Guías para el continuo de atencion de la mujer y el recien nacido 3ed

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CLAP/SMR Publicaci贸n Cient铆fica N潞 1577 - 2011

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,1',&( 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 &HQWUR /DWLQRDPHULFDQR GH 3HULQDWRORJtD 6DOXG GH OD 0XMHU \ 5HSURGXFWLYD

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DiagnĂłstico de malaria Malaria y embarazo PrevenciĂłn de la malaria durante el embarazo Tratamiento en mujeres embarazadas Objetivos: Reducir la morbimortalidad neonatal por estreptococo grupo % Actividad: PrevenciĂłn, detecciĂłn y tratamiento Objetivos: Detectar posibles procesos sĂŠpticos buco-dentales Actividad: Examen buco-dental Objetivos: Detectar posibles alteraciones del pezĂłn, patologĂ­a inflamatoria Actividad: Examen de las mamas Objetivos: Descartar cĂĄncer de cuello, lesiones precursoras y evaluar la competencia cervical Actividad: Examen genital, colpocitologĂ­a, colposcopĂ­a CĂĄncer cervical Incompetencia cervical Objetivos: Pesquisar una posible incompatibilidad sanguĂ­nea materno-feto-neonatal Actividad: DeterminaciĂłn del grupo sanguĂ­neo, del factor Rh y de anticuerpos irregulares Objetivos: Prevenir, detectar y tratar la anemia materna Actividad: Determinar niveles de hemoglobina. AdministraciĂłn de hierro y ĂĄcido fĂłlico PrevenciĂłn de la anemia PrevenciĂłn de los defectos del tubo neural Objetivos: Descartar proteinuria, glucosuria y bacteriuria Actividad: Examen de orina y urocultivo Examen de orina InfecciĂłn urinaria y bacteriuria asintomĂĄtica Objetivos: Descartar diabetes mellitus clĂ­nica y gestacional Actividad: DeterminaciĂłn de la glucemia y prueba de tolerancia oral a la glucosa Diabetes gestacional Glucemia en ayunas Prueba de tolerancia oral a la glucosa ClasificaciĂłn de los estados diabĂŠticos en el embarazo Objetivos: Brindar contenidos educativo-informativos para el parto y la crianza Actividad: PreparaciĂłn para el parto, consejerĂ­a para el amamantamiento Objetivos: Confirmar la existencia de vida fetal Actividad: Pesquisar movimientos y frecuencia cadĂ­aca fetal Movimientos fetales Actividad cardĂ­aca fetal Estetoscopio obstĂŠtrico Objetivos: Anticipar el diagnĂłstico y prevenir el parto prematuro Actividad: Evaluar el patrĂłn de la contractilidad uterina (frecuencia, duraciĂłn e intensidad) Retrasar el parto de pretĂŠrmino. Inducir la maduraciĂłn pulmonar fetal.

DiagnĂłstico de amenaza de parto prematuro Tratamiento Tratamientos que no han demostrado ser efectivos en la amenaza de parto prematuro Inductores de la maduraciĂłn pulmonar Objetivos: Pesquisar alteraciones de la presiĂłn arterial: HipertensiĂłn previa al embarazo.

El sĂ­ndr. de hipertensiĂłn inducida por el embarazo (pre-eclampsia). HipotensiĂłn arterial Actividad: DeterminaciĂłn de la presiĂłn arterial, identificaciĂłn de edemas y proteinuria. &HQWUR /DWLQRDPHULFDQR GH 3HULQDWRORJtD 6DOXG GH OD 0XMHU \ 5HSURGXFWLYD

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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 &HQWUR /DWLQRDPHULFDQR GH 3HULQDWRORJtD 6DOXG GH OD 0XMHU \ 5HSURGXFWLYD

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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.

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Registros.

Soporte afectivo.

