
    , ,,,i,,,,1,,,,,i,,ii,,,r,,,,i,,Ll;i]::,,.|j.:',rl;""lill,i:
    t , , , l r t l t , r 'l i z c l ll 'l tl r ttt'c, t:o ttl
    l. r r pr c nlt t ur ii c u )I\l H , h c l ro rn g i :r i n tra crani al ;i poatc si t nu l )r' i ' l l , r
    .. ,.:''i1'l
    con.il)i'l'il-,'Ll.:,.
    !r, i rr s , r lr ululolo .s i c (.f. l I. l l u td ri s o l ).
    I l, r r r r , r gia s u b c l u l a l i L tr-a u n a i i c l ' t a u o u -ui rscutul ui nratut-, rl rrl , , , l,i 'r'ii,,l', treir.croriacti,"lci,zi,,
    i']]'lll'j';lll'1i.:ill^ie,
    ,.J.i''l'"ti"r'''.t.'illlll1j
    ,'r','i,,,
    llll)ll1
    li'ilt;l,ii;;:':';.l:;'iiillll';i',
    r.r:.t,r l r ur Li! ' r - c a,po a tt fi rl i a g n o s ti c a l i Lc u rn a i l nLl i ti -rsi sur.anti (i n tr, 1,.,
    .rli, r rr Irt'ru oliL g-iaplin hipolic ' la
    r,l l i i r:r
    r(L l.r' 1i i if
    ir ;r1 in .rz,rrilr.
    c az ur ilc in
    i n rcr:rrc
    r i. rs,ur or
    l) L' em at r ll) . A c c a s t i r u l j r l u a t i c c s 1 ,
    r , . l l rcei ' pnrarr-c
    g :rru n in
    i l t .st:tr.c
    1.r^ 1 , , . Ilii lIi1t n
    l )ul l ti. itftct"
    . r , - - , ,(',(1,.,,\,,l
    rl
    1 , . , , , r r l ,r
    i iI: Ii'i''Iii:'..''*:'.i+ilr;:qi;;gpp,,*i:
    , i , , l l . i r t l ( 1 1 ' , , s.ttl tl n d a r c"

    ', rrrtrr' ' r',


    r ' rtr,lrrirIr
    ' t r , lr r ir lc.lup:l
    alur ):lcitc\.:r
    c i l c \.a ori:
    o rr: sau
    s a rrz,ile.
    zilc
    ('iurl lrL'ruoragi:rest() sul)tentorialir, sngarul cstc lctargic situ (.olr)rrt,r,,
    .rr, r',slrinrlii uL.r'cgulatesau crizc {10 apll(-'ltsi poate prczclta rigklitirtcrr
    ' lrr r' ;r,r,iirii,ilii.l;:;:{*r,. r;:r
    r,r;;r:;'
    iii:iilf},i}rli
    .;L rr r'lr iir r - lls . ) r opis to to l l u s .
    ('iuri hcu'rl lgia cstc supratcnt(lrialiu (dt,asupr-auntri t:ltisfr:r cLr, , r,rl 'ii,,,,,,i
    , ,, t, ,rlrti ( lu(lili.
    i,,,rs,,,,t,ti
    r,,,,ri:1:lil'1,,ill:,1;|,lirli':ll:::i,:iii:l'lii;
    ,rrr ;r lnrirrrluLora), fontil-rcl:r alterioirril estc srrb tensiune sau borll,,,r,,,r , r{1i\i1,,r,
    r-ur,,tr.,rl.,il.
    roart. i,
    )t l l rl rr l c s t c : ic : ut i: u h i p c :r' i rta l ri li ta tc s a u c o nvul si i , cepot fi uui l l ti ,I ttcci
    I li '),1,i"1.:l;lli:i]",,llilil..Ji,,.i',;rrLu,;i
    )(: piulr'l ircntoragici subr'luralc, plL]lila cstc dilatatl-Lsi re.ac{ioncazi I' r 1,,
    L rrri n iL;lt oir t c c x is t a s i p to z i l ti L )l tc l rl a i i i .
    ,i ,i',1,, ":,,'.r"iii,,,r,'.
    ,,,,:i,,i.i l,ljT1'."1?,';.i',i::li'ilr:llii.',fi/'
    I r l ' r r r l ( l ( l x l l ( l fl l l t' tl r tl - tcti
    l)iirgnosl.ir:ulsc firr:c pri:t prrtctia spatiuiui subdural (cu urL ac .r'r r .r ,,1 , r, lrilxrrit i. t
    iL s|tl i r tl n l ;ttti .r 'l ;i '
    r l,):i, ( u (lircctie pclpcnclicular-li,in ung'.hiririlclatcrale alc {ontar}clci). | , t 'l r t t i r . t ltttt'ttscttl r tr t:: i l t'g i ttr l ca l l cr i \'tn tr i cu l l l l

    2.11.13.1.,1.
    Hemorogio peri gi introventricr.rlord ::: lrt;i;;
    l ill;iir l u,illf
    ^,1*,ll'',:llmi*l,,,[*tliit llr,l;it
    tiil\,,r'
    l' ,s1 , ccr nia i irn lt olt ant ii r , ; r r lir , I r r I l r lc hc r nol t g i c l - r r t o n a t a l i -itn t i 'i t <. r . r r r r . , rr I ptii'r''1ri'rrt' t' iliilll"i).
    ] li,i] lllllll;'lli'ill,,l]1*'...i'c'rr.scurir)
    cor lt iibir i la- er l it lt |'t cit l. zir t lt ll
    l.ir I)r(rr:rlulii nis c r r t i r lr r 1lr r r nr r i I ut in t ic . 3 . t c L , s i 'i p i i m i n i <h : g , . : r . , 1 r , r r, rrrl ttt tt.tt rr iscr t it t lLt iI '"'r r l"t t t t ' t i"t t '1t "'"i'
    sc cslit lt lr r iu vt r r t lir : t t li : - r r r tt t t
    iirr slrr<i:ri llr rcr"i;t rrisc r r t i t lupl"r r r r ; r i pir t in t li' 32 si r l i t i i r u i n i ) s a u r : a r t , c i r r t , r , , , , , r," t, , rtrl i rrr , t ''. " " r u"t nt : ". iit ": "f it "t 'i
    ', tl ' I' r' l l i tttl o l t z i tttl t l l l i ts t!l t
    rrrn lrrrliri (1 1 | 5()t) il, inc it lr lt lir lx r lii ls . 1i, < lr ' 40 -1.i,,,,. , ,' l Lttrrrl l I r'fl l )fi l l ,
    tl l l rtl l l ti i c l i llr
    rl c l i t l r tl r' Itt-i l rLi Ll r' " trl ttro]rr' qi c i fi rr:i
    lllrrro lrr!rr lx ri s i int lr n"r ' r r lr it . r r l, r li s r ir r t t r l r r c o i n t , r r s c l r r n i <. i , t r l u , r l , r l r tt t t,r \ i l l l l l Ti l
    ,rlrl;rtr', rlirr u r;rlr-i( r . l r t t |r I ) ir r ; r I iVI , s r r lr r ' P|n< l i l ] t i t | i r s i i l l ) i 1 i l \ r rrl r. j r. rrl tr r ,r , ,,"lll
    ",,',1,i',
    ,,,,,l,t11:' \l()r''(rrltrl'l' l'rrlrrltri|sl.' rir IrI
    'r'i"' 'it'l"ii""si' rrl ''ttrti''
    \ (rir:ilii r.l lt(llli, lor r llr c r lr r lr r r iz : r t r , lili { r . s r r i ( l r i s l l s l i l r , t ( . , o l }l 1 l l ( , o ) r z , l , t ,r,'r rrrrtll,,'tr rrr l)l rrrrllr'z,;ii' 'i' 'it1;'.'l /'r l";rittl"r
    r 'l ' ,rrl1r''srrtrorltrrlir'i
    jr, rrlrr rrrirrr l;r r r I I r , r r I oI I r N i I r ( i r L t r r r i z r r l i r i r r r r r r : , r i i . l )
    irrr r , ; r ir r t lr r v t r : . r , r r JL, i . , , t r 'r rirr
    t , ' r ''i 't"l :r ti 'r ' tr i r r r 'l
    1 rrL.r '
    t : t .t

    I
    l: i:'
    cl r d i l i cr tl l l L tr :, ( 'sl ,' l xl r r 'r l i '
    r litt i,.' Itti r tt;r tr sJ'r ttr tl l t' st' i tl sti l ki tzj ,fi
    |) ot t : i.s inr lt olrrrt' (l i n i c c i n s o tL rs cl ru rn o ti r gi rr: 'l ( <I I '_1I I I t I cI t
    t, ,,,,,,,,, rl r,r.i r , r ciiir sjr ur r t r licii glolr ilor oculali, pupilo int r galc
    ',,,
    ir\ l;t.ltnrt sn froacttNi 1'eprczintiro dct0riorirt(l r'rtlrrstlofaliL,llL trott-llitt- . i
    r. ' l' i1, n ' ';i o l t i s l o r ( , r r Lllir-oluJi
    'r.tr''.r ' l u t i r'
    L ' ' r '
    stu, , i '
    i'l'l ; s'a' rl clalcillr l ti L"L t
    , rrl.rrlr:u lrt'rrorngic rnajoriL. Se rnanilest:r clinic Plil ioc, scitderoil lrrLtst:ill!
    ' . ' t . I , lrrlripnct: opistolorlLrs-. ' ' ' 1 , l : :fvillr l : : 1i . : l':l. :
    : l : :r:ilor
    lrlrrr:rlrxlitului, bornbarca l)\ (l-A poate bomba irr Prirnelc 24 ott'il
    lorrr-r:lr:lurl.rreirrrirri: edem cerebral, hemoragie subat'airnoiclianiL, Inlliiuqilll
    ttrutr't'
    i
    ,,rt,rl','f.il
    rrl rl rr'(rrri
    r'
    ,,i,,,,,
    l ro,,l f,,fi,,
    rl i r' i'"..'*:;ui:'::'1,::'i,'.:i"Y
    , ,i i lrrrttt;
    si
    1i l
    .i
    :rtrrt' ' r 'lt 'l)
    ;l:r:i;,;lll;l::l',,1;::,'*'i:';ti3l'.',f#
    lr..:matJm
    tcm at om
    r ', : : l) ir
    ,.ub..lural
    '. u
    alol- J) o:
    cronic.
    t lr r por r t '
    iJc'noragiilt
    dc convulsii focalc'
    u\ olr li'.
    rle
    iit .
    la
    'upt :
    niYclrrl c111jsf1'11'lot
    '

    siru lripcrc;rpricc),.urmate dc comit, pafalizie flascir,stop rcspirator si tiirr:"r..


    ,,,,t' li' 'rrirrt,iruttaticc siru insotitc prtrrr
    {ll' l, i ,tll u .:1 r: c rr I este' contirmirt l'ril nrnrito rr"l'
    r\r'cstiiptip &r hemoragiccerebrall sc sc mai poate itsocia
    mai poate asociacu crizc {ll'
    convuisii, crizc
    cLr convuisii, j:EC, i't cir ICR --irrvcstigafii
    uolrral (iitrrrrr I
    , l,rrr,, ; ,'cliotuccfaklgrafic, 1sq'r3rafie,
    :rl)r{\r,dradicar(lie,pcrsistcnfautrci acitlozcmttabolicc nccxplicabile-sihilxr . I rrrr' .j ta t olc- ir "l111ni'lio11o [ . CR po; r t li 'r ' t t t t r ul"nl
    rqlicr,rttic. 'r r \ lr ir l r r r iLl
    t , ,i t' om ( , r l. Sc f iic pullc{ii subdr ll'a] c r cp( r t at c ( r t l s( :
    l:,) Iiot'ttt,ttsubaudii sc manifestiL ca o deteliorare ,,iu saltur-i" 1a noLt' ,,,rr ,i , fi ni t,r,int : i1, pinir la qolilt r lr Llt lli 'i sir '1ulni '
    n1' ct al- l) r t t i r r t t : 't r
    rrirsr:utulcu hcrnora5Jic rrrai micir; ln acest ultim caz simptomatologiacsto ',,,.,;i'';i,'"lr;;J'ii, pr"' ti'
    lit iL. l1lirLl
    c1riLurlli'
    cf Ll
    t,rr rr' 7rl l i r1. 1r u. i, it l i-r'-
    iI |'," 2- j t:-t'titniir. : c
    sipt ir nir il, 'c Pr : r ' 'i 'r 'i 'i*'ajul
    'ajul
    ,li:r'r'cliLsi poate Ii u;or trccutiLcu vcdorca. Senuul cel mai sigur estc.tl
    ru i,lcrc nbciplicabili :i hcmatocrituluisaulipsa crcstcriisaledupir-o tr-aLnsfuzit:, 2.1I 13.13. Hemotogiosuborqhnokliond
    I)iagnosticul poatc {i considelat precizat cu ajutortl tomogra{ici comptt'
    ictiziLtr:(C-I-sc:rn)iau cu ajutot'rLlultlasonogra{i.'i (t r' tnsfontanela-re) l,l:tI ccrLnrai fi--ccr'r'ntiL fornli. de hemoragic 1irtlou-niscut cu clol trl i'r fit r'"
    r 'r r r lr( '\ lt it
    Itio grt,oit,icut ijr'tcde amploarcfhcmoragiei.in caz de hcmoragi,r ,l rl .r' .,\< r' sl 1i1l dc ) t cnor agie cel ct 'r ir liL: t pr '. lr lut e. lr in r up- cr c11
    rrrorkrrati.j mortalitatc:i este aDroximativ dc 10'l/" si dilatarea rrentricularlt ,,,.,,,,i,,nit,g,'tui la ni'clul mtninSr"rtrc cmislnricc (mai irl' s r ttort:r'
    '
    "iasclor
    I'r'ogrL siliL posthemoragicri dc Z0']/0.Clnd hemolagiaesternattr.
    are o itrciden{iL l,' rrrorrl.liitliitrrl cle uit l-l intcnsitate).
    mai li'r't'' rrl
    ir.rj,,ritaitf nou niscutiior sucombi. La cci cc supravicluicscse dczvoltil iil i,, l',, a;r.. iitto.i" cle tra{'aliu cu hiporie' intilrtitii
    ,, lrirlloccfalie progrcsivir cu cle{icitemotorii .'siintelectuale severe. l ' ! nri i tl rl l rl c r r gr er r t at ea sub. -;i1 500 g.
    'l'r at ain ett,tr,tl
    !t c'iten,li z. Plobabil cir momentelecritice silll .i ;;;
    '\ i t n ;;
    ";1, [o Pl e i; i sl Pr
    h l o l ttl tt0)'i,lil, I ro Si5 ,to.;!.i H"rro'siir". l'l'1i'1..
    nlce Accsr ti1
    clinice I 11)rl' 1r,l
    , vr:rrirrrrrtclepostnatale;dc aceea se va acorda o- importan!:adeosebitiLttLt ,,,, ,,
    ,
    rr, , :i i rr1r',",1i'i,,".'""i,,
    ,l l ri i tr colc i""i
    m ai intgi,'pot'
    1ar gi, pot evoiuatfiirir-scmnc
    cvolur ir i clr
    lccst
    - <r r nnc a 2- a t lr vi; r 11
    rrrrrrrli unor ,,lnanevteagresive" cum sint: \'entilafia asistatl si lcr{uziil(' ,,, .," 1, , , aicnanif t st a*pr i'nconvulsii, 9ir r ] cbut in, ziua
    irrlr':rvcnotse, ci 5i gesturilorcelor rnai anodine,limitindu-nc la o nanipuhrr: ' ,,,,,,,gi ,,
    ,' r.,r,f ,linirjii Lrunir iutrc crile;i ct pro6Juostic {avor:abil'
    r'11rrrli li:clusi ;i blindi a nou-nirscutului prematu-t'. ( ) r orirr)licati() posibilii cstc hidrocefalia'
    ( r,rLrnai e{icace prolilaxii: a hcmoragiei ventriculare ar {i transportul / r ,t 1 ri nt t: rt /ttl' csle nespecific
    rrrlLurclor la carc sc anunli o na;terc pretnalur: spre centre perinatalc ctl
    tlisnun clc iacilititi deosebiteprir:ind r.'suscitareanou-nlsculilor. Deci csl(t leziunitorhipoxice9i ol herorogiei cerebrole
    4. Trdlqmenlul
    2.'11.13.1
    rniii e{icient iransportul mamci cu risc rnare decit a nou-niscutului cu risc
    mai bun incubator de transport este utcrul matern').. coa nlili ( lli
    rullr' (,,c1-'1 I r rr I l m en, t t , t , I l/ aa € lz a , r cpr t zint i m ; sur ur
    'l r,r lotn en,tul cur ati z.' clispunern de posibiliiili rcduse.(clntai sccundarc lcziunilol SN (
    , ,,,,1,, ,i,, r,'iil.e a mort"litAlii 5i a sechelclor
    irrrr',rrlrrlobi,'ctir-imetliarosle mnrtfittcreapcrfuzi'i ccr,-brale. ,,,,,, i,,,,,,.ri,r-.i hemorogi". Elimiiarea traurnatismului obstetrical l,ritrt.ttr
    SciLLrreapresiunii intracranicneirin puncfie lombari (uncori vcrrtrictrlo- r h"t r '' r r L! ' t
    ' ' i ' ,1
    ,,ti , i ' i "ii"- S ?xr t "ut er inc ar lul( a r cz'lvr ' pr ol'lcm
    rl.onie) poate fi indicati. , , , | ;.;i; 1,; ;;-;..itt. 1.".t lucru se poate realiza in doui moduri:
    Lrciterca pcrhzici cetcbral, posl, (ltrc,'la c-'itind''rcahcmor.tgicis,Lrt .\ttl,titldu'ed suJ./in!d. f.etale orin hipoxie in timpul travaliului ptirt
    -l5rgirea
    Lr :rparitia uneii noi. Se vor evita factorii cale duc ila cregtcrea abruptiL.rt (iel pu,tirr) indicaliilor
    hipelcapnia, hipoxemia, acidemia, perfuzi;r ''''';, irrturor nasterrror cu'risc
    ,,,,,rrt,rrizrr..rr ;i
    Iiuxului sangutn
    lLuxulul cerebral ca: rn
    in cereDral
    ',i, , ',
    ' , ' r, ;;;,,il;; it'.o".i"r, ld pre'',;tur in prbz.nlatiepclviani'.NI.t
    r lpidir dc coloizi, zi, singc solulii hipertone.
    sar solulii
    singc sat ' ' oti ttrrtr
    t t ' , , i r r i i . i t * * " r i l n p r i z " n t a t i e. p c l v i a r r i . c s tdee l 6 atic
    Dir:rcnsiunilc vintliculare'pot {i urmitite plin d"terr.Lriliti scrialc -(frl rr,,'r, ,l, r ir r, t',\1r'rriscuttlor cu acrlta;igteLtat", nisculi in -prczenl ' (rt rir
    " ,"i';";i
    , : ' , ' I , ' 'i;".;1";';; pelvienel; promaluri
    ;;; ';; in.iJ"n1"'pi't'"n{afiei
    : r soo estc de 301/o, piocenlul mai mult dccit srurlili
    este-
    r.';;;,i, I , ,'il i
    r rlrr' ((ioklctnlrtrrgll , Nclson K.)
    lrli'r'.
    Flernorogio
    subduroli ill,,ttilru'i.zrrrtla, in plrioadir postnatali, a tuturor nou-nlsculilorcu
    2.1t.13.1,2. hialin'i" crize dc apnec'inlLr!ii r'1t r
    1,,',,,i',;,i;t, ,l, f,il",ti 1,n"^Li'"n'-t
    v'Jnirii accstnia'
    .listr:intihriLiLdin co ln ci: lnai tat in condiliile obstctricii modcrn()' i, tr',, ,,.'r',.', 1,, , iri 1',,sil'il,l)r'
    llr.:rnora(iasc ploclucr:prin ruptura sinusuiuisagital,venoi lti Galt:n,sitttrstt' I t,r I un. r'nIul ottr ctti"o :
    lrri lrri.r.riLsi vi'rr,'lors[pcr:ticiilc la nivclul convexitiriii ccrcbralo. , r , l l l r ( : l l l )i l i o t - l l l l 0 l l Ito r '
    litiot'o1iia t'stc-cxclusivttrLttmltici.(prczeniafiapelvirLniL;i apli'
    ( rtfiir (l,rlr.1.ltlotsi rt forccPsullli). / r / N l t t l t l L l i l ;ti r : l cr tl l i t:i '

    4: 111,
    ,134
    ., I,,.r irr.zi,. { , r 'Il tlinr ( '5 1 ( 1 tl .l t
    .
    i, r il 10, , o 6r ) lr i/ lii ,. i I iLt
    ',t, t r l r lt ' ( ( Jlt vLt lsii {r , ri ir , r 'kr tti tr tr
    t):jllll]]l:ll"i:1- lu, pcnlru rncr.rtin(ir{,r
    l"l 'l i tt
    ]l ,, ,,1,._():: | 11rrr.i
    t)lf), cor(,si)u
    nziit{)r.i .' , .lr,rriu 1,,i,'.,,t', ,,,"t ui'.",' .'l''r"r'iti .itrr:'1.rri:'lii, ':],:i',tll: ...,:.i1.
    (l\1ro1
    11itl rcspiltrfie asistatir. 'ii,
    iii] dc
    ;ii,'iii;i;;';;';i',';.;i.:,..t"eir:ictaccsltip'-rio.'tc )i'iti'i
    r,) _Corcctaroa
    ./ Lorccraroa tulbllra
    tulburi.rjkrr "llt:::l
    rlt'a1'n''tr
    lor- Inetabolice;
    netabolice; hipogliccmic, hipoczrlccni,.,
    ar. ,, .rl, ,t lrtttrtIr. rrrrxliliciLrtiL:rl,,lilitirlii globilor: ocrrlLi ;i clizelc
    rloziL (administ.a.ea de bicarbonat cstc a<imisll,"nLr'r.i' l'r l 2 lE
    itr perfirzk,, liLr.ii
    iri'-iertuzrc, firl it I rl ,l " ,/i, r r 'rlir r , l, ir 'i'. i '1, 'li' nr cf : 'l i"l
    rlrpiL;i^doziL dc 2 mEq rr-a,rligr,24orc.)
    ,l]'l'ratarncntul eclcmuiiii curcbial: 1 . t l )t | t l i : li
    '
    (tirbason I rr.rg/kg); Soluclccortin) i2-2.{ rng/trg/zi,
    ,li. ir,; i1].,)T4"tazon. l :| tr \l l ln ' rt n (l i ! : l t ri 1 | t o r\ n l s i i k l r l l r l o u ' rl i rs i o t (d u f i r] l l i )l P r)

    ll: r Dir ol .o l . l o " o trn l ri ; J :. i i orc, combital cu furoscnricl l mt/ t(' 1l t1ul c i )l rv nl s i i l ttr
    /.{ ,t;) o. ol-r.. ' '' '; l' tt l t ''ti ! { l etrl ez i ,rt:i , 501' 1, dr ' rl
    l r r , Lr r i s ( 1 \ l l i r l t n rrl r s l l r-c mx t n rl '
    g)'IratatllcDtnl conr.ulsiilor.
    lr /r, , Lorri rar(ri 7orl i i .l :L t! S i oL)i l oro' r11ari i s P l s l l rr rl tl
    , ,, ln lunctic de hcn:rtocrit, tLansfuziecu masiLcritrocitar.irpentru | ,L ri fi (!l i c ni i r(,rrl r f:r1Ll fi al c l Leoapc Lor
    Iirr:,, corec- I I
    iur,.rnici
    tcJr,^1,o.r1,. 1i5,,rr1q ig.l li, 1uO,ntr...,inJ",_. hcrnur.agi,:i. \l ,. Li rrI qrr|i i : gri rtrs o,s n.tnl nc ,
    "ub ' :rs c at
    ? r In n .mor J Bt : l s uLdur J I i, pr r r r c t ii - tr l u i u r . ; 1 l . r d p i l i l t r . . r l, l ,,r ! 1,,j i i ,i i rL rrrc nrl )rftor

    ?criioayra ofhiror, Ix{li.j, rr+.r|*, nro(Liti(ir-rfi /i,{,.,1,r,,i,,


    il ll' l, ,,,,,,, : (Lc./i(.fc
    2.ri.13.2.
    coNVUrsruE /l A l l r, IrL,l , ",.,',
    nrrtc !:tr-TrnLri c
    j rc s c ut l l { ri c l i l s c ' ] ac orl P arl tc rl t ai rl rl rr l !r1rrrl "' l

    Flccvcnt:r crizelor convuisiveestc.cli:0,2_0,E% <lin totalul


    lrou_nirs.
    , arc .rpariu primric 3 ,1" a" i,ille ,i au"p:is zrrcac , t1 t t'\i i t n.tnti J ,.,,al ,
    :.:1ft: !^"il-ll:ijlt dc-ohlcci.: h l 11)n](hf i r:j ' 1 c i i rrLi rr Ll
    ll.lill.l.i,.i ll,Ll9].;s:,, teziunitorccrcbralc.Coirvutsiitd
    cc.ap:rrin iu- \l ,,ri ,l ,,rLi f ( x l c rnc nl l )f(l or tro.l )ordotl l |tej ac ts l ti l ) rl c c o11/l i ' i i
    r"1-v. lul c|lpnl|S r nlr,.5-Jt 2i1,.
    dc.],r nrlt,.ro cint mai lrpcr.nniprotJrr-^rlc
    1ulb.r'iiri mctabolicc. Crizolc cour-ulsir-. sint o furmai J,,-,r.r-",.it"st ,'i ",. i ,,' ,l ti tnc rl c rn(1c trs c ul i tc , s ' tr ri trl r l c rLt rrri gf:i ' i ('
    rirrtri cerebtalecare poate .L\rcacaLlzoloc"l" ,o.i 'iioU"for" sut,u ','.,"
    .qcr"r.nf" "Z.lii;.
    "f ( i /,,1 i i l ( r(' ui (, g(rrd' .rl i z utc s i ntas rD ri nl :rtbrrc ([rc ](:(l c (1ec r' 1i c ^rol ato|i l nl
    rarr' ri rf'
    c 1d-c es ' ru trp' r' c rrl '
    't abetut 2.111 ,,, ,, ,,, ', rrs ,,i :r)arLrLri t' ri ati i a1t gi obi l or oc rl ari ' nl i i c i ri ' r\r(s r
    Iliobgi{ (rizrtor, (on\ltlsir{ Lt lo -u:js.ut klnp:r J. I{. .nrecnran) , , ;,i ipi,,1,:,,,,,,r,,,,,,,,i.rt"i11:,:,il:,,:[1ffi;ilii::i]51..: ircscrrt,
    T. ll e t & b a l i c . | | I . rrr LI l|111. L 11 /()lrir.l
    l. Hipoglicemia
    ri i) | )ttt' | .t,\'dt'
    l. Ifipocalceu a
    Ir' rrs l rtrLl r' 1i l
    i. Hipomagneziet{ia \, r 1i l ,tl l ( (,,i /,,l .i i s l r( rat i rri i 1l ri tc Lr n u ' nn s e.i Ii !o!c s l d",It:' l ' l l ' ]l :" l ' 1rrr
    P r-os os i i c rl lc s t(r
    1. P i r n l o r i n , ,,Ir , rr L tri i fi !rrr i !1IS nrrnc c i rl rrc(n c ' rntl tz i c c c rc l )ral i '
    - dependcli / /,' rr, 1i / i 1rti ( l !rn:r c n /;fl trri rl l rdi -
    - delicienu,
    .5. Hipo- ti hipernarrcirria , tl r) tlttt,lt)tLt.r
    (). s u' i o:r"fc ,s i rri r' ri 1' rr11"\"_ L
    -\rllinoacidcmi. .L Lr L, r,f, /rl rl i r1( (l c s l nrrc l rl l r' rs !rLc rori rate al c ruc nrbrc l or
    7. lllperbilirnbinenia 3 { l i hl z e a1c S .\' C ' ' i )|os l l (,s l i fl l l i l l l l o(i r' /o|x |,|'
    .. , ,.'i .]ri ..' .i ..i ."' ... tr|1i 1l j l i l o|
    3. IntrcIlperca (hogurilor adminislmte inaulei : hc(oir1d,
    lar,L)ittlrice, / /r l ri t's rrfi l rrrr,
    L Policit{ruia
    tt. Itrt clii
    l. Sepdccr)1ic
    urt-niLscutse clt'osr'lrlrr
    2. Xlenin8iti, I t, tttrrriltttiIt.: (jilkriness) intilllitc {]'ccvc[L la
    i. E ccralit:r ,,'rrr rrl'rii plitr ntlittiLioatt'1cc:rractcl:isl. ici :
    satdc nri;cirli ltttot trtrl
    L lraunrilic;! r \r1 s(' illsotcst (lo n-,nni{itt:tii alt' privirii
    Ir) Sut,u.rnh,toi(ti:llui ,,l ,i l or rx t r llr t 'i.
    ' l 'l 1, i r r ll
    I t S n 1 !lu fa l:r I l ,," ,r, r , lir t r r |il, 'sillt t lcclanlnt e lf in st ilnular ct lloll- nii\ ( 'lr lt llLll:
    ,tl rl r .rl )i rl sl) ( ) lllit ll.
    clolici' sPlr ilir 'i
    l. . l i : r r i r h c u r o f , r t i c ccr cL fu lr s( ( jr tlr ( ( r ir r I l ' rr' (lr ) lllllii lllL$cit Lcat t cr lr r t - t t ir si t ur st r ucir t a
    .1. (]ll lr(:Drof.tilic IcrivclrLricrLt:rl.i! rrl i i l rrt.
    li t t 't nlr t - t t lt t i'
    . i, C r L h c l l ) { ) r & f i i o! cfivcltr icu l!r r ."!
    $ i illtftL /cl| ( r icu la r i l tl rtt t t t . ilt t t ilr 'ilr t : ci- t 'it ziLt r r I lcxia lr iLsiliL
    \ | . .l tn" a.lii l( d roltala ' /r l r i l xr h l i \'''r l r i .i r {r l r i i r t l i t
    l. l ) i s t j ( ' t l r ) z i c c c r 0t) m li , I t ' t r r ttt:i tr tr i I, Po t fi r r .o r 'i i tl L l i l r r l r i 1 'r " 'r l ccr l ti '
    r I Ii IIt'|) i IIi i |, i ;t
    : , . t i t r t , ) t I i ) \ r | i a / , i t:,1 - J1 | i ,1,' rir '| r r n t . r l , l :t l r ',l l l l a r { l l l tl l ,tttt ttt'ttt'l i 'l i r l u l i ':r t5 i .{ l l 'l :l l l :l
    . 1 . I n , l i r r l r e l , r . r1' , ,rI 1; r. rrr, r; I I r r , . . r r . r , i , t t t r r tti l t"r l i ti i i n l l l ) l l l t l l l r r i l f( '( Y':r l l i i r l l i l r r l ' l r l co l r i l ttl ttr r t tttr tl '
    "

    ril{ i t : i7
    ( or r r r r ls iij, .
    J )rj n l (,:r:l l l (.rl ,l )j i i L . s r1 .l l )(l i r, l ri 1,rr,,i eisi l rl rrol rgi ,,i 1.,
    r,i sl r ir ( :s i' { r ' r . l. r tri ri fr.r.r.r,rtr:i ^ It..t ' l ' ,uttt l sl r Ldnr it t isllliLziit r lllt t t lucnt ul cr lt r vulsiillt la not t t t . . r 't t f
    1 r.;i c ti c a.l i rr i r:rr rr,l ,1.r:2,.' ti rildi 2 rl i rr tri Lrri .l ,,1, r.,l r' ,ri l ( 1r |r r : iziLr i:
    , i , r r r rr ils ir , l r y r, l r L tu r s i t,: ta n o r -r.n,rp,,ui l ,,r-,rl .
    _.\c:est
    . l l l ,l trp rrc cr,rr. rrr l sl c r ur t i ect iv ( lilit lir nobar 'hit a1ul( adm inist lal iuf t - r t r clt or ) 1
    l.l:l:ll "l,,ll,]." ll'i'],,I i 2,1,..1,,tr1
    .1rasrcre r in Ir-ir.rrclc
    ifrccvixr l2'or_rJ,r.,ir .,,l rri i rrr L' t lir r zcpat ncont it r t :bcnzoat dc sodiu cat c dislr ciL I I iI ilt t Lir I I r
    r)r.ir rl rJrircurtJt" ru tf.,tall1cnt.si
    ' sc insolixc dc morbiiiitatc ;i
    .cllli, ( , \ - . pr i|l,1 .,^ ,' r' ' ,J .i i 1 .' ,' l ' : .r1rr i r r' t r ir llr t r t niua;
    f" j n ' r ,,rrl i c .rrl , rr.,rl rrroj ,l i arri_'ror.talitirrr.
    | ri ,3.r,.,-,i , ,r .rxrirt.tr;rr irarbitutii:t:lc r:xisti"Lrisc dc coiaps ;i stolr r ( 'sl ) i l - i l l {) 1 .
    .,\'o r : lLr tlI ' J L) " oJ rrr ,, z .r.i ). (' o n r rl -i i i ,
    1 ,ri rr l ri 1r,,ri ,.sc ot i nsori t.1,. r lrrrl,,r lrnii autor-i (Chisrvicli) se Poatt' adurinistta totu;i, i r r r i o zi r l ,'
    .r ,l I noilir i, ir i rn ^ t.i l .o ;i " ,.:.1 :i Ir..q l i 6 a p ;-. i ,i pu..I,,,rrri t.'
    si hi por,. Lr,.r t) Irrl l /l (g int nLvcuos, lent ( 0, 5 r ngt / r linr r t ) .
    j'rir sccrctic ncacleryati de ADI{ ttabelul 2.113).
    I t,rlLrutcn!ulcontttlsi'ilov rczistett'telt lrttlunuttttl c1lfurobdtl)itdl l'drLtl
    / i, i r. ,rlrrfi,' .1"i,, sc adruinistreaz/l 2,5*4 mi,/lig iutravcnos sau in clisttti
    1ul ,I;:i 2.1I ' :. ,,1,, , t,,rl r O , lr ng, / lt g-int r am usculat ') -
    I'cnrfrr}nncrc:r rii:'!rno'sliruhri Ii,IL|tttLtt||!I dL ,ltiU'ttt,.iul cortaul',siilorla nott-nriscat. Sc lxl tnirtislt 0itzli
    ',t"I,1iil;,1i1,",;r"'","tilc ll.r!.r se fa. utnr.iro*crc c\irkr'.iiri r ,,,,l ,rrl ri l ;tli u lunct ic t b cvoluiia liCG si aspcct ul in dihaln'lic: tid sonr r r ( l( ) I
    ., ri, r,rt/, : Glicorrrle , , ,,1,,1 i ,,. i tt pr ozct t t r cour . nisiilorclonicc f ocale, Pr in t r aum it t ism nr t llr t r r l.
    aalccrlrie ,' rl rtrrrrrl tlt ilr Lr r ct t t nlun int er val de 3- 6 luni ( sub supr at cgilr r "r 'r t t r t ct li
    \Ijfr,,./;^..r,. ,r 1r',1i.111q1 rl,' lL tlisprxrsar-Si a ncuropsihiatrului din policlinit i)
    FosJorcrric
    H e m o l e r c o s ra n r :r i) ,r ;jr l) o cfte
    l',Ilrt l)'ttltt tt ttlulilt inlrclinere se recbmand:tfenobarbital i--7 rrrl;/li;iizr
    T i m p p r o r r o n r l,iJr i 1, ' ,r.rl ' rrrr it r llllr nLr scLr lar ( la 8 or r : ) sau f enit oir r 4 - 8 nr glit g- , / zi,p, 't ot r r l
    ,\strnp , l rt ,Lrl ts( lllli. r '( la li <lr c) .
    ECG l" ttlrrr /ri.ftt.t'r':t:titabililttlawttrcatri, Chisrvicli t-t:cotlltntliLclorrrlltirlr'rl
    . \ y ' , , (r 1 . , i n t u n c . t i ( . . 1. sn sti,:i.,Ir a o ii.jo { :;i:t .r ) g cr :r 1 t d c si l rr.a cl i i ci ;. Llrzi (lr li orrJ sau leuobarLital (in dozelc dc rrrli sus).
    l l l r l l e c l i c I h ( ,r r o ct) tr xr :t, l,t_ , I.{ r ,
    1 ) ) C a u r e c c r d r :r tf: l tt ,,r' ,/ i, / t f >r t st t . r espi, r at olid. 'm onit or izalca t t : spir at ioi ( dc cxt lt llr lr l
    l{ \. cr .a r 1 ir , r i.ir ( i:n ce la l og.enr|-r.i .arrsi l nr r;r1a1j e, 1or,;.ttraL,
    coltlpll1e]1za1a _ ,l i ' r rl , ,rl rrlr r r i, lxut r u apncc) , supolt veut ilat or adoclat ( daci'l c ll( x; ( r sir l') .
    , ) I)(shjdrataft, .rt(:nre r\a, Cl, Ii ltt ',r'. LIt f:rtsitutc in.lracranittnd ct.scl.Ltrd. Acest diagnostic ostq ill)r'orrlx'
    (l) Srsticiuirc .le lr(ral:r metabotici.
    f?. zi p:1_. 3j_i()_at t) ' , 1,,.rl ,rl ri r' pr r s cu ccr t it udit le la noLl- ni, scut( Chisr vicli) , lJc lccclL, : r r : r r lr t sr
    ,j rl ,' r I i r'( ||rIi I rrrI i- l ciL r iLr t ncicincl hipoxia cst c ilr m od claf ciluzii ut t t li; t lr r r lil
    'f r ot art,en.t. Crizclc
    conr.Lu.ii\,r. pot ca.uza,priLr cic inscle, neziur:i ,, I rl ,, r, xci lir lr ilit iLt i glosolane, cst e r czonabil s: r ut ilizit [ l dellt t t t 'ilt ; t zot t , '
    liil" irnlerriLil" P:oxrrrr.ricul tl, pinrib Oe r"cuno";r.r .. I,rcco.,., cou. I f r rrl ri rrurrt ( ] ir f la l2 o|e, t im p dc celm ult 3 zilc ( doza st 'r 'a s<i"L( loil ll'r 'i) lir l)
    :l 'l rII^r dc apirca:,J
    vrrrs ;t rri,ilIlr rliologic.
    rr.,rirrn, l ' ) t)!' )t t ) s/ r 'iaI in convulsii la nou- nit scut , poiit e f i dif of ii ir r lt t r r r 'li.
    l. l,Idsuri genela.le
    : " rul rr,j rrri " rr i; t L oxi m plr r , dacl hipogiicem ia ; i hipocalcem iaslLr t s( r ( : t t r l( lir l( '
    a) Plasarea nou-niLscutului in incubator. I r, r, l)r'olnosti(lli ('si1rl)rost; dacir reprezintiL tulburiLri :;trict t t I t :t IrI rr ,I it , '
    b) l{onitorizarca cardiorespiratoric. ,, ,l r' ti ,)l i r i rr t lr LLr lclinr -pr r ) olnost icul est c bur ( t abclr r l 2. 114) .
    I1,.1i3"1"dc apneclersistente; ventilnlie pr: uascirlintubatic ven. ' 1al )tl l .' .1t I
    ,,,..,.:)
    lrliltrc asistatd. -"i
    t,"tt'!htl rrl rri zrkrr' l .0ri rrrl s i \t' h D orr' ni s c ut i |l l u!rc 1i 0 dc nl eetnr1' a norrrohl J l (;r (,]rrl )i ' !\,,l l ' )
    2. Inainte d.ea t'rimi rczultateleet:flari|rilor peraclaarcese adrrinistreazii
    ,
    un tratament care se adreseazi principalelor carize de convulsii, cu obscr- \1,, l i ,j ',i r(ruf,,l o!i (:i , i l s unri nd c az l rl i l e D c z l oLl arc a norl ]l ol i i i n proul rr' ,'
    vnrea evolutiei crizclor: i rs,x ri r[1ec 11 r (,rl v ul s i i ]]irfi la vilsfa oltlri
    a) Glucozi 20on 2rnl/kg i.v.
    b1 Calciu gluconi. J0o/n,- I- 2rnlrkg i.v. , r,l ,1, Lr l ri l,(,!i (::i . .509;
    c) Sullar de magncziuZ5o/"O,Z;nliks j.m. ,,i 'r,,|,,!,rL',i ri rl Lr Li )i ,l i urri eaYo
    rl) Priridoxina 50 rng/dozi i.v. sub' c6ntrol EEG !j r,,,rrjli j rLjr /clltn, 11li|f; >"1 0 %
    r') In hemoragia.cerebrald.centrali se administreazi plasml, 10
    , .. ml/kg, l)r{1ri
    f0 - I 00,1i,
    J.r E orl SJu mas5.crirrocitari, dtcx cstc n^LLsar. r,rr(l r/.. 50"/.
    'l'ralamenttinptontatic: 50f,
    . ..3. Fenobarbitalul. Aclministrareaunci dozl r'llllr1,i
    t s 20 mg/kg/zaor.e,divizati. in 3 prize, determini un nivcl ptas_ 'l
    rt ,
    I,ILL1|Li-iL|,l - r 0o,,1,
    0
    ,.5 0 ,1 1 ,
    ]]]1!ir:,",1 ' ,r,,|,.t'.. r,rut,,ni l i rl ' .
    rrjruc rr,: ; ] - suttcrcltt pcntnl ;r opri crizele convulsive. Apoi, sc continuii.
    cu r) r t flz_zU,l_Lg,
    ir ( l( : int r r ' l i n e ru rl ,r 2 ,.r -l n y l k g fz i , i n pri m,-.l c.7 zi i c qi .5rng/kA /zi
    I'i ',l itrtsli,nl .:ol ttlsiilot' lLt n,n, t:;lr itr, f\ut.clit: ,lt' ru,',/iJltlirilt I')l"lo
    l l l r'(| | |I II I I I :I t ( . / \ ( r . s l " d o z | l l V i rri .tz i (u v i r sti l g,.S tafi ,)ni rl r' ,, c,rj ri hi i i ri .
    rl .rl r,l r rl .l .l l l i) .

    4 |il.t
    t:Il
    ['r,'(rn r.l i (rrl ( o,r r r r l:iil,r r h ;r .Ir . in ir r ( lir rl r !'r.'rl i i i l .i ||i l . l .]l .l (i 2.12. FARMACOI.OGIANEONATALA
    ,t) I']',:i 1 t,:ti. iir |: l. li Il( l n i) fl]r ' r l
    a. \ iilr r fi r ) | ;ftr r a lc l r| l l )r)\l r1r)n|r1l MEDTCATIET
    2.]2.1.EFECTELE GRAVIDEI
    ADMINISTRAT€
    ')l l \r)ri r('!ii. r r r ' il/.flln :
    L llo ,llljcr "r ' i r r n lt j l rral c
    FATUIUI9l NoU'NASCUTULUI
    ASUPRA
    Yir fllI' Nr r lf ,,s i ,,.r(rr(
    alLl1l- lc( licinll( llt {r lol '
    , t' t tttttt t lil o r lcoscbill'rat ( r f il' elect clor
    ils[ p] 'il nor '- n: r 'r 'l\ '(ului
    scut r r seCa o int licalit 'g- r 'r r '
    l-ir ptcmatur Do(lificit-ile ll].1(i sint t'rrlsorrl iliczttivc pentm progr,,sl i(. ,,, Lr,rr,, g,: , , , i, t , 'i, 1: t t ulLr i
    ii
    r lt ' nr . r lir ';
    i-rr nou-riscutri
    )u-lliscrttti lror-moi)ondorll,
    lt ol-lltot)ondorll. llontnlnoutrll iL a\.ca y:tk)arc
    vaioaro prognosticl,
    nro,'n.r.+ici Elj(;
    l.-l. li , ti rrrl ti i l st r r - cil1iisc- 1'( '( ollllr ncl'to abst inollt 'L t ot all'r - {a{i
    (r nr : jlt st if icai ( lc nar c dt ' t t lnlLi gr ; t r t 'l
    {r, l, ri. . t , , l r : , r i r r r ,r ' ilr , le ) .1 n l ilc lrt dclmtrl cout.ulsiilor si rclxrt:tt dupi {.irzl ,r, l ()i l l ( : ir c( r \ l( : i! ,ull nur uil
    , , f ict , ar lt iacit lc si t liur lt ict : nlc< licaur t 't t t t ' sit t t lr r
    ,, i t,,,,' i t t , ', '\ ccst t
    2.',r'1.13.3.
    HIPOTONIA 1,1 ,,, ,:,,,t,:t ". , , t , '.nf
    ''' i l 'l ll r
    ( ulilit i. dc ciLt r - toLst
    i rrl l ' l
    ' et r iciau l: L r : ': l t r ailr it Liist ot t lot l
    rl l \ " l l l r'
    11ou-ltrs( L
    |rzi tabelul 2. L16. I r l,q,-rl'rrri t:tr r'lt't Lt'Lr nx{licalici natcrll(' asuPril ll-rtului 5i
    r .l r r . i ' '
    , r '. l , , r i , l , tl 'r l ' l l r r i l r ,:r r I'
    tti
    l " t t l t r r t t r tr l l , r l td i t:!'!r 1 ta tt, r i stt!i l a l 'tt!t'l f'tttl t't - l 'i l .tttt r sl t' tttl l t) ']'1
    .ttltli)tt, str r tl i i l r ' ( '\l x) r i m ( xl t.tl p i l n i n r a l L fi i l d i n su {i ci L r l l t' l ) ( r r l r r r i
    ] } i a l t r osli( iu l lr iln r to i i Ia n o u .[:' r s( lll 1,1i rr)i -r
    1)Lr])o\f
    i tz] ( 'sl ( , Il l l ) l ( /r 'l l r
    r r r r Lr r r l o r i c i l i L tt.a l tcL .sto t- i t.,\stl .tl , m r r r l i ca {i a p si h o tr o p a
    srrl)i.tI
    lli"r,tlrfr." ,,,,,,,, l',tl,tiii,,ti )ic\istir P[tioo clatcin litcrit.r'ii asuP]'it.ccstrri
    sirjr:rfii l r"rtl t : !t"' t]t ,, { l r' i rrtr ' r I' c l i ' rl l l i
    I tt1 1,: , ,t ..t 1 \f
    'lt P f' "l
    l ar I t"
    ,,,, , ..,' . i , 'ii i. i , : r L' r lllr " t , r r r 'ini, i, ', , ; ii', ': . it lr '- t : r r i'l' 'i 'l 'i
    n r a llo r ]lr itii lcr ir I i .ufol i ( . l,rl ,ri r Yit(' illi('stia ilnurnitor tlecLicrmt'ntc'
    ill ir ( ( lir 'r
    1,, ,,* ,,,' ,, t , , , i, 'lLlcr xr lulsi iut r t t t r r l r 'ot I i luat c' in considcla{ic
    s,liIlla,,
    ,r,,1 ,ri nrL ir r r lr r clcr l cf iit t r l lot ' ncllt vor abil ilsr l1) l- 11Plo( lust llt t i t lt 'r r l
    i otori c:r,
    llollr r r l r r r ' 1r.' 1,,l rrl 2. ll- \ .
    l()llr1
    I rrrrslr'r'rrlt fiLll s})lac{rntaf ill rncdi(lamentclor cs1ll llll l)l-o{cs
    j
    lr t ii( i it t r 'r 't r
    ,l ,i,]iu it t , l, t l'c un nur r it r t llt t t 'di: lact or i c: r r c t lcbr t ic
    , i,,i
    ,,t, . ' ,,i
    l , ,, , : i, , , 1 s1' clalr r cazii t or it : ii. at cil lclalit a uuol Dr ( ( li( llr r ( 'r ll(
    } r o r sr ir ii1:'ilc llpacitittclt rit' ionizatl
    l j |i l :illb :'oIrrIriIi(IrIt Ir accstora lrr ;i
    sla l ) l l i -i i t tt t : t <t t lr llr t lnt iut lt l:
    l l l l ) l l i i l I( r i L m o l cr :t a t- l 'L;
    l i rL S (:i (Ita .1 i i a l c t l t \ r r l ':r l l i r l i l r I'1 . ( "r l l i r l
    )i i r l )i i
    l gl l r r l t L l tl c Il l i ttl l r i l l 't' Pl a ce tl l a r i L ;
    ttt, litlrolistrttrl lrllrcllttt ill nlcdicilmont(:11)r'

    nornla]:l

    MEDICAMENTETOR
    2.12.2. ELIMTNAREA
    -l' : lr': lc l i n i c MATERN
    PRINLAPTELE
    lllecuomiogralie
    Iliopsie nluscrL <lltlt'],' tl i n Ii l ct r tl tt',
    l Lr 1rri vi tt f : r I scr r '{it i lllt llt t t ' : r nrt'rliciulcll t clll ,
    tnoti\'(':
    Il'lzin)c nn1s, ' r, t0l rl t lt t t t t : t .r'rItt t l t tI IrIt t t c clit l rLntirtoar-c1c
    tt 1 ,
    ,rirr Ioslocli
    ,, ,,.,r t ' , lin . r r r , liil, r r rit ir ', 1 f\(lrctia litctat i l1 ur]('l t1 1 1 :( l i ( ;l n l (
    rrz'r)* 1,, i ,l r'( tl ti l l ( l l l l tl l i l i lx' i l l l l tl l i i l f
    r ( {cl l t i ttl to 'l r tsc irt ttl 1 tl u 'tti i ti r . llll l tl l l r ''l
    r r r r r l l r ' tttr 'r l i cl tttl ,l l i (
    1) i) t rrr l i , rl , ' , l i rr i r ( ( 'sl l ) l l 1 ) r 'l i k r "r '<L 'l r 'l
    !_l l s l l l ( l i i l 1 l l l l l l l i l i ( i n tl i l i r l r ': L :,r 'tr '1 , l l i
    lt ( i l r ttl
    l l l t()l t t tI ' r I i r' It t t t r ' t t I '
    ' ! ( 1 , r ti ri i ri to sl rx.h ;n l l /i l , si. ( r ir ! 11 r r ${ :r r ii i' r ( lisr r ( Jlr r ,rrr.LrrtIfi 'r
    s i l sl tl ) r 'i l l ) l 1 l l l i l l l l l l l l l l l
    l ts ttptl t l l ()l l ' rri (( l l l l l l Ll i ' l l l rl l i l l l
    r f i r i i , rl i l ] 1 i '.tl ,1 (. , I 1,tr' 1i n tr l l i ' r l l |
    rr,,rr rr,r .i .rII rrItri l ,ol trl rr' :
    .t l rl
    l
    I rtt i ul (L & t i i ! !:Ltt, !tbtltll : i l )' t
    l i r r . , t e h u r cd ifr n r r r r r t"r
    fi r u r r sr :r n lr r 0 r r o xiee esul r.n r:.i rnhri:i rorr-,.i i (.rrrhr,

    il - u a{cc1.azi! 1ilt i
    G-6-P D dtl i c i t, di s Loc i r bi l i l 1l bi r' 11
    r ,j t,i h, \,t:,,i 'l j t r1 . i ; t li inl
    1ce:rt1rm cr a1i)r rirt:t
    di :pl l 2i . d{ i rtari t, c aLx fac ti i , 1ul l ru ri rf i

    . , - l- metal)ol;sn1ul hemoglobinci nu alcclt;lz:i {:rtul


    s i r l ici l a i u l
    _i_ cardiopatic,
    i- patiltoskizis, hjposl)rt cfect i;oi!tro,/ari-sat
    srrgerar-e
    -i--t-- dcprcsj c l cspj i al :(ri e, acl aptar(. (l i ti L s te!oz ,, dc c s ol ag i n l l ri n' .Lrl i rLIr' ' 1r !1
    (cxpcricrla artorilorl
    . 1 | i )ro a g u l i ttt!:

    condri oLl i sl tazi r, :(.1rud te!-atogcnic, 1nal{o].lnalii nlultit)1.


    \ ,,ri i ti i hl rl dnfi
    i l . f a r i rra optir:r (r.ar), l}emo]'asii r rl 1,,rri sti iaci (1ul uii (,l i r (l ' rrtrra- tcr'.ltogenic, disostozA craniatlil, Irrr' r'
    g[atic: allornalii al( urcchii, l. al():l' 1/]
    ' : D i | | o rn u l si tu I ri r, rl ('l ol fc:{atrtj
    mi . ri s c 709,.
    l r , : n )b a r.tj i t:rl
    r ,. i e"..l i .r,, . ri . :.r:
    . ri \t Itttl 1rt rdi ards c ul 4rti
    s rnU ul !1e.1A tj uLronj rl r.r sl cr..r,,,r I +i s e l oarc Iol os i i r l |atamdrttul 11l hi r' i|!r l I
    ..t ,' 1 . ,t...: paro)rislic€ letalc
    )1.dt. ,,. t,tr:r r.,t||rt.
    Lr". ,ri .n,. j .,, j j ..i .,l , | ," cleD.esic rcspiraton.r con?nlsLl/
    i ri ..i ,r ;rh ||,1l .rrrosrLez i r
    rn(rl nl i r(l or) ri sc de rnauorJl ati c t0,l hiiolorde {lo1osit !r tra'ratirr)
    'ti 't.t t tt r /, ,, ,t.r. ",,.,,, .,. L,i diimatrrritalc, l,rrdicit-die, LiPogliucrrr rr'
    -1r,11 -. 1r,. . I l i of ,.i ,...: ,'tri deprcsie respiratorie
    'r trombocitopenic
    esol R s !i ti rhl ](l ; !-i sc i i o.,; ,.11,,. (i rzi rl i c t
    :t r t t hi st tt,1 ; t I ;i.,
    dismaturitati:, dislr1olfism lari:rl, ( rr"l' '
    n ti!: rjt.ti.€
    nr aJcctc-rr'r Ii'ltdl (tc{icit mintal, ris.r 70'li,
    latie,

    rru al c!t( xzi .l i ttt uasculitriTar€ litull1i {elni I'i rr; lr' l)rrr I I
    lt/
    i i e de c l i tori s , { nz j rnc l abi o-s rr' ' l r' l i
    &nl ildjaii.! ).-
    mas c ul i l Li z arc aJ :rtuhri Iefiri rri rr,rrr(trrrrl ' l
    !,
    ^r!rinoiihn irilal-\iliiat.., 7it1.rir,f..s, talti(. .rt;(. $i adc [oc arc i nom /agi i ri rl ;]:t s c r* rrl !
    h4)i ,rgl i cemi . rfati ri tori c oulin stenoTir urttl:1li ;i lti(lfoc(rl
    i 6 _i S or, ( 1 (tl ebral , 11]t' tl
    I ' ,L r. 1)r()gi i s tc rol l ,,\' A C ' II1,-s rndrol r"
    C & rdi .1.. 11uhr.dL, Tv l ' hageal I\tt\l
    .I-trnrr, hDerLilirul,jrl.ini{ 11 rx)u-!riitL I'r
    i n { oarte rare oaz uri : di s nrtrl uri t:Lt.
    .t|rl '1 I l i .' pal atos k i z i s , ntur' i 7i r-(: I\rl ti r()]rrrr,l
    , . i ,., .r .,tc(,.r...
    l.nal :i ' -', fc i al i r i ndrni l l i s l rat i nrLi rri c (l ' : rr:rl l rr"

    l ,;t\i l ,r; r ' ' ri r' 1 ' hi l " \i " l ' r' ' l
    ( l , r r ) .h i i r
    ador-t, i uri 'l i tai c, chor.i ori ti rri ri l l i prl bi Li f{ l ,i c ni r (' i Ll )
    ( i r ; r i r!r
    i- 1, + a"ort' tro )bopclric, atrczic dc .soIl! , lrl . p('.rsist(i 11 f :trralulrti rL.ttrixi
    droce{.Ll j e,rctar.dmj ntat, aD or xtj i ot fl ,
    rc, car.di ai r,,f{i l ral c $i al c nr(l l rl '|(l . I
    l r t t l t!U tttttl .tr:. pos i l )11 ox fdi oP l |ti f
    11r af.:cicazri {itnl 1]os i l )i tl \i rh1Os k i z rr.
    date con|oTcrsatf Li l r 'r i ,l ,,l i ral l orri ral .i i r!' rrrtrrrl rrr' (rLl l )fi rrrrtl rrL
    r1r afcctcazii, {r'i1rt

    n nJ,\i i (.l zar Ji ttl tt ttt ,,t I i tr tl l ) L s i nt 0orl fti (l i c al r' Lrr l i rrl pul s i rr(rr' rl
    I t i l ) i t,|i .t fi rl ti )j :l .1 t,( f;.r di s n l uri l 1rtc , P i l t{ (ri Ln Irt:r(v ri l ,, rr,z _
    A ' r t , i , i l i ri r l i 1)i rc (l c l )l i l c t n (r' l
    li/.1 1, f|l (rri i {: l i r ti i l , tl
    1ri .lrrl
    r l | ,)l ,1i r| ri /, I l rrj rl r.ILl , r\rrrl l (' rrr.rl Lr(ri l v r'
    [ ] , . 1 1 , i l r I rl l r r, i rt' t t|l /i -i Ji rl 'i l
    Lr \ ,l ', 1, I, l rrt . l r)r' l t rrrL )! i ' r" l '
    |' 1i i r , r Lr l r it l rl l rrl )

    4 .t! 41il
    i , ,t I r r j r t, I tt t/t :. 7 ), r:!t! ).1l \

    'labcl llr .liinirur:r ||r{ lrnnltrk ot. l;rir la}ttrb nr:rl€tl

    ', r'r i r r . . ' r 1 | r o s f c f i r . ; r i r cccn fn ir | ij.


    fi i ;r , r .s , nf.i ,1, j r i n!ti nr ,!r L
    \,,11. (rtr)ti1atc.r
    ( l(, , r l i l . r i l ( c o l o r d x t a tin l.r r r :r r )
    cakl-col ai1:d bdb! synd.rar.|r o(l m i ni st ra i:." an' :ri s ugl ||
    lh||l?\i
    nl, )ro \ i , 1 ( l o r a r t r o n ( la tar.r, alcctar(, ocular:r etc.)
    fu r r i,io r i)
    '1.r .\ I, 1 Ll i h, r ar . , ur ol ^r j , - ,1, tr _l

    )\I i t.kt 1.Lt


    kt s.,1
    n dr on. (tisnr:rturitrl Ll
    r0xrcilrro c ptlrrb ril l pgilnl
    t:r ou r:l
    (tx,stl ilicciar) a 6-;{) rng p i,25 g/ 100 nn erullie
    ta,.arizii, rLcio,ii;;i il !rri 1, a nB (urnr:')
    rfanr c r tc , r l r i r r o.c l ati e, dec c s I er r r t,
    s , rr/ ' r l l r i ! r . g : r l r i i j i
    7.: rs/i,l
    r)( r, l t c o t o n i i )
    1 1 ri ftn ..r jl! r , tr . ir .A1t) c 7i ( ]dr s ar r l i 95oi riorlc. ser
    lq
    .1.5nrS p. o. ; nrg/100
    ri r nl l ol r ''i L!i j
    l ,I g 1000,,:conccnrraJie
    c ( nr g.:Ii 1atc , nc t.f.r pi l ti e
    l) lr c r l l .fr ( 1c s a]'c , .tc J c c 1.
    dc t,,h n,, lS 0 .- i 4 - 2 ,8 { u g /n 1
    ti ln P| r i ,al f( ) ni c , s tc ni ) z i r i . aor t:l
    l{ 0.26.i pglrn
    r ctcr, hcnr.ti ri r (a(i rni l i si rnt i n i ra. \01) i i ' g i . /.
    \l',l 50(, rug 0 .1 r r r s/1 0 0 n
    rr'' , ' ..r 1 .. ,' .,
    ' .t.' ' ,. I.J,tr r _t, I nr^t?.,:.r i r.r,,.i ,.... ,..,,r nr.l , l l 0(l r 290 ns/inl {50',.i,)
    l l: i, ii : l l ''.; ]? ',rri n 'r'' ',i ,,,' i ,i ,' r ,,, ,^" , r,
    :0 nrg 20 -90 i"tgrrtr1 l c t a rg i (l
    1).25 l l ri _r,' z i 0 ,4 1 - 0 .7 3 0 .6 1 - 0 .9 6 n g l zi
    t Iift:rit clo Li. ns^llt
    ,]]1,,]11:1" ,sL:.dir I.Lctati,.rnrrtc:rnilcolostr_rr,
    laptc socr(,tar ilcttv,
    tl'tii riii'r' ,iii".ii,f i"llil,i'li"liiil
    lr') ptl, c.rn1.iilr1t'.r
    ;iil'l:::11,,#l'i,ll;,:;?lt'.'ll":^:1:J:"'^
    lll('(
    frrII
    sr c l- c t : Ll( ,
    rlc rrroir.jne <i
    1, 1 ac , Ls li c . , J e:
    tj.,,i,l" .li{;_:r,1 _": .
    ,_^^-,i;t ,. {,62 pglrn 4.6t) iasirnl
    0 ,6 - 1 .3 p g l 'r ' 3 ,6 - 6 ,2 p g l m l
    - lri'rc\-cnt datcrc dr-'rito-aturi sc baicaziL
    rlr,'(lrcrurcnt carc au fosrt rlc-sr:risc pc lracfiiic atir.crsc :rle mrn|
    nrmai i,.,tr-uri I e i . ri t, 30 1009{,scr
    (trrlrr:lul 2.11g). ru se fx.fcli Prm
    "ir.,g.,,i:-,:,ri l api c s nb
    2,12,3.FOLOSIREA
    MEDICAMENTETOR
    tA NOU.NASCt,IT
    1-l O nrq :.r. 2 rtrgl l 0{ )

    l (X ) i r- ri 1 ,fi .1 .9 p .g .l 1,1 :,.{ trs i ,r1l


    (].(15r]girri
    ,,.... - - 1. , ] . , " . . : pi" r l c o u a ta i i n u s c l o l ,s rs c i rL rn ,,,l curcrrtrrr.ti tl l ul t< i cl 0_-12n.rr"
    1it(ranl()lto. In aclmilistr-arca ar l .S i 1 0 ? - \i 5): 1() l rl l

    Il;r l1i.{Ji,ll':;1.r",
    ;lfuXgjilljT:j#i;i*:,:i tl,l"'ri,,ii.j
    f;;X; 11I S -i r aer{ r' 1i li
    c rc nl c aol $rrul ,1.

    crrtrrr
    , lr i
    +*+*:tirtril#r*S-lt"l.:;l"
    ii,''i!1{*rliilt:|liffi
    t r . r m , , , , c i. .i ra
    frrma t.' ' .
    i tr l a uoLl tl ,rs-
    Ir{ 10(X r{ )rr.
    l a|1e 0.13 u/ 11
    { l { ),j ; s c r)
    rrrr s -arr c c r!_r1i t1

    (; (, l )l ) (l ( i r( I

    llllll,
    ,:lr xitT:::1,x1i'"lt",i;3$*'.,.1'
    i;l:i:!i'iliiiJTil:li{: ;:,it:,,1:ilii
    ,10 r rs i 0 p.s j nrl { .-(l ' l l ,

    il:"ll,,,,fii:l"]_;5,iiJ;i ;,;;.;;Ill;$:;;l'-,'",-'i;;
    !"r*li,J,*ilii';111
    .l O. l i { l { ) n' -! .l()() 1l gi rrrl l rrl l , l rf i ' r i
    , l i ! i . s l i / (,

    L'outrlt iaptul.'''
    ;l
    "' :,ijill*iiilir-,,*rtiil
    "i,,,,1,,'li,,,liiii,i']'l;i..;rlt.I'itf"i j ""un'ii''"rciliu'i.linsrli-
    r:l,r;*rir*liriii*,i,iilIiiirl;il;, lq
    0..5 {
    ' i. { "', s, f
    l ; (r | ' i ) i ' 1 , 1

    ilill,,l,l' '
    L,,'lilii,llii,i;il,,llll''l:i lljll;,ji i;:;;,;;-i:rii
    iilii ; i,ij,,;jfi
    ill;'ilijll l l )l ) rl rj l ,l 4 1 ,r /r r l 0 .1'l i , l { } { i r!/r r l
    ir \i ir l(

    r,|1
    lt)
    '.ttt',tti, 2. I )tl
    ( el rl i fl l ar! tabl t 2,1
    'l'nhu'i ctr rl|cdleamcntc lolasite lir norbriils('ul

    | (, 1)rc i c l i 1 l 2 glt:l 0,65 : trg/rni 0,{3 ? pg/1nl l'Liz,,i zi olscr''tt1ii


    rnodi Ji catfi
    I
    ' l dnc to p f i jlo
    Iare ( --{ 5.'
    ' l riiod o t i l o r r i n a
    r n lizi l,Spglml
    72,4-236,i itgl l0A
    nemen1i0fl1l l-
    'fhcophylnr 60 0 1 r ;g izi 7i% se. 1,6-26.7 ngh iritabilitat t
    l0 mg -i nigiks/zi S l aE ore
    \ ii. D 5{} 000 n./zi 15-35 mgiks
    2i Hidroxf I glls/zi se v.! rf,,iil[ irr ']rf,
    l l l rrrrttrr.r l l r r i i . /,

    f l l r{ 0,01 ll]s^/Lg p o .r tcr l o tn l l i o r l r 'l i ,'


    Itr,,t,rl i 1
    bip|.rtcnsin'rc
    'Iabctut 2,
    l ' ',,l , r,,l l , s,trl i u i '/ iu crl
    t),r!in2 perf!zie
    l'rl,lirt axitiililc tarDiEoliinstlc$ l{ nor-riiiclt 3 n tq/ks pcste 15
    llIalKSXo,3
    5 n)l/kg/zi h i D o cr( r r r i ( ;
    subcLrtetrat, intfamlrsculor, instabilital€ vasoruotorie 1 * 2 r r L l /ksl | \',
    lllriltl"r (l(, 'r {
    ltrlrr'

    -1
    z re c ()f(1(:l ()i l r. l rt
    orali 24 or{ r; l I Li lrrl )|l I
    c l i gi tal i z l ' i i s (, v ,r
    - Dotilitate irtestixali scAzuta
    - aciditate gastdce sriLzutA adrni ri s trl rurrrl ri
    - dez?oltarc cnzimatii,ir i testinal.i irtirzjat6. i n pc rl rrz i c
    .l () ll{-nt/kg i n poc ul c Ltv tts ,u ,rtt-
    Il ' \l l ,,,!
    1)isttibuti. - roluluul rclativ al orgatletot, corli ntui in gI.,silni;i {luxrt sa gui0 striclic pt:ril, r'i, ri
    - pasajul hemato-cerehral 5- l0 tDl/l{g l n Ii p(i /(nrr' ri 1
    I - 4odilicar€a conlihrrului ill ap;. al diler.iletor co rartimenre
    I i '/. (r)rl r111i i

    __l - albumirrcle serice scezute


    scazula
    t[,',1]r, 1i ,,rl i . r' r.
    5*r0 irg/kg/1nn1t
    0,5- 1 mg/irg zi
    !c rftr,ri .

    ,\t(tabtl isnt
    I s c v a ev j l o j rr l l i l r' f
    Ielaiiv cxescdt l l t,r,,1"r,, scdalc: 0, t-0,8
    !ns/kg/zi bi l i rLrl ri rrrr ri r'
    I't1,tilit - fat: (lc {iitt?fe tlonrerulalit" sclzuti {xm vu l si i :0 ,2 - 2
    I Ir r .. t' 1 "1 ,"1 "r 1 ' .,,,,' ,u 1rg/hs
    i .rN , i ,' ./. n.n. la ternctr li Pf(-
    ma.tur dozi dL' atac l i l r l )ri rrr. rl i fi L
    \'(.'r foiosi nrmai in ceutrc <le neo?ratolog-ie
    sub control farmacologic ( 0,03 giLg/zi :-i r s i rl ri i rrri rl i
    lx Lul 2.120). Doza de intrelirl€re
    0,005 ng/kg/zi
    2 di n $hJ )l i i rrrtrrrr' 1 rI
    $i prematur
    NEONAIATA$t pERtNATAtA
    2.t3. MORTALIIATEA
    0,04 mg/lrg/zi
    I[trclilx)lc
    0,01 i{/lrg/zi
    l l r l , l ', r l . r /rr, r r-9 gilii/zi 2* 4
    lllrr r r,1y,rr i v, .50 nrg/l<g roPctat ]a
    fc ro I rl (' l o rl l l l l l rt

    l1)1gllg I ir. :i-ll or'c lilol ofii I l r| . t n l l L l l (: l


    fttr,rn,,trtr,l
    -3 r i/t*
    .1. 1n a_. 13 ore
    P.') .
    I ll rr' Br,rr :i0- 100 us/l{s l! 6* l2
    iltrllrtrrrrtll,'rr" i .,, i ,n r , I nrg/kg
    It$rlr[r lrlll l |'l [. ]5 tl r t/kg
    Ii r 1 r r ) l r cr l
    i D l |1 fl i l r ( .r \'r

    440 4{7
    (o.nl r!d tt ( l ttl ul rti 2. r ) 0)
    (t tur, l rt, ) Il r)
    ',rti i t

    0,:i mgikg pedurie


    0,1 m8/or.i contiau6,
    s:r ) tatLr iiii i r r r !it3' 7i
    lJ l{ r fm er t i11a 2- r t :iill'
    r i' ,' r i,,:r Ji r g ikg i 7 ,
    1 ) icfl1 u 1 n rir r I' a sa l) 0,05-0,15 ms/tg/zi
    r:rrirr-r 2 rll8ikgi z1 p.o . 0,5-2 g/tglzi
    tr e m :r tl1 ffu ^ 2 :r sa L l! i.Y., ? ,o . 5-50 mglkg/zi
    ti,,1 i1 ,ir i l' r sllis/? r 10-20 ml/t g se poate re
    d o r i d o ita c 1 5 r li t)crtrLr slabillr-l rl
    pet.!
    ll) ,'i r i' r 11. h g r zi iu t( !1 n .ff dozel rfiiosar.c s(] \ l 5 - 10 mlik6
    l!, 1tir,ld
    rtoz:r. ri rcl rrl sctt, , "r1r!tr
    ftsofblia orali! 1 .1' 10-20 mr/kg
    I r, t,r,l |rl ):n:1
    rcoutrol al )i l :r l, ",,

    l
    ,l I i , l i rzi ,l ( lntB,li:lzr

    in i!ir i1 511rrkr : iii c-


    II ',t tr 1ut' (:t))lutLitLc
    't 'l
    /"'t')il,'
    olx Pelilltll&l nlorlali4! (urtl Morbidity '
    FIGO ' tuurcll 79- Zl '
    '
    cind copilul respirir srLrr
    .l0il-"100 r ikS
    t ; i, r. n . rl, ill ,,u,ri,l".:, tou-nlscut fi" la nasterc atunci
    ;;;;;,!t;
    I r,', ,,,,t,i itlt(: semneevidente "r''i'ilt;;; ll':,::tuiace'-pulsiL{:ii
    ale musculaturii.voluntare'
    Pc fr r l z l r ',
    { 1 .r - i i,i, , ',,,f,,'r,rtuionbilical sau cortractii
    ''iiii
    ',,' ,:ttrsitit:riLnou-nisctlt
    -it""'; cind copilul nu prezintl sen]rrc
    0 .2 r u g lli3 iti'[':l" i I[1 nrai rnul L rl '
    ''' "'l',,i : d'/1
    1xlu'
    il| i1 ir l 1 { l n r r kS- t;:i;;itd!ii fctotetardiot.) illr'tnd'yut
    ,,',:',,,1"',;'|,f,linn:uf;l:
    ( 1 .I L l.l n r :il( g r "tr n ,,, ii"'i ,t,:,':i,i,')it"iiiirii'i'Iiii"t'ia'"''uresltirdeinuprczitttiutrsttrrtt
    i . r . i i 2 { l m i-
    2 0 ( ], "1 0 t) r { 1 kl la 6.S sau
    ' ""';1,!,!,,"",i,,,'Ji:';;;^llrf::t,4!,,,,y,,,",,,,,":ij
    ' ,',
    i . rn . . i. r . t) .i12 L) ( 11 r ' LL
    '" deceswt. ,o,-,ai"ui'i'iu''t'u1"i
    "'/;:,;,';,1,i:l'*f,loll"li.ni:;'"1-*0,i,:
    Din',,ui.
    rl' :i ittttitrl'r'dr:28zilc t"'"itii'a'
    al' slat'is'
    prtttctttttle aerlcra
    'iiii'
    { ) ,5 - I r i: iki
    ttt,,litt L:, 'frt"ioacla tt'eona,tald.: 26 zik, ,
    I', 1 rli ri
    I r lLA,lil
    ( 1.5 - 1 i' !
    t,,'t
    ,ti u!:i,i::;'iit",,!i!;ti:,::;;a?Vi;l::,;,A:;1U
    'J6o,i!0,,,,;ii; ,.-....x^,,,1 ,t"
    ^^.A;,i
    a,.ti:t!:,11t.1

    i .Y . t,.r l r Lzii l:1iX li,i \ lJ,l sc (l i |1c.t7:r l i r\ rrr.


