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Manual CTO Ginecologia 7 edicion

Manual CTO Ginecologia 7 edicion

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Publicado porcharly476
aqui les dejo la 7 edicion del cto apartado ginecologia
aqui les dejo la 7 edicion del cto apartado ginecologia

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Published by: charly476 on Nov 26, 2009
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M Lste tema, sl Dlen nO es muy preguntadO
en eI examen, es lundamentaI para en-
tender Ia patOIOgIa glneCOIógICa y su tra-
tamIentO.
MEäê1t|8|êä
M LI COntrOI deI CICÌO OvðrICO pOr parte deI
hIpOtðÌamO se reaIIza a través de Ia seCre-
Clón puIsðtII de GnKH. LOs puIsOs rðpIdOs
estImuÌan Ìa LH, y IOs IentOs Ìa |´H. ´In
emDargO, Ia IIDefaCIón COntInua, COmO
OCurre COn Ia admInIstraCIón de IOs anð-
ÌOgOs de Ia GnRH, desensIDIIIza Ias CéIuÌas,
prOvO una sItuaCIón de hIpOestrO-
genIsmO utII en eI tratamIentO de Ia en-
dOmetrIOsIs, mlOmas uterInOs, puDertad
preCOz, estImuIaOón OvðrICa ...
Ö La |´H estImuIa eI CreClmlentO de Ia Capa
de Ia granuIOsa, lnduCe a aCtIvIdad arOma-
tasa en dICha Capa y COnvIerte IOs andró-
genOs en estradIOI.
M La LH estImuIa eÌ CreClmIentO de Ia Capa
de Ia teCa y, pOr tantO, prOduCe andróge-
nOs. 1amDlén se enCarga de Ia IuteInIza-
CIón deI lOIICuIO trðs Ia OvuIaCIón.
@
LOs andrógenOs sOn usadOs pOr Ia arOma-
tasa de Ia granuIOsa y deI CuerpO IuteO
para Ia prOduCCIón de estrógenOs. ´In
emDargO, ÌOs nlveIes exCesIvamente aÌtOs
prOduCen una lnhIbICIón de esta enzIma y,
pOr tantO, atresIa mIICuIar .
Ø La prOgesterOna se prOduCe unICamente
en eI CuerpO IuteO. ´us lunCIOnes son: ma-
duraCIón endOmetrIaI, dlsmImIón de Ia
exCItaDIIIdad deI musCuIO IIsO mIOmetrIaI,
eÌevaCIón deI metðDOIIsmO DasaI y dIsmI-
nuCIón de Ia CantIdad de mOCO CervICaI y
COntenIdO en ðCIdO sIðÌICO.
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gla, a ÇCSa| CC una aCCcuaCa SCcuCnc|a |C|nCnal , a' gC
la' ' a Cn C' uIC|C (>C. CC A>|C|nan), Cn Cl cC|v|x (C>ICnC>| >)
Õ Cn ' a vag|na (C>ICOC>i>) bi IiCnC l a |Cg' a, >u CnCCnC-
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nC> gCnaCC\|CÇina> || ÇCl >a|| a>. bi C>Iön C' CvaCa> (J·4
vCcC> 'a cil|a nC|na' , ÇuC C> Iû), >C>ÇCc|anC> Ci >lun·
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|| ÇCIölanC C Cn ' a |' ÇCh>|>, CanC> CnlH. >| aunCnIan
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l0|1o|05 ð T0 mU|/m1.Lo5n1V0105d0||o1ðf·
1| nð y d0 Ho|monð ¯||o051 |mU1ðn10 (¯bH)
5on no|mð105. Lð pðf10n10 no m0n51|uð
1|ð5 1ð ðdm1 n151 |ðf|ón d0 p|og051ðg0no,
p0|o51 1o hðf0 ð1ðdm| n|51|ð|Un051 |óg0no
|Un1ofon Un p|og051ðg0no. ¿LUð1 d0 1o5
d1ðgnó511fo5 qU0 ð fon11 nUðf|ón 50 |01ð·
f|onðn0501 mð5fo|t0f1o1:
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4) b1nd|om0 d0 dÐ1f|1 fongÐn11o d0
ho|monð 1 | O0 |ðdo|ð d0 gonðdo1 |op1-
nð5 (Ôn·Kh).
5) Ü|5g0n051ðgonðdð1.
M1K 200J·20U4 KL.J
240.MU|0|d0 19ðÔo5 qU0fon5U11ðpo|110-
Vð| >m050551n |0g1ð.b0 mðn1D051ðp|0ofD-
pðdð po|5U5oO|0p05o,hð051ðdoðd|01ðy
hð p0 |d|do 5 kg0n ö m0505. Af1Uð1m0n10
p05ð47 Kg( m1d0 T , >>).L11051d0 g051ðf|ón
05 n0gð1|Vo. ¿LUð1051ðfðU5ðmð5 p|oOðO10
d0 5U ðm0no||0ð:.
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2|H1pogonðd|6moh|pogonðdot|opo.
J)b1nd|om0 d0 oVð|1opo1 |qU151|fo.
4) H|m0n|mp0 |lo|ðdo.
b)Ad0nomðh1poÞ5ð|1o.
M\K2002·200JKL. 2
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Ö ¯0mð µfðC\ÌCðm0H\0 CCHS\ðH\0 0H ÌðS ÚÌ-
\ÌmðS CCHVCCð\CfÌðS, µCf ÌC ÇU0 0S ÌmµCf·
\ðH\0 ÇU0 ÌC 0S\UCÌ0S 0H C0\ðÌÌ0.
AâpêtIêâEâê1t|ä|êâ[|)
Ø FÌ\0fðCÌDH mUy Íf0CU0H\0, C0 0\ÌCÌCgÍð C0S·
CCHCCÌCð, ÇU0 S0 CðfðC\0fÌZð µCf UHð 0Ì0Vð·
CÌDH C0 LHCCH HÌV0Ì0S C0 PSH HCfmðÌ0SÍ
DðjCS, µCf ÌC ÇU0 0Ì CCCÌ0H\0 |H/PSH0S\ð
ðUm0H\ðCC (>2,5}.
Ð UH 0Ì0VðCC µCfC0H\ðj0 C0 mUj0f0S CCH
CVðfÌC µCÌÌÇUÍS\ÌCC SUÍf0H ðÌ\0fðCÌCH0S m0~
\ðDDÌÌCðS (S|HCfCm0 X), µCf ÌC ÇU0 0S mUy
Íf0CU0H\0 Ìð ðµðfÌCÌDH C0. f0SÌS\0HCÌð ð Ìð
ÌHSUÌÌHð, CD0SÌCðC, ÞÌ µ0|\0HSÌDH, CÌSÌ̵0-
mÌð, Þ̵0|\fÌgÌÌC0fÌC0mÌð, CÌðD0\0S \̵C ||,
ðHCmðÌÍðS C0 Ìð CCðgUÌðCÌDH y C0Ì m0\ð·
DCÌÌSmC 0S\0fCÌC0. 1CCðS 0S\ðS ðÌ\0fðCÌCH0S
ÌmµÌÌCðH UH 0Ì0VðCC fÌ0SgC CðfCÌCVðSCUÌðf.
Ð LCS SÍH\CmðS \͵ÌCCS SCH CD0SÌCðC, \fðS\Cf-
HCS m0HS\fUðÌ0S (CÌÌgCm0HCff0ð, CµSCm0-
HCff0ð), ÞÌ fSU\ÌSmC, f0SÌS\0HCÌð ÌHSUÌÍHÌCð y
0S\0fÌÌÌCðC. LS\ð ÚÌ\Ìmð 0S 0Ì SÍH\Cmð ðÌSÌð-
UC mðS Íf0CU0H\0, y 0S\ð mC\ÌVðCð µCf Ìð
ðHCVUÌðCÌDH CfDHÌCð ÇU0 µf0S0H\ðH 0S\ðS
µðCÌ0H\0S.
Ð LH 0Ì CÌðgHDS\ÌCC, 0S µf0CÌSC Ìð CCmDÌHð-
CÌDH C0 UH CfÌ\0fÌC CÌÍHÌCC y UHC DÌCÇUÍmÌ·
CC (CCCÌ0H\0 LHlFSH0Ì0VðCC, ðUm0H\C C0
ðHCfDg0HCS CVðfÌCCS, 0Ì0VðCÌDH C0 \0S\CS-
\0fCHð y LHLF) jUH\C CCH Ìð CCHDfmðCÌDH
0CCgfðDCð | 1 0 C mðS ÍCÌÍCUÌCS C0 µ0ÇU0HC
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« ·
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0S Ìð CCmµfCDðCÌDH C0 Þ̵0f\0CCSÌS 0H UHð
DÌCµSÌð CVðfÌCð.
J.1 b0000þÎ0
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se ð¯ðCCO ðOI| ðOC|CQCÞC> (C>µl|COC|ðCICOð, ðCCIðIC CC
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DÓ|ÌCð y 0Ì ÌHÍðf\C C0 mÌCCðfCÌC, ð| m0CÌðf
UHð 0Ì0VðCÌÓH C0 ÌCS ÍðC\Cf0S |, ||,Vl|, |X, X
y µ|ðSmÌ HÓg0HC, ðUHÇU0 \ðmDÌPH 0XÌS\0
UH ðUm0H\C C0 |ð ðC\ÌVÌOðC DDfÌHCÌÍ\ÌCð.
ÍCf 0||C, 0S\ðH CCH\fðÌHCÌCðCCS 0H mUj0f0S
CCH fÌ0SgC CðfCÌCVðSCU|ðf [ÍUmðCCfðS >J5
ðÞCS, HC ÍUmðCCfðS >4Û ðÞCS, ðH\0C0C0H·
\0S C0 \fCmDCSÌS µfCÍUHCð C 0mDCÌÌSmC
µU|mCHðf, ðÌ\0fðCÌCH0S C0 Ìð CCðgU|ðCÌÓH,
CÌðD0\0S CCH ðÍ0C\ðCÌÓH VðSCUÌðf, CðfCÌC·
µð\ÍðS gfðV0S . . . ). L\fðS CCH\fðÌHCÌCðCÌC·
H0S µðfð SU U\ÌÌÌZðCÌÓH SCH µðCÌ0H\0S CCH
ðÍ0C\ðCÌÓH Þ0µð\ÌCð ÌmµCf\ðH\0 [ðC0HCmð
Þ0µð\ÌCC, Þ0µð\Cµð\ÍðS ðC\ÌVðS), µCfDfÌð
ðgUCð ÌH\0fmÌ\0H\0, ðH\0C0C0H\0S C0 CC·
Ì0S\ðSÌS ÌH\fðÞ0µð\ÌCð, CÌSCfðSÌð SðHgUÍH0ð,
SðHgfðCC g0HÌ\ðÌ ðHCfmð| HC DÌÌðCC . . .
P|ê¿ä1IäâM|B
ÇMl K Û5-Ûó, 1 74
MlK Û4-Û5, 1 72
MlK Û4-Û5, 1 7J
M|K Û1 -Û2, 1 ó9
M|K 97-9b|, 4J
Ml K 9ó-97|, 1 b4
Ml K 9ó-97, 1 21
M|K 95-9ó, 225
DäâêD||1|têBêp|êâê1IäI|¢ê
@1 7J. UHð µðCÌ0H\0 C0 19 ðÞCS, HUÌÌg0S\ð, ðCUC0
ð Ìð CCHSUÌ\ð µCf ÌffÌ\ðDÌÌÌCðC, ÌH0S\ðDÌÌÌCðC
0mCCÌCHðÌ, C0ÍðÌ0ðS, S0HSÌDÌÌÌCðC y CÌS\0HSÌÓH
mðmðfÌð. Lð SÌH\Cmð\C|CgÍð S0 ÌHÌCÌ
_
UHð
S0mðHð ðH\0S C0 Ìð m0S\fUðCÌÓH y C0Sðµðf0C0
\fðS µf0S0H\ðfS0 | ð f0g|ð. UHð V0Z CCmµfCDðCð
Ìð f0ÌðCÌÓH CCH 0| CÌC|C m0HS\fUðÌ m0CÌðH\0
UH CÌðfÌC C0 SÍH\CmðS, C0CÌCÌmCS µðU\ðf
\fð\ðmÌ0H\C µU0S Ìð µðCÌ0H\0 f0H0f0 ÇU0 |ð
SÌH\Cmð\CÌCg|ð ÌH\0fH0f0 CCH SU \fðDðjC y SUS
f0|ðCÌCH0S SCCÌðÌ0S. ¿ÇUÉ ðCCHS0jðmCS CCmC
µfÌm0fð 0|0CCÌÓH \0fðµ0Ú\ÌCð !.
1) FUm0H\C C0 ÌHg0S\ð C0 CðHÍHð y ðZÚCðf0S
f0hHðCCS 0H S0gUHCð ÍðS0 C0| CÌCÌC m0HS\fUð|.
2) ÎfCg0S\0fCHð 2ÛÛ-JÛÛ mgÍCÍð C0Ì CÍð 14 ðÌ
2J C0Ì CÌCÌC.
J) cV|\ðf 0j0fCÌCÌC ÍÍSÌCC y \Cmðf SUµ|0m0H\C
C0 VÌ\ðmÌHð b1 2 CUfðH\0 SÌH\C
¯
·
\CÌCgÍð ð UHð
CCSÌS C0 1 5Û mgÍCÍð.
4) F|µðfðZCÌðm Û,25 mgÍd ÞCfðS,C0SC0 0Ì
C|ð 2Û C0Ì CÌCÌC ÞðS\ð 0Ì 2³ C|ð C0 |ð f0gÌð,
C|SmÌHUy0HCC C0SµUÉS ð UHð \Cmð ð| CÍð.
5}FH\ÌCCHC0µ\ÌVCS ÞCfmCHðÌ0S Cfð|0S mðS UH
CÌUfP\ÌCC SUðV0 CUfðH\0 |CS C|ðS ÇU0 µf0S0H\0
CÌS\0HSÌÓH mðmðfÌð.
MlK 2004·200b KL. 4
h| µO|îO0S|Ó0 |J1]
¯ luCUC| | |UuC| | ¬1ª (!ð|IC î|îIC||Cð CCUC U|ðî!Cl|Cð).
ªICC!ð ð| b% UC | ðî ÇðC|C|ICî y ðÇð|CCC C| lCî Ç|| UC|Cî
Ô UCîCî. LîIð |C|ðClC|ðUð CC| | ð UCî|î y Cl I|ÇC UC QCî·
!ðQC|C.
¯ |uCUC| CxðCC|Oð| u|ð ¬1ª Ç|CCx|î!C|!C.
¯ Lð 1ª UCîClC|UC ð C|llðî |C|Uð| Cî ð |Cî J·Ô UCîCî UC lð
îuÇ|Cî|C|.
¯ buC|C îC| |CvC, ÇC|C îC hð| UCîC||IC CðîCî UC C|lî|î || ÇC|·
!C|îlvðî CC| I|ðCðîC |C|ð| .
c0ÍO|ROO8O I|ORDOORDÓ||O8
¯ Lð ð|I|CC|CCÇClC| |C|UC|ðl Cî u| lðC!C| UC ||CîQC Çð|ð
| ð C|IC|UCUðU !|CUOCCUOC||Cð y C| | |lð|IC UC UlCCð|U|C.
¯ Lð ð|!|CC|CCÇC|C| hC|UC|ðl ||UuCC ð u|ð C|CvðClC| UC
|Cî IðC!C|Cî '-' '-V' ' -' X-Xy Ç| ðîU| |CQC|C.
¯ ªuUC|Ið| |ð ðC!lvlUðU ÞO|| |C| |I|Cð, îCO|C ICUC lCî CîI|C·
QC|Cî C| ð|!ðî UCî|î.
¯ Lð CUðU îuÇC|lC| ð Jb ðÓCî Çu| |!uÇ| | Cð lCî ||CîQCî.
¯ bC| IðCIC|Cî UC ||CîQC ðÓðUlUC. || ÇC|| | ÇCÇ|C!C| |CU| ð,
¬1ª, IðOðÇu| îUC (> I b Cl Qð||| | | Cî/Ulð), Ul ðOC!Cî y CUðU
>Jb ðÓCî.
¯ ªuUC|!ð| Cl ||CîQC ÇCî!CÇC|ðIO||C ÇC| |C ÇuC îC ðCC|·
îC¡ð îuîÇC|UC||Cî I UCî ð|ICî UC u|ð ||IC|vC|ClC|.
H|O|
|uCUC| Ç|CUuC|| h| ÇC|ÇlQUC|IðClC| î| U| | ð| ð| Cl CðîUð.
MC¡C|ð| Cl ðC|C, lð ðlCÇCC|ð y Cl || |îuIlîUC ÇC| CICCIC
ð|I| ð|U|CQC||CC.
ÛO0OOµIO OO µ||OO|8 8OIJ8| OO0 D8|8 OOS|S
LCî Lb1hÔLLNLb lðvC|CCC| |ð l l ÇCl | îl î ÇC||IC|lCð, Ul îUl ·
|uyC| | ð ðC!|v|UðU UC |ð | | ÇCÇ|C!C| |l l Çðîð, ðuUC|Ið| | ðî
VLLL, ¬LL y ðÇCl | ÇCÇ|CIC||ð ª·I y U| îU| |uyC| | ðî LLL
ªu|ÇuC Cî!lUulð| |ð î||!Cî|î UC !|| Q| |CC||UCî hCÇð!lCCî y
îu ||vC| îC|lCC, lð ||lluC|C|ð Cî!|CQC|| Cð îCO|C |ðî | |ÇCÇ|C·
IC||ðî Cî QlCOð| UC|!C lðvC|ðO|C, yð ÇuC U| îU| |uyC| ÇC|·
CC|Iuð|UC|IC |ðî OCIðll ÇCÇ|C!C||ðî ðIC|CQC|lCðî (LLL·L)
y ðuUC|Ið| |ðî ð| lð | | ÇCÇ|C!Cl|ðî (¬LL·L), ÇC| |C ÇuC îC
ðCCÇ!ð ÇuC îC| ð|I|ð!C|CQC||CCî y Cð|U|CÇ|C!CCIC|Cî. b| |
CUOð|QC Ç|CUuCC| || ÇC|CCðQu| ðOl | l UðU ÇC| ðuUC|!C
UC l|O|l|CQC|C, lðC!C| V'', X, ðCI|v|UðU Ç|ðÇuC!ð||ð y Ul î·
Ul |uC| C| UC ð|I| !|CUO| |ð | | | . (Ml K 9ó-97, 1 2 1 ).
LCî |hLLLb1ºLLNLb ðuUC|Ið| Cl UCÇCî|IC Q|ðîC ÇC||·
lC||CC, Cî!| Uu| ð| |ð | | ÇCÇ|C!C| || | Çðîð C l|hlOC| | ð | | ÇC| | î| î.
l ||| OC| |Cî CICCICî Cî!|CQC||CCî, îuÇ|l Ul C|UC Cl ðuUC|·
IC UC ¬LL·L | |UuC| UC ÇC|
HLLULHÕP L0S µf0geS1ðgen0S
S0n a1ef0génÍc0S ÿÌ0S eS1f0ge-
|Cî CîI|CQC|Cî, ÇC| |C ÇuC
n0S, l0 c0n1fafl0. îC| ð!C|CQC|lCCî. Luð|!C
UðyC| îCð Cl ClCC!C ð|U|C·
QC|l CC UC| Ç|CQCî!ðQC|C, UðyC| ðIC|CQC||ClUðU, Ç|CvC·
Cð|UC ClCC!Cî UC!ðOC|lCCî ||UCîCðO|Cî
Lð |CUuCClC| ICIðl CO!C||Uð CC| |Cî Ç|CÇð|ðUCî CCUOl·
|ðUCî UC Oðjð UCî| î hðCC| ÇuC C| ||CîQC Cð|U|CC||Cu|ð!C·
|| C îCð Cðî| |u|C, îð|vC ÇuC îC ðîCC|C| CI|Cî lðCIC|Cî UC
|lCîQC (luUðUC|ðî UC > Jb ðÓCî, H1ª, COCîlUðU, U| ðOCICî,
|| ÇC|| | ÇCÇ|CIC| |CU| ð !|ÇC | | ).
UI|OS OÍOOIOS
¯ L|I|C C| b·J0 % |CI| C|C| U| îU| |uC| C| UC |ð | | O| UC y
UC | ð CðÇðCl UðU UC C|QðîUC (CCu||C îCO|C !CUC CC|
C| UCîCQCî!|C| )
¯ |u6U6| ðuU6|!8| |Cî ||v6|6î U6 !|ð|SCC|!||ð y ¯bÕ.
¯ |ð|CCC| ðuUC|!ð| | ð l|CCuC|C|ð UC CClð| Cðî y UCÇ|C·
î|C|.
¯ Lð Ul îUC|C||Cð îuC|C CCUC| CC| | ð ðUUl |lîI|ðC|C| UC ð|·
!|CC|CCÇI|vCî C|ðlCî (MlK 97-9b|, 43) ( Ml K 04-0b, 1 73).
ÛO0!|8| 0O|O8O|O0OS 8DSO|JI8S
¯ |ðClC|!Cî CC| ||CîQC Cð|U|CvðîCu|ð|. luUðUC|ðî UðyC·
|Cî UC Jb ðÓCî (C |C IuUðUC|ðî UðyC|Cî UC 40).
¯ ª|!CCCUC|!Cî UC !|CUOCîlî vC|Cîð Ç|CIu|Uð C CUOC·
llîUC Çu| UC|ð|.
¯ L| |uQlð UðyC| CC| Ç|Cvlî|OlCî ÇC||CUCî Ç|C|C|QðUCî UC
l |UCvll|2ðC|C|.
¯ MuIðClC|Cî UC QC|Cî CC| Cð|ðcC| I|CUOCQC||CC (IðC·
!C| V, Ç|CI|CUOl|ð, Ç|CICl|ðî L y b yð|!|!|CUO||ð).
¯ ¬¯ª Uð| CC|I|C|ðUð.
¯ LlðOC!Cî CC| ðICC!ðC|C| vðîCulð| (vðîCulCÇðI|ð, |Cl|C·
ÇðI|ð, |C!l|CÇðIlð C |Cu|CÇð!|ð).
¯ VðîCu| CÇð!|ð l|IlðUð!C||ð.
¯ Lð|UlCÇðIlðî Q|ðvCî.
¯ |ðClC|ICî CC| ðICC!ðC| C| |CÇð!|Cð lUÇC|Ið|!C. ðUC|C·
Uð |CÇðI|CC, |CÇðICÇð!|ðî ðC!|vðî CCUC C|||Cî|î ðC!|vð (|ð
hCÇðIl!|î ª |C îC CC|î|UC|ð CC|I|ð||UlCðC|C| ðOîC|u!ð)
¯ lCfÞflð ðQuUð l |IC|U|IC|!C.
¯ ª|!CCCUC|!Cî UC |C!C||C|ð Uu|ð|!C |ð QCî!ðC|C|, CC|Cî!ð·
îl î ||!|ðhCÇð!|Cð.
¯ LUOð|ð2C, CC|h|UðUC C îCîÇCChðUC.
¯ Lð|CC| UC UðUð y CI|Cî IuUC|Cî hC|UC|C·UCÇC|UlC|·
!Cî.
¯ LlîC|ðîlð îð|Qul|Cð, ð|CU|ð UC CClulðî lðlClIC|UCî.
¯ bð|Q|ðUC QC|lIðl ð|C|Uðl |C h| |ðUC (M| K 01 -02, 1 ó9,
NlK 00-01 |, 1 b2).
ÛO0I|8|0O|O8O|O0OS |O|8I|V8S
MCU|CðClC| ÇuC îC îCÇð ÇuC l|IC|ðC!uð CC| lCî ð|Cvu|ð·
!C||Cî, CÇ||CÇî|ð, U| î| l ÇCU|ðî, Ç|CUlðOCICî, vð||CCî îCvC|ðî,
|l!lðîlî O| l l ð|, CClðlCð, H1ª, UCÇ|Cî|C|, ðîUð, CCllI|î u|CC|Cîð.
ª|!Cî UC| | || C| C UCl I|ðIðUlC|!C CC| ð|!|CC|CCÇC|C|
hC|UC|ðl, Cî l UÇ|CîCl|UlO|C |Cðll2ð| u|ð hlîIC|lð Cll||Cð
y CxðUC| I|îlCC, ÇuC UCOC | |Cl ul | u|ð CxÇ|C|ðC|C| Uð·
Uð||ð (MlK 9b-9ó|, 2 1 b) yu|ð Cl!ClCQ|ð, ðî| CCUC UCU||
| ð Ç|CîlC| ð|!C||ð| y C| ÇCîC. Lðî ÇðC| C|ICî UCOC|ð| !C|C|
u|ð |Cv| îlC| Ql|CCC| CQ| Cð ð|uðl ÇuC | |Cl uyð CxÇ|C|ðC|C|
UðUð||ð, Cl!C|CQ|ð y CC|ÇCîCCÇ|ð, CC|!|C| UC |ð Ç|Cî|C|
ð|!C||ð|, y Ç|uCOðî UC lðOC|ð!C||C ÇuC | |Cl ul |ð|. QluCCU|ð
Oðîðl y ÇCîÇ|ð|Ulðl, CClCî!C|C| ICIð| y | ðî l|ðCClC|Cî HLL y
LLL, I|lQllCC||UCî y ð|I|I|CUO| |ð.
Û.0 | 0Î0|00þ0|00 þ08Î00|Î8|
Lð Ç|COðOlllUðU UC CUOð|ð2C I|ðî Uð|IC|C| |C|ðC|C|Cî
îCxuð|Cî î| | ÇlCICCC|C| C CC| |CIu|ð UC Ç|CîC|vð!lvC vð·
||ð C|I|C u| z0·40%, î| C| CC|IC CCu||C ð U|!ðU UCl C|C|C, y
Cî UC u| b% C| CI|C UCUC|!C UCl ClClC.
¯ LCîIðQC|Cî. Cî C| UC!CUC UC C|CCClC|. UîðUCî |CvC|·
C|QCîI|Cl, /b0 UCQ/T z hC|ðî, v|ð C|ðl, z UCîlî, C O|C| u|ð
UCîlî u|lCð CC| UCî CCUÇl| U| UCî. Lv|!ð C|!|C C| ôb·9b%
UC lCî CUOð|ð2Cî CîÇC|ðUCî, î|C|UC Uuy ChCð2 îl îC ðU·
U| || î!|ð UC|I|C UC lðî Ç|| UC|ðî z4 |C|ðî ÇCî!·CC|!ðlCî, y
Uuy ÇCCC CÞCðz î| îC ðUUl || î!|ð !|ð|îCu|||Uðî Uðî UC /z
|C|ðî. 1|C|C CîCðîð l|ClUC|C|ð UC CICC!Cî îCCu|Uð||Cî (C|
Uðî l|CCuC|!C, |ðuîCðî).
¯ MC!CUC Yu2ÇC. u| CCUO||ðUC UC Cî!|CQC|Cî y Ç|CQCî·
!ðQC|Cî C| ð|Iðî UCîlî, v|ð C|ðl, u| CCUÇ|| U| UC CðUð I z
|C|ðî, UCî !CUðî, UC|!|C UC |ðî Ç|lUC|ðî /z hC|ðî.
¯ L|U ÇCî!·CCl!ð| . bC uîð Cuð|UC |ð| !|ð|îCu|||UC C|!|C
J·b U|ðî ÇCî!·CCl!C Lî Uuy CÞCðz.
¯ MlICÇ|lîIC|ð (hU·4ôÔ). Lî u| Ið|UðCC ð|!lÇ|CQCî!ðQC|C,
uîðUC C| l|!C||uÇClC|Cî vC| u|¹ð|lðî UC| CUOð|ð2C (|VL)
y C| l|!C|CCÇC|C| ÇCîI·CCl!ð|. 1lC|C u|ð ChCðC|ð CC|Cð|ð
ðl I 00%.
Ap|Cx| naCanCn!C Cl I 0· I 5%CC 'a> pa|Cja> >Cn C>IC|l'C>,
dCDCn|nanCC>C C>!C|il|CaC piino||a >|, !|a> ¡ ·z aÕC> >lD
an!|cCDcCpc|Cn, nC >C cCn>|guC uD CnOa|a2C, y >Ccun·
da|la >l, !|a> uDa gC>!aclCn, nC >C cCn>lguC uD DuCvC
CJOa|a2C Cu|anIC z-J aÕC> CC Ou>quCCa ,>C CCDCn| Da
|¤lC|Il'|CaC a la cCD>CcuclCD CC gC>!aclCD, pC|C >| D ' Cg|a|
quC ' 'CguC a !C|n| nC cCD uD |CclCn DaclCC nCinal) bC
dC¤Cnlna >uOlC|!| ' | CaC a ' a C| >n| nuc| CD CC la capaclCaC
dC cCncCO|| ,CnCCnC!||C>|>, C' |gC2CC>pC|n| a, C!c).
LC¤>|CC|anC> quC Cl zû% >CD CC cau>a nlx!a, C' 40% CC
cau>a na>cu' |na, y Cl 4û% CC cau>a lCnCDl Da.
0.1 Û80888 00 08Î0|| ||080
¡. |8OÍO| T8SOJ||0O
hay u¤ aunCnIC nuy >|gDlhcaIlvC Cn la> u'!|na> CCca·
da>. ca> cau>a> CC C>IC|| ' | CaC na>cul l Da va|laD CD la> C|
'C|C¤!C> pCO'ac|CnC> C>!uC|aCa>. |D!|C ' a> na> l|CcuCn·
!C>, ¤C> CncCn!|anC>. va||cCcClC, C>IC|lllCaC na>cul l Da
dC cau>a |C|Cpa!|ca, | n>uhc|CDcla IC>Ilcu'a|, c|lpIC|qu|Cla,
a2CC>pC|nla, C|qu| Cp| C| C| nl !| >, a'IC|aclCDC> |lpCIalanl·
ca>, C!c.
¿.|8OÍO| T|XÍO O O0 O||]00 O0SOO0OO|OO
5upC¤C CDI|C Cl ¹ û·z0% CC 'C> ca>C>, pC| cau>a> |ClCpa·
!|ca>, C pC| |Cacc|Cn lDnuDClCglca al >CnCD quC lnplCC
quC pCnC!|C Cn C' nCcC cC|v|cal.
J.|8OÍO| Í0T00|0O
a) AnCna''a> vaglDa' C>. bCn pCcC l|CcuCDIC> y lacllnCnIC
d|agDC>!|ca O'C> cCD la Cxp|C|aclCD l'>|ca. ||nCD lD!Cg|C,
agCnC>|a CC vaglDa, vag|n|>nC, C!c.
0}A¤Cnalla> cC|v|ca|C>. l DlCcc|CnC> ,C|l anyC|a), hl anc| a
|nadCcuaCa ,pC| CxcC>C CC p|CgC>IagCDC>), |C>lCDC> C
|n!C|vCDclCnC> cC|v|ca|C> quC C| >n| nuyaD Cl nCcC, nal ·
lOiJac|CnC> cC|vlca ' C>, C!c.
c) AnCnalla> uIC|lDa>. H| pCpla>la C nallC|naclCD CCl
u!C|C, a'!C|ac|CnC> CnCCnCI|la'C> ,|C|nCDalC>, | nlCc·
C|C>a>), >lnC|CnC CC A>|C|nan, a'!C|aciCD CC 'a C>!|uc·
!0|a nlCnC!|la', a'!C|aclCnC> !uOa|| ca> C pC||ICnCalC>
,20·40% CC' !C!al), aC|C|Cncla> pC||!CDCa'C>, >alp| ng| Il>,
CndCJC!||C>|>.
C) A'!C|aciCnC> Cva||ca>. AnCvJ' ac| C¤, | D>uhc| Cnc| a CC'
cuC|pC 'u!CC ,anC|CgCnC>, p|C'ac!|Da)
C) A'IC|ac|CnC> p>icCgCna>. Vag| nl>nC, Cl>pa|CuD|a, l||g|·
CC2.
0.¿ Î8Î00|0 00 |8 þ8|0]8 |0Í0R||
ca> p|uCOa> quC CCOCD |Call2a|>C CO' |ga!C||anCnIC CD
!CCC C>!uC|C CC C>!C||'|CaC >CD.
¯ PDðDDB5Ì5, BXÇÌOlðCÌÓD y ðDðÌ Í\ÌCð. ¬| >!C|la c' 'n|ca
gCnC|a', g| nCcC'Cg|ca y >Cxua' CC la pa|Cja. ¯CnanC>
nuC>!|a> pa|a c|IC' Cgla y |Cal|2anC> uD C>!uC|C ana' '!|cC.
|CnCg|ana y vClCclCaC CC >CC|nCD!aclCD, O|Cquln|ca,
C||na, g|upC, H| y >C|C'Cg'a> l|CD!C a |uOCC'a, ICxCp| anC·
>l>, >'hll>, |Cpa!| I| > H,Cy V' ¬.
" LCOglðÍÍð \lðD5VðgÌDðÌ . NC> lDlC|na >CO|C C' u!C|C,
anCjC>, y pC>lO|C> a'IC|ac|CnC> nC|lClCg|ca>, a>l cCnC CC
pa!C'Cg'a CnCCnC!||a', CnCCnC!|lC>|>, Cva||C> pC' | qu'>I|·
cC>, CIc.
¯ VðÌOlðCÌÓD OB l ð OvulaClÓD. MCC|an!C H'A ,|aC| C| nnu·
DCaDall>| >) CC!C|n| nanC> |bH, c¬ y C>!|aClC' Cn |a la>C
p|C' |lCia!|va, CD!|C |C> C'a> Jº·5º CC' c|clC. |n!|C C| C'a zû·
zz (la>C 'uICa), CC!C|n|nanC> p|CgC>!CiCna y piC'ac!|Da.
¨ bBDÌDOgfðDð. bC C>!uC|a C' nu¬C|C, nCvl'lCaC y nC|·
lC'Cgla CC ' C> C>pC|naIC2ClCC>. b| C> nC|nal, >C |Ca'|2a Cl
IC>! CC capac|!ac|CD C>pC|naI|ca C H|M ,HCcupC|aclCD
CC |>pC|na!C2C|CC> MCvllC>), quC aCCna> CC >C| una
p|uCOa C|agDC>!|ca, DC> pC|nl!C CO!CnC| C>pC|na!C2C|·
CC> pa|a >u u>C Cn 'a> !CcDlca> CC |Cp|CCucc|Cn a>l>!|Ca.
" MÌ5\BlO5ðÍÇÌDgOglðÍÍð (MbL). |C|n|IC valC|a| CO>!|uc
c|Cn !uOa|| ca C u!C|| na Òca>|CDa'nCn!C puCCC |C>u'!a|
!C|apCu!|ca y |CpC|nCaO| ' | 2a| una CO>!|ucc|CD !|a> >u
|Ca' |2ac|CD.
ÒI|a >C||C CC p|uCOa> DC >C |Ca|l2a|aD CC |uI|na, >lnC Cn
lunc|Cn CC 'a >C>pCc|a ClagDC>I|ca.
¯ LðÇðlO5COÇÌð. |> cCnplCnCD!a||a a 'a ¬bC |> nuy u!|'
CD C' C| agnC>!|cC y !|a!anlCD!C CC aC|C|Cncla> y CC Cn·
CCnCI||C>|>.
¯ 1B5\ ÇO5\COÌ\ðÍ. bC |Ca'|2a pa|a CC>ca|!a| | ncCnpa!| Ol·
' | CaC CC' nCcC cCD ' C> C>pC|na!C2C|CC>. bC'C >C u>a CD
paiC]a> jCvCnC> y cCn |i>!C||a cC|Ia CC C>!C|| ' | CaC
" MÌ5\BlO5COÇÌð. `C|nl!C v|>ua' | 2a| la cav|CaC u!C|| na y, Cn
Cca>lCnC>, !|aIa| la al!C|ac|Cn. Cn ca>C> CC pC' | pC>, n| C·
t9Î8fÌÌÌ080
8 Ì0Î8RÌÌÌ080
` | ¹ l | ´  l 
0|lê1Iätlä1 M|B
L5 UD \BDð ÇOCO ÇlBgUD\ðOO. LÇðf\B QUB Ø
lBQUÌBlB Dð5 ð\BDCÌÓD ÇOf \U Çðf\B B5 BÌ
ðÇðf\ðOO OB \fð\ðDÌBD\O.
AäpêtIêä Eäê1tlä|êä
LD UD Æ  OB |osCð5O5, BÍ ÍðC\Ol ÌDÇÌÌCðOOÖ
B5 BÍ Dð5CUÍÌDO, BD O\fO 40%, B5 BÍ ÍðC\Ol
Í0DBDÌDO (Íð DðyOfÍð OB ÍO5 Cð5O5 ÇOf ðÌ\B·
fðCÌÓD \UDðfÌCð) y BD UD 20%,B5 UD ÍðC\Ol
DÌX\O O OB OlÌgBD OB5CODOCÌOO.
LD BÍ B5\UOÌO OB B5\BfÌÍÌOðO, B5 ODÍÌgð\OfÌO ÍðÑ
ðDðDDB5Ì5, BXÇÍOlðCÌÓD y ðDðÍÍ\ÌCð, BCOgfð·
h \lðD5VðgÌDðÍ (BVðÍUðCÌÓD OB DOfÍOÌOgÍð
PÕ| y OÌðgDÓ5\ÌCO OB ÇO5ÌDÍB5 Çð\OÌOgÍð5
CODO BDOODB\lÌO5Ì5 O 5ÍDOfODB OB OVðlÌO5
ÇOÍÌQUÍ5\ÌCO5), ðDðÌÍ\ÌCð DOfDODðÍ (BD ÇlÌ·
DBlð Íð5B y BD 5BgUDOð Íð5B), 5BDÌDOgfðDð
(DÚDBfO, DOVÌÌÌOðO y DOfÍOÌOgÍð OB B5ÇBf·
Dð\OZOÌOB5, ð5Í CODO \B5\ OB CðÇðCÌ\ðCÌÓD
B5ÇDTð\ÌCð) B DÌ5\BlO5ðÌÇÌDgOglðÍÍð (DOl·
ÍOÍOgÍð OB CðVÌOðO U\BlÌDð y ÇBlDBðDÌÌÌOðO
\UDðlÌCð).
Îðlð Íð lBðÍÌZðCÌÓD OB ÌD5BDÌDðCÌÓD ðf\Ì·M
ÛCÌðÍ, B5 DBCB5ðlÌO QUB Ìð5 \lODÇð5 5BðD
ÇBlDBðDÍB5. L5 Ú\ÌÌ BD Cð5O5 OB ÇfODÌBDð5
OVUÍð\OlÌO5, CBlVÌCðÍB5 O VðgÌDðÍB5, ð5Í CODO
BD Cð5O5 OB ÌDÇO\BDCÌð Dð5CUÌÌDð O ÇODlB
CðÍÌOðO B5ÇBlDð\ÌCð.
L Í0UDOðCÌÓD |D VÍ\fO B5\ð ÌDOÌCðOð BDÖ
Cð5O5 OB Ìð Çð\OÍOgÍð \UDðfÌCð DÌÍð\BfðÍ, DÚ~
DBfO ÌD5UHCÌBD\B OB B5ÇB|Dð\OZOÌOB5 Çðlð
lBðÌÍZðf ÌD5BDÌDðCÌÓD ðOÌHCÌðÌ O \lð5 BÌ ÍfðCð·
5O OB VðfÌO5 ÌD\BD\O5 OB ÌD5BDÌDðCÌÓD.
Lð DÌClOÌDyBCCÌÓD B5ÇBDTð\ÌCð B5 UDð Vð·M
fÌðD\B OB Î0UDOðCÌÓD Ì D VÍ\|O QUB COD5Ì5\B
BD Íð ÌDyBCCÌÓD OB UD ÚDÌCO B5ÇBfDð\OZOÌOB
OBD\lO OBÍ OVOCÌ\O. S U\ÌÍÍZð BD Cð5O5 OB
OÍÌgO5ÇBlDÌð 5BVBlð, BD BÍ ÍfðCð5O OB Í|V,
O 5Ì QUBfBDO5 lBðÍÌZðl OÌðgDÓ5\ÌCO gBDÉ\ÌCO
fBÌD ÌðD\ð\OfÌO.
P|ê¿ä1IäâM|B
Q Ml K 03·04, 1 05
MlK 02-03, 244
M|K Û\ ·Û2, \ 7\
M|K 00-0T , \ 74
DäâêDl|1|têBêp|êâê1IäI|¢ê
MNO hðy cðsOs c|ln|cOs |Cp|CsCnIð!|vOs.
Uðî, î||CÇu|ðî, !ðC|ÇuCî u!C|||Cî, C!C. |î!ð | |U| CðUð C|
ÇðC|C|!Cî CC| ðCC|!Cî UC |CÇC!|C|C| C Çð|!Cî Ç|C!C|Ul ·
|C, !ðUC|C| C| ÇðC|C|!Cî U|ðQ|Cî!|CðUðî UC ð|!C|ðC|C|Cî
C| lð Cðv|UðU u!C|l|ð ÇC| || î!C|Cîðl Ç| |QCQ|ðl|ð, C Cuð|UC
|C îC C|CuC|!|ð C!|ð Cðuîð UC Cî!C|lllUðU.
¯ b|CÇîlð OC CnUCmC!||C. LCCC |Cðllzð|îC Ç|CUC|î!|uðl·
UC|!C. ªu|ÇuC ð|!l QuðUC|!C C|ð CCllQðUð, OCy îu uîC
CîIð U| îU| |uyC|UC (NlK 00-0T , T 74).
¯ ÜC!C|mlnðC|On OC ðn!lCuC|µCs ðnIlCsµC|mð!|CCs.
¯ Lð||CIlµC. L| CðîC UC îCîÇCC|ð UC ð|CUð| |ð C|CUC·
îCU|Cð UC |Cî Ç|CQC||!C|Cî ¦ðzCCîÇC|Ulð, ðCC|!Cî UC
|CÇC!|C|C|, OljCî Ç|Cv|Cî CC| ð|CuÇl C|Ulðî, C!C). NC CC|î·
!l!uyC u|ð Ç|uCCð | UÇ|CîC| |U| Cl C C| C| Cî!uU|C CðîlCC UC
CîIC||||UðU.
¯ ÜC!CCC|On OC muIðClCnCs OC |ð hC|Cs|s qu|sI|Cð. LCl l ·
Qð!C||ð C| vð|C|Cî ÇuC Ç|CîC|!ð| ð2CCîÇC|Ulð CCî!|uC·
!lvð y îC UCUuCî!|ð ðQC|Cî| ð UC |Cî CC|UuCICî UClC|C|·
!Cî. L| vð|C|Cî CC| |CCuC|!Cî CîÇC|Uð!|CCî Uuy Cð¡Cî,
îC UCCC| UC!C|U| |ð| !ðUC| C| |ðî UlC|CUC|CCC|C|Cî UC|
C|CUCîCUð Yy | ð UC|CCC|C| UC| C|ð2C CC|!C UC| C|CUC·
îCUð Y
0.J 1|8Î8M|00Î0
LCUC lðî Cðuîðî îC| Uul!|Ç|Cî, UCCCUCî |ðCC| u| I|ð!ð·
UlC|!C ||U|vlUuð| |zðUC L| QC|C|ð|, îC CUÇ|Czð ÇC| | |UuC| |
ð | ð CvulðClC| îl |ðî !|CUÇðî y C| îCUC| îC| |C|UðlCî.
ªC!uð| UC|!C îC uîð UC ClCCC|C| | ð |b¬ îuCCu!ð|Cð ¦Çu|ð
C |CCCUC| |ð|!C) y lð ¬LL ¦ÇuC |U|!ð |Cî ClCC!Cî UC |ð L¬).
Lî!ð C| UCîuîC Cl ClCU|lC|C ¦îð|vC C| CðîC UC bL|}
Lî l|CCuC|!C uîð| ð|ð| CQCî UC |ð L|H¬ Ç|Cv|Cî ð |ð l |UuC·
C|C| UC lð Cvul ðCl C| Çð|ð CC|îCQul| l|C|ð| || ÇChîl î y Cvð·
||Cî |ðî!ð ÇuC CCUC|CCUCî |Cî C|C|Cî UC | |UuCC| C| Cvð·
||Cð L| CC|!|C| UC| C|CC|U|C|IC lC| l Cu| ð| îC |ðCC UCU|ð|!C
UC!C|U| |ðC| C|Cî îC|lðUðî UC Cî!|ðU|Cl y CCCQ|ðl|ðî.
18O0|O8S OO |Oµ|OOJOO|Ó0 8S|SI|O8
T. | |îCU| |ðClC| ð|!lhClð| CC|yuQðl.
Lî lð !CC|lCð Uðî î|UÇ|C y Uðî uîðUð. Lðî !|CUÇðî UCCC|
îC| ÇC|UCðC|Cî. LC|î|î!C C| ||UuC|| |ð Cvu|ðC|C| C | |!|C·
UuCl | CC| u|ð Cð|ul ð C| îCUC| CðÇðC|!ðUC UC| CC|yuQC
UC|!|C UCl u!C|C. Lî uI|| C| CðîCî UC Ç|CClCUðî Cvu|ð!C·
||Cî, CC|v|Cð|Cî C vðQ||ð|Cî ¦Cî!C|Cî|î, C!C,). 1ðUC| C| C|
CðîCî UC l UÇC!C|Clð UðîCull|ð C ÇCC|C CðllUðU CîÇC|·
UðIlCð.
z. l |îCU| |ðCl C| ð|!lÞCð| CC| îCUC| UC UC|ð|!C.
Lî îl U| | ð| ð lð ð|IC||C|, ÇC|C Cl îCUC| ÇuC îC uîð Ç|CCCUC
UC u| Cð|CC UC îCUC|. U!|l C| CðîCî UC ð2CCîÇC|U|ð y
UujC|Cî îl| Çð|Cjð.
J. |CCu|UðClC| l |Vl!|C ¦|| V).
1|ðî l |UuCl | ð |ð CvulðC|C|, îC |CCCQC| CvCC|!Cî UCU| ð|!C
HLLULHÕP LF|V n0 aumenta
Çu|ClC| lCl l Cu| ð| v|ð vðQl·
eÌ fÍeSg0 0e maÌÎ0fmaLÍ0neS
c0ngénÍtaS.
|ð| CC| CC|I|Cl CCCQ|ðhCC
¦|ð|ðUC|IC CC| CC|!|Cl
C|UCîCCÇ|CC). bC ÇC|C| C|
CC|!ðC!C |Cî CvCC|ICî Cx!|ðlUCî CC| lCî CîÇC|Uð!CzC|UCî
y, u|ð vC2 CC|îCQulUð |ð lCCu|UðC|C|, îC !|ð|î!C|C| |C
Uðî UC I|Cî CUC|lC|Cî.
