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Z Geburtshilfe Neonatol 2000; 204(6): 203-209
DOI: 10.1055/s-2000-9579
ÜBERSICHT

Georg Thieme Verlag Stuttgart ·New York

Lungenreifetherapie mit Glukokortikoiden bei drohender Frühgeburt[1]

Überlegungen zur Nutzen-Risiko-Abwägung im Sinne der Evidence-based medicineAntenatal glucocorticoids in prematurityAxel Sauerwald, Werner Rath
  • Universitätsklinik für Gynäkologie und Geburtshilfe der Rheinisch-Westfälisch Technischen Hochschule (RWTH) Aachen
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Publication History

Publication Date:
31 December 2000 (online)

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Zusammenfassung

Frühgeburtlichkeit ist häufige Ursache für perinatale Morbidität und Mortalität. Zu deren Senkung hat die Lungenreifebehandlung mit Glukokortikoiden maßgeblich beigetragen. 1994 wurden von den NIH Empfehlungen zur Durchführung der Lungenreifeinduktion publiziert und die Wirksamkeit wurde 1999 von der Cochrane Collaboration erneut evaluiert. Danach reduziert die antenatale Glukokortikoidapplikation signifikant die perinatale Morbidität und die Rate an RDS und Hirnblutungen bei Frühgeborenen zwischen der 24. und 34. SSW.

Der Wert der repetitiven Glukokortikoidgabe ist nicht hinreichend geklärt; insbesondere deren Einfluss auf die Geburtsgewichte der Kinder und auf die Entwicklung von Infektionen bei vorzeitigem Blasensprung sowie die Festlegung des optimalen Wiederholungsintervalls. Nach Glukokortikoidgabe muss passager mit einer Verminderung der Kindsbewegungen und der fetalen Herzfrequenzvariabilität gerechnet werden; nicht geklärt sind die Auswirkungen auf das intrauterine Wachstum, das maternale und fetale Immunsystem und spätere Erkrankungen einschließlich Atopien.

Bei vorzeitiger, nicht muttermundswirksamer Wehentätigkeit wird daher die Indikation zur antenatalen Gabe von Glukokortikoiden zunehmend kritischer beurteilt. Bei vorzeitigem Blasensprung senkt die antenatale Glukokortikoidgabe nicht die Rate an RDS, jedoch signifikant die an Hirnblutungen und an nekrotisierenden Enterokolitiden. Für die Lungenreifebehandlung mit Glukokortikoiden bei Diabetes mellitus und bei intrauteriner Wachstumsretardierung liegen bisher keine prospektivrandomisierten Studien vor. Bei schwerer Präeklampsie vermindert Betamethason die RDS-Häufigkeit und die neonatale Mortalität signifikant.

Ungeachtet des lückenhaftes Wissens und der potenziellen (Langzeit-) Auswirkungen auf Mutter und Kind bleibt die antenatale Glukokortikoidmedikation nach den Empfehlungen der NIH von 1994 gemeinsam mit der Behandlung dieser Schwangeren in einem Perinatalzentrum entscheidender Eckpfeiler im Vorgehen bei Frühgeburtlichkeit. Die Indikation zur repetitiven Gabe von Glukokortikoiden sollte allerdings sorgfältig geprüft werden.

Prematurity is a major cause of perinatal morbidity and mortality. Antenatal administration of glucocorticoids improves the neonatal outcome of preterm born infants. 1994 the NIH published recommendations for the use of glucocorticoids for women at risk of preterm delivery. A recent evaluation by the Cochrane Collaboration in 1999 showed that antenatal administration of glucocorticoids significantly reduced the rate of RDS and IVH in the gestational age between 24 and 34 weeks. Consequences of repeated courses of antenatal glucocorticoids are not sufficiently studied. The effectivity and safety regarding birth weights, infectious diseases, and the best timing remains unknown. Administration of glucocorticoids lowers fetal activity and heart rate variability. Effects on fetal growth, maternal and fetal immunosystem, and the development of atopic diseases are controversely discussed. Thus preterm labour not leading to a cervical ripening is not necessarily a reason for antenatal glucocorticoids. Antenatal glucocorticoids with PROM do not lower the rate of RDS but of IVH. No prospective randomized trial evaluated the effectivity of antenatal glucocorticoids in diabetes mellitus and IUGR. In preeclampsia betamethason could improve the rate of RDS and the neonatal outcome. Still our knowledge of antenatal glucocorticoid administration is not sufficient. But despite possible (longtime-) risks for mother and child the administration of glucocorticoids according to the guidelines of the NIH is a major part in the treatment of prematurity and improves the outcome of premature infants. The indication for multiple courses of glucocorticoids should be considered carefully.

Schlüsselwörter

Frühgeburt - Lungenreife - Glukokortikoide - Evidence-based medicine

Key words

Prematurity - antenatal corticoids - evidence-based medicine

1 Eingang: 24. 5. 2000 Angenommen nach Revision: 27. 7. 2000

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Univ.-Prof. Dr. med. W. Rath

Universitätsklinik für Gynäkologie und Geburtshilfe der Rheinisch-Westfälisch Technischen Hochschule (RWTH) Aachen

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