3a Edición CLAP/SMR Publicación Científica Nº 1577 - 2011 6$/8'6(;8$/<5(352'8&7,9$ *XtDVSDUDHO &217,182'($7(1&,21 GHOD0XMHU\HO5HFLpQ1DFLGR IRFDOL]DGDVHQ$36 5LFDUGR)HVFLQD 'LUHFWRUGHO&/$3605&RRUGLQDGRUGH3URJUDPD665236206 %UHPHQ'H0XFLR $VHVRU5HJLRQDO665&/$3605236206 -RVp/XLV'tD]5RVVHOOR $VHVRU&/$3605236206 *HUDUGR0DUWtQH] $VHVRU&/$3605236206 6X]DQQH6HUUX\D $VHVRU5HJLRQDO665&/$3605236206 3DEOR'XUiQ $VHVRU5HJLRQDO(Q6DOXG3HULQDWDO&/$3605236206 D(GLFLyQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD 6DOXGGHOD0XMHU\5HSURGXFWLYD &/$3605236206 0RQWHYLGHR8UXJXD\ 3XEOLFDFLyQ&LHQWt¿FD&/$36051 )HVFLQD5+'H0XFLR%'tD]5RVVHOOR-/0DUWtQH]*6HUUX\D6'XUiQ36DOXGVH[XDO\UHSURGXFWLYD JXtDVSDUDHOFRQWLQXRGHDWHQFLyQGHODPXMHU\HOUHFLpQQDFLGRIRFDOL]DGDVHQ$36D(GLFLyQ0RQWHYLGHR &/$36053XEOLFDFLyQ&/$3605 ,6%1 6$/8'0$7(512,1)$17,/ 6(59,&,26'(6$/8'5(352'8&7,9$ (1)(50('$'(6'(/5(&,(11$&,'2 $7(1&,Ï135,0$5,$'(/$6$/8' $7(1&,Ï135(1$7$/ $7(1&,Ï1'(/5(&,(11$&,'2 $%2572 *8Ë$ , 7tWXOR ,, &/$3605 1/0:4 $JUDGHFLPLHQWRVD 0DULHOD/DUUDQGDEXUXSRUVXFRODERUDFLyQHQHO³&DStWXOR3UHFRQFHSFLRQDO´ )HUQDQGR6LOYHUD0DULDQHOD5RGUtJXH]\)HUQDQGR0DFtDVSRUVXFRODERUDFLyQHQHO³&DStWXOR$WHQFLyQ GHO5HFLpQ1DFLGR´ )DELiQ5RGUtJXH]SRUVXFRODERUDFLyQHQHO³&DStWXOR$ERUWR´ /D 2UJDQL]DFLyQ 3DQDPHULFDQD GH OD 6DOXG GDUi FRQVLGHUDFLyQ PX\ IDYRUDEOH D ODV VROLFLWXGHV GH DXWRUL]DFLyQSDUDUHSURGXFLURWUDGXFLUtQWHJUDPHQWHRHQSDUWHDOJXQDGHVXVSXEOLFDFLRQHV/DVVROLFLWXGHV \ODVSHWLFLRQHVGHLQIRUPDFLyQGHEHUiQGLULJLUVHD6HUYLFLRV(GLWRULDOHVÈUHDGH*HVWLyQGH&RQRFLPLHQWR \ &RPXQLFDFLyQ .0& 2UJDQL]DFLyQ 3DQDPHULFDQD GH OD 6DOXG :DVKLQJWRQ '& (VWDGRV 8QLGRV GH $PpULFDTXHWHQGUiVXPRJXVWRHQSURSRUFLRQDUODLQIRUPDFLyQPiVUHFLHQWHVREUHFDPELRVLQWURGXFLGRVHQ ODREUDSODQHVGHUHHGLFLyQ\UHLPSUHVLRQHV\WUDGXFFLRQHV\DGLVSRQLEOHV 2UJDQL]DFLyQ3DQDPHULFDQDGHOD6DOXG&/$3605 /DVSXEOLFDFLRQHVGHOD2UJDQL]DFLyQ3DQDPHULFDQDGHOD6DOXGHVWiQDFRJLGDVDODSURWHFFLyQSUHYLVWDSRU ODVGLVSRVLFLRQHVVREUHUHSURGXFFLyQGHRULJLQDOHVGHO3URWRFRORGHOD&RQYHQFLyQ8QLYHUVDOVREUH'HUHFKR GH$XWRU5HVHUYDGRVWRGRVORVGHUHFKRV /DVGHQRPLQDFLRQHVHPSOHDGDVHQHVWDSXEOLFDFLyQ\ODIRUPDHQTXHDSDUHFHQSUHVHQWDGRVORVGDWRVTXH FRQWLHQHQRLPSOLFDQSRUSDUWHGHOD6HFUHWDUtDGHOD2UJDQL]DFLyQ3DQDPHULFDQDGHOD6DOXGMXLFLRDOJXQR VREUH OD FRQGLFLyQ MXUtGLFD GH SDtVHV WHUULWRULRV FLXGDGHV R ]RQDV R GH VXV DXWRULGDGHV QL UHVSHFWR GHO WUD]DGRGHVXVIURQWHUDVROtPLWHV /D PHQFLyQ GH GHWHUPLQDGDV VRFLHGDGHV PHUFDQWLOHV R GH QRPEUHV FRPHUFLDOHV GH FLHUWRV SURGXFWRV QR LPSOLFDTXHOD2UJDQL]DFLyQ3DQDPHULFDQDGHOD6DOXGORVDSUXHEHRUHFRPLHQGHFRQSUHIHUHQFLDDRWURV DQiORJRV6DOYRHUURUXRPLVLyQODVGHQRPLQDFLRQHVGHSURGXFWRVSDWHQWDGRVOOHYDQHQODVSXEOLFDFLRQHVGH OD236OHWUDLQLFLDOPD\~VFXOD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD&/$3605 2UJDQL]DFLyQ3DQDPHULFDQDGHOD6DOXG2UJDQL]DFLyQ0XQGLDOGHOD6DOXG236206 &DVLOODGHFRUUHR0RQWHYLGHR8UXJXD\ 7HOpIRQR)D[ SRVWPDVWHU#FODSRSVRPVRUJ KWWSQHZSDKRRUJFODS KWWSSHULQDWDOEYVDOXGRUJ 6$/8'6(;8$/<5(352'8&7,9$ *XtDVSDUDHO&217,182'($7(1&,21 GHOD0XMHU\HO5HFLpQ1DFLGRIRFDOL]DGDVHQ$36 D(GLFLyQ 3XEOLFDFLyQ&LHQWt¿FD&/$3605 'LVHxRJUi¿FR-XDQ&DUORV,JOHVLDV 6DOXG6H[XDO\5HSURGXFWLYD ,1',&( PROLOGO GLOSARIO CAPITULO I Renovación de la Atención Primaria de la Salud en las Américas Contínuo de atención Enfoque de Salud Familiar y Comunitaria Valores, Principios y Elementos de un Sistema de Salud Basado en la APS Referencias bibliográficas CAPITULO II Cuidado Preconcepcional Objetivos: Identificar y asesorar sobre riesgo preconcepcional Actividad: Consulta previa al embarazo Cuidado preconcepcional Consulta preconcepcional Reducción de la morbimortalidad materna y feto neonatal Defectos congénitos Historia Clínica Antecedentes reproductivos Antecedentes generales Enfermedades médicas no transmisibles Enfermedades médicas transmisibles Estilos de vida Consumo de medicamentos Vacunas Referencias bibliográficas CAPITULO III Control Prenatal, Vigilancia Durante la Gestación, Evaluación del Riesgo Concepcional y Conductas 9 10 12 13 13 13 18 19 19 19 19 19 20 20 20 22 25 25 29 31 34 36 37 39 Objetivos: Contar con una hoja de ruta que guíe al prestador para brindar una atención prenatal de calidad 40 42 43 43 44 44 44 45 46 47 47 47 47 47 57 58 Actividad: Uso de la Historia Clínica Perinatal del CLAP/SMR 58 Objetivos y Actividades propuestas Cronología de las actividades para las consultas prenatales de bajo riesgo Objetivos: Confirmar embarazo Actividad: Realización de exámenes clínicos y paraclínicos para diagnosticar embarazo Objetivos: Mejorar la calidad del control prenatal Actividad: Utilización de algunas tecnologías apropiadas Gestograma Cinta obstétrica Tarjeta de Altura Uterina y Peso Materno Objetivos: Obtener datos para planificar el control prenatal, la atención del parto, el puerperio y el recién nacido Actividad: Empleo del Sistema Informático Perinatal Historia Clínica Partograma Carné Perinatal Procesamiento de datos &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR Objetivos: Detectar riesgos en la población Actividad: Evaluación del riesgo perinatal Objetivos: Conocer información relevante del embarazo Actividad: Anamnesis Objetivos: Fijar un cronograma que permita planificar las actividades del control prenatal Actividad: Determinación de la edad gestacional y de la fecha probable de parto Amenorrea Evaluación del tamaño uterino Antropometría fetal por ecografía Madurez placentaria Objetivos: Evaluar el estado nutricional materno Actividad: Medición del peso y de la talla materna. Cálculo del incremento de peso durante la gestación. Técnica de medición Ganancia de peso Interpretación de la medida a la primera consulta Interpretación de la secuencia de medidas en consultas subsecuentes Relación peso para la talla según edad gestacional Evaluación del incremento ponderal materno Conducta Objetivos: Investigar estilos de vida de riesgo Actividad: Interrogatorio sobre tabaquismo (activo y pasivo), drogas, alcohol y violencia Tabaquismo activo Tabaquismo pasivo Alcohol Drogas Violencia Objetivos: Prevenir el tétanos neonatal y puerperal Actividad: Vacunación antitetánica Objetivos: Disminuir el impacto negativo de las infecciones de transmisión vertical Actividad: Prevención, detección y tratamiento de las infecciones de transmisión vertical Rubeola congénita Toxoplasmosis congénita Hepatitis B VIH/SIDA Objetivos: Prevenir sífilis Actividad: Tamizaje y tratamiento Objetivos: Prevenir las consecuencias materno-perinatales de otras infecciones de transmisión sexual ITS y otras infecciones del tracto reproductivo ITR Actividad: Prevención, detección y tratamiento Flujo (leucorrea), Moniliasis vulvovaginal, vaginosis bacteriana, tricomoniasis, gonococcia, Clamidiasis, herpes simple Objetivos: Prevenir la transmisión vertical de la enfermedad de Chagas Actividad: Prevención, detección y tratamiento Objetivos: Reducir la morbimortalidad materna y prevenir la transmisión vertical del Paludismo o Malaria Actividad: Prevención, detección y tratamiento &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 59 59 60 60 63 63 63 63 64 66 66 66 67 67 68 69 70 70 70 71 71 71 72 73 73 74 76 76 78 78 78 79 81 82 83 83 88 88 88 89 90 90 90 92 92 6DOXG6H[XDO\5HSURGXFWLYD Diagnóstico de malaria Malaria y embarazo Prevención de la malaria durante el embarazo Tratamiento en mujeres embarazadas Objetivos: Reducir la morbimortalidad neonatal por estreptococo grupo% Actividad: Prevención, detección y tratamiento Objetivos: Detectar posibles procesos sépticos buco-dentales Actividad: Examen buco-dental Objetivos: Detectar posibles alteraciones del pezón, patología inflamatoria Actividad: Examen de las mamas Objetivos: Descartar cáncer de cuello, lesiones precursoras y evaluar la competencia cervical Actividad: Examen genital, colpocitología, colposcopía Cáncer cervical Incompetencia cervical Objetivos: Pesquisar una posible incompatibilidad sanguínea materno-feto-neonatal Actividad: Determinación del grupo sanguíneo, del factor Rh y de anticuerpos irregulares Objetivos: Prevenir, detectar y tratar la anemia materna Actividad: Determinar niveles de hemoglobina. Administración de hierro y ácido fólico Prevención de la anemia Prevención de los defectos del tubo neural Objetivos: Descartar proteinuria, glucosuria y bacteriuria Actividad: Examen de orina y urocultivo Examen de orina Infección urinaria y bacteriuria asintomática Objetivos: Descartar diabetes mellitus clínica y gestacional Actividad: Determinación de la glucemia y prueba de tolerancia oral a la glucosa Diabetes gestacional Glucemia en ayunas Prueba de tolerancia oral a la glucosa Clasificación de los estados diabéticos en el embarazo Objetivos: Brindar contenidos educativo-informativos para el parto y la crianza Actividad: Preparación para el parto, consejería para el amamantamiento Objetivos: Confirmar la existencia de vida fetal Actividad: Pesquisar movimientos y frecuencia cadíaca fetal Movimientos fetales Actividad cardíaca fetal Estetoscopio obstétrico Objetivos: Anticipar el diagnóstico y prevenir el parto prematuro Actividad: Evaluar el patrón de la contractilidad uterina (frecuencia, duración e intensidad) Retrasar el parto de pretérmino. Inducir la maduración pulmonar fetal. Diagnóstico de amenaza de parto prematuro Tratamiento Tratamientos que no han demostrado ser efectivos en la amenaza de parto prematuro Inductores de la maduración pulmonar Objetivos: Pesquisar alteraciones de la presión arterial: Hipertensión previa al embarazo. El síndr. de hipertensión inducida por el embarazo (pre-eclampsia). Hipotensión arterial Actividad: Determinación de la presión arterial, identificación de edemas y proteinuria. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 92 92 93 93 95 95 97 98 98 98 98 103 104 104 106 106 107 108 108 108 108 109 111 111 111 112 112 113 114 114 116 116 116 117 118 119 119 120 121 123 123 125 125 &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR Factores que pueden modificar los valores de tensión arterial Técnica de medida, Modificaciones fisiológicas durante el parto Clasificación de estados hipertensivos en el embarazo, Factores de riesgo de hipertensión gestacional y pre-eclámpsia, Prevención Conductas recomendadas Objetivos: Descartar alteraciones del crecimiento fetal Actividad: Evaluación del crecimiento fetal por medio de la altura uterina, ganancia de peso y ecografía. Restricción del crecimiento intrauterino Macrosomía fetal Tecnologías para medir el crecimiento fetal Ejemplos de la evaluación de la relación Altura Uterina/Edad Gastacional a la primera consulta Ejemplos de la evaluación de la tendencia de la relación AU/EG en consultas subsecuentes Objetivos: Detectar precozmente el embarazo múltiple para prevenir sus complicaciones Actividad: Diagnóstico del número de fetos Objetivos: Pesquisar las presentaciones fetales anormales Actividad: Diagnóstico de presentación fetal Presentación pelviana o podálica Situación transversa Objetivos: Detectar posibles distocias pélvicas para definir el nivel de atención del parto Actividad: Examen gineco-obstétrico. Evaluación de la pelvis. Referencias bibliográficas CAPITULO IV Atención del Parto de Bajo Riesgo Asistencia durante el ingreso Objetivos: Diagnosticar el trabajo de parto e identificar el grado de riesgo Actividad: Consulta en recepción Interrogatorio Examen clínico general Examen obstétrico Auscultación de la FCF Patron de contractilidad uterina Examen genital Dilatación, borramiento y posición del cuello Pérdida de secreciones por los genitales Evaluación de la presentación Valoración de la proporción feto-pélvica y la capacidad de la pelvis materna Preparación de la embarazada en la recepción Asistencia durante el período de dilatación (primer período) Objetivos: Controlar bienestar materno y fetal. Detectar y evaluar desviaciones de los límites fisiológicos (progreso del parto). Evaluar riesgo y referir a nivel apropiado. Aplicar maniobras correctivas Actividad: Información a la embarazada. Controles maternos. Controles obstétricos Registro de los controles en el partograma con curvas de alerta. Acompañamiento a la madre durante el parto Controles maternos Controles obstétricos Progreso de la dilatación y descenso de la presentación &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 125 125 126 126 127 127 130 130 130 131 131 133 134 138 138 140 140 140 140 142 142 144 154 154 154 154 155 156 158 159 161 163 164 164 167 170 172 173 173 173 173 174 175 177 6DOXG6H[XDO\5HSURGXFWLYD Partograma con curvas de alerta Trabajo de parto prolongado Asistencia durante el período expulsivo (segundo período) Objetivos: Detectar y evaluar desviaciones de los límites fisiológicos del período expulsivo. Prevenir traumatismo obstétrico. Prevenir hipoxia fetal. Actividad: Control de la FCF. Control de la contractilidad. Control del avance de la presentación y desprendimiento Posición de la parturienta Controles a realizarse durante el período expulsivo Amniotomía Protección perineal Avance de la presentación y desprendimiento Situaciones especiales Distocia de hombro Atención del parto en podálica Atención del recién nacido en sala de partos Recomendaciones sobre uso de medicación en parto de bajo riesgo Asistencia durante el alumbramiento y posalumbramiento (tercer período) Objetivos: Detectar y evaluar desviaciones de los límites fisiológicos del alumbramiento y posalumbramiento Actividad: Control materno. Examen de la placenta Examen de la placenta y membranas Controles durante el alumbramiento Sutura de la episiotomía Prevención para evitar la retención de restos ovulares Prevención de la hemorragia post parto (HPP). Tracción del cordón. Masaje y compresión uterina Postalumbramiento Retención de placenta Hemorragia post parto Cuidados del post parto imediato Categorías A,B,C,D (recomendaciones OMS) Asistencia durante el puerperio Objetivos: Controlar bienestar de la mujer puérpera. Detectar y evaluar desviaciones de los límites fisiológicos. Evaluar riesgo y referir a nivel apropiado. Aplicar maniobras correctivas. Actividad: Educación de la mujer puérpera. Controles clínicos de la mujer y su hijo. Registro de los controles en la historia clínica perinatal. Puerperio mediato Puerperio alejado Puerperio tardío Referencias bibliográficas CAPITULO V Atención del Recién Nacido Objetivos: Recibir al recién nacido y valorar el inicio de la primera respiración espontánea. Actividad: Observar si respira o no. Si no respira deducir si es por asfixia fetal o por depresión farmacológica. Objetivos: Proteger la adaptación a la vida extrauterina en el recién nacido de pretérmino &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 178 183 185 185 185 186 186 187 187 188 189 189 190 193 194 198 198 198 198 198 199 199 199 200 200 201 202 203 207 207 210 210 210 211 212 212 213 215 216 216 222 &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR Actividad: 1. Proveer cuidados inmediatos que faciliten la adaptación, especialmente en los nacidos pretérminos que presenten signos de inmadurez ventilatoria. 2. Desarrollar estrategias tendientes a evitar la pérdida de calor, valorar el flujo bidireccional de sangre desde la placenta a través del cordón umbilical al feto, apoyar y mantener el inicio de la respiración, controlar el aporte de O2, Esquema para el cuidado continuo del recién nacido pretérmino desde el primer minuto de vida Objetivos: Identificar al recién nacido Actividad: Facilitar que la madre lo identifique y cumplir los requisitos locales de identificación al nacer. Objetivos: Evaluar el crecimiento y el desarrollo fetal al nacer. Actividad: Realizar antropometría y valorarla según la edad gestacional y valorar las funciones de adaptación Antropometría neonatal Objetivos: Adecuar el manejo inicial de los recién nacidos con defectos congénitos mayores Actividad: Instaurar en forma precoz las medidas específicas para cada defecto Objetivos: Detectar defectos y/o enfermedades congénitas asintomáticas Actividad: Detección sistémica en el período neonatal por métodos de laboratorio clínico Sífilis congénita Toxoplasmosis congénita HIV Hepatitis B Estreptococo del grupo B Hipotiroidismo congénito Anemia falciforme Hiperbilirrubinemia neonatal no hemolítica Déficit auditivo severo Objetivos: Prevenir la oftalmia gonocóccica Actividad: Instilar antimicrobianos en las conjuntivas al nacer Objetivos: Prevenir enfermedad hemorrágica del recién nacido Actividad: Administrar vitamina K Objetivos: Iniciar y mantener la lactancia materna exitosa Actividad: 1 - No separar al recién nacido y su madre y facilitar el apoyo familiar 2 - Alimentar a libre demanda y no dar biberones 3 - Registrar la alimentación al alta de la maternidad Objetivos: Prevenir tuberculosis grave en el lactante Actividad: Vacuna BCG al nacer Objetivos: Prevenir la muerte súbita del lactante Actividad: Colocar al recién nacido boca arriba para dormir Objetivos: Disminuir los riesgos en los nacidos pretérmino de 35 y 36 semanas (pretérmino tardíos) y los de 37 a 38 semanas (término precoces) Actividad: Aumentar vigilancia en el período de adaptación mientras permanecen en sala con sus madres Referencias Bibliográficas CAPITULO VI Atención conjunta de la madre y el niño después del nacimiento Objetivos: Racionalizar los recursos y disminuir oportunidades perdidas Controlar bienestar de la mujer puérpera y del recién nacido Detectar y evaluar desviaciones de los límites fisiológicos de ambos. Actividad: Atención conjunta de la madre y el recién nacido durante el puerperio Educación de la mujer puérpera. Controles clínicos de la mujer y su hijo. Registro de los controles en la historia clínica perinatal. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 222 225 226 226 226 226 227 228 228 230 230 230 233 233 234 235 237 238 239 241 241 241 242 242 242 242 243 243 243 243 243 243 244 244 248 249 249 249 6DOXG6H[XDO\5HSURGXFWLYD Registros. Soporte afectivo. Controles de la madre y del recién nacido Referencias Bibliográficas CAPITULO VII Planificación familiar Objetivos: Contribuir al ejercicio del derecho a planificar el embarazo Actividad: Asesorar sobre los principales métodos contraceptivos Proceso de asesoramiento Evaluación de las usuarias antes de recomendarles un método contraceptivo Descripción de los métodos anticonceptivos Métodos reversibles Métodos comportamentales Método de la lactancia exclusiva (MELA) Métodos de barrera Contracepción de emergencia Contraceptivos hormonales Dispositivos intrauterinos Criterios de elegibilidad para métodos hormonales y dispositivos intra uterinos Métodos irreversibles Ligadura tubaria Ligadura de los deferentes (vasectomía) Referencias Bibliográficas CAPITULO VIII Aborto Objetivos: Reducir la morbimortalidad por aborto Actividad: Diagnóstico y asistencia del aborto en los distintos períodos Definiciones Prevalencia e incidencia Aborto espontáneo Diagnóstico clínico y etapas evolutivas del aborto Diagnóstico diferencial Conducta Métodos de evacuación Evacuación uterina Cuidados post procedimiento Aborto complicado Complicaciones post evacuación Consejería /Información Anticoncepción por aborto Referencias Bibliográficas &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 249 250 251 254 255 255 255 255 256 257 257 257 258 258 261 262 267 269 272 272 274 276 277 277 277 277 278 279 281 283 283 285 285 286 287 287 288 289 290 &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 35Ï/2*2 0HMRUDU ODV FRQGLFLRQHV GH YLGD GH ODV PDGUHV \ VXV UHFLpQ QDFLGRV VRQ ORV REMHWLYRVGHODV0HWDVGH'HVDUUROORGHO0LOHQLR¿UPDGDVSRUWRGRVORVHVWDGRV PLHPEURV 8QD GH ODV HVWUDWHJLDV PDV FRVWR HIHFWLYD SDUD DOFDQ]DU HVWRV ORJURV HV FDSDFLWDUDOHTXLSRGHVDOXGHQHOPDUFRGHOFRQWLQXRGHFXLGDGRVGHODPDGUH \HOUHFLpQQDFLGRHQIRTXHTXHFRQVWLWX\HODHVHQFLDGHODSHULQDWRORJtD/D UHQRYDFLyQGHODDWHQFLyQSULPDULDGHVDOXGSURSXHVWDHQHVWDJXtDHVWDEDVDGD HQODVPHMRUHVHYLGHQFLDVGLVSRQLEOHV\D\XGDQDOSHUVRQDOGHORVVHUYLFLRVD GHVDUUROODUQRUPDVTXHSURWHJHQ\SURPXHYHQPXMHUHV\QLxRVDVPiVVDQRV /DSUHVHQWHJXtDWLHQHFRPRDQWHFHGHQWHVORVOLEURV³$WHQFLyQ3UHQDWDO\GHO 3DUWR GH %DMR 5LHVJR´ \ OD SULPHUD \ VHJXQGD HGLFLyQ GH ODV ³*XtDV SDUD HO &RQWLQXRGHDWHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR´TXHIXHUDQSXEOLFDGRV SRU HO &/$3 HQ HQ \ UHVSHFWLYDPHQWH (Q HVWD HGLFLyQ VH OHKDQDFWXDOL]DGRWRGRVORVWHPDV\DPSOLDGRVXHQIRTXHSURIXQGL]DQGRORV FRQWHQLGRV GH ORV FXLGDGRV SUHJHVWDFLRQDOHV FRQ XQ FULWHULR GH SURPRFLyQ \ SUHYHQFLyQTXHSURFXUDPHMRUDUHOHVWDGRGHVDOXGGHODPXMHUVXSDUHMD\VX KLMRDFRQPHGLGDVUHODWLYDPHQWHVHQFLOODV,QFRUSRUDWDPELpQQXHYRVDVSHFWRV VREUHSODQL¿FDFLyQIDPLOLDUFRQXQHQIRTXHGHGHUHFKRVGRQGHVHLQFOX\HOD DQWLFRQFHSFLyQGHHPHUJHQFLD\HOFRQFHSWRGHDWHQFLyQLQWHJUDOSDUDHYLWDUODV RSRUWXQLGDGHVSHUGLGDV\PHMRUDUODH¿FLHQFLDGHORVFRQWDFWRVGHOSHUVRQDOGH VDOXGFRQODPXMHU\VXQLxRD /D DPSOLD GLIXVLyQ TXH KDQ WHQLGR ODV HGLFLRQHV DQWHULRUHV \ VX XWLOL]DFLyQ HQ HO SURFHVR GH FDSDFLWDFLyQ FRQWLQXD D SURIHVLRQDOHV GH OD VDOXG HQ OD UHJLyQ FRQVWLWX\H XQ LPSXOVR D FRQWLQXDU HO WUDEDMR GH DFWXDOL]DFLyQ GH VXV FRQWHQLGRV TXH VRQ SHUPDQHQWHPHQWH UHYLVDGRV HQ EDVH DO VXUJLPLHQWR GH QXHYDHYLGHQFLDFLHQWt¿FDDVtFRPRDSDUWLUGHODH[SHULHQFLDDOFDQ]DGDHQODV GLIHUHQWHVDFWLYLGDGHVGRFHQWHVHQODVTXHODV*XtDVKDQFRQVWLWXLGRHOPDWHULDO GHDSR\RSULQFLSDO 'HVGHWDOHQIRTXHSRUWDQWRVHSUHVHQWDHVWDHGLFLyQUHYLVDGD\DFWXDOL]DGD TXHVHHVSHUDFRQWULEX\DDFRQWLQXDU\SURIXQGL]DUODVDFFLRQHVTXHVHYLHQHQ GHVDUUROODQGRHQODUHJLyQD¿QFXPSOLUFRQHOFRPSURPLVRGHPHMRUDUODVDOXG SDUDPXMHUHV\QLxRVDV 'U5LFDUGR)HVFLQD 'LUHFWRU&/$3605 &RRUGLQDGRUGH3URJUDPD665236206 &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD *ORVDULR ACT: Terapias Combinadas en base a Artemisina. AIC: Anticonceptivos Inyectables Combinados. AOC: Anticonceptivos Orales Combinados. APS: Atención Primaria de Salud. ARA II: Antagonistas de los Receptores de la Angiotensina II. ARV: Antirretrovíricos. AU: Altura Uterina. AZT: Zidovudina. BCG: Bacilo de Calmette - Guerin. BhCG: Fracción Beta de la hormona Gonadotropina Coriónica. BPN: Bajo peso al Nacer. CDC: Centros para el Control de Enfermedades de los Estados Unidos. CLAP/SMR: Centro Latinoamericano de Perinatología / Salud de la Mujer y Reproductiva. CIPD: Conferencia Internacional de Población y Desarrollo. CMV: Citomegalovirus. CU: Contracción Uterina. D: Diámetro. d: diámetro. DBP: Diámetro Biparietal. DFO: Diámetro Fronto Occipital. DG: Diabetes Gestacional. DIPs I: Caída de la FCF coincidente con la contracción uterina. DIPs Variables: Caídas de la FCF de probable origen umbilical, de duración, amplitud y de comienzo variables en relación a la contracción uterina. DIPs II: Desaceleración tardía de la FCF en relación a la contracción uterina. DIU: Dispositivo Intrauterino. DM: Diabetes Mellitus. DPPNI: Desprendimiento Previo de Placenta Normoinserta. ECLAMC: Estudio Colaborativo Latinoamericano de Malformaciones Congénitas. EG: Edad Gestacional. EGB: Estreptococo del Grupo B. EP: Enfermedad Periodontal. FPP: Fecha Probable de Parto. FCF: Frecuencia Cardíaca Fetal. FTA- Abs: Prueba de detección de Anticuerpos específicos contra el Treponema pallidum, por inmunofluorescencia. FUM: Fecha de Última Menstruación. GED: Enfoque de Género en el Desarrollo. HAI: Hemoaglutinación Indirecta. Hb : Hemoglobina. HC: Hipotiroidismo Congénito. HCP: Historia Clínica Perinatal. HCG: Hormona Coriónica Gonadotrófica. IC: Incompetencia Cervical. IFI: Inmunofluorescencia Indirecta. Ig G: Inmunoglobulina G. Ig M: Inmunoglobulina M. IECAs: Inhibidores de la Enzima conversora de la Angiotensina II. IM: Intramuscular. IMC: Índice de Masa Corporal. ITR: Infecciones del Tracto Reproductivo. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR ITS: IV: LCR: MAC: MELA: MHA – TP: Infecciones de Transmisión Sexual. Intravenoso. Líquido Céfalo Raquídeo. Métodos Anticonceptivos. Método de Lactancia Exclusiva. Prueba de detección de Anticuerpos específicos contra el Treponema pallidum por Micro – Hemaglutinación. NVP: Neviparina. OMS: Organización Mundial de la Salud. OPS: Organización Panamericana de la Salud. PAP: Papanicolau, colpocitoplogía oncológica. P. Abd.: Perímetro Abdominal. P. Cr.: Perímetro Craneano. PCR: Reacción de la cadena de la polimerasa. PEG: Pequeño para la Edad Gestacional. P. falciparum: Plasmodio falciparum. PG: Prostaglandinas. PMB: Perímetro Medio Braquial. PO2: Presión parcial de Oxígeno. PTOG: Prueba de Tolerancia a la Glucosa. RCI: Restricción del Crecimiento Intrauterino. RCIU: Restricción del Crecimiento Intrauterino. RDTs: Test Rápidos Diagnósticos. RPM: Rotura Prematura de Membranas. RPP: Rapid Plasma reagin. RR: Riesgo relativo. SAF: Síndrome Alcohólico Fetal. SIDA: Síndrome de la Inmunodeficiencia Adquirida. SIP: Sistema Informático Perinatal. SDR: Síndrome de Dificultad Respiratoria. SNC: Sistema Nervioso Central. SRC: Síndrome de Rubéola Congénita. T. cruzi: Tripanosoma cruzi. T4: Hormona tiroidea 4. Td: Tétanos más difteria. TNN: Tétanos Neonatal. T. pallidum: Treponema pallidum. TP – PA: Prueba de detección de Anticuerpos específicos contra el Treponema pallidum por Aglutinación. TPI: Tratamiento Preventivo Intermitente. TSH: Hormona Estimulante Tiroidea. TT: Toxoide tetánico. TBC: Tuberculosis. UCIN: Unidad de Cuidado Intensivo Neonatal. UNAIDS: (ONUSIDA), Programa conjunto de las Naciones Unidas sobre el VIH/SIDA. UNGASS: United Nations General Assambly on AIDS Special Session. UNICEF: Fondo de las Naciones Unidas para la Infancia. USR: Unheated Serum Reagin. VPH: Virus Papiloma Humano. VDRL: Venereal Disease Research Laboratory. VIH: Virus de la Inmunodeficiencia Humana. V/O: Vía oral. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD , & $ 3, 7 8 /2 , 5HQRYDFLyQGHOD$WHQFLyQ3ULPDULD GHOD6DOXGHQODV$PpULFDV 'XUDQWH ODV ~OWLPDV GpFDGDV OD 5HJLyQ GH ODV$PpULFDV KD HYLGHQFLDGR LPSRUWDQWHV DYDQFHVHQWpUPLQRVGHVDOXGSHURHVRVORJURVVRQLQVX¿FLHQWHV\HQWRGRVORVSDtVHV D~QSHUVLVWHQGHVDItRV\GHVLJXDOGDGHVSRUUHVROYHU /DVQDFLRQHVYLQFXODQODVPHMRUDVHQVDOXGDODLQFOXVLyQRDPSOLDFLyQGHODSURWHFFLyQ VRFLDO GHQWUR GHO PDUFR GH ODV UHIRUPDV GHO VHFWRU \ D OD DSOLFDFLyQ GH OD DWHQFLyQ SULPDULDGHVDOXG$36/DDWHQFLyQSULPDULDGHVDOXGFRPRWDOIXHGH¿QLGDHQ HQ OD 'HFODUDFLyQ GH$OPD$WD \ GHVSXpV GH FDVL DxRV GH H[SHULHQFLD VH SXHGH FRQFOXLUTXHORVVLVWHPDVGHVDOXGTXHFXPSOHQFRQORVSULQFLSLRVGH$36KDQORJUDGR PHMRUHV UHVXOWDGRV VDQLWDULRV \KDQDXPHQWDGR ODH¿FLHQFLDHQODDWHQFLyQ GHVDOXG WDQWR LQGLYLGXDO FRPR FROHFWLYD IDFLOLWDQGR XQ PHMRU UHODFLRQDPLHQWR \ SDUWLFLSDFLyQ HQWUHXVXDULRV\SUHVWDGRUHVGHVDOXGS~EOLFRV\SULYDGRV $SHVDUGHOWLHPSRWUDQVFXUULGRHOHVWDGRGHVLWXDFLyQGHOD$36HQORVSDtVHVGHOD 5HJLyQHVPX\GLVSDU3RUHVDUD]yQHQVHSWLHPEUHGHHO&RQVHMR'LUHFWLYRGH OD2UJDQL]DFLyQ3DQDPHULFDQDGHOD6DOXGLQVWyDORV(VWDGRV0LHPEURVDDGRSWDUXQD VHULHGHUHFRPHQGDFLRQHVSDUDIRUWDOHFHUODDWHQFLyQSULPDULDHQVDOXGORTXHFXOPLQy FRQOD³'HFODUDFLyQ5HJLRQDOVREUHODVQXHYDVRULHQWDFLRQHVGHOD$WHQFLyQ3ULPDULDGH 6DOXG´HQVHSWLHPEUHGHHQODUHXQLyQGHO&RQVHMR'LUHFWLYRGH236 /DUHQRYDFLyQGHODDWHQFLyQSULPDULDGHVDOXGHQODV$PpULFDVVHEDVDHQWUHRWUDV FRVDVHQODDSDULFLyQGHQXHYRVGHVDItRVHSLGHPLROyJLFRV3DUDGDUOHVUHVSXHVWDOD $36GHEHDVXPLUODQHFHVLGDGGHFRUUHJLUODVGHELOLGDGHVGHDOJXQRVGHVXVHQIRTXHV GHVDUUROODUQXHYRVFRQRFLPLHQWRV\WHFQRORJtDVVREUHPHMRUHVSUiFWLFDVTXHGHEHQVHU LQFRUSRUDGRVSDUDDXPHQWDUVXHIHFWLYLGDG7RGRHVWRFRQVWLWX\HXQDKHUUDPLHQWDTXH IRUWDOHFHGLUHFWDPHQWHODFDSDFLGDGGHODVRFLHGDGSDUDUHGXFLUODVLQHTXLGDGHVHQVDOXG (VWDQHFHVLGDGGHUHQRYDFLyQHVLPSUHVFLQGLEOHDGHPiVSDUDGDUFXPSOLPLHQWRDORV FRPSURPLVRVGHOD'HFODUDFLyQGHO0LOHQLRTXHORVSDtVHVGHOD5HJLyQKDQ¿UPDGR (Q EDVH D HVWD UHQRYDFLyQ OD $36 VH GH¿QH FRPR XQD ³DWHQFLyQ HVHQFLDO HQ VDOXG EDVDGD HQ PpWRGRV \ WHFQRORJtDV SUiFWLFDV FLHQWt¿FDPHQWH IXQGDPHQWDGDV \ VRFLDOPHQWHDFHSWDEOHVDFFHVLEOHDORVLQGLYLGXRV\DODVIDPLOLDVHQODFRPXQLGDGD WUDYpVGHVXSOHQDSDUWLFLSDFLyQ\DXQFRVWRTXHODFRPXQLGDG\HOSDtVSXHGDQDVXPLU SDUDPDQWHQHUOD«/D$36IRUPDSDUWHLQWHJUDOGHOVLVWHPDGHVDOXGGHXQSDtVDVt FRPRGHOGHVDUUROORHFRQyPLFR\VRFLDOGHODFRPXQLGDG«DFHUFDQGRODDWHQFLyQHQ VDOXGWDQWRFRPRVHDSRVLEOHDOOXJDUGRQGHODJHQWHYLYH\WUDEDMD\FRQVWLWX\pQGRVH HQHOSULPHUHOHPHQWRGHXQSURFHVRFRQWLQXRGHDWHQFLyQHQVDOXG´ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &RQWLQXRGHDWHQFLyQ (O SURFHVR OODPDGR ³FRQWLQXR GH DWHQFLyQ´ R ³FRQWLQXR GH FXLGDGRV´ LPSOLFD HO XVR UDFLRQDO\DSURSLDGRGHODVQXHYDV\PHMRUHVHYLGHQFLDVGLVSRQLEOHVKDVWDHOPRPHQWR SXHVWDVDOVHUYLFLRGHORVLQGLYLGXRV\FRPXQLGDGHVGXUDQWHWRGDVODVHWDSDVGHOFLFOR YLWDO /DVDOXGVH[XDO\UHSURGXFWLYDHVXQEXHQHMHPSORGHFRQWLQXRGHFXLGDGRVFRQHOOD VHSXHGHDSUHFLDUFRPRODLQWURGXFFLyQGHDFWLYLGDGHVGHSURPRFLyQ\SURWHFFLyQGHOD VDOXGGLULJLGDVDORVDGROHVFHQWHVFRQWULEX\HQDGHFLGLUHOPRPHQWRPiVRSRUWXQRSDUD HOFRPLHQ]RGHODVUHODFLRQHVVH[XDOHVKDFHUOROLEUHGHFRHUFLyQ\DGLVPLQXLUHOULHVJR GHHQIHUPDU,769,+6,'$7DPELpQVHPHMRUDHOFRQRFLPLHQWR\HOXVRGHPpWRGRV FRQWUDFHSWLYRVFRQORFXDOVHFRQWULEX\HDUHVSHWDUHOGHUHFKRGHGHFLGLUHOPRPHQWR DSURSLDGRSDUDHPEDUD]DUVH 6LJXLHQGRODOyJLFDGHOFRQWLQXRGHDWHQFLyQVHIRPHQWDODFRQVXOWDSUHFRQFHSFLRQDO GH ODV PXMHUHV SDUD FRQVHJXLU XQ HPEDUD]R HQ ODV PHMRUHV FRQGLFLRQHV \ GLVPLQXLU HO ULHVJR GH HQIHUPDU R PRULU 8QD YH] FRQVHJXLGR HO HPEDUD]R VH SUHWHQGH GDU HO FXLGDGR GH PD\RU FDOLGDG GXUDQWH HO HPEDUD]R HO SDUWR \ HO SXHUSHULR$ SDUWLU GH HVWHPRPHQWRFRQWLQ~DHOFRPSURPLVRFRQORVFXLGDGRVGHODPXMHUFRQWUDFHSFLyQ SUHYHQFLyQGHOFiQFHUJpQLWRPDPDULRFOLPDWHULRHWF\FRPLHQ]DQORVFXLGDGRVGHO UHFLpQQDFLGR\HOQLxRKDVWDOOHJDUQXHYDPHQWHDODDGROHVFHQFLD (QIRTXHGH6DOXG)DPLOLDU\&RPXQLWDULD (O ³FRQWLQXR GH FXLGDGRV´ QR HV GHO WRGR HIHFWLYR VL VH OR FRQ¿QD H[FOXVLYDPHQWH D OD UHVSRQVDELOLGDG LQGLYLGXDO GH ODV SHUVRQDV D FXLGDU VX VDOXG 3RU HVR HO HQIRTXH GH6DOXG)DPLOLDU\&RPXQLWDULDLQWHJUDHQODQXHYDHVWUDWHJLDGH$36ORVFRQFHSWRV GH FLFOR YLWDO \ GH FRQWLQXR GH FXLGDGRV HQ EDVH D XQ WUDEDMR HQ WUHV GLPHQVLRQHV GLIHUHQWHV\FRPSOHPHQWDULDV8QDSULPHUDGLPHQVLyQTXHSDUWHGHOKRJDUHQHOFXDOHO HPSRGHUDPLHQWRGHODPXMHUHVODKHUUDPLHQWDFODYHSDUDHOPDQWHQLPLHQWRGHODVDOXG RSDUDUHVWDXUDUODFXDQGRHVWDVHKDSHUGLGR/DVHJXQGDGLPHQVLyQHVODFRPXQLWDULD GRQGH HO HPSRGHUDPLHQWR VRFLDO \ OD VROLGDULGDG MXHJDQ XQ URO GHFLVLYR /D WHUFHUD GLPHQVLyQ LQYROXFUD D WRGRV ORV VHUYLFLRV HQ JHQHUDO \ D ORV GH VDOXG HQ SDUWLFXODU SUHVLGLGRVSRUXQDOyJLFDHQODFXDOORVVHUYLFLRVGHOSULPHUQLYHOGHDWHQFLyQUHVROYHUiQ HQIRUPDH¿FLHQWHPiVGHOGHODVFRQVXOWDVHQEDVHDORVUHFXUVRVKXPDQRV\ WHFQROyJLFRVORFDOHVGHELHQGRGHULYDUSDUDVXVROXFLyQDVHUYLFLRVGHPD\RUFRPSOHMLGDG ODVVLWXDFLRQHVTXHSRUVXJUDYHGDGRGL¿FXOWDGHVGLDJQyVWLFDVRWHUDSpXWLFDVDVtOR GHPDQGHQ (VWD VHFXHQFLD LPSOLFD FRQWDU FRQ XQ VLVWHPD GH VDOXG RUJDQL]DGR SRU QLYHOHVLQIRUPDFLyQSDUDODRULHQWDFLyQGHODGHPDQGDVLVWHPDVGHFRPXQLFDFLyQ\ WUDQVSRUWHFRQVLGHUDQGRRWUDVIDFLOLGDGHVGHDFFHVR$GHPiVGHJDUDQWL]DUHODFFHVR \FREHUWXUDDORVVHUYLFLRVGHVDOXGORVFXLGDGRVGHEHUiQEDVDUVHHQODFDOLGDGGHOD SUHVWDFLyQ/DLQWHUDFFLyQHQWUHORVVHUYLFLRVGHVDOXGFRQRWURVVHUYLFLRVGDDOHQIRTXH GH6DOXG)DPLOLDU\&RPXQLWDULDVXH¿FDFLDSDUDDOFDQ]DU\PDQWHQHUHQHOWLHPSRORV ORJURVDOFDQ]DGRV 9DORUHV3ULQFLSLRV\(OHPHQWRVGHXQ6LVWHPDGH6DOXG%DVDGRHQOD$36 6H GHEH WHQHU HQ FXHQWD TXH OD QXHYD RULHQWDFLyQ HQ $36 GH 236 FRQVLGHUD XQ FRQMXQWR GH YDORUHV SULQFLSLRV \ HOHPHQWRV HVHQFLDOHV SDUD FRQVWUXLU 6LVWHPDV GH 6DOXG%DVDGRVHQOD$36/D236VRVWLHQHTXHWDOHVVLVWHPDVVRQLQGLVSHQVDEOHVSDUD DYDQ]DUHQOD¿QDOL]DFLyQGHOD³DJHQGDLQFRQFOXVDGHVDOXG´FRQVROLGDU\PDQWHQHU ORVSURJUHVRVDOFDQ]DGRV(QOD¿JXUDTXHVHPXHVWUDDFRQWLQXDFLyQVHUHVXPHQHVRV DVSHFWRV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD $FFHVR\FREHUWXUD XQLYHUVDO $FFLRQHV LQWHUVHFWRULDOHV $WHQFLyQLQWHJUDO HLQWHJUDGD 'DUUHVSXHVWDDODV QHFHVLGDGHVGHVDOXG GHODSREODFLyQ 5HFXUVRV DGHFXDGRV\ VRVWHQLEOHV ,QWHUVHFWRULDOLGDG 5HFXUVRV KXPDQRV DSURSLDGRV 'HUHFKRVDOQLYHO GHVDOXGPiVDOWR SRVLEOH 5HVSRQVDELOLGDG \UHQGLFLyQGH FXHQWDVGHORV JRELHUQRV (TXLGDG 6RVWHQLELOLGDG 3ROtWLFDV\ SURJUDPDV SURHTXLGDG $WHQFLyQ DSURSLDGD 6ROLGDULGDG 3DUWLFLSDFLyQ 3ULPHU FRQWDFWR 2ULHQWDFLyQ KDFLDOD FDOLGDG (QIDVLVHQ SURPRFLyQ\ SUHYHQFLyQ -XVWLFLDVRFLDO 2UJDQL]DFLyQ\ JHVWLyQySWLPDV 2ULHQWDFLyQ IDPLOLDU\ FRPXQLWDULD 0HFDQLVPRV GHSDUWLFLSDFLyQ DFWLYD )LJ9DORUHV3ULQFLSLRV\(OHPHQWRVHVHQFLDOHVGHXQ6LVWHPDGH6DOXGEDVDGRHQ OD$36 $FRQWLQXDFLyQDQDOL]DUHPRVH[FOXVLYDPHQWHORVDVSHFWRVFRQFHUQLHQWHVDORVYDORUHV SRUVHUHOQ~FOHRFHQWUDOGHOD$36\FRPRHOORVVHYLQFXODQFRQODVDOXGVH[XDO\ UHSURGXFWLYD/RVYDORUHVVHEDVDQHQWUHVHQIRTXHVHVHQFLDOHV 'HUHFKRDOQLYHOPiVDOWRGHVDOXG (TXLGDG 6ROLGDULGDG 'HUHFKRDOQLYHOPiVDOWRGHVDOXG &RQVLGHUDU OD VDOXG FRPR XQ DVXQWR GH GHUHFKRV LPSOLFD XQ FDPELR GH SDUDGLJPD VXVWDQFLDO (Q pO VH FRQFLEH D OD VDOXG FRPR XQ GHUHFKR KXPDQR GRQGH VH KDFH QHFHVDULRGDUUHVSXHVWDDORVGHWHUPLQDQWHVVRFLDOHV\SROtWLFRVTXHODFRQGLFLRQDQ (OGHUHFKRDODVDOXGLQYROXFUDHOFRPSURPLVRLQGLYLGXDO\FROHFWLYRGHORVLQGLYLGXRV SDUDPDQWHQHUODDVtFRPRDODUHVSRQVDELOLGDGGHORV(VWDGRV\GHRWURVDFWRUHVSDUD JDUDQWL]DU HO FXPSOLPLHQWR GH HVWH GHUHFKR 3HUR WDPELpQ KDELOLWD D ORV FLXGDGDQRV OD SRVLELOLGDG GH UHFODPDU PHGLDQWH OD ³YtD GHO UHFXUVR´ FXDQGR VLHQWDQ TXH ORV FRPSURPLVRVDVXPLGRVSRUORV(VWDGRVXRWURVDFWRUHVQRKDQVLGRFXPSOLGRV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (OHQIRTXHGH6DOXG\'HUHFKRV+XPDQRVDGHPiVGHORVDVSHFWRVUHFLpQPHQFLRQDGRV VRVWLHQH TXH SDUD DOFDQ]DU ODV PHMRUDV HQ OD HTXLGDG HQ VDOXG SURSXHVWDV GHVGH $OPD$WDGHEHRULHQWDUVHPiVKDFLDHOGHVDUUROORGHSROtWLFDV³LQFOXVLYDVGLQiPLFDV WUDQVSDUHQWHV \ DSR\DGDV SRU FRPSURPLVRV OHJLVODWLYRV \ ¿QDQFLHURV´ TXH D FLUFXQVFULELUVHVyORDDVSHFWRVHVSHFt¿FRVGHODHQIHUPHGDG 'HUHFKRV6H[XDOHV\5HSURGXFWLYRV (VSHFLDO LPSDFWR KD WHQLGR HO HQIRTXH GH VDOXG \ GHUHFKRV KXPDQRV FXDQGR VH OR DSOLFD DO FDPSR GH OD 6DOXG 5HSURGXFWLYD \ ORV 'HUHFKRV 5HSURGXFWLYRV (Q OD &RQIHUHQFLD,QWHUQDFLRQDOGH3REODFLyQ\'HVDUUROOR&,3'UHDOL]DGDHQ(O&DLURHQ VHLQWURGXFHHQODDJHQGDSROtWLFDLQWHUQDFLRQDODODVDOXGVH[XDO\UHSURGXFWLYD GHVGH XQD SHUVSHFWLYD FRPSOHMD H LQWHJUDO SHUR HVWUHFKDPHQWH UHODFLRQDGD FRQ HO HMHUFLFLR GH ORV GHUHFKRV 7DPELpQ HQ HO FDVR GH OD VDOXG VH[XDO \ UHSURGXFWLYD HO HMHUFLFLR GH GHUHFKRV SDUD VX FXPSOLPLHQWR LQYROXFUD OD UHVSRQVDELOLGDG LQGLYLGXDO GHODVSHUVRQDVSDUDHODXWRFXLGDGR\ODGHORV(VWDGRVHQJHQHUDUODVFRQGLFLRQHV VRFLDOHV\ODVFRQGLFLRQHVSROtWLFDVQHFHVDULDV (O3URJUDPDGH$FFLyQGHOD&,3'VHxDODTXHORVGHUHFKRVUHSURGXFWLYRVVRQGHUHFKRV KXPDQRV UHFRQRFLGRV HQ OH\HV QDFLRQDOHV HQ GRFXPHQWRV LQWHUQDFLRQDOHV VREUH GHUHFKRVKXPDQRV\HQRWURVGRFXPHQWRVGH1DFLRQHV8QLGDVDSUREDGRVSRUFRQVHQVR ³(VRVGHUHFKRVVHEDVDQHQHOUHFRQRFLPLHQWRGHOGHUHFKREiVLFRGHWRGDVODVSDUHMDV HLQGLYLGXRVDGHFLGLUOLEUH\UHVSRQVDEOHPHQWHHOQ~PHURGHKLMRVHOHVSDFLDPLHQWRGH ORVQDFLPLHQWRV\HOLQWHUYDORHQWUHpVWRV\DGLVSRQHUGHODLQIRUPDFLyQ\ORVPHGLRV SDUDHOOR\HOGHUHFKRDDOFDQ]DUHOQLYHOPiVHOHYDGRGHVDOXGVH[XDOUHSURGXFWLYD 7DPELpQLQFOX\HHOGHUHFKRDDGRSWDUGHFLVLRQHVUHODWLYDVDODUHSURGXFFLyQVLQVXIULU GLVFULPLQDFLyQ FRDFFLRQHV QL YLROHQFLD /D SURPRFLyQ GHO HMHUFLFLR UHVSRQVDEOH GH HVWRV GHUHFKRV GHEH VHU OD EDVH SULPRUGLDO GH ODV SROtWLFDV \ SURJUDPDV HVWDWDOHV \FRPXQLWDULRVHQODHVIHUDGHODVDOXGUHSURGXFWLYDLQFOXLGDODSODQL¿FDFLyQIDPLOLDU &RPRSDUWHGHHVWHFRPSURPLVRVHGHEHSUHVWDUSOHQDDWHQFLyQDODSURPRFLyQGHODV UHODFLRQHVGHUHVSHWRPXWXRHLJXDOGDGHQWUHKRPEUHV\PXMHUHV´ /RVGHUHFKRVVH[XDOHV\ORVGHUHFKRVUHSURGXFWLYRVSURSRQHQXQDUHIXQGDFLyQ\XQD UHGH¿QLFLyQGHODUHODFLyQHQWUHORS~EOLFR\ORSULYDGR,PSOLFDQXQFDPELRGHSDUDGLJPD HQORVFDPSRVGHODVH[XDOLGDG\ODUHSURGXFFLyQHQWHQGLHQGRTXHpVWRVVHHQFXHQWUDQ HQ XQ FUXFH GH FDPLQRV HQWUH OR tQWLPRSHUVRQDO SULYDGR \ OR S~EOLFRVRFLDO (VWD GLFRWRPtDHQWUHORS~EOLFR\ORSULYDGRKDVLGR\FRQWLQ~DVLHQGRXQDGHODVGL¿FXOWDGHV HQODSURPRFLyQ\GHIHQVDGHORVGHUHFKRVVH[XDOHV\ORVGHUHFKRVUHSURGXFWLYRV (TXLGDGHQVDOXG *DUDQWL]DU GHUHFKRV LPSOLFD HQWUH RWUDV FRVDV GLVPLQXLU OD EUHFKD TXH H[LVWH HQ HO HVWDGRGHVDOXGGHODVSHUVRQDVHQHODFFHVRDODDWHQFLyQ\DDPELHQWHVVDOXGDEOHV \HQHOWUDWRTXHUHFLEHQHQORVVLVWHPDVGHVHUYLFLRVVRFLDOHV\GHVDOXG/DHTXLGDG HVODSLHGUDDQJXODUGHORVYDORUHVVRFLDOHV\DOLJXDOTXHHQXQDFDGHQDVXIRUWDOH]D HVWi PDUFDGD SRU HO HVODEyQ PiV GpELO OD IRUPD FRPR XQD VRFLHGDG WUDWD D VXV PLHPEURVTXHHVWiQHQSHRUVLWXDFLyQPDUFDUiODIRUWDOH]DGHHVDVRFLHGDG/DJHQWH GHEH VHU FDSD] GH FRUUHJLU ODV LQHTXLGDGHV PHGLDQWH HO HMHUFLFLR GH ORV GHUHFKRV PRUDOHV\OHJDOHVSDUDH[LJLUVDOXG\RWURVELHQHVGHFDUiFWHUVRFLDO&XDQGRVHGLFH TXHODHTXLGDGHVHOYDORUFHQWUDOGHXQ6LVWHPDGH6DOXG%DVDGRHQ$36ORTXHVH LQWHQWDFRQVHJXLUHVTXHODVSROtWLFDV\SURJUDPDVGHVDOXGHVWpQRULHQWDGDVKDFLDOD FRQVHFXFLyQGHODHTXLGDG &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (TXLGDGGHJpQHUR 8QDGHODVSULQFLSDOHVGLPHQVLRQHVGHODHTXLGDGVHEDVDHQLQFRUSRUDUHOHQIRTXHGH JpQHURHQVDOXG\DTXHFRQVWLWX\HXQDUHIHUHQFLDLQHOXGLEOHDODKRUDGHDQDOL]DUHO SDSHOGLIHUHQFLDOTXHKRPEUHV\PXMHUHVMXHJDQHQODSURGXFFLyQFRWLGLDQDGHODVDOXG 'HVGHHVWDSHUVSHFWLYDODHTXLGDGHQVDOXGVHWUDGXFHHQWpUPLQRVRSHUDFLRQDOHVHQ ODPLQLPL]DFLyQGHGLVSDULGDGHVHYLWDEOHV\VXVGHWHUPLQDQWHVHQWUHJUXSRVKXPDQRV FRQGLIHUHQWHVQLYHOHVGHSULYLOHJLRVRFLDO (O(QIRTXHGH*pQHURHQHO'HVDUUROOR*('SHUPLWLyIRFDOL]DUHOSDSHOGHODVDOXG FRPRFULWHULRGHHTXLGDGHQWUHORVVH[RV*HQHUR6DOXG\'HVDUUROOR(ODQiOLVLVGHOD GLVWULEXFLyQGHIXQFLRQHVVRFLDOHVVHJ~QVHVHDPXMHUXKRPEUHHVXQRGHORVSXQWRV FODYHVHQODSHUVSHFWLYDGHJpQHURDOLQWURGXFLUDODQiOLVLVHOSRGHUGHODVUHODFLRQHV HQWUH PXMHUHV \ YDURQHV R FRPR VH KD KHFKR OD FRQVWUXFFLyQ VRFLRKLVWyULFD GH OR IHPHQLQR\GHORPDVFXOLQR1RQHFHVLWDPRVSURIXQGL]DUGHPDVLDGRHQHODQiOLVLVSDUD YHUTXHODVH[XDOLGDG\ODVGHFLVLRQHVUHSURGXFWLYDVVRQHOSULQFLSDOFDPSRHQHOTXH VHH[SUHVDQODVUHODFLRQHVGHSRGHUHQWUHORVJpQHURVPiVDXQHOiUHDHQHOTXHVH PDQL¿HVWDQODVUHODFLRQHVGHSRGHUHQWUHJpQHURVVHPDWHULDOL]DHQHOFXHUSRGHOD PXMHUSRUGRQGHSDVDQ\VHFRQFUHWDQODPD\RUtDGHHVWDVGHFLVLRQHV(OHQIRTXHGH *pQHUR6DOXG\'HVDUUROORSURFXUDLGHQWL¿FDU\PRGL¿FDUODVFDXVDVTXHHVWUXFWXUDQ ODVUHODFLRQHVGHSRGHU\TXHFRORFDQDODVPXMHUHVHQXQDSRVLFLyQGHVXERUGLQDFLyQ LQFLGLHQGRHQHODFFHVR\FRQWUROGHORVUHFXUVRVGHODVDOXGSDUDVXSURSLREHQH¿FLR (VWHHQIRTXHFRQFLEHDODPXMHUFRPRXQVHULQWHJUDOHQVXP~OWLSOHFRQGLFLyQGHVHU VH[XDGR\VH[XDOELROyJLFRVRFLRFXOWXUDO\SROtWLFRTXHGHPDQGDVHU³PLUDGD´GHVGH ODLQWHJUDOLGDGIDYRUHFLHQGRVXIRUWDOHFLPLHQWRFRPRVXMHWRGHGHUHFKRDXWRQRPtD\ HPSRGHUDPLHQWR ³/DVGL¿FXOWDGHVHQWpUPLQRVGHGHVLJXDOGDGGHJpQHURHQHOFDPSRSUiFWLFR\GHVGH HOSXQWRGHYLVWDOHJDO\PRUDOVHYXHOYHQPiVGUDPiWLFDVHQVLWXDFLRQHVGHSREUH]D /DOyJLFDGHODVLVWHQFLDOLVPRSUHSRQGHUDFRPRSROtWLFDVRFLDOHQHOFDPSRUHSURGXFWLYR FRQWULEX\HQGRGHHVDIRUPDDOPDQWHQLPLHQWRGHODH[FOXVLyQVRFLDO\DODQRVXSHUDFLyQ GHHVWD7UDQVIRUPDUQHFHVLGDGHVHQGHUHFKRVHVMXVWDPHQWHHOFDPLQRSDUDGHVWUXLU HVDOyJLFD´ (O(QIRTXHGH*pQHURHQHO'HVDUUROORGHEHUtDKDEHUVXVWLWXLGRDOHQIRTXHHQHOTXH VHKDQVXVWHQWDGRORVPRGHORVGHSODQL¿FDFLyQIDPLOLDU\PDWHUQRLQIDQWLOHVFOiVLFRV (Q HVWH ~OWLPR HQIRTXH VH KD SULRUL]DGR OD FRQGLFLyQ GH PDGUH GH OD PXMHU FRQ HO DIiQGHFRQVHJXLUPHMRUHVUHVXOWDGRVQHRQDWDOHVDWUDYpVGHODDWHQFLyQGHO³ELQRPLR PDGUH ± KLMR´ (VWD LGHD GH ³ELQRPLR´ GHVSHUVRQDOL]D D DPERV PLHPEURV \D TXH VH FHQWUDHQOD¿JXUDGHODPXMHUFRPRPDGUH\HQOD¿JXUDGHOQLxRHQWDQWRKLMRDODYH] TXHGHMDSRUIXHUDODSDUWLFLSDFLyQGHOYDUyQHQHOHMHUFLFLRGHODSDWHUQLGDG(QHVWH HQIRTXHDGHPiVGHDVLJQDUOHDODPXMHUFRPRUROSULQFLSDOODPDWHUQLGDGVHFRQVLGHUD TXH ODV PXMHUHV VRQ UHFHSWRUDV SDVLYDV GHO GHVDUUROOR \ TXH OD FULDQ]D \ OD IXQFLyQ GHO FXLGDGR GH OD IDPLOLD HV VX SULQFLSDO DSRUWH DO GHVDUUROOR (VWR KD FRQWULEXLGR HQ WpUPLQRV JHQHUDOHV D IRUWDOHFHU XQ URO PDVFXOLQR HQ HO TXH QR VH LQFOX\H HO KDFHUVH FDUJR GH DVSHFWRV YLQFXODGRV D OD SODQL¿FDFLyQ IDPLOLDU \ DO FXLGDGR GH OD VDOXG GHO Q~FOHRIDPLOLDU (ODQiOLVLVGHJpQHURHVDSHQDVXQDGHODVGLPHQVLRQHVUHOHYDQWHVHQORVSURFHVRVGH FRQVWUXFFLyQGHODVDOXGHQIHUPHGDGODFODVHVRFLDOODHWQLD\ODJHQHUDFLyQVRQRWUDV GHODVGLPHQVLRQHVTXHSHUPLWHQDQDOL]DUODVGLIHUHQFLDVH[LVWHQWHVSDUDHQFRQWUDUORV LQVXPRVQHFHVDULRVSDUDUHGXFLUODEUHFKDH[LVWHQWHDXQHQWUHODVSURSLDVPXMHUHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR /DVROLGDULGDG (V HO JUDGR HQ HO TXH ORV PLHPEURV GH XQD VRFLHGDG VH FRPSURPHWHQ D WUDEDMDU FRQMXQWDPHQWHSRUHOELHQFRP~Q/DVROLGDULGDGVRFLDOHVXQRGHORVPHGLRVSRUORV TXHODDFFLyQFROHFWLYDSXHGHOOHJDUDUHVROYHUORVSUREOHPDVFRPXQHVORVVLVWHPDV GHVDOXG\GHVHJXULGDGVRFLDOVRQPHFDQLVPRVPHGLDQWHORVFXDOHVSXHGHH[SUHVDUVH ODVROLGDULGDGHQWUHLQGLYLGXRVGHGLVWLQWDVFRQGLFLRQHVVRFLDOHV\JHQHUDFLRQDOHV/RV 6LVWHPDVGH6DOXG%DVDGRVHQ$36UHTXLHUHQGHODVROLGDULGDGVRFLDOSDUDJDUDQWL]DU TXH ODV LQYHUVLRQHV HQ VDOXG VHDQ VRVWHQLEOHV SDUD SURYHHU SURWHFFLyQ ¿QDQFLHUD \ PDQHMRPDQFRPXQDGRGHOULHVJRHQVDOXG\SDUDSRVLELOLWDUTXHHOVHFWRUVDOXGWUDEDMH FRQ p[LWR MXQWR D RWURV DFWRUHV VRFLDOHV FX\R LQYROXFUDPLHQWR HV IXQGDPHQWDO SDUD PHMRUDUODVDOXG\ODVFRQGLFLRQHVTXHODGHWHUPLQDQ(VQHFHVDULDODSDUWLFLSDFLyQ\OD UHQGLFLyQGHFXHQWDVHQWRGRVORVQLYHOHVQRVRORSDUDJDUDQWL]DUODVROLGDULGDGVLQR SDUDPDQWHQHUODDWUDYpVGHOWLHPSR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 5HIHUHQFLDVELEOLRJUi¿FDV .HNNL 3 3ULPDU\ KHDOWK FDUH DQG WKH 0LOOHQQLXP 'HYHORSPHQW *RDOV LVVXHV IRU GLVFXVVLRQ *HQHYD:+2 /RSH]$ %HQLD : &RQWHUD 0 *LGD & 'HO HQIRTXH PDWHUQR LQIDQWLO DO HQIRTXH GH OD VDOXG UHSURGXFWLYD7HQVLRQHVREVWiFXORV\SHUVSHFWLYDV0RQWHYLGHR(G5RVJDO 206$WHQFLyQSULPDULDGHVDOXG,QIRUPHGHOD&RQIHUHQFLD,QWHUQDFLRQDOVREUH$WHQFLyQ 3ULPDULDGH6DOXG$OPD$WD8566GHVHSWLHPEUHGH*HQHYD:+2 236 /D WUDQVLFLyQ KDFLD XQ QXHYR VLJOR GH VDOXG HQ ODV$PpULFDV ,QIRUPH DQXDO GH OD 'LUHFWRUD:DVKLQJWRQ'&3$+2 2365HYLVLyQGHODVSROtWLFDVGH$WHQFLyQ3ULPDULDGHVDOXGHQ$PpULFD/DWLQD\HO&DULEH :DVKLQJWRQ'&3$+2 236&RQVHMR'LUHFWLYR6HVLyQGHO&RPLWp5HJLRQDO:DVKLQJWRQ'&(8$ DOGHVHSWLHPEUHGH5HVROXFLyQ&'5$WHQFLyQ3ULPDULDGH6DOXGHQODV$PpULFDV /DVHQVHxDQ]DVH[WUDtGDVDORODUJRGHDxRV\ORVUHWRVIXWXURV 236&RQVHMR'LUHFWLYR6HVLyQGHO&RPLWp5HJLRQDO:DVKLQJWRQ'&(8$DO GHVHSWLHPEUHGH'HFODUDFLyQUHJLRQDOVREUHODVQXHYDVRULHQWDFLRQHVGHOD$WHQFLyQ 3ULPDULDGH6DOXGODUHQRYDFLyQGHODDWHQFLyQSULPDULDGHVDOXGHQODVDPpULFDV2ULHQWDFLyQ HVWUDWpJLFD\SURJUDPiWLFDSDUDOD2UJDQL]DFLyQ3DQDPHULFDQDGHOD6DOXG 3$+2 6SHFLDO 6HVVLRQ RQ WKH WK $QQLYHUVDU\ RI WKH 'HFODUDWLRQ RI $OPD$WD WK 'LUHFWLQJ&RXQFLO3URYLVLRQDU\6XPPDU\3$+2SXEOLFDWLRQ&'65:DVKLQJWRQ'& 81'38QLWHG1DWLRQV3RSXODWLRQDQG'HYHORSPHQWL3URJUDPPHRI$FWLRQ$GRSWHGDW WKH ,QWHUQDWLRQDO &RQIHUHQFH RQ 3RSXODWLRQ DQG 'HYHORSPHQW &DLUR 6HSWHPEHU 1HZ<RUN8QLWHG1DWLRQV'HSDUWPHQWIRU(FRQRPLFDQG6RFLDO,QIRUPDWLRQDQG3ROLF\$QDO\VLV 67(6$6(5$ 818QLWHG1DWLRQV0LOOHQQLXP3URMHFW,QYHVWLQJLQGHYHORSPHQWDSUDFWLFDOSODQWRDFKLHYH WKH0LOOHQQLXP'HYHORSPHQW*RDOV1HZ<RUN0LOOHQQLXP3URMHFW :+2 $ *OREDO 5HYLHZ RI 3ULPDU\ +HDOWK &DUH (PHUJLQJ 0HVVDJHV *HQHYD :+2 &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR ,, & $ 3, 7 8 /2 , , &XLGDGR3UHFRQFHSFLRQDO 2EMHWLYRV,GHQWL¿FDU\DVHVRUDUVREUHULHVJRSUHFRQFHSFLRQDO $FWLYLGDG&RQVXOWDSUHYLDDOHPEDUD]R &DGDYH]TXHXQDPXMHUVHHPEDUD]DH[LVWHXQDSUREDELOLGDGYDULDEOHGHTXHHOODR VX IXWXUR KLMR VXIUDQ XQ IHQyPHQR DGYHUVR GXUDQWH HO SURFHVR UHSURGXFWLYR HVWR VH FRQRFHFRPR5LHVJR5HSURGXFWLYR+LVWyULFDPHQWHVHKDLQWHQWDGRUHGXFLUHOPLVPR DWUDYpVGHOFRQWUROSUHQDWDOGHFDOLGDGODDWHQFLyQGHOSDUWRSRUSHUVRQDOFDSDFLWDGR \ ORV FXLGDGRV GXUDQWH HO SXHUSHULR$ SHVDU TXH D~Q HQ OD 5HJLyQ VH HVWi OHMRV GH XQLYHUVDOL]DUHVWDVSUHVWDFLRQHVFRQODFDOLGDGVX¿FLHQWHVHGHEHFRPHQ]DUDHPSOHDU ODDWHQFLyQSUHFRQFHSFLRQDOFRPRPHGLGDH¿FD]GHGLVPLQXLUHOULHVJRUHSURGXFWLYR (Q $PpULFD /DWLQD HO SRVSDUWR LQPHGLDWR HV XQ PRPHQWR ySWLPR SDUD GHVDUUROODU DFWLYLGDGHV TXH FRQWULEX\DQ D TXH HO IXWXUR HPEDUD]R VH SURGX]FD HQ PHMRUHV FRQGLFLRQHV3RGUtDVHUHOPRPHQWRLGHDOSDUDDGTXLULUKiELWRV VDOXGDEOHVRUHDOL]DU FRQVXOWDVDHVSHFLDOLVWDVTXHDFRUWRSOD]RSRGUtDQUHGXFLUODPRUELPRUWDOLGDGPDWHUQR QHRQDWDODVtFRPRORVGHIHFWRVFRQJpQLWRVHQIXWXUDVJHVWDFLRQHV &XLGDGRSUHFRQFHSFLRQDO (OFXLGDGRSUHFRQFHSFLRQDOHVUHFRQRFLGRFRPRXQFRPSRQHQWHFUtWLFRHQODDWHQFLyQ VDQLWDULDGHODVPXMHUHVHQHGDGUHSURGXFWLYD(OPLVPRVHGH¿QHFRPRXQFRQMXQWRGH LQWHUYHQFLRQHVTXHVHUHDOL]DQDQWHVGHOHPEDUD]RTXHWLHQHQFRPRSURSyVLWRLGHQWL¿FDU \PRGL¿FDUIDFWRUHVGHULHVJRFXDQGRVHDSRVLEOHSDUDUHGXFLUGDxRVRHYLWDUORVHQXQ SUy[LPRHPEDUD]R &RQVXOWDSUHFRQFHSFLRQDO /DFRQVXOWDSUHFRQFHSFLRQDOVHGH¿QHFRPRODHQWUHYLVWDSURJUDPDGDHQWUHXQDPXMHU RXQDPXMHU\VXSDUHMDFRQHOHTXLSRGHVDOXGSUHYLRDOHPEDUD]RFRQHOREMHWLYR GHFRUUHJLUHOLPLQDURGLVPLQXLUIDFWRUHVRFRQGXFWDVGHULHVJRUHSURGXFWLYR\RWUDWDU HQIHUPHGDGHVTXHSXHGDQDOWHUDUODHYROXFLyQQRUPDOGHXQIXWXURHPEDUD]R/DPHWDGHO DVHVRUDPLHQWRSUHFRQFHSFLRQDOHVTXHODPXMHU\VXSDUHMDUHFLEDQWRGDODLQIRUPDFLyQ QHFHVDULDSDUDWRPDUGHFLVLRQHVFRQVFLHQWHVVREUHVXIXWXURUHSURGXFWLYR (/020(172,'($/3$5$(/$6(625$0,(172(635(9,2$/$*(67$&,21 (Q DOJXQDV FRPXQLGDGHV PiV GH OD PLWDG GH ODV JHVWDFLRQHV QR VRQ SURJUDPDGDV \ ODLGHQWL¿FDFLyQGHOHPEDUD]RRFXUUHXQDRGRVVHPDQDVOXHJRGHOUHWUDVRPHQVWUXDO FXDQGR \D WUDQVFXUULy XQD HWDSD FUtWLFD GHO GHVDUUROOR HPEULRQDULR GH HVWD IRUPD HO HPEULyQSXHGHKDEHUHVWDGRH[SXHVWRDDJHQWHVQRFLYRV (QWUHODVPXMHUHVTXHSODQL¿FDQXQDJHVWDFLyQXQDOWRQ~PHURGHHOORVQRSXHGHQDFFHGHU DXQDRULHQWDFLyQSUHFRQFHSFLRQDODSURSLDGDTXHOHVSHUPLWDDIURQWDUHOHPEDUD]RHQ PHMRUHVFRQGLFLRQHV$OJXQDVHVSHFt¿FDPHQWHDFXGHQHQE~VTXHGDGHDVHVRUDPLHQWR SHURJHQHUDOPHQWHpVWHQRHVWiSDXWDGRRHVOLPLWDGR3RUWRGRHOORHVQHFHVDULRDVLVWLU SUHFRQFHSFLRQDOPHQWHDODVPXMHUHVHQHGDGIpUWLO\DVHVRUDUODVVREUHORVIDFWRUHVTXH DXPHQWDQVXVSUREDELOLGDGHVGHHQIHUPDURPRULUHOODRVXVKLMRV6HSURSRQHHQWRQFHV DSOLFDUHQODFRQVXOWDSUHFRQFHSFLRQDOHOFOiVLFRHQIRTXHGHQLYHOHVGHSUHYHQFLyQGH /HYHO\&ODUNSUHYHQFLyQSULPDULDVHFXQGDULD\WHUFLDULD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (VFRQYHQLHQWHDFODUDUTXHHOHQIRTXHVHJ~QQLYHOHVGHSUHYHQFLyQVHHVWDUiDSOLFDQGR DOPLVPRWLHPSRDGRVLQGLYLGXRVODPXMHUTXHTXLHUHVHUPDGUHSRUXQODGR\HOQLxRTXH VHJHVWDUiSRURWUR(QHVWHFDVRUHFRPHQGDFLRQHVRDFFLRQHVGHXQQLYHOGHSUHYHQFLyQ VHFXQGDULD SDUD OD PXMHU SRGUiQ UHSUHVHQWDU XQ QLYHO GH SUHYHQFLyQ SULPDULD SDUD HO QLxRSRUHMHPSORHIHFWXDUXQWUDWDPLHQWRFRUUHFWRSDUDODGLDEHWHVHQXQDPXMHUSXHGH SUHYHQLUODDSDULFLyQGHFRPSOLFDFLRQHVPiVVHYHUDVGHULYDGDVGHOPDOFRQWUROPHWDEyOLFR RGHOGDxRYDVFXODUSURGXFLGRSRUGLFKDHQIHUPHGDGSUHYHQFLyQVHFXQGDULDDOPLVPR WLHPSRTXHHOXVRDGHFXDGRGHODLQVXOLQDSDUDPDQWHQHUODHXJOLFHPLDSURWHJHUtDGH VXIULUGHIHFWRVFRQJpQLWRVDOHPEULyQDJHVWDUVHSUHYHQFLyQSULPDULD 5('8&&,Ï1'(/$025%,0257$/,'$'0$7(51$<)(721(21$7$/ /D FRQVXOWD SUHFRQFHSFLRQDO SURFXUD ORJUDU HO ELHQHVWDU PDWHUQR \ HO QDFLPLHQWR GH XQQLxRVDQR(OHVWDGRGHVDOXGHVXQFRQFHSWRVXPDPHQWHDPSOLRFRQGH¿QLFLRQHV TXH KDQ LGR HYROXFLRQDQGR GHVGH HO FRQFHSWR GH DXVHQFLD GH HQIHUPHGDG KDVWD ORV HQIRTXHV DFWXDOHV PiV LQWHJUDGRUHV D OD YH] TXH FRPSOHMRV (VWH FDStWXOR LQFOX\H UHFRPHQGDFLRQHVWHQGLHQWHVDHYLWDUODSpUGLGDGHOHVWDGRGHVDOXGGHODPXMHUGHORV IHWRV\UHFLpQQDFLGRVFRQVLGHUDQGRGHVGHHYLWDUVXPXHUWHXRWURVGDxRV '()(&726&21*e1,726 'H¿QLFLyQ (Q OD GpFDGD GH ORV RFKHQWD FRQ OD ¿QDOLGDG GH XQL¿FDU FULWHULRV OD 2UJDQL]DFLyQ 3DQDPHULFDQDGHOD6DOXGSURSXVRGH¿QLUGHIHFWRFRQJpQLWRFRPRDTXHOTXHLQFOX\H ODV DQRPDOtDV IXQFLRQDOHV \R HVWUXFWXUDOHV GHO IHWR GHELGDV D IDFWRUHV SUHVHQWHV DQWHV GHO QDFLPLHQWR LQFOX\HQGR GHIHFWRV JHQpWLFRV DPELHQWDOHV R GHVFRQRFLGRV DXQTXHWDOGHIHFWRQRVHDDSDUHQWHHQHOUHFLpQQDFLGR\VRODPHQWHVHPDQL¿HVWHPiV WDUGtDPHQWH3RUORTXHODFHJXHUDODVRUGHUDHOUHWDUGRPHQWDO\RWURVWUDVWRUQRVGHO QHXURGHVDUUROORHVWiQLQFOXLGRVHQHVWHFRQFHSWR )UHFXHQFLD /DIUHFXHQFLDGHPDOIRUPDFLRQHVFOtQLFDPHQWHLPSRUWDQWHVHQORVUHFLpQQDFLGRVHVWi HQWRUQRGHO6LQHPEDUJRORVGHIHFWRVFRQJpQLWRVHQJHQHUDOVRQPiVIUHFXHQWHV DIHFWDQGRHQWUHHO\HOGHOWRWDOGHORVQDFLPLHQWRV (WLRORJtD $~QKR\HQPiVGHOGHORVFDVRVODFDXVDGHORVGHIHFWRVFRQJpQLWRVSHUPDQHFH GHVFRQRFLGD 'H ODV FDXVDV FRQRFLGDV OD FRPELQDFLyQ GH IDFWRUHV DPELHQWDOHV \ JHQpWLFRV KHUHQFLD PXOWLIDFWRULDO H[SOLFD DSUR[LPDGDPHQWH HO GH ORV GHIHFWRV PRUIROyJLFRV 2WUDV FDXVDV LQFOX\HQ HQIHUPHGDG PDWHUQD \ PHGLFDFLyQ PDWHUQD +,6725,$&/,1,&$ 7RGDFRQVXOWDPHGLFDGHEHFRPHQ]DUFRQXQDFRUUHFWDKLVWRULDFOtQLFD\HODQiOLVLVGH DTXHOORVGDWRVHSLGHPLROyJLFDPHQWHUHOHYDQWHV 'DWRVSDWURQtPLFRV (GDG /DHGDGGHODPXMHU\HVSHFLDOPHQWHODVHGDGHVHQORVH[WUHPRVGHODYLGDUHSURGXFWLYD VRQXQIDFWRUTXHVHKDDVRFLDGRGHVGHKDFHPXFKRWLHPSRFRQUHVXOWDGRVDGYHUVRV PDWHUQRQHRQDWDOHV (GDG0DWHUQD$YDQ]DGD 6HODKDDVRFLDGRFRQPD\RUULHVJRGHVXIULUKLSHUWHQVLyQ\GLDEHWHVTXHDVXYH] FRQGLFLRQDQ PD\RUHV FKDQFHV GH VXIULPLHQWR IHWDO DJXGR \R FUyQLFR 2WUR ULHVJR GHODHGDGPDWHUQDDYDQ]DGDVHYLQFXODDODVDQRPDOtDVGHOGHVDUUROORHOSULPHU &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR HMHPSORGHVFULWRIXHHO6tQGURPHGH'RZQ(QQXHVWUDUHJLyQODHGDGGHODPDGUH HVHOSULQFLSDOIDFWRUGHULHVJRHQUHODFLyQFRQGLFKRVtQGURPH(Q/DWLQRDPpULFDODV PXMHUHVGHDxRVRPiVSURGXFHQHOGHWRGRVORVQDFLPLHQWRV\HOGHORV FDVRVFRQ6tQGURPHGH'RZQ6LQSDVDUSRUDOWRORV'HUHFKRV5HSURGXFWLYRVVH SXHGHDVHJXUDUTXHFXDOTXLHUFDPSDxDTXHGHVHVWLPXOHODFRQFHSFLyQHQPXMHUHV PD\RUHVGHDxRVORFXDOQRWHQGUtDLPSDFWRHQODQDWDOLGDGSRGUtDSUHYHQLUOD PLWDGGHORVFDVRVGHXQDHQIHUPHGDGJHQpWLFDJUDYHHLQFXUDEOH (QODWDEODVHSUHVHQWDHOLQFUHPHQWRHQHOULHVJRGHVtQGURPHGH'RZQDPHGLGD TXHODHGDGDYDQ]D (GDGPDWHUQDEDMD 0HQRU D DxRV WDPELpQ HV IDFWRU GH ULHVJR SDUD SUHPDWXUH] \ SDUD DOJXQDV PDOIRUPDFLRQHVHVSHFt¿FDVFRPR*DVWURVTXLVLV\RWURVGHIHFWRV/DVPXMHUHVHQOD DGROHVFHQFLDWHPSUDQDPHQRUHVGHDxRVWLHQHQPD\RUULHVJRGHPRUELPRUWDOLGDG YLQFXODGDDOHPEDUD]R\VREUHWRGRDOSDUWR (GDGSDWHUQDDYDQ]DGD 'HVGHHOSXQWRGHYLVWDSUHFRQFHSFLRQDO\HQYLVWDVDUHGXFLUHOULHVJRGHDOJXQRV GHIHFWRVFRQJpQLWRVHVUHFRPHQGDEOHFRQRFHUODHGDGGHOFRPSDxHURVH[XDO\D TXHFXDQGRHOFRPSDxHURVH[XDOHVPD\RUDDxRVVHKDYLVWRVXDVRFLDFLyQFRQ XQDXPHQWRHQHOULHVJRSDUDQXHYDVPXWDFLRQHVGHWLSRGRPLQDQWH &XDGUR 5LHVJRGHVtQGURPHGH'RZQHQUHFLpQQDFLGRVYLYRVGHDFXHUGRDODHGDGPDWHUQD (GDGHQDxRV 5LHVJR (GDGHQDxRV y 5LHVJR &RQVDQJXLQLGDG $VtFRPRHVLPSRUWDQWHFRQRFHUODHGDGGHOSDGUHSDUDHVWLPDUHOULHVJRGHGHIHFWRV FRQJpQLWRVHVQHFHVDULRGH¿QLUHOJUDGRGHSDUHQWHVFRFRQODSDUHMD/RVLQGLYLGXRV VRQFRQVDQJXtQHRVVLSRUORPHQRVWLHQHQXQDQWHFHVRUFRP~Q(VWHGDWRVHKDFHPiV LPSRUWDQWHD~QHQWUHSREODFLRQHVDLVODGDV\DTXHHQJUXSRVFHUUDGRVODVSUREDELOLGDGHV GHFRQVDQJXLQLGDGVRQPD\RUHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (WQLD 'HPDQHUDVLPLODUTXHFRQODHGDG\ODFRQVDQJXLQLGDGVHKDYLVWRTXHODLQFLGHQFLD GHDOJXQDVPDOIRUPDFLRQHVFRQJpQLWDVHVWiDXPHQWDGDHQJUXSRVpWQLFRVHVSHFt¿FRV 6RQHMHPSORVFOiVLFRVODPD\RUIUHFXHQFLDGHSROLGDFWLOLDSDODGDUKHQGLGRKLSRVSDGLDV DOWHUDFLRQHV GH ODV JORELQDV FRPR OD$QHPLD )DOFLIRUPH HQ QLxRV DIURDPHULFDQRV ODVFDUGLRSDWtDVHQQLxRVEODQFRVROD%HWD7DODVHPLDPiVIUHFXHQWHHQSHUVRQDVGH RULJHQPHGLWHUUiQHR 2FXSDFLyQ &LHUWDV FRQGLFLRQHV GH WUDEDMR KDQ VLGR DVRFLDGDV FRQ XQ DXPHQWR HQ UHVXOWDGRV SHULQDWDOHVDGYHUVRVDERUWRPXHUWHIHWDOSDUWRGHSUHWpUPLQREDMRSHVRDOQDFHU\ DOJXQRVGHIHFWRVFRQJpQLWRV(QWUHGLFKDVFRQGLFLRQHVVHSXHGHQFLWDU 7UDEDMDUPiVGHKRUDVSRUGtD 3HUPDQHFHUGHSLHSRUPiVGHKRUDVHQIRUPDFRQWLQXD ([SRVLFLyQ D Wy[LFRV TXtPLFRV LQFOX\HQGR DJHQWHV DQHVWpVLFRV VROYHQWHV \ SHVWLFLGDV /DV PXMHUHV TXH SXHGDQ WHQHU XQD H[SRVLFLyQ ODERUDO D HVWDV VXVWDQFLDV GHEHUiQ VHU DFRQVHMDGDV SDUD FDPELDU VXV ODERUHV DQWHV GH HPEDUD]DUVH R DSHQDV OR VHSDQ +DVWD HO PRPHQWR QR H[LVWH HYLGHQFLD GH ULHVJRWHUDWRJpQLFRSRUH[SRVLFLyQSDWHUQDDHVWRVPLVPRVDJHQWHV $QWHFHGHQWHV5HSURGXFWLYRV 6L VH SUHWHQGH UHGXFLU HO ULHVJR UHSURGXFWLYR OD UHDOL]DFLyQ GH XQD FRUUHFWD KLVWRULD UHSURGXFWLYDSXHGHLGHQWL¿FDUIDFWRUHVUHODFLRQDGRVDPDORVUHVXOWDGRVHQHPEDUD]RV DQWHULRUHV$YHFHVHVWRVIDFWRUHVSXHGHQVHUFRUUHJLGRVRLQFOXVRHOLPLQDGRVORTXH GHEHUtDUHGXQGDUHQXQQXHYRHPEDUD]RPiVVHJXUR$OGtDGHKR\ODHYLGHQFLDSHUPLWH D¿UPDUTXHHVSDFLDUORVHPEDUD]RVFHVDUHOKiELWRGHIXPDUHOXVDUSURJHVWHURQDV HQ FDVR GH SDUWRV GH SUHWpUPLQR SUHYLRV X RWURV PHGLFDPHQWRV SDUD HQIHUPHGDGHV HVSHFt¿FDVDVtFRPRDOJXQRVWUDWDPLHQWRVTXLU~UJLFRVUHGXFHQHOULHVJRGHUHVXOWDGRV DGYHUVRVPDWHUQRQHRQDWDOHV 6HKDGHPRVWUDGRTXHDOJXQRVIDFWRUHVFRPRHOHVFDVRLQWHUYDORLQWHUJHQpVLFRDERUWRV HVSRQWiQHRV SDUWRV GH SUHWpUPLQR UHVWULFFLyQ GH FUHFLPLHQWR LQWUDXWHULQR PXHUWH IHWDORQHRQDWDOSDUWRTXLU~UJLFRODGLDEHWHVJHVWDFLRQDOODKLSHUWHQVLyQLQGXFLGDSRU HPEDUD]R\ODVPDOIRUPDFLRQHVXWHULQDVLQWHJUDQXQDODUJDOLVWDTXHSXHGHUHODFLRQDUVH FRQODSUHVHQWDFLyQGHFRPSOLFDFLRQHVHQXQQXHYRHPEDUD]R (VFDVRLQWHUYDORLQWHUJHQpVLFR &DGDPXMHUWLHQHGHUHFKRDGHFLGLUHOPRPHQWRTXHFRQVLGHUDRSRUWXQRSDUDWHQHUVX SUy[LPR KLMR SUHFLVDPHQWH OD ³RSRUWXQLGDG´ GHEH HVWDU GH¿QLGD HQWUH RWURV IDFWRUHV SRU HO FRQRFLPLHQWR UHDO GHO ULHVJR TXH LPSOLFD XQD QXHYD JUDYLGH] FRQ XQ SHUtRGR LQWHUJHQpVLFRFRUWRRGHPDVLDGRODUJR /RVHVWXGLRVGLVSRQLEOHVSDUDHVWDEOHFHUHOLQWHUYDORLQWHUJHQpVLFRLGHDOOXHJRGHXQ KLMRQDFLGRYLYRQRVRQVX¿FLHQWHVSRUHOPRPHQWRGHWDOIRUPDH[LVWHQHYLGHQFLDVTXH VXJLHUHQTXHXQLQWHUYDORPHQRUDPHVHVFRPSRUWDPD\RUULHVJRGHPRUELPRUWDOLGDG PDWHUQRSHULQDWDO PLHQWUDV TXH RWURV DXWRUHV VRVWLHQHQ TXH HO ULHVJR KDVWD ORV PHVHV(QEDVHDHVWDVGLVFUHSDQFLDVXQJUXSRGHH[SHUWRVFRQYRFDGRVSRUOD206 HVWDEOHFLy HQ IRUPD DUELWUDULD UHFRPHQGDU FRPR VHJXUR XQ LQWHUYDOR PtQLPR GH PHVHV 0LHQWUDVWDQWRHQORVFDVRVGHHPEDUD]RVTXHWHUPLQDURQHQDERUWRVHUHFRPLHQGD FRPR VHJXUR XQ LQWHUYDOR PD\RU D PHVHV /D LQYHVWLJDFLyQ TXH KD SURYLVWR HVWD HYLGHQFLDHVHQEDVHDGDWRVODWLQRDPHULFDQRVH[WUDtGRVGHOEDQFRGHGDWRVGHO6,3 GHO&/$3:5 &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 3DULGDG /D SDULGDG KD VLGR GHVFULWD FRPR XQR GH ORV IDFWRUHV GH ULHVJR SDUD OD PRUWDOLGDG SHULQDWDO\PRUELPRUWDOLGDGPDWHUQD/DSDULGDGHOHYDGDFXDWURRPiVHPEDUD]RV DXPHQWDDOGREOHHOULHVJRGHPXHUWHIHWDOLQWUDSDUWR<DTXHHVWHHVXQIDFWRUGHULHVJR QRPRGL¿FDEOHVHGHEHUiDGYHUWLUDODVPXMHUHVVREUHHVWHSDUDD\XGDUDGHFLGLUVLHV FRQYHQLHQWH R QR XQD QXHYD JHVWDFLyQ (Q FDVR TXH RSWHQ SRU XQ QXHYR HPEDUD]R VH GHEHUi H[WUHPDU HO FXLGDGR GXUDQWH HO SUHQDWDO \ HVSHFLDOPHQWH HQ HO SDUWR \ SRVWSDUWR $ERUWRSUHYLR <DVHPHQFLRQyODLPSRUWDQFLDGHDFRQVHMDUDODPXMHUTXHGHVHDXQQXHYRHPEDUD]R HQDVHJXUDUXQSHUtRGRLQWHUJHQpVLFRPD\RUDPHVHVOXHJRGHXQDERUWRSDUDUHGXFLU ORV ULHVJRV GH HQIHUPHGDG R PXHUWH PDWHUQRQHRQDWDO 3HUR WDPELpQ HV UHOHYDQWH FRQRFHUHORORVDQWHFHGHQWHVGHDERUWRVSUHYLRV/DSpUGLGDUHFXUUHQWHGHOHPEDUD]R GH¿QLGD FRPR OD DSDULFLyQ GH DERUWRV HVSRQWiQHRV FRQVHFXWLYRV GHEHUi RULHQWDU DO SURIHVLRQDO HQ XQD E~VTXHGD DFWLYD GH PDOIRUPDFLRQHV XWHULQDV LQFRPSHWHQFLD FHUYLFDO GHIHFWRV KRUPRQDOHV R LQFOXVR HQIHUPHGDGHV LQIHFFLRVDV FRPR OD Vt¿OLV \D TXHHVWD,76HVWiHQDXPHQWR\VHFDUDFWHUL]DSRUJHQHUDUXQDSODFHQWLWLVFDSD]GH PDWDUHPEULRQHV\IHWRV<DORVDQWLJXRVREVWHWUDVGH¿QtDQDODVt¿OLVFRPR³ODHVFDOHUD DVFHQGHQWHDODYLGD´HQWHQGLHQGRTXHHQORVSULPHURVDxRVGHLQIHFFLyQVHSURGXFtDQ PXHUWHVIHWDOHVFDGDYH]PiVWHPSUDQDV\TXHFRQHOSDVRGHORVDxRVODHQIHUPHGDG VHKDFtDPHQRVDJUHVLYDSDUDHOIHWRGHMiQGRORVQDFHUDHGDGHVFDGDYH]PD\RUHV 0XHUWHIHWDOSUHYLD (QODFRQVXOWDSUHFRQFHSFLRQDOVHLQWHQWDUiHYDOXDUHOULHVJRGHUHSHWLFLyQGHODPXHUWH IHWDOHQXQIXWXURHPEDUD]RSDUDDVHVRUDUDODPXMHUHQODVSRVLELOLGDGHVGHUHSHWLUHO IHQyPHQR\SDUDSODQL¿FDUHOFXLGDGRTXHGHEHUiUHFLELUHQHOIXWXURHPEDUD]R+DFHU HVWDHYDOXDFLyQSRUODKLVWRULDFOtQLFDQRVLHPSUHHVIiFLOLQFOXVRFXDQGRVHGLVSRQHGHO LQIRUPHGHQHFURSVLDGHOIHWR\ODKLVWRSDWRORJtDGHODSODFHQWDXRWURVyUJDQRV+DEUi RFDVLRQHV HQ ODV TXH VH GHEHUi UHFXUULU D H[iPHQHV GH ODERUDWRULR FRPR SUXHEDV GH WROHUDQFLD D OD JOXFRVD DQWLFXHUSRV DQWLFDUGLROLSLQDV \ HVWXGLRV HVSHFt¿FRV GH OD FRDJXODFLyQ 'XUDQWHXQIXWXURHPEDUD]RSRGUiQUHSHWLUVHHVWRVH[iPHQHVLQWHQVL¿FDUHOFRQWURO SUHQDWDOLQFRUSRUDUHVWXGLRVXOWUDVRQRJUi¿FRVPRUIROyJLFRV\IXQFLRQDOHVHWF 3DUWRGHSUHWpUPLQR (OQDFLPLHQWRGHSUHWpUPLQRHVXQDGHODVSULQFLSDOHVFDXVDVGHPXHUWHQHRQDWDO/DV PXMHUHVTXHKDQWHQLGRXQQDFLPLHQWRGHSUHWpUPLQRDQWHVGHODVVHPDQDVWLHQHQ XQULHVJRGHDGHUHSHWLURWURQDFLPLHQWRGHSUHWpUPLQR(VHULHVJRSXHGH OOHJDU DXPHQWD D XQ GHVSXpV GH \ D XQ GHVSXpV GH QDFLPLHQWRV GH SUHWpUPLQR $GHPiV GHO DQWHFHGHQWH GH SDUWR GH SUHWpUPLQR VH KD YLVWR TXH RWURV IDFWRUHV VH DVRFLDQFRQHOULHVJRGHSUHVHQWDUXQSDUWRGHSUHWpUPLQRHQWUHHOORVVHFLWDQ SHVRGHODPXMHUDOLQLFLRGHOHPEDUD]RPHQRUDNLORVRtQGLFHGHPDVDFRUSRUDO PHQRUNJP WDEDTXLVPR LQWHUYDORLQWHUJHQpVLFRPHQRUDPHVHV FXHOORFHUYLFDODFRUWDGRHFRJUi¿FDPHQWH /D LPSRUWDQFLD GH HVWRV IDFWRUHV SHUPLWLUi DSOLFDU PHGLGDV FRUUHFWLYDV SUHYLDV D XQ QXHYRHPEDUD]R &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 5HVWULFFLyQGHOFUHFLPLHQWRLQWUDXWHULQR5&, ([LVWHQIDFWRUHVGHULHVJRTXHVHYLQFXODQFRQODSRVLELOLGDGGHXQ5&,HQXQDIXWXUD JHVWDFLyQGLFKRVIDFWRUHVVRQHOEDMRSHVRSUHFRQFHSFLRQDOGHODPXMHUPXMHUHVPHQRUHV GHDxRVRPD\RUHVDDxRVXQFRUWRLQWHUYDORLQWHUJHQpVLFRWDEDTXLVPR\DEXVR GHVXVWDQFLDVDVtFRPRRWUDVHQIHUPHGDGHVWDOHVFRPRDIHFFLRQHVFDUGLRYDVFXODUHV KLSHUWHQVLyQLQVX¿FLHQFLDUHQDOLQPXQRSDWtDVDQHPLDHWF &HViUHDSUHYLD /DFHViUHDFRPRIRUPDGHWHUPLQDFLyQGHOHPEDUD]RHVFDGDYH]PiVFRP~QHQQXHVWUD UHJLyQ\HQHOPXQGR'HELGRDODPHMRUDGHODVWpFQLFDVTXLU~UJLFDV\DQHVWpVLFDVORV PDORV UHVXOWDGRV YLQFXODGRV D HOOD KDQ GLVPLQXLGR 3HUR D~Q DVt OD FHViUHD VLJXH VLHQGRPiVULHVJRVDTXHXQSDUWRQRUPDO\ODVFHViUHDVLWHUDWLYDVUHSUHVHQWDQPD\RU ULHVJR GH URWXUD XWHULQD H LQVHUFLRQHV SODFHQWDULDV DQRUPDOHV OR TXH SXHGH OOHYDU D KHPRUUDJLDVJUDYHVD~QHQPXMHUHVHQODVTXHVHSODQHDXQDFHViUHDHOHFWLYD (Q XQD PXMHU TXH VH TXLHUH HPEDUD]DU HV QHFHVDULR FRQRFHU DOJXQRV DVSHFWRV GH OD KLVWRULD GH OD R ODV FHViUHDV SUHYLDV SDUD RULHQWDU DFHUFD GH ULHVJRV HQ IXWXUDV JHVWDFLRQHVWDOHVDVSHFWRVVRQ WLSRGHLQFLVLyQODVLQFLVLRQHVHQ7FRPSRUWDQPD\RUULHVJRGHURWXUDXWHULQDVREUH ODVORQJLWXGLQDOHV\pVWDVPD\RUULHVJRTXHODVWUDQVYHUVDOHVVHJPHQWDULDV DQWHFHGHQWH GH LQIHFFLyQ GH OD KHULGD TXLU~UJLFD HQ HVSHFLDO GH LQIHFFLRQHV SDULHWDOHVSURIXQGDVTXHSRGUtDQSURYRFDUXQDFLFDWUL]DFLyQDQRUPDOTXHFRQOOHYH DPD\RUULHVJRGHURWXUDXWHULQDRKHPRUUDJLDVSRUSODFHQWDFLyQDQRUPDO WLHPSRWUDQVFXUULGRSHUtRGRVLQWHUSDUWRPHQRUHVDPHVHVWLHQHQPD\RUULHVJR PDWHUQR FDQWLGDGGHFHViUHDVSUHYLDVHOULHVJRGHURWXUDXWHULQDSDUHFHHVWDUPiVLQÀXLGR SRUHOWLSRGHLQFLVLyQTXHSRUHOQ~PHURGHFHViUHDV (Q EDVH D WRGRV HVWRV DVSHFWRV XQD PXMHU TXH DFXGH D FRQVXOWD SUHFRQFHSFLRQDO GHEHUi VHU LQIRUPDGD VREUH HO PD\RU ULHVJR GH URWXUD XWHULQD KHPRUUDJLDV SRU SODFHQWDFLyQ DQRUPDO \ DGYHUWLUODV GHO ULHVJR HQ HO XVR GH R[LWyFLFRV SDUD LQGXFLU HO SDUWRHVSHFLDOPHQWHHQHOXVRGH0LVRSURVWRO 0DOIRUPDFLRQHVXWHULQDV 3XHGHQHQFRQWUDUVHHQPXMHUHVFRQXQDKLVWRULDUHSURGXFWLYDQRUPDOSHURVRQPXFKR PiVIUHFXHQWHVHQDTXHOODVFRQSREUHVUHVXOWDGRVREVWpWULFRVHQHVSHFLDOODVTXHKDQ VXIULGRSpUGLGDVUHFXUUHQWHVHQWUHHOSULPHU\VHJXQGRWULPHVWUHGHOHPEDUD]R 6HHVWLPDTXHKDVWDGHFDGDPXMHUHVFRQSpUGLGDUHFXUUHQWHGHOHPEDUD]RSXHGH SUHVHQWDUXQDDQRPDOtDXWHULQD/DVDQRPDOtDVPiVIUHFXHQWHVVRQODKLSRSODVLDXWHULQD \ORVWDELTXHVLQWUDXWHULQRV /DKLVWRULDFOtQLFDGHSpUGLGDVUHFXUUHQWHVFDUDFWHUL]DGDSRUHOLQLFLRGHFRQWUDFFLRQHV SUHPDWXUDVHVSRQWiQHDVDGLIHUHQFLDGHODVLQFRPSHWHQFLDVFpUYLFRtVWPLFDVGRQGHHO SDUWRRDERUWRVXHOHLQLFLDUVH\KDVWDSURGXFLUVHVLQFRQWUDFFLRQHVSHUPLWHVRVSHFKDU XQD DQRUPDOLGDG XWHULQD (VWXGLRV LPDJHQROyJLFRV FRPR OD XOWUDVRQRJUDItD OD KLVWHURVDOSLQJRJUDItDODWRPRJUDItDD[LDOFRPSXWDUL]DGD\KDVWDODUHVRQDQFLDQXFOHDU PDJQpWLFDSHUPLWHQDSUR[LPDUVHDOGLDJQyVWLFR 8QD YH] HVWDEOHFLGR HO GLDJQyVWLFR OD GHFLVLyQ GH HIHFWXDU WUDWDPLHQWRV TXLU~UJLFRV GHEHUiVHUHYDOXDGDFRQODPXMHUVXSDUHMDVLODKD\\FRQHOHVSHFLDOLVWD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $QWHFHGHQWHVJHQHUDOHV 3DUDIDFLOLWDUHODQiOLVLVGHORVDQWHFHGHQWHVORVGLYLGLUHPRVHQ (QIHUPHGDGHVPpGLFDVQRWUDQVPLVLEOHV\ (QIHUPHGDGHVPpGLFDVWUDQVPLVLEOHV (QIHUPHGDGHVPpGLFDVQRWUDQVPLVLEOHV $IHFWDQ D XQD GH FDGD PXMHUHV HPEDUD]DGDV OR TXH FRUUHVSRQGH DO GH OD SREODFLyQIHPHQLQDHQHGDGUHSURGXFWLYD6HSUHVHQWDQSUHYLRVDODJHVWDFLyQ\SXHGHQ DJUDYDUVHGXUDQWHHOHPEDUD]RSXGLHQGROOHYDUDODPXHUWHPDWHUQD7DPELpQSXHGHQ DIHFWDUDOIHWRSRUDOWHUDFLRQHVGHOD¿VLRORJtDPDWHUQD\RSRUODPHGLFDFLyQTXHHOOD UHFLEH$FRQWLQXDFLyQVHGHVFULELUiQODVPiVUHOHYDQWHVWDQWRSRUVXIUHFXHQFLDFRPR SRUVXUHSHUFXVLyQ 'LDEHWHV (VODHQIHUPHGDGQRWUDQVPLVLEOHPiVHVWXGLDGDHQFXDQWRDVXVHIHFWRVVREUHOD JHVWDFLyQSRUODVDOWDVWDVDVGHSUHYDOHQFLDHQPXMHUHVHQHGDGIpUWLO(OREMHWLYR WHUDSpXWLFR SULPDULR HV ORJUDU TXH OD PXMHU TXH VH HPEDUD]D OR KDJD FRQ QLYHOHV QRUPDOHVGHJOXFRVD\DVtORVPDQWHQJDGXUDQWHWRGRHOSHUtRGRSHULFRQFHSFLRQDOGH ORFRQWUDULRDXPHQWDHOULHVJRGHPXHUWHPDWHUQD\IHWDOSUHPDWXULGDGPDFURVRPtD \PDOIRUPDFLRQHVIHWDOHV /DPDGUHVFRQGLDEHWHVWLSR,WLHQHQDYHFHVPiVULHVJRGHGDxRIHWRQHRQDWDO TXHODSREODFLyQJHQHUDOODVPDGUHVFRQGLDEHWHVPHOOLWXVWLSRWLHQHQXQULHVJR YHFHVPD\RU\ODVPDGUHVFRQGLDEHWHVJHVWDFLRQDOWLHQHQHOGREOHGHULHVJRTXHOD SREODFLyQJHQHUDO /DVPXMHUHVFRQGLDEHWHVHVSHFLDOPHQWHODVGH7LSR,WLHQHQXQDPD\RUODELOLGDG \HVWiQH[SXHVWDVDFRPSOLFDFLRQHVJUDYHVFRPRHOFRPDFHWRDFLGyWLFRRDOFRPD KLSRJOXFpPLFR /RVPHMRUHVUHVXOWDGRVREVWpWULFRVVHYHQFXDQGRHODVHVRUDPLHQWRGHODVPXMHUHV GLDEpWLFDV FRPLHQ]D HQWUH \ VHPDQDV SUHYLR D OD FRQFHSFLyQ \ VH ORJUDQ HVWDEOHFHUORVQLYHOHVySWLPRVGHJOXFHPLD (OWDPL]DMHSUHFRQFHSFLRQDOGHUXWLQDSDUDGLDEHWHVSRGUtDDFRQVHMDUVHHQPXMHUHV FRQ DQWHFHGHQWHV GH GLDEHWHV JHVWDFLRQDO HQ XQ HPEDUD]R DQWHULRU VREUH SHVR ,0&NJPXREHVDV,0&NJP\DTXHOODVTXHWLHQHQRPiVIDFWRUHV GHULHVJR /RJUDGRHOHPEDUD]RODJHVWDQWHGLDEpWLFDUHTXHULUiFXLGDGRSRUSDUWHGHXQHTXLSR HVSHFLDOL]DGR (QIHUPHGDGHVWLURLGHDV /D LQFLGHQFLD GH PRUELOLGDG PDWHUQRQHRQDWDO HQ PXMHUHV FRQ KLSHUWLURLGLVPR QR FRQWURODGR HV FRQVLGHUDEOH DXQTXH VX IUHFXHQFLD HV EDMD XQD FDGD HPEDUD]DGDV(QWUHORVGLIHUHQWHVWLSRVGHPRUELOLGDGVHSXHGHQYHUSUHFODPSVLD LQVX¿FLHQFLD FDUGtDFD FRQJHVWLYD FULVLV WLURLGHDV GHVSUHQGLPLHQWR GH SODFHQWD yELWRIHWDO5&,%31\SDUWRGHSUHWpUPLQR (QHORWURH[WUHPRHOKLSRWLURLGLVPRWDPELpQVHDFRPSDxDGHPRUELOLGDGFDUDFWHUL]DGD SRUGp¿FLWLQWHOHFWXDOSUHFODPSVLD\WDPELpQSRUGHVSUHQGLPLHQWRGHSODFHQWDyELWR IHWDO5&,%31\SDUWRGHSUHWpUPLQR ([LVWH FODUD HYLGHQFLD TXH FRQ¿UPD EXHQRV UHVXOWDGRV HQ ODV PXMHUHV TXH FRPHQ]DURQHOWUDWDPLHQWRGHVXGLVIXQFLyQWLURLGHDSUHYLRDOHPEDUD]R (OWUDWDPLHQWRGHORVWUDVWRUQRVWLURLGHRVGHEHUiVHUKHFKRHQFRQMXQWRSRUHOPpGLFR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD WUDWDQWH\HOHQGRFULQyORJRHQDPERVFDVRVKLSHUHKLSRWLURLGLVPRHOREMHWLYRVHUi ORJUDU HO HXWLURLGLVPR DQWHV GHO HPEDUD]R 3DUD HO KLSHUWLURLGLVPR HO DQWLWLURLGHR GHHOHFFLyQHVHOSURSLOWLRXUDFLOR3XGLHQGRVHUQHFHVDULRHOWUDWDPLHQWRUDGLDQWHR LQFOXVRHOTXLU~UJLFR 3DUD ORV FDVRV GH KLSRWLURLGLVPR HO WUDWDPLHQWR HV FRQ KRUPRQDV WLURLGHDV GHELpQGRVHOH DGYHUWLU D OD PXMHU TXH FXDQGR VH HPEDUDFH QR VXVSHQGD OD KRUPRQD &DUGLRSDWtDV 6HHVWLPDTXHHQWUHXQ\XQGHORVHPEDUD]RVVHDVRFLDQFRQFDUGLRSDWtDV \ TXH ODV PLVPDV VHUtDQ XQD GH ODV SULQFLSDOHV FDXVDV GH PRUWDOLGDG PDWHUQD LQGLUHFWD 0iVDOOiGHFXDOVHDODYDULHGDGGHFDUGLRSDWtDHVSULPRUGLDOHVWDEOHFHUDQWHVGHO HPEDUD]R HO HVWDGR IXQFLRQDO GH OD PXMHU HQ FRQGLFLRQHV EDVDOHV SRU TXH HVWi DPSOLDPHQWH GHPRVWUDGR TXH ORV FDPELRV KHPRGLQiPLFRV TXH VH SURGXFHQ VREUHHOVLVWHPDFDUGLRYDVFXODUGHWHFWDEOHVGHVGHODVVHPDQDVGHHPEDUD]R H[SRQHQDXQULHVJRYLWDOHOHYDGRDODPXMHUFRQFDUGLRSDWtD3RUHOORHVPDQGDWRULR HIHFWXDUXQDFRQVXOWDFRQFDUGLyORJR\UHDOL]DUHVWXGLRVIXQFLRQDOHVFDUGtDFRVTXH SHUPLWDQDVHVRUDUDODPXMHUVREUHHOPRPHQWRRSRUWXQRSDUDXQHPEDUD]RVHJXUR RVREUHODFRQYHQLHQFLDGHHYLWDUHOHPEDUD]RGHDFXHUGRDOFRPSURPLVRIXQFLRQDO FDUGLRYDVFXODUHVWDEOHFLGR /DFDSDFLGDGIXQFLRQDOFDUGtDFDVHFODVL¿FDVHJ~QOD³1HZ<RUN+HDUW$VVRFLDWLRQ´HQ FODVHVVLHQGRGHVDFRQVHMDEOHVORVHPEDUD]RVHQODVFODVHV,,,\,9$FRQWLQXDFLyQ VHSUHVHQWDXQDDGDSWDFLyQGHGLFKDFODVL¿FDFLyQ &ODVH,3DFLHQWHVDVLQWRPiWLFDVFRQODDFWLYLGDGItVLFDKDELWXDO6RORSUHVHQWDQ VtQWRPDVFRQHOHMHUFLFLRPX\VHYHUR &ODVH,,$VLQWRPiWLFDVHQUHSRVR3UHVHQWDQVtQWRPDVFRQXQQLYHOGHHVIXHU]R PRGHUDGR &ODVH ,,, $VLQWRPiWLFDV HQ UHSRVR SHUR SUHVHQWDQ VtQWRPDV DQWH HVIXHU]RV OHYHV &ODVH,93DFLHQWHVTXHSUHVHQWDQVtQWRPDVD~QHQUHSRVR (Q FDVR GH SURGXFLUVH XQ HPEDUD]R OD PXMHU GHEHUi DVLVWLUVH HQ XQ VHUYLFLR GH DOWR ULHVJR \ DQWH HVD HYHQWXDOLGDG VH VXJLHUH HPSOHDU ODV UHFRPHQGDFLRQHV GHO ³&RQVHQVRGHH[SHUWRVGHODVRFLHGDGHXURSHDGHFDUGLRORJtD´GHODxRVREUH FRPRVHGHEHQPDQHMDUODVHQIHUPHGDGHVFDUGLRYDVFXODUHVGXUDQWHHOHPEDUD]R /DV PXMHUHV TXH SUHVHQWDQ XQD FDUGLRSDWtD TXH UHTXLHUH XVR GH DQWLFRDJXODQWHV RUDOHVGXUDQWHHOHPEDUD]RQRSRGUiQXVDUORVSRUVXHIHFWRWHUDWRJpQLFR +LSHUWHQVLyQFUyQLFD (VXQDHQWLGDGTXHVHSUHVHQWDFDGDYH]FRQPD\RUIUHFXHQFLD /RV WUDVWRUQRV KLSHUWHQVLYRV GHO HPEDUD]R VXHOHQ VHU XQD GH ODV SULQFLSDOHV FDXVDV GH PRUWDOLGDG PDWHUQD 3UHFLVDPHQWH HV PiV IDFWLEOH OD LQVWDODFLyQ GH XQDSUHHFODPSVLDRGHXQDHFODPSVLDHQPXMHUHVFRQKLSHUWHQVLyQFUyQLFD6HKD GHPRVWUDGRTXHHVWDUHODFLyQSXHGHOOHJDUDVHUGHFDVRGHSUHHFODPSVLDSRU FDGDPXMHUHVTXHSDGHFHQKLSHUWHQVLyQFUyQLFD &XDQGRXQDPXMHUFRQKLSHUWHQVLyQFUyQLFDUHFXUUHDOHTXLSRGHVDOXGHQEXVFDGH RULHQWDFLyQVREUHXQIXWXURHPEDUD]RVHGHEHUiKDFHUXQDFRUUHFWDKLVWRULDFOtQLFD\ XQH[KDXVWLYRH[DPHQItVLFRDGHPiVGHHYDOXDUDVSHFWRVYLQFXODGRVDOWUDWDPLHQWR FRPRHOPHGLFDPHQWRTXHHVWiUHFLELHQGRODGRVLVDGKHVLyQ\ODHIHFWLYLGDGGHO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR PLVPR )LQDOPHQWH GHEHUiQ HIHFWXDUVH H[iPHQHV SDUDFOtQLFRV SDUD HVWDEOHFHU HO JUDGR GH UHSHUFXVLyQ IXQFLRQDO TXH KD RULJLQDGR OD KLSHUWHQVLyQ VREUH yUJDQRV \ VLVWHPDV$OJXQRV PHGLFDPHQWRV DQWLKLSHUWHQVLYRV SXHGHQ VHU WHUDWRJpQLFRV SRU OR FXDO VH GHEHUi FDPELDU OD PHGLFDFLyQ SRU XQD LQRFXD SDUD HO IHWR \ SHUPLWLU HO HPEDUD]RUHFLpQFXDQGRVHKD\DHQFRQWUDGRODGRVLVPtQLPDHIHFWLYDSDUDFRQWURODU ODVFLIUDVGHWHQVLyQDUWHULDO8QHMHPSORORFRQVWLWX\HQORVLQKLELGRUHVGHODHQ]LPD FRQYHUVRUDGHODDQJLRWHQVLQDYHUDQWLKLSHUWHQVLYRVSDJ /D KLSHUWHQVLyQ DUWHULDO VLVWpPLFD VH UHODFLRQD FRQ 5&, EDMR SHVR DO QDFHU SUHPDWXULGDG \ DOWD PRUWDOLGDG SHULQDWDO (O ULHVJR IHWDO HV Pi[LPR FXDQGR H[LVWH SURWHLQXULD(QHOFDStWXORGHDWHQFLyQSUHQDWDOVHDPSOtDQORVDVSHFWRVYLQFXODGRV DHVWHWHPDHQODPXMHUHPEDUD]DGD 7URPER¿OLDV 6HODVFODVL¿FDHQKHUHGDGDVRDGTXLULGDVVRQGLIHUHQWHVHQWLGDGHVTXHWLHQHQHQ FRP~QXQHVWDGRGHKLSHUFRDJXODELOLGDGTXHSXHGHUHSHUFXWLUQHJDWLYDPHQWHHQHO HPEDUD]R /DWURPER¿OLDKHUHGDGDPiVFRP~QHVODPXWDFLyQGHOIDFWRU9GH/HLGHQPLHQWUDV TXHGHQWURGHODVDGTXLULGDVODPiVFRQRFLGDHVHOVtQGURPHDQWLIRVIROLStGLFR (QWUHODPRUELOLGDGTXHSURYRFDQVHGHVWDFDQODVWURPERVLVYHQRVDVSURIXQGDVHO 7(3ORVLQIDUWRVFDUGtDFRV\FHUHEUDOHVHOGHVSUHQGLPLHQWRGHSODFHQWDSUHFODPSVLD DERUWRUHFXUUHQWHPXHUWHIHWDO5&,\SDUWRSUHPDWXUR 'HELGRDODFRPSOHMLGDG\FDQWLGDGGHWHVWGLDJQyVWLFRVH[LVWHQWHVHOSURIHVLRQDOGH DWHQFLyQSULPDULDGHEHUiKDFHUXQFRUUHFWRLQWHUURJDWRULRSDUDKDFHUXQGLDJQyVWLFR SUHVXQWLYRSHURHOGLDJQyVWLFRSDUDFOtQLFRORGHEHUiHIHFWXDUHOHVSHFLDOLVWD (Q OD PXMHU TXH VH FRQRFH HV SRUWDGRUD GH XQD WURPER¿OLD VH OD GHEH DFRQVHMDU DSURSLDGDPHQWHVREUHORVULHVJRVTXHUHSUHVHQWDXQDJUDYLGH]\ODQHFHVLGDGGH FRQWUROHV HVWULFWRV HQ FDVR GH HPEDUD]DUVH (Q DTXHOODV TXH GHFLGHQ SRVSRQHU HO HPEDUD]R R GLUHFWDPHQWH QR OR KDUiQ VH ODV GHEHUi RULHQWDU DGHFXDGDPHQWH VREUH PpWRGRV DQWLFRQFHSWLYRV VDELHQGR TXH ORV HVWUyJHQRV FRQWHQLGRV HQ DOJXQRVFRQWUDFHSWLYRVSURPXHYHQHVWDGRVGHKLSHUFRDJXODELOLGDG(QHVWRVFDVRV VHUi SUHIHULEOH HO XVR GH FRQWUDFHSWLYRV GH SURJHVWHURQD VROR ',8 R PpWRGRV GH EDUUHUD 3UHYLR \ GXUDQWH HO HPEDUD]R HO WUDWDPLHQWR LGHDO HV FRQ KHSDULQDV GH EDMR PROHFXODU/RFXDOLPSOLFDHQWUHQDUDODPXMHUSDUDVXDXWRDGPLQLVWUDFLyQ$SHVDU GHORDOWDPHQWHVHJXUDVTXHVRQVHGHEHUiQSUDFWLFDUFRQWUROHVGHODERUDWRULRGHOD FUDVLVVHJ~QLQGLFDFLyQGHOHVSHFLDOLVWD $QHPLD /D DQHPLD HV XQD GH ODV DIHFFLRQHV PiV SUHYDOHQWHV HQ ODV PXMHUHV GH QXHVWUD UHJLyQ (O WUDWDPLHQWR GHEH HVWDU DFRUGH FRQ HO GLDJQyVWLFR HWLROyJLFR /D DQHPLD IHUURSULYD VXHOH VHU OD PiV IUHFXHQWH GH WRGDV ODV DQHPLDV VH DVRFLD FRQ SODFHQWDSUHYLDKLSHUWUR¿D\GHVSUHQGLPLHQWRSODFHQWDULRSUHFODPSVLD\KHPRUUDJLD SRVWSDUWR6LHVVHYHUDVHDVRFLDD5&,\QDWLPRUWDOLGDG7RGDPXMHUTXHSODQHD XQHPEDUD]R\VXIUHDQHPLDIHUURSULYDGHEHUiUHFLELUPJGHKLHUURHOHPHQWDO SRUGtD (OHPEDUD]RGHSRUVtVXHOHVHUXQSHUtRGRDQHPL]DQWHSRUORTXHFRQVHJXLUTXHODV PXMHUHVOOHJXHQDOHPEDUD]RFRQEXHQRVQLYHOHVKHPiWLFRVFLUFXODQWHV\GHUHVHUYD GHEHVHUXQDGHODVSUHPLVDVGHOFRQWUROSUHFRQFHSFLRQDO/DVPXMHUHVFRQDQHPLD WROHUDUiQSHRU\FRUUHUiQPD\RUULHVJRGHYLGDDQWHFRPSOLFDFLRQHVKHPRUUiJLFDV GXUDQWHHOHPEDUD]RHOSDUWRRHOSXHUSHULR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD $VPD /DVPXMHUHVDVPiWLFDVTXHVHHPEDUD]DQ\QRVXIUHQFULVLVDVPiWLFDVDORODUJR GHO HPEDUD]R WLHQHQ ORV PLVPRV UHVXOWDGRV REVWpWULFRV QHRQDWDOHV TXH ODV QR DVPiWLFDV(QFDPELRODVDVPiWLFDVFRQXQPDOFRQWUROGHVXHQIHUPHGDGGXUDQWH HOHPEDUD]RVXHOHQWHQHUSHRUHVUHVXOWDGRVREVWpWULFRVHQWUHORVTXHVHGHVWDFDQ SUHFODPSVLD KLSHUWHQVLyQ KLSHUpPHVLV JUDYtGLFD DERUWR HVSRQWiQHR 5&, SDUWR SUHPDWXUR\EDMRSHVRDOQDFHU 6HKDYLVWRTXHORDFRQWHFLGRHQHOHPEDUD]RDQWHULRUHVXQEXHQLQGLFDGRUGHOR TXHRFXUULUiFRQHODVPDHQHOIXWXURHPEDUD]RGHWDOIRUPDODVPXMHUHVTXHQR KDQVXIULGRDWDTXHVHQHOSULPHUHPEDUD]RHVUDURTXHORVVXIUDQHQORVVLJXLHQWHV PLHQWUDVTXHTXLHQHVWXYLHURQDJUDYDFLyQGHODVFULVLVHVDOWDPHQWHSUREDEOHTXH YXHOYDQDVXIULUODV /DV PXMHUHV TXH SODQHDQ HPEDUD]DUVH GHEHUiQ XVDU WUDWDPLHQWR SUHYHQWLYR FRQ FRUWLFRLGHVLQKDODWRULRVORVFXDOHVKDQPRVWUDGRVHUVHJXURV(QFDPELRORVFRUWLFRLGHV RUDOHVDXPHQWDQHOULHVJRGHSDODGDUKHQGLGRODELROHSRULQR\EDMRSHVRXQDVD YHFHV /DWHR¿OLQDFRQWLQ~DVLHQGRXQPHGLFDPHQWRVHJXUR /DV PXMHUHV DVPiWLFDV TXH QR GHVHDQ HPEDUD]DUVH GHEHUtDQ VHU DFRQVHMDGDV VREUHHOXVRGHXQPpWRGRDQWLFRQFHSWLYRDGHFXDGR &RQYXOVLRQHV 'HQWUR GH ODV DIHFFLRQHV QHXUROyJLFDV FUyQLFDV TXH RFDVLRQDQ FRQYXOVLRQHV OD HSLOHSVLDDIHFWDDXQDGHFDGDPXMHUHVHQHGDGUHSURGXFWLYD\HVHOGLVWXUELR QHXUROyJLFR PiV IUHFXHQWH GXUDQWH OD JHVWDFLyQ ([LVWH XQ HIHFWR FRPSUREDGR GH DXPHQWRGHGHIHFWRVFRQJpQLWRVSDUDVXGHVFHQGHQFLDGHWDQWRSRUODSDWRORJtD HQ Vt FRPR SRU HO XVR GH ORV IiUPDFRV HPSOHDGRV SDUD FRQWURODUOD (SLVRGLRV UHSHWLGRVGHFULVLVWyQLFRFOyQLFDVJHQHUDOL]DGDVRSDUFLDOHVFRPSOHMDVVHDVRFLDQ FRQDERUWRVHVSRQWiQHRVKLSR[LDIHWDOEUDGLFDUGLD\PXHUWHSHULQDWDODGHPiVGHO SHOLJURGHWUDEDMRGHSDUWRSUHPDWXUR\5&,SRUODHYROXFLyQGHODSDWRORJtDHQVtR HOPDOPDQHMRWHUDSpXWLFR(OFXUVRGHODSDWRORJtDGXUDQWHHOHPEDUD]RSHUPDQHFH LQFDPELDGRHQODPLWDGGHORVFDVRVSXHGHPHMRUDUHQHOGHODVJHVWDQWHV\ HPSHRUDUHQHO $OWHUDFLRQHVSVLTXLiWULFDV (OHPEDUD]RHQWUHRWUDVFRVDVKDVLGRFDUDFWHUL]DGRSRUVHUXQSHUtRGRGHPDUFDGD ODELOLGDGHPRFLRQDO0XFKDVPXMHUHVGXUDQWHHOHPEDUD]RHOSDUWRRHOSXHUSHULR VXIULUiQ OD DSDULFLyQ GH GHVyUGHQHV SVLTXLiWULFRV GH YDULDGD JUDYHGDG R VXIULU OD UHFXUUHQFLDGHSDWRORJtDVSVLTXLiWULFDVSUHYLDV /RV GHVyUGHQHV VLTXLiWULFDV VH KDQ DVRFLDGR FRQ PDORV UHVXOWDGRV PDWHUQR SHULQDWDOHV/DJDPDGHPDORVUHVXOWDGRVHVYDULDEOHGHVGHFXDGURVGHDQJXVWLD ELHQWROHUDGRVKDVWDODGHSUHVLyQVHYHUDFRQDEDQGRQRGHORVFXLGDGRVGHOQLxR\ GHVXVSURSLRVFXLGDGRVOOHJDQGRDOVXLFLGLRRDOLQIDQWLFLGLR 'HELGRDODFDGDYH]PD\RUIUHFXHQFLDGHHVWRVWUDVWRUQRV\DODJUDYHGDGSRWHQFLDO TXH UHSUHVHQWDQ ORV SURIHVLRQDOHV GHEHUtDQ VHU H[KDXVWLYRV HQ OD E~VTXHGD GH VtQWRPDVTXHKLFLHUDQVRVSHFKDUORV 7UDVWRUQRV GHO KXPRU \ DQVLHGDG 6RQ WUDVWRUQRV VXPDPHQWH IUHFXHQWHV \ HQWUHHOORVVHHQFXHQWUDQODGHSUHVLyQ\ORVWUDVWRUQRVGHDQVLHGDG/DVPXMHUHV TXHSODQHDQXQHPEDUD]RGHEHQVHUDGYHUWLGDVVREUHORVULHVJRVGHUHFDtGDV TXHSXHGHQVXSHUDUHOGHORVFDVRVVLVHDEDQGRQDODPHGLFDFLyQ 0XFKRVGHORVPHGLFDPHQWRVTXHVHXVDQSDUDWUDWDUHVWDVDIHFFLRQHVWLHQHQ HIHFWRV WHUDWRJpQLFRV FRQ¿UPDGRV WDO HV HO FDVR GH ODV VDOHV GH /LWLR 2WURV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR PHGLFDPHQWRV QR VRQ UHFRPHQGDGRV \D TXH DXQTXH ODV HYLGHQFLDV QR VRQ FRQFOX\HQWHVVHKDYLVWRFLHUWRJUDGRGHDVRFLDFLyQHQWUHHOORV\HIHFWRVIHWDOHV DGYHUVRVFRPRVXFHGHFRQORVLQKLELGRUHVGHODUHFDSWDFLyQGHODVHURWRQLQD )UHFXHQWHPHQWHHVLPSRVLEOHSRUORVDOWRVQLYHOHVGHUHFDtGDVXJHULUDEDQGRQDU HOWUDWDPLHQWRHQHVHFDVRVHDSHODUiQDORVSODQHVPRQRGURJDV\FRQODPHQRU GRVLVHIHFWLYDSRVLEOH (VTXL]RIUHQLD(VXQDHQIHUPHGDGFUyQLFDTXHVHFDUDFWHUL]DSRUVXJUDYHGDG \ OD DOWD SUREDELOLGDG GH VXIULU GHVFRPSHQVDFLRQHV GXUDQWH HO HPEDUD]R 4XH SRUHOXVRPDQWHQLGRGHPHGLFDFLyQDGLFFLRQHV\ODIDOWDGHDXWRFXLGDGRWLHQHQ DOWDVSRVLELOLGDGHVGHPDOIRUPDFLRQHVIHWDOHVDERUWR5&,GHVQXWULFLyQ\PXHUWH IHWDORPDWHUQD /DVGHVFRPSHQVDFLRQHVSXHGHQVHUGHWDOPDJQLWXGTXHOOHYHQDOLQIDQWLFLGLRR DDXWROHVLRQDUVH 1RHVKDELWXDOTXHPXMHUHVHVTXL]RIUpQLFDVDFXGDQDFRQWUROHVSUHFRQFHSFLRQDOHV JHQHUDOPHQWHORVHPEDUD]RVHQHOODVQRVRQSODQL¿FDGRV (V FRQYHQLHQWH HQ OD YLVLWD SUHFRQFHSFLRQDO PLHQWUDV VH KDFH OD DQDPQHVLV LQWHUURJDUVREUHKLVWRULDIDPLOLDUGHGHVyUGHQHVGHWLSRVLFyWLFRRDQWHFHGHQWHV GHGHVyUGHQHVDIHFWLYRVRKLVWRULDSHUVRQDOGHVLFRVLV$SDUWLUGHOPRPHQWRGH GHWHUPLQDUTXHODPXMHUVXIUHXQDHVTXL]RIUHQLDRSXHGHVXIULUODODSODQL¿FDFLyQ GH XQ HPEDUD]R GHEHUi KDFHUVH FRQ HO VLTXLDWUD WUDWDQWH JDUDQWL]DQGR XQ VHJXLPLHQWR FOtQLFR HVWULFWR GH DPERV \ FRQ SRVLELOLGDG GH FRPXQLFDFLyQ LQPHGLDWDHQWUHODPXMHUODIDPLOLDHOVLTXLDWUD\HOUHVWRGHOHTXLSRGHVDOXG (O WUDWDPLHQWR GH ODV HVTXL]RIUHQLDV VH GHEH UHDOL]DU FRQ DQWLVLFyWLFRV ORV FXDOHV VRQ DOWDPHQWH WHUDWRJpQLFRV SRU HOOR VH UHFRPLHQGD VROR FXDQGR VHD SRVLEOH\EDMRXQHVWULFWRFRQWUROFOtQLFRODVXVSHQVLyQGHORVPLVPRVGXUDQWH OD SODQL¿FDFLyQ LQPHGLDWD GHO HPEDUD]R \ GXUDQWH WRGR HO SULPHU WULPHVWUH 6L ODDIHFFLyQHVGHWDOVHYHULGDGTXHQRSHUPLWHHODXWRFXLGDGRRUHSUHVHQWHXQ ULHVJR SDUD RWUD SHUVRQD R HOOD PLVPD GHEHUi PDQWHQHUVH OD PHGLFDFLyQ R GHVDFRQVHMDUVHHOHPEDUD]R (VWDPXMHUGHEHUiVHUYDORUDGDHQFRQMXQWRFRQHOVLTXLDWUDWUDWDQWHGHELpQGRVH UHFRUGDUTXHDXQTXHWRGRVORVDQWLVLFyWLFRVVRQSRWHQFLDOPHQWHWHUDWRJpQLFRVOD FORUSURPD]LQDKDGHPRVWUDGDVHUODPiVSHOLJURVD3RUHVRHVUHFRPHQGDEOHHQ FDVRGHPDQWHQHUPHGLFDFLyQXVDUKDORSHULGROIHQRWLD]LQD\GHULYDGRVGHHVWD FRPRODVSHUD]LQDV (QIHUPHGDGHV0DWHUQDV7UDQVPLVLEOHV /DPD\RUtDGHODVHQIHUPHGDGHVGHRULJHQLQIHFFLRVRTXHVHSUHVHQWDQDFRQWLQXDFLyQ SXHGHQVHUWHUDWRJpQLFRVGXUDQWHHOGHVDUUROORHPEULRQDULR$XQTXHVXDFFLyQSXHGH FRQWLQXDUOXHJRGHOSHUtRGRHPEULRQDULR\HQDOJXQDVRFDVLRQHVD~QKDVWDGHVSXpVGHO QDFLPLHQWR8QHMHPSORGHHVWRORFRQVWLWX\HODVt¿OLVFRQJpQLWD3RUHVWHPRWLYRHV TXHVHGHEHSULPDULDPHQWHHYLWDUVXRFXUUHQFLDGXUDQWHODJHVWDFLyQ\GHRFXUULUpVWD VHGHEHWUDWDUDODHPEDUD]DGD\DOUHFLpQQDFLGRVLIXHUDQHFHVDULR 5XEpROD 6HUHFRPLHQGDHYDOXDUODVXVFHSWLELOLGDGDOD5XEpRODGHVFDUWDQGRSRUODKLVWRULD FOtQLFD TXH OD PXMHU QR KD\D SDGHFLGR OD HQIHUPHGDG R TXH QR KD\D UHFLELGR OD YDFXQD(QFDVRGHGXGDVVHMXVWL¿FDHIHFWXDUVHURORJtDSDUDUXEpRODDWRGDPXMHU HQHGDGGHSURFUHDU7RGDVODVPXMHUHVQRHPEDUD]DGDVVXVFHSWLEOHVGHEHUiQVHU YDFXQDGDVDQWHVGHOHPEDUD]RRGHVSXpVGHOSDUWR 9DULFHOD 6HUHFRPLHQGDHYDOXDUODVXVFHSWLELOLGDGDOD9DULFHODGHVFDUWDQGRSRUODKLVWRULD FOtQLFD TXH OD PXMHU QR KD\D SDGHFLGR OD HQIHUPHGDG R TXH QR KD\D UHFLELGR OD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD YDFXQD$SHVDUTXHODVPXMHUHVDGXOWDVWHQJDQXQDKLVWRULDQHJDWLYDRLQFLHUWDGH KDEHU SDGHFLGR YDULFHOD PiV GHO VRQ LQPXQHV D HOOD (Q FDVR GH GXGDV VH MXVWL¿FDHIHFWXDUVHURORJtDSDUDYDULFHODDWRGDPXMHUHQHGDGGHSURFUHDU6LQRVH GLVSRQHGHVHURORJtDODYDFXQDFLyQVHUiODRSFLyQ 7RGDVODVPXMHUHVQRHPEDUD]DGDVVXVFHSWLEOHVGHEHUiQVHUYDFXQDGDVDQWHVGHO HPEDUD]RRGHVSXpVGHOSDUWR &LWRPHJDORYLUXV (O&LWRPHJDORYLUXV&09HVODLQIHFFLyQFRQJpQLWDPiVIUHFXHQWH\HVODSULQFLSDO UHVSRQVDEOHSRUORVFDVRVGHVRUGHUDQHXURVHQVRULDO\UHWDUGRPHQWDOGHHWLRORJtD YLUDO (O &09 SHUWHQHFH DO JUXSR GH ORV YLUXV KHUSHV \ HV UHODWLYDPHQWH SRFR FRQWDJLRVRQHFHVLWDQGRFRQWDFWRVHVWUHFKRV\SURORQJDGRV/DLQIHFFLyQHQDGXOWRV QR WLHQH FRQVHFXHQFLDV FOtQLFDV JUDYHV H[FHSWR HQ SDFLHQWHV LQPXQRGHSULPLGDV (VWDLQIHFFLyQRFXUUHHQGHORVQDFLPLHQWRVVRQDVLQWRPiWLFRV 6H GHEHUi DGYHUWLU D WRGDV ODV PXMHUHV HVSHFLDOPHQWH D ODV PDGUHV FRQ KLMRV SHTXHxRV \ D DTXHOODV TXH WLHQHQ FRQWDFWR SURIHVLRQDO FRQ QLxRV PDHVWUDV SHUVRQDOGHVDOXGORVFXLGDGRVKLJLpQLFRVODYDGRGHPDQRVTXHVHGHEHUiQWHQHU DOPDQHMDUSDxDOHVLPSUHJQDGRVFRQRULQDGHQLxRVSHTXHxRVTXLHQHVVXHOHQVHU ODSULQFLSDOIXHQWHGHLQIHFFLyQ 7R[RSODVPRVLV 6HGHEHUiDGYHUWLUDWRGDPXMHUTXHGHVHDHPEDUD]DUVHDFHUFDGHODVIRUPDVSDUD HYLWDUFRQWUDHUXQDWR[RSODVPRVLVHQHOHPEDUD]R\ORVULHVJRVTXHODPLVPDSXHGH RFDVLRQDU(QDTXHOORVSDtVHVHQGRQGHVHHIHFW~HHOWDPL]DMHSDUDWR[RSODVPRVLVVH SRGUiDGYHUWLUDODVPXMHUHVFRQDQWLFXHUSRVDQWLWR[RSODVPDTXHODPDGUHSRUWDGRUD GHLQIHFFLyQFUyQLFDH[FHSFLRQDOPHQWHWUDVPLWHHOSDUiVLWRDOIHWRUHDFWLYDFLyQ9HU WR[RSODVPRVLV HQ HO FDStWXOR GH DWHQFLyQ SUHQDWDO$ WRGD PXMHU TXH FRQRFLHQGR RGHVFRQRFLHQGRVXHVWDGRVHUROyJLFRVHOHGHEHQGDUORVFRQVHMRVJHQHUDOHVGH SUHYHQFLyQSDUDWR[RSODVPRVLV &XDGUR0HGLGDVHGXFDWLYDVDQWHVHURORJtDQHJDWLYDSDUDWR[RSODVPRVLV • • • • • Eliminar el consumo de carne cruda o poco cocida. Usar guantes y lavarse las manos intensamente después de manipular carne cruda. Lavar profundamente todos los utensilios que estuvieron en contacto con carne cruda. Lavar profundamente los vegetales que se comerán crudos. Usar guantes cada vez que se esté en contacto con tierra. Y lavar las manos intensamente después de tocar la tierra. • Mantener los gatos domésticos dentro de la casa y alimentarlos con raciones. • Usar guantes mientras se limpia la “cucha” y lavarse las manos después de hacerlo. 