DELIVRANCE DIRIGEE SYSTEMATIQUE

Présentation au sujet: "DELIVRANCE DIRIGEE SYSTEMATIQUE"— Transcription de la présentation:

1 DELIVRANCE DIRIGEE SYSTEMATIQUE
Delphine HEQUET DES gynécologie-obstétrique

2 QU’EST CE QU’UNE DELIVRANCE DIRIGEE ?

3 DELIVRANCE DIRIGEE = tout ce qui s’oppose à une délivrance naturelle ou physiologique, à savoir, l’expectative.

4 ENJEUX DE LA DELIVRANCE DIRIGEE

5 HEMORRAGIE DE LA DELIVRANCE : déces par an dans le monde dont 99% dans les PVD Premières études dès 1932 : Moir rapporte son étude concernant l’utilisation de l’ergotamine Dans les années 50 aux Etats-Unis, utilisation quasi-systématique de l’ergotamine

6 FAUT-IL REALISER UNE DELIVRANCE DIRIGEE SYSTEMATIQUE ?

7 META-ANALYSE PRENDIVILLE, 1988
9 ETUDES 34 ANS 4494 PATIENTES Taille des études : de 26 à 1459 patientes Médicaments utilisés : ergotamine, oxytocine, association ergotamine-ocytocine, prostaglandines Mode d’administration : intra-vasculaire, intramusculaire, intra-myométrial Moment d’administration : tête, épaule antérieure, après naissance RESULTATS Survenue d’hémorragie de la délivrance Oxytocic Control Odds ratio % CI Howard (1964) / / McGinty (1951) / / Daley (1951) / / Rooney (1985) / / Friedman (1957) / / 0.57

8 Recours aux ocytociques en post-partum Oxytocic Control Odds ratio % CI Howard (1964) / / Newton (1961) / / Friedman (1957) / / Hypertension en post-partum (PAS 17O ou PAS 140 et PAD 90) Oxytocic Control Odds ratio % CI Howard (1964) / / Mc Ginty ( &ç(-) / / Hacker (1979) / / Friedman (1975) / / AU TOTAL : HEMORRAGIES DE LA DELIVRANCE DIMINUEES DE 40%

9 RESULTATS CONTRADICOIRES
DRIFE, 1997 : Rétention placentaire 3  fois plus fréquentes en cas de délivrance dirigée GIACALONE, 2000 MAC DONALD, Pas de différence significative de survenue d’hémorragie de la délivrance entre le BEGLEY, groupe délivrance dirigée et le groupe délivrance physiologique.

10 AUTRES ETUDES EN FAVEUR D’UNE DELIVRANCE DIRIGEE SYSTEMATIQUE
PRENDIVILLE, 1988 : essai randomisé management actif versus management passif de la délivrance 1695 patientes OXYTOCIN 5 UI + ERGOMETRINE 0.5 mg, IV, épaule antérieure, traction sur le cordon clampé à moins de 30 sec de la naissance RESULTATS : 5.9% HD versus 17.9% , odd ratio 3.3 PIERRE, 1991 THILAGANATHAN, Management actif diminue la durée de la troisième phase du travail POESCHMANN, 1991 ROGER, Management actif diminue le risque d’hémorragie de la délivrance

11 COMMENT REALISER UNE DELIVRANCE DIRIGEE

12 DELIVRANCE DIRIGEE MECANIQUE
DRAINAGE DU CORDON THOMAS, 1990 : Etude randomisée, 1908 femmes, administration prophylactique d’oxytocines à l’épaule antérieure. Pas de bénéfice supplémentaire du drainage. DELAI DE SECTION DU CORDON OXFORD MIDWIVES RESEARCH GROUP, 1991 : Etude randomisée, 554 femmes, section rapide ou différée. Pas de différence. TRACTION CONTROLLEE DU CORDON KHAN, 1997 : Etude randomisée, 1648 femmes. Groupe « actif » : oxytocique 10 UI IM et traction du cordon Groupe « passif » : efforts expulsifs maternels Diminution des hémorragies de la délivrance et des rétentions placentaires dans le groupe actif.

13 DELIVRANCE DIRIGEE PHARMACOLOGIQUE
OCYTOCINE + ERGOMETRINE : SYNTOMETRINE ELBOURNE, 1988 : Méta-analyse, 17 essais randomisés Efficacité supérieure aux dérivés de l’ergot de seigle seuls, non concluant versus oxytocine seul Combine la rapidité d’action de l’ocytocine et la durée prolongée de l’action de l’ergotamine. Nombreux EI : HTA, angor, arrêt cardiaque Quasi-totalité des études « management actif-management passif de la délivrance », implique syntométrine. Largement utilisée aux Etats-Unis, non disponible en France.

