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Directive clinique No 392 - Grossesse et obésité maternelle Partie 2 : Planification en équipe de l'accouchement et soins post-partum

      RÉSUMÉ

      Objectif

      La présente directive clinique aborde les aspects essentiels des soins prénataux chez les femmes atteintes d'obésité. La partie 1 porte sur la préconception et les soins prénataux. La partie 2 porte sur la planification en équipe de l'accouchement et les soins post-partum.

      Utilisateurs concernés

      Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières, anesthésiologistes) qui prodiguent des soins relatifs à la grossesse auprès de femmes atteintes d'obésité.

      Population cible

      Femmes atteintes d'obésité qui sont enceintes ou prévoient le devenir.

      Données probantes

      Des recherches ont été menées en consultant les ressources de Statistique Canada, de Medline et de Cochrane Library en vue d'en tirer la littérature relativement aux effets de l'obésité durant la grossesse sur les soins prénataux et intrapartum, la morbidité et la mortalité maternelles, l'anesthésie obstétricale ainsi que sur la morbidité et la mortalité périnatales. Seuls les résultats de revues systématiques, d'essais cliniques randomisés ou comparatifs et d’études observationnelles ont été retenus. Aucune restriction de date ou de langue n'a été employée. Les recherches ont été mises à jour régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en septembre 2018. Nous avons également tenu compte de la littérature grise (non publiée) obtenue sur les sites Web d'organismes d’évaluation des technologies de la santé et d'autres organismes pertinents, dans des collections de directives cliniques et des registres d'essais cliniques, et auprès d'associations nationales et internationales de médecins spécialistes.

      Méthodes de validation

      Le contenu et les recommandations ont été rédigés et acceptés par les auteurs. Les membres du comité de médecine fœto-maternelle ont ensuite passé en revue le contenu et formulé des commentaires aux fins d'examen. Enfin, le conseil d'administration de la Société des obstétriciens et gynécologues du Canada (SOGC) a approuvé la publication de la version définitive de la directive. Les points de désaccord ont été abordés lors de réunions pour enfin arriver à un consensus. La qualité des données et des recommandations a été déterminée à l'aide des critères d’évaluation décrits par le Groupe d’étude canadien sur les soins de santé préventifs.

      Avantages, préjudice et coûts

      La mise en place des recommandations des présentes directives peut améliorer la reconnaissance des fournisseurs de soins obstétricaux relativement aux problèmes qui touchent les personnes enceintes atteintes d'obésité, notamment au moyen de stratégies de prévention clinique; de la communication entre l’équipe de soins de santé, la patiente et la famille; et de la planification de l’équipement et des ressources humaines. Il est à espérer que les organismes régionaux, provinciaux et fédéraux participeront à la formation et au soutien en matière de soins coordonnés pour les personnes enceintes atteintes d'obésité.

      Mise à jour de la directive clinique

      Les directives de la SOGC sont automatiquement passées en revue 5 ans après leur publication. Les auteurs peuvent toutefois proposer une autre date de réévaluation s'ils croient qu'une période de 5 ans est trop courte ou trop longue en fonction de leurs connaissances du sujet à titre d'experts en la matière.

      Promoteurs

      La présente directive a été élaborée à l'aide de ressources financées par la SOGC.