    LI t \ \ I
    S irl 'fflAll rr 1tt,r''' trli trtr,t[i ! n,iscttlt ui'i)'.
    I Slrrc.r7ii .j0 ll" itt,)tt,tL,i!.&t|t! sc cotttpune *9'!i
    fcrxnat&L,I .rl!r.t {:::.lt-,:f-i:W,tt^, ,l},ri,i,!,
    tenrl '11 a tN l )1(rrrrt tr 1:7,*tait'atc.retat'd-t:arttiati)
    ,,"',,',,',,',1,*,'lll;l!',/iiii';':i:;";,;;i,",f-;;'toii'i nlltcr('n
    produoerea Inl rr sdftdn'Linocr Ttrrnerlzd'
    ,),, 'trirl,rl.i,'rrr-ltiisattiloraii cc sufuiit itt
    r rt'ttnt'al'alci
    f"'iif!;rrr.
    \l ir,l ili ' .r txc l. i r r s lis i "r"tt'rliLtl'r:Lt i' mod destul cre adecvat calit'i.rt
    l tr cii:,( .. 2 r r lg lkg l :t 1l ,n.
    , ll::: l]lllil; l,.l,il'iii,*,'u", int'a'ata-1e, eicalit^t.ir
    pruco"";
    postratalc
    l f Iikl,,1,r r i rr S rtl i r-
    ruu|l ri i l r
    'rl (1
    l rr ; i ''i,;' :,lr;';;; ,tccoriimorlii,t'lri'ln'lr"
    p r in ' jlt: r(i tl r (i 'l l r 1i vri rl 'r
    ri ()11-rarscrrl ul uLl tl
    ,:,',',i,,,ii;,1",),i,,,!;,I*iiili;*
    tx,fl ,1zi . I nrl
    ,16
    sr,l r! i c tl arc|l l ( rrrl |l
    r.Lyv|yylrc
    1"?j.1!:*!i 2e;:iLr
    ' ",,,'',;,,.:,';,:,'(,1!,1,1,,1,1,1f,1'iifJl,i!',,i,li;re.:
    tt:tLr
    l .L -t0 url p{:fL!/!t', i,i ,t'iitttirl)inul'rt'i.." ('':i!l1l^1r!:0:!:::i:1;l'':.;,nczi,,ti,.
    t' , ,ii,i1"t,ii),
    /ili1i,1.,,'iililli;:,l1i1iil11:;;j:"';;;,;itlit*
    ,,"o,,'"tol'u trtrti
    t,t,\i
    rcp'i:zirrtir
    rr(LLtri ri sl ri |tc i !, 'l l l
    i''i
    ii, )ji 1,'r,i .i7't1 ,li'' nrortrttit'"::lt|lr.li]..:)ll',,,.-,,0 (ri,r
    iIili;r 1 I lltr r l!ir ; ir i l tt '
    ii,,i1,l,ll;il::i'r;ll'ii',::;',,i,,r;;i,,";ii;'' (tl3-tl4 (ri'rr'oLtit-
    trc:t.it:iu ,,,oL.rir-
    lil, , , , . l r i rrl ;rrrl i lii) .
    'll, l

    I ll;
    l\ , lor l_ir lit lt l r;rl rrrl l rl rrl l i r.,i l r..n )i rrc
    rLr notr-rri rsr:ttt p c n trl l ci h vi r.sta
    ilflil"i:lli1,;,'J";ill i"'1p;ta;i(:
    "'|;'|,i i""aui.r.i' I'e clc altiL parte, naltcrca ;i modul dc irrgrijirc, al rrou-uiscutului ln
    iir,r,rntci,ill";l;i,,i'l;,,
    j,,iill;],i1'#Iiil,
    "p".rii",*pi.,,ii,, *'Liff $;i,i#*.*;.li ',',,r(rnii.;rtilcrnod",nn,
    ,r,. 1x,t ciutcrntirtatuIburdri dc
    prin impiodicrrea
    trtlsament
    "ontactuliri
    irltre
    intrc mami-5i copilul
    acegtia cu conseclnlcneti-
    . . . Irocloli carc due }r tr
    i"ti:'i':;iiu\:{; il:y:;:,'*?':i1fil1il':'if"i',1;.*'/;l;,,
    acestuia din urmi.
    ',m' *;i; ' "r,'l,il" :rsupra
    I'erioarla neonatall. Este recomandabil ca neonatologul cate va avca
    i,,,l.iiii"-"o"-"ai."iJie in contact cu viitorii pirinli lnainte.de. nats--
    ',,: , ',tl.ri "i"l
    cu atlt mai important daci este^vorba de o primiparh
    , t".i.
    "o.."st".,,n
    ,,,.,,i,!ii{{,'ini:i^"|':':::#:",':::#:i!:,"i:'{:{,':,,:,:':::i'i,,i "tt"
    rrr rL: o sarcini cu risc crescut cum-ar fi: sarcinl oblinut[ duptr tratament
    N elegitbnitatea. ru rrlrLr sterilitate, insucceseanterioare ln ducerea unei sarcini 1a termen'
    i, i,,li"t *t.tto"ri a unui copil cu patologic perinatald i ncompatibilitatc
    , neLrorite
    scadenumi.rulna;terilorcu ,'' trt,, ai"l"i rnatern clc. ln acestcimprejuriri, medicul va pregiti mam;t
    ". r'liqj;::ftf K:?:rk:r:{{#,*:, ti rrtrr cvenlualcle prohlemecare s-ar putt'a ivi.imcdiat
    dupiL naqterc,su-
    cf;.ffi
    .^",:{::f":j!,i{#ir:!xi:,::11,":aqi*"j"}*Tif
    ru,monar, ilrrriirr,lrspcctuI po2itiv gi optimist al acestora(accsta-
    ,r , t .i"i'p.oUt"i,." deoitecd nu numir foarte mare de
    este urr mod rcllrst
    nou-nisc.u{i, rezul-

    ::ii*'."i:11x"'"fi
    ,,,"i:ry:.1*!J":1H",'J:i1"':?'ffi fJlik""u,-". r'1i ,liu saiini cu risc sau nasteri complicate,sint perfect.normali)'I se vrt
    .,'lilrLrnamei cl, in situalia sa, are cele mai mu.lte.gans-e de a avea un coplt
    1r'rfr:r:tsinltos dar existi posibilitatea ca acesta si aibi o perio,adi tetnlxr
    air;ti factori nttlf ilt,i, moylalilalea
    .,.- ,?il,,r" letinotalri estetrcs,uldntui l,'r.r ,lLradaotarc la viata ixtrauterin5 ln care va avea nevoie de unclc in'
    if i;,,1:^T:'ii!,1';fy{1r,};t,,!,!tt?;;ll,/}}:iliilii::_i:i:i:ri,;,: ,
    'rirri
    sncciaie:c:i se voi facc toate exploririle necesareln vedereaunui tra-
    i.',i,,,nt'coresputzrLor', ce in nromeniul na;terii va fi asistatl.9i dc cJll'r
    ',:,"i,:,ii;,r:ii,*,;;,!;,f:{:i;,::;;xiil:;,1;:,::;"r,,;';;;,:itur,
    ieprirenii
    I ,rrrludiatru calificet.De asemcnca, se va-anticipa.incazul unel naStcrltlllr
    .,,r,lva rezulta un copil prematur, ci ln vedereaunei supravegherimai atento'
    ,,,,ilrr va fi plasat iirtljun incubator in seclia de terapie intensivi 9i even-

    il1ff
    lf;iltil,l"ffi
    t+{.{$t#fi
    il$ii{i:iJ,,r,'{-"t#i'li
    nn,,,oia,*i.-i",,T;;#;;iri3",14.t"&.*",rf
    i,1".ai*"#:Tl*:lltl*i
    il,rl va fi aliinentat parenteral printr-un tyb-9ge se va.introduce pe uu vtrs
    l,,in care copilul a f<jst hrlnit in timpu,l vielii
    ln cventualitatea in cale mama sc I'a
    intrauterine etc'
    interesa despre gansa de a a'vct
    Dirij alea twturor sarcinijo ,rrr r:uDil norntal, neonatoloqul va sublinia faptul c[, in cea mai mare part(l
    'n,"1n"
    *",r"rz:i::{y'*u;r;;#:';'"";;':;,;i::"Jif':i1lx'"",.:,,.i,i:"1f, ,1,', cizuri. evolutia ulteriiarl a nou-nlscutului va fi bun[' Este neccsltr
    ,.r lxxliatrul si se intereseze<le nivelul intelectua-1al mamei 9i despre cvt tr-
    trr,ri,lc irrformalii pe care aceasta 1e deline 1t] Iegfturl cu eventuale-tecom-
    * nf":;: K:{ g& :f ,,:. r' eri f rin o! era!i e cezttvi and in ! rezentalia nasterei in eventualitatealn care va fi chestional:
    ^K,\y ''',1r,.rliice se not'ivi la
    ^ tte ,1,r,, accstori, r'a sublinia faptul ci aceste probleme survin foarte rar fi
    ,,t^r^",!]:f i!:i;n'# K{ri,3:kipamertt rcsttscitare n'eonatatii,
    tt't io,e' , , irn,xliat clupl nagtere nou-n'f,scutu] va fi siupravegheat,ln acest scns ;i
    I ralemffilul Lr r r,lc rnai miii semne se va aplica tratamentul coresPunzator'
    rtntttcavapti@uuf;rl,:;;:,,!i,,";r'"*xm#i:*,.t
    ,.... , .me-mbronei'hialine
    t'rin.aentila{ie asislati, aceastaboal/r
    I'orioada na5terii. Cu cit anxietatea m aei va fi mai mic[ ln timptrl
    , , t, r ii, cu atlt legitura ulterioar;icu copilul sdu sc va face mai u5or'
    Nou-nlscutul va fi prezentat mamei du-pi nattere in momentul lrr
    , . |, ill:castasi-a recuperat-fortele si in care ea doreste acest ltcru' Tot acnnr
    2.14.ASPECTE
    PSIHOI.OG.ICE
    PRIVINDRELATIA ,.r vrr [i vizilati. de iitre meclicul'neonatolog9i va fi asiguratl cf, nou-tl]is-
    pARrr{rr
    iruiEnr6n6n^ copilul pe patul mamei ln ala fcl
    ilg,[ir1r?,.rr
    , rrlrrl cstc norrnal gi sd.n6tos.Se va .a;eza-
    r r,i{ r|(:c;Isliasir-l poatfl examina 9i prptl.
    Nou-nitscutul prematur ;i eel eu prohlerne la naStere.In ace-steltnpt'c'
    prr,Lri,ln cvr:ntualititea in care rnedicul neonatolognu a venit ln contilct
    ffiil'";,,:1f.;il,..*x
    ,y,$]ii;i1| jfi5"::ij
    trft,11ffi:i ;nit"ffi,
    ;l
    .r, malformat, ..u parotogi"'-;i"*i"'ir'
    r.u-r),i:c*L prcrna-t
    , ,r l,rilinlii luaintc <lenagtcrc,cste bine ca primele informalii despreevoluliiL
    r,,l,,v,rlrriilir.ir copiluJ.uisir fie date de citre medicul obstetrician, sau clt
    ci'd accstir .",
    implicarea
    psihoiogicl"iinpr'1io,-,iorio'. rrr'.,lrrsir.irsolcasliL pccliatrul. Estc de pI:eferatca tn acestecondilii siu srr
    iil;il]":ii'i'liltil,igterc' v. ,,voiias- \'i,rI'r'ir"i(;ii
    cottcurtnitt:ntcu ambii piLrinli, cit mai curlnd posil.rildupir na;l't:Lc;
    vtr {i lll'czcnt lLstr:rt:tlo-
    l, lr1,:rrirliiltLi, tttr itlt tnt:tnltrttrq;rtlpiatal I;rr.nilitli
    4lto
    '$|
    cort'orLrresiLait..,ilor i' r.,rl,irrr:tut uneori cle 1111oalli(rrlJ(:
    ii;ll;ll":t";iiJ]'casiiL mcdicutuicarr:tn. l1' r,l rl,r- Acoilstir. ntlrioarli dc adaplare sc insoltqte

    . tn coldiliilc in care r,',1 ,l, srrtisfactie'legatide deprindereaat'ilififii de ingrijirc a copilultti

    jrxigffi
    :vori,fi;,,, ;*i""*{'fl qiqffi *:!:lm.l,";''.v;*'J,:'"#:l
    ,1,'l l

    I'r ,rrr,lr
    ir ;r<r';rslr-rncrioadl de crizi medicul se va iltilni cit mai des cu atrrltii
    r,i s,' vor lurta disculii desprecopit cit-;i. despresimlimintele mitnrci
    ou-,is.;;;i;;.,;',ijl TS,ff
    f flji[*:; ji TTi]
    ,t',lrii, rrtit f:i!i de nou-iriscut-,cit ;i unul fala de.altul' Neonatologul
    ll.t ' r, .'l,ru:L ttntai si se sustragi" lntrebilritor siciitoare ;i
    ilirr lucru este in ddtrimentul linigtirii
    iepetate ale pr"uitr-
    acestol-a; aceastircategorirr

    [tli#".*$ia*ii:lllll*::lilsnr#1niri;il=li lrl,, irccst


    ,t, ,y,',{iriitori fiind cle fapt, cel mai u;ot ileterminatiLsi' sitrrllia-

    j:i;,,,p1+;lj,#1,"..,;,,:*:";
    ,'irfilr*i*,i:ggi:lii1;
    I r.,rir mallormatia nri este
    ,
    r,. ".'. it l-i nou-niscuful, clt mai
    gravl
    repede
    este de
    posibil'
    pre{erat -accepte
    s5'

    ,\rtrrrtlicind este neccsari translerareanou-niscutulut inLr-un sclvlelll


    r:rtrlrnirm rttll

    rH:i:':"*.1:;*..
    ".*,,
    ##.1.,i,i,ij1*1i-*ii;":?'rl'i
    ,1, ' lrrrrrrSic,ln scopul cercetlrii imediate a-malformaliei
    -(stenozr
    ,1" , iofag), tsri recomandabilsi permitem mam'i sir'5i vrr'l;'Lc'.'fil'tl'
    crtr3' ni-

    t ',1,'1,';xif
    r
    't
    , | ' r.'ttritt,,zc I
    si si realizezestarea gencralSIelrriv l''utri ar't(lrlr'r- lrl

    ',ni
    :,:,;i.ji"ffi ifrtgi#;
    #"ili;*"lx,fi.iTi#tl:".?;?f ,, t, rrrrrrrciuJrrri.
    '' ".'|'.1u,'r,il acesluia
    cste bine si solicitim tatll
    si siJ insoleasca ja
    nou-nSscutului
    sectia Jc chirurgic'
    nou-iSscutul prezinti una sau maj multe rnalhrrrrr:rfii
    sii l)a.tiir'i1tr:

    Jlijf;irrrjl_*i{td.t
    :lt":,** '#jij""i#J"tJJ:
    "*:i",f :::,,,"Jit
    'rriru.i.toa
    ',.' , rrilirl(jcuretlcsi nu-i pun viafa in
    ,,, l',,rr,li,rrrimporiant atit pentiu
    pericoliruediat,r-or con<tjtrriul{r'ri'rt
    el;lt Si pentru farnilia sa, situatilr cstr
    ,litir:il',1,, rizolvat. Acest lucru se lntimpJi in cazul unui nou-nirr'r:ttl

    #i";n#Hfl:i3;}j
    r,,',

    n,j.'r***m;+*.,i***r,,'*ii1ffi ,',' r, ,'lr,itl.li,:rrtja oirjnfilor poale Ii dilcriti: unii ar.ind o pirclc prcr'ort-
    . 1rrt.'rl,:lrrt ricasi; ri,icliuie, rcluzi si vadl copiJr4sau si-l ia rte'rsi:

    ji*#i*itui#;'iifl
    3;g*ti1l;dg$i:}A{liil*.h#ffitH
    .,ri', ,',,,",i,i cu usurinti malfor:ra1ia intereslndu-sede posibilitilile utrt:i
    "' trrrrtir'r'rrliz:iri rrli"riorrn.Rostul neonatolosului
    l'r' rl',ri ri i:r tllcizia ccr lnai lavorabili pcntm ei
    esie de a-i rjuta Pc -Lllirr
    subliniindtotudrlri l:t1rl ttl

    ;rrur::ri*;r*i,li.*r.}.tl; ffi trd:$##::jfqT:ffi ' ' 'rrrii,lilrttc ucc;ti copii pot fi partial ;colariza{i.
    tl*rirrrrtnc.inaral"ln'cvcntualitatca naglcrii unui copil mott s
    ' ' rrl irr tl.rrt:icc,".ul survinedupi na5tere, ambii pnrin!i prczinti tttr
    rr i'r
    "'trr
    r,1r', rll nodificiri psihice care se lncadreaziLin rcaclia de dolitt Actrir:;ir'

    idlt*
    ;f1,,ffidiili
    :i[ilr*;i ,ffilf
    *jri*+,f
    i, ,, rl,i ,,ir,,.. lo
    ',
    intensitate indiferent de .rmltorii factori: tlacir'rt'tt-
    , , irlrrl';Llrlit numai clteva ore sau 2 slptimini: deci"nou-niscutul a :rvtrl
    ' ,,i.,i;:,,i"
    "c"i".i
    lbos sau 4000g; claci a Io1t un copil <lorit,sau nu sau rl:ttii
    r,,,',,.' vrnit in iontact {izii-cu el saunu Reacfia.' ste-similariucu ccil lrr
    ,,
    .rlr'rl.rrtr rrrzul dcccsulujunui copiJmarc sau 'i unui edult aprof'lal'
    l)rrrri o Dr-rioatlidc ptostrilic si stupefac{ie'carc porl^ L|lr'r \rllr:r"r
    ,:,,:,$i.,,tLlifi,,fxfl
    i1""rlF$.&{-ij,islll"".*'f
    fiilr"*,J"J#'fl
    ,,:l ' ',,,1;1,'v:L'zilo, "',
    insml.azi rbaclie de;oc (alu 3l"t-e in r;tlttri rl.r'l rtt
    dccedat' lntre acestc atacuri nlilma l)rr'-
    't, rlr' :rrnitllireanou-niscutu-lui
    irl,,lii.liiiri!!1,:1,:::;.ll:.nil1f'*::'i;i"::;tl#runoran.ma,ii ,,,r., ,t,r,,,,tc a.patie;i clepresiuneaccentuati insolitc de reaclia
    rrnoti'xir'
    (lo.irrlli
    i|itllrilit;rlr..t

    it$lit'ffiT{1ft::t;};lfriry:$*'ii:**fr}}t*-[i',,ru
    1",r" ( r .ittttriotnc asociate sc insolc"c insolrttlia
    r"',1,';ri,t','i,,ti,, i'npot.l"a propriei Pcrsorncsru irttpotrivr 'rtttttr:rirtlrti
    '
    |l ri r]l ri t.c s t c c ea c ar c a c c c ;1 i ' t \,, r1 sittrlr,,trtdc'rc:c!ic du doliu cup:in'lc:.
    t
    rrrtxlilicirrisomaticc: scrtzatiade constric]ie 1;rringi:urir'rlificull;l'
    r;*;x"llrr*".**l,ri:J,::l"*$'$ll;i"ili
    i*:ll*:*':f ,,, ,', r,i,l,ili,',-,'ir,tpin,
    ,,, rli;r rI i,rttsittttt:
    1x tsirIclt{a
    scnza{ic'Llc gol iu lb.lorncir, lLil-'otonir:
    sirtt dutcr<l;
    irlagiuii no tt-nilsctttuluidt:ctxliti:;
    rrttrsr:ttl:tr"i r'ii

    ;*rJ:iiffi,{#ii
    ri,li:*
    r,i*it1xi:#ifiiTi
    ilrLril
    *i;
    : r' t t I i t t tr IIt I t t I tIr vi tto vi r {i l si p r t'o ctq 'a t t'r t l r r !'r r .Ir .:r tr L tm i i l
    'r , , r ''i : i t t t r i r ':ttr ' :r r l i D l l tl l i '|I:II|I IIIi IIi I m o i tl l r

    r u 't I I i ttttr ttI r Ir r l sl i l i l r ti r : Il L l i t r l c l tttItttr l l I


    "L t r r l l l l l l r l l :
    r r 'l l i i r r tt{t:

    , l l): l
    | 'r i l
    rt'n tisittrtc, r jr ( r s t ( ) .
    f un( ) nI c u{ .
    ,L' | (r
    ) srrPt:irrri,,;
    ,.irt)Liirrriui irr.t:t:Pintl
    rr'r:r)itr(l
    .r[l)i
    <1u1.ri()
    o Pt:rioaril i , D .M, * D i az ep.rm and ac ti v c mc i .Lbol i tc i n l J res t mi l l x i d thon l tarF
    , yi
    si ,l;r1,i,in,'r'
    dis.:irtnrl n,,^,l f"ll:lf'aj"j 'l | \.t,., l l A Il ,l tY
    r.i1,s:
    ;r,-r,iior ",#i,,"; l;,nll;ii,,l,oilf,,J,urJ,';,,,
    l"".iii-i.'a,""i,i
    Lrt)sir;r.-(itor 11:,,.l;;r, ,1,lfl: 9l'li 'lt lr 'lt'ccsulcopiluJrri. 1,.f rr) i hc c onl rtc . A l ah. bi s . C hi l d, 1975, 50,741.

    i
    lli';l *'" 0't.3;l' jioli ,,,,,,," , | \l ,ri l ,: Il . -, I.l ry troc hy te l )i s orders i r Infanc y . In A ,J . S c l €{ fc rs and M.L A v c ry (l i } t )

    ff' il.lT,l;T;oyl n*:j"**-.;",1'- n^,,. ariv,/r, |\,Il i {;.


    l)lrriLs{ r, ol thc NewborD, 1977.
    -.S i z e.r.t bi l th, C i ba F]rrdati on S i mpoz i rur 27 A rns terdam, :l s oc i ated S l ri i rti l i ,l
    illii,,)l,"Jlj""l.'?o"t,illi.'
    ''"""'j;, *ff'*",,*:ug*:;,"ib''ilillr:ill?l'liiill,j,{;I,
    ..li:;:,,o:"*::;liipIr;Jf,J;:'.ffi
    itlJi'$Tl"';
    ';":'U I'ul rl i sl r{j fs , 197{ ,

    i; j::ij,':":il;;,
    :; *:"q:i':diff i.,,.,,.
    erectere
    3i'il"'i:il"0:l;?
    ac.s'
    l ,\r \i l i .S -, S l l t I' l l
    rrr. l 9'l !), 384-{ 09.
    A .L. - B ac tc dal s eps i s i n the nes ' borr-r C l i n. Obs t. Gy n. \1' l ::l

    l;ixfi'l'u;'ffi,x.:-#'H:j*:l]::jli:+"
    ,rc,,-.li:r
    piixplici"a.,_f"
    .r"iJl"ri"" ";il;#; :i
    " ih::::1"
    p:f \l ttl l l i .l l . - li ?i dc rni c s ot i nl ec ti ons di s eas es i n i e\y born nurs c ri es , C 1i n. Obs t. Gy rl !{ ,1"
    .'!. rr. 1979,384-409. D l ange C l i ni c al as pec ts and s y s temati c s c reeni ng { or c { ,r,l t(rri -
    Lsorncnear
    :rsctncnea, se
    se va
    va disc,rie
    discuta n^-.^.1-"-l.1rirminat.,.recesut il:: ill llypirthyroidisn in the ne$'born. Acta Ped, Bel€i.a, 191'1, 30, 37-46.
    "r"-l!t:tit*i, I,r |l( )WIlfS V. - :l'he llolpy I ant. Lavel}nam, Spastics Int€rnational Publicatiors. 196!).
    r'r l !r )WIIZ 1-., D U B OW ITZ V ., GOLD B E R G G. - C l i ni c al as s es s emert ol ges l .rl r,rrrl
    :l1o ir thc rcwborn inJant I. Ped,., 1970,'17.

    ;,1';'**,,,,-i"ffi 'lti:"'n'l"..""f
    [",l"tl*1i#":{:i'*}.'fii:"d;"ff ; rr,.l r.ti l l c.,-qIIA IIB .L.,!' A s oN 1r.,R A Y E J .,R .* S odi rnl bal anc ei r' 7er5' l oN bi ri l rl ' j N l rt
    rnfa,ns. /. P ed1A tr., 19' 78,93,83' /.

    ;:';;r'1,:g:,:g,";lf;#[:, jr
    jhrr,"11,.$i,,]lrl]i",i:.:::lli"',',rg; I l i r 1,1\'l A N IIL - N eonatal s ei z ur€s -di agnos i sand memgement. J . P { di atr.. \9' 70,' l i ,' i (11.
    I I || |)r\r'\\N rv .Ii ,
    \1.l i .
    TTJ R S II1C A U II.J ., P R J N TZ I{ .I,., P ITI-I]{ P .T., l i l l { l tl l ^
    '' l' hc rm;c ol oc i c C l o re oi P atent D uc tus A rt€dos us i r the P reurtrtrr' o .Irrl l rtrl .
    llilji

    ri. E'tgI.-J. i,[cd,, 19'76, 295, 52;6,

    '.,,',.,;j;ffi*i?_1"*':Iili:l*",{.'"'"'""'i,1i",:,?"'.cumodrr. , | 1!r\N l ) !L, ttOS E N M.N . -P harmac ol ogi c B as i s for the Tratal l 1ent of C arrl i ac A ry l ttttrtrr.
    t t, ttti .!. 1975. ,55. 59.

    iiil#4::;1;jffi1ft ltg,,s;*t'fr'il
    , I i)riNL\NliANU L{. (sub. red.) ?ediatde, vo1, 2, Edit, }Iedtala, thrcuresti, 1984.

    *p$$tri'l""".,ffi
    , r l i tv l l .-J,, S CII]i /IIITZE R I.I-. - I' i rai hepati ti s t]?e B duri ng pl egra c 5r: 1ho l .(,,r.rtrrl
    l'(,rjod oI infancy. * J. Pediatr., 1977, 90, 368.
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    lrmr, Scha{{er A.J., Avery }LE. (Ed.) Philadeip}ria, Sarnders, 1977.

    r':ruiiiisl;iilffj,illkHi.{i;iiiffi
    :i:n:*"l'.r,::f t#
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    , l l l i l :l l l ,1i '1'l i .,
    I l, rl 1ll,ls l-.Il.*Etiology
    C OIIN B LA TH M,_- N eonatal l i poguc erni a. P edi atrdc s , 19T6,58, l O
    of ltajor Maformation
    l,'f Womel|, 1972-!9'15, Manual oi Neoratal Car€ Cloherty (ed), Boston, 1981.
    Arirong 18, 155 Newborns at Boston I-1o il)ilnl

    r I | | | .li lt l). (;., I]FRRIN D.!I-, MUIRIIEAD D.M. - Renal condiiion i! the nevrborr l! r irnl.
    ( l(trcfly,
    J.P, (lid.) Ilanual o{ N€olatal Care, Little Srox'a, Boston, 1981.
    BIBI.IOGRAFIE rl ,rl t[,{A .N S ,, C H IIIS TI-\N S E N R . - C ongel i tal heart di s eas e i rl c ohort o{ 11)502 l { r1l rl
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    f,rucL,onalde?c loDm c x ror r p, . r | . - -
    ; \ l]lt \ ). 1:'l
    l,?,';
    ;il^,|
    ,T,"*.;t*jtr
    -
    'i"}:):,'2';;.
    T?+iix.s{ tr",i;'ii,
    .izli:,!t:li.' l \f N tl , -- A cutc renal tai l ure i n the neonate, P edi att. C Ii n. N . A tn., 19' 77,24,6\)5' 1,
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    t)iLrrliv thenpeutic ellects cntaneols stituulations and CF"{PIJ - , Pad iatt , 1975, 80. Jltli
    . " l;+.:i,l'*;;;;r;:#:T;;vi;,'1"":T;i:;\:".""?',:lfi,"-,':t.%;;:'/:",1;l
    t;i);;,)31i,!,nlr.l;ir, ct(usst
    l, \ | l WlNlill| J., FLIIMING D., CIIA
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    C. and al .- -{ de.ricc Jor administmit('rr t,l

    'tt*i r'c - A' u,ereaalrLirurp


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    ]]-\NA]{OFF

    ;:3f;ffi;"if%31ui
    X.1.";l1y\rf,:td?l
    11;11 ?i:jl'n,,,,,,
    J",fl;,fhlTJi I lr(,I:lt
    I l \1
    W.J. - P-remalure nrpture of membranes and rnatcrtll-fetal
    l \'1.,(j l tA N I- L., LA U ITD Ii N . - E x c reti oo of dN gs i n hrmarr mi l } . N . 3rgl ../
    i!Ic.1iorl, 32!).
    l l { ,r1,
    t't17,291,' 189.

    $l;t"""'Dent orFrype.^atrc,,,ii
    (l ,l I, a (l al - Iarl y di agnos ti c c dte a oj c ongeD i tal hl Tothy roi di s
    ;,,,_j:11}.i\.1'i"',11);i"'."#9'i"1;iill','flT.
    r,'\\l .l t\ ; tr \(rrl
    l ,f, l l ,'l l si vo s l udy o{ l orty -ni ne c reti ns . .4,} ' ?.J . C hi l i ., 196E ,96, 131* 143.

    1;;ii,'r* .{,{fJx{
    x.i$#:;:#i#J#' ;,}1";"k"
    11"**"",
    n,,,,,u
    ,
    | | | | \' .l 1,,, r\L.tL\S Ltrrl., Mc RAY R.M. - I'ra::nsiert lanilial leoratdl hygr)rilinrbirr.tttitt.
    I tr. J. .I)i t. c hi k l , 1970. 120, 26.
    \l \l (,l i l rs(l l l xl . (s ub rc d). - Tendi nl e moderne, i r P edi atde, E di t, I{ edi c al h, l } r:l |r' c $ti , l rl ti .'
    r,' l \ | l r..\., .N A IIIA N I L. - rl c matol ogi c probl erns i 1l the rew born, In Maj or' 1ttrtLl rtt. rr, l t

    .^*lli;.i
    ,,,,,
    ]],,]].i-i{*_tJ;n*.'$ixffif3,*""i.;"i3:,;;:?#i,.;}",,i!}{.0;*,;;,,"".*,, , I r, | ',r{.rl
    1,.4.
    t)c(l i ol ri (:s . S c al fc l r\.J . (E d.) S aunders , 1972.
    :l l c ratr)l ogi c probl c s . ID N eonatol ogy . :\v ery C .I!. (Ii d.), 1), 379). I' Iri tr(Ir||,|rt' ,
    ' n.ci_ n"go*i","i"ij"t"r_li"
    !; TJI]-r.r.us . **,,"i," u..,r.r\diah.t, |,n,'rr1o, l ,i D i Ic ott, 1975.
    t., ,l \l ',1 LS N l ..l . .N oornrti l J ari rdi c r L "\' /c r.y (;.11. ,,N c oni rtol ogy ' l )hi l c (l fl l tri :t l .i t)I)r' rt(' 11,
    t,r /.1.
    1,,;.
    ,'3"ti.iHtl !1il,':il,,t:iir-,ri;u
    t*1$:l 141;,rr'l${*i,*"i-;t#il;li,i- Mr ri rt r"r' f,.A .. Its r,ts s A f.(;., Irti t,l )t\rA N 1].Ir., Ii Il tIi P -^' fl tl l i S ' l .f:., (;1.(l (rl ( 1.. r' r' l
    I l rl l :l )MA N N !V I. -- C l os nfc oI l hc t)atc nt duc i trs i rrl c ri os s 1v i { h l i trl l i or rl |(l i ri rl o-
    ;;1;,y;;;il
    iir:lliti,iii'f;ir:'i:"iii:lili',i.:ill"i""'ii:
    I :,:^::;I,l _, ',r'l trl i :i fri
    A rrrrru< rr;uti vot|rrri
    . (,:1,
    c rrt< t, J , .l ' tdi n11., 1r)71J , ()39.
    t,l l l l .l l i 1,.(:., l j A (:l l :j l ).4., V l l l L l i , or(l ;r.1.- . S i grri l i c rrnc r:ol D tc c o[i rrrtr rl Lrri rti :]:thottt , .1z ,
    J .t)h:\ttt. t;\' )tttl , 11)l \, 1),1,,l l .\,
    . 1 5 ,i
    llr lr
    M()StIAN(;
    , r , ! , i rf.,
    . , ,B()N
    r , , \ r,r(vi\Nt
    ; I V, \ N| ,\.\t.
    ,\.\t. r , ,lr ) r ixo clisordcrs i
    t: Lhc ncw bofn. In N ooua
    .i"J,: r. 'rt' r.r,.r,,,r,.rr,r,i,L.
    ruro.,r^,t(,/5.
    NA I),\S
    s ,^ .5 ., iill.(,1)
    A,5., lrYL lit t I ).c.
    I) c_ - M , , , , . , , . r i1rItis- *"cs. p cdi a{ri . (.!,Ji ol ogy,217.
    t{ririrr,.\r.\NN
    ,uw _ ,,,,,j,".;h;;; il;H",,"ilij:iT{t,j.1.i"}i}i,Sl.li{i;
    ,Il\,' .r r ,Ii.,I S i l u Lru.s, I,,/21
    6 1, 7 81 .
    Nlt-si^ {,N S.,
    ''r,.,cr,,,;, 3, BOLICARDIOVASCULARE
    :"::'gLH E. _ rrvl6crlru' curcen
    " - sd_Noryestr.ctconcenrrution iD marctu
    raLuon rD maicr'
    ital_plismin a".i"g ^{:_q:t,-19r.{ANS^soN
    .A'",,.i"irri;oll o-"t"--'
    coDtracePtlv to trsing t'ornen.l m, I.
    1911, rzg. 17t. Gfhc.al,l
    t"'"'"1,*1"1,;,"?P,j11T
    :r.hedetemrhation
    ol
    :::l or:c,
    ISPII _n-c:,-.,.styg*
    1bumi,,,11q
    "l:*um.a .l."tnicrerus,
    b,il;;"7.'-ottlii1;] ii;r.'ii, ilT
    ljti,';ir.'1,
    igllf,.*Y;*ff
    Rrn'aEyt
    ;i11i.li!t!ft ltii'"',:l'f,?Ifi
    i,'"".x.
    _consenitar J;?fll',k"f iirJ
    a,,r"..ii",i?ti*'riipff;i""i:;frl;,,1";..J.Dis.chud, 1071
    t t.t.tt"l:Tl*1",..]1y^n!l"l:,.I:lIlRo!FA., LTEBIuANN
    .ttctarcircuratioa J., FLECFTTER
    synaro;;;"':#;i&6f;.$"11. B., r{AynR
    fnri
    1977,li'.:l?"""
    91, 626.
    ";: i,*,11;i
    Ita)WE R. - Abnormal
    ahnd. pulmotrary vasoconstriction iI1 the newborn. pediatuics.
    316. 19'7'7,5t),
    itowD R. Eldocardia-l Fibroelastosis, Iu the Neotute with
    I^.3.^Djsea
    .{IEEIF"^"a-
    ^ se,
    I t os , 5; Cor$nitd,l.
    S,rrunoer
    undersp.
    s p.llu,
    120,
    , , , . , . - ,.:,.
    ,\\ri\sr Hg t, _.\eonatala
    l.. -.\eonatal^ IlvpoAtvkamie.
    }IvDoclv&amie Run.tschau
    R- M.d., t975, 6a, t2ti. 3,1. ABORDAREA COPILUTUI
    DIAGNOSTICUTUI
    .or.r.Xl;?;;.9,:i"^y.:i:r.::1. 6;il;,i#.;, CU BOALA DECORD
    wi_tl and w,thou ircoioqitis. ""oi".ii."'i"-"".",n:L". hish-ri.icinra.nt,
    SCHOENBAUM 1. e,aio"., t976, 88, 473,
    dNBAUM S,C. S.C, _
    - Spccifii pro6lems ir STAMATE
    MIRCEA
    MAIORESCU,
    teDlrar inl.,^Lion. ct1t". ti"l.':i:;T*:,
    andmerasemerL o{ corr' MIRCEA
    obst.
    _ rareulerat nutntion",,,in "-.t
    t?uf,"ff'f;r1""t-"
    tl,1gJ"rT' li:"''
    Ptd;att. ctif. A,.An.. 1973, 20, J3j,
    the menagemenrof sick lo!r. irirth r.cigbt int3ntj., lrr oricc ramurir a medicinii, plalul tcrapeutic. ca ;i stabilirea plogrrori-
    t"nto,J;t;;. tto"t"r Suppo|tive rnanagemert ol tho sick neonatsI,ediatr, tl rrlui sc bazcazi. pc un diagrrostic corcct si complet. Stabilirea diirgnosli-
    cli1r. tv. Am., 1970, rlri r:ortct si coniriet lntr-6 boail cardio'iasculalir la copil neccsitr"rrrlili-
    tdiferite
    j(LAUSN. - Neonarat de exarnen(E Braunrvald),la care srr atlrrtrgi'r
    n"n*,JI"_l l-,.:TgIr.^o *, r,"*iL;"1
    illl,l.r,:.),'i;..,T^ rtp"r"iri,,ii,
    inreclions
    rs?esaunder\.
    ."j'il;;";:;ilH':TlJo
    .rr'rr l 6 nietode
    T;.u9yc_r,3,.
    Saand., 1976,65, n5. ,"or^,. rrrr,rpr:ntru virsta feta1l:
    K..- p€diatric,.vol. 4, Edit, Medicarr,BucureFti1e85 l. An&nrneza
    Tl;i*]*l:l .;. lixamenul fizic
    r'",'
    llti?i*,y:;S":,r.T-:l
    _ rr:.cheai
    "rr",*".i,.i. i,,-i;;.;;.";:;; iii,o,,.s,,,0..re/r.2j:r,
    l;;,ul.rilr,
    l9 7t 1 :1,
    ;;;;;;;;;;;i#;1;#;,i':ili':j:?i,fi;,,li,i;_ij;1, ,i. llad.i,ogra.lia. toracicd
    .1. E xaniini grnJi'cenon 'inaaz'ite:a) echocardiograma;b) fonor:iLrrlio'
    -, chitd
    , tsls 124,
    i82 pulsuluiarterialsi vcnos, ape-\o8rama' citrolirlogr:rtrt:r
    i:i'i,IX^fi,"i. ';;]*il ;;"j#;i, .rt,Dis I r.rrrr'r; , ) inroAistrarna
    ntrclcrri, rrrlirtrrrrliu
    ^)Y:X5:,-?'1?'trT
    ac',r.E-R-,.{.,
    c,q,rMeq-
    ,v,qnora:vni., i,,r.siini" e..
    -iiAr:NoN
    l]. _ G prorr,,irh tt,,'lrrrrr ':L,rografio clinici): d) mctodc dc crrdiologic
    ;;i;..;;;i.;;;i;H';li , qxr'lmirnarS, radioipirornetrie; e) tomodensitometrie(tomografitrt:otrt-
    3T:]',1"'',?:;j::"*t:1)9,*-*T-l:*1"1?':,'d^:1n-;;'",i
    rr\fants. lfehetic.L ped,iatt. Acta,, 1976, 3I, Zgg', '.,ti,
    r,rr1,,r'izatiL triaxialir)
    rnL.wir€(trcl
    '.''-MEii'$:{jl:lK,-.li'6,fiiJfitLJ31liil'"'j,?;.,",
    ra.re. SnritrEerVERl,.\C, 198t. ) Neonatar
    rnlcn$iv :'i. lixatnene intaziae: cateterism gi angiografie
    t;. lrnastiparea ritmulwi fetal' (cardiologie {etalit).
    i,Yl.l.
    3l.I ;*i,,-';:': ;"3'"1;
    Sil-i 5 ';t9?;".ioEN-r4
    uut'.,.?;_fjljt!i,"o
    f:l':l1,".1
    :.,t21,
    !:i,).
    ,- -\^eonatar i"'"."r"" c"," si'i"ger^\-erLE., Ie8r. liiccare rietodir are avantaje si limite. Eficacitatca 1or sporeqtc ittsii,
    _ .qr.,l"-fri"*"-ii""rr#;:-"";';:fi:"ii;;:ioreoc,,.
    ri,c., ;rsocit:rca informafiilor oblinuie prin fiecare dintre ele, Diagnostirrrrl
    U m i c h a D , 1 9 ; 9 , *rlL'"^S
    29 , 6 . 5 9 0 . t,rrr
    \-l'liDnAK \f.J Teolhyline
    ,rrr.i lroli de corclse poate face cir suficientirpreciziepr:in utilizarcn prirtrr:Lrl'
    JURKO - secretior into brea$t milk. pediatfics 197(].
    lA.I,!., 1,,rtr11 rnotode,din celemenlionate.
    l)cscopcrircl unei boli cardiace la. copil se rcalizcazi ln circunrsi:rrrr(,r'
    r'.rrr;rlr."l]niori rccunoasterea afecfiunii estc-inrpusi.d9 prgz-9n!1unol s('rrrtr(l
    irrrrrliou;rle nrajor,, car6 determind adresarea- la medic- Alteori lolnc;Lr'. rlr'
    l,i ( (rrii:rtal'cirirrnri suflu, a cialozei, sau.a unci tulburilri dc ritn clttrlirtt',
    ,1, :,r,pr:r'itccu ocazia unui examcn sistcmatic, ln sfir;ii, ln cazuri nlli trtl''
    r irr r;lrccirrlla vlrstclc mici, descoperircacardiopaticise face ir fnlil ttnttt
    t.rl,lrrrr tltirnrrrtic clt: insuficientl" cardio-respiratoricacuti.
    l)irlBrrostir:rtltrrrci boli crutliitcc,in 6cnerll, ;i rrl un':i clLnliopatii<:otr-
    1,,rrrlrrk., lrr sI)rcirri,filrcurgc ln rnod oltignuitdouit ct;Lpe:
    'lrlirrr:i
    c1;r1iii'rrnrl'Lrir1tt: LioJiicrr:tliacc,liolr:inr) tlt la dlLl.r:lt'
    atcs;tarcir
    , r,,,rr,t,rrirrir:linic, , onrllltrrlc ctr rlzrtltait'lr.r rtunr invlsliglrlii ctrr,'nlr';

    4f iI
    - ((ir. (lc.ir (lolrirr'lril),r.rl'irrlirr,sct-viciilorsltccializlrIr:
    rlit c;u-rli<tl<lgir, sttlrl'rk'[t'c;r{ir"
    ('rrilt('ilzilrLt'Iort-(Jrlirls'
    t,,rrrl l, r i;rtroliclrlr' [l(](l l'lil s(' rr(:(
    - si lrcsrqrrrrrr.r]l rl'ilir,ir diagnosticrrlrriIczio'al, tol.r:rr'ta lrolii
    1r'rli;r.tt.i<:ii
    t:itrrliaccsi" i.t fiscurilor lrr rrrll r:sirrstlpus bolnavlll. Trcbuic subJinill, lnsir, i', i,t,i,,t,i,lrr)'/,lr'ul, rii ir,irl.' 'l(' til) 'ldcm P^ulnrorrar
    'O
    acul rI r'tigirrr
    r:iL mctoclelc de exarncn uou-invazive si invazivc sint doar un suplimcnt irl I
    , r', ,,1 ,,r, ', ,ttt i ,,;i , 'sint rarc la cr4.'ilul catdiac' rlrmifrslarc Particrllitri'
    rmui cxamen ciinic atent. In pius, metodele invazivc, in ciuda valorii lor. ,.,, ,,,,,',ii,:i .,uriio1i;Ltiilorcongcuiialc gialo"ggnecu llux pulmonar s(;ilzrrl
    cnorine, cornportl risc ;i disconfort pentru bolnav qi slnt costisitoar.r:.Dr. l,t' ,.,n,r,lu lllr':rl,){i,r1t,,11r11 (| rtlrt'ziniiu itip"r'pn"':"paroxislici' Cttlsiir
    irceeir,ele nu vor {i cfectuate declt dacf, au o indicatic snecialii si daciL sc ;;; ,', ;r,:c;,i;' i .:j anrnliludirriimigclrilo' rcspiratorii c{'.rcurtril' 'l
    11n(ri['rirr
    a;tcapti ca rezultatelc 1orsE.modifice sau s5"ajute planul tcripcutic al oacierr- . , : i",' :,' ,li"tr"r'i'ii ntodificarcas.nroriului ;i rcprezinti
    ';;".;
    (-'ri'
    tult11. .rl .,.,ii,,'i, i;,';'l;i; ;;J lip de (storc.dc.,vi'u
    hipoxic)''
    '"'diop"tii sug-ar)' r-cprczirrlir
    Cu toate progreselcinscmnate realizate in explorarea aparatului carrlio- ., l, ,l, ,rrlrlt", (torlstatittcuneori la lou-uiscut (un' ori.$Ja
    vascular, examenul clinic 1ti pi"streazi. valoarea, iealizindu-ic gi astizi diag. ,r, ,,i",lr"i tlc cdcn pulmonar'(il prezcnla unei bo1i.cardiace)'
    :rosticesurpriazS.torde exac_tc.numaipr.in anarnnezi si examen itinic. DeSi riir ' r.,,,r
    't.t,i|i,,rnldtt ,,dccide;t certbral" \'i {i ceutat cu griii'.pentru !i p():tt(:
    sorltrroh:trll
    intotdeauna ugoar5.la-copil, in.r'estigareaclinici va ii ficut|r cu metodl
    fi ,,,',., ,,t,i,ri"t:,1;r'ii,i,,. ccfal""u, ulodificirile. dc perlionalitatr:'
    lirbdare, iar rezultatele vor fi interpretate cu corectitudine r.'freloAi..l;rllo1) sugcrccz'e diagnosticul.dc,alx |s <r'tclrr;tl'
    ;i pr.udenflL, tl, ,' ,.t,it ,lrr ';r;;;,;;; la <xr'il <1irtt
    atit la stabilirea diagnosticului, cit si Ia terapia adoptati. Fieiare etapi rr "' t,,;t:,:;'il; ?i; tip aiginoi sint rareori dcscrisc
    'si
    tcttsittttiirrtlr'
    t-.xa'incnuhiclinic_va permitc o orientare diagnostici cire va completa rizul- t,, ,,,',t, .,,,-,li,,n,rtii obstruciivciare sc insolescde.crelterea
    taLi:lc etaprlor ulterioare. ,,,r, ,r,: ,,,,i,,ii'l,ft i,,"otnt.ti-l."pttittcircarc de pr:esiune). ca dc .x.tttlritt ltt
    ,, ,,,,,',,,,,u]ii,,,-,, stilroza pulmoiarit, boala vascular[ obstructivir lnlllr)r'tlrr'i
    estc substernal, imbraci caracter (orlslrr(1r!'
    3,1.1.ANAMNEZA t" ,, .t ,,tri*,,,,ii,sctliul dirrerii
    lcpaos'
    "'r rr ',.r.rzisi , r'rl,:rzi rapid lu uriliti:rli rrorlir''
    . Intcrogatoriul atent al plrinlilor va c5.uta si, precizezeexistenla tulbu- ''nt,tb;1,:Lr clort :rnt raic; ie pol intilni in stcnoza
    rirrilor functiona-le,data si modul lor de instalare. - r,," ' ltr :L rl'rtt;r copil:lril sinconcl^ vasovitgalc slnl mai lrcr'vlnl"
    Sc va lncepe anamneza clJ.circuiirstantelenflgteli.i: greutatea la naEtert,, :rIrII( t il.rrI rrnci pinrdori' a conFlientPi
    | )i ', nccesitt cxanltlrL''('rrrl'l'
    's gri""i"l"i calccmiei,ECC, ,electro:niogrami'I)at:i'ttlirtllrros
    durata sarcinii, scorul Apgar, aparitia cianozei sat dispneei, a dificultililor ,' , , 'li;;r,;;..,;'-
    lrr alirnentalie. '
    ;,, I ,i ,.;';;iiliit?if", ii;p,igli.;i.. ipol*otitit si't eliminatc' diitgtto:ri.rrI
    Unele cardiopatii slnt statistic mai frecvente la copiii cu greutate miciL , l'r.rr ,rlrisrruit csto(iesirlcopi vagtrt'i ln unelc cJztlri' insri' nc vottr ;littrli
    - l':(:('
    la nagtere (PCA, DSV), altele la nou-niscutul cu un lcor Apgar excelent I il' , ;":iiiiiil;;' t"irr"'l'ii"i cl' ritm, cecacc indic:rirlresistrrLrl'l
    (transpozilie completi. a vaselor mari), copiii dismaturi preziljti de 2 or.i , ,trrrrr. Irri n r nct , , claI lolt '- t - .
    rnai frecvcnt sindroame polimalf ormative (cu cardiopatii - asociate). i,i,lri,:'..,s."tw ai" car. slnt.derc'finutp.li1llit ll'il].;'lll:,'1,;
    - seind,tate
    Starea de generald.a unui copil cu boali cardiaci, indiferent ,,,, ,|
    r . r t,tr , r l t| febra,iL are icumatisnnrl.1ri(rrl;rr
    ,,i;.1:;;;",-,,i"* si
    de vlrstS, prezinti interes pcntru diagnostic. Apetitul sclzut, sci.derea rezis- 'l;:;ii;: :i'nut
    il.i,i,rii,t "
    ii-il"i" itt anteccdcntclc
    :tlhllli.i:, 'rrlt!
    ;:l.i'
    tentei gencrale, cresterea ponderali. deficitarl trideazi o tu]burare severil '
    ,, ,, f,' ,,i trrrnilici
    "pi.oud"
    lespi:ttivc sint un argument in plus pcntru a(:clrsli
    'l
    a stirii de senitate. ln cbntextul unui copil cu boali cardiacd., anorexia
    \c itlliir){'ri{l
    poate constitui simptom al decompensS.rii.iln mod similar, infecliile """' ,,,,r,ri|, Ltt ntt,rttbrelein'Jerioare, clupi' u' cfort important'
    -prirnul
    pulmonare recidivante (
    sugereazi lnc!.rcarea vasculari. pulmonare cu presiunc i r , ,,1,rii ctt ollrctatic dc -:rorti'
    ar cn{. E: l-
    venoasi, pulmonarS. crescutf, (shwntS --+D), comuni pentru defectril septal l ,tl , ,l ttt l lt f t t : t r , t lnt t t t ot Ji . inr c6. i: '{r : r r.' ll'lU:
    st lu {l( \ urlll,
    l r'.r r'l':
    : r'
    l, i in ir lln'
    vcntricular, pentru persistenla Iargi a canalului arterial 9i pentru canalul ' ,, | ,,.rr.|I{ i I i rr ci, l'r r t ilor it lr vt lLit " indeos ; 'r ir nt r l
    tl'atam1Jr1(l lrol
    atrio-ventricular. ,,',,,, ,j .,rii ,",t'i"ur rlc alcool, cxpunere la radialii ionizarte'-
    Il"irt.lir
    . A,i-teqripS.rinfii sesizeazi.aparilia dispneei, de la nagtere sau dupl <r ::, i, i:,ii i';iii,;,',,t" 1inr,.oi,r,grilrr' ho:'fisul crr")' deii .r'rr''
    DCnOada de tlmD.
    lJt C rrtral arforial.:'tcnuz'lpttlrltt
    . Se va mi.suia (dr1a distanli, ln somn, dacd.este nevoie) frecventa respi- , , ' ,',,i,ii,:i,f,,,,..f",ii."ila anumito ct'' scltalc- Sc vol ( iitltir
    ratorie a copilului. Cifrele normale slnt urm5.toarele (J. Stdrmer): ',',, , ,r,,,,,r,'tLl':iunut-ilotarterci pdmonarc' ..ie{t
    auditivc) (1'1'zivtrl
    , ,, ,,, ,,, ,,,i Ii i ,, rrsocirLtcirtilgt.'rii cirdiacc (ot:ulare' ,1'
    Nor-n:rscut 313f: lO/minul
    |il. lli3, lliit, 186 si 1ti?)' ln caz dc bloc A-V conBcl]liiil's vi)l
    Sugar 25 .- :is/rninut
    C,pii mici 18 - 2:/ninlrt , r rllrllr' ,l t l tL p r r s i i t m a l ci l ;r m :r r n i ''
    " . r ', '1 ,
    1 "t
    C,,pii icolari 19 - 20i trlinBt f,.,,,i,,I ;,, aicoolicirst-'insoteltch 509/odni cazuti dt' trurtittttt
    L,,i,,t,,,1iIr.
    ,\ilulli (70 kg) 15/ninut
    ,l rr IIri ( | ;rItiiI I ( ' sit t t it lt t lLl'cnt r ict r iilt - c'
    r lr r cst c . bint : t 'lt Lci'ilt Vr r 1r
    l)isputrrir sc intilncstir lt urpii rnrri mari cu insulicicntii. cardioc:r, (lirr l i ,rl rrl .l <liiit {ii in aplr li}ia bolilor r : : r r "diacr :
    iilnt t : ot i8t 't I ] lt . it ilr - r tr: r 'iLr r liit r t lr r r lt li
    r it r Llr
    ,rstr nn sr)rnnmlri fLccvi'ni lr.tlt in insuficicnJa r:tr,rrlilcir cit
    i.;rlripnr';';r r,,l .rl i l ,' l rtir l ll( 'r vcr ll, il t t 'ut t iit '1"it
    ;i t
    ,l51r
    'li,{l
    ,,i I.rrrrilir
    i ' rist' lrl,r ,:,,rs:rrr,:rrirritJ!ij, r j.r ,r ,,rir.i(.i rlisrnorlii,..rPllrilrt ., l , toz:i 11111 "1111'. r r r "r 'ill, . (arlrrroatni: scbaccc; trllcificiri ccrcbrllh;
    llour
    .i.r',' irs'),ri,z.' 1,r,.(
    cu o multo"matr,.-corrgcrritrlir. I..rirt,,nf,runui copil c ,\l(i() : .i r zi, . r , .r ) ir ) t : r li) c" si poate asocia ct rabdoruiom; neurofibto-
    ' ' 1,i 1,.1,si i,'n{
    irttr.,r',larnilir.crcstc riscurilc_dcIICC-la copiii rrllriior.i (pcntru 'dcl:rrliivczl rrrrrIozrLllrr:liliughausi:n.
    ( r proJut rrr.roroglamatl ormatrilor congentalepag. 124_ 130). Tab.l tr3l
    Cardiomegaliadc.
    l)rstatd la attl membn ai familiei respective,cazurile de moarte subitl, inexpli.
    r:al.,ilc,mai ales la ti'eri, a. uneoli o valoarc fundamentali ln diagnosticrrl Asodorllo olrlf uilo hltre bolile 0errcraleti bolilc eardlace(Modiftc^tdupl tr. Iltaurlvdtd|
    rrnol miocardopatii primitivc (miocardopatia hipertrofici. obstructivX idiopa. ---l
    lrcir, llbroclastoza endomiocardicl et"c.). Istoricul iamilial este importani ql Afc(rtiunc general;, I Asociere obiF[uite cll o boald, cariliace
    ln sindromul Marfan (boali cu transmisie autosomal dominanti), atlxia Frii- I
    rlr, t , i I l .
    1,,,.,rr'i . s..rsr r l t t\l t..ni !' dl i l or s uP .-
    DSA
    3.1.2.EXAMENUICIINIC GENERAL t )t:tirr,lii. musa are trIiocardopatil primitive
    Miocardopatii secundare
    Ffectuat mctodic gi sistern11i., la un copil ln prealabil incurajat gl ' It) li!ale .or.Lgcni tald, Aritnii cardiace severe (interval 9T prelrngit) (sin-
    Iini;tit | (sedat
    (scdat.medicamenios
    medicamentos la nevoie),
    Ia ncvoie),exam
    examenuiclinic va evideirtia
    clinictva evidenlia dJ
    de ccl,i
    ccli, drom Jen ell si Lange-Nielsen)
    rnai multcrul1. ori clementc
    elemente utrle
    utile gi
    si valoroas-
    valorbase oentru diagnos[ic. Sindromul cardio-auditiv
    In111tc de auscr tatie, medicul tretuie si piocedeze Ia o inst'ealic Ihpertensiune pulmonare prima,ra
    and,nunlitd. ln.
    " accst timp se_Jncearci se sela;";;;;t; ccpilul;'dactt 1,.1' ,! | tp-ut.ti u j . rr,rl nJ .r, ("i ndrom Dilatalie aortici, prolapsul yalvci mitrale, alornolii
    rncdiculsc rcpedecu stetosiopulla copil, acestapllnge gi examrnul cordu)ui Lurrl,ur, sinfuom jihlers- I)a os, sindrom
    ('5t | .omt)Iomts- 'l ', l , rt i r i ul burr ri |1l ( rnel rbo);s mul Lrr
    \ 1,.7.
    ln 25-30% din cazur.i cardiopatiile congenitale slnt asociate cu o Mio.a.dopa,tii seourdare, tdlburS,ri'le coaduccfo
    -_
    malformafie extracardiacii, adesea evidenti lj insp:cfie. ln aceasti cat,,. ar'rie ventriculrre
    golie intrir urmS.toarelesindroamc: l ntqlrli! AteroscLerozs,coronarian:Lprecoce, tulbnteri de con '
    /r)^Abcr a!iile cromo somal.e: " " .lucere atrio-7enLricular.e,, miocardopatii secu[dir'ro
    Vezi capitolul I (1.4.j.1,,
    pag. 102). hsuficietlfi. cardiad, fibrila.lie z.trialt
    Exarnenul cariotipului este indicat t^ orice copil cu MCC daci aro l ':ttc ,oti dd Peri. !rdire, :fe.lJ'e vrlvrldri oortic:
    m:ri multc malformalii- asociate, intlrziere de crestere .intra/e-rtrauterini gi PericarditS,, endocaldite
    Intirziere psihomotorie. liibroze miocardice, pericardite
    B) Stndroame penetice cw atin g er e a s c hel etul, r.t, i. I tri .tci udtn s di s c tui nt Miocardopatie secundare, valvrlitx,
    Cea mai usor de recunoscut este maladia Marfan (arahnoCactilie) carc srr "l r'
    ?ericardittr, miocardopntie secundare
    llt-ofcttc dc ancyrismc ;i dilatar" aorticd, prolapsd. valv.i mitrali (vL:zi tr[ioc:rrclopatiesecundari
    qi .1.17.7.3., pag. l0s6). Insuficienfe cardiace, ischemie miocardicl
    . Sindromul Holt-Oram (anomalii ale policeiui 9i radiasului) se poilt{, ttt' rtri i tn. t x [ol i ati l \i Insulicienln c:Lrdilcd, cu debit crescut
    ;rsoiL cu I).S.A. sa.r irto-r-.'..i r y,n3LSiiotati anormr.ti.
    C) Si ndtoanele cu, f ac'ies p parLicwlar Ilipotrofit statur'o-pondcralir,raportati. la vaionlc normalo-ptrtrlrLl
    &rticutrar prczintitintero,lll
    :",.-.
    tnci recunoagteri usoare qi al.l specilicitE-fii vi|rliL si sex, scmncleuubr anornaliigcncticc(trisornia 2[ sindrom l{iLr:firn,
    lii relativc
    relativc a cardiopatiei
    cardiopatiei asociftt(!;
    asociato; urrr,lt,rrir'lurucL), ciltalact:L5i surdomutitatea,fa.'icsul pdrticular, semnclr'
    srndromLll
    sindromul Williams-B..urerr
    Williams-Berrreir (facies
    /ffacies .le
    de spiridui,
    spiridug, asocial
    asociat cu stenozr.
    itcnoz r rorticd
    aorticd
    srrpntvalvulard rrrrol boli goneriic, sugcrc:tzir.'ln uncle caz[ri coexistentacu lnele bo]i citr-
    ), sinclr".r
    n,:l Vornrn (siridromul f urncr mrsculin). asociaL
    ,1r.r,,,(tabt-'lul:1.1.)"Vczi Fi punctcte l-4.1-1: 1.5.2.1.3;l 9 9i 3 17'7 . .
    cu. stenozi. pulmonari. atipici, sinJromul -
    Caylsr (pseu loprralizie facialil poite fi consecinla anemiei.sau^.a vasocottsttit:
    pnn b racio-), I''aloureu l,egztkentel,or
    ,aq^n:zia ]dfa{hiul.rrutri- sinCrornul (h,rmi,rtrofin
    Gol,-lnrrh.rr vasoconstricfir.'produsi prin insuficienfil"carrliitrrri
    prvilior rlui urechii, ptus tetralogie). sindromui Di ceor:gn tr'r l)lr:rLr;rzi.
    ri:'tru
    11,':,]1:_l llip"pjlzia ,'r,,r11,'sIit'iL;
    t ahic'irrdiit, timpul clc recoioraie. capilari.prelungit,.hepatomcgalirr
    '.r t'.rr.r)ir.Ltiil(r''ci (scmnl Jt' hip:r'ecrefi, dc catccolsrnlnP)'
    rnurr) ' (v' z.i .\.3.6.1..PalI. 612)- colora{ia
    t.:i',r,u,l,r t tr'gunlr'n
    lt'l'.'l
    (V,'zi ii r.rpitol,rl t, J)r'r:t:lc t.5.
    ;i 1.9. si c.Lpitolul3.17). i:str:
    rrlll(roirso.lot ttn semn frignant, crt ntarc -albistruic
    valo:rtc ln
    scmiologicir' ttut:lr'
    D) Si,ndroawe Jr
    c a r d,i o-cu t c n,a t e caLrecolnDlil.ii p,t.r r;LLl:rr. l ' ,' l r, :tr' l i ov; t s|t t l: t l' .
    nirt" prgm)ni.rtL', p"t ri ,l'.1'ntigr (:in:ir.r.nlll-trlpARD .='L,ntigiirr; rn,rlli. irt irtsttlicitru.f;r. cardiitcit Poatc :rpi*ctt o tol'oruyieicldTir)da togtlllnrrli('l()l
    Plr';r:k::troc.rr'.liolr:r{i..:
    I dlb l.iri .1. ct:r.l-r::r...;
    o.:ul.rrhilr.rt,:[ori-irn,
    ll.r,rno, ,rr r'l'r'lr+t (:a rtrlnitr(r :t stazei hcpltti(t scverc gi dc lungit <lttrati ln cottrltrt'
    rlary stcnosis;anorr:.[iig,rnital.; r-.t rr,11.,..! crctt.]rii; Ll-.;rInr;.r
    (srrrdi[ltrr rlr, . or u[ [ i ln cur sul insuf icir r [ ! r : i t : t t 'r lilr : t : lr u t : o1: il
    i ,tl i c Irr ;rrlt t li. r t l,it r r ir f ii: ir rict
    silr']romrrl
    I,('R)r)pli(:); pttr (1,)cirl:.rircu
    l,rPt,.,
    -,;l,,nozi prrlrn-r,r.ri-,i
    (Wrfsrn), ,,1r, r.| l ur) lit t ai.

    4ti0 4{il
    . . ..1)istrtft,urlt Jttlrt lutLtttr. li rut..triat:lrtlulia ddccast d.c!lh esLt:

    ::li' 'ili;:i,ll""1i:,i'i['r:,i1'[l
    ';''i,Tili; lll;t"::t^*!$il:
    l l ti sti c l pc u[ 111 lr o ]rri rv ri l 1 rr l i r\.\
    i'*..:'J#?;i'i'li],i;li
    ,, li;itxs
    hf*:,'"'1}!,!rf#*$jr##t*:.ff3
    $il*$ii
    i ,rr,l r,ri i (l l ' (D l rrPcnsat lsau cu I
    Catiilc d.entatt,frecr.entcIa copiii cu trICC cianoennppot fi
    'l"f"""rii origin0q
    iii:;;,tt"""t*| 1,;
    ',,"i.'l"-J::K,S:,,::,;:;::;:Y:,.;{:,,,ki:;:?:,H
    urdocarditei
    arditci bacteriene
    bactcricneJala aceqti
    acegli bolnavi, ca ;i f. bolnavii 'i"
    S la de RAA
    ne i",,;,i,.,', ,ii#iff, 1po4i;nii i.l;i"tt33"3:T',;"",#iffi,i
    in cardiopatiite
    r-'--- cianogene,in
    .r special
    rvLLa.r in
    cclc ln!2r:: rtr
    care existi
    -!,,-.!r!o steiozi. strl' nsa" a. arterer-
    ^l:!^":h-,1lpa1:
    iiiir:iiii:ll;rr:'r*:ii**";-t*".*x'rJi:
    pulmonar.e, spontat sau cu oca.

    iil,J:,H"il":l:;"i:[nl'.niil"';"i::;*J;,,gxi-ll,::::":*:":iiil":iii:ryiil
    tl: la simpla ..ttt.,i.|iaglrosticu1dedextropozi!iecardiac[.

    l,Ill.T' ii,1,1,' ("#


    ,"",,i"i' I ; lll:,']
    ,':'it"o'"i
    ::,t: ; :o'!,:,rt^f
    f.i."oT';,,.9o"1:T'::i).,tr:i5l[i'
    drirurgicai. ,.,r,,I, i,' arara
    riniei i,,,li
    i].,il"ltiii,
    ,,^r",ZX:{:iI:""
    txjtl&:ut"in reumatismul
    articularacut'stenoza
    pulmo' iY"::iiri"
    i;.i,ri,,l*..';;";r,l;.,!T:***ul't"*':',:Tff
    i:l*Hf,
    ,3;,ffiT::p:l?t.,T*:,liI:l'l'l.*{,"rU*,,'ff
    ,".,1*#:!,!KK.l:;.:::p,K#f*:,:ffi '"1f
    'i,,li;:,j;
    t,:'ll""X?$lf"',?elli:i*,llfi
    t;/].ir:l*"$*"'t".Ji"*:11,"*:'Jit
    l;lil'i"iil;"r'ffitl:f
    irag.970).
    Mamlloanel,e dccesani an fost descrise ln asocialie cu
    pulmonari. 1,,,,,i' *-*51,ti;ffi
    i.,:,,'#:'i'"i"t"ri.
    hipertensiunee

    ,,,,.,,,;Iio:z#i:"tii'!;Kr::,{!'yli?: anoma,ii
    a,r' t{lmg,,""rrf*:*1';*
    S",ff,::!:;,J"3i,.i"*.."
    i'li ll,ffi #q1,[f #F::;xiintlai"'*r,t
    conge-
    ,,'!^!iKlJ{"f-{|o#,"J::'i:{:;:;{^"0u":;:$:'if"i;i-',X:,;^'diopatie
    l"', i-:rl,Trti
    :
    n,i:,.1;:,1i0:.x?Tlill,{;{tr{fi
    riiii::';m,.'":ll'*,g:;nf lllliri,,ilij;li;'"{;:iTn'"x'"T:lii:"'"T'9::**l-:#Huusub
    sisr-e
    .
    mit i. Astfor,diminui struni,:l o -u-s'ii1di"it."pr.,r"i se amcrioreazr.
    Exam,inareasislemuluineraoscattral,lr"ta ,*.oi-1"tf.d"." f"-
    .'""i'"1""".,;iii'i a"r"oil ' fuF*i$I#*:u:mq##f
    i,::''i*,'il"iff lls;;rTi'n
    ;.;'..,,,; l;' i ii;l;ii- e' aortei, trrlnchiul arterial comun'
    ili;l'ili:'.i'.lr:'i:%,:iii::lTii;"li,H-iil"".lll""i"; r*,h"?.#:'":fi
    r'(,cutiar\ttarcdecrto"*T"i:,l#iif i#t:ffit$',,"i1llli',:
    j:::::,:1iijffiq:i",i1{"',ixi!""ilJ';;il#:'::#ili;;,1*#"::;ll:f
    "JflN Il) ) llllil;;?*8ili"fi'i:,fr!"i""iiiii"i^lu."i"ie'
    imicom"titat")'
    i,liffi),fol?.e*iJ:,fy::i?
    J""":J1J,1g$"ii
    :Hlji"ffiJ:Erij.l#f ,,1;;lnl'***r,tl":nJ:':l:ffl-"f
    i:'.nLx',.l'#:'.;.';il
    ilH,#
    t,cA.
    tl,fi':,1tiui"*i?,&l'::::.gi:'*pr.**:x
    ;ifu**.:I* irii'liiii**ij:"ttr'.u:l :;i:x'.i'l4t
    t"tilttrltll,: ;';;
    t'";a
    Inspeclia toracel&,i.Bombarca regiunii precordiale atrage atentria
    inlediat l,,i;,1,1,,1,''i,r,? no,,-ni,s
    ,'l:il';,,rl.i;:l,:l*iiiJ;lLret'l:il"ff","T1'fli.1*f*lio
    rlr]l :tiili':::*,:;i":T,,::*":u*:*,*.:**n I
    :lil-1$i'c:i;ii#1"ffi ll;l,llllr:ls*:wj,1,",'fili,'#J::x.lJll[
    jl_li,tri:,1,,fr|il*T:{i:::d'*i"!i::i,t'f;j::$l.li"tiiTr:;,,: '
    ;,otttt rrP,.:ri:ttt
    1111,,,1r'
    ";]i,,l,,ll
    rl'' limita sup rioari a matrlatll llcpattc'-
    A, it lnrr"tititlii ciLrtliaccabsolutc se dt:limitcazir'prin
    percutic u;oari lttli
    itllll;"i'JiliHfi"i#':i::1,i:i::li,:f:""l:i,,:ffi:i,:t,{];lliJ
    *Lxii?,li,l[]
    iii;ii:lli,* jli.:l':i"$h
    )i"*ii:i";l'i,,iiJ["it ir,]ff*fl,;,*:rl*i..j** ; :',..iii:iil1;iffiii;ltiilii*g;i;ltl:fil1lif,'L r n) lxr r t ar r t t '
    Lrrrv" . rl i l :L i. r t iil, ii lr ilr 'r 't r '"I iil c; r r '( lt ir t : r '
    4tJz 4ti.l
    llstc dinrinuirt
    ,,,,,"/..t1.';,t!r!^il'#.il'i#1'if
    i,Ji""#li;Tl,t',1lili:#Hlii,; ,rrl,'rirrlir 5i ln d.cfcctul scptal ventricular cu un dcbit crfscut'
    ,r,',i ii,i"iu,.fuf PR e alirngit sau ln afecfiunitc- miocaldice : in insuficicnfir
    :i#3,:i#'"ffix1ii,"":,:':;:.1i,il#ff :"":31Tfi :l$::*ij j1yJ"ffi
    sp-afiulinterscapulovenebral,a-rilcle,.spalele,gttJ, "i.li"ilii.ioao-."
    rrrlr.rl:-r. ncricarrlitc
    ',,i, ,,'1'uil.
    sr este
    'ii"J,rtt"i.u ,i"Aultt, ln blocrrl de ramuri sau in irrsuli'i
    -iiot"ot"t"i
    I poatefi totusi normal[ la copii'
    Z rotnotul' al II-Lca marchcazl sfii;itul sistolei 5i inceputul {[n';le)r'i I
    lj:.:gt?._-: I!:cven,ra,caracrerisricite'
    qi. n:odlifi.iritc po-'"-" t. r , ,,r r i,:iilarcsi estc r.xoresiainchidcrii valvulelorsomilunarc aoltl cc 9t l)ruln(
    ,
    g-t",:H_ii p:ezenla unor fenomeneu"u.ii.n l."n*i,
    (cLrcR-wr).lxamenu_lse poate race
    "3rJi.,1i' face cu
    cu urecnea
    urechea sau
    sau cu
    -o.-ot" cu stetoscop"l
    iteto"",, adecv J rSz
    F;;;*;'.d':?"1ii':i?. t::f a) 6a/apa/ria/ saupresista/ic (J+)
    hubripiesi.
    p*t.,"""!.,it"i" i?t"il'tf,-Xffir
    de cauciuclcu peretcgros)trtJbuie.si H*#"rtffi**l*;
    fi"'r"trJ-zi_5ii jumen ."i, i
    o,oc ou
    fr__l
    .n,ata aiametiJa"),i' J,i' ei plnia
    H.,{1d,.:J:J:Tl.ii*::byiE
    de.2cmdiametru. Stetoscoput u" inii-*-*6";";i;'"# co
    dri.'i: ill pnmu/ui zgomol cardt'ac
    b) Dedub/area
    "st" depinde de Lir!i-""'t"t"fU,
    nuie.,-.ticu ti:npul, r chei ;ficienli. "fr
    volurir'
    EC
    =e/i t bn c/lck)
    ;i:fl&i?liJ'ilttl'#::,T'.1;"0,T;l:,:,lll:'r**;*Lg,#iU--J c1C/tb./e e1bcy'e,oslo//c
    ' dor/ic siu y'u/monar /fC
    42 P2
    ii:1ilil1iili"".'#Hr:it"dp':llfi
    ^
    {re,cvenfele -."ialrf"i
    inalte. AuscutialiJ
    I ll
    necesitel L----- --x/?t d) Dedub/area .tgonolu/ui doi
    9i11TS-"1,p*jru
    antrcn3ment, e{cctuindu-sc'intotdeauna "::iX|{i"L'i#lil'"X'i,1*?;,ri
    intii cu'pilnia
    e) Pocn'lqry'^/edescliderein sleozzd
    l tl mtrrd/d ( uJ /

    I t.tr Zgomolu/ a/ J-/ea a/ cordu/u/ (.re)


    I l r fl

    .. . Revelind
    ja cord, suflurile c"' iiecvlnp joasi
    se aud mai bine
    l lt g) Ch'c mezottob|c lac = s!t/o//c c|bk)
    pilnia stetoscopuluj aplicatl uror..pe roracL;,iir timp
    inaltc sc pcrcep mai binc apasin'd oiifragrniJ;" -;;fi;""". co frecvenleie,
    precordiali. f f ,i;*";,.'."::i:;;ff :ifd#'ii
    .li:*:l"i'.:ff
    i";:."-i13J
    z';rrttr"
    ,r.rrt si r1 vibratiilor aortei ascendente ;i artcrei puJmonlrc' Stttdittl
    ,,,i,ilrIIr""'rJio."ri,i pJ-onor.i cstcdeimporianli"cardinali 1r ,;tr''1i.1,
    , i,, n"ai"tti"e. De obicei nu existl o coincidenli pcrlccti lntre printir rx)rll
    a1 ll-lea.;i iea de a doua (P*. . pttl
    ui,:""Ji1l t',":J.,lf;
    t""t ilanevoie
    in braleie ,;;;'i,;;;l-A;':;riici) a ,gomotului
    0,03 sec" zgomotul a[ Il-k:u '"
    o. r"ilflXtlt T:i#.i.P"t i',,'i,,.,,1.'CilO&.trnt', Oi.T." ele depigegte
    aort,'i- A', - aparc lnairrtiainchi'lcrii 1'ttltrrr'
    i":,.,.",,'i#rurJil*itld;; -este mai mar-e1n a611itrlr'<'il
    ,r".ib"?:i"1"f,:x'#lJ:l"1lT;i##':T.:il."';"TTll.#.aTbirdemare
    E"
    1,,"'.,i::;{:.- l;ii"iil, pt".i"""n riiasfolci'
    it .opirrf'no.."1, zgomotulal lllea estc dcdrrblatltt inspit;r
    t*r"i""i-t"te a" lL cevorsi.sededide
    ."rui"r$?di;l' i,'' nurrn""itai.
    ';;;;;'r;i"-ii v('r1(':r\11l'l
    "a;;ir,i ,; '';; e*pitatic.'1i i'spir:a!iecreitc intoxrccrcA
    . La auvultalia cordului estc necesaydcancenlraleaasubr& umdtnl vcntliculului dcci r'i'r'
    1,"iitr'ii""i. lt"it*- t-'pr"."t ;i,timpul .rl'
    b):!tu;t
    i::y'i1!:',:.1-'ry::..'^'y::!!!id; 'lrept' lnclrl(l('rll villvr'l
    l,iza "iilii".iiii,rli""{,u'xu);c.)
    d.irtrezgomotete'roia"tii,
    fi,ecdruia ti,.. Itlclungiica eiectici vcntriculare dctermini intirzlerc-a-
    l;',i;,;;";;";i"il'i"'"*pri.i a"J"ltot"" zgomotului al lI-lca lrr slrirrrlir"
    -i
    bine (alex,- spyliul
    .II- intercostaletc.)',"iiiii;iil:it-iridiir"firiii
    tare ,iir tTnirn ttci ahso iJ'';;;^;i;;-t;;otrl. tii.i do cazuri, rlc<liblarca zgomotrrlui rrl.
    IT-ltrt .|'t'rtl''
    yy(: :: lrl cet.nai.s.rab.;i ca nat puteiiii;-ii""iii'"i,ii"t
    "rji a" a" ;i";l,;;ii ii- iti'",'Ipi."ti". De obicei, detlublarca zgomotr'rlrri al Il'|l'rt ltt
    c.qreesre.ttqtuen!&resporalieiasuprd intens,itdlii
    ,:,::,.:::i!::::,,,:Yie^^fAc?ttd si,deiublii;ii. Analiza : il",,ir"ii,,"." 'l"iiin,,sii* ii",f debitul ventricululuidrept e crcs0ui (llliA
    .inoiniea )"',i*t"u, 1, l,'i,,"i.]i'ii t, tt"".'t".'uiili"""tt"itto,*.r"1 clrtclcvacurtr"asa i' jenirtit(rlt tt'i'ir
    ,tu:tttllaloyii anormale (fig. J.
    ,.
    "aanant'suliuiiil'i-;i" s;ttrc:intlristola c prtlrrrtgitri(bloc complct
    (lc rirrnrlril(lllillrlir)
    Zgomotul,1 coincidc cu incrputul sistolei ventr:icularegi cstc atr:ibuit I'rrlrn,rn;rllt)
    al ll-l';L
    c_ontraclieimiocardului ventriculai Obs"ivar,',r atcntil a cclor douir componcnic ;rle zgornotulrri
    9i lnghirlcrii ,f,.,1'l,f]ii',.;i,.',f,i lnr:lrir!'Lii
    iritcn.sitr"tii
    practicltl Aprr:cir;tt'rL.
    lis'r accentuiLtla virf, clncl inl*vilrrl pif .;i. "if'Woi:oirjo_u,,ntri.u,tirrcl
    .;,,;f;; ir rl"lnbli:ii), {inc tlclxpt-
    '.,i*'ittip"ri"rlLa',1,,i,,t,',,nt1,nn,i:ti
    r'st(icfcscLlt;ll1 stcr)oz.milr,ri'r, sindronrurhipcrl<i'atic, tt<:,i.iulc:lrrliao ,.l'rin,ii,ir-"tf,i"i1urln,ott,,r'.:11'n,
    (A Nrr'lrts}'
    rir l,iru.,.t,r,riirin.,* rrcrr{il,rL' .rrrr,, tiI1rrIi;rtit nr:ti Ittttltttt copii
    .i li I 4$lt
    (jiurl cornlxtttcrrl;L TrrrrLrl .l r' si( r r ir liipat ologict . , sr qr r aaclit r glr t zgonl<r ir 'I r r t . 'lr t . t lilr ccr t or t na'lr : '
    lLrlorlr l)lllrrouarir_ sc andc cu intcnsitatccr<:scutil cliclt - ur i'
    itt spaliul rLl 2-lea iutcrt.ositl tr,l t,( rr r' tn' l, r lr r r ilit ', I' "'or ner r " : r . r lst ic' at t or m llo: r . 'l; r ct n. lt i. cEi
    sting.,sc,mnificalia.f,,4"riti este de hiper- .l,l;,,t.'ir, su{luri cardioviLsculare9i {recituri pericardicc (sufluri tlxtra-
    t(iDsnrncpulrnonarl, asa clrrl sr: obsr:rvi 'rr,i'
    ln cardiipatiilc congenitale cu shun_ I rl r l l i r'('J,
    Itur stinga-dreapta notabilc, sau ln
    stenoza mltraH. O rnodilicare ausculta. r lacutanlelesint zgomote cardiace cri drrratl scurtir (0.'02-0-'05 scc')'
    lorit: similari. mai poate fi constatati.
    lnsi. si in Uocot ae ramurd. clreapttr , ,, t , , ,,,,niii'ittoltir (50:600 c/scc.), carc dau senzalia auditivi de pocnct
    sau i' transpozilia de mari , , 'r , ,,u,,iiiii.ii cel I]iai frecveni ;i mai cunoscut este clacmentul de <leschi-
    vase (in aceasti uitimi situafie, semnific?l
    .
    ,:::"^]^"t1,"1. t,,, ,r u',iiu,,i ,"itrale. Zgomotul survine caracteristic in stenoza mitralii ;i
    aorticel).O.intirire a l l l puncrca uu tensiune a valvelor.mitlale sudate'-sclcro-
    D rus ud ssub
    a bruii
    "o*poo"r,rJ-**aouaa zgomotului
    l]j.li r','rrltli rlin
    '||i l ,t (l T)rl l l c rc-ia
    .. r r-rea are mal mare semnificalie lnfeputul
    lnceputul fazei de umplere rapidi a vcntricultrlui' dirr
    lazei
    de hipertensiune pulmonarf, declt un ,rl,
    ,,",,i ri cllcificate,
    ,,r,i.li-i" la
    zgomot fl.puternic (la artera pulmonari.) ,,r 1l,,,,t,
    ,',.'r rv,:rlr.irt)ir
    errirea rcir in alie condi!ii
    si ln
    Si patologicein-care sc tcal2eazi tttr gt'rr-
    conditii pa1
    dar unic 1""a"iotf"q, cu exceplia sting la inceputul.lirsto-
    trtnspozitiei. crescutintre atriul .5iventriculul
    si ventriculul.sting
    '1, ',r' ,1,'1,rcliunc inalrrlrri arterial,
    arterial.
    il i":"p'll1
    s"otal ii1:-1-
    delcctul septal r', rttri-
    Dedublarea zgomotului al Il-tea pr-in r, , i,,'iruiri iiii.t .tittg, persistenla cinalului
    lntirzierea componentei aorticc , l t t , r rJ .
    ('slc o situalie.rari la
    copil, lnfilniti ln unele afecfiuni cu hipertrofie
    (:ulitliL stingd. importantf, ventri_ Ast'rnlnltoare clacmentelorsint clich-:urile,sunete scurte 9i inaltc' rL<'tltr'
    sau in blocul a" ,*r"i.; .if*e. r, r, i't .*rritolic, situate la inceputul sistolei,imcdiat dupi.zgomol rrl l'
    Absenla sau sci.derea intensitilii poststenoticd.aortici
    aorticd pulmonar'
    sau.pulmonari'
    sau c/?cR-ul (lt r'Jr\'.-
    zgomotuJui r'rLtluc iilaiarea poststenoticd.
    prulmonararati. cb. presiulea in artera'pulnion".f
    ff-f"u ln focarul ' '||, Ilr:rduc'dilalarca ^p"t."p"'.u jntcnsiiatc'jos, pt' margin"rrrlirrgi
    jos, p
    "j- .rollicir.i, n-""
    sc DcrccDecu maximummaximum de intensitate,
    U", sau ci. pozilia l tl
    ^spatiile eiectrc lrt s('
    illtorci pulnonare este anorma-li. ""t" | , tr'l tl lului
    l nl l in 3-4 intercostal, iar clickul de -pulmonir
    (exlmplu in tetralogia Fallot se audc
    ".---^-
    .^^-'*'---;-aa ct4noi r ctcrnrrlrri cnafirl ai inl{ r ( r 'sl; r l
    lllca intr:rlost;tl
    al Il-lea
    rrumai inchidereavalvei aortice Ar); r,,r,
    ||'
    r r'l )(| s1l
    sus s pc'm ar Rinea st ingi a st er nului - spat iul
    componenta pol*o.rurTl S, nu se audc, ', , ini. "Jit "t ea in I inclie dc r cspi'alit : ( sp'c dcosebir c d"lilir r l
    .::r"r".* pulmonare
    srrinscsauin tetratogia
    Falrot,zgomo- rr
    ' ' r,' ,,,ti Ji .i
    l l r').
    lli:1i,,,1",.^:
    ,,,,.,rr rr-r,a :l
    nu se mar percepedeloc deoarececomponenta 'n
    pulmonari estc I{ i1.rnul tlc ga-lop reprezinte intensificarea a1oq1a1tr a zgomotcirr l l l
    slLhi ;i lntirziati,. iar componenta
    aortice este acoperiti d.e suflul sistolic ' tt ,1,,,.1'Jctitpcrccptibilesi intense(ritnl in 'i limpi)' ln rapori crr t'r'rr'ltr
    <:csc p_relungegte ' vnnlncular' I'r'xlrr:r
    plni la sfirgitul sistolei ventriculului
    drept. ir.' '.rrrli:rr'isn b"scritr lrci tipuri de galop-:J) e; op
    Un zgomot II unic, nededublat, poate r,rrr, ,,c,',rttuarcaanormal[ a zigomot[lui II1: b) galop stria], Prin irrli'nsi-
    indica fie inchider.ea sincronl ll, .,r,rt rrnormall a zgomotului IV; c) galop dc sumalrc, pnn supral)lrncr('rl
    doui valve (aortic5. pulmonaie) .uo
    :: :r"i, ;i potrrru_ rr,,,rrrolr,lor III qi IV.
    narr: (trunchi arterial comu "lr"rrfu "oipoo"ot"i rt;ot
    Ititlrrrl de qaloD trideaz;. un miocard dilatat, hipoton' .clestius
    Dedubrarea
    ,ro,r,o,or*?,il:,:l" cn ,i ,.ll-t,i,,.." ioitita ti rapitl5. a singelui ln timpul fazei rJc utnltk'r'r'
    r:irrc componentele siqt de intensitate "LTT:T?,azr r.esprralia
    ;i rrr ,r,
    ', atriale (galop lrrial) -:r'rrrtri
    egald., este aproape patogrlomonicl ,',,,,1t.i(",'lut,t"ttiii.J"tt..tointimpulsisiolci
    'jl:rloj,ului
    pcntru defectul septal atrial. rr'','1r.' dc sumali,' oste ;.ecasi ca si a ritmuriior d( gal()l)I"l
    Zgomotwla/,I -treaeste rezultatul vibraliilor r , l rrrl l i zol l t.
    procluse in peretu ventri_ binc in
    se aut l m ai binc lecubiI latcral
    in tdecubit st ing- 5i ln
    lat cr al sting.$ lr t . t i'git r -
    .culru'iaflafi tn stare de
    relaxare qi supuqi destinderi il;i;; Z1;onrotclcc1cgalop sc-audmai
    umplerii vcn- , rr i rlrx'rinnii gaLopulllr
    in cazul gaiopu) ui VS) {S) . Galopul
    Calopr r l VD se
    sc audc
    aud' dc
    d" o1;
    olxcr 'r ln
    .1pid:.d-.la,inceputuidiastotei. x' .!i ani r (lin
    l.1i::1,T"
    rrti)rriifatcla virlul cordului
    il;.;;;;;;? maxrnum
    - d. ,,, r,'i,,', iringi a slcnt;lui in partca irtfctiorrir'
    cu pilnia stetoscopului,aop? in.pi."!J,
    i.-.i"*_ ptticardice se.datoresc
    rr'ritrrriic pt'rieardite
    lirrrlrtrrrilc se.dato.resc {oilclor pericardicc <:ttlsttl
    freclrii {oilclor
    freclrii
    bit latcral sting. Acest zgomoi diminui. -...taccentn"ari la -in lL
    f" ir.pi."f l r' rrr i rl (l litL:lcrr uscate
    1L(i l or_ L l s c .l Lc sau
    s i l Lr al
    dr pencarolrelor
    P l rru4rurrLrv '
    exsudative
    "^"i ::_"1..' -' debut'
    * ----' . -Scltrclrp.itl
    irfr:cfiunile care cresc umpl"ereaventriculari. 9l lrr
    stingf, (defect septaj ventr.icultf, ', '';' lnrliastotiL,irumailnariamatiti{iitl1t"i9h1i::lltif,iii"l
    l' 'ii,,in,""itqi
    canaluluiarterial,insuficienln i ,,, .il .;;i dc la o zi ia ilta 9i chiar dc LLtttr
    mitrail). ie poateJuzi6i Ia copihrt ""-i"l "
    ';:ril'J1ii;,^
    iiffiff:t"
    . ..Zgomotul, al IV-lea; corespunde sistolei atriale si cste rczultatul vi- (li6'
    lrrtLfiilol produse in ventricrrli ln
    timpul sistolel atriJ". lErt" .u..,r.i pur- iii' r"t;:i;i*,'"u;; t..'tot .It sistcmuluicardiovascular
    t:r'prrt auscultatoriu, constituind ',iii,iiiii"
    mai mult un sernn fonocardiologic. Ctrrtl
    r:stc pt:r'ccput, atriul drcpt are vglsp1 A rl r tl tt r r lr r r lr . t t lt -: r l, r lngt lt t i ir u 3 cllr zr ' |r inci|alt :
    sau presiunc crcscr:ti.. In rx:r,st siru ilrtl)1'-
    r:irz sr: nrorlilicir cu rr:spirafia.Clnd i tlct't't ir tltlrli llltx sanguitr cxrrgt tat printl--o valvli norl)lrlli-L
    uu sc rnorii{ir:ircu tcspiralia,
    irrrlir::L
    insrrfir:iltrIit
    \' )triculrrrilstir]gij. lxxLte
    4\ii
    40(i
    - tr{.coltcit unui 1lux sanguin noflnirl int cr at lialir c r it lr '( ) ri ( lr '\ r I '
    :tnorrrralir.,in tlircctia unui vas sau a l)l.intr:o valvl ingustatir 1 ,r ' l rr.rl r' 2 , sir Dt im ilr i, i'r r sullul dc colnunicar c
    unot cavllaL(i:
    -- rcgurgltareil {luxului sanguin printr-o 'valvi
    rnsuficienti. sau '' ' il,',,\\'ill'
    ll"Ji$:l illt^"I"''u, anumitorcrt'rrrr:1r'tr':
    aprecicrer.
    ;il,: ; lirjil:ll
    anomaliocorgcnitali (comunicarea"int".i.niii"uf".i'al
    exemplu). ''"""rori.
    ;;11;xl'h'*lltl1't
    iii,i:t l';l':iru::"fi .i I ;1
    l;'
    :'i''' ii
    tlL JJ
    .i$;,\:i1f;it1lnt"ri 'l"fffi
    t; ..:,T:',:',U
    f,jt,ll'^:::T,;:
    i'
    - tr ,)t. J p-?.. .o .
    d-, J/e.-o!,J _,/f-./o
    l i' ','i,,,,r
    ;;.Ul
    "dcsecuntlc
    ":"1d*h1^lf,lirllT'?Jil;
    :i;l|;;;;,;
    '";;.;i;";i'J"-io-so
    :,:,'1,"i:'il:$i:1"i.ii:l'":".'"1"'f;si'l;
    :u, ":,i4ir:.:'ll:;*Il,J
    ,'I; : Iri;IIi li'qi'; j'.i#
    i"till.h iilriii
    i:i,i;iili":i'j.i"i',
    ,1,,' r,r",, irrsc,t'stedc frermir

    ;ir,rr,,rii,l":tt*5}([iti]jT,i""';f
    L{T$jril5ffii{
    II rt t I "t
    3J'tia,r""),:i, i. : j:i:j';*1
    llil,ri:,lt li*:,itll;*i,tTfi
    t!:#e."r*::,:l* ii''-,i;l,
    il1::
    L j
    .'
    *'*' "* -*,_ 7/''""1
    -I{yl{?$14^i4r
    {,";8"",W/t?,!!lt!?1,/,,f!,:f{
    tuf/L d.tt b/tc t,)rtr.. g;!,il/{f!x i:il,i;'; iil':,il'li":,-"':"til'ir:"11
    *jljii:;,$;.t*1l"l"s*.t
    _|
    t.
    ,.1!.jrl__ g) Juflu dbclc/rc ccurl dqti €.7rmola/ jala/c ;rir*i';il[:;:r:*=t:i,:13,*ffi
    li'qi.1*J*'";*,i
    htttir/i;i{ii'!g;,1,/r,f,,fr
    jt"f :i{!.ui,,a,ztritensttuh i'i,li','i,,,,'.i'.i,'t"ilJ' "'t"*"f il"*ll.iT{i"l,.jg,S.iilm
    ,ll,:;l,1
    lil;lrl",'L?il,I.']it:t
    (l''"t" t"'.'*t'J,ix;1,,;..' tJ_ilfllt
    i,,s,,,i,:
    lltl; i.J;.J,,, r
    't *Ig;",&::lt7i;
    /:isr?:Ettrslg/"*",,i, lj ,,,,1,"'
    rrtrtr;'
    slru ,l: r.., tir ;111ir1|^,artL:fittv 'rrt
    .Fig. 3, 2. - Succesiufleain timp a principalelor
    sufluri cardiace (dupi Sokolo\\,,l
    M.l
    r,ir s,,tt',r ,n,:zodiastblict"":n:,ii"#.'"1Tffi:iTli],'.-}i:tJ;
    Tt:,l,1ll,i;;l
    mentionatecel pulin 6 aspectea1eunui suflu r, l l ' r i rl rri i l r ; ingc pr in valvr
    ,n.^^,,Ti.Oiii (4. Nadnl| r'rrrvi sLu.,,'r,to,i,i"i ', il''';,,11,'l"l1
    descoperirii sufluini prczintj. rrn^ori inicr.cs: ' | ,rttl l tt lr Llust :c1e sist ola rAl;il,t"'l*lt:":?-:l',lii"'.t*to

