{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T19:43:09Z","timestamp":1783539789886,"version":"3.55.0"},"reference-count":68,"publisher":"Federacion Colombiana de Obstetricia y Ginecologia","issue":"3","license":[{"start":{"date-parts":[[2022,9,30]],"date-time":"2022-09-30T00:00:00Z","timestamp":1664496000000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"}],"content-domain":{"domain":["revista.fecolsog.org"],"crossmark-restriction":false},"short-container-title":["Rev. Colomb. Obstet. Ginecol."],"abstract":"<jats:p>Introducci\u00f3n: el espectro de acretismo placentario (EAP) es una condici\u00f3n asociada a sangrado masivo posparto y mortalidad materna. Las gu\u00edas de manejo publicadas en pa\u00edses de altos ingresos recomiendan la participaci\u00f3n de grupos interdisciplinarios en hospitales con recursos suficientes para realizar procedimientos complejos. Sin embargo, algunas de las recomendaciones de estas gu\u00edas resultan dif\u00edciles de aplicar en pa\u00edses de bajos y medianos ingresos.Objetivos: este consenso busca formular recomendaciones generales para el tratamiento del EAP en Colombia.Materiales y m\u00e9todos: en el consenso participaron 23 panelistas, quienes respondieron 31 preguntas sobre el tratamiento de EAP. Los panelistas fueron seleccionados con base en la participaci\u00f3n en dos encuestas realizadas para determinar la capacidad resolutiva de hospitales en el pa\u00eds y la regi\u00f3n. Se utiliz\u00f3 la metodolog\u00eda Delphi modificada, incorporando dos rondas sucesivas de discusi\u00f3n. Para emitir las recomendaciones el grupo tom\u00f3 en cuenta la opini\u00f3n de los participantes, que lograron un consenso mayor al 80 %, as\u00ed como las barreras y los facilitadores para su implementaci\u00f3n.Resultados: el consenso formul\u00f3 cinco recomendaciones integrando las respuestas de los panelistas. Recomendaci\u00f3n 1. Las instituciones de atenci\u00f3n primaria deben realizar b\u00fasqueda activa de EAP en pacientes con factores de riesgo: placenta previa e historia de miomectom\u00eda o ces\u00e1rea en embarazo previo. En caso de haber signos sugestivos de EAP por ecograf\u00eda, las pacientes deben ser remitidas de manera inmediata, sin tener una edad gestacional m\u00ednima, a hospitales reconocidos como centros de referencia. Las modalidades virtuales de comunicaci\u00f3n y atenci\u00f3n en salud pueden facilitar la interacci\u00f3n entre las instituciones de atenci\u00f3n primaria y los centros de referencia para EAP. Se debe evaluar el beneficio y riesgo de las modalidades de telemedicina. Recomendaci\u00f3n 2. Es necesario que se definan hospitales de referencia para EAP en cada regi\u00f3n de Colombia, asegurando el cubrimiento de la totalidad del territorio nacional. Es aconsejable concentrar el flujo de pacientes afectadas por esta condici\u00f3n en unos pocos hospitales, donde haya equipos de cirujanos con entrenamiento espec\u00edfico en EAP, disponibilidad de recursos especializados y un esfuerzo institucional por mejorar la calidad de atenci\u00f3n, en busca de tener mejores resultados en la salud de las gestantes con esta condici\u00f3n. Para lograr ese objetivo los participantes recomiendan que los entes reguladores de la prestaci\u00f3n de servicios de salud a nivel nacional, regional o local vigilen el proceso de remisi\u00f3n de estas pacientes, facilitando rutas administrativas en caso de que no exista contrato previo entre el asegurador y el hospital o la cl\u00ednica seleccionada (IPS).Recomendaci\u00f3n 3. En los centros de referencia para pacientes con EAP se invita a la creaci\u00f3n de equipos que incorporen un grupo fijo de especialistas (obstetras, ur\u00f3logos, cirujanos generales, radi\u00f3logos intervencionistas) encargados de atender todos los casos de EAP. Es recomendable que esos grupos interdisciplinarios utilicen el modelo de \u201cpaquete de intervenci\u00f3n\u201d como gu\u00eda para la preparaci\u00f3n de los centros de referencia para EAP. Este modelo consta de las siguientes actividades: preparaci\u00f3n de los servicios, prevenci\u00f3n e identificaci\u00f3n de la enfermedad, respuesta ante la presentaci\u00f3n de la enfermedad, aprendizaje luego de cada evento. La telemedicina facilita el tratamiento de EAP y debe ser tenida en cuenta por los grupos interdisciplinarios que atienden esta enfermedad.Recomendaci\u00f3n 4. Los residentes de Obstetricia deben recibir instrucci\u00f3n en maniobras \u00fatiles para la