Hiperbilirrubinemianeonatal-InTERNA RESIDENTADO ECUADOR

8/18/2019 Hiperbilirrubinemianeonatal-InTERNA RESIDENTADO ECUADOR

1/55

http://2.bp.blogspot.com/_yv1e5YUot1E/SMaa73BmIKI/AAAAAAAAKok/x-ioSgbxI64/s1600-h/1.jpg


2/55


3/55

Madre de 25 años, sana, ORH positivo, VDRL

negativo. Primigesta, embarazo bien

controlado, sin complicaciones. Parto cefalovaginal, recién nacido de seo

femenino, !" semanas de edad gestacional,

vigoroso, peso 25#$gr, per í metro cef álico

!#cm, longit%d #"cm, ORH positivo

&in patolog í a perinatal, alimentado a seno

directo ecl%sivo, alta a las #'(s, peso al alta

2#$$ gr. Reingresa a los 5 d í as de vida por

ictericia generalizada. Peso al ingreso 2)2$gr.

&%cción pobre e ineficaz, escasa di%resis *

deposiciones en las últimas #'(s. +febril

http://espaciociencia.com/wp-content/uploads/2009/05/madre-e-hijo.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNlAtvOI/AAAAAAAAKps/lbKZ1_yI1VI/s1600-h/9.jpghttp://2.bp.blogspot.com/_yv1e5YUot1E/SMaa73BmIKI/AAAAAAAAKok/x-ioSgbxI64/s1600-h/1.jpg


4/55

ámenes de laboratorio- bilirr%binas totales

2$,52mgdl, bilirr%bina indirecta )"mgdl.

Hemograma gl ób%los blancos )$.2$$

elementosmm, 5$/ polimorfon%cleares * )/

ca*ados, !!$$$$ pla0%etas, (ematocrito 1!/,(emoglobina 2).) gl. Retic%locitosis $.'/

l ámina perif érica no se observan esferocitos

ni otras anomal í as. licemia 3'mgdl.



5/55

Lista de problemas:

• Alta precoz antes de las 72hs•Bilirrubinas totales 20,52mg/dl,

bilirrubina indirecta 17mg/dl•Succión pobre e ineficaz, escasa diuresis y

deposiciones en las últimas 48s•Perdida de peso (2400 gr; 2120gr )


6/55

GLOBINA

HEMO

Fe libre(Fe2+ a Fe3+)

La bilirrubina es

el producto final

del grupo HEM

biliverdina

hemo-oxigenasa

CO

80% proviene de

destrucción diaria de

eritrocitos

20% de eritropoyesis

inefectiva de la medula

ósea y en el hígado

Extraido de Pediatrics in Review, en español, vol.28 Nº3 Mayo 2007

http://www.google.com.ec/imgres?imgurl=http://4.bp.blogspot.com/_02O01AZHwk0/SgMJbBwqToI/AAAAAAAAAI4/JQFN2SVegBA/s400/AA%2Bni%C3%B1o%2Bcon%2Bpulmones.jpg&imgrefurl=http://aprendiendobiologiaconcayetano4009.blogspot.com/&usg=__9K3eeAi7TCEDJl66z_sMfqdwxKk=&h=328&w=250&sz=17&hl=es&start=12&itbs=1&tbnid=1Idgw8Iq3OeriM:&tbnh=118&tbnw=90&prev=/images%3Fq%3Dni%25C3%25B1o%2Bcon%2Bpulm%25C3%25B3n%26hl%3Des%26gbv%3D2%26tbs%3Disch:1http://3.bp.blogspot.com/_yv1e5YUot1E/SMabMz_rT0I/AAAAAAAAKpM/4RDDGucM4mY/s1600-h/6.jpg


7/55Extraido de Pediatrics in Review, en español, vol.28 Nº3 Mayo 2007

http://3.bp.blogspot.com/_yv1e5YUot1E/SMabMz_rT0I/AAAAAAAAKpM/4RDDGucM4mY/s1600-h/6.jpg


8/55

1.- FASE DE PRODUCCIÓN

Se origina principalmenteen los glóbulos rojos

2.- FASE DE TRANSPORTEBNC se une a la albúmina y estransportada a sinusoides

hepáticos

3.-FASE DE CONJUGACIÓNBNC en hepatocito BC

4.-FASE DE ELIMINACIÓN

En intestino (Urobilinógeno ,estercobilina)

1.- FASE DE PRODUCCIÓN• Vida media del eritrocito•Hcto aumentado•Más células deformes

2.- FASE DE TRANSPORTE•Disminución de la albúmina(Prematuro , RCI)

3.-FASE DE CONJUGACIÓN•Disminución de acidoglucurónido•Disminución de ligandinas•Disminución de UDP