LCî CUC||C|Cî |C I|ð|îlC||UCî îC| C||CÇ|CîC|vðUCî y
!|ð|îlC|lUCî C| C| C| Cî ÇCîIC|lC|Cî. |uCUC ðuUC|!ð| lð
||C|UC|C|ð UC QCîIðC|C| CC!CÇ|Cð C ðCC|!Cî, ÇC|C |C ðu·
UC|!ð l ðî UðllC|UðC|C|Cî CC|QC||Iðî (Nl K 02·03, 244) .
LîIð ||U|CðUð C| CðîC UC.
¯ |ð!ClCQlð IuCð|lCð Cl l ðIC|ðl, CCUC CCîI|uCClC| UC l ðî
!|CUÇðî.
· | |îul|C|C|!C |uUC|C UC CîÇC|Uð!CzC| UCî Çð|ð |Cð||·
zð| l|îCUl|ðC|C| l|!|ðu!C|||ð .
¯ L| CðîC UC l|ðCðîC UC | |îCU| |ðCi C| i|!|ðu!C|||ð !|ðî
4·ó ||!C|!Cî (Nl K 0T -02, \ 7T ).
4 Lð Ul C|Cl|yCCC|C| CîÇC|Uð!|Cð ¦|Lb| ).
LC|î| î!C C| ||yCC!ð| u| u|l CC CîÇC|Uð!CzC|UC UC|!|C
UC| CvCC|!C. Lî u|ð vð||ð|!C UC |ð |lV, ÇuC Cî!ð l|UlCðUð
C| CðîCî UC CllQCîÇC|U|ð îCvC|ð, | |C| uîC Cx!|ðyC|UC lCî
CîÇC|Uð!CzC|UCî U| |CC!ðUC|!C UC| !Cî!|Cu|C. 1ðUClC|
Cî!ð l|U| CðUð C| CðîC UC lðl l C UC ||V, C Uð|ð Cð||UðU UC
|Cî CvCC|!Cî. Lî!ð !CC||Cð ÇC|U|!C |Cð||zð| U|ðQ|Cî!|CC QC·
|C!|CC Ç|C|UÇlð|Ið!C|lC C| |Cî CUC||C|Cî, îC|CCC|C|ð|·
UC CUC|lC|Cî C|CUCîCU|CðUC|!C îð|Cî C |C ðlCCICî UC
COlC|UCUðUCî QC|CIlCðî ¦Cj. ||C|Cî|î ÇulîI|Cð, OCUChl|ð,
ð!|Cl|ð UuîCul ð| CîÇ||ðl, CIC.).
|8|R8OOS ORµ|O8OOS O0 |Oµ|OOUOO|Ó0 8S|SI|O8
I . L|I|ð!C UC C| CU|lC|C. bu ðCClC| îC UCCC ð |ð u|| C| UC|
lð|UðCC CC| |Cî |CCCÇ!C|Cî Cî!|CQC|lCCî UCl O| ÇC!ðlðUC,
ÇuC Ç|CvCCð Cl ClCÇuCC UC |ð |C!|Cðl l UC|!ðC|C| |CQðI|·
vð UC| Cî!|ðU|C| y ðC!|vð Cl UCCð|lîUC |Cu|CC|UCC|||C
Çð|ð |ð îCC|CClC| UC L|H¬ ªUCUðî, îC Oð UCUCîI|ðUC
u| ClCCIC U| |CC!C îCC|C | ð || ÇCÞî|î, UC|UC Ç|CCðClCUC|·
!C ðC!uð CCUC u| ðQC|lî!ð Cî!|CQC||CC, ðuUC|!ð|UC lð
llCC|ðC|C| UC QC|ðUCI|CÇ||ðî CîIlUulðUð ÇC| lð L|H¬
Lî!ð | |UlCðUC C| Uu¡C|Cî ÇuC îul|C| C| | QC/ð|Cvu|ðC|C|
NC Cî ChCðz C| ÇðC|C|!Cî CC| ðUC|C||Cð O| ÇC!ð| ðU| Cð
C lðl l C Cvð||CC Ç|CUð!u|C. |C| !ð|!C, C| CðîC lUCð| îC||ð |ð
ÇðC|C|!C CC| îl|U|CUC UC Cvð|| C ÇCl l Çu|îI|CC.
z. LC|ðUCI|CÇ||ðî. LC!C|lUðî ÇC| Çu||hCðC|C| ð Çð|!|| UC
lð C|||ð UC UujC|Cî ÇCîIUC|CÇðuîlCðî ¦|ML) C ÇC| |C·
CCUC||ðClC| QC|CI|Cð ¦||b¬, |LH), îC CUÇlCð| Çð|ð | ð Cî·
!| Uul ðCl C| Cvð||Cð C| !CC||Cðî UC |CÇ|CUuCC|C| ðî|î!|Uð.
J. LC|ðUC!|CÇ||ð CC|lC|lCð |uUð|ð ¦|LL). bC ðUU| || î·
I|ð Çð|ð UCîC|CðUC|ð| l ð CvulðClC|, ÇuC îC Ç|CUuCC u|ðî
J4·Jó |C|ðî UCîÇuCî.
4. ª|ð|CQCî UC lð L|H¬ LvlIð| C| Ç|CC Ç|CUð!u|C UC L¬
CC| | ð lu!Cl|lzðC|C| ÇCî!C||C| UC| lC||CulC ÇuC, CC| l|C·
CuC|Clð, CCu||C Uu|ð|!C | ð Cî!l Uu| ðC| C| CC| QC|ðUC!|C·
Ç| |ðî. LxlîIC| UCî !|ÇCî. lCî ðQC|| î!ðî, ÇuC ðUU| |l î!|ðUCî
UC lC|Uð CC|!||uð Ç|CvCCð| u|ð | | CC|ðClC| | || C| ð| UC
QC|ðUCI|CÇl|ðî ¦ClCC!C llð|C·uÇ), ÇuC vð îCQu| UC UC u|
C|CÇuCC |CvC|îlC|C UC lð l | CC|ðC|C| || ÇChîð||ð UC |b¬ y
LH, y |Cî ð|!ðQC||î!ðî, CuyC UCCð||îUCî UC ðCC|C| Cî ð
!|ðvCî UC | ð îuÇ|CîlC| UC lð | | CC|ðClC| UC lðî QC|ðUC!|C·
Çl|ðî ÇC| CCUÇC!lC|C| CC| lð L|HH C| |ð CCuÇðC|C| UC
|Cî |CCCÇ!C|Cî UC Cî!ð C| lðî UCUC|ð|ðî CCl ul ð|Cî UC | ðî
CC| ul ðî QC|ðUC!|CÇðî.
b|0O|ORO OO 0|µO|OSI|RJ|8O|Ó0 OV8||O8
bC I|ð!ð UC u|ð |CîÇuCî!ð CxCCîlvð UC| Cvð|lC ð lð l |UuC·
C| C| UC | ð Cvu| ðCl C| ÇuC UCîC|CðUC|ð u|ð Cx!|ðvðîðC|C|
UC l|ÇulUC. Lðî ÇðClC|!Cî CC| îl|U|CUC UC Cvð||C ÇC| | ·
Çulî!lCC I|C|C| Uðî |lCîQC UC OlÇC|CîIlUulðClC|. buC|C
îC| u| CuðU|C Cl |||CC ÇuC îC UCîC|CðUC|ð I|ðî | ð ðUU| ·
||î!|ðClC| UC |LL y îC |CîuClvC C| ! ·z îCUð|ðî, Cu|îð|·
UC CC| U| î!C|î|C| ðCUCUl|ðl, Q|ð|UCî Cvð|lCî llC|Cî UC
lCllCu|Cî, UC| C| ðCUCUl |ðl , vCU|ICî, U| ð||Cð y ðîC|!lî. |uC·
UC llCQð| ð îC| Q|ðvC y Ç|CvCCð| l|ðCðîC |C|ðl, I|CUCCCU·
CCllîUCî, bLHª y ÇC|C| C| |lCîQC lð vlUð UC l ð ÇðC|C|IC.
L| lCî CðîCî |CvCî·UCUC|ðUCî, Cl !|ðIðU|C|!C CC|î|î!C C|
|CÇCîC, O|U|ð!ðClC| y CC|I|Cl UC lðî CC|î!ð|ICî vl!ðlCî. L|
|Cî CðîCî Q|ðvCî, ÇuCUC ||CQð| ð |CÇuC||| u|ð l ðÇð|C!CU|ð
u|QC|!C, C| | ð ÇuC | |IC|!ð|CUCî îC| |C Uðî CC|îC|vðUC·
|Cî ÇCîlClC. bC UCCC Cv|Ið| | ð QCîIðClC|, Cð|CC|ð|UC |ðî
l |îCUl |ðClC|Cî C C|lCÇ|CîC|vð|UC |Cî CUC||C|Cî, C| C|
CðîC UC ÇðClC|ICî îCUCI|Uðî ð lCCu|UðCl C| l | vl!|C.
CC|>|>!C CD la p|C>Cnc|a y p|C'|IC|ac|Cn CC IC]lCC CDCC·
0C!|la' IuC|a CC la caviCaC uIC||na. |CCCnC> CncCD!|a|
CnCCnCI||C>l> CD cualqu|C| !C¡lCC CC ' a aDaICn'a. La aCC·
nC0|C>|> ,CDCCnCI||C>|> n|CnC!||al) CCOC cCn>lCC|a|>C
aµa|!C, ya quC C> nuy I|CcuCnIC y a>lD!CnaIlca.
Î.1 Îþ|00M|0|0§|8
^0|quC 'a p|Cva' Cnc|a va|la nuc|C >CguD lC> au!C|C>,
aICc!a ap|CxlnaCanCD!C a| ¹ û% CC la> nujC|C>.
cC> Iac!C|C> CC ||C>gC >Cn.
¯ |CaC IC|I| ' .
¯ NC |ay uDa |C' ac| CD c' a|a cCD la |aza.
" Clc'C> cC|IC> ( z/ C|a>) cCD >aDg|aCC nCD>I|ua' aOun·
Ca|!C ,>/ C'a>) IavC|CcC|'aD C' |CIlu]C CC >aDg|C a ' a ca·
viCaC pC||!CnCa'.
¨ c' !aOacC pa|CcC ICDC| uD CICc!C p|C!CcIC| >CO|C ' a CD·
CO0C!||C>|>, pC| C| >n| nul | C' C>!|aC|C' .
Î.Î ÎÎ|0þ8Î0§00|8
la C!lCpa!CgCDla cCnI| nua >| CnCC CC>cCDCclCa. la> !CC·
|'a> 0a> acCpIaCa> >CD 'a> >l gulCDIC>.
¯ MCn>I|uaclCn |C!|Cg|aCa. cC' ul a> CnCCnC!||alC> CC>
µ|C|C|Ca> Cu|anIC ' a nCD>I|uaclCn ''Cgan a la cav|CaC
µC||!CnCa', CCDCC >C l npl aD!aD y p|CllIC|aD.
" MC!ap'a>|a cC'Cnlca a pa|!|| CC LC]lCC quC >C C| IC|CDc|a
a C|CC0C!||C.
¯ ^'!C|ac|CnC> lnnunC'Cg|ca> Cn C' ICjlCC pC||ICnCal quC
KLLULKÜP  P Dð5 D0D5IfU8¬
| nplCCn la ' l>l> CCl !CjlCC
OR, Dð5 fÌ05@OO0 0DOOD0~
005Ì5! D0D8fQUÌ8 µfmO/
OO0 COOO5, D0D5IfUðCÍÓD
ðþUDO8DI0. · .
Î.J L008||I80|00
CDCCnCI|la' Cc!Cp|cC. CaCa
C'a pa|CcC Ca|>C na> | npC|·
!aDcla al IacIC| | DnunClCg|·
cC CD >u paICgCnla.
ca 'Oca||zaciCn na> I|CcuCnIC CC la CDCCnCI|lC>|> C>
C0 C| Cva|lC |M|R0T -02, \ 7J),cCD I|CcuCDc|a >C IC|naD
qui>!C> quC >C l'Cnan CC >ang|C, y C>C cCnICDlCC na||CD
O>c0|C, pa|Cc|CC al c|CcC'a!C, |acC quC >C ' C> ' ' anC ¨qul >·
!C> CC c|CcClaIC¨ lC >lguCD CD I|CcuCnc| a CC lCcallzaclCD.
Cl '|ganCDIC aDc|C pC>IC|lC|, ' | ganCDIC> u!C|C>ac|C>, C'
'|ga0Cn!C aDc|C aD!C||C|, ICDCC CC >acC CC LCug' a>.
Í.4 Û||0|08
" cC'C| ,9'%) L' >|n!Cna na> ca|ac!C|'>!|cC y I|CcuCn!C
CD ' a CnCCnC!||C>|> C> Cl CC'C| >u |nICn>lCaC C> nuy va·
|| aO' C. buClC C>!a| lCcal|zaCC Cn ' a pC'v|>, y >u IC|na na>
ca|ac!C|l>!lca CC p|C>CD!ac|Cn C> cCnC C| >nCnC||Ca p|C·
g|C>|va quC DC cCCC a la ICna CC an!|cCncCp!|vC> C|a'C>
¯anO| Cn puCCC apa|CcC| CC' C| cCD ' a> |C|ac|CnC>. C| >pa·
|Cun| a |Ml R00-0T , T 75,M| R0ô·07, \ 7J).
" A'!C|aclCnC> MCD>!|ua' C> ,ô'%). CCnC ya |CnC> v|>!C,
'a nCna|qul a >C aCC' anIa, lC> clclC> >Cn cC|!C> y cCD >aD·
g|aCC aOuDCanIC, y ' a |Cgla C> CC'C|C>a.
" lnIC|IlllCaC ,4! %) |> una cau>a I|CcuCDIC CC C>!C||llCaC.
la> cau>a> >CD va|la> y pCcC cCnCciCa>. cic'C> aDCvula!C|lC>,
C'Cvac|CD CxcC>|va CC l¬ cCD |C·
HLLULHÜP LDOOD0IfÌO-
5l5 05 ÎÕUPL 8 OOÍOf ÍOl5~
!|a>C CD C' aunCn!C CC p|CgC>·
D0DOD08, OÌ5µ8f0UDÍ8 . . .   } !C|Cna, a|!C|ac|CDC> | nnun|!a||a>,
CO>!|ucc|Cn !uOa||ca, C!c.
" Ò!|C>. AOCCn| na' C>. C| >!CD>|Cn aOCCn| na' , |Cc!C||a·
gia>. U|iDa|| a>. Cl>u|| a, CIc. |uCCC p|CCuc|| una C'CvaclCD
nCCC|aCa CC Ca ! z5 >C||cC |M|R 02-0J, 2J9).1anO| Cn
puCCC apa|CcC| DCunCIC|ax caIanCnl a' , cCIa' Ca>, C!c.
,ÒO>C|va quC ' a CDCCnC!|iC>|> C> >| nCDl nC CC CClC|).
Í.0 Û|8§008Î|00
bC >C>pCc|a pC| ' a c' 'n| ca ca CcCg|aIa·CCpp' C| nC> pC|·
n|!C Cvalua| 'a> ca|ac!C|'>!|ca> CC ' a pC'v|>, pC|C ac!ua' ·
nCD!C, C' C| agDC>!|cC CC cC|!C2a CC ' a CnCCnC!||C>|> C>
pC| lapa|C>cCp|a, quC p|C>Cn!a ' a> >l gu|CD!C> vCnIa]a>
pC|n| IC vl>ua' | za| Cl |CcIanCnIC ' a> 'C>lCDC>, quC !lCnCn
a>pCc!C CC quCnaCu|a CC pC'vC|a, pCCCnC> valC|a| C'
|C>!C CC' apa|a!C gCDl!a' , |Ca'|za| ' a C>IaClhcaclCD, y !C·
na| nuC>!|a> pa|a C>IuC|C aDa!CnC·pa!C'Cg|cC.
ACCna>, CD C' n|>nC ac!C ' apa|C>cCp|cC, >C puCCC |Ca' |·
2a| uD !|a!an|Cn!C qu| |u|g|cC.
bC c|a>|hca CD 4 C>!aC|C>, CC acuC|CC cCD una puDIua·
clCD quC va' C|a ' a p|C>Cncia CC l C>| CnC> y aC|C|CDcla>
CD pC||!CnCC, ICnCC CC >acC pC>IC||C|, Cva|| C> y !|Cnpa>,
>|CnCC Cl C>!aC|C ' n'D|nC, C|  '' 'CvC, C' ||| nCCC|aCC, y Cl
'V >CvC|C.
t000M8ÎIÌ08Ì8
l · ` I  
0||ê1Iätlää M|B
LS!£  !£mð  S£  µl£gUH!ð  ÍuHCðm£H!ð|m£H!£ Ø
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|CS C£SgÌCS£S. 
AäpêtIêä Eäê1t|ä|êä
Lð £!|CÌCgÍð C£ Ìð £HCCm£!lÌCS|S ðÚH  HC £S!ð Ö
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!£S  C£  CÞCCC|ð!£'.  ¯lðS  £Ì  DVðlÌC,  S£  SU£Ì£H 
ðÍ£Clðl £| |Ìgðm£H!C ðHCÞC  y ÌCS U!£lCSðClCS, 
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H|Cð y µCl  Ìð £CCglðÍÍð, £H  Ìð  qU£ £S  ÞðD|!Uð| 
Ìð  V|SUð|Ì2ðCÌDH  C£  ÌCS  qU|S!£S  £HCCm£!lÌD·
SÌCCS,  SÌ  DÌ£H  £Ì  C|ðgHDS!|CC  C£DHÌ!|VC  £S ð 
!lðVÉS  C£  |ð  ÌðµðlCSCCµ|ð,  qu£  ðC£mðS  HCS 
µ£lmÌ!Ìlð !lð!ðl ð Ìð µðCÌ£H!£. 
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£HC0H!lðmCS  ðH!£  muj£l£S  jDV£H£S,  y  £H
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VCS ÞClmCHðÌ£S,  £S!ðg£HCS  CðHðZCÌ. . . . 
P|ê¿ä1IääM|B
Ñ M|R0ó-07, \7J
M|R 02-0J, 2J9
M|R0\ -02, 17J
M|R00-0\ , I 75
OääêOl|1|têBêp|êäê1IäI|¢ê
M2J9. PaC|ente de J0 aDOs, nuI|gesta, COn
u|t|ma regIa haCe 20 d|as, que aCude
a |a COnsu|ta pOr presentar ester|I|dad
y d|smenOrrea |mpOrtante. Ln Ias
exp|OraC|Ones que se reaI|zan, destaCa
tumOraC|Ón anex|a| en |a eCOgraÍ|a y
e|evaC|Ón mOderada de La- 1 25 sér|CO.
[Luð| es e| d|agnÓst|CO de presunC|Ón!:
\ ) LmDarazO eCtÓp|CO.
2) LðnCer de Ovar|O.
J) M|Oma uter|nO.
4) LndOmetr|Os|s.
5) Qu|ste Ovðr|CO ÍunC|OnaI.
M|R 2002-200J RL: 4
\ 7J. Un paC|ente de J2 aDOs, COn un CuadrO
C||n|CO de sangradO menstruaI |rreguIar,
d|smenOrrea, d|spareun|a, yuna ester|I|dad
de J aDOs de evOIuC|Ón, presenta una
ana||t|Ca hOrmOna| nOrma| y un estud|O
eCOgrðÞCO transvag|naI que |nÍOrma de
un uterO nOrmaI y sendas ÍOrmaC|Ones
qu|st|Ca Ovðr|Cas D|Iatera|es de 4 os COn
s|gnOs eCOgrðhCOs de sOspeCha. ¿LuðI ser|a
|a Or|entaC|Ón d|agnÓst|Ca!:
\) ´|ndrOme adherenC|aI pé|v|CO.
2) HemOrrag|a uter|na d|sÍunC|OnaI.
J) ´|ndrOme de| Ovar|O pOI|qu|st|CO.
4) LndOmetr|Os|s.
5) Qu|stes dermO|des D|IateraIes.
M|R 200ó-2007 RL: 4
Ì.0. 1|8Ì8M|00Ì0
ì |öpö¯C>cCpö. c> C' !¯ö!öJ|C¯!C CC C'CccCn CC 'ö Cn
CC¤C!¯lC>>. `C¯J!C ¯C>C'vC¯ g¯ön pö¯!C CC ' ö> l C> CnC>
¯COC >C¯ uD !¯ö!ö¤lCn!C cCn>C¯vöCC¯, cuyC CO|C!vC C> 'ö
¯C>Iðu¯öcCn CC ' ö önöLCJ|ö. bC !C¤ön OCp:ö> y c!C'C·
g|ö CC ' |qu CC pC¯!CnCö', >C ¯Cölïö qul >!Cc!CJ|ö, >C Cx!¯·
pön C >C CC>!|uyCn 'C> Jp'ön!C> pC¯!CnCö'C>, >C |Cölïö
'övöCC pC¯!CnCö' hnö' , y Cn Ccö>CnC>, >C u>ön >u>!öDcö>
ön! öC|C¯Cn!C> pö¯ö 'C> önCjC>
cC> mCC C> CC >CccCn y lu' gu¯öci Cn >Cn ' C> Jð> ChcöcC>
y ¤CnC> 'C>vC>.
Z. Cl|ug|ö HöC cö' . |>!ð nCcöCö cuönCC 'ö CDlC¯JCCöC
nC |ö pCCCC >C¯ cCn!¯C'öCö cCn !|ö!öJCD!C qu ¯ulgcC
cCn>C¯vöCC¯ n cCn ¯!C. JCC cC `C¯ C|CJp' C. CC' C¯ ¯C
> >!CO!C ö' !¯ö!ö¤lCn!C C nvö' Cön!C, ölCc!öclCn CC C!¯C>
C¯gönC>. n!C>!nC, v|ö> u¯ nö¯ö>, C!c. |n cö>C CC c|ug|ö
¯öCcö', p¯öc!lcö|C¤C> | >!C¯Cc!CJ|ö !C!ö' cCn CCO' C
önCxCc!CJ|ö
3.¯¯ö!öJCn!C ¤CC cC. |> cCn!¯CvC¯!CC y pCcC Chcöz.
bC Oö>ö Cn lö CCö CC quC |ö CnCCJC!¯lC>> nCcC>l!ö un
öJO|Cn!C |C|JCnö' CC C>!¯CgCnC> y !öJO Cn CC p¯C
gC>!ðgCnC> (pC¯ C''C, nC öpö¯CcC ön!C> CC 'ö ¤Cnö¯qu ö,
CC>öpö¯CcC !¯ö> 'ö ¤CnCpöu> ö, y'öuJCn!ö ö' cCJCnzC
CC| CJOö¯öïC). |n Ccö>lCnC> 'L u>ö p¯C y pC>!c¯ugö. cC>
¤ð> u>öCC> >Cn.
¯ Anð' CgC> CC l ö CDHH, (p¯ClC|l O|C¤CD!C pC¯ v|ö >uOcu!ð·
nCö) Cu¯öD!C O JC>C>. c¯CöD un ö¤OCn!C | pCC>!¯CgCn ·
cC quC pö¯CcC IövC¯öO'C.
¯ ¯önöïC' ,400·800 Jg/Clö, O ¤C>C>). lö c¯CöcCn CC un
öJOCn!C |l pC¯öDC|CgCncC C | pCC>!¯CgCncC lövC¯CcC
' ö ö!¯Chö CnCC¤C!¯öl.
¯ CC>!ðgCnC> (cC¤C Cl öcC!ö!C CC ¤CC¯Cx p¯CgC>!C¯Cnö),
quC p¯CCucC unö öccCn |Ccöl, y >u ClCc!C >CcunCö|C
¤ð> l¯CcuCn!C C> p¯CCuc ¯ öl!C¯öcCnC> ¤Cn>!¯uö'C>.
¯ An!cCDcCp!vC> C|ö' C> Cu|ön!C O¬ JC>C>. (>CO¯C !CCC
'C> ¤CDClð>cC> cCD gC>!ðgCDC> pC!Cn!C>). p¯CCucCn
n| O clCn cCD!¯ö' y CCc Cuöl lï3cCn |Ccöl.
Ì.Ì. Î000M0Ì||08|8 ÿ 08000|
Lö CnCC¤C!¯lC>> C> unö CDIC¯¤CCöC OCngnö. |n 'C> ¯ö
¯C> cö>C> CC CnCC¤CL¯C>l> ö!|pcö, >| |öy un pC!0nC|ö'
p¯CcöDcC¯C>C.
cC> !pC> |l>!C'CglcC> quC >C ö>Cc ön cCD JöyC¯ !¯CcuCn·
c ö >Cn C' cö¯clDCJö CDCCJC!¯ C CC CC Cvö¯C y C' cö¯c|·
DC¤ö CC cC' ul ö> clö¯ö>.
Û. Ì u0Í|0|0|00 } 00000µl08
LdS VUlVCVdQ| || \lS CO|S\|\uyED UD S||O|C0E C||D|CC CC·
0uD ÇUE SE O| dQ|CS\|Cd E| 0dS OE| z5% OE ldS 0U¡E|ES
60 |dS CC|SU|\dS OE EDÍE|0EOdOES OE \|d|S0|S| Ó| SEXUdl.
Ld VdQ|Dd ES UD CC|OUCIC Cd|E|\E OE Ql dDOU| dS Ç|CÇ|dS,
ÇuE ES\d \dÇ|ZdOd ÇC| EÇ|\E||C Ç| d|C ÇC||ES\|dI|DCdOC. L|
Í|u¡O VdQ| |d| |C|0d| ES D|dDCC, DC 0C0CQCDEC E ||COC
|O. |´OV|E|E OEl O|E|d|E E| ld VdQ|Dd OE O|ÍE|ED\ES Ql d|
0u|dS (Ql d|OU|dS VES\| DU| d|ES, Ql dDOU| dS OE bd|\0C|||C,
O6| CC|V|X, OE| EDOC0E\||C y OE| E|OCSdlÇ|DX), OE| ||ÇU|OC
\|dSuOdOC OE ld Çd|EO VdQ| |dl y OE CCl Ul dS VdQ| Dd|ES OES
Cd0dOdS. LdS 0C|0CDdS SEXUd|ES (ES\|ÓQEDCS y Ç|CQES
\6|O0d) |DÍ|UyED SCD|E |dS Cd|dCIE||SI|CdS OE l d SEC|EC|ÓD
yÍ|O|d VdQ||d|ES.
Ld VdQ|Dd ES U| 0EO|C dC|OC L| DdC|lC OE LOOE|lE|| dC|
O|0Cd E| 0EO|C. Ç|COUCE dC|OC |dC\|CC 0dS\d UD ÇM OE 4
6D ld 0U¡E| ED EOdO ÍC|I|l. L| ld OEÍC|E|C|d OE ESI|ÓQE|CS
(6¡. 0EDCÇdUS|d), El Ç| SUElE SE| SUÇE||C| d ô.Ld dO|C| Ó|
O6 || O|ÓX|OC OE ÇC\dS| C dl ! û%dl EXUOdOC DC Cd0D| d E|
OlO|. ES |d OE|C0|DdOd ×Ç|UEDd OE |dS d0|DdS». Ld ÍÍC|d
VdQ| |dl |C|0dl ES\d CC|S\|\U|Od ÇC| 0|C|CC|Qd||S0CS
d6|OD|OS y d|dE|CD|CS. LD l d Í|C|d |C|0dl, ES ÇCS|DlE ED·
CODI|d| 0|C|CC|QdD|S0CS QUE SCD ÇdIÓQEDCS Dd¡C C|E|\dS
C||Cu|SIdDC|dS, CC0C l col/, 5oc!c/o/dc: //ogili:, 5 ou/cu:,
c:!|cp!ococo:dc| g/upo5yc:pccic:dcCondido.
L0 |OS O|dS ÇE||CVUld\C||CS OE ld EOdO ÍC|\||, ED ld ÇUDE| y
6D ld ÇCSI0E|CÇdUS|Cd, El Ç| dSC|E|OE, ÇE|0|I|EDOC ld
g6DES|S OE ldS | |ÍECC| O|ES VdQ|Ddl ES Q|dVES.
LODS|OE|d0CS dÇd|\E ld Dd|I0Cl | || \| S, CUyd CdUSd 0dS Í|E
Cu6D\E ES ld ODSI|UCC|ÓD OEl Cd|d| EXC|EIC| OE l d Ql d|OU
|d, S|EDOC l d | |ÍECC|Ó| CdUSdOd ÇC| |d Í|C|d |CCd|. PU|QUE
6D u| Ç|| |C|Ç| C SE ÇUEOE 0dCE| U| \|dId0|ED\C 0CO|CC
COD ÍIUC|QU| |Cl C|dS C CEÍdl CSÇC|| |dS 0dS 0EI|CD|OdZC|,
COD Í|ECUEDC|d |EÇU|E|E I|d\d0|E|IC QU| |U|Q|CC, ÇUE ÇUE
O6 CO|S|SI|| ED 0d|SUÇ| dl |ZdC|ÓD OE | d Q| d|OUl d. SE SU\U|d
ld µd|EO OEl QU|S\E d l d Çd|EO VESI| DUl d|, C D|ED ÇCOE0CS
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M|K 205-2084
2Jû. Ånte unð mu]er de 2û ðÔOs que
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1J.1 Î|0Í| |8I|8 ÿ 0|8§008l|00
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cö cl!C'Cgiö cC|vcCvög Dö' C IC>I CC löpöD cCl öu C> Cl
nCICCC nð> CICc!vC CD C' c|OöCC CCl cðDcC| cC¯vlcö' .
CCD>>!C CD ' ö I|l p' C ICnö CC cC|ulö> CCl I|öcIC gCD !öl
(vög Dö' , CDCCcC¯vlcöl y Cc!CcC¯vlcö') cCD Cl hD CC >C>·
pCc|ö¯ lö Cxl>!COclö CC Cl >pl ö> ö> öDIC> CC ÇuC >C |öyö
p¯CCucCC Dvö>ÓD CC' C>!¯Cnö pC| cCl u| ö> DCCp' ð> cö>.
¯CDC uDö Oöjö >CD>l O ' CöC ('û·ôû%), CCOl Cö IuDCönCD·
Iö'nCD!C ö C|¯C|C> CD ' ö !Cnö y C¯¯C¯C> CD ' öOC¯öIC|C, y
uD öl!C pC¯cCD!öjC CC Iö' >C> DCgöIlvC> ÇuC puCCC l ' Cgö¯
ö' Jû%. bD CnOö¯gC, CD C' öCCDCcö|clDCnö, C >n DuyC
lö >CD>OillCöC.
¯COC ¯Cöllïö|>C CC nöDC¯ö > >!CnðIlcö ö !CCö> l ö> nujC·
¯C> CC>CC C' Dl c C CC ¯C' öclCDC> >CxuölC> C CC>CC ' Os ! o
ö¤C>, CC nöDC|3 öDuöl Cu¯öDIC J öÙC> cCD>CcuIivC>, y
ö pö¯!l| CC CD!COcC>, > 'Os ¯C>ulIöCC> >CD DCgö!vC>, >C
¯CpC!¯ð ' ö c !C' Cg|ö cöCö z·J öÙC>, C
|
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cö>C CC DC |öOC¯
Iöc!C¯C> CC ¯lC>gC (p¯Cn >cu CöC. >Cxuö|, L1b, ¬lV, C!c)
C öDuö' nCD!C, > Cx>ICD Clc|C> Iöc!C¯C> CC |lC>gC, |ö>!ö
'C> ô'-7û öÙC>. bu u>C |ö ¯CCuc CC 'ö> nuC|IC> pC| cðD·
cC| CC cC¯vx CD nð> CCl 'û%.
Ac!uölnCD!C Cxl >!CD DuCvö> !CcDcö>.
¯ Lö clIC'Cglö CO nCClC l|Çu CC. cCD>l >!C CD C l u ¯ ' ö
p¯uCOö CD uDö >Cl uc ÓD ÞjöCC|ö y p|CcC>ö|lö.
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M.»-·..·... . -.·.-:.
¯l >nl DuyC C' DunC¯C CC c!C' Cg|ö> DC völC¯ö OlC> y pC¯·
nl !C 'ö ¯CölïöcÓD CC !CcD cö> öC c CDö' C>, cCnC 'ö CC
!C¯n Döc ÓD CC ¬`V CD ' ö nuC>!¯ö.
AunCDIö ' ö >CD>l O ' CöC cCD ¯C>pCcIC ö ' ö c!C'Cglö cCD-
vCDcCDö' , >D ¯CCucl | >gDhcö!lvönCDIC >u C>pCclÞclCöC.
NC C>Ið nuy np'öDIöCö CCOCC öl cC>IC mð> C' CvöCC.
* ¯C!C| n Döc ÓD CC' HlV. DC CCICcIö |C>l CDC>, > DC
ÇuC CC!C|nl Dö DICcclÓD CC' vl ¯u>. |> nuy >CD>i Ol C
y pCcC C>pCc|Ilcö. bÓl C >C öpl l cö CD öÇuCl l ö> pöcl CD·
!C> ÇuC yö p|C>CDIöD öl guD !l pC CC ' C>l ÓD (AbCUb C
Cl >p' ö> ö), pö¯ö ö>l CC!C¯ nl Dö| C' gCDCI pC CC ¬lV y
>öOC¯ Cl |l C>gC CDcCgCOl cC (' C> gCDCI pC> ! ô y ! o >CD
CC öl!C |l C>gC). `uCCC ¯Cöl l zö¯>C CD ci ICl Cg|ö> ' |Çu Cö>
y O Cp> ö>.
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0Cn >C|. ÇC| Cx!Cn>l Cn Cl |Cc!ö, ÇC| viö l | nlö!|cö C ÇC|
vö >öngunCö, Ç|Cducl CnCC >ln!Cnö> >Cgun Cl C|gönC
ö!Cc!öCC.
cö Cx!Cn>| Cn ' Ccö' >C Ç|CCucC löc| ö lö vöginö C, |ö!C|ö'·
1Cn!C, |öciö lC> Çö|önC!||C> ÇC| cCn!|gu|CöC (C' !C|ninC
pö|ö0C!||C löcC |ClC|Cnc|ö ö lC> !C|iCC> ÇuC >C unCn ö'
u!C|O. ' igönCn!C> u!C|C>öc|C> y cö|Cinö' C>).
|ò|¯vö>|Cn CC lö vöginö C> Oö>!ön!C Ç|CcCz, CC>!|uyCn·
0O>C Ç||nC|C ' C> lCnCC> CC >öcC> vögi nö' C> cCn |nvö>|Cn
µO>!C||O| CC >u !C|c|C >uÇC|iC|, y Cn C>!öCiC> övönzöCC>,
'ö |¯vö>|Cn llCgö ö' !C|c|C |nlC|iC|.
ln 'O> cö>C> Cn lC> ÇuC !CCC Cl C>ÇöciC Çö|öcC|vicöl C
pö|ö0C!||ö' C>!ö invöCiCC, >C Ç|CCucC l C ÇuC >C cCnCcC
cO0O «ÇC'vi> cCngC'öCö».
|ö|ö C' C>!uCiC CC Cx!Cn>|Cn, ÇuCCC |Cöli2ö|>C unö u|C·
g|ölö |n!|övCnC>ö, c|>!C>cCÇ|ö, 1AC, lMN.
c0> cö>C> cCn C| >C0i nöci Cn vö>cu'ö| ÇuCCCn Cö| lugö|
ö mC!ö>!ö>| > Çu' nCnö|C>, l C ÇuC Ccu||C Cn C' b% CC lö>
CnlC|nCCöCC> övönzöCö>.
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cö C>!öCiUcöciCn CC' cöncC| CC cC|vix C> ÇrCÇui |u|gicö
|MJK9ô-9ô,224).VC| !öOlö CC C>!öCiUcöc|Cn.
! J.Ì ÎI0008ÎÌ00
50n löc!C|C> CC nö' Ç|CnC>!|cC.
¯ 'òmönO!unC|ö' .
" ||OlunC|CöC CC lö invö>iCn !unC|ö' .
¯ '0vö>iCn ' |nlö!|cö y vö>cu' ö|
¨ cö Cxis!CnCiö CC öCCnCÇö!ös.
L' löc!C| Ç|CnC>!icO nö> i nÇC|!ön!C C> Cl C>!öC| C cl ·
0|cO.
1 J.ë 1I8Î8MÌ00Î0
lö ci |ugö. || >!C|Cc!Cnlö |öC|cö' !|ÇC WC|!|C|n-MC|g>,
ÇuC l ncl uyC ' | nlöCCnCc!Cnö ÇC'vicö CC cöCCnö> | ' öcö>
Ç|in|!ivö, Cx!C|nö, |n!C|nö y CC lö lC>ö CO!u|ö!|iz, y ' ö |ö·
C|C!C|öÇ|ö cCnO| nöCö. Cx!C|nö y O|öÇu|!C|öÇ|ö ('ö O|öÇu|·
!C|öÇ|ö cCnä|>!C Cn |öC|C!C|öÇiö ' Ccöl |n!|övög| nö' ) >C lön
nC>!|öCC | guö' nCn!C ClCc!ivö> Çö|ö C' !|ö!ön|Cn!C CCl
cöncC| CC cC|v|x | nvö>ivC Cn >u> C>!öCiC> | n|ciölC>.
lö CilC|Cnc|ö Cn!|C unö li >!C|Cc!Cnö !C!ö' y unö |öCicö|
cCn>|>!C Cn ÇuC, Cn ' ö !C!ö' , >C Cx!i|Çö l ö «!C!öliCöC» CC'
u!C|C. cuC|ÇC y cC|v| x, n|Cn!|ö> ÇuC l ö |öC|cöl vö nö>
öl ' ö, y öDöCC ö ' ö !C!ö' 'ö Cx!||Çöc|Cn CC un nöngui!C
vög| nöl .
|n C' WC|!lCin-MCig>, >C |Cö'|zö unö ||>!C|Cc!Cnö |öCicö'
nö> linlöCC¯Cc!Cnö ÇClvicö CC ' ö> cöCCnö> yö CC>c||!ö>.
HLLULHÜP LÌ LðÞL0f
lö Çu| niC!C|öÇiö >C |C>C|vö Çö|ö
U0 L0OlX U0jð U0 S0f
QulfúfgÍc0 LuÞU0
ð!eð ð µðfðm0tfl0S.
CC!C|nlnöCC> cö>C> CC C>!öC|C>
| | | y lV, Çö|ö C| >nl nui | ' ö> nC!ö>!ö·
>|> ö Ci>!önc|ö. cC> lö|nöcC> nö>
u>öCC> >Cn. c| >Ç' ö!| nC, b·huC|öc|' C,
O' CCnicinö, C |lC>lön| Cö cö Çu| n|C!C|öÇ|ö nCCöCyuvön·
!C (Ç|Cv|ö ö c| |uglö C |öC|C!C|öÇ|ö) Çö|CcC öunCn!ö| ' ö>
!ö>ö> CC >uÇC|v|vCnc| ö.
¯ |b1AL'Ò ' A.
¬i >!C|Cc!CUö !C!öl >| nÇ' C, cCn C >i n CCOlC önCxCc!Cnlö,
>Cgun CCöC. b| CC>Cö CC>cCnCCnc|ö, C> ÇC>|OlC l ö cCn|2ö·
clCn, >|CnÇ|C ÇuC lC> nö|gCnC> CC ' ö Ç|Czö C>!Cn l l O|C> y
iCölicC un öCCcuöCC >Cgu| niCn!C |M| KUõ·U4, \ Uô)
¯ |b1A¯lÒ l b y' ' A.
¬|>!C|Cc!CUlö |öCi cöl cCn ' | nlöCCnCc!Cnö ÇC'v|cö (WC|·
!|C| n-MC|g>).
¯ |b1A¯lÒ JJb.
löCiC!C|öÇ|ö Cx!C|nö y O|öÇu|!C|öÇ|ö.
¯ |b1A¯lÒ |||.
löC|C!C|öÇ|ö Cx!Crnö y OröÇul!C|öÇiö.
¯ |b1A¯lÒ 'V.
löCiC!C|öÇiö y, Çö|ö ' ö> nC!ö>!ö>|>, C>!ö inCicöCö 'ö Çu| ·
n|C!C|öÇiö.
kâpêtI0âEâê1t|älêâ[||)
LUðndo e| 1Umo|5e ||m|1ð ð| CUe||o, Con
Un1ðmðÔo |nle||o| ð 7X>mm, no5 enCon-
1 |ðmo5 ConUne51ðd|o ÌA. Ln e51o5 Cð5o5,
5| 5e 1 |ð1ð de mUje|e5 jóVene5 Con de5eo5
de de5CendenC|ð, |eð||Zð|emo5 Unð Con|·
ZðC|ón, m|en1 |ð5 qUe en e1 |e51o de Cð5o5
p|oCede|emo5 ð Unð h|51e|eC1om|ð 1o1ð|
5| mp1e Ln|ð5 pðC|en1e5Con1Umo|e5 ene5·
1ðd|o|b||e51ode1Umo|e5 ||m|1ðdo5 ðÌCé|·
V|X)oe51ðd|o|JA|ðleC1ðC|ón2/J5Upe||o|e5
de Vðg|nð, 5| n ðleC1ðC|ón pð|ðme1 ||ð1), |ð
C||Ug|ð|nd|Cðdðe5 e| WeHhe|m·Me|g5
P|ê]01IäâM|B
MJKU>-U7,T 7> Ñ
MJK J J·UT |, T öT
MJK 9ö·99, T 7T
MJK9>-9>,224
Uäâ0U||1|t0Bêp|êâê1IäI|r0
T öT . Ln Unð pðC|en1e 5ome1|dð ð Con|Zð- M
C|ón po|5 o5 peChð de neop|ð5| ð |n1 |ðep|·
1e||ð| e5Cðmo5ð de ð|1o g|ðdo (L|N |||}, Ìð
Anð1om|ð|ð1oÌóg|Cðno5 |nlo|mðdeZonð5
de|nVð5|ónde|e51|omðConUnðp|olUnd|·
dðd de >mm ¿Lómo denom|nð||ðmo5 ð
e51eCð5oÏ:
\)Lð|C|nomð| n5|1U .
2)L51ðd|o|ðT deCð|C|nomðdeCUe||o
J)L51 ðd|o|ð2deCð|C|nomðdecUe||o
4) L51ðd|o|OdeCð|C|nomðdeCUe||o
>)L51ðd|o||deCð|C|nomðdeCUeÌ|o.
M|K 2UUU-2UU\IKL.4
bH6Î0 QcÎVÍ£0
U||ê1Iät|01 M|B 
M Ls un tema pOcO |mpOrtante, as| que pue-
des OOv|ar|O s| nO vas O|en de t|emp.
AäpêtI0ä Eäê1t|ä|êä 
O LOs lactOres pred|spOnentes para |a apar|-
c|ón de prO|apsOs gen|ta|es sOn |a par|dad,
|a edad, |a menOpaus|a y e| aumentO de |a
pres|ón aOdOm|na| (esluerzOs, estreñ|m|en-
tOcrón|cO, OOes|dad).
Ð L| c|stOce|e se caracter|za pOr un descensO
de |a pared vag|na| anter|Or prOduc|dO pOr
un descensO de |a ve]|ga. L| rectOce|e cOnst|-
tuye e| descensO de |a pared pOster|Or vag|-
na| mOt|vadO pOr e| descensO de| rectO, y e|
enterOce|e es un prO|apsO de| mndO de sacO
vag|na| pOster|Or.
Ð L| tratam|entO de| gradO l es cOnservadOr,
cOn e]erc|c|Os de rehaO|||tac|ón de |a mus·
cu|atura de| sue|O pé|v|cO, m|entras que |Os
gradOs ||y |||prec|san cOrrecc|ón qu|rurg|ca,
cOn O s|n ma||as, cuandO sean s|ntOmát|cOs.
L|ncOnt|nenc|a de Or|na es |a pérd|da |n-
' vO|untar|a de Or|na pOr parte de |a pac|en-
te. CuandO se prOduce ante aumentOs de
|a pres|ón aOdOm|na|, se deOe a un la||O en
|Os mecan|smOs de c|erre uretra|, y se de-
nOm|na |ncOnt|nenc|a ur|nar|a de esluerzO.
Ln |Os casOs |eves, se ut|||zan e]erc|c|Os de
rehaO|||tac|ón, m|entras que para |Os casOs
severOs, se cO|Ocan Oandas suOuretra|es. S|
|as pérd|das se asOc|an a un deseO |mpe-
r|OsO de m|cc|Onar (urgenc|a), nOs encOn·
tramOs ante una |ncOnt|nenc|a ur|nar|a de
urgenc|a, mOt|vada pOr una cOntracc|ón
|nvO|untar|a de| detrusOr, y se trata cOn lár-
macOs ant|cO||nérg|cOs.
1 4. 1 å|8Ì0M8 00 808þ008|00 §00|Ì8|
Höy / ¯|¯ICnö¯ önö!Ón|cC¯ ÇuC cCnpCnCn C' ¯|¯ICnö CC
¯u¯pCn¯|Ón ,!önO|CD ' ' önöCC Iö¯c|ö CnCCpC'v|cö).
¯ cö pC'v|: Ó¯Cö
¯ |C¯ l l gönCn!C¯ öDc|C y |CCCnCC
¯ ¦lgönCD!C¯ uIC|C¯öc|C¯ y cö|C| nö' .
¯ ||öI|ögnö u|CgCD|!ö', cCnpuC¯IC pC|. C¯I|n!C| C¯!|löCC
CC' önC, nu¯cu'C¯ l¯Çu|CcövC|nC¯C¯, Oul OCcövC|nC¯C¯,
!|öD¯vC|¯C¯ CC' pC||nC, y C¯I'n!C| C¯!||öCC CC lö u|C!|ö
|Ml R 97·98, 2ÛÛ) .
¯ |ö pC|c|ÓD CC Iö¯clö ÇuC ¯C unC ö 'ö pö|CC vög| nö| pC¯·
IC|lC| y IC|nö Cl C¯pöclC |Cc!CvöglDöl.
