SESIÓN 1 SEMIOLOGÍA OBSTÉTRICA Semiología (del griego Semeion, signos, síntomas; logos, discurso, ciencia), es la ciencia que estudia los signos y síntomas de las enfermedades. enfer medades. Semiología Obstétrica, es parte de la Semiología general, que se encarga del estudio de los signos y síntomas fisiológicos y patológicos que presenta la mujer durante el embarazo, parto y el puerperio. Por signo, se entiende todo indicio de enfermedad; por síntoma toda manifestación ostensible de enfermedad. Los anglosajones prefieren denominar signos a las manifestaciones objetivas o físicas de enfermedad y síntomas a los trastornos, molestias o sensaciones subjetivas de enfermedad. La Semiología se compone de dos dos partes: 1. Semiotecnia o técnica de la búsqueda del signo. 2. Clínica Propedéutica (del griego pro, delante; paidevo, yo enseño), enseñanza clínica preparatoria, destinada a reunir e interpretar los signos y síntomas, para hacer un diagnóstico. Por consiguiente, la Semiología, puede ser dicha, el arte y la ciencia del diagnóstico. Por síndrome (del griego sin, con; dromos, carrera, curso), se entiende un conjunto de signos y síntomas, con una misma carrera y evolución, por proceder de una misma causa, cualquiera que ésta sea. Por ejemplo: la fiebre (hipertermia, taquicardia, taquípnea, anorexia, malestar general, etc...). Por enfermedad se entiende un conjunto de signos y síntomas, con una misma evolución, pero procedentes siempre de una causa determinada o específica. Por ejemplo: la fiebre tifoidea (fiebre, postración, esplenomegalia, etc., debida a una septicemia por bacilos de Eberth). Pródromos (del griego pro, delante; dromo, carrera), se denomina a los signos o síntomas iniciales de una enfermedad o síndrome s índrome,, siendo por lo general vagos, poco característicos. Patognomónico (del griego pathos, enfermedad; gnomon, indicador), se dice al signo bien característico, casi exclusivo de una enfermedad. En realidad hay muy pocos signos patognomónicos; patognomónicos; quizás, ninguno. ninguno. Para llegar a un diagnóstico, se comienza con la investigación de los signos o síntomas (Semiotecnia), luego se los agrupa e interpreta (clínica (c línica Propedéutica). Para llegar a un diagnóstico completo se deben hacer los siguientes s iguientes diagnósticos diagnósticos parciales: 1. Diagnóstico de los síntomas y signos.
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2. 3. 4. 5.
Diagnóstico de síndromes (diagnóstico fisiopatológico) Diagnóstico anatómico Diagnóstico etiológico Diagnóstico de la capacidad funcional
Para establecer la capacidad funcional, además del conocimiento de las condiciones actuales, es necesario pensar en el pronóstico (del griego pro, delante, anticipadamente; gignosko, yo conozco). A los signos o síntomas que permiten prever el curso bueno o malo de una enfermedad, se les denomina pronósticos. Para llegar a un diagnóstico, se utilizan los procedimientos clínicos fundamentales: interrogatorio, inspección, palpación, percusión y auscultación, ayudado por los procedimientos auxiliares, los instrumentales y los de laboratorio, muchas veces tan imprescindibles como aquellos. (1) Pensamos que la mejor forma de encarar el estudio semiológico de una mujer embarazada, es hacerlo tal como lo practicamos diariamente en la consulta, cuando no sabemos aún cuál es la problemática que trae la paciente: ¿se trata de definir si un atraso menstrual corresponde a un embarazo?, o ¿se trata de saber cómo evoluciona un embarazo ya diagnosticado?, ¿para cuándo será el parto?, ¿cómo diagnosticar las eventuales desviaciones de lo normal durante el embarazo y en el parto? (2). TERMINOLOGÍA OBSTÉTRICA
Grávida.- Toda mujer que está embarazada. P rimigesta rimigesta.- Grávida por primera vez. rimigesta muy joven.- Edad menor de 15 años. P rimigesta P rimigesta rimigesta joven.- Grávida cuya edad está entre 15-19 años. rimigesta añosa .- Grávida cuya edad está entre 35-39 años. P rimigesta P rimigesta rimigesta muy añosa .- Grávida de 40 años o más. ultigesta.- Mujer en su segundo o posterior embarazo. M ultigesta .- Se dice que una mujer ha parido cuando ha dado a luz por cualquier vía P aridad aridad .-
(vaginal o por cesárea) uno o más productos (vivos o muertos) que pesan 500 gr. o más, o que poseen más de 20 semanas de edad gestacional (un embarazo múltiple se consigna como una sola paridad). Si el producto no alcanza este peso o edad gestacional se denomina denomina aborto. a borto. ulípara.- Mujer que no ha parido nunca. N ulípara rimípara.- Mujer que ha parido una vez. P rimípara ultípara .- Mujer que ha parido 2 o más veces. M ultípara Gran M ultípara ultípara .- Mujer que ha parido 6 veces o más. mbrión.- Se denomina al macizo de células internas desde la fertilización hasta las E mbrión.8 semanas. eto.- Desde las 8 semanas de edad gestacional hasta el término del embarazo. F eto.nfante.- Se denomina desde que nace hasta el primer año de vida I nfante.-
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SESIÓN 2 MODIFICACIONES Y CAMBIOS EN EL ORGANISMO MA TERNO DURANTE EL EMBARAZO Las modificaciones que produce el embarazo en la mujer, se inician con la nidación del huevo en su fase de ³blastocisto´ en la mucosa endometrial, la cual se encuentra preparada para recibir al huevo fecundado. Las próximas modificaciones tendrán por objeto proteger al producto y rodearlo de los cambios necesarios para su evolución y desarrollo, así como preparar los cambios y adaptaciones necesarias para par a el parto y lactancia. Los cambios que produce el embarazo en la mujer, son modificaciones anatómicas y fisiológicas, debido a las alteraciones hormonales que se producen en la gestación, especialmente a nivel de las hormonas sexuales y a la incorporación de un potente órgano endocrino, que es la ³placenta´ y cuyas secreciones tienen por objeto servir a las necesidades del feto en su evolución y desarrollo. La relación biológica mutua, entre la madre y el nuevo ser se denomina ³simbiosis armónica homogénea´.
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Las modificaciones del organismo materno durante el embarazo se s e agrupan en dos: 1. Modificaciones Generales 2. Modificaciones Locales
Modificaciones Generales: Son los cambios que se producen en el organismo de la mujer gestante, excepto los cambios ca mbios que se producen a nivel de aparato genital. 1. Modificaciones en la piel y anexos Se produce hiperpigmentación de la piel, que es una característica del embarazo, se pigmenta la cara a nivel de la frente, nariz y mejillas, lo que se conoce como cloasma gravídico. Hay hiperpigmentación de pezones, ombligo, línea alba, vulva y también se hiperpigmentan hiperpigmentan las cicatrices cica trices anteriores, todo esto es por acúmulo de melanina. Se producen estrías en la parte baja del abdomen y en la región lateral de las caderas, las estrías son rojo azuladas o violáceas originadas por la distensión de la piel a este nivel y produciéndose la ruptura de las fibras elásticas de la piel. Estas estrías después del parto no desaparecen y quedan como huella del embarazo presentando un aspecto esteriado brillante y nacarado. Las glándulas sudoríparas y sebáceas aumentan su actividad, hay aumento de sudoración en las manos, pies y pliegues cutáneos. El tejido celular se engruesa, y la gestante pierde la finura de su rostro, haciéndose más lleno y tosco. Con frecuencia se observa edemas y depósitos de tejido adiposo a nivel de nalgas, mamas, monte de Venus y pared abdominal. Los músculos se vuelven más excitables y con frecuencia se producen calambres en miembros inferiores. 2. Modificaciones en la Temperatura La temperatura basal se mantiene elevada en algunos décimos durante los tres primeros meses, por acción de la Progesterona ovárica producida por el cuerpo amarillo, comienza a descender hacia las 14 semanas y a las 20 semanas alcanza los niveles de la fase de proliferación del ciclo. La elevación de la temperatura t emperatura constituye un signo precoz de embarazo.
