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Dr. José Rafael Olmedo FloresMédico Residente de Ginecología y Obstetricia

SANGRADODE !" #R$MES#RE

%om&le'o (os&italario Dr. Man)el Amador G)errero

E A*OR#O

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$N#ROD+%%$,Na &alabra aborto &ro-iene del -ocablo latín AB /)e

signi0ca &ri-ar o &ri-aci1n lo c)al nos da a entender /)eesta &alabra en s) &rimera &arte se2ala /)e el aborto es la&ri-aci1n de algo.

a otra &arte de la &alabra es ORTUS lo c)al signi0canacimiento.

“La privación del nacimiento”

2

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DEF$N$%$,NEs la &erdida de la gestaci1n

antes de las 33 semanas deembara4o o la e5&)lsi1n de)n &rod)cto con &eso de 677gramos o menos.

3

*aillieres *est 8ract Res %lin ObstetGynaecol. 37779!:;6?@

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% AS$F$%A%$,NTEMPRANO < 12Semanas

TARDÍO >12 y

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% AS$F$%A%$,NESPONTANEO

AMENAZA DEABORTO

ABORTO ENEVOLUCIONABORTO INEVITABLEABORTOINCOMPLETOABORTO COMPLETOABORTO DI ERIDOABORTO AREPETICI!N

ABORTO SEPTICO

INDUCIDO

A*OR#O #ERA8E+#$%OA*OR#O EGA% ANDES#$NO

E E%#$ O

"

Estadíos %línicos

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DEF$N$%$ONS#

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AMENBA DE A*OR#OSangrado &ro-iniente de ca-idad )terina;$era manifestacion<%ontracciones )terinas dolorosasA)sencia de modi0caciones cer-icales.

8)ede afectar ! de cada 6 embara4osa mitad c)lminara en aborto

$

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D$AGNOS#$%O8resencia de -italidad del embrionCfeto.

8r)eba de embara4o &ositi-aSangrado de magnit)d -ariable

+SG= 8resencia de F%Fmo-imientos fetales -is)ali4aci1ndel saco -itelino

%

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$NE $#A* EDilatacion del c)ello con rot)ra

franca de membranas mani0esta&or la e5&)ls)ion de A.

%)ando membranas o-)laresfeto o &lacenta son -isibles atra-és del ori0cio cer-ical

&

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D$AGNOS#$%O(emorragia

R)&t)ra de membranas consalida de li/)ido amniotico

1'

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A*OR#O $N%OM8 E#OEs la e5&)lsi1n &arcial de los

&rod)ctos o-)lares a tra-és del

cer-i58ersistencia del dolor ti&o c1licoemorragia

El ori0cio cer-ical &ermanecedilatado

12

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A*OR#O %OM8 E#OEs la e5&)lsi1n com&leta y

es&ont nea de los &rod)ctosde la conce&ci1nse da )na regresi1n de los

síntomasDismin)cion del sangrado ydolor.

13

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A*OR#O RE%+RREN#EEs la &érdida es&ont nea de ? o m sembara4os consec)ti-osSe dan dentro de la 6 a !3 semanasSe debe est)diar &or $$%enfermedades a)toinm)nes.

14

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A*OR#O S 8#$%OAborto incom&leto no res)elto sons)ce&tibles a infecciones ascendentesdesde el cér-i5 -agina y -)l-a

FiebreDolor &él-ico generali4ado o locali4ado(emorragia genitalFl)'o -aginal fétido

1"

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A*OR#O S 8#$%Oa infecci1n es &olimicrobiana=E. coliEnterobacter aerogenes8rote)s -)lgarisEstre&tococo emolíticosEsta0lococosclostridi)m &erfringes

1#

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$N%$DEN%$AEl aborto es&ontaneo es la com&licaci1n m scom n del embara4o tem&rano

a frec)encia dismin)ye con el incremento dela edad gestacional

(ay dos escenarios

%linicamenteconocido

S)bclínico

1$

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$N%$DEN%$A1%

EM*ARABO %ONO%$DO

>C37H Aborto Es&ontaneo

Riesgo Relati-o 7.IHDes&)és de la semana !6

>7H!3sem

ang K % en % ang % en D G)ang Frenc J%once&tion early &regnancy loss and time to clinical &regnancy= a &o&)lationCbased&ros&ecti-e st)dy. Fertil Steril. 377?9L@;?

