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Résumé

La femme obèse en age de procréer est plus fréquemment en situation d’hypofertilité avec des chances réduites de grossesses naturelles mais aussi médicalement assistées. En cas de grossesse, elle est plus à risque de nombreuses complications materno-fœtales pouvant être sévères. La patiente obèse est plus à risque de développer une hypertension gravidique et/ou une pré-éclampsie. Les femmes en surpoids, obèses ou sévèrement obèses sont respectivement deux, quatre et huit fois plus à risque de développer un diabète gestationnel, en comparaison aux femmes de poids normal. Pendant la grossesse et surtout le post-partum, le risque de thrombose veineuse profonde est augmenté. Le risque de mort fœtale in utero chez la femme obèse est de plus en plus fréquemment rapporté.

La pertinence du diagnostic échographique des malformations et la qualité de l’image sont fortement altérées en cas d’adiposité maternelle importante. Les foetus de mères obèses sont plus à risques de non-fermeture du tube neural, d’anomalies cardiovasculaires, de fentes palatines ou labiopalatines, d’atrésies anorectales, d’hydrocéphalie et d’anomalies de réduction des membres.

La patiente est d’autant plus à risque de césarienne que l’index de masse corporelle (IMC) est élevé. La probabilité de césariennes en urgence est aussi augmentée avec des temps opératoires prolongés et des saignements plus importants. La pose d’analgésie loco-régionale chez la patiente obèse est difficile et l’anesthésie générale, dont la morbidité est majorée du fait de nombreuses autres comorbidités, doit être évitée le plus possible. Les suites de couches sont marquées par plus d’endométrites postopératoires et une hospitalisation prolongée. Le risque thromboembolique déjà plus important en fin de grossesse est majeur.

L’HTA gravidique ou la pré-éclampsie, plus fréquentes, peuvent nécessiter des déclenchements aux risques d’échec plus élevés.

La chirurgie bariatrique améliore la fertilité et réduit le risque de complications materno-fœtales en réduisant l’incidence de diabète gestationnel, d’hypertension gravidique et de pré-éclampsie, de macrosomie fœtale et le recours à la césarienne. Face à la fréquence croissante de l’obésité maternelle, la HAS a établi en 2009 et 2011 des recommandations sur la prise en charge médicale première de l’obésité en cas de grossesse, sur la prise en charge chirurgicale de l’obésité chez ces femmes et sur l’orientation de la patiente enceinte obèse vers les maternités.

Mots clés

obésité maternelle risques périnatals chirurgie bariatrique diabète hypertension pré-éclampsie césariennes morbidité périnatale morbidité maternelle 

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© Springer-Verlag France 2013

Authors and Affiliations

  • N. Ranisavljevic
    • 1
  • P. Boulot
    • 1
  1. 1.Département de médecine materno-fœtale, Pôle Naissance-pathologie de la femmeHôpital Arnaud de VilleneuveMontpellierFrance

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