TEMA 5. PROCEDIMIENTOS DIAGNÓSTICOS Y TERAPEÚTICOS.

5.1 LAS EXPLORACIONES COMPLEMENTARIAS DE IMAGEN

Las ecografías, las radiografías, la tomografía computarizada (TC) y la resonancia magnética (RM) son, en general, compatibles con la lactancia materna. En la gran mayoría de las exploraciones de imagen no es necesario interrumpir la lactancia. Esta recomendación incluye también, de forma rutinaria, los estudios con contraste yodado intravenoso y los estudios con contraste basado en gadolinio, ya que la cantidad que pasa a la leche es mínima y la fracción que finalmente absorbe el lactante por vía digestiva es extraordinariamente baja.

Menos del 1% de la dosis Materna administrada se excreta a la leche materna y menos del 1% del contraste ingerido por el lactante se absorbe a nivel intestinal. Por tanto, la Dosis Sistémica del lactante es menor del 0,01% de la dosis intravenosa administrada a la madre (Bettman 2004, Webb 2005, Tremblay 2012).

La ACR (American College of Radiology) establece que es seguro para la madre continuar amamantando tras administración con contrastes yodados intravenosos. Esta recomendación se basa en múltiples estudios que han demostrado la seguridad y eficacia del contraste yodado en pacientes lactantes (Bettman 2004, Webb 2005, Tremblay 2012, ACR 2018).

Los contrastes yodados pueden alterar el sabor de la leche, pero no es dañino para el lactante (ABM protocolo nº 31).

Con respecto a las gammagrafías, hay que consultar cuidadosamente cuanto tiempo se debe dejar de amamantar si lo que se va a practicar es una prueba con isotopos radioactivos o radionúclidos que se emplean en este tipo de pruebas (véase Tabla 3).

Las medidas para tener en cuenta en caso de que la prueba diagnóstica incluya radionúclidos son las siguientes:

Intentar emplear el radionúclido de vida media más corta. Asesorarse con el radiólogo.
Almacenar leche extraída previamente para darla tras la exploración. Extraerse la leche el tiempo indicado, desechándola.
Tener en cuenta que en el caso de que se empleen Yodo-131 y el Estroncio-89M empleados como radionúclidos, se debe suspender la lactancia.

Cuando se valora su compatibilidad con la lactante, se debe tener en cuenta que el lactante puede exponerse a la radiación a través de dos rutas. La ruta más común es la radiactividad dentro de la propia leche materna. La otra ruta posible es el contacto con la madre irradiada mediante exposición externa (ABM protocolo nº 31). Esta segunda vía de exposición tiene relevancia en caso de que se emplee el radionúclido fludeoxiglucosa-F18 (FDG), el agente utilizado en la prueba de
Tomografía de Emisión de Positrones (PET) para el diagnóstico de distintos tipos de cáncer y que se acumula en el tejido mamario que presenta una alta actividad metabólica durante la lactancia (Siegel 2002). Los otros agentes que figuran en la tabla 3 no se acumulan en el tejido mamario activo.

Los tiempos de interrupción de lactancia o de evitar contacto cercano se han calculado mediante mediciones para que el lactante esté expuesto como máximo a 1 milisievert (1 mSv = 0,1 rem) de radiación (ARSAC 2025, Howe 2008).

Los periodos específicos de interrupción de la lactancia y los tiempos efectivos de exposición para cada radiofármaco deben consultarse preferentemente en la tabla 7.2y la tabla 7.3 de la guía ARSAC 2025, que actualiza las recomendaciones previas para pacientes en periodo de lactancia.

Como referencia, un adulto recibe entre 3 y 6 mSv anuales procedentes de la radiación ambiental según la región en que viva, más una media de 3 mSv por exploraciones médicas y hay lugares del mundo en los que la exposición llega a 70 mSv anuales sin efectos dañinos demostrados (Goodman 2012).