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$N%$DEN%$A1&

EM*ARABO NO %ONO%$DO

!?C3I H AbortoEs&ontaneo

?!H oc)rre des&)és de laim&lantaci1n

ang K % en % ang % en D G)ang Frenc J%once&tion early &regnancy loss and time to clinical &regnancy= a &o&)lationCbased&ros&ecti-e st)dy. Fertil Steril. 377?9L@;?

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$N%$DEN%$A2'

6!> N)li&aras 37C?:y

3IH

I:H 3H

>H

ang K % en % ang % en D G)ang Frenc J

%once&tion early &regnancy loss and time to clinical &regnancy= a &o&)lationCbased&ros&ecti-e st)dy. Fertil Steril. 377?9L@;?

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FA%#ORES DER$ESGO• Edad materna

a-an4ada•

Aborto es&ontaneo&re-io• F)mar d)rante el

embara4o22

3

FA%#ORES DE

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FA%#ORES DER$ESGO

FA%#ORES RE8ROD+%#$ OS

+SO DE MED$%AMEN#OS S+S#AN%$AS

O#ROS FA%#ORES

23

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FA%#ORES

RE8ROD+%#$ OS

24

@

!L 37

:7

>7

EDAD MATERNA ) TASA DE ABORTO ESPONTANEO

Nybo Andersen AM o lfa rt J % ristens 8 Olsen J Melbye MMaternal age and fetal loss= &o&)lation based register lin age st)dy. *MJ.37779?37;L36!.

Denmar from!@L> to !@@39 atotal of I?: 3L3

omen and ! 33!6:I &regnancyo)tcomes.

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FA%#ORESRE8ROD+%#$ OSABORTO ESPONTANEO PREVIO

2"

37

3>

:?

En m)'eres conembara4o anteriory &rod)cto -i-o latasa de aborto f)ede solo 6H

Regan *ra)de 8R #rembat 8 . $nP)ence of &ast re&rod)cti-e&erformance on ris of s&ontaneo)s abortion. *MJ.!@>@93@@;II@>

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FA%#ORESRE8ROD+%#$ OSMULTIPARIDAD

No ay datos claros sobre el efecto dela m)lti&aridad sobre la &robabilidad deaborto sin embargo el &eriodointergenesico corto &)ede ser )n factor

de riesgo &ara aborto es&ontaneo.

2#

Roman EA Alberman E 8 aroa 8O. 8regnancy order andre&rod)cti-e loss. *r Med J !@>79 3>7=L!6.

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FA%#ORESRE8ROD+%#$ OSTIEMPO PROLON*ADO ENTRE

OVULACION E IMPLANTACI!Nas &erdidas tem&ranas an sidoasociadas a )n retardo en la im&lantaci1n;Q!7 dias<

2$

ilco5 AJ *aird DD einberg %R. #ime of im&lantation of t econce&t)s and loss of &regnancy. N Engl J Med !@@@9 ?:7=!L@I.


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FA%#ORESRE8ROD+%#$ OSP+,m,-es.as .a+/0as

Est)dios obser-acionales s)g)ieren /)eay )n riesgo a)mentado de abortoes&ontaneo en este gr)&o de m)'eres.

2%

A5mon A (agmar . #ime to &regnancy and &regnancy o)tcome. Fertil Steril 37769 >:=@II.

Jo e M i B. Association of time to &regnancy and t e o)tcome of &regn

ancy. Fertil Steril !@@:9 I3=L!.

