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Grossesse extra-utérine |
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Qu'est ce qu'une GEU ? C'est l'implantation d'une grossesse en dehors de l'utérus. Mais ils existent différents types de GEU. La GEU s'implante le plus souvent dans la trompe (99 %), plus rarement dans l'ovaire (1 %) et de façon tout à fait exceptionnelle dans la cavité péritonéale. Au niveau de la trompe, la localisation la plus fréquente est dans l'ampoule (75 %) des cas. Mais elle peut aussi se situer dans la portion isthmique (15 %), au niveau du pavillon (8 %) ou dans la portion interstitielle (2 %). Comment évolue une GEU ? L'implantation de la GEU est superficielle ou profonde, mais tous les intermédiaires existent. Dans le premier cas, il y a simple adhésion du trophoblaste contre la muqueuse tubaire. De ce fait la vascularisation de la GEU est mauvaise et elle involue rapidement ce qui explique que certaines GEU peuvent guérir spontanément. En cas d'implantation profonde, le trophoblaste envahit la paroi tubaire. La vascularisation est efficace et entraîne une augmentation du volume de la GEU dans la trompe qui n'est pas extensible comme l'utérus. De ce fait l'évolution se fera vers une rupture brutale de la trompe qui sur le plan clinique correspond à une rupture cataclysmique, c'est-à-dire à une hémorragie interne massive qui est mortelle sans traitement de grande urgence. Dans les stades intermédiaires, il y a colonisation partielle de la paroi tubaire avec des décollements du trophoblaste, qui occasionnent des saignements dans la trompe ce qui constitue un hematosalpinx (hématome dans la trompe). Cet hematosalpinx se déverse progressivement dans le péritoine occasionnant un hémopéritoine (hémorragie dans l'abdomen) de constitution progressive. Les deux occasionnent des douleurs qui conduisent au diagnostic. Comment survient une GEU ? La GEU est une spécificité de l'espèce humaine. Ceci vient des caractéristiques très invasives du trophoblaste (placenta) humain L'implantation dans la trompe s'explique par plusieurs mécanismes : - Un blocage du transit de l'embryon du fait d'altérations de la trompe
- Un retard au transit dans la trompe du fait de facteurs hormonaux ou environnementaux (tabac)
- Un retour de l'embryon de l'utérus vers la trompe du fait de facteurs hormonaux.
La GEU représente une grossesse sur 50. Certains facteurs contribuent à augmenter sa fréquence : - -Les pathologies tubaires infectieuses que sont un facteur majeur. Les antécédents de salpingite, de plastie tubaire, de stérilité.
- -L'antécédent de GEU : une femme qui a déjà présenté une GEU voit son risque augmenté par un facteur 8 et après 2 GEU par un facteur 50.
- -Le tabac (plus de 10 cigarettes par jour) augmente le risque de GEU par un facteur 3.
- -Avec l'age, le risque de GEU augmente indépendamment des autres facteurs
- -Le stérilet pose un problème complexe. Il protége mieux contre la GIU que contre la GEU. Donc une patiente porteuse de stérilet a moins de risque de GEU par cycle qu'une femme qui cherche à être enceinte. Par contre si elle devient enceinte son risque de GEU est multiplié par 5.
- -Le syndrome Distilbène s'accompagne d'une fréquence très augmentée (x 4) de GEU
Le diagnostic de la GEU Nous ne détaillerons pas trop ce chapitre complexe. Le diagnostic de GEU est rarement facile. La suspicion repose sur la notion de grossesse, des pertes de sangs et des douleurs. Le taux d'HCG et l'échographie sont les moyens d'approcher le diagnostic. Il sera en règle confirmé par une coelioscopie sauf dans les cas où un traitement médical sera décidé. Pour arriver au diagnostic, 2 ou 3 consultations avec taux d'HCG et échographie peuvent être nécessaire. Un chiffre de 3 ne doit pas être dépassé. Les traitements de la GEU Traitement chirurgical radical Il consiste en une salpingectomie (ablation de la trompe) sans ovariectomie (ablation de l'ovaire). Il est fait par coelioscopie ou par laparotomie. Traitement chirurgical conservateur Il consiste à n'enlever que la grossesse. La trompe est incisée en regard de la GEU. Celle-ci est enlevée par aspiration ou par pression. Après contrôle de la vacuité tubaire, l'hémostase est assurée par de petites touches d'électrocoagulation. La trompe est laissée ouverte et cicatrisera d'elle même. La suture de l'incision n'est plus pratiquée. Ce traitement est fait essentiellement par coelioscopie. C'est le traitement de référence. Il a été mise au point en France dans les années 1975-1985 (Dr Manhés et Pr. Bruhat) Le traitement coelioscopique conservateur se solde par un échec dans 5 % des cas où une partie du trophoblaste (placenta) persiste dans la trompe. Ceci oblige à un traitement médical de rattrapage et plus rarement en une deuxième coelioscopie avec salpingectomie (ablation de la trompe). La surveillance de la décroissance du taux d'HCG en post-opératoire est donc indispensable. iconographie du traitement conservateur de la geu Traitement médical Publié pour la première fois en 1982, il a été remis à la mode dans les années 1990-1995, mais il est aujourd'hui de plus en plus discuté du fait de son taux d'échec très élevé. Il consiste à administrer 1 mg/Kg de Méthotrexate, soit en IM soit directement dans la GEU (si elle bien visible en échographie). Après une semaine, cette dose peut être répétée. C'est un traitement conservateur. Il ne s'applique qu'aux patientes qui ne présente pas de signe de rupture ni de pré-rupture, dont le taux d'HCG est inférieur à 5000 UI, dont la GEU n'excède pas 4 cm de diamètre et ne présente pas d'activité cardiaque, dont le taux de progestérone est inférieur à 10 ng/ml. Ceci représente au plus 20 à 30 % des cas. Malheureusement son taux d'échec est élevé. Si dans les séries contrôlées, il n'a pas excédé 10 % dans les séries tout venant, il est couramment de 25 à 35 % ce qui en fait une méthode thérapeutique de plus en plus discutée. L'adjonction de RU486 (pilule abortive) semble améliorer un peu son efficacité. La surveillance post-traitement est impérative. Elle dure en général un mois. L'abstention Dans de rares cas, il est concevable de ne pas traiter et d'attendre une guérison spontanée. Ceci n'est possible que si le taux d'HCG est faible (<500 UI) et en étant prêt à intervenir si les choses n'évoluent pas normalement. Quel traitement et son résultat La question se situe à deux niveaux : - -Faut il enlever la trompe (traitement radical) ou seulement la GEU (traitement conservateur) ?
