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No 373 - Insuffisance cervicale et cerclage cervical

      RÉSUMÉ

      Objectif

      La présente directive clinique vise à fournir aux cliniciens un cadre à utiliser pour déterminer quelles femmes présentent un risque accru d'insuffisance cervicale et dans quelles situations le cerclage aurait une valeur potentielle.

      Données probantes

      Nous avons examiné des études publiées récupérées au moyen de recherches dans PubMed, Medline, CINAHL et The Cochrane Library en 2018 à l'aide d'une terminologie (p. ex., uterine cervical incompetence) et de mots-clés (p. ex., cervical insufficiency, cerclage, Shirodkar cerclage, McDonald cerclage, abdominal, cervical length, mid-trimester pregnancy loss). Nous avons tenu compte des résultats provenant de revues systématiques, d'essais cliniques randomisés, d'essais cliniques contrôlés et d’études observationnelles. Aucune restriction de date ou de langue n'a été employée. Les recherches ont été refaites régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en juin 2018. Nous avons également tenu compte de la littérature grise (non publiée) trouvée sur les sites Web d'organismes d’évaluation des technologies de la santé et d'autres organismes liés aux technologies de la santé, dans des collections de directives cliniques et des registres d'essais cliniques, et obtenue auprès d'associations nationales et internationales de médecins spécialistes.

      Valeurs

      La qualité des données probantes a été évaluée en fonction des critères décrits dans le rapport du Groupe d’étude canadien sur les soins de santé préventifs.

      RECOMMANDATIONS

      • 1
        On devrait évaluer chez les femmes enceintes ou qui prévoient le devenir la présence de facteurs de risque d'insuffisance cervicale. Un examen approfondi des antécédents médicaux lors de la première consultation peut mettre en évidence des facteurs de risque lors de la première grossesse (III-B).
      • 2
        Une évaluation détaillée des facteurs de risque devrait être effectuée après une fausse couche au deuxième trimestre ou un accouchement prématuré précoce, ou encore si de telles complications se sont produites durant une grossesse antérieure (III-B).
      • 3
        Chez les femmes qui présentent des antécédents d'insuffisance cervicale, une analyse d'urine (à des fins de mise en culture et pour la tenue d'une épreuve de sensibilité) et des mises en culture vaginales visant la vaginose bactérienne devraient être effectuées dans le cadre de la première consultation obstétricale, et toute infection ainsi mise au jour devrait être traitée (I-A).
      • 4
        Les femmes qui ont déjà connu au moins trois fausses couches au deuxième trimestre ou accouchements extrêmement prématurés et chez qui aucune cause particulière autre qu'une insuffisance cervicale potentielle n'a été identifiée devraient se voir offrir un cerclage planifié (entre la 12e et la 14e semaine de grossesse) (I-A).
      • 5
        Dans le cas des femmes présentant des antécédents classiques d'insuffisance cervicale chez qui la mise en place précédente d'un cerclage par voie vaginale a échoué, la mise en place d'un cerclage par voie abdominale peut être envisagée en l'absence de facteurs atténuants additionnels (II-3C).
      • 6
        Les femmes qui ont subi une trachélectomie devraient faire l'objet d'un cerclage par voie abdominale (II-3C).
      • 7
        La mise en place d'un cerclage d'urgence pourrait être envisagée chez les femmes dont le col présente une dilatation inférieure à 4 cm, sans contractions, à moins de 24 semaines de grossesse (II-3C).
      • 8
        Les femmes pour lesquelles la mise en place d'un cerclage n'est pas envisagée ou justifiée, mais dont les antécédents semblent indiquer un risque d'insuffisance cervicale (1 ou 2 fausses couches au deuxième trimestre ou accouchements extrêmement prématurés), devraient se voir offrir des évaluations échographiques répétées de la longueur cervicale (II-2B).
      • 9
        La mise en place d'un cerclage devrait être envisagée chez les femmes connaissant une grossesse monofœtale qui présentent une possible insuffisance cervicale ou des antécédents d'accouchement prématuré spontané en présence d'une longueur cervicale inférieure à 25 mm avant 24 semaines de gestation, (I-A).
      • 10
        Le cerclage n'est d'aucune utilité dans le cas des femmes chez qui une échographie a révélé de façon fortuite la présence d'un col court et qui ne présentent pas d'autres facteurs de risque d'accouchement prématuré ou d'insuffisance cervicale (II-1D).
      • 11
        Les données actuelles n'appuient pas la mise en place planifiée d'un cerclage dans le cadre d'une grossesse multiple, même en présence d'antécédents d'accouchement prématuré; cette pratique devrait donc être évitée (I-D).
      • 12
        Dans le cadre d'une grossesse multiple, la mise en place d'un cerclage en fonction de la longueur cervicale n'est pas soutenue par la littérature (II-1D).
      • 13
        La mise en place d'un cerclage lors d'une grossesse gémellaire après que l’échographie a révélé un col de l'utérus court (moins de 25 mm) pourrait faire augmenter le risque d'accouchement prématuré (II-1D).
      • 14
        Le cerclage d'urgence ou de sauvetage devrait être envisagé durant une grossesse gémellaire si le col de l'utérus est dilaté (plus de 1 cm) avant le seuil de viabilité (II-2B).

      Mots clés

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