    I1l:!::* (' ii;i'"'iiX':',


    ";'J;1..i
    lirsta
    ;: :i,il,f l,,:.
    aortic;i) ;';;:1.ti"'
    ; suftuia" co-""i"irJl"i.-*"ft;;;fiJ;',j""?'i'; :{iH;i
    sauide stenozd
    , t, ,r ,.,,rrrnitrllir, strinsir.
    l,L:rrlILr;r.nl1iza suflurilor, tle ulr ajutor
    ..iot
    pr:c!ios,est(. fonocat'tlioEltitlirt
    *i,i ti..i*,.i'B iitili;llliliiii,."',llllll:
    :
    .T audi inainto surjiriril,,,;ist,rlicc ""t"
    .
    : r 1 , Lt . L ,P i , Im t) L I[ '
    Tabelul 3 ', r . r '
    Cafactorirlieile cllnicc olo suflurllor Lo
    ' "li,,l,:ill1i1;11;,11,:ili;';l\lk,,ii;'il',i1uno.i
    '";l,i'Ji
    ":r.:i:::ill,,lx"xll;
    ' . 11,l:^ '
    ,:,, rl xri.:Fi in r pv oiulir
    - ar d, i: r c t r :
    iuperioari...r.Lnai;iili:
    ,,, ,'i,,r,,ii,,iiL'ii ?11'.::"iT:r:i;i":,*
    ll :lljlfly;:it;"T, itiiil;.o",ll="*,1ii1,
    ilit",,.,ii." ,,ll' l
    i,ll ;; ",ii,;'i'1,:l l,
    ,illi,,i 1'..,i
    ,,,',i
    ,il'rr e
    triro;'
    sLtrr li",,jlllli
    ,i,,,ir,irii,;",iio'.u,,,ofl".n*,:iy*;":"t;"it;,W:,l
    1,,,,,,
    l,i **::{:i:l{i: J;fi1;:jil*,'"j1.:r,'Tf;,ilL:j} p;;;;1,'
    .';;!;"';:,;:'ii!,f#,i';;;''- mr
    protoziuo''
    ,. ;I,:;i;lii::,
    (de,ocumorivs) "ii3jJ;#ti"*,"".*unn ,, ,
    . i |cn1r, , r f i l c r ijr ^ r i.e g r r t,,t t *r ,
    r'J , , t , ' I i r r - .:,, ' 1 1 , , r , * ,tir q r o tiu L .,,r ,r r tr r t { L r ljn c) rl't;ll'
    l, | .tsl,tlttr.

    i:;ill
    , 1. l_ 4 ( t.^ r jn c)
    , ;'il;], i ,,il;l;i1i;,1':ii::ili
    "',,;{,1'oii,,!,,,
    '1il.lilj:lliil::ill'i';ilil"l
    li''liiil:'ll
    ":'1"
    1, . l'u { : t u l r r r i r x i r r ) ei illtco si1 i.1 i
    1 ; r r l t l 0 l i i t r ) c r l i 7{ l.o a 1 ,:i!Dsr n ir jifi
    tl| r Il) ,.o r n l ki t i ,i s]\nto) ,:l;llll" :l;l ,"'",
    :,il;'i , lllfll' J'':l
    ,ll'l:iilj;;l 'l:1ll'lll'' iil
    , lli{ } 'l l l l l
    '.llrroz,L pnlt)t{rtarr' 5i aoltit.r'lrr rrivcl valvul.ar; o parte din sullurik, ,,jr
    ,r'rri r." s ir r l t lc t ip ej c c fi o l i rl .
    :ll'iltilill\;,1^1il:':1"*fr:;,'ix:;""J;lr
    ti"!;*f'j,'f'"':llti:.1!tli'J'il.:
    i l,ii;:,,."t,i:i:itli;x*;r'",1;*mrm!i
    .
    ;,t(lurilr sislolitc de r(!t!tkit"tli. inccp cu primul zgonrot
    I,i r;r l i r z s om or r L[ [ I , d c c i i i n t h b l o .i s ro i i c ..
    5i s,. ,.r,r,ril
    ;,i;'li,
    i,i,,
    . . Sc aud in. comunicaliile interuentdcr are, insuficienta rr itrall, iLrsufi_
    , i, n trr tr-icusnidiani. iii|;iii;,,il*irs?i"tt'?$"t1'tili1""'81
    rsuin
    sa,
    ,',,.,,,,, ri,".'iui
    ln inslficienla tricuspidianS., ln timpul inspiraliei, presiunea rntra- -;iii*,"lt:*,lff1:t;$:'i:*"li;,:iilJi;
    l,,rrcicii
    cii.scade,
    scade, ceea ce cregte
    cr-egtelntoarcerea
    lntoalcerea veiroas;
    venoasi.Ii
    <irrlir suflul se accentueazi"pe marginea stlngd a .t"*"i"i
    ( ;r.rvalho).
    atiiul d:rept; ln raons(!
    Ia ati.iui
    i."ir""f tr{ivt:r's.
    Degi comunicarea interventricular.i qi insuficien{a mitral:i se canrtcri.
    ii,;;.,$iii;,]rg*;i;i;;i;1;'1i;,r,1
    n"illritr pr monarei. !^ +
    zclziL printr-un suflu holosistolic, aceast-eregule comporte exceptii: untig ii 'lli,i;:iil'i":t"-?,i'rq1":i'""'nt'iu1 -
    -

    ,,,:iil-*ll*:$;'xlit*+l'ltp:*'*t?
    ...n'.rniciri interventriculare de talie mici.; comunicdiilej intervbntricr:lara
    r:u arteriali. pulmonari. obstructivl pot avei de asemrtrca uft
    ^hipertensiune
    srrllu scurt gi cu caracter ejecfiona.l.
    Suflu,I at'ical.pansis.tolic(hohsist.olic)iD,,lignituri de vapori,, tracluca
    ":"li[iii:
    .rploape coltstart regurgitarea mitrali sau tr-icusfidi" legate de -incompctentil
    r'.rlv,.it,'spective.
    ;{{*{#ffiffi;
    -!:rliiy!!i',{),':!,i,i,{,,1,r
    Srrflul holosistolic are un numi.r mai mare de vibralii pe sccunrl?t
    (r' rlai lnait) si e mai muzical decit suflui de ejeclie. ii*'iJ;**i';5;*x,1
    rrrti[dt$:i'ftiJ:ffi
    f
    Tnterventia farmacologicl accentueazidi{erbntele intre suflurile dr eir:c-
    (irr si tx.le pansistolice, la adult. La copil insiL, loca-lizarpa stflului, tr;ins-
    nrisia sa fi cali,tat:a suflului ajung de obicei pentru identificarea llziopa-
    ""''ilihTJ':"**il-t:i*i'J.':il"1'll{tt"'***',,*
    l ologir.i salc (W. G. Guntheroth).
    llnclc sufluri nu pot Ii clasate lntr-una sau alta din aceste czLtegor.ii
    (rJr'<:jec!iesat de regurgita{ie); dc exemplu, suflurile produsc de mioraido- i,ir,,*m:r*:#*tffi 5ii:*
    fii4,31','ffi
    :*:p;.;;
    i'r"'
    lrirtiilc. obstructive complicate crr insuficienfi. mitr-a-li.-sau cele proclut cltl
    rornunici.rile ilterventriculare cu stenoz;. pulnxonarS.inlundibulari.
    ii'rii! .id"ffiii:T,,$J1'.r*:;:1",?1
    . Cal,itateasuJktlu,i se poate cxemplifica,cu su{lul sistolic de insuficitirlfi
    ruitralir sau de DSY, care a,uun caracter uniforrn, cu frecventi. inaltii. Soicr
    rir'oscirirc de acestea, suflul de- ejeclie de stenoze aortici sau pu}non:rrr1 jl:i:;
    ,;",i4-ru1;rutl';U.:t"*i,:i"i,'i
    ilfriilii;il+$+;;#**+-*-LLt.t
    .,r,
    ,u('.spcctru,larg
    slnciru lrrg clc
    dc frccvcnli, dind
    dind un-suJlu
    un suJluaspru, ln comparatie cu sullul
    -lrccv€ntd,
    rnrri drrlce din .insuficienla mitrald.. In plus. suflu de ejeclie cie;te plni la
    rrn uraximum in miJlocul
    mijlocul sistolci ti -sufluri
    un maximum 5i se transmite bine spre glt. Alte sufluri
    ",islolicr: sint cu caracter muzica-I. Suflul de stenozd subaoitici (secundarL
    {secundarL
    hipcr:tlofici miocarclice idiopatice) are un caracter vibrator gi se audc ln. il'; ' ai"li'i'' a;:,Ttj"f:#Jtl;.]i''llq:,',::^tLrr)
    poar"ri hor'rri^st'rric'1
    z,rna infcrioari a marginii sternale stingi (unde uneori se pcr.ep suflrrilc
    inoccr:tc). Uaractefl
    inoctr:tc).
    inoc(xltc). Caracterul vrt'rator
    Caracterul vibrator al accstui sullu
    suflu patologic,
    oatoloe"ic ca qi
    si-arrsnrlhlr':
    auscultar-calrri
    lui
    " " l:l,*Jii" t'l'r'l
    toar'l:'
    urml
    irrt:rc apcx ti marginea sternaH stlngl inferioarS.inlesnesc diagnosticui rlif<.:- ,,ti:li1';l::u;itll"."T,'"11fiil1"i.:
    it1y^-,';1tr1.
    petiii:fS*:.*l,RitX'l'r"t'.''."i::|}'lliiii:llilil
    llul i rrl . clntors
    ,,,,i,l,,,i,i.vur
    Sullul sistolic rugos
    rllr'1:tc a sternului cste de -perceput
    ia extremitatea snpedoarS.a maqinii
    asemenea relativ specificf indiclnd str:tioza
    iiji;rlrrut* ji:j::l',,r
    3ri1
    ffi'!ffi:}1;*ll?"lffi
    $htlTjttf
    ,rolt.iciL(suflul $e cjcglie). Spre deo.sebirede aceita, suflurile sistolici: pcr-
    IX. margiu{r srirrgi ., stelnuJrdsinr mai-prrlinsppciljcc,corcsprurzinrl
    ', 1)rrlr'
    Ir, llt)\ r i.lr.nOZCl)utmonilrc' r-CIA vc pnn d-blt pu.lmonar CrtSCUt (rl,,lr.Ct
    gi;;r*;::xy;"*:f'}""','$
    iliittisinl{fiq,'l r
    r, 1 't:rlrrl tiir l, nc r s is t . : u fi rl o c i L n ;rJ ;rrtr:r' j a lfi),c fl u x u l ui mi .ri t pri l rtr-ul t' ,J,,f,,r:I
    r. ,.l ,trl vc r lr ' ic ulal s r r r(E u rg i ta l i ,' i tri c u s p i ,l i u n c . Intr-o proporl i c srrrrrri fi -
    iffilJlfi
    rrlti,i;i;rt,, ;r;irr',1;i'
    l.l]lr...
    ,-irlivit tlr: citz,uIi, sulltlr'rlc ])crccpuLc pc mtrginca sttrtglL:r, str:rnulLri l;lnl
    -3,i:,i#t**j*lil,ritH,
    4'io
    ;r r l i r "i sr :r 'r r l "ti'L l ) l l sliut l l stsr
    U l t) ii 1ir lt
    ( 'r r t rr ,' ' :r
    sislolit l ' t r lsuht i lt t
    " lr
    , P(i1lrr'( in rh.ft,ctul scptal atrial, lrr clrrr: llrrrrrl (rcscnt ptirr val\ril tt,ir ll 'l'r rl ll hl
    s l rll lt)ri Ll
    l t irl ul ttL
    t ' r' trr'x.tl , ' ' rr" '
    .,,' r.. ,.i ;" ,.i ( '. iut i[ I ) , : '1, f n
    ' ttspttlr-rprodrrcc rur suflu diastolic perccput 1x, rrrLr.ginca
    rrr, lir
    I ur, Lr cxtremttatea
    r:rl rcmitat(.a sa rnferioara".
    stingiLir str:r.rrrt.
    ,;lili'
    ,;,1 r;l''ill;',r'J' lll:iit;*i:tH***L:li;";;::'l;
    . : 1. . . .
    evic{cntc illt'l'
    cinrr
    1,[rsrrr
    inferioar;". SuJlurile
    SuJluri]ediastolicc pcr.cepute
    tcr.cenutela baza cotlrrlrrl
    rittt dctcrminate in majoritatea cazurilor de insuliiienlir aorticir (suflu dcs"-
    .or{ JrrI nl
    'llX"Jiii;li
    il,fiu.lill;,J,"1i1ilil"|ll;,iil'ii,",jiiiti"'r.i';i";;;i
    rr
    ( rcsccndo, dulce, aspirativ, cu {recven!5. mare,
    care se transmite pe nur" 'ns166{n
    ,":.rT^,j,::lfllil5,n't)-|ff?":fi',,':";i.'jiJ'' ;i
    ltir{r stingi. a stcrnuJ*i sprc,vir{ gi carc 5g.a11jsmai bine-cu diair.rgrnll
    slctoscopului in protodiastoli) sau de insuficienlh pulmonara.
    SuJlurile sislol,i,co-diastol,icecantinue (tnnelar, ca o locomotiv.l) sln+
    :;:il";;f:1t;,h.:A1';lh
    'Ji'5lilj,:ll;
    t.r,;I;iluji"ilt*'nt i:l::"ir*;T,Jc
    ,ii:,,'' 'tffi1;i$={$?:"t"";
    iltilnitc ia copil ln douiLcircumstanfe:in pr.ezcnfacanalului arferial ia,i'ii
    srrflurilc veno,ase.
    legi dificili, diferen{ierea clinici. dintre aceste doul etiri
    lo(ii cste posibili. Sullnl din cana.lular:terial permeabil se percepe cu maxi.
    rttunr de intensitate subclavicular stins. atit ln oozitie verticalS
    Pozi!'r verticitS cit ;i"; i-
    lxzilic culcatS, iar suflurile venoasese perccp cu prec!.dere pe a.ia "i+
    ln
    illli*"rtn:";*xl
    *\,,:..i ;s*:f1t"H:::f
    * ;icrrca.'l'
    ;t#;l::f
    de'i,rg- ,,
    ,1liitt*lgury**t*iii
    .,llrltalrc
    rrrltatic.
    ultatic aortici si in vasele vasele de la baza
    baia gitului.
    giiului.- Sullul veiros dispare
    SuIIul l-enos <lisparesa$
    siu

    *t1i
    ,rrnrnllir
    rlirLrinuirpnn prin comprestunea yenelol juguiarJgi iu
    cornpresiunea".venelor ln pozilie
    pozi.ti,. culcat, in -tirnp
    timp 6p
    Jugularc $i co

    ',;
    :r,.r'1,'aci
    mancvr._nu modificl sau chiar cresc irriensitatea suflului continuu
    rliu persistenla de canal arterial. Daci. suflut c tipic, diagnosticul de FCf,
    s,: v:l pune chiar dac:'r.modificirilc radiologice .".i ECG lip."r".
    Suflul de PCA devine mai puternic ln sistoll, cu maximum l^t S^ jlIjiir,
    ruismnr;isi?'i'$';l ser:it';'|'
    x5'#.li*i'r:1"-"'1or
    |i :tpoi tlcscrtqte ln diastolJ. ln caz de hipr.rtcnsiunepulmonari, faza di,.rG-r
    Itr:i a >uflului dispare, in schimh faza Cresccndodin sistolt sn tcrmin;-u
    r;u
    "' '.'';;,i;;],ffi?,:1j,,,
    u;,1,.1oJT,1":.fr:"?",..*"T'J
    l'"ilffi
    rrrr zrrourot 2 puternic (acesta stabilegte cliagnosticul).

    ;,,rltlt#*''*".iffi t:iffi ui
    .ll.rr.lieroaunui suJlupoatc {i uneori d" aiutot. pcrrtru orecizareaoripi,il
    lrri. I ),. cxcmplu, suflui- sistoiic apical cu' ir.adiiro in ixili si 1" b;'i
    i)UIr,ronrr.1
    ""'
    ,r,itzir
    -sting;
    :':"'.''
    posterior. este caracteristic pentrn insu{icienfa mitralil,
    ::lfl]'r..i-i:l:11.^Il..jll 1. .baza
    cordr:lui.cu.transmisie suprast.rnatifi ln l,
    i
    lirtulrn estc datorat foarte probabiJ stenozei aortice sau pulmonarc,
    l)n suflu care sc transmite dc la bazi la unul din plnml4 poat6 t pi"*r*
    rlr..stcnozaramurc-i clrepte sau stingi a arterei pulmoiar"- f..'".-it*"5',ioi
    srrflLr poate modifica caracterele s-aleqi se p6ate pnne lntrebarea rlaci nti
    ;',' li.l,;,hf *:i*i'i+*;i*+
    ,rrrrvlr sirrt doui suflrrri diferite (conliextul-clinic i factorul clecisiv).
    . Ilxamemrl laseular completeazd.in mocl obiigatodu examenul iardiac
    \r l)r'('sulune palparea prrl.ului periferic
    \',r paipa
    v;L I); pa siniultan
    srnlulfan la ambele
    ambelc artere
    ;i misuraiea t.nsiunii arterialc. S0
    artere iadiale
    radja-lcsi femurale.
    fernurale,
    i: ,
    ,i ,iI,ii*|.,
    -fr;ffi
    t'";i;,,1';ll"l
    i,lllilti,ll:l,li,iil;,",_,q,iidl;rl:t:;,,1
    trt'utl
    ]irccaentnrful.sul.ui pe minut este urmi.ioarea (J. Stcirmer):
    Nou-rrl,scut
    I'init la 6 luli
    90* 180(12s_ 130)
    1 0 0 -1 4 0
    'iii;15l13i'ffiT*'s*
    sim*1tati ii
    a prcsi''l':
    6*1 2 Iun i
    2*6 ani
    100- 120
    90- 110 lli,{;i:tl'';ill,.I,;i;11il:::i:i"-':i
    ,,,,'f:,''1,,"
    7-- 10 ani
    1l- 14 an i
    80* 100 rrr:rldicat
    . p:,,.l
    Nlcl.otr;r .t;::x:1":1iT1,.i1,*,, u rnai5.].':ii
    70-90

    . .. Absenla sau diminuarea pulsului arterial are o marc valoarc. 5cmicrlp.


    d"crt
    sang"i'r
    l1i{i'lfii,iil1;11.'i,lr;i';i;;;iui ,, t".,r,,"*'t,.ilo "]n
    ,, t
    : i,;'1.sugnrinddilgnosti._uld" cbarctati,-cind.lipscsfcpulsul f^murrl,
    ;r',nlciLstnnsir, pcflcardrli conslricfivii, sau alri catrzi de Scid"rc
    trr r'iuitrilc (poc, insulicienfi cardiaci), cinrl pulsul nstc djDtinuat lx
    stcnozil
    a dcbitft. ,,,,.,',,,,
    f:..],Jlll;l,,li:l;iiiil:x$.'"{#1
    .,ri,,,;*i*r* l
    'r,,,'r,,i"ri
    toxt0
    iuri,r,t. rulcut radrxt, humcral sau femural siltdrct
    5i vizibil sr: inliln(,sto ,,rsi ' " -
    ir iusrrlic.it:n{a aorticii, pcrsisten_facanalului arteriil,' tircotoxicoz;i,'-i,Uiii,
    .rur'rrrrr.,Irslrrl;i ,rr-tr'liov|noasir,bJoc cornplet. li',',1"'
    ,,',',\,ili:'',i,1'', l*ilnq{l,i:;i};:lllr'.,,lll
    l;illi"J:,[ii:r'i;'
    lilll,l; 'i]l'i;i-"
    4'.i!
    .
    t) .litrt.tr.trlii,t.lt'o:ril tutlia(i .ltr.:nlrtr, rtlttrltrl /.I r.rlr,: S0 I Z\ | ,,r Lr ,1r ttt l it yir sl: t t k: l it l q; i I t : ur la vlt 'st a dc 5 r t r r i ( r 'r 'slct t 'ltr lillt t "t r
    ,f{) r r 0r llg ( r . , v i rs ta l n a n i ). rr, l i , ,rl rtl tt i r : t t nr ar t incit lot unjit iL li dulcr 'os ilr t " l) lr r r {' im lxr r lir t t li ilr
    "
    l 'r { 5t llt r , il \ ls t o l rc ;i c s tL ' i n mOd n Or-:l a l l | l i ri l i tarc l i l ntcrD l rr(]l I ,lr r( rl irtstrlir:it:rtfi'iiardirLcc (vr:7i cairitolul rcspcctiv). Ih {icat prrls:tlil
    roi l la ccli: .superioare(din cauza sumirii rrDclcilutcrogr:(li: t:1r rrrrlX ' irrrti irr itrsrtficicuta tr:icttspidiarlirsau in stenozzt pulrnonarii c1l s( l)t
    t,t\ ,(l((il trl rrl ri , rrl :tt it r i. it "t : i: .
    'l'l ,.
    ' ttt\)u
    ti/'otrtti,
    t,l t)
    r: lt::rltt,,:,1
    t . ' 1, .rs;ru
    ; r r r cL,l
    ,_,r,rr: cccJ
    r . l pulrn
    cf.l p u l i n cegala
    pu{in
    pulin g c l a cu
    egali c u preslunca
    presiunca
    p re s i u n t,r de rlc.. la
    rl l a membrclo
    lrr.mbr.,:i<: sl]lx,ri(,
    sulx.ro rrll,
    \,
    \, r ,i, -\:r\7.
    ,
    ,'.i trr lirrrl sittttfi-jc ptr linia llrcdiani lnsolc5te boli congcnitali: scvctr'
    ',r:.
    ',rsrrl(.ri
    r ( l, . r i i dir
    diagrosticul
    g ro s ti c u I c o a i c i a i i c (la
    d e coaictafie
    de 1 l a copi
    copilul mai rrrilrc c{. I
    r ,\| l /<lovr:clit
    ,trrt.r'sir' t ov { \ nt dr ,l (r', rrItir:rrI rrnic, sindlomul lvemarl: etc.) Srlzr.>" il?i er6,,s colrll)lct
    dccit
    (.rL d daci. p re s l u .d d
    a .x presi*rea de { . lil a rncmbreie
    rD c l nbrcl c suocri (,stc , I rr
    oar,. r.\1,.
    superioarc 'l
    2 t t r lr n l- lR lna i m.rrC d e c i l p re s i rrn e a< j c Ia mcm' brr,l ej rrf,.ri r,:rr. ,r .' l | r' rr' r c, n) nili( 1i( : s"vnr i.
    I'u l i r
    l,l(,r()nrAirlit cstc irlportanti pentru diagtlosticui de endocartlil:i
    l',,r i rr,, rr,"rlir ,ri (si
    (si rn..Li
    rrrrrll.rnli
    {s r rirrrli. r;utinbcntru
    rrutin
    l rl r} rrr bentru
    Pcluu diagnosticui
    dialnosticui
    u a o 6 u u rL rv u r de cardiopatie congcnitillir
    de cardiopatie congcnitalit '
    Valorile 1'rI la copti ile diletite llrsto, h nrm Bg (dupi Na,lasf ' I' r , .,," ;'
    ', lii
    ,i i i ,
    :r, ,,,*,tiil',.i1
    r r r s, , {it i'de linefom.,pn-lie
    lr npat om egClie, s]lsercaz:L
    st ger caziu ci om cgaliir tttt
    heoatorncgahir
    hepat tttt
    , ,l , ,l, inr.rilir:i,'ui,'r ci silt d:rlor;rteambolc unci infectii sistl
    <:rLrdiacirl
    _!9I"'!f91 :lrteria.ri. {mml{s) ru t(,rrrllr(r{rih) s.r.llultei hemopatii
    liirqta toracic) sr"tgr:r:trazii
    abclolninal (cu sau fiLrii s'ifutsi tt"-t:t'stt's
    ,ltr:; itt't,:vstr"s
    r" ,r (u o t:arcliopatiecongcnitall
    80+16 {6 + 1ft
    89*29 69:E 10
    96+30 6 6 +2 5
    3.1,3. TESTEDE TABORATORDE RUTINA
    99*25 6 {+2 5 IN CARDIOTOGIAPEDIATRICA
    100+ 25 6',7): 2t)
    9 9+ 2 0 {t5 :L i0 llrrtrrtolrttlrlt utinir cYidc[tiazir albutrinurie Si u;oari hematuritr itt
    94*14 55 :L t) trr r!1,, nlii cLtrlirrcit-congestivirgi hcmaturie ln endocarditelebacterienr"
    100* 15 ',
    fi z + 1 5
    56:r3
    56 j: lJ
    Ilr^rr14;runrn(,ornpl;tii co'jtati leucocitozi moderatl in i,suficit'r rl,rr
    r05 + 16 5'7 l, !) , ir,/ , r , riiIx;rrrlii.:r Bactcrianrisat in rcumatismul articular acut (cu sittr
    107+ 16 57 I rr , ' ,rrIi< icrr1ii c:rrrliacii).Tlt:matocritul este crcscut in cardiopirtiil: r'ott-
    -ir:)
    1 1 1+ 1 7 J 8 +l 0 r irrttogcttr'.listr.' olrligatoric insir. determinarea concomitentit.fi rr
    1 1 3F 1 8 .59.l- 1r)
    l l .5 + 1 9 , , l, , r llr irrriici t titrrrcitart (vblum trritrocitar mediu, hemoglobinalliilr'
    t r.rlia ticdic critrocitari!de hemoglobilil) pcntrtt (l('s((l
    59 -t, 10
    1 1 8* 1 9 fnl l. 10 I rl ' r,!li. si r'(
    '('\1'il(:('r
    ntllrlo anctDiihipocromccarc necesitl tratamcnt (:ll li(t'
    r,,rr, , rrrrli
    ,,,,,,!,',ii"::'::"!.i?#rK,r{{!,'\::':J,*r:"f c obrigar<rri'
    16 'l r,' ,',,uilr,1,,'rrirr cstc intllnitir Ia adolcscenliicr:rcianozl sever:i.
    i:!:":#{i.:ioa,z lrrrlr,i irIr.r.sl,i!l !.iilebi'ehi'riec pr-ezint5.
    :
    interespentru bolnavul t:iLt-rliirt

    rrrrr:li,ilili f,fil,Fll;:ii: li,;'ii:


    :":li;
    :'ii'.,i,il;i;;l],,. l;:l,f
    ,l,1,,i:,: itrccusattguinri (iri:scutitin iripoiia severi si prcltrn;il r'
    . ,trt stt.ltt:uitLti,
    . r lrroi,ln' L lf Ira lrbcon f a c oar c ilt i|j.
    rrr ,,r , rr(rr r'rLtliitcii.t:ongcstiviL,bolilc renale cu hipertensiun'' ar'tcli;Lli)'
    ,t, , (i, iizrrliLin poJir:iii:rrriilcuconatalc),g&z.lesdrrixt'inc p"O,r,.p0('),,)
    ,,u. <listensia qi r:vcntualch biLtiii alc jrrgrrt.rrrr+ ,l; rrrlcrill siu ci\)rli\l, ttrLctdllliidc ;fazd acutd (YSH, -(P!], fiblircttrir''
    ,.., .i
    r,,r ,..."
    r / ' ':.:.:l:!-1...:..1rj,
    r ( lt ( ) it , ' ; . nr v:4t:.1"? f1r
    (.l u l u i d o l rc s i u t)(. J i n a triul .l k,pi (\,.2i ,;,t;i t;,t
    rrl rrIi r,i. r r |; rr r r r diali, .,-o n g c s ti v i .5 i c rp i i o l u J ,1 ,, poti rn,.,i ,n< )g,rj ' ,, ' '
    l ,l g r.,,,r ,.r ( !(:r( livi- ! ) -
    r'\; r r ) r ' uuI c : r r d ra c v a rr c o ml l ,' Ia t (u d :rtcJo frrr.rri zi rt,,,1,. r,1;,11r, ) l l\41f orlf!f{f frar:t.rrt,iqlt4liqrf l .sorologio€ Pfc,sup.u.tr,cul'tufi , /e'f cttllL' lt.t.l
    . , 1 ,'rl ;r lt , ; lllir ill' : i i i s l , m .. 1111! L,, (l )r.nl nl ciilr t ir r or l s. lr ( ] Pt ococuluihcr nolit ic- A) , kem ocu'lluvif ic. t t t t lt t
    l./rl
    Inspec,tia aprcciazii numiirul rlc rrspir.alii
    ,tt irrlil,' irrrlcosllri fit riirgnosticul c docarditi'lor: bact(xieur ti
    lul.,,rfrl
    _ !,,::':,',r,,!l
    )r r ir l, , r . luluonar.
    I n , oa rc l a ti a ,L l n N o n i , i n .p e c ti a si p;rl prrti ;r i ;.,.,l i i l or: 1i r.trrr," |t"., t.l\'lttlii t. l,itrttltr,i ./l'51-0 (l'czi 3. 11.7., pag. 960).
    , .).rti rt. ll' ir t l' t ( l. v il \.i l s p c o l a rc ra l o g t.o J S,,.Sc m nul ,r,t,,1.
    l j w ari t,si ,. rr rrl l l rl rtl f
    1rirrrrglriularil, situatiL lateral dc coloana v,,rlrlrral;i si la
    rrir lrtrrlrrr r-cviirsatur perical<Jic si carc
    biLzli, pirtoi3u(,rlr" SETECTIVA
    BIBLIOGRAFIE
    ti. oin'cornpr"si,r '1,firi",iiiii,
    l,;r iLuscultirtiu ljulmonari sc qg.at: pcr.ccpc: 'ezr wlxrzing, riilurr l r,i i lr,
    r:iu.iLcrlrr,url;
    ,1. i'i..1i. saristazir. InlbrmClii <lc.s!rr:v61'mul r"sp)i:iLtor:cu.,,,rt
    r. \\ ll1t 7in5) sr. poi oblin,-.gi (r:irr,.rr|,tr
    {ini,rr:a stetosr:opuiri in Iai,, grrrii,,:,,1i,I'Itri1 \1. l ' l rLl \r,t t 1.. C rrr' l i J , ,,
    'r .l l ' lr ' ut t lt ll s , P;L l 1 r,' u z.rr1 ;i ' .rIi ,i i rl ;i r.rr l , ti i rrl r,f,. ,, ,t,,' ..,,,f" ,i |
    'ri'
    rrrrrl ;i rr . r rf ir : lLt t t lr r ilii u i r c rtp i l ,rrrrt:7.l. l l u to (l l ro '' i tl , l ni11,,:rrrr.,r
    ri ,.l ,r,i r i ,,t.,,,i ,,.,,,t'
    lir';rl rrl rr is r ' P lr llx ' ir z r li ' i r 3 r' n r s rrrrrrrrrl i ;i rrl l o i i
    r.o s i .i rrir)r'
    r i i rri i rri rrrrr,xrri rvi r.rrr,rr;r [ti l

    't74 4it
    i , . {; lrN11 l l , ) t O ' t l . I
    ) nu . ,
    w ' c , _ In ila l li./.!lu a tio r ] o I 1 1 ) c( lr it(t 1, , l I.art
    1 9 7 6 , 2 5 , 4 , p .6 5 ' l- 6 1 5 .
    di scas(., !Lr]. ( ti )1, (.\-iirnrll(linanic a1 cor<luluice pcrmite o l)lttrii lrrtrrgirtclt antplitu-
    /. ll.ll,lSOtl L .-. S!!:rioiogia gener-al;, cardiovasc!1.rrx, U(1. iU(di.aur, Ilrcur(sri, 19;6.
    ^.
    'I'r'rr l,: l;rilirl r:rtrlirrcr', r, pulsrtilililii vavlor-djrr hil
    s l.w,\l),\S ,{.S. -- Iaediatric Cardiology, WB, Sarincicrs, Coml,art r'otalia pacicirtului (in lozilia oblicit si laterali)' se pot n'i<krn-
    lJliill.lclllia, l.trir(f l)rir)
    | lditi c r u , 1 9 7 2 . || | lr|( l uli :lscllllsc;
    ,r. ll()TiOT,O\\r M., IiC ILROY XI,
    (: x . i i o n s , 1 9 7 9 .
    - Clinical Cardiology, 2_'.t ltdition, Lange Medical ltrl)l!
    rrtrrtmiit:structuri extracardiace(dc c:;emplutimusul) pot Ii scp:Lratrr
    l { r. V l. r\ I (u R . , D L ' D E A C. - Pr o Dcd e u tica b o lilo r ca r d iovascul are, Id. \l edi catx, !uc
    ,l' Llrrllrr ' 'ruitt c:trciiaciL;
    ittpestio.de bariu sc pot cvidentia amprcntelc esofagicncsiul
    "
    lc lri , 1 9 7 6 .
    t' ,,r.,r i,,rrt;,tiuni r-crine, lirirr,l d.l cord ;i de vaselemari:
    'ofere inlormalii
    irt lin.l radioscopia ,si desprc.alte.ol8ane intratorrr-
    3.2, EXPI.ORAREA
    APARATUI.UI
    CARDIOVASCUTAR . 1' f ir',t ir rr dia{rrgmului,curburil' coicancivertebraleetc l'
    ' care-reducedozc rl''
    1,,;,, ;" ,it"r;; ; Jc un rmJ'liiicatorde imlgine'
    .""tnin"ie), loarie importanti. o perjoadi"t,rl('
    RADIOTOGIC*
    3,2.1.EXAMENUT r ,. ,'i,' ii , :tipui-4. ':t'' Attl.Pcnrm rlolo-
    ,,..rr't:,r,'j:r inlurrcrlc (lumini roqie) fls cnl putin 5 mlnute
    MIRCEAA4AiORESCU,
    MIRCFASTAMATE ,,,,',r' ,1.,rrr'.ri alcs p"11111 16rljcgrlIic. trrbuie:'i dlspunr'm do mrllo;Icr'(l''
    .rrrttr'
    ,J',, ,'; .1,.i,,r", p,'nrru im;iidica misci,ril""opilului i'r iimpul
    "
    Bxamcnul radiologic al inimii Si vaselor mari reprezinte un monicnt
    irr pozitir
    irrryrortunt al bilallului cardiac la copil. in{ormatiile obtinute, corelatc ctl ll'ntrrt o colectI, interpretare, radiogra{iiie v.ol Ii licute
    rlirlr'li'clcctrocardiografice, completeazl eficient examenul clinic, constitrr- ,,'rt,.i'i jn.piralj' prolundi folosind ur-nritnarule poei!ii 'l:rnd:rtil;
    '[ostcl i. (P- A),
    irrrl lnz;r diagncsiicului in majoritatea bolilor cardiovascuiare. Limitol0 uozi(il o]antoriorr
    ,\r1r('nlrlui radiolcgic sint dcficnslratl. pa dc o parte de irr,pcsiOilitatea eti. i.r-'ziiiuicler ali (dc Profil),
    r.lrl.iuii cardiopatiilor exclusiv prin mijloace rrdiologicc
    ;i pe cie altl partc,
    I ,,ziiia oblic-anl,iioarl-singi (OAS)'
    ,lc inposibilitatea elimindrii ur,ei carcliofaiii revpre in prezenla unui conl i., ziiir, ol,lic'anterioari-drtapti iOAD)'
    r;rrl i l l r,gic nor m al. f ,,',,',' tt,t.tti, ,.i.- nri iir majoritaicacazurilof () r'ilrRrrri. r:(li')
    ""li.i'
    ortostatism,ln proieclia postero-anterioarir (P-A)'
    , | ;i,';ji;;;iiiir
    3.2.I.], MEIODE DE EXAMINARS '| r nutgtrfil inimii Si aaselarmali ilregislrcaz'i cartlio-vrrr.
    tomogra{ii-structudle
    ln strat lrttrlirl'
    ,,,1.,r sincur strat. Se pot face
    ',1,, inlr-1111
    '"1,,,.", difi'rir, ,a(- d, :'ul.rlla.l'a M' t'r'l''
    [[ctode]e de cxaminare radiolc,gici sc I,azeazi {ic pe r _':plorarcarlixrlfl , t.,'ili" Jir.;-i ^cor1'ului
    atrjuluJ slllrS m;rrll' lrr r'\'t
    ,r 1r'suturilor card;ovasculare prin ccnrrast cu plirninii iadiotranspar.enti, Ijrr ',r,', 'i.rr, rrt.jl':irr jdLntilicarcasi dcterminarca de aortir' iL vits('l(rr'
    uliliz-ind substanle de ccnt|ast carc permit vizitalizarea ca\,itililoi ininii ,i' ,,ii, ,,,, ,tu.ti.-.t artcrial persistent,a unei coarctalii
    fi rl irrdrrrsr'l'i
    r:rsr'l o t- . ,, i,],,,',,,,' ,fi" irit sau in diignosticul calcificirilor iritr-acardiace'
    Iixaurc:uul racliografic lixelzi pc {ilur iin;rgitrilt care I ot fi a.poi ana"li" 1,,, ,,1,ilrrlntarc.
    /.irl{' li (:onlparzrtecu exatncneJeulterioare. Contrastul mai lun astfel rei izitt qrr{ic Iulsaljjl(^inintii.1i trsrlor rrrirr'i
    li,r,lial,ivtopraIia ' rjdr ntjrzir ic D' tr"ain'ir'r itnlr.'tt:'ttlr
    lr.rnriir, cilirca unor dctaiii care nu pot {:i rcpcr:rtc scopic, iar;radierea cstc: p,""u Ii a1'r'.^)atnIrili''co.1
    ,lc rr;ri rlicir imtort:rnti- ' ,,,,,r, tliiereilier-crt t9]",!ii19t lnrri(irr(li(r'
    , nr('lodirlfi plstreaza viioart.,.in contt-rtr'{iilot
    hnr ' buintind ul cchip.rmcnl radioscopic coit\rrjrltiontl, iir :ttare bunit. ",,;i;:i'r;;it,t'"'
    ,l ,,,,,t,' tlilatiiri'c;irtliace,prccum ;i in aprecierea arnplitudinii
    rirrrJ,(lr. I minut dc I adiosccpic st'producc o iradiere de aprrr,rimaiiv 5 rl_,cnt-. i,,,,,,," i r,;1,i ifi*ffi''-u1dlt|tariloriardiaie'
    ,1r'rri^(rJ. u:.Lui de ima5Jine,red'rcc aci:asLidozrala I l10 - cavitililor cardiacc si rt t';rst'lot
    _Utilizarea
    l /? . I' , I lf lu ] r . r s oan ri-an';plificator
    , x p L L t" . ri rn p u l d , rr. Ji o..opi .. r,.t" :ar pnni :u 1,. ' 'Itlr i,,c(rvdiogreJ'id peffnife \il\fi\izarca
    ,1,' ,,.ri rri i ' r' t:rl car inel subst anle dc cont r ast r adioopace'
    l , i rt, ,' r llt , r jer n ldec v a t.' .1 C U r' i rrtr.is i ra s c l o r ' .,t < rrlI- .t nrj rruti .. l n l :i r:j
    rr] (.irz irli sc va dcpisi tinipul de raclioscopie dc 5-10 minutc (la 50 T() NORMAIA A INIMII
    3.2,1,?.ANATOMIARADTOLOGICA
    L i l rrvo l i :) . vAsELoRMARI
    9l
    l)c do altiL parte, un bun {iim toracic posi.-roar tcr.ior utiijzeazii rloal
    , t,rt' r (r J . , r ' c r r : r i'rrn. r i m u l t d ,, i i o ri :ri i o s c o p i :1 . cavitllilor. c-arciircc rezttliii iri
    Arttltilrt:t. pozilici sii dimcusiurilol
    ,\r:t:slca.slnt ialiunile care lu_dus la i:cstriciri in privilfa rariioscr4>ici, , , ,llit l,"i'iir.,i carcliacc c{fctuat('in r)r('irt:1ii
    l)c radic'gra{ii
    .
    ,\r lrt tilr rlc invcstigatic nu se va facc de mtinii, ci nrunai dlcii radiorr:rrlia. "'itt,,':i "ii"titi
    ,i ,,',r,",.l,i" ,ir,,utinar".I.lift'ritniit rcu ;i ir vas('lolnrirri
    i:ar-cliacLr
    ttavii:rtiilol
    I r ic( li; l$li
    rt;rirj vt-t.oir.nomalictc port Ii cl:u.ificat;iprin Iluoroscr,pi,. Itr:ltltarc:r :rLrlio-
    f,, ,,,f,,,, l rl l ,rl ir r slir r r r iiL cst t : r lilit : lli t lr Li<: r it i sulr r aplinr i t 'r Bat t clor
    ' (' llli lJ il r ' r l l r l : r t nllrlll ( ,n r lt I.,r lt ( j,t' iji' C! S( l' :'C ,. r'i rrrr , -l , l l r.(,,$: .i I j ti <lt r [ r t sit iLlt trr t t ilt r t t t t r t '
    l ;:,1;1,' ;;;,,' ,i ;' ;i; , ; I , i, , , , i'r . i, , ir , . llaf , t t r t ir t r 'r r r r r ( ir lnr l'r '(
    , l, r ri ,r'i l o r lr li lir 3- . 5 a n i . A v i u rl .rrj c l cra d i o s c o i r i ci(fati rl t,gri ri i c) si rri rrl rrri i - ( r llt t l {lil } 'j) {, r 't r I r t r r t r
    l. t , ir 'g r r t ir r : 1ir 'ii "r r t lit r
    l ' roi t' t' l i tt l( t r lr 'r ( , - lllllt 'l rl r ti rI
    l,,rrrr l , ( 4, Nr r illl. ) : ,j l ('(rrl 'l lllllll IIII),' ' i A l ' t l l l :l l lrIl ' l l ' rtl trrrl l rt' l l i r' )
    '.,,r'l .rt, ''''''i

    . l'tti I 'i'i
    St'iqrlrcntul diafragmatic al imaginii cardiovrtslttl;rtr'('st(i dittoritl
    vizibil lLbiiLrlrrpir vllsl.rLrl,, I rrrr, ('st. convex si cotespunrlecrosci aorticc, ,,,rrIrrlrrlrrivcntriculului clrr:ptpiniLla nivelul virfului irrirnii (situat dcrLsuprit
    ri'r:rrl uijlociu, rcctili'ia si'r rriior.,,.rrvcx, corcspundeiirfundibulului si nrar. ventriculul drept cstc ln nod lornltl
    'lr,Llrrilurcila sugar, pcrioadl ln care
    Airrii.'Lirrtjia rfl,rci.l )ulnr',r:rr','.
    I.;r copil dupi opinia majoritifii auiorilor., rr',ri rrr;rrc). Suprafa{a cea mai mare a
    .rtrirrl.:iirrg nu pani cip,rirr rrrod rrormalja for.rnireaportiunii in[,,rioar..n rrrrrlr|r'i<lfitii:rcc este ocupat;t de ventri-
    .r(:(,sLur-arc,asa cum se obscrvi. la aduit. Arcul inferior descrie o curbir larglt, rrlrrlrltr:pt.
    r:orrvcrirsi corcspundeconturului ventriculului sting. La copilul mic, ventii.
    I'roi{{.!i oblio-rulerioad slingi (fi6.
    1 l) Lirnila rrnterjoJr; r imaginiicardio-
    r',r',,rrlltc cste constituiti din dou[ arcuri
    ,.,rv|x('. Arcul infedor corespundeven-
    tr ir rrlr:luidrept continuat flrl o dema.r-
    r,rIir' prccisir cu atriul drept, iar arcul
    ,rr1r,r'ior cotcspunde trunchiului arterei
    l'r||rIrorurc$i aortei ascendente, continuat
    , rrrrrir] cu o opacitate in formi de
    r,r,rvii, corcspunzindcrosei aortei. Intre -pot-
    Arcu/ cupenbr
    rrr.'rllinr:aanterioare a cordului $i stern
    drel //C,t , \r'.r,i un spaliu ciar, a ,^irui disparitie
    Ir,r,lrrr. cregterea ventriculului drept.
    ,4rca/ my/ocru s/fng I rrrrilir posterioari este constituitii in
    1,rrr lirrrt:a inferioariLde ventriculul sting, liis.
    -
    3.1. * ?roieclia oblic ftJrloti-
    rr li)r {irnca mij.locicdr' atriul sting, iar oare sting;l
    vi) - v€ntiicut dreltj \rS - venlri.ll srirrlr
    rrlu,riorsc distinge trunchiul arterei pu1- At) - atli! dlept: AS * atriu sthA; Ao -'
    rorta j AP -artela frlfondrLi.
    4rcu/ t'nfenbr lr,rr;rrt si bifurcalia sa. Intre arcul aortic,
    rlriri (lcilsupra, gi bi{urcafia arterei pulmonare se constat;" uneori 0 lol)i
    drep/ Arcu/ n,&r/or .r/1zg ' Lrr,i, rtumiti ,,fereastrapulmcnare", determinati- de absenta sa hilx,l)lir'
    . t.r ,rrt,ri i pu)rnortrrc.
    I'roioeiia oblicanterioari dreapll (fig. 3.5). ln accast'i proieclic, irtrirrl
    -formti;tzit ,:r'tt t
    1,1, irr pei'fiuncainferioari si atrilul sting
    sdini cea superioari,
    in cea superioari, formt';tzit..,:r't
    'lr' rcrrlizrtti
    trrrirl rxrsir'rioral urnbrei cardiovascularclLimirl anterioald cstc
    t/c/
    lrr 1ror{iuncailferioari de ventriculul drept, iar in portiunea sttporioari rlr'
    Jr/1. .3,3, - Proieclia c:lviteflor carcliacesi a marilor vase pe silueta caraliace il1 lrrrlclrirr'lartcrci
    lrrrlclriul artcrei pulmonare
    Drrlmonaresi nutin vizibili pinl
    aotfei pulin oinl l;r vilsLlt <lr
    llr virsLa rlt'
    proiectia postero-antedoar5 (dup6 F. Leca Cheiochire). ;i crosa aortei,
    I 1 i l nt.
    !lr -vrxttricll drept; VS -ventricul stjng; AD -at6u drept; AS-atriu sri,g; Ao _aoriaj VCI _verr
    c',a ,D I" r ;odli V( S - v.nd (de.pr.ofil) (fig. 3.6)._Limita anterioarl, a,utttbL<'i
    .. Itrticctirr laterali
    _Jr r F r , nul fl otur - .
    - - € .upc.ior J; Ap
    , rrlrrl.rlrc,pl, ar-ind o pozitic anterioarl ln raport cu ventriculul sting, poatf ,,rt,liovrtscui:rro este formati- de veniricutul drept, conul si trunchiul trttrrci
    (i,r)l|il)ui la {ormarea dursLrr lrrlrrrottittc
    I'rrlrrrorrirrc gi
    si pcretele anterior al
    Dcreteleanrell0r
    ;l pcrcrele al aortei ascen
    ascenaente, , iat postorioilril.
    limitil post('r
    iar limitl i0 rit
    acestrri drr.
    arc_.Virful cordului se
    vlt1u1 coroulul se proleclcaza
    proiecteazi" pe
    pi cirpoln. l'Illllollarc
    rlirrfnqmatici.. Unirea arcului inferior stlng cu bolta -diafragmei ,l, r',rrlritrrlul sting gi atriul sting.
    .gmei di
    df, naFtcro
    rrrri;hiului
    rillrrnlur cardiofrenic
    cardiofrenic-sting, acope[it uneori de o umbrl triunghiularir triung.hiularir rJo
    rJO l,lxrrttcnrrl osolaqului opacifiat cu substanli de contrast complclt irzit
    rrrir;iiintensitate datiLde paniculul adipos pericardic sau de ligam6ntul frt:no, tr\',:,lili;rliir r-adiolo{icira aparatulni cardiovascular.I)upiL adrniriisl- r'tlr';r
    1r'rir:rrrclic. rrrrtipirstqbaritate sau a altci substanfedc contlast fluidc, csofagulapar('(:ir(,
    Contuml drept a1 imaginii cardio-vasculareeste format din doui arcru.l l,,lr(larr(il{rllati, firlil. amprentenotabile. ln proieclia P-A sc notcazlLo <lis-
    :ursil.ril cgalc ca lungime. Arcul superior, usor convex, este fomat de rnargl. r tr'lri iu<;iztu'iL crl corlca;italea spre stinga siiuati ia nivclul crosciaort('i, i:rr:
    rrr:rurh'capti| a vcnei cave superioare si de tiunchiul brahiocefalic. Arcul inili," tr lrr)lil sc (rr)stirtir o usoarirculburi, iarc privcgte fala losterioari r[ (xn:
    ior, (:olrvcx,
    tIlor, r:onvcx, corcspunde
    corcsDundeconturului
    conturului ]ateral al atriului atrirrlri drent.
    Jrept. TTnirea ;rr"crlrr{
    LlnircaiuculLri rlrrlrtt.
    irrl, r'i'rr crr.diafragtrul.drept diL nas,ter.c unghiului cardiofr6nicdrcpt, in cnlo Avatrl.ajr:lc ladiogla{ici asirpra radioscopici constau ln iladicrca rtuti.
    :,.
    " . ll^r,rl(i uusrx
    x,i rl , . obs v . uo rurca
    { . rvi! mi c i urnDril (tc l i rn i tJ ti s.Dre orea
    u mb r:t 0.cllnltata dreapta de o linie vr:::tictl!1, l,rlrrrii rr txrqrului, prccizia rnai rnar:ea detaliilor, documcnt lrelmancllll ({l('
    ' ,i < : rrr. cori'.Irrrrtlc p or liunii llr r nir r r lr . f l v en, . i c avre
    o iin{erio;rrc,
    n lnaintc rk: <.lcg" Irrrpurl;rrfii.rltpitalii in uunij.rircl cvolutici unci boli cardirlc(r. 'Iirtrtt:t:lr'
    ,lrirlr,ri'rL r''i iu ntr:iu1dropt. Clnd vr,na.cavl infefioari. sc var.sirjrr;rl.rirrl stlrrl ,,,1,ilrrlrri ir','lnic siLfit'ilr contitct(liroct itr filrrrrl gi trrbtrl trrrlrrrir:
    l'ixat ll
    (rItr(||IIlIi(' rruir) sr,olrsr,tviL uu lrial.trs lrr rnrghiulcardiolrcnit: rlrr.Pl(A, N;Lrlari,
    ,1Tll
    4:l ll
    2- ttt <lt prLr:ilrrt, ltt rrclr I rrrorl, rl.lirllllrlctt siluctfi cardiace cste Ininintlt \( l ti ( l l l i l i l l ill
    l{)'/,). l)rr rcgtrlir, trclruir: lrrrrlr.r'r:l lrLrfiu 2 pozi}ii (anteroposterior li latcrrill) r,. rrl. i r r i r r r l tl l l l r sl ) r ct Sl tr l r ttl o s i tr i xp i tl r ti t ' l i l tr r tg i l 1 i
    .li uu(iori 4 (ol.,licanttriol rlrr'pl si olrlic anterior stlng). 1' rrl i r' .
    iil,,llri.l.ri int)ortar)1c 1,11nrri si dimclsiunikl,L'
    , i r , i r r : u l ,
    " t-'-'..
    t tl ) r tl l t.r i
    -
    l l l "u' trofia tinric"t' aclt'noplrtiil': llll,:1..i::::1,i']';:
    Ptl nlcdiasiillal' ll:l:
    lltl)li"-
    I 1,r t rlnus tllll
    l-a idtttificart'n
    l, .rl rlilLrliofill('. cltlstuul'-' lut'diastiu;rle ctc . l
    | t t lI
    it r jos, o r llr
    ir.tilc salr i1lIcIi.,ar( sc rliica-i i n stls sl 111

    t/c.t

    l;it. 3. 5. -'. P.oiec{ia obiic a terioare Fig, 3.6, - Proiectia lateruU (do
    drerpte !rolil)
    vl) -v.rt.ioul drept; \:S -venirl.uL stnrg; AD -.tiLt VD - teohieui drcpl ; VS - @tri.dl sthll ; !---:1
    1:
    '|,T'ri AS -airiu st'ng r\r -^ortaj AP-arteia flrldronR- AS - atlir stl'.q j AP - art€6 pula()Ei ; RS - c l i s .:ul L1fi "!tn i i i i us pi rati e '
    /i ,". 1.".7 - IrLdi c c l c c r11' 1r' o-l orac i(c
    r.iLj VCI - vqra crii iilerioari; VCS - vcna coyi srpeli.arli, j ranrnl stiLrg al dierei puleoode j Ao-aorta.

    it. tordului.or.r.at.\rai.multc.*:!:{:^tlill$}qii;
    r)irrrr,rrsiuu l],l,l,l.l:,]t,
    Forma umbrei cardiace variazi considerabil1a copilul cu cord s5.n5.to$
    in funclie de numero;i factori: virsti, tip constitutionrl, migciri ale dia{rag.
    rI
    Ii; iIil;iiiliJ, .,::,:;.n
    J,':t[.+i ffi ,,t;l l;;
    rnci, rnallorllralii a1escheletului toncic-sau ale coloanei vertebrale etc. I::l
    t,orr-ni'Lscutul la termen,opacilateacardiacS.
    rrrrlgirrcac'lrcaptir"
    cste in mod obisnuit globuloas[, llf':titilt*::tii:*Tld
    ,i,,,,,,1 ,fi,*i,ttl.ti lransvcls al inirnii 9i clianx'trul trarsr('rs al
    t'r.acclttt titrt.
    estc mai alungiti gi mai incurbrti. butonul aortic cstc
    rrrcoli 'i'izibil, iar marilc r.ase sint greu de di{ercnfiat. In lunile urmi,toarr,
    ' .1'1]io,o,".,.
    l'1,,:ll].lli'*iil1;:r,J":ltfili:"ttjl cstr'0ri'i'
    I;irrou'nirst*t
    r rrrrlrrlincepe sii coboal.ein toracc, iar axa longitudiuali. la nou-n5.scutdcvinu
    olrlici in sensul acelol de ceasornic.AceastS"silueti cardiaci scurtir qi latll,,
    rrrrrrr: trrristic.lpcrioadei do nou-n5.scut si de sugar este determinati de tirnrt. llll,,,ll,i;illlii,iil'll't,*::lll,ii';i';#.?i:11"":iJ!::,,'',i:it.:} 'li'i'l
    ,llllii;1,"::;il;::i;ii;";i.: d; o,oopine1a2 rnni'.trai rratt'dc0'55rr.
    .rrl lllativ_ mare ;i o.epczifia ina-lti a dia{ragmei, ascensionat5.de ficat gi drl
    conlinulul crescutde g:rzedin stomac,intestin si colon. | ,' l rrri LL2i rtri ,ur air ', t r r r "a"o, jodt t t ait a12at i'naim ar cdc0'{5dit t i. l't
    ,1, l .' rLni(( 1. I) upuis ; i colab. ) .
    .. Constitulia sor;ratici'rin.ilacnleaziLsemnificativ irnlginca radiologicll,
    l jrr(Iiol"ascnlart si prin retercusiunil-- sale asupra conformaliei diametrclor
    loracjccsi poziliei diafrf€m,-i.La cooiii iongiliui, cu torace alungit qi lngllt, 3.2.1.3.CRlrERllnADloLoclcE AtE coRDulul PATOIOGI{
    ,:rr pozilie diafragtnaticiL j'rasi. rmbra cardiacl este lungl gi lngustii., inf
    i,'qrn1'ntclesiluetei cardiacc sint grcu de cjefinit. La cei brevilini, cu diamel;rtt pat r 'r logicclr t t lir r ''
    l rrl l ,ut' i rl ill lt <'t r otlir r am icc t 1u1t r - t uit l'LtLlc.
    t 1lr.l lr n( ( \
    lorir:ic vertical mrii scurt in raport cu cliirmetrul transvctsal si cu diafra5lmttl
    r i<iicai.umbla r:ardjaci1 cstr:s&rtit si latl, iar arcurile marginalc ale r;rLviHt. r"",r'';;,1'1,:.1'i,,11:l'll,:il,',jl'1,;'
    :lllll'i'i;,'';ii
    lilot , ,rrrli,rc, mar ,lis{.inr:1,
    . r'lili.iliLsi rl.rtt'
    ,r,it' il'' lri'cr.t.r'{ic5i <l,ilatiLtr',<'stt'
    'irrJ i,';,:;.i ;;i,. 'i,irrtr,t ('\rtctirir ittl)'
    l.ir toti:c vifsl:ctc,rlirni:nsinnil,.sifor.rnl inimii sfi.rt rnorliIir:11:rr
    rl.rrmlf" ,l, rrlt. irrv.itigrr(ii'.t'tttriI t'itlttrru'ir
    ',;;;iiLi..,':1
    ,,;;,i,"'.i,'i, fiiti,
    riitil lr'spilrrloliiprin liriir,ii.r'iIc ;i colror'lriL: rliafraemci,puit:t.niclcg th d0 trrlrrlrri ttrlt it ii r';tttIiIIII
    .

    4{r0 48 t.
    ,;ililii,n li()ri(.ol)i(. alungiri'a- scgmcntlhi diatritgttr;Lttt'' ilsccllsloLlltroil
    rl ( orltuhri (ftrronrscol>iL:)
    trot Ii rccunoscl ,r, rrlui infcrior dtcpt,
    ,,,,, ,,l,iiil, J:r( ., ;';. .l,i",l iti,'s, ir rittttlui lur'lut!,
    'l;;i;;,'i; ' :i inimii crcsto- liLr'
    i n OA S , conl'c: 'it at ca uar - gt t tii antero-in{erioarc
    , . r ^^, , - +, , :rlxr'rli.i
    . ^*. r \ ir i
    , .,ri',1",,;;;;,1#' iil;'t#;i il'i 1l d'"i''111,
    '- -
    1'"'tei
    'i'rjilt*ir."i.i;:"il;-i;"liiL, -i"to*tcarcliac
    \'olunul c irufi' moiliiicat
    ',,',i
    {" Atriul stitts' Dilatarca
    ,rrirrhii sting so traduce ll .p:oi:clla
    ll'
    ' . { i,ti'i
    .\ l ) Il l l ll'",nrhrtr',
    r r r nl r \ i t i | J lirrii
    I ' t r" t r
    infcrio
    " ' r\
    I v ' ""

    ,' ,, ,,i t' i i'r s-ir r l , n'' 'liat st r L


    ' -i j 1" , puln.rouale, cobor-irca
    i r rrtt:hiul art'crci
    !sl(' url scrnn dc insuficienli miiralir. ,,",r.h:l'i G (dind imDresia de
    /dind impresia de mtc;o-
    m1c9o-
    r,rrrrll-ului
    . ]:asc l,ari:ali& pulmontLriiestc mai bine pe radiografie. Rarll0r i.,,, ,,. arcului r-cntricular stlng), ima-
    "apreciati -
    i.j'lll:i
    j. 'oLrr;i un"li dat" va]e16a51, cum ar fi prezenla sau abienta pulsalii. 1in'' ilc duLrlrt contnr l1u1 srrpraprllrl
    rlans altcr.i.rl,;,
    care se iniilir,,ltein IICC tlrr slrid r)( i r' ,'
    1 .l i n' a dr er pr i inim ii ir t
    llll -'l',.':",.j:r.(ega.rrumil.ul ' ,r '
    .l ,l .ri i ri l c ,i tr" rr r r r io r r r i t lui st in: '
    .r,,,slrrpoatc aiulgc sir Jormezc coDtu-
    s, jlsol^s. ,lr r ,,' t,,;lern chcrrt al inirnii.
    .cong,:stic vasculari pulmonarl). 'atritrlui
    I{lrirea stiug sc po:rtc
    . conccntrice
    gi lS ,,t ,.rva cel nl .Li Dr . i, , ' . : ( ' l r r r ci hit 't
    o ;rri, r r ( ' t lis lalr l: , d r ma r;i n e a .o i d u l u i . ,rr | | \1,. l rr f cc, <t . incicicr t ll allilll
    ,4prccicrea
    1r:plt'Lt,cfttt aotunlulttl
    uolumtdui-cordutu?
    cordul,ui se se poate
    poate facc global prin
    lace globa-l prin indicele car.dior ' rrrg L,ombca zi ir r por f iunc. r m ilio'i'
    {,)r'ir(r(--J
    r--,sau
    sau analitic,
    analitic, cavitate car.itaic. pcntru "apreci&ei irclicele
    pcntru "apreci&ei
    car.dio.
    ost ' r ior ' I t r t f i
    cavitate cucu cavit.ric. globaJi
    tloiJe sc {olo.
    sc {olo. ' onl urul ui car diac l c1c
    ;,1,1,,,,, j"di."1" cardiotoracicutil prin simplicitatcasai;".,-ii;;.?;"t"i ii:;#" rrr:rilrea unci cantitir'{i ninime
    lt ): t t l\ ' . l,r,t:ultit dc contrast, esofagrrl r'a prc-
    jll :.('"fi:::;l\^:tllill Tlxt,g at rrririlii licqft'ei..eavitifiin parrrr,r,l .,ullo amfrcntii in dreptul atriuiui
    In('znrti.
    r"j:ii,l,j:1".i'.ijl;.d::.
    arrantajo, dar;i anumitcll;,ii;; G;.;;i,.-irit"",i,#I.ii"lllliiiirii
    limite:.cle .l ,rrr saLt ra ii ir npin: d^ cit r F accsli
    !,-,,1,"'it; aUt"i"I ri*i'.i"liIii
    dciii.hjpertrofia -exempl",
    parictali. (miii ir* a"1ip conccntric)'i .i .i r' * r lr bapt a ( t ig. 3'8. 1 i1
    i,,,:.i],]li']t,..):llillii
    cazclcctrocarclio!-r.ama ' ,.,' !,ri
    lll.,:lr::l:*
    (Iiilgnostic- ;i i.rro."i.,r,J[iu-i.ir;-;I ili;";;il/,i r' ' ,,i ,i ri ., ,l ,. pr of il sn obf int o im aginc
    r.{ rrri l l i toaro cr r cca din O AD.
    '1'.,1
    u t tt l.u I s t,'i,n g. Cre;te.rea ventricululuistlngestcevidcnliltd, LIn alt scrrn de dilatar:c a atriu-

    ;i r1,rr:stlngrL;,
    .':]ii:3i;i'#
    :,1.....,Y^, !
    il ::,:::":'*-l;1;t:1,
    .
    :;.'i;i;i;'*s;'1#il1*;iiff['Jlli
    iiimii, alungirl.a;i ,.."ntuii"u g-ji,fri^ j" .rr""ij
    lri sting estc impingerea posterioari a ,,i
    'r - i'J. - .\.1' .. i ' i r,' S tc n' / t
    i ro: ):L i t' \n
    rrri rfLl l tl

    l,lrr1\gieiPrinciPale stingi. ' i .' r' s ""' .,,' ' .t.


    ' :i I|' ' t!i i I/i |
    IS'
    -viifuliri
    r):rr. l lrcrluL lr)lcnor ssting
    t in€" ssii edinr
    adincirna
    _ir ne .c6nrur.ului
    ^hr , , , \t r r , ; sringit
    i r ,inirnii.
    -;.-:: r.,_r:_....r_ ciilrtar|a imlt,rrlnte
    ".1__ In,tiii,lo D - A tt' i t r 't ' dt ePt . Est c lcavi- ^
    ,;rrrli.rur;r,ic cr',lte p, .c2p.-2i-r.qt"rli'rcgm"ni"i"i .if"g
    i iiarnctrului trans- Lrl oa cel mai greu de afirnlat a {i anor-
    r', rs rrl inimii. ei-sint lrecvcnte' rn l)rolt'( '
    vcntlicular se poate ingro;a ulrcori doar pe scama r:amcrcl, ;i crorilc ln plus sau in minus in aprccicrct
    rrrrrliL
    Lr'lgimii arcului infcrior rir'rPl'
    lYt"_91,.,9.]t ti;r lt--A se constatatcrcst{..rca.""i i;i
    111 grput;ic(rril,rrrro{ie concentiici.
    ir"iJte)lla.e-.iqiJia "criametrurui
    L''rri" "'iilitii l'r r'oi"r'riroA:' ( ('r'
    l;;'.:; :il,::.rii;i':'""';*rii.r"i ""liii"-i'''ui''lrt'pt pt rt ct'r'lttltti
    \'.ts (ll1(llcc carJrotoracic normal .ao
    sau po{irr..",'";+
    nrrtin r-re.",,/\ iiip;;i.ofia
    FTinorl-r^rio vcntricu.
    i,,!1r.,i,.,i_ l:i''.riii'"i'""ii',ii;; *".jinii un',-rioir'dr,. rtr"
    I:,::.fi:tl:.^::_.q9!g1a9lc,
    lrrr':r 19rmal
    st i.gr'1.antrcneazi-,rotalia antcrioari i ';*;;;;;t " dr epl
    i"td"ol aortic tlcvirul 1' ,r .i rrrrghi u l f or m ; r t d' aor t i ) i
    v' r r t r iculul
    llri]r ,'vldr'nt, arcul lniJlociu ca}it;r rrn r.pcct "o.a"f"i'
    r.cctiliniu sau concav t>rirr
    -ai",rtoi F..' I' rutr c lt 'ir t l ovt t r r i b t r 'lt r t ounr r ' iu pr oiccli3. t ', ''. \ '
    sl('rgcr-c:r:!u
    sl('rgcr-c:r infundibulului
    infundibulului
    u u u u u ru ru l arterei
    arterei
    ar ,lL( il ( pulmonare,'
    nulmonare-, bombarea
    bomhe,""
    lomta."a ,,"",,i,J in{erior
    ;-i^,1, i,"i,. arctlltlt url]lo-
    arcului inte eslr: ,liJrrtlrreatrurtchiului artcrci pulnotlrre realize'tzi 1'ombarcl
    rrrirr
    rrrirr acccntuat5,
    acccntuat5, iar virful
    Scrunnlc
    virful ini
    inimii este proiectat in jos .si la sfinga.
    mrilirii rentriculrrluisti'rgapr,.ici ; i;,';ii;g. I" lilli. t1egradui J" aitot"t" a arteti:i pul'ronarc' :rccastl ]'t'Tr)-
    pi""ol""qi ir"i ll 1>oato[i:
    ll,rr
    ir prrricclia
    ticclia OAS,
    OAS, Arcul
    Arcul infcrior (vcntricul-ar)
    infcrior (v ""i,f"ut
    ; bombeai:i
    -,1i
    bombeaZi t" spaliul r.,rr.,.,,r!
    in ".it.i;l r,:trocar . rtticiL,rlctcrminind un aspcct rcctiliniu a1 art:ultti niilociu;
    i'tr-o mirsiirri,rai ml,i-..;";;i;;.,,T;:il
    ill.l,':..1p,,r,1:li'ldu-sc ,,;I,;iltr.
    Lr: l)lolll, \'cn tllct u l s t t - ng s c r lloi. c lr t ; r z i in i^ c e i t n . - ^ i
    injos rr"f"i,'ii. i ; - i"r,i1il"
    , . , , 1 , , 1 i r , ..iii
    ,,.. .rrtijl<ric, corcspuuz.inilurrui asircct ulor corlvcx:
    l]l;,]":flll ::tj:fl,lyt.s1ing-sc.lroiccrcaziL
    l, ri| (ir1i infcrioarit s,, modifii;]. ;i aproapc ltt'ntisfcricl'trt
    - rllirri',,clr o convltlritttr foat'tc cxprimatiL' I trti;tc ln shutr!-rth'ilc
    . ,/i. I trt.lrict,ltt I Irtl>t.ln pr-oicclitP_A, crc$tor(!;L
    ,I u( v(rrl)lului vi"lt. rl.rl.rri i tft:. I )il;rlitrcit t ntrrtgnrultri*itt'i"i- p"ttiiut'"tt' s'' ilti
    U,llIur{D.l)t {'stc strsirirtir(l('cn:iitcrc;t , .'ii.^i,ii,,.,i,:iiii,r,,,,o
    ,u:i"irinul r':Lt'irlarir
    insrrtir.ir.nJi"r
    rlialtctrttlrtitt:itrtsvcrs,
    irc(\llltllitr{lll, l',,ir,,,n,l,,,ii,
    '*pro'.rii.
    .lut 4ll';J
    , l , ,1, ,,r lr l, r 'r rr r lr r lr 'ir r l, ils( \ 'i( l r ill( \ ) li it t lt r 'it r t lr l lt l' Llir rr t ' it t llr t r r i
    \l r Llt jr . \ Ll IIi | |, ,| ,|.| / |,| .,rtrr,,i '
    . l )l rl )l t(rx l l -(,i lr i i l tr j 1i i n nuntrr_oasr,L.l r_rl ro I,, l .rl | l t ,l t:i tL,ri ] ] ir . il) t llr li in t r r it r L, . , rL. - r t r : r - nt l) i. t r 'zr 't llll Ull{) I - iL|i( I I I I ( 'I IVlls(
    1: iI ,
    ,, rrrt , , f ! r t r r l. r I r iI li ' r rrri rr. rrr rrrrx l o l ti s n u i t l sl r| ctrrl col car. caractcr.i :rl i r f t
    I rl , rr lr t j,r r iiloc iu sti l l i - ri i l l ,rr:,l r.u L rl rt.rc rL :s fu Lri,l ti tri rur.i l ot. ' l r,.r r,,rr1 ,' r;1
    i r' \ 'it s( lllr llal llt t lt r lot llLt
    t'. . l u t ' t q P trl l l (nti r-r. r,,rrr,,s1j ,tt, s1r r r r . lir . ir<lt r cirr . lt sclcr lil: r t at t rau lir : Dit c.cLar e, billr 't Llilt ilr ';
    '1,;r:i\iL
    .,i rl.,r(i l ) l r r ot - t a tJor ) oa l (.1 )r1 .rc n t, ;l rr,rJ l i l i i .1 ,. c.ri i l rl r si -tl r si tu:Lti l . C r.r,l ,r . ,; .t ir (ctl,.tIl1Llfl lr(tlilr) s(l carilcteri/'('azilPrin lit-nitc vascltllrt''
    - a c i c riLr l c s c | .n ,l r,n 1 ,i.i,tL l i | t" l .t ,l i -i :rl rl ,rtr.Lhccisi coLoi rr,i ,
    '" , . , r r , , r . i, l. ' 1 ,.; I rl r,.' ri ,. p . r, ,l i J ,,| , , ,. t' .,1,..i r,z, s i i ci ..rr. ,1, ,'1" ,l,, , 1,r'ir 11)lrliLrcil cillrJ)lll:iloL pulrlonarc. I)i:Lgnosticul di{o-t'lrlirtl
    ,,,r,1,' :ti i t | lr sivil si ir r {r : r : 1ir1, , llhr lor io] - t . r r r lr 's'1'li{icil: L: ong- cst ia plsit r
    I't't r',r t r ; ( |- . \ r at t a s ti ' !:r a tfa l l c e i to ra c i c c , li | i o ;,,r,,
    '.
    r 1 ,l rry . ,ri, 1, ac i{ ii. ri , c s o fa !tl u i ), o a n .p l rc n tl a o r/. i ci Ll a' < l )ara\.crtcl ),,dl ,t(l r(,i l l )l i l , ,, .r,,i l ,i ,i , ' ir r lt ii; i in ir ', i'r . a r nc'lit r ' 1'1'nr juilo' si t sf c. 'i1r 't r r t lis
    i rcapti r i :ol oanci l ,rrri
    .,1 . I r. . , r ' . . r . , rr i, . i rrr. r I.r ,J r,..,1 ,r.,.^ r ,rl , .-r , j ;,.\-i \l { C (,r rr l ,r t,' I' r rt.L l ri l rri l l rr l.
    . r'ri rJ , olr , r i) , l{ r r,,l o :i . l j ,rl l n rj . ( rrttil,r.ii;r l).rsivi 1d()cxcrnlllu lrr stcrroza lllitrali'l) c--ctcrnai lrr:lr-'illi ill
    j )tlir t ll. L aof t i i i rs c L n rl (1 l tcrj c \-;t
    l l o c tr i n caz rl r. l n.r snpcfi or { l r(.1)l ,,,1,,ri 1,ri tf.r' i <iar . c:s.r t 'r acliaf r a- gnat jcc ii sc ilr solcs- t et lc clar - it at c l. llr li'i
    ,\. I )il.rrrr.a , l,r ,, rrL Irlic rL junritr-ilii sLrp,lriiinlr iL cinlprlrilol: pulrloo.aro l'ot in corll' ".
    1oa1o fi posLstr:loticir (in stcnozl iLor.ticiiorificjalai),
    I| ,i r ' , ] ]1. , r . , rrr,'rsir'prr1r'nouln-ilsc pot vcdca liniilc licrler'-lilcischiiel:, olizolltirl("
    'j " r l - , ' r l ( irr Io rr,rl ,,;j , I..rl l ,,rl .. ,1 I,rj j n.| ]ti , i ,.r,r:r \.,1\ tl ,r. . I,l
    ' ' ri tj ,tl ot i. r , , : c i -l t,l ,.| t. .. l t,.c \.,rti ,l i l .,tl t.1 , , 1,r,'ziniiLlirrtiii.icI corl,glstionai-eimprcrtnir cu distcDsia spaliilor irrll r
    ;i ;rrrl ..,ri l .
    I I r l .rr, (\. \rrrlr s) .
    3.2.1.3.1,
    Tulbuliri d€ ventiloliesecundore
    cordiopotiitor l rrl ,,l i i i r' 1 ) lr lnr or lar csint dist r ibr r it e ca opacit ir "! i bilt cir - ct r r lr t 't i- ": "
    puhnonalil, r r (ir lir r ( t
    1,,r i rrti i rri i ri ir ', 'it t t ct t ir cdie si ext er ni"r a cinpt lr ilor
    .\r'csr.ca si:rvid 1nai aics la sugar rliD cauzir clintcnsirLlilor1nici l rl ,. j r, pcullr lt iht li.
    alr r.,ri.. ' I
    t h.rn rc tr.r, i n m c rl i c , p c n tr.u l rr ousi i l c
    | r.i nci pal c i r, .,,,r,,:l I) :Ll l i (l r( siiulla lL r - a: 'ct t l. r r iz, r t i. 'ipulnr onLr r 9 leplczit lt iL vr t sr 'lt l; r t iz'
    lll ',.:::.i l l, ' , D,
    1. _. ( t . , " r
    l \ , . 1. -1 . It.rt r n'- - " ) t i: i r r "t i it r ' t
    ,1'..1
    .'l l l,']i l ,l , : , r . , i \ ir :r: :i.a,l
    l ',',,' tv .: rrz i .r.rrr^ r r.,l u s 1,, ,,r, ,l ol ,,r.r i rr,.l ,.l ,. ; ,r' ,,,J:,t t: l' . li' "r J' r it t . '' l 1 i1 r l'n. 'r " l
    ,,,
    i rr c :r,2 ,, r. ri i i r ot,i l i r..ri ,, .,,r,.,i l ri .i rr,.. t r,l , l ri rIrrl ot] : it r Pf inciPalc idr - 't |LlL ii slir ! a) , it t ullc, l '1i|st t ' \ : ir s1 ) r llllr I
    t rt , t i l I l l l l t I ] .
    l , tr' l l rri l si lic hil, diir r nct iul lor scr - Lzind cli'r s'r c 1il slr r . lr . i
    lfjl:i, rr terci pulnrrrnaresi ii r.amurilor- ,, 'izilr ilt "i'
    .,1,' rtti i r cinr l) ulLr iPuhr r oilil. . l) acil, insiL, \ : ascle pnlnor 'r r c vir l dir r ( r ) lir "
    s:i1cprecrrmsi tlil:ri;u.ca|r,r
    'rr.l rl r lll|1.,rl ul :i lr lir r,r, t..i c,., r-rn 1 .,1 l, l,r(t)sicc (c:lr'inatri'zia l)!lnlollar:L sau alrezia ir-icuspiclt'i) , \'lrs|l{' ,r.rI
    .. " ti q rn , a c o m l , ,. i J n t. 1" ,t r,,.l i t., :,.,1,,,I.r
    r'. I r.l: , ' \ , I lr l. , lr ' - , ' t ,,' ,fi r,.r,, o b ,,..,,.' t,. Iri i rr"r..,, ...,,: , i ri ni rr i rit r - o opacit r Lt , \i - ir scular i hilaliL : ilLf or lr ir dc vir - guli' si 'li"
    i ,r,l rIrun.ri ...r .l ' r ' ,r 'lol
    r rrurrrilor.siilc in s/iual-urilc S-I. inrport.LnLecc,ntpriu.i
    l,r.oirsin prirr,.i1',,r1 L rl rlr irr cintpttlilr' llulnlonill'c c unifor:rrlir sub {orina rtnr'i r'' lll"
    'ti r', r I ipot c r r r il: , r i^ ,a .i r,.. ,' ,,1,r1 i l r' 1l r1tnot r it r -trirpr cziut it o o81indI e] ilct i a vascular izaf ici r r t 'lr 'Li: r l': i
    .r,l -rri n rri ..i :,i ' rrr. rr, l c ,, .,i i ., 1" .,,,i ,,i i rri ,.r,,,r
    or loL,utui :uperior. stin_g).AJtcori couiprr:siac m ai pcrilirr ir .r , l )r1l nr() t lill1', t t 'slxt l: jlll) ili ir iint t 'u: r 'plor Jm at i\ ' 90o; Llin r l' r t r "iir r ir '; t
    l.:l l.l l ll']i11 " ,'
    i | || |r.r,,r |, ' iJ r ,"al
    - ; r lrri C ro ip u i n ,o tra r, tl r,l ,r, ,, r,tpri tni L,ro-.i ,1,,,,.,i ..'rrr,,l | i, ' ,' ,1,,,' i ,l r rL 1,lir r ni'ilcnl.l'lxist i- ro st r insiLinic'dcp'idenlii ^int 'L' r r r 'xlilir '; ir il'
    r t| l .,] , ,t r' rr,.,J ' l: , , nr liz cr. . I ]o l rrl u i ,L ,rl i rr. ,,,1r.,, si ,,1 , 1, , t 1nt t , , t , r , ',r nodilicit r ilc car dilt cc ir r i- l( r r frir' l li
    (), J : ij, l. r r t . r ] , i l rl i i " ^ l d l ', -llilnr
    lt eccdil'ld
    int c. 'scr t zir iL'; dcscr lr r l si lr rrtr
    , rr'rrr
    , l .ti :ti l l . l o .,l , pto(,11.. j ,t,Lrl r..ri .l ,...r l , 1,,I,t,,tr;rr' ,. \ li, r ljf ici. ik' lnlllllollilr t '
    , 1. r ll. Lr .1 l | | -, j n i ri rl ,. ..1 . r,,L u l ui i rrt,r.i t,r. Iri l ,111n, 1,j r1l r11 , rt.r l rrl nrrtlir t t i, liillr 'J io: id, 'aullir : Lsociat cint r t : clc
    ' ulr ,t tt'
    l |n . l ,r , i\ n' . ' , , , li- l, r-i ,r , L rc ,rr.,,., , r i n .p i .r;, r.; i n.rr_.i
    i .p,,i , i ,r,..r l rtl rr, j l rrr lt 'r 'r 'l,si 1r ( 'nf lcpulnt ir l: t r t ' sint r csPonsabil(. dc'. 90"; ' r lir r '1'
    ,l ]l ,l: . il] : ) ] , : , s t ingi .l tc z u tta tu i .s t. ti r t,,tc i t.L )i . r i ,ui l rronul Lrii ti ng r r;r,l i ol o gir i r , r r onr lr l st t t t lit t i r . ascular izir t icj Pt t lt r r . , t t r"r
    i rl r; i, r r Lr lcit r r r lir i
    ',i i ,.:,t nL rDrf|r.:tL . \lrr inapoi a pl1lmortului , r,,. t, )tl )(t f ir lll.
    stlig pr.in car-cliortr,,q,
    r":,.,
    / ,'r.',, r rl. l, , r r r nr , r - . r : c j /u ri r, ,' l rc d c r-i te Ii z i b i J i i pc cl i fcul d,.r fati :
    li,
    ' ' , l l ttrrrrl jc s( lxr t ( iist it 'it c lllili 11lnlt ( lt ipt t ; : i r lc r ': r sct r lalizlt i'' pt llr lt ot t : r t
    lrrr I )rtl i s' ' . ,,l i rri ,r
    liir li l) llllr r r l
    Iri l rr' r'r r : , t t l; r lizalif r lct ilit {cu sr t u I ill'r hipt r t t 't l siunc iir t (
    3.2.i.3.2.Aspectr.icirnpurilorpulnronere
    l ri 1r,t| rtst r t llt t izir ( i, ' it r r ) inonr r liL pr r sivir pr ) u st ilt jcr iir ''r r l"l" ""'
    t i r r r I y r jl1 lr nlnt o tr.r:t
    1 o t i i i l rp r' L rti tc c o n vel tti ol l al i n -l scc.toi rt.,, r,.r l ,rtl trt' r r r r ':
    r i . ,, : l t ut , t r . t nl, . . t n l i ,d i u s i 1 r.c i m c a c rte n tl l ri Jxrrr r 'ult llr r iz; r ! ir ' 1: ult llut lr lt r -frizolat ir sau insot it ii r L'
    ( ) ( il1r 1lL1r '
    (,_mi i l ttaui l ,, pul nt()l l l rl l L)
    \olnrirl, rl:sclrLl vasculaL se obscrviL bini: in arlbirlc lrilur.i i .,t, r,rl r ri .tl rt r ir '; t r ll sr llt |'r 'r r ') ;
    (nlri l,irr,, it r cr : i r Lr i l) lr llr lor r i
    i .i l rl lr , l' r , lr , . ir ir r r, l .ri n ...:J r,.c J i r_ ,1 ri r ,l u
    i rr..,;,i r,.r ,oi l r.),ri . i rr 1.rr.r r,l )i rfl i li( it r I g- ; r lirr r r '; r scir ir r r - iza! ici
    r r.r .rr.l ' 11, . t jiI ( ) 11llr - . i ttt
    l\ ) : 1. { lr ) r , ' . \. l l l , rrr,rrrc l n \....rt1 ,,,, ,l i D ,1.., rtrrl l ,i l . . :i I' r .I.rrrrrr i . ti i 1,,, t , , t . t Ll; r t izir 1) ul- nt
    ( M
    "it r 'f it r r
    r t t t lili I t r
    t ,, , , , , , r , ,, , I' | ,i i LrI rt i : r t t t , lt lit i ir l l, r r hlt r r ir ( s/ ilr r ll S- J) ) . . i''
    rc n o l o t. l )u l tn o n a rc .,\t.tcr.cl csi r,,Iur,Ir, ( ll
    1','1 ,,1 1. , . , . . t , , . , , , ' l, lr lrto ri u n s i a l r IrrrIIIrnrr.rr,, ' t , t lr " ljil, r t lr r '; ' r 'lLs|lot vir
    : f lllilol r t t I I I I rI t I I rt r' 1) I llr l
    l, r"l rl rl
    ' '.rl' , { , r , i. r lll\ ' ( t ! \l )tu (o r(J | o l l i t.i z rrtc ior:gi l rtrl i l ]rrl :r.rrrri rrrLrj rrrl ,. ' , ' ,' r' rtri l ,,r I 'Lt lt t t , r ;
    i lr)r r\ T ( r||.L l ll(l 5 t ,|l r t r ' l, s illt s ilt t iiic n] ir i lut t r , r - i o r ; ,, i ' 1i .,ri l r ,,r1, , ] lr Lli: r r | or lsiit r r i' r t t r I r r t t rlir lr 'l 1i 1'r '"'r '' r ''1. i, 'r 'r '( '11(
    11' r r l. xl, 1
    l', 1"
    r.ollllulll \, r l,)t (, titi ( lr ': \ 'lll. r ( l' llll'
    ' , i ; r. t llrr ,l{}Siti) li ,,Silt r , r t nlr i , ,l l ,,l rl ,ri \' r , t r ) lir l l )l l l l rl (,rr;rr ' ( ''lil't r r J r r '' l"l r illr Lr r lr ) l
    lx r s ic t ior ,