3. Modificaciones del Sistema Esquelético El aumento de peso de la embarazada, determina una sobre carga para el sistema esquelético, para los medios articulares y para los músculos, que deben resistir al final del embarazo hasta un 20% de sobre peso.
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Debido al crecimiento uterino se produce el desplazamiento del centro de gravedad, por lo que la gestante trata de compensar llevando los hombros y espalda hacia atrás y se produce una exageración en la lordosis lumbar provocándole provocándole lumbalgias y radiculalgias. En las articulaciones se observa reblandecimiento de los ligamentos con una mayor movilidad, que facilita la adaptación pélvica en el parto. En algunos casos a nivel del pubis se puede producir una disyunción o separación que es sumamente dolorosa a la palpación y se llama diastasis de pubis. pubis. Debido a la movilidad aumentada de las articulaciones, sobre todo a nivel de las articulaciones sacroilíacas, se originan dolores lumbosacros a partir del 6to. mes. Al final del embarazo observamos el caminar de la gestante con su característico balanceo llamado ³marcha de pato´.
4. Modificaciones en el Peso La variación del peso es notable durante el embarazo: -
En las primeras ocho semanas sema nas de gestación el peso disminuye. En el 2do. Trimestre el peso aumenta 1200 gr mensual. En el 3er. Trimestre el peso aumenta hasta 1500 ó 2000 gr mensual.
No debe exceder en las últimas semanas de gestación los 500 gr. semanales, al final del embarazo, específicamente en las dos últimas semanas de gestación el aumento de peso debe ser muy escaso. Al final del embarazo, el aumento de peso es entre 9 y 12 Kg que se distribuyen de la siguiente manera: Feto Placenta, Placent a, membranas membrana s y cordón umbilical umbilica l Líquido amniótico amni ótico Útero Mamas Aumento Aument o de volumen sanguíneo sanguí neo Agua retenida, aumento de la grasa subcutánea y de relleno rell eno
... ... ... ... ... «
3500 gr 600 gr 1000 gr 1000 gr. 500 gr 1000 gr
...
2400 gr
El peso de la gestante debe controlarse en todas las visitas pues su aumento exagerado nos orienta hacia una desviación patológica como: cuadro preeclámptico a descartar, una nefropatía, cardiopatía, endocrinopatía, endocrinopatía, etc.
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En lo funcional se produce un aumento en el número de respiraciones, que de 16 llegan a 25 respiraciones por minuto.(2) La capacidad pulmonar se mantiene y la presión abdominal se compensa con el ensanchamiento del tórax. Por otra parte, la ventilación pulmonar aumenta considerablemente dado que existe mayor requerimiento de oxígeno. Es necesario que la mujer gestante aprenda a respirar adecuadamente para evitar la disnea, y sobre todo para suplir sus necesidades tisulares y los requerimientos del feto, aportando el oxígeno necesario al espacio intervelloso a fin que se realicen con ventaja los intercambios gaseosos a este nivel que son de vital importancia para el desarrollo del producto. Este entrenamiento de la respiración se hará con la preparación psicofísica de la gestante en forma adecuada.
6. Modificaciones en el Aparato Cardiovascular e mbarazo se producen algunas modificaciones modificaciones debido al Sistema Central: en el curso del embarazo cambio de posición ligado al crecimiento uterino. El diafragma se eleva y se produce una rotación y horizontalización del eje cardíaco con desplazamiento hacia la izquierda y hacia afuera del choque de la punta. Estos cambios originan alteraciones de los ruidos cardíacos y se pueden apreciar soplos cardíacos funcionales. FIsiológicamente aumenta la velocidad circulatoria durante el embarazo, debido al aumento de volumen de contracción cardíaca.
Sistema Periférico: el pulso se acelera llegando a 100 por minuto y como consecuencia de la hipotensión el pulso es blando. Hay aumento de la presión venosa en la parte inferior del cuerpo debido a la dificultad en el retorno venoso produciéndose las várices en miembros inferiores y en la vulva, la vena cava es comprimida por el útero ocupado. La permeabilidad capilar está aumentada pero su resistencia disminuida. dis minuida.
7. Modificaciones Hematoló He matológicas gicas El número de glóbulos rojos, la cantidad de hemoglobina y el hematocrito, disminuyen desde el segundo mes de gestación progresivamente hasta el sexto mes de gestación, en que se estabilizan y se mantienen en los mismos niveles hasta el final del embarazo. Si el embarazo se inicia con valores normales, al 6to. mes lo encontraremos con los siguientes
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Los leucocitos aumentan desde el 2do. mes de gestación alcanzando cifras de 10 mil a 12 mil que se mantienen hasta el final del embarazo. En el trabajo de parto prolongado y laborioso los leucocitos se elevan hasta 20 mil. El volumen sanguíneo aumenta hasta en 1000 cc a lo que se atribuye atr ibuye que la concentración de hematíes, de hemoglobina, disminuya por dilución, hablándose de una hipervolemia con oligocitemia que es la expresión de un proceso fisiopatológico de adaptación. adapta ción. La concentración de proteínas totales está disminuida, a base de las albúminas, pues las globulinas están aumentadas, por eso la velocidad de sedimentación está acelerada durante el embarazo. Aunque la capacidad para retener el hierro durante el embarazo casi se duplica, los niveles séricos descienden en 20 a 30 por ciento. La coagulación de la sangre no se modifica, y al final del embarazo se encuentra hipercoagulabilidad ya que la tasa de protombina aumenta durante el embarazo, aumenta también el fibrinógeno hasta 500 mg %.
8. Modificaciones en el Aparato Digestivo Las modificaciones digestivas no revisten mayor importancia ya que se interpretan como una fijación psíquica condicionada. En el primer trimestre es frecuente el aumento de secreción salivar que la gestante a veces magnifica para evidenciar su estado. Discreto grado de náuseas es común, pero cuando se exacerban y se llega al vómito reiterado, se debe muchas veces a causas psicógenas. Se debe evitar uso de fármacos cuya acción teratogénica no haya sido investigada. El crecimiento uterino produce desplazamiento del estómago hacia arriba sin modificar su motilidad, también se desplaza el colon y el ciego. La acidez gástrica disminuye en el primer trimestre, aunque se afecta la absorción, al final del embarazo se produce aumento de las secreciones gástricas.
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Hay aumento de diuresis, es mayor en las noches, se altera el ritmo. En la vejiga existe alargamiento y ensanchamiento de la base del trígono, hay congestión de la submucosa por compresión del útero y de la presentación, sobre todo al final del embarazo, ocasionando polaquiuria, disuria e incontinencia urinaria. La densidad urinaria disminuye. La vejiga disminuye su tono y se torna flácida, con insuficiencia de la válvula vésicouretral, que ocasiona reflujo hacia los uréteres. Hay edema e hiperemia en la vejiga que conjuntamente con la alteración del tono condicionan la predisposición a la bacteriuria asintomática.
