3a Edición

CLAP/SMR Publicación Científica Nº 1577 - 2011

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PROLOGO 9
GLOSARIO 10
CAPITULO I
Renovación de la Atención Primaria de la Salud en las Américas 12
Contínuo de atención 13
Enfoque de Salud Familiar y Comunitaria 13
Valores, Principios y Elementos de un Sistema de Salud Basado en la APS 13
Referencias bibliográficas 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
Reducción de la morbimortalidad materna y feto neonatal 20
Defectos congénitos 20
Historia Clínica 20
Antecedentes reproductivos 22
Antecedentes generales 25
Enfermedades médicas no transmisibles 25
Enfermedades médicas transmisibles 29
Estilos de vida 31
Consumo de medicamentos 34
Vacunas 36
Referencias bibliográficas 37
CAPITULO III
Control Prenatal, Vigilancia Durante la Gestación,
39
Evaluación del Riesgo Concepcional y Conductas
Objetivos y Actividades propuestas 40
Cronología de las actividades para las consultas prenatales de bajo riesgo 42
Objetivos: Confirmar embarazo 43
Actividad: Realización de exámenes clínicos y paraclínicos para diagnosticar embarazo 43
Objetivos: Mejorar la calidad del control prenatal 44
Actividad: Utilización de algunas tecnologías apropiadas 44
Gestograma 44
Cinta obstétrica 45
Tarjeta de Altura Uterina y Peso Materno 46
Objetivos: Obtener datos para planificar el control prenatal, la atención del parto, el puerperio y el recién nacido 47
Actividad: Empleo del Sistema Informático Perinatal 47
Historia Clínica 47
Partograma 47
Carné Perinatal 47
Procesamiento de datos 57
Objetivos: Contar con una hoja de ruta que guíe al prestador para brindar una atención prenatal de calidad 58
Actividad: Uso de la Historia Clínica Perinatal del CLAP/SMR 58

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Objetivos: Detectar riesgos en la población 59

Actividad: Evaluación del riesgo perinatal 59
Objetivos: Conocer información relevante del embarazo 60
Actividad: Anamnesis 60
Objetivos: Fijar un cronograma que permita planificar las actividades del control prenatal 63
Actividad: Determinación de la edad gestacional y de la fecha probable de parto 63
Amenorrea 63
Evaluación del tamaño uterino 63
Antropometría fetal por ecografía 64
Madurez placentaria 66
Objetivos: Evaluar el estado nutricional materno 66
Actividad: Medición del peso y de la talla materna. Cálculo del incremento de peso durante la gestación. 66
Técnica de medición 67
Ganancia de peso 67
Interpretación de la medida a la primera consulta 68
Interpretación de la secuencia de medidas en consultas subsecuentes 69
Relación peso para la talla según edad gestacional 70
Evaluación 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 tétanos neonatal y puerperal 76
Actividad: Vacunación antitetánica 76
Objetivos: Disminuir el impacto negativo de las infecciones de transmisión vertical 78
Actividad: Prevención, detección y tratamiento de las infecciones de transmisión vertical 78
Rubeola congénita 78
Toxoplasmosis congénita 79
Hepatitis B 81
VIH/SIDA 82
Objetivos: Prevenir sífilis 83
Actividad: Tamizaje y tratamiento 83
Objetivos: Prevenir las consecuencias materno-perinatales de otras infecciones de transmisión sexual ITS y 88
otras infecciones del tracto reproductivo ITR
Actividad: Prevención, detección y tratamiento 88
Flujo (leucorrea), 88
Moniliasis vulvovaginal, vaginosis bacteriana, tricomoniasis, gonococcia, 89
Clamidiasis, herpes simple 90
Objetivos: Prevenir la transmisión vertical de la enfermedad de Chagas 90
Actividad: Prevención, detección y tratamiento 90
Objetivos: Reducir la morbimortalidad materna y prevenir la transmisión vertical del Paludismo o Malaria 92
Actividad: Prevención, detección y tratamiento 92

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Diagnóstico de malaria 92
Malaria y embarazo 92
Prevención de la malaria durante el embarazo 93
Tratamiento en mujeres embarazadas 93
Objetivos: Reducir la morbimortalidad neonatal por estreptococo grupo% 95
Actividad: Prevención, detección y tratamiento 95
Objetivos: Detectar posibles procesos sépticos buco-dentales 
Actividad: Examen buco-dental 97
Objetivos: Detectar posibles alteraciones del pezón, patología inflamatoria 
Actividad: Examen de las mamas 98
Objetivos: Descartar cáncer de cuello, lesiones precursoras y evaluar la competencia cervical 98
Actividad: Examen genital, colpocitología, colposcopía 98
Cáncer cervical 98
Incompetencia cervical 103
Objetivos: Pesquisar una posible incompatibilidad sanguínea materno-feto-neonatal 104
Actividad: Determinación del grupo sanguíneo, del factor Rh y de anticuerpos irregulares 104
Objetivos: Prevenir, detectar y tratar la anemia materna 106
Actividad: Determinar niveles de hemoglobina. Administración de hierro y ácido fólico 106
Prevención de la anemia 107
Prevención 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
Infección urinaria y bacteriuria asintomática 109
Objetivos: Descartar diabetes mellitus clínica y gestacional 111
Actividad: Determinación 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
Clasificación de los estados diabéticos en el embarazo 113
Objetivos: Brindar contenidos educativo-informativos para el parto y la crianza 114
Actividad: Preparación para el parto, consejería para el amamantamiento 114
Objetivos: Confirmar la existencia de vida fetal 116
Actividad: Pesquisar movimientos y frecuencia cadíaca fetal 116
Movimientos fetales 116
Actividad cardíaca fetal 117
Estetoscopio obstétrico 118
Objetivos: Anticipar el diagnóstico y prevenir el parto prematuro 119
Actividad: Evaluar el patrón de la contractilidad uterina (frecuencia, duración e intensidad) 119
Retrasar el parto de pretérmino. Inducir la maduración pulmonar fetal.
Diagnóstico 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 maduración pulmonar 123
Objetivos: Pesquisar alteraciones de la presión arterial: Hipertensión previa al embarazo. 125
El síndr. de hipertensión inducida por el embarazo (pre-eclampsia). Hipotensión arterial
Actividad: Determinación de la presión arterial, identificación de edemas y proteinuria. 125

