[
    {
        "page": 1,
        "title": "SAF Y TROMBOFILIAS",
        "body": "<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">TROMBOFILIAS<\/strong><\/p>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">DEFINICI\u00d3N<\/strong><\/p>\r\n\n\r\n<ul><li><strong style=\"background-color: transparent;\">Trombofilia:<\/strong><span style=\"background-color: transparent;\"> predisposici\u00f3n hereditaria o adquirida a desarrollar trombosis debido a anomal\u00edas en la coagulaci\u00f3n.<\/span><\/li><li><span style=\"background-color: transparent;\">En el embarazo, se asocia a:<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Trombosis venosa profunda (TVP), embolia pulmonar.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Morbilidad placentaria: p\u00e9rdida fetal, preeclampsia, RCIU, DPPNI.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">CLASIFICACI\u00d3N<\/strong><\/p>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Trombofilias hereditarias (50%)<\/strong><\/p>\r\n\n\r\n<ul><li><strong style=\"background-color: transparent;\">Mutaci\u00f3n del factor V Leiden (FVL):<\/strong><span style=\"background-color: transparent;\"> resistencia a la prote\u00edna C activada.<\/span><\/li><li><strong style=\"background-color: transparent;\">Mutaci\u00f3n de protrombina G20210A:<\/strong><span style=\"background-color: transparent;\"> \u2191 niveles de protrombina.<\/span><\/li><li><strong style=\"background-color: transparent;\">Deficiencia de antitrombina (AT):<\/strong><span style=\"background-color: transparent;\"> inhibidor natural de la trombina.<\/span><\/li><li><strong style=\"background-color: transparent;\">Deficiencia de prote\u00edna C y prote\u00edna S:<\/strong><span style=\"background-color: transparent;\"> anticoagulantes naturales.<\/span><\/li><li><strong style=\"background-color: transparent;\">Hiperhomocisteinemia:<\/strong><span style=\"background-color: transparent;\"> generalmente secundaria a mutaciones MTHFR (relaci\u00f3n cl\u00ednica controversial).<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Trombofilias adquiridas<\/strong><\/p>\r\n\n\r\n<ul><li><strong style=\"background-color: transparent;\">S\u00edndrome antifosfol\u00edpido (SAF):<\/strong><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Presencia de anticuerpos antifosfol\u00edpidos (aFL) + manifestaciones cl\u00ednicas.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Principal causa adquirida de trombofilia obst\u00e9trica.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">FISIOPATOLOG\u00cdA<\/strong><\/p>\r\n\n\r\n<ul><li><span style=\"background-color: transparent;\">Durante el embarazo existe un <\/span><strong style=\"background-color: transparent;\">estado de hipercoagulabilidad fisiol\u00f3gica<\/strong><span style=\"background-color: transparent;\">:<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">\u2191 fibrin\u00f3geno, factores VII, VIII, X.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">\u2193 prote\u00edna S libre.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Disminuci\u00f3n de fibrin\u00f3lisis.<\/span><\/li><li><span style=\"background-color: transparent;\">Las trombofilias amplifican este estado:<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">\u2191 riesgo de trombosis materna.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Alteraciones en la placentaci\u00f3n \u2192 infartos, isquemia, complicaciones fetales.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">RIESGO DE TROMBOSIS EN EL EMBARAZO<\/strong><\/p>\r\n\n\r\n<ul><li><span style=\"background-color: transparent;\">Embarazo: riesgo de tromboembolismo venoso (TEV) se \u2191 5-6 veces.<\/span><\/li><li><span style=\"background-color: transparent;\">Mayor riesgo:<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Tercer trimestre y puerperio.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Inmovilizaci\u00f3n, ces\u00e1rea, obesidad, &gt;35 a\u00f1os.