¯ |l C|öI|ögnö pC' v|cC, cCD¯I|!ulCC pC| lö¯ !|C¯ pö|!C¯ CC'
C' CvöCC| CC' önC.
¯ |' cuC|pC pC||nCö' y C' C¯Iln!C| önö' Cx!C|nC.
1 4.¿ Î|0|8þ80 ¥8§|08| [Û0|þ000|0J
|' IöcIC| p|CC|¯pCDCn!C nö¯ | npC|IöD!C C¯ 'ö pö|lCöC,
öunÇuC !önO|Cn p|CC|¯pCnCn 'ö CCöC, ' ö nCDCpöu¯|ö y
C' öunCn!C CC ' ö p|C¯|Ón öOCCn| nö' ,C¯IuC|2C¯, C¯!|CÒl·
nlCD!C c|Ón|cC, C!C).
lçur 19 |l0|dµ50 uÎ6|||T0
¯ C|¯ICcC'C c¯ C| CC¯cCn¯C CC lö pö|CC vöginöl önIC||C|,
p|CCuciCC pC| un CC¯cCn¯C CC lö vCj| gö ,!önC|Cn puCCC
' ' önö|¯C cClpCcC'C öD!C||C|, cuönCC DC ¯C öcCnpöÒö CC
CC¯cCD¯C CC ' ö vCj| gö)
¯ HCc!CcC'C. |¯ C| CC¯cCn¯C CC lö pö|CC vög| nöl pC¯!C||C|,
p|CCuclCC pC| uD CC¯cCn¯C CC' |CcIC ,!önOlCn puCCC
l l önö|¯C cClpCcC'C pC¯!C||C|).
" |D!C|CcClC. |l p|C'öp¯C CC' ICnCC CC ¯öcC CC ¯Cuglö¯
¯uClC cCD!CDC| lD!C¯IlDC C Cpl p' Ón ,!önO|Cn puCCC l'ö·
nö|¯C CCuglö¯cClC).
cl !|öIönlCnIC C¯ Çu| |u|glcC, |Cöll2öDCC unö cC' pCpC·
||nCC||öhö Cn 'C¯ C¯!öClC¯ 'l y ||| ,puCCC |Cö'l2ö|¯C Clc|ö
cC||Ccc|ÓD nCC| öD!C C' u¯C CC nö' ' ö¯ cCnC cuö|Çu|C|
|C|D|ö). |C¯ C¯IöClC¯ | nC ¯C ¯uC' Cn CpC|ö|, ¯|CnCC CC
C' CcclÓn uDC¯ CjC|clclC¯ pö|ö |CIC|2ö| lö nu¯cu'öIu|ö CC'
C|öI|ögnö u|CgCD|!ö' .
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CCD¯|¯!C Cn Cl CC¯cCD¯C CCl uIC|C pC| CCOöjC CC ¯u
pC¯| c| Ón |öOl!uö' . |C¯ IöcIC|C¯ p|CCl¯pCnCn!C¯ ¯Cn ' C¯
Îf0Ì8þS0 gf800 |
Îf0Î8þS0 gf800 ||
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00rmö|
Îf0l8þS0 gf800 |||
¤l>nC> quC Cn C' p|C'ap>C vagl nal (pai!C vag' na' , CCaC,
¤CnCpau>'a, C>!iCÓ'n|Cn!C, CjC|c' c'C>, ... ).
" ||C'ap>C u!C|'nC CC p|lnC| g|aCC. |l cC|v'x DC ' 'Cga a'
µ'a0C CC 'a vu' va
" `|C'ap>C CC >CguDCC g|aCC cl cuCl l C uIC|lDC a>Cna a
!|avC> CC' 'nI|C'!C vu' va| (Ml H 9ô-97|, T 7ô).
" `|Clap>C CC IC|cC| g|aCC. |' cC|v'x C>Ia pC| IuC|a CCl pla·
0C dC 'a vu'va
ca c' ||' ca na> I|CcuCn!C C> ' a >CD>aclCn CC cuC|pC Cx!|a·
¤C Cn 'a vu'va.
|l !|a!aniCnIC va|la CD IuDc'Cn CC' g|aCC CC p|Clap>C y
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RÌ0D\lð5 QU0 0Ì l05\O O0 ÌO5 5UD\ÌÇO5 Çl0~
CÌ5ðD, ðO0Rð5 O0 Ìð DÌ5\0leC\ORÍð ÿ OODÌe
ðD0X0CIORÍð, O0 Ì ÌDÍðO0D0CIORÍð ÇÉÌVÌCð
COD lðOÌO\0lðÇÌð.
LÌ 05\ðOÌO || ðglUÇð ð \UROle5 QU0 ðÍ0C\ðD M
ðÌ CÉlVÌX U\0lÌDO 0D ÌO5 QU0 % l0ðÌÌZðlð DÌ5·
\0l0CIORÍð lðOÌCðÌ \ÌÇO W0f\D0ÌR~N0Ìg5 ÿ
lðOÌO\0lðÇÌð.
LD ÌO5 05\ðOÌO5 |||ÿ |VÇOOl0RO5 l0ðÌÌZðl CÌlU~M
gÍð CÌ\Oll0OUCIOlð, 50gUÌOð O0 lðOÌO\0lðÇÌð.
|ê¿ä1IääM|B
Ö VlR 06-07,  I 79 
VlR 05-06, I75 
Vl R 05+6,  I 79 
VlR 04-05, I 74 
VlR 04-05, 257 
Vl R 0\ -02, \ 68 
VlR 0I ·02, \ 74 
Vl R 99·00F, \ 84 
Vl R 97-98, Ô
OääêO||1|têBêp|êäê1IäI|¢ê
@I75. Una mu]er de 65  aDOs cOnsuÌta pOr
metrOrrag|as escasas desde hace tres
meses. La expÌOrac|Ón g|necO|Óg|ca es
nOrma|. Ln una ecOgraÍ|a transvag|naÌ se
Observa un uterO de 7 x 3 x 4 cm cOn un
endOmetr|O de \ 4 mm de espesOr, yunOs
Ovar|Os atrÓÞcOs. La c|tOÌOg|a cérv|cO-
vag|naÌ |nÍOrma de un ÍrOt|s atrÓhcO, s|n
Otras aÌterac|Ones ceÌuÌares. Ln una b|Op-
s|a endOmetr|aÌ reaÌ|zada pOr asp|rac|Ón
cOn una cðnuÌa ÍIex|b|e de t|pO LOvan|er
O P|peÌÌe (m|crOÌegradO), se |nÍOrma de
escasO mater|aÌ endOmetr|a| de t|pO atrÓ-
0cO, |nsuhc|ente pðra un d|agnÓst|cO en·
dOmetr|aÌ adecuadO. ¿LuðÌ de Ìas s|gu|en·
tes |nd|cac|Ones es Ìa mðs adecuada!:
I )   1ratam|entO hemOstðt|cO cOn
estrÓgenOs +prOgestðgenOs,
segu|dO de prOgestðgenOs c|cÌ|cOs
cada mes, durante 6 meses.
2) H|sterectOm|a.
3) Kepet|c|Ón de Ìa b|Ops|a s|
}
ueÌve
a sangrar, yen casO cOntrar|O,
repet|c|Ón de Ìa ecOgraÍ|a 8ÌOs 4-6 
meses.
4) H|sterOscOp|a.
5) LOmpÌetar e| estud|O cOn
determ|nac|Ón de marcadOr tumOraÌ
LA \ 2,5 yOtras pruebas de |magen
cOn RNV O 1AL.
VlR 
t- . ,-.. .- .-.-·.. - ·--· ..- - -.·,.:. ..,-. -- . ,.-- -.. ,:·-. . ...--.·.·
10.0 Û|8§008l|00
L> l Jp|C>cl nCl O' C pö|ö C' ClögnÓ>!cC CC cðncC| CC CnCC·
JCI|lC ' ö OCp>ö CnCCJC!|lö' . |l C ögnÓ>!lcC, pC| !önIC,
C> | S!ClÓglcC AnIC !CCö JCI|C||öglö Cn unö pöclCn!C
pC| C pC>!JCnCpðu>lcö, >C CCOC >C>pCc|ö| cðncC| CC
CnCCJC!|C ¯öJO Cn Cn JujC|C> pC>IJCnCpðu> cö> cCn
plCJCI|ö C cCn cC' u' ö> CnCCJC!|ö' C> Cn ' ö c!C' Cg'ö
L' JC!CCC CCöl pö|ö CO!CnC| ' ö OCp>ö CnCCJCI|öl C>
|Cöllïö| unö | >!C|C>cCplö ¬ OCp>ö C | g Cö. cö O >IC|C>·
cCplö pC|Jl!C vl >uö' ïö| ' ö ' C> Ón y O Cp>lö| pö|3 cCnÍ|
JöclÓn | >!ClÓgcö, y öc!uö' JCn!C >C p|CIC|C ö' 'Cg|öCC
I|öccl CnöCC, ÇuC |ö pö>öCC ö >C| CC >CgunCö C'CcclÓn
(VlR  0\ ·02,  \ 74)  ¦ Vl R  05-06,  I 75).  ÒI|ö CpclÓn C> lö
OCp>ö pC| ö>p |öclÓn cCn cðnu' ö I'CxlO'C, öunÇuC cCn
C>!C JC!CCC nC >lCJp|C cCn>Cgu JC> Jö!C|löl >uhc Cn·
!C pö|ö Cl C ögnÓ>!lcC.
cö CcCg|öI'ö !|ön>vöglnöl, ncl u>C cCJplCJCn!3Cö cCn
Cl CICc!C CCpp' C| cC'C| C >CnC| >!C|Cg|öIiö (nI|CCuccÓn
CC ' 'ÇuCC Cn cövCöC uIC|nö pö|ö JCjC|ö| lö cö|CöC CC
' ö CcCg|öIlö) C> >Ó|C C|Cn!ö!vö, y Cn nl ngun cösC >u>!l·
IuyC 3 lö OlCp>ö.
Unö vCï CO!CnlCC Cl C ögnÓ>!cC CC cðncC| CC CnCCJC·
!|C, |Cö' l ïöJC> un C>!uC C CC CxICn>l Ón JCC önIC pöl
pöc Ón CC öCCnCpöI|ö> l ngul nölC> y >up|öc' övlcu' ö|C>, y
|öClCg|öI'ö CC IÓ|öx.
|n l C> cö>C> cCn >C>pCc|ö CC JC!ð>!ö> > CxI|3uIC|nö,
pCCCJC> p|öc!cö| ¯C C HM, öunÇuC nC C> p|Ccl>C |Cö
' ïö|' C> CC |uI nö.
10.Î Î|0008l|00
Lö JöyC|lö CC ' ö> JujC|C> cCn cðncC| CC CnCCJCI|lC
p|C>CnIön Cn Cl C ögnÓ>!cC un C>!öCC p|CcCï ¦', |').
cC> Iöc!C|C> ÇuC nIÌuyCn Cn C' p|CnÓ>IlcC >CO lC> >
gu CO!C>.
* |CöC. ' ö> JujC|C> jÓvCnC> !lCOCn JCjC| p|CnÓ>!cC.
¯ ¯pC hl>IC'ÓglcC. Cl cö|cl nCJö CC cC' ul ö> c'ö|ö> C> C' CC
pCC| p|CnÓ>IlcC. Ln gCnC|öl, ÇCC| p|CnÓ>!cC ICCC> 'C>
ÇuC nC >Cön CnCCJCI|CCC>.
* L|öCC | >!ClÓgcC. ' C> IuJC|C> Jð> CIC|CncöCC> IC·
nCn JCjC| p|CnÓ>IlcC L ! . ClIC|CncöCC, Lz. JCCC|öCö·
JCn!C CIC|CncöCC, LJ. nCl IC|CncöCC.
¯ lnvö>lÓn JlCJCI|löl. l nCl cö pCC| p|CnÓ>IcC cuönIC Jö·
yC| >Cö ' ö nvö>Ón CCl JlCJC!|lC.
* Cl!ClCg|ö pC|l!CnCöl. Cn ' C> cö>C> cCn c!ClCg|ö pC|l!C·
nCö' pC>l!lvö, C' p|CnÓ>!cC C> ÇCC|.
¯ HCcCp!C|C> hC|JCnö' C>. ö J3yC| cön!CöC CC |CcCp!C·
|C> CC C>!|ÓgCnC> y CC p|CgC>!C|Cnö, JCjC| p|CnÓ>!cC.
¯ 1öJönC !uJC|ö' . MCjC| p|CnÓ>IcC > <z cJ.
¯ Ò!|C> IöcIC|C> CC Jöl p|CnÓ>IcC. lnvö>lÓn vö>cu'ö| vCnC·
>ö C l nIðIlcö, JCIð>Iö>> Cn göOgl C> pC'vlcC> C pö|ööÓ|I·
cC>, p|C>Cncö CCl CncCgCn ¬||·z/nCu, C >CO|CCxp|C>lÓn
CC 'ö p|C!C'nö p'J.
10.Û 1|8l8M|00l0
cl I|ö!öJ Cn!C CC' cðncC| CC CnCCJC!| C CCpCnCC CC'
C>!öCC. |n ' C> C>IöClC> ' y | ' , C> Oð> cöJCn!C Çu |u|g cC
>C |Cö'lïö unö l öpö|CICJlö cCn |Cv > Ón CC ' ö cövlCöC
pC|lICnCöl, l n!C>! nC CCl göCC y cC' Cn, y cl ICl Cg'ö> pC·
| !CnCö' C>.
|l !pC CC hl>IC|Cc!CJlö y ' ö öp' cöcÓn C nC CC |öClCIC|ö
plö vö|'ö Cn Iunc Ón CC' C>!öCC y g|öCC hl>IClÓgcC. LC>
C>IöClC> ' | | y lV nC >Cn CpC|öOlC>, > nC ÇuC >C !|öIön JC·
Cl ön!C |öClC!C|öpl ö.
Í  LSI80|0S 00| 800|J068| 0||J0|IJ80|J00|IJ0I||8|
1!0. |80|0Î6|8µ|8 µ6|V|08 Ì  q0|ü|0I6|8µ|8
|V-b
1!0' 0|SÎ6|60Î0ü|8 Î0Î8| *  ü80:
§0|Î0 V8§|08| [6|I06|ü) ±  000|6
806X60I0ü|8 ±  ||0Í806060Î0ü|8
µ6|V|08 ±  |80|0Î6|8µ|8 µ6|V|08
1!0. |80|0Î6|8µ|8 µ6|V|08 Ì  q0|ü|0I6|8µ|8
" LbJPL|L 0,|d Cl y | D C¹ . M|SIE|ECIC0|d ICId| CC| OCD|E
80EXECIC0|d |M| R04-0S, \ 74).
¯ hLb1L LbJPL| Lb |.|| SIE|ECIC0|d ICId| CC| OCD| E d|E·
XECIC0|d, 0dS | | |ÍdOE|ECIC0|d QÉ| V| Cd y |dO| CIE|d·
þ| d.
" Lb1PL|L ' ' . ||SIE|ECIC0|d |dO| Cd| I|QC YE|I|E|0NE|QS,
y |dO|CIE|dQ|d (M|R99-00|,\ ß4).
" LbJPL|L | | | . ¬dO|CIE|dQ|d QÉ|V|Cd, E| d| QU|CS CdSCS SE·
|ECC|C|dOCS, SE QUEOE |Ed||Zd| C| |UQ|d C|IC||EOUCIC|d Q|E·
V|d d |d |dO|CIE|dQ|d.
" LbJPL|L |V ¬dO|CIE|dQ|d yÍC QU| 0|CIE|dQ|d.
¯ |C|0C|CIE|dQ|d (PCEIdIC OE NEO|CX|Q|CQESIE|C|d) y
QU| 0|CIE|dQ|d. SE |d| USdOC E| ESIdO|CS 0Uy dVd|ZdOCS
( ' ' ' y |V) yE| |EC|O|VdS, CC| |ESU|IdOCS QCCC EÍCdCES.
Oääê O||1ltê 8êp|êäê1IäIl¢ê
\ ôß. Pac|enIede5ßañOsque ha s|dO d|ag· M
nOsI|cada de adenOcarc|nOma de endO-
meIr|O. Ln e| |nlOrme anaIOmOpaIO|Og|cO,
se rehere una |nvas|On mayOr de|50%de|
m|OmeIr|OyalecIac|On de| esIrOma endO-
cerv|ca| pOre|IumOr. L| gradO de d|leren-
c|ac|On es mOderadO. ¿Cuá| es e| esIad|O
\ ) |b G2.
2)|c G2.
J) ||a G2.
4) ||b G2.
5) |||a G2.
M|R20\ -202RC:4
de|IumOr!.
\ 79. L|esIud|Oh|sIOpaIO|OgicOde|a p|eza
qu|rurg|ca de h|sIerecIOm|a muesIra, Iras
|a esIad|hcac|On cOmp|eIa y cOmO un|ca
lOca||dad neOp|õs|ca, un adenOcarc|nOma
endOmeIr|O|de, ||m|IadO a| endOmeIr|O,
cOn aprOx|madamenIe un J0% de paIrOn
decrec|m|enIOsO||dO. |nd|quesee|esIad|O
\ ) |a G\.
2) |a G2.
J) |b GJ.
4)|c GT .
S) |c G2.
M|R20-207RC:2
ygradO:
|\1::| !: Uì¡||ª
0t|01M|B
M
cS uÞ temð ÌmpDftðÞte. UÞ ðSpeCtD muy
pfeguÞtðUD SDÞ |DS U|ÍefeÞteS tIpDS ÞIS·
tD|0gICDS Ue CðÞCefUeDVðfID,ðSÍqueÞD
UejeS UeeStuUIðfle|D.
AäpêtIêäEäê1t|ë|êä[|)
M c|CðÞCefUeDVðfIDt|eÞe uÞðDð|ðÍfeCueÞ·
C|ðpefD,SIÞemDðfgD,eS|ðpfÍmefðCðuSðUe
muefte pDfCðÞCefgIÞeCDÍ0gICD. ÐmDtI·
VðUD,SDDfetDUD, pDf |ð ðuSeÞCIð UeSÍÞtD·
mðSÞðStðeStðUIDS ðVðÞ2ðUDSy|ððuSeÞCIð
UeuÞ pfDgfðmðUeSCfeeÞIÞgVð|IUDpðfðe|
U|ðgÞ0St|CDeÞetðpðSpfeCDCeS.
Ö be CDÞSIUefðÞ MCtDfeS Ue fIeSgD |ð eUðU
ðVðÞ2ðUð, ÞIStDf|ð Mm||Iðf y |ð pæIð
Ue mutðC|DÞeS Ue |DS DÞCDgeÞeS bKLÅ \ Y
bKLÅ2 bDÞÍðCtDfeSpfDteCtDfeS|ðmu|tIpð·
m,|ð ut|ÌRÞ UeðÞtICDÞCÇ ÞDf-
mDÞð|eS, Íð ÞIStefeClDmÍð, |ð eStefI|0Þ
tuDðf|CðyÍðO  mÍð.
M UtumDfeS epIte|Ið|eS SDÞ |ð eStIfpe mðS
me Ue CðÞCef Ue DVðfID y SueÌeÞ
ðpðfeCefeÞ mu|ef0SUeeUðUðVðÞ2ðUð.D
e||DS,|ðVðf|eUðUmðSÍfeCueÞteSDÞ|DSSefD-
SDS,Segu|UDSUe|DSmuC|ÞDSDS.
@ |JStumDfeSgefmInð|eSSueÍeÞðpðf0efeÞ
mþ |0W L gfðÞ mðyDfÍð CDII0S·
pDÞUeÞ ð|tefðtOqu|StICDmðUufDDquIS-
teUefmDÌUe,queeSDeÞIgÞD.LtfDStumDfeS
UeeSte gfupDSDÞ e| U|SgefmIÞDmð [mð|Ig·
ÞDqueUefIVðUe|ðCe|u|ðgefmÍÞðÌ), tumDf
Ue|SeÞDeÞUDUefmICD(pfDUuCeÅ| |), CðfCl-
ÞDmðemDfIDÞðfID [pfDUuCeÅ| |), C0f·
CIÞDmð [pfDUuCeHLG), ...
M m tumDfeS Ue k æ æk
U M Íð 0 meÞDS mu y M
CðmÞ pf |ð5ÍmUehE
wS que pefmIte queM pueUðÞ UIðg·
mf mðS pfeCD2mente que DtmS tIpDS.
LDS mðS mæ M k u Ue |ð
gfðÞu|DSð[WSmICð), SµuIUDS Ue
kæb(SÍmUeðÞUK ).
1Ì.1 ε|00M|0|0§|8
A pC>ö| CC >C| Cl J°·4° Cn I|CcuCncö, C' cðncC| CC Cvö|C
C> lö p|JC|ö cöu>ö CC JuC|!C pC| cðDcC| ginCCClÓg|cC
(CxcluyCnCC C' cðncC| CC JöJö). cC pöCCcCn ¹ CC cöCö
/û JujC|C>.
c| p|CnÓ>!icC CCl cðDcC| CC Cvö|lC CCpCnCC CCl C>IöCC.
ö>l, l ö >upC|vlvCDcö ö lC> b öÙC> CC pöclCD!C> Cn C>IöCiC>
p|CcCcC> C> CCl ºû%, J Cn!|ö> ÇuC Cn C>!öCC> övönïö·
CC> CC>clCDCC |ö>!ö uD ! o%. `C| CC>g|öcö, C' C ögnÓ>·
!cC Ç|CcCz C> cö>l l JpC>iO' C, pC| ' C ÇuC Cn C' JCJCn!C
CC' C ögDÓ>!cC >uC|CD p|C>Cn!ö| C>IöCC> övöDïöCC>.
Cö> C' ºû% CC 'C> cðDcC|C> CC Cvö|C >Cn CC C|gCD Cpl·
ICllöl, y >u inclCCnciö öuJCn!ö cCn ' ö CCöC, !CDlCDCC >u
Jðxl nö I|CcuCnclö Cn!|C ôb y oû önC>
cC> Iöc!C|C> CC | C>gC Cn C' cðncC| CC Cvö|C C>!ðn pCcC
c' ö|C>. `ö|ö Cl cðncC| Cp!C|lö' CC Cvö|C, >C p|CpCnCn.
ì¯CC|'ö CC |ö Cvu' öc Ón iDcC>ön!C. `ö|CcC ÇuC C' Jlc|C·
!|öuJö p|CCucCC Cu|ön!C 'ö |C!u|ö CC ' ö cðp>u'ö Cvð|cö
ÇuC Ccu||C Cn cöCö Cvu'öcÓn >C|'ö un C>!'Ju' C pö|ö lö
öpö|lclÓn CC' cðncC| CC Cvö|C.
* Nu' lgC>Iö> ICnCn JöyC| nc CCnc ö CC cðncC| CC Cvö·
|lC, yö ÇuC l ö gC>IöcÓn C> uD pC|'CCC CC |CpC>C Cvu·
'öIC|lC.
· c>!ðn p|C!Cg Cö> lö> JujC|C> cCD bÒl y ' ö> ÇuC ICJön
ön!cCncCp!vC> C|ö' C> (n nguDö CC C|lö> Cvu' öO, pC| ' C
ÇuC >C Cv !ö C' C>!' Ju' C Cvð|cC)
1ð0|dÜ 1u00|6S060¥d||0
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Iöc!C|C> p|CICc!C|C> CCOiCC ö unö C >J nuc Ón CC iö Cvu·
löciÓD pC| CCICc!C Cn ' ö || göc Ón vö>culö|.
2 LCnC!cC. L> Jð> I|CcuCnIC Cn pöciCn!C> cCn |>!C|ö
IöJ l l ö| CC cðncC| CC Cvö|lC. `ö|CcC ÇuC C' Jû% CC 'C>
cðncC|C> CC Cvö|lC Cxp|C>öD OlvC'C> C' CvöCC> CC CC!C|·
J nöCö> JuIöclCnC> gCnC!lcö>.
1 Ì.¿ 10M0|08 0µ|l0|Ì8|08
bupCDCn C /b% CC ICCC> lC> IuJC|C> CC Cvö||C (iDc' u·
yCnCC OCD gnC> y Jö' gnC>) y C| ºû% CC ' C> Jö' gnC>.
|DglCOö ö un cCnjunIC CC !uJC|C> CC|vöCC> CC' Cp!C' C
CC |CvC>!l J Cn!C CC' Cvö|lC, y puCCCD CvCl ucl Cnö| |öc ö.
ì bC|C>C> (ôû·oû%) (cl>ICöCCDCJö, cl>ICöCCnCcö|cnC·
Jö) bCn 'C> Jð> I|CcuCnIC> CCD!CnC Çu >!C> ''CnC> CC
' 'Çu CC >C|C>C. Mð> CC' /û% >CD O ' ö!C|ö'C> cC> cuC|pC>
CC p>öJCJö >Cn pCÇuCnö> cölcihcöcCnC> ÇuC öpö|CcCn
Cn 'ö JöyC|'ö CC ' C> !uJC|C> OlCn C IC|CncöCC>, >CnCC
>gnC CC OuCD p|CnÓ>!cC. ' Dclu>C Cx>!C unö vö|önIC
' l öJöCö p>öJCcö|cnCJö, cCJpuC>!C pC| C>!C> cuC|pC>
CC p>öJCJö, ÇuC ö pC>ö| CC >C| nvö>C|, >C cCJpC|!ö
cCJC OC|CC|' nC. LC> >C|C>C> Jö' gn zön J vCcC> Jð>
ÇuC lC> Juc.DC>C>.
z. MuclDC>C> (zb%). (cl>!CöCCDCJö, c>!CöCCnCcö|clnC·
Jö). Lö JöyC|'ö >Cn OCDlgDC> (oû%) CCn!CnCn Çu>!C>
Ju| ! ' Ccul öCC>, ÇuC puCCCn ' 'Cgö| ö >C| Juy g|önCC>,
' 'CnC> CC Juc nö A vCcC> >C ösCcö ö un p>CuCCJxCJö
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Ld EXIEDS|ÓD || DÍdIlCd SE Ç|OOUCE ÇO| I|ES V|dS Ç||DC|ÇdlES,
S|E|OO |d Ç||0E|d d |OS QdDQ||OS Çd|ddÓ|IlCOS. Ld V|d |E·
0dIÓQE|d ES 0E|OS Í|ECUEDIE.
LE 0d|E|d dDECOÓIlCd, E| CdDCE| OE OVd||O ÇUEOE OEDU·
Id| CO| U|d 0dSd U0Dl | | Cd| |DÓOU|O OE l d GE|0d|d Nd||d
1DSE).
1Í.1 1 1|8l8N|00l0
ì. Ll I|dId0lEDIO l |l Cl dl OE| CdDCE| OE OVd||O ES S|EHÇ|E
µul |Ú|Q|CO, y |d ESIdO|DCdClÓD ÇOSIÇU| |U|Q|Cd. . C||UQ|d
0E E|ECClÓ| CO|S|SIE ED.
¯ || SIE|ECIO0|d IOId| COD dDEXECIO0|d D||dIE|dl.
¯ LdVdOO y dSÇ||dC|Ó| OE ||ÇU|OO ÇE|lIODEd|.
¯ LXÇlO|dC|Ó| OE ld SUÇE|DC|E ÇE||IODEd| y D|OÇS|d OE
|ES|O|ES SOSÇECGOSdS.
¯ \0E|IECIO0|d |EXIl|ÇdC|Ó| OE| EÇlÇ|ÓD).
¯ OlOÇSldS OE ÇE|lIO|EO VES|Cd|, ÍO|OO OE SdCO OE
LOUQl dS, ESÇdClOS Çd|lEIOCÓllCOS y CUÇU| d O|dÍ|dQ·
0dIlCd.
¯ PÇE|O|CECIO0|d, ESÇEC|dl0E|IE ED |OS IU0O|ES
0UCl |OSOS.
¯ L|DÍdOE|ECIO0|d OE d|IE|ldS y VEDdS l l |dCdS EXIE|DdS
y CO0UDES.
· L||ÍdOE|ECIO0|d ÇElV|Cd y Çd|ddÓ|I|Cd.
c¤ÇdClE|IES ¡ÓVE|ES, CO| OESEOS |EÇ|OOUCI|VOS y ESIdOlO
lF \J , SE ÇUEOE Ç|dCIlCd| U|d C||UQ|d 0dS CODSE|VdCO|d,
|EdllZd|OO d|EXECIO0|d U|l|dIE|d| y CO0Ç|EIdDOO ld C|·
|uQ|d dl CU0Çl l | |OS OESEOS QE|ES|COS (M|R 00-01 |, 1 83).
c¤ESIdOlOS dVd|ZdOOS SE Ç|dCIlCd Cl |UQ|d ClIO||EOUCIO|d,
µUE EXI||Çd |d 0dyO| CdDIlOdO ÇOS|D|E OE DEOÇ|dSld, OE
ÍD|0d ÇUE E| IU0O| |ES|OUdl SEd 0E|O| OE z C0, ÇE|0|·
IlEDOO U|d 0dyO| EDCdC|d OE | d ÇUl 0|OIE|dÇ|d ÇOSIE||O|,
y0E¡O|dDOO |d SUÇE|V|VE|C|d. LD CdSO OE l|OÇE|dDl||OdO,
SE I|dId 0EO|dDIE ÇUl 0|OIE|dÇ|d [M|R 02-03, 233).
2.[Ul0lOIE|dÇld dOyUVd|IE. L| l OS ESIdO|OS |P y |O, Id|IO
C! CO0O L2, 0O SE Ç|EClSd |l DQU|d IE|dÇ|d dOyUVd|IE
¦M|R 98
¸
99|, 1 73). L| lOS ESIdOlOS l P y l O COD Q|dOO L3 y
E0 El lL, Od|E0OS SÓlO 3 C|C|OS OE ÇU| 0|OIE|dÇ|d dOyUVd|·
IE |ClSÇldIl|O). LESOE El ESIdOlO | | P E| dOE|dDIE. ' | O, |',,l||
y 'V, I|dId0OS CO| ÇOl l ÇUl 0|OIE|dÇ|d dOyUVdDIE |OE||Vd·
0OS OE| Ç|dIl|O y OE| IdXO|).
3. |dSdOOS ô ClClOS OE I|dId0lE|IO ÇUl 0l OIE|dÇlCO dOyU·
Vd|IE, SE |Ed||ZdDd S| SIE0dI|Cd0E|IE U|d SEQUDOd ldÇd
|OIO0|d Çd|d CO|OCE| El ESIdOO OE l d E|ÍE|0EOdO, l l d0d
Od SECODO|OOK S| l d Ç|l 0E|d Cl |UQ|d ÇU|IÓ IOOO E| IU0O|,
y Cl |UQ|d OE |ESCdIE S| SE CODOCE ÇUE |dy |ESIOS OE IU0O|,
dU|ÇUE |Oy DO SE |ECO0|E|Od l d |EdllZdC|Ó| S|SIE0dIlCd,
S|DO Id| SÓlO E| CdSOS SE|ECClO|dOOS.
1 Í.1 ¿ b0§0|N|00l0
LS 0Uy l 0ÇO|Id|IE OEIECId| Ç|ECOZ0E|IE l dS |ECl O| ·
VdS. |d|d E| l O, OEDE| EÍECIUd|SE |EV|S|ODES ÇE|l ÓOl CdS.
Ll SEQU| 0lEDIO | |C| UyE. Vdl O|dCl Ó| Cl |Dl Cd, GE0dIOl Ó·
Ql Cd y D| OÇU|0| Cd |Çd|d OEIECId| IU0O|ES | DOUCl OOS
ÇO| | d ÇUl 0|OIE|dÇld, CO0O | EUCE0l dS) y OEIE|0l Dd·
Cl Ó| OE 0d|CdOO|ES IU0O|dl ES |Ld ¡ z5). |dS Ç|UEDdS
OE l 0dQE| USdOdS SE|d|. ECOQ|dÍ|d, 1CO ¬N, SEQÚ| l dS
|ECESl OdOES.
1 Í.1 J Û|8§008l|00 þ|000t. b0|000|0§
P ÇESd| OE ÇUE El Cd|CE| OE OVd||O ES UDd EDÍE|0EOdO
CUyO Ç|O|ÓSI|CO 0E¡O|d||d Sl ÍUESE ÇOSlDlE OldQ|OSI|Cd|·
lO ED ESIdOlOS Ç|ECOCES, OE SE| U|d CdUSd | 0ÇO|Id|IE
OE 0O|IdllOdO, y IEDE| UDd ÍdSE Ç|EC||D|Cd OEIECIdD|E y
I|dIdDlE, ES ÇOCO Ç|EOO0||d|IE. LED|OO d ESO, SE||d |E·
CESd||O U| IESI Ol dQDÓSIlCO COD U|d dl I|Sl0d SE|S|D||lOdO
y ESÇEClÍClOdO.
Ld CO0Dl|dC|Ó| OE Ld I z5 y ECOQ|dÍ|d VdQl|dl DO ES lO
SUÍ|ClEDIE0E|IE E¯CdZ Çd|d SE| UIll lZdOO CO0O IESI OE
SC|EE|l|Q |UIl|d|lO E| IOOdS l dS 0U¡E|ES.
LD 0U¡E|ES CO| U|O O 0dS Íd0l l | d|ES OE Ç|l 0E| Q|dOO
dÍECIdS OE Cd|CE| OE OVd|lO O OE Cd|CE| OE 0d0d, dU|·
ÇUE |O |dy EV|OEDC|d ClE|I|0Cd OE SU UI| l | OdO, SE dCOD·
SE|d EXÇlO|dC|Ó|, ECOQ|dÍ|d I|dDSVdQ||d| y 0EO|ClÓD OE
Ld ! z5 SE||CO d|Udl 0E|IE, Çd|d OESCd|Id| |d Ç|ESEDC|d
OE d|QUDO OE |OS S||O|O0ES Íd0l l | d|ES ÇUE l|C| UyED
Cd|CE| OE OVd||O, CO0O E| SO. OE Ly|C| IlÇO ' | (M| R 04-
05, 1 7ô).
1 Í. 1 4 |8l0|0§|8 000|§08 00 0V8||0
! [UlSIE |OllCUld| O |Ol|CU|O ÇU|SIlCO. PlQU|O OE lOS ÍOl|·
CU|OS ÇUE SE dI|ES|dD ED CdOd ClC|O ÇUEOE C|ECE| y dCU·
0Ul d| CODIED|OO ||ÇU|OO O SE0|SÓ|lOO ED SU lDIE|lO|. LE·
DE|d|0EDIE SOD ÇEÇUE0OS y dS| DIO0dIlCOS, y dÇd|ECE|
ED E| ÇE||OOO ÍE|Ill. bUElED |ESO|VE|SE ESÇODId|Ed0E|IE,
ÇO| lO ÇUE ld dCIlIUO |dD|IUdl ES ld ODSE|VdC|Ó| d |dS 4-ô
SE0dDdS, ESÇE|d|OO SU OESdÇd|lClÓ|.
z. [U|SIES lUIEOS
¯ L|d|UlOSd lUIE||lCOS. LE|lVd| OE U| CUE|ÇO lUIEO
|O|0d| y ÇUEOE| Ç|OOUCl| dlIE|dC|O|ES 0EDSI|UdlES
¯ JECdl UIE||lCOS. PÇd|ECE| I|dS ESI|0UlO CO| Cl O0|ÍE·
DO |G|ÇE|ESIl 0Ul dC|Ó|) O |LL |0O|d). bO| 0Ul I| Çl ES y
DlldIE|dlES. |O Ç|EClSd| I|dId0lEDIO ÇU| |U|QlCO.
Aâpêcl0â Eâê1c|ä|êâ [ll)
La c|as|Þcac|On de| cánce| de Ova||O se hace M
med|anIe |apa|OIOmía exp|O|adO|a, pO| |O
que se |ea||za|á a IOdas |as mu]e|es. Ln |a
mayO||a de |Os casOs, encOnI|a|emOs IumO-
|es en esIad|Os avanzadOs, ya que |a v|a de
d|sem|nac|On es |a |mp|anIac|On d||ecIa pO|
s|emb|a pe||IOnea| de cé|u|as IumO|a|es.
L| I|aIam|enIO es lundamenIa|menIe qu|-W
|u|g|cO, |ea||ZandO h|sIe|ecIOm|a cOn dOb|e
anexecIOm|a, | |nMdenecIOm|a pé|v|ca y pa-
|aaOrI|ca, apend|ceIOm|a, OmenIecIOm|a,
b|Ops|as de p||IOneO y |avadO y asp||ac|On
de ||qu|dO pe||IOnea|. Ln func|On de |Os
ha||aZgOs, pdemOs c|as|hca| e| cánce| de
Ova||O: esIad|O | ||m|IadO a| Ova||O, esIad|O ll
afecIac|On p|v|ca, esIad|O |||alecIac|On de |a
supe|hc|e pe||IOnea| y esIad|O |V meIásIas|s.
Lqu|m|OIe|ap|a es |a adyuvanc|a en e| cán-M
ce| de Ova||O, y se ap||ca|á en |Os esI8d|Os
|A-|b-G3, |L, ||, l||y|V.
P|ê]01läâ M|B
M|R 04-05, 1 7ô
M|R 03-04, 1 00
M|R 02-03, 233
, M|R 01 -02, 1 72
M| R 00-01 |, 1 83
M| R 00-0T, 1 70
M| R 00-01, 1 71 Ñ
M|R 99-00|, 1 7ô
M|R 98-99|, 1 73
M|R 98-99|, 1 79
M|R 98-99|, 1 8J
Uäâ0 U||1|c0 Bêp|êâê1läl|r0
233. Una mu¡e| de 52 aÔOs ha s|dO d|agnOs· M
I|cada de un ca|clnOma de Ova||O se|OsO,
que ha |esu|IadO |nOpe|ab|e pO| exIens|On
abdOm|na| mas|va. La cOnducIa a segu||
más adecuada es:
1) Lu|dadOs pa||aI|vOs.
2) Rad|OIe|ap|a abdOm|na|.
3) Çu|m|OIe|ap|a.
4) ||OgesIágenOs.
5) AnI|esI|OgenOs.
M|R 2002·203 RL: 3
1 83. Pac|enIe nu||gesIa de 23 aÔOs, d|ag-
nOsI|cada de IumO|ac|On Ová||ca ecOg|á-
hcamenIe sOspechOsa de ma||gn|dad. 5e
|nlO|ma de |a pOs|b|||dad de |ea||za| c||ugia
cOnse|vadO|a en casO de cump|||se c|e|IOs
|equ|s|IOs |nd|spensab|es. ¿Luá| de |Os s|-
gu|enIes supuesIOs desacOnse¡a||a d|cha
acI|Iud qu||u|g|ca!:
1) La. Lp|Ie||a| |nh|I|ðnIe b|en d|Íe|en-
c|adO.
2) b|Ops|a de Lp|p|On negaI|va.
3) 1umO| encapsu|adO.
4) Va|O|es de La. 1 25 supe||O|es a 35 U
un esIud|O p|eOpe|aIO||O.
5JAsc|I|s.
M|R 200-201 F RL: 5
Ïa¡0Î0gÍa UCHÎgHa
0C Îa HaHa
0||ê1läc|ê1 M|B
M Tema de |mporIanc|a |nIermed|a para e|
examen. 5obre Iodo, no de¡es de esIud|ar
e| hbroadenoma y la masIopaI|a hbro-
qu|sI|ca.
Mâ Eâê1c|ä|êâ [l)
Õ La Ie|orrea o secrec|ón por e| pzón es un
s|gno |mporIanIe. 5obre Iodo, hay que ana·
||zar s| es un| o b||aIera| y e| aspeIo que pre-
senIa. Además, es necesar|a |a rea||zac|ón de
c|Iología de |a secrec|ón. La Ie|orrea un||aIe-
ra| puede ser deb|da a eIas|a ducIa|, carc|-
noma ducIal, pap|loma |nIraducIa| o qu|sIes
sol|Iar|os. | serecìón bì|aIeral sobre Ioo
nos ham pensar en IrasIornos func|ona|es,
hs|o|óg|cos o mrmacológ|cos.
W | masIopaI|a hbroquísI|ca se caracIer|za
por una a|Ierac|ón en |a pro||ferac|ón del es-
Iroma y parenqu|ma mamar|o, producíendo
qu|sIes y Iumores pa|pab|es, Iodos e||os b
n|gnos. Es |a enfermedad ben|gna más fre·
cuenIe de la mama, y sobre Ioo la encon·
Iraremos en mu¡eres pæmenopus|cas.
M E| r|esgo de cáncer de mama se re|ac|ona
con |a h|perp|as|a ducIal aI|p|ca y la h|pr-
p|as|a lobu|ar aIip|ca.
M E| do|or es e| s|nIoma más muenIe de |a
masIopaIia hbroqu|sI|ca. 5ue|e aparecer pre-
mensIrua| y deæparece Iras |a reg|a. Ademá,s
p enconIrar oIros s|nIomas como |n-
durac|ón mamar|a o nódu|os pa|pab|es.
M LmasIopaI|a hrou|sIìca no prec|æ IraIa·
m|enIo, pmes neesar|o asegurar e| d|ag-
nósI|co con PAF o b|ops|a. Para e| conIro|
de |a masIo|n|a, pemos ap||car proges-
Ierona Ióp|ca en |a segunda fase He| c|c|o.
M E| hbroadenoma es e| Iumor ben|gno más
hecuenIe. 5ue|e aparecer en mu¡eres enIre
los 15 y35 años. 5caracIer|za por aumen-
Iar de Iamaño duranIe e| embarazo y |a
toma de anI|concepI|vos hormona|es por
un Iumor esIróeno·deDnd|enIe.
Ld QdIClCQ|d DE||Q|d 0d0d|| d ES 0dS Í|ECUE|IE QUE El
Cd|CE|. bU CC|CC|0|E|IC |CS QE|0|I||d |dCE| U| CC||ECIC
C| dQ|ÓSI|CC C| ÍE|E|C|dl.
1 0.1 1|88l0|008 l000|008|08
1E|C||Ed. Ld D| l dIE|dl | CdC CE l d IElC||Ed SUQ|E|E IE|C||EdS
ÍU|C|C|dlES, ÍS|ClÓQ|CdS C Íd|0dCClÓQ|CdS.
Ld IElC||Ed U|||dIE|dl y U||C|| HC| d| SE Cd E| S|IUdC|C|ES
CC0C. ECIdS|d CUCIdl, Cd|C||C0d CUCId|, QdQ|lC´d ||I|d·
CUCId|, E|ÍE|0ECdC ÍD|CQU|SI|Cd, QU|SIES SCl|Id||CS (M| R
95-9Ó, 229) Ld Ql U||C| |Í|C| dl | CdC SUQ| E|E dÍECC|O|ES 0dS
C|ÍUSdS, CC0C 0dSICQdI|d. L| ÍI U| CC QU|UlE|¹C | |C| Cd
Q|CCESC ||ÍECC|CSC. Ld IElC||Ed Sd|QU| |C|E|Id ES 0dS
Q|ECCUQd|IE y ES I|Q|Cd CEl Cd|CE|, El QdQ| l C0d y |d QdQ|
lC0dICS|S. bEC|EC|C|ES CE dSQECIC |ECGCSC QUEUE| Cd|SE
E| IElC||EdS ÍU|C|C|dlES y 0dSICQdI|dS.
'dl dCIC||Ed Ld QdldCIC|lEd ES l d SEC|EC|Ó| ldCIEd ÍUE|d CE
|d QESIdC| Ó| y CEl QUE|QEl| C. bE I|dId CE U|d SEC|EC|Ó|
D| l dIE|d| y Ql U|| C|| ÍC| dl . LSId CEIE|0||dCd QC| l d Q|C|dCI|
|d Ll I|dId0|E|IC SE|d El CE l d CdUSd Q||0d||d C |EI||d| El
Íd|0dCC |ESQC|SdDlE.
LCIdS|d CUCIdl. LC|S|SIE E| U|d C| ldIdC|Ó| CE lCS CC|CUC·
ICS Qd|dCIÓÍC|CS Q|| |C| QdlES. Ld ECdC 0dS Í|ECuE|IE CE
dQd||C|Ól ES `Û·ÚÛ d|CS cd SEC|EC|Ó| SUElE SE| CE CCl C|
VE|CCSC, |EQ|d C 0d||Ó| LS | 0QC|Id|IE Q|dCI|Cd| U|d
0d0CQ|dÍ|d Qd|d El C| dQ|ÓSI|CC C|ÍE|E|C| d| CC| El Cd|CE|
b| E0Q|E SE CEDE |Edl|Zd| C|IClCQ|d CE ld SEC|EC|Ó|. b| El
CUdC|C |C ES | 0QC|Id|IE, |C ES |ECESd||C I|dId|lC, QE|C
SE CEDE Q|dCI|Cd| ESC|S|Ó| lCCdl S| 'd Cl ||| Cd ES | 0[C|Id|IE,
S| l d lES|Ó| QE|S|SIE, C S| |C SE QUECE CESCd|Id| U| Q|CCESC
0dl | Q|C.
Í 0.¿ 1|88l0|008 | 0l|8N8l0||08
NdSI| I| S. LdS 0dSI|I|S QUE|QEldlES dQUCdS SC| ld ÍC|0d
0dS Í|ECUE|IE CE dQd|| C| Ó|, dU|QUC Gd dU0C|IdCC ld
Í|ECUE|C| d CE 0dSI|I|S dQUCdS |C dSCC|dCdS CO| ld ldC
Id|C|d. LCS QC|0E|ES 0dS Í|ECUE|IES SC|. bIdQ|ylCCCC·
CUS dU|EUS, bIdQ|y|CCCCCUS EQ| CE|0| C| S y ESI|EÇICCCCCS.
bE Q|ESE|Id CC0C CC|Cl E| U| CUdC|d|IE CE |d 0d0d,
dCC0Qd|dCC CE | | |Íd|Q| I| S 0d0d||d y Í|ED|E CE 3¬·¬Û'L.
Ld ||ÍECC|Ó| QUECE Q|CQ|ESd| y C|| Q| |d| U| dDSCESC, QUE
|EQU|E|E C|E|d¡E QU| |U|Q| CC. |l C| dQ|ÓSI|CC C|ÍE|E|C| dl
CEDE ESIdDlECE|SE CC| El Cd|C| |C0d ||ÍId0dIC||C, QUE
|C SUE| E dCC0Qd|d|SE CE ÍEDlE. L| CdSC CE CUCd, ESId
| |C| CdCC |Ed||Zd| U|d D| CQS|d. Ll IldId0|E|IC CC|S|SIE E|
0EC|CdC| Ó| S| |IC0dI|Cd y ClCXdC| l | |d. L| CdSC CE dl E|Q| d.