glucuronil transferasa debilirrubina

4.-FASE DE ELIMINACIÓN•Recirculación enterohepática•Hígado y riñones inmaduros


9/55

hiperbilirrubinemia

Ictericia

Aumento de niveles séricosde bilirrubinas sobre el nivel

normal para edad y peso

No conjugadasConjugadas

Condición clínica en que labilirrubina sérica está lo

sufcientemente aumentadacomo para observar un tinte

amarillo en la escleróticaocular, mucosas y piel del RN

http://www.google.com.ec/imgres?imgurl=http://www.todoensalud.org/Infogen1/fotos/IctericiaNeonatal.jpg&imgrefurl=http://www.todoensalud.org/Infogen1/servlet/CtrlVerArt%3Fclvart%3D9506&usg=__Iu1nvRj-ekUNdiZkVQ-aJXWz-ik=&h=110&w=110&sz=12&hl=es&start=71&itbs=1&tbnid=kRNGJtpVGwEXYM:&tbnh=85&tbnw=85&prev=/images%3Fq%3Dictericia%26start%3D60%26hl%3Des%26sa%3DN%26gbv%3D2%26ndsp%3D20%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://i.esmas.com/image/0/000/005/141/ictenenatNTnva.jpg&imgrefurl=http://pekebebe.com/2160-ictericia-en-los-recien-nacidos-tipos-consejos-y-situaciones-de-emergencias&usg=__YU5cR8Od_UbbjH07QNjFphChQj0=&h=270&w=370&sz=9&hl=es&start=5&itbs=1&tbnid=tgvH0OynufcliM:&tbnh=89&tbnw=122&prev=/images%3Fq%3Dictericia%26hl%3Des%26gbv%3D2%26tbs%3Disch:1http://images.google.com.ec/imgres?imgurl=http://www.elblogdebebes.com/wp-content/uploads/2009/04/ictericia-1-150x137.jpg&imgrefurl=http://www.elblogdebebes.com/desarrollo/ictericia/&usg=__PXeKTyas-CsQHyAxEi9BYCy9DC8=&h=137&w=150&sz=7&hl=es&start=43&tbnid=DXtMTuqQfc_XaM:&tbnh=88&tbnw=96&prev=/images%3Fq%3Drecien%2Bnacido%2Bict%25C3%25A9rico%26gbv%3D2%26ndsp%3D18%26hl%3Des%26sa%3DN%26start%3D36http://images.google.com.ec/imgres?imgurl=http://www.mundomamas.com/archivos/imagenes/13762-t.jpg&imgrefurl=http://www.mundomamas.com/&usg=__A7flbfQ3xab3SV4XlHBCOIfHMKo=&h=130&w=130&sz=6&hl=es&start=53&tbnid=HAM9tLLhNZKnxM:&tbnh=91&tbnw=91&prev=/images%3Fq%3Drecien%2Bnacido%2Bict%25C3%25A9rico%26gbv%3D2%26ndsp%3D18%26hl%3Des%26sa%3DN%26start%3D36


10/55

TORCH

http://images.google.com.ec/imgres?imgurl=http://www.moondragon.org/images2/bilirubinuvtreatment.jpg&imgrefurl=http://carlosvirtual.wordpress.com/2008/03/07/ictericia-en-recien-nacidos-jaundice-in-newborns/&usg=__iySWkaYwyHgy-rjdJ5p1-nRb2_s=&h=283&w=300&sz=20&hl=es&start=52&tbnid=oRMRbtetnqD4cM:&tbnh=109&tbnw=116&prev=/images%3Fq%3Drecien%2Bnacido%2Bict%25C3%25A9rico%26gbv%3D2%26ndsp%3D18%26hl%3Des%26sa%3DN%26start%3D36http://images.google.com.ec/imgres?imgurl=http://www.mundomamas.com/archivos/imagenes/13762-t.jpg&imgrefurl=http://www.mundomamas.com/&usg=__A7flbfQ3xab3SV4XlHBCOIfHMKo=&h=130&w=130&sz=6&hl=es&start=53&tbnid=HAM9tLLhNZKnxM:&tbnh=91&tbnw=91&prev=/images%3Fq%3Drecien%2Bnacido%2Bict%25C3%25A9rico%26gbv%3D2%26ndsp%3D18%26hl%3Des%26sa%3DN%26start%3D36http://4.bp.blogspot.com/_yv1e5YUot1E/SMabNaq6TvI/AAAAAAAAKpc/eFNOki-wmDg/s1600-h/8.jpg


11/55

La velocidad deproducción de Bb excede

la velocidad deeliminación

= fnal es elaumento () de Bb

sérica total

http://4.bp.blogspot.com/_yv1e5YUot1E/SMabNaq6TvI/AAAAAAAAKpc/eFNOki-wmDg/s1600-h/8.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMaa70ig9pI/AAAAAAAAKos/gjXjP4_2020/s1600-h/2.jpg


12/55

FISIOL!I"#$urante la primerasemana de vida (%&

' da)emite de manera

espont*nea

#

http://www.google.com.ec/imgres?imgurl=http://www.bebescr.com/media/bebe1.jpg&imgrefurl=http://www.bebescr.com/bebes/bebe0044.shtml&usg=__AE-6DLuxncrYzygkibSXAMonRzc=&h=164&w=142&sz=4&hl=es&start=31&itbs=1&tbnid=KCZY6Y55FijpnM:&tbnh=98&tbnw=85&prev=/images%3Fq%3Dictericia%2Bfisiologica%26start%3D20%26hl%3Des%26sa%3DN%26gbv%3D2%26ndsp%3D20%26tbs%3Disch:1http://4.bp.blogspot.com/_yv1e5YUot1E/SMaa70ig9pI/AAAAAAAAKos/gjXjP4_2020/s1600-h/2.jpghttp://3.bp.blogspot.com/_yv1e5YUot1E/SMabNd2VTvI/AAAAAAAAKpk/opK2-muyfac/s1600-h/10.jpg