    .t r.l
    , ll,ir( ( ll ;tl \.;ls( lo l lr illi. lor (
    . I lilr , , , , d, il l) at uht i \ . i t s ( . l l l i r r ( J ( . r r , r 1 . i . r , i r l r i r l l r
    ,ir "). I)a cii srl/rl-ul rr, ,'lir r r r il, sr r 1r t r t I r iI r t r ',1,, ,r i1t i1lur :si sr r pr - adili| : llpr lr iirr r ' Ar : r 'sl'
    S I ) r . r r r r . i ir upc ir t ant , l , i 1 i : . , : , , r , , , , i , , , , , , , , , r ' ,' l
    , irl:(:crIttlcu ziLiu r noc l dilll; : ; ilr . Lr l. ( . li] I )rr l | | r(, rr,| | ,i , rrr,l r , : r lr lii slt t l lt il, clt vlLr n'lLr f Lt ll'llonar cnor m eii: .
    Si r . c nc l c s i n i r l i l a l l i r I t u i . , ! r t r , i l l t , ,
    lrilrrtil.r, clar.;i. la pcr-ifer.ie, undc rle'iir ,.r.rr,' rl i ,rr l r i, " ir jlr or : r r st l,1l l2; l1i, : pulnor l. '. tr i lr or 1- " Ji p'r t s ir t r r r ll'i
    rl,,,.il ir, ,r,,"1
    ' rrr , r,r,l. ' r r t llir xlr r t {iicll l, 'illl L] r 'r lle P- f- r Llul- S- ll pr ol) Lls lllllf : t
    .,siin trcimca.c"rli:l.rira cimpurito. "i*if" ".U'tf,,l'Lrt.c.\,.,,rt,.t:i
    ll1]lll]:11:,:I]ji-.
    ,l1l,rl,1lll,l 1,i,t,ni,,,1,n,. trrr',,.r
    ,rrr,,l , I I l, ';rr .lrilr iir, |r:tttlu dirLr3rrosLicul tiL: li1-'or':rscul;rriza|c pultttotrrtt ':
    ,ic hiperprllsatiiitatehiirLrir.Sr.rrir,,l,.sl r.;ir/
    ';,..]
    D ' l. r , l! , , 1f -:",insotlqlr,
    , . / 1, . .i i rr r s 1 )n ;i 1 qd , r.o rLl t- I ', r rl, rrolrrr:rl i rallortului intlc dialttiltnll ralllurci {l('lc(ln{}'nli i
    -rj n rA
    ( ir ' J I r l. . i, : t l .r.l t.r:r-r,rl ;,r,.p u J mn n l ,.. . , , rrIrrr.rr r r t lr lr ',r l. c la or igiir ea sa si di. am et lul t l- allct 'iclt asl; Dr a lt r t t I r t 't t
    , cre:c i hi 1,.r., :rj tu,r(. i rrl ,.rrrl l
    ous t m c trv i r.,L s Pc c tu l v a s c u l a ri z afi ci pul i nonarc rr:1, . r {r l r ioinr al csie in jui r ic 1) .
    l,,''ri
    ,,l l l ]l i " ll; , sc sr:hi rri l ,.r ' 1,. '
    i ,\ r . r n' * dlt at a l c s r h i ' c tp d s a ti l e ,
    l n c o ntrast cu pedfcri a pu[.,,,,,.,,,
    lr 1,,,,t; r t r lt i lt r cf ar t i! 'i e r , t r . i. s ct t lit r i z. r : t i( . i f tti
    -ca .' ,,. l rr rr r t r l obisuuit , vascular iiaf ia llulnolr ar i cst e ir lcir t ici ir r r ''lr
    ' '1' (l('rrinchipo'ascurarizatiL. exemprua".it"oti"Iti- ir.rc s. irtirr1..,r,
    cimpur:i1oi:pu}nonar-c p'erifcricei"' .oni.ort -.u i,,,,,',;.,,,
    lrilrr.rr-liLritatc:r r. ,rrrl ,rrril , r r lr nr it , r r r i.lr r at lt m it c cazt it - it Jc 1t r : r sist cr l! acalli[ ului ilr icr r 'r i
    lrilrLlitorpoatr: ser.visindrornultii.,,r,or&g";. -i;"."rt.. , r , ,r:.1:r,, l rilropcr-Ittzirt a pulmoutrlui sting carr,:aPirrc rrrai clar ilr rirJx)rI
    '.. 1 " . . pr l .zLr".i, la angiolli,rtr ,, I rrri rrrrlrl rr '1r 1.I ) ist libnlic ir lcgali. a vascllar izalici pulnlonill'( s( ' r t r r r i
    L; r r lis lc ra n rrl i ,l n 1 ,r,tl ,,ru :rr(
    l . jit s " . . r r pc , - t e d c Iti rl i -\,a s c l tl l ri z a ti c p u hl onari r r,t 1,. | | :,lr,izirr ;rltcr-r,iPulmonarc prilrciDalc drcptc silu stingi.
    se pot datoi .r rrrr,,r
    , ','' ( , r ' , i. . . r ; I i | l n d , l .{ z ,." c u ,p c R e tt" l r1 .l l' r rr rrrrl lr,liolojlir: titbuic sir lttccizczc clc :tst'incnca cristcrt!rr rl.'lirr
    ] r,.drrsr si r. rl di oqr.rti i , ,. ,
    rr" r . li . 1t . . ir L ir r s p i rrJ i n l -,ro frrrL :. ,. ,' 1,,r l ,,r.,ri r: , si llr l'. lr r iLlc ( ci{oscolioza,in{ut iclar ca st er lului) , lr ': ilx) t r : it
    I r I rl ' r :rr ll, r r r r lliiir : it i a1c siluet ei car dii'. cc,iaf collst at ar cil lr r r r ) r lt ,
    ,1 t . l{ ih{ r " . , n' s c tt. l a " ri ::tt!i a !u l ,Mo :t arci ,,/,rs? rr ri ,, (.j 1,. ,.
    ,, ,, i , rr,rrl i r( : r ir r lt r iot r iL ir cor Lst clor3- - 6 cvocit diagnost ir : r r rl lL'r 'o: r r rl'r
    trrrl;li piirliciicr- din calca intoar.cerji
    , lruloirlrare sarl 1.11,rt,rtl
    ,:i l :.^, prirr oi""noos"
    h u r' ; ,r, . d ,.,,11,,,r ii. 1 1 .
    .| ,r
    't
    tL.
    i i ,,'1,
    ' : ir)rr:' . . )r i.l ::ijTgll,,'.
    l r tL llct.
    .ol..rrr
    ii r .cr L ;tictr l:L r ,r
    ", \ r r, ,rrr, , I i i I r' :i, lr,'kiului tolacjc ltrtt Ii sccurdrrr.r car<liopll i.iilrt- :rrrrt 'rr"'
    ilrjlt
    ,, ' , 1 i, r ; t c r . . : r p r.p s i u tri vi (.n o ,r- "iin g j. , J , , , , 1 , r r r . r r l i l L {i n ca r l n r l u n o r .l i r l d r o a l n e : d c t,'i cm p l u si r l ,l r o r l r u l l l ',l l
    ,
    .',; ,rL .l rrro ni l c.. ;nodcral r.:,crj i br,r) r , I r r rr r r 'r,
    I'rr' |r , ) r ) i, r ' c r . : 1.. j :1 l i r i n :.c g i rrn ,r v i rfu ri l or. C i nd pr..si rr ,..r r, r,,,, ,
    , 1r , t jl. { - f0 m m IIg )_ r' , [,' l c v i r.fu ri lor si i rr di i .ri i r.c..i ;.1,.rr i . t ; r r i , t t | tl r ^ _ txi trtlttsr
    tr t)tl.tL i .tti u tJtfl u l cti i ttL ,l ttttta si i tr l i ti tt l ttYtd ti !t,1 tn ,t '(
    .,'.:.1
    ,j l '.'1 rr.;,lr:'l." ]rlll :,,.rrr.r, t , : r t , t 'l id r r y",i r t L tr i i r "l tr l tt,tt'ti c tL tt tst ,t',tsi !'i l ,i [,i t,i i ttl cg r tr r t:tr r i i 't
    et Lr s t t lr J t . rn rts ti rl p L 1 l mo rml n i :v a s c crl contur '
    ,,fl u,i , ai
    t| l :r.n r Lur c c ul\ F r n l a rc r| l o rl u i tr.c u s c i L d c rc a -d i { uzi rati :ansparentci prtl rrrl ,rr,tr,.ccrrtrrrrr,,r , ' 't 'i l i t ) t i i .:i ..r l , r t::r tl h l .i i tr J:ttr ttt:,tl u d e l l 1 . i ,tr tsti g ,tl i i .
    vi;rilrilitatca arioLrnalr-ra scizurilor, liniile ts alc lui
    lier-]"r1, ,nrc rer.ar.rsrt l,l,
    |l r'i u . SELECTIVA
    BIBLIOGRAFIE
    (ihrtl plcsiunca crc;Lc
    ... ia JO. rnrnHg, apar opaciti;i parenchrrnlt r),r.,,
    , - u_, , , . , J,,,i )j rrrrri
    lI :,1 :1 1 ::l,Ll.n e d e n t p u l mo u il. i ..s i o mpc.),i cor,tui gl c,,1,1,r11111
    1 ,.1 r.;rl ri h r.i ,,
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    t..foartemarcatii,erlemulalvcol:rr;i ilrtl:r.st,1,,,1
    , ..,.,,1]:1^1""t1",-.l".lL"l-ft
    .-111.,""-.1:" (itsp(rt,irr:u-ipidc flutru.ccu rnaxirnumpcrihilar'sauLr rl,,r
    :ll
    r.r i, r .-,,I'l.rmrn U'( , t us dl
    ),
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    . .- i rl.\.uti
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    iusoft-;tcafecfirLniiccardiacecarc se asociazir_ cu scidcrrr vrl' l sl i.
    rrrru! \,Lr_llrl dlR mica cir-culatie.Sci.derear.,olurnului
    sanguin srrrvirrr.irr
    '1'r,,r,r .,rt.rr-i puJmonarc..Lr.lora tr.icu{l)idi.i,Lro.rh l-bsicin, :}.22. EXAMENUL EI.ECTROCARDIOGRAFIC
    lrjr",r,l.,..r,
    ,ul pulinorak.dreptcsau_sriugi, sLi ozil ;rr;,rilor I,,,i,,,L,,.,,, Mtfi(.t
    A t"4AloR[scu, SERAFIM
    NlcoLAE
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    lt.adrolo8ic 5. obscr\ipcfondul rransprrn.ntci rr,.s,.ut,,u,.hrI,,rrrI,,r .':'.1. I:IECTRoCARDIOGRAMANORMATA tA SUGAR 5l CoPIL
    iji].:j,... dcst.nl)utmorirr foarte fin, format din artcrc pu[norrirrl"r,It,
    l]lll"l,lli1l.;
    tl,r- UrtrlntL. "1
    sutt de ls!.nreD|.ii foarte rnici, ramLrrilcprirrcipalciil;lrc irvirr,lrrrr t L ', r i l r l ,, i r ,,r r r r l i o g r i L fi r ' l r r co p i l u l 5 i su g l r r u l i to l r u r l l Pr l ztr t.l r "
    ,.ililrr u foa'tc rcdLrs.\rizibilitatc:r.clescnuluipr,lrnoiiai . , I r r t r r l " {;IIi |( |,Ii :IL |( I( I ci r l - ,' i l d e o sr :l l t'sc <k' :ts1 l .'i 1 r tl l l o l l l l i l l ( l i l '
    -Jr,i" 0,, l,r hit ,1,,,,
    1, rit.iic gi urrcor-icste atil dc rcdns inclt crc6azi i-pr"rii-"i nlcl n, (.rr,tit . i l r i r r l , r , r r l ,r ,,'l ( ' r .r r :i l i i _ r :r i r 'r ,i r l cr tti r cr .l ci l - co l ) i l u l |st( tl ) i r i l l r i ( , ;tr 'r 'r r r 'l .l
    i ii )i|tl Pulln0nar. i r l r :r ' r
    r , l , , 'l r r . t r r i r r r ;r t;r l l l r i sl i r i i r r :r tr r tl o tn tl l i zi o l o g i l l ( i l l ' 'l r '7 '\'( ti i l l l i l l .
    I rtro |i ,{isti] ,, c ir ! ul t i t l, . s upl, . r . . , pr in c , 1 1 1 1 l x l. r r l , : r . r i r l , , , 1 ', ', , ', 1 , , , r '. ,i r ,r r l r t r l i L i l tl ti o ;r t1 i L l l i ;r l i , l r L tta stL :r c ;i :t|'r i i r i l r cr i o r r r l ;.t.'r '1 r i
    . r . .r' rI llr ',.rti r.,rr{ tr. ,r ot t ic i ( v ; r i, . Lr r . O n. ir r . ,r , a, n si trt.irr r,r.,,,
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    tuli clatoritiL l uRctionalitiilii irr rrr.r,irrsi r-r'3im ckrplcsiunc (irrr.siunt(iI slst(.ttti
    , I'il;::,lilJ:';;,1i"1,1":iLil,iii,,li;l,lll":i,'l'lilii,,l
    (stc cgalh crr cca pLrlmonitt'r"r, lrr jrLr"dc. [i0 mnttlg). Pii.sinlt'a r,r.r.scrrtr'r
    rtttcr':tpulrnol:riL si ventlicrrlul drept rste dctcrmirratii rk, nccr,sillrfcli ir111 l';.!':'#ii1;1
    **i:i;;*h"l*
    qr'rii singclui iu aolt-ii prin canahLl irlterial din artcra pLrln.rouaraL
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    si ck' rlzi
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    cllor' 2 r-cntriculiqint-sensibilcgali, iar raportul grcutiL{iiVJ)i V S cltc d,, t ,11
    in contlast cu adultul ullalcaccstrapolt e-stc112,6.Ptut acca-sta sc explir.i"t
    pi
    "
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    lxrnclcrenta lcntriculariL dlcaptil, prezenti la nasterc.

    '";,|;liii
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    ' '' ,i,rl,',,)"11,i1:\.;iiiiii .,,"1*,;illi,{i,i:ll
    .'illr*.',:.,,**l:":l
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    ji;lixiii;l:,il;,'"':
    lrili sc o'idcntiazi prin modifici rilc r,,polarizarii r,,:ntricul:Lre la niyr
    ( r)rIdract'rilor precorrliale dreptc. La accstL. adapttlri hcmoclili:Lmicc st, il i,,,iillil'tii:l,t,uji.i;li,ll
    r'ilzr'Lgi posibilclc pclturb;rri biologicc (aciclozi, hlpo.ric) dii accastiL pr,r.irx
    rh' r'ia{r'1.clrLc de ascrncneapot modiiica trasefll electric.
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    '.iitt"i'in,,' \-' vA'i"Pjll';l';;':"
    \rr l"
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    ,t, c.uV" il,.V,o itI Titport -J';,il1i
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    9).
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    ;i:iiil liliii;l i"iri:'zoo"_zlbtliiii,i,i-

    Anal.;--./.ECG trebuie si se faciL in_motl sistematic, clui;ii un plarr


    roi, l)i'ntru a cvita si ne scapco anornalien,,r".r.ros"uti. '

    I tt I ,0. . li'rNvenla Pu1-


    1,,'!,1i (ido v i rs tS (du-
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    Or-icc in const"ula. reproducerii complexcior IrflltSf


    .1 . rro mlli3eregularitate
    ccnstituieo tulburarc ,-1.r.irm:arrd, .oniuqpr,..
    -i
    .,. ".11,C al.culot/, f r,ecaen,!e,i se poate face socotindnurrrtirrrlrla
    scparRdou.t undb R qi lnipirlinrt apoi 6O iecuncicLr nrrrull.
    !l:ililql.k .i.i.i,*
    I I| t S | | lrrr t,,, d C So .u dc adunt t o ir 11. - "t . nln 2 uqdC R -
    , . [tntru a nu_mai opera cu virgule .(sutjrni de secuncii.)sc inrpal.tr. (, u00
    (suti*rilc clesecundii ce sc af][ tntr-rin miiut) 1a o, ir" .,.,.ir,r,Itr'
    rlirrtr-c2 culmi ctirdiace si se afli astfel Ireci,cnla.
    ""-:,i"i'r,iii-
    tjreuglltl 1: intro 2 unCe R se :r{1e2J p6lle;1eie_micide cite 4 sutinli
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    -
    L:vtnflul 2: intre 2 unde R se a,fli. t0 pilrrrele mi,:i de cite 4 sutrr,Lisccur,(tt
    ((,,t).tlr
    40; frtovenfa este 6000: 40: l50lminutl
    rh ,r|rlirlir.. tlar carerevin la va.lorilenorma"lein rcpaus.Daci insir, frecv|l:{rr
    r,rr'lr.',:r's,inr,'n{inr'ri{icati 5i in rcpau",intrc rr'0;i 200/minut' atragclt' n-
    dintre doud unde R'nu corespundeunui nurni.r ,._rar:trl0 ii,, ., .,,,rr,,rlosibilititii un,i'insufiiicn!o crrdia,". ln cazul valortlor }r'rlr'
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    lll:_g::ttt"
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    iii:
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    "itllr.i'ili 1,'',,'.,,t,,'1,r'itnului'
    "' ak,rilm'lrri cardiacscirrscriuln jur de 120-130/'ri''t
    ' il:lil1]ii:' intre 3-5ani; dc 10o/minutintre 6-9 anl i
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    100-
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    retative
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    corrrp)r'rrrlrri
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    ,,,,,,i 1 "' l i.,,,'
    ' ,,,,,i ,r,' L,ri ::,i l i l :l ' l l " ,i l ::J,,,11,1' l ],
    . b) I J t it lin. , t t,,t l .i i u d " n i ;,.tre 2 ,5 n rr n i n r,,,r, rl ,.ri v:rti i k, (rr
    l .L L a nJ 5i 3 m m r n ri ri rz i u . L .r,. m .ri n e tri ,rn p l i ti rt.l i n,.Lj n i .t" , dar.' r,r.rLzi i r l,iti I:;rt, r'
    i ,,,|i
    i;,,ri,"1::rlll,iii;rlitl,,iliil:jitiiiii:jilul
    r"'l'rl 'ttrtt'tl I:t trt'tlrtlA --\ ' 'ltct^11"'
    l-l:ll1\. l'i'l,lli r"rr* irrt.r'''irll' lt
    1rcatc fi uneori^mai mare.jn I), sau a\rli sau i't conducer-il: irrccorclitl,., I
    ::'. Jcl ir s nx s c - in. i v a l o ri l c mj x i rn " .
    i,:lli ' I,ll1"t',ll
    li,l:]li,illil,ii; ii)u;'u"'i""
    :;;:;i'l',;';,'"i'::':illi
    c) Forma si axu} si:'u: unda p e normal roturijiti si alc un i1l 110rnl
    . ,',,',,i,,:,
    lr, 3.13;r'rzi;i-tabtJr$"i;o"in"t virstii 1t.t- pR
    s'trat inr n" plan
    plx n trontal i n i rn j O o s i 8 0 " .' A rc s r ta p t -spl i c.i dn cc rrn,l i r P
    lr ont a l lntre ', riii. cLr 9i
    - foarte pozitivi in Dr;
    - incd.pozitivi in D.: ,,,,, r,;ilil'i,
    ';::, "ilti:i,:,'i*l,ijl,ll lli:il
    iit;ini"lli,':'-':llll,.li o
    'ar.iazir
    t , t " 'l , i i l o p i l tr l tl l i l l n r l c
    - slab _pozitivi. sau iltversati. in Dr;
    i tl tfr'J sspus: P2 . P
    pus : P">
    \,'-,i;,1,;itil,nli*lT"',u,ll,J:liil,llf,Ti',l;'u',,,
    i;:;; ,:,.'il ''
    (,st(,
    i,,',((ri,'
    P,>
    llll,il'i,tri*:'{iHs"':'"ul+lt"*l
    r > P..
    P B.
    Ados c a ur r c laP e i n v e rs rL i i n VL c i l o td c a na i n aV R .
    t Ptincdpatrcle
    [) ce d ureazS.
    l'eaz5.rrrai
    anomslii ale undii p (fiA. J.lz) (tabclul3.6).Or.ict
    mai mult de 0,08 sec. gisi rnisoarl
    m peste
    Deste'2.5 2,5 mm
    mrn arnplitudinr:
    arnirlitrulin
    I
    ill II li..
    ;:*x'i:'"fi:iLl ",;
    rurormall si
    ;rnotmali qi traduce
    traducc o hipertrolie
    hipcrtrofic atriali.
    . ,,ll'1,,i;ill;li:ll'l*'m"i;:l;iii: 'i.''t.'''
    "t'i'u
    - DaciL unda P anomalilir (e aasculiti,
    ScL lr IIa , inaltii,
    Ill al tU , gotici,
    Jj
    lolrnaliL,_-vorbitnqe lipertrofie atriali clieapti (p p titmonar.r.izibil tn
    clar. (1('
    otr{1, dar. rl, d ",
    "'r"r"ll.l',,,u.,i,, intcrv'l*t
    I),, ;i in prccordialcle drepte) .
    .- llacir unda o I' n'cvct t liL
    ill';]i;on;l:.
    dc 80 sau'';jl o",iii,,tl ;".:;,!f""i,l:;.,:J''i
    . -- l,a(.i uDdal,
    I, anomalit
    anor.mjtic tur.tit.'r,
    rrrrrir.i,alungitir
    al cl duratiL, cu doui.L 1r' ttl l tt
    vor{rirnde hipcr.troficatriatii sting:! llll " i tl tit t lt t t t r L.
    l'rttt
    11,mitr.aivizibil ln lu Dr, I)n qi
    D,, T)u $i tn ""
    A i , , ', ', "t ii olt int t nalt t lni I t - li
    rtialelcstingii
    , ,' ili-' l i t . ' , t U ( : ( ) , 1 {,)s c c . ) :
    . -- Abscnfa totaliLa unc]ciIt in toatc r:outltrct:rik:
    trarlmroalrscrrfir llll( r ;
    vittrtii ltlirrl,' (hloc sirro-atriiLl, l xrsilr il lr L sr lgir r ul
    rk. r,xr.rtrplrr).
    4ll3
    41r:l
    1):\'""1"11']..1l,.illl:::l'lJ;.llll;i'lll"ili
    i,rrpoi(r'ccLorrtr
    .i rliilLirrrc
    r,,," _. (ltrn
    j rr. t (.
    {i rrrrri tur uoclal(irr carc tirnPrrlrl,, r,orrtluccre
    ,,lli:-,]l
    lltua l);
    ttt,,rte una din caracteristicilesindr.onrului
    atrio-vcutri(,rF ,l r I I l l l ,l

    ,lr:;',,'l;,'
    :iiii,t,ii. ll
    ii.,ii,u;+llilhllq"liliii,:lli:rr'fl;;l
    Itr

    , ,.,,.,,,u,1r,,,,tt
    - itr cli,.o;tnozol" cardiacc.
    de preexcitalie vcn_
    l1 ;lr.iil,'l:i,l\,i,l,rj,li:,:llili,il:i:1,;"11,"{'**,
    ' ,, ' , " , , t , ' r i r t t . r ict t lr r l't idr " ir L n<t c m a'r m ir r ( . : 'r
    dr ur L"I
    " ] i", f i* i ir r - . - r iir r 'lt i- 'c 'lcct t oc: Lt r lt t '
    I') I,Il .luirR; tr\ r.l (.rtl :l i tLl : ri c i l i rmIl l Itl ' l l "t i.
    '

    t,o
    -+-J!-r-.1 2
    FH++F
    -H--J--+-t-t I - rnTf_|

    si
    I
    '&glaealq
    TT-r]-r?
    I Seqme/7/,t/
    il taf-rrn
    l

    t .U

    hiira/rV a '5
    Nr -r_ri__i--] ,
    /.tate EaEtectrttd

    /; Y+zTt
    u9)
    $\ ' . 1 Y 1 ,,,+'
    1)|' ,,r\r"
    i-]--H {
    ffi/n bnd/ ar H+f+ iI
    ttt1-n -rtrrrr---i-f-+
    T-TT-1-fi -T.Trffffi
    +f_L!-r-] --. -#-
    a4 oq .q 4 4 6 ,te€u/zdc r:- . ta - Dcl l x ' r/J i tr v (rl t:' ul rr' ' 1i "l
    I II l )L 1,,' l rrri Taroj r v entri c _l l _ 't t
    '*t .' ' 1, -i"r , r "_'. r ( '1ur - r c. r rrr'
    o'r 'r i 't : t "'
    'I .l rILrrrI c l c otroc ardm-
    ljii,.i;,lir";
    :",i,*:::;l?
    i:f';',iJ"i:.:d;:lTj::",:,:"j:; ';
    1,t:Lrrl r|rrr:rl i i
    ori z ortal '
    "''" pt'tu 11^n. l It: l

    .trl'i,J'li:"11.
    1 i , r' ! i I rs t l ) rrn ri ; 1 l r -
    ''rLi
    |
    I ' ltit,,,',.,;l
    ,,r,t
    '
    I l- u

    '
    'i '. I , i ; '' . "1'
    r '"'"t i:t1 ' 'r r 'L i r vr '
    -- l)l!,c atrioventricular de gr. I (carditii reumatismali); " 1i
    -- l)R lung congenital drcptc si uncic S aciinci in conciucelik'1rt''rcotrIirtk'
    ,.) l,li conrtletnniogular"d^ la un complexla I r . r l t , rrrrrl, l{ itl crxtrluccrilc
    .
    altul:
    l)loc al I lO\ Fnl ricrrlar COmnlct
    r) -'Rr rriaL,'cur"q'l".iii!:":.0:s:ilH:::5"i:il: uncli'ni1'rrrr'
    5 l t (l l l l ( l

    ^. stingi
    jj'
    '.: l.o"q,," 2 r,e'frirrrri ,,ill;lllliiJilli:'ii,:itlli"i,ii"r'i".-t"ii..i.il"'-i*"'iai't"
    ',,,,,,'ri','r',,il.llf
    ;I;;Irllilt';,,ru*,*:;l;.i:#
    u*ti',:'lrx;#"'
    #riiill, *,illll
    :t6mn*rrr: iiiii:iilti,*l#j1:35'ilffii.=$J
    estea.potnil'"tl "tiai
    prccoc<'

    urir'ii$+*,r*pi;
    ;''ri;]l:i;""i""'J'f" .I,"r*,iiHi,'apicalii rl'r ir

    ;il''i,;l;iil,9
    ?'.,,,?;3ii;,;'iJol:''ll'lL.;,il?,'Jll":,ilSifli:,iiliiiii*:lilli,l
    '"iilittl*Ui.t:i,t*,'i'#\1i+#ffr"fr;;:li.f
    lj g
    ,ii; :i,i m,iffi :::il*.4'**,X,r .',*wi lj
    lnl.l;;" :l'il,ljili"ii!,ii-i*i.]ij:iiiHii,lT**it",m,
    :iiiir vA,
    *q|$
    clcrastinsai,,'i;,,:;;t:'H,.:;:filiil^'' i. rirorr
    ,,ri,,,rir.e.rnst:ric ir,rrrrrrt
    i:r'l
    il,11
    lii'ffixril;.f$fj',r
    ijl:"i-i,T"!r j
    i''i,i:ii
    ;'iliillg:;fi:*
    ,,ul,llliil:irril'ill,',:,,Til:,,,ill;l,iiililiililli:,;':il:,:li,,h:r,:,l,ir,il,l;:l,i:,
    ' l t) . 1
    Jil: ,1i
    'l iil"li,l)ilXiJ',1li],',, por{irrnii
    p,,,.c1r,r,i
    \.{,,,1,i(.,t}
    /:lli'll];i:
    ,lif:"",',r
    Sc ttrjso;r[i tlc l;L irrr.r,r,rrirr].r,,ntl)1,,\ujlLi '
    '.,rl rti l r s|l l l ii r Lr]qc l j ri (ari r ,l c l l , \r(r rl l i s \,,1(l rfl l ri Ii
    t ., \
    l, ,rl !' l ' n.: ,' 1,,'
    t' ri i r rr.!rfi rr(l l rrrrl ,l i rrr,l i rLi i

    t 1l r l { I f i rurrr s j S - i rl ]rt s rrrra rrl qc l )ri dr: ' i 5


    r)t(rs,(1,rzi j)irr:lIa prutetuJrrrrrL, \,r I )rJ\ i I I I r | | 1rr. I i r c :r s l |l l r;I tLl g.l j ri .ar l l .,trrpl ox r:l tri f l i S a c ondrr.fl i i I .= -i -B nr r s i s trrurl
    -()llS
    P,r.p,.rrtlicrJrrr.ii,.,,l:,:l],1-ll],,rirful
    und.i lt,* li'i. iz.r,kcrr.ir ,,r, ,,,,,,',i ,,,rrr1,l cxr rl ,ri(l l tS (l i ,r c ol l l 1r|{ rl tL III ' = s ,ni 1 .\x :r ]Ie(l i i ' QItS (."1(i ' ' * .' 10' r'
    ;1rr,r ,.a,,obo.i
    1,r'ndic,rarii pdi;i^;i;;iitc
    l;i;:illli),li:',ll1ii',.l,uil,':1';,:::r:111"::" jl,.l':Jll:i vi,ruri,
    .1,ra,,u;,;iiii,i;,#,":;'ji:i ri:r l )r(I sfrrrcl ( rrl s (l r' ;.c (l i rr c ordl rc (.r' (rr t s an III s j nr' nrai rrari rl e l 0- s c i nrIrtr' 1r Itr I
    Hli.jlii,li:i Lrt r., 1 .. ni i i I
    ',
    ,l i ' q.: r.,,' .

    ;U[r;*:1{i"l
    i]l;;:,,lljl'1,',(l,T]|i.:ii,,Il
    ri,:li,,l,$i l; nraitirziudccitin \,,. \.itr,,r.j
    :::l):1,:.,Ilror4caulla
    lir
    ;i rirlr:ii#]:i;ll
    :i:ii:Jlf:iii#
    lllli rlir
    i*t **ir $!r ; ;,; (-.xll (r?70)

    ;t'il3;fiti "it
    " "'iill:i'l'1l,,oJli'1,,|',"iii I
    l^', 1?""ii'.;";;:T;':"i'':il
    Iarr''Lni
    ,,ii,i r,,',,ir,luiJll-.i; :;"i:]Ji;"l:,' "'rirularii,, dia6nosri,
    rrrrript
    fri,'ll'
    :t'i::i;l;;li:i.'.."1{+H+.i*t\';ih'::,i:.*,1u";.u;"tit';:
    ; ",9JiJ,n
    li":i.:ii.;il,jlf :;i ll,,*,TTi';)T':i"
    ,;: PT;";: ;;,,.ii::.1i; +90

    ,,11,;,riiirl,iiftfr{'1i#li,*1,!'
    ,,i f:n,.l i*,fir:rl*fr",l:r*i$
    :*t;'.,*:;iii;,i",1;
    I,,
    rrll\
    i l o. - \':r dal i i l c a x e i
    i | | l u c l i e ( l c '/ i f s t i +vn
    lj:;lit
    ;;l,.1*;;i ,hli;,;;;iixj ' \ dl r s l r l ) r nnr l unn (l e ! i i l a
    , tr rr'l f(i!tle.-'!bi
    ' l L" !r '1,. l ( r i f.r nt
    , ,, r ,r " ti ,i . ( ) j ts dl r i
    QRS
    jn
    bj to l a re s i
    p ri n ri
    -a 0 {+2765

    ti'll :,:!ilt.1?"tiq!".:lii:J"?i',nc{uleRs: .-" " 6{" r 'r


    r . , ', l i r r :r r ) i r i r Ia 1c J i i i c !
    , r ') ,l '1,1\ul r i Q H S l r rf t
    '1! ,! r '
    r ,fj i ( J i c p l r i ttuhr r . i n n l
    i r l1 jr : . no,t p o z i ti \-
    il,
    x) r , j = _75(tJ46)
    - , as lr . c t fo a rl ^ l )o z i ti \
    membrer.r
    Rs.
    J"L Y.
    fiil':;#,t::.ffii:t,::'j:il1:#:;:,:".*"J"$
    Xiil:j.i" l:..::j::,,^o1i"i|:'."
    llJ..lil:lll:iil,:,11"f1il1,,..i."
    '';X,,H]i,];"r..,1'.',T1".":J (ir:crr.
    t/80
    ^ ai^i
    ,,
    ,t,ttrn sirnpiiiiiii corrsriin;

    I
    +/J5' ,."/.AL
    "
    uSn *90 ^ftn
    rv n
    :1,::,1:*;,iiiiii,::i."#li,li
    "{i,f;:.illJ.:'.."".x.',ll,i;r,U.},lH;,j,
    ;l:i;;,;'Ji?l'::h;::,3""i-;
    fn:.""f,,,*"1[,
    iSX,;#ilI;ii.ilds,,u".' \lolfoiogia t'onrplt'xulrri pRS variazii in r-aport cu pozifia electricir rr
    rrrrrriisj cu riirrta 1t;ih.lul:l.rf In rotatia orarii,'in carc'vcntriculttl rlrcpt
    ;rllir'inrrirr[cqi lnrpirgt' r't'ntriculul stlng lnapoi, pozi{ie frccvent lnttlnit lL
    "'
    ln lnimii nni rki tirtii, iispt'ctrrlcomplexuliriveirtricrilarcste de SrQs. Undt
    (t ilin corrdur','r,'a,.1)" disnareln insniratic rrrofirndi. Rotatia antcorarii,mri
    irrl lrrtlhritll, prcr.inii r',in'tricululsilng inaintc pi vcntricrilul drept lnapoi,
    , l, r'lrrx'nrtljogriafic lnscrijndr:-sc aspcctultlc Qr53.
    401;
    497
    *rtLuiui;ia cuticitoracice
    sepo:Lte
    intilni lrr lrirna siptiLruini tlc via{ir sc poate uota-norm-al aspcctul Rsr'iu r:otl-
    ,,,,,,,t1,1'i,1,)l]li.f,ri,li,l-il'ii1i;l,
    l1i, 'l \' ,. r' srr,i t c, sc Dor it , , r - lir r dc pini la \ ', 5i \ '" in cut c' insi, und'r r '
    i,,r''i i:,,iiljij; i;,,'r;,,
    en..s it,]'ii"u11'rul;'Hl:jil:.i-:'i,:"iL
    :?filii;
    ,1" ' '
    ' ,,,
    , .r, r,r.' i rri i ri i l " 5 t n. t t ir r dur at c com plexul't i Q RS ' st e nor m al{ ( ir r f tr ioir r i
    ,t1r,r,1,.0,07 scc. ) . Tot , a un asPoct t t or m al it t t oat i Pcr ioada-coPlli- r r lt 'l
    Oeriyatr'aI ,,,,1,,, prnlenf a dn cr cst at luii Jr c unda R in cr , nducor jlcVr , D, 9i aVI - '
    - 1,' ,' ,,.
    -3 4'7-6 6-1 8 -Z-/ & +/'Z+344*r6r'zr8/,9 lrr .''")j, tlin cazuri.
    l,\ .lsbcctul &)nLblr-\uhti0RS in devi'aaliileprccordialeeste determillat
    .i,.,,,;i',"r" VD,
    1,,,,1,,,niirrrnla\ 'l ) cu
    .,' atlt
    arit irai importanti
    imnortanfi cu cit couilul
    crriit c mai rnic'
    copilul e tnic.
    {,r irliuc, in prccor<lialelc drepte (de la trr la Yr) cst-epozitil
    -aspcctul
    l i ,, irr lrrccorclialclcstingi (de 1a \', 1a V6) aspectulcste in oglindiL,rS'
    ' dc predo-
    .' ( r virslir accst aspect se va invcrsa, pentru a lua aspectul
    rlr rrl,r tilinSiI, tipicir pentru adult.
    |,r topil in gcneral complexele ventriculare in conclucerile precordialc
    \ ' rl l rri ri :rnrr)l cdccit la at lult .
    .5 o t Inri,r. Q estc prezcnt:'t in mod normal pe clectrocardiograma copi-
    lrlrr ir Ur)irs;Lu mai mlultc tlin conducerile periferice. Semnifica$ia sa t-' rnlti
    N rrrl,., l,r copil rli'cit la aclult (unde are importalfi mare in diagnosticul ittfart:-

    q | " l rrI
    lr ,.orrdrrccLcaDr unda Q este, ccl mai adesea absenti. Ia na;tcrc ;t
    l ,r I rrr.r l rrt:r, i .rr , ir r d', '. t c pr ez- cnt i a: : e am plit udine m icf r , de 0, 2 m m I ) r t |ii
    r lr | , ,l, l lnri s, irrtiinestc relativ frecvent, in 50]l din cazuri, cu un voltaj
    rrr,,lrrr ,lr' {),5 rrrnr. Arnpliiudinea maximl in aceasti deriv,atie- mr -dcpi;t';tt'
    nr, i,',l,li, 4 trtn, cifriL iotati in perioada 6 luni 9i 1 an (tabclul 3 6)
    lrr , orr<ltrr:r'rilt: I), ;i D3 unda Q este prezentraaproape constant, trtt
    ,rl rr' | rIrr,Ii rril u tttc <lic C" Z- j m m . Am plit udinea cea m r i m ar e se int ihr ( r $i( '
    Oeriraft'af lrr I'r Lr I 3 irni ctr aclincimea de 6 Inm-;i de t0,5 mm in D, in perioada 3 0
    Fig. 3,17. - Di:Lgrana lui Diouaide pentru calculDl axei *r'
    electdce, trr r.rtrlrtct'rilc rrnipolarc alc membrelor imaginea de -QS in aVR con"
    irt
    'lir11, rr rrsPcr:trclativ comln iu aVl- unda Q iste mai frecventi decit
    Tabelul 3. 4 m edie nu dcp; est e 0, 36 m h cif r i int ilnit i int r e 3- 5
    l r, i , ,, rry,l i l utl inca
    pozitillc eletrics ale cordullii
    ,,,1, r' , .' ri ' ,,r :,i in D" unda O s, ' po. 1t ^ jnt jlni insa am plit udincr 'i r n. 'r lit '
    Rotalia,orard {de-a 1uneu1a tui longitudioal, pdvind cordut cte la , r' rrrt , ,l , L ' ;rut t i intrc"l 5i 2 inm.' Amplituinea .maximi lntilnitir cstc rlir
    r,,i,iLrtcsi i,npinse v-S inapoi: c"omptexete.re.;;;r." apex) aduce Vl}
    d;i;;;ii-p,"rir#"r.,ir. r" v{ sa. vr t r. r' rrrri rrl rr' .1 6 ani si d' 6 m r n int r e b - 12 iur r i.
    - aspect Sr 93 a1 complexului ventricular, l rr ' ,,rr,Irr,' rii' pincor dir l. ( xr r t m c dr ept c - Yln poat e ir r li) t r i
    yng; e in Ds di. parc in in.prrdriFprofunoa. ' - . 'n
    -
    t?.tatia anliotard (dea iuneul axului lon€itudinal. pri/ind cordul dc Ia apex) t,' ' ," ' l ' , r' r' ,l i p in 1'r 'im . rsipt im lnJ de viat i' in 6% dr n cazun, r cr t n vr
    o(luila ( l( '
    ventric'iare
    ;i-gipJ'ri gisite"in
    v,: i rr l l ' ,, ,l i rr ,.ni i i , m cnliur ica ca . r nda Q sf , . nu depigeasci adincim ca
    "t "":':.l":fB:g:.'i?"tffil"ixi:;',TP1exet"e i ,,,,,, 1,, ,, rlisPltir lu "r i zilclc urmitoarc. In aceeagi-perioadidc via![ ln contlu-
    Catd in bazilie urticatd, (.
    YD irainte_ si VS inapoi, ir contact cu diafragmui ,' r' t ,, \,' rrr,lc Q , st ^ ebscnli r u dc am ll ii- ud- inrm : .ici.
    - p o r " - ! i d l c l " \ ' S :ln r c.te r p cie ctiv :r Dr . a \:F . \... \'.. .,st c. ! r ' ' i 1,i ' ui ' .1,, , lr '- 7 2. if t , in conduccr ilc pr cior dialc dr ept c - . . \ - , 'ln5i V2,
    - i r t D , . \ ' L . \ r , 1' ,:: r .p ccr r S ( ^ a r a cte r i- cr ;cp .,,tr . f n1.
    rt,
    rr,, , rr" l ' .rr' r tttt r l; t 0, 1) r 'zr nli , i liil d ( onsider at i ca pat ologici cor t t lt t
    crtd i p o z i ! i e Dti..0 tn a 1 ,i , ' ,rr 1,r,r, r' l i :rl , . r iiilr i - r ', , '; j V, . - unor Q : e- lnijlneslc. dc . la, n'r ', "1r 'r .
    VS inaiflte Fi VD i{ contact cu cliafragmul:
    1,, r,l l .. ' l ,r,.' zrrri. li t hvin, r lt r i ( ( r : t r nl f r ( zr n1a cial n'dcpir Flnd f llr r lxl
    - a s p e c t q R i n Dr , Dr , \r .. 1 ' 6 j
    -a s p e c t r S i r L D 3 , a \.F . Vl, \! Ir,l rl ,,r,l r' ,l rtttttttt lr r ir r ul: r n<lcviaiiLgi4m m dupiaceast ivir st i, cncor ( xr t l
    r ll r i tr' ltr .! l trr r i 1r il lt t t i poir lc ; t t ir igc nor n. r al5i valoar ca dc 5- 6 t nnl'
    iniurii vcrticalizatc,in carc v.ntriculul drept sr.a[J;-r alfnr iur fi vclllr;rrrlul | ,r rrrl l rrtrrl r t r r tr r r r r r i t' .'i tl r l l r ttr , cl i l r j tr , ( ) r l l r i l i - r I;t',l i n t'i |i l r tg i
    slirrl; llostcr-ior,ln contacl, potcntialcl, vcntricrrluluisllq; l ' r l r, ,rV l | i r \', . \.. i r tr tr ,i r l :r ' t;r 1 r L l l ( n l ( 1 l i r 'i l ,l l l l l l r l l g l l l t'i l 'r l ) Ol l ) l i l l l
    slut culr-'so clc elcctmzii Dr, :1,,(itn]nr(nul,.
    a\lfi,,v.,,V.,r:i.icv;t lttscri'' Irrl rl,,<ll{-lli t ||l r rr,t r (|l ol l i l l r'
    '
    - .r i 'i ';1 i 1 ',I , :.i r ' , , ' . , ' ' ttti o r i r t<l i ,;i s,'Lt'l r ( l i r l i tr ti r r ta t'l r tl i
    ;tcr,slr' lrr.cincl1n I),, a\r),, Vr, V,, aspcctrrlviL fi "tp,r
    <lr.rivlrfii rS. ;rr rl, l r r r r r l t t rr ' r t l t i l ) ,I) ( 'r 'l l ( l ( 'l l l l t )

    't1 )l l , ll) ll
    l,lll1il,,ii intricir
    lllll:l,l:! l.',t:.lll.tr,.:'\,1"(ccu,,\'.(to,:initriar
    sl) r '|( (lr";ll)(,r) i t ir ' r |ir Z, i lr r lr , r t r ( lli; r \ S. pLrLr. ,,rl ,rl ,rr rr vi l st r r , lr r r DliLut liucirt r t cilil cct t t lt i nt at c int ilniud. u- seint r c 3; i l2
    t (l11
    t . / t . J,L
    t J ,r.
    a kl! tfiDr ,rIl
    L r.i
    |. i,r.:i
    in rtrt rrt'r'to*r
    . , r ;1i|,i i,l , ,p, ,,r.i
    - , , - , .l.,.ri
    . . . .c n ,
    ti ;rl rrr;i i r,l cs lrt lrr r'ontlttr:r't'ikrI)., valorilc rttrlci R sint in medie 10 rnm, cu vlLloti
    ",,;',rji;,,,ilil;l;llii,rJiiir,,l;'iij''ili,;i'.,"oli'il.arcs
    . ll c
    rr rr rrl r' r' rr r ; lclr . : pi pr im iL sir l>t inr ir r iL; i int r c 8 9i l2 ani ( f ig' 3. 18) . .
    { orrrlrrr:,irilr:trnilrolalc alr tLtt:tttbrclor5i in special aVIi aru valoli trttrlii
    tjis.
    r'i
    :'. 13, - :\sl)ccrrlr_ c o r n p t . r r , l r r i f . i l t
    pl aR rl ' rrrrrl l i l i ir r ir Lr '( [ c l0 1nt n, t : t t valoli m ai m ar i int r e 3 ; i 12 at t i.
    l | onfaL in r u r 1 L i 1 r(.t e , . 'i t s i d ,
    lrr rlllivrLJiilc precorcliale ilrcplc 9i arlrrme io \-r, unda R csttr tLrrtlrlil
    I
    T 1,rrrrl rr .l ,,, r i, ', r r r r it lo, r r ca lncr li. ln jt lf , . lt 10 nr lr , ia apoi sl"Ldcst : t 't 'asci
    2 i ,r,,;,r, .i r' . \' rLloL: nr
    ilc, axim e clup: L dil! r it i iluL, r r i sint ext r er n dc valiir lr ill
    2 trr' ,,rrrrrrl rrs| iDt t 'c 1. 5; i 27 r nf t r ( I ig. 3. 19) . Condue, - 'r ea\ r - ar c valor ilc - apt lr -
    1. \lrr,rli.\' (,Sirl( ctt alc condttcctii \',, dar pufin rnai mari ln prccordiaJll,'
    6
    a ' l rrl ti \' , -\ 'u - - ir t pr iluclc zile dc viat i, unda R est c de aur plit ut lit r , r
    rrt, L l;rli. rlc 1>rccorrlialclcclrepte. I/alor-ile rnedii cresc clc la na;tcrc irr (r
    lrri, l){'r(r'r ir liLrlinc la acelea;i valori, in jur dc 20 rr m, piuiL Il .5 rrtti,
    r,' ,i rrrl rrl x r i c( ) nt int r t l pinit 1a vir st : r adult iL ( f ig. 3 20) .
    li.r rriir rLrtrici R rliL inlorrnatii asupt:r coldlcerii iltravcnlricttlirtr';
    ,ri .| ,IIrIr' rr rlI r r lr : lor ll insca"t r r t r irt uibular t c dc conducelc int r avcnt r i( 1ll; llii
    (. ] lt S bizar c
    |
    ' rrrl ' l (' \t' li lalgi ( m ai illult i1e 0, 12 sec. ) apal il'l l) l( xllr ril. '
    ,,,rrrirlrrl rlii liLttruriL.Accstc comflc.re QRS bizare -sint icleni:icer(:r1 ir(('l( il
    ,l rrr ,,rl rLsi slolclo vent r icular c, ct t clcosebir cacir in blocnl de r &n) llt ii ( '\ it l i
    . \ 'r 't r lt i
    ,' r' l .r{i ,' l i xri 5i r cgt ] lat iLir lt r c I ' ; i O RS, in vlem e cc cxt r asist olclc
    , rl rr, :.i trt r . ot t t lr l, l it t dct r . t idct r t c dc r cr ir it r t , a r r t ilr li
    I t ttlt '\ ' itr couducclile stanclard I), ;i I), estc pr:czcntiLitr aprorrlrr'
    l ' ,,ri r rrzrrtilr , ,t lir nir uind ca. zr m plit lt t linc l) r ogr esiv t lc lr t nalt elc' 1a l0 r r t t i
    r
    lq1 | t., rtttrlr i vltiazir pulin ca ampl itudinJlntnf inindLr-st 1a r':rloli ttrit i,
    lrr ,l, rlivrr{irrttrrilxrlatiLa\il amplitucliric:r undei S scadc progresiv t1cla nit;lr't'
    I r , ,,1rilul rrttc j valotrtca naxinir. sc intilne;tc in primele 3 luni dt' t'irr{11
    'lir
    l,rrr,r lr) ttttu, Contlucerca. aVF arc aceiea;i r:aiactcristici ir.Lci' privr'l;t'
    , r, rr' I i t rr, Ii rrc i L r r r , lt i > t ir : i lr t t r lt t c' t , r I J' ( t r L, clr r l 3. - ) .
    '
    lrr rlolivrL!iilc pt"cr.ilialc drepln sc consl:tt.i untle S clc ampliirrilirr.'
    8l
    ,tt,rt, lrr trtiilr'tc, runlrlitudinc cc diminuir apoi pinit 1a sfir;itul printci-ltrtti,

    1/
    ,{

    ,t,L,1,
    JI , r ,r lirniriir stalrilii piniL la vilsta cle 1 dn, itL virlori sub l0 mm. l)ttpri
    ri ,,,r,i l i rvi l sl- ir t t nda S c: r t '9t t :pr ogr esir , in m eclie valor ile sint de l2 lt r nr '
    =r iil8'l lt )-or
    8f '
    I I
    l
    In r:ondttcelilc p.,'.ut.liu1i siingi, \r- ;i \-o valorile :lcdii ale rrtldt'i 5
    ll 4: l', I

    #t, - J:- -
    ., ,rrl pl rgrcs iv dc ia t t - l0 m r n la valor i de l- 2 m r l. -.

    1,
    2l tl - J l -i / ,\ prccicrcir a.mplituctinii normale a undclol R ;i S in cur'sul.crcll "r'ir

    t t'l 4r l l
    -er
    N ,,,1,rlrrlriicslt: rlcstr.rlile di{icil dc preciz-at evin.1 in vede,rc{aptul ciL accsit'rt
    ,l ,,i rrrr,l ,l ' : r 'r r r i; r t iile 13I osir nii per et elui vent r i, r t lr t lr r i dr cpt 9i slit lg. , \ t c. 't
    -lol' 'l I
    r t :t" rr r r xlilici r "- pi. l in pr im l ir il't : r nin; i d. ' vie! . i ca ir iiugr i
    n
    t6L
    tvi
    /6",:cdpl
    ' j ' ,r
    1't,,11r,'siY vlLlorilo tlc li aclult.
    "Arnplitudi
    ca truclei,R- in
    - cpoi- - s)prccot
    conduccrilc
    .

    /sJpl 3d//i
    /,ta,z; ,/dn Jdn/ illrri,. rlr:r:trt.r: si iric undci S in coriducerilc lret'ordiale stingi este itt L'itlrotl
    //nni ldn t6mt' ,,, ,l, rv,ritar:cit vclrtricul[lti c]rept, iat pro{Lrrrzirncaundci in precorrliirh'lc
    t " S, :, R d D o rtu J u n Je to r l( rr S FiB 3, 20. - .\spectnllLrL,lut,)r i rL lpliiudinet undci li in ccli st iugi cu ver t r iculul st ing,
    I n- 1 9v,r. , -i.I l , r n L iic d e vlfsi[. It si r ' l rr,pl r ;i
    tlr Juncfie (lc v irslil
    o l l ,rh, , r lt t l li, . '; it t l'r laa! iilc / 'r t t or 'lit l, . ln cot t dt t cclt a \ 'r 5i \ 'r t ; r por '-
    Iu cr,n,Iuc..r.,..r
    D, arnplitrrdirrca
    undci ll cstc mai nicl,t liL ntqtr,n:, Itrl l tl S r:ti :r t c r lc l: r t r as( cr c pir ii la- sf ir ; it r r L lr lim ci I uni, ir poi sc t ) li( : l( ) r {'ilzii
    l;llli::, ji I Lur
    rlj";1
    (llrlrchll3.7).
    i, alnilint ptnnri i- JrrJLtiiii",,1i',,i,
    i11" .,,on,rr r,,r:r' ,.' ,jrri v i r ; -lar . l6 aui. t l1, oit , lt r ccr ilcl) r |cof ( liillcs[ ir r gi - \ '6 ; i \ ', , - t it ; xt t '
    "i' l rrl ' , r' r.51' .' c1, ll , r uLSlcr ,lr ' t l2 r Lt r i,peilt : n ir scit dcil ir l per ioada l2- 16 Lr t r i
    l
    ,l)r gi D, valoril. rn,,cliirle unclgiR vari;rziL l l ,rl rrl ul 3.5. 5i lnlr clt 3. 7) ,
    ,.. t)r
    .ro ,, ir.rr
    l]...o*du.qlilc
    o rrrnplit
    rrrlinc, lo;rr[e
    rniciiirrrirrf,,
    ,t,. r t,iiii ,ri.t' ,.r,,ii*.ii''
    ,,noi nr S Ii r,l rtl'r , sit , ( ) lt lr ,considcr ircit f ir t x) l, t ulli/ S t |clr uic illlr f PI ( 'llilt lt t {r r r r t{i, '
    ,1,.,rrrI I rI i I rrrI i rrr1i r r r r r r L, iS. lll r . ir zur . il,irj r , r r ll' r r r r r llrS t r I r , r . r r lot 'ist t l, 2 nt t lt
    tl(xl
    501
    (lrplrrk'nivclnr'') siru ln sens ncgativ (subdenivelarc) a segmcntului S'l'
    ::Hgt 4:1,1" clin {idclil ltc rlr<.rtl'r.'c
    .rlir valori mari. Sc consicterd.
    ca
    ln eonrluclret
    \r,lncareurldaS,"i"liur,z rr,,r,,, llairlv,'lrlca sr'lrncntului ST c mri pulin frccvcnti in plan frontal (poatc ti
    iliXffi".?rt9.tXo":,Tului I[pr'(l,.nivcl t lll I)r-Dr gi aVF in primelc luni (cu mai putin de 2 mm);
    ltlrl;rrrritsc lnttlncgtc in plan orizontal.(in Vt 9i Vq), gnde ia di{erite asp-ecte:
    I irrrrvrxitrrtesuicrioail (cel mai adesea),iectiliniu, in panti ascendentl
    Tabetd 3,
    uecrilc 'iiecqrrliatc (dirpi Gemid)
    naporlul IVS tn, a(rDrt
    .

    't ,t,t) ,982


    L 'a I vg
    4
    -24 ore ..95,x
    | -7 zile 4, ct
    0,90 o' 71 0,68
    7 -30 zile z,88 1,57 .1f, ,-7SX
    1,t6 l ;14
    t,92 1,26 z,tz
    3-6 luni 1,62 1 ;q 6 , 2,78
    6- 12 luai 1, 51 ?,83 1,39 --50.2
    I,1 1 . 2,70
    1-3 ani 1, 13 1,05 3,0{ '7,5 - '-25/
    3*J aui , 0, 65 0$7
    6*8 ani 1,20.' i '7,38 |
    0, 51 o,l7
    8* 12 ani 0, 1: o,A7 5,80 ''6'7Q
    12,6t' r
    0. 39 o '16 3;60 'l
    8,14
    10 lntre 1 luni Ei 1 an
    4 iulre 4luni si E ani \+-
    \----;a/-- ..
    2 peste 8 ani,' ---J
    / t, i,l
    --J
    lan/

    1l f:t':t:tl :1T^Td1L.tI",.. maimare


    +gditudi_1e
    dezmm,aru
    ',o".Tto,T/f;f p,aitu",iiil"iJ.*
    n"riiil;
    ffi;il: ;ffih:,iiil / nilivo/l " /0 nm
    T,l,;ro"." ' = medl'e
    3 fntre 3luni;i 3 ani r ltt|, 3,2!. - ltoportrJ Sokolow (Svr 4 Rvo) in funclie de virstb (dupe Dai/ignon A.).
    2,2 intre 3 gi 5 ani 1 uilivolt -10 mm. - @edie-
    1,3 intre 5 9i 12 ani.
    IndicetreSohol,oa
    Jnd.Lcele Sokolou aduni
    aduni amplitudinea
    arnoliiudinea R
    in+r-^ nr^^^-J..^ sl
    intr:o precordiali l/+R l/o
    cu amptitudineaS tntr_ooreco,diatndrgaqtF(R% _i dv;i.
    gi mai ales de la 8 la l6 ani. not,fi atinse D"pi 3 i
    valoii i*i,ortl"'t",-rrdi
    ror4 con
    loru consid"rate
    oerareanonnal superioare I
    anormalde
    dd ridicatela-adult;
    ta aauti I vaibrile
    val[iif" percentiteilgj
    40 rnm dc Ia 5 Ia 12ani,penrrunV.-giSVrgi ct i". oo #*1"",r"
    ""rl"ii,,",
    o. iu^.
    n4 EA'9 /ip neondfd/ y.-
    evitacrorile si recomandi
    i"r"iii""-l"l.r"rrr'ir[."1.2 I pi I
    ll!:ttLrl. I I
    ,, Redim scherraticECG de tip neonatal,de tip suger
    gi de tipi,a; -4r-* .JFl.*
    (dupf, Shinebourne)(fig. 3.22). fKG hP ougar
    F. S egm,e,ntul .Sf ifig, 3.13)irReprezinti,fmpreunl
    procesulde repolarizareventriculard..Treceria d" la'.;;'p1;;ul
    *."t*
    cu unOc
    gns i;l
    il
    !r\
    lI_.,.-_11:."
    l.i,t."" _pT.t ;" t;;;iil";';;;;ii:i","
    J. FKG ttp ada/f I
    Este intervalutceseoar5 sfirqitulcomplexuluigni a""i"i.i"tuf
    'l'. Este adeseadificil de.-indivrouatrzat. Fig. 3.22.- n"ni:"!;"n;i:l*" al Ecc la di-
    Nonnal, este izoelectric;.
    T*;?titi'ilii.illi;";iffi
    li;ti,lit|'l':ff ,lff:ti"iii[#,ilJ,ffii u ddscendentd. Acestemodiiici.ri ale segmentuluiST nu se intovlrllesc
    do modlficlri ale untlci T.
    Dcnivclarcapunctulr.riT fal6,de segmentulTp saq pR,
    rcprcrenta linia iZoelectricd,-
    a.pf oiirii -i,
    pcr'nriteap-recicrea . Dursta sa o greu de apreciat,segmcntulST anormalde alungit tradtrco
    l$nlci o hlDocalccmle.
    603
    508
    :l
    a
    a/-= i.j^ii I
    t;
    F: i., lrLl-- -,1
    =- ll
    1l-l-i:;.- ^'Lr''rlLr
    'ii i,

    r - 5-
    i, l '^' I I 1 I i
    'i : tt> tt> r' 2 tI . ttl
    7 '' 1 >> i - r :r '
    ; -.:
    !r 1:

    ..5> :
    i lr
    t^
    Li

    1,.
    :r
    ; (-j
    L 1 IL
    7: *:-- i ;i IL
    ' r' n
    ;- t,. l rl
    ,11
    = .,tl
    . :1 f': ,,.
    ;l
    : 'I' ii
    : ]
    t 2 l; ,, ]:
    , !i ,,
    = E
    a
    ;:.= z E a!
    I L -t-
    r_ts : 'i - rii : ; l , i
    't:. I
    tlr
    .l .l .ri 'i
    -=z.,7' : ' i
    ll
    ! 'i n
    ti , li ri
    -r:
    cd9 ' ,::/ It
    .tE 2 l',
    ,: ,, 11
    x -i '"1
    ' . ii
    :! ;
    al i rii'l
    I
    I
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    ,../ e t1'i l,
    .E < r' - ,rj
    ',) L '-; Ei tl I ii
    !
    ,?.= -"., i.7 Ii i ;] '
    I ,. rl L
    o -q o -
    I I
    ;-a n! i'
    1,|:iii
    ^_; -i '^ i) tii I
    2'Za-' i
    I" till
    ;-'3
    f;
    9^
    r:_ F:
    l- i- !i ':
    I

    iaas lr .r - - ,_ ,tl '

    I
    I I l tl
    I
    ,i l

    504
    Di)il
    tT n o r n tl tl tl ,\(
    .lttotttuliilt ( r ) l l :'l l l l l i l i i ttt'r 'L sl tl t'l L r r sIr 'r l l l r t
    1'nb.lul
    .t.,,,, r r ri i l r r r ': u i t t :
    l tt'i ttci l 'L tl t

    srLflrin{[ rniocaldio.-l
    tu d o I' sulrt<rir1,.,'rlcarca \ cntriculilrir sisLoliciL (dreaptir' sau stiu8iL drtpi t:tttlr
    l i .' i i i ,r . , liul ir I 'r : ccor Llir , l"' , r npLc sl'u st inci) ;
    ' r, ' rr;
    rlncir) tull)rrirri clrctroliticr:: hipocalcemia 9i hiperlialiemia se ins<r
    lI1 cste pozitiri
    Vo cgativi,
    Asp e ct de prcf.i nderenl S vcntri c tl rtl l, sr: rll o Lrncl:t'l'amp1l 9i ascufitiL; hipoiraliemia diL o undir turtit:r sau lnvfr'
    drca!1ir daiorite riodil;c;rritor hctu(xjirlll_
    ..rt.Lr(.- i l , i r:oti loi'li. m ul si suf , - r in- 1e m iocar dic') .
    l]lice apirute drpi, natlefe
    l l . I tr t r r | , r I p- 7 m isoar J" ansxm blul acr ivit ilii 'l'cir jc''
    "t
    \'(\lrriculclor (sistola eleatfici) $i se rn:rsoarii de la irceputul conllLe\L1lur
    ol {> l ri ni l e sfilsir ul undci i ( f ig 3. lj) .
    burata OT'cste in {unctic .1"efrc'cr;enla cardiacl (mai mult chiar dc(]ill
    \l ltt /.i11: \! negativi ,, ,,,r,rl P R l , .i r aiit m ai qcur t i cu cit acnast i f r ccvcnt i ' nr r i r ' pi'li'
    T? ncgati./i "st ".r -u' per m ir si m ; t sur at cu t ] - f cor 'idcr : r t
    L\i sLi tabe l 'om Pf , r im Q T
    \'., -, \i6 poziti\';.
    | | ( r)t norm][. i i n i, r J . r m . r d' f lecvcnli.
    \1 r cgativ:.
    ' I'cntru a'afiir valorile normale a1e inttrvalului OT Bztzett proprlno
    Se tr e ce progresi y de l a prepondfrfrl rl
    V, egati'/ir" sar po?itir; /' r ' r icllh i ,l r^rt{i .j ,t,;:.a La rsl ,-r,,, ' r,,1i " 1 Ql cof(ct iLt ( Q Tc) , ( r , 'pr ezinlii o. npor t ilr c. r inlcr valt r lui m isr r r : r t
    _
    \'r*Va pOzi1i./:r. ' ,' - ,r } ilib r u :r ,e.rn i . ,r.j ,,i 2v(r',i , I,l | ' IrC G ]J rJ,l .:t cinr lr ilf r eLlr r LllllJlFr r lcllllul car olilc

    i a la n r .' r r n are de astoci c ncr etc c)'l ]rr ,i | !)1c: Q'l Dlirsurrtr!/a;;G R - R
    a e clilib i l l ri B |:rl omi c i nl re cei 2 .i Lrrur
    cu li Dupi. Dr-rpuis ;i co1ab. QTc nu depl;e;te 0,400 sec' inainte de 12 ani
    ncgati,,A
    I {,.430 sec. duoii aceastir"vilsti.
    \ ,^ - r .r ( "r l j',,,t_, .., --.pj ot i ,.J, ..r.,.rr.l
    Vr ncgati"5, siru pozili./:'l r r lr l.| r l la f,,l L,l l . '.rl r:, ,: l ro;..:i . o An'omati'ile Princi'fale :
    Vi *\'6 tozitjT: p o n cl€ r e n 1 a vcrtri cl l ar.b. drral ta
    1,r, * uto"Sii"u iniervalirlui QT se intilnqte in: hipocalcemie (raportul
    i j rLl j i I
    a sp cftc- de prel oncl crcnl X venl l i cl l i rr,,
    sttr g e . ]n lcrj oada.l e vi al i 3-8 ari r (X l i l i
    "'ll:ggll- in mod normal rriai mic de 0,42,depi;egte 0,50),in siudromtrl
    trr
    d"rile sirt n.seDlificatiye
    .,nlioaoditi,, Jervell-Lange-Nielscn(Q'l prelungit 9i. surditate congcnitalir
    poziti?; nr toirrc con.t ccrile ,- \ta ' jlia tr ogresi v:r a pretorderenl ci ,(,rl l, p|rcl.plic),in dgpletiedc pola.iu, in cardrtareumatrsmatr:
    ' e scirrtat in supradozajul digitalic, hipercalccnit:'
    triculare stingi fiziologicc - i.tt"*ntot bl
    lriPi:riialiemie
    n lr iargiL, plati, r,izibiliL in derivaiiile standard in 50%,
    j '- f ' u. d, ! T r c l rc z i trfi l ri .p o l a ri z a l -c a \rcntri cul ari . E ste o urr,l rr lrrr liCG norrnale. "r,"
    rolir|l.llr,r, as]lDetrlc.r,cu fanti ascendcnti mai lcntir, cu urmltorcle
    cafitl Importanla sa practici nu e bine cunoscuti'
    ll't t : t l t ( . 1 i

    iet(lcauna pozitive in D, (5i D! si a\il-); gNDROAME


    PRINCIPAIETE
    3.2.2.2, ECG
    : r , l' s , lr t r os ; J i v i i n D r.
    (suprosolici'6rile)
    Hipertroliile
    3.2.22.1.
    ' totclcauna Dcgativi. in aVIl;
    , . t nr ir . i. i. r r prc c o rd i rl c l ..d r.c p L ,rV ,-V3 ), dutr.i p1.j p" a unci hipcrrrolii atriale 9i in special
    si fl ,trni i {1,. Itccurtoaster,'l' I cctrocrrdiografic-i.
    r rr{i . (ti rr c i, . l) oz iliv ?) s i p i n i l a 5 a rri , c i n d d " v i n c (rabci ul .1.7 1,i .1. r{ti':ulare cit c mai Jificili lr c;pi[, in specialla.suga-r,-din cauzamodrlr-
    I,ozi ti vi I ',
    t l,'ri l i vi i .rl{ . i , r nd. i T i n . p ri n ra _ s :r1 ,l .tmi n id n v i a tLi ' f.,rp a l i drtori (l i i s..ir,. ' rril,L {izioloric'' itlc inirnii la 'rctste virsLc (tabelele 36,3'7 $i 3'8)'
    ll, l l l rl l ,()l l. r lr 1, ' Llar ' at e c o l a m tn cl n a c ' ts l .i p rri Oa d j d, r.i a!i : l)itc,Lin lrrtologiiL D'G s, t'oln+'1tctermenu] de suprasolicitare sxu d('
    - pozitiv:r in prec,ordialele stjngi, iu afarir rlu primele 4_7 zilc (lulrir, trrrrr:r-trolit:, nr.i:norrrhYrc[t ir ventricLrlari-reprezintii o situa]ie normalir avintl
    r r.rsr,r',. lc inr l ' nc gr ti v i s a u i z n c l (, ti j c r' ,): u,.t.,i, rLparLtuluicardioiascular Iegate.de vlrstiL' Ilxislit
    '
    'rrr,rol,,rir, 'ir,uiliicittit,,
    () I,i rfl)ou(lurllL!t;" l'cntricLllarildrea.ptiLla sugar ti o prepondc:r'eDfi
    Anrplitudinca undci T (pozitilc srru 11ig1ii1's)arc I alori cg 1u rI1rrir,r,r,L,
    t i rrrr'.i n ' ir : i o slirrgriliu copilul rrLatc;i adul[.
    ti,lrrlrr.r.i
    _c onduc e rc.-) a mp l i tu rJ i :r.a c rc s c u l i a rrndci ' l i n I)' s,,rl i ' i i i ,,; ".rrl ti"i"i",titi
    l, zirrrri rrriocardir:c isclcmice, tulburlt c ck,ctt-oljticiL sau dcxtrociir<lir.. ,iit tripertiofic dr:senireazii un sindrom electric ;i rrn llsl'(];1.
    Sclrr.matic vor}ind, o unrli l 1r zitir:'L itr \', ,: .rrr.rloric. I,rrrrlr: li vor.l'rrrle hipcrlro[icp.rr-i"tali,de dilatalic,sltl ltrlllrirl'li'
    . 'l lrLtulogir:it lnlr.r. r,,lrr,lrr l, r.rr:st(lr0 .l r)|rsilutii i[trirvcniricrrliLr,:,'f.ili modiliciLrcanatoruiciLnotitbiliL'
    , 1, 1 ri i Plir ni' ii s i. t i ;i o u r)(l i i n \ ,, ,.i rrrl ,,l o[i r.i < l i rr,.l ,, rl i r &r {i srrpcrflulr,dupit rrrtii attt't'i
    i;, ,ii,i,'iiu iitti:" iiil,i,ii.,,ii,' $i srrprrrsolioii..rc
    pr .ri .rrrl ;r r t . . . r r ilr li ; 'i lii rr V ,,, rl i rrr,l ,,,l '' ,S
    , ri,rti
    rs\i
    l ;rL rl r,:, ri rri i l rrrl ,rri ssi < ,rrl rrl r
    ).
    '507
    li0(;
    ll
    Jfll
    (l )rt|rri s l. ) , l, f i r' o l l r' :{ r ,l c o l ri c ti rl L , l l tl ) r l rr)l i (, ci rrrl rronr| l c,vrl (Jl (S
    ', Itt :tr f' rtttt lt r il, r t t r r , t lr t r l, i . \ lll/ gr i \ '( : f l( t ul lllii. r it ( l( ' r ir : t ilr t l. r ' lilt iit li
    , ttrrrr lilt r ' : r it : Lrr l1r i i (l u ri tti i ;i s t,ro r lrl t(,(l {r sl rP l i rsol i ciar.,
    l i trL ,l i n r' i (,i trd
    l It,l | | ,,() (l l l rir lir r r r : r ir r r ir t r ', I r ' t it t r I r f nt it r lt r r r t : ct or ul at t - ial clt - r : Ptr,lr Lt t itiiir
    r)t{'l i rl rolis DnrIl ni{ x t i u l l l rl u i c s tc s u fi c i r' t} t (l (' i rl l (l i tl i l c ci cesul (l (, l r.i rri l l i I
    rrl)lrs, inr:it sc nroclilici {aza de rc1:ol;rrizirrcS -'.t'. fl
    I
    I' l rrlrr | ,r
    r,, I l l Lr rl i rr
    (l ( l xllir r . izir t ( 'iLit r lir r lii st i: t gi sc {ace clr 0, 03 slx '. t lt r Lj iit zir r '
    rrri tr r slir cut t ziLt r t vc( : ior r : r r o dulat . : r m ai m ; r r c ; i uudr t I t i; i
    Sttprrtslrlicil.trou ttrill:i. Rccrinoasterea suplrsolicitirii al rilric strltrasolicitarea atrialir stingiL so lt't rt-
    i,rzr'rr7i1pq; rnotlificiu.ilc clc uorfologie, amplitudinc li durati, ale un(lci P. lll rrl tl l r ,lrrrrrlrr. l,)lrx:1rocar-diogla[ic,
    ttl .Irl ,.r | l r'||r ilir : , 1, ' r llor lif i, ir i:
    l rr,l ,, I' ar c o dt lLit t ii ce dcllLsesic lim it ir supt r ioar li a uolnlillilllli
    Itl ,' " ;' ,.,l | t' ' ,t , r inr ii 2: 'ni- i t t . l0sc'- . dr r Pr Jcca- t ir \ ir ; li) . \ l: 't it t r t r <l't t . r i, i
    !rr,l , r t' ,' l;r,
    Lr,,t, Lr, r: scgncnt ulr ii PQ
    , l, lr ir n, . r r iul scgncntulrii
    i rr tlclr-ittrcrr1.ir1
    ,; irr PQ care car e sc sc scurtcaz;r Put in( l clriu'
    scur t caz; rPutin(l clr ilr
    fil ,li ,r.
    1',rr,r. Sc
    Sc lrtisoalit
    lrisoalir ccl
    ccl tnai
    tnai lrjne
    lrjne in
    in conducerca
    conducerca D-,
    I)r sau
    sau I)r-
    l)z
    I r(i,r l ) iii rt
    r(i ,r l)i1i oililiciL
    r r oililiciLm morlologia
    or lologiain in conduccrile
    conduccr ileDr D, gi
    Dr ,, Dr 9i in plecorrlirr*
    a utldeiP csti:1tglr1i
    dc dullliLcocoalir.Prima cocoagir
    irrrrli.lrrirrrlrrslr'r'irtl

    lr r ()r(llr(:('r1 l plccot-tlia)it clrcnpt[ - \r, ;i uneori chiiLr. \r, - s,'


    |it, ,,r rr(liL I' si f ic (lifazi(:i"rc1t priua dcflt'xiunc rnici ;i l.rozitiviL irrI rr
    rr r' r,rl i \' ,r ;i li|lgli, r 'u ilt r r r r t a ar r . t bc] ordef lcxiuni Pest e valor ilc ll) r l\ ir r r I
    trr rl '
    l i .rl ,orl t r l r lr r t at ci r t lt lci I ', / clut r it ascgnt L:trului 1'R at - c valor i r r li
    l ,(r l l i r, . 1. 2"1) .

    tt r' t,/ n/.t : i .tt,"!nf{ ' l

    ,r!4 ti 1
    i:i\,- 3. :j. Slr ir r a sr )j.ita
    l rc a lr ia li d fcr T ,l;r si -/entri cul af:L drci pi :"r
    tio d ir st.lic: -,.t11*-*..--i. ^--,1**

    lrr srrpn1s11lisill1ga atriali Sc produc noclilir:iri ir.i direc!ia lortclor- clc rlrl ,t..
    rizll', in scllsrll cf, in sujrrasolicitarca dreapti-t r:ectorul esto il(lrcrptltt ,rlt
    rior', pc cinc'l ln cca stingf r.cctorul arc o dilcc{ic postc oar.r.
    . in rusolicitarel oiri.tr.lidrcaltti '; ectorti nliLrit al atriuhri'tlr.r1,l
    ;r,lrrrrgill-stt..fi
    vcctorul nomral a1 atriirliri sting si prin suntatic sc pr.rrrlritu
    ( r, sl('r(, ir lnrplitudinii undei P, PeECGria apa.r.c o iurdl t, as<;uJiiii.irtrrl
    r'rrrrrlrlitutlinca care rkpirge;te2,5 rnm pi4iL la 1 ;Ln.5i mm dulrii ;rcr
    -j /,4,/r-'*;.,*- lt
    l ils ii (tig. 3.23
    lc prccordialcdrcptc sc pol iltiJni
    | l )]rl tc V aliant e S i an u tn e :
    .--.r) ulrdir difaz-icii.
    cu prima componcntirmarc pozitivl si ir ,lo.rr;r
    r L\'*-+- /', lr
    lr)l)r' llt :i r i\ ir ll.rr'ali v a:
    () 1rn(lirdifazicir cu pri:Ia co rltoncntit dc aecastfr dirlit ('flltivllr -),,r-.*-til
    ,1 r.u .r -poz ,ti il i : airittli stirlg:i'
    lti:1, 3.24' -- Srll)rasoli(iiicro
    *-o ltiLnifrstar-en'tai rafi, in catc cxistiL o singLrr[ contlxrrrcnlir, rtc11,
    , rr o iullrri:irncrnai tlirrc (k.2,5 D]m la sugar si 3 mm la copilnl pcsh, I lr,r't,, (l(' s\ll)1il-
    \ tt l,, tt ilttl't tt l,i,tlr ittlir sc l or'llllollst() Prill llsociL'rcrl d'it-('r-iil(Jr
    Iill:;rpoltrrl ,rlintl
    l i r t r , t .llr n .ln i 1) 'trtl
    "i rlulal.r (li l
    ,nor'l"l *t1 - .
    drrrartasi ,r
    .1 ."..i
    undci t) rtl \ /l
    ' stgrnt,rrtllliti,,t,()
    ",,,,-;-.r,,1;"; 1 1 , , , , : r t r i , r l i r r l tcr r l r l i r r :tt cr 'l c r ttr i r tl ,'sl i r i g i , tn tl l L I'l n tb l i L l i n r l i l l a r :r 'tl sl i t
    srrprtsrilii:itarca
    irilir:itarcaatli;rlir rlrcaptir,
    rlrcaptil va fi urainric
    rlai nrir.rk.
    rlc I (I[acnrp, ,rit;rtlki
    iliacnrz, oit;r{lirr l r ) r u l i tsl ) ( '( 1 i
    l t r rl l r l l l l i
    rro r'D l i rir
    l c ' , s t r ir p( ) r l ; " c r' :tl o ri i l rt]1 , l * -i ,fi ; i n . srrP r.i rsol i ci ,l . rrtrj i rl l l r
    i Lrrq,tr r t t t r l , l i l ur l i r r ( r r i i r i l i r l l t':;tr '\'l l l Q) 'i l f l l o l l l l l i ( 2 ,5 r r l tr l J;t i i l l g i l l l i 3 l l r l l l
    v.rl o ti l r, s iul r r r ai t na l i rL ' r' i i ; 1 ,6 .
    r r r l , t l r r l I 'r 'r ( r ' I i r tt) ;

    lt)li l;{|l'
    ll. llI ir li
    . _l) sl
    ( c l i l tl i i c l (, s l tl )(r' i r)i U | Il r' r l ,rl , (l ),07 s(' c. l )i i i l i l I rrrrrl i l ii ilr i s|r 't t t t t lit t r ' , 1, t , l, olr r t iu. r r I i11 ' ''r t 'lr t ' r 'r il( ' Pr r llor ( ljiLl'
    r.i si 0, lt ) s . t : . r lupi Lrrc c a s ti -L v i rs l r" r),(.l r i L s r,(
    i r,r,,r rrr.rl i [i t:i Lri l or.i L,
    rrrrrrl ,rl ,,,,rr, ,l r f,i i l l rrrl rr'l'lxr zilivi r lr r pil . t 1- r zi t le vla{; L pir i l: r . s 't ni in ( xt l( lt lcr r r r
    . r, , , P r . r , oiic il; r t i r ;rrti .ri .i -l i ]l l .1 r., i,lrrlzirrlri LrLlin'lrrl rlc siLpt-:tsolit:ilarcvrintriculilr:! clrc';rftit, st:rlltr r:r' ' t'
    Strprasolicitarca lultli(.uhrit. il r:iLzul sLrl)rasoliciti rii \,(,ulri(.r'1.r,, l. rilcccilsiundr "rT pozit iv; . ; i il conr lr r "
    r,l r,,, i l i r ilr Li. tr Lr r . Ls( ir so( : iaz,(rr"t
    t,,ri ,.il t , ir . c lr ic t 's ilt i n d ri .p t:L te c i rtrc v e n tri c u lul cl orni nant, i ;Lr rni Lri rrr,.rr l ,,r 'i' ,l r r ( cu condilia ca unda'l's[ f ic pozit ivi : 'i ir r
    ' i ,, 1, 1, ( \ - , R, \ 'nlt )
    i ,.i ( !1 " ir l r apor t c r l g l o s i m r:a p c rc tc l u i r.e rn tri cul 4rsau cu cl i l atarcrr< .rrri lrfrl , , , , , ,
    ' ,', , ,
    r
    I r 1 i : r1 h slingi) .
    r,,:pcclir.'t..\rcctorul nccliu \,'entricularin suprasolicitarca ventricularii (1r.,1,1|
    li,, rrrrorrllci,i supl:asolicit:rrii vcltriculare drcpte de tip. sistolir; rsi'
    , ,l , rlilijat c it r c . dr ca l )ta g i a n trri o r ;i i n i rL r.ecazuri poatc fi i nrl rcpl rrt ,t,tr,rl ,1,. l fi .rri llr ci1r i] , i: u pr 'r r t r u ler ioada dc nou- ni. r ut nici nu sr : |r r r t i'
    ,.i I,r
    ,ir,.ryrtir si posterior-. 1n suprasoliritarFe r.cI]tric ulariL-stins.i,r'cctonrl rrr,.,l r r ,', li, r orrsi<lcli ct suprasolicil:nc dc 1ip sistolic-cazurilc pc c?lrep.€ cl(x)irr)
    '' lc olientat postcliot' ;i la stiuga. Acr:stc rnodificiLri in mirimcii vcr:irrrrlor
    ' , ,lr.i' rrrrri'r,rl)irl lrodiiic:rri marcate dC reilolarizare in conducerilil pr{\'()r
    i irr dircclia lor vol duce la ulmitoarcle aspectc eicctrocar-diografi ct,: jnr - cr sat iLlr L
    ' i l , ,l rr' 1rl rr.Si: gnllt r t i Sl cst e subdenivclat , unda T c'st e '; t t '
    - clevierca axci electrice mcdii in plrur frontal, . , ., ,,, i ;i zi i si o unt li. R inalt l ( f ig- 3. 25) '
    - modificarca corrfiguralici ;i anplitudinii unclelor- colrplc_,irIrri vr rr lrr sulrirtsolicitarca ventricuiai'i dreapii de tip diastoii<: sc intiLI( t
    t,i , rrl i r r , in s pec iai i n p l a rr o l i z o n ta l ; ,, rr .ri ' r;rrr,l r' ,rsl) Lr jt cclect r ocar diogr af ice:
    - prclungirea duratci cleflexirruii intriusL,coiJ* (tirnpul tLr rr,.{ir.rr, ,,,rrr1rl,'x<ivcltriculare iu ionducerile procordia-1e drcpt{) ct1 ilsln'i
    ' 'rtri , ll, , r J ir r ol, rrrr' .r' i l , p r, l ^ ^ rd i a t,. i r rl r. ti lr r sli', r sr 's' sau r SR';
    rnodificiLri sccundarc de repolarizare ventricularir (sognrr,rrlrrl,, I '1,,,1,i .r.'
    rrrr<li S tirgit)i 5i crcsiniiL hr D. ;i aVL, asociatl cu o rurdir lt irrrrrl
    ,r Lrrrrla'l')apirute in uma rnodiiicirrii procesului dc dt_.polarizal:vcr)iri{ rl.rr I
    r ,i , ,i l rl ri l i i iL in ; LVI I ;
    ,ltt prttsolic'itarea t)1alltri.uln.rti dteaptci. Rcctnoastcrea suprasoli( rl,'r ll rrrr,l .r> l, r r '3ili ir r \ - u:
    ,, rrl l i r : r r lr Lrdr
    c ept c c s tc d i fi c i l i r i r p c ri o a d a d c sug-rl si dc copi l nri r. rl :rl .rr| l l rrrrrllt lt in \', clc amplitudinc miiritii prczentlld una sau rllai Irrrrll'
    I'r, Jronrlt'renlci ventricuiare dreptt liziologice in-prinra lorioaclir 1| r r.rl.r, ,,, l .l rrri ;
    j)rt r rrl si datoriti cxistenlci unei pr't'ioadevadilbilc de timp in oirr, rir, l,r,l
    'lrrcr' lrlcclca la plcponclercnta yentrictllaril sting:i. Pcntru sustinr:rr';r ,lr.l,
    rr clc suprasolicit:rrc r-entriculari drcaptt"r-sL: urmiLrcsc (rr.il(.rr ,ll
    ':rlir:rrlrri
    ,,ri(,rrlirr'(lspalialir, de dur:rtl ;i dc voltaj.
    ()itcriul dc orientarc spatialir"este rcpl'ezentat cle divicrea. :rxci r'1,,,tr r, r,
    rrrlii cirtrc clreapta, pestc valorile normalc virstci, inscr.isii in (.irlr.rlll
    i rrl cl i o l s t ing.
    (llitcriul rlc durati cste rcprezcntat de tlurat:r de'flc-riuuii i rrI r i .,, , , ,r, Ir
    i rr r:rnr lur : c lilc < lr c p te- \, ;i V, - p e s tc 0 ,03 sr:c., cu pi r.strarcrrrr,,rrrr,rl .l
    l;r rlr rla tt'i complexului vcntricnlar.
    ( lr it c r iilc c lc v o l ta j s e a d re s e a z l la mp l i tu d i ni i undel ol Il si S ;i ,,,rr.l ,rt
    ! :

