Clap1577 PDF

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CLAP/SMR Publicacin Cientfica N 1577 - 2011

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PROLOGO 9
GLOSARIO 10
CAPITULO I
Renovacin de la Atencin Primaria de la Salud en las Amricas 12
Contnuo de atencin 13
Enfoque de Salud Familiar y Comunitaria 13
Valores, Principios y Elementos de un Sistema de Salud Basado en la APS 13
Referencias bibliogrficas 18
CAPITULO II
Cuidado Preconcepcional 19
Objetivos: Identificar y asesorar sobre riesgo preconcepcional 19
Actividad: Consulta previa al embarazo 19
Cuidado preconcepcional 19
Consulta preconcepcional 19
Reduccin de la morbimortalidad materna y feto neonatal 20
Defectos congnitos 20
Historia Clnica 20
Antecedentes reproductivos 22
Antecedentes generales 25
Enfermedades mdicas no transmisibles 25
Enfermedades mdicas transmisibles 29
Estilos de vida 31
Consumo de medicamentos 34
Vacunas 36
CAPITULO III
Control Prenatal, Vigilancia Durante la Gestacin,
39
Evaluacin del Riesgo Concepcional y Conductas
Objetivos y Actividades propuestas 40
Cronologa de las actividades para las consultas prenatales de bajo riesgo 42
Objetivos: Confirmar embarazo 43
Actividad: Realizacin de exmenes clnicos y paraclnicos para diagnosticar embarazo 43
Objetivos: Mejorar la calidad del control prenatal 44
Actividad: Utilizacin de algunas tecnologas apropiadas 44
Gestograma 44
Cinta obsttrica 45
Tarjeta de Altura Uterina y Peso Materno 46
Objetivos: Obtener datos para planificar el control prenatal, la atencin del parto, el puerperio y el recin nacido 47
Actividad: Empleo del Sistema Informtico Perinatal 47
Historia Clnica 47
Partograma 47
Carn Perinatal 47
Procesamiento de datos 57
Objetivos: Contar con una hoja de ruta que gue al prestador para brindar una atencin prenatal de calidad 58
Actividad: Uso de la Historia Clnica Perinatal del CLAP/SMR 58
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Objetivos: Detectar riesgos en la poblacin 59

Actividad: Evaluacin del riesgo perinatal 59
Objetivos: Conocer informacin relevante del embarazo 60
Actividad: Anamnesis 60
Objetivos: Fijar un cronograma que permita planificar las actividades del control prenatal 63
Actividad: Determinacin de la edad gestacional y de la fecha probable de parto 63
Amenorrea 63
Evaluacin del tamao uterino 63
Antropometra fetal por ecografa 64
Madurez placentaria 66
Objetivos: Evaluar el estado nutricional materno 66
Actividad: Medicin del peso y de la talla materna. Clculo del incremento de peso durante la gestacin. 66
Tcnica de medicin 67
Ganancia de peso 67
Interpretacin de la medida a la primera consulta 68
Interpretacin de la secuencia de medidas en consultas subsecuentes 69
Relacin peso para la talla segn edad gestacional 70
Evaluacin del incremento ponderal materno 70
Conducta 70
Objetivos: Investigar estilos de vida de riesgo 71
Actividad: Interrogatorio sobre tabaquismo (activo y pasivo), drogas, alcohol y violencia 71
Tabaquismo activo 71
Tabaquismo pasivo 72
Alcohol 73
Drogas 73
Violencia 74
Objetivos: Prevenir el ttanos neonatal y puerperal 76
Actividad: Vacunacin antitetnica 76
Objetivos: Disminuir el impacto negativo de las infecciones de transmisin vertical 78
Actividad: Prevencin, deteccin y tratamiento de las infecciones de transmisin vertical 78
Rubeola congnita 78
Toxoplasmosis congnita 79
Hepatitis B 81
VIH/SIDA 82
Objetivos: Prevenir sfilis 83
Actividad: Tamizaje y tratamiento 83
Objetivos: Prevenir las consecuencias materno-perinatales de otras infecciones de transmisin sexual ITS y 88
otras infecciones del tracto reproductivo ITR
Actividad: Prevencin, deteccin y tratamiento 88
Flujo (leucorrea), 88
Moniliasis vulvovaginal, vaginosis bacteriana, tricomoniasis, gonococcia, 89
Clamidiasis, herpes simple 90
Objetivos: Prevenir la transmisin vertical de la enfermedad de Chagas 90
Objetivos: Reducir la morbimortalidad materna y prevenir la transmisin vertical del Paludismo o Malaria 92
Diagnstico de malaria 92
Malaria y embarazo 92
Prevencin de la malaria durante el embarazo 93
Tratamiento en mujeres embarazadas 93
Objetivos: Reducir la morbimortalidad neonatal por estreptococo grupo% 95
Objetivos: Detectar posibles procesos spticos buco-dentales
Actividad: Examen buco-dental 97
Objetivos: Detectar posibles alteraciones del pezn, patologa inflamatoria
Actividad: Examen de las mamas 98
Objetivos: Descartar cncer de cuello, lesiones precursoras y evaluar la competencia cervical 98
Actividad: Examen genital, colpocitologa, colposcopa 98
Cncer cervical 98
Incompetencia cervical 103
Objetivos: Pesquisar una posible incompatibilidad sangunea materno-feto-neonatal 104
Actividad: Determinacin del grupo sanguneo, del factor Rh y de anticuerpos irregulares 104
Objetivos: Prevenir, detectar y tratar la anemia materna 106
Actividad: Determinar niveles de hemoglobina. Administracin de hierro y cido flico 106
Prevencin de la anemia 107
Prevencin de los defectos del tubo neural 108
Objetivos: Descartar proteinuria, glucosuria y bacteriuria 108
Actividad: Examen de orina y urocultivo 108
Examen de orina 108
Infeccin urinaria y bacteriuria asintomtica 109
Objetivos: Descartar diabetes mellitus clnica y gestacional 111
Actividad: Determinacin de la glucemia y prueba de tolerancia oral a la glucosa 111
Diabetes gestacional 111
Glucemia en ayunas 112
Prueba de tolerancia oral a la glucosa 112
Clasificacin de los estados diabticos en el embarazo 113
Objetivos: Brindar contenidos educativo-informativos para el parto y la crianza 114
Actividad: Preparacin para el parto, consejera para el amamantamiento 114
Objetivos: Confirmar la existencia de vida fetal 116
Actividad: Pesquisar movimientos y frecuencia cadaca fetal 116
Movimientos fetales 116
Actividad cardaca fetal 117
Estetoscopio obsttrico 118
Objetivos: Anticipar el diagnstico y prevenir el parto prematuro 119
Actividad: Evaluar el patrn de la contractilidad uterina (frecuencia, duracin e intensidad) 119
Retrasar el parto de pretrmino. Inducir la maduracin pulmonar fetal.
Diagnstico de amenaza de parto prematuro 120
Tratamiento 121
Tratamientos que no han demostrado ser efectivos en la amenaza de parto prematuro 123
Inductores de la maduracin pulmonar 123
Objetivos: Pesquisar alteraciones de la presin arterial: Hipertensin previa al embarazo. 125
El sndr. de hipertensin inducida por el embarazo (pre-eclampsia). Hipotensin arterial
Actividad: Determinacin de la presin arterial, identificacin de edemas y proteinuria. 125
Factores que pueden modificar los valores de tensin arterial 125

