DELIVRANCE DIRIGEE SYSTEMATIQUE Delphine HEQUET DES gynécologie-obstétrique

QU’EST CE QU’UNE DELIVRANCE DIRIGEE ?

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

ENJEUX DE LA DELIVRANCE DIRIGEE

HEMORRAGIE DE LA DELIVRANCE : 500 000 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

FAUT-IL REALISER UNE DELIVRANCE DIRIGEE SYSTEMATIQUE ?

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 95% CI Howard (1964) 24/963 25/470 0.43 0.23-0.78 McGinty (1951) 1/150 5/50 0.04 0.01-0.27 Daley (1951) 45/490 80/510 0.55 0.38-0.80 Rooney (1985) 34/346 42/278 0.61 0.38-0.99 Friedman (1957) 24/717 2/177 2.19 0.82-5.83 0.57

Recours aux ocytociques en post-partum Oxytocic Control Odds ratio 95% CI Howard (1964) 46/984 58/475 0.32 0.21-0.49 Newton (1961) 1/50 11/50 0.15 0.05-0.51 Friedman (1957) 100/717 36/177 0.61 0.39-0.96 0.40 Hypertension en post-partum (PAS 17O ou PAS 140 et PAD 90) Oxytocic Control Odds ratio 95% CI Howard (1964) 153/983 50/475 1.57 1.15-2.15 Mc Ginty ( &ç(-) 43/150 6/50 2.45 1.17-5.15 Hacker (1979) 9/20 0/6 6.77 1.03-44.38 Friedman (1975) 14/717 1/177 2.32 0.64-8.33 1.76 AU TOTAL : HEMORRAGIES DE LA DELIVRANCE DIMINUEES DE 40%

RESULTATS CONTRADICOIRES DRIFE, 1997 : Rétention placentaire 3  fois plus fréquentes en cas de délivrance dirigée GIACALONE, 2000 MAC DONALD, 2000 Pas de différence significative de survenue d’hémorragie de la délivrance entre le BEGLEY, 1990 groupe délivrance dirigée et le groupe délivrance physiologique.

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, 1993 Management actif diminue la durée de la troisième phase du travail POESCHMANN, 1991 ROGER, 1998 Management actif diminue le risque d’hémorragie de la délivrance

COMMENT REALISER UNE DELIVRANCE DIRIGEE

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.

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.

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

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

AUTRES ETUDES COMPARANT SYNTOCINON-SYNTOMETRINE ATHAVALE, 1991 KHAN, 1994 Même efficacité, EI moindres SORIANO, 1996 YUEN, 1995 ELBOURNE, 1998 Même efficacité, EI moindres mais plus de rétention placentaires MC DONALD, 2006 : méta-analyse incluant 6 essais, 9332 femmes HD 500-1000 ml : supériorité de syntométrine HD >1000 ml : même efficacité EI ( vomissements, HTA) : supérieurs avec syntométrine

« 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, 1989 Réduction des pertes sanguines et de la troisième phase du travail DAHIYA, 1995 CHESNUT, 1987 YOUNG, 1988 Pas d’effet statistiquement prouvé

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

Etudes randomisées Misoprostol HD (>1 000) Recours Ocytociques Etudes randomisées Misoprostol HD (>1 000) Recours Ocytociques Effets Indésirables HOFMEYR, 1998 6%-9% RR=0,65 NS 2,8 %-8,4% RR=0,33 Tremblements 19%-5%RR=3,69 250 Misoprotol 400 µg Po Vs. 250 Placebo DANIEL, 1999 7%-15% NS 16%-38% RR=0,47 31 Misoprostol 600 µg Po Vs. 34 Placebo WHO, 2001 4%-3% RR=1,39 15%-11% RR=1,40 Tremblements RR=3,48 9264 Misoprostol 600 µg Po Hyperthermie RR=7,17 Vs. 9266 Oxytocine 10 UI IV NG, 2001 5%-4% RR=1,26 NS 22,6%-14% RR=1,62 1026 Misoprostol 600 µg Po Vs. 1032 Syntométrine IM 1mL VILLAR, 2002 (Revue) RR=1,36 RR=1,80 Tremblements RR=3,27 10 539 Misoprostol 600 µg Po Hyperthermie RR=6,96 Vs. 10 558 Oxytocine IV O BORO, 2003 1%-0% RR=3,02 NS Tremblements 57%-14% RR=4,06 966 Patientes Misoprostol 600 µg Po Vs. Oxytocine IV 10 UI HOFMEYR, 2004 5,1%-9,2% RR=0,56 NS 57%-56% RR=1,01 NS Mortalité maternelle 2,6%-0% 117 Misoprostol 1 000 µg Po,IR,S Fièvre 9,6%-1,7% RR=5,69 Vs. 121 Placebo LAEGER, 2006 11%-17% RR=0,66 Misoprostol 600 µg SL Vs. Oxytociques

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

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

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

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

CONCLUSION

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 : 2003 : Indonésie 2004 : Uruguay 2005 : Gambie, Angola 2006 : Egypte, Tibet, Vietnam

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