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Directive clinique no 401 : Mesure échographique de la longueur du col en cas de grossesse monofœtale : Techniques et applications cliniques

      Résumé

      Objectifs

      • Évaluer l'association entre la mesure échographique de la longueur du col et l'accouchement prématuré.
      • Décrire les diverses techniques échographiques pour mesurer la longueur du col.
      • Passer en revue l’évolution naturelle du col court.
      • Passer en revue les utilisations cliniques, la valeur prédictive et l'utilité du col court mesuré par échographie.

      Résultats

      Réduction du taux de prématurité et/ou amélioration de l'identification des femmes à risque, ainsi que la prévention possible des interventions inutiles.

      Professionnels concernés

      Cliniciens impliqués dans la prise en charge obstétricale ou de l'imagerie du col des patientes qui présentent un risque accru de col court.

      Population cible

      Femmes qui présentent un risque accru de col court ou qui risquent d'accoucher prématurément.

      Données probantes

      Des recherches ont été effectuées dans les bases de données PubMed et Cochrane Library pour extraire la littérature publiée jusqu'en juin 2019 en utilisant le vocabulaire contrôlé et les mots clés suivants : preterm labour, ultrasound, cervix, cervical insufficiency, transvaginal, transperineal, cervical length, fibronectin. Seuls les revues systématiques, les essais cliniques randomisés, les essais cliniques comparatifs et les études observationnelles ont été retenus. Aucune restriction de date ou de langue n'a été employée. Nous avons également prise en compte la littérature grise (non publiée) obtenue sur les sites Web d'organismes d’évaluation des technologies de la santé, 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

      Les données probantes et la présente directive clinique ont été examinées par le comité d'imagerie diagnostique de la Société des obstétriciens et gynécologues du Canada, et les recommandations ont été faites et classées selon la grille d'interprétation du Groupe de travail canadien sur les soins de santé préventifs (tableau A1 en annexe en ligne).

      Bénéfices, risques, coûts

      L'accouchement prématuré est une des premières causes de morbi-mortalité périnatale. Les techniques échographiques analysées dans le cadre de la présente directive clinique pourraient contribuer à l'identification des femmes risquant d'accoucher prématurément et, dans certains cas, favoriser les interventions qui peuvent réduire le taux d'accouchements prématurés.

      DÉCLARATIONS SOMMAIRES (classement selon la grille d'interprétation du Groupe d’étude canadien sur les soins de santé préventifs entre parenthèses)

      • 1
        L’échographie endovaginale peut être utilisée pour évaluer le risque d'accouchement prématuré chez les femmes ayant un antécédent d'accouchement prématuré spontané et pour différencier les femmes qui présentent un risque élevé d'accouchement prématuré de celles à faible risque (II-2).
      • 2
        Dans la population obstétricale générale, la longueur du col demeure relativement stable au cours des 2 premiers trimestres de la grossesse. L’évolution naturelle du changement de la longueur du col peut ne pas être utile pour identifier les femmes qui présentent un risque accru d'accouchement prématuré. Étant donné les variations possibles en matière d’évolution, de vitesse et/ou d'apparition du raccourcissement de la longueur du col, la réévaluation de la longueur du col peut s'avérer utile chez les patientes qui présentent un risque élevé d'accouchement prématuré spontané (II-2).
      • 3
        La mesure de la longueur du col peut être utilisée pour déterminer un risque accru d'accouchement prématuré chez les femmes asymptomatiques à < 24 semaines d'aménorrhée qui présentent d'autres facteurs d'accouchement prématuré (anomalie utérine ou des antécédents de multiples interventions de dilatation-aspiration après 13 semaines d'aménorrhée). Toutefois, les données probantes ne sont pas suffisantes pour recommander des stratégies de prise en charge spécifiques à ce groupe de femmes (II-2).
      • 4
        Il n'y a pas de consensus quant à la chronologie ou à la fréquence optimales des évaluations en série de la longueur du col. Si l'on a recours aux évaluations en série, il y a lieu de les mener à un intervalle adéquat pour limiter les risques d'erreur d'interprétation (II-2).
      • 5
        Aucun essai randomisé particulier n'a étudié quelque intervention que ce soit chez les femmes asymptomatiques qui ont initialement été classées après 24 semaines d'aménorrhée comme présentant un risque accru d'accouchement prématuré (p. ex. celles ayant un antécédent d'accouchement prématuré spontané ou de multiples interventions de dilatation-aspiration après 13 semaines d'aménorrhée) et qui présentent un col court. Cependant, le fait de connaître la longueur du col après 24 semaines d'aménorrhée peut aider à la prise en charge empirique de ces femmes, par exemple par un transfert et la surveillance accrue (III).
      • 6
        En cas de possible menace d'accouchement prématuré avec membranes intactes, l’évaluation échographique endovaginale de la longueur du col peut être utilisée pour classer le risque d'accouchement prématuré et prévenir les interventions inutiles sans porter atteinte. L'information qui en ressort peut contribuer à réduire le risque de prématurité tardive, mais on ignore si elle a une incidence cliniquement significative (II-2B).
      • 7
        Par comparaison au cerclage systématique indiqué d'après l’évaluation clinique, la surveillance de la longueur du col est une option sûre pour les patientes ayant un antécédent de cerclage sur indication échographique, des antécédents d'incompétence du col incertains et un antécédent d'accouchement prématuré spontané; elle peut réduire le besoin de recourir à un autre cerclage (II-2B).
      • 8
        Bien que l’échographie endovaginale semble sécuritaire en présence d'une rupture prématurée des membranes avant terme, sa valeur prédictive clinique demeure incertaine dans ce contexte (II-2).
      • 9
        À l'heure actuelle, les données probantes sont insuffisantes pour étayer une opinion de comité sur la fréquence ou le moment de l’évaluation échographique de la longueur du col après un cerclage. On ignore si ce genre d’échographie a des bienfaits cliniquement significatifs (III).
      • 10
        L’évaluation échographique de la longueur du col et le dosage de la fibronectine fœtale semblent avoir des valeurs prédictives similaires chez les patientes symptomatiques, et leur valeur combinée pourrait ne pas être significativement différente de l’évaluation de la longueur du col seule. Toutefois, d'autres recherches sont nécessaires à ce sujet (II-2).

      RECOMMANDATIONS (classification selon la grille d'interprétation du Groupe d’étude canadien sur les soins de santé préventifs entre parenthèses)

      • 1
        L’échographie endovaginale constitue la voie privilégiée pour l’évaluation cervicale en vue d'identifier les femmes qui présentent un risque accru d'accouchement prématuré spontané et peut être offerte aux femmes ayant un risque élevé d'accoucher prématurément (II-2B).
      • 2
        L’échographie transpérinéale peut être offerte aux femmes qui présentent un risque accru d'accouchement prématuré, lorsque l’échographie endovaginale n'est pas disponible ou qu'elle ne constitue pas une option acceptable (II-2B). L’évaluation échographique transabdominale de la longueur du col peut être une option utile pour le dépistage dans certains contextes.

      Mots clés

      Abréviations:

      CAD (conisation à l'anse diathermique), RPMAT (rupture prématurée des membranes avant terme), SA (semaines d'aménorrhée)
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