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Factores que pueden modificar los valores de tensión arterial 125

Técnica de medida, 125
Modificaciones fisiológicas durante el parto 126
Clasificación de estados hipertensivos en el embarazo, 126
Factores de riesgo de hipertensión gestacional y pre-eclámpsia, Prevención 127
Conductas recomendadas 127
Objetivos: Descartar alteraciones del crecimiento fetal 130
Actividad: Evaluación del crecimiento fetal por medio de la altura uterina, ganancia de peso y ecografía. 130
Restricción del crecimiento intrauterino 130
Macrosomía fetal 131
Tecnologías para medir el crecimiento fetal 131
Ejemplos de la evaluación de la relación Altura Uterina/Edad Gastacional a la primera consulta 133
Ejemplos de la evaluación de la tendencia de la relación AU/EG en consultas subsecuentes 134
Objetivos: Detectar precozmente el embarazo múltiple para prevenir sus complicaciones 138
Actividad: Diagnóstico del número de fetos 138
Objetivos: Pesquisar las presentaciones fetales anormales 140
Actividad: Diagnóstico de presentación fetal 140
Presentación pelviana o podálica 140
Situación transversa 140
Objetivos: Detectar posibles distocias pélvicas para definir el nivel de atención del parto 142
Actividad: Examen gineco-obstétrico. Evaluación de la pelvis. 142
Referencias bibliográficas 144
CAPITULO IV
Atención 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 recepción 154
Interrogatorio 155
Examen clínico general 156
Examen obstétrico 158
Auscultación de la FCF 159
Patron de contractilidad uterina 161
Examen genital 163
Dilatación, borramiento y posición del cuello 164
Pérdida de secreciones por los genitales 164
Evaluación de la presentación 167
Valoración de la proporción feto-pélvica y la capacidad de la pelvis materna 170
Preparación de la embarazada en la recepción 172
Asistencia durante el período de dilatación (primer período) 173
Objetivos: Controlar bienestar materno y fetal. Detectar y evaluar desviaciones de los límites fisiológicos 173
(progreso del parto). Evaluar riesgo y referir a nivel apropiado. Aplicar maniobras correctivas
Actividad: Información a la embarazada. Controles maternos. Controles obstétricos 173
Registro de los controles en el partograma con curvas de alerta.
Acompañamiento a la madre durante el parto 173
Controles maternos 174
Controles obstétricos 175
Progreso de la dilatación y descenso de la presentación 177

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Partograma con curvas de alerta 178

Trabajo de parto prolongado 183
Asistencia durante el período expulsivo (segundo período) 185
Objetivos: Detectar y evaluar desviaciones de los límites fisiológicos del período expulsivo.
Prevenir traumatismo obstétrico. Prevenir hipoxia fetal. 185
Actividad: Control de la FCF. Control de la contractilidad.
Control del avance de la presentación y desprendimiento 185
Posición de la parturienta 186
Controles a realizarse durante el período expulsivo 186
Amniotomía 187
Protección perineal 187
Avance de la presentación y desprendimiento 188
Situaciones especiales 189
Distocia de hombro 189
Atención del parto en podálica 190
Atención del recién nacido en sala de partos 193
Recomendaciones sobre uso de medicación en parto de bajo riesgo 194
Asistencia durante el alumbramiento y posalumbramiento (tercer período) 198
Objetivos: Detectar y evaluar desviaciones de los límites fisiológicos 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 episiotomía 199
Prevención para evitar la retención de restos ovulares 199
Prevención de la hemorragia post parto (HPP). 199
Tracción del cordón. 200
Masaje y compresión uterina 200
Postalumbramiento 201
Retención de placenta 202
Hemorragia post parto 203
Cuidados del post parto imediato 207
Categorías A,B,C,D (recomendaciones OMS) 207
Asistencia durante el puerperio 210
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. 210
Actividad: Educación de la mujer puérpera. Controles clínicos de la mujer y su hijo.
Registro de los controles en la historia clínica perinatal. 210
Puerperio mediato 211
Puerperio alejado 212
Puerperio tardío 212
Referencias bibliográficas 213
CAPITULO V
Atención del Recién Nacido 215
Objetivos: Recibir al recién nacido y valorar el inicio de la primera respiración espontánea. 216
Actividad: Observar si respira o no. Si no respira deducir si es por asfixia fetal o por depresión farmacológica. 216
Objetivos: Proteger la adaptación a la vida extrauterina en el recién nacido de pretérmino 222