6t¿OLV &RQRFHUHOHVWDGRVHUROyJLFRSDUDVt¿OLVDQWHVGHOHPEDUD]RFRQWULEX\HDHIHFWXDUHO WUDWDPLHQWRGHODPXMHU\VXVFRQWDFWRVHQXQPRPHQWRLGHDO/DVPXMHUHVFRQVt¿OLV GHEHUiQVHULQIRUPDGDVVREUHORVULHVJRVGHWUDQVPLVLyQYHUWLFDOGHHVWDLQIHFFLyQ GHWUDQVPLVLyQVH[XDO 9,+ /DVPXMHUHVHQHGDGIpUWLOWLHQHQHOGHUHFKRGHVRPHWHUVHDSUXHEDVGHWDPL]DMHSDUD 9,+SUHYLDFRQVHMHUtD\JDUDQWL]DQGRODFRQ¿GHQFLDOLGDG(VUHFRPHQGDEOHVXJHULU HOWDPL]DMHDWRGDPXMHUTXHVHTXLHUHHPEDUD]DU(QFDVRGHSUXHEDVSRVLWLYDVVH GHEHUiLQIRUPDUVREUHHOULHVJRGHWUDQVPLVLyQYHUWLFDO\ORVWUDWDPLHQWRVSUR¿OiFWLFRV H[LVWHQWHV(QDTXHOODVPXMHUHVTXHGHFLGDQQRHPEDUD]DUVHVHOHVGHEHUiRIUHFHU PpWRGRVDQWLFRQFHSWLYRVVHJXURV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR +HSDWLWLV% /DLQIHFFLyQIHWDOSRUKHSDWLWLV%VHDVRFLDDSUHPDWXULGDG\QLxRVSHTXHxRVSDUD OD HGDG JHVWDFLRQDO 6H GHEHQ LGHQWL¿FDU PXMHUHV QR YDFXQDGDV \ R VXVFHSWLEOHV GHFRQWUDHUODHQIHUPHGDG7RGDODSREODFLyQ\HVSHFLDOPHQWHORVDGROHVFHQWHV\ PXMHUHV HQ HGDG IpUWLO GHEHUtDQ UHFLELU OD YDFXQD FRQWUD OD KHSDWLWLV % FXDQGR QR WLHQHQ DQWLFXHUSRV (VWD YDFXQD SXHGH VHU DSOLFDGD D~Q GXUDQWH HO HPEDUD]R \D TXHVHWUDWDGHXQDYDFXQDDYLUXVPXHUWRV *ULSH /DYDFXQDDQWLLQÀXHQ]DHVWiFRPSXHVWDSRUYLUXVLQDFWLYDGRVQRLQIHFWDQWHVSRUOR TXHVHFRQVLGHUDVHJXUDD~QHQHOHPEDUD]R3RUORTXHODVPXMHUHVTXHSODQL¿TXHQ HPEDUD]DUVHSRGUiQUHFLELUODYDFXQDVLQLQFRQYHQLHQWHV(QDOJXQDVLQIHFFLRQHV SRU YLUXV LQÀXHQ]D FRPR HQ HO FDVR GH OD SDQGHPLD SRU LQÀXHQ]D $ +1 ODV HPEDUD]DGDV SUHVHQWDQ PD\RU PRUWDOLGDG SRU OR TXH HV UHFRPHQGDEOH TXH WRGD PXMHUTXHSODQHDHPEDUD]DUVHVHDYDFXQDGD 0DODULDR3DOXGLVPR 'HELGR D OD DQHPLD VHYHUD TXH SURYRFD HQ PXFKDV ]RQDV GH$PpULFD GRQGH HO SDOXGLVPRHVHQGpPLFD\DRWUDVFRPSOLFDFLRQHVFRQWULEX\HDODPRUWDOLGDGPDWHUQD 3RU OD PLVPD UD]yQ SXHGH SURYRFDU DERUWR HVSRQWiQHR 5&, SDUWR SUHPDWXUR \ QDFLPLHQWRVFRQ%31 $ODVPXMHUHVTXH\DKDQVXIULGRSDOXGLVPR\TXLHUHQHPEDUD]DUVHHVQHFHVDULR PHMRUDUOHVXVQLYHOHVQXWULFLRQDOHV\GHKHPRJORELQDDODYH]GHDGYHUWLUODVVREUH HOHVWULFWRFRQWUROSUHFRQFHSFLRQDOTXHGHEHUiQUHFLELU /DVPHGLGDVGHSUHYHQFLyQSDUDODVPXMHUHVTXHQRKDQWHQLGRSDOXGLVPRSDVDSRU UHFRUGDUOHVQRYLDMDUDiUHDVHQGpPLFDVSDUDSDOXGLVPR3DUDODVTXHGHEHQYLDMDU RYLYHQHQ]RQDVGHSDOXGLVPRODVUHFRPHQGDFLRQHVGHSUHYHQFLyQLPSOLFDQHOXVR GHFDPDVFRQPRVTXLWHURVFRQLQVHFWLFLGDV\TXLPLRSUR¿OD[LVDQWLSDO~GLFD 7XEHUFXORVLV /D7XEHUFXORVLV GXUDQWH HO HPEDUD]R SXHGH FDXVDU 5&, %31 VHSVLV QHRQDWDO \ PXHUWH 7RGD PXMHU TXH OOHJXH DO FRQWURO SUHFRQFHSFLRQDO GHEHUi VHU FRQVXOWDGD DFHUFDGHVLUHFLELyYDFXQDDQWLWHWiQLFD\VLODPLVPDHVWiYLJHQWH(QFDVRGHQR KDEHUODUHFLELGRVHFRPHQ]DUiHOHVTXHPDGHYDFXQDFLyQ (QFDVRGHLQIHFFLyQDFWLYDVHVXJHULUiSRVSRQHUHOHPEDUD]RKDVWDKDEHUREWHQLGR HODOWDPpGLFRSRUOD7XEHUFXORVLV (VWLORVGHYLGD $OJXQRV KiELWRV SXHGHQ GHWHUPLQDU XQD VHULH GH ULHVJRV SDUD ODV PXMHUHV HQ HGDG IpUWLO/DLGHQWL¿FDFLyQ\PRGL¿FDFLyQGHGLFKRVKiELWRVSXHGHEHQH¿FLDUDODVPXMHUHV \VXIXWXURHPEDUD]R +iELWRVQXWULFLRQDOHV 6HGHEHQLGHQWL¿FDUHQODHYDOXDFLyQSUHFRQFHSFLRQDOPDORVKiELWRVQXWULFLRQDOHV\VXV FRQVHFXHQFLDV VREUHSHVR GHOJDGH] DQRUH[LD EXOLPLD \ VXSOHPHQWDFLyQ YLWDPtQLFD LQDGHFXDGD/DFDOLGDGGHODGLHWDDQWHV\GXUDQWHHOHPEDUD]RWLHQHLQÀXHQFLDVREUH DOJXQRV UHVXOWDGRV PDWHUQRV SHULQDWDOHV SRU HVR PDQWHQHU XQD GLHWD VDOXGDEOH \ EDODQFHDGDHVWDQLPSRUWDQWHDQWHVFRPRGXUDQWHHOHPEDUD]R3RUHVWDUD]yQWRGD PXMHU TXH DFXGD DO FRQWURO SUHFRQFHSFLRQDO GHEHUi UHFLELU LQVWUXFFLyQ YHUEDO \ SRU HVFULWRGHFXDOHVVRQORVDOLPHQWRVLGHDOHVHQFDQWLGDG\FDOLGDGTXHGHEHUiFRQVXPLU PLHQWUDVVHSUHSDUDSDUDHOHPEDUD]R\GXUDQWHHOPLVPR3DUDGDUHVWDFRQVHMHUtD VH UHFRPLHQGD TXH ODV QXWULFLRQLVWDV SDUWLFLSHQ DFWLYDPHQWH GHO HTXLSR TXH EULQGD DVLVWHQFLD SUHFRQFHSFLRQDO EULQGDQGR FRQVHMHUtD GLUHFWD R FRQWULEX\HQGR FRQ VX &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD FRQRFLPLHQWRDODSUHSDUDFLyQGHODLQIRUPDFLyQDGLIXQGLU\HODERUDQGRVXJHUHQFLDV GHEDMRFRVWRSDUDLQFRUSRUDUORVDOLPHQWRVDGHFXDGRVHQDTXHOORVFRQWH[WRVGRQGHHO IDFWRUHFRQyPLFRSXHGDVHUXQDEDUUHUDSDUDHODFFHVRDWDOHVDOLPHQWRV +D\HVWXGLRVTXHFRQ¿UPDQTXHPXFKDVPXMHUHVQRFXPSOHQFRQORVUHTXHULPLHQWRV GHYLWDPLQDV$%&'(\iFLGRIyOLFRFDOFLRKLHUURPDJQHVLR\]LQF 6H KD YLVWR TXH OD PDOQXWULFLyQ GXUDQWH HO HPEDUD]R VH DVRFLD D SUHPDWXUH] 5&, PRUWDOLGDGSHULQDWDO\GHIHFWRVGHOWXERQHXUDO6HGHEHQUHDOL]DUFDPSDxDVLQIRUPDWLYDV SULRUL]DQGRHOYDORUQXWULFLRQDOGHODGLHWDSUHYLR\GXUDQWHODJHVWDFLyQUHIRU]DQGRHO XVR GH DOLPHQWRV ULFRV HQ IRODWRV \ FDURWHQRLGHV 0HMRUDU OD QXWULFLyQ HQ JHVWDQWHV SREUHVDWUDYpVGHFDQDVWDVEiVLFDVSXHGHVHUXQDRSFLyQDFRUWRSOD]R /DHYLGHQFLDDFWXDOGHPXHVWUDTXHPiVGHODPLWDGGHORVFDVRVGHGHIHFWRVGHOWXERQHXUDO SRGUtDQVHUHYLWDGRVVLODPDGUHKXELHUDFRQVXPLGRVX¿FLHQWHiFLGRIyOLFRSRUORPHQRVXQ PHV\PHGLRDQWHVGHOHPEDUD]R\KDVWDORVWUHVSULPHURVPHVHVGHODJHVWDFLyQ /RV GHIHFWRV FRQJpQLWRV GH OD HVSLQD GRUVDO \ HO FHUHEUR FRPLHQ]DQ DQWHV TXH ODV PXMHUHVVHSDQTXHHVWiQHPEDUD]DGDV $QLYHOLQGLYLGXDOVHUHFRPLHQGDHOXVRSUHFRQFHSFLRQDOGH D PJGtD GH ÈFLGR )yOLFR SDUD SUHYHQLU OD RFXUUHQFLD GH GHIHFWRV GHO WXER QHXUDO E/DVPXMHUHVTXH\DWLHQHQHODQWHFHGHQWHGHXQQLxRFRQXQGHIHFWRGHWXER QHXUDO\SUHWHQGHQHPEDUD]DUVHGHEHQWRPDUXQDGRVLVYHFHVVXSHULRU PJGHiFLGRIyOLFRGtDSDUDSUHYHQLUODUHFXUUHQFLD 7RPDUiFLGRIyOLFRFXDQGR\DVHFRQRFHHOHPEDUD]RQRD\XGDDSUHYHQLUHOGHIHFWR GHOWXERQHXUDO $ QLYHO SREODFLRQDO OD IRUWL¿FDFLyQ GH ODV KDULQDV KD VLGR LPSOHPHQWDGD HQ DOJXQRV SDtVHVGHODUHJLyQ$~QHQHVWRVSDtVHVTXHKDQIRUWL¿FDGRORVDOLPHQWRVFRQÈFLGR )yOLFR ODV PXMHUHV TXH FXHQWHQ FRQ DQWHFHGHQWHV GH GHIHFWRV GHO WXER QHXUDO HQ JHVWDFLRQHVDQWHULRUHVGHEHUiQUHFLELUODGRVLVGHPJGHiFLGRIyOLFRGtDWDOFRPR VHLQGLFySUHYLDPHQWH 2WURHMHPSORGHSUHYHQFLyQGHGHIHFWRVFRQJpQLWRVDQLYHOSREODFLRQDOHVHOVXSOHPHQWR FRQ\RGRHQUHJLRQHVFRQDOWDIUHFXHQFLDGHFUHWLQLVPRHQGpPLFR(VWDPHGLGDOOHYD D XQD UHGXFFLyQ LPSRUWDQWH GH HVWD SDWRORJtD VLQ HIHFWRV DGYHUVRV FRQRFLGRV (Q YDULRVSDtVHVGHODV$PpULFDVH[LVWHSRUOH\ODREOLJDWRULHGDGGHIRUWL¿FDUODVDOSDUD HOFRQVXPRKXPDQRFRQ\RGR(VWRKDKHFKRTXHHOWUDVWRUQRVHUHGX]FDD]RQDVGH SREODFLyQ GH EDMRV UHFXUVRV TXH FRQVXPHQ VDO EUXWD VLQ SURFHVDPLHQWR 'RQGH OD VXSOHPHQWDFLyQQRHVODQRUPDVHUHFRPLHQGDDFRQVHMDUDODVPXMHUHVFRQGH¿FLHQFLD GH\RGRDPDQWHQHUXQDGLHWDGHPLFURJUDPRVGXUDQWHHOSHUtRGRSUHFRQFHSFLRQDO ODTXHVHGHEHHOHYDUDPLFURJUDPRVGXUDQWHHOHPEDUD]R\ODFWDQFLD 2EHVLGDG /D REHVLGDG \ HO VREUHSHVR VRQ FDGD YH] PiV IUHFXHQWHV HQ QXHVWUD UHJLyQ (QWHQGLHQGR SRU REHVLGDG D OD PXMHU FRQ ËQGLFH GH 0DVD &RUSRUDO ,0& LJXDO R PD\RUD.JP(QWUHODVUHSHUFXVLRQHVLQGHVHDGDVGHODREHVLGDGHQODPXMHU GXUDQWHHOHPEDUD]RVHSXHGHREVHUYDUODDSDULFLyQGHKLSHUWHQVLyQLQGXFLGDSRU HOHPEDUD]RGLDEHWHVWUDVWRUQRVWURPERHPEyOLFRVDXPHQWRGHOSDUWRRSHUDWRULR LQIHFFLRQHVDQHPLDSRVWSDUWR\PXHUWHPDWHUQD0LHQWUDVTXHHQORVUHFLpQQDFLGRV VH SXHGHQ YHU GHIHFWRV GHO WXER QHXUDO SDUWR GH SUHWpUPLQR PDFURVRPtD IHWDO SDUWRVGLVWyFLFRVGHSUHVLyQQHRQDWDO\PXHUWHIHWDO (VUHFRPHQGDEOHRIUHFHULQIRUPDFLyQVREUHORVULHVJRVTXHUHSUHVHQWDODREHVLGDG \ HO VREUHSHVR \ JDUDQWL]DU HO DFFHVR D SURJUDPDV GH UHGXFFLyQ GH SHVR (Q &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR SULPHUOXJDUVHGHEHVXJHULUXQSODQGHFRQVHMHUtDGLHWD\HMHUFLFLRSURJUDPDGRV PHGLGDVTXHKDQGHPRVWUDGRVHUPiVHIHFWLYDVTXHODFLUXJtD/RVWUDWDPLHQWRVFRQ PHGLFDPHQWRVVRODPHQWHQRKDQPRVWUDGRVHUEHQH¿FLRVRV(QDOJXQRVFDVRVFRQ IDOWDGHUHVSXHVWDDOWUDWDPLHQWRKLJLpQLFRGLHWpWLFRSXHGHSODQWHDUVHODUHDOL]DFLyQ GHSURFHGLPLHQWRVTXLU~UJLFRV %DMRSHVRSUHJUDYtGLFR 6HHQWLHQGHSRUEDMRSHVRDTXHOODSHUVRQDFRQXQ,0&PHQRUD.JP(O EDMRSHVRSUHJUDYtGLFRVHKDDVRFLDGRFRQSDUWRGHSUHWpUPLQREDMRSHVRDOQDFHU \JDVWURVTXLVLV /DVPXMHUHVTXHDFXGDQDXQFRQWUROSUHFRQFHSFLRQDOFRQEDMRSHVRGHEHUiQVHU HYDOXDGDV SDUD GHVSLVWDU Gp¿FLW HQ HO DSRUWH YLQFXODGR D SUREOHPDV GH DFFHVR D DOLPHQWRV HQ FDQWLGDG \ FDOLGDG GHVyUGHQHV DOLPHQWDULRV R HQIHUPHGDGHV FRH[LVWHQWHV 'HVyUGHQHVDOLPHQWDULRV 'HQWURGHORVGHVyUGHQHVPiVFRQRFLGRVSRGHPRVFLWDUDORVWUDVWRUQRVGHDQRUH[LD \EXOLPLD/DVPXMHUHVFRQDQRUH[LDVHYHUDWLHQHQGL¿FXOWDGHVSDUDHPEDUD]DUVH PLHQWUDV TXH ODV EXOtPLFDV ORJUDQ HPEDUD]DUVH FRQ PD\RU IDFLOLGDG $PEDV SDWRORJtDVVHDFRPSDxDQGHDOWDVWDVDVGHDERUWREDMRSHVRDOQDFHU\XQDJDPD DPSOLD GH FRPSOLFDFLRQHV REVWpWULFDV (VWDV PXMHUHV SRU VX ODELOLGDG HPRFLRQDO SUHVHQWDQXQDPD\RUIUHFXHQFLDGHGHSUHVLyQSRVWSDUWR (VWRVWUDVWRUQRVGHEHQVHUUHJXODUPHQWHLQWHUURJDGRVHQODFRQVXOWDSUHFRQFHSFLRQDO VDELHQGRTXHPXFKDVYHFHVODVSDFLHQWHVVXHOHQRFXOWDUOR(QDTXHOODVRFDVLRQHV TXHVHOOHJXHDOGLDJQyVWLFRSUHFRQFHSFLRQDOVHGHEHUiVXJHULUSRVSRQHUHOHPEDUD]R HQWDQWRQRVHKD\DFRUUHJLGRHOGLVWXUELR\SDUDHOORVHGHEHUiHQFDPLQDUDODPXMHU SDUDVXWUDWDPLHQWRFRQXQHTXLSRHVSHFLDOL]DGRHQODPDWHULD (MHUFLFLR 3RU UHJOD JHQHUDO HO HMHUFLFLR \ ORV GHSRUWHV VRQ VDOXGDEOHV \D TXH SURGXFHQ ELHQHVWDUItVLFR\SVLFROyJLFRWDQWRSDUDODVPXMHUHVFRQLQWHQFLyQGHHPEDUD]DUVH FRPR SDUD ODV TXH \D OR HVWiQ (Q HVWDV ~OWLPDV HO HMHUFLFLR ItVLFR DHUyELFR HV FRQYHQLHQWH GXUDQWH OD JHVWDFLyQ \ SUHYLR D HOOD SDUD IRUWDOHFHU ORV P~VFXORV \ DFWLYDUODFLUFXODFLyQYHQRVD &RQVXPRGHVXVWDQFLDV (OFRQVXPRGHVXVWDQFLDVOHJDOHVHLOHJDOHVVLJXHVLHQGRHOHYDGR\HVSHUMXGLFLDO SDUDODPXMHUFRPRSDUDVXKLMR(QWpUPLQRVJHQHUDOHVODSREODFLyQHVWiLQIRUPDGD VREUHORVULHVJRVTXHUHSUHVHQWDHOFRQVXPRGHVXVWDQFLDVLOHJDOHVHLQFOXVRHOXVR GH WDEDFR GXUDQWH HO HPEDUD]R SHUR HVWi PHQRV LQIRUPDGD VREUH ORV SHUMXLFLRV GHODOFRKRO6HKDYLVWRTXHHOFRQWUROSUHFRQFHSFLRQDOHVXQPHMRUPRPHQWRSDUD LQWHUURJDU VREUH HO XVR \ DEXVR GH VXVWDQFLDV \ TXH H[LVWH XQD UHODFLyQ HQWUH FRQVXPRSUHFRQFHSFLRQDO\FRQVXPRGXUDQWHHOHPEDUD]R6HKDGHPRVWUDGRTXH HQPXMHUHVTXHGHVHDQHPEDUD]DUVHSRVSRQHUHOHPEDUD]R\WUDWDUODDGLFFLyQHV XQDPHGLGDHIHFWLYD 7DEDFR (OKiELWRGHIXPDUDFWLYR\SDVLYRDIHFWDWDQWRDOIHWRFRPRDODPDGUH (QWUHORVGDxRVDWULEXLGRVVHGHVFULEHQLQIHUWLOLGDGDERUWRHVSRQWiQHREDMRSHVRDO QDFHUUHVWULFFLyQGHOFUHFLPLHQWRIHWDOULHVJRGHSDUWRSUHWpUPLQRGHVSUHQGLPLHQWR GHSODFHQWDPXHUWHIHWDO\SHULQDWDODXPHQWRGHOULHVJRGHLQIHFFLRQHVGHOWUDFWR UHVSLUDWRULRGHOUHFLpQQDFLGR(VSULRULWDULRGHVDFRQVHMDUVXFRQVXPR\RIUHFHUXQ SURJUDPDDFWLYRGHFHVHGHIXPDUDODVJHVWDQWHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD $OFRKRO 6HWUDWDGHXQDJHQWHSUREDGDPHQWHWHUDWRJpQLFR\QRH[LVWHXQDGRVLVFRQVLGHUDGD VHJXUDSDUDVXXVRGXUDQWHODJHVWDFLyQ6HDVRFLDFRQPXHUWHLQWUDXWHULQDUHVWULFFLyQ HQ HO FUHFLPLHQWR SUH \ SRVWQDWDO EDMR SHVR DO QDFHU DOWHUDFLRQHV GHO VLVWHPD QHUYLRVRFHQWUDO\GHODFRQGXFWD(OFRQVXPRH[FHVLYRGHDOFRKROWHPSUDQDPHQWH HQ OD JHVWDFLyQ SXHGH SURGXFLU HO VtQGURPH GHO$OFRKRO )HWDO HQ WRUQR DO GH ORV HPEDUD]RV /DV FDPSDxDV GH HGXFDFLyQ VRQ GH H[WUHPD LPSRUWDQFLD \D TXH QRH[LVWHODQRFLyQGHHVWHULHVJRHQODSREODFLyQ/DVPLVPDVGHEHQHQIDWL]DUVH HQHODOFRKRO\QRHQHO³DOFRKROLVPR´0LHQWUDVQRVHFRQVLJDHODEDQGRQRGHOXVR GHDOFRKROGHEHVXJHULUVHSRVSRQHUHOHPEDUD]RKDVWDTXHVHORJUH3DUDHVWRVH UHFRPLHQGDLQGLFDUHOXVRGHXQFRQWUDFHSWLYRHIHFWLYR 'URJDVLOHJDOHV 'HXQDIRUPDJHQHUDOVHSXHGHD¿UPDUTXHWRGDVODVGURJDVDIHFWDQHQIRUPDQHJDWLYD DODPXMHUVXHQWRUQR\DOIXWXURHPEDUD]R/DPD\RUSDUWHGHODVGURJDVLOtFLWDVDO DWUDYHVDUODEDUUHUDSODFHQWDULDDIHFWDQDOIHWRHOTXHHVPX\YXOQHUDEOHODVGURJDV GHSHVRPROHFXODUPX\EDMRSDVDQDOIHWRFRQJUDQIDFLOLGDG\XQDSHTXHxDFDQWLGDG SXHGHWUDQVIRUPDUVHHQXQDVREUHGRVLV(OXVRGHFRFDtQDGXUDQWHODJHVWDFLyQKD VLGR YLQFXODGR D GHIHFWRV SRU GLVUXSFLyQ YDVFXODU H[SUHVDGRV HQ DQRPDOtDV GHO VLVWHPDQHUYLRVRFHQWUDOGHIHFWRVSRUUHGXFFLyQGHPLHPEURV\5&,/DPDULKXDQD SUHVHQWDHIHFWRVVLPLODUHVDORVFDXVDGRVSRUHOFLJDUULOOR $GHPiVGHH[SOLFDUORVULHVJRVGHHOFRQVXPRGHVXVWDQFLDVVHGHEHSURSRQHUXQ SODQGHWUDWDPLHQWRSDUDHODEDQGRQRGHODDGLFFLyQPLHQWUDVHVWRQRVHFRQVLJXHVH GHEHUiVXJHULUSRVSRQHUHOHPEDUD]RSDUDORFXDOGHEHLQGLFDUVHXQFRQWUDFHSWLYR VHJXUR &DIpWpPDWHEHELGDVFROD 'HEH DFRQVHMDUVH XQ XVR PRGHUDGR GH HVWRV HVWLPXODQWHV GH FRQVXPR KDELWXDO 6XXVRDDOWDVGRVLVHQHOSULPHUWULPHVWUHGHOHPEDUD]RVHKDDVRFLDGRFRQDERUWR HVSRQWiQHR$ORODUJRGHOHPEDUD]RVRQFDSDFHVGHSURYRFDUEDMRSHVRDOQDFHU &RQVXPRGHPHGLFDPHQWRV (O FRQVXPR QRUPDO GH PHGLFDPHQWRV HV QHFHVDULR SDUD FXUDU R FRQWURODU XQD GHWHUPLQDGDDIHFFLyQHQHVRVFDVRVVLHPSUHVHGHEHUiYDORUDUHOPRPHQWRRSRUWXQR SDUDUHFRPHQGDUXQHPEDUD]R3HURHQRWUDVRSRUWXQLGDGHVHOXVRGHPHGLFDPHQWRV SRU DXWRLQGLFDFLyQ SXHGH FRQ¿JXUDU XQ SDWUyQ DGLFWLYR HQ HVWRV FDVRV FRPR \D VH LQGLFy FRQ HO DEXVR GH RWUDV VXVWDQFLDV VH GHEHUi LQIRUPDU VREUH ORV ULHVJRV TXH LPSOLFDHOXVRVREUHODVDOXGGHODPXMHU\GHXQIXWXURHPEDUD]R/DSUHPLVDDGDUD WRGDPXMHUTXHSLHQVDHPEDUD]DUVHHV³/RVPHGLFDPHQWRVGHEHQHYLWDUVHDPHQRVTXH VHDQLQGLVSHQVDEOHV´\HQHVWRVFDVRVGHEHUiFRQVXOWDUDOHTXLSRGHVDOXGSDUDHYDOXDU FXLGDGRVDPHQWHHOULHVJRIHWDOIUHQWHDOEHQH¿FLRPDWHUQRGHGLFKDPHGLFDFLyQ /D FDQWLGDG GH PHGLFDPHQWRV H[LVWHQWHV HV WDQ JUDQGH TXH VROR PHQFLRQDUHPRV DTXHOORV TXH SRU VX HIHFWR GHOHWpUHR GHEHQ VHU HYLWDGRV HQ PXMHUHV TXH SODQHDQ HPEDUD]DUVH ,VRWUHWLQRtQD /D YLWDPLQD $ \ DOJXQRV GH VXV GHULYDGRV iFLGR 5HWLQRLFR WLHQHQ XQD ODUJD \ FRPSUREDGDDFFLyQWHUDWRJpQLFDHQKXPDQRV /D,VRWUHWLQRtQDSDUDHOWUDWDPLHQWRGHO$FQp4XtVWLFR\HO(WUHWLQDWRSDUDWUDWDUOD 3VRULDVLVVRQDOWDPHQWHWHUDWRJpQLFRV'HEHUiGHVDFRQVHMDUVHHOHPEDUD]RKDVWD XQDxRGHVSXpVGHKDEHUVXVSHQGLGRVXXVRHLQGLFDQGRXQDQWLFRQFHSWLYRVHJXUR /RV GHIHFWRV DO QDFLPLHQWR FDXVDGRV SRU ORV UHWLQRLGHV VRQ IXQGDPHQWDOPHQWH FUDQHRIDFLDOHV FDUGLRYDVFXODUHV GHO VLVWHPD QHUYLRVR FHQWUDO \ WLPR (O UHWDUGR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR PHQWDOWDPELpQKDVLGRREVHUYDGRHQODPLWDGGHORVFDVRVGHQLxRVVREUHYLYLHQWHV PD\RUHVDDxRVXQWHUFLRGHHVWHJUXSRQRSUHVHQWDEDGHIHFWRVDOQDFLPLHQWR /DFRQWUDLQGLFDFLyQGHOXVRGHHVWDYLWDPLQD\VXVGHULYDGRVGXUDQWHHOHPEDUD]R GHEHVHUGLYXOJDGRHQWUHORVHTXLSRVGHVDOXG\HQODSREODFLyQJHQHUDO 7DOLGRPLGD (VXQPHGLFDPHQWRSUREDGDPHQWHWHUDWRJpQLFRTXHSURYRFDXQFXDGURFDUDFWHUtVWLFR FRQIRFRPHOLDFD\yHQGHVXVRKDVWDKDFHSRFRVDxRVHQTXHHQFRQWUyVXOXJDU SDUDHOWUDWDPLHQWRGHODOHSUD\HO9,+7RGDPXMHUTXHHVWpUHFLELHQGRWDOLGRPLGD GHEHUiVXVSHQGHUODDQWHVGHOHPEDUD]R $QWLFRQYXOVLYDQWHV 0XFKDV GH ODV GURJDV XVDGDV SDUD HO WUDWDPLHQWR GH ODV FRQYXOVLRQHV KDQ VLGR YLQFXODGDV FRQ P~OWLSOHV WUDVWRUQRV DXQTXH H[LVWH FLHUWD GL¿FXOWDG HQ GHWHUPLQDU VLWRGDVODVDOWHUDFLRQHVVHGHEHQDORVPHGLFDPHQWRVRVHFRUUHVSRQGHQFRQOD HQIHUPHGDGGHIRQGR 'L)HQLO+LGDQWRtQD6HDVRFLDFRQPD\RUULHVJRGHSURYRFDUGHIHFWRVGHOWXER QHXUDOSRUORTXHVHGHVDFRQVHMDVXXVR\DTXHODVPLVPDVSXHGHQLQWHUIHULU HQHOPHWDEROLVPRGHORVIRODWRVSRUORTXHVHUHFRPLHQGDHVSHFt¿FDPHQWHHO XVRGHÈFLGR)yOLFRDUD]yQGHPJGtDGXUDQWHHOSHUtRGRSHULFRQFHSFLRQDO 3HURODHQWLGDGPiVFRQRFLGDHVHOVtQGURPHKLGDQWRtQLFRIHWDOLQFOX\HQGR5&, PLFURFHIDOLD GLVPRU¿DV IDFLDOHV SDODGDU KHQGLGR \ ODELR OHSRULQR KLSRSODVLD GLJLWDOGLVWDO\DYHFHVFDUGLRSDWtD &DUEDPD]HSLQD6HODKDYLQFXODGRFRQULHVJRGHPXHUWHIHWDOGHIHFWRVGHOWXER QHXUDOGHIHFWRVFDUGtDFRV\SDODGDUKHQGLGRDGHPiVGHRWURVGHIHFWRV ÈFLGR9DOSURLFR+DVLGRYLQFXODGRFRQGHIHFWRVGHOWXERQHXUDO5&,UHWUDVRHQ HOGHVDUUROOR\HQHODSUHQGL]DMHDGHPiVGHFDUGLRSDWtDFRQJpQLWD &XPDUtQLFRV (O HPSOHR GH DQWLFRDJXODQWHV FXPDUtQLFRV HVWi UHVWULQJLGR EiVLFDPHQWH D ODV PXMHUHVFRQYiOYXODVFDUGtDFDVSURWpVLFDVRFRQDQWHFHGHQWHVGHWURPERVLVYHQRVD SURIXQGD (OHIHFWRWHUDWRJpQLFRVHH[SUHVDHQKLSRSODVLDGHOFDUWtODJRQDVDODWUR¿DySWLFD HSt¿VLVSXQFWDWDGHQRPLQDGDHPEULRSDWtDSRUZDUIDULQDSRUORTXHVHUHFRPLHQGD FDPELDUDKHSDULQDVGHEDMRSHVRPROHFXODUGHVGHHOPRPHQWRHQTXHVHFRPLHQ]D DSODQL¿FDUXQHPEDUD]R $QWLKLSHUWHQVLYRV 7RGRVORVDJHQWHVDQWLKLSHUWHQVLYRVGHEHQVHUXVDGRVFXLGDGRVDPHQWHGHELGRDORV ULHVJRVYLWDOHVTXHUHSUHVHQWDQSDUDODPXMHUSRUHMHPSORDOSURYRFDUXQDKLSRWHQVLyQ VHYHUD(OULHVJRGHKLSRWHQVLyQVHYHUDVXHOHVHUPiVJUDYHSDUDHOIHWR3HURPiV DOOi GH ORV ULHVJRV KHPRGLQiPLFDV TXH JHQHUD HO XVR GH HVWR PHGLFDPHQWRV VH KD SRGLGR HVWDEOHFHU TXH DOJXQRV GH HOORV VRQ WHUDWRJpQLFRV GH WDO PDQHUD TXH FXDQGRXQDPXMHUSODQHDHPEDUD]DUVHRGHKHFKRSUHVHQWDXQHPEDUD]RHQHWDSDV LQFLSLHQWHVGHEHUiLQGLFiUVHOHHOFDPELRSRUDQWLKLSHUWHQVLYRVPiVVHJXURVFRPR ODDOIDPHWLOGRSDHQODKLSHUWHQVLyQDUWHULDOFUyQLFD\ODKLGUDODFLQDHQKLSHUWHQVLyQ DUWHULDODJXGD ,QKLELGRUHVGHOD(Q]LPD&RQYHUVRUDGHOD$QJLRWHQVLQD,(&$V\$QWDJRQLVWDV GH ORV 5HFHSWRUHV GH OD$QJLRWHQVLQD ,, $5$ ,, (VWRV DQWLKLSHUWHQVLYRV KDQ VLGRYLQFXODGRVDGDxRUHQDOIHWDOHVSHFLDOPHQWHFXDQGRVRQXVDGRVGXUDQWHHO VHJXQGR\WHUFHUWULPHVWUH &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 6DOHVGH/LWLR (V XQ PHGLFDPHQWR DQWLGHSUHVLYR TXH HQ ORV IHWRV KXPDQRV SXHGH SURYRFDU FDUGLRSDWtDFRQJpQLWDDGHPiVGHRWUDVPDOIRUPDFLRQHVHQWUHODVTXHVHLQFOX\HQ GHIHFWRVGHOWXERQHXUDO'HEHVHUVXVSHQGLGRRFDPELDGRSRUDQWLGHSUHVLYRVPiV VHJXURVHQDTXHOODPXMHUTXHVHHQFXHQWUDSODQL¿FDQGRXQHPEDUD]R $QWLELyWLFRV (OXVRGHDQWLELyWLFRVHVVXPDPHQWHH[WHQGLGR\VXQLYHOGHVHJXULGDGHVEDVWDQWH DOWR'HWRGDVIRUPDVVLJXHDSOLFDQGRHOFRQFHSWRJHQHUDODQWHULRUPHQWHLQGLFDGR GHUHVWULQJLUVXXVRVRORDDTXHOODVVLWXDFLRQHVHQODVTXHHOEHQH¿FLRVHDPD\RU TXHORVULHVJRV 6HDGYLHUWHWHQHUHVSHFLDOFXLGDGRFRQORVVLJXLHQWHVDQWLELyWLFRV (VWUHSWRPLFLQD \ .DQDPLFLQD +DQ VLGR DVRFLDGRV FRQ VRUGHUD SRU VX RWRWR[LFLGDG 7HWUDFLFOLQDV 6X XVR GXUDQWH HO HPEDUD]R VH KD UHODFLRQDGR FRQ WUDVWRUQRV HVTXHOpWLFRV \ GH OD FRQVWLWXFLyQ GHO HVPDOWH GH ORV GLHQWHV 7DPELpQ VH KD DVRFLDGR D WR[LFLGDG KHSiWLFD GH ODV PXMHUHV \ D RWURV WUDVWRUQRV QHRQDWDOHV FRPR GHIHFWRV GHO WXER QHXUDO SDODGDU KHQGLGR ODELR OHSRULQR FDUGLRSDWtDV \ UHGXFFLyQGHPLHPEURVHQWUHGHRWURVWUDVWRUQRV 0LVRSURVWRO +D VLGR UHODFLRQDGR FRQ PDOIRUPDFLRQHV FRQJpQLWDV YLQFXODGDV DO HIHFWR GH OD LQWHUUXSFLyQ R DOWHUDFLyQ GHO ÀXMR FLUFXODWRULR HPEULRIHWDO WDPELpQ FRQRFLGR FRPR GLVUXSFLyQ YDVFXODU (QWUH GLFKDV PDOIRUPDFLRQHV VH GHVWDFDQ SDUiOLVLV IDFLDO SDUiOLVLVGHODPLUDGDODWHUDOKLGURFHIDOLD\FDUGLRSDWtDV 9DFXQDV /DFRQVXOWDSUHFRQFHSFLRQDOGHEHVHUXQiPELWRSDUDODDWHQFLyQLQWHJUDOGHODVDOXG GHODPXMHU6LELHQYDFXQDUDQWHVGHOHPEDUD]RHVXQDPHGLGDGHSUHYHQFLyQSULPDULD TXHKDGHPRVWUDGRVHUDOWDPHQWHHIHFWLYDSDUDGLVPLQXLUODWUDQVPLVLyQPDWHUQRIHWDO GHFLHUWDVLQIHFFLRQHVWRGDPXMHUTXHOOHJXHDODFRQVXOWDSUHFRQFHSFLRQDOGHEHVHU LQYHVWLJDGDVREUHVXHVWDGRLQPXQLWDULR\YDFXQDGDHQFRQVHFXHQFLDDXQTXHGHVFDUWH ODSRVLELOLGDGGHHPEDUD]DUVH 9DULFHOD (VLGHDOTXHWRGDVODVQLxDVVHDQYDFXQDGDVFRQWUDODYDULFHODHQHWDSDVLQFLSLHQWHV GHVXYLGD3HURHQFDVRGHPXMHUHVTXHQRKDQVLGRYDFXQDGDV\QRKD\HYLGHQFLDV GH TXH KD\DQ VXIULGR YDULFHOD HQ DOJ~Q PRPHQWR SRGUiQ VHU YDFXQDGDV GXUDQWH OD FRQVXOWD SUHFRQFHSFLRQDO (VWD YDFXQD WLHQH FRQWUDLQGLFDGD VX DSOLFDFLyQ GXUDQWH HO HPEDUD]R 5XEpROD $XQTXHHVWDYDFXQDKDGHPRVWUDGRVHUEDVWDQWHVHJXUDVHFRQWUDLQGLFDVXDSOLFDFLyQ GXUDQWHHOHPEDUD]R +HSDWLWLV%7pWDQRV\*ULSH 6L ELHQ HV LGHDO DGPLQLVWUDU HVWDV YDFXQDV GXUDQWH OD FRQVXOWD SUHFRQFHSFLRQDO HV LPSRUWDQWHVDEHUTXHWDPELpQSXHGHQVHUDSOLFDGDVGXUDQWHHOHPEDUD]R\DTXHKDQ GHPRVWUDGRTXHVXEHQH¿FLRHVPD\RUTXHORVULHVJRVTXHFRPSRUWDQ 0XFKDVGHODVDFFLRQHVGHVFULWDVSDUDHYLWDUGHIHFWRVFRQJpQLWRVWLHQHQODYLUWXGGH PHMRUDUODVDOXGPDWHUQDFRQWUROGHODKLSHUWHQVLyQDUWHULDOGHODGLDEHWHVHWF\SRU ORWDQWRUHGXFHQHOULHVJRGHGDxRDODPXMHU &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 5HIHUHQFLDV%LEOLRJUi¿FDV %ULJV**&RFDLQH,Q)UHPDQ5.<DIHH6-%ULJV**HGV'UXJVLQSUHJQDQF\DQGODFWDWLRQ DUHIHUHQFHJXLGHWRIHWDODQGQHRQDWDOULVN7KHGLWLRQ%DOWLPRUH/LSSLQFRWW:LOOLDPV:LONLQV SS &DSLWiQ-XUDGR0&DEUHUD9pOH]5/DFRQVXOWDSUHFRQFHSFLRQDOHQ$WHQFLyQ3ULPDULD(YDOXDFLyQ GHODIXWXUDJHVWDQWH0(',)$0 &DVLPLUR)$UHQD-2UHUD0\FRO*XtDSDUDOD3UHYHQFLyQGHGHIHFWRVFRQJpQLWRV0LQLVWHULRGH 6DQLGDG\&RQVXPR6HFUHWDULD*HQHUDOGH6DQLGDGGH(VSDxD &DVWLOOD((/ySH]&DPHOR-63D]-(2ULROL,03UHYHQFLyQ3ULPDULDGHORV'HIHFWRV&RQJpQLWRV 5LRGH-DQHLUR(GLWRUD)LR&UX] &RRQURG'9-DFN%:%RJJHVV.$/RQJ5&RQU\-$&R[61&HIDOR5+XQWHU.'3L]]LFD$ 'XQORS$/7KHFOLQLFDOFRQWHQWRISUHFRQFHSWLRQFDUHLPPXQL]DWLRQVDVSDUWRISUHFRQFHSWLRQFDUH $P-2EVWHW*\QHFRO'HF6XSSO6 &RRQURG'9-DFN%:6WXEEOH¿HOG3*+ROOLHU/0%RJJHVV.$&HIDOR5&R[61'XQORS$/ +XQWHU.'3UDVDG05/X0&&RQU\-$*LEEV56+RJDQ9.7KHFOLQLFDOFRQWHQWRISUHFRQFHS WLRQFDUHLQIHFWLRXVGLVHDVHVLQSUHFRQFHSWLRQFDUH$P-2EVWHW*\QHFRO'HF6XSSO 6 'DJQLQR03UDWR$'H0HQH]HV6)ORUHV5,Q076DQVHYHULQR'6SULW]HUO6FKOHU)DFFLQL 2UJ0DQXDOGHWHUDWRJrQHVH3RUWR$OHJUH(GLWRUDGD8QLYHUVLGDGHSS 'H0XFLR%7HUDWRORJLD0HGLFDPHQWRV\RWUDVVXVWDQFLDV(Q6FKZDUF]5)HVFLQD5'XYHUJHV &2EVWHWULFLDHGLFLyQ%XHQRV$LUHV(O$WHQHRSS 'XQORS$/*DUGLQHU306KHOOKDDV&60HQDUG0.0F'LDUPLG0$7KHFOLQLFDOFRQWHQWRISUH FRQFHSWLRQFDUHWKHXVHRIPHGLFDWLRQVDQGVXSSOHPHQWVDPRQJZRPHQRIUHSURGXFWLYHDJH$P- 2EVWHW*\QHFRO'HF6XSSO6 'XQORS$/-DFN%:%RWWDOLFR-1/X0&-DPHV$6KHOOKDDV&6+DOOVWURP/+6RORPRQ%' )HHUR:*0HQDUG0.3UDVDG057KHFOLQLFDOFRQWHQWRISUHFRQFHSWLRQFDUHZRPHQZLWKFKURQLF PHGLFDOFRQGLWLRQV$P-2EVWHW*\QHFRO'HF6XSSO6 (NERP$:DNH¿HOG$=DFN0$GDPL23HULQDWDOPHDVOHVLQIHFWLRQDQGVXEVHTXHQW&URKQ¶VGLV HDVH/DQFHW (\QDUG$50XQR]65XL]0RUHQR/3DVTXDOLQL0('H)DEUR63$JJUHJDWRU\EHKDYLRXURISODWH OHWVLQFXEDWHGZLWKVXEFHOOXODUIUDFWLRQVRIQRUPDODQGFKDJDVLFKXPDQV\QF\WLRWURSKREODVW5HY,QVW 0HG7URS6DR3DXOR )LVKLQJHU0RXUD&3RQWH/,Q076DQVHYHULQR'6SULW]HUO6FKOHU)DFFLQL2UJ0DQXDOGH WHUDWRJr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yQ 3ULPDULD GH ORV GHIHFWRV GH WXER QHXUDO (Q 8UXJXD\HVQHFHVDULDODIRUWL¿FDFLyQGHDOLPHQWRVFRQIRODWRV$UFKLYRVGH*LQHFRORJtD\2EVWHWULFLD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD /DUUDQGDEXUX 0 9DJOLR$ /HPHV$ 4XDGUHOOL 5 'HIHFWRV FRQJpQLWRV HQ 8UXJXD\ 8Q DERUGDMH HSLGHPLROyJLFR7HQGHQFLDVHQ0HGLFLQD /RZH6$'UXJVLQSUHJQDQF\$QWLFRQYXOVDQWVDQGGUXJVIRUQHXURORJLFDOGLVHDVH%HVW3UDFW5HV &OLQ2EVWHW*\QDHFRO5HYLHZ /\QEHUJ0&.KRXU\0-/X;0DWHUQDOÀXIHYHUDQGWKHULVNRIQHXUDOWXEHGHIHFWVDSRSX ODWLRQEDVHGFDVHFRQWUROVWXG\$P-(SLGHPLRO 0DUWtQH])UtDV0/%ROHWtQGHO(&(0&(VWXGLR&RODERUDWLYR(VSDxROGH0DOIRUPDFLRQHV&RQJpQL WDV5HYLVWDGH'LVPRUIRORJtD\(SLGHPLRORJtD 0DUWtQH])UtDV0/(SLGHPLRORJLFDODQDO\VLVRIRXWFRPHVRISUHJQDQF\LQGLDEHWLFPRWKHUVLGHQ WL¿FDWLRQ RI WKH PRVW FKDUDFWHULVWLF DQG PRVW IUHTXHQW FRQJHQLWDO DQRPDOLHV $P - 0HG *HQHW -RKQVRQ.3RVQHU6)%LHUPDQQ-HWDO5HFRPPHQGDWLRQVWR,PSURYH3UHFRQFHSWLRQ+HDOWKDQG +HDOWK &DUH 8QLWHG 6WDWHV$ 5HSRUW RI WKH &'&$76'5 3UHFRQFHSWLRQ &DUH :RUN *URXS DQG WKH6HOHFW3DQHORQ3UHFRQFHSWLRQ&DUH00:5$SULO55>,QWHUQHW@ODVW UHYLHZHG 'LVSRQLEOH HQ KWWSZZZFGFJRYPPZ5SUHYLHZPPZUKWPOUUDKWP ÒOWLPRDFFHVRGHIHEUHURGH 2¶5RXUNH .0 5RGG\ 0( :LOOLDPV ' 0HQD 3UHGLFWRUV RI HDUO\ SRVWSDUWXP YLWDPLQ XVH DPRQJZRPHQRI0H[LFDQRULJLQLPSOLFDWLRQVIRUKHDOWKFDUHSURYLGHUUHFRPPHQGDWLRQV(WKQ'LV 3RQWH / /RJXHUFLR /HLWH - ,Q 07 6DQVHYHULQR ' 6SULW]HU O 6FKOHU)DFFLQL 2UJ 0DQXDO GH WHUDWRJrQHVH3RUWR$OHJUH(GLWRUDGD8QLYHUVLGDGHSS 5DPRV$UUR\R 0$ 5RGULJXH] 3LQLOOD ( &RUGHUR -) 0DWHUQDO GLDEHWHV WKH ULVN IRU VSHFL¿F ELUWK GHIHFWV(XU-(SLGHPLRO-XO 5HSRUWRID:+27HFKQLFDO&RQVXOWDWLRQRQ%LUWK6SDFLQJ*HQHYD6ZLW]HUODQG±-XQH 'LVSRQLEOH HQ KWWSZZZZKRLQWPDNLQJBSUHJQDQF\BVDIHUGRFXPHQWVELUWKBVSDFLQJHQLQGH[ KWPO~OWLPRDFFHVRGHRFWXEUHGH 5RVHQQ % 0LRGRYQLN 0 &RPEV &$ .KRXU\ - 6LGGLTXL 7$ *O\FHPLF WKUHVKROGV IRU VSRQWDQH RXVDERUWLRQDQGFRQJHQLWDOPDOIRUPDWLRQVLQLQVXOLQGHSHQGHQWGLDEHWHVPHOOLWXV2EVWHW*\QHFRO 6FKZDUF]5)HVFLQD53HQ]R60/RVFXLGDGRVSUHFRQFHSFLRQDOHV(Q6FKZDUF]5)HVFLQD5 'XYHUJHV&2EVWHWULFLDHGLFLyQ%XHQRV$LUHV(O$WHQHRSS 6XEUDPDQLDQ'0RLVH.-:KLWH$&-U,PSRUWHGPDODULDLQSUHJQDQF\UHSRUWRIIRXUFDVHVDQG UHYLHZRIPDQDJHPHQW&OLQ,QIHFW'LV 6WXEEOH¿HOG3*&RRQURG'95HGG\806D\HJK51LFKROVRQ:5\FKOLN')-DFN%:7KHFOLQLFDO FRQWHQWRISUHFRQFHSWLRQFDUHUHSURGXFWLYHKLVWRU\$P-2EVWHW*\QHFRO'HF6XSSO 6 7HQ.DWH/3(SLGHPLRORJ\RISRWHQWLDOO\DYRLGDEOHELUWKGHIHFWV(XU-(SLGHPLRO 7KRP'+1HOVRQ/09DXJKDQ7/6SRQWDQHRXVDERUWLRQDQGVXEVHTXHQWDGYHUVHELUWKRXWFRPHV $P-2EVWHW*\QHFRO3W 7KRPSVRQ-63ULQFLSLRVJHQHUDOHV\DQRPDOtDVDXWRVyPLFDV(Q7KRPSVRQ7KRPSVRQ*HQp WLFDHQ0HGLFLQDWDHG3KLODGHOSKLD0DVVRQ 7KXUQ-+XPDQSDUYRYLUXV%KLVWRULFDODQGFOLQLFDOUHYLHZ5HY,QIHFW'LV 5HYLHZ 9LHUD6DQVHYHULQR07,Q076DQVHYHULQR'6SULW]HUO6FKOHU)DFFLQL2UJ0DQXDOGHWHUD WRJrQHVH3RUWR$OHJUH(GLWRUDGD8QLYHUVLGDGHSS &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR ,,, & $ 3, 7 8 /2 , , , &RQWURO3UHQDWDO 9LJLODQFLD'XUDQWHOD*HVWDFLyQ (YDOXDFLyQGHO5LHVJR&RQFHSFLRQDO\&RQGXFWDV (),&$&,$'(/&21752/35(1$7$/'(587,1$ (QHODxR+XQWLQJWRQD¿UPyTXH³HOFRQWUROSUHQDWDOVHSDJDSRUVtPLVPR´\HQHVWH VLJORODVHYDOXDFLRQHVFUtWLFDVGHOFRQWUROSUHQDWDOKDQFRLQFLGLGRFRQHVDD¿UPDFLyQ /DPD\RUtDGHORVDXWRUHVDFWXDOPHQWHFRLQFLGHQHQVXH¿FDFLD\ORVSDtVHVKDFHQ ORVPD\RUHVHVIXHU]RVSRUDXPHQWDUODFREHUWXUD\PHMRUDUODFDOLGDGPLHQWUDVTXHOD SREODFLyQORGHPDQGDFRQPD\RUGHFLVLyQ $XQTXH ODV HYLGHQFLDV VRQ IDYRUDEOHV KDQ KDELGR IDFWRUHV TXH FRQWULEX\HURQ DO GHVSUHVWLJLRGHOFRQWUROSUHQDWDOSUHVWDFLRQHVTXHEDMRHOUyWXORGHFRQWUROSUHQDWDOVRQ VyORYLVLWDVHQODVTXHQRVHFXPSOHFRQORVHVWiQGDUHVPtQLPRVGHFDOLGDGKDELHQGR XQDSREUHLQWHUDFFLyQHQWUHODXVXDULDVXIDPLOLD\ORVWUDEDMDGRUHVGHVDOXG3RUHVWD UD]yQHVQHFHVDULRHVWDEOHFHUFXDOHVVRQORVFULWHULRVTXHGH¿QHQDOFRQWUROSUHQDWDO GHFDOLGDG 'H¿QLFLyQ\JHQHUDOLGDGHV 6HHQWLHQGHSRUFRQWUROSUHQDWDOFRQWURODQWHQDWDODVLVWHQFLDSUHQDWDOFXLGDGRSUHQDWDO FRQVXOWDSUHQDWDODODVHULHGHHQWUHYLVWDVRYLVLWDVSURJUDPDGDVGHODHPEDUD]DGD FRQLQWHJUDQWHVGHOHTXLSRGHVDOXGFRQHOREMHWLYRGHYLJLODUODHYROXFLyQGHOHPEDUD]R \REWHQHUXQDDGHFXDGDSUHSDUDFLyQSDUDHOSDUWR\ODFULDQ]D &RQHOFRQWUROSUHQDWDOVHSHUVLJXH ODGHWHFFLyQGHHQIHUPHGDGHVPDWHUQDVVXEFOtQLFDV ODSUHYHQFLyQGLDJQyVWLFRWHPSUDQR\WUDWDPLHQWRGHODVFRPSOLFDFLRQHVGHO HPEDUD]R ODYLJLODQFLDGHOFUHFLPLHQWR\ODYLWDOLGDGIHWDO ODGLVPLQXFLyQGHODVPROHVWLDV\VtQWRPDVPHQRUHVDVRFLDGRVDOHPEDUD]R ODSUHSDUDFLyQSVLFRItVLFDSDUDHOQDFLPLHQWR ODDGPLQLVWUDFLyQGHFRQWHQLGRVHGXFDWLYRVSDUDODVDOXGODIDPLOLD\ODFULDQ]D 8QFRQWUROSUHQDWDOH¿FLHQWHGHEHFXPSOLUFRQFXDWURUHTXLVLWRVEiVLFRV 3UHFR] &RPSOHWR 3HULyGLFR 'HDPSOLDFREHUWXUD 3UHFR] /D SULPHUD YLVLWD GHEH UHDOL]DUVH WHPSUDQDPHQWH HQ OR SRVLEOH GXUDQWH HO SULPHUWULPHVWUHGHODJHVWDFLyQ(VWRSHUPLWHODHMHFXFLyQRSRUWXQDGHODVDFFLRQHVGH SURPRFLyQSURWHFFLyQ\UHFXSHUDFLyQGHODVDOXGTXHFRQVWLWX\HQODUD]yQIXQGDPHQWDO GHOFRQWURO$GHPiVWRUQDIDFWLEOHODLGHQWL¿FDFLyQWHPSUDQDGHORVHPEDUD]RVGHDOWR ULHVJRDXPHQWDQGRSRUORWDQWRODSRVLELOLGDGGHSODQL¿FDUH¿FD]PHQWHHOPDQHMRGH FDGDFDVRHQFXDQWRDODVFDUDFWHUtVWLFDVGHODDWHQFLyQREVWpWULFDTXHGHEHUHFLELU 3HULyGLFR/DIUHFXHQFLDGHORVFRQWUROHVSUHQDWDOHVYDUtDVHJ~QHOJUDGRGHULHVJRTXH SUHVHQWDODHPEDUD]DGD/DVPXMHUHVFRQHPEDUD]RVGHEDMRULHVJRUHTXHULUiQXQQ~PHUR PHQRUGHFRQWUROHVHQWUH\TXHODVGHDOWRULHVJR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD &RPSOHWR/RVFRQWHQLGRVPtQLPRVGHOFRQWUROGHEHUiQJDUDQWL]DUHOFXPSOLPLHQWRHIHFWLYR GHODVDFFLRQHVGHSURPRFLyQSURWHFFLyQUHFXSHUDFLyQ\UHKDELOLWDFLyQGHODVDOXG $PSOLDFREHUWXUD(QODPHGLGDTXHHOSRUFHQWDMHGHODSREODFLyQFRQWURODGDHVPiV DOWRORLGHDOHVTXHDEDUTXHDWRGDVODVHPEDUD]DGDVPD\RUVHUiHOLPSDFWRSRVLWLYR VREUHODPRUELPRUWDOLGDGPDWHUQD\SHULQDWDO (Q JHQHUDO SDUD UHDOL]DU XQ FRQWURO SUHQDWDO HIHFWLYR GH SRU Vt DPEXODWRULR QR VH SUHFLVDQLQVWDODFLRQHVFRVWRVDVDSDUDWRVFRPSOLFDGRVQLODERUDWRULRVR¿VWLFDGRSHUR Vt VH UHTXLHUH HO XVR VLVWHPiWLFR GH XQD KLVWRULD FOtQLFD TXH UHFRMD \ GRFXPHQWH OD LQIRUPDFLyQ SHUWLQHQWH \ HO HPSOHR FULWHULRVR GH WHFQRORJtDV VHQVLEOHV TXH DQXQFLHQ WHPSUDQDPHQWHODH[LVWHQFLDGHXQULHVJRPD\RUTXHHOHVSHUDGR (OFRQWUROSUHQDWDODGHFXDGRHQFDQWLGDGFDOLGDGFRQWHQLGRVRSRUWXQLGDGGLIHUHQFLDGR DFRUGHDOULHVJRWLHQHXQHQRUPHSRWHQFLDOGHFRQWULEXFLyQDODVDOXGIDPLOLDU\HVXQ FODURHMHPSORGHPHGLFLQDSUHYHQWLYD'RWDGRFRQHVWDVFDUDFWHUtVWLFDV\RULHQWDFLRQHV HVXQIHQyPHQRGHJUDQGHVDUUROORHQORV~OWLPRVFXDUHQWDDxRV$SOLFDGRHQIRUPD UXWLQDULD\H[WHQVLYDFRQMXQWDPHQWHFRQRWUDVPHGLGDVGHVDOXGS~EOLFDFRPRODDWHQFLyQ LQVWLWXFLRQDOGHOQDFLPLHQWRHOHPSOHRGHFULWHULRVGHULHVJRSDUDGHWHUPLQDUUHIHUHQFLD \QLYHOHVGHDVLVWHQFLD\ODDWHQFLyQLQPHGLDWDGHORVUHFLpQQDFLGRVFRQWULEX\HDHYLWDU PXHUWHVOHVLRQHVPDWHUQDV\SHULQDWDOHV $GHPiVGHODPHMRUtDHQODWDVDGHPRUWDOLGDGSHULQDWDO\ODUD]yQGHPRUWDOLGDGPDWHUQD TXHSXHGHQDVRFLDUVHFRQODLQFOXVLyQGHOFRQWUROSUHQDWDOH[WHQVLYRHQORVSURJUDPDV PDWHUQRLQIDQWLOHVKD\SRVLEOHVHIHFWRVDGLFLRQDOHVGHLPSDFWRGLItFLOGHPHGLUSHURQR PHQRV LPSRUWDQWHV$OHMDU ODV GXGDV GH ODV JHVWDQWHV GHVSHMDU ORV PLHGRV \ WDE~HV UHVSHWDQGRODVSDXWDVFXOWXUDOHVORJUDUPD\RUDFHUFDPLHQWR\FRQ¿DQ]DKDFLDHOVLVWHPD GHVDOXGXQDDFWLWXGPiVSRVLWLYDKDFLDODPDWHUQLGDGKDFLDHOHVSDFLDPLHQWRGHORV KLMRV HO PHMRUDPLHQWR GH ORV KiELWRV IDPLOLDUHV PHMRU GLVSRVLFLyQ SDUD HO FRQWURO GHO FUHFLPLHQWR\GHOGHVDUUROORXOWHULRUGHOQLxRIRPHQWDUODDFWLWXGKDFLDODODFWDQFLDQDWXUDO GDUDFRQRFHUHOSODQGHYDFXQDFLyQHWFVRQHMHPSORVGHODVP~OWLSOHVYHQWDMDVTXH WLHQHXQEXHQSURJUDPDGHFRQWUROSUHQDWDO 6RQEDUUHUDVSDUDHOFRQWUROSUHQDWDOHIHFWLYR DVXFRVWRFXDQGRQRHVJUDWXLWRSDUDODXVXDULDDORTXHVHGHEHDJUHJDUJDVWRV GHWUDQVSRUWHSpUGLGDGHKRUDVODERUDOHVHWF ELQDGHFXDGDFDSDFLGDGFDOLGDGWLHPSRHWFGHOHTXLSRGHVDOXG FSUREOHPDVHQODRUJDQL]DFLyQSDUDEULQGDUHOFRQWUROSUHQDWDO GEDUUHUDVGHRUGHQFXOWXUDO HLQDFFHVLELOLGDGJHRJUi¿FD I GHVFUHLPLHQWRHQODVERQGDGHVGHOVLVWHPDGHVDOXG\HQODQHFHVLGDGGHFRQWURO JIDOWDGHSURPRFLyQHQODVFRPXQLGDGHV\DSURSLDFLyQGHVXLPSRUWDQFLD 2%-(7,926<$&7,9,'$'(635238(67$6 (O RUGHQ HOHJLGR SDUD SUHVHQWDU ORV REMHWLYRV HVSHFt¿FRV \ ODV DFWLYLGDGHV TXH VH SURSRQHQ SDUD HO FRQWURO SUHQDWDO GH FDOLGDG WUDWDQ GH DFRPSDxDU OD GLDJUDPDFLyQ SUHVHQWDGD HQ OD +LVWRULD &OtQLFD 3HULQDWDO GHO &/$3605 (VWD KLVWRULD LQWHQWD VHU OD KRMD GH UXWD SRU OD TXH GHEHUi WUDQVLWDU HO SURIHVLRQDO FXDQGR TXLHUD EULQGDU XQD DWHQFLyQGHFDOLGDGDODJHVWDQWH\VXKLMR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR Cuadro 3. Objetivos específicos y actividades propuestas para el control prenatal Objetivos específicos Actividades propuestas Confirmar el embarazo. Realización de exámenes clínicos y paraclínicos para diagnosticar embarazo. Mejorar la calidad del control prenatal. Utilización de algunas tecnologías apropiadas. Obtener datos para planificar el control prenatal, la atención del parto, el puerperio y el recién nacido. Empleo del Sistema Informático Perinatal. Contar con una hoja de ruta que guíe al prestador para brindar una atención prenatal de calidad. Uso de la Historia Clínica Perinatal. Detectar riesgos en la población Evaluación del riesgo perinatal. Conocer información relevante del embarazo Anamnesis Fijar un cronograma que permita planificar las actividades del control prenatal. Determinación de la edad gestacional y fecha probable de parto. Evaluar el estado nutricional materno. Medición del peso y de la talla materna. Cálculo del incremento de peso durante la gestación. Investigar estilos de vida de riesgo. Interrogatorio sobre tabaquismo (activo y pasivo), drogas, alcohol y violencia. Disminuir el impacto negativo de las infecciones de transmisión vertical. Prevención, detección y tratamiento de las infecciones de transmisión vertical. Prevenir el tétanos neonatal y puerperal Vacunación antitetánica Detectar posibles procesos sépticos buco dentales Examen buco-dental. Detectar posibles alteraciones del pezón, patología inflamatoria y/o tumoral de la mama. Examen de mamas. Descartar cáncer de cuello, lesiones precursoras y evaluar la competencia cervical. Examen genital, colpocitología oncológica, colposcopía. Pesquisar una posible incompatibilidad sanguínea materno-feto-neonatal. Determinación del grupo sanguíneo y el factor Rh. Prevenir, detectar y tratar la anemia materna Determinar niveles de hemoglobina y tratamiento con hierro y ácido fólico Descartar proteinuria, glucosuria y bacteriuria Examen de orina y urocultivo. Detectar diabetes mellitus y gestacional Determinación de glucemia y prueba de tolerancia oral a la glucosa. Brindar contenidos educativo-informativos para el parto y la crianza. Preparación para el parto, consejería para el amamantamiento. Confirmar la existencia de vida fetal. Pesquisar movimientos y Frecuencia Cardíaca Fetal Anticipar el diagnóstico y prevenir el parto prematuro. Evaluación del patrón de contractilidad uterina. Pesquisar alteraciones de la presión arterial Medición de la presión arterial, identificación de edemas y proteinuria. Descartar alteraciones del crecimiento fetal. Evaluación del crecimiento por medición de la altura uterina, ganancia de peso materno, ecografía. Detectar precozmente el embarazo múltiple para prevenir sus complicaciones. Diagnóstico de número de fetos. Pesquisar presentaciones fetales anormales. Examen de la presentación fetal. Detectar posibles distocias pélvicas. Evaluación de la pelvis. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD &5212/2*Ë$'(/$6$&7,9,'$'(63$5$/$6&2168/7$635(1$7$/(6'( %$-25,(6*2 /DVDFWLYLGDGHVSDUDHOFRQWUROSUHQDWDOGHEHQHVWDUGLVSXHVWDVHQXQFURQRJUDPDTXH FRQWHPSOHODPD\RUFDQWLGDGGHDFWLYLGDGHVFRQOD¿QDOLGDGGHUHGXFLUDOPtQLPR~WLOHO Q~PHURGHFRQWUROHV (QHVWHGRFXPHQWRVHSURSRQHXQQ~PHURPtQLPRGHFRQVXOWDVTXHSHUPLWDHOFXPSOLPLHQWR GHWRGDVODVDFWLYLGDGHVQHFHVDULDVSDUDORJUDUXQFRQWUROSUHQDWDODGHFXDGRVLHPSUH TXHODVFDUDFWHUtVWLFDVGHOHPEDUD]RFRQWLQ~HQVLHQGRGHEDMRULHVJR /D HOHFFLyQ GHO Q~PHUR \ RSRUWXQLGDG GH FDGD FRQVXOWD VH EDVy HQ HO FRQRFLPLHQWR GH OD HSLGHPLRORJtD GH ORV SUREOHPDV PDWHUQRV \ SHULQDWDOHV PiV IUHFXHQWHV ODV SRVLELOLGDGHV GH GLDJQRVWLFDUORV UHVROYHUORV R FRQWURODUORV FRQ ODV WHFQRORJtDV DSURSLDGDVODVPHMRUHVSUiFWLFDV\FRQSURFHGLPLHQWRVGHH¿FDFLDGHPRVWUDGDSRUODV PHMRUHV HYLGHQFLDV H[LVWHQWHV &XDQGR RFXUUD XQD FRQVXOWD WDUGtD VH UHDOL]DUiQ ODV DFWLYLGDGHVFRUUHVSRQGLHQWHVDODVFRQVXOWDVSUHYLDVTXHQRIXHURQUHDOL]DGDV &XDGUR&URQRORJtDGHODVDFWLYLGDGHVSDUDODVFRQVXOWDVSUHQDWDOHVGHEDMRULHVJR Actividades Prueba de embarazo Cálculo de la amenorrea Historia clínica perinatal y evaluación de riesgo Examen clínico completo Peso corporal Talla Investigar estilos de vida de riesgo Detectar susceptibilidad a la Rubéola Vacuna antitetánica (**) Examen odontológico Examen de mamas Ex. ginecológico, PAP, colposcopía (***) Grupo sanguíneo y factor Rh Detectar toxoplasmosis Detección VIH Determinación de hemoglobina Suplementación con hierro y ácido fólico Detección Sífilis Detección de Chagas Detección de Paludismo Cultivo de orina Detectar diabetes Detectar infección por Estreptococo B Contenidos educativos para el parto y la lactancia Determinación de la presión arterial Evaluación del crecimiento fetal. Evaluación del líquido amniótico Diagnóstico de vida fetal Evaluación de la capacidad pelviana Consejería y provisión de anticoncepción Antes de Las 20 (*) 1ª visita X X X X X X X X Semanas de consultas Entre las Entre las Entre las 22 y 24 27 y 29 33 y 35 2da visita 3ª visita 4ª visita X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Entre las 38 y 40 5ª visita X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X (*) Las actividades programadas para la primer visita se deberán hacer siempre, independientemente de la edad gestacional al momento de la consulta (**) Si se sospecha que la gestante no volverá o porque así lo indica la norma nacional se podrá vacunar antes de la semana 20 (***) Lo más precozmente o según norma nacional. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 2EMHWLYRV $FWLYLGDG &RQ¿UPDUHOHPEDUD]R 5HDOL]DFLyQGHH[iPHQHVFOtQLFRV\SDUDFOtQLFRVSDUDGLDJQRVWLFDU HPEDUD]R (OGLDJQyVWLFRGHOHPEDUD]RVHEDVDUiHQORVFOiVLFRVVLJQRVGHSUREDELOLGDG\FHUWH]D (QHOFXDGURVHUHVXPHQGLFKRVVLJQRV\WpFQLFDVHPSOHDGDVSDUDVXHYDOXDFLyQ &XDGUR6LJQRVGHSUREDELOLGDG\FHUWH]D\WpFQLFDVGLDJQyVWLFDV 6LJQRVGHOHPEDUD]R 3UREDELOLGDG $PHQRUUHD 0RGL¿FDFLRQHVXWHULQDV 'HWHFFLyQGH+&* &HUWH]D 'HWHFFLyQGHVXEXQLGDGEHWDGH+&* 'HWHFFLyQGHSDUWHVIHWDOHV /DWLGRVFDUGtDFRVIHWDOHV 9LVXDOL]DFLyQIHWDO 7pFQLFDVGLDJQyVWLFDV ,QWHUURJDWRULR ([DPHQJLQHFRREVWpWULFR 'HWHUPLQDFLyQHQVDQJUHXRULQD 'HWHUPLQDFLyQHQVDQJUHXRULQD 3DOSDFLyQDEGRPLQDO (VWHWRVFRSLRREVWpWULFR GHWHFWRUHV'RSSOHUR(FRJUDItD (FRJUDItD 6,*126'(352%$%,/,'$' $PHQRUUHD $QWH FXDOTXLHU PXMHU HQ HGDG IpUWLO TXH SUHVHQWH XQ DWUDVR HQ OD DSDULFLyQ GH VX PHQVWUXDFLyQVHGHEHUiSHQVDUHQXQDJUDYLGH] 0RGL¿FDFLRQHVXWHULQDV /D IRUPD GHO ~WHUR VH KDFH PiV JOREXORVD ORV IRQGRV GH VDFR YDJLQDOHV VH KDFHQ FRQYH[RVVLJQRGH1REOH%XGLQ\ODFRQVLVWHQFLDGLVPLQX\H &XDGUR0RGL¿FDFLRQHVGHOWDPDxRXWHULQRHQODSULPHUDPLWDGGHODJHVWDFLyQ 6HPDQDVGHDPHQRUUHD 7DPDxRXWHULQR 1RDOFDQ]DHOSXELV $OFDQ]DODVtQ¿VLVS~ELFD (OIRQGRDPLWDGGHGLVWDQFLDHQWUHVtQ¿VLV\RPEOLJR (OIRQGRDOFDQ]DDOWXUDGHORPEOLJR +RUPRQD&RULyQLFD*RQDGRWUy¿FD+&* /D+&*SXHGHGHWHFWDUVHDSHQDVGtDVGHVSXpVGHSURGXFLGDODIHFXQGDFLyQSRUOR WDQWRD~QDQWHVTXHVHSHUFLEDXQUHWUDVRPHQVWUXDO (OPD\RUSLFRGH+&*VHSURGXFHDORVRGtDVGHOD~OWLPDPHQVWUXDFLyQ/D +&*SXHGHGDUIDOVRVSRVLWLYRVSRUODLQWHUIHUHQFLDTXHSURYRFDODKRUPRQD/+HVWR VHVXHOHHYLWDUGRVL¿FDQGRODVXEXQLGDGEHWDGHOD+&* ([LVWHQ WHVW FRPHUFLDOHV UiSLGRV VHQFLOORV \ UHODWLYDPHQWH HFRQyPLFRV SDUD VHU XVDGRVHQHOKRJDU6XHOHQVHUDOWDPHQWHVHQVLEOHV3DUDPHMRUDUVXVHQVLELOLGDGVH UHFRPLHQGDUHDOL]DUORVFRQODSULPHURULQDGHODPDxDQD 6,*126'(&(57(=$ 6XEXQLGDG%HWDGHOD+&* /DVXEXQLGDGEHWDGHOD+&*HVGHWHFWDEOHD~QDQWHVGHODQLGDFLyQ\HVH[FOXVLYDPHQWH SURGXFLGD SRU HO VLQFLFLRWURIREODVWR FRQ OR TXH VH HYLWDQ ODV UHDFFLRQHV FUX]DGDV FRQ RWUDV KRUPRQDV &RQVWLWX\H HO PpWRGR GH GLDJQyVWLFR GH HPEDUD]R PiV SUHFR] \ VHQVLEOH /RV UHVWDQWHV VLJQRV GH FHUWH]D GHO HPEDUD]R VH GHWDOODQ GHQWUR GH ODV DFWLYLGDGHVGH³'LDJQyVWLFRGHYLGDIHWDO´ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2EMHWLYRV $FWLYLGDG 0HMRUDUODFDOLGDGGHOFRQWUROSUHQDWDO 8WLOL]DFLyQGHDOJXQDVWHFQRORJtDVDSURSLDGDV (O &/$3605 LQWHQWD SRQHU DO DOFDQFH GH WRGRV ORV SURIHVLRQDOHV GH VDOXG WHFQRORJtDV SUREDGDVHIHFWLYDV\GHEDMRFRVWRSDUDFRQWULEXLUDODHQWUHJDGHSUHVWDFLRQHVGHFDOLGDG *(672*5$0$ $OFDOHQGDULRREVWpWULFRVHDJUHJDURQPHGLGDVGHDOJXQRVSDUiPHWURVVHOHFFLRQDGRVSRU FRQ¿DEOHV\SUHFLVRVTXHSHUPLWHQDSDUWLUGHODIHFKDGH~OWLPDPHQVWUXDFLyQ)80FDOFXODU ODHGDGJHVWDFLRQDO\GHOUHFLpQQDFLGRYLJLODUHOFUHFLPLHQWR\YLWDOLGDGIHWDO\YHUL¿FDUOD QRUPDOLGDGGHOLQFUHPHQWRGHSHVRPDWHUQRGHODSUHVLyQDUWHULDO\GHODVFRQWUDFFLRQHV XWHULQDV $Vt HQ XQ GLVFR TXH JLUD VREUH RWUR DO KDFHU FRLQFLGLU OD ÀHFKD URMD FRQ HO SULPHU GtD GH OD )80 \ EXVFDQGR OD IHFKD FRUUHVSRQGLHQWH D OD FRQVXOWD VH HQFRQWUDUi OD HGDGJHVWDFLRQDOHQVHPDQDVFXPSOLGDV/RVYDORUHVDFRPSDUDUHVWiQXELFDGRVDOD L]TXLHUGDGHODVHPDQDHQFRQWUDGDSHUFHQWLOHV\GHODDOWXUDXWHULQDSHUFHQWLOHV \GHJDQDQFLDGHSHVRPDWHUQR\SHUFHQWLOHV\GHOSHUtPHWURDEGRPLQDO IHWDOSRUHFRJUDItD ),*85$$QYHUVR\UHYHUVRGHOJHVWRJUDPD $GHPiVGHOFiOFXORGHODHGDGJHVWDFLRQDODPHQRUUHDHVWDFDUDGHOJHVWRJUDPDSHUPLWHOD GHWHFFLyQGHFDVRV xFRQUHVWULFFLyQGHOFUHFLPLHQWRLQWUDXWHULQRPHGLGDVPHQRUHVTXHORVYDORUHVPiV EDMRVGHORVSHUFHQWLOHVUHVSHFWLYRV xGHPDFURVRPtDPHGLGDVPD\RUHVTXHORVYDORUHVPiVDOWRVGHORVSHUFHQWLOHV FRUUHVSRQGLHQWHV xGHDOWHUDFLRQHVGHODGXUDFLyQGHOHPEDUD]RHQPHQRVSUHPDWXULGDGRHQPiV SURORQJDGRFURQROyJLFDPHQWH xFRQFRQWUDFWLOLGDGPD\RUTXHODFRUUHVSRQGLHQWHDODHGDGDQWHVGHODVVHPDQDV 6LVHGHVFRQRFHOD)80HOUHYHUVRGHOJHVWRJUDPDSHUPLWHHVWLPDUODHGDGJHVWDFLRQDO FRQXQHUURUFRQRFLGRDSDUWLUGHPHGLGDVHFRJUi¿FDVHPEULRIHWDOHV'HVGHODVHPDQD VH SUHVHQWDQ ORV YDORUHV GH ORV 3 \ 3 GHO SHVR IHWDO \ GHO 3 GH OD WDOOD FRUUHVSRQGLHQWHDFDGDVHPDQD 6LVHLJQRUDOD)80\QRH[LVWHQPHGLGDVIHWDOHVUHDOL]DGDVSRUHFRJUDItDGXUDQWHHO HPEDUD]R VH SXHGHQ XWLOL]DU ORV YDORUHV GH SHVR WDOOD \ GHO GLiPHWUR ELSDULHWDO GHO UHFLpQQDFLGRPHGLGRFRQFRPSiVSDUDREWHQHUXQDDSUR[LPDFLyQUiSLGD\VHQFLOODGH ODGXUDFLyQGHOHPEDUD]R &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 6H UHFXHUGDQ ORV SHUFHQWLOHV \ GH SUHVLyQ DUWHULDO PDWHUQD VLVWyOLFD \ GLDVWyOLFD HVWDQGRODPDGUHVHQWDGDYiOLGRVSDUDWRGRHOHPEDUD]R /RV GDWRV FRQWHQLGRV HQ HO JHVWRJUDPD SURYLHQHQ GH LQYHVWLJDFLRQHV UHDOL]DGDV SRU &/$3605HQSREODFLRQHVODWLQRDPHULFDQDVVDQDVVHJXLGDVORQJLWXGLQDOPHQWH &,17$2%67(75,&$ $ OD FLQWD PpWULFD FRQYHQFLRQDO VH DJUHJDURQ PHGLGDV GH DOJXQRV SDUiPHWURV VHOHFFLRQDGRV SRU FRQ¿DEOHV \ SUHFLVRV TXH SHUPLWHQ YLJLODU HO FUHFLPLHQWR \ YLWDOLGDG IHWDOYHUL¿FDUODQRUPDOLGDGGHOLQFUHPHQWRGHSHVRPDWHUQRGHODSUHVLyQDUWHULDO\GH ODFRQWUDFWLOLGDGXWHULQDSHUPLWLHQGRDGHPiVFRQRFHUHOSHVRIHWDOSDUDXQDGHWHUPLQDGD HGDGJHVWDFLRQDO )LJXUD$QYHUVR\UHYHUVRGHODFLQWDREVWpWULFD &(1752/$7,12$0(5,&$12'(3(5,1$72/2*,$ 6$/8''(/$08-(5<5(352'8&7,9$ &/$3605236206 ZZZFODSRSVRPVRUJ /DFLQWDREVWpWULFDFRQVWDGHGRVFDUDV (ODQYHUVRGHFRORUEODQFRTXHVHSUHVHQWDHQOD¿JXUDFRQWLHQH xHOGLEXMRTXHLOXVWUDODWpFQLFDGHPHGLFLyQDODTXHFRUUHVSRQGHQORVYDORUHVPi[LPRV \PtQLPRVQRUPDOHVGHODDOWXUDXWHULQDHQIXQFLyQGHODHGDGJHVWDFLRQDO x ODFLQWDPpWULFDSURSLDPHQWHGLFKDHQODTXHVHGHVWDFDQHQWUHGRVEDUUDVQHJUDVJUXHVDV ORVYDORUHVQRUPDOHVGHDOWXUDXWHULQDSDUDXQHPEDUD]RGHWpUPLQRFRQIHWR~QLFR x ORVYDORUHVQRUPDOHVGHSUHVLyQDUWHULDOVLVWyOLFD\GLDVWyOLFD (OUHYHUVRGHFRORUDPDULOOR¿JXUDFRQWLHQH xORVYDORUHVPtQLPRV\Pi[LPRVQRUPDOHVSDUDFDGDHGDGJHVWDFLRQDODSDUWLUGHOD VHPDQD\KDVWDODVHPDQDGH RDOWXUDXWHULQDHQFHQWtPHWURV RJDQDQFLDGHSHVRPDWHUQRHQNLORJUDPRV RSHVRIHWDOHQNLORJUDPRV xORVYDORUHVPi[LPRVGHODVFRQWUDFFLRQHVXWHULQDVKDVWDODVHPDQD xORVFXDGURVFOtQLFRVTXHGHWHUPLQDQXQDDOWXUDPHQRURPD\RUDODHVSHUDGDVHJ~Q ODHGDGJHVWDFLRQDO 'H LJXDO IRUPD TXH HQ HO JHVWRJUDPD ORV GDWRV FRQWHQLGRV HQ HVWD FLQWD REVWpWULFD SURYLHQHQ GH LQYHVWLJDFLRQHV UHDOL]DGDV SRU HO &/$3605 HQ SREODFLRQHV ODWLQRDPHULFDQDVVDQDVVHJXLGDVORQJLWXGLQDOPHQWH &8$'523ULQFLSDOHVGDWRVTXHSURSRUFLRQDQODFLQWDREVWpWULFD\JHVWRJUDPDGH&/$3605 $OWXUD8WHULQDS\S ,QFUHPHQWRGHSHVRPDWHUQRS\S &RQWUDFFLRQHVXWHULQDVSRUKRUDSGHVGHODVHPDQD 3UHVLyQDUWHULDOPDWHUQDS\S 3HVRIHWDOSDUDFDGDHGDGJHVWDFLRQDOS\S 7DOODIHWDOSDUDFDGDHGDGJHVWDFLRQDOS 3HUtPHWURDEGRPLQDOIHWDOSRUHFRJUDItDS\S &iOFXORGHODHGDGJHVWDFLRQDO S SHUFHQWLO &LQWDREVWpWULFD ; ; ; ; ; &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD *HVWRJUDPD ; ; ; ; ; ; ; ; ; 6DOXG6H[XDO\5HSURGXFWLYD 7$5-(7$&219$/25(61250$/(6'($/785$87(5,1$ *$1$1&,$'(3(620$7(512<3(623$5$/$7$//$ %GPVTQ.CVKPQCOGTKECPQFG2GTKPCVQNQIÈC5CNWFFGNC/WLGT[4GRTQFWEVKXC%.#25/4 )LJXUD$QYHUVR\UHYHUVRGHODWDUMHWDGHDOWXUDXWHULQD\SHVRPDWHUQR (Q XQD GH ODV FDUDV VH KDFH XQD EUHYH UHIHUHQFLD D FRPR VH HYDO~D HO FUHFLPLHQWR IHWDO \ VXV GHVYLDFLRQHV DVt FRPR OD QXWULFLyQ PDWHUQD 7DPELpQ VH SUHVHQWDQ ORV YDORUHVSDWURQHVQRUPDOHVGHVGHODVKDVWDODVVHPDQDVGHHGDGJHVWDFLRQDO GHOLQFUHPHQWRGHSHVRPDWHUQR\GHODDOWXUDXWHULQD¿JXUD (QODRWUDFDUDVHSUHVHQWDQORVYDORUHVQRUPDOHVSHUFHQWLOHV\GHOSHVRPDWHUQR SDUDODWDOODGHVGHODDODVHPDQDGHJHVWDFLyQ(OSHVRSDUDODWDOODVHHODERUy HQEDVHDOtQGLFHTXHPLGHODUHODFLyQSHVRDFWXDOGHODHPEDUD]DGDSHVRWHyULFRSDUD ODWDOODGHPXMHUHVQRHPEDUD]DGDV 3HVRSDUDODWDOOD SHVRDFWXDOGHODHPEUD]DGD SHVRWHyULFRSDUDODWDOODGHPXMHUHVQRHPEDUD]DGDV (OSHVRWHyULFRSDUDODWDOODGHPXMHUHVQRHPEDUD]DGDVIXHWRPDGRGH-HOLIIH'%(YDOXDFLyQ GHOHVWDGRGHQXWULFLyQGHODFRPXQLGDG6HULH0RQRJUi¿FD1206±*LQHEUD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 2EMHWLYRV $FWLYLGDG 2EWHQHUGDWRVSDUDSODQL¿FDUHOFRQWUROSUHQDWDOODDWHQFLyQGHO SDUWRHOSXHUSHULR\HOUHFLpQQDFLGR (PSOHRGHOVLVWHPDLQIRUPiWLFRSHULQDWDO 3DUDJDUDQWL]DUXQDFRUUHFWDHMHFXFLyQGHODQRUPDGHFRQWUROSUHQDWDOHVLPSUHVFLQGLEOH GLVSRQHUGHXQVLVWHPDTXHSHUPLWDUHJLVWUDUWRGDODLQIRUPDFLyQUHOHYDQWHSDUDXQD FRUUHFWDSODQL¿FDFLyQGHODDWHQFLyQGHODHPEDUD]DGD\VXKLMR(OVLVWHPDGHUHJLVWUR HVHOLQVWUXPHQWRPiVDSURSLDGRSDUDVXSHUYLVDUHOFXPSOLPLHQWRGHODQRUPD\EULQGDU ORVGDWRVLQGLVSHQVDEOHVSDUDVXHYDOXDFLyQXOWHULRU (VWHVLVWHPDLQFOX\HODKLVWRULDFOtQLFD\HOFDUQpSHULQDWDOGHO&/$3605 +,6725,$&/,1,&$3(5,1$7$/ /DKLVWRULDFOtQLFDSHULQDWDO+&3LQWHQWDXQLIRUPL]DUHOFRQWHQLGRGHODGRFXPHQWDFLyQ FRUUHVSRQGLHQWHDOHPEDUD]RSDUWRSXHUSHULR\DOUHFLpQQDFLGRHQHOSHUtRGRQHRQDWDO LQPHGLDWR6XGLDJUDPDFLyQJHQHUDO\VXLQVWUXFWLYRGHOOHQDGRIDFLOLWDUiTXHORVGDWRV FRQVLGHUDGRVGHLPSRUWDQFLDVHDQVLVWHPiWLFD\XQLIRUPHPHQWHUHFDEDGRV\UHJLVWUDGRV HQHOPRPHQWRRSRUWXQR(ORUGHQDPLHQWRGHORVGDWRVSHUPLWLUiVXUHFROHFFLyQHQXQ WLHPSREUHYHDODYH]TXHDJLOL]DUiHODQiOLVLVSRVWHULRU\DVHDSRUTXLHQUHFRJLyORV GDWRVRSRUDTXHOTXHQRKDELHQGRKHFKRHOUHJLVWURQHFHVLWDODLQIRUPDFLyQLQFOXLGDHQ ODKLVWRULD(VWDVLWXDFLyQVHSUHVHQWDSRUHMHPSORWRGDYH]TXHHOSDUWRQRVHUHDOL]D HQODPLVPDLQVWLWXFLyQGRQGHVHHIHFW~DHOFRQWUROSUHQDWDO/RPLVPRRFXUUHFXDQGRHO FRQWUROSRVWSDUWR\SHGLiWULFRVHUHDOL]DIXHUDGHODLQVWLWXFLyQGRQGHQDFLyHOQLxR (QODV¿JXUDV\VHPXHVWUDHOPRGHORGHOD+&3GH&/$3605TXHMXQWRFRQ HO SDUWRJUDPD &/$3605 UHFRPLHQGD SDUD WRGRV ORV FDVRV (VWRV IRUPXODULRV VRQ VX¿FLHQWHVSDUDHOEDMRULHVJRSHULQDWDOTXHFRPSUHQGHDODPD\RUtDGHODSREODFLyQ /D +&3 ¿JXUD UH~QH HQ XQD SiJLQD ORV GDWRV PtQLPRV LQGLVSHQVDEOHV SDUD OD SODQL¿FDFLyQGHODDWHQFLyQGHOHPEDUD]RSDUWRSXHUSHULR\UHFLpQQDFLGR6XOLVWDGRGH SUHJXQWDVFRQVWLWX\HXQUHFRUGDWRULRTXHRULHQWDDOSUHVWDGRUHQODDWHQFLyQDPDQHUD GHXQDKRMDGHUXWDHVWRD\XGDDOFXPSOLPLHQWRGHODVQRUPDVGHDWHQFLyQDOWLHPSR TXHIDFLOLWDORVSURFHVRVGHDXGLWRULD&XHQWDDGHPiVFRQXQVLVWHPDGHDGYHUWHQFLD VREUHDOJXQRVIDFWRUHVTXHSXHGHQHOHYDUHOULHVJRSHULQDWDORTXHUHTXLHUHQPD\RU DWHQFLyQ VHJXLPLHQWR R FXLGDGR (VWH VLVWHPD VH FDUDFWHUL]D SRU GHVWDFDU DOJXQRV FDVLOOHURVFRQFRORUDPDULOOR(VWHFRORUVHXVDFRPRFyGLJRLQWHUQDFLRQDOGHDOHUWD (OUHYHUVRGHOD+&3¿JXUDFRQWLHQHOLVWDVDEUHYLDGDVSDUDODFRGL¿FDFLyQGHODV SDWRORJtDVPiVIUHFXHQWHVGHOHPEDUD]RSDUWRSXHUSHULR\GHOUHFLpQQDFLGR7DPELpQ VH KD LQFOXLGR XQD OLVWD SDUD OD FRGL¿FDFLyQ GH ODV SULQFLSDOHV LQGLFDFLRQHV GH SDUWR RSHUDWRULR R GH LQGXFFLyQ GHO SDUWR DGHPiV GH XQD OLVWD GH PHGLFDFLyQ HIHFWXDGD GXUDQWHHOSDUWR 3$572*5$0$ 'HEHVHUXWLOL]DGRMXQWRFRQOD+&3GXUDQWHHOWUDEDMRGHSDUWRVHGHVFULEHHQODSiJLQD &$51e3(5,1$7$/ (O FDUQp SHULQDWDO &3 GHO &/$3605 HV XQ LQVWUXPHQWR TXH SHUPLWH LQWHJUDU ODV DFFLRQHVTXHHOHTXLSRGHVDOXGUHDOL]DGXUDQWHHOHPEDUD]RSDUWR\SXHUSHULR7LHQGH DHYLWDUODIDOWDGHGDWRVTXHSXHGHSURGXFLUVHHQDOJ~QPRPHQWRGHHVWDVHWDSDVGHO SURFHVRUHSURGXFWLYR\FRQHOORFRQWULEX\HDPHMRUDUODFDOLGDGGHODDWHQFLyQ'HEH HVWDUVLHPSUHHQSRGHUGHODHPEDUD]DGDTXLHQORXWLOL]DUiSDUDWRGDDFFLyQPpGLFD TXHVROLFLWHHQVXHVWDGRJUiYLGRSXHUSHUDO &RQHOFDUQpSHULQDWDOVHDVHJXUDTXHORVGDWRVGHPD\RULPSRUWDQFLD UHODWLYRVDOFRQWUROSUHQDWDODOVHUUHJLVWUDGRVVLVWHPiWLFDPHQWHHQFDGDFRQVXOWD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD OOHJXHQDPDQRVGHTXLHQDWLHQGHSRVWHULRUPHQWHDODHPEDUD]DGD\DVHDHQRWUR FRQVXOWRULRH[WHUQRRHQHOOXJDUGHODLQWHUQDFLyQ YLQFXODGRV D XQD LQWHUQDFLyQ GXUDQWH HO HPEDUD]R SDUWR \ SRVWSDUWR VHDQ FRQRFLGRVSRUTXLHQWLHQHDVXFDUJRHOFRQWUROGHOSXHUSHULR SDUDHOVHJXLPLHQWRGHOUHFLpQQDFLGROOHJXHQDFRQRFHUVHSRUTXLHQWLHQHDVX FDUJRHOFRQWUROGHOQLxR PHVWL]D 7(/() )$0,/,$5(6 QR VL $17(&('(17(6 3(5621$/(6 QR VL 7%& , GLDEHWHV KLSHUWHQVLyQ 2%67(75,&26 QHIURSDWtD YLROHQFLD 7$//$FP )80 )33 .J ,QVS YLVXDO GtD PHV DxR GtD PHV DxR QRVH QRUPDO DQRUPDO KL]R *5832 B 5K VL ȖJOREXOLQDDQWL' QR VL &2168/7$6$17(1$7$/(6 HPE HFWySLFR QR VH KL]R VL ),1(0%$5$=2$17(5,25 YLYHQ GtD SDUWRV PXHUWRV UD VHP QDFLGRV PXHUWRV FHViUHDV PHV DxR (0%$5$=23/$1($'2 QR 9,+ VHP SHVR QR VL VHP QR EDUUHUD ',8 KRUPR HPHU QDWXUDO XVDED QDO JHQFLD 3$ )H QR JGO VL VL JGO QR VH KL]R QR VL PRYLP SURWHL IHWDOHV QXULD QR (;1250$/ 2'217 0$0$6 6,),/,6'LDJQyVWLFR\7UDWDPLHQWR 3UXHED 7UDWDPLHQWR WUHSRQpPLFD +E VHP )RODWRV J QR QRWUHSRQpPLFD VG QF VG J VHP 35(3$5$ &216(-(5,$ (675(372 &,213$5$ /$&7$1&,$ &2&2 % 0$7(51$ VHP VHPDQDV (/3$572 QR VL VROLFL PJGO WDGR UHDOL ]DGR DOWXUD SUHVHQ )&) XWHULQD WDFLyQ OSP )H)2/$726 LQGLFDGRV +EVHP VHP QR VG QF VL QR VG QF VG VL VL )5$&$620(72'2$17,&21&(3 GHVSXpV UD VHP VROLFL WDGR UHDOL ]DGR QR 7WR GH OD SDUHMD VG QF VL ,QLFLDOHV 7pFQLFR VLJQRVGHDODUPDH[iPHQHVWUDWDPLHQWRV VL QR VL VG QF QR VL VG QF SUy[LPDFLWD &$51e VL QR KRUD PHV KRUD YDULHGDG SRVLF )&)GLSV PHFRQLR GHWDOOHV HQSDU WRJUDPD QHIURSDWtD , DxR JGH 9'5/ WR 7WR QRVH KL]R WUDVODGR IDOOHFH KRUD VL QF PLQ IDOOHFH ('$'$/(*5(62 GXUDQWHR HQOXJDU GtDVFRPSOHWRV GHWUDVODGR GtD QR VL VG $/,0(172 $/$/7$ ODFW H[FO OXJDU 5HVSRQVDEOH DUWLILFLDO HVWLPXODF DVSLUDFLyQ PiVFDUD R[tJHQR PDVDMH WXER QR VL )$//(&( HQ/8*$5 GH3$572 VL QR %&* QR VL GtD PHV LQIHFFLyQ SXHUSHUDO FyGLJR PHGLF $7(1',2 PpGLFR REVW HQI DX[LO HVWXG HPSLU RWUR PHGLF 1RPEUH 3$572 1(21$72 38(53(5,2 GtD KRUD 7& QR 3$ SXOVR LQYROXWHU ORTXLRV VL $17,&21&(3&,21 ȖJOREXOLQD QR VL QF DQWL ' QR VL QF DxR IDOOHFH YLYD IDOOHFH GXUDQWHR QR VL GtDVFRPSOHWRV GHVGHHOSDUWR HQOXJDU GHWUDVODGR J 23(5 HU WULP QRWDV ( * 5 ( 6 20 $7 ( 5 1 2 WUDVODGR OXJDU 3(62$/(*5(62 ,1'8& WULP 0HFRQLR HUGtD $QWLUXEHROD SRVWSDUWR VL FyGLJR GR SRVWSDUWR RWUD FRQG JUDYH 5()(5,'2 DORM QHRQD RWUR FRQM WRORJ KRVS QRVH KL]R %RFD DUULED QR * VL QR HU WULP ,1',&$&,2135,1&,3$/'( RWUD ,1'8&&,2123$57223(5$725,2 7R[R 76+ +ESDWtD %LOLUUXE ,J0 QR FyGLJR FyGLJR HU SHT (67,0$'$ SDUFLDO ,G 51 1RPEUH5HFLpQ1DFLGR $3*$5 PLQ 3(62 (* (&2 VL VL DQHVW DQHVW WUDQVIXVLyQ RWURV QR VL DQWLELRW DQDOJHVLD DQHVW ORFDO UHJLRQ JUDO QR QR QR QR QR QR HVSHFLILFDU VL VL VL VL VL VL RFLWyFLFRV HQ 7'3 QR VL 7$0,=$-( 1(21$7$/ ( * 5 ( 6 25 1 YLYR PHV QR yPiV PHQRU YDFXXP ,, RWUR QLQJXQR 5&,8 URWXUD SUHP GH PHPEUDQDV DQHPLD FDUGLRSDWtD IRUFHSV DGHF /21*,78' FP J J PD\RU GtD HFODPSVLD IDPLOLDU VL QR LQIHF RYXODU LQIHF XULQDULD DPHQD]D SDUWR SUHWHU SDUHMD QR VL +7$SUHYLD +7$LQGXFLGD HPEDUD]R SUHHFODPSVLD FHViUHD SUHFR] )80 QLQJXQD QR QR 08/7,3/( yUGHQ 7(50,1$&,21 HVSRQW QR VL /,*$'85$ &25'21 VL 3&()$/,&2 FP ('$'*(67$&,21$/ VHP GLDV J '()(&726 &21*(1,726 3/$&(17$ UHWHQLGD QR 3(62$/1$&(5 (1)(50('$'(6 QR GHILQLGR DxR QR *UDGR D SUHDOXPEU SRVWDOXPEU QR VL QR VL FRPSOHWD VL 5 ( & , ( 11 $ & , ' 2 6(;2 I P 2&,72&,&26 PHV 0(',&$&,21 5(&,%,'$ FXFOLOODV GtD 5($1,0$&,21 DFRVWDGD (3,6,2720,$ 326,&,213$572 LJQRUD PRPHQWR QR '(6*$5526 PLQ FHIiOLFD SHOYLDQD SRU )80 SRU (FR $&203$f$17( 7'3 3 7$0$f2 )(7$/ $&25'( WUDQVYHUVD 75$%$-2 '(3$572 SDUWR KRUD 35(6(17$&,21 6,78$&,21 WHPS & PLQ FHVDUHOHFW DOWXUD SUHVHQW ('$'*(67 DOSDUWR VHPDQDV GtDV GLDEHWHV 1$&,0,(172 9,92 08(572 DQWHSDUWR VHQWDGD VHP DxR VL QR VL SXOVR FRQWU¶ GLODWDFLyQ 3$ GtD KV LQGXFLGR LQLFLR QF SRVLFLyQGH ODPDGUH PLQ QR +(0255$*,$ QLQJXQD 52785$'(0(0%5$1$6$17(3$572 ,1,&,2 HVSRQWiQHR yPiV DxR QLQJXQD PHV (1)(50('$'(6 GtD FyGLJR &257,&2,'(6 +263,7$/,= $17(1$7$/(6 HQ &2168/7$6 (0%$5$=2 FRPSOHWR 35( VL QR 1$7$/(6 LQFRPSO GtDV VHPDQD WRWDO $ % 2 5 72 )(&+$ '( ,1*5(62 'HVFULSFLyQGHFyGLJRVHQHOUHYHUVR 1 ,GHQ WLGDG 3$ 5 72 +&3(6$935HJLRQDO YLYH VROD QR QDFLGRVYLYRV QR VL */8&(0,$(1$<81$6 VHP HGDG JHVW DxR RWUR )80$ $&7 )80$ 3$6 '52*$6 $/&2+2/ 9,2/(1&,$ $17,58%(2/$ $17,7(7$1,&$ (* &21),$%/( SRU QR VL QR VL QR VL QR VL QR VL SUHYLD QRVDEH )80 (FRV HUWULP YLJHQWH QR VL D D QR '26,6 WULP HPEDUD]R QR PHV VL HUWULP JHVWDFLyQ YDJLQDOHV /XJDUGHO SDUWRDERUWR VROWHUD PHQRVGHDxR DFRQVXOWD ,J0 QF QRVH QRUPDO DQRUPDO KL]R VHP PHV ñ J RWUD DERUWRV HVSRQW FRQVHFXWLYRV VHP ,J* 3$/8',602 %$&7(5,85,$ 0$/$5,$ GtD QRUPDO DxRVHQHO PD\RUQLYHO /XJDUGHO FRQWURO SUHQDWDO FDVDGD XQLyQ HVWDEOH VHPDQDV VHPDQDV 3$3 &2/3 QR VH KL]R J ,QPXQL] 72;23/$6026,6 QR VHP ,J* QR VH KL]R QF $QWHFHGHQWH GHJHPHODUHV RWUDFRQG PpGLFDJUDYH 3(62 $17(5,25 JHVWDVSUHYLDV 8/7,0235(9,2 FDUGLRSDW SUHHFODPSVLD HFODPSVLD *(67$&,21$&78$/ &(59,; ,, QR VL VHFXQG XQLYHUV VL QHJUD GH !GH FLUXJtD JHQLWRXULQDULD LQIHUWLOLGDG * (678',26 EODQFD %(7$ QLQJXQR SULPDULD LQGtJHQD QR ('$' DxRV /2&$/,'$' $/)$ (71,$ DxR '20,&,/,2 &+$*$6 QRLQGLFDQHFHVDULDPHQWHULHVJRQLSUiFWLFDVLQDGHFXDGDV PHV GtD VHPDQDV VHPDQDV (VWHFRORUVLJQLILFD$/(57$ )(&+$'(1$&,0,(172 $3(//,'2 (67$'2&,9,/ +,6725,$&/,1,&$3(5,1$7$/&/$3605236206 120%5( 5HVSRQVDEOH )LJXUD+LVWRULD&OtQLFD3HULQDWDO5HJLRQDO$QYHUVR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &216(-(5,$ QR 0(72'2(/(*,'2 ',8SRVW OLJDGXUD HYHQWR WXEDULD QDWXUDO ',8 EDUUHUD RWUR KRUPRQDO QLQJXQR VL &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR )LJXUD+LVWRULD&OtQLFD3HULQDWDO5HJLRQDO5HYHUVR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD )LJXUD&DUQp3HULQDWDO5HJLRQDO$QYHUVR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR )(&+$'(1$&,0,(172 '20,&,/,2 7(/() $17(&('(17(6 2%67(75,&26 FDUGLRSDW QHIURSDWtD 7$//$FP .J GtD PHV DxR GtD PHV DxR QRVH QRUPDO DQRUPDO KL]R *5832 B 5K QR VL VHP HGDG JHVW DxR SHVR 3$ SDUWRV ),1(0%$5$=2$17(5,25 GtD PHV DxR PXHUWRV UD VHP (0%$5$=23/$1($'2 QR QR VH KL]R $/&2+2/ 9,2/(1&,$ QR VL QR VL 9,+ )H)2/$726 LQGLFDGRV +EVHP VHP QR VL VROLFL WDGR UHDOL ]DGR VHP )H QR EDUUHUD ',8 KRUPR HPHU QDWXUDO XVDED QDO JHQFLD $17,7(7$1,&$ $17,58%(2/$ SUHYLD QRVDEH HPEDUD]R QR J QR QR JGO VL VL JGO YLJHQWH QR '26,6 QR VH KL]R QR VL PRYLP SURWHL IHWDOHV QXULD QR 2'217 0$0$6 D PHV JHVWDFLyQ QRWUHSRQpPLFD VG QF VG J VHP 35(3$5$ &216(-(5,$ (675(372 &,213$5$ /$&7$1&,$ &2&2 % 0$7(51$ VHP VHPDQDV (/3$572 QR VL (;1250$/ VL D 6,),/,6'LDJQyVWLFR\7UDWDPLHQWR 3UXHED 7UDWDPLHQWR WUHSRQpPLFD +E VHP )RODWRV VL )5$&$620(72'2$17,&21&(3 QR VG QF VL QR VG QF VG VL VL 7WR GH OD SDUHMD VG QF VL ,QLFLDOHV 7pFQLFR VLJQRVGHDODUPDH[iPHQHVWUDWDPLHQWRV QR QR VL VG QF QR VL VG QF SUy[LPDFLWD DxR QLQJXQD &$51e VL QR 1$&,0,(172 9,92 08(572 DQWHSDUWR LQLFLR GtD GtD PHV VL IHWRV ~QLFR ,1'8& 23(5 FyGLJR FHViUHD 1RWDV RWUD FXFOLOODV VL PHQRU PHV JGH 9'5/ WR DxR WUDVODGR IDOOHFH KRUD QRVH KL]R PLQ VG IDOOHFH ('$'$/(*5(62 $/,0(172 $/$/7$ GXUDQWHR HQOXJDU GtDVFRPSOHWRV ODFW GHWUDVODGR GtD H[FO QR VL OXJDU 5HVSRQVDEOH DUWLILFLDO QR HVWLPXODF DVSLUDFLyQ PiVFDUD R[tJHQR PDVDMH WXER IDPLOLDU RWUR VL VL VL VL LQIHF RYXODU QHIURSDWtD GLDEHWHV QR VL )$//(&( HQ/8*$5 GH3$572 VL QR , ,, * LQIHF XULQDULD DPHQD]D SDUWR SUHWHU 5&,8 URWXUD SUHP GH PHPEUDQDV DQHPLD RWUD FRQG JUDYH HU WULP VL FyGLJR GR WULP HU WULP SRVWSDUWR LQIHFFLyQ SXHUSHUDO QRWDV FyGLJR PHGLF PHGLF 1RPEUH 3$572 1(21$72 38(53(5,2 GtD KRUD 7& 3$ SXOVR LQYROXWHU ORTXLRV 0HFRQLR HUGtD QR VL QR VL QF $17,&21&(3&,21 JJOREXOLQD QR VL DQWL ' QR VL QF &216(-(5,$ (*5(620$7(512 WUDVODGR GtD QR $7(1',2 PpGLFR REVW HQI DX[LO HVWXG HPSLU RWUR 5()(5,'2 DORM QHRQD RWUR FRQM WRORJ KRVS $QWLUXEHROD SRVWSDUWR %&* QR QLQJXQR QR HFODPSVLD FDUGLRSDWtD QRVH KL]R %RFD DUULED QR VL +7$SUHYLD +7$LQGXFLGD HPEDUD]R SUHHFODPSVLD 7R[R 76+ +ESDWtD %LOLUUXE ,J0 VL QF SDUFLDO ,G 51 1RPEUH5HFLpQ1DFLGR 7WR QR QLQJXQD FyGLJR ( * 5 ( 6 25 1 YLYR SRU )80 SRU (FR SDUHMD QR SHOYLDQD DQHVW DQHVW WUDQVIXVLyQ RWURV QR VL DQWLELRW DQDOJHVLD DQHVW ORFDO UHJLRQ JUDO QR QR QR QR QR QR HVSHFLILFDU VL VL VL VL VL VL RFLWyFLFRV HQ 7'3 QR VL 7$0,=$-( 1(21$7$/ PD\RU GtD $3*$5 PLQ HU SHT (67,0$'$ yPiV QR (&2 VL 3(62 (* DGHF /21*,78' FP J J QR )80 J '()(&726 &21*(1,726 SUHFR] 3&()$/,&2 FP ('$'*(67$&,21$/ VHP GLDV 3(62$/1$&(5 /,*$'85$ &25'21 VL UHWHQLGD QR FyGLJR QR GHILQLGR 3/$&(17$ QR *UDGR D SUHDOXPEU SRVWDOXPEU QR VL QR VL FRPSOHWD 5 ( & , ( 11 $ & , ' 2 6(;2 I P 2&,72&,&26 5($1,0$&,21 DFRVWDGD QR '(6*$5526 0(',&$&,21 5(&,%,'$ VHQWDGD (3,6,2720,$ YDFXXP 326,&,213$572 FHIiOLFD WHPS & PLQ $&203$f$17( 7'3 3 7$0$f2 )(7$/ $&25'( WUDQVYHUVD 08/7,3/( yUGHQ DxR 35(6(17$&,21 6,78$&,21 VHPDQDV GtDV FHVDUHOHFW PHV ,1',&$&,2135,1&,3$/'(3$57223(5$725,22,1'8&&,21 HVSRQW IRUFHSV ('$'*(67 DOSDUWR VHP DxR KV KRUD LJQRUD PRPHQWR SDUWR 7(50,1$&,21 PLQ QR LQGXFLGR QF KRUD 52785$'(0(0%5$1$6$17(3$572 ,1,&,2 HVSRQWiQHR yPiV PHV QLQJXQD GtD +(0255$*,$ &257,&2,'(6 +263,7$/,= $17(1$7$/(6 HQ &2168/7$6 (0%$5$=2 FRPSOHWR 35( VL QR 1$7$/(6 LQFRPSO GtDV VHPDQD WRWDO $ % 2 5 72 )(&+$'(,1*5(62 (1)(50('$'(6 3$ 5 72 &3((6$935HJLRQDO VL YLYHQ QDFLGRV PXHUWRV FHViUHDV )80$ $&7 )80$ 3$6 '52*$6 QR VL QR VL QR VL VROLFL PJGO WDGR UHDOL ]DGR DOWXUD SUHVHQ )&) XWHULQD WDFLyQ OSP 1 ,GHQ WLGDG GHVSXpV UD VHP */8&(0,$(1$<81$6 VHP YLYH VROD QR QDFLGRVYLYRV YDJLQDOHV QR VL FRQVXOWD ,J0 QRVH QRUPDO DQRUPDO KL]R VHP HPE HFWySLFR VHP ,J* QF RWUD DERUWRV /XJDUGHO SDUWRDERUWR RWUR PHQRVGHDxR D 3$/8',602 %$&7(5,85,$ 0$/$5,$ PHV J DxRVHQHO PD\RUQLYHO HVSRQW FRQVHFXWLYRV (* &21),$%/( SRU )80 (FRV HUWULP QR WULP VL HUWULP VL ȖJOREXOLQDDQWL' GtD QRUPDO VHFXQG XQLYHUV VL QHJUD VROWHUD VHPDQDV VHPDQDV 3$3 &2/3 QR VH KL]R J ,QPXQL] 72;23/$6026,6 QR VHP ,J* QR VH KL]R QF $QWHFHGHQWH GHJHPHODUHV )80 3(62 $17(5,25 JHVWDVSUHYLDV 8/7,0235(9,2 RWUDFRQG PpGLFDJUDYH )33 QRLQGLFDQHFHVDULDPHQWHULHVJRQLSUiFWLFDVLQDGHFXDGDV QR VL YLROHQFLD * ( 6 7$ & , 2 1$ & 7 8 $ / &(59,; ,, FLUXJtD JHQLWRXULQDULD LQIHUWLOLGDG * SUHHFODPSVLD HFODPSVLD &+$*$6 PHVWL]D ('$' DxRV /XJDUGHO FRQWURO SUHQDWDO FDVDGD XQLyQ HVWDEOH VHPDQDV VHPDQDV (VWHFRORUVLJQLILFD$/(57$ 3(5621$/(6 QR VL 7%& , GLDEHWHV KLSHUWHQVLyQ &2168/7$6$17(1$7$/(6 EODQFD %(7$ QR QLQJXQR SULPDULD GH !GH )$0,/,$5(6 QR VL (678',26 $/)$ (71,$ DxR LQGtJHQD /2&$/,'$' ,QVS YLVXDO PHV GtD $3(//,'2 (67$'2&,9,/ &$51e3(5,1$7$/&/$3605236206 120%5( PHV DxR 3(62$/(*5(62 J OXJDU 0(72'2(/(*,'2 OLJDGXUD ',8SRVW WXEDULD HYHQWR QDWXUDO ',8 EDUUHUD RWUR KRUPRQDO QLQJXQR 5HVSRQVDEOH 3DWURQHV GH DOWXUD XWHULQD H LQFUHPHQWR GH SHVR PDWHUQR VHJ~Q HGDG JHVWDFLRQDO 8QD YH] FRQRFLGD OD HGDG JHVWDFLRQDO VH OD XELFD HQ OD JUiILFD \ VH FRPSDUDQ ORV YDORUHV REWHQLGRV FRQ ORV FHQWLOHV 3 3 \ 3 JUDILFDGRV )LJXUD&DUQp3HULQDWDO5HJLRQDO5HYHUVR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 6,),/,6 3DUHMD &21',&,21 $/,1*5(62 VG 75$7$0,(172 FyGLJR ',$*126 7,&2 ',$*1267,&235(6817,92 PROD 'LDPHWUR ORQJLWXGLQDO 3UHVXQWLYR PP OHVLyQ OHVLyQ FRQWUDFRQVHMR PpGLFR 772 /XJDU 7UDVODGR $XWRSVLD 1R SUHI DFFHG SUHI DFFHG SUHI DFFHG Ȗ JOREXOLQD SVLFRORJtD YLROHQFLD DGROHV FHQFLD QF DQWLFRQ FHSFLyQ LQIHUWLOLGDG IDOOHFHGXUDQWHR 1R HQOXJDUGHWUDVODGR RWURHVWDEO 6L RWUR 9,+,76 )LJXUD)RUPXODULRFRPSOHPHQWDULRSDUDPXMHUHVHQVLWXDFLyQGHDERUWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6L &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR +263,7$/,=$&,211(21$7$/&/$3605236206 VL QR ,167,78&,21 '(1$&,0,(172 6,3 7LHQHSXOVHUDGH,' QR 51QRPEUH HVWHFRORUVLJQLILFD$/(57$ 1+,6725,$ 5(&,(11$&,'2 VL 1+,6725,$ &/,1,&$0$'5( 0$'5(QRPEUH VHHQFXHQWUDHQ PLVPRKRVSLWDO RWURKRVSLWDO GRPLFLOLR &RQGLFLyQGHVDOXG IDOOHFLGD QRUPDO &RQRFLyDVXKLMR QR FUtWLFD 3$'5(QRPEUH &RPXQLFDFLyQ FRQODIDPLOLD 'LUHFFLyQ (PDLO PLVPRKRVSLWDO VDODGHSDUWR 75$163257( ',67$1&,$ 7,32 DpUHR WHUUHVWUH RWURKRVSLWDO '85$&,21 +RUDV 0LQ 027,92 UHLQJUHVR QR .P &203/,&$&,21(6 GXUDQWHHOWUDQVSRUWH QR VL QR VL QR LQFXEDGRUD PRQLWRUHR &3$3 YHQRFOLVLV R[tJHQR LQWXEDGR 0HV $xR ('$' 'tDV +RUDV 0LQ +RUD 9$/25$&,21 WHPSD[LODU &LDQRVLV QR & (*FRUUHJLGD 6HP QR VL '52*$6 92/,9 P/ 6D2 GLDV )L2 VL 6'5 QR 3DOLGH] QR VL VL 9LJLOLD QRUPDO FRPD 'LXUHVLV QR VL 0(',&2 3(62 /21*,78' &RQYXOVLRQHV QR VL J 3(5&5$1($12 FP 127$6$/,1*5(62 ,1)250(,1,&,$/$/$)$0,/,$ 5HVSRQVDEOHGHOLQJUHVR 7,32 (1)(50(5$ HUD 'tD VL VL ,1*5(62 $ 1(2 (1 )+1(6$93 VL 7HOpIRQRV GLUHFWD WHOHIyQLFD QRVHORJUy )LUPD )LJXUD+LVWRULDGH+RVSLWDOL]DFLyQ1HRQDWDO$QYHUVR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD FP 6DOXG6H[XDO\5HSURGXFWLYD 3$72/2*,$6 QR DVIL[LD DO QDFHU PHPEUDQD KLDOLQD 6'5 DVRF PHFRQLR KLSHUW SXOPRQDU GXFWXV DUW WUDWDGR HVWHFRORUVLJQLILFD$/(57$ VL 6(36,6 QR VL QR VL QHXPRWyUD[ QR VL GLVSO EURQ SXOP (&1 FRQILUPDGD SHUI LQWHVW IRFDO VtILOLV 5(7,123$7,$ QRVH DLVOy QR JHUPHQ RIWDOPRVFRStD DJHQWH WUDWDGDGHVGH GtD PHV DxR GtD PHV DxR GtD PHV DxR GtD PHV DxR HGDG JHVWDF HU H[ JUDGR Pi[ 75$7$0,(1726 OHXFRPDODFLD KHPRUUDJLD FUDQHDQD JUDGR Pi[ GtDV 5HTXLHUH FLUXJtD QR VL DVItFWLFR FFRQYXOVLRQHV 'HIHFWRFRQJpQLWRPD\RU D ('$' GRVLV KRUDV QR VL PLQXWRV &8,'$'265(63,5$725,26 QR VL '85$&,21 &3$3SUHYHQWLO GtDV VXUIDFWDQWH &,58*,$ GXFWXV KRUDV (&1 &3$3 LQGRLEXSWUDW DPLQRIFDIHt GtDV R[tJHQR DOLPHQWDFLyQ SDUHQWHUDO GtDV WUDQVIXVLRQHV (*5(62 YLYR WUDVODGR IDOOHFH OXJDU QHFUR QR VL DxR VL VHP $/,0(172 $/(*5(62 ODFWDQFLD H[FOXVLYD GtDV SDUFLDO DUWLILFLDO QR VL 7$0,=$-(6,1081,=$&,21(6 6,),/,6 QHJ 76+ )$/&,)250( QRUPDO QRUPDO WUDWDGR HOHYDGR GpILFLW DQRUPDO QR WUDWDGR VG VG VG %&* +HS%YDF ,1',&$&,21(6 5(63216$%/( $/(*5(62 /DFWDQFLD H[FOXVLYD VL VL 'RUPLU ERFD DUULED VG VG 3UHYHQFLyQ FRQWDJLR UHVSLYLUXV 7(/()212 /XJDU 2IWDOPROyJLFR QR VL $XGLROyJLFR QR VL $SR\R3VLFRVRFLDO QR VL QR VL QR QR VG 3HGLiWULFR +2*$5$/(*5(62 0$'5( -8172$51 FRQPDGUHSDGUH ',$35(9,2 RWURVIDPLOLDUHV GtD\QRFKH DGRSFLyQ VyORGtD DPSDURLQVWLWXF VyORYLVLWy QF QRYLVLWy 35202&,21'(6$/8'7HPDVDERUGDGRV $8',&,21 QRUPDO 6(*8,0,(172 &225',1$'2 )RWRFRSLDU JUiILFR GH SHVRHGDG ('$'*(67 $/(*5(62 2;,*(12 (1+2*$5 GtDV /21*,78'FP 3(5 &5$1($12 FP 3(62 J RWUD PO9ROWRWDO ('$'$/ (*5(62 208(57( GtD SHVRDODV VHP $1752320(75,$$/(*5(62 KLGURFHI GtDV !G HGDG UHFXSHUD SHVR J 523 GtDV IDOOHFH GXUDQWHR HQOXJDU GHWUDVODGR QR &5(&,0,(172 ,1,&,$/ SHVRPtQLPR QR VL YHQWLODGR(7 LQGRPHWSURILO )+1(6593 VHP +,9 SHULQDWDO DSQHDV PHV QR VL HFRJUDItD LQGLUHFWD 2WUDVFyGLJR\QRPEUH GtD (1&()$/2 VL QF QR VL 8VR DOFRKROJHO 'HUHFKRV SURWHF VRFLDO (QWUHJR PDWHULDO LPSUHVR (0$,/ 7HOpIRQR )HFKD GtD PHV DxR GtD PHV DxR GtD PHV DxR 3RUFXiQWDVVHPDQDV ODPDGUHQRUHDOL]DUi WDUHDVIXHUDGHOKRJDU" )LJXUD+LVWRULDGH+RVSLWDOL]DFLyQ1HRQDWDO5HYHUVR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD VHPDQDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD (VWHFRORUVLJQLILFD$/(57$ )(1(6$93 3(5','$6 $3257(25$/ $3257(3$5(17(5$/ )LJXUD3ODQLOODGLDULDGH(QIHUPHUtD1HRQDWDO$QYHUVR 9,$ 9,$ &(175$/ 3(5,)(5,&$ )250$'( $'0,1,675$&,21 7,32< 92/80(1 35(6,21 $57(5,$/ $31($6 ,1&8%$'25$ 7,(032GH 5(&2/25$&,21 5(6,'8$/ *$675,&2 <920,726 '(326,&,21(6 0,&&,21(6 6$1*5( (;75$,'$ &2/25 )5(&8(1&,$ &$5',$&$ )5(&8(1&,$ 5(63,5$725,$ 3$3$ 0$0$ VL QR HQ FDVD 326,&,21 (67$'2'(&21&,(1&,$ 7(03(5$785$ $;,/$5 +V35(9,$6 &21752/(69,7$/(6 3527(&&,217(50,&$ +80('$' 9,(1(1<0(75$(1/(&+( ¢48,(10(&8,'2" +25$'(&8,'$'26352*5$0$'26 RWUR KRVSLWDO QR VL PO RWUD FDVD VL QR QR VL PO QR VL PO QR VL VL QR QR VL PO VL QR QR VL PO 021, 725(6 )&DUG )5HVS FXLGD\ VRVWLHQH GDGH OLPSLD HQEUD]RV FRPHU )RWRWHUDSLD VL QR PLPD\ 0$0$0( DFRPSDxD $SQHD HVWH 0$0$ (67$(1 KRVSLWDO $SQHD LQFXEDGRUD $SQHD VHUYRFXQD $SQHD FXQD VL QR QR VL PO VL QR 7HPS JHUPHQ DPD PDQWD 6D2 $SQHD 1,9(/'( &8,'$'2 PtQLPR LQWHUPHGLR LQWHQVLYR $SQHD &21',&,21$&78$/ $SQHD QR VL PO 6(36,6(1&8562 QR VL VL QR PO QR VL 3(5&() FP 0(6 ',$69,'$ ',$ $SQHD VyORFOtQLFD EDFWHULDQD KRQJRV VHP VL QR QR VL PO 3(62DFWXDO VL QR J G ',$6+263 (*&255(*,'$ $f2 $SQHD 0, 120%5( QR VL PO J 727$/'( /(&+( 0$7(51$ QR VL PO $3257( &$/25,&2 %$/$1&( +,'5,&2 VL QR 9$5,$&,21 3(62 +25$6 35(9,$6 $SQHD 3DSi $SQHD 0,6 5(*,67526 ',$5,26 &/$3605 236206 VL QR $SQHD 0DPi QR VL PO PO PO &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR FDO.JG )LJXUD3ODQLOODGLDULDGH(QIHUPHUtD1HRQDWDO5HYHUVR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD HVWHFRORUVLJQLILFD$/(57$ )(1(6593 6D2 62/,&,7$'26 36,&2/2*,$ 127$6$',&,21$/(6<&8,'$'26 75$7$0,(1720(',&2XVDUOHWUDGHPROGHSHTXHxD\FODUD $6,67(17(62&,$/ &21&855(1 $32<236,&262&,$/ VL QR )5 7LHPSR,QVS 'UHQDMH7yUD[ 6HFUHFLRQHV &DQWLGDG7LSR $127$55(68/7$'26 )L2 3,0 33& 309$ 6(71DVDO&DUSD 92/80(1 PO '26,6\9,$ $127$5)$50$&26 6(5(48,(5( (;$0(1(63$5$&/,1,&26 &8,'$'26 5(63,5$725,26 0(',&$&,21 &803/,'$ +25$'(&8,'$'26352*5$0$'26 6DOXG6H[XDO\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 352&(6$0,(172'(/26'$726'(/$+&3 (O&/$3605KDGHVDUUROODGRXQSURJUDPDSDUDFRPSXWDGRUHVSHUVRQDOHVTXHSHUPLWH GHVFHQWUDOL]DU HO SURFHVDPLHQWR UHDOL]iQGROR HQ HO PLVPR OXJDU GRQGH VH SUHVWD OD DWHQFLyQ'HHVWDPDQHUDHOSHUVRQDOGHVDOXGFXHQWDFRQLQIRUPDFLyQHQWLHPSRUHDO HQHOPRPHQWRTXHVHODUHTXLHUHSDUDIDFLOLWDUODHYDOXDFLyQGHODDVLVWHQFLD\ODWRPD GHGHFLVLRQHV (VWH SURJUDPD UHFLHQWHPHQWH KD VLGR DFWXDOL]DGR RSHUDQGR HQ DPELHQWH ZLQGRZV FRQ OOHQDGR IDFVLPLODU HQ SDQWDOOD (VWRV LPSRUWDQWHV FDPELRV WHFQROyJLFRV PHMRUDQ VX SRWHQFLD \ SURGXFWLYLGDG FRQVHUYDQGR DO PLVPR WLHPSR WRGD OD LQIRUPDFLyQ JHQHUDGD SRU YHUVLRQHV SUHYLDV (O SURFHVDPLHQWR GH ORV GDWRV WLHQH FRPR UHVXOWDGR XQD VHULH GH GRFXPHQWRV TXH FRQVWLWX\HQ XQ UHVXPHQ GH OD DFWLYLGDG GH OD LQVWLWXFLyQ HQ XQ SHUtRGR GDGR HVWDGtVWLFD EiVLFD R VRQ HOHPHQWRV GH LQYHVWLJDFLyQPiVHVSHFt¿FDSRUHMHPSORULHVJRUHODWLYRGHVFULSFLyQGHYDULDEOHVHWF 8QDVHULHGHLQGLFDGRUHVSUHYLDPHQWHGH¿QLGRV\GHIiFLOREWHQFLyQEULQGDQLQIRUPDFLyQ UHOHYDQWHDOFOtQLFRDOJHVWRUDOHSLGHPLyORJRRDOKDFHGRUGHSROtWLFDVHQVDOXG (O DUFKLYR GH KLVWRULDV TXHGD D GLVSRVLFLyQ GH OD UHG LQIRUPiWLFD GH OD PDWHUQLGDG VDOYDJXDUGDQGRODFRQ¿GHQFLDOLGDGGHORVGDWRVGHODVXVXDULDVHQODVKLVWRULDVFOtQLFDV LQIRUPDWL]DGDV(OFHQWURGHDVLVWHQFLDHPLWHVXVLQIRUPHVSHULyGLFRVKDFLHQGRXVRGH ORVSURJUDPDVGHFyPSXWRV /RV FHQWURV GH FyPSXWRV FHQWUDOHV R UHJLRQDOHV UHTXLHUHQ OD LQIRUPDFLyQ GH ODV JHVWDQWHV \ UHFLpQ QDFLGRV DWHQGLGRV HQ HO QLYHO ORFDO 3RU HOOR HO FHQWUR DVLVWHQFLDO HQWUHJDUiGXSOLFDGRVGHODEDVHGHGDWRVTXHFRQWLHQHVXVKLVWRULDV\DLQJUHVDGDV\ FRUUHJLGDV/RVFHQWURVGHFyPSXWRVUHJLRQDOHV\ORFDOHVWDPELpQRSHUDQFRQHO6,3OR TXHSHUPLWHFRQVROLGDUWRGDODLQIRUPDFLyQ $XQTXHQRHVORLGHDOH[LVWHWDPELpQODSRVLELOLGDGGHSURFHVDUORVGDWRVGHOD+&3 IXHUDGHOOXJDUGRQGHVHUHDOL]DODDVLVWHQFLDSHULQDWDOHQFDVRTXHHVWRIXHVHQHFHVDULR EDVWDUiUHPLWLUGXSOLFDGRVGHODVKLVWRULDVDXQQLYHOORFDOGHPD\RUFRPSOHMLGDGFDSD] GHSURFHVDUORVGDWRV(VWDVLWXDFLyQSXHGHGDUVHHQDTXHOORVFDVRVHQTXHQRVHD SRVLEOHFRQWDUFRQXQFRPSXWDGRURTXHHOYROXPHQGHFDVRVPHQVXDOHVQRMXVWL¿TXH VXDGTXLVLFLyQ /DV FDUDFWHUtVWLFDV VDOLHQWHV GHO VLVWHPD GHVDUUROODGR SXHGHQ UHVXPLUVH HQ ORV VLJXLHQWHVSXQWRV (O SURFHVDPLHQWR ORFDO GH ORV GDWRV FRQ HO 6,3 IRUWDOHFH OD FDSDFLGDG GH DXWR HYDOXDFLyQ DVLVWHQFLDO SHULQDWDO PHGLDQWH HO DQiOLVLV GH GDWRV HQ OD SURSLD LQVWLWXFLyQDVLVWHQFLDO +DFH WRPDU FRQFLHQFLD DO SHUVRQDO GH OD LPSRUWDQFLD GH XQD GRFXPHQWDFLyQ FRPSOHWDGHODVDFFLRQHV\REVHUYDFLRQHVGHVDOXG 3URSRUFLRQDDORVHQWHVDVLVWHQFLDOHVSHULQDWDOHVXQDKHUUDPLHQWDiJLO\GHIiFLO PDQHMRSDUDODVLQYHVWLJDFLRQHVRSHUDFLRQDOHV 3DUDPD\RULQIRUPDFLyQVREUHHO6LVWHPD,QIRUPiWLFR3HULQDWDO6,3\VXSURFHVDPLHQWR YHUSXEOLFDFLRQHVFLHQWt¿FDV&/$3605\ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2EMHWLYRV&RQWDUFRQXQDKRMDGHUXWDTXHJXtHDOSUHVWDGRUSDUDEULQGDUXQD DWHQFLyQSUHQDWDOGHFDOLGDG $FWLYLGDG8VRGHOD+LVWRULD&OtQLFD3HULQDWDOGHO&/$3605 (O&HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD&/$3 605HQSXEOLFyOD+LVWRULD&OtQLFD3HULQDWDO+&3FRQODLQWHQFLyQGHWHQHUXQ UHJLVWURXQLIRUPL]DGR\GHFDOLGDGGHODDWHQFLyQGHODVPXMHUHVHPEDUD]DGDV\GHORV UHFLpQQDFLGRVHQOD5HJLyQ (VWHLQVWUXPHQWRIXHGLVHxDGRSDUDFRQWULEXLUHQODWRPDGHGHFLVLRQHVUHODFLRQDGDV FRQHOPDQHMRFOtQLFRLQGLYLGXDOGHODPXMHUHPEDUD]DGDGXUDQWHHOFRQWUROSUHQDWDO SDUWR\SXHUSHULR\GHOQHRQDWRGHVGHHOQDFLPLHQWRKDVWDHOPRPHQWRGHODOWD9HU 3XEOLFDFLRQHV&LHQWt¿FD&/$3605\ /D+&3DGHPiVGHLQWHQWDUIDFLOLWDUODWDUHDGHORVFOtQLFRVHQHOWHUUHQR\GHHVWDQGDUL]DU HO UHJLVWUR GH GDWRV EXVFD IDFLOLWDU OD VXSHUYLVLyQ \ HYDOXDFLyQ GHO FXPSOLPLHQWR GH QRUPDVFOtQLFDV\SURPRYHUXQPDQHMRFOtQLFRLQGLYLGXDOL]DGR\HIHFWLYR 6LELHQORVGDWRVFRQWHQLGRVHQOD+&3SXHGHQVHUSRVWHULRUPHQWHLQJUHVDGRVDXQD EDVHGHGDWRVODSULRULGDGGHOFOtQLFRHVFRQWDUFRQXQDEXHQDKLVWRULDFOtQLFD\SRU pVWDUD]yQHO&/$3605SULRUL]DHOOOHQDGRFRPSOHWRGHOD+&3 'HVGHVXFUHDFLyQOD+&3KDVLGRPRGL¿FDGDHQYDULDVRFDVLRQHV(VWDVPRGL¿FDFLRQHV REHGHFHQDODQHFHVLGDGGHPDQWHQHUDFWXDOL]DGRVXFRQWHQLGRFRQODPHMRUHYLGHQFLD FLHQWt¿FDGLVSRQLEOHDVtFRPRLQFOXLUODVSULRULGDGHV±QDFLRQDOHVHLQWHUQDFLRQDOHV GH¿QLGDVSRUORV0LQLVWHULRVGH6DOXGGHOD5HJLyQ6XIRUPDWR\GLVHxRVLQHPEDUJR KDVXIULGRSRFDVPRGL¿FDFLRQHVHKLVWyULFDPHQWHVHKDLQWHQWDGRPDQWHQHUODPLVPD GLDJUDPDFLyQ$FWXDOPHQWHHOGLVHxRGHOD+&3FRQWHPSODODVVLJXLHQWHVVHFFLRQHV LGHQWL¿FDFLyQ DQWHFHGHQWHVIDPLOLDUHVSHUVRQDOHV\REVWpWULFRV JHVWDFLyQDFWXDO SDUWRRDERUWR HQIHUPHGDGHVGXUDQWHHOHPEDUD]R SXHUSHULR HJUHVRPDWHUQR UHFLpQQDFLGR HQIHUPHGDGHVGHOUHFLpQQDFLGR HJUHVRGHOUHFLpQQDFLGR DQWLFRQFHSFLyQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 2EMHWLYRV'HWHFWDUULHVJRVHQODSREODFLyQ $FWLYLGDG(YDOXDFLyQGHOULHVJRSHULQDWDO 3DUDLPSOHPHQWDUODVDFWLYLGDGHVGHQRUPDWL]DFLyQGHOFRQWUROSUHQDWDOGLULJLGRDODV PXMHUHV FRQ HPEDUD]RV GH EDMR ULHVJR HV QHFHVDULR XQ LQVWUXPHQWR TXH SHUPLWD LGHQWL¿FDUODV(VWHREMHWLYRVHORJUDDOFRQVWDWDUODSUHVHQFLDRODDXVHQFLDGHIDFWRUHV GHULHVJR /D HYDOXDFLyQ GHO ULHVJR QR HV XQD WDUHD VHQFLOOD (O FRQFHSWR GH ULHVJR HV IXQGDPHQWDOPHQWHSUREDELOtVWLFR\ODFDGHQDTXHDVRFLDXQIDFWRUGHULHVJRFRQGDxR QR VLHPSUH HVWi GH¿QLGD 3RU HMHPSOR HQ RFDVLRQHV HO GDxR ³PXHUWH IHWDO´ GHULYD FODUDPHQWHGHXQIDFWRUSHURHQRWUDVODUHODFLyQHVPXFKRPiVGLItFLOGHHVWDEOHFHU SRUGHVFRQRFLPLHQWRGHOIDFWRURIDFWRUHVLQWHUYLQLHQWHVRSRUODGL¿FXOWDGHQHVWDEOHFHU HOSHVRLQGLYLGXDOGHFDGDXQRGHHOORVFXDQGRHOSUREOHPDHVPXOWLIDFWRULDO /RV SULPHURV VLVWHPDV GH HYDOXDFLyQ GH ULHVJR IXHURQ HODERUDGRV HQ EDVH D OD REVHUYDFLyQ\ODH[SHULHQFLDGHVXVDXWRUHV\VRORUHFLHQWHPHQWHKDQVLGRVRPHWLGRVD HYDOXDFLRQHVSHUVLVWLHQGRD~QGXGDVVREUHVXFDOLGDGFRPRGLVFULPLQDGRUHV /RV VLVWHPDV EDVDGRV HQ SXQWDMH DGROHFHQ D~Q GH H[DFWLWXG HQ HO YDORU DVLJQDGR D FDGDIDFWRU\DODVDVRFLDFLRQHVGHHOORV+D\JUDQGHVYDULDFLRQHVGHDFXHUGRDVX DSOLFDFLyQVHJ~QVHWUDWHGHLQGLYLGXRVRSREODFLRQHV3DUDTXHIXHVHQPiVDGHFXDGRV GHEHUtDQHODERUDUVHHQFDGDOXJDUOXHJRGHFRQRFHUHOUHDOSHVRTXHWLHQHQORFDOPHQWH ORVIDFWRUHV (OHPSOHRGHPpWRGRVFRPRHOGHODDSOLFDFLyQGHOOLVWDGRTXHFRPRHMHPSORVHPXHVWUD D FRQWLQXDFLyQ SHUPLWH VHSDUDU D ODV HPEDUD]DGDV HQ GRV JUXSRV +D\ DOJXQDV FDUDFWHUtVWLFDVFX\DSUHVHQFLDHQODHPEDUD]DGDODFDOL¿FDQFRPRGHDOWRULHVJR\OD H[FOX\HQGHOFRQWUROSUHQDWDOGHEDMRULHVJR (QWUH ORV IDFWRUHV TXH DXPHQWDQ HO ULHVJR SHULQDWDO VH FLWDQ ~QLFDPHQWH DTXHOORV FX\RFRQWUROUHTXLHUHDFWLYLGDGHVQRFRQWHPSODGDVHQHVWDSURSXHVWD\TXHQHFHVLWDQ DFFLRQHVGHPD\RUFRPSOHMLGDGQRUPDVGHDOWRULHVJR &8$'52)DFWRUHVGHULHVJRSHULQDWDO &DUGLRSDWtD +LSHUWHQVLyQ 'LDEHWHV 7XEHUFXORVLV +HPRJORELQDPHQRUGHJO $QWHFHGHQWHVGHPXHUWHSHULQDWDO $OORLQPXQL]DFLyQVHQVLELOL]DFLyQ5K 0DFURVRPtDIHWDO (PEDUD]RP~OWLSOH 5HVWULFFLyQGHOFUHFLPLHQWRLQWUDXWHULQR 3ROLKLGUDPQLRV 2OLJRDPQLRV +HPRUUDJLDJHQLWDO $PHQD]DGHSDUWRGHSUHWpUPLQR 5RWXUDSUHPDWXUDGHODVPHPEUDQDVRYXODUHV 7DOODPDWHUQDFP 3HVRPDWHUQRSUHJUDYtGLFR.J (VFDVRRH[DJHUDGRLQFUHPHQWRGHSHVRPDWHUQR $QWHFHGHQWHVJHQpWLFRVGHVIDYRUDEOHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2EMHWLYRV $FWLYLGDG &RQRFHULQIRUPDFLyQUHOHYDQWHGHOHPEDUD]R $QDPQHVLV &RQHOLQWHUURJDWRULRFRPLHQ]DHOH[DPHQFOtQLFRGHWRGDJHVWDQWH3RUODVFRQVHFXHQFLDV DGPLQLVWUDWLYDV\OHJDOHV\SRUODDVRFLDFLyQTXHDOJXQRVIDFWRUHVWLHQHQFRQHOULHVJR SHULQDWDOXQDFRUUHFWDDQDPQHVLVGHEHLQFOXLU 'DWRVGHOHPEDUD]RDFWXDO $QWHFHGHQWHVIDPLOLDUHV $QWHFHGHQWHVSHUVRQDOHV +,6725,$&/,1,&$3(5,1$7$/&/$3605236206 120%5( )(&+$'(1$&,0,(172 GtD $3(//,'2 PHV DxR '20,&,/,2 7(/() GH !GH $/)$ (678',26 EODQFD %(7$ QLQJXQR SULPDULD LQGtJHQD QR PHVWL]D ('$' DxRV /2&$/,'$' (71,$ QHJUD VL RWUD VHFXQG XQLYHUV DxRVHQHO PD\RUQLYHO (67$'2&,9,/ ,GHQWL¿FDFLyQGHODJHVWDQWH (VWDGRVRFLRHGXFDFLRQDO $QWHFHGHQWHVREVWpWULFRV FDVDGD XQLyQHVWDEOH VROWHUD RWUR YLYH VROD QR VL /XJDUGHO FRQWURO SUHQDWDO /XJDUGHO SDUWRDERUWR 1 ,GHQ WLGDG )LJXUD+&36HFFLyQLGHQWL¿FDFLyQ\HVWDGRVRFLRHGXFDFLRQDO ,GHQWL¿FDFLyQ GHODJHVWDQWH 1RPEUHV\$SHOOLGRV 'RPLFLOLR /RFDOLGDG 7HOpIRQR )HFKDGHQDFLPLHQWR\HGDG /XJDUGHOFRQWUROSUHQDWDO /XJDUGHOSDUWRDERUWR 1GHGRFXPHQWRGHLGHQWLGDG +D\DFXHUGRHQFRQVLGHUDUDODVJHVWDQWHVGHDDxRVFRPRHOJUXSRHWDULRGH PHQRUULHVJRSHULQDWDO/DPRUWDOLGDGIHWDOQHRQDWDO\ORVGHIHFWRVFRQJpQLWRVVXHOHQVHU PiVIUHFXHQWHVHQODDGROHVFHQFLDWHPSUDQDPHQRUHVGHDxRVFRPRDSDUWLUGHORV DxRVGHHGDG (VWDGRVRFLR HGXFDFLRQDO (WQLD 1LYHOHGXFDFLRQDO (VWDGRFLYLO /D IXHUWH DVRFLDFLyQ H[LVWHQWH HQWUH PDORV UHVXOWDGRV SHULQDWDOHV \ EDMR QLYHO VRFLR HGXFDFLRQDOREOLJDDFRQVLGHUDUHVWDVYDULDEOHVWRGDYH]TXHVHHYDO~DXQDJHVWDQWH (OGHWHULRURVRFLRHGXFDFLRQDOVHDVRFLDDXQPHQRUQ~PHURGHFRQVXOWDVSUHQDWDOHV DIDPLOLDVPiVQXPHURVDVDKDFLQDPLHQWRDPD\RUSRUFHQWDMHGHHPEDUD]DGDVTXH UHDOL]DQ WUDEDMR ItVLFR DO PDQWHQLPLHQWR GH OD DFWLYLGDG ODERUDO KDVWD HWDSDV PiV DYDQ]DGDVGHOHPEDUD]RDPHQRUQLYHOGHLQVWUXFFLyQ\DXQDPD\RUIUHFXHQFLDGH JHVWDFLRQHVHQXQLRQHVLQHVWDEOHV/RVDVSHFWRVHQXQFLDGRVSUHYLDPHQWHVHYLQFXODQ VHJ~QVHSHUWHQH]FDRQRDGHWHUPLQDGRVJUXSRVpWQLFRV /RVSXHEORVLQGtJHQDV\ODVSREODFLRQHVDIURGHVFHQGLHQWHVFRQVWLWX\HQPiVGHO GHODSREODFLyQGHOD5HJLyQ $17(&('(17(6 +D\HWQLDVTXHSUHVHQWDQULHVJRVSHULQDWDOHVHVSHFt¿FRVLQGHSHQGLHQWHPHQWHGHVX FRQGLFLyQ VRFLRHFRQyPLFRFXOWXUDO VH SXHGH FLWDU D PDQHUD GH HMHPSOR OD DQHPLD IDOFLIRUPHHQODVSREODFLRQHVDIURGHVFHQFLHQWHV$GHPiVGHVXLPSRUWDQFLDGHPRJUi¿FD \SRUFRQGLFLRQHVFOtQLFDVSDUWLFXODUHVHVWRVJUXSRVSREODFLRQDOHVYLYHQHQFRQGLFLRQHV PiVGHVIDYRUDEOHVTXHRWURVJUXSRVSREODFLRQDOHV+DFHUYLVLEOHVHVWDVGLIHUHQFLDVD WUDYpVGHLQGLFDGRUHVGHVDOXGGHVDJUHJDGRVSRUHWQLDHVXQDHVWUDWHJLDSDUDPHMRUDU VXVLWXDFLyQ )$0,/,$5(6 QR VL 3(5621$/(6 QR VL 7%& GLDEHWHV KLSHUWHQVLyQ SUHHFODPSVLD HFODPSVLD RWUDFRQG PpGLFDJUDYH , ,, FLUXJtD JHQLWRXULQDULD LQIHUWLOLGDG * FDUGLRSDW QHIURSDWtD YLROHQFLD QR VL 2%67(75,&26 JHVWDVSUHYLDV J QRUPDO ñ J $QWHFHGHQWH GHJHPHODUHV YDJLQDOHV QDFLGRVYLYRV ),1(0%$5$=2$17(5,25 YLYHQ GtD PHV DxR PHQRVGHDxR 8/7,0235(9,2 QF DERUWRV HVSRQW FRQVHFXWLYRV HPE HFWySLFR SDUWRV FHViUHDV QDFLGRV PXHUWRV QR VL PXHUWRV UD VHP GHVSXpV UD VHP (0%$5$=23/$1($'2 QR VL )5$&$620(72'2$17,&21&(3 QR EDUUHUD ',8 KRUPR HPHU QDWXUDO XVDED QDO JHQFLD )LJ+&36HFFLyQDQWHFHGHQWHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $QWHFHGHQWHV IDPLOLDUHV 7XEHUFXORVLV 'LDEHWHV +LSHUWHQVLyQ 3UHHFODPSVLD (FODPSVLD 2WUDVFRQGLFLRQHVPpGLFDVJUDYHV 6HWUDWDUiLQYHVWLJDUHQORVSDULHQWHVFHUFDQRVPDGUHSDGUHKLMRVKHUPDQRVSDUHMD GHODJHVWDQWHVLH[LVWHDOJ~QDQWHFHGHQWHTXHREOLJXHDDGRSWDUPHGLGDVHVSHFLDOHV GHGLDJQyVWLFRRGHWUDWDPLHQWR $QWHFHGHQWHV SHUVRQDOHV 7XEHUFXORVLV 'LDEHWHV +LSHUWHQVLyQ 3UHHFODPSVLD (FODPSVLD &DUGLRSDWtD 2WUDVFRQGLFPpGLFDVJUDYHV1HIURSDWtD &LUXJtDJHQLWRXULQDULD 9LROHQFLD ,QIHUWLOLGDG (Q RFDVLRQHV HV LPSUHVFLQGLEOH HYDOXDU HO JUDGR GH GDxR TXH XQD HQIHUPHGDG SUHH[LVWHQWH R OD YLROHQFLD SXGR KDEHU FDXVDGR \ FRPR HOOR SXHGH UHSHUFXWLU GHVIDYRUDEOHPHQWHVREUHHOHPEDUD]R $QWHFHGHQWHV REVWpWULFRV 1~PHURHYROXFLyQ\WHUPLQDFLyQGHODVJHVWDFLRQHVSUHYLDV 1DFLGRVYLYRV\PXHUWRV )LQDOL]DFLyQGHO~OWLPRHPEDUD]R $QWHFHGHQWHVGHPDFURVRPtDREDMRSHVRDOQDFHU $QWHFHGHQWHVGHJHPHODULGDG $VSHFWRVUHIHULGRVDODSODQL¿FDFLyQGHOHPEDUD]R /RV GDWRV UHODWLYRV D ORV HPEDUD]RV DQWHULRUHV WLHQHQ YDORU SDUD HO SURQyVWLFR GHO DFWXDOHPEDUD]R+D\XQDWHQGHQFLDDTXHHOULHVJRVHUHSLWD 6H GHEHQ MHUDUTXL]DU DTXHOORV GDWRV TXH SRU VX UHOHYDQFLD SXHGDQ LQÀXLU VREUH ORV UHVXOWDGRV GHO HPEDUD]R DFWXDO SRU HMHPSOR DERUWRV HVSRQWiQHRV FRQVHFXWLYRV TXH VH PDUFDQ HQ XQ FtUFXOR DPDULOOR REOLJDQ DO SUHVWDGRU D YDORUDU OD FRQGLFLyQ GHDERUWDGRUDKDELWXDOGHHVDPXMHU\GHVDUUROODUODVDFWLYLGDGHVTXHVHFRQVLGHUHQ DSURSLDGDVSDUDHYLWDUXQQXHYRDERUWR /DVQXOtSDUDVUHTXHULUiQXQDDWHQFLyQHVSHFLDO\DTXHDGHPiVGHQRWHQHUXQFDQDO GH SDUWR SUREDGR SUHVHQWDQ SDWRORJtDV TXH VXHOHQ VHU PiV FRPXQHV HQ HOODV SRU HMHPSORSUHHFODPSVLD /DV JUDQGHV PXOWtSDUDV UHTXHULUiQ FXLGDGRV HVSHFLDOHV HQ HO PRPHQWR GHO SDUWR GXUDQWHHODOXPEUDPLHQWR\HQHOSXHUSHULR\DTXHODVREUHGLVWHQVLyQGHOD¿EUDXWHULQD VHYLQFXODFRQPD\RUULHVJRGHDWRQtDXWHULQD\KHPRUUDJLD /D¿QDOL]DFLyQGHOHPEDUD]RDQWHULRUHVXQGDWRGHMHUDUTXtDFXDQGRLQGLTXHXQFRUWR LQWHUYDOR LQWHUJHQpVLFR /D +&3 DGYLHUWH DO SURIHVLRQDO GH VDOXG SDUD TXH FRQVXOWH HO LQWHUYDORLQWHUJHQpVLFR&XDQGRHOLQWHUYDORVHDPHQRUDDxRTXHGDUiUHJLVWUDGRHQ DPDULOORFRPRVLJQRGHDOHUWD 8Q JUXSR WpFQLFR UHXQLGR SRU OD RUJDQL]DFLyQ PXQGLDO GH ODVDOXG206KDUHFRPHQGDGRXQHVSDFLDPLHQWRGHSRU OR PHQRV PHVHV OXHJR GHO QDFLPLHQWR GH XQ KLMR YLYR R GH PHVHV HQ FDVR GH DERUWR \ XQ IXWXUR HPEDUD]R FRQODLQWHQFLyQGHUHGXFLUUHVXOWDGRVDGYHUVRVPDWHUQRV SHULQDWDOHV\QHRQDWDOHV (VLPSRUWDQWHWHQHUHQFXHQWDHVWRVFRQFHSWRVSDUDDVHVRUDU DODVPXMHUHVDFHUFDGHFXDOHVHOPRPHQWRELROyJLFRPiV DSURSLDGRSDUDXQQXHYRHPEDUD]R (QGH¿QLWLYDODVGHFLVLRQHVVRQSRWHVWDGGHODVPXMHUHV\ VXVIDPLOLDV\VRQHOODVODVTXHXQDYH]LQIRUPDGDVRSWDUiQ VREUHFXDOHVHOPRPHQWRRSRUWXQRSDUDXQQXHYRHPEDUD]R (VWDGHFLVLyQHVXQDFXHVWLyQGH'HUHFKRVHQXQFLDGDHQHO 3ODQGHDFFLyQGH(O&DLURGH )LJXUD )UDJPHQWRGHOD+&3 ,QWHUYDORLQWHUJHQpVLFR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD /RVSUHVWDGRUHVGHEHUiQWHQHUSUHVHQWHHODQWHFHGHQWH GHXQUHFLpQQDFLGRFRQSHVRPHQRUDJUDPRV\D TXHHVWRH[SRQHDODJHVWDQWHDPD\RUSUREDELOLGDGGH UHSHWLUHOQDFLPLHQWRGHRWURKLMRFRQEDMRSHVRDOQDFHUHQ HOQXHYRHPEDUD]R$TXHOODVJHVWDQWHVFRQDQWHFHGHQWHV GHPDFURVRPtDIHWDOFRUUHQPD\RUULHVJRGHSUHVHQWDUXQ QXHYRHPEDUD]RFRQXQIHWRPDFURVyPLFRHVWRGHEHUtD JHQHUDUDFWLYLGDGHVSDUDGHVFDUWDUSRVLEOHVDOWHUDFLRQHV GHOPHWDEROLVPRKLGURFDUERQDGR/DPDFURVRPtDIHWDOVH SXHGHDFRPSDxDUGHPD\RULQWHUYHQFLRQLVPRREVWpWULFR \SRUHQGHGHPD\RUPRUWDOLGDGSHULQDWDO )LJXUD )UDJPHQWR+&3 $QWHFHGHQWHVGHO~OWLPR 51\JHPHODULGDG (ODQWHFHGHQWHGHHPEDUD]RP~OWLSOHREOLJDDGHVFDUWDUHQIRUPDH[KDXVWLYDXQQXHYR HPEDUD]R P~OWLSOH /RV HPEDUD]RV P~OWLSOHV H[SRQHQ D ODV PXMHUHV \ D VXV KLMRV D VHULRVULHVJRV/DPRUWDOLGDGIHWDOHVYHFHVPD\RUTXHSDUDORVHPEDUD]RV~QLFRV (ODOWRtQGLFHGHSUHPDWXULGDG\EDMRSHVRVHDVRFLDQFRQXQDDOWDPRUWDOLGDGQHRQDWDO /D DQHPLD SUHHFODPSVLD KLSHUHPHVLV JUDYtGLFD OD DWRQtD XWHULQD \ OD KHPRUUDJLD SRVWSDUWR VXHOHQ YHUVH PiV IUHFXHQWHPHQWH HQ ORV HPEDUD]RV P~OWLSOHV TXH HQ ORV ~QLFRV (VLPSRUWDQWHGHWHUPLQDUVLHOHPEDUD]RQRHVWDEDSODQL¿FDGR\DTXHFRQIUHFXHQFLDKD\ XQDDVRFLDFLyQHQWUHHPEDUD]RVQRSODQHDGRV\HPEDUD]RVQRGHVHDGRV&XDQGRORV HPEDUD]RVQRVRQGHVHDGRVDXPHQWDODSUREDELOLGDGGHTXHDSDUH]FDQFRPSOLFDFLRQHV WDOHVFRPR PDQLREUDVDERUWLYDVHQiPELWRVGHULHVJR VLQWRPDWRORJtDItVLFDGHUHFKD]RKLSHUHPHVLV JUDYtGLFD UHSHUFXVLRQHVHPRFLRQDOHVTXHLQÀXLUiQVREUH ODJHVWDQWH\VXKLMRGHSUHVLyQPHQRUFXLGDGR SHUVRQDOFRQGXFWDVGHULHVJRPHQRUFXLGDGR GHVXKLMR )LJXUD )UDJPHQWR+&33ODQL¿FDFLyQGHO HPEDUD]R\IUDFDVRGHOPpWRGR 5HOHYDUHOXVRGHPpWRGRVFRQWUDFHSWLYRV\HOIUDFDVRGHOPpWRGRXVDGRHVSHFLDOPHQWH HQ DTXHOODV PXMHUHV TXH QR SODQL¿FDURQ HO HPEDUD]R FRQVWLWX\H XQD LQIRUPDFLyQ PX\YDOLRVDWDQWRGHVGHHOSXQWRGHYLVWDSREODFLRQDOSXHVWRTXHHVWRSHUPLWHDORV JHVWRUHV HVWDEOHFHU DQiOLVLV VREUH OD DFFHVLELOLGDG D ORV PpWRGRV FRPR GHO SXQWR GHYLVWDLQGLYLGXDO\DTXHVHSRGUiGHWHUPLQDUHQFDVRVGHIUDFDVRGHPpWRGRVODV HVWUDWHJLDVSDUDEULQGDUODFRQWUDFHSFLyQDSURSLDGDDHVDPXMHUXQDYH]TXH¿QDOLFHHO HPEDUD]RDFWXDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 2EMHWLYRV )LMDUXQFURQRJUDPDTXHSHUPLWDSODQL¿FDUODVDFWLYLGDGHVGHO FRQWUROSUHQDWDO $FWLYLGDG 'HWHUPLQDFLyQGHODHGDGJHVWDFLRQDO\GHODIHFKDSUREDEOHGHSDUWR *HVWDFLyQDFWXDO /XHJRGHKDEHUFRQ¿UPDGRHOHPEDUD]RVHGHEHUiHVWDEOHFHUODHGDGGHOPLVPR\OD IHFKDSUREDEOHGHSDUWR /RVPpWRGRVKDELWXDOPHQWHXVDGRVSDUDGHWHUPLQDUODHGDGJHVWDFLRQDOVRQ ,QWHUURJDWRULRVREUHODDPHQRUUHD (YDOXDFLyQGHOWDPDxRGHO~WHURHVSHFLDOPHQWHHQHOHUWULPHVWUH $QWURSRPHWUtDHFRJUi¿FDVRORHVWiLQGLFDGDVLSHUVLVWHQGXGDVFRQORVPpWRGRV FOtQLFRV $PHQRUUHD /D PHGLFLyQ GHO WLHPSR WUDQVFXUULGR GHVGH OD IHFKD GH ~OWLPD PHQVWUXDFLyQ )80 HVHOPpWRGRGHHOHFFLyQSDUDFDOFXODUODHGDGJHVWDFLRQDOHQODVPXMHUHVFRQFLFORV PHQVWUXDOHV UHJXODUHV \ TXH QR KDQ XVDGR HQ ORV ~OWLPRV PHVHV FRQWUDFHSWLYRV KRUPRQDOHV )LJXUD+&36HFFLyQ*HVWDFLyQ$FWXDO (VQHFHVDULRLQWHUURJDUSRU~QLFDYH]HQIRUPDSUHFLVD\WUDQTXLODDFHUFDGHOSULPHU GtD\HOPHVGHOD~OWLPDPHQVWUXDFLyQ6LHVWRVGDWRVVRQFRQ¿DEOHVDSDUWLUGHHOORV VHFDOFXODUiODHGDGGHOHPEDUD]R\ODIHFKDSUREDEOHGHSDUWR /DVVHPDQDVGHJHVWDFLyQVHSXHGHQHVWLPDUXVDQGRHO*HVWRJUDPDGHO&/$3605 )LJ+DFLHQGRFRLQFLGLUODÀHFKDURMDTXHGLFH³)HFKDHQTXHFRPHQ]yOD~OWLPD PHQVWUXDFLyQ´FRQHOGtDGHOD)80\EXVFDQGRODIHFKDFRUUHVSRQGLHQWHDOGtDGHOD FRQVXOWDVHREWHQGUiQODVVHPDQDVGHDPHQRUUHD(QVXGHIHFWRVXPDQGRORVGtDV WUDQVFXUULGRVGHVGHOD)80KDVWDODIHFKDGHODFRQVXOWD\GLYLGLpQGRORVHQWUHWDPELpQ VHREWHQGUiQODVVHPDQDVGHDPHQRUUHD /D IHFKD SUREDEOH GH SDUWR )33 WDPELpQ VH SXHGH FDOFXODU IiFLOPHQWH FRQ HO JHVWRJUDPD GHO &/$3605 +DFLHQGR FRLQFLGLU OD ÀHFKD URMD \D GHVFULSWD FRQ HO SULPHUGtDGHOD~OWLPDPHQVWUXDFLyQEDVWDUiFRQREVHUYDUODIHFKDTXHFRUUHVSRQGH DODVHPDQDSDUDREWHQHUOD)336LQRVHFXHQWDFRQJHVWRJUDPDRFDOHQGDULR REVWpWULFRODIHFKDSUREDEOHGHSDUWRVHSXHGHGHWHUPLQDUPHGLDQWHHOXVRGHXQDGH ODVVLJXLHQWHVUHJODV :DKO DOSULPHUGtDGHOD)80DJUHJDGtDV\DOPHVOHUHVWD 1DHJHOHDOSULPHUGtDGHOD)80DJUHJDGtDV\DOPHVOHUHVWD 3LQDUG DO~OWLPRGtDGHOD)80DJUHJDGtDV\DOPHVOHUHVWD GtDV SDUWLHQGRGHOSULPHUGtDGHOD)80VHFRQWDUiQGtDVVREUHXQ FDOHQGDULRODIHFKDFRUUHVSRQGLHQWHDOGtDVHUiOD)33 (YDOXDFLyQGHOWDPDxRXWHULQR /D )80 FXDQGR HV FRQ¿DEOH FRQVWLWX\H HO HVWiQGDU GH RUR SDUD FDOFXODU OD HGDG JHVWDFLRQDO 6L TXHGDUDQ GXGDV VREUH OD HGDG JHVWDFLRQDO GH¿QLGD SRU OD )80 VH &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD SRGUiQXWLOL]DUPHGLGDVPHQRVSUHFLVDVSHURTXHSHUPLWLUiQDSUR[LPDUQRVDHOOD/D UHDOL]DFLyQ GH XQ H[DPHQ XWHULQR ELPDQXDO DQWHV GH ODV VHPDQDV GH JHVWDFLyQ SURYHH XQ GDWR GH JUDQ YDORU SDUD HVWLPDU OD HGDG JHVWDFLRQDO 0iV DOOi GH ODV VHPDQDVGHJHVWDFLyQODPHGLGDGHODDOWXUDXWHULQDWLHQHSRFRYDORUSDUDFDOFXODUOD HGDGJHVWDFLRQDO'HEHWHQHUVHSUHVHQWHTXHODHYDOXDFLyQGHOWDPDxRXWHULQRDSHQDV HVXQDIRUPDLQGLUHFWDGHHVWLPDUODHGDGGHOHPEDUD]R\TXHODPLVPDSXHGHHVWDU PRGL¿FDGDSRUGLVWLQWDVVLWXDFLRQHVTXHVHGHWDOODQHQHOVLJXLHQWHFXDGUR &XDGUR (OHPHQWRVTXHPRGL¿FDQODHGDGJHVWDFLRQDOHVWLPDGDSRUHYDOXDFLyQGHOWDPDxRXWHULQR 0LRPDV 2OLJRDPQLRV (QIHUPHGDGWURIREOiVWLFD0ROD 5HVWULFFLyQGHOFUHFLPLHQWRLQWUDXWHULQR5&, (PEDUD]RP~OWLSOH 0DOIRUPDFLRQHVIHWDOHV 3ROLKLGUDPQLRV 0DFURVRPtDIHWDO $QWURSRPHWUtDIHWDOSRUHFRJUDItD (Q DOJXQDV RFDVLRQHV ORV HOHPHQWRV FOtQLFRV VRQ LQVX¿FLHQWHV SDUD FDOFXODU OD HGDG JHVWDFLRQDO HQ HVRV FDVRV VH SRGUi DSHODU D OD XOWUDVRQRJUDItD 6X DSOLFDFLyQ HVWi EDVDGDHQODUHODFLyQTXHH[LVWHHQWUHODDPHQRUUHDHOGHVDUUROORDQDWyPLFRGHOIHWR \ OD PHGLGD GH FLHUWRV VHJPHQWRV IHWDOHV &XDQWR PiV WHPSUDQDPHQWH VH UHDOLFH VH REWHQGUi PD\RU SUHFLVLyQ DGHPiV GH SRGHU UHSHWLU ODV PHGLFLRQHV FRQ FLHUWD SHULRGLFLGDGORTXHGLVPLQX\HFRQVLGHUDEOHPHQWHHOHUURUGHHVWLPDFLyQ /DV PHGLGDV DQWURSRPpWULFDV TXH VH XVDQ DFWXDOPHQWH SRU VX PHMRU FRUUHODFLyQ FRQ OD DPHQRUUHDVRQ /RQJLWXGPi[LPDFpIDORFDXGDOFRQVLVWHHQPHGLUODPD\RUGLVWDQFLDH[LVWHQWHHQWUH DPERVSRORVIHWDOHV(VHOSDUiPHWURHFRJUi¿FRPiV¿HO6HXVDHQWUHODVVHPDQDV \ (OHUURUGHODHVWLPDFLyQVHVLW~DHQGtDVFXDGUR &XDGUR(VWLPDFLyQGHODHGDGJHVWDFLRQDOVHJ~QORQJLWXGFpIDORFDXGDO /RQJLWXGFpIDORFDXGDO/&& PP $PHQRUUHD VHPDQDV D D D D D D D D D D D 9DULDELOLGDG VHPDQDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 'LiPHWURELSDULHWDOVHREWLHQHPLGLHQGRGHVGHODWDEODH[WHUQDGHOSDULHWDOSUR[LPDOD ODWDEODH[WHUQDGHOSDULHWDOGLVWDOFXDGURRGHODWDEODH[WHUQDGHOSDULHWDOSUR[LPDO D OD WDEOD LQWHUQD GHO SDULHWDO GLVWDO FXDGUR 6H SXHGH FRPHQ]DU D SDUWLU GH OD VHPDQD\KDVWDHOWpUPLQR (OHUURUGHODHVWLPDFLyQYDUtDHQUHODFLyQGHORWDUGtDRWHPSUDQDGHODIHFKDHQTXH VHKDFHODPHGLFLyQ &XDGUR(VWLPDFLyQGHODHGDGJHVWDFLRQDODSDUWLUGHODPHGLGD GHOGLiPHWURELSDULHWDO'%37DEODH[WHUQDH[WHUQD Diámetro biparietal (mm) Amenorrea (semanas) D D D D D D D D D D D D D D Intervalo de confianza 90% (semanas) Diámetro biparietal (mm) Amenorrea (semanas) Intervalo de confianza 90% (semanas) D D D D D D D D D D D D D D &XDGUR(VWLPDFLyQGHODHGDGJHVWDFLRQDODSDUWLUGHODPHGLGD GHOGLiPHWURELSDULHWDO'%3PHGLRGHERUGHH[WHUQRDERUGHLQWHUQR Diámetro biparietal (mm) Amenorrea (semanas) D D D D D D D D D D D D D D Intervalo de confianza 90% (semanas) Diámetro biparietal (mm) Amenorrea (semanas) Intervalo de confianza 90% (semanas) D D D D D D D D D D D D D D /RQJLWXG GHO IpPXU VH REWLHQH PLGLHQGR OD ORQJLWXG Pi[LPD GHO IpPXU D SDUWLU GH OD VHPDQD\KDVWDHOWpUPLQRFXDGUR(QORVIHWRVGHDVHPDQDVVHSXHGH YLVXDOL]DUHOQ~FOHRGHRVL¿FDFLyQGHOIpPXUQ~FOHRGH%pFODUGTXHDOWpUPLQRPLGHGH DPP &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD &XDGUR(VWLPDFLyQGHODHGDGJHVWDFLRQDODSDUWLUGHODPHGLGDGHODORQJLWXGGHO IpPXU Longitud fémur (mm) Amenorrea (semanas) Intervalo de confianza 90% (semanas) Longitud fémur (mm) Amenorrea (semanas) Intervalo de confianza 90% (semanas) D D D D D D D D D D D D D D D D D D D D D D D D D D D D 0DGXUH] SODFHQWDULD DXQTXH QR HV XQ LQGLFDGRU GH HGDG JHVWDFLRQDO VH KD YLVWR EXHQDFRUUHODFLyQHQWUHODPDGXUH]SODFHQWDULDSRUHFRJUDItD\ODPDGXUH]SXOPRQDU IHWDO (VWR HV HVSHFLDOPHQWH UHOHYDQWH FXDQGR VH GHVFRQRFH OD HGDG JHVWDFLRQDO \ HV QHFHVDULR WRPDU XQD FRQGXFWD UHODFLRQDGD FRQ OD LQWHUUXSFLyQ R FRQWLQXDFLyQ GHO HPEDUD]R 2EMHWLYRV $FWLYLGDG (YDOXDUHOHVWDGRQXWULFLRQDOPDWHUQR 0HGLFLyQGHOSHVR\GHODWDOODPDWHUQD &iOFXORGHOLQFUHPHQWRGHSHVRGXUDQWHODJHVWDFLyQ (O SHVR PDWHUQR SUHJUDYtGLFR LQVX¿FLHQWH OD EDMD WDOOD GH OD PDGUH \ HO HVFDVR R HO H[DJHUDGR LQFUHPHQWR GH SHVR GXUDQWH HO HPEDUD]R KDQ VLGR DVRFLDGRV FRQ PDORV UHVXOWDGRVSHULQDWDOHV &XDQGR HO SHVR SUHJUDYtGLFR HV FRQRFLGR R OD SULPHUD FRQVXOWD RFXUUH HQ HO SULPHU WULPHVWUH\HOSHVRGHWHUPLQDGRVHDVXPHFRPRSUHJUDYtGLFRVHFDOFXODHOtQGLFHGH PDVD FRUSRUDO ,0& GLYLGLHQGR HO SHVR HQ .J HQWUH OD WDOOD HQ PHWURV DO FXDGUDGR (VWRSHUPLWHHVWLPDUORVUDQJRVGHDXPHQWRDGHFXDGRGHSHVRVHJ~QHO,0&SUHYLRDO HPEDUD]R&RPRVHYHHQODWDEODODJDQDQFLDDGHFXDGDGHSHQGHUiGHOD,0&LQLFLDO &XDGUR$XPHQWRGHSHVRUHFRPHQGDGRSDUDPXMHUHVVHJ~Q,0&SUHJHVWDFLRQDO &DWHJRUtDGHSHVR ,0&NJP $XPHQWRWRWDOGHSHVR.J %DMRSHVR ± ± 3HVRQRUPDO ± ± 6REUHSHVR ± ± 2EHVLGDG RPiV /DYDULDFLyQGHOSHVRGXUDQWHODJHVWDFLyQHVPX\JUDQGH\RVFLODHQWUH\.JDO WpUPLQRGHSHQGLHQGRGHOHVWDGRQXWULFLRQDOSUHYLRDOHPEDUD]R)LJXUD(OSHUtRGR GHPi[LPRDXPHQWRGHSHVRVHSURGXFHHQWUHODVVHPDQDV\ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 7pFQLFDGHPHGLFLyQ (O SHVR VH GHEH PHGLU HQ FDGD FRQWURO SUHQDWDO FRQ OD JHVWDQWH HQ URSD OLYLDQD \ VLQ FDO]DGR &RQYLHQH XVDU EDODQ]DV GH SHVDV ODV TXH GHEHUiQ VHU FDOLEUDGDV UHJXODUPHQWH /D WDOOD GHEHUi PHGLUVH HQ HO SULPHU FRQWURO /D WpFQLFD FRQVLVWH HQ TXH OD JHVWDQWH VHXELTXHGHSLHVLQFDO]DGRFRQWDORQHVMXQWRVFRQVXHVSDOGDORPiVFHUFDQDDO WDOOyPHWURELHQHUJXLGDFRQORVKRPEURVKDFLDDWUiV\FRQODYLVWDDOIUHQWH *DQDQFLDGHSHVR 6L OD JHVWDQWH FRQRFH VX SHVR KDELWXDO SUHJUDYtGLFR VH FRQWURODUi VX LQFUHPHQWR XWLOL]DQGR FRPR SDWUyQ GH UHIHUHQFLD ORV YDORUHV GH OD ¿JXUD TXH WDPELpQ VH HQFXHQWUDQJUD¿FDGRVHQHOFDUQpSHULQDWDOGH&/$36056HUHVWDDOSHVRDFWXDOHO SUHJUDYtGLFR\GHHVWDPDQHUDVHGHWHUPLQDHOLQFUHPHQWRGHSHVR(VWHLQFUHPHQWRGH SHVRVHUHODFLRQDFRQODHGDGJHVWDFLRQDOSDUDGHWHUPLQDUHQGH¿QLWLYDHOLQFUHPHQWR GHSHVRSDUDHVDHGDGJHVWDFLRQDO'LFKRYDORUHVWUDVODGDGRDODJUi¿FDGHOFDUQp 6XVOtPLWHVPi[LPRS\PtQLPRSWDPELpQVHSXHGHQHQFRQWUDUHQODFLQWD PpWULFDHQODWDUMHWD3HVR7DOOD\HQHOJHVWRJUDPDGH&/$3605 NJ 3 3 $XPHQWRGHSHVR 3 3 $PHQRUUHDVHPDQDV )LJXUD,QFUHPHQWRGHSHVRPDWHUQRHQIXQFLyQGHODHGDGJHVWDFLRQDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD ,17(535(7$&,21'(/$0(','$$/$35,0(5$&2168/7$ NJ 3 DIAGNOSTICO Buen estado nutricional $XPHQWRGHSHVR El punto se sitúa entre las curvas de los percentilos 25 y 90 del peso de referencia para la edad gestacional 3 CONDUCTA - seguir cronograma habitual de consultas - explicar a la gestante que su peso es adecuado para la edad gestacional $PHQRUUHDVHPDQDV NJ 3 - dar orientación nutricional El punto se sitúa por debajo del percentilo 25 de la curva de referencia $XPHQWRGHSHVR 3 CONDUCTA - investigar la historia nutricional, hiperemesis gravídica, infecciones, parasitosis, anemia, enfermedades debilitantes. NJ $PHQRUUHDVHPDQDV El punto se sitúa por encima del percentilo 90 de la curva de referencia 3 DIAGNOSTICO Gestante de riesgo, por presentar peso superior al normal para esa edad gestacional; tanto mayor será el riesgo cuanto más elevado sea su sobrepeso. - citar a consulta en un intervalo menor que lo fijado en el cronograma habitual. 