Salud sexual y reproductiva: guías para el continuo de

3a Edición
CLAP/SMR Publicación Científica Nº 1577 - 2011
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PROLOGO
GLOSARIO
CAPITULO I
Renovación de la Atención Primaria de la Salud en las Américas
Contínuo de atención
Enfoque de Salud Familiar y Comunitaria
Valores, Principios y Elementos de un Sistema de Salud Basado en la APS
Referencias bibliográficas
CAPITULO II
Cuidado Preconcepcional
Objetivos: Identificar y asesorar sobre riesgo preconcepcional
Actividad: Consulta previa al embarazo
Cuidado preconcepcional
Consulta preconcepcional
Reducción de la morbimortalidad materna y feto neonatal
Defectos congénitos
Historia Clínica
Antecedentes reproductivos
Antecedentes generales
Enfermedades médicas no transmisibles
Enfermedades médicas transmisibles
Estilos de vida
Consumo de medicamentos
Vacunas
Referencias bibliográficas
CAPITULO III
Control Prenatal, Vigilancia Durante la Gestación,
Evaluación del Riesgo Concepcional y Conductas
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Objetivos: Contar con una hoja de ruta que guíe al prestador para brindar una atención prenatal de calidad
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Actividad: Uso de la Historia Clínica Perinatal del CLAP/SMR
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Objetivos y Actividades propuestas
Cronología de las actividades para las consultas prenatales de bajo riesgo
Objetivos: Confirmar embarazo
Actividad: Realización de exámenes clínicos y paraclínicos para diagnosticar embarazo
Objetivos: Mejorar la calidad del control prenatal
Actividad: Utilización de algunas tecnologías apropiadas
Gestograma
Cinta obstétrica
Tarjeta de Altura Uterina y Peso Materno
Objetivos: Obtener datos para planificar el control prenatal, la atención del parto, el puerperio y el recién nacido
Actividad: Empleo del Sistema Informático Perinatal
Historia Clínica
Partograma
Carné Perinatal
Procesamiento de datos
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Objetivos: Detectar riesgos en la población
Actividad: Evaluación del riesgo perinatal
Objetivos: Conocer información relevante del embarazo
Actividad: Anamnesis
Objetivos: Fijar un cronograma que permita planificar las actividades del control prenatal
Actividad: Determinación de la edad gestacional y de la fecha probable de parto
Amenorrea
Evaluación del tamaño uterino
Antropometría fetal por ecografía
Madurez placentaria
Objetivos: Evaluar el estado nutricional materno
Actividad: Medición del peso y de la talla materna. Cálculo del incremento de peso durante la gestación.
Técnica de medición
Ganancia de peso
Interpretación de la medida a la primera consulta
Interpretación de la secuencia de medidas en consultas subsecuentes
Relación peso para la talla según edad gestacional
Evaluación del incremento ponderal materno
Conducta
Objetivos: Investigar estilos de vida de riesgo
Actividad: Interrogatorio sobre tabaquismo (activo y pasivo), drogas, alcohol y violencia
Tabaquismo activo
Tabaquismo pasivo
Alcohol
Drogas
Violencia
Objetivos: Prevenir el tétanos neonatal y puerperal
Actividad: Vacunación antitetánica
Objetivos: Disminuir el impacto negativo de las infecciones de transmisión vertical
Actividad: Prevención, detección y tratamiento de las infecciones de transmisión vertical
Rubeola congénita
Toxoplasmosis congénita
Hepatitis B
VIH/SIDA
Objetivos: Prevenir sífilis
Actividad: Tamizaje y tratamiento
Objetivos: Prevenir las consecuencias materno-perinatales de otras infecciones de transmisión sexual ITS y
otras infecciones del tracto reproductivo ITR
Actividad: Prevención, detección y tratamiento
Flujo (leucorrea),
Moniliasis vulvovaginal, vaginosis bacteriana, tricomoniasis, gonococcia,
Clamidiasis, herpes simple
Objetivos: Prevenir la transmisión vertical de la enfermedad de Chagas
Actividad: Prevención, detección y tratamiento
Objetivos: Reducir la morbimortalidad materna y prevenir la transmisión vertical del Paludismo o Malaria
Actividad: Prevención, detección y tratamiento
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Diagnóstico de malaria
Malaria y embarazo
Prevención de la malaria durante el embarazo
Tratamiento en mujeres embarazadas
Objetivos: Reducir la morbimortalidad neonatal por estreptococo grupo%
Actividad: Prevención, detección y tratamiento
Objetivos: Detectar posibles procesos sépticos buco-dentales
Actividad: Examen buco-dental
Objetivos: Detectar posibles alteraciones del pezón, patología inflamatoria
Actividad: Examen de las mamas
Objetivos: Descartar cáncer de cuello, lesiones precursoras y evaluar la competencia cervical
Actividad: Examen genital, colpocitología, colposcopía
Cáncer cervical
Incompetencia cervical
Objetivos: Pesquisar una posible incompatibilidad sanguínea materno-feto-neonatal
Actividad: Determinación del grupo sanguíneo, del factor Rh y de anticuerpos irregulares
Objetivos: Prevenir, detectar y tratar la anemia materna
Actividad: Determinar niveles de hemoglobina. Administración de hierro y ácido fólico
Prevención de la anemia
Prevención de los defectos del tubo neural
Objetivos: Descartar proteinuria, glucosuria y bacteriuria
Actividad: Examen de orina y urocultivo
Examen de orina
Infección urinaria y bacteriuria asintomática
Objetivos: Descartar diabetes mellitus clínica y gestacional
Actividad: Determinación de la glucemia y prueba de tolerancia oral a la glucosa
Diabetes gestacional
Glucemia en ayunas
Prueba de tolerancia oral a la glucosa
Clasificación de los estados diabéticos en el embarazo
Objetivos: Brindar contenidos educativo-informativos para el parto y la crianza
Actividad: Preparación para el parto, consejería para el amamantamiento
Objetivos: Confirmar la existencia de vida fetal
Actividad: Pesquisar movimientos y frecuencia cadíaca fetal
Movimientos fetales
Actividad cardíaca fetal
Estetoscopio obstétrico
Objetivos: Anticipar el diagnóstico y prevenir el parto prematuro
Actividad: Evaluar el patrón de la contractilidad uterina (frecuencia, duración e intensidad)
Retrasar el parto de pretérmino. Inducir la maduración pulmonar fetal.
Diagnóstico de amenaza de parto prematuro
Tratamiento
Tratamientos que no han demostrado ser efectivos en la amenaza de parto prematuro
Inductores de la maduración pulmonar
Objetivos: Pesquisar alteraciones de la presión arterial: Hipertensión previa al embarazo.
El síndr. de hipertensión inducida por el embarazo (pre-eclampsia). Hipotensión arterial
Actividad: Determinación de la presión arterial, identificación de edemas y proteinuria.
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Factores que pueden modificar los valores de tensión arterial
Técnica de medida,
Modificaciones fisiológicas durante el parto
Clasificación de estados hipertensivos en el embarazo,
Factores de riesgo de hipertensión gestacional y pre-eclámpsia, Prevención
Conductas recomendadas
Objetivos: Descartar alteraciones del crecimiento fetal
Actividad: Evaluación del crecimiento fetal por medio de la altura uterina, ganancia de peso y ecografía.
