Guía de Práctica Clínica
Prevención del Parto Prematuro
1.- Recomendación / Juicio del Panel y Evidencia
1. En embarazadas menores de 16 semanas de edad gestacional con aumento de riesgo de parto prematuro por indicación médica, el Ministerio de Salud RECOMIENDA USAR aspirina (100-150 mg) por sobre no utilizarla.
Comentarios del Panel de Expertos:
La definición de aumento del riesgo de parto prematuro que se utilice para aplicar esta recomendación debe considerar los siguientes antecedentes de las 11-14 SEMANAS si están disponibles:
►Clínicas, tales como pre eclampsia o restricción de crecimiento intrauterino en embarazo previo, enfermedades renales, trombofilias, índice masa corporal elevado, aumento de la presión arterial, etc.
►Biofísicas, tales como el aumento de resistencia de arterias uterinas y presión arterial media.
►Bioquímicas, tales como factor de crecimiento placentario o Proteína plasmática asociada al embarazo.
El Panel de Expertos analizó y debatió cada uno de las preguntas de la “Tabla de la evidencia a la decisión”, considerando tanto la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes. Una vez consensuada la postura del panel respecto a las preguntas, emitieron un juicio seleccionando la opción de respuesta que mejor representaba la opinión del conjunto (destacada con color). Finalmente cuando el panel emitió su juicio sobre todas las preguntas, se emitió la recomendación.
A continuación se presenta la “Tabla de la evidencia a la decisión” con el resumen de los juicios, la evidencia de investigación evaluada, consideraciones adicionales y comentarios planteados por el panel.
1.- ¿El problema es una prioridad?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
El problema ha sido definido como prioritario en el marco de las Garantías Explícitas en Salud (GES), régimen integral de salud que prioriza un grupo de patologías o problemas de salud, garantizando el acceso a tratamiento oportuno y de calidad.
2.- ¿Qué tan significativos son los efectos deseables anticipados?
| Trivial | Pequeño | Moderado | Grande | Varía | No lo sé |
|---|
Grandes: El panel de expertos consideró que los efectos deseables de usar bevacizumab son grandes, en función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
Aspirina precoz en mujeres con alto riesgo de parto prematuro |
|||||||
|
Pacientes |
Mujeres embarazadas con alto riesgo de parto prematuro |
||||||
|
Intervención |
Aspirina |
||||||
|
Comparación |
Placebo |
||||||
|
Desenlaces |
Efecto relativo (IC 95%) |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
|||
|
SIN aspirina |
CON aspirina |
Diferencia (IC 95%) |
|||||
|
Hipertensión gestacional |
RR 0,54 (0,41 a 0,70) (12 ensayos/ 838 |
287 |
155 por 1000 |
Diferencia: 132 pacientes menos por 1000 (169 menos 86 a menos) |
⊕⊕⊕⊕3 Alta |
La aspirina disminuye la incidencia de hipertensión gestacional. |
|
|
Eclampsia |
RR 0,94 (0,59 a 1,48) (9 ensayos/ 22584 |
3 |
3 |
Diferencia: 0 pacientes por 1000 (1 menos a 2 más) |
⊕⊕◯◯1,2,3 Baja |
La aspirina podría tener poco o nulo efecto en la incidencia de eclampsia |
|
|
Mortalidad materna |
RR 2,57 (0,39 a 17,06) (3 ensayos/ 12709 |
0 |
0 |
Diferencia: 0 pacientes por 1000 (0 a 3 más) |
⊕⊕⊕◯1,3 Moderada |
El uso de aspirina probablemente no impacta en la mortalidad materna |
|
|
Parto prematuro |
RR 0,89 (0,81 a 0,97) (10 ensayos/ 3252 |
381 |
339 |
Diferencia: 42 pacientes menos por 1000 (72 menos a11 menos) |
⊕⊕⊕⊕3 Alta |
La aspirina disminuye la incidencia de parto prematuro |
|
|
Mortalidad neonatal y fetal |
RR 0,69 (0,53 a 0,90) (17 ensayos/ 4443 |
58 |
40 |
Diferencia: 18 pacientes menos por 1000 (27 menos a 6 menos) |
⊕⊕⊕⊕3 Alta |
La aspirina disminuye la mortalidad neonatal y fetal |
|
IC 95%: Intervalo de confianza del 95%.