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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 222
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 225
Objetivos: Identificar al recién nacido 226
Actividad: Facilitar que la madre lo identifique y cumplir los requisitos locales de identificación al nacer. 226
Objetivos: Evaluar el crecimiento y el desarrollo fetal al nacer. 226
Actividad: Realizar antropometría y valorarla según la edad gestacional y valorar las funciones de adaptación 226
Antropometría neonatal 227
Objetivos: Adecuar el manejo inicial de los recién nacidos con defectos congénitos mayores 228
Actividad: Instaurar en forma precoz las medidas específicas para cada defecto 228
Objetivos: Detectar defectos y/o enfermedades congénitas asintomáticas 230
Actividad: Detección sistémica en el período neonatal por métodos de laboratorio clínico 230
Sífilis congénita 230
Toxoplasmosis congénita 233
HIV 233
Hepatitis B 234
Estreptococo del grupo B 235
Hipotiroidismo congénito 237
Anemia falciforme 238
Hiperbilirrubinemia neonatal no hemolítica 239
Déficit auditivo severo 241
Objetivos: Prevenir la oftalmia gonocóccica 241
Actividad: Instilar antimicrobianos en las conjuntivas al nacer 241
Objetivos: Prevenir enfermedad hemorrágica del recién nacido 242
Actividad: Administrar vitamina K 242
Objetivos: Iniciar y mantener la lactancia materna exitosa 242
Actividad: 1 - No separar al recién nacido y su madre y facilitar el apoyo familiar 242
2 - Alimentar a libre demanda y no dar biberones 243
3 - Registrar la alimentación al alta de la maternidad 243
Objetivos: Prevenir tuberculosis grave en el lactante 243
Actividad: Vacuna BCG al nacer 243
Objetivos: Prevenir la muerte súbita del lactante 243
Actividad: Colocar al recién nacido boca arriba para dormir 243
Objetivos: Disminuir los riesgos en los nacidos pretérmino de 35 y 36 semanas (pretérmino tardíos) y los de
37 a 38 semanas (término precoces) 244
Actividad: Aumentar vigilancia en el período de adaptación mientras permanecen en sala con sus madres 244
Referencias Bibliográficas 248
CAPITULO VI
Atención conjunta de la madre y el niño después del nacimiento 249
Objetivos: Racionalizar los recursos y disminuir oportunidades perdidas
Controlar bienestar de la mujer puérpera y del recién nacido 249
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.
249
Registro de los controles en la historia clínica perinatal.

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Registros. 249
Soporte afectivo. 250
Controles de la madre y del recién nacido 251
Referencias Bibliográficas 254
CAPITULO VII
Planificación familiar 255
Objetivos: Contribuir al ejercicio del derecho a planificar el embarazo 255
Actividad: Asesorar sobre los principales métodos contraceptivos 255
Proceso de asesoramiento 255
Evaluación de las usuarias antes de recomendarles un método contraceptivo 256
Descripción de los métodos anticonceptivos 257
Métodos reversibles 257
Métodos comportamentales 257
Método de la lactancia exclusiva (MELA) 258
Métodos de barrera 258
Contracepción de emergencia 261
Contraceptivos hormonales 262
Dispositivos intrauterinos 267
Criterios de elegibilidad para métodos hormonales y dispositivos intra uterinos 269
Métodos irreversibles 272
Ligadura tubaria 272
Ligadura de los deferentes (vasectomía) 274
Referencias Bibliográficas 276
CAPITULO VIII
Aborto 277
Objetivos: Reducir la morbimortalidad por aborto 277
Actividad: Diagnóstico y asistencia del aborto en los distintos períodos 277
Definiciones 277
Prevalencia e incidencia 278
Aborto espontáneo 279
Diagnóstico clínico y etapas evolutivas del aborto 281
Diagnóstico diferencial 283
Conducta 283
Métodos de evacuación 285
Evacuación uterina 285
Cuidados post procedimiento 286
Aborto complicado 287
Complicaciones post evacuación 287
Consejería /Información 288
Anticoncepción por aborto 289
Referencias Bibliográficas 290

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ACT: Terapias Combinadas en base a Artemisina.

AIC: Anticonceptivos Inyectables Combinados.
AOC: Anticonceptivos Orales Combinados.
APS: Atención Primaria de Salud.
ARA II: Antagonistas de los Receptores de la Angiotensina II.
ARV: Antirretrovíricos.
AU: Altura Uterina.
AZT: Zidovudina.
BCG: Bacilo de Calmette - Guerin.
BhCG: Fracción Beta de la hormona Gonadotropina Coriónica.
BPN: Bajo peso al Nacer.
CDC: Centros para el Control de Enfermedades de los Estados Unidos.
CLAP/SMR: Centro Latinoamericano de Perinatología / Salud de la Mujer y Reproductiva.
CIPD: Conferencia Internacional de Población y Desarrollo.
CMV: Citomegalovirus.
CU: Contracción Uterina.
D: Diámetro.
d: diámetro.
DBP: Diámetro Biparietal.
DFO: Diámetro Fronto Occipital.
DG: Diabetes Gestacional.
DIPs I: Caída de la FCF coincidente con la contracción uterina.
DIPs Variables: Caídas de la FCF de probable origen umbilical, de duración, amplitud y de comienzo
variables en relación a la contracción uterina.
DIPs II: Desaceleración tardía de la FCF en relación a la contracción uterina.
DIU: Dispositivo Intrauterino.
DM: Diabetes Mellitus.
DPPNI: Desprendimiento Previo de Placenta Normoinserta.
ECLAMC: Estudio Colaborativo Latinoamericano de Malformaciones Congénitas.
EG: Edad Gestacional.
EGB: Estreptococo del Grupo B.
EP: Enfermedad Periodontal.
FPP: Fecha Probable de Parto.
FCF: Frecuencia Cardíaca Fetal.
FTA- Abs: Prueba de detección de Anticuerpos específicos contra el Treponema pallidum, por
inmunofluorescencia.
FUM: Fecha de Última Menstruación.
GED: Enfoque de Género en el Desarrollo.
HAI: Hemoaglutinación Indirecta.
Hb : Hemoglobina.
HC: Hipotiroidismo Congénito.
HCP: Historia Clínica Perinatal.
HCG: Hormona Coriónica Gonadotrófica.
IC: Incompetencia Cervical.
IFI: Inmunofluorescencia Indirecta.
Ig G: Inmunoglobulina G.
Ig M: Inmunoglobulina M.
IECAs: Inhibidores de la Enzima conversora de la Angiotensina II.
IM: Intramuscular.
IMC: Índice de Masa Corporal.
ITR: Infecciones del Tracto Reproductivo.
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ITS: Infecciones de Transmisión Sexual.