Restricción del crecimiento intrauterino
Macrosomía fetal
Tecnologías para medir el crecimiento fetal
Ejemplos de la evaluación de la relación Altura Uterina/Edad Gastacional a la primera consulta
Ejemplos de la evaluación de la tendencia de la relación AU/EG en consultas subsecuentes
Objetivos: Detectar precozmente el embarazo múltiple para prevenir sus complicaciones
Actividad: Diagnóstico del número de fetos
Objetivos: Pesquisar las presentaciones fetales anormales
Actividad: Diagnóstico de presentación fetal
Presentación pelviana o podálica
Situación transversa
Objetivos: Detectar posibles distocias pélvicas para definir el nivel de atención del parto
Actividad: Examen gineco-obstétrico. Evaluación de la pelvis.
Referencias bibliográficas
CAPITULO IV
Atención del Parto de Bajo Riesgo
Asistencia durante el ingreso
Objetivos: Diagnosticar el trabajo de parto e identificar el grado de riesgo
Actividad: Consulta en recepción
Interrogatorio
Examen clínico general
Examen obstétrico
Auscultación de la FCF
Patron de contractilidad uterina
Examen genital
Dilatación, borramiento y posición del cuello
Pérdida de secreciones por los genitales
Evaluación de la presentación
Valoración de la proporción feto-pélvica y la capacidad de la pelvis materna
Preparación de la embarazada en la recepción
Asistencia durante el período de dilatación (primer período)
Objetivos: Controlar bienestar materno y fetal. Detectar y evaluar desviaciones de los límites fisiológicos
(progreso del parto). Evaluar riesgo y referir a nivel apropiado. Aplicar maniobras correctivas
Actividad: Información a la embarazada. Controles maternos. Controles obstétricos
Registro de los controles en el partograma con curvas de alerta.
Acompañamiento a la madre durante el parto
Controles maternos
Controles obstétricos
Progreso de la dilatación y descenso de la presentación
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Partograma con curvas de alerta
Trabajo de parto prolongado
Asistencia durante el período expulsivo (segundo período)
Objetivos: Detectar y evaluar desviaciones de los límites fisiológicos del período expulsivo.
Prevenir traumatismo obstétrico. Prevenir hipoxia fetal.
Actividad: Control de la FCF. Control de la contractilidad.
Control del avance de la presentación y desprendimiento
Posición de la parturienta
Controles a realizarse durante el período expulsivo
Amniotomía
Protección perineal
Avance de la presentación y desprendimiento
Situaciones especiales
Distocia de hombro
Atención del parto en podálica
Atención del recién nacido en sala de partos
Recomendaciones sobre uso de medicación en parto de bajo riesgo
Asistencia durante el alumbramiento y posalumbramiento (tercer período)
Objetivos: Detectar y evaluar desviaciones de los límites fisiológicos del alumbramiento y posalumbramiento
Actividad: Control materno. Examen de la placenta
Examen de la placenta y membranas
Controles durante el alumbramiento
Sutura de la episiotomía
Prevención para evitar la retención de restos ovulares
Prevención de la hemorragia post parto (HPP).
Tracción del cordón.
Masaje y compresión uterina
Postalumbramiento
Retención de placenta
Hemorragia post parto
Cuidados del post parto imediato
Categorías A,B,C,D (recomendaciones OMS)
Asistencia durante el puerperio
Objetivos: Controlar bienestar de la mujer puérpera. Detectar y evaluar desviaciones de los límites
fisiológicos. Evaluar riesgo y referir a nivel apropiado. Aplicar maniobras correctivas.
Actividad: Educación de la mujer puérpera. Controles clínicos de la mujer y su hijo.
Registro de los controles en la historia clínica perinatal.
Puerperio mediato
Puerperio alejado
Puerperio tardío
Referencias bibliográficas
CAPITULO V
Atención del Recién Nacido
Objetivos: Recibir al recién nacido y valorar el inicio de la primera respiración espontánea.
Actividad: Observar si respira o no. Si no respira deducir si es por asfixia fetal o por depresión farmacológica.
Objetivos: Proteger la adaptación a la vida extrauterina en el recién nacido de pretérmino
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Actividad: 1. Proveer cuidados inmediatos que faciliten la adaptación, especialmente en los nacidos
pretérminos que presenten signos de inmadurez ventilatoria.
2. Desarrollar estrategias tendientes a evitar la pérdida de calor, valorar el flujo bidireccional de
sangre desde la placenta a través del cordón umbilical al feto, apoyar y mantener el inicio de
la respiración, controlar el aporte de O2,
Esquema para el cuidado continuo del recién nacido pretérmino desde el primer minuto de vida
Objetivos: Identificar al recién nacido
Actividad: Facilitar que la madre lo identifique y cumplir los requisitos locales de identificación al nacer.
Objetivos: Evaluar el crecimiento y el desarrollo fetal al nacer.
Actividad: Realizar antropometría y valorarla según la edad gestacional y valorar las funciones de adaptación
Antropometría neonatal
Objetivos: Adecuar el manejo inicial de los recién nacidos con defectos congénitos mayores
Actividad: Instaurar en forma precoz las medidas específicas para cada defecto
Objetivos: Detectar defectos y/o enfermedades congénitas asintomáticas
Actividad: Detección sistémica en el período neonatal por métodos de laboratorio clínico
Sífilis congénita
Toxoplasmosis congénita
HIV
Hepatitis B
Estreptococo del grupo B
Hipotiroidismo congénito
Anemia falciforme
Hiperbilirrubinemia neonatal no hemolítica
Déficit auditivo severo
Objetivos: Prevenir la oftalmia gonocóccica
Actividad: Instilar antimicrobianos en las conjuntivas al nacer
Objetivos: Prevenir enfermedad hemorrágica del recién nacido
Actividad: Administrar vitamina K
Objetivos: Iniciar y mantener la lactancia materna exitosa
Actividad: 1 - No separar al recién nacido y su madre y facilitar el apoyo familiar
2 - Alimentar a libre demanda y no dar biberones
3 - Registrar la alimentación al alta de la maternidad
Objetivos: Prevenir tuberculosis grave en el lactante
Actividad: Vacuna BCG al nacer
Objetivos: Prevenir la muerte súbita del lactante
Actividad: Colocar al recién nacido boca arriba para dormir
Objetivos: Disminuir los riesgos en los nacidos pretérmino de 35 y 36 semanas (pretérmino tardíos) y los de
37 a 38 semanas (término precoces)
Actividad: Aumentar vigilancia en el período de adaptación mientras permanecen en sala con sus madres
Referencias Bibliográficas
CAPITULO VI
Atención conjunta de la madre y el niño después del nacimiento
Objetivos: Racionalizar los recursos y disminuir oportunidades perdidas
Controlar bienestar de la mujer puérpera y del recién nacido
Detectar y evaluar desviaciones de los límites fisiológicos de ambos.
Actividad: Atención conjunta de la madre y el recién nacido durante el puerperio
Educación de la mujer puérpera.
Controles clínicos de la mujer y su hijo.