10. Modificaciones en el Metabolismo El metabolismo aumenta desde las primeras semanas de gestación, alcanzando de 15 a 20% sobre lo normal, debido a las mayores demandas energéticas del feto y el aumento en actividad de los órganos órga nos maternos (circulación, respiración). El balance proteico es positivo, mientras que el balance hidrocarbonado se mantiene inalterable, y en el metabolismo graso hay aumento de lípidos en el suero sanguíneo. En el metabolismo mineral lo más importante es la retención de sodio a nivel de los tejidos por acción estrogénicas. El metabolismo del agua se caracteriza por la retención hídrica progresiva, que puede intensificarse llevando a la gestante a perturbaciones patológicas graves.
11. Modificaciones de las Glándulas Endocrinas Las suprarrenales aumentan de peso en un 50% debido al ensanchamiento de la corteza suprarrenal. Hay aumento de excreción de Aldosterona, debido a esto hay retención de sodio y agua, y tendencia a los edemas. La Tiroides también aumenta de peso, incrementando su actividad secretora. Hay mayor producción de hormona Tirotropa, aumento del nivel del yodo protéico y aumento de la
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Conforme aumenta el tamaño de las mamas, se hace visibles unas delgadas venas justo por debajo de la piel. Las modificaciones de los pezones y las aréolas son aún más características; los primeros crecen considerablemente, muestran una pigmentación más intensa y se tornan más eréctiles. Después de los primeros meses, mediante un suave masaje de los pezones, a menudo es posible posible exprimir un líquido espeso espeso y amarillento, el calostro. En este momento las aréolas aumentan de tamaño y muestran una pigmentación más profunda. La intensidad de la pigmentación varía con el color de la piel de la mujer: Dispersas por toda la aréola hay varias elevaciones pequeñas, las llamadas glándulas de Montgomery, que son glándulas sebáceas hipertróficas. Si las mamas aumentan mucho de tamaño, pueden aparecer estrías similares a las la s que se observan en el abdomen. abdomen. SESIÓN 3
MODIFICACIONES LOCALES Modificaciones en la Pelvis Las articulaciones adquieren mayor movilidad, inicialmente los estrógenos actúan sobre los ligamentos y luego lo hace la Relaxina la cual se origina en el cuerpo amarillo y contribuye con su acción a producir un verdadero reblandecimiento en las articulaciones pélvicas, encontrándose en ellas aumento de la luz articular y del aparato ligamentoso, a veces casi imperceptible, pero que se puede comprobar en forma radiológica y anatomopatológicamente. En muchas embarazadas se observa aflojamiento de la sínfisis púbica y a veces la separación de los cabos (disyunción) que puede llegar hasta 3 cm. La palpación de dicha zona es muy dolorosa.
Modificaciones en la vulva Hay congestión e ingurgitación venosa y reblandecimiento que le dan un aspecto suculento; a veces se observa várices váric es vulvares que desaparecen después del parto.
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deben al aumento de fibras elásticas, de la hipertrofia de las fibras musculares y de la infiltración edematosa de los tejidos. Los pliegues transversales se arrugan y se hacen más gruesos, las papilas de la dermis son a menudo más salientes y a veces se palpan como pequeños gránulos resultando como consecuencia la pared par ed vaginal muy muy rugosa. Se produce aumento en la circulación sanguínea en las paredes vaginales, las venas se dilatan y la mucosa vaginal presente un color violáceo o rojo vinoso. Las secreciones vaginales, que en realidad son trasudados, tras udados, son más abundantes en algunas mujeres, mujeres, estas secreciones s ecreciones pueden ser blanquecinas de aspecto lechoso y otras veces pueden ser grumosas y espesas parecidas al esmegma, y su reacción es ácida. La vagina está contaminada en su parte inferior por microorganismos que provienen del recto y la uretra, los cuales pueden ser arrasados hacia arriba con el coito y los tactos. En la vagina predomina el bacilo de Doderlein el cual transforma el glucógeno en ácido láctico, durante el embarazo la secreción vaginal es ácida y el Ph es bajo (4 y 3.8) en particular en los últimos meses, cuando el nivel de estrógenos alcanza su acmé.
Modificaciones en el Útero Durante el embarazo el útero experimenta un crecimiento progresivo. Fuera del embarazo pesa entre 30 y 60 gr y al final del embarazo pesa entre 1000 gr y 1500 gr Las paredes uterinas se distienden por el crecimiento del huevo y feto y sus elementos musculares se hipertrofian. El útero es globuloso en los primeros meses de gestación y al final es ovoide con el eje mayor vertical y su extremidad extremida d superior superior es más voluminosa.
Estructura del Cuerpo Uterino Posee tres capas de fibras musculares: 1.
C apa apa I nterna nterna
o Submucosa : proviene de la musculatura del ligamento redondo y de la
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Los vasos internos transcurren entres estos anillos musculares, y después del alumbramiento cumplen una función decisiva en la hemostasia fisiología actuando como ligaduras vivientes.
Segmento Inferior Está situado entre el cuerpo y el el cuello uterino. uterino. Se desarrolla a expensas expensas del istmo uterino que es una pequeña porción de 7 a 8 mm. Cuando se inicia el embarazo, el útero se reblandece y da lugar al signo de Hegar. El segmento inferior inicia su formación al 3er. mes de gestación, y en las primigestas completa su formación antes que la multípara, entre el 8vo. ó 9no. Mes. El segmento inferior es muy delgado debido a su pobreza muscular pues carece de la capa plexiforme. El segmento inferior tiene la forma de una copa, cuyo pie es el cuello uterino que se adapta con contenido líquido a la forma y volumen de la presentación.
Cuello Uterino A partir del segundo trimestre se eleva y se hace posterior y se reblandece, toma un color violáceo, en la nulípara tiene forma de barril y en la multípara tiene forma de tapón de champagne. Durante el parto deberá abrirse y permitir el paso del feto al exterior. El conducto cervical está obstruido por secreciones cervicales que constituye el tapón. Hay hipersecreción y se aprecia los huevos o quistes de Naboth.
Modificación de los Ovarios y Trompas Durante el embarazo los ovarios aumentan de tamaño especialmente el que posee el cuerpo amarillo. Presentan edema, mayor vascularización y aumentan las células intersticiales y formaciones deciduales debajo de la túnica albuginea. a lbuginea.
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HISTORIA CLÍNICA OBSTÉTRICA La Historia Clínica debe consignar los datos de filiación incluyendo la dirección actual y datos concernientes al esposo.
Datos Generales: . Edad .-
Es un dato sumamente importante. Algunos autores consideran que la edad más propicia para procrear está entre los 20 y 25 años adquiriendo un valor pronóstico en las primigestas muy jóvenes (menos de 18 años) y en las primigestas añosas (más de 35 años); en estos casos se las considera como formando parte del cuadro clínico llamado ³embarazo de alto riesgo´.
Nombre.-
Sirve para la identificación de la paciente. Debe ser tomado con corrección y lo más completo posible, a los efectos de evitar errores que lleven posteriormente a confusiones en dicha identificación. De este dato se desprende muchas veces que la embarazada puede ser soltera o que vive en unión libre, hecho éste que tiene cierto valor para la calificación de la gravidez.
Domicilio.-
Este dato es importante y debe completarse con los elementos que se consideren necesarios cuando no es claro, de modo tal que pueda localizarse a la paciente en cualquier momento. Si tiene teléfono, este es un dato de suma utilidad. Muchas veces es conveniente agregar el teléfono de algún familiar.
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complicaciones que puede presentar, debe calificarse también como conformando parte de los embarazos de alto riesgo.