IV: Intravenoso.
LCR: Líquido Céfalo Raquídeo.
MAC: Métodos Anticonceptivos.
MELA: Método de Lactancia Exclusiva.
MHA – TP: Prueba de detección de Anticuerpos específicos contra el Treponema pallidum por
Micro – Hemaglutinación.
NVP: Neviparina.
OMS: Organización Mundial de la Salud.
OPS: Organización Panamericana de la Salud.
PAP: Papanicolau, colpocitoplogía oncológica.
P. Abd.: Perímetro Abdominal.
P. Cr.: Perímetro Craneano.
PCR: Reacción de la cadena de la polimerasa.
PEG: Pequeño para la Edad Gestacional.
P. falciparum: Plasmodio falciparum.
PG: Prostaglandinas.
PMB: Perímetro Medio Braquial.
PO2: Presión parcial de Oxígeno.
PTOG: Prueba de Tolerancia a la Glucosa.
RCI: Restricción del Crecimiento Intrauterino.
RCIU: Restricción del Crecimiento Intrauterino.
RDTs: Test Rápidos Diagnósticos.
RPM: Rotura Prematura de Membranas.
RPP: Rapid Plasma reagin.
RR: Riesgo relativo.
SAF: Síndrome Alcohólico Fetal.
SIDA: Síndrome de la Inmunodeficiencia Adquirida.
SIP: Sistema Informático Perinatal.
SDR: Síndrome de Dificultad Respiratoria.
SNC: Sistema Nervioso Central.
SRC: Síndrome de Rubéola Congénita.
T. cruzi: Tripanosoma cruzi.
T4: Hormona tiroidea 4.
Td: Tétanos más difteria.
TNN: Tétanos Neonatal.
T. pallidum: Treponema pallidum.
TP – PA: Prueba de detección de Anticuerpos específicos contra el Treponema pallidum por
Aglutinación.
TPI: Tratamiento Preventivo Intermitente.
TSH: Hormona Estimulante Tiroidea.
TT: Toxoide tetánico.
TBC: Tuberculosis.
UCIN: Unidad de Cuidado Intensivo Neonatal.
UNAIDS: (ONUSIDA), Programa conjunto de las Naciones Unidas sobre el VIH/SIDA.
UNGASS: United Nations General Assambly on AIDS Special Session.
UNICEF: Fondo de las Naciones Unidas para la Infancia.
USR: Unheated Serum Reagin.
VPH: Virus Papiloma Humano.
VDRL: Venereal Disease Research Laboratory.
VIH: Virus de la Inmunodeficiencia Humana.
V/O: Vía oral.

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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
Empleo del Sistema Informático Perinatal.
atención del parto, el puerperio y el recién nacido.
Contar con una hoja de ruta que guíe al prestador
Uso de la Historia Clínica Perinatal.
para brindar una atención prenatal de calidad.
Detectar riesgos en la población Evaluación del riesgo perinatal.
Conocer información relevante del embarazo Anamnesis
Fijar un cronograma que permita planificar las Determinación de la edad gestacional y fecha probable
actividades del control prenatal. de parto.
Medición del peso y de la talla materna. Cálculo del
Evaluar el estado nutricional materno.
incremento de peso durante la gestación.
Interrogatorio sobre tabaquismo (activo y pasivo),
Investigar estilos de vida de riesgo.
drogas, alcohol y violencia.
Disminuir el impacto negativo de las infecciones de Prevención, detección y tratamiento de las infecciones
transmisión vertical. 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
Examen de mamas.
inflamatoria y/o tumoral de la mama.
Descartar cáncer de cuello, lesiones precursoras y Examen genital, colpocitología oncológica,
evaluar la competencia cervical. colposcopía.
Pesquisar una posible incompatibilidad sanguínea
Determinación del grupo sanguíneo y el factor Rh.
materno-feto-neonatal.
Determinar niveles de hemoglobina y tratamiento con
Prevenir, detectar y tratar la anemia materna
hierro y ácido fólico
Descartar proteinuria, glucosuria y bacteriuria Examen de orina y urocultivo.
Determinación de glucemia y prueba de tolerancia oral
Detectar diabetes mellitus y gestacional
a la glucosa.
Brindar contenidos educativo-informativos para el Preparación para el parto, consejería para el
parto y la crianza. 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.
Medición de la presión arterial, identificación de
Pesquisar alteraciones de la presión arterial
edemas y proteinuria.
Evaluación del crecimiento por medición de la altura
Descartar alteraciones del crecimiento fetal.
uterina, ganancia de peso materno, ecografía.
Detectar precozmente el embarazo múltiple para
Diagnóstico de número de fetos.
prevenir sus complicaciones.
Pesquisar presentaciones fetales anormales. Examen de la presentación fetal.
Detectar posibles distocias pélvicas. Evaluación 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
1ª visita 2da visita 3ª visita 4ª visita 5ª visita
Prueba de embarazo X
Cálculo de la amenorrea X X X X X
Historia clínica perinatal y evaluación de riesgo X X X X X
Examen clínico completo X
Peso corporal X X X X X
Talla X
Investigar estilos de vida de riesgo X X X
Detectar susceptibilidad a la Rubéola X
Vacuna antitetánica (**) X X
Examen odontológico X
Examen de mamas X
Ex. ginecológico, PAP, colposcopía (***) X
Grupo sanguíneo y factor Rh X
Detectar toxoplasmosis X X
Detección VIH X X
Determinación de hemoglobina X X
Suplementación con hierro y ácido fólico X X X X X
Detección Sífilis X X
Detección de Chagas X
Detección de Paludismo X
Cultivo de orina X X
Detectar diabetes X X
Detectar infección por Estreptococo B X
Contenidos educativos para el parto y la lactancia X X X X X
Determinación de la presión arterial X X X X X
Evaluación del crecimiento fetal. X X X X
Evaluación del líquido amniótico X X X X
Diagnóstico de vida fetal X X X X
Evaluación de la capacidad pelviana X
Consejería y provisión de anticoncepción X
(*) Las actividades programadas para la primer visita se deberán hacer siempre, independientemente de la edad gestacional al
momento de la consulta