3 $XPHQWRGHSHVR DIAGNOSTICO Gestante de riesgo, con peso insuficiente para la edad gestacional (desnutrición) CONDUCTA - determinar causas: obesidad, edema, polihidramnios, macrosomía, embarazo múltiple - citar a consulta en un intervalo menor que lo fijado en el cronograma habitual. $PHQRUUHDVHPDQDV - el peso ganado durante toda la gestación no debe superar los 16 kg (p90) &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR ,17(535(7$&,21'(/$6(&8(1&,$'(0(','$6(1&2168/7$6 68%6(&8(17(6 NJ 3 Trazado con inclinación ascendente entre las curvas del percentil 25 y el percentil 90 del peso de referencia para la edad gestacional $XPHQWRGHSHVR 3 CONDUCTA - seguir cronograma habitual de consultas NJ $PHQRUUHDVHPDQDV 3 $XPHQWRGHSHVR 3 - dar orientación nutricional que la gestante se mantenga dentro de la faja de normalidad Trazado entre las curvas de percentil 25 y 90, con inclinación horizontal o descendente o trazado por abajo de la cuva del percentil 25, con inclinación horizontal o ascendente, sin alcanzar la faja considerada normal (p25) DIAGNOSTICO Gestante de riesgo con referencia a su ganancia adecuada de peso: CONDUCTA - Identificar causas: déficit nutricional, infecciones, parasitosis, anemia, entre otras. Tratarlas cuando esten presentes y dar orientación nutricional - referir a control prenatal de alto riesgo. NJ $PHQRUUHDVHPDQDV 3 Estas medidas intentan que la gestante llegue al término de la gestación con una ganancia de peso mínima de 8 kg. Trazado por encima de la curva del percentil 90 de peso de referencia para la edad gestacional. DIAGNOSTICO Gestante de riesgo visto que su ganancia de peso es superior a lo ideal para su edad gestacional; cuanto mayor sea su sobrepeso mayor será el riesgo $XPHQWRGHSHVR DIAGNOSTICO Buen estado nutricional (ganancia adecuada de peso): 3 $PHQRUUHDVHPDQDV CONDUCTA - investigar posibles causas: obesidad, diabetes y edema. - si persiste, derivar a control de alto riesgo. - en caso que exista polihidramnios, macrosomía, o gravidez múltiple, está indicado derivar a control de alto riesgo. Esas medidas procuran que la gestante llegue al término con un peso final dentro del rango de la normalidad (máximo de 16 kg) &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 0XFKDVJHVWDQWHVGHVFRQRFHQVXSHVRKDELWXDOSUHYLRDOHPEDUD]R(QHVWRVFDVRV VH SXHGH FRQWURODU HO DXPHQWR GH SHVR SRU ORV LQFUHPHQWRV VHPDQDOHV DFHSWDQGR FRPRQRUPDOXQDXPHQWRSURPHGLRGHJVHPDQDOHVHQHOVHJXQGRWULPHVWUH\GH JVHPDQDOHVHQHOWHUFHUWULPHVWUH 5HODFLyQSHVRSDUDODWDOODVHJ~QHGDGJHVWDFLRQDO &XDQGRODPDGUHGHVFRQRFHVXSHVRSUHJUDYtGLFR\ODFDSWDFLyQHVWDUGtDH[LVWHRWUD PDQHUDGHFRQRFHUVLHOSHVRDOFDQ]DGRKDVWDHVHPRPHQWRHVDGHFXDGRSDUDHVD HGDGJHVWDFLRQDO3DUDHOORVHSXHGHXWLOL]DUODWDEOD¿JXUDTXHGHVFULEHORVYDORUHV GHSHVRDOFDQ]DGRDHVDHGDGJHVWDFLRQDOVHJ~QODWDOOD (QODLQWHUVHFFLyQGHFDGDVHPDQDGHDPHQRUUHDFRQODWDOODPDWHUQDVHSUHVHQWDQORV SHUFHQWLORV\GHOSHVRJUDYtGLFRHVSHUDEOHSDUDHVDHGDGJHVWDFLRQDO ,QWHUSUHWDFLyQ 1RUPDO 6HUiFXDQGRDXQDHGDGJHVWDFLRQDOGHWHUPLQDGDHOSHVRDOFDQ]DGRSRUOD PDGUHVHHQFXHQWUDHQWUHORVSHUFHQWLOHV\GHODWDEODGHUHIHUHQFLD $QRUPDO 6HUi FXDQGR HO SHVR PDWHUQR VH VLW~H SRU HQFLPD GHO SHUFHQWLO R SRU GHEDMRGHOSHUFHQWLO &RQHVWH~OWLPRSURFHGLPLHQWRQRVHFRQRFHHOLQFUHPHQWRGHSHVRPDWHUQRSHURVH SXHGHVDEHUVLHOSHVRDOFDQ]DGRSRUXQDJHVWDQWHGHDFXHUGRDVXWDOODHVDGHFXDGR RQRSDUDXQDGHWHUPLQDGDHGDGJHVWDFLRQDO /DVJHVWDQWHVFRQYDORUHVGHSHVRSDUDODWDOODLQVX¿FLHQWHVRFRQGp¿FLWGHLQFUHPHQWR GHSHVRGHEHUiQUHFLELUFRQVHMRQXWULFLRQDO\VXSOHPHQWDFLyQDOLPHQWDULD (YDOXDFLyQGHOLQFUHPHQWRSRQGHUDOPDWHUQR (ODXPHQWRH[FHVLYRGHSHVRPDWHUQRSUHGLVSRQHDODPDFURVRPtDIHWDO\HOHVFDVR LQFUHPHQWRVHDVRFLDFRQUHVWULFFLyQGHOFUHFLPLHQWRLQWUDXWHULQR5&, 6L DOJ~Q YDORU HV PD\RU DO SHUFHQWLO GH VX SDWUyQ UHVSHFWLYR GHEH VRVSHFKDUVH H[FHVRGHLQJHVWDGLDEHWHVPHOOLWXVRUHWHQFLyQKtGULFD 6HVRVSHFKDUiVXEQXWULFLyQPDWHUQDFXDQGRHOLQFUHPHQWRGHSHVRVHDPHQRUTXHHO SHUFHQWLORHOSHVRSDUDODWDOODVHDPHQRUTXHHOSHUFHQWLOGHVXVUHVSHFWLYRV SDWURQHV(VWRVVLJQRVVRQRULHQWDGRUHVGH5&,(OLQFUHPHQWRGHSHVRPHQRUDOS WLHQHXQDVHQVLELOLGDGFDSDFLGDGGHGLDJQRVWLFDUORVYHUGDGHURVSHTXHxRVSDUDODHGDG JHVWDFLRQDO3(*FHUFDQDDO/DDOWXUDXWHULQDDLVODGDFXDQGRVHHQFXHQWUDSRU GHEDMRGHOSHQUHODFLyQDVXFXUYDGHUHIHUHQFLDWLHQHXQDVHQVLELOLGDGFHUFDQDDO 3HURFXDQGRVHDVRFLDQDOWXUDXWHULQD\JDQDQFLDGHSHVRPDWHUQRODVHQVLELOLGDG GLDJQyVWLFDDXPHQWDDO &RQGXFWD (QORVFDVRVFRQVRVSHFKDFOtQLFDGH5&,XQDYH]H[FOXLGRVORVFDVRVGHROLJRDPQLRV GHHUURUGHDPHQRUUHDHWFVHGHEHUiFRQ¿UPDUHOGLDJQyVWLFRSRUXOWUDVRQLGRSDUD GHVFDUWDUIDOVRVSRVLWLYRV\VHUHIHULUiDOVHUYLFLRGHDOWRULHVJR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 2EMHWLYRV ,QYHVWLJDUHVWLORVGHYLGDGHULHVJR $FWLYLGDG ,QWHUURJDWRULRVREUHWDEDTXLVPRDFWLYR\SDVLYRGURJDVDOFRKRO \YLROHQFLD )LJXUD)UDJPHQWRGH+&3(VWLORVGHYLGD ([LVWHQ HVWLORV GH YLGD TXH SXHGHQ VHU ULHVJRVRV SDUD OD PXMHU \ VX IXWXUR KLMR (O HPEDUD]RVXHOHVHUXQPRPHQWRHVSHFLDOHQHOTXHODPD\RUtDGHODVPXMHUHVHVWiQ GLVSXHVWDVDKDFHU³VDFUL¿FLRV´SDUDJDUDQWL]DUODVDOXGGHVXIXWXURKLMR3RUHVWDUD]yQ PXFKRVSURJUDPDVSDUDFHVDFLyQGHOWDEDTXLVPRHODOFRKRO\ODVGURJDVVXHOHQWHQHU PiVp[LWRGXUDQWHHVWHSHUtRGR7DPELpQRFXUUHORPLVPRFRQORVDVSHFWRVYLQFXODGRV D OD YLROHQFLD FRQWUD OD PXMHU /DV PXMHUHV TXH VXIULHURQ YLROHQFLD GXUDQWH SHUtRGRV SURORQJDGRV \ OR KDQ DFHSWDGR HVWiQ GLVSXHVWDV D EXVFDU D\XGD PLHQWUDV HVWiQ HPEDUD]DGDV3RUHVWDVUD]RQHV&/$3605LQFRUSRUyHVWRVDVSHFWRVDOD+&3$~Q VDELHQGRTXHHVGLItFLOSDUDORVSUHVWDGRUHVLQWHUURJDUHVWRVDVSHFWRV\TXHWDPELpQ HVFRPSOHMRSDUDODVPXMHUHVDGPLWLUDOJXQDVGHHVWDVVLWXDFLRQHV\TXHODVPLVPDV SXHGHQ YDULDU D OR ODUJR GHO HPEDUD]R VH UHFRPLHQGD UHLQWHUURJDU HVWRV DVSHFWRV (VWD E~VTXHGD HQ GLIHUHQWHV LQVWDQFLDV SHUPLWLUi FRQVWDWDU VL ODV LQWHUYHQFLRQHV GHVDUUROODGDVVRQH[LWRVDVRSRUHOFRQWUDULRVLODVPLVPDVIUDFDVDQ /RVVHUYLFLRVGHEHUiQWHQHUHVWDEOHFLGRVORVSDVRVSDUDEULQGDUDSR\RHQODVVLWXDFLRQHV HQODVTXHVHHVWDEOH]FDQHVWRVGLDJQyVWLFRV/DIDOWDGHUHVSXHVWDRODLPSURYLVDFLyQ SXHGHQVHUDOWDPHQWHSHUMXGLFLDOHV 7DEDTXLVPRDFWLYR (OWDEDFRHVXQDGHODVGURJDVPiVIUHFXHQWHPHQWHFRQVXPLGD/D206HVWLPDTXH HQ ORV SDtVHV GHVDUUROODGRV HO FRQVXPR GH WDEDFR SRU ODV PXMHUHV HVWi SRU HQFLPD GHOPLHQWUDVTXHHQORVSDtVHVHQYtDVGHGHVDUUROORODVFLIUDVGHPXMHUHVTXH IXPDQVHXELFDQHQWRUQRDOFRQDPSOLDVRVFLODFLRQHV0XFKDVGHHVWDVPXMHUHV SHUVLVWLUiQIXPDQGRGXUDQWHHOHPEDUD]R /RVHIHFWRVGHOWDEDFRQRVRORSXHGHQGDxDUDODPXMHUVLQRTXHVXXVRGXUDQWHHO HPEDUD]RSXHGHSURYRFDUVHULRVGDxRVDOIHWR\DORVUHFLpQQDFLGRV(VWiGHPRVWUDGR TXH VX FRQVXPR HQ HO HPEDUD]R HQ IRUPD DLVODGD R FRQWLQXD DXPHQWD HO ULHVJR UHSURGXFWLYR $SUR[LPDGDPHQWH HO KXPR GHO FLJDUULOOR FRQWLHQH PiV GH SURGXFWRV TXtPLFRV PXFKRVGHHOORVDOWDPHQWHQRFLYRV\RWURVGHORVTXHD~QQRVHKDQGHWHUPLQDGRVXV YHUGDGHURVHIHFWRV (OFRQVXPRGHFLJDUULOORVGXUDQWHHOHPEDUD]RKDVLGRDVRFLDGRFRQ x%DMRSHVRDOQDFHU x5HVWULFFLyQHQHOFUHFLPLHQWRIHWDO x3DUWRVGHSUHWpUPLQR x&RPSOLFDFLRQHVGHOHPEDUD]RGHOSDUWR\GHOSXHUSHULR x$ERUWRVHVSRQWiQHRV x0XHUWHIHWDO x0XHUWHVQHRQDWDOHV x'LVPLQXFLyQGHODFDOLGDG\FDQWLGDGGHODOHFKHPDWHUQD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD /RVKLMRVGHODVIXPDGRUDVSHVDQHQSURPHGLRDOQDFHUHQWUH\JPHQRVTXH ORVKLMRVGHODVQRIXPDGRUDV(VWDGLIHUHQFLDGHSHVRJXDUGDUHODFLyQFRQHOQ~PHUR GHFLJDUULOORVIXPDGRV6HFDOFXODTXHFDGDFLJDUULOORGtDSXHGHVHUUHVSRQVDEOHGH JUDPRVPHQRVGHSHVRDOQDFHU (OSRUFHQWDMHGH%31HVPD\RUHQODVIXPDGRUDVHOLQFUHPHQWRGH%31YDUtDVHJ~Q GLYHUVRVDXWRUHVGHVGHXQDXQ(OULHVJRGH%31SDUDORVKLMRVGHPDGUHV IXPDGRUDVFDVLVHGXSOLFD 7DPELpQVHKDFRQ¿UPDGRODDVRFLDFLyQHQWUHSUHPDWXUH]\KiELWRGHIXPDU(OSRUFHQWDMH GHSUHPDWXUH]HQODVIXPDGRUDVVHHOHYDHQFRPSDUDFLyQFRQODVQRIXPDGRUDVHQWUH XQ\XQ (OSULQFLSDOFRPSRQHQWHGHO%31HQHOFDVRGHODVIXPDGRUDVHVOD5&,\VHFXQGDULDPHQWH ODSUHPDWXUH] /DDVRFLDFLyQHQWUH%31\SUHPDWXULGDGDXPHQWDHOULHVJRGHTXHHOUHFLpQQDFLGRVXIUD SUREOHPDV GH VDOXG GXUDQWH HO SHUtRGR QHRQDWDO GLVFDSDFLGDGHV SDUiOLVLV FHUHEUDO UHWDUGRPHQWDO\SUREOHPDVGHODSUHQGL]DMHHLQFOXVRODPXHUWH /RVKLMRVGHPDGUHVIXPDGRUDVWLHQHQYHFHVPiVSUREDELOLGDGGHVXIULUPXHUWHV~ELWD 6LODPDGUHORJUDFHVDUHOXVRGHOWDEDFRHQHOSULPHUWULPHVWUHGHOHPEDUD]RFDVLQR VHQRWDUtDQGLIHUHQFLDVHQWUHORVKLMRVGHPDGUHVIXPDGRUDV\QRIXPDGRUDV,QFOXVR VL OD JHVWDQWH VROR FHVD GH IXPDU HQ HO WHUFHU WULPHVWUH HV SUREDEOH TXH PHMRUH HO FUHFLPLHQWRIHWDO /RVFLJDUULOORVVHDVRFLDQFRQHOGREOHGHSUREDELOLGDGGHTXHODVPXMHUHVTXHIXPDQ GXUDQWHHOHPEDUD]RGHVDUUROOHQSUREOHPDVYLQFXODGRVDODSODFHQWDSODFHQWDSUHYLD GHVSUHQGLPLHQWRSUHPDWXURGHSODFHQWDVLVHODVFRPSDUDFRQPXMHUHVQRIXPDGRUDV 7DPELpQVHKDYLVWRXQDXPHQWRHQHOULHVJRGHURWXUDSUHPDWXUDGHPHPEUDQDVHQODV PXMHUHVTXHIXPDQGXUDQWHHOHPEDUD]R&XDQGRHVWDVFRPSOLFDFLRQHVVHSURGX]FDQ DQWHVGHODVVHPDQDVSRGUiQDVRFLDUVHFRQSUHPDWXULGDG (O KiELWR GH IXPDU HQ SDUWLFXODU HQ JUXSRV GH PXMHUHV TXH DGHPiV SUHVHQWHQ RWUD FRQGLFLyQ GH ULHVJR PD\RUHV GH DxRV JUDQGHV PXOWtSDUDV RWUDV FRQGLFLRQHV PpGLFDV JUDYHV RWUDV DGLFFLRQHV HWF KD VLGR DVRFLDGR FRQ PD\RU PRUWDOLGDG SHULQDWDO (VWD DVRFLDFLyQ SHUVLVWH FODUD HQ ORV SDtVHV HQ YtDV GH GHVDUUROOR HQ ORV FXDOHV ODV SUHYDOHQFLDV VRQ DOWDV \ GRQGH ODV IXPDGRUDV VHJXUDPHQWH FRQFHQWUDQ XQD PD\RU SURSRUFLyQ GH RWURV IDFWRUHV GH ULHVJR VRFLRFXOWXUDOHV HFRQyPLFRV GH DWHQFLyQHWF 7DEDTXLVPRSDVLYR 6HUIXPDGRUDSDVLYDGXUDQWHHOHPEDUD]RWDPELpQSXHGHDXPHQWDUODVSUREDELOLGDGHV GHXQD5&,FRQULHVJRGH%31 /RV SDGUHV TXH FRQWLQXHQ IXPDQGR XQD YH] QDFLGR HO QLxR GHEHUiQ KDFHUOR DO DLUH OLEUH /RV QLxRV H[SXHVWRV DO KXPR GHO WDEDFR VXIUHQ PiV IUHFXHQWHPHQWH LQIHFFLRQHVUHVSLUDWRULDVEDMDV\RWLWLV/RVQLxRVTXHHVWiQH[SXHVWRVHQORVSULPHURV DxRV GH YLGD DO KXPR GH WDEDFR WLHQHQ PiV SUREDELOLGDG GH GHVDUUROODU DVPD 'HEHUiQHVWDEOHFHUVHSURJUDPDVGHFHVDFLyQGHWDEDTXLVPRSDUDDTXHOODVJHVWDQWHV TXHORQHFHVLWHQ(VSUREDEOHREWHQHUp[LWRHQODFHVDFLyQVLODVPXMHUHV\DKDQWHQLGR RWURVLQWHQWRVSRUGHMDUGHIXPDUWLHQHQSDUHMDVTXHQRIXPDQ\RWLHQHQDSR\RIDPLOLDU SDUDGHMDUHOFLJDUULOOR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $OFRKRO (O FRQVXPR GH DOFRKRO GXUDQWH HO HPEDUD]R VH KD DVRFLDGR FRQ GHIHFWRV ItVLFRV \ SVtTXLFRVDOQDFHUTXHUHFLEHQHOQRPEUHGHVtQGURPHDOFRKyOLFRIHWDO6$) 1RVHKDQGHPRVWUDGRQLYHOHVGHVHJXULGDGSDUDEHEHUDOFRKROGXUDQWHHOHPEDUD]R\OD ODFWDQFLDSRUORFXDOQRVHUHFRPLHQGDHOFRQVXPRGHDOFRKROGXUDQWHHOHPEDUD]R (O DOFRKRO DWUDYLHVD OD SODFHQWD \ HV PHWDEROL]DGR PX\ OHQWDPHQWH SRU OR TXH ORV QLYHOHVHQODVDQJUHGHOIHWRVXHOHQVHUPXFKRPiVDOWRV\SHUPDQHFHUSRUPXFKRPiV WLHPSRTXHHQODPDGUH(VWHHIHFWRSXHGHVHUWHUDWRJpQLFRSDUDHOIHWR(O6$)HVXQD GH ODV FDXVDV PiV FRPXQHV GH UHWDUGR PHQWDO \ HV WRWDOPHQWH SUHYHQLEOH$GHPiV GHORVVtQWRPDVQHXUROyJLFRVVXHOHQVHUSHTXHxRVSDUDODHGDGJHVWDFLRQDO\WHQHU DOWHUDFLRQHVPRUIROyJLFDVFDUDFWHUtVWLFDVRMRV\QDUL]SHTXHxRVPHMLOODVSODQDV\HQ RFDVLRQHVDOJXQDVYDULHGDGHVGHFDUGLRSDWtDFRQJpQLWD 6HJ~QLQIRUPHVGHO&'&FDGDDxRHQORV(VWDGRV8QLGRVQDFHQHQWUH\ QLxRVFRQ6$)(O6$)VHSUHVHQWDHQDSUR[LPDGDPHQWHHOGHORVQLxRVKLMRVGH PDGUHVDOFRKyOLFDVFUyQLFDVRTXHWLHQHQUHLWHUDGRVHSLVRGLRVGHDEXVRFRQDOFRKRO GXUDQWH HO HPEDUD]R SHUR WDPELpQ VH KD YLVWR HQ PXMHUHV FRQ HVFDVR FRQVXPR GH DOFRKROGXUDQWHHOHPEDUD]R/DVDOWHUDFLRQHVPRUIROyJLFDVVXHOHQYLQFXODUVHFRQHO FRQVXPRGHDOFRKROHQHOSULPHUWULPHVWUHORVSUREOHPDVGHOFUHFLPLHQWRHQFDPELR HVWiQ UHODFLRQDGRV FRQ HO FRQVXPR HQ HO WHUFHU WULPHVWUH 3HUR HO HIHFWR GHO DOFRKRO VREUHHOFHUHEURIHWDOVHSURGXFHGXUDQWHWRGRHOHPEDUD]R +D\HVWXGLRVTXHKDQFRQ¿UPDGRTXHD~QHQPXMHUHVTXHFRQVXPHQHQIRUPDVRFLDO XQ SURPHGLR GH WUDJRV SRU GtD SXHGHQ SUHVHQWDQ QLxRV FRQ PHQRU LQWHOLJHQFLD \ PD\RUHV SUREOHPDV GH FRQGXFWD HQ FRPSDUDFLyQ FRQ ORV KLMRV GH PDGUHV TXH QR EHEtDQ $GHPiVGHORVDVSHFWRVYLQFXODGRVDO6$)HOFRQVXPRGHDOFRKROGXUDQWHHOHPEDUD]R KDVLGRDVRFLDGRFRQPD\RUULHVJRGHDERUWRPXHUWHIHWDO\%31 /RVSURIHVLRQDOHVGHVDOXGGHEHUiQKDFHUpQIDVLVHQUHFRUGDUDODVPXMHUHVJHVWDQWHV TXHDSHQDVVHSDQRVRVSHFKHQTXHHVWiQHPEDUD]DGDVGHEHQVXVSHQGHUHOFRQVXPR GHEHELGDVDOFRKyOLFDV\DTXHQRVHKDGHWHUPLQDGRFXDOHVHOQLYHOVHJXUR )LQDOPHQWH HO FRQVXPR GH DOFRKRO GXUDQWH OD ODFWDQFLD SXHGH GLVPLQXLU OD H\HFFLyQ OiFWHD\SURYRFDUDOJXQRVWUDVWRUQRVQHXUROyJLFRVPHQRUHVHQHOUHFLpQQDFLGR (QFDVRTXHXQDPXMHUHPEDUD]DGDQHFHVLWHD\XGDSDUDVXVSHQGHUHOFRQVXPRGH DOFRKROGXUDQWHHOHPEDUD]R\QRVHFXHQWHFRQVHUYLFLRVLQVWLWXFLRQDOHVVHODSRGUi YLQFXODUFRQRUJDQL]DFLRQHVORFDOHVGH$OFRKyOLFRV$QyQLPRVPDQWHQLHQGRHOYtQFXOR FRQORVHTXLSRVREVWpWULFRVD¿QGHHYLWDUTXHODPXMHUVHVLHQWDSRFRFRQWHQLGD 5HFLHQWHPHQWH VH KD GHPRVWUDGR TXH ODV PXMHUHV HQ DOWR ULHVJR GH H[SRVLFLyQ DO DOFRKROGXUDQWHHOHPEDUD]RVHEHQH¿FLDQGHVHVLRQHVFRQXQFRQVHMHURSDUDUHGXFLU HOFRQVXPR 'URJDV (OSRUFHQWDMHGHPXMHUHVTXHXVDGURJDVLOHJDOHVFRPRODPDULKXDQDFRFDtQDp[WDVLV DQIHWDPLQDVRKHURtQDHVGLItFLOGHGHWHUPLQDUSHURVHHVWLPDVHDLQIHULRUDOGHORV HPEDUD]RVVHJ~QGDWRVFRPXQLFDGRVSRUHO&'&(VWDV\RWUDVGURJDVLOHJDOHVSXHGHQ SURYRFDUGLYHUVRVULHVJRVGXUDQWHHOHPEDUD]R$OJXQDVGHHOODVVHDVRFLDQFRQUHFLpQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD QDFLGRVSHTXHxRVSDUDODHGDGJHVWDFLRQDORXQDPSOLRHVSHFWURGHVtQWRPDVFRPR GHIHFWRVFRQJpQLWRVSUREOHPDVGHFRQGXFWDRDSUHQGL]DMH3HURFRPRODPD\RUtDGH ODVJHVWDQWHVTXHFRQVXPHQGURJDVLOHJDOHVWDPELpQFRQVXPHQDOFRKRO\WDEDFRHV GLItFLOGHWHUPLQDUFXDOHVVRQORVSUREOHPDVGHVDOXGHVSHFt¿FDPHQWHSURYRFDGRVSRU ODVGURJDVLOtFLWDV &RFDtQD /DFRFDtQDXVDGDGXUDQWHHOHPEDUD]RSXHGHDIHFWDUDODPDGUH\VXIHWRGH GLYHUVDV PDQHUDV 'XUDQWH ORV SULPHURV PHVHV SXHGH DXPHQWDU HO ULHVJR GH DERUWRPiVWDUGtDPHQWHSXHGHGHVHQFDGHQDUXQSDUWRGHSUHWpUPLQRRJHQHUDU XQDUHVWULFFLyQGHOFUHFLPLHQWRLQWUDXWHULQR5&,FRQHOULHVJRGHSURYRFDUXQ UHFLpQ QDFLGR SHTXHxR SDUD OD HGDG JHVWDFLRQDO 3(* (VWi HVWDEOHFLGR TXH ORVQLxRV3(*WLHQHQYHFHVPiVSUREDELOLGDGHVGHPRULUHQHOSULPHUPHV GHYLGDTXHORVQLxRVFRQSHVRDGHFXDGR/RVVREUHYLYLHQWHVDVXYH]FRUUHQ PD\RUULHVJRGHSUHVHQWDUGLVFDSDFLGDGHVLQFOX\HQGRUHWDUGRPHQWDO\SDUiOLVLV FHUHEUDO/RVQLxRVH[SXHVWRVGXUDQWHVXYLGDLQWUDXWHULQDDODFRFDtQDVXHOHQ WHQHU SHUtPHWUR FHIiOLFR PiV SHTXHxR OR TXH LQGLUHFWDPHQWH UHÀHMD XQ PHQRU GHVDUUROOR GHO FHUHEUR7DPELpQ VH KD VRVWHQLGR TXH ORV QLxRV H[SXHVWRV D OD FRFDtQDFRUUHQPD\RUULHVJRGHSUHVHQWDUGHIHFWRVFRQJpQLWRVHVSHFLDOPHQWH GHIHFWRVGHOWUDFWRXULQDULR\SRVLEOHPHQWHFDUGLRSDWtDFRQJpQLWD 6H KD PHQFLRQDGR XQ SRVLEOH DXPHQWR GH GHVSUHQGLPLHQWR SUHPDWXUR GH SODFHQWDQRUPRLQVHUWDHQODVJHVWDQWHVTXHFRQVXPHQFRFDtQD /RV UHFLpQ QDFLGRV TXH KDQ HVWDGR H[SXHVWRV D OD FRFDtQD PXHVWUDQ PHQRU DWHQFLyQ\UHÀHMRVTXHORVUHFLpQQDFLGRVQRH[SXHVWRV$OJXQRVUHFLpQQDFLGRV SRGUtDQSUHVHQWDUH[FHVLYROODQWR\WHPEORUHVGHIRUPDVLPLODUDOVtQGURPHGH DEVWLQHQFLDGHORVDGXOWRVRWURVSXHGHQSUHVHQWDUGL¿FXOWDGHVSDUDGRUPLURSRU HOFRQWUDULRSHUPDQHFHUGXUPLHQGRSRUPXFKDVKRUDVVHKDFRPXQLFDGRTXHORV KLMRVGHPDGUHVFRFDLQyPDQDVWLHQHQPD\RUSUREDELOLGDGGHVXIULUXQVtQGURPH GHPXHUWHV~ELWD\PD\RUGL¿FXOWDGSDUDDOLPHQWDUVH(VWRVWUDVWRUQRVVXHOHQVHU WUDQVLWRULRV\UHYLHUWHQHQORVSULPHURVPHVHVGHYLGD 0DULKXDQD $OJXQRVHVWXGLRVVXJLHUHQTXHORVKLMRVGHPDGUHVTXHFRQVXPtDQPDULKXDQD GXUDQWHHOHPEDUD]RWLHQHQPD\RUSUREDELOLGDGGHSUHVHQWDUXQD5&,\GHQDFHU SUHPDWXURV$PERVDVSHFWRVIDYRUHFHQODSRVLELOLGDGTXHHOQLxRDOQDFHUWHQJD EDMRSHVR $OJXQRVQLxRVDOQDFHUSRGUtDQSUHVHQWDUH[FHVLYROODQWR\WHPEORUHVGHIRUPD VLPLODUTXHHOVtQGURPHGHDEVWLQHQFLDHQORVDGXOWRV +DVWD HO PRPHQWR QR VH KD GHPRVWUDGR XQ ULHVJR HOHYDGR GH SUREOHPDV GH DSUHQGL]DMHRFRQGXFWDHQHVWRVQLxRV $TXHOODV PXMHUHV TXH GHVHHQ DEDQGRQDU HO FRQVXPR GH GURJDV GXUDQWH HO HPEDUD]RGHEHUiQVHUDSR\DGDVHQWDOHPSUHQGLPLHQWR\UHIHULGDVDRUJDQL]D FLRQHVTXHVHHVSHFLDOLFHQHQDWHQGHUDSHUVRQDVFRQGURJRGHSHQGHQFLD 9LROHQFLD /D 206 HQWLHQGH SRU YLROHQFLD ³(O XVR GHOLEHUDGR GH OD IXHU]D ItVLFD R HO SRGHU \D VHD HQ JUDGR GH DPHQD]D R HIHFWLYR FRQWUD XQR PLVPR RWUD SHUVRQD R XQ JUXSR R FRPXQLGDG TXH FDXVH R WHQJD PXFKDV SUREDELOLGDGHV GH FDXVDU OHVLRQHV PXHUWH GDxRVSVLFROyJLFRVWUDVWRUQRVGHOGHVDUUROORRSULYDFLRQHV´ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR /D 236 FRQVLGHUD D OD YLROHQFLD LQWHUSHUVRQDO FRPR XQ SUREOHPD GH VDOXG S~EOLFD /DVPXMHUHVQLxRV\DQFLDQRVVXHOHQVHUORVJUXSRVPiVYXOQHUDEOHVHQWpUPLQRVGH YLROHQFLD /DYLROHQFLDGHJpQHURFRUUHVSRQGHD³WRGRDFWRGHYLROHQFLDEDVDGDHQODSHUWHQHQFLD DOVH[RIHPHQLQRTXHWHQJDRSXHGDWHQHUFRPRUHVXOWDGRGDxRRVXIULPLHQWRItVLFR VH[XDO R VLFROyJLFR SDUD OD PXMHU DVt FRPR OD DPHQD]D GH WDOHV DFWRV OD FRDFFLyQ RODSULYDFLyQDUELWUDULDGHOLEHUWDGWDQWRVLVHSURGXFHHQODYLGDS~EOLFDFRPRHQOD SULYDGD´ 6HHQWLHQGHSRUYLROHQFLDGRPpVWLFDD³WRGDDFFLyQXRPLVLyQGLUHFWDRLQGLUHFWDTXH SRUFXDOTXLHUPHGLRPHQRVFDEHOLPLWDQGRLOHJtWLPDPHQWHHOOLEUHHMHUFLFLRRJRFHGH ORVGHUHFKRVKXPDQRVGHXQDSHUVRQDFDXVDGDSRURWUDFRQODFXDOKD\DWHQLGRXQD UHODFLyQ DIHFWLYD EDVDGD HQ OD FRKDELWDFLyQ \ RULJLQDGD SRU SDUHQWHVFR QRYLD]JR PDWULPRQLRRSRUXQLyQGHKHFKR´ 2EWHQHU HVWD LQIRUPDFLyQ VXHOH VHU GLItFLO D SHVDU GH TXH HO SUREOHPD HV EDVWDQWH IUHFXHQWHDGHODVPXMHUHVVXIUHQDOJXQDIRUPDGHYLROHQFLDTXHVHSURGXFH HQ WRGRV ORV JUXSRV VRFLDOHV LQGHSHQGLHQWHPHQWH GH VX QLYHO VRFLRHFRQyPLFR HGXFDFLRQDO$YHFHVODGL¿FXOWDGDVLHQWDHQIDFWRUHVYLQFXODGRVDLJQRUDQFLDSUHMXLFLRV R D FRVWXPEUHV GH ORV SURYHHGRUHV D ODV FDUDFWHUtVWLFDV GH OD FRQVXOWD R D IDOWD GH FRPSHWHQFLDSDUDDERUGDUHOWHPD(QRWUDVRFDVLRQHVODVGL¿FXOWDGHVSURYHQGUiQGH ODVSURSLDVPXMHUHVTXHSXHGHQVHQWLUVHHVWLJPDWL]DGDVRFRQWHPRUVLUHYHODQHVWDV VLWXDFLRQHV /D IUHFXHQFLD GH YLROHQFLD GRPpVWLFD HQWUH PXMHUHV HPEDUD]DGDV HQ SDtVHV HQ GHVDUUROORYDUtDGHVGHXQDXQ/RVHIHFWRVGHODYLROHQFLDSXHGHQOOHJDUKDVWD ODPXHUWHPDWHUQDSDVDQGRSRUWRGDXQDJDPDGHOHVLRQHVItVLFDV\RVLFROyJLFDV /RV KLMRV GH PDGUHV TXH VXIUHQ YLROHQFLD SXHGHQ VXIULU EDMR SHVR DO QDFHU SDUWR GH SUHWpUPLQRDERUWR\PXHUWHVIHWDOHVHQWUHRWUDV $QWHVLWXDFLRQHVGHYLROHQFLDVHUiQHFHVDULRFRQVHJXLUDSR\RFRQHVSHFLDOLVWDVHQOD WHPiWLFDSDUDSRGHUGDUXQDUHVSXHVWDHIHFWLYDDODVPXMHUHVTXHODVXIUHQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2EMHWLYRV $FWLYLGDG 3UHYHQLUHOWpWDQRVQHRQDWDO\SXHUSHUDO 9DFXQDFLyQDQWLWHWiQLFD (OWpWDQRVHQIHUPHGDGDPHQXGRIDWDOHVSURGXFLGDSRUODH[RWR[LQDGHO&ORVWULGLXP WpWDQL\HVWRWDOPHQWHHYLWDEOHPHGLDQWHLQPXQL]DFLyQDFWLYDGHODJHVWDQWH (ODXPHQWRGHODFREHUWXUDYDFXQDOHQOD5HJLyQGHODV$PpULFDVKDFRQWULEXLGRDOD HOLPLQDFLyQGHOWpWDQRVQHRQDWDO711FRPRSUREOHPDGHVDOXGS~EOLFD6HFRQVLGHUD TXH HO 711 KD VLGR HOLPLQDGR FRPR SUREOHPD GH VDOXG S~EOLFD FXDQGR ODV WDVDV DQXDOHVGH711HQWRGRVORVPXQLFLSLRVGHXQSDtVVRQLQIHULRUHVD[QDFLGRV YLYRVQY(QHOSHUtRGRWUDQVFXUULGRHQWUH\ODLQFLGHQFLDGH711GHVFHQGLy XQ(QHODxRODLQFLGHQFLDGH711SDUDWRGD$PpULFDIXHGH[ QY2VFLODQGRGHVGHWDVDVGHFHURHQODPD\RUtDGHORVSDtVHVSDVDQGRD[ QYHQORVSDtVHVGHOÈUHD$QGLQDSDUDOOHJDUDODPi[LPDWDVDHQHO&DULEH/DWLQR [QYDODFXDO+DLWtFRQWULEX\HFRQHOGHORVFDVRV /DWDVDGHOHWDOLGDGSRUWpWDQRVQHRQDWDOSDUDFDVRVQRWUDWDGRVHVFHUFDQDDO \ GH HQ FHQWURV GH DOWD FRPSOHMLGDG TXH FXHQWDQ FRQ DVLVWHQFLD UHVSLUDWRULD PHFiQLFD /DLQPXQL]DFLyQDGHFXDGDGHODVPXMHUHVFRQWR[RLGHWHWiQLFR77SUHYLHQHHOWpWDQRV QHRQDWDO \ SXHUSHUDO (O UHFLpQ QDFLGR TXHGD SURWHJLGR HQ IRUPD SDVLYD JUDFLDV D ORV DQWLFXHUSRVDQWLWR[LQDPDWHUQRVTXHSDVDQSRUODSODFHQWDDOVLVWHPDFLUFXODWRULRGHOIHWR /DVEXHQDVSUiFWLFDVGHKLJLHQHGXUDQWHHOSDUWR\HOFXLGDGRGHOD KHULGDXPELOLFDOKDVWDTXHpVWDFLFDWUL]DVRQPHGLGDVTXHFRQWULEX\HQ SDUDSUHYHQLUHOWpWDQRVQHRQDWDO\RWUDVLQIHFFLRQHV/DLQPXQL]DFLyQ DGHFXDGDGHODVPXMHUHVJHVWDQWHVFRQ77HVH¿FD]LQFOXVRVLOD KHULGDXPELOLFDOVHLQIHFWDFRQ&ORVWULGLXPWpWDQL /D+&3SURYHHXQUHFRUGDWRULRDORVSURIHVLRQDOHVGHVDOXGDFHUFD GHOHVWDGRYDFXQDODQWLWHWiQLFRGHODPXMHUHPEDUD]DGD(OHVTXHPD Fig. 22. GHYDFXQDFLyQUHFRPHQGDGRSDUDODSULPRYDFXQDFLyQGHPXMHUHVHQ Fragmento de HCP HGDGIpUWLOLQFOXLGDVODVHPEDUD]DGDVHVHOVLJXLHQWH Vacuna antitetánica &XDGUR3ODQGHYDFXQDFLyQUHFRPHQGDGRSDUDODVPXMHUHVHQHGDGIpUWLOTXH QRKDQVLGRSUHYLDPHQWHYDFXQDGDV Dosis Plan Los intervalos indicados en el cuadro se refieren al tiempo mínimo aceptable entre vacunaciones; no existen intervalos máximos. TT1 o Td1 En el primer contacto o cuanto antes durante el embarazo TT2 o Td2 Al menos cuatro semanas después de la primera dosis TT3 o Td3 De 6 a 12 meses después de la segunda dosis o durante un embarazo posterior TT4 o Td4 De uno a cinco años después de la tercera dosis o durante un embarazo posterior TT5 o Td5 De uno a 10 años después de la cuarta dosis o durante un embarazo posterior 77 7R[RLGH7HWiQLFR7G 7pWDQRVGLIWHULD )XHQWH (OLPLQDFLyQ GHO WpWDQRV QHRQDWDO *XtD 3UiFWLFD HGLFLyQ 236 3XEO &LHQWt¿FD \ 7pFQLFD$xR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $XQTXHQRKD\LQGLFLRVGHWHUDWRJHQLDSURGXFLGDSRUODYDFXQDODVGRVLVGHUHIXHU]R HQHOSHUtRGRGHJHVWDFLyQVHUHFRPLHQGDDGPLQLVWUDUODVGHVSXpVGHOFXDUWRPHVGH HPEDUD]R\XQPHVDQWHVFRPRPtQLPRGHODIHFKDSUHYLVWDSDUDHOSDUWR 3XHGHQ DGRSWDUVH LQWHUYDORV PiV EUHYHV VL TXHGDQ PHQRV GH VHPDQDV HQWUH OD SULPHUDGRVLV\ODIHFKDSUREDEOHGHSDUWR/RVUHFLpQQDFLGRVD~QUHFLELUiQSURWHFFLyQ VDWLVIDFWRULDSHURQRySWLPDFXDQGRVHDGPLQLVWUDQDODPXMHUJHVWDQWHGRVGRVLVGH 77DGVRUELGRFRQFXDWURVHPDQDVGHLQWHUYDOR/RVLQWHUYDORVPiVFRUWRVQRSXHGHQ FRQVLGHUDUVHVDWLVIDFWRULRVSHURSXHGHQXVDUVHVLQRKD\RWUDDOWHUQDWLYD 3DUD FRQVLGHUDU TXH XQD PXMHU VH HQFXHQWUD SURWHJLGD DO PRPHQWR GHO SDUWR GHEH KDEHUUHFLELGROD~OWLPDGRVLVDOPHQRVVHPDQDVDQWHVGHOSDUWR (Q iUHDV GH PRGHUDGR D DOWR ULHVJR GH WpWDQRV QHRQDWDO VH UHFRPLHQGD LQLFLDU OD SULPHUDGRVLVRDSOLFDUODGRVLVGHUHIXHU]RHQODSULPHUDFRQVXOWDTXHHIHFW~DODPXMHU HPEDUD]DGD(OLQWHUYDORHQWUHODSULPHUD\ODVHJXQGDGRVLVVLHPSUHGHEHVHUPD\RU GHVHPDQDV (IHFWLYLGDGGHODYDFXQD /XHJRGHGRVGRVLVVHORJUDXQDH¿FDFLDFRQWUDHOWpWDQRVGHDGXUDQWHXQ PtQLPR GH WUHV DxRV HQ WRGDV ODV SHUVRQDV (¿FDFLD TXH VH HOHYD FDVL DO \ SUREDEOHPHQWHSDUDWRGDODYLGDVLVHKDQFRPSOHWDGRODVGRVLVUHFRPHQGDGDV $SHQDVXQDGRVLVGH77DSOLFDGDDPXMHUHVGXUDQWHHOHPEDUD]RGHPRVWUyVHUHIHFWLYD HQODSUHYHQFLyQGHOWpWDQRVQHRQDWDOHQXQ55,&± (QFDPELRVHQHFHVLWDQQRPHQRVGHGRVGRVLVGHYDFXQDSDUDSURWHJHUDOQHRQDWRGH ODPXHUWHSRU71155,&± (QHOFDVRGHPXMHUHVDODVTXHVHODVYDFXQDSRUSULPHUDYH]GXUDQWHODJHVWDFLyQHO SDUWRSUHPDWXURSRGUtDUHGXFLUODSURWHFFLyQGHOUHFLpQQDFLGR\DTXHORVDQWLFXHUSRV DQWLWR[LQDGHODPDGUHVHUtDQLQVX¿FLHQWHVSDUDSDVDUDOIHWR (PEDUD]DGDVDFRQWURODU 6, 9DFXQD DQWLWHWiQLFD SUHYLD 12 (VTXHPDSUHYLR DGPLQLVWUDGR 12 77 777777 77DxRV 6, 6, 1RVHYDFXQD 77 77 77DxRV 12 77 77 77 77 77DODFDSWDFLyQ 77yPiV VHPDQDVGHVSXpV )LJXUD(VTXHPDHVFDORQDGRGHGHFLVLRQHVSDUDODLQPXQL]DFLyQDQWLWHWiQLFD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2EMHWLYRV $FWLYLGDG 'LVPLQXLUHOLPSDFWRQHJDWLYRGHODVLQIHFFLRQHVGHWUDQVPLVLyQ YHUWLFDO 3UHYHQFLyQGHWHFFLyQ\WUDWDPLHQWRGHODVLQIHFFLRQHVGH WUDQVPLVLyQYHUWLFDO /DVLQIHFFLRQHVGHWUDQVPLVLyQYHUWLFDOVHGH¿QHQFRPRDTXHOODVLQIHFFLRQHVTXHVH WUDQVPLWHQGHVGHODPXMHUHPEDUD]DGDDOIHWRRDOUHFLpQQDFLGR /DWUDQVPLVLyQGHHVWDVLQIHFFLRQHVSXHGHRFXUULU 'XUDQWHHOHPEDUD]RSULQFLSDOPHQWHSRUYtDWUDQVSODFHQWDULD 'XUDQWHHOSDUWRDWUDYpVGHOFRQWDFWRFRQVDQJUHRVHFUHFLRQHVLQIHFWDGDVHQ HOFDQDOGHOSDUWR 'HVSXpVGHOSDUWRDWUDYpVGHODODFWDQFLDPDWHUQDRFRQWDFWRFRQVHFUHFLRQHV PDWHUQDV 6RQQXPHURVDVODVLQIHFFLRQHVTXHSXHGHQVHUWUDQVPLWLGDVSRUODPXMHUDOQLxRGXUDQWH HOHPEDUD]RHOSDUWR\HOSXHUSHULR\TXHVLJQL¿FDQXQULHVJRGHHQIHUPDURPRULUSDUD HOIHWRRUHFLpQQDFLGR (Q HVWH FDStWXOR GHVFULELUHPRV VROR DTXHOODV LQIHFFLRQHV TXH VH KDQ LQFRUSRUDGR D OD KLVWRULD FOtQLFD SHULQDWDO GHO &/$3605 FRPR UHVXOWDGR GH XQD FRQVXOWD D ORV SURJUDPDVGH³VDOXGGHODPXMHU´\³PDWHUQRLQIDQWLOHV´GHORVPLQLVWHULRVGHORVSDtVHV GHOD5HJLyQ (QWUHODVLQIHFFLRQHVTXHVHGHVDUUROODQVHHQFXHQWUDQ 5XEpROD7R[RSODVPRVLV9,+6t¿OLV(QIHUPHGDGGH&KDJDV3DOXGLVPR(VWUHSWRFRFR GHOJUXSR% 5XEpRODFRQJpQLWD /D 5XEpROD HV XQD HQIHUPHGDG IHEULO HUXSWLYD TXH SRFDV YHFHV VH FRPSOLFD \ TXH GHVDSDUHFH HVSRQWiQHDPHQWH $ SHVDU GH VX DSDUHQWH EHQLJQLGDG VL VH DGTXLHUH GXUDQWH HO SULPHU WULPHVWUH GHO HPEDUD]R SXHGH SURYRFDU HO VtQGURPH GH UXEpROD FRQJpQLWR 65& FDUDFWHUL]DGR SRU PDQLIHVWDFLRQHV WDOHV FRPR DERUWR HVSRQWiQHR yELWRIHWDOUHWUDVRPHQWDOVRUGHUDFHJXHUD\FDUGLRSDWtDFRQJpQLWD/DDOWDSUREDELOLGDG GH LQIHFFLyQ IHWDO DOFDQ]D FDVL DO HQ FDVR TXH OD LQIHFFLyQ RFXUUD DQWHV GH OD VHPDQDGHJHVWDFLyQ (O65&HVWRWDOPHQWHHYLWDEOHPHGLDQWHODYDFXQDFLyQGHWRGDVODVQLxDVRPXMHUHVHQ HGDGIpUWLO$QWHVGHODDSDULFLyQGHODYDFXQDVHSURGXFtDQSRUDxRHQOD5HJLyQXQRV FDVRVGH65&(QHODxRVHUHSRUWDURQHQWRGDODUHJLyQDSHQDVFDVRV GH65& /DYDFXQDFRQWUDOD5XEpRODHVHIHFWLYD\XQDGRVLV~QLFDFRQ¿HUHLQPXQLGDGGH SRUYLGD $XQTXHPXFKRVSDtVHVGHOD5HJLyQVHHQFDPLQDQDODHOLPLQDFLyQGHOD5XEpROD\ HO6tQGURPHGH5XEpROD&RQJpQLWD65&HQRWURVD~QVLJXHVLHQGRXQUHWR(OLPLQDU OD UXEpROD VLJQL¿FD LQWHUUXPSLU OD WUDQVPLVLyQ HQGpPLFD GHO YLUXV \ OD GHVDSDULFLyQ GHFDVRVGH65&3DUDDOFDQ]DUHVWDPHWDVHUHTXLHUHXQDUiSLGDLQWHUUXSFLyQGHOD FLUFXODFLyQ HQGpPLFD GHO YLUXV GH OD UXEpROD D WUDYpV GH SURJUDPDV \ FDPSDxDV GH YDFXQDFLyQPDVLYDTXHDOFDQFHQWDVDVGHFREHUWXUDFHUFDQDVDOHQWRGRVORV PXQLFLSLRV\HQWRGRVORVJUXSRVGHHGDGWDQWRHQKRPEUHVFRPRHQPXMHUHV1RORJUDU HVWHQLYHOGHFREHUWXUDLPSOLFDGHMDUEROVRQHVGHSREODFLyQFRQHOULHVJRGHDSDULFLyQ GHQXHYRVFDVRV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 8QDIRUPDGHFRQWULEXLUDHVWHHVIXHU]RQDFLRQDO\UHJLRQDOHV LQGDJDUHQIRUPDUXWLQDULDVREUHHOHVWDGRGHYDFXQDFLyQDQWL UXEpRODGXUDQWHHOFRQWUROSUHQDWDO3RUHVWDUD]yQOD+&3GH &/$3605KDLQFRUSRUDGRXQUHFRUGDWRULRVREUHHOHVWDGRGH YDFXQDFLyQDQWLUXEHyOLFD Figura 24. Fragmento de HCP Vacunación antirubeola 6H LQWHQWDUi JDUDQWL]DU TXH WRGD PXMHU HQ HGDG IpUWLO UHFLED OD YDFXQD DQWLUXEpROLFD DQWHVGHHPEDUD]DUVH1RVHDFRQVHMDUiODYDFXQDFLyQHQODPXMHUJHVWDQWHSHURODV FDPSDxDV PDVLYDV GH YDFXQDFLyQ KDQ SHUPLWLGR DFXPXODU HYLGHQFLD VX¿FLHQWH SDUD JDUDQWL]DUTXHQRH[LVWHDVRFLDFLyQHQWUHODYDFXQDDQWLUXEHyOLFDUHFLELGDGXUDQWHOD JHVWDFLyQ\ODDSDULFLyQGH65&RPXHUWHIHWDO 3RU HVWD UD]yQ HQ FDVR TXH XQD PXMHU HPEDUD]DGD UHFLED LQDGYHUWLGDPHQWH OD YDFXQD VH UHFRPLHQGD XQ HVWULFWR VHJXLPLHQWR GHO IHWR \ GHO UHFLpQ QDFLGR 1RKD\MXVWL¿FDFLyQSDUDODLQWHUUXSFLyQGHODJUDYLGH] ,QWHQWDQGR DOFDQ]DU ODV Pi[LPDV FREHUWXUDV HQ HGDG IpUWLO \ HQ DUDV GH QR ³SHUGHU RSRUWXQLGDGHV´HVUHFRPHQGDEOHYDFXQDUHQHOSXHUSHULRDWRGDPXMHUTXHKD\DOOHJDGR DOSDUWRVLQKDEHUUHFLELGRODYDFXQD 3DUD HOOR OD +LVWRULD 3HULQDWDO GH &/$3605 WUDH XQ UHFRUGDWRULRDORVSURIHVLRQDOHVSDUDLQPXQL]DUDDTXHOODV PDGUHVQRLQPXQL]DGDVDQWHVGHOHJUHVRPDWHUQR 7R[RSODVPRVLVFRQJpQLWD $QWLUXEHROD SRVWSDUWR QR VL QF Figura 25. Fragmento de HCP. Antirubeola postparto /D WR[RSODVPRVLV HV XQD ]RRQRVLV HQGpPLFD FDXVDGD SRU HO 7R[RSODVPD JRQGLL SURWR]RDULR FX\R KXpVSHG GH¿QLWLYR VRQ ORV IHOLQRV \ TXH JHQHUDOPHQWH FXDQGR FRPSURPHWH D OD HVSHFLH KXPDQD WLHQH XQ FXUVR EHQLJQR FRQ OD H[FHSFLyQ GH GRV VLWXDFLRQHV /DVSHUVRQDVLQPXQRVXSULPLGDV9,+6,'$7%&HQIHUPRVRQFROyJLFRV )HWRVRQLxRVTXHKDQDGTXLULGRODLQIHFFLyQLQ~WHURWUDQVPLWLGDVSRUVXVPDGUHVD WUDYpVGHODSODFHQWD(VWHULHVJRVRORH[LVWHFXDQGRODPXMHUDGTXLHUHODLQIHFFLyQ DJXGDGXUDQWHHOHPEDUD]R /D WR[RSODVPRVLV FRQJpQLWD SXHGH SURYRFDU VHYHURV GDxRV WDOHV FRPR PXHUWH IHWDO FRULRUUHWLQLWLV FDOFL¿FDFLRQHV LQWUDFHUHEUDOHV PLFUR R KLGURFHIDOLD TXH SXHGHQ GHWHUPLQDU UHWDUGR PHQWDO FRQYXOVLRQHV FHJXHUD HWF 7LHQH XQD IUHFXHQFLD TXH VH HVWLPD SDUD ORV SDtVHV GHVDUUROODGRV HQ WRUQR D FDVR FDGD QDFLGRV YLYRV OD SUHYDOHQFLD GH PXMHUHV VXVFHSWLEOHV HV DOWDPHQWH YDULDEOH HQ ORV GLIHUHQWHV SDtVHV \ DXQ HQ ODV GLIHUHQWHV FLXGDGHV \ PXQLFLSLRV GH XQ PLVPR SDtV /D VLWXDFLyQ HQ /DWLQRDPpULFDHQWpUPLQRVHSLGHPLROyJLFRVHVGHVFRQRFLGDSHURH[LVWHQLQIRUPHVGH DOJXQRVSDtVHVTXHLQGLFDQSUHYDOHQFLDVVLPLODUHVDODGHORVSDtVHVGHVDUUROODGRV +D\YDULRVHVWXGLRVTXHFRLQFLGHQHQHVWDEOHFHUTXHHOULHVJRGHODWUDQVPLVLyQPDGUH ±KLMRHVPtQLPRHQHOSULPHUWULPHVWUH\Pi[LPRHQHO~OWLPRPHV8QHVWXGLRUHFLHQWH DFHUFDGHOULHVJRGHODWUDQVPLVLyQPDGUH±KLMRHVWLPDTXHDXPHQWDGHDODV VHPDQDVKDVWDXQDODVVHPDQDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD ([LVWHFRQWURYHUVLDVREUHODQHFHVLGDGGHLPSOHPHQWDUSURJUDPDVGHWDPL]DMHXQLYHUVDO SDUD7R[RSODVPRVLV (Q OR TXH KD\ FRLQFLGHQFLD HV HQ LPSOHPHQWDU DO FRPLHQ]R GHO HPEDUD]RPHGLGDVHGXFDWLYDV\GHKLJLHQHSDUDODSUHYHQFLyQ (O GH ODV LQIHFFLRQHV SULPDULDV SRU WR[RSODVPRVLV HQ HPEDUD]DGDV LQPXQRFRPSHWHQWHVVRQDVLQWRPiWLFDVHOGLDJQyVWLFRGHODLQIHFFLyQPDWHUQDHVVyOR GLDJQRVWLFDEOHSRUVHURFRQYHUVLyQGHWHFWDEOHSRU,J*R,J0 (QOD+&3GHO&/$3605VHLQFOX\yXQUHFRUGDWRULRJHQHUDO SDUDHOWDPL]DMHHQDTXHOORVSDtVHVTXHDVtORGLVSRQHQHQVXV QRUPDVQDFLRQDOHVSHURD~QHQORVTXHQRVHKDFHWDPL]DMH VHUYLUiSDUDTXHORVSURIHVLRQDOHVGHVDOXGUHFXHUGHQDODV PXMHUHVJHVWDQWHVODVPHGLGDVHGXFDWLYDVSUHYHQWLYDV Figura 26. Fragmento de HCP. Toxoplasmosis. &XDGUR0HGLGDVHGXFDWLYDVDQWHVHURORJtDQHJDWLYDSDUDWR[RSODVPRVLV (OLPLQDUHOFRQVXPRGHFDUQHFUXGDRSRFRFRFLGD 8VDUJXDQWHV\ODYDUVHODVPDQRVLQWHQVDPHQWHGHVSXpVGHPDQLSXODUFDUQHFUXGD /DYDUSURIXQGDPHQWHWRGRVORVXWHQVLOLRVTXHHVWXYLHURQHQFRQWDFWRFRQFDUQHFUXGD /DYDUSURIXQGDPHQWHORVYHJHWDOHVTXHVHFRPHUiQFUXGRV 8VDU JXDQWHV FDGD YH] TXH VH HVWp HQ FRQWDFWR FRQ WLHUUD < ODYDU ODV PDQRV LQWHQVDPHQWHGHVSXpVGHWRFDUODWLHUUD 0DQWHQHUORVJDWRVGRPpVWLFRVGHQWURGHODFDVD\DOLPHQWDUORVFRQUDFLRQHV 8VDUJXDQWHVPLHQWUDVVHOLPSLDOD³FDPD´\ODYDUVHODVPDQRVGHVSXpVGHKDFHUOR (QHOVLJXLHQWHFXDGURVHUHVXPHQFXDWURSRVLEOHVVLWXDFLRQHVTXHVHH[WLHQGHQGHVGHORV FDVRVHQORVTXHVHHIHFW~DHOWDPL]DMH\DTXHOORVHQORVTXHQRVHUHDOL]D &XDGUR$QiOLVLVIUHQWHDGLIHUHQWHVVLWXDFLRQHVHQHOWDPL]DMHGHWR[RSODVPRVLV Posibles resultados Interpretación Conducta - No hay infección. Existe riesgo de contraerla Comunicar medidas de protección. Eventual repetición de IgG según norma nacional + - Infección pasada Continuar control en forma habitual + + Infección actual Evaluar riesgo de infección fetal. Evaluar realización de tratamiento médico Riesgo desconocido Comunicar medidas de protección realizar tamizaje según norma nacional IgG IgM - No se hizo No se hizo &RQGXFWD $XQTXHH[LVWHQGXGDVVREUHODHIHFWLYLGDGGHOWUDWDPLHQWRGHODWR[RSODVPRVLVGXUDQWH HOHPEDUD]RKD\DFXHUGRHQTXHODVPXMHUHVFRQXQDWR[RSODVPRVLVDFWLYDGHEHUiQ VHUUHIHULGDVDFRQWUROGHDOWRULHVJRSDUDVXFRUUHFWRHVWXGLR\HYHQWXDOWUDWDPLHQWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &XDGUR6XJHUHQFLDGHWUDWDPLHQWRHQHPEDUD]DGDVFRQLQIHFFLyQ WR[RSOiVPLFDFRQWUDtGDGXUDQWHHOHPEDUD]R 6LWXDFLyQFOtQLFD 7UDWDPLHQWR 'RVLV 'XUDFLyQ Infección aguda Hasta el final materna sin 3 g/día oral repartidos en 3 dosis, del embarazo o Espiramicina confirmación de (separados de las comidas) que se confirme infección fetal infección fetal. Dosis carga: 100 mg/día oral, Hasta final del Pirimetamina divididos en 2 dosis, durante 2 días. embarazo Continua: 50 mg/día oral Dosis carga: 75 mg/Kg/día oral, divididos en 2 dosis, durante 2 días. Hasta final del Infección fetal Sulfadiazina Máximo 4 g/día. embarazo confirmada (entre Continua: 100 mg/Kg/día oral las 12 y 18 emanas) divididos en 2 dosis. Máximo 4 g/día. Durante y hasta una semana Acido folínico 5 a 20 mg/día después de usar la Pirimetamina. (PEDUD]DGDDFRQWURODU 6L ,J*DFRQVXOWD 1R VHP 3RVLWLYR 1HJDWLYR ,J0 7tWXORVDQWLJXRV GH,J* 5HVXOWDGR 1HJDWLYR 3RVLWLYR &RQVHMHUtD 3UREDEOH LQIHFFLyQDJXGD 3RVLWLYR ,J* !VHP 1HJDWLYR 3UREDEOHLQIHFFLyQDJXGD 1RKD\ULHVJR 1RUHTXLHUHPiVFRQWUROHV 5HIHULUSDUDHYDOXDFLyQ\ WUDWDPLHQWRHQDOWRULHVJR &RQWURO5HFLpQ1DFLGR )LJXUD(VTXHPDHVFDORQDGRGHGHZFLVLRQHVSDUDODGHWHFFLyQSUHYHQFLyQ\ WUDWDPLHQWRGHODWR[RSODVPRVLVHQHOHPEDUD]R +HSDWLWLV% /D+HSDWLWLV%HVXQDLQIHFFLyQTXHFRQWUDHQODVPXMHUHVVXVFHSWLEOHVDOHQWUDUHQFRQWDFWR FRQVDQJUHVHPHQ\RVDOLYDGHXQDSHUVRQDLQIHFWDGD\TXHSXHGHVHUWUDQVPLWLGDDO UHFLpQQDFLGRSRUHOFRQWDFWRFRQVDQJUHPDWHUQDRGXUDQWHHODPDPDQWDPLHQWR (O HPEDUD]R QR DOWHUD HO FXUVR GH OD HQIHUPHGDG \ DSDUHQWHPHQWH OD +HSDWLWLV % QR FDXVDUtDWHUDWRJpQHVLVSHURVHKDYLVWRXQDUHODFLyQHQWUHKHSDWLWLVSUHPDWXUH]\5&, 6H HVWLPD TXH GH FDGD UHFLpQ QDFLGRV GH PDGUHV LQIHFWDGDV GXUDQWH HO WHUFHU WULPHVWUH VHUiQ SRUWDGRUHV DVLQWRPiWLFRV FDSDFHV GH VXIULU XQD KHSDWLWLV FUyQLFD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (VWDV UD]RQHV DYDODQ HO WDPL]DMH VLVWHPiWLFR GH ORV DQWtJHQRV GH VXSHU¿FLH GH OD +HSDWLWLV%HQODSULPHUDYLVLWDSUHQDWDO&RQHVWRVHSXHGHLGHQWL¿FDUDODVPXMHUHV VXVFHSWLEOHV\HYLWDUODLQIHFFLyQPHGLDQWHODDSOLFDFLyQGHODYDFXQDHVSHFt¿FDD~Q GXUDQWHHOHPEDUD]R$XQTXHVXHOHVHUPiVIUHFXHQWHODYDFXQDFLyQGHODVJHVWDQWHV TXHSUHVHQWDQIDFWRUHVGHULHVJRSDUDODKHSDWLWLV%WDOHVFRPRGURJDVLQWUDYHQRVDV WUDQVIXVLRQHVWDWXDMHVHWF /D YDFXQD VH DSOLFD HQ WUHV GRVLV \ JHQHUD UiSLGD LQPXQLGDG (Q FDVR GH PXMHUHV VHURQHJDWLYDV QR YDFXQDGDV TXH VH KDQ H[SXHVWR D +HSDWLWLV % SXHGH VHU ~WLO OD DSOLFDFLyQGHJDPDJOREXOLQDKLSHULQPXQHDQWL+HSDWLWLV%J*+DQWL+%HQODVSULPHUDV KRUDVTXHVLJXHQDOFRQWDFWRLQIHFWDQWH (QORVUHFLpQQDFLGRVGHPDGUHVVHURSRVLWLYDVVHUHFRPLHQGDSURWHJHUORVFRQHOXVR GHJ*+DQWL+%LQPHGLDWDPHQWHGHVSXpVGHQDFHU 'HELGRDTXHHVWDHVXQDLQIHFFLyQTXHSXHGHWUDQVPLWLUVHDORVWUDEDMDGRUHVGHVDOXGVH HVWLPXODODSURWHFFLyQVLVWHPiWLFDFRQYDFXQDGHWRGRVORVSURIHVLRQDOHVGHOD6DOXG 9,+6,'$ /D SDQGHPLD GHO YLUXV GH LQPXQRGH¿FLHQFLD KXPDQD HV XQD LQIHFFLyQ TXH VH GLVWULEX\H HQ WRGRVORVJUXSRVHWDULRVSULQFLSDOPHQWHHQWUHORVDGROHVFHQWHV\MyYHQHVDDxRV\TXH DIHFWDFDGDYH]PiVDPXMHUHV\QLxRV/DPD\RUtDGHORVQLxRVTXHFRQWUDMHURQODLQIHFFLyQOR KLFLHURQPHGLDQWHODWUDQVPLVLyQPDWHUQRLQIDQWLOTXHSXHGHSURGXFLUVHGXUDQWHHOHPEDUD]RHO WUDEDMRGHSDUWRHOSDUWRRGXUDQWHODODFWDQFLDPDWHUQD6LQQLQJ~QWLSRGHLQWHUYHQFLyQHQODV SREODFLRQHVHQODVTXHVHVXSULPHODODFWDQFLDPDWHUQDHOULHVJRGHODWUDQVPLVLyQHVGHD /DODFWDQFLDPDWHUQDDXPHQWDHOULHVJRGHODWUDQVPLVLyQGHXQDXQ /RV (VWDGRV 0LHPEURV GH OD 206 UHD¿UPDURQ HQ OD FXPEUH GH ODV 1DFLRQHV 8QLGDV HQ VHSWLHPEUH GH HO FRPSURPLVR SOHQR SDUD FXPSOLUODGHFODUDFLyQGHO81*$66GHTXHFRQVLVWHHQUHGXFLUSDUD HOODSURSRUFLyQGHODFWDQWHVLQIHFWDGRVSRUHO9,+HQXQ 3DUDHOORHVQHFHVDULRFRQRFHUHOHVWDGRVHUROyJLFRGHODVHPEDUD]DGDV \DTXHHOULHVJRGHWUDQVPLVLyQYHUWLFDOSXHGHUHGXFLUVHDPHQRVGH PHGLDQWHLQWHUYHQFLRQHVFRPRODSUR¿OD[LVFRQDQWLUUHWURYtULFRV$59 ODFHViUHDHOHFWLYDDQWHVGHOLQLFLRGHOWUDEDMRGHSDUWR\ODUXSWXUDGH )LJXUD PHPEUDQDV\ODVXSUHVLyQWRWDOGHODPDPDQWDPLHQWR )UDJPHQWRGH+&39,+ 3RUHVWDUD]yQ206\81$,'6UHFRPLHQGDQRIUHFHUODSUXHEDGHGHWHFFLyQGHODLQIHFFLyQSRU 9,+DWRGDVODVPXMHUHVTXHDFXGHQDORVVHUYLFLRVGHDWHQFLyQPDWHUQRLQIDQWLO $VHJXUDQGR &RQ¿GHQFLDOLGDG &RQVHMHUtD\ 5HDOL]DFLyQGHODSUXHED~QLFDPHQWHGHVSXpVGHREWHQHUFRQVHQWLPLHQWRLQIRUPDGR 5HDOL]DGDVGHPDQHUDDGHFXDGDODFRQVHMHUtDMXQWRDODFRQ¿GHQFLDOLGDGDXPHQWDQODSUREDELOLGDG TXHODPXMHUDFFHGDDWHQHUODSUXHEDHQIRUPDYROXQWDULDHLQIRUPDGD7RGRHOSHUVRQDOGHVDOXG SXHGHEULQGDUFRQVHMHUtDVLVHHQFXHQWUDHQWUHQDGR/RVVHUYLFLRVGHEHUiQJDUDQWL]DUHODFFHVR DODVSUXHEDVGHWDPL]DMHSUXHEDVUiSLGDVGHPXHVWUDVGHVDQJUHRVDOLYDRSUXHEDGH(OLVD VLHVWDVVRQUHDFWLYDVGHEHUiQHIHFWXDUVHWHVWFRQ¿UPDWRULRVPHGLDQWHWpFQLFDGH:HVWHUQEORWR SRULQPXQRÀXRUHVFHQFLD/DVSHUVRQDV9,+SRVLWLYDVGHEHUiQVHUDFRQVHMDGDVVREUHGHUHFKRV FRQGXFWDVDVSHFWRVSVLFRVRFLDOHVHLPSOLFDQFLDVPpGLFDVGHODLQIHFFLyQSRU9,+\GHEHUtDQVHU SXHVWDVHQFRQWDFWRFRQVHUYLFLRVHVSHFLDOL]DGRV\UHFLELUWUDWDPLHQWRGHDFXHUGRDODVQRUPDV QDFLRQDOHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR /D236KDSXEOLFDGRXQDJXtDFOtQLFDSDUDODHOLPLQDFLyQGHODWUDQVPLVLyQPDWHUQRLQIDQWLOGHO 9,+\GHODVt¿OLVFRQJpQLWDHQ$PpULFD/DWLQD\HO&DULEHTXHSUHVHQWDODVSDXWDVGHWUDWDPLHQWR FRPSOHWDV3XEO&/$31 /DVHPEDUD]DGDVFRQ9,+GHEHUiQUHFLELUODSUR¿OD[LVFRQDQWLUUHWURYtULFRV =LGRYXGLQD$=7GXUDQWHHOHPEDUD]RDSDUWLUGHODVVHPDQDV $=7\/DPLYXGLQD7&PiVXQD~QLFDGRVLVGH1HYLUDSLQD193GXUDQWHHOSDUWR $=7GXUDQWHXQDVHPDQD\GRVLV~QLFDGH193SDUDHOUHFLpQQDFLGR6LODPDGUHUHFLELy PHQRVGHVHPDQDVGH$=7GXUDQWHHOHPEDUD]RVHUHFRPLHQGDSURORQJDUDVHPDQDV HO$=7DOQLxR 5HFRPHQGDFLRQHVSDUDWLSRGHSDUWRHQPXMHUHVHPEDUD]DGDVFRQ9,+ &HViUHDSURJUDPDGDDODVVHPDQDVDDTXHOODVPXMHUHVTXH 1RWHQJDQXQDFDUJDYLUDOKHFKDHQHOWHUFHUWULPHVWUHGHOHPEDUD]R 7HQJDQXQDFDUJDYLUDO!FRSLDVPO 2IUHFHUSDUWRYDJLQDODDTXHOODVPXMHUHVVLQLQGLFDFLyQREVWpWULFDGHFHViUHDHQ7$59 HVWDEOH EXHQD DGKHUHQFLD \ FDUJD YLUDO UHDOL]DGD HQ HO ~OWLPR WULPHVWUH GHO HPEDUD]R FRSLDVPO$,93XEO&/$31 3DUDUHGXFLUDOPtQLPRHOULHVJRGHWUDQVPLVLyQGHO9,+DORVQLxRVHOJUXSRGHH[SHUWRVGH OD5HJLyQGHODV$PpULFDVSURSXVRUHIRU]DUODHVWUDWHJLDGHVXSULPLUODODFWDQFLDPDWHUQD HQORVKLMRVGHPXMHUHVFRQ9,+(QHVWHVHQWLGROD236RPVUHFRPLHQGDHYLWDUODODFWDQFLD PDWHUQDVLHPSUH\FXDQGRHVWDRSFLyQVHDDFHSWDEOHIDFWLEOHDVHTXLEOHVRVWHQLEOH\VHJXUD $)$66 /DSUR¿OD[LVFRQ7$59WULSOHWHUDSLDUHDOL]DGRDPXMHUHVFRQ9,+TXHQRUHTXLHUDQWUDWDPLHQWR KDGHPRVWUDGRVHUPX\HIHFWLYDHQUHGXFLUODWUDQVPLVLyQYHUWLFDOGHO9,+/DVJHVWDQWHVFRQ9,+ TXHHVWiQHQWUDWDPLHQWRUHTXLHUHQUHYLVLyQGHVXWUDWDPLHQWRSRUHOHVSHFLDOLVWDSDUDRSWLPL]DUOR \PLQLPL]DUODSRVLELOLGDGGHWR[LFLGDG 2EMHWLYR $FWLYLGDG 3UHYHQLUODVt¿OLVFRQJpQLWD 7DPL]DMH\WUDWDPLHQWRGHODVt¿OLVHQODVHPEDUD]DGDV /DVt¿OLVFRQWLQXDVLHQGRXQJUDYHSUREOHPDGHVDOXGS~EOLFDVHFDOFXODTXHFDGDDxR KD\PiVGHPLOORQHVGHQXHYDVLQIHFFLRQHVSRU7UHSRQHPDSDOOLGXPGHORVFXDOHV PiVGHPLOORQHVVHSURGXFHQHQPXMHUHVHPEDUD]DGDV'HEHPHQFLRQDUVHTXH$/& WLHQHXQDWDVDHVWLPDGDGHVt¿OLVPDWHUQDPiVDOWDTXHFXDOTXLHURWUDUHJLyQHVWLPDGD SRUOD206HQWUH\HQ&RQGLFKDWDVDVHFDOFXODTXHSXHGHKDEHU DSUR[LPDGDPHQWHFDVRVGHVt¿OLVJHVWDFLRQDOHQOD5HJLyQGHODV$PpULFDV H[FHSWXDQGR((88\&DQDGiRULJLQDQGRFDGDDxRGHDFDVRVGH Vt¿OLVFRQJpQLWD6&(QODPD\RUSDUWHGHHVWRVFDVRVODLQIHFFLyQHVWUDQVPLWLGDDO IHWRHQJHQHUDOHQWUHODVVHPDQDV\GHHPEDUD]R\FRQOOHYDXQSURQyVWLFRIDWDO HQHOGHFDVRV /D 236 SRU UHVROXFLyQ GH ORV SDtVHV PLHPEURV KD GHVDUUROODGR HO ³3ODQ SDUD OD HOLPLQDFLyQ GH OD Vt¿OLV FRQJpQLWD´ HO TXH SUHWHQGH UHGXFLU OD LQFLGHQFLD GH Vt¿OLV FRQJpQLWD D PHQRV GH FDVRV SRU QDFLGRV LQFOXLGRV PRUWLQDWRV /D 236MXQWRFRQRWUDVRUJDQL]DFLRQHVSURSRQHLPSXOVDUXQD,QLFLDWLYDUHJLRQDOSDUDOD HOLPLQDFLyQGHODWUDQVPLVLyQPDWHUQRLQIDQWLOGHO9,+\GHODVt¿OLVFRQJpQLWDHQ$PpULFD /DWLQD\HO&DULEH /DVt¿OLVHVXQD,76SURYRFDGDSRUXQDHVSLURTXHWDHO7UHSRQHPDSDOOLGXPTXHGHMDGD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD HYROXFLRQDUWLHQHHVWDGLRVFDUDFWHUtVWLFRV3XHGHVHUDVLQWRPiWLFDRSUHVHQWDUHOVLJQR PiVSUHFR]FKDQFURHQXQOXJDURFXOWRTXHORKDJDSDVDUGHVDSHUFLELGR$VtTXHD WRGDPXMHUHPEDUD]DGDVHOHGHEHUiUHDOL]DUSUXHEDVSDUDHOWDPL]DMHGHVt¿OLVGXUDQWH HOHPEDUD]R &/$3605236KDLQFRUSRUDGRHQOD+&3ODSRVLELOLGDGGHUHJLVWUDUGRVFRQWUROHV SDUDHOWDPL]DMHGHODVt¿OLVGHDFXHUGRDORVTXHUHFRPLHQGDQODVPHMRUHVHYLGHQFLDV \HQFRQFRUGDQFLDFRQODPD\RUtDGHODVJXtDVQRUPDWLYDVGHOD5HJLyQ /DVHFXHQFLDFURQROyJLFDUHFRPHQGDGDFRQVLVWHHQ HIHFWXDUODSULPHUDSUXHEDDOPRPHQWRGHODFDSWDFLyQDQWHVGHODVVHPDQDV \UHDOL]DUVLJXLHQWHHQHOWHUFHUWULPHVWUH 6HDJUHJyXQHVSDFLRGHVWLQDGRDUHJLVWUDUVLHUDRQRQHFHVDULRHIHFWXDUHOWUDWDPLHQWR \ HQ FDVR GH VHUOR VL HO PLVPR VH UHDOL]y 7DPELpQ VH LQFOX\H HO WUDWDPLHQWR GH OD SDUHMD(QHOHPEDUD]RHVWDQLPSRUWDQWHHOWUDWDPLHQWRGHODHPEDUD]DGDFRPRHO GHVXSDUHMD/DIDOWDGHWUDWDPLHQWRGHODSDUHMDHVODSULQFLSDOIXHQWHGHUHLQIHFFLyQ GXUDQWH HO HPEDUD]R (Q WRGDV ODV YLVLWDV VH GHEH SURSRUFLRQDU FRQVHMHUtD D ¿Q GH UHGXFLU HO ULHVJR GH DGTXLULU Vt¿OLV R 9,+ GXUDQWH HO HPEDUD]R 6H UHFRPLHQGD HQ DTXHOODV VLWXDFLRQHV HQ TXH VH VRVSHFKD TXH QR KDEUi FRQWLQXLGDG HQ HO FRQWURO SUHQDWDOVLHPSUHTXHKD\DGLVSRQLELOLGDGUHDOL]DUSUXHEDVUiSLGDVSDUDFRQWDUFRQ XQGLDJQyVWLFRLQPHGLDWR 6,),/,6'LDJQyVWLFR\7UDWDPLHQWR 3UXHED 7UDWDPLHQWR QRWUHSRQpPLFD WUHSRQpPLFD VG QR VL VHP VG VG QF VG QF VHPDQDV VHPDQDV VHPDQDV VHPDQDV VHP 3UXHEDVGLDJQyVWLFDV VG QF QR VL VG QF 7WRGHOD SDUHMD QR VL VG QF QR VL VG QF )LJ)UDJPHQWRGH+&36t¿OLV (OGLDJQyVWLFRVHUROyJLFRGHODVt¿OLVVHEDVDHQODUHDOL]DFLyQGHSUXHEDVWUHSRQpPLFDV \SUXHEDVQRWUHSRQpPLFDV /DVSUXHEDVQRWUHSRQpPLFDVLQFOX\HQHO9'5/9HQHUHDO'LVHDVH5HVHDUFK/DERUDWRU\ \ HO 535 UDSLG SODVPD UHDJLQ 8QD SUXHED QR WUHSRQpPLFD UHDFWLYD SXHGH LQGLFDU LQIHFFLyQDFWXDOLQIHFFLyQUHFLHQWHWUDWDGDRQRWUDWDGDRXQUHVXOWDGRIDOVRSRVLWLYR /RVUHVXOWDGRVIDOVRVSRVLWLYRVRFXUUHQHQDOGHODSREODFLyQ\HQJHQHUDOWLHQHQ XQ WtWXOR EDMR 3XHGHQ VHU QHJDWLYDV HQ IDVHV LQLFLDOHV GH OD LQIHFFLyQ R FXDQGR HO WtWXORHVPX\DOWRIHQyPHQRGHSUR]RQD\VXHOHQQHJDWLYL]DUVHRGLVPLQXLUDWtWXORV PX\ EDMRV GHVSXpV GHO WUDWDPLHQWR (Q ORV FDVRV GH Vt¿OLV WUDWDGD FRUUHFWDPHQWH HO 9'5/WLHQGHDQHJDWLYL]DUVHFRQHOSDVRGHOWLHPSRDXQTXHHQFDVRVH[FHSFLRQDOHV VHSXHGHPDQWHQHUSRVLWLYRGXUDQWHPXFKRWLHPSRGHSRUYLGD3XHGHQYHUVHIDOVRV SRVLWLYRVHQHQIHUPHGDGHVDXWRLQPXQHVWXEHUFXORVLVPRQRQXFOHRVLVHQGRFDUGLWLV\ HQHOSURSLRHPEDUD]R /DV SUXHEDV WUHSRQpPLFDV VRQ SUXHEDV HVSHFt¿FDV PiV FRPSOHMDV \ FRVWRVDV H LQFOX\HQHO73+$7UHSRQHPDSDOOLGXPKDHPDJJOXWLQDWLRQDVVD\HO733$7UHSRQHPD SDOOLGXPSDUWLFOHDJJOXWLQDWLRQHO0+$73PLFURKDHPDJJOXWLQDWLRQDVVD\IRUDQWLERGLHV WR 7UHSRQHPD SDOOLGXP \ HO )7$$EV ÀXRUHVFHQW WUHSRQHPDO DQWLERG\ DEVRUSWLRQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 6HXWLOL]DQSDUDFRQ¿UPDUXQUHVXOWDGRGHXQDSUXHEDQRWUHSRQpPLFD/DVWpFQLFDV PiVXWLOL]DGDVVRQHO0+$73\)7$$EV (VWDV SUXHEDV SHUVLVWHQ SRVLWLYDV LQGHSHQGLHQWHPHQWH GHO WUDWDPLHQWR \ SXHGHQ REVHUYDUVHIDOVRVSRVLWLYRVPHQRVGHOHQRWUDVHQIHUPHGDGHVSRUHVSLURTXHWDV OHSWRVSLURVLVHQIHUPHGDGGH/\PH¿HEUHSRUPRUGHGXUDGHUDWDVHQHVWRVFDVRV VXHOH HVWDU SUHVHQWH HO DQWHFHGHQWH HSLGHPLROyJLFR LQIHFWLYR $Vt VL XQD SUXHED WUHSRQpPLFDHVSRVLWLYD\QRVHUH¿HUHWUDWDPLHQWRSUHYLR\RQRVHGDQODVFRQGLFLRQHV FLWDGDVVHGHEHWUDWDU /DV³SUXHEDVUiSLGDV´VRQSUXHEDVVHQFLOODVTXHVHSXHGHQXWLOL]DUHQHOOXJDUGHOD FRQVXOWDSURSRUFLRQDQGRUHVXOWDGRVHQPLQXWRVORTXHSRVLELOLWDUHDOL]DUHOWUDWDPLHQWR HQIRUPDLQPHGLDWD6XHOHQVHUWLUDVUHDFWLYDVLPSUHJQDGDVFRQDQWtJHQRVWUHSRQpPLFRV TXHVHWRUQDQSRVLWLYRVGDQGRXQDUHDFFLyQHQFRORUHQFRQWDFWRFRQVXHURSODVPDR VDQJUHGHXQSDFLHQWHFRQDQWLFXHUSRVSDUDVt¿OLV7LHQHQXQWLHPSRGHOHFWXUDUiSLGR PHQRUDPLQXWRV\VHODVLQFOX\HHQODVSUXHEDVWUHSRQpPLFDV([LVWHQPiVGH SUXHEDVHQHOPXQGRFRQYDULRVJUDGRVGHVHQVLELOLGDG\HVSHFL¿FLGDG\VHFXHQWD FRQDOJXQRVHVWXGLRVGHFRPSDUDFLyQ\FRVWRHIHFWLYLGDG6RQHVSHFLDOPHQWH~WLOHV FXDQGRQRVHFXHQWDFRQSUXHEDVWUHSRQpPLFDVHVWiQGDU&XDQGRODVSUXHEDVUiSLGDV VRQ SRVLWLYDV VH UHDOL]DQ ODV SUXHEDV QR WUHSRQpPLFDV TXH SHUPLWHQ D WUDYpV GH OD FXDQWL¿FDFLyQHYDOXDUODUHVSXHVWDDOWUDWDPLHQWR 2WUDVSUXHEDVGHODERUDWRULRSDUDHOGLDJQyVWLFRGHODVt¿OLV 9LVXDOL]DFLyQGHODVHVSLURTXHWDV(QHWDSDVPX\WHPSUDQDVGHODLQIHFFLyQFXDQGR DSHQDVVHSXHGHYHUHOFKDQFURGHLQRFXODFLyQ\ORVHVWXGLRVVHUROyJLFRVVXHOHQVHU QRUHDFWLYRVVHSRGUiKDFHUGLDJQyVWLFRGHFRQ¿UPDFLyQDOYHUDODVHVSLURTXHWDVDOD PLFURVFRStDGHFDPSRRVFXURRSUXHEDVGHLQPXQRÀXRUHVFHQFLDGLUHFWDFRQWRPDGH PDWHULDOGHODOHVLyQ &XDGUR5HVXOWDGRVHLQWHUSUHWDFLyQGHODVSUXHEDVVHUROyJLFDV 5HVXOWDGR 17 7 17 7 17 7 17 7 ,QWHUSUHWDFLyQ $XVHQFLDGHLQIHFFLyQ6LODH[SRVLFLyQHVPX\UHFLHQWHVHUHFRPLHQGD UHSHWLUODVSUXHEDV ,QIHFFLyQDFWLYDHQHVSHFLDOFRQWtWXORVDOWRV!GHODSUXHEDQR WUHSRQpPLFD$WtWXORVEDMRVSXHGHGHEHUVHDXQDVt¿OLVDQWLJXDWUDWDGD (QJHQHUDOVHGHEHDXQDVt¿OLVDQWLJXDWUDWDGDQRDFWLYD ([FHSFLRQDOPHQWHSXHGHVHUXQIDOVRSRVLWLYRGHODSUXHEDWUHSRQpPLFD 6HUHFRPLHQGDUHSHWLUXWLOL]DQGRRWURPpWRGRGHSUXHEDWUHSRQpPLFD 6LFRQWLQ~DVLHQGRQHJDWLYDVHWUDWDGHXQUHVXOWDGRIDOVDPHQWHSRVLWLYR GHODSUXHEDQRWUHSRQpPLFD\DXVHQFLDGHLQIHFFLyQ 17SUXHEDQRWUHSRQpPLFD7SUXHEDWUHSRQpPLFD 7UDWDPLHQWRGHODHPEDUD]DGD (O WUDWDPLHQWR GH OD Vt¿OLV HQ XQD PXMHU HPEDUD]DGD GHEH LQLFLDUVH GH LQPHGLDWR GHVSXpVGHREWHQHUHOUHVXOWDGRGHXQDSUXHEDGHWDPL]DMHSRVLWLYDWUHSRQpPLFDRQR SUHIHULEOHPHQWHHQHOSULPHUQLYHOGHDWHQFLyQDPHQRVTXHODVFRQGLFLRQHVGHODPXMHU UHTXLHUDQXQDDWHQFLyQGHPD\RUFRPSOHMLGDG&RQYLVWDVDODSUHYHQFLyQGHODVt¿OLV FRQJpQLWDVHFRQVLGHUDDGHFXDGRVLVHKDFHDOPHQRVXQPHVDQWHVGHOSDUWR (O WUDWDPLHQWR SDUD Vt¿OLV SULPDULD VHFXQGDULD \ Vt¿OLV ODWHQWH WHPSUDQD FRQVLVWH HQ XQD GRVLV ~QLFD GH PLOORQHV GH XQLGDGHV GH SHQLFLOLQD EHQ]DWtQLFD * SRU YtD LQWUDPXVFXODU &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (O WUDWDPLHQWR SDUD OD Vt¿OLV ODWHQWH WDUGtD R Vt¿OLV ODWHQWH GH GXUDFLyQ GHVFRQRFLGD FRQVLVWHHQPLOORQHVGHXQLGDGHVGHSHQLFLOLQDEHQ]DWtQLFD*HQWRWDODGPLQLVWUDGDV HQWUHVGRVLVXQDSRUVHPDQDGHPLOORQHVGHXQLGDGHVGHSHQLFLOLQDEHQ]DWtQLFD *SRUYtDLQWUDPXVFXODU 6HGHEHKDFHUSUXHEDSDUDVt¿OLVDWRGRVORVFRQWDFWRVVH[XDOHVLQIRUPDGRVSRU ODHPEDUD]DGD\WUDWDUDORVSRVLWLYRV/DUHLQIHFFLyQSRUODSDUHMDQRWUDWDGDHV XQDGHODVFDXVDVPiVLPSRUWDQWHVGHODVt¿OLVFRQJpQLWD 7RGDVODVPXMHUHVWUDWDGDVGHEHQVHUHYDOXDGDVFRQSUXHEDVVHUROyJLFDVFXDQWLWDWLYDV FRQXQDSHULRGLFLGDGGHDPHVHV8QDXPHQWRGHORVWtWXORVLJXDORVXSHULRUD YHFHVFRQVWLWX\HLQGLFDFLyQGHQXHYRWUDWDPLHQWRDOFRQVLGHUDUVHIUDFDVRWHUDSpXWLFR UHLQIHFFLyQRQHXURVt¿OLVTXHDGHPiVUHTXLHUHHOHVWXGLRGHOtTXLGRFpIDORUDTXtGHRVL KD\GLVSRQLELOLGDGSDUDHVWDSUXHED /D DGPLQLVWUDFLyQ GHO WUDWDPLHQWR GHEH VHU VXSHUYLVDGD \ UHJLVWUDUVH HQ OD KLVWRULD FOtQLFD6LQRVHHQFXHQWUDHYLGHQFLDHQODKLVWRULDFOtQLFDGHVXDGPLQLVWUDFLyQHO UHFLpQQDFLGRGHEHUtDVHUFRQVLGHUDGRXQFDVRGHVt¿OLVFRQJpQLWD /DUHDFFLyQGH-DULVK+HU[KHLPHUHVXQDUHDFFLyQFRQVLVWHQWHHQ¿HEUH\PDOHVWDGR JHQHUDOGHELGRDODOLEHUDFLyQGHDQWtJHQRVSRUODPXHUWHGHORVWUHSRQHPDV&XDQGR HO WUDWDPLHQWR VH UHDOL]D HQ OD VHJXQGD PLWDG GHO HPEDUD]R HVWD UHDFFLyQ SRGUtD H[FHSFLRQDOPHQWHGHVHQFDGHQDUHOWUDEDMRGHSDUWR 0DQHMRGHSDFLHQWHVFRQSRVLEOHDOHUJLDDODSHQLFLOLQD 1RH[LVWHQDOWHUQDWLYDVDODSHQLFLOLQDGHH¿FDFLDGHPRVWUDGDSDUDHOWUDWDPLHQWR GHODQHXURVt¿OLVGHODVt¿OLVFRQJpQLWDGHODVt¿OLVHQPXMHUHVHPEDUD]DGDV3RU RWURODGRYROYHUDDGPLQLVWUDUSHQLFLOLQDDXQSDFLHQWHFRQPDQLIHVWDFLRQHVDOpUJLFDV SUHYLDVSRGUtDFDXVDUUHDFFLRQHVJUDYHVHLQPHGLDWDV 6HHVWLPDTXHXQGHODVSHUVRQDVTXHUH¿HUHQKDEHUWHQLGRUHDFFLRQHVDOpUJLFDV JUDYHV D OD SHQLFLOLQD SHUPDQHFHQ DOpUJLFDV &RQ HO SDVR GHO WLHPSR OD PD\RUtD GH HVWDV SHUVRQDV GHMDQ GH SURGXFLU LQPXQRJOREXOLQDV ( HVSHFt¿FDV D OD SHQLFLOLQD 6L VH SXGLHUD GHWHUPLQDU TXH ODV ,J ( HVSHFt¿FDV KDQ GHVDSDUHFLGR HVWDV SHUVRQDV SRGUtDQVHUWUDWDGDVGHPDQHUDVHJXUDFRQSHQLFLOLQD([LVWHQSUXHEDVFXWiQHDVFRQ GHWHUPLQDQWHVPD\RUHV\PHQRUHVGHDOHUJLDDODSHQLFLOLQDTXHSRGUtDQLGHQWL¿FDUGH IRUPDH¿FD]DODVSHUVRQDVGHDOWRULHVJRGHVXIULUXQDUHDFFLyQFRQWUDODSHQLFLOLQD 0XMHUHVTXHFRQFXUUHQDOFRQWURO GHOHPEDUD]R 0XMHUHVTXHFRQFXUUHQHQWUDEDMR GHSDUWRVLQFRQWUROGHOHPEDUD]R 2IUHFHUVLVWHPiWLFDPHQWHFRQVHMHUtD \SUXHEDVSDUD9,+\6tILOLV 2IUHFHUVLVWHPiWLFDPHQWHFRQVHQWLPLHQWR LQIRUPDGR\SUXHEDVUiSLGDVSDUD9,+\6tILOLV 6HURORJtDSRVLWLYD 6HURORJtDQHJDWLYD 9,+\6tILOLV 3UHYHQFLyQ SULPDULD\ (YDOXDFLyQ GHULHVJR 5HSHWLU VHURORJtDV 9,+\6tILOLV HQHOWHUFHU WULPHVWUH 6HURORJtDQHJDWLYD 3UXHEDUiSLGDSRVLWLYD 9,+ ,QLFLDUFRPSRQHQWHV LQWUD\SRVWSDUWR GHOD370, 6tILOLV 7WRFRQ SHQLFLOLQD DODPXMHU\ VXVFRQWDFWRV 9,+ ,QLFLDU7$59 3URJDPDUHYDOXDFLyQ GH7$59\VHURORJtD DODVSDUHMDV 6tILOLV 7UDWDPLHQWR DODPXMHU VXVFRQWDFWRV \DOQHRQDWR 6HURORJtD QHJDWLYD 3UHYHQFLyQ DULD 3UHYHQFLyQDULD )LJXUD(VTXHPDHVFDORQDGRGHGHFLVLRQHVSDUDODGHWHFFLyQ\WUDWDPLHQWRGH Vt¿OLV\9,+HQHOHPEDUD]R &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 'HVHQVLELOL]DFLyQ /RVSDFLHQWHVFRQSUXHEDSRVLWLYDDXQRGHORVGHWHUPLQDQWHVGHODSHQLFLOLQDSXHGHQ VHUGHVHQVLELOL]DGRV(VXQSURFHVRUHODWLYDPHQWHVHJXURSHURODERULRVRTXHSXHGH VHUUHDOL]DGRGHIRUPDRUDORGHIRUPDLQWUDYHQRVD&XDGURDXQTXHODVGRVIRUPDV GHGHVHQVLELOL]DFLyQQRKDQVLGRFRPSDUDGDVODRUDOSDUHFHPiVVHJXUD\PiVIiFLOGH UHDOL]DU/DGHVHQVLELOL]DFLyQVHGHEHUHDOL]DUHQXQPHGLRKRVSLWDODULRGHELGRDTXHODV UHDFFLRQHVDOpUJLFDVDXQTXHSRFRIUHFXHQWHVSXHGHQRFXUULU/DGHVHQVLELOL]DFLyQVH SXHGHFRPSOHWDUHQFXDWURKRUDVGHVSXpVGHODVFXDOHVVHDGPLQLVWUDODSULPHUDGRVLV GH SHQLFLOLQD $OJXQRV DXWRUHV UHFRPLHQGDQ PDQWHQHU GRVLV GLDULDV EDMDV 8, SRU 92 GH SHQLFLOLQD KDVWD FRPSOHWDU ODV VHPDQDV /D GHVHQVLELOL]DFLyQ GHEH UHDOL]DUVHEDMRVXSHUYLVLyQPpGLFD\WHQLHQGRFRUWLFRLGHV\DGUHQDOLQDDGLVSRVLFLyQSRU VLVHSUHVHQWDUDDOJ~QHIHFWRVHFXQGDULR (VWHHVTXHPDGHEHUiUHSHWLUVHDQWHVGHFDGDGRVLVLQ\HFWDEOHVHPDQDO (Q FDVR GH QR SRGHU XWLOL]DU SHQLFLOLQD QR VH GLVSRQH GH DOWHUQDWLYDV HIHFWLYDV GH WUDWDPLHQWR 3RGUtD XWLOL]DUVH HULWURPLFLQD PJ K GXUDQWH GtDV &,,, TXH SXHGHQRVHUVX¿FLHQWHSDUDODPDGUHUHTXLULHQGRWUDWDPLHQWRFRQGR[LFLFOLQDWUDVHO SDUWRFRQPJGtDGXUDQWHGtDV(OWUDWDPLHQWRFRQHULWURPLFLQDGHODJHVWDQWH HVDEVROXWDPHQWHLQH¿FD]SDUDWUDWDUDOIHWRSRUORTXHVHDGPLQLVWUDUiSHQLFLOLQDDO QLxRVHJ~QHVTXHPDUHFRPHQGDGRPiVDGHODQWH &XDGUR3URWRFRORSDUDODGHVHQVLELOL]DFLyQRUDOSDUDSDFLHQWHVFRQSUXHED FXWiQHDSRVLWLYD 3HQLFLOLQD9 VXVSHQVLyQGHGRVLV &DQWLGDG 8,PO PO 8, 'RVLVDFXPXODGD 8, 3HUtRGRGHREVHUYDFLyQPLQXWRVDQWHVGHODDGPLQLVWUDFLyQSDUHQWHUDOGHODSHQLFLOLQD )XHQWH:HQGHO*2-U6WDUN%--DPLVRQ5%0HOLQD5'6XOOLYDQ7-3HQLFLOOLQDOOHUJ\DQGGHVHQVLWL]DWLRQLQVHULRXV LQIHFWLRQVGXULQJSUHJQDQF\1(QJO-0HG± (OLQWHUYDORHQWUHODVGRVLVHVGHPLQXWRVWLHPSRWUDQVFXUULGRKRUDV\PLQXWRVGRVLVDFXPXODGDPLOORQHV GHXQLGDGHV/DFDQWLGDGHVSHFL¿FDGHSHQLFLOLQDVHGLOX\HHQDSUR[LPDGDPHQWHPOGHDJXD\GHVSXpVVH DGPLQLVWUDRUDOPHQWH &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 5HSHUFXVLyQIHWRQHRQDWDO /DLQIHFFLyQGHORVIHWRVVHSURGXFHSRUHOSDVDMHWUDQVSODFHQWDULRGHODHVSLURTXHWD $XQTXH OD WUDQVPLVLyQ VXHOH RFXUULU HQ ORV GRV ~OWLPRV WULPHVWUHV GHO HPEDUD]R OD HVSLURTXHWD SXHGH DWUDYHVDU OD SODFHQWD HQ FXDOTXLHU PRPHQWR$GHPiV GH PXHUWH HQODHWDSDIHWDORQHRQDWDOORVQLxRVTXHQDFHQFRQVt¿OLVFRQJpQLWDSRGUiQSUHVHQWDU P~OWLSOHVPDQLIHVWDFLRQHVPXFRFXWiQHDVODVTXHVHREVHUYDQHQHOGHORVUHFLpQ QDFLGRV\SXHGHQVHUHYLGHQWHVHQODVSULPHUDVVHPDQDVGHYLGD /RVVtQWRPDVFXWiQHRVLQFOX\HQ 3pQ¿JRSDOPRSODQWDUYHVtFXODVDPSROORVDVHQSDOPDV\SODQWDVGHFRQWHQLGR WXUELR\YHUGRVRTXHVHURPSHQUiSLGDPHQWHGHMDQGRODGHUPLVGHVFXELHUWD 6L¿OLGHVPDFXORSDSXORVDV(QH[WUHPLGDGHV\]RQDVSHULRUL¿FLDOHV,QLFLDOPHQWH WLHQHQ XQ FRORU VRQURVDGR TXH OXHJR VH SLJPHQWDQ PDQFKDV FRORU FDIp FRQ OHFKH (GHPDGLIXVRGHODSLHO&RQDIHFWDFLyQSDOPRSODQWDU $ORSHFLDDQWHULRU 5DJDGtHVSHULEXFDOHV\HQHOPDUJHQSHULDQDO 8OFHUDFLyQGHODFLFDWUL]XPELOLFDOFKDQFUR /RVVtQWRPDVPXFRVRVLQFOX\HQ 5LQLWLVRFRUL]DVL¿OtWLFD(VHOVLJQRPiVSUHFR]GHODVt¿OLVFRQJpQLWDVHFUHFLyQ PXFRKHPRUUiJLFD\XOFHUDFLRQHVQDVRODELDOHV 7DPELpQSXHGHQSUHVHQWDUVtQWRPDVYLVFHUDOHVHQWUHORVTXHVHLQFOX\HQ +HSDWR\HVSOHQRPHJDOLD2WUDVYLVFHURPHJDOLDVVXHOHQDSDUHFHUWDUGtDPHQWH <VtQWRPDVyVHRVFRPR 1DUL]HQVLOODGHPRQWDU 7LELDVHQVDEOH 'LHQWHVGH+XWFKLQVRQ 2EMHWLYR 3UHYHQLU ODV FRQVHFXHQFLDV PDWHUQRSHULQDWDOHV GH RWUDV LQIHFFLRQHV GH WUDQVPLVLyQ VH[XDO ,76 \ RWUDV LQIHFFLRQHV GHO WUDFWRUHSURGXFWLYR,75 $FWLYLGDG 3UHYHQFLyQGHWHFFLyQ\WUDWDPLHQWR /D 6t¿OLV \ HO 9,+6,'$ \D KDQ VLGR GHVFULSWDV D FRQWLQXDFLyQ VH UHVXPHQ DOJXQRV DVSHFWRVGHRWUDV,76,75TXHGHEHQVHUWHQLGDVHQFXHQWDGXUDQWHHOFRQWUROGHXQD HPEDUD]DGD\DTXHUHSUHVHQWDQIUHFXHQWHVPRWLYRVGHFRQVXOWD )OXMRYDJLQDOOHXFRUUHD'XUDQWHHOHPEDUD]RKD\FDPELRVFXDQWLWDWLYRV\FXDOLWDWLYRV GHODÀRUDPLFURELDQDGHODYDJLQD$XPHQWDHOQ~PHURGHODFWREDFLORV\GLVPLQX\HQORV RUJDQLVPRVDQDHURELRV+D\XQDFRSLRVDVHFUHFLyQYDJLQDOFRQVLVWHQWHHQSURGXFWRV GHGHVIROLDFLyQGHOHSLWHOLR\EDFWHULDVTXHODKDFHQPDUFDGDPHQWHiFLGD 2WUDIXHQWHGHVHFUHFLyQGHPXFXVVHRULJLQDHQODVJOiQGXODVFHUYLFDOHVHQUHVSXHVWDDOD KLSHUHVWURJHQHPLD\TXHWLHQHXQHIHFWRSURWHFWRUDQWHODVLQIHFFLRQHVDVFHQGHQWHV /D OHXFRUUHD RFDVLRQDOPHQWH HV SDWROyJLFD HVWDQGR HQ VX JpQHVLV JpUPHQHV FRPR &iQGLGD DOELFDQV *DUGQHUHOOD YDJLQDOLV &KODPLGLDV WUDFKRPDWLV 7ULFKRPRQDV YDJLQDOLV0LFRSODVPD1HLVVHULDJRQRUUKRHDHHWF &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 0RQLOLDVLV YXOYRYDJLQDO SURYRFDGD SRU &iQGLGD DOELFDQV HVWi SUHVHQWH HQ HO GH ODV HPEDUD]DGDV DO WpUPLQR DXQTXH OD PD\RUtD GH ODV YHFHV HVWD LQIHFFLyQ WUDQVFXUUH HQ IRUPD DVLQWRPiWLFD /D HQIHUPHGDG VH FDUDFWHUL]D SRU SUXULWRDUGRU\ÀXMREODQFRJUXPRVRDGKHUHQWHFRQDVSHFWRGHOHFKHFRUWDGD $OPLFURVFRSLRDJUHJDQGRXQDVJRWDVGHKLGUy[LGRGHSRWDVLRRFRQWLQFLyQGH *UDPVHSXHGHQYHUORVPLFHOLRV\ODVSVHXGRKLIDV(OWUDWDPLHQWRLGHDOHVFRQ &ORWULPD]RO R 0LFRQD]RO FUHPD YDJLQDO X yYXORV SRU GtDV /D SDUHMD VH[XDO DVLQWRPiWLFDQRVHWUDWDUi 9DJLQRVLV EDFWHULDQD SURYRFDGD SRU *DUGQHUHOOD YDJLQDOLV R +DHPRSKLOOXV YDJLQDOLV 0LFRSODVPD KRPLQLV 3UHYRWHOOD VS 0RELOXQFXV VS 7tSLFDPHQWH VH GHVFULEH SRU ÀXMR EODQFR JULViFHR FRQ RORU D SHVFDGR TXH VH LQFUHPHQWD FRQ HODJUHJDGRGHKLGUy[LGRGHSRWDVLR(OS+VXHOHVHU!GH$OPLFURVFRSLR VHHQFXHQWUDQODVFpOXODVWDFKRQDGDVFRQSHTXHxDVLPiJHQHVTXH UHFXHUGDQ FRPDV³FOXHFHOOV´(OWUDWDPLHQWRHVFRQ0HWURQLGD]RORUDOPJYHFHVDOGtD SRUGtDVJHOXyYXORVYDJLQDOHVWRGDVODVQRFKHVSRUGtDV(OFRPSDxHUR VH[XDODVLQWRPiWLFRQRVHWUDWDUi 7ULFRPRQLDVLVSURYRFDGDSRU7ULFKRPRQDVYDJLQDOLV$OUHGHGRUGHOGHODV HPEDUD]DGDVSDGHFHQLQIHFFLyQSRUHVWHSDUiVLWRODFXDOWUDQVFXUUHDVLQWRPiWLFD ODPD\RUtDGHODVYHFHV/RVVLJQRVWtSLFRVFRQVLVWHQHQÀXMRPDOROLHQWHYHUGRVR FODUR HVSXPRVR D YHFHV DFRPSDxDGR GH SUXULWR HQURMHFLPLHQWR \ SLTXHWHDGR KHPRUUiJLFRGHFXHOOR\YDJLQDFXHOORGHIUHVD(QHOHVWXGLRHQIUHVFRSXHGH YHUVH HO SURWR]RDULR DO PLFURVFRSLR (O WUDWDPLHQWR LQFOX\H D OD JHVWDQWH \ VXV FRQWDFWRVVH[XDOHVFRQ0HWURQLGD]RORUDOJHQGRVLV~QLFDRPJYHFHV DOGtDSRUGtDV27LQLGD]ROJRUDOHQGRVLV~QLFD/DHPEDUD]DGDWDPELpQ SXHGHVHUWUDWDGDFRQ0HWURQLGD]ROyYXORVRJHOLQWUDYDJLQDOGXUDQWHQRFKHV 'XUDQWH PXFKR WLHPSR HVWXYR SURVFULSWR HO XVR RUDO GHO PHWURQLGD]RO HQ ODV JHVWDQWHVGHVGHKDFHDOJXQRVDxRVKDVLGRLQFOXLGRSDUDXVRSRUOD)'$FRPR XQPHGLFDPHQWRVHJXUR *RQRFRFFLDSURYRFDGDSRU1HLVVHULDJRQRUUKRHDH3XHGHVHUDVLQWRPiWLFDR SUHVHQWDUÀXMRSXUXOHQWR\SURGXFLUXQDUHDFFLyQORFDOLQÀDPDWRULDFRQH[XGDGR PXFRSXUXOHQWRGHODVPXFRVDVHQGRFHUYLFDOHV\RXUHWUDODQDOSXGLHQGRSURYRFDU GLVXULDSRODTXLXULD\WHQHVPRYHVLFDO$OPLFURVFRSLRVHYHQORVSROLPRUIRQXFOHDUHV FRQ HO GLSORFRFR *UDP QHJDWLYR LQWUDFHOXODU 7DPELpQ VH SXHGH LGHQWL¿FDU HQ FXOWLYRVFRQPHGLRVHVSHFLDOHVDJDUFKRFRODWH7KD\HU0DUWLQ $ODVHPDQDGHODLQIHFFLyQSXHGHQVHUUHDFWLYDVODVSUXHEDVVHUROyJLFDVHQWUH ODVTXHVHLQFOX\HQPRGHUQDVSUXHEDVSDUDLGHQWL¿FDUHO$'1GHODEDFWHULD /DJRQRFRFFLDFXDQGRDIHFWDHOHQGRPHWULRSXHGHSURGXFLUDERUWRHQRFDVLRQHV HVFDXVDGHDERUWRKDELWXDO$XQTXHODLQIHFFLyQGHOIHWRSRUYtDWUDQVSODFHQWDULD HVH[FHSFLRQDOSXHGHHQFDPELRGXUDQWHHOSDUWRFRQWDPLQDUODVFRQMXQWLYDVGHO QLxR\SURYRFDUOD³RIWDOPLDSXUXOHQWDEOHQRUUiJLFD´3RUHVWDUD]yQVHKDLQVWLWXLGR HQIRUPDREOLJDWRULDODSUR¿OD[LVGHODRIWDOPLDSXUXOHQWDPHGLDQWHODLQVWLODFLyQ HQ ORV VDFRV FRQMXQWLYDOHV GHO UHFLpQ QDFLGR GH XQ FROLULR FRQ VDOHV GH SODWD PpWRGRGH&UHGpRDQWLELyWLFRVLQPHGLDWDPHQWHGHVSXpVGHOQDFLPLHQWRHQOD SURSLDUHFHSFLyQQHRQDWDO/DJUDYLGH]SXHGHLQÀXLUQHJDWLYDPHQWHDJUDYDQGR XQD JRQRUUHD SUHYLD GDQGR PDQLIHVWDFLRQHV HQ OD SRUFLyQ LQIHULRU GHO DSDUDWR JHQLWDOFRQDXPHQWRGHODOHXFRUUHDFROSLWLVJUDQXORVDEDUWKROLQLWLVLUUDGLDFLyQD ]RQDVYHFLQDV\VtQWRPDVXULQDULRV\UHFWDOHV'HVSXpVGHOSDUWRSXHGHDVFHQGHU \ SURYRFDU HQGRPHWULWLV VDOSLQJLWLV \R SHOYLSHULWRQLWLV (O WUDWDPLHQWR HV GH OD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD HPEDUD]DGD\VXFRPSDxHURVH[XDOFRQXQDGRVLV~QLFDLQWUDPXVFXODUGH3HQLFLOLQD *8RGRVLV~QLFDRUDOGH&HIWULD[RQDPJR&H¿[LPHPJ &ODPLGLDVLV SURYRFDGD SRU &KODPLGLDV WUDFKRPDWLV *HQHUDOPHQWH HV DVLQWRPiWLFD&XDQGRKD\ÀXMRVXHOHVHUDPDULOOHQWR\HVSHFLDOPHQWHHQGRFHUYLFDO 3XHGHDFRPSDxDUVHGHGLVSDUHXQLDVDQJUDGR\XUHWULWLV(OGLDJQyVWLFRVHSXHGH KDFHUREVHUYDQGRODVLQFOXVLRQHVFLWRSODVPiWLFDVFRQWLQFLyQGH3DSDQLFRODRXR FRQWpFQLFDGH*LHPVD6HSXHGHQHPSOHDUFXOWLYRVHQPHGLRVHVSHFLDOHVSDUD FODPLGLDVDQWLFXHUSRVPRQRQXFOHDUHVÀXRUHVFHQWHVHWF(OWUDWDPLHQWRHVSDUD ODPXMHUJHVWDQWH\VXFRPSDxHURVH[XDOVHUHFRPLHQGD$]LWURPLFLQDJRUDOHQ GRVLV~QLFDR$PR[LFLOLQDPJRUDOYHFHVDOGtDGXUDQWHGtDV +HUSHVVLPSOH([LVWHQGRVWLSRVGH+HUSHVKRPLQLVHOWLSR,FRQSUHGLOHFFLyQ SRUHOWHMLGRHFWRGpUPLFRGHSLHO\PXFRVDULQRIDULQJHD\HOWLSR,,RKHUSHVYXOYDU GHORFDOL]DFLyQJHQLWDO\FRQWDJLRYHQpUHR6HPDQL¿HVWDSRUYHVtFXODVP~OWLSOHV SUXULJLQRVDV R GRORURVDV TXH WRPDQ XQD FRORUDFLyQ EODQFR DPDULOOHQWD \ SRVWHULRUPHQWHVHXOFHUDQ(OSDVDMHWUDQVSODFHQWDULRDXQTXHUDURSXHGHRULJLQDU OHVLRQHVIHWDOHVWDOHVFRPRUHVWULFFLyQGHOFUHFLPLHQWRLQWUDXWHULQRPLFURFHIDOLD \R FDOFL¿FDFLRQHV LQWUDFUDQHDQDV TXH SXHGHQ PDQLIHVWDUVH HQ OD LQIDQFLD SRU UHWDUGR SVLFRPRWRU /D LQIHFFLyQ HQ HO UHFLpQ QDFLGR VH SURGXFH SRU FRQWDFWR GLUHFWRDWUDYpVGHOFDQDOGHSDUWR6XHOHVHUVLHPSUHJUDYH\DPHQXGRPRUWDO DRFDVLRQDLFWHULFLDKHSDWRHVSOHQRPHJDOLDKHPRUUDJLDV\VHSWLFHPLD(Q HOKtJDGRSXOPyQVXSUDUUHQDOHV\FHUHEURVHSXHGHQFRQVWLWXLUIRFRVQHFUyWLFRV 3RU HVWD UD]yQ OD H[LVWHQFLD GH XQ KHUSHV JHQLWDO DFWLYR GXUDQWH HO SDUWR VHUi LQGLFDFLyQ GHFHViUHDHOHFWLYD6LKD\YLUXVDOPRPHQWRGHOSDUWRHOULHVJRGH LQIHFFLyQGHOUHFLpQQDFLGRHVGHOORFXDOVHUHGXFHFRQVLGHUDEOHPHQWHVH VHUHDOL]DODFHViUHDDQWHVGHTXHVHURPSDQODVPHPEUDQDVRYXODUHVRQRPiV DOOi GH KRUDV GH SURGXFLGD OD UXSWXUD (O GLDJQyVWLFR VXHOH VHU FOtQLFR$ ODV YHVtFXODV\DGHVFULSWDVVXHOHDVRFLDUVHGLVXULDGRORU\HQRFDVLRQHV¿HEUH(O WUDWDPLHQWRVHKDUiFRQ$\FLFORYLURUDOPJWUHVYHFHVDOGtDGXUDQWHGtDV 3XHGHDVRFLDUVHFUHPDGH$F\FORYLUDOSDUDDSOLFDFLyQWySLFDGXUDQWHGtDV 29DODF\FORYLUJRUDOYHFHVDOGtDGXUDQWHGtDV(OFRPSDxHURVH[XDOVL WLHQHVLQWRPDWRORJtDGHEHUiUHFLELUHOPLVPRWUDWDPLHQWR 2EMHWLYR $FWLYLGDG 3UHYHQLUODWUDQVPLVLyQYHUWLFDOGHODHQIHUPHGDGGH&KDJDV 3UHYHQFLyQGHWHFFLyQ\WUDWDPLHQWR /D HQIHUPHGDG GH &KDJDV HV FDXVDGD SRU HO 7ULSDQRVRPD FUX]L \ HV H[FOXVLYD GH QXHVWURFRQWLQHQWH(VFRQVLGHUDGDHQGpPLFDHQSDtVHVGHOD5HJLyQ\VHHVWLPD TXHKD\PiVGHPLOORQHVGHSHUVRQDVLQIHFWDGDV /DSUHYDOHQFLDGHLQIHFFLyQSRU7FUX]LHQJHVWDQWHVYDULDHQWUH\GHSHQGLHQGR GHOiUHDJHRJUi¿FD'HELGRDODXPHQWRHQODVPLJUDFLRQHVODVLQIHFFLRQHVFRQJpQLWDVGH 7FUX]LKDQDXPHQWDGRVXIUHFXHQFLDHQ]RQDVXUEDQDV\HQSDtVHVQRHQGpPLFRV (QDTXHOORVSDtVHVTXHKDQHOLPLQDGRODWUDQVPLVLyQYHFWRULDO\WLHQHQXQEXHQFRQWURO GHORVEDQFRVGHVDQJUHOD~QLFDYtDSRUODTXHVHSURGXFHQQXHYRVFDVRVHVDWUDYpV GHODWUDQVPLVLyQYHUWLFDOPDGUHKLMRGXUDQWHHOHPEDUD]R (OQ~PHURGHUHFLpQQDFLGRVFRQ&KDJDVFRQJpQLWRYDUtDHQWUH\HOSXGLHQGROOHJDU KDVWDHOHVWDDPSOLDYDULDFLyQVHYLQFXODFRQODUHJLyQJHRJUi¿FD\ODVFRQGLFLRQHV VRFLRHFRQyPLFDVGHORVJUXSRVHVWXGLDGRV(QWUHHO\GHORVFDVRVGHLQIHFFLyQ FRQJpQLWD VRQ DVLQWRPiWLFRV /RV FDVRV VLQWRPiWLFRV SUHVHQWDQ IUHFXHQWHPHQWH SUHPDWXULGDG EDMR SHVR DO QDFHU \ KHSDWRHVSOHQRPHJDOLD (Q DOJXQRV FDVRV SXHGH YHUVHDQDVDUFD\VtQGURPHUHVSLUDWRULRDJXGR/DPHQLQJRHQFHIDOLWLV\ODPLRFDUGLWLVVRQ PiVIUHFXHQWHVFXDQGRFRH[LVWHLQIHFFLyQSRU9,+ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 1RH[LVWHXQPDUFDGRUFOtQLFRHVSHFt¿FRGHODLQIHFFLyQ FRQJpQLWDGHODHQIHUPHGDGGH&KDJDV Figura 31. Fragmento de HCP. Chagas (QDTXHOORVSDtVHVFRQLQIHFFLyQHQGpPLFDVHUHFRPLHQGDODUHDOL]DFLyQGHODSUXHED VHUROyJLFDHQODJHVWDQWH3DUDGHWHFWDUDQWLFXHUSRVHVSHFt¿FRVDQWLWULSDQRVRPDFUX]L \ UHDOL]DU XQD FRQ¿UPDFLyQ GLDJQyVWLFD VH XWLOL]DUiQ SRU OR PHQRV GRV UHDFFLRQHV VHUROyJLFDVQRUPDWL]DGDVTXHSHUPLWHQDOFDQ]DUHQWUHHO\GHVHQVLELOLGDG (QWUHHOODV+$,,),+$,(/,6$\(/,6$,), +$,+HPRDJOXWLQDFLyQLQGLUHFWD ,),,QPXQRÀXRUHVFHQFLDLQGLUHFWD (/,6$(QVD\RLQPXQRHQ]LPiWLFR (O WUDWDPLHQWR TXLPLRWHUiSLFR HVSHFt¿FR GXUDQWH HO HPEDUD]R HVWi FRQWUDLQGLFDGR SHUR OD PDGUH LQIHFWDGD SRGUi VHU HVWXGLDGD SDUD GHVFDUWDU FRPSURPLVR FDUGtDFR \ JDUDQWL]DUODDWHQFLyQREVWpWULFDVHJXUD\GHFDOLGDG6LODSUXHEDHVSRVLWLYDODIDPLOLD GHEHVHULQIRUPDGDDFHUFDGHORVSURFHGLPLHQWRV\WUDWDPLHQWRVDVHJXLUFRQHOUHFLpQ QDFLGR(QORVKLMRVGHPDGUHFRQVHURORJtDFKDJiVLFDSRVLWLYDVHUHFRPLHQGD 3HVTXLVDSDUDVLWROyJLFDGLUHFWDQHRQDWDOHOPLFURKHPDWRFULWR0+HVODWpFQLFD GH HOHFFLyQ SRU VX IDFLOLGDG SRUTXH UHTXLHUH XQ SHTXHxR YROXPHQ GH VDQJUH PO\WLHQHXQDDOWDVHQVLELOLGDGDO/RVPpWRGRVSDUDVLWROyJLFRV LQGLUHFWRV;HQRGLDJQyVWLFR,QRFXODFLyQDUDWRQHV\HO+HPRFXOWLYRWLHQHQDOWD VHQVLELOLGDGSHURUHTXLHUHQFRPSOHMDLQIUDHVWUXFWXUD\ORVUHVXOWDGRVWDUGDQGH DGtDV 3HVTXLVDVHUROyJLFDFRQYHQFLRQDOGLIHULGDHQWUHORV\PHVHVGHHGDG/D E~VTXHGDGHDQWLFXHUSRVHVSHFt¿FRVQRHV~WLOSDUDHOGLDJQyVWLFRHQORVSULPHURV PHVHVGHYLGDSXHVWRTXHHOHVWXGLRVHUROyJLFRKDELWXDOGHWHFWDDQWLFXHUSRV,J* ORVTXHSXHGHQKDEHUVLGRWUDQVPLWLGRVSDVLYDPHQWHSRUODPDGUH/DGHWHFFLyQ GH OD IUDFFLyQ ,J0 HVSHFt¿FD HODERUDGD SRU HO IHWR SHUPLWH XQ GLDJQyVWLFR SUHFR]SHURFRQEDMDVHQVLELOLGDG (OFULWHULRSDUDFRQVLGHUDUXQFDVRGH&KDJDVFRQJpQLWRHVHOVLJXLHQWH UHFLpQQDFLGRKLMRGHPDGUHFRQVHURORJLDSRVLWLYDSDUD7FUX]L SDUiVLWRV LGHQWL¿FDGRV DO QDFLPLHQWR R SDUiVLWRV R DQWLFXHUSRV HVSHFt¿FRV QR PDWHUQRVGHWHFWDGRVGHVSXpVGHOQDFLPLHQWRVLHPSUH\FXDQGRQRKD\DH[LVWLGR WUDQVIXVLyQVDQJXtQHDSUHYLDRFRQWDPLQDFLyQYHFWRULDO (IHFWXDUGLDJQyVWLFRDQWHQDWDOSHUPLWHDOQHRQDWyORJRHIHFWXDUWUDWDPLHQWRHVSHFt¿FR HQHOQHRQDWRTXHJDUDQWLFHODFXUDFLyQ $OQDFLPLHQWRXQDPXHVWUDGHVDQJUHGHOFRUGyQSXHGHVHUXWLOL]DGDSDUDODE~VTXHGD GH SDUiVLWRV HQ OD VDQJUH (O WUDWDPLHQWR HVSHFt¿FR HV FRQ 1LIXUWLPR[ PJNJ GtD \ SRVWHULRUPHQWH %HQ]LGD]RO PJNJGtD SRU GtDV (VWDV GURJDV VRQ GH DOWD HIHFWLYLGDGFXDQGRVHDGPLQLVWUDQDQWHVGHORVDxRVGHYLGD\SURYRFDQSRFRVHIHFWRV VHFXQGDULRV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2EMHWLYR 5HGXFLUODPRUELPRUWDOLGDGPDWHUQD\SUHYHQLUODWUDQVPLVLyQ YHUWLFDOGHO3DOXGLVPRR0DODULD $FWLYLGDG 3UHYHQFLyQGHWHFFLyQ\WUDWDPLHQWR /DPDODULDHVXQDLQIHFFLyQFDXVDGDSRUSURWR]RDULRVGHOJpQHUR3ODVPRGLRORVFXDOHV VRQLQRFXODGRVDOVHUKXPDQRSRUODSLFDGXUDGHODKHPEUDGHOPRVTXLWR$QRSKHOHV(Q QXHVWUDUHJLyQHOUHVSRQVDEOHGHORVFDVRVGHSDOXGLVPRHV3ODVPRGLXPIDOFLSDUXP (VHQGpPLFDHQGHORVSDtVHVGHOD5HJLyQ0iVGHOGHORVFDVRVQRWL¿FDGRV VH RULJLQDQ HQ ORV SDtVHV TXH FRPSDUWHQ OD VHOYD DPD]yQLFD 6LHQGR ODV PXMHUHV HPEDUD]DGDV\ORVQLxRVHVSHFLDOPHQWHVXVFHSWLEOHV /RV DVSHFWRV FOtQLFRV GHSHQGHQ HQ JUDQ PHGLGD GH ORV SDWURQHV H LQWHQVLGDG GH OD WUDQVPLVLyQ GH OD 0DODULD HQ HO iUHD GH UHVLGHQFLD OR FXDO GHWHUPLQD HO JUDGR GH LQPXQLGDGDGTXLULGD (Q iUHDV HVWDEOHV DOWD WUDQVPLVLyQ ORV SREODGRUHV HVWiQ FRQWLQXDPHQWH H[SXHVWRV D OD LQRFXODFLyQ SRU 0DODULD VXHOHQ DGTXLULU LQPXQLGDG SDUFLDO D OD HQIHUPHGDG FOtQLFD \ ODV PDQLIHVWDFLRQHV PiV VHYHUDV ODV SUHVHQWDQ HQ OD LQIDQFLD /RV DGROHVFHQWHV \ DGXOWRV VRQ SDUFLDOPHQWH LQPXQHV \ UDUDPHQWH VXIUHQHQIHUPHGDGFOtQLFD/DLQPXQLGDGVHUHGXFHGXUDQWHHOHPEDUD]R\SXHGH SHUGHUVHFXDQGRODVPXMHUHVVHPXGDQIXHUDGHODV]RQDVGHWUDQVPLVLyQ (QiUHDVGHPDODULDLQHVWDEOHEDMDWUDQVPLVLyQWDOFRPRVHYHHQ$PpULFD /DWLQDGRQGHODHQIHUPHGDGSHUPDQHFHHQGpPLFD/DVWDVDVGHLQRFXODFLyQVRQ EDMDVFRQORTXHVHUHWDUGDODDGTXLVLFLyQGHODLQPXQLGDG\HOUHVXOWDGRHVOD LQIHFFLyQDJXGDHQWRGRVORVJUXSRVGHHGDGQLxRVMyYHQHV\DGXOWRVFRQDOWR ULHVJRGHSURJUHVLyQDODVIRUPDVVHYHUDVGHODHQIHUPHGDGGHQRVHUWUDWDGD (QODViUHDVGHDOWDWUDQVPLVLyQORVQLxRVVHHQFXHQWUDQHQDOWRULHVJRGHPRULUSRUPDODULD PLHQWUDVTXHHQODVGHEDMDWUDQVPLVLyQWRGRVORVJUXSRVGHHGDGHVWiQHQULHVJR 'LDJQyVWLFRGH0DODULD 6HEDVDHQFULWHULRVFOtQLFRVGLDJQyVWLFRGHVRVSHFKDRSRUODLGHQWL¿FDFLyQGHORV SDUiVLWRVGLDJQyVWLFRGHFRQ¿UPDFLyQ 'LDJQyVWLFR&OtQLFR (OGLDJQyVWLFRFOtQLFRDLVODGRHVPX\SRFRHVSHFt¿FR\VHUHDOL]DHQEDVHDODSUHVHQFLD GH¿HEUHHQORVGtDVSUHYLRVVLQRWUDVHYLGHQFLDVGHHQIHUPHGDGHVVHYHUDV /RV SULPHURV VtQWRPDV GH OD PDODULD HQ XQ FXDGUR QR FRPSOLFDGR VXHOHQ VHU LQHVSHFt¿FRV\SXHGHQFRQIXQGLUVHFRQXQHVWDGRGHLPSUHJQDFLyQYLUDOWtSLFR3XHGH SUHVHQWDUFHIDOHDVDVWHQLDIDWLJDPROHVWLDVDEGRPLQDOHVGRORUPXVFXODU\DUWLFXODU VHJXLGRSRU¿HEUHHVFDORIUtRVVXGRUDFLyQDQRUH[LDHWF (QORVHVWDGLRVVLQHYLGHQFLDVGHGLVIXQFLyQRUJiQLFDODVWDVDVGHPRUWDOLGDGVRQEDMDV FLUFDSDUDLQIHFFLRQHVSRU3IDOFLSDUXPVLVHSURYHHWUDWDPLHQWRHIHFWLYRSUHFR] 3RVWHUJDUHOWUDWDPLHQWRRXVDUGURJDVLQHIHFWLYDVSXHGHQOOHYDUDXQDXPHQWRGHOD VHYHULGDG\DJUDYDFLyQGHOFXDGURHQSRFDVKRUDV /DDJUDYDFLyQVHSXHGHPDQLIHVWDUSRUXQRRPiVGHORVVLJXLHQWHVVtQWRPDVFRPD PDODULDFHUHEUDODFLGRVLVPHWDEyOLFDDQHPLDVHYHUDKLSRJOLFHPLD\HQDGXOWRVIDOOD UHQDODJXGDRHGHPDDJXGRGHSXOPyQ(QHVWHHVWDGLRODPRUWDOLGDGD~QHQSHUVRQDV TXHUHFLEHQHOWUDWDPLHQWRDGHFXDGRVHHOHYDKDVWDXQ6LQRHVWUDWDGDODPDODULD VHYHUDDPHQXGRHVPRUWDO 0DODULD\HPEDUD]R 3RU WHQHU QXHVWUD UHJLyQ XQ SHU¿O GH EDMD WUDQVPLVLyQ ODV PXMHUHV HQ HGDG UHSURGXFWLYD WLHQHQ HVFDVD LQPXQLGDG DGTXLULGD IUHQWH D OD PDODULD (Q HVWH &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR HVFHQDULRVRQFRPXQHVORVFDVRVJUDYHVGHHQIHUPHGDGPDWHUQDPDODULDVHYHUD FRQ FRPSOLFDFLRQHV GHO VLVWHPD QHUYLRVR FHQWUDO KLSRJOLFHPLD KLSHUSLUH[LD DQHPLD KHPROtWLFD VHYHUD HGHPD SXOPRQDU \ PXHUWH 2EYLDPHQWH ORV FDVRV JUDYHV VH SXHGHQ DFRPSDxDU GH PDORV UHVXOWDGRV UHSURGXFWLYRV WDOHV FRPR 5&,%31SUHPDWXULGDGDERUWRPXHUWHIHWDO\PXHUWHLQIDQWLO 'LDJQyVWLFRSDUDVLWROyJLFR /RVGRVPpWRGRVVXJHULGRVSDUDHOGLDJQyVWLFRSDUDVLWROyJLFRVRQOD0LFURVFRStDGH /X]\ORV7HVWUiSLGRVGLDJQyVWLFRV5'7V /DPLFURVFRStDGHOX]WLHQHODYHQWDMDGHOEDMRFRVWRODDOWDVHQVLELOLGDG\HVSHFL¿FLGDG (Q HOOD VH LQFOX\H HO ³WHVW GH OD JRWD JUXHVD´ TXH HV HO ³HVWiQGDU GH RUR´ SDUD HO GLDJQyVWLFR \ TXH FRQVLVWH HQ DQDOL]DU XQD JRWD GH VDQJUH SHULIpULFD FRQ WLQFLyQ GH *LHPVD HQ EXVFD GHO SDUiVLWR 6H UHTXLHUHQ WUHV IURWLV QHJDWLYRV VHSDUDGRV SRU KRUDVSDUDGHFODUDUTXHODSHUVRQDQRWLHQHLQIHFFLyQPDOiULFD /RVWHVWUiSLGRV5'7VSDUDGHWHFFLyQGHDQWtJHQRVGHOSDUiVLWRVRQPiVFDURV\VX ODELOLGDGDDOWDVWHPSHUDWXUDV\KXPHGDGVRQXQDLPSRUWDQWHGHVYHQWDMD /DVWpFQLFDVSDUDGHWHFWDU$'1GHORVSDUiVLWRVEDVDGDVHQODUHDFFLyQGHODFDGHQD GHODSROLPHUDVD3&5VRQDOWDPHQWHVHQVLEOHV\PX\XVDGDVSDUDGHWHFWDULQIHFFLRQHV PL[WDVHQSDUWLFXODUDQWHEDMDVFDQWLGDGHVGHSDUiVLWRV (O GLDJQyVWLFR SDUDVLWROyJLFR GHEH VHU HIHFWXDGR D ODV PXMHUHV HPEDUD]DGDV GH ODV iUHDVHQGpPLFDVSDUDGLVWLQJXLUODVFDXVDVGHOD¿HEUH\UHGXFLUHOXVRLQQHFHVDULRGH DQWLELyWLFRVDQWLSDO~GLFRVHQHOHPEDUD]R (QiUHDVGRQGHKD\DPiVGHGRVHVSHFLHVGHSDUiVLWRVSURGXFWRUHVGHODPDODULDVHUi QHFHVDULRLGHQWL¿FDUORVSDUiVLWRVSDUDHOORVRORXQPpWRGRSDUDVLWROyJLFRSHUPLWHHO GLDJQyVWLFRGHHVSHFLHV 3UHYHQFLyQGHODPDODULDGXUDQWHHOHPEDUD]R &RQWURODU ORV HIHFWRV GH OD LQIHFFLyQ SRU PDODULD HQ ODV PXMHUHV HPEDUD]DGDV \ VXV IHWRVFRQODVVLJXLHQWHVLQWHUYHQFLRQHV 7UDWDPLHQWRGHODPXMHUFRQPDODULDODDQHPLD\ODVRWUDVFRQVHFXHQFLDVGHOD LQIHFFLyQ 8VR GH PRVTXLWHURV WUDWDGRV FRQ LQVHFWLFLGDV SRGUtDQ UHGXFLU HQ XQD FXDUWD SDUWHODVPXHUWHVSRUPDODULD 7UDWDPLHQWR SUHYHQWLYR LQWHUPLWHQWH 73, HQ iUHDV GH DOWD WUDQVPLVLyQ GH PDODULD 7UDWDPLHQWRHQPXMHUHVHPEDUD]DGDV /DPXMHUHPEDUD]DGDFRQ0DODULDDJXGDVLQWRPiWLFDGXUDQWHHOVHJXQGRWULPHVWUHGHO HPEDUD]R WLHQH PiV SRVLELOLGDG GH GHVDUUROODU XQD IRUPD VHYHUD TXH RWURV DGXOWRV D PHQXGR FRPSOLFDGD FRQ HGHPD SXOPRQDU H KLSRJOXFHPLD /D PRUWDOLGDG HV DSUR[LPDGDPHQWHGHOODFXDOHVPXFKRPiVDOWDTXHHQPXMHUHVQRHPEDUD]DGDV /DPXHUWHIHWDO\HOSDUWRSUHPDWXURVRQIUHFXHQWHV3RUHOORVHLPSRQHHOWUDWDPLHQWR FRQHOREMHWLYRSULPDULRGHVDOYDUODYLGDGHODPDGUH /RVDQWLPDOiULFRVFRQVLGHUDGRVVHJXURVHQHOSULPHUWULPHVWUHVRQ4XLQLQD&KORURTXLQD 3URJXDQLO3LULPHWDPLQD\6XOIDGR[LQD±3LULPHWDPLQD'HHVWRVOD4XLQLQDHVODPiV HIHFWLYD\SXHGHVHUXVDGDHQWRGRVORVWULPHVWUHVGHOHPEDUD]R6HSUH¿HUHOD4XLQLQD GXUDQWH HO SULPHU WULPHVWUH \ ODV 7HUDSLDV &RPELQDGDV HQ EDVH D$UWHPLVLQD $&7 $UWHVXQDWRR$UWHPHWHUGXUDQWHHOVHJXQGR\WHUFHUWULPHVWUHV &RPRORVDQWLPDOiULFRVVRQDQWLIROtQLFRVGHEHDGPLQLVWUDUVHVLHPSUHiFLGRIyOLFR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 'URJDVFRQWUDLQGLFDGDVGXUDQWHHOHPEDUD]R 0HÀRTXLQD3ULPDTXLQD\7HWUDFLFOLQDV$PRGLDTXLQD&KORUSURJXDQLO'DSVRQD +DORIDQWULQD/XPHIDQWULQD\3LSHUDTXLQD 7UDWDPLHQWRGHOD0DODULDIDOFLSDUXPQRFRPSOLFDGDGXUDQWHHOHPEDUD]R 3ULPHUWULPHVWUH4XLQLQD&OLQGDP\FLQDGXUDQWHGtDV $&7GHEHVHUXVDGRVRORVLHVHO~QLFRWUDWDPLHQWRHIHFWLYRGLVSRQLEOH 6HJXQGR\WHUFHUWULPHVWUHV$&7&OLQGDP\FLQDGXUDQWHGtDV R4XLQLQD&OLQGDP\FLQDGXUDQWHGtDV /D H[SRVLFLyQ LQDGYHUWLGD D ORV DQWLPDOiULFRV QR HV XQD FDXVD GH LQWHUUXSFLyQ GH OD JUDYLGH] 0XMHUHVDPDPDQWDQGR /D FDQWLGDG GH DQWLPDOiULFRV TXH SDVDQ D OD OHFKH PDWHUQD VRQ EDMDV /D ~QLFD H[FHSFLyQDHVWDUHJODODFRQVWLWX\HQODV'DSVRQDVVRQH[FUHWDGDVDODOHFKHGH OD GRVLV GHO DGXOWR /DV7HWUDFLFOLQDV WDPELpQ HVWiQ FRQWUDLQGLFDGDV SRU VXV HIHFWRV VREUHORVKXHVRV\GLHQWHVGHORVQLxRV &XDGUR(VWUDWHJLDVGHLQWHUYHQFLyQSDUDODPDODULDGXUDQWHHOHPEDUD]RHQ XQHVFHQDULRGHEDMDWUDQVPLVLyQ Tratamiento Preventivo Mosquiteros tratados Manejo del caso Intermitente (TPI) con insecticida Alto riesgo de malaria activa Proveer TPI (después de Buscar y tratar la anemia con antimaláricos percibir los movimientos Comenzar el uso en el recomendados y suplementos con hierro y Ac. fetales) durante los Fólico. embarazo y continuarlo controles prenatales, en el postparto. próximo a las 26 y 32 Rápido reconocimiento y tratamiento de semanas. todos los casos de malaria activa con drogas reconocidamente efectivas (O73,FRQVLVWHHQODDGPLQLVWUDFLyQVXSHUYLVDGDGHDQWLPDOiULFRVDGRVLVGHWUDWDPLHQWR \ D LQWHUYDORV SUH GH¿QLGRV GXUDQWH HO HPEDUD]R 6H LQLFLDQ HQ HO VHJXQGR WULPHVWUH GHVSXpVTXHODPXMHUKDSHUFLELGRORVSULPHURVPRYLPLHQWRVIHWDOHV6HUHFRPLHQGDQ GH D GRVLV FRQ XQ LQWHUYDOR PtQLPR HQWUH GRVLV GH XQ PHV (O PHGLFDPHQWR GH HOHFFLyQ HV OD 6XOIDGR[LQDSLULPHWDPLQD 63 GHELGR D TXH VH KD FRQ¿UPDGR VX VHJXULGDGFXDQGRHVXVDGDHQWUHHOVHJXQGR\HOWHUFHUWULPHVWUH (OHVTXHPDGHXVRUHFRPHQGDGRHVHOVLJXLHQWH GRVLVSUy[LPDDODVVHPDQDV GRVLVSUy[LPDDODVVHPDQDV GRVLVHQDTXHOORVSDtVHVFRQDOWDSUHYDOHQFLDGH9,+SUy[LPDDODVVHPDQDV 1R H[LVWH HYLGHQFLD TXH DGPLQLVWUDU PiV GH WUHV GRVLV GH 73, FRQ 63 GXUDQWH HO HPEDUD]RRIUH]FDEHQH¿FLRVDGLFLRQDOHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 2EMHWLYR $FWLYLGDG 5HGXFLUODPRUELPRUWDOLGDGQHRQDWDOSRUHVWUHSWRFRFRJUXSR% 3UHYHQFLyQGHWHFFLyQ\WUDWDPLHQWR (O HVWUHSWRFRFR GHO JUXSR % (*% 6WUHSWRFRFFXV DJDODFWLDH HV XQD EDFWHULD JUDP SRVLWLYR HQFDSVXODGD FDSD] GH FDXVDU HQIHUPHGDG LQYDVLYD HQ UHFLpQ QDFLGRV \ HQ PXMHUHVHPEDUD]DGDVVREUHWRGRHQJUXSRVFRQFRQGLFLRQHVPpGLFDVHVSHFLDOHVHM GLDEpWLFDV (Q ODV HPEDUD]DGDV OD LQIHFFLyQ SRU (*% FDXVD LQIHFFLyQ XULQDULD LQIHFFLyQ RYXODU HQGRPHWULWLVRVHSVLV/DLQIHFFLyQJUDYHHVUDUDHQODVHPEDUD]DGDV(QRFDVLRQHVHO SDUWRSUHPDWXURRODPXHUWHIHWDOSXHGHQDWULEXLUVHDODLQIHFFLyQSURYRFDGDSRU(*% (Q ORV UHFLpQ QDFLGRV VXHOH PDQL¿HVWDUVH SRU EDFWHULHPLD QHXPRQtD R PHQLQJLWLV 3XHGHQYHUVHRWURVVLQGURPHVFHOXOLWLV\RVWHRPLHOLWLV$SUR[LPDGDPHQWHHOGH ORVFDVRVGHLQIHFFLyQQHRQDWDOSRU(*%VHSURGXFHHQQLxRVGHSUHWpUPLQR (Q SDtVHV GHVDUUROODGRV DQWHV GHO XVR H[WHQGLGR GH DQWLELyWLFRV SUR¿OiFWLFRV OD LQFLGHQFLDGHHQIHUPHGDGLQYDVLYDSRU(*%SUHVHQWDEDXQDIUHFXHQFLDGHDSRUPLO QDFLGRVYLYRV(OHPSOHRGHODVSUXHEDVGHWDPL]DMHFRQWUDWDPLHQWRSRVWHULRUUHGXMHURQ ODLQFLGHQFLDDPHQRVGHSRUPLO\ODHQIHUPHGDGLQYDVLYDHQODVHPEDUD]DGDVFD\y HQDxRVXQ (Q DOJXQRV SDtVHV GH OD 5HJLyQ VH MXVWL¿FD OD LQFRUSRUDFLyQ GH HVWH WDPL]DMH D ODV QRUPDVQDFLRQDOHVSDUDUHGXFLUDXQPiVODPRUWDOLGDGQHRQDWDODXQTXHORVFRVWRV\OD ORJtVWLFDSXHGHQVHUXQDOLPLWDQWH/DRSFLyQGHXVDUDQWLELyWLFRVHQIRUPDUXWLQDULDHQ EDVHDXQGHVSLVWDMHPHGLDQWHIDFWRUHVGHULHVJRQRKDGHPRVWUDGRVHUHIHFWLYR &RORQL]DFLyQSRU(*% (OWUDFWRJDVWURLQWHVWLQDOHVHOUHVHUYRULRQDWXUDOGHOHVWUHSWRFRFR%\VHFXQGDULDPHQWH FRORQL]DODYDJLQD/DIUHFXHQFLDGHLQIHFFLyQYDJLQDOSRU(*%HQSDtVHVHQGHVDUUROOR QRHVWiELHQHVWXGLDGD\PXHVWUDDPSOLDYDULDFLyQ(QDOJXQRVVHUYLFLRVGHSDtVHVGHOD UHJLyQVHREVHUYDQLQFLGHQFLDVTXHYDQGHODOGHODVJHVWDQWHVTXHVHFRQWURODQ /D FRORQL]DFLyQ PDWHUQD HV HO SULQFLSDO IDFWRU GH ULHVJR SDUD OD WUDQVPLVLyQ YHUWLFDO GHO HVWUHSWRFRFRDOUHFLpQQDFLGRHVSHFLDOPHQWHFXDQGRODVPHPEUDQDVRYXODUHVHVWiQURWDV $XQTXHODFRORQL]DFLyQWHPSUDQDHQHOHPEDUD]RQRHVSUHGLFWLYDGHVHSVLVQHRQDWDOHO WDPL]DMHPHGLDQWHFXOWLYRGHPXHVWUDVYDJLQRUHFWDOHVSDUD(*%HQODV~OWLPDVVHPDQDVGHO HPEDUD]RSXHGHLQGLFDUFXDOHVVRQODVPXMHUHVTXHHVWiQFRORQL]DGDVDOPRPHQWRGHOSDUWR \DVtHVWDEOHFHUTXLHQHVHVWiQFRQPD\RUULHVJRGHWUDQVPLWLUODLQIHFFLyQDOUHFLpQQDFLGR 'LDJQyVWLFRGH(*% 6HGHEHUiWRPDUFRQKLVRSRXQDSULPHUDPXHVWUDGHOLQWURLWRYDJLQDO\FRQHOPLVPRX RWURKLVRSRVHWRPDUiXQDVHJXQGDPXHVWUDGHOHV¿QWHUDQDO/DVPXHVWUDVGHEHUiQVHU HQYLDGDVDOODERUDWRULRHQPHGLRVGHFXOWLYRDSURSLDGRV/DVPLVPDVGHEHQVHUH[WUDtGDV HQWUHODV\VHPDQDVGHJHVWDFLRQSDUDPHMRUDUODVHQVLELOLGDG\HVSHFL¿FLGDGGH ODGHWHFFLyQGHPXMHUHVTXHSHUPDQHFHQFRORQL]DGDVDOPRPHQWRGHOSDUWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD /DFRORQL]DFLyQSRU(*%HQHPEDUD]RVSUHYLRVQRGHEH VHU FRQVLGHUDGD FRPR XQD LQGLFDFLyQ SDUD HIHFWXDU WUDWDPLHQWRSUR¿OiFWLFRHQXQDQXHYDJHVWDFLyQ3RUTXH OD FRORQL]DFLyQ SXHGH VHU WUDQVLWRULD SRU OR WDQWR HO YDORUSUHGLFWLYRGHORVFXOWLYRVHVPX\EDMR\GHEHQVHU HIHFWXDGRVQRPiVGHVHPDQDVDQWHVGHOSDUWR Figura 32. Fragmento de la HCP. Estreptococos )DFWRUHVGHULHVJRDGLFLRQDOSDUDHQIHUPHGDGSHULQDWDOSRU(*% 2WURVIDFWRUHVTXHDXPHQWDQHOULHVJRGHLQIHFFLyQSHULQDWDOVRQ (GDGJHVWDFLRQDOVHPDQDV 5RWXUDGHPHPEUDQDV!KRUDV )LHEUH!&TXHKDJDVRVSHFKDULQIHFFLyQRYXODU 3DUDUHFRUGDUHVWRVSXQWRVHQHOUHFXDGURGH5XSWXUDGH 583785$'(0(0%5$1$6$17(3$572 VHP GtD PHV DxR QR PHPEUDQDVVHLQFOX\HQHVWRVDVSHFWRVSDUDTXHHOHTXLSR KV VL GH VDOXG WRPH ODV PHGLGDV TXH FRQVLGHUH DGHFXDGDV WHPS& KRUD PLQ 6H VXJLHUH HQ HVWDV VLWXDFLRQHV HIHFWXDU WUDWDPLHQWR DQWLELyWLFRLQWUDSDUWRFRPRVHGHVFULELUiPiVDGHODQWH Figura 33. Fragmento de la HCP. Ruptura de membranas anteparto &XDGUR(VTXHPDVUHFRPHQGDGRVGHWUDWDPLHQWRSUR¿OiFWLFRLQWUDSDUWR 5HFRPHQGDGR PLOORQHVGHXQLGDGHVLYGRVLVLQLFLDO PLOORQHVGHXQLGDGHVLYFKRUDVKDVWDHOSDUWR 3HQLFLOLQD* $OWHUQDWLYR JLYGRVLVLQLFLDO JLYFKRUDVKDVWDHOSDUWR $PSLFLOLQD $OHUJLDDODSHQLFLOLQD JLYGRVLVLQLFLDO JLYFKRUDVKDVWDHOSDUWR &HID]ROLQD &HViUHDSODQL¿FDGD (O(*%SXHGHDWUDYHVDUODVPHPEUDQDVRYXODUHVVDQDVSRUHVDUD]yQODFHViUHDQR SUHYLHQH OD WUDQVPLVLyQ YHUWLFDO PDGUHKLMR 'H WRGDV IRUPDV VRQ H[FHSFLRQDOHV ORV FDVRVGHFRORQL]DFLyQGHOIHWRFXDQGRVHSUDFWLFDXQDFHViUHDHOHFWLYDHQDXVHQFLDGH WUDEDMRGHSDUWR\FRQPHPEUDQDVLQWHJUDV3RUHVRHQHVWRVFDVRVQRVHMXVWL¿FDHO WUDWDPLHQWRSUR¿OiFWLFRGHUXWLQD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 2EMHWLYRV 'HWHFWDUSRVLEOHVSURFHVRVVpSWLFRVEXFRGHQWDOHV $FWLYLGDG ([DPHQEXFRGHQWDO (O H[DPHQ EXFRGHQWDO GHEH LQFRUSRUDUVH HQ OD YDORUDFLyQ FOtQLFD GH WRGD JHVWDQWH GHVGHXQDSHUVSHFWLYDLQWHJUDOQRVRORLPSRUWDFRQ¿UPDURGHVFDUWDUODSUHVHQFLDGH FDULHVGHQWDOHVVLQRTXHGHEHGHVSLVWDUVHHQIHUPHGDGSHULRGRQWDO(3\OHVLRQHVGH ERFD\OHQJXD(VSUHFLVRUHFRUGDUTXHHQHWDSDVLQLFLDOHVODVt¿OLVSXHGHPDQLIHVWDUVH ~QLFDPHQWHSRUXQDOHVLyQXOFHUDGDFKDQFURVL¿OtWLFR\TXHSXHGHDSDUHFHUHQODPX FRVDEXFDO /DHQIHUPHGDGSHULRGRQWDOHVXQRGHORVSURFHVRVLQIHFFLRVRVFUyQLFRVPiVIUHFXHQ WHV VX SUHYDOHQFLD YDUtD VHJ~Q ODV FRQGLFLRQHV VRFLRVDQLWDULDV GH ODV SREODFLRQHV HQWUHXQ\XQ /D(3LQFOX\HODJLQJLYLWLVXQDDIHFFLyQLQÀDPDWRULDGHORVWHMLGRV EODQGRVTXHURGHDQDOGLHQWH\ODHQFtD\ODSHULRGRQWLWLVTXHLQ YROXFUDODGHVWUXFFLyQGHODVHVWUXFWXUDVGHVRVWpQGHORVGLHQWHV WDOHV FRPR HO OLJDPHQWR SHULRGRQWDO HO KXHVR HO FHPHQWR \ ORV WHMLGRVEODQGRV/D(3VHRULJLQDSRUHOFUHFLPLHQWRH[DJHUDGR Figura 34. GH FLHUWDV HVSHFLHV GH EDFWHULDV HQ HVSHFLDO JpUPHQHV *UDP Fragmento de la HCP. QHJDWLYRV Odontología y mamas. /DHQIHUPHGDGSHULRGRQWDOVHYLQFXODUtDFRQPDORVUHVXOWDGRVSHULQDWDOHVHQHVSHFLDO EDMR SHVR DO QDFHU \ SDUWR GH SUHWpUPLQR DERUWR PXHUWH IHWDO \ SUHHFODPSVLD 'H FRQ¿UPDUVHTXHOD(3HVXQIDFWRUGHULHVJRLQGHSHQGLHQWH\PRGL¿FDEOHSHUPLWLUtD PHGLDQWHVXSUHYHQFLyQ\WUDWDPLHQWRDGHPiVGHPHMRUDUODVDOXGGHODPXMHUPHMRUDU ORV UHVXOWDGRV SHULQDWDOHV 5HFLHQWHV LQYHVWLJDFLRQHV SRQHQ HQ GXGD ORV UHVXOWDGRV DQWHULRUHV\VHxDODQTXHH[LVWHQRWURVGHWHUPLQDQWHVTXHVHDVRFLDQDORVPDORVUHVXO WDGRVSHULQDWDOHV\TXHODDVRFLDFLyQHQFRQWUDGDSUHYLDPHQWHHVWDUtDYLQFXODGDDXQ PDOFRQWUROGHYDULDEOHVGHFRQIXVLyQ )LQDOPHQWH HV EXHQR UHFRUGDU TXH HO HPEDUD]R UDUDPHQWH HV FRQWUDLQGLFDFLyQ SDUD WUDWDU ODV DIHFFLRQHV EXFRGHQWDOHV ,QFOXVR GH VHU QHFHVDULR UHDOL]DU HVWXGLRV UD GLROyJLFRVORVPLVPRVGHEHUiQHIHFWXDUVHPDQWHQLHQGRPHGLGDVGHUDGLRSURWHFFLyQ (OXVRGHDQHVWpVLFRVORFDOHVHVGHEDMRULHVJRVLHPSUHTXHQRDVRFLHQYDVRFRQVWULF WRUHVHQVXFRPSRVLFLyQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2EMHWLYRV 'HWHFWDUSRVLEOHVDOWHUDFLRQHVGHOSH]yQSDWRORJtDLQÀDPDWRULD \RWXPRUDOGHODPDPD $FWLYLGDG ([DPHQGHODVPDPDV (OH[DPHQGHODVPDPDVHVSDUWHGHOH[DPHQJLQHFROyJLFR\VHGHEHUiHIHFWXDUHQ FRQGLFLRQHVGHSULYDFLGDG\UHVSHWR6HUHFRPLHQGDUHDOL]DUORHQODSULPHUDFRQVXOWD VLHOUHODFLRQDPLHQWRFRQODXVXDULDORSHUPLWH/D+&3LQFRUSRUDXQUHFRUGDWRULRSDUD TXHQRROYLGHQHVWDSUHVWDFLyQ /RVFDPELRV¿VLROyJLFRVGHODPDPDFRPLHQ]DQSUHFR]PHQWH\VRQORV~OWLPRVFDP ELRVHQUHWLUDUVHFRQGLFLRQDGRVSRUHOWLHPSRHQHOTXHVHPDQWLHQHODODFWDQFLD (OH[DPHQGHPDPDVWLHQHFRPRREMHWLYRVLGHQWL¿FDUWUDVWRUQRVTXHSXHGDQLQWHUIHULU FRQODODFWDQFLDFRPRDOWHUDFLRQHVHQHOSH]yQPDVWLWLV\SDWRORJtDWXPRUDOHVEHQLJQDV \PDOLJQDV (QFRQWUDU GXUDQWH HO HPEDUD]R XQ WXPRU VRVSHFKRVR GH PDOLJQLGDG HQ OD PDPD QR FRQWUDLQGLFDODUHDOL]DFLyQGHHVWXGLRVGHFRQ¿UPDFLyQGLDJQyVWLFD +DVWDHOPRPHQWRKD\FRQWURYHUVLDVREUHVLVHGHEHHIHFWXDUDOJ~QWLSRGHWUDWDPLHQ WR HQ FDVR GH HQFRQWUDU SH]RQHV SODQRV R XPELOLFDGRV /D WHQGHQFLD PiV PRGHUQD VXJLHUH TXH HO HMHUFLFLR GHO SH]yQ HV LQQHFHVDULR \D TXH SRU WUDWDUVH GH XQ WHMLGR EODQGR VyOR EDVWDUtD FRQ XQD DGHFXDGD WpFQLFD GH DPDPDQWDPLHQWR SDUD FRUUHJLU HVWDVLWXDFLyQ3RURWUDSDUWHKD\TXLHQHVUHFRPLHQGDQHIHFWXDUHMHUFLFLRVGHVGHOH PRPHQWRGHOGLDJQyVWLFR(QWUHORVHMHUFLFLRVPiVFRPXQHVVHSXHGHQGHVFULELUORV OODPDGRVHMHUFLFLRVGH+RIIPDQTXHFRQVLVWHQHQHOHVWLUDPLHQWRGHOWHMLGRSHULDUHRODU GHWDOPDQHUDGHREWHQHUODHYHUVLyQSDXODWLQDGHOSH]yQ2HVWLUDU\URGDUHOSH]yQ HQWUHHOGHGRtQGLFH\HOSXOJDUYDULDVYHFHVDOGtD(VWRVGHEHQVHULQWHUUXPSLGRVHQ FDVRGHDPHQD]DGHSDUWRSUHPDWXUR /RVFXLGDGRVGHODVPDPDV\ORVSH]RQHVGXUDQWHHOHPEDUD]RFRQVLVWHQHQ /DYDGRH[FOXVLYDPHQWHFRQDJXD (YLWDUHOXVRGHFUHPDV\ORFLRQHV 6LORVSH]RQHVVRQVHQVLEOHVVHORVSXHGHH[SRQHUDODOX]VRODUGXUDQWHD PLQXWRVSRUGtD 8WLOL]DUVRVWHQHV¿UPHVFDSDFHVGHFRQWHQHUODVPDPDVVLQFRPSULPLUODV 2EMHWLYRV $FWLYLGDG 'HVFDUWDUFiQFHUGHFXHOOROHVLRQHVSUHFXUVRUDV\HYDOXDUOD FRPSHWHQFLDFHUYLFDO ([DPHQJHQLWDOFROSRFLWRORJtDRQFROyJLFDFROSRVFRStD &$1&(5&(59,&$/ (OFiQFHUFHUYLFDOHVHOVHJXQGRFiQFHUPiVIUHFXHQWHHQWUHODVPXMHUHV\IXHUHVSRQVDEOH GHPiVGHPXHUWHVHQHOPXQGRHQHODxRDSUR[LPDGDPHQWHHOGH HVDV PXHUWHV VH SURGXMR HQ SDtVHV HQ GHVDUUROOR$PpULFD /DWLQD \ HO &DULEH QR VRQ ODH[FHSFLyQ/DSUHYHQFLyQGHHVDVPXHUWHVSRUXQDGHFXDGRWDPL]DMH\WUDWDPLHQWR FRQWULEXLUiQHQSDUWHDDOFDQ]DUODV0HWDVGH'HVDUUROORGHO0LOHQLR /DPD\RUtDGHODVPXHUWHVHQORVSDtVHVHQGHVDUUROORVHSURGXFHHQPXMHUHVMyYHQHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR )DFWRUHVGHULHVJR 0~OWLSOHVIDFWRUHVVHKDQLGHQWL¿FDGRFRPRIDFWRUHVGHULHVJRHQWUHORVTXHVHGHVWDFDQ PXOWLSDULGDGLQIHFFLRQHVGHWUDQVPLVLyQVH[XDO,76HVSHFLDOPHQWHODVYLQFXODGDVD ODVYDULHGDGHV\GHOYLUXVGHOSDSLORPDKXPDQR+39WDEDTXLVPRDFWLYR\R SDVLYRP~OWLSOHVFRPSDxHURVVH[XDOHVFRPSDxHURVH[XDOFRQPXFKDVFRPSDxHUDV VH[XDOHVLQLFLRWHPSUDQRGHODVUHODFLRQHVVH[XDOHVOHVLRQHVSUHFXUVRUDVGHOFiQFHU GHFXHOORGLVSODVLDVROHVLRQHVHVFDPRVDVLQWUDHSLWHOLDOHV (OH[DPHQGHODPXMHUHPEDUD]DGD 8Q FRUUHFWR H[DPHQ JLQHFROyJLFR LQFOX\H XQD GHWHQLGD LQVSHFFLyQ YXOYDU GH ODV SDUHGHVYDJLQDOHV\GHOFpUYL[FRQHVSpFXOR\HOWDFWRYDJLQDO6HUHFRPLHQGDKDFHU XQD HYDOXDFLyQ HQ OD SULPHUD FRQVXOWD DXQTXH HQ RSRUWXQLGDGHV GHELGR D IDFWRUHV SVLFRHPRFLRQDOHV TXH URGHDQ DO H[DPHQ JLQHFROyJLFR \ D OD IDOWD GH FRQRFLPLHQWR HQWUHODHPEDUD]DGD\HOHTXLSRGHVDOXGSRGUiSRVSRQHUVHHOH[DPHQKDVWDTXHVH FRQVLGHUHPiVDSURSLDGR ,QVSHFFLyQYLVXDO /DLQVSHFFLyQSRGUiKDFHUVHEDMRHVSpFXOR\SRGUiDSOLFDUVHiFLGRDFpWLFRROXJROOD WLQFLyQFRQHVWDVVXVWDQFLDVQRPHMRUDODVHQVLELOLGDGSDUDGHWHFWDUFiQFHUGHFXHOOR\ OHVLRQHVSUHPDOLJQDVSRUORFXDOQRVHUHFRPLHQGDVXXVRHQIRUPDUXWLQDULD ,QVSHFFLyQFRQiFLGRDFpWLFRYLQDJUHFXDQGRVHDSOLFDVREUHHO FXHOOR SXHGH FDPELDU HO FRORU URVDGR QRUPDO WRPDQGR XQD FROR UDFLyQEODQFDHSLWHOLRDFHWREODQFRTXHLQGLFDXQDDQRUPDOLGDG ,QVSHFFLyQ FRQ OXJRO VROXFLyQ GH \RGR\RGXUDGD FXDQGR VH DSOLFDVREUHHOFXHOORQRUPDOHVWHVHWLxHGHFRORUPDUUyQRVFXUR Figura 35. Fragmento de HCP. /DVOHVLRQHVVRVSHFKRVDVQRVHWHxLUiQ Estudio del cérvix. &RQWUROGHO&iQFHUGHFXHOOR 3UHYHQFLyQ SULPDULD LQWHQWD PHGLDQWH HGXFDFLyQ JHQHUDU FRQGXFWDV VH[XDOHV VHJXUDVRLQWHQWDUFDPELDUFRQGXFWDVVH[XDOHVGHULHVJRSDUDGLVPLQXLUODH[SRVLFLyQ DO+39XRWURVFRIDFWRUHVIDYRUHFHGRUHVGHOFiQFHUGHFXHOOR3UREDEOHPHQWHOD LQFRUSRUDFLyQGHODVYDFXQDVFRQWUDODVYDULHGDGHV\GHO+39VHLQWHJUHQ DODSUHYHQFLyQSULPDULDHQUHODWLYDPHQWHFRUWRWLHPSR7DPELpQODHVWUDWHJLDGH SUHYHQFLyQSULPDULDLQWHQWDIRPHQWDUHVWLORVGHYLGDVDOXGDEOHVSDUDGLVPLQXLURWURV IDFWRUHVYLQFXODGRVDOFiQFHUGHFXHOORHVSHFLDOPHQWHHOWDEDFR 3UHYHQFLyQVHFXQGDULDVHEDVDHQHOGLDJQyVWLFRSUHFR]HPSOHDQGRODVWpFQLFDV GH WDPL]DMH HVSHFLDOPHQWH OD FROSRFLWRORJtD RQFROyJLFD 3$3 \ UH¿ULHQGR D OD PXMHU DO QLYHO DSURSLDGR GH DWHQFLyQ FDGD YH] TXH VH HIHFW~D XQ GLDJQyVWLFR SDWROyJLFR7DPELpQHVLPSRUWDQWHDGYHUWLUDODVXVXDULDVDFHUFDGHORVVtQWRPDV \VLJQRVPiVIUHFXHQWHVFRQORVTXHVHPDQL¿HVWDHOFiQFHUFHUYLFDO 3UHYHQFLyQWHUFLDULDXQDYH]GLDJQRVWLFDGRHOFiQFHURORVHVWDGRVSUHFDQFHURVRV VHGHEHUiJDUDQWL]DUHOWUDWDPLHQWRHOTXHIUHFXHQWHPHQWHVHUiFXUDWLYR\DYHFHV SHUPLWLUiFRQVHUYDUHOyUJDQR\ODIXQFLyQ2WUDVYHFHVVHUiFXUDWLYRSHURPXWLODQWH \HQRSRUWXQLGDGHVVRORVHUiSDOLDWLYR\VHLQWHQWDUiFRQVHJXLUODPHMRUFDOLGDGGH YLGD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 7DPL]DMHSDUDHOFiQFHUFHUYLFDO 3DUD OD SREODFLyQ GH PXMHUHV VH UHFRPLHQGD HPSOHDU GRV HVWUDWHJLDV ORV WDPL]DMHV RUJDQL]DGRVRORVWDPL]DMHVGHRSRUWXQLGDG 7DPL]DMH GH RSRUWXQLGDG HQ HVWH WLSR GH LQWHUYHQFLyQ ORV HTXLSRV GH VDOXG SURSRQHQ D FDGD PXMHU TXH OOHJD DO VHUYLFLR OD UHDOL]DFLyQ GH XQ 3$3 (VWH HQIRTXH VH H[WLHQGH SULQFLSDOPHQWH D PXMHUHV MyYHQHV FRQ PHQRV ULHVJR TXH DFXGHQ D OD FRQVXOWD SUHQDWDO D ODV FRQVXOWDV GH SODQL¿FDFLyQ IDPLOLDU R D ORV VHUYLFLRV GH VDOXG LQIDQWLO &RPR LQFRQYHQLHQWHV SUHVHQWD XQD PD\RU SpUGLGD HQHOVHJXLPLHQWR\XQDOWRFRVWRHIHFWLYLGDGVLVHORVFRPSDUDFRQORVWDPL]DMHV RUJDQL]DGRV 7DPL]DMHRUJDQL]DGRVHGLVHxDSDUDDOFDQ]DUHOPD\RUQ~PHURSRVLEOHGHPXMHUHV FRQ PD\RU ULHVJR GH FRQWUDHU FiQFHU FHUYLFDO 6H FDUDFWHUL]D SRU SODQL¿FDU OD DWHQFLyQSRUQLYHOHV\DSURYHFKDUPiVUDFLRQDOPHQWHORVUHFXUVRV/RVJUXSRV GHHGDG\ODIUHFXHQFLDGHORVH[iPHQHVUHFRPHQGDGRVVHUHVXPHHQODWDEOD VLJXLHQWH &XDGUR(GDGHV\IUHFXHQFLDUHFRPHQGDGDVSDUDUHDOL]DU ODFROSRFLWRORJtDRQFROyJLFD3$3 &RPHQ]DUDSDUWLUGHORVDxRV([FHSFLRQDOPHQWHDSDUWLUGHORVDxRV (OWDPL]DMHDQXDOQRVHUHFRPLHQGDDQLQJXQDHGDG (QWUHORV\DxRVXQDFLWRORJtDFDGDDxRVSXHGHVHUVX¿FLHQWH (QWUHORV\DxRVXQDFLWRORJtDFDGDDxRVSXHGHVHUVX¿FLHQWH $SDUWLUGHORVDxRVFRQGRVFLWRORJtDVSUHYLDVQRUPDOHVQRUHSHWLUODFLWRORJtD 7DPL]DMHHQODPXMHUHPEDUD]DGD 6L OD PXMHU HPEDUD]DGD WLHQH XQ 3$3 QRUPDO UHDOL]DGR GH DFXHUGR D ORV FULWHULRV UHVXPLGRV HQ HO FXDGUR QR VHUi QHFHVDULR UHSHWLUOR D PHQRV TXH ODV QRUPDV QDFLRQDOHVDVtORLQGLTXHQ $XQTXH HO HPEDUD]R QR HV HO PRPHQWR LGHDO SDUD HIHFWXDU DQiOLVLV FLWROyJLFRV SRU ORV FDPELRV ¿VLROyJLFRV TXH VH SUHVHQWDQ HQ HVWH SHUtRGR \ TXH SXHGHQ OOHYDU D LQWHUSUHWDFLRQHVHUUyQHDVVHUHFRPLHQGDHIHFWXDUHOWDPL]DMHHQWRGDPXMHUHPEDUD]DGD TXHQRWHQJDYLJHQWHHOHVWXGLRFLWROyJLFRGHFXHOORRQXQFDVHORKD\DHIHFWXDGRFDGD YH]TXHVHREVHUYHXQDDQRUPDOLGDGFHUYLFDORH[LVWDQIDFWRUHVTXHKDJDQVRVSHFKDU TXH OD PXMHU QR UHJUHVDUi DO VHUYLFLR GH VDOXG HQ HO DIiQ GH UHGXFLU RSRUWXQLGDGHV SpUGLGDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 2EWHQFLyQGHODPXHVWUDGH3$3 /DWRPDGH3$3GHEHVHUUHDOL]DGDHQHOSULPHUQLYHOGHDWHQFLyQODREWHQFLyQGHOD PXHVWUDUHTXLHUHXQPtQLPRGHHQWUHQDPLHQWR\PDWHULDO (OPDWHULDOPtQLPRUHTXHULGRHV JXDQWHVGHVFDUWDEOHV HVSpFXOR IXHQWHGHOX] PHVDJLQHFROyJLFD PDWHULDOSDUDREWHQHUODPXHVWUDHVSiWXODGHPDGHUDFHSLOORHQGRFHUYLFDO OiPLQDGHYLGULRSDUDPLFURVFRSLR OiSL]SDUDURWXODUODOiPLQD\ VSUD\¿MDGRURDOFRKRODO 3URFHGLPLHQWRFRQHVSiWXODGHPDGHUD 8QDYH]YLVXDOL]DGRHOFXHOORFRQHVSpFXORVHLQVHUWDODSDUWHPiVODUJDGHODHVSiWXOD HQHORUL¿FLRFHUYLFDO\VHURWDHQFtUFXORJUDGRV $PERV ODGRV GH OD HVSiWXOD GHEHQ VHU H[WHQGLGRV VREUH OD OiPLQD FXLGDGRVDPHQWH Figura 36. Instrumental para muestras de PAP. a) espátula de madera b) cepillo endocervical c) cepillo / escoba Figura 37. Fijación de lámina de PAP con spry. ,QPHGLDWDPHQWHGHH[WHQGLGDODPXHVWUDHQODOiPLQD¿MDUODFRQVSUD\¿MDGRUDXQD GLVWDQFLDGHFPHQiQJXORUHFWRR¿MDUODVXPHUJLpQGRODHQXQIUDVFRTXHFRQWHQJD DOFRKRODO 1RROYLGDULGHQWL¿FDUODOiPLQDFRUUHFWDPHQWHFRQORVGDWRVGHODPXMHU (VUHFRPHQGDEOHQRREWHQHUODPXHVWUDVLODPXMHUWLHQHVDQJUDGRSURIXVRRHOHPHQWRV GHLQIHFFLyQJHQLWDOEDMD 2WUDVDOWHUQDWLYDVGLDJQyVWLFDV &ROSRVFRStD /DFROSRVFRStDFRQVLVWHHQHOH[DPHQGHOFXHOORODYDJLQD\ODYXOYDFROSRVFRSLRXQ LQVWUXPHQWRTXHSURYHHLOXPLQDFLyQ\PDJQL¿FDFLyQGHODYLVLyQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 'HEHVHUUHDOL]DGDSRUXQSURYHHGRUFRQHQWUHQDPLHQWRVX¿FLHQWH 8VDGDFRPRXQDKHUUDPLHQWDGLDJQyVWLFDHQPXMHUHVFRQFLWRORJtDSRVLWLYDSDWROyJLFD WLHQH XQD DOWD VHQVLELOLGDG \ XQD HVSHFL¿FLGDG GH SDUD OD GHWHFFLyQ GH OHVLRQHVSUHFXUVRUDV\GHFiQFHU %LRSVLD /DELRSVLDFRQVLVWHHQODUHPRFLyQGHXQIUDJPHQWRGHWHMLGRVRVSHFKRVRSDUDHIHFWXDU GLDJQyVWLFRKLVWRSDWROyJLFRFRQH[FHSFLyQGHODVOHVLRQHVPDFURVFySLFDVGHEHUtDVHU UHDOL]DGDEDMRYLVLyQFROSRVFySLFD 0XMHUHPEDUD]DGD 1HJDWLYR 3$3 6L 1HJDWLYR 5HHYDOXDUHQ DxRVRVHJ~Q 1RUPD1DFLRQDO &ROSRVFRStD %LRSVLD 3RVLWLYR 'LVSRQHGH FROSRVFRStD\ELRSVLD" 1R 3RVLWLYR 5HIHULUSDUD WUDWDPLHQWRDQLYHOGH PD\RUFRPSOHMLGDG 5HIHULUSDUD GLDJQyVWLFRDQLYHOGH PD\RUFRPSOHMLGDG &XDQGRHO3$3HVLQIRUPDGRFRPR$6&86R6,/GHEDMRJUDGR/6,/OHVLRQHV SHUVLVWHQWHVUHSRUWDGRVHQ3$3GHQWURGHPHVHVDDxRGHEHUtDQVHULQYHVWLJDGDV )LJXUD(VTXHPDHVFDORQDGRGHGHFLVLRQHVSDUDHOPDQHMR VHJ~QUHVXOWDGRVGH3$3 ,QWHUSUHWDFLyQGHORVUHVXOWDGRV ([LVWHQDFWXDOPHQWHQXPHURVRVVLVWHPDVSDUDFODVL¿FDUDODVOHVLRQHVGHOFXHOORGRVGH OORVVRQSUHGRPLQDQWHPHQWHGHWLSRFLWROyJLFRFRPRODFODVL¿FDFLyQGH3DSDQLFRODRXRHO VLVWHPDGH%HWKHVGDPLHQWUDVTXHORVRWURVGRVVRQGHWLSRKLVWROyJLFRFODVL¿FDFLyQSRU QHRSODVLDVLQWUDHSLWHOLDOHVFHUYLFDOHV1,&RSRUHOVLVWHPDGHGHVFULSFLyQGH206 0XFKDV YHFHV HQ XQ PLVPR LQIRUPH VH UHFLEH XQD VXSHUSRVLFLyQ GH ODV GLIHUHQWHV FODVL¿FDFLRQHV\HVRJHQHUDFRQIXVLyQHQHOSUHVWDGRU\RHQODXVXDULDSRUHOOR\SDUD IDFLOLWDU OD FRPSUHQVLyQ HQ OD WDEOD VLJXLHQWH VH FRPSDUDQ \ UHODFLRQDQ ORV VLVWHPDV PHQFLRQDGRV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &XDGUR7HUPLQRORJtDVXVDGDVSDUDHOWDPL]DMH\HOGLDJQyVWLFRFLWROyJLFRH KLVWROyJLFRGHODVOHVLRQHVGHFXHOOR &ODVL¿FDFLyQFLWROyJLFD WDPL]DMH &ODVL¿FDFLyQKLVWROyJLFD FRQ¿UPDWRULD 3$3 %HWKHVGD 1,& 206 FODVL¿FDFLyQGHVFULSWLYD &ODVH, 1RUPDO 1RUPDO 1RUPDO &ODVH,, $6&86 $6&+ $WLStD $WLStD &ODVH,,, /6,/ 1,&LQFOX\H FRQGLORPDSODQR &RLORFLWRVLV &ODVH,,, +6,/ 1,& 'LVSODVLDPRGHUDGD &ODVH,,, +6,/ 1,& 'LVSODVLDVHYHUD &ODVH,9 +6,/ 1,& &DUFLQRPDLQVLWX &ODVH,9 &iQFHULQYDVRU &iQFHULQYDVRU &iQFHULQYDVRU $6&86VLJODHQLQJOpVTXHVHWUDGXFHFRPR³FpOXODVHVFDPRVDVDWtSLFDVGHVLJQL¿FDGRLQGHWHUPLQDGR´ $6&+VLJODHQLQJOpVTXHVHWUDGXFHFRPR³FpOXODVHVFDPRVDVDWtSLFDVTXHQRSHUPLWHQGHVFDUWDUOHVLyQ HVFDPRVDGHDOWRJUDGR´ /6,/VLJODHQLQJOpVTXHVHWUDGXFHFRPROHVLyQHVFDPRVDLQWUDHSLWHOLDOGHEDMRJUDGR +6,/VLJODHQLQJOpVTXHVHWUDGXFHFRPROHVLyQHVFDPRVDLQWUDHSLWHOLDOGHDOWRJUDGR 1,&QHRSODVLDLQWUDHSLWHOLDOFHUYLFDO 7UDWDPLHQWRGHOFiQFHUFHUYLFDOGXUDQWHHOHPEDUD]R 8VXDOPHQWH ODV PXMHUHV FRQ GLDJQyVWLFR GH FiQFHU FHUYLFDO R OHVLyQ SUHFXUVRUD GH FiQFHU GHEHUiQ VHU DVLVWLGDV HQ XQ QLYHO GH PD\RU FRPSOHMLGDG HQ HO TXH VH SXHGD JDUDQWL]DUXQFRUUHFWRWUDWDPLHQWR (O WUDWDPLHQWR GHSHQGHUi GH OD HGDG JHVWDFLRQDO ORV GHVHRV GH OD JHVWDQWH \ GHO HVWDGtRDVLJQDGR ,1&203(7(1&,$&(59,&$/,& (QRFDVLRQHVHORUL¿FLRFHUYLFDOLQWHUQRGHOFXHOORGHO~WHURVHGLODWDHQIRUPDSDVLYD\ HVLQFDSD]GHPDQWHQHUHOHPEDUD]R(VWDHVXQDHYHQWXDOLGDGSRFRIUHFXHQWHTXHQR VXSHUDORVFDVRVFDGDPLOSDUWRV /D,&SXHGHVHUGHFDXVDFRQJpQLWDYLQFXODGDDPDOIRUPDFLRQHVXWHULQDVRDGTXLULGD JHQHUDOPHQWHVHFXQGDULDDGLODWDFLyQ\FXUHWDMHSDUWRVRSHUDWRULRV\RGHVJDUURV 'LDJQyVWLFR (OHOHPHQWRPiVRULHQWDGRUHVHODQWHFHGHQWHGHDERUWRVWDUGtRVRSDUWRVLQPDGXURV JHQHUDOPHQWHLQGRORURVFRQH[SXOVLyQGHOIHWRYLYRHOTXHSXHGHH[SXOVDUVHHQYXHOWR HQODVPHPEUDQDV 'XUDQWHHOHPEDUD]RHOGLDJQyVWLFRVHHIHFW~DSRUORVDQWHFHGHQWHV\RSRUHOKDOOD]JR GHXQFXHOORFRQGLODWDFLyQPD\RUTXHODHVSHUDGDSDUDODHGDGJHVWDFLRQDOHQDXVHQFLD GHFRQWUDFFLRQHV(QRFDVLRQHVODVPHPEUDQDVSXHGHQSURWUXLUSRUHORUL¿FLRFHUYLFDO H[WHUQRPHPEUDQDVHQUHORMGHDUHQD 5HFLHQWHPHQWH OD HFRJUDItD WUDQVYDJLQDO VH XVD SDUD HYDOXDU HO HVWDGR GHO RUL¿FLR FHUYLFDOLQWHUQR\GHHVDPDQHUDFRQWULEXLUDOGLDJQyVWLFRGHLQFRPSHWHQFLDFHUYLFDOHQ HWDSDVPiVSUHFRFHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 7UDWDPLHQWR (OWUDWDPLHQWRGHODLQFRPSHWHQFLDFHUYLFDOHVTXLU~UJLFR\FRQVLVWHHQFHUUDUHOFXHOOR FRQXQDFLQWDHVSHFLDO\EDMRDQHVWHVLDGHVGHODVVHPDQDV\QRPiVDOOiGHODV VHPDQDV(VWHSURFHGLPLHQWRUHFLEHHOQRPEUDGHFHUFODJH3DUDODUHDOL]DFLyQGHXQ FHUFODJHODPXMHUHPEDUD]DGDGHEHUiVHUGHULYDGDDXQQLYHOGHPD\RUFRPSOHMLGDG 2%-(7,926 $&7,9,'$' 3HVTXLVDUXQDSRVLEOHLQFRPSDWLELOLGDGVDQJXtQHDPDWHUQRIHWR QHRQDWDO 'HWHUPLQDFLyQGHOJUXSRVDQJXtQHRGHOIDFWRU5K\GHDQWLFXHUSRV LUUHJXODUHV /DV PXMHUHV 5K QHJDWLYDV TXH FXUVDQ XQ HPEDUD]R FRQ XQ IHWR 5K SRVLWLYR WLHQHQ XQ GH SUREDELOLGDG GH LVRLQPXQL]DUVH FRPR FRQVHFXHQFLD GH HVH HPEDUD]R /D PD\RUtD VH LQPXQL]DUiQ GXUDQWH HO SDUWR PLHQWUDV TXH XQD SHTXHxD IUDFFLyQ OR KDUiGXUDQWHHOHPEDUD]R&XDQGRH[LVWHLQFRPSDWLELOLGDGVDQJXtQHDGHWLSR$%2OD SUREDELOLGDGGHDORLQPXQL]DFLyQSRU5KVHUHGXFHDO /DLVRLQPXQL]DFLyQSRUIDFWRU5KHVXQSURFHVRTXHSXHGHVHUSUHYHQLGRFRQHOXVR GH JDPPDJOREXOLQD KLSHULQPXQH DQWL ' HQ HO SXHUSHULR R HQ HO SRVWDERUWR$~Q HQ DTXHOODV VLWXDFLRQHV HQ ODV TXH OD SUR¿OD[LV IUDFDVD HO UHVXOWDGR SHULQDWDO SXHGH VHU PRGL¿FDGREHQH¿FLRVDPHQWHPHGLDQWHODPRQLWRUL]DFLyQGHOJUDGRGHLVRLQPXQL]DFLyQ \ODFRPSUREDFLyQGHODDIHFWDFLyQIHWDO /D IRUPD GH GLVPLQXLU OD LQPXQL]DFLyQ HQ PXMHUHV JHVWDQWHV VH FRQVLJXH FRQ OD DSOLFDFLyQGHJDPPDJOREXOLQDDQWL'GHQWURGHODVKRUDV x GHODERUWRDWRGDPXMHU5KQHJDWLYDR xGHO SDUWR D WRGDV ODV SXpUSHUDV 5K QHJDWLYDV FRQ KLMRV 5K SRVLWLYRV QR LQPXQL]DGDVSUHYLDPHQWH &RQ HVWD LQWHUYHQFLyQ HO SRUFHQWDMH GH PXMHUHV DORLQPXQL]DGDV VH UHGXFH GUiVWLFDPHQWH (QDTXHOORVSDtVHVGRQGHVHDSOLFDJDPPDJOREXOLQDDQWL'HQHOSRVWSDUWRODIUHFXHQFLD GHLVRLQPXQL]DFLyQVHUHGXFHGHDPHQRVGHO6LDGHPiVVHUHDOL]DSUR¿OD[LV LQWUDHPEDUD]RHQWUHODVVHPDQDV\ROXHJRGHXQDKHPRUUDJLDRPDQLREUDV LQYDVLYDVSXQFLyQDPQLyWLFDFRUGRFHQWHVLVHWFODIUHFXHQFLDGHDORLQPXQL]DFLyQVH UHGXFHDO4XHGDQGRFDVLVRORUHVWULQJLGDDORVFDVRVGHDERUWRRDIUDFDVRVGH ODLQPXQRSUR¿OD[LV 3RU HO DOWR FRVWR TXH LPSOLFD HQ UHODFLyQ D VX HIHFWR SURWHFWRU HV GLVFXWLEOH OD DGPLQLVWUDFLyQGHJDPPDJOREXOLQDDQWL'GXUDQWHHOHPEDUD]RHQIRUPDUXWLQDULD 'HELGRDTXHQRWRGRVORVFDVRVGHDORLQPXQL]DFLyQPDWHUQD\ULHVJRGHHQIHUPHGDG KHPROtWLFD SHULQDWDO VH YLQFXODQ DO IDFWRU 5K QHJDWLYR HVWi MXVWL¿FDGR HIHFWXDU OD GHWHUPLQDFLyQGHORVDQWLFXHUSRVLUUHJXODUHVWHVWGH&RRPEVLQGLUHFWRWDQWRDJHVWDQWHV 5KQHJDWLYDVFRPRSRVLWLYDV 9DORUDFLyQ&OtQLFDVHUHFRPLHQGDHIHFWXDUXQFRUUHFWRLQWHUURJDWRULRGHODJHVWDQWH HQE~VTXHGDGH $QWHFHGHQWHV GH DERUWR PXHUWHV SHULQDWDOHV LFWHULFLD HQ XQ UHFLpQ QDFLGR DQWHULRU QHFHVLGDGGHH[VDQJXLQRWUDQVIXVLyQIRWRWHUDSLDDGPLQLVWUDFLyQGHJDPPDJOREXOLQD DQWL ' WUDQVIXVLRQHV PDQLREUDV LQYDVLYDV GXUDQWH HO HPEDUD]R DPQLRFHQWHVLV FRUGRFHQWHVLV WUDQVSODQWHV R LQMHUWRV GURJDGLFFLyQ LQWUDYHQRVD FRPSDUWLHQGR MHULQJXLOODV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 9DORUDFLyQ3DUDFOtQLFDHQODSULPHUDFRQVXOWDVHVROLFLWDUiD ODHPEDUD]DGDODGHWHUPLQDFLyQGHOJUXSRVDQJXtQHRHOIDFWRU 5K\GHORVDQWLFXHUSRVLUUHJXODUHVWHVWGH&RRPEVLQGLUHFWR Figura 39. Fragmento de HCP. Grupo y Rh &RQGXFWD *HVWDQWH 5K QHJDWLYD FRQ DQWLFXHUSRV LUUHJXODUHV QHJDWLYRV FRQWLQ~D HO FRQWURO VHJ~QQRUPDLQFOX\HQGRQXHYDVGHWHUPLQDFLRQHVGHDQWLFXHUSRVLUUHJXODUHV\HYHQWXDO SUR¿OD[LVFRQJDPPDJOREXOLQDDQWL' *HVWDQWH5KQHJDWLYDFRQDQWLFXHUSRVLUUHJXODUHVSRVLWLYRVVHHIHFW~DGLDJQyVWLFR GH DORLQPXQL]DFLyQ PDWHUQD (Q HVWH FDVR VH GHEHUi UHIHULU D XQ QLYHO GH PD\RU FRPSOHMLGDGSDUDGHVFDUWDURFRQ¿UPDUSRVLELOLGDGGHHQIHUPHGDGKHPROtWLFDSHULQDWDO DIHFWDFLyQIHWDO *HVWDQWH 