Si se desea que no reciba nada de radiación hay que interrumpir la lactancia durante 5 a 10 vidas medias radiológicas del radionúclido utilizado.

En caso de tener que interrumpir la lactancia tras la exploración, conviene extraerse la leche y ofrecer, en su lugar, leche previamente extraída y almacenada en frigorífico antes de la prueba (ARSAC 2025, Moretti 2000).
La leche extraída tras la prueba se puede congelar y emplear una vez pasadas 10 vidas medias radioactivas del isótopo correspondiente (Hale 2017).

Hay guías para saber si hay o no que evitar el contacto cercano con el lactante (Mountford 1999).

Fuente: https://apilam.org http://www.e-lactancia.org

Cabe señalar que las madres lactantes que participan en el cuidado de pacientes sometidos a procedimientos de medicina nuclear y/o estudios de imagen y procedimientos deben tomar precauciones estándar. Dado que estos profesionales sanitarios no están ingiriendo, inhalando o recibiendo radiofármacos intravenosos y/o contraste, no se requiere interrupción en la lactancia materna.

5.1.1 Ecografía

La ecografía utiliza ondas sonoras y no radiación ionizante, por lo que no altera la producción ni la composición de la leche materna. Puede realizarse durante la lactancia sin necesidad de esperar ningún tiempo para volver a amamantar. En el caso de la mama, la ecografía constituye además la técnica inicial de elección ante una masa palpable u otros síntomas sospechosos en mujeres embarazadas o lactantes.

La biopsia mamaria percutánea guiada por ecografía puede realizarse también durante la lactancia. La evidencia reciente indica que la biopsia con aguja gruesa, con anestesia local y colocación de clip si está indicado, es segura y no obliga a interrumpir la lactancia. Puede existir un discreto aumento del riesgo de sangrado por la mayor vascularización de la mama lactante, y el riesgo de fístula láctea es bajo; en cualquier caso, estos riesgos no deben retrasar una biopsia necesaria.

5.1.2 Mamografía e imagen mamaria durante la lactancia

La mamografía, como cualquier exploración con rayos X, no contraindica la lactancia, ya que la radiación no permanece en la mama ni se excreta por la leche. Por ello, tras una mamografía se puede amamantar con normalidad. La lactancia puede aumentar la densidad mamaria y dificultar parcialmente la interpretación, pero esto no impide la realización de la prueba cuando está clínicamente indicada. Se recomienda amamantar o extraer leche inmediatamente antes de la exploración para disminuir la congestión mamaria, reducir molestias y optimizar la sensibilidad diagnóstica.

Las guías actuales insisten en que la imagen mamaria no debe retrasarse por el hecho de que la mujer esté lactando. En mujeres con alto riesgo, la indicación de mamografía de cribado se mantiene según edad y perfil de riesgo. La RM mamaria con gadolinio puede realizarse durante la lactancia cuando esté clínicamente indicada, aunque en el contexto de cribado se individualiza según el riesgo, la duración prevista de la lactancia y la situación clínica. Tras la prueba, incluida la RM con gadolinio, no es necesario suspender la lactancia.

5.1.3 Radiografías, TC y RM con o sin contraste

Las radiografías simples, la mamografía, la fluoroscopia, la TC y la RM sin contraste son compatibles con la lactancia y no requieren ninguna interrupción. Del mismo modo, la administración de contraste yodado o de gadolinio no obliga de rutina a extraer y desechar la leche. Según el ACR Manual on Contrast Media 2025, la dosis sistémica que recibe el lactante a través de la leche es inferior al 0,01% de la dosis materna para los contrastes yodados y menor del 0,0004% para los contrastes con gadolinio. Por ello, no se recomienda suspender la lactancia tras su administración.

Además, el ACR señala que no existen datos sólidos que justifiquen realizar cribado tiroideo rutinario en los lactantes expuestos a contraste yodado a través de la leche materna tras una TC convencional, por lo que esta monitorización no se recomienda de forma sistemática. Si, a pesar de la información disponible, la madre prefiere minimizar aún más una exposición ya muy baja, puede decidir abstenerse de amamantar y desechar la leche durante 12–24 horas, aunque el beneficio real de hacerlo es escaso y no hay valor en prolongarlo más allá de 24 horas.