Tcnica de medida, 125
Modificaciones fisiolgicas durante el parto 126
Clasificacin de estados hipertensivos en el embarazo, 126
Factores de riesgo de hipertensin gestacional y pre-eclmpsia, Prevencin 127
Conductas recomendadas 127
Objetivos: Descartar alteraciones del crecimiento fetal 130
Actividad: Evaluacin del crecimiento fetal por medio de la altura uterina, ganancia de peso y ecografa. 130
Restriccin del crecimiento intrauterino 130
Macrosoma fetal 131
Tecnologas para medir el crecimiento fetal 131
Ejemplos de la evaluacin de la relacin Altura Uterina/Edad Gastacional a la primera consulta 133
Ejemplos de la evaluacin de la tendencia de la relacin AU/EG en consultas subsecuentes 134
Objetivos: Detectar precozmente el embarazo mltiple para prevenir sus complicaciones 138
Actividad: Diagnstico del nmero de fetos 138
Objetivos: Pesquisar las presentaciones fetales anormales 140
Actividad: Diagnstico de presentacin fetal 140
Presentacin pelviana o podlica 140
Situacin transversa 140
Objetivos: Detectar posibles distocias plvicas para definir el nivel de atencin del parto 142
Actividad: Examen gineco-obsttrico. Evaluacin de la pelvis. 142
CAPITULO IV
Atencin del Parto de Bajo Riesgo 154
Asistencia durante el ingreso 154
Objetivos: Diagnosticar el trabajo de parto e identificar el grado de riesgo 154
Actividad: Consulta en recepcin 154
Interrogatorio 155
Examen clnico general 156
Examen obsttrico 158
Auscultacin de la FCF 159
Patron de contractilidad uterina 161
Examen genital 163
Dilatacin, borramiento y posicin del cuello 164
Prdida de secreciones por los genitales 164
Evaluacin de la presentacin 167
Valoracin de la proporcin feto-plvica y la capacidad de la pelvis materna 170
Preparacin de la embarazada en la recepcin 172
Asistencia durante el perodo de dilatacin (primer perodo) 173
Objetivos: Controlar bienestar materno y fetal. Detectar y evaluar desviaciones de los lmites fisiolgicos 173
(progreso del parto). Evaluar riesgo y referir a nivel apropiado. Aplicar maniobras correctivas
Actividad: Informacin a la embarazada. Controles maternos. Controles obsttricos 173
Registro de los controles en el partograma con curvas de alerta.
Acompaamiento a la madre durante el parto 173
Controles maternos 174
Controles obsttricos 175
Progreso de la dilatacin y descenso de la presentacin 177
Partograma con curvas de alerta 178