(**) Si se sospecha que la gestante no volverá o porque así lo indica la norma nacional se podrá vacunar antes de la semana 20

(***) Lo más precozmente o según norma nacional.

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 gestacional
 DIAGNOSTICO
Buen estado nutricional
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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 orientación nutricional

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

DIAGNOSTICO

Gestante de riesgo, con peso insuficiente para la
$XPHQWRGHSHVR

 edad gestacional (desnutrición)

3

CONDUCTA

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

enfermedades debilitantes.

- citar a consulta en un intervalo menor que lo
      
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3
curva de referencia


 DIAGNOSTICO
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al normal para esa edad gestacional; tanto mayor
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 será el riesgo cuanto más elevado sea su

3 sobrepeso.


 CONDUCTA

- determinar causas: obesidad, edema,
polihidramnios, macrosomía, embarazo múltiple

 - citar a consulta en un intervalo menor que lo
fijado en el cronograma habitual.
      
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debe superar los 16 kg (p90)

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3 Trazado con inclinación ascendente entre las
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 de referencia para la edad gestacional

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 DIAGNOSTICO
3

Buen estado nutricional (ganancia adecuada de
peso):


 CONDUCTA

- seguir cronograma habitual de consultas

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

con inclinación horizontal o descendente o
NJ

3 trazado por abajo de la cuva del percentil 25, con
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 faja considerada normal (p25)
 DIAGNOSTICO
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 Gestante de riesgo con referencia a su ganancia

3 adecuada de peso:


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

esten presentes y dar orientación nutricional

- referir a control prenatal de alto riesgo.
      
$PHQRUUHDVHPDQDV Estas medidas intentan que la gestante llegue al
término de la gestación con una ganancia de peso
mínima de 8 kg.

Trazado por encima de la curva del percentil 90 de

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

- si persiste, derivar a control de alto riesgo.
 - en caso que exista polihidramnios, macrosomía,
o gravidez múltiple, está indicado derivar a
 control de alto riesgo.


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Posibles resultados
Interpretación Conducta
IgG IgM
No hay infección. Comunicar medidas de protección.
- - Existe riesgo de contraerla Eventual repetición de IgG según norma nacional

+ - Infección pasada Continuar control en forma habitual

Evaluar riesgo de infección fetal.

+ + Infección actual
Evaluar realización de tratamiento médico
No se hizo No se hizo Comunicar medidas de protección
Riesgo desconocido
realizar tamizaje según norma nacional

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Infección aguda Hasta el final
materna sin 3 g/día oral repartidos en 3 dosis, del embarazo o
Espiramicina
confirmación de (separados de las comidas) que se confirme
infección fetal infección fetal.
Dosis carga: 100 mg/día oral,
Hasta final del
Pirimetamina divididos en 2 dosis, durante 2 días.
embarazo
Continua: 50 mg/día oral
Dosis carga: 75 mg/Kg/día oral,
divididos en 2 dosis, durante 2 días.
Infección fetal Hasta final del
Sulfadiazina Máximo 4 g/día.
confirmada (entre embarazo
Continua: 100 mg/Kg/día oral
las 12 y 18 emanas)
divididos en 2 dosis. Máximo 4 g/día.
Durante y hasta
una semana
Acido folínico 5 a 20 mg/día
después de usar
la Pirimetamina.