Registro de los controles en la historia clínica perinatal.
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Registros.
Soporte afectivo.
Controles de la madre y del recién nacido
Referencias Bibliográficas
CAPITULO VII
Planificación familiar
Objetivos: Contribuir al ejercicio del derecho a planificar el embarazo
Actividad: Asesorar sobre los principales métodos contraceptivos
Proceso de asesoramiento
Evaluación de las usuarias antes de recomendarles un método contraceptivo
Descripción de los métodos anticonceptivos
Métodos reversibles
Métodos comportamentales
Método de la lactancia exclusiva (MELA)
Métodos de barrera
Contracepción de emergencia
Contraceptivos hormonales
Dispositivos intrauterinos
Criterios de elegibilidad para métodos hormonales y dispositivos intra uterinos
Métodos irreversibles
Ligadura tubaria
Ligadura de los deferentes (vasectomía)
Referencias Bibliográficas
CAPITULO VIII
Aborto
Objetivos: Reducir la morbimortalidad por aborto
Actividad: Diagnóstico y asistencia del aborto en los distintos períodos
Definiciones
Prevalencia e incidencia
Aborto espontáneo
Diagnóstico clínico y etapas evolutivas del aborto
Diagnóstico diferencial
Conducta
Métodos de evacuación
Evacuación uterina
Cuidados post procedimiento
Aborto complicado
Complicaciones post evacuación
Consejería /Información
Anticoncepción por aborto
Referencias Bibliográficas
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ACT:
Terapias Combinadas en base a Artemisina.
AIC:
Anticonceptivos Inyectables Combinados.
AOC:
Anticonceptivos Orales Combinados.
APS:
Atención Primaria de Salud.
ARA II:
Antagonistas de los Receptores de la Angiotensina II.
ARV:
Antirretrovíricos.
AU:
Altura Uterina.
AZT:
Zidovudina.
BCG:
Bacilo de Calmette - Guerin.
BhCG:
Fracción Beta de la hormona Gonadotropina Coriónica.
BPN:
Bajo peso al Nacer.
CDC:
Centros para el Control de Enfermedades de los Estados Unidos.
CLAP/SMR:
Centro Latinoamericano de Perinatología / Salud de la Mujer y Reproductiva.
CIPD:
Conferencia Internacional de Población y Desarrollo.
CMV:
Citomegalovirus.
CU:
Contracción Uterina.
D:
Diámetro.
d:
diámetro.
DBP:
Diámetro Biparietal.
DFO:
Diámetro Fronto Occipital.
DG:
Diabetes Gestacional.
DIPs I:
Caída de la FCF coincidente con la contracción uterina.
DIPs Variables: Caídas de la FCF de probable origen umbilical, de duración, amplitud y de comienzo
variables en relación a la contracción uterina.
DIPs II:
Desaceleración tardía de la FCF en relación a la contracción uterina.
DIU:
Dispositivo Intrauterino.
DM:
Diabetes Mellitus.
DPPNI:
Desprendimiento Previo de Placenta Normoinserta.
ECLAMC:
Estudio Colaborativo Latinoamericano de Malformaciones Congénitas.
EG:
Edad Gestacional.
EGB:
Estreptococo del Grupo B.
EP:
Enfermedad Periodontal.
FPP:
Fecha Probable de Parto.
FCF:
Frecuencia Cardíaca Fetal.
FTA- Abs:
Prueba de detección de Anticuerpos específicos contra el Treponema pallidum, por
inmunofluorescencia.
FUM:
Fecha de Última Menstruación.
GED:
Enfoque de Género en el Desarrollo.
HAI:
Hemoaglutinación Indirecta.
Hb :
Hemoglobina.
HC:
Hipotiroidismo Congénito.
HCP:
Historia Clínica Perinatal.
HCG:
Hormona Coriónica Gonadotrófica.
IC:
Incompetencia Cervical.
IFI:
Inmunofluorescencia Indirecta.
Ig G:
Inmunoglobulina G.
Ig M:
Inmunoglobulina M.
IECAs:
Inhibidores de la Enzima conversora de la Angiotensina II.
IM:
Intramuscular.
IMC:
Índice de Masa Corporal.
ITR:
Infecciones del Tracto Reproductivo.
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ITS:
IV:
LCR:
MAC:
MELA:
MHA – TP:
Infecciones de Transmisión Sexual.
Intravenoso.
Líquido Céfalo Raquídeo.
Métodos Anticonceptivos.
Método de Lactancia Exclusiva.
Prueba de detección de Anticuerpos específicos contra el Treponema pallidum por
Micro – Hemaglutinación.
NVP:
Neviparina.
OMS:
Organización Mundial de la Salud.
OPS:
Organización Panamericana de la Salud.
PAP:
Papanicolau, colpocitoplogía oncológica.
P. Abd.:
Perímetro Abdominal.
P. Cr.:
Perímetro Craneano.
PCR:
Reacción de la cadena de la polimerasa.
PEG:
Pequeño para la Edad Gestacional.
P. falciparum: Plasmodio falciparum.
PG:
Prostaglandinas.
PMB:
Perímetro Medio Braquial.
PO2:
Presión parcial de Oxígeno.
PTOG:
Prueba de Tolerancia a la Glucosa.
RCI:
Restricción del Crecimiento Intrauterino.
RCIU:
Restricción del Crecimiento Intrauterino.
RDTs:
Test Rápidos Diagnósticos.
RPM:
Rotura Prematura de Membranas.
RPP:
Rapid Plasma reagin.
RR:
Riesgo relativo.
SAF:
Síndrome Alcohólico Fetal.
SIDA:
Síndrome de la Inmunodeficiencia Adquirida.
SIP:
Sistema Informático Perinatal.
SDR:
Síndrome de Dificultad Respiratoria.
SNC:
Sistema Nervioso Central.
SRC:
Síndrome de Rubéola Congénita.
T. cruzi:
Tripanosoma cruzi.
T4:
Hormona tiroidea 4.
Td:
Tétanos más difteria.
TNN:
Tétanos Neonatal.
T. pallidum: Treponema pallidum.
TP – PA:
Prueba de detección de Anticuerpos específicos contra el Treponema pallidum por
Aglutinación.
TPI:
Tratamiento Preventivo Intermitente.
TSH:
Hormona Estimulante Tiroidea.
TT:
Toxoide tetánico.
TBC:
Tuberculosis.
UCIN:
Unidad de Cuidado Intensivo Neonatal.
UNAIDS:
(ONUSIDA), Programa conjunto de las Naciones Unidas sobre el VIH/SIDA.
UNGASS:
United Nations General Assambly on AIDS Special Session.
UNICEF:
Fondo de las Naciones Unidas para la Infancia.
USR:
Unheated Serum Reagin.
VPH:
Virus Papiloma Humano.
VDRL:
Venereal Disease Research Laboratory.
VIH:
Virus de la Inmunodeficiencia Humana.
V/O:
Vía oral.
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•
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•
•
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Eliminar el consumo de carne cruda o poco cocida.
Usar guantes y lavarse las manos intensamente después de manipular carne cruda.
Lavar profundamente todos los utensilios que estuvieron en contacto con carne cruda.