Trabajo de parto prolongado 183
Asistencia durante el perodo expulsivo (segundo perodo) 185
Objetivos: Detectar y evaluar desviaciones de los lmites fisiolgicos del perodo expulsivo.
Prevenir traumatismo obsttrico. Prevenir hipoxia fetal. 185
Actividad: Control de la FCF. Control de la contractilidad.
Control del avance de la presentacin y desprendimiento 185
Posicin de la parturienta 186
Controles a realizarse durante el perodo expulsivo 186
Amniotoma 187
Proteccin perineal 187
Avance de la presentacin y desprendimiento 188
Situaciones especiales 189
Distocia de hombro 189
Atencin del parto en podlica 190
Atencin del recin nacido en sala de partos 193
Recomendaciones sobre uso de medicacin en parto de bajo riesgo 194
Asistencia durante el alumbramiento y posalumbramiento (tercer perodo) 198
Objetivos: Detectar y evaluar desviaciones de los lmites fisiolgicos del alumbramiento y posalumbramiento 198
Actividad: Control materno. Examen de la placenta 198
Examen de la placenta y membranas 198
Controles durante el alumbramiento 198
Sutura de la episiotoma 199
Prevencin para evitar la retencin de restos ovulares 199
Prevencin de la hemorragia post parto (HPP). 199
Traccin del cordn. 200
Masaje y compresin uterina 200
Postalumbramiento 201
Retencin de placenta 202
Hemorragia post parto 203
Cuidados del post parto imediato 207
Categoras A,B,C,D (recomendaciones OMS) 207
Asistencia durante el puerperio 210
Objetivos: Controlar bienestar de la mujer purpera. Detectar y evaluar desviaciones de los lmites
fisiolgicos. Evaluar riesgo y referir a nivel apropiado. Aplicar maniobras correctivas. 210
Actividad: Educacin de la mujer purpera. Controles clnicos de la mujer y su hijo.
Registro de los controles en la historia clnica perinatal. 210
Puerperio mediato 211
Puerperio alejado 212
Puerperio tardo 212
CAPITULO V
Atencin del Recin Nacido 215
Objetivos: Recibir al recin nacido y valorar el inicio de la primera respiracin espontnea. 216
Actividad: Observar si respira o no. Si no respira deducir si es por asfixia fetal o por depresin farmacolgica. 216
Objetivos: Proteger la adaptacin a la vida extrauterina en el recin nacido de pretrmino 222
Actividad: 1. Proveer cuidados inmediatos que faciliten la adaptacin, especialmente en los nacidos
pretrminos que presenten signos de inmadurez ventilatoria.
2. Desarrollar estrategias tendientes a evitar la prdida de calor, valorar el flujo bidireccional de 222
sangre desde la placenta a travs del cordn umbilical al feto, apoyar y mantener el inicio de
la respiracin, controlar el aporte de O2,
Esquema para el cuidado continuo del recin nacido pretrmino desde el primer minuto de vida 225
Objetivos: Identificar al recin nacido 226
Actividad: Facilitar que la madre lo identifique y cumplir los requisitos locales de identificacin al nacer. 226
Objetivos: Evaluar el crecimiento y el desarrollo fetal al nacer. 226
Actividad: Realizar antropometra y valorarla segn la edad gestacional y valorar las funciones de adaptacin 226
Antropometra neonatal 227
Objetivos: Adecuar el manejo inicial de los recin nacidos con defectos congnitos mayores 228
Actividad: Instaurar en forma precoz las medidas especficas para cada defecto 228
Objetivos: Detectar defectos y/o enfermedades congnitas asintomticas 230
Actividad: Deteccin sistmica en el perodo neonatal por mtodos de laboratorio clnico 230
Sfilis congnita 230
Toxoplasmosis congnita 233
HIV 233
Hepatitis B 234
Estreptococo del grupo B 235
Hipotiroidismo congnito 237
Anemia falciforme 238
Hiperbilirrubinemia neonatal no hemoltica 239
Dficit auditivo severo 241
Objetivos: Prevenir la oftalmia gonocccica 241
Actividad: Instilar antimicrobianos en las conjuntivas al nacer 241
Objetivos: Prevenir enfermedad hemorrgica del recin nacido 242
Actividad: Administrar vitamina K 242
Objetivos: Iniciar y mantener la lactancia materna exitosa 242
Actividad: 1 - No separar al recin nacido y su madre y facilitar el apoyo familiar 242
2 - Alimentar a libre demanda y no dar biberones 243
3 - Registrar la alimentacin al alta de la maternidad 243
Objetivos: Prevenir tuberculosis grave en el lactante 243
Actividad: Vacuna BCG al nacer 243
Objetivos: Prevenir la muerte sbita del lactante 243
Actividad: Colocar al recin nacido boca arriba para dormir 243
Objetivos: Disminuir los riesgos en los nacidos pretrmino de 35 y 36 semanas (pretrmino tardos) y los de
37 a 38 semanas (trmino precoces) 244
Actividad: Aumentar vigilancia en el perodo de adaptacin mientras permanecen en sala con sus madres 244
Referencias Bibliogrficas 248
CAPITULO VI
Atencin conjunta de la madre y el nio despus del nacimiento 249
Objetivos: Racionalizar los recursos y disminuir oportunidades perdidas
Controlar bienestar de la mujer purpera y del recin nacido 249
Detectar y evaluar desviaciones de los lmites fisiolgicos de ambos.
Actividad: Atencin conjunta de la madre y el recin nacido durante el puerperio
Educacin de la mujer purpera.
Controles clnicos de la mujer y su hijo.
249
Registro de los controles en la historia clnica perinatal.
Registros. 249
Soporte afectivo. 250
Controles de la madre y del recin nacido 251
CAPITULO VII
Planificacin familiar 255
Objetivos: Contribuir al ejercicio del derecho a planificar el embarazo 255
Actividad: Asesorar sobre los principales mtodos contraceptivos 255
Proceso de asesoramiento 255
Evaluacin de las usuarias antes de recomendarles un mtodo contraceptivo 256
Descripcin de los mtodos anticonceptivos 257
Mtodos reversibles 257
Mtodos comportamentales 257
Mtodo de la lactancia exclusiva (MELA) 258
Mtodos de barrera 258
Contracepcin de emergencia 261
Contraceptivos hormonales 262
Dispositivos intrauterinos 267
Criterios de elegibilidad para mtodos hormonales y dispositivos intra uterinos 269
Mtodos irreversibles 272
Ligadura tubaria 272
Ligadura de los deferentes (vasectoma) 274
CAPITULO VIII
Aborto 277
Objetivos: Reducir la morbimortalidad por aborto 277
Actividad: Diagnstico y asistencia del aborto en los distintos perodos 277
Definiciones 277
Prevalencia e incidencia 278
Aborto espontneo 279
Diagnstico clnico y etapas evolutivas del aborto 281
Diagnstico diferencial 283
Conducta 283
Mtodos de evacuacin 285
Evacuacin uterina 285
Cuidados post procedimiento 286
Aborto complicado 287
Complicaciones post evacuacin 287
Consejera /Informacin 288
Anticoncepcin por aborto 289
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ACT: Terapias Combinadas en base a Artemisina.

AIC: Anticonceptivos Inyectables Combinados.
AOC: Anticonceptivos Orales Combinados.
APS: Atencin Primaria de Salud.
ARA II: Antagonistas de los Receptores de la Angiotensina II.
ARV: Antirretrovricos.
AU: Altura Uterina.
AZT: Zidovudina.
BCG: Bacilo de Calmette - Guerin.
BhCG: Fraccin Beta de la hormona Gonadotropina Corinica.
BPN: Bajo peso al Nacer.
CDC: Centros para el Control de Enfermedades de los Estados Unidos.
CLAP/SMR: Centro Latinoamericano de Perinatologa / Salud de la Mujer y Reproductiva.
CIPD: Conferencia Internacional de Poblacin y Desarrollo.
CMV: Citomegalovirus.
CU: Contraccin Uterina.
D: Dimetro.
d: dimetro.
DBP: Dimetro Biparietal.
DFO: Dimetro Fronto Occipital.
DG: Diabetes Gestacional.
DIPs I: Cada de la FCF coincidente con la contraccin uterina.
DIPs Variables: Cadas de la FCF de probable origen umbilical, de duracin, amplitud y de comienzo
variables en relacin a la contraccin uterina.
DIPs II: Desaceleracin tarda de la FCF en relacin a la contraccin uterina.
DIU: Dispositivo Intrauterino.
DM: Diabetes Mellitus.
DPPNI: Desprendimiento Previo de Placenta Normoinserta.
ECLAMC: Estudio Colaborativo Latinoamericano de Malformaciones Congnitas.
EG: Edad Gestacional.
EGB: Estreptococo del Grupo B.
EP: Enfermedad Periodontal.
FPP: Fecha Probable de Parto.
FCF: Frecuencia Cardaca Fetal.
FTA- Abs: Prueba de deteccin de Anticuerpos especficos contra el Treponema pallidum, por
inmunofluorescencia.
FUM: Fecha de ltima Menstruacin.
GED: Enfoque de Gnero en el Desarrollo.
HAI: Hemoaglutinacin Indirecta.
Hb : Hemoglobina.
HC: Hipotiroidismo Congnito.
HCP: Historia Clnica Perinatal.
HCG: Hormona Corinica Gonadotrfica.
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: ndice de Masa Corporal.
ITR: Infecciones del Tracto Reproductivo.
ITS: Infecciones de Transmisin Sexual.