Motivos de Consulta: Teóricamente una embarazada puede consultar por cualquier causa, y hay ciertos signos o síntomas que se presentan con mayor frecuencia. 1. Amenorrea
La amenorrea es un signo de probabilidad de embarazo y s e define como la ausencia de menstruación durante noventa días o más. Obviamente esto es lo frecuente en la consulta obstétrica y más bien deberíamos hablar de atrasos menstruales que son el trastorno por el cual consulta con mayor frecuencia la presunta embarazada. En este sentido en toda mujer en edad genital activa, bien reglada, todo atraso menstrual cobra valor como dato de probabilidad de gravidez. Conviene precisar con toda la claridad posible, cuál fue la fecha de la última menstruación tratándola de relacionar con algún acontecimiento de cierta relevancia, como podría ser un fin de semana, un día feriado, etc. si la mujer no está segura de su respuesta. Es preciso aclarar bien que no se trata de la primera falta menstrual, sino de la última vez en que la paciente tuvo su regla. Este dato cobra
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periódico del vientre, que nos puede orientar hacia el diagnóstico de contracción uterina. La presencia de lipotimias o mareos en una gravidez aún no claramente diagnosticada, puede orientar hacia el diagnóstico de un embarazo complicado ya sea extrauterino o intrauterino. 3 .
Pérdida de líquido
La pérdida de líquido por los genitales durante el embarazo suele producir preocupación a la gestante que ve en ello un signo de amenaza de su gravidez. El interrogatorio entonces debe orientarse a preguntas sobre cantidad y calidad de las pérdidas y su relación con las distintas causas que pueden provocarlas. Durante la primera mitad del embarazo pueden ser debidas a la ruptura del saco amniocorial precediendo en algunas oportunidades a la genitorragia que acompaña al trabajo de aborto. Por otra parte existen otras causas extraovulares que pueden dar lugar a pérdida de líquido por los genitales, tales como el flujo fisiológico o patológico que también debe ser interrogado en forma correcta y completa. Es conveniente hacer el interrogatorio siguiendo el siguiente esquema: - Cantidad: escasa o abundante, pudiendo producir incapacidad para realizar tareas normales. -
Coloración: blanquecino, es el flujo por hipersecreción o trasudación; cuando es
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Otra pérdida de líquido por los genitales muy frecuente es la pérdida de orina, que se produce en la grávida debido sobre todo a una disminución del tono muscular unida a la compresión del trígono por el útero que crece. La hidrorrea decidual acompañada de vetas sanguinolentas es una expresión de infección endometrial y se objetiva con el estudio microscópico (piocitos, sangre, bacterias); se aprecia por lo general en el primer trimestre. Finalmente, la retención de líquido de irrigaciones puede ser toda la patología de una consulta. En la segunda mitad del embarazo, las pérdidas de líquido adquieren una importancia mucho mayor con respecto a la continuidad del embarazo; también aquí las causas extraovulares están constituidas por el flujo y la pérdida de orina ya mencionadas y eventualmente restos de líquido de irrigación. En cambio, la pérdida de líquido amniótico adquiere una relevancia capital y debe ser cuidadosamente estudiada, ya que la fisura alta de las membranas o la ruptura intempestiva (fuera de tiempo) y prematura constituyen un signo importante de amenaza de parto prematuro. El diagnóstico correcto de esta situación debe hacerse de inmediato en virtud de su importancia, agravada cuando se agregan contracciones c ontracciones uterinas. El líquido amniótico se investiga microscópicamente buscando lanugo, vernix caseoso y células que pueden colorearse con azul de Nilo, después de las 26 semanas.
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Ya sean localizados, por ejemplo en miembros inferiores, superiores o cara, o también generalizados. En el curso del embarazo embaraz o normal puede retenerse hasta unos seis litros de agua, cifra ésta que representa casi la mitad del total de aumento de peso del embarazo, esta agua se reparte y está en constante intercambio entre los distintos compartimentos orgánicos. El interrogatorio, el examen clínico y los métodos auxiliares, nos llevarán a diagnosticar si se trata de un edema fisiológico o patológico, tratando de buscar o descartar si existe alguna vinculación con alteraciones del aparato cardiovascular, alteraciones vasculares de los miembros inferiores (várices, etc.), o si responden a alteraciones del metabolismo hidro-salino. hidro-salino. Se preguntará sobre su: Aparición (diurna, nocturna, rápida o progresiva) Tipo (localizado o generalizado) Intensidad (se refiere a extensión del edema) Evolución (si ha disminuido, aumentado o se mantiene igual desde su instalación y si se modifica con las distintas posiciones).
. 7
Alteraciones del Sistema Neurovegetativo
Vinculadas sobre todo al comienzo del embarazo, tienden a atenuarse a partir del segundo trimestre, especialmente aquellas dependientes del sistema parasimpático
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Frecuencia o intervalos entre las mismas.
Debemos averiguar además sobre la aparición de otros elementos a saber: sa ber: pérdida de tapón mucoso, caracterizado por la salida a través de los genitales de una secreción viscosa, de color variable (transparente, blanquecino, rosa o teñido de sangre), que puede preceder a las contracciones uterinas en horas o días o aparecen en forma simultánea con ellas y la salida de líquido por los genitales (claro, transparente, más o menos abundante) debido a la rotura de las membranas que puede ser prematura (antes del término del embarazo y previa a la aparición de los otros elementos del trabajo de parto) o precoz cuando acontece al comienzo del trabajo de parto.
Reglas para conocer la Fecha Probable de Parto (FPP) A partir de la fecha de la última menstruación se s e hace el cálculo de la fecha probable probabl e
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j E
l :
il y la fecha act al = 24 de agos to, entonces : Si FUR = 14 de abr il 14-IV + 10 = 24-IV. En tre est e día y la fecha act al hay 4 meses; por tanto, se deben sumar 2 semanas más. En conclusi n: EG = 4 meses (16 semanas) + 2 sem. = 18 semanas b) Conociendo la altura uter ina (A.U.): se utili a la R eg egla de McDonald: AU (en cm.) x 2/7 = EG en meses lunares AU (en cm.) x 8/7 = EG en semanas sema nas (2)
METODO CALENDAR IO IO: conoc iendo la fecha de la última mestruaci n se contab ili an el total de días transcurr idos y se d i ide entre siete. E jm: FUR: 10 de enero. Fecha de consu lta: 20 agos to
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SESIÓN 5 INTERROGATORIO POR TRIMESTRE Primer Trimestre
Elementos Fisiológicos.- Casi todos ellos están vinculados a una labilidad especial del sistema neurovegetativo propio del embarazo. Se interrogará sobre alteraciones del gusto y del olfato, aunque a veces se presentan hipoacusias y modificaciones en menos de la visión, modificaciones del carácter (irritabilidad, depresión) alteraciones del sueño (exceso o insomnio) modificaciones del apetito (en más o en menos) y finalmente, los trastornos del S.N.V. que
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según la gravedad de la enfermedad. Estos cuadros se acompañan casi siempre de estreñimiento o de la presencia de focos infecciosos dentarios o amigdalinos.
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Tercer Trimestre
Elementos Fisiológicos.- Es de especial importancia la presencia de movimientos fetales y la molestia que produce en la gestante debido a la intensidad con que puede presentarse y el crecimiento regular y progresivo del útero. Vinculado con el crecimiento uterino, se observa el descenso del fondo uterino en el último mes, en las primigestas al producirse el encajamiento de la presentación. Elementos Patológicos.- El crecimiento exagerado y rápido del útero se debe a un exceso de líquido. Preguntar si ha habido aumento exagerado de peso, edemas, cefaleas, acúfenos y fosfenos, lo cual nos orientará hacia posible toxemia que se corroborará
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- Sangrado vaginal. - Pérdida de líquido amniótico (ruptura de membranas), más aún si ha transcurrido más de 24 horas. - Secreción vaginal desusadamente espesa o mal oliente. - Fiebre.