Lavar profundamente los vegetales que se comerán crudos.
Usar guantes cada vez que se esté en contacto con tierra. Y lavar las manos intensamente después de
tocar la tierra.
• Mantener los gatos domésticos dentro de la casa y alimentarlos con raciones.
• Usar guantes mientras se limpia la “cucha” y lavarse las manos después de hacerlo.
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Cuadro 3. Objetivos específicos y actividades propuestas para el control prenatal
Objetivos específicos
Actividades propuestas
Confirmar el embarazo.
Realización de exámenes clínicos y paraclínicos para
diagnosticar embarazo.
Mejorar la calidad del control prenatal.
Utilización de algunas tecnologías apropiadas.
Obtener datos para planificar el control prenatal, la
atención del parto, el puerperio y el recién nacido.
Empleo del Sistema Informático Perinatal.
Contar con una hoja de ruta que guíe al prestador
para brindar una atención prenatal de calidad.
Uso de la Historia Clínica Perinatal.
Detectar riesgos en la población
Evaluación del riesgo perinatal.
Conocer información relevante del embarazo
Anamnesis
Fijar un cronograma que permita planificar las
actividades del control prenatal.
Determinación de la edad gestacional y fecha probable
de parto.
Evaluar el estado nutricional materno.
Medición del peso y de la talla materna. Cálculo del
incremento de peso durante la gestación.
Investigar estilos de vida de riesgo.
Interrogatorio sobre tabaquismo (activo y pasivo),
drogas, alcohol y violencia.
Disminuir el impacto negativo de las infecciones de
transmisión vertical.
Prevención, detección y tratamiento de las infecciones
de transmisión vertical.
Prevenir el tétanos neonatal y puerperal
Vacunación antitetánica
Detectar posibles procesos sépticos buco dentales
Examen buco-dental.
Detectar posibles alteraciones del pezón, patología
inflamatoria y/o tumoral de la mama.
Examen de mamas.
Descartar cáncer de cuello, lesiones precursoras y
evaluar la competencia cervical.
Examen genital, colpocitología oncológica,
colposcopía.
Pesquisar una posible incompatibilidad sanguínea
materno-feto-neonatal.
Determinación del grupo sanguíneo y el factor Rh.
Prevenir, detectar y tratar la anemia materna
Determinar niveles de hemoglobina y tratamiento con
hierro y ácido fólico
Descartar proteinuria, glucosuria y bacteriuria
Examen de orina y urocultivo.
Detectar diabetes mellitus y gestacional
Determinación de glucemia y prueba de tolerancia oral
a la glucosa.
Brindar contenidos educativo-informativos para el
parto y la crianza.
Preparación para el parto, consejería para el
amamantamiento.
Confirmar la existencia de vida fetal.
Pesquisar movimientos y Frecuencia Cardíaca Fetal
Anticipar el diagnóstico y prevenir el parto prematuro.
Evaluación del patrón de contractilidad uterina.
Pesquisar alteraciones de la presión arterial
Medición de la presión arterial, identificación de
edemas y proteinuria.
Descartar alteraciones del crecimiento fetal.
Evaluación del crecimiento por medición de la altura
uterina, ganancia de peso materno, ecografía.
Detectar precozmente el embarazo múltiple para
prevenir sus complicaciones.
Diagnóstico de número de fetos.
Pesquisar presentaciones fetales anormales.
Examen de la presentación fetal.
Detectar posibles distocias pélvicas.
Evaluación de la pelvis.
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Actividades
Prueba de embarazo
Cálculo de la amenorrea
Historia clínica perinatal y evaluación de riesgo
Examen clínico completo
Peso corporal
Talla
Investigar estilos de vida de riesgo
Detectar susceptibilidad a la Rubéola
Vacuna antitetánica (**)
Examen odontológico
Examen de mamas
Ex. ginecológico, PAP, colposcopía (***)
Grupo sanguíneo y factor Rh
Detectar toxoplasmosis
Detección VIH
Determinación de hemoglobina
Suplementación con hierro y ácido fólico
Detección Sífilis
Detección de Chagas
Detección de Paludismo
Cultivo de orina
Detectar diabetes
Detectar infección por Estreptococo B
Contenidos educativos para el parto y la lactancia
Determinación de la presión arterial
Evaluación del crecimiento fetal.
Evaluación del líquido amniótico
Diagnóstico de vida fetal
Evaluación de la capacidad pelviana
Consejería y provisión de anticoncepción
Antes de
Las 20 (*)
1ª visita
X
X
X
X
X
X
X
X
Semanas de consultas
Entre las Entre las Entre las
22 y 24
27 y 29
33 y 35
2da visita
3ª visita
4ª visita
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Entre las
38 y 40
5ª visita
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
(*)
Las actividades programadas para la primer visita se deberán hacer siempre, independientemente de la edad gestacional al
momento de la consulta
(**)
Si se sospecha que la gestante no volverá o porque así lo indica la norma nacional se podrá vacunar antes de la semana 20
(***) Lo más precozmente o según norma nacional.
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gestacional
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adecuado para la edad gestacional
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- dar orientación nutricional
El punto se sitúa por debajo del percentilo 25 de la
curva de referencia
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gravídica, infecciones, parasitosis, anemia,
enfermedades debilitantes.
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DIAGNOSTICO
Gestante de riesgo, por presentar peso superior
al normal para esa edad gestacional; tanto mayor
será el riesgo cuanto más elevado sea su
sobrepeso.
- citar a consulta en un intervalo menor que lo
fijado en el cronograma habitual.
3
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DIAGNOSTICO
Gestante de riesgo, con peso insuficiente para la
edad gestacional (desnutrición)
CONDUCTA
- determinar causas: obesidad, edema,
polihidramnios, macrosomía, embarazo múltiple
- citar a consulta en un intervalo menor que lo
fijado en el cronograma habitual.
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debe superar los 16 kg (p90)
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curvas del percentil 25 y el percentil 90 del peso
de referencia para la edad gestacional
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mantenga dentro de la faja de normalidad
Trazado entre las curvas de percentil 25 y 90,
con inclinación horizontal o descendente o
trazado por abajo de la cuva del percentil 25, con
inclinación horizontal o ascendente, sin alcanzar la
faja considerada normal (p25)
DIAGNOSTICO
Gestante de riesgo con referencia a su ganancia
adecuada de peso:
CONDUCTA
- Identificar causas: déficit nutricional, infecciones,
parasitosis, anemia, entre otras. Tratarlas cuando
esten presentes y dar orientación nutricional
- referir a control prenatal de alto riesgo.
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Estas medidas intentan que la gestante llegue al
término de la gestación con una ganancia de peso
mínima de 8 kg.
Trazado por encima de la curva del percentil 90 de
peso de referencia para la edad gestacional.
DIAGNOSTICO
Gestante de riesgo visto que su ganancia de peso es
superior a lo ideal para su edad gestacional; cuanto
mayor sea su sobrepeso mayor será el riesgo
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o gravidez múltiple, está indicado derivar a
control de alto riesgo.
Esas medidas procuran que la gestante llegue al
término con un peso final dentro del rango de la
normalidad (máximo de 16 kg)
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Figura 25. Fragmento de HCP.