      Déclarations Sommaires

      • 1
        Le col de l'utérus non favorable et le déclenchement artificiel du travail sont plus fréquents dans les cas d'obésité maternelle. Le rôle du déclenchement artificiel du travail et les risques associés à une césarienne demeurent incertains (II-2).
      • 2
        Il est recommandé d'exercer une surveillance électronique fœtale chez les femmes en travail actif dont l'indice de masse corporelle est supérieur à 35 kg/m2. Un indice de masse corporelle maternel élevé peut compliquer l'examen du col de l'utérus, le monitorage des contractions utérines et la surveillance de la fréquence cardiaque fœtale (III).
      • 3
        Le délai entre la prose de décision et l'accouchement augmente chez les femmes atteintes d'obésité (II-2).
      • 4
        Un indice de masse corporelle élevé accroît les risques d'infection du champ opératoire et de complications de plaie (II-2).
      • 5
        L'obésité maternelle augmente les risques anesthésiques (II-2).
      • 6
        Le taux de réussite de l'allaitement est moins élevé chez les femmes atteintes d'obésité que chez les autres femmes (II-2).
      • 7
        Les femmes atteintes d'obésité ont accès à plusieurs méthodes de contraception efficaces (III).
      • 8
        Les femmes atteintes d'obésité présentent un risque accru de dépression et d'anxiété post-partum (II-2).
      • 9
        Les soins prénataux, intrapartum et post-partum peuvent s'avérer plus complexes chez les femmes atteintes d'obésité que chez les autres femmes (III).

      Recommandations

      • 1
        Il est recommandé d'exercer une surveillance électronique fœtale chez les femmes en travail actif dont l'indice de masse corporelle est supérieur à 35 kg/m2. Un cathéter de pression intra-utérine peut faciliter la surveillance des contractions pendant le travail. Les électrodes du cuir chevelu fœtal peuvent être utiles pour assurer une surveillance fœtale continue lorsqu'indiquée (III- B).
      • 2
        Il peut s'avérer bénéfique d'administrer une dose d'antibiotiques préopératoires plus élevée que la normale aux femmes atteintes d'obésité en cas de césarienne (I- A).
      • 3
        Il est recommandé de réapproximer les tissus sous-cutanés en plusieurs plans lors de la césarienne pour réduire les complications de plaie (II-2 A).
      • 4
        L’évaluation prénatale et l'anesthésie obstétricale peuvent contribuer à la planification d'un accouchement sécuritaire chez les femmes atteintes d'obésité (III- A).
      • 5
        Étant donné que les femmes atteintes d'obésité présentent un risque accru de thromboembolie veineuse après une césarienne, il est recommandé d'administrer une thromboprophylaxie postopératoire aux doses indiquées en fonction de l'indice de masse corporelle (II-3 A).
      • 6
        Il est conseillé d'offrir du soutien à l'allaitement aux femmes atteintes d'obésité pendant la période post-partum (III- C).
      • 7
        Étant donné que l'obésité maternelle constitue un facteur de risque de dépression et d'anxiété post-partum, il est recommandé d'en dépister les signes chez les femmes atteintes d'obésité (II-2 A).
      • 8
        Il est suggéré d'accompagner les femmes atteintes d'obésité dans la gestion de leur poids durant la période post-partum afin de réduire les risques pour les grossesses subséquentes (II-2 A).
      • 9
        La planification en équipe des soins obstétriques peut faciliter le cheminement des femmes atteintes d'obésité entre les soins prénataux, intrapartum et post-partum (III-3 A).

      Mots clés

      ABBREVIATIONS:

      AVAC (accouchement vaginal après césarienne), AMPR (acétate de médroxyprogestérone), DIU (dispositifs intra-utérins), IMC (indice de masse corporelle), TEV (thromboembolie veineuse)
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      Linked Article

      • Correction à la directive clinique no 392
        Journal of Obstetrics and Gynaecology Canada Vol. 42Issue 3
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          Les auteurs de la Directive clinique No 392 - Grossesse et obésité maternelle Partie 2 : Planification en équipe de l'accouchement et soins post-partum1 souhaitent réviser leur recommandation relativement à la surveillance électronique fœtale chez les femmes dont l'indice de masse corporelle excède 35 kg/m2 de sorte qu'elle reflète les directives actuelles sur la surveillance électronique fœtale2. La directive a été modifiée afin d'indiquer que la surveillance électronique fœtale peut être envisagée au lieu d’être recommandée pour les femmes en travail actif et dont l'indice de masse corporelle est supérieur à 35 kg/m2.
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