Controles de la madre y del reciĂŠn nacido Referencias BibliogrĂĄficas

CAPITULO VII PlanificaciĂłn familiar Objetivos: Contribuir al ejercicio del derecho a planificar el embarazo Actividad: Asesorar sobre los principales mĂŠtodos contraceptivos Proceso de asesoramiento EvaluaciĂłn de las usuarias antes de recomendarles un mĂŠtodo contraceptivo DescripciĂłn de los mĂŠtodos anticonceptivos MĂŠtodos reversibles MĂŠtodos comportamentales MĂŠtodo de la lactancia exclusiva (MELA) MĂŠtodos de barrera ContracepciĂłn de emergencia Contraceptivos hormonales Dispositivos intrauterinos Criterios de elegibilidad para mĂŠtodos hormonales y dispositivos intra uterinos MĂŠtodos irreversibles Ligadura tubaria Ligadura de los deferentes (vasectomĂ­a) Referencias BibliogrĂĄficas

CAPITULO VIII Aborto Objetivos: Reducir la morbimortalidad por aborto Actividad: DiagnĂłstico y asistencia del aborto en los distintos perĂ­odos Definiciones Prevalencia e incidencia Aborto espontĂĄneo DiagnĂłstico clĂ­nico y etapas evolutivas del aborto DiagnĂłstico diferencial Conducta MĂŠtodos de evacuaciĂłn EvacuaciĂłn uterina Cuidados post procedimiento Aborto complicado Complicaciones post evacuaciĂłn ConsejerĂ­a /InformaciĂłn AnticoncepciĂłn por aborto Referencias BibliogrĂĄficas

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*ORVDULR 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.

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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.

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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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Antes de Las 20 (*) 1ยช 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 3ยช visita 4ยช visita X X

X X

X X

X X

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X

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X X X X X X X X X X X X X X X

Entre las 38 y 40 5ยช visita

X X

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(*)

Las actividades programadas para la primer visita se deberรกn hacer siempre, independientemente de la edad gestacional al momento de la consulta

(**)

Si se sospecha que la gestante no volverรก o porque asรญ lo indica la norma nacional se podrรก vacunar antes de la semana 20

(***) Lo mรกs precozmente o segรบn norma nacional.

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DIAGNOSTICO Buen estado nutricional

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CONDUCTA - seguir cronograma habitual de consultas

- explicar a la gestante que su peso es adecuado para la edad gestacional

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- dar orientaciĂłn nutricional

El punto se sitĂşa por debajo del percentilo 25 de la curva de referencia

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CONDUCTA - investigar la historia nutricional, hiperemesis gravĂ­dica, infecciones, parasitosis, anemia, enfermedades debilitantes.

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El punto se sitĂşa por encima del percentilo 90 de la curva de referencia

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DIAGNOSTICO Gestante de riesgo, por presentar peso superior al normal para esa edad gestacional; tanto mayor serĂĄ el riesgo cuanto mĂĄs elevado sea su sobrepeso.

- citar a consulta en un intervalo menor que lo fijado en el cronograma habitual.

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DIAGNOSTICO Gestante de riesgo, con peso insuficiente para la edad gestacional (desnutriciĂłn)

CONDUCTA - determinar causas: obesidad, edema, polihidramnios, macrosomĂ­a, embarazo mĂşltiple

- citar a consulta en un intervalo menor que lo fijado en el cronograma habitual.

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- el peso ganado durante toda la gestaciĂłn no debe superar los 16 kg (p90)

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Trazado con inclinaciĂłn ascendente entre las curvas del percentil 25 y el percentil 90 del peso de referencia para la edad gestacional

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- dar orientaciĂłn nutricional que la gestante se mantenga dentro de la faja de normalidad Trazado entre las curvas de percentil 25 y 90, con inclinaciĂłn horizontal o descendente o trazado por abajo de la cuva del percentil 25, con inclinaciĂłn 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: dĂŠficit nutricional, infecciones, parasitosis, anemia, entre otras. Tratarlas cuando esten presentes y dar orientaciĂłn nutricional

- referir a control prenatal de alto riesgo.

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Estas medidas intentan que la gestante llegue al tĂŠrmino de la gestaciĂłn con una ganancia de peso mĂ­nima 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 serĂĄ el riesgo

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DIAGNOSTICO Buen estado nutricional (ganancia adecuada de peso):

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CONDUCTA - investigar posibles causas: obesidad, diabetes y edema.

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Esas medidas procuran que la gestante llegue al tĂŠrmino con un peso final dentro del rango de la normalidad (mĂĄximo de 16 kg)

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Plan Los intervalos indicados en el cuadro se refieren al tiempo mĂ­nimo aceptable entre vacunaciones; no existen intervalos mĂĄximos.