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">TROMBOFILIAS Y EMBARAZO<\/strong><\/p>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Eventos asociados<\/strong><\/p>\r\n\n\r\n<ul><li><strong style=\"background-color: transparent;\">Trombosis venosa.<\/strong><\/li><li><strong style=\"background-color: transparent;\">Complicaciones obst\u00e9tricas:<\/strong><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">P\u00e9rdida fetal recurrente (&gt;10 sem o \u22653 &lt;10 sem).<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Preeclampsia grave o precoz (&lt;34 sem).<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">RCIU (&lt;10 percentil).<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">DPPNI.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">DIAGN\u00d3STICO<\/strong><\/p>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Sospecha cl\u00ednica<\/strong><\/p>\r\n\n\r\n<ul><li><span style=\"background-color: transparent;\">Historia personal o familiar de trombosis venosa.<\/span><\/li><li><span style=\"background-color: transparent;\">P\u00e9rdidas fetales inexplicadas.<\/span><\/li><li><span style=\"background-color: transparent;\">Preeclampsia temprana o RCIU sin otra causa.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Pruebas de laboratorio<\/strong><\/p>\r\n\n\r\n<ul><li><strong style=\"background-color: transparent;\">FVL y protrombina G20210A:<\/strong><span style=\"background-color: transparent;\"> PCR.<\/span><\/li><li><strong style=\"background-color: transparent;\">Antitrombina, prote\u00ednas C y S:<\/strong><span style=\"background-color: transparent;\"> determinaci\u00f3n funcional (ojo con niveles falsamente bajos en embarazo).<\/span><\/li><li><strong style=\"background-color: transparent;\">Homociste\u00edna plasm\u00e1tica:<\/strong><span style=\"background-color: transparent;\"> utilidad limitada.<\/span><\/li><li><strong style=\"background-color: transparent;\">SAF (criterios de Sapporo):<\/strong><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Cl\u00ednicos: trombosis o p\u00e9rdida fetal.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Laboratorio (repetidos en \u226512 semanas):<\/span><\/li><li class=\"ql-indent-2\"><span style=\"background-color: transparent;\">Anticoagulante l\u00fapico.<\/span><\/li><li class=\"ql-indent-2\"><span style=\"background-color: transparent;\">Anticardiolipina IgG\/IgM (t\u00edtulo medio-alto).<\/span><\/li><li class=\"ql-indent-2\"><span style=\"background-color: transparent;\">Anti-\u03b22-glicoprote\u00edna I IgG\/IgM.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">MANEJO DE TROMBOFILIAS HEREDITARIAS<\/strong><\/p>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Sin antecedentes de trombosis<\/strong><\/p>\r\n\n\r\n<ul><li><span style=\"background-color: transparent;\">Profilaxis no indicada de rutina.<\/span><\/li><li><span style=\"background-color: transparent;\">Considerar si:<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Trombofilia de alto riesgo (deficiencia de AT, PC, PS).<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Historia obst\u00e9trica adversa (\u22652 p\u00e9rdidas).<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Con antecedentes de trombosis<\/strong><\/p>\r\n\n\r\n<ul><li><span style=\"background-color: transparent;\">Profilaxis con <\/span><strong style=\"background-color: transparent;\">heparina de bajo peso molecular (HBPM)<\/strong><span style=\"background-color: transparent;\"> durante embarazo y 6 semanas postparto.<\/span><\/li><li><span style=\"background-color: transparent;\">Dosis intermedia o terap\u00e9utica seg\u00fan el caso.<\/span><\/li><li><strong style=\"background-color: transparent;\">Evitar ACO<\/strong><span style=\"background-color: transparent;\"> si trombofilia de alto riesgo.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">S\u00cdNDROME ANTIFOSFOL\u00cdPIDO (SAF)<\/strong><\/p>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Diagn\u00f3stico<\/strong><\/p>\r\n\n\r\n<ul><li><span style=\"background-color: transparent;\">Requiere \u22651 criterio cl\u00ednico + \u22651 criterio de laboratorio (en 2 ocasiones separadas \u226512 sem).