    {)rcstcreain voltaj a undei R in conducerile pnrerrdiak: Lir.r.ptr'1r, l,


    r rlolitc lirnitir nornrale virstei (dc obicei peste 20 urm). in conclruu.r.il,pr,,,,r
    rii:rI stiugi \-. si Ve ca si ln I), sc r,.flecti accfaii rn.'Lr iure dr: Irr.!:i ir',.r lrr
    ri.ui lrogativ, api.rind unde S anornal Ll adinci in .Lcestccoltlrru:r'i ;
    . pr . r ent a un .i l n d e l t rl o mi n a n tn i n rV R j ;
    -' undi R dorninantiL gi inalti, preccdatil rk: rrr.rdaQ irr r',rrrrlrr,,r,,l
    \'1. l)upii liorver acest aspect ci;tigr"r in spccificitatt: drici. s(. ;rru)(I,r,,.| .r rl
    r;('lrul(jdc suprasolicitare atrialir dreaptiL. ln schimb (iunthllollr rrrr .r,"r,l,l !4
    r|r1x'ctultriqR o ma.re specificitate, sustiDind ch se poatc intilrri |i irr ,.rr.rrrllu
    rrounalc, rlar carc plczintir o deviere c6.tre stlnga a- vcctomhri irrifirrl. lrr ./;/,1. i. llj. -- Srlxisoli( i1:\r'r,v.rriri{:Dlarir(1r..r|1i! 1il, sisi(njr-
    |'rt
    rrr,|: 7 zilc dc vittiL aspectul qR in Vr se poate intllni ll moil rrorrrrrrI irr ltt",|
    r , 1 x , l r rr i zr r r , 1 ,11 1 l 1 i 1 1 l ;tr i l tl o tttt;tl i r t1 i 1 i tl l r l r r l l Ito r i tl tl ti i sj i r r tl r r
    ri i l l (:A z ur i;
    -- r-itln)ttlrl Il/S Pcstc va.lorilc norntaLlt, supfal\riti , irt r: rr,ltr,,,rlh, : r r : r I )l r 'S r o r l r i l l r si r r l l r l l i r r ( l t'\'i i l t;i Jl t tl r r ':t1 ti l L .
    ; i s rrl rrrn i ' .n r-i nc o n tl u c c ri k : prr:corrl i ri l r ri l i rl -l i , (r r or,l tl l rl
    1 ,r,r'o t . r I i; r L, t lr r . pi '. t t l , r r , :, ,i t r t | , r t r . r ','ttt/ttt 1 !l ttttt sl i ttt'ti . 1 t r ';ttl ttt) sttPr l tso Ji ri l i r i i r '' r r l r i ' r r
    r.r rrrt r lr rlt li r r ilr : io i rrrr1 rIi IrrrIi rrc rL : 1 rr.s l .r'
    Ii rrt rr; t,r . l r r r l r r r i r , r i r r ,l i ,r 'r r l i l r l , r r l r r l r i .r r r i l r ti r tl ( l ( ( ) l i {( l l l i l l l l r l 'r r {i .r l i L r ,i ,l '

    i ; tl ) rrl I
    coLoborltcu
    uotnrtlllllli' nccst rlpol't nLr cstc scrnnificativ cl'clL
    (lrlriLi"ii, (lirr (r'ilcriLr l ( ! r c t ir r nili nt af c poll( lr ' t f ilr s r l s l i l l ( 'r l '; L d i i t g n ( ) s l i ( t l ' lr, r,lclttt'ttit'rlil criLcriil' tlc vttltaj ;
    l sl c uc c la r lc v olt aj . nllr,
    prin sulldcui-
    ('r'itcrirrl dr: <it'icntarcspalialiL incliciL ax;r ciccilitl ncdic 0[tS tlrrv l\4otlifit.rilikr sccuuclarcclc rcpolarizare se evidenfiazl sttngi
    iiil si prr:z,unla.di;
    ,r,,[ t('r.rr]u'lttrrlui it"tl"'l negativeiir conducerilc
    lrr slirrgu cu laloli pcstc O0 (ilttc O0 si .- 900),inst:riittrlu-scin cldranrtl sttltttt
    r)l'pt. l)in accst moti\'. rlupl'Lunii cardiologi, tcrrncnul ,,a\i suPt)rioari" .,( li '' l"i'l]^l'rii"i''i:i
    ,i' ii"''iia'-l'i,o"iliii'. maimoll!-'sau. ' ln
    maiputinamplil
    a*li'"!ii,
    i','ii;'^;,,1,1.i;;,ii''*''in:' aceste
    prliclabil accluia (lc ,,dcviere la stlnga a axului clectric" si cste justili -T:Jif::i i.lA,Ti,,,.l{I:S:
    ,iiii i;Vj.^i";;,="i"i1""snti""oea1
    lr'1,,\liiri:l''."ii,: rindei".rfii v',-vo
    irind QRS cstc ncgativ in a\rF (ax mai negatir' decit - 30'). -I-a su5larinttt acl fibroelasto:1I.
    pr,,z"iifa uuei devieri a axci spre stiuga poate fi tn indiciu dc -suprasolicit
    eltloLniocardj
    rl',"ii,:",, i,ii,,,t.ii,' is, r%o boali 1ex'-
    i'r,ntlicularir stingir, cu corcctiivr-ricir-ir.r-r-are cazld (1 2o,,' tlin cazr.rli) ,\1,t,,iir,,nl,,lrri 'f in Yr-\; poate avea o valoare daciLlaportul R/'f
    poatc intllni normal o dcvierc a arei la stinga 1n prirna lunl de viatd. Deriol r r t '] l , 1 l r .1 1 ) ( l ) l ]p tr r s)
    lxirli larstlnga ci;tigl ln specificitatedacir se .asoeiazicu rotatia ant($l'tl ^ r ^ ,,i .\r i
    (fJS,,itconduccreastandarcl)
    - ' ()'iteriul ;i cuzona(ietranziliedeplasat:r1a drcapt-iL
    de durati sc'realizeaz:iptin pielungirea duratei dcflL'xi
    (Vr, V
    ,frllrllit$iilllTli;t
    '"!T]11
    inllitrsccoidepester.alorilenormaie de 0,04-5-0,05sec. in conduccrilt'
    , r,rilirl' .tirLpi \-..
    (lriteriile dc loltaj dupiL calc s!' reculoaitf
    I:rriLstingir sint formate din urmi'Ltoarqleelemcnte:
    o suprasolicitar'e \'('rlt 'i;tli,ii+i*i:i*'.l,',niffi
    [,,il'"lI-,..litliJi;ttryt:':":l'tt";+".i"xi'3
    ,
    l ,rrrol tl i a l, ' clr cPt c) .
    (fig.3:2]l1,1.,p-Yl:?^1i
    ii,,.,',.,liastolicr
    ,i;;1,r,;",,i, ..:"fithtl**
    -
    -Prezenla
    unei unde (] profirndc in conducerile ptecordiale stirtgi' , ,' uncli.Q
    ;:l|i:;'ilii:'ilil:L"a;i3";'i;.;i""i""""ii11uiot'"irst'i' ln :1":}iliil:
    conduccrilc
    \'. si Vn cu valoii cle pestc 4 irm la copilul Pcstc 1 an ;i de pcstc 2 lllllt r, slinfii llrc o adlucr'mea9 ft"1i" Z rnm la s.uggr
    sLigil tnsolitiL de o undl R cu ampliturl.inede peste 15 mrn 5i asociatirctt 1t "rliltl(' ii"
    ril'l]i,ii'',1:,:),:'it,:'l'it"'rii" lesate deundJRji:] S$",iar rrnda'r
    ^pj:,t:-i,Tt::"}::
    cstc
    z rl;.r rrn,i undc S in \-,' r,irlr ttt'rtutitl itt r:onclucerilestlngi'
    ""t';:
    ' lindc R inalte in Dr, aYI- 1i in in I-, ;i Yu pnstcvaloril'littt nu ar e
    "pccial stt;ttttrol it 'ilt t t ct t bilt 'r r t liur r lnr i'. 'Sul'asolicilar ea bivent r icular d
    C) rudri R anormal de inalii ! i'n.1xralt'
    rrotlriilt' alc virstei respectir,'e.
    IrI r' .i l l li ( 1" r cct Lt ) oat t ( r r ( Cr alI t ) '
    slnr rrilir:ativi pentru snprasolicilarca vcntr-iculari stingl, -l'rcbLtic tt e mai dificil declt it'ccla
    liicrLlir o lcrnarcir asupra aplicirii criteriului dc voltaj pertru concltx('r{'il lrr,,lrr,,sri ul dc suprasolicitare biventriculari
    *t*qt"-,1':l1t:Ylirq"3li.il
    ilrkLtir(\'l.r'sau\'-S)'-Uneori:r"*"1
    ,,,11,;i:;;,
    rh o;rn'cciu aceastl cbnciucireamplitudineaundei R'estc mai micir ilr'ctl
    ;lli:.li;l'l i,i
    lil"i*,i',j1i')(:'i,"ti"ji' (vD cci
    \.cctorii ei
    cottdLrccrca\i5. Diri cauza apropieiii locului de aplicarc a cclor'2 clcct t'ozl '"i -poatc"ri,.i"'i-clndca normalir'
    ti"i: ,;',;,i;,;:, i"ti.: - bcc Ii interpretati-
    trot Drotlucc uncle erori de aplicare :r electrodului gi ca ulrnare sir sc i sebazeazl4. compafa-
    trtzc voltajc false; ",rii,',f rl(] susfi
    IrltrIIIII'IIi. erc a diagnosticuiui
    -tixlclor "lli]r1precordial"c'
    ,' ilrr..iii,ii QRS din con-duccrile
    - Iioiosirca tabelelor del normalitate pentru aprccierea tndci lt "omp"lexului in u ni-
    irl)solutneccsari,pentru cii pestc4 ad 9i mai alespcstel0 ani, in prccotrlialt ,r,,,;i,:' r:;;,',:':.".."1ioii" ..ts1iie suptasjlicitareabiventricularS'
    :,inSi:, intilnpsc'urrd'R amplc 125nim si p"sLc,-Fati' ajrrtotuitirl','1,'lof r,1,,sitrlL{ii(Iig 3.28).
    artormal dc nrafi'
    ,r r'r'rrLcstrrlui ciiric nu s" pori, r{irma totusj hiPcrlroliaslingr-l.[){ t \r'lnF lirisi,'ni,t'rlnor icrmple*c QRS clc amplitudinc
    Irilrlrtlolia stingi.poatefi numai efecl,ulunui excesde tonu.s,catecrllatnit Irr ,,rttrlrtr', ttlr' I)l{coldialcdrt'ptt ciL 5t stingr;
    din cott-
    lrr tr:casti-rvirstii (crctism cardiac), tncori e nccesali confruntarcl ctl l rr rt ' tt ttI iiatz-Wachtel (unde R -1. S lntr-una s:iu dotir
    , rrr t I
    (lr(lioiramr l( trLra di"tingc intrc un cJctismsimpltrsi o hipc'rtr:olit' .1' r,tll, rlr' tt rruzi{ir''(\rr, \'4 > 70 mV) i
    r:ili siirrgi sau o dilatarc vintriculerirsrin8i (DuPuis).Sumi Rr -1"116 rrurl, lt ;i s inari, iliiazicc ln condtcerile precordiale
    medii Vo' Va
    \'cntric
    1ratologicii peste 3O- mm (in absenla semlelor t1c hipetrofi!' '' l' rrr Ii i tr<l p"st u 50 r nlll:
    rt .
    rllcairtirln precordiale). ru.l l Il 1(' lli(lt;
    ,r,'rrrri,' dc ssuprasolicitale
    i .l .,tr oc l uJ r ds ur-rLrLdr rontricularl dlcap]i
    -asoil-T,.:l:,,:'
    9i irtrlt-
    ampli-r
    - tlnda S de amplitudirlc dc peste 15-2O rnm in coniLtlcltik' 1 I o ," 'i,' I rtloril: clc 2 inm 9i r.lspccriv4 rnm' crrurLdaR
    'l
    rrrrrlr'i (ncgiLtivi)fir conducerilcpr^rco.ftl1al:
    dialc drcpte - Vr, \isi ur o''ri'.,,1,'i
    ' ^''1,,llllll."'l,ll"'..,lnl#5ii:ilJJ"'*";;i't."i;fii It
    $hsi;;i;ff.o .,s1r. ,lllg!." ..,...,.,t,
    - Suma amplitudinii undei R ln V, cu atlincimca undei S ln V
    lruic siLaibir.r'alori <lcpeste 35 ln pr:r'ioada, de nou niLscut,-dcpestt'{0 rrrrr1,I i t rr, Ii rr, rrriritfr\'r-;i \'r^;. Tadidogicc
    I lrrnii si 7 ani si clc prxte 45 tlrrpir'7 ani. \rcck consider;L cil ptczolll0 rrsrrr'r'l|lct ( t oclitclloglalrc nornral dar cu scmne cliriice ;i
    c ri L,.r'iLL'(intlicelc 5e1iirl6vLyon) sc iutilne;tc constallt la copil ln sult | l | t I l t r r | | l r '}( i l {,
    ":i'ri::;:;r'it tr;ri
    l '.
    lr scit sLiu infatrfs'
    l- I car r (discasc
    l .rrl ti l i noi ((.f.
    r : Linoi J. ILiebmrrn, lt Pionscv
    . ielr t nit n' R in-Heart
    t 'looscv ln
    Iirroir vcntricrular'h ( stiugiL;
    rrrrrbcl
    eYit ar ca
    ( 1( '; \ '. l M osi) r econt aLr diL
    . l?ulrorttLlR/S in couiluccliJr'prccoldialc dlcptc - Vr cstu. i' r,tr,r rl : , 'l l. iir . Lr ii, ct l a t l- a, 197?, sislolicil
    i,,'iii,',ii".:iii, ,1,'ll,'riunc 1i sLrlrlrsolicitar'':
    intririsccoick'i
    trrr trr rlrirlii 3 iLnisi sc itrscticctt r';Lloti 5i nrai rnici snb 0,'10pttslt * 'iiir-'il:
    vltsti'1.'1ncott,lrtc,:iilcpro(:0rdiir[(slingi \'., \"r it\juil vit[(tl'i rnui ttritril dlnnlolit l,

    q6v Bt3
    {i tltili-
    itr(r llici o bazit"ttlr:rcticlL pcntItl,a'
    ll,,ll,'rrrrtr,;r itt t risrlrroitliL.ltl
    pl1r,1,t r rit.r'irr tlt: , irrecortlialc stlngt
    ,lil'i',',,lii.'il ri,:iii'", .,,'.iij,.,4i 1!::9"15
    -suplasoltcturt lg;:::1,-t-"**ccrile
    *:io':,'r "^?:*'
    ill li"ii.r"iq'"'i""'f,*i*"J'?I'J:-tl
    l;;;,ii::."::'lii,:,1'ii'i'i -hemodin'amice' se
    lir prezcnt'
    ll'lili l";'ll'ii''iJilffiitilil:;;;rt'

    *rT""
    ,! I/.ry

    \,, * 4'/ttt/

    'slprasolicitare ..'cntricrtari ro llo"to/I 7,,


    Fig. 3.25. - stingi tifj-sis1,)1ic

    /1
    S ul raj ol i i i ts r' e bi /c rrl ri !ul x r' 1
    Jri4. 3.:s . -

    l rl
    dl n, i.,' i:i":1"3
    l'il'il;1^:'li'.T',"'*'l
    :1,;l::' :: lli#lll3[il
    #3*.u"'ll
    Ttlbclul 3 8

    ltowc' Nehrizi 9i Nurltu'


    dr irt||| tltolk'l1rul'
    (s[t]lcnlur':i drco[ltr fl rtl sn - rlupt
    (modi{icrt(J

    tt \,' I | | i t Ltt t drc l IJ


    llt giu qr trr V1 duPtr {- / zrrc
    - olt
    "of;;
    - ilY:i,i:i'i,fff
    "lT 'uunr pozitivltn\'6eivr
    :'?$i i:1i'i)'li:'il"u'i,,lnll
    I l l l l l |i rt
    {lc -l'tto0-(cf,'trcnul infcrjorstin&)
    -- A!i:r ()lts rrrjriorilrc , , I 'L: r 'L r it ivltt r ) t 'ssi v0
    : 'iv: Pr
    '; ; , vr
    ; 1i, , . '', , ',
    - rrR in
    r('rrnnrc'
    vnro'iro o dc2 irrr
    : i.lXlllli I
    '"^i 'o
    \'d n rf u l tnic tlc
    - S Dfllso ljcilo r o vul tri r)ar[ ,[
    stillg ii 1 it, ( liIsl ol i c "li'J"'il';'"1il
    slfi
    614
    qlo ropolorizdriiYenlflculort
    l t,,'i ! t,I t.i t t l nl r t l l 3.?.2.2,2,Altoririlc pri$uro
    - - 1' ll
    * iirt t (i lll lnrri - lg iili lr "le{azci. t lr ' l( 'ln) lr r liz'Lt r 'Sl
    l rr i r(cst1'cxzur i r ( '/ 'ul1i- illlolllillii
    t
    - 1-)a .gRS, mai trolc dc ,l
    L'llcror strl|tsr
    r)r'(dcvierc tr (tfcntrlirt
    ;,.,1ru*lj$i**lti:m:';'g:jli"i;liili:n
    *li;;,i rili,:illii]llll;:ti :':m:
    --:':fvr
    i,l \r5
    pozitii/A pi:re h 8 :,rli a?oi iregativri cr r1n(la tf
    ' ;i;i ;'i1;ril'",1',X*il:*liJ,iili,ill'$t11*,g,* (hipoxie,
    ischr- e auerat
    9i Vi{
    - Itll lnni marc de 15 mrn

    " "iil;ll'tli*,lll **::*;u.il::'f*'"'iiii::'*:.'::1.''horrno.!


    - Itaportrl 1ti S irr \-, supe rio jniieiii iar tu t; irfo or. 11
    '
    5 ulrt t it ) i i t : i t e y c a s i s t t t i c d .
    rr. rou nascrli n se poa.te prcciza ':"1]
    ll':li;l[ii:,lltr,ti'e:ruiiltt:1"'":''o*::l:,':'
    - peste'rirsta de 1 lrrfl se di{eronfiaze pe prezella:
    - u n J,t L tr - ir i7 ^ n iu . ,'J 5 r:,i a, ,o; n.;rrj /j , ll ''
    '" 'illll',,1;',"i[:ili"]",:.,:i,:tfi,fi1,$AlL1Ulill
    =1Ti:XX']ii:$
    Jl; J ^ u | | d i 1 t in .r lr{ i n \r
    - :' ; n . [i| l] S L . :.r l o cni z"l "t ,"""'l,llit,lL.ilo,iij*14?l1liil{;,jii:}iffi'-jll.."jtj
    :; l.nnrdicihti,tct tii&st.tatd
    Oorlplcre gItS "X,i::Jf"'ill:
    l'x,Itfxlj:':t"f;]i'#:l'-i::lirj:tj'"
    - rodi{icate ca orloiogie

    i' ;;:'nl.*.
    iln,
    {aspect
    r SR' ) ,
    - qnqa S adincir ir Dr, a\,-I- asociati cu o u|dtr R indltb jn lr

    S , l' t . t : ir l i ( i t a r c a s t i n g d
    - Unda It irelii, ijr 1:1 ii unda S prezenti ir1 v,r
    ";'l')11;;:;"l,j;.';;i;,,i;;
    ;:l,;:;t*,"
    ;r l,,,:,'i;;ii,Ji,i.'
    ri1e.
    tu ?y-n:i :^:ll:::l*1;; nrintr-oundir'f ,rcsi,rivl,
    -,\:ro QRS dcriat:r la stirlga peste _i_j0" (il 1_2 din c^/|rl
    :i r*,frr*;+hiVlijii'
    rl, ,i,,]irti.;.;?ri"'i;ffi
    po_a.te
    me.tior:L de.Tierela stinga qi in mod normal)
    - ItV6 ]nai l1]are de 16 1r]m
    SY1 ]1lai lnare de 21 mm 1a iou nlscut Ia teNren
    ,i
    |i, ,,,,1l,;,1;:;i:'t*tt*liit#lf'-fl::nli
    i,,.c,i
    26 inn1 lil prenatur
    ,,|,,
    i*:r;:'U#iifif
    - QVi, rllai mare de 2 mn1

    ''"'#i$
    - R/S il Y, interior rrrit?i1;;i intre 2 ? zite
    51portu1 $i

    uii:i#tfiffi
    lj,6 dupai 7 zile
    - ,Sul1raarnplitudinii lt\'j + S\l Dir_i rna.e Ce 3-i
    -- i! r1r' c l , 13 luri
    - \x, ( r liS d "/:e jj 1 .r - ll..:.r y ,,"-. +j 0 . .:",:, rroci uzi i

    ffiir+:t**a$'ffi
    r u r ,.,,r sr :r zo r : d { . 1 .n n /' r j, c. , .r \r S ' \': "c
    - gvs mai mare dc { nurr

    kI 1-i-:
    i;,
    It\i6 mai narc de 20 m
    S\-r mai marc de 15-20 mrn
    ( ct6 r d l ir /S - ,r b d .i I Y,
    '

    - i,rlrr. ltl iuri ti 16 e,li


    .- Suma, It1'5 + S1,'r ll1ai a.r; de {0

    ;;.l ::;l:riiii;.1nl*,1[+ t_,,


    il:i;t-*r.x;,
    ji,,r,,,*,i,
    -,{xa QRS .itriat,
    .r .r 5 t- r u l q r .r :;
    Ia stiDga cu -ralori nesati\'e, rlacir se
    zo n :r ,t, r r .rrzri c :,e l n \ ,i \..
    L *,,
    i;i:i*ilttrffi$l{##
    - R\i6 mai mare de 20 mm
    S\:1 ]i1ai ll}axe rle 15*20 nrt]l
    Ita p o r tll Ii/S r a \l m a i:n ic rJe 0,4
    .Sr ir r r R\;- ,- s\, m a r r .r .r i- de 40-50
    - Iu lr ' ,,r :r L lc r .. la ,r za r r jn D t, aV I. \,. \
    :S /,, n\ti it;ilctj,€ sist.li i
    _ De"ierea a:'ei eiis
    ireste +0" (Ia sringa) I ' ,l r,10'r' rr' (vczi | g. 7 19) '
    - q abseut.-rsru de rmFliludire rnicfu ru D., 1r.r,\..,, V0
    _ Undzr,t.t.)tilti .a,r negiii,.i in )r, Dr, \,0, \." crr rrr,1a,.f
    rlo
    11orr[al il1 \'1, \ir SELECIIVA
    BIBLIOORAFIE
    Slt lt ! ' l) c i t t . a dia:titici
    r*ti"s of tht rreolt- lr:roctr'ocrr-
    - Axa (llts i lirrlitc nounale I t \rr{rirrr\ ri,,\{()Nr(()\rI {; ;,rr;]l,,liril',\;1i,*;;;ti" ,o'rrrrrrro
    ,r"'u,"r,hi( rr'll' .1il;jlrr1l,i,'
    - I in \ $npcr.ior Z mm la sugar 9i 4 n]lu li| rol,it I 1,1.... .,.-.1il:i,.,',,r,.r'^r".r...,.",,r'nLfin,n'
    _ I- lr r p la :.{ 1 1 ir i- ir r Dr , 1 ) ,, \-, \,. / '' 'i,f,li,l,l'1.,;,i;'l/i,)
    ,i,;,;'l:'1,n,'
    - ( r ir L jr ijlcl ,1 . /r lr iji r r lc u ,r ( tci lr j n \.;, \,,f, s j r \.j , \,!
    "' '"'' 517
    {il0
    l. (; lJ N t l i l { ( ) 1 l I \ \ 1 ( ;. - . Dlcctr o ca r ( lio g n p h io cl!( .2 l .,rti ,ri Ii d. Matoi rl r,
    t,l ri ! l rt(rl t, care-L fact: t jrrlirr inili'rlir" a sitt-
    4- lililiN l i . N . - L , o : j td a ta l d cwcio p p :n cr r r o f r c tr u r r n rr (i rf(l i nc vertri cl cs,
    .[. l |rdt, 1i ,,1, ,t,r1r.rl'rrlr' lxc rabilitir.tilc, zgomotului pe
    ti 9 , 4 l t { .
    it . I ilt UP P N - I . A . , S - W E r T E., UICL IDL] tt., 1{oE n.L. physi ci an.s |l .rrrl . "' nic:i cear''I' o'igi'r'
    9i frecvenli.
    { .J.., JAEWIZ
    booL, Iiing(j lledical Publications, Los Altos. 197J. "',lli,;iit'"to',l,tlitl'"o "-ptitodinc
    6. f i{IqCU R., I{AIORESCU l!L, SE}IAFIM N. Ele enre dc electro_clrcliogthiic urlirr ,', '.,',,i',,,i:,l"rlrtir a silrgtlui in vaselemart'
    tridr", Ildit, Meclicau, I]ucurcsti, 1971.
    7. SEI _ C H T I I I i J . , T - A SRY P., GERARD R.,
    JOUVF - A. - Le ra.pporL Ia/S cl 1 V l cr \,r f1,,,/
    l e n t r r t r L o r n ) d 1 .4" h . Ir d t. { , .r /, 1 9 r ,9 ,r r 2 . l0 - .t.
    li. \'LACIIU R., DUDEAC.- Diagrosticul bolilor carclioTasoulare, Idit, }1ed_icali, I:]uc11r.(.i.l|,
    1979.
    ,). zlticr-Elt it.ir. _ Eiectronlfdioillapbic .t.tr,l
    studies in noi|nal ir{ants and c}ildren,[d.
    ,,J. St,. ,,jtict,l.

    3,2.3.FONOCARDIOGRAFIA
    MIRCEA
    MAIORESCU,
    MIRCEA
    STAMATE,
    MARIANAMARDARESCU

    Iionoclr-dio8r.rIia
    .(f.c.g.) reprczinti mctoda dc inregistrare !r zgonr(l lr.) lltfrlc2rrtcre scbenlaiici a' zgo_
    1,1,,Jcaf,liacc.,Faira.s.i. sc-pc'-atilsubstitld unci auscultatii-compctentc crrr,, ,,,,,r,i ,,,1 .."i i i ,t, rtor' rl l al e s i c nor al e:
    tru,rl,.surgindc varialii dc finete alc intcnsitiilii si tonaliiilii zgc,mot(.1,1 'Ir"r' :I l:_
    ,:rriJirr".rrormaioori ale f, rromcnclorascultator.iisrrpr.{d.d;rilAdrc-(r .l1itUr.l 'j 'i
    .,r :'''oi -; , "'"'j" / rI
    -" | tI
    rli;rstolicir,rugoasi din stenoza mitral:, suftul diastilic cu timl,rrr '
    , ,.i
    '
    i
    r" " rr r
    "
    o j o " r' r
    ,' ,1,,
    "orlic
    rlrrii:r, aspiratirr-etc.), f.c.g. poate itdrrceo scric dc preciz.rli in legiituri lrr ,., l . l " i { r "
    " r" i P -l l d
    ;'..'.," . , ', , , j 1 ,
    , , ..',: ti ,. .', i - ' L '"r ':a
    rl.rrriLtazgonotelor sau situalia lor in ciclul car.diac(iir special zgor;otelc tr,,i '', ^ , t . . . . r. ' . 1 . , mi t , .
    ":
    { L l ' } I r'
    L . i " o ' c (: l
    :,ril)iitr-u), sLtccesiunea cronologic:i a zgomotelor si sufluriior, mai ales la frrrr . ,.,,.- : ,:,, , ' : t 0 . 1 i
    l \ ' n " r'
    . , .i -. 1 i r: i : l
    r'' rri'-,:rr,lircor-apid.,si dcci in spccialla copil. Do as,.m.n.:ti.c.g. cst,. rtr ".
    lrl:il;i,(11snccesp-cntrucliagrosticuldiferenfial,cum ar {i, de cxemplu, inir,,
    'rrr ,.tlol, pr',.sistolic;i ded[blarea primului zgomot sau pentru di{6rentir:rr..r
    rrrri cjacr)rcntde deschidcrcde zgomotul trei Pc lingii iceste consiclcir.rr I r,,
    rrl.ilitatea{.c.g. constl ln aceea.ci__ reprezintirun rnijloi de urmirire ln titrrlr
    rr. ruror fenomcne acusticc, oferind posiblitatea verificani gr.afice (cleci rrrir
    olrir'ctive) a evolulici unei afccfiuni precum si a eficienlei ierapiei'rncclic;r1,,
    rxi chirurgicaleaplicate.

    3.2.3.1.
    ZGOMOTEI,E
    CARDIACE
    NORMAIE
    cr) Zgomotwl.I. (ZI ) omotul sistolic este sincron perictad(ji (1.
    rlr:but -sa_u_"
    ,:r. c-ontraclicirrcntricnlului.sting ;i ventriculului drept,'inceputulrri
    1x.r-ioadcidc ejeclie a ventr-icuiului drept 5i a cclui stlng si c;te alcf,tirit (litl
    p,rlru c,ln1pep, n[o plincipalc1fig. J.Z9j:
    '* vibraliile iniliale cu frecvcl{i_
    j,"lii,l
    ,, ,.1,;t |'j:#;'il,i':ffi,''J.';'$;l;',;
    r?'.::,:1*
    :11',1':"f;l"i,ll!,
    ;i arnplitudine mici a ciror (rrn.z.i l)irrlr''
    r:l c at r ilr r r ilii inc c p u tu J u i c o n l ra c ti c i l n i o c a rdui ui i n {aza protoizovolurrtr, ' il"il;,l,il,';:ti:'i':i:i'1"T3'"Je ;i extracradi'rci'
    ractoricarcliaci
    l rtci in c ir r c geom c tri a v e n L ri c u trr! s ' tra n s [o rrni i bl l .. i n r-edercircjcc!ili
    sistolice (faza dc rnulaj); ci''lrr'rl
    " ;;l;lil:'*tlillilliix'jX,ftl,:1i'"?"j:x'i;..putu1.sisto1ei;
    p'*r"""
    rrr,,itia"i",i'iui
    .r,:.,'iti'" liri
    cjlrrrl
    -- vibra{iikr ample, cu frccvent,"i mare (-[I,) nrotlusc t1c Drlo(fc;r trl | | il;]"'1,;;:; "l-?9.t^T*.illiis'
    l . ttsi i tt r , s i inc lr i, J ,L :, v ;rh u l e l o l rrri ri e l . s i rn . n,.i tj rl dc ,,l ovj rni , l r.r,.ti l ,,r.
    t, trl ti c r r lr r lr r i. . 1ilg si J ,,tJ i ;tl ra 6 rn c i r.l i v u l a rt r i l cdtr,. si ng,,l ,,
    1i ' t' '""'il,ll;lii'l*.ii'"'ii:i.;l:fftif'::l.i'li"lillll,il)
    i),ii,i,lt*tn
    ;rfr;*;iii
    l rrrs l rl , i ,.,,
    lrlt lllr, ,

    , -un rLl ckiikragrup r1c vibrLfii crr amplitudint: ruar:c('l',.) r.r. slrn,irr
    l.r .1.rr-ori
    i, ra1.iv 0,02 .0,03sr:c.rlrrPirVIr-Acostgrtrp rlo vilrra!ii iisl..lr.ilrrril
    rLr,'tt'r'iiriilrrrrsl. rr sing.lui in ur.rrr.nrrrlincliilr:r'iiyrrlvrrl'l<i:trir:rrpirL,
    1i.
    |li;1{h"r;trr,xitr.
    ,,; 1 l ,' i ,,t,' ,' , /. r ''ir r
    I
    't t vil. z' i li t lir r r ir r r t iiir l
    t ilr l' r '. l- r cir t ltcr
    ' rr,l r,' 1r.rl i i ,rtr i\ r '( l(r r l t ( - )
    li lrl t r 'l
    (i l rtl ttti r' tI lt l l rtrttl ttt
    { i l l (l v ()l rl i l l l l l \' ( Il tIi (:ul al { f(l i (
    Ll .rti , tri L tttri
    l)inLr:r: {iictorii critfacardiaci grosimca l)(.r,1('lui toracic, licirirlrrl irrllr.
    ,i ' , , r lr ', loi it r t lf t llll : r ist olci at r i'lle'
    lrlculitl, cm{izcmul pulmor.rar pot afecta intcnsilriiiriL tnturor zgorlrot(,tor.{ ilr LL"'r 1. "r '( t lr r , 'r i iu slt it -
    ,' ,, i" ,r' ,
    )i ,,,,, ', , , lxr alL'{i ir r r t 'gist r '"i t 'it pt "c: 'Jt r " r"DtlliJ?;i in-
    'lir'
    {. ' ,,il ',',].i',ll'
    ,ril'r,tj tfit't,'1i' 1t1..""tiintre s{ir:1itu1
    l",lll
    llC(",,-t'
    7,a:|.t ilc. elcclic pentru inlregistr:rrca Z.I este rcgiunca apcitillnir rlrrlrr
    ;'1 ,.,r lr ir t t . . ol|r r r , ,i , tO:ri ,., o m fo n e n t( l ^ z q o mutU l i l i , , l l pf. Ll omi ni rrrl ,r{. Ir, rrrrrli, ( l |r ' i
    pon:nta lIr; parastornal sting (spatiul III-I\- intcr-costai) co:nponcntclr i\|, CARDIACE
    ANOMALII'Ai'EZGOMOTELOR
    3.?.3.:I,
    ,si'f, sccgalizcaziL, iar ciLtrc bazii componcntelc Z.I sint inai putin l,in,.,1,.'
    Ii n i tc.
    .',\,t,,t!L1 (',cstrr|rt
    n','itit::!'lli,,1--,:"1:l:-1i"
    1,,'ll.:liili"lill.ll'
    b) Zgc,rt<ttt
    { r lr mili poartiL clenumirca -II
    (Z.II), rnarchcazii lnccputul cliastoloi, iapt portrrr
    dc zgonot diastolic.
    , i i,i,ifi' J,';l'l:"r
    l" rr r iir 1()l)rr '"- ,;;"'':'';;l!tlll",:l l:t::'il,'lliitll,,ll:,'l;,
    sistolei l
    pL.sittttL'rt
    ,1,,,,,r,rurr l l |lt t t zt li, ill lnom clt u 'f ti"r*i"l"i
    ,\c{rst zgolnot are doul com
    r, L l f | l l ,,',,ll',',ili1i;;i,;,";;ffi;
    1,,,"' . l i ] l i i 1 l ( l ]a l scstc Pl 1 ]sr u r &t ,ii'!
    ,i:;1l11gyt,
    'eniric'lare er . r lr r . r r l
    iti'.li:.1i,11\'.:.S:.,"l
    1a ini'putu1
    "r .
    ii1i,,,:,:,.iilcsr:lisl a u'ii:i"iut.'i
    ori{iciului,mitralla in
    , ,, ,',i ll]ilif'lli;:,liil'li;,5,J""
    '";i;.;i,li,iri;,,,,i ",rtrar :lLl"1ii''"'
    1j,r' irr_ cc.r^dc-a dorLa (P") cn
    _iuchirlcrca seurihua.rclor artcrci pulrlonrrrr ' '.tl,
    I'il\'ti,:'.;; iatirzi:';t-i
    Pinji
    .ll l1::cilil
    'iu'lcr.escutirrirL .:]lllli
    ,ilriur
    \, inrpliciL
    S,, urllhci-t iir gcncz;r accstol r.'ibratii rapida clcccktrarc a sing.,:lui, in 1,irrrIrrl ,l'i"p4ipi*i.,"ea
    l]iil ,l'li,l]lii,;fi:',li,i.i,:ilil'o""ii"
    l)ulr{ r-ii in L{-rrsiun. .t sigmoidclor, 1:r inchiclcrl'a ioi, grarlicntul rfu
    ioi, grarlicntul rll p; i,sirrrr,,
    1r;.i,sirrrr,
    r, rlizilt illire artcrr: ;i ycntliculi corrstituinri ior!:r gcncratoar-c a. r.iiirlrliilrrr,
    0:r ;i in cazul Z.I, intcnsitatea Z.Il estc conditionatir :rtit dt: Iacllrl
    r';r'rlirci cil ;i clc I;ictori r-':itracarcliaci.l)intr:c i:rctorii carrliai:i un rol prirl,,r , ,,, 'll,,ll,,'l
    ;:li;;":l,llt'il',Xi"'iii,",."?l;:...r.':'ilil
    I;Irr,,iiltlW*,. i1i1.,,
    iir:rJll",:llrl'll
    riirtl
    .il
    joacl"r presiur..cadin aortil si artcra pulmonarir
    Irrlrri r.:Lh'tl:rr (aolti.. ,i pulncna':). Facrorii cxtracaidiaci -implicrLii rlrrt
    (, i ,, n' rLodili(ir distarta rliutrc cord si pcrr.iclc e,.ili:rn a.1toracc{ni,
    -si intcgrit:rtca-;L1rrrr,r

    1rl,r rrrrr
    r,j1
    l' ' l'1"i" r"i..4.'$i;f-rt,:l i:,'I
    ,,,''11'''ri
    ':''r''i',rr,l:n'$;:|,:lt,,1::-i6;:itJt;ltiol"fia'.'Jix
    si r lInsitatca accstor structuri.
    I)rrr;rta
    l) r lr at a int
    intcn-alului ,fiirl,r'c
    c r r:a l u l u i ,fi i rl ,r' r cclc
    rtl . tl o u i L {cn i l ,,,ol ,,r11-,\,r \i Ir" qstc r.rrri r
    rlouir-
    rr',
    Ij;;,, l*ni*:*":",*r;l''"';1t*,,
    liij':xilr,it ;
    l ,i l i iir lunr : t ic 4t .'l z tz c l l :c i c l i i l u i r.s Pi r:r+ o r. \.i i ,.1, i n.rltrpi
    '\,. ;i l',, ru rlcpir;r:;tc in moC noimal 0,02 scr:, in tirnp ce in irrspir rr.ccslirr
    .i cir-al
    i l r i .' 1., trl ,l
    val ul

    l (r\.ri l) r ) ; t t cajung c i i i n i r 1 a 0 ,0 fi s c c , m e d i a d ural ei l ui fi i nd de 0,{ l .l -.0,(} 4r,r,,


    i\,,r1:riii ck'ciublatc fiziologicir. ir 2.11 r:ste corsccinta intir-zir:r!i inr.lrirlr,ril
    i rrirrr
    < 1i r,,

    ,,'lll,,' pe "i*,i,,
    l.,i l ,;il' ;: l "' :i : i l ' i l i . i i , " ' i ' , , , : " , . , r ^cicstcrea
    inaittt.
    ' r i r ' i ,lrtttslri
    ur ;r
    lrrli rLklt.,r-puln:onare. (prelungir:ca duratei ejectici r,crtr.icuiuiui rlrepl, qrrrr,rlll ,, , 11' 17.'ttt,liit ii ir lcirt ricului''ti lt'itg - "tttti 'lr
    .ll"ciosl.crca :rllulului de singc cc arc loc in i:ispir. citre inirna <ircajrl;'i),;l
    rr irii bidcrii precocr a signordclor aortice (sistola veutricul:rrir stingi liilil ijirlr,ilii,lllil:*;*:t;*li,::t;:*:'r,"n:ii:!:
    i::,, ',',r'i, a u.ui L'l"c,deramurir'slir'i'lir'
    s( iu1lLi, ca. ur.rtar-ca sciidcrii a{luriirlui de singe ciLtr-r'ilima stingii, lu,r'rr,,l,t
    sl irgnirrl 1a livclul trritoriului pulmon;rr).
    I ) r r iat a t c t a i i L a . Z .II o s tc l n me c l i e A ,l A -A ,12 sec. rl ar l a < .o1ri r,rrl i r
    l, i:1",i
    jlffi,iiir;;:.,ljF"Tj+l*:
    ,il;,r1,,,fili
    1,,f''
    ,i:t;,,'l;.,,i';turn.1.,i,
    jr;i,;, """tt"

    I rLLrir'l lu dur-ca.-rir- iu medie m:ri mult dc 0,0,{ 0,05 scr.


    c) lg,omotu,l ltI (Z.tII ), cu o duratiL dc 0,04 0,0-5s.,r., .r(. :t|r',.ftl ,i c,iiilil3":lijj:.::i;",.1?jl,;Tl]:,:il,:,
    rrr:si1*tlii.in
    ',,il;'l]),,,,1,
    IrcrLz,;"i Ir'r rtt'r la copii ;i tineri cr o vibrafie c..'.lrccveuliL joasi! la ulr ilt,.r
    ' ,r' I rl rri Il i; i lxr r r t t ' m ir i lo (lt)ll:t
    \rl ( l( 0, 1{ 6 s c c. d i rp i r r\r,,\c c s t z g o i n o t, care apat:1a i nccputul rl i l rsl ol ,,l jiilr{l cli precizic car-c ciiltrc
    , , , t : t t t riI rrlto(lrl t'-l'i"ii"i '(
    r'itr',' sfirsrtul umoiclii ventricular-e rapidc, cste atribuit nturciii in llrrrirrrr,, ' , ' i r' | i l
    rl lor rl:rjr.1ort sp61 r111r',i
    "'1"1',1,,'r;;,i,',,'l,,ll,ri',,ii3,,.,$ir.i:i:'i:{::,,:.L:,:'.1.
    irri,'ir.;11.(lrcstcrr.a a,1lr-rxului r':no:; (asa cum se intiln-rpi. in c{or Lul Iizir., .rlirl ,, i ii,riz.,rzii ill;*ll,;'tJ:"I'ii,!lt;ii',iii,i',,i]ii,,l:,1l"ll
    r'..,rst,'isirt
    t.l rri l t , , r r r anc r , r a' l rq td e l r.l l b u ::g c i c .) p o a tc inrl ucc ap,i r.i fi a zgonrol rrl rri l l l
    .t.r r:,c-ii,r,.:a arrtplitLLdiniilui. Crr:-.t,:rcaaltt-llituriiitii Z.lII lxrail li rrolrrlll ' i :,ii;;i,,illllli'
    '
    ;,Tlr;i:ii:*Li.l.*'11il;;;a:;:;,,s
    ;l;;'it;l:.,*;
    i,,:l si in insr..,ricicitrai:arcliaciLsau in inioclilditc. rr . L r r i rr l r i cr r i i ti cr tsi fi cr
    fo '
    l t', i l l i a r c m a xi u r tl n : cl i : i u tcn si l l L L t'i tt
    S c r liiLl , : ic c h c ti { r t-.u rtru i l l ' 1 l i s 1 n trl l r 2.1-[I c,stc 1r,' gi q1rr,
    rl .r1r' ,,i ,rrr,1, l r r r L , r ,l ,r l r i l tl r ti i 1 l ( ) l ) l p l r l l (l l tl l ( 'st( ' cl r va tn :r i ttti t:r i <l r '<l l
    ci r
    i r slr r r i: r l i, r r llc r L b i t l a tc ta l s 1 i u g . , , I l ! i r r r , r r l l i r l i r ' 'l l r 'r "'* ti i n u i "'ti i '"i r ''- i l csi

    ; : i:iljj,,,,;l''; 'll;iiiiiilI,l":ll'r'rif
    ' lili',i;',lllill::,;'lli',,''t,'l; iili'l:';
    lll'ir':,';'"l'lll/i'
    ;;:ill',;:,1:lil,l,,'l:li','1,i:;,ll;
    ,:,:i,i,:;;;;il:iiil;lll;
    Irl f,l rl r,l
    lr:.ll
    rilrapl;1.1,t5. crm aparc iu dr:fi:t:lrrlrrtri;rl),lir: o cl.crtcrca
    11.i,;l,tlli[
    rrlr ilr irft{rt-aptduronari.. ,,,(r,i(r{,,,,
    r,,(,',i,rL,f,i
    1,,1;l'i,i',i11,,.,,,}}itii'l]]::i',,1;l
    ( ( ri i I I { ' i l Zg0l l l ()
    tti!ii 4ontotwlai 11, c;r rrrrrrarea_.scir.dcrii ,r ,l rrl ,l .rrrt I )i I I i I I )
    r.lrplrl
    !.L::,:i',:,:rr-!,:1,:,rTsi
    rliuii unci:L or:i altcia dintr'c cel"edoui componentc, p""t" ii-iiurlJl ,i,,'1'r1 'i" ri "'l"j;,;;;'t;,|}.]:,Ht#;"1,,i,1'',,ji''t:, a zrrr Ilz'i-
    un'io"t"patologicr
    ,1'r,'.r,r.lir-sticititiiuneil din vaivule (ca ld stc'oza'aorticir.sa. pulnr'rrirI
    Ijl: l_dl:i'l:'_1,:
    . lrr:siunii in.aortii.orr in,arterap;h;";;t, ''",",,,,, rrs ,rrirr,rt
    'lis{;rn_l-oi,lintr" oiiginea suntclor si loculdc inicgiii;u;- ""li"ai,
    '' "i"lr,
    ,:i::: ii':lrr:.,;li -"t:ii?,,ffi{.dl,,t"'iili:i:::*ru,;iiil
    <.,.,
    ,
    l:du..tl
    ind prcsiunea
    u amplitudinii A, s" ir_Lilncslc tipic in insuficicntrr rrortr,
    intraaoftici diminui r.apicila ihc"ptitul ainrtol"iiu,j iri' ,:, riiT::i:I!i:ii'ii:l:ii
    ** Jijxk "uansiunl,i,p ;
    .LltcriLrii pcrformanlei miocardice ce ire drcpt 'consecinii o
    climinurrr.,.
    r.rtcr dc sci(iere a presiunii intravcntriculare G inceputul' disatolci.
    disatolci. .l)i,,rr.pr
    ID|nLa,_o rcduccre a amplitudinii A, are loc in cazul'unei stenozc
    r.:rhrulelc caicifiatc sau -in coarctatlia de aorti..
    .l)i, ,r
    a.ot.tl(,r,
    i',,1:,rli;;ruij;itl;i1t*i;1"1t',"5:";"li:
    Reducerea amplitudinii componelltci l'., ,r, ,'
    i ;:,
    r:ift?il6l'{i::tjj:l::x"il*
    l:rilirl;riil'':'
    ;jiri o."oo",,,
    obscrv5.,.in stenozapulmonari modcraLi. ||,.ritr11
    ca s5 displ.ri coinplcr in cazul stonor(:i lrrl. :l 1,
    1
    :'ll',
    li ffi t qii
    l,liilUli:lJ;l,l:T".:;"J*,1*i";?'#*1,-"'' "'
    monare severeori ln cazul tetrabgiei Fallrt.'
    Dedablareazgomotwlui,If poatc fi afilrrr,rttt
    ,,' l , ',t1,,,1t,1.,,1.pi,';,t,ri,
    " .rl r,1,r r lr r 1'r
    i ot "'iia: l<- r iic'
    1i''i,p,,.!(i{!ir!;fif";il,;ill';tiil;,"1,
    .
    in cazul prnlungirii int,.rvrlului -\- - 1,,, rr,,.,t,,
    lui p,ri.r.;ri,:ii
    0,04 scc. in crpiL,Lti,..jrr inspirrric ilir.rtrrlrrl , ]] 'lil,l 'lll],'lu,!l'f,"'Y,1lti.i,,i
    ,'.t.i. patorosici.'.\garitia
    dintrc A, si P, porrtc[i in mod normalJ(.o,l ,,., 1i,,;,'
    II;III'i#ii:fi ;tl^.*;:r*l"Y.:ffiu'illiJi;1 " "'
    L'i'
    (fis.3.30). 'i,,,,.i,'r,.
    v,'rrir:rlrrr i)i
    *;t j1;;:n*,t Jitjl, f;':11'llit;ii,9i'1,,.'*,,
    La originea dedrrblirii sti {ir_. intir.zi.r,,rr
    componenteiP, (ccl mai arlesea),fir: :rpar:ifirr .
    cocea componentei P".
    1,r,
    ";i"il
    ,,l t.,t .rl l Li prri rr of it 'i, al I i] : r c
    IV r'
    't ' ',);'i'),',)i,,1,,,, slunol'ie-Atunci cincl.zgomotul III ;i '
    lntirzierea componentei P, poatc li <l,rtrr, l,) -zgornotul
    rati. mai multor cauze: ' ,'r'' L,.r,r;i
    r1""1t
    11-1i.;;'ri;I'"5;lJ,'l*r11#"il;1'""r"3Ji
    ,,iiIlii,i-r,,illiili*
    rffi$.tffi'"'n* Iilli'
    i;linmt'*3:'."il
    - crestereavolumulni sistolic al irlrirrlrrl
    drept, consecinfa unui defect septal atr-ial orr o
    unui defect septal ventricular;
    ; ;;iL;i,'i1r t.'lricrrrdiil'srt|rr lcnt riculate'
    - scidcreaIont.i a prc.iurriidin art,.t:rl, l
    monari in prima parie a dia.rqlci,anr ( rrri .,rr CARDtovAScutARE
    3.2.3.3suF1'uRlLE
    intlmplir in dilatalia idiopaticl dc artirir" prrlrrr,r,
    nara. si'tcnul cardiovastlllarclttc
    ',rrllrtrill sittt {cllomcncacusticeprodusein
    Dedublattalorodoxalti a zXoutol,ttltti ll y,.r,
    l^ fi consecinld[io a unci inc6-;,1"r1 irrtlrzi,ri, ,r
    valvulelor aortice. dupi fnchir.lereavalrrulclor lrril.
    $?1i#""1T'f;;':
    11*;;"{}i"tti,:lxT
    ; ;;l;lrl:,ll,,llll:,1,*,llli:l J JIJ'
    r,rr' , r l r t t 't rrI , ,t I i I i t ;-Iri Itn n tn d i ttn m tcc {l l g

    lli-"f ..' monare, fie^a unei lnchideri precocca r.th"rrli,|r,r


    . , pulmonare inaintea celor aor.tice.
    \!,,,rt :stt,ut,t,,h'aduc':r':' T,lillilll ;l
    i*?"liJ;1.1"i1.;
    t'tg. J. -J(1.- Reprezenta,le lntlrzierca lnchrdem
    Intrrzlelca lnchiderii valvulelol
    valvulelor rrorlir l ILl.l""iIirri,l]ri "i:ti,":"J;"'."# i\{rx'iIi
    ;.";l]ilii.;,,:ililT#:il"'ffrui*;ix',$i""sc
    llrcmaticir a,d.edubhdi zgc- poate avea loc intr_o scrie dc siluiqii: , ,111, r' l xrl t l :l l (J Irl ul l or li
    motrlui II
    N , ) r n r . l ; l M - j .sl fi ci h t, - stenoza aorticl -
    m it.all; or-o." ,l ,,1,,,,1.ii,ii l ' r, l ,,ri i r r r r ; t lor nici1. lotf i r cpr czent ali
    pr in:
    rllil) jl:"^.',"i]:1,;"".,*,._:1._ duratei ". sHngi. I)c<lrrlrlrrrr.,r
    sistolci r.cntricutrarc por lit r t r '' t lt r t t
    <lt t t t 'r r t t ir r ''tt lccer ci br uscil r lint r - o
    l ) l o ,) d 1 : rxmu ri d ra D tr: Sp-
    :l:1.i,;:li,... - r.!t^rinr..!nn r.l ti ttrlr t t r ', ,
    'r1
    apare atutrci cinrl gradicntirl dc pr(isj(t|r,',,j.l,r ', lt '
    l:i:'iil'.
    ":j,,;ll:ljii,*;lli::,; l ,r ., rtrl rl,' 1'r 'liiir r r ' r r r r r lt r r r r List r - illt ir : sir t r t t t lt i
    de pr:str 70 mrn Hg; por liunc lolt llt li
    ,l i l ,rl rr l. , r r 'li<i llt lcir ilL lr lu: r ciLdint r - o
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    3,2.4.M-E'ODE.MECANOONAFICE
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    DE EXPTORARE
    CARDIOVASCULAIA
    M. MAIORESCU,
    MIRCEASTAMATE,MARIANA MARDARESCU

    lntre metodeje neinvazive de cxplorarc, rnecanolonc,cardiogrlfirr ^ \ Ttmc delnhrztbre


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    '', ' r r ' r r t r r , i, r irrrl ,rri rri1 r, ,,,.-" .:tl ' ,, c i rr s i 1 ,.,, .' ,, ,' t' i ' ;
    .:;ll:jj;,i1,,,,,]1,
    ,r,,;,;., , ., ,,,;i.,;1;'i,:;,ti, ' ,]j ' .:.
    j :::11]l l ' |l Lr I, l l r)S r i td.

    ,r;-: i ,,,,,,,:,:;-i,i,:,,i,1,)l
    ETG .
    4- - -7-{
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    ,,'*.,,. ('.\rr
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    7-, lz
    r;ii'..l';t; ' ii,ror,ii, i,,
    7.t9, .r'. :l{. - Itl:pr-ozcntarc schcrDticl a ?rtsnlLri .rro1i,Ur!'r
    l;u-'ol
    ii;;i'^::f;;'^:i'' .Tll:fu1'',,
    -n.r ti a lorloctlrdio-qramr:i in insuficjerrla aorticir.
    I ' r' (p u ! : rn . r. o t i { t i a . ) p r{ , j rl r D J t rL . . s c : . ; . n t . , . 1 ! rr \ . rt rc . L t . r. , rf , t . L ! , ,
    l i r| rl L i l i d , , p u l s b i s r. rj c n s . ' r, j i c i L d j . rr, m. , : . ! rh , -rr r, r; , . rrrt ,
    , r' ' , r. . o r. r. . : " . . . . ro"ih. " t s Llli). . . / , r, ,

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    3.2,4.2.PUI.sUtJUGUTAR

    i ;j""'rt'
    irr':
    Iiorrlirlrrlalia normirla rr juuulocramei (fig. 3.35). Tr.ascll
    lrrrlsrrlrri jr

    ii;;'r;:;li*tfi,'*:!f''*iriilii"i; ili
    i ,l 1r ,l ,,i .i tr . llL'r 'ii r nodiliciir ilc de volum diu vcna jugular . i r sli, ir r lr r r r r , r
    r' ,11r,1 5i 111 il1s nr o<lif icir ilor r lc pr . csiunece au loc ir i: iir jr r l r lr . r 1r t .1r r r . r . 11i, .
    r," ,., i rrr,rr|, 'i. r r ur r r 'i

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    ,.",r,J,l*;l ,,
    ii "ii[h*,;ii,;r;,:;n:1:l,,
    ljug) iur . r 'pc pr int r - o unr lii , , ir , , la or igit r ct r 'ir r . r , ilr , : , 1,
    ' l tr.r, (r.r .rl r ir r hr i r lr - r 'pi.( it r r l. r , , c, , car c sucr : cciirunr lci , , a. , ( . si. c conr ii( l( , r ir l, r
    ' r l rr(l (l i riolir t ir inchir lcr ii 5i bom Jr it r ii valvulclor t i- icr ispir lc. I jr t r l; r , , r , ,
    , r, ,, rn(1i r r r r . i1lr l. ivi,r xr : t sccir ili I iclar : ir ii r r t r ialt si,
    1, , , *il, il,in lr ; r i r r r i, ,
    ':"'i''pi""'.,""".";l':':l';:ll:''1",1,:lj;;:
    .,':'i:li
    r,r rrr i l rri rr r Llr lir sar ca iu . jos : r t n, h ui r '. Lh. ullLr : i r vLllr iculului <lr . r , I l r r r
    '

    ;,i1,1,t'it*.;
    il;:, ' rr rrl l x ri orr <llrsr i r krclr . 'conir aciicizot onl. Unc] a . , , , , . in. "1r c <lit r
    ,,.' r.r.r rrrrrjr ,,i , ir , . ,csl( 'int r cr upt iL ilt : r r ncln 1r ; r r . llr rir r l,

    ;:,;^il::'ll;",i'::'
    j;,:.,,,T:,:,"?::,1
    t,lli';':
    " : ;l;ll;il'*li; '
    , i ,,l ' r. l l ,,rl rr , , r , . . , r - t ul. si; r r r r r lc
    , , c, . si apoi se r : ouiilr r r i ir r lir r r gr r l
    cr cst ct - ii pr csiunii in- ai: r iul r lr cpt ( plr r icr r . r

    lj!
    ;';;i::';., ;;' l;:;,1
    l;lrl
    . ,r' l .rri .r). rL . slI r ir lr t ii i f ir : ur ipidci( vir . f ul) si t ii'i; ut ulr r i gohii r r ir ir iir r i
    i rr, rr.l rrl rrjrl r( . 1) l( l) it r t ( ': rr I t scr 'lr icnt i. ) . lir t dlr nc3: it i. vii
    ;.i r,,,,,

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    trrl ,1, .rl ri rl .r'ii
    r, " r' .rl l l i r, ( .'ritrrh,
    ( :.:l.( lo"
    , , 1r , ;inr : , , 1r ,ir r r ior r r , r
    t r ir : uspick' ; i at ingr ir laxir num r l. iir 'lr r , zir r r , . ir
    r 'i.r:]izclr z; 'igolir cr r .c, liast oliciil r r t r iulLt i r ir . t , pi-

    'i,1,,,";;:;,;)1;'.,lll,"i'
    j t;tf ;i,il
    l ' r(l i r , , 1r , ': r piur . <loaLr r t r r r i. i cinr l <lLr r a. t ir t ir : lult t i c, : 11r . r , i; r liv llr r il. r , . r
    rr i l (, /.,i slir . r illr l r r r r r l'l, , r . iivr . r r 1: r ir . llr r lt rrilr cpi. si r ir licir t r , r Llr r lvr r l, . i ( Lr

    liil'; ;1;',
    ,i;;,1',il':llll:,:i;.;1,,i;1lil,;;;1,:
    ,, t' ,,l , ,r' :1 , , lr ) ( . ir lr ir r ll r ll r lllr r r l t Li cor r t . r 'I r r '1, rir, .r i. t r lr . ir . r r lr r lr, lllPi
    a l ' l t/ilt t lt t r l it t ''ut \ |. i. t t i , , iit . r , t li, , lt t iit i
    ri .

    :,1;,;:l:liri;
    il,,,,l
    ;l:,,1,:l
    l;lilililJ
    i'
    tttttl
    r I t)t , i . i) r t l, t t os/ ir it l '; i t it dlit dt , t t t t t t t , r r t l, t lt t t , | , , , r , , / r r t r , ( 1i: 1. i. \ 'r )
    ttt ' tl ttttl tl ti / ) ir r ! / ) iJii t r '1r t r t 'ir r lt i t r D; r r lir r ; lr r . t ir r r r ilr r r I r . , '/ ir r l; r r r r r o, lr , l
    , Irl l ,IIi l tr' , ll r r r r r , jiji'r r r , ir l
    ilr , r r lor r . llr , i. lr r ir l. r r liri, . r r l. r lr 1, r 1 1r r , lr r r l, t r r

    l, "t ll
    urr(lo,,v" cu arDplitudin(-'foaltc tnarr: cc lnc(,;) l)r'(r'(nc;i tind sii i'stonrl)(,zl
    rrrxlanegativiL,,x,,. ln insuficienlelcsevere,uncla ,,rr', inccpe dc h sur irrl ' l r,.ry,i rrI, i llzist cr llt pr r lt t t our Lr ii r t olm alii, llnd; l , , v": unpliL r u li o r : onsccir r ( , r
    r ,1,l l l l rrl r r i st pt ir l; r Lt r iul r lr cyr l.sr ' unr pl: r apicl int r - o pcr ioa<lr "L
    t ir r r l vr r lvr r
    rliat dupl unda ,,c" si sc terminii cu unda necativr't ,,r" . ln acc'stccazrrri l , I' l ri < rrspir krsint iuchisc si cint l clcci nu- si poat c cvacua cr lt linulLr l. 1r r
    turda ,,v,,,,Fpaltii denumir-eadc ttndir cle regurgitatic (R). , r;rl irr litttr :r1l;trchipcrtensiurrlrL in teritoriul puhnonar, urrclr,Ir ,,ir., rilvirr
    I)iagnosticul difererrlial al rtrr | ,r ' , || ' | | | i rri rrri ( in anplituclinc.
    delor ,,v,' cu amplitudinc gi clulrrlri
    crescutl trebuic flcut cu insrrlili 3.2.4.3.APEXOCARDIOGRAMA
    ,fu\-Ec6 enla cardiacir congestivl firrir s.trr
    ne de insuficicnli. tricuspidiarri. lrr Iirrrligrrxtlia lormall a apexocardioglamei (fig. 3.36.{). .,\1r.xrxrrlrlirr
    acestecazuri este posibil ca volrr , r,rrrr.r (A(i{i) rcprt'zintiL inr.-gistrareu gra{iciL a vihr.ttijlol .qcrrr.r';r1r. rl,
    FC6 nr.rl lezidual din atriul drcpt sii ii,' ,l , l ,l .r,rl r' :r r r lt cr nat ivii a vir f ului inim ii in r it lor t cu lt nr et cl- ' iollu. i<, .NI iSr 'r r r , . , r
    ctescut, cceacc face ca attiul ttt ,l .r;rro1rillr' iL r.irlului inimii sc inscric ca o undii pozitivir itr 1.irnpcr. rri;
    'f r - asculllr cr t x lr r . r lir llr ; r li,
    complet golit si {ie rapid reutnplrtl ' | ' .r ,l ' . i r( l( . 1) ir t ar ersc inscr ie ca o unclil ncgat ivi.
    la lnceputul perioadci de rclrtrttr', r,' ,rrrrrl i rrlr . pl pr in ingr cgist r ar ca unci undc cu am piit ut l: inc r t r ir : ii.( A) , , .
    y'/armd/ atrirgind o supradistensie a ir(ji'slri,l ,1,r,''ir clrr-slll pr:rioaili:i dc contractie a atriului sting. I-;L ll'r-soirrrr.ll rror
    manifestati prin aparilia pLcctxl irr rrrrl , , rl rrt ir t r r .r r udci A nu depir scst c 0, 09 sc: c,iar . ar nir lit udilt , ; r li r , slr , r r l,
    sistol,ia unci untlr ,,r '' ampl'. l " ' ,,rl i rrrl i s lau{t Lvr : r t icala'r int r epr r nct r 'L'Esi0, inm cdir . r it , r |t r r r ir lr r livli, 'j,
    I nsuficipnti tricuspirli:rttii, I rrrrr' ,ri l ir . r uu<liLasr : cndent iral r r r pt : L ( C) Acc m ar chcaz, - Ld, lr r r lr r l plr ir r r r r l,r
    caracterizeazl, de asemcnca,1rtttt
    tr-o undir ,,1"' rapidi ;i arlimi, r'r,tr
    secinla unei umpleri ventlil ttl.rtr'
    drepte rapide ln protodiashrlri, Itr --J--t-'.=/',- nn
    aceste conditii unda r,y" (rsl(' rrl
    Jlenzi..- matl de o pantl gradatir rts(r'rr' f(,o
    mcusP/dd denti, carc daci ciclul cstc rttli '{[ EC6
    cient de lung se terminir crr o tttt
    di. ,,h" ori ln platou. t',\ i:gn
    Perrcardr/i r' l'fro'-,i17€47n-@
    rco /nsulkttlh)
    c0n,r/ncr/tld- ,Stenozatrintspid,ti praz.illti rl" ni/td/,)
    obicei unda ,,a" ampll ca urrrur, i" ,, 1 ' ;i "-
    a cresIeriirczistcntoih [Juxrlirr',1'r,, li
    atriul drept citrc ventriculul rltr'pl
    Unda negatifi ,,y" cstc sttlx,rli(irl t
    /ntuf.aeJti ln, pulin :rdlnci.,cu opanti rt.irltt
    '-t/enozi
    {'lrd,/dca' denii. redusi ori chiar rLlrrlttl,l, AC6
    /r//rd/)
    Existii posibilitateaca in r:rlr,rtl rlr,
    nozelor tricuspidiene unrla ,,,,"' ril
    lie aparent nolmalir, c:t o ( on'tri
    ftbn/alre cintiL a scircleriiprcmatur'( ir lrrr,'
    da/d/d ,furictr l,t
    siunii din atriri drcpt, <:r.rttrrlruil co/Blrh://i)
    i:,i6. 3..35.-Reprozcrtarca schematice a jtgu- deplasirrii ln jos a pltns,'trlrti rt
    logramci - aspectnormal si a principalclor tlioventricular dt'cpt, ltlrrrtli r'ltll
    ospcctc latologicc. acesta se rclaxcazir ia in{r,prrlltl | ' I tr .r. r',i,,',1i1,,,t,,t,. rqnrlr: rL, rruxogramr;i-norrnar 1cx1,lila1;iin i(.\rl; lt. At,,\.,
    f,,' ,,' ,,,, | ,| : i|, I |'L'r t nr in t ext ) . pcr i( , r r ( t it i, o, Nt , i, |, \ . , i
    r ; rit r r lil.si sl. i) lr ozrilr alll ( explicalii
    diastolei. ,,'l;rt'r,riirl(,li(i (rur(l:r lrrtjrii:/il si asCcDsiuDc (tilslolid!(und:ipozitirri).
    I)ofecl:rtlscftal' atrial t:stc in urod normal asociat cu tttttlt' ,,1'"
    tlr' amplc, ascutitc, egalc s;ru chiar mai m;rri ca unclcli:,,i1", (lill llll ,1, rrrrrl .ri,, , ir '; r t r .r . slr 'lnilcr nPt . i r r r r lor i d, 'o r nir '. 'r: Ln, : of i c, ' nlir r ( . lt {, ir . zrnti o
    pcrLzr-rrrnrlu ,,r". .,\rnplitudinca untk:i ,,r"' dopi"rl(litc pc ct:a rt. lttrtlt i l l rrl rrl i rrr lr i. , l,r ii vlt lvu| lr r r -ir ir i, '. v, 'r r t r i<r r l; r r t .: i it r r r . pr l[ 11]l, 'r iol1f t , i <1, . r , , r r
    l r r, l r, i z,)\ , , llr r r r , lr ir . ii.O , lr r liL r . r r ir r r ; r '1lr i: ulllr 'r iolxlci r lr t I , jr . c{ic lr r ir 111, , lr r i
    lrrttli r:irr<lsr fttlos c ir Lcc r r llt r t r c I r lt ' t i' I r ' t - ir t f l"r] ) 1 'l l i - r l t a l n l ) o l ( 'l t L t t t r 'l r ' , , r ' , r\r l ,rl
    ri0rr rrr |sll' r'ir|rt,'lr , r ' is iic r I r' l' r' r: t r rI t ri s r ' Plr r l t t c r : o t t t P l i t i r i ( t t l r i r t l / r 1 f i ) i r t i ' ){ I/rl|rl ' l l tr r' , rrl ri , r r l ir r : r orli, llLr r lr r r r l, r 'r 1111; inifr ir r l sc ir r t r r r r lpl ( pr ir r r . lll li) , li. r lr . r
    l ,' i r| | | | r,l l | , r ' ir t lr r r r t lr li r |, , I r |r 'r t <|,
    t t I ir r |lt r lit , ljr t ; 'i, A. r . : r 't lii Pt r r t l, i, r . r i ll. , , r

    llil
    t , liI
    \,' ttto::rtt t ilt , t lt l sc ciilr r it ir r iziiLzi- r Dr int t - odiir r ir t r r r lcir ar nplit nllillilt t 11'lri
    ' L r', i tl P lt ior r ir r r k ' r' j c i :ti c l a P i c l i L ,s L .tc fL u i l ti r i r l rrrrrcl ul I) 1l r. 111r1ll r' rrrt
    l rtttl l L r li' s r : t ' nr |11i l L c u L [e i d c v i l r: a i tru p ti L , ] 1i t1.i p(L i nceputui l r' l i rrrrti i \ i i Irni U ' (. r rl: 1<Lr L<: 0r liriir : ir . t lr rrilL:sir . r gcdinspr 0 al. t iLLlst ing slnf vcdlr i( . |] lI l
    'rrlri( ul:lr'('. Uncori pc ilceastir pautiL abrupti't 1rrrq. l)irtiotiritrtic rttnpli:Let'ai)i(ii'L(,rito;,Lclesca scurtatir ia avnutajrrl trnrl'.i rl,.
    l)oritc li obselvati o nri, i rrl rl ,l 'r( l { ' nl )'r , c: r . r - .cst
    c c alulgil.
    t:rli.ruti (1,) cc punctcazir rnomcDt]-ll inchiderii r.a]r'ulclor scrnilrlr)itr, tl
    ,i,,i rrlirsitul J)clioa(lci dc ejcctic. Dupit aceastir incizuri, traseul dcvill rrr'l
    L .r({ rr(1{ll1, nalciurl pc|ioada Ce r:claxare izovolumetrici. Accastii Prrrrl,i 3.2.4.ri.
    TIHNICA INREGiSTRARII
    UNEt MECANOCARDiOGRAtiIE
    I i ('u(l(rrt:r si, tcruriniL in ploximitate:r. momentului de deschidciir iil r rrl
    r,rI j o r r niLr ' . r i. iut r u n p u n i L i n s c mn a t c u O. O dati r cu i nceperca uul l )l (,ri l irrlcgist:-ri.r'i1e mccanocarrliogr:liice con{in unul sau m:ii mrrltc i llrs,.,.
    | , r, rdiogi afice, {onocarr'liogralice 9i trasee mecanocardiogra{icc cxtr,rrrc
    ' L l ti ' r lar c r . t pir l, ' in rc o i s l ra rc a p i c z i n ti o n o u i l pant;t descendenti L,l l rrl i i , 'r';r
    , Ltrtirt ii ctr o rnic.i und:r pozitivi F (unc1ede rilr1plere rapide'r. Ihrj)ii .l r rt,"irloAr-lLrn:r,jugulograma, aperograma). Pcntru insclir:rearundclor sini
    ,rlr.. Lr(,apa':rrtcpoligrafe, prevlizute cu citeva elemente debaz'a ctt: microlorr,
    , .r',1,r rrrrtl.t ;rscorsiuncir culrbei continui- lin, re{leciind unipleica vi,nlri
    , rrlrrlii lcni:iL. Atunci clnd diastola cstr: suficient de lungii se poatr, rtlrrriiti L . !,' r'irl(, c:r.1>tatoarc dr puls, filtre ctc. lriteza dc iuscriere rccoman(lalii. (.sll
    I II i 00 1nm,/sfc. Poligraful trebuie sir aibi. minintum 3 - 4 c:inalt'"
    ', ;ri xociLrtliog|anir un piatou diastolic akngit, in cursul cf,ruia \1.ult'i l)i'r1ru inr-egistran:agraiici," a fcnomenelor acusticc, produsc in inirrri 1i
    ' Lirrl lsli: probabil compiet plin. ' , L rrIilri,dr cir.r:e se ocupl {onocardiografia, microfoa|Lelese aplici intr*rrrrrrl
    c [ it ilit at ea d i a g rto s ti c i i a 6 tt r e g i , s t r d.r i i rl tt .l ' r rrcl rl r' l c it cust icc' pr ecolCiale: apexian sat spat iul I f inlcr cosiir l
    .,, rr:, 1 ia! r ur Lc i . D ,i a g n o s ti c ttl ;i e ,ta l u a rcaunor q.fec,ti unii tqhul tnt' irrr prrlaslclrtr.l, spafiul 1I pi.Lr-rstcrnalrtin5 sair drcpi. lnrcgistralt't lirr,,
    '',. tto::rr. L'a o corsccirti a cre;terii prcsiunii intrr \'. ntricular. rililllil , l,,lncitzi i'r rxpiraiiq rclaxatir, in decubit dorsal, cu partca supcfiorli ir
    I' slitsitrrl 'rorlicti. '
    diastolci, chiar si atunci clnd nu cxisti o hitertlofie vent:ricrrlirt,l . un unghi de 45'. Se ir r eEisir ea- zi., 1- - 5ciclur i r : alr ljr r , , .
    ' ,,r l ,rrl rri l i di r: Llr - rla
    iirr;i, in sicnoz:t aort icl 'inrcg istrarea apexocarcliogra;ei indiciL c\islr nl,l , rr-r liccurr for:er. llorlologia zgomotelor sc apreciazl"r mai binc la vilr,zrr
    Lrtoi lrurlc r\ rmplc Aparitia acestor unde indic:t in gencral o stcll()zi \r' lr i r l D In/S t'i ',
    '''Ili r'u un glaclicnt de presiunc trln:r.a1r"ular de pestc 75 mm Hg. Oirrrl sl,
    I rrtL'gisilalrr;rgraficiL a. pulsirlii1or arteriale sub foima dc sfigmogranrr.s,.
    r,rz,r lrlr' 'inso{itir de hipertro{ic rentriculari, 1urda sistolicir cstc irnrlrlli,
    rl' rzi. pt-itr jnscricrea.pulsuL.ri aoltic (aortcgrama e{ternit, subclaviculrrr,
    ',: 1,1111r {sl l,l cstc ulmat dc un platou, ce lnlocBieite panta dcsccr(l('rli1
    rr ' liiLn (r:atotidograna) sau al altor artcrc cr ajutr:r'ul captatoarclor' ( l
    lirri (lil-l) cc urmeaz:! ln mod normal punctului E. Linda dc umpkrr c r:rr1ri,lfl
    r I l 1' l )i czl )cl\ t f t r icc.
    ir ;rclitc cuzuri este rrciusi ori chiar abseniiL.
    t ;rt-olitlograrna cste sligmograrna cu cea mai marc utililatc pr';r,l i, ,i
    .\'lt:tto::tt hiperlraficd su.baoyticd.idiopaticd ( cordiotnioPatiu obslrrrlir'11 l rrr,l rr:j or r1r'olr linut si r epr czent ind un, , puls ar lcr ial cer . r t r al't ,apr of iir i r lr :
    lr,zintir, dc ascrnenea, ca trisiitul:r caracteristici, o crettere a amplitrr,lirrll
    ,rrrlci A, 90')b din cazuli prezentintl aceasti modificare, ceea ce facc rlrrrsr,lrll ' rl. :r' olr !iu,' l)lasind micro{onul pe o arteri car-otidl la nivclul gitrrlui, r'rrlrrrl
    trrr,l rri l ai Lrlor :( 1. 5"- 30") de par t ea opusli. Locul ccl m ai pr opicr : cslt . r l, '
    ,l, uiiLii iurcgi:ttrarca ACG in diagnosticul acestei afecliuni.
    ", ri, 1r('iLn{iirrrrijlocie a gitului, iniunirul pu;chiului sternocleidomirsioir lirrrr,
    l\lcrliosistolic, ACG prezintiL o undfr convex:r caracteristiciL, dc irtlrr. riirrr,l r:orrrirLt.si:r pc sinusul carotidian. In anumite siiuaiii (dc cxcmplrr,
    rrrlrt'r'cir parrtci descendentece urmeaze punctului E, Virful acestei un(l('irl),url i,r{i;L rl.c ir(rtir), esic nccesarir;i inregistrarea pulsul[i {enrural, <rrr]torri.
    rrr,rliosistolic, in pcrioada de maximum a suflului sistolic de ejeclic. A, r';r'rln '.r,,
    l,rrl 'u l)ulsirI caroticli:rn. Plasarea captatorului se face sub arcada (:fllrillii,
    rrrrlr''- sc <latorestefaptului ci perioada lniliali a ejectiei cste normalir iii rrrr,rl , r I , rrl ir crrr'<.se dctcclerazirpulsaliile arterei femuralc, \riteza dc clcrnl;rrc rr
    irr lcir tlc a doua parte a ejecliei, dupi ce volumul ventricular e dimi rlli, rt|o l rtrl i , i ,' sl c ri L '50 '- 100 r nm / sec. , inr cgist r indu- sc cel put in 5 ciclur i car dir r ir . .
    ir'l olrstructi:i irJluxului.
    Iuti'ilislrrrca gra{ic:r a pulsului r'encs, flebograma, cste ccl mai rlificil
    Insw.ficianl* aorli.cd genercazi.uunde ample pe ACG doar or:rrzi,rttnl, I' r,.l i zi rl . Singur i: lc vcue cu pulsalii m ai bine def init e sint veneic jugulr r r r . ,
    .rirrut:icind refluxul cstc mare fi determini o cle;tcrc a presiunii intravlrr{t'1"
    rrr 1,r.L,lit:ri hrlosiurlu-sc curent jugrrlogramele, Pentru inregistrarc, lrolrrirlrrl
    rrrliLrc stingi la sfirsitul diastolci. In cazurile in care rcgurgitatia irrrtlltI
    , | ,l rrirl jr: rl<'r:rrlritclolsal cu capul ridicat pin5"ia 30" usor rotat pr. p:rrlr.,r
    rirlicir prcsiunca diastolicl din ventricultrl stiug foarte rnult, forfa <1cr:orllrrr'lhr ti
    ,rllirLliLnu reuicsto sir crceze o prcsiune superioarir celei vcntriculat(';i ;rillttl r' rr, ,.tr rri i , () r r pt lLt or 'ulcst c plasa. t deasupl: r claviculei in alar a sLcr uock'ir l, r .
    ,rrrlclc A dcvin'foartc mici ori-pot chiat;i lipseasciL.Panta cLs.r'nr]r.rrii1rl{ 1,' i rl i rrl trl l i.
    rurnr:uzirpunctului D cste abrupti in cazul insuficicufr:i aortic.,. ' rrr
    ( 1111lirr1r'rrrrrir. voutliculLiL"risting sau apcxogr.rlna cstc cel urai li:npor:lirtrt
    I ttsu.fici.c. n ltt m,itrald. gene:rczzi modificlri apexocardiografjcr itt pctirrrr{lL r ,,,r' | f,r /i ri rl i ( r LiPLr lsa! iilorplccor cliak: . Rolnavul cst c plasat in decllllil lir lr . r : r l
    ,lrrrsioliciL,dc utnplclc ventlicular,-1. In gencral unda dc umplcr(: r'rrpitlii rtt[6
    Itrr., prrl pi .i tr lrsc r sr r cr r lapoxit n, lt r acest loc sc plascazt "r m iclo[ or r r r ] .l\ . nllr r
    rrouurtlir,oli alrlu|tiL, tcrminindu-sc lllusc cu un virf urn:rt clc o rnicli rlr,ltt'0.
    ,rrrrrc,r: c pr c r : r r liLr r uc l ac 1 cu m p k rtt: l < ' n i i r ({ i g . 3 , 36.[]). A cr:asl rLrl i trrrl l ti r r,l tf l l | r,L D r.r' l tlr ) l. lr ': r t r rtirlllr , t nlt i it L: s pcnt r u pnlsr r l cir r ot i{lir r t r ,Sc it lt r . gislI r , r r zr l
    l ru l ri r r r i c r hilt lnat c l i p s i , a ti rrg i n rl L r-s ,'ra p i d pcri oada pl tl ortl rri rl i ,r' ' i rtl l g, i l tl r i r l rrri cr r Tr liiLcrl)'.o lr ; i: lr r r 'r ) cr la L, sf ir '; iir r l ir nr . gir ; t r iir - iLo:
    sr -' lr ot uliliz, r
    ,L r.r {r' ir lir li I i r r r rrl )k :rr:rr \.c l ri l ' i (il l l i l ri c s l rr l rfl rri rtl l i ' L i rrci ,l , l rr i r,, Irtt11f i rrr \r,LL,l r,,L ir r l, r l, . r lir ljr lr lir '( V, r lsr r lvir ) slr t ilir r lr li lr r r r r r t cr r t lir r r r r ri.r i,
    l i ,rrl o l l i.
    i 'i l :i
    t t:l
    NEINVAZIVA
    DEIERMINAREA
    3.1].{.5. DE TIMPI
    A INTIRVAIEIOR
    (l.T.s.)
    sisToLrcl ,,,,,|1,'i]:ll'i1..:,";:l:'":1fl,;.1,J,:,iillii,llt::]lr;ili'
    r ::irillru)grilllnlL.
    ,t,