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bacterias, micosis o tricomoniasis y en especial la Gonococia. Averiguar si hubo esterilidad primaria o secundaria que pueden condicionar la clasificación de la paciente como una embarazada de alto riesgo. Saber si ha sido sometida a intervenciones quirúrgicas ginecológicas, como prolapso, miomectomia o cesáreas anteriores, que pueden modificar la conducta obstétrica o también a operaciones
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población prestataria, evaluar los resultados de la atención brindada, identificar los problemas prioritarios y realizar r ealizar un sinnúmero de investigaciones epidemiológicas. La Historia Clínica Perinatal Base es de uso sencillo y de bajo costo está constituida por una serie de sectores que contienen la documentación referida a los acontecimientos
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Este carné debe estar siempre en poder de la embarazada, quien lo utilizará para toda acción de salud que reciba en su estado grávido puerperal. En su diseño se mantiene la estructura de la HCPB para facilitar el volcado de datos. Se excluyen del carné los controles durante el trabajo de parto por no constituir
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Es importante valorar la talla de la gestante, porque las pacientes muy bajas que miden menos de 1.50 cm pueden presentar problemas óseos pélvicos, sobre todo cuando son debidas a raquitismo, enanismo a acondroplasia.
Actitud.- Observaremos cuál es la actitud de la paciente, pues a medida que crece el
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tranquilidad, nos parece una oportunidad que debemos brindar principalmente a las primigestas.
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SESION 14 14 SIGNOS Y SÍNTOMAS DEL TRABAJO DE PAR TO Clínicamente el parto se inicia cuando la actividad uterina progresa rápidamente originando contracciones que aumentan en intensidad, frecuencia y duración con acciones efectivas sobre la dilatación del cuello y se extiende hasta el nacimiento del niño, la expulsión de los anexos y el puerperio inmediato. Por lo tanto, atender el parto significa: diagnosticar, vigilar y dirigir el curso clínico desde su etapa inicial hasta el puerperio.
PRÓDROMOS Son aquellos signos y síntomas que se presentan antes de iniciarse el parto, se hacen presentes días u horas antes y son los siguientes: 1. Descenso del fondo del útero, a lo que se refiere la gestante indicando que su cintura ha disminuido. Es más notorio en la primeriza pr imeriza que en la multípara. 2. Parestesias en las extremidades inferiores y deseos frecuentes frecuentes de miccionar. 3. Aumento del flujo vaginal. 4. Reacciones vasomotoras en el rostro. 5. Intensificación de las contracciones de Braxton Hicks que aumentan en intensidad sin llegar a ser molestosas. 6. Irritabilidad uterina. 7. Eliminación del tapón mucoso del orificio cervical, que conjuntamente con alguna pequeña cantidad de sangre proveniente de erosiones en el conducto cervical constituyen los limos.
PERÍODOS DEL PAR TO 1. Primer Período o Dilatación.- Desde que hay contracciones útiles, hasta que se completa la dilatación. Comprende el borramiento o incorporación del cuello, la formación de las las bolsas de las aguas y la apertura apertura del cuello. Dura de 10 a 12 horas horas en primerizas y de 4 a 5 horas en las multíparas.
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frecuencia. En pleno período de dilatación las contracciones deben alcanzar intensidad de 30 a 50 mmHg. con duración de 40 a 60 segundos y frecuencia y mínima de tres contracciones y un máximo de 5 en 10 minutos. La intensidad de las contracciones se controla aplicando la mano al abdomen y la duración y frecuencia midiendo el tiempo respectivo y su presencia en 10 minutos. 2. Segundo Período o Expulsivo .- Comprende desde la culminación de la dilatación, hasta el nacimiento del feto. En este proceso se cumplen los mecanismos del parto. Dura hasta dos horas en las primerizas y 30 minutos en las multíparas.
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Sintomatología: Las contracciones uterinas se hacen más intensas y en forma espontánea aparecen los pujos, que así vienen a reforzar la acción uterina mediante la acción de la prensa abdominal; la paciente tiene la sensación de defecar y en forma involuntaria colabora adaptándose a un mejor trabajo de parto, mediante esfuerzos intensos para hacer progresar el móvil fetal. La frecuencia de las contracciones aumenta hasta cuatro y cinco contracciones. La presentación progresa y desciende dilatando vagina y periné.
3. Tercer Período o Alumbramiento Se extiende desde el nacimiento del feto, hasta la expulsión de la placenta. Comprende al despegamiento de la placenta y su expulsión. Dura de 5 a 15 minutos. Sintomatología: Después del nacimiento del niño, la parturienta queda tranquila, mientras tanto en la cavidad uterina se forma el hematoma retroplacentario que hace el despegamiento de la placenta de la decidua basal conjuntamente con las membranas. Después del lapso indicado (5 15 minutos) se presenta nuevamente nuevamente sintomatología contráctil comprobándose al examen abdominal la elevación y lateralización del útero como signo de que la placenta se ha desprendido, para seguidamente producirse la expulsión. La placenta se elimina unas veces en forma de sombrilla invertida, apareciendo primero la cara fetal (Mecanismo de Schultze); otras veces se desprende por uno de los bordes (Mecanismo de Duncan). Se vigilará la pérdida sanguínea mientras se realiza el desprendimiento y una vez expulsada debe evaluarse la cantidad que se pierde en total.
4. Cuarto Período o de Puerperio Inmediato Dura dos horas y comprende la vigilancia y control de la madre, después del nacimiento y de expulsada la placenta. Durante esta etapa se practicarán los controles vitales seriados, control de altura uterina y control de pérdida sanguínea.(2)
SESIÓN 15 15 TOXEMIAS GRAVÍDICAS:
PREECLAMPSIA PREECLAMPSIA Y ECLAMPSIA
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a) b) c) d)
Hipertensión arterial. Edema. Proteinuria. Hiperactividad uterina.
Que pueden acompañarse a veces de convulsiones y coma, agrupándose con la denominación de toxemias gravídicas, para indicar que ocurren únicamente durante la gestación en una mujer que estuvo libre de estos trastornos antes del embarazo y en las veinte semanas de gestación. Mientras que por el contrario, puede haber trastornos hipertensivos debidos a patología vascular crónica, presentes antes de la gestación, que se complican con el estado de embarazo y que consecuentemente evoluciona evoluciona simultáneamente como trastornos hipertensivos y gestación. Por consiguiente, los trastornos hipertensivos en el embarazo se diferencian agrupándolos en: -
Trastornos hipertensivos originados únicamente en la gestación o toxemias gravídicas. Trastornos hipertensivos previos a la gestación.
