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 mondedont 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, 19889 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 0.05-0.51Friedman (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 1.15-2.15Mc Ginty ( &ç(-) 43/150 6/50 2.45 1.17-5.15Hacker (1979) 9/20 0/6 6.77 1.03-44.38Friedman (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 moindresSORIANO, 1996

YUEN, 1995ELBOURNE, 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

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 travailDAHIYA, 1995

CHESNUT, 1987YOUNG, 1988 Pas d’effet statistiquement prouvé

« TIMING » D’ADMINISTRATION

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 MisoprostolEtudes 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 PoVs. 250 Placebo

DANIEL, 1999 7%-15% NS 16%-38% RR=0,47 31 Misoprostol 600 µg PoVs. 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=7,17Vs. 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=6,96Vs. 10 558 Oxytocine IV

O BORO, 2003 1%-0% RR=3,02 NS Tremblements 57%-14% RR=4,06 966 Patientes Misoprostol 600 µg PoVs. 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=5,69Vs. 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

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

AUTRES PROSTAGLANDINES

DE GROOT, 1996 : Etude randomisée comparant ergométrine – oxytocine

Diminution des pertes sanguines : 5% pour ergométrine versus 9% pour oxytocine

METHYLERGOMETRINE : METHERGIN

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 : Indonésie2004 : Uruguay2005 : Gambie, Angola2006 : Egypte, Tibet, Vietnam

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