    s i n g e l u i cl i n rrenl ri r:rtl i rr ' :i i , rrrrrl


    ,';:ilm xl:ffi
    l{{:**li;1#*lilb;;Hli?i'
    tiilor- tlc irlnlir-Lltccvcnlii a1c coi ir z( "r ) r "
    ]' ,' i ' ,,,,1., , r:" ,l j i, t , r i . l eLl. '. int r L lut r r l'on"nt nlo i'or t ir 'i li Pr r inr onr r r
    . rl irr: rl),
    r'ontrlctilitatca mioca.rdului ;
    ,,,r,,, d.rimirr.i;.i,',1';ll
    u;o,.
    rr,p.,,niri,,,r il :1;::"i:m:;*p,,i1,;,1i;
    sint'13ir contraclici diferitelor pirr{i a1e iliTii'
    l'r in lrri.ir-Lraacestor paramefri in}na poele fi ulrlu'r-Li. irr t ' Ir
    . , r l r\i l ,rl (r c i dc pom pii s a u a mc c a n i c j i mu s c h i u l u i cardj ' rc C r' l t:tttrti
    rrrIIo rIr'rI r rs t ut liir e a a c ti v i ti L !:i id c p o m p i r a i n i rn i i si D t reprczrt)l
    ;rrr'
    ;ri ( {l
    I t'
    r'
    r
    rl ' rl '
    rl '
    i.i';f
    i{tiltffi,i+iii-tr**l$0ru**:
    l, rr,ri rr:rr ' r L
    ' l, t i rrrq rs is
    < li{ er it c lor
    loliL: c : .
    f a z e a 1 e i i s to l c i v e ::i ri c u l a rc sau al e i i ;a-zi scl rrti rrl ' r' ''l' ""'tT,i,,;,i":';'iI:;:';,1.il',tll",',ii}j,,,.',*!, l:':ltl
    ii1,,.,l
    tr r ,'rrrlr',in func{ie tle frccvenla ci
    li'trrliile clin ultimiiani, ln speciai aleiui \Veisslcr si colaL , au rl'l irrril rl '
    de^timp sisto}icc (fig' 3 37) : r rri \\-cisslcr sint:
    , orrrlxrrr.nl{roscnlialc ali: intervalelor (Q - Z'): 0'40 sec' (:\\-
    r. > i. t ul. r lot ir l; , ( !.' 1 r' ,r)l r.a n i c i (Q - -\" ) - sistola total'L electroutcanicir
    .r.. 'lirnpul tli: ejccfie a1 vcltriculului stinS;(Th\-S) (t-VJ"l )r'
    :. l' ' r i, ' , r , 1; t, 1. - ' p -^ n j ,\' i i c (l ' )PF .) i J ]EI' ). sting ( f llvs) :0'30 sec' (AV
    """tlolili,nt,,r, clecjcciieal r-entriculLlui
    \,,s lc iui. c r . v at rd a u " { o i t d c tc rm i n l te p ri n i nrcgi :i tr" Ltil xrl i i :rrtrl i r' 11r' rl r"
    r,rrrr irrlci:istriu-c:r simultanl a elcctrocardiogramci, fonocardiogtrttttli 'r ' "'/"tttlt|"r,r,.-0., dc preejeclic(PPn) :0'11 sec' (AY.: Tolminut)
    1 ','l .,rrl ,r, il, ir r r ii< lian( c u o v i te z l - d e d c ru l a re
    d e .5 0 mrn,/stl c'sarr l (X ) trrtrrl " '' 1
    [;'L:"i
    ,,,'.,^;il'ii's:J"*n-;':.":;;:;'l1"ti'J'",:
    i,:1"f,;;;-;iar;;r_111i1,9f
    y
    , .rllort cstc invers P|oPorPor 1,,x,.",:.n.u"'i.',1:ii"Ti-:;i
    ": IT5TA COPIL
    DFTERMINAREA
    3.2.4.6,
    existcnla unor particularitir'! i itL
    Mlsularca ITS la copil demotstreazi
    cea rnai pregnant5' observatir rczidi irl
    , ,,,,,t" a.-J^ir*u ;i sex, iro'Jifi"t'e:!
    totale electromecanice(Q - Zt)'
    ,i',',,,ir". Ut {utcfie dc virstiL a sistolei
    " '';;;j;^;!t" ttt'' l"ait" a1 imbunltl]irii capacitiLlii ccrtractile :r rtrio
    cardiovascularS' Alungirea Q - z'
    ,1,,1;i,i" cJdrul procesului c1ematulare
    '
    ,.,,,rilizcazlrnaialespescamaptrioadcideprecjccJic,r'alotiapropiatr:rlt:rrl| rl''
    virstei de i4 ani' lrr :Lltfelir.tliicraturiL
    ,,lrrlittluirltnarcinclt-sein lLuul cor.rrrrrr
    PPE (saude-P"1n3re in tensiuuc)'
    l;;lli;;;,;t;,i;;t;;at depreejeclic
    definitca indt:r a co'triL{rili
    l;'; ;;;:;.ti i'r;iiir:evs i*a"'cc1esistolic)a fost
    r irLl,rrlrrl,l(,r rli LrrrLl' l , 't
    lii I I l i o c i l r ( l i c( '.
    lti* !1.37. - Ite!r(,z(lltlrfca rtdr.m:r1i(rir siut m.r l)r(ll-
    :,isl,'li(:{LYnf ,,. t4I "r€}ltti.rtldttit.tia)L ti1)1rIst'' <')Pl:r rrrir. i,,,,,,,1,'".c modificarilc il {unclie de sex acestea
    (o rrtl(tr11 i jl lit c ! ir ' 1ur ' lx
    : r r Lir r r ' llt \ s dL s i l 'l 'l l ' ' l \ r t J t t " 1 t
    r ' ( h l l ) i l ) l l l ) ( 'r'rivc;tc
    l i l t( "
    t.,'i.l l)cntru l'r'11'). ') . '| | l I l S cii t:l'alr'tal-r'rr
    'l'olt1r' llcr':llrr (x)l$tiLiilri nu {li: tlccit sir int:-Lre:Lscilideca
    irt lltvrrlttl OZr, s is t t , l; t iolalit c lc c lr t r nlt l< : lt t t i t ; i l , l t ' l o s r i r l l l . t t t t t t t r l l 't l t ' l r tu n cfi o n a l i ti L l i i cl r r l i l ttL r 1 . t:.|i l '
    rrr,r,rrrliloriirrlrr'<lil,rtltr l r lt lx r lr r r iz il ii t ' r t t lt it : t lllLLc ( t t r l r l l l
    ( ) r r l ') ( i ( ') , r 1 'r r t t t r r , , r','r;,;r;,;i;r t l i i t t t t tr ti i l .t: r l i :.sc5 r t d i : i u vt:sti g a r c r 'r r r l r r t'
    r cfi o n tl i I i n i r r i i i n . d cz'- o l l l tr "
    rrl, r, rf i, rlI irrrrllii lrr', 1|r l! i r r ' < , r t r r l' r t t ' r r f i , r ( r t i i ( c : ) z 1 1 t 'r r r 0 i r r l r r il l ( r \ I ,; ; ; 'i i i ; ', " ;,:'i r ,'r r I]:tL 'ia tl a p l r ttL r r r tt
    tl tt:r r '1 r 'ti sl i tr ' 1 x' l i cr ':ttr ' 1 1 r r t1 r 'ir l l '
    L'l r r r r r r i {r r r l r i I }l i r t I ( ( I i r rI I I I II I I I rII t i n l t|r 'l i l tl o r '
    nl\, 1 ..t (t,i t r,)ttti,l,|,it,it,,, lir r ,) .r I' lll' ( lt,j ,'/i ,'I /,r ,/' )
    '{1" ',r
    , r .r r'ri' rj l rl rl r ri r r "l i l rr.lr.
    '

    lr , i l
    STIECTIVA ].2.5.VECTOCARDIOGRAFIA,
    BIBTIOGRAFIE
    VAL,ERIU
    IONTSCU

    1 9 7 7, 1'1, 44, 3-l ' ('i ' S, slic r:r"r(iocLiill5irrl'ilsi trtiu'ltlta spa!i'rl:r la L'ral( fil)rc1c ltio(:ar(li( ('
    l . . \ l' li'l lll l l I l . , \ r . t C 1 t r l !. - c( .r r 1 ( ,lo r r tx) .r r d io g r a Jia l'
    r!rrrl rrrrl ri rl r 'r' rl 'r ,t, , j. , ii, , , , r , r iv, 1, ''l' po] ar izr r r c.! " li' [ 'az]
    .'. lll: N( L I i X I O I - - \ . , D I M OND Ii.G - Ei( ( tio ]1 tin e ir a o ri i ' sl !'rrosi 5 ' ' ,, " ..,,i ' ;i - 1t , ' -l Pr d' - irr)nr rJnl]
    n: r ll'1- ; lll'
    1964,
    '
    ,,1r,,....,rrr, ,, I i I i, . .r i I 'r u. ; r , r ] r . r r r x, . . on^cnt r dt ii ionl, o I t nl\ ''
    . lrt . I . C i k n o g y , 5 ,2 2 8 - 2 1 3 ,
    i 1x )NNli l t , \ . J . , ' l l r \ \ ' j l I - IID- - Sisto lic ti1 1 1 eiDtc| r ttls irr r:.rrg|si i rI LLrrrl Iri l Ll ti r , l,l rr, r't: !!r1IL]'t t;ti fulale cell.tltra d, tTc,liutlc'
    fottnt -- . :rl
    1, r ; 1 , , r ' t j cs i c l o s i s r , C i fctla lio li 4 5 a n d 4 6 : 1 3 3 , 1 9 7 2 lrrrt.LiiiL.aritclo;r'rlui t1e i:ou;.uctor de ordinul II (c:L apa cL1 sarc).
    I lllill( li l \ l i R I . - I ( r l i c ir a ir ticir d , vo l. II, L ito g r a fia l f,l r' , ,,f ,lri ()nl1'll('sc,itccste {(inolnene se manifesii-r in miocard, pe cpitriLrri ii irl
    f i rrLrl Ll rrrrr'l sdrci]Li ll(lti("
    ',. t lt i, \ lrNW \ L D L . , r \ ) - G E \ ] 1 ., IiOCHOIT F S D. - Co n g c ni kl 'r('ti r:1(rLol i s ,' r,i.,,,i,1til, corpului pin:r l.i trg1rnlnnte._])rin at''aritia ",le
    li)o l, 2 6 , 4 0 ( i . ',,. t tittti. s,tt)lr f; hl,ogrLr.fie'r,'lil ln'tiobile, cuplatc in diPoli
    'l i ti
    (]. l' I l] \ | (; I i l j . - O l l t h e g e x.sr j o t h e a r .t so u r r cls. Cr - ) n tr ' i}rrti oi l l l l l :r<!rll ,r'1,.1|l 4l |11|1
    ,i; , i : r;=" .:, 2s-. ^,.n:ilizir('lu l tocar{llogrilmci reprezintiL aprecier-eaindirtrcli a' siirrali"i
    ' '.'';'1,
    1| : l, s '| . lilN ] | , J . , C , \ L r l , s l 1 l ] DN._ Ass.]ssce lt0 | a o lticsL ( ]]1 o 5 isl) ' (l j r.i Itl '('rl i 'l Il l l l 1|||i |
    r" l :' r' r:r r '', , , r lil' , 'lii, oli I ' I r lr anii in: lir r t anni pr oduii 'l i'r : ir
    it : r t r r
    tori c l " i D f' Ti l l ti j l l ' Tl l l \' l ' i rl l r' (i Ir{
    ,l . i t'i .r' i l rri l rl i ttl l ,' r d' ort
    ri(l p r l l s { , . . \ ' a/ c . I } f i t , HL clr t .1 , 1 9 6 4 ,2 6 ,8 6 , "" ir lr r ) r '
    i 'i. I I iI I ' lI )I I I i l t ( ; C . I i . - T he h e a r ta n L l cir cd la ti' ) r il1 a n e m ia, i r] Lti sci s(
    ('}i 1]r'l rti l rl l hl l l l ' r' ,,,t i ,r,'r ir li lr t ioliir l ) . : \ cc: r st iL sit ualic spalialir ' nor m ali silll
    ,lirt aulrllitu.linLa si scnsul cleflcxiriniior ECCi inregisl t r' I t' .1t''
    , l. lt n1 i r a r r d L o n c l o n , 1 9 6 6 $ r . S..n n d cr s Co r n p , { 4 p , p l 6?E ,| |
    i n s\'''l "l i r i i rrr' l rrtr'l l
    ' z.rtlt.L .
    tr. (i \ t ilt , \ It D , \ \ r J a I S S l , L R , DODGii - T h e r e la tio n str ip o i ai l tcrati orrs
    455 'l (r.'' l r"l l
    , rls 1 r )o j ( c l i o n { r a c t i o n in Pa tin n ts \tith ca r d ia c d ise a sc ' C i rcul al i (x}' 42:
    l (r . (; l: l. l)li l ) . , l l l i t l S ' l l I N I- - - Systo lic Pl.r se s o f th e o a r ' ]i :rc cl tl e
    j 1l chi l (l fci r' ( i r' rrl l l "i r' pr:oiec!ii1caclrslor(lil)()li
    ' 12. :I 0 2 1 ) , 1 9 7 0 .
    | .i i i .1..i ,':i ",i i .,i un.l
    ,.,' ,' ii;,,.',.,,,; ,]f i - l ]i ; ,-i l l ]l ::l l '
    l l . (; ()l(lX ) \ , \ . l i W Y - f' Ie iiica i ' Iin le s, a d s. 1 9 7 8 - ' o i 106, rr' E '
    , ,, ,* ,," 1" ,r"iii'tiiirot
    'cle :l l :,"',1
    rlistari,tLr l ,:..:i
    clcclrozi
    clirit.i: crrr'l'
    I ;i
    al i ,!| 'l l ht]l has(.s.|| l l l 't||.t|||' 'l'i
    rr r,,:1 i, r 'r lr conccm it cnt ir asupr e - {ascir : ululuielcct t clic al llnlli 'i ir ll'
    ItANS]< l] r \' o ' I]u l
    Il ' ll^llI lI s ] , . ( ] , , 1 \ T D I S S L ET i D.M ' ,
    Ca r ,liclu r y l {: l 4r' I''{'1
    l ,i',1',1,',',,,
    ' . , 1 : ) r , l . r ; i , r . r l - <ir r J' n ilL ll.n AIr ' r ' J ,r, l, rr ,,rL<,'l.irrlclorr:atcliaci:rr:coltl.ic de citi: douir dcriva_tii i.,ipollircritnrtl-
    r \ . , ! l . l ) . J - I l ] \ l { A N - IllJe cts o { tlig o xil o n sysi ol i c'l i c Ji rtel -/rl s r'l N r'' 11 l $r
    ll l, l, V!
    r',,, L l r l o ,Li
    I i ( '1,L,,,i
    \ l l L i (",
    l i ni,ci l e l r u tusi
    , ( incit
    . i,tsi <leiinit
    zcPcr eze
    i n Gccr r r r cr
    Pe .Plr!u
    indr u l rcelc ei. planur i spaJir t ir ',
    i ]/1 1 itLr't!
    . l| x l l n l r l n t s . C i r c n l a t io n , o ct. 1 9 7 2 , p 8 1 6 , t2 3 '
    12 d'l i rl l 'i ri rrl 't'4p1 a r't'-'ti 'lit.'il tgll-"i., 1.ll]l':}
    , ,,', r, ,,ilr,,,ir',t ;i sagital-- r','ctoc:rdi.o5r-a{i
    . \ . - - \ u s c t l ta tio n o l th e h e a r t in ' l lr h o n o citrcl i ography' i
    li temporalca dipolilor car-rlirl
    I LllAlI I () \ l
    t 975 . r I r ,,',i,t,'i,,i,,it;iiiiii,iut:,tii -*patialc
    t1 \ 1. \ lolt D S ( ' t - r l L , S E l i a ,{ .F }i ,1 ) , R- \lfu \{ . - 1 - ltiliia tea dctrmi ;ri Lri i i tIr'IrrI I''' tl r 1r , L r t t , 'i .
    ' ( rrrrrl trrr''rrr
    . ' . 1 , , i i . , " c a m t t otif L le L licg n o stic ii p r o g n o stic ir1 cl i ni ca P (l i i i tl i c:r' n u l xcr o i r sc- si stcl r r c d l r l tr l i l l r {i i
    i, u', ,
    ( ) Ir r l l t r t l r 'ttl ti tu p u l tti a L t fo st u ti l i za tc
    l: ' \ s , r ' . " r ' r i i n 1 i f t ' J r r ' r' r L L r l \iC d - t lo Eo
    j n i ofl i (: i trr(l rr rl r'l l ,,,ti,,li ,fi. , .iiuit,, .,,'.. 'istcmul ortoSlnal-propus. de Duchosal' rrttrtlilitr
    l rr . \ lt )Slio W I ' I I I R . L . , W ECSL Btt - L e lt ? e n tr icr la r e jc cti orr ti rno ' Sulzcr, l94O), a lost,pr'-{' r'tcmtrirltot'
    ra'f-rnultir'
    y rrl/ . ( l i s e a s e . A m . J Ca r d io lo g l", 1 5 :8 0 9 , 8 1 4 , 1 9 6 5' ,,, , ,,'iii iir, iotli'i (Ductrosal;i
    (l j agrrosl i r l rl rrl l ts . i1,,,t",t,,1 i, preconizit utilizarea e trti derir a{ii tripolar:c lotrt<:icrr:
    l 1 l, lr\ li'f lN C . n . , R I i D D Y I' j.S., I- EO:N DF - - Ge n e sjs, {rcqu{ trcr- '!nd
    l(l'll orizontali, inlct:ioarit
    ,,,'",,, ,,r .i"Jti"n *""a l'r oa"rt"Llitr, t"t'"i"gr'- oI liall.t ilrit. ilc'trt l ' l()71' ''1' , .,, ,,ii, i,,,.,,.,:i,,"tit'ch'ca.ptri si
    -?osterioari
    .(pctrlttt
    cu tli:rivrt{ilt
    r i . , A L D O i- U.lSIl) A - !o r r o la tio r r n sJ-sl oJi t i 'rr'1 'l rrl sl r)l i o
    i rrl trvIl 'r l 0 1,1 r rrri llirrrlrLl)sr rLrrLt rol,t,st t,libarir.in{crioarii drcaptir'
    ts. t , , \ (t lI l- L l -calc'
    pl'tnui lrans\'ors'
    '. , r.' ,r,tl',iltti 1'lr::rtrl'',rgit'rL,iar cu bipoiara oriz-ontalir
    r r l l i^ r ' ' . ll' \1 : u la r b iscr' / l 25 i r"/ l 'r77 ,
    r: r. ' , rr'lir' r o L r r r l' {
    (i l ('ctftrrr'l i
    'rrrrl rt l i \l h accstui sistcn - ci a1 altoll - era iusiL rlisllttt{lt
    '.rrlirirrl. nraii.,ral
    t,) . t , t rl$O l l I t . , I { A I O R E S CU ]{ ., SF ItAF I} I N. - Ille m c ntc lr ;i
    'l e
    : rrir,, r , i . l , . \ l c J . lq7l
    i L ,iiii,: ,,filcLroziioxplor.;Lt,.,ri;i inirn,L (sur-ia potcn{iaicior) ; rtr;rirtlr",
    ( r l 1 ''i '' ' l l o t.n ti l L ]r ' l l .' i | .tl l J'l |l l |'' i l l |.4 }|o fl t''l '
    ' , t ) . s()li()I,t)wNI',]{clL RoY M . I l. _Clinic a, lCar < 1iology , lan g e 1 D ( x l i c l ] | }l l l n i ( 'l | . | | l t , : | ' ''l r l I l ', '.'''l i :r ':'l i l r t
    tr)7'.1.',11,307, 351, 387, 517. r r 1 l 'n l l 'b l d i u \ l "r n r l sl .'( ( l n L ! ( l t d'.'II
    |r l \"r \l l
    *Usc o{ 1e{t vclrtriculat cil'r:iion li )c irr rtss(ti'rlrllllf l l r ', l '1 r ' l :,' r ''r ' i 'l
    .rr. :Jlriioris
    - 1.i, r,Elyrs.x.1. ', " 2 i ,
    r'iiri*c:a1:r'':oltliiiilL'inicr-prLririi \'"(tr)rialc
    c,,y,,fltv ol .,,*i" Lrrcuiation 43
    stcnosls. Circuiation
    ir.or-trcstdnosis. 44:225, 197 1971|
    ' ', ,,,ji,,1;r.,i'i,i ", l.?i:l{llill.fl
    ,),!ioT:ltorr
    s,r',"i.J;t:'
    X r; C.i,. "r"
    ^DC
    , ST.ETNFELD L. -. Syst,,tic1im." r"tcrvals i1l i| lltlll
    s \ri lh ( (,I!( sl i ,/tr I li'rfl ,,. ,rrrl,,ir Dlii. , rlistlrnlr ,;allL inrtr r:1r'ctruzii ll lrrlltrrr,
    (liroulation, XL\rII, Tnrre 1973' i, i iLinlt,tii rriLrlri in t orr'liliil i Jistatrit: t:gnli .r'lr
    IrrlilLrro. 'roi. juol l()/tr ii ,'r i,,, f i .autslL
    vr,iiiiil-rr., l)u.l)rA c. - lriagrrostiJtlLolilor cartliovas:ul'r" Iilii l\1rrrl" '
    lrti'n' . L, : r',,,'"'
    . i, , . I I I I lu. r l '1'r ' lcr lic'li t t l c: t z't l t ttt' i
    r i.,iii:fr rt.1 i)ilDli.A' C. 'Propedcltica boiilor car{ljovas(rrrlirrLr litl. ', , r '|. '. r "or i
    vr,If i(rlrlf j,v rplr ' ,,,. . , r , . r j. i: 'liz. , ' , : r 'l | , . r jr li r r ''; r 1: J. lrm ar il. l' I l : r t t t plr '; r
    ir;,ii.i.ii:ii '_,ri,,-irirctr .r. .1n. _"i1,,"ii," .t thc l,ra!(.!jor ri,rr. ' ,;,,. vcct or ilot vit f i t t r r
    (rir) , l t { r ( I . , 1 L . ( \ l , 1 , 1 9 6 3 . ,' .,1 ' ,, l ;,,, 11, ' ( r Jt r .,i'r r lii pl lr t t . r rit r accst caz'pr oir r r : 't ia,
    1l r(r svsl ol i '" l i tr)rl ,i rri "r/l l l " [r dif azicr t "it l I ) , Pt ' r 'r r t t
    W l. : lS S l , l i l t l . l { . , L l l ,WIS I' .R, L IIT ( ;} Ill( ) } l R F
    i rr i l arri i ol 'rl v, l ()7J, 1r' l 5l l , 1 ' i ,, '' ',,i .,
    , I , . ii, r r , . i i, 1r, rl;Iit iiI I | li'r r I l" r r r iLi, iL'lL'sca
    , 'roI
    r. i r r n f i : r ) l t r f l . / . l | i l' icr r la f lxfr lo r n li! o c ir r r n r r n . l' r o lr ' css
    ,;,,' ': , ; ; ', , t ' , , p' t pct r <iit : t t 1n i" pc l) , r 'r L . f i , ; t pt or r lr L'. t t t t li'
    ! V l, llS S t , l i l l \ . 1 \ ' t , I l A l itltS \v S Svslr ) li( r ljIn ' ir L l(r"nl rt i tr l 'l l ri l l i l rrr. i rr rui r'r l "l tt
    t,l ,rl ,, lr t r iit l lir j'r r li f i'z ir r t ihii r i'r '1r '"ir i lr i L1r 'r iva{iciI sir t i r llt t r t {t
    'i',,
    r I lir l i , ! r 17: l'lr), l9 ( r ii.
    (rrr'l i r' ,' , , ,t,i ' ,,1,,ri. 1 il; L , li'llr r lr i, 1, 'r : r , r 'Ll' it t ir '3ir r 'l 1x'Ll r t lir r lr nt 'gir li. r r 'ii r r 1'r 'or r lt l
    r \ . N ' l , ( : , \lili,\l' ll) llvr lr lll,, llL r r i, ir lr | r r r ls i rr i i i rrl i rr' (l i :ti Ii . ' ,, ( lr r li<i it lit l lli r loi r llr '1t ozi ; r i r r r r "llli r llt i
    wllls f jl , l ; l l , ,t, r,rl i l r t . \ r i lir r ', 'r '1r1, 1)
    l)i , l l r r I l ( ) l ( 1 .
    ri37
    lr l1li
    \rr1 i i ) f : i nu s ( iir r ( ili s l rc z ( i rr .rr,l rrro rrrL :rt r ''r t t li"
    1Ll ,' rrrri rt)i i(1rr, 'cizir r r i: : it it t r lt : t r r l; i inlcnsif ir t ca act r st ot l) ir r t r t ioca. t t lilr ',
    d i { e rcn!c dc l l oi r:Itl i rrl i trrl x)rl ,rrl i (
    l rr crrz r r lin c r r lt , la rc c l a ;i :,L rl ,i,, i . I), rrr l i i n rcgi sl ri !1:rl i tsi rttl ,' l l i l rotl rtl rr,' ' r,1,.rl i i si rrni, lL,boli c{) ngdlilir lc"
    l rrti r'1 r c lr : r t ul dr c p t, i n s :i . rr.p rr4 ri i rrlc l c t:tro d u l pozi l i v {l o i ni tri L (tttrtl i rrtl ttI, l)r'sigtLr,in illlrcticiL) atlploiL{clr accstor avantajc estc ceria mai ltrlttsrL
    rl, r'rcruplu, de pe bralul sting pc clLvicula stiugir) rcaiizind tlt:i o irtt'g.rli1:rt, lrr, l,r ri 1rr.gisir:'r: clcctr *.ardioilraficiL atcntir fi co'.rct:t, cu cltr:tttrtt.rr
    :r rlist:Lnltlor r:elor doi eler:trozilaliL de cord, am ir:;i din condi{iih inl.r:t1rr, tiir ir ,,,,,1 , \;rrn{rr(i .scrialc, sc adilugar cot'rtcrtul clinic ;i dc laborator, cliticrtlrr
    r .r'toli:rlc ;i am inregistra pc acest tip dc I), o falsir dcviafit: dr-crtlttiLrr rr:,, r |{ i, .r'r( ( ir1- irr rr.ns:Lmblu (adiir'Lt:ficienJaa.-*ociatiei respecti'e) creltl) ir)rrro(l
    ()llS. (Aceastil deoarece acum electrodul pozitiv al derivatici va irrsrti, ,' , rri [rLliLrlc acccsibilii:atcamai rc:;trinsir actualmentc, a lrcctocardiog]rtlr( r'
    ',1
    rr,g;rlivita te :ri puternicir, fiirxl mai aproape de ccutml cimpului rcgr l i\ ,rl
    ,lilrrlikir marimi QI{S dccit clectrodul riuias lc braJr.rldrcpt, dcsi coltlLrl rrrr
    ,.i rr s|irirnl.,at pozilia ii axa).
    silualiei descrisc rnai sus oferiL una din clrcil:: ilfclrgcr:ii ,,,rirlr
    '\naliza
    liiiol inlcrprct:arii vectoriaic, aplicabilc atit irL elcctrocaldiograiic, c:i1.si rrr
    r,.ci o t iLr - diogr aiic "
    l lir sl se rcmedieze clelicii:n{clc cic mai sus, lranck (19,j6) a cfc( l Lrirl
    r r pllrrlc slutiii pc modelc toracicc urnane, utiiizintl dr:riva.fii toriLli, ,,cori l
    irLlr"' irr al cirror cilcuit a iltrodus rezistentc cornpcll-(atoarcale ,,disianlr'I,,t
    .IllililL:'' irrega.li:<1intr-cclectrozi ;i cord datoriii tlifer-enfclortlir.rtrcstrrtr lttr,r
    I ( sutrrilor iiricrpuse intre ctrld si electrozii cxploratori ;i rcrt;ind sii.slirl)il, ir:i(.r
    rsi.lr'l sistenul de clerivalii veciocnrdiografice cel mai corect {olositc rl irrrl
    rrrrrilr'. Sistcrlul liranl< cste alcirtuit dingapte electrozi: cinci clcr:it'ozi itl.r:r'r{r
    l)( rn r( r(: iorar:ic 1l nivclul spaliuiui 5 intcrcosl.irldclirnitincl pla1lLrloriz,'Iirrl
    .\ lrr \,,; (.1la \'.,,; J- anterior mediosternal aplo:rpc c1e\:2; I latcr-al tlrqrt trrr\,,
    ,lr,,pi ; \[ rr-,rrlianpostcrior';din cei1allidoi rlcctrozi, cel denunit,,Ii" r5fr'pl.r"rrl
    lrr rrL.rnlnul in{crior sting, iar electrodui ,,trI" pc t-'cairi, delirnitintl plrrrrrrl'
    lroui:rl ;i sagita.l prin combiralii cu electrozii din pl:rnul orizontal.
    .1i'/rttltr.itle pritcit'tla ttle rtelodei re tlocudiogrttfice.' c) olcrir viztlirli:/;rr,l
    tlir.cir"La crirbei variatiilor spa{ialc ;i tenporale ale ilipolilor cartliar i pt'r'urilrrr,l
    ,rrrlizu urorfologiciL:r buclr:lor descrise tiic tlipolii I", QIiS;i T (1o1xr;rrrli,r
    ,1ttirrl"L, lbrna, miLrinea ;i suprataf a bucielor);
    i) prin inlcgistralca punctatiL :r curlelor, au o {I'ccvcntir I ilit-rlrrp, r ilrrr
    lrolului luminos dc 400/secsi o precizic dc'mirsur:rtr: a vil.czci {1()rli'sfisrt rr ' ,,
    I
    l )r(,(i !'lor r : lec t r ic er n i o c a rd i c c d e 0 ,0 0 2 .5s e c . (fal i r cl e mal r:aj ul tl r: i i rrr1,,l , '
    h t.: l. VCt 3ullcl ar.,listntc cu tn.pet
    .u Pafl€ iqgro9ari
    e
    j r
    n_
    .
    'l5arLl
    oJrolt''

    r),{)7-:roc. utilizat in electrociudiografie) se poate icicntiiir:a cu usulirtli :, r'rrl ^o toLuril.r "

    r rrlirriiikl' clcctrice, adici al diferitelot conpulente aLe crtr-lrclor,rlttpi :r,rr.'rrl lri |ir:rur. 3.38 trrrzrrrtiLm scirematic: o \rC(i nonrialir iu sistt:ln iitrtrrl'
    ,1 ,'rl r'1 ' lr s ar ea s pot u ri l o r (fi e c a re p u rr,t l u n ri n o s i tr mi l ' nr; i ttl ' gi stl i rr,l Lr ' ,' r,, l !l i \i ' rrr' ,, u, t , '1f 115dc- sf ir sur indu- seant ior ar int oat ePlar ] [ r i] cf it oln) gf ir
    ,rrlr Ir,r'ma rrnei ,,r'irgrile" cu ,,coa11a" inainte 5i ,,punr:1u1"irapoi (1i,, 1 rr,r ,,,r ,l i rri rrrr r r r li st iir ( i. inf ur ioar ir li post cr ioali"r(. bur l. c ( JI iS ir at r sr Lt t t lr lr L
    r,.ico l rilr . , 1961) - inv c rs l a u n c l c a p a ra l c ' , c e c a cc conducc l a:rl rri ri l i l l r n,,r .l r ,l ,l .i rIl] , 1 r t r t l it "t t t ; r l qr t lr pt t nr t ul zct c'. l"'r ipir r ' a lr r r r lclol l' ( ) li: '
    ,lrnr(,nt( scrliologice suplimentale (scnsul r1c rotirrc a burlci, lor'nl si lir, I'ril , I Lr lit t : : r r ' , ' \ '{ r ; i'r pt r r r f r ur r : r ) lr r 'r nli ( ii; ' 1l I l) IrI ' Irr t i rrrrr' I
    l,r r:rrc lcspcr:tivnl -.tr.rssc sch:imbirctc.). ' ,, i ,,. ,i slit r g l't cr ior si r r r - cr c'z:secht 't lar i'tpr ir ) ir r lir r '(i
    , ,' l ,,,l i rrrr" ,: irl, lr x l'ast : icLt LlLt
    ln :rcestc t:onclilii, cu ajutorul r'cctor:arclirigrarncisc itrr{ r1irrr1rrlrrii, L ,,, ,,, rr(l i ( i rrl . r i( 'r ' ( Zr r r ) r [ ir cscu ii colr r lr '' 1976) Din cauzit 1'culi11Licr ir-rii r r r 'r r r
    rrrri rtrrrlti cfrlittLdine d.cr:ilprin liC[i unrle blocrLli irtr ar,cutricrrirrrr' ;ii, , , , , ' ,,, 1...r ,i ,rrl rir ', it lc it , f ; Lt r : t ,pt : 't 'lir r : t r t li: at ciiogr ar na dit t {ig : l'38 I l llr r : 'r ' t r r ' I
    , rl l rrrri J nr pt r t lr ut l,u n n u m i rr a p ro tp c c 1 u l r)u< l i :i n l trc:1r' rtti rl crtl rl i r,i rri .,r L ,1, i , , ' ,rr ,i .rl, r , 1,, ir , l, r i: Lli. i - t ingiL . r axei O RS ( car c nu at ing- t rinsr i i{) Lr r
    .r, l ri l l zic v c r l r - ic ulat - r' Lfa ) ti L i l c p o s i b i l i i i " L !i 1 tlr'c i l rocrrl rl i o;l rrl i r i . l )rr;r, l l l f t : ' i' r t l r f it r r t cr ior ( r nr : nt ioninn r : ir pt t r t : olt lil| 1. I 'it r l
    , l ri rrrol( lt ) 7f i) 1r r - int lc ri v a fi i l c l ,-r' i L n lsi c i rl l rl i l i ,' l " L2.1rl i tr l ' i t rrzrrl i , rr rr, l rrr ' ;t,
    I 1r" i l rrl l'1"' 't inl
    I rl I uol rrrrLlr '): li ( lr lllii. l( rlLt 't ll- i( ' st r poalc vcr le: r -un q m it r or ; i r Jis<r r lr t lr il
    ,J |r'rr' 1r '\ ' ( ' lr lr i( ular s l i u g p l i rr i D l rrrr' 1r i r l ro rrl i rr 1r| i ri r:rr':i " ,' 1),.l r: I l rr. ,, I t,,,, :r \ 1. , l, l, 't z r r ''r 'r t i: Llt t t t t t a. icxit gcr in( l so Poat c r lot ll: , , ll(r '11'zL
    '
    rrr l i n rP r i l' r ' ir r l, ) ( l( ; rl c l n l i n i i , rl o rr II c rru rl i < l i rr-1.1. ,,,' .' .. r 'r , 't r , 1. ' t ' t I I lr i' '' \ "'. r nr it t or Pt lz' t t l I lr 'r "' r r l
    ' .," ;,' .i1, i, . ' '1
    l rr lr lr lir Lirir ' , r lo rttc tri rri l r tl tc l tt ,, ,trn , l ' r ,rl ,l ' ,trr,rrJi rr,rr,, l i ,.,1i i , | , r,r rl rrrr . 1r r , . r llr lir lir r 1l, r : r icir lir t r r r r t zr u t cr I t r <r 'l- iiligr r Lii li'i' ir lsr sr r ; 'slir
    ,,rL ,l i ,',1r r li, , : r illlt m l rtl rri l ti ,rr;rr,l i r ,, l rr r,i l l r, \ ' , ( l ()/ rrr rl i , ; i r ., i I l ,r Lrrl , I r' rr.,,. ri l rl, l r r l r r i li, 'r '. 1r 'Pr r '; r r r r i' llL{r ir lr '; lt r lPlilr t r liur '; l) t t ( r l'r l lr llr 1lii
    , t rrn i r r r r t llr rir l r r ; r i( l , r1 r'irl rl , r 1 r,r r, i ,,r. . i i r ,l i ,rr l r' ..l i r ,,r l r ,r /, ,l , l i l , \ r | | | ro r i rrr I , I , ', l, l' cilll"r r r r : l'i icl <lc lr lor 'l' r r 'r ''lx llllr r r r r r
    ' 1,.ri r , lji
    r l r,rrr i, , t r r ot lr t ll ,rtl ri ,l , ,,' n rl rt,,t, rl r.,rrrl ri ,rl .Lr, i ).,ri r .Ll ,, r,rl r ,L| 1,, i ,rr r I l'. r r l1 r ( ) lit r r lr r i \ ( ( l lr or r lr r lr r( lii1' I t t i li) ; r t r r i r ir r r t '

    rlilrlL
    rILi rL Irr I r iI r ' (r'iuix ' r io rrfi s l i l R i ' r i u r(r.l ra l i -ifi t l () )()l r. t ,rl r,, rr l rut.l L,jOl tS (l (,,r.Il ,ri l l I it ' r l't t r r r t I t i t kr ar , , t lci'iat ic ir r ilr lir lr rlsl " ilt s iuiillilii 1. ,
    , 1' ,r l rrl ri l rrrir r ir r rsi
    l nr.,ri ,rnl i zcn r illo; i. 'l'ot r r ; i ; i lipr r l C clc ll\ r l) por Lt t t i inlilnit la t r 4r iii , r r
    l ,u u r'1( r luiz ( ' r ( , , ( u ( ) i l -u u i r p ;rrti : c t d c s c l i t o r r rrl r r rr r.onr:l iitt:i r_tc i nl ,,ri ri i rr,ri
    rr :i (sn s . ( r ' ir r . l) at olo g i cr:c, a p a rc c a r:fc c t a l a l s r:tri t,i l toi trrti i tl .:l ori rl l r:ri ol Li r,rl i tr i rr,rzrrP rrl nr ot lr t i st : r 'ctir ir so( r iir t il( u dcf cct t : scpt alc si clt iar in s1r 'lnr z! 1, '
    r;"rrziLr.:ic:rtricc,isi rar-c, <1upit0,02.5 sec., se oriltnl('itzil it1 sclts antlorilt. 1.n (l ||'rl r.r l r' l rV i trl si l l (i .

    lrozilit auormalir a raLnurii afercnte deasupra ramurii rfcrenl.e a birclci i)ltS, I'
    , l;rI oli1.iLLlocului fascicular sting anterior- (BliSA).
    .\<tf, l. in
    /l
    -\sl1cl, irr aacest
    ,c:i e-xcrnplu,
    "\ ( r nplu, uar ciatoriti alr i, t ' r J j i . i . . , r r . i r J j - f a r i : , ( 1 , r , , . r \ i
    or ! iil tl.opografic I
    l:L!ii inititlr,
    rlitirrlt, raportului
    rapoltului dinlrc
    dintrc rarnur.ile
    114r-
    rarnulile buclii \:CG pcrrnitc
    OIRS. \:CG
    buclci OIRS, ncrrnitc sii st- rrfir.rrrr.
    si st ;rfir.rrrr, it
    ,rl)r()irl)(.cir.ctrtitudinc {;i nu c;r ,,posibititate,,rloar.,con{ormECti) c::i.1r.rrfrr I
    ,.,r'lrcl'i dc.iliarct inferior' ;i a bloculd fascicular sting anterior.
    l'rintrc
    lI)rintrc
    , l l r L r L r iavantajcb
    avantajcl{r
    t v i l r l L i t j rl| \:C(;
    \:C()
    \L t' care
    cSr e au aplicai.ii
    aplitaiii
    xu a p tl( a l]l si
    s l irl
    lirr
    t] nafoiogirr
    pajolr,tjr
    pa10l ('a1a linfrintilri rrrLi
    !
    nl ti l l tl i i i l )l l Ll
    ritrirr ii-r'r'r'c'r'rtul
    aspectECG RR'iu Vicu rirfLrl1t'-uluila sub0,08scr:.rl,,lrr I
    itrlr'prrlrrl complc-.iului QIIS. Se l'.ie ci. accasti:rlromaiie poatf fi lrcirrlx,r
    trrrrli lrL adult (in afari de cazul c:r cste asociatir cu tulbuliri dc coucltiitrl -!A '"'- --^ /j - "' i.^*

    i)r':rl1( riun11ri hissir:r:r), arjcsea cir csic doar semu dc hipcr.trofie dc, ,rrs/rr
    ,,trf,r,r,ttul.ricularisla tineri: dar: illl'\:, estc :rlrormal ja copiii in virstr'Lrj,, rrrlr i7t I
    i2 rrni in pr-occntde 93'].;,intilnilriu, seiie crcrnpiu la 6001,iiiu cazurilc cu r,L,fr.r I /,'/,1:/i")
    sr'y11rr1 rLtriai, \-CG prin r:a::actcrul\-itezci dc dis{i,,;urif.-: r:u
    ;ror.liuni rlai ),.rrtr.
    .,rrr rn ; ' i r apit lr . a buc l t,i Ol i S ,p o a tc s i a ra te d a c []tli ' \ , (i n l i i l i i el e dc rl rrr..r,l .r
    l ,(,tl il- . J lr . : us ) ti p r.Z j ri i rn .h l o .. i n I rt1 ,l " r" J. r' rn| | l l .r Jri ,.i pt ((.j t,/
    r.r.r')srr.rrhil;t'rtrofia ventricular.i drtrpt:i (cazr".lcrl nrai lrtcr.trrt). Pri,l,,rLlti
    J,ir.fl(,l)-rn lrosibilitatca pc care o o{erii dc an:lliu::'r a situatiei sfa.tialc ir i,rr l, I I
    ol{S, \a(; pcrrrrirc diignosticarea anumitor ti,bttri clc' hipi4ioJit: rln,t
    l l l VI.t) ( f ig. 3. 39) dt : i mp o rta n l i i c l i n i c i r, i n c a z u ri -i n car-cpe E C Gi ru sr- t;,,ri 1,,
    1tt,r ( --,'i',--
    rlilrrrr rktit ciL existiLltYll, in general, lirriL aitc prc-ciziri. Semniii..rrli,
    rrr, slor liuL:r'idc ll\rD estc lcr-ificati si grr-u po;:.te{i obiir.rutli priu altc i}r,,jo(lr,
    r1, r'r,irLrriLr-c DcsinecrindiL.
    .l Llt I-Il'l) se caractefi/-cazi lrintr-o rlesisurari: in pl;ruul lri
    .!:i!trl
    zortal, in intrr:gir:re anterioarl dreaptiL ;i iD.scns orif 21. buclci QIIS, ctL l',rr.lr J
    l-ulLri ir.r {)pozilic, situatar posterior 5i spr. sti ga. Accsl. tip i1c }ripr,:-lrrrli,. lj 'z''"'ir""-''
    rlrciqrtl'r sc intilne;te in incjrrciiile vtlntricul;rr. di.cpt a, cuntuatc c?r iir sl(,.
    r)oz1'l(,-i)nlnton.u e strinse, tetraioS;iaFallot ori crrrclul"pulncurar scr.r:i-. .l i,,.t .:i i
    . lm /if)ul lJ d.cI{l:D, i)ucla (lRS !n llauol oriznrrill s, Jts|'isoarir rrl,i,rri t)l ,,i,4)
    trrrliv in rnod egal ;i irntcrior si posterior sting faif, cic punctul ,.ic origiir,,, r rr
    rir'rri lrtiolar. Ila indicl astfel e-ristenta rrnci itrcdomiuantc i:,r'idcntca i,trlri
    r rrlrrlrti tlrcpt care insi nu anul..rzi prc,-lun.ir,ru1aiiziolsgir-, a lnitscl lli.ur ir
    t'r'trlri'uh ui sting - cal:e in ca.zurilc normale detcrmiui! a]lroatlc in1{.{ttitl
    silrrir{iii pcsi i'rioaLliisiingii a buclei QRS normale i;t planul ririz,r.,riel. lirr, I,t
    r r'1x;lariziirii {a T-u1ui) nu e\rolucaz5-in opozifie.u lrlrl.la QRS ir.r acr:ri iilr rlr,
    l l \ i ), nr ai ! r 1t in s e v o I, i n ti l n i ti r i n s tc n o ra rui tr:a1ar,
    rrr,iniui, rL.f,:,ctscptal \'cntricular, mai rar atri;rl.
    l i i l r:ri crrsi urL| i ' rrl
    r .r-e

    i
    .2^\,
    , " -l"a-
    'l'iful C clc 11[,'l) si: c:Lracti:rizcaziiprin t:r'olirtiir po-si
    crioirliL rlrL Lt,].i il I
    l ,rtrl l i 0f lS ir t plaoul o ri z o n te l , i n s c n s a l l i o ra r si { i rl " r opozi ri L' l oi ul i i ;t i ,rrr,l rl l ll
    l . ,\r'c s t iip s t ' ir r t ilt r c s tc tn i l i a l L s l a r< l u l tu l , rr rrl rtl l rl l nr,,rr.rl sl r.rrrrrl trlrl rr,f I
    l ro l i ro r t ir : r . 'l) Lt lr ilot l a rcti p b t o l h o p re u mo p a t i i .rcl otri ci r obstrucl i l ri . l rr r,.,' ;l o
    4)t I -.u.1' 4 '/!i /-''-\'
    rrrzttri , r r r pc rr'l1r u r rl.
    l ' -)LC,rCr i st
    st p
    P0oltr
    a lee co
    c otir
    l l Lullt(
    n rj1 a c u l rrt lto(.
    4 cu l lL:(tcl
    l)t()( ti Ls< .il l l<U;rrl sirLl
    : sl i ni ,t
    l )(. Il ,r li l t'l
    ti ll ])(..
    , i rrrl rrrlr O lt S ( , s 1cI )l ' (' (l (J r)ti t]a lrlnltr,;t1 tti :rl rr r u rrtr l rl ot. Irrl l i r.rrl rl sl i l .l ,i l l r' ,
    i,/ fl/1) I
    ti o i l i rrl : r r : ; r( . ) liS iisi c rl r v i rL l i l rr s ti trl rrr. \t.r' rs 1 i i l tl ti l ri i l )r,sj l )i l i r,rt,, . i rrr.f.
    ' l i l ,L, i ,1, l ri t,, r1r ,|Lr,r t 1, l ,l i i , ' .1 l Lri l i i i rl
    i (ri S l )t (' z { ,l rl i i u I), s i rrri trrrroJ1rrj rII
    r i ,,r \l r\ ) r Lr ( , , , , r r r r , t l ar)ti Ol (:) l )r,,, rl ,. l l l ' 11, ,, r,l fi ,
    .rl r"i r , r u. r r ' . jr t l) r ' r l i i rl i rri l rL ll i c trrrr l i l (,i .l ,.,l Jl Jrl , l Lrl l ,Lrl i (l L,rol l tLr
    L, \| ]
    r,l r' l
    '1,.,'

    lrrll
    I)c tctnat'catcir in toatc accstccazrrriECG lrlirlri lLu aspccttLsclrlitni-rtor' rrlt:
    lt: cclclaltc
    cclclaltc metode invcstigalic neinvazive ;i/sau irtvitzilL: lu accrtsili
    metoile de inv
    ,,, , t,,rio1io-,l-.,i"n drcaptd 9i unde Il arnple in V, - \'" cu iau liLrl S :r'rnplrr ,'"Lcrotic iint incadrate insuficitnta mitrall, rupeica cordajelor tendiuoist"
    (1ig.3.39).
    {iziologit: - valvulare aortice, tricuspide 9i pulmonare, nriocardopatia ne-obstnte-
    k:zirinilc
    l'rcbuie insl si. subliniem cf, inirna nou-n5'scutuluifiindirr mod ii",i. bicteridne', hipertensiuneapulmonartr''rtntlc
    de I{VD descrisc rniti ".*"i"tiif" "ndo.u.8i." la diagltts
    ,, i',lrJ.iii"Jo-i"u"fe dt"apti, semnificalia.tiptrilor ,r,l'li.rrnr"-tii
    -if iongenitale de cord in care(chocaldiografiacontribuie
    .ib t"r"tuo undr fimite de vi1{1'- Ast{el' la 600/o (eviden{iercaconscrinlclot,htToitl]:.-;
    ,."; i;:;b;;;;;;;i"1J rii piin t"'re secundard,indir^ecti
    ,iitt i,".-"a*'"iii normali ".i*"i VCG orizontald are aspectulde HVD tip A.cu sens ,;.J;i; "t". *o.iotogi.' ' 1n aieastl categorieslnt citate defectrrl
    ouct:t
    ,'r'rrl rLlbuclci bRS: tu zo% aspectde IIVD tip B, iar la 20% acDecfde
    ','lii.'i""iit*rtir"]sl'. .,,frtuf atrial,
    srptal ittiut, de{ectulseptalve'ntricular,
    defcctul
    -t"-Jl"i persistenlacanalnlui
    , persistenta co:tt'r:-
    arrcrial,coat''
    canal'1ui,arterial' -
    T;"'i.i" de 6 luni inslr!0% prezinti. deja '- ^'
    talia de aortl, intoarcerea v_exoasapulmonara. anomlala' .trr treilea gruP rL'
    ';,,'': gRS, -dil.s9ffri
    ;;ila!i s07o avind o bucli\
    ;;;;i"ti"'norm.i antiorai aI buclei t"i-tt ditt boli pentrir diagnosticul chrora echocardiografiaale
    ";
    iiiit' prezenta
    iir -s;:. l; virsta de 18 luni nici un copil normal nu mai poate "ii.lit"i
    rnr ".1"
    rlol insuficient dovedit, deci' utilitate rlbtivi
    d,rvedit. deci diagnosil-
    precizarea dlagnosl
    relativi pentru plecizarea. i-
    formd de ,,8". "'..':,Ji".'*l.i."i ancvrismele- vcntricrLlare, bolile corottit'
    ,'' l,tct:r QRS in , sint ancvrjsmul de aortd,
    vectocardio- tuiburirile tle ritm, evaluarea funclionirii protezelor valvulare'
    "toi.-As^
    J)c aceeain general, o rotalie in sens orar a buclei QRS rrlor,
    r'(:lor,
    virsta de 6 |uni satio btrcll
    :1r:rlirein plan oriTonral la copii duJ'i QRSirt Echocardiografia in modul lI permite masurarea dimensiunilor it'l'-
    i,,'i"i..r"',,bt;a"pavirstade l8iurri cJrcrnormal' 5i sugestivir de HVD (Braun-
    ,lirstoliie qi tele#tolice ale ventriculului sting,din relafia clrora pot.fi crrlttt.
    \1,,1,1, rs80). r,,i,:tir.iii de eieclio v..ntriculara,viteza de siurtare circumfcren! iali a fil'l i
    r"iocardite si fiactia de scurtare, elemente deosebit-de importante plttittt
    SELECTIVA
    BTBLIOGRAFIE ,,'rr""i"r"u dontraitilitliii ventriculului sting. Studiul funcliei ventlicttlitr r
    rri,i,tcfi comoletat prin calculareainicrr-alelorde timp sislolic '
    f-;-ii"i" cxarirenuluiechocaldiograficcarc tin in-mare-mdsuri dc li'l''
    ' ' 28-ro,1e76,
    l . l] I iNCI {t i { o L A . - 3 r c l I n t e f n a tio n a lCo n sr e sso L lEl^ ctr o ca r d io jo gy,B l [ssel s,Juc
    u**,
    Abstract ,,ir,," t"itnicii (TM),-costLilrela,tiv ridicat aJ aparaturii, frrJr-
    l, lllt,\llNw,{LD E. - lleart Disea! ',:ijiJ"i:::;:'.:il,Fi,lltTiail]'ri,,,lo?, ,nuo, n. r,r. lrrl cir examenul trebuie flcut obligatoriu de.medicui.p.ediat-ruavizat in prLto
    -onodimensionale
    l. iii;i:iiiiS,qr p lv., sur-zpn n - T-avectocardioarafhic, s Karqer Basel' 1949'
    . r. i i i 'ri i Nin Cl. , iluc lr N rl o l rz p .c , L E \ rN .l lF I.D .- A mer.H eart J,196r' 62' 2' 237' t.,lli" .aldio"..""1arl a sugarului, precum ;i unele di{icultili i:rtimpinatc itr
    ,,ri.cutareainvcsiigatiei,in spesislla nou-niscuti..sugttt.!t 9o4it^l]].1-lll-,.1':],
    ,"rltt;scur', L'nbrlat
    ,l ),,1'il,Y,'i.r1.;'iih"1'3iiiitf1 BUBUE-{N.' c.,.DRrculEscu N. , rx)Dcrcazi-imnun .a invesligareaechocardiografiei si. Iie judicios prcscrrsir '
    rili;r'i N., PEtEc Motfh'I' Phlsial 1976' 1:i' 3' 1Bl'
    I{. - R",. ilo"t* ,rrrriraiin ..roti bin" seleclionite9i cu indicalii prccisc'

    3.2.6.I.TEHNICIECHOCARDIOGRAFICE
    3.2.6.SCHOCARDIOGRAFIA
    A. E c h o c a r d.i. o g r a f i' a ir' nood'ul'..M^. .s ttlt' standLtrl'
    EUGENCIOFU "un slngur cristal in pozilie-Jix5' care emite enr:tiir'
    MiiCFA MAIORES€U, r,,',,.t:, i.tt"i"i folosqte
    rrltlnsonicidc tip pulsiLil,cu uririlmrapidde2s - Sopulsalii/scc'pcrmilirrrl
    llnlcllmcnslollil ll
    l Jes c ooc r it ! dc 3 0 d o a n i (t9 5 5 ) d r ' E d l ' r;i H eri z, echocardi ogra{ i a.-rr rrrlr'(istrareastruciurilor cardiacein migcare Reprezenta.rea
    pa-rfe din t.hnicilt' j-a pozitioi structuriior, raporlatd.la timprr) de deplasar''.'r
    ,,r,,nr.u, o il^ii <Jezvoltarcin riltimii arri Ea {ece acum i;"il;;;ilftlan 'reaiizcazl echocardiogra{iain modul M (line moliott Nl\
    ,f,,"ii,'""rliJi"-"einiazi"l de bazl in eardiologia copilului. Ec]rocardiogra{iLr , i,,.rui"i olriasoi'ice
    .' r
    i;;i;.";f ;i;"nte esen{iale asupra mor{ologiei ;i iunc}iei ca"rdiace'.permi- ,.,,"?*" o ai"e."-I. i\'larcaiulvertical al diagramei-(incm) pennitc mlsttl'rtt "l
    boll iar m.-arcaiul orizoirial (in ms) pcr nrit'
    i;ii,l di"e,tosti..,l ;i rupravcghereaerolutiei a numeroasemaltormatu $t , ii,,"rrri.rii"i"rti".l.-,iiior-itir.glrtr"t.,
    , :Lrdio,taiculare,lobindit". ,l.tclrninalca vitezei de migcarea acestora'
    Incercind o ierarhizare a importanlei aportu)ui .ecbocardiografiei in 11,E ckocavd,iografia bttlir e c ! i o n a I' d... 3 n 4' 5 6a:Iitt
    sl)il
    r,r,,.ir.-"i."-J i"snost icrrlui bt-rlilorde iord, un prim 5r-upde.afecliuniesfc.
    con- ,, ,, l,i.' i,iout".e in mulie b6li congenitalede cord-relaliile anatomi(:c
    'ii,,1,,
    cirora apo-rtul cs{o hoth- .tt"it"ti sint comp"lexe, posibilitllilc de.investiga]ic.ol.t il.'
    liit;lfa;; iroiip"n,r" diagnosticul -(vizualizarca. ititt"-af.it.
    -.Fchocardiografiei
    directi) a dolcrtul'i u*itui., putind fi comparale cu partea vizibill a unui rr:r'1';'i1'
    ,iio. iio"r"." |eugeltedetectueaptintri il;. l;;;;iM;i;i
    rlr'
    .urltomic. lrr acesl grup dc boli sint illcadrate perrcadrtele' stcnozamltrftla' tri,i ,rccastlLcarrzl eforturile au fost indteptate sire dezvoltareatehnicilol
    miocardopatia obstructivll in jtLrul Jnui piin, din carc r"ztrlti itnagitt"
    ;',.rhr;;i ;i;i ml?rai, tumorile i,tracavitare, '',,'ri"i? ctt t:rictalin nli5care
    'rrv.slisirrc
    iolrrlici cilc ( rl
    i;;;ii;"t ;ii";*rtii congcnitale dc cord: hjPoplazia cordului sting' atrezin ,'' ,,"ifttit,i i'i sectiunePlan. trrrr>\'c;sali \' ncsti
    arrerial comun, vcntlrcul unrc, 'ec)rocrrdlogra{ic scclionrli ( t.i'ntt l )'
    t r-oss-s.ec
    i.,,tici tric,,=rridc, ictrllogia Fallot, trunchiul t,'i, ,fii"riic dL'nLtmiri:
    stenoza itorticiL valvulari.. Pentru cliag'osiicLrl 'l ",iiiii Pcntru in1'lngcrcu ecllogmtlcc btdlr('{'11('-
    iil;rl;;;;." dr"riini uo..l 'rllr:r'irrrrx irt',littl,,mosrafic. .tcLdicii
    cchogra{iciirir.aliz.cazi-c.rrprccizia-lehlicilor. i.vaz,ivc, prr , r,:',..'iiitiiiir i"t ii"'rticnul de srdltnilt{ cc'ltogr:L{ic cart rcplczinl"iLcx nittitt'crt
    ,,,.,,r,i"i:iiJi, ',, .'i [itsci('rrl
    "i"toda
    ,:;,;,,i;,;,"rti ;ffi'tlcpirli;r exactitatc. r\1 dt'ilci grup dc a{ectirrnicstc for rirt' , tt i;';';., it utteistr'rlfc!t,ltrin'1t'trtrs-:tt'''r r';r'itl'-rdc 'it'r'rrn
    .oitttil,u{irLaliitrrri ',;;',; ill) rrt: jrnirFirrt'it
    t-or'.'mpttsrirr srrl)r'irf('l' i
    .i,rirlo'".r-t."i2Li"Si^iiiigi'",lnc,,
    ,ii,,'frifir*ii ,ii,li,,er.,iirti,,ut 1i"",'f, ltfli,,"t',i,:". ,',
    "'t.iin.itl,
    543
    5 42
    , \l )l or ill( , lir r r . ir |i rl i ' z o l t!r l L ti l .ri l ro i i s o
    s i i n t rtrtr:r.r
    ri r.. l )rr:i or.i dc ci i r:,ri l .sr:i 1 i Itl i i sl tti l tc tr '1 l o t:l ttr l i r r
    Lirtrl rltra.so*ic .src i. miscari: | , r I r i I i I , r r t t r r r i tr r r r tl Ir 'r 'Ii Il Ii i sl :ttttl r ttr l r k' i tti r ''t|l ctl tl r '
    si: r,:alizcazi.;,,;,,;;;1,r;_;l'*lrrgralic. i, *:lLo- . , , 1 , , , I( tlt trttritrlr/
    t u r t ; ,,,' .\o{ \.,,,,/ r ' oi
    o i lir
    ti , hrx tn l i o t'vq h l tt') :) :
    h tt trdiogruflt1'
    biclircctionalir,' i..t.tlr,,\ ?r'l.\' -cluc
    '.1'11$,1fij, transductorul, ,,i,i .tJ Ji."*i un s!ngur.r:r.istal, structurilc iutilnittr itr st'ttrr
    ir'(' rnrsciirroscilaroriii. iur.ul unui porrci"or" hlr trtl i,tth:ti. t tltttl,: hoslttiotrc fn
    ti". .fi;,"r""-.*iltrric a frLsr:ir:*_ ,' , ,,,,,,' ,' ' i ;ti ,' sir r 1: 1, ,1,t , 1, . r t r t t 'r ior a1 r 'cut r ir : r ului dr ept , cavit at c: r ' v( lr
    ,,li; l']iil't),; In sccrord^ c,.rc,c,,rc,in motlobi;nuirr:_r,
    , l;,':,::.li:ll, t,r,,rl ,rl i rl rcrL pt ii, sr lpt ul it r t t : lvcnt r icular , cavit at ca vent r icular : r sl'ir liir i'
    ,,iiiiii".i'ili;if
    .L carc_rcafizcazi
    il:''l,i;:i;iiii,ii'il:,:il:l,illlnil{:i;:,,.',";"1;,,ill:[l 1" r' rr'l' 1xrs1,ikrt ril vcntriculului sting
    ({ig. 3.40);
    o rczolutiemai Luni (*r;;,l-u1 li*;;",'...i
    Jo_por).
    Ii c.h o t: n r eli o g r u f i3 crr,.
    -l).
    z, a:zir .D.o !!.1 Aceasti. tchnicl se ba-
    pe aplicarea c{ectului Dopplcr-in ilvcstigar:ca cu ultrasunete a aparatului
    ' .r -rlrovascular X{cctul Dopplii poatc fi cnir"gal * lrpJi*r,
    modi{icare a
    Ir''cvcnfci undclor sonorc in funclie rle viteza
    relativir.cle cleplasar-e
    asursci
    'l:LitiLtoarefa{ir. de obserr.ator. IJaciL
    sutsa.si obscrvatorul se cleplaseaz,,rir.r
    iii fcasi.dircciie in sirinsi. aproplcrc treclenla
    obser\.ati estc mai inalti decit
    -r'eh'ica Doprler fol0se;te
    ' 'L crnisi iu'rod curcnt encrgia urtr.asonici con-
    I rnuir. Cind {ascicnlululir".n,.,i
    L,,r'ular,per.:te
    v"ul,i"oru,,uo'loiJllt".:':;IJ:1H:;l;Til
    f :;#:i:.j
    (r',c|enler ser.uu:rliLlui
    rccc.p{ionat.
    j ': . h a , o : I I o g y ,r I i r. ctr substa.nlci
    ,. | de coltrrast.
    rr lr(l])rLli arest r rnr.l,..rclc
    sc Lazcazi pc posibilitatca dctectiLrii prin ultrasrr-
    !r' 1c,auror.sul)sLr.nfe cchog..c iurrorlusein circulatir:. substantcleiniroclusr,
    ; ,.,11i-solutiiizotour:girrcozrtcsarisalii.rc,apl distilaii,
    singe, produsi <lc con- rr. r,. ,1ri , ,r ,l x rJ (' . noc l ul X ' l ) i l rrJ amrl
    U]?:,,ir-Ui rrdioloiit ... e. \ici ula rlirtre acestc varl /uL 11111liltc
    .,Ltr(.1.
    l|. )rngLrr[l rmpcr.rtir- substante1ru estc sPc-
    csJ( c.l illjcctareasubstanteisii determineformar|ir
    r1.r)rc''boli de iulerfaliLacustic:,1
    s'ficicnt!. pc,atru o ."ii."tn ,,ftro.onctcl, irr
    rirrrpul treccrii rrin ca'it.ltilc cordurui. Iractcrii .-k:tcrmina'!i
    ai cariiii{ii c,rr.
    irastulLriconsi-:ruiu viteza ir.rji:ctiLrii(pcntru folnarea
    cmbolilor cclrogr:rri
    i.jL:ctarcaiurrar.eroasirtr.r:buie:ri se fac:Lr-apid)
    gi reglajul aparatului ir.^1'r
    'rl)liner.a celei r:rai mar.i sc'sibilitiLli .rciectirii unorlccouri dc slrrr'i
    rLt'plitudine..,\tit in tiurpLrlinjcr:tirrii 'tcc-s:rrc
    substanfci cit si dupi accearraus.'(.
    Lr)rul.ste mcntinut in rolitie tirii. trtititatea p.".ii"i
    . ,:,,
    sirlrstanlirdc contrast cbnstirin ,linc"o;ii.;r*,
    ;.i ir.^iri, "irro.u.aio6..ii"iiri.rr "
    r rrldiacc. "^'r"n*"t_urilor.
    3.2.6.2, ICHOCANDIOGRAFIA NORMATA iN MODUTM
    Fi'ntlu rcalizarca r:chocardiogrameistandarci transcluctor-ul
    lr.r,lrrir:
    r'lesatin spatiul lll sau I\r intcrcostiLl,lzt1*Z cm
    dc margineastingarii sl(,1"
    rrirlui,1)crpenrlic.larpe p*etel: to.ecic. pentru interpretaia
    corcctii a srr:r.rrr..
    i Llilor ;i cr.enimi:ntclor- functionalr care au loc irr timprrl ciclul'i <.ur.rli,rr l ;i g. :1. 11. .,- I)(hogral i .r i n P 1ant1 v al v c i aortei

    ' ;Lr ()blig.{e1igin.cgistr;rrla sirnLrlt.nii,:r traseuruiciectrocar.cliogra jnr 'gist r r t ' t r r ct ul t h


    fic. r'ir.lr. hl ,rttr t ', r 1,i', t r avlit , it t t . r l{ sint . i' 1ir '. 'lit r
    ' rrrrliograurat f'-rrlui'-' intciprctatii pr-in irxarniner-ea mctodicii irlrr-o Ilrrrir,r:l ,' ,,i ,,i ' .tfiit ', f , 'r ilin, ; r ir or t ( 'i) , vir . I virlor t ci, iavilr r t "'r at liulir st in; 1i' ir t r ''
    'r,rrila'clizeti,1'r'r'iri'd t1r'rz'-i'r'c'tr'r. r.rtcrior :rr tor..ccruifi conti^rlllrr (' , ' r..rt.r
    ,r' ,, srrl r l r, iLir r , , , ir r [ r 'r i, ) i1r ir ': i, r r igir r ii aor t t i ( planul Z) . ( t iK ] '4t ) . :
    , r rlulLtcaIir'<,irr-r,i striLr.trriiintllrriir, ,i!r altcrior. r:iLtrc. n,tltttt'1,'/,,i ,tttltriotlltr,' vitlvrtl:r mitrali antcriolr:! I v:rtv{r trnlllspl(lir;
    ,\rr lorl
    Posl.cr.ior,. lrr
    hLtutrrl,itn:intrii sttf'rnfu rnr'th.:(axul Y) llr car0.si[l lnrcffistrntr
    , ,' i ' r., : niii"st . liot t t it 'lt r t tf lt 1t 'lt t t svt 'r s: 'r: t, lt t : t ^ t lr r : ^, t ii' llt
    'l'{ irtilrj l ) l , i ) 1 , 1 ,. ( lf0 t . t1 5 t) r :r r t, fr r tir ir | L
    ;r i ti ri r i rrrr ' , " 1,i '
    \l i tl l i 't t llr t . t r r r t l'r
    ' l rl l
    ill
    ti,1lr
    || l ,trrr, (,l r' A Ii rr lliL or igiDii : t or t t 'i ( f ig. 3. a3) . I \ 'r 'ct |l, . r r t l( . r iot '; t l lc"st t r i'r
    Vulva l|itrul{, lnregistrareaacesteivalvr: urrrsl;ituieun punc:t(l\'ri'Der | r l rrr,' 11r' .t' ,.,2. valvulci lr t it r lLlt 'lt t t cr ioar c' Eclt o-
    i n, t ot t l. it t uar lr tr r clt r t gt r t t nci
    iurportant peirtru repera-reaaltor structuri cardiacc. ln timpul ,J.,rslniel,, ll{||td l||r' valvc] iro)'tio'
    (isllrrtli ilir valvci
    lrrr,r:rslt.tl,r itpare suD
    ilol-uct' ilparc sub forma unor' rruu
    lurrll4 ullur echografict:
    linii. uurlulir4rr!-rt
    txxrulvalvulei anterioare a mitralei este lnregistrat sub o {orm5. car"r{lr.Tisticd, Irthll,r .rrrr:rt,lrrlrc r:ei doi percfi lri;iginii aortei, Se pot evidenlia ntrmai
    (lc litori M. La inceputul diastoiei valvula ie deolaseazi brusc cltrc ar:tcrior
    pcntru a atinge puictul de deschidere maximn; numit punctul E. ln acest
    punct, imaginea.lnregistratl a ecoului val.rrlei mitra-le anterioare po6r'r ;rtinto
    ituug.incaccoului suprafe{eiposterioarea septului interventricular.Tt rimpr:l
    umflerii rapide ven:triculard, valvula are 6 deplasare cEtre posteri,--,r,sfro
    j',rzi1ia de inchidere ln punctul F. Contractia airiali forteazl redcschidciea
    valvulci pini in punctui A (unda atriall) care este, ln gene'ral,de amp]ltudino
    nrai mici. UrmeazS.o pantX descenden{l de lnchidere (oanta B). idchit]erea
    ,.rrrnplcti.ficindu-se fn -punctul C, care este punctul cel mii Dosteriora.t,.roulul
    inlcgistrat al valvuiei mitrale anterioarei ln timpu.l sisiolei ventr' .rlare,
    littia echoglafici. care reprezintl ecoul. valvei mitrale lnchise are ur: lraiect
    progrcsiv anterior (ventriculul stlng ln intregime este deplasat c;ir, ;. icriof
    in Lirnpulsistolei)din punciul C pini 1n punctul D, care marcbeaz:.,l.i$itul
    qistolei ventricu.lire si momentril redesihiderii valvei mitrale. r-rri( r.rilnd
    fas:icuiul ultrasonic pu{in mai caudal, se fnregistreazi. simultan rci-r{rfjlilma
    valvulci milralc post:erioarecare are o imaeine'(d.eolasare)opusf, , i j ;rntu-
    rioare (inragine,,iir oglin-dI" sau W) qi de ahplitudine mai redusi ,"'.t. i.42),
    Valltr trieuspirld. Inregistrarea'echosramei valvei tricuspidc llrfinc
    1,r'iu orieutarea trinsductorrilui medial faiS de pozilia standird. :,r trlil)ul t:i l''. 3.43. - E c hos ral i e (moc l ul M):,l re(erea del x pl anul
    ' ral v c i m:i tr.rl ( c i l rc p' c ,nul ori gi ni i ro_rei '

    Diaslo/ ii Ji,slo/d
    Fig. 3.42. - SchenD eohogramei valvei nitrale.

    rnarrevreide orientare a fasciculului de ultrasunete, echogramascpi;rrlrri


    vcntricular se deplaseazi cf,tre posterior, echograma valvei trictsi'irin [ig, 3 44, - schcmo echogl?meivalvei ]rulmonore
    gistrfndu-se deasupra ecoului septal. Echograma valvei tricuspirir' ,rlo
    rnLnltoare cu cea a va]vei mitrale.
    durti vrrlvrrlc:ccit antcfioarii.;icct posterioarf,.ValvuLclcaortci slnt sublili
    OriJyinoauortei (tractul de icgire din ventriculul sting) 9i vrLlr'; proprit'tltli carc cxplicii comportamentullor echo-
    I'rin orientarea transductorrrluidin pozilia siandar(l clitrc mcdi:rl si ;l rrrrirr,'rli,' forrrtc nriciL,
    t,'t7
    it4{i
    rl ri rl i ir l) ilr li. uliu, ( :i )!l s tl i l (li rr rl l s rl ri tItr, 1 i i r r, l r ,1,,rr'l rrrrsci . i trrpri i rrrrrl r,
    i' t r l
    Irtrc r t r r t t t ' i LI s c : lr i rl c l li rtu ;tc , r,i rh ' rrl c l cs tu u t l rr,l ri r l i rr ti rrrpi rl r,;.i ol ri , j rrr, ' rl r, ri , 1,, rl, L r r r lr r r .r , r r i I r L.r t r r Lrr ir r n lli, iulit Lljci(r t ( , r t t t t lt ; r lr r , , , t r 't t lir
    l i str:l1c c ; L c loul' ili ti i p a ra l c i € , i l p o i s c i n c h i < l l i r l ,l rL: l rusc. l rr 1i rrr1,rr| , I i rrr, l i r ; Lr': , 1 r lir t t t llt t i , r r z, r , r t lot ilt : r xr t lt t lr lo f ir ll ir llil) lr ilt r |r lll( ' ! r r
    ' .,,1t,rIrr.
    iolci t t:hoglama aparc ca o linie dc inchider-c crLlc, in functic. rlr :rrrl rrl:r1i,r l ,,rl :rr{ i rri i tlir r r ': ir r z, ri'r L lr nr lr cicr t l, i r . lLivi'i lt it r alLr .
    lrrrsrlrrctorului, poate {i ccntral:r. silu usor excentricl in intcriolrLl r,riror]r:r L i1,'.,r ,li :;t!iilta'. .ir.tLr.:[t:rcttliLrli iVcf ) :L fibrr:i rniocarr]iti( irr( 111' l' rrr
    ', j r' 1 0 1 , { l t } I l aoltel. i ,' r,l Jr-r i i r:tPr r I r lc li, r : t io vct . r i:irt : Lr I Llr st "r iugl ( f . E. ) :
    },lulva pulmonar*. Echogramavah'ci pulmonareseoblirc cu c1iil,.llrrl,
    uvs-'
    ,liir clruzallozitiei anatomicea arterei pulmonarecare la iesireadin rrrr,! .rr, r'"r.' !1):1 -
    ])i\, sdrX TE
    ' ' rJircotir:postcrioari. Nu poate fi lnregistratdeclt ecoulr.alvuleiposLr'rjj)ir l
    ,,1 rr1r'alvulci anterioarenu poate fi oblinut din catza pozifiei acestti:rrrrr',
    ,:ill Daraleli cu fasciculul dc ultrasuncte. Dchogramavalyiilci priiliorirl I)i'cscriItiLrilc sr'nt cxpiicate la {ormula {racfici de scurtaro. Vrrl()rrlr
    rorrnrLlcla sugar sint l ,5i+ 0,04 circumferinle1's, iar la copii irr Yhsi;i 'lr'
    ,rrr:{r:r-ioare are urm;.toareIerepere: unda (dcpresiunca) ,zreprezintir .ll,(lrl , lir ; ;
    , orrt lir ctiei atr iale asupra acesteivah'ule ; punctul b rn?IrcheazS. , 15 ani : t , i+ +o, ll cir - cunf er in! c/ s. Calcului Vcf e- st cr t il |t t it t t
    pozitia vil | \ rIl' I
    lrr irrr:< cjectiei ventriculare; panta b-c reprezintd deschiderea .,cir
    i,'li{.i 'ro:rticul bol;.i miocarrl'Jui. lrcf redusl se lntilnestc in miocarlolr:tl it trtlt'
    1rntn1 ,,Lr<lozt:si st,nozir ni.trali. ircf crescuti sc intilnc;te in stenoza sLtlrrrrrrlir'li
    r;rlrirli, iar pzLntac-d pozilia deschisl a valvukri in timpul sistolci;1,rril
    lrilrcr-tloficiL kliopaticl, boli struciurale de cord cu s/zzrzl stilga-,lt':r1'l r,
    ,/ r' i-cplezintir inchiderea diastolicl iar panta e*J pozitiainchisi a vl.f\ r.i rl
    l,rnzir aorticit nroderatl, 1a boinavi carc priinesc tr:l.tame[t ctt rltrlorttt
    iirrrqrtrldiastolei ventriculare. Valva pulmonarS.se poate deschideirrrirl,.,
    \, l r':rriazl imrnrs proportional cu postsarcina si dircct propolfional ctt rlrtt;'
    irr:cpirtului sistolei ventricularc ca rczultat al contracfiei atriului ,lr';,t , rrrliacir. l'cntrt cvit a]ea-interpr-etirilor cronate, Vtf calcrlatir trcl>ttit "rt"
    ,\(rcirstacste posibil datoritl presiunii tr-ansmisein timpul contraclici irir,l
    i rii in fuirc{ir: cle alura ventriiulari. Frcsarcila nu influenleazir \i lr.
    Nrricircpt care depisegtcpresiuneadiastolici din artera pulmonari. I'r,'lrrrr
    zirur:adepresiunii a gi pozifia punct .oJ:uli b variazi. fiziologic cu miscirile- ri r I ,;r.l Fractia ric cier:fie .;cntrictrlari stingir (FE) sc calculeazir drtlrii lor rrrrrlr
    lorii, ,k:oateceaccsteainflueirle:rzi.fluxul sanguinin cordul drept, 1r, i,'.1,rr IlrYsd * Drvss;
    rr)(lirri cstc mai adlncf,si punctll D mai jos situat (fig. 3.44).
    DIV,rii

    3.2,6.3.DETERMINAREA
    ECHOGRAFICA
    A FUNCTIEI
    VENTRICUIARE Ialoarca lror:nral:rlncdic cstt dc 70,9! @inhi - 50ii).
    Iiitcn.rilclt: 11L'tirnl sistolic eieu rlialii asupra inotroili:rllrtlrti \r"r'l t
    \'l,'loclelc riltrasonice sint folosite din ce in ce mai frecyent tclrlir ' \.
    ic t r icula. r X ( PI r E) ; i t im pt l dc t 'jL'r : t icI 'r 't r lt t ' r t lr r r
    i L i P cri o:tdiLr lc 1; r - t 'r : lr 'ctvcr
    i rri L rilcc ant it at iv e a i e fu n c l i e i c a rd i a c e . A p re ci erea cea mai si nrt,l ,L:Ltrr,, l l L I I ll\') si pr-.t li c;iicirl:itt pcntru liccai'e vcntdcul in Partc.
    vcu1r'ir:ularcprin cchografie in moclul II se baz-eazl pe misurarca diru' r, ,irrlr
    PPil cstc intrrralul clc iinp iirlrc clebutul complcxulLri {]1lS pc r lr r ltl
    lrrr' {.clc<l.iastolice ii tclesistolicc ale ventricujului sting. Xli.surarca clinr,.r rr,r,l ,.IrLli{)g|ir-nlair[cgistratiL;i cleschiclercavalvei aortice ;i |espcctil' l)llhr]()rr;rl
    iclcrliastolice permite comlaralea acesteiacu valorilc considcrate irir in,rl
    II' l Y l cpl l z ini- iL ir t t lr - alul r le t inip int r c dcschider la ; i inchi<J, r , r r ', r lr ' t
    lxrrtru virstL,- in timp ce diferenla intre dimensiunea telccLiastolici r.i rr.r r,rrticr r-,ircspi:clir pulnonarc.
    i,'lrrsistolici. pennite aprecierca contlactiei in timpul fazei de ejec{ili rlrr
    ljcnltrr {iccnr<:vcntricui in partc Poate fi crlculat raportlri I)l'l'l/'l l'i\ .
    i r ic:rrLLr iL stinrii.
    tirtclia ie su{tlara ?r {il:r'ei miocardice sc poate calctla dupir lorrrrl, lutcr-r'a1c1t' r1ctimp sistolic sint ilfluenlatc dc patru lat:tori: |'i : ,.' irr''
    , ,,r:,1 srrLcina, stiu(-'a colrtli:tctili a miocardului ;i conductibilii a tt';r lllc l r i, ir
    Dr\'.d - Dr\'"s
    .r irirrrii. J)iLr:iLloti iLcc;ti factori sint coust?rn!i , timpii sistolici sinl rrl!ll
    Dtv"d
    Iu rtru rlctcr-rliuarca pcrformanlci cardiace.
    irr rorc I I I \ a c s i e d i m en siu n e a iBte r ! a ? e n td cu lu lti sti ng i n tl i astoi i , i ar l l l vss r,,t,rr',i Il;rportrrl I'l'llvd/l'D\rd arc un inalt grad de corclarc cl1 l)r(isilrrr(ir itr'l(
    ,lirucnsirrnee interna a ventriculului sting in sistou".
    rrrrli 1>ulnronrrrirliastolicir, rezisten!a vascularl pulmonari"tsi frcsillllcll l)r,llrr(l
    trialorilenormale ia copil sint 0,28-0,45 sau 28%-{51iJ gi nrr ,irrl ,,.rri ul'rlic', fiirrrl lolcsit pcntr-u evitluarea circulalici pulmonarc. l,a rt()rrrr ii'r rrl
    irrflrren{atede virstl, suprafate corporalS.sau aluri. cardiaci. Fr;r:l,i:r ,l', ,r ( onstirtlt o scixlllc ir raportdui in primelc zilc de vi:r!iL, atrilrrriii r., irl tit
    loultarc are valod scizute ln miocardopatii, insuficienli c;rrdia<:ir,rrril r,zi sl t' ntci t 'r r s<: r r l; r rl) : lonilr c dup5. nast er c. I t apor t cr cscir t s( ' 1r ) lt : il; r lr l
    - ruhr
    , rrrdozcinduse prin tratamentul cu adriamicini sau unele ancstclzi<'i, (lr,rlrr
    rr pr.r-sis(r'r{rrtipulrri fctal dc circulatie. Raportul pcntru r cntri<rulttl :dirr11
    1an), insuficicnfi aodicl. Valori crescutea]e {ractiei de scurtare sc irrlilr(,rl
    lrr lrrcmaturii cu persistenla canalului arterial si s/r.zrzfstinga-<lrr;rpl.rr r;i lrr .r lrrsl strrrlirrt lir lrolurrvi ,ru <1-transpoziticdc mari vastr, cil'curnstarllii 1r t:irll
    lxrlnavii care primesctratament cu cligoxin.Fracjia dc scurtruc l)o lr. ,r\'fu ,,l , crrrr,l i rl ( ll slt lt ir oil'oul: Lli( t ipulm onit lc. I ) r 't cr nr ir t air : iLinlr 'r - r , ulI r r , lr '
    r,:rlorinorrnalein unclc condi{ii patoJogicr:carc inclucl lczinni <rrrsll})lirIr{llt Irrrrp r;i sIt:lir :r , r lr vlr Lr sl. r :o, ir "l, , , li. r 'I icicnl. ii ixt t f ir r st r r r liul r lir r il, r , r slicif f i
    <rrlrr volurnctrici stiugiL cotnpersatii: insuficicrtfir aotticir iz()lir{ii, i,l('rrrrh ,l , rl I r i rrts pozi{ ir '.

    l;411 i) l1)
    i'rr
    (:r'lrorsstrriir)r'
    inPt.ttttii
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    l],,',i 'i'rIrrt

    ,, ' Il':,u :;lll,'uJl',1'l'iilii,lllil$H:i:,:?:ili"i,1':filf


    I lrl. ( t ( ll \ . . . , , , | . ' i ) c h o o a r d io g r ap h ie ' ' . M cd , ct. } lyg ,, L 9 7/, t j , .\287,
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    li' i l";'.;;i'iii'il-i!i pi''"''1la orltordecxploriri 1''l!l;1;;'l;.',:'liii:]:
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    ,I
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    .i;;;'
    a'l'
    i";;"'"''
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    r:r,jr,lrv \ llardbool<; Ye:Lr Book Medical Prblishers, Itc. Chicago, Londot, 1961). ,,1,, , ,' ' . ilsu- r qs l , i t" fl n's c uT , l 9'5R ) '
    '' \l \l(rliir:sLlU M. -,,Metode de investigafie specializate qonin./azive ln carcliolo8ir!t)nrll{. l rl l.(rior s-auclezvoltatlaboratoareasem[rltoaret" o,,Mlltii"l],1'll;
    r rL;r . feudi le moderneir pediatrie, red. MaiorescuM., 8.1, Medicalx, Bucrrrolt i, I 0flp pi"ile
    t,,rr ,",i',ii,ti" llucureqti, 'i'it,l:i2,,n1,
    si,,rn,..rc
    't)l
    %,u1,,:ili]titl:i
    / u \1,)lillsilu M., CIOFU E., STAMATE M., DI.q.CONUTII. -,,Valoarea irrvostixlr{l{
    '. L,',-t!,|r:|r:io pediatrie - domenii de aplicare li ljmite. Partei! I - Echoon.(lio(rllll"
    ilLn.,iirrta'iL'
    1',' lllll:ll,!nll',-,t'i'i;lii'l'i;;;"'.,,,iio'1..',r.."
    /',Jr,,r,,r, 1983, XXXII, 3, 207.
    'i \ ll: V l, ; li : t . - , , E c h o c a , x d io g r a p h y' ' . Ilca r t Djse a sc i ln f& nts, C hi l cl rer an.l A ,l ol !N ,fl l a, CARDIAc
    l,l,i ;! I I-.r, Moss -q.c , Adams F H., Errrmarouilides C.C,, The Williams and Wjlli n (' ,l 3.2.7.2.INDICATIIIEcAlErERtSMUtUl
    I t . , lt r , ) 1 . r , . . 1 9 7 7 . tipul ccllocaltlio;r'tii'i'
    ,) r)lt l. lliI I A N S L I I . - , , L ' u tilit6 d e 1 ' 6 ch o ca "r d io g r .L p h ie
    d a is I'anl ayse dcs l nal fo l |.Ll l 'rna l),zvoltiur'ir mctoclc-[orneinvazivcrnoderue<le
    , rrf{liri,iu,rs cyanog6nes", MAd. et llfg., 1977, :3, 3 320.
    l rl lilrllS ll\ t j S E R W -,,La d 6 te n n in a tio n 6 ch o ca r d icg r aphi qne de l a toncLi oo v('l |l r[\r.
    li, ir(. i , r , , i ] l r e " . M e i | . . e t HyE., 1 9 7 ' 1 ,3 5 , 3 3 4 0 .
    II . ] I t , \ )i I) . . I , - \ ] - T - E N I { . D,, GOL DBERG S,J,,.SOL INGEII R ., ME Y I'II R ,A , ,,IhIIt|'
    *;,i'i,ii::i,i;,,.,,;Xr:5i6[i{l,
    ; rlill Ill' ";! g::*lll"ffi,?"i'llilli;,,t,
    r, L, . i , i L , r f d i o g f r l p h y: A r e lvic.r o f its Clin ica l L ltiijty". /. P di atr,, 1975, u7, 3, .l l t,
    r. ilt \ N i ) i , D E M A R I A KISSL O J., \fliYI{ ,A.N A. -,,R ecommcndati o $ ,(l {{r,l l [l I'iriiiS*,";*lj,l *n cxtrcrrr dc vrr:'t'l'
    l,,,li,:,L1iar'1,'ctrrirlii,caleterismului vascular este
    , i , ii! i l : r t j . ) n i n M - m o de^ .,, cch o ia r .lio g r a p h y: Re su lts o { :, suf/ey of echocar(l i ol rrpl rl q
    , , r' ,I r i r L
    . l lrrnneel lrrttss . C i r c u la tio .! 1 9 7 8 ,. 5 t,
    t. 1 0 7 1 . II
    I, , ll. \ \ I
    f , l?i .