Antirubeola postparto
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Posibles resultados
Interpretación
Conducta
-
No hay infección.
Existe riesgo de contraerla
Comunicar medidas de protección.
Eventual repetición de IgG según norma nacional
+
-
Infección pasada
Continuar control en forma habitual
+
+
Infección actual
Evaluar riesgo de infección fetal.
Evaluar realización de tratamiento médico
Riesgo desconocido
Comunicar medidas de protección
realizar tamizaje según norma nacional
IgG
IgM
-
No se hizo No se hizo
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3 g/día oral repartidos en 3 dosis,
del embarazo o
Espiramicina
confirmación de
(separados de las comidas)
que se confirme
infección fetal
infección fetal.
Dosis carga: 100 mg/día oral,
Hasta final del
Pirimetamina
divididos en 2 dosis, durante 2 días.
embarazo
Continua: 50 mg/día oral
Dosis carga: 75 mg/Kg/día oral,
divididos en 2 dosis, durante 2 días.
Hasta final del
Infección fetal
Sulfadiazina
Máximo 4 g/día.
embarazo
confirmada (entre
Continua: 100 mg/Kg/día oral
las 12 y 18 emanas)
divididos en 2 dosis. Máximo 4 g/día.
Durante y hasta
una semana
Acido folínico
5 a 20 mg/día
después de usar
la Pirimetamina.
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con insecticida
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percibir los movimientos Comenzar el uso en el
recomendados y suplementos con hierro y Ac.
fetales) durante los
Fólico.
embarazo y continuarlo
controles prenatales,
en el postparto.
próximo a las 26 y 32
Rápido reconocimiento y tratamiento de
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todos los casos de malaria activa con drogas
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Alteraciones del sistema
de coagulación.
Diastólica > 90 mm Hg. Hemólisis.
Sistólica > 140 mm Hg. Hemorragia cerebral.
Insuficiencia hepática.
Insuficiencia renal.
Mortalidad aumentada
)HWDORYXODU
Aborto.
Desprendimiento
normoplacentario.
Restricción del crecimiento
intrauterino (RCI).
Sufrimiento fetal agudo
intraparto.
Oligoamnios
Mortalidad aumentada
1HRQDWDO
Pequeño para la edad
gestacional (PEG).
Pretérmino.
Síndrome de dificultad
respiratoria.
Depresión neonatal.
Mortalidad aumentada
Restricción del crecimiento
intrauterino (RCIU).
Mortalidad aumentada.
Pequeño para la edad
gestacional (PEG)
Mortalidad aumentada.
Hipotensión
Lipotimias y desmayos.
Diastólica < 55 mm Hg.
Sistólica < 95 mm Hg.
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Evolución nornal
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Estimulación ocitócica
Bradicardia fetal
Dips II
Tratamiento del sufrimiento fetal in útero. Referencia de alto riesgo.
Taquicardia fetal
Decúbito lateral - Controlar PA materno
Dips variables
Dips I con membranas íntegras
Control más frecuente de FCF
Parto prolongando
(según curva de alerta)
Reevaluar antecedentes de patología cervical, proporción fetopélvica y contractilidad; corregir hipodinamia; control en una hora.
Si no progresa, amniotomía: referencia a alto riesgo.
Hemorragia genital
Según normas específicas amniotomía. Referencia a alto riesgo
Líquido amniótico meconial
Control más frecuente. Aspiración inmediata del RN
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Engle W A, Tomashek K M, Wallman C. Committee on fetus and Newborn. American Academy of Pediatrics.
Late-preterm infants: a population at risk. A clinical report. Pediatrics 2007, 120(6):1390-401.
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Madre
Recién nacido
Primeras 24 horas
Puerperio inmediato
• Estado de conciencia, lúcida y tranquila.
• Facies, piel y mucosas, deberán estar bien coloreadas
(excepto en anemia previa).
• Frecuencia del pulso en condiciones basales, (60 y 100
Ipm) y lleno.
• Presión arterial en rangos normales.
• Temperatura corporal, no deberá superar los 37° C. En el
postalumbramiento, pueden observarse escalofríos, que
son normales y raramente duran más de 30 minutos.
• Retracción del útero (globo de seguridad de Pinard), en
estas horas, el fondo del útero no sobrepasa la cicatriz
umbilical y la consistencia es firme adquiriendo una
consistencia leñosa al ser estimulado. Es indoloro a la
palpación y es común el dolor cuando el niño es puesto al
pecho (entuertos).
• En caso de dolor, estarán indicados los analgésicos
comunes y los antiinflamatorios no esteroideo.
• En caso de sangrado vaginal abundante con el útero bien
contraído efectuar inspección minuciosa del canal del
parto para descartar lesiones (desgarros) en vagina y en
cuello de útero.
• Describir los principales signos de alerta y vigilar con
atención aquellas condiciones Que pueden poner en
riesgo la vida de la madre. (ver cuadro).
• Animarla para Que comience a movilizarse. En las
madres obesas considerar el riesgo de tromboembolismo
por reposo en cama.
• Mujeres que no estén inmunizadas contra el tétanos o
contra la rubéola deberán ser inmunizadas antes del aIta.
• En las Rh negativas no inmunizadas con recién nacido
Rh positivos proceder a la inmediata administración de la
correspondiente dosis de gammaglobulina según normas
locales.
• Orientar y facilitar el acceso a métodos de planificación
familiar.
• En ocasiones pueden aparecer hemorroides fluxivas que
mejoran parcialmente con hielo y cremas locales con
anestésicos tópicos.
• La retención urinaria es excepcional; se tratará con
cateterismos vesicales intermitentes, Higiene perineal:
• Cada vez que la mujer requiera cambiar el apósito, se
debe higienizar la zona con agua limpia y jabón o un
antiséptico. El lavado se hará por arrastre, siempre en
sentido antera posterior (de la vulva hacia el ano). Se
secará con un paño o gasas limpias.
• La ropa interior será separada por un apósito (gasaalgodón-gasa) o por protectores “nocturnos” de los que
se consiguen en el mercado,
• Los lavados intravaginales son desaconsejados.
• En caso de episiotomía, los cuidados serán similares,
pero se insistirá en mantener la zona seca el mayor
tiempo posible.
Cuidado de los pezones:
• Deberá exponer la areola y el pezón al sol entre diez y
quince minutos por día lubricarla exclusivamente con
calostro o leche materna.
Un niño saludable
• No separe al recién nacido de su madre.
• Promueva que estén cerca físicamente.
• Promueva la colocación temprana del
bebe al pecho si la madre lo desea.
• Si es primípara, explíquele que al principio
no todas las madres se sienten con
fuerzas y deseo de cuidar a sus bebes [as
24 horas del día y que eso va cambiando
los primeros días.
• Acompañe a la madre sugiriéndole como
poner a su niño a mamar, sin tocar sus
senos y respetando su pudor natural.
• Informe de las ventajas de mantener la
alimentación al pecho exclusiva y que si
tiene molestias al inicio de la lactada es
normal pero serán pasajeras.
• No administre otra leche que no sea la de
su propia madre sin la debida indicación
médica y consentimiento de la madre.
