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
- 1On 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).
- 2Une 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).
- 3Chez 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).
- 4Les 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).
- 5Dans 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).
- 6Les femmes qui ont subi une trachélectomie devraient faire l'objet d'un cerclage par voie abdominale (II-3C).
- 7La 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).
- 8Les 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).
- 9La 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).
- 10Le 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).
- 11Les 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).
- 12Dans 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).
- 13La 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).
- 14Le 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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Article info
Publication history
No 373, février 2019 (remplace No 301, décembre 2013)
Footnotes
Le présent document correspond aux avancées cliniques et scientifiques qui se dessinaient au moment de sa publication et est susceptible d’être modifié. Les renseignements qu'il contient ne doivent pas être considérés comme les seuls traitements ou les seules interventions à suivre. Les établissements locaux peuvent imposer des modifications aux opinions ci-incluses. Toute modification apportée par un établissement local doit être bien documentée. Le contenu du présent document ne peut être reproduit d'aucune manière, en tout ou en partie, sans l'autorisation écrite préalable de l’éditeur.
Chaque personne a le droit et la responsabilité de prendre des décisions éclairées relativement aux soins qu'elle reçoit en partenariat avec ses fournisseurs de soins de santé. Pour aider les patientes à faire un choix éclairé, il faut leur fournir un soutien et des renseignements qui reposent sur des données probantes, sont adaptés à leur culture et correspondent à leurs besoins.
La présente directive clinique utilise un langage qui place les femmes au centre des soins. Cela dit, la SOGC est déterminée à respecter les droits de chaque personne, y compris les personnes transgenres, non binaires ou intersexuées, à qui la directive clinique pourrait s'appliquer. La SOGC encourage les fournisseurs de soins de santé à s'engager dans une conversation respectueuse avec les patientes relativement à leur identité de genre, car cette approche joue un rôle crucial dans la prestation de soins sécuritaires et appropriés. Les valeurs, croyances et besoins individuels de chaque patiente et de sa famille doivent être pris en compte, et l'ultime décision de la patiente quant à ses options de soins et de traitements doit être respectée.
Identification
Copyright
© 2018 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc.
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- No. 373-Cervical Insufficiency and Cervical CerclageJournal of Obstetrics and Gynaecology Canada Vol. 41Issue 2