TT1 o Td1

En el primer contacto o cuanto antes durante el embarazo

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Al menos cuatro semanas despuĂŠs de la primera dosis

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De 6 a 12 meses despuĂŠs de la segunda dosis o durante un embarazo posterior

TT4 o Td4

De uno a cinco aĂąos despuĂŠs de la tercera dosis o durante un embarazo posterior

TT5 o Td5

De uno a 10 aĂąos despuĂŠs de la cuarta dosis o durante un embarazo posterior

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Interpretaciรณn

Conducta

-

No hay infecciรณn.

Existe riesgo de contraerla

Comunicar medidas de protecciรณn.

Eventual repeticiรณn de IgG segรบn norma nacional

+

-

Infecciรณn pasada

Continuar control en forma habitual

+

+

Infecciรณn actual

Evaluar riesgo de infecciรณn fetal.

Evaluar realizaciรณn de tratamiento mรฉdico

Riesgo desconocido

Comunicar medidas de protecciรณn realizar tamizaje segรบn norma nacional

IgG

IgM

-

No se hizo No se hizo

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Dosis carga: 100 mg/dรญa oral, Hasta final del Pirimetamina divididos en 2 dosis, durante 2 dรญas. embarazo Continua: 50 mg/dรญa oral Dosis carga: 75 mg/Kg/dรญa oral, divididos en 2 dosis, durante 2 dรญas.

Hasta final del Infecciรณn fetal Sulfadiazina Mรกximo 4 g/dรญa. embarazo confirmada (entre Continua: 100 mg/Kg/dรญa oral las 12 y 18 emanas) divididos en 2 dosis. Mรกximo 4 g/dรญa.

Durante y hasta una semana Acido folรญnico 5 a 20 mg/dรญa despuรฉs de usar la Pirimetamina.

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Restricciรณn del crecimiento intrauterino (RCI).

Sufrimiento fetal agudo intraparto.

Oligoamnios Mortalidad aumentada

1HRQDWDO Pequeรฑo para la edad gestacional (PEG).

Pretรฉrmino.

Sรญndrome de dificultad respiratoria.

Depresiรณn neonatal.

Mortalidad aumentada

Restricciรณn del crecimiento intrauterino (RCIU).

Mortalidad aumentada.

Pequeรฑo para la edad gestacional (PEG) Mortalidad aumentada.

Hipotensiรณn Lipotimias y desmayos.

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Observaciรณn sin maniobras ni medicaciรณn y traslado a sala de parto con dilataciรณn completa

Hiperdinama

Combio de posiciรณn y uteroinhibiciรณn. Referencia a alto riesgo

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Bradicardia fetal Dips II

Tratamiento del sufrimiento fetal in รบtero. Referencia de alto riesgo.

Taquicardia fetal

Decรบbito lateral - Controlar PA materno

Dips variables Dips I con membranas รญntegras

Control mรกs frecuente de FCF

Parto prolongando (segรบn curva de alerta)

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Si no progresa, amniotomรญa: referencia a alto riesgo.

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Segรบn normas especรญficas amniotomรญa. Referencia a alto riesgo

Lรญquido amniรณtico meconial

Control mรกs frecuente. Aspiraciรณn inmediata del RN

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5HIHUHQFLDV %LEOLRJUiÂżFDV McCall EM, et al. Interventions to prevent hypothermia at birth in preterm and low birth weight. Cochrane Database Rev 2008, Jan 23.

Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, Jagt EW van der , Zaritsky AL.. Pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2010 Nov;126(5):e1361-99.

Epub 2010 Oct 18.

American Academy of Pediatrics. Section on Ophthalmology, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2006 Feb; 117(2):572-6.

Hutton EK et al, Late versus Early clamping Of the umbilical cord in full term neonates: Systemic review and metanalysis of controlled trials. JAMA 2007;2007:1241-1252.

Rabe H et al. A systematic review and metanalisys of a brief delay in camping the umbilical cord of preterm infant. Neonatology 2008;93:138-144.

Rabe H, Reynolds GJ, Diaz-Rosello JL. Early versus delayed umbilical cord clamping in preterm infants.

Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD003248. DOI: 10.1002/14651858.

CD003248.pub2.

McDonald SJ, Middleton P Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004074.

Finer NN, Carlo WA, Duara S, Fanaroff AA, Donovan EF, Wright LL, Kandefer S, Poole WK. National Institute of Child Health and Human Development Neonatal Research Network. Delivery room continuous positive airway pressure/positive end-expiratory pressure in extremely low birth weight infants: a feasibility trial.