• No permita publicidad de fórmulas de
leche de vaca, ni que les entreguen
muestras gratis a las madres.
• Se alimenta y succiona bien.
• Descansa entre lactadas y se despierta
para alimentarse. No está excesivamente
irritable.
• Tiene un color normal para su etnia
(controlar cianosis o ictericia)
• Moviliza el intestino y orina varias veces
al dia (sus pañales cada 3 horas están
mojados).
• Frecuencia respiratoria entre 30 y 60
respiraciones por minuto.
• Frecuencia cardiaca entre 120 y 160
latidos por minuto.
• Temperatura no mayor a los 37° (axilar o
inguinal).
• Mantenga al niño arropado hasta que
logre el control térmico
• Mencione la administración de Vitamina
K que ya se realizó al recién nacido e
indique la repetición a los 7 días si fue
administrada por vía oral.
• Señale que el cordón debe mantenerse
limpio y seco.
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Información al egreso.
Durante la internación por el parto, la madre y la familia deberán haber recibido información para el cuidado
postnatal y la protección de la salud de ella y su recién nacido. Al alta deberá señalarse con precisión:
• la forma en que ella puede mantener una comunicación continua con los servicios
• las nuevas necesidades de apoyo familiar y los recursos comunitarios a los que pueda acceder para
encontrar soporte en la función parental y
• pautas que la guíen para la consulta en caso que aparezcan elementos de alarma para la salud de ambos.
• Es recomendable otorgar el alta a las 48 horas
del parto, si no ha habido complicaciones y
siempre que la mujer está en condiciones de
administrar cuidados a su recién nacido.
Cuando deba otorgarse el alta en forma
precoz, deberán garantizarse instancias de
seguimiento domiciliario.
• De ser necesario, instrumentar sistemas de
consulta telefónica con referentes de! centro
de salud o de la comunidad. Recordar que las
primeras 24 horas, suelen ser las de mayor
riesgo vital, tanto para la mujer, como para su
recién nacido.
• Recuerde a la madre de las ventajas de mantener
la alimentación al pecho exclusiva. Informar acerca
de importancia del vaciado periódico de las mamas,
higiene de los pezones y corpiño que sostenga y no
apriete para la prevención de problemas mamarios
• Recuerde la higiene de manos y el cuidado del cordón
umbilical
• Prevención del Síndrome de Muerte Súbita del
Lactante: colocar al niño boca arriba para dormir,
no abrigarlo en exceso, no fumar en el ambiente,
desestimar el colecho
• Orientar para el reconocimiento de Signos de alarma.
• Indicar las Inmunizaciones correspondientes al
momento del nacimiento y primer semana, según
esquema
• Verificar identificación del niño y su madre.
• Brindar orientación para la inscripción del niño en el
Registro Civil.
• Indicar claramente fecha y lugar del primer control,
a los 7 días del alta (preferentemente coordinar la
contrarreferencia)
• Valorar, previo, al alta condiciones de riesgo social
• Orientar acerca de las pruebas de Pesquisa y
obtención de los resultados
• En muchos casos puede ser útil la elaboración y
entrega de folletos instructivos con los conocimientos
básicos a transmitir al alta.
Primera consulta conjunta entre 7 y 10 días.
Puerperio mediato: Se extiende desde
el segundo y hasta el 10° día del parto
• Brindar información sobre higiene perineal o
cuidado de la cicatriz de cesárea.
• Recuérdele que la alimentación exclusiva
(día y noche) al pecho, sin dar ningún otro
tipo de alimento a su bebe, tiene un efecto
anticonceptivo fugaz e impredecible y que aun
amamantando puede tener otras opciones
contraceptivas.
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• Verificar que moja los pañales con frecuencia y
elimina meconio, que la succión es audible, vigorosa
y sostenida y que la boca está húmeda.
• Examinar al bebé sin incomodarlo procediendo a
obtener la información que permita detectar nuevas
condiciones que puedan requerir tratamiento.
• Investigar si tiene elementos de riesgo de displasia
de caderas. (asimetría de los miembros o pliegues
en la región anterior de muslo, Maniobras de Barlow
y Ortolani)
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• Signos vitales (temperatura, frecuencia cardiaca y presión
arterial).
Cualquier alteración de los signos vitales, obligará a
la búsqueda del agente etiológico y ante la presencia
de dudas, deberá ser enviada a un nivel de mayor
complejidad, para continuar su atención.
• Evaluación de los loquios (cantidad, aspecto, composición
y olor). Es difícil estimar la cantidad, por lo que se
recomienda ver si la madre tiene o no anemia. El color
a esta altura del puerperio, debe ser rojo o rosado. El
color marrón, achocolatado hará sospechar infección.
Suelen además de sangre, contener fragmentos tisulares
pequeños. El olor puede ser fuerte, en caso de fetidez, se
deberá sospechar infección.
• Control de involución uterina. La involución es sumamente
rápida, aproximadamente a 2 centímetros por día y se
estima mediante palpación del fondo uterino. A los 6
días de puerperio se situará entre el ombligo v el borde
superior del pubis. A los 10 días estaré próximo al pubis.
• En ocasiones se pueden ver hemorroides flexivas y
dolorosas, que no mejoran con tratamiento médico,
en esos casos deberé descartarse una trombosis
hemorroidal, la que se soluciona fácilmente con un
mínimo drenaje quirúrgico con anestesia local.
Otras veces el dolor puede ser expresión de una fisura
anal, que suele revertir con tratamiento médico. Luego de
unas semanas.
Es común observar una incontinencia de orina que suele
remitir espontáneamente en algunos días o semanas.
• Bajada de la leche. En estos días se sustituye el calostro
por la leche definitiva.
• No realizar doble pesada, ni siquiera es
necesario pesarlo todos los días.
• Ante la aparición de ictericia valorar
elementos de riesgo.
• Promover la higiene de manos, el uso de
alcohol gel.
• Informar sobre el riesgo de contagio de
enfermedades virales respiratorias y las
formas de evitarlas.
• Si tiene indicado alimentación por fórmula,
explicar su forma de preparación y el
cuidado e higiene de los implementos.
• Investigar cuales son los apoyos sociales
con los que la madre o los padres cuentan.
Segunda visita conjunta entre los 15 y 30 días
Puerperio alejado: Abarca desde el
11° hasta el 42° día del postparto
• Reforzar la conserjería en anticoncepción y espaciamiento
intergenésico, intentando mantener la lactancia.
• Controlar la evolución de la lactancia.
• Continúa la involución uterina y el restablecimiento del
estado pregravídico.
• Investigar síntomas menores de depresión. Si persisten
las alteraciones depresivas más allá del día 14 deberá
consultar con un profesional.
• Prevenir la reinfección por enfermedades de transmisión
sexual en especial si fueron detectadas y tratadas en esta
gestación.
• Prestar atención a situaciones de desamparo y violencia
doméstica.
• A los 25 días del parto, puede advertirse un sangrado
vaginal escaso (pequeño retorno) que generalmente
se debe a una proliferación endometrial normal que no
requiere ningún estudio o tratamiento especial
• El reinicio de las relaciones sexuales es habitual ya que
desaparecen los Loquios Esto ocurre entre los 30 y los 40
días del puerperio.
