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Dr. Ruiz Villanueva Noe.
Asesor de caso.
Medico Familiar adscrito UMF #82
Caso clínico.
R2MF: Marín Hernández
Neftalí Alejandro.
Ficha de identificación.
AVMM nsss
01
APNP.
Residencia los lobos, municipio de los
reyes, religión católica, toxicomanías
negadas.
02
AHF.
abuela materna diabética.
03
APQX.
Fracturas de la diáfisis del cubito a los
9 años, Quirúrgicos una cesárea,
04
APP.
9 años 2017 22/08/2018 21/07/2020 2020
Varicela Mastitis
desde
los 22
años.
Colecistiti
s litiasica,
ultima val
22/08/21
Policont
undida
caida de
bicicleta
IVU
recurren
tes, EAP
(24/09/2
0
APP.
24/11/20 18/02/2022
02/06/2021 2022 2021
Lumbalgia
cronica
SARS CoV-2
en dos
ocasiones.
Tenosinovitis
de hombre
derecho
Vacunada
para covid-
19
Cuadro de
vacunacion
completo
¿Antecedente de importancia para
su padecimiento?
Colecistitis Cronica
litiasica
AGO.
Menarca a los 10 años
IVSA: 18 años.
G-2, P0, A-0, C-1
Regular 28 x 5 dias.
FUM 05/11/2021,
MPF: DIU, Preservativos.
¿Recomendación MPF para su
padecimiento?
Uso de AOC o DIU.
Control prenatal 11/12/21
FUP: 21/07/2021
(BACTERIAS BACILAR,
INFLAMACION X, NEGATIVO
A CANCER)
Fecha de ultiva cesarea
14/03/15
Bajo peso al nacer <2500 grs
Total de consultas 10
Infección de vías urinarias primer y
segundo, trim.
suplementos vitamínicos ácido fólico y
vitaminas y minerales..
¿Acciones realizadas en la primera consulta?
NOM 007.
- determinación del grupo sanguíneo ABO y Rho, (en embarazadas con Rh negativo y se sospeche
riesgo, determinar Rho antígeno D y su variante débil Dμ),
- Valoración del riesgo obstetrico.
- aplicación de al menos dos dosis de toxoide tetánico (primera durante el primer
contacto de la paciente con los servicios médicos y la segunda a las cuatro u ocho semanas posteriores,
- orientación nutricional tomando en cuenta las condiciones sociales, económicas y sociales de la
embarazada;
- Detección del virus de la inmunodeficiencia adquirida humana VIH en mujeres
de alto riesgo (transfundidas, drogadictas y prostitutas), bajo conocimiento y
consentimiento de la mujer y referir los casos positivos a centros especializados,
respetando el derecho a la privacidad y a la confidencialidad.
- Prescripción profiláctica de hierro y ácido fólico;
- examen general de orina desde el primer control.
A las 24, 28,32 y 36.
¿ A QUE SEMANA SE SOLICITAN EGO?
FUA 21/07/22.
¿Cuál es la fecha probable de
parto?
Riesgo obstétrico ???
Femenina de 27 años, presento COVID hace 4
meses. FUR 05/11/2021, FPP 12/08/2022
cursa embarazo de ¿?????? semanas de
gestación, con riesgo obstétrico de 8.
12/082022
PA: Niega perdidas transvaginales --paciente quien ha presento
prurito generalizado con exacerbación de 2 semanas de mayor
predomino en mano y pies en ocasiones se refiere estar amarilla...
paciente quien ya ha estado internada en varias ocasiones. ultimo
internamiento el 13 de julio de 2022 y acudió a valoración con
ginecología 16/07/2022 sin dejar cita a paciente.
Padecimiento actual.
¿Que
estudios
solicitarias?
laboratorio del dia 13/07/22.
BH: normal.