prevenci\u00f3n y el tratamiento del sangrado intraoperatorio masivo por placenta previa y EAP, tales como: la compresi\u00f3n manual de la aorta, el torniquete uterino, el empaquetamiento p\u00e9lvico, el bypass retrovesical y la maniobra de Ward. Los conceptos b\u00e1sicos de diagn\u00f3stico y tratamiento de EAP deben incluirse en los programas de especializaci\u00f3n en Ginecolog\u00eda y Obstetricia en Colombia. En los centros de referencia del EAP se deben ofrecer programas de entrenamiento a los profesionales interesados en mejorar sus competencias en EAP de manera presencial y virtual. Adem\u00e1s, deben ofrecer soporte asistencial remoto (telemedicina) permanente a los dem\u00e1s hospitales en su regi\u00f3n, en relaci\u00f3n con pacientes con esa enfermedad.Recomendaci\u00f3n 5. La finalizaci\u00f3n de la gestaci\u00f3n en pacientes con sospecha de EAP y placenta previa, por im\u00e1genes diagn\u00f3sticas, sin evidencia de sangrado vaginal activo, debe llevarse a cabo entre las semanas 34 y 36 6\/7. El tratamiento quir\u00fargico debe incluir intervenciones secuenciales que pueden variar seg\u00fan las caracter\u00edsticas de la lesi\u00f3n, la situaci\u00f3n cl\u00ednica de la paciente y los recursos disponibles. Las opciones quir\u00fargicas (histerectom\u00eda total y subtotal, manejo quir\u00fargico conservador en un paso y manejo expectante) deben incluirse en un protocolo conocido por todo el equipo interdisciplinario. En escenarios sin diagn\u00f3stico anteparto, es decir, ante un hallazgo intraoperatorio de EAP (evidencia de abultamiento viol\u00e1ceo o neovascularizaci\u00f3n de la cara anterior del \u00fatero), y con participaci\u00f3n de personal no entrenado, se plantean tres situaciones:Primera opci\u00f3n: en ausencia de indicaci\u00f3n de nacimiento inmediato o sangrado vaginal, se recomienda diferir la ces\u00e1rea (cerrar la laparotom\u00eda antes de incidir el \u00fatero) hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirug\u00eda segura.Segunda opci\u00f3n: ante indicaci\u00f3n de nacimiento inmediato (por ejemplo, estado fetal no tranquilizador), pero sin sangrado vaginal o indicaci\u00f3n de manejo inmediato de EAP, se sugiere realizar manejo en dos tiempos: se realiza la ces\u00e1rea evitando incidir la placenta, seguida de histerorrafia y cierre de abdomen, hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirug\u00eda segura.Tercera opci\u00f3n: en presencia de sangrado vaginal que hace imposible diferir el manejo definitivo de EAP, es necesario extraer el feto por el fondo del \u00fatero, realizar la histerorrafia y reevaluar. En ocasiones, el nacimiento del feto disminuye el flujo placentario y el sangrado vaginal se reduce o desaparece, lo que hace posible diferir el manejo definitivo de EAP. Si el sangrado significativo persiste, es necesario continuar con la histerectom\u00eda haciendo uso de los recursos disponibles: compresi\u00f3n manual de la aorta, llamado inmediato a los cirujanos con mejor entrenamiento disponible, soporte de grupos expertos de otros hospitales a trav\u00e9s de telemedicina. Si una paciente con factores de riesgo para EAP (por ejemplo, miomectom\u00eda o ces\u00e1rea previa) presenta retenci\u00f3n de placenta posterior al parto vaginal, es recomendable confirmar la posibilidad de dicho diagn\u00f3stico (por ejemplo, realizando una ecograf\u00eda) antes de intentar la extracci\u00f3n manual de la placenta.Conclusiones: esperamos que este primer consenso colombiano de EAP sirva como base para discusiones adicionales y trabajos colaborativos que mejoren los resultados cl\u00ednicos de las mujeres afectadas por esta enfermedad. Evaluar la aplicabilidad y efectividad de las recomendaciones emitidas requerir\u00e1 investigaciones adicionales.<\/jats:p>","DOI":"10.18597\/rcog.3877","type":"journal-article","created":{"date-parts":[[2022,10,28]],"date-time":"2022-10-28T13:01:49Z","timestamp":1666962109000},"page":"283-316","update-policy":"https:\/\/doi.org\/10.18597\/crossmark","source":"Crossref","is-referenced-by-count":4,"title":["Consenso Colombiano de Tratamiento del Espectro de Acretismo Placentario (EAP)"],"prefix":"10.18597","volume":"73","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5639-9127","authenticated-orcid":false,"given":"Albaro Jos\u00e9","family":"Nieto-Calvache","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0720-9248","authenticated-orcid":false,"given":"Jos\u00e9 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