Mortalidad materna

Escenario:  A Pregnant Patient Reporting Acute Chest Pain Always Should Undergo an Immediate Computed Tomography Angiogram 

Pulmonary embolism remains a leading cause of death in pregnant women.1 Recent recommendations by the American College of Obstetricians and Gynecologists advocate the routine use of the pneumatic compression device in all women undergoing cesarean delivery who are not already receiving medical prophylaxis.2 However, fatal pulmonary embolism may present in any trimester. Importantly, 30% of women with pulmonary embolism have no associated clinical evidence of deep venous thrombosis; thus, in a woman presenting with acute chest pain, the absence of signs of deep venous thrombosis is not particularly reassuring.3 There are many causes of chest pain in pregnancy, most of them benign. However, for a pregnant woman reporting acute chest pain, no combination of clinical experience or judgment, history, physical examination, or laboratory tests can exclude pulmonary embolism during pregnancy with sufficient sensitivity to obviate the need for a definitive test. Further, an effective treatment is readily available; the risk of death from pulmonary embolism is extremely low once the patient has been adequately anticoagulated. In a disturbing number of cases of death attributable to pulmonary embolism chest pain was ignored or definitive diagnosis and treatment were delayed by unnecessary consultation or meaningless nondiagnostic testing. In a clinically stable pregnant patient reporting acute chest pain, move directly to computed tomography angiogram with contrast or an equivalent diagnostic test.4 If clinical suspicion is high, a loading dose of heparin may also be warranted pending the results of the definitive test.

Errores frecuentes

• Minimizar la sintomatología de la paciente al creer que todos los síntomas se deben a los cambios fisiológicos del embarazo como la taquicardia, disnea y edema de miembros pélvicos
• El retraso en el tratamiento, el cual debería ser introducido de manera inmediata tras la sospecha del diagnostico

Intervenciones para disminuir la mortalidad

1. Es indispensable realizar una evaluación minuciosa en las embarazadas desde la primera valoración para valorar el riesgo de trombosis durante el embarazo y posteriormente llevar un adecuado control y vigilancia durante el puerperio
2. La movilidad temprana y las medias de compresión gradual son métodos ligeramente efectivos, seguros y no invasivos para disminuir el riesgo de esta enfermedad.
3. Se debe considerar la tromboprofilaxis en pacientes con factores de riesgo como un índice de masa corporal mayor o igual a 25kg/m2 y la inmovilización de mas de 1 semana en mujeres con tromboembolismo venoso muy elevado

Bibliografía: Vallejo G, Fuentes M, Prieto A. Prevención del tromboembolismo venoso durante el embarazo y el puerperio en atención primaria y especializada. Semergen. 2017;43(6): 450-456.

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