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F+MAR

F)mar m s de !7 cigarrillos &or día estaasociado con )n incremento del riesgorelati-o de &erdida del embara4o ;RR !.3 a?.:<Se asocia a defectos cromosomicos del&rod)cto &or mecanismos no m)y bienconocidosEl ser f)madora &asi-a tambien estaasociado a riesgo de &erdida del embara4o

2&

% ateno)d 8ara44ini F di %intio E et al. 8aternal and maternal smo ing abits before conce&tion and d)ring t e 0rst trimester= relation to s&ontaneo)s abortion. Ann E&idemiol !@@>9 >=637.

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A %O(O%ons)mo moderado alto de alco ol incrementael riesgo de aborto es&ontaneoEn )n est)dio se describe /)e el cons)mo de m s

de ? co&as &or semana d)rante el &rimertrimestre a)mento el riesgo de aborto es&ontaneo.El alco ol es teratogeno y no ay )na dosis oni-el Tseg)roU &or lo /)e debe ser e-itado d)ranteel embara4o.

3'

ind am G% on *e ren J Fenster et al. Moderatematernal alco ol cons)m&tion and ris of s&ontaneo)sabortion. E&idemiology !@@L9 >=67@.

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%O%A$NAEl )so de cocaina esta identi0cado como )nfactor de riesgo &ara aborto es&ontaneo.+n est)dio reali4ado en )na &oblaci1n de 6L7m)'eres conocidas &or )so de cocaina secom&robo el )so de la s)stancia en ebras decabello se com&robo )n incremento en la&re-alencia de aborto es&ontaneo;OR !.:9 @6H %$ !.7C3C!<

31

Ness R* Grisso JA (irsc inger N et al. %ocaine and tobacco )se and t e ris of s&ontaneo)s abortion. NEngl J Med !@@@9 ?:7=???.


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A$NESEl )so de A$NES e5ce&to acetaminofenin iben el rol de las &rostaglandinasencargadas de fa-orecer la im&lantaci1n&or lo /)e s) )so alrededor del tiem&o dela conce&ci1n esta asociado abortos.

32

i DV i) Odo)li R. E5&os)re to nonCsteroidal antiCinPammatory dr)gs d)ring &regnancy and ris of miscarriage= &o&)lation based co ort st)dy. *MJ 377?9 ?3

L=?I>.

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%ONS+MO DE %AFE$NAEn general e5isten metaCanalisis deest)dios controlados donde se aobser-ado la asociaci1n entre altas dosisde cafeína y el riesgo de abortoes&ontaneo sin embargo no se anidenti0cado las dosis e5actas a las /)eesto oc)rre y el mecanismo /)e &rod)ce

el aborto.

33

Grosso M *rac en M*. %a eine metabolism genetics and &erinatal o)tcomes= a re-ie of e5&os)re assessment considerations d)ring &regnancy. Ann E&idem

iol 37769 !6=:I7.

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O#ROS FA%#ORES

34

*AJOS N$ E ES DEFO A#O%arioti&o Normal -s

Anormal ;IC!3sem<

S)&lementos deWcido F1lico

NO 8RE $ENENA*OR#O

X3.!@ngYd

8RE $ENENDEFE%#OS DE #+*O NE+RA

George Mills J Jo ansson A et al. 8lasma folate le-els and ris of s&ontaneo)s abortion. JAMA 37739 3>>=!>IL.


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O#ROS FA%#ORES

3"

!>.6

36- m2

$ndice de masa cor&oral &re-io al embara4o

(elgstrand S Andersen AM. Maternal )nder eig t and t e ris of s&ontaneo)s abortion. Acta Obstet Gynecol Scand 37769 >:=!!@L.


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O#ROS FA%#ORES

3#

F$E*RE• #em&erat)ra de ?L.>"% o m s d)rante el

embara4o &)ede incrementar el riesgo deaborto &ero esto solo se a est)diado en doslargos trials con res)ltados inconsistentes.

Vline J Stein B S)sser M arb)rton D. Fe-er d)ring &

regnancy and s&ontaneo)s abortion. Am J E&idemiol !@>69 !3!=>?3.

Andersen AM astr)& 8 o lfa rt J et al. Fe-er in &regnancy and ris of fetal deat = a co ort st)dy. ancet 377

39 ?I7=!663.