Grupo y Rh A positivo glucosa 66.5 mg/dl 870/110 mg/dl), crea
0.5 mg/dl (0.6-1.3), ac urico 5.8 mg/dl (3.5-7.2), BT 0.66 (0-1
mg/dl), BD 0.42 (0-0.30 mg/dl), BI 0.24 (0-1.1 mg/dl), TGP/ALT
318 (30-65 U/L), TGO/AST 202 (15/37 U/l), DHL 221 (135/225
U/l), EGO color amarillo, DU 1.020 pH 6, sedimento, leuoc 18-20
bacterias moderada.
ULTRASONIDO OBSTETRICO.
Producto único vivo cefalico longitudinal dorso al izquierda placenta
normoinserta G 2 aparente circular de cordon a cuello.
dx embarazo de de 34 semasna peso fetal 2363 placenta normoinserta g
2 ila normal circualr de cordon dra erandi ceja medico radiologo.
Ultrasonido abdomen superior:
Se observa imagenes en relación con esteatosis hepatica
leve / ccl sin datos de a gudizacion luz vesicular en totalidad
por litos
28/02/2022
Exploración Fisica.
Consciente activa con
palidez de piel y
mucosas no se observa
tinte ictérico, cavidad
oral húmeda tórax
ventilados sin ruidos
agregados Ruidos
Cardiacos rítmicos de
buena intensidad no
soplo ni terceros ruidos.
Abdomen Globoso por
PUVI altura de fondo
uterino. 33 cm Fcf 137 X
minuto presentación
cefálico longitudinal
dorso a la derecha
Giordano y puntos
ureterales negativos n o
palpo datos de irritación
peritoneal. Exploración
Genital y Tacto vaginal
diferido Extremidades
sin edema con buen
llenado capilar..
Diagnostico.
Embarazo de 38.4 SDG X FUM
Colestasis + CCL
Infeccion de vías Urinarias.
Diagnostico Diferencial.
Hígado graso agudo gestacional.
HELLP
Hepatitis viral: VHA, VHB, VHC, EBV,
CMV
Hepatitis autoinmune
Obstrucción biliar
Factores de riesgo durante el embarzo.
Complicaciones durante el
embarazo.
- Parto pretermino.
- Muerte fetal
- Preclampsia.
Complicaciones fetales de la
patologia?
- Presencia de meconio.
- Diestres respiratorio.
- RCIU
Ovadia C, Seed PT, Sklavounos A, et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of
pregnancy with biochemical markers:results of aggregate and individual patient data meta-analyses. Lancet 2019;
393:899.
4.3 embarazo de alto riesgo: Aquel en el que se tiene la certeza o la probabilidad de estados
patológicos o condiciones anormales concomitantes con la gestación y el parto, que aumentan los
peligros para la salud de la madre o del producto, o bien, cuando la madre procede de un medio
socioeconómico precario.
4.24 calidad de la atención: Se considera a la secuencia de actividades que relacionan al prestador
de
los servicios con el usuario (oportunidad de la atención, accesibilidad a la unidad, tiempo de espera,
así
como de los resultados).
4.25 calidez en la atención: El trato cordial, atento y con información que se proporciona al usuario
del
servicio.
5.2.2 El control prenatal debe estar dirigido a la detección y control de factores de riesgo obstétrico,
a la
prevención, detección y tratamiento de la anemia, preeclampsia, infecciones cérvicovaginales e
infecciones
urinarias, las complicaciones hemorrágicas del embarazo, retraso del crecimiento intrauterino y otras
patologías intercurrentes con el embarazo.
Presentación.
Colestasis intrahepatica o
cholestasis obstetrica.
- Finales del Segundo trimester o tercer trimester.
- Prurito manos y plantas de los pies
- PFH alteradas.
- Bilirrubinas helevadas.
Clinical Updates in Women's Health Care Summary: Liver Disease:
Reproductive Considerations. Obstet Gynecol 2017; 129:236.
La incidencia.
- oscilandoentre <1 y 27.6 por ciento (indios araucanos en Chile)
ETIOLOGÍA.