5K SRVLWLYD FRQ DQWLFXHUSRV LUUHJXODUHV QHJDWLYRV FRQWLQ~D HO FRQWURO VHJ~Q HO FURQRJUDPD KDELWXDO \ QR UHTXHULUi QLQJXQD RWUD GHWHUPLQDFLyQ GH JUXSR IDFWRU5KQLGHDQWLFXHUSRVLUUHJXODUHV *HVWDQWH5KSRVLWLYDFRQDQWLFXHUSRVLUUHJXODUHVSRVLWLYRVVHHIHFW~DGLDJQyVWLFR GH DORLQPXQL]DFLyQ PDWHUQD (Q HVWH FDVR VH GHEHUi UHIHULU D XQ QLYHO GH PD\RU FRPSOHMLGDGSDUDLGHQWL¿FDUHODQWLFXHUSRUHVSRQVDEOH\GHVFDUWDURFRQ¿UPDUSRVLELOLGDG GHHQIHUPHGDGKHPROtWLFDSHULQDWDODIHFWDFLyQIHWDO (VTXHPDVGHSUR¿OD[LV /D LQPXQRSUR¿OD[LV GHSHQGHUi GHO HVWDGR LQPXQLWDULR GH OD JHVWDQWH GH OD HGDG JHVWDFLRQDO GH OD HYROXFLyQ GH OD JUDYLGH] PDQLREUDV LQYDVLYDV JHQLWRUUDJLD \ GH ODGLVSRQLELOLGDGGHORVUHFXUVRVQHFHVDULRV(QFDVRGHFRQWDUFRQODSRVLELOLGDGGH HIHFWXDU LQPXQRSUR¿OD[LV HQ DTXHOODV VLWXDFLRQHV GH ULHVJR VH VXJLHUH HPSOHDU HO VLJXLHQWHHVTXHPDOXHJRGH *HQLWRUUDJLDRPDQLREUDVLQYDVLYDVHQHOHUWULPHVWUH DPFJGHJDPPDJOREXOLQDDQWL',0R,9 *HQLWRUUDJLDRPDQLREUDVLQYDVLYDVGHVSXpVGHOHUWULPHVWUH DPFJGHJDPPDJOREXOLQDDQWL',9R DPFJGHJDPPDJOREXOLQDDQWL',0 3RVWSDUWR DPFJGHJDPPDJOREXOLQDDQWL',9R DPFJGHJDPPDJOREXOLQDDQWL',0 &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD *HVWDQWHDFRQWURODU )DFWRU5K DFRQVXOWD 7HVWGH &RRPEVLQGLUHFWR 7&, 7HVWGH &RRPEVLQGLUHFWR 7&, 1RUHSLWH7&, 'LDJQyVWLFRSRVLWLYRGH DORLQPXQL]DFLyQPDWHUQD 5HSLWH 7&,DPLWDGGHO HPEDUD]R &RQWLQ~DFRQWURO GHEDMRULHVJR &RQWUROHQ$52SDUDFRQILUPDU RGHVFDUWDUDIHFWDFLyQIHWDO &RQWLQ~DFRQWURO GHEDMRULHVJR 6HDSOLFDUiLQPXQRSURILOD[LVDQWL'VHJ~QQRUPDQDFLRQDO )LJXUD(VTXHPDHVFDORQDGRGHGHFLVLRQHVSDUDHOPDQHMRGHODHQIHUPHGDG KHPROtWLFDSHULQDWDO 2%-(7,926 3UHYHQLUGHWHFWDU\WUDWDUODDQHPLDPDWHUQD $&7,9,'$' 'HWHUPLQDUQLYHOHVGHKHPRJORELQD $GPLQLVWUDFLyQGHKLHUUR\iFLGRIyOLFR /DDQHPLDHVXQSUREOHPDGHVDOXGS~EOLFDSRUODVFRQVHFXHQFLDVTXHWLHQHVREUHOD VDOXGKXPDQDHVSHFLDOPHQWHHQHOHPEDUD]RGRQGHVHDVRFLDFRQDXPHQWRGHOULHVJR GHPRUWDOLGDGPDWHUQDPRUWDOLGDGSHULQDWDOHQHVSHFLDOHQFDVRVGHDQHPLDVHYHUD SUHPDWXUH]EDMRSHVRDOQDFHU\5&, 'H¿QLFLyQ 6H FRQVLGHUD TXH XQD JHVWDQWH SDGHFH DQHPLD FXDQGR HO YDORU GH KHPRJORELQD HV PHQRU D JG/ GXUDQWH HO SULPHU R HO WHUFHU WULPHVWUH R FXDQGR HO YDORU GH OD KHPRJORELQDGXUDQWHHOVHJXQGRWULPHVWUHHVPHQRUDJG/6LODKHPRJORELQDVH VLW~DHQWUH\JG/VHFRQVLGHUDTXHODDQHPLDHVPRGHUDGD\FXDQGRHVPHQRU DJG/ODDQHPLDVHFRQVLGHUDVHYHUD 7DPL]DMHSDUDDQHPLDHQHOHPEDUD]R (QODSULPHUDFRQVXOWDVHLQFOX\HGHQWURGHOH[DPHQJHQHUDOGHODJHVWDQWHODLQVSHFFLyQ GHSLHO\PXFRVDV\HOH[DPHQFDUGLRYDVFXODUSDUDGHVFDUWDURFRQ¿UPDUXQDDQHPLD /DSUXHEDGHKHPRJORELQDVHHIHFWXDUiGHDFXHUGRDODQRUPDQDFLRQDO(O&/$3605 VXJLHUHHIHFWXDUXQSULPHUH[DPHQDOPRPHQWRGHODFDSWDFLyQ\XQVHJXQGRH[DPHQ GHVSXpVGHODVHJXQGDPLWDGGHOHPEDUD]R(VWRVGDWRVSXHGHQVHUUHJLVWUDGRVHQOD +&3ODTXHDVXYH]VLUYHGHUHFRUGDWRULRVREUHODVSULQFLSDOHVPHGLGDVSUHYHQWLYDV TXHORVSURIHVLRQDOHVGHEHQVXJHULUDODVJHVWDQWHVVXSOHPHQWDFLyQFRQKLHUUR\FRQ IRODWRV JG/ JG/ )LJXUD)UDJPHQWRGH+&3$QHPLD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 'H¿FLHQFLDGHKLHUUR ([LVWHQGLYHUVDVIRUPDVGHDQHPLDODPiVFRP~QGHHOODVVHYLQFXODFRQGH¿FLHQFLDHQ ORVQLYHOHVGHKLHUUR/DDQHPLDSRUGH¿FLHQFLDGHKLHUURHVWiSUHFHGLGDSRUGHSyVLWRV GHKLHUURDJRWDGRV\VHHVWLPDTXHHVODGH¿FLHQFLDQXWULFLRQDOPiVFRP~QHQWUHODV PXMHUHVHPEDUD]DGDV/DSUHYDOHQFLDRVFLODHQWUH\GHODVPXMHUHVJHVWDQWHV GHORVSDtVHVHQYtDVGHGHVDUUROOR(VQHFHVDULRWHQHUHQFXHQWDTXHODDQHPLDSXHGH WHQHUPiVGHXQDFDXVDWDOFRPRVHYHHQODGH¿FLHQFLDGHYLWDPLQD$%SLULGR[LQD SURFHVRVLQÀDPDWRULRVFUyQLFRV9,+PDODULDHLQIHFFLRQHVSDUDVLWDULDV 'LDJQyVWLFR $GHPiVGHOGp¿FLWGHKHPRJORELQDHQORVFDVRVGHDQHPLDIHUURSpQLFDVHHQFRQWUDUiQ JOyEXORV KLSRFUyPLFRV \ PLFURFtWLFRV /D H[SUHVLyQ FOtQLFD GH HVWH Gp¿FLW UHSHUFXWH FOtQLFDPHQWH HQ OD PXMHU JHVWDQWH RFDVLRQDQGR FDQVDQFLR IDWLJD SDOLGH] FXWiQHR PXFRVD\DXPHQWRGHODIUHFXHQFLDFDUGtDFD(QRWUDVRFDVLRQHVXQDUHVWULFFLyQGHO FUHFLPLHQWRIHWDOLQWUDXWHULQRSXHGHVHUHOHOHPHQWRGHVRVSHFKDGHODDQHPLD 'H¿FLHQFLDGHIRODWRV /D VHJXQGD FDXVD GH DQHPLD QXWULFLRQDO GXUDQWH HO HPEDUD]R HV OD GH¿FLHQFLD GH IRODWRV (O Gp¿FLW GH IRODWRV GXUDQWH HO HPEDUD]R HV PX\ IUHFXHQWH GHELGR D TXH HO UHTXHULPLHQWRDXPHQWDKDVWDXQ\ODLQJHVWDVXHOHVHUPtQLPD 'LDJQyVWLFR /D DQHPLD SRU Gp¿FLW GH IRODWRV FRPSDUWH ORV PLVPRV VLJQRV FOtQLFRV TXH OD DQHPLD IHUURSpQLFD/DGLIHUHQFLDVHDSUHFLDHQHOHVWXGLRGHODOiPLQDHQHOFXDOORVJOyEXORV URMRVVHUiQPHJDOREOiVWLFRV\PDFURFtWLFRV(VWDVFDUDFWHUtVWLFDVGHORVJOyEXORVURMRV VRQFRPSDUWLGDVSRUODVDQHPLDVSRUGp¿FLWGHYLWDPLQD%TXHHVODWHUFHUDIRUPD PiVFRP~QGHDQHPLDQXWULFLRQDO 3UHYHQFLyQGHODDQHPLD /RVUHTXHULPLHQWRVGHKLHUUR\DFLGRIyOLFRDXPHQWDQGXUDQWHHOHPEDUD]R\HVGLItFLO SDUDXQDPXMHUHPEDUD]DGDVDWLVIDFHUHVWDPD\RUGHPDQGDVyORFRQODGLHWDSRUOR WDQWR ODV HVWUDWHJLDV GH SUHYHQFLyQ GH OD DQHPLD SRU GH¿FLHQFLD GH KLHUUR VH EDVDQ HQ x0RGL¿FDUODGLHWDSDUDDXPHQWDUHOFRQVXPRGHKLHUUR\GHORVIDFLOLWDGRUHVGHVX DEVRUFLyQDOWLHPSRGHLQWHQWDUGLVPLQXLUHOFRQVXPRGHLQKLELGRUHV x)RUWL¿FDUORVDOLPHQWRVGHFRQVXPRKDELWXDOFRQKLHUUR\iFLGRIyOLFR x6XSOHPHQWDUFRQPHGLFDPHQWRVTXHFRQWHQJDQKLHUUR\iFLGRIyOLFR x7UDWDU DTXHOODV LQIHFFLRQHV TXH SXHGHQ DOWHUDU OD DEVRUFLyQ GH KLHUUR \ RWURV QXWULHQWHVSRUHMHPSORSDUDVLWRVLV /RV VXSOHPHQWRV GH KLHUUR KDQ VLGR VXJHULGRV FRPR XQD HVWUDWHJLD SDUD PHMRUDU HO QLYHOGHKLHUURPDWHUQR\DVtPHMRUDUODVREUHYLGD\VDOXGGHODPDGUHHOWDPDxRIHWDO \GHVDUUROORGHOQLxRGXUDQWHHOSHUtRGRQHRQDWDO\SRVWQHRQDWDO 3RU WDO PRWLYR VH UHFRPLHQGD VXSOHPHQWDU D WRGDV ODV HPEDUD]DGDV FRQ PJ GH KLHUURHOHPHQWDOSRUGtD'HVGHHOPRPHQWRHQTXHVHVRVSHFKHHOHPEDUD]R\KDVWD HO SHULRGR SRVW SDUWR (O WLHPSR WRWDO GH VXSOHPHQWDFLyQ QR GHELHUD VHU PHQRU D PHVHV\HQOXJDUHVGRQGHODSUHYDOHQFLDGHDQHPLDGXUDQWHODJHVWDFLyQHV!DO HVUHFRPHQGDEOHPDQWHQHUODVXSOHPHQWDFLyQFRQKLHUURKDVWDPHVHVGHVSXpVGHO SDUWR 9DULRVSDtVHVGHOD5HJLyQKDQIRUWL¿FDGRDOJXQRVDOLPHQWRVGHFRQVXPRKDELWXDOFRQ KLHUUR\XRWURVQXWULHQWHVSDUDPHMRUDUHOHVWDGRGHODSREODFLyQJHQHUDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 3UHYHQFLyQGHORVGHIHFWRVGHOWXERQHXUDO (Q HO FDStWXOR GH FXLGDGRV SUHFRQFHSFLRQDOHV \D VH KD PHQFLRQDGR TXH SDUD OD SUHYHQFLyQGHORVGHIHFWRVGHOWXERQHXUDOODVPXMHUHVGHEHUtDQUHFLELUPJGtDGH iFLGRIyOLFRGHVGHXQRVWUHVPHVHVDQWHVGHHPEDUD]DUVHPtQLPRVHPDQDVDQWHV \FRQWLQXDUORVKDVWDHOWHUFHUPHVGHJHVWDFLyQ /DVHVWUDWHJLDVGHIRUWL¿FDFLyQGHDOJXQRVDOLPHQWRVWDPELpQHVWiQVLHQGRDGRSWDGDV SRUDOJXQRVSDtVHVGHODUHJLyQ\DTXHHQODVFRQGLFLRQHVDFWXDOHVHVSRFRSUREDEOH TXHHOGHODVPXMHUHVTXHVHHPEDUD]DQUHFLEDQSUHFRQFHSFLRQDOPHQWHHOiFLGR IyOLFR 7UDWDPLHQWR /DDQHPLDUHTXHULUiWUDWDPLHQWRGHODFDXVDTXHODSURYRTXHSRUHMHPSORVLODFDXVD GH OD DQHPLD HV GHELGD D XQD SDUDVLWRVLV VH GHEHUi DGPLQLVWUDU D OD JHVWDQWH HO WUDWDPLHQWRDQWLSDUDVLWDULRHVSHFt¿FR3HURDOPLVPRWLHPSRVHGHEHUiWUDWDUODDQHPLD LQGLFDQGRPJGHKLHUURHOHPHQWDOGtD\PJGHiFLGRIyOLFR (Q FDVRV GH DQHPLD VHYHUD HO WUDWDPLHQWR SRGUi UHTXHULU FXLGDGRV LQVWLWXFLRQDOHV \ WUDQVIXVLRQHVGHFRQFHQWUDGRVJOREXODUHVRKLHUURSDUHQWHUDO 2%-(7,926 'HVFDUWDUSURWHLQXULDJOXFRVXULD\EDFWHULXULD $&7,9,'$' ([DPHQGHRULQD\XURFXOWLYR /DRULQDGHODPXMHUHPEDUD]DGDVXIUHPRGL¿FDFLRQHVTXHVRQFRQVLGHUDGDV¿VLROyJLFDV (QWUH HVDV PRGL¿FDFLRQHV HV SRVLEOH HQFRQWUDU XQD GLVPLQXFLyQ SURJUHVLYD GH OD GLXUHVLV\GHODGHQVLGDGXULQDULDWDPELpQHVUHODWLYDPHQWHIUHFXHQWHLGHQWL¿FDUXQD JOXFRVXULD \ KDVWD HV IDFWLEOH REVHUYDU XQD SURWHLQXULD GH J/ HQ OD RULQD GH KRUDV3RUHOFRQWUDULRHOVHGLPHQWRXULQDULRQRVHPRGL¿FDVXVWDQFLDOPHQWH ([DPHQGHRULQD $WUDYpVGHODRULQDHVSRVLEOHGHWHFWDUDIHFFLRQHVTXHSRQHQHQULHVJRODYLGDGHOD PXMHUGHOQLxRRDPERV/RVHOHPHQWRVPiVIUHFXHQWHVTXHVHSXHGHQLGHQWL¿FDUHQOD RULQD\SHUPLWHQVRVSHFKDUSDWRORJtDVGXUDQWHHOHPEDUD]RVRQ x3URWHtQDV x%DFWHULDV x*OXFRVD $XQTXH OD SUHVHQFLD GH JOXFRVD HQ OD RULQD SXHGH VHU QRUPDO GXUDQWH HO HPEDUD]R QLYHOHV!PJG/SXHGHQUHODFLRQDUVHFRQXQDGLDEHWHVJHVWDFLRQDO/DVSURWHtQDV SXHGHQ LQGLFDU XQD LQIHFFLyQ XULQDULD HQIHUPHGDG GH ORV ULxRQHV R WUDVWRUQRV KLSHUWHQVLYRVGHOHPEDUD]R (OH[DPHQGHRULQDHVWiLQFRUSRUDGRDODPD\RUSDUWHGH ODVQRUPDVGHFXLGDGRDQWHQDWDOGHFDVLWRGRVORVSDtVHV GHOD5HJLyQDXQTXHKD\GLVFXVLyQVREUHODXWLOLGDGGHO H[DPHQGHRULQDHQODUXWLQDDQWHQDWDO /D +&3 SHUPLWH UHJLVWUDU XQ H[DPHQ GH SURWHtQDV HQ OD RULQD HQ FDGD FRQWURO DXQTXH FRQ WUHV DQiOLVLV HV VX¿FLHQWH Figura 42. Fragmento de HCP Control prenatal &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR x8QH[DPHQGHRULQDHQODSULPHUDFRQVXOWDSDUDGHVFDUWDUODH[LVWHQFLDOHVLRQHV UHQDOHVKHPDWXULDSURWHLQXULDFLOLQGUXULDHWF\GHGLDEHWHVJOXFRVXULD x8QVHJXQGRH[DPHQSUy[LPRDODVVHPDQDVTXHWHQGUiFRPRSULQFLSDO¿QDOLGDG ODGHWHFFLyQGHSURWHtQDVSDUDGHVFDUWDUXQDSUHHFODPSVLD x8Q WHUFHU H[DPHQ GH RULQD HQWUH ODV \ VHPDQDV SRGUi KDFHU VRVSHFKDU FXDOTXLHUD GH ODV WUHV FRQGLFLRQHV SDWROyJLFDV VHxDODGDV DXQTXH VX SULQFLSDO ¿QDOLGDG VHD GHVFDUWDU SUHHFODPSVLD 7DPELpQ VHUi ~WLO SDUD GHVFDUWDU XQD LQIHFFLyQXULQDULD /DSURWHLQXULDXVXDOPHQWHHVHOVLJQRGHDSDULFLyQPiVWDUGtRHQHOFXUVRFOtQLFRGHOD SUHHFODPSVLD\VHUHODFLRQDFRQODPDJQLWXGGHODSUHVLyQDUWHULDO/DSURWHLQXULDVXHOH DSDUHFHUFXDQGRODVFLIUDVGHSUHVLyQGLDVWyOLFDDOFDQ]DQORVPPGH+J\HVPD\RU FXDQWRPD\RUVHDODKLSHUWHQVLyQ (O DQiOLVLV GH RULQD FRQ WLULOODV UHDFWLYDV P~OWLSOHV SDUD EDFWHULXULD \ SURWHLQXULD HV IDFWLEOHGHUHDOL]DUDXQTXHUHFLHQWHVHVWXGLRVVXJLHUHQTXHWLHQHQXQDEDMDVHQVLELOLGDG GLDJQyVWLFDWDQWRSDUDLGHQWL¿FDUSURWHtQDVFRPRSDUDLGHQWL¿FDULQIHFFLyQ3RUORTXH PXFKRVDXWRUHVUHFRPLHQGDQDEDQGRQDUVXXVR /RVQLYHOHVGHDOE~PLQDHQXQDPXHVWUDGHRULQDDODFHFKRGHEHQOODPDUODDWHQFLyQ FXDQGRVXSHUDQJ/ ,QIHFFLyQXULQDULD\EDFWHULXULDDVLQWRPiWLFD (O WpUPLQR LQIHFFLyQ XULQDULD ,8 VH UH¿HUH D OD SUHVHQFLD GH XQ Q~PHUR FUtWLFR GH FRORQLDVEDFWHULDQDVHQODRULQDJHQHUDOPHQWHPD\RUDPO 3XHGHVHUDVLQWRPiWLFDEDFWHULXULDDVLQWRPiWLFDRPDQLIHVWDUVHSRUVtQWRPDVGLYHUVRV WDOHVFRPRFLVWLWLVVtQGURPHXUHWUDO\SLHORQHIULWLV /DV,8EDMDVDIHFWDQDODYHMLJDPLHQWUDVTXHODV,8DOWDVFRPSURPHWHQDORVULxRQHV SLHORQHIULWLV/DFLVWLWLVEDFWHULDQDSXHGHSUHVHQWDUHQWUHVXVVLJQRV\VtQWRPDVGLVXULD GRORUPLFFLRQDOSRODTXLXULDRULQDWXUELDRFDVLRQDOPHQWHKHPDWXULD\IUHFXHQWHPHQWH SLXULDUHFXHQWRGHJOyEXORVEODQFRVHQRULQDPD\RUDPO/RVVLJQRV\VtQWRPDV GH SLHORQHIULWLV LQFOX\HQ GRORU OXPEDU ¿HEUH HVFDORIUtRV FRQ WHPEORUHV \ PDO HVWDGR JHQHUDODGHPiVGHORVVtQWRPDVGH,8EDMD/DSLHORQHIULWLVDJXGDHVXQDHQWLGDGJUDYH HQODVHPEDUD]DGDV $SUR[LPDGDPHQWH GHO DO GH ODV HPEDUD]DGDV SXHGHQ VXIULU XQD FRORQL]DFLyQ EDFWHULDQDHQDXVHQFLDGHVtQWRPDV'HELGRDODUHSHUFXVLyQTXHSXHGHWHQHUHQOD VDOXG GH OD PXMHU JHVWDQWH \ GH VX IXWXUR KLMR WRGD EDFWHULXULD DVLQWRPiWLFD TXH VH GLDJQRVWLTXHHQHOHPEDUD]RGHEHUiVHUWUDWDGD (OWDPL]DMHSDUDEDFWHULXULDDVLQWRPiWLFDPHGLDQWHXURFXOWLYRHVWi UHFRPHQGDGRSDUDWRGDVODVJHVWDQWHVHQODSULPHUDYLVLWDSUHQDWDO 8QFXOWLYRREWHQLGRHQWUHODV\VHPDQDVGHHGDGJHVWDFLRQDO SXHGHLGHQWL¿FDUHOGHODVPXMHUHVJHVWDQWHVFRQXQDEDFWHULXULD Figura 43. DVLQWRPiWLFD/DKLVWRULDFOtQLFDSHULQDWDOGHO&/$3605UHFXHUGD Fragmento de HCP. VROLFLWDUXQDEDFWHULXULDHQODSULPHUDPLWDGGHOHPEDUD]R Bacteriuria 6HHVWLPDTXHUHSLWLHQGRHOXURFXOWLYRHQIRUPDPHQVXDOVHSXHGHLGHQWL¿FDUGHXQ DXQDGLFLRQDOHQFDGDPHVGHEDFWHULXULDVDVLQWRPiWLFDV+DVWDHOPRPHQWRQR H[LVWHFRQVHQVRHQODIUHFXHQFLDySWLPDSDUDUHSHWLUORVFXOWLYRVGHRULQD/DGHWHFFLyQ WHPSUDQDGHXQDEDFWHULXULDDVLQWRPiWLFDHQXQDPXMHUHPEDUD]DGDHVXQIDFWRUGH ULHVJRFRQRFLGRGHFRPSOLFDFLRQHVFRPRODSLHORQHIULWLVHOSDUWRGHSUHWpUPLQR\HOEDMR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD SHVR DO QDFHU (Q YLVWDV D UHGXFLU HO ULHVJR GH SUHPDWXUH] YLQFXODGR D OD EDFWHULXULD DVLQWRPiWLFDHO&/$3605VXJLHUHHIHFWXDUXQVHJXQGRFRQWUROGHEDFWHULXULDSUy[LPR DODVVHPDQDVGHHGDGJHVWDFLRQDO 'LDJQyVWLFR 6HFRQVLGHUDUiTXHXQDEDFWHULXULDHVSRVLWLYDFXDQGRODGHWHFFLyQGHFRORQLDVHQHO FKRUURPHGLRGHXQDPXHVWUDGHODSULPHUDRULQDGHODPDxDQDREWHQLGDHQFRQGLFLRQHV HVSHFLDOHVGHDVHSVLDGHORVJHQLWDOHV\FRORFDGDHQXQUHFLSLHQWHHVWpULOHV! EDFWHULDVP/ 7UDWDPLHQWR (VWXGLRVFOtQLFRVFRQWURODGRVHVWXGLRVGHFRKRUWH\PHWDDQiOLVLVKDQGHPRVWUDGRTXH WUDWDQGRODEDFWHULXULDDVLQWRPiWLFDVHSXHGHUHGXFLUODLQFLGHQFLDGHODVFRPSOLFDFLRQHV \DFLWDGDV *HQHUDOPHQWHODHOHFFLyQGHODQWLPLFURELDQRVHKDUiHQIXQFLyQGHODVXVFHSWLELOLGDG GHO JHUPHQ KDOODGR \ OD LQRFXLGDG GHO DQWLELyWLFR SDUD HO IHWR DXQTXH QR H[LVWH XQ DQWLELyWLFRLGHDO7DPSRFRKD\DFXHUGRHQODGXUDFLyQGHOWUDWDPLHQWRSDUDPDQWHQHU ODRULQDHVWpULO/RVWUDWDPLHQWRVGHGtDVSDUHFHQVHUORVTXHPiVVHDFHUFDQDOR LGHDOSDUDHOWUDWDPLHQWRGHODVEDFWHULXULDVDVLQWRPiWLFDV\DTXHFRQHOORVVHREWLHQH ODPHMRUUHODFLyQULHVJREHQH¿FLR/RVUHJtPHQHVGHDGtDVHUUDGLFDQODEDFWHULXULD HQHODGHORVFDVRV\VRQFRQVLGHUDGRVGHHOHFFLyQSDUDHOWUDWDPLHQWRGHODV LQIHFFLRQHVXULQDULDVVLQWRPiWLFDV/RVHVTXHPDVGHGRVLV~QLFDVKDVWDHOPRPHQWR VRQGHVDFRQVHMDGRVSRUVXPHQRUH¿FDFLD $ FRQWLQXDFLyQ VH SUHVHQWDQ HVTXHPDV GH WUDWDPLHQWR VXJHULGRV SDUD OD EDFWHULXULD DVLQWRPiWLFDFXDQGRVHGHVFRQRFHHOJHUPHQ (VTXHPDGHWUHVGtDV x$PR[LFLOLQDPJ92FKRUDVR x$PSLFLOLQDPJ92FKRUDVR x&HIDOH[LQDPJ92FKRUDV $QWHIDOODVHQHOWUDWDPLHQWRGHGtDVVHVXJLHUHHPSOHDU x1LWURIXUDQWRLQDPJ92FKRUDVGXUDQWHGtDV (QPXMHUHVFRQEDFWHULXULDUHFXUUHQWHVHSXHGHLQGLFDUWUDWDPLHQWRVXSUHVRU XQDGRVLVDODFRVWDUVHFRQPJGH1LWURIXUDQWRLQD92R &HIDOH[LQDPJ92 (VTXHPDGHGtDVDGtDV x1LWURIXUDQWRLQDPJ92FKRUDVR x$PR[LFLOLQDPJ92FKRUDVR x$PSLFLOLQDPJ92FKRUDVR x&HIDOH[LQDPJ92FKRUDV (QFDVRGHLQIHFFLRQHVUHFXUUHQWHVVHSXHGHHPSOHDUSUR¿OD[LVSRVWFRLWDO x'RVLV~QLFD&HIDOH[LQDPJ92R x1LWURIXUDQWRLQDPJ92 6HJXLPLHQWR 'RVDFXDWURVHPDQDVGHVSXpVGHKDEHUFXOPLQDGRHOWUDWDPLHQWRVHGHEHUiHIHFWXDU XQQXHYRXURFXOWLYRGHFRQWURO(QFDVRGHVHUQHJDWLYRSXHGH VHUUHSHWLGRXQDV VHPDQDVGHVSXpV 1RKD\FRQVHQVRDFHUFDGHUHDOL]DUXQQXHYRFRQWUROGHXURFXOWLYRHQDTXHOODVPXMHUHV TXHSUHVHQWDURQEDFWHULXULDSRVLWLYDDODVVHPDQDVGHOSDUWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 2%-(7,926 'HVFDUWDUGLDEHWHVPHOOLWXVFOtQLFD\JHVWDFLRQDO $&7,9,'$' 'HWHUPLQDFLyQ GH JOXFHPLD \ SUXHED GH WROHUDQFLD RUDO D OD JOXFRVD 6H HVWLPD TXH GH FDGD PXMHUHV HPEDUD]DGDV XQD VXIUH GLDEHWHV PHOOLWXV '0 \ TXH FDGD PXMHUHV HPEDUD]DGDV D GHVDUUROODUiQ XQD GLDEHWHV JHVWDFLRQDO'* /D IUHFXHQFLD GHO SUREOHPD HV SRFR FRQRFLGD HQ LQVWLWXFLRQHV /DWLQRDPHULFDQDV SRU OD IDOWD GH HVWXGLRV HSLGHPLROyJLFRV SREODFLRQDOHV HVWR FRQGLFLRQD XQD IDOVD ³EDMD SUHYDOHQFLD´GHELGDDOVXEGLDJQyVWLFR (Q JHQHUDO ORV FDVRV GH GLDEHWHV PHOOLWXV TXH FRQFXUUHQ DO FRQWURO DQWHQDWDO VXHOHQ VHUFODUDPHQWHLGHQWL¿FDEOHVSRUSUHVHQWDUDQWHFHGHQWHVIDPLOLDUHVGHODHQIHUPHGDG VLQWRPDWRORJtDFOtQLFDKLVWRULDREVWpWULFDFRQPDORVUHVXOWDGRVRKDOOD]JRVREVWpWULFRV RULHQWDGRUHV FODURV TXH SHUPLWHQ KDFHU XQ GLDJQyVWLFR VLQ GL¿FXOWDGHV 1R HV WDQ VHQFLOORGLDJQRVWLFDUORVFDVRVGHGLDEHWHVJHVWDFLRQDOGHODSREODFLyQJHQHUDOSDUD HOORVHUHTXLHUHHOHPSOHRGHSURFHGLPLHQWRVGHGHWHFFLyQ 'LDEHWHVJHVWDFLRQDO 6HFRQVLGHUDGLDEHWHVJHVWDFLRQDODODLQWROHUDQFLDDORVKLGUDWRVGHFDUERQRGHVHYHULGDG \HYROXFLyQYDULDEOHVTXHVHUHFRQRFHSRUSULPHUDYH]GXUDQWHODDFWXDOJHVWDFLyQ(VWD GH¿QLFLyQHVDSOLFDEOHHQIRUPDLQGHSHQGLHQWHGHVLVHXWLOL]DRQRLQVXOLQDFRPRWUDWDPLHQWR RVLODDOWHUDFLyQSHUVLVWHGHVSXpVGHOHPEDUD]R7DPSRFRH[FOX\HODSRVLELOLGDGGHTXH ODGLDEHWHVKD\DSRGLGRHVWDUSUHVHQWHDQWHVGHODJHVWDFLyQ 7DPL]DMHFOtQLFR (QODSULPHUDFRQVXOWDGHEHUHDOL]DUVHXQDYDORUDFLyQGHOULHVJRGHGLDEHWHVJHVWDFLRQDO SDUDHVRVHUiQHFHVDULRHIHFWXDUXQDFRUUHFWDDQDPQHVLV\H[DPHQItVLFRLQWHQWDQGR EXVFDURGHVFDUWDUORVVLJXLHQWHVIDFWRUHVGHULHVJR $QWHFHGHQWHV x3UHVHQFLDGHGLDEHWHVHQIDPLOLDUHVGHSULPHUJUDGRSDGUHVKLMRVKHUPDQRV x'LDEHWHVJHVWDFLRQDOHQHPEDUD]RVDQWHULRUHV x0XHUWHVSHULQDWDOHVGHFDXVDGHVFRQRFLGD x$ERUWRVHVSRQWiQHRVDUHSHWLFLyQGHFDXVDGHVFRQRFLGD x3ROLKLGUDPQLRVDUHSHWLFLyQ x0DFURVRPtD51FRQSHVR!JUDPRV x0DOIRUPDFLRQHVIHWDOHV $FWXDOHV x(GDGPDWHUQD!DxRV x2EHVLGDGDOLQLFLRGHOHPEDUD]RFRQtQGLFHGHPDVDFRUSRUDO,0&PD\RUD x*DQDQFLDH[FHVLYDGHSHVRGXUDQWHHOHPEDUD]R x3UHHFODPSVLDKLSHUWHQVLyQLQGXFLGDSRUHOHPEDUD]R x3ROLKLGUDPQLRVHQHOHPEDUD]RDFWXDO x,QIHFFLRQHVDUHSHWLFLyQHMXULQDULDJHQLWDO 7DPL]DMHSDUDFOtQLFR $XQTXH QR KD\ FRQVHQVR WRWDO HQ OD OLWHUDWXUD PpGLFD DFHUFD GHO WDPL]DMH XQLYHUVDO GH GLDEHWHV JHVWDFLRQDO HQ WRGDV ODV HPEDUD]DGDV OD LPSODQWDFLyQ GH SURJUDPDV GHVWLQDGRV D OD GHWHFFLyQ GH OD GLDEHWHV JHVWDFLRQDO HQ IRUPD XQLYHUVDO SXHGH MXVWL¿FDUVHSRU x/DHOHYDGDPRUELPRUWDOLGDGSHULQDWDOTXHODDFRPSDxDHQDTXHOORVFDVRVTXHQR HVGLDJQRVWLFDGDRSRUWXQDPHQWH x4XH PiV GH OD PLWDG GH ORV FDVRV GH '* GHVDUUROODQ FRQ HO WLHPSR GLDEHWHV PHOOLWXVFOtQLFD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD x/DSRVLELOLGDGFLHUWDGHSUREOHPDVSRVWQDWDOHVYLQFXODGRVDODVKLSHUJOXFHPLDV GHOHPEDUD]RWDOHVFRPRREHVLGDG\GLDEHWHV x/DH[LVWHQFLDGHSURFHGLPLHQWRVGLDJQyVWLFRVGHUHODWLYDVHQFLOOH]GHDFHSWDEOH H¿FDFLD\GHFRVWRQRH[DJHUDGR x4XHVHSXHGHQPHMRUDUQRWRULDPHQWHORVUHVXOWDGRVVLHOGLDJQyVWLFRHVSUHFR]\ HOWUDWDPLHQWRDGHFXDGR\RSRUWXQR 5HFLHQWHVHVWXGLRVGHPXHVWUDQTXHHOWUDWDPLHQWRGHODGLDEHWHVJHVWDFLRQDOUHGXFLUtD HQIRUPDLPSRUWDQWHODPRUELOLGDGSHULQDWDO\PHMRUDUtDODFDOLGDGGHYLGDGHODVPXMHUHV DORVWUHVPHVHVGHOQDFLPLHQWR2WURVHVWXGLRVHSLGHPLROyJLFRVKDQPRVWUDGRTXHOD SUHYDOHQFLDGHGLDEHWHVJHVWDFLRQDOHVPD\RUHQPXMHUHVLQGtJHQDVHKLVSDQDVFXDQGR VHODVFRPSDUDFRQWUDPXMHUHVDQJORVDMRQDV(VWDVGRVUD]RQHVVHVXPDQSDUDMXVWL¿FDU ODUHDOL]DFLyQGHHVWXGLRVGHWDPL]DMHSDUDGLDEHWHVJHVWDFLRQDOHQQXHVWUD5HJLyQ *OXFHPLDHQD\XQDVDXQTXHQRH[LVWHDFXHUGRVREUHODXWLOLGDGGHHIHFWXDUJOXFHPLDV HQ D\XQDV SDUD GLDJQRVWLFDU XQD GLDEHWHV JHVWDFLRQDO KD\ HYLGHQFLDV TXH VXJLHUHQ TXH PXHVWUDV DLVODGDV GH JOXFHPLD SRGUtDQ VHU WDQ VHQVLEOHV FRPR XQD SUXHED GH WROHUDQFLDRUDODODJOXFRVD372*SDUDGLDJQRVWLFDUGLDEHWHVJHVWDFLRQDO(QJHQHUDO VH UHFRPLHQGD KDVWD TXH QR KD\D HYLGHQFLDV ¿UPHV TXH OR UHFKDFHQ UHDOL]DU XQD JOXFHPLDHQD\XQDVHQODSULPHUDYLVLWDDQWHQDWDO )LJXUD)UDJPHQWRGH+&3*OXFHPLD (QFDVRGHREWHQHUVHXQDJOXFHPLDHQD\XQDV!PJG/GHEHUiUHSHWLUVHHOH[DPHQ \HQFDVRGHUHJLVWUDUVHQXHYDPHQWHFLIUDVGHJOXFRVDHQVDQJUH!DPJG/VH KDEUi KHFKR HO GLDJQyVWLFR GH GLDEHWHV JHVWDFLRQDO 6L OD QXHYD GHWHUPLQDFLyQ HV PHQRUDPJG/GHEHUiHIHFWXDUVHXQDSUXHEDGHWROHUDQFLDDODJOXFRVD (QDTXHOORVHQWRUQRVHQORVTXHQRVHFXHQWHFRQODSRVLELOLGDGGHHIHFWXDUXQD372* HQWUHODV\VHPDQDVODJOXFHPLDHQD\XQDVSRGUiVHUODPHMRUDOWHUQDWLYDSDUD GHVSLVWDUODH[LVWHQFLDGHXQDGLDEHWHVJHVWDFLRQDO3RUHVDUD]yQVHLQFOX\yHQOD+&3 XQUHFRUGDWRULRSDUDHIHFWXDUXQDQXHYDJOXFHPLDDSULQFLSLRVGHOHUWULPHVWUH 3UXHEDGHWROHUDQFLDRUDODODJOXFRVDKD\DFXHUGRJHQHUDOHQUHDOL]DUXQD372* HQWUH ODV \ VHPDQDV GH JHVWDFLyQ FRPR SUXHED GH WDPL]DMH SDUD OD GLDEHWHV JHVWDFLRQDO x(QORVWUHVGtDVSUHYLRVVHSHUPLWLUiGLHWDOLEUH x/DPXMHUFRQFXUULUiDOH[DPHQSRUODPDxDQD\FRQXQPtQLPRGHKRUDVGHD\XQR x(QUHSRVRVHQWDGD\VLQIXPDU x+DELHQGRGHVFDUWDQGRLQIHFFLRQHVLQWHUFXUUHQWHV x6HH[WUDHUiPXHVWUDSDUDJOXFHPLDHQD\XQDVYDORUQRUPDOPJG/ x6HGDUiDEHEHUHQQRPiVGHPLQXWRVJGHJOXFRVDGLOXLGRVHQD POGHDJXDFRQDPOGHMXJRGHOLPyQ x$ODVGRVKRUDVVHREWHQGUiXQDVHJXQGDPXHVWUDGHJOXFHPLDYDORUQRUPDO PJG/ &ULWHULRVGLDJQyVWLFRVGHFRQ¿UPDFLyQ x'RVJOXFHPLDVHQD\XQDV!PJG/ x*OXFHPLD!PJG/DODVGRVKRUDVHQXQD372*FRQJGHJOXFRVD /DV WLULOODV UHDFWLYDV OD GHWHUPLQDFLyQ GH KHPRJORELQD JOXFRVLODGD IUXFWRVDPLQD \ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR ODV JOXFHPLDV SRVWSUDQGLDOHV QR VRQ SURFHGLPLHQWRV DFHSWDEOHV SDUD FRQ¿UPDFLyQ GLDJQyVWLFD &ODVL¿FDFLyQGHORVHVWDGRVGLDEpWLFRVHQHOHPEDUD]R 'LDEHWHVSUHJHVWDFLRQDO 7LSR,LQVXOLQRGHSHQGLHQWHRMXYHQLO 7LSR,,QRLQVXOLQRGHSHQGLHQWHRGHODGXOWR 'LDEHWHVJHVWDFLRQDO $JOXFHPLDHQD\XQDVPHQRUDPJG/FRQ372*DQRUPDO $JOXFHPLDHQD\XQDV!PJGOKDVWDPJG/ %JOXFHPLDHQD\XQDV!PJG/ (Q FDVR GH FRQ¿UPDFLyQ GLDJQyVWLFD VH GHEH GHULYDU D OD JHVWDQWH D FRQWURO GH DOWR ULHVJR/DHYDOXDFLyQHQDOWRULHVJRHVWDUiGLULJLGDHQWUHRWUDVFRVDVDGHWHUPLQDUHOSHU¿O JOLFpPLFRGLDULRFRQpOVHGHWHUPLQDUiQORVQLYHOHVGHJOXFRVDEDVDOHV\SRVWSUDQGLDOHV DORODUJRGHOGtD7DPELpQVHUHDOL]DUiKHPRJORELQDJOLFRVLODGDRIUXFWRVDPLQDSDUD GHWHUPLQDUFRPRKDHVWDGRHOFRQWUROPHWDEyOLFRHQORVPHVHVSUHYLRV *OXFHPLDHQD\XQDVSULPHUDFRQVXOWD 5HVXOWDGR PJG/ 6L 1R 5HSLWHJOXFHPLD HQD\XQDV 5HVXOWDGR PJG/ 6L 6L 372* VHPDQDV 3UXHEDGHWROHUDQFLDRUDO DODJOXFRVD372* 6L 5HVXOWDGR QRUPDO 1R 1R 5HVXOWDGR QRUPDO 6L 5HSHWLU372* DODVVHPDQDV 6L 'LDEHWHVPHOOLWXV 5HVXOWDGR QRUPDO 1R 'LDEHWHVJHVWDFLRQDO 'HVFDUWDGLDEHWHV (QPXMHUHVVLQIDFWRUHVGHULHVJRSDUDGLDEHWHVSXHGHVXVWLWXLUQXHYDJOXFHPLDHQWUHODVVHPDQDV )LJXUD(VTXHPDHVFDORQDGRGHGHFLVLRQHVSDUDODGHWHFFLyQGHODGLDEHWHV JHVWDFLRQDO 5HFODVL¿FDFLyQGHODGLDEHWHVJHVWDFLRQDOGHVSXpVGHOSDUWR $ SDUWLU GH ORV GtDV GHO SXHUSHULR VH UHSHWLUi XQD SUXHED GH WROHUDQFLD RUDO D OD JOXFRVD372*GDGRTXHODVFRQGLFLRQHVPHWDEyOLFDVVXHOHQYDULDU&RQHVWHH[DPHQ VH UHFODVL¿FDUi OD PXMHU FRPR GLDEpWLFD HQ FDVR GH FRQ¿UPDUVH SHUVLVWHQFLD GH ORV YDORUHVGHJOXFHPLDHQD\XQDV!PJG/R!PJG/DODVGRVKRUDVSRVWFDUJD GHJGHJOXFRVD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2%-(7,926 %ULQGDU FRQWHQLGRV HGXFDWLYRLQIRUPDWLYRV SDUD HO SDUWR \ OD FULDQ]D $&7,9,'$' 3UHSDUDFLyQSDUDHOSDUWRFRQVHMHUtDSDUDHODPDPDQWDPLHQWR ([LVWHQ PRGL¿FDFLRQHV HQ HO FRPSRUWDPLHQWR GH OD PXMHU HPEDUD]DGD TXH VH DFRPSDxDQ JHQHUDOPHQWH GH UHTXHULPLHQWRV HVSHFLDOHV GH FRPSDxtD \ DSR\R SVLFRDIHFWLYR (VDV QHFHVLGDGHV KDQ VLGR FRQVLGHUDGDV VLHPSUH SRU HO SHUVRQDO GH VDOXGDWUDYpVGHODHVSHFLDODWHQFLyQTXHVHOHEULQGDHQODVFRQVXOWDVSUHQDWDOHVODV FODVHVGHSUHSDUDFLyQSVLFRSUR¿OiFWLFDODDWHQFLyQFRQWLQXDGXUDQWHHOWUDEDMRGHSDUWR \SDUWR\ODGHGLFDFLyQGHODIDPLOLD\HOSHUVRQDODODVQHFHVLGDGHVGHODPXMHUPDGUH \GHVXKLMRHQORVSULPHURVGtDV\VHPDQDVOXHJRGHOSDUWR /DLQVWLWXFLRQDOL]DFLyQGHOSDUWRSDUWRVDVLVWLGRVHQKRVSLWDOHVFHQWURVGHVDOXGFRQ FDPDVHWFTXHGHSHQGHQGHOVLVWHPDIRUPDOGHDWHQFLyQUHVSRQGtDDOREMHWLYRGH UHGXFLUODHOHYDGDPRUWDOLGDGPDWHUQDTXHRFXUUtDHQORVSDUWRVGRPLFLOLDULRV3RUHOOR ODPXMHUHUDKRVSLWDOL]DGDDOLQLFLRGHOSDUWREDMRQRUPDVJHQHUDOHVH[LVWHQWHVHQHVDV LQVWLWXFLRQHVSDUDHOFXLGDGRGHSDFLHQWHVFRQSDWRORJtDVGLYHUVDV /D LQVWLWXFLRQDOL]DFLyQ GHO SDUWR ORJUy SULQFLSDOPHQWH UHGXFLU OD HOHYDGD UD]yQ GH PRUWDOLGDG PDWHUQD HQ OD PHGLGD TXH VH IXH LPSOHPHQWDQGR HQ ORV SDtVHV 6LQ HPEDUJRORVDVSHFWRVVRFLDOHV\HOVRSRUWHSVLFRDIHFWLYRUHODFLRQDGRVFRQHOSURFHVR UHSURGXFWLYRIXHURQUHOHJDGRVGHVDWHQGLGRVRSRFRSULRUL]DGRV (Q OD DFWXDOLGDG HO FRQFHSWR GH ³SDUWR LQVWLWXFLRQDO´ LPSOLFD QR VROR OD YLJLODQFLD HVWULFWDPHQWHSURIHVLRQDOGHODPXMHUHQHOPRPHQWRGHOSDUWRVLQRWDPELpQFRQVLGHUD D LJXDO QLYHO ORV DVSHFWRV SVLFRDIHFWLYRV FXOWXUDOHV \ VRFLDOHV UHODFLRQDGRV FRQ OD PDWHUQLGDG /DVSULQFLSDOHVDFWLYLGDGHVTXHFRPSOHWDQODDWHQFLyQPpGLFDVRQ x/DSDUWLFLSDFLyQGHOFRPSDxHUR\GHPiVPLHPEURVGHODIDPLOLDTXHODJHVWDQWH GHVHHGXUDQWHODDVLVWHQFLDSUHQDWDOHOWUDEDMRGHSDUWR\HOSDUWR x/DHGXFDFLyQ\SUHSDUDFLyQSVLFRItVLFDGHODPXMHUSDUDHOSDUWR\ODODFWDQFLD x(OFRQWDFWRSUHFR]LQPHGLDWRDOQDFHUGHODPDGUH\HOSDGUHFRQVXKLMR x(ODORMDPLHQWRFRQMXQWRGHODPDGUH\VXKLMRGXUDQWHHOSXHUSHULRLQVWLWXFLRQDO MXQWRFRQODHGXFDFLyQSDUWLFLSDWLYDSDUDHOFXLGDGRGHOQLxR\HODXWRFXLGDGRGH ODPDGUHGXUDQWHHOSXHUSHULR\ODODFWDQFLD )LJXUD)UDJPHQWRGH+&33UHSDUDFLyQ\DFRPSDxDQWH &XLGDGRVDQWHQDWDOHV 9LVLWD GRPLFLOLDULD GH DSR\R VRFLDO HQ PXMHUHV SULPtSDUDV DGROHVFHQWHV R HQ DTXHOODV TXH DIURQWDQ HO HPEDUD]R VRODV R HQ FRQGLFLRQHV GH H[WUHPD SREUH]D OD YLVLWD GRPLFLOLDULD SRU SHUVRQDO GH VDOXG KD PRVWUDGR VHU HIHFWLYD HQ LQFUHPHQWDU OD H¿FDFLDGHORVFXLGDGRVSUHQDWDOHV/DHGXFDFLyQHODSR\RVRFLDOODLQÀXHQFLDSDUD FHVDUGHIXPDUORVQH[RVFRQRWURVUHFXUVRVGHODFRPXQLGDG\HOPHMRUDPLHQWRGHOD DXWRHVWLPDGHODPXMHUHPEDUD]DGDVRQORVFRPSRQHQWHVGHHVWDLQWHUYHQFLyQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (GXFDFLyQSDUDODVDOXGFRQVLVWHHQODSDUWLFLSDFLyQGHODPXMHUJHVWDQWHHVSHFLDOPHQWH OD SULPLJHVWD HQ DFWLYLGDGHV TXH OH SHUPLWDQ DSUHQGHU VREUH VX HPEDUD]R SDUWR \ FXLGDGRVGHVXKLMRSRUQDFHU/RVMXHJRVSDUWLFLSDWLYRVGH&/$3605³(OFDPLQRGHO HPEDUD]R´ ³(O WUpERO GHO HPEDUD]R´ \ ³1XHVWUR SULPHU PHV´ DERUGDQ HVWD WHPiWLFD HQIRUPDLQWHJUDOFRQHOHPHQWRVGHSURPRFLyQGHVDOXGSUHYHQFLyQGHHQIHUPHGDG\ VHxDODPLHQWRGHVLJQRVGHDOHUWDTXHUHTXLHUHQDWHQFLyQLQPHGLDWD )LJXUD-XHJRVHGXFDWLYRV 3URPRFLyQ GH ODFWDQFLD QDWXUDO GXUDQWH OD DWHQFLyQ SUHQDWDO VH KD GHPRVWUDGR TXHODHGXFDFLyQHVSHFLDOSDUDSURPRYHUODODFWDQFLDGXUDQWHHOHPEDUD]RHVH¿FD]HQ GLVPLQXLUODIUHFXHQFLDGHGHVWHWHHQORVGRVSULPHURVPHVHVSRVSDUWR/RVFRQWHQLGRV HGXFDWLYRVHVWDUiQGHVWLQDGRVDGHPRVWUDUODVYHQWDMDVGHODODFWDQFLDQDWXUDOVREUH OD DOLPHQWDFLyQ FRQ OHFKH GH YDFD \ SUHSDUDGRV FRPHUFLDOHV FRQ OHFKH GH YDFD PRGL¿FDGDDVtFRPRDXPHQWDUODDXWRHVWLPDGHODPXMHUSDUDFRQVHJXLUVXSHUDUODV GL¿FXOWDGHVLQLFLDOHV(QHO&XDGURVHUHVXPHQORVGLH]SDVRVGHODHVWUDWHJLDGH 81,&()\206SDUDREWHQHUXQDODFWDQFLDH[LWRVD(VWRVGLH]SDVRVVRQXQDVHULHGH UHFRPHQGDFLRQHV &XDGUR(VWUDWHJLD'LH]SDVRVSDUDXQDODFWDQFLDH[LWRVD81,&()206 'LVSRQHUGHXQDSROtWLFDSRUHVFULWRUHODWLYDDODODFWDQFLDPDWHUQDTXH VLVWHPiWLFDPHQWHVHSRQJDHQFRQRFLPLHQWRGHWRGRHOSHUVRQDOGHDWHQFLyQ GHODVDOXG &DSDFLWDUDWRGRHOSHUVRQDOGHVDOXGGHIRUPDTXHHVWpHQFRQGLFLRQHVGH SRQHUHQSUiFWLFDHVDSROtWLFD ,QIRUPDUDWRGDVODVHPEDUD]DGDVGHORVEHQH¿FLRVTXHRIUHFHODODFWDQFLD PDWHUQD\ODIRUPDGHSRQHUODHQSUiFWLFD $\XGDUDODVPDGUHVDLQLFLDUODODFWDQFLDGXUDQWHODPHGLDKRUDVLJXLHQWHDO DOXPEUDPLHQWR 0RVWUDUDODVPDGUHVFyPRVHGHEHGDUGHPDPDUDOQLxR\FyPRPDQWHQHUOD ODFWDQFLDLQFOXVRVLKDQGHVHSDUDUVHGHVXVKLMRV 1RGDUDORVUHFLpQQDFLGRVPiVTXHODOHFKHPDWHUQDVLQQLQJ~QRWURDOLPHQWR REHELGDDQRVHUTXHHVWpQPpGLFDPHQWHLQGLFDGRV )DFLOLWDUODFRKDELWDFLyQGHODVPDGUHV\ORVODFWDQWHVGXUDQWHODVKRUDVGHO GtD )RPHQWDUODODFWDQFLDPDWHUQDDOLEUHGHPDQGD 1RGDUDORVQLxRVDOLPHQWDGRVDOSHFKRFKXSHWHVDUWL¿FLDOHV )RPHQWDUHOHVWDEOHFLPLHQWRGHJUXSRVGHDSR\RDODODFWDQFLDPDWHUQD\ SURFXUDUTXHODVPDGUHVVHSRQJDQHQFRQWDFWRFRQHOORVDVXVDOLGDGHO KRVSLWDORFOtQLFD * Este paso fue incluido previo al conocimiento de una posible protección del chupete contra la muerte súbita del lactante &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD /D +&3 UHFXHUGD DO SUHVWDGRU GH VDOXG GXUDQWH HO SUHQDWDO TXH HV DSURSLDGR EULQGDU FRQVHMHUtD SDUD HO DPDPDQWDPLHQWR Figura 48. Fragmento de HCP Lactancia 2%-(7,926 &RQ¿UPDUODH[LVWHQFLDGHYLGDIHWDO $&7,9,'$' 3HVTXLVDUPRYLPLHQWRV\IUHFXHQFLDFDUGtDFDIHWDO /RVSDUiPHWURVFOtQLFRVPiVXVDGRVSDUDFRPSUREDUODH[LVWHQFLDGHYLGDIHWDOVRQORV PRYLPLHQWRVIHWDOHV\ORVODWLGRVIHWDOHV3UHVHQWDQHOLQFRQYHQLHQWHGHVHUSHUFLELGRVSRU ODPDGUHHQHWDSDVDYDQ]DGDVGHOHPEDUD]R\D~QPiVWDUGtDPHQWHSRUHOFOtQLFR 0RYLPLHQWRVIHWDOHV $GHPiVGHVHUXQHOHPHQWRTXHLQGLFDYLWDOLGDGORVPRYLPLHQWRVIHWDOHVVHDVRFLDQ FRQVDOXGHPEULRIHWDO/RVPRYLPLHQWRVSXHGHQVHUREVHUYDGRVPX\SUHFR]PHQWHSRU XOWUDVRQRJUDItD\PiVWDUGHVHJXQGRWULPHVWUHVRQSHUFLELGRVSRUODPDGUH\OXHJR SDOSDGRVSRUXQREVHUYDGRUH[WHUQRRUHJLVWUDGRV /DSUHVHQFLDGHPRYLPLHQWRVLQGLFDLQWHJULGDGGHOVXVWUDWRDQDWyPLFR\GHODFDSDFLGDG GHOIHWRSDUDSURGXFLUIXQFLRQHVFRPSOHMDV8QDPDUFDGDGLVPLQXFLyQRHOFHVHGHORV PLVPRVSXHGHQLQGLFDUSUREOHPDVHQODVDOXGRODPXHUWHIHWDO 3XHGHQVHUSHUFLELGRVGHGLIHUHQWHVPDQHUDVVHJ~QVHHMHPSOL¿FDHQHOFXDGUR &XDGUR'HWHFFLyQGHPRYLPLHQWRVHPEULRIHWDOHV (GDGJHVWDFLRQDO VHPDQDV 0pWRGR GHVGHODV (FRJUDItDGHWLHPSRUHDOWUDQVYDJLQDOWUDQVDEGRPLQDO GHVGHODV 'HWHFWRU'RSSOHU GHVGHODV 3HUFLELGRVSRUSDOSDFLyQDEGRPLQDOODPDGUHSXHGHSHUFLELUORV GHVGHODVVHPDQDVDXQTXHHQHVWHFDVR QRVHFRQVLGHUDVLJQRGHFHUWH]DSRUODVXEMHWLYLGDGGHOGDWR /DVPDQHUDVGHYHUL¿FDUORVPRYLPLHQWRVIHWDOHVVRQ x3HUFHSFLyQPDWHUQD x3DOSDFLyQDEGRPLQDOSRUXQREVHUYDGRU x(FRJUDItD 3HUFHSFLyQPDWHUQDODVJHVWDQWHVSHUFLEHQORVPRYLPLHQWRVIHWDOHVDHGDGYDULDEOH VHJ~QODDJXGH]D\XPEUDOLQGLYLGXDOSDUDDSUHFLDUORV/DSULPtSDUDORKDFHHQWUHODV \ VHPDQDV \ OD PXOWtSDUD DOJXQDV VHPDQDV DQWHV 3ULPHUR VRQ LGHQWL¿FDGRV FRPRXQOLJHURFRVTXLOOHR\OXHJRVHKDFHQSDXODWLQDPHQWHPiVLQWHQVRV/DXELFDFLyQ GHODSODFHQWDHQODFDUDDQWHULRUGHO~WHURSXHGHSURYRFDUXQUHWUDVRHQODSHUFHSFLyQ GHORVPRYLPLHQWRVSRUSDUWHGHODPDGUH 5XWLQDULDPHQWHDSDUWLUGHODVVHPDQDVHOSUHVWDGRUGHVDOXGGHEHUiLQWHUURJDUHQ ODFRQVXOWDSUHQDWDOVREUHODSHUFHSFLyQGHPRYLPLHQWRVIHWDOHVHQODV~OWLPDVKRUDV \VLHVWRVWLHQHQXQDIUHFXHQFLDQRUPDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (O SURPHGLR KRUDULR GH PRYLPLHQWRV IHWDOHV SHUFLELGRV SRU OD PDGUH WLHQH JUDQGHV YDULDFLRQHV LQGLYLGXDOHV /RV IHWRV SDVDQ SRU SHUtRGRV DOWHUQDGRV GH DFWLYLGDG SURPHGLRPLQXWRV\GHUHSRVRSURPHGLRPLQXWRVTXHLQÀX\HQVREUHODFDQWLGDG GH PRYLPLHQWRV +D\ RWURV IDFWRUHV FDSDFHV GH SURGXFLU YDULDFLRQHV HQ OD GXUDFLyQ GHHVWRVSHUtRGRVHQWUHHOORVVHFLWDQWDEDTXLVPRDOJXQRVPHGLFDPHQWRVDFWLYLGDG ItVLFDPRPHQWRGHOGtDHGDGJHVWDFLRQDOHWF (O OtPLWH LQIHULRU GH OD QRUPDOLGDG VH HVWLPD HQ PRYLPLHQWRV HQ KRUDV R PRYLPLHQWRVHQXQDKRUD (QFDVRGHVRVSHFKDGHFRPSURPLVRHQODVDOXGIHWDOVHSXHGHLQVWUXLUDODPDGUH SDUDTXHFRQWUROHORVPRYLPLHQWRV\ORVUHJLVWUHHQXQDSODQLOOD(VWDWDUHDFRPRRWUDV HQODVTXHODSDUWLFLSDFLyQGHODPDGUHSXHGHD\XGDUDODYLJLODQFLDGHOHPEDUD]RGHEH VHUVROLFLWDGDVRORHQFDVRVHVSHFLDOHVGDGRTXHHODXWRFRQWUROGLDULRSXHGHRFDVLRQDU DQVLHGDG\HVWUpV /DWpFQLFDPiVVHQFLOODSDUDFRQWDUORVPRYLPLHQWRVIHWDOHVFRQVLVWHHQ DFRQWDUORVPRYLPLHQWRVIHWDOHVSDUWLHQGRGHXQDKRUDGHWHUPLQDGD EVLDSDUHFHQPRYLPLHQWRVHQODSULPHUDKRUDVHFRQVLGHUDQRUPDO FVLHQODSULPHUDKRUDQRVHSURGXFHQPRYLPLHQWRVFRPRPtQLPR VHFRQWLQXDUiKDVWDDOFDQ]DUPRYLPLHQWRVHQODVSULPHUDVKRUDV (QFDVRGHQRDOFDQ]DUORVPRYLPLHQWRVIHWDOHVHQKRUDVVHRULHQWDUiDODJHVWDQWH SDUDTXHFRQVXOWHHQHOFHQWURGHVDOXG $XQTXHODWpFQLFDGHUHJLVWURPDWHUQRGLDULRGHORVPRYLPLHQWRVIHWDOHVHVWiDPSOLDPHQWH GLIXQGLGDQRKD\HYLGHQFLDVVX¿FLHQWHVSDUDDFRQVHMDUORRGHVDFRQVHMDUORFRPRPHGLGD GHYDORUDFLyQGHOELHQHVWDUIHWDO 3DOSDFLyQDEGRPLQDOSRUXQREVHUYDGRUHQFRQGLFLRQHVQRUPDOHVORVPRYLPLHQWRV VXHOHQSHUFLELUVHDSDUWLUGHODVVHPDQDV&RQODJHVWDQWHHQGHF~ELWRODWHUDOL]TXLHUGR \ODPDQRGHOREVHUYDGRUVREUHHODEGRPHQGXUDQWHDOJXQRVPLQXWRV6LQRVHSHUFLEHQ ORV PRYLPLHQWRV GHVSXpV GH XQRV PLQXWRV SXHGH HVWLPXODUVH H[WHUQDPHQWH DO IHWR PRYLpQGROR D WUDYpV GH OD SDUHG DEGRPLQDO PDWHUQD 6L VH H[DPLQD D OD PDGUH HQ GHF~ELWRGRUVDOGHEHUiHYLWDUVHFRQIXQGLUORVPRYLPLHQWRVIHWDOHVFRQHOODWLGRDyUWLFR WUDQVPLWLGR (FRJUDItDORVPRYLPLHQWRVIHWDOHVSXHGHQVHUDGYHUWLGRVDSDUWLUGHODVpSWLPDVHPDQD R LQFOXVR DQWHV HQ H[SORUDFLRQHV WUDQVYDJLQDOHV \ D SDUWLU GH OD QRYHQD VHPDQD R DQWHVHQH[SORUDFLRQHVWUDQVDEGRPLQDOHV $FWLYLGDGFDUGtDFDIHWDO /DDXVFXOWDFLyQGHODWLGRVIHWDOHVHVWDOYH]HOVLJQRPiVFRQ¿DEOHGHYLWDOLGDGIHWDO /DHGDGJHVWDFLRQDOLGHDOSDUDGHWHFWDUODWLGRVHVYDULDEOH\GHSHQGHGHPDQHUDSULQFLSDO GHOPpWRGRTXHVHHPSOHH(QHOFXDGURVLJXLHQWHVHHVTXHPDWL]DQODVVHPDQDVGH GHWHFFLyQGHORVODWLGRVIHWDOHVGHDFXHUGRDODWpFQLFDHPSOHDGD &XDGUR'HWHFFLyQGHODWLGRVFDUGtDFRVHPEULRIHWDOHV (GDGJHVWDFLRQDOVHPDQDV 0pWRGR GHVGHODV (FRJUDItDGHWLHPSRUHDOYtDYDJLQDODEGRPLQDO GHVGHODV 'HWHFWRU'RSSOHU GHVGHODV (VWHWRVFRSLRREVWpWULFR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD /DIUHFXHQFLDGHORVODWLGRVIHWDOHVRVFLODHQFRQGLFLRQHVQRUPDOHVHQWUH\ ODWLGRVSRUPLQXWRGXUDQWHORVHVSDFLRVOLEUHVGHFRQWUDFFLRQHVIUHFXHQFLDEDVDO 7DOFRPRVHPHQFLRQyHQHOFXDGURDQWHULRUORVODWLGRVIHWDOHVSXHGHQVHUGHWHFWDGRV GHODVVLJXLHQWHVPDQHUDV x(VWHWRVFRSLRREVWpWULFR x'HWHFWRU'RSSOHU x(FRJUDItD (VWHWRVFRSLRREVWpWULFRHVXQHVWHWRVFRSLRGHGLVHxRHVSHFLDOSDUDXVRREVWpWULFR TXHSHUPLWHODDXVFXOWDFLyQGHORVODWLGRVDSDUWLUGHODVVHPDQDVGHHGDGJHVWDFLRQDO HQRFDVLRQHVHVSHFLDOHV\HQSDFLHQWHVGHOJDGDVGHVGHODVVHPDQDVGHJUDYLGH] SXHGHQVHUGHWHFWDGRV7pFQLFRVGH&/$3605KDGLVHxDGRXQHVWHWRVFRSLRIHWDOHQ PDWHULDOSOiVWLFRUHVLVWHQWHFRQH[FHOHQWHFRQGXFFLyQGHOVRQLGRDOTXHVHOHLQFRUSRUDURQ LOXVWUDFLRQHVFRQHOPpWRGRGHDXVFXOWDFLyQ\ODUHODFLyQHQWUHODIUHFXHQFLDFDUGtDFD IHWDO\ODVFRQWUDFFLRQHVGHULYDGDVGHLQYHVWLJDFLRQHVGHVDUUROODGDVHQ&/$3605 )LJXUD(VWHWRVFRSLRGH3LQDUGGH&/$3605 /D WpFQLFD GH DXVFXOWDFLyQ FRQVLVWH HQ DSOLFDU HO HVWHWRVFRSLR SHUSHQGLFXODUPHQWH VREUH HO IRFR GH DXVFXOWDFLyQ TXH FRUUHVSRQGH DO KRPEUR IHWDO DQWHULRU ORFDOL]DGR SUHYLDPHQWH SRU SDOSDFLyQ SDUD OR FXDO VH UHTXLHUH TXH OD JHVWDQWH VH HQFXHQWUHHQGHF~ELWRGRUVDO/DWUDQVPLVLyQKDFLD HO HVWHWRVFRSLR VH KDFH VLJXLHQGR FDSDV VyOLGDV TXHVRQEXHQDVSURSDJDGRUDVGHOVRQLGR )LJ7pFQLFDGHDXVFXOWDFLyQ /D FDEH]D GHO H[DPLQDGRU HMHUFHUi XQD SUHVLyQ VXDYH SHUR FRQWLQXD VREUH HO HVWHWRVFRSLR/DPDQROLEUHWRPDUiHOSXOVRGHODPDGUHD¿QGHGLIHUHQFLDUORVODWLGRV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR PDWHUQRVGHORVODWLGRVIHWDOHV6HUHWLUDODPDQRTXHVXMHWDEDHOHVWHWRVFRSLRSDUDQR LQWHUIHULUFRQUXLGRVH[WHUQRV(VDPDQRGHEHUiFRORFDUVHVREUHHO~WHURSDUDSRGHU DSUHFLDUVLKD\FRQWUDFFLRQHV (VWRHVHVSHFLDOPHQWHLPSRUWDQWHGXUDQWHHOWUDEDMRGHSDUWR\DTXHDXVFXOWDUGHQWUR \ IXHUD GH OD FRQWUDFFLyQ SHUPLWH DGYHUWLU ',36 (O H[DPLQDGRU FRQWDUi ORV ODWLGRV PLHQWUDVREVHUYDXQUHORM\ORVH[SUHVDUiHQODWLGRVSRUPLQXWR (IHFWR'RSSOHUH[LVWHQHQODDFWXDOLGDGHTXLSRVEDVDGRVHQHOHIHFWR'RSSOHUFX\D VHQVLELOLGDGHVVLJQL¿FDWLYDPHQWHPD\RUTXHODEULQGDGDSRUHOHVWHWRVFRSLRREVWpWULFR 3HUPLWHODGHWHFFLyQDHGDGHVPiVWHPSUDQDVVHPDQDVDQLYHOVXSUDS~ELFR (QRFDVLRQHVHOODWLGRVHLGHQWL¿FDFODUDPHQWHPLHQWUDVTXHHQRWUDVRSRUWXQLGDGHVVH HVFXFKDUiQUXLGRVIXQLFXODUHVTXHDORV¿QHVSUiFWLFRVWLHQHQHOPLVPRYDORUGLDJQyVWLFR SDUDFHUWL¿FDUYLWDOLGDGIHWDO 6XHOH VHU GH JUDQ XWLOLGDG HQ DTXHOODV VLWXDFLRQHV HQ ODV TXH OD DXVFXOWDFLyQ FRQ HO HVWHWRVFRSLRREVWpWULFRHVGL¿FXOWRVD (FRJUDItDORVODWLGRVFDUGtDFRVVHSXHGHQYHUPHGLDQWHHFRJUDItDGLQiPLFDDSDUWLUGHODV DVHPDQDVSRUYtDWUDQVYDJLQDO\GHODVDVHPDQDVSRUYtDWUDQVDEGRPLQDO 2%-(7,926 $QWLFLSDUHOGLDJQyVWLFR\SUHYHQLUHOSDUWRSUHPDWXUR $&7,9,'$' (YDOXDUHOSDWUyQGHODFRQWUDFWLOLGDGXWHULQD IUHFXHQFLDGXUDFLyQHLQWHQVLGDG 5HWUDVDUHOSDUWRGHSUHWpUPLQR ,QGXFLUODPDGXUDFLyQSXOPRQDUIHWDO (OSDUWRGHSUHWpUPLQRRSUHPDWXURFRQWLQ~DVLHQGRXQDGHODVSULQFLSDOHVFDXVDVGH PRUWDOLGDG\PRUELOLGDGQHRQDWDOHQWRGRHOPXQGR([FOX\HQGRDODVPDOIRUPDFLRQHV FRQJpQLWDVH[SOLFDGHFDGDPXHUWHVSHULQDWDOHV\ODPLWDGGHODVDQRUPDOLGDGHV QHXUROyJLFDVGHODLQIDQFLD'HDFXHUGRDODGH¿QLFLyQGHOD&ODVL¿FDFLyQ,QWHUQDFLRQDO GH(QIHUPHGDGHV&,(WRGRQDFLPLHQWRTXHVHSURGXFHDSDUWLUGHODV\DQWHV GHODVVHPDQDVVHFRQVLGHUDXQSDUWRSUHPDWXUR (O SDUWR SUHPDWXUR SXHGH VHU HVSRQWiQHR HQ HVWH FDVR LQFOX\H ORV QDFLPLHQWRV GH SUHWpUPLQR GH FDXVD FRQRFLGD R GHVFRQRFLGD UXSWXUD HVSRQWiQHD GH PHPEUDQDV RYXODUHVHLQFRPSHWHQFLDFHUYLFDO(OSDUWRSUHPDWXURSRULQGLFDFLyQVHSURGXFHSRUOD QHFHVLGDGPpGLFDGHDQWLFLSDUHOQDFLPLHQWRDQWHXQULHVJRPDWHUQRIHWDORDPERV /DIUHFXHQFLDHVVXPDPHQWHYDULDEOHGHSDtVDSDtVGHWDOPDQHUDTXHHQDOJXQRV SDtVHVGHVDUUROODGRVODIUHFXHQFLDHVPHQRUDOPLHQWUDVTXHHQDOJXQRVSDtVHV HQ GHVDUUROOR ODV FLIUDV VXSHUDQ HO $XQTXH ORV SDtVHV GHVDUUROODGRV VH KDQ FDUDFWHUL]DGR SRU XQD GLVPLQXFLyQ JUDGXDO GH OD SUHPDWXUH] HQ ORV ~OWLPRV DxRV DOJXQRVGHHOORVKDQH[SHULPHQWDGRXQDVFHQVRSURJUHVLYRYLQFXODGRDODQHFHVLGDG GHLQWHUUXPSLUORVHPEDUD]RVSRULQGLFDFLyQPpGLFDDQWHVGHOWpUPLQR +D\YDULDGRVIDFWRUHVTXHLQFUHPHQWDQHOULHVJRGHSDUWRSUHPDWXURHOORVVHSXHGHQ GLYLGLUHQWUHVFDWHJRUtDVSULQFLSDOHV x&DUDFWHUtVWLFDVGHPRJUi¿FDV\JHQpWLFDV x+iELWRVFRQGXFWDV\IDFWRUHVDPELHQWDOHV x)DFWRUHVPpGLFRV\REVWpWULFRV 'HELGR D OD GL¿FXOWDG GH HQFRQWUDU XQD FDXVD ~QLFD TXH H[SOLTXH OD WRWDOLGDG GH ORV SDUWRV SUHPDWXURV DFWXDOPHQWH VH ORV FRQVLGHUD FRPR XQ VtQGURPH 'H HVWD PDQHUDHOSDUWRSUHPDWXURVHUtDXQDFRQGLFLyQGHVHQFDGHQDGDSRUP~OWLSOHVFDXVDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD JHQHUDOPHQWHFRH[LVWHQWHVTXHVHH[SUHVDQ¿QDOPHQWHFRQFRQWUDFFLRQHVXWHULQDV\ FDPELRVFHUYLFDOHV (O IDFWRU GH ULHVJR PiV FODUDPHQWH GH¿QLGR HV HO DQWHFHGHQWH GH SDUWR SUHPDWXUR HQXQDJHVWDFLyQSUHYLDVHKDYLVWRTXHXQDPXMHUTXHKDWHQLGRXQSDUWRSUHPDWXUR WLHQH FDVL YHFHV PiV SUREDELOLGDG GH VXIULU XQ SDUWR SUHPDWXUR TXH OD TXH FDUHFH GHHVHDQWHFHGHQWH6HKDUHSRUWDGRTXHHVWHULHVJRVHFRUUHODFLRQDFRQHOQ~PHUR GHSDUWRVSUHPDWXURVDQWHULRUHV\WLHQGHDLQFUHPHQWDUVHIXHUWHPHQWHFXDQWRPHQRU VHDODHGDGGHOSDUWRSUHPDWXURDQWHULRU2WURVIDFWRUHVDVRFLDGRVDSDUWRSUHPDWXUR VRQ HO HPEDUD]R P~OWLSOH HQ OD DFWXDO JHVWDFLyQ OD LQFRPSHWHQFLD FHUYLFDO \ ODV PDOIRUPDFLRQHVXWHULQDV 2WURVIDFWRUHVGHULHVJRSRVLEOHVLQFOX\HQ xHGDGHVH[WUHPDV xWDEDFRDOFRKRO\GURJDV xLQIHFFLRQHVJpQLWRXULQDULDV xGLDEHWHVPHOOLWXV xKLSHUWHQVLyQDUWHULDO x)DOWDRWDUGtRFRQWUROSUHQDWDO 'HWRGRVHVWRVIDFWRUHVGHULHVJRDOJXQRVVRQSRWHQFLDOPHQWHUHPRYLEOHVGXUDQWHHO HPEDUD]RPLHQWUDVTXHRWURVQRORVRQODVSRVLELOLGDGHVGHDFFLyQVHEDVDQHQLQWHQWDU FRQWURODURHOLPLQDUDTXHOORVIDFWRUHVUHPRYLEOHV 'LDJQyVWLFRGHDPHQD]DGHSDUWRSUHPDWXUR (OGLDJQyVWLFRVHIXQGDPHQWDHQWUHVDVSHFWRV x(GDGJHVWDFLRQDO x&RQWUDFFLRQHVXWHULQDV x(VWDGRGHOFXHOORXWHULQR (GDGJHVWDFLRQDOGDGRTXHHOSDUWRGHSUHWpUPLQRVHGH¿QHHQEDVHDXQDUHODFLyQ WHPSRUDOHVQHFHVDULRGHWHUPLQDUODHGDGJHVWDFLRQDOFRPR\DVHKDPDQLIHVWDGRHQ ODGH¿QLFLyQGHFDVR &RQWUDFFLRQHVXWHULQDVGXUDQWHODVHJXQGDPLWDGGHODJHVWDFLyQODSDOSDFLyQGHO DEGRPHQSHUPLWLUiUHFRQRFHUHOWDPDxR\FRQVLVWHQFLDGHO~WHURWRQRRWHQVLyQDVt FRPR OD H[LVWHQFLD GH FRQWUDFFLRQHV HVSRQWiQHDV (VWD SDOSDFLyQ GHEHUi UHDOL]DUVH FRQODHPEDUD]DGDHQGHF~ELWRODWHUDOSUHIHUHQWHPHQWHL]TXLHUGR/DVFRQWUDFFLRQHV QRUPDOHVSXHGHQVHUSHUFLELGDVIiFLOPHQWHSRUSDOSDFLyQRSRUXQWRFyJUDIRH[WHUQR (Q HO FXDGUR VH SUHVHQWD HO YDORU Pi[LPR QRUPDO S GH OD IUHFXHQFLD GH ODV FRQWUDFFLRQHVSRUKRUDVHJ~QODHGDGJHVWDFLRQDO(VWRVYDORUHVFRUUHVSRQGHQDXQD VHULHGHHPEDUD]DGDVGHEDMRULHVJRUHJLVWUDGDVHQGHF~ELWRODWHUDOVHPDQDOPHQWH KDVWDHOWpUPLQRGHODJHVWDFLyQ &XDGUR&RQWUDFFLRQHVXWHULQDVGHDFXHUGRFRQODHGDGJHVWDFLRQDO (GDGJHVWDFLRQDO VHPDQDV 1~PHURGHFRQWUDFFLRQHV SRUKRUDSHUFHQWLOR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR /RV YDORUHV GHO FXDGUR FRUUHVSRQGHQ DO SHUFHQWLOR \ PXHVWUDQ XQ DXPHQWR SURJUHVLYR GH OD IUHFXHQFLD GH ODV FRQWUDFFLRQHV SRU KRUD HQWUH ODV VHPDQDV \ ORTXHOXHJRVHHVWDELOL]D$VtHQODVHPDQDVHSRGUtDHVSHUDUHQHOGH ODVHPEDUD]DGDVQRUPDOHVXQDIUHFXHQFLDGHKDVWDRFKRFRQWUDFFLRQHVSRUKRUD(V LQWHUHVDQWHGHVWDFDUTXHHQWRGRVORVSDUWRVTXH¿QDOL]DURQSUHPDWXUDPHQWH\HQORV TXHVHHVWXGLyVXSDWUyQGHFRQWUDFFLRQHVpVWHVHHQFRQWUDEDDXPHQWDGRSRUHQFLPD GHOSHUFHQWLORSUHYLDPHQWHDOGHVHQFDGHQDPLHQWRGHOSDUWR &XDQGR OD IUHFXHQFLD GH ODV FRQWUDFFLRQHV HV OLJHUDPHQWH VXSHULRU D OD HVWDEOHFLGD SDUDHOSHUFHQWLORGHOSDWUyQQRUPDOFRQODHPEDUD]DGDDFRVWDGD\TXHGDQGXGDV DFHUFD GHO GLDJQyVWLFR GH SRVLEOH SDWUyQ FRQWUiFWLO DOWHUDGR VH SURFHGHUi D HVSHUDU XQDKRUD\VLHOSDWUyQGHFRQWUDFFLRQHVDXPHQWDGRSHUVLVWHVHKDUiODFRQVXOWDROD UHIHUHQFLDGHODPDGUHDOQLYHOTXHFRUUHVSRQGDeVWRVYDORUHVVHHQFXHQWUDQLPSUHVRV HQYDULDVGHODVWHFQRORJtDVGHO&/$3605FRPRHQHOJHVWRJUDPD¿JXUD\HQOD FLQWDREVWpWULFD¿JXUD (VWDGRGHOFXHOORXWHULQRORVSULQFLSDOHVVLJQRVDWHQHUHQFXHQWDVRQHOERUUDPLHQWR OD GLODWDFLyQ \ OD SRVLFLyQ GHO FXHOOR (O DFRUWDPLHQWR R ERUUDPLHQWR GHO FXHOOR GH XQ RPiVODGLODWDFLyQGHXQRRPiVFHQWtPHWURV\ODFHQWUDOL]DFLyQGHOFXHOORVRQ HOHPHQWRVRULHQWDGRUHVGHXQDDPHQD]DGHSDUWRSUHPDWXUR'HWRGDVPDQHUDVORV FDPELRVFHUYLFDOHVDLVODGRVSXHGHQUHVXOWDULQVX¿FLHQWHVSDUDHVWDEOHFHUHOGLDJQyVWLFR GHDPHQD]DGHSDUWRSUHPDWXUR 7UDWDPLHQWR &DGDYH]TXHVHDSRVLEOHLGHQWL¿FDUXQDFDXVDFRPRODUHVSRQVDEOHGHODDPHQD]D GHSDUWRSUHPDWXURVHUHDOL]DUiHOWUDWDPLHQWRHWLROyJLFRSRUHMHPSORDQWLELyWLFRVHQ ODVLQIHFFLRQHVXULQDULDVFHUFODJHHQODLQFRPSHWHQFLDFHUYLFDOHWF3HURSRUWUDWDUVH GH XQ VtQGURPH HQ PXFKDV RFDVLRQHV QR KDEUi SRVLELOLGDG GH KDFHU WUDWDPLHQWR HWLROyJLFR \ VROR VH SRGUi KDFHU WUDWDPLHQWR VLQWRPiWLFR (O WUDWDPLHQWR VLQWRPiWLFR WLHQHSRU¿QDOLGDGGLVPLQXLURGHWHQHUODVFRQWUDFFLRQHVXWHULQDVDQRUPDOHVDOWLHPSR GHHVWLPXODUODPDGXUH]SXOPRQDUIHWDOFRQFRUWLFRLGHV (OWUDWDPLHQWRVHKDUiVLHPSUHTXH xHOFXHOORXWHULQRQRHVWpGLODWDGRPiVGHFP xQRKD\DDPQLRQLWLV xQRKD\DSUHHFODPSVLDVHYHUD xQRKD\DKHPRUUDJLDDFWLYD xQRKD\DVXIULPLHQWRIHWDO x\HOIHWRHVWpYLYR 5HSRVRHQFDPD (OUHSRVRHQFDPDVLHPSUHKDVLGRLQGLFDGRFRPRXQRGHORVSULPHURVSDVRVSDUDHO WUDWDPLHQWRGHODDPHQD]DGHSDUWRGHSUHWpUPLQR+DVWDHOPRPHQWRQRKD\HYLGHQFLDV VX¿FLHQWHVSDUDLQGLFDUORVLVWHPiWLFDPHQWHRSURVFULELUOR'HWRGDVIRUPDVGHELGRD ODLQVX¿FLHQWHLQYHVWLJDFLyQDOUHVSHFWRHVDFRQVHMDEOHDGHFXDUHVWDLQGLFDFLyQDODV SRVLELOLGDGHVUHDOHVGHODHPEDUD]GD 7RFROtWLFRV 'HQWURGHORVWRFROtWLFRVPiVHIHFWLYRVVHFXHQWDFRQ x%HWDPLPpWLFRV x$QWLSURVWDJODQGLQDV x%ORTXHDGRUHVGHORVFDQDOHVGHFDOFLR x$QWDJRQLVWDVGHODRFLWRFLQD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD /RVEHWDPLPpWLFRVXVDGRVSRUYtDHQGRYHQRVDWLHQHQXQUiSLGRHIHFWRTXHVHLQVWDOD HQWUHORV\PLQXWRVGHVXDGPLQLVWUDFLyQ/RVHIHFWRVWDPELpQVXHOHQGHVDSDUHFHU FRQEDVWDQWHUDSLGH]DPLQXWRV 6HKDGHPRVWUDGRTXHVRQHIHFWLYRVHQ x3URORQJDUODJHVWDFLyQDOPHQRVKRUDVHQHOGHORVFDVRV x3URORQJDUODJHVWDFLyQKRUDV\PiVHQHOGHORVFDVRV x5HGXFLUXQODVFKDQFHVGHEDMRSHVRDOQDFHU%31 3UHVHQWDQHOLQFRQYHQLHQWHGHWHQHUHIHFWRVFRODWHUDOHVLQGHVHDEOHVFRPR x7DTXLFDUGLDPDWHUQD x9DVRGLODWDFLyQ x+LSRWHQVLyQH[FHSWRODHWLOHIULQD x+LSHUJOLFHPLD x1DXVHDVYyPLWRV x(VFDORIUtRV\WHPEORUHV (OEHWDPLPpWLFRPiVXVDGRHQODUHJLyQHVHO)HQRWHUROFRPHQ]DQGRFRQGRVLVGH PLFURJUDPRSRUPLQXWRDXPHQWDQGRD\KDVWDPLFURJUDPRVPLQXWRVLQRKDVLGR HIHFWLYR$FRQWLQXDFLyQVHSUHVHQWDQORVHIHFWRVXWHURLQKLELGRUHV\FDUGLRYDVFXODUHV GHORVSULQFLSDOHVEHWDPLPpWLFRV &XDGUR(IHFWRVXWHURLQKLELGRUHV\FDUGLRYDVFXODUHVGHDOJXQDVGURJDVEHWDPLPpWLFDV VHJ~Q6FKZDUF]'tD]\)HVFLQD Efecto uteroinhibidor Efectos cardiovasculares maternos Contracciones Infusión I/V Presión arterial mg/min Frecuen- Frecuencia Amplitud cia cardíaca Sistólica Diastólica Droga ,VR[XSULQD 6DOEXWDPRO 7HUEXWDOLQD 5LWRGULQD )HQRWHURO (IHFWRPRGHUDGR (IHFWRLQWHQVR ,QFUHPHQWR 2UFLSUHQDOLQD 'LVPLQXFLyQ (WLOHIULQDHWLODGULDQRO 'LVPLQXFLyQ YDULDFLyQPtQLPD $QWLSURVWDJODQGLQDV GHQWUR GH ODV DQWLSURVWDJODQGLQDV OD LQGRPHWDFLQD KD GHPRVWUDGR VHU VXPDPHQWH SRWHQWH HQ RFDVLRQHV DXQ PiV TXH ORV EHWDPLPpWLFRV (QWUHORVHIHFWRVORJUDGRVVHSXHGHGHVWDFDU x3URORQJDUHOSDUWRSRUKRUDV\PiVHQHOGHORVFDVRV x3URORQJDUHOSDUWRKDVWDXQDVHPDQD\PiVHQHOGHORVFDVRV x5HGXFLUHQXQHO%31 x5HGXFLUODPRUWDOLGDGSHULQDWDOHQXQ &RPRHIHFWRLQGHVHDEOHSULQFLSDOVHUHFRQRFHHOULHVJRGHOFLHUUHSUHFR]GHOFRQGXFWR DUWHULRVR(VWDFRPSOLFDFLyQVHSURGXFLUtDDSDUWLUGHODVVHPDQDVGHJHVWDFLyQ\ VLHPSUHTXHODVGRVLVVXSHUHQORVPJ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR /DGRVLVUHFRPHQGDGDHVGHPJYtDUHFWDO (QWUH ODV FRQWUDLQGLFDFLRQHV SDUD VX XVR VH LQFOX\HQ DOHUJLD DO PHGLFDPHQWR DOWHUDFLRQHVGHODFRDJXODFLyQRWURPERFLWRSHQLD %ORTXHDQWHV GH ORV FDQDOHV GH FDOFLR GHQWUR GH HOORV OD PiV FRQRFLGD HV OD 1LIHGLSLQD &XDQGR VH UHTXLHUH WUDWDPLHQWR ~WHURLQKLELGRU SDUD GHWHQHU OD DPHQD]D GH SDUWR SUHPDWXURORVFDOFLRDQWDJRQLVWDVVRQVXSHULRUHVDFXDOTXLHURWURPHGLFDPHQWR &RPSDUDGRVFRQORVEHWDPLPpWLFRVKDQGHPRVWUDGRPD\RUHIHFWLYLGDGSDUDWUDWDUDODV PXMHUHVFRQDPHQD]DGHSDUWRSUHPDWXUR\DTXH x3URORQJDQHQPiVFDVRVHOSDUWRSRUKRUDV x3URORQJDQHQPiVFDVRVHOSDUWRSRUXQDVHPDQD x5HGXFHQPiVHO6'5 x&DUHFHQGHHIHFWRVVHFXQGDULRVTXHREOLJXHQDVXVSHQGHUHOWUDWDPLHQWR &XHQWDQFRQODYHQWDMDGHTXHSXHGHQVHUDGPLQLVWUDGDVSRUYtDRUDO\VXEOLQJXDOSRU ORFXDOVRQLGHDOHVSDUDVHUXVDGRVHQDPELHQWHVGHUHFXUVRVOLPLWDGRV/DGRVLVHVGH PJVXEOLQJXDO6HSXHGHUHSHWLUODPLVPDGRVLVFDGDPLQXWRVKDVWDFRPSOHWDU PJHQXQDKRUD (VWiQ FRQWUDLQGLFDGRV HQ DOJXQRV FDVRV HQ HQIHUPHGDG FDUGtDFD \ QR GHEHQ VHU XVDGRVDOPLVPRWLHPSRTXHHOVXOIDWRGHPDJQHVLR $QWDJRQLVWDVGHODRFLWRFLQDHOPiVFRQRFLGRHVHO$WRVLEDQ+DVWDHOPRPHQWRQRVH KDSRGLGRGHPRVWUDUTXHVHDQVXSHULRUHVDORVEHWDPLPpWLFRVHQWpUPLQRVGHH¿FDFLD WRFROtWLFDRGHUHVXOWDGRVLQIDQWLOHV6RORWLHQHQYHQWDMDVVREUHORVEHWDPLPpWLFRVHQ WpUPLQRVGHSURGXFLUHVFDVRVHIHFWRVLQGHVHDEOHVHQODVPXMHUHVJHVWDQWHV(OKDOOD]JR GHXQDXPHQWRHQODVPXHUWHVIHWDOHVHQXQHVWXGLRFX\RFRQWUROHUDSODFHERSRQHHQ DOHUWDVREUHODQHFHVLGDGGHWRPDUSUHFDXFLRQHV &RQWUDLQGLFDFLRQHVSDUDODXWHURLQKLELFLyQ 'HEHUiVXVSHQGHUVHRHYLWDUVHODXWHURLQKLELFLyQVLHPSUHTXHKD\D xSUHHFODPSVLDVHYHUD xGHVSUHQGLPLHQWRGHSODFHQWD xLQIHFFLyQRYXODU xGLODWDFLyQFHUYLFDODYDQ]DGD xPXHUWHIHWDO 7UDWDPLHQWRVTXHQRKDQGHPRVWUDGRVHUHIHFWLYRVHQODDPHQD]DGHSDUWR SUHPDWXUR 6XOIDWRGH0DJQHVLRUHFRPHQGDGRHQRFDVLRQHVSDUDHOWUDWDPLHQWRGHODDPHQD]D GHSDUWRSUHPDWXURHVLQHIHFWLYR\DXPHQWDODPRUWDOLGDGQHRQDWDOSRUORTXHVXXVR GHEHVHUGHVDFRQVHMDGR +LGUDWDFLyQKD\HVFDVDHYLGHQFLDHQHVWHDVSHFWR3HURORYLVWRKDVWDHOPRPHQWR LQGLFDTXHQRSURGXFHQLQJ~QEHQH¿FLR 2[LGRQLWURVRKDVWDHOPRPHQWRQRKD\HYLGHQFLDTXHMXVWL¿TXHVXXVRHQOXJDUGH ORVWUDWDPLHQWRVFRQYHQFLRQDOHV %HWDPLPpWLFRVSRUYtDRUDODSHVDUGHORDPSOLDPHQWHXVDGRVQRH[LVWHHYLGHQFLD GHVXHIHFWLYLGDG ,QGXFWRUHVGHODPDGXUDFLyQSXOPRQDUIHWDO 1R WRGRV ORV FRUWLFRLGHV KDQ GHPRVWUDGR VHU HIHFWLYRV SDUD LQGXFLU OD PDGXUDFLyQ SXOPRQDUIHWDOORVPiVHIHFWLYRVKDQVLGR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD x%HWDPHWDVRQDHQGRVLV,0GHPJVHSDUDGDVSRUKRUDV x'H[DPHWDVRQDHQGRVLV,0GHPJVHSDUDGDVSRUKRUDV x+LGURFRUWLVRQDHQGRVLVGHPJ,9VHSDUDGDVSRUKRUDV /DPD\RUSDUWHGHORVHVWXGLRVKDQGHPRVWUDGRHIHFWLYLGDGFXDQGRVRQDGPLQLVWUDGRV HQWUH ODV \ ODV VHPDQDV DXQTXH QXHYDV HYLGHQFLDV VXJLHUHQ TXH VH MXVWL¿FD VX XVR GHVGH ODV VHPDQDV HVSHFLDOPHQWH HQ FDVRV GH SUHHFODPSVLD URWXUD GH PHPEUDQDV HPEDUD]R P~OWLSOH \ FDGD YH] TXH VH VRVSHFKH TXH HO SDUWR SXHGH SURGXFLUVHHQPHQRVGHKRUDV /RVSULQFLSDOHVHIHFWRVVRQUHGXFFLyQGH xGHODPRUWDOLGDGSHULQDWDO xGHO6'5 xGH+HPRUUDJLD&HUHEUR9DVFXODU xGH(QWHUR&ROLWLV1HFURWL]DQWH xGHLQJUHVRVD8&,1 /RVHIHFWRVEHQH¿FLRVRVGHORVFRUWLFRLGHVQRWLHQHQGLIHUHQFLDVVHJ~QVH[RFRPRVH VRVWHQtDDQWLJXDPHQWH\QRDXPHQWDQVLJQL¿FDWLYDPHQWHHOULHVJRGHVHSVLVPDWHUQD $FRQWLQXDFLyQVHHVTXHPDWL]DHOWUDWDPLHQWRGHDWDTXHHQODDPHQD]DGHSDUWR\SDUWR SUHPDWXURPLHQWUDVVHWUDQV¿HUHODJHVWDQWHDXQQLYHOGHPD\RUFRPSOHMLGDGSDUDOD DWHQFLyQHVSHFLDOL]DGDGHOQHRQDWR 7RFROLWLFR,9GHUiSLGDLQVWDODFLyQ 3HMIHQRWHUROFRPLHQ]RPJPLQ %HWDPHWDVRQDPJ,0 GRVLVFRQLQWHUYDORGH KRUDVFXDQGRODJHVWDFLyQ HVGHDVHPDQDV ,QKLELFLyQXWHULQDLQVXILFLHQWH DXPHQWDUODGRVLVDPJPLQ ,QKLELFLyQXWHULQDLQVXILFLHQWH DXPHQWDUODGRVLVDPJPLQ ,QGRPHWDFLQDPJUHFWDO GRVLVFRQLQWHUYDORVGH KRUDVFXDQGRODJHVWDFLyQ HVVHPDQDVRSFLRQDO 0DQWHQHUODLQIXVLyQ,9FRQHO~WHURLQKLELGR GXUDQWHKRUDVDQWHVGHSDVDUDO WUDWDPLHQWRGHVRVWpQVyORLQGRPHWDFLQD (YLWDUWDTXLFDUGLDPDWHUQDPD\RUGH ODWLGRVSRUPLQXWR ,QLFLR PLQ KV Pi[LPRSDUDORV WRFROtWLFRVEPLPpWLFRV )LJXUD(VTXHPDSDUDHOWUDWDPLHQWRGHODDPHQD]DGHSDUWRSUHPDWXUR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 2%-(7,926 3HVTXLVDUDOWHUDFLRQHVGHODSUHVLyQDUWHULDO +LSHUWHQVLyQSUHYLDDOHPEDUD]R (OVtQGUGHKLSHUWHQVLyQLQGXFLGDSRUHOHPEDUD]RSUHHFODPSVLD +LSRWHQVLyQDUWHULDO $&7,9,'$' 'HWHUPLQDFLyQGHODSUHVLyQDUWHULDOLGHQWL¿FDFLyQGHHGHPDV\ SURWHLQXULD /DKLSHUWHQVLyQHQHOHPEDUD]RHVXQDFRPSOLFDFLyQFRP~Q\SRWHQFLDOPHQWHSHOLJURVD SDUDODPDGUHHOIHWR\HOUHFLpQQDFLGR(QPXFKRVSDtVHVVXHOHVHUODSULPHUDFDXVD GHPRUWDOLGDGPDWHUQD3XHGHSUHVHQWDUVHVRODRDVRFLDGDFRQHGHPD\SURWHLQXULD/D SUHVHQFLDGHHGHPDHVDOJRKDELWXDOHQODVHPEDUD]DGDV6LQHPEDUJRVLHPSUHHVWi SUHVHQWHHQORVFDVRVGHSUHHFODPSVLDVHYHUD\HQODHFODPSVLD/DSURWHLQXULDHVXQ LQGLFDGRU GH VHYHULGDG \ DSDUHFH WDUGtDPHQWH \ VH UHODFLRQD HQ IRUPD GLUHFWDPHQWH SURSRUFLRQDOFRQODVFLIUDVGHSUHVLyQDUWHULDO (QHORWURH[WUHPRODKLSRWHQVLyQDUWHULDOPDWHUQDWDPELpQVHSXHGHDVRFLDUFRQPD\RU PRUWDOLGDGIHWDOQHRQDWDO\FRQSHTXHxRSDUDODHGDGJHVWDFLRQDO3(* (QHOFXDGURVLJXLHQWHVHUHVXPHQORVSULQFLSDOHVGDxRVTXHVHDVRFLDQFRQYDORUHV DQRUPDOHVGHODWHQVLyQDUWHULDOPDWHUQDGXUDQWHHOHPEDUD]R &XDGUR7HQVLyQDUWHULDO\FRPSOLFDFLRQHVSHULQDWDOHV &RPSOLFDFLRQHV 0DWHUQD Hipertensión Alteraciones del sistema de coagulación. Diastólica > 90 mm Hg. Hemólisis. Sistólica > 140 mm Hg. Hemorragia cerebral. Insuficiencia hepática. Insuficiencia renal. Mortalidad aumentada )HWDORYXODU Aborto. Desprendimiento normoplacentario. Restricción del crecimiento intrauterino (RCI). Sufrimiento fetal agudo intraparto. Oligoamnios Mortalidad aumentada 1HRQDWDO Pequeño para la edad gestacional (PEG). Pretérmino. Síndrome de dificultad respiratoria. Depresión neonatal. Mortalidad aumentada Restricción del crecimiento intrauterino (RCIU). Mortalidad aumentada. Pequeño para la edad gestacional (PEG) Mortalidad aumentada. Hipotensión Lipotimias y desmayos. Diastólica < 55 mm Hg. Sistólica < 95 mm Hg. )DFWRUHVTXHSXHGHQPRGL¿FDUORVYDORUHVGHODWHQVLyQDUWHULDO /RV YDORUHV TXH VH REWLHQHQ GL¿HUHQ VHJ~Q OD JHVWDQWH HVWp VHQWDGD HQ GHF~ELWR VXSLQRRHQGHF~ELWRODWHUDO([LVWHQDGHPiVIDFWRUHVGHORSHUDGRURGHOLQVWUXPHQWR TXHVHSXHGHQFRQWURODUFRQXQDFRUUHFWDPHWRGRORJtD(OHV¿JPRPDQyPHWURGHEHVHU FRQWURODGR SHULyGLFDPHQWH HQ UHODFLyQ DO HVWDGR GH VXV GLIHUHQWHV SDUWHV PDQJXLWR EUD]DOHWHWXERVYiOYXODV\VLIXHVHGHWLSRDQHURLGHHQHVWHFRQWUROVHGHEHUiLQFOXLUOD FDOLEUDFLyQFRPSDUDQGRODVPHGLGDVFRQODVGHXQPDQyPHWURGHPHUFXULRGLVSXHVWR HQSDUDOHOR1RVRQUHFRPHQGDEOHVORVPDQyPHWURVDQHURLGHVFRQWRSHHQHOH[WUHPR LQIHULRUGHODHVFDOD 7pFQLFDGHPHGLGD x PLQXWRVGHUHSRVRVHQWDGDSUHYLRDODWRPD x 3RVLFLyQVHQWDGDFRQHODQWHEUD]RGHOPLHPEURVXSHULRUTXHFRUUHVSRQGHDOD PDQRKiELODSR\DGR\H[WHQGLGRDODDOWXUDGHOFRUD]yQ x &RORFDFLyQGHOPDQJXLWRGHOHV¿JPRPDQyPHWURGHVLQÀDGRHQODPLWDGGHOEUD]R OD SRUFLyQ LQÀDEOH GHEHUi FXEULU OD FDUD LQWHUQD GHO EUD]R (O ERUGH LQIHULRU GHO PDQJXLWRGHEHUiVLWXDUVHDFPGHOSOLHJXHGHOFRGR x %~VTXHGDSRUSDOSDFLyQGHOODWLGRDUWHULDOHQODSDUWHLQWHUQDGHOSOLHJXHDOOtVH DSR\DUiODFiSVXODGHOHVWHWRVFRSLRELDXULFXODU &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD x ,QVXÀDFLyQGHOPDQJXLWRKDVWDPPSRUHQFLPDGHODPHGLGDHQTXHVHGHMDURQ GHSHUFLELUORVODWLGRV x $SHUWXUDOHQWDGHODYiOYXODGHOHV¿JPRPDQyPHWUR\GLVPLQXFLyQGHODSUHVLyQ GHOPDQJXLWRDXQDYHORFLGDGGHPPSRUVHJXQGR x 5HJLVWUDU HO YDORU GH DSDULFLyQ GH ORV ODWLGRV FRPR WHQVLyQ DUWHULDO Pi[LPD R VLVWyOLFD x (OYDORUFRUUHVSRQGLHQWHDODDWHQXDFLyQDSDJDPLHQWRRHQVXGHIHFWRGHVDSDULFLyQ GHORVODWLGRVVHUHJLVWUDUiFRPRSUHVLyQDUWHULDOPtQLPDRGLDVWyOLFD 0RGL¿FDFLRQHV¿VLROyJLFDVGXUDQWHHOSDUWR /DV FLIUDV WHQVLRQDOHV WLHQHQ VXV YDORUHV PiV EDMRV HQWUH ODV VHPDQDV \ LQFUHPHQWiQGRVHKDFLDHO¿QDOGHODJHVWDFLyQVLHQGRHVWHDXPHQWRPiVQRWRULRHQORV QLYHOHVGHSUHVLyQDUWHULDOGLDVWyOLFD 3RU RWUD SDUWH ORV YDORUHV DOWHUDGRV GH SUHVLyQ DUWHULDO GLDVWyOLFD WLHQHQ PD\RU YDORU SURQyVWLFRTXHORVGHODVLVWyOLFD 6HFRQVLGHUDKLSHUWHQVLyQFXDQGR x /RVYDORUHVGHSUHVLyQ'LDVWyOLFDVRQGHPP+JRPD\RUHV x /RVYDORUHVGHSUHVLyQ6LVWyOLFDVRQGHPP+JRPD\RUHV x $XPHQWRGHODVLVWyOLFDGHPP+JRGHODGLDVWyOLFDGHPP+JR PiVUHVSHFWRDORVYDORUHVQRUPDOHVGHHVDPXMHUIXHUDGHOHPEDUD]R (QFDVRGHUHJLVWUDUYDORUHVDQRUPDOHVVHGHEHUHSHWLUODWRPDGHSUHVLyQDUWHULDOFRQOD PXMHUVHQWDGDOXHJRGHXQDKRUDGHUHSRVRHQGHF~ELWRODWHUDO6LORVYDORUHVGHODVHJXQGD PHGLGDVHHQFXHQWUDQGHQWURGHOtPLWHVQRUPDOHVODJHVWDQWHQRGHEHUiVHUFDWDORJDGD FRPRKLSHUWHQVD\GHEHUiVHUFLWDGDSDUDFRQWUROVHJ~QHOFURQRJUDPDKDELWXDO &ODVL¿FDFLyQGHORVHVWDGRVKLSHUWHQVLYRVGHOHPEDUD]R x +LSHUWHQVLyQJHVWDFLRQDO+LSHUWHQVLyQWUDQVLWRULDRLQGXFLGDSRUHOHPEDUD]R VHWUDWDGHXQDKLSHUWHQVLyQTXHVHGLDJQRVWLFDSRUSULPHUDYH]OXHJRGHODV VHPDQDVGHJHVWDFLyQVLQSURWHLQXULD/DSUHVLyQYXHOYHDODQRUPDOLGDGDQWHV GHODVVHPDQDVGHOSDUWR x 3UHHFODPSVLDVHWUDWDGHXQHVWDGRKLSHUWHQVLYRTXHVHGLDJQRVWLFDOXHJRGH ODVVHPDQDVGHOHPEDUD]RVHDFRPSDxDGHSURWHLQXULD\UHYLHUWHHQORVGtDV VXFHVLYRVDOSDUWR x (FODPSVLDVHGHQRPLQDDVtDODSUHHFODPSVLDTXHVREUHDJUHJD FRQYXOVLRQHV \RFRPD/DHFODPSVLDHVXQDFRPSOLFDFLyQREVWpWULFDGHH[WUHPDJUDYHGDG\ DOWDPRUWDOLGDGPDWHUQD\IHWDO x 3UHHFODPSVLD VREUHLPSXHVWD D KLSHUWHQVLyQ FUyQLFD VREUH XQ SURFHVR KLSHUWHQVLYR FUyQLFR DXPHQWDQ ODV FLIUDV GH SUHVLyQ DUWHULDO \ VH LQVWDOD XQD SURWHLQXULDTXHGHVDSDUHFHFRQOD¿QDOL]DFLyQGHOHPEDUD]R x +LSHUWHQVLyQFUyQLFDHVFXDQGRVHFRQVWDWDKLSHUWHQVLyQIXHUDGHOHPEDUD]RR HQODVSULPHUDVVHPDQDVGHOHPEDUD]R 6HFRQVLGHUDKLSRWHQVLyQFXDQGR x/RVYDORUHVGHOD'LDVWyOLFDVRQPHQRUHVDPP+J x/RVYDORUHVGHOD6LVWyOLFDVRQPHQRUHVDPP+J /D SUHVLyQ DUWHULDO VH PHGLUi HQ FDGD FRQVXOWD SDUD SHVTXLVDU OD KLSHUWHQVLyQ R OD KLSRWHQVLyQPDWHUQD3DUDGHVFDUWDUODKLSHUWHQVLyQSUHYLDDODJHVWDFLyQHVFRQYHQLHQWH FRPHQ]DUORVFRQWUROHVGHSUHVLyQDUWHULDODQWHVGHODVVHPDQDVGHJHVWDFLyQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR )DFWRUHVGH5LHVJRGHKLSHUWHQVLyQJHVWDFLRQDO\SUHHFODPSVLD x 1XOLSDULGDG x $GROHVFHQFLD x (GDG!GHDxRV x (PEDUD]RP~OWLSOH x 2EHVLGDG x +LVWRULDIDPLOLDUGHSUHHFODPSVLD±HFODPSVLD x 3UHHFODPSVLDHQHPEDUD]RVDQWHULRUHV x 'LDEHWHVPHOOLWXVSUHJHVWDFLRQDO x $QWHFHGHQWHVGHWURPER¿OLDV x (QIHUPHGDGUHQDOFUyQLFD x (QIHUPHGDGHVDXWRLQPXQHV 3UHYHQFLyQ /D SULQFLSDO PHGLGD SUHYHQWLYD HV HVWLPXODU HO FRQWURO SUHQDWDO SUHFR] SHULyGLFR \ FRPSOHWRFRQHOREMHWLYRGHUHPRYHUDTXHOORVIDFWRUHVGHULHVJRTXHVHDVRFLHQFRQ ODKLSHUWHQVLyQDUWHULDO2WUDVPHGLGDVGHVDOXGS~EOLFDGHOLPLWDGDHIHFWLYLGDGLQFOX\HQ ODVGLHWDVFRQDFHLWHVULFRVHQiFLGRVJUDVRVPDULQRV\HQSREODFLRQHVFRQGLHWDVEDMDV HQFDOFLRSURPRYHUODVXSOHPHQWDFLyQGHODGLHWDFRQFDOFLR /DDGPLQLVWUDFLyQGLDULDGHEDMDVGRVLVGHDVSLULQDDPJGtDGXUDQWHHOWHUFHU WULPHVWUH GHO HPEDUD]R UHGXFH OD LQFLGHQFLD GH SUHHFODPSVLD HQ SDFLHQWHV FRQ DOWR ULHVJRGHVXIULUOD(VWHHIHFWRSUHYHQWLYRQRVHKDFRUURERUDGRHQODSREODFLyQJHQHUDO FRQEDMRULHVJRGHVXIULUSUHHFODPSVLD 3UHGLFFLyQ +DVWDHOPRPHQWRQRH[LVWHXQDSUXHEDGHWDPL]DMHFRQ¿DEOHSDUDDQWLFLSDUHOGHVDUUROOR GHXQDSUHHFODPSVLD &RQGXFWD /DVPXMHUHVJHVWDQWHVFRQKLSHUWHQVLyQDUWHULDOGHEHUiQVHUDVLVWLGDVGHDFXHUGRDOD QRUPDQDFLRQDOGHDOWRULHVJR &21'8&7$65(&20(1'$'$6 +LSHUWHQVLyQLQGXFLGDSRUHOHPEDUD]R 3RGUi DVLVWLUVH HQ IRUPD DPEXODWRULD VL VH SXHGHQ PDQWHQHU FRQWUROHV GH SUHVLyQ DUWHULDOSHULyGLFRVVHPDQDOPHQWHDQDOL]DUODRULQDHQEXVFDGHSURWHLQXULD\HYDOXDUHO HVWDGRGHVDOXGIHWDO 6L OD SUHVLyQ DUWHULDO HPSHRUD DSDUHFH DOE~PLQD HQ OD RULQD R KD\ XQD 5&, VHYHUD RUGHQH OD KRVSLWDOL]DFLyQ \ FRQGX]FD HO WUDWDPLHQWR FRPR VL VH WUDWDVH GH XQD SUH HFODPSVLD 'HEHUiUHFRPHQGDUVHDODPXMHUTXHDPSOtHORVSHUtRGRVGHGHVFDQVR7DPELpQVHOH GHEHUiDGYHUWLUDHOOD\VXIDPLOLDVREUHORVULHVJRV\ORVVtQWRPDV\VLJQRVGHDOHUWD 3UHHFODPSVLDOHYH $GHPiVGHODVPHGLGDVGHWDOODGDVSDUDODVPXMHUHVFRQKLSHUWHQVLyQLQGXFLGDSRUHO HPEDUD]RVHGHEHUiQWRPDUODVVLJXLHQWHVSUHFDXFLRQHV 6LODVFLIUDVGHSUHVLyQDUWHULDOGLDVWyOLFDQRDOFDQ]DQDORVPPGH+JVHSRGUi FRQWLQXDUHOFRQWUROGHODSUHVLyQDUWHULDORULQD\HVWDGRIHWDOGRVYHFHVSRUVHPDQDQR VHUiQHFHVDULRFRPHQ]DUFRQDQWLKLSHUWHQVLYRVQLLQGLFDUVHGDQWHVRGLHWDKLSRVyGLFD 6LHVWRQRIXHUDSRVLEOHVHGHEHUiKRVSLWDOL]DUDODJHVWDQWH6LVHWUDWDGHXQHPEDUD]R GHWpUPLQRSURFHGDDLQWHUUXPSLUODJUDYLGH]\VLHOHPEDUD]RHVGHSUHWpUPLQRLQGX]FD PDGXUH]SXOPRQDUFRQFRUWLFRLGHV\FRQWLQ~HFRQORVFRQWUROHVELVHPDQDOHV(QFDVR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD GHDJUDYDFLyQGHORVVtQWRPDVKRVSLWDOLFHDODHPEDUD]DGD\DVtVWDODFRPRXQDSUH HFODPSVLD VHYHUD$XQTXH SXHGH QR VHU GH¿QLWLYR VH KD GHPRVWUDGR TXH HO UHSRVR KRVSLWDODULRUHGXFHODSUHPDWXUH]\ORVHSLVRGLRVKLSHUWHQVLYRVVHYHURV 3UHHFODPSVLDVHYHUD\ODHFODPSVLD +DVWDHOPRPHQWRHOWUDWDPLHQWRLGHDOGHODSUHHFODPSVLDVHYHUD\ODHFODPSVLDFRQVLVWH HQODLQWHUUXSFLyQGHODJHVWDFLyQ$HVRVHGHEHQVXPDURWUDVPHGLGDVWHUDSpXWLFDV TXHVHGHWDOODQDFRQWLQXDFLyQ (QWRGDVODVVLWXDFLRQHV $VHJ~UHVHGHFRQWDUFRQORVUHFXUVRVQHFHVDULRVSDUDDVLVWLUDHVWDPXMHUGHORFRQWUDULR GHULYHDOQLYHOGHDWHQFLyQDGHFXDGR6RQUHFXUVRVQHFHVDULRVSHUVRQDOHQWUHQDGR HQPDQHMRGHSDFLHQWHFUtWLFRR[tJHQRODULQJRVFRSLRWXERVHQGRWUDTXHDOHVPiVFDUD EROVDKLGUDOD]LQDRQLIHGLSLQDVXOIDWRGHPDJQHVLR\JOXFRQDWRGHFDOFLRDO x /DJHVWDQWHGHEHHVWDUDFRPSDxDGDSRUSHUVRQDOGHVDOXGHQWRGRPRPHQWR x &DWHWHULFHXQDYHQDGHJUXHVRFDOLEUHFiQXODRVXSHULRU x ,QIXQGDÀXLGRV 6ROXFLyQVDOLQDRODFWDWR5LQJHUFFKRUDVLQRKD\HGHPDSXOPRQDU x &RORTXHFDWpWHUYHVLFDOFRQEROVDFROHFWRUDSDUDPHGLUGLXUHVLV x $GPLQLVWUHPHGLFDPHQWRVDQWLKLSHUWHQVLYRVVLODSUHVLyQGLDVWyOLFDHV! PPGH+JEXVFDQGRHVWDELOL]DUODHQWUH\PPGH+JVHJ~QHVTXHPD ³RSFLRQHVWHUDSpXWLFDVFRQDQWLKLSHUWHQVLYRV´ &XDGUR2SFLRQHVWHUDSpXWLFDVFRQDQWLKLSHUWHQVLYRV 0HGLFDPHQWR +LGUDOD]LQD /DEHWRORO 'RVLVGHDWDTXH PJLYOHQWRFDGDUHSLWLHQGRGRVLVFDGDPLQXWRVKDVWDORJUDUHIHFWR GHVHDGRVLQVXSHUDUGRVLV PJLYOHQWRSXGLHQGRGXSOLFDUGRVLVPJPJHWFFDGD PLQXWRVKDVWDDOFDQ]DUHIHFWRGHVHDGRVLQVXSHUDUGRVLV 1LIHGLSLQD PJVOSXGLHQGRUHSHWLUGRVLVFDGDPLQXWRV $GPLQLVWUHVXOIDWRGHPDJQHVLRVHJ~QHVTXHPD³RSFLRQHVWHUDSpXWLFDVFRQ VXOIDWRGHPDJQHVLR´ x 2EWHQJDPXHVWUDVGHVDQJUH\RULQDSDUDH[iPHQHVGHYDORUDFLyQGHOD JHVWDQWH (QFDVRGHPXMHUHQFRPDRFRQFRQYXOVLRQHV $WRGDVODVSUHFDXFLRQHVDQWHULRUHVVHOHGHEHDJUHJDUHQHVWHWLSRGHVLWXDFLRQHVORV VLJXLHQWHVFXLGDGRV x $VHJXUDUODSHUPHDELOLGDGGHODYtDDpUHDDVSLUDUIDULQJHLQWXEDU x 3URWHJHUODOHQJXDGHPRUGHGXUDV x $GPLQLVWUDUR[tJHQR 7UDWDPLHQWRFRQ6XOIDWRGH0DJQHVLR (OVXOIDWRGHPDJQHVLRSRGUiVHUXVDGRHQHOSULPHUQLYHOGHDWHQFLyQVL x VHJDUDQWL]DQORVUHFXUVRVQHFHVDULRV\DGH¿QLGRV x ODSURGXFFLyQGHRULQDGLXUHVLVVXSHUDORVPOSRUKRUD x ODIUHFXHQFLDUHVSLUDWRULDHV!DUHVSLUDFLRQHVSRUPLQXWR x HOUHÀHMRSDWHODUHVWiFRQVHUYDGR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &XDGUR2SFLRQHVWHUDSpXWLFDVFRQVXOIDWRGHPDJQHVLR (VTXHPD 3ODQGH$WDTXH 0LHQWUDVKD\D FRQYXOVLRQHV 0DQWHQLPLHQWR (QGRYHQRVR ([FOXVLYR J,9VROXFLyQDOD SDVDUHQDPLQXWRV JDO,9 FDGDPLQXWRV KDVWDHOLPLQDUODV FRQYXOVLRQHV J,9DO SRUKRUD HQLQIXVLyQ FRQWLQXD JDO,9 FDGDPLQXWRV KDVWDHOLPLQDUODV FRQYXOVLRQHV J,0DO FDGDKRUDV J,9VROXFLyQDOD 0L[WR SDVDUHQDPLQXWRV HQGRYHQRVR 6HJXLGRGHJ,0VROXFLyQ LQWUDPXVFXODU DOJHQFQDOJD ,QWR[LFDFLyQSRU6XOIDWRGH0DJQHVLR 'HSUHVLyQ5HVSLUDWRULD (QFDVRGHLQWR[LFDFLyQHQSDFLHQWHYHQWLODGDQRVHUiQHFHVDULRXVDU DQWtGRWR\VHSRGUiPDQWHQHUHOWUDWDPLHQWR (QFDVRGHLQWR[LFDFLyQHQSDFLHQWHQRYHQWLODGD x9HQWLODUHQIRUPDPDQXDORPHFiQLFD x6XVSHQGHULQPHGLDWDPHQWHODLQIXVLyQGHOVXOIDWRGHPDJQHVLR\ DGPLQLVWUDUJOXFRQDWRGHFDOFLRJ,9OHQWRGHVROXFLyQDO +LSRWHQVLyQVHYHUD 'HEHWHQHUVHSUHVHQWHTXHHOVXOIDWRGHPDJQHVLRHVXQDJHQWHKLSRWHQVRU\TXH SXHGHSRWHQFLDUHOHIHFWRGHORVDQWLKLSHUWHQVLYRVXVDGRV 2WURVDQWLFRQYXOVLYDQWHV /DVHYLGHQFLDVFLHQWt¿FDVVRQLQFRQWUDVWDEOHVHOVXOIDWRGHPDJQHVLRHVHOWUDWDPLHQWR DQWLFRQYXOVLYDQWHGHHOHFFLyQSDUDODHFODPSVLD\HVSURWHFWRUGHODVFRQYXOVLRQHVHQOD SUHHFODPSVLDVHYHUD([FOXVLYDPHQWHFXDQGRQRVHFXHQWHFRQpOVHGHEHUiXVDURWUR DQWLFRQYXOVLYDQWH (O GLD]HSDP HV OD EHQ]RGLDFHSLQD PiV XVDGD VX SULQFLSDO ULHVJR HVODGHSUHVLyQUHVSLUDWRULDSRUORTXHVHGHEHQWRPDUSUHFDXFLRQHVVLPLODUHVDODV HPSOHDGDVFRQHOXVRGHOVXOIDWRGHPDJQHVLR 3ODQGHDWDTXH xPJ,9OHQWRDSDVDUHQPLQXWRV x6LSHUVLVWHQODVFRQYXOVLRQHVPLQXWRVGHVSXpVGHODSULPHUDGRVLVVHUHSLWH XQDQXHYDGRVLVDSDVDUHQPLQXWRVKDVWDFRPSOHWDUXQDGRVLVWRWDOGH JUDPRVHQODSULPHUDKRUD 3ODQGHPDQWHQLPLHQWR xPJGHGLD]HSDPHQPOGHVROXFLyQVDOLQDDSDVDUHQKRUDV ,QWR[LFDFLyQSRU'LD]HSDP 'HSUHVLyQUHVSLUDWRULD (QFDVRGHLQWR[LFDFLyQHQSDFLHQWHYHQWLODGDQRVHUiQHFHVDULRXVDU DQWtGRWR\VHSRGUiPDQWHQHUHOWUDWDPLHQWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (QFDVRGHLQWR[LFDFLyQHQSDFLHQWHQRYHQWLODGD x9HQWLODUHQIRUPDPDQXDORPHFiQLFD x6XVSHQGHULQPHGLDWDPHQWHODLQIXVLyQGHGLD]HSDP\ xDGPLQLVWUDUÀXPD]HQLODQWtGRWRGHODVEHQ]RGLDFHSLQDVPJ,9OHQWRHOHIHFWR VXHOHVHUGHUiSLGDLQVWDODFLyQ\GHUiSLGDGHVDSDULFLyQSXHGHQQHFHVLWDUVH GRVLVVXFHVLYDV +LSRWHQVLyQVHYHUD 'HEHWHQHUVHSUHVHQWHTXHHOGLD]HSDPHVXQDJHQWHKLSRWHQVRU\TXHSXHGHSRWHQFLDU HOHIHFWRGHORVDQWLKLSHUWHQVLYRVXVDGRV 8QDYH]HVWDELOL]DGDODPXMHUVHGHEHUiSURJUDPDUODLQWHUUXSFLyQGHODJUDYLGH]SRUOD YtDPiVUiSLGD\VHJXUDSRVLEOH 2%-(7,926 'HVFDUWDUDOWHUDFLRQHVHQHOFUHFLPLHQWRIHWDO $&7,9,'$' (YDOXDFLyQGHOFUHFLPLHQWRIHWDOSRUPHGLRGHODDOWXUDXWHULQD JDQDQFLDGHSHVR\HFRJUDItD /DV DOWHUDFLRQHV HQ HO FUHFLPLHQWR IHWDO SXHGHQ VHU SRU Gp¿FLW 5HVWULFFLyQ GHO &UHFLPLHQWR,QWUD8WHULQR5&,RSRUH[FHVRPDFURVRPtDIHWDO 5HVWULFFLyQGHOFUHFLPLHQWRLQWUDXWHULQR 8QIHWRWLHQHXQDUHVWULFFLyQHQHOFUHFLPLHQWRLQWUDXWHULQRFXDQGRVXFUHFLPLHQWRHV PHQRUTXHHOHVSHUDGRSDUDODHGDGJHVWDFLRQDO6LQDFLHVHHQHVHPRPHQWRVHHVWLPD TXHVXSHVRVHUtDPHQRUTXHHOYDORUGHOSHUFHQWLORGHORVSDWURQHVQRUPDOHVGH SHVRQHRQDWDOHQIXQFLyQGHODHGDGJHVWDFLRQDO (QXQVHQWLGRHVWULFWRQRWRGRVORVQLxRVTXHDOQDFHUSHVHQPHQRVTXHORVYDORUHV FRUUHVSRQGLHQWHVDOSHUFHQWLORVRQ5&,SXHGHWUDWDUVHGHQLxRVFRQPHQRUSHVR TXHHOHVSHUDGRSHURFRQXQSRWHQFLDOGHFUHFLPLHQWRQRUPDO (QQXHVWURVSDtVHVODSUHYDOHQFLDGHO5&,RVFLODHQWUHHO\HOGHWRGRVORV QDFLGRVYLYRV /RV5&,SUHVHQWDQXQDWDVDGHPRUWDOLGDGSHULQDWDORFKRYHFHVPD\RU\XQULHVJRGH DV¿[LD VLHWH YHFHV VXSHULRU FXDQGR VH ORV FRPSDUD FRQ ORV UHFLpQ QDFLGRV GH SHVR DGHFXDGRSDUDODHGDGJHVWDFLRQDO\HVWRHVDXQPiVJUDYHFXDQGROD5&,VHDVRFLD FRQSUHPDWXUH] /RV QHRQDWRV FRQ 5&, SXHGHQ VXIULU IUHFXHQWHPHQWH KLSRJOXFHPLD KLSRFDOFHPLD SROLFLWHPLD \ HVWUpV SRU HQIULDPLHQWR (Q HWDSDV PiV DYDQ]DGDV SXHGHQ SUHVHQWDU GL¿FXOWDGHQHODSUHQGL]DMH\WUDVWRUQRVHQVX¿VLRORJtD\PHWDEROLVPRTXHVHPDQLIHVWDUiQ HQODHGDGDGXOWDSRUGLDEHWHVREHVLGDGKLSHUWHQVLyQ\HQIHUPHGDGFRURQDULD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR )DFWRUHVTXHVHDVRFLDQFRQPD\RUIUHFXHQFLDDO5&, x 5&,HQHPEDUD]RDQWHULRU x +iELWRGHIXPDU x &RQVXPRGHDOFRKRO x &RQVXPRGHGURJDV x ,QVX¿FLHQWHSHVRPDWHUQRDOLQLFLRGHOHPEDUD]R x ,QVX¿FLHQWHDXPHQWRSRQGHUDOGXUDQWHODJHVWDFLyQ x +LSHUWHQVLyQDUWHULDOSUHYLDRLQGXFLGDSRUHOHPEDUD]R x 6tQGURPHVWURPERItOLFRV x (PEDUD]RP~OWLSOH x $QHPLDPDWHUQD x ,QIHFFLRQHVLQWUDXWHULQDV x 3ODFHQWDSUHYLD x 'LDEHWHVFRQYDVFXORSDWtD x 'HIHFWRVFRQJpQLWRV 0DFURVRPtDIHWDO 8QIHWRHVPDFURVyPLFRJUDQGHSDUDVXHGDGJHVWDFLRQDOFXDQGRDOQDFHUWLHQHXQ SHVRPD\RUTXHHOYDORUGHOSHUFHQWLORGHORVSDWURQHVGHSHVRQHRQDWDOHQIXQFLyQ GHODHGDGJHVWDFLRQDO /DPDFURVRPtDIHWDOWLHQHXQULHVJRGHPXHUWHSHULQDWDODSDUWLUGHODVVHPDQDV FXDWUR YHFHV PD\RU TXH ORV UHFLpQ QDFLGRV GH SHVR DGHFXDGR 7DPELpQ WLHQH XQD IUHFXHQFLDPD\RUGHSDUWRLQVWUXPHQWDOGLVWRFLDGHKRPEURVVXIULPLHQWRIHWDODJXGR LQWUDSDUWR GHSUHVLyQ QHRQDWDO \ VHFXHODV QHXUROyJLFDV (VWRV QLxRV WLHQHQ XQD SHRU DGDSWDFLyQ D OD YLGD H[WUDXWHULQD HQIHUPHGDG GH PHPEUDQD KLDOLQD GL¿FXOWDG UHVSLUDWRULDWUDQVLWRULD\RKLSRJOXFHPLD )DFWRUHVTXHVHDVRFLDQFRQPD\RUIUHFXHQFLDDODPDFURVRPtDIHWDO x x x x 0DFURVRPtDHQHPEDUD]RDQWHULRU 'LDEHWHVPDWHUQDQRYDVFXODU ,VRLQPXQL]DFLyQ5K 0DGUHREHVDFRQH[FHVLYRDXPHQWRSRQGHUDOGXUDQWHODJHVWDFLyQ 7HFQRORJtDVSDUDPHGLUHOFUHFLPLHQWRIHWDO /DVWHFQRORJtDVPiVXVDGDVVRQ x(YDOXDFLyQGHOLQFUHPHQWRGHODDOWXUDXWHULQD x(YDOXDFLyQGHODJDQDQFLDGHSHVRPDWHUQR x$QWURSRPHWUtDIHWDOSRUHFRJUDItD 'HEHGHVWDFDUVHTXHHODQWHFHGHQWHREVWpWULFRGHSHTXHxRSDUDODHGDGJHVWDFLRQDO 3(* R GH PDFURVRPtD IHWDO HQ XQD JHVWDFLyQ DQWHULRU DXPHQWD DSUR[LPDGDPHQWH FXDWURYHFHVHOULHVJRGHTXHHOHYHQWRVHUHSLWDHQHOHPEDUD]RDFWXDO (YDOXDFLyQGHOLQFUHPHQWRGHODDOWXUDXWHULQD (OIHWRDXPHQWDVXWDPDxRFRQODHGDGJHVWDFLRQDO\HVHFUHFLPLHQWRVHPLGHFOtQLFDPHQWH SRUODPHGLFLyQGHODDOWXUDXWHULQDFRQXQDFLQWDPpWULFDÀH[LEOHHLQH[WHQVLEOHGHVGH HO SXELV KDVWD HO IRQGR XWHULQR GHWHUPLQDGR SRU SDOSDFLyQ ¿JXUD (Q HO &/$3 605VHKDQGHVDUUROODGRFXUYDVGHDOWXUDXWHULQDHQIXQFLyQGHODHGDGJHVWDFLRQDOHQ GRQGHORVSHUFHQWLORV\PDUFDQORVOtPLWHVGHODQRUPDOLGDG¿JXUD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 3DWURQHVQRUPDOHVGHODDOWXUDXWHULQDHQIXQFLyQGHODHGDGJHVWDFLRQDO (VWDVFXUYDVIXHURQ GLVHxDGDVFRQSREODFLRQHV ODWLQRDPHULFDQDVQRUPDOHV HPSOHDQGRFRPRWpFQLFDGH PHGLGDODVLJXLHQWH Figura 52. Gráfico de Altura Uterina en función de la Edad Gestacional (O DXPHQWR LQVX¿FLHQWH GH OD DOWXUD XWHULQD FXDQGR VH WLHQHQ GDWRV FRQ¿DEOHV GH DPHQRUUHD\VHKDGHVFDUWDGRHOIHWRPXHUWR\RHOROLJRDPQLRVSHUPLWHGLDJQRVWLFDU 5&,FRQXQDVHQVLELOLGDGGH\XQDHVSHFL¿FLGDGGH /DVHQVLELOLGDGGHODDOWXUDXWHULQDSDUDHOGLDJQyVWLFRGHODPDFURVRPtDIHWDOHVGHO \ODHVSHFL¿FLGDGGHXQDYH]H[FOXLGRHOHPEDUD]RJHPHODUHOSROLKLGUDPQLRV \ODPLRPDWRVLVXWHULQD ([LVWHQGLVWLQWRVWLSRVGHPHGLGDTXHJHQHUDQGLIHUHQWHV YDORUHVSRUORFXDOHVLPSUHVFLQGLEOHQRUPDWL]DUODIRUPD GHPHGLU\XWLOL]DUSDWURQHVQRUPDOHVGHUHIHUHQFLDTXH KD\DQVLGRHODERUDGRVFRQODPLVPDWpFQLFD 6HFRORFDHOFHURGHODFLQWDVREUHHOERUGHVXSHULRUGHO SXELVFRQXQDPDQRGHVOL]iQGRODFLQWDHQWUHORVGH Figura 53. Técnica de medida, con GRVtQGLFH\PD\RUGHODRWUDPDQRKDVWDDOFDQ]DUHO cinta entre dedos índice y mayor IRQGRXWHULQRFRQHOERUGHFXELWDOGHHVDPDQR 2WUDIRUPDGHPHGLGDFRQVLVWHHQFRORFDUHOFHURGHOD FLQWDVREUHHOERUGHVXSHULRUGHOSXELV\ODFLQWDVHFRORFD GHEDMRGHOERUGHFXELWDOGHODPDQRSRUORFXDODOGHVFULELU XQDFXUYDWXUDPD\RUHOYDORUTXHVHREVHUYDHVGH FPVXSHULRUHQHOHUWULPHVWUHGHODJHVWDFLyQVLVH ODFRPSDUDFRQODWpFQLFDGHPHGLGDFLWDGDDQWHULRUPHQWH (VWDWpFQLFDGHPHGLGDQRVHFRUUHVSRQGHFRQODVWDEODV GLVHxDGDVSRUHO&/$3605 Figura 54. Técnica de medida, con cinta debajo del borde cubital. (OYDORUKDOODGRHQODPHGLFLyQVHWUDVODGDDODFXUYDGHDOWXUDSDUDODHGDGJHVWDFLRQDO GHOFDUQpSHULQDWDO ,QWHUSUHWDFLyQ 9DORUQRUPDO(VHOFRPSUHQGLGRHQWUHORVSHUFHQWLORV\GHODFXUYDSDWUyQGH DOWXUDXWHULQDSDUDODHGDGJHVWDFLRQDO 9DORUDQRUPDO(VHOTXHH[FHGHDOSHUFHQWLORRHVWiSRUGHEDMRGHOSHUFHQWLORGH ODFXUYDGHUHIHUHQFLD 7RGDJHVWDQWHFRQXQYDORUDQRUPDOGHEHVHUUHIHULGDDYDORUDFLyQGHDOWRULHVJR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (-(03/26'(/$(9$/8$&,21'(/$5(/$&,21 $/785$87(5,1$$8('$'*(67$&,21$/(* $/$35,0(5$&2168/7$ 6LWXDFLyQ (OSXQWRVHVLW~DHQWUHODVFXUYDVGH ORVSHUFHQWLORV\GHODFXUYDGH UHIHUHQFLD ,QWHUSUHWDFLyQ 9DORU1RUPDO &RQGXFWDV 6HJXLUFDOHQGDULRKDELWXDOGH FRQVXOWDV ([SOLFDUDODJHVWDQWHTXHOD$8HV DGHFXDGDSDUDVXHGDGJHVWDFLRQDO (OQLxRFUHFHELHQ 6LWXDFLyQ (OSXQWRVHXELFDSRUHQFLPDGHOD OtQHDGHOSHUFHQWLOR ,QWHUSUHWDFLyQ $OWXUDXWHULQDPD\RUTXHODDPHQRUUHD &RQGXFWDV 'HVFDUWDUHUURUGHFiOFXORGHOD(* 'HWHUPLQDURWUDVFDXVDV SROLKLGUDPQLRVPDFURVRPtDIHWDO HPEDUD]RP~OWLSOHPRODPLRPDWRVLV XWHULQDREHVLGDG &LWDUDYDORUDFLyQSRUHTXLSRGHDOWR ULHVJRHQPHQRVGHGtDV 6LWXDFLyQ (OSXQWRVHXELFDSRUGHEDMRGHOD OtQHDGHOSHUFHQWLOR ,QWHUSUHWDFLyQ $OWXUDXWHULQDPHQRUTXHODDPHQRUUHD &RQGXFWDV 'HVFDUWDUHUURUGHFiOFXORGHOD(* 'HWHUPLQDURWUDVFDXVDV5&,yELWR IHWDOROLJRDPQLRV &LWDUDYDORUDFLyQSRUHTXLSRGHDOWR ULHVJRHQPHQRVGHGtDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (-(03/26'(/$(9$/8$&,21'(/$7(1'(1&,$'(/$5(/$&,21 $/785$87(5,1$$8('$'*(67$&,21$/(* (1&2168/7$668%6(&8(17(6 6LWXDFLyQ /DOtQHDWUDQVFXUUHHQWUHODVFXUYDVGH ORVSHUFHQWLORV\ ,QWHUSUHWDFLyQ &UHFLPLHQWRQRUPDO &RQGXFWDV 6HJXLUFDOHQGDULRKDELWXDOGH FRQVXOWDV ([SOLFDUDODJHVWDQWHTXHHO FUHFLPLHQWRHVQRUPDO 6LWXDFLyQ /DOtQHDWUDQVFXUUHSRUHQFLPDGHOD OtQHDGHOSHUFHQWLOR ,QWHUSUHWDFLyQ 3RVLEOHHUURUGH(*FRQFUHFLPLHQWR QRUPDO &RQGXFWDV 'HVFDUWDUHUURUGHFiOFXORGHOD(* (YDOXDUSRUHTXLSRGHDOWRULHVJRHQ PHQRVGHGtDVSDUDGHVFDUWDU PDFURVRPtDSROLKLGUDPQLRVHWF 6LWXDFLyQ /DOtQHDWUDQVFXUUHSRUGHEDMRGHOD OtQHDGHOSHUFHQWLOR ,QWHUSUHWDFLyQ 3RVLEOHHUURUGH(*FRQFUHFLPLHQWR QRUPDO &RQGXFWDV 'HVFDUWDUHUURUGHFiOFXORGHOD(* (YDOXDUSRUHTXLSRGHDOWRULHVJRHQ PHQRVGHGtDVSDUDGHVFDUWDU ROLJRDPQLRVR5&, &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 6LWXDFLyQ /DOtQHDDVFLHQGHGHVGHODIDMDGHOD QRUPDOLGDGSS ,QWHUSUHWDFLyQ &UHFLPLHQWRDQRUPDOHQPiV &RQGXFWDV 'HULYDUDFRQWUROGHDOWRULHVJRHQ PHQRVGHGtDVSDUDGHVFDUWDU SROLKLGUDPQLRVPDFURVRPtD HPEDUD]RP~OWLSOHHWF 6LWXDFLyQ /DOtQHDGHVFLHQGHGHVGHODIDMDGHOD QRUPDOLGDGSS ,QWHUSUHWDFLyQ &UHFLPLHQWRDQRUPDOHQPHQRV 3RVLEOH5&, &RQGXFWDV 'HULYDUDFRQWUROGHDOWRULHVJRHQ PHQRVGHGtDV x(YDOXDFLyQGHODJDQDQFLDGHSHVRPDWHUQR /DVRVSHFKDGH5&,VHUHD¿UPDVLDGHPiVGHXQDDOWXUDXWHULQDPHQRUTXHHOS H[LVWHXQDJDQDQFLDGHSHVRPDWHUQDPHQRUTXHHOSRXQSHVRPDWHUQRSDUDODWDOOD PHQRUTXHHOS /D DVRFLDFLyQ GH OD DOWXUD XWHULQD HQ SDUDOHOR FRQ OD JDQDQFLD GH SHVR GH OD PDGUH GXUDQWHODJHVWDFLyQWLHQHXQDDOWDVHQVLELOLGDGSDUDSUHGHFLU3(*VyORVXSHUDGD SRUHOSHUtPHWURDEGRPLQDOIHWDOPHGLGRSRUHFRJUDItD &RQGXFWD /RVFDVRVFRQVRVSHFKDFOtQLFDGH5&,H[FOXLGRHOROLJRDPQLRVHOHUURUGHDPHQRUUHD HWFGHEHUiQVHUFRQ¿UPDGRVSRUHFRJUDItDSDUDGHVFDUWDUORVIDOVRVSRVLWLYRV\XQD YH]FRQ¿UPDGRHOGLDJQyVWLFRVHGHEHUiUHIHULUDHVWDVJHVWDQWHVDFRQVXOWDGHDOWR ULHVJR x$QWURSRPHWUtDIHWDOSRUHFRJUDItDELGLPHQVLRQDO 6H WUDWD GHO H[DPHQ FRPSOHPHQWDULR PiV VHJXUR SDUD GLDJQRVWLFDU DOWHUDFLRQHV GHOFUHFLPLHQWRIHWDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 6H KDQ GHVDUUROODGR WDEODV \ FXUYDV GH OD HYROXFLyQ GH YDULRV SDUiPHWURV DQWURSRPpWULFRVIHWDOHVTXHSHUPLWHQFRQRFHUVXFUHFLPLHQWRHQUHODFLyQFRQODHGDG JHVWDFLRQDO /DHFRJUDItDSHUPLWHGLIHUHQFLDUHQWUHUHVWULFFLyQGHFUHFLPLHQWRLQWUDXWHULQRVLPpWULFR \DVLPpWULFRDGHPiVGHGHWHFWDUORVPiVSUHFR]PHQWHTXHODVPHGLGDVFOtQLFDV7LHQH FRPRLQFRQYHQLHQWHHOFRVWRGHOHTXLSDPLHQWR\ODQHFHVLGDGGHSHUVRQDOHQWUHQDGR (Q5&,GHWLSRVLPpWULFRWRGDVODVPHGLGDVIHWDOHVVHHQFXHQWUDQUHGXFLGDVSHUtPHWUR FUDQHDQRWDOOD\SHVRPLHQWUDVTXHHQHODVLPpWULFRVyORGLVPLQX\HHOSHVRSHUtPHWUR DEGRPLQDO\ODWDOOD\SHUtPHWURFUDQHDQRVHPDQWLHQHQQRUPDOHV /DVPHGLGDVPiVXVDGDVVRQ DSHUtPHWURDEGRPLQDOIHWDOVHORSXHGHPHGLUGLUHFWDPHQWHGHOHTXLSRGHHFRJUDItD UHFRUULHQGRHOSHUtPHWURH[WHUQRGHODEGRPHQIHWDODQLYHOGHO'XFWXV9HQRVRGH$UDQFLR RGHWHUPLQDQGRHOGLiPHWURPD\RU'\HOGLiPHWURPHQRUGSHUSHQGLFXODUDODQWHULRU DPERVPHGLGRVGHERUGHH[WHUQRDERUGHH[WHUQR$SOLFDQGRODIyUPXODGHODHOLSVHVH REWLHQHHOSHUtPHWUR 3$EG 'G[ 6HWUDWDGHODPHMRUPHGLGDSDUDHYDOXDUHOFUHFLPLHQWRIHWDOFRQXQDVHQVLELOLGDGGH \ XQD HVSHFL¿FLGDG GH SDUD HO GLDJQyVWLFR GH UHVWULFFLyQ GH FUHFLPLHQWR LQWUDXWHULQR \ GHO \ GH VHQVLELOLGDG \ HVSHFL¿FLGDG UHVSHFWLYDPHQWH SDUD HO GLDJQyVWLFRGHPDFURVRPtDIHWDO EGLiPHWURELSDULHWDOIHWDOSDUDHOGLDJQyVWLFRGH5&,WLHQHXQDVHQVLELOLGDGGH \XQDHVSHFL¿FLGDGGH (Q ORV IHWRV PDFURVyPLFRV ORV YDORUHV VRQ VLPLODUHV D ORV GH IHWRV FRQ FUHFLPLHQWR QRUPDO FSHUtPHWUR FUDQHDQR IHWDO VH FRPSRUWD GH PDQHUD VLPLODU DO GLiPHWUR ELSDULHWDO '%3 1R VH PRGL¿FD HQ ORV IHWRV PDFURVyPLFRV 6H PRGL¿FD SRFR HQ ODV 5&, DVLPpWULFDV \ VH DOWHUD FRQVLGHUDEOHPHQWH HQ ODV 5&, VLPpWULFDV OR TXH SHUPLWH KDFHUGLDJQyVWLFRGLIHUHQFLDOGHWLSRGH5&, (QHOPLVPRSODQRTXHVHPLGHHO'%3DQLYHOGHOFDYXPGHOVHSWXPSHOO~FLGXP VH PLGH HO GLiPHWUR IURQWR RFFLSLWDO ')2 GHVGH HO ERUGH H[WHUQR GHO IURQWDO DO ERUGHH[WHUQRGHORFFLSLWDO&RQDPERVGLiPHWURVDSOLFDQGRODIyUPXODGHODHOLSVH VHREWLHQHHOSHUtPHWURFUDQHDQR 3&U '%3')2[ &XDGUR9DORUHVHVSHUDGRVVHJ~QODDOWHUDFLyQGHOFUHFLPLHQWR $OWHUDFLyQ 9DORUHVHVSHUDGRV 3HUtPHWURDEGRPLQDOIHWDO 3HUtPHWURFUDQHDQRR'%3 0DFURVyPLFR !S HQWUHS\S 5&,VLPpWULFD S S 5&,DVLPpWULFD S HQWUHS\S G 5HODFLyQ 3HUtPHWUR DEGRPLQDO IHWDO/RQJLWXG GHO IpPXU \ YHORFLGDG GH FUHFLPLHQWR GHO SHUtPHWUR DEGRPLQDO VHJ~Q YDORU SUHYLR VRQ LQGLFDGRUHV GH FUHFLPLHQWRLQGHSHQGLHQWHVGHODHGDGJHVWDFLRQDO(VWRHVORPiVDSURSLDGRSDUD XVDUHQFDVRVGHJHVWDQWHVGHHGDGJHVWDFLRQDOGHVFRQRFLGD\FDSWDFLyQWDUGtD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR *HVWDQWHHQFXLGDGRSUHQDWDO (GDG JHVWDFLRQDO(* FRQRFLGD\VLQ GXGDV 6L 0HGLGDVHULDGDGHDOWXUDXWHULQD$83HVR PDWHUQR309ROXPHQOLTDPQLyWLFR/$ ,QYHVWLJDFLyQGHIDFWRUHVGHULHVJR 1R $8S 30S 2OLJRDPQLRV )DFWRUHVGH ULHVJR 6L 6L 1R &DSWDFLyQ DQWHVGHODV VHPDQDV 'HWHUPLQDFLyQSRU(&2GH(* /&& GHDVHPDQDV '%3 DSDUWLUGHVHPDQDV /) DSDUWLUGHVHPDQDV 1R (&2XWLOL]DQGRLQGLFDGRUHVGH FUHFLPLHQWRLQGHSHQGLHQWHGHOD(* 3HU$EG 5HODF /) 9HOFUHFLPLHQWRVHJ~QYDORUSUHYLR GHO3HU$EG 6RVSHFKD 5&, $WHQFLyQVHJ~QSDXWDGHEDMRULHVJR $WHQFLyQVHJ~QSDXWDGHDOWRULHVJR )LJXUD(YDOXDFLyQGHOFUHFLPLHQWRIHWDO 7UDWDPLHQWR /RV FDVRV HQ ORV TXH VH GLDJQRVWLTXH 5&, GHEHUiQ VHU DVLVWLGRV HQ HO QLYHO GH DOWR ULHVJR 0LHQWUDVODHPEDUD]DGDFRQWLQ~HVXDWHQFLyQHQHOSULPHUQLYHOVHGHEHUiLQGLFDU x0HGLGDVJHQHUDOHV 6XVSHQGHU HO WDEDFR DOFRKRO \ GURJDV &DOPDU OD DQVLHGDG \ PHMRUDU OD QXWULFLyQ x$XPHQWDUHOÀXMR~WHURSODFHQWDULR 5HSRVR HQ FDPD SUHIHUHQWHPHQWH HQ GHF~ELWR ODWHUDO L]TXLHUGR GRVLV EDMDV PJGtDGHiFLGRDFHWLOVDOLFtOLFR x7UDWDUSDWRORJtDPDWHUQDVLH[LVWH (OWUDWDPLHQWRGHODKLSHUWHQVLyQDUWHULDOODDQHPLDSRUKHPRUUDJLDFDUHQFLDVX RWUDVHQIHUPHGDGHV\HOFRQWUROGHODGLDEHWHVSXHGHQJHQHUDUXQFUHFLPLHQWR GHUHFXSHUDFLyQ (Q ORV HPEDUD]RV GH WpUPLQR HO WUDWDPLHQWR LGHDO FRQVLVWLUi HQ OD ¿QDOL]DFLyQ GH OD JUDYLGH]SRUODYtDPiVDGHFXDGD/RTXHVHUiGHWHUPLQDGRHQFDGDFDVRFOtQLFRHQ SDUWLFXODU /D FRQGXFWD REVWpWULFD HQ ORV HPEDUD]RV GH SUHWpUPLQR VRPHWHUi D ORV HTXLSRV D ODGLV\XQWLYDGHH[WUDHUXQQLxRLQPDGXURFRQULHVJRGHPXHUWHQHRQDWDORVHFXHODV \ PDQWHQHUOR KDVWD DOFDQ]DU OD PDGXUH] \ FRUUHU HO ULHVJR GH TXH VH SURGX]FD XQD PXHUWH IHWDO 'H OD PLVPD PDQHUD OD YtD GHO SDUWR VH GH¿QLUi HQ IXQFLyQ GH OD HGDG JHVWDFLRQDO\GHODVDOXGIHWDO\ODWROHUDQFLDDODVFRQWUDFFLRQHVXWHULQDV(QORVFDVRV GHHPEDUD]RVGHSUHWpUPLQRHOWUDWDPLHQWRFRQFRUWLFRLGHVSDUDLQGXFLUODPDGXUDFLyQ SXOPRQDUIHWDOHVXQUHFXUVRIXQGDPHQWDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2%-(7,926 'HWHFWDU SUHFR]PHQWH HO HPEDUD]R P~OWLSOH SDUD SUHYHQLU VXV FRPSOLFDFLRQHV $&7,9,'$' 'LDJQyVWLFRGHOQ~PHURGHIHWRV (PEDUD]RP~OWLSOH /DIUHFXHQFLDGHOHPEDUD]RGREOHRJHPHODUHOPiVFRP~QGHORVHPEDUD]RVP~OWLSOHV RVFLODHQWRUQRGHXQRFDGDDQDFLPLHQWRV~QLFRV&RQODLQWURGXFFLyQGHODV WpFQLFDVGHHVWLPXODFLyQGHODRYXODFLyQ\ODIHUWLOL]DFLyQLQ9LWURHQPXMHUHVHVWpULOHVVH KDLQFUHPHQWDGRHOQ~PHURGHODVJHVWDFLRQHVP~OWLSOHV$SHVDUGHHVWRODIUHFXHQFLD GHHPEDUD]RVP~OWLSOHVHQHOWRWDOGHQDFLPLHQWRVRVFLODHQWUH\ 'HORVHPEDUD]RVGREOHVXQWHUFLRVRQPRQRFLJyWLFRVRJHPHORVLGpQWLFRV\GRVWHUFLRV VRQELFLJyWLFRVRIUDWHUQRV/DLQÀXHQFLDGHODHGDGPDWHUQDODSDULGDGODKHUHQFLDOD UD]D\ORVPHGLFDPHQWRVVHH[SUHVD~QLFDPHQWHHQORVHPEDUD]RVP~OWLSOHVELFLJyWLFRV WDOFRPRVHH[SUHVDHQHOFXDGUR &XDGUR,QÀXHQFLDGHDOJXQRVIDFWRUHVVREUHODIUHFXHQFLDGHHPEDUD]RVP~OWLSOHV ELFLJyWLFRV 3DULGDG HQSULPHUSDUWR HQFXDUWRSDUWR +HUHQFLD $QWHFHGHQWHVPDWHUQRVDXPHQWDQGHD YDFHVODSUREDELOLGDG 'URJDVDQWLFRQFHSWLYDV 3RVWDQRYXODWRULRVRUDOHVHQHOPHVVLJXLHQWHD VXLQWHUUXSFLyQ 'URJDVLQGXFWRUDVGHODRYXODFLyQ *RQDGRWUR¿QD&RULyQLFD+XPDQD &ORPLIHQR 5D]D QHJUDF EODQFDF DPDULOODF /D GXUDFLyQ GHO HPEDUD]R \ HO SHVR GH ORV UHFLpQ QDFLGRV VRQ PHQRUHV FXDQGR VH ORV FRPSDUD FRQ HPEDUD]RV ~QLFRV (O YDORU PHGLR GH HGDG JHVWDFLRQDO DO SDUWR HV GHXQDVVHPDQDVPHQRU\HOYDORUPHGLRGHOSHVRDOQDFHUHVJPHQRUHQORV HPEDUD]RVP~OWLSOHV )5 [ 3 3 3 1 (PEDUD]RV ~QLFRV [ 3 3 3 1 (PEDUD]RV ~QLFRV [ 3 3 3 1 HGDG JHVWDFLRQDO )5 (PEDUD]RV P~OWLSHV [ 3 3 3 1 SHVRJ (PEDUD]RV P~OWLSHV HGDG JHVWDFLRQDO Figura 56. Distribución de la edad gestacional al momento del parto en embarazos únicos y múltiples sin intervenciones especiales durante el prenatal SHVRJ Figura 57. Distribución del peso al nacer en embarazos únicos y múltiples sin intervenciones especiales durante el prenatal &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (Q PDWHUQLGDGHV S~EOLFDV FRQ SREODFLRQHV GH FRQGLFLyQ VRFLRHFRQyPLFD EDMD DSUR[LPDGDPHQWHODPLWDGGHORVHPEDUD]RVP~OWLSOHVWHUPLQDQHQSDUWRVGHSUHWpUPLQR PHQRVGHVHPDQDV'HORVTXHOOHJDQDWpUPLQRPiVGHODPLWDGVXIUHQXQD5&, /DDV¿[LDJUDYHDOSULPHU\DOTXLQWRPLQXWRGHYLGDWUHV\FXDWURYHFHVUHVSHFWLYDPHQWH PD\RUTXHHQORVSDUWRV~QLFRV &XDGUR3DWRORJtDVTXHVHDVRFLDQFRQHPEDUD]RP~OWLSOH 0DWHUQDV )HWDOHV 1HRQDWDOHV $QHPLDV 0DOIRUPDFLRQHV 3UHWpUPLQR 3UHHFODPSVLD 5&, 3(* 'HSUHVLyQ QHRQDWDO DO $FFLGHQWHVSODFHQWDULRV 6)$LQWUDSDUWR HU\PLQXWR 3ROLKLGUDPQLRV 3UHVHQWDFLRQHVDQRUPDOHV +HPRUUDJLDSRUDWRQtDXWHULQD /DPRUWDOLGDGQHRQDWDOHQORVHPEDUD]RVP~OWLSOHVHVFXDWURYHFHVPiVDOWDTXHHQ ORVHPEDUD]RV~QLFRV/DPRUELOLGDGWDPELpQHVPD\RUTXHHQORVHPEDUD]RV~QLFRV OD LQFLGHQFLD GH UHWUDVR HQ HO GHVDUUROOR ItVLFR \ PHQWDO \ OD SDUiOLVLV FHUHEUDO HVWiQ DXPHQWDGDVHQHVWRVQLxRV 'LDJQyVWLFRGHHPEDUD]RP~OWLSOH 6RVSHFKD x $QWHFHGHQWHVIDPLOLDUHVPDWHUQRVRSHUVRQDOHVGHHPEDUD]RP~OWLSOH x 7R[HPLDWHPSUDQDHQHOHPEDUD]R x +LSHUHPHVLV x 7UDWDPLHQWRSUHYLRDODFWXDOHPEDUD]RFRQHVWLPXODQWHVGHODRYXODFLyQ 3UHVXQFLyQ x ÒWHURGHPD\RUWDPDxRTXHHOHVSHUDGRSDUDODHGDGJHVWDFLRQDO x $OWXUD XWHULQD SRU HQFLPD GHO S GH OD FXUYD GH DOWXUD XWHULQD VHJ~Q HGDG JHVWDFLRQDO x 3DOSDFLyQGHQXPHURVDVSDUWHVIHWDOHV x 3DOSDFLyQGHPiVGHGRVSRORVIHWDOHV x 3DOSDFLyQGHGRVSRORVIHWDOHVLJXDOHVGRVSRORVFHIiOLFRVRGRVSRGiOLFRV x 3DOSDFLyQGHGRVSRORVIHWDOHVGLVWLQWRVPX\FHUFDRPX\OHMRVXQRGHORWURFRPR SDUDFRUUHVSRQGHUDOPLVPRIHWR x $XVFXOWDFLyQGHPiVGHXQIRFRGHODWLGRVIHWDOHVFRQIUHFXHQFLDGLIHUHQWH &HUWH]D x 9LVXDOL]DFLyQGHGRVIHWRVSRUHFRJUDItD x 'HWHFFLyQ GH GRV UHJLVWURV VLPXOWiQHRV GH IUHFXHQFLD FDUGtDFD IHWDO QR VLQFUyQLFRV 'LDJQyVWLFRGLIHUHQFLDO 'HVFDUWDGR HO GLDJQyVWLFR GH HPEDUD]R P~OWLSOH D YHFHV XQD GLVFRUGDQFLD HQ PiV HQWUH OD DOWXUD XWHULQD \ OD DPHQRUUHD HV H[SOLFDGD SRU XQD PDFURVRPtD IHWDO XQ SROLKLGUDPQLRVRXQDPLRPDWRVLVXWHULQD7DQWRHOSROLKLGUDPQLRVFRPRODPDFURVRPtD IHWDOSXHGHQVHUFRQVHFXHQFLDGHXQDGLDEHWHVFRQFRPLWDQWHFRQHOHPEDUD]R\DVHD JHVWDFLRQDORQR &RQGXFWD &RQGLDJQyVWLFRFRQ¿UPDGRGHHPEDUD]RP~OWLSOHODJHVWDQWHGHEHVHUUHIHULGDSDUD VX XOWHULRU FRQWURO HQ DOWR ULHVJR \ OD DWHQFLyQ GHO SDUWR VH HIHFWXDUi HQ XQ QLYHO GH PD\RUFRPSOHMLGDG &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2%-(7,926 3HVTXLVDUODVSUHVHQWDFLRQHVIHWDOHVDQRUPDOHV $&7,9,'$' 'LDJQyVWLFRGHSUHVHQWDFLyQIHWDO 6HGH¿QHFRPRSUHVHQWDFLyQODSDUWHGHOIHWRTXHVHHQFXHQWUDHQFRQWDFWRFRQODSHOYLV PDWHUQD FDSD] GH FXPSOLU FRQ XQ PHFDQLVPR GH SDUWR 3XHGH VHU OD FDEH]D IHWDO SUHVHQWDFLyQFHIiOLFDRSXHGHQVHUORVPLHPEURVLQIHULRUHVRODVQDOJDVSUHVHQWDFLyQ SHOYLDQDRSRGiOLFD6LHOTXHVHRIUHFHDODSHOYLVHVHOKRPEURIHWDOVHGHQRPLQD VLWXDFLyQWUDQVYHUVD\QRVHUiFDSD]GHWHUPLQDUHVSRQWiQHDPHQWHHQSDUWRSRUYtD YDJLQDO 3UHVHQWDFLyQSHOYLDQDRSRGiOLFD /DIUHFXHQFLDGHODSUHVHQWDFLyQSHOYLDQDHQHPEDUD]DGDVGHWpUPLQRFRQIHWR~QLFR GHSHVRLJXDORPD\RUDJYDUtDHQWUH\GHORVSDUWRV (OSDUWRHQSHOYLDQDVHDVRFLDFRQPD\RUPRUELPRUWDOLGDGSHULQDWDO &LUFXQVWDQFLDVTXHDXPHQWDQODIUHFXHQFLDGHSUHVHQWDFLyQSRGiOLFD x 3DUWRGHSUHWpUPLQR x (PEDUD]RP~OWLSOH x 3ROLKLGUDPQLRV x 3ODFHQWDSUHYLD x 0DOIRUPDFLRQHVIHWDOHVDQHQFHIDOLDKLGURFHIDOLDHWF x 0DOIRUPDFLRQHVXWHULQDV 6LWXDFLyQWUDQVYHUVD 6XIUHFXHQFLDHVPHQRUDFDGDSDUWRV6HDVRFLDFRQODVPLVPDVFLUFXQVWDQFLDV TXHIDYRUHFHQDODSUHVHQWDFLyQSHOYLDQD'HMDGDDVXHYROXFLyQHVSRQWiQHDWHUPLQD HQURWXUDXWHULQDPXHUWHPDWHUQD\IHWDO 'LDJQyVWLFRGHSUHVHQWDFLyQSHOYLDQDRVLWXDFLyQWUDQVYHUVD &OtQLFR 3DUD HIHFWXDU HO GLDJQyVWLFR GH OD FRORFDFLyQ GHO IHWR HQ HO ~WHUR VH UHFRPLHQGD IDPLOLDUL]DUVHFRQODVPDQLREUDVVLVWHPDWL]DGDVGH/HRSROG 3ULPHUD PDQLREUD SDOSDQGR HO IRQGR VH SXHGH LGHQWL¿FDUHOSRORIHWDOTXHORRFXSD6LHOSRORHV GXURHVIpULFRUHJXODUSHORWHD\SUHVHQWDHOVXUFR GHOFXHOOR\WDQWRODSDOSDFLyQFRPRHOSHORWHRVRQ GRORURVRVVHSXHGHDVXPLUTXHHOIRQGRGHO~WHUR HVWiRFXSDGRSRUODFDEH]D6LVHFRQ¿UPDTXHOD FDEH]DHVWiHQHOIRQGRVHKDEUiKHFKRHQWRQFHV GLDJQyVWLFRGHSUHVHQWDFLyQSHOYLDQD Figura 58. Primera maniobra de Leopold 6HJXQGD PDQLREUD SDOSDQGR ORV ÀDQFRV VH GHWHUPLQD VLWXDFLyQ \ XELFDFLyQ GHO GRUVR IHWDO 1RUPDOPHQWH HQ OD VLWXDFLyQ ORQJLWXGLQDO VH SDOSDUi D XQ ODGR HO GRUVR \ HQ HO RWUR HO YLHQWUH IHWDO3RUHOFRQWUDULRHQODVLWXDFLyQWUDQVYHUVDVH SDOSDUiQ DPERV SRORV IHWDOHV XELFDGRV D DPERV ODGRVGHOYLHQWUHPDWHUQR Figura 59. Segunda maniobra de Leopold &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 7HUFHUD PDQLREUD SHUPLWH SDOSDU HO SROR TXH VH RIUHFHDODSHOYLV(QODVSUHVHQWDFLRQHVGHQDOJD VHSRGUiHQFRQWUDUXQSRORTXHSXHGHVHUJUDQGH QDOJD FRPSOHWD R FKLFR QDOJD LQFRPSOHWD SHUR VHDFXDOIXHUHODPRGDOLGDGHOSRORVHUiLUUHJXODU EODQGRSRFRUHVLVWHQWH\GLItFLOGHKDFHUORSHORWHDU 1RVHUHFRQRFHUiQLODIUHQWHQLHOVXUFRGHOFXHOOR (Q FDVR GH VLWXDFLyQ WUDQVYHUVD OD SHOYLV VH HQFRQWUDUiYDFtD Figura 60. Tercera maniobra de Leopold &XDUWD PDQLREUD SHUPLWH HYDOXDU HO JUDGR GH HQFDMDPLHQWR GH OD SUHVHQWDFLyQ HQ OD SHOYLV \ HO JUDGR GH ÀH[LyQ 6L ORV GHGRV VH LQWURGXFHQ HQ XQD H[FDYDFLyQ YDFtD VH VRVSHFKDUi VLWXDFLyQ WUDQVYHUVD Figura 61. Cuarta maniobra de Leopold 3DUDFOtQLFD 6L FRQ HO H[DPHQ FOtQLFR SHUVLVWHQ GXGDV VREUH OD XELFDFLyQ IHWDO OD XOWUDVRQRJUDItD VHUiHOPpWRGRGHHOHFFLyQSDUDHVWDEOHFHUHOGLDJQyVWLFR&XDQGRQRVHGLVSRQJDGH XOWUDVRQRJUDItDODUDGLRJUDItDUD\RV;SXHGHVHUXQDRSFLyQDSURSLDGD &RQGXFWDHQODSUHVHQWDFLyQSHOYLDQD\ODVLWXDFLyQWUDQVYHUVD $SDUWLUGHODVVHPDQDVVHGHEHGHWHUPLQDUODVLWXDFLyQ\SUHVHQWDFLyQIHWDOHQFDGD FRQWURO /DHYLGHQFLDH[LVWHQWHKDVWDHOPRPHQWRVXJLHUHTXHODFHViUHDSODQL¿FDGDWLHQHPHQRU PRUWDOLGDGSHULQDWDO\PHQRUGHSUHVLyQUHVSLUDWRULDGHORVQHRQDWRVLQGHSHQGLHQWHPHQWH GHODSDULGDGGHODPXMHU\HOHQWUHQDPLHQWRGHOSURIHVLRQDOTXHDVLVWHFXDQGRVHOD FRPSDUDFRQHOSDUWRYDJLQDO 6HUHFRPLHQGDHQFDVRVGHSUHVHQWDFLyQSHOYLDQD\WUDQVYHUVDODUHDOL]DFLyQ GHXQDFHViUHDHOHFWLYDDOWpUPLQR 3DUD GLVPLQXLU OD IUHFXHQFLD GH FHViUHDV DQWH HO GLDJQyVWLFR GH SUHVHQWDFLyQ R VLWXDFLyQIHWDODQRUPDOHVFRQYHQLHQWHHYDOXDUHOFDVRSRUODSRVLELOLGDGGHLQWHQWDUOD DFRPRGDFLyQH[WHUQDGHOIHWRSUHYLRDOFRPLHQ]RGHOWUDEDMRGHSDUWR /DYHUVLyQH[WHUQDGHEHVHUOOHYDGDDFDERVRORHQDTXHOODVSDFLHQWHVTXH QRWHQJDQFRQWUDLQGLFDFLRQHV~QLFDPHQWHSRUSHUVRQDOFDSDFLWDGRHQUHDOL]DU ODPDQLREUD\HQDPELHQWHFRQUHFXUVRVSDUDUHVROYHUODVFRPSOLFDFLRQHVTXH SXHGDQSUHVHQWDUVHSRUODPDQLREUDVXIULPLHQWRIHWDODJXGRGHVSUHQGLPLHQWR GHSODFHQWD(VWRVUHFXUVRVVRQTXLUyIDQR\HOHPHQWRVSDUDODUHDQLPDFLyQ GHODPDGUH\GHOQLxR &RQWUDLQGLFDFLRQHVSDUDUHDOL]DUODYHUVLyQH[WHUQD x (GDGJHVWDFLRQDOPHQRUDVHPDQDV x 'HVSURSRUFLyQSpOYLFRIHWDO x 2SHUDFLRQHVSUHYLDVVREUHHO~WHURFHViUHDVPLRPHFWRPtDVHWF x 7RQRXWHULQRHOHYDGR x ÒWHURPDOIRUPDGR\RFRQPLRPDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD x x x x x x x (PEDUD]RP~OWLSOH )HWRPXHUWR 0DOIRUPDFLRQHVIHWDOHVPD\RUHVKLGURRDQHQFHIDOLDHWF 3ODFHQWDSUHYLD 2OLJRDPQLRV 2EHVLGDGPDWHUQD 1RFRQWDUFRQSRVLELOLGDGGHUHDOL]DUFHViUHDGHHPHUJHQFLD 2%-(7,926 'HWHFWDU SRVLEOHV GLVWRFLDV SpOYLFDV SDUD GH¿QLU HO QLYHO GH DWHQFLyQGHOSDUWR $&7,9,'$' ([DPHQJLQHFRREVWpWULFR(YDOXDFLyQGHODSHOYLV ,QWHUURJDWRULR 'HEHUi UHFDEDUVH GDWRV VREUH SDUWRV DQWHULRUHV \ H[LVWHQFLD GH DIHFFLRQHV \ WUDXPDWLVPRV TXH SXGLHUDQ KDEHU DIHFWDGR OD SHOYLV HQ HVSHFLDO DOWHUDFLRQHV GH OD QXWULFLyQ SRU HMHPSOR UDTXLWLVPR (Q ODV PXOWtSDUDV XQ GDWR TXH SHUPLWH VXSRQHU TXHKD\XQEXHQFDQDOyVHRHVHODQWHFHGHQWHGHSDUWRVSUHYLRVGHUHFLpQQDFLGRV YLYRVFRQSHVRPD\RUDJ3RUHOFRQWUDULRXQDDQRPDOtDHQODHYROXFLyQGHXQ SDUWRDQWHULRUFRQXQUHFLpQQDFLGRPHQRUDJUDPRVGHEHKDFHUVRVSHFKDUXQD YLFLDFLyQSHOYLDQD 'LDJQyVWLFRGHHQFDMHGHODSUHVHQWDFLyQ /D SUHVHQWDFLyQ HVWi HQFDMDGD FXDQGR HO SODQR GHO GLiPHWUR ELSDULHWDO VH HQFXHQWUD SRUGHEDMRGHOSODQRGHOHVWUHFKRVXSHULRUGHODSHOYLVSURPRQWRULR±OtQHDLQQRPLQDGD ±ERUGHVXSHULRUGHOSXELV(OGLDJQyVWLFRVHHVWDEOHFHPHGLDQWHSDOSDFLyQDEGRPLQDO \WDFWR3RUSDOSDFLyQDEGRPLQDOPHGLDQWHODFXDUWDPDQLREUDGH/HRSROGVHFRQVLGHUD TXHODSUHVHQWDFLyQHVWiHQFDMDGDFXDQGRHOSRORTXHVHRIUHFHDOHVWUHFKRVXSHULRU QRVHSXHGHHOHYDU\RKDFHUSHORWHDU3RUHOWDFWRVHKDFHGLDJQyVWLFRUHODFLRQDQGR ODSDUWHPiVGHVFHQGLGDGHODFDEH]DIHWDOFRQHOSODQRGHODVHVSLQDVFLiWLFDVFXDQGR HVWRVSXQWRVVHHQFXHQWUDQHQHOPLVPRSODQRODFDEH]DHVWiXVXDOPHQWHHQFDMDGD 6HFRQVLGHUDTXHVLODSUHVHQWDFLyQFHIiOLFDHVWiHQFDMDGDHVLPSUREDEOHTXHKD\D DOWHUDFLRQHVSHOYLDQDVDQLYHOGHOHVWUHFKRVXSHULRU /DFRPSUREDFLyQGHXQDSUHVHQWDFLyQHQFDMDGDHVHYLGHQFLDGHVX¿FLHQFLD SpOYLFDGHOHVWUHFKRVXSHULRU\PHGLR 3HOYLPHWUtDLQWHUQD\SHOYLJUDItDGLJLWDO (QFDVRVGRQGHQRVHWHQJDDQWHFHGHQWHVHYLGHQWHVGHFDSDFLGDGSpOYLFDFRQYLHQH OXHJR GH OD VHPDQD UHDOL]DU XQ H[DPHQ GHO FDQDO FRQ SHOYLPHWUtD \ SHOYLJUDItD GLJLWDO/DSHOYLJUDItDSRUUDGLRORJtDQRKDGHPRVWUDGRVHUHIHFWLYD\SXHGHVHUULHVJRVD SDUDHOIHWRHQXQIXWXURGHELGRDOHIHFWRDFXPXODWLYRGHODVUDGLDFLRQHV 7pFQLFDSDUDODSHOYLJUDItDGLJLWDO x *HVWDQWHFRQYHMLJDYDFtDDFRVWDGDHQSRVLFLyQREVWpWULFD x 6DFURELHQ DSR\DGR VREUHHOSODQR KRUL]RQWDO ODDQWHRUHWURYHUVLyQ IDOVHDORV UHVXOWDGRV x 7DFWRELGLJLWDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR x ,QWHQWDUWRFDUHOSURPRQWRULRGLItFLOGHDOFDQ]DUGXUDQWHHOHPEDUD]R 6LQRVHWRFDHOSURPRQWRULRVHFRQVLGHUDTXHHOGLiPHWURFRQMXJDGR GLDJRQDOHVQRUPDO 6LVHWRFDHOSURPRQWRULRPHGLUHOGLiPHWURSURPRQWRVXESXELDQRR FRQMXJDGR GLDJRQDO KDELWXDOPHQWH GH FP ¿JXUDV \ SDJ $ OD PHGLGD REWHQLGD VH UHVWD FP \ VH REWLHQH HO GLiPHWUR SURPRQWR SXELDQRPtQLPRRFRQMXJDGRREVWpWULFRRGLiPHWUR~WLOQRUPDOFP x 5HFRUUHUODVSDUHGHVSHOYLDQDV x 7DFWDUODVHVSLQDVFLiWLFDV 6RVSHFKDUHVWUHFKH]SpOYLFDFXDQGR 6HREVHUYDQDOWHUDFLRQHVHQODVLPHWUtDGHODSHOYLVODHVWiWLFDFRUSRUDOR ODPDUFKD (QODVQXOtSDUDVDWpUPLQRODSUHVHQWDFLyQVHPDQWLHQHDOWD 6HDOFDQ]DHOSURPRQWRULRFRQIDFLOLGDG 6HFRQ¿UPDHOGLDJQyVWLFRGHHVWUHFKH]SpOYLFDFXDQGR (OGLiPHWURFRQMXJDGRGLDJRQDOHVPHQRUGHFP\SRUORWDQWRHO FRQMXJDGRREVWpWULFRHVPHQRUGHFP 6HFRQVWDWDQREVWiFXORVTXHGLVPLQX\HQODOX]GHOFDQDORDOWHUDQVXWUiQVLWR &RQGXFWD $QWHVRVSHFKDGHHVWUHFKH]SpOYLFDSODQL¿FDUODUHIHUHQFLDRSRUWXQDSDUDODDWHQFLyQ GHOSDUWRGH$OWR5LHVJR6LH[LVWHFRQ¿UPDFLyQGHHVWUHFKH]SpOYLFDVHGHEHUiSODQL¿FDU HOPRPHQWR\OXJDUDSURSLDGRSDUDHIHFWXDUXQDFHViUHDHOHFWLYD *HVWDQWHFRQHPEDUD]RVHPDQDV 6L 1R 3DUWR YHJLQDODQWHULRUFRQ 51J $QW WUDXPDWLVPR IHWDORWUDXPDWLVPRSpOYLFR SRVWHULRUDO SDUWR 1R (IHFW~DSHOYLPHWUtD \SHOYLJUDItDGLJLWDO 1RUPDO $WHQFLyQGHOSDUWRVHJ~Q QRUPDGHEDMRULHVJR 1R $WHQFLyQGHOSDUWRHQ QLYHOGHDOWRULHVJR )LJXUD(VTXHPDHVFDORQDGRGHGHFLVLRQHVSDUDODYDORUDFLyQSpOYLFD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 5HIHUHQFLDVELEOLRJUi¿FDV Abalos E, Duley L, Steyn DW, Henderson-Smart DJ. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database of Systematic Reviews 2007, Issue 1. Ábalos E, Gulmezoglu AM, Carroli G. Assessing the scientific value of screening for antenatal infections. In: Newell ML, McIntyre J. Congenital and Perinatal Infections. Cambridge: Cambridge University Press, 2000. pp, 64-79. American Academy of Pediatrics. Committee on Substance Abuse and Committee on Children With Disabilities. Fetal alcohol syndrome and alcohol-related neurodevelopmental disorders. Pediatrics. 2000 Aug;106(2 Pt 1):358-61. ACOG educational bulletin. Smoking cessation during pregnancy. Number 260, September 2000. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 2001 Dec;75(3):345-348. Review. ACOG committee opinion. Number 316, October 2005. Smoking cessation during pregnancy. Obstet Gynecol. 2005 Oct;106(4):883-888. ACOG committee opinion. Number 316, October 2005. Smoking cessation during pregnancy. Obstet Gynecol. 2005 Oct;106(4):883-8. ACOG. Gestational diabetes. ACOG Practice Bulletin no. 30. American College of Obstetricians and Gynecologists. Obstet Gynecol September 2001;98:525-538. ACOG practice bulletin. Antepartum fetal surveillance. Number 9, October 1999 (replaces Technical Bulletin Number 188, January 1994). Clinical management guidelines for obstetrician-gynecologists. Int J Gynaecol Obstet. 2000 Feb;68(2):175-185. AIDS info 2006. Perinatal Guidelines. Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States - October 12, 2006. http://www.aidsinfo.nih.gov/ Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines&Search=Off&GuidelineID=9&ClassID=2 (Último acceso 3 de Mayo de 2007) American Diabetes Association: Gestational diabetes mellitus. Diabetes Care 23(Suppl. 1):S77–S79, 2000 American Diabetes Association. Gestational diabetes mellitus. Diabetes Care. 2002; 25 (Suppl 1):S94-96. Anotayanonth S, Subhedar NV, Neilson JP, Harigopal S. Betamimetics for inhibiting preterm labour. Cochrane Database of Systematic Reviews 2004, Issue 4. ASJOG 2004. Prevention and management of pretrm labor. http://www.asjog.org/Journal/Issue%203%20 Final/175%20tailored%20Guidelines.pdf(último acceso 10 de Julio 2007) Bada, H.S., et al. Gestational Cocaine Exposure and Intrauterine Growth: Maternal Lifestyle Study. Obstet Gynecol. 2002 Nov;100(5):916-924. Bassani DG, Olinto MTA, Kreiger N. Periodontal disease and perinatal outcomes: a case-control study. J Clin Periodontol. 2007;34(1):31-39 Berger H, Crane J, Farine D, Armson A, De la Ronde S, Keenan-Lindsay L, Reid G, Van Aerde J. Screening for gestational diabetes mellitus. J Obstet Gynaecol Can. 2002;24(11):894-912. Britton C, McCormick FM, Renfrew MJ, Wade A, King SE. Support for breastfeeding mothers. Cochrane Database of Systematic Reviews 2007, Issue 1. Boggess KA, Lieff S,Murtha AP, Moss K, Beck J, Offenbacher S.Maternal periodontal disease is associated with an increased risk for preeclampsia. Obstet Gynecol 2003;101:227–231. Boog G. Maternal determination of fetal movements. A sure and simple method of monitoring the pregnancy. Rev Fr Gynecol Obstet. 1988 Nov;83(11):693-695. Review. Bower P, Rowland N. Effectiveness and cost effectiveness of counselling in primary care. Cochrane Database of Systematic Reviews 2006, Issue 3. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR Brocklehurst P. Interventions for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database of Systematic Reviews 2002, Issue 1. Broening HW, Morford LL, Inman-Wood SL, Fukumura M, Vorhees CV. 3,4-methylenedioxymethamphetamine (ecstasy)-induced learning and memory impairments depend on the age of exposure during early development. J Neurosci. 2001 May 1;21(9):3228-3235. Calvo E, López LB. Anemias en la etapa perinatal y nutrición de la embarazada. En: Schwarcz R, Fescina R, Duverges C. Obstetricia. 6ª edición. Buenos Aires: El Ateneo, 2005. pp 392-396. Carlier Y, Torrico F. 2003. Congenital infection with Tripanosoma cruzi: from mechanisms of transmisión to strategies for diagnosis and control: conclusions of round tables and sinopsis o fan interntional colloquium. Cochabamba, Bolivia, 6-8 Novembre 2002. Revista da Sociedade Brasileira de medicina Tropical 36(6): 767-771 Carroli G, Ábalos E. Enfermedades del aparato urinario. En: Schwarcz R, Fescina R, Duverges C. Obstetricia. 6ª edición. Buenos Aires: El Ateneo, 2005. pp, 370-376. Carroli G, Rooney C, Villar J. How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of evidence. Pediatric Perinat Epidemiol. 2001;15 Suppl 1:1-42 CDC 2006. Achievements in public health: Reduction in perinatal transmission of HIV infection --- United States, 1985 - 2005. Morbidity and Mortality Weekly Report, volume 55, number 21, June 2, 2006, pages 592-597 CDC 2002. Alcohol use among women of childbearing age—United States, 1991-1999. Morbidity and Mortality Weekly Report, volume 51, number 13, April 5, 2002, pages 273-276. CDC 2006. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoide and acellular pertussis vaccines. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and Recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for Use of Tdap Among Health-Care Personnel. MMWR 2006;55(No. RR-17):1–33. CDC 2006. Sexually Transmitted Diseases Treatment Guidelines. MMWR Recommendations and reports August 4, 2006 / 55(RR11);1-94. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm (Último acceso 12 de Julio de 2007) CDC 2001. Revised Guidelines for HIV counseling, testing and referral and Revised recommendations for HIV Screening of Pregnant Women. MMWR 50(RR-19) CDC 2006. Intimate Partner Violence During Pregnancy: A guide for Clinicians. www.cdc.gov/nccdphp/drh/ violence/ipvdp.htm. Ultimo acceso 4 Jun 2006. CDC 2004. A Strategic Framework for Malaria Prevention and Control During Pregnancy in the African Region. http://www.cdc.gov/malaria/pdf/strategic_framework_mip_04.pdf (Último acceso 15 de Julio de 2007) Conférence de consensus. Grossesse et tabac, 7 et 8 octobre 2004, Lille (Grand Palais) Texte de recommandations. http://www.has-sante.fr/portail/upload/docs/application/pdf/Grossesse_tabac_long.pdf Último acceso 4 de Junio de 2007 Cram LF, Zapata M, Toy E, Baker B 3erd. Genitourinary infections and their association with preterm labor. Am Fam Physician. 2002;65(2):241-248. Crowther CA. Hospitalisation and bed rest for multiple pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 1. Crowther CA, Harding JE. Repeat doses of prenatal corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease. Cochrane Database of Systematic Reviews 2007, Issue 3. Crowther CA, Hiller JE, Doyle LW. Magnesium sulphate for preventing preterm birth in threatened preterm labour. Cochrane Database of Systematic Reviews 2007, Issue 2. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med. 2005;352(24):2477-2486. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD Crowther CA, Middleton P. Anti-D administration in pregnancy for preventing Rhesus alloimmunisation. Cochrane Database of Systematic Reviews 1999, Issue 2. Crowther CA, Thomas N, Middleton P, Chua M, Esposito M. Treating periodontal disease for preventing preterm birth in pregnant women. Cochrane Database of Systematic Reviews 2005, Issue 2. Cuervo LG, Mahomed K. Treatments for iron deficiency anaemia in pregnancy Cochrane Database of Systematic Reviews 2006, Issue 1. Dare MR, Middleton P, Crowther CA, Flenady VJ, Varatharaju B. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database of Systematic Reviews 2006, Issue 1. Demicheli V, Barale A, Rivetti A. Vaccines for women to prevent neonatal tetanus. Cochrane Database of Systematic Reviews 2005, Issue 4. De Veciana M, Major CA, Morgan MA, Asrat T, Toohey JS, Lien JM, Evans AT. Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy. N Engl J Med. 1995;333(19):1237-1241. Díaz AG, Schwarcz R, Fescina R, Duverges C. Control prenatal. Publ. Científica CLAP Nº 1071, 1986. Di Mario S, Basevi V, Gagliotti C, Spettoli D, Gori G, D’Amico R, Magrini N. Prenatal education for congenital toxoplasmosis. (Protocol) Cochrane Database of Systematic Reviews 2006, Issue 4. Dodd JM, Crowther CA. Specialised antenatal clinics for women with a multiple pregnancy to improve maternal and infant outcomes. Cochrane Database of Systematic Reviews 2007, Issue 2. Dodd JM, Crowther CA, Dare MR, Middleton P. Oral betamimetics for maintenance therapy after threatened preterm labour. Cochrane Database of Systematic Reviews 2006, Issue 1. Dodd JM, Flenady V, Cincotta R, Crowther CA. Prenatal administration of progesterone for preventing preterm birth. Cochrane Database of Systematic Reviews 2006, Issue 1. Doyle LW, Crowther CA, Middleton P, Marret S. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database of Systematic Reviews 2007, Issue 3. Drakeley AJ, Roberts D, Alfirevic Z. Cervical stitch (cerclage) for preventing pregnancy loss in women. Cochrane Database of Systematic Reviews 2003, Issue 1. Duckitt K, Thornton S. Nitric oxide donors for the treatment of preterm labour. Cochrane Database of Systematic Reviews 2002, Issue 3. Duley L, Henderson-Smart DJ. Magnesium sulphate versus phenytoin for eclampsia. Cochrane Database of Systematic Reviews 2003, Issue 4. Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 3. Duley L, Henderson-Smart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database of Systematic Reviews 2007, Issue 2. Duley L, Gülmezoglu AM, Henderson-Smart DJ. Magnesium sulphate and other anticonvulsants for women with pre-eclampsia. Cochrane Database of Systematic Reviews 2003, Issue 2. Dyson L, McCOrmick F, Renfrew MJ. Interventions for Promoting the initiation of breastfeeding. Cochrane Database of Systematic Reviews 2005. Ebrahim SH, Gfroerer J. Pregnancy-related substance use in the United States during 1996-1998. Obstet Gynecol. 2003 Feb;101(2):374-379. Enkin M, Keirse MJ, Neilson J, Crowther C, Duley L, Hodnett E, Hofmeyr GJ. Effective care in pregnancy and childbirth: a synopsis. Birth 2001 Mar;28(1):41-51. Frank DA, Jacobs RR, Beeghly M, Augustyn M, Bellinger D, Cabral H, Heeren T. Level of prenatal ocaine exposure and scores on the Bayley Scales of Infant Development: modifying effects of caregiver, early intervention, and birth weight. Pediatrics. 2002 Dec;110(6):1143-1152. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR Fescina RH, Quevedo C, Martell M, Nieto F, Schwarcz R. Uterine height as a method of predicting fetal growth. Bol Oficina Sanit Panam. 1984 May;96(5):377-386. Fescina RH, Martell M. Intrauterine and extrauterine growth of cranial perimeter in term and preterm infants. A longitudinal study. Am J Obstet Gynecol. 1983 Dec 15;147(8):928-932. Fescina RH. Weight increase during pregnancy. Method for its calculation when the normal weight is unknown. Bol Oficina Sanit Panam. 1983 Aug;95(2):156-162. Fescina RH, Ucieda FJ, Cordano MC, Nieto F, Tenzer SM, Lopez R. Ultrasonic patterns of intrauterine fetal growth in a Latin American country. Early Hum Dev. 1982 Jul;6(3):2392-48. Fescina RH, Ucieda FJ. Reliability of fetal anthropometry by ultrasound. J Perinat Med. 1980;8(2):93-99. Fescina RH, Lastra L, Sugo M, Parreño J, García A, Schwarcz R. Evaluación de diferentes métodos para estimar la edad gestacional. Obstet Ginecol Latinoam 1984;42:237-242. Fescina RH, Schwarcz R, Díaz AG. Vigilancia del crecimiento fetal. Manual de autoinstrucción. Montevideo, CLAP 1992; Publ. Cient. CLAP Nº 1261. Gagnon AJ, Sandall J. Individual or group antenatal education for childbirth or parenthood, or both. Cochrane Database of Systematic Reviews 2007, Issue 3. Gamble C, Ekwaru JP, ter Kuile FO. Insecticide-treated nets for preventing malaria in pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 2. Gantes M, Schy DS, Bartasius VM, Roberts J. The use of daily fetal movement records in a clinical setting. J Obstet Gynecol Neonatal Nurs. 1986 Sep-Oct;15(5):390-393. Garner P, Gülmezoglu AM. Drugs for preventing malaria in pregnant women. Cochrane Database of Systematic Reviews 2004, Issue 3. Garner P, Okun N, Keely E, Wells G, Perkins S, Sylvain J, Belcher J. A randomized controlled trial of strict glycemic control and tertiary level obstetric care versus routine obstetric care in the management of gestational diabetes: a pilot study. Am J Obstet Gynecol. 1997;177(1):190-195. Gaunekar NN, Crowther CA. Maintenance therapy with calcium channel blockers for preventing preterm birth after threatened preterm labour. Cochrane Database of Systematic Reviews 2006, Issue 4. Gibbs RS. The relationship between infections and adverse pregnancy outcomes: an overview. Ann Periodontol 2001;6:153–163. Gómez JE, Castaño JC, Montoya MT. 1995. Toxoplasmosis congénita en Colombia: un problema subestimado de salud pública. http://colombiamedica.univalle.edu.co/VOL26NO2/toxoplasmosis.html. Ultimo acceso 4 de Junio 2007 Grant A, Elbourne D, Valentin L, Alexander S. Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons. Lancet. 1989;2(8659):345-349. Grosse S, Boyle C, Kenneson A, Khoury M, Wilfond B (2005) From Public Health Emergency to Public Health Service: The Implications of Evolving Criteria for Newborn Screening Panels. http://www.cdc.gov/ genomics/activities/publications/newborn.htm Último acceso 23 de Octubre 2006. Gülmezoglu AM. Interventions for trichomoniasis in pregnancy. Cochrane Database of Systematic Reviews 2002, Issue 3. Haider BA, Bhutta ZA. Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 4. Hamza H, Berkowitz LB, Khattak F. Bacterial infections and pregnancy. eMedicine, last updated: October 28, 2004. Disponible en: http://www.emedicine.com/med/topic3269.htm (Última consulta 28 de Febrero de 2007) Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000 Oct 21;356(9239):1375-83. Hannah ME, Hannah WJ, Hodnett ED, Chalmers B, Kung R, Willan A, Amankwah K, Cheng M, Helewa M, Hewson S, Saigal S, Whyte H, Gafni A; Term Breech Trial 3-Month Follow-up Collaborative Group. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term: the international randomized Term Breech Trial. JAMA. 2002 Apr 10;287(14):1822-31. Harper RG, Greenberg M, Faharian G, et al. Fetal movement, biochemical and biophysical parameters, and the outcome of pregnancy. Am J Obstet Gynecol. 1981;141(1):39-42. Hill-Smith I. Professional and patient perspectives of NICE guidelines to abandon maternal monitoring of fetal movements. Br J Gen Pract. 2004 Nov;54(508):858-861. Review. Hodnett ED, Gates S, Hofmeyr G J, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2003, Issue 3. Hofmeyr GJ, Atallah AN, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database of Systematic Reviews 2006, Issue 3. Hofmeyr GJ. Corticoesteroides antes del parto prematuro: Comentario de la BSR (última revisión: 26 de Agosto de 2003). Biblioteca de Salud Reproductiva de la OMS, Nº 9, Update Software Ltd, Oxford, 2006. Huntington J, Connell FA. For every dollar spent—the cost-savings argument for prenatal care. N Engl J Med. 1994 Nov 10;331(19):1303-1307. ICSI 2005. Health Care Guideline : Routine Prenatal Care. Institute for Clinical Systems Improvement. Ninth Edition, August 2005. Último acceso 4 de Junio de 2007. http://www.icsi.org/prenatal_care_4/prenatal_care__routine__full_version__2.html Institute of Medicine 1996. Fetal alcohol syndrome: Diagnosis, epidemiology, prevention, and treatment. Washington, D.C., National Academy Press, 1996. Jamieson DJ, Theiler RN, Rasmussen SA. Emerg Infect Dis. 2006 Nov;12(11):1638-43. Review. Emerging infections and pregnancy. Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenerg RL, Hauth JC. Periodontal infection and preterm birth: results of a prospective study. J Am Dent Assoc 2001;132:875–880. Jeffcoat MK, Hauth JC, Geurs NC, Reddy MS, Cliver SP, Hodgkins PM, et al. Periodontal disease and preterm birth: results of a pilot intervention study. J Periodontol 2003;74:1214–1218. Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. Cochrane Database of Systematic Reviews 2003, Issue 4. Johns Hopkins University Press. .National Toxicology Program. Marijuana. Shepard’s Catalog of Teratogenic Agents. http://ntp.niehs.nih.gov/index.cfm?objectid=E87E5E94-BDB5-82F8-FDCBD97D0C1CE4BC. Last updated on 04/03/2006. Último acceso 2 de Julio de 2007 Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of membranes. Cochrane Database of Systematic Reviews 2003, Issue 2. Kesmodel, U., et al. Moderate alcohol intake during pregnancy and the risk of stillbirth and death in the first year of life. Am J Epidem. 2002 Feb;155(4):305-312. Kiningham RB. Asymptomatic bacteriuria in pregnancy. Am Fam Physician. 1993;47(5):1232-1238. King JF, Flenady VJ, Cole S, Thornton S. Cyclo-oxygenase (COX) inhibitors for treating preterm labour. Cochrane Database of Systematic Reviews 2005, Issue 2. King JF, Flenady VJ, Papatsonis DNM, Dekker GA, Carbonne B. Calcium channel blockers for inhibiting preterm labour. Cochrane Database of Systematic Reviews 2003, Issue 1. Kourtis AP, Lee FK, Abrams EJ, Jamieson DJ, Bulterys M. Mother-to-child transmission of HIV-1: timing and implications for prevention. Lancet Infect Dis. 2006 Nov;6(11):726-732. Review. Kravetz JD, Federman DG.Toxoplasmosis in pregnancy. Am J Med. 2005 Mar;118(3):212-6. Review. Kuzuya T. Early diagnosis, early treatment and the new diagnostic criteria of diabetes mellitus. Br J Nutr. 2000 Dec;84 Suppl 2:S177-181. Kuzuya T, Nakazawa S, Satoh J, et al. Report of the Committee on the classification and diagnostic criteria of diabetes mellitus. Diabetes Res Clin Pract. 2002 Jan;55(1):65-85. Liabsuetrakul T, Choobun T, Peeyananjarassri K, Islam QM. Prophylactic use of ergot alkaloids in the third &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR stage of labour. Cochrane Database of Systematic Reviews 2007, Issue 2 Liljestrand J. Políticas de episiotomía en partos vaginales: Comentario de la BSR (última revisión: 20 de Octubre de 2003). Biblioteca de Salud Reproductiva de la OMS, Nº 9, Update Software Ltd, Oxford, 2006 Lopez NJ, Smith PC, Gutierrez J. Higher risk of preterm birth and low birth weight in women with periodontal disease. J Dent Res 2002;81: 58–63. Lopez NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: a randomized controlled trial. J Periodontol 2002;73:911–924. Lumley J, Oliver SS, Chamberlain C, Oakley L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews 2004, Issue 4. .Magee LA, Duley L. Oral beta-blockers for mild to moderate hypertension during pregnancy. Cochrane Database of Systematic Reviews 2003, Issue 3 Mahomed K. Iron and folate supplementation in pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 1. Mahomed K. Iron supplementation in pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 1. Mangesi L, Hofmeyr GJ. Fetal movement counting for assessment of fetal wellbeing. Cochrane Database of Systematic Reviews 2007, Issue 1. McDonald HM, Brocklehurst P, Gordon A. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database of Systematic Reviews 2007, Issue 1. McDonald S, Abbott JM, Higgins SP. Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour. Cochrane Database of Systematic Reviews 2004, Issue 1 McDonald HM, Brocklehurst P, Gordon A. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database of Systematic Reviews 2007, Issue 1. Meher S, Abalos E, Carroli G. Bed rest or without hospitalization for hypertension during pregnancy. Cochrane Database of Systematic Reviews 2007, Issue 2. Meher S, Duley L. Rest during pregnancy for preventing pre-eclampsia and its complications in women with normal blood pressure. Cochrane Database of Systematic Reviews 2006, Issue 2. Montoya JG, Liesenfeld O.Toxoplasmosis. Lancet. 2004 Jun 12;363(9425):1965-76. Review. Michalowicz BS, Hodges JS, DiAngelis AJ, Lupo VR, Novak MJ, Ferguson JE, Buchanan W, Bofill J, Papapanou PN, Mitchell DA, Matseoane S, Tschida PA; OPT Study. Treatment of periodontal disease and the risk of preterm birth. N Engl J Med. 2006 Nov 2;355(18):1885-94. Moore S, Randhawa M, Ide M. A case-control study to investigate an association between adverse pregnancy outcome and periodontal disease. J Clin Periodontol 2005;32:1–5. Moore S, Ide M, Coward PY, RandhawaM, Borkowska E, Baylis R, et al. A prospective study to investigate the relationship between periodontal disease and adverse pregnancy outcome. Br Dent J 2004;197:251– 258; discussion 247. National Institute on Alcohol Abuse and Alcoholism 2000. Fetal alcohol exposure and the brain. Alcohol Alert, number 50, December 2000. Neilson JP. Symphysis-fundal height measurement in pregnancy. Cochrane Database of Systematic Reviews 1998, Issue 1. NICE 2003. Antenatal care Routine care for the healthy pregnant woman. Clinical Guideline 6. National Institute for Clinical Excellence, October 2003. http://guidance.nice.org.uk/CG6/niceguidance/pdf/English/ download.dspx Último acceso 4 de Junio de 2007. NIDA Research Report - Heroin Abuse and Addiction: NIH Publication No. 05-4165, Printed October 1997, Reprinted September, 2000, Revised May 2005. http://www.nida.nih.gov/ResearchReports/Heroin/Heroin. html Último acceso 2 de Julio de 2007. Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996;67(10 Suppl):1103–1113. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD Offenbacher S, Boggess KA, Murtha AP,et al. Progressive periodontal disease and risk of very preterm delivery. Obstet Gynecol. 2006;107(1):29-36. Offenbacher S, Beck J. Has Periodontal Treatment Failed to Reduce Adverse Pregnancy Outcomes? The Answer May Be Premature. J Periodontol. 2007;78(2):195-197 OPS 2005. Boletín de Inmunización. Organización Panamericana de la Salud Volúmen XXVIII, Número 4 Agosto de 2006 http://www.ops-oms.org/spanish/ad/fch/im/sns2804.pdf Último acceso 4 de Junio de 2007. OPS 2004. Consulta sobre Enfermedad de Chagas Congénito, su epidemiología y manejo (OPS/DPC/ CD/301/04). Unidad de Enfermedades Transmisibles Área de Prevención y Control de Enfermedades (OPS/AD/DPC/CD) y CLAP OPS 2005. Eliminación del tétanos neonatal: guía práctica. Washington, D.C.: OPS, © 2005. (Publicación Científica y Técnica No. 602). http://www.paho.org/spanish/ad/fch/im/GuiaPractica_TetanosNeonatal.pdf (Último acceso 4 de Agosto de 2007). OPS 2003. Grupo Étnico y Salud. 37 sesión del subcomité de planificación y programación del comité ejecutivo (SPP37/10). OMS 2005. Infecciones de transmisión sexual y otras infecciones del tracto reproductivo. Una guía para la práctica básica. Departamento de Salud Reproductiva e Investigación. OPS 2006. Inmunización en las Américas. Resumen 2006 http://www.ops-oms.org/Spanish/AD/FCH/IM/ IMBrochure_2006.pdf Último acceso 2 de Junio de 2007. OPS 2004. Informe final (Conclusiones y recomendaciones). La cultura de la prevención: un modelo de control para las enfermedades prevenibles por vacunación. XVI Reunión del grupo técnico asesor de la OPS sobre enfermedades prevenibles por vacunación. Washington, D.C.: OPS; 2004. OPS 2005. Plan Regional de VIH/ITS para el sector salud 2006-2015. Unidad de VIH/Sida. Ostlund I, Hanson U. Repeated random blood glucose measurements as universal screening test for gestational diabetes mellitus. Acta Obstet Gynecol Scand. 2004 Jan;83(1):46-51. Orton L, Garner P. Drugs for treating uncomplicated malaria in pregnant women. Cochrane Database of Systematic Reviews 2005, Issue 3. Pacqué M. Como prevenir y tratar la malaria durante el embarazo. INFO Project Johns Hopkins Bloomberg School of Public Health. 2005. http://www.maqweb.org/techbriefs/stb18malpreg.pdf (Último acceso 22 de Junio de 2007) Papatsonis D, Flenady V, Cole S, Liley H. Oxytocin receptor antagonists for inhibiting preterm labour. Cochrane Database of Systematic Reviews 2005, Issue 3. Pattinson RC, Farrell E. Pelvimetry for fetal cephalic presentations at or near term (Cochrane Review). Cochrane Database of Systematic Reviews 2006, Issue 1. Pena-Rosas JP, Viteri FE. Effects of routine oral iron supplementation with or without folic acid for women during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 3. Penzo SM. Diagnóstico de vitalidad fetal. En: Schwarcz R, Fescina R, Duverges C. Obstetricia. 6ª edición. Buenos Aires: El Ateneo, 2005. pp 121-142. Peyron F, Wallon M, Liou C, Garner P. Treatments for toxoplasmosis in pregnancy. Cochrane Database of Systematic Reviews 1999, Issue 3. Preboth M. ACOG guidelines on antepartum fetal surveillance. American College of Obstetricians and Gynecologists. Am Fam Physician. 2000;62(5):1184, 1187-1188. Puolakka J, Janne O, Pakarinen A. Serum ferritin as a measure of iron stores during and after normal pregnancy with of without iron supplements. Acta Obstet Gynecol Scand Suppl 1980;95:43-51 Reveiz L, Gyte GML, Cuervo LG. Treatments for iron-deficiency anaemia in pregnancy. Cochrane Database of Systematic Reviews 2007, Issue 2. Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systematic Reviews 2006, Issue 3. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR Rizzi RG. Diabetes y embarazo. En: Schwarcz R, Fescina R, Duverges C. Obstetricia. 6ª edición. Buenos Aires: El Ateneo, 2005. pp 358-367. Scannapieco FA, Bush RB, Paju S. Periodontal disease as a risk factor for adverse pregnancy outcomes. Annals of Periodontology 2003;8(1):70-8. Scott DA, Loveman E, McIntyre L, Waugh N. Screening for gestational diabetes: a systematic review and economic evaluation. Health Technology Assessment 2002; Vol. 6: No. 11 Schkolink S, Del Popolo F. Los censos y los pueblos indígenas en América Latina: Una mitología Regional. Seminario Internacional Pueblos indígenas y afro-descendientes de América Latina y el Caribe: relevancia y pertinencia de la información sociodemográfica para políticas y programas. CEPAL, Santiago de Chile, 27 al 29 de Abril de 2005 Schrag S, Gorwitz R, Fultz-Butts K, Schuchat , A. Prevention of Perinatal Group B Streptococcal Disease. (Revised Guidelines from CDC). Division of Bacterial and Mycotic Diseases National Center for Infectious Diseases August 16, 2002 / 51(RR11);1-22 Schwarcz R, Gonzalo Diaz A, Fescina RH, Diaz Rossello JL, Martell M, Tenzer SM. Historia Clínica Perinatal Simplificada. Propuesta de um modelo para la atención primaria de baja complejidad. Bol Oficina Sanit Panam. 1983 Aug;95(2):163-172. Schwarcz R. Norms of perinatal care: proposal of a program of standard information for the management of perinatal prematurity. Bol Oficina Sanit Panam. 1979 Oct;87(4):361-365. Scwarcz R, Uranga A, Lomuto C, Martínez I, Galimberti D, García O, Etcheverry ME, Queiruga M. El cuidado prenatal. Guía para la práctica del cuidado preconcepcional y del control prenatal. http://www.msal.gov.ar/ htm/site/promin/UCMISALUD/CONTROLPERINATAL.PDF (Último acceso 14 de Junio de 2007). Schwarcz R, Gonzalo Diaz A, Fescina RH. The Perinatal Information System I: The Simplified Perinatal Clinical Record. J Perinat Med 1987;15 (Suppl. 1):9. Schwarcz R, Fescina RH, Duverges C. Obstetricia. 6ª ed. Buenos Aires: El Ateneo, 2005. Signorell LM, Seitz D, Merkel S, Berger R, Rudin C. Cord blood screening for congenital toxoplasmosis in northwestern Switzerland, 1982-1999. Pediatr Infect Dis J. 2006 Feb;25(2):123-8. Simini F, Díaz AG, López R, Schwarcz R. The Perinatal Information System: development of a software package for perinatal care analysis. J Perinat Med 1987; 15 (Suppl. 1):131. Smaill F. Intrapartum antibiotics for Group B streptococcal colonisation. Cochrane Database of Systematic Reviews 1996, Issue 1. Smaill F, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database of Systematic Reviews 2007, Issue 2. Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour. Cochrane Database of Systematic Reviews 2006, Issue 4. Smith N, Packel L, Kevany S, Doolan K, Horvath T, Grossman-Kahn R, Kennedy GE. Routine vs. voluntary HIV testing for increasing HIV testing rates. (Protocol) Cochrane Database of Systematic Reviews 2007, Issue 3. Sosa C, Althabe F, Belizán J, Bergel E. Bed rest in singleton pregnancies for preventing preterm birth. Cochrane Database of Systematic Reviews 2004, Issue 1. Stan C, Boulvain M, Hirsbrunner-Amagbaly P, Pfister R. Hydratation for treatment of preterm labour. Cochrane Database of Systematic Reviews 2002, Issue 2. Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database of Systematic Reviews 2005, Issue 2. Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database of Systematic Reviews 2006, Issue 3. Stephenson MJ. Screening for gestational J Fam Pract. 1993;37(3):277-83. Review. diabetes mellitus: a critical review. Teppa RJ, Roberts JM. The uriscreen test to detect significant asymptomatic bacteriuria during pregnancy. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD J Soc Gynecol Investig. 2005;12(1):50-53. The Internacional Nutricional Anemia Consultative Group (INACG). 2004. Report of the 2004 Symposium: Iron deficiency in early life: Challenges and progress. Lima-Perú. Rush D.2000. Nutrition and Maternal mortality in ten developing countries. Am J Clin Nutr 72(suppl): 212S-240S Thiébaut R, Leroy V, Alioum A, Binquet C, Poizat G, Salmi LR, Gras L, Salamon R, Gilbert R, Chêne G.Biases in observational studies of the effect of prenatal treatment for congenital toxoplasmosis. Eur J Obstet Gynecol Reprod Biol. 2006 Jan 1;124(1):3-9. Epub 2005 Sep 2. Review. Tuffnell DJ, West J, Walkinshaw SA. Treatments for gestational diabetes and impaired glucose tolerance in pregnancy. Cochrane Database of Systematic Reviews 2003, Issue 3 Uncu Y, Uncu G, Esmer A, Bilgel N. Should asymptomatic bacteriuria be screened in pregnancy? Clin Exp Obstet Gynecol. 2002;29(4):281-285. UNICEF. El Paludismo. http://www.unicef.org/spanish/health/index_malaria.html (Último acceso 12 de Junio de 2007) U.S. Department of Health and Human Services 2004. The Health Consequences of Smoking: A Report of the Surgeon General—2004. Centers for Disease Control and Prevention, Office on Smoking and Health, Atlanta Georgia, May 2004. U.S. Preventive Services Task Force. Screening for bacterial vaginosis in pregnancy: recommendations and rationale.Am J Prev Med. 2001 Apr;20(3 Suppl):59-61. U.S. Preventive Services Task Force. Screening for gestational diabetes mellitus: recommendations and rationale. Obstet Gynecol. 2003;101(2):393-5. U.S. Preventive Services Task Force. Screening for Rh (D) Incompatibility: Recommendation Statement. February 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/ clinic/3rduspstf/rh/rhrs.htm (Último acceso 24 de Julio de 2007) Vazquez JC, Villar J. Treatments for symptomatic urinary tract infections during pregnancy. Cochrane Database of Systematic Reviews 2003, Issue 4. 9LJLO'H*UDFLD3/DVVR05XL](HWDO6HYHUHK\SHUWHQVLRQLQSUHJQDQF\K\GUDOD]LQHRUODEHWRORO$ UDQGRPL]HGFOLQLFDOWULDO(XU-2EVWHW*\QHFRO5HSURG%LRO Villar J, Ba’aqeel H, Piaggio G, Lumbiganon P, Miguel Belizán J, Farnot U, Al-Mazrou Y, Carroli G, Pinol A, Donner A, Langer A, Nigenda G, Mugford M, Fox-Rushby J, Hutton G, Bergsjø P, Bakketeig L, Berendes H, Garcia J; WHO Antenatal Care Trial Research Group.WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet. 2001 May 19;357(9268):1551-1564. Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gülmezoglu M. Patterns of routine antenatal care for lowrisk pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 4. Villar J, Widmer M, Lydon-Rochelle MT, Gülmezoglu AM, Roganti A. Duration of treatment for asymptomatic bacteriuria during pregnancy. Cochrane Database of Systematic Reviews 2000, Issue 2. Volmink J, Siegfried NL, van der Merwe L, Brocklehurst P. Antiretrovirals for reducing the risk of mother-tochild transmission of HIV infection. Cochrane Database of Systematic Reviews 2007, Issue 1. Walker GJA. Antibiotics for syphilis diagnosed during pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 3. WHO 1993. Breastfeeding Counseling: A training course. WHO/CDR/93.4 UNICEF/NUT/93.2 WHO 2006. Comprehensive cervical cancer control: A guide to essential practice. Organización Mundial de la Salud. RHR Salud reproductiva e investigaciones conexas, 2006. http://www.who.int/reproductivehealth/publications/cervical_cancer_gep/index.htm (Último acceso 20 de Julio de 2007) WHO 1999. Consultation report: Definition, diagnosis and classification of diabetes mellitus and its complications. Part I: Geneva, WHO/NCD/NCS/99.2, World Health Org., 1999. WHO 2001. Dept. of Nutrition for Health and Development. Iron deficiency anaemia: assessment, prevention and control: a guide for programme managers. [Internet]. Geneva: 2001. Disponible en: http:// &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR whqlibdoc.who.int/hq/2001/WHO NHD 01.3.pdf Ultima consulta 28 Abril de 2007 WHO 2003. Ensayo clínico aleatorizado de control prenatal de la OMS: Manual para la puesta en práctica del nuevo modelo de control prenatal. WHO/RHR/01.30. Organización Mundial de la Salud, Ginebra, 2003. WHO 1999. Field manual for neonatal tetanus elimination. Geneva: WHO; 1999. (Document WHO/ V&B/99.14.) WHO 2003. HIV and Infant feeding: framework for priority action. World Health Organization WHO 2005. Infecciones de transmisión sexual y otras infecciones del tracto reproductivo: una guía para la práctica básica. Organización Mundial de la Salud. RHR Salud reproductiva e investigaciones conexas, 2005. http://www.who.int/reproductive-health/publications/es/stis_gep/index.htm (Último acceso 20 de Julio de 2007) WHO/UNICEF 2001. Joint integral workshop on maternal and neonatal tetanus elimination. Geneva: WHO; 2001. WHO 2002. Manejo de las complicaciones del embarazo y el parto: Guía par obstetrices y médicos. Organización Mundial de la Salud. RHR Salud reproductiva e investigaciones conexas, 2002. http://www. who.int/reproductive-health/publications/mcpc/index_sp.html (Último acceso 20 de Junio de 2007) WHO 2006.Pregnancy, Childbirth Postpartum and Newborne Care: A guide for essential practice. 2nd ed. http://www.who.int/making_pregnancy_safer/publications/PCPNC_2006_03b.pdf (Último acceso 4 de Julio de 2007). WHO 2005. Report of a WHO Technical Consultation on Birth Spacing Geneva, Switzerland 13–15 June 2005 Department of Making Pregnancy Safer (MPS) Department of Reproductive Health and Research (RHR). WHO 2006. Standards for Maternal and Neonatal Care. Department of Making Pregnancy Safer. 2006. http://www.who.int/making_pregnancy_safer/publications/standards/en/index.html (Último acceso 4 de Julio de 2007). WHO 1996. The “high-risk” approach: the WHO-recommended strategy to accelerate elimination of neonatal tetanus. Wlky Epidemiol Rec 1996;71:33–36. WHO 2002. WHO antenatal Care Randomized Trial: Manual for the Implementation of the new model. http://www.who.int/reproductive-health/publications/RHR_01_30/index.html (Último acceso 20 de Junio de 2007) Xiong X, Buekens P, Fraser WD, Beck J, Offenbacher S. Periodontal disease and adverse pregnancy outcomes: a systematic review. BJOG. 2006 Feb;113(2):135-143. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD ,9 & $ 3, 7 8 /2 , 9 $WHQFLyQGHO3DUWRGH%DMR5LHVJR 2EMHWLYRVJHQHUDOHV %ULQGDUDVLVWHQFLDGHFDOLGDGEDVDGDHQHYLGHQFLDVGXUDQWH x(OLQJUHVR x(OSHUtRGRGHGLODWDFLyQSULPHUSHUtRGR x(OSHUtRGRGHH[SXOVLyQVHJXQGRSHUtRGR x/RVSHUtRGRVGHDOXPEUDPLHQWR\SRVWDOXPEDUDPLHQWRWHUFHUSHUtRGR $6,67(1&,$'85$17((/,1*5(62 2EMHWLYR 'LDJQRVWLFDUHOWUDEDMRGHSDUWRHLGHQWL¿FDUHOJUDGRGHULHVJR $FWLYLGDG &RQVXOWDHQUHFHSFLyQ /DJHVWDQWHFRQVXOWDSRUORTXHVRQRFUHHTXHVRQVtQWRPDVGHWUDEDMRGHSDUWR x3HUFHSFLyQGHFRQWUDFFLRQHVXWHULQDVGRORURVDV x3pUGLGDGHPXFRVLGDGOtTXLGRRVDQJUHDWUDYpVGHORVJHQLWDOHV (VLPSRVLEOHGHWHUPLQDUHOPRPHQWRH[DFWRGHOFRPLHQ]RGHOWUDEDMRGHSDUWRSXHVWR TXH OD WHUPLQDFLyQ GHO HPEDUD]R HV XQD VHFXHQFLD LQVHQVLEOH GH IHQyPHQRV FX\D FDXVDOLGDGQRHVWiSOHQDPHQWHHVWDEOHFLGD3RUHVWHPRWLYRVHHVWDEOHFHDUELWUDULDPHQWH TXHHOWUDEDMRGHSDUWRVHKDLQLFLDGRFXDQGR x+D\FRQWUDFFLRQHVXWHULQDVSHULyGLFDV\UHJXODUHVSHUFLELGDVSRUODPDGUHRSRU XQREVHUYDGRUSRUORPHQRVGXUDQWHGRVKRUDV x/DVFRQWUDFFLRQHVWLHQHQXQDIUHFXHQFLDGHRPiVFDGDPLQXWRV x(OFXHOORXWHULQRHVWiDOPHQRVSDUFLDOPHQWHERUUDGR x/DGLODWDFLyQHVPD\RUDFPHQODVQXOtSDUDVRVHHQFXHQWUDHQSURJUHVRHQ ODVPXOWtSDUDV (OWUDEDMRGHSDUWRVHGLYLGHVHJ~QODGLODWDFLyQ\HOGHVFHQVRGHODSUHVHQWDFLyQHQ WUHVHWDSDV x3HUtRGRGHGLODWDFLyQRSULPHUSHUtRGR x3HUtRGRGHH[SXOVLyQRVHJXQGRSHUtRGR x3HUtRGRSODFHQWDULRDOXPEUDPLHQWRRWHUFHUSHUtRGR (OSHUtRGRGHGLODWDFLyQHVWiSUHFHGLGRGHXQDIDVHGHGXUDFLyQYDULDEOHTXHUHFLEH GLVWLQWRVQRPEUHVSUHSDUWRSUyGURPRVGHOSDUWRHWF/DJHVWDQWHSXHGHFRQVXOWDUHQ FXDOTXLHUPRPHQWR\GHEHVHUDGHFXDGDPHQWHHYDOXDGDSDUDHVWDEOHFHUHOJUDGRGH ULHVJRDOPRPHQWRGHODFRQVXOWD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR ,QWHUSUHWDFLyQGHO&DUQp3HULQDWDO ,QWHUURJDWRULR\([DPHQ&OtQLFRREVWpWULFR 6L )DFWRUHV GH5LHVJR 5HIHUHQFLD D&RQVXOWD $OWR5LHVJR 6L 7UDEDMR GH3DUWR 1R 6L 1R $GPLVLyQGLIHULGD 6HJXLPLHQWR DPEXODWRULR )DFWRUHV GH5LHVJR 5HIHUHQFLDDO 1LYHOGH$WHQFLyQ GH$OWR5LHVJR 1R $GPLVLyQSDUD $WHQFLyQ GHO3DUWR )LJXUD(VTXHPDHVFDORQDGRGHGHFLVLRQHVHQODUHFHSFLyQGHXQDHPEDUD]DGD &20321(17(6'(/$&2168/7$(15(&(3&,Ï1 x,QWHUURJDWRULR x,QWHUSUHWDFLyQGHO&DUQpSHULQDWDO x([DPHQFOtQLFRJHQHUDO x([DPHQREVWpWULFR ,QWHUURJDWRULR (VWiGHVWLQDGRDLGHQWL¿FDUODVUD]RQHVTXHPRWLYDURQODFRQVXOWD\DHYDOXDUHOJUDGR GHULHVJRGHODJHVWDQWH(VHOFRPSOHPHQWRGHODOHFWXUDGHOFDUQpSHULQDWDO 3HUPLWHHYDOXDUVtQWRPDVGHOSDUWRDQWHFHGHQWHVGDWRVRPLWLGRVHQHOFRQWURORQXHYRV DFRQWHFLPLHQWRVTXHDSDUHFLHURQGHVGHHO~OWLPRFRQWURO 6LODJHVWDQWHQRKDFRQWURODGRVXHPEDUD]RRDFXGHVLQHOFDUQpSHULQDWDOVHGHEHUi LQWHUURJDUVLJXLHQGR³ODUXWD´TXHVXJLHUHOD+LVWRULD&OtQLFD3HULQDWDO ,GHQWL¿FDFLyQ /DPD\RUtDGHORVIDFWRUHVGHULHVJRVRFLRHFRQyPLFRV\HGXFDFLRQDOHVQRGHWHUPLQDQ FDPELRV HQ OD FRQGXFWD IUHQWH DO SDUWR VL HO HPEDUD]R OOHJD D WpUPLQR FRQ XQ IHWR \ XQDPDGUHVDQRV(QHVWDHWDSDHVWRVIDFWRUHVVRQGHLPSRUWDQFLDSDUDFRQWURODUORV ULHVJRVSRVQDWDOHVDORVTXHSXHGHQDVRFLDUVH $QWHFHGHQWHVIDPLOLDUHVSHUVRQDOHV\REVWpWULFRV &LHUWDVFRQGLFLRQHVSDWROyJLFDVVHDVRFLDQFRQPD\RUULHVJRPDWHUQRIHWDO\RQHRQDWDO GXUDQWHHOSDUWR6XH[LVWHQFLDDOPRPHQWRGHOLQLFLRGHOWUDEDMRGHSDUWRGHWHUPLQDTXH VHDFODVL¿FDGRGHDOWRULHVJR $QWHFHGHQWHVGHRWURVUHFLpQQDFLGRVGH%31 (GDGGHR!GHDxRV 3HUtRGRLQWHUJHVWDFLRQDOPHQRUDXQDxR %DMRSHVRPDWHUQRSUHJHVWDFLRQDOHLQVX¿FLHQWH JDQDQFLDGHSHVR +iELWRGHIXPDU &RQVXPRGHDOFRKRO\RWUDVGURJDVSURKLELGDV (PEDUD]RP~OWLSOH +LSHUWHQVLyQ\SUHHFODPSVLD &DUGLRSDWtD (QIHUPHGDGHQGyFULQRPHWDEyOLFD ,QIHFFLyQXULQDULD\RWUDVLQIHFFLRQHV 9,+6LGD &RQGLORPDWRVLVYXOYRYDJLQDOSRU+39 +HUSHVYXOYRYDJLQDO +HPRUUDJLDVGHOHPEDUD]R $QHPLDFUyQLFD &RQWUROSUHQDWDODXVHQWHRLQDGHFXDGR &RORQL]DFLyQUHFWRYDJLQDOSRU(*% &LUXJtDXWHULQD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (QHOVLJXLHQWHFXDGURVHDQDOL]DQSUREDEOHVULHVJRVSURYRFDGRVSRUDOJXQDVGHHVWDV FRQGLFLRQHV\ODVIUHFXHQFLDVFRQTXHHVWDVSDWRORJtDVVXHOHQSUHVHQWDUVHGXUDQWHHO HPEDUD]R &XDGUR5LHVJRGHOSDUWRDVRFLDGRDSDWRORJtDPDWHUQD Diabetes Hipertensión Crónica Cirugía Uterina Cardiopatía 0.3% - 1% Riesgo materno en el parto 0.3% - 2% DPPNI (4%) de las Traumatismo hipertensas. obstétrico Accidente vascular Descompensación encefálico. Pre-eclampsia metabólica sobreagregada Malformaciones RCI Riesgo Macrosomía Sufrimiento fetal agudo fetoneonatal Infección neonatal Prematurez Hipoglicemia 2% - 30% 1%-2% Insuficiencia cardíaca. Rotura uterina. Edema agudo Mayor frecuencia pulmonar. Enfermedad de intervenciotromboembólica. nes obstétricas Endocarditis bacteriana Derivado del riesgo materno. Traumatismo obstétrico RCI Prematurez Sufrimiento fetal agudo Depresión neonatal ([DPHQFOtQLFRJHQHUDO 3HUPLWHHYDOXDUHOHVWDGRJHQHUDOGHODHPEDUD]DGDItVLFR\SVtTXLFRVXVIXQFLRQHV YLWDOHV\GHVFDUWDUSDWRORJtDTXHLQFUHPHQWHHOULHVJR (O H[DPHQ FOtQLFR UHTXLHUH VHU HIHFWXDGR SRU SHUVRQDO FDSDFLWDGR SDUD HYDOXDU DSURSLDGDPHQWHORVSULQFLSDOHVVLJQRVGHSDWRORJtDVGHULHVJRWDOHVFRPR x6tQGURPHKLSHUWHQVLYR x,QIHFFLyQVHYHUD x$QHPLDJUDYH x&DUGLRSDWtDHWF 3DUDHYDOXDUORVVHGHEHH[SORUDUORVVLJXLHQWHVDVSHFWRVTXHDGHPiVSXHGHQRULHQWDU KDFLDRWUDVSRVLEOHVSDWRORJtDV 3LHO\PXFRVDV /DSLHO\ODVPXFRVDVGHEHQWHQHUXQDFRORUDFLyQWHPSHUDWXUD\KXPHGDGQRUPDOHV (QRFDVLRQHVVHYHUiQVLJQRVRULHQWDGRUHVGHGLYHUVDVVLWXDFLRQHVSDWROyJLFDVORVTXH VHHVTXHPDWL]DQDFRQWLQXDFLyQ &XDGUR$OWHUDFLRQHVGHSLHO\PXFRVDV\VXUHODFLyQFRQ FLHUWRVHVWDGRVSDWROyJLFRV 6LJQR 3DOLGH] &LDQRVLV ,FWHULFLD 0XFRVDVVHFDV (GHPD /HVLRQHVGpUPLFDV 7UDVWRUQRVTXHVXJLHUH $QHPLD±6KRFN 7UDVWRUQRVFDUGLRYDVFXODUHVRUHVSLUDWRULRV±6KRFN &ROHVWDVLV+HSDWLWLV&ROHFLVWRSDWtDV 'HVKLGUDWDFLyQ±DEGRPHQDJXGR±GLDEHWHVGHVFRPSHQVDGD 3UHHFODPSVLD,QVX¿FLHQFLDFDUGtDFD±WUDVWRUQRVUHQDOHV +HUSHVJHQLWDO±3DSLORPDYLUDOKXPDQR6t¿OLV6FDELRVLV 3UHVLyQDUWHULDO /RVVtQGURPHVKLSHUWHQVLYRVGHWHFWDGRVDOLQLFLRGHOSDUWRGHWpUPLQRFRUUHVSRQGHQD KLSHUWHQVLyQDUWHULDOFUyQLFD\RLQGXFLGDSRUHOHPEDUD]RSUHHFODPSVLDHFODPSVLD6RQ SRWHQFLDOPHQWHSHOLJURVRVSDUDODPDGUH\HOIHWRIUHFXHQWHPHQWHSDVDQLQDGYHUWLGRV SDUDHOODSHURVXJUDYHGDGVHDVRFLDDVtQWRPDVGHLUULWDELOLGDGGHOVLVWHPDQHUYLRVR FHQWUDO61&FRPSURPLVRUHQDO\RKHSiWLFR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (QSUHVHQFLDGHKLSHUWHQVLyQGHEHLQWHUURJDUVHVREUH &HIDOHD 0DUHRVRYpUWLJRV 3pUGLGDGHFRQFLHQFLD &RQYXOVLRQHV 7UDVWRUQRVYLVXDOHVHVFRWRPDVDPDXURVLV 7UDVWRUQRVDXGLWLYRV 2OLJXULDRDQXULD 'RORUDEGRPLQDOSDUWLFXODUPHQWHHOGRORUHQEDUUD $GHPiVGHEHQH[DPLQDUVHHVSHFLDOPHQWH 5HÀHMRVRVWHRWHQGLQRVRVSDWHODU 3DOSDFLyQDEGRPLQDOHOGRORUHQKLSRFRQGULRGHUHFKRRODKHSDWRPHJDOLDVRQ VLJQRVGHJUDYHGDG /DSUHVHQFLDGHFXDOTXLHUDGHHVWRVVLJQRVRVtQWRPDVLQGLFDJUDYHGDGGHOVtQGURPH KLSHUWHQVLYR /D KLSRWHQVLyQ DO ¿QDO GHO HPEDUD]R HV PHQRV FRP~Q (Q RFDVLRQHV SXHGH VHU OD PDQLIHVWDFLyQ GH XQ VKRFN (O VKRFN HQ REVWHWULFLD HV KDELWXDOPHQWH VHFXQGDULR D KHPRUUDJLD FRQ PXFKR PHQRU IUHFXHQFLD HV GHELGR D VHSVLV HPEROLD GH OtTXLGR DPQLyWLFRGHSOHFLyQVDOLQDXRWUDFRQGLFLyQPpGLFDJUDYHFDUGLRSDWtDGLDEHWHV(Q FDVRGHKLSRWHQVLyQGHEHEXVFDUVH +HPRUUDJLDJHQLWDO 3XOVRGHHOHYDGDIUHFXHQFLDGHELO\R¿QR +LSHUWRQtDXWHULQD 3LHOIUtD\VXGRURVD 3DOLGH]\RFLDQRVLV 3ROLSQHD 2OLJXULD /D SUHVHQFLD GH FXDOTXLHUD GH HVWRV VtQWRPDV GHEH DOHUWDU VREUH OD SRVLELOLGDG GH LQVWDODFLyQGHXQVKRFN /DWpFQLFDGHPHGLGDHLQWHUSUHWDFLyQGHORVYDORUHVGHSUHVLyQDUWHULDOVHSUHVHQWDHQ VHFFLyQSUHQDWDO /D+7$OHYHSXHGHWUDQVIRUPDUVHHQVHYHUDHQFXDOTXLHULQVWDQWHHVUHFRPHQGDEOHUHIHULU DDOWRULHVJRDWRGDVODVSDFLHQWHVFRQVtQGURPHVKLSHUWHQVLYRVLQGHSHQGLHQWHPHQWH GHVXVHYHULGDG 3XOVR /DIUHFXHQFLDQRUPDOGHOSXOVRHQHOHPEDUD]RGHWpUPLQRHVGHDSXOVDFLRQHVSRU PLQXWR6HFRQVWDWDSRUPHGLRGHODSDOSDFLyQGLJLWDOGHODDUWHULDUDGLDOVREUHODPXxHFD GXUDQWHPLQXWR ,QWHUSUHWDFLyQ 1RUPDODSXOVDFLRQHVSRUPLQXWR %UDGLFDUGLDSXOVDFLRQHVSRUPLQXWR 7DTXLFDUGLD!SXOVDFLRQHVSRUPLQXWR &RQGXFWD /DVDOWHUDFLRQHVGHEHQHYDOXDUVHHQFRQMXQWRFRQRWURVKDOOD]JRVGHOH[DPHQ 7HPSHUDWXUD /D SUHVHQFLD GH ¿HEUH SXHGH VHU XQ VLJQR GH LQIHFFLyQ JUDYH R GH SURFHVRV SRFR LPSRUWDQWHV TXH QR DOWHUDQ HO ULHVJR GHO SDUWR 'HEH SRU OR WDQWR LQYHVWLJDUVH RWURV VLJQRV\VtQWRPDVTXHSXHGDQRULHQWDUDORULJHQGHOD¿HEUHWDOHVFRPR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 3pUGLGDGHOtTXLGRDPQLyWLFRSRUURWXUDGHPHPEUDQDV 'RORUDEGRPLQDOGLIHUHQFLDEOHGHFRQWUDFFLRQHV 'LVXULDSXMRV\WHQHVPRYHVLFDO (GHPDGRORU\HQURMHFLPLHQWRGHH[WUHPLGDGHVLQIHULRUHV &XDOTXLHUD GH HOORV VXJLHUH LQIHFFLyQ SRWHQFLDOPHQWH VHYHUD LQIHFFLyQ RYXODU SLHORQHIULWLVQHXPRSDWtDDEGRPHQDJXGRRVHSVLVVLOD¿HEUHHVWiDVRFLDGDDRWURV VLJQRVGHVKRFNWURPERÀHELWLV 5HJLVWURGHODWHPSHUDWXUD &RORFDU HO WHUPyPHWUR HQ OD D[LOD HQ OD ERFD R HQ HO UHFWR GXUDQWH PLQXWR FRPR PtQLPR ,QWHUSUHWDFLyQ 1RUPDOKDVWD&D[LODU KDVWD&UHFWDOREXFDO &RQGXFWD &XDQGR VH FRQVWDWDQ VtQWRPDV \ VLJQRV GH LQIHFFLyQ VHYHUD VH GHEH UHIHULU D QLYHOGHDWHQFLyQGHDOWRULHVJR &XDQGRORVKDOOD]JRVVRQVXJHUHQWHVGHSDWRORJtDVSRFRLPSRUWDQWHVVHSRGUi DGPLWLUHQHOQLYHOGHEDMRULHVJRFRQWURODQGRODWHPSHUDWXUDSXOVR\RWURVVLJQRV \ VtQWRPDV FDGD KRUDV 0DQWHQLHQGR D OD JHVWDQWH KLGUDWDGD RIUHFLpQGROH OtTXLGRV SRU YtD RUDO (Q FDVR GH LGHQWL¿FDU OD FDXVD HIHFWXDU HO WUDWDPLHQWR HVSHFt¿FRHWLROyJLFR6LFRQPHGLGDVItVLFDVWDOHVFRPRGXFKDWLELDURSDVOLJHUDV HKLGUDWDFLyQQRVHFRUULJHODWHPSHUDWXUDVHUHFRPLHQGDHPSOHDUDQWLWpUPLFRV 3HVR (OSHVRDFWXDOGHEHVHUHYDOXDGRPHGLDQWHXQDWDEODGHJDQDQFLDGHSHVRPDWHUQR HQIXQFLyQGHODHGDGJHVWDFLRQDO(OSHVRPDWHUQRLQVX¿FLHQWH\HOHVFDVRLQFUHPHQWR GHSHVRGXUDQWHHOHPEDUD]RVHUHODFLRQDQFRQUHVWULFFLyQGHOFUHFLPLHQWRLQWUDXWHULQR 5&,(OLQFUHPHQWREUXVFR\H[DJHUDGRGHSHVRPDWHUQRSXHGHGHEHUVHDUHWHQFLyQ KtGULFDSUHHFODPSVLD\RGLDEHWHV\GHEHUiVHUYDORUDGRHQFRQMXQWRFRQRWURVVtQWRPDV \VLJQRVSDUDGH¿QLUODHWLRORJtD ([DPHQFOtQLFRSRUVLVWHPDV $SOLFDUODVWpFQLFDVVHPLROyJLFDVKDELWXDOHVDODOFDQFHGHOSHUVRQDOFDOL¿FDGR &RQGXFWD &XDQGRVHHVWiHQSUHVHQFLDGHVtQWRPDV\VLJQRVVXJHUHQWHVGHSDWRORJtDPpGLFDJUDYH FDUGLRSDWtDDQHPLDVHYHUDHWFVHGHEHUiUHIHULUDODJHVWDQWHDQLYHOGHDWHQFLyQGH DOWRULHVJR ([DPHQREVWpWULFR 3HUPLWH &RQ¿UPDUHOGLDJQyVWLFRGHWUDEDMRGHSDUWR (YDOXDUHOULHVJRPDWHUQRIHWDOSDUDHOSDUWR\SDUDHOUHFLpQQDFLGR 3DOSDFLyQDEGRPLQDO /RVREMHWLYRVTXHVHSHUVLJXHQVRQGHWHUPLQDU 9ROXPHQXWHULQR 3RVLFLyQ\WDPDxRIHWDO 1~PHURGHIHWRV &DQWLGDGGHOtTXLGRDPQLyWLFR 6LWXDFLyQIHWDO $OWXUDGHODSUHVHQWDFLyQ 3UHVHQWDFLyQIHWDO 3UHVHQFLDGHFRQWUDFFLRQHVXWHULQDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (O HPEDUD]R P~OWLSOH OD SUHVHQWDFLyQ GLVWyFLFD OD GHVSURSRUFLyQ IHWRSpOYLFD R ODV DOWHUDFLRQHVGHODFDQWLGDGGHOtTXLGRDPQLyWLFRVRQIDFWRUHVGHULHVJRGHLPSRUWDQFLD SDUD HO SDUWR 6L ELHQ HQ OD PD\RUtD GH ORV FDVRV HVWDV VLWXDFLRQHV KDEUiQ VLGR GHVFDUWDGDV GXUDQWH HO FRQWURO SUHQDWDO ODV JHVWDQWHV VLQ FRQWURO R SRVLEOHV HUURUHV GLDJQyVWLFRV R FDPELRV SURGXFLGRV GHVGH HO ~OWLPR FRQWURO KDFHQ LPSUHVFLQGLEOH FRQ¿UPDURGHVFDUWDUHVWDVVLWXDFLRQHVHQODDGPLVLyQ (VWHH[DPHQVHFRPSOHPHQWDFRQODPHGLFLyQGHODDOWXUDXWHULQD\ODVPDQLREUDVGH /HRSROGWDOFRPR\DVHGHVFULELHURQHQHOFDStWXORSUHQDWDO /D VRVSHFKD GH GHVSURSRUFLyQ IHWR SpOYLFD GHEH FRQ¿UPDUVH FRQ HO H[DPHQ JHQLWDO FRPRVHGHWDOODHQODVSiJLQDVGHSUHQDWDO $OWXUDXWHULQD 3HUPLWHHYDOXDUHOWDPDxR\FUHFLPLHQWRIHWDOFRPRVHLQGLFyHQHOFDStWXORGHSUHQDWDO &RQGXFWD /DVRVSHFKDGHUHVWULFFLyQGHFUHFLPLHQWRLQWUDXWHULQR5&,8PDFURVRPtDHPEDUD]R P~OWLSOHSUHVHQWDFLyQGLVWyFLFD\SROLKLGUDPQLRVGHWHUPLQDQODDVLVWHQFLDGHOSDUWRHQ XQQLYHOGHDOWRULHVJR $XVFXOWDFLyQGHODIUHFXHQFLDFDUGtDFDIHWDO)&) 3HUPLWHFRQ¿UPDUODYLWDOLGDG\HOJUDGRGHELHQHVWDUIHWDO /DDXVFXOWDFLyQGHORVODWLGRVIHWDOHVDVHJXUDQTXHHOIHWRHVWiYLYR/DHYDOXDFLyQGH OD IUHFXHQFLD FDUGtDFD IHWDO )&) DQWHV GXUDQWH \ GHVSXpV GH ODV FRQWUDFFLRQHV SHUPLWH DSUHFLDU FRQ FLHUWD VHJXULGDG HO HVWDGR GH VDOXG IHWDO /D SUHVHQFLD GH VHYHUDVDOWHUDFLRQHVGHOD)&)LQGLFDXQDIXQGDGDSUHVXQFLyQGHKLSR[LDIHWDOFRQHO FRQVLJXLHQWHULHVJRGH 0XHUWHIHWDO 0RUELOLGDGQHRQDWDO 'HSUHVLyQDOQDFHU 0XHUWHQHRQDWDO (Q FRQGLFLRQHV QRUPDOHV HO IHWR WROHUD DGHFXDGDPHQWH OD GLVPLQXFLyQ GH OD SUHVLyQ SDUFLDOGHR[tJHQR32SURYRFDGDSRUODVFRQWUDFFLRQHVXWHULQDV+D\FRQGLFLRQHV GHULHVJRTXHDIHFWDQODUHVHUYDIHWRSODFHQWDULDSURYRFDQGRXQDGLVPLQXFLyQGHOD 32SRUGHEDMRGHOQLYHOFUtWLFR6XWUDGXFFLyQFOtQLFDHVODWDTXLFDUGLDSRUDXPHQWRGHO WRQRVLPSiWLFREUDGLFDUGLDWUDQVLWRULDSRVWFRQWUDFFLyQ',3,,REUDGLFDUGLDVRVWHQLGD SRUDXPHQWRGHOWRQRSDUDVLPSiWLFR/DWDTXLFDUGLDDLVODGD\PDQWHQLGDSXHGHVHUHO SULPHUVLJQRGHVXIULPLHQWRIHWDO (VIUHFXHQWHREVHUYDUHQHOWUDQVFXUVRGHOSDUWRFDtGDVGHOD)&)FRLQFLGHQWHVFRQ OD FRQWUDFFLyQ ',3 , HQ SDUWLFXODU VL ODV PHPEUDQDV HVWiQ URWDV \R OD FDEH]D GHO IHWRHVWiHQFDMDGD(VWHVLJQRQRUHVSRQGHDXQDKLSR[LDIHWDOVLVWpPLFDVLQRDXQD HVWLPXODFLyQYDJDOSRUFRPSUHVLyQ/RV',36,QRVHDVRFLDQJHQHUDOPHQWHFRQPXHUWH IHWDOQLFRQKLSR[LDQHRQDWDO (QRWUDVRFDVLRQHVDSDUHFHQ',36HQORVTXHQRHVIiFLOGH¿QLUVLVHWUDWDGH',36,R,, SRUTXHSDUHFHQLQWHUFDODUVHORVXQRVFRQORVRWURV\VRQGHGLIHUHQWHPRUIRORJtDHQWUH Vt(VWRV',36YDULDEOHVRXPELOLFDOHVVRQSURGXFWRGHXQDRFOXVLyQWUDQVLWRULDGHORV YDVRVXPELOLFDOHVFXDQGRVHFRQWUDHHO~WHUR6LODRFOXVLyQHVEUHYHPHQRUGHR VHJXQGRVVRORVHSURGXFHXQDHVWLPXODFLyQGHOYDJR6LHVPiVSURORQJDGDPD\RU GHVHJXQGRVVHGHVDUUROODWDPELpQKLSR[LDIHWDO(QHVWHFDVRHO',3YDULDEOHVHUtD VLQyQLPRGHVXIULPLHQWRIHWDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD &XDGUR,QWHUSUHWDFLyQGHODIUHFXHQFLDFDUGtDFDIHWDO )&)HQWUHFRQWUDFFLRQHV)&)EDVDO 1RUPDO $OHUWD+LSR[LDOHYH $QRUPDO +LSR[LDVHYHUDREORTXHRFDUGtDFRFRQJpQLWR (QWUHODWPLQ (QWUHODWPLQEUDGLFDUGLD 6REUHODWPLQWDTXLFDUGLD )&)ODWPLQEUDGLFDUGLD )&)DVRFLDGDDODVFRQWUDFFLRQHV 1RUPDO 6LQYDULDFLyQVLJQL¿FDWLYDFRQODEDVDODFHOHUDFLRQHVWUDQVLWRULDV 'LSV,RGHVDFHOHUDFLyQSUHFR]VLQFUyQLFDFRQODFRQWUDFFLyQXWHULQD&8 $OHUWD 'LSVYDULDEOHVRXPELOLFDOHVGHGXUDFLyQDPSOLWXG\PRPHQWRGHFRPLHQ]R YDULDEOHVHQUHODFLyQFRQOD&83RVLEOHSDWRORJtDIXQLFXODU $QRUPDO 'LSV,,RGHVDFHOHUDFLyQWDUGtD,QLFLDFLyQWDUGtDHQUHODFLyQDOD&8\ UHFXSHUDFLyQGHVSXpVTXHpVWDKDWHUPLQDGR$OFDQ]DVXYDORUPtQLPRHQWUH \VHJXQGRVGHVSXpVGHODFPpGHOD&8 %UDGLFDUGLDVRVWHQLGDODWPLQ'HVDFHOHUDFLyQLQLFLDGDHQOD&8TXHQR VHUHFXSHUDXQDYH]WHUPLQDGDpVWD 6LKD\IDFWRUHVGHULHVJRGHEHQH[WUHPDUVHORVFXLGDGRVHQODDXVFXOWDFLyQGHOIHWR &RQODWpFQLFDGHDXVFXOWDFLyQGHVFULSWDHQODSDJGHEHHPSOHDUVHHOVLJXLHQWH PpWRGRSDUDGHWHFWDUFDtGDVGHOD)&)(QWUHODVFRQWUDFFLRQHVVHGHWHUPLQDOD)&) EDVDO6HDXVFXOWDGXUDQWHVHJXQGRV\VHPXOWLSOLFDHOYDORUSRU 'XUDQWHODFRQWUDFFLyQHLQPHGLDWDPHQWHGHVSXpVGHODFRQWUDFFLyQVHSHVTXLVDUiQ YDULDFLRQHV 6H GHEHUi DXVFXOWDU GHVGH HO FRPLHQ]R GH OD FRQWUDFFLyQ \ KDVWD VHJXQGRVGHVSXpVGHWHUPLQDGDODPLVPDHQSHUtRGRVGHVHJXQGRV6HPXOWLSOLFDUi FDGDYDORUSRUVHORVFRPSDUDUiHQWUHVt\FRQOD)&)EDVDO &20,(1=2<),1$/'($86&8/7$&,21 ODWPLQ )5(&8(1&,$ D E F G &$5',$&$ )(7$/ PP+J 'LS ,, VHJ &2175$&&,21 87(5,1$ )LJXUD 0pWRGR SDUD GHWHFWDU FDtGDV GH OD )&) GXUDQWH \ GHVSXpV GH ODV FRQWUDFFLRQHV FXDQGR VH XWLOL]D OD DXVFXOWDFLyQ FOtQLFD SRU PHGLR GHO HVWHWRVFRSLRREVWpWULFR &RQGXFWD &XDQGRVHUHJLVWUDEUDGLFDUGLDVRVWHQLGDR',36,,HOSDUWRGHEHUiVHUFRQVLGHUDGRGH DOWRULHVJR/DWDTXLFDUGLD\ORV',36YDULDEOHVVRQVLWXDFLRQHVGHDODUPDDQWHODVTXH VHGHEHH[WUHPDUODYLJLODQFLDGHOD)&)FRQODSDFLHQWHHQGHF~ELWRODWHUDOL]TXLHUGR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 3DWUyQGHFRQWUDFWLOLGDGXWHULQD 6H GHEH GHWHUPLQDU HO WRQR XWHULQR OD IUHFXHQFLD GXUDFLyQ H LQWHQVLGDG GH ODV FRQWUDFFLRQHV\HQTXHPRPHQWRODJHVWDQWHQRWDODLQWHQVL¿FDFLyQGHDOJXQRGHHVWRV SDUiPHWURV 3DUD TXH VH SURGX]FD HO ERUUDPLHQWR OD GLODWDFLyQ FHUYLFDO \ HO GHVFHQVR GH OD SUHVHQWDFLyQ VH UHTXLHUH XQ SDWUyQ DSURSLDGR GH FRQWUDFFLRQHV XWHULQDV 8QDFRQWUDFFLyQQRUPDOSURYRFDPRGL¿FDFLRQHVWUDQVLWRULDV¿VLROyJLFDVGHODFLUFXODFLyQ ~WHURSODFHQWDULD\GHODR[LJHQDFLyQIHWDO/DKLSHUDFWLYLGDGXWHULQDWDTXLVLVWROtD\R KLSHUWRQtD SXHGH SURYRFDU KLSR[LD IHWDO 7DPELpQ SXHGH SURYRFDU URWXUD XWHULQD VL H[LVWHQ IDFWRUHV SUHGLVSRQHQWHV FLFDWULFHV XWHULQDV PDOIRUPDFLRQHV GHVSURSRUFLyQ IHWRSpOYLFDHWF /RVSDUiPHWURVTXHVHFRQVLGHUDQSDUDHVWDEOHFHUHOSDWUyQGHFRQWUDFWLOLGDGXWHULQDVRQ 7RQRSUHVLyQPiVEDMDHQWUHODVFRQWUDFFLRQHV )UHFXHQFLDQ~PHURGHFRQWUDFFLRQHVHQPLQXWRV 'XUDFLyQWLHPSRWUDQVFXUULGRGHVGHHOLQLFLRKDVWDHO¿QGHODFRQWUDFFLyQ ,QWHQVLGDGODGLIHUHQFLDHQWUHODPi[LPDSUHVLyQDOFDQ]DGDSRUODFRQWUDFFLyQ\ HOWRQR 3DUDTXHODVFRQWUDFFLRQHVVHDQSHUFLELGDVVXLQWHQVLGDGGHEHVREUHSDVDUXQFLHUWR YDORUXPEUDOGHSHUFHSFLyQSRUSDOSDFLyQ(QFRQGLFLRQHVQRUPDOHVHOYDORUSURPHGLR GHOXPEUDOGHSHUFHSFLyQSRUSDOSDFLyQHVGHPP+JSRUHQFLPDGHOWRQRQRUPDOGH ODSUHVLyQDPQLyWLFDFXDGUR &XDGUR3DUiPHWURVGHFRQWUDFWLOLGDGXWHULQD $QRUPDO 1RUPDO $QRUPDO 1RUPDO 35(6,21 ,175$87(5,1$ &/,1,&2 0e72'2'(5(*,6752 7RQR )UHFXHQFLD 'XUDFLyQ ,QWHQVLGDG FRQWUDFFPLQ VHJXQGRV PP+J D DOHUWD PP+J !PP+J ! ! !PP+J KLSHUVLVWROtD D (O~WHUR QRVHGHSULPH HQHODFPpGH ODFRQWUDFFLyQ 6HSDOSDQ SDUWHVIHWDOHV 6HGHSULPH ~WHURHQWUH FRQWUDFFLRQHV +LSHUWRQtD ,PSRVLEOHSDOSDU SDUWHVIHWDOHV 'RORU D ! WDTXLVLVWROLD ! +LSHUVLVWROtD hWHURQRVH GHSULPHHQ QLQJ~QPRPHQWR GHODFRQWUDFFLyQ 1RWDDORVHIHFWRVGHODHVTXHPDWL]DFLyQQRIXHURQLQFOXtGRVHQHVWHFXDGURODKLSRWRQtDQLODKLSRVLVWROtD /DSULPHUD\OD~OWLPDSDUWHGHODFRQWUDFFLyQXWHULQDQRVRQSHUFLELGDVSRUSDOSDFLyQ DEGRPLQDOODGXUDFLyQFOtQLFDHVWLPDGDSRUHVWHPpWRGRHVPHQRUTXHODGXUDFLyQUHDO PHGLGDSRUXQUHJLVWURGHSUHVLyQLQWUDXWHULQD &XDQWRPD\RUVHDODLQWHQVLGDGGHODFRQWUDFFLyQWDQWRPiVVHHQGXUHFHUiODSDUHG XWHULQD &XDQGR OD SUHVLyQ DPQLyWLFD VREUHSDVH ORV PP+J OD SDUHG XWHULQD VH SRQGUiWDQGXUDTXHQRSRGUiGHSULPLUVHFRQHOGHGR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (ODXPHQWRSRUHQFLPDGHORVYDORUHV¿VLROyJLFRVGHFXDOTXLHUDGHHVWRVSDUiPHWURV SXHGH WUDGXFLUVH HQ FRPSURPLVR GH OD FLUFXODFLyQ ~WHURSODFHQWDULD UHVXOWDQGR HQ KLSR[LDIHWDO /DGLVPLQXFLyQGHODDFWLYLGDGXWHULQDSXHGHSURGXFLUXQOHQWRSURJUHVRGHOSDUWRRVX GHWHQFLyQ 7pFQLFDSDUDHYDOXDUODFRQWUDFWLOLGDG 3DOSDFLyQDEGRPLQDO (OFRQWUROFOtQLFRGHODVFRQWUDFFLRQHVXWHULQDVVHGHEHUHDOL]DUSRUSHUtRGRVQRPHQRUHVDORV PLQXWRVFRORFDQGRODPDQRH[WHQGLGDVREUHHODEGRPHQPDWHUQRVLQHVWLPXODUHOFXHUSR XWHULQR &RQGXFWD &XDGUR&RQGXFWDUHFRPHQGDGDDQWH &RQWUDFWLOLGDG QRUPDO +LSHUGLQDPLDSULPLWLYD KLSHUWRQtDWDTXLRKLSHUVLVWROtD +LSHUGLQDPLDVHFXQGDULD $GPLWLUSDUDDWHQFLyQ &RORFDUDODSDUWXULHQWDHQGHF~ELWRODWHUDO HQQLYHOGHEDMR L]TXLHUGR ULHVJR 2EVHUYDUSURJUHVR GHOSDUWR ,QLFLDUXWHURLQKLELFLyQFRQEHWDPLPpWLFRV SRUYtDHQGRYHQRVD 3HVTXLVDFDXVD +LSRGLQDPLDSULPLWLYD EUDGLRSROLVLVWROtD $GPLWLUSDUDDWHQFLyQHQQLYHO GHEDMRULHVJR 2EVHUYDUSURJUHVRGHOSDUWR 6LQRKD\SURJUHVRGHOSDUWR DSOLFDURFLWRFLQDHQGRYHQRVD 6LHVWDVPHGLGDVQRVRQHIHFWLYDVUHIHULU ODJHVWDQWHDQLYHOGHDOWRULHVJR (PEDUD]DGDGH7pUPLQRHQ7UDEDMRGH3DUWR 12 $OWXUD8WHULQD 1RUPDO 6, +LSHUGLQDPLD 0DFURVRPtD 'LVWRFLDGH 3UHVHQWDFLyQ *HPHODU 5&, 3UHPDWXUH] 12 &RQWUDFW 1RUPDO 12 +LSRGLQDPLD 6, 2EVHUYDFLyQ 7UDWDPLHQWR 7UDWDPLHQWR 12 (IHFWLYR 6, 6, )&) 1RUPDO 12 7UDWDPLHQWR $WHQFLyQHQ1LYHO GH$OWR5LHVJR 6, 6XIULPLHQWR )HWDO 12 (YROXFLyQ QRUPDO 12 6, $GPLVLyQD%DMR5LHVJR )LJXUD(VTXHPDHVFDORQDGRGHGHFLVLRQHVEDVDGRHQHOH[DPHQREVWpWULFRGHOD HPEDUD]DGDHQWUDEDMRGHSDUWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR ([DPHQ*HQLWDO 7DFWRYDJLQDO 3HUPLWHHYDOXDU $PSOLWXG\HODVWLFLGDGGHSDUWHVEODQGDV 'LODWDFLyQERUUDPLHQWR\SRVLFLyQGHOFXHOOR (VWDGRGHODVPHPEUDQDVRYXODUHV 3UHVHQWDFLyQYDULHGDGGHSRVLFLyQ\DOWXUDGHODSUHVHQWDFLyQ *UDGRGHHQFDMDPLHQWR (YDOXDFLyQ GH OD HVWUXFWXUD \ GLiPHWURV SpOYLFRV iQJXOR VXES~ELFR GLiPHWUR EL LVTXLiWLFR 3URSRUFLRQDOLGDGIHWRSpOYLFD 7pFQLFDSDUDHOWDFWRYDJLQDO (OH[DPHQJHQLWDOGHEHHIHFWXDUVHFRQYHMLJDYDFtDPHGLDQWHPLFFLyQHVSRQWiQHDFRQ ODJHVWDQWHHQSRVLFLyQJLQHFROyJLFDFRQHOVDFURELHQDSR\DGRHQODFDPLOOD 3URFHGLPLHQWR ,QVSHFFLyQ GH ORV JHQLWDOHV H[WHUQRV OHVLRQHV YiULFHV SpUGLGD GH VDQJUH VHFUHFLRQHVRSUHVHQFLDGHWXPRUHV $VHRJHQLWDOFRQVROXFLyQGHVLQIHFWDQWH *XDQWHVHVWpULOHV 6HSDUDUORVODELRVPHQRUHVFRQORVGHGRVtQGLFH\SXOJDUGHODPDQRPHQRVKiELO ,QVSHFFLRQDUHOLQWURLWR (Q FDVR GH SpUGLGD GH OtTXLGR R VDQJUH SRU ORV JHQLWDOHV GHEH HYDOXDUVH VX SURFHGHQFLD\PDJQLWXGSRUHVSHFXORVFRStDSUHYLDDOWDFWRYDJLQDO ,QWURGXFLU KRUL]RQWDOPHQWH ORV GHGRV tQGLFH \ PHGLR GH OD PDQR PiV KiELO HQ OD GLUHFFLyQGHOHMHYDJLQDOFRQORVGHGRVDQXODU\PHxLTXHÀH[LRQDGRV\HOSXOJDU H[WHQGLGR 3DOSDUFRQODVXSHU¿FLHSDOPDUGHORVGHGRV 0DQWHQHUHODQWHEUD]RHQSRVLFLyQKRUL]RQWDO $SR\DUHOIRQGRXWHULQRFRQODPDQRH[WHUQD 1RUHWLUDUORVGHGRVGHODYDJLQDKDVWDQRKDEHUFRPSOHWDGRHOH[DPHQ $OUHWLUDUORVGHGRVFRPSUREDUVLHOUHFWRHVWiYDFtR &RQWURODUHQHOJXDQWHODSRVLEOHSUHVHQFLDGHPXFRVLGDGVDQJUHROtTXLGR )LJXUD7pFQLFDGHOH[DPHQYDJLQDO (VSHFXORVFRStD 6HSDUDUORVODELRVPHQRUHV ,QWURGXFLUHQIRUPDGHOLFDGDHOHVSpFXORFHUUDGRGLULJLpQGRORREOLFXDPHQWHKDFLD DWUiVGHSULPLHQGROLJHUDPHQWHHOSHULQp $EULUHOHVSpFXOR\REVHUYDUHOFXHOORXWHULQRODVFDUDFWHUtVWLFDVGHODVVHFUHFLRQHV TXHSXGLHVHQH[LVWLUPXFRVLGDGVDQJUHOtTXLGR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (YDOXDFLyQGHODDPSOLWXG\HODVWLFLGDGGHOFDQDOGHOSDUWR 1RFRQVWLWX\HQKDELWXDOPHQWH REVWiFXORV SDUDHOSDUWRSHUROD IDOWDGHHODVWLFLGDG \ DPSOLWXGSXHGHQSURORQJDUVXGXUDFLyQ /RVWUDVWRUQRVGHODDPSOLWXG\HODVWLFLGDGGHOFDQDOGHSDUWRVHVXHOHQREVHUYDUHQ FLHUWDVFRQGLFLRQHV 3ULPLJHVWDDGROHVFHQWHRDxRVD +LSHUWUR¿DGHODPXVFXODWXUDSHULQHDO (VWHQRVLVFLFDWUL]DOHVSODVWLDVFiXVWLFRV 7XPRUHVGHO~WHURFXHOORYDJLQDRYXOYD FRQGLORPDWRVLVPDVLYDTXLVWHVWXPRUHVSUHYLRVHWF 7DELTXHVYDJLQDOHVWUDQVYHUVDOHV 3HUVLVWHQFLDGHOKLPHQ 'LODWDFLyQERUUDPLHQWR\SRVLFLyQGHOFXHOOR (OERUUDPLHQWR\ODGLODWDFLyQFHUYLFDOVHSURGXFHQSRUHOHIHFWRGHODVFRQWUDFFLRQHV\ PRGL¿FDFLRQHVELRTXtPLFDVGHOFXHOORDO¿QDOGHOHPEDUD]R (OERUUDPLHQWRHVODUHGXFFLyQGHODORQJLWXGGHOFXHOOR$OFRPSOHWDUVHHOERUUDPLHQWR HO RUL¿FLR FHUYLFDO H[WHUQR VH FRQIXQGH FRQ HO LQWHUQR +DELWXDOPHQWH OD SULPLJHVWD FRPSOHWDHOERUUDPLHQWRDQWHVGHLQLFLDUODGLODWDFLyQHQODPXOWtSDUDHQFDPELRORV SURFHVRVVXHOHQVHUVLPXOWiQHRV (O ERUUDPLHQWR VH GHVFULEH LQGLFDQGR OD ORQJLWXG GHO FDQDO HQGRFHUYLFDO \D VHD HQ YDORUHVDEVROXWRVDFPRHQSRUFHQWDMHGHERUUDPLHQWRD /D GLODWDFLyQ HV OD DPSOLDFLyQ GHO FXHOOR XWHULQR TXH YDUtD HQWUH DOJXQRV PLOtPHWURV KDVWDOOHJDUDORVFP6HSURGXFHSRUXQGREOHPHFDQLVPRODWUDFFLyQGHOD¿EUD PLRPHWULDOTXHVHDSR\DSDUDFRQWUDHUVHHQHOWHMLGRFRQMXQWLYRGHOFXHOOR\ODSUHVLyQ GH OD EROVD GH DJXDV R GH OD SUHVHQWDFLyQ IHWDO VREUH HO RUL¿FLR FHUYLFDO LQWHUQR /D GLODWDFLyQVHPLGHLQWURGXFLHQGRORVGHGRVH[SORUDGRUHVHQHORUL¿FLRFHUYLFDOLQWHUQR\ VHSDUiQGRORVKDVWDWRFDUORVERUGHVGHOFXHOOR (QHOFXHOORLQPDGXURHORUL¿FRFHUYLFDOH[WHUQRVHHQFXHQWUDJHQHUDOPHQWHHQHOIRQGR GHVDFRSRVWHULRU$OPDGXUDUVXSRVLFLyQFDPELDKDVWDKDFHUVHFHQWUDO $~Q FRQ FRQWUDFFLRQHV QRUPDOHV DOJXQDV FRQGLFLRQHV SXHGHQ GL¿FXOWDU OD GLODWDFLyQ \ HO ERUUDPLHQWR DJOXWLQDFLyQFHUYLFDOGHELGDDXQDHQGRFHUYLFLWLVXRWUDSDWRORJtD FLFDWULFHVFHUYLFDOHVFRQL]DFLyQGHVJDUURV (GHPDFHUYLFDO (VWDV VRQ VLWXDFLRQHV SRFR IUHFXHQWHV TXH SXHGHQ GHWHQHU HO SURJUHVR GHO SDUWR /D SRVLFLyQ SRVWHULRU GHO FXHOOR SXHGH SURORQJDU HO WUDEDMR GH SDUWR SXHVWR TXH SRU FRPSUHVLyQGHOODELRDQWHULRUHQWUHODSUHVHQWDFLyQ\HOSXELVVHSXHGHSURGXFLUHGHPD FHUYLFDO 3pUGLGDGHVHFUHFLRQHVSRUORVJHQLWDOHV &XDQGRHOPRWLYRGHFRQVXOWDHVODSpUGLGDGHVHFUHFLRQHVSRUYtDJHQLWDOVHGHEHUi GHWHUPLQDUDTXHFRUUHVSRQGHQ 7DSyQPXFRVROLPRV /tTXLGRDPQLyWLFR 2ULQD 6DQJUH 6HFUHFLRQHVSXUXOHQWDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR ,QWHUURJDUVREUHHOPRPHQWRGHDSDULFLyQODFDQWLGDG\DOJXQDVFDUDFWHUtVWLFDVFRPR DVSHFWR FRORU RORU HWF 'HEH SUHJXQWDUVH DGHPiV DFHUFD GH OD SHUFHSFLyQ GH ORV PRYLPLHQWRVIHWDOHV\VLHVWRVKDQYDULDGRRKDQGHVDSDUHFLGR 7DSyQ0XFRVR (VXQDVHFUHFLyQHVSHVDDYHFHVVDQJXLQROHQWDFX\DH[SXOVLyQ REHGHFHDOFRPLHQ]RGHOERUUDPLHQWR\ODGLODWDFLyQGHOFXHOOR /tTXLGR$PQLyWLFR/DVPHPEUDQDVRYXODUHVSRUGHODQWHGHODSUHVHQWDFLyQIRUPDQ ODEROVDGHODVDJXDV/DSUHVHQFLDGHXQDEROVDGHDJXDVPX\ SURPLQHQWHRHQUHORMGHDUHQDGHEHKDFHUVRVSHFKDU 'HVSURSRUFLyQIHWRSpOYLFD 3UHVHQWDFLyQFHIiOLFDGHÀH[LRQDGD 6LWXDFLyQRSUHVHQWDFLyQGLVWRFLFD (QFRQGLFLRQHVQRUPDOHVODVPHPEUDQDVVHFRQVHUYDQtQWHJUDVKDVWDTXHODGLODWDFLyQ VHFRPSOHWDGHODVYHFHV )5 )5 Q 3DUWRV ',/$7$&,21&(59,&$/FP 3HUtRGR )LQDO ([SXO GHO VLYR 3DUWR )LJXUD (WDSDGHOSDUWR HQTXHODURWXUD HVSRQWiQHDGH PHPEUDQDVRYXODUHV VHSURGXFHFXDQGR VHDGRSWDXQDDFWLWXG FRQVHUYDGRUD $O URPSHUVH ODV PHPEUDQDV OR KDELWXDO HV OD VDOLGD GH OtTXLGR WUDQVSDUHQWH GH RORU FDUDFWHUtVWLFRDVHPHQ RKLSRFORULWR GHVRGLR (QRFDVLRQHV SXHGH VHUDPDULOOHQWR R YHUGRVRPHFRQLRRSXUXOHQWRVLKD\LQIHFFLyQRYXODU (O GLDJQyVWLFR GH OD URWXUD GH ODV PHPEUDQDV HV KDELWXDOPHQWH VHQFLOOR /D PXMHU UH¿HUHSpUGLGDEUXVFDGHOtTXLGRSRUORVJHQLWDOHV(QHOGHORVFDVRVVHFRQ¿UPD VLPSOHPHQWHSRUODLQVSHFFLyQJHQLWDODOYHUÀXLUOtTXLGRSRUODYXOYD 'HEHKDFHUVHGLDJQyVWLFRGLIHUHQFLDOFRQODHPLVLyQLQYROXQWDULDGHRULQDGHUHODWLYD IUHFXHQFLDDO¿QDOGHOHPEDUD]R\TXHVHUHFRQRFHSRUVXRORUFDUDFWHUtVWLFR 6HHQWLHQGHSRUURWXUDSUHPDWXUDGHPHPEUDQDVRYXODUHV530DOFXDGURFDUDFWHUL]DGR SRUODURWXUDHVSRQWiQHDGHODVPHPEUDQDVGHVGHXQDKRUDDQWHVGHOLQLFLRGHOWUDEDMR GHSDUWR &XDQGROD530VHSURGXFHHQHPEDUD]RVGHWpUPLQRORXVXDOHVTXHHOWUDEDMRGHSDUWRVH LQLFLHHVSRQWiQHDPHQWHHQPiVGHOGHORVFDVRVGHQWURGHODVSULPHUDVKRUDV 6HFRQVLGHUDSHUtRGRGHODWHQFLDDOWLHPSRWUDQVFXUULGRHQWUHHOPRPHQWRHQTXHVH SURGXFHODURWXUDGHPHPEUDQDV\HOSDUWR&XDQGRHVWHSHUtRGRVXSHUDODVKRUDV VH FRQVLGHUD XQD URWXUD SURORQJDGD GH PHPEUDQDV 6H HVWLPD TXH OD IUHFXHQFLD GH URWXUDSURORQJDGDGHPHPEUDQDVHVSUy[LPDDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD /DVSULQFLSDOHVFRPSOLFDFLRQHVGHORVHPEDUD]RVFRQ530VRQ LQIHFFLyQRYXODUFRQ530KRUDV\FRQ530!KRUDV LQIHFFLyQIHWDOQHRQDWDOSRU(*%FRQ530!KRUDV SUHPDWXUH] $QWHODSUHVHQFLDGHKLGURUUHDSpUGLGDGHOtTXLGRODHYDOXDFLyQGHEHVHUUiSLGDSDUD GHFLGLUODRSRUWXQDUHIHUHQFLDDOQLYHODSURSLDGR 3pUGLGDGH/tTXLGR$PQLyWLFR 6, ,QIHFFLyQ \RVHP 12 12 7UDEDMR GH3DUWR 6, $GPLWLUVLQ 7DFWR9DJLQDO (VSHUDUKV 1RHIHFWXDU 7DFWR9DJLQDO 12 &RQWLQXDU (VTXHPDGH $GPLVLyQ )DFWRUHV GH5LHVJR 3UHVHQWHV 7UDEDMRGH3DUWR (VSRQWiQHR 6, 6, 5HIHUHQFLD DO1LYHOGH$WHQFLyQ GH$OWR5LHVJR ,QIHFFLyQ 12 6, 12 $WHQFLyQGH3DUWR\GHO 5HFLpQ1DFLGR6HJ~Q1RUPDV GH%DMR5LHVJR )LJ(VTXHPDHVFDORQDGRGHGHFLVLRQHVFXDQGRVHFRQVWDWDSpUGLGDGHOtTXLGRDPQLyWLFR 6DQJUH (VFRP~QREVHUYDUSHTXHxRVVDQJUDGRVDVRFLDGRVDODGLODWDFLyQFHUYLFDOSHURWRGD SpUGLGDGHVDQJUHSRUORVJHQLWDOHVGHEHHYDOXDUVHDGHFXDGDPHQWHFRQPD\RUUD]yQ VLHOYROXPHQHVDEXQGDQWH /DV KHPRUUDJLDV JUDYHV FRQVWLWX\HQ XQD VLWXDFLyQ GH DOWR ULHVJR TXH XVXDOPHQWH UHTXLHUHQH[WUDFFLyQIHWDOSRUODYtDPiVUiSLGD $SUR[LPDGDPHQWHODPLWDGGHODVKHPRUUDJLDVDOWpUPLQRVRQGHELGDVD SODFHQWDSUHYLD GHVSUHQGLPLHQWRSUHPDWXURGHSODFHQWDQRUPRLQVHUWD'331, 3ODFHQWDSUHYLD /D IUHFXHQFLD HV GH D GH ORV HPEDUD]RV GH HOODV PHQRV GHO VRQ RFOXVLYDVWRWDOHVRSDUFLDOHV(QHOGHORVFDVRVODSODFHQWDSUHYLDVHDVRFLDFRQ PXOWLSDULGDG 'HVSUHQGLPLHQWRSUHPDWXURGHSODFHQWDQRUPRLQVHUWD'331, /DIUHFXHQFLDRVFLODHQWUH\GHORVHPEDUD]RV &DVLXQGHHOODVUHVXOWDQIDWDOHVSDUDHOIHWR 3XHGHYHUVHDVRFLDGDDKLSHUWHQVLyQDUWHULDOEUHYHGDGGHFRUGyQ\DODQWHFHGHQWH GHRWUR'331,HQHPEDUD]RVSUHYLRV 2WUDVFDXVDVGHKHPRUUDJLD 6RQFDXVDVPHQRVIUHFXHQWHVGHKHPRUUDJLDODVFHUYLFRSDWtDVLQFOX\HQGRHOFiQFHU FpUYLFRXWHULQR\ODURWXUDXWHULQD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (Q SUHVHQFLD GH KHPRUUDJLD OD HYDOXDFLyQ GHEH VHU UiSLGD SDUD GHFLGLU OD RSRUWXQD UHIHUHQFLDDOQLYHODSURSLDGR 3pUGLGDGH6DQJUHSRU*HQLWDOHV 7RQR8WHULQR +LSHUWRQtD 3UREDEOH '331, 12 7UDQVIXVLyQR 5HSRVLFLyQGH /tTXLGRV 1RUPDO 6, 3UREDEOH 3ODFHQWD 3UDHYLD 6, +HPRUUDJLD $EXQGDQWH 121 (VSHFXORVFRStD 6, (VSHFXORVFRStD 6, +HPRUUDJLD LQWUDXWHULQD +HPRUUDJLD LQWUDXWHULQD 12 12 7UDEDMR GH3DUWR 12 12 7UDEDMR GH3DUWR 6, 6, $PQLRWRPtD 5iSLGD5HIHUHQFLDDO1LYHO GH$WHQFLyQGH$OWR5LHVJR 3UREDEOH&HViUHD &RQVXOWDD (VSHFLDOLVWD 3DWRORJtD*LQHFROyJLFD $WHQFLyQGH3DUWR 6HJ~Q1RUPDV GH%DMR5LHVJR )LJ(VTXHPDHVFDORQDGRGHGHFLVLRQHVFXDQGRVHFRQVWDWDSpUGLGDGHVDQJUHSRUORV JHQLWDOHV 6HFUHFLRQHVSXUXOHQWDV 6XHOHQYLQFXODUVHDSURFHVRVLQIHFFLRVRVHQYXOYDYDJLQDRFXHOORXWHULQRXRULJLQDUVH HQXQDLQIHFFLyQRYXODU /RVSURFHVRVLQIHFFLRVRVGHYXOYD\YDJLQDSXHGHQLQIHFWDUDOIHWRGXUDQWHVXSDVDMH SRUHOFDQDOGHOSDUWR'HEHFRQVWDWDUVHODLQGHPQLGDGGHODVPHPEUDQDV\SUHFLVDUHO RULJHQGHODVHFUHFLyQPHGLDQWHHVSHFXORVFRStD (YDOXDFLyQGHODSUHVHQWDFLyQ (OWDFWRYDJLQDOSHUPLWHLGHQWL¿FDUODSUHVHQWDFLyQ6LVHWRFDXQSRORGXUR\UHJXODU SXHGHFRQFOXLUVHTXHODSUHVHQWDFLyQHVFHIiOLFD6LVHHQFXHQWUDODH[FDYDFLyQYDFtD RXQSRORYROXPLQRVREODQGRHLUUHJXODU\ODSDOSDFLyQDEGRPLQDOPXHVWUDSHORWHRHQHO IRQGRGHO~WHURRHQXQRGHORVÀDQFRVVHGHEHVRVSHFKDUXQDSUHVHQWDFLyQSRGiOLFD RXQDVLWXDFLyQWUDQVYHUVD\SRUWDQWRHOSDUWRVHUiFRQVLGHUDGRGHDOWRULHVJR $OWXUD\YDULHGDGGHSRVLFLyQHQODSUHVHQWDFLyQFHIiOLFDGHYpUWLFH (OSURJUHVRGHOSDUWRVHHYDO~DSRUHOJUDGRGHHQFDMHGHODSUHVHQWDFLyQDGHPiVGH ODFRQWUDFWLOLGDG\ODGLODWDFLyQFHUYLFDO+DELWXDOPHQWHODVQXOtSDUDVLQLFLDQHOWUDEDMR GH SDUWR FRQ OD FDEH]D IHWDO HQFDMDGD \ HO GHVFHQVR VH DFHOHUD DO ¿QDO GHO SHUtRGR GH GLODWDFLyQ /DV PXOWtSDUDV HQ FDPELR VXHOHQ LQLFLDU OD GLODWDFLyQ FRQ OD FDEH]D IHWDOLQVLQXDGDR¿MDKDVWDHOPRPHQWRGHODGLODWDFLyQFRPSOHWDVXFHGLpQGRVHHQHO SHUtRGRGHH[SXOVLyQHOHQFDMDPLHQWR\ODURWDFLyQ 3DUD YDORUDU OD DOWXUD GH OD SUHVHQWDFLyQ VH XVDQ KDELWXDOPHQWH GRV PpWRGRV TXH UHODFLRQDQ HO SXQWR PiV GHFOLYH GH OD SUHVHQWDFLyQ FRQ OD SHOYLV \ TXH VHJ~Q ODV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD GLVWLQWDVHVFXHODVVRQORVSODQRVGH+RGJHSDUDODHVFXHODHXURSHD\ODVHVWDFLRQHV GH'H/HHSDUDODHVFXHODQRUWHDPHULFDQD &XDGUR3ODQRVGHODSHOYLV\VXUHODFLyQFRQODDOWXUDGHODSUHVHQWDFLyQ 3ODQRVGH+RGJH HVFXHODHXURSHD %RUGHVXSHULRUGHO SXELV\SURPRQWRULR %RUGHLQIHULRUGHOSXELV (VSLQDVFLiWLFDV 9pUWLFHGHOFR[LV (VWDFLRQHVGH'H/HH HVFXHODQRUWHDPHULFDQD ,3ODQR (VWDFLyQ ,,3ODQR ,,,3ODQR ,93ODQR 3ODQRVSDUDOHORV (VWDFLyQ (VWDFLyQ (VWDFLyQ 3ODQRVSHUSHQGLFXODUHVDOFDQDOGHOSDUWR 1 2 3 4 -4 -2 )LJ3ODQRVGH+RGJH 0 +4 )LJ(VWDFLRQHVGH'H/HH 3DUD KDFHU HO GLDJQyVWLFR GH SUHVHQWDFLyQ FHIiOLFD PRGDOLGDG GH YpUWLFH GHEH LGHQWL¿FDUVHODVXWXUDLQWHUSDULHWDOFRQHOGHGRTXHWDFWD\VHJXLUODKDVWDHQFRQWUDUOD IRQWDQHODSRVWHULRUPHQRURFFLSLWDORODPEGDTXHVHLGHQWL¿FDSRUVXIRUPDWULDQJXODU \GHPHQRUWDPDxRTXHODDQWHULRUIURQWRSDULHWDOREUHJPDGHIRUPDFXDGUDQJXODU\ PD\RUWDPDxR 3XHGH SURGXFLU XQ UHWDUGR HQ HO GHVFHQVR GH OD FDEH]D IHWDO HQ ODV YDULHGDGHV SRVWHULRUHVODVGHÀH[LRQHV\ORVJUDGRVOtPLWHGHSURSRUFLyQIHWRSpOYLFD /DYDULHGDGGHSRVLFLyQVHGH¿QHQSRUODUHODFLyQH[LVWHQWHHQWUHXQSXQWRGHUHSDUR IHWDORFFLSLWDOHQHOFDVRGHODVPRGDOLGDGHVGHYpUWLFH\ODSHOYLVPDWHUQD)LJXUD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 2,($ 2,'3 2,(' 2,(7 2,'7 2,'$ 26 23 )LJXUD9DULHGDGHVGHSRVLFLyQHQSUHVHQWDFLyQGHYpUWLFH2 2FFtSLWR $ $QWHULRU3 3RVWHULRU7 7UDQVYHUVD, ,OtDFD, ,]TXLHUGD' 'HUUHFKD /DLGHQWL¿FDFLyQGHODIRQWDQHODSRVWHULRUSHUPLWHDSUHFLDUHOJUDGRGHÀH[LyQ\DTXHVH HQFRQWUDUiPiVH[FpQWULFDPLHQWUDVPD\RUVHDODGHÀH[LyQ)LJXUD )LJ,GHQWL¿FDFLyQGHODIRQWDQHOD SRVWHULRU )LJ,GHQWL¿FDFLyQGHODIRQWDQHOD DQWHULRU &XDQGR UHVXOWD LPSRVLEOH LGHQWL¿FDU OD IRQWDQHOD SRVWHULRU \ HQ FDPELR OD IRQWDQHOD DQWHULRUVHWDFWDHVSRVLEOHTXHODGHÀH[LyQVHDH[WUHPD\VHWUDWHGHXQDSUHVHQWDFLyQ FHIiOLFD HQ PRGDOLGDG GH IUHQWH R GH FDUD VLWXDFLyQ GH DOWR ULHVJR TXH UHTXLHUH UHIHUHQFLDDOQLYHODSURSLDGR)LJXUD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (Q OD SUHVHQWDFLyQ FHIiOLFD PRGDOLGDG GH IUHQWH SXHGHQ UHFRQRFHUVH ORV DUFRV RUELWDULRVORVRMRV\ODQDUL](OGLiPHWURRIUHFLGRHVHOPHQWRRFFLSLWDOGHFPHO PD\RUGLiPHWURGHOSRORFHIiOLFRSRUORTXHHOSDUWRVLVHORJUDHVH[WUHPDGDPHQWH ODERULRVR\WUDXPiWLFR /D SUHVHQWDFLyQ FHIiOLFD PRGDOLGDG GH FDUD HV HO JUDGR Pi[LPR GH GHÀH[LyQ 6H DVRFLDDSHOYLVSODQD\PDOIRUPDFLRQHVIHWDOHV6HGLDJQRVWLFDSRUODLGHQWL¿FDFLyQGH ORVDUFRVFLOLDUHVRMRVQDUL]ERFD\PHQWyQGXUDQWHHOWDFWRYDJLQDO $PEDVSUHVHQWDFLRQHVPXHVWUDQHQODSDOSDFLyQDEGRPLQDOHOVLJQRGHO³JROSHGHKDFKD´ &RQGXFWD /DVSUHVHQWDFLRQHVGLVWyFLFDVGHEHQVHUUHIHULGDVDQLYHOHVGHDWHQFLyQGHDOWRULHVJR 9DORUDFLyQGHODSURSRUFLyQIHWRSpOYLFD\ODFDSDFLGDGGHODSHOYLVPDWHUQD $QWHVGHOSDUWRHOWDPDxRGHODFDEH]DIHWDOVRORHVVXVFHSWLEOHGHHVWLPDFLyQFOtQLFD DSUR[LPDGDPHGLDQWHODHYDOXDFLyQGHODDOWXUDXWHULQDHOWDPDxRIHWDO\ODUHODFLyQ GHODFDEH]DIHWDOFRQHOSODQRGHOHVWUHFKRVXSHULRU(OWLSRGHSHOYLV\VXVGLiPHWURV SXHGHQHYDOXDUVHDSURSLDGDPHQWHPHGLDQWHHOWDFWRYDJLQDO 6LODSUHVHQWDFLyQHVWiHQFDMDGDHVXQEXHQLQGLFLRGHODSURSRUFLRQDOLGDGSDUDHVH IHWRHQSDUWLFXODU 6LODSURSRUFLyQHVWiOHYHPHQWHDMXVWDGD\QRHVREVWiFXORSDUDHOSDUWRVHSURGXFLUi HO HQFDMDPLHQWR SHUR OD HYROXFLyQ GHO SDUWR VHUi OHQWD \ FRQ PD\RU IUHFXHQFLD GH GHÀH[LyQ\DVLQFOLWLVPRSHOYLVOtPLWH /DGHVSURSRUFLyQDGHPiVGHLPSHGLUHOSDUWRYDJLQDOVHDVRFLDFRQEROVDGHDJXDV SURPLQHQWH\HOFRQVLJXLHQWHULHVJRGHSURODSVRGHFRUGyQ /DHYDOXDFLyQGHODSHOYLVSRUPHGLRGHOWDFWRVHHIHFW~DWUDWDQGRGHWRFDUHOSURPRQWRULR FRQHOGHGRPHGLR6LVHORJUDWDFWDUHOSURPRQWRULRVH¿MDHOERUGHUDGLDOGHOGHGR tQGLFHFRQWUDODVtQ¿VLV\VHVHxDODHOSXQWRGHFRQWDFWR/DPHGLGDHQWUHHVHSXQWR \HOYpUWLFHGHOGHGRPHGLRHVHOFRQMXJDGRGLDJRQDORGLiPHWURSURPRQWRVXES~ELFR ¿JVXSHULRUHQFPDOFRQMXJDGRREVWpWULFRRSURPRQWRUHWURS~ELFRGHFP 3XHVWRTXHHOGLiPHWURELSDULHWDO'%3IHWDODWpUPLQRHVDSUR[LPDGDPHQWHGH FPVHFRPSUHQGHUiTXHVLHVWHFRQMXJDGRVXSHUDORVFPHOSDUWRYDJLQDODWpUPLQR HVSRVLEOH(QSHOYLVQRUPDOHVQRVHWRFDRVHWRFDFRQJUDQGL¿FXOWDGHOSURPRQWRULR 'HEHQ FRQVLGHUDUVH HQ HO H[DPHQ OD DPSOLWXG GH OD YDJLQD \ OD YXOYD OD UHODMDFLyQ SHULQHDO\ODORQJLWXGGHORVGHGRVGHOH[SORUDGRU )LJ3HOYLPHWUtDLQWHUQDPHGLGD GHOFRQMXJDGRGLDJRQDORGLiPHWUR )LJ&RQ¿UPDFLyQGHODPHGLGD GHOFRQMXJDGRGLDJRQDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 6LVHWRFDHOSURPRQWRULRVHVRVSHFKDUiHVWUHFKH]SpOYLFDODTXHGHEHUiVHUFRQ¿UPDGD SRUODVPHGLGDVDQWHGLFKDV 8QDYH]FRPSOHWDGRHOH[DPHQJHQLWDOODYDORUDFLyQGHWRGRVORVGDWRVSHUPLWH +DFHUGLDJQyVWLFRGHWUDEDMRGHSDUWR (YDOXDUHOULHVJRSDUDGHFLGLUVLVHWUDWDGHXQSDUWRGHEDMRRDOWRULHVJR $GPLWLURUHIHULUVHJ~QFRQGLFLRQHVHVSHFt¿FDVGHODSDUWXULHQWD &RQGXFWD 6L HQ HO H[DPHQ JHQLWDO QR KD\ KDOOD]JRV SDWROyJLFRV OD HPEDUD]DGD VHUi DGPLWLGD SDUDDWHQFLyQVHJ~QQRUPDGHEDMRULHVJR 'HEHUiUHIHULUVHDQLYHOGHDWHQFLyQGHDOWRULHVJRVLODSDUWXULHQWDSUHVHQWDXQDGHODV VLJXLHQWHVSDUWLFXODULGDGHV 3HOYLVHVWUHFKDRDVLPpWULFD 'HVSURSRUFLyQIHWRSpOYLFDHYLGHQWHRVRVSHFKRVD 530!KRUDVRFRQVLJQRVGHLQIHFFLyQ (PEDUD]RVHPDQDVGHDPHQRUUHD +HPRUUDJLD 7DELTXHVYDJLQDOHVWUDQVYHUVRVHVWHQyWLFRV 2WURVREVWiFXORVGHOFDQDOGHSDUWREODQGRWXPRUSUHYLRJUDQGHVTXLVWHVHVWHQRVLV YDJLQDOHWF (QODVLJXLHQWH¿JXUDVHUHVXPHQODVGHFLVLRQHVDWRPDUGXUDQWHHOH[DPHQFRPSOHWR GHDGPLVLyQSDUDHOSDUWR 3DOSDFLyQ$EGRPLQDO 0DQLREUDVGH/HRSROG ([DPHQ*HQLWDO 3UHVHQWDFLyQ R6LWXDFLyQ 7UDQVYHUVD &HIiOLFD 3RGiOLFD 6, 'HIOH[LRQDGD 12 9pUWLFH 12 $GHFXDGD 3URSRUFLyQ )HWRSpOYLFD 12 (QFDMDGD 6, 6, 'LDJQyVWLFRGH9DULHGDGGH3RVLFLyQ 5HIHUHQFLDD1LYHOGH $WHQFLyQGH$OWR5LHVJR $WHQFLyQGHO3DUWR6HJ~Q 1RUPDVGH%DMR5LHVJR )LJXUD(VTXHPDHVFDORQDGRGHGHFLVLRQHVVHJ~QGLDJQyVWLFR\DOWXUDGHOD SUHVHQWDFLyQYDULHGDG\SURSRUFLyQIHWRSpOYLFD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 3UHSDUDFLyQGHODHPEDUD]DGDHQODUHFHSFLyQ $~QFRQPHPEUDQDVRYXODUHVtQWHJUDVODSURORQJDFLyQGHOWUDEDMRGHSDUWRDXPHQWD HO ULHVJR GH LQIHFFLyQ 6H UHFRPLHQGD UHGXFLU ORV WDFWRV YDJLQDOHV DO PtQLPR LPSUHVFLQGLEOH /DV PHGLGDV KLJLpQLFDV DSURSLDGDV SDUD OD SUHSDUDFLyQ ItVLFD GH OD SDUWXULHQWD GLVPLQX\HQHOULHVJRGHLQIHFFLyQ 6HUiUHFRPHQGDEOHDOLQJUHVREDxRGHGXFKD\HOXVRGHYHVWLPHQWDKROJDGD\OLPSLD 1RVHUiQQHFHVDULRVGHUXWLQDORVHQHPDVQLHOUDVXUDGRGHODJHVWDQWH (O SDUWR SXHGH DVRFLDUVH FRQ ULHVJR GH LQIHFFLyQ VL VH SUHVHQWDQ ODV VLJXLHQWHV FRQGLFLRQHV 0DODVFRQGLFLRQHVKLJLpQLFDVGHODPDGUH 0DODVFRQGLFLRQHVKLJLpQLFDVGHOOXJDUGHDWHQFLyQ ([FHVRGHH[iPHQHVSRUYtDYDJLQDORFRQWpFQLFDLQDGHFXDGD (SLVLRWRPtDGHVJDUURV 7UDEDMRGHSDUWRSURORQJDGR 5RWXUDSURORQJDGDGHPHPEUDQDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $6,67(1&,$'85$17((/3(5,2'2'(',/$7$&,2135,0(53(5,2'2 2%-(7,92 &RQWURODUELHQHVWDUPDWHUQR\IHWDO 'HWHFWDU\HYDOXDUGHVYLDFLRQHVGHORVOtPLWHV¿VLROyJLFRV SURJUHVRGHOSDUWR (YDOXDUULHVJR\UHIHULUDQLYHODSURSLDGR $SOLFDUPDQLREUDVFRUUHFWLYDV $&7,9,'$' ,QIRUPDFLyQDODHPEDUD]DGD &RQWUROHVPDWHUQRV &RQWUROHVREVWpWULFRV 5HJLVWURGHORVFRQWUROHVHQHOSDUWRJUDPDFRQFXUYDVGHDOHUWD /DDWHQFLyQFRQVHUYDGRUDGHOSDUWRQRUPDOSURFXUD x9LJLODUHOWUDQVFXUVRGHOPLVPR x1R LQWHUIHULU FRQ DVSHFWRV ¿VLROyJLFRV \ SVLFROyJLFRV HYLWDQGR PDQLREUDV LQQHFHVDULDV x3URPRYHUODSDUWLFLSDFLyQDFWLYDGHODPDGUH\PLHPEURGHOJUXSRIDPLOLDUTXHOD DFRPSDxD x3URPRYHUFRQWDFWRSUHFR]PDGUHKLMR ,QIRUPDFLyQDODHPEDUD]DGD (VWDGHEHLQLFLDUVHGHVGHODYLVLWDSUHFRQFHSFLRQDORHOSUHQDWDO\GHEHVHUUHIRU]DGD HQ FDGD FRQWDFWR GHO SHUVRQDO FRQ OD PXMHU JHVWDQWH TXLHQ DGHPiV GHEH UHFLELU XQD DWHQFLyQ WUDQTXLOL]DGRUD VLQ HVWULGHQFLD QL DQVLHGDG ,QFOX\H OD SURPRFLyQ GH OD SDUWLFLSDFLyQGHOFyQ\XJHXRWURPLHPEURGHOJUXSRIDPLOLDUHQHOSDUWR8QDYH]LQLFLDGR HOSDUWRVHGHEHQHQIDWL]DUORVVLJXLHQWHVFRQWHQLGRV x ,QIRUPDFLyQVREUHHOWUDEDMRGHSDUWR x 5HFRPHQGDFLRQHVVREUHVXSDUWLFLSDFLyQDFWLYD\IDPLOLDU x ,PSRUWDQFLDGHODSRVLFLyQYHUWLFDO\GHDPEXODFLyQSDUDHOSHUtRGRGHGLODWDFLyQ x ,PSRUWDQFLDGHODKLGUDWDFLyQGXUDQWHHOWUDEDMRGHSDUWR /DLQIRUPDFLyQTXHVHHQWUHJDDODPDGUHGHEHVHUYHUD]\GHEHFRQWULEXLUDTXHVH HVSHUHHOGHVDUUROORGHOSDUWRVLQDQVLHGDG'HEHXVDUVHXQOHQJXDMHDSURSLDGRDVX QLYHOFXOWXUDO 'HEHHVWLPXODUVHODDFWLYDSDUWLFLSDFLyQGHODPXMHUJHVWDQWHKDFLpQGRODFRQVFLHQWH GHODVPRGL¿FDFLRQHVTXHYDVXIULHQGRHLQVWDQGRDVXIDPLOLDUDEULQGDUHODGHFXDGR DSR\RSVLFRItVLFRTXHODVLWXDFLyQUHTXLHUH 'HEH UHFRPHQGDUVH OD OLEUH LQJHVWD GH OtTXLGRV GH SUHIHUHQFLD D]XFDUDGRV SDUD GLVPLQXLUHOULHVJRGHGHVKLGUDWDFLyQTXHVHDVRFLDDODDFWLYLGDGItVLFD\DODIUHFXHQWH KLSHUYHQWLODFLyQPDWHUQD 0DQHMRFRQVHUYDGRUGHOSDUWRVHGHQRPLQDDVtDODIRUPDGHDVLVWLUHOSDUWRPHGLDQWH ODFXDOVHORGHMDHYROXFLRQDUHQIRUPDQDWXUDOVLQLQWHUYHQFLRQHVLQMXVWL¿FDGDV $FRPSDxDPLHQWR D OD PDGUH GXUDQWH HO WUDEDMR GH SDUWR OD SUHVHQFLD GH XQD R PiVSHUVRQDVTXHDFRPSDxHQDODSDUWXULHQWDGXUDQWHHOWUDEDMRGHSDUWR\SDUWRHVXQ FRPSRQHQWHFRQVWDQWHHQFDVLWRGDVODVWUDGLFLRQHV(QODDVLVWHQFLDLQVWLWXFLRQDOGHO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD SDUWRKDQDSDUHFLGRUHVWULFFLRQHVTXHKDQSHUPDQHFLGRKDVWDHOGtDGHKR\&XDQGR HVWR RFXUUH OD PXMHU HV DVLVWLGD H[FOXVLYDPHQWH SRU SHUVRQDO GH VDOXG \ HQ PXFKDV RFDVLRQHVSHUPDQHFHVRODGXUDQWHJUDQSDUWHGHOSHUtRGRGHGLODWDFLyQ&XDQGRHVWi SURKLELGDODGHDPEXODFLyQODPXMHUSXHGHWHQHUPD\RUDQJXVWLDORTXHVHUHÀHMDHQ XQPD\RUUHTXHULPLHQWRGHDQDOJpVLFRVVHGDQWHVHLQWHUYHQFLRQHVREVWpWULFDVFRPR ODLQIXVLyQGHRFLWRFLQDHOXVRGHIyUFHSVHVSiWXODVYDFXXPRLQFOXVRFHViUHD6H KDQUHDOL]DGRP~OWLSOHVHVWXGLRVFOtQLFRVFRQWURODGRVTXHPLGHQHOLPSDFWRSRVLWLYRGHO DFRPSDxDPLHQWRGXUDQWHHOWUDEDMRGHSDUWR\SDUWRSRUSHUVRQDVH[WHUQDVDOHTXLSR GHVDOXG(QHVWHVHQWLGRKD\HVWXGLRVTXHHQSDUWLFXODUKDQPHGLGRHOLPSDFWRSRVLWLYR TXH WLHQH OD SUHVHQFLD GH XQ DFRPSDxDQWH GH VH[R IHPHQLQR H[WHUQR D OD IDPLOLD \ DO HTXLSR GH VDOXG$OJXQRV LQYHVWLJDGRUHV SURSXVLHURQ OODPDUOH ³'RXOD´ GHO JULHJR ³VLUYLHQWD´ \D TXH HQ OD DQWLJXD *UHFLD ODV VLUYLHQWDV DFRPSDxDEDQ D OD SDUWXULHQWD GXUDQWH OH WUDEDMR GH SDUWR7RGRV HVWRV HVWXGLRV FRQFOX\HQ TXH OD SUHVHQFLD GH XQ DFRPSDxDQWHGLVPLQX\HHOXVRGHLQWHUYHQFLRQHVLQQHFHVDULDV\VHREWLHQHQPHMRUHV UHVXOWDGRVPDWHUQRV\QHRQDWDOHVOOHJDQGRLQFOXVRDSURORQJDUVHODODFWDQFLDQDWXUDO &/$3605 FRPR RUJDQLVPR GH OD 236206 UHFRPLHQGD HVWLPXODU XQD VHULH GH SUiFWLFDVTXHKDQGHPRVWUDGRVHUEHQH¿FLRVDVSDUDODPXMHU\VXIXWXURKLMRHQWUHODV TXHHQHVWHDSDUWDGRVHFLWDQVRORGRV x$SR\RHPRFLRQDOSRUORVSUHVWDGRUHVGHVHUYLFLRGXUDQWHHOWUDEDMRGHSDUWR\HOSDUWR x5HVSHWRDTXHODPXMHUHOLMDVXVDFRPSDxDQWHV 5HFLHQWHV LQYHVWLJDFLRQHV FOtQLFDV DOHDWRUL]DGDV VHxDODQ TXH HQ DTXHOORV VHUYLFLRV PDUFDGRVSRUIXHUWHLQWHUYHQFLRQLVPRREVWpWULFRHODFRPSDxDPLHQWRSXHGHQRFDPELDU ORVUHVXOWDGRVREVWpWULFRV &RQWUROHVPDWHUQRV 3DUDHYLWDUODDSDULFLyQGHVLWXDFLRQHVGHGHVHTXLOLEULRKHPRGLQiPLFRGHEHUiQFRQWURODUVH xHOSXOVRGHODPXMHU xODSUHVLyQDUWHULDO xWHPSHUDWXUDD[LODU (VWRV FRQWUROHV VH HIHFWXDUiQ HQWUH FRQWUDFFLRQHV FDGD KRUDV 6L DSDUHFLHUDQ VtQWRPDVWDOHVFRPR x 'LVQHD x)RWRSVLDV x /LSRWLPLDV x$F~VIHQRVHWF x &HIDOHDV 'HEHUiQUHVSHWDUVHORVFRQWUROHVHQODVVLJXLHQWHVFRQGLFLRQHV x &RORFDUDODSDUWXULHQWDHQGHF~ELWRODWHUDOL]TXLHUGR x 9LJLODUHVWULFWDPHQWHOD)&) x 5HSHWLUHOFRQWURODORVPLQXWRV x 6L KD\ KLSRWHQVLyQ VH SXHGH FRQVLGHUDU OD DGPLQLVWUDFLyQ GH XQD LQIXVLyQ GH VROXFLyQVDOLQD 6L KD\ VLJQRV R VtQWRPDV VXJHUHQWHV GH SUHHFODPSVLD VHYHUD VKRFN WUDVWRUQR FDUGLRYDVFXODUR¿HEUHDOWDGHEHFRQVLGHUDUVHHVWDVLWXDFLyQFRPRGHDOWRULHVJR(Q HVWH FDVR VH HYDOXDUi HO SURJUHVR GHO SDUWR SDUD GHFLGLU VX HYHQWXDO UHIHUHQFLD DO QLYHODSURSLDGR/DPLVPDFRQGXFWDGHEHUiDGRSWDUVHVLODVPDQLREUDVLQGLFDGDVQR FRUULJHQODVLWXDFLyQVHDVRFLDQDWUDVWRUQRVGHOD)&)RDKLSHUWRQtDXWHULQD 6HSURSLFLDUiODPLFFLyQHVSRQWiQHDSDUDHYLWDUFDWHWHULVPRYHVLFDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &RQWUROHV2EVWpWULFRV (O WUDEDMR GH SDUWR HV XQ SURFHVR GLQiPLFR FX\D QRUPDOLGDG SXHGH VHU DOWHUDGD HQ FXDOTXLHUPRPHQWR(OORH[LJHHYDOXDU &RQWUDFWLOLGDGXWHULQDFDGDDPLQXWRVHQSHUtRGRVGHPLQXWRVGHDFXHUGR DORVFULWHULRVHQXQFLDGRVHQHOFDStWXORGHDGPLVLyQ )UHFXHQFLDFDUGtDFDIHWDOVHVXJLHUHXQFRQWUROFDGDDPLQXWRV 'XUDFLyQGHOSDUWR(QHOFXDGURVHPXHVWUDODGXUDFLyQHQPLQXWRVGHOSHUtRGRGH GLODWDFLyQFHUYLFDOGHVGHORVDFPKDVWDORVFPHQXQDSREODFLyQGHPDGUHVGH EDMRULHVJRFRQHPEDUD]RV~QLFRVVLQSDWRORJtDFRQRFLGDGHWpUPLQRHQSUHVHQWDFLyQ FHIiOLFD VLQ GHVSURSRUFLyQ FpIDORSpOYLFD GH LQLFLR \ WHUPLQDFLyQ HVSRQWiQHD \ VLQ PHGLFDFLyQ 7HQLHQGR HQ FXHQWD OD SRVLFLyQ PDWHUQD OD SDULGDG \ HO HVWDGR GH ODV PHPEUDQDVRYXODUHV &XDGUR'XUDFLyQHQPLQXWRVGHOWUDEDMRGHSDUWRVHJ~QSRVLFLyQPDWHUQD SDULGDG\HVWDGRGHPHPEUDQDVRYXODUHV 0HPEUDQDVURWDV DORV±FPV 1XOtSDUDV 7RGDVODVSDULGDGHV 0HPEUDQDVtQWHJUDVKDVWDORVFP 3RVLFLyQKRUL]RQWDO 3RVLFLyQKRUL]RQWDO 3RVLFLyQYHUWLFDO 333 333 333 1XPHURVDV HYLGHQFLDV VHxDODQ TXH HO WUDEDMR GH SDUWR HV PiV ¿VLROyJLFR FXDQGR VHSHUPLWHTXHODPDGUHDGRSWHOLEUHPHQWHODSRVLFLyQYHUWLFDOGXUDQWHHOSHUtRGRGH GLODWDFLyQFX\DYHQWDMDSDUHFHUHVLGLUHQ xHOiQJXORHQWUHHMHIHWDO\HVWUHFKRVXSHULRUIDYRUHFHHOHQFDMDPLHQWR xODVFRQWUDFFLRQHVVRQPiVLQWHQVDV\H¿FLHQWHV xODPXMHUHVWiPiVFyPRGD\VXIUHPHQRVGRORU xODGXUDFLyQGHOWUDEDMRVHDFRUWD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD )5 72'$6/$63$5,'$'(6 326,&,210$7(51$ +25,=217$/ 1 3520(',2 PLQXWRV 0(',$1$ ³ 3HUF ³ 3HUF ³ ',)(5(1&,$ PLQXWRV KRUDV 7(67'( .2/02*2529 S 6LJQLILFDWLYR )5 326,&,210$7(51$ 9(57,&$/ '(3,(&$0,1$1'26(17$'$ 1 3520(',2PLQXWRV 0(',$1$ ³ 3HUF ³ 3HUF ³ KRUDV )LJ'XUDFLyQGHOSHUtRGRGHGLODWDFLyQHQWUHFP\FPGHGLODWDFLyQ 6LQPHGLDURWUDVPDQLREUDVODSRVLFLyQYHUWLFDODFRUWDODGXUDFLyQGHOWUDEDMRGHSDUWR HQ XQ ¿JXUD (VWD QR LQÀX\H HQ HO PRPHQWR GH OD URWXUD HVSRQWiQHD GH PHPEUDQDVQLVREUHODIUHFXHQFLDGHPRGHODMHFHIiOLFRHQSDUWLFXODUVREUHODEROVD VHURVDQJXtQHDFXDQGRODVPHPEUDQDVHVWiQtQWHJUDV\IDYRUHFHODURWDFLyQLQWHUQD FHIiOLFD 6L OD PDGUH HVFRJH OD SRVLFLyQ KRUL]RQWDO pVWD GHEH VHU HQ GHF~ELWR ODWHUDO GH SUHIHUHQFLD L]TXLHUGR SDUD SUHYHQLU OD SRVLEOH DSDULFLyQ GH KLSRWHQVLyQ PDWHUQD FRQ ULHVJRGHKLSR[LDIHWDO /DDPQLRWRPtDDFRUWDODGXUDFLyQGHOWUDEDMRGHSDUWRSHURVHDVRFLDDXQDVHULHGH ULHVJRVSDUDODPDGUH\VXKLMR $OWHUDHOPRPHQWR ILVLROyJLFRGHUXSWXUDGH PHPEUDQDVRYXODUHV $XPHQWDHOFDSXW VXFFHGDQHXP\HO GHVDOLQHDPLHQWRHQWUH KXHVRVSDULHWDOHV HQHOUHFLpQQDFLGR 3URGXFHULHVJRSRWHQFLDO GHLQIHFLyQSRVSDUWR \QHRQDWDOVLWUDQVFXUUHQ PiVGHVHLVKRUDV KDVWDHODOXPEUDPLHQWR $XPHQWDODFRPSUHVLyQ GHODFDEH]DIHWDO 326,%/(6/(6,21(6 $/$0$'5((/)(72 <(/5(&,(11$&,'2 325$01,2720,$ 35(&2='85$17( (/3$5721250$/ $XPHQWDODGHVDFHOHUDFLyQ SUHFR]GHOULWPRFDUGtDFR IHWDO'LSWLSR, )DFLOLWDODRFOXVLyQGH YDVRVXPELOLFDOHVGXUDQWH ODVFRQWUDFFLRQHVXWHULQDV 'LSYDULDEOHV +DFHIUHFXHQWHHOXVR GHIyUFHSVHQSDUWRV GHEDMRULHVJR )LJXUD$PQLRWRPtDSUHFR]GXUDQWHHOSDUWRQRUPDO &RQVHUYDQGR OD SRVLFLyQ YHUWLFDO SXHGH DFRUWDUVH OD GXUDFLyQ GHO WUDEDMR GH SDUWR /D DPQLRWRPtD QR WLHQH LQGLFDFLyQ FRPR PDQLREUD UXWLQDULD HQ HO WUDEDMR GH SDUWR QRUPDO 6HGHEHLQGLFDUVyORDQWHODDSDULFLyQGHFRPSOLFDFLRQHVWDOHVFRPR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR x 7UDEDMR GH SDUWR SURORJDQGR GHVFDUWDGD OD GHVSURSRUFLyQ IHWRSpOYLFD H KLSRGLQDPLD x 1HFHVLGDGGHDFRUWDUHOWUDEDMRGHSDUWRSRUSDWRORJtDPDWHUQRIHWDOQRVXVFHSWLEOH GHUHIHUHQFLDDQLYHOGHDOWRULHVJR x 3ROLKLGUDPQLRV x +HPRUUDJLDSRUSODFHQWDSUHYLDPDUJLQDO x 'HVSUHQGLPLHQWRSUHPDWXURGHSODFHQWDQRUPRLQVHUWD x )HWRPXHUWRRPDOIRUPDFLyQIHWDOQRVXVFHSWLEOHVGHUHIHUHQFLD x 1HFHVLGDGGHYDORUDUHOOtTXLGRDPQLyWLFR 3URJUHVRGHODGLODWDFLyQ\GHOGHVFHQVRGHODSUHVHQWDFLyQ 6HHYDOXDUiSRUPHGLRGHOH[DPHQJHQLWDO(OH[DPHQSRUYtDYDJLQDOGHEHVHUHIHFWXDGR FRQHOGHELGRFXLGDGRSDUDQRSURYRFDUODURWXUDGHODVPHPEUDQDV (OSURJUHVRGHODGLODWDFLyQQRHVXQDIXQFLyQOLQHDO\VXYHORFLGDGQRHVFRQVWDQWH 'RVWHUFLRVGHOWLHPSRWRWDOTXHGXUDODGLODWDFLyQVHFRQVXPHQKDVWDORV±FP\ HO WHUFLR UHVWDQWH KDVWD OD GLODWDFLyQ FRPSOHWD ¿JXUD (VWH SDWUyQ QRUPDO SXHGH DOWHUDUVHHQHOVHQWLGRGHODSURORQJDFLyQRODDFHOHUDFLyQ (OGHVFHQVRGHODSUHVHQWDFLyQWDPELpQHVXQIHQyPHQRSURJUHVLYRTXHVHDFHOHUDDO ¿QDOGHOSHUtRGRGHGLODWDFLyQ6HYHLQÀXLGRSRU x ODYDULHGDGGHSRVLFLyQ x HOJUDGRGHÀH[LyQGHODFDEH]DIHWDO x HOJUDGRGHSURSRUFLyQSpOYLFRIHWDO x ODSDULGDG x ODSRVLFLyQPDWHUQD x HOHVWDGRGHODVPHPEUDQDVRYXODUHV 'LODWDFLyQ\GHVFHQVRVRQSURFHVRVtQWLPDPHQWHUHODFLRQDGRVTXHH[LJHQVXHYDOXDFLyQ VLPXOWiQHD (O&/$3605KDFRQIHFFLRQDGRXQIRUPXODULRFRPSOHPHQWDULRGHOD+&3HO3DUWRJUDPD ¿JXUD HQ GRQGH VH JUD¿FD OD HYROXFLyQ GHO WUDEDMR GH SDUWR $ HVWD KRMD VH WUDQV¿HUHQORVYDORUHVUHJLVWUDGRVSUHYLDPHQWHHQOD+&3 (O SDUWRJUDPD HV XQ LQVWUXPHQWR TXH IDFLOLWD OD UiSLGD HYDOXDFLyQ GH OD PDUFKD GHO SDUWR\WLHQHSRUORWDQWRPXFKRYDORUSDUDODGRFHQFLD\VXSHUYLVLyQGHODFDOLGDGGH ODDVLVWHQFLD ',/$7$&,21&(59,&$/FP +DVWDFPGHWLHPSR +DVWDGLODWDFLyQ FRPSOHWD GHWLHPSR +25$6 )LJXUD'LODWDFLyQFHUYLFDOHQIXQFLyQGHOWLHPSRGHWUDEDMRGHSDUWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 3DUWRJUDPDFRQFXUYDVGHDOHUWD 6HWUDWDGHXQVLVWHPDGHYLJLODQFLDWDQWRSDUDODSUHYHQFLyQGHOSDUWRSURORQJDGRFRPR SDUD OD SUHYHQFLyQ GH LQWHUYHQFLRQHV QR VLHPSUH RSRUWXQDV FRPR OD HVWLPXODFLyQ FRQ RFLWRFLQDRODRSHUDFLyQFHViUHD(VXQRGHORVLQVWUXPHQWRVLQGLVSHQVDEOHVSDUDHYDOXDU ODFDOLGDGGHODDWHQFLyQGHOSDUWRDODYH]TXHUHVXOWDXQDKHUUDPLHQWDSUiFWLFDSDUDYLJLODU HOSURJUHVRGHOSDUWRHQXQFDVRLQGLYLGXDO /DVFXUYDVPDUFDQXQOtPLWHH[WUHPRSHUFHQWLOGHODHYROXFLyQGHODGLODWDFLyQFHUYLFDO HQIXQFLyQGHOWLHPSRTXHLQFOX\HHOGHODWRWDOLGDGGHORVSDUWRVQRUPDOHV3HUPLWHQ DOHUWDU SUHFR]PHQWH DQWH DTXHOORV FDVRV TXH DO WUDVSDVDU HVH OtPLWH (VWpQ PRVWUDQGR XQHQOHQWHFLPLHQWRTXHUHTXLHUDPD\RUYLJLODQFLDSDUDGHVFDUWDUDOJXQDSRVLEOHGLVWRFLD %ULQGDQ SRU OR WDQWR WLHPSR VX¿FLHQWH SDUD SHUPLWLU OD FRUUHFFLyQ GH OD DQRPDOtD HQ HO SURSLROXJDURSDUDODUHIHUHQFLDRSRUWXQDGHOFDVR /DVFXUYDVGHDOHUWDSUHVHQWDQODGXUDFLyQGHODGLODWDFLyQFHUYLFDOGHVGH±FPKDVWDHO ¿QDOGHOSDUWR/RVYDORUHVSDUDVXHODERUDFLyQIXHURQREWHQLGRVGHGRVLQYHVWLJDFLRQHV SURVSHFWLYDV UHDOL]DGDV SRU &/$3605 VREUH SDUWRV GH EDMR ULHVJR GH LQLFLR \ WHUPLQDFLyQHVSRQWiQHDVLQPHGLFDFLyQ\FRQUHFLpQQDFLGRVQRUPDOHV\YLJRURVRV 3DUD HVWDEOHFHU ODV FXUYDV SDWUyQ QRUPDOHV VH DQDOL]DURQ SUHYLDPHQWH DOJXQDV FDUDFWHUtVWLFDVGHODSREODFLyQHVWXGLDGDTXHSXGLHVHQLQÀXLUHQODHYROXFLyQGHODGLODWDFLyQ 6HVXEGLYLGLyODPXHVWUDVHJ~QODSDULGDGODSRVLFLyQPDWHUQDGXUDQWHHOWUDEDMRGHSDUWR \HOHVWDGRGHODVPHPEUDQDVRYXODUHV/DVSDULGDGHVVHGLYLGLHURQHQQXOtSDUDVQLQJ~Q SDUWRSUHYLR\PXOWtSDUDVXQRRPiVSDUWRVSUHYLRV/DSRVLFLyQGXUDQWHHOSHUtRGRGH GLODWDFLyQIXHYHUWLFDODGHOWLHPSRVHQWDGDSDUDGDRFDPLQDQGRRODKRUL]RQWDO HQFDPD6HJ~QHOHVWDGRGHODVPHPEUDQDVRYXODUHVDORV±FPGHGLODWDFLyQ FHUYLFDOHOJUXSRVHGLYLGLyHQPHPEUDQDVURWDV\PHPEUDQDVtQWHJUDV (QOD¿JXUDVHPXHVWUDQORVSDWURQHVQRUPDOHVUHVXOWDQWHVGHHVWHDQiOLVLV ',/$7$&,21&(59,&$/HQFP 3$572 326,&,21 0$7(51$ 3$5,'$' 0(0%5$1$6 298/$5(6 +RUL]RQWDO 0XOWtSDUDV 5RWDV 9HUWLFDO 7RGDV ,QWHJUDV +RUL]RQWDO 0XOWtSDUDV ,QWHJUDV +RUL]RQWDO 0XOWtSDUDV 5RWDV +RUL]RQWDO 0XOWtSDUDV ,QWHJUDV 1727$/ 1 )LJXUD3DWURQHVGHGLODWDFLyQFHUYLFDOHQIXQFLyQGHOWLHPSR3 &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD +25$6 &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (QXQDSREODFLyQGHPXMHUHVDIULFDQDV 3KLOSRW GHVFULELy XQD VROD FXUYD GH DOHUWD$ GLIHUHQFLD GH DTXHO HVWXGLR OD FRQIRUPDFLyQ GH YDULDV FXUYDV GH DOHUWD SURYHQLHQWHV GH HVWRV FLQFR JUXSRVRIUHFHPD\RUHVSRVLELOLGDGHV GHXELFDUHOFDVRLQGLYLGXDOGHQWURGH XQ SDWUyQ QRUPDO TXH UHÀHMH OR PiV ¿HOPHQWH SRVLEOH HO FRPSRUWDPLHQWR HVSHUDGR¿JXUD $ FRQWLQXDFLyQ VH SUHVHQWD HO IRUPXODULRGH3DUWRJUDPDFRQYDORUHV 3SDUDWUD]DUODVFXUYDVGHDOHUWD VHJ~Q OD VLWXDFLyQ GH FDGD FDVR ¿JXUD 326,&,21 3$5,'$' 0(0%5$1$6 9(57 +25,=217$/ 08/7,3$5$6 ,17( *5$6 527$6 18/Ì3$5$6 ,17( *5$6 527$6 72'$6 ,17( *5$6 )LJXUD9DORUHVSDUDODFRQVWUXFFLyQGHODV FXUYDVGHDOHUWD3 &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 52785$(63217$1($0(0% 326,&,210$7(51$ /DWGHUHFKR /' /DWL]TXLHUGR/, 'RUVDO' 6HPLVHQWDGD66 6HQWDGD6 3DUDGDRFDPLQDQGR3& )5(&8(1&,$&$5',$&$)(7$/ 'LSVWLSR, 'HVFHOHUDFLyQSUHFR], 'LSVWLSR,, 'HVFHOHUDFLyQWDUGtD,, 'LSVYDULDEOHV 'HVFHOHUDFLyQYDULDEOH9 0HFRQLR0 ,17(16,'$' )XHUWH 1RUPDO 'pELO 52785$$57,),&,$/0(0% '2/25 /RFDOL],QWHQV )5(&&2175$&&,21(6 '85$&,21&2175$&&,21(6 )5(&8(1&,$&$5',$&$)(7$/ 38/620$7(512 7(16,21$57(5,$/ 326,&,210$7(51$ +25$ +25$5($/ D 3DUWR +25$6'(5(*,6752 /2&$/,=$&,21 6XSUDS~ELFR63 6DFUR6 5(0 5$0 INICIA LA CURVA DE ALERTA LINEA DE BASEDESDE LA QUE SE 3/$126'(+2'*(< 9$5,('$''(326,&,21 ',/$7$&,21&(59,&$/ 6&+:$5&=5',$=$* 1,(72)&/$3 3XEO&LHQWLILFD1 0RQWHYLGHR8UXJXD\ 0(0%5$1$6 E F G H I 2#461)4#/#%.