La denominación de toxemia no corresponde precisamente a lo poco que se ha logrado conocer de estas entidades propias del embarazo, ni se ha descubierto toxina alguna como causa del cuadro que pueda justificar la denominación empleada. Por lo demás, el nombre ha hecho fortuna en obstetricia creando vivencia de la afección en la práctica clínica como muchas otras denominaciones en medicina, cuya etimología no corresponden precisamente a lo que representa y que el uso mantiene desde la antigüedad. Los franceses las agrupan en el término ³disgravidez´ y los alemanes en el grupo de las ³gestosis´ que en realidad es demasiado amplio.
a) Hipertensión Para considerar hipertensión debe existir aumento de la presión sistólica en 30 mmHg o aumento de la presión diastólica en 15 mmHg sobre s obre cifras de presión conocidos anteriormente. O puede considerarse en general valores de presión sistólica de 14 o más y de diastólica en 9 o más.
b) Edema El edema se presenta de preferencia en la cara y extremidades por acumulación excesiva de líquido tisular, debido prácticamente a la retención de sodio y agua. Se
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No siempre corresponde a trastornos hipertensivos, pues su etiología puede estar también en hipoproteinemia, ingesta excesiva de sal, compresión del sistema venoso de las extremidades inferiores, acción estrogénica , hormona hor mona antidiurética, etc.
c) Proteinuria Se considera proteinuria cuando se comprueba la existencia de proteínas en cantidad de un gramo o más en una muestra de orina o cuando exceden de 300 mg en orinas de 24 horas. Debe comprobarse en dos oportunidades separadas con diferencia de 24 horas.
d) Hiperactividad uterina A la triada clásica de hipertensión, edema y proteinuria, nosotros le agregamos la hiperactividad uterina, comprobable clínicamente a veces en forma temprana desde el primer trimestre, lo que puede ser signo precoz para el pronóstico y en especial para desde ya tomar medidas preventivas. pre ventivas. Hay exacerbación de la actividad uterina que se manifiesta por contractibilidad más intensa y frecuente durante la gestación, cuyas manifestaciones pueden ser confundidas con la amenaza de aborto y establecerse erróneamente el tratamiento correspondiente. Avanzada la gestación las contracciones de Braxton Hicks son de mayor intensidad, frecuencia y duración.
REQUISITOS PARA CLASIFICAR LAS CLASES DE TOXEMIA a) Toxemia gravídica aguda
Preeclampsia.- La aparición después de las veinte semanas de gestación de hipertensión, albuminuria o edema patológico justifica diagnosticar diagnosticar preeclampsia. pr eeclampsia. Eclampsia.- En una embarazada o puérpera las convulsiones y coma constituyen eclampsia cuando coexisten hipertensión edema o albuminuria. b) Enfermedad vascular hipertensiva crónica
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a) Enfermedad vascular hipertensiva crónica sin toxemia aguda sobreañadida. - Mujeres en quienes se comprueba hipertensión antes de comenzar el embarazo. - Mujeres con hipertensión antes de la vigésima semana s emana de embarazo. b) Enfermedad vascular hipertensiva crónica con toxemia aguda sobreañadida. 3. Toxemia recurrente. 4. Toxemia no clasificada. Se diagnostica toxemia recurrente cuando después de un embarazo complicado de toxemia aguda se encuentran en un embarazo ulterior signos toxémicos. No debe haber hipertensión con albuminuria albuminuria y edema en los intervalos entre los embarazos. embaraz os. La toxemia no clasificada comprende a los trastornos que no pueden incluirse en otros grupos a causa de datos insuficientes o de mejores investigaciones.
Frecuencia y riesgo Entre 1.2 y 1.6 por mil partos. En las Antillas 27 por mil, en Italia 4 por mil. En Georgia (USA) 10 por mil. En realidad las cifras son muy variables de un país a otro y prácticamente de un hospital a otro según el nivel de las pacientes que atienden. En nuestro medio no hemos podido precisar cifra. El riesgo de toxemia es mayor en primigestas jóvenes y en primigestas de más de 35 años. También el riesgo de toxemia es mayor en gestantes con enfermedad hipertensiva previa, diabetes, obesidad, gestación múltiple, polihidramnios, estado socio económico bajo y por supuesto en la falta de control prenatal como factor importantísimo de alto riesgo en obstetricia. En la primigesta hay mayor tendencia a la retención de líquidos y esta predisposición contribuye como un factor de riesgo. Es interesante mencionar que el hábito de fumar determina notoria disminución en la
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llega a adquirir el tamaño normal, lo mismo que la placenta que igualmente no alcanza su desarrollo normal encontrándose ambos en la toxemia gravídicas con tamaño inferior. Esta teoría supone que el flujo sanguíneo que recibe el útero es inferior a lo normal, lo que en realidad sucede, ya que el volumen minuto de sangre en la placenta que ha sido calculada en 500 a 600 cc; en la eclámptica apenas si llega a los 200 cc evidenciando la grave disminución de riego sanguíneo que se encuentra en la toxemia gravídica. La isquemia placentaria produce zonas de infarto a nivel de la misma placenta, cirrosis vellositaria, disminución del espacio intervelloso y de la superficie vellositaria. Las zonas de tejido placentario en degeneración liberarían una sustancia (histerotinina o tromboplásica de Hunter y Howard), la albuminuria se produciría por modificaciones a nivel del glomérulo causadas por la misma hipertensión. Nelson, recientemente, después de estudiar los lípidos en madre, feto y placenta encuentra aumento de los triglicéridos en la placenta de las madres toxémicas, suponiendo que la acumulación de estos en la placenta supone cambios degenerativos que ocurren en este órgano por isquemia útero-placentaria, al continuar el fenómeno se produce la necrosis celular, siendo posible que las células necróticas liberen factores de coagulación hacia el espacio intervelloso. La liberación de estas sustancias causa depósito intravascular de fibrina que explicaría las lesiones observadas en el hígado, riñones y cerebro de la eclámptica. Perturbaciones en la producción de algunas prostaglandinas de útero y placenta, participarían como factores etiológicos en el desencadenamiento desencadenamiento de las manifestaciones toxémicas del embarazo. Hay que señalar también que en la etiología de las toxemias gravídicas existen factores de predisposición entre los cuales podemos citar la hipertensión arterial, nefritis crónica, diabetes. Estas enfermedades precisamente son las que suelen producir el síndrome de insuficiencia placentaria y por ende predisponen a la toxemia gravídica. También se señalan entre los factores predisponentes: el embarazo gemelar, el hidramnios agudo, la mola hidatiforme, etc., procesos en los cuales el útero puede ser llevado a estado de distensión con los consiguientes fenómenos de isquemia útero-placentaria.
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La eclampsia se caracteriza por la aparición de uno o más crisis convulsivas, clínicamente análogas a las crisis epilépticas seguidas de coma. En sus pródromos la cefalea se hace más intensa, así como las náuseas y vómitos, hay exacerbación del dolor epigástrico (signo de Chaussier), la tensión arterial aumenta con disminución marcada de la diferencial y se s e encuentra hiperreflexia. La eclampsia confirmada puede pasar directamente al estado de coma sin convulsiones previas, pero lo frecuente es el ataque eclámptico siga cuatro c uatro fases: 1. Período de invasión por contracciones fibrilares. 2. Período de contracciones tónicas al que se pasa bruscamente con opistótonos y rigidez de los miembros en extensión. 3. Período de convulsiones convulsiones clónicas que se inician inicia n con una larga inspiración seguida s eguida de convulsiones convulsiones generalizadas. 4. El coma sigue la fase eclámptica y puede ser más o menos profundo. El número de crisis es variable, puede ser una o repetirse seguidamente. Al despertar la paciente se encuentra en amnesia. a mnesia.
Fisiopatología 1. Todos los signos y síntomas de las toxemias gravídicas se pueden explicar de manera adecuada por la retención de sodio y la vasoconstricción generalizada presentes en esta afección. Así pues el mayor aumento de peso y el edema se explican por la mayor retención de sodio. La disminución del riego sanguíneo de una región particular dependiendo de la vasoconstricción cerebral aumentada produce isquemia que origina coma y convulsiones. La constricción de los vasos periféricos explican el aumento de la presión arterial. Por último, la mayor vasoconstricción en la circulación renal, explica en parte la disminución de la excreción renal. Así pues cabe deducir que la vasoconstricción es la anomalía más importante de la que depende la enfermedad vascular de la madre y las lesiones del feto en las toxemias gravídicas.