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Madre Recién nacido

Primeras 24 horas
Puerperio inmediato Un niño saludable
• Estado de conciencia, lúcida y tranquila. • No separe al recién nacido de su madre.
• Facies, piel y mucosas, deberán estar bien coloreadas • Promueva que estén cerca físicamente.
(excepto en anemia previa). • Promueva la colocación temprana del
• Frecuencia del pulso en condiciones basales, (60 y 100 bebe al pecho si la madre lo desea.
Ipm) y lleno. • Si es primípara, explíquele que al principio
• Presión arterial en rangos normales. no todas las madres se sienten con
• Temperatura corporal, no deberá superar los 37° C. En el fuerzas y deseo de cuidar a sus bebes [as
postalumbramiento, pueden observarse escalofríos, que 24 horas del día y que eso va cambiando
son normales y raramente duran más de 30 minutos. los primeros días.
• Retracción del útero (globo de seguridad de Pinard), en • Acompañe a la madre sugiriéndole como
estas horas, el fondo del útero no sobrepasa la cicatriz poner a su niño a mamar, sin tocar sus
umbilical y la consistencia es firme adquiriendo una senos y respetando su pudor natural.
consistencia leñosa al ser estimulado. Es indoloro a la • Informe de las ventajas de mantener la
palpación y es común el dolor cuando el niño es puesto al alimentación al pecho exclusiva y que si
pecho (entuertos). tiene molestias al inicio de la lactada es
• En caso de dolor, estarán indicados los analgésicos normal pero serán pasajeras.
comunes y los antiinflamatorios no esteroideo. • No administre otra leche que no sea la de
• En caso de sangrado vaginal abundante con el útero bien su propia madre sin la debida indicación
contraído efectuar inspección minuciosa del canal del médica y consentimiento de la madre.
parto para descartar lesiones (desgarros) en vagina y en • No permita publicidad de fórmulas de
cuello de útero. leche de vaca, ni que les entreguen
• Describir los principales signos de alerta y vigilar con muestras gratis a las madres.
atención 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 está excesivamente
por reposo en cama. irritable.
• Mujeres que no estén inmunizadas contra el tétanos o • Tiene un color normal para su etnia
contra la rubéola deberán ser inmunizadas antes del aIta. (controlar cianosis o ictericia)
• En las Rh negativas no inmunizadas con recién nacido • Moviliza el intestino y orina varias veces
Rh positivos proceder a la inmediata administración de la al dia (sus pañales cada 3 horas están
correspondiente dosis de gammaglobulina según normas mojados).
locales. • Frecuencia respiratoria entre 30 y 60
• Orientar y facilitar el acceso a métodos de planificación 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
anestésicos tópicos. inguinal).
• La retención urinaria es excepcional; se tratará con • Mantenga al niño arropado hasta que
cateterismos vesicales intermitentes, Higiene perineal: logre el control térmico
• Cada vez que la mujer requiera cambiar el apósito, se • Mencione la administración de Vitamina
debe higienizar la zona con agua limpia y jabón o un K que ya se realizó al recién nacido e
antiséptico. El lavado se hará por arrastre, siempre en indique la repetición a los 7 días si fue
sentido antera posterior (de la vulva hacia el ano). Se administrada por vía oral.
secará con un paño o gasas limpias. • Señale que el cordón debe mantenerse
• La ropa interior será separada por un apósito (gasa- limpio y seco.
algodón-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.

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6DOXG6H[XDO\5HSURGXFWLYD 

Información al egreso.
Durante la internación por el parto, la madre y la familia deberán haber recibido información para el cuidado
postnatal y la protección de la salud de ella y su recién nacido. Al alta deberá señalarse con precisión:
• la forma en que ella puede mantener una comunicación continua con los servicios
• las nuevas necesidades de apoyo familiar y los recursos comunitarios a los que pueda acceder para
encontrar soporte en la función parental y
• pautas que la guíen para la consulta en caso que aparezcan elementos de alarma para la salud de ambos.
• Es recomendable otorgar el alta a las 48 horas • Recuerde a la madre de las ventajas de mantener
del parto, si no ha habido complicaciones y la alimentación al pecho exclusiva. Informar acerca
siempre que la mujer está en condiciones de de importancia del vaciado periódico de las mamas,
administrar cuidados a su recién nacido. higiene de los pezones y corpiño que sostenga y no
Cuando deba otorgarse el alta en forma apriete para la prevención de problemas mamarios
precoz, deberán garantizarse instancias de • Recuerde la higiene de manos y el cuidado del cordón
seguimiento domiciliario. umbilical
• De ser necesario, instrumentar sistemas de • Prevención del Síndrome de Muerte Súbita del
consulta telefónica con referentes de! centro Lactante: colocar al niño 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.
recién nacido. • Indicar las Inmunizaciones correspondientes al
momento del nacimiento y primer semana, según
esquema
• Verificar identificación del niño y su madre.
• Brindar orientación para la inscripción del niño en el
Registro Civil.
• Indicar claramente fecha y lugar del primer control,
a los 7 días del alta (preferentemente coordinar la
contrarreferencia)
• Valorar, previo, al alta condiciones de riesgo social
• Orientar acerca de las pruebas de Pesquisa y
obtención de los resultados
• En muchos casos puede ser útil la elaboración y
entrega de folletos instructivos con los conocimientos
básicos a transmitir al alta.
Primera consulta conjunta entre 7 y 10 días.
Puerperio mediato: Se extiende desde • Verificar que moja los pañales con frecuencia y
el segundo y hasta el 10° día del parto elimina meconio, que la succión es audible, vigorosa
• Brindar información sobre higiene perineal o y sostenida y que la boca está húmeda.
cuidado de la cicatriz de cesárea. • Examinar al bebé sin incomodarlo procediendo a
• Recuérdele que la alimentación exclusiva obtener la información que permita detectar nuevas
(día y noche) al pecho, sin dar ningún 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. (asimetría de los miembros o pliegues
amamantando puede tener otras opciones en la región anterior de muslo, Maniobras de Barlow
contraceptivas. y Ortolani)