    I rlf i1.
    l).J. -,,ltirr!r'irlre

    I i l\ l l(l, ll. \ N t J C . , D I I . \ G UL ESCU


    t o - d ir n .L r sicr lxl ech o ca .r rilo graphy" J. P cdi al .t., l t)l l J, qU l

    S.I. - Iico ci,r d ir - r g r a lie cl i ni d., E d. Facl a,, 'f i rrri f'a11
    | ||lrlI l"l
    W n,:;i:
    i:i',,ii:r,li,i,l*tU
    1,, m;ilirt:il
    :iiii#,'
    cinr' ' ltr
    I Ni ; I J J {I ] , \ N U . O L A I I I U
    ' : i\ Vt ll - D S C U - q .N.\, SO' JAC].U
    .\NA, T ODERAN V ,, A N A S TA S I U MA II I A N A l irtlrtltl,'liullrt cJinkla ilpc'ltazir Ia catctcrismul catdiovascnlar
    M\RTA: ,,De p istf"fca p le co cc 4 u n o r mal fo nati i congcri tal t. (1, ,r'trl
    l. r., r)r - ' r ; s c u t u l ; i r n g ar r il tin i,r ", Pr iid L r ia , 1 9 1 i, XXVIII, 2, 119.
    u::l,lilllil;ic"lgllr*:l'li:Hiifil""ii,T''3;lf1l::"
    ,, .:;Jilll:"
    CARDIAC SI ANGIOCARDIOGRAFIA
    3.2.7. CATETFRISMUL ' ,l]i.,l'l,lliill:i auo.l.rricafic
    arrsiografia ra 1,',,i'vi
    ur;sr;truriL
    ' l9fl0)' \"
    (\1'trtuL:tu
    BRADUFOTIADE
    t, ;l;";;,iii':iri'u'ii^t"tiic"r ''ii""'scrrlar
    "
    ' '
    l)fin cateterismcardiacse intclege'trhnica de introduccrea unoi sourl0
    lrr irrlr.r'iorulcavitirlilor cordului. Caleadc inttarc a sondeicstc o v(:ri-rI)r,r'ifnl 3.?.7.3.CONTRAINDICAIII
    ri,:ri (r:rLtr:tr:risrn
    v{-.nos)sau o rrtere peri{crici (catcterismartorial). Ilxllnn
    {l, r:rr-lic utilizeazi tchnicade Dunctionaretranstoracicl a inimii. Prin rlr'rtu.
    ,r ,il'l,iiiil'iil' : ,.;lil1:i:,,i: j;,lJ::.])::JJ:'"ff11',,:tli
    lrirr',r d{r cateterismdlept gi stio.g sc preciz.r.izi calc dia cavithtrilc(lr"lrtl ;ilr"ili,
    *,1 t,,,,,rt,'tld;'t ca.rrn bolnav cu-f9no1nen3c1cirlsuficirrr{rr 'ilt-'

    ; :IIr';jii;lril :ll';:ii*r[,i#$g
    rrirI sttngi ale cor:duluisint catetcrizate, Irr 11,rrr rtl

    llli;], #"'Tjxni:l.{r ii":],1i:


    ilii' ''l"l
    3.?.7.1.ISTORlC

    l)r'irlul catci.clisrn i;r oin a fost ,-rfcct[al.in i929 dr: ciLllc W, Folsslnnnq ii:;1, j,lliilli,
    x,lliil'l* *i#xffi l;T:,T1";\1
    ::,t*:i':":f
    L', l)r')Jnia-i pi^r'so:nlar. Ci.utinti o rnctodit dirfctri. dc rnisurar,,' l cl,bil,rflttlr
    , ili;,";ir,' :llllil'"1;lltl';l'.:i;ii':i$':'!yfq'Ti**il,.
    ;'ii,il,ll',i;l
    ,rLr'1Lir),si-t inti:orius singur o sonrlir prinLt-o r.cnir l brltd[i plnit ln rrt.r'lUl
    , ,r,,',
    lr "',1 , rL c r nons t r iu( lc ol c g i i o r i n o c u i ta tl rr n rc to L l c i .
    irr ,L:ccniul rr|rnii.lot clr.totr:rislnLrlciulliiL(: rL f,rst lrLiliaaL:jl)()r'ilrli{:rl'} S,
    i r r' l trg h ,:z iy i fr;rrrc r' z i .(l ,ri r:r ' i Lu l )us tcl rni (rr Ii r l )l ul 0l
    r , 'ri . .1 . i { ' r ' uit i' r , lot lx
    ;li ir 11ffi N;i, j',rr*'l1 ;tT lTilili,' :1fiiliil;lii
    iii...irrrtr|'1r'ric)
    r ; i,ri L i rrl ,r 1s o r ' . r r r , 1( x l i ( l u r' n i i i (l ! < l i rrl tto ::l i c i rl l i rri r' )i i rrr l rsi . A . (l {rrl rt d iill"i ,,',,,i,i,
    ]11;,,:)1,,,;ll"','i,i,l,';l)l,"l,i ri,
    Ix: ,r*rlil;rr ..""uf
    i )i ) I
    tift(J
    l ):tr'l i t lt s r ' lx r at t ' asi g u l a s c r:u l i ta tc :i p a i :i t' l l r rl rri 1i rl aci r urr sl srorrl ,.rrzl l , Itr:rt:ti ci rtsit , pt r nt lt t l- r olt t avt t(l : ill1'cst ( rir t : it '2,clt llt t , ir t cr cz'ilot li. it l 'r r ll
    ,l rl rrl l rrttt' i tr;Jr ipc- cr t r t - r pcr ienf i, r r r 'cit hnt nlc sint pr act ic r t ul Silr ; . ir t t clt '
    init-o iiruclioralc a (:orditici bolnavuiui ln rapoll. ,:ir riatclc cxltlot'irlii, iLlrrrrt:l
    , rrlctt:r-ismulcardiac cstc contraindicat ca fiind irLLrtilii pcriculos. ,rr,r,l,ttlc cilr'(' flr'cu pot fi Prcv( ui1c sint cvcntuala ilocularr: ctt l'it'ttsttl
    lr, lrrrlilli sarr airarilidi frisortuhri, alrindoui. legate de dificultalr'rL o1r{irt'rii
    ,rrr,,islrrriliziili pctlittc ;r matcriilhllui plastic care nu lezistii.la allto( litvrtri'-
    3.2.7.4.TNCIDENTE
    fl ACCTDENTE l rrr ir(:r'st.rloiiri sr: r-ccourandir ca intrctxl set de sonde, seringi, Prclulliiitoiul',
    aruncate dtpiL lrrimrr.
    Aceasti- rr.etodir dc examen nu este compict ilo{ensivi. lirei:vcnt;r rii ',,l,irrllr,, [itinguri, teci, clilatatozrrc din plastic si fie
    latca incidentelor
    r'r:rviiatca ,rrl tr' l rni rttal t' .
    depind in p|imul
    incidentelor depind plimul rirrd
    rirrd tlc cxperienta
    experienta personalir
    personalir gi
    IIrrcrcntr: sint
    l )('r_C nt(: S siI 0\Iras
    l nI S crtrasistolele
    bl Ol erc (l (rLutl l rl i l .rl s u!:
    <lcterminate rrdu|:v r drc d sondci iLr ltrirr
    de lm:rnevraLea
    {r'lrnir:iLutilizati.. (},{arinescuV. 9i co1ab.,194E).Pentru in{ormatic rcdr"rrrr
    irr l;Lbclrrl3.9. o statistic:rDublicati
    publicatl ln 1968. , r'r,nllic:ul.Controirrl continuu a1 ECG permite semnalizareala timp a accs-
    1968,care reDrezinti"
    reprezinti"accidentclcrlitl
    rrr;Lirrnltc centre medicale din Statele Unite, unele crr experienfi. mai redtlsll, "r .rlitmii
    l,,r .rlitnii si
    ;i core.flrr'ea
    crotectaleanozitiei sondei dc
    poziliei sondei dc cateterism.
    cateterism.
    .rllll c:rrun rulaj mai nare de bolnavi (tabehl 3.9).
    frccvenla" incidentelor si accidentelor cleste la persoaneleln1iicoyrlr,, REAClllLA ANGIoGRAFIE
    3.2.7.5.
    irr,rrlit:icntsedate,cu iritabilitate miocardici.,cu cianozi sau acidozirlrt.trr,
    ( r'hr mai multe preparate utilizate ln ultimul timp sint t:otn1:rt;iiri
    lxrlir-i. Pc dc alti parte anestezia general;. la un copil este o conditic dc[;r
    ni Di fi cu
    rlr.ririzoatuluisa11a iot;lamatului cu baza de sodiu sau rnetilSlucin
    vorizautil datoriti dificultdfilor ce le ridici controlu-l eficientei ventilalir,i
    slDntane la subiectulneintubat. rl, l t izrt:rt.
    I)upi statistica sus-amintitir. a iui E. Brauuvald, complicatii najot'f Substanla romineascir. Odiston ecbivalentl cu Uro-Srafin--- Salr''rir111
    compus amidotrizoat cu rnetil-glucamini ltl irli('
    rl)irf in medie la 3lo din bolnavii peste un an, la 6,6.0/odin copiii sub t a fi 'rrr romiro-Bracco, cstLr
    I
    lrr l5,4ll dit.t sugarii sub 1 luni. Pc dc alti par-te,dacl mortalitatea-la catclt,. rrrrlltrrlii sc ut.ilizeazitcori'aentratia75)^, rar cea de 60%' Pentru o itricr'l;ttl
    risrrr<'stcde O,14okla cei pestc 1 an, ea crc;te la 6a/o\a sugarii sub o hrrrll, ,rrrJ,ir4llr{icl"L se rccomirudl o cantitate maximi de 1 ml/kg. Sc po| )( l)( tir
    lu .r(.('(tsri sedinti. oiuiL la 3 ml/kl. Dacf, este necesar si se mai cxccut(' rllrglr)-
    .l.l). I(eith $i colab. comunicirln 1978incider{a inortalitilii l:r caLt'tc 1,,.,1iisrr'plimcr.rtar6sc a;teapth iUminarea substanlei prin rinichi (con1r'olul
    lisrr, r ric este dc 0,051d1a cei 7 843 copii peste 1 an, de 0,51/ola2942 coltri
    r,,,liolo,-ii: al vczicii udnar:cJ, rcspectiv cca 20 minutc. Doza to'tali lirrriti
    lrrlrr I iuni Ei I an ;i de 6,6o1u 1z 1 470 sugari sub o lund.. pcntru sugar 4 ml/lrg 9i pentru copihrl mat(r :i (t
    rrrr ilr lrrrie sir clcpr-Lscascir
    r' ,l i l ., / l i ci th I. D. . 1971t ) .
    7 dbel tl Lt)
    lir tab,rlirl .1.t0 r-eilirn frt'cvenla incidentelor <latoritit ma.rt:vlclol rlr'
    ll,-\1xr!.u rrccid$rtclor h fatetcrisrDul car{i:re. h bol a{ii c! vi$[n poslc I an (Erpericrr{;r rrr,rr ,rr1'rrlglrfic din statistica strinsir dc E. Braunl'ald.
    r)rllat;r pc rr mr r.rf do 12:i67 de troccduri, dupa t}x.r,u w':,ld E. 9i oolab., 1968) il privin{a testului dc descopcrire a sensibilitllii la substan]iL tlrr rrrtt
    t',r',1, rlaiolitatea autorilor sint de acord c[ aceastl precaulie se dovlrllslc
    illolht I i| t e 0 , 1 . 1 , r ; r lr l,r,rLti, inutili, nt'ajutincl la decelarea cazudlor care vor pr{rzcnta itlcirlctrl,'
    t : , , )nf t ilLl i i 3 , q i L , r csfc.t;' , I
    'najare rrr r,ru:tii nedoritc la angiogr:rfie (J.ll. Keith, 1978).
    -- -\ritnii gra;c: - libdLa-fic ycniricliar; 0,48,f;,
    ' Jnbt:l tl i . 1l )
    -tahicardic par-ox$tice yentricular:l 0, r0,)1,
    - b:adicardie accentu:Ltl 0, .i0,/i,
    - bloc completA.V. a,0'r'li | , "r! r'rrl rolnplionrlihr rsodale angio-g1risi.ltT".:'i;h).".*"tatii. Pc 9 483 ProcecLuri''lrr|,fr
    - l)er{c,r:rfii cardiace sau ale Il1adlor vASe 0, lr0,ll,
    - Complicatii locale arteriale {trombozii, disecfie, pcr-Jorajii, fals are-
    |,t,tt , ,,trl,l'ic&tii;3,590
    - Ernbolie sistemici 0,0()')i, ,latoriti substanlei de coatrast 0,9(i'il,
    - Embolie, irJarct pullrtorar 0,09,),!
    - Irziuri a1e sistemului nervos central (looaLc san I tloram,r. ccvit[lii catdiace cu extrovazarea snbstalltei de contr''st irl
    rrrcul perio.rrdic 0
    diluze, embolice sa! toxice) 0, r9,i1, 'll'i1,
    lulbtrirri rlifuzr,.[c sistcluulllicc iral 0.011"
    HipoLcrlsiurc sevcrS, (reactrie waso-raga1i, la substanfa de contrast) 0, 13ili, '
    - Cory sLr:rin r;nas in organisl4 (inroda,re sordd, rupere de ac sau soudir,) 0, oltot,
    - Alergie ta substanla de contrast 0. 0.1'1, TEHNTGA
    3.2.7,6.
    -- IJrocese inflama,torii generalc 0,02,7i ,
    - Inleclii ir! locul de intrare 0, 08,){, 3,2"7,6,').Sondolodo aqtelorirm

    Cauzclernor{:iis-au clatolat pcrforidi inirnii sau vascloi:rnali (cu sourln Sirrt tuburi (ionlccltonatc tUn rrutcrirl plastic cu o illurinafit' t'.rIcrtlri
    (ru iullxnl r it : I ixar c la t ubulat ur a t ) c pcr f ir zic ; i o t i: I t r r it t ; r ( it '
    11' r,rri rurLl i t)
    sa.rrjctul dc substinlir cle colrtrasi),;rritniilor gravr: irccl.uctibilc(br:rLtl ir'rr.r',lin
    (:u irsistolic,fibrilafic vcntlicularl), iuf;Lr"r:tuluin]iocardic 1i tlisr:cfici rLr'Ir'r'cl tirt, r ui (tlistal() (:r uuir silu nr;ti nr ltrr gilrrri (r:u sitrr lii rir vllf ilrjtupat) Sorr(lt'l(
    (l)l)ll;r Tc(uliirlih, rklrtirr:a o t:onscr:irtfi'r
    ir r:ti ctelizirt'iiill{,f{ri c{)tn)riul). , r r rrrr si ngur olif it : iu lI r vlr f slnt ( t t ilizilI r ' ] x'lllr lr inr |gist r r t r ciL lr t - r 'sit r r t ilot

    irlt li
    r,r11,l i ' :i rr)ri(i r'r il: i ( ; ind s, 'init r xlt t r ', sot t . h pr in t ; t vi inf ct ; oa[ ll, ill - P" ir r l lr t
    Itrrrrrrl l cl r , .r I rt it i ( lr ( r pt ( i f oar l" 'lil: I t ir t c ( it cf encscu T ' ] q58) '
    l)r'sl.r,r I rtr.]a,r:hirurgicalir ir vasclor la membrul superioL s' L'st:cttlir
    l,r rrrvi'ltrl ,lr rr cotului. ln schirnb, pentru intioducerea transcrltir'luLsc rr'(o
    ,,,,' ' ' ,t,' ,,1 ' ,r,,, , , . axilar l, unr l, vascl; sint m ult m ai gr oase dLr ( r it lr l) lir ; l
    | .,1l r l l l l ,

    ; il:;Ii"tiil;; i *li'* A:,A:*":il


    i';l; i;n11[!ili;]'iil;
    ;*,1,*:"'#
    1''r'ii#"'",-.:
    l;*,:tlLt':,re"g:*li"t
    i':i, ::i i,ll',?:tr iL!*'ii
    :iil:
    hcm6dinamicio condi!ii sp cialc cc : irrrr
    ;:',; ,,-ffi;ii";;
    t ;;t;;; traksautakd'
    iespcctivuluir,i
    li,ll r,,ir rr"'"" i.irr" arrpr inchidereachirurgicali.aparic Fil. 3 45. - r*:,:&o:o*X:"Yr",*r"Y:'o0"""'"
    ,: ..,:;., .;:. dan pentru lr't
    fi rltilizate De de altii p iri a :''
    -^,..+ -ei'not A. nuncliP tttu(r'\ir'l\ J vasilD), F terragPlei Jrului I nA intre'ln8{
    inlr;ol|o'.ii'[,'lra'Ih'o'el.li.lnhmPn;D'sel.th8ParUl-o.r1f
    soDda pest' nr'ud-rmu) brldn.jI \onda'tr lrn fllil
    ,,i .iou"toa." sau dilatarea forlatl a unei stenoze ,r"in"*.t; f. *
    t
    s$tii[d'
    , *t_ tD,Pinsl tr'o lud.nll vl.lx.t.
    -'..,'.'

    3. APorolvtq
    3.2.7.6
    .\r,r(iltrrrrladioloAicd,st^compusf,dint'-omasispccialitk'6;lfslctistrt
    , tirb rurli,rlogicrlcd"srrbt5i ampli{icatorde lurninozitalr' cu sir;t{rlrl(ii'
    ' 'rr,
    r' l, vizirrn, ln circuit inchis deasuprabolnavului ({ig' 3'46)'
    ftrrcristririle ltemodinamice se fac pe o aparaturl ml ticanal, crrrr'
    tr-ascuECG (rv' tr
    t,,,rr. r,,('rlpliouacel pulin o.presiuneintracavitarl Si un
    1'','t ,l,,ui,irran,nnctr6,un miiroelectromanometru, un canal pentru calcrllrrl
    rrr,lir:ilr>r<lcrivali din op/dt, doui canale pentm TCG - I{iss, un ptllrrr
    -sincronizator pentru dcclangarea -canal
    sistemului dc irljrr'
    , rr,Lr ftnu:arditiArtiir:,
    t,r. iu raDort cir faza ciclului cardiac etc.)'
    riocirtrencincmatografierea imaginilor amplificatorului dc luminoz'i'
    r,rr,. rrc lilni dc 16 ntln-sau 35 mm cu viteza de 24-48 imagini pc st'cttntlii
    ,'t, r,'istrrrn cr:l nei utilizat. Existl posibilitateade a controla tr)ccclitrul
    .1,,lr.l.vizinrrcirnrginilc r?rdiologicc Prin lnrcgistrurr';tsinrttl"
    care sc filtnt:ztziL.
    t,rrrii:r irnaginilot'th:tt:levizir:nc g: bandl ma6nctic5, toatl stx;vcnfitdc lntt'
    tcnninarcn iniectllni.
    Irrrli(. lx) lc Ii vizualizatlt irnr:diat duph
    lt 5l,,
    1n :Lrrgiogr:afie ;rr.irrjcctczco , i rLl ti fuf,. ti ' l i r.l i v trr:ttr',l ,trl ,-
    i:r't'lrrrir.rrr coagulm-c' rrloca si clraiittittlt
    . i (,rlllol('itzir rrltimilc probc <lt' singcrarc -
    s[iLrtlirdo contrast intr-uu LirrrplilLrtc scurt. AccastiL inj ectarr: rtcltutindu-sc
    clcctua cu nina, sint seriugi clc injectare automatc, propulsati: dc rLcrul r l r,"ij,r'UZ
    rl tllaL.
    '
    comprimat, sau electromecanice. orl ln:rintc clc examcn se face o preancsteziecu Ronrc|i]rru
    30 m3/kg)'
    ' ';',,: i.,n. si Irirr' patn i.m. (0'25-0
    '' , ,,,tii* ex1,lo'riLii
    elecruarea rrrrrrr:ri
    l ,;t copi l ul pcst c ui..t" cle6'ani sc incearci
    j#tr."t"rj".a1"p u estemai mic sau nu. poatcfi convirrsI i
    ",;;i,,i;".i"
    .,;"1;.1;
    il',i;t,i.'*'irr.titii"'o"i".t",i" c,t""*lt--"-l
    pipe Gucclcl
    -, * -, ^ , . , , t , , , -
    .!,1*tflli1]]tt:l'l:,:i:lli',:i
    coutrolttl
    A;l;;; g;;[ necesitl moritarea unei ;i
    ,,' rl i rtru al resPir aliei.
    <lrqrii irlilt'
    I t, scopcrirta chilurgicali sau ounctia transcutanir sc lacc
    1n inai multe stratuti (nu ilai trrrrit rl''
    .'4 luc ii cu xilini 0,5-l)
    l ||
    ' | /kg). sont li ( l rrr 1li[ 1i7
    l)c la inccPut se introduce un bo1 dc heParini p1'rn
    rrl r,i .,nt pentru t oat i durata cateterismuiui.

    CARDIAC
    TACTICACATEIERISMUTUI
    3.2.7.7.
    r n ( or r lr lr l r / I
    l \r b:rza cxanenului clinic ; i al csplor ir it or : r t r it t r '; r zir l
    c'r1' tclisrrt l)' l';rr r
    ,',' , ti,,g,rJtii.'a,, pl'czumiJlie cart rnotivL'azi indica!i'r ''f
    carc trebuic sir fie unnatiL in tinrprtl lrlrl't'r
    ,,, i,,i'aut,, sc hJtirri;te^tictica
    t t t t t ' i l"t "'
    ri-. , ' r, 'fr, , x, mnl r L, 'l', ci "t , n vor ha . i <' L'1?t it '/ ' int nnt r lr l '
    ' , lo pi, ir r rrrl
    .,,rnl i ,i ni ' r, i- t , .t . r . i nur n. r i m . i. u'. 1 or i 'iur r " "' 'r ''l'r l. r lr 'I 'r ' l'r . 'l
    r ,rrirttttria in singclc din artcr't 'Jt pulmonar-i F1 artora l)drkr-r.:'r'
    "
    i;;'"-;;;;,rii, catetcrismul cpt cstc suiicitl]t- clrc r P|r'zirrl i
    -coPilLrl
    I ir l' r lr : r ll {'ll'r ' l
    ,,,.| l ,l i ,,rral i ' colr '1,llit ali cu sr lpls5oli ilalo: lcol'lJlul 'l11lt l
    :,' , ,i ll. i"i : l, r alc cJ, r 'r ot t o- puJm on r t r t : i. t "r il"l' 1'r r 'sir t r t '
    - r rni' I ir r ' r \ r '' ir r r qi"'lr : 'lr '
    ' ,,r.,.i ' i ll.;' ;;;
    ,r" l ' i , , 'i'i' i"'li, . CL'1 an( icr gf I i 'r r
    'avit r {
    , r,], . ur i. i. n, " p, nr r , . , lr r "ct r t : "a Ji, , ; : nosLi(I r lr r i : r r ': r l"t r r i',
    t t t 'r 't t
    j ,' ,,' ,,' ,' ;i
    ' i " i ' .l ,i i,i
    ' i :n
    i ,.",
    dii, ll ca capacit it ! ii uc! ionilc I lent t it ulului dr cpi 9i r t '
    , i"r f ir
    | | tr, i l )l l l rnol )ar L'.
    l.'zirrrt'
    ' ri,i,,:t'1"i:, rliagrrosticul clinic este cle dublir lcziune -mitraLi'
    cc afectcazl cavitir{ilc stirrs' irr'lrrrr'
    .,,,'ti,,i s,,.uili'lcct congenital .cordului
    drept
    , ," "ri'"iit,,r., |i tn cait'terism,stiug.in atc.'tsi, s.din{it,cu cel
    t:,,t,itcris.i,.rL sting sc rcalizcai"t p. cale t.anssepiuli ctr tchrlit:ll l{t'sr
    trcccfe:r Sond;i printr-un foraruen, oUalL: prri:<'ttt(irr
    l1rr,,li.rrlrrcrtrth sarr c,r
    rnici). LrLcoiliii mali, se utilizr:azil" Jrecvent calca l'clLosr.ilrlil
    F ig . 3 .4 6 . - Se la d e a a te td isn :i . dl l gi agraJi e. r,,' r.rl I.L cr-,iriii
    r ' r r lr r
    :,,r '..", - o r " i ."j ,t.J- .J... .I r p ,i,l lt.tu n "r un.r.o/, te(u.i ,TLt,'" r.ep:i . p" :r,ur;.t.
    ,,u l ; , : ;,' 1,,', i, ", , . "i, '1, i1'r in - igm oid' lna"r iic' it t r t 'nt r icr t lulst ingli'
    i. , ,if.
    JU I'e tr: I 1-.ircm1ioqrati. r. nlrsd de cooandt a apataiuii lt@nrgen ii alararr.a de misxiar ti idr. i tt ,t r r r r l 't ing ( t ihit "sct r l" si colaL' lq5lt )
    ' l ' l rr.rt ' . -
    .:,ir.rr plram:i'ii iiziorosiei:4. ar doircat[b mdioiosi.r,lji:,r:j:iT,1T:. *,.r-fi ;. c! fln,e mari {Aor, iJuc]oi
    L,r,l rrl r r ndc sc- 'cicct ucazii algiogr a{ia select iviL, plecut n- |i. lr r r zi! ir r
    in i( I r r r
    ,,1,,,1;;ri,,i;ti,ij'iri,' al,'asiucu griji, a"vind in vedtl.c c i .numirtul d('
    Pcntru asigurarca sccurit[tii bolnavu]ui ln sala de carcterism trcbuit ', ( . i r n"axim iL adr nisibilir de subst anli ( k) . ( : ( ) r r' lr ir iil'
    I l i i ,,i trrl . r l, , r t it at ca
    t t t ' l'
    . , r'iiste hrti'egul instrrlmentar
    1,tn11u 1.^.rrimare cardiopulmonarir, clil c;ir.r. \1 " .' ., 1', ir
    ,
    ",r, ' r 'r n'r t l u 'lr l'
    l"ln 'lir : no- t ic. clinic. 'i cr r ' lr 'r r r '
    r:,r.ttcbuic si. lipseascirrriza dc oxigen, iru.a de intubatic, rcsniratorul ar.ti- i ; ;,, i, , l; ii"; 1"r . o\ ir r r ' f r ici si f ozit ioi r xdidlogic'' it ''r t r 'l. r '
    ' '..1 r l < : J ,[:L .i l " J o i u l c a c d i a r , s f, r' n. im r r llir r iLt lr '
    ' nr nr r l l ,' zi rl l r r t t r l lir t iLi |t : 1r : izlL 'r 'lcr ncnl- c1orhcm odir lam icc . si ll
    pt t t t
    ,,r' r,, r,rl r' , r '', r r i , \ l'r illl r L ' l: r r ' : t r l'liniir r 'lr r "- 'l't ' l" siqt t t "- r l"
    3.2.7.6.4. 11; ri l l rl rl (l l l l r' t !i l l r' l |l l
    Pregdtirecr
    bolnovr.rlui ,t ,1' l tr' l ii ,' rr' I i r rr r i i - r r t ' l i ;r' t' 1
    '
    '' '1 t t t l lxr r t l'
    ,,,,f 'L,,,i i ,,,. . 1r ir r , , xli r . i. r r 1r rs'il. lr t lr r i l. t t r t r l. t t i . r 'r 'zt r llr rt t1l sr : r is
    ','l
    I t r r lir ninelr t a z i l ,' i rl r.c :i p l o ra rc t:c 4 ri l rrln rL rl i rni nci r tri rl i t. r' rr 2.1 ,r,. , , t I , 'r 'li' r r r ''r li<, - clt t
    it lr g r 'it llt t c't 'r '. sii' so. xl) 11lr ij't ( lr lt r '
    i ,,i r)1 , s ( . ir ir c lnlt i. trtr.i l h a { i ;i i rr' irrl rl o c trnt"t L5 i di gi tal ti L. l rrai ntc rl ,, < :l rtrl r,, i ,,t,,,,ri ,l i ' ., rriir ii, ir i
    | ' r' l Irr| (| l I( | ( , I iLi, , r . i , l. , l; r l'r r lr '1ot 1r r 'br t zr r . iiiot 'r t sr 'lr olr it illt '11\ '( 'lllllllr llllcil
    r .rr s ' lir { , , r n io l l to l rl i rc i l rr rr rrPi i rrrt.o sttLl c i rrl i r:{i orrsi i i l i l ri .rral l i i .
    I' r,rq,r' rtl i r lr r . r i I r vr r ilr l'ilr r Lo|t t I t I t t I t t i
    , ,'i {i
    \4 ,i rnult, ln crzrt[ catctcrizirii unei vcnc pulttrottrLt'e sc poatc apltciitl'
    dact vena rcsp(eflvir sc vlrsl llorlllal
    CARDIAC
    oBTINUTEFRINCAIETERISM
    3.2.7.8.REZUITATEIE .luoi n.zitia rldiologici a sotxlci,
    .;ift-;;"t"tt*"i in co'dui drept' De aselnenea se pot face a1:rcci
    n;il,|;l
    .,.i]i." , "'-?.i*ii si pozitiei unoi J"i".i t"p'al atrial, sau d"spr"- "xisltrnta
    Vom trece ln revistit datele hemodinamice Ei radiologice c': se irortir
    obline (ln afar5. de angiografie). rrnci rn rsS-ria raportuti:i de pozigie dintre artera pu-tmonxra$t
    (transpazitie
    -f;,t-ti""ii"de mari vase).
    Pozilia radioloqiei a sondei poate si ne dea multe indicalii
    -
    ,.vi.Dtualaianomalii congenitale.
    ''-* intraeavitart. A.. P r e s i u n i tre , a b s o l'.u t e se m:tsoar:1
    t" lii".f"f hidrostatic di ',zeto" este la jumltatea diametrului
    nn mod normal sonda introdusb. in vena cavi inferioarit (a) an i:ormsterior al toracelui.
    te-*iio*
    rlirijatl spre atriul drept (b), ventriculul drept (c) ;i artera '"*"Ei;t pi..i""" care intereseaze: presiunea sistolicl- P"'
    ;;;;""l"oia"
    (rl) (1ig.d.a7). presiunea-diastolic[ Pd Ei presiunea medie F' Presiunea medie este inte-
    t^ -'- de un sistem
    i'ratl electronic.
    -t"i*r"r"
    aie-piesiunilor sint indicate ln tabelul 3'11' Dopi't'

    [rr\ [qr\tkr)b
    vt"ili"
    certi{ici existenla unei steri patologiie'
    t"*- *.'.'stoi limite
    oir*o
    i;;;"il; si se'refin5 toate ;ifrele de presiunc' Asi f' l'
    "" "ti"-"tit pt*inea'medie. La ventriculi nu intcrcscazlt
    "ii"iiirii"
    """r.;''"fri?";.i; t;*.dilt$ presiunea sistolicl9i presiunca chrl'L
    $;T;;;#;, telediastolicir'
    -Eio"ta,,aj'), denumit.presiu;ee
    SriisiiJai"it"Gi 1i-"ii"t aopJ"oa"
    p"rii.r **"t" seielin toateiele trei valoii, ceamai-importanta fiind prt:si-
    _,iriil11,, rrnea medie' "
    3' I I
    ,7\i
    . 1t :.!

    ?r1
    'obetrul

    ,4"j , t+j
    rr c .. lzt ir
    .fre$lunilc iqtavascultro
    -'iit.*1"
    fi"l.*t"rul
    (in metrg)
    de e:'plor#
    qasite la copii 9t 24 adu-lti din prmet ilo aeiloro hol|lo'
    i""l}io"*re'aI Spitahlui clinic Fuudeni - Bucuro$ti)

    -.a '. I ?ara,metrul mA$rrat

    PAD 0, 6 3, 5
    Presitlnea, medie in atriul drePt

    trAiIro:ih:i
    dreaPtd PtdVD 5, 5
    PrcsiuEe4 telediastolice ve[trictlara 26, 0 0'9 I 1, 2
    Presiutlea sistolicd ventricubre dreaPta PsVI)
    Crartienlul sistotic intre vetrtdculul drept li artera 3, 8 0, 5 3, ti
    oulmooa.rb
    dpvD-AP
    PSAP 21,8 O,E 10,{
    I'resiunea sistotca din irtera pulmoaare 7, 7 0, 5 3, 6
    Presiunet aliastoliob, ditr artera Putnotrar6
    PdAP
    FAP t 2, 6 0, 4 5, 3
    lresmdcx medie din artela pulmonara
    Presiunea medie din capilsrul pulmooar Fip 0, 3 {, r
    PsAo 116, 8 2, E 33, 5
    Presiullea sistolic; din aorta 69,5 1, 9 22, 5
    Presisnea diastolicd aLitr ao*e PdAo
    88, 5 2, 2 26,5

    ,.iL$J"
    Pr€siunoo medie di! aort6 6, 8 0, 2 6'l
    Fr€siude& telediastolic, veatriclrlad' stitgd Ptdvs

    N'E.Nus.auobselvatdi'Jfel1lesemniJicativestatisticltrtfeP.afametriisubiec'tlolodultl
    " -' "t.Jl
    a" coPiilor. To;te cateterismele s_au etecutat sub anestezie1oca15"
    lat. ""i.l
    superioarl a presiunii ventricularc
    Fig, 3.47, * Schefia !/oieelaei rail,iol,ogiaee sondei de adteterisrrl. Se accepttr ca limitl -telediastolice ventriculul
    lmarl,,i ndld.oDice ltr roziti. anl€.oDostdi@ra lAPr s, latFta.l llai,. a. sondact vnlul In vrna cavd lDS"h a."oti" ffroit"l
    'ffiii!. d"-t ;-r* 1noti"a"'n', 1966) iar pentru
    h. ti.trlul (lrerri; " ln v;n; rilul drepr; d, lo dtc,a ituibontrd tozilic ,,n fxndal.' sau D , oPilatulu | lult|'oDut ' ; n.
    lirir"e'rz i".^t" complianta ventriculariesteanormal
    ln .triul s11tr8prin comuicde ial*aitiau 'n j f-ln vena PnlrnolrarAs1iifid i
    nrl eond.j r:rc tF.rr
    ?. ti io v.'rrri$lul srln8. de scirz,utit (hlpcrtroue
    "l".t""iii"ite
    mar",.t1, pericarditl c6nstlictivi' insuiicien]l con-
    ttnt"llh,ra
    ln defectele septale atriale sonda poate trece.ln atriul. stlng tn vecleredificuliatea cateterizlriiatriutui stlng,.seacceptlt
    lntr-o veni. puln:onai{ (f) sau chiar ln ventriculul sttng (g). l)o asem
    poate trece printt'-tut (lcli]cll
    aortl printr-ur tk.lli:cl sr
    presiun"ai c"plionat[ ln aqa-ziiapoziliede ',punte" saude capilarpulmo'
    drcpt sonda poate
    ul drcpt
    din vcutriculul 1n aort[
    trece ln
    intclvcntricularsus situat, s50
    ss8
    l)l ,l IL p, , , 1 I , ; I , .7, .1r I i rrr I
    ' li:., ,l ; lr r c s iunc a r l i u r r t r . i r r l s t i r r g ( l i , ; . t . t ) '' ""
    r(rlrl.r l||.llir{lllri ilr : r r t , . r . r I , r| | rI r, , rr: I r ; r l, l. in , . i r l , . l , . t i s | l r r l l i , t r t r . s t , . r r r r r r r I i t I I
    il,ll l)r't tl{
    '. Pitli_q ' 1, . 1, , . ' , . 1, . . . r : ls lu! ; o t nic i r i r I L ( . f i r 1I u Ir ri , , r, : r r ; , . [ r l i r , , . , 1
    Itl(irl| | lll r)r'rljctul dl n v ir lll . . r , , lI i nu llr ir i r ,i l , . . L r l , f r r [ ] r r r . r r l i L , r , .: ,r rrrr rI rr1
    lrrtcla I
    'lrn. pulmonara, ci r-(c(]ptioneazi.prcsiunilc transmisc rctirrgrrrrlrlilr
    rlrirl .tilr(' prin vcnFlFgi crrpilarcl^puim.,nar,.

    Sonda a/rid/d s/fngf &$


    ri.. j..16. : tir
    la ..t. t a ;/ti.r stt,t, | 0 ., tt,..i ..Jt p.!,.!i . -., ,t !1.49, - C l ftba Ll e pres hal e nc v mal i ddtl atri n (s ti ,.' i ' ). D e s ns l nj os , ti mpul , E C G, c urb
    . . a p :to t !tr i p .tt,..a ,... . ":.
    , ,. lrresiure, liria de rcfedll?l de presilne ,,zero". La stlnga, scala presiunilor in flln}{g.

    :"i.l:{ii-:i' ;,;;-i;:l;Ji[r riii,;[j,ri"i,


    i,?i.;rl,*i l]ri;iri11 ,| 1rac1i. at.i.li ; C. flosentrl inchidsii lih'elor iirioaentlicllse jX - depresiuneadaloralii denlagitii Pldietr]! i .trnl

    -.
    r "':'
    ...;.1,,':
    'i'rnd
    sDle ratricrl tu titrf.l expllzieii Y- derli.l@ valtai {id.veriricllartj Y =tc.io.dr de urDletetir'nlii
    "."?-L,""::,t:';iiii".:",\,
    1i:."1n-!'.o,.d" j?,,:j:..;-;;::.;,:

    :I
    l)resiuneacapilar.i_.mcdie rnar.cdccit 1:r,,irrrrr,l
    ,.
    rrrr'<liL' -
    din.atri rl.sting, diferen!i_este,cu 4uJ1n._.rnai
    insi neglij;bilI. p,ltru clinic:1,i,, ,1,,,1,,1
    r:irrrl r:rist-i o hipertensiune v€noase puidonar;r.
    l)resiuneacapilari este un paramdtru hemodinamic extrciti (l(, rrrot
    l;rr{ carc.arat5.,gradnl de cr-egterea prcsiunii arteriale stingl
    ir, f,,,,,,J,,ri,
    rrrit.al.:,iar. in lipsa afecfiuni- mitrale cstc un i'dicator al trrrr,.1i,,t
    -urrei
    rlr' lxrmpir a ventriculului sting.
    li...C.trbelc de.y'reii rt zlsinr dilrr iic dcla cirm!,rjl;r ,.,r,r,.r,1
    tnl"qi.,t"ta in atriu. prezinra oscihrii clc .rrrrlrlir|l,trr''
    lr||r'
    l,,',.,,),f,1.:
    ,r (_drlcr(lyll,1
    nllata. mrca) la valo.ri nrici de pr,.siun,, curba ,j,.
    ,]l', l,r,.i|l|||'.
    ).li"lll:,1 gI:'tl^rtg 1-o,t,Odine nraresiiroiico_diaslotici
    (rriri:r,,r,1rirt,,
    . ' rl 'ti r), t ar . ur ba de p rc s i u l )c d i n a rto rJ c s fl . ( u atnpl i l udl n,. I.r.,I,.
    r ,t,rl
    r .r \'.'l n n) lll1 m ar m a rt d e C i t i n a tti rr.
    I)rcsiunea normall atriali., (fig. 3.a9_)are o configur.afit:
    ciLr.r t,:ri.,
    li, ii <rrrtlci unde pozitive (a, c, v) urmate de tr-ci pantc ri'cgativ,,
    (x, r,, v)
    . Cl r: l. , iL. de pr . s iu n ( d i n v e n tri c u l c s t,. i d cnf i ci cu cca rl i r, ;rtri rr t,r
    I 'i l ,,.r'l a dc t lm p c it v a l v c l c a tri o _ v c n tr.i c u l a rnsi nt d,.scl rj sc.D rrl r.i ,:...r,,..i ,,
    pr i: iu n :a i n s c ri c . o p a n r.i ,rs ccnrl cutri i n ti ni l ,rrl ,,i :.tol ,.l
    I1;rl .y; 1| lnlli'
    {,vr,1 - , . inc, ,hid,
    un. plat ou i n l rc rl o i u l l ,..\p l rl s i (.i .rpoi () pal l i i r ,l i .s(,, ,l ,,nl l l uB
    ;r
    ' r-{'l tr\ll t ls ov olllm t cr' v { .n l tl c u l i [.r..
    (lurlra !;i t, 3.50. - C l ba de f,res i v ne hal nal d. d.i 1r' u)rtri c ul (drz !t). D e s us i rr i os , l i mpul , D C C ,
    _de prcsiunc :r vcntrir.rrlultri rlrcpl sc ascaminir nrrrll {.u (r,tl , lrLaL dc t)rcsinflc, Iinia do refclirrlr". l,tr sllng& scila presirnilor ln nrl{g. Ps '. plcsiunc& 6i$
    'r rri 'i t : r r I r r I uis i: ir g ( fi g . 3 .5 0 ). l )i l i ' r' r,n { r l rr' rr.r .r' al i .onsl l l . l i rrrrrr' | ,l r'
    'r tol i c i t s rl u rmrx i nrl t. l ' l rl prc s i ul |c l d4di as tol i c d,

    I r(i 0
    5$l
    , r".i, lr,,ilrrrirrrrrrtor.izoutal
    Lr vrllr.ir:ulrrl
    stin( 1i t1r,.,r,,111
    ],'ll'il;_lll"lk,'; r t.rrrr,l ri .r r ': , 1| t t cct 'slr t iipr : t t lt r t r ; lilcular t ladcllit r r lt t i sit llgLli: rl'r r lr r r or r 'r t
    /.r \, rfr trlrhrlllr, l'i. \r',.r',i/ ,lili,n,utiL
    cstc r:orrcli].iotrlLtir
    rk:r.czisl'r,rr
    rr r r r r l.
    i L f;r rlilr ,l r' l I' l rr, tl ti tt l lr r i liir h ; i pr lr lr 'r r t lir r glr osliculcvcnlt t alclor . r / r ai; "1t r r r r lir ir
    i lalir . dc a l i -r,r;r 1 rrrIrrr,rr;rr,r.S c i r,l crci r ,.x| tri rn,' i al L l L
    ltortrr (lotcrmiui. lnc.[nilrca
    a1)rttillotcmrua . 1ri ,,si ,rrri i r,l ,,l ,' rr.r ri l c ul: t {ii.
    lnclinirLca platoului
    Dlatorrlrri sistolic
    si.rtolic a r vc]ntriculului
    vi.nlri,.,,t,,t,,i stiitg,
    .+ii,,, ,-.-l
    ( f, : 1, ,' - ,. r de pr e s i u n , i n . t,.ri t p u l mo n a r.i s.L,L r 1x. /rrl rl rrl r llt ': r lr lr tsiit t g: r t r slc iLr dicat cu lit cr a. ; ; i poat r ' 1t lr r r r ir I
    .c r r lor \ ' . nt r r c u l l _ (d ^ c x c mp l u , d i n c a u z a S ,rl i z;,,i ,rrprr..i rrrri l ,,i,l i .rtri ,l r' , r 'r : r ir ict r lu - l" sat al m ar ilor vase - t "'
    urrui rl oj ,.t.r ...p[;,1 v.rrl ri ,.rl L'
    't1' , , 1, :' lt . eaz l p l a to u l s i j to l i c a v o n tri r-ul rLl ui tl rqoL. ' Itrrtl rll rrlitrgirtlLoirpla inscrlnat cu liter:L - l' - cstc t1'f"r'' ' i' tirll r rl t
    ., ,r" , r ,.rrrl i liili t lc silf c din cilculalia st ingi- L spr e cea dr i , pl i l;
    de presiune diir artera pulmonari. si iortir sc asc;uua.rrri 'r t r "l
    , r lr r llicular - y" sau aor t o pulm onar - - r
    r .I ii111l{1
    {Ic, 9"*.
    irirld o-pant:r
    o panti ascendenti
    rscendent; rapide,
    rapidi., un platorL
    platou sistolic
    sistolic asemirniilot_
    ,i rrrl r"
    ( l(
    asemirniilor_r,rr ' ,i /r/ rr l lslc diagnost icat pe baza conr l) ar a. t ici Pr ol) "illi ') r r r r ; . 'r r
    vcntiicrilar, incizura dicroti. datorafi inchicl-criibrustc a valvelor.sigrr.ir
    lir r,,,,l r ,1, ,l i rr r r r vit i! ikr inim ii. I n cazul unei sr r spiciuni cL':t h't t n'l : . 11n! . ', t t
    dlgl".i[,91rpe^.1:S
    presiunea
    scactc
    tent plniuia,, rrr ,l r, ' 1,1.r r' , ri r r r g pt obc t lin cele doui cave, din at dul dr ept - r lit r vt 'r t it i r t l t l
    .'l:::1i:i^9:a"41
    {l('schidere sigmoideior1f4j. :.st). ,l r' 1' .r.rtl l t,r lir r lir r onar il( uneor i chiar m ai m ult e pr obe ciiijr i. ( r lir r ; r ''" r , i
    . .9]iTtro pnn.sanglrin{ direeti. " Mi.surarea concentraliei oxigenulrri , ,, rr ,t, ) l)rrcri Du (rstc uu shunt stinga-dreapta, oximetria chtr v|rrr lt ' rr"'
    sond: se poate face.printr.o analizi. chimici (Van SI ,ri rl , r' r' rrl ti c t t l ; i at - t ct 'apulm onar i sint idcnt ice. J. iacir r x: it lr 'lr i'r r r r r ''li' : r
    ill.:,111:
    :",t1.":
    clcctrometrici
    lpresiuneapariiali a oxilenLrluicu ,,,,, i,, ,,1,,r ,l ,,rr,i r r v, ' , 'st r : m ai m icit dccit oxim et r ia clin at : i: : vcr r lt r r r r l , L
    '
    "i".i.o.iri-Cro*y
    mclric.rin doui lungr'mide undl, rogu si infraroqu (oximetru Atlas. l(irr ' rrl ,r, g,Lrl rrr or r t t . ii, at t t nci exist i un s/ zaaf st inga- dr capt a ir r i'L: r lr ir l l' r ' r
    uetoflr lotometrlc; este cea mai utilizatl fiind rapidl, comode si ,' rrr| | ' l rr.r ,l i r r ( . r r t , t :cst e egali cu cea din at r iu, dar in venir i( r r l : r r r r i't '
    n(,i.cjiiil
    caltiliti reduse de singe. 1,rrl rrr, rr.rr,r rr l iliist : ; t c un suplim ent de singe oxigena. t , ,inr lr r . ilil r 'lr r ' r
    trt | t .i rrutl l r r r r ivr : l vt : nt t icular . Un canal ader ial cu sr ?lt r i r '1; r t li.(rlr ' ! l'l l
    l' I rrrL. , rr 'llcr clr oxilt r : t r iei in ar t er a pulm onar : r f at ir r i r : ; r vilr ilr t ' 'ir r r

    l rrr1,.,\. [ 1. lt r r dolph gi G . G . Cayler ( 1958) pent r u a t i ; 'i; ; r r r <r , r 'r i li


    ri , ,| ,1 :,1i rr i'r rr lr t '[ l>l. a,t r ebuic ca dif cr cnla de sat ur at c ill ''r . ii] t t r r r I t ( , l"'t
    ,l rr, rl rrrrl ,l r,,pi llii 1ir :cu 10 pr ocent e lr ai m at e {af idc plolr r r , liir vlt r r l t '1
    ' .tt,. I rr' .u.r: 1 , i, r lr : rdc singc din vent r iculul dr ept si I ic cL1- cr rir l t r lir r 7'7, r r r 'r r
    l ,r' ,l ,,rl i ,r r lr r r r lcir sing- elui din at r iul df ept ; pr ola de t ir r g( ( lir r : r r i I . r
    ir / r 'r 1: t I 'r r llr
    ; ,1r I rrr, ' rr.rr.r : r,i lir ' <: r rccl pulin 5%) m ai r nat e decit sat ur ar i: a iu ''! 1
    l rl ,l rrr r' , rrIr ir : r t lr I It lr cpt .
    Ir, ,rl rr ir l'ir ar - t cr iali lr cr iicr icl cor cspt r ndcscir dcr ii oxillr r t r t ir 'i ; r r l( r r '] lr '
    r ) ll"r i I I bO r . Cot npar ind pr obele de singe r ccollat e t lit t r t ( t r r r l
    I' ,,r1,r, ,' rrrlr
    l ttr,r' . r' , rrl ri , r r lr r l'siir r g; iit olt ii, 'sc poat e pune diagnost icr . r existl ( : n1( 'i\ , / / / / 1
    rrl rrr ,l r,.rIl ;r r ; 1it lAir .
    lirrrrrrrrrttl dt oxillrrtr lllol) 1. (lollsumul de oxigen aI subiecttrhri .r 1r' 'rl
    r'
    ,1,,11,., 1,rr,rt r t r 'lr t t r lit t f or r t t t l; r liicll pent r u calcular ca. dol) it ului '; lr ( li '
    t,rr, ,rri rrrl rl r . oxiplr 't tsc r t r iiso: t t itpe o dur at i dc 10 m in. , r ecolt hl( l a( 't r r l
    ,.1,rr.ri rl r' l, olr r r r v : ii r lnllizinci conccnt r at ia oxigenului t lit t alt t t 'r r lt r : r t l
    rr'l 'r,i l v
    t,rrr,,rr r r r t t tl lc oxigcu sc indiciL cu sim bolul- VO r - 5i s( : ( r il) r . ir r r 'rr.t l
    IP rrrl ,,,r1' r' rr1rt ,r t t it t t t i cr insunt lJi de subicct in per ioada de r ccolt lr t ' r lit r lir t r
    Fig. 7. 51..- Curba dt..pytsiu'rc ,Larmdtd.tlir| o,yteld,(pulrnond.rd), De sus ir jos tirnplt, 1,l l ,,' l , l l ri sr r t t t lLt i,
    curDa.dc presrunc..in:a dc re[erinfi. L3 stjnga scjlJ presiunilorin,nmllq. l 4.rr ;rrr lin lr r t : cr i5, 1611s111n11.t le oxigen
    1 se poat e apr ecia leor t lit li 'lir r
    I'; --rrf lrunea sistolicl; Pl - presiurc. diasloticn, id
    -iscizdra dicot, sau dollcolu, inchiderii valvctor tul ,, l , .rl ,' ' rrr i'lr r llolisnur lr rbazal
    i ir t f uncf ie de sex, vir st : r , Sr cut ni( 'li ir r il
    l l t ttr
    Valorile seexprimd.ln volume de oxigen conlinute in 100 ml r.le singo
    PARAMEIRIIORHEMODINAMICI
    1../.7.9.CAI.CUTUI.
    (vol. Oz/1oom1) sau in procente de saturaiie in oxigen a hen.roglolrinnl
    Jlz
    SOr - (HbOs%). lntle acesterlouir valori este o relafie constantiltr,I gr.illn I' r. l l rzr r r , : r lor ilor oI r I ir r r r t c ir r lir npul ciii r '( r 'tislt t t t lt t i cit t r lir , ( 1u, 'r , r r r r r i,
    hctnolllolriniL
    cornplct oxigenatl fixind 1,34 vol. O". ,,,rl rrr,l ri i ti r or r slt t t r lc oxigcr t ) sl t lir l<; t t lt : anii i, ir ( li( r dc r lat t lt clt t ot lnt lt r t t ict '
    l nl . r rrr i ,' lit , , 't v, f t llr l, lot r l I t ir t r '{ior I I t | ; t l lr olt llt vlt lr t i.
    l;{iu
    I r liil
    . , . ?olitul sauguirr.Se mi.soari..debitul circulafiei pjrhonare _ ep rltri olc., tlar ccl mai importatrt rirmine frccarea diutre singe 9i peretii
    ,lcbitul circulaliei sistemicesau d.ebitul uortl" _ f,":. ft,*:"r." .ni"-...ii. direct proporJional cu ingustarea l rmenului vas-
    sh#:tt Qeo I!l eventuatctcb
    't'' - -,. sau sringa_dreapta _ ey _.
    rierocracea_s_tllsa
    ^d::a!^tamal exactd-gx.
    de determinare-a d"biiului cirdiac sc
    y:,.principiullui Fick:

    to:
    B:
    ^
    wA _ \-v
    itl,|rtfo h nlrm;idtor este consumul
    .rrr.rr."venoasi, tn oxiger a stngeluialeoxrgen al orgatDlui exarninat, iar la numitor
    iitra !i i"."i?ii-r;G;;;;i ;;;.;:
    "or"

    g,nrrtuidin singele "liff


    venos
    ;d;;;_
    c";
    Ti#,Hl*i*';lil11'l
    :::l:*!r1::$d*i'i"T:#:i:T$;ffi
    _'ffi;::;#";"d'#,uJl";j trrrr'il)ill (stt'noziivalvul rri., co:rrcraliearteriali).
    rlrrr .iirrgcledin artera puimonari ' it,n,iti'r,iiui,"nlinn-i.t care coreleazdrezistcnta- R- cu debitul
    C"".,
    de catiut a debirutui"aortic, ta numdritor ,,,rr - () -- qi cu presiunea - P - este:
    r'irc;i"or,,consumul
    ,,. ..",i^1"^:a:ll d" remine acdl
    r;;;;ililr, ii"l?r.iii'f il#,lilI"il'l
    "'.t;"i
    j.:lll:l::.li.l!i...*igenuiuidin pormo',"ia :_ a,;:_ ;;;;; R-
    P
    -.-
    ox:ri,)rrrrlur "e,r" ""o
    9ll .T"g]" celor 2 cave- Cu. _.
    t.a*-subiectii I
    firh a-"titii"pol_oo", este egal cu cel
    "lr"l_"ii rrl l ,. r:rrvi rtl r' ,t ) ( t ) t r , r J( pl. r r . r f r . 'l unei anut nile canlji5li dc iinge in t ilnP,
    Y:i.r.',tft:H*L
    l;iirtlt;iil{Ji.*#::?'i'l:':i'Xa:"[ffi?"ff tr.r rrrrLi rczi st cult '<lir r. lit c'r it r r l cir culat or . inim a r r ebr r ie s5,c, r : , ls, citpr, ( : siu:
    lru,rltn,,lnl',itlc r',,zlistent:t.Prcsiunea este rezultanta dintre debitul de singtr
    ,,,,,,^,,,11'1",;l/ulXf,&,t:;fi
    X""1,"1J,i',:;,1,r"'1fi'y#,J:T:l'lif
    lrl;
    rrrl,rrliri rczistcn!a 1a ie;irea din circuit.
    |.,'r,\ ,rrrt,,,tcircul;rrornnrmal,si:lemelcdc contTolau tcndill!1 dc-il
    pulmonari:.oricc tnrrtli'
    r,r rr'r)llili
    'r ) l l i l i lll('l)l-c:-irlnill- tnr',lii
    l ( 'l) l - c:- i l l n i l .l - tn dill
    r \l l l d aorti
    lll a 5i aartera
    o r l i l Sr r te r a p ulrnonirra orl
    ,, ,l,ll,it'rlnilsanguinsc insole;te de o adaptare a vasomotricitifii pattlhri
    ,i,r p,,rifcr:iccu rnodificaiei corespunz6toare, a rezisten!eivasculartr,
    """""1,l;i';llli;":,?'T;T:1,*r:i.,X""ifi;*i:,"i;,,lliT.",1X,:'";if,i,,,i,,'ro"ifi,ll11,,i
    'rl i .r l)n:siLulcrtrnedie din arterii si. fie
    menlinuti la nivel collstant'
    energetice C'(i'S'
    ln unitlli
    ll,'listcntclc vascularc se dimensioneazi
    rl l rr,,. srr:./c t l - 6, cn f or m ula:
    Parametxul misurat

    Ii \dvne.sc.. : f{*n'HsJ' t t;:


    Ir t ! 10\ c ud i a c (l/min/m) ".-01 t(n /sc!.)
    l)tl)it sistolic (mUlnr)
    r.c. 0,2
    Oorrs urrrc l c , o x i g e n r J o r e i i c la p o ,r a L P sist. l'6 !r txrre I J;l.l osto ftl,ctorul de corclalie.
    ta ccl m iisu j.a r 1,0
    (/xultctn.1 in artcra
    pulrnonani 0
    l . 4rurnc d c o x j g e [ i D a f f e "a p u lm o n a r a {bor%AP 0,6
    ( r$lnc lrii, i n a o r t 5 , cAl 13,9 0,3
    V olruDe d e o x i g e r i n c o r td HbOs%Ao 97,3 0,3
    i nlc t c | lli, a r t c r i o . / e n o a s i pu lm o n iL r j c-ro o'1
    in o \ig e r r croc,rr o ,I ll;
    N.B_.ND s-.ru gjsit di{erente scmtrilica
    ,hve statistic tntre yalorile l& oopil I4d d!
    {rdulrurui.
    'I'oate c4teterismele s-au
    cxecutat sqb aoestezrelocali,t.

    vaseulari.Gradul cu carebe'opunepatul vascular


    ...^ ,,|!:j:t.rt"sauguin le rllu'lt puhirrinath.aduiratit-la rezistenla capilar[ puhnonari"
    'cil 'uxurui. cste denum-itr.ezistenlrL
    irascuiar{.AJeastore I;ormtik'l,rla L,nlcul'slnt:
    :*:^P*St,:T-t1T11.dcmai nrLrlli factori, rcspectiv de ,.eeilnuide ecur
    )$$ii,i:::1fiil'ffi
    (rczervornl
    clasric),
    dc
    iill:it,i3il,11h,,,litiilil.f*-,d:f,'llll,*i,t'#
    'f;vifr.za
    de.rbqt".uoliiii iniirili,"fi*i'"li,,
    ltt A(J (,1\r... Roc.crri)
    -
    PAo (tn11]{n")

    0Ao (ml/ioc)
    '
    1 332

    ^*rrrfi
    5fJ4 66$
    pAp (mmHa) do slttrnl'l)irgnosticLrl scbirzi)azii
    lttl, {,ry c. s,{ . ,in,-o)- ____-:_:. J li2
    tlr lurtlrirr ltr sitrtlromul ;:1ill"tllTl
    oximctri.ide-la n cavitat''
    ,t,::li;:;;,1i,i,,i'l,,i"-"iiti"r''i-'';;i;i{i""ii;;"^'

    tll'a:;'lt"*:;iT'::ln'f
    gAp(mt/6ec.)

    iriiilul';'
    ;iriirli:i,,ir
    ,i,.,.x,,rr1>luo crcritcr.n',-,"i"ittorn-ro-tt*:lf *:""";f.:lf-l:lilll

    'fil'ii;
    111,r
    RaP (dyne,sec. crn-6)
    -
    ?*f * Fcr lmmng)

    QAP (ml/sec.)
    .1332

    lr, illIl
    lif, ":$
    ( l l | 'l ) l .
    Rcp (dyue.sec.crn{) P9S4
    : . t :r, 7 a b a l u l .l .l l
    gAp (Er/sec.)
    in care 1332 estecoelicientul
    de coreia,tie, r'rt'orto"t1 r'ilcriuto Itrlmo are i rnl$t4 cu rc7istg:s:ctl::l;:I-:I1
    ?Ao_ presiur,€a lr,rdiedi'l acrlr, IAII_
    rnea nrediedir a*era ptrlmonali, pcpl: prcsiunr^e ::ll
    n,.J;. a,o .r1if-ai.,i1uro,ouo",

    *I$,?itt.rT:rstenletor
    vascularera 42 de subiecfinormalisint rso,.n,:'
    1^-*i#ffi;
    ;l;
    _l
    " Avind ln vedere cb.rezistenleie vasculare cresc sau
    j'*":g't*:t.-"*l*ru:
    |;ur,!i#"'i.::?1f"il;'?19"",1?ti,
    fi fiziologici sau patoiogici.
    scad in mod
    Inii'
    '^-'lT*l}r:Lmn
    toLolf, Puhnoflata';
    ItlD , rrrzisl.tiDl.l,
    . Pi" acest motiv se-recomandi raportarea rezistentei totale ttti,, . r'r'ristcll-a, totalt aortic5"
    - aortici ntplna. i_
    uk cre;tere
    -1yt:t*t.j::"1i.
    a RtP-eluipestelirnitelb ""r"1"
    indicate "riii"ii""i""l
    in t.tarig.1t, d"r c* *'I se utilizeazi formule derivatt: ditr
    f',,rrtlu tlitncnsio nttea skunt'dd'
    r, rl rul l rl i Lr ick.
    Irr l i tztttilc ct t un singur shunt,
    vol:tmuLacc5tuia sn d':duce tlin tlilt'-
    nczistctrtolo va,seularetl frcc.i:entacariliaei obscnald la lB copli p4
    ntorul de expbre.i tulctionate a Spitalului Clinii Frlnrtni9l ndulil uortuolt
    l r ,l i rrll t: tlt $it ul
    sanguin Pulmonar ti ccl ststcmlc'
    _ i3ucuregtl) - Y-
    A \l l (rl l ,(jl1t r t l slraftt-tl stlnga-drcapta:
    Preoaturul Dldslrrat lt . By- Qr - geo
    sirurrl-uld rcaPta-stitrga: - x-
    lr. l|.lt
    Ilnzistenla toraLl pulmonara (dyDe sec. cm &)
    l(PzistenF artpriolar; pulmol]iri (dyne. sec. c(l {)
    liezistertc capilari rrlmoncri ldy6e. sec. cm 6)
    RtP
    RaP
    232 l",
    118 19,4 Px: gno - Pt
    RcP u8
    licztstenlatotBlS aorrrca(dyne.sec.cm-6) formule mai cornplcxc:
    tlirrrl r:*istit shunt-ttribiditeclionalese utiiizeaz[
    RtAo 1678 132
    I(aporlullntre rpzjs+ec1aairer;o1ard
    g capitad pulmo.
    RaP/RcP 1,0
    I
    .llaportul lntre rezistenla, totali pulmoaari 10,0s
    9i aortici gy: Br,o- O"
    x 100
    Itecventa cardiacib colii
    RtP/RAo
    F 106
    ln,o *
    Frecvetrta carctiaci la aadti 13,8
    82 t
    12, Qx:Qr- o'.*_#:
    N.B, Toate catetedsmele s-au licut sub aae-stezielocal6,. lntre parametlii
    copilbr
    r! se gesesc diferente sedqificative statistic l; ito.a - .ie 'trecuoulo {
    adullilor
    (p < 0,01) Ol
    I "b':;.',l,,q
    f6 r,rrrrQy csteilebitul skunt-t1tttij:t."ci:*i,:"{-Lg:"t::11t":::,1i;:lil
    iiil'i;illl;l'i,\"ifl
    i1,,.,
    ;ll,, *;, g [i"P:'.i]'""1J]l[:tff'oxigenului
    Jtrftl'*1
    rn vu-
    RtP/RAo normal, corespunde unei c_regteri
    fiziologicea rezistenlei
    liliii
    -X "?fi
    ;r#*l[#;;;i;;il;"r';,-9*,,::*'':Ti];.
    ;:;1;::it:ll:
    pulmonare(sciderede q;bit cardiac,hiloxie, ilro"o". i,li"'i"';.1;";ic*
    l"''illillll'.hJ' ?::q:*:i,'.:,'TT"1;
    sansuintr
    ia"ion"""t"9ia a oxigenului
    1l^::llpP^-"1-"I"*a
    RtP-urrd estepat6lo.gicl -"ai8u"r""t"
    dacl qi raportui
    clescut.(spasmarteriolarpulmofar, hilertrofia Jar"i[;il;; ntlr ( "ii?r,l""l'i''viii",
    ltr vrrl, )n lr 100mt destnge'
    peretelui
    perctelutarteriolar ' ;;;i;ilfr thr",rri sltlrl-ul stlnga-dreaPta este
    raoortat Ia mtrrimea dcbitulur
    artenolar pulmonar,
    pulmonar, pat pulmonar
    pulironar exclus,
    exclus.lio-r,l tr.,"n ,ro.",
    trorrrlrozc
    pill_?rij"l stenozdmitrali, pericarditd constrictivil, conrpljflrll:1
    Venlncululul sting).
    eror
    vascur
    ateranonn
    dt o'%= ' 100
    dr.,tt:'s1.Xltt"3i'li##SilJ'ffitff"Tfistenf *:
    |8r
    560
    ,5hru/,t) <lrcrtplrr
    r,lrrr1,,r.r,r:rprrrtclrzj.
    la tlcbitLrlaoliir::
    l! rlr l| irr r:o1rilrlc I iur, reprcziutiro stcnozirluedic pcntru un copil dc .vlrsti
    1',,1.'r.rsi r.riic o shnozir strinsiLlxrrtru un adult. Am propus mai clcmttll
    ,,- t?' . 161;
    1',,'1, lr.rilrr'r' rlc stcnozarc" a orificiului trortic Ei pulmonar (liotiadc ll., lq.5())
    ilAo
    este raporrarcadebitului u.riciir irr.rrt.r(tl
    , | |....,,,']]
    cr ;u _]tl-.]"".U1",.:.nrii11i:.
    marrl crrculatii _ Op/QAo, ./r/n
    care la subiectul normal i,slr, ,,Airl r,il l /ll l A l
    est"suprau"it",'iirlJ^slz,,t-,,t t/g -,.J1-'!,^1 F/---1'^-+-^-1'*'r"^--i"-J",*4.^'J,^-{^
    ,l,il,,r,t,,
    'iii'?i"ki"rY#,1tli.stinsa-cfreapia
    Datele clinice pe serii mar.i ric bollavi arati ci, o crestere a i_alror.trrlrrl
    ',,
    1 V " " . P " s I o. I , J s i ru g l - p r.s t(, -]3 % d i n o p
    l , rrl rr ( lr ( uiallF c A rtsm o ti v ,.a z i r c o r..c ti ; rh i ri _ .
    /r'orma/
    :l:,1-:Li)'.';'ij j"]ilt;;l i:";Tlll:"1"t
    si"ii.",,l"'' :i :lii :''"i;i,,,;li;;
    oif".* difercnla deI r t 'r " s i t r t t l
    ,, ixii:li *:,*t'lr ;rto.;,L,::t;i1?*.:
    '",,Gradientu] piesion:ri poate, fi ,,cte ;iJ;;;;i; diferen{a t:r"ir rrrnl
    rrr:rr" tdintre
    linlr n ccele
    . lc doui
    do u i cca\ititi
    :rv i l i ri comunlcanfe
    urlcante, sau
    san gradientul,,mcclirr,'
    r,r,/,tion+,,1ri^.r;.., f( ,1.
    prcsi.ile,;"Ai';;;i";;"ie ;;;iil, mirs.,,r.;
    lll,illl"ftr,:,'-Tr:1jintrc. r,,l n'
    J,r'rioada cinrl o1. conrunici.
    . .. Gradientul de r.{rf are valoare numai infornativl, in sc]iimb cctrrrrr.rlirr
    iririr in calculul suprafctci de scurgere a
    orificiului.
    \
    l]f ne.nosti ttl ..p-o;"ra/i, oi'";'t , uo2ei ; ,., I,r.
    lr]i:*Jii ,.url.,eidc pr-esiunela re_tragereasondei dintr'-o
    rrl l rr',(fi
    lijl1 ]]l:,'
    g. 3. 52) .
    dintr_o carrl.rr(.
    cavii rir. irr
    lrl
    ln nlo(] uu sint difer-cnlc.dcpresiune
    semnificative
    in timpul aiastot:iventiicuh?*;;"".:#;l'o'irrtr" inl.i..
    119r1"-^rrtllat
    ,ri vr.nhicut
    ,,r
    rrlrirr
    rrttr.rri. perioada
    in perioada ' u, , i,,,,1
    ,] ll.ll*4lll explrsiei
    expursiei niir"g"ii;"!l"a"i
    n.lr"n"rir^^.l"a.r
    Iletragerea ,iin
    ilii rr
    sondei rlin ,,,i,,r1
    ,,ir,,r,1
    r icril
    'ri """t.t.ri".".
    ""nt.lcuia.".
    o curbi t;ri gioienf
    i, ,;,,::tl,"Fijl 1L:1,i"^"ft lSscrie
    :'.1,,:t.f,^:1iq:i;#""":iii;jil'iil.iJJJ".1#:",f ';i;?;
    prsrrurred cresTetn 1."qil:' 11i11
    a^eprcsu,rr,,
    a ta re. In ltg. -i.ti,t i,,ri
    )l 'lll"\.*l"mnli. moditicarea
    reialiilor p.;.16;;i;;i;;:;d,"." ia tii,.rirrl
    1i1;rrridc stenozi.
    l\. [,tiagnosti,uI rratl-y,.I.w_i. d,e slenozatd
    ,.rl(,rlni suDrafi,reide scurgcre" se tir(.,.l)rl
    a orifiiiului .t;".;;i d"p;;nnula lrri (irrrl
    l jr, (l' )5l)

    S (c:rr!) : Q (ml/sec.) Itit. 3. 52. -- Sthila t rb(i d. frLsilt]le la rtlvagerea sondei tlu; artelii li1td
    .K./ItG;E-s)
    4d.5
    l,1i,i'l"1li,:,1i.Y,11i'?'j::$"ffi'"'iff(1:,.,11:&::nif,"1::,Ji:ilii*,:t;i*iil;l
    ,',, si sii'r.i1cirl septrt v€,lricnlar *.i .t.i"i tIl,l,,illl .n's i ( r r r l ) r r l ,rrrs i rrmi n o . J n . ] I . D . r, . a r. rc rt l i p s a
    tiv..t.i,ril, t)rf(xru si tipsc rjftdienlnlxl
    g e a d i . n t n h i d o l r. s i u ' rc s i s t o l i { : i i re t rl , rl
    de pr.sn!d. diistolic dilnrc dt.in si vcllrr'
    j (l(i
    ii."tl"a","ld;r j, ;iil3';;'.:L,cient
    ,{1../,r rxfb,r prcsiLlLcpiiologi.:r la !. crz ip.r.dn .n ir.i sle.ozo elajrte, xri la njv.lll
    (i,. , , ,,, j ri,r, oriii.irltri 5iltn!)nlirn rifu.let{rnid apilil Smdi.ntrhi de Fesiurc sist.lic dirl.. v.r1,icll ti
    {!tdl1, tr rlorr nr i'rL.lriorul ventrjcrhi, stmozll intundinllart carc -!e lnsoicnle de an Fr.di.rt
    ,l.j;;i\_,i::j_q:itil:i_ teziuni.mitro-tricuspidicnr: sistolio lnL!r (1,{iL {rrlr. de Iftsiru dc N)rIdogL idenlicl. ti r ireia 1a dvelul crilici!lri crti.'
    adultilor, in schinbf"::Iil9' .cuaortice ,,irrl vdrtrljurar cn qrddienr rliaslllic trltre .iriu,{i vnrticll.

    :;,i,lii
    1qr',rrp:L
    ii,"il1?'.lii,i:Hiiu'!f?X"j:'iX1'.":,fi:,i#T:ilS""#":.Slr,i;,
    stenozele
    ll,l ri 5t|l )l ;l
    , rr, r rlilirrrir, glrxlul clt: ilgrrsturi' a orificiului faff, de ditnt'nsirrncl nolttnlii.
    Lrlii, o<l;rti cu r,'hsta, cste necesarca
    ,;;iir;,i:i1",';?l'l*:jl$#"-i:
    tttoitliart stcnozat s:'i fi. r,]n^rf.+6 :1,:l,XiX'T;*:Fg":X,,il,:iil,;,,':l;i,,,i;t
    r" .,,
    normalil a ortticiultti r|r;rl,r'lir''
    ,,,r,' r,l )rrnzfrt()rt tvilst ci pacicnt r r lr t i r it t pI f or t nulir :
    li;'i;;;l; il;;it#,;:l:i'r[sLrPrarala
    ,r,rr.) vfrsrii
    virsrirr;,,ri,,. i';;,;#'
    ta alr,n n s1f,.r
    .', .r,."^j1l"i,::ll3it1.'slplalt ,d.'
    strrt0z;i'rlih'r"'r
    ifriri#li.lirJ#ltl!"ll",,ll:'lliiiii,,'lli:1il In,l r, (.1, (l (. r,1fn{ J z i il l } 0 l 1 l l rr)
    (,"'}")
    s,rpr. {irLlr)oLrtli
    )r r00
    ^;ii s,,t'r . r ',l r n r l l l . ( ,.'r ':)
    l;0ti
    5r]0
    sc
    {orm[ ovalva' MLugincrL sit-'l)osl]fl:ioarlr
    Suprafala tcorctir: lronrrirlii rr or.ificiuluiaortic Si Dulfto ar sl])l lrr txrz,itia latcrall este de
    tl":U'*':1";i:iu"'l'h"l]ilt:
    cu'""u "oi"tJ'i'['*"'i#io
    Irr*rin sirsclircct
    ciatc dupi cercetlrilc iurirlorrricl alc lui Sutter.
    Datclc- clinice, prc- gi postopcratorii la un lot mare de bolna.vi .irr
    lus si se afinne cA un indicc de s1enoz5.
    'II;,,iil,:
    li,J":i.tlTd;:ttrjit'
    ii :#l;::lil";;:
    :";::l ,ll;
    ;",)ffi
    de 50o/oreprezintl o stmr.rzi n ',it.'^pE c.
    la limita de semnificafie. Sub 50o/" stenoza csi6 prta larg:r ca s)i rlr, *.r , drcapti aPare
    Urechiuga
    o suferin!f, obiectivi S-i^ ln conseiinle nu este indicate iperalia, trr ,r
    ' i'Llii
    o srcnozare
    stenozare de peste J0".^
    50o,/oreprezrnti
    reprezinti un baraj
    baraj hemodinamic
    hemodinaniic impolta|l,
    rmpol.rarl,
    rl.termina. suprasolici tarea ventriculari" cu scdder.cacapaeititii hrr,"1,
    la cfort, fapt..ce susline interv.enfia operatorie corectoaire.Mijoritrrtril
    rravilor operaji, cu stenoze aortice sau pulmonare, prezentau indicck rltr
    nozare peste 75%"
    Indicele de stenozare ajuti pe_de.alti parte la diferenfier.crr rl
    rrrr gradient presional sistolic ia nivelul orificiutrii pulmonar datorat rlrrr
    ;i gradicntu.luitare_ insotcEte dilatarea arterei liuJmonarc (cum r.ristll
    ('\cmplu jn def*ctu.l
    .septal atrjal cu shunt mite .ringa-di,.s1rrr).
    In cazul dilatirijor, indicele de stenozareja valorl ncgativr, ,r,k
    suprafetei de sctrgele dind o suprafati mai mare decit cca no]malii.

    3.2.7.1
    O. ANGIOCARDIOGRAFIA

    ] r,i1.,f i,rf ?i.rdr' r!