No se entiende completamente, pero
probablemente implica una combinación
de:
- Susceptibilidad genética (mayor riesgo en
parientes de primer grado), el gen ABCB4 .
- Factores hormonales (el estrógeno causa
colestasis,
toman anticonceptivos de estrógeno-
progestina ) y factores ambientales.
Referencias 1,2,3,4,5,6
Progesterona no hay evidencia de colestasis.
hidroxiprogesterona describe una incidencia del 8 por ciento de prurito en
mujeres tratadas y enumera la ictericia colestásica del embarazo,los tumores
hepáticos (benignos o malignos) o la enfermedad hepática activa como
contraindicaciones para la terapia.
Bacq Y, Sapey T, Bréchot MC, et al. Colestasis intrahepática del embarazo: un estudio prospectivo
francés. Hepatología 1997; 26:358.
- El examen físico puede mostrar marcas de rasguños, excoriaciones y nódulos de prurigo
secundarios al rascado (pero no hay lesionescutáneas).
- La ictericia ocurre en el 14 al 25 por ciento de los pacientes, generalmente se desarrolla de
una a cuatro semanas después del inicio de la picazón
Laboratorio
- Aminotransferasas séricas (elevadas en el 60 por ciento de los casos) dos veces el límite
superior de lo normal.
- Fosfatasa alcalina, que puede estar elevada cuatro veces.
- Concentraciones totales y directas de bilirrubina (elevadas en el 25 por ciento de los casos),
rara vez superan los 6 mg/dL.
- El tiempo de protrombina suele ser normal (se prolonga por la deficiencia de vitamina k
secundario a la esteatorrea).
Furrer R, Winter K, Schäffer L, et al. Postpartum Blood Loss in Women Treated for Intrahepatic Cholestasis
of Pregnancy. Obstet Gynecol 2016;128:1048.
Acido ursodesoxicólico.
es el tratamiento preferido del prurito
materno, 300 mg tres veces al día (o 15
/ kg por día) hasta el parto.
Tratamiento.
American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, Society for
Maternal-Fetal Medicine. Medically Indicated Late-Preterm and Early-Term Deliveries: ACOG Committee
Opinion, Number 831. Obstet Gynecol 2021; 138:e35.
La guía del Royal College of Obstetricians and Gynecologists (RCOG)
sobre ICP afirma que los datos disponibles pueden justificar la inducción
deltrabajo de parto a las mujeres después de los 37 años
El Colegio Americano de Obstetras y Ginecólogos (ACOG) recomienda el
parto a los 36 años hasta 39 semanas de gestación para pacientes
conniveles totales de ácidos biliares <100 micromol/L, o en el momento
del diagnóstico si se diagnostican a >39 semanas
1.- Pataia V, Dixon PH, Williamson C. Embarazo y trastornos de ácidos biliares. Am J Physiol Gastrointest
Liver Physiol 2017; 313:G1.
2.- Gonzalez MC, Reyes H, Arrese M, et al. Colestasis intrahepática del embarazo en embarazos
gemelares. J Hepatol 1989; 9:84.
3.-Dixon PH, Williamson C. La fisiopatología de la colestasis intrahepática del embarazo. Clin Res
Hepatol Gastroenterol 2016; 40:141.
4.- Sookoian S, Castaño G, Burgueño A, et al. Asociación de las variantes del gen de la proteína
asociada a la resistencia a múltiples fármacos (ABCC2) conla colestasis intrahepática del embarazo. J
Hepatol 2008; 48:125.
5.- Wånggren K, Sparre LS, Wramsby H. Ictericia severa en el embarazo temprano de FIV. Eur J Obstet
Gynecol Reprod Biol 2004; 112:228.
6.- Mutlu MF, Aslan K, Guler I, et al. Dos casos de colestasis intrahepática de primer inicio del
embarazo asociados con el síndrome de hiperestimulaciónovárica moderada después del tratamiento
de FIV y la revisión de la literatura. J Obstet Gynaecol 2017; 37:547.