IV: Intravenoso.
LCR: Lquido Cfalo Raqudeo.
MAC: Mtodos Anticonceptivos.
MELA: Mtodo de Lactancia Exclusiva.
MHA TP: Prueba de deteccin de Anticuerpos especficos contra el Treponema pallidum por
Micro Hemaglutinacin.
NVP: Neviparina.
OMS: Organizacin Mundial de la Salud.
OPS: Organizacin Panamericana de la Salud.
PAP: Papanicolau, colpocitoploga oncolgica.
P. Abd.: Permetro Abdominal.
P. Cr.: Permetro Craneano.
PCR: Reaccin de la cadena de la polimerasa.
PEG: Pequeo para la Edad Gestacional.
P. falciparum: Plasmodio falciparum.
PG: Prostaglandinas.
PMB: Permetro Medio Braquial.
PO2: Presin parcial de Oxgeno.
PTOG: Prueba de Tolerancia a la Glucosa.
RCI: Restriccin del Crecimiento Intrauterino.
RCIU: Restriccin del Crecimiento Intrauterino.
RDTs: Test Rpidos Diagnsticos.
RPM: Rotura Prematura de Membranas.
RPP: Rapid Plasma reagin.
RR: Riesgo relativo.
SAF: Sndrome Alcohlico Fetal.
SIDA: Sndrome de la Inmunodeficiencia Adquirida.
SIP: Sistema Informtico Perinatal.
SDR: Sndrome de Dificultad Respiratoria.
SNC: Sistema Nervioso Central.
SRC: Sndrome de Rubola Congnita.
T. cruzi: Tripanosoma cruzi.
T4: Hormona tiroidea 4.
Td: Ttanos ms difteria.
TNN: Ttanos Neonatal.
T. pallidum: Treponema pallidum.
TP PA: Prueba de deteccin de Anticuerpos especficos contra el Treponema pallidum por
Aglutinacin.
TPI: Tratamiento Preventivo Intermitente.
TSH: Hormona Estimulante Tiroidea.
TT: Toxoide tetnico.
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: Va oral.
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Cuadro 3. Objetivos especficos y actividades propuestas para el control prenatal

Objetivos especficos Actividades propuestas
Confirmar el embarazo. Realizacin de exmenes clnicos y paraclnicos para

diagnosticar embarazo.
Mejorar la calidad del control prenatal. Utilizacin de algunas tecnologas apropiadas.
Obtener datos para planificar el control prenatal, la
Empleo del Sistema Informtico Perinatal.
atencin del parto, el puerperio y el recin nacido.
Contar con una hoja de ruta que gue al prestador
Uso de la Historia Clnica Perinatal.
para brindar una atencin prenatal de calidad.
Detectar riesgos en la poblacin Evaluacin del riesgo perinatal.
Conocer informacin relevante del embarazo Anamnesis
Fijar un cronograma que permita planificar las Determinacin de la edad gestacional y fecha probable
actividades del control prenatal. de parto.
Medicin del peso y de la talla materna. Clculo del
Evaluar el estado nutricional materno.
incremento de peso durante la gestacin.
Interrogatorio sobre tabaquismo (activo y pasivo),
Investigar estilos de vida de riesgo.
drogas, alcohol y violencia.
Disminuir el impacto negativo de las infecciones de Prevencin, deteccin y tratamiento de las infecciones
transmisin vertical. de transmisin vertical.
Prevenir el ttanos neonatal y puerperal Vacunacin antitetnica
Detectar posibles procesos spticos buco dentales Examen buco-dental.
Detectar posibles alteraciones del pezn, patologa
Examen de mamas.
inflamatoria y/o tumoral de la mama.
Descartar cncer de cuello, lesiones precursoras y Examen genital, colpocitologa oncolgica,
evaluar la competencia cervical. colposcopa.
Pesquisar una posible incompatibilidad sangunea
Determinacin del grupo sanguneo y el factor Rh.
materno-feto-neonatal.
Determinar niveles de hemoglobina y tratamiento con
Prevenir, detectar y tratar la anemia materna
hierro y cido flico
Descartar proteinuria, glucosuria y bacteriuria Examen de orina y urocultivo.
Determinacin de glucemia y prueba de tolerancia oral
Detectar diabetes mellitus y gestacional
a la glucosa.
Brindar contenidos educativo-informativos para el Preparacin para el parto, consejera para el
parto y la crianza. amamantamiento.
Confirmar la existencia de vida fetal. Pesquisar movimientos y Frecuencia Cardaca Fetal
Anticipar el diagnstico y prevenir el parto prematuro. Evaluacin del patrn de contractilidad uterina.
Medicin de la presin arterial, identificacin de
Pesquisar alteraciones de la presin arterial
edemas y proteinuria.
Evaluacin del crecimiento por medicin de la altura
Descartar alteraciones del crecimiento fetal.
uterina, ganancia de peso materno, ecografa.
Detectar precozmente el embarazo mltiple para
Diagnstico de nmero de fetos.
prevenir sus complicaciones.
Pesquisar presentaciones fetales anormales. Examen de la presentacin fetal.
Detectar posibles distocias plvicas. Evaluacin de la pelvis.
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Semanas de consultas
Antes de Entre las Entre las Entre las Entre las
Actividades Las 20 (*) 22 y 24 27 y 29 33 y 35 38 y 40
1 visita 2da visita 3 visita 4 visita 5 visita
Prueba de embarazo X
Clculo de la amenorrea X X X X X
Historia clnica perinatal y evaluacin de riesgo X X X X X
Examen clnico completo X
Peso corporal X X X X X
Talla X
Investigar estilos de vida de riesgo X X X
Detectar susceptibilidad a la Rubola X
Vacuna antitetnica (**) X X
Examen odontolgico X
Examen de mamas X
Ex. ginecolgico, PAP, colposcopa (***) X
Grupo sanguneo y factor Rh X
Detectar toxoplasmosis X X
Deteccin VIH X X
Determinacin de hemoglobina X X
Suplementacin con hierro y cido flico X X X X X
Deteccin Sfilis X X
Deteccin de Chagas X
Deteccin de Paludismo X
Cultivo de orina X X
Detectar diabetes X X
Detectar infeccin por Estreptococo B X
Contenidos educativos para el parto y la lactancia X X X X X
Determinacin de la presin arterial X X X X X
Evaluacin del crecimiento fetal. X X X X
Evaluacin del lquido amnitico X X X X
Diagnstico de vida fetal X X X X
Evaluacin de la capacidad pelviana X
Consejera y provisin de anticoncepcin X
(*) Las actividades programadas para la primer visita se debern hacer siempre, independientemente de la edad gestacional al
momento de la consulta
(**) Si se sospecha que la gestante no volver o porque as lo indica la norma nacional se podr vacunar antes de la semana 20
(***) Lo ms precozmente o segn norma nacional.
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DIAGNOSTICO
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3

CONDUCTA
- seguir cronograma habitual de consultas

- explicar a la gestante que su peso es

adecuado para la edad gestacional

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- dar orientacin nutricional
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3 El punto se sita por debajo del percentilo 25 de la
curva de referencia

DIAGNOSTICO

Gestante de riesgo, con peso insuficiente para la
$XPHQWRGHSHVR
edad gestacional (desnutricin)

3

CONDUCTA

- investigar la historia nutricional, hiperemesis
gravdica, infecciones, parasitosis, anemia,

enfermedades debilitantes.