<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Manejo<\/strong><\/p>\r\n\n\r\n<ul><li><strong style=\"background-color: transparent;\">Con p\u00e9rdida fetal previa:<\/strong><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">HBPM + aspirina 81 mg\/d\u00eda desde diagn\u00f3stico hasta 6 sem postparto.<\/span><\/li><li><strong style=\"background-color: transparent;\">Con trombosis previa:<\/strong><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Anticoagulaci\u00f3n plena con HBPM + aspirina.<\/span><\/li><li><strong style=\"background-color: transparent;\">SAF catastr\u00f3fico o refractario:<\/strong><span style=\"background-color: transparent;\"> requiere anticoagulaci\u00f3n agresiva, corticoides, inmunoglobulina o plasmaf\u00e9resis.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">ANTICOAGULANTES EN EL EMBARAZO<\/strong><\/p>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Heparinas<\/strong><\/p>\r\n\n\r\n<ul><li><strong style=\"background-color: transparent;\">HBPM (ej. enoxaparina):<\/strong><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Preferidas por seguridad y farmacocin\u00e9tica predecible.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">No cruzan placenta.<\/span><\/li><li><strong style=\"background-color: transparent;\">Heparina no fraccionada (HNF):<\/strong><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Uso limitado por riesgo de osteoporosis, trombocitopenia.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Puede revertirse con protamina.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Antagonistas de vitamina K (AVK)<\/strong><\/p>\r\n\n\r\n<ul><li><span style=\"background-color: transparent;\">Warfarina contraindicada en embarazo (efecto teratog\u00e9nico).<\/span><\/li><li><span style=\"background-color: transparent;\">Uso posible postparto o en mujeres que no desean embarazo.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Nuevos anticoagulantes orales (DOAC)<\/strong><\/p>\r\n\n\r\n<ul><li><span style=\"background-color: transparent;\">Contraindicados en embarazo y lactancia.<\/span><\/li><li><span style=\"background-color: transparent;\">No hay datos suficientes de seguridad fetal.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">MONITOREO Y CONTROL<\/strong><\/p>\r\n\n\r\n<ul><li><strong style=\"background-color: transparent;\">Anti-Xa:<\/strong><span style=\"background-color: transparent;\"> \u00fatil para ajustar HBPM en pacientes de alto riesgo o peso extremo.<\/span><\/li><li><span style=\"background-color: transparent;\">Control de plaquetas si uso prolongado de HNF.<\/span><\/li><li><span style=\"background-color: transparent;\">Evaluaci\u00f3n de funci\u00f3n renal y hep\u00e1tica si anticoagulaci\u00f3n prolongada.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">CONSIDERACIONES POSTPARTO<\/strong><\/p>\r\n\n\r\n<ul><li><span style=\"background-color: transparent;\">Mayor riesgo tromb\u00f3tico: continuar HBPM al menos 6 semanas.<\/span><\/li><li><span style=\"background-color: transparent;\">Evaluar anticoagulaci\u00f3n a largo plazo seg\u00fan riesgo individual.<\/span><\/li><li><span style=\"background-color: transparent;\">Anticoncepci\u00f3n segura:<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">ACO combinados contraindicados si trombofilia de alto riesgo.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Progest\u00e1genos solos o DIU preferidos.<\/span><\/li><\/ul>\r\n\n\r\n<p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">CONSEJER\u00cdA Y PRON\u00d3STICO<\/strong><\/p>\r\n\n\r\n<ul><li><span style=\"background-color: transparent;\">Acompa\u00f1amiento multidisciplinario.<\/span><\/li><li><span style=\"background-color: transparent;\">Buen pron\u00f3stico con diagn\u00f3stico y tratamiento adecuados.<\/span><\/li><li><span style=\"background-color: transparent;\">Planificar embarazos futuros con hematolog\u00eda y obstetricia de alto riesgo.<\/span><\/li><li><span style=\"background-color: transparent;\">Educaci\u00f3n sobre signos de trombosis.<\/span><\/li><\/ul>",
        "footer": "P\u00e1gina 1"
    }
]