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cole embarazo.pptx

  • 1. Dr. Ruiz Villanueva Noe. Asesor de caso. Medico Familiar adscrito UMF #82 Caso clínico. R2MF: Marín Hernández Neftalí Alejandro.
  • 2. Ficha de identificación. AVMM nsss 01 APNP. Residencia los lobos, municipio de los reyes, religión católica, toxicomanías negadas. 02 AHF. abuela materna diabética. 03 APQX. Fracturas de la diáfisis del cubito a los 9 años, Quirúrgicos una cesárea, 04
  • 3. APP. 9 años 2017 22/08/2018 21/07/2020 2020 Varicela Mastitis desde los 22 años. Colecistiti s litiasica, ultima val 22/08/21 Policont undida caida de bicicleta IVU recurren tes, EAP (24/09/2 0
  • 4. APP. 24/11/20 18/02/2022 02/06/2021 2022 2021 Lumbalgia cronica SARS CoV-2 en dos ocasiones. Tenosinovitis de hombre derecho Vacunada para covid- 19 Cuadro de vacunacion completo
  • 5. ¿Antecedente de importancia para su padecimiento? Colecistitis Cronica litiasica
  • 6. AGO. Menarca a los 10 años IVSA: 18 años. G-2, P0, A-0, C-1 Regular 28 x 5 dias. FUM 05/11/2021, MPF: DIU, Preservativos.
  • 7. ¿Recomendación MPF para su padecimiento? Uso de AOC o DIU.
  • 8. Control prenatal 11/12/21 FUP: 21/07/2021 (BACTERIAS BACILAR, INFLAMACION X, NEGATIVO A CANCER) Fecha de ultiva cesarea 14/03/15 Bajo peso al nacer <2500 grs Total de consultas 10 Infección de vías urinarias primer y segundo, trim. suplementos vitamínicos ácido fólico y vitaminas y minerales..
  • 9. ¿Acciones realizadas en la primera consulta?
  • 10. NOM 007. - determinación del grupo sanguíneo ABO y Rho, (en embarazadas con Rh negativo y se sospeche riesgo, determinar Rho antígeno D y su variante débil Dμ), - Valoración del riesgo obstetrico. - aplicación de al menos dos dosis de toxoide tetánico (primera durante el primer contacto de la paciente con los servicios médicos y la segunda a las cuatro u ocho semanas posteriores, - orientación nutricional tomando en cuenta las condiciones sociales, económicas y sociales de la embarazada;
  • 11. - Detección del virus de la inmunodeficiencia adquirida humana VIH en mujeres de alto riesgo (transfundidas, drogadictas y prostitutas), bajo conocimiento y consentimiento de la mujer y referir los casos positivos a centros especializados, respetando el derecho a la privacidad y a la confidencialidad. - Prescripción profiláctica de hierro y ácido fólico; - examen general de orina desde el primer control. A las 24, 28,32 y 36. ¿ A QUE SEMANA SE SOLICITAN EGO?
  • 12. FUA 21/07/22. ¿Cuál es la fecha probable de parto? Riesgo obstétrico ??? Femenina de 27 años, presento COVID hace 4 meses. FUR 05/11/2021, FPP 12/08/2022 cursa embarazo de ¿?????? semanas de gestación, con riesgo obstétrico de 8. 12/082022
  • 13.
  • 14.
  • 15. PA: Niega perdidas transvaginales --paciente quien ha presento prurito generalizado con exacerbación de 2 semanas de mayor predomino en mano y pies en ocasiones se refiere estar amarilla... paciente quien ya ha estado internada en varias ocasiones. ultimo internamiento el 13 de julio de 2022 y acudió a valoración con ginecología 16/07/2022 sin dejar cita a paciente. Padecimiento actual.