- citar a consulta en un intervalo menor que lo

$PHQRUUHDVHPDQDV
fijado en el cronograma habitual.
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curva de referencia

DIAGNOSTICO
Gestante de riesgo, por presentar peso superior

al normal para esa edad gestacional; tanto mayor
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ser el riesgo cuanto ms elevado sea su

3 sobrepeso.

CONDUCTA

- determinar causas: obesidad, edema,
polihidramnios, macrosoma, embarazo mltiple

- 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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de referencia para la edad gestacional

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DIAGNOSTICO
3

Buen estado nutricional (ganancia adecuada de
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CONDUCTA

- seguir cronograma habitual de consultas

- dar orientacin nutricional que la gestante se
mantenga dentro de la faja de normalidad
$PHQRUUHDVHPDQDV
Trazado entre las curvas de percentil 25 y 90,

con inclinacin horizontal o descendente o
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3 trazado por abajo de la cuva del percentil 25, con
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DIAGNOSTICO
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Gestante de riesgo con referencia a su ganancia

3 adecuada de peso:

CONDUCTA
- Identificar causas: dficit nutricional, infecciones,
parasitosis, anemia, entre otras. Tratarlas cuando

esten presentes y dar orientacin nutricional

- referir a control prenatal de alto riesgo.

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trmino de la gestacin con una ganancia de peso
mnima de 8 kg.
Trazado por encima de la curva del percentil 90 de

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3
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 ser el riesgo
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3 CONDUCTA
- investigar posibles causas: obesidad, diabetes
y edema.

- si persiste, derivar a control de alto riesgo.
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Interpretacin Conducta
IgG IgM
No hay infeccin. Comunicar medidas de proteccin.
- - Existe riesgo de contraerla Eventual repeticin de IgG segn norma nacional
+ - Infeccin pasada Continuar control en forma habitual
Evaluar riesgo de infeccin fetal.

+ + Infeccin actual
Evaluar realizacin de tratamiento mdico
No se hizo No se hizo Comunicar medidas de proteccin
Riesgo desconocido
realizar tamizaje segn norma nacional
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Dosis carga: 100 mg/da oral,
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embarazo
Continua: 50 mg/da oral
Dosis carga: 75 mg/Kg/da oral,
divididos en 2 dosis, durante 2 das.
Infeccin fetal Hasta final del
Sulfadiazina Mximo 4 g/da.
confirmada (entre embarazo
Continua: 100 mg/Kg/da oral
las 12 y 18 emanas)
divididos en 2 dosis. Mximo 4 g/da.
Durante y hasta
una semana
Acido folnico 5 a 20 mg/da
despus de usar
la Pirimetamina.
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Madre Recin nacido