RR: Riesgo relativo.
GRADE: grados de evidencia del GRADE Working Group (ver más adelante).
*Los riesgos SIN aspirina están basados en los riesgos del grupo control en los estudios. El riesgo CON aspirina (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
1 Se disminuyó un nivel de certeza de evidencia por indirecta, ya que el estimador de efecto proviene de la población de cualquier mujer embarazada y no exclusivamente de mujeres de alto riesgo, escenarios que el panel de expertos considera diferentes.
2 Se disminuyó un nivel de certeza de evidencia por imprecisión ya que a cada extremo del intervalo de confianza pudiese conllevar una decisión diferente.
3 Se decidió no disminuir certeza de evidencia por riesgo de sesgo, pese a que algunos ensayos presentaban secuencia de aleatorización no clara, ya que la mayoría de los ensayos grandes presentaban menor sesgo.
Fecha de elaboración de la tabla: 8 de Mayo de 2018
Referencia
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| Grande | Moderado | Pequeño | Trivial | Varía | No lo sé |
|---|
Pequeños: El panel de expertos consideró que los efectos indeseables de usar aspirina de dosis baja son pequeños, en función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
Aspirina precoz en mujeres con alto riesgo de parto prematuro |
|||||||
|
Pacientes |
Mujeres embarazadas con alto riesgo de parto prematuro |
||||||
|
Intervención |
Aspirina |
||||||
|
Comparación |
Placebo |
||||||
|
Desenlaces |
Efecto relativo (IC 95%) |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
|||
|
SIN aspirina |
CON aspirina |
Diferencia (IC 95%) |
|||||
|
Hipertensión gestacional |
RR 0,54 (0,41 a 0,70) (12 ensayos/ 838 |
287 |
155 por 1000 |
Diferencia: 132 pacientes menos por 1000 (169 menos 86 a menos) |
⊕⊕⊕⊕3 Alta |
La aspirina disminuye la incidencia de hipertensión gestacional. |
|
|
Eclampsia |
RR 0,94 (0,59 a 1,48) (9 ensayos/ 22584 |
3 |
3 |
Diferencia: 0 pacientes por 1000 (1 menos a 2 más) |
⊕⊕◯◯1,2,3 Baja |
La aspirina podría tener poco o nulo efecto en la incidencia de eclampsia |
|
|
Mortalidad materna |
RR 2,57 (0,39 a 17,06) (3 ensayos/ 12709 |
0 |
0 |
Diferencia: 0 pacientes por 1000 (0 a 3 más) |
⊕⊕⊕◯1,3 Moderada |
El uso de aspirina probablemente no impacta en la mortalidad materna |
|
|
Parto prematuro |
RR 0,89 (0,81 a 0,97) (10 ensayos/ 3252 |
381 |
339 |
Diferencia: 42 pacientes menos por 1000 (72 menos a11 menos) |
⊕⊕⊕⊕3 Alta |
La aspirina disminuye la incidencia de parto prematuro |
|
|
Mortalidad neonatal y fetal |
RR 0,69 (0,53 a 0,90) (17 ensayos/ 4443 |
58 |
40 |
Diferencia: 18 pacientes menos por 1000 (27 menos a 6 menos) |
⊕⊕⊕⊕3 Alta |
La aspirina disminuye la mortalidad neonatal y fetal |
|
IC 95%: Intervalo de confianza del 95%.
RR: Riesgo relativo.
GRADE: grados de evidencia del GRADE Working Group (ver más adelante).
*Los riesgos SIN aspirina están basados en los riesgos del grupo control en los estudios. El riesgo CON aspirina (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
1 Se disminuyó un nivel de certeza de evidencia por indirecta, ya que el estimador de efecto proviene de la población de cualquier mujer embarazada y no exclusivamente de mujeres de alto riesgo, escenarios que el panel de expertos considera diferentes.
2 Se disminuyó un nivel de certeza de evidencia por imprecisión ya que a cada extremo del intervalo de confianza pudiese conllevar una decisión diferente.