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O#ROS FA%#ORESENFERMEDAD %E $A%A

a enfermedad celiaca sin tratamiento estaasociada a )n alto riesgo de aborto es&ontaneo.

3$

*)stos D Moret A #amb)tti M et al. A)toantibodies in Argentine omen it rec)rrent &regnancy loss. Am J Re&rod $mm)nol 377I9 66=37!

.*radley RJ Rosen M8. S)bfertility and gastrointestinal disease= Z)ne5&lainedZ is often )ndiagnosed. Obstet Gynecol S)r- 377:9 6@=!7>.

Sta4i A Manto-ani A. [%eliac disease. Ris factors for omen in re&rod)cti-e age\. Miner-a Ginecol 37779 63=!>@.

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E#$O OG]A

^% ales son las ca)sas m s com)nesa las /)e se asocian los abortos_

3%

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FA%#ORESFE#A ESDEFE%#OS %ROMOSOM$%OS

as anomalias cromosomicas re&resentan la !` ca)sa de

aborto es&ontaneo an sido detectadas en el 67H detodos los abortos.

3&

Sacoacío @7H>C!!sem

67H

!IC!@Sem?7H

P+e a en5,a /e /e6e5.7s en e 5a+,7.,87

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FA%#ORESFE#A ESDEFE%#OS %ROMOSOM$%OS

a &re-alencia y ti&os de anormalidades cromosomicas se

obser-aron en la re-isi1n de > >:! abortos es&ontaneos delos c)ales el :!H res)ltaron con carioti&o anormal los m scom)nes f)eron=

#R$SOM$AS A+#OSOM$%AS 63HMONOSOM$A K !@H

8O $8 O$D$AS 33HO#RAS LH

4'

(s) F. 8renatal diagnosis of c romosomal abnormalities t ro)gamniocentesis. $n= Genetic disorders and t e fet)s :t ed Mil)ns y A ;Ed<

# e Jo ns (o& ins +ni-ersity 8ress *altimore !@@>. &.!L@

TRISOMIA1#

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FA%#ORES FE#A ESANOMALIASCON*ENITAS

P9e/en se+ 5a9sa/as87+ 87+ an7ma ,as-ene.,5as 7 6a5.7+ese:.e+n7s 57m7 ;an/a

amn,7.,5a 7 e:87s,5,7na .e+a.7-en7s

TRAUMAS

P+75e/,m,en.7s 57m7.7ma /e m9es.+as /e

e 7s,/a/es 57+,7n,5as7 amn,75en.es,s 89e/en

e a+ a a;7+.7

41

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FA%#ORES MA#ERNOS

42

En )na re-isi1n de m)'eres embara4adas con malformaciones)terinas no tratadas la tasa de abortos f)e la sig)iente=

+tero +nicorne ?I.6H+tero Didelfo ?3.3.H+tero *icorne ?IH+tero Se&tado ::.?H+tero Arc)ato 36.LH

Miomas S)bm)cosos?>.6H

(einonen 8V Saari os i S 8ystynen 8. Re&rod)cti-e &erformance of omen it )terine anomalies. An e-al)ation of !>3 cases. Acta Obstet Gynecol Scand !@>39 I!=!6L.


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FA%#ORES MA#ERNOS

43

$NFE%%$ONES

isteria

#o5o&lasmosis

%itomegalo-ir)s

ME#A*O $%AS

Disf)nci1n #iroidea

SO8

Diabetes Mellit)s

A+#O$NM+NES

SAF

ES*aird DD einberg %R ilco5 AJ et al. (ormonal &ro0les of nat)ralconce&tion cycles ending in early )nrecogni4ed &regnancy loss. J %lin

Endocrinol Metab !@@!9 L3=L@?.


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8RESEN#A%$,N% ]N$%A

4"

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8RESEN#A%$,N % ]N$%A

4#

Sangrado aginal

Dolor *Y #i&o %1lico

(alla4go de +SG

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SANGRADO AG$NAEl sangrado -aginal /)e acom&a2a alaborto &)ede ir desde sim&les gotas asta&erdidas im&ortantes /)e lle-en al s ocemorragico.El sangrado -aginal es com)n en el &rimer

trimestre y &)ede oc)rrir en el 37 al :7H detodas las embara4adas.