#25/41251/5 ' , / $ 7 $ & , 2 1& ( 5 9 , & $ / F P 9(57 +25,=217$/ 18/Ë3$5$6 72'$6 08/7,3$5$6 ,17( ,17( 527$6 ,17( 527$6 *5$6 *5$6 *5$6 J K 120%5(<$3(//,'2 L M N O GtD P PHV DxR Q R S ,9 ,,, ,, , 3/$126 1'(+,6725,$&/,1,&$ 37*(6$93 326,&,21 3$5,'$' 6DOXG6H[XDO\5HSURGXFWLYD )LJXUD3DUWRJUDPDFRQFXUYDGHDOHUWD&/$3605 3URFHGLPLHQWRSDUDJUD¿FDUODGLODWDFLyQFHUYLFDO\ODVFXUYDVGHDOHUWD /RVGDWRVSDUDFRQVWUXLUODVFXUYDVSDWUyQGHDOHUWDIXHURQREWHQLGRVGHVGHORV± FPGHGLODWDFLyQFHUYLFDOSULPHUSXQWRFRQ¿DEOHGHSDUWLGDSDUDODPHGLGDSRUHOWDFWR 3RUHOORODFXUYDTXHVHHOLMDSDUDFDGDWUDEDMRGHSDUWRVHWUD]DUiDSDUWLUGHTXHHO PLVPRKD\DDOFDQ]DGRRVXSHUDGRORVFPGHGLODWDFLyQFHUYLFDOOtQHDGHEDVH &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (Q HO H[WUHPR VXSHULRU L]TXLHUGR GHO SDUWURJUDPD VH SUHVHQWD XQD WDEOD FRQ YDORUHV FRUUHVSRQGLHQWHV DO SHUFHQWLO GHO WLHPSR HQ HO TXH FDGD XQR GH ORV VXEJUXSRV DQWHULRUPHQWHPHQFLRQDGRVLQFUHPHQWDQODGLODWDFLyQGHFPDGHDGHD GHDGHD\GHDOSDUWR /DFXUYDGHDOHUWDVHFRPLHQ]DDWUD]DUFXDQGRODFXUYDGHGLODWDFLyQFUX]DODOtQHD GHEDVH(VWHSXQWRGHLQWHUVHFFLyQHQWUHDPEDVFXUYDVVHUiHOSXQWRGHSDUWLGDGH OD FXUYD GH DOHUWD (O REVHUYDGRU D SDUWLU GH HVH PRPHQWR SXHGH HOHJLU GH OD WDEOD LPSUHVD HQ HO SDUWRJUDPD ORV YDORUHV FRUUHVSRQGLHQWHV D ODV VLWXDFLRQHV REVWpWULFDV DUULEDVHxDODGDV8QDYH]VHOHFFLRQDGDODDOWHUQDWLYDTXHPHMRUVHDVHPHMDDOFDVR LQGLYLGXDOGHVGHODOtQHDGHEDVHHQHOSXQWRHQTXHpVWDHVFUX]DGDSRUODFXUYDGH GLODWDFLyQGHOFDVRVHPDUFDUDQORVYDORUHVGHOSDWUyQHOHJLGR ,QJUHVRWHPSUDQR (Q HO HMHPSOR D ODV KRUDV UHDO VH FRPHQ]y HO UHJLVWUR GH ORV GDWRV GH XQ QXOtSDUDFRQPHPEUDQDVRYXODUHVtQWHJUDV\HQSRVLFLyQKRUL]RQWDO(OWDFWRUHDOL]DGR HQHVHPRPHQWRFRPSUREyXQDGLODWDFLyQFHUYLFDOGHFP(OSXQWRGHHVWDSULPHUD REVHUYDFLyQ VH PDUFy DO LQLFLR GHO UHJLVWUR$ ODV KRUD UHDO VH FRPSUREy XQD URWXUDHVSRQWiQHDGHODVPHPEUDQDVRYXODUHV\HOWDFWRHQFRQWUyFPGHGLODWDFLyQ 6HPDUFyXQQXHYRSXQWRHQODLQWHUVHFFLyQGHODDEFLVDDODKRUDUHDOKRUD GHOFRPLHQ]RGHOUHJLVWURFRQODRUGHQDGDDORVFPGHGLODWDFLyQ¿JXUD /D OtQHD TXH XQH ORV SXQWRV D ORV FP \ FP SHUPLWH YLVXDOL]DU HO SURJUHVR GH OD GLODWDFLyQFHUYLFDO 3DUWR ' ,/ $7$& ,21 & (59,& $/ FP (Q HO VLJXLHQWH H[DPHQ REVWpWULFR UHDOL]DGR D OD KRUD UHDO D KV GHO LQLFLR GHO UHJLVWUR HQ HO SDUWRJUDPD OD GLODWDFLyQ FHUYLFDO DOFDQ]yORVFP (YROXFLyQGH ODGLODWDFLyQ FHUYLFDO =21$'($/(57$ &XUYDGH$OHUWD &RPR VH YH OD LQWHUVHFFLyQ HQWUH OD /tQHDGH%DVH FXUYDGHGLODWDFLyQ\ODOtQHDGHEDVH VHSURGXMRDODVKVGHOLQLFLRGHO 5(0 3XQWRFHURGHOD &XUYDGH$OHUWD UHJLVWUR HQ HO SDUWRJUDPD (VWH HV HO SXQWR GH SDUWLGD SDUD FRPHQ]DU D +25$6'( 75$%$-2 FRQVWUXLUODFXUYDGHDOHUWDGHVGHORV '(3$572 30 FPGHGLODWDFLyQFHUYLFDO¿J +25$5($/ Figura 84. Ejemplo con ingreso temprano 'HODWDEODVHH[WUDHUiQORVYDORUHVFRUUHVSRQGLHQWHDHVWHFDVRSRVLFLyQKRUL]RQWDO QXOtSDUDPHPEUDQDVURWDV3DUDFRPHQ]DUDWUD]DUODFXUYDGHDOHUWDGHHVWHFDVR DODVKRUDVGHOSXQWRGHVXSDUWLGDVHPDUFDUiHOFRUUHVSRQGLHQWHDORVFPGH GLODWDFLyQ$SDUWLUGHHVWHQXHYRSXQWRKVGHVSXpVVHPDUFDUiHOSXQWRSDUDORV FP'HVGHpVWHVHPDUFDUiKRUDVGHVSXpVHOGHORVFP\DVtVXFHVLYDPHQWH KDVWDHO¿QDOGHOSDUWR (QHVWHFDVRHOWUDEDMRGHSDUWR\HOSDUWRWXYLHURQXQDHYROXFLyQQRUPDO\ODFXUYDGH GLODWDFLyQFHUYLFDOVHPDQWXYRDODL]TXLHUGDGHODFXUYDGHDOHUWD (Q HVWD PLVPD ¿JXUD VH SUHVHQWD RWUR FDVR HQ HO TXH D SDUWLU GH ORV FP /D YHORFLGDG GH OD GLODWDFLyQ VH HQOHQWHFH \ VX JUi¿FD FUX]D OD FXUYD GH DOHUWD OtQHD SXQWHDGD(QHVWHFDVRFRQLJXDOHVFRQGLFLRQHVGHLQJUHVRTXHHODQWHULRUDODV KRUDVUHDO\KRUDVGHVSXpVGHOLQLFLRGHOUHJLVWURHQHOSDUWRJUDPDVHREVHUYyXQ WUDEDMRGHSDUWRSURORQJDGR$OHUWDGRSRUHVWHVLVWHPDGHYLJLODQFLDHOHTXLSRGHVDOXG UHYLVyHOFDVR\SXGRDSOLFDURSRUWXQDPHQWHODVPHGLGDVDSURSLDGDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD /D FXUYD GH DOHUWD VH LQLFLy GHVGH HVWH SULPHU WDFWR $ SDUWLU GHO PLVPRpVWDVHWUD]yFRQORVYDORUHV FRUUHVSRQGLHQWHV D ODV FRQGLFLRQHV GHLQJUHVRGHOFDVR 3DUWR ',/$7$&,2 1&(59,&$/F P ,QJUHVRWDUGtR /D ¿JXUD PXHVWUD XQD QXOtSDUD FRQPHPEUDQDVtQWHJUDVHQSRVLFLyQ KRUL]RQWDOTXHLQJUHVyDOUHJLVWURFRQ FPGHGLODWDFLyQFHUYLFDO (YROXFLyQ GHOD GLODWDFLyQ FHUYLFDO =21$'($/(57$ &XUYDGH$OHUWD /tQHDGH%DVH $ GLIHUHQFLD GHO HMHPSOR DQWHULRU +25$6'( 75$%$-2 HQ ORV LQJUHVRV FRQ FP R PiV GH '(3$572$0 GLODWDFLyQ HO SXQWR GH SDUWLGD GH OD +25$5($/ FXUYD GH DOHUWD VLHPSUH VHUi HO GHO Figura 85. Ejemplo con ingreso tardío SULPHUYDORUDQRWDGRGHODGLODWDFLyQ FHUYLFDOHQHOSDUWRJUDPD &RQGLFLRQHVFDPELDQWHVGXUDQWHHOWUDEDMRGHSDUWR 6L YDUtDQ ODV FRQGLFLRQHV GH LQJUHVR GXUDQWH HO WUDQVFXUVR GHO WUDEDMR GH SDUWR VH GHEHUiDFWXDOL]DUODFXUYDGHDOHUWDLQLFLDOPHQWHWUD]DGD 3DUWR ' , / $7$ &, 2 1 &( 59 , &$ / F P /D ¿JXUD PXHVWUD HO FDVR GH XQD PXOWtSDUD HQ SRVLFLyQ KRUL]RQWDO \ FRQ ODV PHPEUDQDV RYXODUHV tQWHJUDV ,QJUHVy DO UHJLVWUR GHOSDUWRJUDPDDODVKV 30 FRQ FP GH GLODWDFLyQ FHUYLFDO\KRUDVPiVWDUGH DOFDQ]yFP 1XHYDFXUYD GHDOHUWD (YROXFLyQGH ODGLODWDFLyQ FHUYLFDO 5(0 =21$'($/(57$ &XUYDGH$OHUWD2ULJLQDO 3XQWRGH&DPELR /tQHDGH%DVH /D JUi¿FD GH OD GLODWDFLyQ FRUWy OD OtQHD GH EDVH D ORV PLQXWRV GHO FRPLHQ]R GHO SDUWRJUDPD 'HVGH HVWH +25$6'( 75$%$-2 SXQWR VH FRQVWUX\y OD FXUYD '(3$57230 GH DOHUWD DSURSLDGD SDUD HO +25$5($/ FDVR Figura 86. Ejemplo para condiciones cambiantes 'HELGRTXHDORVFPODVPHPEUDQDVVHURPSLHURQHVSRQWiQHDPHQWHIXHQHFHVDULR FRQVWUXLU XQD QXHYD FXUYD GH DOHUWD VXVWLWX\HQGR ORV YDORUHV SUHYLRV SRU ORV GH XQD PXOWtSDUDHQSRVLFLyQKRUL]RQWDOSHURFRQODVPHPEUDQDVURWDV (OGLEXMRGHODQXHYDFXUYDGHDOHUWDVHLQLFLyGHVGHODFXUYDSUHYLDDQLYHOGHORVFP HQTXHVHFRQVWDWyODURWXUDGHODVPHPEUDQDV(VWD~OWLPDFXUYDGHDOHUWDIXHODTXH PHMRUVHFRUUHVSRQGLyFRQODQXHYDVLWXDFLyQ 3DUDIDFLOLWDUODFRQVWUXFFLyQGHODVFXUYDVGHDOHUWD&/$3605GLVHxyXQDSODQWLOODGH SOiVWLFRFRQUDQXUDVFXUYDVFRUUHVSRQGLHQWHVDORVSDWURQHVDUULEDGHVFULWRV (VWDSODQWLOODTXHVHWUDQVSRUWDVREUHHOIRUPXODULRGHOSDUWRJUDPDSHUPLWHGLEXMDUOD FXUYDGHDOHUWDHOHJLGDSDUDHOFDVRHQSRFRVVHJXQGRV¿JXUD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR )LJXUD3ODQWLOODGHSOiVWLFRFRQUDQXUDVSDUDWUD]DUODVFXUYDVGHDOHUWD 2WURV HOHPHQWRV GHO SDUWURJUDPD TXH D\XGDQ D OD YLJLODQFLD GHO SURJUHVR GHO SDUWR\GHODVFRQGLFLRQHVPDWHUQR±IHWDOHV (QODFXDGUtFXODFHQWUDOGHOSDUWRJUDPDDGHPiVGHODGLODWDFLyQFHUYLFDOFRQVXFXUYD GHDOHUWDFRUUHVSRQGLHQWHVHSXHGHUHJLVWUDUODDOWXUDGHODSUHVHQWDFLyQODYDULHGDG GHSRVLFLyQHOHVWDGRGHODVPHPEUDQDVRYXODUHVODIUHFXHQFLDGHODVFRQWUDFFLRQHV XWHULQDV\ODIUHFXHQFLDFDUGtDFDIHWDO¿J (Q OD FXDGUtFXOD LQIHULRU GHO SDUWRJUDPD VH FRQVLGHUDQ OD SUHVLyQ DUWHULDO SXOVR \ SRVLFLyQPDWHUQDLQWHQVLGDG\GRORUGHODVFRQWUDFFLRQHVHWF 7UDEDMRGHSDUWRSURORQJDGR *HQHUDDJRWDPLHQWRItVLFRGHODPDGUHDQVLHGDGFUHFLHQWHDXPHQWDODIUHFXHQFLDGH VXIULPLHQWRIHWDO\HOWUDXPDWLVPRREVWpWULFRFXDGUR /D SURORQJDFLyQ GHO WUDEDMR GH SDUWR REHGHFH KDELWXDOPHQWH D XQD R YDULDV GH ODV FDXVDVVLJXLHQWHV x &XHOORLQPDGXURRSDWROyJLFR x +LSRGLQDPLD x ,DWURJHQLDXVRLQDGHFXDGRGHVHGDQWHVDQDOJpVLFRVRDQHVWpVLFRVGHFRQGXFFLyQ x 'LVWRFLDVGHODSUHVHQWDFLyQ x 'HVSURSRUFLyQIHWR±SpOYLFD x 9HMLJDOOHQD x 5HFWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD &XDGUR&RQGXFWDHQHOSHUtRGRGHGLODWDFLyQ &RQGLFLyQ &RQGXFWD Evolución nornal Observación sin maniobras ni medicación y traslado a sala de parto con dilatación completa Hiperdinama Combio de posición y uteroinhibición. Referencia a alto riesgo Hipodinama Estimulación ocitócica Bradicardia fetal Dips II Tratamiento del sufrimiento fetal in útero. Referencia de alto riesgo. Taquicardia fetal Decúbito lateral - Controlar PA materno Dips variables Dips I con membranas íntegras Control más frecuente de FCF Parto prolongando (según curva de alerta) Reevaluar antecedentes de patología cervical, proporción fetopélvica y contractilidad; corregir hipodinamia; control en una hora. Si no progresa, amniotomía: referencia a alto riesgo. Hemorragia genital Según normas específicas amniotomía. Referencia a alto riesgo Líquido amniótico meconial Control más frecuente. Aspiración inmediata del RN ,QJUHVRHQWUDEDMRGHSDUWR &RQWUROGHVLJQRVYLWDOHVPDWHUQRV &RQWUDFWLOLGDG)&)3URJUHVRGHOSDUWR 1R &RQGXFWDV VLPSOHV QRUPDOL]DQ 1RUPDO 6L 6L 1R 1R +LSHUGLQDPLD 6L 'HF~ELWRODWHUDO 8WHURLQKLELFLyQ 6L %UDGLFDUGLD 'LSV,, 3DUWRSURORQJDGR VHJ~QFXUYDVGHDOHUWD 6L 1R 'HVSURSRUFLyQ SpOYLFD +LSRGLQDPLD SULPLWLYD 1R 6L 2FLWRFLQD $PQLRWRPtD 1R 5HIHUHQFLDDOQLYHOGH DWHQFLyQGHDOWRULHVJR 3URJUHVR GHOSDUWR 1R 3DUWRJUDPD FRQFXUYDV GHDOHUWD KDVWD GLODWDFLyQ FRPSOHWD 6L $WHQFLyQGXUDQWHSHUtRGRH[SXOVLYR VHJ~QQRUPDVGHEDMRULHVJR )LJXUD(VTXHPDGHGHFLVLRQHVGXUDQWHHOSHUtRGRGHGLODWDFLyQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $6,67(1&,$'85$17((/3(5,2'2(;38/6,926(*81'23(5,2'2 2%-(7,92 'HWHFWDU\HYDOXDUGHVYLDFLRQHVGHORVOtPLWHV¿VLROyJLFRVGHO SHUtRGRH[SXOVLYR 3UHYHQLUWUDXPDWLVPRREVWpWULFR 3UHYHQLUKLSR[LDIHWDO $&7,9,'$' &RQWUROGHOD)&) &RQWUROGHODFRQWUDFWLOLGDG &RQWUROGHODYDQFHGHODSUHVHQWDFLyQ\GHVSUHQGLPLHQWR 6HREVHUYDUiQHVWULFWDPHQWHODVQRUPDVGHDVHSVLD $OFDQ]DGRHOFRPLHQ]RGHOSHUtRGRH[SXOVLYRUHVWDQD~QVLWXDFLRQHVGHULHVJRTXHGHEHQ VHUSUHYLVWDV\DOWHUDFLRQHVGHOD¿VLRORJtDTXHGHSUHVHQWDUVHGHEHQFRUUHJLUVH 3HUtRGRH[SXOVLYRSURORQJDGRTXHSXHGHGHEHUVHD D+LSRGLQDPLD E3XMRPDWHUQRLQH¿FD] F'HIHFWRVGHURWDFLyQFHIiOLFD G'HVSURSRUFLyQIHWRSpOYLFDQRGLDJQRVWLFDGD (OWUDXPDWLVPRREVWpWULFRSXHGHSURYRFDUHQODPDGUH 'HVJDUURVYDJLQRSHULQHDOHV 'HVJDUURFHUYLFDO\VHJPHQWDULR 5RWXUDXWHULQD (OWUDXPDWLVPRREVWpWULFRSXHGHFDXVDUHQHOIHWR 6XIULPLHQWRIHWDO 0DUFDGRGHVDOLQHDPLHQWRyVHRFHIiOLFRSDULHWRIURQWRRFFLSLWDO &DEDOJDPLHQWRyVHRFHIiOLFR 7XPRUVHURVDQJXtQHRRFDSXWVXFFHGDQHXPH[DJHUDGR &pIDORKHPDWRPD +HPRUUDJLDLQWUDFUDQHDQD )UDFWXUDV 3DUiOLVLV /HVLRQHVGHWHJXPHQWRV 3HUtRGRH[SXOVLYR $OJXQDVGHODVFRPSOLFDFLRQHVPHQFLRQDGDVSXHGHQVXSHUDUVHHQFRQGLFLRQHVGHEDMR ULHVJRHQIRUPDSUHYHQWLYDRSRUODRSRUWXQDDGRSFLyQGHPHGLGDVFRUUHFWLYDV2WUDV VRQ LQVXSHUDEOHV VLQ OD HMHFXFLyQ GH PDQLREUDV R LQWHUYHQFLRQHV TXH HVFDSDQ D OD QRUPDGHEDMRULHVJR\TXHGHEHQVHUHIHFWXDGDVSRUXQSURIHVLRQDOFRQDOWRJUDGRGH HQWUHQDPLHQWRFHViUHDIyUFHSVHWF (ORSRUWXQRGLDJQyVWLFRGHODGHVSURSRUFLyQIHWRSpOYLFDHYLWD 'HWHQFLyQGHODH[SXOVLyQ 7UDXPDWLVPRPDWHUQRIHWDO 6XIULPLHQWRIHWDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (OSXMRPDWHUQRHVSRQWiQHRHVKDELWXDOPHQWHDGHFXDGRSDUDODH[SXOVLyQIHWDOVLHVWH VHUHDOL]DVLQFUyQLFDPHQWHFRQODFRQWUDFFLyQXWHULQD+D\TXHHYLWDUHOSXMRGLULJLGR FXDQGRREOLJDDODPDGUHDPDQLREUDVGH9DOVDOYDPiVSURORQJDGDVTXHODGXUDFLyQGH ODFRQWUDFFLyQSRUTXHVHDVRFLDDDJRWDPLHQWRPDWHUQR /DDGHFXDGDSURWHFFLyQSHULQHDOSUHYLHQHORVGHVJDUURV &RPR QRUPD JHQHUDO QR VH DFRQVHMD UHDOL]DU OD HSLVLRWRPtD GH UXWLQD H[FHSWR HQ DTXHOODVSDUWXULHQWDVTXHSUHVHQWHQXQSHULQpPX\UHVLVWHQWHFRQULHVJRGHGHVJDUURR VHYD\DDHIHFWXDUXQSDUWRLQVWUXPHQWDO (QORVHQVD\RVFOtQLFRVFRQWURODGRVVHREVHUYyTXHKXERXQQ~PHURPD\RUGHGHVJDUURV GHOSHULQpDQWHULRUFXDQGRHOXVRGHODHSLVLRWRPtDIXHUHVWULQJLGRFRPSDUDGRFRQHOXVR OLEHUDO3RUHOFRQWUDULRORVWUDXPDWLVPRVSHULQHDOHVSRVWHULRUHVIXHURQPHQRUHVHQHO JUXSRUHVWULQJLGRFRPSDUDGRFRQHOOLEHUDO(OGRORUDODOWDIXHPHQRUHQHOJUXSRGHXVR UHVWULQJLGR(OVHJXLPLHQWRUHDOL]DGRKDVWDORVWUHVPHVHVQRPRVWUyGLIHUHQFLDVHQOR UHIHUHQWHDGRORUHVSRQWiQHRHOLQLFLR\GRORUHQODVUHODFLRQHVVH[XDOHVHLQFRQWLQHQFLD GHRULQD 3UHSDUDFLyQ 'XUDQWHODDVLVWHQFLDGHOSHUtRGRH[SXOVLYRVHREVHUYDUiQHVWULFWDPHQWHODVQRUPDVGH DVHSVLD8QDDGHFXDGDSUHSDUDFLyQLPSOLFD 5RSDOLPSLD ,QVWUXPHQWDOHVWpULOSDUDODDWHQFLyQGHOSDUWR *XDQWHVHVWpULOHV /DYDGRTXLU~UJLFRGHPDQRV $VHSVLDSHULQHDO &DPSRVHVWpULOHV 3RVLFLyQGHODSDUWXULHQWD 'HEHHYLWDUVHODSRVLFLyQGHOLWRWRPtDSLHUQDVHVWpQFROJDQGR\RDWDGDVDOQLYHOGHORV WRELOORV\ODJLQHFROyJLFDFOiVLFD(OHJLUHQWUHODVVLJXLHQWHVSRVLFLRQHV 6HPLVHQWDGDUHVSDOGRGHODFDPDGHSDUWRVFRQXQiQJXORGHDJUDGRV\FRQ DSR\DSLp 6HQWDGDHQFDPDGHSDUWRVFRQUHVSDOGRHQiQJXORGHJUDGRVRHQVLOOD (QFXFOLOODVGL¿FXOWDODDXVFXOWDFLyQFDUGtDFDIHWDO\ODSURWHFFLyQGHOSHULQp &RQWUROHVDUHDOL]DUVHGXUDQWHHOSHUtRGRH[SXOVLYR )&)FDGDPLQXWRVHQWUHFRQWUDFFLRQHV(VQRUPDOTXHVHSURGX]FDQGHVFHQVRVKDVWD DODWLGRVFDUGtDFRVIHWDOHVSRUPLQXWRGXUDQWHHOSHUtRGRH[SXOVLYRGHELGRD XQDFRPSUHVLyQFHIiOLFD8QD)&)PHQRUGHODWLGRVSRUPLQXWRPDQWHQLGDHQWUH SXMRVVXJLHUHVXIULPLHQWRIHWDO¿JXUD (¿FDFLDGHODFRQWUDFWLOLGDGXWHULQD\SXMRVPDWHUQRV 'HEHUiQHYDOXDUVHHQIRUPDFRQWLQXD/DSURJUHVLyQGHOGHVFHQVR\GHODURWDFLyQGH ODFDEH]DTXHHQFDVRGHSURJUHVRHVLQGLFDGRUDGHQRUPDOLGDG &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &RQGXFWDJHQHUDO D/DKLSRGLQDPLDSULPLWLYDGHEHWUDWDUVHFRQHVWLPXODFLyQRFLWyFLFD&XDGUR (QODKLSRGLQDPLDVHFXQGDULDFXDQGRHVWiLQGLFDGDXVDURFLWyFLFRV GHVFDUWDUFRQWUDLQGLFDFLyQSDUDORVPLVPRV E(VWLPXODUHOSXMRPDWHUQRHVSRQWiQHRVHxDODQGRHOPRPHQWRDSURSLDGR MXQWRFRQODFRQWUDFFLyQ\HYLWDQGRHODJRWDPLHQWR F(VWLPXODUXQDDGHFXDGDYHQWLODFLyQ\UHODMDFLyQHQWUHODVFRQWUDFFLRQHV $PQLRWRPtD 6L GHVSXpV GH PLQXWRV GH FRPSOHWDGD OD GLODWDFLyQ HQ QXOtSDUDV R GH PLQXWRV HQPXOWtSDUDVFRQSUHVHQFLDGHSXMRPDWHUQRQRVHSURGXFHGHVFHQVR\URWDFLyQVH HIHFWXDUiDPQLRWRPtDVLHPSUHTXHHOSRORFHIiOLFRHVWpRFXSDQGRHQWHUDPHQWHODFDYLGDG SpOYLFDSUHVHQWDFLyQ¿MDRHQFDMDGD 7pFQLFDGHODDPQLRWRPtD 6H SURFHGH GH OD VLJXLHQWH PDQHUD FRQ HO Pi[LPR ULJRU HQ OD DVHSVLD VH LQWURGXFH XQ LQVWUXPHQWRFRQSXQWDGHQWDGDSRUHMHPSORXQDPQLyWRPRRXQDUDPDGHSLQ]DGH.RFKHU HQWUHHOGHGRtQGLFH\HOPD\RUGHODPDQRTXHWDFWDKDVWDOOHJDUDODEROVD\UDVJDUODFRQOD SXQWDGHQWDGDGHGLFKDUDPD 3URWHFFLyQSHULQHDO /DSURWHFFLyQSHULQHDOHVODSULQFLSDOPHGLGDSUHYHQWLYDSDUDHYLWDUGHVJDUURV¿JXUD (OULHVJRGHGHVJDUURGHSHQGHGH ODSDULGDG ODHODVWLFLGDGGHORVWHMLGRV HOWDPDxRIHWDO ODYHORFLGDGGHODH[SXOVLyQ 6L VH HVWLPD TXH HVWDV FRQGLFLRQHV DXPHQWDQ HO ULHVJR GH GHVJDUUR GHEH HIHFWXDUVH LQ¿OWUDFLyQ SHULQHDO FRQ DQHVWHVLD ORFDO DQWHV GH LQLFLDGR HO GHVSUHQGLPLHQWR SDUD SRVWHULRUPHQWH UHDOL]DU XQD HSLVLRWRPtD¿J /D HSLVLRWRPtD VH HIHFWXDUi HQ HO PRPHQWR GH OD F GLVWHQVLyQ SHULQHDO SRU HO SROR FHIiOLFR GXUDQWH D E HO SXMR HQ IRUPD GLDJRQDO KDVWD OD WXEHURVLGDG LVTXLiWLFDDEDUFDQGRHQODVHFFLyQWRGRVORVWHMLGRV GHO ODELR PD\RU 6H LQFLGH HQ SURIXQGLGDG HQ OD )LJXUDDPHGLD PHGLGDGHODDPSOLDFLyQYXOYDUQHFHVDULD6HSUH¿HUH EPHGLRODWHUDO ODHSLVLRWRPtDPHGLRODWHUDO FODWHUDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD $YDQFHGHODSUHVHQWDFLyQ\GHVSUHQGLPLHQWR 3HUPLWLU HO DYDQFH GH OD SUHVHQWDFLyQ PDQWH QLHQGR VX ÀH[LyQ KDVWD TXH OD FLUFXQIHUHQFLD VXERFFLSLWREUHJPiWLFD KD\D WUDVSDVDGR HO DQLOOR YXOYDUGLVWHQGLGR ,QVWUXLUDODPDGUHSDUDTXHMDGHH\QRSXMHHQHVH PRPHQWR (QOHQWHFHUHOGHVSUHQGLPLHQWRDSR\DQGRODPDQR L]TXLHUGDVREUHODSUHVHQWDFLyQSDUDTXHODGHÀH[LyQ VHUHDOLFHOHQWDPHQWHGLVWHQGLHQGRSURJUHVLYDPHQWH ORVWHMLGRVSDUDHYLWDUGHVJDUURV,QVWUXLUOXHJRDOD PDGUHSDUDTXHSXMHVXDYHPHQWH )LJXUD3URWHFFLyQSHULQHDO &RORFDUFRQODPDQRGHUHFKDXQDSyVLWRVREUHHOSHULQpDEDUFiQGRORHQWUHHOSXOJDU\ ORVGHGRVUHVWDQWHVGHODPDQR6RVWHQHUODSUHVHQWDFLyQSDUDTXHQRHIHFW~HVXDYDQFH \GHÀH[LyQEUXVFDPHQWH$FHUFDUKDFLDHOUDIHSHULQHDOORVWHMLGRVODWHUDOHVGHOSHULQp FRPRSDUDIUXQFLUORVKDFLHQGRGLVPLQXLUODWHQVLyQ¿JXUD 7HUPLQDUHOGHVSUHQGLPLHQWRFRQOHQWLWXGFRQODVDOLGDGHODIUHQWHODFDUD\HOPHQWyQ ,QVWUXLUQXHYDPHQWHDODPDGUHSDUDTXHQRSXMH $XQTXH HO UHVWR GHO FXHUSR FRQ IUHFXHQFLD VH GHVSUHQGH HVSRQWiQHDPHQWH HV KDELWXDO D\XGDU D VX VDOLGD ¿QDO 3DUD HOOR XQD YH] GHVSUHQGLGD OD FDEH]D \ URWDGD HVSRQWiQHDPHQWH KDFLD VX SRVLFLyQ SULPLWLYD URWDFLyQ H[WHUQD GH OD FDEH]D VH REVHUYD VL KD\ DOJXQD FLUFXODU GH FRUGyQ DMXVWDGD DO FXHOOR OD TXH GH H[LVWLU GHEH GHVOL]DUVHVREUHODFDEH]DRVREUHHOKRPEUR6LODWHQVLyQGHODPLVPDORLPSLGHVH VHFFLRQDGHLQPHGLDWRHOFRUGyQHQWUHGRVSLQ]DVGH.RFKHU 6HWRPDODFDEH]DFRQDPEDVPDQRVGHORVSDULHWDOHVHQSRVLFLyQDQWHULRU\SRVWHULRU \VHODWUDFFLRQDVXDYHPHQWHSULPHURKDFLDDEDMRGHVFHQGLHQGRFRQHOORHOKRPEUR HQ SRVLFLyQ DQWHULRU KDVWD VREUHSDVDU HO SXELV SDUD LQYHUWLU GH LQPHGLDWR HO VHQWLGR GH OD WUDFFLyQ DKRUD KDFLD DUULED FRQ OR TXH VH REWLHQH HO GHVSUHQGLPLHQWR GHO KRPEURSRVWHULRU(OUHVWRGHOFXHUSRDOVHUPHQRVYROXPLQRVRTXHORVVHJPHQWRV\D GHVSUHQGLGRVVHH[SXOVDIiFLOPHQWHGHELpQGRVHFRQWHQHUDOIHWRSDUDTXHQRORKDJD FRQEUXVTXHGDG (OGHVFHQVRSURIXQGRGHOKRPEURHQSRVLFLyQDQWHULRUHVGHULJRUDQWHVGHFRQWLQXDU ODVWUDFFLRQHVGHORFRQWUDULRDOUHWHQHUVHpVWHGHWUiVGHOSXELVSXHGHVHUPRWLYRGH IUDFWXUDGHFODYtFXODRGHHORQJDFLyQGHOSOH[REUDTXLDOFRUUHVSRQGLHQWH¿JXUD )LJXUD$\XGDPDQXDOSDUDHOGHVSUHQGLPLHQWRGHORVKRPEURV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 6,78$&,21(6(63(&,$/(6 'LVWRFLDGHKRPEUR 3DUWRHQSRGiOLFD 'LVWRFLDGHKRPEUR (VXQDVLWXDFLyQSRWHQFLDOPHQWHJUDYHTXHVHFDUDFWHUL]DSRUTXHOXHJRGHODVDOLGDGH ODFDEH]DIHWDOVHGHWLHQHHOSDUWR 'LDJQyVWLFR /DVPDQLREUDVKDELWXDOHVSDUDOLEHUDUHOKRPEURDQWHULRUIUDFDVDQ 6L VH SURGXFH GLVWRFLD GH KRPEUR FRQ KRPEUR DQWHULRU LPSDFWDGR WUDV OD VtQ¿VLV SXELDQDVHGHEHQHIHFWXDUODVVLJXLHQWHVPDQLREUDV 6LQRKDKHFKRHSLVLRWRPtDKiJDODVLODKL]R\HVSHTXHxDDPSOtHOD &RQODSDUWXULHQWDHQGHF~ELWRGRUVDOVROLFtWHOHTXHÀH[LRQHIXHUWHPHQWHVXV SLHUQDVVREUHHOSHFKR 6ROLFLWHDXQD\XGDQWHTXHFRPSULPDODUHJLyQVXSUDS~ELFDLQWHQWDQGRGHVWUDEDU HOKRPEURDQWHULRUHLPSXOVDUORKDFLDODYDJLQD $SOLTXHVLHPSUHWUDFFLyQ¿UPH\FRQLQXDKDFLDDEDMR¿J6LORKDFH GHPDVLDGRHQpUJLFDPHQWHSXHGHSURYRFDUSDUiOLVDVGHOSOH[REUDTXLDO 6LHVWDVPDQLREUDVIUDFDVDQLQWHQWHODURWDFLyQFXLGDGRVDOOHYDQGRHOKRPEUR HQSRVLFLyQDQWHULRUKDFLDDWUiVHQVHQWLGRGHOGRUVRIHWDOTXHVXHOHOLEHUDU HOKRPEUR¿JXUD3XHGHD\XGDUDODURWDFLyQ\DOGHVSUHQGLPLHQWRDSOLFDU SUHVLyQVREUHHOKRPEURIHWDODQWHULRUHQGLUHFFLyQDOSHFKRIHWDO (OIUDFDVRGHHVWDPDQLREUDREOLJDDLQWHQWDUODH[WUDFFLyQGHOEUD]RHQSRVLFLyQSRVWHULRU ,QWURGXFLUHQODYDJLQDODPDQRFRUUHVSRQGLHQWHDOYLHQWUHIHWDO 3UHVLRQDUODIRVDDQWHFXELWDOGHOEUD]RSRVWHULRUORTXHKDUiGHVFHQGHUHODQWHEUD]R TXHVHWRPD\VHFRQGXFHSRUHOSHFKRGHOQLxRKDVWDDIXHUD¿J(VWRUHGXFLUi HOGLiPHWURIHWDORIUHFLGRDODSHOYLV\SHUPLWLUiODOLEHUDFLyQGHOKRPEURDQWHULRU )LJXUD0DQLREUDGHURWDFLyQ HQODGLVWRFLDGHKRPEUR )LJXUD/LEHUDFLyQGHOEUD]RSRVWHULRU 6L WRGDV HVWDV PDQLREUDV UHDOL]DGDV HQ HVFDVRV PLQXWRV IUDFDVDQ SURFHGD D IUDFWXUDUODFODYtFXODIHWDO (QRFDVLRQHVODFODYtFXODIHWDOVHIUDFWXUDDFFLGHQWDOPHQWHGXUDQWHODVPDQLREUDVGH WUDFFLyQ (VWR GHEHUi VHU H[SOLFDGR D OD PDGUH \ QR RFXOWDUOR \D TXH HVWD VLWXDFLyQ SRGUiFRQWULEXLUDVDOYDUODYLGDGHOIHWRTXHKDTXHGDGRUHWHQLGR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 3HUtRGR([SXOVLYR &RQWUDFWLOLGDG& 3XMR3\'HVFHQVRGHOD 3UHVHQWDFLyQ' (ILFDFHV 12 $PQLRWRPtD &3\' (ILFD] 6, 6, %UDGLFDUGLD )HWDO 6, 12 2FLWRFLQD &3\' (ILFD] 6, 12 6, !PLQ 3HUtRGR([SXOVLYR 12 3HULQp (OiVWLFR (SLVLRWRPtD 12 12 6, 3URWHFFLyQ3HULQp$\XGD 'HVSUHQGLPLHQWRGHOD&DEH]D 6, 12 'LVWRFLD GH+RPEUR 0DQLREUDVGH 'HVSUHQGLPLHQWR 'HVSUHQGLPLHQWR (VSRQWiQHR $SOLFDFLyQGH1RUPDV GH$OWR5LHVJR ([WUDFFLyQ)HWDO ,QPHGLDWD 5HFHSFLyQGHO5HFLpQ1DFLGR )LJXUD)OXMRJUDPDGHGHFLVLRQHVGHOSHUtRGRH[SXOVLYR $WHQFLyQGHOSDUWRHQSRGiOLFD ([LVWHQHYLGHQFLDVTXHDVHJXUDQTXHHOQDFLPLHQWRSRUFHViUHDHQFDVRGHSUHVHQWDFLyQ SRGiOLFDHVPiVVHJXURTXHHOSDUWRYDJLQDO3HURHQRFDVLRQHVQRKDEUiRWUDSRVLELOLGDG TXHDVLVWLUHOSDUWRHQHVWDSUHVHQWDFLyQ/RVPHMRUHVUHVXOWDGRVVHORJUDUiQFXDQGR HO SUHVWDGRU PDQWHQJD OD FDOPD H LQWHUYHQJD FXDQGR HVWp LQGLFDGR FRQ PDQLREUDV GHOLFDGDV\SUHFLVDV&RPRPDQLREUDSUHYLDFDWHWHULFHVLVWHPiWLFDPHQWHODYHMLJDSDUD TXHGXUDQWHHOSURFHGLPLHQWRpVWDVHHQFXHQWUHYDFtD'HKDEHUXQIyUFHSVGLVSRQLEOH WpQJDORSURQWRHQODPHVDGHSDUWRSRUVLVHSURGXMHUDXQDUHWHQFLyQGHFDEH]D 6HLQWHQWDUiFRQVHUYDUODVPHPEUDQDVtQWHJUDVKDVWDFRQVHJXLUODGLODWDFLyQFRPSOHWD VLODVPHPEUDQDVVHURPSHQVHGHEHYHUL¿FDUTXHQRKD\DSURFLGHQFLDSURODSVRGH FRUGyQDGHPiVGHHYDOXDUODPRGDOLGDGGHODSUHVHQWDFLyQ 6HHYLWDUiHOSXMRPDWHUQRKDVWDFHUWL¿FDUTXHHOFXHOORGHO~WHURHVWiWRWDOPHQWHGLODWDGR \ODSUHVHQWDFLyQVHHQFXHQWUDLQJUHVDQGRHQODYDJLQD 'HVSUHQGLPLHQWRGHORVPLHPEURVLQIHULRUHV x6HHYLWDUiWLURQHDUGHORVPLHPEURV\VHFRORFDUiXQDPDQRRSRQLHQGRUHVLVWHQFLD DOGHVSUHQGLPLHQWRGHODSUHVHQWDFLyQDSHQDVHVWDDVRPHHQHOSHULQp x(IHFWXDUXQDHSLVLRWRPtDDPSOLD\SHUPLWLUTXHVHH[SXOVHQODVQDOJDVKDVWDYHU DSDUHFHUODHVSDOGD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR x6H UHFRPLHQGD HYLWDU HO SXMR KDVWD TXH ODV QDOJDV VH KD\DQ H[SXOVDGR HVSRQWiQHDPHQWHEDMRODIXHU]DGHODVFRQWUDFFLRQHV x8QDYH]TXHODVQDOJDVVHKDQGHVSUHQGLGRVHHQYXHOYHDODEGRPHQGHOIHWRFRQ XQDFRPSUHVDWLELD x$ODSDUHFHUHORPEOLJRIHWDOFRPLHQ]DODIDVHDFWLYDHQODSDUWLFLSDFLyQGHOREVWHWUD HQHVDRSRUWXQLGDGVHWUDFFLRQDUiGHOFRUGyQ\VHKDUiXQDVD x6LODVSLHUQDVQRVDOHQHVSRQWiQHDPHQWHH[WUDHUFRQGHOLFDGH]DXQDSLHUQDSRU YH]ÀH[LRQDQGRODURGLOOD\WUDFFLRQDQGRGHVGHHOWRELOOR 'HVSUHQGLPLHQWRGHORVPLHPEURVVXSHULRUHV x&XDQGRDSDUHFHQORViQJXORVGHORVRPySODWRVVHSHUPLWLUiDODPXMHUSXMDU(Q RFDVLRQHV EDVWDUi FRQ ORV SXMRV PDWHUQRV SDUD FRQVHJXLU OD H[SXOVLyQ GH ORV KRPEURV6LHQGRVRWUHVSXMRVQRVHORJUDHOUHVXOWDGRHVSHUDGRVHGHEHUiXVDU ODPDQLREUDGH%UDFKWHVWDPDQLREUDWLHQHODYHQWDMDGHTXHVLUYHDOPLVPRWLHPSR SDUDHOGHVSUHQGLPLHQWRGHKRPEURV\FDEH]D\QRUHTXLHUHODLQWURGXFFLyQGHOD PDQRHQODYDJLQD0LHQWUDVXQD\XGDQWHFRPSULPHODFDEH]DIHWDOHQGLUHFFLyQ DODSHOYLV(ORSHUDGRUWRPDUiDOIHWRSRUHOWURQFR\ORVPXVORVFRPSULPLHQGR ORVPXVORVVREUHHOWURQFRVHOHYDQWDDOIHWRVLQWLUDU\VHORKDUiJLUDUHQWRUQRDO SXELVPDWHUQR\HQGLUHFFLyQDOYLHQWUHPDWHUQR )LJXUD0DQLREUDGH%UDFKW x6LQRIXHVHHIHFWLYDODPDQLREUDGH%UDFKWSDUDHOGHVSUHQGLPLHQWRGHKRPEURVVH DSOLFDUiODPDQLREUDGH5RMDVSRUODFXDOPLHQWUDVVHVRVWLHQHDOIHWRGHVXVPXVORV FRQGHOLFDGH]D\DSR\DQGRORVSXOJDUHVHQHOVDFURVHLQWHQWDUiKDFHUURWDUDOIHWR DSOLFDQGRXQDOLJHUDWUDFFLyQGHVFHQGHQWHSDUDFRQVHJXLUHOGHVSUHQGLPLHQWRGHO KRPEURSRVWHULRUXQDYH]GHVSUHQGLGRHOKRPEURSRVWHULRUVHHIHFW~DXQJLURHQ VHQWLGRRSXHVWRDODQWHULRUSDUDGHVSUHQGHUHOKRPEURDQWHULRU &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD )LJ0DQLREUDGH5RMDV HUWLHPSR )LJ0DQLREUDGH5RMDV WLHPSR x2WUDPDQLREUDSDUDHOGHVSUHQGLPLHQWRGHORVKRPEURVHVODPDQLREUDGH3DMRW SRUODFXDOVHGHEHUiHOHYDUDOIHWRWRPDGRGHDPERVWRELOORV\FRQGRVGHGRV VHLQWHQWDUiGHVSUHQGHUHOKRPEURSRVWHULRU\OXHJREDMDQGRHOIHWRVHLQWHQWDUi GHVSUHQGHUHOKRPEURDQWHULRU x&XDQGRORVEUD]RVHVWpQHOHYDGRVVREUHODFDEH]DIHWDOVHGHEHUiLQWURGXFLUOD PDQRHQODYDJLQDSDUDÀH[LRQDUHOFRGR\GHVFHQGHUHOEUD]RSRUGHODQWHGHOD FDUDGHOIHWRHQGLUHFFLyQDOWyUD[ Hombro posterior )LJXUD'HVSUHQGLPLHQWRGHEUD]RVXELFDGRVVREUHODSUHVHQWDFLyQ 'HVSUHQGLPLHQWRGHODFDEH]D x&XDQGR OD PDQLREUD GH %UDFKW QR VHD HIHFWLYD SDUD GHVSUHQGHU OD FDEH]D VH GHEHUi PDQWHQHU OD SUHVLyQ SRU SDUWH GH XQ D\XGDQWH GH OD FDEH]D IHWDO SRU HQFLPD GHO SXELV HQ GLUHFFLyQ D OD YDJLQD SDUD D\XGDU HQ HO GHVFHQVR GH OD FDEH]D\HYLWDUODGHÀH[LyQ x$SR\DUDOIHWRERFDDEDMRFDEDOJDQGRVREUHHODQWHEUD]RGHODPDQRPiVKiELO GHORSHUDGRUPDQLREUDGH0RULFHDX x&RORFDU ORV GHGRV tQGLFH \ PD\RU GH OD PDQR TXH VRVWLHQH DO IHWR GHQWUR GH OD ERFD IHWDO WUDFFLRQDQGR OD PDQGtEXOD KDFLD HO WyUD[ IHWDO SDUD ÀH[LRQDU OD FDEH]D x/RVGHGRVtQGLFH\PD\RUGHODRWUDPDQRVHDSR\DUiQDPDQHUDGH³WHQHGRU´ VREUHORVKRPEURVIHWDOHVHVWRVGHGRVQRGHEHQWUDFFLRQDU x6H WUDFFLRQDUi GHOLFDGDPHQWH DO WLHPSR TXH HO IHWR VH HOHYDUi HQ GLUHFFLyQ DO YLHQWUHPDWHUQR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR )LJXUD0DQLREUDGH0RULFHDX x6L HVWDV PDQLREUDV IUDFDVDUDQ VH UHFRPLHQGD OD DSOLFDFLyQ GH XQ IyUFHSV GH FDEH]D~OWLPD8QD\XGDQWHHOHYDUiHOIHWRGHVGHVXVWRELOORVHORSHUDGRUDSOLFDUi DPEDVSDODVGHOIyUFHSVSRUHOODGRYHQWUDOGHOIHWRLQWHQWDQGRUHDOL]DUXQDWRPD VLPpWULFD/XHJRVHWUDFFLRQDUiSULPHURKDFLDDEDMRSDUDGHVFHQGHUODFDEH]D\ ¿QDOPHQWHKDFLDDUULEDSDUDGHVSUHQGHUOD9HU¿JXUD )LJXUD$SOLFDFLyQGHOIyUFHSVGHFDEH]D~OWLPD $WHQFLyQGHO5HFLpQ1DFLGRHQVDODGHSDUWRV $FRQWLQXDFLyQVHUHVXPHQXQDVHULHGHSDVRVSDUDODDWHQFLyQLQPHGLDWDGHOUHFLpQ QDFLGRQRUPDOWRGRVHVWRVDVSHFWRV\RWURVVHHQFXHQWUDQGHVDUUROODGRVHQHOFDStWXOR 9$WHQFLyQGHO5HFLpQ1DFLGR 8QDYH]SURGXFLGRHOSDUWRDSR\DUDOUHFLpQQDFLGRVREUHXQDVXSHU¿FLHFXELHUWD FRQXQSDxRVXDYHDXQQLYHOPiVEDMRTXHHOGHODPDGUHRVREUHORVPXVORVHQXQD FHViUHD 6HFDUVXFDUDFDEH]DFXHUSR\FXEULUORSDUDTXHQRVHHQIUtH &RQ¿UPDUTXHUHVSLUDQRUPDOPHQWH $VSLUDUORVRORHQFDVRTXHKD\DPHFRQLR\HOUHFLpQQDFLGRD~QQRKD\DUHVSLUDGR VLUHVSLUDDQWHVGHODDVSLUDFLyQDVSLUDUORQRVHUiGHXWLOLGDG 6LWRGRHVQRUPDOQRKD\DV¿[LDFRUWDUHOFRUGyQXPELOLFDOUHFLpQGHVSXpVTXHGHMD GHSXOVDURORKDFHHQIRUPDFDVLLPSHUFHSWLEOH\VHHQFXHQWUDÀiFFLGR &RORFDU XQD JDVD HPEHELGD HQ DOFRKRO HQWRUQR DO PXxyQ GHO FRUGyQ SDUD TXH HO PLVPRVHYD\DGHVHFDQGRHQODIRUPDPiVUiSLGD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 7pFQLFDSDUDODOLJDGXUDGHOFRUGyQ 6H REVHYDUiQ HVWULFWDPHQWH ODV QRUPDV GH DVHSVLD 6H FRORFD XQD SLQ]D IXHUWH SHM3LQ]DGH.RFKHUDRFPGHODLQVHUFLyQXPELOLFDOIHWDO\RWUDSLQ]DDODPLVPD GLVWDQFLDSHURHQGLUHFFLyQDODSODFHQWD6HFRUWDFRQWLMHUDHQWUHDPEDVSLQ]DV/DV SLQ]DGHOODGRIHWDOVHUiVXVWLWXLGDSRUXQDSLQ]DSOiVWLFDRSRUOLJDGXUDFRQKLORJUXHVR HVWpULOWRPDUODSUHFDXFLyQGHFHUUDU¿UPHPHQWHODSLQ]DRDQXGDUHOKLORFRQQXGRGH FLUXMDQR\GHMDUORELHQDMXVWDGR 2WUDV LQWHUYHQFLRQHV TXH GHEHQ VHU UHDOL]DGDV HQ OD UHFHSFLyQ LQPHGLDWD GHO UHFLpQ QDFLGR 3UHYHQLU OD RIWDOPLD JRQRFyFFLFD VHJ~Q QRUPD QDFLRQDO GLIHUHQWHV RSFLRQHV VH GHVFULEHQHQHOFDStWXOR9 3UHYHQLU HQIHUPHGDG KHPRUUiJLFD GHO UHFLpQ QDFLGR VHJ~Q QRUPD QDFLRQDO R UHFRPHQGDFLRQHVGHOFDStWXOR9 5HFRPHQGDFLRQHVVREUHXVRGHPHGLFDFLyQHQHOSDUWRGHEDMRULHVJR (OSDUWRHVXQSURFHVRQDWXUDO¿VLROyJLFR\SRUWDQWRQRHVWiLQGLFDGDODDGPLQLVWUDFLyQ UXWLQDULDGHPHGLFDPHQWRV6yORGHEHQXVDUVHSDUDODSUHYHQFLyQ\HOWUDWDPLHQWRGH ODVFRPSOLFDFLRQHV /DVUD]RQHVKDELWXDOHVSDUDHOXVRGHPHGLFDFLyQVRQ DGRORU\DQVLHGDGLQWHQVRV EWUDVWRUQRVGHODFRQWUDFWLOLGDGXWHULQD FVXIULPLHQWRIHWDODJXGR D'RORU\DQVLHGDGLQWHQVRV 3DUDVXFRQWUROVRQKDELWXDOPHQWHVX¿FLHQWHV xODDGHFXDGDSUHSDUDFLyQSVLFRItVLFDGHODPDGUHHQHOSHUtRGRSUHQDWDO xODPRWLYDFLyQGHODPDGUHSDUDHOSDUWRQDWXUDO xHODSR\RSVLFRDIHFWLYRGXUDQWHHOWUDEDMRGHSDUWRSRUHOSDGUHXRWURIDPLOLDU xHODSR\RSVLFRDIHFWLYRSRUSDUWHGHOHTXLSRGHVDOXG xODOLEHUWDGGHSRVLFLyQGHODPDGUH $SHVDUGHHOORHQDOJXQDVRFDVLRQHVKD\PDGUHVTXHSUHVHQWDQLQWHQVDDQJXVWLD\ DQVLHGDGFRQIXHUWHGRORU\SXHGHQSHUGHUHODXWRFRQWURO(VWRSXHGHLQWHUIHULUHQOD FRQWUDFWLOLGDG XWHULQD \ HO SURJUHVR GHO SDUWR QRUPDO FRQ FRQVHFXHQFLDV TXH SXHGHQ OOHJDUKDVWDODKLSR[LDIHWDOSRUGLVPLQXFLyQGHODLUULJDFLyQ~WHURSODFHQWDULD$GHPiV GHJHQHUDUXQDH[SHULHQFLDSRFRJUDWL¿FDQWHSDUDODPXMHU 6L DGHPiV GH ODV PHGLGDV GH DSR\R SVLFR HPRFLRQDO ODV PHGLGDV ItVLFDV SDUD HO WUDWDPLHQWR GHO GRORU PDVDMHV HQ OD UHJLyQ OXPER VDFUD R GXFKDV WLELDV QR ORJUDQ GLVPLQXLUORFRQVLGHUDEOHPHQWHVHGHEHUiUHFXUULUDOXVRGHPHGLFDPHQWRV $QDOJpVLFRV x0HSHULGLQDPJGLVXHOWRVHQFFGHVROXFLyQVDOLQDHQLQIXVLyQLQWUDYHQRVD OHQWD x3RUUHJODJHQHUDOQRGHEHXVDUVHDSDUWLUGHORVFPGHGLODWDFLyQ x/DGRVLVDGPLQLVWUDGDGHEHVHUODPtQLPDQHFHVDULDSDUDDOLYLDUHOGRORUGHOD SDUWXULHQWD x'HEHQSUHIHULUVHDTXHOODVGURJDVTXHWHQJDQDQWtGRWRVFRQWUDVXVHIHFWRV\HVWDU VHJXURVGHFRQWDUFRQHOORV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR /RVHIHFWRVFRODWHUDOHVLQGHVHDEOHVVRQ x 'HSUHVLyQ GHO 61& GH PDGUH H KLMR LQFOX\HQGR HO FHQWUR UHVSLUDWRULR 6HFXQGDULDPHQWHKLSRYHQWLODFLyQPDWHUQDFRQKLSR[HPLDHKLSHUFDSQLD x+LSRWRQtDKLSRUUHÀH[LD\DSQHDQHRQDWDO x'LVPLQXFLyQGHORVPHFDQLVPRVIHWDOHVGHGHIHQVDFRQWUDODKLSR[LD x,QWHUIHUHQFLDFRQODSDUWLFLSDFLyQDFWLYDGHODPDGUHHQHOSDUWR x,QWHUIHUHQFLDFRQODUHODFLyQSUHFR]PDGUHKLMR\ODODFWDQFLD $QHVWHVLDUHJLRQDOHSLGXUDOUDTXtGHD/DDQHVWHVLDUHJLRQDOHVXQSURFHGLPLHQWR TXHVyORGHEHVHUHIHFWXDGRSRUSHUVRQDOPpGLFRFRQDOWRQLYHOGHHQWUHQDPLHQWR /RVHIHFWRVFRODWHUDOHVLQGHVHDEOHVVRQ x+LSRWHQVLyQPDWHUQDFRQUHGXFFLyQGHSHUIXVLyQSODFHQWDULDHKLSR[LDIHWDO x,QWHUIHUHQFLDFRQODGHDPEXODFLyQPDWHUQDGXUDQWHHOWUDEDMRGHSDUWR x,QWHUIHUHQFLDFRQHOSXMRPDWHUQRGXUDQWHHOSHUtRGRH[SXOVLYR x$XPHQWRGHLQWHUYHQFLRQHVREVWpWULFDV x&HIDOHD E7UDVWRUQRVGHODFRQWUDFWLOLGDGXWHULQDGLVWRFLDVGLQiPLFDV (OSURJUHVRGHOSDUWR\HOELHQHVWDUGHPDGUHHKLMRSXHGHQYHUVHDIHFWDGRVSRUORV WUDVWRUQRV GH OD FRQWUDFWLOLGDG VHDQ pVWRV OD KLSRGLQDPLD R OD KLSHUGLQDPLD$PEDV UHTXLHUHQFRUUHFFLyQ +LSRGLQDPLD,QFOX\HODSURYRFDGDSRUODLQFRRUGLQDFLyQXWHULQD (OPHGLFDPHQWRGHHOHFFLyQHVODRFLWRFLQDVLQWpWLFDTXHDXPHQWDODLQWHQVLGDG\OD IUHFXHQFLDGHODVFRQWUDFFLRQHV(VXQDGURJDSHOLJURVDFXDQGRVHGHVFRQRFHQVXV GRVLVVXYtDGHDGPLQLVWUDFLyQRVXFRQWUROGXUDQWHVXXVR (QFDVRGHHVWLPXODUHO~WHURFRQRFLWRFLQDVHGHEHUHFRUGDUTXHODGRVLVLQLFLDOGHSHQGH GHOJUDGRGHFRQWUDFWLOLGDGH[LVWHQWH6HUHFRPLHQGDFRPHQ]DUFRQP8PLQSRUYtD LQWUDYHQRVD 8QDVROXFLyQGH8,GHRFLWRFLQDHQOLWURGHVXHURJOXFRVDGRDOVHFRPHQ]DUi LQIXQGLHQGR JRWDV SRU PLQXWR PO HQ SRU PLQXWR 6L HQ PLQXWRV QR KXER FDPELRV GXSOLFDU OD GRVLV /D QHFHVLGDG GH GRVLV PD\RUHV UHTXLHUH XQD H[KDXVWLYD UHYLVLyQGHOFDVREDMRHVWULFWDYLJLODQFLDPpGLFD/DLQIXVLyQ\SRUHQGHODPDGUH\HO IHWRQRSRGUiQVHUGHVFXLGDGDV &DEHUHFRUGDUTXH x/DUHVSXHVWDLQGLYLGXDOGHODRFLWRFLQDHVYDULDEOHHLPSUHGHFLEOH x/DHVWLPXODFLyQPLRPHWULDOLQDGHFXDGDSXHGHFDXVDUKLSHUWRQtDKLSRSHUIXVLyQ ~WHURSODFHQWDULDHKLSR[LDIHWDO x/DKLSHUWRQtDXWHULQDSURYRFDGDSRUODDGPLQLVWUDFLyQLQDGHFXDGDGHRFLWRFLQD SXHGHFDXVDUURWXUDXWHULQD\RWUDVFRQVHFXHQFLDVJUDYHVFRPRHOVXIULPLHQWR IHWDODJXGR x 'HEH GHVFDUWDUVH VXIULPLHQWR IHWDO GHVSURSRUFLyQ IHWRSpOYLFD YLFLRV GH SUHVHQWDFLyQ(QHOFDVRGHFHViUHDDQWHULRUFLFDWULFHVXWHULQDVRPDOIRUPDFLRQHV XWHULQDVHOXVRGHODRFLWRFLQDGHEHUiKDFHUVHEDMRHVWULFWDYLJLODQFLD\HQFDVR GHQRFRQWDUFRQSRVLELOLGDGGHUHVSXHVWDTXLU~UJLFDVHUiSUHIHULEOHGHULYDUDOD PXMHUDXQQLYHOGHPD\RUFRPSOHMLGDG &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD +LSHUGLQDPLD(QOD~WHURLQKLELFLyQLQWUDSDUWRGHEHSUHIHULUVHHOXVRGHORVDJHQWHV EHWDDGUHQpUJLFRVSRU DPD\RUYHORFLGDGGHLQVWDODFLyQGHVXHIHFWR EPD\RUSRWHQFLDXWHURLQKLELGRUD 3RUODPHQRULQWHQVLGDGGHORVHIHFWRVVHFXQGDULRVVRQGHHOHFFLyQHOIHQRWHUROROD ULWRGULQD(QHOFXDGURVHVHxDODQVXVGRVLV\HIHFWRVXWHURLQKLELGRUHVSRULQIXVLyQ HQGRYHQRVDFRQWLQXD (IHFWRVVHFXQGDULRVGHORVEHWDDGUHQpUJLFRV /RV PiV LPSRUWDQWHV VRQ ORV FDUGLRYDVFXODUHV FDUGLRDFHOHUDFLyQ YDVRGLODWDFLyQ H KLSRWHQVLyQFXDGUR 3URGXFHQ DGHPiV DXPHQWR GH OD OLSyOLVLV \ JOXFyJHQROLVLV QiXVHDV YyPLWRV \ HVFDORIUtRV &RQWUDLQGLFDFLRQHVSDUDVXXVR x+LSRWHQVLyQPDWHUQD x$QWHFHGHQWHVRVLJQRVGHFDUGLRSDWtD x'LDEHWHVGHGLItFLOFRQWUROPHWDEyOLFR x+LSHUWLURLGLVPR 0RGRGHDGPLQLVWUDFLyQ&RORFDUDODPDGUHHQGHF~ELWRODWHUDOL]TXLHUGR$MXVWDUOD YHORFLGDGGHLQIXVLyQGHDFXHUGRFRQHOHIHFWRXWHURLQKLELGRU\ODIUHFXHQFLDFDUGtDFD PDWHUQD'HEHHYLWDUVHXQDWDTXLFDUGLDVXSHULRUDODWLGRVPLQ 6LODDGPLQLVWUDFLyQGHHVWRVIiUPDFRVQRFRUULJHODKLSHUGLQDPLDHQPLQXWRVGHEH UHIHULUVHDQLYHOGHDWHQFLyQGHDOWRULHVJR F3pUGLGDGHELHQHVWDUIHWDOLQWUDSDUWR (OWUDWDPLHQWRLQ~WHURGHOVXIULPLHQWRIHWDOHVXQSURFHGLPLHQWRSUHYLRDODH[WUDFFLyQ SRUODYtDPiVUiSLGD &DPELRGHSRVLFLyQ'HF~ELWRODWHUDOL]TXLHUGR &RUUHFFLyQGHKLSRWHQVLyQPDWHUQD6LKD\KLSRWHQVLyQPDWHUQDTXHQRPHMRUHFRQ HOGHF~ELWRODWHUDOL]TXLHUGRUHIHULUODDOQLYHOGHDWHQFLyQGHDOWRULHVJR 7HPSRUDOPHQWHHV~WLOODSRVLFLyQGH7UHQGHOHPEXUJRODHOHYDFLyQGHODVSLHUQDVGH ODPDGUH 6XVSHQGHURFLWRFLQD6LVHHVWiXVDQGR 8WHURLQKLELFLyQ /DV EDVHV GHO WUDWDPLHQWR FRQ EHWDPLPpWLFRV HVWULEDQ HQ PHMRUDU OD SHUIXVLyQ XWHURSODFHQWDULD \ OD R[LJHQDFLyQ IHWDO SRU PHGLR GH OD GLVPLQXFLyQ R VXSUHVLyQGHODVFRQWUDFFLRQHVXWHULQDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR Cuadro 41. Efectos uteroinhibidores y cardiovasculares maternos de algunos agentes betamiméticos D $XPHQWD D D ! ! Sist FCM Presion arterial Diast 'LVPLQX\H Frecuencia Instalación efectos de las con- de tracciones máximos (min) )HQRWHURO 3DUWXVLVWHQ Duración de efectos suspendido el fármaco (min) 5LWRGULQH 3UHSDU Amplitud de las contracciones Fármaco Infusión I/V mg/min /DUHVSXHVWDLQGLYLGXDOHVPX\YDULDEOH &RQGXFWD x GHEHHYDOXDUVHHOSURJUHVRGHOSDUWRSDUDGHFLGLUVLHVSRVLEOHODUHIHUHQFLDD QLYHOGHDWHQFLyQGHDOWRULHVJRODTXHGHEHHIHFWXDUVHVLHPSUHTXHHOSDUWRQR VHDLQPLQHQWH x VLGHEHDWHQGHUVHHOSDUWRHQQLYHOGHEDMRULHVJRHVQHFHVDULRHVWDUSUHSDUDGRV SDUDODUHDQLPDFLyQQHRQDWDOLQPHGLDWD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD $6,67(1&,$ '85$17( (/$/80%5$0,(172 < 326$/80%5$0,(172 7(5&(53(5,2'2 2%-(7,92 $&7,9,'$' 'HWHFWDU \ HYDOXDU GHVYLDFLRQHV GH ORV OtPLWHV ¿VLROyJLFRV GHO DOXPEUDPLHQWR\SRVDOXPEUDPLHQWR &RQWUROPDWHUQR ([DPHQGHODSODFHQWD (ODOXPEUDPLHQWRHVHOSHUtRGRTXHVHH[WLHQGHGHVGHODVDOLGDGHOUHFLpQQDFLGRKDVWD ODH[SXOVLyQGHODSODFHQWD(VXQSHUtRGRGHHOHYDGRULHVJR\DTXHXQDDOWDSURSRUFLyQ GHODVPXHUWHVPDWHUQDVHVSHFLDOPHQWHODVGHELGDVDKHPRUUDJLDVHGHVHQFDGHQDQ GXUDQWHHVWHSHUtRGR$XQTXHODSUHYDOHQFLDGHODKHPRUUDJLDSRVWSDUWRHVYDULDEOH SHUVLVWHFRPRODSULQFLSDOFDXVDGHPXHUWHPDWHUQDHQWRGRHOPXQGR (QORVSULPHURVPLQXWRVTXHVLJXHQDOQDFLPLHQWRVHSURGXFHQLQWHQVDVFRQWUDFFLRQHVQR GRORURVDV\VLQPHGLDUQLQJXQDLQWHUYHQFLyQHQODPD\RUtDGHORVFDVRVHODOXPEUDPLHQWR VHSURGXFLUiHVSRQWiQHDPHQWHHQWUHORV\ORVPLQXWRVTXHVLJXHQDOSDUWRSXGLHQGR UHWUDVDUVHKDVWDPLQXWRVVLQFRPSRUWDUPD\RUULHVJR 6tQWRPDV\VLJQRVGHOGHVSUHQGLPLHQWRSODFHQWDULR /DUHDSDULFLyQGHOGRORUGHODVFRQWUDFFLRQHV /RVFDPELRVGHIRUPDGHO~WHURHOFXDOVHYXHOYHJOREXODUGLVPLQX\HVXWDPDxR DGRSWDXQDFRQVLVWHQFLD¿UPH\HOIRQGRVHXELFDSRUGHEDMRGHORPEOLJR /DVDOLGDGHXQYROXPHQPRGHUDGRGHVDQJUHDWUDYpVGHORVJHQLWDOHV (OFRUGyQSURWUX\HSRUIXHUDGHORVJHQLWDOHV\DOFRPSULPLUHOIRQGRXWHULQRSRU HODEGRPHQHOFRUGyQQRDVFHQGHUiKDFLDHOLQWHULRUGHO~WHURLQGLFDQGRTXHOD SODFHQWD VH GHVSUHQGLy WRWDOPHQWH (VWR WDPELpQ VH FRQ¿UPD FXDQGR DO HOHYDU FRQ XQD PDQR HO IRQGR GHO ~WHUR SRU HO DEGRPHQ QR VH SHUFLEH VHQVDFLyQ R FDPELRDOJXQRDQLYHOGHODPDQRTXHWUDFFLRQDGHOLFDGDPHQWHGHOFRUGyQVLJQR GHOSHVFDGRU (QFRQGLFLRQHVQRUPDOHVXQDYH]TXHODSODFHQWDVDOLyGHO~WHURHOVDQJUDGRGLVPLQX\H FRQVLGHUDEOHPHQWH ([DPHQGHODSODFHQWD\ODVPHPEUDQDV 8QD YH] TXH OD SODFHQWD KD VDOLGR VH SURFHGHUi D XQ H[DPHQ PLQXFLRVR GH HOOD \ GH ODV PHPEUDQDV 6H UHFRPLHQGD DSR\DU OD SODFHQWD VREUH XQD VXSHU¿FLH SODQD \ REVHUYDUODSULPHURSRUVXFDUDPDWHUQDLGHQWL¿FDQGRVLHVWiQWRGRVORVFRWLOHGRQHV\ VLORVPLVPRVVHHQFXHQWUDQtQWHJURV&XDQGRIDOWHQFRWLOHGRQHVVHDGYHUWLUiXQD]RQD UXJRVDTXHSXHGHRQRVDQJUDU&XDQGRORTXHIDOWDHVXQIUDJPHQWRGHXQFRWLOHGyQ VHYHUiXQDVROXFLyQGHFRQWLQXLGDGVDQJUDQWH (OH[DPHQGHEHFXOPLQDUFRQODH[SORUDFLyQGHODFDUDIHWDOGHODSODFHQWDLQWHQWDQGR YHUVLODGLVWULEXFLyQYDVFXODU¿QDOL]DHQHOERUGHSODFHQWDULRRVHH[WLHQGHPiVDOOiGHO PLVPR6LVHDSUHFLDTXHORVYDVRVVHH[WLHQGHQPiVDOOiGHOGLVFRVHSXHGHHVWDUHQ SUHVHQFLDGHXQFRWLOHGyQDEHUUDQWH(QHVWHFDVRVHGHEHUiFHUWL¿FDUTXHHQODFDUD PDWHUQDVHHQFXHQWUDHOFRWLOHGyQFRUUHVSRQGLHQWHDHVDGLVWULEXFLyQYDVFXODU (QHOH[DPHQGHODVPHPEUDQDVVHLQWHQWDUiUHFRQVWUXLUODEROVDDPQLyWLFDD¿QGH GHVFDUWDUODSRVLELOLGDGGHUHWHQFLyQGHPHPEUDQDV &RQWUROHVGXUDQWHHODOXPEUDPLHQWR &XDQGRORVKHFKRVVHVXFHGHQHVSRQWiQHDPHQWHVHGHEHYLJLODU &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 3UHVLyQ\SXOVRPDWHUQR 3pUGLGDGHVDQJUHSRUJHQLWDOHV &RORU\JUDGRGHKXPHGDGGHODVPXFRVDV 6LJQRVGHGHVSUHQGLPLHQWRGHODSODFHQWD 6XWXUDGHODHSLVLRWRPtD &XDQGRVHSURGXFHHODOXPEUDPLHQWR\VHFRQVWDWDODUHWUDFFLyQXWHULQDGHEHUHYLVDUVH HOFDQDOGHOSDUWRSDUDSHVTXLVDUSRVLEOHVGHVJDUURVGHFXHOORRYDJLQD6LVHHIHFWXyXQD HSLVLRWRPtDGHEHUHDOL]DUVHODVXWXUD8QDFRQGXFWDVDOXGDEOHFRQVLVWHHQUHDOL]DUOD HSLVLRUUD¿DPLHQWUDVVHHVSHUDHODOXPEUDPLHQWRHVWRDGHPiVGHGLVPLQXLUHOVDQJUDGR SHUPLWLUiTXHHOWpFQLFRGLVPLQX\DHOJUDGRGHLQWHUYHQFLRQLVPRLQQHFHVDULRPLHQWUDV HVSHUD HO DOXPEUDPLHQWR 6L VH RSWD SRU HVSHUDU TXH VH SURGX]FD HO DOXPEUDPLHQWR DQWHVGHHIHFWXDUODHSLVLRUUD¿DHVUHFRPHQGDEOHDOPHQRVOLJDUORVYDVRVVDQJUDQWHV GHPD\RUFDOLEUHSDUDGLVPLQXLUODSpUGLGDGHVDQJUH 7pFQLFDGHODVXWXUD *HQHUDOPHQWHQRHVQHFHVDULRUHLQ¿OWUDUORVWHMLGRVFRQXQDQHVWpVLFRORFDO6HDIURQWDQ WHMLGRVLJXDOHVGHDPERVODGRVGHODLQFLVLyQHVGHFLUPXFRVDFRQPXFRVDP~VFXOR FRQP~VFXOR\SLHOFRQSLHOGHOSHULQp6HSURFHGHDODVXWXUDFRPHQ]DQGRSRUHOiQJXOR VXSHULRU GH OD PXFRVD YDJLQDO FRQ SXQWRV VHSDUDGRV R FRQ VXUMHW D SXQWR SDVDGR /XHJRVHDIURQWDQORVSODQRVPXVFXODUHV\FHOXODUVXEFXWiQHRHYLWDQGRGHMDUHVSDFLRV ³PXHUWRV´ FRQ SXQWRV VHSDUDGRV GH OD PLVPD VXWXUD XVDGD HQ OD PXFRVD YDJLQDO \ ¿QDOPHQWHVHVXWXUDODSLHOFRQSXQWRVVHSDUDGRVRVXUMHWGHODPLVPDVXWXUDHPSOHDGD SUHYLDPHQWH8QDULJXURVDDQWLVHSVLDGHODUHJLyQGXUDQWHORVGtDVVLJXLHQWHVJDUDQWL]DUi HOp[LWRGHODVXWXUD /DDWHQFLyQGHEH¿QDOL]DUFRQDVHRJHQLWDO\FRQWUROGHSUHVLyQDUWHULDOSXOVRUHWUDFFLyQ XWHULQD\HYDOXDFLyQGHODSpUGLGDKHPiWLFD 3UHYHQFLyQSDUDHYLWDUODUHWHQFLyQGHUHVWRVRYXODUHV 3DUD HYLWDU OD UHWHQFLyQ GH UHVWRV SODFHQWDULRV R PHPEUDQDV GHEH DGRSWDUVH XQD DFWLWXG H[SHFWDQWH SHUPLWLHQGR TXH ORV IHQyPHQRV GH HVWH SHUtRGR VH GHVDUUROOHQ HVSRQWiQHDPHQWH$GHPiVGHUHDOL]DUWRGDVODVPDQLREUDVFRQVXDYLGDG 1RWUDFFLRQDUHOFRUGyQQLLQWHQWDUDSUHVXUDUHODOXPEUDPLHQWRPLHQWUDVQRKD\D VLJQRVGHGHVSUHQGLPLHQWR 8QD YH] FRQVWDWDGR HO GHVSUHQGLPLHQWR GH OD SODFHQWD HIHFWXDU XQD VXDYH \ VRVWHQLGDWUDFFLyQ $O DVRPDU OD SODFHQWD SRU OD YXOYD VRVWHQHUOD FRQ XQD PDQR SRU GHEDMR GHO SHULQpHOHYDQGRHO~WHURFRQODRWUD 3XHGH IDFLOLWDUVH HO GHVSUHQGLPLHQWR GH ODV PHPEUDQDV URWDQGR OD SODFHQWD GHVSUHQGLGDVREUHVXHMH 3URGXFLGR HO DOXPEUDPLHQWR GHEH FRQVWDWDUVH OD IRUPDFLyQ GHO JORER GH VHJXULGDGGH3LQDUGLQGLFDGRUGHUHWUDFFLyQXWHULQD\H[DPLQDUODSODFHQWD\ODV PHPEUDQDVFRQVWDWDQGRVXLQWHJULGDG 3UHYHQFLyQGHOD+HPRUUDJLD3RVW3DUWR+33 'HELGR D OD LPSRUWDQWH FDUJD GH HQIHUPHGDG \ PXHUWH TXH UHSUHVHQWD OD +33 HVSHFLDOPHQWH YLQFXODGD D DWRQtD XWHULQD HV TXH VH KDQ GHVDUUROODGR GLIHUHQWHV HVTXHPDV GH WUDWDPLHQWR SUR¿OiFWLFR TXH LQFOX\HQ GURJDV XWHUR WyQLFDV PDVDMHV \ FRPSUHVLyQXWHULQD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 'URJDV~WHURWyQLFDV /DV GURJDV PiV XVDGDV VRQ OD 2FLWRFLQD OD 0HWLOHUJRQRYLQD HO 0LVRSURVWRO \ PiV UHFLHQWHPHQWHORVIiUPDFRVDJRQLVWDVGHODRFLWRFLQD&DUEHWRFLQD /RVHVTXHPDVYDUtDQVHJ~QHOIiUPDFRXVDGRODGRVLVODYtD\HOPRPHQWRHQTXH VRQDSOLFDGRV ,QPHGLDWDPHQWHGHVSXpVGHODVDOLGDGHOKRPEURDQWHULRUODLQ\HFFLyQGHD 8,GHRFLWRFLQDHQHVWHSHUtRGRKDGHPRVWUDGRTXHGLVPLQX\HHOVDQJUDGR\HO Q~PHURGHWUDQVIXVLRQHV7LHQHFRPRLQFRQYHQLHQWHTXHDXPHQWDODUHWHQFLyQGH SODFHQWD\GLVPLQX\HODWUDQVIXVLyQVDQJXtQHDGHVGHODSODFHQWDDOUHFLpQQDFLGR (VWRFRQOOHYDPD\RUULHVJRGHDQHPLDGHOQLxR ,QPHGLDWDPHQWHGHVSXpVGHOQDFLPLHQWRVHKDQXWLOL]DGRODLQ\HFFLyQGHD 8,GHRFLWRFLQDRDPJGHPHWLOHUJRQRYLQDRHOPLVRSURVWRODPJSRU YtDRUDORWUDQVUHFWDOPRVWUDQGRDFFLRQHVVLPLODUHV7RGRVHOORVKDQLQFUHPHQWDGR HOULHVJRGHUHWHQFLyQSODFHQWDULD\DQHPLDGHOUHFLpQQDFLGR/DPHWLOHUJRQRYLQD SRUVXSDUWHSURYRFDHIHFWRVVHFXQGDULRVFRPRDXPHQWRGHODSUHVLyQDUWHULDO\ YyPLWRV /XHJRGHODOXPEUDPLHQWRVHKDQXWLOL]DGRODVWUHVGURJDVHQXQFLDGDVDQWHV HQODVGRVLV\YtDVLQGLFDGDVDORVTXHUHFLHQWHPHQWHVHDJUHJDQORVDJRQLVWDV RFLWyFLFRVFDUEHWRFLQDTXHKDGHPRVWUDGRVHUPiVSRWHQWHTXHODRFLWRFLQD/D JUDQYHQWDMDGHXVDUFXDOTXLHUDGHHVWRVDJHQWHVHQHVWHSHUtRGRGHVSXpVGHO DOXPEUDPLHQWRHVTXHVHHOLPLQDHOULHVJRGHUHWHQFLyQGHSODFHQWD\GHDQHPLD GHOQLxR 7UDFFLyQGHOFRUGyQ /DWUDFFLyQ³FRQWURODGD´GHOFRUGyQOXHJRGHOLJDGRKDVLGRXWLOL]DGDVRODPHQWHDVRFLDGD DOXVRGHRFLWyFLFRV\PDVDMHOXHJRGHODH[SXOVLyQSODFHQWDULD1RH[LVWHQHYLGHQFLDV TXHHVWDPDQLREUDSRUVtGLVPLQX\DHOULHVJRGHKHPRUUDJLDSRVWSDUWRJUDYH3RUHO FRQWUDULR VX XVR UXWLQDULR H[SRQH D PD\RU DQHPLD QHRQDWDO FXDQGR VH DVRFLD FRQ OLJDGXUDSUHFR]HLQYHUVLyQXWHULQD 0DVDMH\FRPSUHVLyQXWHULQD (OPDVDMH\ODDFFLyQGHFRPSULPLUHOFXHUSRXWHULQRDWUDYpVGHODSDUHGDEGRPLQDO HVWLPXODQODFRQWUDFWLOLGDGXWHULQD\ODIRUPDFLyQGHOJORERGHVHJXULGDGGH3LQDUGSDUD UHGXFLUODKHPRUUDJLDSRVWSDUWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $OXPEUDPLHQWR 1R (VSRQWiQHR !PLQy +HPRUUDJLD 6L 2FLWyFLFR3URILOiFWLFR 0DVDMH8WHULQR\2FLWRFLQD $OXPEUDPLHQWR 6L 1R +HPRUUDJLD LPSRUWDQWH ([WUDFFLyQ0DQXDOGH ODSODFHQWD,QPHGLDWD 5HYLVLyQ &DQDO %ODQGR 6XWXUD 6L3URFHGH $VHR *HQLWDO &RQWUROHV3RVW DOXPEUDPLHQWR )LJXUD(VTXHPDHVFDORQDGRGHFRQGXFWDV\GHFLVLRQHVHQHODOXPEUDPLHQWR 3RVWDOXPEUDPLHQWR (OSHUtRGRGHSRVDOXPEUDPLHQWRFRPSUHQGHODVKRUDVVLJXLHQWHVDOSDUWR'HQWURGH HVWDVSULPHUDVKRUDVODPXMHUHVWiH[SXHVWDDPD\RUULHVJRGHKHPRUUDJLD\VKRFN 7DPELpQHOUHFLpQQDFLGRSXHGHWHQHUKHPRUUDJLDDQWHXQGHVSLQ]DGRLQDGYHUWLGRGH VX FRUGyQ 3RU HVWDV UD]RQHV HV UHFRPHQGDEOH TXH GXUDQWH HVWDV GRV SULPHUDV OD PXMHU\VXKLMRSHUPDQH]FDQHQXQVHFWRUHQHOTXHVHOHVJDUDQWLFHVXSHUYLVLyQGH HQIHUPHUtD 3RUHOORVHUHFRPLHQGDTXHODSDUWXULHQWDHVWpDFRPSDxDGDHQWRGRPRPHQWRSRUXQ IDPLOLDUGXUDQWHODVSULPHUDVKRUDVTXHVLJXHQDODVDOLGDGHODVDODGHSDUWRV\TXH SRUORPHQRVFDGDPLQXWRVHOHTXLSRVDQLWDULRYLJLOHORVVLJXLHQWHVDVSHFWRV 3UHVLyQDUWHULDO\SXOVRPDWHUQR *UDGRGHUHWUDFFLyQXWHULQD *ORERGHVHJXULGDGGH3LQDUG 6DQJUDGRJHQLWDO 6L FRPSOHWDGR HVWH SHUtRGR GH REVHUYDFLyQ WRGR HV QRUPDO OD SXpUSHUD \ VX QLxR SRGUiQSDVDUDXQVHFWRUWUDGLFLRQDOGHDORMDPLHQWRFRQMXQWRHQHOTXHORVFRQWUROHV VRQPHQRVIUHFXHQWHV $FRQWLQXDFLyQVHUHVXPHHQXQHVTXHPDHVFDORQDGRGHGHFLVLRQHVODVFRQGXFWDVD WRPDUGXUDQWHHODOXPEUDPLHQWRVHJ~QODHYROXFLyQGHOFDVR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 3RVWDOXPEUDPLHQWR 6L $WRQtD 1R +HPRUUDJLD 1R 6L 2FLWyFLFRV 7UDWDPLHQWR HILFD] 5HYLVLyQGHO&DQDO%ODQGR 6L 1R 1R 'HVJDUURV 6L 6XWXUD 1R &HVD VDQJUDGR 6L 5HIHUHQFLDDO1LYHOGH$OWR5LHVJR &RPSOHWDU+RUDVGH&RQWURO )LJXUD(VTXHPDGHGHFLVLRQHVFRUUHVSRQGLHQWHDOSRVWDOXPEUDPLHQWR $OWHUDFLRQHVGHODOXPEUDPLHQWR 5HWHQFLyQGHSODFHQWD +HPRUUDJLDSRVWSDUWR 5HWHQFLyQ GH SODFHQWD 6L OXHJR GH HVSHUDU PLQXWRV HQ DXVHQFLD GH KHPRUUDJLD QR VH SURGXFH HO DOXPEUDPLHQWR VH GHEH PDVDMHDU HO ~WHUR 6L OD UHWHQFLyQ SHUVLVWH VH DGPLQLVWUDQ XQLGDGHV LQWHUQDFLRQDOHV 8, GH RFLWRFLQD LPRLY6LHVWDVPDQLREUDVVRQLQHIHFWLYDVVHGHEHSURFHGHUDODH[WUDFFLyQ PDQXDOGHODSODFHQWD /DUHWHQFLyQGHSODFHQWDSXHGHVHUWRWDORSDUFLDO 7RWDOHVFXDQGRODWRWDOLGDGGHODSODFHQWDSHUVLVWHDGKHULGDDO~WHURHVWRSXHGHVHU SURGXFWRGHXQDFRQWUDFWLOLGDGXWHULQDLQH¿FD]DWRQtDRGHEHUVHDXQDDGKHVLYLGDG DQRUPDOGHODSODFHQWDDO~WHURDFUHWLVPR 3DUFLDO HV FXDQGR TXHGDQ UHWHQLGRV XQR R PiV FRWLOHGRQHV SODFHQWDULRV VL ELHQ OD UHWHQFLyQGHFRWLOHGRQHVSXHGHGHEHUVHDODVPLVPDVFDXVDVTXHJHQHUDQODUHWHQFLyQ WRWDO GH OD SODFHQWD HQ HVWH FDVR HV PiV FRP~Q TXH VH SURGX]FD SRU PDQLREUDV LQDGHFXDGDVGXUDQWHHODOXPEUDPLHQWR 7pFQLFDSDUDHODOXPEUDPLHQWRPDQXDO /DH[WUDFFLyQPDQXDOGHEHHIHFWXDUVHFRQDQHVWHVLDJHQHUDOHQSODQRTXLU~UJLFR6LQR KD\KHPRUUDJLD\ODUHIHUHQFLDDQLYHOGHDOWRULHVJRHVIiFLO\UiSLGDGHEHUHIHULUVHFRQ YHQRFOLVLV LQIXQGLHQGR VROXFLyQ ¿VLROyJLFD DGLFLRQDGD GH 8, GH RFLWRFLQD SRU FDGD P,GHVROXFLyQ1RHPSOHDUPHWLOHUJRQRYLQDSRUTXHSXHGHDJUDYDUODUHWHQFLyQGH ODSODFHQWD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 6XMHWDUHOIRQGRXWHULQRFRQXQDPDQR ,QWURGXFLUODPDQRPiVKiELOHQODYDJLQD\HQHO~WHURKDVWDDOFDQ]DUHOERUGH SODFHQWDULR 'HVOL]DU ORV GHGRV HQWUH OD SODFHQWD \ ODV SDUHGHV GHVJDUUDQGR ODV DGKHUHQFLDV 8QDYH]OLEHUDGDFRPSOHWDPHQWHUHWLUDUODPDQRFRQODSODFHQWD $GPLQLVWUDU8,GHRFLWRFLQDHQGRYHQRVDOHQWDGLOXLUHQPO )LJXUD7pFQLFDGHDOXPEUDPLHQWRPDQXDO /DPDQLREUDHVKDELWXDOPHQWHH¿FD] /D LPSRVLELOLGDG GH GHVSUHQGHU OD SODFHQWD SXHGH GHEHUVH D DFUHWLVPR SODFHQWDULR (OIUDFDVRREOLJDDODLQPHGLDWDUHIHUHQFLDGHODSXpUSHUDDXQQLYHOFRQSRVLELOLGDGGH HIHFWXDUFLUXJtD /DWUDFFLyQH[DJHUDGDPHQWH¿UPHVREUHHOFRUGyQ\ODFRPSUHVLyQJURVHUDGHOIRQGR XWHULQRSXHGHQGHVHQFDGHQDUGRORULQWHQVRURWXUDGHFRUGyQUHWHQFLyQGHUHVWRVGH SODFHQWDRLQYHUVLyQXWHULQD 5HYLVLyQLQWUDXWHULQD 1RGHEHVHUXVDGDGHUXWLQDGHELGRDTXHHOULHVJRGHLQIHFFLyQHVPD\RUDOEHQH¿FLR TXHRIUHFH 6LH[LVWHVRVSHFKDGHUHWHQFLyQGHUHVWRVGHSODFHQWDUHWHQFLyQSDUFLDOVHKDUiXQ WDFWRLQWUDXWHULQR\GHVHUSRVLEOHVHH[WUDHUiQORVUHVWRVPDQXDOPHQWH$PHQRVTXH VH WHQJD FHUWH]D GH XQD HYDFXDFLyQ FRPSOHWD VHUi DFRQVHMDEOH UHDOL]DU XQ OHJUDGR UDVSDGRFRQFXUHWDURPDGH3LQDUG 6LKD\UHWHQFLyQGHPHPEUDQDVODVPLVPDVVHSXHGHQSLQ]DUFRQXQDSLQ]DGH.RFKHU ODUJD\HQVD\DUVXH[WUDFFLyQPHGLDQWHWRUVLyQ\WUDFFLyQOHQWD\¿UPH +HPRUUDJLD3RVW3DUWR (OYROXPHQGHVDQJUHTXHVHSLHUGH¿VLROyJLFDPHQWHHQHVWHSHUtRGRWUDVXQSDUWRQR VXHOHDOFDQ]DUORVPO\OXHJRGHXQDFHViUHDGHEHVHUPHQRUGHPO&XDQGR HOVDQJUDGRVXSHUDHVRVYRO~PHQHVVHFRQVLGHUDTXHVHHVWiIUHQWHDXQDKHPRUUDJLD SRVWSDUWR+33 &ODVL¿FDFLyQ /DV+33VHVXHOHQFODVL¿FDUVHJ~QHOSHUtRGRGHWLHPSRGHVXDSDULFLyQHQ +33SULPDULDFXDQGRDSDUHFHHQODVSULPHUDVKRUDVTXHVLJXHQDOSDUWR +33VHFXQGDULDRWDUGtDFXDQGRVHSURGXFHHQWUHODVKRUDV\ORVGtDV (VWD FODVL¿FDFLyQ HV LPSRUWDQWH GHELGR D TXH VH VXHOH YLQFXODU FRQ OD FDXVD TXH OD SURGXFH 0LHQWUDV ODV +33 SULPDULDV VXHOHQ VHU SURGXFLGDV SRU DWRQtD XWHULQD ODV VHFXQGDULDVHVWiQPiVUHODFLRQDGDVDODUHWHQFLyQGHUHVWRVRYXODUHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD )DFWRUHVGHULHVJRGHKHPRUUDJLDSRVWSDUWR $XQTXH OD +33 HV LPSUHGHFLEOH H[LVWHQ IDFWRUHV GH ULHVJR TXH MXVWL¿FDQ DQWLFLSDU PHGLGDV GH VHJXULGDG WDOHV FRPR DVHJXUDU TXH HO SDUWR VH UHDOLFH HQ XQ QLYHO TXH FXHQWHFRQVDQJUHVHJXUD\GLVSRQLELOLGDGTXLU~UJLFDRHQHOSHRUGHORVFDVRVWHQHU DVHJXUDGDVODVFRQGLFLRQHVSDUDXQWUDVODGRLQPHGLDWR 6RQIDFWRUHVGHULHVJRSDUDXQD+33 YLQFXODGRVDODSDULGDGSULPLJUDYLGH]\JUDQPXOWLSDULGDG FDXVDVTXHGLVWLHQGHQHO~WHURPDFURVRPtDSROLKLGUDPQLRVHPEDUD]RP~OWLSOH SDUWRSURORQJDGR\RLQGXFLGR KHPRUUDJLDDQWHSDUWR +33HQHPEDUD]RSUHYLR WUDVWRUQRVGHODFRDJXODFLyQ SDUWRRSHUDWRULRIyUFHSVYDFXXP FHViUHDSUHYLD REHVLGDG LQIHFFLyQRYXODU PLRPDWRVLV &DXVDVGHODKHPRUUDJLDSRVWSDUWR /DVFDXVDVGH+33VHSXHGHQUHVXPLUHQJUXSRVSULQFLSDOHV 7UDVWRUQRVGHOWRQRDWRQtDRKLSRWRQtDGHELGRVDIDFWRUHVTXHVREUHGLVWLHQGHQHO ~WHURRTXHDJRWDQOD¿EUDPXVFXODUXWHULQD6XHOHQVHUODFDXVDPiVIUHFXHQWH IUHFXHQFLDHQWUH\GHWRGDVODV+33 5HWHQFLyQ GH UHVWRV RYXODUHV SODFHQWD R FRWLOHGRQHV GHELGR D LDWURJHQLD SRU WUDFFLyQSRUDQRPDOtDVHQODSODFHQWDFLyQSODFHQWDFRQDOJ~QJUDGRGHDFUHWLVPR SODFHQWDSUHYLDRGHFDXVDGHVFRQRFLGD/DUHWHQFLyQGHSODFHQWDH[SOLFDHQWUHXQ \XQGHODV+33 7UDXPiWLFDVSRUGHVJDUURVFHUYLFDOHV\RYDJLQDOHVURWXUDRLQYHUVLyQXWHULQD 7UDVWRUQRVGHODFRDJXODFLyQGHELGRVDFRDJXORSDWtDV+(//3LQIHFFLRQHVRDO XVRGHDQWLFRDJXODQWHV &RQGXFWD ,QGHSHQGLHQWHPHQWH TXH OD GH¿QLFLyQ GH +33 VH VLW~D HQ YRO~PHQHV LJXDOHV R PD\RUHVDP/ODUHSHUFXVLyQTXHRFDVLRQDHOVDQJUDGRVHUHODFLRQDFRQHOQLYHO GHKHPRJORELQDSUHYLRGHODPDGUH8QDPXMHUFRQDQHPLDSUHYLDWROHUDUiSHRUXQD KHPRUUDJLDGHLJXDOYROXPHQTXHRWUDPXMHUFRQQLYHOHVDGHFXDGRVGHKHPRJORELQD 3RUORWDQWRHQXQDUHJLyQGRQGHODDQHPLDFUyQLFDDIHFWDDPiVGHODWHUFHUDSDUWH GH ODV SDUWXULHQWDV HO WUDWDPLHQWR GH OD +33 FRPLHQ]D HQ HO SUHFRQFHSFLRQDO \ HO SUHQDWDOLQWHQWDQGRFRQVHJXLUTXHODVPXMHUHVOOHJXHQDOSDUWRFRQQLYHOHVQRUPDOHV GHKHPRJORELQD $QWHFXDOTXLHUKHPRUUDJLDSRVWSDUWR 3LGDFRODERUDFLyQDOUHVWRGHOSHUVRQDOGHOVHUYLFLRHQHOTXHXVWHGVHHQFXHQWUD DVLVWLHQGRHOSDUWR $VHJ~UHVHGHFRQVHJXLUXQDYtDYHQRVDSHULIpULFDGHEXHQFDOLEUHDJXMD1R GHPD\RUFDOLEUH &RPLHQFH UHSRVLFLyQ FRQ VROXFLyQ VDOLQD R GH ODFWDWR 5LQJHU D DOWD YHORFLGDG /DYHORFLGDGGHSHUIXVLyQGHODVROXFLyQGHSHQGHUiGHVLVHGHWHFWDQVLJQRVGH VKRFN (QFDVRTXHHO~WHURVHHQFXHQWUHVXELQYROXFLRQDGRSRUHQFLPDGHORPEOLJR\ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR FRQFRQVLVWHQFLDEODQGDPDVDMpHORWDQWRFRPRVHDQHFHVDULRSDUDHYDFXDUOD VDQJUH\FRiJXORV\FRQVHJXLUXQDPHMRUFRQWUDFWLOLGDG $QWHXQVDQJUDGRSRUDWRQtDVLFRQ¿UPDTXHODKHPRUUDJLDHVSRUDWRQtDXWHULQD &RQWLQ~HFRQHOPDVDMHGHOIRQGRXWHULQR $GPLQLVWUH8,GHRFLWRFLQD\XQDDPSROODGHPHWLOHUJRQRYLQDPJLYVHJXLGD GH 8, GH RFLWRFLQD GLVXHOWDV HQ P, GH VROXFLyQ ¿VLROyJLFD D UD]yQ GH JRWDV PLQXWR 2WUD RSFLyQ HV XVDU PHWLOHUJRQRYLQD DPSROODV GH PJ WRWDOPJGLVXHOWDVHQPOGHVROXFLyQ¿VLROyJLFDDJRWDVPLQXWR 6L QR VH UHVXHOYH OD KHPRUUDJLD OD VLWXDFLyQ FOtQLFD HV JUDYH \ VH FXHQWD FRQ SRVLELOLGDGHVTXLU~UJLFDVHIHFW~HKLVWHUHFWRPtDWRWDORVXEWRWDOGHFRQYHQLHQFLD 6L QR FXHQWD FRQ FLUXJtD FRQWLQ~H OD UHSRVLFLyQ FRQ ODV VROXFLRQHV GHVFULSWDV \ FRQFHQWUDGRVGHJOyEXORVURMRVRVDQJUHWRWDO\UH¿HUDDXQFHQWURGHPD\RUQLYHO GHUHVROXFLyQ (IHFW~HHOWUDVODGRFRQORVPLHPEURVHOHYDGRV\HIHFWXDQGRFRPSUHVLyQELPDQXDO GHO~WHUR/DFRPSUHVLyQELPDQXDOVHKDFHFRQJXDQWHVHVWpULOHVHOSXxRGHXQD PDQRVHFRORFDHQODYDJLQDSUHVLRQDQGRODFDUDDQWHULRUGHO~WHURPLHQWUDVTXHOD RWUDPDQRFRPSULPHDWUDYpVGHODEGRPHQODFDUDSRVWHULRUGHO~WHUR )LJXUD&RPSUHVLyQELPDQXDOGHO~WHUR $QWHXQVDQJUDGRSRUUHVWRVSODFHQWDULRVVLVHFRQ¿UPDTXHHOVDQJUDGRVHRULJLQD HQODUHWHQFLyQGHUHVWRVSODFHQWDULRVSODFHQWDFRQIDOWDGHFRWLOHGRQHVSURFHGDD HYDFXDUORVFRQFXUHWDGH3LQDUGH[SOLFDQGRDODPXMHUHOSURFHGLPLHQWR\HPSOHDQGR DQDOJpVLFRVRDQHVWpVLFRV 6LTXHGDUDQGXGDVVREUHODSHUVLVWHQFLDGHUHVWRVVHSXHGHHIHFWXDUXQDH[SORUDFLyQ HQGRXWHULQDFXLGDQGRHVWULFWDPHQWHODVPHGLGDVGHDVHSVLD\DQWLVHSVLD (QRFDVLRQHVSRFRIUHFXHQWHVSXHGHRFXUULUTXHODSODFHQWDRDOJXQRGHVXVIUDJPHQWRV FRWLOHGRQHVVHDQGLItFLOHVGHVHSDUDUGHO~WHURHVWRVHGHQRPLQDDFUHWLVPRSODFHQWDULR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (QHVWRVFDVRVFRQYHQGUiGHULYDUODPXMHUDXQQLYHOGHPD\RUFRPSOHMLGDG\DTXH HVWRVSURFHGLPLHQWRVSXHGHQFRPSOLFDUVHFRQSHUIRUDFLyQXWHULQDKHPRUUDJLDVHYHUD RUHTXHULUKLVWHUHFWRPtD $QWH GHVJDUURV 6L HO ~WHUR HVWi UHWUDtGR \ FRQWLQ~D HO VDQJUDGR UHYLVDU HO FDQDO EODQGR6LKD\GHVJDUURVVXWXUDUORVDSOLFDQGRSUHYLDPHQWHDQHVWpVLFRVORFDOHV6LQR ORVKD\RVLIUDFDVDQODVPDQLREUDVUHIHULUODPDGUHDQLYHOGHDWHQFLyQGHDOWRULHVJR DVHJXUDQGRODUHSRVLFLyQGHVDQJUHRVROXFLRQHVVDOLQDVVLHVQHFHVDULR $QWH XQD LQYHUVLyQ XWHULQD (Q FDVRV H[FHSFLRQDOHV JHQHUDOPHQWH YLQFXODGRV D PDQLREUDVFRPRWUDFFLyQYLROHQWDGHOFRUGyQSXHGHSURGXFLUVHXQDLQYHUVLyQXWHULQD (QHVWRVFDVRVGHEHUiDGPLQLVWUDUVHXQDQDOJpVLFRSRWHQWH0HSHULGLQDDPSROODGH PJGLOXLGDHQFPGHVROXFLyQVDOLQDLQ\HFWDQGROHQWDPHQWHGHDFPSUREDQGR WROHUDQFLD6LVHFXHQWDFRQDQHVWHVLVWDHOSURFHGLPLHQWRGHEHUiVHUSUDFWLFDGRFRQ DQHVWHVLDJHQHUDO 1RXVHPHGLFDFLyQRFLWyFLFDSRUTXHSXHGHDJUDYDUODVLWXDFLyQ &RQPDQLREUDVPDQXDOHVWDOFRPRVHUHSUHVHQWDHQOD¿JXUDLQWHQWHUHSRQHUHO IRQGRXWHULQRDVXOXJDU )LJXUD&RUUHFFLyQGHODLQYHUVLyQXWHULQD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &XLGDGRVGHOSRVSDUWRLQPHGLDWR $ORMDPLHQWRFRQMXQWRODVHSDUDFLyQLQMXVWL¿FDGDGHODPDGUH\VXUHFLpQQDFLGROXHJR GHO SDUWR \ OD LQWHUIHUHQFLD FRQ HO DPDPDQWDPLHQWR D GHPDQGD GHVGH ODV SULPHUDV KRUDVGHYLGDVRQSUiFWLFDVHUUyQHDVIUHFXHQWHVHQODVLQVWLWXFLRQHV\TXHGHEHQVHU GHVHVWLPXODGDV 3RUHOFRQWUDULR&/$3605UHFRPLHQGDHVWLPXODUHQHVWHSHUtRGRHOFRQWDFWRSUHFR] HQWUHPDGUHHKLMR\DSR\DUDOLQLFLRGHODPDPDQWDPLHQWRHQODSULPHUDKRUDSRVWSDUWR /D UHODFLyQ HQWUH OD PDGUH \ VX UHFLpQ QDFLGR HV XQ FRPSOHMR SURFHVR ELROyJLFR \ SVLFRDIHFWLYRFX\DLPSRUWDQFLDHVHVHQFLDOHQODVREUHYLGDGHOQLxR\HOELHQHVWDUGH DPERV(VWHLQLFLRGHUHODFLyQHVWiHQODEDVHGHOGHVDUUROOR\ODSURPRFLyQGHVXVDOXG PHQWDO /RV HVWXGLRV TXH DYDODQ HVWH FRQFHSWR GH FXLGDGR SVLFRDIHFWLYR KDQ HYDOXDGR ODV FRQVHFXHQFLDV GH OD VHSDUDFLyQ LQMXVWL¿FDGD HQ OD GLVPLQXFLyQ GH OD GXUDFLyQ GH OD ODFWDQFLDHQHOLQFUHPHQWRGHFRPSRUWDPLHQWRVPDWHUQRVQHJDWLYRVTXHDEDUFDQORV H[WUHPRVGHOPDOWUDWRLQIDQWLO\HODEDQGRQR /DVLQVWLWXFLRQHVTXHQRVHSDUDQDODVPDGUHVGHVXVKLMRVUHFLpQQDFLGRVKDQFUHDGR VDODVGHLQWHUQDFLyQGRQGHDPERVSHUPDQHFHQMXQWRVWRGRHOGtD\UHFLEHQFXLGDGRV GHHQIHUPHUtDHQIRUPDFRQMXQWDSHUPLWLHQGRTXHODVIDPLOLDVWDPELpQSDUWLFLSHQHQ VXVFXLGDGRV\DSURYHFKDQGRHOSHUtRGRGHLQWHUQDFLyQSDUDDFWLYLGDGHVGHHGXFDFLyQ SDUDODVDOXG(VWDVVDODVVHOODPDQKDELWXDOPHQWH³DORMDPLHQWRVFRQMXQWRV´TXHKDVWD HOGtDGHKR\QRVHKDQXQLYHUVDOL]DGRHQOD5HJLyQ %XVFDQGR PHMRUDU OD FDOLGDG GH DWHQFLyQ \ FRQ OD LQWHQFLyQ GH FRQVHJXLU PHMRUHV UHVXOWDGRVDFRQWLQXDFLyQVHSUHVHQWDQODVGLYHUVDVSUiFWLFDVXVDGDVHQODDWHQFLyQ GHOSDUWRVHJ~QFXDWURFDWHJRUtDV (QHVWDVFDWHJRUtDVVHDJUXSDQODVSUiFWLFDVGHPRVWUDGDPHQWH~WLOHV\TXHGHEHQVHU HVWLPXODGRVKDVWDDTXHOODVLQQHFHVDULDVRTXHSURYRFDQULHVJRV &DWHJRUtD$ 3UiFWLFDVTXHVHKDQGHPRVWUDGR~WLOHV\TXHGHEHQVHUHVWLPXODGDV 8QSODQSHUVRQDOKHFKRFRQODPXMHU\VXIDPLOLDGXUDQWHHOHPEDUD]RHQHOTXHVH GHWHUPLQHTXLpQHIHFWXDUiHOSDUWR\GyQGH (YDOXDFLyQGHOULHVJRGXUDQWHHOFXLGDGRSUHQDWDOUHHYDOXiQGRORHQFDGDFRQWUROHQ HOPRPHQWRGHODSULPHUDDWHQFLyQGXUDQWHHOSDUWR\DWUDYpVGHOPLVPR &RQWURODUHOELHQHVWDUWDQWRItVLFRFRPRHPRFLRQDOGHODPXMHUGXUDQWHHOSDUWR\DO ¿QDOL]DUHOSURFHVRGHOQDFLPLHQWR 2IUHFHUOtTXLGRVGXUDQWHHOWUDEDMRGHSDUWR 5HVSHWDUODHOHFFLyQLQIRUPDGDGHODPXMHUVREUHHOOXJDUGHOQDFLPLHQWR 3URYHHU XQ FXLGDGR GXUDQWH HO WUDEDMR GH SDUWR HQ HO QLYHO PiV SHULIpULFR GRQGH HO SDUWRVHDSRVLEOH\VHJXUR\GRQGHODPXMHUVHVLHQWDVHJXUD\FRQ¿DGD 5HVSHWDUHOGHUHFKRGHODPXMHUDODSULYDFLGDGHQHOOXJDUGHOSDUWR %ULQGDUDSR\RHPSiWLFRGXUDQWHHOSDUWR\QDFLPLHQWR 5HVSHWDUODHOHFFLyQGHODPXMHUVREUHTXLpQODDFRPSDxDUiHQHOSDUWR 'DUDODVPXMHUHVWDQWDVH[SOLFDFLRQHVHLQIRUPDFLyQFRPRHOODVGHVHHQ 8WLOL]DUPpWRGRVGHDOLYLRGHOGRORUGXUDQWHHOSDUWRQRLQYDVLYRV\QRIDUPDFROyJLFRV WDOHVFRPRPDVDMHV\WpFQLFDVGHUHODMDFLyQ 0RQLWRUHRIHWDOSRUDXVFXOWDFLyQLQWHUPLWHQWH 8VR ~QLFR GH PDWHULDO GHVHFKDEOH \ HVWHULOL]DFLyQ DSURSLDGD GH ORV PDWHULDOHV UHXWLOL]DEOHVGXUDQWHHOSDUWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 8VR GH JXDQWHV HQ HO H[DPHQ YDJLQDO HQ HO PDQHMR GHO UHFLpQ QDFLGR \ HQ OD PDQLSXODFLyQGHODSODFHQWD /LEHUWDGGHPRYLPLHQWRSDUDODPXMHU\DGRSFLyQGHODSRVWXUDTXHSUH¿HUDGXUDQWH HOSDUWR $OHQWDUODSRVLFLyQQRVXSLQDGXUDQWHHOSDUWR (YDOXDFLyQFXLGDGRVDGHOSURJUHVRGHOSDUWRSRUHMHPSORXWLOL]DQGRHOSDUWRJUDPD $GPLQLVWUDFLyQGHRFLWRFLQDSUR¿OiFWLFDHQHOWHUFHUSHUtRGRGHOSDUWRHQPXMHUHVFRQ ULHVJRGHKHPRUUDJLDSRVSDUWRRTXHKD\DQVXIULGRXQDSHTXHxDSpUGLGD (VWHULOLGDGHQHOFRUWHGHOFRUGyQXPELOLFDO 3UHYHQLUODKLSRWHUPLDGHOUHFLpQQDFLGR 3UHYHQFLyQGHODKHPRUUDJLDQHRQDWDOFRQHOXVRGHYLW. 3UHYHQFLyQGHODRIWDOPLDJRQRFyFFLFDFRQHOXVRGHQLWUDWRGHSODWDRDQWLELyWLFR &RQWDFWR SUHFR] SLHO D SLHO HQWUH OD PDGUH \ VX UHFLpQ QDFLGR$SR\DU OD SXHVWD DO SHFKR GXUDQWH OD SULPHUD KRUD SRVSDUWR GH DFXHUGR D ODV UHFRPHQGDFLRQHV GH OD 206SDUDDOLPHQWDFLyQDOSHFKR $ORMDPLHQWRFRQMXQWR 6XSULPLUODODFWDQFLDHQPDGUHV9,+SRVLWLYDV ([DPHQUXWLQDULRGHODSODFHQWD\PHPEUDQDV &DWHJRUtD% 3UiFWLFDVTXHVRQFODUDPHQWHGDxLQDVRLQHIHFWLYDV\TXHGHEHQVHUHOLPLQDGDV 8VRUXWLQDULRGHHQHPDV 8VRUXWLQDULRGHOUDVXUDGRS~ELFR 8VRUXWLQDULRGHODVLQIXVLRQHVHQGRYHQRVDVGXUDQWHHOSDUWR 8VRUXWLQDULRGHXQDFiQXODHQGRYHQRVDSUR¿OiFWLFD 8VRUXWLQDULRGHODSRVLFLyQVXSLQDGXUDQWHHOWUDEDMRGHSDUWR ([DPHQUHFWDO ([iPHQHV YDJLQDOHV UHSHWLGRV R IUHFXHQWHV HVSHFLDOPHQWH FXDQGR VRQ UHDOL]DGRV SRUPiVGHXQDSHUVRQD 8VRGHODSHOYLPHWUtDUDGLROyJLFD $GPLQLVWUDFLyQGHRFLWyFLFRVHQFXDOTXLHUPRPHQWRDQWHVGHOH[SXOVLYRGHPRGRWDO TXHVXVHIHFWRVQRSXHGDQVHUFRQWURODGRV 8VR UXWLQDULR GH OD SRVLFLyQ GH OLWRWRPtD FRQ R VLQ ³FROJDU´ ODV SLHUQDV GXUDQWH HO SDUWR 3XMRVSURORQJDGRVPDQLREUDGH9DOVDOYDGXUDQWHHOVHJXQGRSHUtRGRGHOSDUWR 0DVDMHDU\HVWLUDUHOSHULQHRGXUDQWHHOVHJXQGRSHUtRGRGHSDUWR 8VROLEHUDORUXWLQDULRGHODHSLVLRWRPtD 8VRGHSDVWLOODVGHHUJRPHWULQDHQHOWHUFHUSHUtRGRGHOSDUWRSDUDSUHYHQLURFRQWURODU XQDKHPRUUDJLD 8VRUXWLQDULRGHHUJRPHWULQDSDUHQWHUDOHQHOWHUFHUSHUtRGRGHOSDUWR /DYDGRUXWLQDULRGHO~WHURGHVSXpVGHOH[SXOVLYR 5HYLVLyQUXWLQDULDH[SORUDFLyQPDQXDOGHO~WHURGHVSXpVGHOH[SXOVLYR 0DQLREUD GH .ULVWHOOHU R VLPLODU FRQ IXHU]D LQDGHFXDGD DSOLFDGD DO IRQGR XWHULQR GXUDQWHHOH[SXOVLYR 3UiFWLFDOLEHUDOGHFHViUHD $VSLUDFLyQQDVRIDUtQJHDGHUXWLQDHQHOUHFLpQQDFLGRQRUPDO 0DQWHQLPLHQWRDUWL¿FLDOGHDLUHIUtRDVDODGHSDUWRDQWHV\GXUDQWHHOQDFLPLHQWR &ODPSHRSUHFR]GHOFRUGyQGHUXWLQD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &DWHJRUtD& 3UiFWLFDV SDUD ODV TXH H[LVWH HYLGHQFLDV LQVX¿FLHQWHV FRPR SDUD HPLWLU XQD UHFRPHQGDFLyQ GH¿QLWLYD \ TXH GHEHQ VHU XWLOL]DGDV FRQ SUHFDXFLyQ PLHQWUDV LQYHVWLJDFLRQHVIXWXUDVFODUL¿FDQVXXVR 0pWRGRVQRIDUPDFROyJLFRVGHDOLYLRGHOGRORUGXUDQWHHOSDUWRWDOHVFRPRKLHUEDV LQPHUVLyQHQDJXD\HVWLPXODFLyQQHUYLRVD $PQLRWRPtDSUHFR]UXWLQDULDHQHOSULPHUSHUtRGRGHOSDUWR 0DQLREUDVUHODFLRQDGDVFRQODSURWHFFLyQGHOSHULQHR\HOPDQHMRGHODFDEH]DIHWDO HQHOPRPHQWRGHOSDUWR 0DQLSXODFLyQDFWLYDGHOIHWRHQHOH[SXOVLYR 2FLWRFLQDUXWLQDULDWUDFFLyQFRQWURODGDGHOFRUGyQRXQDFRPELQDFLyQGHODVPLVPDV GXUDQWHHOWHUFHUSHUtRGRGHOSDUWR (VWLPXODFLyQ GHO SH]yQ SDUD DXPHQWDU ODV FRQWUDFFLRQHV XWHULQDV GXUDQWH HO WHUFHU SHUtRGRGHOSDUWR &DWHJRUtD' 3UiFWLFDVTXHVHXWLOL]DQIUHFXHQWHPHQWHHQIRUPDLQDSURSLDGD 5HVWULFFLyQGHDOLPHQWRV\OtTXLGRVGXUDQWHHOSDUWR &RQWUROGHOGRORUSRUDJHQWHVVLVWpPLFRV &RQWUROGHOGRORUSRUDQDOJHVLDSHULGXUDO 0RQLWRUHRIHWDOHOHFWUyQLFRHQEDMRULHVJR 8WLOL]DFLyQGHPiVFDUDV\FDPLVROLQHVHVWpULOHVGXUDQWHODDWHQFLyQGHOSDUWR 8VRUXWLQDULRGHRFLWRFLQDGXUDQWHHOWUDEDMRGHSDUWR 0RYLOL]DFLyQUXWLQDULDGHODPXMHUHQWUDEDMRGHSDUWRDXQDKDELWDFLyQGLIHUHQWHHQHO FRPLHQ]RGHOVHJXQGRSHUtRGR &DWHWHUL]DFLyQYHVLFDO $OHQWDUDODPXMHUDSXMDUFXDQGRVHKDGLDJQRVWLFDGRXQDGLODWDFLyQFRPSOHWDDQWHV TXHODPXMHUVLHQWDODQHFHVLGDGGHKDFHUORHOODPLVPD 0DQWHQHUVHUtJLGRHQFRQVLGHUDUQRUPDOXQDGXUDFLyQ¿MDWDOFRPRXQDKRUDSDUDHO VHJXQGRSHUtRGRGHOSDUWRVLODVFRQGLFLRQHVPDWHUQRIHWDOHVVRQEXHQDV\HOWUDEDMR GHSDUWRSURJUHVD 3DUWRLQVWUXPHQWDOGHUXWLQD 8VROLEHUDORUXWLQDULRGHODHSLVLRWRPtD ([SORUDFLyQPDQXDOGHO~WHURGHVSXpVGHOSDUWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD $6,67(1&,$'85$17((/38(53(5,2 2%-(7,92 &RQWURODUELHQHVWDUGHODPXMHUSXpUSHUD 'HWHFWDU\HYDOXDUGHVYLDFLRQHVGHORVOtPLWHV¿VLROyJLFRV (YDOXDUULHVJR\UHIHULUDQLYHODSURSLDGR $SOLFDUPDQLREUDVFRUUHFWLYDV $&7,9,'$' (GXFDFLyQGHODPXMHUSXpUSHUD &RQWUROHVFOtQLFRVGHODPXMHU\VXKLMR 5HJLVWURGHORVFRQWUROHVHQODKLVWRULDFOtQLFDSHULQDWDO 'H¿QLFLyQ (O SXHUSHULR FRPR WDO FRPLHQ]D XQD YH] TXH KD WHUPLQDGR HO DOXPEUDPLHQWR \ VH H[WLHQGHSRUXQDVVHLVVHPDQDV'XUDQWHHVWHSHUtRGRUHYHUWLUiQWRGRVORVFDPELRV ¿VRLROyJLFRV TXH VH SURGXMHURQ GXUDQWH HO HPEDUD]R FRQ OD VROD H[FHSFLyQ GH ORV FDPELRVPDPDULRVTXHVHLQWHQVL¿FDUiQSDUDPDQWHQHUHODPDPDQWDPLHQWRH[LWRVR 3XHUSHULRLQPHGLDWRDEDUFDODVSULPHUDVKRUDVGHOSRVWSDUWRHLQFOX\HHQpODODV KRUDVTXHFRQWLQ~DQDODOXPEUDPLHQWR6XLPSRUWDQFLDUDGLFDHQTXHHVHQHVWHSHUtR GRHQHOFXDOVHSURGXFHODPD\RUFDQWLGDGGHFRPSOLFDFLRQHVJUDYHVHVSHFLDOPHQWH ODVYLQFXODGDVDWUDVWRUQRVSRUVDQJUDGR 3RUVXPD\RUULHVJRGHKHPRUUDJLD\VKRFNHOSRVWDOXPEUDPLHQWRSULPHUDVKRUDV GHOSXHUSHULR\DKDVLGRDQDOL]DGRMXQWRFRQHODOXPEUDPLHQWR /RVFRQWUROHVGXUDQWHODVSULPHUDVKRUDVGHEHUiQLQFOXLU (VWDGRGHFRQFLHQFLDODSDUWXULHQWDGHEHUiHVWDUO~FLGD\WUDQTXLOD )DVFLHVODFRORUDFLyQGHSLHO\PXFRVDVGHEHUiHVWDUELHQFRORUHDGDH[FHSWRVL WHQtDXQDDQHPLDSUHYLD )UHFXHQFLDGHOSXOVRGHODPXMHUGHEHUiVHUOOHQR\WHQHUXQDIUHFXHQFLDQRUPDO HQWUH\ODWLGRVSRUPLQXWRHQFRQGLFLRQHVEDVDOHV 3UHVLyQDUWHULDOQRGHEHUiDSDUWDUVHVXVWDQFLDOPHQWHGHORVYDORUHVSUHYLRV 7HPSHUDWXUDFRUSRUDOHVQRUPDO\QRGHEHUiVXSHUDUORV&(QHOSRVWDOXP EUDPLHQWRSXHGHQREVHUYDUVHHVFDORIUtRVTXHVRQQRUPDOHV\UDUDPHQWHGXUDQ PiVGHPLQXWRV 5HWUDFFLyQGHO~WHURJORERGHVHJXULGDGGH3LQDUGHQODVSULPHUDVKRUDVHO IRQGRGHO~WHURQRGHEHUiVREUHSDVDUODFLFDWUL]XPELOLFDO\ODFRQVLVWHQFLDVHUi ¿UPHHOiVWLFDDGTXLULHQGRXQDFRQVLVWHQFLDOHxRVDDOVHUHVWLPXODGRSHUPDQH FLHQGRLQGRORURDODSDOSDFLyQ6RORSRGUiSHUFLELUVHGRORUFXDQGRVHSUHQGDHO QLxRDOSHFKRPDWHUQRHQWXHUWRV(QFDVRGHGRORUHVWDUiQLQGLFDGRVORVDQDO JpVLFRVFRPXQHV\ORVDQWLQÀDPDWRULRVQRHVWHURLGHRV 6DQJUDGRYDJLQDOHQFDVRTXHHOVDQJUDGRYDJLQDOVHDDEXQGDQWH\VLHO~WHUR HVWiELHQFRQWUDtGRGHEHUiHIHFWXDUVHXQDLQVSHFFLyQPLQXFLRVDGHOFDQDOGH SDUWRLQWHQWDQGRGHVFDUWDUOHVLRQHVGHVJDUURVHQYDJLQD\HQFXHOORGH~WHUR $OWHUDFLRQHVUHJLRQDOHVHQRFDVLRQHVVHSXHGHYHUHQHODQRKHPRUURLGHVÀX[L YDVTXHPHMRUDQSDUFLDOPHQWHFRQKLHOR\FUHPDVORFDOHVFRQDQHVWpVLFRVWySL FRV$QLYHOXULQDULRHVH[FHSFLRQDOODUHWHQFLyQXULQDULDVHWUDWDUiFRQFDWHWHULV PRVYHVLFDOHVLQWHUPLWHQWHV$OFDERGHXQDVKRUDVVXHOHUHPLWLU &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR )LJXUD)UDJPHQWR+&3&RQWUROHVHQHOSXHUSHULR +LJLHQHSHULQHDO 6HWUDWHGHXQSDUWRFRQRVLQHSLVLRWRPtDFDGDYH]TXHODPXMHUUHTXLHUDFDPELDUHO DSyVLWRVHUiUHFRPHQGDEOHTXHKLJLHQLFHOD]RQDFRQDJXDOLPSLD\MDEyQRFRQDJXD OLPSLDDODTXHVHOHDJUHJyXQDQWLVpSWLFR(OODYDGRVHKDUiSRUDUUDVWUHVLHPSUHHQ VHQWLGRDQWHURSRVWHULRUGHODYXOYDKDFLDHODQR6HFRPSOHPHQWDUiFRQVHFDGRGH XQSDxROLPSLRRFRQJDVDVOLPSLDV /DURSDLQWHULRUVHUiVHSDUDGDSRUXQDSyVLWRJDVDDOJRGyQJDVDRSRUSURWHFWRUHV ³QRFWXUQRV´GHORVTXHVHFRQVLJXHQHQHOPHUFDGR /RVODYDGRVLQWUDYDJLQDOHVVRQGHVDFRQVHMDGRV (QFDVRGHHSLVLRWRPtDORVFXLGDGRVVHUiQVLPLODUHVSHURVHLQVLVWLUiHQPDQWHQHUOD ]RQDVHFDHOPD\RUWLHPSRSRVLEOH &XLGDGRGHORVSH]RQHV 'XUDQWHHOHPEDUD]RODPXMHUGHEHLQWHQWDUPDQWHQHUDLUHDGDOD]RQDGHOSH]yQ\OD DUHRODOXEULFDUODFRQXQDJRWDGHOSURSLRFDORVWUR\H[SRQHUOD]RQDDOVROHQWUHGLH]\ TXLQFHPLQXWRVSRUGtD'XUDQWHODODFWDQFLDHVUHFRPHQGDEOHUHSHWLUHOSURFHGLPLHQWR UHHPSOD]DQGRHOFDORVWURSRUODOHFKH 2ULHQWDFLyQVREUHFXLGDGRVGHOFRUGyQ\ODFWDQFLD 6HGHVDUUROODQHQHOFDStWXORQHRQDWDO 3XHUSHULRPHGLDWR 6HH[WLHQGHGHVGHHOVHJXQGR\KDVWDHOGtDGHOSDUWR 6LJQRV YLWDOHV WHPSHUDWXUD IUHFXHQFLD FDUGtDFD \ SUHVLyQ DUWHULDO &XDOTXLHU DOWHUDFLyQGHORVVLJQRVYLWDOHVREOLJDUiDODE~VTXHGDGHODJHQWHHWLROyJLFR\ DQWHODSUHVHQFLDGHGXGDVGHEHUiVHUHQYLDGDDXQQLYHOGHPD\RUFRPSOHMLGDG SDUDFRQWLQXDUVXDWHQFLyQ (YDOXDFLyQGHORVORTXLRVFDQWLGDGDVSHFWRFRPSRVLFLyQ\RORU(VGLItFLOHVWL PDUODFDQWLGDGSRUORTXHVHUHFRPLHQGDYHUVLODPDGUHWLHQHRQRDQHPLD(O FRORUDHVWDDOWXUDGHOSXHUSHULRGHEHVHUURMRRURVDGR(OFRORUPDUUyQDFKRFR ODWDGRKDUiVRVSHFKDULQIHFFLyQ6XHOHQDGHPiVGHVDQJUHFRQWHQHUIUDJPHQ WRVWLVXODUHVSHTXHxRV(ORORUSXHGHVHUIXHUWHHQFDVRGHIHWLGH]VHGHEHUi VRVSHFKDULQIHFFLyQ &RQWUROGHLQYROXFLyQXWHULQD/DLQYROXFLyQHVVXPDPHQWHUiSLGDDSUR[LPDGD PHQWHDFHQWtPHWURVSRUGtD\VHPLGHPHGLDQWHSDOSDFLyQGHOIRQGRXWHULQR$ ORVGtDVGHSXHUSHULRVHVLWXDUiHQWUHHORPEOLJR\HOERUGHVXSHULRUGHOSXELV\ DORVGtDVHVWDUiSUy[LPRDOSXELV $OWHUDFLRQHVUHJLRQDOHVHQRFDVLRQHVVHSXHGHQYHUVHKHPRUURLGHVÀX[LYDV\ GRORURVDVTXHQRPHMRUDQFRQWUDWDPLHQWRPpGLFRHQHVRVFDVRVGHEHUiGHV FDUWDUVH XQD WURPERVLV KHPRUURLGDULD OD TXH VH VROXFLRQD IiFLOPHQWH FRQ XQ PtQLPRGUHQDMHTXLU~UJLFRFRQDQHVWHVLDORFDO2WUDVYHFHVHOGRORUSXHGHVHU H[SUHVLyQGHXQD¿VXUDDQDOTXHVXHOHUHYHUWLUFRQWUDWDPLHQWRPpGLFROXHJR GHXQDVVHPDQDV&RQUHODFLyQDODYHMLJD\ORVPHFDQLVPRVGHFRQWHQFLyQHV IDFWLEOHREVHUYDUXQDLQFRQWLQHQFLDGHRULQDTXHVXHOHUHPLWLUHVSRQWiQHDPHQWH HQDOJXQRVGtDVRVHPDQDV %DMDGDGHODOHFKH(QHVWRVGtDVVHVXVWLWX\HHOFDORVWURSRUODOHFKHGH¿QLWLYD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 3XHUSHULRDOHMDGR $EDUFD GHVGH HO KDVWD HO GtD GHO SRVWSDUWR (VWH HV XQ EXHQ SHUtRGR SDUD FRQWURODUODHYROXFLyQ GHODODFWDQFLD\SUHSDUDUDODPXMHUSDUDHOUHWRUQRDVXYLGD VH[XDO (Q HVWH PRPHQWR HV UHFRPHQGDEOH RULHQWDU VREUH DQWLFRQFHSFLyQ \ HVSDFLR LQWHUJHVWDFLRQDO &RQWLQ~D OD LQYROXFLyQ XWHULQD \ HO UHVWDEOHFLPLHQWR GHO HVWDGR SUHJUDYtGLFR$ SDUWLU GHORVGtDVGHOSDUWRSXHGHDGYHUWLUVHXQVDQJUDGRYDJLQDOQRUPDOHOTXHJHQHU DOPHQWHVHGHEHDXQDSUROLIHUDFLyQHQGRPHWULDOH[FOXVLYDPHQWHYLQFXODGDDHVWUyJH QRV5DUDYH]SXHGHGHEHUVHDXQDSUROLIHUDFLyQHVWUyJHQR±SURJHVWDFLRQDO (OUHLQLFLRGHODVUHODFLRQHVVH[XDOHVHVUHFRPHQGDEOHOXHJRGHODGHVDSDULFLyQGHORV ORTXLRVORTXHVHSURGXFHHQWUHORV\ORVGtDVGHOSXHUSHULR (QDOJXQRVFDVRVpVWHVHUiHO~OWLPRFRQWUROHQWUHODPXMHU\HOHTXLSRGHVDOXG3RU HVRHVUHFRPHQGDEOHDGHPiVGHODFRQVHMHUtDHQFRQWUDFHSFLyQUHVWDEOHFLPLHQWRGH ODVUHODFLRQHVVH[XDOHV\ODFWDQFLDHIHFWXDUXQH[DPHQFOtQLFRJHQHUDO\JLQHFROyJLFR HQFDVRTXHIXHVHQHFHVDULR 3XHUSHULRWDUGtR (VWHSHUtRGRVHH[WLHQGHPiVDOOiGHOGtD\QRPiVDOOiGHXQDxR7RPDVXLP SRUWDQFLD HQ TXH KD\ DOJXQDV VLWXDFLRQHV PyUELGDV R LQFOXVR PRUWDOHV TXH SXHGHQ SURGXFLUVHHQHVWHSHUtRGR (O$OWD (VUHFRPHQGDEOHRWRUJDUHODOWDDODVKRUDVGHOSDUWRVLHVTXHQRKXERFRPSOLFD FLRQHV\VLHPSUHTXHODPXMHUHVWiHQFRQGLFLRQHVGHDGPLQLVWUDUFXLGDGRVDVXUHFLpQ QDFLGRHQIRUPDFRPSHWHQWH &XDQGR GHED RWRUJDUVH HO DOWD HQ IRUPD SUHFR] GHEHUiQ JDUDQWL]DUVH LQVWDQFLDV GH VHJXLPLHQWRGRPLFLOLDULR\GHVHUSRVLEOHLQVWUXPHQWDUVLVWHPDVGHFRQVXOWDWHOHIyQLFD FRQUHIHUHQWHVGHOFHQWURGHVDOXGRGHODFRPXQLGDGUHFRUGDUTXHODVSULPHUDV KRUDVVXHOHQVHUODVGHPD\RUULHVJRYLWDOWDQWRSDUDODPXMHUFRPRSDUDVXUHFLpQ QDFLGR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 5HIHUHQFLDV%LEOLRJUi¿FDV Campbell DA, Lake MF, Falk M, Backstrand JR. A randomized control trial of continuous support in labor by a lay doula. J Obstet Gynecol Neonatal Nurs. 2006;35(4):456-464. Cotter A, Ness A, Tolosa J. Prophylactic oxytocin for the third stage of labour. Cochrane Database of Systematic Reviews 2001, Issue 4. Dyson L, McCormick F, Renfrew MJ. Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systematic Reviews 2005, Issue 2. Hodnett ED, Lowe NK, Hannah ME, et al. Effectiveness of nurses as providers of birth labor support in North American hospitals: a randomized controlled trial. JAMA.2002; 288: 1373-1381. Ekstrom A, Nissen E. A mother’s feelings for her infant are strengthened by excellent breastfeeding counseling and continuity of care. Pediatrics. 2006;118(2):e309-314. Escobar GJ, Braveman PA, Ackerson L, et al. A randomized comparison of home visits and hospital-based group follow-up visits after early postpartum discharge. Pediatrics. 2001;108(3):719-727. Gülmezoglu AM, Forna F, Villar J, Hofmeyr GJ. Prostaglandins for preventing postpartum haemorrhage. Cochrane Database of Systematic Reviews 2007, Issue 3. Hodnett ED. Caregiver support for women during childbirth. Cochrane Database of Systematic Reviews 2002, Issue 1. Johnston RA, Sidall RS. Is the usual method of preparing patients for delivery beneficial or necessary?Am J Obstet Gynecol. 1992;4:645-650. Kennell J, Klauss MH, McGrath S, Hinkley C. Continuous emotional support during labor in a US hospital. A randomized controlled trial. JAMA. 1991;265(17):2197-2201 Kominiarek MA, Kilpatrick SJ. Postpartum hemorrhage: a recurring pregnancy complication. Semin Perinatol. 2007 Jun;31(3):159-66. Review. Labarere J, Gelbert-Baudino N, Ayral AS, et al. Efficacy of breastfeeding support provided by trained clinicians during an early, routine, preventive visit: a prospective, randomized, open trial of 226 mother-infant pairs. Pediatrics. 2005;115(2):e139-146 Langer A, Campero L, García C, Reynoso S. Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers’ wellbeing in a Mexican public hospital: a randomised clinical trial. Br J Obstet Gynaecol. 1998;105(10):1056-1063. Liabsuetrakul T, Choobun T, Peeyananjarassri K, Islam QM. Prophylactic use of ergot alkaloids in the third stage of labour. Cochrane Database of Systematic Reviews 2007, Issue 2 Lomuto C, Albaizeta D. Lactancia Materna. En: Schwarcz R, Fescina R, Duverges C. Obstetricia. 6ª edición. Buenos Aires: El Ateneo, 2005. pp 515-519. Madi BC, Sandall J, Bennett R, et al. Effects of female relative support in labor: a randomized controlled trial. Birth. 1999;26(1):4-8. Maughan KL, Heim SW, Galazka SS. Preventing postpartum hemorrhage: managing the third stage of labor. Am Fam Physician. 2006 Mar 15;73(6):1025-1028. McDonald S, Abbott JM, Higgins SP. Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour. Cochrane Database of Systematic Reviews 2004, Issue 1. PATH 2004. Prevención de la hemorragia post parto: herramientas para los proveedores de atención clínica. Versión condensada. Washington, D.C.: PATH. 2004. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database of Systematic Reviews 2000, Issue 3. Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 4. Shaw E, Levitt C, Wong S, Kaczorowski J; The McMaster University Postpartum Research Group. Systematic review of the literature on postpartum care: effectiveness of postpartum support to improve maternal parenting, mental health, quality of life, and physical health. Birth. 2006 Sep;33(3):210-220. Review. Schwarcz R. El parto patológico. Distocias del canal pelvigenital.En: Schwarcz R, Fescina R, Duverges C. Obstetricia. 6ª edición. Buenos Aires: El Ateneo, 2005. pp 392-396. Schwarcz R, Diaz AG, Fescina R, De Mucio B, Belitizky R, Delgado L. Atención Prenatal y del Parto de Bajo Riesgo. Montevideo, CLAP 1995; Publ. Cient. CLAP Nº 1321.01 Schwarcz R, Fescina RH, Duverges C. Obstetricia. 6ª ed. Buenos Aires: El Ateneo, 2005. Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour. Cochrane Database of Systematic Reviews 2006, Issue 4. Su LL, Chong YS, Samuel M. Oxytocin agonists for preventing postpartum haemorrhage. Cochrane Database of Systematic Reviews 2007, Issue 3. Tessier V, Pierre F; College National des Gynecologues et Obstetriciens Francais; Agence Nationale d’Accreditation et d’Evaluation en Sante. Risk factors of postpartum hemorrhage during labor and clinical and pharmacological prevention] J Gynecol Obstet Biol Reprod (Paris). 2004 Dec;33(8 Suppl):4S29-4S56. Review. Yamazaki H, Uchida K. A mathematical approach to problems of cephalopelvic disproportion at the pelvic inlet. Am J Obstet Gynecol. 1983 Sep 1;147(1):25-37. UNICEF. 10 pasos para la lactancia materna eficaz. http://www.unicef.org/spanish/nutrition/23964_ breastfeeding.html (Último acceso 28 de Febrero de 2007) UNICEF/WHO. Baby Friendly Hospital Initiative, revised, updated and extended for integrated care, preliminary version, January 2006. http://www.who.int/nutrition/topics/bfhi/en/index.html (Último acceso 28 de Febrero de 07) Villar J, Gülmezoglu AM, Hofmeyr GJ, Forna F. Systematic review of randomized controlled trials of misoprostol to prevent postpartum hemorrhage. Obstet Gynecol. 2002 Dec;100(6):1301-1312 Winter C, Macfarlane A, Deneux-Tharaux C, Zhang WH, Alexander S, Brocklehurst P, Bouvier-Colle MH, Prendiville W, Cararach V, van Roosmalen J, Berbik I, Klein M, Ayres-de-Campos D, Erkkola R, Chiechi LM, Langhoff-Roos J, Stray-Pedersen B, Troeger C. Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe. BJOG. 2007 Jul;114(7):845-54. WHO. Care in normal birth: A Practical Guide (WHO/FRH/MSM/96.24) [Internet]. Disponible en: http:// www.who.int/reproductive-health/publications/MSM_96_24/care_in_normal_birth_practical_guide.pdf (consulta 28-2-07) WHO 2002. Manejo de las complicaciones del embarazo y el parto: Guía par obstetrices y médicos. Organización Mundial de la Salud. RHR Salud reproductiva e investigaciones conexas, 2002. http://www. who.int/reproductive-health/publications/mcpc/index_sp.html (Último acceso 20 de Junio de 2007) WHO 2006.Pregnancy, Childbirth Postpartum and Newborne Care: A guide for essential practice. 2nd ed. http://www.who.int/making_pregnancy_safer/publications/PCPNC_2006_03b.pdf (Último acceso 4 de Julio de 2007). &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 9 & $ 3, 7 8 /2 9 $WHQFLyQGHO5HFLpQ1DFLGR (Q HVWD VHFFLyQ VH SUHVHQWDQ ORV REMHWLYRV HVSHFt¿FRV GH PD\RU UHOHYDQFLD \ ODV DFWLYLGDGHV FRUUHVSRQGLHQWHV SDUD OD DWHQFLyQ QHRQDWDO EiVLFD 6H GHVWDFDQ ODV YDULDEOHVGHOD+LVWRULD3HULQDWDOTXHUHJLVWUDQODVDFWLYLGDGHVGHDWHQFLyQQHRQDWDO 2%-(7,926 $&7,9,'$'(6 2EVHUYDU VL UHVSLUD R QR \ VL SHUVLVWH HQ 5HFLELUDOUHFLpQQDFLGR\YDORUDUHOLQLFLRGHOD DSQHDGHWHUPLQDUVLHVSRUDV¿[LDIHWDORSRU SULPHUDUHVSLUDFLyQHVSRQWiQHD GHSUHVLyQIDUPDFROyJLFD\SURYHHUYHQWLODFLyQ DVLVWLGDDO51HQDSQHD 3URYHHU FXLGDGRV LQPHGLDWRV TXH IDFLOLWHQ 3URWHJHUODDGDSWDFLyQDODYLGDH[WUDXWHULQD OD DGDSWDFLyQ HVSHFLDOPHQWH HQ ORV QDFLGRV HQHOUHFLpQQDFLGRSUHWpUPLQR SUHWpUPLQR TXH SUHVHQWHQ VLJQRV GH LQPDGXUH]YHQWLODWRULD ,GHQWL¿FDUDOUHFLpQQDFLGR )DFLOLWDUTXHODPDGUHORLGHQWL¿TXH\FXPSOLU ORVUHTXLVLWRVORFDOHVGHLGHQWL¿FDFLyQDOQDFHU (YDOXDU HO FUHFLPLHQWR \ GHVDUUROOR IHWDO DO 5HDOL]DUDQWURSRPHWUtD\YDORUDUODVIXQFLRQHV QDFHU GHDGDSWDFLyQVHJ~QOD(GDG*HVWDFLRQDO $GHFXDUHOPDQHMRLQLFLDOGHORVUHFLpQQDFLGRV ,QVWDXUDU PHGLGDV HVSHFt¿FDV SDUD FDGD FRQGHIHFWRVFRQJpQLWRVPD\RUHV GHIHFWRHQIRUPDSUHFR] (YDOXDU HQ IRUPD VLVWHPiWLFD XQLYHUVDO R VHOHFWLYDDORVUHFLpQQDFLGRVSDUDSUHYHQLU\ 'HWHFWDU SUHYHQLU \ WUDWDU GHIHFWRV \R WUDWDU HQIHUPHGDGHV LQIHFFLRVDV WUDQVPLWLGDV HQIHUPHGDGHV FRQJpQLWDV LQIHFFLRVDV \ QR SRUVXPDGUH LQIHFFLRVDVDVLQWRPiWLFDV 'HWHFFLyQVLVWHPiWLFDGHGHIHFWRVFRQJpQLWRV RHQIHUPHGDGHVQRLQIHFFLRVDVSRUPpWRGRV GHODERUDWRULRELRFOtQLFRRLQVWUXPHQWDOHV 3UHYHQLUODRIWDOPLDJRQRFyFFLFD ,QVWLODU DQWLPLFURELDQRV HQ ODV FRQMXQWLYDV DO QDFHU 3UHYHQLU OD (QIHUPHGDG +HPRUUiJLFD GHO $GPLQLVWUDU9LWDPLQD. 5HFLpQ1DFLGR 1RVHSDUDUDOUHFLpQQDFLGR\VXPDGUH\ IDFLOLWDUHODSR\RIDPLOLDU ,QLFLDU \ PDQWHQHU OD ODFWDQFLD PDWHUQD $OLPHQWDU D OLEUH GHPDQGD \ QR GDU H[FOXVLYD ELEHURQHV 3URPRYHUODODFWDQFLDH[FOXVLYD 3UHYHQLUOD7%&GHOODFWDQWH 9DFXQDFLyQ%&*DOQDFHU 3UHYHQLUODPXHUWHV~ELWDGHOODFWDQWH &RORFDUDO51ERFDDUULEDSDUDGRUPLU OD YLJLODQFLD HQ HO SHUtRGR GH 'LVPLQXLUORVULHVJRVHQORVQDFLGRVSUHWpUPLQR $XPHQWDU DGDSWDFLyQPLHQWUDVSHUPDQHFHQHQODVDOD GH\VHPDQDV FRQVXVPDGUHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2EMHWLYRV 5HFLELUDOUHFLpQQDFLGR\YDORUDUHOLQLFLRGHODSULPHUD UHVSLUDFLyQHVSRQWiQHD $FWLYLGDGHV 2EVHUYDUVLUHVSLUDRQR6LQRUHVSLUDGHGXFLUVLHVSRUDV¿[LD IHWDORSRUGHSUHVLyQIDUPDFROyJLFD 8QHYHQWR¿VLROyJLFRIXQGDPHQWDOHQODDGDSWDFLyQDODYLGDH[WUDXWHULQDHVHOLQLFLRGH ODVSULPHUDVLQVSLUDFLRQHVHVSRQWiQHDV\ODYHQWLODFLyQSXOPRQDUGHVGHORVSULPHURV VHJXQGRVGHQDFLGR(OPRPHQWRGHLQLFLRGHODYHQWLODFLyQHVSRQWiQHDHVYDULDEOHHQ HOSURFHVRQRUPDOGHDGDSWDFLyQSXHVDXQSHUVLVWHODIXQFLyQGHUHVSLUDFLyQSODFHQWDULD SRUHOFRUGyQXPELOLFDO\DOJXQRVUHFLpQQDFLGRVVDQRVSXHGHQLQLFLDUORVPRYLPLHQWRV UHVSLUDWRULRVOXHJRGHVHJXQGRVGHQDFHU 6LXQUHFLpQQDFLGRQRLQLFLDHVSRQWiQHDPHQWHORVPRYLPLHQWRVGHLQVSLUDFLyQSXHGH VHUSRUDV¿[LDIHWDOVHYHUDRSRUODDFFLyQGHSUHVRUDGHO6LVWHPD1HUYLRVR&HQWUDOSRU IiUPDFRVVHGDQWHVRDQHVWpVLFRVDGPLQLVWUDGRVDODPDGUHDQWHVGHOQDFLPLHQWR $V¿[LDIHWDOLQWUDXWHULQD &XDQGR OD DV¿[LD IHWDO HV VHYHUD SXHGH GHWHFWDUVH SRU ODV FDUDFWHUtVWLFDV GH OD IUHFXHQFLD FDUGLDFD IHWDO ,QLFLDOPHQWH VH PDQL¿HVWD LQ ~WHUR FRPR WDTXLFDUGLD PiV GHODWLGRVSRUPLQXWR\SURJUHVLYDPHQWHVHGHWHULRUDFRQSHULRGRVGHEUDGLFDUGLD SRVWFRQWUDFFLyQXWHULQD',36,,REUDGLFDUGLDVHYHUDPDQWHQLGD/DDV¿[LDDIHFWDOD KHPRGLQDPLDIHWDO\DOQDFHUVHPDQL¿HVWDSRUEUDGLFDUGLD\HQORVFDVRVPDVVHYHURV HOUHFLpQQDFLGRVVHHQFXHQWUDHQVKRFNFRQSDOLGH]H[WUHPD\HOFRUGyQXPELOLFDOHVWi ÀiFFLGRSRUODKLSRWHQVLyQDUWHULDO\HOFRODSVRYHQRVR/DDV¿[LDIHWDOHVPDVIUHFXHQWH HQORVIHWRVFRQUHVWULFFLyQGHOFUHFLPLHQWRDGHOJD]DGRVSRULQVX¿FLHQFLDSODFHQWDULD /DVFDXVDVDJXGDVPiVIUHFXHQWHVVRQ'331,SODFHQWDSUHYLDVDQJUDQWHSURODSVR \RQXGRUHDODMXVWDGRGHFRUGyQ\URWXUDXWHULQD 'HSUHVLyQFHQWUDOSRUGURJDV &XDQGR OD GHSUHVLyQ IHWDO LQ ~WHUR HV H[FOXVLYDPHQWH IDUPDFROyJLFD QR GHVDUUROOD DV¿[LDSXHVODSODFHQWDIXQFLRQDQRUPDOPHQWHKDVWDHVHPRPHQWR\SRUFRQVLJXLHQWH QR H[LVWH DOWHUDFLyQ GH OD KHPRGLQDPLD VX FRUGyQ XPELOLFDO DO QDFHU HVWi HUpFWLO \ WLHQH IUHFXHQFLD FDUGLDFD QRUPDO (O UHFLpQ QDFLGR FRQ GHSUHVLyQ IDUPDFROyJLFD HVWi HQ DSQHD QR UHDOL]D PRYLPLHQWRV UHVSLUDWRULRV WLHQH XQD KLSRWRQtD H[WUHPD GHELGDDORVIiUPDFRVGHSUHVRUHV6LVHPDQWLHQHVLQUHVSLUDUDPHGLGDTXHFHVDOD IXQFLyQ SODFHQWDULD HQ SRFRV VHJXQGRV FRPHQ]DUi D DV¿[LDUVH FRQ GHWHULRUR GH VX KHPRGLQDPLDEUDGLFDUGLD\SDOLGH] 5HDQLPDFLyQGHOUHFLpQQDFLGR $SUR[LPDGDPHQWHGHORVUHFLpQQDFLGRVUHTXLHUHQGHDOJ~QWLSRGHDVLVWHQFLDSDUD LQLFLDUORVPRYLPLHQWRVYHQWLODWRULRV6LQHPEDUJRPHQRVGHUHTXLHUHPDQLREUDVGH UHDQLPDFLyQHVSHFt¿FDV (QIRUPDVHQFLOODSXHGHYDORUDUVHODQHFHVLGDGGHLQVWDXUDURQRPHGLGDVGHDSR\R YHQWLODWRULR 1R UHTXHULUiQ GH PDQLREUDV HVSHFt¿FDV GH UHDQLPDFLyQ DTXHOORV UHFLpQ QDFLGRVFRQODVVLJXLHQWHVFDUDFWHUtVWLFDV ż5HFLpQQDFLGRVDWpUPLQR ż/ORUDRVHHYLGHQFLDQPRYLPLHQWRVYHQWLODWRULRV ż3UHVHQWDEXHQWRQRPXVFXODU &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $QWH XQ UHFLpQ QDFLGR GH WpUPLQR TXH OORUD \ SUHVHQWD EXHQ WRQR PXVFXODU QR HV QHFHVDULRLPSOHPHQWDUPHGLGDVGHUHDQLPDFLyQ\HOUHFLpQQDFLGRSRUWDQWRQRGHEH VHUVHSDUDGRGHODPDGUH (QFDVRTXHQRVHGHQHVDVFRQGLFLRQHVHOUHFLpQQDFLGRGHEHUiUHFLELUXQDRPiVGH ODVVLJXLHQWHVLQWHUYHQFLRQHV $ 3DVRVEiVLFRVGHHVWDELOL]DFLyQHYLWDUHQIULDPLHQWRGHVREVWUXLUYtDDpUHDVL HVQHFHVDULRVHFDUOR\UHDOL]DUHYDOXDFLyQGHODFRORUDFLyQGHSLHO\PXFRVDV % 9HQWLODFLyQ & &RPSUHVLRQHVWRUiFLFDV ' $GPLQLVWUDFLyQGHDGUHQDOLQD /DVPHGLGDVLQFOXLGDVHQORVSXQWRV$D'FRUUHVSRQGHQDLQWHUYHQFLRQHVGHLQWHQVLGDG FUHFLHQWH HQ UHVSXHVWD D OD JUDYHGDG \ SHUVLVWHQFLD GH ORV VLJQRV R VtQWRPDV HVSHFt¿FRV/DGHFLVLyQDFHUFDGHOSURJUHVRHQODVLQWHUYHQFLRQHVHQWUHORVSXQWRV$ \'GHSHQGHUiGHODDWHQWDHYDOXDFLyQGHGRVVLJQRVYLWDOHV 9HQWLODFLyQSUHVHQFLDGHDSQHDRGL¿FXOWDGHQORVPRYLPLHQWRVYHQWLODWRULRV ³JDVSLQJ´ )UHFXHQFLDFDUGtDFDYDORUDQGRVLHVPD\RURQRGHODWLGRVSRUPLQXWR 8QD DGHFXDGD HYDOXDFLyQ \ VHJXLPLHQWR GXUDQWH OD JHVWDFLyQ \ HQ HO PRPHQWR GHO SDUWRSHUPLWHLGHQWL¿FDUODSUHVHQFLDGHFRQGLFLRQHVGHULHVJR TXHVHUiQHVHQFLDOHV SDUD SUHGHFLU OD QHFHVLGDG GH LPSOHPHQWDU PDQLREUDV GH UHDQLPDFLyQ SUHPDWXUH] VXIULPLHQWRIHWDOUHVWULFFLyQGHOFUHFLPLHQWRLQWUDXWHULQRHWF (VIXQGDPHQWDOLPSOHPHQWDUORVSDVRVEiVLFRVSURSRUFLRQDUFDORUDOFRORFDUDOEHEp EDMR XQD IXHQWH GH FDORU UDGLDQWH YDORUDU OD SHUPHDELOLGDG GH OD YtD DpUHD VHFDU HO EHEp\HVWLPXODUODUHVSLUDFLyQ\DTXHWDOHVPHGLGDVFRQVWLWX\HQHVWtPXORVEiVLFRV HQHOUHFLpQQDFLGR (QOD¿JXUDVHREVHUYDODVHFXHQFLDGHDVSHFWRVDHYDOXDU\FRQGXFWDDVHJXLU 6LD~QOXHJRGHKDEHULQVWDXUDGRODVPHGLGDVEiVLFDVVHREVHUYDGL¿FXOWDGYHQWLODWRULD RODIUHFXHQFLDFDUGtDFDHVLQIHULRUDODWLGRVSRUPLQXWRVVHUHTXHULUiHQWRQFHVGH DSR\DUDOUHFLpQQDFLGRFRQYHQWLODFLyQDVLVWLGDPHGLDQWHHOXVRGHPiVFDUD 6LQRVHREVHUYDQPHMRUDV\ODEUDGLFDUGLDVHDFHQW~DD~QPiVFRQIUHFXHQFLDFDUGtDFD PHQRUDODWLGRVSRUPLQXWRGHEHUiQUHDOL]DUVHFRPSUHVLRQHVWRUiFLFDVUtWPLFDV'H SHUVLVWLUODEUDGLFDUGDHQHVRVYDORUHVVHLQGLFDUiDGUHQDOLQD (QFDVRTXHODIUHFXHQFLDFDUGtDFDVXSHUHORVODWLGRVSRUPLQXWRVSHURFRQFLDQRVLV \GL¿FXOWDGYHQWLODWRULDSHUVLVWHQWHGHEHUiHYDOXDUVHODSRVLELOLGDGGHEULQGDUR[tJHQR DGLFLRQDO 8QD YH] TXH OD YHQWLODFLyQ FRQ SUHVLyQ SRVLWLYD R OD DGPLQLVWUDFLyQ GH R[tJHQR VXSOHPHQWDULR VH LQLFLy DGHPiV GH OD YDORUDFLyQ GH OD IUHFXHQFLD FDUGLDFD \ GH OD UHVSLUDFLyQ GHEH YDORUDUVH HVWUHFKDPHQWH HO HVWDGR GH R[LJHQDFLyQ FX\D ySWLPD HYDOXDFLyQ GHEH UHDOL]DUVH PHGLDQWH HO XVR GH XQ R[tPHWUR GH SXOVR /D IUHFXHQFLD FDUGtDFD\VXYDULDFLyQFRQVWLWX\HQLQGLFDGRUHVGHODUHVSXHVWDFRUUHFWDDFDGDSDVR (OLQFUHPHQWRGHODIUHFXHQFLDFDUGtDFDLQGLFDDGHFXDGDUHVSXHVWDGHOUHFLpQQDFLGR 3RU WDQWR OD DGPLQLVWUDFLyQ GHO R[LJHQR UHTXLHUH GH OD HYDOXDFLyQ GH UHVXOWDGR \ GH VHJXULGDG 5HVXOWDGR±LQFUHPHQWRGHODIUHFXHQFLDFDUGtDFD! 