Primeras 24 horas
Puerperio inmediato Un nio saludable
Estado de conciencia, lcida y tranquila. No separe al recin nacido de su madre.
Facies, piel y mucosas, debern estar bien coloreadas Promueva que estn cerca fsicamente.
(excepto en anemia previa). Promueva la colocacin temprana del
Frecuencia del pulso en condiciones basales, (60 y 100 bebe al pecho si la madre lo desea.
Ipm) y lleno. Si es primpara, explquele que al principio
Presin arterial en rangos normales. no todas las madres se sienten con
Temperatura corporal, no deber superar los 37 C. En el fuerzas y deseo de cuidar a sus bebes [as
postalumbramiento, pueden observarse escalofros, que 24 horas del da y que eso va cambiando
son normales y raramente duran ms de 30 minutos. los primeros das.
Retraccin del tero (globo de seguridad de Pinard), en Acompae a la madre sugirindole como
estas horas, el fondo del tero no sobrepasa la cicatriz poner a su nio a mamar, sin tocar sus
umbilical y la consistencia es firme adquiriendo una senos y respetando su pudor natural.
consistencia leosa al ser estimulado. Es indoloro a la Informe de las ventajas de mantener la
palpacin y es comn el dolor cuando el nio es puesto al alimentacin al pecho exclusiva y que si
pecho (entuertos). tiene molestias al inicio de la lactada es
En caso de dolor, estarn indicados los analgsicos normal pero sern pasajeras.
comunes y los antiinflamatorios no esteroideo. No administre otra leche que no sea la de
En caso de sangrado vaginal abundante con el tero bien su propia madre sin la debida indicacin
contrado efectuar inspeccin minuciosa del canal del mdica y consentimiento de la madre.
parto para descartar lesiones (desgarros) en vagina y en No permita publicidad de frmulas de
cuello de tero. leche de vaca, ni que les entreguen
Describir los principales signos de alerta y vigilar con muestras gratis a las madres.
atencin aquellas condiciones Que pueden poner en Se alimenta y succiona bien.
riesgo la vida de la madre. (ver cuadro).
Animarla para Que comience a movilizarse. En las Descansa entre lactadas y se despierta
madres obesas considerar el riesgo de tromboembolismo para alimentarse. No est excesivamente
por reposo en cama. irritable.
Mujeres que no estn inmunizadas contra el ttanos o Tiene un color normal para su etnia
contra la rubola debern ser inmunizadas antes del aIta. (controlar cianosis o ictericia)
En las Rh negativas no inmunizadas con recin nacido Moviliza el intestino y orina varias veces
Rh positivos proceder a la inmediata administracin de la al dia (sus paales cada 3 horas estn
correspondiente dosis de gammaglobulina segn normas mojados).
locales. Frecuencia respiratoria entre 30 y 60
Orientar y facilitar el acceso a mtodos de planificacin respiraciones por minuto.
familiar. Frecuencia cardiaca entre 120 y 160
En ocasiones pueden aparecer hemorroides fluxivas que latidos por minuto.
mejoran parcialmente con hielo y cremas locales con Temperatura no mayor a los 37 (axilar o
anestsicos tpicos. inguinal).
La retencin urinaria es excepcional; se tratar con Mantenga al nio arropado hasta que
cateterismos vesicales intermitentes, Higiene perineal: logre el control trmico
Cada vez que la mujer requiera cambiar el apsito, se Mencione la administracin de Vitamina
debe higienizar la zona con agua limpia y jabn o un K que ya se realiz al recin nacido e
antisptico. El lavado se har por arrastre, siempre en indique la repeticin a los 7 das si fue
sentido antera posterior (de la vulva hacia el ano). Se administrada por va oral.
secar con un pao o gasas limpias. Seale que el cordn debe mantenerse
La ropa interior ser separada por un apsito (gasa- limpio y seco.
algodn-gasa) o por protectores nocturnos de los que
se consiguen en el mercado,
Los lavados intravaginales son desaconsejados.
En caso de episiotoma, los cuidados sern similares,
pero se insistir en mantener la zona seca el mayor
tiempo posible.
Cuidado de los pezones:
Deber exponer la areola y el pezn al sol entre diez y
quince minutos por da lubricarla exclusivamente con
calostro o leche materna.
Informacin al egreso.
Durante la internacin por el parto, la madre y la familia debern haber recibido informacin para el cuidado
postnatal y la proteccin de la salud de ella y su recin nacido. Al alta deber sealarse con precisin:
la forma en que ella puede mantener una comunicacin continua con los servicios
las nuevas necesidades de apoyo familiar y los recursos comunitarios a los que pueda acceder para
encontrar soporte en la funcin parental y
pautas que la guen para la consulta en caso que aparezcan elementos de alarma para la salud de ambos.
Es recomendable otorgar el alta a las 48 horas Recuerde a la madre de las ventajas de mantener
del parto, si no ha habido complicaciones y la alimentacin al pecho exclusiva. Informar acerca
siempre que la mujer est en condiciones de de importancia del vaciado peridico de las mamas,
administrar cuidados a su recin nacido. higiene de los pezones y corpio que sostenga y no
Cuando deba otorgarse el alta en forma apriete para la prevencin de problemas mamarios
precoz, debern garantizarse instancias de Recuerde la higiene de manos y el cuidado del cordn
seguimiento domiciliario. umbilical
De ser necesario, instrumentar sistemas de Prevencin del Sndrome de Muerte Sbita del
consulta telefnica con referentes de! centro Lactante: colocar al nio boca arriba para dormir,
de salud o de la comunidad. Recordar que las no abrigarlo en exceso, no fumar en el ambiente,
primeras 24 horas, suelen ser las de mayor desestimar el colecho
riesgo vital, tanto para la mujer, como para su Orientar para el reconocimiento de Signos de alarma.
recin nacido. Indicar las Inmunizaciones correspondientes al
momento del nacimiento y primer semana, segn
esquema
Verificar identificacin del nio y su madre.
Brindar orientacin para la inscripcin del nio en el
Registro Civil.
Indicar claramente fecha y lugar del primer control,
a los 7 das del alta (preferentemente coordinar la
contrarreferencia)
Valorar, previo, al alta condiciones de riesgo social
Orientar acerca de las pruebas de Pesquisa y
obtencin de los resultados
En muchos casos puede ser til la elaboracin y
entrega de folletos instructivos con los conocimientos
bsicos a transmitir al alta.
Primera consulta conjunta entre 7 y 10 das.
Puerperio mediato: Se extiende desde Verificar que moja los paales con frecuencia y
el segundo y hasta el 10 da del parto elimina meconio, que la succin es audible, vigorosa
Brindar informacin sobre higiene perineal o y sostenida y que la boca est hmeda.
cuidado de la cicatriz de cesrea. Examinar al beb sin incomodarlo procediendo a
Recurdele que la alimentacin exclusiva obtener la informacin que permita detectar nuevas
(da y noche) al pecho, sin dar ningn otro condiciones que puedan requerir tratamiento.
tipo de alimento a su bebe, tiene un efecto Investigar si tiene elementos de riesgo de displasia
anticonceptivo fugaz e impredecible y que aun de caderas. (asimetra de los miembros o pliegues
amamantando puede tener otras opciones en la regin anterior de muslo, Maniobras de Barlow
contraceptivas. y Ortolani)
)LJXUD )LJXUD
0DQLREUD 0DQLREUD
GH%DUORZ GH2UWRODQL
Signos vitales (temperatura, frecuencia cardiaca y presin No realizar doble pesada, ni siquiera es
arterial). necesario pesarlo todos los das.
Cualquier alteracin de los signos vitales, obligar a Ante la aparicin de ictericia valorar
la bsqueda del agente etiolgico y ante la presencia elementos de riesgo.
de dudas, deber ser enviada a un nivel de mayor Promover la higiene de manos, el uso de
complejidad, para continuar su atencin. alcohol gel.
Evaluacin de los loquios (cantidad, aspecto, composicin Informar sobre el riesgo de contagio de
y olor). Es difcil estimar la cantidad, por lo que se enfermedades virales respiratorias y las
recomienda ver si la madre tiene o no anemia. El color formas de evitarlas.
a esta altura del puerperio, debe ser rojo o rosado. El Si tiene indicado alimentacin por frmula,
color marrn, achocolatado har sospechar infeccin. explicar su forma de preparacin y el
Suelen adems de sangre, contener fragmentos tisulares cuidado e higiene de los implementos.
pequeos. El olor puede ser fuerte, en caso de fetidez, se Investigar cuales son los apoyos sociales
deber sospechar infeccin. con los que la madre o los padres cuentan.
Control de involucin uterina. La involucin es sumamente
rpida, aproximadamente a 2 centmetros por da y se
estima mediante palpacin del fondo uterino. A los 6
das de puerperio se situar entre el ombligo v el borde
superior del pubis. A los 10 das estar prximo al pubis.
En ocasiones se pueden ver hemorroides flexivas y
dolorosas, que no mejoran con tratamiento mdico,
en esos casos deber descartarse una trombosis
hemorroidal, la que se soluciona fcilmente con un
mnimo drenaje quirrgico con anestesia local.
Otras veces el dolor puede ser expresin de una fisura
anal, que suele revertir con tratamiento mdico. Luego de
unas semanas.
Es comn observar una incontinencia de orina que suele
remitir espontneamente en algunos das o semanas.
Bajada de la leche. En estos das se sustituye el calostro
por la leche definitiva.
Segunda visita conjunta entre los 15 y 30 das
Puerperio alejado: Abarca desde el Continuar vacunaciones segn esquema.
11 hasta el 42 da del postparto Insistir en la higiene de manos, el uso de
Reforzar la conserjera en anticoncepcin y espaciamiento Alcohol en gel y el riesgo de enfermedades
intergensico, intentando mantener la lactancia. virales respiratorias, si estn en ambiente
Controlar la evolucin de la lactancia. epidmico.
Contina la involucin uterina y el restablecimiento del Valorar el crecimiento y la alimentacin.
estado pregravdico. Tener en cuenta la posibilidad de
Investigar sntomas menores de depresin. Si persisten administrar hierro adicional y vitamina D.
las alteraciones depresivas ms all del da 14 deber Reiterar examen fsico,
consultar con un profesional. Reiterar informacin sobre el riesgo de
Prevenir la reinfeccin por enfermedades de transmisin muerte sbita.
sexual en especial si fueron detectadas y tratadas en esta
gestacin. Aconsejando que:
Prestar atencin a situaciones de desamparo y violencia El recin nacido duerma boca arriba, en
domstica. cuna, en el cuarto de la madre los primeros
A los 25 das del parto, puede advertirse un sangrado 6 meses.
vaginal escaso (pequeo retorno) que generalmente No prohibir el uso del chupete
se debe a una proliferacin endometrial normal que no Colocar al beb con los pies en contacto
requiere ningn estudio o tratamiento especial con la piesera de la cuna. (para evitar el
El reinicio de las relaciones sexuales es habitual ya que desplazamiento debajo de las mantas) I
desaparecen los Loquios Esto ocurre entre los 30 y los 40 Evite:
das del puerperio. el humo del tabaco en el hogar
En algunos casos, ste, ser el ultimo control entre la el colecho con los padres, que se duerman
mujer y el equipo de salud, por eso es recomendable con el beb en un silln (frecuente si
efectuar un examen clnico general y ginecolgico. existe consumo de bebidas alcohlicas,
Analizar con los padres los planes de reinicio de las toman psicofrmacos o tienen cansancio
actividades laborales o educativas, verificando la extremo).
proteccin de sus derechos en la nueva situacin de vestir al nio con ropas abotonadas por
maternidad. delante
Cuadro 47 PROBLEMAS COMUNES EN LAS MADRES