E||I|C0| C| |d. L| I| QC CE 0dSI| I| S C|Ó||Cd ES | d E|ÍE|0E
CdC CE NC|CC|, QUE CC|S| SIE E| U|d I|C0DCÍIED| I| S CE
l dS VE|dS SUDCUId|EdS CE | d Qd|EC IC|dC|Cd. LS SECU|Cd·
||d d U| I|dU0d |CCdl. |UECE QE|S|SI|| Vd||CS 0ESES, QE|C
|C |EQU|E|E I|dId0|E|IC.
NdSICC| || d. Ld 0dSICC|||d ES El Q|||C|Qd| S||IC0d CE ld
0dSICQdI|d ÍD|CQU|SI|Cd |N|[). LC|S| SIE E| U| CC|C|
0d0d|| C C|C||CC QUE dU0E|Id E| El QE||CCC Q|E0E|S
I|Udl. LEDE C| SI| |QU| |SE CE| CC|C| 0d0d|| C E| QE|E|dl,
lld0dCC 0dSId|Q|d. b| E0Q|E QUE EX|SId CCl C|, CEDE CES·
Cd|Id|SE |d EX|SIE|C|d CE U|d QdIClCQ|d 0d0d|ld SUDyd·
CE|IE.
1 0.J Ñ88l0þ8l|8 l|0|0q0|8l|08
[Ñ|0) Û 0|8þ|88|8 N8N8||8
bE I|dId CE U|d E|ÍE|0ECdC DE|| Q|d y C|Ó|lCd, Cd|dCIE
||ZdCd QC| U|d d|IE|dC|Ó| E| |d Q|C||ÍE|dC|Ó| CEl ESI|C0d
y CEl Qd|E|QU| 0d 0d0d||C, CESd||Cl l d|CC IU0C|ES C
QU|SIES Qd|QdDl ES. LS l d E|ÍE|0ECdC 0dS Í|ECUE|IE CE |d
0d0d E| l d 0U¡E| Q|E0E|CQdUS| Cd, y ES 0Uy |d|d CES·
QUES CE |d 0E|CQdUS|d. bE CESCC|CCE l d CdUSd. bE Gd
Q|CQUESIC l d | |Íl UE|C| d CE U| CESEQU| | | D||C |C|0C|dl ,
CC| Gl QE|ESI|CQE||S0C, dU|QUE |C ES CC|SId|IE
U||1|tl
|C |dy U|d C| ||| Cd ESQEC|ÍCd CE l d N|[. Ll S||IC0d 0dS
Í|ECUE|IE ES El CC| C| 0d0d|| C, QUE SUElE SE| Q|E0E|·
SI|Ud| y 0E¡C|d CC| l d |EQ|d |0dSICC| || d). Ll CClC| ES
D| l dIC|ô| . |UCCC| ôQô|ECE| C!|CS S||IC0dS CC0C | |CU·
|dC| Ó| 0d0d||d C |ÓCUl CS Qdl QdDl ES |l E0Dd|dZC y l d
l dCId|C| d Q|CCUCE| E| l d 0d0d 0dSICQdI|Cd U| ESIdCC
CE |EQCSC.
T | a h|05g0 |0|d\|¥0 þd|d 0d|0|I!0lRd I|!¥d5|¥0 û0 |11d0d
m
m0
Åû6ß08|8
L0Î88|8 ûu0Î8|
Í|0|08û60008
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IamOxilenO(anIiesIrOgenO).
Ln |a exp|Orac|On, sOn s|gnOs sOspechOsOsÑ
de ma||gnidad |a presenc|a de un nOdu|O
durO, hjO, de cOnIOrnO |rregu|ar, cOn re-
Iracc|On de |a pie| O e| pezOn, ademõsde
|a secreciOn sanguinO|enIa uni|aIera| y |a
presenc|ade adenOpaI|asdurasyhjas hO-
mO|aIera|es.
La mamOgral|aeslundamenIa| ene|diag· M
nOsI|cOde|cõncerdemama. LOssignOsde
ma||gn|dadsOn: nOdu|OdensO, espicu|adO
yde bOrdes |mprecisOs, reIracciOn de p|e|
OedemacuIõneO,pérd|dade arqu|IecIura
O desesIrucIurac|On de| parénquima ma-
mar|O, densidad lOca| as|méIrica y |as m|-
crOca|c|hcaciOnesagrupadas.LsIasu|I|mas
sOne|s|gnOqueaparecemõsprecOzmenIe
en |a mamOgral|a.Se debe rea|izarmamO-
gral|as per|Od|cas en IOdas |as mujeres
a parI|r de |Os 40 añOs. Si I|enen anIece·
denIes lami|iares, |alrecuenc|a serõ anua|,
mienIras que s| nO |Os I|enen, se pOdrõn
rea|izarcadaT ·2añOs.
Lavar|edadh|sIO|OgicamõslrecuenIeeselM
carcinOma ducIa|in¤|IranIe.
NðHOQ|ðÍ|ð. |> |Cy C' nC!CCC |np|C>c|nC|OlC Cn Cl
C|ögnC>I|cC p|CcC2 CC' cöncC| CC nönö (N|K 0T -02,
\ 7ô). bC |Cö'|2ön CC> p|CyCcc|CnC>. c|önCCcöuCöl y COl|·
cuö nCC|C'öIC|öl. bC cCn>|CC|ön >|gnC> nönCg|öhcC> CC
pC>lO'C nö' |gn|CöC.
¯ ||C>Cnc|ö CC un nCCu|C CCn>C, C>picu|öCC, CC OC|·
CC> |np|Cc|>C>, cCn |C!|öcc|Cn CC ' ö plC' C CCCnö cu-
!önCC |>!C CCCnö C> CCO| CC ö| O' CÇuCC CC lC> ' | nIö·
!|cC> >uOCC|n|cC> pC| lö> cCl u| ö> cöncC|C>ö>, ö vCcC>
C>!C |öl lö2gC C> CO>C|vöCC nö> p|CcC2nCn!C ÇuC Cn
' ö Cxp'C|öc|Cn c' 'nlcö, cuyö nöO|IC>IöclCn C> lö !lp|cö
plCl CC nö|önjö
¯ M|c|Ccö'clhcöclCnC> ög|upöCö> önö|ÇulcönCnIC Cn
nunC|C |guö' C >upC|lC| ö 5,nC C| >Cn| nöCö>, l l nCö' C>
C |ön|hcöCö>, CC C|>I||OuclCn >CgnCnIö|lö y CC Iö·
nönC >|nC!|lcC. cö> nlc|Ccö'c|hcöc|CnC> >Cn C| >l gnC
>C>pCc|C>C CC nö' lgn|CöC ÇuC öpö|CcC nö> p|CcC2·
nCnIC Cn lö nönCg|öIlö (N|K 99-00, 4\ ).
¯ |C|C|Cö CC lö ö|ÇulICcIu|ö y CC>C>I|ucIu|öc|Cn CCl
ICj|CC nönö||C cö !ö>ö CC Iöl>C> nCgöI|vC> C>cllö öl·
|CCCCC| CC' I 9%, >lCnCC nuy >upC||C|C> lö> Iö>ö> CC
Iöl>C> pC>|I|vC>
¯ ¯Cn>|CöCC> ICcölC> ö>| nC!||cö>.
|ö lnC|cöc|Cn CC cuönCC CCOC |Cöll2ö|>C unö nönCg|öI'ö
C> pC'Cn|cö. Ln gCnC|ö' .
¯ |n nujC|C> cCn Iön| l | ö|C> CC p|lnC| g|öCC cCn cön·
cC| CC nönö, p|öcI|cö|CnC> unö nönCg|öI'ö önuöl .
¯ |n ' ö> nujC|C> >| n C>IC> önICcCCCn!C> CnI|C 'C> Jb·
40 önC>, >C öcCn>Cjö |Cöl|2ö| uOö nönCg|öI'ö CC |C·
IC|Cnclö. A pö|I|| CC lC> 40 önC>. CxplC|öclCn c' 'n|cö
önuöl y unö nönCg|öI'ö cöCö I ·z öÒC>. A pö|I|| CC
'C> 50önC>, |Cö' l2ö| un C>!uClC cCnplCIC cöCö z önC>,
|ö>!ö 'C> /0 önC>.
¯ NC |öy Cö!C> cCnc'uyCn!C> >CO|C lö u!lllCöC CCl
>c|CCn|ng ö pö|!|| CC ' C> /0 öÒC>.
LCOQ|ðÍ|ð. |> nö> Chcö2 Cn nujC|C> jCvCnC>. bC CCOC
>C>pCc|ö| nö' | gn|CöC önIC unö l nögCn CcCg|öhcö >C' |·
Cö, |||Cgu' ö|, ||pCCcCgCn|cö C |C!C|CgCnCö cCn OC|CC>
nö' CChn|CC> y pC|C|Cö CCl CcC pC>IC|lC|.
|uHC|ÓH ðSþ||ðC|ÓH COH ðQU|ð 0Hð AnIC !CCö >C>pCc|ö
CC pö!C'Cg'ö nönö||ö, >C CCOC p|öc!lcö| unö |AA| cCn
C>IuClC clIC|CglcC CCl nö!C|lö' COICn|CC |> unö p|uCOö
CcCnCn|cö, cCn pCcö> cCnpllcöclCnC> y g|ön vö'C| C|ög·
nC>!lcC. 1|CnC unö >Cn>|OlllCöC CCl 9I % y unö C>pCc|I'c|·
CöC CC| 9ô%
b|OþS|ð COH ðQU|ð Q|UESð (¨LO|E·D|OþS|ð`). 1|CnC unö
>Cn>lOll|CöC CC' ß9% y unö C>pCclhClCöC CC' I 00%, ynC
p|Ccl>ö pö!ClCgC> C>pCc|ö'nCn!C CO!|CnöCC>, cCnC Ccu·
||C cCn lö |AA~, y pC|nl!C Cl >I| ngu| | l ö> IC|nö> lnvö>C|ö>
CC lö> nC lnvö>C|ö>. |n !unC|C> nuy pCÇuCÒC>, pC|n|IC
lö Cx!||pöc|Cn CC lö 'C>|Cn cCn nö|gCnC> l | O|C>.
b|OþS|ð. NC> Cö C' C|ögnC>I|cC CChOlIlvC. |COC |Cöl|2ö|>C
ö ICCö nujC| cCn >C>pCc|ö CC cöncC| CC nönö. bC puC·
CC |Cö||2ö| CC nönC|ö önOu' ö!C|lö Cn cö>C CC !unC|C>
g|önCC>, C, ' C ÇuC C> |öOlIuö' , Cn Çu| |CIönC OöjC önC>·
IC>|ö gCnC|öl, Cnv|önCC pö|IC CC' Iuco| pö|ö C>!uClC CC
|CcCpIC|C> |C|nCnö'C>. ln Cl cö>C CC IunC|C> v|>lO' C>
pC| nönCg|öIlö pC|C nC pö' pöO' C>, pCCCnC> p|öcI|cö| |ö
O|Cp>|ö y pC>pCnC| lö cl|uglö |ö>Iö COICnC| Cl |C>u'IöCC
|l>IC'Cg|cC, ICn|CnCC culCöCC CC nö|cö| OlCn |C> OC|CC>.
c> 'C ÇuC >C llönö ¨O|Cp>|ö ClIC||Cö¨
!|QOS ß|SIO|O§|OOS
|ö ÒMb c'ö>|0cö C' cöncC| CC nönö >Cgún >u ' ugö| CC
1ao|a151|µ05 |WÎ0|0g|005 ß0 |ßVd5|V05
ûI I0æ
L0ð0 Y000µ8U8l088
W0
W I W0
6II0|æ 5l / W0
A10|808
M 0ß m
C|lgCn |CucIö|C> C ' COul | ' ' ö|C>) C >u cö|öcIC| ||n >l Iu C
|nvö>|vC) y pC| >u pö!|Cn C>!|uc!u|ö' .
I . NO l nvð>O|ES
¯ Cö|c|nCnö |nI|öCuc!öl C cö|c|nCnö CucIö' |n >|Iu
|C|lb). HCp|C>Cn!ö C| ß0% CC ' C> cö|c|nCnö> l n >lIu
|1|> Cn l ö c' ö>lhcöclCn 1NM). bC cCn>lCC|ö un ICnC·
nCnC lCcöl, >|n |C!u|ö CC lö nCnO|önö Oö>öl Ol lö
lnvö>lCn CC' C>!|Cnö cl |cunCön!C. |' ô0% CC lC> cö|·
cl nCnö> | nh' I|önIC> I|CnCn ö>CclöCC cCnpCnCn!C
ln >lIu cö CCöC nCClö CC öpö||clCn C> CC 49 öOC>.
|ö IC|nö CC p|C>Cn!öclCn nö> |öO|!uö| (/b·ß'%)
C> ö>lnICnöIlcö, |CCnIlhcönCC>C Cn lö> nönCg|ö·
I'ö>, öunÇuC !önO| Cn puCCCn CCOuIö| cCnC IunC|
pö' pöOl C, >Cc|Cc|Cn y/C CnIC|nCCöC CC |ögC!. bl >C
I|ö!ö CC unö 'C>|Cn nC pö' pöO' C, >C |Cöl | 2ö Ol Cp>l ö
C| ||glCö cCn ö|pCn. |l !|ö!ön| Cn!C >C Oö>ö Cn C' 'n·
C|cC p|CnC>!|cC CC Vön Nuy>, ÇuC vö' C|ö C| !önönC
CC ' ö lC>lCn, ' C> nö|gCnC> ' l O|C> y C' g|öCC nucl Cö|.
|un!uöcl CnC> Oöjö>. !unC|CcICn'ö, punIuöClC·
nC> |nIC|nCC|ö>. IunC|Cc!Cnlö cCn |öClCIC|öplö y
pun!uöcl CnC> ölIö>. nö>ICcICn'ö. cö öpö|| cl Cn CC
nC!ö>!ö>|> Cn öCCnCpöI'ö> öx| ' ö|C> C> < z%, pC| 'C
ÇuC nC >C öcCn>Cjö CC IC|nö >|>!Cnö!|cö ' ö | | nIöCC·
nCcICnlö.
¯ Cö|c|nCnö l COu' | l l ö| ln >l!u |C||b). |> nulIlcCnI||cC
Cn un ô090% y !lCnCC ö >C| O| ' öIC|öl (Jb·ô0% I|CnIC
öl I 0·z0% Cn Cl CucIöl) nC >| nulIönCC. NC C> unö lC·
>lCn pölpöO' C n| Cö >'n!Cnö>, C> un p|CcC>C >l'COIC.
1CCö pöc|Cn!C ClögnC>!|cöCö CC Cclb !|CnC un z0·Jb%
CC pC>|O|'|CöCC> CC pöCCcC| un cöncC| |nvö>lvC CO C'
>Cgu|n| Cn!C ö z0 öÒC> |C>IC ||C>gC C> >lnllö| pö|ö ön·
Oö> nönö>, Cn Cl CucIöl, Cl ||C>gC ÇuCCö 'ln|!öCC ö
' ö nönö ÇuC p|C>CnIö lö 'Cs|Cn). |n Cl I|öIön|CnIC >C
|ön uI|ll2öCC 'ö IunC|CcICnlö önpllö y lö nö>ICcIC·
n'ö >|nplC O|'öIC|ö' cCn |np'ön!C> p|Ch'öc!lcö. |C nö>
l npC|IönIC C> Cl cCnI|C' C>!|Cc|C CC ' ö pöc|Cn!C
2. |HVðSOIES. Cö. cönöl | cul ö| |nvö>C| C Cuc!öl |nh' !|ö n!C
|C> C' nö> I|CcuCnIC, |Cp|C>CnIönCC Cl /0·ß0% CC lC>
cö>C>) (N| K 02-0J, 242).
LC> CI|C> !|pC> >Cn. cö cönö' | cu' ö| |nvö>C| cCn p|CCC·
n| n| C CC' cCnpCnCn!C ln!|öCuc!öl, cö |COu' | ' ' ö| |nvö>C|,
cö nuc| nC>C, cö nCCu' ö|, cö pöp| ' ö|, cö. !uOu' ö|, cö öCC·
m|0æ
5l
W0
+++
nCÇu'>I|cC, cö. >Cc|C!C| |juvCnl' ), cö. öpCc||nC, cö cCn
nC!öp' ö>|ö |!lpC C>cönC>C, !|pC Iu>CcC' ul ö|, !lpC cö|!|·
' ög| nC>C y C>CC).
Û|8S|Í|O8O|Oû SB§Uû B| §|8OO D|SIO|O§|OO
|l g|öCC || >IClCg|cC CC cöCö IunC| C> un IöcIC| |npC|·
!önIC pö|ö CCIC|nl nö| Cl p|CnC>I|cC.
¯ C|öCC ' . b|Cn ClIC|CnclöCC.
¯ C|öCC ' ' . MCCC|öCönCnIC ClIC|Cnc|öCC.
¯ C|öCC l ' ' . Möl C|IC|Cnc|öCC.
1 Û.0 Û||0|08 ÿ 0088||0||0
|l | nl cl C >uCl C >C| ö>inICnö!lcC. |ö ' Ccö' |2öclCn nö> I|C-
cuCn!C C> Cn cuöC|önIC> >upC|CCxIC|nC>. |n nö> CC'
ß0%, 'ö p|lnC|ö nön|IC>IöclCn cl'nlcö C> lö p|C>Cnc|ö CC
un !unC| C l nCu|öclCn. Un I b·z0% öcuCCn pC| p|C>CnIö|
ö'IC|öclCnC> Cn Cl cCnplCjC ö|CC'ö·pC2Cn |CccCnö, >C·
c|Cc|Cn C |CI|öcc|Cn) |n CIöpö> nö> övön2öCö>, puCCC
C||g|nö| |C!|öcclCn, u' cC|öclCn y CCCnö cu!önCC ¨p|C' CC
nö|önjö¨ |>Iö> pöc|CnIC> >Cn cöCö vC2 nCnC> I|CcuCnIC>
y >Cn |CI'CjC CC p|CcC>C> nuy övön2öCC>.
1 Û.0 ¥|88 00 0|80M|080|00
||>Cn|nö !ön Iöc| ' nCnIC ÇuC CCOC cCn>|CC|ö|>C cCnC
unö CnIC|nCCöC >|>ICnlcö cö>l CC>CC C' p||nclp|C.
L|SEH|HðC|ÓH Ì|HÍd\|Cð. |> 'ö p||nclpöl viö CC C|>Cnlnö·
clCn Cn Cl cöncC| CC nönö. |C> g|upC> nö> I|CcuCn·
ICnCnIC öICcIöCC> >Cn |C> öxl|ö|C> |CnClö!C|ö'C> |>| Cl
!unC| C>!ö Cn un cuöC|önIC Cx!C|nC), ' C> CC |ö cöCCnö
nönö|| ö |nIC|nö |>| Cl !unC| C>Iö Cn cuöC|ön!C> | n!C|·
nC>), y Cn !C|cC| ' ugö|, lC> >up|öclöv|culö|C>. |l !önöÒC
CCl IunC| p|lnö||C C>!ö C| |Cc!önCn!C |ClöclCnöCC cCn
C| pC|cCnIöjC CC nC!ö>!ö>|> pu' nCnö|C>. cö öICcIöc|Cn
göngl l Cnö| >C |Cö'|2ö |öO|!uöl nCnIC CC nönC|ö C>cö'C·
nöCö, >|gulCnCC lC> J n|vClC> CC bC|g. NlvCl l, pC| CCOöjC
CCl OC|CC lnIC||C| CC' nú>culC pCc!C|öl nCnC|. N|vC' ' l,
pC>IC||C| ö' pCc!C|ö' nCnC|. NlvCl lll, >uOc|öv|culö| Cn C|
öngu' C CC lö vCnö öxi ' ö|. |xl>!C unö v'ö CC CxICn>lCn 'Ccö'
l l nIöI|cö |öclö C' |'göCC ö !|övC> CCl öngu' C Cplgö>I||cC.
NE\dS\ðS|S. |ö> nC!ö>!ö>l> pu' nCnö|C> >Cn 'ö> nö> I|C·
cuCnIC> ,ôJ%) bC |ö CC>c||IC un pöI|Cn C|IC|CnIC CC
nC!ö>!ö>|> >|>!Cn|cö ö>CclöCC ö' cö|clnCnö lCOu' | ' ' ö| |n·
Ü|!|ð|!C, sie|dc masl|CCuC|!C> C| C>!C !lµC UC Cð|CC|C>
quC C| Cl UuC!ðl | ð ðICC!ðClC| UC | ð >C|C>ð µC|l!C|Cð|,
|C!|CµC||!C|CC, !|ðC!C Qð>!lC||!C>!l|ðl y C|Qð|C> QC|| ·
!ð|C>, µuUlC|UC µ|CUuCl|>C |ð UC!ð>!ð>|> UuC|C> ðOC>
0C>µuC> UCl !uUC| µ|| U|!lvC UðUð|| C.
c| Cð|CC| UC UðUð CC|>!l!uyC lð µ|lUC|ð Cðu>ð UC UC·
!ð>!ð>|> C>Cð ðlCC!ð|UC ð µC|v|>, CC| uU|ð, ICUu|, CC>!lllð>,
Clð¯CC.
Lð UC!ð>!ð>l> C| C|CCIðlC !ðUC|C| !|C|C CCUC µ|l |Cl µð|
O||QC| C| Cð|CC| UC UðOð. Lð ðICC!ðC|C| UC lCµ!CUC|| |·
QC> C> C>µCClð|UC|!C I|CCuC|!C C| Cl Cð|CC| |CCu| l | |ð|
(MlK Û1  -02, 249).
|| Cð|CC| UC UðUð !ðUClC| C> Cl ÇuC µ|CvCCð CC| UðyC|
l|CCuC|Clð UC!ð>!ð>|> CO C| C¡C, µuU| C|UC >Cl C||ð!C|ðl y
µ|OvCCð|UC vl>|C| CC||C>ð.
Í Û.Î Î8Î80|î|080|00
(c>!ð C| UC>u>C Cl !C|Ul|C «Cð|C| |CUð U||| UC UC
UðUð») (NlK 94-9b, 1 2ô).
Í Û.Û M8|0800|08
|O> Uð|CðUC|C> >C| UC µCCð u!lllUðU C| Cl Ul ðQ|C>!lCC,
µC|O µuCUC| ðyuUð| C| C| CC|!|C| UCl !|ð!ðU|C|!C, lð UC·
!CCC|C| UC |CC|U|vð> y CÞ | ð vð|C|ðC|C| UC| µ|C|C>!|CC. LC>
0ð> u>ðUC> >C|. |CCCµ!C|C> UC C>!|CQC|C y µ|CQC>!C|C·
0ð, µbz, Cð!Cµ>| |ð L, N|Ú7. 
ÍÛ.Û Î80Î0|08 00 M8Ì þ|0008Î|00
· NuUClC UC Qð|Q| lC> ðlCC!ðUC>. C> Cl Uð> | UµC|!ð|!C
COUO C|CUC|!C µ|C|C>!|CC ( Nl K ÛÛ·Û1 , 1 ó7) (NlK 04·0b,
I /9).
¯ 1ðUðOC !uUC|ð| UðyC| UC z CU.
¯ c0ðU UC|C| UC Jb ðÓC>.
¯ GlðUC Ol>!C|CQlCC Cz (UCUC|ðUðUC|!C UlIC|C|ClðUC) C
u3 (µCCC U|lC|C|C|ðUC).
¯ Lð¯CCl ÞjC ð µCC!C|ð| y/C CC>!| | | ð.
¯ |¯ll!|ðC|C| Cu!ð|Cð.
¯ Mul!|CC|!||C|UðU.
· |0vð>|C| vð>Cu|ð| C l l |lð!|Cð.
¯ ^C!|v|UðU ðuUC|!ðUð UC |ð ð|QlCQC|C>|>.
¯ LOUµC|C|!C l|!|ðUuC!ðl Cx!C|>C (ð|!C ||C>QC UC lCClU|·
vð |OCðl C| Cl |uQlð CC|>C|vðUC|ð).
¯ dO|UC C>Cð>C C ðICC!C.
¯ HCCCµ!C|C> C>!|CQC|lCO> |CQð!lvC>. |ð µ|C>C|C|ð UC |C·
CCµ!O|C> C>!|CQC||CC> µ|CU|CC CuC|ð |C>µuC>!ð ð lð !C·
|ðµ|ð |C|UC|ðl, µC| |C ÇuC >u ðu>C|C| ð C> >| Q|C UC Uð|
µ|O¯O>!|CO (Nl K 03-04, 92) (Nl K 0b-0ó, I 77).
¯ Lð¯CC| l|llðUð!C|lC.
¯ LOUCUCCð|Cl|CUð.
¯ ^|!C|ðClC| UCl C|CCQCO C·C|C bz y UCl QC| >uµ|C>C| !u·
0O|ð| p·bJ (Nl K 0ó-07, 1 Ï 1 ). 
¯ GC>!ðC|C|.
ÍÛ. Í Û 1|8Î8M|00Î0 00|
|8|0|00M8 00 M8M8 |0î| |Î|80Î0
c| !|ð!ðU|C|!C UCl Cð|CC| UC UðUð C> u| !CUð CCUµ| C¡C
y C¯ CC|!l|uð |Cv| >lC|. |ðy ÇuC !C|C| C| CuC|!ð ÇuC >C
tO¯>|UC|ð u|ð C|lC|UCUðU >l>!CU|Cð UC>UC C| µ|l|Clµ|C,
µO| |C ÇuC ðOðU| |CUC> u|ð !C|ðµlð ðUyuvð|!C ð lð Cl|uQ|ð
y |ð |ðUlC!6|ðµlð C| | C> Cð>C> UC ||C>QC.
Lð C|luQlð ðQ|C>|vð UuC>!|ð u|C> |C>u|!ðUC> Uuy µð|CC|·
0O> ð lð C| |uQ|ð CC|>C|vðUC|ð, >| >C >C|CCC|C|ð ðUCCuðUð·
0C|!C ð l ð> µðC|C|!C>, µC| lC ÇuC >C !|C|UC ð CC|>CQul|
Cl UðyC| QlðUC UC >uµC|vlvC|C|ð CC| C| UC|C| Q|ðUC UC
0u!||ðClC| µC>|ClC.
1 0 Û|d5|Í|0d0|00 1NM þd|d 0| 0d|\08| 00 0d|Td
T.1u00l 
Tx. L| Îu00| þ||0ß||0  00 þu6û6 86| û6Î6|0l0ßû0 
I0. N0 0ßy  6¥|û600|ß û6  Îu00| þ||0ß||0 
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CCnICS Iön| l | ö|CS CC cöncC| CC nönö (SCO|C ICCC Si
Ç|CSCnIön nuIöciCnCS Cn Cl gCn bHCAz) y Cn ÇöciCnICS
cCn g| nCcCnöSI| ö
L' SnC|CnC CC ªl | nCIC' IC| CS un IöcIC| CC ||CSgC Cn
C' vö|Cn (|iCSgC CC' 5-ó%). bC SuCl C C| ögnCSI| cö| ö lCS
! û- ! o nCSCS CCl | n| c| C CC 'CS SlnICnöS. L' IiÇC nöS
I|CcuCnIC CS Cl | nhlI|önIC, y Cl I|öIöniCnIC cCnS|SIC Cn
nöSICcICnlö |öCi cö' SCgu| Cö CC |öC| CIC|öÇ| ö, S| |öy
öICcIöc| Cn ' | níöI| cö |Ml R Vô·VÎ|, ¿bô) .
LnÍC|mCdðd dC |ðgC!.
'S un cöncC| CC nönö ÇCcC I|CcuCnIC ( ! -5% CC ICCCS
lCS cöncC|CS CC nönö) ÇC|C nöl i gnC. bC nönihCSIö
cCnC unö lCS|Cn CCl ÇCzCn y CC lö ö|CClö, Ç|u|| g| nCSö,
cCn C|CSiCnCS CccCnöICSöS, ÇC| ' ö Ç|CSCnc| ö CC ce' ulöS
IunCiö' CS Cn lö CÇ| CC|n| S CC' ÇCzCn Ln C' JJ% CC ' CS
cöSCS cCCx|SIC cCn un cö|c| nCnö CC nönö, ÇuC ÇuCCC
kâpêtI0âEâê1t|ä|êâ[||)
L| Cð|C|nomð duC!ð| |n s|!u Cs |ð Ío|mð mðsM
Í|CCuCn!C dC Cð|C|nomð s |n s|!u. bC Cð|ðC·
!C||Zð po| sC| UH ÍCnómCno |oCð| s|n |o!u|ð
dC |ð mCmb|ðnð bðsð|. bC puCdC !|ð!ð| Con
!umo|CCtom|ð, !umo|CC!omlð Con |ðd|o!C·
|ðp|ð o mðs!CC!om¡ð Cn ÍunC|ón dC| |Csu|·
!ðdo dC| |nd|Q p|onós!|Co Vðn Nuys.
L| ÍðC!o| p|onós!|CU mðs |mpo|!ðn!C Cn C| M
CðnCC| dC mðmð Cs |ð ðÍCC!ðC|ón gðng||o·
nð|. AdCmðs, CX|swn o!|os Como C| !ðmðÔo
!umo|ð| (>2Cmg Cdðd ( Jb ðÔos), mu|!|·
CCn!||C|dðd, ðwCtðC|ón Cu!ðnCð, musCu|ð|
u ósCð, |nvðÐón vðsCu|ð| o | |nÍð!|Cð, Com·
ponCn!C |n!|ðduC!ð| CX!Cnso, |CCCp!o|Cs
Þo|monð|Cs nCgð!|vos, sob|CCXp|Cs|ón
onCogen L·C|bb2 y p5J ¿ o o o
L| !|ð!ðm|Cn!o qu| |u|g|Co dC| CðnCC| dCÑ
mðmð Cs!ð|ð |nd|Cðdo Cn !odos |os Cð·
sos, sð|vo Cn |ðs pðC|Cn!Cs Cðnd|dð!ðs ð
nCoðdyuvðnC|ð Con qu| m|o!C|ðp|ð (¯4, N2,
NJ, M\}.bC puCdC |Cð||Zð| C||ug|ð ConsC|vð·
do|ð Cn !umo|Cs <5Cm ð Cond|C|ón dC quC
no Cs!e Con!|ð|nd|Cðdð (mu|!|ÍoCð||dðd,
ComponCn!C |n!|ðduC!ð| CX!Cnso, Cð|C|no·
mð |ðgC! Con !umo| ð|C]ðdo, |mpos|b|||dðd
dC ðdm|n|s!|ð| |ðd|o!C|ðp|ð). b|Cmp|C quC
op!Cmos po| C||ug|ð ConsC|vðdo|ð, ||ð sC·
gu|dð dC |ðd|o!C|ðp|ð pos!opC|ð!o||ð.
Lð mðs!CC!om|ð % |Cð||Zð|ð Cn |os !umo|CsÕ
>5Cm o quC no puCdCn sC| !|ð!ðdos Con C|-
|ug|ð ConsC|vðdo|ð. Ln |os Cðsos Cn |os quC
CXIs!ð un C|Cvðdo ||Csgo dC |CC|d|vð (4 gðn·
g||os pos|!|vos, CX!Cns|ón CXt|ðCðpsu|ð|,
mð|gCnCs ðÍeC!os o p|óX|mos), ðdm|n|s!|ð·
|Cmos |ðd|o!C|ðp|ð sob|C |ð pð|Cd !o|ðC|Cð
y ð|Cðs gðng| |onð|Cs.
Lð qu|m|o!C|ðp|ð Cs C| p||n6|pð| !|ð!ðm|Cn·Õ
!o ðdyuvðn!C, y % |nd|Cð|ð Cn |ðs mu¡C|Cs
Con gðng||os pos|!|vos o Cn ðque||ðs Con
gðng||os nCgð!|vos, pC|o Con ÍðC!o|Cs dC
mð| p|onóst|Co.
Lð Þo|mono!C|ðp|ð sC u!|||Zð|ð só|o Cn !u·Ñ
mo|Cs Con |CCCp!o|Cs Þo|monð|Cs pos|!|·
vos. Ln mu|C|Cs postmCnopðus|Cðs, C| Íð|·
mðCo dC p||mC|ð ||nCð son |os |nÞ|b|do|Cs
dC |ð ð|omð!ðsð, sob|C !odo pð|ð Cv|!ð| |os
p|ob|Cmðs dC| !ðmoXIÍeno sob|C C| Cndo·
mC!||o. Ln ðquC||ðs pðC|Cn!Cs quC Cs!en !o·
mðndo !ðmoX|hno, M vð|o|ð|ð Cðmb|ð| !|ðs
2·b ðÔos ð |nÞ|b|do|Cs dC |ð ð|omð!ðsð.
Ln |os !umo|Cs quC sob|CCXp|CsCn C| onCo·Ê
gen L·C|b b2 (HC|2/nCu) sC puCdC u!|||2ð|
C| ¯|ðs!uZumðb (HC|CCp!|n), quC Cs un ðn!|·
CuC|po monoC|onð| CspCC|hCo Con!|ð Cs!C
onCogen.
M|B
M|K 0J-04, \04
MIK 02-0J, \42
MIK 0\-02, \75
M|K 05-0, \7ö M|K 0\-02, \ 7ó
MÌK 0 \7ö MIK 0·0\|,²ö0
MIK 04-05, \79 M|K Û-0², \óö
M|K 0J-04, 92 M|K 9 ,4\
M|K 0J-04, 9
DääêO||1|têBq ê
M\7ö. Unð mu]er de ô ðDOs hð sIdO |nter-
w med|ðnte tumOretOm|ð de un
æ de mðmð. ´e trðtðDð de un
tumOr de 2 Cm COn gðngI|Os I|Dres y reep·
tOres hOrmOnðÌes negðtlvOs. ¿LuðI de Iðs
s|gu|entes q de trðtðm|entO reO-
mendðr|ð!.
I )  QuImlOteröp|ð COn un tðxðnO.
2) KðdIOterðp|ð ðnte.
J) 1ðmOxINn ðdyuvðnte.
4) KevIslOnes ðnuðIes IOs dOs
pr|merOs ðDOs.
5) ÐCurðdð; puede reðI|zðræ
reCOnstruCC|ón mðmðr|ð.
M|K 2Û-205 8.2
T 75. Unð þðC|ente de J5 ðÔOs hð s|dO
sOmet|dð ð mðWM pr CðnCer de
mðmð. Ln Ið plezð quIrurg|Cð se enCuentrð
un CðrC|nOmð duCtðI InhItrðnte de 2 Cm y
ex|ste |nvðs|ón de J de |Os gðng|IOs ðx|Ið-
res ðIsIðdOs. LOs |eeptOres de estrpenOs
y prOgestðgenOs sOn negðt|vOs. ¿LuðI es
Ið COnduCtð ð seguìr mðs ðprOpIðdð trðs Ið
mðsteCtOm|ð !.
\) UDservðC|ón y COntrOIes
perlód|COs.
2) Kðd|Oterðp|ð sODre IeChO mðmðr|O.
J) Qu|m|Oterðplð ðdyuvðnte.
4) HOrmOnOterðp|ð ðdyuvðnte.
5) LðstrðCIón qu|rurg|Cð.
M|K 20\-202 KL: J
J 74. Unð mu]er de 59 ðDOs presentð unð
lmðgen esp|CuIðdð de ö mm de dIðmetrO
en Ìð mðmð derehð en eI estud|O mð-
mOgrðhCO. Unð D|Ops|ð COn ðgu]ð gruesð
ev|denC|ð Ìð presenC|ð de un CðrC|nOmð
duCtðI |nhItrðnte grðdO 2, COn reeptOres
pðrð estrqenOs ps|t|vOs en un ö0 de
Iðs CéIuIðs tumOrðIes, reCeptOres pðrð prO-
gesterOnð pOsItIvOs deI 6, y un OnCpén
Her-2 nQðt|vO. ¿LuðI serIð eI trðtðm|entO
pr|mðr|O deIeC|ón!:
\) Qu|mlOterðplð pr|mðr|ð en
COmD|nðClón COn trðstuzumðD.
2) 1umOreCtOmíð COn exéres|s de|
gðngIIO Cent|neIð COn rðd|Oterðp|ð
pOster|Or.
J) HOrmOnOterðplð COn 1ðmOxllenO.
4) MðsteCtOm|ð COn I|nlðdeCtOm|ð
ðx|Iðr.
5) Kðd|Oterðp|ð externð COmO un|CO
trðtðm|entO.
M|K 20-207 82
>C| O!|öCuc!ö' cCn JöyC| I|CcuCnc ö, C nh' !|ön!C. bl
nC Cx>!C !uJC|öc Cn ö>Cc öCö, >C c' ö> hcö cCJC cö|·
c| nCJö n > !u (1 >), > ' ö |öy, >C c' ö> hcö CC öcuC|CC ö'
!öJönC !uJC|ö' .
Cáncer de mama y emOarazO
|> ' ö n0Cp| ö>l ö Jö' Qnö qu0 cCn Jö> I|Ccu0nc ö >0
CC!Cc!ö Cu|ön!C C' CJOö|öïC y/C puC|pCl C bC C>! Jö
unö l nc CCnc ö CC 1 /Jûûû pö|!C> y |Cp|C>Cn!ö Cl ! z%
CCl !C!öl CC cöncC|C> CC JöJö. cö CCöC JCCl ö CC p|C·
>Cn!öclCn C> CC J' öÙC>.
|' |C!|ö>C Cn C' C öQnC>! cC C> C' p| nc pö' cCnC c Cnön·
!C CC' pCC| p|CnC>! cC CC' cöncC| CC JöJö ösCc öCC
ö ' ö qC>!öc Cn. `C| C' 'C, >C |CcCJ CnCö ' ö Cxp' C|öc Cn
> >!CJö! cö CC ' ö> JöJö> Cu|ön!C ' ö QC>!öc| Cn y C
puC|pC| C, ö> ' cCJC ' ö |Cö' zöc Cn CC CcCQ|öI'ö, JöJC·
Q|öI'ö y `AA| Cn !CCö ' C> Cn >C>pCc|C>ö, > n CCJC|ö| lö
Cxp' C|öc Cn CC>puC> CCl pö|!C cC> cö>C> CC Cl sCJl nö
cl Cn ö| IC!C >Cn CxcCpc Cnö' C> y, Cn Juy |ö|ö> Ccö>C·
nC>, ' C |ö p|C>Cn!öCC lö pl öcCn!ö.
cC> !l pC> | >!C' CQ cC> >Cn l C> J >JC> quC luC¯ö CC ' ö
QC>!öci Cn, > COCC !öJOi Cn C' cö|c nCJö Cuc!ö' nh'
!|ön!C C' Jö> I|CcuCn!C.
|n C' !|ö!öJCO!C, CCOCn !CnC|>C Cn cuCn!ö Iöc!C|C>
CCpCnC Cn!C> CC' 'uJC| y CC ' ö pöc Cn!C, ö>' cCJC ' C>
pC> O' C> C!Cc!C> CC' !|ö!öJ Cn!C >CO|C C' lC!C, pC¯ ' C
quC Cn ' ö JöyC|'ö CC ' C> cö>C> >C !|ö!ö CC un !|ö!öJ Cn
!C nC v Cuö' lzöCC y Jul! C >c pl nöi
¯ NC >C |ö CCJC>!|öCC quC C' öOC|!C JCjC|C C' p|CnC>·
!lcC CC ' ö CnIC|JCCöC.
¯ Ll traIam|entO qu| rurg| cO CC C' Cccl Cn C> lö Jö>!Cc·
!CJ'ö Jö> l nIöCCnCc!CJlö, pC|C cuönCC lö 'C>Cn C>
pCquCnö, >uClC Cp!ö|>C pC| ' ö !uJC|Cc!CJ'ö C cuö·
C|ön!Cc!CJ|ö, quC CCOC >C| cCJp' CJCn!öCö cCn |ö·
C C!C|öp ö
¬öy C >cu> Cn >CO|C cuönCC |Cöl zö| l ö c |uQ'ö, öunqu0
CöCö ' ö pCcö |CpC|cu> Cn quC ' ö c |uQ'ö ! CnC >CO|C C'
CJOö|öïC, nC C>!ö j u>!| hcöCö CCJC|ö|l ö Jö> CC z C J
>CJönö>.
¯ Ln ' ö> pöc Cn!C> cCn !|ö!öJ Cn!C cCn>C|vöCC|, ' ö |ö·
C C!C|öpl ö CCOC CCJC|ö|>C |ö>!ö CC>puC> CC' pö|!C,
öunquC !ön!C lö H1 cCJC l ö [1 >uC' Cn cCJCnïö|>C Cn
'ö> ô >CJönö> > Qul Cn!C> ö 'ö c |uQ'ö. cC> CICc!C> CC 'ö
H! CCpCnCCn CC 'ö CCöC QC>!öc| Cnö' y >Cn CC> >·CC·
pCnC Cn!C>
¯ cö qu| m|Oterap|a öCyuvön!C CCOC >C| l ö nC|Jö Cn ' ö>
pöc Cn!C> cCn QönQl C> pC>l!vC>, C | ncl u>C cuönCC >Cn
nCQö!lvC> y ' ö CCöC C> JCnC| CC J' önC>. ¯CJC|ö| l ö
Ç1 puCCC C >J nu | >u> OCnChclC>.
`uCCC p|CCuc| öOC|!C, pö|!C p|CJö!u|C, Jö' IC|Jö·
c CnC> (JöyC| nc CCnc ö Cn ¹` !| JC>!|C), C' H, JuC|·
!C | n!|öu!C|C y !|ön>Jl > Cn CC ' ö !CxcCöC Jö!C|nö ö'
¦C!C. ¯COC >C| CC>öcCn>CjöCö C¯ C' ¡ ' !¯ JC>!|C, pC|C
Cu|ön!C C' zº y Jº !| JC>!|C, puCCC u! ' zö|>C cCn OöjC
|C>QC lC!ö' .
|l plCnC>!cC IC!ö' nC >C vC öICc!öCC Cl |Cc!öJCn!C pCl
C' cöncC|, öunquC >i l nC |Cc!ö¯Cn!C puCCCn nI' ul | |C·
c|C> cCJC C' CC!C|lC|C Jö!C|nC y C' CJp' CC CC cC|!C>
JC!CCC> C öQnC>! cC> y !C|öpCu! cC>.
|' c' |nöíC|iO ES uOö CíaÇö CC |ö v|Cö CC 'ö nu¡C|, ÇuC Cu|ö
ö¤C>, Cu|önIC ' ö cuö' Ccu||C Cl Çö>C CC lö CCöC IC|I| ' ö 'ö
CCöC nC IC|!| ' .
cö nCnCÇöu>|ö C> un >C' C Cö, C' Cö CC lö u' !| nö |Cg' ö
¦öunÇuC Çö|ö |öcC| Cl CiögnC>IicC CChn|I|vC CC nCnC·
µöu>iö, C> Ç|Cc|>C ÇuC |öyö Çö>öCC I öDC CC önCnC||Cö
CC>CC ' ö u' !| nö |Cg'ö).
5C ''önö ÇC||nCnCÇöu>iö öl ÇC|lCCC CC !|CnÇC ( ! ·z öDC>)
q0ÇÇ|CcCCC y >|guC ö ' ö nCnCÇöu>iö, y ÇuC >C cö|öc!C|i·
zö ÇC| ' ö öÇö|| c| Cn g|öCuö' CC ' ö cllnicö ÇuC öcCnÇöDö öl
c'|nö!C|iC, y ÇC| önCvu'öciCn. Lö CCöC CC lö nCnCÇöu>| ö
C>. bû 2 ! ,b öDC>. ¯Chn| nC> nCnCÇöu>iö Ç|CcC2 cuönCC
Ccu||C ön!C> CC lC> 4û öÒC>.
¿0.1  b||0Ì08
5C Ç|CCucC un ögCIöniCnIC CC lC> ICllculC> Ç|inC|Ciö' C>
y,cCnC cCn>CcuCnc|ö, C' >ucC>C clövC CC l ö nCnCÇöu>iö.
lö cöCö CC C>!|CgC¯C> (MlR  97-98|,  4b).  lö nöyC|lö CC
|ö> nöniIC>!öciCnC> cllnicö> vön ö vCn| | cCnC| c| CnöCö>
µC| C>!C CC>cCn>C C>I|CgCn| cC
o|ûIOH8S ûOU|OVO§O!8IlVOS
¯ bCICcC>. >Cn ' C> nö> I|CcuCn!C> CC !CCC> lC> >ln!Cnö>
|U5%). CCn>i>!Cn C¯ ClCöCö> CC cö'C| ÇuC |CcC||Cn Cl
cuC|ÇC, öcCnÇöÒöCö> CC vö>CC|'ö!öciCn y >uCC|öc|Cn.
¯ ·uCCCn öÇö|CcC| C!|C> >ln!Cnö> nCu|CvCgCIö!|vC>
cCnC. >uCC|öc|CnC>, Çö' Çi!öc|CnC>, Çö|C>IC>|ö>, in>Cn·
¤|C, vC|I|gC, cCIö' Cö, CIc.
o|ûIOH8S µSlOO|0§lOOS
|> I|CcuCnIC 'ö öÇö| c| Cn CC ' öO| ' | CöC CnCciCnöl, nC|v|C·
>|>nC, | ||| IöO| ' | CöC, C>IöCC CC öni nC CCÇ|C>ivC, C| >n| ·
¤uc| Cn CC ' ö ' | OiCC, Cn Çö|!C |Clöc|CnöCC> cCn C' CCÞciI
0C|nCnö| y Cn Çö|IC cCn ö>ÇCc!C> Ç>icC>Cc|ölC>.
cö CiÞcu'!öC CC cCncCn!|öc|Cn y ÇC|C|Cö CC nCnC|iö
mC|CcCn ö!CnciCn, yö ÇuC C>Iö Cn C>!uC|C C' ÇC>|OlC
CICc!C Ç|C!CcIC| CC ö IC|öÇ|ö |C|nCnö' >u>!|Iu!ivö I|Cn!C
ö 'ö CnIC|nCCöC CC A'zhCinC|.
o|û!OH8S §OHlIOU|lû8|lOS ]OUI8HOOS
¯ |C> C>!|CgCnC> IiCnCn un CICc!C I|CÞcC >CO|C Cl öÇö|ö!C
gCn|!Cu||nö||C ICnCn| nC y lö cCn>CcuCnciö CCl CChc|! C>·
!|CgCn| cC vö ö >C| ' ö ö!|Chö gCnlIöl y CCl öÇö|öIC u|i nö|i C
'ö vu' vö >C ö!|CÞö, y ÇuCCC öÇö|CcC| Ç|u|| IC vu| vö|, |ö vö·
g|nö C| >n| nuyC >u >Cc|Cc|Cn, ÇuC| CnCC öÇö|CcC| C| >Çö·
|Cun| ö y cC' Ç| !| >, ' ö vCj| gö y u|C!|ö >C öI|Chön y öunCn!ön
'ö> | nICcc|CnC> u|| nö|iö>, Cl u!C|C C| >n| nuyC CC IönöÒC y
C' CnCCnCI|iC öCC'gözö.