13/55

90 días

http://3.bp.blogspot.com/_yv1e5YUot1E/SMabNd2VTvI/AAAAAAAAKpk/opK2-muyfac/s1600-h/10.jpghttp://www.google.com.ec/imgres?imgurl=http://salud.medicinatv.com/images/pregunta/3179.jpg&imgrefurl=http://salud.medicinatv.com/consejo/muestra.asp%3Fid_consejo%3D3179%26amp%3Bid_agrupacion%3D0%26amp%3Bid_pat%3D0&usg=__aKrqLWON1xSsAV1mng70Dfy_ffM=&h=120&w=140&sz=5&hl=es&start=15&um=1&itbs=1&tbnid=-6ZLNRCAQwHiEM:&tbnh=80&tbnw=93&prev=/images%3Fq%3DPOLICITEMIA%26um%3D1%26hl%3Des%26gbv%3D2%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://www.hepatitisc2000.com.ar/blog/wp-content/uploads/2010/03/esteatosis-hepatica.jpg&imgrefurl=http://www.hepatitisc2000.com.ar/blog/index.php/2010/03/26/higado-graso-o-esteatosis-hepatica/&usg=__8VAS1VN1TROu7Yen6gzaiV3EaJE=&h=241&w=300&sz=20&hl=es&start=37&itbs=1&tbnid=5Ax47BLUWavWnM:&tbnh=93&tbnw=116&prev=/images%3Fq%3Dmetabolismo%2Bintrahepatico%26start%3D20%26hl%3Des%26sa%3DN%26gbv%3D2%26ndsp%3D20%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://www.educa.madrid.org/cms_tools/files/fe30eb52-9388-46e5-a543-ec76cdf9223c/globulosrojos01.png&imgrefurl=http://www.educa.madrid.org/portal/c/portal/layout%3Fp_l_id%3D6605.111%26p_p_id%3Dvisor_WAR_cms_tools%26p_p_action%3D0%26p_p_state%3Dmaximized%26p_p_width%3D214%26p_p_col_order%3Dn2%26p_p_col_pos%3D0%26p_p_col_count%3D2%26_visor_WAR_cms_tools_contentId%3Da6dae986-0d6e-4136-a565-efedb6e3e84b%26_visor_WAR_cms_tools_fieldId%3D--&usg=__t51NljKOucLhe9kQaCviINrFxfM=&h=429&w=645&sz=641&hl=es&start=19&itbs=1&tbnid=Ny2sodZZ5oOqVM:&tbnh=91&tbnw=137&prev=/images%3Fq%3Deritrocitos%26hl%3Des%26gbv%3D2%26tbs%3Disch:1


14/55

+O FISIOL!I"#

B+" ,-%./m01dl +#2B+" ,-3m01dl +42 (vara se05n edad

0estacional 6 peso)+ivel de Bb 7ue aumenta ,89%m01dl1hr o

,3m01dl1daIctericia durante las -ras %:h de vidaIctericia clnica 7ue persiste , de -semana +#2 6 , de % semanas en

prematuros

Gomella Neonatology, five, sixth edition

http://www.google.com.ec/imgres?imgurl=http://www.todoensalud.org/Infogen1/fotos/IctericiaNeonatal.jpg&imgrefurl=http://www.todoensalud.org/Infogen1/servlet/CtrlVerArt%3Fclvart%3D9506&usg=__Iu1nvRj-ekUNdiZkVQ-aJXWz-ik=&h=110&w=110&sz=12&hl=es&start=29&itbs=1&tbnid=kRNGJtpVGwEXYM:&tbnh=85&tbnw=85&prev=/images%3Fq%3Dictericia%2Bfisiologica%26start%3D20%26hl%3Des%26sa%3DN%26gbv%3D2%26ndsp%3D20%26tbs%3Disch:1


15/55

http://4.bp.blogspot.com/_yv1e5YUot1E/SMaa8e-C5jI/AAAAAAAAKpE/sT0WTarvZ24/s1600-h/5.jpg


16/55

B#+;


17/55

INCOMPATIBILIDAD RH

Traspaso de

IgG anti RHmaternas alfeto

MADRE

RH -FETORH +

vacuna que elimina los anti-Rh, llamada la

gamma inmunoglobulina RhoGAM

Sensibilización previa


18/55

INCOMPATIBILIDAD GRUPO CLÁSICO

Traspaso de anticuerpos maternos, anti A o anti al fetoTraspaso de anticuerpos maternos, anti A o anti al feto

MADRE

O

FETOA, , A

dos tipos de sangre diferentes e

incompatibles se mezclan

http://www.blog.com.es/srv/media/media_item.php?item_ID=982940


19/55

http://2.bp.blogspot.com/_W1qgRsi3Xq4/Su2XqIu2o5I/AAAAAAAAAnk/6-_H5gB3J7s/s1600-h/imag.+tabala+compatib.+sanguinea.jpghttp://www.google.com.ec/imgres?imgurl=http://blogs.librodearena.com/myfiles/charles/ni%C3%B1o-1.jpg&imgrefurl=http://www.librodearena.com/blog/charles/1647%3F%26total%3D64%26page%3D3&usg=__UIoXVLGkrZY2gzj9n60AwtlZyHk=&h=540&w=510&sz=39&hl=es&start=60&um=1&itbs=1&tbnid=xyCSsUM4jbqaEM:&tbnh=132&tbnw=125&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26start%3D40%26um%3D1%26hl%3Des%26sa%3DN%26ndsp%3D20%26tbs%3Disch:1


20/55

$ ;?2#@#S#"I+S#+!A>+;#

"ealohematomasemorra0ia intraventricular 6

pulmonarematoma hep*tico subcapsular

emorra0ia 0astrointestinal oculta

(;"+)

" 4OLI"I2;


21/55



22/55

F

Nivel séricomáimo -./

0.mg1dl entre los-. y -2 días de

vida

http://2.bp.blogspot.com/_yv1e5YUot1E/SMaa73BmIKI/AAAAAAAAKok/x-ioSgbxI64/s1600-h/1.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMaa8T9biDI/AAAAAAAAKo8/7hxiJ2Eyo58/s1600-h/4.jpg