  • 16. ¿Que estudios solicitarias? laboratorio del dia 13/07/22. BH: normal. Grupo y Rh A positivo glucosa 66.5 mg/dl 870/110 mg/dl), crea 0.5 mg/dl (0.6-1.3), ac urico 5.8 mg/dl (3.5-7.2), BT 0.66 (0-1 mg/dl), BD 0.42 (0-0.30 mg/dl), BI 0.24 (0-1.1 mg/dl), TGP/ALT 318 (30-65 U/L), TGO/AST 202 (15/37 U/l), DHL 221 (135/225 U/l), EGO color amarillo, DU 1.020 pH 6, sedimento, leuoc 18-20 bacterias moderada. ULTRASONIDO OBSTETRICO. Producto único vivo cefalico longitudinal dorso al izquierda placenta normoinserta G 2 aparente circular de cordon a cuello. dx embarazo de de 34 semasna peso fetal 2363 placenta normoinserta g 2 ila normal circualr de cordon dra erandi ceja medico radiologo.
  • 17.
  • 18. Ultrasonido abdomen superior: Se observa imagenes en relación con esteatosis hepatica leve / ccl sin datos de a gudizacion luz vesicular en totalidad por litos 28/02/2022
  • 19. Exploración Fisica. Consciente activa con palidez de piel y mucosas no se observa tinte ictérico, cavidad oral húmeda tórax ventilados sin ruidos agregados Ruidos Cardiacos rítmicos de buena intensidad no soplo ni terceros ruidos. Abdomen Globoso por PUVI altura de fondo uterino. 33 cm Fcf 137 X minuto presentación cefálico longitudinal dorso a la derecha Giordano y puntos ureterales negativos n o palpo datos de irritación peritoneal. Exploración Genital y Tacto vaginal diferido Extremidades sin edema con buen llenado capilar..
  • 20.
  • 21. Diagnostico. Embarazo de 38.4 SDG X FUM Colestasis + CCL Infeccion de vías Urinarias.
  • 22. Diagnostico Diferencial. Hígado graso agudo gestacional. HELLP Hepatitis viral: VHA, VHB, VHC, EBV, CMV Hepatitis autoinmune Obstrucción biliar
  • 23. Factores de riesgo durante el embarzo.
  • 24. Complicaciones durante el embarazo. - Parto pretermino. - Muerte fetal - Preclampsia.
  • 25. Complicaciones fetales de la patologia? - Presencia de meconio. - Diestres respiratorio. - RCIU Ovadia C, Seed PT, Sklavounos A, et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers:results of aggregate and individual patient data meta-analyses. Lancet 2019; 393:899.
  • 26. 4.3 embarazo de alto riesgo: Aquel en el que se tiene la certeza o la probabilidad de estados patológicos o condiciones anormales concomitantes con la gestación y el parto, que aumentan los peligros para la salud de la madre o del producto, o bien, cuando la madre procede de un medio socioeconómico precario. 4.24 calidad de la atención: Se considera a la secuencia de actividades que relacionan al prestador de los servicios con el usuario (oportunidad de la atención, accesibilidad a la unidad, tiempo de espera, así como de los resultados). 4.25 calidez en la atención: El trato cordial, atento y con información que se proporciona al usuario del servicio. 5.2.2 El control prenatal debe estar dirigido a la detección y control de factores de riesgo obstétrico, a la prevención, detección y tratamiento de la anemia, preeclampsia, infecciones cérvicovaginales e infecciones urinarias, las complicaciones hemorrágicas del embarazo, retraso del crecimiento intrauterino y otras patologías intercurrentes con el embarazo.
  • 28. Colestasis intrahepatica o cholestasis obstetrica. - Finales del Segundo trimester o tercer trimester. - Prurito manos y plantas de los pies - PFH alteradas. - Bilirrubinas helevadas. Clinical Updates in Women's Health Care Summary: Liver Disease: Reproductive Considerations. Obstet Gynecol 2017; 129:236.