3 Se decidió no disminuir certeza de evidencia por riesgo de sesgo, pese a que algunos ensayos presentaban secuencia de aleatorización no clara, ya que la mayoría de los ensayos grandes presentaban menor sesgo.
Fecha de elaboración de la tabla: 8 de Mayo de 2018
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Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
4.- ¿Cuál es la certeza general de la evidencia sobre efectos?
| Muy baja | Baja | Moderada | Alta | Ningún estudio incluído |
|---|
Moderada: Existe confianza respecto del efecto de usar aspirina de dosis baja.
Evidencia de investigación
|
Desenlaces (Outcomes) |
Importancia |
Certeza de la evidencia |
|
Parto prematuro |
CRITICAL |
⨁⨁⨁◯ |
|
Mortalidad perinatal |
CRITICAL |
⨁⨁⨁◯ |
|
Pre-eclampsia |
CRITICAL |
⨁⨁⨁⨁ |
a. El funnel plot de revisiones que han analizado un conjunto mayor de ensayos (inicio AAS antes de las 16 semanas por cualquier causa) es asimetrico
5.- ¿Hay incertidumbre importante o variabilidad sobre qué tanto valora la gente los desenlaces principales?
| Incertidumbre o variabilidad importantes | Posiblemente hay incertidumbre o variabilidad importantes | Probablemente no hay incertidumbre ni variabilidad importantes | No hay variabilidad o incertidumbre importante |
|---|
No hay variabilidad o incertidumbre importante: El panel de expertos consideró que no existe variabilidad o incertidumbre importante respecto a lo que la mayoría de los pacientes podrían llegar a elegir, en función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
No se encontraron estudios que abordaran valores y preferencias de los pacientes respecto de esta pregunta.
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de valores y preferencias de los pacientes
6.- El balance entre efectos deseables e indeseables favorece la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | No lo sé |
|---|
Favorece la intervención: Considerando que la intervención es «usar aspirina de dosis baja» y la comparación es «no usar», el panel de experto opinó que el balance entre efectos deseables e indeseables claramente favorece usar aspirina de dosis baja.
7.- ¿Qué tan grandes son los recursos necesarios (costos)?
| Costos extensos | Costos moderados | Costos y ahorros despreciables | Ahorros moderados | Ahorros extensos | Varía | No lo sé |
|---|
Costos y ahorros despreciables: El panel de expertos consideró que para implementar la intervención usar aspirina de dosis baja no implica ni recursos ni ahorros significativos, en función de los antecedentes recolectados, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
Aspirina 100mg
Valor comprimido mercado público $4,8 (x30): $144
Valor comprimido privado (IMS Health) $67 (x30): $2.100
Búsqueda y Síntesis de Evidencia
Busqueda de costos
8.- ¿La costo-efectividad de la intervención beneficia la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | Ningún estudio incluído |
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Favorece la intervención: Considerando que la intervención es «usar aspirina de dosis baja» y la comparación es «no usar», el panel de experto opinó que claramente la alternativa más costo-efectiva es usar aspirina de dosis baja.
Evidencia de investigación
No se encontraron estudios de costo efectividad
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de costo-efectividad y de costos
9.- ¿Cuál sería el impacto en equidad en salud?
| Reducido | Probablemente reducido | Probablemente ningún impacto | Probablemente aumentado | Aumentado | Varía | No lo sé |
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Aumentada: El panel de expertos consideró que la equidad en salud aumentaría, dado que se identificó grupos o contextos desaventajados que podrían mejorar su situación si se recomendase la intervención usar aspirina de dosis baja.
10.- ¿La intervención es aceptable para las partes interesadas?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Sí: El panel de expertos consideró que usar aspirina de dosis baja SÍ es aceptable para las partes interesadas (profesionales de la salud, gestores de centros de salud, directivos servicios de salud, pacientes, cuidadores, seguros de salud, otros).
11.- ¿Es factible implementar la intervención?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Sí: El panel de expertos consideró que usar aspirina de dosis baja SÍ es factible implementar, contemplando la capacidad de la red asistencial, los recursos humanos disponibles a nivel país, recursos financieros, preferencias de los pacientes, etc.