¯ cn Ç| C' y nucC>ö> öÇö|CcC ö!|CÞö, >CÇuCCöC, Ç|u||IC C
¤i|>u!|>nC 'CvC.
o|W1ÛYÂb b|b1LY|LÛb
¯ AunCn!ö ' ö Çö!C'Cgö cö|C|Cvö>cu' ö|. ö|!C||C>clC|C>l>,
cö|C|CÇö!ö | >ÇuCnicö, ¬!A, C!c., yö ÇuC lC> C>I|CgCnC>
CnCCgCnC> CjC|cCn un ÇöÇCl Ç|CICcIC| ÇC| >u öcciCn vö·
>CC|'ö!öCC|ö y önIiöIC|CgCnicö.
¯ AunCn!ö Cl ||C>gC CC C>!CCÇC|C>|> Cu|önIC Cl cl i nö!C·
|iC, lö nujC| Ç|C|CC öÇ|Cx|nöCönCn!C C' 7û% CC l ö nö>ö
C>Cö ÇuC ÇC|CC|ö ö l C 'ö|gC CC >u viCö. lC> IöcIC|C> CC
||C>gC CC C>!CCÇC|C>|> >Cn
ö) |CöC. C> C' Iöc!C| nö> inÇC|!önIC. A nöyC| CCöC,
nöyC| ÇC|C|Cö CC huC>C
O) |öcIC|C> OC¯C!icC>. ' ö |özö öI|CönC|icönö !|C·
nC nöyC| nö>ö C>Cö |C| !ön!C, lö |özö O' öncö
C>!ö nö> Ç|CCi>ÇuC>!ö ö ÇöCCcC| C>ICCÇC|C>|:
( Ml R 9b·9ô, 4J). 
C) |öcIC|C> |Clöc|CnöCC> cCn C' C>!öCC C>!|CgCn|cC.
nCnö|Çu| ö !CnÇ|önö (>C cCniCnzön ö gö>!ö| Ç|CnIC
lC> IC'culC> Ç|CCuc!C|C> CC C>!|CgCnC>), nCnCÇöu·
>|ö Ç|CcCz ¦>C CCjön CC Ç|CCuc| | Ç|Cn!C ' C> IC' cu' C>),
CCIC|CcICnö !CnÇ|önö ¦Ç|CCucC unö nCnCÇöu>| ö
Ç|CcCz).
C) HöO|!C> || g| CnicC·CiC!C!|cC> 'ö CC'göCCz C> un
Iöc!C| CC ||C>gC, yö ÇuC ' ö> nujC|C> COC>ö> !lCnCn
unö Ç|CCucciCn ÇC|iIC|icö CC C>!|Cnö, ÇuC, öunÇuC
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¯ LC|dOC0| 0ÉI|CCS [1|DC|C|d). ||COUCE EÍECICS ESI|C·
QÉ||CCS, QESIdQÉ||CCS y d|O|CQÉ|| CCS, ESI| 0U| d|OC
E| I|CÍS0C OE | d 0UCCSd VdQ| |d| LS EÍ|CdZ EO E| I|d·
Id0|E|IC OE| S||O|C0E C| | 0dIÉ||CC y Çd|ECE Ú\|| E| | d
Ç|EVE|C| C| OE E|ÍE|0EOdOES Cd|O|CVdSCU|d|ES y CSIEC·
ÇC|CS|S, dU|QUE |C |dy SURC|E|IE EV|OE|C| d C| E|I|ÍCd
QUE | CS dVd|E.
|C| SUS EÍECICS d|O|CQÉ|| CCS, Çd|ECE dU0E|Id| | d | | D| ·
OC y O| S0| |U| | | CS I|| Q| |CÉ||OCS, dU|QUE Çd|ECE ÍdVC|E·
CE| E| || |SUI| S0C.
" NCOU| dOC|ES bE|ECI|VCS OE ¬ECEÇIC|ES LSI|CQÉ|| CCS
(¬d| CX|ÍE|C). bE U|E d | CS |ECEÇIC|ES OE ESI|CQE|CS E|
| CS IE|l OCS E| | CS QUE E| ESI|CQE|C ES DE|ERC|CSC. DUE
SC, dÇd|dIC Cd|O| CVdSCU| d|, O| S0| |UyE|OC E| CC| ESIE|C|
ICId|, LLL y ÍD|| |CQE|C ÇE|C |C E| | CS QUE ÇE|¡UO|Cd
(0d0d, E|OC0EI||C). LE DEC|C, Çd|ECE Ç|EVE|| | E|
Cd|CE| OE 0d0d. NC 0E¡C|d | d dI|CÍd U|CQE|| Id| || | CS
S| |IC0dS VdSC0CIC|ES (M| RÜbÜ1, ZbÜ) .
¯ ||ICESI|CQE|CS. bC| SUSId|C| dS OE C|| QE| VEQEId| QUE
SE E|CUE|I|d| E| l EQU0D|ES, SC¡d, EIC. 1| E|E| U|d dC·
C| C| ESI|CQÉ||Cd OÉD|| y V| Od 0EO| d 0Uy CC|Id. LdS |SC·
Í!dVC|dS SC| | d C| dSE 0dS ÇCIE|IE OE ÍICESI|CQE|C y
SE UI| | |Zd| CC0C I|dId0|E|IC S| |IC0dI|CC OE| S| |O|C0E
C| | 0dIÉ||CC.
·LI|CS. L|SÇC|E0CS OE |U0E|CSCS Íd|0dCCS USdOCS
Çd|d | d S| |IC0dIC|CQ|d C| | 0dIÉ||Cd. C| C|| O| |d, DE|ZC·
O| dCEÇ| |dS, dCE|IE OE C|dQ|d, V|Id0| |d bô. |d|d | d Ç|C·
D| dX| S y E| I|dId0| E|IC OE | d CSIECÇC|CS|S, Id0D| É| SE
USd| Cd| C| IC|| |d y O|ÍCSÍC|dICS.
M|RÛb·Ü, 1 1å
M|R03,Û1
M|RÛÛ·ÛÎ, 1 1Û
M|RÛÛ·ÛÎ, 1 öÛ
M|RÛ1·ÛöÍ, 4Z
P|êyä1lää M|B
M|RÛ1·ÛöÎ, ÔÖ
M|RÛ1·Ûö, 1 Û2
M|RÛb·Û1Î, ZÛÛ
M|R Ûb·Ûb, 4å
Oääê O||1ltê Bêpmll¢ê
1 1Û. ¿Cuá|de|Oss|gu|entestratam|entOsesM
e| másadecuadOen unamujerdebb añOs,
menOpáus|cadesdehaceunOpOrhabérse·
|epract|cadO una h|sterectOm|acOn dOb|e
anexecIOm|a,quepadeceuns|ndrOmec||-
matér|cO|mpOrtante!:
1) Cak|OOra|ybenzOd|acep|nas.
Z) LstrógenOsyprOgestágenOs 1Û nOr-
der|vadOs.
J)LstrógenOsyvera||pr|de.
4) LstrógenOsyprOgesterOnanatura|.
b) LsIrógenOsexc|us|vamente.
M|R 1 ÛÛÛ·ZÛÛÛÎ RC:b
Ô.  Pac|ente de Ô  añOs, fumadOra de ZÛ
c|garr|||Osld|aybebedOrade bÛ·ÛÛ gde a|-
cOhO|lsemana. MenOpaus|a a |Os41 añOs.
Ls h|pertensa cOnOc|da desde hace un
añO,yse cOntrO|a cOnh|drOc|OrOt|az|daZb
mg/d|ayatenO|O| \0mg/d|a.Haceå añOs,
sufr|óunafracturadeCO||esderecha.Lntre
susháb|IOs,destaca desdes|empreunmuy
bajOcOnsumOde|echeyder|vadOs,una|tO
cOnsumOdeprOte|nasyunav|dasedenta-
r|a.Ara|zdeuncuadrOdedO|OrdOrsa|agu-
dO,has|dOd|agnOst|cadapOrsuméd|cOde
ap|astam|entO verIebra| secundarìO a Os-
teOpOrOs|s. ¿Cuá| de|Ossìgu|entescOnjun-
tOsdefactOrespuedenhaberfavOrec|dOe|
desarrO||Ode|aOsteOpOrOs|s!:
1) L menOpaus|a precOz,e|tabaqu|s-
mOye|cOnsumOdet|az|das.
Z) La menOpaus|a precOz, |a |ngesta
baja de ca|c|O y e| cOnsumO de t|az|-
das.
å) L menOpaus|a precOz, |a |ngesta
bajadeca|c|Oye|sedentar|smO.
4) L| cOnsumO det|az|das,e|cOnsumO
bajO de ca|c|O y e| cOnsumOe|evadO
deprOte|nas.
b) L| cOnsumOe|evadOdeprOteínas,|a
menOpausìa precOz y |a h|pertens|ón
arIer|a|.
M|R1 ÛÛ1-1 ÛÛöÎ RC:å
Í|\|ê|êg|1 1t| tH01|1lê
0||ê1Iät|01M|B
Ø 10mð 0H 0Ì ÇU0, SCDf0 \CUC, HC U0D0S U0·
jð|\0 U0 0S\UUÌðf ÌðS mCUßÌCH0S DSÌCÌÓ-
gÌCðS U0Ì 0mDðfðZC.
AâpêtIêâEâê1t|ä|êâ[|)
ØLð µÌðC0H\ð \Ì0H0 UHð ÍUHCÌÓH U0 \fðHSµCf-
\0. LCS m0CðHÌSmCS ÍUHUðm0H\ðÌ0S SCH
Ìð UÌÍUSÌÓH SÌmµÌ0 (O2,CO2, ðgUð y 0Ì0C-
\|0ÌÌ\CS) SÌH gðS\C 0KC, Ìð UÌÍUSÌÓH
Í8CÌÌÌ\ðUð (gÌUCCSð) SÌH gðS\C 0H0fgÉ\ÌCC,
0Ì \fðHSµCf\0 ðC\ÌVC [hÌ0ffC, ðmÌ HCðCÌUCS y
VÌ\ðmÌHðS) CCH gðS\C 0H0fgÉ\KC µCf ÌUChðf
CCH\fð UH gfðUÌ0H\0 U0 CCHC0H\fðCÌÓH y Ìð
µÍHCCÍ\CSÌS µðfð ÌðS mCÌÉCUÌðS U0 gfðH \ð-
mðHC [Ì̵CµfC\0ÍHðS, RSÍOÌ͵ÌUCS, ðH\KU0f-
µCS, VÌfUS . . . ).
ÐLð µÌðC0H\ð \ðmDÌÉH \Ì0H0 UHð ÍUHCÌÓH
U0 SÍH\0SÌS hCfmCHðÌ. ÍfCCUC0 HCG CUyCS
HÌV0Ì0S mðXÌmCS SCH UUfðH\0 0Ì µfÌm0f
\fÌm0S\f0, yð ÇU0 0S Ìð 0HCðfgðUð U0Ì mðH-
\0HÌmÌ0H\C U0Ì CU0fµC ÌÚ\0C. NCS 0S U0
U\ÌÌÌUðU 0H 0Ì UÌðgHÓS\ÌCC U0 g0S\ðCÌÓH y 0Ì
UÌðgHÓS\ÌCC µf0Hð\ðÌ U0 CfCmCSCmCµð\ÍðS.
1ðmDÌÉH µfCUUC0 ÌðC\Óg0HC µÌðC0H\ðfÌC.
bUS HÌV0Ì0S VðH ð Ìf ðUm0H\ðHUC ð ÌC ÌðfgC
U0 Ìð g0S\ðCÌÓH, y 0S Ìð hCfmCHð ÇU0 Vð ð
ðS0gUfðf 0Ì SUmÌ HÌS\fC U0 gÌUCCSð ðÌ ÍP\C.
ØÌðS mCUÌDCðCÌCH0S CðfUÌCVðSCUÌð|ES ÇU0
VðmCS ð CDS0|Vðf SCH. ðUm0H\C U0Ì V-
ÌUm0H VðSCUÌðf, U0SC0HSC U0 Ìð 1F 0H 0Ì
µfÌm0f y S0gUHUC \fÌm0S\f0 y ðUm0H\C
DSÌCÌÓgÌCC ð ÌC ÌðfgC U0Ì ÚÌ\ÌmC \fÌH,
ðUm0H\C U0 µf0SÌÓH V0HCSð 0H µ0NS y
µÌ0fHðS, UÌSmÌHUCÌÓH U0 Ìð fESÌS\0HCÌð VðS-
CUÌðf, ðµðfÌCÌÓH U0 SCµÌCS SÌS\ÓÌÌCCS, fUÌUC
U0 gðÌCµ0 y U0SUCDÌðmÌ0H\C U0 |oºfUÌUCS
CðfUÌðCCS, \ðÇUÌCðfUÌð y U0SVÌðCÌÓH U0Ì 0j0
CðfUÌðCC ð Ìð ÌZÇUÌ0fUð.
Ð LH ÌðS 0mDð,S ðµðf0C0 ðH0mÌð ð µ0-
Sðf U0Ì ÌHCf0m0H\C 0H Ìð µfCUUCCÌÓH U0Ì
HÚm0fC U0 h0mð\Í0S, µfCCUCÌUð ÍUHUð~
m0H\ðÌm0H\0 µCf Ìð h0mCUÌÌUCÍÓH.
¿1 . 1 Î0000080|00 0 |Mþ|80Î80|00
c| lð ÇC|clC| ðUÇu| ð| UC |ð I|CUÇð Ccu||C | ð lCcu|Uð·
c|C|, y C| Cvu| C lCcu|UðUC C. I|ð|.ÇC|IðUC ð .u | uQð| UC
| UÇlð|IðclC| C| Cl C|UCUCI||C, cuð|UC ðu| C.Ið C| |ð
lð.C UC C| ð.ICc|.IC. Lð l UÇlð|Iðc|C| Ccul|C C·7  U|ð. I|ð.
lð Cvulðc|C|.
c| Clð.ICc|.IC C. u|ð C.I|ucIu|ð C.lC||cð |CUCðUð ÇC| u|ð
cuClC|Ið ||ðUðUð I|CICC|ð.IC, ÇuC vð ð IC|C| lð U| .l C| UC
¢Cxcðvð|» C| C|UCUCI|lC Çð|ð ClCcIuð| lð | UÇ|ð|IðclC|.
LC.ÇuC. UC |ð l UÇ|ð|Iðc|C|, Cl C|UCUCI||C .C UCUlhcð
y Çð.ð ð llðUð|.C UCc| Uuð. Lð zC|ð CUC||C|ð||ð ÇuC C.Ið
C| cC|IðcIC cC| | ð UCc| Uuð uIC|||ð .C UCUlÞcð y .C l | ðUð
cC||C|, ÇuC CvC| uc| C|ð|ð hð.Ið lCl Uð| lð ÇlðcC|Ið.
¿1 .¿ Î|8000Î8
LuUÇ| C u|ð lu|c|C| UCcl.|vð C| |ð |uI||c|C|, clCc|UlC|IC
y UCIðCC||.UC lCIð|, y UC.ð||C||ð u|ð ðcI|vlUðU C|UCc|l|ð
Uuy l UÇC|Ið|IC.
bu lC|UðclC| cCU|C|zð ð Çð|I|| UCl 9Ulð ÇC.IlCcu|Uð·
cl C| (I|OICClð.IC), ÇC|C |C ð|cð|zðlð .u C.I|ucIu|ð UCÞ|l·
I|vð (Ulvl.|C| C| cCI||CUC|C.) hð.!ð C| bº UC.. Lð ÇlðcC|Ið
ðcIuð cCUC Cð||C|ð, cCUC |uQð| UC ||IC|cðUC|C UðIC|·
|C·lCIð|, y C| |ð lC|Uðc|C| UC .u.Ið|clð. cC| Iu|c|C|C.
C|UCc|||ð..
|u|c| C| UC Cð||Clð. Cv|Ið |ð cCUu|| cðc| C| U| |CcIð C|I|C |ð
c| |culðclC| UðIC||ð y lð lCIðl, ð.l cCUC Cl Çð.C UC UCIC|·
Ul |ðUð8 .u.Ið|c|ð..
1|ð|.IC|C|clð ÇlðcC|Ið|lð. |ð llCQðUð UC |uI||C|IC. Uð·
IC||C. ð| ICIC ÇuCUC Ç|CUuc||.C Qlðclð. ð U|vC|.C. UC·
cð|l .UO..
J û|ß8 
Ü¥u|ß0|00 
! Lllu.|C| .| UÇ| C. Çð.ð| ÇC| Q|ðU|C|IC UC cC|cC|·
I|ðclC|, ð| C|cC|I|ð|.C C| UðyC| cC|cC0I|ðc|C| C|
.ð|Q|C UðICl|ð. c. Cl UCcð|| .UC u.ðUC ÇC| lC. Qð·
.C. (Lz, LLz), ðQuð, y | ð UðyC||ð UC C|CcI|C||IC.. NC
cC|.uUC CxlQC|C.
z. L|lu.|C| IðclllIðUð. C. cð|ðcIC||.I|cC UC | ð Q| ucC.ð.
ªu|ÇuC hðy UlIC|C|c|ð UC Q|ðU|C|IC ¦lð cð|I|UðU UC
QlucC.ð C. UðyC| C| .ð|Q|C UðIC||ð ÇuC C| lð ICIð|),
|C. ð.CQu|ðUC. .u Çð.C ð| ICIC ÇC| UCU|C UC U|lu·
.|C| lðc| | |IðUð.
J. 1|ð|.ÇC|IC ðcI|vC. || C||C, ðU| |Cðc|UC. y v|IðUl|ð.
hl U|C.C|uClC.. c.Ið| ð UðyC| cC|cC|I|ðc|C| C| .ð|·
Q|C lCIð|, ÇC| C.C |CcC.|Ið| |uchð| cC|I|ð Q|ðU|C|IC
Çð|ð Çð.ð| ðl lCIC.
º.  |||CclIC.|.. UCl Ccul ð. UC Q|ð| IðUðÓC (| | ÇCÇ|C·
ICl|ð., lC.lCl|ÇlUC., ð|IlcuClÇC. lQL, UCIC|U||ðUC.
vl|u.).
a. bCluclC|C. UC cC|Il |ul UðU. lð Cxl.IC|c|ð UC ÇCÇuC·
Oð. |CIu|ð. Ç|ðcC|Ið||ð. ÇuCUC ÇC|UlI|| C| Çð.C UC cC·
|ulð. ||IðcIð. (|CUðI|C.).
c. |CcC.ð||C |CcC|Uð| ÇuC ð| Qu|ð. .u.Ið|c|ð. cCUC | ð | |
.u| | |ð C |CÇð|l |ð |C ÇuCUC| ðI|ðvC.ð| l ð ÇlðcC|Ið.
|U0O|00 8000O||0B
! . bO08OOl|Oµ|08 OO||Ó0|O8 HJR808 |hÛb]
c. | ð C|cð|QðUð UC Uð|IC|Cl C| cuC|ÇC | uICC.
1|C|C u|ð Iu|c|C| C|C|CQ|cð Çð|CClUð ð |ð LH bC UCICc·
Ið C| .ð|Q|C UðIC||ð I|ð. |ð | UÇ|ð|Iðc| C| bu. ||vC|C.
ðuUC|Ið| ð l C lðlQC UCl Ç|| UC| I|| UC.I|C, ðlcð|zð|UC
C| Uðx|UC ðl |CUCUC| UC lð ! Jª .CUð|ð |a0.000 UUl/U|),
Çð|ð U| .U| |ul | ÇC.IC||C|UC|IC |M|R 9b-99, 2 T 9).
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ÅCC|On hs|C|Og|Cð
¯ |u|clC| | u!CC!|Chcð >| | UuUð |ð Uð> |UµC|!ð|!C. Mð|·
!|C|C C| cuC|µC |u!CC | ð> µ|l UC|ð> >CUð|ð> |ð>!ð ÇuC | ð
µlðcC|!ð C> cðµðz UC >| |!C!lzð| µ|CQC>!C|C|ð (N| K 97·
9b|, 3b)
¯ c>!C|C|UCQC|C>|>. l|!C|vlC|C C| | ð >||!C>|> UC QC>!ðQC·
|C>, ð|U|CQC|C> (C>!lUulðclC| UC lð >Cc|CclC| UC !C>·
!C>!C|C|ð µC| Cl !C>!lcu|C lC!ð|, y UC L¬cªb µC| | ð >uµ|ð·
||C|ðl), ð>| cCUC c|C|!ð ðcclC| lbHl| <C ð ||vC| UC| Cvð||C
'C!ð|. 1ðUC|C| !lC|C u|ð ðcc|C| !l|C!|Cµ|cð .
|nIC|8s C|ln|CC
¯ L| ðQ|C>!|cC UC QC>!ðclC|. >C UC!Cc!ð C| >ð|Q|C Uð!C|·
|ð ð µð|!|| UC |ð l Uµ| ð|!ðclC|, y C| C|l|ð ð µð|!|| UC |ð b³
>CUð|ð UC ðUC|C||Cð ¦C> | ð >u>!ð|c|ð ÇuC UC!Cc!ð| C|
C|i|ð 'O: !C>!> UC QC>!ðc|C|). |uCUC| Cx|>!i| lð|>C> |CQð·
!|vC>.
¯ L|ðQ|C>!lcC UC µð!ClCQlð> CC>!C!||cð>. ||vC|C> ðuUC|·
!ðUC> µuCUC| C|l C|!ð| hðcl ð CUCð|ðzC UC|ð|, QCUClð|,
c|CUC>CUCµð!|ð> C !uUC|C> µ|CUuc!C|C> UC ¬LL. ||vC·
|C> Ul >Ui |u|UC> >uQlC|C| u| ðCC|!C. 1ðUC| C| >C u>ð C| Cl
U| ðQ|C>!|cC y cC|!|C| UC | ð QC>!ðc|C| Cc!Cµ|cð.
¿. L8OIÓgO0O µ|8OO0I80O |h|L]
Vð ð ð>CQulðl Cl >uU| ||>!|C UC QlucC>ð IC!ðl. bC UC!Cc!ð
C| >ð|Q|C C| |O:a·ó Ulð> µC>!|Uµ|ð|!ðc|C|, ðuUC|!ð|UC
µ|CQ|C>|vðUC|!C >u> |lvClC> ð l C lð|QC UC | ð QC>!ðclC|
(UC>C!ð ð l ð> J4·Jó >CUð|ð>), µuC> >C C|cuC|!|ð C| |Clð·
c|C| cC| |ð Uð>ð µlðcC|!ð|lð.
ÅCC|On hs|C|Og|Cð
¯ ª>CQu|ð| C| >uUl |l>!|C UC Ql ucC>ð. C>!| Uu| ð lð l l µC| | >|>,
y |O: ðclUC> Q|ð>C> IC|UðUC> Ul >Ul|uyC| | ð ðcc|C| UC
|ð l |>ul | |ð (>CC|C !CUC ð µð|!|| UC lð >CQu|Uð U|!ðU UC|
CUCð|ðzC).
¯ ||Cµð|ðc|C| UC lð Q| ð|Uul ð UðUð|| ð µð|ð lð |ðc!ð|c|ð. >u
| UµC|!ð|c| ð C> Uuy l|IC||C| ð l ð UC lð µ|Clðc!||ð.
|CÇuCOð ðcc|C| cCUC hC|UC|ð UC c|CclUlC|!C lC!ðl.
|nIC|8s C||n|CC
||ðc!|cðUC|!C |ulC, ð CxcCµc|C| UC >u |Clðc|C| cC| |ð
Uð>ð µ|ðcC|!ð||ð
J. hO|RO08S OSIO|O|OO8S
LC> µ|Ccu|>C|C> 'O: ðµC|!ð| | ð UðU|C C Cl IC!C, yð ÇuC |ð
µ|ðcC|!ð cð|CcC UC C>!C> µ|Ccu|>C|C>.
||CgCs!CrCnð. Lð µ|CQC>!C|C|ð >l|!C!|zðUð µC| C| cuC|
µC |u!CC Uð!C||C Uu|ð|!C | ð> `· ¹ 0 µ||UC|ð> >CUð|ð>
C> lu|UðUC|!ð| µð|ð C| cCU|C|zC UC | ð QC>!ðc|C|, y ð
µð|!|| UC lð ! 0· ¹ .ª >CUð|ð, |ð µ|CUucc|C| UC µ|CQC>·
!C|C|ð >C UCCC lu|UðUC|!ðl UC|!C ð lð µ|ðcC|!ð. c|
µ|| |cl µð| µ|Ccu|>C| UC l ð µ|CQC>!C|C|ð C> C| cC|C>!C|C|
Uð!C||C, y C>!ð >| |vC cCUC l UµC|!ð|!C µ|Ccu|>C| C| lð
C>!C|Ci UCQC|C>l > lC!ðl . ªu|ÇuC ||vC|C> ðUCcuðUC> UC
µ|CQC>!C|C|ð >C| |CcC>ð|lC> µð|ð C| C|C|C>!ð| IC!ð| , |C
C> u| CuC| Uð|cðUC| UC ClC|C>!ð|, yð ÇuC ð|!C C>!ðUC>
cCUC lð ð|C|cClðl | ð C lð UuC|!C lC!ð|, |C> ||vClC> UC µ|C·
QC>!C|C|ð µuCUC| µC|>l>!l| ðl!C> Uu|ð|!C >CUð|ð> (N| K
9ó-97|, T b0)
Ls!|OgCnCs. C>!|ðUlC| y C>!|C|ð. lC|UðUC> ð µð|!| | UC
L¬cª UC lð> >uµ|ð||C|ðlC> Uð!Cl|ð> y lC!ðlC>.
c>!||Cl. µð|ð >u C|C>l|!C>|>, C> |CcC>ð||C u0 µ|Ccu|>C| |90%
lC!ðl) ÇuC µC>!C|lC|UC|!C C> >u|lð!ðUC y ð|CUð!|zðUC C|
|ð µ|ðcC|!ð (N|K 04-0b, \ ó9). c>, µC| !ð|!C, |CcC>ðl|ð |ð
||!CQ|lUðU UCl |lQðUC y lð> >uµ|ð||C|ð|C> lC!ðlC> µð|ð >u
lC|UðclC| (N| K 9b-9ó, 223), UC ð|l >u u!| | | UðU cCUC Uð|·
cðUC| UC ClC|C>!ð| lC!ðl.
| nIerés cl lD|cO
CCnC yö >C |ö nCncCnöCC, C' C>!¯C' C> uD nCcöCC¯ CC
OlCDC>!ö¯ IC!öl . ¯ >nl nuyC Cn c|CnC>CnCpö!'ö> y C>!ö
öu>Cn!C Cn 'ö nC' ö cO n·
ÑcLUcÑÜP ÌDSuÌÍDð, h0µðfÍDð 0
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plC!ö.
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önp' C>, ¯!Cn>C> y Cu¯öCC¯C> (|ö>!ö >C> >Cnönö> pC>!pö¯·
!C) y cCD>guCn un önOlCn!C öCCcuöCC ö' CC>ö¯¯Cl|C CC 'ö
gC>!öcCn, >D cCnp¯CnC!C| 'ö >öl uC CC ' ö nujC¯ >öDö
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|D C' CnOö|öïC >C p¯CCucC uDö >CO¯Ccö¯gö cl|cu' ö!C¯ö
quC DC >uC'C ¯Cp¯C:CD!ö| Dlngun |lC>gC Cn unö nujC|
DC¯nö', pC¯C quC puCCC >upCnC¯ uD pC' g¯C CD cö>C CC
pöcC¯!C> cö¯CCpö!a>.
¯ VO| umen vascu|ar. C' vC' unCn !C!öl y Cl p' ö>nö!lcC c¯C·
cCD Cu¯ön!C lö gC>!acCD, ö' cöDïönCC vö'C|C> nöxlnC>
|öc ö 'ö zo·Jz >CnöDö> (4û% >upC¯ C¯ öl völC¯ p|CvlC ö'
CnOö|özC).
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(vö'C¯C> n'nnC> |öc|ö 'ö zo >Cnönö), y >C C' Cvö p¯Cg|C>·
vönCD!C Cn C' !CicC¯ !¯lnC>!¯C, >l!uönCC>C Cn ' C> DlvC'C>
nC¯nö'C> pö¯ö 'ö pCOlöcCD gCDC¯ö' ( ¹ 4û/ºû). Lö p|C>CD
vCDC>ö >C nön!CnC cCD>!ön!C, >ölvC CD Cx!¯Cn CöCC>
DIC¯C¯C> y pClvl>, CCnCC >C vC nc¯CnCn!öCö.
* Hes|sIenc|a Vascu|ar. Cl >n nuyC CCO CC ö ' ö öcclCD ¯Clö·
jön!C CC ' ö p¯CgC>!C¯CDö >CO¯C Cl nu>culC ' >C.
¯ TamanO de| cOrazÓn. ' ö pC>lclCn cö¯C'öcö >C vC öICc!öCö
pC¯ 'ö p¯Cg¯C>vö C'CvöcCn CC' C öI¯ögnö, ' C quC p|CCucC
uD CC>p'öïönCn!C |öclö CC' öD!C, uDö |C¯ïCn!öllïöcCn
y CC>vlöc|CD CC' CjC ö lö lïquC|Cö. ¯CCC C>!C CC>p' öïö C'
lö!CC CC lö puD!ö pC¯ IuC¯ö CC lö l'nCö nCC Cc' öv cu' ö¯ y
pC| Cncnö CC' 4º C>OöcC n!C¯cC>!ö'.
· Auscu|Iac|Ón. ö>l n >nC, öunCD!ö Cl !¯öOöjC cö|C'öcC,
>CO¯e !cCc a pa¯!¯ del >eguDCc !¯ ne>!¯e y Cu¯an!e e'
pö¯!C, 'C quC puCCC p¯CCuc¯ 'ö öpö¯cCn CC uD >Cp'C
>l>!C'|cC IuDcCnö' y un ¯CIuClïC CCl >CgunCC |uCC pu' ·
nCDö¯, C gö'CpC bJ. `CCCnC> cCD>lCC|ö¯ DC¯nö' C!¯ö>
>l!uöcCnC>, cCnC un CC>CCOlönlCD!C önp' C CC' p¯ nC¯
¯uCC, pC|C nC cCD>ldC¯önC> h>lC'CgcC uD >Cp'C Clö>!C
l cC ¦M|H 98-99|, ! 7S)
¯ cCG yr|ImO. |D Cl |CL CncCn!¯ö¯CnC> >lgDC> CC | pC¯
!¯C'ö, >CO¯Ccö¯gö, CC>vöcCn CC' CjC ö lö ïqulC|Cö y ö' gu·
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l0dµÍd0|00 û0TdÍ0|0g|0d
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vC'unCD p'ö>nö!cC öunCD!ö p|CpC¯clCDölnCn!C nö>
quC 'ö nö>ö CC |Cnö!'C>, pCl |C quC >C p¯CCucC unö
öDCn|ö ¯C'ö!vö h>C Cgcö ( ¬O ¹ ! g/C', H!C J4%) ¦M|H
9ô-97|, ! 82)
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¹ z.ûûû) quC >C öcCn!uö Cu¯ön!C Cl pö¯!C y C' puC¯pC¯C
nnCCö!C NC >uC' C | ¯ öcCnpönöCö CC CC>vöcCD ï·
quC¯Cö.
¯ COagu| ac| Ón öunCn!ön 'ö nöyC¯'ö CC 'C> Iöc!C¯C> CC
' ö cCögu' öcl CD, cCnC p' öquC!ö>, lC> !öc!C|C> ' , ' ' ',Vll, V' ' | ,
' X y X.
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vC'CcCöC CC >CClnCn!öc|Cn, öpölCcCD nc|CnCD!öCC>
l0dµÍd0|00 µd|T00d|
bC p¯CCucC un öunCn!C CC' cCn>unC CC CxlgCnC, ö>'
cCnC CC ' ö vCn! ' öc Cn pu' nCnö¯, ' C quC p¯CCucC unö
'CvC ö' cö' C> > ¯C>p¯ö!C¯ö |n cuön!C ö 'C> vC' unCnC> pu' ·
nCnö|C>, Cl >nl nuyC C' vC' unCD ¯C>lCuöl y öunCn!ön C'
vC' unCn cC¯¯CD!C y ' ö cöpöcCöC n>pilö!C|lö.
l0dµÍd0|00 00| dµd|dÍ0 d||0d||0
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¯önCn!C. bC p¯CCucC unö C 'ö!öcCn pC'vcCu¯C!C¯ö', nö>
n!Cn>ö Cn C' ' öCC CC¯Cc|C, quC Iöc ' !ö |ö c¯>> |CnCu¯C!C·
¯ö' >ln ' ! ö> > ¦M|H 9S·9ô|, 209). bC p¯CCucC ö>l nl >nC un
¯C!¯ö>C Cn ' ö C' niDöcCn u¯ nöll ö (Iöc l CöC pö¯ö 'ö nICc·
cCD) y uDö C >n nuc Cn CD lö Chcöcö CC' C>I'n!C¯ u¯C!¯öl
quC puCCCn p¯CvCca¯ unö cC|!a lncCn!nCDca.
* CamO|Os lunc|Ona|es. bC p¯CCucC un lDc¯CnCD!C CC'
I'ujC p' ö>nö!cC ¯CDö' (nCC öCC pC¯ C' H`c) y CCl h' !|öCC
g' CnC¯u' ö¯ CC |ö>!ö un 4û% ¦M| H 99-00, J\ ) ,  quC p|C·
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(cCD lö cCD>CcuCn!C Cl >nl DuclCn CC >u> nvC'C> p' ö>nö·
!cC>) ¦M| H 9ô·97, 248) |' öclCC u¯| cC C >n nuyC 'lgC¯ö·
nCn!C CD ' ö gC>!öclCn pC| öunCn!C CC >u Cxc¯CcCn .ö
g' ucC>ö >ö!u|ö C' >>!Cnö CC !¯öD>pC¯!C !uOu' ö¯ y puCCC
p¯C>CD!ö¯>C unö glucC>u¯lö ö' hnö' CC ' ö gC>!öcCn >D
quC Cxl>!ö |l pC¯g' ucCnl ö.
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C>!ön ¤l pClCn cö> C | pC|!¯Chcö> (>öDg|öCC> I¯CcuCn·
!C>) puC CnCC Cx>!l¯ Cpu' l > C öngl Cg¯önu' Cnö g ng vö' .
e> una Ic¯na Ce g Dgl v ! > | pe¯p' a> ca Ce' enOa¯öïC
quC >öDg¯ö Iöc 'nCD!C. AunquC ' ö | pC¯!¯Chö CC ' ö>
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cCD I¯CcuCnc ö Cl Cpu' l > ¯CqulC¯C >C¯ Cx! |pöCC qul ¯u¯·
gl cönCD!C ¦M|H 9ô-97, 240), l ö >ö' vöcCn C> nö> öOun·
Cön!C y nö> öc Cö. Lö p¯CgC>!C¯CDö p¯CCucC ¯ClöjöcCD
CC ' ö nu>cu' ö!u|ö ' >ö l n!C>! Dö' C >nl nuyC l ö nC! l CöC
n!C>!l Dö' , IövC|Ccl CDCC C' ¯Cl'ujC gö>!¯CC>CIögcC, p ¯C·
> >, C>!¯Cn nCD!C C |l pC!CD'ö vC> cu' ö¯ (löc ' CöC pö¯ö
' ö ' ! ö> >).
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nCC |Cpö!lcC, öunquC lC> cönOlC> IunCönCD!ölC> >C
p|CCucCn ö nvC' CC lö IuDc|Cn |Cpö!lcö. | nc¯CnCD!C CC
Ic>Ia!a>a a' ca' na |a!a 1 ,D·2vCcC> ' a cI¯a DC¯nal ¦M| H 00-
0T , T 4) , cC'C>!C|C' y !¯lg' cC¯ CC> (öunCn!C CC' cCclCn!C
|¯'¬¯c) y g' COu' l Dö>, C >n nucCD CC p|C!C'Dö> (ö' Ou·
n nö y gönnöglCOullDö>) y cC' nC>!C¯ö>ö. NC >C nCC h·
cön ' ö> !¯öD>önlDö>ö>
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yOEl CCDSU0C OE CX|QEDC.
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C|Ó| SE VE 0U|I| Q||CdOd).
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ldCIEd.
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00Dd|dZC |C QdIClÓQ|CC ES dI|| DU| D| E d| dU0E|IC OEl Id·
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CC|SECUEDIE dU0EDIC OE |d VdSCUld||ZdC|Ó|. bE Q|COUCE
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OESCE|SC D|USCC, Qd|d VClVE| d ||C|E0E|Id|SE CC| CdOd
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CE| l d DCC|CQE|ES|S.
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dU0E|IC OE ld dCIlVlOdO dl OCSIE|C|d |I|dS UD dU0E|IC
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ICIdl OE SCO| C. 1d0D|ED SE E|CUE|I|d E|EVdOd l d IESICS·
IE|C|d.
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Q|dV|O|CdS y ldS d!dOdS VdSCUld|ES. |S Í|ECUEDIE |d G|ÇE|Ç|Q·
0EDIdC|Ó| ED VU|Vd, ÇUD| S, C0D||QC, l||Ed dlDd y d|EC|dS.
Ld G|QE|Q|Q0E|IdC|ÓD ED Cd|d y CUEl|C Od |UQd| dl ClCdS0d
Q|dV|O|CC, OED|OC d ld ESI|0U|dClÓ| OE ld Nb| 0EOldOd QC|
ld Ç|CQESIE|C|d |S Í|ECUE|IE CDSE|Vd| ld |lÇE|QldS|d Ql d|·
OUl d| SCDdCCd 0d0d|| d |ÎUDE|CU|CS OE NC|IQC0E|y).
Aâpêcl0â Eâê1clä|êâ [ll)
Aparece |eucOc|!Os|s |eve, perO s|n desv|a-W
c|On |zqu|erda.
Lx|s!e una s|!uac|On de h|perCOagu|aO|||dadÕ
med|ada pOr e| aumen!O de |a mayOr|a de
|Os fac!Ores de cOagu|ac|On, !rOmOOc|!Os|s
y d|sm|nuc|On de |a ac!|v|dad ÞOr|nO||!|ca.
A n|ve| rena|, OOservamOs un aumen!O de| Õ
Þ|!radO g|Omeru|ar, |O que va a supOner
que urea y crea!|n|na es!én pOr deOa]O de
|O haO|!ua|. 1amO|én se va a prOduc|r una
re|a¡ac|On de| muscu|O ||sO, cOn |O que apa-
recerá una d| |a!ac|On de| s|s!ema excre!Or,
¡un!O a un re!rasO en |a e||m|nac|On ur|na-
r|a e |ncOn!|nenc|a de Or|na.
A n|ve| d|ge.!|vO, |a mOd|Þcac|On pr|nc|pa| M
va a ser | a d|sm|nuc|On de |a cOn!rac!|||dad
de| muscu|O ||sO, pOr |O que sOn frecuen!es
|a apar|c|On de es!reÔ|m|en!O, p|rOs|s, ref| u-
]O gas!rO|n!es!|na|, h| pO!On|a ves|cu|ar . . .
Además, puede aparecer unas enc|as h|-
per!rOÞcas e h|perém|cas [épu||s).
L| h|gadO va a d|sm|nu|r |a s|n!es|s de prO-Ñ
!e|nas !ranspOr!adOras y cO|| nes!erasa, cOn
un aumen!O de cO|es!erO|, !r|g||cér|dOs y
fOsfa!asa a|ca||na. Las !ransam|nasas nO se
mOd|Þcan pOr e| emOarazO.
M|R 04-05, \ ô9
M|R 01, \ 4
M| R 99-00, J \
P|ê]01läâ M|B
M|R 98-99, 2\9 Ñ
M|R 97-98|, J8
M|R 9ô-97|, ! 80
M|R 98-99|, \ 75 M|R 9ô-97|, 82
M| R 98-99|, \ 82 M|R 95-9ô, 22J
Uäâ0 U||1lc0 Bêp|êâê1lällr1
209. Una mu¡er ges!an!e, en su semana 2J, Î
presen!a dO|Or |umOar derechO pers|s!en-
!e, y en |a ecOgraf|a se OO¡e!|va ún|camen!e
d| |a!ac|On p|e|Oure!era| derecha mOdera-
da. NO !|ene ÞeOre y e| sed|men!O ur|nar|O
es nOrma|. La ac!|!ud a segu|r deOe ser..
T) Lfec!uar una urOgraf|a lv. de cOn!rO|
cada dOs semanas has!a e| par!O.
2) 1ra!ar cOn ana|gés|cOs y efec!uar
cOn!rO| ecOgráÞcO per|Od|cO.
J) Adm|n|s!rar an!|O|O!|cOs para ev|!ar
|a |nfecc|On.
4) |rOvOcar e| par!O para preven|r
cOmp||cac|Ones u|!er|Ores.
5) UesacOnse¡ar nuevOs emOaraZOs.
M|K \ 99b-\ 99ô| KL: 2
Ì\Jl|J°|1ä Û?i|J°|1äJl
0||ê1Iät|01M|B
M Es un  Iema  lundamenIa|  de  cara  al   exa-
men,  ya  que  Ie  ayudará  a  conIesIar  un 
gran número de  pregunIas. 
AäpêtIêäEäê1t|ä|êä[|)
M b| d|agnósI|co de gesIac|ón se puede hacer 
con HC. 5u deIecc|ón en sangre es e| dìag-
nósI|co más precoz, m|enIras que en orìna 
es el d|agnósI|co hab|Iua| de gesIac|ón. 5| 
queremos  un  d|agnósI|co de cerIeza,  será 
a Iravés de |a ecogral|a. 
Ö La ecogral|a  de|  pr|mer  Ir|mesIre  nos  per-
m|I|rá  d|agnosI|car  que  ex|sIe  embarazo, 
s|  es  ún|co  o  mú|I|ple,  s|  es  |nIrauIer|no  o 
exIrauIer|no  y  |a  v|Ia||dad  de|  embr|ón. 
Además,  nos  perm|Ie  deIerm|nar  |a_ edad 
gesIac|ona| med|anIe |a med|c|ón deI CHL
M Los  man ecográhcos  de  cromoso-
mopaI|as de|  pr|mer Ir|mesIre son. Irans|u-
cenc|a nuca| >3mm, h|groma qu|sI|co, a|Ie-
rac|ones del ñujo en e| conducIo venoso de 
Aranc|o,  ausenc|a  de  hueso  nasal  y  a|Iera-
c|ón de |a morfo|og|a de |a ves|cu|a v|Ie||na. 
@ La  ecograf|a  de|  segundo  Ir|mesIre  nos 
serv|rá  para  eva|uar  e|  crec|m|enIo  leIa|  y 
|a morfo|og|a feIa|. Es |a ecogral|a de| d|ag-
nósI|co prenaIa|. 
M L ecograf|a  de|  Iercer Ir|mesIre  nos  per·
m|I|rá d|agnosI|car s| ex|sIe  un  crec|m|enIo 
|nIrauIer|no reIardado y eva|uar |a p|acenIa 
y el  liqu|do amn|óI|co. 5| ex|sIe un deca|aje 
en Iodos |os parámeIros kIa|es (DL|, ab-
domen), esIaremos anIe un C|H I|po |,pro-
duc|do mæpcmopaI|as o 
|nkcc|ones æ|Ias (TORCH}. 5| e| d
|aje só|o aa| ab kta|, m|enIras 
que  D6P y L|  son acordes a  |a amenorrea, 
Iendremos  un  C|H I|po  || que esIá  produ·
c|do  por una  a|Ierac|ón  p|acenIar|a,  por  |o 
que rea||zaremos una BuxomeIrm dopp|er. 
¿¿. 1 Û|8§008l|00 00 §08l80|00
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Clö CC önCnC¯¯Cö C' p¯ nC| C'ö CC >öng¯öCC nCn>I¯uö'
CC lö ul ! nö ¯Cglö.
Ün CnOö¯öïC Cu|ö öp¯CxlnöCönCnIC zo0 C'ö> (40 >Cnö-
nö>), öunquC lC cCn>lCC¯önC> ö IC¯nnC ö pö¯! ¯ CC 'ö>
J7 >Cnönö>.
¯ UeIecc|Ón de HCG. C' !C>! CC CnOö¯öïC I¯öClc|Cnö' CC·
!CcIö nC' Ccu' ö> CC ¬CL Cn C¯l nö cö CC!CccCn Cn >öng¯C
C> Cl nC!CCC nð> p¯CcCï ¦ M| H 99-00, J7). 
* Lcograf|a 1ransvag| na| .  nC> pC¯n!C |öcC¯ un C ögnC>-
!cC CC CnOö|öïC CC cC|!Cïö y p¯CcCï ¦M| H 98-99|, \77)  . 
|> C' nCICCC p|CcCï nð> p|Cc>C.
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y ! z, ' ö >CgunCö CC ' ö ¹ o ö 'ö zû, y 'ö !C¯cC¯ö CC ' ö J4 ö l ö>
Jô >Cnönö>.
Lcograf|a  de|  pr|mer Ir|mesIre  (8-l 2 semanas).  p¯C!Cn·
CC cunp' ¯ lC> >l guCn!C> COjC!lvC>.