23/55

!#L2;#"IO+;S


24/55

#A


25/55

ISustancias 6 trastornos 7ueaectan la fDación de Bb a

alb5mina

#spirinaSulonamidas4enicilina

!entamicinaEcidos 0rasos presentes en

órmulas nutricionales

#sfxia#cidosisSepsis

ipotermiahipo0lucemia

http://www.google.com.ec/imgres?imgurl=http://lp77.files.wordpress.com/2009/02/rn-con-rubiola1.jpg&imgrefurl=http://lp77.wordpress.com/2009/02/12/rubeola/rn-con-rubiola1/&usg=__WPtpyryJVS42sE2Xz4YwTDzwxNU=&h=444&w=585&sz=46&hl=es&start=11&um=1&itbs=1&tbnid=PfmwoBCRJ3S7vM:&tbnh=102&tbnw=135&prev=/images%3Fq%3Drn%26um%3D1%26hl%3Des%26gbv%3D2%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://www.bebeguia.net/wp-content/uploads/2009/05/parto.jpg&imgrefurl=http://www.bebeguia.net/category/parto&usg=__gpuNNpKLpTMApAiW0t-fDsqKHt4=&h=290&w=435&sz=26&hl=es&start=10&um=1&itbs=1&tbnid=loGqEQbI6HrTIM:&tbnh=84&tbnw=126&prev=/images%3Fq%3Dparto%26um%3D1%26hl%3Des%26gbv%3D2%26tbs%3Disch:1http://4.bp.blogspot.com/_yv1e5YUot1E/SMabNDdXyzI/AAAAAAAAKpU/yf8NsAjO2Og/s1600-h/7.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNlAtvOI/AAAAAAAAKps/lbKZ1_yI1VI/s1600-h/9.jpg


26/55

+ivel sérico de Bb 3&Gm01dl

Letar0oechaHo delalimento@ómitos

ipotona conpro0resión hacia

el desarrollo deconvulsiones

http://www.google.com.ec/imgres?imgurl=http://www.solohijos.com/images/articulo/a0242001.jpg&imgrefurl=http://www.solohijos.com/html/articulo.php%3Fidart%3D242&usg=__GVpehxSvSpeu1PPG3toZr_Z0Wkg=&h=205&w=138&sz=5&hl=es&start=10&um=1&itbs=1&tbnid=NMqgHUvBlAdKEM:&tbnh=105&tbnw=71&prev=/images%3Fq%3Dbebe%2Bcon%2Bictericia%26um%3D1%26hl%3Des%26gbv%3D2%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://i.esmas.com/image/0/000/005/141/ictenenatNTnva.jpg&imgrefurl=http://www.esmas.com/salud/enfermedades/cronicas/572956.html&usg=__aY6NKrCSD3cFKJgQK_pr-LzrcgM=&h=270&w=370&sz=9&hl=es&start=2&um=1&itbs=1&tbnid=tgvH0OynufcliM:&tbnh=89&tbnw=122&prev=/images%3Fq%3Dbebe%2Bcon%2Bictericia%26um%3D1%26hl%3Des%26gbv%3D2%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://www.aurorahealthcare.org/healthgate/images/Jaunduce_baby.jpg&imgrefurl=http://www.aurorahealthcare.org/yourhealth/healthgate/getcontent.asp%3FURLhealthgate%3D%2522121230.html%2522&usg=__DQmXMuDQAW2DXlKwDehIxdzPwaM=&h=400&w=312&sz=74&hl=es&start=1&um=1&itbs=1&tbnid=-VvenrM1JSaw1M:&tbnh=124&tbnw=97&prev=/images%3Fq%3Dbebe%2Bcon%2Bictericia%26um%3D1%26hl%3Des%26gbv%3D2%26tbs%3Disch:1http://4.bp.blogspot.com/_yv1e5YUot1E/SMabNlAtvOI/AAAAAAAAKps/lbKZ1_yI1VI/s1600-h/9.jpg


27/55

9 $; J#


28/55

J;+I"2;AS

por lo 0eneral no aecta la corteHacerebral. se puede revertir si el nivelsérico de Bb desciende antes de 7ue

ten0a lu0ar la saturación de los n5cleosdel S+"9

4i0mentación 6necrosis de las

neuronas

0an0lios

basales

corteHahipocampic

a

n5cleossubtal*mic

os

cerebelo

Se debe a la acción directa de la bilirrubina indirecta libre sobre el sistema nervioso

central, inhibiendo la fosforilación oxidativa de las mitocondrias y los procesos de

síntesis proteica

http://upload.wikimedia.org/wikipedia/commons/5/58/Schmorl_kernicterus.JPGhttp://www.mdconsult.com/das/patient/body/0/0/10041/22694_en.jpghttp://www.google.com.ec/imgres?imgurl=http://blogs.librodearena.com/myfiles/charles/ni%C3%B1o-1.jpg&imgrefurl=http://www.librodearena.com/blog/charles/1647%3F%26total%3D64%26page%3D3&usg=__UIoXVLGkrZY2gzj9n60AwtlZyHk=&h=540&w=510&sz=39&hl=es&start=60&um=1&itbs=1&tbnid=xyCSsUM4jbqaEM:&tbnh=132&tbnw=125&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26start%3D40%26um%3D1%26hl%3Des%26sa%3DN%26ndsp%3D20%26tbs%3Disch:1http://4.bp.blogspot.com/_yv1e5YUot1E/SMaa8e-C5jI/AAAAAAAAKpE/sT0WTarvZ24/s1600-h/5.jpg


29/55

http://4.bp.blogspot.com/_yv1e5YUot1E/SMaa8e-C5jI/AAAAAAAAKpE/sT0WTarvZ24/s1600-h/5.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNDdXyzI/AAAAAAAAKpU/yf8NsAjO2Og/s1600-h/7.jpg


30/55

Entre el 0 y el !" de

los ni#os con ictericia

nuclear mueren

preco$mente

http://4.bp.blogspot.com/_yv1e5YUot1E/SMabNDdXyzI/AAAAAAAAKpU/yf8NsAjO2Og/s1600-h/7.jpg