Pediatrics. 2004 Sep;114(3):651-7.

Morley Colin J, Davis Peter, Doyle Lex W, Brion Luc P, Hascoet Jean-Michel, Carlin John B. Nasal CPAP or Intubation at Birth for Very Preterm Infants. N Engl J Med 2008; 358:700-708.

Engle WA, Kominiarek MA.Late preterm infants, early term infants, and timing of elective deliveries. Clin Perinatol. 2008, 35(2):325-41, vi. Review 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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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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InformaciĂłn al egreso.

Durante la internaciĂłn por el parto, la madre y la familia deberĂĄn haber recibido informaciĂłn para el cuidado postnatal y la protecciĂłn de la salud de ella y su reciĂŠn nacido. Al alta deberĂĄ seĂąalarse con precisiĂłn: â&#x20AC;˘ la forma en que ella puede mantener una comunicaciĂłn continua con los servicios â&#x20AC;˘ las nuevas necesidades de apoyo familiar y los recursos comunitarios a los que pueda acceder para encontrar soporte en la funciĂłn parental y â&#x20AC;˘ pautas que la guĂ­en para la consulta en caso que aparezcan elementos de alarma para la salud de ambos. â&#x20AC;˘ Es recomendable otorgar el alta a las 48 horas del parto, si no ha habido complicaciones y siempre que la mujer estĂĄ en condiciones de administrar cuidados a su reciĂŠn nacido.

Cuando deba otorgarse el alta en forma precoz, deberĂĄn garantizarse instancias de seguimiento domiciliario. â&#x20AC;˘ De ser necesario, instrumentar sistemas de consulta telefĂłnica 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 reciĂŠn nacido.

â&#x20AC;˘ Recuerde a la madre de las ventajas de mantener la alimentaciĂłn al pecho exclusiva. Informar acerca de importancia del vaciado periĂłdico de las mamas, higiene de los pezones y corpiĂąo que sostenga y no apriete para la prevenciĂłn de problemas mamarios â&#x20AC;˘ Recuerde la higiene de manos y el cuidado del cordĂłn umbilical â&#x20AC;˘ PrevenciĂłn del SĂ­ndrome de Muerte SĂşbita del Lactante: colocar al niĂąo boca arriba para dormir, no abrigarlo en exceso, no fumar en el ambiente, desestimar el colecho â&#x20AC;˘ Orientar para el reconocimiento de Signos de alarma. â&#x20AC;˘ Indicar las Inmunizaciones correspondientes al momento del nacimiento y primer semana, segĂşn esquema â&#x20AC;˘ Verificar identificaciĂłn del niĂąo y su madre. â&#x20AC;˘ Brindar orientaciĂłn para la inscripciĂłn del niĂąo en el Registro Civil. â&#x20AC;˘ Indicar claramente fecha y lugar del primer control, a los 7 dĂ­as del alta (preferentemente coordinar la contrarreferencia) â&#x20AC;˘ Valorar, previo, al alta condiciones de riesgo social â&#x20AC;˘ Orientar acerca de las pruebas de Pesquisa y obtenciĂłn de los resultados â&#x20AC;˘ En muchos casos puede ser Ăştil la elaboraciĂłn y entrega de folletos instructivos con los conocimientos bĂĄsicos a transmitir al alta.

Primera consulta conjunta entre 7 y 10 dĂ­as.

Puerperio mediato: Se extiende desde el segundo y hasta el 10° dĂ­a del parto â&#x20AC;˘ Brindar informaciĂłn sobre higiene perineal o cuidado de la cicatriz de cesĂĄrea. â&#x20AC;˘ RecuĂŠrdele que la alimentaciĂłn exclusiva (dĂ­a y noche) al pecho, sin dar ningĂşn 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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â&#x20AC;˘ Verificar que moja los paĂąales con frecuencia y elimina meconio, que la succiĂłn es audible, vigorosa y sostenida y que la boca estĂĄ hĂşmeda. â&#x20AC;˘ Examinar al bebĂŠ sin incomodarlo procediendo a obtener la informaciĂłn que permita detectar nuevas condiciones que puedan requerir tratamiento. â&#x20AC;˘ Investigar si tiene elementos de riesgo de displasia de caderas. (asimetrĂ­a de los miembros o pliegues en la regiĂłn 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

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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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Otras situaciones

Post-placentario

Puerperio Inmediato

Puerperal

Intracesรกrea

Post-aborto

No mรกs de 10 minutos despuรฉs de la salida de la placenta.