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6. En la toxemia gravídica hay hipertonía e hiperirritabilidad uterina. La actividad contráctil del útero durante el embarazo se encuentra aumentada y tanto más elevada cuanto mayor es la gravedad del cuadro. Aunque la paciente no se encuentre en trabajo de parto las pequeñas contracciones desaparecen y las contracciones de Braxton Hicks aumentan en intensidad y frecuencia llegando a valores que sobrepasan a los que se encuentran durante el parto. 7. La isquemia útero placentaria trae como consecuencia la producción de sustancias vasoconstrictoras que pasan a la circulación donde causan espasmos manifiestos en los diversos territorios del organismo. Además estos fenómenos isquémicos útero-placentarios causan elevada mortalidad natal y perinatal, ya que la nutrición del feto se encuentra muy afectada debido al insuficiente aporte de anabolitos y de oxígeno, debido a la reducción del flujo de sangre materna por el espacio intervelloso a las lesiones a nivel placentario que disminuyen la capacidad de la placenta para los intercambios fetomaternos. Ambas causas contribuyen a que tanto el peso del feto como la saturación de oxígeno en la sangre arterial de cordón sean muy inferiores en las toxemias en relación con lo que se encuentra en los embarazos normales. 8. Niveles altos de alfa-fetoproteína en el suero materno, en ausencia de malformaciones del tubo neural, han sido reportados en casos de gestantes preeclámpticas con proteinuria.
Anatomía patológica No existen signos histopatológicos característicos de las toxemias gravídicas. Se encuentran lesiones generalizadas como cambios vasculares difusos. En el cerebro se encuentra edema, petequias múltiples y zonas hemorrágicas. En pulmones líquido pleural. El hígado lesiones periportales y necrosis de células hepáticas. A nivel renal se encuentra en la eclampsia frecuentemente engrosamientos difusos de los capilares glomerulares.
Diagnóstico
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3. En el examen de fondo de ojo, que es muy importante en el manejo de la gestante toxémica, se encuentra EDEMA y ESPASMO ARTERIOLAR RETINIANOS pudiéndose pudiéndose encontrar enc ontrar hemorragias de retina y desprendimiento. desprendimiento. 4. Cuando se presentan cuadros convulsivos en gestantes que han pasado las veinte semanas de gestación, durante el parto o dentro de las primeras 24 horas del puerperio, es casi seguro que el cuadro corresponde a una toxémica eclámptica. Sin embargo, debe tenerse presente los antecedentes epilépticos que pueda tener la paciente, así como los cuadros cua dros de trombosis de las venas cerebrales.
Métodos auxiliares en el diagnóstico 1. Registro reiterado de la presión arterial. 2. Control de peso, para descubrir al retención de líquidos, calificar el cuadro y establecer el tratamiento. 3. Análisis repetido de orina para investigar y dosar proteinuria a fin de controlar la evolución y establecer el pronóstico y tratamiento. 4. Determinación del ácido úrico en sangre. Hallazgos mayores de 6 mg/100ml. están en relación con pronóstico severo. 5. El hematocrito como indicador del volumen intravascular, cuando aumenta en la toxemia ensombrece el pronóstico, pues indica disminución del volumen intravascular. 6. El aumento de las transaminasas es un índice de mal pronóstico. 7. Es importante la valoración de la función renal por determinación de los niveles plasmáticos de nitrógeno uréico y creatinina. Puede ser necesaria la depuración de creatinina en 24 horas.
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Preeclampsia leve Aparece discretamente y puede mantenerse hasta el final del embarazo, con manifestaciones que deben ser descubiertas en el control prenatal, pues lo frecuente es que sea progresiva y que desapercibidamente progrese a etapas más graves. Se caracteriza por: a) Tensión arterial entre 120/80 y 140/90 mmHg en pacientes controladas aumentó de 30 mmHg en la sistólica a 15 mmHg en la diastólica. Presión arterial media menor de 106 mmHg. b) Edema que aparentemente puede ser discreto, pero que se descubre con alza de peso desproporcionada en relación a los controles controles anteriores. c) Proteinuria de 1gr o más por litro 0 300 mg o más en orina de 24 horas. d) Los reflejos se mantienen normales y no hay trastornos visuales. e) No hay alteración en los factores fa ctores de coagulación ni trombocitopenia. f) No se objetivan alteraciones en el quimismo sanguíneo. Los datos de laboratorio indican creatinina 1 mg/100 ml úrea normal y ácido úrico igualmente entre límites máximos normales.
Preeclampsia moderada Objetivamente se aprecia en la gestante el edema de cara y manos y su referenciaal edema maleolar además de otros síntomas que la paciente percibe y que deben investigarse en la anamnesis y confirmarse con el examen exa men clínico. a) La tensión arterial definitivamente es alta, 150/100 mmHg, con las manifestaciones
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a) La tensión arterial definitivamente es alta, 160/110 mmHg, y más. Presión arterial media por encima de 126 mmHg. b) El edema se hace muy intenso y sumamente notorio en cara y extremidades, con tensión y deformación del rostro. c) La proteinuria se manifiesta en cantidades elevadas con pérdida de proteínas por esta vía. d) Al examen clínico la hiperreflexia es muy intensa y mucho más evidente a medida que la paciente está más cerca de convulsionar. e) El examen de fondo de ojo revela signos oculares típicos con espasmo arteriolar y edema de la retina. f) Puede haber dolor en epigastrio u opresión a nivel de la región torácica anterior, lo que es premonitor de que la embarazada está en riesgo de convulsionar. Cefalea, escotomas, tinitus. g) Hay hemoconcentración e hipovolemia. h) Trombocitopenia y peligro de alteración de los factores de coagulación. i) La creatinina y la úrea algo aumentadas, mientras que el ácido úrico aumenta por encima de 6 mg/100ml. j) Hay oliguria, menos de 500 cc en 24 horas y riesgo de anuria. k) El cuadro puede complicarse a esta altura con trastornos de hipofibrinogemia, hipovolemia y desprendimiento prematuro de placenta.
Pronóstico El pronóstico se agrava con las siguientes manifestaciones clínicas: a) Oliguria: menos de 500 cc de orina en 24 horas.
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Objetivos: 1. Detección y tratamiento precoz. 2. Controlar la preeclampsia preecla mpsia y prevenir la eclampsia. 3. Reducir el vaso espasmo. 4. Prevenir las complicaciones cerebrales, renales y oftálmicas. 5. Recordar que las toxemias del embarazo se complican con desprendimiento prematuro de placenta, debido a la hiperactividad uterina. Así como también, coagulación intravascular diseminada. 6. Vigilar el estado fetal y prevenir riesgos que comprometan la vitalidad fetal, dirigiendo el caso de acuerdo a la calificación de alto riesgo. Preeclampsia leve
1. Muy buenos buenos resultados se obtienen limitando las actividades, por lo tanto ta nto se indicará reposo en cama, de preferencia en decúbito lateral, permitiendo mayor flujo sanguíneo renal y uterino, e impidiendo la compresión de los grandes vasos por el útero. 2. Dieta balanceada. 3. Controles diarios de peso y presión. pr esión. 4. Reposo en decúbito lateral izquierdo. 5. Control semanal por consultorio de alto riesgo. 6. Sedantes del tipo del diacepam, dia cepam, si fueran necesarios. O fenobarbital. fe nobarbital. 7. Análisis de control prenatal. 8. En caso de progresar el cuadro indicar hospitalización para mejor vigilancia y tratamiento.