6HJXULGDG±0RQLWRUHRGHODVDWXUDFLyQGHR[tJHQR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD /DDGPLQLVWUDFLyQGHR[tJHQRGHEHEULQGDUVH62/2FXDQGRVHFRQVLGHUHQHFHVDULD GDGRTXHVLQRVHDGPLQLVWUDHQIRUPDFRUUHFWDSXHGHJHQHUDUFRPSOLFDFLRQHV\GDxRV LPSRUWDQWHVHQHOUHFLpQQDFLGR /DSHUPHDELOLGDGGHODYtDDpUHDPHUHFHXQFRPHQWDULRHQSDUWLFXODU ([LVWHHYLGHQFLDTXHPXHVWUDTXHODDVSLUDFLyQGHODQDVRIDULQJHDVtFRPRODDVSLUDFLyQ HQGRWUDTXHDOHQUHFLpQQDFLGRVLQWXEDGRVTXHUHFLEHQYHQWLODFLyQPHFiQLFDFXDQGRVH UHDOL]DHQIRUPDUXWLQDULDHVGHFLUHQDXVHQFLDGHHYLGHQFLDGHVHFUHFLRQHVQDVDOHV XRUDOHVSXHGHQIDYRUHFHUHIHFWRVQRGHVHDGRVFRPREUDGLFDUGLDRDVRFLDUVHFRQ GHWHULRUR GHODGLVWHQVLELOLGDGSXOPRQDUODR[LJHQDFLyQ FHUHEUDO \ODUHGXFFLyQ GHOD YHORFLGDGGHOÀXMRVDQJXtQHR 3RU OR WDQWR VH UHFRPLHQGD TXH OD DVSLUDFLyQ LQFOX\HQGR OD DVSLUDFLyQ FRQ SHUD GH JRPDVHUHDOLFH62/2HQORVFDVRVTXHSUHVHQWDQREVWUXFFLyQHYLGHQWHDODUHVSLUDFLyQ HVSRQWiQHDRTXHUHTXLHUHQYHQWLODFLyQFRQSUHVLyQSRVLWLYD933 /D DVSLUDFLyQ GH PHFRQLR DQWHV R GXUDQWH HO SDUWR R GXUDQWH OD UHDQLPDFLyQ SXHGH FDXVDUVtQGURPHGHDVSLUDFLyQGHPHFRQLR1RH[LVWHHYLGHQFLDVX¿FLHQWHTXHDSR\H XQFDPELRGHSUiFWLFDHQHVWHVHQWLGR $ IDOWD GH HVWXGLRV DOHDWRUL]DGRV \ FRQWURODGRV QR KD\ SUXHEDV VX¿FLHQWHV SDUD UHFRPHQGDUXQFDPELRHQODSUiFWLFDDFWXDOGHUHDOL]DUODDVSLUDFLyQHQGRWUDTXHDOGH QLxRVQRYLJRURVRVFRQOtTXLGRDPQLyWLFRPHFRQLDO 2WURDVSHFWRIXQGDPHQWDODFRQVLGHUDUHVODDGPLQLVWUDFLyQVXSOHPHQWDULDGHR[tJHQR WDO FRPR VH PHQFLRQy DQWHULRUPHQWH /D UHFRPHQGDFLyQ LQGLFD TXH HO LQLFLR GH ODV PDQLREUDVGHEHUHDOL]DUVHFRQDLUHRXQDPH]FODGHR[tJHQRMXQWRFRQHOPRQLWRUHR GHODFRQFHQWUDFLyQGHR[tJHQRFRPRVHGHVFULELyDQWHULRUPHQWH (V IXQGDPHQWDO FRQWDU HQ ORV VHUYLFLRV FRQ SHUVRQDO DGHFXDGDPHQWH HQWUHQDGR HQ HVWRV DVSHFWRV \ TXH HQ FDGD SDUWR VH FXHQWH FRQ SRU OR PHQRV SHUVRQD FX\D SULQFLSDO UHVSRQVDELOLGDG VHD OD UHFHSFLyQ \ YDORUDFLyQ GH HVWRV DVSHFWRV HQ HO UHFLpQQDFLGRHLQWHUYHQJDRSRUWXQD\DGHFXDGDPHQWH(VWDSHUVRQDGHEHVHUFDSD] GH LQLFLDU OD UHDQLPDFLyQ LQFOX\HQGR OD DGPLQLVWUDFLyQ GH OD YHQWLODFLyQ FRQ SUHVLyQ SRVLWLYD\FRPSUHVLRQHVHQHOSHFKRHOPRQLWRUHRGHODDGPLQLVWUDFLyQGHR[tJHQR\OD DGPLQLVWUDFLyQGHGURJDVHQFDVRGHUHTXHULUVH &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 1$&,0,(172 1$&,0,(172 *HVWDFLyQDWpUPLQR" *HVWDFLyQDWpUPLQR" /LTXLGRDPQLyWLFRFODUR /LTXLGRDPQLyWLFRFODUR 5HVSLUDROORUD" 5HVSLUDROORUD" %XHQWRQRPXVFXODU" %XHQWRQRPXVFXODU" %ULQGDUFXLGDGRVGHUXWLQD %ULQGDUFXLGDGRVGHUXWLQD (YLWDUHQIULDPLHQWR (YLWDUHQIULDPLHQWR 'HVREVWUXLUYtDDpUHDVLHVQHFHVDULR 'HVREVWUXLUYtDDpUHDVLHVQHFHVDULR 6HFDUOR 6HFDUOR (YDOXDUFRORU (YDOXDUFRORU 6L 1R 1R $ (YLWDUHQIULDPLHQWR 'HVREVWUXLUYLD 'HVREVWUXLUYLD DHUHDVLHVQHFHVDULR DHUHDVLHVQHFHVDULR 6HFDUORHVWLPXODUORUHSRVLFLRQDUOR 1R (YDOXDUHVIXHU]RUHVSLUDWRULRIUHFXHQFLDFDUGLDFD\FRORU (YDOXDUHVIXHU]RUHVSLUDWRULRIUHFXHQFLDFDUGLDFD\FRORU 1R 5HVSLUD)&R$SQHD" 3HUVLVWHFLDQyWLFR 'LILFXOWDGYHQWLODWRULD 6, % 9HQWLODFLyQDVLVWLGDFRQSUHVLyQSRVLWLYDFRQPiVFDUD \$0%8 &RQVLGHUHR[tJHQRDGLFLRQDO&3$3 )&! )& & 6, &RPSUHVLRQHVWRUiFLFDVUtWPLFDVSRUPLQXWR &RPSUHVLRQHVWRUiFLFDVUtWPLFDVSRUPLQXWR &216,'(5$5,158%$&,21 (1'275$48($/ )& ' $GPLQLVWUDUDGUHQDOLQD $GPLQLVWUDUDGUHQDOLQD )XHQWHDSDUWLUGH.DWWZLQNHO-HWDO$PHULFDQ+HDUW$VVRFLDWLRQ1HRQDWDOUHVXVFLWDWLRQ $PHULFDQ +HDUW$VVRFLDWLRQ *XLGHOLQHV IRU &DUGLRSXOPRQDU\ 5HVXVFLWDWLRQ DQG (PHUJHQF\&DUGLRYDVFXODU&DUH3HGLDWULFV1RYH )LJXUD$OJRULWPRSDUDODUHDQLPDFLyQGHOUHFLpQQDFLGR 5HFHSFLyQGHOUHFLpQQDFLGR\(YDOXDFLyQGHODYLWDOLGDGDOQDFHUHQORVSULPHURV VHJXQGRVGHYLGD 6RVWHQHUDOUHFLpQQDFLGRTXHHJUHVDGHOYLHQWUHPDWHUQR\DSR\DUORVREUHXQD VXSHU¿FLH FXELHUWD FRQ XQ SDxR VXDYH D QLYHO GHO SHULQp PDWHUQR R VREUH VXV PXVORVHQXQDFHViUHD &RQWDUODIUHFXHQFLDFDUGLDFDHQORVSULPHURVVHJXQGRVGHVSXpVGHOQDFLPLHQWR PHGLDQWH OD REVHUYDFLyQ R OD SDOSDFLyQ GH ORV SXOVRV DUWHULDOHV GHO FRUGyQ XPELOLFDORODDXVFXOWDFLyQGHORVODWLGRVFDUGtDFRV(OFRUGyQXPELOLFDOQRUPDOHV HUpFWLOFRQXQDYHQDLQJXUJLWDGD\GRVDUWHULDVFRQSXOVRVYLVLEOHVFRQIUHFXHQFLD VXSHULRUDODWLGRVSRUPLQXWR\TXHDXPHQWDKDVWDRPDVGXUDQWH HOOODQWR(OFRUGyQÀiFFLGRRFRQSXOVRVGpELOHV\EUDGLFDUGLDHVDQRUPDO\FRQ IUHFXHQFLDVHGHEHDODDV¿[LDIHWDO2EVHUYDUVLLQLFLDPRYLPLHQWRVUHVSLUDWRULRV UHFRUGDQGRTXHODSULPHUDUHVSLUDFLyQSXGHUHWDUGDUVHXQRVVHJXQGRV 1R HV QHFHVDULR DVSLUDU HO OtTXLGR DPQLyWLFR H[LVWHQWH HQ OD FDYLGDG QDVRIDUtQJHD 7RGR HO WUDFWR UHVSLUDWRULR WLHQH OtTXLGR DPQLyWLFR HQ HO PRPHQWR PLVPR GH QDFHU \ HVUHDEVRUELGRQDWXUDOPHQWHSRUPHFDQLVPRV¿VLROyJLFRVHQORVSULPHURVPLQXWRVGH YLGD/DDVSLUDFLyQDXPHQWDHOWRQRYDJDOSURGXFHEUDGLFDUGLDUHÀHMDHQOHQWHFLHQGRHO LQFUHPHQWR¿VLROyJLFRGHODVDWXUDFLyQVDQJXtQHDGHR[tJHQR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD &XDQGR HO OtTXLGR DPQLyWLFR HV PHFRQLDO OD UHFHSFLyQ GHO UHFLpQ QDFLGR GHEH KDFHUVHSRUSHUVRQDOFDSDFLWDGRHQHOXVRGHOODULQJRVFRSLR6LHOUHFLpQQDFLGR QRUHDOL]DLQVSLUDFLRQHVHVSRQWiQHDVLQPHGLDWDVDOQDFLPLHQWRGHEHYLVXDOL]DUVH ODYtDDpUHDVXSHULRUVXSUDHLQIUDJOyWLFD\DVSLUDUHOFRQWHQLGRPHFRQLDODQWHV TXH UHDOLFH OD SULPHUD LQVSLUDFLyQ R GH SURFHGHU D LQVXÀDU VXV SXOPRQHV FRQ SUHVLyQSRVLWLYD 6LQRUHVSLUDHVWLPXODUOR\VLQRLQLFLDORVPRYLPLHQWRVLQVSLUDWRULRVFRPHQ]DU YHQWLODFLyQDUWL¿FLDOLQVXÀDQGRODYtDDpUHD /DPDQHUDPiVHIHFWLYDGHYHQWLODUORVDOYpRORVHVOD¿VLROyJLFDSXHVODLQVSLUDFLyQ HVSRQWiQHD D~Q HQ ORV SUHPDWXURV SXHGH OOHYDU SUHVLRQHV QHJDWLYDV LQWUD WRUiFLFDV VXSHULRUHVDFPGH+2VLQULHVJRGHUXSWXUDDOYHRODU 6LHOFRUGyQXPELOLFDOHVWiÀiFFLGRVHFRQVWDWDEUDGLFDUGLD\HQORVSULPHURVVHJXQGRV QRLQLFLDORVPRYLPLHQWRVUHVSLUDWRULRVVHGHEHHVWLPXODUFRQXQSDxRVXDYHVHFDQGR FRQYLJRUHOWURQFR\ORVPLHPEURV/DHVWLPXODFLyQH[WHUQDSXHGHVHUVX¿FLHQWHSDUD TXHUHDOLFHODSULPHUDLQVSLUDFLyQHVSRQWiQHD 6L QR UHVSRQGH DO HVWLPXOR FXWiQHR VH GHEH FRORFDU HQ GHF~ELWR GRUVDO H LQVXÀDU DWUDYpVGHVXERFD\QDUL]3DUDLQVXÀDUODYtDDpUHDGHEHDMXVWDUVHXQDPiVFDUD QDVRRUDOGHWDPDxRDGHFXDGRHLQVXÀDUDLUHLQLFLDOPHQWHVLQR[LJHQRDGLFLRQDOFRQ XQDIUHFXHQFLDGHYHFHVSRUPLQXWR6HSXHGHLQVXÀDUHQGLYHUVDVIRUPDVODPiV IUHFXHQWH VH FRQRFH FRPR$0%8 $UWL¿FLDO 0DQXDO %UHDWKLQJ 8QLW TXH FRQVLVWH HQ XQDEROVDDXWRLQÀDEOHFRQYiOYXODVTXHDVHJXUDQXQÀXMRXQLGLUHFFLRQDO\TXHLPSLGH H[FHGHUVHGHFP+2GHSUHVLyQ([LVWHQRWUDVIRUPDVERFDDERFDERFDPDVFDUD R$0%8DWUDYpVGHXQWXERQDVDO\VLVWHPDVEDVDGRVHQHOÀXMRFRQWLQXRGHVGHXQ WDQTXHGHR[LJHQRRGHDLUHRPH]FODTXHSHUPLWHYHQWLODUFRQWURODQGRFRQSUHFLVLyQ ODSUHVLyQGHLQVXÀDFLyQ\ODSUHVLyQUHVLGXDOHVSLUDWRULDHQODYtDDpUHD1HRSXII\ YHQWLODGRUHVQHRQDWDOHVPiVFRPSOHMRV (YROXFLyQHVSHUDGDGHODVPDQLREUDVGHLQVXÀDFLyQGHODYtDDpUHD 6L OD LQVXÀDFLyQ SXOPRQDU HV HIHFWLYD OD IUHFXHQFLD FDUGLDFD VH UHFXSHUDUi UiSLGDPHQWHFRPRRFXUUHHQODDV¿[LDIHWDOFXDQGRFHVDODFRQWUDFFLyQXWHULQD \TXHVHFDUDFWHUL]DFRPR',3,,3URJUHVLYDPHQWHDGTXLULUiFRORUDFLyQURVDGD HQ ODELRV \ OHQJXD )LQDOPHQWH LQLFLDUi OD UHVSLUDFLyQ HVSRQWiQHD \ HO OODQWR PRPHQWRHQTXHODVPDQLREUDVGHLQVXÀDFLyQSXHGHQFHVDU 6LODLQVXÀDFLyQSXOPRQDUQRHVHIHFWLYDHOVLJQRLQLFLDOPDVFODURHVODSHUVLVWHQFLD GHODEUDGLFDUGLD\GHEHUiHYDOXDUVHHODMXVWHGHODPiVFDUDRURQDVDOODSRVLFLyQ QHXWUDGHOFXHOORODSUHVLyQ\IUHFXHQFLDGHODYHQWLODFLyQFRQHO$0%8PHGLDQWH ODREVHUYDFLyQGHORVPRYLPLHQWRVWRUiFLFRV 6LQRPHMRUDFRQHVWDVFRUUHFFLRQHVSXHGHUHTXHULUVH,QWXEDFLyQ2URWUDTXHDO\ YHQWLODFLyQDWUDYpVGHOWXER 9DORUDUOD9LWDOLGDGDOHUR\WRPLQXWR3XQWDMHGH$3*$5 (Q 9LUJLQLD $SJDU DQHVWHVLVWD REVWpWULFD DPHULFDQD SURSXVR XQ SXQWDMH TXH SHUPLWLHUDFXDQWL¿FDUODYLWDOLGDGGHORVUHFLpQQDFLGRV(VWHSXQWDMHVHUHDOL]DPHGLDQWH ODREVHUYDFLyQGHIXQFLRQHVQHFHVDULDVSDUDHOLQLFLRGHODUHVSLUDFLyQHVSRQWiQHDORV PRYLPLHQWRVLQVSLUDWRULRVUHJXODUHV\ODKHPRGLQDPLDUHSUHVHQWDGDSRUODIUHFXHQFLD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR FDUGLDFD \ HO FRORU \ VH FRPSOHPHQWD FRQ OD REVHUYDFLyQ GHO IXQFLRQDPLHQWR GHO VLVWHPDQHUYLRVRFHQWUDOPHGLDQWHODUHDFWLYLGDGDQWHHVWtPXORV\HOWRQRPXVFXODU/D IUHFXHQFLDFDUGtDFDHVHOVLJQRTXHPHMRUHYDO~DHOp[LWRGHODUHDQLPDFLyQ &XDGUR7(67'($3*$5 PUNTAJE ESFUERZOS RESPIRATORIOS FRECUENCIA CARDIACA COLOR RESPUESTA ESTÍMULO ORO-NASAL TONO 2 REGULARES MAS DE 100 TODO ROSADO INTENSA FLEXIÓN FIRME 1 IRREGULARES MENOS DE 100 CIANOTICO DÉBIL LEVE FLEXION 0 AUSENTES AUSENTE PALIDO AUSENTE FLACCIDO /DYDORUDFLyQGHHVWHSXQWDMHDOFXPSOLUHOHUPLQXWR\HOWRPLQXWRGHYLGDVHKDQ XVDGRXQLYHUVDOPHQWHGHVGHHQWRQFHV ,QWHUSUHWDFLyQGHOSXQWDMHGH$3*$5 (OSXQWDMHDOHUPLQXWRH[SUHVDODFRQGLFLyQDOQDFHUDXQTXHSXHGHHVWDULQÀXLGRSRU ODLQWHUYHQFLyQGHTXLHQORDWLHQGHHQORVSULPHURVVHJXQGRVGHYLGD8QSXQWDMHGHR PHQRVLQGLFDVHYHUDGHSUHVLyQ&XDQGRODGHSUHVLyQHVSRUDV¿[LDIHWDOVHYHUDH[LVWH EUDGLFDUGLD (OSXQWDMHDOWRPLQXWRVLQWHWL]DODVHYHULGDGGHODGHSUHVLyQLQLFLDO\HOUHVXOWDGRGH ODVPDQLREUDVUHDOL]DGDV6LVHPDQWLHQHODEUDGLFDUGLDLQGLFDTXHODLQVXÀDFLyQQRKD ORJUDGRLQLFLDUODYHQWLODFLyQSXOPRQDURTXHODVHYHULGDGHVH[WUHPD(OSURQyVWLFRYLWDO PHMRUD FXDQGR HQ ORV SULPHURVPLQXWRV GH YLGD H[LVWH XQ LQFUHPHQWR VLJQL¿FDWLYR GHVGHXQSXQWDMHLQLFLDOEDMR 5HJLVWURGHOD$FWLYLGDG (QHOPRPHQWRGHFRPSOHWDUODDWHQFLyQHQ6DODGH3DUWRV VH GHEH UHJLVWUDU HO 3XQWDMH GH $SJDU \ ODV PDQLREUDV UHDOL]DGDV (O RUGHQ GH UHJLVWUR GH ODV PDQLREUDV GH UHDQLPDFLyQHQOD+&3UHVSRQGHDXQRUGHQSRULQWHQVLGDG GHOSURFHGLPLHQWR (QDPDULOORVHPDUFDODUHDOL]DFLyQGHODVPDQLREUDVTXH QR VRQ QHFHVDULDV HQ HO UHFLpQ QDFLGR VDQR TXH LQLFLD OD UHVSLUDFLyQHQIRUPDHVSRQWiQHD\TXHSXHGHQVHUXVDGDV SDUDLQLFLDUODUHDQLPDFLyQGHXQUHFLpQQDFLGRFRQDSQHD DOQDFHURTXHUHTXLHUHVRSRUWHUHVSLUDWRULRSRULQPDGXUH] Figura 108. Fragmento de HCP. Apgar y reanimación &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2EMHWLYR 3URWHJHUODDGDSWDFLyQDODYLGDH[WUDXWHULQDHQHOUHFLpQQDFLGR GHSUHWpUPLQR $FWLYLGDG 3URYHHU FXLGDGRV LQPHGLDWRV TXH IDFLOLWHQ OD DGDSWDFLyQ HVSHFLDOPHQWHHQORVQDFLGRVSUHWpUPLQRVTXHSUHVHQWHQ VLJQRVGHLQPDGXUH]YHQWLODWRULD 'HVDUUROODU HVWUDWHJLDV WHQGLHQWHV D HYLWDU OD SpUGLGD GH FDORU YDORUDU HO ÀXMR ELGLUHFFLRQDO GH VDQJUH GHVGH OD SODFHQWD D WUDYpV GHO FRUGyQ XPELOLFDO DO IHWR DSR\DU \ PDQWHQHUHOLQLFLRGHODUHVSLUDFLyQFRQWURODUHODSRUWHGH2 (OUHFLpQQDFLGRSUHWpUPLQRVHHQFXHQWUDHQXQDVLWXDFLyQGHHVSHFLDOYXOQHUDELOLGDG \ORVSULPHURVPLQXWRVGHYLGDWLHQHQHVSHFLDOLPSDFWRVREUHODVREUHYLGD\PRUELOLGDG D ODUJR SOD]R (Q OD PD\RUtD GH ORV FDVRV QR UHTXLHUHQ GH PHGLGDV GH UHDQLPDFLyQ SXHVQRHVWiQDVItFWLFRVQLHQFRODSVRFLUFXODWRULR(QJHQHUDOODSURSRUFLyQGHUHFLpQ QDFLGRVTXHUHTXLHUHUHDQLPDFLyQHVLQIHULRUD (YLWDUODSHUGLGDGHFDORU /DKLSRWHUPLDSRUSpUGLGDH[FHVLYDGHFDORU\RFHVHGHODSURGXFFLyQSRUKLSR[HPLD RGp¿FLWGHHQHUJtDHVXQDFRQGLFLyQDGYHUVDSDUDORVUHFLpQQDFLGRV\HQHVSHFLDOORV SUHWpUPLQRSRUVXLQPDGXUH]/DKLSRWHUPLDUHWUDVDODSULPHUDUHVSLUDFLyQHVSRQWiQHD SXHGHDOWHUDUORVFDPELRV¿VLROyJLFRVGHODDGDSWDFLyQKHPRGLQiPLFDPDQWHQLHQGRXQ UpJLPHQGHKLSHUWHQVLyQSXOPRQDUSHUVLVWHQWH\GHDFLGRVLVPHWDEyOLFD 3DUDPDQWHQHUODWHPSHUDWXUDHQWUH\GHEHHYLWDUVHTXHODVSpUGLGDVGHFDORU SRUFRQYHFFLyQHYDSRUDFLyQFRQWDFWRHLUUDGLDFLyQH[FHGDQDODSURGXFFLyQHQGyJHQD GHFDORU 8QDPDQLREUDSURWHFWRUDVHQFLOODHQHOPRPHQWRGHQDFHUHVSDVDUDOUHFLpQQDFLGR GH ODV PDQRV GHO REVWHWUD \ VLQ VHFDUOR D XQD EROVD GH SROLHWLOHQR PDQWHQLHQGR OD FDEH]DIXHUDGHODEROVD\FXEULpQGRODFRQXQDJRUUD )DYRUHFHUHOSDVDMHGHVDQJUHHQORV~OWLPRVPLQXWRVGHODIXQFLyQSODFHQWDULD 'XUDQWHORVSULPHURVPLQXWRVGHYLGDVHGHEHHVSHUDUHOPRPHQWRRSRUWXQRSDUDSLQ]DU HOFRUGyQXPELOLFDO (OFHVHGHORVSXOVRVGHOFRUGyQXPELOLFDOHQHOODGRPDWHUQRPiVFHUFDQRDOSHULQp LQGLFD TXH HO SDVDMH GH VDQJUH GHVGH OD SODFHQWD D WUDYpV GHO FRUGyQ DO FXHUSR GHO UHFLpQ QDFLGR VH KD FRPSOHWDGR \ OD IXQFLyQ KD FHVDGR (O SLQ]DPLHQWR GHO FRUGyQ XPELOLFDOGHEHUHDOL]DUVHHQHVWHPRPHQWR /DWUDQVIXVLyQSODFHQWDULDFRPSOHWDDXPHQWDHOKHPDWRFULWRHQODVSULPHUDVKRUDVGH YLGD\GLVPLQX\HHOULHVJRGHDQHPLDIHUURSpQLFDGHOODFWDQWH/RVSUHWpUPLQRVFX\R FRUGyQ XPELOLFDO HV SLQ]DGR DQWHV GH ORV VHJXQGRV UHTXLHUHQ PD\RU Q~PHUR GH WUDQVIXVLRQHVUHTXLHUHQPiVWUDWDPLHQWRSRUKLSRWHQVLyQ\WLHQHQPiVIUHFXHQFLDGH KHPRUUDJLDLQWUDFUDQHDQD /D REVHUYDFLyQ GHO FRUGyQ XPELOLFDO SXHGH UHDOL]DUVH HQ IRUPD VHJXUD \ VLQ ULHVJR GH KLSRWHUPLD FXDQGR HO UHFLpQ QDFLGR IXH FRORFDGR GLUHFWDPHQWH GH ODV PDQRV GHO REVWHWUDDXQDEROVDGHSROLHWLOHQR\HODPELHQWHVHHQFXHQWUDFDOHIDFFLRQDGR /DSUiFWLFDKDELWXDOGHUHWLUDUHQIRUPDLQPHGLDWDDOUHFLpQQDFLGRSUHWpUPLQRH[WUHPR SDUD VX PDQHMR HQ XQ OXJDU GLVWDQWH LPSOLFD OD VHFFLyQ GHO FRUGyQ XPELOLFDO (VWD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR SUiFWLFDHVWiVLHQGRUHYLVDGDDOGHPRVWUDUVHTXHODOLJDGXUDHQWHVGHORVVHJXQGRV \DXQDQWHVGHORVPLQXWRVHVSHUMXGLFLDO(OUHFLpQQDFLGRGHEHUiSHUPDQHFHUXQLGR D VX PDGUH SRU HO FRUGyQ PiV WLHPSR PLHQWUDV OD FLUFXODFLyQ SODFHQWDULD ¿VLROyJLFD SHUVLVWH $SR\DU\PDQWHQHUHOLQLFLRGHODUHVSLUDFLyQSURFXUDQGRHOPi[LPRFRQIRUW /RVPRYLPLHQWRVWRUiFLFRVLQVSLUDWRULRVVRQLQWHUPLWHQWHVHQODYLGDIHWDO\VHHVWDEOHFHQ HQIRUPDFtFOLFDHQORVSULPHURVPLQXWRVGHYLGD,QPHGLDWDPHQWHDOQDFLPLHQWRHVRV HVIXHU]RVLQVSLUDWRULRVLQLFLDQODYHQWLODFLyQDpUHD\SHUVLVWHLQLQWHUUXPSLGDPHQWHSDUD WRGDODYLGD(QORVSUHWpUPLQRVPHQRVPDGXURVHVWDGLQiPLFDYHQWLODWRULDHVPHQRV H¿FD]\SXHGHVHULQVX¿FLHQWHSRUODLQPDGXUH]GHOFHQWURUHVSLUDWRULRODGHELOLGDGGH ODFDMDWRUiFLFD\P~VFXORVUHVSLUDWRULRV\SRUODWHQGHQFLDDOFRODSVRGHODYtDDpUHD DVRFLDGRDOGp¿FLWGHVXUIDFWDQWH 8QD SUDFWLFD VLPSOH GH VRSRUWH YHQWLODWRULR HQ ORV SUHWpUPLQR GHVGH ODV SULPHUDV UHVSLUDFLRQHVHVSRQWiQHDVHQVDODGHSDUWRVFRQVLVWHHQODDGPLQLVWUDFLyQSUHFR]SRU YtDQDVDOXRURQDVDOGHXQÀXMRGHDLUHTXHORJUHXQDSUHVLyQFRQWLQXDHQODHVSLUDFLyQ &3$3\PDQWHQJDORVDOYpRORVGLVWHQGLGRV6LHVQHFHVDULRVHSXHGHDSOLFDUYHQWLODFLyQ DVLVWLGDFRQLQVXÀDFLRQHVFtFOLFDVFRQXQDIUHFXHQFLDLQLFLDOGHUSP (OVRSRUWHYHQWLODWRULRKDHYROXFLRQDGRDIRUPDVTXHHYLWDQHOGDxRSRUXVRH[FHVLYR LQWHJUDQGRODDGPLQLVWUDFLyQGHFRUWLFRLGHVDQWHQDWDOHVHOVRSRUWHLQLFLDOFRQ&3$3 QDVDOODDGPLQLVWUDFLyQSUHFR]GHVXUIDFWDQWHODYHQWLODFLyQFRQPtQLPRVSDUiPHWURV \ODH[WXEDFLyQSUHFR]FXDQGRUHTXLULyLQWXEDFLyQRURWUDTXHDO$~QORVPiVSHTXHxRV (*VHPSXHGHQDGDSWDUVHFRQPtQLPRDSR\RVLQUHTXHULULQWXEDFLyQWUDTXHDO /RV FULWHULRV GH SHVR \ HGDG JHVWDFLRQDO XVDGRV WUDGLFLRQDOPHQWH SDUD SURFHGHU D XQD LQWXEDFLyQ LQPHGLDWD HQ HO PRPHQWR GH QDFHU QR GHEHQ XVDUVH FRPR UXWLQD &XDQGRVHGHFLGHODLQWXEDFLyQWUDTXHDOSDUDDGPLQLVWUDUVXUIDFWDQWHRLQFUHPHQWDUHO DSR\RYHQWLODWRULRHOSURFHGLPLHQWRGHEHVHUKHFKRFRQODPi[LPDGHVWUH]DEUHYH\ SUHIHUHQWHPHQWHFRQXQSURWRFRORGHVHGRDQDOJHVLDXOWUDFRUWD /D DVSLUDFLyQ GH OD RURIDULQJH \ ODV IRVDV QDVDOHV SURYRFD DSQHD \ EUDGLFDUGLD SRU ORTXHGHEHWDPELpQDEDQGRQDUVHVXXVRUXWLQDULR(QORSUHWpUPLQRVWDPSRFRGHEH OLPSLDUVHFRQDJXDODVDQJUHGHODSLHORGHOFXHURFDEHOOXGRSXHVIDYRUHFHODSpUGLGD GHFDORU/DVPDQLREUDVGHH[SORUDFLyQGHODSHUPHDELOLGDGHVRIiJLFD\DQDOWDPELpQ SURYRFDQEUDGLFDUGLDSRUHVWLPXODFLyQYDJDO\QRGHEHQVHUUXWLQDULDV/DREVHUYDFLyQ FULWHULRVDGHODDGDSWDFLyQSHUPLWHVHOHFFLRQDUDTXHOORVUHFLpQQDFLGRVTXHUHTXLHUHQ GLFKD PDQLREUDV 3RU HMHPSOR SROLKLGUDPQLRV H[FHVR GH VDOLYDFLyQ LPSHUIRUDFLyQ DQDODXVHQFLDGHGHSRVLFLyQPHFRQLDOHQSULPHUDVKRUDV &RQWURODUHODSRUWHGH2VXSOHPHQWDULR /DHYDOXDFLyQGHODR[LJHQDFLyQQHRQDWDOSUHVHQWDGL¿FXOWDGHVHQORVSULPHURVPLQXWRV GHYLGDHLQGXFHIUHFXHQWHPHQWHDHUURUHV\XVRH[FHVLYRGHR[LJHQR/DFLDQRVLVHQ ORV SULPHURV PLQXWRV GH YLGD HV ¿VLROyJLFD SXHV OD VDWXUDFLyQ GH R[LJHQR GHPRUD KDVWDPLQXWRVSDUDOOHJDUDOHQORVQDFLGRVQRUPDOHVPD\RUHVGHVHPDQDV TXHUHVSLUDQDLUH1RHVSRVLEOHGLIHUHQFLDUODKLSR[HPLD¿VLROyJLFDGHODYLGDIHWDO\ GHORVSULPHURVPLQXWRVGHDGDSWDFLyQGHORVYDORUHVGHKLSR[HPLDGHODDV¿[LD/D SUHVHQFLDGHDSQHD\EUDGLFDUGLDSHUVLVWHQWHSHUPLWHQUHDOL]DUHOGLDJQyVWLFRGHDV¿[LD QHRQDWDO (Q HO SUHWpUPLQR TXH PDQWLHQH XQD IUHFXHQFLD FDUGtDFD QRUPDO \ GHELGR D OD FRQFHQWUDFLyQGHKHPRJORELQDIHWDO\VXD¿QLGDGSRUHO2VHVXJLHUHPDQWHQHUOD6D2 HQWUH\SDUDDVHJXUDUXQDR[HPLDDGHFXDGD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (O XVR GH R[tJHQR HQ HO PRPHQWR GHO QDFLPLHQWR HV XQD SUiFWLFD PX\ IUHFXHQWH \ D YHFHV HV OD ~QLFD XVDGD SDUD OD UHDQLPDFLyQ GH XQ UHFLpQ QDFLGR 6LQ HPEDUJR KR\H[LVWHQSUXHEDVVX¿FLHQWHVTXHLQGLFDQTXHQRHVQHFHVDULRHOXVRGHR[LJHQR DGLFLRQDOHQWRGRVORVUHFLpQQDFLGRVHQDSQHDTXHUHTXLHUHQUHDQLPDFLyQ7DPELpQ VHVDEHTXHHOR[LJHQRSXHGHWHQHUHIHFWRVDGYHUVRVGHVGHXQUHWDUGRHQHOLQLFLRGH ODYHQWLODFLyQHVSRQWiQHDDGDxRVWLVXODUHVSRUWR[LFLGDGGHOR[LJHQRRGHVXVUDGLFDOHV OLEUHVHQVLWXDFLyQGHSRVWKLSR[LDRKLSHUR[LD /DDGPLQLVWUDFLyQGHR[LJHQRDGLFLRQDOGHEHUtDOLPLWDUVHDORVTXHSHUPDQHFHQFLDQyWLFRV OXHJRGHORVSULPHURVPLQXWRVRHQORVTXHODPHGLFLyQGHOD6D2SRUR[LPHWUtDGH SXOVRUHYHODYDORUHVLQIUD¿VLROyJLFRV(OXVRDGLFLRQDOGH2[tJHQR)L2!HQYH] GHDLUHGXUDQWHODLQVXÀDFLyQSXOPRQDUGHORVQDFLGRVPD\RUHVGHVHPDQDVGHHGDG JHVWDFLRQDOQRGHEHUtDLQLFLDUVHVLHVVX¿FLHQWHODYHQWLODFLyQFRQDLUH (O XVR GH OD VDWXURPHWUtD GH SXOVR SDUD GHWHUPLQDU OD 6DWXUDFLyQ GH 2[LJHQR HQ OD VDQJUHHVXQDWpFQLFDQRLQYDVLYDH[WUHPDGDPHQWHYDOLRVDSDUDDGHFXDUHODSRUWH GHR[LJHQRDODVQHFHVLGDGHVGHOUHFLpQQDFLGR(VWDWHFQRORJtDHVWDVLHQGRFDGDYH] PiVDFFHVLEOHSRUHOGHVDUUROORGHPRGHORVVLPSOHV\HFRQyPLFRVTXHVRQQHFHVDULRV WDPELpQSDUDHOPDQHMRGHRWUDVVLWXDFLRQHVPX\IUHFXHQWHVHQORVVHUYLFLRVGHVDOXG FRPR ODV HQIHUPHGDGHV FRQ LQVX¿FLHQFLD UHVSLUDWRULD GH QLxRV \ DGXOWRV DVt FRPR SDUDODPHMRUYLJLODQFLDGXUDQWHODDQHVWHVLDJHQHUDO 7DPELpQ VRQ QHFHVDULRV ORV PH]FODGRUHV GH DLUH \ R[LJHQR TXH SHUPLWHQ HQWUHJDU OD FRQFHQWUDFLyQGH2[LJHQRQHFHVDULDDVtFRPRORVVLVWHPDVTXHUHJXODQODKXPHGDG\OD WHPSHUDWXUDGHODPH]FODHYLWDQGRGDxRDODPXFRVDGHODYtDDpUHDVXSHULRU &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (648(0$3$5$(/&8,'$'2&217,182'(/5(&,e11$&,'235(7e50,12 '(6'((/35,0(50,1872'(9,'$ 7LHPSR GHYLGD 2EMHWLYRV HUPLQXWR &RQVHUYDUHOFDORU\ODKXPHGDG%ROVDGHSROLHWLOHQR±JRUUR )DYRUHFHUHOSDVDMHGHVDQJUHGHODSODFHQWDDOFXHUSRGHO513LQ]DGRXPELOLFDODOFHVH GHOSXOVRGHODVDUWHULDVXPELOLFDOHV 2EVHUYDUHOLQLFLRGHODUHVSLUDFLyQFRQVLGHUDU&3$3SUR¿OiFWLFRRGHUHVFDWHSUHLQWXEDFLyQ HQGRWUDTXHDO $VLVWLU OD LQVX¿FLHQFLD YHQWLORUHVSLUDWRULD FRQ HTXLSDPLHQWR VHJXUR HYLWDQGR H[FHVR GH SUHVLyQ (YLWDUXVRLQQHFHVDULRGH2DGLFLRQDOHQORVSULPHURVPLQXWRV\YDORUHVSRVWHULRUHVGH 6D2VXSHULRUHVD $VSLUDU OD YtD DpUHD VXSHULRU VROR SDUD YLVXDOL]DU JORWLV HQ LQWXEDFLyQ R H[WUDFFLyQ GH PHFRQLRHQDVItFWLFRVVHYHURV 1RH[SORUDUSHUPHDELOLGDGHVRIiJLFD\DQDOGHUXWLQD *DUDQWL]DU LGHQWL¿FDFLyQ FRQ VX PDGUH \ HO OLEUH DFFHVR D VX OXJDU GH LQWHUQDFLyQ VL VH UHTXLHUHVHSDUDUORV HUGtD 0DQWHQHUKXPHGDGDPELHQWDO\WHPSHUDWXUDFXWiQHDHQWUHD& 6LHVQHFHVDULRDGPLQLVWUDU6XUIDFWDQWHKDFHUORGHLQPHGLDWRHQODVSULPHUDVKRUDV &3$3SUHFR] ,QWXEDFLyQ VROR SDUD DGPLQLVWUDU VXUIDFWDQWH R SRU EUHYHV SHULRGRV GH YHQWLODFLyQ LQLFLDO SURFXUDQGRH[WXEDFLyQWHPSUDQtVLPD (YLWDU XVR LQQHFHVDULR GH 2 DGLFLRQDO FRQ YDORUHV GH 6D2 VXSHULRUHV D ,QLFLDU VXSOHPHQWRGH2VRORFRQYDORUHVGH6D2LQIHULRUHVD $OLPHQWDFLyQSDUHQWHUDOSUHFR]$PLQRiFLGRVDJ.JGtD*OXFRVD!PJ.JPLQ (YDOXDUHOLQLFLRGHODDOLPHQWDFLyQHQWHUDOFRQOHFKHKXPDQDH[FOXVLYDPHQWH (YDOXDUODKHPRGLQDPLD\GHFLGLUUHTXHULPLHQWRVGHDSR\R 3UHYHQLU LQIHFFLRQHV 0LQLPL]DU PDQLSXODFLyQ \ H[WUHPDU DVHSVLD HQ PDQLREUDV LQYDVLYDV 3URWRFRORUHVWULFWLYRGHH[WUDFFLyQGHVDQJUHSDUDODERUDWRULR $WHQGHU QHFHVLGDGHV HPRFLRQDOHV PDWHUQDV \ HVWDEOHFHU FRPXQLFDFLyQ \ GLVSRQLELOLGDG FRQODIDPLOLD ,QLFLDUDSR\RPDWHUQRSDUDODFWDQFLD HUD VHPDQD 5HFRQVLGHUDUSHUPDQHQWHPHQWHODVQHFHVLGDGHVGH$90\2SURFXUDQGRODH[WXEDFLyQ WHPSUDQtVLPD ,QLFLDU\DXPHQWDUDOLPHQWDFLyQHQWHUDOLQLFLRKVWUy¿FD±FRQDXPHQWRP/.JGtD &RQVLGHUDU GD RSLQLyQ VLHPSUH TXH VH SODQWHH UHGXFLU R VXVSHQGHU DSRUWH HQWHUDO (M $SDULFLyQGHUHVLGXDOJiVWULFR\VRVSHFKDGHSDWRORJtDGLJHVWLYD $YDQ]DUVLQSDXVDVHODSRUWHSDUHQWHUDOREMHWLYRFDOyULFRFDONGtD 0RQLWRUHRHVWULFWRGHOEDODQFHKtGULFR\FDOyULFRPLQLPL]DQGRHOGp¿FLWDFXPXODGRHQOD SULPHUDVHPDQD *UD¿FDULQFUHPHQWRGHSHVRHQUHODFLyQDHVWiQGDUHVGHFUHFLPLHQWRIHWDO\SRVWQDWDO 3UHYHQLULQIHFFLRQHVPLQLPL]DULQYDVLYLGDG\PDQLSXODFLyQ 'HWHUPLQDUQHFHVLGDGHVGHFXLGDGRVPDWHUQRV\VDWLVIDFHUVXVDVSLUDFLRQHVGHSDUWLFLSDFLyQ HQORVFXLGDGRV )DFLOLWDUODH[WUDFFLyQGHOHFKHPDWHUQD\VXXVRIUHVFR HUPHV *UD¿FDULQFUHPHQWRGHSHVRHQUHODFLyQDHVWiQGDUIHWDO\SRVWQDWDO $YDQ]DU QXWULFLyQ HQWHUDO VHJ~Q UHVXOWDGRV HQ FUHFLPLHQWR PD[LPL]DU SRVLELOLGDGHV FDOyULFDVIRUWL¿FDGRUFUHPDWRFULWR ,QLFLDUDSRUWHGHKLHUUR 3UHYHQLULQIHFFLRQHVLQYDVLYLGDGQXODKLJLHQHGHPDQRVFRQDOFRKROJHO 0DQWHQHUH[WUDFFLyQGHOHFKHPDWHUQD\SURYLVLyQRUDOGHOHFKHIUHVFD 7DPL]DMHV&RQWUROGH523GtDV!VHPDQDV 6DWLVIDFHUGLDULDPHQWHODSDUWLFLSDFLyQPDWHUQDHQUHODFLyQFRQODVQHFHVLGDGHVGHDPERV FRPSDxtDKLJLHQHDOLPHQWDFLyQDPDPDQWDPLHQWR 9DORUDUGHSUHVLyQPDWHUQDDORVGtDV\QHFHVLGDGGHDSR\RSVLFRVRFLDODGLFLRQDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2EMHWLYR ,GHQWL¿FDUDOUHFLpQQDFLGR $FWLYLGDG )DFLOLWDU TXH OD PDGUH OR LGHQWL¿TXH \ FXPSOLU ORV UHTXLVLWRV ORFDOHVGHLGHQWL¿FDFLyQDOQDFHU /DLGHQWL¿FDFLyQGHOUHFLpQQDFLGRWLHQHFRPRREMHWLYRTXHVHDVHJXUHHOYLQFXOR¿OLDWRULR HQWUHODPDGUH\HOUHFLpQQDFLGR'HDFXHUGRDORVUHTXLVLWRVORFDOHVVHXWLOL]DUiQORV HOHPHQWRV FRUUHVSRQGLHQWHV TXH SXHGHQ LQFOXLU HO UHJLVWUR GH ODV KXHOODV GDFWLODUHV GHDPERVRVLPSOHPHQWHODFRORFDFLyQGHXQDEDQGDLGHQWL¿FDWRULDFRQHOQRPEUHR FyGLJRTXHORVLGHQWL¿TXHDDPERV (QWRGRVORVFDVRVVHGHEHSURFXUDUTXHODPDGUHYHD\WHQJDDVXKLMRHQHOPD\RU JUDGRGHSUR[LPLGDGSRVLEOH\SRUHOWLHPSRTXHHOODGHVHH\ORSHUPLWDODFRQGLFLyQ GHOUHFLpQQDFLGR (VWH DFHUFDPLHQWR LQPHGLDWR DO QDFLPLHQWR HV XQ GHUHFKR \ OD VHSDUDFLyQ SRVWHULRU VRORVHMXVWL¿FDSRUODQHFHVLGDGGHFXLGDGRVHVSHFLDOHVGHDPERVRSRUODRSFLyQGH ODPDGUHTXHVROLFLWHD\XGDSDUDFXLGDUOR 2EMHWLYR (YDOXDUHOFUHFLPLHQWR\HOGHVDUUROORIHWDODOQDFHU $FWLYLGDG 5HDOL]DUDQWURSRPHWUtD\YDORUDUODVHJ~QODHGDGJHVWDFLRQDO\ YDORUDUODVIXQFLRQHVGHDGDSWDFLyQ 'XUDQWHHOFRQWURODQWHQDWDOHOFUHFLPLHQWRIHWDOSXHGHVHUHVWLPDGRSRUODVPHGLFLRQHV LQGLUHFWDVGHOWDPDxRIHWDOODDOWXUDXWHULQD\ODDQWURSRPHWUtDIHWDOSRUHFRJUDItD $OQDFHUHOWDPDxRHVGHWHUPLQDGRFRQSUHFLVLyQPHGLDQWHWUHVPHGLGDVVLPSOHVSHVR ORQJLWXG \ SHUtPHWUR FHIiOLFR 'HO DQiOLVLV GH ODV PHGLGDV DQWHQDWDOHV \ SRVWQDWDOHV SXHGHGHGXFLUVHFRPRIXHHOFUHFLPLHQWRIHWDO 3DUDHYDOXDUHOFUHFLPLHQWR\HOGHVDUUROORGHOUHFLpQQDFLGRGHEHFRPSDUDVHFRQHO GHODSREODFLyQQRUPDODODPLVPDHGDGJHVWDFLRQDO3RUHVHPRWLYRHVLPSUHVFLQGLEOH UHDOL]DUXQFRUUHFWRFiOFXORGHODHGDGJHVWDFLRQDOHQHOPRPHQWRGHOQDFLPLHQWR(O PLVPRVHEDVDUiIXQGDPHQWDOPHQWHHQHOPHMRUFRQRFLPLHQWRGHODIHFKDGHOD~OWLPD PHQVWUXDFLyQ\VXFRQ¿DELOLGDGUHJLVWUDGDGXUDQWHODJHVWDFLyQ &iOFXORGHOD(GDG*HVWDFLRQDO /DHGDGJHVWDFLRQDOVHFDOFXODSRUODGLIHUHQFLDHQWUHODIHFKDGHOSULPHUGtDGHOD~OWLPD PHQVWUXDFLyQ\HOGtDGHODHYDOXDFLyQ(VQHFHVDULRFDOFXODUODHOGtDGHOQDFLPLHQWRR GXUDQWHODDWHQFLyQQHRQDWDO /DPD\RUXWLOLGDGGHOD(GDG*HVWDFLRQDOHVHQHOPRPHQWRGHGHFLGLUODRSRUWXQLGDGGH QDFLPLHQWR/XHJRGHQDFHUFDGDUHFLpQQDFLGRVHYDORUDGHDFXHUGRDODVFDSDFLGDGHV LQGLYLGXDOHVGHDGDSWDFLyQDODYLGDH[WUDXWHULQD (QFDVRTXHH[LVWDQGXGDVVREUHOD)80HOFiOFXORSXHGHEDVDUVHHQODIHFKDGHOD SULPHUDHFRJUDItD9HUFiOFXORHGDGJHVWDFLRQDO (VWLPDFLyQGHOD(GDG*HVWDFLRQDO 3UHYLRDOGHVDUUROORGHODDQWURSRPHWUtDHFRJUi¿FDIHWDOVHXWLOL]DEDQODVFDUDFWHUtVWLFDV VRPiWLFDV GHO UHFLpQ QDFLGR SDUD OD HVWLPDFLyQ GH OD HGDG JHVWDFLRQDO 0pWRGRV GH 'XERZLW] %DOODUG R &DSXUUR (VWDV HVWLPDFLRQHV WLHQHQ XQD JUDQ YDULDELOLGDG VHPDQDVTXHHVDXQPD\RUHQORVSUHWpUPLQR\HQORVUHFLpQQDFLGRVFRQUHVWULFFLyQ GHFUHFLPLHQWRLQWUDXWHULQR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (VWRVPpWRGRVQRWLHQHQXWLOLGDGFOtQLFD\DTXHFDUHFHQGHSUHFLVLyQVX¿FLHQWHSDUD RULHQWDUODDWHQFLyQGHHVRVUHFLpQQDFLGRV 3URSXHVWDVLPSOHSDUDHVWLPDFLyQUiSLGDHQSUHWpUPLQRV &XDQGRVHSURGXFHXQQDFLPLHQWRDQWHVGHODVVHPDQDVODPHGLGDGHO3HUtPHWUR &UDQHDQR3&DOQDFHUHVXQDPHGLGDGHVLPLODUYDORUTXHODREWHQLGDSRUHFRJUDItD REVWpWULFD SUHFR] 3RU OR WDQWR VL QR VH FRQRFH OD )80 SRGUtD XVDUVH HO 3& HQ OD HVWLPDFLyQGHODHGDGJHVWDFLRQDO /D&LQWD1HRQDWDOGH&/$3605WLHQHORVYDORUHVPHGLRVGH3HUtPHWUR&UDQHDQRSDUD FDGD(GDG*HVWDFLRQDO &XDQGRVHGHVFRQRFHOD)80\QRKD\XQDPHGLGDHFRJUi¿FDSUHYLDGHOWDPDxRGHOD FDEH]DIHWDORGHOIpPXUIHWDOVHSXHGHWRPDUODPHGLGDGHO3&SDUDLQLFLDUORVFiOFXORV GH(*DSDUWLUGHHVDIHFKD6HFRQRFHODGLVWULEXFLyQGHORVYDORUHVGH(*SDUDFDGD YDORUGH3HUtPHWUR&UDQHDQR 3RU(M6LVDEHPRVTXHSDUDORVQDFLGRVFRQ3& FPHOSGH(* VHPDQDV HOSGH(* VHPDQDV\HOSGH(* VHPDQDV3RGHPRVHVWLPDUTXHOD(GDG *HVWDFLRQDOGHOTXHWLHQH3& FPHVGHVHPDQDV 'DGRTXHHO3HUtPHWUR&UDQHDQRHQWUHODV\ODVVHPDQDVFUHFHDSUR[LPDGDPHQWH FPSRUVHPDQDXQDUHJODVLPSOHSDUDODHVWLPDFLyQUiSLGDGHOD(GDG*HVWDFLRQDO HVVXPDUOHDOYDORUGHOSHUtPHWURFUDQHDQR 3RU(M/DPHGLDGH(*GHORVUHFLpQQDFLGRVFRQXQ3& FPHVVHPDQDV $1752320(75,$1(21$7$/ 3HVRDOQDFHU (VHOSULPHUSHVRGHVQXGRPHGLGROXHJRGHODVHFFLyQ \SLQ]DGRGHOFRUGyQXPELOLFDO&XDQGRHOFRUGyQHV SLQ]DGRSUHFR]PHQWHHOSHVRQHRQDWDOSXHGHVHUKDVWD PHQRUTXHFXDQGRVHSLQ]DDO¿QDOL]DUHOSDVDMHGH VDQJUHGHVGHODSODFHQWD\DTXHHOYROXPHQGHVDQJUH WUDQVIXQGLGRSXHGHVHUPD\RUGHJUDPRV Figura 109. Fragmento de HCP. Datos RN /RQJLWXG /DORQJLWXGFpIDORSODQWDUVHPLGHFRQXQSHGLyPHWURFRQHOUHFLpQQDFLGRDFRVWDGR SODQRHQGHF~ELWRGRUVDOPDQWHQLHQGRXQPLHPEURLQIHULRUH[WHQGLGR6HPLGHHQ FHQWtPHWURVFRQXQGHFLPDO 3HULPHWURFHIDOLFR (OSHUtPHWURFHIiOLFRWDPELpQGHQRPLQDGRFLUFXQIHUHQFLDFUDQHDQDVHPLGHHQHOSODQR Pi[LPR RFFtSLWR IURQWDO 6H FRORFD OD FLQWD PpWULFD DOUHGHGRU GH OD FDEH]D PLHQWUDV VH OD VRVWLHQH VREUH OD IUHQWH (Q HO Pi[LPR SHUtPHWUR OD FLQWD DMXVWDGD GHEH SRGHU GHVOL]DUVHVREUHHORFFLSLWDO )LJXUD 7(&1,&$6'(0(','$ 3HUtPHWUR&UDQHDQR 3HUtPHWURGHOEUD]R /RQJLWXG &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 3HVRSDUDODHGDGJHVWDFLRQDO $OQDFHUVHSXHGHGHWHUPLQDUVLHOSHVRHV$GHFXDGR3HTXHxRR*UDQGHSDUDOD(GDG *HVWDFLRQDO 3DUD HOOR VH OH FRPSDUD FRQ ORV SHUFHQWLOHV \ GH OD SREODFLyQ SDUDFDGDVHPDQDGHJHVWDFLyQ3HTXHxRVVRQORVTXHQDFHQSRUGHEDMRGHOS $GHFXDGRVHQWUHHOS\S\*UDQGHVSRUHQFLPDGHOS(VWRVYDORUHVVHSXHGHQ HQFRQWUDUHQHOJHVWRJUDPD)LJODFLQWDREVWpWULFD\ODFLQWDQHRQDWDO ([LVWHQGRVWLSRVGHIDFWRUHVTXHSXHGHQLQÀXLUVREUHHOSDWUyQGHFUHFLPLHQWR ORVGHRULJHQFRQVWLWXFLRQDORJHQpWLFRLQGHSHQGLHQWHPHQWHGHODRIHUWDQXWULFLRQDO\ ODVSDWRORJtDVTXHVHDVRFLDQDUHVWULFFLyQXH[FHVRGHODWDVDGHFUHFLPLHQWR 2EMHWLYR $FWLYLGDG $GHFXDUHOPDQHMRLQLFLDOGHORVUHFLpQQDFLGRVFRQGHIHFWRV FRQJpQLWRVPD\RUHV ,QVWDXUDUHQIRUPDSUHFR]ODVPHGLGDVHVSHFt¿FDVSDUDFDGD GHIHFWR /RVGHIHFWRVFRQJpQLWRVVRQXQDGHODVFDXVDVGHPXHUWHQHRQDWDOTXHSHUVLVWHQFRQ PHQRVGHVFHQVRUHODWLYR/DIRUPDPDVH¿FLHQWHGHGLVPLQXLUODPRUWDOLGDGQHRQDWDOSRU GHIHFWRVFRQJpQLWRVHVODSUR¿OD[LV\SUHYHQFLyQSUHFRQFHSFLRQDOLGHQWL¿FDQGRIDFWRUHV GHULHVJR\DFWXDQGRVREUHHOORVSDUDGLVPLQXLUHQIRUPDGLUHFWDRLQGLUHFWDORVIDFWRUHV GHWHUPLQDQWHVFRPRVHDQDOL]DGHWHQLGDPHQWHHQHOFDSLWXORFRUUHVSRQGLHQWH &XDQGRHOGHIHFWRFRQJpQLWRIHWDOLPSLGHODDXWRQRPtDUHVSLUDWRULDVXPXHUWHSRVWQDWDO LQPHGLDWDHVDQWLFLSDEOHFRUUHVSRQGHDVLVWLUORHQIRUPDFRPSDVLYDEULQGiQGROHFRQIRUW DOQHRQDWR\DSR\RHPRFLRQDODVXVSDGUHV )UHQWHDODQRWLFLDGHTXHVXKLMRYDDQDFHUFRQXQGHIHFWRODIDPLOLDFXUVDHWDSDV HPRFLRQDOHVVLPLODUHVDODVGHVFULWDVSDUDHOGXHORXRWUDVSpUGLGDV /D FRPXQLFDFLyQ FRQ ORV SDGUHV VREUH VX UHFLpQ QDFLGR \ HO GHIHFWR FRQJpQLWR TXH SUHVHQWDUHTXLHUHPDVGLVSRQLELOLGDGDIHFWLYDGHTXLHQHVORVDWLHQGHQ4XLHQGHODQRWLFLD DFRPSDxH D OD IDPLOLD GHVGH HVH PRPHQWR R GHED WRPDU GHFLVLRQHV DVLVWHQFLDOHV GHEHHVWDUFDSDFLWDGR\WHQHUFRQTXLHQFRPSDUWLUODGLItFLOWDUHDGHDFRPSDxDUDHVD IDPLOLDSRUSHUtRGRVODUJRV /RV UHODWRV DQWHQDWDOHV ODV LPiJHQHV \ H[SOLFDFLRQHV TXH GLVSRQHQ ORV SDGUHV OHV SHUPLWHQFRPSUHQGHUHOGHIHFWRSHURHQJHQHUDOQRSXHGHQLPDJLQDUVHQLFHQWUDUVX DWHQFLyQHQODSDUWHQRUPDOGHVXKLMR(QHOPRPHQWRGHOQDFLPLHQWRORTXHORVSDGUHV YHDQ SXHGH VHU GLIHUHQWH GH OR TXH ORV PpGLFRV \ HO SHUVRQDO GH VDOXG YHQ 3DUD HO SHUVRQDOGHVDOXGSXHGHUHVXOWDULQHVSHUDGRTXHORVSDGUHVYHDQDVXKLMRGHIRUPD GLIHUHQWH (V FRP~Q TXH VL VH OHV PXHVWUD HO UHFLpQ QDFLGR FRQ HO GHIHFWR FXELHUWR ORV SDGUHV YHDQ XQD SDUWH KDVWD HVH PRPHQWR LQLPDJLQDEOH GH VX KLMR$~Q HQ ODV VLWXDFLRQHVH[WUHPDVGHXQUHFLpQQDFLGRFRQDQHQFHIDOLDODSUDFWLFDGHPRVWUDUORFRQ HOFUiQHRFXELHUWRSHUPLWHDORVSDGUHVUHFRUGDUDVXKLMRTXHSRVWHULRUPHQWHIDOOHFHGH XQDIRUPDPDVKXPDQD &XDQGR ORV GHIHFWRV FRQJpQLWRV QR LPSOLFDQ XQ SURQyVWLFR YLWDO LQH[RUDEOH \ H[LVWHQ RSRUWXQLGDGHVGHWUDWDPLHQWRHOPDQHMRQHRQDWDOGHEHFRPHQ]DUHQHOPLVPRPRPHQWR GHOQDFLPLHQWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 2QIDORFHOH\JDVWURTXLVLV /RVGHIHFWRVGHFLHUUHGHODSDUHGDEGRPLQDOVHPDQL¿HVWDQSRUSURWUXVLyQGHYtVFHUDV DEGRPLQDOHV D WUDYpV GH XQD DSHUWXUD RQIDORFHOH R DG\DFHQWH DO FRUGyQ XPELOLFDO JDVWURTXLVLV 6X LQFLGHQFLD HV GH HQ D 51 YLYRV 3XHGHQ QDFHU SRU YtDYDJLQDORFHViUHD\GHVGHHOQDFLPLHQWRVHSXHGHSURWHJHUPHGLDQWHXQDVRQGD QDVRJiVWULFDFRQDVSLUDFLyQVXDYHSDUDGHJUDYLWDU\SUHYHQLUODGLODWDFLyQGHODVDVDV LQWHVWLQDOHV(OVDFRRODVYtVFHUDVGHEHQVHUFXELHUWDVFRQXQDEROVDSOiVWLFDHVWpULO TXHHYLWDSpUGLGDVGHFDORU\OtTXLGR(OUHFLpQQDFLGRGHEHSHUPDQHFHUHQGHF~ELWR ODWHUDOSDUDHYLWDUHODFRGDPLHQWRGHOLQWHVWLQRTXHDOWHUDVXLUULJDFLyQ6XUHSDUDFLyQ TXLU~UJLFD QR HV QHFHVDULDPHQWH XQD HPHUJHQFLD LQPHGLDWD DO QDFLPLHQWR \ SXHGH VHUFRRUGLQDGD XQDYH]HVWDELOL]DGR RWUDVODGDGR DXQQLYHO GH UHIHUHQFLD TXLU~UJLFD HVSHFLDOL]DGD 0LHORPHQLQJRFHOH (VXQGHIHFWRGHFLHUUHyVHRGHODFROXPQDYHUWHEUDOTXHH[SRQHXQVDFRGHDUDFQRLGHV \GXUDPDGUHFXELHUWDRQRGHSLHOFRQOtTXLGRFHIDORUUDTXtGHRHQVXLQWHULRU\PpGXOD PDOIRUPDGD 6XLQFLGHQFLDHVGHDSRUUHFLpQQDFLGRVYLYRV $OQDFHUVHGHEHFRORFDUiDOUHFLpQQDFLGRHQGHF~ELWRSURQRSDUDSUHYHQLUOHVLRQHV GHODSODFD\VHFXEUHFRQFXUDFLyQHVWpULOSUHYLDGHVLQIHFFLyQFRQDQWLVpSWLFRGHOD SLHOVDQDTXHURGHDDOGHIHFWR6HFXEUHFRQSROLHWLOHQRHVWpULOTXHVHVRVWLHQHFRQWHOD DGKHVLYDHQORVERUGHVVREUHSLHOVDQD6LQRVHGLVSRQHGHOiPLQDGHSROLHWLOHQRHVWpULO VHSXHGHFXEULUFRQJDVDFRQYDVHOLQDHVWpULOSDUDTXHQRVHDGKLHUDDODSODFD +HUQLDGLDIUDJPiWLFD (VXQDIDOODHQHOFLHUUHQRUPDOGHORVSOLHJXHVSOHXURSHULWRQHDOHVTXHSURYRFDXQ RUL¿FLRGLDIUDJPiWLFRSRUHOFXDODVFLHQGHQYtVFHUDVDEGRPLQDOHVDOWyUD[6XLQFLGHQFLD HV GH HQ UHFLpQ QDFLGRV YLYRV (O HV D L]TXLHUGD HO D GHUHFKD \ HOHVELODWHUDO6HPDQL¿HVWDSRUGL¿FXOWDGUHVSLUDWRULDGHLQVWDODFLyQLQPHGLDWD\ SURJUHVLYDGHVGHHOQDFLPLHQWR 6LUHTXLHUHDSR\RYHQWLODWRULRGHEHKDFHUSRULQWXEDFLyQHQGRWUDTXHDOSXHVODYHQWLODFLyQ SRU PDVFDUD SXHGH LQVXÀDU HO WXER GLJHVWLYR LQWUDWyUDFLFR \ DXPHQWDU OD UHVWULFFLyQ YHQWLODWRULD /DFRORFDFLyQGHXQDVRQGDQDVRJiWULFDFRQDVSLUDFLyQVXDYHFRQWULEX\HDGHJUDYLWDU HOWXERGLJHVWLYRKDVWDODUHSDUDFLyQTXLU~UJLFDGHOGHIHFWR /DPDJQLWXGGHOGHIHFWRHVSURSRUFLRQDODVXJUDYHGDG\FRQGLFLRQDHQODYLGDIHWDOHO FUHFLPLHQWRSXOPRQDUFXUVDQGRDOQDFLPLHQWRFRQVHYHUDKLSHUWHQVLyQSXOPRQDUTXH FRQGLFLRQDVXVREUHYLGD5HTXLHUHXQFXLGDGRFRQWLQXRHQOXJDUGHPi[LPDFRPSOHMLGDG DVLVWHQFLDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 2EMHWLYR $FWLYLGDG 'HWHWDUGHIHFWRV\RHQIHUPHGDGHVFRQJpQLWDV DVLQWRPiWLFDV 'HWHFFLyQVLVWHPiWLFDHQHOSHUtRGRQHRQDWDOSRUPpWRGRVGH ODERUDWRULRELRFOtQLFR (O PRPHQWR GH QDFHU HV XQD RSRUWXQLGDG SDUD GLVPLQXLU HO GDxR TXH SXHGHQ SURGXFLU FLHUWDV HQIHUPHGDGHV FRQJpQLWDV DVLQWRPiWLFDV TXH GHEHQ VHU WUDWDGDV GH LQPHGLDWR 3DUD GHWHFWDUODV SUHFR]PHQWH HV QHFHVDULR UHDOL]DU SURFHGLPLHQWRV GLDJQyVWLFRV HQ IRUPD VLVWHPiWLFD D ORV UHFLpQ QDFLGRV /D GHWHFFLyQ VLVWHPiWLFD SXHGH VHU ³XQLYHUVDO´ FXDQGR HVWi LQGLFDGD SDUD WRGRV ORV UHFLpQ QDFLGRV R ³VHOHFWLYD´ HQ DTXHOODV HQIHUPHGDGHV TXH VROR DIHFWDQ D UHFLpQ QDFLGRV FRQ IDFWRUHV GH ULHVJR SRFR IUHFXHQWHVHQODSREODFLyQJHQHUDO Figura 111. Fragmento HCP. Tamizaje neonatal (OWDPL]DMHQHRQDWDOXQLYHUVDOVHUHDOL]DDWRGRVORVUHFLpQQDFLGRV\HQPXFKRVSDtVHV GH$PpULFD/DWLQDHVWDHVWDEOHFLGRSDUDODVVLJXLHQWHVSDWRORJtDV (QIHUPHGDGHVLQIHFFLRVDVGHWUDQVPLVLyQYHUWLFDO 6t¿OLV 7R[RSODVPRVLV (QIHUPHGDGHVQRLQIHFFLRVDV +LSRWLURLGLVPR IHQLOFHWRQXULD ¿EURVLV TXtVWLFD GH SiQFUHDV JDODFWRVHPLD KLSHUSODVLD VXSUDUUHQDO FRQJpQLWD GH¿FLHQFLD GH ELRWLQLGDVD UHWLQRSDWtD GHO SUHPDWXUR&KDJDV (O WDPL]DMH QHRQDWDO VHOHFWLYR VH UHDOL]D VRODPHQWH D DOJXQRV UHFLpQ QDFLGRV FRQ IDFWRUHVGHULHVJRHOHYDGRV\HQPXFKRVSDtVHVGH$PpULFD/DWLQDHVWDHVWDEOHFLGR SDUDODVVLJXLHQWHVSDWRORJtDV (QIHUPHGDGHVGHWUDQVPLVLyQYHUWLFDO +HSDWLWLV%HQPDGUHV+%9SRVLWLYDV +,9HQPDGUHV+,9SRVLWLYDV (VWUHSWRFRFR *UXSR%HQ PDGUHV SRUWDGRUDV HQHO PRPHQWR GHO SDUWR RUHFLpQ QDFLGRVFRQIDFWRUHVGHULHVJR 7ULSDQRVRPD&UX]LHQPDGUHV&KDJiVLFDV (QIHUPHGDGHVQRLQIHFFLRVDV 5KVLODPDGUHHV5KQHJDWLYDLQPXQL]DGDRQR $QHPLDIDOFLIRUPHVLORVSDGUHVVRQDIURGHVFHQGLHQWHV 5HWLQRSDWtDVHYHUDGHOSUHPDWXURVLHVGH0X\%DMR3HVR 6,),/,6&21*e1,7$ 'HWHFFLyQVLVWHPiWLFDWUDWDPLHQWR\VHJXLPLHQWRGHVt¿OLVFRQJpQLWD /DVt¿OLVHVXQDHQIHUPHGDGFDXVDGDSRUXQDEDFWHULD7UHSRQHPDSDOOLGXPODFXDOHV WUDQVPLWLGDHQIRUPDVH[XDO /DVt¿OLVFRQJpQLWDSXHGHVHUDGTXLULGDGHODPDGUHLQIHFWDGDYtDWUDQVSODFHQWDULDHQ FXDOTXLHUPRPHQWRGHOHPEDUD]R\GHOSDUWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 'H¿QLFLyQ 6HGH¿QHFRPR6t¿OLVFRQJpQLWDFXDOTXLHUDGHODVVLJXLHQWHVFRQGLFLRQHV 7RGR UHFLpQ QDFLGR DERUWR R PRUWLQDWR GH PDGUH FRQ HYLGHQFLD FOtQLFD ~OFHUD JHQLWDO R OHVLRQHV FRPSDWLEOHV FRQ Vt¿OLV VHFXQGDULD R FRQ SUXHED WUHSRQpPLFDLQFOXLGRSUXHEDVUiSLGDVRQRWUHSRQpPLFDSRVLWLYDRUHDFWLYD GXUDQWHODJHVWDFLyQSDUWRRSXHUSHULRTXHQRKD\DVLGRWUDWDGDRKD\DVLGR WUDWDGDLQDGHFXDGDPHQWH 2 7RGR QHRQDWR FRQ WtWXORV GH 5359'5/ FXDWUR YHFHV PD\RU TXH ORV WtWXORV GHODPDGUHRORTXHHTXLYDOHDXQFDPELRHQGRVGLOXFLRQHVRPiVGHORV PDWHUQRVSRUHMHPSORGHD 2 7RGR QLxR FRQ XQD R YDULDV PDQLIHVWDFLRQHV FOtQLFDV VXJHVWLYDV GH Vt¿OLV FRQJpQLWDDOH[DPHQItVLFR\RHYLGHQFLDUDGLRJUi¿FDGHVt¿OLVFRQJpQLWD\R UHVXOWDGRUHDFWLYRGHXQDSUXHEDWUHSRQpPLFDRQRWUHSRQpPLFD 0DQLIHVWDFLRQHV FOtQLFDV VXJHVWLYDV GH 6& 'LVWUR¿DV QHXPRSDWtDV ODULQJLWLV OODQWR URQFR \ FRQWLQXDGR JDVWURHQWHULWLV KHSDWRHVSOHQRPHJDOLD RVWHRFRQGULWLVGHKXHVRVODUJRVDOH[DPHQUDGLROyJLFRULQLWLVPXFRSXUXOHQWD SVHXGRSDUiOLVLVLFWHULFLD\RDQHPLDOHVLRQHVPXFRFXWiQHDVSiSXODVSODFDV LQ¿OWUDGDVURML]DVHQUHJLyQSHULEXFDOPLHPEURVSDOPDVSODQWDVSHULDQDOHV\ SHULJHQLWDOHVURVHRODVGHJUDQGHVPDQFKDVDPSROODVSDOPRSODQWDUHV 2 7RGR SURGXFWR GH OD JHVWDFLyQ FRQ GHPRVWUDFLyQ GH 7 SDOOLGXP SRU FDPSR RVFXURLQPXQRÀXRUHVFHQFLDXRWUDFRORUDFLyQRSURFHGLPLHQWRHVSHFt¿FRHQ OHVLRQHVSODFHQWDFRUGyQXPELOLFDORPDWHULDOGHDXWRSVLD 7RGDVODVPDGUHVGHEHQVHUWHVWDGDVHQHOPRPHQWRGHOSDUWRSXHVHO9'5/PDWHUQRHV PiVVHQVLEOHTXHHO9'5/QHRQDWDO3XHGHQH[LVWLUFDVRVGH9'5/QHRQDWDOQHJDWLYR HQPDGUHVVL¿OtWLFDVQRWUDWDGDVSRUEDMRWtWXORPDWHUQRRLQIHFFLyQPDWHUQDUHFLHQWH 7DPELpQ VH UHDOL]D HO WDPL]DMH PHGLDQWH HO HVWXGLR GHO 9'5/ HQ VDQJUH GHO UHFLpQ QDFLGRSUHIHUHQWHPHQWHHQVDQJUHGHFRUGyQXPELOLFDO (Q ODV PDGUHV TXH WLHQHQ XQ WHVW GH Vt¿OLV QHJDWLYR HQ HO PRPHQWR GHO SDUWR HO H[DPHQ GH OD VDQJUH GHO FRUGyQ GH UHFLpQ QDFLGR QR HV QHFHVDULR 6LQ HPEDUJR QR HV DFRQVHMDEOH DEDQGRQDU HVWD SUiFWLFD GH GHWHFFLyQ VLVWHPiWLFD XQLYHUVDO D WRGRV ORVUHFLpQQDFLGRV\DTXHDXQH[LVWHXQUHOHYDQWHSRUFHQWDMHGHPDGUHVTXHQRWLHQHQ GLFKRH[DPHQDOGtDHQHOPRPHQWRGHOSDUWR 6L OD PDGUH WLHQH XQ WHVW GH Vt¿OLV SRVLWLYR QR WUDWDGR DGHFXDGDPHQWH DGHPiV GHO 9'5/QHRQDWDOVHGHEHUHDOL]DU ([DPHQFOtQLFRGHOUHFLpQQDFLGRRULHQWDGRDODE~VTXHGDGHVLJQRVHQRUGHQGH HVSHFL¿FLGDG 6LJQRVUDGLROyJLFRVGHRVWHtWLV\SHULFRQGULWLV ,FWHULFLD 5DJDGLHVULQRUUHDKHPRUUiJLFD +LGURSVIHWDO &RQGLORPDWRVLV /LQIRDGHQRPHJDOLDV /HVLRQHVPDFXODUHVEXOORVDVRHF]HPDWRVDV JHQHUDOL]DGDV 3pQ¿JRHQSDOPDV\SODQWDVGHSLH 1HXPRQLWLV 3DUFKHVPXFRVRV $XPHQWRGHOWDPDxRGHODSODFHQWD +HSDWRHVSOHQRPHJDOLD 5HVWULFFLyQGHO&UHFLPLHQWR ,QWUDXWHULQR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (VWXGLRGHO/tTXLGR&pIDOR5DTXtGHR9DORUHVGHSUREDEOH1HXURVt¿OLV *OyEXORVEODQFRVPiVGHPP\ 3URWHtQDV HOHYDGDV PD\RU R LJXDO D PJGO HQ HO WpUPLQR R PD\RU LJXDO GH PJGOHQHOSUHWpUPLQR 9'5/SRVLWLYRHQDXVHQFLDGHFRQWDPLQDFLyQFRQVDQJUH 5HFRPHQGDPRV TXH HQ ORV FDVRV TXH HO HVWDGR VHUROyJLFR GH ODV PDGUHV HV GHVFRQRFLGRHVREOLJDWRULRKDFHUHO9'5/SDUDORVQLxRVDQWHVGHOHJUHVRKRVSLWDODULR 0$1(-2&/,1,&2 $ ([DPHQ ItVLFR DQRUPDO FRPSDWLEOH FRQ Vt¿OLV FRQJpQLWD R 9'5/535 FXDQWLWDWLYR YHFHV PD\RUHV D ORV QLYHOHV PDWHUQRV R FDPSR RVFXUR R DQWLFXHUSRVÀXRUHVFHQWHVSRVLWLYRVHQOtTXLGRVFRUSRUDOHV (YDOXDFLyQ 9'5/FRQWHRFHOXODU\SURWHtQDVHQOtTXLGRFpIDORUDTXtGHR +HPRJUDPDFRPSOHWRFRQUHFXHQWRSODTXHWDULR 5DGLRJUDItDGHKXHVRVODUJRVGHWyUD[IXQFLRQDOKHSiWLFRHFRJUDItDWUDQVIRQWDQHODU SRWHQFLDOHVHYRFDGRVDXGLWLYRVVLFRUUHVSRQGHQ 7UDWDPLHQWR 3HQLFLOLQD * FULVWDOLQD HQ VROXFLyQ DFXRVD ± XQLGDGHV.JGtD DGPLQLVWUDQGRXQLGDGHVNJGRVLV,9FDGDKRUDVGXUDQWHORVSULPHURVGtDV \FDGDKRUDVOXHJRKDVWDFRPSOHWDUGtDVR 3HQLFLOLQD*3URFDtQDXQLGDGHVNJGRVLV,0XQDYH]SRUGtDSRUGtDV 6LVHSLHUGHPiVGHGtDGHWUDWDPLHQWRGHEHUHDOL]DUVHQXHYDPHQWHHOWUDWDPLHQWR FRPSOHWR (Q ORV VLJXLHQWHV HVFHQDULRV GHEHUi FRQVLGHUDUVH WDPELpQ OD KLVWRULD PDWHUQD GH OD HQIHUPHGDG\VXWUDWDPLHQWRDORVHIHFWRVGHGHFLGLUHOHVWXGLR\WUDWDPLHQWRGHOUHFLpQ QDFLGR %([DPHQItVLFRQRUPDOFRQ9'5/535FXDQWLWDWLYRVLJXDOHVRYHFHV PHQRUHVTXHORVGHODPDGUH (QFDVRTXHODPDGUH1RKD\DVLGRWUDWDGDIXHLQDGHFXDGDPHQWHWUDWDGDRKD\GXGDV RIXHWUDWDGDFRQHULWURPLFLQD\RWURUpJLPHQQRSHQLFLOtQLFRRUHFLELyWUDWDPLHQWRSHUR IXHPHQRVGHVHPDQDVDQWHVGHOSDUWR (YDOXDFLyQ &RQWHRFHOXODU\SURWHtQDVHQOtTXLGRFpIDORUDTXtGHR +HPRJUDPDFRQUHFXHQWRGHJOyEXORV\SODTXHWDV 5DGLRJUDItDGHKXHVRVODUJRV 6LVHDGPLQLVWUDQGtDVGHWUDWDPLHQWRSDUHQWHUDOQRVHUtDQHFHVDULDODHYDOXDFLyQ FRPSOHWDSHURODSXQFLyQOXPEDUSXHGHGRFXPHQWDUDQRPDOtDVGH/&5\FRQGLFLRQDU XQVHJXLPLHQWRPDVHVWULFWR 7UDWDPLHQWR 3HQLFLOLQD * &ULVWDOLQD HQ VROXFLyQ DFXRVD ± XQLGDGHV.JGtD DGPLQLVWUDQGRXQLGDGHV.JGRVLV,9FDGDKRUDVGXUDQWHORVSULPHURV GtDV\FDGDKRUDVKDVWDFRPSOHWDUGtDVR 3HQLFLOLQD*3URFDtQDXQLGDGHV.JGRVLV,0HQXQDGRVLVGLDULDGXUDQWH GtDVR 3HQLFLOLQD*%HQ]DWtQLFDXQLGDGHV.JGRVLV,0HQGRVLV~QLFD 6HJXLPLHQWR 7RGRVORVUHFLpQQDFLGRV9'5/SRVLWLYRVGHEHUiQVHUYLJLODGRV\HO9'5/VHUHSHWLUi FDGD D PHVHV KDVWD TXH VHD QHJDWLYR R GHVFLHQGD YHFHV /RV WtWXORV GHEHQ GHVFHQGHUDORVPHVHV\VHUQHJDWLYRVDORVPHVHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &([DPHQItVLFRQRUPDO\WHVWVQRWUHSRQpPLFRVLJXDOHVRYHFHVPHQRUHV TXHORVGHODPDGUH (QFDVRTXHODPDGUH )XHWUDWDGDGXUDQWHHOHPEDUD]RHQIRUPDDGHFXDGDPiVGHFXDWURVHPDQDVDQWHV GHOSDUWR\QRWLHQHHYLGHQFLDVGHUHLQIHFFLyQ 6HUHFRPLHQGD 1RUHDOL]DURWUDVHYDOXDFLRQHV5pJLPHQUHFRPHQGDGR 3HQLFLOLQD*%HQ]DWtQLFDXQLGDGHV.J,0GRVLV~QLFD '([DPHQItVLFRQRUPDO\WHVWVQRWUHSRQpPLFRVLJXDOHVRYHFHVPHQRUHV TXHORVGHODPDGUH (QFDVRTXHODPDGUH +D\D VLGR WUDWDGD DGHFXDGDPHQWH DQWHV GHO HPEDUD]R \ VXV WtWXORV GH 9'5/ VRQ 535 1RHVQHFHVDULRKDFHURWUDVHYDOXDFLRQHVQLWUDWDPLHQWRV 72;23/$6026,6&21*e1,7$ /D7R[RSODVPRVLV&RQJpQLWDHVXQDDIHFFLyQLQIHFFLRVDRFDVLRQDGDSRUHO7R[RSODVPD *RQGLLWUDVPLWLGRSRUODPDGUHGXUDQWHHOHPEDUD]RFXDQGRHOODFXUVDXQDSULPRLQIHFFLyQ ([LVWHQ QXPHURVRV SDtVHV FRQ DOWD SUHYDOHQFLD GH 7R[RSODVPRVLV \ HO FRQVHFXHQWH ULHVJRPDWHUQRGHDGTXLULUODGXUDQWHHOHPEDUD]R /RV SURJUDPDV PDV H[LWRVRV VRQ SUHYHQWLYRV UHFRPHQGDQGR D OD PDGUH SUiFWLFDV KLJLpQLFDVSDUDQRDGTXLULUODHQIHUPHGDGHQHOHPEDUD]R~QLFRPRPHQWRHQHOTXH VXVFRQVHFXHQFLDSXHGHQVHUGHH[WUHPDJUDYHGDGSXHVOHVLRQDHO6LVWHPD1HUYLRVR &HQWUDO GHO IHWR /DV PHGLGDV SUHYHQWLYDV SUHFRQFHSFLRQDOHV \ GXUDQWH HO HPEDUD]R VRQ DQDOL]DGDV HQ OD DWHQFLyQ DQWHQDWDO DVt FRPR OD LQWHUSUHWDFLyQ \ PDQHMR GH OD WR[RSODVPRVLVDJXGDPDWHUQDGHWHFWDGDGXUDQWHODJHVWDFLyQ (O7DPL]DMH1HRQDWDOGHWRGRVORVUHFLpQQDFLGRVLQGHSHQGLHQWHPHQWHGHODFRQGLFLyQ PDWHUQDHVXQDLQWHUYHQFLyQGLDJQyVWLFDH¿FD](OWDPL]DMHQHRQDWDOGHWHFWDIRUPDVGH LQIHFFLyQDVLQWRPiWLFDVTXHSXHGHQHYROXFLRQDUHQHOODFWDQWHSURYRFDQGRVHYHURGDxR RFXODUFRQSpUGLGDSURJUHVLYDHLUUHYHUVLEOHGHODYLVLyQ /D GHWHFFLyQ VH UHDOL]D SRU OD GHWHUPLQDFLyQ GH DQWLFXHUSRV ,J0 HVSHFt¿FRV DQWLWR[RSODVPDHQODVDQJUHGHOUHFLpQQDFLGR/DVDQJUHSXHGHVHUUHFRJLGDGHOFRUGyQ DOQDFHU\SXHGHVHUWUDQVSRUWDGDHQSDSHO¿OWURFRPRVHUHFRJHSDUDRWURVH[iPHQHV GH WDPL]DMH SHM +LSRWLURLGLVPR &RQJpQLWR (Q DOJXQDV iUHDV VH KDQ GHWHFWDGR FDVRV GH WR[RSODVPRVLV FRQJpQLWD DVLQWRPiWLFD FDGD QDFLPLHQWRV 6L QR VRQ WUDWDGRV SXHGHQ WHQHU OHVLRQHV GH FRULRUUHWLQLWLV HQ ORV SULPHURV DxRV GH YLGD (O PpWRGR GHWHFWD HQWUH \ GH ORV QHRQDWRV DIHFWDGRV \ WLHQH HVSHFL¿FLGDG HVWLPiQGRVHTXHGHFDGD,J0SRVLWLYRVPiVGHHVWDUiHQIHUPR 7UDWDPLHQWR 3LULPHWDPLQD GRVLV FDUJD PJNGtD SRU GtDV GRVLV GH PDQWHQLPLHQWR PJNGtD SRUDPHVHVFRQWLQXDQGRFRQODPLVPDGRVLVYHFHVDODVHPDQDKDVWDDxR PDV VXOIDGLD]LQD PJNGtD HQ GRVLV KDVWD DxRV PDV iFLGR IROtQLFR PJ YHFHV SRU VHPDQD HV OD TXLPLRWHUDSLD DQWLWR[RSODVPD TXH VH KD DGPLQLVWUDGR FRQPiVIUHFXHQFLDDORVUHFLpQQDFLGRVTXHVHGHWHFWDQFRQLQIHFFLyQWR[RSOiVPLFD DVLQWRPiWLFD(VWDWHUDSLDSXHGHRFDVLRQDUQHXWURSHQLDSRUWR[LFLGDGPHGXODU(VWiHQ HVWXGLRHOWUDWDPLHQWRDOWHUQDWLYRFRQHVSLURPLFLQDFRWULPR[D]RO\D]LWURPLFLQD +,9 (OYLUXVGHLQPXQRGH¿FLHQFLDKXPDQD7KHOSHUGHOVLVWHPDLQPXQHFDXVDQGRSURJUHVLYD UHGXFFLyQGHVXQ~PHUR\HYHQWXDOPHQWHHO6tQGURPHGH,QPXQRGH¿FLHQFLD$GTXLULGD 6,'$ (Q DXVHQFLD GH WUDWDPLHQWR LQGHSHQGLHQWHPHQWH GH OD ODFWDQFLD PDWHUQD HQWUH HO GH ORV UHFLpQ QDFLGRV VHUiQ LQIHFWDGRV SRU +,9$XPHQWD HQ XQ OD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD WUDQVPLVLyQGXUDQWHODODFWDQFLDPDWHUQDVLFRQWLQ~DKDVWDHOVHJXQGRDxRGHYLGDGH VXPDGUHLQIHFWDGDFRQ+,9 /DWUDQVPLVLyQYHUWLFDOSXHGHUHGXFLUVHDPHQRVGHVLODPDGUHUHFLEHSUR¿OD[LV FRQDQWLUUHWURYLUDOHVFHViUHDHOHFWLYDDQWHVGHOLQLFLRGHOWUDEDMRGHSDUWR\ODURWXUD GH PHPEUDQDV \ OD VXSUHVLyQ WRWDO GH OD ODFWDQFLD 3DUD HOOR HO VFUHHQLQJ GHO +,9 DQWHQDWDOXQLYHUVDOHVQHFHVDULR 7RGDHPEDUD]DGDTXHQRUHFLELyDWHQFLyQSUHQDWDOGHEHUHDOL]DUVHHOWHVWUiSLGRGH +,9HQHOPRPHQWRTXHFRQVXOWDHQWUDEDMRGHSDUWR 6H LQLFLDUD WDQ SURQWR VHD SRVLEOH OD SUR¿OD[LV DQWLUUHWURYLUDO VLQ HVSHUDU HO WHVW FRQ¿UPDWRULR:HVWHUQEORWRLQPXQRÀXRUHVFHQFLD 0DQHMRFOtQLFR $ 0DGUHTXHQRUHFLELySUR¿OD[LVFRQDQWLUUHWURYLUDOHVHQHODQWHQDWDOQLHQWUDEDMRGH SDUWR ,QLFLDU='9GHQWURGHODKVGHYLGD='9\FRQWLQXDUODKDVWDODVVHPDQDV % 0DGUH TXH UHFLELy SUR¿OD[LV FRPSOHWD DQWHSDUWR H LQWUDSDUWR ='9 RUDO GHVGH VHPDQDVDVHPDQDVPJYHFHVDOGtDRPJYHFHVDOGtDHLQWUDSDUWR ='9LYPJ.JGHXQDLQIXVLyQFRQWLQXDVHJXLGRGHPJNJKRUDKDVWDHOSDUWR $O UHFLpQ QDFLGR ,QLFLDU ='9 RUDO GHQWUR GH ODV KV GH YLGD \ FRQWLQXDU SRU VHPDQDV R0DVGHVHPDQDVPJNGRVLVFDGDKV RVHPDQDVPJNGRVLVFDGDKVOXHJRGHODVVHPDQDVFDGDKV 6LHVWDFRQWUDLQGLFDGDODYtDRUDORQRHVWROHUDGDDGPLQLVWUDUGRVLVLYPJNHQORV PLVPRVLQWHUYDORV0RQLWRUL]DUODKHPRJORELQDDQWHV\GHVSXpVGHOWUDWDPLHQWRGDGR TXHODDQHPLDHVXQHIHFWRDGYHUVR /D ¿QDOL]DFLyQ GHO HPEDUD]R SRU FHViUHD UHGXFH VLJQL¿FDWLYDPHQWH OD WUDQVPLVLyQ SHULQDWDOGHO9,+HQ /DVPDGUHVTXHQRUHFLELHURQWHUDSLDDQWLUUHWURYLUDODQWHQDWDO /DVPDGUHVTXHUHFLELHURQVRODPHQWH='9SDUDODSUR¿OD[LVGHODWUDQVPLVLyQSHULQDWDO 6LGXUDQWHHOHPEDUD]RORVQLYHOHVGH51$+,9VRQPD\RUHVGHFRSLDVPO 1RHVFODURTXHODFHViUHDOXHJRGHODURWXUDGHPHPEUDQDVRLQLFLRGHWUDEDMRGHSDUWR WHQJDEHQH¿FLRHQUHGXFLUODWUDQVPLVLyQ 5HFRPHQGDFLRQHVVREUHODDOLPHQWDFLyQGHOUHFLpQQDFLGR 3DUDUHGXFLUDOPtQLPRHOULHVJRGHWUDQVPLVLyQGHO9,+DORVQLxRVHOJUXSRGHH[SHUWRV GH OD 5HJLyQ GH ODV$PpULFDV SURSXVR UHIRU]DU OD HVWUDWHJLD GH VXSULPLU OD ODFWDQFLD PDWHUQD HQ ORV KLMRV GH PXMHUHV FRQ 9,+ (Q HVWH VHQWLGR OD 236206 UHFRPLHQGD HYLWDU OD ODFWDQFLD PDWHUQD VLHPSUH \ FXDQGR HVWD RSFLyQ VHD DFHSWDEOH IDFWLEOH DVHTXLEOHVRVWHQLEOH\VHJXUD$)$66 +(3$7,7,6% /DWUDQVPLVLyQGHOYLUXVKHSDWLWLV%GHVGHODPDGUHDOQLxRRFXUUHPiVIUHFXHQWHPHQWH HQHOPRPHQWRGHOSDUWRODWUDQVPLVLyQLQWUD~WHURHVUDUD /D PD\RUtD GH ORV UHFLpQ QDFLGRV ODFWDQWHV \ QLxRV TXH DGTXLHUHQ OD LQIHFFLyQ SHULQDWDO SHUPDQHFHUiQ DVLQWRPiWLFRV SRU H[WHQVRV SHULRGRV 3HUR WLHQHQ DOWR ULHVJRGHGHVDUUROODULQIHFFLyQFUyQLFD(OULHVJRGHGHVDUUROODULQIHFFLyQFUyQLFDHVWD LQYHUVDPHQWHUHODFLRQDGDFRQODHGDGGHLQIHFFLyQ$SUR[LPDGDPHQWHHOGHORV QLxRVTXHDGTXLHUHQODLQIHFFLyQHQODHWDSDSHULQDWDOGHVDUUROODUDQLQIHFFLyQFUyQLFD FRPSDUDGRFRQGHORVTXHVHLQIHFWDQHQODHWDSDDGXOWD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $SUR[LPDGDPHQWHHOGHODVSHUVRQDVFRQLQIHFFLyQFUyQLFDVHFUHHTXHDGTXLULHURQ ODLQIHFFLyQFRPRUHVXOWDGRGHODWUDQVPLVLyQSHULQDWDORHQODLQIDQFLDWHPSUDQD /DPXHUWHSRUFLUURVLVRFDUFLQRPDKHSDWRFHOXODURFXUUHHQGHODVSHUVRQDVTXH DGTXLULHURQOD+%HQODLQIDQFLDFRPSDUDGRFRQHOGHORVTXHODDGTXLULHURQHQOD HWDSDDGXOWD (VWDVUD]RQHVDYDODQHOWDPL]DMHGHDQWtJHQRVGHVXSHU¿FLHDODHPEDUD]DGD\SUHYHQLU ODLQIHFFLyQDOUHFLpQQDFLGR /DYDFXQDFLyQGHKHSDWLWLV%HVXQDPHGLGDHIHFWLYDSDUDSUHYHQLUODLQIHFFLyQYLUXV +%\VXVFRQVHFXHQFLDV 0DQHMRFOLQLFR±3UHYHQFLyQGHODWUDQVPLVLyQSHULQDWDO $ 206UHFRPLHQGDODYDFXQDFLyQXQLYHUVDOGHORVUHFLpQQDFLGRVODSULPHUDGRVLV DOQDFHU\ODVGRVGRVLVVXEVLJXLHQWHVLQFRUSRUDUODVDOHVTXHPDGHYDFXQDFLyQGH UXWLQDGHOSULPHUDxRGHYLGDFRPRHVWUDWHJLDSDUDSUHYHQLUODLQIHFFLyQSRU+% % 5HFLpQQDFLGRVGHPDGUHFRQ+%V$JSRVLWLYR 6HGHEHDGPLQLVWUDUYDFXQDGHKHSDWLWLV%\DGPLQLVWUDULQPXQRJOREXOLQDDQWLKHSDWLWLV %,*+%HQGLIHUHQWHVVLWLRVHQODVSULPHUDVKVGHYLGD6HGHEHFRPSOHWDUODV WUHVGRVLVGHODYDFXQDDORV\DORVPHVHVGHYLGD /DDGPLQLVWUDFLyQGHDPEDVKDGHPRVWUDGRVHUPiVGHHIHFWLYDHQODSUHYHQFLyQ GHODLQIHFFLyQ9+%DJXGD\FUyQLFDGHQLxRVGHPDGUHVFRQ+%V$JSRVLWLYR /XHJRGHUHFLELUODYDFXQD\OD,*+%SXHGHUHFLELUODFWDQFLDPDWHUQD 6HJXLPLHQWR WHVW DQWLFXHUSRV DQWL +%V$J D ORV D PHVHV GH HGDG QHJDWLYRV FRQ¿UPDODHIHFWLYLGDGGHODSUR¿OD[LV & 5HFLpQQDFLGRVGHPDGUHFRQ+%V$JGHVFRQRFLGR 'HEHUHFLELUYDFXQD+%HQODVSULPHUDVKVGHYLGD 5HDOL]DUVHURORJtDSDUD+%V$JDODPDGUHVLHVSRVLWLYDHOUHFLpQQDFLGRGHEHUHFLELU ,*+%WDQSURQWRVHDSRVLEOHQRPiVGHGtDV$PEDVLQWHUYHQFLRQHVSUHYLHQHQXQ GHODVLQIHFFLRQHVSHULQDWDOHV 6LODVHURORJtDPDWHUQDHVQHJDWLYDORVUHFLpQQDFLGRVGHWpUPLQRPD\RUGHJ GHEHQUHFLELUODYDFXQDDODOWD 6LHVSUHWpUPLQRSHVRPHQRUGHJODUHVSXHVWDDODYDFXQD+%HVWiGLVPLQXLGDVL VHDGPLQLVWUDDQWHVGHOPHVGHYLGD3RUORWDQWRODYDFXQD+%GHEHVHUDGPLQLVWUDGD PHVOXHJRGHOQDFLPLHQWRRDODOWDKRVSLWDODULD6LHOSUHWpUPLQRUHFLEHXQDGRVLVDO QDFHUQRVHWRPDHQFXHQWDSDUDFRPSOHWDUODVGRVLV (675(372&2&2'(/*5832% $SUR[LPDGDPHQWH DO GH ODV PXMHUHV HPEDUD]DGDV HVWiQ FRORQL]DGDV WUDQVLWRULDPHQWHHQIRUPDFUyQLFDRLQWHUPLWHQWHFRQHOHVWUHSWRFRFRGHOJUXSR% HQYDJLQDRUHFWR (Q DXVHQFLD GH SUHYHQFLyQ DSUR[LPDGDPHQWH HO GH ORV UHFLpQ QDFLGRV VH FRORQL]DUDQFRQ(*%GXUDQWHHOSDUWR\DSUR[LPDGDPHQWHHOGHHOORVGHVDUUROODUDQ XQDHQIHUPHGDGLQYDVLYDSRUHVWUHSWRFRFRGHOJUXSR% /DTXLPLRSUR¿OD[LVFRQSHQLFLOLQD*RDPSLFLOLQDLQWUDSDUWRUHGXFHODFRORQL]DFLyQ GHOUHFLpQQDFLGR\ODVHSVLVSUHFR]VLHVDGPLQLVWUDGDKVRPDVSUHYLRDOSDUWR /DHQIHUPHGDGLQYDVLYDGHOUHFLpQQDFLGRVHGLYLGHHQLQLFLRSUHFR]GHQWURGHORV GtDVOXHJRGHOQDFLPLHQWR\GHLQLFLRWDUGtRHQWUHORV±GtDVGHYLGD /DWUDQVPLVLyQYHUWLFDOH[SOLFDODHQIHUPHGDGGHLQLFLRSUHFR]QRDVtODGHLQLFLRWDUGtR /DWUDQVPLVLyQPDWHUQDH[SOLFDHOGHORVFDVRVGHVHSVLVWDUGtD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 0DQHMR GH OD SUR¿OD[LV VH EDVD HQ OD H[LVWHQFLD GH OD FRORQL]DFLyQ PDWHUQD \ HQ IDFWRUHVGHULHVJRGHWUDQVPLVLyQYHUWLFDO $ 0DGUHFRQIDFWRUHVGHULHVJRGHWUDQVPLVLyQYHUWLFDO/DVVLJXLHQWHVVRQ LQGLFDFLRQHVGHDGPLQLVWUDFLyQGHDQWLELyWLFRVLQWUDSDUWR *HVWDFLyQPHQRUGHVHPDQDV 5RWXUDGHPHPEUDQDVPD\RUGHKRUDV 7HPSHUDWXUDLQWUDSDUWRPD\RUD& TXHHQHOSDUWRSUHYLRKD\DWHQLGRXQKLMRFRQHQIHUPHGDGLQYDVLYDSRU HVWUHSWRFRFRJUXSR% ODSUHVHQFLDGHEDFWHULXULDHQHVWHHPEDUD]R % 6FUHHQLQJPDWHUQRDQWHQDWDO 6HUHFRPLHQGDHOVFUHHQLQJPHGLDQWHHOFXOWLYRGHXQKLVRSDGRUHFWRYDJLQDOHQWUHODV DVHPDQDVGHHGDGJHVWDFLRQDODXQTXHVHSODQHHXQDFHViUHDVLQWUDEDMRGHSDUWR 3UR¿OD[LVDQWLELyWLFDLQWUDSDUWR (VWiLQGLFDGDTXHUHFLEDQSUR¿OD[LVODVPDGUHVFRQVFUHHQLQJSRVLWLYR\ODVTXHWHQJDQ SRUORPHQRVIDFWRUGHULHVJRGHWUDQVPLVLyQYHUWLFDO (ODQWLELyWLFRUHFRPHQGDGRHVODSHQLFLOLQDLY\HVDOWHUQDWLYRODDPSLFLOLQDRFHID]ROLQD 9HUFDS,,FRQWUROSUHQDWDO /DSUR¿OD[LVHVDGHFXDGDFXDQGRUHFLEHHODQWLELyWLFRUHFRPHQGDGRHQIRUPDLYHQHO WUDEDMRGHSDUWRSRUORPHQRVKRUDVDQWHVGHOSDUWR &XDGUR 0$1(-2'(/5(&,e11$&,'26(*Ò1&21',&,Ï11(21$7$/<0$7(51$ 5,(6*2 1(21$7$/ $/72 0(',2 %$-2 0Ë1,02 &21',&,21(60$7(51$6<1(21$7$/(6 (9$/8$&,Ï1<75$7$0,(172 (YDOXDFLyQSDUDFOtQLFDFRPSOHWD 51VLQWRPiWLFRGL¿FXOWDGUHVSLUDWRULDPDOD KHPRJUDPDFRPSOHWRKHPRFXOWLYR SXQFLyQOXPEDU SHUIXVLyQDSQHDRVKRFN &RPHQ]DUWUDWDPLHQWRLQWUDYHQRVR FRQDPSLFLOLQD\JHQWDPLFLQD (YDOXDFLyQ FRPSOHWD KHPRJUDPD 51GHPDGUHVFRQVRVSHFKDGH FRPSOHWR KHPRFXOWLYR SXQFLyQ FRULRDPQLRQLWLVRFRQ¿UPDGDDFXDOTXLHU OXPEDU HGDGJHVWDFLRQDO \ 6LQWHQHUHQFXHQWDVLODPDGUHUHFLELyR QRDQWLELyWLFRVKVKRUDVRPDVSUHYLRDO &RPHQ]DU WUDWDPLHQWR LQWUDYHQRVR FRQDPSLFLOLQD\JHQWDPLFLQD SDUWR (YDOXDFLyQ FRQ KHPRJUDPD \ 3UHWpUPLQRPHQRUDVHPDQDV KHPRFXOWLYR\ 2EVHUYDFLyQFOtQLFDSRUKRUDV 51PD\RURLJXDODVHPDQDVQDFLGRVGH PDGUHV &RORQL]DGDVSRU(*%RWXYLHURQ¿HEUH 2 URWXUDSUHPDWXUDGHPHPEUDQDVKVR PiV 2 +LVWRULDGHXQKLMRSUHYLRFRQHQIHUPHGDG LQYDVLYDSRU(*% 2 1RUHFLELySUR¿OD[LVDGHFXDGDSHQLFLOLQDR DPSLFLOLQDSRUPDVGHKVDQWHVGHOSDUWR (YDOXDFLyQFRQKHPRJUDPD FRPSOHWRKHPRFXOWLYR\ REVHUYDFLyQFOtQLFDSRUKV 2 2EVHUYDFLyQFOtQLFDSRUKV\ KHPRJUDPDV\SURWHtQD&UHDFWLYD VHULDGDVHQODVSULPHUDVKRUDV 6LHVWiVLQWRPiWLFRFRPHQ]DU DQWLELyWLFRVLYOXHJRGHUHDOL]DU KHPRFXOWLYR 51PD\RURLJXDODVHPDQDV DVLQWRPiWLFRFX\DVPDGUHVUHFLELHURQ SUR¿OD[LVDGHFXDGD 2EVHUYDFLyQFOtQLFDGHD KRUDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (1)(50('$''(&+$*$6 /DHQIHUPHGDGGH&KDJDVHVFDXVDGDSRUXQSDUDVLWR7U\SDQRVRPDFUX]L /D WUDQVPLVLyQ FRQJpQLWD HQ ORV SDtVHV HQ GRQGH OD (QIHUPHGDG GH &KDJDV HV HQGpPLFDDIHFWDDOGHORVUHFLpQQDFLGRVGHPDGUHVLQIHFWDGDV 'LDJQyVWLFRQHRQDWDODORVQDFLGRVGHPDGUHVLQIHFWDGDVDQWHVRGXUDQWHHO HPEDUD]R\HQODViUHDVGRQGHODHQIHUPHGDGHVHQGpPLFDORVQDFLGRVGH PDGUHVVLQVFUHHQLQJDQWHQDWDO /D GHWHFFLyQ GH 7 &UX]L HV HO SURFHGLPLHQWR GLDJQyVWLFR HQ OD HQIHUPHGDG FRQJpQLWD ([DPHQ PLFURVFySLFR XQD PXHVWUD GH VDQJUH IUHVFD DQWLFRDJXODGD SDUD OD E~VTXHGDGHSDUiVLWRV $LVODPLHQWR GHO DJHQWH SRU D LQRFXODFLyQ D UDWRQHV \ E FXOWLYRV HQ PHGLRV HVSHFLDOHV (OPpWRGRHVWiQGDUGHGLDJQyVWLFRGHODHQIHUPHGDGFRQJpQLWDHVHOPLFURPpWRGR H[DPHQGHVDQJUHIUHVFDKHSDULQL]DGDVHSXHGHUHDOL]DUHQVDQJUHGHFRUGyQRHQ VDQJUHSHULIpULFDFRQXQDVHQVLELOLGDGGHO /RV QDFLGRV GH PDGUHV FKDJiVLFDV TXH QR IXHURQ GLDJQRVWLFDGRV FRQ LQIHFFLyQ SRU7&UX]LGHEHQUHDOL]DUVHVHURORJtDDQWLFXHUSRV,J*DORVPHVHVGHHGDG XVDQGR ORV PpWRGRV GH ,)$ \ (/,6$ GDGR TXH HQ ORV SULPHURV PHVHV GH YLGD HOHVWXGLRVHUROyJLFRGHWHFWDDQWLFXHUSRV,J*TXHSXHGHQKDEHUVLGRWUDQVPLWLGRV SDVLYDPHQWHSRUODPDGUH &ULWHULRVSDUDFRQVLGHUDUXQFKDJDVFRQJpQLWR UHFLpQQDFLGRGHPDGUHFRQVHURORJtDSRVLWLYDSDUD7&UX]L SDUiVLWRV LGHQWL¿FDGRV DO QDFLPLHQWR R SDUiVLWRV R DQWLFXHUSRV HVSHFt¿FRV QR PDWHUQRVGHWHFWDGRVGHVSXpVGHOQDFLPLHQWRVLHPSUH\FXDQGRQRKD\DH[LVWLGR WUDQVIXVLyQVDQJXtQHDSUHYLDRFRQWDPLQDFLyQYHFWRULDO 7UDWDPLHQWR %HQ]LGD]ROPJNGtDSRUPHVHV 1LIXUWLPR[PJNGtDSRUPHVHV (OVFUHHQLQJGXUDQWHHOHPEDUD]RSHUPLWHODGHWHFFLyQ\HOWUDWDPLHQWRGHODLQIHFFLyQ FRQJpQLWDFRQXQDFXUDFLyQGHFHUFDGHO +,327,52,',602&21*e1,72 'HWHFFLyQVLVWHPiWLFDWUDWDPLHQWR\VHJXLPLHQWRGHKLSRWLURLGLVPRFRQJpQLWR (O+LSRWLURLGLVPR&RQJpQLWR+&DIHFWDDFDGDUHFLpQQDFLGRV&XDQGRQRHV GLDJQRVWLFDGR \ QR HV WUDWDGR HQ IRUPD LQPHGLDWD DIHFWD VHYHUDPHQWH HO GHVDUUROOR SVLFRPRWRU /RV VLJQRV FOtQLFRV GH +& DSDUHFHQ WDUGtDPHQWH HQ ORV SULPHURV PHVHV GH YLGD FXDQGRHOGDxRGHO6LVWHPD1HUYLRVR&HQWUDO\DHVLUUHYHUVLEOH (OPpWRGRGLDJQyVWLFRHVODGHWHUPLQDFLyQGHORVQLYHOHVVpULFRVGH76+\R7HQOD VDQJUHGHOFRUGyQXPELOLFDOROXHJRGHODVSULPHUDVKRUDVGHYLGD(QODVSULPHUDV KRUDV GH YLGD KD\ XQ LQFUHPHQWR ¿VLROyJLFR GH 76+ TXH SURGXFH PXFKRV IDOVRV SRVLWLYRV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD (OWDPL]DMHVLVWHPiWLFRLGHDOUHTXLHUHTXHVHGHWHUPLQHQDPEDVKRUPRQDVHQWRGRVORV UHFLpQQDFLGRV &XDQGRVHRSWDSRUGHWHUPLQDU76+HQWRGRV\7VRORHQORVTXHWLHQHQ76+HOHYDGD QRVHGHWHFWDQORV+&RULJLQDGRVHQXQGHIHFWRFHQWUDOKLSRWiODPRKLSR¿VDULR GHORVFDVRV &XDQGRVHRSWDSRUODGHWHUPLQDFLyQGHVLVWHPiWLFDGH7QRVHGLDJQRVWLFDQIRUPDV OHYHVGH+&FRQ7QRUPDOTXHSHUVLVWHQFRQQLYHOHVDOWRVGH76+\WDPELpQUHTXLHUHQ WUDWDPLHQWR /RVYDORUHVGH76+VXSHULRUHVDP8/UHTXLHUHQXQDQXHYDGHWHUPLQDFLyQLQPHGLDWD /RVYDORUHVGH76+VXSHULRUHVDP8/FRQ7EDMRODPD\RUtDGHORV+&GHEHQVHU WUDWDGRVHQIRUPDLQPHGLDWD ,QIRUPDFLyQDORVSDGUHV ,QLFLDOPHQWHVHGHEHLQIRUPDUDORVSDGUHVTXHHOWUDWDPLHQWRQRGHEHLQWHUUXPSLUVH 181&$\SUREDEOHPHQWHORUHTXLHUDSDUDWRGDODYLGD (O GHVDUUROOR LQWHOHFWXDO QRUPDO GHSHQGH GH OD SUHFRFLGDG GH LQLFLR FRQWLQXLGDG \ VX¿FLHQFLDGHOWUDWDPLHQWRHQORVSULPHURVDxRVGHYLGD 7UDWDPLHQWR 6HFRPLHQ]DGHLQPHGLDWRFRQ/HYRWLUR[LQD7YtDRUDO/DGRVLVHVPFJ.JGtD \VHDMXVWDFRQODGHWHUPLQDFLyQGHORVQLYHOHVGH7\76+/DVGRVLVHQHOUDQJRDOWR PFJ.JGtDORJUDQODQRUPDOL]DFLyQGH7HQGtDV\GH76+HQVHPDQDV /DGRVLVGLDULDGHEHDMXVWDUVHUiSLGDPHQWHFRQHOLQFUHPHQWRGHSHVR\GHDFXHUGR DORVYDORUHVVpULFRVSHULyGLFRVGH7\76+(OYDORUHVSHUDGRGH7OXHJRGHXQD VHPDQDGHWUDWDPLHQWRGHEHVHUHQWUHJGO 6HJXLPLHQWR /DVGHWHUPLQDFLRQHVGH7\76+GHEHQUHSHWLUVHDODVGRVVHPDQDV\DOPHVGHLQLFLDGR HOWUDWDPLHQWR\OXHJRFDGDRPHVHVHQHOSULPHUDxROXHJRSXHGHHVSDFLDUVHFDGD PHVHVKDVWDORVDxRV $1(0,$)$/&,)250( 'HWHFFLyQ6LVWHPiWLFD8QLYHUVDOR6HOHFWLYDGHKHPRJORELQRSDWtDV /D DQHPLD IDOFLIRUPH HV OD KHPRJORELQRSDWtD PiV FRP~Q \ VH GHEH D XQD KHUHQFLD DXWRVyPLFD UHFHVLYD TXH PRGL¿FD OD +HPRJORELQD$ HQ +HPRJORELQD 6 (VWD IRUPD GH+HPRJORELQDHQFRQGLFLRQHVGHGLVPLQXFLyQGHOR[LJHQRPRGL¿FDODIRUPDGHORV HULWURFLWRV\DXPHQWDVXDGKHVLyQDOHQGRWHOLRORTXHIDFLOLWDRFOXVLRQHVYDVFXODUHV/D IUHFXHQFLDHQWUHODSREODFLyQQHJUDHVGHFDGD\HOWLHQHQHOFDUiFWHUGH KHWHURFLJRWRV (QORVSDtVHVHQTXHODSREODFLyQQHJUDHVPD\RUGHOVHGHEHUHDOL]DUWDPL]DMH QHRQDWDOXQLYHUVDOPLHQWUDVTXHVLHVPHQRUGHOSRGUtDUHDOL]DUVHVHOHFWLYDPHQWH HQORVUHFLpQQDFLGRVGHIDPLOLDVGHUD]DQHJUD (OWDPL]DMHVHUHDOL]DSRUHOHFWURIRUHVLVGHOD+HPRJORELQD 6XH[SUHVLyQFOtQLFDFRPLHQ]DHQODSULPHUDLQIDQFLD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (O GLDJQyVWLFR HQ HO SHUtRGR QHRQDWDO HV QHFHVDULR SDUD HO PHMRU PDQHMR SRU VXV IDPLOLDV HO GLDJQyVWLFR SUHFR] GH ODV FULVLV \ ODV LQWHUYHQFLRQHV SUHYHQWLYDV GH ODV FRPSOLFDFLRQHV /D HQIHUPHGDG VH FDUDFWHUL]D SRU DQHPLD KHPROtWLFD FUyQLFD FRQ FULVLV \ HSLVRGLRV GH LVTXHPLD SRU RFOXVLyQ YDVFXODU TXH RFDVLRQDQ QHFURVLV yVHD DYDVFXODU LQIDUWRV HVSLQDOHVGRORURVRVHGHPDGRORURVRGHPDQRV\SLHVGDFWLOLWLVLQIDUWRVHVSOpQLFRV QHIURSDWtDHLQIDUWRVFHUHEUDOHV (Q IRUPD DVRFLDGD SUHVHQWDQ SUHGLVSRVLFLyQ D LQIHFFLRQHV JUDYHV SRU 1HXPRFRFR +HPR¿OXV\6DOPRQHOD /D GHWHFFLyQ SUHFR] SHUPLWH DFRQVHMDU D OD IDPLOLD HQ HO FXLGDGR GHO QLxR \ UHDOL]DU LQWHUYHQFLRQHVSUHYHQWLYDVFRPROD9DFXQDFLyQ$QWL1HXPRFyFLFD$QWLJULSDO\SUR¿OD[LV DQWLELyWLFDFRQ3HQLFLOLQD9HQORVSULPHURVDxRVGHYLGD +,3(5%,/,558%,1(0,$1(21$7$/12+(02/Ë7,&$ 'HWHFFLyQVLVWHPiWLFDXQLYHUVDOGHKLSHUELOLUUXELQHPLD /DLFWHULFLDHVXQKDOOD]JRFRP~QHQHOUHFLpQQDFLGRGHWpUPLQRVDQRPiVIUHFXHQWH HQORVPHQRUHVGHVHPDQDV\HQORVDOLPHQWDGRVDSHFKRH[FOXVLYR /DV LFWHULFLDV KHPROtWLFDV VHYHUDV TXH UHTXLHUHQ H[VDQJXLQHR WUDQVIXVLyQ DSDUHFHQ HQ ODV SULPHUDV KRUDV GH YLGD \ VX PDQHMR GHEH VHU UHDOL]DGR SRU SHUVRQDO HVSHFLDOL]DGR (QODLFWHULFLDGHOUHFLpQQDFLGRVDQRORVYDORUHVGHELOLUUXELQHPLDVHLQWHQVL¿FDQKDVWD HOHUDWRGtDSRUORTXHDQWHVGHODOWDKRVSLWDODULDVHGHEHHYDOXDUHOULHVJRTXHOOHJXH DFLIUDVTXHSRQJDQHQULHVJRGHHQFHIDORSDWtDELOLUUXEtQLFD (OGLDJQyVWLFRGHLQWHQVLGDG\ODYHORFLGDGGHSURJUHVLyQSHUPLWHQLQGLFDUXQFRQWURO PiVHVWULFWR\HOXVRHYHQWXDOGHIRWRWHUDSLDSUHYLRDODOWDKRVSLWDODULD/DYDORUDFLyQ FOtQLFDGHODLQWHQVLGDGGHODLFWHULFLDHVXQPpWRGRSRFRVHQVLEOH/DSURJUHVLyQFpIDOR FDXGDOWDPSRFRSHUPLWHHVWLPDUORVYDORUHVGHULHVJRTXHUHTXLHUHQLQWHUYHQFLyQ &XDQGR OD LFWHULFLD DSDUHFH DQWHV GH ODV KRUDV GH YLGD GHEH UHDOL]DUVH XQD GHWHUPLQDFLyQGHELOLUUXELQHPLDVpULFDRGHODLQWHQVLGDGGHOFRORUDPDULOORGHODSLHO SRULFWHUyPHWUR/DLFWHURPHWUtDFXWiQHDUHDOL]DGDFRQLQVWUXPHQWRVDGHFXDGRVWLHQH XQD H[FHOHQWH VHQVLELOLGDG SHUR EDMD HVSHFL¿FLGDG 3RU HVWH PRWLYR VH XWLOL]D FRPR WDPL]DMHQRLQYDVLYRSDUDUHGXFLUHOQ~PHURGHH[WUDFFLRQHVVDQJXtQHDV/RVQLYHOHV VpULFRVGHELOLUUXELQDVHFRQ¿UPDQHQWRQFHVVRODPHQWHHQORVTXHWLHQHQYDORUHVDOWRV SRULFWHURPHWUtD /RVFULWHULRVGHWUDWDPLHQWR\VHJXLPLHQWRGHEHQDGHFXDUVHDOGLDJQyVWLFRGHFDXVD6L SRUORVDQWHFHGHQWHV\ODDXVHQFLDGHKHPyOLVLVVHGHVFDUWDODSDWRORJtDKHPROtWLFDHO PDQHMRVHUiVHJ~QORVQLYHOHVGHELOLUUXELQHPLDGHDFXHUGRODHGDGHQKRUDVGHYLGD (Q ORV UHFLpQ QDFLGRV FRQ LFWHULFLD HQ ODV SULPHUDV KRUDV HO YDORU LQLFLDO GH ELOLUUXELQHPLDGHEHVHUFRPSDUDGRFRQORVYDORUHVGHUHIHUHQFLDGHODWDEODDGMXQWD HYDOXDQGRDGHPiVODYHORFLGDGGHLQFUHPHQWRKRUDULR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 3 %LOLUUXELQD6pULFDPJGO V K XLPLHQWR %6VHJ KV LHQWR VHJXLP %67F KV XLPLHQWR 7FVHJ )RWRWHUDSLDLQWHQVLYDVLHO LQFUHPHQWRHV!PJGOK 3 3 3 6HJXLPLHQWRFOtQLFR RLFWHURPHWUtDFXWiQHD HQKRUDV 9LJLOHLFWHULFLDFDGDKRUDV (GDG3RVWQDWDOKRUDVVHJ~Q9LQRG%KXWDQLHWDO )LJXUD9DORUHVGHUHIHUHQFLDSDUDODSUHYHQFLyQGHOHVWDGtRDJXGRGHODHQFHIDORSDWtD ELOLUUXEtQLFD6HJ~Q9LQRG%KXWDQLHWDO &RQGXFWDVXJHULGDVHJ~QYDORUHVLQLFLDOHVHQUHFLpQQDFLGRVGHWpUPLQRVLQ HQIHUPHGDGKHPROtWLFD x!S 6HLQLFLD)RWRWHUDSLDLQWHQVLYD 0DQWHQLHQGRODODFWDQFLDH[FOXVLYD xS 6LHOLQFUHPHQWRHVPD\RUGHPJG/KRUD VHLQLFLD)RWRWHUDSLD,QWHQVLYD xS 6HRWRUJDHODOWD FRQFRQWUROGHQLYHOHVVpULFRVGHELOLUUXELQHPLDRLFWHURPHWUtD FXWiQHDHQKRUDV xS 6HRWRUJDHODOWDFRQHYDOXDFLyQFOtQLFDHQKRUDV &XDQGRVHGLVSRQHGHOLQVWUXPHQWRSDUDUHDOL]DULFWHURPHWUtDFXWiQHDHV UHFRPHQGDEOHTXHVHUHDOLFHXQDGHWHUPLQDFLyQVLVWHPiWLFDDWRGRVORVUHFLpQ QDFLGRVHQHOPRPHQWRGHODOWDSURFHGLHQGRFRQORVFULWHULRVDQWHULRUHV &XDGUR&ULWHULRVVXJHULGRVSDUDWRPDUGHFLVLRQHVDOOPRPHQWRGHGHFLGLUHODOWD KRVSLWDODULD Edad en horas en el momento de la determinación de bilirrubinemia 24 horas 48 horas Si el valor es igual o menor controlar en: 3-5 días Mantener hospitalizado si el valor es mayor que Si los valores están dentro de este rango controlar en: PDVGH 0RGL¿FDGDGH9LQRG%KXWDQLHWDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &XDQGRSUHYLRDODOWDKRVSLWDODULDVHUHDOL]DHOWDPL]DMHDWRGRVORVUHFLpQQDFLGRV\ VH VLJXHQ ORV FULWHULRV VXJHULGRV VH ORJUD GLVPLQXLU VLJQL¿FDWLYDPHQWH OD IUHFXHQFLD GH UHLQJUHVRV \ ORV YDORUHV H[FHVLYDPHQWH DOWRV GH ELOLUUXELQHPLD HQ UHFLpQ QDFLGRV HQDWHQFLyQDPEXODWRULD/DWDVDGHUHDGPLVLyQQHRQDWDOVHUHGXFHDHOXVRGH IRWRWHUDSLDHVFHUFDQR\ODWDVDGHH[VDQJXLQHRWUDQVIXVLyQPHQRUD 6L ORV YDORUHV HVWiQ GHQWUR GHO UDQJR GH IRWRWHUDSLD OD PLVPD VH GHEH KDFHU HQ HO KRVSLWDOMXQWRDVXPDGUH\PDQWHQLHQGRODODFWDQFLDH[FOXVLYDDOVHQR 'e),&,7$8',7,926(9(52 (O Gp¿FLW DXGLWLYR ELODWHUDO SHUPDQHQWH \ VHYHUR GH PiV GH GHFLEHOHV GH RULJHQ FRQJpQLWRDIHFWDDFDGDPLOQDFLGRV/DPLWDGGHHVWRVQLxRVQRWLHQHQIDFWRUHVGH ULHVJR\HVLPSRVLEOHUHFRQRFHUORVFOtQLFDPHQWH +DELWXDOPHQWH ORV SDGUHV \ ORV VHUYLFLRV GH VDOXG GHWHFWDQ OD VRUGHUD FRQJpQLWD HQ IRUPDPX\WDUGtDOXHJRGHOHUDxRGHHGDG ([LVWHQ PpWRGRV HOHFWUR¿VLROyJLFRV TXH SHUPLWHQ GHWHFWDU HVWH Gp¿FLW HQ HO UHFLpQ QDFLGR PXFKR DQWHV TXH ORV PpWRGRV FOtQLFRV H LQLFLDU OD UHKDELOLWDFLyQ VHQVRULDO WHPSUDQDPHQWH/DD\XGDDXGLWLYDDXGtIRQRVLQLFLDGDHQORVSULPHURVPHVHVGH YLGDPHMRUDVLJQL¿FDWLYDPHQWHHOGHVDUUROORYHUEDOGHHVWRVQLxRVFRPSDUDGRVFRQORV TXHVRQGHWHFWDGRVGHVSXpVGHORVSULPHURVPHVHVGHYLGD /DGHWHFFLyQVLVWHPiWLFDGHO'p¿FLW$XGLWLYR&RQJpQLWR'$&HVHOSULPHUSDVRRSRUWXQR H LPSUHVFLQGLEOH HQ XQ 3URJUDPD GH $VLVWHQFLD ,QWHJUDO SXHV SHUPLWH VX FDSWDFLyQ SUHFR]\IDFLOLWDODUHKDELOLWDFLyQHQIRUPDUHOHYDQWH (Q DTXHOORV FRQWH[WRV HQ ORV TXH VH SXHGH LQFRUSRUDU UDFLRQDOPHQWH HO WDPL]DMH GHO '$& VH SRGUi SRQHU HQ PDUFKD OD LQYHVWLJDFLyQ GH ODV HPLVLRQHV RWRDF~VWLFDV FRFOHDUHV\ORVSRWHQFLDOHVDXGLWLYRVHYRFDGRVGHWURQFR 2EMHWLYR $FWLYLGDG 3UHYHQLUOD2)7$/0,$*212&2&&,&$ ,QVWLODUDQWLPLFURELDQRVHQODVFRQMXQWLYDVDOQDFHU (QHOPRPHQWRGHOSDUWRYDJLQDOHOUHFLpQQDFLGRSXHGHVHULQRFXODGRFRQ1HLVVHULD *RQRUUHD*RQRFRFRSUHVHQWHHQORVJHQLWDOHVGHVXPDGUHSRUWDGRUDGHXQDFHUYLFLWLV QRWUDWDGD /DIRUPDPiVVHYHUDGHPDQLIHVWDFLyQGHODLQIHFFLyQSRU1*HQHOUHFLpQQDFLGR HVOD2IWDOPtD1HRQDWDO\ODVHSVLVTXHSXHGHLQFOXLUDUWULWLV\PHQLQJLWLV/DVIRUPDV PHQRV VHYHUDV LQFOX\HQ OD ULQLWLV YDJLQLWLV XUHWULWLV /D LQIHFFLyQ RFXODU FRPLHQ]D KDELWXDOPHQWH HQWUH \ GtDV OXHJR GHO SDUWR \ SXHGH FRPSOLFDUVH FRQ SHUIRUDFLyQ RFXODU\FHJXHUD (OGLDJQyVWLFRVHVRVSHFKDSRUHOKDOOD]JRGHGLSORFRFRV*UDPQHJDWLYRVHQHOH[XGDGR FRQMXQWLYDO6HFRQ¿UPDSRUFXOWLYREDFWHULROyJLFR 3UHYHQFLyQ /D SUiFWLFD GH ³VH[R VHJXUR´ HO GLDJQyVWLFR \ WUDWDPLHQWR DQWHQDWDO RSRUWXQRV HV OD IRUPDGHSUHYHQLUHVWDLQIHFFLyQQHRQDWDO 3UR¿OD[LV /DLQVWLODFLyQGHDQWLPLFURELDQRVLQPHGLDWDDOQDFLPLHQWRSRUYtDYDJLQDORFHViUHDHV XQDSUiFWLFDVHJXUDVLPSOH\GHEDMRFRVWR /DVRSFLRQHVVRQ 6ROXFLyQUHFLHQWHPHQWHSUHSDUDGDGH1LWUDWRGH3ODWDDO (VWHPpWRGROOHYDHOQRPEUHGH&UHGpSRUVHUGLFKRPpGLFRTXLHQORDSOLFyHQORVRMRV GHORVUHFLpQQDFLGRVSRUSULPHUDYH]HQHO6LJOR;,;OXHJRGHKDEHUVLGRXVDGRSRU GpFDGDVHQHOWUDWDPLHQWRGHODVXUHWULWLVJRQRFRFyFFLFDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 8QJHQWRRIWiOPLFRGH(ULWURPLFLQDDORGH7HWUDFLFOLQDDOHQXQDVROD DSOLFDFLyQHQHOPRPHQWRGHOQDFLPLHQWR (OWUDWDPLHQWRGHODRIWDOPtDHV&HIWULD[RQHPJ.JQRH[FHGLHQGRPJ DGPLQLVWUDGRSRU,9R,0HQXQDGRVLV~QLFD 2EMHWLYR $FWLYLGDG 3UHYHQLUODHQIHUPHGDGKHPRUUiJLFDGHOUpFLHQQDFLGR $GPLQLVWUDU9LWDPLQD. /D (QIHUPHGDG +HPRUUiJLFD GHO 5HFLpQ 1DFLGR HV XQD HQWLGDG FOtQLFD FOiVLFD FDUDFWHUL]DGDSRUKHPRUUDJLDHVSRQWiQHDLQHVSHUDGDHQXQUHFLpQQDFLGRGHDVSHFWR VDOXGDEOH6XIRUPDSUHFR]RFXUUHHQORVSULPHURVGtDV\WLHQHXQLQFLGHQFLDQDWXUDO GH\HQWUHORVUHFLpQQDFLGRV/DIRUPDWDUGtDHQWUH\VHPDQDVRFXUUH PHQRV IUHFXHQWHPHQWH HQWUH \ SRU QDFLGRV SHUR VH SUHVHQWD FRPR KHPRUUDJLDV~ELWDLQWUDFUDQHDQDRFDVLRQDQGRPXHUWHRVHYHUDLQFDSDFLGDG 6XSULQFLSDOtQGLFHGHKLSRFRDJXODELOLGDGHVODGLVPLQXFLyQGHOWLHPSRGHSURWURPELQD /DLQWHUYHQFLyQSUHIHULGDHVODDGPLQLVWUDFLyQHQHOPRPHQWRGHQDFHUGHXQDGRVLV ~QLFD GH PJ ,0 GH 9LWDPLQD . (VWD GRVLV HV VX¿FLHQWH SDUD SUHYHQLU OD (QIHUPHGDG+HPRUUiJLFDGHO5HFLpQ1DFLGRTXHRFXUUHHQORVSULPHURVGtDVGHYLGD /DDGPLQLVWUDFLyQGHXQDGRVLVRUDOGHPJPHMRUDORVtQGLFHVGHFRDJXODFLyQGXUDQWH ORVSULPHURVGtDVGHYLGD6LQHPEDUJRQRH[LVWHQHVWXGLRVFOtQLFRVTXHGHPXHVWUHQ OD H¿FDFLD GH OD DGPLQLVWUDFLyQ GH XQR R YDULDV GRVLV RUDOHV HQ OD SUHYHQFLyQ GH OD +HPRUUDJLD1HRQDWDO 2EMHWLYR ,QLFLDU\PDQWHQHUODFWDQFLDPDWHUQDH[LWRVD $FWLYLGDG 1RVHSDUDUDOUHFLpQQDFLGR\VXPDGUH\IDFLOLWDUHODSR\RIDPLOLDU $OLPHQWDUDOLEUHGHPDQGD\QRGDUELEHURQHV 5HJLVWUDUODDOLPHQWDFLyQDODOWDGHOD0DWHUQLGDG 1RVHSDUDUDOUHFLpQQDFLGR\VXPDGUH\IDFLOLWDUHODSR\RIDPLOLDU 'HVGHHOPRPHQWRHQTXHQDFHHOUHFLpQQDFLGR\VXPDGUHWLHQHQHOGHUHFKRDQRVHU VHSDUDGRV7RGDODDWHQFLyQGHEHUHDOL]DUVHSURFXUDQGRUHGXFLUDOPtQLPRODVLQVWDQFLDV HQODVTXHODDWHQFLyQGHFDGDXQRGHHOORVQRSXHGDKDFHUVHMXQWRDORWUR (VWD SUiFWLFD VH FRQRFH GHVGH KDFH DxRV FRPR $ORMDPLHQWR&RQMXQWR 8QDLQVWLWXFLyQDVLVWHQFLDOUHVSHWXRVDGHORVGHUHFKRVGHOD IDPLOLDGHEHDVHJXUDUTXHODPDGUHWHQJDHODSR\RIDPLOLDU Figura 113. Fragmento HCP. TXHVROLFLWHSDUDSRGHUFXLGDUDVXKLMR Referencia del RN $OQDFHUXQDYH]FHVDGDODFLUFXODFLyQXPEtOLFRSODFHQWDULD\FRODSVDGRHOFRUGyQHQORV SULPHURVPLQXWRVGHYLGDVHHVWDEOHFHODUHVSLUDFLyQUHJXODU/XHJRGXUDQWHODSULPHUD KRUDGHYLGDHOUHFLpQQDFLGRPDQWLHQHXQOODPDWLYRHVWDGRGHYLJLOLDDOHUWDHQHOTXH FRQIUHFXHQFLDH[SORUDHOVHQRPDWHUQRHLQLFLDORVSULPHURVLQWHQWRVGHVXFFLyQ (OFRQIRUWGHODPDGUHORVDSR\RVIDPLOLDUHV\GHOSHUVRQDOVRQLPSUHVFLQGLEOHVSDUDHO LQLFLRH[LWRVRGHODODFWDQFLD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $OLPHQWDUDOLEUHGHPDQGD\QRGDUELEHURQHV (O FRPLHQ]R SUHFR] GH OD DOLPHQWDFLyQ DO VHQR OD GLVSRQLELOLGDG FRQWLQXD GH OD RIHUWD PDWHUQD OLEUH GHPDQGD \ OD QR DGPLQLVWUDFLyQ GH ELEHURQHV FRQWULEX\HQ DO HVWDEOHFLPLHQWR\PDQWHQLPLHQWRGHODODFWDQFLD 5HJLVWUDUODDOLPHQWDFLyQDODOWDGHOD0DWHUQLGDG $ODOWDGHEHUHJLVWUDUVHHOWLSRGHDOLPHQWDFLyQUHFLELGDSRUHOUHFLpQ QDFLGR HQ ODV ~OWLPDV KRUDV &XDQGR VH UHJLVWUD /DFWDQFLD ([FOXVLYD VLJQL¿FD TXH HQ HVDV KRUDV QR KD UHFLELGR QLQJ~Q RWURDOLPHQWRTXHOHFKHGHVXSURSLDPDGUH Figura 114. Fragmento HCP. Alimentación al alta 2EMHWLYR $FWLYLGDG /D SUHFLVLyQ GH HVWH GDWR VLUYH SDUD PRQLWRUHDU OD FDOLGDG GH OD SUiFWLFD GH OD ODFWDQFLD QDWXUDO HQ OD LQVWLWXFLyQ \ FRUUHJLU ODV VLWXDFLRQHVTXHLQWHU¿HUHQFRQXQDEXHQDSUiFWLFD 3UHYHQLUOD7XEHUFXORVLV*UDYHHQHOODFWDQWH 9DFXQDFLyQ%&*DOQDFHU Figura 115. Fragmento HCP. Vacunación BCG /DUHGXFFLyQGHODWXEHUFXORVLVHQODSREODFLyQHVHOUHVXOWDGRGH XQDVHULHGHPHGLGDVGHKLJLHQHSUHYHQWLYDVGHGHWHFFLyQSUHFR] GHFDVRV\VXWUDWDPLHQWR /DYDFXQDFLyQ%&*%DFLORGH&DOPHWWH\*XHULQDOQDFHUHVSDUWHGHHVHFRQMXQWR \KDVLGRDGRSWDGD\XQLYHUVDOPHQWHDGPLQLVWUDGDDWRGRVORVUHFLpQQDFLGRVGHVGH KDFHPDVGHDxRV,QLFLDOPHQWHVHKL]RVRORDORVQDFLGRVHQFRQWDFWRFRQIDPLOLDUHV WXEHUFXORVRV /DYDFXQD%&*FRQVLVWHHQODLQ\HFFLyQ0\FREDWHULXP%RULVSDUDLQGXFLUSURWHFFLyQ FRQWUDODLQIHFFLyQSRU0WXEHUFXORVLV /RV UHFLpQ QDFLGRV ODFWDQWHV \ QLxRV PHQRUHV VRQ H[WUHPDGDPHQWH VXVFHSWLEOHV DO FRQWDJLRGH7%& /DDGPLQLVWUDFLyQGHOD%&*SURWHJHHQPDVGHXQDOUHFLpQQDFLGRYDFXQDGR VLQ LQÀXLU HQ OD FDGHQD GH WUDQVPLVLyQ /D SURWHFFLyQ WDPELpQ HV LPSRUWDQWH SXHV VL ELHQQRLQPXQL]DFRQWUDFXDOTXLHUIRUPDGHWXEHUFXORVLVSUHYLHQHODVIRUPDVJUDYHV PHQLQJLWLV\WXEHUFXORVLVGLVHPLQDGDRPLOLDU 3XHGH SURGXFLU XQD UHDFFLyQ SDSXODU ORFDO H KLSHUWHUPLD \ FRQ PHQRV IUHFXHQFLD OLQIDGHQLWLV\DEVFHVRORFDO 2EMHWLYR $FWLYLGDG 3UHYHQLUODPXHUWHV~ELWDGHOODFWDQWH &RORFDUDOUHFLpQQDFLGR%2&$$55,%$SDUDGRUPLU /DPXHUWHV~ELWDGHOODFWDQWHRFXUUHHQXQQLxRVDQRGXUDQWHHOVXHxRVLQXQDHQIHUPHGDG DJXGDTXHODMXVWL¿TXH\VXIUHFXHQFLDHVHQWUH\QLxRVFDGDPLOQDFLGRVYLYRV 'HVGHKDFHPiVGHXQDGpFDGDYDULRVSDtVHVKDQLPSOHPHQWDGRSUiFWLFDVGHPDQHMR GHO QLxR \ GHO DPELHQWH TXH KDQ GLVPLQXLGR PiV GH XQ OD IUHFXHQFLD GH PXHUWH V~ELWD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 'XUDQWHHOFRQWURODQWHQDWDOODLQWHUYHQFLyQSUHYHQWLYDPiVLPSRUWDQWHHVORJUDUTXHOD PDGUHDEDQGRQHHOKiELWRGHIXPDU\TXHQDGLHIXPHGHQWURGHVXKRJDU(OKDOOD]JR GHXQDPD\RUIUHFXHQFLDGHSRVWXUDERFDDEDMRGXUDQWHHOVXHxRHQORVODFWDQWHVTXH IDOOHFLHURQ GH PXHUWH V~ELWD FRPSDUDGR FRQ ODFWDQWHV VLPLODUHV HQ HGDG \ PRGR GH FULDQ]DTXHQRIDOOHFLHURQHQVXYHFLQGDULRHQODPLVPDpSRFDLPSXOVyODSUiFWLFDGH '250,5%2&$$55,%$SDUDSUHYHQLUODPXHUWHV~ELWD 0LHQWUDV OD PDGUH \ VX EHEp HVWiQ KRVSLWDOL]DGRV LQPHGLDWDPHQWHGHVSXpVGHOSDUWRHVXQEXHQPRPHQWRSDUD YHUL¿FDUVLODPDGUHDFXHVWDDVXEHEpERFDDUULED\DFRQVHMDU VREUHODPHMRUSUiFWLFD %RFD DUULED Figura 116. Fragmento HCP. Posición del RN en la cuna 7DPELpQH[LVWHQRWURVIDFWRUHVSURWHFWRUHVFRPR x(YLWDUHOH[FHVRGHDEULJR\ODWHPSHUDWXUDDPELHQWDOPD\RUD& x(YLWDUORVFROFKRQHVGHPDVLDGREODQGRVODVDOPRKDGDV\ORVFREHUWRUHV YROXPLQRVRV3UH¿ULHQGRFROFKRQHV¿UPHV\XQRRGRVFREHUWRUHV¿QRV x(YLWDUTXHVHGXHUPDHQHOPLVPRVLOOyQTXHORVSDGUHVHVWiQPLUDQGRODWHOHYLVLyQ /DODFWDQFLDPDWHUQDHVXQIDFWRUSURWHFWRULPSRUWDQWHSUREDEOHPHQWHGHELGRDOVXHxR PDVOLJHURTXHRFXUUHGXUDQWHODQRFKH\ODIUHFXHQFLDPD\RUGHYHFHVTXHODPDGUHOR DWLHQGHSDUDDOLPHQWDUOR (VSUREDEOHTXHHOFKXSHWHWHQJDXQHIHFWRSURWHFWRUSHURHVWHFRQFHSWRQRHVDFHSWDGR XQLYHUVDOPHQWH6LQHPEDUJRH[LVWHQVX¿FLHQWHVHYLGHQFLDVSDUDQRGHVDFRQVHMDUVX XVRVLORVSDGUHVSLGHQRSLQLyQDOHTXLSRGHVDOXG 2EMHWLYR 'LVPLQXLUORVULHVJRVGHORVQDFLGRVGHDVHPDQDVSUHWpUPLQR WDUGtRV\ORVGHDVHPDQDVWpUPLQRSUHFRFHV $FWLYLGDG $XPHQWDU OD YLJLODQFLD HQ HO SHUtRGR GH DGDSWDFLyQ PLHQWUDV SHUPDQHFHQHQVDODFRQVXVPDGUHV (O DJUXSDPLHQWR FRQYHQFLRQDO GH ORV UHFLpQ QDFLGRV VHJ~Q VX (GDG *HVWDFLRQDO GLIHUHQFLDWUHVJUXSRV3UHWHUPLQRKDVWDODVVHPDQDV7HUPLQRGHVGHODVKDVWD ODV\3RVWHUPLQRPD\RUHVGHVHPDQDV /D GHFLVLyQ GH OD RSRUWXQLGDG GH QDFLPLHQWR HV XQ KHFKR FOtQLFR IUHFXHQWH HQ OD REVWHWULFLDPRGHUQD(VWRVQDFLPLHQWRVVHOHFWLYRVHVWiQLQFUHPHQWDQGRHOQ~PHURGH UHFLpQQDFLGRVHQHGDGHVLQIHULRUHVDODVTXHRFXUULUtDQHVSRQWiQHDPHQWH /DGHFLVLyQGHLQWHUUXPSLUGHVSXpVGHODVVHPDQDVSRUHOPD\RUULHVJRGHPXHUWH IHWDOHVWiSOHQDPHQWHMXVWL¿FDGD 8QQ~PHURVLJQL¿FDWLYRGHQDFLPLHQWRVVHSURGXFHQOXHJRGHODVVHPDQDV\DQWHV GHO WpUPLQR (VWRV UHFLpQ QDFLGRV VH GLIHUHQFLDQ GH ORV GH PHQRU HGDG JHVWDFLRQDO SXHV IUHFXHQWHPHQWH WLHQHQ FRPSOHWD OD PDGXUDFLyQ SXOPRQDU \ SXHGHQ LQLFLDU OD DOLPHQWDFLyQDOVHQR (O PD\RU Q~PHUR GH QDFLPLHQWRV VHOHFWLYRV FRPLHQ]D D SDUWLU GH ODV VHPDQDV \ VHGLIHUHQFLDQGHORVGHPHQRUHGDGJHVWDFLRQDOSXHV\DKDQORJUDGRODPDGXUDFLyQ SXOPRQDU\ODVXFFLyQGHJOXFLyQTXHVRQODVIXQFLRQHVFHQWUDOHVSDUDVXDXWRQRPtD 6LQHPEDUJRORVQDFLPLHQWRVVHOHFWLYRVHQWUHODV\VHPDQDVSUHVHQWDQPD\RU PRUELOLGDGDVRFLDGDSRUWUDVWRUQRVGHODDGDSWDFLyQ/DPRUELOLGDGDXPHQWDFRQFDGD VHPDQDGHHGDGJHVWDFLRQDOTXHVHDQWLFLSDHOQDFLPLHQWR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $SDUWLUGHODVVHPDQDV\KDVWDODVVHPDQDVHVHOSHUtRGRGHPHQRUPRUELOLGDG 'HELGR D TXH ODV VHPDQDV VH FRQVLGHUDQ SRU FRQYHQFLyQ FRPR HO LQLFLR GHO SHUtRGRGHWpUPLQRHVWHJUXSRGHQDFLPLHQWRVVHOHFWLYRVVHKDGLYLGLGRHQGRVJUXSRV GHQRPLQDGRV3UHWpUPLQRVWDUGtRVFXDQGRQDFHQGHVGHODVVHPDQDVKDVWDODV VHPDQDV\7pUPLQRVSUHFRFHVDODV\VHPDQDV 3UHWpUPLQRVWDUGtRV /RVSUHWpUPLQRVWDUGtRVVHGH¿QHQFRPRORVQDFLGRVGHVHPDQDVGtDKDVWD VHPDQDVGtDV\FRQVWLWX\HQHOGHWRGRVORVSUHWpUPLQRVVLHQGRHOGHORV QDFLGRVYLYRVFXDQGRODWDVDGHSUHWHUPLQRHV /RVIDFWRUHVTXHKDQVLGRLPSOLFDGRVHQHODXPHQWRGHORVSUHWpUPLQRVWDUGtRVVRQ 0HMRUDPLHQWR GH GLDJQyVWLFR SUHQDWDO GH FRPSOLFDFLRQHV IHWDOHV R PDWHUQDV DXPHQWDHOLQWHUYHQFLRQLVPRREVWpWULFR ,QH[DFWLWXGGHOFiOFXORGHHGDGJHVWDFLRQDO $XPHQWRGHORVHPEDUD]RVP~OWLSOHVHQSDUWHH[SOLFDGDSRUHODXPHQWRGHOD UHSURGXFFLyQDVLVWLGD /DFUHHQFLDHUUyQHDTXHODPDGXUH]FRPSOHWDVHDOFDQ]DDODVVHPDQDV $XPHQWRGHODFHViUHDVHOHFWLYDV 6L ELHQ OD PD\RUtD GH HVWRV UHFLpQ QDFLGRV WLHQHQ PDGXUDFLyQ SXOPRQDU FRPSOHWD \ IUHFXHQWHPHQWHSXHGHQDOLPHQWDUVHDOVHQRHQVDODFRQVXVPDGUHVQRRFXUUHHQHO \SRUHVHPRWLYRWLHQHQPD\RUPRUWDOLGDG\PRUELOLGDGTXHDHGDGHVPD\RUHV /DPRUWDOLGDGQHRQDWDODGtDVGHORVQDFLGRVGHDVHPDQDVHVYHFHV PD\RU D ORV WpUPLQRV DO LJXDO TXH OD PRUWDOLGDG LQIDQWLO GH D GtDV GH HGDG FURQROyJLFDHVYHFHVPD\RUTXHORVQDFLGRVGHWpUPLQR (QFRPSDUDFLyQFRQORVQDFLGRVGHWpUPLQRWLHQHQPDVGL¿FXOWDGHVSDUDDOLPHQWDUVH YHUVXV KLSRJOLFHPLD YHUVXV LFWHULFLD YHUVXV LQHVWDELOLGDG WpUPLFD YHUVXV DSQHD YHUVXV PHQRV GH \ 6'5 YHUVXV7DPELpQSUHVHQWDQYHFHVPiVSUREDELOLGDGGHWHQHURPiV FRPSOLFDFLRQHVGXUDQWHODLQWHUQDFLyQ&XDQGRHODOWDHVRWRUJDGDDQWHVGHORVGtDV GHYLGDVXUHKRVSLWDOL]DFLyQHVDYHFHVPiVIUHFXHQWHGHELGRDLFWHULFLD VRVSHFKDGHLQIHFFLyQ\GL¿FXOWDGSDUDDOLPHQWDUVH 7pUPLQRSUHFR] (OUHFLpQQDFLGRGHWpUPLQRSUHFR]VHGH¿QHFRPRORVQDFLGRVHQWUHODVVHPDQDV GtD\VHPDQDV\GtDV6RQGHORVQDFLGRVYLYRV (VWH JUXSR WLHQHQ PD\RU LQFLGHQFLD GH GL¿FXOWDGHV HQ OD DGDSWDFLyQ UHVSLUDWRULDV FRPR HV OD WDTXLSQHD WUDQVLWRULD GHO UHFLpQ QDFLGR VtQGURPH GH GLVWUHVV UHVSLUDWRULR \ODKLSHUWHQVLyQSXOPRQDUSHUVLVWHQWH/RVQDFLGRVDODVVHPDQDVWLHQHQYHFHV PiVVtQGURPHGHGLVWUHVVUHVSLUDWRULRTXHORVQDFLGRVDODVVHPDQDV\YHFHV PiVIUHFXHQWHTXHORVQDFLGRVDODDVHPDQDVGHHGDGJHVWDFLRQDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD &XDGUR 6LQGURPHGH'L¿FXOWDG5HVSLUDWRULDHQWUHODV\VHPDQDVGH(GDG*HVWDFLRQDO (GDGJHVWDFLRQDO VHPDQDV ,QFLGHQFLDGH6'5 SRUQDFLGRVYLYRV 'DWRVH[WUDtGRVGH0DGDU-5LFKPRQG6+H\(VXUIDFWDQWGH¿FLHQWUHVSLUDWRU\GLVWUHVVDIWHU HOHFWLYHGHOLYHU\DWWHUP$FWD3DHGLDWU /DFHViUHDHVXQLPSRUWDQWHIDFWRUGHULHVJRLQGHSHQGLHQWHTXHVHDVRFLDDODXPHQWRGH ODPRUELOLGDGUHVSLUDWRULDHQORVQDFLGRVGHWpUPLQR &XDGUR ,QFLGHQFLDGHPRUELOLGDGUHVSLUDWRULDHQSUHWpUPLQRWDUGtR\UHFLpQQDFLGRGHWpUPLQR VHJ~QYLDGHSDUWR &HViUHD Q 3DUWRYDJLQDO Q 7RWDO Q 2GGVUDWLR &, SDUDFHViUHD 1DFLGRVYLYRV 7DTXLSQHDWUDQVLWRULD 6'5 +LSHUWHQVLyQSXOPRQDU 7RWDO ([WUDtGR GH /HYLQH (0 *KDL 9 %DUWRQ -- 6WURP &0 0RGH RI GHOLYHU\ DQG ULVN RI UHVSLUDWRU\GLVHDVHVLQQHZERUQV2EVWHW*\QHFRO0DU &XLGDGRVMXQWRDVXPDGUH /RV UHFLpQ QDFLGRV HQWUH ODV \ VHPDQDV UHTXLHUHQ PD\RUHV FXLGDGRV GH HQIHUPHUtDSHURVHEHQH¿FLDQGHHVWDUUiSLGDPHQWHWRGRHOGtDFRQVXVPDGUHVD~Q FXDQGRUHTXLHUDQIRWRWHUDSLDFRQWUROHVGHJOLFHPLDSHULyGLFRVRFRQWUROHVGLDULRVGHSHVR /DLPSOHPHQWDFLyQGHHVWRVFXLGDGRVGHHQIHUPHUtDMXQWRDODPDGUHSDUDHVWHJUXSR GH UHFLpQ QDFLGRV HV WDPELpQ EHQH¿FLRVD SDUD ORV TXH KDELHQGR QDFLGR D HGDGHV JHVWDFLRQDOHV PHQRUHV GH VHPDQDV \D KDQ VXSHUDGR ORV SUREOHPDV LQLFLDOHV GH DGDSWDFLyQ&XLGDGR,QWHQVLYR\SRUVXHGDGSRVWQDWDOSHVR\PDGXUDFLyQVHEHQH¿FLDQ VLSDVDQD6DODVGH,QWHUQDFLyQFRQVXVPDGUHV &RQWUROGHLQIHFFLRQHV 8Q REMHWLYR HVHQFLDO HV OD SUHYHQFLyQ GH LQIHFFLRQHV HQ HO UHFLpQ QDFLGR VDQR \ GH WpUPLQR \ SDUWLFXODUPHQWH HQ HO UHFLpQ QDFLGR TXH UHTXLHUD LQWHUYHQFLRQHV \ SUiFWLFDV LQYDVLYDVGHSHQGLHQGRGHODVFRPSOLFDFLRQHVTXHVHSUHVHQWHQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR (Q PXFKRV FDVRV ODV LQIHFFLRQHV QRVRFRPLDOHV VRQ VXEHVWLPDGDV GHELGR D TXH HQ PXFKRVFDVRVORVQLxRVVRQGDGRVGHDOWDDQWHVGHODDSDULFLyQGHORVVtQWRPDV (VWDV VLWXDFLRQHV VRQ UHOHYDQWHV \ SRWHQFLDOPHQWH PiV IUHFXHQWHV HQ XQLGDGHV GH QHRQDWRORJtD\GHFXLGDGRVLQWHQVLYRVSXGLHQGRYDULDUVXIUHFXHQFLD\FDUDFWHUtVWLFDVFRQ ODVXQLGDGHVGHFXLGDGR\VXFRPSOHMLGDGFRQORVKiELWRVGHSUHVFULSFLyQ\UHFXUUHQFLD DORVSURFHGLPLHQWRVLQYDVLYRV\GHSHQGLHQGRSDUWLFXODUPHQWHGHODVFDUDFWHUtVWLFDV\ FDOLGDGGHDWHQFLyQ /D SUHYHQFLyQ GH ODV LQIHFFLRQHV LPSOLFD XQ SURFHVR FRQWLQXR TXH DEDUFD GHVGH OD JHVWDFLyQ KDVWD HO FXLGDGR GHO QLxR HQ HO KRJDU XQD YH] GDGR GH DOWD ,PSOLFD OD SUHYHQFLyQ GH OD SUHPDWXUH] OD SUHYHQFLyQ GLDJQyVWLFR \ WUDWDPLHQWR RSRUWXQR GH LQIHFFLRQHVGXUDQWHODJHVWDFLyQ/DDGRSFLyQGHFRUUHFWDVPHGLGDVGHKLJLHQHSRUSDUWH GHWRGRHOSHUVRQDOHQFRQWDFWRFRQHOUHFLpQQDFLGRDVtFRPRODPDGUH\ODVSHUVRQDVHQ FRQWDFWRFRQpO(OLQLFLRSUHFR]GHODODFWDQFLDPDWHUQDFRQVWLWX\HFODUDPHQWHXQIDFWRU SURWHFWRUFRQWUDODVLQIHFFLRQHVHQHOUHFLpQQDFLGR(VWRVDVSHFWRVGHEHQVHUWUDEDMDGRV HQODVLQVWLWXFLRQHV\GHEHQIRUPDUSDUWHLPSRUWDQWHGHORVFRQVHMRVEULQGDGRVDODPDGUH DOPRPHQWRGHODOWD(QHOFDVRGHUHTXHULUVHORVSURFHGLPLHQWRVLQYDVLYRVGHEHQVHU OLPLWDGRVHQVXXVR\VXGXUDFLyQ $OWD &RQGLFLRQHVHLQGLFDFLRQHVSDUDHODOWD (VDFRQVHMDEOHTXHHOQLxR\VXPDGUHSHUPDQH]FDQHQODLQVWLWXFLyQGXUDQWHDOPHQRV KRUDVGHPRGRGHSRGHUYDORUDUODHYROXFLyQHQDPERVSHUPLWHGHVFDUWDUSDWRORJtDV HYDOXDU HO LQLFLR \ WpFQLFD GH OD ODFWDQFLD PDWHUQD \ EULQGDU DSR\R H LQIRUPDFLyQ D OD PDGUH\DOJUXSRIDPLOLDU /RVDVSHFWRVFHQWUDOHVTXHGHEHQDERUGDUVHDOPRPHQWRGHODOWDLQYROXFUDQ $OLPHQWDFLyQ R ,QIRUPDUDFHUFDGHUHÀHMRVTXHHVWLPXODQXQDEXHQDODFWDGDSRVLFLRQHV SDUDDPDPDQWDULPSRUWDQFLDGHOYDFLDGRSHULyGLFRGHODVPDPDVKLJLHQHGH ORVSH]RQHV\SUHYHQFLyQGHSUREOHPDVPDPDULRV R ,QIRUPDUDFHUFDGHOGHVFHQVR¿VLROyJLFRGHSHVR +LJLHQHJHQHUDO\&XLGDGRGHOFRUGyQXPELOLFDO 3RVLFLyQ DO GRUPLU \ SUHYHQFLyQ GHO 6LQGURPH GH 0XHUWH 6~ELWD GHO /DFWDQWH &RORFDU DO QLxR ERFD DUULED SDUD GRUPLU QR VREUHDEULJDUOR QR IXPDU HQ HO DPELHQWHGHVHVWLPDUHOFROHFKR 2ULHQWDUSDUDHOUHFRQRFLPLHQWRGH6LJQRVGHDODUPD*HQHUDOHVGHODFRORUDFLyQ GHSLHO\PXFRVDV5HVSLUDWRULRV&DUGLRYDVFXODUHV*DVWURLQWHVWLQDOHV8ULQDULRV 1HXUROyJLFRV0XVFXORHVTXHOpWLFRV %ULQGDU LQIRUPDFLyQ DFHUFD GHO ,QWHUYDOR LQWHUJHQpVLFR ySWLPR \ FRQVHMHUtD HQ VDOXGUHSURGXFWLYD ,QGLFDUODV,QPXQL]DFLRQHVFRUUHVSRQGLHQWHVDOPRPHQWRGHOQDFLPLHQWR\SULPHU VHPDQDVHJ~QHVTXHPD 9HUL¿FDULGHQWL¿FDFLyQGHOQLxR\VXPDGUH %ULQGDURULHQWDFLyQSDUDODLQVFULSFLyQGHOQLxRHQHO5HJLVWUR&LYLO ,QGLFDU FODUDPHQWH IHFKD \ OXJDU GHO SULPHU FRQWURO D ORV GtDV GHO DOWD SUHIHUHQWHPHQWHFRRUGLQDUODFRQWUDUHIHUHQFLD 9DORUDUSUHYLRDODOWDFRQGLFLRQHVGHULHVJRVRFLDO 2ULHQWDUDFHUFDGHODVSUXHEDVGH3HVTXLVD\REWHQFLyQGHORVUHVXOWDGRV (QPXFKRVFDVRVSXHGHVHU~WLOODHODERUDFLyQ\HQWUHJDGHIROOHWRVLQVWUXFWLYRVFRQORV FRQRFLPLHQWRVEiVLFRVDWUDQVPLWLUDODOWD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 5HIHUHQFLDV%LEOLRJUi¿FDV McCall EM, et al. Interventions to prevent hypothermia at birth in preterm and low birth weight. Cochrane Database Rev 2008, Jan 23. Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, Jagt EW van der , Zaritsky AL.. Pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2010 Nov;126(5):e1361-99. Epub 2010 Oct 18. American Academy of Pediatrics. Section on Ophthalmology, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2006 Feb; 117(2):572-6. Hutton EK et al, Late versus Early clamping Of the umbilical cord in full term neonates: Systemic review and metanalysis of controlled trials. JAMA 2007;2007:1241-1252. Rabe H et al. A systematic review and metanalisys of a brief delay in camping the umbilical cord of preterm infant. Neonatology 2008;93:138-144. Rabe H, Reynolds GJ, Diaz-Rosello JL. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD003248. DOI: 10.1002/14651858. CD003248.pub2. McDonald SJ, Middleton P Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004074. Finer NN, Carlo WA, Duara S, Fanaroff AA, Donovan EF, Wright LL, Kandefer S, Poole WK. National Institute of Child Health and Human Development Neonatal Research Network. Delivery room continuous positive airway pressure/positive end-expiratory pressure in extremely low birth weight infants: a feasibility trial. Pediatrics. 2004 Sep;114(3):651-7. Morley Colin J, Davis Peter, Doyle Lex W, Brion Luc P, Hascoet Jean-Michel, Carlin John B. Nasal CPAP or Intubation at Birth for Very Preterm Infants. N Engl J Med 2008; 358:700-708. Engle WA, Kominiarek MA.Late preterm infants, early term infants, and timing of elective deliveries. Clin Perinatol. 2008, 35(2):325-41, vi. Review Engle W A, Tomashek K M, Wallman C. Committee on fetus and Newborn. American Academy of Pediatrics. Late-preterm infants: a population at risk. A clinical report. Pediatrics 2007, 120(6):1390-401. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 9, & $ 3, 7 8 /2 9 , $WHQFLyQFRQMXQWDGHODPDGUH\HOQLxR GHVSXpVGHOQDFLPLHQWR 2%-(7,92 5DFLRQDOL]DUORVUHFXUVRV\GLVPLQXLURSRUWXQLGDGHVSHUGLGDV &RQWURODUELHQHVWDUGHODPXMHUSXpUSHUD\GHOUHFLpQQDFLGR 'HWHFWDU \ HYDOXDU GHVYLDFLRQHV GH ORV OtPLWHV ¿VLROyJLFRV GH DPERV $&7,9,'$' $WHQFLyQ FRQMXQWD GH OD PDGUH \ HO UHFLpQ QDFLGR GXUDQWH HO SXHUSHULR (GXFDFLyQGHODPXMHUSXpUSHUD &RQWUROHVFOtQLFRVGHODPXMHU\VXKLMR 5HJLVWURGHORVFRQWUROHVHQODKLVWRULDFOtQLFDSHULQDWDO 'XUDQWH OD LQWHUQDFLyQ SRVW SDUWR \ KDVWD HO DOWD D VX KRJDU OD PDGUH \ HO UHFLpQ QDFLGRUHFLEHQDWHQFLyQHQIRUPDFRQMXQWD(OSHUVRQDOHVWiFDSDFLWDGRSDUDDWHQGHU VLPXOWiQHDPHQWH ODV QHFHVLGDGHV GH DPERV EULQGDQGR DORMDPLHQWR FRQMXQWR WRGR HO GtD SULYDFLGDG GHVFDQVR \ DOLPHQWDFLyQ DGHFXDGD /D GXUDFLyQ GH OD LQWHUQDFLyQ FRQMXQWD VH H[WLHQGH PLHQWUDV HO KRVSLWDO PDQWHQJD YHQWDMDV VREUH HO KRJDU SDUD OD DGDSWDFLyQGHOUHFLpQQDFLGR\SDUDORVFXLGDGRVSRVWSDUWRLQPHGLDWRVGHODPDGUH (VIUHFXHQWHTXHOXHJRGHODOWDGHOD0DWHUQLGDGODDWHQFLyQGHODPDGUH\GHOUHFLpQ QDFLGRVHUHDOLFHSRUSHUVRQDOGLIHUHQWHHQPRPHQWRV\iPELWRVItVLFRVGLIHUHQWHV 1R HV KDELWXDO TXH H[LVWD XQ SURWRFROR FRP~Q GH DWHQFLyQ D~Q FXDQGR OD FRQGLFLyQ GH FULDQ]D GHO EHEp PDQWLHQH YtQFXORV ELROyJLFRV LQWHUDFWLYRV HQWUH OD PDGUH \ VX QLxR(OREMHWLYRGHSODQL¿FDUODDWHQFLyQSRVWQDWDOFRQMXQWDSUHWHQGHUDFLRQDOL]DUORV UHFXUVRVKXPDQRVTXHORVFXLGDQDSURYHFKDUWRGDVODVLQVWDQFLDVSDUDODSURPRFLyQ\ HOFXLGDGRGHODVDOXGGHDPERV\GLVPLQXLUODVRSRUWXQLGDGHVSHUGLGDV (YLWDU ODV FRQVXOWDV SRU VHSDUDGR LPSOLFD UHGXFLU JDVWRV GH WLHPSR \ GH UHFXUVRV HFRQyPLFRVDODVIDPLOLDV 5HJLVWURV 3DUD LQLFLDU OD DWHQFLyQ SRVW QDWDO GH PDGUH \ QLxR HV VX¿FLHQWH OD LQIRUPDFLyQ FRQWHQLGDHQOD+LVWRULD&OtQLFD3HULQDWDOGHODPDGUH\GHVXUHFLpQQDFLGRSXGLHQGR FRPSOHPHQWDUVHFRQODLQIRUPDFLyQGHODOWDGHKRVSLWDOL]DFLyQQHRQDWDOHQORVFDVRV TXHVHKD\DUHTXHULGRGHLQWHUQDFLyQHQFXLGDGRVHVSHFLDOHV )LJXUD)UDJPHQWR+&3&RQWUROHVHQHOSXHUSHULR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 6RSRUWHDIHFWLYR (QFDGDHQFXHQWURVHHVSHUDTXHHOSHUVRQDOGHVDOXGVHSUHRFXSHSRU x HOELHQHVWDUHPRFLRQDOGHODPDGUH x ODD\XGDTXHREWLHQHGHODIDPLOLD\GHORVGHPiVPLHPEURVGHVXFRPXQLGDG SDUDSRGHUUHVROYHUORVSUREOHPDVGLDULRVTXHWLHQHSRUVXFRQGLFLyQGHPDGUH 6L OD IDPLOLD R OD PDGUH UHODWDQ TXH HOOD WLHQH FDPELRV HQ HO HVWDGR HPRFLRQDO R HO FRPSRUWDPLHQWRKDELWXDOVHSURSLFLDUDODFRQVXOWDFRQXQSURIHVLRQDOTXHODHYDO~H\ DWLHQGD /DVPDGUHV\ODVIDPLOLDVGHEHUiQVHUVLHPSUHWUDWDGDVFRQFDULxRUHVSHWR\GLJQLGDG 6XVSXQWRVGHYLVWDFUHHQFLDV\YDORUHVHQUHODFLyQDODXWRFXLGDGR\HOFXLGDGRGHO QLxR GHEHUiQ VHU FRQWHPSODGRV \ VDOYR HQ DTXHOODV RFDVLRQHV TXH SXHGDQ UHVXOWDU QRFLYRVVHQHJRFLDUiHQIRUPDUHVSHWXRVDFRQHOOD\VXIDPLOLDHOFDPELRQHFHVDULROHQ EDVHDLQIRUPDFLyQYHUD]\RSRUWXQD6HHVSHUDTXHODVPDGUHVSXHGDQWRPDUVLHPSUH ODVGHFLVLRQHVVREUHVXSURSLRFXLGDGRRWUDWDPLHQWRVQHFHVDULRV /D EXHQD FRPXQLFDFLyQ HV HVHQFLDO /RV FXLGDGRV \ OD LQIRUPDFLyQ FRQVLGHUDUDQ HO LGLRPDDSURSLDGR\ODVSUiFWLFDVFXOWXUDOHVGHODPDGUHWHQLHQGRHQFXHQWDQHFHVLGDGHV HVSHFLDOHVSRUGLVFDSDFLGDGHVItVLFDVFRJQLWLYDVRVHQVRULDOHV &DSDFLGDGHVGHOSHUVRQDO (O SHUVRQDO TXH FXLGD D DPERV ±PDGUH \ UHFLpQ QDFLGR GHEH WHQHU FRPSHWHQFLDV GHPRVWUDGDV\H[SHULHQFLDSDUD x UHDOL]DU OD YDORUDFLyQ \ UHFRQRFHU VLJQRV GH DODUPD HQ OD PDGUH \ HO UHFLpQ QDFLGR x DSR\DUHQHOLQLFLR\PDQWHQLPLHQWRGHODODFWDQFLD x UHFRQRFHUVLJQRV\VtQWRPDVGHSUREOHPDVGHVDOXGPHQWDOGHODPDGUH x UHFRQRFHU ORV ULHVJRV VLJQRV \ VtQWRPDV GH YLROHQFLD GRPpVWLFD \ DEXVR LQIDQWLO x LGHQWL¿FDUORVUHFXUVRVGLVSRQLEOHVSDUDTXHODPDGUHREWHQJDFRQVHMR\DSR\R 'H¿QLFLRQHV (O SXHUSHULR FRPLHQ]D XQD YH] TXH KD WHUPLQDGR HO DOXPEUDPLHQWR \ VH H[WLHQGH VHLVVHPDQDV'XUDQWHHVWHSHULRGRUHYHUWLUiQWRGRVORVFDPELRV¿VLROyJLFRVTXHVH SURGXMHURQGXUDQWHHOHPEDUD]RFRQODVRODH[FHSFLyQGHORVFDPELRVPDPDULRVTXH VHLQWHQVL¿FDUiQSDUDPDQWHQHUHODPDPDQWDPLHQWRH[LWRVR 3XHUSHULRLQPHGLDWRDEDUFDODVSULPHUDVKRUDVGHOSRVWSDUWRHLQFOX\HHQpODODV KRUDVTXHFRQWLQ~DQDODOXPEUDPLHQWR6XLPSRUWDQFLDUDGLFDHQTXHHVHQHVWHSHUtRGR HQHOFXDOVHSURGXFHODPD\RUFDQWLGDGGHFRPSOLFDFLRQHVJUDYHVHVSHFLDOPHQWHODV YLQFXODGDVDWUDVWRUQRVSRUVDQJUDGR 3XHUSHULRWDUGtR (VWH SHUtRGR VH H[WLHQGH PiV DOOi GHO GtD \ QR PiV DOOi GH XQ DxR 7RPD VX LPSRUWDQFLDHQTXHKD\DOJXQDVVLWXDFLRQHVPyUELGDVRLQFOXVRPRUWDOHVTXHSXHGHQ SURGXFLUVHHQHVWHSHULRGR$FRQWLQXDFLyQVHLQGLFDQORVDVSHFWRVPiVUHOHYDQWHVD FRQVLGHUDUHQORVFRQWUROHVVXEVLJXLHQWHVDODPDGUH\HOUHFLpQQDFLGR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &RQWUROHVGHODPDGUH\GHOUHFLpQQDFLGR Madre Recién nacido Primeras 24 horas Puerperio inmediato • Estado de conciencia, lúcida y tranquila. • Facies, piel y mucosas, deberán estar bien coloreadas (excepto en anemia previa). • Frecuencia del pulso en condiciones basales, (60 y 100 Ipm) y lleno. • Presión arterial en rangos normales. • Temperatura corporal, no deberá superar los 37° C. En el postalumbramiento, pueden observarse escalofríos, que son normales y raramente duran más de 30 minutos. • Retracción del útero (globo de seguridad de Pinard), en estas horas, el fondo del útero no sobrepasa la cicatriz umbilical y la consistencia es firme adquiriendo una consistencia leñosa al ser estimulado. Es indoloro a la palpación y es común el dolor cuando el niño es puesto al pecho (entuertos). • En caso de dolor, estarán indicados los analgésicos comunes y los antiinflamatorios no esteroideo. • En caso de sangrado vaginal abundante con el útero bien contraído efectuar inspección minuciosa del canal del parto para descartar lesiones (desgarros) en vagina y en cuello de útero. • Describir los principales signos de alerta y vigilar con atención aquellas condiciones Que pueden poner en riesgo la vida de la madre. (ver cuadro). • Animarla para Que comience a movilizarse. En las madres obesas considerar el riesgo de tromboembolismo por reposo en cama. • Mujeres que no estén inmunizadas contra el tétanos o contra la rubéola deberán ser inmunizadas antes del aIta. • En las Rh negativas no inmunizadas con recién nacido Rh positivos proceder a la inmediata administración de la correspondiente dosis de gammaglobulina según normas locales. • Orientar y facilitar el acceso a métodos de planificación familiar. • En ocasiones pueden aparecer hemorroides fluxivas que mejoran parcialmente con hielo y cremas locales con anestésicos tópicos. • La retención urinaria es excepcional; se tratará con cateterismos vesicales intermitentes, Higiene perineal: • Cada vez que la mujer requiera cambiar el apósito, se debe higienizar la zona con agua limpia y jabón o un antiséptico. El lavado se hará por arrastre, siempre en sentido antera posterior (de la vulva hacia el ano). Se secará con un paño o gasas limpias. • La ropa interior será separada por un apósito (gasaalgodón-gasa) o por protectores “nocturnos” de los que se consiguen en el mercado, • Los lavados intravaginales son desaconsejados. • En caso de episiotomía, los cuidados serán similares, pero se insistirá en mantener la zona seca el mayor tiempo posible. Cuidado de los pezones: • Deberá exponer la areola y el pezón al sol entre diez y quince minutos por día lubricarla exclusivamente con calostro o leche materna. Un niño saludable • No separe al recién nacido de su madre. • Promueva que estén cerca físicamente. • Promueva la colocación temprana del bebe al pecho si la madre lo desea. • Si es primípara, explíquele que al principio no todas las madres se sienten con fuerzas y deseo de cuidar a sus bebes [as 24 horas del día y que eso va cambiando los primeros días. • Acompañe a la madre sugiriéndole como poner a su niño a mamar, sin tocar sus senos y respetando su pudor natural. • Informe de las ventajas de mantener la alimentación al pecho exclusiva y que si tiene molestias al inicio de la lactada es normal pero serán pasajeras. • No administre otra leche que no sea la de su propia madre sin la debida indicación médica y consentimiento de la madre. • No permita publicidad de fórmulas de leche de vaca, ni que les entreguen muestras gratis a las madres. • Se alimenta y succiona bien. • Descansa entre lactadas y se despierta para alimentarse. No está excesivamente irritable. • Tiene un color normal para su etnia (controlar cianosis o ictericia) • Moviliza el intestino y orina varias veces al dia (sus pañales cada 3 horas están mojados). • Frecuencia respiratoria entre 30 y 60 respiraciones por minuto. • Frecuencia cardiaca entre 120 y 160 latidos por minuto. • Temperatura no mayor a los 37° (axilar o inguinal). • Mantenga al niño arropado hasta que logre el control térmico • Mencione la administración de Vitamina K que ya se realizó al recién nacido e indique la repetición a los 7 días si fue administrada por vía oral. • Señale que el cordón debe mantenerse limpio y seco. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD Información al egreso. Durante la internación por el parto, la madre y la familia deberán haber recibido información para el cuidado postnatal y la protección de la salud de ella y su recién nacido. Al alta deberá señalarse con precisión: • la forma en que ella puede mantener una comunicación continua con los servicios • las nuevas necesidades de apoyo familiar y los recursos comunitarios a los que pueda acceder para encontrar soporte en la función parental y • pautas que la guíen para la consulta en caso que aparezcan elementos de alarma para la salud de ambos. • Es recomendable otorgar el alta a las 48 horas del parto, si no ha habido complicaciones y siempre que la mujer está en condiciones de administrar cuidados a su recién nacido. Cuando deba otorgarse el alta en forma precoz, deberán garantizarse instancias de seguimiento domiciliario. • De ser necesario, instrumentar sistemas de consulta telefónica con referentes de! centro de salud o de la comunidad. Recordar que las primeras 24 horas, suelen ser las de mayor riesgo vital, tanto para la mujer, como para su recién nacido. • Recuerde a la madre de las ventajas de mantener la alimentación al pecho exclusiva. Informar acerca de importancia del vaciado periódico de las mamas, higiene de los pezones y corpiño que sostenga y no apriete para la prevención de problemas mamarios • Recuerde la higiene de manos y el cuidado del cordón umbilical • Prevención del Síndrome de Muerte Súbita del Lactante: colocar al niño boca arriba para dormir, no abrigarlo en exceso, no fumar en el ambiente, desestimar el colecho • Orientar para el reconocimiento de Signos de alarma. • Indicar las Inmunizaciones correspondientes al momento del nacimiento y primer semana, según esquema • Verificar identificación del niño y su madre. • Brindar orientación para la inscripción del niño en el Registro Civil. • Indicar claramente fecha y lugar del primer control, a los 7 días del alta (preferentemente coordinar la contrarreferencia) • Valorar, previo, al alta condiciones de riesgo social • Orientar acerca de las pruebas de Pesquisa y obtención de los resultados • En muchos casos puede ser útil la elaboración y entrega de folletos instructivos con los conocimientos básicos a transmitir al alta. Primera consulta conjunta entre 7 y 10 días. Puerperio mediato: Se extiende desde el segundo y hasta el 10° día del parto • Brindar información sobre higiene perineal o cuidado de la cicatriz de cesárea. • Recuérdele que la alimentación exclusiva (día y noche) al pecho, sin dar ningún otro tipo de alimento a su bebe, tiene un efecto anticonceptivo fugaz e impredecible y que aun amamantando puede tener otras opciones contraceptivas. )LJXUD 0DQLREUD GH%DUORZ • Verificar que moja los pañales con frecuencia y elimina meconio, que la succión es audible, vigorosa y sostenida y que la boca está húmeda. • Examinar al bebé sin incomodarlo procediendo a obtener la información que permita detectar nuevas condiciones que puedan requerir tratamiento. • Investigar si tiene elementos de riesgo de displasia de caderas. (asimetría de los miembros o pliegues en la región anterior de muslo, Maniobras de Barlow y Ortolani) )LJXUD 0DQLREUD GH2UWRODQL &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR • Signos vitales (temperatura, frecuencia cardiaca y presión arterial). Cualquier alteración de los signos vitales, obligará a la búsqueda del agente etiológico y ante la presencia de dudas, deberá ser enviada a un nivel de mayor complejidad, para continuar su atención. • Evaluación de los loquios (cantidad, aspecto, composición y olor). Es difícil estimar la cantidad, por lo que se recomienda ver si la madre tiene o no anemia. El color a esta altura del puerperio, debe ser rojo o rosado. El color marrón, achocolatado hará sospechar infección. Suelen además de sangre, contener fragmentos tisulares pequeños. El olor puede ser fuerte, en caso de fetidez, se deberá sospechar infección. • Control de involución uterina. La involución es sumamente rápida, aproximadamente a 2 centímetros por día y se estima mediante palpación del fondo uterino. A los 6 días de puerperio se situará entre el ombligo v el borde superior del pubis. A los 10 días estaré próximo al pubis. • En ocasiones se pueden ver hemorroides flexivas y dolorosas, que no mejoran con tratamiento médico, en esos casos deberé descartarse una trombosis hemorroidal, la que se soluciona fácilmente con un mínimo drenaje quirúrgico con anestesia local. Otras veces el dolor puede ser expresión de una fisura anal, que suele revertir con tratamiento médico. Luego de unas semanas. Es común observar una incontinencia de orina que suele remitir espontáneamente en algunos días o semanas. • Bajada de la leche. En estos días se sustituye el calostro por la leche definitiva. • No realizar doble pesada, ni siquiera es necesario pesarlo todos los días. • Ante la aparición de ictericia valorar elementos de riesgo. • Promover la higiene de manos, el uso de alcohol gel. • Informar sobre el riesgo de contagio de enfermedades virales respiratorias y las formas de evitarlas. • Si tiene indicado alimentación por fórmula, explicar su forma de preparación y el cuidado e higiene de los implementos. • Investigar cuales son los apoyos sociales con los que la madre o los padres cuentan. Segunda visita conjunta entre los 15 y 30 días Puerperio alejado: Abarca desde el 11° hasta el 42° día del postparto • Reforzar la conserjería en anticoncepción y espaciamiento intergenésico, intentando mantener la lactancia. • Controlar la evolución de la lactancia. • Continúa la involución uterina y el restablecimiento del estado pregravídico. • Investigar síntomas menores de depresión. Si persisten las alteraciones depresivas más allá del día 14 deberá consultar con un profesional. • Prevenir la reinfección por enfermedades de transmisión sexual en especial si fueron detectadas y tratadas en esta gestación. • Prestar atención a situaciones de desamparo y violencia doméstica. • A los 25 días del parto, puede advertirse un sangrado vaginal escaso (pequeño retorno) que generalmente se debe a una proliferación endometrial normal que no requiere ningún estudio o tratamiento especial • El reinicio de las relaciones sexuales es habitual ya que desaparecen los Loquios Esto ocurre entre los 30 y los 40 días del puerperio. • En algunos casos, éste, será el ultimo control entre la mujer y el equipo de salud, por eso es recomendable efectuar un examen clínico general y ginecológico. • Analizar con los padres los planes de reinicio de las actividades laborales o educativas, verificando la protección de sus derechos en la nueva situación de maternidad. • Continuar vacunaciones según esquema. • Insistir en la higiene de manos, el uso de Alcohol en gel y el riesgo de enfermedades virales respiratorias, si están en ambiente epidémico. • Valorar el crecimiento y la alimentación. Tener en cuenta la posibilidad de administrar hierro adicional y vitamina D. • Reiterar examen físico, • Reiterar información sobre el riesgo de muerte súbita. Aconsejando que: El recién nacido duerma boca arriba, en cuna, en el cuarto de la madre los primeros 6 meses. No prohibir el uso del chupete Colocar al bebé con los pies en contacto con la piesera de la cuna. (para evitar el desplazamiento debajo de las mantas) I Evite: • el humo del tabaco en el hogar • el colecho con los padres, que se duerman con el bebé en un sillón (frecuente si existe consumo de bebidas alcohólicas, toman psicofármacos o tienen cansancio extremo). • vestir al niño con ropas abotonadas por delante &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD Cuadro 47 PROBLEMAS COMUNES EN LAS MADRES SIGNOS y SINTOMAS ACCIONES Depresión puerperal. Si persisten los síntomas más de 14 días consultar Dolor perineal, olor de los Evaluar infección o cicatrización defectuosa de la episiotomía. Recomendar exudados vaginales, dolor en frío local, analgésicos y si no son efectivos considerar antiinflamatorios no las relaciones sexuales esteroideos locales u orales. Dolor en las relaciones Evaluar herida. Aconsejar lubricantes en base acuosa. sexuales Dolor de cabeza post anestesia Líquidos analgésicos y reposo sin almohada epidural o raquídea Fatiga persistente Investigar otros síntomas en especial anemia. Señalar la necesidad de alimentación y aporte de hierro y ejercicio Dolor de espalda Tratar como en la población general Constipación Recomiende dieta con fibras y Líquidos. Puede usarse un laxante suave Hemorroides Si son severas, edematizadas o prolapsadas, referir. Incontinencia fecal Evaluar severidad, duración y Frecuencia, Si persiste> 1mes referir Incontinencia urinaria Enseñe ejercicios de piso pélvico. Si persiste referir. Retención de orina (en las Procure que tome una ducha tibia. Si persiste considere colocar sonda primeras 6 horas Postparto) vesical Cuadro 48 PROBLEMAS COMUNES EN LOS RECIEN NACIOOS SIGNOS y SINTOMAS ACCIONES Ictericia Consulta de emergencia Mugget oral Tratamiento con antimicóticos tópicos Eritema del pañal Recomendar cambio más frecuente de los pañales. De ser muy molesto persistente usar antimicóticos No expulsión de meconio en Consulta de EMERGENCIA las primeras 24hs Constipación en no alimentado Consulta al pecho Diarrea Aumentar frecuencia de las lactadas. Si está alimentado por fórmulas verificar higiene de la preparación y consulta de urgencia llanto inconsolable Consulta de urgencia “Cólicos’ Aconsejar que alcen y sostengan al bebé mientras llora y que busquen apoyo de otros padres si se sienten desbordados. SIGNOS Y SINTOMAS Pezones dolorosos agrietados Senos ingurgitados. Mastitis Cuadro 49 PROBLEMAS AL AMAMANTAR ACCIONES o Considere la posibilidad de que tengan infección por cándida Pezones invertidos I Aconseje lactancia a demanda, masajes de los senos, ordeñe manual, analgesia. Si persiste por horas consultar y si hay elementos claros de infección considerar ATB. Brindar más apoyo, tranquilizando a la madre. 