En la primera semana, no mรกs allรก de las 48 horas postparto

Despuรฉs de las 4 semanas postparto.

Despuรฉs de la revisiรณn y limpieza endouterina, antes de la histerorrafia.

Inmediatamente despuรฉs de evacuados los restos ovulares y si no hay signos de infecciรณn.

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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 &HQWUR /DWLQRDPHULFDQR GH 3HULQDWRORJtD 6DOXG GH OD 0XMHU \ 5HSURGXFWLYD

LNG

implantes

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intravaginales

parches

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CARACTERÍSTICAS PERSONALES E HISTORIA REPRODUCTIVA

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Combinados Condición

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ANEMIAS Talasemia DrepanocĂ­tica FerropĂŠnica INTERACCIĂ&#x201C;N CON DROGAS Drogas que afectan la funciĂłn del hĂ­gado Algunos antibiĂłticos (rifampicina, griseofulvina, etc.).

Otros antibiĂłticos Algunos anticonvulsivantes (fenitoina, carbamazepina, barbitĂşricos, etc.).

Use el mĂŠtodo en cualquier circunstancia Use generalmente el mĂŠtodo No se recomienda el mĂŠtodo a menos que no se disponga o no se acepten otros No usar el mĂŠtodo

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Cuidado El procedimiento normalmente se realiza en un cuadro de rutina, pero con preparaciĂłn y precauciones extra.

Retrasar El procedimiento debe retrasarse hasta que la condiciĂłn sea evaluada y/o corregida.

Deben proveerse mĂŠtodos temporales alternativos de contracepciĂłn 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 mĂŠdico de respaldo. Para estas condiciones tambiĂŠn se necesita la capacidad de decidir sobre el procedimiento mĂĄs apropiado y el rĂŠgimen de anestesia. Se deben ofrecer mĂŠtodos temporales alternos de contracepciĂłn, 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.

Reprod Health Matters. 2003 Nov;11(22):185-186.

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, Issue 2.

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 Systematic Reviews 2007, Issue 3.

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.

The Measurement and Meaning of Unintended Pregnancy. Perspectives on Sexual and Reproductive Health 35(2): 94-101 Van der Wijden C, Kleijnen J, Van den Berk T. Lactational amenorrhea for family planning. Cochrane Database of Systematic Reviews 2003, Issue 4.

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/ reproductive-health/publications/RHR_00_8/PDF/female_condom_guide_planning_programming.pdf (Úlimo acceso 20 de Julio de 2007) WHO 2002. WHO Information Update: Considerations regarding Reuse of the Female Condom July 2002. http://www.who.int/reproductive-health/stis/docs/reuse_FC2.pdf (Último acceso 20 de Julio de 2007).

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ECOGRAFĂ?A

EMBARAZO ECTĂ&#x201C;PICO

Dolor.

Sangrado negruzco y escaso.

TamaĂąo del Ăştero < a la amenorrea.

TumoraciĂłn parauterina.

TumoraciĂłn parauterina inespecĂ­fica.

Ausencia de saco gestacional.

Pseudosaco gestacional.

MOLA HIDATIFORME

Sangrado rojo, a veces con vesĂ­culas.

TamaĂąo uterino > a la amenorrea.

Quistes ovĂĄricos.

Ă&#x161;tero: imagen tĂ­pica con vesĂ­culas.

Ovarios: quistes luteĂ­nicos uni o bilaterales.

ABORTO

Dolor.

Sangrado inicialmente escaso y oscuro, posteriormente abundante y rojo rutilante.

No hay tumoraciones anexiales

Ă&#x161;tero ocupado por el saco o por restos ovulares y/o coĂĄgulos. Solo estarĂĄ vacĂ­o en el aborto incompleto

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Recomendations on Ethical Issues in Obstetrics and Gynecology by The FIGO Committee for the Ethical aspects of Human Reproduction and Women´s Health, FIGO, London, United Kingdom, November 2003.

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World Health Organization. Pregnancy, Chilbirth, Postpartum and Newborn Care: A guide for essential practice, Geneva, 2003.

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3a Edici贸n

http://new.paho.org/clap

http://perinatal.bvsalud.org/ r

ISBN 978-92-75-33177-4

CLAP/SMR Publicaci贸n Cient铆fica N潞 1577 - 2011