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• Signos vitales (temperatura, frecuencia cardiaca y presión • No realizar doble pesada, ni siquiera es
arterial). necesario pesarlo todos los días.
Cualquier alteración de los signos vitales, obligará a • Ante la aparición de ictericia valorar
la búsqueda del agente etiológico y ante la presencia elementos de riesgo.
de dudas, deberá ser enviada a un nivel de mayor • Promover la higiene de manos, el uso de
complejidad, para continuar su atención. alcohol gel.
• Evaluación de los loquios (cantidad, aspecto, composición • Informar sobre el riesgo de contagio de
y olor). Es difícil 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 alimentación por fórmula,
color marrón, achocolatado hará sospechar infección. explicar su forma de preparación y el
Suelen además de sangre, contener fragmentos tisulares cuidado e higiene de los implementos.
pequeños. El olor puede ser fuerte, en caso de fetidez, se • Investigar cuales son los apoyos sociales
deberá sospechar infección. con los que la madre o los padres cuentan.
• 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.
Segunda visita conjunta entre los 15 y 30 días
Puerperio alejado: Abarca desde el • Continuar vacunaciones según esquema.
11° hasta el 42° día del postparto • Insistir en la higiene de manos, el uso de
• Reforzar la conserjería en anticoncepción y espaciamiento Alcohol en gel y el riesgo de enfermedades
intergenésico, intentando mantener la lactancia. virales respiratorias, si están en ambiente
• Controlar la evolución de la lactancia. epidémico.
• Continúa la involución uterina y el restablecimiento del • Valorar el crecimiento y la alimentación.
estado pregravídico. Tener en cuenta la posibilidad de
• Investigar síntomas menores de depresión. Si persisten administrar hierro adicional y vitamina D.
las alteraciones depresivas más allá del día 14 deberá • Reiterar examen físico,
consultar con un profesional. • Reiterar información sobre el riesgo de
• Prevenir la reinfección por enfermedades de transmisión muerte súbita.
sexual en especial si fueron detectadas y tratadas en esta
gestación. Aconsejando que:
• Prestar atención a situaciones de desamparo y violencia El recién nacido duerma boca arriba, en
doméstica. cuna, en el cuarto de la madre los primeros
• A los 25 días del parto, puede advertirse un sangrado 6 meses.
vaginal escaso (pequeño retorno) que generalmente No prohibir el uso del chupete
se debe a una proliferación endometrial normal que no Colocar al bebé con los pies en contacto
requiere ningún 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:
días del puerperio. • el humo del tabaco en el hogar
• En algunos casos, éste, será 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 bebé en un sillón (frecuente si
efectuar un examen clínico general y ginecológico. existe consumo de bebidas alcohólicas,
• Analizar con los padres los planes de reinicio de las toman psicofármacos o tienen cansancio
actividades laborales o educativas, verificando la extremo).
protección de sus derechos en la nueva situación de • vestir al niño con ropas abotonadas por
maternidad. delante

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6DOXG6H[XDO\5HSURGXFWLYD 

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.

Cuadro 49 PROBLEMAS AL AMAMANTAR

SIGNOS Y SINTOMAS ACCIONES
Pezones dolorosos o Considere la posibilidad de que tengan infección por cándida
agrietados
Senos ingurgitados. Mastitis 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.
Pezones invertidos I Brindar más apoyo, tranquilizando a la madre.

5HIHUHQFLD%LEOLRJUi¿FD
National Collaborating Centre for Primary Care. Routine postnatal care of women and their babies London. NICE clinical
guideline 37. ISBN 1-84629-248-4 National Institute for Health and Clinical Excellence. www.nice.org.uk/CG037 Julio 2006

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Inserción en el postparto Otras situaciones

Puerperio
Post-placentario Puerperal Intracesárea Post-aborto
Inmediato
No más de En la primera Inmediatamente
Después Después de la
10 minutos semana, después de
de las 4 revisión y limpieza
después de no más allá evacuados los restos
semanas endouterina, antes
la salida de la de las 48 horas ovulares y si no hay
postparto. de la histerorrafia.
placenta. postparto signos de infección.

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Combinados Solo progesterona DIU

Condición

inyectables
implantes
vaginales
parches
orales

orales
intra-

LNG
Cu
CARACTERÍSTICAS PERSONALES E HISTORIA REPRODUCTIVA
Edad
Desde la menarca hasta los 19 años
20 a 44
45 y más años
Paridad
Nulípara
1 o más partos
Lactancia natural
< 6 semanas postparto
> 6 semanas a < 6 meses postparto
> 6 meses postparto
Postparto (amamantando o no)
< 48 horas
48 horas a < 4 semanas
> 4 semanas
Postaborto
1er trimestre
2º trimestre
Inmediatamente después de aborto séptico
Antecedente de embarazo ectópico
Historia de cirugía pélvica
Fumar
Edad < 35 años
Edad > 35 años
< 15 cigarrillos/día
> 15 cigarrillos/día
Obesidad
> 30 Kg/m2 del índice de masa corporal (IMC)
ENFERMEDADES CARDIOVASCULARES
Factores múltiples de riesgo para enfermedad
arterial cardiovascular (diabetes, HTA, etc.).
Hipertensión
Mujer con historia de HTA que no la controla
Mujer con historia de HTA que la controla
adecuadamente
P.A. sistólica de 140 a 159 y diastólica de 90 a 99
mm Hg
P.A. sistólica >160 y diastólica > 100 mm Hg
Enfermedad vascular