• En algunos casos, éste, será el ultimo control entre la
mujer y el equipo de salud, por eso es recomendable
efectuar un examen clínico general y ginecológico.
• Analizar con los padres los planes de reinicio de las
actividades laborales o educativas, verificando la
protección de sus derechos en la nueva situación de
maternidad.
• Continuar vacunaciones según esquema.
• Insistir en la higiene de manos, el uso de
Alcohol en gel y el riesgo de enfermedades
virales respiratorias, si están en ambiente
epidémico.
• Valorar el crecimiento y la alimentación.
Tener en cuenta la posibilidad de
administrar hierro adicional y vitamina D.
• Reiterar examen físico,
• Reiterar información sobre el riesgo de
muerte súbita.
Aconsejando que:
El recién nacido duerma boca arriba, en
cuna, en el cuarto de la madre los primeros
6 meses.
No prohibir el uso del chupete
Colocar al bebé con los pies en contacto
con la piesera de la cuna. (para evitar el
desplazamiento debajo de las mantas) I
Evite:
• el humo del tabaco en el hogar
• el colecho con los padres, que se duerman
con el bebé en un sillón (frecuente si
existe consumo de bebidas alcohólicas,
toman psicofármacos o tienen cansancio
extremo).
• vestir al niño con ropas abotonadas por
delante
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Cuadro 47 PROBLEMAS COMUNES EN LAS MADRES
SIGNOS y SINTOMAS
ACCIONES
Depresión puerperal.
Si persisten los síntomas más de 14 días consultar
Dolor perineal, olor de los Evaluar infección o cicatrización defectuosa de la episiotomía. Recomendar
exudados vaginales, dolor en frío local, analgésicos y si no son efectivos considerar antiinflamatorios no
las relaciones sexuales
esteroideos locales u orales.
Dolor en las relaciones Evaluar herida. Aconsejar lubricantes en base acuosa.
sexuales
Dolor de cabeza post anestesia Líquidos analgésicos y reposo sin almohada
epidural o raquídea
Fatiga persistente
Investigar otros síntomas en especial anemia. Señalar la necesidad de
alimentación y aporte de hierro y ejercicio
Dolor de espalda
Tratar como en la población general
Constipación
Recomiende dieta con fibras y Líquidos. Puede usarse un laxante suave
Hemorroides
Si son severas, edematizadas o prolapsadas, referir.
Incontinencia fecal
Evaluar severidad, duración y Frecuencia, Si persiste> 1mes referir
Incontinencia urinaria
Enseñe ejercicios de piso pélvico. Si persiste referir.
Retención de orina (en las Procure que tome una ducha tibia. Si persiste considere colocar sonda
primeras 6 horas Postparto)
vesical
Cuadro 48 PROBLEMAS COMUNES EN LOS RECIEN NACIOOS
SIGNOS y SINTOMAS
ACCIONES
Ictericia
Consulta de emergencia
Mugget oral
Tratamiento con antimicóticos tópicos
Eritema del pañal
Recomendar cambio más frecuente de los pañales. De ser muy molesto
persistente usar antimicóticos
No expulsión de meconio en Consulta de EMERGENCIA
las primeras 24hs
Constipación en no alimentado Consulta
al pecho
Diarrea
Aumentar frecuencia de las lactadas. Si está alimentado por fórmulas
verificar higiene de la preparación y consulta de urgencia
llanto inconsolable
Consulta de urgencia
“Cólicos’
Aconsejar que alcen y sostengan al bebé mientras llora y que busquen
apoyo de otros padres si se sienten desbordados.
SIGNOS Y SINTOMAS
Pezones
dolorosos
agrietados
Senos ingurgitados. Mastitis
Cuadro 49 PROBLEMAS AL AMAMANTAR
ACCIONES
o Considere la posibilidad de que tengan infección por cándida
Pezones invertidos I
Aconseje lactancia a demanda, masajes de los senos, ordeñe manual,
analgesia. Si persiste por horas consultar y si hay elementos claros de
infección considerar ATB.
Brindar más apoyo, tranquilizando a la madre.
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National Collaborating Centre for Primary Care. Routine postnatal care of women and their babies London. NICE clinical
guideline 37. ISBN 1-84629-248-4 National Institute for Health and Clinical Excellence. www.nice.org.uk/CG037 Julio 2006
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Inserción en el postparto
Otras situaciones
Post-placentario
Puerperio
Inmediato
Puerperal
Intracesárea
Post-aborto
No más de
10 minutos
después de
la salida de la
placenta.
En la primera
semana,
no más allá
de las 48 horas
postparto
Después
de las 4
semanas
postparto.
Después de la
revisión y limpieza
endouterina, antes
de la histerorrafia.
Inmediatamente
después de
evacuados los restos
ovulares y si no hay
signos de infección.
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Edad
Desde la menarca hasta los 19 años
20 a 44
45 y más años
Paridad
Nulípara
1 o más partos
Lactancia natural
< 6 semanas postparto
> 6 semanas a < 6 meses postparto
> 6 meses postparto
Postparto (amamantando o no)
< 48 horas
48 horas a < 4 semanas
> 4 semanas
Postaborto
1er trimestre
2º trimestre
Inmediatamente después de aborto séptico
Antecedente de embarazo ectópico
Historia de cirugía pélvica
Fumar
Edad < 35 años
Edad > 35 años
< 15 cigarrillos/día
> 15 cigarrillos/día
Obesidad
> 30 Kg/m2 del índice de masa corporal (IMC)
ENFERMEDADES CARDIOVASCULARES
Factores múltiples de riesgo para enfermedad
arterial cardiovascular (diabetes, HTA, etc.).