5HIHUHQFLD%LEOLRJUi¿FD National Collaborating Centre for Primary Care. Routine postnatal care of women and their babies London. NICE clinical guideline 37. ISBN 1-84629-248-4 National Institute for Health and Clinical Excellence. www.nice.org.uk/CG037 Julio 2006 &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 9,, 2EMHWLYRV $FWLYLGDG &$3,78/29,, 3/$1,),&$&,21)$0,/,$5 &RQWULEXLUDOHMHUFLFLRGHOGHUHFKRDSODQL¿FDUHOHPEDUD]R $VHVRUDUVREUHORVSULQFLSDOHVPpWRGRVFRQWUDFHSWLYRV $SDUWLUGHODGpFDGDGHOODSODQL¿FDFLyQIDPLOLDUVHLQFRUSRUDUHJXODUPHQWHDORV VHUYLFLRV GH VDOXG 'HELHURQ SDVDU FDVL DxRV SDUD TXH D ¿QDOHV GHO VLJOR ;; \ FRPR UHVXOWDGR GH ODV FXPEUHV PXQGLDOHV RUJDQL]DGDV SRU ODV 1DFLRQHV 8QLGDV OD SODQL¿FDFLyQIDPLOLDUIXHUDFRQVLGHUDGDFRPRXQGHUHFKRKXPDQRGHQWURGHOFRQWH[WRGH ODVDOXGVH[XDO\UHSURGXFWLYD(O3URJUDPDGH$FFLyQGHOD&RQIHUHQFLD,QWHUQDFLRQDOGH 3REODFLyQ\'HVDUUROORHIHFWXDGDHQ(O&DLURHQHQXQDGHVXVSDUWHVHVWDEOHFH «´ORVSURJUDPDVGHDWHQFLyQGHODVDOXGUHSURGXFWLYDGHEHUiQSURSRUFLRQDUORVPiV DPSOLRVVHUYLFLRVSRVLEOHVVLQQLQJ~QWLSRGHGLVFULPLQDFLyQ7RGDVODVSDUHMDVWLHQHQHO GHUHFKRIXQGDPHQWDOGHGHFLGLUOLEUH\UHVSRQVDEOHPHQWHHOQ~PHUR\HVSDFLDPLHQWR GHVXVKLMRV\GHGLVSRQHUGHODLQIRUPDFLyQODHGXFDFLyQ\ORVPHGLRVQHFHVDULRVSDUD SRGHUKDFHUOR´« 3URFHVRGH$VHVRUDPLHQWR /D LQIRUPDFLyQ \ OD FRQVHMHUtD VREUH PpWRGRV FRQWUDFHSWLYRV VH HQPDUFD GHQWUR GHO SURFHVRGHDVHVRUDPLHQWRHQSODQL¿FDFLyQIDPLOLDU'XUDQWHHVWHSURFHVRHOSURIHVLRQDO SRQHDGLVSRVLFLyQGHFDGDPXMHU\FDGDKRPEUHORVFRQRFLPLHQWRVQHFHVDULRVSDUD TXHRSWHQOLEUHPHQWHFXDOPpWRGRYDQXWLOL]DUVLHVTXHGHFLGHQKDFHUOR (ODVHVRUDPLHQWRGHEHUiFRQVLGHUDUODVGLIHUHQWHVHWDSDVGHODYLGDUHSURGXFWLYDGHO FLFOR YLWDO DGROHVFHQFLD MXYHQWXG SHULPHQRSDXVLD \ HO JUDGR GH DFWLYLGDG VH[XDO 3DUDODHOHFFLyQGHOPpWRGRVHGHEHUiSURYHHULQIRUPDFLyQVREUHODVHJXULGDGH¿FDFLD IRUPDGHXVRFRPRGLGDGHIHFWRVVHFXQGDULRVDFFHVLELOLGDGHFRQyPLFDHQXQPDUFR GH UHVSHWR D ORV GLIHUHQWHV HVWLORV GH YLGD \ YDORUHV DVt FRPR WDPELpQ OD HYHQWXDO DFHSWDFLyQSRUSDUWHGHODSDUHMD (OREMHWLYRSULPRUGLDOTXHHQHVWDHWDSDGHEHUiFXPSOLUHOHTXLSRGHVDOXGVHUiDSR\DU DODSHUVRQDRODSDUHMDDHOHJLUHOPRPHQWRDSURSLDGRSDUDORJUDUXQHPEDUD]RGH¿QLU ODFDQWLGDGGHKLMRVTXHWHQGUiQRHYLWDUHOHPEDUD]R $VHVRUDPLHQWR\(GXFDFLyQ6H[XDO (O SURFHVR GH DVHVRUDPLHQWR HV LQGLVSHQVDEOH \ QR VH SXHGH REYLDU DXQTXH H[LVWD HGXFDFLyQHQVH[XDOLGDG/DHGXFDFLyQVH[XDOGHEHUiLQLFLDUVHDQWHVGHODSXEHUWDG GHPDQHUDTXHFXDQGRODQLxDWHQJDVXSULPHUDPHQVWUXDFLyQ\DFRQR]FDVXFXHUSR \ OD ¿VLRORJtD GH OD FRQFHSFLyQ /D LGHD TXH VH SUHWHQGH ORJUDU HV TXH SDUD HO PRPHQWRHQTXHODQLxDDGROHVFHQWHPXMHUGHEDHQIUHQWDUVHDRSWDUVREUHPDQWHQHU UHODFLRQHVVH[XDOHVORSXHGDKDFHUVLQORVWHPRUHVGHODLJQRUDQFLDFRQRFLHQGRODV IRUPDV GH SURWHJHUVH GH ODV ,76 \ GH XQ HPEDUD]R QR GHVHDGR FRQ OD DXWRQRPtD \ FRQ¿DQ]D VX¿FLHQWH SDUD QHJRFLDU HO PRPHQWR \ ODV FRQGLFLRQHV DSURSLDGDV (OYDUyQDGHPiVGHUHFLELULJXDOHVFRQRFLPLHQWRVTXHODQLxDGHEHUiUHFLELURULHQWDFLyQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD GHVGHXQDSHUVSHFWLYDGHJpQHURTXHOHSHUPLWDDVXPLUFRQUHVSRQVDELOLGDGVXVDFWRV \HYHQWXDOPHQWHSUHSDUDUORSDUDXQDSDWHUQLGDGUHVSRQVDEOH 'HVDIRUWXQDGDPHQWHHQOD5HJLyQGHODV$PpULFDVODHGXFDFLyQVH[XDOHVXQDPDWHULD SHQGLHQWHHQODVDJHQGDVGHODPD\RUtDGHORVSDtVHV3HVHDTXHODHGXFDFLyQVH[XDO QRHVUHVSRQVDELOLGDGGLUHFWDGHOVHFWRUVDOXGORVHTXLSRVQRGHEHUiQGHVDSURYHFKDU ODVLQVWDQFLDVGHFRQWDFWRFRQODVXVXDULDVRVTXHVHSUHVHQWHQSDUDDYDQ]DUHQHVWD WHPiWLFD (YDOXDFLyQGHODVXVXDULDVDQWHVGHUHFRPHQGDUOHVXQPpWRGRFRQWUDFHSWLYR 6HUHFRPLHQGDTXHDQWHVGHLQGLFDUFXDOTXLHUFRQWUDFHSWLYRVHSURFHGDDXQDFRUUHFWD YDORUDFLyQGHODPXMHUODTXHGHEHUiLQFOXLUSUXHEDV\HYHQWXDOPHQWHH[iPHQHVVHJ~Q ODVLJXLHQWHFODVL¿FDFLyQ &ODVH$([iPHQHVHVHQFLDOHV\PDQGDWDULRVSDUDXQXVRVHJXURGHOFRQWUDFHSWLYR &ODVH%([iPHQHVTXHQRVRQHVHQFLDOHVSHURFRQWULEX\HQDOXVRVHJXUR\HIHFWLYR VXUHDOL]DFLyQGHSHQGHUiGHODFDSDFLGDGGHOVHUYLFLR &ODVH&([iPHQHVTXHQRFRQWULEX\HQDOXVRGHOPpWRGRSHURGHEHUiQVHUUHDOL]DGRV FRQUHJXODULGDGGHVGHXQDSHUVSHFWLYDLQWHJUDOGHVDOXGGHODPXMHU DIU C A C B C A B C Vasectomía C C C C C C C * Ligadura tubaria C C C C C C C * Barrera Examen mamario por proveedor Examen pélvico/genital Tamizaje con PAP Hemoglobina Exámenes de rutina Valoración de riesgo para ITS Tamizaje para ITS/VIH Medición de la presión arterial Progesterona solo Situación Específica Combinados &XDGUR5HVXPHQGHORVH[iPHQHVDUHDOL]DUGHDFXHUGRDOPpWRGRFRQWUDFHSWLYR UHFRPHQGDGR C C C C C C** C** C C C C B C C C A n/a A n/a C C C C C*** 6LHPSUH HV UHFRPHQGDEOH HO FRQWURO GH OD SUHVLyQ DUWHULDO SHUR QR FRQWDU FRQ SRVLELOLGDGHVGHPHGLUODSUHVLyQDUWHULDOQRGHEHUiLPSHGLUHOXVRGHHVWRVPpWRGRV FRQWUDFHSWLYRV 6HUHFRPLHQGDQRXVDUFRQGRQHVFRQQRQR[LQROHQSHUVRQDVFRQDOWRULHVJRGH LQIHFFLyQSRU9,+ 6RORSDUDSURFHGLPLHQWRVTXHVHHIHFW~DQFRQDQHVWHVLDORFDO &ODVL¿FDFLyQGHORVPpWRGRVDQWLFRQFHSWLYRV /RVPpWRGRVFRQWUDFHSWLYRVVRQGHGRVWLSRVUHYHUVLEOHVHLUUHYHUVLEOHV /RV PpWRGRV UHYHUVLEOHV VRQ ORV GH PD\RU DSOLFDFLyQ \ DFHSWDFLyQ SRU SDUWH GH ODV XVXDULDV\FRPRVXQRPEUHORLQGLFDXQDYH]VXVSHQGLGRVVHUHVWDXUDODIHUWLOLGDGHQ FDPELRORVPpWRGRVLUUHYHUVLEOHVOLPLWDQHQIRUPDGH¿QLWLYDODFDSDFLGDGGHFRQFHELU &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR '(6&5,3&,Ï1'(/260e72'26&2175$&(37,926 $0pWRGRVUHYHUVLEOHV 0pWRGRV FRPSRUWDPHQWDOHV VH EDVDQ HQ OD REVHUYDFLyQ GH VLJQRV \ VtQWRPDV TXHDSDUHFHQGHPRGRQDWXUDOHQODVIDVHVIpUWLOHVHLQIpUWLOHVGHOFLFORPHQVWUXDO$O FRQRFHUORVGtDVIpUWLOHVXQDPXMHUSRGUiHYLWDUHOHPEDUD]RXVDQGRDOJ~QRWURPpWRGR HQHVRVGtDVRELHQDEVWHQLpQGRVHGHPDQWHQHUUHODFLRQHVVH[XDOHV ([LVWHQYDULRVPpWRGRVFRPSRUWDPHQWDOHVSHURVRORGHVDUUROODUHPRVFXDWURGHHOORV HQUD]yQGHVHUORVPiVGLIXQGLGRV\PiVVHQFLOORVGHUHDOL]DU 6L VH SUHWHQGH OD Pi[LPD VHJXULGDG FRQWUDFHSWLYD ORV PpWRGRV FRPSRUWDPHQWDOHV VROR GHEHUtDQ VHU XVDGRV SRU PXMHUHV TXH WHQJDQ FLFORV UHJXODUHV \ FXHQWHQ FRQ HO HQWHQGLPLHQWR\GLVFLSOLQDVX¿FLHQWHV (VWRVPpWRGRVFXHQWDQFRQODYHQWDMDGHQRWHQHUJDVWRHFRQyPLFR /RV PpWRGRV FRPSRUWDPHQWDOHV HQ FRQMXQWR SUHVHQWDQ FRPR GHVYHQWDMD TXH QR SURWHJHQFRQWUDODV,76\HO9,+6,'$ )DOODV(QFRQMXQWRDOFDQ]DQHOSDUDWRGRVORVPpWRGRVFRPSRUWDPHQWDOHV x 0pWRGRGHOULWPRRFDOHQGDULR2JLQR.QDXVHVHOPpWRGRFRPSRUWDPHQWDO PiVXVDGR/RVDXWRUHVGHOPpWRGRGHPRVWUDURQTXHHQHOFLFORPHQVWUXDOH[LVWH XQSHUtRGRGHIHUWLOLGDGTXHHQXQFLFORGHGtDVWLHQHOXJDUDOUHGHGRUGHO GtD(OPpWRGRVHEDVDHQODDEVWLQHQFLDGXUDQWHODpSRFDGHODRYXODFLyQ&RPR ODSXHVWDRYXODUSXHGHYDULDUD~QHQFLFORVUHJXODUHVVHLPSRQHODDEVWLQHQFLD FRQ FLQFR GtDV GH DQWLFLSDFLyQ \ KDVWD FLQFR GtDV GHVSXpV GH OD VXSXHVWD IHFKDGHODRYXODFLyQ 'HEH FRQVLGHUDUVH DGHPiV TXHODYLGDGH XQyYXOR HV DSUR[LPDGDPHQWH GH KRUDV PLHQWUDV TXH HO HVSHUPDWR]RLGH FRQVHUYD VX SRGHUIHFXQGDQWHKDVWDXQRVGtDV /DDEVWLQHQFLDSHULyGLFDSUHVHQWDXQHOHYDGRSRUFHQWDMHGHIDOODVVXVFHSWLEOHGHVHU PHMRUDGRFRQHOUHVSDOGRGHODWRPDGHODWHPSHUDWXUDEDVDO\FRQODPHGLFLyQGHOD ¿ODQFLDGHOPRFRFHUYLFDO 'HVYHQWDMDV6RORHVDFRQVHMDEOHHQFLFORVUHJXODUHVQRPHQRUHVDGtDVUHTXLHUH DOWRQLYHOGHLQVWUXFFLyQPRWLYDFLyQ\GLVFLSOLQDSDUDVXDSOLFDFLyQ x 0pWRGRGH%LOOLQJVRGHODKXPHGDGFRQVLVWHHQGLVWLQJXLUORVGtDVSHULRYXODWRULRV EDViQGRVHHQODKXPHGDGTXHSHUFLEHODPXMHUHQVXVJHQLWDOHV$SULQFLSLRVGHO FLFORDSHQDVSHUFLELUiXQDVHFUHFLyQHVFDVDEODQFRDPDULOOHQWDGtDVVHFRV\ DPHGLGDTXHVHDFHUFDDODRYXODFLyQODVHFUHFLyQFRPHQ]DUiDKDFHUVHPiV ¿ODQWH\PiVWUDQVSDUHQWHGtDVK~PHGRVGHVSXpVGHODRYXODFLyQODVHFUHFLyQ VHUi HVFDVD \ FRQ FDUDFWHUtVWLFDV VLPLODUHV D OD GH ORV SULPHURV GtDV 'HVGH TXH OD PXMHU QRWD HO DXPHQWR GH VHFUHFLyQ \ KDVWD GtDV GHVSXpV GHO SXQWR GHPi[LPDKXPHGDGRYXODFLyQGHEHUiVXVSHQGHUODVUHODFLRQHVVH[XDOHVVLQ SURWHFFLyQ 'HVYHQWDMDV 6H UHTXLHUH XQ DOWR QLYHO GH PRWLYDFLyQ \ GLVFLSOLQD SDUD VX XVR /DV UHODFLRQHVVH[XDOHVHQORVGtDVSUHYLRVDOWHUDQHOJUDGRGHKXPHGDGYDJLQDO'LYHUVRV WUDWDPLHQWRV YDJLQDOHV yYXORV FUHPDV MDOHDV H LUULJDFLRQHV R ODV ,76 DOWHUDQ OD KXPHGDGYDJLQDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD x 0pWRGR GH OD ¿ODQFLD 6SLQQEDUNHLWFRQ HVWH PpWRGR VH LQWHQWD GHWHFWDU OD RYXODFLyQDWUDYpVGHOD¿ODQFLDGHOPRFRFHUYLFDO&RQVLVWHHQPHGLUODHODVWLFLGDG TXH WLHQH XQD JRWD GH OD VHFUHFLyQ YDJLQDO FRORFDGD HQWUH ORV GHGRV SXOJDU H tQGLFH6LODJRWDOOHJDDHVWLUDUVHXQRVFPyPiVVLQURPSHUVHVHFRQVLGHUD TXHODPXMHUVHHQFXHQWUDHQVXSHUtRGRIpUWLO<PLHQWUDVGXUHHVWD¿ODQFLDQRVH GHEHUiPDQWHQHUUHODFLRQHVVH[XDOHV 'HVYHQWDMD5HTXLHUHDOWDPRWLYDFLyQ\SUHVHQWDHOLQFRQYHQLHQWHTXHODPHGLFLyQGHOD ¿ODQFLDGHEHVHUUHDOL]DGDGLDULDPHQWH x 0pWRGRGHODWHPSHUDWXUDEDVDORVLQWRWpUPLFRFRQVLVWHHQWRPDU\UHJLVWUDU GLDULDPHQWHODWHPSHUDWXUDVXEOLQJXDOGHODPXMHUDSHQDVVHGHVSLHUWH\DQWHV GHOHYDQWDUVH&XDQGRVHUHJLVWUDXQDXPHQWRGHDSUR[LPDGDPHQWHXQRVD &VHHVWLPDTXHVHSURGXMRODRYXODFLyQ+DVWDODVKRUDVSRVWHULRUHVDO DVFHQVRGHODWHPSHUDWXUDEDVDOHVHOPRPHQWRGHPD\RUIHUWLOLGDG 'HVYHQWDMDV(OSULQFLSDOLQFRQYHQLHQWHUDGLFDHQTXHKD\XQUHWUDVRGHXQDVKRUDV HQGLDJQRVWLFDUODRYXODFLyQSRUORTXHDQWHVGHLGHQWL¿FDUHODVFHQVRWpUPLFRVHSXHGH SURGXFLUXQHPEDUD]RVLQRVHPDQWXYLHURQUHODFLRQHVVH[XDOHVFRQRWUDSURWHFFLyQ 1R VH SXHGH XWLOL]DU HQ FDVR GH ¿HEUH 5HTXLHUH XQ PtQLPR HQWUHQDPLHQWR SDUD OD PHGLFLyQ\HOUHJLVWURGHODWHPSHUDWXUD 0pWRGRGHODODFWDQFLDH[FOXVLYDODUHODFLyQHQWUHODGXUDFLyQGHODODFWDQFLD\OD GXUDFLyQGHODDPHQRUUHDKDVLGRVX¿FLHQWHPHQWHGHPRVWUDGD$PD\RUGXUDFLyQGHOD ODFWDQFLDPD\RUGXUDFLyQGHOSHUtRGRGHDPHQRUUHD /DGXUDFLyQSURPHGLRGHOSHUtRGRGHDPHQRUUHDHQODVPDGUHVTXHQRDPDPDQWDQHV GHDGtDVUDQJRGH\GtDV/DODFWDQFLDH[FOXVLYDVHDVRFLDFRQSHUtRGRV PiVODUJRVGHDPHQRUUHDHLQIHUWLOLGDGTXHODODFWDQFLDSDUFLDO (O PpWRGR GH OD ODFWDQFLD H[FOXVLYD FRQVLVWH HQ XWLOL]DU OD ODFWDQFLD FRPR PpWRGR WHPSRUDOGHFRQWUDFHSFLyQ )DOODVPHQRVGHO /DVIDOODVVRQPtQLPDVVLHPSUHTXH x (ODPDPDQWDPLHQWRVHDH[FOXVLYR\DOLEUHGHPDQGD x 1RVHKD\DQUHDQXGDGRORVFLFORVPHQVWUXDOHV x 1RVHDOFDQFHQORVPHVHVGHOSDUWR 'HVYHQWDMDV 1R SURWHJH FRQWUD OD WUDQVPLVLyQ YHUWLFDO GHO 9,+ DO UHFLpQ QDFLGR HQ PDGUHV9,+SRVLWLYDV &RPSDUWHFRQORVPpWRGRVFRPSRUWDPHQWDOHVODGHVYHQWDMDGHQRSURWHJHUFRQWUDODV ,76\HO9,+6,'$\ODYHQWDMDGHQRWHQHUFRVWRHFRQyPLFR\QRDOWHUDUHOPHWDEROLVPR GHODXVXDULD 0pWRGRV GH EDUUHUD H[LVWHQ GLYHUVRV PpWRGRV GH EDUUHUD GH ORV FXDOHV ORV PiV GLIXQGLGRVVRQORVFRQGRQHVPDVFXOLQRV7DPELpQKD\FRQGRQHVIHPHQLQRVGLDIUDJPDV FDSXFKRQHV\HVSHUPLFLGDV /DV PXMHUHV FRQ FXDGURV FOtQLFRV SDWROyJLFRV TXH KDFHQ GHO HPEDUD]R XQ ULHVJR LQDFHSWDEOH GHEHUiQ VHU LQIRUPDGDV TXH ORV PpWRGRV GH EDUUHUD SXHGHQ QR VHU OD PHMRURSFLyQFXDQGRVRQXVDGRVGHPDQHUDLQFRQVWDQWHHLQFRUUHFWDGHELGRDVXDOWR tQGLFHGHIDOODV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR x &RQGyQPDVFXOLQRMXQWRFRQHOFRQGyQIHPHQLQRDGHPiVGHVHUDQWLFRQFHS WLYRV VRQ ORV ~QLFRV PpWRGRV TXH SURWHJHQ GH ODV LQIHFFLRQHV GH WUDQVPLVLyQ VH[XDO\HO9,+6,'$GREOHSURWHFFLyQ3RUHVWDUD]yQVHGHEHHVWLPXODUVXXVR D~QHQPXMHUHVXKRPEUHVTXHXVDQRWURVPpWRGRVFRQWUDFHSWLYRV'HODPLVPD PDQHUDVLH[LVWHULHVJRGH,769,+GXUDQWHHOHPEDUD]RVHDFRQVHMDUiVXXVR GXUDQWHWRGRHVWHSHUtRGR $XQTXH HVWH HV XQ PpWRGR HPLQHQWHPHQWH PDVFXOLQR ORV SURYHHGRUHV GHEHUiQ HVWLPXODU HO HMHUFLFLR GH ORV GHUHFKRV VH[XDOHV \ UHSURGXFWLYRV GH ODV PXMHUHV SDUD TXHDWUDYpVGHSURFHVRVGH³QHJRFLDFLyQ´FRQVLJDQHVWLPXODUHOXVRGHOFRQGyQSRU SDUWHGHVXVSDUHMDV &RQVHMRVDGDUDORVXVXDULRV x 3UHFDXFLRQHV SUHYLDV DO XVR VH GHEHUi LQVWUXLU HQ YHUL¿FDU OD HODVWLFLGDG GHO FRQWHQLGR HQ HO HQYDVH DLUH \ PRYLOLGDG VL HO FLHUUH HV KHUPpWLFR TXH QR HVWpQYHQFLGRVHQFDVRTXHHOHQYDVHVRORFXHQWHFRQIHFKDGHIDEULFDFLyQVH DGPLWHQKDVWDDxRVGHYDOLGH] x 3UHFDXFLRQHV GXUDQWH HO XVR QR DEULU HO HQYROWRULR FRQ ORV GLHQWHV FRORFDUOR SUHYLRDOFRLWRHQHOSHQHHUHFWR$OFRORFDUORVHGHEHGHMDUXQDSHTXHxDSRUFLyQ OLEUHVREUHHOJODQGH\OXHJRGHVHQUROODUOR5HWLUDUHOSHQHGHODYDJLQDPLHQWUDV VHHQFXHQWUDHUHFWRVXMHWDQGRHOFRQGyQGHVGHVXDQLOOR&KHTXHDUTXHQRKD KDELGRURWXUD8WLOL]DUXQQXHYRFRQGyQHQFDGDFRLWR 5HFRUGDUTXHHQFDVRGHURWXUDRTXHKD\DTXHGDGRHOFRQGyQHQODYDJLQDVHSRGUi HPSOHDUDQWLFRQFHSWLYRVGHHPHUJHQFLD )DOODVHQFRQGLFLRQHVLGHDOHVODVIDOODVOOHJDQDO\HQFRQGLFLRQHVUHDOHVGHXVR DXPHQWDQKDVWDHO 9HQWDMDVSURWHJHQFRQWUDODV,769,+6,'$1RWLHQHQRWURVHIHFWRVLPSRUWDQWHVVREUH OD VDOXG GH OD PXMHU QL GHO KRPEUH 6RQ GH EDMR FRVWR \ VRQ IiFLOPHQWH DFFHVLEOHV 3XHGHQFRQWULEXLUDUHWDUGDUODH\DFXODFLyQSUHFR] 'HVYHQWDMDVUHTXLHUHPRWLYDFLyQSDUDVXXVRFRQVWDQWH(QSHUVRQDVDOpUJLFRVSXHGH KDEHUKLSHUVHQVLELOLGDGDOOiWH[RDORVOXEULFDQWHVTXHFRQWLHQHQ(QFDVRGHDOHUJLD DO OiWH[ VH SRGUiQ XVDU FRQGRQHV GH SROLXUHWDQR R GH SLHO GH FRUGHUR HVWRV ~OWLPRV QDWXUDOHV VRQ VHQVLEOHPHQWH PHQRV HIHFWLYRV SDUD SURWHJHU FRQWUD ODV ,76 ± 9,+ 6,'$TXHORVFRQGRQHVGHOiWH[ x &RQGyQIHPHQLQRHVXQDIXQGDGHOJDGDVXDYH\KROJDGDGHPDWHULDOSOiVWLFR TXHVHFRORFDHQHOLQWHULRUGHODYDJLQDDODTXHFXEUHHQVXWRWDOLGDG7LHQH GRVDQLOORVÀH[LEOHVXQRLQWHULRUHQHOH[WUHPRFHUUDGRTXHVHXVDSDUDLQVHUWDU \FRORFDUHOGLVSRVLWLYRGHQWURGHODYDJLQD\XQRH[WHULRUTXHTXHGDIXHUDGHOD YDJLQD\FXEUHORVJHQLWDOHVH[WHUQRV &RQVHMRVDGDUDODVXVXDULDV 6HSXHGHLQVHUWDUKDVWDKRUDVDQWHVGHOFRLWR 6XFRORFDFLyQVHKDFHRSULPLHQGRHODQLOORTXHVHHQFXHQWUDHQHOH[WUHPRFHUUDGRGHO FRQGyQHLQWURGXFLpQGRORORPiVSURIXQGDPHQWHSRVLEOHHQODYDJLQDHVWHH[WUHPR FXEULUi HO FpUYL[ 6H UHFRPHQGDUi TXH HO H[WUHPR VXSHUH OD SUR\HFFLyQ GHO KXHVR S~ELFR\TXHHOFRQGyQQRKD\DTXHGDGRWRUFLGR (OH[WUHPRDELHUWRTXHGDUiSRUIXHUDGHODYDJLQDFRPRVHGHVFULELyDQWHV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD $OWHUPLQDUHOFRLWRVHSUHVLRQDUiHODQLOORH[WHULRU\VHORWRUFLRQDUiGHPDQHUDTXHDO VDFDUORHOVHPHQTXHGHFRQWHQLGRHQpOPLHQWUDVVHWUDFFLRQDVXDYHPHQWH /RVFRQGRQHVIHPHQLQRVQRGHEHUtDQUHXWLOL]DUVH )DOODVHQFRQGLFLRQHVLGHDOHVIDOODHQPHQRVGHOGHORVFDVRV\HQFRQGLFLRQHV UHDOHVGHXVRWLHQHKDVWDXQGHIDOODV 9HQWDMDV3URWHJHQFRQWUDODV,769,+6,'$6XXVRGHSHQGHH[FOXVLYDPHQWHGHOD YROXQWDGGHODPXMHU1RWLHQHQRWURVHIHFWRVLPSRUWDQWHVVREUHODVDOXGGHODPXMHU QLGHOKRPEUH 'HVYHQWDMDVHVPiVFRVWRVRTXHHOFRQGyQPDVFXOLQRHVSRFRGLVFUHWRUXLGRVR 3XHGHVHUGLItFLOGHFRORFDU\GHH[WUDHU x 'LDIUDJPDFRQVLVWHHQXQ³FDSXFKyQ´GHOiWH[RVLOLFRQDTXHFXEUHHOFpUYL[ 'HEHFRORFDUVHHQODYDJLQDKDVWDKRUDVDQWHVGHODUHODFLyQVH[XDO\SXHGH TXHGDU HQ YDJLQD KDVWD QR PiV GH KRUDV GHVSXpV GH OD UHODFLyQ VH[XDO 6X XVR GHEH DVRFLDUVH DO GH HVSHUPLFLGDV SDUD DXPHQWDU VX HIHFWLYLGDG 'HVSXpVGHH[WUDHUORGHEHODYDUVH\JXDUGDUVHHQXQHVWXFKHHVSHFLDO )DOODVHQFRQGLFLRQHVLGHDOHVVHREVHUYDKDVWDXQGHIDOODV\HQFRQGLFLRQHV UHDOHVGHXVRWLHQHKDVWDXQGHIDOODV 9HQWDMDV7LHQHSURWHFFLyQSDUFLDOFRQWUDDOJXQDV,766XXVRGHSHQGHH[FOXVLYDPHQWH GHODYROXQWDGGHODPXMHUSXHGHVHUXVDGRGXUDQWHODPHQVWUXDFLyQHVGLVFUHWR1R WLHQHRWURVHIHFWRVLPSRUWDQWHVVREUHODVDOXGGHODPXMHUQLGHOKRPEUH 'HVYHQWDMDV HV PiV FRVWRVR TXH ORV FRQGRQHV \ UHTXLHUH XQD YDORUDFLyQ PpGLFD SUHYLD QR SURWHJH FRQWUD HO 9,+6,'$ SXHGH SURYRFDU DOHUJLD DO OiWH[ DOJXQDV PXMHUHVWHQGUiQGL¿FXOWDGSDUDFRORFDUOR8VDUORHQIRUPDFRQWLQXDSRUPiVGH KRUDVSXHGHDXPHQWDUHOULHVJRGHVXIULUXQVKRFNWy[LFR 1RGHEHQVHUXVDGRVFRQPHGLFDFLyQROXEULFDQWHVGHEDVHROHRVD x (VSRQMDVVHWUDWDGHYHUGDGHUDVHVSRQMDVLPSUHJQDGDVHQHVSHUPLFLGDTXH VHFRORFDQHQODYDJLQDDQWHVGHODUHODFLyQVH[XDO$OLJXDOTXHHOGLDIUDJPD GHEHFRORFDUVHHQODYDJLQDKDVWDKRUDVDQWHVGHODUHODFLyQVH[XDO\SXHGH TXHGDUHQYDJLQDKDVWDQRPiVGHKRUDVGHVSXpVGHODUHODFLyQVH[XDO )DOODVYDUtDQVHJ~QVHWUDWDGHQXOtSDUDVRPXOWtSDUDV(QQXOtSDUDVHQFRQGLFLRQHV LGHDOHVGHXVRVHREVHUYDKDVWDXQGHIDOODV\HQFRQGLFLRQHVUHDOHVGHXVR KDVWD XQ GH IDOODV (Q PXOWtSDUDV HQ FRQGLFLRQHV LGHDOHV GH XVR VH REVHUYD KDVWDXQGHIDOODV\HQFRQGLFLRQHVUHDOHVGHXVRKDVWDXQGHIDOODV 1RHVXQPpWRGRUHFRPHQGDEOHSDUDPXMHUHVPXOWtSDUDV 9HQWDMDV6XXVRGHSHQGHH[FOXVLYDPHQWHGHODYROXQWDGGHODPXMHUH[LVWHXQ~QLFR WDPDxR\QRUHTXLHUHSUHVFULSFLyQPpGLFDQRWLHQHHIHFWRVLPSRUWDQWHVVREUHODVDOXG GHODPXMHUQLGHOKRPEUH 'HVYHQWDMDVQRSURWHJHFRQWUDHO9,+6,'$SXHGHSURYRFDUDOHUJLDDOJXQDVPXMHUHV WHQGUiQ GL¿FXOWDG SDUD FRORFDUOR \ SDUD UHWLUDUOR 1R SXHGH VHU XVDGR GXUDQWH OD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR PHQVWUXDFLyQ8VDUORHQIRUPDFRQWLQXDSRUPiVGHKRUDVSXHGHDXPHQWDUHOULHVJR GHVXIULUXQVKRFNWy[LFR &RQWUDFHSFLyQGHHPHUJHQFLD /RVFRQWUDFHSFLyQGHHPHUJHQFLDLQFOX\HPpWRGRVKRUPRQDOHV /RV FRQWUDFHSWLYRV KRUPRQDOHV GH HPHUJHQFLD WDO FRPR OR GLFH VX QRPEUH KDQ VLGR GLVHxDGRV SDUD VLWXDFLRQHV HVSHFLDOHV DO VHU PHQRV HIHFWLYRV TXH ORV PpWRGRV GH XVRUHJXODUVRQUHFRPHQGDGRVH[FOXVLYDPHQWHSDUDVLWXDFLRQHVGHHPHUJHQFLD3RU VLWXDFLRQHV GH HPHUJHQFLD VH HQWLHQGH D WRGD UHODFLyQ VLQ SURWHFFLyQ VLQ GHVHR GH FRQFHSFLyQ FDVRV GH YLROHQFLD VH[XDO R FXDQGR KD KDELGR LQFRQYHQLHQWHV FRQ HO PpWRGRDQWLFRQFHSWLYRKDELWXDO ([LVWHQFRQWUDFHSWLYRVFRPELQDGRVHVWUyJHQR±SURJHVWiJHQRV\GHSURJHVWiJHQRV H[FOXVLYRVLQGHSHQGLHQWHPHQWHGHFXDOVHXVHH[LVWHHYLGHQFLDVX¿FLHQWHSDUDDVHVRUDU DODVXVXDULDVD¿UPDQGRTXHQRLQWHUUXPSHQXQHPEDUD]RHVWDEOHFLGR &RQVHMRVSDUDODVXVXDULDV /D H¿FDFLD FRQWUDFHSWLYD VH UHODFLRQD FRQ HO WLHPSR TXH WUDQVFXUUH HQWUH OD UHODFLyQ VH[XDO QR SURWHJLGD \ OD WRPD GHO DQWLFRQFHSWLYR GH HPHUJHQFLD 6RQ PiV HIHFWLYRV FXDQWRPHQRUVHDHOWLHPSRWUDQVFXUULGRGHVGHHOFRLWRKDVWDODWRPDSRUORTXHVH HVWLPXODUi WRPDU HO FRQWUDFHSWLYR OR DQWHV SRVLEOH 6H VHxDOD TXH OD HIHFWLYLGDG HV Pi[LPD KDVWD ODV KRUDV SRVWFRLWR DXQTXH OD HIHFWLYLGDG VH GHEH DGYHUWLU D ODV XVXDULDVTXHD~QKDVWDORVGtDVSRVWHULRUHVDOFRLWRD~QSHUVLVWHXQHOHYDGRJUDGR GHHIHFWLYLGDG x &RQWUDFHSWLYRV FRPELQDGRV ³UpJLPHQ GH <X]SH´ VH HPSOHDQ GRV GRVLV GH PLFURJUDPRV GH HWLQLOHVWUDGLRO PLFURJUDPRV GH OHYRQRUJHVWUHO FDGDXQDVHSDUDGDVSRUXQLQWHUYDORGHKRUDVLQLFLiQGRODVGHQWURGHODV KRUDVGHODUHODFLyQQRSURWHJLGD&RPRDOWHUQDWLYDHQDTXHOORVOXJDUHVTXHQR FXHQWHQFRQSUHSDUDGRVGHHPHUJHQFLDHVSHFt¿FRVVHSXHGHXVDUStOGRUDVGH XQFRQWUDFHSWLYRFRPELQDGRWUDGLFLRQDOFRQGRVLVVLPLODUHVRVXSHULRUHVDODV GHO0LFURJ\QyQ x &RQWUDFHSWLYRV GH /HYRQRUJHVWUHO VROR VH UHFRPLHQGD OD WRPD GH ODV GRV StOGRUDVTXHWUDHHOHQYDVHMXQWDVHQXQDVRODYH]2HQVXGHIHFWRWRPDUODV HQIRUPDFOiVLFDXQSULPHUFRPSULPLGRORDQWHVSRVLEOH\HOVHJXQGRKRUDV GHVSXpV /RV FRQWUDFHSWLYRV GH HPHUJHQFLD WLHQHQ P~OWLSOHV PHFDQLVPRV GH DFFLyQ 3XHGHQ LQWHUIHULU FRQ HO GHVDUUROOR IROLFXODU HO PRFR FHUYLFDO OD PLJUDFLyQ HVSHUPiWLFD \ OD IHUWLOL]DFLyQ &RQWUDLQGLFDFLRQHV 1RVHFRQRFHQSRUHOPRPHQWR )DOODV /DVIDOODVYDUtDQVHJ~QHOWLHPSRTXHSDVHHQWUHODUHODFLyQQRSURWHJLGD\ODWRPDGHOD StOGRUD'HHVWDPDQHUDOD206FRPXQLFyIDOODVGHDSHQDVXQFXDQGRHOPpWRGR VHXVyHQODVSULPHUDVKRUDV\GHFXDQGRVHXVyHQWUHODV\KRUDVGHVGH HOFRLWR&XDQGRVHDQDOL]DQODVIDOODVHQJHQHUDOLQGHSHQGLHQWHPHQWHGHOPRPHQWRGH WRPDODVPLVPDVVHVLW~DQDOUHGHGRUGHODO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 9HQWDMDV 6RQGHFRVWREDMRGHIiFLOWRPD\QRVHFRQRFHQHIHFWRVPpGLFRVDGYHUVRVJUDYHVQL WHUDWRJpQLFRV 'HVYHQWDMDV 1RSURWHJHQFRQWUD,769,+6,'$ 3XHGHQSURYRFDUQiXVHDV\YyPLWRVHVSHFLDOPHQWHHOUpJLPHQGH<X]SHSRUORTXH HQ FDVRV GH YyPLWRV UHLWHUDGRV VH SXHGH LQWHQWDU VX XVR SRU YtD YDJLQDO FRPR XQD RSFLyQDOWHUQDWLYD7DPELpQSXHGHQSURYRFDURWURVHIHFWRVLQGHVHDEOHVFRPRFHIDOHDV PDUHRVVHQVLELOLGDGPDPDULD\VDQJUDGRV &RQWUDFHSWLYRVKRUPRQDOHV ([LVWH JUDQ YDULHGDG GH FRQWUDFHSWLYRV KRUPRQDOHV OD PD\RUtD FRPELQDQ HVWUyJHQRV \ SURJHVWiJHQRV DXQTXH WDPELpQ H[LVWHQ ORV FRQWUDFHSWLYRV H[FOXVLYDPHQWH GH SURJHVWiJHQRV 'HDFXHUGRDVXIRUPDGHXVRVHORVFODVL¿FDHQ 2UDOHVLQ\HFWDEOHVWUDQVGpUPLFRVYDJLQDOHVHLPSODQWHV x&RQWUDFHSWLYRV2UDOHV&RPELQDGRV 0RGRGHXVR (Q WRGRV ORV HVTXHPDV \D VHD GH R FRPSULPLGRV HO SULPHU SDTXHWH VH FRPHQ]DUiHOSULPHUGtDGHODPHQVWUXDFLyQ\DSDUWLUGHDKtVHWRPDUiXQFRPSULPLGR WRGRVORVGtDVSUHIHUHQWHPHQWHDODPLVPDKRUDSDUDJHQHUDUKiELWR\HYLWDUROYLGRV (QORVHVTXHPDVGHFRPSULPLGRVVHKDUiXQDVHPDQDGHSDXVDHQWUHHO~OWLPR FRPSULPLGRGHOSDTXHWHDFWXDO\HOSULPHURGHOVLJXLHQWHFRPHQ]DQGRDOGtDGHVGH HO~OWLPRFRPSULPLGR (QORVHVTXHPDVGHGtDVORVSDTXHWHVVHWRPDQHQIRUPDFRQWLQXD\QRVHGHEH KDFHUSDXVDHQWUHSDTXHWHV (QFDVRGHROYLGRVVHUHFRPHQGDUiQODVVLJXLHQWHVFRQGXFWDV FRPSULPLGR UHFRPHQGDU VX WRPD OR DQWHV SRVLEOH \ OD VLJXLHQWH D OD KRUD KDELWXDO SXHGH VHU QHFHVDULR WRPDU ODV GRV StOGRUDV MXQWDV 1R VH UHTXLHUHQ FXLGDGRVHVSHFLDOHVVLVHFRQWLQ~DFRQHOPpWRGRHQIRUPDFRUUHFWD DStOGRUDVHQODSULPHUDVHPDQDUHFRPHQGDUWRPDUOD~OWLPDStOGRUDROYLGDGD GHVFDUWDUODVTXHIXHURQSUHYLDPHQWHROYLGDGDVFRQWLQXDUFRQHOWUDWDPLHQWR\ SURSRQHUDQWLFRQFHSFLyQFRQPpWRGRVGHEDUUHUD D StOGRUDV HQ OD PLWDG R DO ¿QDO GHO SDTXHWH VH GHEH UHFRPHQGDU HO XVR GHO FRQWUDFHSWLYR LJXDO TXH HQ HO FDVR DQWHULRU SHUR \D QR VHUi QHFHVDULD OD SURWHFFLyQFRQRWURPpWRGR 6L HO ROYLGR HV GH R PiV StOGRUDV VH GHEH DFWXDU FRPR HQ OD VLWXDFLyQ &RQWLQXDUWRPDQGRODVStOGRUDVUHVWDQWHV\XVDUPpWRGRVGHEDUUHUD 6HGHEHUiVXJHULUXQPpWRGRGHEDUUHUDHQODVVLJXLHQWHVVLWXDFLRQHV x (QORVFDVRVGHROYLGR x (QORVSULPHURVTXLQFHGtDVTXHVHFRPLHQ]DDXVDUXQFRQWUDFHSWLYRRUDO x $QWHWUDVWRUQRVGLJHVWLYRVYyPLWRVGLDUUHD x 8VRGHPHGLFDPHQWRVTXHDIHFWHQHOPHWDEROLVPRKHSiWLFR x 6DQJUDGRVDQRUPDOHV x 3UREDELOLGDGGH,76,75 &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &RQWUDLQGLFDFLRQHV &XDGUR &RQWUDLQGLFDFLRQHVDEVROXWDV &RQWUDLQGLFDFLRQHVUHODWLYDV Antecedentes de Antecedentes de Enfermedades Abuso de tabaco tromboembolismo tromboflebitis renales Mujeres mayores Enfermedades Ateroesclerosis Cáncer de mama de 40 años cardíacas Cáncer de endometrio Hepatopatías Hipertensión Diabetes Anemia falciforme Embarazo Hiperlipidemia Metrorragia sin diagnóstico )DOODV HQ FRQGLFLRQHV LGHDOHV GH XVR VRQ GH HQ FRQGLFLRQHV UHDOHV GH XVR OOHJDQKDVWDHO 9HQWDMDV 5HJXODQHOFLFORPHQVWUXDOHQDTXHOODVPXMHUHVTXHORQHFHVLWDQ 0HMRUDQODGLVPHQRUUHD\HOGRORUSpOYLFRYLQFXODGRDODRYXODFLyQ 'LVPLQX\HQODDQHPLDFUyQLFD 'HVYHQWDMDV 1RSUHYLHQHQFRQWUDODV,76,759,+6,'$QLODKHSDWLWLVWUDQVPLWLGDVH[XDOPHQWH 1RSXHGHQXVDUVHGXUDQWHODODFWDQFLD 5HTXLHUHQHVIXHU]RGHPHPRULD\FDSDFLGDGGHFRPSUHQVLyQ 3XHGHQSUHVHQWDUHIHFWRVVHFXQGDULRVQiXVHDVYyPLWRVDXPHQWRGHSHVRHGHPD WHQVLyQ PDPDULD GHSUHVLyQ DPHQRUUHD VDQJUDGR LQWROHUDQFLD D ORV KLGUDWRV GH FDUERQRDVPDKLSHUOLSLGHPLDDJUDYDPLHQWRGHODVPLJUDxDVODVHQIHUPHGDGHVGHO FRUD]yQUHQDOHVRODHSLOHSVLDVLH[LVWtDQSUHYLDPHQWH ,QFUHPHQWDQGHDYHFHVPiVHOULHVJRGHWURPERVLVYHQRVDVLVHORVFRPSDUDFRQ PXMHUHVTXHQRXVDQPpWRGRVKRUPRQDOHV $XPHQWDQOLJHUDPHQWHHOULHVJRGHFiQFHUGHPDPD x $QWLFRQFHSWLYRV,Q\HFWDEOHV&RPELQDGRV /RV$,&HVWiQFRPSXHVWRVSRUXQHVWUyJHQRQDWXUDOPiVXQDSURJHVWLQDSURJHVWiJHQR \DFW~DQSULQFLSDOPHQWHPHGLDQWHODLQKLELFLyQGHODRYXODFLyQ /RV DQWLFRQFHSWLYRV LQ\HFWDEOHV FRPELQDGRV $,& PiV XVDGRV FRPSUHQGHQ ODV VLJXLHQWHVFRPELQDFLRQHV PJ GH DFHWDWR GH PHGUR[LSURJHVWHURQD PiV PJ GH FLSLRQDWR GH HVWUDGLRO &\FORIHP PJ(QDQWDWRGHQRUHWLVWHURQDPiVPJYDOHUDWRGHHVWUDGLRO0HVLJ\QD 9HQWDMDV /RVHVWUyJHQRVGHORV$,&DOVHUQDWXUDOHVWLHQHQXQDDFFLyQPiV¿VLROyJLFD\ORVHIHFWRV VHFXQGDULRV UHVXOWDQ PHQRV SRWHQWHV TXH OD SURGXFLGD SRU ORV HVWUyJHQRV VLQWpWLFRV FRQWHQLGRVHQORVDQWLFRQFHSWLYRVRUDOHVFRPELQDGRV$2&$GHPiVODDGPLQLVWUDFLyQ SRUYtDSDUHQWHUDOHOLPLQDHOSDVRKRUPRQDOSRUHOKtJDGR /RV$,&FRQVWLWX\HQXQPpWRGRUHODWLYDPHQWHQXHYRHQFRPSDUDFLyQFRQORV$2&/RV HVWXGLRVH[LVWHQWHVVRQDFRUWRSOD]R\ORVUHVXOWDGRVPXHVWUDQHIHFWRVVHFXQGDULRV PiVOHYHVTXHORVSURGXFLGRVSRUORV$2&VREUHHODSDUDWRFDUGLRYDVFXODUPHWDEyOLFR ODFRDJXODFLyQ\ODIXQFLyQKHSiWLFD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 6H UHTXLHUHQ GH HVWXGLRV TXH PXHVWUHQ UHVXOWDGRV D ODUJR SOD]R 6LQ HPEDUJR ODV HYLGHQFLDV GLVSRQLEOHV GH ORV $2& VH DSOLFDQ SDUD ORV $,& HQ OD PD\RUtD GH ODV LQVWDQFLDVFRQDOJXQDVH[FHSFLRQHV $PERVSURGXFWRVVRQDOWDPHQWHH¿FDFHV/DWDVDGHIDOODHQGRFHPHVHVGHXVRHVWi HQWUH\'HVSXpVGHVXVSHQGLGRHO$,&HOUHWRUQRGHODIHUWLOLGDGHQSURPHGLR FRUUHVSRQGHDWUHVPHVHV 7LHQHHIHFWRVEHQH¿FLRVRVVREUHHOFRQWUROGHOFLFORODGLVPHQRUUHD\HOPHWDEROLVPR yVHR1RSURGXFHPRGL¿FDFLRQHVVLJQL¿FDWLYDVHQODSUHVLyQDUWHULDOQLHQORVIDFWRUHV GHODFRDJXODFLyQ (IHFWRVVHFXQGDULRV 'XUDQWHORSULPHURVPHVHVGHXVRSXHGHQDVRFLDUVHLUUHJXODULGDGHVPHQVWUXDOHV $OJXQDVXVXDULDVSXHGHQSUHVHQWDUJDQDQFLDGHSHVRWUDQVLWRULDTXHQRVXSHUDORV .JFHIDOHDVPDUHRVRPDVWDOJLD 6HJ~Q OD 206 ORV$,& FRPSUHQGLGRV HQ OD FDWHJRUtD QR VH SXHGHQ XVDU HQ ODV VLJXLHQWHVVLWXDFLRQHV (PEDUD]RRVRVSHFKD 0XMHUHQSHUtRGRGHODFWDQFLDFXUVDQGRSXHUSHULRLQIHULRUDVHLVVHPDQDV 0~OWLSOHVULHVJRVFRQYDULRVIDFWRUHVDVRFLDGRVHQIHUPHGDGDUWHULDOYDVFXODU PXMHUPD\RUIXPDGRUDKLSHUWHQVLyQDUWHULDO\GLDEHWHV&DWHJRUtD± +LSHUWHQVLyQDUWHULDO!R +LSHUWHQVLyQDUWHULDOFRQHQIHUPHGDGYDVFXODU )XPDGRUDGHPiVGHFLJDUULOORVSRUGtD\PD\RUGHDxRV &HIDOHDVGHWLSRPLJUDxDFRQVtQWRPDVQHXUROyJLFRVIRFDOHV $QWHFHGHQWHVRSUHVHQFLDGHWURPERVLVYHQRVDSURIXQGDRHPEROLDSXOPRQDU $QWHFHGHQWHVRSUHVHQFLDGHFDUGLRSDWtDLVTXpPLFDLQIDUWRDJXGRGHPLRFDUGLR DFFLGHQWHYDVFXODUHQFHIiOLFRGHHQIHUPHGDGYDOYXODUFRPSOLFDGD 'LDEHWHV FRQ HQIHUPHGDG YDVFXODU FRPSOLFDGD R FRQ PiV GH DxRV GH HYROXFLyQ&DWHJRUtD &iQFHUGHPDPDHQFXUVR &LUURVLVVHYHUD +HSDWLWLVDFWLYD 7XPRUHVGHKtJDGR &LUXJtDPD\RUFRQLQPRYLOL]DFLyQSURORQJDGD 0RGRGHXVR (O$,&VHDGPLQLVWUDSRUYtDLQWUDPXVFXODUSURIXQGDPHQVXDOPHQWHFRQXQPDUJHQGH FRORFDFLyQGHPiV±PHQRVWUHVGtDV 6yORHOSULPHULQ\HFWDEOHVHYLQFXODFRQODPHQVWUXDFLyQ\VHLQLFLDSUHIHUHQWHPHQWHHQ ORVSULPHURVGtDV/RVVLJXLHQWHVLQ\HFWDEOHVVHFRORFDQXQDYH]SRUPHVHQODPLVPD IHFKDLQGHSHQGLHQWHPHQWHGHODPHQVWUXDFLyQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $ODVGRVVHPDQDVGHODFRORFDFLyQDSDUHFHXQVDQJUDGRPHQVWUXDOFDXVDGRSRUHO $,&\HVQRUPDO3RVWHULRUPHQWHODPHQVWUXDFLyQVHSUHVHQWDUiXQDYH]SRUPHV (O$,&QRGHEHVXVSHQGHUVHFRQODDSDULFLyQGHJRWHRLUUHJXODULGDGHVPHQVWUXDOHVR DPHQRUUHD6yORVHVXVSHQGHVLORVVtQWRPDVVRQPX\LQWHQVRV\VHFRPSUXHEDTXH VRQVHFXQGDULDVDOXVRGHOPpWRGR\WDPELpQVLVHSUHVHQWDDOJXQDGHODVFRQGLFLRQHV LQFOXLGDVHQODFDWHJRUtDGHOD206FRUUHVSRQGLHQWHDFDGD$,& 1R VH UHFRPLHQGD VX XVR GXUDQWH OD ODFWDQFLD HVSHFLDOPHQWH GXUDQWH ORV SULPHURV VHLV PHVHV 6L QR KD\ ODFWDQFLD HO SULPHU LQ\HFWDEOH VH DGPLQLVWUD GHVSXpV GH OD WHUFHUDVHPDQDSRVSDUWR(QFDVRGHDERUWRVHSXHGHFRPHQ]DULQPHGLDWDPHQWHHQ HOSHUtRGRSRVDERUWR x 3DUFKHVFRQWUDFHSWLYRV &RQWLHQHQHWLQ\OHVWUDGLRO\QRUHOJHVWURPLQVXPHFDQLVPRGHDFFLyQHVVLPLODUDOGH ORVFRQWUDFHSWLYRVKRUPRQDOHVFRPELQDGRV 0RGRGHXVR 6HDSOLFDQDSDUWLUGHOSULPHUGtDGHOFLFOR\VRQFDPELDGRVGXUDQWHWUHVVHPDQDV HQODFXDUWDVHPDQDQRVHDSOLFDXQQXHYRSDUFKHUHFLpQDODTXLQWDVHPDQDVH FRPHQ]DUiXQDQXHYDVHULHGHWUHVSDUFKHV$GPLWHQXQUHWUDVRHQODDSOLFDFLyQGH KDVWDKRUDV6HVXJLHUHFRORFDUORVFRQODSLHOVHFDHQGRUVRJO~WHRV\EUD]RVR HQFXDOTXLHURWUD]RQDDOHMDGDGHPDPDV\JHQLWDOHV &RPSDUWHQ ODV PLVPDV YHQWDMDV GHVYHQWDMDV FRQWUDLQGLFDFLRQHV \ IDOODV TXH ORV FRQWUDFHSWLYRVRUDOHVFRPELQDGRV3UHVHQWDQODYHQWDMDGHQRSURYRFDUWUDVWRUQRV GLJHVWLYRV/DVGHVYHQWDMDVSDUWLFXODUHVGHHVWHPpWRGRVRQVXPHQRUHIHFWLYLGDGHQ PXMHUHVFRQSHVRPD\RUD.LORVODDOHUJLDDODGKHVLYRHQHOVLWLRGHFRORFDFLyQ\ ODSRVLELOLGDGGHGHVSHJDUVH x $QLOORVFRQWUDFHSWLYRVYDJLQDOHV 6RQ DQLOORV ÀH[LEOHV \ WUDQVSDUHQWHV GH XQRV FHQWtPHWURV GH GLiPHWUR TXH FRQWLHQHQHWLQ\OHVWUDGLRO\HWRQRUJHVWUHOVXPHFDQLVPRGHDFFLyQHVVLPLODUDORVGH ORVFRQWUDFHSWLYRVRUDOHVFRPELQDGRV 0RGRGH8VR 6HGHEHFRORFDUXQDQLOORYDJLQDODOPHVGXUDQWHGtDVFRQXQSHUtRGROLEUHGHXVR GHXQDVHPDQD$GPLWHQKDVWDXQDVHPDQDGHROYLGR &RPSDUWHQHQJHQHUDOODVPLVPDVFRQWUDLQGLFDFLRQHVYHQWDMDVGHVYHQWDMDV\IDOODV TXHORVFRQWUDFHSWLYRVRUDOHVFRPELQDGRV3RUVXVFDUDFWHUtVWLFDVHVSHFLDOHVSXHGHQ SURYRFDUYDJLQLWLVOHXFRUUHD\PROHVWLDVYDJLQDOHV/DH[SXOVLyQHVXQDFRPSOLFDFLyQ SRFRIUHFXHQWH3XHGHQHVWDUFRQWUDLQGLFDGDVXFRORFDFLyQHQSURODSVRVYDJLQDOHV GHWHUFHUJUDGRRHQFDVRGHVLQHTXLDVYDJLQDOHV x &RQWUDFHSWLYRVGH3URJHVWiJHQRVVRORV ([LVWHQSUHSDUDGRVHQEDVHD/LQHVWUHQROQRUHWLQGURQDDFHWDWRGHPHGUR[LSURJHVWHURQD \OHYRQRUJHVWUHO3RUQRFRQWHQHUHVWUyJHQRVHVWiQHVSHFLDOPHQWHLQGLFDGRVHQWRGDV DTXHOODVVLWXDFLRQHVRSDWRORJtDVHQODVTXHORVHVWUyJHQRVHVWiQFRQWUDLQGLFDGRV SRUHMHPSORODFWDQFLDPXMHUHVFRQHQIHUPHGDGHVDXWRLQPXQHV 6HORVSXHGHFRQVHJXLUHQIRUPDGHFRPSULPLGRVGHXVRRUDOLPSODQWHVVXEGpUPLFRV 1RUSODQWRLQ\HFWDEOHVGHGHSyVLWR'HSRSURYHUDHWF &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 0RGRGHXVR /RVFRPSULPLGRVGHEHQWRPDUVHWRGRVORVGtDVVLQGHVFDQVR\UHVSHWDQGRHQIRUPD UHJXODUORVLQWHUYDORVHQWUHStOGRUDV6HDFRQVHMDUiXQUHWUDVRRXQDGHODQWDPLHQWR GHQRPiVGHKRUDVSDUDPDQWHQHUODHIHFWLYLGDG\HYLWDUORVHIHFWRVLQGHVHDEOHV 1RUPDOPHQWHVHHVSHUDUiDOSULPHUGtDGHODPHQVWUXDFLyQSDUDFRPHQ]DUODWRPD GHOFRQWUDFHSWLYRVHSRGUiFRPHQ]DUDODVVHLVVHPDQDVGHOSRVWSDUWRHQPXMHUHV TXHVHHQFXHQWUDQDPDPDQWDQGR /RV LQ\HFWDEOHV VH XVDQ HQ HVTXHPDV GH LQ\HFFLyQ GLIHUHQWHV GHSHQGLHQGR GHO FRPSXHVWRXVDGR/RVFRPSXHVWRVHQEDVHDDFHWDWRGHPHGUR[LSURJHVWHURQDVRQ GHXVRWULPHVWUDO/DSULPHUDLQ\HFFLyQVHDSOLFDHOSULPHUGtDGHOFLFOR\VHUHSLWH FDGDPHVHVSXGLHQGRDGHODQWDURUHWUDVDUODGRVLVKDVWDKRUDV(QHOFXDGUR TXHVHSUHVHQWDDFRQWLQXDFLyQVHUHVXPHQODVGLVWLQWDVSRVLELOLGDGHVSDUDHOLQLFLR GHOWUDWDPLHQWRFRQDQWLFRQFHSWLYRVLQ\HFWDEOHV &XDGUR0RPHQWRGHDSOLFDFLyQGHOSULPHULQ\HFWDEOH &RQFLFORVPHQVWUXDOHV (QDPHQRUUHD /DFWDQFLD (Q ORV SULPHURV GtDV GHOVDQJUDGRPHQVWUXDO \QRUHTXHULUiPHGLGDV FRQWUDFHSWLYDV FRPSOH PHQWDULDV (Q FXDOTXLHU PRPHQWR VL KD\ VHJXULGDGGHQRHVWDUHPEDUD]DGD \GHEHUiDEVWHQHUVHGHPDQWHQHU UHODFLRQHVRKDFHUORFRQSURWHFFLyQ DGLFLRQDOHQORVVLJXLHQWHVGtDV 6LKDQSDVDGRPHQRV GHPHVHVGHOSDUWR VH FRQGXFH FRPR HQ HO FDVR PXMHU HQ DPHQRUUHD $SDUWLUGHOGtDSXHGH DSOLFiUVHOH VL KD\ VHJXULGDG GH QR HVWDU HPEDUD]DGD \ GHEHUi DEVWHQHUVHGHPDQWHQHU UHODFLRQHVRKDFHUORFRQ SURWHFFLyQ DGLFLRQDO HQ ORVVLJXLHQWHVGtDV 6LKDQSDVDGRPiVGH PHVHV \ SUHVHQWD FLFORV VH GHEHUi FRQGXFLU FRPR HQ ORV FDVRV FRQ FLFORV PHQVWUXDOHV /RV LPSODQWHV VXEGpUPLFRV GHEHQ VHU HPSOD]DGRV HQ IRUPD TXLU~UJLFD SRU XQ SURYHHGRUFDSDFLWDGRVLHPSUHVHWHQJDODVHJXULGDGGHTXHODPXMHUQRVHHQFXHQWUD HPEDUD]DGDSRUHVWDUD]yQVHUiUHFRPHQGDEOHLPSODQWDUORHQORVSULPHURVVLHWHGtDV GHOFLFOR (OLPSODQWHGHEHUiVHUUHWLUDGRDORVFLQFRDxRVGHKDEHUVLGRFRORFDGR &RQWUDLQGLFDFLRQHV /DV ~QLFDV FRQWUDLQGLFDFLRQHV DEVROXWDV SDUD HO XVR GH FRQWUDFHSWLYRV HQ EDVH D SURJHVWLQDVH[FOXVLYDPHQWHODFRQVWLWX\HQXQFiQFHUGHPDPDDFWXDO\XQHPEDUD]R 3XHGHQVHUFRQWUDLQGLFDFLRQHVUHODWLYDVODVPHWURUUDJLDVVLQGLDJQyVWLFRKHSDWRSDWtDV FDUGLRSDWtDVFRDJXORSDWtDV'HEHUiFRQVLGHUDUVHHVSHFLDOPHQWHHOXVRGHLQ\HFWDEOHV GHDFHWDWRGHPHGUR[LSURJHVWHURQDHQDGROHVFHQWHV\PXMHUHVMyYHQHVSRUODSpUGLGD GHPDVDyVHD )DOODVSDUDODVStOGRUDVHQFRQGLFLRQHVLGHDOHVGHXVRHVPHQRUDO\HQFRQGLFLRQHVGH XVRKDELWXDOSXHGHQOOHJDUKDVWDXQ/RVLQ\HFWDEOHV\ORVLPSODQWHVHQFRQGLFLRQHV LGHDOHVIDOODQHQPHQRVGHXQ\HQFRQGLFLRQHVWtSLFDVGHXVRXQ 9HQWDMDV 3XHGHQ VHU XVDGRV HQ SHUtRGR GH ODFWDQFLD \ HQ PXMHUHV FRQ LQWROHUDQFLD D ORV HVWUyJHQRV 1RDXPHQWDQHOULHVJRGHWURPERVLVRDFFLGHQWHVFHUHEURYDVFXODUHV 'LVPLQX\HQODDQHPLDFUyQLFD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 'HVYHQWDMDV 1RSUHYLHQHQFRQWUDODV,76,759,+6,'$QLODKHSDWLWLVWUDQVPLWLGDVH[XDOPHQWH /DVStOGRUDVUHTXLHUHQHVIXHU]RGHPHPRULD\FDSDFLGDGGHFRPSUHQVLyQ 3XHGHQSUHVHQWDUFRPRHIHFWRVLQGHVHDEOHVFHIDOHDVDXPHQWRGHSHVRGLVPLQXFLyQ GHODSURGXFFLyQGHOHFKHWUDVWRUQRVPHQVWUXDOHVGLVPLQXFLyQGHODGHQVLGDGPLQHUDO yVHDTXLVWHVIXQFLRQDOHVGHRYDULR 'LVSRVLWLYRVLQWUDXWHULQRV (QPXFKRVSDtVHVGHOD5HJLyQVHHQFXHQWUDQGLVSRQLEOHVGRVWLSRVGHGLVSRVLWLYRV LQWUDXWHULQRVPHGLFDGRVXQRVTXHFRQWLHQHQFREUH\RWURVTXHFXHQWDQFRQXQVLVWHPD OLEHUDGRU GH KRUPRQD OHYRQRUJHVWUHO (Q DPERV FDVRV VH WUDWD GH GLVSRVLWLYRV GH SROLHWLOHQRHQIRUPDGH76RQPpWRGRVLGHDOHVSDUDDTXHOODVPXMHUHVTXHGHVHDQXQD DQWLFRQFHSFLyQUHYHUVLEOHDODUJRSOD]R 0HFDQLVPRGHDFFLyQ /RVGLVSRVLWLYRVLQWUDXWHULQRVWLHQHQQXPHURVRVPHFDQLVPRVGHDFFLyQSHURHOSULQFLSDO SDUHFH VHU OD SUHYHQFLyQ GH OD IHUWLOL]DFLyQ LQDFWLYDFLyQ GH ORV HVSHUPDWR]RLGHV DOWHUDFLyQGHODYHORFLGDGGHWUDQVSRUWHGHOyYXOR &RQWUDLQGLFDFLRQHV /DVPXMHUHVFRQLQIHFFLRQHVSpOYLFDVHQGRPHWULWLVPLRPDVVXEPXFRVRVKLSRSODVLDR PDOIRUPDFLRQHVXWHULQDV 9HQWDMDV /RV',8PHGLFDGRVFRQFREUHVRQGHEDMRFRVWR\GHODUJDYLGD~WLODxRV 7RGRV FRPSDUWHQ HQWUH VXV YHQWDMDV OD UiSLGD UHYHUVLELOLGDG GHO HIHFWR FRQWUDFHSWLYR \TXHSXHGHQVHUXVDGRVGXUDQWHODODFWDQFLD([LVWHQGXGDVVREUHHOXVRGHORV',8 PHGLFDGRV FRQ KRUPRQDV GXUDQWH OD ODFWDQFLD D VX YH] HVWRV GLVSRVLWLYRV WLHQHQ OD JUDQYHQWDMDGHGLVPLQXLUORVVDQJUDGRVPHQVWUXDOHVHLQWHUPHQVWUXDOHV 'HVYHQWDMDV /RV',8FRQKRUPRQDVWLHQHQODGHVYHQWDMDGHVHUPHQRVGXUDEOHVDxRV\WHQHUXQ FRVWRVHQVLEOHPHQWHVXSHULRUTXHORVGHFREUH$PERVWLSRVGH',8QRSURWHJHQFRQWUD ODV,76±9,+6,'$ /D 7 GH FREUH SXHGH SURYRFDU VDQJUDGR PHQVWUXDO DEXQGDQWH \ VDQJUDGRV PHVRFtFOLFRV )DOODVHQFRQGLFLRQHVLGHDOHVORV',8GHFREUHIDOODQHQXQ\HQFRQGLFLRQHV WtSLFDVGHXVRIDOODQKDVWDXQ /RV',8KRUPRQDOHVWDQWRHQFRQGLFLRQHVLGHDOHVFRPRWtSLFDVGHXVRDSHQDVIDOODQHQ HO/RTXHORVKDFHDOWDPHQWHVHJXURV 5LHVJRV /RVULHVJRVDVRFLDGRVFRQODLQVHUFLyQVRQODSHUIRUDFLyQXWHULQDDSRUPLOOD H[SXOVLyQTXHYDUtDGHVGHXQDXQHQHOSULPHUDxRGHXVR (OULHVJRGHLQIHFFLyQHVLQYHUVDPHQWHSURSRUFLRQDODOWLHPSRGHFRORFDFLyQ$XQTXH H[LVWHQHYLGHQFLDVFRQWURYHUVLDOHVSDUHFHKDEHUXQPD\RUULHVJRGHHPEDUD]RHFWySLFR HQODVPXMHUHVTXHXVDQ',8 &RORFDFLyQ /RKDELWXDOHVFRORFDUORFRQODPXMHUPHQVWUXDQGR\DTXHHVWRJDUDQWL]DODDXVHQFLDGH XQHPEDUD]R\IDFLOLWDHOSURFHGLPLHQWR 7DPELpQSXHGHFRORFDUVHIXHUDGHOSHUtRGRPHQVWUXDOGXUDQWHORVSULPHURVGtDVGHO FLFORSDUDGHVFDUWDUXQHPEDUD]R$QWHGXGDVGHXQDSRVLEOHJHVWDFLyQVHGHEHUtDQ VROLFLWDUH[iPHQHVGHJRQDGRWUR¿QDFRULyQLFDVXEXQLGDGEHWDSDUDGHVFDUWDUOD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD /DFRORFDFLyQGHO',8DQXOtSDUDVQRHVWDFRQWUDLQGLFDGD 7DPELpQHO',8VHSXHGHFRORFDUHQPRPHQWRVHVSHFLDOHVHQODOODPDGDFRORFDFLyQ SRVWHYHQWRREVWpWULFRDERUWRSDUWRFHViUHD &XDGUR,QVHUFLyQHQFRQGLFLRQHVHVSHFLDOHV Inserción en el postparto Otras situaciones Post-placentario Puerperio Inmediato Puerperal Intracesárea Post-aborto No más de 10 minutos después de la salida de la placenta. En la primera semana, no más allá de las 48 horas postparto Después de las 4 semanas postparto. Después de la revisión y limpieza endouterina, antes de la histerorrafia. Inmediatamente después de evacuados los restos ovulares y si no hay signos de infección. $QWLELyWLFRV (O XVR GH DQWLELyWLFRV VROR HVWDUi LQGLFDGR FXDQGR OD WpFQLFD GH LQVHUFLyQ KD\D VLGR ODERULRVD R SXHGD KDEHUVH SHUGLGR OD HVWHULOLGDG GHO GLVSRVLWLYR (Q HVH FDVR VHUiQ VX¿FLHQWHVKRUDVGH$PR[LFLOLQDR$PSLFLOLQD $QDOJpVLFRV 3XHGHMXVWL¿FDUVHHOXVRGHDQDOJpVLFRVGHWLSRDQWLHVSDVPyGLFRVHQODVSULPHUDV KRUDVTXHVLJXHQDODFRORFDFLyQ $GYHUWHQFLDV 6H LQGLFDUi FRQVXOWDU HQ FDVR GH H[SXOVLyQ GHO GLVSRVLWLYR GRORU TXH QR FDOPD FRQ DQDOJpVLFRVFRPXQHVÀXMRIpWLGRVLHOVDQJUDGRDXPHQWDHQGXUDFLyQ\YROXPHQ2 DQWHODSUHVHQFLDGHVDQJUDGRLQWHUPHQVWUXDO &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &XDGUR&ULWHULRVGHHOHJLELOLGDGSDUDPpWRGRVKRUPRQDOHV\GLVSRVLWLYRVLQWUD XWHULQRV Edad Desde la menarca hasta los 19 años 20 a 44 45 y más años Paridad Nulípara 1 o más partos Lactancia natural < 6 semanas postparto > 6 semanas a < 6 meses postparto > 6 meses postparto Postparto (amamantando o no) < 48 horas 48 horas a < 4 semanas > 4 semanas Postaborto 1er trimestre 2º trimestre Inmediatamente después de aborto séptico Antecedente de embarazo ectópico Historia de cirugía pélvica Fumar Edad < 35 años Edad > 35 años < 15 cigarrillos/día > 15 cigarrillos/día Obesidad > 30 Kg/m2 del índice de masa corporal (IMC) ENFERMEDADES CARDIOVASCULARES Factores múltiples de riesgo para enfermedad arterial cardiovascular (diabetes, HTA, etc.). Hipertensión Mujer con historia de HTA que no la controla Mujer con historia de HTA que la controla adecuadamente P.A. sistólica de 140 a 159 y diastólica de 90 a 99 mm Hg P.A. sistólica >160 y diastólica > 100 mm Hg Enfermedad vascular &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD LNG implantes orales intravaginales parches orales CARACTERÍSTICAS PERSONALES E HISTORIA REPRODUCTIVA DIU Cu Solo progesterona inyectables Combinados Condición 6DOXG6H[XDO\5HSURGXFWLYD Trombosis venosa profunda (TVP) y embolia pulmonar (EP) Historia de TVP/EP TVP/EP actual Historia familiar de TVP/EP (parientes de primer grado) Cirugía mayor con inmovilización prolongada Cirugía mayor sin inmovilización prolongada Cirugía menor sin inmovilización Trombosis venosa superficial Venas varicosas Tromboflebitis superficial Cardiopatía isquémica antecedentes personales o enfermedad actual Accidente cerebro vascular Hiperlipidemias conocidas Valvulopatías No complicadas Complicadas ALTERACIONES NEUROLÓGICAS Cefaleas No migrañosas Migrañosas Sin síntomas neurológicos focales Edad < 35 años Edad > 35 años Con síntomas neurológicos focales Epilepsia INFECCIONES Y ENFERMEDADES DEL TRACTO REPRODUCTIVO Patrones de sangrado vaginal Patrón irregular sin sangrado intenso Patrones regulares e irregulares con sangrado intenso Sangrado vaginal sin explicación Endometriosis Tumores benignos de ovario Dismenorrea severa Enfermedad trofoblástica gestacional Benigna Maligna Ectropion cervical Neoplasia intraepitelial cervical Cáncer cervical (esperando tratamiento) Enfermedades de la mama Tumor sin diagnóstico anatomopatológico Enfermedad benigna Historia familiar de cáncer de mama Cáncer actual Cáncer con 5 años sin evidencias de enfermedad Cáncer de endometrio Cáncer ovárico &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR Miomas uterinos Sin distorsión de la cavidad Con distorsión de la cavidad Enfermedad inflamatoria pélvica (EIP) Pasada y sin riesgo actual de ITS Con embarazo posterior Sin embarazo posterior Actual o en los últimos 3 meses ITS Actual o en los últimos 3 meses Vaginitis sin cervicitis purulenta Riesgo aumentado de ITS VIH/SIDA Alto riesgo de VIH VIH Positivo SIDA OTRAS INFECCIONES Tuberculosis Malaria ALTERACIONES ENDÓCRINAS Diabetes Diabetes gestacional Diabetes no vascular No insulino dependiente Insulino dependiente Nefropatía/retinopatía/neuropatía Otra enfermedad vascular o diabetes de más de 20 años de evolución Tiroides Bocio simple Hipertiroidismo Hipotiroidismo ALTERACIONES GASTROINTESTINALES Enfermedad de la vesícula biliar Sintomática Tratada con colecistectomía Tratada médicamente Actual Asintomática Historia de colestasis Relacionada con un embarazo Relacionada con contraceptivos Hepatitis viral Activa Portador Cirrosis Leve (compensada) Severa (descompensada) Tumores de hígado Benigno (adenoma) Maligno (hematoma) &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD ANEMIAS Talasemia Drepanocítica Ferropénica INTERACCIÓN CON DROGAS Drogas que afectan la función del hígado Algunos antibióticos (rifampicina, griseofulvina, etc.). Otros antibióticos Algunos anticonvulsivantes (fenitoina, carbamazepina, barbitúricos, etc.). Use el método en cualquier circunstancia Use generalmente el método No se recomienda el método a menos que no se disponga o no se acepten otros No usar el método 0pWRGRVLUUHYHUVLEOHV /RV PpWRGRV LUUHYHUVLEOHV IHPHQLQRV FRPR ORV PDVFXOLQRV FRPSDUWHQ OD PLVPD FODVL¿FDFLyQ HQ OR TXH D FULWHULRV GH HOHJLELOLGDG VH UH¿HUH HQ OD WDEOD VLJXLHQWH VH GH¿QHQORVFXDWURVFULWHULRVGH¿QLGRVSRUOD206 &XDGUR&DWHJRUtDVGHPpWRGRVLUUHYHUVLEOHV A C R E Aceptar No hay razones médicas para negar la esterilización a una persona en esta condición. Cuidado El procedimiento normalmente se realiza en un cuadro de rutina, pero con preparación y precauciones extra. Retrasar El procedimiento debe retrasarse hasta que la condición sea evaluada y/o corregida. Deben proveerse métodos temporales alternativos de contracepción Especial El procedimiento debe llevarse a cabo en un marco que involucre a un cirujano y personal experimentados y el equipo necesario para proveer anestesia general y otro apoyo médico de respaldo. Para estas condiciones también se necesita la capacidad de decidir sobre el procedimiento más apropiado y el régimen de anestesia. Se deben ofrecer métodos temporales alternos de contracepción, si es necesario referir al paciente . 'HELGR D TXH OD PD\RU SDUWH GH ODV FRQGLFLRQHV GH HOHJLELOLGDG FRLQFLGHQ FRQ ODV FDUDFWHUtVWLFDVGHVFULSWDVHQ$\&VRORVHUHVXPLUiQSDUDORVFDVRVGHHVWHULOL]DFLRQHV TXLU~UJLFDV ODV FRQGLFLRQHV TXH GHEHQ VHU FRQVLGHUDGDV FRQ FLHUWR JUDGR GH H[FHSFLRQDOLGDG5\( /LJDGXUDWXEDULD 6HWUDWDGHXQPpWRGRFRQWUDFHSWLYRGH¿QLWLYRTXHFRQVLVWHHQOLJDUFRUWDU\RFDXWHUL]DU RFRORFDUDQLOORVXRWURVGLVSRVLWLYRVHQODVWURPSDVGH)DORSLR(VXQSURFHGLPLHQWR TXLU~UJLFRTXHGHEHVHUHIHFWXDGRSRUSHUVRQDOFDOL¿FDGR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR /DHOHFFLyQGHODOLJDGXUDWXEDULDSRUSDUWHGHODPXMHUGHEHVHUIUXWRGHODOLEUHHOHFFLyQ D~QHQDTXHOODVVLWXDFLRQHVHQODVTXHXQDQXHYDJHVWDFLyQFRPSRUWHXQULHVJRYLWDO 3RUHVWDUD]yQVHUHTXLHUHEULQGDUODLQIRUPDFLyQQHFHVDULD\FRQODPD\RUFODULGDGD FDGDPXMHUFRQVLGHUDQGRVXQLYHOLQWHOHFWXDO\IDFWRUHVVRFLRFXOWXUDOHV 8VXDOPHQWH OD OLJDGXUD WXEDULD VH UHDOL]D HQ WUHV WLSRV GH SURFHGLPLHQWRV ORV GRV SULPHURV VXHOHQ VHU HVSHFt¿FRV SDUD HIHFWXDU OD OLJDGXUD WXEDULD PLHQWUDV TXH HQ HO WHUFHURVHODUHDOL]DFRPRLQGLFDFLyQVHFXQGDULD x 0LQLODSDURWRPtD x /DSDURVFRStD x ,QWUDFHViUHDRGXUDQWHRWURSURFHGLPLHQWRTXLU~UJLFR &XDQGRHIHFWXDUODHVWHULOL]DFLyQ /XHJRGHUHFLELUXQFRPSOHWRDVHVRUDPLHQWRFXDOTXLHUPXMHUHVWiHQFRQGLFLRQHVGH VROLFLWDUXQDHVWHULOL]DFLyQTXLU~UJLFD1RKDEHUWHQLGRKLMRVRQRHVWDUFDVDGDQRVRQ PRWLYRVSDUDQRUHDOL]DUXQDHVWHULOL]DFLyQTXLU~UJLFD6LHVWiFDVDGDVHUiVX¿FLHQWH FRQODVLPSOHYROXQWDGGHODPXMHU\QRVHQHFHVLWDUiDXWRUL]DFLyQGHOPDULGR ([LVWHQVX¿FLHQWHVHYLGHQFLDVSDUDD¿UPDUTXHODSULQFLSDOFDXVDGHDUUHSHQWLPLHQWR HQWUHODVPXMHUHVTXHVHVRPHWLHURQDHVWHULOL]DFLyQTXLU~UJLFDVHYLQFXODFRQODHGDG WHPSUDQDSDUDODUHDOL]DFLyQGHOSURFHGLPLHQWR 6LQRKD\XQDUD]yQPpGLFDTXHORLPSLGD\VLVHKDGHVFDUWDGRXQHPEDUD]RFXDOTXLHU PRPHQWRVHUiRSRUWXQRSDUDUHDOL]DUHOSURFHGLPLHQWRGHOLJDGXUD (QODVPXMHUHVTXHVHHQFXHQWUDQPHQVWUXDQGR\QRXVDQPpWRGRVFRQWUDFHSWLYRVVH UHFRPHQGDUiUHDOL]DUHOSURFHGLPLHQWRHQORVSULPHURVVLHWHGtDVGHOFLFOR 9HQWDMDV 8QDYH]UHDOL]DGDQRVHQHFHVLWDYROYHUDSHQVDUHQPpWRGRVDQWLFRQFHSWLYRV(VGH WRWDOGHFLVLyQGHODPXMHU1RVXHOHWHQHUHIHFWRVLQGHVHDEOHV\HOLPLQDHOHVIXHU]RGH PHPRULD 'HVYHQWDMDV 1RSURWHJHFRQWUDLQIHFFLRQHVGHWUDQVPLVLyQVH[XDO9,+6,'$ (VLUUHYHUVLEOH5HTXLHUHSHUVRQDOHQWUHQDGRLQYROXFUDSURFHGLPLHQWRVDQHVWpVLFRV\ TXLU~UJLFRV 5LHVJRV /D UHDOL]DFLyQ GH SURFHGLPLHQWRV TXLU~UJLFRV \ DQHVWpVLFRV D~Q FRQ DQHVWpVLFRV ORFDOHVH[SRQHDULHVJRGHFRPSOLFDFLRQHV6LELHQHOULHVJRGHHVWRVSURFHGLPLHQWRV HVH[WUHPDGDPHQWHEDMRHVQHFHVDULRLQIRUPDUDODVPXMHUHVGHTXHHOORVH[LVWHQ )DOODV 6HWUDWDGHXQRGHORVPpWRGRVFRQWUDFHSWLYRVPiVHIHFWLYRVVHHVWLPDTXHDSHQDV IDOOD HQ PHQRV GHO SRU GH ORV FDVRV PiV H[DFWDPHQWH HQ GH FDGD SURFHGLPLHQWRV HIHFWXDGRV (O ULHVJR GH IDOODV GLVPLQX\H FRQVLGHUDEOHPHQWH FRQ HO SDVRGHOWLHPSR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD &XDGUR&RQGLFLRQHVGHHOHJLELOLGDGFODVHV5\(SDUDOLJDGXUDWXEDULD Condiciones que deben retrasar el procedimiento (R) Condiciones que requieren consideraciones especiales (E) Embarazo Enfermedad trofoblástica gestacional maligna Rotura o perforación de útero Postparto de 7 a 41 días Cáncer cervical, ovárico o de endometrio Presión arterial > 160/100 mmHg. Pre-eclampsia severa/eclapmsia Enf. Inflamatoria Pélvica actual o Enfermedad vascular en los últimos tres meses Rotura prolongada de membranas ITS actual Endometriosis Sépsis o fiebre intraparto, puerperal o postaborto Enf. de vesícula biliar actual TBC pelviana Hemorragia severa antes o después del parto o del aborto Hepatitis viral activa Diabetes con nefropatía, retinopatía y/o neuropatía Trauma severo del tracto genital Hb < 7 g/dL postparto o postaborto (desgarro cervical o vaginal) Cirrosis severa (descompensada) Hematometra aguda Infección de pared abdominal Hipertiroidismo Trombosis Venosa Profunda o Trombo Embolismo Pulmonar actual Enfermedades respiratorias agudas Alteraciones de la coagulación Cirugía mayor con inmovilización Infección sistémica prolongada Enfermedades respiratorias crónicas Cardiopatía isquémica actual Utero fijo Sangrado vaginal sin explicación Hernia de la pared abdominal o umbilical /LJDGXUDGHORVGHIHUHQWHVYDVHFWRPtD 6HWUDWDGHXQPpWRGRFRQWUDFHSWLYRGH¿QLWLYRTXHFRQVLVWHHQFRUWDUOLJDU\RFDXWHUL]DU ORVFRQGXFWRVGHIHUHQWHVDQLYHOHVFURWDOSDUDLPSHGLUHOSDVDMHGHHVSHUPDWR]RLGHV (VXQSURFHGLPLHQWRTXLU~UJLFRTXHGHEHVHUHIHFWXDGRSRUSHUVRQDOFDOL¿FDGRTXHVH SXHGHUHDOL]DUSRUGLYHUVDVWpFQLFDVTXLU~UJLFDVFRQDQHVWHVLDORFDORJHQHUDO /DHOHFFLyQGHODYDVHFWRPtDSRUSDUWHGHOKRPEUHGHEHVHUIUXWRGHODOLEUHHOHFFLyQ SRUORTXHVHUHTXLHUHEULQGDUODLQIRUPDFLyQQHFHVDULD\FRQODPD\RUFODULGDGDFDGD KRPEUHFRQVLGHUDQGRVXQLYHOLQWHOHFWXDO\IDFWRUHVVRFLRFXOWXUDOHV &XDQGRHIHFWXDUODHVWHULOL]DFLyQ /XHJRGHUHFLELUXQFRPSOHWRDVHVRUDPLHQWR\VLQRKD\FRQWUDLQGLFDFLRQHVPpGLFDV FXDOTXLHUPRPHQWRHVRSRUWXQRSDUDUHDOL]DUHOSURFHGLPLHQWR 9HQWDMDV 8QDYH]UHDOL]DGDQRVHQHFHVLWDYROYHUDSHQVDUHQPpWRGRVDQWLFRQFHSWLYRV(VGH WRWDOGHFLVLyQGHOKRPEUH &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 'HVYHQWDMDV 1RSURWHJHFRQWUDLQIHFFLRQHVGHWUDQVPLVLyQVH[XDO9,+6,'$ (VLUUHYHUVLEOH5HTXLHUHSHUVRQDOHQWUHQDGRHLQYROXFUDSURFHGLPLHQWRVDQHVWpVLFRV \TXLU~UJLFRV 5LHVJRV /DV FRPSOLFDFLRQHV \ ULHVJRV VRQ H[FHSFLRQDOHV SHUR SXHGH YHUVH HQ ORV SULPHURV PHVHV \ KDVWD DOJXQRV DxRV GRORU HVFURWDO R WHVWLFXODU KHPDWRPDV R LQIHFFLRQHV ORFDOHV )DOODV 6LQRVHUHDOL]DQFRQWUROHVGHOVHPHQSXHGHQYHUVHKDVWDXQGHIDOODVHQHOSULPHU DxR(QORVKRPEUHVTXHVHHIHFW~DQH[iPHQHVGHOH\DFXODGRODVIDOODVVRQFDGD PLOOLJDGXUDV 3DUDGLVPLQXLUODSRVLELOLGDGGHIDOODVVHUHFRPLHQGDXVDUFRQGyQHQORVWUHVPHVHV VLJXLHQWHVDODOLJDGXUD &ULWHULRVGHHOHJLELOLGDG 1RKD\XQDFRQGLFLyQPpGLFDTXHUHVWULQMDGHPDQHUDDEVROXWDODHOHJLELOLGDGGHXQD SHUVRQD SDUD OD HVWHULOL]DFLyQ$OJXQDV FRQGLFLRQHV \ FLUFXQVWDQFLDV LQGLFDQ TXH VH GHEHWRPDUFLHUWDVSUHFDXFLRQHV &XDGUR&RQGLFLRQHVGHHOHJLELOLGDGFODVHV5\(SDUDYDVHFWRPLD Condiciones que deben retrasar el procedimiento (R) Condiciones que requieren consideraciones especiales (E) Infecciones locales (escrotal, orquitis, epididimitis, balanitis) Hernia inguinal ITS activa Alteraciones de la coagulación Infección sistémica o gastroenteritis SIDA Filariasis, elefantiasis Tumor intraescrotal &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD Referencias Bibliográficas Cheng L, Gülmezoglu AM, Van Oel CJ, Piaggio G, Ezcurra E, Van Look PFA. Interventions for emergency contraception. Cochrane Database of Systematic Reviews 2004, Issue 3. French R, Van Vliet H, Cowan F, Mansour D, Morris S, Hughes D, Robinson A, Proctor T, Summerbell C, Logan S, Helmerhorst F, Guillebaud J. Hormonally impregnated intrauterine systems (IUSs) versus other forms of reversible contraceptives as effective methods of preventing pregnancy. Cochrane Database of Systematic Reviews 2004, Issue 3. Litt IF. Placing emergency contraception in the hands of women. JAMA. 2005 Jan 5;293(1):98-99. Ministerio de Salud Pública. Guías en Salud Sexual y Reproductiva. Capítulo Anticoncepción (Métodos Reversibles). Montevideo - Uruguay 2005. http://www.msp.gub.uy/imgnoticias/5039.pdf Philpott A. Re-use of the female condom: now for the practical realities. Reprod Health Matters. 2003 Nov;11(22):185-186. Planned Parenthood Federation of America. Facts About Birth Control. Prescription. http://www.plannedparenthood.org/birth-control-pregnancy/birth-control/prescription.htm (Último acceso 20 de Julio de 2007) Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database of Systematic Reviews 2007, Issue 2. Power J, French R, Cowan F. Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy. Cochrane Database of Systematic Reviews 2007, Issue 3. Prine L. Emergency contraception, myths and facts. Obstet Gynecol Clin North Am. 2007 Mar; 34(1):12736, ix-x. Santelli J, Rochat R, Hartfield-Timajchy K, Colley B, Curtis K, Cabral R, Hirsch J, Schieve L, et al. 2003. The Measurement and Meaning of Unintended Pregnancy. Perspectives on Sexual and Reproductive Health 35(2): 94-101 Van der Wijden C, Kleijnen J, Van den Berk T. Lactational amenorrhea for family planning. Cochrane Database of Systematic Reviews 2003, Issue 4. WHO 2005. Emergency contraception. (Último acceso 20 de Julio de 2007) www.who.int/entity/mediacentre/factsheets/fs244/en/ WHO 2004. Medical Eligibility Criteria for Contraceptive Use. 3rd ed. 2004. http://www.who.int/reproductivehealth/publications/mec/index.htm (Último acceso 20 de Julio de 2007). WHO 2004. Selected practice recommendations for contraceptive use. 2nd ed. 2004. http://www.who.int/ reproductive-health/publications/spr/index.htm (Último acceso 20 de Julio de 2007). WHO 2007. Family Planning A global handbook for providers. 1st ed. 2007. http://www.who.int/reproductivehealth/publications/fp_globalhandbook/index.htm (Último acceso 15 de Agosto de 2007). WHO.The Female Condom: A guide for planning and programming. http://www.who.int/ reproductive-health/publications/RHR_00_8/PDF/female_condom_guide_planning_programming.pdf (Úlimo acceso 20 de Julio de 2007) WHO 2002. WHO Information Update: Considerations regarding Reuse of the Female Condom July 2002. http://www.who.int/reproductive-health/stis/docs/reuse_FC2.pdf (Último acceso 20 de Julio de 2007). WHO 2004. The male latex condom Specification and guidelines for condom procurement. http://www.who.int/reproductive-health/ publications/m_condom/who_specification_04.pdf (Último acceso 20 de Julio de 2007). &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 9,,, & $ 3, 7 8 /2 9 , , , $ERUWR 2%-(7,9265HGXFLUODPRUELPRUWDOLGDGSRUDERUWR $&7,9,'$'(6'LDJQyVWLFR\DVLVWHQFLDGHODERUWRHQORVGLVWLQWRVSHUtRGRV (ODERUWRUHTXLHUHSRUVXFRPSOHMLGDG\VHQVLELOLGDGXQHQIRTXHFRPSUHKHQVLYRGHORV VHUYLFLRV \ GH ORV SURIHVLRQDOHV GH OD VDOXG 6XV P~OWLSOHV GLPHQVLRQHV LQYROXFUDQ XQDVHULHGHDVSHFWRVFRPRORVHVSHFt¿FDPHQWHFOtQLFRVORVGHODVSHUVRQDV\HO HQWRUQRVRFLRHFRQyPLFROHJDO\pWLFR /DVFRPSOLFDFLRQHVGHODERUWRFRQVWLWX\HQXQDVGHODVSULQFLSDOHVFDXVDVGHPXHUWH PDWHUQDHQODUHJLyQ/DWLQRDPHULFDQD(OPD\RUFRPSRQHQWHGHPRUWDOLGDGSRUDERUWR VH GHEH DO DERUWR SURYRFDGR HQ FRQGLFLRQHV GH LQVHJXULGDG VLQ HPEDUJR DOJXQDV PXHUWHVVRQVHFXQGDULDVDOFRQMXQWRGHIDFWRUHVTXHGHULYDQHQXQDPDODFDOLGDG DVLVWHQFLDOGHORVVHUYLFLRVGHVDOXG 8QD GH ODV SULQFLSDOHV HVWUDWHJLDV VDQLWDULDV SDUD OD SUHYHQFLyQ GHO DERUWR LQVHJXUR FRQVLVWHHQFHQWUDUODDWHQFLyQGHODPXMHUEDVDGDHQFXDWURSLODUHVIXQGDPHQWDOHV )RPHQWDUODDWHQFLyQHQODFRPXQLGDG 3URPRYHUHODFFHVRDORV6HUYLFLRVGH6DOXG &DSDFLWDUSURIHVLRQDOHVFRQFRQRFLPLHQWRVEDVDGRVHQODHYLGHQFLDFLHQWt¿FD 3URYHHUDOWDFDOLGDGGHDVLVWHQFLDFOtQLFD\GHVHUYLFLRVGHSODQL¿FDFLyQIDPLOLDU '(),1,&,21(6 $ERUWRVHGH¿QHFRPRODH[SXOVLyQRH[WUDFFLyQGHOSURGXFWRGHODFRQFHSFLyQIXHUDGHO ~WHURPDWHUQRFRQXQSHVRLJXDORLQIHULRUDJUDPRVRDQWHVGHODVVHPDQDV $ERUWR LQVHJXUR WDPELpQ OODPDGR $ERUWR HQ FRQGLFLRQHV GH ULHVJR HV FXDQGR HO SURFHGLPLHQWR SDUD ¿QDOL]DU XQ HPEDUD]R QR GHVHDGR HV SURYRFDGR \ VH UHDOL]D SRUSHUVRQDVTXHFDUHFHQGHOHQWUHQDPLHQWRQHFHVDULRRTXHVHOOHYDDFDERHQXQ DPELHQWHGRQGHVHFDUHFHGHXQHVWiQGDUPpGLFRPtQLPRRDPERV $ERUWRKDELWXDOHVODUHSHWLFLyQGHWUHVRPiVDERUWRVHVSRQWiQHRVFRQVHFXWLYRVRGH FLQFRRPiVQRVXFHVLYRVFRQ¿JXUDHOFXDGURGHDERUWRKDELWXDO $ERUWRFRPSOHWRFRQVLVWHHQODH[SXOVLyQRH[WUDFFLyQWRWDOGHOKXHYRIXHUDGHODFDYLGDG XWHULQDHQXQWLHPSRFRPSOHWR\HQWHUR8QDYH]SURGXFLGRFHVDQODVFRQWUDFFLRQHV XWHULQDVGHVDSDUHFHHOGRORUGLVPLQX\HHOWDPDxRGHO~WHUR\HOVDQJUDGRJHQLWDOH LQYROXFLRQDQODVPRGL¿FDFLRQHVFHUYLFDOHV $ERUWR LQFRPSOHWR HV OD H[SXOVLyQ R H[WUDFFLyQ GHO KXHYR HV SDUFLDO \ TXHGDQ &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD UHWHQLGDVODSODFHQWD\RODVPHPEUDQDVRYXODUHV3HUVLVWHQODVFRQWUDFFLRQHVXWHULQDV GRORURVDV\HOVDQJUDGRJHQLWDOHO~WHURHVWiEODQGR\HOFXHOORSHUVLVWHGLODWDGR $ERUWR HVSRQWiQHR HV FXDQGR VXFHGH VLQ OD LQWHUYHQFLyQ GH FLUFXQVWDQFLDV TXH LQWHU¿HUDQDUWL¿FLDOPHQWHHQODHYROXFLyQGHODJHVWDFLyQ $ERUWRIUXVWURWDPELpQOODPDGRDERUWRGLIHULGRRKXHYRPXHUWR\UHWHQLGRHVFXDQGR HOHPEULyQRIHWRPXHUHDQWHVGHODVVHPDQDVSHURHOSURGXFWRHVUHWHQLGRD~QQR HPSH]DURQHVSRQWiQHDPHQWHODVFRQWUDFFLRQHVXWHULQDVQLKD\GLODWDFLyQFHUYLFDO6X GLDJQyVWLFRHVSRUHFRJUDItD (PEDUD]R QR YLDEOH HV FXDQGR VH KD GHWHUPLQDGR TXH HO IHWR R HPEULyQ SUHVHQWDQ XQDDIHFFLyQTXHORKDFHLQFRPSDWLEOHFRQODYLGDH[WUDXWHULQD(VWRULJHSDUDDTXHOORV SDtVHVGRQGHH[LVWHXQPDUFROHJLVODWLYRTXHORFRQWHPSOD $ERUWR WHUDSpXWLFR FXDQGR OD LQWHUUXSFLyQ GHO HPEDUD]R VH UHDOL]D FRQ ¿QHV WHUDSpXWLFRV SRU HQIHUPHGDGHV HQ ODV TXH HO HPEDUD]R SRQH HQ ULHVJR OD YLGD PDWHUQD $ERUWRWHUDSpXWLFRIDOOLGR(VWDYDULDEOHVHUHJLVWUDHQFDVRGHLQWHUUXSFLRQHVOHJDOHV TXHIUDFDVDQ/RVSURFHGLPLHQWRV\RODPHGLFDFLyQXWLOL]DGRVIXHURQLQDGHFXDGRVR LQHIHFWLYRVSDUDHVD¿QDOLGDG6LVHFRQVWDWDODIDOODRVHSUHVHQWDXQDERUWRLQFRPSOHWR VH UHTXHULUi GH XQ PpWRGR TXLU~UJLFR FRPSOHPHQWDULR SDUD OD HYDFXDFLyQ GHO ~WHUR DVSLUDFLyQDOYDFtRRGLODWDFLyQ\FXUHWDMHSDUDORVHPEDUD]RVGHOVHJXQGRWULPHVWUH 35(9$/(1&,$(,1&,'(1&,$ (ODERUWRHVSRQWiQHRRFXUUHHQHODOSRUFLHQWRGHORVHPEDUD]RVFRQRFLGRV$ VXYH]VHHVWLPDTXHDQLYHOPXQGLDOPLOORQHVGHHPEDUD]RV¿QDOL]DQHQXQDERUWR SURYRFDGRFDGDDxR\DSUR[LPDGDPHQWHPLOORQHVVRQLQVHJXURV(OGHODV PXHUWHVPDWHUQDVVHDWULEX\HQDODVFRPSOLFDFLRQHVGHDERUWRVLQVHJXURV /DVSULQFLSDOHVFDXVDVGHPXHUWHVRQODVKHPRUUDJLDVODLQIHFFLyQ\ODLQWR[LFDFLyQSRU VXVWDQFLDVXWLOL]DGDVSDUDLQGXFLUHODERUWR(OGHHVWRVVHSURGXFHQHQSDtVHVHQ GHVDUUROOR &RQUHVSHFWRDODHGDGGRVGHFDGDWUHVRFXUUHQHQPXMHUHVHQWUH\DxRV /DLQFLGHQFLDGHODERUWRLQVHJXURHQODUHJLyQGH$PpULFD/DWLQD\HO&DULEHHQHODxR VHHVWLPyHQSRUFDGDPXMHUHVHQWUH\DxRV 'HOWRWDOGHPXHUWHVPDWHUQDVHQ6XGDPpULFDGHFDGDVHGHEHQDODERUWRLQVHJXUR PLHQWUDVTXHHQ&HQWURDPpULFDHVGHFDGD\HQHO&DULEHFRUUHVSRQGHDGHFDGD )LJXUD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR )LJXUD (VWLPDFLRQHV GH LQFLGHQFLD DQXDO GHO DERUWR LQVHJXUR \ PRUWDOLGDG PDWHUQDGHELGRDOPLVPRSRUUHJLRQHV\VXEUHJLRQHVGHOPXQGRFLUFDDxR Gráfico realizado en base a los datos obtenidos del estudio de la WHO; Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2000. Fourth edition, Geneva, 2004. NOTA: En las regiones de América del Norte y Europa Occidental las estimaciones resultan insignificantes. $%2572(63217È1(2 (ODERUWRHVSRQWiQHRHVODFRPSOLFDFLyQPiVIUHFXHQWHGHOHPEDUD]R(ORFXUUH DQWHVGHODVVHPDQDVGHJHVWDFLyQ (WLRORJtD 6HHVWLPDTXHGHOWRWDOGHyYXORVIHFXQGDGRVVHSLHUGHQHQORVSULPHURVFDWRUFH GtDVGHOHPEDUD]RVLQGDUVLQWRPDWRORJtDVHSUHVHQWDQGHVSXpVGHXQEUHYHUHWUDVRR FRLQFLGHQFRQODIHFKDPHQVWUXDO &DXVDVFRQRFLGDVVHFODVL¿FDQHQRYXODUHV\H[WUDRYXODUHV &DXVDV RYXODUHV VRQ ODV PiV IUHFXHQWHV \ PiV GH OD PLWDG GH ORV DERUWRV WHPSUDQRV VH SURGXFHQ SRU XQ GHVDUUROOR HPEULROyJLFR DQRUPDO VHFXQGDULR D IDFWRUHVKHUHGLWDULRVRDGHIHFWRVFURPRVyPLFRVDGTXLULGRV +,6725,$&/,1,&$3(5,1$7$/&/$3605236206 120%5( $3(//,'2 )(&+$'(1$&,0,(172 GtD PHV DxR '20,&,/,2 7(/() GH !GH $/)$ (678',26 EODQFD %(7$ QLQJXQR SULPDULD LQGtJHQD QR PHVWL]D ('$' DxRV /2&$/,'$' (71,$ QHJUD RWUD VL VHFXQG XQLYHUV DxRVHQHO PD\RUQLYHO (67$'2&,9,/ /DVDQRPDOtDVFURPRVyPLFDVVXSHUDQHOGHORVFDVRV/RVSULQFLSDOHVIDFWRUHV SUHGLVSRQHQWHVGHODVDQRPDOtDVFURPRVyPLFDVVRQHGDGGHODPXMHUPD\RUD DxRVHQIHUPHGDGHVYLUDOHVFRQWUDtGDVHQHOSHUtRGRSUHYLRLQPHGLDWRRGXUDQWHOD JHVWDFLyQ\SURJHQLWRUHVFRQDQWHFHGHQWHVGHDQRPDOtDVFURPRVyPLFDV FDVDGD XQLyQHVWDEOH YLYH VROD QR VROWHUD RWUR VL /XJDUGHO FRQWURO SUHQDWDO /XJDUGHO SDUWRDERUWR 1 ,GHQ WLGDG )LJXUD)UDJPHQWRGH+&3DERUWR,GHQWL¿FDFLyQGHODPXMHU (QOD6HFFLyQ$QDPQHVLVGHOD+&3VHSRGUiQHQFRQWUDUYDULDEOHVTXHLQGLFDQIDFWRUHV GHULHVJRSDUDHODERUWRFRPRODHGDG\RWURVYLQFXODGRVDOQLYHOVRFLRHFRQyPLFR\ HGXFDFLRQDOGRPLFLOLRORFDOLGDGHWQLD\QLYHOHGXFDWLYR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD &DXVDVH[WUDRYXODUHVVHGHEHQDIDFWRUHVPDWHUQRV\SDWHUQRV'HQWURGHORV IDFWRUHVPDWHUQRVVHGHVWDFDQODVFDXVDVRUJiQLFDV (QIHUPHGDGHV LQIHFFLRVDV JHQHUDOHV \ ORFDOHV /DV LQIHFFLRQHV JHQHUDOHV SXHGHQ VHU GH WLSR HVSHFt¿FR R LQHVSHFt¿FR HQ DPERV FDVRV ORV JpUPHQHV SXHGHQ DWUDYHVDU OD SODFHQWD \ DIHFWDU DO IHWR FRPR HYHQWXDOPHQWH VXFHGHHQODVt¿OLVWXEHUFXORVLVWR[RSODVPRVLVOLVWHULRVLVHQIHUPHGDGGH&KDJDV SDOXGLVPREUXFHORVLVHWF(QWUHODVLQIHFFLRQHVORFDOHVVHHQFXHQWUDQLQIHFFLRQHV JHQLWDOHVSURGXFLGDVSRU0\FRSODVPDKRPLQLV8UHRSODVPDXUHDO\WLFXP&ODP\GLD 7UDFKRPDWLV\HQPHQRUSURSRUFLyQSRU1HLVVHULDJRQRUUKRHDH (QIHUPHGDGHV SpOYLFDV ORFDOHV PDOIRUPDFLRQHV WXPRUHV \ ODV DOWHUDFLRQHV XWHULQDV \ FHUYLFDOHV KLSRSODVLD VLQHTXLDV PLRPDWRVLV LQFRPSHWHQFLD FHUYLFDO GHVJDUURVHWF &DXVDV WUDXPiWLFDV HO WUDXPDWLVPR DFFLGHQWDO R LQWHQFLRQDO YLROHQFLD SXHGH VHUFDXVDGHDERUWR &DXVDV SDWHUQDV HVSHUPiWLFDV SULPDULDV R VHFXQGDULDV D DOWHUDFLRQHV FURPRVyPLFDVLQIHFFLRVDVPHWDEyOLFDVHQGRFULQDVWy[LFDVHQWUHRWUDV &DXVDV IXQFLRQDOHV$EDUFDQ HQWUH DO /D DOWHUDFLyQ SUHGRPLQD HQ OD IXQFLyQ GH ORV yUJDQRV \ DIHFWD HO GHVDUUROOR QRUPDO GHO HPEDUD]R 6H LQFOX\HQ HQIHUPHGDGHV PHWDEyOLFDV FRPR OD GLDEHWHV HQGRFULQDV FRPR HO KLSR H KLSHUWLURLGLVPR HO KLSHUDQGURJHQLVPR \ ORV GLVWXUELRV HQGRFULQRV GHO RYDULR WURIREODVWR\GHODSODFHQWD(QHO~OWLPRFDVRQRHVWiFRPSUREDGRTXHHOEDMR QLYHOGHSURJHVWHURQDVHDODFDXVDSUREDEOHPHQWHFRQVWLWX\DODFRQVHFXHQFLDGHO DERUWRHQGRFULQRFRULDORJRQDGDO &DXVDVLQPXQROyJLFDV/DVPiVIUHFXHQWHVVRQGHWLSRDXWRLQPXQHVtQGURPH GHDQWLFXHUSRVDQWLIRVIROtSLGRVDQWLFXHUSRVDQWLQXFOHDUHV\WURPER¿OLDV ,QWR[LFDFLRQHV 6HFXQGDULDV D SORPR PHUFXULR DUVpQLFR IRVIDWRV EHQ]ROHV JDVHVDQHVWpVLFRV\DOFRQVXPRGHDOFRKRO\GURJDV 2WUDVFDXVDV,QWHUYHQFLRQHVTXLU~UJLFDVPD\RUULHVJRHQODVJLQHFROyJLFDV\HQ ODVDEGRPLQDOHVFRQSHULWRQLWLVUDGLDFLRQHVGHVQXWULFLyQVHYHUDKLSRYLWDPLQRVLV HQIHUPHGDGHVPDWHUQDVFUyQLFDV\DOWHUDFLRQHVSVLFRVRPiWLFDV )LJXUD)UDJPHQWRGH+&3DERUWR$QWHFHGHQWHV /D +&3 LQFOX\H OD VHFFLyQ DQWHFHGHQWHV SHUVRQDOHV GRQGHVHSXHGHFRQVLJQDUODSUHVHQFLDGHHQIHUPHGDGHV FUyQLFDVTXHSXHGHQHOHYDUHOULHVJRGHDERUWR(QHOVH GHWDOODQDOJXQDVHQIHUPHGDGHVFRQVLJQDGDVHLQFOX\H XQHVSDFLRHQEODQFRSDUDLQFOXLURWUDVQRGHVFULWDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR &XDGUR$ERUWRHVSRQWiQHRHQUHODFLyQDODHGDGJHVWDFLRQDOGHVDUUROORGHO SURGXFWRFRQFHSFLRQDO\VXPRGDOLGDG 'FCF)GUVCEKQPCN UGOCPCU 'XQNWEKÎPFGNRTQFWEVQ EQPEGREKQPCN 8+#$+.+6 *7'81 '/$4+¦0 ('61 /QFCNKFCF 24'%1< 6#4& 1 'LDJQyVWLFRFOtQLFRGHDERUWRHVSRQWiQHR $SUR[LPDGDPHQWH HO GH ORV DERUWRV HVSRQWiQHRV WLHQHQ VLJQRV \ VtQWRPDV HYLGHQFLDEOHV $QDPQHVLV VH VRVSHFKDUi XQ DERUWR R DPHQD]D GH DERUWR DQWH XQD PXMHU HQ HGDG IpUWLO FRQ UHWUDVR PHQVWUXDO R XQ HPEDUD]R FRQ¿UPDGR TXH SUHVHQWD PHWURUUDJLD GH OD SULPHUD PLWDG GHO HPEDUD]R GRORU DEGRPLQDO WLSR FyOLFR \ HYHQWXDOPHQWHSpUGLGDGHUHVWRVRYXODUHV ([DPHQ DEGRPLQDO \ JHQLWDO WLHQHQ FRPR REMHWLYR GHWHUPLQDU HO WDPDxR XWHULQR SDUD GHFLGLU YtD GH HYDFXDFLyQ GH VHU QHFHVDULR GHVFDUWDU LUULWDFLyQ SHULWRQHDOSUHVHQWHHQFDVRVGHSHUIRUDFLyQXWHULQDYLQFXODGDDPDQLREUDVRHQ HPEDUD]RV HFWySLFRV FRPSOLFDGRV WXPRUDFLRQHV DEGRPLQRSpOYLFDV GHELGDV D FRPSOLFDFLRQHV LQIHFFLRVDV DQH[LDOHV HPEDUD]R HFWySLFR HQIHUPHGDG WURIREOiVWLFDJHVWDFLRQDORSDWRORJtDVWXPRUDOHVFRH[LVWHQWHV )LJXUD)UDJPHQWRGH+&3DERUWR([FOtQLFR\JLQHFROyJLFR ',$*1267,&2&/,1,&2<(7$3$6(92/87,9$6'(/$%2572 $PHQD]DGHDERUWR(QHVWDHQWLGDGHOSURGXFWRFRQFHSFLRQDOVHHQFXHQWUDGHQWURGH ODFDYLGDGXWHULQD (O GLDJQyVWLFR VH UHDOL]D SRU OD SUHVHQFLD GH FRQWUDFFLRQHV XWHULQDV GRORURVDV \R PHWURUUDJLD\DOH[DPHQJHQLWDOHOFDQDOFHUYLFDOHVWiFHUUDGR $ERUWRLQPLQHQWHLQHYLWDEOHRHQFXUVR/DPHWURUUDJLDHVDEXQGDQWH\FRQWLQXD ODPD\RULQWHQVLGDGGHODVFRQWUDFFLRQHVXWHULQDVSURYRFDQODDEHUWXUD\GLODWDFLyQGHO FXHOORHOFDQDOFHUYLFDOHVWiSHUPHDEOH([LVWHSpUGLGDGHOtTXLGRDPQLyWLFRHQIRUPD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD GHKLGURUUHDFODUDRPH]FODGRFRQODHPLVLyQGHVDQJUH\RGHFRPSRQHQWHVRYXODUHV (QRFDVLRQHVHOKXHYRVHGHVSUHQGH\SURWUX\HDWUDYpVGHOFHUYL[XWHULQR $ERUWRFRQVXPDGR&RQVLVWHHQODH[SXOVLyQGHOKXHYRIXHUDGHODFDYLGDGXWHULQD ([LVWHQGRVPRGDOLGDGHVWRWDORFRPSOHWR\SDUFLDORLQFRPSOHWR (O 'LDJQyVWLFR VH HVWDEOHFH FXDQGR HO KXHYR VH H[SXOVD FRPSOHWDPHQWH FHVDQ ODV FRQWUDFFLRQHV GHVDSDUHFH HO GRORU HO ~WHUR GLVPLQX\H GH WDPDxR GLVPLQX\H OD PHWURUUDJLDHLQYROXFLRQDQODVPRGL¿FDFLRQHVFHUYLFDOHVHQHVWHFDVRVHGLFHTXHHO DERUWRKDVLGRFRPSOHWR6LHQFDPELRODH[SXOVLyQHVSDUFLDO\TXHGDQUHWHQLGRVUHVWRV RYXODUHVODVFRQWUDFFLRQHVSHUVLVWLUiQDOLJXDOTXHHOGRORUFRQWLQXDUiODPHWURUUDJLDHO ~WHURHVWDUiVXELQYROXFLRQDGR\HOFXHOORHVWDUiSHUPHDEOHRSDUFLDOPHQWHSHUPHDEOH HQHVWHFDVRVHHVWDUiIUHQWHDXQDERUWRLQFRPSOHWR $ERUWR IUXVWUR R GLIHULGR 6H SURGXFH OD PXHUWH GHO SURGXFWR FRQFHSFLRQDO VLQ VX H[SXOVLyQ/DGLQiPLFDXWHULQDHVLQVX¿FLHQWHSDUDH[SXOVDUHOKXHYR'HVSXpVGH KRUDVFRPLHQ]DQODVPRGL¿FDFLRQHVHVWUXFWXUDOHVGHOHPEULyQ\GHOVDFRJHVWDFLRQDO OLVLVGHIRUPDFLyQDFKDWDPLHQWRGHOHPEULyQ\GHOVDFR\HQHWDSDVPiVDYDQ]DGDV SXHGHSURGXFLUVHPDFHUDUDFLyQRPRPL¿FDFLyQ/DLQIHFFLyQRYXODUHVPiVIUHFXHQWH FXDQGRHOKXHYRWLHQHFRQWDFWRFRQHOH[WHULRU '6#2#5 #OGPC\C FGCDQTVQ #DQTVQ KPOKPGPVG #DQTVQEQPUWOCFQ +PEQORNGVQ %QORNGVQ &+#)0¦56+%1 /GVTQTTCIKC 2VFXUD\HVFDVD %QPVTCEEKQPGU WVGTKPCUFQNQTQUCU 3UHVHQWHV 5RMDDEXQGDQWH 3HUVLVWH \FRQWLQXD $XPHQWDQIUHFXHQFLD 3HUVLVWHQ HLQWHQVLGDG &XHOORDELHUWR 5HVWRVRYXODUHV &DQDOSHUPHDEOH HQ~WHUR\RYDJLQD ([SXOVLyQHQGRV 3URWUXVLyQ WLHPSRV5HWHQFLyQ SDUFLDOGHOKXHYR GHDQH[RV /QFKHKECEKQPGU EGTXKECNGU &XHOORFHUUDGR &GURTGPFKOKGPVQ [GZRWNUKÎP $XVHQWHV 'EQITCHÈC +HPRUUDJLDGHFLGXDO &RiJXORVXEFRULDO ([SXOVLyQ (PEULyQYLYR HQFXUVR LQWUDXWHULQR 5HVWRV HQGRFDYLWDULRV \YDJLQDOHV 0tQLPD &HVDQ\PHUPD HOGRORU &XHOORFHUUDGR ([SXOVLyQWRWDO KXHYR\DQH[RV ÒWHUR LQYROXFLRQDGR \YDFtR &XDGUR(WDSDVHYROXWLYDVGHODERUWR 'LDJQyVWLFRSDUDFOtQLFR (OGLDJQyVWLFRGHDERUWRHVSUHGRPLQDQWHPHQWHFOtQLFR/DUHDOL]DFLyQGHORVHVWXGLRV SDUDFOtQLFRVQRFRQVWLWX\HXQLPSHGLPHQWRSDUDLQLFLDUODWHUDSpXWLFD\VRORVHUHVHUYD SDUDDTXHOODVVLWXDFLRQHVFRQHOHYDGDFRPSOHMLGDGGLDJQyVWLFDRFXDQGRODSUHRFXSDFLyQ GHODPXMHU\VXIDPLOLDREOLJXHQDDFHOHUDUORVSDVRVGLDJQyVWLFRV (FRJUDItD FXDQGR VH GLVSRQJD GH XOWUDVRQRJUDItD VH SRGUi GHWHUPLQDU VL HO HPEDUD]RHVLQWUDXWHULQRVLH[LVWHYLWDOLGDGHPEULRQDULD\RVLKD\GHFRODPLHQWRV KHPDWRPDVUHWURFRULDOHVRVLHOKXHYRKDVLGRH[SXOVDGRWRWDOPHQWHDERUWR FRPSOHWR R SDUFLDOPHQWH DERUWR LQFRPSOHWR 7DPELpQ SRGUi HYDOXDUVH OD SUHVHQFLDRDXVHQFLDGHWXPRUDFLRQHVDQH[LDOHV\FROHFFLRQHVOtTXLGDVHQIRQGR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR GH VDFR GH 'RXJODV (VWRV GDWRV SXHGHQ VHU FRQVLJQDGRV HQ OD KLVWRULD 6,3 $%2572 6XEXQLGDGEHWDGHODKRUPRQDFRULyQLFDJRQDGRWUy¿FD%HWD+&*FXDQWLWDWLYD VHULDGDFXDQGRH[LVWDQGXGDVDFHUFDGHODYLWDOLGDGHPEULRQDULDHQHPEDUD]RV PX\SUHFRFHVPHQRUHVDVHPDQDVHODVFHQVRGHORVWtWXORVGH%HWD+&*HQ GHWHUPLQDFLRQHVVHULDGDVVHSDUDGDVSRUDKRUDVFRQ¿UPDUiODYLWDOLGDG 'LDJQyVWLFRGLIHUHQFLDO /DVKHPRUUDJLDVGHODSULPHUDPLWDGGHOHPEDUD]RTXHVLJXHQHQIUHFXHQFLDDODERUWRVRQ HPEDUD]RHFWySLFR HQIHUPHGDGWURIREOiVWLFDJHVWDFLRQDOPRODKLGDWLIRUPH JLQHFRSDWtDVFRH[LVWHQWHVSyOLSRVOHVLRQHVFHUYLFDOHVPDOLJQDVRSUHPDOLJQDV WUDVWRUQRVGHODFRDJXODFLyQ &XDGUR+DOOD]JRVFOtQLFRV\HFRJUi¿FRVGHORVSULQFLSDOHVGLDJQyVWLFRV GLIHUHQFLDOHVGHODERUWRHVSRQWiQHR CLÍNICA ECOGRAFÍA EMBARAZO ECTÓPICO Dolor. Sangrado negruzco y escaso. Tamaño del útero < a la amenorrea. Tumoración parauterina. Tumoración parauterina inespecífica. Ausencia de saco gestacional. Pseudosaco gestacional. MOLA HIDATIFORME Sangrado rojo, a veces con vesículas. Tamaño uterino > a la amenorrea. Quistes ováricos. Útero: imagen típica con vesículas. Ovarios: quistes luteínicos uni o bilaterales. ABORTO Dolor. Sangrado inicialmente escaso y oscuro, posteriormente abundante y rojo rutilante. No hay tumoraciones anexiales Útero ocupado por el saco o por restos ovulares y/o coágulos. Solo estará vacío en el aborto incompleto &RQGXFWD $PHQD]DGHDERUWR 9DULDUi6HUHFRPHQGDUiUHSRVRItVLFRSVtTXLFR\VH[XDOKDVWDODGHVDSDULFLyQGHOD VLQWRPDWRORJtD 6H HVSHUDUi SULPHUR TXH GLVPLQX\DQ ODV FRQWUDFFLRQHV \ FRQ HOOR HO GRORU\HOVDQJUDGR(QHVWHSHUtRGRVHLQWHQWDUiGH¿QLUODFDXVD\WUDWDUODSRUHMHPSOR HQODLQVX¿FLHQFLDGHOFXHUSRO~WHRVHSRGUiLQGLFDUJHVWiJHQRV $ERUWRHQFXUVR 9DULDUiHQIXQFLyQGHVLH[LVWHRQRUHSHUFXVLyQKHPRGLQiPLFD +HPRUUDJLDOHYHDPRGHUDGDVLQUHSHUFXVLyQKHPRGLQiPLFD VHUHFRPLHQGDFDOPDUHOGRORUFRQDQDOJpVLFRV\RWUDQTXLOL]DQWHV 'LFORIHQDFPJ92R .HWRSURIHQRPJ92R &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD $FHWDPLQRIHQRDPJ92R ,EXSURIHQRDPJ92 (QFDVRGHGRORULQWHQVRVHUiUHFRPHQGDEOHFRPELQDUDQDOJpVLFRVQDUFyWLFRVFRQ QRQDUFyWLFRV $FHWDPLQLIHQR&RGHtQDPJ92 (ODQVLROtWLFRPiVXVDGRHVHO'LD]HSDPPJ92 HVSHUDUTXHVHFRPSOHWHODHYDFXDFLyQHVSRQWiQHD HQFDVRGHUHVWRVFRPSOHPHQWDUFRQHYDFXDFLyQSRUDVSLUDFLyQ +HPRUUDJLDSURIXVD\RUHSHUFXVLyQKHPRGLQiPLFD YtD YHQRVD SHULIpULFD HQ YHQD GH JUDQ FDOLEUH LQIXQGLU 6ROXFLyQ GH /DFWDWR 5LQJHUDJRWDVPLQXWR R[tJHQRFRQPiVFDUDGHÀXMROLEUH DQDOJHVLDGHVHUQHFHVDULDGHDFXHUGRDORUHVXPLGRHQFDVRGHKHPRUUDJLDOHYH (QFDVRGHHYDFXDFLyQHVQHFHVDULRFRQWDUFRQDQHVWHVLDORFDORJHQHUDO VL QR VH GLVSRQH GH SRVLELOLGDG GH HYDFXDFLyQ XWHULQD QL VDQJUH VHJXUD GHULYDU D QLYHO GH PD\RU FRPSOHMLGDG HQ HO WUDVODGR OD PXMHU GHEHUi HVWDU DFRPSDxDGDSRUSURIHVLRQDOHQWUHQDGRHQPDQLREUDVGHUHDQLPDFLyQ )LJXUD)UDJPHQWRGH+&3DERUWR0HGLFDFLyQ $ERUWRFRQVXPDGR /DFRQGXFWDYDULDUiVHJ~QVHWUDWHGHXQDERUWRFRPSOHWRRLQFRPSOHWR $ERUWRFRPSOHWRXDQGRVHVRVSHFKHTXHHODERUWRKDVLGRFRPSOHWRSXHGHQR UHTXHULUVHPiVWUDWDPLHQWRHQHVHFDVRSRGUiRWRUJDUVHHODOWDKRVSLWDODULRYHU FXLGDGRVSRVWSURFHGLPLHQWR /DFRQ¿UPDFLyQGHXQDERUWRFRPSOHWRVHHIHFW~DSRUHFRJUDItD $ERUWRLQFRPSOHWRVLODHYDFXDFLyQIXHLQFRPSOHWD\QRKD\VLJQRVGHLQIHFFLyQ VHGHEHFRPSOHPHQWDUODHYDFXDFLyQFRQOHJUDGRDVSLUDWLYRRTXLU~UJLFR $QWHVGHOSURFHGLPLHQWRHVQHFHVDULRTXHHOHTXLSRGHVDOXGGHXQDH[SOLFDFLyQ FODUD\WUDQTXLOL]DGRUDVREUHHOSURFHGLPLHQWRDHIHFWXDU (QFDVRGHGRORUHIHFWXDUVHGDFLyQ\RDQDOJHVLDFRPRIXHGHVFULWRHQHO FDVRGHKHPRUUDJLDOHYH &RORFDUYtDYHQRVDSDUDLQIXQGLU6ROXFLyQGH/DFWDWR5LQJHUDJRWDV PLQXWR &RQYLVWDVDOSURFHGLPLHQWRSUDFWLFDUDQDOJHVLDSDUDFHUYFLFDOODDQHVWHVLD JHQHUDOSRGUiXVDUVHVLVHGLVSRQHGHORVUHFXUVRVKXPDQRV\PDWHULDOHV LQGLVSHQVDEOHV 1RH[LVWHQHYLGHQFLDVTXHDYDOHQHOXVRVLVWHPiWLFRGHDQWLELyWLFRVSUR¿OiFWLFRVHQORV SURFHGLPLHQWRVGHHYDFXDFLyQXWHULQD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 0pWRGRVGHHYDFXDFLyQ /DPD\RUtDGHORVSURIHVLRQDOHVHQWUHQDGRVSXHGHQHIHFWXDUXQDHYDFXDFLyQKDVWDODV VHPDQDVFRPSOHWDVGHOHPEDUD]R +DVWD ODV VHPDQDV FRPSOHWDV ORV PpWRGRV SUHIHULGRV GH HYDFXDFLyQ VRQ ORV GH DVSLUDFLyQ DO YDFtR PDQXDO R HOpFWULFD HVWRV PpWRGRV VXHOHQ VHU PiV VHJXURV DOSURYRFDUPHQRVSHUIRUDFLRQHVXWHULQDVHQWUHRWUDVFRPSOLFDFLRQHV(QHVFHQDULRV HQORVTXHQRVHGLVSRQJDGHPpWRGRVDVSLUDWLYRVVHXWLOL]DUiODGLODWDFLyQ\FXUHWDMH FOiVLFRV &XDQGRVHDQHFHVDULRFRPHQ]DUHOSURFHGLPLHQWRGHHYDFXDFLyQVLQGLODWDFLyQFHUYLFDO VH UHFRPHQGDUi HO XVR GH DQHVWpVLFRV ORFDOHV OLGRFDtQD SDUD REWHQHU XQ EORTXHR SDUDFHUYLFDO(QFDVRVHVSHFLDOHVSXHGHVHUQHFHVDULRXVDUDQHVWHVLDJHQHUDOORFXDO H[LJHUHFXUVRVKXPDQRV\PDWHULDOHVTXHVXSHUDQDORVGLVSRQLEOHVHQHOSULPHUQLYHO 0iV DOOi GH ODV VHPDQDV FRPSOHWDV \ VL QR KD\ GLODWDFLyQ QL FRQWUDFFLRQHV VH SUHIHULUi FRPHQ]DU HO SURFHGLPLHQWR GH HYDFXDFLyQ DSHODQGR D PpWRGRV PpGLFRV SDUD FRQVHJXLU OD GLODWDFLyQ GHO FXHOOR \ OD H[SXOVLyQ GHO IHWR GHELGR D TXH HQ HVWD HGDGJHVWDFLRQDOORVSURFHGLPLHQWRVGHHYDFXDFLyQH[SRQHQODPXMHUDPD\RUULHVJR SHUIRUDFLyQKHPRUUDJLD(QWDOVHQWLGRHVWiLQGLFDGRHOXVRGH GLODWDGRUHV RVPyWLFRV WLHQHQ HO LQFRQYHQLHQWH GH VX FRVWR \ GHO WLHPSR TXH UHTXLHUHQSDUDVHUHIHFWLYRV SURVWDJODQGLQDVHOHPSOHRGHO0LVRSURVWROXQDQiORJRGHODSURVWDJODQGLQD( SRUYtDYDJLQDOPFJGLVWULEXLGRVHQHOIRQGRYDJLQDO\PFJYtDRUDOFDGD RKRUDVPi[LPRGRVLV /XHJR GH SURGXFLGD OD H[SXOVLyQ GHO IHWR VH FRPSOHPHQWDUi FRQ HYDFXDFLyQ SRU DVSLUDFLyQ R SRU FXUHWDMH (O FXUHWDMH HV PHQRV VHJXUR PiV GRORURVR \ PiV OHQWR TXH OD HYDFXDFLyQ SRU DVSLUDFLyQ /D DVSLUDFLyQ SUHVHQWD DSHQDV XQ WHUFLR GH ODV FRPSOLFDFLRQHVTXHVHVXHOHQSUHVHQWDUSRUODWpFQLFDGHFXUHWDMH )LJ)UDJPHQWRGH+&3DERUWR7UDWDPLHQWR3URFHGLPLHQWR (YDFXDFLyQXWHULQD (O~WHURSXHGHVHUHYDFXDGRPHGLDQWHGLVWLQWDVWpFQLFDV$QWHVGHFDGDSURFHGLPLHQWR ODPXMHUGHEHUHFLELUDQDOJHVLD\RDQHVWHVLDORFDOOLGRFDtQDSDUDFHUYLFDORDQHVWHVLD JHQHUDOGHDFXHUGRDODVQHFHVLGDGHV\GLVSRQLELOLGDGGHFDGDFDVRHQSDUWLFXODU /D DVSLUDFLyQ DO YDFtR VHD PDQXDO R HOpFWULFD HV HO PpWRGR TXLU~UJLFR PiV VHJXUR \UiSLGRGHDPLQXWRV\SXHGHUHDOL]DUVHHQIRUPDDPEXODWRULD(VHOPpWRGR GH HOHFFLyQ SDUD OD HYDFXDFLyQ GH HPEDUD]RV KDVWD ODV GRFH VHPDQDV FRPSOHWDV &RQVLVWHHQXQDFiQXODSOiVWLFDRGHPHWDOXQLGDDXQDIXHQWHGHYDFtR3UHYLDPHQWHD ODLQVHUFLyQGHODFiQXODVHUHTXLHUHGHGLODWDFLyQFHUYLFDOXVDQGRGLODWDGRUHVRVPyWLFRV RPHFiQLFRVVRORVRDVRFLDGRVDSURVWDJODQGLQDVRELHQPDGXUDFLyQFHUYLFDO $0(8DVSLUDFLyQPDQXDOHQGRXWHULQDHOYDFtRVHFUHDXWLOL]DQGRXQDVSLUDGRUSOiVWLFR RMHULQJDGHPOVRVWHQLGR\DFWLYDGRPDQXDOPHQWH6HGLVSRQHGHFiQXODVHVWpULOHV GHVFDUWDEOHV\VXWDPDxRYDUtDGHDPPGHGLiPHWUR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD $(8DVSLUDFLyQHOpFWULFDHQGRXWHULQDODIXHQWHGHODERPEDDOYDFtRHVHOpFWULFD /8,OHJUDGRXWHULQRLQVWUXPHQWDOHVXQSURFHGLPLHQWRTXLU~UJLFRTXHVHXWLOL]DSDUD ODHYDFXDFLyQPHGLDQWHODGLODWDFLyQGLODWDGRUHVGHPHWDO\FXUHWDMHGHO~WHUR(VXQ PpWRGRPHQRVVHJXUR\WLHQHPD\RUtQGLFHGHFRPSOLFDFLRQHVSHUIRUDFLRQHV3XHGH VHUXVDGRHQHPEDUD]RVPHQRUHVGHVHPDQDVFXDQGRQRVHGLVSRQJDGHPpWRGRV GH DVSLUDFLyQ DO YDFtR HQ HPEDUD]RV PD\RUHV D VHPDQDV VL QR VH GLVSRQHQ GH PpWRGRV PpGLFRV SDUD OD GLODWDFLyQ \ H[SXOVLyQ IHWDO \ HQ IRUPD FRPSOHPHQWDULD FXDQGRVHSURGXMRODH[SXOVLyQIHWDO\QRVHGLVSRQHGHPpWRGRVGHDVSLUDFLyQDOYDFtR SDUDODHYDFXDFLyQXWHULQD 0HGLFDPHQWRVHOXVRGHPLVRSURVWRODQiORJRGHSURVWDJODQGLQDVHVPX\HIHFWLYR\ VHJXURSDUDODLQWHUUXSFLyQGHOHPEDUD]RGXUDQWHHOSULPHUWULPHVWUH (V UHFRPHQGDEOH HQYLDU VLHPSUH ORV UHVWRV RYXODUHV H[WUDtGRV SDUD HVWXGLR DQDWRPRSDWROyJLFR )LJXUD )UDJPHQWRGH+&3DERUWR$QDWRPtDSDWROyJLFD &XLGDGRVSRVWSURFHGLPLHQWR 'XUDQWHODVSULPHUDVGRVKRUDVTXHVLJXHQDOSURFHGLPLHQWRGHEHUiHYDOXDUVHHOHVWDGR GHFRQFLHQFLDVLVXIUHGRORUODFRORUDFLyQGHSLHO\PXFRVDVODIUHFXHQFLDUHVSLUDWRULD OD SUHVLyQ DUWHULDO OD IUHFXHQFLD FDUGtDFD OD WHPSHUDWXUD FRUSRUDO HO DEGRPHQ \ OD PDJQLWXG\FDUDFWHUtVWLFDGHODVSpUGLGDVYDJLQDOHV 6LWRGRVORVSDUiPHWURVVRQQRUPDOHV\VHFRQ¿UPyTXHODPXMHU WLHQHXQWDPL]DMHSDUDVt¿OLVQHJDWLYR\9,+ UHFLELyDFWXDOL]DFLyQGHODVYDFXQDVFRQWUDHOWpWDQRVUXEpROD\RKHSDWLWLV%HWF UHFLELyRULHQWDFLyQVREUHSODQL¿FDFLyQIDPLOLDURVHOHSURSRUFLRQyDQWLFRQFHSFLyQ SRVW HYHQWR /D FRORFDFLyQ GHO ',8 HQ HO SRVW DERUWR LQPHGLDWR HV SUiFWLFD \ VHJXUDFRQWDVDVGHH[SXOVLyQVLPLODUHVDODVGHODFRORFDFLyQGHVSXpVGHXQ LQWHUYDOR VHOHDGPLQLVWUySUR¿OD[LVFRQLQPXQRJOREXOLQDDQWL'HQFDVRGHWUDWDUVHGHXQD PXMHU5KQHJDWLYRQRLQPXQL]DGDFRPRVHPHQFLRQDHQHOFDStWXORGHDWHQFLyQ SUHQDWDO 6L VH FXPSOLHURQ WRGRV ORV SDVRV UHFLHQWHPHQWH UHVHxDGRV OD PXMHU HVWDUi HQ FRQGLFLRQHVGHUHFLELUHODOWDKRVSLWDODULDSDUDORFXDOVHGHEHUiQLQGLFDU ORVFRQWUROHVGRPLFLOLDULRVDUHDOL]DUD¿QGHGHVSLVWDUSUHFR]PHQWHFRPSOLFDFLRQHV WHPSHUDWXUD FRORU FDQWLGDG \ RORU GH ODV SpUGLGDV YDJLQDOHV SHUVLVWHQFLD GH GRORUWUDVWRUQRVGHOWUiQVLWRGLJHVWLYR ORV SDVRV D VHJXLU HQ FDVR GH VXIULU DOWHUDFLRQHV HQ ORV FRQWUROHV VXJHULGRV R QRWDUFXDOTXLHUHOHPHQWRTXHODSUHRFXSH UHLQLFLRGHODDFWLYLGDGVH[XDOFXDQGRGHVDSDUH]FDQODVSpUGLGDV \ FRRUGLQDU XQD YLVLWD GH VHJXLPLHQWR HQWUH ORV \ GtDV SRVW DERUWR SDUD HYDOXDUODHYROXFLyQ\FRPSOHWDUODVDFFLRQHVTXHQRVHKD\DQSRGLGRUHDOL]DU DQWHVGHODOWD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR $%2572&203/,&$'2 /DV FRPSOLFDFLRQHV PiV LPSRUWDQWHV GHO DERUWR LQFRPSOHWR VRQ OD KHPRUUDJLD FRQ DQHPLDDJXGD\ODLQIHFFLyQ\VLKDQH[LVWLGRPDQLREUDVLQVWUXPHQWDOHVSUHYLDVSXHGH KDEHUULHVJRGHSHUIRUDFLyQ (QHODERUWRHVSRQWiQHRODVLQIHFFLRQHVPiVIUHFXHQWHVVHSURGXFHQSRUHODVFHQVR GH ORV JpUPHQHV TXH KDELWDQ HQ HO WUDFWR JHQLWDO LQIHULRU$VLPLVPR HQ HO DERUWR QR HVSRQWiQHRHO~WHURSXHGHLQIHFWDUVHSRUHOXVRGHPDWHULDOFRQWDPLQDGR /DJUDYHGDGGHOFXDGURDEDUFDXQDPSOLRUDQJRTXHYDGHVGHODHQGRPLRPHWULWLVKDVWD ODVHSVLV /D,QIHFFLyQSXHGHVHUJHQLWDOFXDQGRH[LVWDQVtQWRPDV\VLJQRVFRPSDWLEOHVFRQ XQD LQIHFFLyQ ¿HEUH HVFDORIUtRV VHFUHFLRQHV YDJLQDOHV IpWLGDV GRORU DEGRPLQDO R SpOYLFRHVSRQWiQHR\RDODPRYLOL]DFLyQGHO~WHURPHWURUUDJLDSURORQJDGD\HOHYDFLyQ GHOUHFXHQWROHXFRFLWDULRR,QIHFFLyQSHOYLDQDORVKDOOD]JRVPiVIUHFXHQWHVVRQGRORU DEGRPLQDORSpOYLFRVLJQRVSHULWRQHDOHVHYLGHQFLDGRVSRUGRORUDODGHVFRPSUHVLyQ DEGRPLQR SpOYLFD GRORU D OD PRYLOL]DFLyQ GHO ~WHUR ¿HEUH LJXDO R PD\RU D & \ OHXFRUUHDPXFRSXUXOHQWD\RIpWLGDUHFXHQWROHXFRFLWDULRHOHYDGR /D6HSVLVHVXQFXDGURJUDYHFRQJUDQFRPSURPLVRGHOHVWDGRJHQHUDOSXHGHDIHFWDU ODFRQFLHQFLDDFRPSDxDGDGH¿HEUH\WRTXHPXOWLSDUHQTXLPDWRVRLFWHULFLDDQXULDR ROLJRDQXULDKLSRWHQVLyQDOWHUDFLRQHVUHVSLUDWRULDVWUDVWRUQRVGHODFRDJXODFLyQHWF (VXQDFRPSOLFDFLyQTXHVHDVRFLDIUHFXHQWHPHQWHDODERUWRUHDOL]DGRHQFRQGLFLRQHV LQVHJXUDVSRUSHUVRQDOQRFDOL¿FDGR\RHQPDODVFRQGLFLRQHVGHDVHSVLD +HPRUUDJLD H[FHVLYD PHWURUUDJLD DEXQGDQWH \ FRQWLQXD VXSHUD ORV PO 6H YLQFXODPiVIUHFXHQWHPHQWHDDWRQtDXWHULQDPiVFRP~QFXDQWRPD\RUVHDODHGDG JHVWDFLRQDO WDPELpQ SXHGH VHU VHFXQGDULD D OD UHWHQFLyQ GH UHVWRV RYXODUHV R D OHVLRQHVSHUIRUDFLRQHVGXUDQWHHOSURFHVRGHHYDFXDFLyQ (O6KRFNKLSRYROpPLFR(VSURGXFLGRSRUXQDKHPRUUDJLDH[FHVLYD\GHHYROXFLyQ UiSLGD VHFXQGDULD D XQD FRPSOLFDFLyQ 6H DFRPSDxD GH JUDQ FRPSURPLVR GH OD FRQFLHQFLDGHOHVWDGRJHQHUDO\UHSHUFXVLyQKHPRGLQiPLFDVHYHUD 3HUIRUDFLyQ GHVJDUUR R GDxR OD SHUIRUDFLyQ HV XQD FRPSOLFDFLyQ UHODWLYDPHQWH IUHFXHQWH HQ HO SURFHVR GH HYDFXDFLyQ XWHULQD HVSHFLDOPHQWH FXDQGR VH UHDOL]D FXUHWDMH3XHGHFRUUHVSRQGHUDXQDSHUIRUDFLyQPHQRUJHQHUDOPHQWHDVLQWRPiWLFD\VH UHVXHOYHHVSRQWiQHDPHQWHRFRQODDGPLQLVWUDFLyQGHRFLWyFLFRV6LODSHUIRUDFLyQHVGH PD\RUHQWLGDGSXHGHSUHVHQWDUVtQGURPHGHLUULWDFLyQSHULWRQHDOVKRFNKHPRGLQiPLFR \UHTXHULUiODUHDOL]DFLyQGHXQDODSDURWRPtDH[SORUDGRUD6HUHFRPLHQGDFRQVXOWDUOD 3XEOLFDFLyQ&LHQWt¿FD&/$3605 (QRWUDVRFDVLRQHVVHFRQVWDWDQGHVJDUURV(QFXDOTXLHUDGHODVGRVVLWXDFLRQHVVH GHEHUi LGHQWL¿FDU OD WRSRJUDItD GH OD OHVLyQ YDJLQDO XWHULQR \R SpOYLFR 5HJLVWUDU OD WRSRJUDItDGHOGHVJDUUR\RSHUIRUDFLyQYDJLQD~WHURVHLQWHUSUHWDSRUSpOYLFRODOHVLyQ GHXQyUJDQRSHOYLDQRUHFWRYHMLJDRYDVRVSpOYLFRV2WURFRUUHVSRQGHDOHVLRQHVGH RWURVyUJDQRVDEGRPLQDOHV &RPSOLFDFLRQHVSRVWHYDFXDFLyQ &RPSOLFDFLRQHVLQPHGLDWDV\PHGLDWDV +HPRUUDJLDVXHOHYLQFXODUVHDXQDDWRQtDXWHULQDPiVFRP~QDPHGLGD T X H PD\RUVHDODHGDGJHVWDFLRQDOWDPELpQSXHGHGHEHUVHDODUHWHQFLyQGHUHVWRV RYXODUHVRDOHVLRQHVSHUIRUDFLRQHVGXUDQWHHOSURFHVRGHHYDFXDFLyQ ,QIHFFLyQVXHOHFDUDFWHUL]DUVHSRUILHEUHHVFDORIUtRVVHFUHFLRQHVY D J L Q D O H V IpWLGDVGRORUDEGRPLQDORSpOYLFRRDODPRYLOL]DFLyQGHO~WHURXQDPHWURUUDJLD SURORQJDGDRHOHYDFLyQGHOUHFXHQWROHXFRFLWDULR &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD 3HUIRUDFLyQXWHULQDHVXQDFRPSOLFDFLyQUHODWLYDPHQWHIUHFXHQWHHQORVSURFHVRV GH HYDFXDFLyQ XWHULQD HVSHFLDOPHQWH FXDQGR OD PLVPD VH HIHFW~D PHGLDQWH FXUHWDMH (O HVSHFWUR GH PDQLIHVWDFLRQHV GH HVWD FRPSOLFDFLyQ YD GHVGH OD SHUIRUDFLyQ DVLQWRPiWLFD TXH VyOR UHTXHULUi RFLWyFLFRV FRPR WUDWDPLHQWR D OD FODUDPHQWHYLVLEOHFRQVtQGURPHGHLUULWDFLyQSHULWRQHDORVKRFNKHPRGLQiPLFR &RPSOLFDFLRQHVWDUGtDV ,QIHUWLOLGDGHVXQDFRPSOLFDFLyQSRFRIUHFXHQWH\TXHVHVXHOHYHUPiV IUHFXHQWHPHQWHUHODFLRQDGDFRQODHYDFXDFLyQSRUFXUHWDMH 6LWXDFLRQHVHVSHFLDOHV $ERUWRLQIHFWDGRGHOSXQWRGHYLVWDFOtQLFRVHFDUDFWHUL]DSRUUHDSDULFLyQGHOGRORU ¿HEUHJHQHUDOPHQWHHQSLFRV3XHGHDVRFLDUVHJHQLWRUUDJLD\RÀXMRIpWLGR (O~WHURHVWiDJUDQGDGREODQGX]FR\GRORURVRDODFRPSUHVLyQ (QHVWRVFDVRVHVWiLQGLFDGRFRPHQ]DUHOWUDWDPLHQWRDQWLELyWLFRLQWHQVR\GHDPSOLR HVSHFWURKRUDVDQWHVGHSURFHGHUDODHYDFXDFLyQGHORVUHVWRVRYXODUHV'HSHQGLHQGR GHODJUDYHGDGGHOFXDGURVHGHEHUiYDORUDUHQTXHQLYHOGHFRPSOHMLGDGVHGHEHUi HIHFWXDUHOPLVPR $ERUWRUHWHQLGRHVXQDHQWLGDGHQODFXDOVHKDGLDJQRVWLFDGRODPXHUWHGHOHPEULyQR GHOIHWRSHURDXQQRKDQFRPHQ]DGRODVFRQWUDFFLRQHVXWHULQDVQLODGLODWDFLyQFHUYLFDO (QHVWRVFDVRVODH[SXOVLyQHVSRQWiQHDGHOFRQWHQLGRHQGRXWHULQRHVPHQRVULHVJRVD TXHDFHOHUDUODH[SXOVLyQ\DTXHODVPDQLREUDVGHHYDFXDFLyQFRQFXHOORFHUUDGR\ UtJLGRIDYRUHFHQODVOHVLRQHVGHOFXHOORGHO~WHUR\ODHYDFXDFLyQLQFRPSOHWD (V QHFHVDULR DGYHUWLU D OD PXMHU \ VX IDPLOLD VREUH HVWRV ULHVJRV (Q FDVR GH QR FRQWDUFRQSRVLELOLGDGHVGHXQVHJXLPLHQWRFOtQLFRGHODPXMHUVHUiUHFRPHQGDEOHOD HYDFXDFLyQSDUDORFXDOVHSURFHGHUiHQWRGDVODVHGDGHVJHVWDFLRQDOHVGLODWDQGRHO FXHOOR\SRVWHULRUPHQWHHYDFXDQGRHO~WHURFRPR\DVHKDH[SOLFDGRHQPpWRGRVGH HYDFXDFLyQSDJ &216(-(5Ë$,1)250$&,Ï1 /DPXMHUGHEHUtDUHFLELULQIRUPDFLyQVREUH&XLGDGRVEiVLFRV6LJQRVGHDODUPD\R $QWLFRQFHSFLyQ\VHFRRUGLQyXQD&LWDGHVHJXLPLHQWRRFRQWURO )LJXUD )UDJPHQWRGH+&3DERUWR&RQVHMHUtD &XLGDGRVEiVLFRVGHVSXpVGHODOWDGXUDQWHORVSULPHURVGtDVVHUHDOL]DUiQFRQWUROHV GRPLFLOLDULRVGH WHPSHUDWXUDFRORUFDQWLGDG\RORUGHODVSpUGLGDVYDJLQDOHVSHUVLVWHQFLDGHOGRORU \WUDVWRUQRVGHOWUiQVLWRGLJHVWLYR/DSUHVHQFLDGHDOJXQDRYDULDVDOWHUDFLRQHV HQpVWRVSDUiPHWURVXRWURVVLJQRVTXHVHDQSUHRFXSDQWHVSHUPLWLUiQGHWHFWDU SUHFR]PHQWHFRPSOLFDFLRQHV\VHGHEHUiFRQVXOWDUHQIRUPDLQPHGLDWD /DDFWLYLGDGVH[XDOVHSRGUiUHLQLFLDUFXDQGRGHVDSDUH]FDQODVSpUGLGDVGHODV VHFUHFLRQHVJHQLWDOHV 6HFRRUGLQDUiXQDYLVLWDGHFRQWUROHQWUHORV\GtDVSRVWDERUWRVHHYDOXDUiOD HYROXFLyQ\UHDOL]DUiQODVDFFLRQHVTXHQRVHKD\DQVLGRFXPSOLGRDQWHVGHODOWD &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR 6LJQRVGHDODUPDVHGHEHUiLQVWUXLUDODPXMHUDUHFRQRFHUpVWRVVLJQRV\FRQVXOWDU LQPHGLDWDPHQWH IUHQWH D OD SHUVLVWHQFLD GHO GRORU DXPHQWR GHO VDQJUDGR ¿HEUH &FDPELRHQODFDQWLGDGFRORURORU\DVSHFWRGHODVSpUGLGDVVHFUHFLRQHVJHQLWDOHV IpWLGDV ORTXLRV FRQ UHVWRV RYXODUHV SDOLGH] FXWiQHR ± PXFRVD PDUHRV OLSRWLPLDV SpUGLGDGHODFRQFLHQFLD $QWLUXEHRODSRVWDERUWRVHUH¿HUHDVLHVQHFHVDULRDGPLQLVWUDUODYDFXQDDQWLUUXEHyOLFD HQ HO SHUtRGR SRVWDERUWR HQ PXMHUHV FRQ KLVWRULD GH QR KDEHU VLGR LQPXQL]DGDV SUHYLDPHQWH(VWDPHGLGDSUHYHQWLYDEXVFDSURWHJHUDODPXMHU\DGHPiVEHQH¿FLDUOD HQHOVLJXLHQWHHPEDUD]R *DPDJOREXOLQDSRVWDERUWRFXDQGRVHWUDWDGHXQDPXMHU5KQHJDWLYRQRLQPXQL]DGDQR WLHQHDQWLFXHUSRVDQWL'DQWHVGHODOWDSRUDERUWRGHEHUiUHFLELUȖJOREXOLQDKLSHULQPXQH DQWL'VHJ~QQRUPDQDFLRQDO Jglobulina QF )LJXUD )UDJPHQWRGH+&3DERUWR9DFXQDFLyQ $17,&21&(3&,Ï13267$%2572 (O SRVW DERUWR LQPHGLDWR HV XQ PRPHQWR SURSLFLR SDUD DQDOL]DU MXQWR D OD PXMHU ORV PpWRGRVDQWLFRQFHSWLYRVPiVDGHFXDGRVSDUDHOOD SUHI DFFHG SUHI DFFHG SUHI DFFHG )LJXUD )UDJPHQWRGH+&3DERUWR $QWLFRQFHSFLyQ /DDFWLYLGDGVH[XDOFRLWDOYDJLQDOSXHGHUHLQLFLDUVHXQDYH]TXHODPXMHUORGHVHH\QR SUHVHQWHJHQLWRUUDJLD 3DUDODPD\RUtDGHORVPpWRGRVQRKD\UHVWULFFLRQHV6LRSWDUSRUXQDQWLFRQFHSWLYR RUDO HO PLVPR GHEH LQLFLDUVH HQ IRUPD LQPHGLDWD (VWD HVWUDWHJLD GLVPLQX\H OD SUREDELOLGDGGHTXHTXHGHHPEDUD]DGDDQWHVGHODSUy[LPDPHQVWUXDFLyQ /DLQVHUFLyQLQPHGLDWDGHXQGLVSRVLWLYRLQWUDXWHULQRGHVSXpVGHXQDERUWRHVSRQWiQHR RLQGXFLGRHVSUiFWLFD\VHJXUD/DLQVHUFLyQVHUHDOL]DGXUDQWHODSUiFWLFDGHOOHJUDGR RKDVWDODVKUVSRVWHULRUHVSDVDGRHVWHWLHPSRHVFRQYHQLHQWHGLIHULUODLQVHUFLyQ GXUDQWHGtDV\DTXHHOtQGLFHGHLQIHFFLRQHVDXPHQWD (VWHPpWRGRSXHGHVHUFRQYHQLHQWHHQSDUWLFXODUSDUDDTXHOODVPXMHUHVTXHQRFXHQWDQ FRQIiFLODFFHVRDORVVHUYLFLRVGHVDOXGRHQODVTXHVHGXGHGHODFRQWLQXLGDGGHVX DVLVWHQFLD$GHPiVVHKDGRFXPHQWDGRTXHPXFKDVGHODVPXMHUHVTXHRSWDQSRUOD LQVHUFLyQGLIHULGDQRUHJUHVDQDOFHQWURGHDWHQFLyQSDUDVRPHWHUVHDOSURFHGLPLHQWR 8QDGHODVGHVYHQWDMDVHVTXHHQFRPSDUDFLyQFRQODLQVHUFLyQGLIHULGDODLQPHGLDWD WLHQHPiVSUREDELOLGDGHVGHH[SXOVLyQGHOGLVSRVLWLYR(VWDSRVLELOLGDGHVPXFKRPD\RU FXDQGRHO',8VHLQVHUWDOXHJRGHXQDERUWRHQODPLWDGGHOHPEDUD]RTXHHQHWDSDV PiVWHPSUDQDVGHODJHVWDFLyQRHQXQDERUWRHVSRQWiQHR &XDQGR VH FRQVLGHUD LQFOXLU OD LQVHUFLyQ SRVWDERUWR GH XQ GLVSRVLWLYR LQWUDXWHULQR HQ XQ VHUYLFLR GH DERUWR GHEHUtD GHVWDFDUVH OD LPSRUWDQFLD GH OD RULHQWDFLyQ SUHYLD \ SRVWHULRU DO SURFHGLPLHQWR SDUD IRPHQWDU GH HVWD IRUPD OD DFHSWDFLyQ GHO PpWRGR \ SHUPLWLUDODVPXMHUHVWRPDUGHFLVLRQHVLQIRUPDGDV &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 6DOXG6H[XDO\5HSURGXFWLYD Referencias Bibliográficas Alan Guttmacher Institute. Women, society and abortion worldwide. New York and Washington D. C., 1999. Burrow – Ferris. Complicaciones médicas del embarazo. Editorial Médica Panamericana. Cuarta edición, Buenos Aires, Argentina, 1996. Centres for Disease Control and Prevention (CDC). Sexual transmitted diseases: Treatment guidelines, 2002. CEPAL. Panorama Social de América Latina. Edición 2005. LC/G. 2288 – P. Santiago de Chile, marzo de 2006. CEPAL. La fecundidad en América Latina: ¿Transición o revolución? LC/L 2097 – P. Santiago de Chile, mayo de 2004. Conferencia Internacional sobre Población y Desarrollo (CIPD), El Cairo, 1994. Cuarta Conferencia Mundial sobre la Mujer, Beijing, 1995. Fiala C, Swahn ML, Stephansson O, Gemzell-Danielsson K. The effect of non-steroidal anti-inflammatory drugs on medical abortion with mifepristone and misoprostol at 13-22 weeks gestation. Hum Reprod. 2005;20(11):3072-3077. Epub 2005 Grimes DA, Lopez LM, Schulz KF, Stanwood N. Immediate postabortal insertion of intrauterine devices. Cochrane Database of Systematic Reviews 2004, Issue 4. May W, Gülmezoglu AM, Ba-Thike K. Antibiotics for incomplete abortion. Cochrane Database of Systematic Reviews 1999, Issue 4. Moulier R, Mesle B. Interrupción voluntaria del embarazo. Enciclopedia Médico Quirúrgica, GinecologíaObstetricia, E- 738-A-40. París: Elsevier 2007. 20 p. OliÄnyk IuV. Using ketoprofen in gynaecological practice. Lik Sprava. 2006; (3):65-69. OliÄnyk IuV. Using ketoprofen in gynaecological practice. Lik Sprava. 2006;(3):65-69. Organización Panamericana de la Salud. Guía práctica del manejo del aborto. Washington D. C., 1998. Organización Mundial de la Salud. Aborto sin riesgos. Guía técnica y de políticas para Sistemas de Salud. Ginebra, 2003. Organización Mundial de la Salud. Recomendaciones sobre prácticas seleccionadas para el uso de anticonceptivos. Segunda edición, Ginebra, 2005. Organización Mundial de la Salud. Criterios médicos de elegibilidad para el uso de anticonceptivos. Una guía esencial de la OMS sobre Planificación Familiar. Tercera edición. Ginebra, 2005. Organización Panamericana de la Salud. Imán Servicios: Normas de atención de salud sexual y reproductiva de adolescentes. Washington, D. C. OPS, 2005. Pan American Health Organization (PAHO) / World Association Sexology (WAS). Promotion of sexual health: Recommendation for action. Washington D. C., 2000. Penney G. Treatment of pain during medical abortion. Contraception. 2006;74(1):45-47. Epub 2006 Ramos Silvina et al. ”A comprehensive assessment of maternal deaths in Argentina translating multicentre collaborativr research into action” in Bulletin of the World Health Organization (BLT) volume 85, Number 8, August 2007, 569-648. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD &RQWLQXRGH$WHQFLyQGHOD0XMHU\HO5HFLpQ1DFLGR Recomendations on Ethical Issues in Obstetrics and Gynecology by The FIGO Committee for the Ethical aspects of Human Reproduction and Women´s Health, FIGO, London, United Kingdom, November 2003. Schwarcz R, Fescina R, Duverges C. Obstetricia. Editorial El Ateneo, 6ª edición, Buenos Aires, Argentina 2005. Thinkhamrop J, Laopaiboon M, Lumbiganon P. Prophylactic antibiotics for transcervical intrauterine procedures. Cochrane Database of Systematic Reviews 2007, Issue 3. World Health Organization. Unsafe abortion. Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2000. Fourth edition, Geneva, 2004. World Health Organization. Frecuently asked clinical questions about medical abortion. Conclusions of an International Consensus Conference on Medical Abortion in Early First Trimester, Bellagio, Italy, 2006. World Health Organization. Pregnancy, Chilbirth, Postpartum and Newborn Care: A guide for essential practice, Geneva, 2003. &HQWUR/DWLQRDPHULFDQRGH3HULQDWRORJtD6DOXGGHOD0XMHU\5HSURGXFWLYD 3a Edición http://new.paho.org/clap http://perinatal.bvsalud.org/ r ISBN 978-92-75-33177-4 CLAP/SMR Publicación Científica Nº 1577 - 2011