¯ CCnh|nöc Cn CC quC >C !|ö!ö CC unö gC>!öclCn nI¯öu!C
¯C (pC¯ Iön!C, CC>cö¯Iö¯ unö gC>!öcCn Cc!Cplcö)
¯ ¯CIC¯n nöc Cn CC lö CCöC gC>IöclCnö' cCn ' ö nðx| nö
p¯Cc > Cn. cö nCCcCn CC' CHc (' Cng !uC c¯önCC ¯öqu CCö
C c¯önCCcöuCöl) C> C' pö¯ðnC!¯C nð> höO' C pö¯ö Cö!ö¯ ' ö
CCöC gC>!öc Cnö' (öO!C unö C >cC¯Cönclö CC' ! CnpC CC
gC>!öc Cn Cn!¯C ' ö ICc|ö CC ' ö u'! nö ¯Cg' ö y lö CcCg|öI'ö
CCl p¯ nC¯ !¯ nC>!¯C, cCn>lCC¯önC> cC¯¯CcIC C' ICnpC CC
önCnC|lCö >Cgun 'ö CcCg¯öI'ö) ¦M| H 00·0\ |, \79)  
¯ Vi!öllCöC CCl CnO¯ Cn. C' löICC cö|C'öcC puCCC CC!Cc
!ö¯>C ö pö|Il| CC lö /ª >Cnönö cCn lö >CnCö öOCCn nö' , y
CC ' ö ôª cCn lö vög nö' .
¯ ¯CICc!ö¯ gC>!öc|CnC> nu'! p' C> y gC>!öcCn nC' ö|.
¯ Vö'C|önC> lö nC¯IC'Cg'ö CC' u!C¯C y 'C> önCjC>.
* LC!CccCn CC nö¯cöCC¯C> CC c¯CnC>Cpö!lö ¦M| H 05·
0ô, \ô5). 
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· ¬l g|Cnö qu'>!cC, cö|öcIC¯l>IcC CCl >'nC¯CnC CC
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· A|!C¯öclCnC> CCl ñujC >öngulnCC Cn C' Cuc!u> vCnC·
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cuCn!C Cn C' >lnC¯CnC CC ¯Cwn).
· MC¯IC'Cg'ö ö'!C¯öCö CC 'ö vC>'cu' ö vl!C' nö.
Lcograf|a  del  segunCo Ir|mesIre  ( l 8-20  semanas)   pC¯
Cl IönönC IC!ö' y pC¯ ' ö öOunCönc ö CC l 'qul CC önnCIcC,
>C cCn>CC¯ö Cl nCjC¯ nCnCn!C pö¯ö |öcC¯ un C ögnC>·
IlcC nC|IC'CglcC.
¯ CCnh|nöc Cn CC vlCö ICIö' y CC CnOö¯öïC uncCjul ·
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Lb` (C ðnCI¯C O pö|lC!ö'), ' Cng !uC ICnC|öl y Cl ðnC!¯C>
öOCCn nö' C> (!¯ön>vC¯>C, | Cng !uC nö| y c¯cunIC¯Cnc|ö
öOCCn nö' ).
¯ AnöICnlö IC!ö' y CögnC>IlcC CC nölIC¯nöclCnC>. l ö>
nö'IC¯nöcCnC> quC nð> >C Cl ögnC>Icön >Cn ' ö> CCl
bNC, |CnölC>, |C>pl|ö!C|ö> y C gC>!lvö>, >l CnCC lö> CC nð>
C|I'cl ' Cl ögnC>IcC l ö> cö¯Clöcö> ¦M| H 98-99|,  \84)  y lö>
nölIC|nöclCnC> Iöc ö' C>.
* AnCjC> Cvulö|C>. pö!ClCg'ö CC' cC|CCn, CC ' ö plöcCn!ö y
CCl vClunCn CC llqulCC önnlC!cC.
Lcogral|a  de|  Iercer  IrìmesIre  (J2·Jô  semanas). Vö'C¯ö
lö> öl!C¯öcCnC> CC' c¯Cc nl CnIC IC!öl . |l |C!|ö>C CC' c¯Cc·
nlCnIC quC öpö|CcC Cn l ö> u' Il nö> >Cnönö> CCl CnOö|ö·
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Ö b| UOpp|C| ÞOS pC|m|!C COÞOCC| C| CS!ðUO
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|Cð||Zð|OÞOuÞðp|uCDð|ÞvðS|vð.
Ö b| SC|CCCÞ|Þg D|Oqu|m|COSC puCUC |Cð||Zð|
CÞ C| p||mC| !||mCS!|C, UC!C|m|ÞðÞUO HLG
|pð!O|0g|CðS|ðumCÞ!ðUð)y|A||·A(pð!O|0·
g|CðS|U|Sm|Þu|Uð)OCÞC|SCguÞUO!||mCS!|C,
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Ö b| SC|%Þ|Þg ðCOÞSCjðUO CÞ |ð ðC!uð||UðU
COÞS|S!CCÞ|ðCOmD|ÞðC|0ÞUCCUðUmð!C|Þð,
mð|CðUO|CSD|Oqu|m|COSUC|p|ÌmC|!|ÌmCS!|C
y|ð mCU|C|0Þ UC |ð !|ðÞS|uCCÞC|ð ÞuCð| p|
SC||ðCOmD|ÞðC|0ÞCOÞ >SCÞS|D||UðU.
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SC puCUC |Cð||Zð| mCU|ðÞ!C D|OpS|ð CO·
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C|Cg||ð ÍuÞUðmCÞ!ð|mCÞ!C CÞ ÍuÞC|0Þ UC
|ð CUðU gCS!ðC|OÞð| y C| ||CSgO UC ðDO|!O
ðSOC|ðUO.Lð !éCÞ|CðmðSu!|||ZðUðCS|ð ðm·
Þ|OCCÞ!CS|S, pO| SC||ðmðSSCgu|ðUC!OUðS
C||ðS. Lð ÍuÞ|Cu|OCCÞ!CS|S SC |CSC|vð pð|ð
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pö|ö Cl u>C CC nCICI|Cxö!C. AnöC| nC> öc|CC IC''n|cC pö|ö
p¯CvCn| ¯ 'ö !CxiciCöC. L' >Cgu| niCn!C !önO|Cn >C ¤ö¯ö cCn
CC!C¯niDöciCDC> >C¯|öCö> CC þ·HCC y CcCg¯öI'ö.
J. 1¯ö!öniCn!C Çui |ú¯g|cC. bC |Cöl|zö¯ö p¯CIC|Cn!CnCD!C
nCC|öD!C löpö|C>cCpiö, öuDÇuC CCpCDCC|ö CC lö pöciCn!C,
CC >u> CC>CC> gCDC>icC> y CC lö 'CcölizöciÓn CCl CnOö¯özC
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Eäê1t|ä|êä[||)
I|  tratam|entO  de|  abOrtO  precOz  cOns|ste 
en  |a  rea||zac|On  de  un |egradO bajO anes-
tes|a  tras  d| |atac|On  cerv|ca|.  Ln  |Os  casOs 
de  abOrtOs  tard|Os,  se  prehere |a  adm|n|s-
trac|On  de  prOstagIand|nas  que  abren  e| 
cérv|x y pOster|Ormente rea||zar e| |egradO. 
La amenaza de  abOrtO  se trata cOn  repOsO 
re|at|vO y abst|nenc|a  de  re|ac|Ones  sexua-
|es. 
SOn  IactOres  de  r|esgO  de  embarazO  ec-
tOp|cO.  antecedentes  de  ectOp|cO,  c|rugia 
tubõr|ca  prev|a,  enlermedad  |nImmatOr|a 
pé|v|ca, ester|||dad y técn|cas de reprOduc-
c|On as|st|da, U|U y endOmetr|Os|s. 
La  |Oca||zac|On  mõs lrecuente es |a pOrc|On 
ampu|ar de |a trOmpa. La  c||n|ca caracter|s-
tica  es  |a  apar|c|On  de  metrOrrag|a  escasa 
asOc|ada a dO|Or abdOm|na|. 
L|  d|agnOst|cO  se  rea||za  Iundamenta|men·
te  med|ante  ecOgraI|a,  a|  v|sua||zar  una 
cav|dad uter|na vacia y una |magen anex|a| 
sugest|va/d|agnOst|ca  de  gestac|On.  Ln 
casO  de  duda,  nOs  pOdemOs  ayudar  cOn 
|a  determ|nac|On  de  HCG.  Ln e|  embarazO 
ectOp|cO  presentarõ  n|ve|es  mõs  ba]Os,  y 
ademõs  aumentarõ  mõs  |entamente  que 
en e| embarazO nOrma|. 
L| tratamientO de|  embarazO ectOp|cO  pO·
drõ  ser cOnservadOr  cuandO  sea  pequeñO 
| 4cm),  tenga  va|Ores  ba¡Os  de  nCG y  nO 
haya  sangre  ||bre  en  |a  cav|dad  abdOm|-
na|. CuandO  nO  cump|a  estOs  requ|s|tOs  O 
cuandO haya IracasadO e| tratam|entO cOn 
metOtrexate,  |nd|caremOs  e|  tratam|entO 
qu|rurg|cO.  L |aparOtOmia  urgente  se  re-
serva para |as pac|entes que  ||egan cOn un 
abdOmen  agudO  e  |nestab|||dad  hemOd|·
nõm|ca. 
|igua O 1|dÍdm|60Í006|d60Í6|m60d0Í|0Í00|d5Í|0d(MÌhUö·U4, ÜO M|h Üb·Ü1,¿41|
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cCn a>pl|aclCD CC' cCDICDlCC Cvu' a|.
|¤ lC> ca>C> Cn 'C> quC ' a I|Cnpa C>IC nuy CanaCa, |aya
gC>IaclCD CcICplca |Ccu||CnIC C 'C> CC>CC> gCDC>'cC>
0>ICD cunpllCC>, >C CxI'|pa ' a I|Cnpa aICcIaCa. >al pl D·
guCcICn|a ICIa' .
b' |ay lDC>IaO' ' l CaC |CnCC' Dan' ca, p|acIlca|CnC> uDa
'apa|CICn|a u|gCDIC.
ÎJ.J Î0Í0|M0080 Î|0Í00|88Î|08
|' IC|nlDC CnIC|nCCaC I|CICOla>I'ca CnglCOa uDa >C|lC
dC paIC'Cg|a> Cn ' a> quC |ay uDa p|Cl'IC|aclCD aDC|na'
|C'ac'CnaCa cCn la gC>Iac' Cn. HCnC> v' >IC cCnC C' I|CIC·
0'a>IC 'DvaCC C' CnCCnCI|'C CD Ou>ca CC CxlgCDC. CuaD·
dC 'a vCllC>'CaC I|CICOla>Ilca CDcuCDI|a una zCna |'ca Cn
OxlgCnC, CCI'CDC >u c|Cc'nlCDIC
LuaDCC una 2CDa CC I|CICO' a>IC nC I'CDC nC>CCC|nC
ICIal quC p|CCuzca va>C> >angu|DCC>, nC |ay OuCDa
I|an>nl>'CD CC Cx|gCDC y la ICDCCDcla a ' a p|C' ' IC|aclCD
µC|naDCcC. CDIC|nCCaC I|CICO' a>Ilca.
ca au>Cnc'a CC va>C> lìDIaIlcC> pC|n' IC quC >C acunu·
'C ' | qui CC CxI|acCl ul a|, pC| ' C quC Cl ICj l CC aCCpIa uDa
d' >pC>l cl Cn qul>Il ca. lC| IaDIC, ' a CnIC|nCCaC I|CIC·
0' a>I' ca C> qul>Ilca y ava>cul a|. |D C>Ia CDIC|nCCaC >C
0Dg' COan l a> nC' a> cCnp' CIa> ,ICCC C> nCl a, DC |ay
0nO|' Cn) y nC' a> ' DcCnplCIa> ,zCDa CC placCDIa >aDa
y CnO|' CD).
cµ|O0R|O|O]|8
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¹ /! .500 CnOa|a2C>. La mayCl|a |Cg|C>a C>pCDIaDCanCD·
IC ,B0%). |' ¹ 5% CvCluclCDa a CDIC|nCCaC I|CICO'a>I'ca
µC|>'>ICDIC ,|¯|) DC nCIa>Ia>'ca y C' '% a |¯| nCIa>·
Ia>'ca. La nCla 'Dva>C|a ,CDIC|nCCaC I|CICOla>I'ca cCD
Capac'CaC CC I|a>pa>a| C' CDCCnCI|lC) Ccu||C ap|Cxlna·
danCDIC Cn ! /! 5.000 CnOa|a2C>.
la nlIaC CC lCs cC|'Cca|clDCna> ,CnIC|nCCaC I|CICO' a>·
I'ca 'DC'IC|Cnc'aCa, cCD capacl CaC CC I|a>pa>a| C' CDCC·
nCI|lC y >'n ICnCCnc|a a IC|na| vCllC>lCaCC>J p|CvlCDCn
CC uDa nCla, C' z'% CC aOC|IC>, y C' zû% CC uD CnOa|a
zC nC|nal. MCIa>IaI'za pC| v|a >aDgu|DCa.
cI|Oµ8IO]00|8
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nC> gCnCIlca> CO la placCnIa, OajC nlvC' >Cc'CCcCDCn'cC,
cCD>angu' n' CaC, CIc `a|CcC CC>a||C''a|>C un |uCvC a
pa|Il| CC z C>pC|naICzC'CC>, >'n pa|I'c'pac'CD gCnCI'ca
CC' Cvu'C. ' a nC|a cCnp'CIa >C|la 4ô, XX, pC|ICnCc'CnCC
anOC> c|CnC>Cna> X a' paC|C.
bO08OOI|Oµ|08 OO||Ó0|O8
ca p|CCucc'CD CC ¬CC C> nuc|C nayC| quC CD una gC>·
!ac'Cn DC|na' CCO'CC al CC>a||C' ' C I|CICO' a>!'cC CxcC>'vC,
' nc' u>C llCganCC a' nl ' 'CD CC un' CaCC>.
bu CICcIC |b¬·ll|C ,|CcuC|Ca quC ¬CC, |b¬, c¬ y ¯bH I'C·
DCn una >uOun' CaC a'Ia cCnun) C>I' nu' a C' c|Cc' n' CnIC
CC a' gunC> IC' |culC> Cva|'cC>, quC >C ' uIC' n'zan pC| C'
CICcIC c¬·' ' <C.
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>C>. NC |CqulC|Cn I|aIan'CnIC, ya quC |Cg|C>an C>pCnIa·
nCanCDIC a' >C| CvacuaCa la nC'a. bCn p|CCucIC|C> CC
p|CgC>IC|CDa.
AcIlvlCaC C>Ilnu' anIC CCl I'|C'CC>. Hay uD aunCDIC Cn
la acIl v' CaC CCl I' |ClCC> CD al guDa> paclCDIC> cCn CnIC|·
nCCaC I|CICO' a>I'ca CxICn>a. Un 5% CC la> pac'CnIC> cCn
|! nCIa>Ia>lca paCCcCn Il|CICxlcC>l>. |>IC >C CCOC a la
acclCn 1bH·llkC.
|>I|CgCDC> |' CSI|'C', quC |Cqu'C|C ' a pa|I'c'pac'Cn ICIa'
C>Ia nuy C' >n' Ou' CC ,C' C>I|aC'C' puCCC C>Ia| a' gC au·
nCDIaCC pC| ' C> qul >IC> ICcaluIClDlcC>).
`|CgC>IC|CDa >C|'ca. AunCDIa la p|CgC>IC|Cna >'gDlhca·
I'vanCDIC, CCO' CC IanIC al I|CICOla>IC cCnC a 'Cs qul >IC>
ICca'uIClD|cC>.
||CCc' anp>'a. Òcu||C CD Cl I '% CC ' a> paclCnIC> cCD nC' a.
|> uDa CC la> pCca> cl|cuD>IaDc'a>, ,junIC a ' a> gC>IaclCDC>
nu'IlplC>, C |'C|Cp> ICIa' pC| ' >C' nnuD'zac|CD H|) Cn la>
quC C>Ia cCnp''cac'Cn Ccu||C anIC> CC ' a >Cnana z0
MpMk Eäê1tlä|êä [|||}
La e-f8medad trOfOb|ást|ca es |a causaM
más rara de hemOrrag|as de| pr|mer tr|-
mestre.La c||nica es|apresenc|ademetrO-
rrag|a,uterOmayOrqueamenOrreay,sObre
tOdO, mucha s|ntOmatO|Og|a t|p|ca de em-
barazO (náuseas yvóm|tOs). Ln OcasiOnes
pueden aparecer h|pertens|ón precOz y
s|ntOmasdehipert|rOid|smO.
L| d|agnóst|cO de sOspecha se rea||za me·M
diante eegraf|a, cOn |a v|sua||zac|ón de
unacavidaduter|naOcupadapOruna|ma-
gen mu|t|ves|cu|ar (imagen en nevada),
aunque |a cOnhrmación será anatOmOpa-
tO|óg|ca, tras |a rea||zac|ón de un |egradO
pOrasp|rac|ón.
Sedebe rea||zarunsegu|m|entO pOst|egra-M
dO med|ante |a determ|nac|ón semana| de
HCG. CuandO tres va|Ores sOn negativOs,
pasamOsarea||zarcOntrO|es mensua|es.Sin
embargO, s| nO se negat|v|za, nOs ind|cará
que s|gue ex|st|endO enfermedad y debe-
remOs buscar|a. Lne| estud|O de extens|ón
rea||zaremOs una R de tórax, 1AC abdO-
m|na| y1AC cerebra|.Si tOdO e| estud|Oes
negativO, estaremOs ante una enkrmedad
trOfOb|ást|ca pers|sIente que trataremOs
cOnmetOtrexateyun segundO |egradO.
La enfermedad metastás|ca se trata só|OË
cOnqu| m|Oterap|a.L|tipOdequ| miOtera-
p|a | Odeterm|narán |OsfactOresprOnós-
t|cOs (HCG>1 00.000, >4 meses, metás-
tas|s cerebra|es O hepát|cas, fracasO de
qu|m|Oterap|a prev|a y edad >40 añOs).
S| t|ene buen prOnósticO, ut|||zaremOs e|
metOtrexate cOmO un|cO qu| m|Oterápi-
cO,m|entrasques|t|ene ma| prOnóst|cO,
ap| |caremOsprOtOcO|OsdepO||qu|miOte·
rapia.
P|ê¿ä1IääM|B
Ö M|R 0ô-07,  \ 78 
M|R 05-0ô, \ ô5 
M|R 0J-04, 9
M|R 0J-04, T 0T 
M|R 02-0J, 2ô0 
M|R 0\ -02, \ ô2 
M|R 00-0\ |, \ 78 
M|R 00·0T |, l 79
M| R 00-0\ |, \ 97 
M|R 99¬ |, \ 82 
M|R 99-00, J4 
M|R  9+,J7 
M| R 9ô-97, 245 
M|R 95-9ô|, 2\ 4 
M| R 95-9ô, 222 

OääêO||1|têBêp|êäê1IäI|¢ê[|)
M T ó.  Pr|m|gesIa  de  J2  añOs  que  acude  a 
urgenc|as  rehr|endO  sangradO  gen|Ia|  y 
prueba de embarazO en larmac|a pOs|I|va. 
Se  rea||za  exp|Orac|On  g|necO|Og|ca,  y  |Os 
ha||azgOs  ecOgráhcOs  y  ana||I|cOs  sug|e-
ren e| d|agnOsI|cO de mO|a ves|cu|ar. ¿Cuá| 
ser|a e| IraIam|enIO de e|ecc|On!. 
l) Qu|m|OIerap|a cOn MeIOIrexaIO. 
2)  LegradO  uIer|nO cOn  |egra  de  Re-
cam|er y p|nza W|nIer. 
J)  LegradO pOr asp|rac|On. 
4) H|sIerecIOmia s|mp|e (cOnservadO 
Ovar|Os). 
5) H|sIerecIOm|a rad|ca|. 
M|R 200-207 RC. J 
2J7. Una mujer en su cuarIO mes de emba-
razO cOm|enza a sangrar, y e| méd|cO |e de-
IecIa un uIerO más grande que e| espradO 
para su egesIac|Ona|. Dec|de |nIerrum-
p|r e| embarazO, y |e prac|ca
·
un |gradO. L| 
paIO|OgO,  a| exam|nar |a  muesIra, Observa 
numerOsOs qu|sIes avascu|ares cOn prO||fe-
rac|On  s|gnmI|va  de|  IrOlOb|asIO,  nO  hay 
kIO y nO  se  deIecIa  |nvas|On  de|  ¬Ome·
Ir|O. ¿Cuá|  será e| d|agnOsI|cO!. 
\) MO|a |nvas|va. 
2) MO|a h|daI|fOrme parc|a|. 
J) MO|a h|daI|krme cOmp|eIa. 
4)T  umOr IrOlOb|ásI|cO de| |echO 
p|acenIar|O. 
5) COr|Oarc|nOma. 
M|R 202-20J RC. J 
Y0ld 0|0dÍ|l0|T0
¬öy, cCnC |CnC> v>!C, unö p¯C'IC¯öcÓn CxcC>vö CC'
!¯ClCO' ö>!C, |un!C cCn CCCnö CC ' ö> vC' ' C>CöCC>.
¯ CCmp' C!ö. nC Cx>!C nö!C¯ö' gCnC!lcC nö!C¯DC. |' cö·
¯C!pC C> 4ô //, >CnCC önOC> c¯CnC>Cnö> / CC' pö·
C¯C. NC |öy ICIC y nC >C CCICc!ö nvö>Ón CC' CnCCnC!¯C
( M| R 02·03, 237) . |' ! û% puCCC CvC' uc Cnö¯ ö nvö>C¯ö y
C' J% nC!ö>!ö!zö.
* `ö|c ö' . |x>!C un CnO¯ Ón y nCzc'ö CC vC' ' C> CöCC> nC¯·
nöl C> cCn C!|ö> quC p¯C>CO!ön CCgCnC¯öcÓn h|C|Óplcö.
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gCnC!lcC> nö!C¯nC> `uCCC cCnvC|!l¯>C Cn nC'ö l Dvö>C¯ö,
y CxcCpc Cnö' nCn!C Cn cC¯lCcö¯cnCnö.
b|g008 ]8l0Í0Td8
ln C' cu|>C CC un CnOö|ö7C cCn uIC|C CC !önönC nöyC¯
quC C' cC¯¯C>pCDCCnIC ö' !CnpC CC önCDC¯¯Cö, öpö¯CcC
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Cxpu' > Ón C>pCn!önCö CC vC>'cu' ö> >CnCjön!C> ö uvö>
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' C> mönIC>IöcCnC> cCnC. |lpC¯CnC>>, p¯CCc' önp> ö,
| pC¯! ¯C C.>nC C CnOC' . >nC pu' nCnö¯.
Û|dg008Í|00
¯ |cCg¯öI'ö. |> 'ö !Ccncö CögnÓ>!cö CC C' Ccc Ón. 'C öp¯C·
c ö uOö nögCn cö|öc!C¯'>!cö Cn cCpC> CC nlCvC quC cC·
¯¯C>pCnCC ö lö> vC>'cu' ö> | C¯Ópcö>. NC >C vC >öcC gC>·
IöclCOö' nl p¯C>Cncö CC IClC, pC¯C lö> nagCnC> nC >Cn
C>pCc'ícö>, yö quC puCCCn öpö¯CcC| nögCnC> > nl | ö¯C>
Cn n| Cnö> cCl ncCCn!C> cCO gC>!öcÓn !Cnp¯önö.
¯ |' C| ögnÓ>!cC CC cC¯!Czö nC> 'C Cö lö önö!Cn'ö pöIC'Ó·
gcö !¯ö> C' 'Cg¯öCC.
!|dÍdT| 00Í0
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y >Cgu n CnIC pC>!C¯C¯ CC lö Cn!C¯nCCöC. c|!¯ö!ön Cn·
!C CvöcuöCC¯ CC C'Ccc·Ón C> 'Cg¯öCC pC¯ ö>p| ¯öcÓn
¦M|R 0ô-07, l ôô)
|n nujC¯C> cCn nöyC¯ |C>gC CC CCgCnC¯öcÓn nö' g¯ö.
C' CvöCö pö¯ CöC C Cn öquC' ' ö> cCn CC>CC> gCnC>cC>
cunpllCC> y nö> CC 40 öÙC>, p|öc!cö¯CnC> | >!C¯Cc!C·
n'ö !C!öl cCD nClö l D > Iu. NÒ C>!ö nC cöCö ' ö qu. nC!C
|öp ö Cn C>Iö C!öpö.
ÜU|80 0||0|00
|n Cl oû% CC 'C> cö>C>, ' ö CnIC|nCCöC |Cg¯C>ö CC>puC>
CC |öOC¯ CvöcuöCC Cl u!C¯C. cC> nvC' C> CC llCC CC>cCn·
CCn ¯öpl CönCD!C
CuöDCC C>IC> nlvClC> nC CC>clCnCCD C pC|nönCcCn C' C
vöCC> ö ' ö> o >CnöDö>, >C |öC' ö CC CnIC¯nCCöC pC¯>>·
!Cn!C
b0gd|T|00Í0
! . LC!C¯nl DöclCDC> >CnöDö' Cs CC HCC |ö>!ö 'ö ¯Cn > Ón
cCnp' C!ö (cC>C CC lö |CnC||ög ö, u!C¯C nvC' ucCnöCC,
önCjC> DC¯nö'C> y DlvClC> nC¯nö' C> CC HCC Cu¯ön!C J
>Cnönö>) (M| R 03-04, 95; M| R 9ô·97, 247).
z ¯C>puC> CC ' ö |Cnl> Ón cCnpl C!ö, >C |ö¯ön CC!C¯n
nöc CnC> CC ¬CC nCD>uöl nCO!C Cu¯öD!C ô nC>C>, y O
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pul nCn (75%) y CC>puC> vög| nö (5û%), cC|CO|C C |göCC.
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un öOC|!C C un CnOö|öZC Cc!CpicC
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c| CnC> CC' ! ûû%. |> nCnC> !Cx|cC ÇuC ' ö cCnO| nöCö.
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SemðnðS, ðS|ntomðt|Cð, S|n ev|denC|ð, me·
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unð C|Þð de250  mU/mL AnteeStoSdðtoS,
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2) ÔeStðC|ón no|mðÌ Con meno|t|em-
podeevo|uC|ónde|Co||eSpond|enteð
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ðS|ntomðtICð.
4) AOo|top|eCoZCompÌeto, ConeXpu|·
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||noS.
b) LmOð|ðZomoÌð|de|n|C|o,S|nS|gnoS
eCog|ðÞCoS|nt|ðute||noS.
M|K \999-2000  KL.J 
\ 75.  Unð pðC|ente, Con ðnteCedente de
ðOo|to tð|d|o ðnte||o|, |ng|eSð ð |ð \8²  Se-
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muCoSð.
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M|K \ 998-1 999 KL:2 
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Jû% CC ' a> gC>Iac|CnC> gCnC'a|C>, >|CnCC nö> I|CcuCn!C
CnI|C gCnC'C> nCnCc|gC!C> Una CC ' a> cau>a> Ç|| nc|
¡

' C> C> C' >nC|CnC CC !|an>Iu>|Cn gCnC'C a gCnClC bC Ca
ca>| Cxc'u>|vanCn!C Cn gCnC'C> nCnCcC||a'C> |M|R  02·
0J,  2J8),  y C> nCcC>a||C ÇuC >C CC>a||Cl'Cn ana>!CnC>|>
va>cu' a|C> Cn!|C anOC> ICIC>, IunCanCn!a'nCn!C a|!C||C·
vCnC>a> (MlR  00-0\ , \ ôJ),  CanCC 'uga| a un IC!C !|an>Iu·
>C| y a un IC!C !|an>IunC|CC. |' IC!C !|an>IunC|CC ÇuCCC
llCga| a un C>!aCC CC ÇC'|c|!Cn|a !a' ÇuC CC>CncaCCnC
una | n>u¯c|Cnc|a ca|Caca CC a'!C ga>!C, y ÇuC CC>a||C' ' C
una C|IC|Cnc|a CC ÇC>C a >u IavC| cCn C' C!|C gCnC' C CC
mö> CC' zû%, a> cCnC ÇC' | || C¯ann|C>. A >u vCz, C' IC!C
!|an>Iu>C| CC>a||C''a|ö anCn|a, C' H y C'|gCann|C>. CuanCC
bl00|l8l Ul800|0!l08  Y00000|l8l Ul8m0|0!l08  Y00000|l8|  m0008m0l0!l08 
b06Î80Ì0ß M0ÌÎÌþÌ8
U||ê1Iät|01M|B
Ls un tCmð poCo |mpo|tðntC. Lstud|ð, so· Æ
b|C todo, C| ðpð|tðdo dC |ð V|ð dC| pð|to CD
C| Cmbð|ðZo gCmC|ð|.
kâpêtI0âEâê1t|ä|êâ
L| Cmbð|ðZo mu|t|p|C Cs un Cmbð|ðZo dC Õ
ð|to ||Csgo po| C| ||Csgo dC ðpð||C|ón dC
mðyo| numC|o dC Comp||CðC|oDCs. Fo·
dCmos CnCont|ð| mðyo| Í|CCuCnC|ð dC
ðbo|tos, mð|Ío|mðC|onCs, Þ|pC|CmCs|s
g|ðv|d|Cð, Þ|pC|tCns|ón ðttC||ð|, |otu|ð p|C·
mðtu|ð dC mCmb|ðnðs, ðmCDðZð dC pð|to
p|Cte|m|Do, pðto|ogíð dC| Co|dón, ðb|upt|o
p|ðCCDtðC.
Unð Comp||CðC|ón CspCC|BCð Cs C| C|CC|· Ñ
m|CDto d|sCo|dðntC dC ðmbos gCmC|os,
p|odu6|do Cn muCÞos Cðsos po| C| slndto·
mC dC t|ðnsÍus|óD ÍCtoÍCtð|. Lstð ptovoCðdo
po| |ð p|CsCnC|ð dC ðnðstomos|s VðsCu|ð|Cs
Cnt|C ðmbos ÍCtos, Cn |os Cðsos CD |os quC
CX|stC unð p|ðCCntð moDoCo||ð|. Ûð |ugð| ð
un ÍCto t|ðnsÍuso| (ðnCm|ð, L|K y o||goðm·
D|os) y ð un ÍCto t|ðnsÍund|do (po||C|tCm|ð,
|DsuhC|CnC|ð Cð|d|ðCð dC ð|to gðsto, po||Þ|·
d|ðmD|os).
L V|ð dC| pðtto Cn |ðs gCstðC|onCs mo· M
DoðmD|ót|Cðs sC|ð s|Cmp|C |ð CCsð|Cð. bó|o
ðdm|t||Cmos C| pð|to Vðg|nð| Cn |ðs gCstð·
C|onCs b|ðmn|ót|Cðs CD |ðs quC C| p||mC|
gCmC|o Cste Cn CCÍð||Cð, s| son gCstðC|oDCs
dC >J4sCmðnðs, m|CDt|ðs quC s| soD <J4
sCmðnðs, só|o sC ðdm|t||ð s| ðmbos gCmC·
|os Cstð Cn CCÍð| |Cð.
P|êgä1Iäâ M|B 
Ø M| H 04-0S, T ôS
MlH 02-0J, 2J8
MlH 0\ |, \ 74
M|H 0\ , \ ôJ
Däâ0 D||1l00 Bêp|êâê1IäI|r0 
Ø T 74. Acude a su centrO una mujer pr|m|·
gesta de JS añOs pOr sensac|ón de d|nám|-
ca regu|ar. Se trata de una gestac|ón geme·
|ar mOnOcOr|a|, O|amn|ót|ca en |a semana
Jô+4, cuyO cursO ha s|dO nOrma|, |a exp|O-
rac|ón reve|a un cérv|x OOrradO, cOn S cm
de d||atac|ón, O|andO y centradO, pr|mer
geme|O en presentac|ón celõ||ca, segundO
en transversa, OO|sa |ntQra y amn|OscOp|a
negat|va. ¿Cuá| es |a act|tud cOrrecta de
cara a| partOì:
T) Hea||zar una cesárea urgente,
ya que se trata de una gestac|ón
O|amn|ót|ca.
2) De]ar evO|uc|Onar e| panO pOr v|a
vag|na|.
J) Dejar evO|uc|Onar e| partO vag|na|
de| pr|mer geme|O, y rea||zar una
cesárea nO e|ect|va de| segundo.
4) |n|c|ar |a adm|n|strac|ón de tOO||·
t|cOs, puestO que se trata de una ges·
tac|ón de Jô semanas, y es prev|s|O|e
que |Os ktOs sean muy |nmadurOs.
5) Hea||zar una cesárea urgente,
puestO que e| segundO geme|O está
en transversa.
M|H 2000-200T | HC. 2
HLLULHÜP L 085 ÍlECUEOIEE5
C' >|>lCnö c|¯cuiö!C¯|C CC'
Íð 0ODOOlÍðÍ·DÍð0DÍÓ\ÌCð.
IC!C !¯ön>IunC|CC öCÇu|C·
|C p¯CCCni n| C >CO¯C C' CCl
IC!C !¯ön>Iu>C¯, >C puCCC ' ' Cgö| ö lö >|!uöc|Ón CC ÇuC C>!C
>C cCnv|C¯!ö Cn un IC!C öcö¯C|C |uCCC !¯ö!ö¯>C CÇui ' | O¯ön·
CC Cl vC'unCn CC ''ÇuiCC Cn!¯C önOö> OC'>ö> nCC|ön!C
vCnIönö> önniÓ!icö> C cCögulöc|Ón pC¯ lö>C¯ CC lö> önö>!C·
nC>|> vö>cu'ö¯C>.
/. cö> nö'IC¯nöc|CnC> cCngCn|!ö> >Cn J vCcC> nö> I|C
cuCn!C> Cn gC>!öc|CnC> gCnC'ö¯C>, p¯inc| pö' nCn!C 'ö> cö¯·
CiCpö!'ö> cCngCn|!ö> y 'C> CCICc!C> CC' !uOC nCu¯ö' .
HLLULHÜP ÎOl OEDð¿OOE
34 5E0ðDð5, 5ÓÍO QðOOva·
@ÍDðÍ, 5Í ÍO5 OO5 EO CEÍ8ÍÍCð.
ß. CCn I¯CcuCnc|ö, öpö|CcC pö·
!C|Cg'ö CC cC¯CÓn, >CO¯C ICCC
p¯Clöp>C CC cC|CÓn, Cn cö>C>
CC gC>!öc|CnC> nCnCönn|Ó!i·
cö> C cCn pC' | || C¯önniC>
9 |' öO¯up!|C p'öcCn!öC C> un |iC>gC IiCcuCn!C Cu¯ön!C C'
pö¯!C, CCO|CC ö 'ö CC>cCnp¯C>iÓn O|u>cö CC' u!C|C !|ö> Cl
nöc|n|Cn!C CC' p¯|nC¯ gCnC'C C !¯ö> lö CvöcuöciÓn CC un
pCl||iC¯önn|C> cCCx|>!Cn!C.
¿0.0 Û|8§008Ì|00
AnönnC>i>. |C> önICcCCCn!C> Iön| ' |ö¯C> C pC¯>Cnö'C> CC
gC>!öc|Ón gCnC'ö¯, ö>' cCnC C' u>C CC |nCuc!C¯C> CC 'ö
Cvu'öc|Ón
HLLULHÜP UDð 5OÍð
DOÍ5ð, CE58lEð 5ÍE0QlE.
b|gnC> cl'nicC>.
_
!C¯C CC nöyC¯
!önöÒC ÇuC C' ÇuC cC¯¯C>pCnCC
ö' !|CnpC CC önCnC¯¯Cö.
|¯uCOö> cCnp'CnCn!ö¯|ö>. |cCg¯öI'ö, p¯öc!|cöCö Cu¯ön!C C'
p¯inC|!¯|nC>!¯C CC CnOö¯özC. VC¯ C' !ipC CC p'öcCn!öc|Ón y
C' nunC¯C CC OCl>ö>, yö ÇuC C' p|CnÓ>!|cC vö¯'ö cCn>|CC¯ö·
OlCnCnIC, >Cgun >C I¯öIC CC unö gC>!öc|Ón nCnC C Oiön-
niÓ!|cö, y >Cgun Cl nunC¯C CC CnO¯|CnC> !¯|gCnC'ö¯, C!c.
¿0.0 Û00000Ì8 008Ì0Ì||08
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CC cC¯CÓn ö' iCnpC| 'ö OC'>ö, cC'i>|Ón CC önOC> gCnC'C>
Cn Cl cönö' CCl pö¯!C), >C |CcCn|CnCö cC>ö¯Cö C|Cc!|vö, | n·
CCpCnCiCnICnCn!C CC 'ö C>!ö!icö CC 'C> gCnC'C>.
" |n C' cö>C CC gCnClC> O| önniÓ!icC>, 'ö v'ö CC' pö¯!C C>Iö
cCnC|ciCnöCö p¯| nc| pöl nCnIC ö 'ö C>!ö!|cö CC lC> ICIC> y ö
'ö CCöC gC>!öciCnö' .
· |C| CCOöjC CC Jb >Cnönö>, >Ó' C >C öcCp!ö¯ö Cl pö¯!C pC¯
vlö vög|nö' >| önOC> gCnC'C> C>!ön Cn >|IuöclÓn 'Cng|!uC|·
nö' y p|C>Cn!öc|Ón cCIöl| cö b| unC C önOC> IC!C> öCCpIön
' ö p¯C>CnIöciÓn pCCöl|cö, >C ¯Cö'|zö¯ö unö cC>ö¯Cö C'Cc!ivö.
|C¯ Cncinö CC Jb >Cnönö>, >C pC¯n|!|¯ö C' pö¯!C pC¯ v'ö
vög|nö' >| Cnp¯C ÇuC Cl p|inC¯ gCnC'C >C CncuCn!¯C Cn
p|C>Cn!öc|Ón cCIö' |cö
¯ ! ¯ cCIöl|cö · 2¹cCIö' | cö. C> C' !|pC nö> I¯CcuCn!C. pö¯!C
vöginöl.
¯ I ° cCIölicö · z?pCCölicö pö¯IC vöginö' . `¯ö> 'ö Cxpu'>|Ón
CC' p¯|nC| gCnC'C, >C puCCC | n!CnIö¯ö C' pö¯!C Cn pCCö' | ·
cö CCl Z?,CC C'Ccc|Ón)
¯ ! ¯ cCIöl|cö ¯ 2¹!¯ön>vC¯>ö pöi!C vöginö'. |' >CgunCC gC-
nC'C puCCC ¯CIö| C>pCn!önCönCn!C ö ' Cng|!uC|nöl. b| nC
¯C!ö C>pCnIönCönCnIC, >C |Cö'|zö unö vC¯>|Ón in!C¯nö y
g¯ön Cx!¯öcc|Ón CC' z?gCnC'C ,CC C'Ccc|Ón) |Ml H 00-0! |,
T 74). Ò!|C> öu!C|C> p¯ChC¯Cn cC>ö|Cö C' CcI|vö CC Cn!¯öCö.
¯ ! ¯ pCCölicö C !|ön>vC|>ö. cC>ö|Cö, |nCCpCnCiCn!CnCnIC
CC lö C>!öIicö CCl !¹gCnC'C.
|> CCc||. pö¯ö ÇuC un pö¯!C gCnC'ö¯ >Cö pC| v'ö vög|nö',
C> | np¯C>cinCiO'C ÇuC C' p|| nC¯C C>!C Cn cCIö' | cö |ö¯ö ö'
gunC> öu!C¯C>, >iCnp¯C >C|ö vög|nö' >i C' p¯|nC¯C C>Iö Cn
cCIölicö, niCn!|ö> ÇuC CI¯C> |öcCn cC>ö|Cö >l Cl >CgunCC
C>!ö Cn I¯ön>vC|>ö.
'C CC>cCnCcCO 'C> nCcaO| >nC> quC CC>COcaCCOaO C'
pa|IC ca Cxl!Cc|Oa p|CvCca C' pa|!C, IaO!C ' a naIC|Oa
cCnC la lCIal . 1anOl CO pa|CcCO acI|va|'C ' a> |C|nCOa>
>up|a||COa'C> na!C|OC·lC!a' C> y Cl ICOC >l npaI|cC
ca aCCcuaCa |l C|a!ac|CO, C' |CpC>C y la piCgC>!C|COa
ac!uaO cCnC u!C|C| O|| O|CCiC> bC CC>cCOCcC quC lac!C|
|CnpC CCl O|!|vanCOIC C' Cqu| ' | O||C, auOquC C' iChCjC CC
'C|gu>CO ,aunCO!C CC cCO!|ac!lllCaC !ia> Cl C>!lnu' C
cC|v|cal) puCCC ICOC| al guO papCl [N| H 9ô·97,2J9).
c' pa|IC a !C|n|OC apa|CcC CO!|C 'a> >CnaOa> J/ y 4z UO
¹ z% >ucCCC COI|C la> >CnaOa> zB y J/, pC| ' C quC Cl cCO·
cCp!C CC pa|!C p|CIC|nl OC C> pu|anCOIC c|COC'Cg|cC.
.a anCOa2a CC pa|!C p|CIC|nl OC >C CChOC cCnC | a apa·
||c|CO CC uOa C na> cCO!|acc|COC> u!C||Oa> CO !0 n| Ou·
!C>, cCO Ou' a> C C>ca>a> nCC|hcaclCOC> cCiv|ca|C> y cCO
|C!u|a C OC CC nCnO|aOaS, CO uOa gC>IaclCO CC nCOC>
CC J/ >CnaOa>.
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||C>gC. CCaCC> Cx!|Cna>, OajC O|vCl >CciCCcCOCn|cC,
cC|>unC CC !aOacC, a' cC|Cl C cCcaiOa, CChcl! OuI|lclC·
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gC>!ac|CO nu| !|p|C, pC' | || C|anOlC>, aO|up!lC, placCO!a
µiCv|a, p|CCclanp>la, n|Cna>, C!c.
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p|CC|>puC>Ia> a ICOC| pa|!C p|C!C|nlOC. Ua>a|CnC> C'
c||OaCC CO.
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¯ `C|C|Ca p|Cna!u|a CC' IapCO nucC>C ,nCcC cC|v|ca'),
cCO pC|C|Ca CC la> luOc|COC> aO!ln|ciCOlaOa> y aO!| p|C·
!CC'|!|ca> quC C>!C !lCOC
¯ CCO!|acc|COC> y |CnC||ag|a vaglOa' ¬ay cCO!|acc|COC>
l>|C'Cg|ca> ,U|ax!CO·H|c<>) quC >uC'CO >C| C>pC|aC|ca>,
nCOC> CC J pC| |C|a, C |||Cgu' a|C>.
Y8|O8OO|0S 0OO]|8Í|OOS
bC |a CCnC>I|aCC la uI| ' | CaC CC 'a valC|aclCO CcCg|ahca
CC !|C> pa|anCI|C>.
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'a ' COg| !uC cC|v|ca' y la l|CcuCOc|a CC pa|IC piC!C|n| OC
|O!|C ' a> >CnaOa> ! z·Jô, C' cC|vlx CCOC nCC| | 4 +/· ! ,z
cn. lCOg|!uCC> cC|v|ca'C> | OlC||C|C> a J cn >upCOCO uO
c' aiC ||C>gC CC pa|!C p|C!C|n|OC.
" c| ' a!ac|CO CC' C||hcC cC|v|ca' |O!C|OC (ÒC') CC ¹ cn C
na> COI|C 'a> >CnaOa> zB·J4, cCO uO cC|vlx OC||aCC na>
CC uO J0%.
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lca CO CnOuCC
¯ Ò!|C na|caCCi CcCg|ahcC CC>O|!C C> 'a C| >n| OuclCO
CC nCv|n|CO!C> |C>p||a!C||C> lC!a' C> pC| acc|CO CC 'a>
p|C>!agl aOC| Oa> bC CO>C|va 4B |C|a> aO!C> CC' pa|!C
p|C!C|nlOC.
Y8|O8OO|0S 0|OQJ|T|OOS
¯ ||O|COCc!lOa. |> uOa gl lcCp|CIC|Oa IC|naCa pC| | a>
nCnO|aOa> lC!a' C> quC >C CC!Cc!a CC naOC|a h>lClCglca
CO cC|v|x y vag|Oa |a>Ia ' a >CnaOa z0 ,p|COaO'CnCOIC
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cCO ' a CCc|Cua) `C|C >u CC!Ccc|CO na> a' ' a CC ' a >CnaOa
|/C1CRLS NLURCLNLCCR' NCS
|/C1CRLS N' CNL1R' ALLS
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· ||08Î8g|800|088
|/C1CRLS lL1ALLS
· Í8ÎI0g6008 /µI0g68Îßg6008
· H606µÎ0|68 06 0X|Î00|08 60 8û0l08 yû60|û08
· ||08Î8g|80û|088
Fr08I00lma0Iµu|a0I00
· ÛX|Î00|08 yV880µ|68|08
l/C1CRLS CLRVl C/LLS
: Í800g6008 /µI0g68Îßg6008
· Û0|8g608888
·
· Å0|00 0|8|0|00|00,
06|08Îß0·80ÍÍ8Î0 y
000ûI0|Î|0·80|Í8Î0
· Åg08
Î8R0 þf8Î8fMÌß0
0|lê1lätlää M|B
LsunIema presenIeen|asu|I|mascOnvO- M
caIOr|as,sObreIOdOe|aparIadOdemane-
jOde|aamenaza deparIOpreIérm|nO.
Aäpêtlêä Eäê1tlä|êä [|}
L ecOgral|a nOs resu|Ia de uI|||dad en |aÖ
pred|cc|ón de| r|esgOde parIOpreIérm|nO.
SObre IOdO nOs s|rve para eva|uar|a |Ong|-
Iudcerv|ca|.Una |Ong|Iud|nfer|OraJcmsu-
pOne un c|arO r|esgO de parIO preIérm|nO.
OIrOsparámeIrOsava|OrarsOn|ad||aIac|ón
de| Or|hc|O cerv|ca| |nIemO y |a prOIrus|ón
de|asmembranasaIravésde|OCl(|magen
enembudO).
LahbrOnecI|naesunaprOIe|naqueseprO- Ö
duceen |as membranas de manerahs|O|ó-
g|cahasIa|a semana 20.CuandOsedeIecIa
más a||áde |a semana 20,|mp||ca r|esgOde
parIOpreIérm|nO.