Hipertensión
Mujer con historia de HTA que no la controla
Mujer con historia de HTA que la controla
adecuadamente
P.A. sistólica de 140 a 159 y diastólica de 90 a 99
mm Hg
P.A. sistólica >160 y diastólica > 100 mm Hg
Enfermedad vascular
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LNG
implantes
orales
intravaginales
parches
orales
CARACTERÍSTICAS PERSONALES E HISTORIA REPRODUCTIVA
DIU
Cu
Solo progesterona
inyectables
Combinados
Condición
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Trombosis venosa profunda (TVP) y embolia
pulmonar (EP)
Historia de TVP/EP
TVP/EP actual
Historia familiar de TVP/EP (parientes de primer grado)
Cirugía mayor con inmovilización prolongada
Cirugía mayor sin inmovilización prolongada
Cirugía menor sin inmovilización
Trombosis venosa superficial
Venas varicosas
Tromboflebitis superficial
Cardiopatía isquémica antecedentes personales
o enfermedad actual
Accidente cerebro vascular
Hiperlipidemias conocidas
Valvulopatías
No complicadas
Complicadas
ALTERACIONES NEUROLÓGICAS
Cefaleas
No migrañosas
Migrañosas
Sin síntomas neurológicos focales
Edad < 35 años
Edad > 35 años
Con síntomas neurológicos focales
Epilepsia
INFECCIONES Y ENFERMEDADES DEL TRACTO REPRODUCTIVO
Patrones de sangrado vaginal
Patrón irregular sin sangrado intenso
Patrones regulares e irregulares con sangrado intenso
Sangrado vaginal sin explicación
Endometriosis
Tumores benignos de ovario
Dismenorrea severa
Enfermedad trofoblástica gestacional
Benigna
Maligna
Ectropion cervical
Neoplasia intraepitelial cervical
Cáncer cervical (esperando tratamiento)
Enfermedades de la mama
Tumor sin diagnóstico anatomopatológico
Enfermedad benigna
Historia familiar de cáncer de mama
Cáncer actual
Cáncer con 5 años sin evidencias de enfermedad
Cáncer de endometrio
Cáncer ovárico
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Miomas uterinos
Sin distorsión de la cavidad
Con distorsión de la cavidad
Enfermedad inflamatoria pélvica (EIP)
Pasada y sin riesgo actual de ITS
Con embarazo posterior
Sin embarazo posterior
Actual o en los últimos 3 meses
ITS
Actual o en los últimos 3 meses
Vaginitis sin cervicitis purulenta
Riesgo aumentado de ITS
VIH/SIDA
Alto riesgo de VIH
VIH Positivo
SIDA
OTRAS INFECCIONES
Tuberculosis
Malaria
ALTERACIONES ENDÓCRINAS
Diabetes
Diabetes gestacional
Diabetes no vascular
No insulino dependiente
Insulino dependiente
Nefropatía/retinopatía/neuropatía
Otra enfermedad vascular o diabetes de más de 20
años de evolución
Tiroides
Bocio simple
Hipertiroidismo
Hipotiroidismo
ALTERACIONES GASTROINTESTINALES
Enfermedad de la vesícula biliar
Sintomática
Tratada con colecistectomía
Tratada médicamente
Actual
Asintomática
Historia de colestasis
Relacionada con un embarazo
Relacionada con contraceptivos
Hepatitis viral
Activa
Portador
Cirrosis
Leve (compensada)
Severa (descompensada)
Tumores de hígado
Benigno (adenoma)
Maligno (hematoma)
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ANEMIAS
Talasemia
Drepanocítica
Ferropénica
INTERACCIÓN CON DROGAS
Drogas que afectan la función del hígado
Algunos antibióticos (rifampicina, griseofulvina, etc.).
Otros antibióticos
Algunos anticonvulsivantes (fenitoina,
carbamazepina, barbitúricos, etc.).
Use el método en cualquier circunstancia
Use generalmente el método
No se recomienda el método a menos que no se disponga o no se acepten otros
No usar el método
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A
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R
E
Aceptar
No hay razones médicas para negar la esterilización a una persona en esta condición.
Cuidado
El procedimiento normalmente se realiza en un cuadro de rutina, pero con preparación y
precauciones extra.
Retrasar
El procedimiento debe retrasarse hasta que la condición sea evaluada y/o corregida.
Deben proveerse métodos temporales alternativos de contracepción
Especial
El procedimiento debe llevarse a cabo en un marco que involucre a un cirujano y personal
experimentados y el equipo necesario para proveer anestesia general y otro apoyo médico
de respaldo. Para estas condiciones también se necesita la capacidad de decidir sobre
el procedimiento más apropiado y el régimen de anestesia. Se deben ofrecer métodos
temporales alternos de contracepción, si es necesario referir al paciente .
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Referencias Bibliográficas
Cheng L, Gülmezoglu AM, Van Oel CJ, Piaggio G, Ezcurra E, Van Look PFA. Interventions for emergency
contraception. Cochrane Database of Systematic Reviews 2004, Issue 3.
French R, Van Vliet H, Cowan F, Mansour D, Morris S, Hughes D, Robinson A, Proctor T, Summerbell C,
Logan S, Helmerhorst F, Guillebaud J. Hormonally impregnated intrauterine systems (IUSs) versus other
forms of reversible contraceptives as effective methods of preventing pregnancy. Cochrane Database of
Systematic Reviews 2004, Issue 3.
Litt IF. Placing emergency contraception in the hands of women. JAMA. 2005 Jan 5;293(1):98-99.
Ministerio de Salud Pública. Guías en Salud Sexual y Reproductiva. Capítulo Anticoncepción
(Métodos Reversibles). Montevideo - Uruguay 2005. http://www.msp.gub.uy/imgnoticias/5039.pdf
Philpott A. Re-use of the female condom: now for the practical realities.
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Planned Parenthood Federation of America. Facts About Birth Control. Prescription.
http://www.plannedparenthood.org/birth-control-pregnancy/birth-control/prescription.htm
(Último acceso 20 de Julio de 2007)
Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency
contraception for pregnancy prevention (full review). Cochrane Database of Systematic Reviews 2007,
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Power J, French R, Cowan F. Subdermal implantable contraceptives versus other forms of reversible
contraceptives or other implants as effective methods of preventing pregnancy. Cochrane Database of
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Prine L. Emergency contraception, myths and facts. Obstet Gynecol Clin North Am. 2007 Mar; 34(1):12736, ix-x.
Santelli J, Rochat R, Hartfield-Timajchy K, Colley B, Curtis K, Cabral R, Hirsch J, Schieve L, et al. 2003.
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WHO 2005. Emergency contraception.
(Último acceso 20 de Julio de 2007)
www.who.int/entity/mediacentre/factsheets/fs244/en/
WHO 2004. Medical Eligibility Criteria for Contraceptive Use. 3rd ed. 2004. http://www.who.int/reproductivehealth/publications/mec/index.htm (Último acceso 20 de Julio de 2007).
WHO 2004. Selected practice recommendations for contraceptive use. 2nd ed. 2004. http://www.who.int/
reproductive-health/publications/spr/index.htm (Último acceso 20 de Julio de 2007).
WHO 2007. Family Planning A global handbook for providers. 1st ed. 2007. http://www.who.int/reproductivehealth/publications/fp_globalhandbook/index.htm (Último acceso 15 de Agosto de 2007).
WHO.The Female Condom: A guide for planning and programming. http://www.who.int/
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(Úlimo acceso 20 de Julio de 2007)
WHO 2002. WHO Information Update: Considerations regarding Reuse of the Female Condom July 2002.
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WHO 2004. The male latex condom
Specification and guidelines for condom procurement. http://www.who.int/reproductive-health/
publications/m_condom/who_specification_04.pdf (Último acceso 20 de Julio de 2007).
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Tamaño del útero < a la amenorrea.
Tumoración parauterina.
Tumoración parauterina inespecífica.
Ausencia de saco gestacional.
Pseudosaco gestacional.
MOLA
HIDATIFORME
Sangrado rojo, a veces con vesículas.
Tamaño uterino > a la amenorrea.
Quistes ováricos.
Útero: imagen típica con vesículas.
Ovarios: quistes luteínicos uni o
bilaterales.
ABORTO
Dolor.
Sangrado inicialmente escaso y
oscuro, posteriormente abundante y
rojo rutilante.
No hay tumoraciones anexiales
Útero ocupado por el saco o por
restos ovulares y/o coágulos. Solo
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3a Edición
http://new.paho.org/clap
http://perinatal.bvsalud.org/
r
ISBN 978-92-75-33177-4
CLAP/SMR Publicación Científica Nº 1577 - 2011