31/55



32/55

;studios de laboratorio

Bilirrubina total 6directa

emo0rama completo 6recuento deeticulocitos

!rupo san0uneo 6actor h

4rueba de "oombsdirecta en el niMo

+ivel sérico de alb5mina

Bilirrubinometratranscut*nea

http://www.google.com.ec/imgres?imgurl=http://imagenes.mailxmail.com/cursos/imagenes/0/4/examenes-de-laboratorio-hemoglobina-glicosilada_24440_3_1.jpg&imgrefurl=http://www.mailxmail.com/curso-diabetes-mellitus-sintomas-tratamiento-dieta/examenes-laboratorio-hemoglobina-glicosilada&usg=__yPwbmhKXMCwqpozI-vtQ5eND7_I=&h=227&w=310&sz=60&hl=es&start=5&um=1&itbs=1&tbnid=8A4gGfD0L5EOcM:&tbnh=86&tbnw=117&prev=/images%3Fq%3Dexamenes%2Bde%2Blaboratoria%26um%3D1%26hl%3Des%26gbv%3D2%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://www.perfilesytrazas.com.co/images/fotos/fot14.jpg&imgrefurl=http://www.perfilesytrazas.com.co/temas/index.htm&usg=__DfvTch0w_y4syCFGcSd14Z3BrHo=&h=260&w=213&sz=13&hl=es&start=3&um=1&itbs=1&tbnid=pCtbn4_enQLsaM:&tbnh=112&tbnw=92&prev=/images%3Fq%3Dexamenes%2Bde%2Blaboratoria%26um%3D1%26hl%3Des%26gbv%3D2%26tbs%3Disch:1http://2.bp.blogspot.com/_yv1e5YUot1E/SMaa73BmIKI/AAAAAAAAKok/x-ioSgbxI64/s1600-h/1.jpg


33/55

9 $; J#


34/55

Fototerapia

;xan0uinotransusión

Farmacoterapia

http://images.google.com.ec/imgres?imgurl=http://www.elblogdebebes.com/wp-content/uploads/2009/04/ictericia-1-150x137.jpg&imgrefurl=http://www.elblogdebebes.com/desarrollo/ictericia/&usg=__PXeKTyas-CsQHyAxEi9BYCy9DC8=&h=137&w=150&sz=7&hl=es&start=43&tbnid=DXtMTuqQfc_XaM:&tbnh=88&tbnw=96&prev=/images%3Fq%3Drecien%2Bnacido%2Bict%25C3%25A9rico%26gbv%3D2%26ndsp%3D18%26hl%3Des%26sa%3DN%26start%3D36


35/55


36/55


37/55

3+4+45RA'6A7 longitudes de onda de 82. nm a 2.. nm

#$creción por la orina

% heces

de un producto

soluble en a&ua no

tó$ico

trans'orm(ndola enisómeros no tó$icos

)lumirrubina* e

hidrosolubles

"otoisomeri9ación

"otooidación

6someri9aciónestructural

http://www.google.com.ec/imgres?imgurl=http://www.nlm.nih.gov/medlineplus/spanish/ency/images/ency/fullsize/9050.jpg&imgrefurl=http://www.nlm.nih.gov/medlineplus/spanish/ency/esp_imagepages/9050.htm&usg=__G0-2rsPEF8p8l1nq3UPEiZ7xang=&h=320&w=400&sz=11&hl=es&start=7&um=1&itbs=1&tbnid=pOphjVloKPy18M:&tbnh=99&tbnw=124&prev=/images%3Fq%3Dintestinos%26um%3D1%26hl%3Des%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://www.nlm.nih.gov/medlineplus/spanish/ency/images/ency/fullsize/10022.jpg&imgrefurl=http://www.monclovitas.com/foro/showthread.php%3Fpage%3D11%26t%3D38672&usg=__j5TtsYSdZqgGNgNzrTOcaUGCeTs=&h=320&w=400&sz=13&hl=es&start=48&um=1&itbs=1&tbnid=B5GzizBPbGnpPM:&tbnh=99&tbnw=124&prev=/images%3Fq%3Dri%25C3%25B1ones%2Bde%2Bbebe%26start%3D40%26um%3D1%26hl%3Des%26sa%3DN%26ndsp%3D20%26tbs%3Disch:1http://images.google.com.ec/imgres?imgurl=http://www.moondragon.org/images2/bilirubinuvtreatment.jpg&imgrefurl=http://carlosvirtual.wordpress.com/2008/03/07/ictericia-en-recien-nacidos-jaundice-in-newborns/&usg=__iySWkaYwyHgy-rjdJ5p1-nRb2_s=&h=283&w=300&sz=20&hl=es&start=52&tbnid=oRMRbtetnqD4cM:&tbnh=109&tbnw=116&prev=/images%3Fq%3Drecien%2Bnacido%2Bict%25C3%25A9rico%26gbv%3D2%26ndsp%3D18%26hl%3Des%26sa%3DN%26start%3D36


38/55


39/55

"+-+


40/55

Ó


41/55

EXANGUINEOTRANSFUSIÓN • Remoci!n

mec"nica dela sangre delR# $ su

reempla%opor sangrede un

donadorcompati&le


42/55


43/55

http://1.bp.blogspot.com/_yv1e5YUot1E/SMaa8T9biDI/AAAAAAAAKo8/7hxiJ2Eyo58/s1600-h/4.jpg