- -Par quelle voie (traitement chirurgical, coelioscopique ou médical) ?
La décision de garder ou non la trompe repose sur les arguments suivants : - Est ce que la patiente désire encore des enfants ? :Si elle en désire, il est plus logique de garder la trompe
- Est ce que le risque de nouvelle GEU est élevé ? : S'il est très élevé, il est logique d'enlever la trompe, voire les deux pour supprimer ce risque et de " passer " en FIV
- Est ce que c'est techniquement faisable ? Cela ne s'évalue qu'au cours de la chirurgie. Il est des cas où le chirurgien, faute d'arriver à arrêter le saignement n'a d'autres solutions que d'enlever la trompe
- Est ce que le risque d'échec du traitement conservateur est élevé ? : Dans certains cas devant un taux d'HCG élevé (>10000 UI) ou une grossesse bien évolutive dans la trompe, le risque d 'échec est tel, que le traitement conservateur présente certains risques et doit être évité.
Le choix de la voie de traitement - Pour enlever une trompe, le choix se résume entre la laparotomie (ouverture de l'abdomen) ou la coelioscopie (endoscopie). La deuxième solution est presque toujours possible sauf dans le contexte de très grande urgence.
- La principale question se situe, en cas de traitement conservateur entre le traitement endoscopique et le traitement médical. Si le taux d'HCG est faible (<5000), s'il n'y a pas de signe de rupture ni de pré-rupture (douleurs importantes), si la GEU n'excède pas 4 cm de diamètre à l'échographie et ne présente pas d'activité cardiaque, et si le taux de progestérone est inférieur à 10 ng/ml, le traitement médical doit être préféré car il évite une intervention et une anesthésie. Dans les autres cas, le traitement coelioscopique reste le traitement de référence.
La fertilité après GEU Une femme qui a présenté une GEU court un risque de stérilité de l'ordre de 30 à 40 %. Ce risque est à moduler des autres antécédents. Ainsi une patiente qui présente une troisième GEU a un risque de stérilité de plus de 95 %. Après plastie tubaire, la stérilité post-GEU est de plus de 90 %. A contrario, après une GEU sur stérilet, le taux de stérilité n'excède pas 10 %. Ce risque d'infertilité est un peu augmenté si une salpingectomie unilatérale a été pratiquée. Chez une femme désireuse de grossesse après une GEU, il est logique de se donner un délai de 24 mois pour l'obtention. Passer ce délai, tous les arguments épidémiologiques et scientifiques plaident pour un recours direct à la Fécondation In Vitro sans nouvelle exploration tubaire par hystérosalpingographie ou par coelioscopie. Dans ce contexte (hors stérilité anovulatoire associée) il n'y a pas de place pour les stimulations de l'ovulation ni pour les inséminations intra-utérines. Par contre après une deuxième GEU, il est logique de proposer le recours à la FIV, compte tenu des chances faibles de grossesse et du risque élevé de nouvelle récidive. De même si la GEU survient dans les suites d'une plastie tubaire, le recours direct à la FIV s'impose car les chances de grossesse sont très faibles (5 %) pour un risque de récidive de 15 à 20 %. Le risque de GEU en FIV Lors d'une FIV, une GEU peut survenir. Les embryons mis dans l'utérus migrent dans la trompe et s'implantent. Globalement 2 à 3 % de Grossesses FIV sont des GEU. On connaît deux facteurs favorisants : des trompes pathologiques et les stimulations de l'ovulation avec du clomifène. Une des spécificités des GEU en FIV est qu'elles peuvent être associées à une grossesse dans l'utérus, ce qui complique sérieusement le traitement sources: http://perso.wanadoo.fr
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