5.1.4 Medicina nuclear y estudios con radiofármacos

La principal excepción dentro de las exploraciones de imagen la constituyen los estudios de medicina nuclear. En estos casos, la compatibilidad con la lactancia no depende solo de la técnica, sino del radiofármaco concreto, de la actividad administrada y de la posible irradiación externa del lactante por contacto estrecho con la madre. Por ello, las recomendaciones deben individualizarse y seguir siempre las instrucciones del servicio de Medicina Nuclear.

La guía ARSAC 2025 recuerda que los tiempos de interrupción se calculan para que la dosis total al lactante sea inferior a 1 mSv, teniendo en cuenta tanto la ingestión de leche como la irradiación externa. También subraya que estos tiempos no son aplicables al periodo de calostro, en el que debe individualizarse la recomendación hasta comprobar mediante mediciones que es seguro reanudar la lactancia.

Como orientación práctica, cuando vaya a administrarse un radiofármaco conviene que la madre amamante justo antes de la prueba, disponga de leche extraída previamente y, si es preciso, se extraiga y deseche la leche durante el periodo indicado. Algunos ejemplos de la tabla ARSAC 2025 son: 18F-FDG: 1 hora; 99mTc-pertecnetato: 30 horas con 80 MBq y 57 horas con 800 MBq; 111In-pentetreótido: 60 horas; 123I-yoduro: 42horas; y131I-yoduro: suspensión de la lactancia. Algunos radiofármacos, en cambio, no requieren interrupción o precisan tiempos muy cortos.

En consecuencia, este apartado debe formularse siempre con prudencia: no basta con decir que una “gammagrafía” es o no compatible; hay que identificar el radiofármaco exacto. En todos los estudios de medicina nuclear, la recomendación final debe quedar individualizada por el servicio responsable.

5.1.5 Diagnóstico prenatal invasivo

La amniocentesis y la biopsia corial son técnicas invasivas de diagnóstico prenatal cuyo riesgo de pérdida gestacional adicional es bajo cuando son realizadas por operadores con experiencia. Las recomendaciones actuales sitúan ese riesgo adicional, de forma general, por debajo del 0,5%, aunque la cifra exacta depende del procedimiento, la edad gestacional y el contexto clínico.

Desde el punto de vista de la lactancia, no existe una base farmacológica ni radiológica para indicar la suspensión del amamantamiento tras una amniocentesis o una biopsia corial. Por tanto, la lactancia puede mantenerse. Las recomendaciones de reposo relativo o de reducción temporal de esfuerzos tras la prueba obedecen al propio procedimiento obstétrico, no a un riesgo para el lactante amamantado.

5.1.6 Intervención quirúrgica y anestesia

La intervención quirúrgica, ya sea con anestesia general, regional, epidural, raquídea, local o sedación, no contraindica por sí misma la lactancia. La recomendación actual es abandonar la antigua práctica de “extraer y tirar” (“pump and dump”) de forma rutinaria tras la anestesia. La mayoría de los fármacos anestésicos y perioperatorios pasan a la leche en cantidades muy bajas o clínicamente poco relevantes, por lo que la lactancia puede reanudarse tan pronto como la madre esté despierta, orientada, clínicamente estable y en condiciones de sostener o colocar al bebé al pecho.

En cirugías prolongadas o cuando se prevea una separación larga entre madre y lactante, conviene planificar con antelación la extracción de leche para evitar ingurgitación, mantener la producción y disponer de leche para las tomas mientras dure la separación. Cuando la cirugía afecta directamente a la mama, el impacto posterior sobre la lactancia dependerá del tipo de intervención, de la localización de las incisiones y del grado de resección del parénquima mamario.

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