44/55

si0no de disunciónhepatobiliar se manifesta

después de - semanaIncapacidad para eliminar

Bb conDu0ada

, -93 a %m01dL o , %8R

se Bb2

http://www.google.com.ec/imgres?imgurl=http://www.auxilio.com.mx/manuales/higado.gif&imgrefurl=http://nivoservi-sil-10.blogspot.com/2007/08/4-nvl-tm.html&usg=__AKO1BLCJt6bzM5abtInQ58LK8kE=&h=441&w=640&sz=44&hl=es&start=2&um=1&itbs=1&tbnid=HDNMoWZNEtMlDM:&tbnh=94&tbnw=137&prev=/images%3Fq%3Dhigado%2By%2Bv%25C3%25ADas%2Bbiliares%2Bde%2Bni%25C3%25B1o%26um%3D1%26hl%3Des%26tbs%3Disch:1http://1.bp.blogspot.com/_yv1e5YUot1E/SMaa8T9biDI/AAAAAAAAKo8/7hxiJ2Eyo58/s1600-h/4.jpghttp://3.bp.blogspot.com/_yv1e5YUot1E/SMabMz_rT0I/AAAAAAAAKpM/4RDDGucM4mY/s1600-h/6.jpg


45/55

;+F;


46/55

;+F;


47/55

http://3.bp.blogspot.com/_yv1e5YUot1E/SMabNd2VTvI/AAAAAAAAKpk/opK2-muyfac/s1600-h/10.jpg


48/55

;studios de laboratorio

Bilirrubina total 6directa

emo0rama completo 6recuento de

eticulocitos4F+iveles séricos de

colesterol. tri0licéridos.alb5mina

+ivel sérico de urea.

0lucosa

;studios radioló0icosBilirrubinometra

transcut*nea

http://www.google.com.ec/imgres?imgurl=http://cris1818.files.wordpress.com/2008/11/2007112034laboratorio_200711211.jpg&imgrefurl=http://cris1818.wordpress.com/2008/11/26/subiendo-una-imagen/&usg=__gSgYbpyGJYCGyCp63Sp74AbWXnY=&h=300&w=600&sz=59&hl=es&start=1&um=1&itbs=1&tbnid=yc-oWeWSbgHrBM:&tbnh=68&tbnw=135&prev=/images%3Fq%3Dlaboratorio%26um%3D1%26hl%3Des%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://puntoazul.files.wordpress.com/2008/09/laboratorio1.jpg&imgrefurl=http://puntoazul.wordpress.com/2008/09/15/un-hallazgo-casual-podria-allanar-el-camino-a-una-vacuna-contra-el-vih/&usg=__kNqBRh7dtegRffneX31RYDUwFd0=&h=1131&w=1698&sz=141&hl=es&start=2&um=1&itbs=1&tbnid=GTyMOf9vyuahjM:&tbnh=100&tbnw=150&prev=/images%3Fq%3Dlaboratorio%26um%3D1%26hl%3Des%26tbs%3Disch:1http://3.bp.blogspot.com/_yv1e5YUot1E/SMabNd2VTvI/AAAAAAAAKpk/opK2-muyfac/s1600-h/10.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMaa8e-C5jI/AAAAAAAAKpE/sT0WTarvZ24/s1600-h/5.jpg


49/55


50/55

2#2#


51/55

peso al alta en ascenso 2!"$gr, eamenne%rol ó gico normal. 4ilirr%binas al alta totales

)),#2 mgdl.

http://www.google.com.ec/imgres?imgurl=http://blogs.librodearena.com/myfiles/charles/ni%C3%B1o-1.jpg&imgrefurl=http://www.librodearena.com/blog/charles/1647%3F%26total%3D64%26page%3D3&usg=__UIoXVLGkrZY2gzj9n60AwtlZyHk=&h=540&w=510&sz=39&hl=es&start=60&um=1&itbs=1&tbnid=xyCSsUM4jbqaEM:&tbnh=132&tbnw=125&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26start%3D40%26um%3D1%26hl%3Des%26sa%3DN%26ndsp%3D20%26tbs%3Disch:1http://3.bp.blogspot.com/_yv1e5YUot1E/SMabNd2VTvI/AAAAAAAAKpk/opK2-muyfac/s1600-h/10.jpghttp://3.bp.blogspot.com/_yv1e5YUot1E/SMabMz_rT0I/AAAAAAAAKpM/4RDDGucM4mY/s1600-h/6.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpg


52/55

http://www.google.com.ec/imgres?imgurl=http://blogs.librodearena.com/myfiles/charles/ni%C3%B1o-1.jpg&imgrefurl=http://www.librodearena.com/blog/charles/1647%3F%26total%3D64%26page%3D3&usg=__UIoXVLGkrZY2gzj9n60AwtlZyHk=&h=540&w=510&sz=39&hl=es&start=60&um=1&itbs=1&tbnid=xyCSsUM4jbqaEM:&tbnh=132&tbnw=125&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26start%3D40%26um%3D1%26hl%3Des%26sa%3DN%26ndsp%3D20%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://images01.olx.com.ec/ui/5/99/86/1269704914_64689386_2-Tiernos-gorros-Para-Ninas-y-ninos-Guayaquil-1269704914.jpg&imgrefurl=http://guayaquil.olx.com.ec/tiernos-gorros-para-ninas-y-ninos-iid-64689386&usg=__cKllBdMsSYZ2jUuwWg2j42yxqbk=&h=392&w=400&sz=29&hl=es&start=44&um=1&itbs=1&tbnid=DfbYeTtbYfiOLM:&tbnh=122&tbnw=124&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26start%3D40%26um%3D1%26hl%3Des%26sa%3DN%26ndsp%3D20%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://i42.tinypic.com/xrejb.jpg&imgrefurl=http://google.taringa.net/posts/imagenes/2774522/Los-Ni%25C3%25B1os.html&usg=__v7aSsq5scm3cIE_nzq9OeK02fYw=&h=1024&w=1280&sz=73&hl=es&start=14&um=1&itbs=1&tbnid=CooZDO9iT4WyYM:&tbnh=120&tbnw=150&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26um%3D1%26hl%3Des%26sa%3DN%26tbs%3Disch:1http://4.bp.blogspot.com/_yv1e5YUot1E/SMaa8e-C5jI/AAAAAAAAKpE/sT0WTarvZ24/s1600-h/5.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMaa8T9biDI/AAAAAAAAKo8/7hxiJ2Eyo58/s1600-h/4.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMaa70ig9pI/AAAAAAAAKos/gjXjP4_2020/s1600-h/2.jpghttp://2.bp.blogspot.com/_yv1e5YUot1E/SMaa73BmIKI/AAAAAAAAKok/x-ioSgbxI64/s1600-h/1.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNlAtvOI/AAAAAAAAKps/lbKZ1_yI1VI/s1600-h/9.jpghttp://3.bp.blogspot.com/_yv1e5YUot1E/SMabNd2VTvI/AAAAAAAAKpk/opK2-muyfac/s1600-h/10.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNDdXyzI/AAAAAAAAKpU/yf8NsAjO2Og/s1600-h/7.jpghttp://3.bp.blogspot.com/_yv1e5YUot1E/SMabMz_rT0I/AAAAAAAAKpM/4RDDGucM4mY/s1600-h/6.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNaq6TvI/AAAAAAAAKpc/eFNOki-wmDg/s1600-h/8.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpg


53/55

http://3.bp.blogspot.com/_yv1e5YUot1E/SMabMz_rT0I/AAAAAAAAKpM/4RDDGucM4mY/s1600-h/6.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://3.bp.blogspot.com/_yv1e5YUot1E/SMabNd2VTvI/AAAAAAAAKpk/opK2-muyfac/s1600-h/10.jpg


54/55

+os veo traa"ar a mi alrededor.

+os oigo !alar de mí. Sé %ue se preocupan.

veces me asusto al verlos, sore tod o cuando vienen !acia mí con agu"as.

Pero tamién me asusto cuando no los v eo. veces paso muc!o tiempo sin ver a

nad ie.#-ué !orrile es no poder llamarlos cuando los nec esito$

N o me de"en. ependo de ustedes. Mis padres y yo confiamos en ustedes.

lgunos sé %ue me %uieren de verdad. No s*lo como prof esionales.

M &s, si creen como yo %ue es posile %uerer m& s.

Me doy cuenta por l a forma en %ue me tocan, a(n cuando lo %ue me !acen es doloroso.

/tros sé %ue no me %uieren, %ui'&s por%ue significo m& s traa"o.

Me tratan con rude'a y sin afecto.

P ero y o les pido... si no me %uieren, por favor no me c uiden.

No se enga0en a sí mismos por%ue a mí no me enga0an.

Sé d iferenciar una caricia y el afecto de una agresi*n y el rec!a'o.

Tamién sé %ue algunos de ustedes son me"ores, m& s capaces.

) o no pretendo %ue s*lo ellos me cuiden.

T( %ue eres nu evo puedes !acerlo pero, por favor... si tienes dudas,

si ves %ue no puedes, llama al m&s capa'.

Re%uiere m&s v alor decir %ue no saes %ue ocultarte protegido por mi silencio.

)o nunca te denunciaría. No puedo. No %uiero... T( te cond enarías solo.