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Trombosis venosa profunda (TVP) y embolia

pulmonar (EP)
Historia de TVP/EP
TVP/EP actual
Historia familiar de TVP/EP (parientes de primer grado)
Cirugía mayor con inmovilización prolongada
Cirugía mayor sin inmovilización prolongada
Cirugía menor sin inmovilización
Trombosis venosa superficial
Venas varicosas
Tromboflebitis superficial
Cardiopatía isquémica antecedentes personales
o enfermedad actual
Accidente cerebro vascular
Hiperlipidemias conocidas
Valvulopatías
No complicadas
Complicadas
ALTERACIONES NEUROLÓGICAS
Cefaleas
No migrañosas
Migrañosas
Sin síntomas neurológicos focales
Edad < 35 años
Edad > 35 años
Con síntomas neurológicos focales
Epilepsia
INFECCIONES Y ENFERMEDADES DEL TRACTO REPRODUCTIVO
Patrones de sangrado vaginal
Patrón irregular sin sangrado intenso
Patrones regulares e irregulares con sangrado intenso
Sangrado vaginal sin explicación
Endometriosis
Tumores benignos de ovario
Dismenorrea severa
Enfermedad trofoblástica gestacional
Benigna
Maligna
Ectropion cervical
Neoplasia intraepitelial cervical
Cáncer cervical (esperando tratamiento)
Enfermedades de la mama
Tumor sin diagnóstico anatomopatológico
Enfermedad benigna
Historia familiar de cáncer de mama
Cáncer actual
Cáncer con 5 años sin evidencias de enfermedad
Cáncer de endometrio
Cáncer ovárico

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Miomas uterinos
Sin distorsión de la cavidad
Con distorsión de la cavidad
Enfermedad inflamatoria pélvica (EIP)
Pasada y sin riesgo actual de ITS
Con embarazo posterior
Sin embarazo posterior
Actual o en los últimos 3 meses
ITS
Actual o en los últimos 3 meses
Vaginitis sin cervicitis purulenta
Riesgo aumentado de ITS
VIH/SIDA
Alto riesgo de VIH
VIH Positivo
SIDA
OTRAS INFECCIONES
Tuberculosis
Malaria
ALTERACIONES ENDÓCRINAS
Diabetes
Diabetes gestacional
Diabetes no vascular
No insulino dependiente
Insulino dependiente
Nefropatía/retinopatía/neuropatía
Otra enfermedad vascular o diabetes de más de 20
años de evolución
Tiroides
Bocio simple
Hipertiroidismo
Hipotiroidismo
ALTERACIONES GASTROINTESTINALES
Enfermedad de la vesícula biliar
Sintomática
Tratada con colecistectomía
Tratada médicamente
Actual
Asintomática
Historia de colestasis
Relacionada con un embarazo
Relacionada con contraceptivos
Hepatitis viral
Activa
Portador
Cirrosis
Leve (compensada)
Severa (descompensada)
Tumores de hígado
Benigno (adenoma)
Maligno (hematoma)

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ANEMIAS
Talasemia
Drepanocítica
Ferropénica
INTERACCIÓN CON DROGAS
Drogas que afectan la función del hígado
Algunos antibióticos (rifampicina, griseofulvina, etc.).
Otros antibióticos
Algunos anticonvulsivantes (fenitoina,
carbamazepina, barbitúricos, etc.).

Use el método en cualquier circunstancia

Use generalmente el método
No se recomienda el método a menos que no se disponga o no se acepten otros
No usar el método

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A Aceptar
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C Cuidado
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precauciones extra.
R Retrasar
El procedimiento debe retrasarse hasta que la condición sea evaluada y/o corregida.
Deben proveerse métodos temporales alternativos de contracepción
E Especial
El procedimiento debe llevarse a cabo en un marco que involucre a un cirujano y personal
experimentados y el equipo necesario para proveer anestesia general y otro apoyo médico
de respaldo. Para estas condiciones también se necesita la capacidad de decidir sobre
el procedimiento más apropiado y el régimen de anestesia. Se deben ofrecer métodos
temporales alternos de contracepción, si es necesario referir al paciente .

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Condiciones que deben Condiciones que requieren

retrasar el procedimiento (R) consideraciones especiales (E)
Embarazo Enfermedad trofoblástica Rotura o perforación de útero
gestacional maligna
Postparto de 7 a 41 días Cáncer cervical, ovárico o de Presión arterial > 160/100
endometrio mmHg.
Pre-eclampsia severa/eclapmsia Enf. Inflamatoria Pélvica actual o Enfermedad vascular
en los últimos tres meses
Rotura prolongada de ITS actual Endometriosis
membranas
Sépsis o fiebre intraparto, Enf. de vesícula biliar actual TBC pelviana
puerperal o postaborto
Hemorragia severa antes o Hepatitis viral activa Diabetes con nefropatía,
después del parto o del aborto retinopatía y/o neuropatía
Trauma severo del tracto genital Hb < 7 g/dL Cirrosis severa
postparto o postaborto (desgarro (descompensada)
cervical o vaginal)
Hematometra aguda Infección de pared abdominal Hipertiroidismo
Trombosis Venosa Profunda o Enfermedades respiratorias Alteraciones de la coagulación
Trombo Embolismo Pulmonar agudas
actual
Cirugía mayor con inmovilización Infección sistémica Enfermedades respiratorias
prolongada crónicas
Cardiopatía isquémica actual Utero fijo
Sangrado vaginal sin explicación Hernia de la pared abdominal o
umbilical

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EMBARAZO Sangrado negruzco y escaso.
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ECTÓPICO Tamaño del útero < a la amenorrea.
Pseudosaco gestacional.
Tumoración parauterina.

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 3a Edición

http://new.paho.org/clap
http://perinatal.bvsalud.org/
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ISBN 978-92-75-33177-4

CLAP/SMR Publicación Científica Nº 1577 - 2011