La grossesse extra-utérine

 

Définition

 

La survenue d'une GEU peut compromettre l'avenir génital voir, la vie de la femme. Plus le traitement est tardif, plus il y a de difficultés.

Six jours après l'ovulation l'ouf se fixe quel que soit l'endroit où il se trouve.

Il peut se situer dans la trompe de Fallope, au niveau de la jonction des trompes et de l'utérus ou dans le péritoine.

Sa fréquence augmente chez les femmes ayant pus de 30 ans.

 

II. Mécanismes de survenue

 

Nous savons que l'oeuf se fixe quel que soit l'endroit où il se situe au 6 ème jour après l'ovulation.

Pourquoi l'ouf est-il en retard ?

 

1ère cause : retard à la captation de l'ouf par le pavillon de la trompe, une fois fécondé, il se fixe dans la cavité abdominale : GEU abdominale. GEU ovarienne ou GEU ampoulaire.

 

2e cause : arrêt ou ralentissement de l'ouf dans la trompe.

Mouvements péristaltiques ralentis : malformation congénitale, séquelles inflammatoires (endométriose, salpingite, chirurgie sur la trompe, réimplantation après FIV...).

 

3e cause : ouf anormalement gros ;

localisation : 98% tubulaire : 78% ampoulaire, 20% isthmique, 1.3% abdominale, 0.1% ovarienne.

Diagnostic clinique très difficile à faire et source de nombreuses erreurs.

III. Étiologies

 

- Séquelles de MST, Salpingites

- Endométriose ( cellules de l'endomètre dans la trompe de Fallope)

- Chirurgie tubaire

- Anomalie congénitale

- Stérilet

 

IV. Clinique

 

Penser systématiquement à une grossesse extra utérine jusqu'à preuve du contraire.

 

- Aménorrhées (ainsi que tous les signes de la grossesse

- Métrorrhagies noirâtres peu abondantes (dans 20% des cas, pas de métrorragie.)

- Patiente avec de violentes douleurs hypogastrique (hypogastre = Partie inférieure de  l'abdomen, située au-dessus du pubis)

- Douleurs unilatérales

- Abdomen gonflé

- Recherche du cri de Douglas (toucher vaginal sur hématome dans le creux de Douglas, très douloureux)

 

Examen clinique : état général correct, ventre souple mais douloureux, toucher vaginal : douleur à la mobilisation utérine.

 

V. Examens complémentaires

 

- Dosage de BHCG plasmatique et quantitatif (hormone placentaire )

Taux de BHCG très important dans les formes trompeuses :

Évolution de BHCG : si grossesse normale, il double toutes les 48h. Si le taux chute, il peut s'agir d'une fausse couche, en GEU, le taux stagne.

 

- Échographie (utérus vide et masse latéro-utérine, sac embryonnaire, épanchement liquidien au niveau du cul de sac.)

- Colioscopie (élimination d'un kyste hémorragique)

Seule la vision d'un embryon dans le sac dans l'utérus est signe d'absence d'une GEU.

 

VI. Évolution

 

1. Si traitement précoce

-Stérilité du côté lésé à 30-40% mais risque de récidive (12%)

 

2. Forme non diagnostiquée

 

- Hématome progressif

Douleur scapulaire, syncope

Fébricule

Subictère

 

- Rupture cataclysmique

Douleur brutale avec vertiges

Rupture de la trompe = Collapsus

C'est une urgence chirurgicale

 

VII. Traitement

 

1. Réanimation en cas de collapsus

2. Médicamenteux : 

- Associe le RU486 et Méthotrexate® (antimitotique pour cancer) 

- Action sur la GEU ( la trompe expulse cette grossesse. Se fait sur des grossesses très jeunes, pas de retentissement pour la patiente. Ce traitement permet d'éviter l'intervention chirurgicale s'il est bien suivi.

 

3.Chirurgicale : 

Par colioscopie,

- Chirurgie conservatrice, garder la trompe de Fallope =  salpingotomie, 

- Si trompe abîmée : ablation de la trompe de Fallope = salpingectomie.

- Sans colioscopie : laparotomie (ouverture de l'abdomen).

 

4. Prévention des endométrioses et infections

7 votes. Moyenne 3.43 sur 5.

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