14 OCYTOCINE : SYNTOCINON
MC DONALD, 1993 : Etude randomisée en double aveugle, oxytocine versus oxytocine+ergométrine 3497 patientes 1730 oxytocine(5 UI) + ergométrine(0,5 mg) dont 664 à bas risque d’hémorragie ( grossesse unique, parité inf 5, pas d’ATCD d’HD, travail spontané inf à 12 h, accouchement voie basse normal) 1753 oxytocine(10 UI) dont 658 à bas risque d’hémorragie

15

16 Au total : ocytocine est aussi efficace que l’association ocytocine-ergométrine et entraine moins d’EI.

17 AUTRES ETUDES COMPARANT SYNTOCINON-SYNTOMETRINE ATHAVALE, KHAN, Même efficacité, EI moindres SORIANO, YUEN, 1995 ELBOURNE, Même efficacité, EI moindres mais plus de rétention placentaires MC DONALD, 2006 : méta-analyse incluant 6 essais, 9332 femmes HD ml : supériorité de syntométrine HD >1000 ml : même efficacité EI ( vomissements, HTA) : supérieurs avec syntométrine

18 « TIMING » D’ADMINISTRATION
SORIANO, 1996 : administration d’oxytocine à l’expulsion de la tête versus à l’expulsion du placenta meilleure prévention lors d’une administration précoce. ZAMORA, 1999 : tendance à une diminution d’HD (pas de résultats significatif) lors d’une administration précoce (avant délivrance placentaire) des oxytociques. COCHRANE, 2006 : Étude en cours VOIE D’ADMINISTRATION ETUDE DE LA VOIE OMBILICALE REDDY, Réduction des pertes sanguines et de la troisième phase du travail DAHIYA, 1995 CHESNUT, 1987 YOUNG, Pas d’effet statistiquement prouvé

19 MISOPROSTOL : CYTOTEC EL-REFAEY, 1997 : Etude prospective descriptive. 600 µg misoprostol per os; efficacité dans le traitement des HD. Intérêt dans les PVD. Nombreuses études randomisées

20 Etudes randomisées Misoprostol HD (>1 000) Recours Ocytociques
Etudes randomisées Misoprostol HD (>1 000) Recours Ocytociques Effets Indésirables HOFMEYR, %-9% RR=0,65 NS ,8 %-8,4% RR=0, Tremblements 19%-5%RR=3, Misoprotol 400 µg Po Vs. 250 Placebo DANIEL, %-15% NS %-38% RR=0, Misoprostol 600 µg Po Vs. 34 Placebo WHO, %-3% RR=1, %-11% RR=1, Tremblements RR=3, Misoprostol 600 µg Po Hyperthermie RR=7,17 Vs Oxytocine 10 UI IV NG, %-4% RR=1,26 NS ,6%-14% RR=1, Misoprostol 600 µg Po Vs Syntométrine IM 1mL VILLAR, 2002 (Revue) RR=1, RR=1, Tremblements RR=3, Misoprostol 600 µg Po Hyperthermie RR=6,96 Vs Oxytocine IV O BORO, %-0% RR=3,02 NS Tremblements 57%-14% RR=4, Patientes Misoprostol 600 µg Po Vs. Oxytocine IV 10 UI HOFMEYR, ,1%-9,2% RR=0,56 NS %-56% RR=1,01 NS Mortalité maternelle 2,6%-0% Misoprostol µg Po,IR,S Fièvre 9,6%-1,7% RR=5,69 Vs. 121 Placebo LAEGER, %-17% RR=0, Misoprostol 600 µg SL Vs. Oxytociques

21 Au total : Efficacité Moindre Effets secondaires plus nombreux Pas d’indication dans les centres équipés

22 VOIE D’ADMINISTRATION
ETUDE DE LA VOIE INTRA-RECTALE O’BRIEN, 1998 : 14 présentant une hémorragie de la délivrance, traitées avec succès par 1000 µg de cytotec intra-rectal seul DIAB, 1999 : Etude comparant 200 µg misoprostol IR (25 patientes) 400µg misoprostol IR (45 patientes) syntométrine IM (75 patientes) Diminution significative des pertes sanguines avec le misoprostol IR quelque soit la dose BAMIGBOYE, 1996 : 271 patientes 400 µg cytotec IR – 275 patientes placebo 1997 : 241 patientes 400 µg cytotec IR – 250 patientes syntométrine pas de réduction significative d’hémorragie de la délivrance avec le cytotec pas d’EI supplémentaire avec cette voie d’administration à ces doses

23 AUTRES PROSTAGLANDINES
ANALOGUE PGE2 : NALADOR POESCHMANN, 1991 : Efficacité équivalente à l’ocytocine mais EI nombreux ANALOGUE PGF2α CHUA, 1995 : CARBOPROST versus syntométrine : même efficacité mais EI fréquents (diarrhée) et prix 20 fois supérieur LAMONT, 2001 : HEMABATE versus syntométrine : même conclusion Au total : pas d’avantage des prostaglandines dans la prévention des hémorragies de la délivrance

24 METHYLERGOMETRINE : METHERGIN
DE GROOT, 1996 : Etude randomisée comparant ergométrine – oxytocine Diminution des pertes sanguines : 5% pour ergométrine versus 9% pour oxytocine

25 CONCLUSION

26 AVANTAGES A UNE DELIVRANCE DIRIGEE SYSTEMATIQUE SYNTOCINON ASSOCIE L’EFFICACITE ET PEU D’EFFETS SECONDAIRES L’UTILISATION DU CYTOTEC EST PEU CONCLUANTE MALGRE LES AVANTAGES QU’IL PRESENTE NOTAMMENT POUR LES PVD DERNIERES ETUDES PORTENT SUR L’APPLICATION ET LA FAISABILITE D’UNE DELIVRANCE DIRIGEE SYSTEMATIQUE DANS LES PVD : : Indonésie : Uruguay : Gambie, Angola : Egypte, Tibet, Vietnam

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