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1. Reposo absoluto en cama especial con barandas. Aislamiento en ambientes libre de estímulos como luces y sonidos. Disponer a la mano del material indispensable en previsión para el caso que la paciente convulsione. convulsione. 2. Examen clínico reiterado, control de reflejos, fondo de ojo, diuresis. Control de presión arterial y latidos fetales. 3. Indicación para el control de orina en 24 horas, proteinuria en muestras aisladas y en 24 horas, control de peso diario. Igualmente, se indicarán los exámenes auxiliares necesarios: creatinina, ácido úrico, proteínas totales, electrolitos, balance hídrico, hematocrito, transaminasas, factores de coagulación, tiempo de protombina, tromboplastina y los que se requieran para conocer el estado de la paciente, evolución, pronóstico, riesgos y detección de complicaciones. 4. Determinación del estado fetal y las pruebas necesarias de acuerdo a la calificación de alto riesgo, para la vigilancia del producto. 5. Calificada la preeclampsia severa debe establecerse el tratamiento de acuerdo a las siguientes pautas: a) Favorecer la diuresis. b) Corregir la hemoconcentración, administrando líquidos por venoclisis, como glucosa al 5%, evitando evita ndo la sobrehidratación. c) Sedación, mediante diacepam o fenobarbital. d) Promover la vasodilatación y controlar la hipertensión. Se indicará hidralacina o metildopa. No bajar mucho la presión por el peligro de disminuir el flujo sanguíneo. e) Reponer la pérdida de proteínas con dieta balanceada e hiperporteica. Limitar el consumo de sal. 1. Cuando el cuadro se ha estabilizado y el tiempo de gestación sea de 38 semanas, es recomendable proceder a la terminación del embarazo, mediante la inducción,
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1. 2. 3. 4. 5. 6. 7. 8.
Cama con barandas laterales para proteger a la paciente durante las convulsiones. convulsiones. Cuidado y protección de la boca y medidas para evitar mordeduras en la lengua. Aspiración aérea en caso necesario. Control repetido de presión arterial, latidos fetales y actividad uterina. Auscultación frecuente del tórax. Cuidados durante la convulsión. Balance hidroelectrolítico. Administración de sedantes, anticonvulsivantes e hipotensores. a) Es preferible de entrada 5 a 10 mg de diacepam, por vía intravenosa, lentamente en un minuto, con supresión inmediata de la convulsión. Puede continuarse con 5 a 20 mg por vía intramuscular. b) Fenobarbital de 30 a 60 mg por vía intramuscular cada 6 horas. c) Si se prefiere puede usarse como anticonvulsivante, sulfato de magnesio de 2 a 4 gr lentamente por vía endovenosa en 4 a 6 minutos. d) Administrar antihipertensivos. 1. Oxigenoterapia en caso de cianosis o edema pulmonar.
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ETIOLOGÍA Las causas del aborto abort o espontáneo se pueden agrupar en: * Anomalías del huevo * Anomalías del aparato reproductor * Enfermedades generales de la madre CRITERIOS DE DIAGNÓSTICO El diagnóstico del aborto se basa, principalmente, en los criterios clínicos. Para que un embarazo temprano termine en un aborto espontáneo, ha tenido que pasar por estadíos o fases evolutivas: Criterios para el diagnóstico de los estadíos del aborto ESTADÍO
DOLOR SANGRA DO
ESTADO DEL
ESTADO DE
EXPULSI ÓN DE
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b. Complicación infecciosa, originada por contaminación de bacterias que migran de la vagina a la cavidad uterina, en donde los restos feto-placentarios y los coágulos de sangre actúan como medios de cultivo, si no son retirados a tiempo.
EMBARAZO EC TÓPICO Un óvulo fecundado que se implanta fuera de la cavidad uterina significa un embarazo ectópico. Esto sucede una vez en 150-200 concepciones. Ocurre 90% en las trompas de Falopio, y cerca de 60% de éstos se presentan del lado derecho. Casi 80% se diagnostican dentro de los dos primeros meses consecutivos a la concepción. El embarazo ectópico puede tener lugar en cualquier etapa de la vida reproductiva, pero en 40% de los casos ocurre en mujeres entre lo 20 y 29 años de edad. La frecuencia de embarazo extrauterino es inversamente proporcional a la paridad; es decir, es mayor en las pacientes infértiles (especialmente en las mujeres con esterilidad secundaria o postparidad única). No existe una predisposición racial, pero el embarazo ectópico
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El sangrado puede cesar temporalmente después de la ruptura extra o intracapsular, pero pero el embrión sobrevive raras veces. En casos excepcionales el embarazo puede proseguir si se conservar una porción suficiente de placenta adherida, o cuando sucede una implantación secundaria en otro sitio. s itio. El cuerpo amarillo del embarazo continúa su desarrollo mientras el trofoblasto permanezca viable. El útero se agranda un poco y se reblandece; contiene decidua pero no trofoblasto. Al morir el producto, la decidua se desprende y sobreviene un sangrado. Solamente en casos de embarazo intersticial intersticial el útero drena el sangrado tubárico. Terminación del Embarazo El embarazo ectópico puede terminar como sigue: s igue: a) Tubárico: aborto tubárico, aborto tubárico retenido, ruptura al ligamento ancho, ruptura a la cavidad ca vidad peritoneal.
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c) Dolor abdominal, ocasionado por la ruptura de la bolsa corioamniótica, con hemorragia local o secundaria al crecimiento del producto, pulsión y tracción. d) Masa pélvica, correspondiente al crecimiento del del producto; a hematoma, hematoma, por desprendimiento de la placenta o por sangrado del órgano huésped; adherencias intestinales intestina les y de epiplón, o infección.
Diagnóstico Diferencial Existen cerca de 50 condiciones patológicas que presentan similitud clínica con el embarazo ectópico. Las más comunes de éstas son la apendicitis, la salpingitis, quiste roto del cuerpo lúteo o de un folículo ovárico, y el aborto uterino.
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MOLA HIDATIDIFORME Se llama así a la anormalidad de la placenta, caracterizada por degeneración hidrópica de las vellosidades coriales con proliferación del trofoblasto; es de naturaleza benigna. Corresponde a un grupo de anormalidades del trofoblasto que, bajo la denominación de enfermedad del trofoblasto, tienen características comunes como su potencial
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reportes se deba a los diagnósticos, cada vez más precoces. Se describe una incidencia que oscila entre el 5 y el 27%. Los quistes teca-luteínicos se producen por una respuesta exagerada de los ovarios a niveles altos de hormona gonadotrofina coriónica, generalmente son bilaterales y se reporta con una frecuencia de 15 a 25%. Pueden sufrir complicaciones como torsión de pedículo, necrosis y ruptura; de no ser así, regresionan espontáneamente al ser evacuada
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PLACEN TA PREVIA Se llama así a la placenta implantada en el segmento inferior del útero, muy cerca del orificio cervical interno, cubriéndolo parcial o totalmente. Constituye una causa importante de muerte tanto para la madre como para el feto y el recién nacido. na cido.
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* P lacenta parcial mente el orificio ya mencionado. lacenta previa parcial la placenta cubre parcialmente * P lacenta lacenta previa marginal cuando la placenta está implantada muy cerca del orificio cervical, sin llegar a cubrirlo ni parcial ni totalmente; pero puede ocasionar sangrado conforme el cérvix se dilata.
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* Signos de sufrimiento fetal. Las manifestaciones clínicas del desprendimiento prematuro de placenta generalmente son proporcionales a la magnitud del problema, sin embargo, existe un porcentaje minoritario de pacientes en las que no es así, que aunque el cuadro es catastrófico, tienen pocas manifestaciones clínicas.
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