La acI|Iud ObsIéIr|ca anIe |a amenaza deÖ
parIOpreIérm|nOvaadependerde |aedad
gesIac|Ona|,de|amOd|hcac|óncerv|ca|yde
s| ex|sIe O nO rOIura de membranas.NO se
uI||`uarán |OsfármacOsIOcO||I|cOsen gesIa-
c|OnesdemásdeJ4semanas,yaque|aun|-
cavenIajadeesIeIraIam|enIOesdemOrare|
panO hasIa a|canzar |a madurez pu|mOnar
que |nduc|mOs cOn |a adm|n|sIrac|ón de
cOrI|cO|des.
L| fármacO de e|ecc|ón en |a IOcó||s|s es e|Ö
aIOs|bán,pOr|aescasezdeefecIOssecunda-
r|OsquepresenIa.LsunfármacOanIagOn|s·
Ia de |a Ox|IOc|na que |nh|becOmpeI|I|va-
menIe|aOx|IOc|na.
AäpêtIêäEäê1t|ä|êä[||)
M LOs  Oetam|mét|cOs sOn  un fármacO de  de-
mOstrada ehcac|a, perO cOn un e|evadO nú-
merO de efectOs secundar|Os y, pOr tantO, de 

cOntra|nd|cac|Ones (card|Opatas, d|aOét|cas, 
p|acenta  prev|a,  h|pertens|On,  h|pert|rO|d|s-
mO  . . .   ).  Un  efectO  secundar|O  pe||grOsO  de 
su  ut|||zac|On,  sOOre  tOdO  a| asOc|ar|O  a  |Os 
cOrt|cO|des, es e| edema pu|mOnar pOr e| au·
mentO de |a permeaO|||dad vascu|ar. 
Ö LOs  ant|prOstag|and|n|cOs  (|ndOmetac|na) 
tamO|én  se  pueden  ut|||zar  cOmO  fárma-
cO  tOO||t|cO,  perO  cOn  precauc|On,  pOr  |Os 
efectOs  secudar|Os  feta|es  que  puede  pre-
sentar. c|erre  precOz  ductus  arter|OsO yO||-
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CC | nCucc|Cn, C>Iö lnC| caCa 'a naCu|ac|Cn cC|v|ca' cCn
p|C>!ag' anCi na> Cn ce|vix | nnaCu|C> an!C> CC p|CcCCC|
a l3 |nIu>| Cn CC Cxi!Ccina.
Y8ÌOOOS OO lûOJOOl0û
! . Me!CCC> I>|cC>
· Ann| C||Cx|> (HCIu|a CC 'a OC'>a ann|C!|ca) bC Cn
plCa Cn cuCl'C> nuy IavC|aO'C>, cCnC cCnp' CnCn·
IC CC ' a Cx|!Cc| na Hay ÇuC !CnC| p|Ccauc| Cn pa|a
Cv|!a| un p|C'ap>C CC cC|CCn.
· Man| CO|a CC Han| '!Cn. CCn>i>IC Cn CC>pCga| la>
nCnO|ana> nCCian!C un na>ajC |nI|acC|v|cal, pa|a
IavC|CcC| ' a l i OC|ac|Cn lCca' CC p|C>!ag' anC| na>.
2. Me!CCC> Çun|cC> ' Cca' C> MaCu|aci Cn cC|vical,
· `|C>Iagl anC| na> |z |nI|acC|v|ca'. `uCCC u>a|>C Cn
IC|na CC gC', cCnp|| n| CC> vag| na' C>, C Cn C|>pC>|I|·
vC> CC ' | OC|ac|Cn ' Cn!a cC|v|ca' |> C' nCjC| ne!CCC
pa|a Cl ce|v|x | nnaCu|C Cn ca>C CC u!C|C a !e|n| nC
cCn OC'>a ln!Cg|a. MaCu|a C' cuC' ' C y Iac|'|!a C' pa|!C
pC>!C||C|.
J. Me!CCC> ÇunicC> >i>IenicC>
· Òx|!Cc|cC>. ||CCucCn cCn!|acciCnC> Cn ca>i ICCa c||·
cun>!ancia, pC|C >Cn Cl neICCC nö> Chcaz cuanCC
Cl cuC' l C C> nuy naCu|C, cuanCC ' a OCl>a C>!ö |C!a C
cuanCC Cl |C>!C C>!ön cCnI|a| nC| caCC> (M| R 0J-04, 
9J).  NC >C Cnp' Can C >C u>an Cn Oaja> CC>|> >i |ay
cica!||cC> C na' IC|nac|CnC> uIC||na>, pC| Cl |iC>gC
CC |CIu|a .
bC |an CC>c|i!C a' gunC> ca>C> CC nuC|!C naIC|na cCn
C' u>C cCnjun!C CC p|C>!ag' anCi na> Cn gCl y Cxi!Ccina
i.v. , pC| l C ÇuC >C CCOCn C>pC|a| a' nCnC> ó·! z |C|a>
CC>CC la aCn| n| >!|aciCn CC p|C>!ag' anCi na> |a>Ia Cl u>C
C6 Cx|!CC| na.
b08Î80Ì0ß
0f0ß0Ì0§Ì08M0ßÎ0
þf0Ì0ߧ808

U||ê1Iät|01M|B
Ls un tCmð poCo |mpoNðntC. Lstud|ðtC |osM
ðspCCtos CsCnC|ð|Cs.
kâµEâê1t|ä|êâ
LntCndCmos poI CmbðIð2o C|ono|óg|Cð· Õ
mCntC pIo|ongðdo Cuðndo duIð mðs dC 42
sCmðnðs. bu Ct|o|og|ð Cs dCsCono|dð.
ÛCbCmos ICð||2ðI un Cont|o| ðmbu|ðto||oÕ
dC| Cstðdo dC b|CnCstðI htð| mCd|ðntC H
g|stIo CðId|otoCÇIðhCo bðsð|, CCog|ðÍ|ð ÿ
ðmn|osCop|ð, y dCC|d|I C| momCnto dC |ð
|nduCC|ón.
L |nduCC|ón M ICð||ZðIð Con p|ostðg|ðn· M
d|nðs Cuðndo C| Ce|V|X Cste dCsMVoIðb|C
(D|sÞop <5)  o Con |nhs|ón dC oX|to|nð ÿ
ðmn|oIICX|s Cuðndo C| CeIV|X Cstð ÍðVo|ðb|C
(b|sÞop 2b).
P|ê]01IäâM|B
M|R 0J¬, 9J  Ø
Uäâ0U||1|t0Bq I|r0
No Þðy Cðsos C|In|Cos Ñ
L|tÆtä|äî 1t |ätä|äg|1
0t|01M|B
@ 1CmðUC|quCUCDCS|CCO|Uð||OquC!C |C·
Sum|mOSCÞ|OSðSpCCtOSCSCÞC|ð|CS.
\Eäê1t|ë|êä[|)
M LðS|!uðC|0ÞCS|ð |C|ðC|0Þ CÞ!|C C|ÍC!O y|ð
vC|t|Cð| u!C||Þð y puCUC SC| |OÞg|!uU|Þð|,
!|ðÞSvC|SðuOD||Cuð.
Ö Lð p|CSCÞ!ðC|0Þ CS |ð pðftCÍC!ð| quC CS!ð
CÞ |C|ðC|0Þ COÞ |ð µv|S mð!C|Þð. Lð g|ðÞ
mðyO||ð SOÞ p|CSCÞ!ðC|OÞCS CCÍð||CðS. ÖC
éStðS, !OUðS puCUCÞ SC| uÞ pð|tO vðg|Þð|,
CxCCp!O |ðp|CSCÞtðC|0ÞUCÍ|CÞ!CyUCCð|ð
vð||CUðU mCÞ!OpOS!C||O|.
Lð pOS|C|0Þ CS |ð Of|CÞ!ðC|0Þ |CSpCCtOð |ð
pCNS,ypuCUCSC|ðÞ!C||O|OpOS!C||O|,UC·
|CCÞðO|Zqu|C|Uð.
LððC!|!uU ÞOS|ÞÍO|mðUC|g|ðUOUCÍ|Cx|0Þ
UC |ðCðDC2ðÍetð|.LuðÞ!O mðSUCÍÌCx|OÞð·
UðCS!é, mðSU|Í|C||CSC|pð|tOpO|v|ð vðg|·
Þð|(vé|!|CC,S|ÞC|puC|O,ÍfCÞ!Cy Cðfð).
LðSpðC|CÞ!CSquC !|CÞCÞ UOSo mðSC|Cð!||·
CCSu!C||ÞðSÞOUCDCÞ!CÞC|uÞpðftOvðg|·
Dð|pO|C| ||CSgOUC|O!u|ðu!C||ÞððSOC|ðUO.
LuðÞUO S0|O!|CÞCÞ uÞðC|Cð!||2u!C||Þð, SC
puCUC p|ðÞ!Cð| uÞ pð|!O vðg|Þð|CÞ CðSOS
SC|CCC|OÞðUOS.
LðS CSpð!u|ðS SC Cmp|CðÞ CÞ |ð pð|tC h·
Þð| UC| Cxpu|S|vO. HCqu|C|CÞ |ð U||ð!ðC|0Þ
COmp|C!ðyquC|ð pfCSCÞ!ðC|0ÞCSteCÞuÞ
CuðHO p|ðÞO UC HOUgC. bu p||0C|pð| |ÞU|·
CðC|0ÞCSðD|Cv|ð|uÞCxpu|S|vO|ð|gOOCOÞ
pð!O|Og|ðÍe!ð|.
¿Û.1 Û808| 00| µ8R0
cö pClv¯ C¯Cö ¯C C v CC Cn pC'v¯ nöyC| ,C Iö' ¯ö pC'vl¯, pC|
¯u C¯cö¯ö |C'Cvöncö Cn C' pö|!C) y pC'vl¯ nCnC|.
cö vC|CöCC|ö pC'v¯ CO¯!C!|cö C¯ 'ö pC'v¯ nCnC|, ÇuC CCOC
¯C| cCn¯CC|öCö cCnC un c ' nC|C C¯CC cCn unö IC|nö pC
cu' l ö|. tl c ' nC|C C¯!ö öcCCöCC |öcö CClönIC, pC| ' C ÇuC 'ö
cö|ö ön!C|C| C¯ nuc|C nö¯ cC|!ö y 'C¯ p'önC¯ CC 'ö öOC|!u·
|ö ¯upC|lC| (C¯!|Cc|C ¯upC|C|) C l nIC|C| (C¯!|Cc|C nIC|C|)
nC ¯Cn pö|ö'C'C¯. Ln 'ö cö|ö pC¯!C|C| |öy un |C¯ö'!C (C' p|C·
nCnIC|C) ÇuC |öcC ÇuC C' C¯!|Cc|C ¯upC|C| ¯Cö C' 'pIcC,
cCn C' C önC!|C nöyC| Cn ¯Cn!CC !|ön¯vC|¯C
L| CðnC!|C cCnjugöCC CO¯!C!|lcC C vC|CöCC|C (CC' p|C·
nCn!C|C ö| pun!C nö¯ pC¯IC|C| CC' puO¯) n CC ¹ û,' cn,
nCn!|ö¯ ÇuC C' C önC!|C !|ön¯vC|¯C CO¯!C!|cC nCC ¹ z
cn, OC| ' C ÇuC Cl C¯!|Cc|C ¯upC|C| C¯, cCnC |CnC¯ Cc|C,
unö C' p¯C !|ön¯vC|¯ö.
|l C¯I|Cc|C nIC|C| C¯ C' un cC ÇuC C¯ C'ö¯!cC, y !COC IC|nö
CC |CnOC CCn C' C önCL|C nöyC| Cn dn!C|CpC:IC|C| L:!ö
' nl!öCC 'öIC|ö'nCn!C pC| 'ö¯ !uOC|C¯CöCC¯ ¯Çulö!cö¯, y
ön!C|CpC¯!C|C| pC| C' cCx¯ y C' OC|CC nIC|lCl CC' puO ¯.
L| C önC!|C ' Cng !uC nö' ¯uO¯öc|CpuOönC nCC CC º ö ¹ z
cn, puC¯ C' cCx¯ puCCC |Cc|öïö|¯C. | ' C önC!|C !|ön¯vC|¯C
n!C|C¯p|nC¯C nCC ¹ ¹ cn.
Í|gulß ÜO Ûd0d|06|µdR0 yµ|d005 06 d00g6
|C¯ p' önC¯ CC HCCgC ¯Cn nöginö|C¯, y ¯ |vCn pö|ö |C·
cö' 'ïö| |ö cöOCïö IC!öl cCn |C¯pCc!C ö |ö pC'vi¯. |' p|nC|
p' önC pö¯ö pC| C' OC|CC ¯upC| C| CC' puO'¯ lö¯!ö C' p|C·
nCn!C|C (C¯ C| p' önC ¯upC| C| CC' C¯!|Cc|C ¯upC|C|)
|l ¯CgunCC plönC C¯ pö|ölC'C ö' ön!C|C|, pC|C pC| CCOöjC
CC' OC|CC l nIC||C| puOl önC. t' !C|cC| pl önC pö¯ö pC| 'ö¯
C¯plnö¯ clöIcö¯, y Cl cuö|IC, pC| C' Cx!|CnC CC' cCx¯.
¿Û.¿ Î|0M00l08 Í0l8|08
|ö cöOCïö CC' ICIC ö !C|nl nC C¯ un CvCCC, CC º cn pC|
! J cn CC C önCI|C. |nI|C 'C¯ pö|C!ö' C¯ y 'C¯ I|Cn!ö'C¯ ¯C
CncuCn!|ö lö ICnIönClö nöyC| (O|CgnöIcö), y Cn!|C 'C¯
pö|lC!ölC¯ y Cl Ccclp!öl, l ö ICn!önC' ö nCnC| (' önOCCCCö)
ÇuC C¯ Cl CI|C vC|IcC CC' CvClCC. cC¯ Cl önC!|C¯ !|ön¯vC|·
¯C¯ (O pö|lCIö' . º,' cn y OICnpC|öl. o,' cn) ¯Cn C' CO¯!ö
cul C |öOl !uö' .
¿Û.J Î8l8l|08 Í0l8|
lö pC¯Iu|ö y cC'CcöcCn CC' ICIC ln!|öu!C|C ¯C CC¯c|OC
cCn 'C¯ ¯lgu|Cn!C¯ pö|önC!|C¯.
¯ b !uöc Cn. |¯ ' ö |C'öcCn Cn!|C IC!C y ' ö vC|!cö' u!C|lnö.
' Cngl !uC nö' , I|ön¯vC|¯ö, u CO' cuö
¯ `|C¯Cn!öc Cn. t¯ lö pö|IC IC!ö' ÇuC C¯!ö Cn |C'öcCn cCn
Lsm00suµ0rI0r
ÛU||0u08 [1 1 ,b · 1 ¿ 0m)
1|a08v0|80 [1 J 0m)
C00¡uga00 0U8tut||00 (1 O,b ! ! cm)
B||8qu|8t|00 [1 1 0m)
A0I0|0p08t0||0| [1 ? cm)
L8m00I0!0II0I
FIa00sJ0huJg0
N!u0
S|tua0|00
|ð ÇClvi> Uð!C||ð, lð ÇuC >C «Ç|C>C|!ð» ð |ð ÇClvl>. CCIðllCð,
ÇClvlð|ð (M|R 00-01 ,2bV).
¯ |C>|ClC|. L|lC|!ðClC| |C>ÇCC!C ð lð ÇClvl>. ð|!C||C| C
ÇuO|Cð, ÇC>!C|lC| C >ðCrð, UC|CChð, lzÇu|C|Uð. ||CCl>ð u|
Çu|!C UC |CIC|C|C|ð .
¯ ªC!|!uU. L> lð |C|ðC|C| ÇuC !lC|C| C|!|C >| lð> Ul IC|C|!C>
Çð|!C> lC!ð|C>. c| lð> Ç|C>C|!ðClC|C> CCIðl l Cð> CC||C>ÇC|·
UC ð| Q|ðUC UC llCxlC|. vC|!lCC, >| |C| ÇuClC, I|C|!C y Cð|ð.
¿Û.4 b000|0|0008 §000|8|08 00| þ8R0
Lð> CC|UlC|C|C> UCl CC|v|x >C UlUC| CC| Cl l|UlCC UC
bl>hCÇ. bC CC|>|UC|ð ÇuC C| Çð|!C CCUlC|zð Cuð|UC >C
ðlCð|zð| z CU UC Ullð!ðC|C|, CuCl l C CC||ðUC u| a0, y
Ul|ðUlCð ðC!|vð. ðl UCÞC> z CC|!|ðCClC|C> / ! 0 Ul |u!C>
UC UCUlð|ð l|IC|>lUðU. L| ÇC|lCUC UC Ul | ð!ðClC| !C|Ul|ð
KLLULHÕP Îðfð ÞðC0f U0
þðHOlR$IfUm0RIðÌ, 0$ RB0WHO!
0ÍÌðIðCÌÓR COmQÌ0Ið, DlW fOIð,
þf0$00IðCÌÓ0 C0ÍðÌÌCð ÿCðD0zð
ÑtðÌ $Ì0 ð0OmðÌÍð5.
CC| lð U|lð!ðClC| CCUÇlC·
!ð. ª|!C> UC l | CQð| ð lð Ul ·
l ð!ðCl C| CCUÇlC!ð, NL >C
ÇuCUC| CUÇl Cð| lC|CCÇ>,
vC|!C>ð C C>Çð!ulð>, ÇC|
| C ÇuC Ç|ðC!|Cð|CUC>
CC>ð|Cð C| Cð>C UC >C| |CCC>ð|lð |ð Cx!|ðCClC| IC!ðl. Ll
ÇC|lCUC CxÇul>|vC CCUlC|zð CC| | ð Ul lð!ðClC| CCUÇlC!ð,
y !C|Ul|ð CC| |ð CxÇu|>lC| lC!ðl . 1|ð> lð CxÇu|>lC| lC!ð| CC·
UlC|zð C| ðl uUC|ðUl C|!C C CxÇul>iC| UC lð ÇlðCC|!ð.
hC!u|ð UC UCUC|ð|ð>. bC UC|CU||ð |C!u|ð Ç|CUð!u|ð
UC UCUO|ð|ð> ð |ð |C!u|ð ð|!C> UC| l|lClC UC| !|ðOðjC UC
Çðl!C. LC>UC Cl UCUC|!C UCl | |l C| C UCl !|ðOð¡C UC Çð|!C,
hð>!ð |ð U| | ð!ðClC| CCUÇ|C!ð, lð |C!u|ð >C l | ðUð Ç|CCCz. L|
U||ð!ðC|C| CCUÇ| C!ð, |CClCC Cl |CUO|C UC !CUÇC>!lvð. b|
|ð OCl>ð C>!ð ||!CQ|ð C| Cl UCUC|!C UC lð CxÇu|>lC| IC!ðl,
>C l l ðUð !ð|Ulð. Lð |C!u|ð CÇC|!u|ð >C|lð lð ÇuC CCu||C C|
Cl ÇC|lCUC UC Ul l ð!ðClO|, C> UCCl |, C|Q| COð||ð ð l ð Ç|CCCz y
ð lð !CUÇC>!lvð (M| R Vb-VV|, 1 b0).
| |UuCClC|. LC|¡u|!C UC UC!CUC> ÇuC CC|>|QuC| ÇuC C|
CC|v|x ðlCð|CC lð> CC|U|ClC|C> UC| Çð|!C. bC l l ðUð UðUu·
|ðC|C| CC|vlCðl ðl Ç|CCCSC ÇC| Cl ÇuC UC¡C|ðUC> lð l |Uu·
C| O| | | UðU CC|vlCð|. b| Cl Çð|!C yð |ð CCUC|zðUC ÇC|C Ç|C·
Q|C>ð CC| |C|!l!uU, lC ÇCUCUC> ðCClC|ð|. C>!l Uu| ðClC|.
LC>ð|Cð. bC CUÇ|Cð CuðOUC l ð> CC|UlClC|C> | UÇ|UC| u|ð
l¯UuCClC| C Çð|!C CC| >uÞClC|!C >CQu|lUðU. |uCUC >C|
C|CC!|vð, >| >C Ç|ðC!|Cð UC Uð|C|ð Ç|CQ|ðUðUð, C u|QC|!C,
C| Iu|ClC| UC lð> Cl|Cu|>!ð|Clð> CC>!C!|lCð>.
Lð> Cðu>ð> Uð> l|CCuC|!C> UC CC>ð|Cð> C| c>ÇðOð >C|.
(vC| !ðC|ð J0)
LCUC CC|>CCuC|Clð UC| ðuUC|!C Ç|CQ|C>lvC C| Cl |u·
UC|C UC CC>ð|Cð>, CðUð vCz C> Uð> I|CCuC|!C C| C|CC|!|ð|
QC>!ð|!C> CC| u|ð C Uð> CC>ð|Cð> ð|!C||C|C> ¦l!C|ð!lvð).
U|ð CC>ð|Cð ð|!C||C| ÞC C> CC|!|ðl|UlCðClC| ðO>C|u!ð
Çð|ð C| Çð|!C ÇC| vlð vðQ||ðl. LC> C Uð> CC>ð|Cð> ð|!C|lC-
|C> >| |C >C| |M|R 00-0\ |, T 7ó).
Lð U| >!CC|ð C lð|!ð UC ÇlCQ|C>|C| UC| Çð|!C C> lð Ç||UC|ð
Cðu>ð UC CC>ð|Cð C| L>ÇðOð y lð >CQu|Uð Cðu>ð UCl ðu·
UC|!C UC CC>ð|Cð C| LLUU UC>UC l C> ðOC> ó0, UC>ÇuC>
UC lð CC>ð|Cð l!C|ð!lvð.
LC> CC>!ðCulC> UCCð||CC> ð |ð Ç|CQ|C>lC| UCl Çð|!C >C| |ð
Cðu>ð Uð> I|CCuC|!C UC hlÇC|Ul|ðUlð u!C|l|ð >CCu|Uð|lð
(MlR 00-01 , 1 ó0) . LCCC Cvl!ð|>C Ul ðQ|C>!lCð| UC>Ç|CÇC|·
C|C| ÇC|vlCCCClð|lCð ð|!C> UC l | CQð| s C| |ð!ðClC| CCUÇl C!ð
(ðÇ|Cx ! U CU), y C| UujC|C> CC| ð|ð| QC>lð ÇC|lUu|ð|, >C
CC|>lUC|ð CxCC>lvð lð Uu|ðC| C| UC lð >CQu|Uð Çð|!C UC|
Çð|!C >l >CO|CÇð>ð |ð> J |C|ð> C| |ul lÇð|ð> C UC> hC|ð>
C| Uu|!lÇð|ð>.
||uCCð UC Çð|!C. LC|>|>!C C| CClCCð| ð lð ÇðClC|!C C| lð
UC>ð UC Çð|!C>, Çð|ð ÇuC ð| C>!ð| C| UCCuC|!C >uÇl|C CC|
llCx|C| UC lC> Ul CUO|C> | |lC|lC|C>, >C ðÇl ð|C |ð lC|UC>l> y
C| CjC CC|uU|ð·ÇClv|> >Cð Uð> lðvC|ðC|C. bC CUÇlCð C|
· : LSµ0Iu| d3 I0||0µ8 v00!08ö
ÐI88
D 0m Lu8|\0 µ|800 00 h00g0 10|00| 0 0u8|\0 µ|800 b0gu000 µ|800 00 h00g0
00 hæg0
la0k Å0|0v|8| u0 0Xµu|8lv0 M8||0!80|0008 I0!8|08 Å0|0v|8| 0Xµu|8lv0
buI||0|00!0 I0!8| Å0|0v|8| 0Xµu|8|v0
buI||0|00!0 læ
Rðµ|00 Rðµ|00 M0008 !|8u0ð!|00,
8|0 8008!08|8
110|a ZÜ |00|0d0|0005 00 |80058|0d [M|h ÛZ~Ûd ZºO, M| h Û! ·ÛZ, ! ÜÜ, M| h ÛO·ÛÜ
W06wNW
||8000!8 µ|0v|8 0|u8|v8 !0!8|
b000|08 0000800|0!|008 (8|00µ|0)
ÅR0|80|0008 00 |8 08!ð!|08 I0!3|. µl0800!80|00 00 I|00!0,
00 08|8 000!0µ8!0||0|, 8|!u80|00 h808v0|%
||0800!80|00 00 µ0|v|808 0ð8 8|gu0 I80!0! 00 ||08g0
|80!0r08 00 ||08g0 08I0|00 qu0 µu0080 µ0|]u0|08| 8' I0!0
[0¡. ¥ld)
h|8!0||8 008!0!||08 008I8v0|80|08 (008 008ð|088 µ|0v|88,
0|0000!00l8 000 8µ0|1u|8 00 08vl080 . . . )
ô08µ|0µ|0|00 µ0|v|00I8||08
J|ð Ûdd5d5 00 C05d|0d 00 L5þd|\d
ô|8!0|8
oÞ8 00 ||08g0 00 µ0|0|08 00| 0l0008!8| I0I8|
L08ð|08 80!0||0|
|!0800!80|00 µ0|v|808
U!|88
Å0|uµ!|0 µ|8000!80 |b||W)
R0!u|8 00 v8%8 µ|0v|08
||0|8µ80 00 00|00
b0I||0|00!0 I0!8| (µh <Í.¿, v8|I80|||080 8||00!0 0 8|00%|08)
ôl8!0|8 0 I8|!8 0 µ|0gl08|00 00l µ8|!0
M8| 08!800 08!0|00
dd,JJ7 
¿Û,JÛ7 
1 J,J¿7 
1 J,ͪ7 
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L| lórceps se emp|ea para |a extracc|ón fe-
ta| cuandO presenta d||atac|ón cOmp| eta y
|a presentac|ón está en eI tercer p|anO de
HOdge. Ls un |nstrumentO ráp|dO que nOs
perm|te rea||zar tracc|ón y rOtac|ón, |O que
|O cOnv|erte, en un |nstrumentO muy ut|| en
casOs de sulr|m|entO leta|.
La ventOsa e]erce una pres|ón negat|va, y
as| perm|te que tracc|OnemOs de |a caOeza
leta|. Pr0c|sa d||atac|ón cOmp|eta y que lð
presentac|ón esté en un segundO p|anO de
HOdge.
  E| !etO en presentac|ón pe|v|ana es |nd|·
cac|ón de cesárea, sa|vO en a|gunOs casOs
se|ecc|OnadOs, en |Os que se cump|en tO·
dOs |Os requ| s|tOs, y rea||zðremOs un partO
vag|na| tras e| cOnsent|m|entO |nlOrmadO
de |a gestante (edad gestac|Ona| Þ Jô se-
manas, pesO <J500 g, DbF<9ômm, pe|v|s
adecuada, na|gas puras O cOmp|etas, ca-
Deza hex|Onada y ausenc|a de. anOma|ías
!eta|es, cOntra|nd|cac|Ones v|a vag|na|,
patO |Ogia méd|ca u OOstétr|ca y c|catr|ces
uter|nas).
ä1Iäâ M|B 
Ml H 02-0J, 245
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cC¯ö¯Ca, ¯| nC ¯C C|C¯an ' a¯ cCnC|clCnC¯ CO¯ICI¯|ca¯ pa¯a 'a
u!| ' |zac|Ón CC C¯!C |n canO| C, p¯C¯Cn!a 'a vCn!aja CC ¯C¯
nCnC¯ !¯aunöI|cC y CC pCCC|¯C ap' i ca¯ ¯| n anC¯!C¯|a.
|n gCnC¯al, puCCCn nacC| pC| via vag|na' !CCC¯ 'C¯ ICIC¯
cCn p|C¯CnIac|ÓD cCIö' | ca, CxcCp!C la¯ va¯|CCaCC¯ CC I¯Cn·
!C, y 'C¯ ICIC¯ cCn p|C¯Cn!ac|ÓD CC ca¯a va¯|CCaC nCnIC·
pC¯!C|iC¯, ÇuC ¯C¯öO |nC|cac|Ón CC cC¯ö¯Ca (MlH 02-0J,
245, M| H 0\ -02, T ôô, M| H 95-9ô, 225) .
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IlCxiCnaCC¯ ¯CO¯C C| !|CDcC y la¯ p|C¯na¯ CxICDC|Ca¯ pC|
CC'anIC CC' !|CDcC, p¯C¯Cn!anCC a ' a pClv|¯ unicanCn!C
'a¯ na' ga¯. |n ' a va¯|CCaC CC Dalga¯ cCnp'CIa¯, Cl IC!C ¯C
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¯C¯pCc¯a pC¯ Iac!C vagiDa' , pC¯C CCOC ¯acC|¯C una CcC·
g|aI'a aOCCn| nal.
A' gunC¯ au!C¯C¯ |CcCniCDCaD ¯Caliza¯ una ¯aC|Cg|aIia
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'a anpli!uC CC ' a pClv|¯, aunÇuC C!¯C¯ auLC|C¯ nC ' C cCD¯|
CC¯an DCcC¯a|iC ( Ml H 9ô-97, 242).
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ClCcc'CD CC 'C> pa|IC> Cn pC'v'aDa (M| R99-0|, T ßT ).
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" Au>Cncla CC anCna' 'a> IC!a'C>.
¯ Au>Cnc'a CC ' npCClnCnIC> C cCn!¯alnC'cac'CnC> paia
la vla vag' na' .
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¯ Au>CDc'a CC cca!¯'cC> u!C¯'na>
cu¯aD!C C' !|aD>cu|>C CC' Cxpu'>'vC Cn un pa¯IC Cn p¯C
>Cn!ac'Cn pC|v'ana, >Cn cau>a CC C' >!Cc'a nCcanlca 'a
p|CclCCnc'a CC un plC, Cl>ICc'a CC |CnO¯C>, ' a |CIac'Cn
CC ' a caOC2a a Ccc'p'!C·>ac¯a, C' >!Cc'a CC caOC2a ul I' na
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lD!CnIa|a C' CC>p|CnCln'CnIC 'CD!C y >uavC CC ' a caOC2a
ICIa' pa|a Cv'!a¯ 'C>'CDC> (M|R0J-04,T 02)
ca vC¯>'Cn Cx!C¯na p¯CICnCC C' >nl Du' ¯ C' nunC¯C CC p|C·
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¯Ca' ' 2aCa> cCn C>!a lDC' caciCD
Oääê O||1ltê Bêp|êäê1läll¢ê [|}
245. L MaIrOna av|æ a| G|necó|OgO paraM
aIenderaunagestanIeaIérm|nOen Iraba-
jOdepanOque ||eva unahOraene|per|OdO
expu|s|vO.Ln|aexp|Orac|ón,seObjeI|vak
un|cOenpresenIac|óndecaramentO-µste·
r|Orde|||p|anO.LcOnducIaasegu|res:
1 ) Ap||cac|óndelórceps.
2)Ap||cac|óndevacuumexIracIOr.
J)Vers|ón|nIernaygranextracc|ón.
4)Cesárea.
5)DejarevO|uc|Onare| expu|s|vO una
hOramásenpr|m|parasyT l2hOramás
enmu|I|paras,anIesdedec|d|r.
M|R2002·200J RC:4
1ß1. Una pac|enIe secund|gesIa, cOn anIe-
cedenIe de parIO vag|na| anIer|Or, |ngresa
en su ð" semana de gestac|ón pOrpartO
en cursO. Med|anIe IacIO vag|na| se d|ag-
nOsI|ca d||aIac|ón de ô cm ypresenIac|ón
pe|v|ana (na|gaspuras),var|edad S.|.|.A.,en
|| p|anO.LcOgráhcamenIe, se esI|ma que e|
pesO leIa| esIará cOmprend|dO enIre 2.T ÛÛ
y 2.J00 g. Seña|e |a cOnducIa ObsIéIr|ca
cOrrecIa:
1 ) Perm|I|r |a evO|uc|ón espOnIánea,
ev|IandO |a ayuda manua| duranIe e|
per|OdOexpu|s|vO.
2) Dejar evO|uc|Onar hasIa per|OdO
expu|s|vO, y pracI|car man|Obras de
ayuda manua| para abrev|are| per|O-
dO expu|s|vO,Iras |a sa||da de| ángu|O
|nler|Orde|aescápu|a.
J)Perm|I|r|a evO|uc|ón hasIa per|OdO
expu|s|vO, y hna||zar ésIe med|anIe
ap||cac|ón de krceps, para ev|Iar |a
d|sIOc|adecabezau|I|ma.
4)1erm|nare|parIOmed|anIecesárea.
5) DeIerm|nar |a acI|Iud de |acabeza
leIa|¸med|anIe una rad|Ogral|a s|mp|e
de|abdOmen maIernO.
M|R 1 999-2000|RC.4
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!u|ö u!C|nö (M| R 94-95,  T 29)   Cu|>ö cCn Jö' ö cCD·
!|öcclCn u!C|Dö.
· CC|vlx. löcC|öclCDC> y ¨CJC||ögö> !|ö> ' ö Cxpu' > Cn
IC!ö' , pC|>l>!CD, öuD, cCn OuCnö cCn!|öcc Cn u!C|lnö
(M|R 9ô-97|, ¡ 73)
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J'ö.
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pC|lCCC pC>!pö|!C.
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CcCg|öI'ö, CCOC |Cöllïö|>C lCg|öCC puC|pC|ö' .
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Aäpêtlêä Eäê1tlä|êä [1)
LOslacIOres de r|esgOdeendOmeIr|I|ssOnÖ
|a cesárea,parIOs|nsIrumenIa|es,rOIura de
membranas prO|Ongada, cOr|Oamn|On|I|s,
panOsprO|OngadOs,anem|a. . . Ln esIOsca-
sOs,esIá|nd|cada |aprOh|ax|scOnamOx|c|||-
na-Oavu|án|cOOcOnamp|c|||na.
L |acIanc|aesIá cOnIra|nd|cada en casOs Ö
de |nlecc|Ones (Iubercu|Os|s, VM, hepaI|-
I|s agudas),drOgad|cc|On O pOr|a IOma de
lármacOsquepuedanpasara|a |eche(OO
kslam|da, c|c|OspOr|na, ||I|O, meIOIrexaIe).
L|mrmacOdee|ecc|OnescabergO||na,¡unIO
amed|das|Oca|es.
Hä1lää M|B
M|R99-0|, \Æ
M|R9ß-99,\ 7ô
M|R9ô-97|, T 7J
M|R9ô·97,24J
M|R 95-9ô|,22T
Uääê O||1ltê Bêpmll¢ê
\ 7ô. Una pac|enIe sOmeI|da a cesárea pOrM
|nducc|On la|||da Iras amn|Orrex|s premaIu-
ra pIa, en su Iener d|a de puO,
ma|esIar genera| mde Ƭ |Oqu|Os
N, úesub|nvO|uc|OnadO ydOk
a |a pa|p. ¿Cuá| es e| d|agnOsI|cOmás
prObab|eì:
\ ) LndOmeIr|I|spuerpera|.
2) Deh|scenc|ade|ah| sIerecIOm|a.
J)ReIenc|OnderesIOsp|acenIar|Os.
4) NecrOs|s |squém|ca de m|Oma uIe-
rìnO.
5)AbscesOdeparedabdOm|na|.
M|R\ 99ß-\ 999R\
\ 7J.Pr|m|gesIaque,duranIee|hna|de|pe-
r|OdO expu|sìvO, presenIa un sangradO de
sangre rO]a muy escasO que se hacelran-
camenIe hemOrrág|cO |nmed|aIamenIe
despuésde expu|sarse e| leIO. La p|acenIa
esa| umbrada\ 0m|nuIOsdespués,e|uIerO
se cOnIrae cOrrecIamenIe. La hemOrrag|a
pOr vvag|na|cOnI|nua. De |Os s|gu|enIes
d|agnOsI|cOs,e|másprObab|ees.
\ ) AIOn|a uIer|na.
2) ReIenc|On de un cOIi|edOn p|acen-
Iar|O.
· J)DesgarrOdecue||OuIer|nO.
4)COagu|OpaI|a.
5)ROIurauIer|na.
M|R\ 99ô-\ 997|RC:J
¡sl800s hlpcrlcnsl\0s
0cl cmh8r8z0
0||ê1Ut|01M|B
M
ÐuÞtemðp|eSeÞteeÞ|ðSu|t|mðSC0ÞV0ð·
t0||ðS,p0||0que UeDeSUeU|Cð||et|emp0.
UpêtIêäEäê1t|ä|êä
Ñ Lð et|0|0g|ð Ue |ð p|eeC|.mþS|ð eS UeSC0-
Þ0C|Uð. bÞ|ðSmuje|eSC0ÞÍðCt0|eSp|eU|S·
p0ÞeÞteS,Sep|0UuCeuÞðð|te|ðC|0Þ|Þmu·
Þe que p|0UuCe |Squem|ð y ||De|ðC|0Þ Ue
ÍðCt0|eS VðS0C0ÞSt||Ct0|eS C0m0 e| t|0m-
D0XðÞ0, p|0V0CðÞU0 uÞð |eS|0Þ eÞU0teÌ|ð|
U|Sem|ÞðUð que Uð |ugð| ð |0S U|Íe|eÞteS
SÍÞt0mðSyS|gÞ0SUe|ðeÞÍe|meUðU.
M bSt0SÍðCt0|eS p|0UuCeÞ uÞð VðS0C0ÞSt||C·
C|0Þ geÞe|ð||2ðUð, p|0V0CðÞU0 uÞð e|eVð·
C|0Þ Ue |ð teÞS|0Þ ð|te||ð|. Lð ð|te|ðC|0Þ ð
Þ|Ve| g|0me|u|ð| tIp|Cð eS |ð eÞU0te||0StS
g|0me|u|ð|,quep|0UuCep|0te|Þu||ð.bSt0S
S0Þ |0SU0S|equ|S|t0Spð|ð |eð||2ð|e|U|ðg·
Þ0St|C0Uep|eeC|ðmpS|ð.
B b| S|ÞU|0me Ue HbLLÎ eS Ìð ðS0C|ðC|0Þ Ue
hem0||S|S, e|eVðC|0Þ Ue |ðS eÞ2|mðS Þepð·
t|CðSyp|ðquet0peÞ|ð,quepueUeðpð|eCe|
eÞ muje|eS C0Þ p|eeC|ðmpS|ð y Sup0Þe
uÞðC0mp||CðC|0Þg|ðVe.
Ñ bX|SteÞ uÞ0S
·
C||te||0SUeg|ðVeUðU,tðÞt0c|Ï-
Þ|C0S C0m0 ðÞð|It|C0S, que UeDeS eStuU|ð|,
que Þ0S pe|m|teÞ C|ðS|hCð| |ð p|eeC|ðmpS|ð
eÞ k0gfðVe,yqueÞ0SðyuUð|ðÞðd·
U|||ðCD0DStMeÞ CðUðCðS0.
Ø b| t|ðtðm|eÞt0 Ue e|eCC|0Þ eS |ð hÞð||2ð·
C|0Þ Ue |ð geStðC|0Þ, y Se|ð |ð C0Þ0UCtð ð
Segu||eÞt0UðS|ðSgeStðÞteSðté|m|Þ0.b|Þ
emDð|g0, eÞgeStðC|0ÞeS p|eté|m|Þ0, Se|ð
m||0e|t|ðtðm|eÞt0méU|C0ðÞt|Þ|pe|·
1eÞS|V0p|0g|ð|C0Þt|0|ð||ðeÞÍe|meUðU
y p|0|0Þgð| e| emDðfð20 hðS1ð ð| meÞ0S
ÞðDe| ð|CðÞ2ðU0 |ð mðUu|e2 pu|m0Þð|.
bSto Se|ð p0S|D|e S|emp|eque Þ0 es1em0s
Í|eÞte ðuÞ CuðU|0Uep|eeC|ðmpS|ðg|ðVe.
J1 .1 ε|00M|0|0§|8 y 0l|0|0§|8
bu I|CcuCnclö C>c' ö Cn!|C ¹ -'% CC CJOö|özC> bu C!C'C·
g|ö >guC >lCnCC uD J >!C|C >D |C>C'vC|, öunÇuC pö|CcC
>C| Ju' !iIöc!C|löl c>!C> Iöc!C|C> C!C'CglcC> >C C v CCD CD
CC> g|önCC> g|upC>
ì . |öc!C|C> p' öcCn!ö| C>. cö p|CCc' öJp>| ö C> uD >|nC|CJC
ÇuC öpö|CcC Cxc'u>vöJCn!C Cn C' CJOö|öïC, y nCcC>!ö
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un CCICc!C Cn 'ö p'öcCn!öcCn y un Iö' ' C Cn lö |CC|gön ·
zöcCD CC ' ö> ö|!C|ö> C>p|ö'C> (' ö> ö|!C|lö> C>pl|ölC> ||-
gön 'ö >upC|hc C CnCCJC!| öl y >C |CC|gönïöD Cu|öD!C
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n!C|cöJOC u!C|CplöcCn!ö|lC) |>!C Iöl l C CD lö plöcCn!ö·
clCD puCCC !CDC| uD C| gCn l DJuDC'CgcC. CöCC ÇuC lö
uDlCöC plöcCn!ö|lö IuncCnö cCJC uD ölClDjC|!C, öl I|öcö·
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p|Cvö, hlpC|!Cn>lCn c|CDcö, CDlC|JCCöC |Cnö' c|Cnlcö,
Cl öOC!C> JC' ' !u> p|CgC>!öc Cnö' , gC>!öcCn Ju' ! plC,
p|C>Cncö CC !|CJOCh' ö>.
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cCnC 'a u!| ' |2ac|Cn CC
pmpwpmenæaparçer p|C>!ag' anCl na> ' Cca' C>
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cuaCanCn!C la Clla!ac|Cn, an!C >C>pCc|a CC >ul||n|Cn!C
lC!al, CnpCC|anlCn!C CC' C>!aCC na!C|nC C nal cCn!|C'
CC ' a gC>!an!C (M|R99-00|, \ 83) (M|R04·05, \ 7 \ ).
bC !C|n| na|ö la gC>!ac|Cn Cn !CCa> aquC' ' a> pac|Cn!C> a
!C|n|nC cCn p|CCc' anp>| a. Ln 'a> gC>!aciCnC> p|C!C|n|·
nC >C CCc| C| |ö Cn lunc|Cn CC la g|avCCaC CCl cuaC|C cl |O| ·
cC quC p|C>CO!C la CnOa|a2aCa y CC' C>!aCC lC!a'.
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ca CnlC|nCCaC nC >uC'C |Cc|C|va| Cn CnOa|a2C> pC>!C·
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L>, ac!ua' nCn!C, 'a Jª cau>a CC nC|!a' |CaC na!C|na.
Pgä1lää M|B
M|R 0ô-07, \ ô9
M|R0ô-07,\ 77
M|R04-05,\ 7\
M|R03·04,\ 03
M|R02·03,235
M|R 0\ -02, \ ô\
M|R 00-0\ |, \ 75Ø
M|R 00-0\, \ôô
M|R99-00|, T ß3
M|R99-00,3ô
M|R99-00,40
M|R9ß-99, \ 73
Oääê O||1ltê Bêpml|¢ê
\ ô\ . Gestantede2ôsemanasdeamenOrreaM
que presenta, desde hace 5 d|as, ma|estar
genera|,asten|a,náuseas,cela|ea,edemasy
||gerOdO|Oren h|pcOndr|OderehO. En lõ
ana||t|ca pract|cada presenta:Hbßgld|,b|-
||rrub|na \,4 mgldL, LDH ô70UllLAS1Tß2
U|lL,p|aquetasß0.00lmmJ.LOmásprOba-
b|eesqueM tratedeunembarazO cOmp||-
cadOpOr:
\ ) EmbO||smOde ||qu|dOamn|ót|cO.
2)Muerteleta|cOn pasOdesustanc|as
trOmbOp|ást|casa|a c|rcu|ac|ón
materna.
3)Desprend|m|entOprematurOde
p|acentasuper|Ora|50%.
4) |sO|nmun|zac|óner|trOc|tar|acOn
translus|ón letO-materna.
5)Freec|amps|asevera.
M|R200\ -2ÛRL:5
\ß3. Se hOsp|ta||za a una gestante de 35
semanas pOr presentar pres|ón arter|a| de
\ô5l\00 mmHg en repet|das tOmas, ede·
masprOgres|vOsyprOte|nur|a s|gn|hcatìva.
Se |nstaura tratam|entO cOn h|dra|ac|na y
su|latO demagnes|O.Se|shOrasdespués, |a
pac|ente reherecela|ea |ntensa,ep|gastra|·
g|aylOtOlob|a.SeOb]et|va O||gur|a,pres|ón
arter|a|de \ß0lT20mmHg,aumentOde |Os
edemas,letO en presentac|ón celá||ca cOn
cérv|x lOrmadO y cerradO. L mOn|tOr|za-
c|ónkta| nO estresante presenta una ||nea
debasede \40|at|dOslm|nutO, r|tmOs||en-
te,ausenc|adeace|erac|Onesde |alrecuen-
c|acard|acakta|ydesace|erac|Onestard|as
cOncadacOntracc|ón.¿Cuá|es|acOnducta
cOrrecta!:
\ ) Rea||zarunperh|b|Ol|s|cOleta|.
2) Aumentar |as dOs|s de ant|h|per-
tens|vOs y ant|cOnvu|s|vantes hasta
cOntrO|are| cuadrOy rea||zar una |n-
ducc|ónde|partO.
3) Determ|nar |a madurez pu|mOnar
leta|med|anteestud|Ode|||qu|dOam-
n|ót|cO.
4) ||na||zar|agestac|ón med|ante ce-
sárea.
5) Ap||car tratam|entO cOn n|tr|tOs y
d|acepam, manten|endO una cOnduc-
taexpectantes|cede|ah|penen$|ón.
