Geburtsplanung bei fetalen Fehlbildungen aus neonatologischer Sicht

Zusammenfassung

Mithilfe der pränatalen Sonografie ist heute ein Großteil schwerer angeborener Fehlbildungen lange vor dem Geburtstermin bekannt. Das eröffnet die Möglichkeit, die Geburt des betroffenen Kindes im Voraus zu planen und vorzubereiten. In der vorliegenden Übersicht wird für einige typische angeborene Fehlbildungen zur Wahl von Geburtsort, Geburtszeitpunkt und Geburtsmodus Stellung aus neonatologischer Sicht bezogen. Da diesbezüglich nur wenig Evidenz vorliegt, besteht dringender Bedarf an prospek­tiven Studien. Die Antwort auf die Frage nach dem Geburtsort bei einer fetalen Fehlbildung ist von mehreren wissenschaftlichen Fachgesellschaften in einer AWMF-Leitlinie konsentiert. Danach soll bei Diagnose einer schwerwiegenden fetalen Fehlbildungen die Schwangere in ein Perinatalzentrum eingewiesen werden. Die Geburt außerhalb eines Perinatalzentrums verschlechtert die Prognose hinsichtlich Mortalität bei der Zwerchellhernie und hinsichtlich Komplikationen bei der Gastroschisis. Bei der Wahl des Geburtszeitpunktes gilt es, die Risiken einer iatrogenen Frühgeburt gegen den potentiellen Nutzen für das Neugeborene abzuwägen. Nur bei wenigen Fehlbildungen gibt es Hinweise auf einen Vorteil für das betroffene Kind durch eine vorzeitige Beendigung der Schwangerschaft. Ein geplanter Kaiserschnitt hat bei einer fetalen Fehlbildung in der Regel vor allem organisatorische Gründe, ohne dass medizinische Vorteile für das betroffene Kind belegt sind. Zusammenfassend sollte bei bekannter fetaler Fehlbildung die Planung der Geburt immer im interdisziplinären Gespräch zwischen den prä- und postnatal beteiligten Spezialisten und unter Einbeziehung der werdenden Eltern erfolgen.

Abstract

Nowadays, most major congenital malformations are detected by prenatal ultrasound long before birth. This offers the opportunity to plan and organise the birth of such a baby in the most favourable setting. This paper gives an overview about how to decide on place, timing, and mode of delivery in some typical congenital malformations from the neonatologist’s point of view. As, in most cases scientific evidence is lacking, there is an urgent need for prospective clinical trials. The question concerning the best place of birth is answered in a national guideline, which has been consented by several scientific societies. In this guideline, the transfer of the pregnant woman to a high level perinatal centre is recommended in the case of a known foetal malformation. Delivery outside a perinatal centre has been shown to increase mortality in infants with congenital diaphragmatic hernia and complications in infants born with gastroschisis. With respect to the timing of the delivery, the risks of an iatrogenic preterm birth must be considered in relation to the potential benefit for the newborn baby. ­There seems to be some advantage of a birth before the regular date only in few malformations. In most cases of congenital malformation, only a Caesarean section has a remarkable advantage with respect to the organisation of the delivery room management, but has no medical necessity for the baby. In summary, the delivery of a baby with a congenital malformation should be planned and organised by an interdisciplinary team of prenatal and postnatal specialists in close contact and consent with the parents.

Schlüsselwörter

angeborene Fehlbildung - Geburtsmodus - Geburtszeitpunkt - Geburtsort - Erstversorgung des Neugeborenen

Key words

congenital malformation - mode of delivery - timing of birth - place of birth - delivery room management

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