+es pido por favor por%ue yo estoy preparado para decir1 muc!as gracias

http://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMaa8e-C5jI/AAAAAAAAKpE/sT0WTarvZ24/s1600-h/5.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNaq6TvI/AAAAAAAAKpc/eFNOki-wmDg/s1600-h/8.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMaa8e-C5jI/AAAAAAAAKpE/sT0WTarvZ24/s1600-h/5.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMaa8e-C5jI/AAAAAAAAKpE/sT0WTarvZ24/s1600-h/5.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNlAtvOI/AAAAAAAAKps/lbKZ1_yI1VI/s1600-h/9.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNaq6TvI/AAAAAAAAKpc/eFNOki-wmDg/s1600-h/8.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNlAtvOI/AAAAAAAAKps/lbKZ1_yI1VI/s1600-h/9.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNlAtvOI/AAAAAAAAKps/lbKZ1_yI1VI/s1600-h/9.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://2.bp.blogspot.com/_yv1e5YUot1E/SMaa73BmIKI/AAAAAAAAKok/x-ioSgbxI64/s1600-h/1.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://www.google.com.ec/imgres?imgurl=http://i42.tinypic.com/xrejb.jpg&imgrefurl=http://google.taringa.net/posts/imagenes/2774522/Los-Ni%25C3%25B1os.html&usg=__v7aSsq5scm3cIE_nzq9OeK02fYw=&h=1024&w=1280&sz=73&hl=es&start=14&um=1&itbs=1&tbnid=CooZDO9iT4WyYM:&tbnh=120&tbnw=150&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26um%3D1%26hl%3Des%26sa%3DN%26tbs%3Disch:1http://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://www.google.com.ec/imgres?imgurl=http://blogs.librodearena.com/myfiles/charles/ni%C3%B1o-1.jpg&imgrefurl=http://www.librodearena.com/blog/charles/1647%3F%26total%3D64%26page%3D3&usg=__UIoXVLGkrZY2gzj9n60AwtlZyHk=&h=540&w=510&sz=39&hl=es&start=60&um=1&itbs=1&tbnid=xyCSsUM4jbqaEM:&tbnh=132&tbnw=125&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26start%3D40%26um%3D1%26hl%3Des%26sa%3DN%26ndsp%3D20%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://i42.tinypic.com/xrejb.jpg&imgrefurl=http://google.taringa.net/posts/imagenes/2774522/Los-Ni%25C3%25B1os.html&usg=__v7aSsq5scm3cIE_nzq9OeK02fYw=&h=1024&w=1280&sz=73&hl=es&start=14&um=1&itbs=1&tbnid=CooZDO9iT4WyYM:&tbnh=120&tbnw=150&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26um%3D1%26hl%3Des%26sa%3DN%26tbs%3Disch:1http://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://www.google.com.ec/imgres?imgurl=http://blogs.librodearena.com/myfiles/charles/ni%C3%B1o-1.jpg&imgrefurl=http://www.librodearena.com/blog/charles/1647%3F%26total%3D64%26page%3D3&usg=__UIoXVLGkrZY2gzj9n60AwtlZyHk=&h=540&w=510&sz=39&hl=es&start=60&um=1&itbs=1&tbnid=xyCSsUM4jbqaEM:&tbnh=132&tbnw=125&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26start%3D40%26um%3D1%26hl%3Des%26sa%3DN%26ndsp%3D20%26tbs%3Disch:1http://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://www.google.com.ec/imgres?imgurl=http://blogs.librodearena.com/myfiles/charles/ni%C3%B1o-1.jpg&imgrefurl=http://www.librodearena.com/blog/charles/1647%3F%26total%3D64%26page%3D3&usg=__UIoXVLGkrZY2gzj9n60AwtlZyHk=&h=540&w=510&sz=39&hl=es&start=60&um=1&itbs=1&tbnid=xyCSsUM4jbqaEM:&tbnh=132&tbnw=125&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26start%3D40%26um%3D1%26hl%3Des%26sa%3DN%26ndsp%3D20%26tbs%3Disch:1http://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNDdXyzI/AAAAAAAAKpU/yf8NsAjO2Og/s1600-h/7.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNDdXyzI/AAAAAAAAKpU/yf8NsAjO2Og/s1600-h/7.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNDdXyzI/AAAAAAAAKpU/yf8NsAjO2Og/s1600-h/7.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMaa70ig9pI/AAAAAAAAKos/gjXjP4_2020/s1600-h/2.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMaa70ig9pI/AAAAAAAAKos/gjXjP4_2020/s1600-h/2.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://www.google.com.ec/imgres?imgurl=http://blogs.librodearena.com/myfiles/charles/ni%C3%B1o-1.jpg&imgrefurl=http://www.librodearena.com/blog/charles/1647%3F%26total%3D64%26page%3D3&usg=__UIoXVLGkrZY2gzj9n60AwtlZyHk=&h=540&w=510&sz=39&hl=es&start=60&um=1&itbs=1&tbnid=xyCSsUM4jbqaEM:&tbnh=132&tbnw=125&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26start%3D40%26um%3D1%26hl%3Des%26sa%3DN%26ndsp%3D20%26tbs%3Disch:1http://4.bp.blogspot.com/_yv1e5YUot1E/SMaa8e-C5jI/AAAAAAAAKpE/sT0WTarvZ24/s1600-h/5.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMaa8T9biDI/AAAAAAAAKo8/7hxiJ2Eyo58/s1600-h/4.jpghttp://2.bp.blogspot.com/_yv1e5YUot1E/SMaa73BmIKI/AAAAAAAAKok/x-ioSgbxI64/s1600-h/1.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNlAtvOI/AAAAAAAAKps/lbKZ1_yI1VI/s1600-h/9.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMabNDdXyzI/AAAAAAAAKpU/yf8NsAjO2Og/s1600-h/7.jpghttp://3.bp.blogspot.com/_yv1e5YUot1E/SMabMz_rT0I/AAAAAAAAKpM/4RDDGucM4mY/s1600-h/6.jpghttp://1.bp.blogspot.com/_yv1e5YUot1E/SMabY8WJMGI/AAAAAAAAKp0/g23dEsdkbBI/s1600-h/11.jpghttp://www.google.com.ec/imgres?imgurl=http://i42.tinypic.com/xrejb.jpg&imgrefurl=http://google.taringa.net/posts/imagenes/2774522/Los-Ni%25C3%25B1os.html&usg=__v7aSsq5scm3cIE_nzq9OeK02fYw=&h=1024&w=1280&sz=73&hl=es&start=14&um=1&itbs=1&tbnid=CooZDO9iT4WyYM:&tbnh=120&tbnw=150&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26um%3D1%26hl%3Des%26sa%3DN%26tbs%3Disch:1http://www.google.com.ec/imgres?imgurl=http://images01.olx.com.ec/ui/5/99/86/1269704914_64689386_2-Tiernos-gorros-Para-Ninas-y-ninos-Guayaquil-1269704914.jpg&imgrefurl=http://guayaquil.olx.com.ec/tiernos-gorros-para-ninas-y-ninos-iid-64689386&usg=__cKllBdMsSYZ2jUuwWg2j42yxqbk=&h=392&w=400&sz=29&hl=es&start=44&um=1&itbs=1&tbnid=DfbYeTtbYfiOLM:&tbnh=122&tbnw=124&prev=/images%3Fq%3DNI%25C3%2591OS%2BTIERNOS%26start%3D40%26um%3D1%26hl%3Des%26sa%3DN%26ndsp%3D20%26tbs%3Disch:1http://4.bp.blogspot.com/_yv1e5YUot1E/SMabNaq6TvI/AAAAAAAAKpc/eFNOki-wmDg/s1600-h/8.jpghttp://3.bp.blogspot.com/_yv1e5YUot1E/SMabNd2VTvI/AAAAAAAAKpk/opK2-muyfac/s1600-h/10.jpghttp://4.bp.blogspot.com/_yv1e5YUot1E/SMaa70ig9pI/AAAAAAAAKos/gjXjP4_2020/s1600-h/2.jpg


55/55

LA PAZ COMIENZA CON UNA SONRISA

2+os pe%ue0os detalles de la vida son

los %ue marcan y !acen las grandes

diferencias2

Documents

Hiperbilirrubinemianeonatal-InTERNA RESIDENTADO ECUADOR