  • 29. La incidencia. - oscilandoentre <1 y 27.6 por ciento (indios araucanos en Chile) ETIOLOGÍA. No se entiende completamente, pero probablemente implica una combinación de: - Susceptibilidad genética (mayor riesgo en parientes de primer grado), el gen ABCB4 . - Factores hormonales (el estrógeno causa colestasis, toman anticonceptivos de estrógeno- progestina ) y factores ambientales. Referencias 1,2,3,4,5,6
  • 30. Progesterona no hay evidencia de colestasis. hidroxiprogesterona describe una incidencia del 8 por ciento de prurito en mujeres tratadas y enumera la ictericia colestásica del embarazo,los tumores hepáticos (benignos o malignos) o la enfermedad hepática activa como contraindicaciones para la terapia. Bacq Y, Sapey T, Bréchot MC, et al. Colestasis intrahepática del embarazo: un estudio prospectivo francés. Hepatología 1997; 26:358.
  • 31. - El examen físico puede mostrar marcas de rasguños, excoriaciones y nódulos de prurigo secundarios al rascado (pero no hay lesionescutáneas). - La ictericia ocurre en el 14 al 25 por ciento de los pacientes, generalmente se desarrolla de una a cuatro semanas después del inicio de la picazón Laboratorio - Aminotransferasas séricas (elevadas en el 60 por ciento de los casos) dos veces el límite superior de lo normal. - Fosfatasa alcalina, que puede estar elevada cuatro veces. - Concentraciones totales y directas de bilirrubina (elevadas en el 25 por ciento de los casos), rara vez superan los 6 mg/dL. - El tiempo de protrombina suele ser normal (se prolonga por la deficiencia de vitamina k secundario a la esteatorrea). Furrer R, Winter K, Schäffer L, et al. Postpartum Blood Loss in Women Treated for Intrahepatic Cholestasis of Pregnancy. Obstet Gynecol 2016;128:1048.
  • 32. Acido ursodesoxicólico. es el tratamiento preferido del prurito materno, 300 mg tres veces al día (o 15 / kg por día) hasta el parto. Tratamiento. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, Society for Maternal-Fetal Medicine. Medically Indicated Late-Preterm and Early-Term Deliveries: ACOG Committee Opinion, Number 831. Obstet Gynecol 2021; 138:e35.
  • 33. La guía del Royal College of Obstetricians and Gynecologists (RCOG) sobre ICP afirma que los datos disponibles pueden justificar la inducción deltrabajo de parto a las mujeres después de los 37 años El Colegio Americano de Obstetras y Ginecólogos (ACOG) recomienda el parto a los 36 años hasta 39 semanas de gestación para pacientes conniveles totales de ácidos biliares <100 micromol/L, o en el momento del diagnóstico si se diagnostican a >39 semanas
  • 34. 1.- Pataia V, Dixon PH, Williamson C. Embarazo y trastornos de ácidos biliares. Am J Physiol Gastrointest Liver Physiol 2017; 313:G1. 2.- Gonzalez MC, Reyes H, Arrese M, et al. Colestasis intrahepática del embarazo en embarazos gemelares. J Hepatol 1989; 9:84. 3.-Dixon PH, Williamson C. La fisiopatología de la colestasis intrahepática del embarazo. Clin Res Hepatol Gastroenterol 2016; 40:141. 4.- Sookoian S, Castaño G, Burgueño A, et al. Asociación de las variantes del gen de la proteína asociada a la resistencia a múltiples fármacos (ABCC2) conla colestasis intrahepática del embarazo. J Hepatol 2008; 48:125. 5.- Wånggren K, Sparre LS, Wramsby H. Ictericia severa en el embarazo temprano de FIV. Eur J Obstet Gynecol Reprod Biol 2004; 112:228. 6.- Mutlu MF, Aslan K, Guler I, et al. Dos casos de colestasis intrahepática de primer inicio del embarazo asociados con el síndrome de hiperestimulaciónovárica moderada después del tratamiento de FIV y la revisión de la literatura. J Obstet Gynaecol 2017; 37:547.
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