SIGNOS y SINTOMAS ACCIONES
Depresin puerperal. Si persisten los sntomas ms de 14 das consultar
Dolor perineal, olor de los Evaluar infeccin o cicatrizacin defectuosa de la episiotoma. Recomendar
exudados vaginales, dolor en fro local, analgsicos 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 Lquidos analgsicos y reposo sin almohada
epidural o raqudea
Fatiga persistente Investigar otros sntomas en especial anemia. Sealar la necesidad de
alimentacin y aporte de hierro y ejercicio
Dolor de espalda Tratar como en la poblacin general
Constipacin Recomiende dieta con fibras y Lquidos. Puede usarse un laxante suave
Hemorroides Si son severas, edematizadas o prolapsadas, referir.
Incontinencia fecal Evaluar severidad, duracin y Frecuencia, Si persiste> 1mes referir
Incontinencia urinaria Ensee ejercicios de piso plvico. Si persiste referir.
Retencin 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 antimicticos tpicos
Eritema del paal Recomendar cambio ms frecuente de los paales. De ser muy molesto
persistente usar antimicticos
No expulsin de meconio en Consulta de EMERGENCIA
las primeras 24hs
Constipacin en no alimentado Consulta
al pecho
Diarrea Aumentar frecuencia de las lactadas. Si est alimentado por frmulas
verificar higiene de la preparacin y consulta de urgencia
llanto inconsolable Consulta de urgencia
Clicos Aconsejar que alcen y sostengan al beb mientras llora y que busquen
apoyo de otros padres si se sienten desbordados.
Cuadro 49 PROBLEMAS AL AMAMANTAR

SIGNOS Y SINTOMAS ACCIONES
Pezones dolorosos o Considere la posibilidad de que tengan infeccin por cndida
agrietados
Senos ingurgitados. Mastitis Aconseje lactancia a demanda, masajes de los senos, ordee manual,
analgesia. Si persiste por horas consultar y si hay elementos claros de
infeccin considerar ATB.
Pezones invertidos I Brindar ms apoyo, tranquilizando a la madre.
5HIHUHQFLD%LEOLRJUiFD
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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Combinados
Vasectoma
Situacin Especfica Barrera
DIU
Examen mamario por proveedor C C C C C n/a

Examen plvico/genital C C A C C A
Tamizaje con PAP C C C C C n/a
Hemoglobina C C B C B C
Exmenes de rutina C C C C C C
Valoracin de riesgo para ITS C C A C** C C
Tamizaje para ITS/VIH C C B C** C C
Medicin de la presin arterial * * C C A C***
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postparto. de la histerorrafia.
placenta. postparto signos de infeccin.
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Combinados Solo progesterona DIU

Condicin
inyectables
implantes
vaginales
parches
orales
orales
intra-
LNG
Cu
CARACTERSTICAS PERSONALES E HISTORIA REPRODUCTIVA
Edad
Desde la menarca hasta los 19 aos
20 a 44
45 y ms aos
Paridad
Nulpara
1 o ms 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
2 trimestre
Inmediatamente despus de aborto sptico
Antecedente de embarazo ectpico
Historia de ciruga plvica
Fumar
Edad < 35 aos
Edad > 35 aos
< 15 cigarrillos/da
> 15 cigarrillos/da
Obesidad
> 30 Kg/m2 del ndice de masa corporal (IMC)
ENFERMEDADES CARDIOVASCULARES
Factores mltiples de riesgo para enfermedad
arterial cardiovascular (diabetes, HTA, etc.).
Hipertensin
Mujer con historia de HTA que no la controla
Mujer con historia de HTA que la controla
adecuadamente
P.A. sistlica de 140 a 159 y diastlica de 90 a 99
mm Hg
P.A. sistlica >160 y diastlica > 100 mm Hg
Enfermedad vascular
Trombosis venosa profunda (TVP) y embolia