M|R \ 999-20 |RL:4
ü|10|||\ g|\|1||1ä1|
M|B
bS uÞtemð ð meU|ðS C0Þ ÎeU|ðtf|ð. Apf0·
VeChðpðfðeStuU|ðfte,S0Dfet0U0,e|U|ðg·
Þ0St|C0Ue|ð U|ðDeteSUufðÞtee|emDðfð·
Z.
m|Hµ)
|ðS C0mp||CðC|0ÞeS que Se ðS0C|ðÞ C0Þ |ð
U|ðDeteS eÞ e| pef|0U0 emDf|0Þðf|0 S0Þ
uÞð mðy0f tðSð Ue ðD0ft0S y Ue mð|Í0f·
mðC|0ÞeS.
|ð mð|Í0fmðC|0Þ m8SBeCueÞte ðS0C|ðUð ð
|ðU|ðDeteSeS |ð h|peH Ue|tðD|queCðf·
U|ðC0,m|eÞtfðSque|ð mðS CðfðCtef|St|Cð eS
el S|ÞUf0meUefegfeS|0ÞCðuUð|.
|ð Uetefm|ÞðC|0Þ Ue hem0gÍ0D|Þð g||C0·
S|!ðUð eÞ e| pf|mef tf|meStfe Þ0S pueUe
p|eUeC|f e| f|eSg0Uemð|Í0fmðC|0ÞeSðS0·
C|ðUðS.LuðÞU0eStépUeDðj0Ue| 7%, |ð
geStðÞte U|ðDét|Cð t|eÞe e| m|Sm0 f|eSg0
Uemðm|0ÞeSqueS|Þ0|0Íuefð.
|ðSC0mp||CðC|0ÞeSqueSeðS0C|ðÞUufðÞte
e|SeguÞU0ytefCeftf|meSt|eSe fe|ðC|0ÞðÞ
C0Þ |ðS ð|tefðC|0ÞeS Ue| CfeC|m|eÞt0 (mð·
Cf0S0m|ðMtð|),ð|\efðC|0ÞeSUe|ðmðUufe2
pu|m0Þðf (mðy0f |ÞC|UeÞC|ð Ue eÞÍefme-
UðU Ue memDfðÞð h|ð||Þð) y C0Þ pf0D|e·
mðSeÞe|m0meÞt0Ue|pðN0p0fe|f|eSg0
UeU|St0C|ðp0f|ðmðCf0S0m|ð.
b|U|ðgÞ0St|C0 Ue |ðU|ðDeteS Se hðCe me·
U|ðÞte e| teSt Ue Lbu|||vðÞ (SCfeeÞ|Þg),
que Se hðCe ð t0UðS |ðS emDðfð2ðUðS eÞ
|ðS SemðÞðS z4zs Ue g|0Þ. L0ÞS|Ste
eÞ |ð meU|C|0Þ Ue g|uCem|ð DðSð' y ð |ð
hUe|ð|ÞgeStðUe50g Ueg|uC0Sð. b|e|
Vð|0f eS Supef|0f ð 1% mgíU|, eS p0S|t|V0,
y feð||2ðfem0S |ð S0DfeCðfgð C0Þ 1 Ûg Ue
g|uC0Sð, eÞ |ð que hðfemOS Cuðtf0 Uetef·
m|ÞðC|0ÞeS.
J¿.1 Û|800l08 y b08l80|00
cC> cönO C> nC!öOC' l cC> Cn ' ö nujC| gC>!ön!C >Cn nuy
D!CD>C>. UDC CC | O:ö>pCcIC> nð> l npC|!önIC> C> C' |C·
l öc CDöCC cCD ' O: ¨l C|öIC> CC cö|OCDC, CC lC|nö quC
C' ¹ ·J% CC ICCö> 'ö> gC>!ön!C> nuC>!|öD n!C' C|önc ö ö
' ö g' ucC>ö.
Lö nöyC|'ö CC C>!ö> pðclCD!C> >Cn nujC|C> cCn p|C·
C >pC> cl Cn gCDC!cö C nCIöOC' l cö ö l ö C öOC!C>, lDcö·
pöcC> CC cCnpCD>ö| CC IC|nö öCCcuöCö ' C> CICc!C>
Cl öOCICgCDC> CC' CnOö|özC. bC CCDCnl nö Cl öOC!C>
gC>Iöc Cnö' ö öquC' lö C öOC!C> quC >C ClögDC>!lcö pC|
p| nC|ö vCï Cu|ön!C ' ö gC>!öc Cn, nCCpCnClCD!CnCn!C
CC ' ö >CvC|lCöC, |CÇuC|lm CnIC n>u' lncC, C pC|>l>!CDc ö
pC>I·pö|!C.
|' glupC CC pöclCn!C> ÇuC C>!öOön C ögnC>!cöCö> CC
¯ öOC!C> MC' l !u> (¯M) p|CvönCn!C ö ' ö gC>IöcCn >C
c' ö> hcöD cCnC ¯ öOC!C> p|CgC>Iöc CDö| .
J¿.¿ ÎÍ00l0 0|800l0§00|00
00Ì 0M08|8L0
ì HC>l>ICncö ö ' ö n>u' nö. |ClöCICnöCö lunCönCn!ö' ·
nCn!C cCn Cl ' öc!CgCnC pl öcCn!ö| C (H`c) CC l ö Zº n ·
IöC CC ' ö gC>IöclCn.
_
>!C C >n nuyC l ö u! ' zöclCn pC| ·
Í|gU  M0|D|||080 ÎUÍd| 00 UI3D0Í0S
9
SÍd0|0|I8|
Yòc|080m|ò, p0llclt0mlò
Cò|0l0m0gòllò
h0pòt0m0gòllò
1|0mU08l8
U0 lò v00ò |00òl
lC|cö CC 'ö gl ucC>ö, p|CvCcönCC unö l pClg|ucCn ö y
un |l pC|l n>u| nl >nC cCnpCn>ö!Cl C ACCnð>, öunCD!ö
' ö p|CCuccl Cn CC cC|! >Cl, C>!|Cl, p|CgC>!C|Cnö y C!|ö>
|C|nCnö> cCDI|ö O>ul ö|C>, y >C p|CCucC uD öunCnIC CC
' ö CCg|öCöcl Cn pl öcCDIö|l ö y |Cnöl CC l ö D>u' l nö
Z. AunCnIC CC lö l ÇC' l >i > l ö nöC|C u>ö lö g|ö>ö pö|ö cu
O|l | >u> DCcC> CöCC> cöl C| cö> y guö|Cö ' ö g' ucC>ö pö|ö
cuO|l | 'ö> CCl ICIC. cö l pCl > > p|CCucC ðcCC> g|ö>C> 'l·
O|C> ÇuC nC öI|övC>ön ' ö p|öcCn!ö, öunÇuC >l ' C |öcCn
Cl g' lcC|Cl y l C> cuC|pC> cC!CDlcC>.
J. CönOl C> CD l ö g| ucCnCCgCDC>l >. Cl lC!C CnplCö cC|·
IC> ön DCðclCC>, ptlvönCC ö lö nöC|C CC ' O:p|l Dc pöl C>
>u>I|öIC> pö|ö ' ö g' ucCnCCgCnC> >.
A>', Cn ' ö gC>!öcl Cn, C >Il ngu nC>
! `C|'CCC p|CcCz, ðDöOCl cC.
· ¬öy uD öunCO!C CC ' O:CCpC> !C> g|ö>C>.
· Hl pCgl ucCnl ö nöIC|Dö (lö gl ucC>ö >C C>!ð ¨guö|·
CöDCC`, y pC| C>C >C |C!|ö CC ' ö Cl |cu| öc Cn).
¯ >n Duc CD CC ' ö l n>u' nö y CC >u> nCcC>CöCC>, Cn
¯M p|CgC>Iöc| Cnö' (öl ¨öOC| ¨ pCg' ucCn ö Cn C>!C
pC|'CCC, C >nl nuyC ' ö DCcC>CöC CC l n>u' l nö).
Û|8t|08 |08pl|òt0|l0
C0|00 lïqul0|00
¸ H|p0pl88lc0
hl p0còlc0mlò
Htp0g|uc0mlò
.. .ª Ul!ðU UC |ð QC>!ðc|C|, cð!ðUC||>UC'
· l| ÇCl| îlî. ðuUC|!ð| lCî ðc| UCî Q|ðîCî l | U|Cî UC!ð·
UC||zðUCî ð cuC|ÇCî cC!C||cCî. bC| lð luC|!C UC
C|C|Qlð IC!ð| .
· HCî|î!C|c|ð ð |ð | |îu| | |ð. |l ÇC|Q| ucCUl ð, ðuUC|!C UC
| ðî UC|Ccu|ðî UC | |îul | |ð y UC îuî |CcCîlUðUCî C| | ð
LM Ç|CQCî!ðc| C|ð| (ð| îC| Cî!C ÇC|lCUC |lÇC|QlucC·
UlcC, îC |CcCî| !ð Uðî | |îul | |ð cCUÇC|îð!C||ð).
3. |Cî!Çð|!C. U| îU| |ucl C| UC l ðî |CcCî|UðUCî UC | |îu| | |ð,
yð ÇuC îC |C|Uð||zð | ð || ÇC|Q| ucCUl ð.
J¿.J M0|0|||080 M8Î0|08
ªuUC|!C UC 'Os ðUC|!Cî CîÇC|!ð|CCî, |l U|ðU|lCî
(zb%), hCUC||ðQ| ðî ÇCî!Çð|!C, Ç|CCc| ðUÇîl ð (b· ! b%),
||lCcclC|Cî (|1U, cð|Ul U| ðîl î, cC|| CðU|| C|l !l î y C|UC·
0C!||!|î ÇCî!Çð|!C), cCîð|Cðî, Ç|CQ|Cî|C| UC | ð |C!||C·
Çð!lð, |Cl|CÇð!lð y U| Ccð|Ul CÇð!|ð C| Çðcl C|!Cî U| ðUC·
!|cðî.
J¿.4 M0R8||080 þ0||08Î8|
Ócu||C C| ðÇ|Cx|UðUðUC|!C Cl 4%, lu|UðUC|!ð| UC|!C
|C|ðc|C|ðUð cC| Uð|IC|Uðc|C|Cî cC|QC|l!ðî (|ð cðuîð
Uðî l|CcuC|!C), Ç|CUð!u|lUðU, Ulî!|Cî |CîÇ||ð!C|lC, | |lCc·
c|C|Cî y !|ðuUð!lîUCî CUî!C!||cCî.
J¿.Û M0|0|||080 î0Î8|
Lu|ð|!C Cl ÇC|lCUC CUU||C|ð||C, ðÇð|CcC| cCUÇ||cðc|C·
|Cî cCUC lðî Uð|lC|Uðc|C|Cî C ðUC|!Cî.
cO C| ÇC|lCUC lC!ðl, ÇuCUC ð|!C|ð|îC | ð UðUu|C2 Çu| UC|ð|,
|C ÇuC ÇuCUC Ç|CUuc|| Ulî!|Cî |CîÇ|lð!C||C C| Cl |Cc|C| |ð·
c| UC. 1ðUU|C| ðuUC|!ð lð l|c| UC|c| ð UC UuC|!C lC!ðl | |·
!|ðu!C|| |ð, y ð|!C|ðclC|Cî C| C| c|Cc|UlC|!C, !ð|!C Uðc|C·
îCU|ð cCUC lC cC|!|ð||C, Clh. |Cî lC!Cî Uðc|CUCîCUlcCî
!lC|C| ||CîQC UC U| î!Cc|ð C| C| Çð|!C y, C| cC|îCcuC|clð,
UC îul||| !|ðuUð!lîUCî CUî!C!|lcCî.
Lu|ð|!C Cl Çð|!C, ðuUC|!ð |ð ||clUC|c|ð UC |C!u|ð Ç|C·
Uð!u|ð UC UCUU|ð|ðî, Çð|!C Ç|C!C|Ul|C y Ç|C|ðÇîC UC
cO|UC|.
LO C| |CC|ð!C ðÇð|CcC| ð|!C|ðc|C|Cî UC!ðUC||cðî. || ÇC·
Ql UcCU| ð (Cî | ð Uð||lCî!ðc| C| Çð!C|CQ|cð Uðî l|CcuC|!C
CO C| ||jC UC UðU|C UlðUC!|cð). 1ðUU|C| ÇuCUC ðÇð|CcC|
|| ÇCcð|cCU|ð, || ÇC|Ul l | ||uU| |CU| ð, C ÇC||c|!CUlð
MðlIC|Uðc|C|Cî cC|QC||!ðî.
¯ cîÇuClC!|cðî. |ð Uðî cð|ðc!C||î!|cð Cî C| îl|U|CUC UC
|CQ|CîlC| cðuUð| .
¯ bNC. ð|C|cClðl | ð, |C| CÇ|CîC|cClð| | ð, C|cClðlCcClC, C!c.
Iææ 0S
w¿W7 &|ëë1|1g a Das las gësU1!ës
W >?4Jë |a }l00
W U%g. 0g|m
¥ææ G|0l0a ô1|0 < J 4O1gJ|
0SJ|||1a1 palG0
a1a11ës|s pa
c1 |0s Ië!||1ësFës, s| ës p|ë0|R
Ua| J OOg. Jë g|J00sa
GlJ0ë1|a
O< J51g/ú|
ôO<l BO1g/J|
JZO< Jbb 1þJ|
JBO< I4O1g/J|
¯ Lð|U|Cvðîcul ð|C>. !|ð|>ÇC>|clC| UC lC> Q|ð|UC> vð>C>,
C| V, Clª, Lªl C!c.
¯ LC||!Cu|l|ð|lC ðQC|Cîlð |C|ð|, UuÇl|cðc|C| u|C!C|ðl, C!c.
¯ L|. (Qðî!|C||!Cî!| |ð|Cî) || ÇCÇlðîlð UC cC|C| |2ÇulC|UC,
ð!|Cîlð ð|ðl .
J¿.0 Û|8§008Î|00
! . |ðc!C|Cî UC |lCîQC ÇuC |CÇulC|C| u|ð vðlC|ðc|C| îC|Cc·
!lvð UC Ul ðUC!Cî cC| lð |Cð||zðc|C| UC u| !Cî! UC Óbu| | lvð¯
ð| cCUlC|2C UCl CUUð|ðzC.
ÓUCî|UðU (lMC>JU) Cî Cl UC UðyC| ||CîQC.
· ¬lî!C||ð lðU| | | ð| UC LM (ÇðU|Cî C hC|Uð|Cî).
· ª|!CcCUC|!Cî CUî!C!||cCî. ðUC|!Cî UC |CÇC!|c| C|, lC
!Cî UuC|!Cî, UuC|!C |CC|ð!ð| |C CxÇ|¡cðUð, Ç|CUð·
!u|lUðU, Uð|lC|UðclC|Cî cC|QC|l!ðî, || U|ðU|lCî,
Uðc|CîCUlð lC!ðl, Olî!C||ð UC Çð|!C !|ðuUð!lcC.
· ¬1ª c|C|lcð, Ç|CCc| ðUÇî| ð, cð|U| U| ðî| î, |1U UC |CÇC·
!lclC|.
· ª|!CcCUC|!Cî ÇC|îC|ðlCî UC Ul ðUC!Cî QCî!ðc|C|ðl C
l|!ClC|ð|clð Ql uclUlcð.
· bC UCUC |ðcC| u|ð UC!C|U| |ðc| C| UC ¬U Q| |cCî|lðUð
C| | ð Ç|lUC|ð v|îl!ð CUî!C!||cð ð | ðî Çðc|C|!Cî ÇuC
yð îC| U| ðUC!|cðî Ç|Cv|ðUC|!C ð |ð QCî!ðclC| (M|R
9b-99|, 1 74)
· |ð UC!CcclC| UC u|ð Ql ucCU| ð Uðîðl ÇC| C|c|Uð
Oa| Jlë!a Jë l&G
·Hq< 1O0§0|
.
P0la| <I4O0§0Ì
Pa!0|0g|00 s| ?Jëlëi1l1Y|01ës R1 µa!0|0g|O
10b 190
<T40m§l0|
¦
Nmml
1M00
Û¯
1bb T 4b
z \40m§l0|
¦ Tb0
T 90
50 00
§1 00 § T4b
Ì%0Æ\ß
¿Vðµ
T wp
\Eäê1t|ë|êä[||)
Ö be U|ðgÞ0St|Cð|ð U|ðDeteS geStðC|0Þð|
CuðhU00DteÞgðm0S z 0 mðSVð|0|eSð|te·
|ðU0SeÞ|ðS0D|eCð|gðUeg|uC0Sð,CuðÞU0
tehgðm0S U0S Vð|0|eS eÞ ðyuÞðS Supe||0-
|eSð !2ô mgíU|0O0SVð|0feSeÞCuð|qu|e|
m0meht0Supe||0|eSðzoo mglU|.
M be U|ðgÞ0St|Cð|ð |Dt0|e|ðÞC|ð ð |ð g|uC0Sð
CuðÞU0 0DteÞgðm0S uÞ Vð|0| ð|te|ðU0. bÞ
eSt0S CðS0S Se eSpe|ðh z-1 SemðÞðS, y Se
|ep|te hueVðmeÞte |ð S0D|eCð|gð Ue g|u-
C0Sð.
Ö c| t|ðtðm|eÞt0 Ue |ð U|ðDeteS Uu|ðÞte e|
emDðIð20 eS C0Þ U|etð, eje|C|C|0 Í|S|C0 e
|Þ5u||hð. L05 ðÞt|O|ðDét|C05 0|ð|e5 e5tðh
C0ht|ð|ÞU|CðU0S.
P|ê¿ä1IääM|B
Ö M|R o1-o, 98 
M|R 98-99|,  \ 74 
M|R 98-99, \ 74 
OääêOl|1|têBêpmI|¢ê
M N0hðyCðS0SC|Íh|C0S|ep|eSeÞtðt|V0S
CC ¹ zô Jg/C' CO z C'a> C|¦C|Cn!C> pC|J|!C |acC| C'
C agnC>L|cO CC C aOC!C> gC>LacO¯a C |Cc!aJCnLC,
>n nCcC>CaC CC |acC| >c|CC¯ ng ¦M|H 98-99, ¡ 74),
a' gua| quC z va'O|C> a' aza| JayO|C> CC zûû Jg/C
z. bc|CCn ng. ¯C>L CC Òbu' ' van. bC p|ac!ca a !OCa CJOa·
|azaCa Cn!|C ' a> >CJana> z4ª·zoª (|CcuC|Ca quC an!C> nO
>uC' C |aOC| p|OO' CJa> CC |l pC|g' ucCJ a), aunquC pa|C·
cC nO >C| nCcC>a|lO Cn gC>Lan!C> JCnO|C> CC z' anO> > n
!acLO|C> CC |C>gO. bC aCJ n >!|an 'û g CC gl ucO>a y >C
CC!C|Jl na ' a g' ucCJ a Oa>a' y ¹ |O|a pO>! ngC>La. b C'
val O| C> ¹ 4û Jg/C' O JayO|, >C placLca una >OO|Cca|ga
O|a' CC g' ucO>a (bÒC) ¦M|H 03-04, 98)
J. ¯Cs! CC bOO|Cca|ga Ò|a' CC C' ucO>a. bÒC CuanCO >O>·
pCc|aJO> C aOC!C> gC>!ac Ona' !|a> C' >c|CCn ng, p|ac!·
caJO> C>!a pluCOa, quC cOn>>!C Cn. Jan!CnC| Cu|anLC
J C'a> cOn C C!a Oaja Cn ca' O|'a> ( ¹ .oûû ca'O|'as) MCC |
'a g' ucO>a Oa>a' , y aCJ n>!¯a¯ ¹ ûû g CC g' ucO>a. A cOn·
L nuac Cn >C J CC 'a g' ucO>a una vCï caCa |O|a, Culan·
!C ' as J |O|a> > guCn!C> a ' a aCJ| O >!|acCn. |O> va'O|C>
|CcOJCnCaCO> cOJO |CIC|C¯ca >On. ¹ û', ¹ ºû, ¹ ô', ¹ 4'
Jg/Cl
¯agOO>!caJO> C aOC!C> gC>LacOna' > |ay z va|O|C>
gua' C> O JayO|C> a ' O> CC |C!C|Cnc a
bl >C' O ¹ va'O| C> JayO| O gua' , >C CChnC cOJO O!O'C|an·
cla a 'a gl ucO>a, y |Cqul C|C |CpC!| Cl IC>! CD J >CJana>.
J¿.Ì Û00l|0Ì 00|80l0 Ì8 §08l80|00
¹ . `C|h'C> g' ucCJcO>. >C n>L|uyC a 'a pacCnLC Cn Cl au·
!OcOOL|O' g' ucCJcO p|C y pO>!p|anC a' .
z. ¯ CLa |C>L|lcLva CvLa| C' azucal |ChnaCO (pa>!C'C>, ca·
|aJC' O>, |CI|C>cO>, C!c) y |Ca' ïa| CjC|ccO I'>icO.
J. ' O>u| na C>!ö · nC|caCa cuanCO nO >C cOn>|guC un aCC·
cuaCO cOnL|O' g' ucCJcO a pC>a| CC 'a OiCLa y C| CjC|ccO
¯aJO.Cn >C u>a Cn ca>O CC Jac|O>OJ'a O pO' | C|aJn O>
IC!a' , > CnCO Cl >cu! CO >u u>O CC JanC|a p|CvCn!va.
4 ca ¬O Aìc nO> lnIO|Ja CC' mC!aOO' >JO Cn 'a> u' L| Ja>
o·¹ z >CJana>. ¯CnC va' O| p|OOC>LcO pa|a ' a> Ja'IO|Ja
c OnC>
' na|zacCn CC' CJOa|azO. |O> c|LC|O> CC l na' zacCn CC'
CJOa|azO >OD gC>LaclCD a LC|m nO, >uI|JCnLO ICLa' , Ja'
cOn!|O' JCLaOC' cO (g' ucCJ as JayO|C> CC ¹ 4û Jg/C').
|n p|lnclpO, >C n!CnIa quC C' pa|!O >Ca vag na' . ca> nCl·
cacOOC> CC cC>ð|Ca >On 'a> J>Ja> quC Cn ' a gC>Lan!C
nO C aOC!ca.
|n 'a> pacCn!C> cOD |C!lDOpa!'a p|O' IC|a!va >CvC|a C>!ð
nCcaCO aOlCvla| Cl pC|'OCO Cxpu' >lvO, JCCanLC cC>ö|Ca
O JCCan!C pa|!O lD>I|uJCnIal, pa|a Cv!a| un CC>p|CnC·
JCnLO CC |CI na t>Ia cOnvCn Cnc a CC aO|Cva| C' pC||O
CO Cxpu' >vO >C apl l ca LaJO CO Cn JOpla Jagna y OL|a>
pa!O'Ogla> Ocu' a|C> cOn |lC>gC CC CC>p|CnC JCnIO CC
|CIna, nCCpCDClCnLCJCnIC CC quC ' a JaC|C >Ca C aOC·
L ca O nO.
COnL|O| JCLaOC' cO nI|apa|LO bC cOJCnza una pC|Iu
>Cn .v. CC >uC|O gl ucO>aCO al ¹ û%, cOn cOnI|O' |O|a|O
CC ' a g' ucCJ a, y CC la cC!Onu| a Cn caCa JlccCn bl ' a
g' ucCJ a C> JayO| CC ºû Jg/C' , >C cOJ Cnïa ' a n>u' nO·
LC|ap|a, quC >C nLC||uJpl |ð CO Cl Cxpu' >lvO.
`uC|pC|O bC JaD!CnC C' >uC|O gl ucO>aCO al ¹ û% |a>!a
|CanuCa| ' a al l JCnIaclCn. A 'O> CO> JC>C> CC' pa|LO, y
una vCz hnallzaCa 'a ' acLanc a, >C CCOC lCa'za| Jna >O·
O|Cca|ga O|a' cOn /' g|aJO> CC g' ucO>a.
JJ.1 ¥800080|0008
t¯!a| cCD!lai|C|caCa¯. pa¯C!iCiI|¯, |uOCC' a (Ml h 99·00,
J9), ¯a¯anp|C|, hCO¯C ana¯| ' ' a (¯C| v|¯u¯ vivC¯ a!C|ua-
CC¯). NC ¯C ¯CcCniCDCa 'a vacu|aciC| ¯|¯!Cna!ica cC|I¯a.
g|ipC, pC'|Cn|Cli!i¯, |Cpa!iI|¯ b  (M|h 99-00, 2 T 7), au|quC
¯C| vacuDa¯ pC¯n|!iCa¯ Cu|aD!C Cl CnOa|a2C, ¯i IuC¯aD
¤CcC¯a¯|a¯.
ca vacu|ac|CD I|CD!C a la hCO¯C !ilCiCCa C¯ pC¯ni¯|OlC,
¯|Cnp¯C quC C¯!C aO¯C' uIanC|IC | DC| caCa.
ca CC la |aO| a, C| IIC¯|a y C' ICIaDC¯ ¯ CCOC| aCni D|¯I¯a¯¯C
cuaDCC C¯!CD iDCicaCa¯ (¯CD IOxCiCC¯), al igual quC ' a !C¯
IC|iDa (cClula¯ nuC¯!a¯).
JJ.¿ 10I0þ|88M08|8
SC !¯a!a CC uDa ||ICcciCD ||Ccua C| C' aCu'!C, quC cC|
I|CcuCDc|a pa¯a a¯| |!Cna!|ca. `uCCC apalCcC| | |ICcciCD
IC!a' pC¯ va I|a|¯p' acCD!al|a cCnC cC|¯CcuC|c|a CC p¯|·
0C| |ICcc|CD paCCciCa pC¯ la naC¯C Cu¯a|!C C' CnOa¯a·
2C.
c' l|C¯gC CC' lCIC C¯!a CD ¯Clac|C| cC| C' nCnC|IC CD
quC Ccu¯¯C la | |ICcc|C| na!C¯|a A¯l, ¯C cal cu' a quC Cl
¯|C¯gC CC i|ICcciCD lC!a' a' caD2a C' J ', J0 yô0% ¯CgúD
ICDga 'uga¯ C| Cl p¯| nC|C, ¯CguDCC y IC¯cCl I¯|nC¯!¯C CC
'a gC¯!ac|CD ¯C¯pCc!|vanCD!C. S| | CnOa|gC, ' a g¯avCCaC
C¯ nuc|C nayC| ¯i Ccu||C C| 'a¯ p¯| nC¯a¯ ! z ¯Cna|a¯,
puC¯ ¯C p|CCucC u| alIC pClcCD!ajC CC aOC|!C¯ C CnO|iC-
pa!a¯ g¯avC¯.
ca i|ICcc|CD C| l a CnOa¯a2aCa ¯C ca¯acIC¯i2a pC| ' a apa|i ·
c|CD CC a¯ICD| a y aDC¯Cx| a, acCnpanaCa¯ CC aCC|Cpa!la¯
cC¯v|ca'C¯ y cuaC|C Ia|i DgCan| gCal a¯. t¯IC cuaC¯C puCCC
¯| nu' a| uDa nCDC|uclCC¯|¯ | |ICcc|C¯a.
ca c' || ca C| C' IC!C ¯C ca¯ac!C|i2a pC| cC¯|C¯¯CI|D|!i¯ (na¯
I¯CcuCD!C), || C|CcCIa' |a, ca' c|hcac|CDC¯ cC|CO|alC¯ y cC|
vu' ¯iCDC¯ (!C!¯aCa CC SaOiD), au|quC 'a cllDica C¯ nuy
va|iaO' C y puCCC| apa¯CcC| IC¯na¯ ¯| | !CCa 'a ¯||ICna-
!C'Cgla.
Û|8]OÓSÍ|CO
SC|C'Cga C| 'a p¯| nC¯a v|¯iIa p¯CDaIal. |D ca¯C CC naC¯C¯
¯i| aD!icuC|pC¯, ¯C ¯CpC!|¯a 'a ¯ClClCga CD Cl ¯Cgu|CC y
!C¯cC| !|| nC¯I¯C CC gC¯Iac|C| pa|a CC!Cc!a¯ pC¯iOlC¯ ¯C|C·
cC|vC|¯|CDC¯ a¯iD!CnaI|ca¯. SCD iDCicaI|vC¯ CC iDICcc|C|
ac!|va uDa 'gL c|Cc|CD!C C uDa l gM pC¯|Iiva. ;l C|agDC¯·
I|cC CC ' a ||ICcc|CD lCIa' ¯C |Cali2a a pa¯I| ¯ CC ' lquiCC an·
Di CI| cC C ¯aDg|C IC!a' , CC!C|n| DaDCC ' gM, |Lh C Cul!lvC¯.
|a p¯C¯8Dc|a CC |i C|CcCIal | a C calciÞcaciCDC¯ cC¯CO|alC¯
C|¯pC¯¯a¯ ¯CD Ca!C¯ CcCg¯ahcC¯ quC ¯ug|C|C| ' a p¯C¯CD·
c|a CC |DICcc|C| lCIal.
||OÍ||8X|S
ca¯ nCCiCa¯ p¯| na|i a¯ quC ¯C ¯CcCni CDCa| pa¯a Cv|Ia| ' a
||ICcciCD CD l a¯ gC¯!a|IC¯ ¯u¯cCp!|OlC¯ ¯C|. Cv|!a¯ ICca¯
CjC¯ y OCca ¯i D 'ava|¯C 'a¯ na|C¯ CC¯puC¯ CC |aOC| !C·
caCC ca|DC c¯uCa, Cv|Ia| la iDgC¯!a CC ca¯DC pCcC cCciCa,
Cv|Ia¯ C' cCD!ac!C cCD aDi na' C¯ ¯C¯C|vC|iC (gaIC¯ , cCDC·
jC¯, gal ' | |a¯, pa'Cna¯ y pC¯¯C¯), a¯Cgu¯a|¯C CC 'ava| O|CD
I|uIa¯ y vC¯Cu¯a¯ a|!C¯ CC cC|¯un|¯'a¯, pC|C¯¯C guaD!C¯
¯| |ay quC ¯Ca' | 2a¯ !¯aOajC¯ CC ja¯CiDC¯a, C!c
i |8I8T |0OIO
c| la¯ gC¯!a|IC¯ CD la¯ ¯C CO¯C¯vC ¯C¯CcCDvC|¯|CD, C¯!a
|DCiCaCC C' I|a!aniCD!C CC| CSp| ¯aniCiDa Cu|aD!C ICCC
Cl CnOa¯a2C. Si ¯C CiagDC¯I|ca | |ICcciCD IC!a', ¯C CCOC
anaCi¯ p| ¯i nC!aniDa y ¯ulIaCia2iDa CD cic'C¯ CC J ¯C·
naDa¯, a' !C¯|a|CC cC| C¯p| ¯an| c| |a |a¯Ia C' hDal CC 'a
gC¯!ac|C|. SC ¯CcCn|CDCa 'a ¯uplCnC|!ac|C| cCD aciCC
IC' ||cC pa¯a p¯CvC|| ¯ 'a CCp¯C¯|C| nCCu'a¯ p¯CCuc|Ca
pC¯ 'a p| ¯| nCIaniDa.
JJ.J h0080|8
ca |DICcc|C| cC|gC||!a pC¯ ¯uOCC' a |a C| ¯n| Du| CC C¯a¯I|·
canCDIC pC| ' a vacu|ac|C| gCDC¯al|2aCa CC la pCO'ac|C|
ICnCD||a CD ' a puOC¯!aC, ¯| OiC| C¯!anC¯ a¯i¯!|C|CC a u|
pCquCOC ¯CpuD!C CC 'a n|¯na CCO·CC a 'a pCO'ac|C| | |n| ·
g¯aDIC quC |C C¯Ia vacuDaCa I¯C|!C a 'a Ci c|a ||ICcc|CD.
ca ¯uOCC'a puCCC p¯CvCca¯ g¯avC¯ a'!Clac|C|C¯ IC!a'C¯,
CCpCDCiC|CC CC ' a CpCca CC 'a gC¯!ac|CD CuaDCC 'a
naC|C ¯C cC|!agia CCD!|C CC l a¯ p¯| nC|a¯ o ¯CnaDa¯, 'a
| |ICcc|C| IC!a' ¯upC¯a C' o0%, ¯|C|CC ' a ¯C|CC¯a |Cu¯C¯C|·
¯C¯|a' C' CCICc!C na¯ cCnuD CDcCD!laCC CD 'C¯ ||OC¯ quC
¯C i DlCc!a¯C| C|!|C ' a 9ª· ì Jª ¯Cna|a. LC¯puC¯ CC C¯!a IC·
cha, ' a¯ nallC|nac|C|C¯ ¯CvC¯a¯ ¯C| nCDC¯ I¯CcuC|!C¯
Û|8]OÓSI|CO
cl C| agDC¯!icC ¯C ¯Ca'|2a nCC|a|IC 'a CC!Ccc|CD CC a|Ii·
cuC¯pC¯. ÜD !!u'C ~ ì /ì ô ||C|ca ¯u¯cCp!|Oil|CaC a 'a ||ICc·
c| C|. Ü|a 'gL pC¯|!|va cC| 'gM |Cga!|va ¯| g|| hca quC 'a
paciC|IC |a pa¯aCC 'a ||ICcciC| (M|h 9b-9ô|, 2 \ J) Ü|a
lgM pC¯|Iiva | np' |ca |DlCcc|CD lCc|C|!C.
|a apa¯| c| CD CC 'gM na!C¯Da pC¯|!iva cC|¯!|!uyC u|a
i DCi caci CD pa¯a la CC!C|n||ac|CD CC l gM IC!a' (Ml h 98·
99, T 72). |a p¯uCOa na¯ u¯aCa C¯ C' tc' SA. SC CC¯ca¯!a
¯uOCC'a cC|gC||!a ¯| 'a naC¯C |C !|C|C a|!| cuC¯pC¯ 'gL
C ¯i lC¯ I!ulC¯ CC ig L C| C' ||OC (pC¯|!lvC¯ a' |ac| n|C|!C)
CC¯c|C|CCD |a¯!a CC¯apa¯CcC| C| ô· ! z nC¯C¯
||OÍ||8X|S ÿI|8I8T| 0OIO
NC |ay !¯aIan|C|!C a|!ivi¯al CICc!|vC pa¯a 'a |uOCCla
cC|gCDi!a NC ¯C |CcCniC|Ca C' u¯C p¯Chlac!icC CC la
gannag' COu' | |a u|a vC2 quC |a !C||CC ' a CxpC¯|c|C|,
puC¯ |C pa¯CcC Ci ¯ni Du| ¯ C' |ie¯gC lCIal. ca p¯CvCDc|CD
nCC|a|!C ' a¯ canpaOa¯ CC vacuDaciC| C¯ lu|CanCD!a' .
ca u||ca nCC|Ca p¯CvC|!|va cC|¯| ¯!C CD vacuDa a !CCa
nujC| |C | |nu|C C| CCaC lC¯!| ' y CCnC¯a¯ C' CnOala2C
|a¯!a pa¯aCC¯ pC| ' C nCDC¯ !¯C¯ nC¯C¯ CC¯CC la vacu·
Dac|CD, au|quC DC ¯C |a CCnC¯!¯aCC quC C' v|lu¯ CC 'a
vacuDa ¯Ca pC¯juC| c| a' pa¯a Cl IC!C.
JJ.4 Û|Î0M0§8|0¥||08
t' ci!CnCga'Cvilu¯ (CMV) C¯ u|a CC ' a¯ v|¯|a¯|¯ ¯u¯cCp!i·
OlC¯ CC ¯C¯ CCD!|alCa¯ pC| la naC|C Cu|a|IC 'a gC¯IaCiCD
y CC aICcIa| al lC!C tD la naC¯C, 'a ||ICcc|C| ¯uC'C ¯C¯
a¯||!Cna!ica. Au|quC u| | npC¯!a|!C pC¯cCD!ajC CC ' a¯
CnOa¯a2aCa¯ ¯C| ¯u¯cCpI|OlC¯ a ' a | |ICcc|C| al i Di ci a| la
gC¯Iac|C|, ¯ClC uD J% cCD!¯aC| 'a p¯| nC| |ICcc|C|, y CC
C¯!a¯ ¯ClC CD u| b0% ¯C p¯CCucC 'a ||ICcc|CD IC!a' . S| 'a
p¯| nCi DICcciCD I|CDC 'uga| CulaD!C C' p¯inCl !|inC¯!¯C,
lC¯ C¯ga|C¯ aICc!C¯ puCCCD ¯C¯ SNC, cC|a2CD, CjC¯ y
CCC
,a |DICcc|C| Cu|aD!C Cl ¯Cgu|CC !|inC¯I|C puCCC p¯CCu·
c| ¯ nic|CcCIal | a, |CpaICC¯p' CDCnCgalia, Cl L C ic!C¯|c|a.
Û| 8]OÓSI|CO
AO!C l a ¯C¯pCc|a CC C|IC|nCCaC naIC¯|a, CCOC ¯C' | c| ·
!a¯¯C ¯ClC'Cga CC CMV Ü| val C¯ ClCvaCC CC ' gM C¯ C| ag·
DC¯I| cC CC | |ICcc|C| ac!|va p¯| na¯| a C ¯Ccu||C|IC. `a¯a C'
Ciðg|CS!iCC CC iDlCCC|CD IC!a' , CS nuC|C naî haOl C la
CCnC¯!¯ac|CD CCl agCDIC C| Cl ' qu| CC anDiC!icC quC Cl
C¯¹uCl CCC la ¯a¯g¯C IC!a'

b0MÿÌÌ080Ì0008
Ì0Î000Ì0$8$
. t- t i | t
0||ê1târ|e1 N|H
L5 UD I0Rð ÇOCO Ì RÇOlIðDI0. c5IÚOÌðI0 |osÑ
ð5Ç0C\O5 050DCÌðÌ05.
M Etc1r|â|ct [||
Lð5 ÚDÌCð5 VðCUDð5 QU0 50 Ç0lRÌI0D OUlðD~Õ
I0 Ìð g05IðCÌÓD 5OD |osIOXOÌO05 [IÉIðDO5,
lðDÌð, OÌÍI0lÌð), RÌ0DIlð5 QU0 ðQU0ÍÌð5 O0
VÌlU5 VÌVO5 ðI0DUðOO5 05IðD IOIðÌR0DI0
CODIlðÌDOÌCðOð5 (ÇðlOIÌOÌIÌ5, lUDÉOÌð, 5ð~
fðRÇÌÓD, H0Dl0 ðRðlÌÌÌð).
lÆ ÇlÌROÌ DÍECÌÓD ÇOl IOXOÇlð5Rð OUlðDI0 Ø
0Ì 0RDðlðZO ÇU0O0 ÇlOVOCðl UDð ÌDÍ0CCÌÓD
Í0IðÌ ÇOl VÍð IlðD5ÇÌðC0DIðlÌð. L5 lUIÌDðlÌð
Ìð 50lOÌOgÍð O0 IOXOÇÌð5Rð 0D 0Ì ÇlÌR0l
IlÌR05Il0. ÌÆ5 ÇðCÌ0DI05 ÌDRUD05 DO Çl0~
O5ðD Rð5 CODIfOÌ05, RÌ0DIlð5 QU0 Ìð5 DO
ÌDRUD05 O0D0D l0Ç0IÌl CODIlOÌ05 IOOO5 ÌO5
IlÌR05Il05. ÅO0Rð5, 50 l0CORÌ0DOðD R0~
OÌOð5 Çl0V0DIÌVð5 Çðlð 0VÌIðl Ìð ÌDÆCCÌÓD,
CORO 0VÌIðl Ìð Ì Dg05Ið O0 CðlD0 ÇOCO CO~
CÌDðOð, ÌðVðl DÌ0D ÍlUIð5 ÿ V0lOUlð5, 0VÌ\ðl
CODIðCIO COD ðDÌRðÌ05 l050lVOlÌO . . .
bÌ ðÇðl0C0 50lOCODV0l5ÌÓD Çðlð IOXOµÌð5~M
U, 50 Ì DÌCÌðlð IlðIðRÌ0DIO COD 05ÇÌlðRÌCÌ~
Dð ÿ % CORÇlODðlð 5Ì 0XÌ5I0 O DO ÌDÆCCÌÓD
Í0IðÌ. bÌ 0XÌ5I0, ðDðOÌl0RO5 ðÌ IlðIðRÌ0DIO
5UÍÍðOÌðCÌDð ÿ ÇÌfÌR0IðRÌDð.
Lð ÌDÍ0CCÌÓD CODgÉDÌIð ÇOl lUDÉOÌð Dð OÌ5· M
RÌDUÌOO ÇOl Ìð VðCUDðCÌÓD 5Ì5I0RðIÌCð. cÌ
OÌðgDÓ5IÌCO 50 l0ðÍÌZð R0OÌðDI0 Ìð O0I0l·
RÌDðCÌÓD O0 ðDIÌCU0lÇO5. Lð Çl050DCÌð O0
ÌgN ÌRÇÌÌCð ÌDÆCCÌÓD l0CÌ0DI0. NO 0XÌ5I0
UD IlðIðRÌ0DIO 0ÆCIÌVO Çðlð Ìð lUDÉOÌð
CODgÉDÌIð.
¶ Eäê1t|ë|ê䦶
M |a se·o|oq|a pata s|6||s es o|qatot|a eo e|
pt|met tt|mestte. se tea||zatao ptuebas oo
ttepooém|cas y s|, éstas tesu|tao pos|t|vas,
se oatao ptuebas mém|cas. s| soo po-
s|t|vas, ptocedetemos coo e| ttatam|eoto
coo peo|c|||oa |o mas ptecoz pos|b|e, ya
que s| se ·ea||za aotes de |a semaoa ¡ 6, ev|-
ta |a s|6||s cooqéo|ta.
Ö |a pto6|ax|s coo |soo|ac|da puede tea||zat-
se eo aque||os casos eo |os que e |od|-
cada.
M ëo uo caso de vat|ce|a dutaote |a qesta-
c|oo, adm|o|sttatemos ac|dov|t s|. desatto-
||o tu|m|oaote, vat|ce|a bemottaq|ca, 6ebte
a|ta, oeumoo|a var|ce|osa o oetpes zostet.
Ladm|o|sttac|oo de qammaq|obu||oa oo
esta |od|cada, sa|vo que e| cuadto apatez-
ca eo |as z-1 semaoas ptev|as a| paoo, y
se ut|||za pata d|sm|ou|t |a qtavedad de |a
vat|ce|a oeooata|.
Ö ëo e pac|eotes v|n, es oecesat|o e| tta-
tam|eoto dutaote e| embatazo pata d|s-
m|ou|t |a ttaosm|s|oo vett|ca|. se ut|||zata
pauta de tt|p|e tetap|a como eo pac|eotes
oo qestaotes, ev|taodo |os tatmacos que
t|eoeo demosttada tetatoqeo|a (etav|teoz
y de|atv|d|oa;.
Ö ësta·a |od|cada |a exttacc|oo teta| me-
d|aote cesatea s|. detet|oto |omuoo|oq|co
(c
O
zæ;, catqa v|ta| detectab|e, oo tta-
tam|eoto aot|ttettov|ta| dutaote e| emba-
tazo, ptematut|dad y totuta ptematuta >4 
|otas.
W se ·ecom|eoda tea||zat a todas |as qestao-
tes a| 6oa| de| embatazo (1s-16 semaoas)
uo cu|t|vo vaq|oa| y otto aoortecta| pata
detectat a |as mu]etes pottadoras de| es-
tteµo b y pautat pto6|ax|s aonbiot|ca
|ottapa·to coo peo|c|||oa o amp|c|||oa. ëo
|as mu]etes coo cu|t|vo oeqat|vo eo |as que
ex|steo ottos tactotes de t|esqo de seps|s
p·ecoz (o}o ptev|o coo eotetmedad pot
5Gb, bactet|ut|a pot 5Gb, ptematut|dad,
totuta de membtaoas > ¡so, 6ebte |otta-
patto;, tamb|éo esta |od|cado e| ttatam|eo-
to aot|bm.
!|dÍdT|00Í0
NC Cx>!Cn nCC Cö> p|Ch'ðc!cö> n !C|öpCu!cö> C>pCc·
hcö>
JJ.0 b|Í|||8
cö >'h' > cCngCn!ö öun >C p|CCucC Cn nuC>!|C pö'>, öun·
quC ' ö p|Cvö' Cnc ö CC C>!ö CnlC|nCCöC C> Oöjö. |>Iðn C>·
pCc ö' nCn!C CxpuC>!ö> ö' cCn!ögC 'ö> gC>!önIC> jCvCnC>
C|CgöCc!ö>, CC OöjC nvC' >CcCCcCnCncC y cCO p|Cn>
cul CöC >Cxuöl.
Lö> nujClC> cCn nð> p|COöO' CöC CC !CnC| |jC> öICc!C>
>Cn 'ö> nC I|ö!öCö> cCn >'hll> p| nö| ö, >CcunCö|ð C 'ö!Cn·
cö p|CcCï. Yö quC Cn nuc|C> cö>C> 'ö> nujC|C> öICc!ö
Cö> OC p|C>CnIön nön|IC>!öcCnC> vl>O'C>, C> p|CcCpIvC
|Cölzö| unö p|uCOö >C|C'Cgcö (nC !|CpCnCncö) ö !CCö>
'ö> gC>!önIC>
b C' n nC >C nICc!ö, 'C> >lgnC> CC >'h' > p|CcCz >C CC>ö·
||C' l ön CCn!|C CC ' C> !|C> nC>C>, >CO|C !CCC lö> ' C>CnC>
cu!önCCnucC>ö>, ' ö C>!CCcCnC| ! > y ' ö |Cpö!CC>p' CnC·
nCgöl ö.
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V¯HL C H`H. bCn p|uCOö> nC !|CpCnCncö>, i nC>pCc|hcö>,
vð' Cö> pö|ö C' >c|CCn| ng (quC C> COlgö!C|C) (M|R 05-0ô,
l ôô), pC|C nC pö|ö C' C ögnC>!cC C>pCc|lcC, yö quC C'
CnOö|özC C> ' ö p| nC|ö cöu>ö CC lö'>C pC>l!vC.
'¯A·AO> C M¬A·¯` bCn p|uCOö> !|CpCnCncö> bC |Cö' ·
ïö|ðO Cn cö>C CC pC>!vC Cn ' ö> nC !|CpCnCn cö> NC>
p|CpC|cCnön un CögnC>!cC C>pCc'hcC
i|dÍdT|00Í0
|l önI OC!cC CC C'CccCn C> 'ö pCn c ' nö |l !|öIönCnIC
ön!C> CC lö> l ô >Cnönö> Cv!ö 'ö >lh' > cCngCn!ö cC>puC>
CC ' ö ! O >Cnönö> cu|ö 'ö nICccCn, pC|C nC Cv!ö ' C> C>
!gnö> cCngCn!C>. |n cö>C> CC ö' C|g ö, >C puCCC u! ' zö|
' ö C| !|Cn c nö, > O Cn I CnC unö> !ö>ö> CC cu|öc Cn nu
c|C nCnC|C> pC| ' C quC C> öcCn>CjöO'C n>| >! | Cn C' !|ö!ö·
nCn!C cCn pCn c ' nö (|Cö'zö| CC>Cn> O ' zöcCn).
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M|R20-205RC:J
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de, desarrO||a un cuadrO de exanIema y
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r|esgOde|nkcc|ónembr|O-kta|.
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