    [E;l -'-'

    1,,.,, - D"xt,'can'l"?'I' 11,-"::11 :l


    :,T*i;;;;;'.:i1"ffii"l:iij
    t"
    :1"i,';"";; l ti''.""' ""'it"''"
    ', ;j;,llIlll'til:;'lilJ,:1"]i
    i'frr.-
    ce se sup(apunccu regi*nea
    rrr{r.riorth. vcna.cavll srporioarir
    ',rr.r

    i;,ij,;
    iir,lli,
    I'li,\:::'lllio
    il+i"'ffi
    illiij:',ii*,r 'tf''ffi#n*-
    ,,'.,,11,,,ii"'l:l','iii
    1".'l:1",T,::;i.^'{"({:::\"
    ,ill,'" i,',''',::*iii,
    'i,ri' 'jlli;J^:J",[:'i1il,
    flilf,f1l"":::1:';""=tl
    3.2.7.'10,1.
    Aspecrulde$rogromeinormqle({ig. 3.59)

    , .:tt.:*t drcpt in proiecgie anteroposlcrioardapalc ovalar, nral.t:,ur,[ 'llil'il,,i"y;l:ieriliif;,


    1,,,1;:;i, ;p;"it"'"J.'::llll
    ii":ll"::';;':"; illl'
    (lrcapta,lormeazi
    (lr()apt5 1'ormeaz!marginea convexi"
    convcxi dreapti.
    dreapriLa inimii. Substanfa
    Substantadc il,rrrlr
    i.,rrrlfl "ii"ii'1111
    l)oate rcJtua spre. ven('leravL-.peretele medial esteformat de septul inl, I rrllll
    lncllrl dc tnst"-r.l1.-
    a r/alvei fricuspide se proiecteazi.pL, maigint:a .r,r,gl,
    rrx,r,,,r ,r:,'l*ll,Tli;.iltiil,ll5il'll'.11*,lu''
    ',,,'| :j'i::i ::::t:i:
    corolucr vcrtebratc, lmcdrat dcasupfa dialragnului
    $i poate fi r|cr,rrot61
    pr.iltr-o miti. anco;f,pe marginca .upr'riori qi inferiojrl, precnlrrsi t,rinhl
    r'(]uccru a rrrtcrrsitS.tiisubstanlci dc contrrst la accst ni.icl. Vllvrr'r,uutl
    cstc singura carc poate fi bine evidcnjiati'L prin substanfa de contru\l.
    sr'.lr.nlinc mli rnult tirnp in spat(.kr v:rlvcjfntre ca gi sr.pirrlint({vlntrn
    ^
    rlrri,r (l pii <r. vr.r:triculrrllr irrcr.pt sil sr. Aolt,ascii.
    571
    570
    l r r' ,' ,r 1xr:l t,ri o ; r r i sr r lr , 'r 'io; r liilr i it t t ii, r r llit r l si. l|g f iit lr l ir lil- o lxr zilir
    l' r'rllr'lc irtlcrior li r li1, r i r lr ' , li, t lr r r gt t r , iit t t t t i t t l g i t t , l t l t r r : 1 r 'r i r ' r t . i r r ' l ' ii ir r l r lr '' 1t l r \ t . sl 1't 'r 'r '1rlr' . slr 'r 'i'r ' cslc 1r ( : ot ll. f l
    rlrLiil. rlc vitlva tlicLrs 1r ir lr r . it r iir r t lr r r l s is t olc i < : o r l r r r l t s t t ' l o i t t l r ' l t t l i r t l i t l i i rr t r' , .i , ' r i , ,rrr ii tl, 't il
    r ,
    ' slll) l'ill) Llll( 'l(
    :ri r i i l s u s , i n fn rtl i brrl ul ;i l trrrrcl ri trl ,rl
    ,l cs.o r- iir r r pt ' c ur t irc.r r 1 rtc Irrrr1 Ii r,rr * l tl tr , rt , rurl ;rJ ] t t l.At t ii't ir lr , lir r r it r : r l r iLr lni st t onlundLL.lll r r l
    rrL. i. r r I r r I r t slt
    i r r r '. lr r ' lt Ll : r r it r 't l poat c f i lr r t z'r '
    i ,i i , ," ,r,' t,,, r' ,
    l rrrl rrrx r t r c , f or m c az i r u n i ,r,l )(r' l rl t s c m i l u n i cu cotl ci i vi ti li cr| (l i l ' i i i rl ,l ,,| | ,,,, (:l | ' {( , r 'ii) I | , l, ' : r I r iovcnt t ict t l: r r st ^idc'r
    i: t g t i{icat
    T't t Lr t li.'rs"
    ' r "lr :
    l l l i o r'. h{ unt libulul e s tc ' rl r' l i rtu i L l .u b u l a ri c u contttr mttl l rrrrti tt, l r,l r i t,,,, ; : r 't {r r lr r i
    , 1u' zi 1 i,r 'r , r r t ir r r 'l v: r jv, i r I r it r r ll' r nar i at 't "r io Ti ( lr r ' st r r ll' it 'r -
    cor'lrul vcnlricrluiui. Orificjrl iu{undibulului poatc fi lccutrrrsrttl ptirr ,' iir ,
    ,l ," r , r r lvit : r or i. icir nccot ot t iit l. Dcschider ea aqs5111i vl vc 5r ' lr t r 'r '
    irirlstare a luuenului, datorat crcstci supraYcntriculilrc. i i | ,1 r,,t,,i ,,i
    , i crLtttl:11. \"alva postcrioar[ cste mai pulin vizihiiii'
    Din aparatrr-l sigmoidian pulmonar se pot vcdea unoli lorlir'rlrl ,ii,r, lrrrr{irrl
    '
    rlilrrtiLtc ale sintsurilor pulmonare ;i imediat sub clc la lrivclul urr( | il \' ..rrIri r.rl l tr ] siilr i3ir r ilozit ir 'post cr oant cr ioar icst t 'r ] r : |or . m iir . ] illii. , r
    st t prt "
    lliri riiscrete este rianui vaivular. Valvele normale rarcori s('vil(l r',1 r n | l ' l l ,U rl : l ,,,r r ) ir r \ lL] " lii r p^r 51'r n dlor pr r 5i- in sus - Ur r ; 'ln"r
    azi l unv^\ ir at "i] inf or ior t <t in; ''r "r; r r ot t lt t
    lirii sLrbLiriner adi-oopacein cilcuitul de ieSire a1 contlui vcntricttl;rr. \ i ,rt' r.rl .,,.t' ' ," ,, , r v's, i sj [ or m ' '"t
    ( r l c'r vilif ii st " nelcd. ir r sp' ial r nr r - \ inr . 't t ir l'r l'
    ..,' i i .' , . Pc.
    l)ulrronari este in aflopierea marginei antdrioar-ea aortei ascolnL(til( irl i i 1' ,, ' ' ,r 'r lr r f ' '
    Mrrr-
    liLrtrr,;isa proximall, in proicclic laterali. Pe de alti parte, in ;xrtirli 1n i ,i i ;' . ,,,,' r,,, rl i rrtl r ; t t cor r t t t nt l ir abcculat al cor pului venir iculului dr cpl'
    . t r e f inc cr est dt uli. Pc cgnjul f acc cu or izot r t r t lr r
    rtliologicl, val.,'a pulmonarl
    lrrtlioloe-icl.
    lr oulmonarl cste cu putin outin mai antctior dc vcttit llv llv, r t,i i ,,,, ,,,1,,i ,,,,' i r t r ] c1li: [ 1ii ;i
    pcrioluir.
    ',rr, ,,,,111,i ,1, ;rproxirnativ '15'. Apexul este si cl slab trabeculal 'Spri: lrlz"i
    r;;;" , I' r' ,1' l i li c, 'i, nr , Jianil convclg spr o va'lva Jor t ic: \ 't lv; r : r "r li''
    ' ;,.' t or act lc {r : r u 7 Ja dr eapir i It I rrrt t I i I ' rI I ' rI rrr
    Aspectullevogrcmeinormole({ig. 3.54)
    3.2.7.i0.2. ,1,' , ,:t, ,, l " '.ia
    cr t ,clrcapta
    ht oi
    -i "iv. l"i jos de plarr;cul vrtlvt l"t
    r, rI 'I , , , | , r I rri ,lri'Pt, dcr'i 9i pulin mai
    '
    ln proiectie anteroposterioarl atriul stlng este de formir ovalrtt , trttl ttr,rl Irl l (.
    ii()lriit ilr unghiul pe carc-l formeaz;rrmirea celor doul bronhii |tt'r, l rr rrroi r' ,i i l llt t cr : r li, lnar giucit 1) ost cr ioali est c dat i dc vl vlL lt r ilt it l'r '
    rrlipit liind de bronhia siingiL. lirecJriu;a stlng;t,.clnd se umplc, cstr' 1,' Il ,,' ,' ,' ]' ,'stttu' tli, r , , t irest c'; onv; xi, |- e cind m algit ci] inicr ioal- ii cst ir Pir t '( i; r l
    girrct
    1lIr cil stin5Jl a conturului cardiac intre convexitatea vcntriculului 1l ,n I rrrl r r\ r.
    lrrl.crci puhnonare. Sint 4 r'ene puhnonare, doui <1c fiecarc paltr', \rrl l l t st' r , t , t lt ' clar in a. eaSt i llr oicct ie 9i est c poZit ionat it ir nr r liilI it l
    - eort ic p6at e- {i iecunoscut dr t PiLt r t iI ir
    l ,l , rti l | r t lr '. I 'lauul r '. r lvular ' -
    ' ,rl !r' i
    l l " ,r t,,r, rr rtotici, l) l'oxim it l dc dilat ar ca sinusur ilor lui f r alsalva'

    sting
    3.)./.10.3. Cqlcululvolumelorventricululoi
    v
    \ rrli irrllr rriilt vtlntriculului sling pcnnitc mi surarcJ vohl1nu1iLccslt'i cl t t
    ,i i .,,,i i ,t;t; i ir r sist oliL,pr in cxam inar ea im aginci in lclcdiast olir 9i l' l'
    r,1, ,,, 'srnL
    r t,,l,L (irr ttttit rlonir proieclii radiologice)'
    lrr ,lirrsloli (:ir!itatcil vcntriculului sting arc o^fotmi clipticiL tltrn(:llirrlii
    r
    l ,r I' z,r l t i r rlr l z, r t t 'L r r l. 'r r ului t nir r al si aor 'lic ln O AD 30o r r l lt r r r gi
    r , , ,t , , rrI i rI n i , il' pr,.rutciitru planul filmului, astfel c:I.ln accastit Pl'oi('( 1i.
    ' acest ltrolil
    , | , , ,, , ,' .i i i , i I, r,t nilicrrlni sint cel n'Iai binc reprezentate' .I)in
    'r,r'i.i ' calculul volumelor vcrllt'ictt
    rr t)rol('ctlc i'stt: cea rnai utilizatir penirri
    Axclc utilizat6 in aceste formule sint indicattr irr
    i,,,,, ,ii;,ii.,,;,
    - -lirg''t plan.
    iiugu,-
    i
    ;;,' A'r - L - Porne5te !o la t'i'I ;i intretaic
    pcr pendlcular -pLxnul
    r lalx (,vrtl\1
    l( ir \ 'l
    ,r" rl i ,, l ;r Iri i l ,r, 'r r l 'i, Axa r ninor iL- D- cst e jt llr lll
    . l, r :\i Il r ri riilocul r i, I ior m ulclc { ar e im plicd exam enul r ll dcuir . I t
    diam et nr l r nic l) '
    ,,,r,,,,,1i ,,,t,,t:,1'ir r t i" clc, t nisoar i ir r planul lat cr al
    il|,ii,,,
    Fig. 3.5a. - Leltagvatn.tnarwald. Ia. cilcva securldedllpl irj(r1i{ rli|l ii n,i.'iu'f"iur uniplinc apreciazi c1 dimensiunilecelor douir diartrt:(tc
    ventriculul drept substanlr cle contlast pir'trscFtcpatul ar1{rriallluIuourlr', rrrr,il) qi l)' slnt practic egale.
    $i parcurge carit:4ile cordului sting rcspectiv vcreic pulr)r.r|itr.r tVI')
    at ul stins (AS), .'eniriculul sting (\iS) ;i aorta (-^(t. l,irrjrnulrtrxrutru calculareavolumului ventriculului sting intr-un sitrlirlf
    : voluntrtl
    ,,1,,,,i(;r,.;.,i'si'(:o6b.,196?)cstc: V : 0,44L.D'z,-Fc ln carc: V
    axa iurgii t cav,itilii
    vcnil lobului urcdian <lrept sc varsir scparat in atrirr in lot: sl'i s, trt| l',t''l;iiil rti','ii,''-ir,ln't"t" irn factor de co]-clarc,L:
    it cavititlii vcrrtricularcir cm ;i Ii<:
    ;,:;i'''i,l;;l'il;i-it'r1,,;; b = axit \( rrrtil
    Plt'rlabil cu vena pulmouaril drcrptir slpcrioarir. i,,,'r,,,;,i.',"".,'l"lic al irnaginii rcspt'ctiv lrtngimca lcalit r.portfllir
    Tn proieclie latcrdi, atrilri sr: rrorkrsituat postcro-sul"r'ior,,
    r'rrirxul hlng rliriirtt craniocarllal,M;uginc'asir lxrslltio:rti1|
    ov;rlirr-ir., lrr lrtttgitut';L Pc fiLn.
    I )loicctltta'r 'r'oir.ctirtc,
    r.7,t
    572
    fol.rrrulll.sr.r.rrl:rrl,aztr,,volurnul. vt tri-
    :,,i, ',t;;*ltil . _vcntricululuis ng ln tel0r I rl lilr:t.:rtrrrir.sllt 1)r.opuse tue to(Le dc nrirsurate a volumulrri
    :jl:l:.11t_
    rrlrI|1r(:,
    \',,::,"': YJ1,; ii ln rr.r.sisr,,rri - vls -.-iiu,,;;:,;i;;i,i;,1"1:1i.k, , ,1ii'pi,'1tt.',,rr- ;i'a,itriuhii sting tlar clo lu au intrat ln uzul curcnt'
    I{,_]trt
    I r ezintd.
    |z r lr ld ssistOlic
    ts l o l rc ddc lnge *
    r' sslnge __ VS
    vs ei ectat dc vcnt
    .voLurnul
    : ,| |i rIl ({r,,;rt . . t ut aor t lc
    , v o l u rn u t
    la c a rr. s t. trd a u g l e v c n tu al de6i tul dc rctu HEMODINAMICE PATOIOGICE
    tt i l ral ra., aorticsau de skuu,ts,.ga-driapta i"l;";;;r,;. 3.2.7.11.ASPECTE
    ;r' ;?;ii];il;
    monar). Daci. nu existih l r" l rari c rrror lilir ir il" I 'alolo{ic( 5" pot im pir li in J nr ar j sindloatnc:
    ", de r:egulgitarc
    , /i) sau regurgitafic, atunci volrrmul rt,,,1,,,,,',il,l,t bat"j, sinclromul dc 's,:uricircuit si sindror.rul
    srsroucradro-togrceste eg:rlcrr vor i.
    l ,rl t rrl tLt
    lumul-bltaie determinaicu ructu. Tabelutr3.16
    da Fick sau a curbeior de cliludin. alitgnosticul 0i!cNelor 1ilrrli cltrdioltli i
    Daci debitul radioloAic estc l,:llrlr ta rnctoilelol. e iDlQsligalit l
    'le
    mare declt debitut Fick, lt
    Marometria .{nSiogra,{ia
    se poate aprecia mhrirnelL volu.
    mului de recircularc (shtnl, rct
    grgltare) : .1.
    l l ' rr,' /,, vrl vl rl ai i !
    VS recirc.: VSRX_ Vsr,,r(!k l l , r,,.',r nnrscul arl
    t- -l'
    1l
    |,,{,1,,,,,,,1i Lvahul arl
    Raportul dintre volrrrnql l r' n,1 rn!r)l al
    sistoiic radiologic Ei volurnul telo. 4,,,,r.. 1, ,l c (rrrr l uri \i ru ' 1. ! "i l j '
    tl
    diastolic rcprczintl aqa-zisa flrrr:r A l l ,,.',, :r '',,,1r,r.ti l ,i l i ri l :i ni oc ar' l l l ui
    ! . / = - *' U "z-
    'tJ lie de cjcclie - FE - clt'rrrrntl
    de bazi in apreciereafrnc!ir,i dl l ,i 'tt,l ;l 1 -- = u! i r{ i Y dl oal c di ag os ti c :r;
    /. i a'; - ..)alaLtll. LaIwn&INrioen*i,c1rtu.luisting -f = ar-e vltloalc diagnostici;
    r,ozitie radiologicd, OAD. pompe a ventriculului stlrg, | :l -, cto(lil lodrtc sensi'bil:t'
    : | .. n r.u rrt l n -r.r:j,ul dia.,otiFij Vf: *v lum ul
    a tl ifrr-itclor
    Trr tabr:lul 3.16 sc scht-'matizeazir va]oarca cliagnostici
    ,' i i .to l ci : D -.1' dn"r r ut sLui \au
    - Jir or ill:
    i:,i,t' h -sr6ined pdeteld tiber. Jos loeul;
    , rl.,rl a vollmlitri cavitalii veniriclhe. YTS invazivl, iar in tabelnl E 17 rnodificit'ilc reginrului
    rr,'t,ul,i dn investigarc
    l- L r,)rlnali e;!e peste 0,5 (500/o).SciLdereasub accastri lirrrltl rl , 1,r,..i rrrrcj ntrrc ildia, in diver s" car diopalji'
    -FE.indic[ :' . 17
    ir, -1' , ial sub,0,3 o scide_reimpoiiinti a functi .i vcntriculrrr.r, slilrgl,
    ' Iabtl i tl
    {ir .ijtrtorul formulelor de volum se potrte aprer:ia aprccia gi massi'L
    mass.Lrnitx'rrl
    rnitx'rrlllrlfi lh:f
    - r l lttlllouhli proslolral (iin sbdron'ul de l'allri
    rlltltr tt,'',rlului
    v,r', trrlt stlng,
    ,'',rlulu i stln e. scizind din wnlr
    s c iz ind din volumui
    m "t ' + ^+ rl
    total al w veniiricrrlului
    ventricrrlului
    eniricnlnllli /lcirv
    ^ , , r , iii1rrlnr
    (lrviirrlnl , 'r '- . S('ltclrlallzaroa
    p lt ' ' :'rrrsirnca peretelui) volumui telediastolic(Graharn T.P. gi cotritr.,tOll),
    Massal(sn)l: vt - VTD
    vr : 0,52. (D .+ 2hy. (L + 2h) . rrca
    Il l t", i cns;rul c :Lttcr'i al e s j s l el ni c :r
    ', ] ,,,._ l l l . / nL, r 1rtuL oia l i rrg rn ;D : c i i a n e trum L i c a l c a . ,.i ti rti
    i ni crnj t,.. {l i i l (,t| l rl t l -
    , ,,,;l.l:j.ll',,-'"^t-_:'-: ; ;
    ,1 ,' ; , ) " 4 e co rcta ,tre :i.jli-"1-
    peretetuinuscularliber.incmin drcpruL(tioLr)r1llrl,rr rr l tr I r,,rrtl i l i i , foD stri cti v A
    1 :L
    4
    +
    r
    !c fdclor J^ ,"r l .,i. 1l imd.i,r pi p, r i .,.l a,"
    r,,,lurnelenormale slnt indicate I |
    'tri l |trl fi onar
    cfoni c +
    ln tabelul 3.15. l !.'rr)rl l t)ul 11r,'rr!ri , -l- + +
    't r.rrtttr ,t ll hl ' | {)z11i fi cnsl ]i {l i {l n? t +
    presiunea-nfilic ditl
    {rlru r, li u o n f r l c n l u l t r l s t l n t Ir 5 tr lr ie e tii o o r m r ll! r cd i.r fi l l u \l fl txt rd I.1uT,]1(l ) r;rtrhafl l,,r't,tl: l)rcsirrni) Ilorlnat!; + : presiune crescrte; FAD:
    ,. , 1, 1,1, . I ' t ? 1 l a c o p i i , ( 2 ) D o d g e Si co h L ., 1 9 6 9 t:L n lL r L 1 ' le
    ' .ir .l (l ) Foi i .r,h It,, j rrfi i r,' ,,,l ntl l l rllrinl ((r(:l)l; 1'1,1yp: presirrne telediastolicb' ventdctlarzi dreapte; llAP =' lro-
    | )ldv S
    si(ln(iil 1lr(,(li(,(li artern Pulmorara j-PAS : presiunea$edie dill atriul sting ;
    ( l) ( 1) medie dir norir't'
    co p il sn l) (2) (r) prcsirrrc tck:diasLolicllventricrlad. stitgtr;?Ao- ?rcsiuneo
    2 ruri 2 a i lvhrll f , h,l l

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    19Q, vo|. 25, p. t5. r!,.1.
    l rri fN lr iu P . , GA-V]IILESCU
    ci SI. - Angiografia tl1 pxactica rneaticali, Ed. Ftacilflr, i rr'r riLi'lixi i.t \'.,-l{,\ir$cir r., ForrAriE B. - utilitatea erylorenlor, comple*e -p^en'
    L..Y1IY
    ( llrlNl; 1,.,
    D.t{. - euick L.efcxenoe
    to carrjiorlsculat ttiseasc,J. e, r.ipfi*.,t ,;;' .,;it",,;, glc;cLilor'cle inclicalic operatoiie in ohirurgia caidiace lted lf,t ' 1960'
    c_"p. i , , ) l 1 2 , p . l . E {3.
    1t7 7.
    / . {{X )| , ! . Y t t . N . , S C F IIiEIBEIi lI- H - Ra d io io g y o f the heart and gr.car rr iiri Niiiiu r'--'l.orrADE ll , T-rT.A.RczEK D. - Der lveri der Functionnelle$ Herz
    WilLiams - trViikills - Londor, 1978.
    '/csscrl r, i ,",Lq"ii-U"*.tr"tt"rgen {ar die l{reislaufchirurgie' Unsere Edahrungen a! 2000 Fauen'
    r. I ollllNr\ND A., R,\NGES H.A, _ Carhetcrizrtior ol right auriclc ic 111an. ?,1r..
    l,)it;chriit lilr die Ge;ante Ilnere Mediz:':'''1964' vol. 15, p. 77'
    ll \t \s()N D..f. - L.onqestiveheart la ure. eclaiisms, eviluation and treatmert' York
    . .t :1...!l!': yed: L q 7 t. ,o t. { ' J. p . 4 5 2 .
    Ntr(1i0 Boolis ri. 1-ork, 1976.
    ',. l)1,;SlI,UTSD.T., HOFFMT\N R. - A ne$.rnethodof percutancouscathctclzaLior, / assess-
    t,,Rt, 1965,voi. 85, p. 1{7. |i \ IillitTOOI-A S.I{. - L;ft vertricuiar end - diastoiic and iiling Pressures in
    llr IX)(;1,)il.'f., BAXLEY W.A. - T.eit ?ertricuiar volurue and , r " r 'r n 1 . , . , : r r r l rl ) r r r r r rr,i o n C .e s tr 7 3 u o 1 l r t. p 8 5 8 '
    lr1assan.t their.siij ili P'di-
    rl. l l l l J i . ^ J , . A m . I. Co r d to ta e y, t9 6 9 , ,o t. 2 J, D. j 28. 1]liI](jt-PII A.1I., C-\YLER G.C. - Cardiac catheteri;ation in in{al1ts and children'
    i. lS I I i l N S . L . , t l L t s EN C.u ., ST A\tp f ER' N. _ Chrrd. ter,:i r.ri 01 ur i trc Li rL:,rt[r ntti.. CIin. tYarth.Altt.rica, 1953'voi, 5, p. 907
    rosponsc to rna.Lima1 upright exexcise in normal subjects aud patieris r rjilrcdJs.j. - laLheter replacemeli of the Ireedlein per:cutaneousadheriograplty
    with tiearr
    I iitctalatior, 1967 , vot. 35, p. 1 049, 1 . .t L a , f . o 1 . ,l oj i , /o l . .1 9 ,p i 6 8 .
    I I I r)'lt^l)u R., STEFiNESC' TR., LITARCZII( D. _Foluula pertfu rr,:r,ixiiCu r., cirlTliscu T, FOTTADE B. - cateterism'rl cardiac drept in oardict
    calculareiL(L0t ftal d atd u! l'ld, vol. i l3J'
    llri.np rrl ilifjlL , !:,1. P] aLt c apt e . ay diot oli. , ls 5r , /. t , p . r r j . i ..l l :.
    !,J r ,r r :LJ l ' . tl?..
    ' Iiti
    P
    r, lr(I|l,\t)lt l]., cIItT.4 \L, LTTARCZEIT b. _ Co"ti";.ni.it . ii].i."; . ";Riin6iil n.c - cardiac cathcterizationand angiocardiosraPhv'
    tte stcnoz,,rc,rru rr.rr ' ( li. ]-ivirgstorc - Londou, 1973.
    1(ffir lrcmo.liraruic a,l steuozetorpulmonare, plobt ne ttecardiotagie, 1959,,.1. .r,
    rl. l,l)fiAt)U Tt., DANCIU L, LTTARCZEI( U. _ Elemente l;, ,iii, 'f ,;ltllriiC L, vL-\IcU 1i. - Contributlon cu 'liagirostique dc la stenose congenittrlc p 35Z'
    a" .'.p-rir*.-"ri,,i"A (Lc l:!txr't , ,,1J"ctesl.,rrt.f,es de 1'art lrlmonairc n'u' Raumaln' ae ltta int ' 1964'vol i'
    lof, c.Lfo r{rte.'ir o scldere a rczerveLor fr1nctioflale ale
    nioca'rctului
    'iillll: D., vlArcu R - cortribution au diaSlostic dcs ano-
    ,| , ,| ( .tll.
    Jl:L?,gots,.", ".rr".i a"Cn..,,Mai
    1e64
    Il L\ l)Ij Il., I,ITAIiCZEK D., D$.Cly I. _
    (rn
    ""r"*"rri;ie;;;.:""ii1i'.ii"]iiii
    |l . r,;irr,:,iiri i.. irl-ilur-rsci,
    !ririlil,s1-ereuscssuPer. Cor et Yasa 1964,vol' 6, p {9'
    Conrriburii La srucLiuicrrcuragicilrrrlrrrr|, f-o:ff,tnB B. - inscmnatalea cateterisflului cardiac in chirur-
    .'l I ll 1i., PoPESClif.,
    ,,rirli,iL jft:,",'l;.,*i;"1
    i.'l'i,Tlt"Jii""T:'T,.ii:i',l".lX'il. r . ' r . f l n n . r ; . \'e s,n r cl - Ii r u g b i i . i 9 0 i . vo l . 'r 0 ' P. 6 i
    co,(,,
    "i?irrciiei
    s,ns'Arir-Ieacong'c"
    ,uh,,1 .i l;; ; ; . - : " . .i .i . i r ,'i .i r R e "r ' Pl .ysi o l . ( i i r i .a l r e 'p j r ', p h vsi o r o e l Al 'b r cvi i r -
    {;,i"i;;:*::li#::.i,,i"1:'fiit"' wa1 o" c \ \ ,r r r r e n t - \u g L 'r l 9 7 8 L d f( 'l \o n r a e - R IC '
    -7. l()tl;lli,' 'tr<ri.rrrxrll '. r r o r k i n g d ^
    t , \ l) t i B . , B O I U S., M IL U' M . _ - T o p o g r a lia a n gi ogi ?fi ce a l ezi uni tor
    ot)str[,]l ya
    ,,, ,.iil,l'ii;"i: jlli;T1,ff;Yi;."I.! deca!:diorosie,
    8"c., tszz.\,or.corglcsrrrui,
    |.ni 3.3. BOLI CONGENITALE
    tl in voL
    ,. . l)f ,.!,.lac.!io
    . :)u1,. c.r. Nesollr..r.. ff;il; lilltculosrafia ";rngirriu1rccto|rtlll'i MIRCEASTAMATE
    MIRCEAMAIORESCU,
    r' , l, l \i)l: Il. - C o f o n n r o g r .r lL r se tcctiT ii li z- e u tr icu lo gra{i a i ]l cl i agno:urrL
    rl ry r r ( i i o p a i i e i i s c h e m ice . T e ze iie d o cto ia t IM F la si," 1981. t)frj ,tx,rl l ri rt,
    l l) l{ )lt q\ N I A N N W . - Die So n .lilr r r g a le s r cch te n lle r lzens. Il Li ni sce Wooher
    3.3.1.INCIDENTA
    Lsol tri jI , l ,tj ul
    ro1 . 8 p . 2 085.
    llirciclcn!;r
    irri,Ittta maiiormatici
    m l l to r m a ti tr congenita"le
    co de
    n g e n tl a l c o co Jo este
    e cord e sL c apreciate lntre 5 9i I
    , , ,, FTEFiNESCU rR., srINCEScutrr._ Anri,,(r(1,r,
    ].1 .lll:t!:ll-lt 9*]9sirr..9.,"
    lifrtril o]rpel.tl11entali, si clinic:L Drin cateteriz:Lrea cold1rlui. Ful. lust. dc.fix.npc (tcat lr t r r t t r l , ' r i . , r r ti vi i 1 i r , c"l c m a i m u l to sca ti sti ci ) +.
    r\ Ln ! 1 . l { t r R ,
    ,,;i:iiiscii'ii.G;ib$ut?'..,rot.,
    1954, p. 83. Nir,lk:r'.ciNeal socotescacestecifre Preamici, pentru ci nu lin seama
    srEFANrscu rn.,rio:r,\rrr,: r]. rq; ,r, ,,',,niollit.'.".diaccce nu pot fi descoparite la.na;tere,ci sint recunoscute
    sondir - tehnica ii "n*DA,
    va,loarearnebodeicle diagnostic, ri.Aioiogi"., tO,tZ,:rui,'ii
    ^,,f {,.r. DiA, anbmaliilearcului
    r,,,,lrrrr.,itir.zir.r aortic,valva aortici bicuspidi).
    l',,,l;n.n'Ut
    (;ll t:l'ESCIJ T.OTIADE 8., $TEF,{'\F SCU TR., I-ITAIiCZEri i ; ; ,;;;iii ;;;; ,i.' {ost urmirili o pedoadi de timp mai inci-
    .'.t'-, l). __ C,rr(it,.riri't$i -lndelunsatir'.
    '/irr1ricullrlui stirg pe catc rctrog.acl5,aorticir. Ite?. Chirurgie, 1955,nr.- 2,
    lr, Zlj .
    ,-" ,i , r.,'tii.c ,,. riirtca{i socotiti 20 la i 000 ndscuffvii Nlscu}ii morfi tre-
    (;Ottt,tN It., cOI{LtN S.D. _ I{vrlrarrlic
    Iornula Ior calculation of urc arct oI r(r lt[. r, I , r.f,"i clir'istatistici,lentru ci incidenlaMCCia acegtiae mult mai maf c'
    rotic rrlit.al ?al?c. other ca'r. val.res ancl centrlai ;t;;.,;;;;
    ,*,:r. i,
    ' populationale includ un numlr mare de plematuri'
    1951 , vo l. {1 , D.1. "i_,i-,,",r",. l),!cir statistir:ilc
    l),Lcl stirtLstlcllc Po
    r) (;ltAl-IANI 'r'.r,., JARMAK,A.NI X{.M., CAN]INT It.V. r., rr{a vr:i:
    11 l 1l l'",' M0C .poat c.{ifi'io'*od
    in fals grup de copii
    lu1t crescutl, pentru c;- la acest grup-
    vr)lrrJDe ristimation in_ .f MA.nltOW X,t.N. t_ctrht|Atl .
    , .i .r., ',rt,orrelii
    'ii*i.
    caltliaccln nnrtio
    proporlie mai
    mai maic, dar
    dar carc
    care se
    se pot
    lot lnchide spon-
    spon-
    iltansy child hoorl._Ito cvaliatiorr ot rirr,.tttlr,toiol;y ar,t lourll "'a-rr.
    vi'llr)s, CiftjalaLion, 1971,?ol. 4J, p. S95. l'OA, .l)S\r mic).
    (;lllil.lNll D.(;., (tj.ltLISLit ti., (;ttANT 1
    ", ',,rutri(fulirr.rolunrc
    C., It(tNNLLI I.I.. - tr:sri0rl}ri., (,1 trll Ircirh:ttta depindt' de niiloaccle tle diagnostic ti tratament' ca..ti de
    .:
    by o (j l)larrofinolllirilIigography,Cir.craiiorr, 1067,vot. .1.,t. ol ,
    I l, l liS C t J ( 1 . ( . - - M c t o ( lo ( lc in vclltig a tiI
    t,. l,rrrl,rl rlirri i;i,r'
    t,';,r',t',r',,:i ItC.\ qisi ps4
    I)SA (forimnt
    fforirnur' r1rlr1"^.lnl'r::Pllt,::*
    otnle) sint socotitc sau nu anomalll car-
    lu.*:f T:*T
    lhr(x r f ( i n f i , 1 9 5 ( ) .
    r !lf r lp a xn tn ri car.rl i o,,ri |.t|rrl,trrf,il, Mc(ll({lt, ij, ,, i , i,':irri i,i,ti, ,.i,'uinili. lirccvcnla MCC in prima luni de viafii dcpinde
    '
    . l l. l{ llI ' f lt T,l),, t{()!Vli l{ . 1) , , VLAI ) 1, , lt r . . ' r t r lj! x , : . . nj r r i n l l u r . y r r . r r rcl h i l r r r x r r l , l i r l q
    N rij illir l,ll l)listri |lt , I q7ll, {, \ , . ? i t , 1 , i I l ) x{. 1 ..1 .}

    iT (i
    l l l ,' ,rr' r' rcr vl noi rsi l) r r llnolr aLr iLr ') r 'r ) r ir lit ot : t lir ; i \ r t Dllul at l iovont r i( lll lir r
    < 1cd i a g n o s trc i a u to p s i e s i u l trri ll r,ri sm (sc pr:sLtl rutrr', i 1
    rl i ri c rr r i. ilor x : r ' Lr (ftlr'll' r, Ncrl). 1n 2.11, dir.r <:rrz,rrri, r:ist.-rnna sru tnai rnultc rnalfolrttrt!ii
    lr rsi supLrgii:atr:tclismului numai nou-nirscutii sirirptomatici). i \t,.,,,,rl i i rrr, rLsot ; iat r;:i ln 8- - 9'1, r lin cr zur i car diopat ia congcnit alit ir pr r l-
    lrsufir:ienla cardiaci congestivS.e rareori prezcnti. la nagtcrr', l l tt, rrrrrrisi tttl tonr cor nplc- , tt nalf ot t t r at iv.
    r i r:cic mzri mr te ],ICC nu modifici" semnificativ circulatia sau bcrrr l r.rrri l rozi ti rr.m ur ilor vasl', lr ipoplr t zia dt cor cl st ilg si at lczia f llinlo-
    rnicir. [r.taliL. In caz rie insr:licienli. cardiaci. congestivi 1a.na;terc sr: r'rtt ft. .r , rr rr'Pl iu lcr.v<rrtricular inLrct lirrt asociqln jn proporlic mai rc(lllsii
    itt r:orsiciler-;trcinsu{icienfa valvulari severi., rhabdomiornul, arit.nrii l'rr r I r| |, )r rl I irI i i r';<ilar:arcliace, in rrycnrt-' cr: rnai mult c1c i/3 din copiii t:lr
    rlirrcc, anemic severi. '
    dlf,, | ,1'' ntrillrri ondocardici,cu I'CA, DSA, malpozifie cardiacir au ano-
    lit prima sirptlrrfni de viali i\[CC care dau cel mai des sirnptorrr,' r ir 'ri, r t , (Nloller (
    \ , 'iLl) . Ccle ccvcnjr ' ;::Lnoltralii
    l!r,rlr
    t,rlrr rir( ilt (
    llr;rcirrrlirrcc rasociatc lI ioi) or si
    1i Ncal). 'lc mai
    m li {r {recvcntc r not r t : t lii
    ;rlr',zia aortei, transpozilia de mari vase, coarctalia aortei gi anorDirlii
    !'', ,, , irri r'r'll r rLlriirci, apoi cele digestlve,urogcnitale ti ncllrologic('-
    r'irrlc r:rr atrr-'zia valvui;rr[ pulmonari. $i ln prima lunir de via]ir rLt f r,l 'rrr,lrr1';r( . ['r'r'notplincipalelemallonnaliiasociate
    cu MCC.Ctc'xcr'pfirL
    lroli sint ceLe nai fi'ecvente. 111,,r' .r (rllrrpicr-r toate accste mal{ormalii sint
    tru'i fl.cialc, rncningomielocetr):
    'Xabt:lal t1 Jrrtr l nr;ri [n.r:r,r'ntcl: copiii cu cardiopatii congenitale (tabeiul 3.18).
    i",',,t,il, nrirlfoLmirtivcsint inultiple in 5d% dir cazuri. llnele (hcrnivr:t-
    Fril!0tlarcle rnallor:na.tii asoeiate (C. Pernot) * fr,l', ) rrprrr'{inrLproiLpctotdcauna ului cornplcx malformativ, 11! \.Lclnc
    5r, rlt'l' (lirnlrft: {rLciak:)sint de obicei izoia.te.Asocialiile dc rnallotmirfii
    SiiRI/oa ele lliti"elor arcNlri b/anl'iale $rrt ,l' .l oti rnrti ft'ccvcntc'la copiii dismaturi. Ele sint totdcauniLttrttJ(ipl,r
    h rr,lr,'rrrrrl rrticrci ombilicalcunice (C. Pernot).
    o) f.rr r' l l l .i a l " sjr r r pl ,livi/:une p.lr Lind
    cl ,l i so sro rr. ma n dr buio- lcciale
    I.)ierrc,Iiobin (DSV) 3,3.2. ETIOI,OGIE
    Goidcnha.r {tetraiogia" Fallot)
    Frarlceschetti (DSV, coarcta-fia de aortl) l, I i,rloiliiLmirjolitr"r{ii nal{orrnaliiior congcnitalc cardiacc-.estc lcr:rr-
    Ilaller ann-Streiff (tetralogia Fallot, stenoza pulmouari)
    flrrr,irl.,, r'r'lcn)ti rtrultc cirzuri apar spor.adic,izolat, in f:imilii aplri:rtt not-
    S;]irot ul lanlelor 3:i 4 al lui Di, Geo/ge Itr,rl ' tt| zi I.l t.3.2 . Pag. 124) .
    de timlls Si lara,tiroide, facies padicular (trunchi ar:terialcomnD, t(trril,'tla
    . apler,zi:r, I rr,lc sturlii cPidemiologice sugcreazir inttrvan!ia <1ifr:ritilor {ar:toli,
    Iraliot, anornaliii a arcurilor ao ice, agelezia valvelor pullnonale)
    rrr.rrpllistaltici (ctcmediu) ca de exemplu: sinclromulcarr
    li t his: i ncuva*
    - l)israfii, Klippei-Feil
    lrr, | , rrrri frirr:vr:ntla-.dcsccndentii
    la...dcsccndentii via Li rnrrrt'
    popuiaJiilornordicc; viala
    -. ll($)iv.r*ebre, disllezic vertebio-costa1, illtlrr,l,rr, conditioncaziro {rccvcnt5"crcscuti a PCA gi epidcmiilc rlc lxtli
    +lr rl ,r lost
    lost nLrsc li:girturl.cu
    cu apalitia
    analitia fibroelastozei
    fibroelastozei(r.inisuJ. urliatt. (-rrx-
    (r.inisuj.urliatt, (-rrx-
    - Ilenirgonielocel lrLrsclu li:girturl
    1r l r' l i ).
    lrr r'ck'rrrri nrultc: cazuri so poatc consideracf, etiologia NICC trzrrli:l"r
    -- polideci:ilie sindactilie, aplazia radiusului (DSV)
    - l)i(ior stri b alll ',,rrl'ir)irfiir rrn(.)rprcdispozilii gcneticc cu factoli de rncdiu (peristaltici).
    l,,,rrl N{CCIa}iL <lr a<:cgtifactori etioiogici sc poatc lcpr:czclta cir ir]
    .4 | t I dt L ligcstia
    arlr'r,rr rrrrrrirlorLtc (drrpiLRobert tr{. \Volfe) (fig. 3.56).
    --:ltrezie esotagiarS,listnle csc-trahe?le(DS1r, ananl.Llii alc arcrrriJorar,rlirr,
    coarctafie, tetralogia Fallot) I:AC.I.ORi DE ]IIED] II
    '- impertoralie anaH (DSV)
    '- atrezia ceilor biliare extrahepatice (cardiol-'alie cialogclra complexa) ReurnatisDl ?oliar-ticulat acut
    '- ca./clrlonr hepatic (DSA)
    -- omtalocel (tetralogia lailot) Hipertcnsiune arieria1; csenlia]:!

    . lLut , at uI g c n . i i o u r i , na l lJoli ale art€felor corontlre


    { d e ce la te 1 a u o g r a fia si sl cmi cl , cu l ri l cj ul i rngi o r,l
    lloli aougeuitalede cord
    - llipospadi:Ls, criptoririCie
    !i g .3 .5 6
    - Iiir)ich; !nic, inichi in poicoa'/i, bazinct dublr
    - J \ l r ' p o . . i i i , d i l J (a i . ( F t, r ) ,.
    ( ,r rrrr.r:rutisttt
    gcncral qi comun ln celc mai rnultc cazuri so poatc ul)a-
    .
    $ ir unr,lc cazuri malformelia cardiacS, as,ociate tru este plczeDti li {lo arofll ||tl ;lrr,r r.rr.rlrr rrnli crtzimc chrc acfioneazdasupra unci {ormafii celul:rc cu
    t rt L. rr! ion u t i . . ir,l ,,'1;,rrriz,rto:"' (tlc cxcmplu grupul dc cclulc nlllrlil ,o,ills li consi{lcrirt
    llolile
    llolilc as;ociate
    r:-ociatt'cu
    cu irigatic
    irigafic pulmonari crescutir(DSV, P(iA) rJau I dr, \,rri I'r'nigh (:l avlnd rol-de Inodelator al tubuh.riclrdiac).
    I ol c tllp1 r'irsia rle 2-3 iuni. l', r'iorrrirtvulucrabilir pentru influcnta teratogcnicl a rtnor factoli dc
    ln insuficicnla r:ardiaciL ce apare intrc vlrsi:a tlrr (r Il
    cong.rstiva'r ttr,'lrr (rrlrtl:"r, ltlidonrirla, CoxsackieI3) asupra dczvoltitlii cal(lk)\'ascLr-
    lrrrr in tliscrrfir::r.r'tiocarditil.,
    rniocar<liopa.tiilc
    (inclrrsiv filrrolilrl ht', r",1, (u[)rinsi tnttcziuaa20-a ;i zirriLa 34-rrdt: san:irti (.l..l Norrr)'

    579
    iiTu
    rl',,,r, I l)r\\rr ir loi-l j.iisitir o sitrgu)ii irl)olrlalio cirrdiaci in 45lo diu crLzuri,
    nt,r' ' l ,,., l ,i r ri l ir isor nia 13; i 1lt , hr car c s- au g: lsit dcf ect e car diacr rizolr t lr '
    tl t,,,, ,, l l i l (]o.i, . ljn {t azuli.

    ' fabi t|l :l l tl

    ..,,,l l otrrri l l o tr! rrrrs rrl rrD or :l bc r:rl i i c rotuos orntrl e(drp[ C -. D upui s , nrodi l i c ai )

    Tipul de car:diopatie, in ordinca frccv c1r1(ri

    I 50 Ca,nal atrioventricular, DSV, l)SA, 1'(:4.


    tcsralotia l.allot
    100 DSV, ?CA, DSA, stcrozt pulrllorar:l
    90 DS\r, PCA, I)-sA, dextrocardie
    61 1]S A , D S \I, P C A

    1Ll drrdiopatie congcnit!.l; co tilr"iir, DS\I, I)SA


    D S ,\, D S \I, P C A
    ZO D S \ . ],C A . D S A , c ar l i oJ ,31:' .r' rl ' l , ri
    35 ' or" ri ' i 1 dc .Lorl t 1.r' l -.l u tal :.5r"' r,,/:.:,,"
    tidr, DSA
    \r .\ stenoz:r pnlmorlari,
    '/\ ' 14 lC,\, DS-\, cnomalic dc cmergc]]l:! . cor(,rrr
    1ei r;tj ns i
    10 ]rC A , tei ral ogi a. Ial l ot, s tc noT:L ti ,l roD l l ri l ,

    tr ,,l lrr{i.r
    rr{ i .r r r r r r ir r , . iilYascl]liu-ii
    vasqLr la; - rPrrlmonarn
    puim
    "L onar i TrIn' S. "'I )
    . sf lr r ?t5-"'1., ( ' l)li '
    ('
    hicc ca miocardopatia hipedroficS. asimetrici. geneticii. 1, r , llririr(1ll
    1rr, lr in sltltlx[
    [r,, r,1, ,' ,r,rr
    ,r,rr,,' ,i,',],,,,',
    ,,r r', It lor t 'n: in accst;tadiu,
    ir r , jr r , r Lro\\rjin accstit acliu, dispalilia suf lului poilt('(lrl((
    dispalit ia suflului po; t t t '
    ll ,',' , '. r'lr, 1,,ii'i. tlru-sttrlitclc dc hipertcnsiunc arrterial:Lprtlltrottlttii
    3.3.2.].FACTORT
    ET|Ot
    OGtCI '
    llr,,t r1,.rrili,r , irrro:rci) sh't c\"ideute._
    I r,,r' ,1:Li( J1 ; , r u iuccr cat sii al. r ibuie cr onosom ului X un t r r l lr r
    . . J. J. Nora, So/n_din trlCCsint produs.,rlc [artori 1rrirrr,rrisr
    Lr'r, ^?rpi
    lvo sint produsr p|n lJ.toti primari de nt(Jiu
    -j 900;,s,. t)ro,l r I
    Inl 'ir-cliunealaci-orilorgnn(rici cu cei de mediu (.r.,litaio nrrrlrit,r,
    r,,rtj
    L F aet or ii Dr imx ri q o x o ti c i s i n i rc D rrz e ntai i dc:
    - abr r af ii ir om o s o i n a l " , 5 0 n d i n ' c a z u ri l c de ,\l C C

    rr,. r ,l ,,,t ir r r lilor r r r l{ii ii', r r lir ir : cin dt lr lia par f illir a }. lt a! t llui lt r t t ; ;
    ll ' ,,,,,, ' ,, r ' rr r il lr lr : p I ) ) , r lt 'Jct il ir r . ! iali'i ; t ir r aluJui hlg r r t t t t t i t 'r
    '

    \! ),1,' t,t , t t i: l, ; . t .r , ' nr r i; t I t l, izolat r ') lr pr : t 'zilt iL cat t r . r t t t lt n r t llll


    l ' | r rtr ' , r,l r.,,, , , , r 1'ir ' ! 1r l) ) lLslr cclt:
    ,r r ,,l .rl , , Ll ir r . , r ijir ' , k' nr lt lf or nt t {ii t ': lt r acat r li; r ct );
    t,r r, , 1, rr rrr| | r rI tt t rrI i i ( \ ilir ( ildiit ( r ( r ( in cadr uJ ur lor sir lt lt or t lt lt ')
    ' ,(i l (
    t| \l ( l t t l, t lt , l'r 'r t 1r u ir |r 'cir 'r ', 1 r olt t lt t i l, r ct or ilot lScnct iciit t lt lr lr *
    l ,l ,t ,,rrl l rrrrrr,rfr ilor , . r t , lir t <r ' iut 'lr r l" , : , i, iI t l1r "tl; r t t t si r t it ' onsir lr t it t n r t o-
    alc Irtusurilor endocardici.PCA e mai rarl clccii:in lrisortriri lf j t,,
    li I I, ' ,l .1" ,;rl, rt ( |t ll, r r ill] it r lc r 't r r l" r 'r t r t , 'lilit r t lt ciit ') <4: , icii,
    r 'i si cr nt si^
    lr-o sori()de 140 copii cu [fCC stucliafi nccroptic rlr: \\,;111;11;1,., l tl .r ,u , t,.r,rl l i r ; r ( ' l) o, r li it t plt t lr '. ( t t r i11"1, r 'r r 'r 'plii, pln{: r r I r ir i r , lr olt lii
    '
    h ll(, 58t,
    . , ,Ij ]{ri ttl i ( lr ' ( { ) r . ' l if r ,\ri ., f r)rl s i rrp l u (l c tl arl snftcrc cl ' cdi ti rri (l l r| 11 i .).\' 1,.i l Il r' l tci t r iscul r r t llat r : ic ( 4, 4) uu dilcr ir l) ir 'r r r ir ili. dr r ilcidct t lr r
    l, r,i l i ' l rri N{ r . nr ll. { , , r r ,.tr, I i ,,i , , (rn p l e x i r fi ri scl l l geneti c tt-cbtti c i ttti i vi Dr I),,t)Lrlir{iiL;1tjr}crll.l. (0,31o) sc poate presupuD(r cr"ri"Li'tr:i-iiiir-rnctir:ittlr
    ,lrrrrliza.tlltrtl.r l ll;.clr', lxr;,.i: r;i rl, r:c1cmai rrrultc or-i arc valabilit;rtc liscrtl i'rttt r,,l t:scrrlial ilr FtioloSia DSV izolat S-air ticscris itisi'i si.crLztrti
    1,,.1,
    rrrlrilir: r,Lco:ri-rcr: plltlr r ('l( urai multe XICC alc vaiabilitatc mrxhlrrl r|l' ,1, l)S\r izolitt cu-ttansmiterc autosonarl domiiranti iir -.rqcic fanilii'
    I' rrr;rrittr c or:riital"r liuitiiactorialiL. /'C;t r: <lc 2 3 ori mai frecventi la fete, frr:ci'i:nla. il poyrlalia grlr'-
    Iiorrnele sporariicr: (atr-ibuitc tLnc'i mutafii gtrlicc) sint mult mai {r'{!' r,rlri t'si:e r.lc 0,2"/^ ;i 1a frafii bolnavilor de 3,4o/o un p:'Lriirtc cu I'(lA,
    \, rtc dcclt Iofilcir' Jamiiialc. -Pentn'-
    rr, ul aoaritici ticfectului la urrnagi cste cle ali;
    Cind caldicpatia l--.:rrc izolati!, se vor ciLuta crl griji alte :itigmrl( Ititratigia l;allot ta sc trairsmite drrpii rc;;'.rlilc :r;ielriclicrc ci tl'r"i
    rrli:rnrorfie cranio-iacialii, c1.:bilitaternir..tali- sau deficitc senzoriale) sau (l('r'
    rr',,rlr:1ulmuliifactorial. Iiiscul genotic e ,Je 7 -- 40,u. .4celirsi lucru c valaLrl
    rrLl.ogiifolc (cc sirt corsici,:r'ate vcritabili m.tvheli gcl'LetLcr). Dacir exirilri r,' hlru transrozitia maril-,r lase, pentru alrczia de rrieuspitli.
    .,:r'rrlneir stiljinai'r, I rlrd.ioPati:r poatc si nu {i.: izolati, ci sir {aci p;rrll
    Sttno'.tie aortic., \\\ cazul stehozelor aortice su;lrllti{vuh rc, se dislittll
    ,iiulr un sild-r-om ('--.;.rnphL.l)S-\ cu anomali:i air: miinii poate fi sindr'otl , i iprrri: tipul simplu 5i
    11 1 ,Jf ,Ora r nl. '
    -['ransmit.r"',- r'i.r:i]r'lian:i a cerdiopatiilor izolatc nu intereseaziLdcrit - tipui complicat cu dcfccte inteli:ct'ar'lc .'rl c-orpl;llil (siuti I ' ' 1
    \\ llhams- beuren).
    .r ' f:rnril.iiicie ,.r,-',r-r;i;: 1-tSr\ tip osti'u,nrstcLtll.ltulLcu Pil aiuagit). -\d.-sca sc pot dovcdi in aceastd. ultimir fo;rn."L o l;ipc ri'rl cl iltic itr lrr:
    in tot:r1it,,Lt.,,.nr',r1uici,, transrnitere rrrendelian:i-(dominantl,. rcccsir ri ,r' tt Lu:tisau ani . Faciesul" lipic ( 'pir idu. ') lr in' n, lr i ' . '1i: ; t t us: / t :
    . L llgirtir ce s.-<) n llai-l;lrtiu di:cit o micir minoritatc de cazuri (3]l - cltLpll
    l,irir).rconvergent, buzi inferioiri 5ioasi. mandihuli -L'-' i lilll rtrici, -i ' l r rr
    .1. Nor-;r) -.r i:it,:;r::c.:rz:"r ir s,,rtcial rn nunli.r dc sindroame polimallir' itrl:Lirlil,i
    J,rr:Ltie.liste"coltroversati legiitura acestei forme tle 1fperciricr:vri,:
    rrrLlilc (ce lor fi r ::n:tt'r s::ir lcrlml de tabci mai jos). Vezi pag. 581 ., rrciati. cu stenozir aortich supravahrulari. cu rnctabclismr:.1 vitanliuli l)
    Si in cli;,.:rilc ,.r.,ILC.C. izolatc cstc escrtial si recunoastem laniliih, ' Lr uramir. S-a putut realiza crperinlental Ia iepur' '. t: --ni:ol:l :rinlillu lirir)
    Lr r rLr-ciic{ect.:lr' r lr'iiace cori ritalr sc transmit drrpi legile mendc)i, rrrr I -
    .,r,.,i t C n vi tanti nr i) la r t t r m i ( Fr 'ict lr nr r r , llills. i"6'i) '
    " 1rrr r:i ii: ar:t:.i. 'iz ;is'ru1 lo: rlc rr:curenld.este mult mai mare decii lrl ,l S{ mai t)oate aso.ia cr1 hipoplazia aortei iLstudelt"' Lu stenttzc rrtl.tr-'
    t,rLriliilc oli;rnir:r. il ci-r.ri: .:rodirl dc transmitere este muitifactodal (tabclrl p lrrronaie si sistcmicc md1iiile, cu hilx:rtcnsi;ro:rrti:rir1;'L cu 'qiru it)fi
    ; rrl ). ''.'l,
    .l' ooi:L artereloi renale.
    :I abehtl 3.'tt
    Form:r simpli du boaLl {spre deosebilc cit fc'rnla t;rrlt}icatir (sil<l "tL'
    li'r'rrrrfll:r irxirxrirlirl.clrr fl1ir.ji,p:rtii ronltenilalc izolafc (i:irir mal{ormtlli exlmcrrdiacc} In tt itli-rms Bcurcnj poat, apdrei familiai Relalia lnl;( cfle Z folrnc rr't '
    l' rrlrii i e t i i d r s f l d r r tl,i fr r 1 ]L ili;lo rh cir a u n ild ivid e stc hol na! (dri p?'!J,.1. N ora)
    , rrrtoscutS.
    i rf: - _...r ;i:i lr l I.cc /crrti r Stenoza fibroqsii subaoviicd. cu sau firir altc anor:.ir';ii carilltrcc s-:r rlrrr''
    (l, Lr, L i o p r , i i i r l r l .r av.i . U n 1l 5c 6enet ie t ie . 1. 6"o l; Jr ilf ii I , : . r : t r . . r ) : - . : . :r
    s' n..r.l; i fratri o
    tti bobtd:i 4 co r ( it t lt ! islillPsc t r in. m it n in 'r lr ' I i''n 'l: : r ''t r o 'm ir l ' '

    ii,l
    l r) .rc.'st'.i, riscui rccur,nici cstn de 2511. trt cclt nai r:ltlte rrazrtri, irr :i
    .5 1,1 '+ r,,r:ril enDiric este de 1]1.
    '
    0.,r): 3, -5 i ,,1 Fibrielastoza en,lacarriiiii (il prociui:erca. cilreia s-a pr:(isrlPrs o inlt0li(
    {)L 2,,7 r ilrLJir prenatalf,) prezintir un risc iirpiric dc i:'rc';lcrtii <i'-: 3,8(;'"' Ar i'lr: 1rt
    '1.
    o. il! 3, 2 3,2 2.5
    , r o fonr:ri ralir, c,r sc tra,nsrnite XJinkat
    I\11lnr)- ,Stc,;to::clcPrtlffiatldve reprczintit ilI gruD icrlr'ir: hctcrlgcn dc ntrilli't

    iiiil
    0. 001 2. 9 2,9 3,6
    {1.00.i 2, I 2,2 3.9 rrrLlii. Riscul crirpiric de rcciirenlii este Cc 2 'i'l',,' c':r."itce ttatlucL': tltt rrtruir
    0.1106 2,1t I,E 2,i ,lr.'transmiten: rirnti{actoriali. Cil1ri sitsno7-'ryiillrc,r.rr'l i":i rrarte dinll trrt
    rrrrltotit, clt rralformalii asociatc (txcrrpJn .L! -- Ll'lr'(--r"'li .1Jf'rd, sirrtllritrrii
    I)cntru riia i{l;r,af iiil clirdiace izolate se folosesc de obicei datc crr4ri ' ' , ,ni dl ) Ii r,L,t J( li'ul. nt - l c t nuh r r Li nLI '.
    rr,,' |:ivitoare la. risctil Scnetic- Accstea nu sint prca exacte" pentnl (ll cr,,n ri'z-utrtitrlin r,riele ohserva-lii;i aitc }ICC;rrezinti'- c distril'ttli'

    iill
    "
    r:Ilrir- la valori rirrdii in po?llalie qi nu ia lndivizi, dar slnt folositc ot i, tt '\sa ptitt';tfi rlati..rumailrr r:azii1ur'iri rt''rmitL st't;tri
    {ii 1 r\' p cnt r u s ir t il gr ,t-.tti r. i.,,llll,,ft.:,jcil,,ilf1.|ijrt:il.va
    l).rA (ti/) r'i_i lrrisi:i {amilii, in care sint indicajii pentru o transr}lit{'fr. lnotuitlia libitdin s-a g:rsit la coL-,ii<iin pir':i:li consjangl.'ri'
    rrrlosornal dorilir:nti :r dr:iectuiui {caz in carc riscul e rnult mai trrirrc ( l(.' il I n srrlir:ict l;r. mitrll[;i acrrticii ir {ost i..,lrsii:r ::giLr;ur-ii1'rr o trlrTr' rr:
    , I rrlr'rtat cir: rlareie cnrpir-icc). ln aproapc ir)atc acestc crzur.i crir vi)rlr.t t, r ,. \-l i nl i rLl i i .
    , i, rrrr I)S A LLct i, t s c .ftl u n s e u t,td tru t,r' o i n b i ra t cu tul bul i Lri dc cri rtl ttr' ,tr, 5l Irl or,r. r)l rl lt l( t ] . r . lirr . , ct i{, r 'icitl).oa1! : lD'lr r 'lr Lr r r il'r '1'; r ilt l; q'iilt lii cLt r Llir '
    .'lril ltrrl:rir:uiiir.i. ,rtr:r-ilstirsonbiuaiic c neobignuitir ln fortnr:lc rtc[inttilirtlr,, l ,,rl j I , rrrI rr i, ,r ':rt i :t lt t l. , cr , lit . i, sinr lt onr lr l lihJlr : , I ) r r 'iilos,: 'ir t t iior nt t I Nt ''r ir r 'r ii)
    'r ,
    ll r;i . r.x is lii : ir ar ior ' , i a l i i-.c h e l e ti L :r' c o n i :o n ti te n tc
    1> oatcfi voti rt tl r rrn si rt ,, r :r' s0ri rrl r' i rr srr r . r lii: r t |,r nuli: ipkr t . r r lr 'ilicri"u( r ; 'r . liLr ir ') Lr |r rir ii. ir ; Llr , 'r ' ir . ')
    , r,,,rrr l i oli- { } r il|r , r lr . . r;r' rI]rrrc rr.(i r tri u rs m i tc fi ' l r utosonrtl rj otl i rti r.nl i . { ii) jit lt llr "'lr r ir l r r 1"
    ,r l rrrrl ri < l ril irl i l l rr copii r lzr r llit {i r lir t l

    il
    "
    lr l l l '
    ' l tl .tLtl .i )z
    li! | (sinrlrorrrntJ.
    lt) lICtJ ittsLtlilt,L:n,rll,trtt,tlii.t:.vtvacalL!i Itisi rr] ril llr'rr. S l ndrourl o i ul os orual dorD l nrrt|l o rs .(hrt$ ({ r nomul l i (:rrdi l ,t i l s (rrl rtrrl
    f(:nti" al accstor sill(h)rltrr. r.sl.r'tnult mai nritr'cdccit in morlclul lttrili" (duf:, N o,:t, .,, .l ., nrodi l j c at)
    factolial (adicii 25o/otlacr-ri;rrra rurtanti r recesifir, 50il,i daciL gcna ruut:rnl:r'L -i n P roc c nte l rec v e ta atr rrl l ti rri
    c dorniniurti"j cind sindromul este X-iinkat rcccsir', rnaraclc ht.tcloziauti. sI ti DltoAl\{E ^N OI\L{ LII ca):clrace
    prezintir risc de rccurcntir clc 50o/o pentru fiii lor). tsoai:r con6rnitrl.i ,1,.
    cord, insiL, poate sii nu fic prezentl la fiecarc indivici ce prezintiL sintlromul DS\r, tetralogie !'allot
    respcctiv. Frecvenla atingcdi cardiovasculare in cadrul acestor sindro:rmo PCA, coarctatia aortei
    poate varia fo;rrtc :nult, intrc 50/o;i 100% (J. J. Nora). Este cscn{ia1sit i ' t,t l )(ni as (ma i al es ti pul I\I) lluptura ruarilor vase de singc (ex caroli(l;I)
    recunoastem {arniiiilc ln care MCC se transmit dupiL legile mendeliene si ai;vrisn disecart al aortei (S0-100'%)
    I r t, t I i ;i a f et Ladicd Jar';lisld I:lipokalemie, tahicardie supraventriculall
    in care riscul recuentci cstc mult mai mare decit in f;rmiliile olisluitr'. Insir{icienli, nlitrai5.
    ln care tranimiterea se iace a"p:i tiG.!"ri"l. t" i"fr"f"f" '",r"r- D S .{ , D S V , tul bul :tri de ri tm, anonl al i i tortr-
    toarc, 3.21, 3.22, Si 3.23, rcproclusc -oa"tof "rirf
    dup:L J. J. Ncra, a.u iost selecta'Lc sin. c i c e (1009t)
    i ,t,':d. sl tbaarti cd, i di aP .rti .d Hipcrtro{ie nuscnlari s{baolticir
    1'ui ;cl yl 3,21 S1au.)zi pulll1ollad, P-li Preltngit, urldc J.rrr o) -
    Sindlonmc arutosornnl racosile crr :rnornalii cardiovilscrrlare asocinfe .l B pi t ]i r.a J. J,, modj l ;ctl 1) mate (95 ol)
    , r'i 'l .,]1 l fti l roy s i l l ei s c ) l-im{edcnl
    SINDRO,.\}T]]
    ANOI{,{LII - rn prrr'r..te irec'r3i1}c Ane1,risme ale trlarilor a.rtere, insulicicrrlii ;rr)f
    atingerii cit:diac. ti c ;,, prol aps de w €rl v .|rmi tral i r, i s rr{ i (fi ' rr1i l
    i tl au. (100 % )
    t tt.Iie llLintoni(.d \Sleitcrt) Nliocardopatie
    Sind n n a d , r e n o - g e nita l( 2 1 ,i 3 ) FliDcrkaliet ic, arRS liir Lait, a:;tr1rji ' feoc ronoc i tom c l l hi l x r
    tit,Jib/onetced S tenoz : tul monari ,
    Ateroscleroz.l, .lal.Itlcpatie tensi!nl} arterialtr, coatctalio trorl(li
    i,cA
    ) ll .l,e) -nLtfi1l Tc l angi ec taz i e mul ti pl i , i l s tl l e l ul mo)' a' i i fl t'
    DSV, PC A
    Aterosclerozi pfeco..j ,,,,t'.itt:si.s i nt:i,eyJe.tLl Insr.ticienti. aortici
    C tis la)e Hipertensiune lu!l1o1r.1di, stri.za '
    lcrijfri'.]r'.,
    ^ 8-T prclungit, n1oarie snbit:r
    arterei lulnlotlar. D S \T, IC A , D S A
    t r ,rt tur-C otrItns
    Cor.l puirllclar lihabdomiotll miocardic
    t, | 0/ti luberads&
    liIIis-xan C"/e*t,J (caaiiapatit, Paliddclila. J DSA, atri r !;,1r, ai rc.l ,i C C t60".i ,1
    L i | :.h-]loar1 atL {f,:jlIotiP l'urrrer cu {ormrli S tc noz :! pul tnonar:!, D .S .A , s tenoz :r s ul )l l (' rl i r' i
    r s:ur liY, nx e lotdcaur..r doninant) idiopaticS. lipertrc,fidL (90?i')
    tl tuxia, Ft iedveith rllio€rdopat j,:l Il i ernpngi oame, l eoc ronrac i tonr ou h4rc r1( rrr;i rr|(r
    1 ,t I lipfct-LirTAat!
    {:licoge}roN.i.I|a, IIla ti Ir- Miocardopalic artcrialA
    l'rombola coi.Ji.aillcl. si :! rlroi ;ese
    .[eroell-Lang!-Niel selr (sindrorlu] car.lio'
    .rurlitiT) I abc l l tl ::.Ll .l
    QT p r el ungi t, n1 :f. Jnl -i tr'L (100':.i
    Lauvetl ce-M ootu- B i cttrI DSV 9i alte I{CC.
    lfr'.ali.pidazd IIi trialvulop:rtie aor aA Si ihoarnc X-llDk{te (tcricsire Fi alominante) (u arromalli asocialc (llrdlolasr'rrl l{l
    klLtcapali zahalito zd, ( M PZ ) I"Iwler lloali a arkrr.i carof.am, rio:ticil, (duP:; l'{ora J J')
    ;i mitr:rli' i30-d09;)
    M.PZ. - Sclrie, Matq io, Ma./atat r-L.L1trt- l lvnlop:rtic eoftica_r,'i,o;,li a arbiei rolonarc
    (30 .s0i/o) SII\TDnO,\liD
    Ij ANOTIALII]
    Oncbge ezd ,'tntpev.f.c
    Id \ral,-ulopa'iic :rorti.; L
    Aterosolerozi precocl
    Ps eu d a a aLt hoame el a st i c l nt Irlsrfici.nfr:. coro ara,, n1itrala., iipcrie,'rsiulir ."-, ? l /u]ofi ,1i ,'
    \l 1.,Z-llutLlcl (X-7eces,i, ) l l .r1: : .rc r.r,i L."|
    arteriau (95 _11,)
    ]liley Da! llllertensiure tri!;lrDJic ntrls.Mlald D chetLlrc
    ?r'terial; .cisoiliciL, hl l otr'.ni unc Iliocardopatie
    posturali (x-rccesi v:i )
    lle Je cie de conduc.rc al ri J-ventri cul ar"
    l )i i l al i c m sc l nv d D Tei J s s
    l \.r'.cesi vl l ) Iliocar--dopatie
    DSV, FCI^T
    llio ca idop.!1i ., i nsLtl i ci eri :i uri l .l l ;r I \.a l i ntnl i a l J i gl urnl i
    ( x.(l oi l ri nant) ]]CA
    :; ,|Lith-Lemli-O fi! ! DSY, ?C,\ Si all3 XICC oc az i orri rl (, I' l
    t,t)ttt (xal j i nur!) D e{ ec te (:ar.l i ac c c orrS fl l i tak
    tleninrctie Flu: tra doxitopeJie flus radiui
    :DSA, tetra.l o"i e Fal i ot, dc-rl .ocrr,r.l i o (i 0,,1,)
    '1'hatasan:,e majord l{iocardop:rtic
    (crr
    l4reill-nlarchcsani PC,\ ,lr'<xuirc r:t: i't lrrl risc dc li! dcstul dq lrliue al .bolii ca.diacc
    Scleroz;.rascular::r 'ecuro
    rr, sint I rtlln rrlrri) cr:r:a cc cste do lolos llt :rlitrrl gcttrrLic'
    :;ikdlotu .,1r..liac-n{tanat sclrcletia ( Faleh ) Co r .Lb il c,cul nr,l /L, rr t t dttl vi osus (I()tt",II .*-il,r-ii,,,r,l
    t,;Lrtr:
    ' ar.r'irraliil: c*f(Jio\lasc.liirlr (lir) fcl(: tr-ri tri;r_.lcsint rnal6l-
    :;indl om liarlagenev Dcxtr o cardi c (10091,I
    :;in1rc1n1tl l ;s,rt.cJalic I' C\, I)S A , sl cl l ozi ! pul r!r,i Jl ,r i l 5(l 'r,l sir t r llor t t ul llilr lat r , sit lt lf ot t lt t l
    rrnrfi i ,,rrrrgIrrit r Ll| , lt ir lo $nsxa; <lr : r '. . - cr . nI llu
    , iinl r o t t l I u I i h t r t , ( r !r ( lir r l r.l ,arl i , c,),rrL i L:1,'.l J, i , rrrl l 1 1l (r ,l ,l
    5l.llr
    118
    4
    TT
    '.IrJ,Iri i) r r ilI ( ) r i r ir . l r rrrl ,,1 ,o l r.,rl r,rri rl o z e l(M c I)Z), cl nr i u rrri xl r:rrl vr.rri i orr.l l ]' ri I 'L l Lr"r i i l o (' l r)l )l ()s ()l l l l l
    \i tl dtt)l tl tt/ N oorl (tLt ar' c l r' nr' i r1' rrI i o' l l ' ' ur
    ' '
    ; Llr iot ' . f ii ( I r i r, ,i ,,,ri rr,rIi i r i j u n c ti v o -i ' L' rst i cc ctc.) si l rt i ' c;r(rrrr( rrl u r \1't'tenozciPrtltrr'.
    tii.' i'rtcrcs'';'ri.pr'('
    'r'ri r'
    rrr ':rstl_li gt r t r _- ,ril. i, 0 l i . 'r ixi- .." xl;
    . .,li',';,;l;,;,;ii'
    de iip lin:inir:), tlcosclrir| rl'
    (litoyir (.Drneittinii i:L iabclclc crpuse ,, rr,. ry.rrlLrri[cr]St Stn{1r-oln1-.,tt-t,.,tt,*
    ',ittit"".,ftritiit"i -spre
    i , ]'iirr,:',1* (Xd) carc sirt ,situst' la lr.'tea sti'gir' '
    ). t lc li nt ! ! as o n o l re c e s i te . S l ro utl cftl ,d;o_l tl l i l i N(.1,.1\,,,11
    I
    ,,r -a'g,c, )iielsr:n, Ilor,-rano-\lrarrl) * vezi capitotul lleten:linir.i
    ',./,,,.r r r , ,.,,,, t0 t,r1 :i r.rb e .i u l 1 .2 b , p-;. t.l 2
    carriii,,. ,,t ,rlii,:J: l ' l i ; l ; ' , " i ; , i l i : ;'';1, , i:il:' ';,,,-1i J, ,; , '.,' - , 'i,r j , r ' , r r : r ' z
    . d' , . ,
    j sLuL!o\0t1tt.!ti ,:/-txiict!n, atingc pielea,
    ochiui qi sistemul circrrl;rlrrr
    , , ,r,,,-',li,,ol,r"i..i.,,,t,r,i'i^,-.,.,;;;': il:.,,:,. ; J-r,,. il,f.*,.,.i,)l:,,;;,
    i\,1,)rlilicirilc r.r--..tal:rtcconsl:ru 1n p-iercierca ciasticitilii si imposilriiiirrt",r c LIctip parlicirlar,
    1,,ii,r,,nrLri.
    , 'orrlrun,niocardopatle ntp"iioiiti rurco;i pr<ilapr al '':litrak:i' displrLzi
    l,r rrriLrii cuL"1o,--;r,,ii_,irr runelc d; s.prasolicitarc m6c,,,,.,ici:
    ixiliL, z,rr,.lr,
    i rl, \ri ilrfr-Lri r-'. 1,, rL.tini. sint vasc dilatate, {ocarc heuror_agir:r,, "",i.,,ro,"rfi de'
    r:,i, . l lclr or:rgiill:. ii-asfrointestin:rli: sint frccrrenie.
    ir,rlr,, etiolofjiei primnri {le rnediu slrrt }elirez*tet1 c.rrj";r'
    rir:lrrl,.r. Nora Ti ii"''i'"tttti itil.t"rii
    "t.ri:'rririilc
    FC''!) ir! 'sti--
    arroxrnrrLlr"
    ,.. ,1p-ari,-ti ..:-ir-i:liollscularlxcz_intiLscntnc dc insuficientl ar.tcri;rlii 11,,rr,,
    r, l.i
    "onrl.r"'a
    ,i, lrr,aliLcarcliov:iscul;rlri congeoitaliila copii iD5\:'
    (irtlusir.'r]i1ai*fia r,.ortci).iledia artcreior pcr.iferice se'calcificiL 2 lia <:rL1r'r'
    , , ,'.r."..c 'ut' l.r. irr m,,ragii |rr:c,r,,,, l" ,lin caztri. ln inlecliilc tti"i-il""1I'lttit'- d| xiCl ':-qtc'li
    ;i hipertr:nsiunc artcriali. IJ r:ciificiil.ilc virs, rrl.,r,. dupii riscui tic surditatc
    r" t l l ,.t t J . . r . - ui , .1 . ,J ,r i ri ..t,n l a . l n 1 ,1 p .g (rL \.i l si .r. ',ri. rLrlitn iitttst;l tlktxt.tgtliei :ttt'tt:itt/h'r
    '1'r;a1,,1i1;urii,,:.Jc;11PZ i''i.vLtsttlCorsai;ic ll, '
    'r t :'"'ittrl.ie.ijpui
    proclui anomalii aic sistemului citr-dio'rr,.r.rrl.rr
    ,,t;,. p.tltr,iL't".;i )'t 1.,'A)' sdrttrilele lrllr iiirir e.l-'rir
    "rt"tt't' latt iri l'rirliLrr)(rrlri
    i1I (E. W. Kcclr). t;;t]ri";i -tiali,l''rr.i'r perir":r ir'i'j.'.1rn{'l('('r('r'
    ', 1,,,, ,i,,i (stenoz"rp"r1monar5"
    -,\rror:ral :iir: sistr.r,..ru1ui carclio'i'ascularin tipul I gi IT constau in ir1;r,r rluc la o rr'." rr',
    t :tr'J \r r"rr'rrrrr'l
    :'ir':r virlvclor corti:r si mitlalt, :r cordajelor icndinloase, a arterelor r,rro ,,,,,].iir.,|
    ,l I lli,',,'ri;
    ,
    ;"i
    i,"ii"l i-l
    ,r,,;;.?"u, .,,,i,
    i.. ,.1 ,i)(
    r.rr'. I)i:ltum'r,.:r c!' intcopolizah;lride in 'intin.i:i :lultor i,a.sc (a:.r1t-1, rrl,,r,,
    "',n
    ".
    l,'r,rrsu1 critenatos sl:ltcrlllc
    f,il il;;i'1
    ,l;,'.i",, . ,) l
    ,r,;,
    ,rrrlrrilrrArcit.a1:llc p,..lifetice) duce la ingustarea lumenului lor. A1.il1,r.r,,.r
    l i,,'l;.,'"s;ir.-",,lil.,:l;1lr:l r,r
    ,I'".r'ir-rr cl:ililr:i. r:uicazi aceeasi orcliue m. in RAA (mitr.ail, eorti, lii, rr,
    p'li''rri::ir-). 1rLi.ipui 11r, V jililsc
    ' iJffi:*li:t-f,ir:i,,,r,rtur, anrit,'r,r
    (.r:rrr
    1,i,1r1, poate ajungc ia insuficicnti. rr..r1r,.r inin,1- t.--'ro'.r ogcstativclt:
    rrr,i,,"fftiiL.t.,i""t", trit
    f i;rr rrf.iogr:i-r.il .,.air.r'ioraodicc. "tniiott':)' .ulel ^
    O nralflirni.iil ,:artliacir ',,,.'1"ro5".,','i',.1":r.iin1'ulo"j16'"11';rgrar:i.l:lti-;LIrLr' i :r r ''l i tr r t
    irrcpriu-zisi nu cxisti in llIpZ_ i t- "r r .l b :;o l i ' l ';f i ' ''n i ' 'r '
    , r , ) . 1 m F r r 'l 'Ji l r r '. \"""t'i t
    ,\ttiiit'o;;tt,,l,it ;,,.,ttc!it:,tront.lttt:itcy'tc,nis se car.ctcd:rrazir Dt-iit t.oml)1r(.rli, ,, :i I'ipuxir' {pritr :' - n" J ui I ;/' t'r'-'rr l l: ' rrl'rr'I
    ,i r ri {: c r l it ' . i: r iir s c ir ;:l t c i r mrl :L " .ri i o , i t,, s i u rr otr r.i cj i ,l l cuccnoi rl l ,,,rrr ']il'iJi ',r'litLil L\.1.2.2.. r'-.t. ,ib:
    r,r,rinolilrr:; t,"til,ii,zt': , " i '.J.2.3.. p.r;. \ri ,.i 'i'z't t"iJiopiriir" Jin c1rr'-ul lortr t'
    .i..'r-adius billtL-rJl,i. l rlLur':irile J:icinatulogiccs. arrrr.lr,,
    r '.u;ir :;l:orrtiir riui-,.-,.r' an. Diagnostic difcrenlial cu aacltia l.llnconr. It.;a; iJ llit.,.ir,t 'mb'ioriitiilor
    c; . r . , , r i. ,rt'(l.joilse sau lnitri{ioraie'
    . ..,.,rrs L ,r i rL l i o s r, i L .c r m,otu!.i l ur . .r l ,,.,,l ,. rrrrr,,

    I
    ' rl r'.
    I r' .
    ,.., r ' ,,.:-,,i , I.c l ;,l 3 p fj l j n , ;' n o tn i ,l i i gJsj roi n,,.j i . rl i : ..j rrr,,
    ,,.,liiii*hill:tl":*iH"i*1:*::f'T,.:llJ,tTi:*1l
    a; l,{cc(eoiig"qes",' J.Ji"..l;,^
    , ,iri".iiliiiir"i n:.;;:,T,,:.'li;:1ll',,
    .\'i)l.tttuvi.ill ( ilyd'irir.cu.taritrt-schcktig (Falek) consti in: ilrtiozir, c_.ilri,rrrr l l ct'- i lr
    ' r" IlLi : t 'o t o L 'tt" tr t'i u n 'c:'l o 'I^ l l c
    I i1il, rJil stirga :iir11r_iindreapta slnt rudimentarc. jt- irlii o .aozit pur cxogen:a' u"ti-d"tt'1i'
    5\,udi t.t,n,,ul r', ,ilt i.:, i ---.,r.. tlc "uiri ttrttllr
    (':r r- \:orir'r
    ttu.iiltlr.", {n11,LStIr, I i\ r, Drain, cy:) : hipotonir, licpatorrr,,l.i, lr
    , lirc(litatea multilactorralir nu"lnscartnir
    ' : t ,"-fr! ir . ' . r r . i ' ' j rru l ,a ti e p i g n r, n i rr.j . p .r.i tardi td. corr.tri " ti v:r. tp"t'il" a" '-1ctiila:'' '--;'-
    rr.'' \sri.e si tlcrlil'll' '
    z. 1; o / ; I L. " rt { o t o n t.a l . ti o tti n , a n te. r ,,,,,,f;"t;;;;i; vrtriir"
    S .i ttdryomull -Iol l ,..()t,rn "t--oa alc
    1 ,' rrl rr. " r i) : , . t , . ' .:.- D d a r,.l i p s :. u o l r^ a \,, 1 trni {al arg.. ,r, rrilljianir. Xlotli:blc ''rccliti-tii "rribjfar:torialc
    io-pi"""' E-'cr'iiairL] t.r''iror corstiL irr rttttrr''
    i ,Ji gi rrrl i z.rr,..r :il: il;';;,1;i" il;i;1; ,'i'oa"l"
    -ottt-a,ii""
    'r ' rr,r' ! r ' , ' . ) . , . , " ,1 l mfl a n ts .t;i n .r e .L n o o oz;Lbi l : osi st.l _j ,r .i i r,),t.,/,
    Ii ,:Ltr'l
    "" r':
    . r
    ' ' ' 'l r. rri . : , , . , , . r ' l. : r r ,z j p ro n a !i a ri s u p i n rri rr . (di agno:ri cul ui t .r,,rrri .ri,,r "" l'i n-'alfoftli'1i(r (rlr(llr)
    ,,rr.i r"rr r r lll' . r , , , , . . r ' l d i n c a rc indivitlul trt'burr: sir {ic prcdispus 3cn'riic
    (
    " t1 5 1 i | .;2 i ,.p n . o-.,.,1or.rrl ul ,ri /. :rzrrrrl , ,rrl l ati L,
    'rporirlill :ini.,:;rr.i cc diaenosticat. 11{111rn;rlrtl
    ritr ir' Jt;r'trii''1-'ll
    ttcbrrit: si lirr ;l () predispozilie SencticiL
    ,'iirri.yt:tii:;tlI{ arfct:t c o boali genelaiizati it mezodcrmrrlui rrr, :rl irr ,, .',:,';:iljl,,'1i",r,1111.i"",1;tt
    ,', lrirrl (s,rbhLrrLtiac r-istalinului), schetetul (lungirlea cxcesiv:Lir rur rrrl,r,ll,
    ' ' "'"'u nr".lirrtrt'i:uic:r';ir-parair pcrioailr'trr''rrrl'ili
    .r rlr11r'tr'lnr' ('r.r;Lhnorlactilie)-.qia.aparatuiui cardiovascular. (pr.ollLpsrll r,.rlr,, <: t r r : r r tsr
    L 'r 'r : lr : ii) '
    r il
    , t,,t,,ti ' ,i , i i ,:,Lr iliar , ( ar liciLlir ar t c pr ccoi
    rrrrlr rlri ,r rlirt inczo:tistolir:,dilatafia aortr:i, anr:vrisnr discclrtrt lLl :rorlr ,
    r 'rtr,rrrl . nl, . r, l: lat llt i: r a l to i r a rtc l (], d c ,tx c rn p l rr c aroti al .-,
    lrr rr.l .i i r r r r r , Li r ; ull, t r ; l i rrl i a cl a u n l ri !(:i 1 ' n Lc rr s i rttl ronr Il arfl i .
    1rIrIrrron;r rr,. A 1r,rir(r r . il,'f'l i , )'l;i,ll,i,:l'ilii,lil"t'll l:ii'il'il, ,:ii:i;I,,)li';,:;l;ii':ili
    Ii ,, ri rrr l' t nr it r it t t t t c[ ' r r r zir t t r ' t . 1r ) '] i lr "r 'l( , . , r
    , i , ,l i ;, ii, ir r rir r i" r r l ri ;r a o rl l r. 1xr;Ll :r, i ,,,,i f, , f,, r'r r r ' r l'
    1"''t it '- I
    r 'r r 'ii1 li'' ' l' ' l'llt lr t t
    t,rrrr l :rrrr,rl rl rllr ir r llr olr lr f t 'l"l' 'i'
    it l tl r Si
    :I uLtttr .t Nt dc tncdiu a stricat echilibrul ilstabil ln calc
    ,\,lrr,rsultrutri factor dc:clatrsatol:
    Itolul u||or lr{,1ori 0roilolll l (cncticir 5i astftl a :tpirut o malformaliecardiact' Riscul
    '' ,rll:r l)irlrrlr.liL
    ,rr||tl[(rrrN canlloFallilor(r) gc italr ({Lui.ii(, ],(r|)()l)+
    i i; rudi' ,lc gr:dul inrii uste c('l empiric (intre I -5o/o),prczcntai
    .rrri'r;;';r'
    irtiiitrtc la capitolul MCC izolatc.
    A C]:N I' cAltD to1,,\'l'rI-
    y'? praqu/ m6 i4 '/r/,1!i/u.
    f cp,'d"J[cd P'd1 ': /
    ' I 0X I CE 'l/L'l cd/dtAie ia,/,Jen//d/. " t".- J
    d. Ld/.p det/;, sdFJ"J/
    /rpti de f:c\tar tttctrtttl,:/t'''
    25*50%l?) dn rnet//a /d/// neClu.
    DSA, DSV, PCA \,
    5 -t0 o /o(? ) DSV, PCA, DSA, t ,r:rpoliiji

    2 -r0 % \l j Stenoz:rprlnonarA, sterozir,aortidr, ri,)i r'


    ta!ie, I;.C,A
    15*30% , tetral ogj a l al l ot, hi p0l ,l i rl i rl
    cordului sting
    10./" atrczie tricuspidir, DSA
    I l 0 f lrorli s o s u a l i 2*4% S\' , lr a n sp .z;i rc tetral ogre 1.,11,'l
    'l h rli(lornk ii r 5 -1 0 % Ia ll.i r, D S l ', D S .\, l rLrncLi i ,, r, rl 'tl

    I N II ]')C !'II
    l i r l)c o1a Ste u o z; p 1 1 lmonari , stcnozi pul nl r)rr.rI
    pcriferici. PCA, DSV
    I I . I 1. , 4DI I X,TATERNE
    fa - ,,' l e I'/i
    I ) irl){ r1 20 3,5rt/a DSV, coirrctalie ;t /
    rJ
    ,),1.. ,1!
    l .L rl, rs elitcmatos dise-
    atrio'r'entriclrl.rr con rltetr

    25-50 %
    endocardicii
    etralosie Fallct, DSV, DSA
    ipoterice.".,T:iriffi*tii:,rslijiib }tcc si prag*lintlue'{ci'r'-
    i..3.57.- 3 cLLLLo

    $ \rszi 1.8.3.2.2.(pag. 126.)


    lcapal.itiir
    Cu cit rLc{cctulcarr]iacr mai frccvc'nt,cu atit e mai.probabill
    sir apari' intr-o familie decit ittrr:zirt
    lr,'l)|li{' asamblateintr-o ordine prccis5-Fi cu o vitezi anuniti. Daci"Lrrrrrr 1 i (d;;;";fil'n-SV Probabil
    tttiH3;fk " -.,1
    lirr picsc'lcconstitutivc ale septului
    rlirr sentului apare
    sep aDareprea
    Drea tirziu sa,.rare rnelc
    unelctrlr.h,
    rlr.irrr,
    , ttl,' rninoic de constructie,septul nu se va lnchide complet- ,,PragLrl"rl|
    r, crbditateamulti{actorialicrc;te iJpicl cu-numlrul de ru(lc
    dsc,l c d(l
    ,r,' *."a'"fi"iii ;i;;i;;;. Dal;t slnt 2 rude de gradulf afcc,tate'
    l;r ,llzvoltarea normali la cea anormalS. a fost trecut. Probabit cir it)i(r.ilr,
    Ittli,npJirin anomaliiie dc dezvoltare a septulni dupi. modelul de errrrlit;rlr. ii";;"8'l

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