4$

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SANGRADO AG$NA4%

Deaton J (onoré GM () man %S *a)g)ess 8. Early trans-aginal )ltraso)nd follo ing an acc)rately dated &regnancy= t e im&ortance of 0ndi

ng a yol sac or fetal eart motion. ()m Re&rod !@@L9 !3=3>37.

Est)dio 8ros&ecti-o : 777M)'eres

Aborto !3H sangrado!?H sin Sangrado

DiagnosticoDiferencial Restos O-)lares

@7C@IHsangraron LC!!

sem

Sangrado 8rof)so


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EVALUACI!NCLÍNICA DE LA

PACIENTE

4&

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EKAMENES DE

A*ORA#OR$O

"'

* %G

Relaci1n con el +SG

Est)dio seriado

R

R ;D

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"1DIA*NOSTICO

DI ERENCIAL

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"2

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"3

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"4

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""

"

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MANEJO

"#

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LUI AMEUEs a e a59a5,=n /e 57n.en,/79.e+,n7 87+ me/,7 /e as8,+a5,=n

57n 5 n9 asLa AMEU s= 7 se 89e/e ?a5e+ s,n+,es-7 as 8+,me+as 12 semanas@3 meses /e em;a+a 7

Es a e:.+a55,=n /e

57n.en,/7 9.e+,n7 a .+a s/e +as8a/7 87+ me/,7 /e9na 59+e.a

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"%M,s78+7s.7 as .?e 8+,ma+y a-en. 67+

me/,5a a;7+.,7n ,n a 7 ,n57me 9+;an

se..,n-*orgatta M)llally * rago-ic O Gittinger E % en A.S79+5eDe&artment of Obstetrics and Gynecology *oston +ni-ersity Sc ool of Medicineand *oston Medical %enter >6 East %oncord Street It Floor *oston MA 73!!>+SA. lynn.borgatta bmc.orgA;s.+a5.

# e &)r&ose of t is st)dy as to assess t e o)tcomes of early medical abortionin an innerCcity os&ital abortion ser-ice )sing miso&rostol as t e &rimary agent.

# is as a retros&ecti-e c art re-ie from J)ly 377! t ro)g December 3773.omen ere eligible if t ey ad a -iable &regnancy it gestational age > ee s

or less by trans-aginal )ltraso)nd and no medical contraindications. # o doses of>77 microg miso&rostol ere administered -aginally 3: a&art. $nitial follo C)&

as sc ed)led 3C? days later. Of t e ::7 omen o )nder ent medicalabortion ?L? ;@7.>H @6H con0dence inter-al ;%$< >>C@:H< com&leted abortionmedically ?> ;@.3H< ad )terine as&iration and t e remainder ad incom&lete orno follo C)&. Of )terine as&irations !! ere medically indicated gi-ing a rate ofindicated as&iration of 3.LH. Gestational age age gra-idity &arity &ast abortion

istory et nic gro)& and &ayer did not signi0cantly correlate it o-erall rate ofas&iration or rate of follo C)& b)t gestational age as correlated it medicallyindicated as&iration. Among 6L omen o re&orted a time of tiss)e &assage