pulmonar (EP)
Historia de TVP/EP
TVP/EP actual
Historia familiar de TVP/EP (parientes de primer grado)
Ciruga mayor con inmovilizacin prolongada
Ciruga mayor sin inmovilizacin prolongada
Ciruga menor sin inmovilizacin
Trombosis venosa superficial
Venas varicosas
Tromboflebitis superficial
Cardiopata isqumica antecedentes personales
o enfermedad actual
Accidente cerebro vascular
Hiperlipidemias conocidas
Valvulopatas
No complicadas
Complicadas
ALTERACIONES NEUROLGICAS
Cefaleas
No migraosas
Migraosas
Sin sntomas neurolgicos focales
Edad < 35 aos
Edad > 35 aos
Con sntomas neurolgicos focales
Epilepsia
INFECCIONES Y ENFERMEDADES DEL TRACTO REPRODUCTIVO
Patrones de sangrado vaginal
Patrn irregular sin sangrado intenso
Patrones regulares e irregulares con sangrado intenso
Sangrado vaginal sin explicacin
Endometriosis
Tumores benignos de ovario
Dismenorrea severa
Enfermedad trofoblstica gestacional
Benigna
Maligna
Ectropion cervical
Neoplasia intraepitelial cervical
Cncer cervical (esperando tratamiento)
Enfermedades de la mama
Tumor sin diagnstico anatomopatolgico
Enfermedad benigna
Historia familiar de cncer de mama
Cncer actual
Cncer con 5 aos sin evidencias de enfermedad
Cncer de endometrio
Cncer ovrico
Miomas uterinos
Sin distorsin de la cavidad
Con distorsin de la cavidad
Enfermedad inflamatoria plvica (EIP)
Pasada y sin riesgo actual de ITS
Con embarazo posterior
Sin embarazo posterior
Actual o en los ltimos 3 meses
ITS
Actual o en los ltimos 3 meses
Vaginitis sin cervicitis purulenta
Riesgo aumentado de ITS
VIH/SIDA
Alto riesgo de VIH
VIH Positivo
SIDA
OTRAS INFECCIONES
Tuberculosis
Malaria
ALTERACIONES ENDCRINAS
Diabetes
Diabetes gestacional
Diabetes no vascular
No insulino dependiente
Insulino dependiente
Nefropata/retinopata/neuropata
Otra enfermedad vascular o diabetes de ms de 20
aos de evolucin
Tiroides
Bocio simple
Hipertiroidismo
Hipotiroidismo
ALTERACIONES GASTROINTESTINALES
Enfermedad de la vescula biliar
Sintomtica
Tratada con colecistectoma
Tratada mdicamente
Actual
Asintomtica
Historia de colestasis
Relacionada con un embarazo
Relacionada con contraceptivos
Hepatitis viral
Activa
Portador
Cirrosis
Leve (compensada)
Severa (descompensada)
Tumores de hgado
Benigno (adenoma)
Maligno (hematoma)
ANEMIAS
Talasemia
Drepanoctica
Ferropnica
INTERACCIN CON DROGAS
Drogas que afectan la funcin del hgado
Algunos antibiticos (rifampicina, griseofulvina, etc.).
Otros antibiticos
Algunos anticonvulsivantes (fenitoina,
carbamazepina, barbitricos, etc.).
Use el mtodo en cualquier circunstancia

Use generalmente el mtodo
No se recomienda el mtodo a menos que no se disponga o no se acepten otros
No usar el mtodo
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C Cuidado
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El procedimiento debe retrasarse hasta que la condicin sea evaluada y/o corregida.
Deben proveerse mtodos temporales alternativos de contracepcin
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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 mdico
de respaldo. Para estas condiciones tambin se necesita la capacidad de decidir sobre
el procedimiento ms apropiado y el rgimen de anestesia. Se deben ofrecer mtodos
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Condiciones que deben Condiciones que requieren

retrasar el procedimiento (R) consideraciones especiales (E)
Embarazo Enfermedad trofoblstica Rotura o perforacin de tero
gestacional maligna
Postparto de 7 a 41 das Cncer cervical, ovrico o de Presin arterial > 160/100
endometrio mmHg.
Pre-eclampsia severa/eclapmsia Enf. Inflamatoria Plvica actual o Enfermedad vascular
en los ltimos tres meses
Rotura prolongada de ITS actual Endometriosis
membranas
Spsis o fiebre intraparto, Enf. de vescula biliar actual TBC pelviana
puerperal o postaborto
Hemorragia severa antes o Hepatitis viral activa Diabetes con nefropata,
despus del parto o del aborto retinopata y/o neuropata
Trauma severo del tracto genital Hb < 7 g/dL Cirrosis severa
postparto o postaborto (desgarro (descompensada)
cervical o vaginal)
Hematometra aguda Infeccin de pared abdominal Hipertiroidismo
Trombosis Venosa Profunda o Enfermedades respiratorias Alteraciones de la coagulacin
Trombo Embolismo Pulmonar agudas
actual
Ciruga mayor con inmovilizacin Infeccin sistmica Enfermedades respiratorias
prolongada crnicas
Cardiopata isqumica actual Utero fijo
Sangrado vaginal sin explicacin Hernia de la pared abdominal o
umbilical
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Condiciones que deben Condiciones que requieren consideraciones

retrasar el procedimiento (R) especiales (E)
Infecciones locales Hernia inguinal
(escrotal, orquitis, epididimitis, balanitis)
ITS activa Alteraciones de la coagulacin
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Filariasis, elefantiasis
Tumor intraescrotal
Referencias Bibliogrficas
Cheng L, Glmezoglu 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
Litt IF. Placing emergency contraception in the hands of women. JAMA. 2005 Jan 5;293(1):98-99.
Ministerio de Salud Pblica. Guas en Salud Sexual y Reproductiva. Captulo Anticoncepcin

(Mtodos 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
(ltimo 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
Prine L. Emergency contraception, myths and facts. Obstet Gynecol Clin North Am. 2007 Mar; 34(1):127-
36, 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
WHO 2005. Emergency contraception. www.who.int/entity/mediacentre/factsheets/fs244/en/

(ltimo acceso 20 de Julio de 2007)
WHO 2004. Medical Eligibility Criteria for Contraceptive Use. 3rd ed. 2004. http://www.who.int/reproductive-
health/publications/mec/index.htm (ltimo 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 (ltimo acceso 20 de Julio de 2007).
WHO 2007. Family Planning A global handbook for providers. 1st ed. 2007. http://www.who.int/reproductive-
health/publications/fp_globalhandbook/index.htm (ltimo 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
(limo 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 (ltimo acceso 20 de Julio de 2007).
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 (ltimo acceso 20 de Julio de 2007).
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Grfico realizado en base a los datos obtenidos del estudio de la WHO; Unsafe abortion: Global and regional
estimates of the incidence of unsafe abortion and associated mortality in 2000. Fourth edition, Geneva, 2004.
NOTA: En las regiones de Amrica del Norte y Europa Occidental las estimaciones resultan insignificantes.
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ECTPICO Tamao del tero < a la amenorrea.
Pseudosaco gestacional.
Tumoracin parauterina.
Sangrado rojo, a veces con vesculas. tero: imagen tpica con vesculas.
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3a Edicin
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3a Edicin

CLAP/SMR Publicacin Cientfica N 1577 - 2011

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Factores que pueden modificar los valores de tensin arterial 125

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