C

http://www.ncbi.nlm.nih.gov/pubmed?term=Borgatta%20L%5BAuthor%5D&cauthor=true&cauthor_uid=15288216http://www.ncbi.nlm.nih.gov/pubmed?term=Mullally%20B%5BAuthor%5D&cauthor=true&cauthor_uid=15288216http://www.ncbi.nlm.nih.gov/pubmed?term=Vragovic%20O%5BAuthor%5D&cauthor=true&cauthor_uid=15288216http://www.ncbi.nlm.nih.gov/pubmed?term=Gittinger%20E%5BAuthor%5D&cauthor=true&cauthor_uid=15288216http://www.ncbi.nlm.nih.gov/pubmed?term=Chen%20A%5BAuthor%5D&cauthor=true&cauthor_uid=15288216http://www.ncbi.nlm.nih.gov/pubmed?term=Chen%20A%5BAuthor%5D&cauthor=true&cauthor_uid=15288216http://www.ncbi.nlm.nih.gov/pubmed?term=Gittinger%20E%5BAuthor%5D&cauthor=true&cauthor_uid=15288216http://www.ncbi.nlm.nih.gov/pubmed?term=Vragovic%20O%5BAuthor%5D&cauthor=true&cauthor_uid=15288216http://www.ncbi.nlm.nih.gov/pubmed?term=Mullally%20B%5BAuthor%5D&cauthor=true&cauthor_uid=15288216http://www.ncbi.nlm.nih.gov/pubmed?term=Borgatta%20L%5BAuthor%5D&cauthor=true&cauthor_uid=15288216

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#

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%ONS$DERA%$ONESEGA ES

A+.059 7 144 No se a&licar n las &enas se2aladas en los artíc)losanteriores=!. Si el aborto es reali4ado con el consentimiento de la m)'er &ara&ro-ocar la destr)cci1n del &rod)cto de la conce&ci1n oc)rridacomo consec)encia de -iolaci1n carnal debidamente acreditada eninstr)cci1n s)marial y3. Si el aborto es reali4ado con el consentimiento de la m)'er &orgra-es ca)sas de sal)d /)e &ongan en &eligro la -ida de la madre odel &rod)cto de la conce&ci1n.En el caso del n)meral ! es necesario /)e el delito sea deconocimiento de la a)toridad com&etente y /)e el mismo se&racti/)e dentro de los dos &rimeros meses de embara4o y en elcaso del n)meral 3 corres&onder a )na comisi1n m)ltidisci&linariadesignada &or el Ministerio de Sal)d determinar las ca)sas gra-esde sal)d y a)tori4ar el aborto.En ambos cases el aborto debe ser &racticado &or )n médico en )ncentro de sal)d del Estado.

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*$* $OGRAF]AS87n.ane79s a;7+.,7nF R,sG 6a5.7+sH e.,7 7-yH5 ,n,5a man,6es.a.,7nsH an/ /,a-n7s.,5

e a 9a.,7nA9.?7+s F #ogas #)landi MD M(%M (ayaM AlCFo4an MD

L,.e+a.9+e +e ,e 59++en. .?+79-?F A)g 37!?.

T?,s .78,5 as. 98/a.e/F ago 3I 37!?.

#1

#

http://www.uptodate.com/contents/spontaneous-abortion-risk-factors-etiology-clinical-manifestations-and-diagnostic-evaluation/contributorshttp://www.uptodate.com/contents/spontaneous-abortion-risk-factors-etiology-clinical-manifestations-and-diagnostic-evaluation/contributorshttp://www.uptodate.com/contents/spontaneous-abortion-risk-factors-etiology-clinical-manifestations-and-diagnostic-evaluation/contributorshttp://www.uptodate.com/contents/spontaneous-abortion-risk-factors-etiology-clinical-manifestations-and-diagnostic-evaluation/contributorshttp://www.uptodate.com/contents/spontaneous-abortion-risk-factors-etiology-clinical-manifestations-and-diagnostic-evaluation/contributorshttp://www.uptodate.com/contents/spontaneous-abortion-risk-factors-etiology-clinical-manifestations-and-diagnostic-evaluation/contributorshttp://www.uptodate.com/contents/spontaneous-abortion-risk-factors-etiology-clinical-manifestations-and-diagnostic-evaluation/contributorshttp://www.uptodate.com/contents/spontaneous-abortion-risk-factors-etiology-clinical-manifestations-and-diagnostic-evaluation/contributorshttp://www.uptodate.com/contents/spontaneous-abortion-risk-factors-etiology-clinical-manifestations-and-diagnostic-evaluation/contributors

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#2

#

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#3

TEd)caci1n se5)al&ara decidiranticonce&ti-os &arano abortar y abortolegal &ara no morirU

#

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#4

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