Medikamentöse Wehenhemmung - aktueller Stand

Zusammenfassung

Die Frühgeburtenrate konnte in den letzten 10 Jahren nicht gesenkt werden. Klinisches Leitsymptom der Frühgeburt sind meist vorzeitige Wehen, die nur behandelt werden sollten, wenn gleichzeitig zervikale Veränderungen vorliegen. Vorzeitige Wehen werden seit mehr als 30 Jahren mit Tokolytika behandelt. Das ideale Tokolytikum existiert bisher nicht. Ziele der Tokolyse sind eine Prolongation der Schwangerschaft für mindestens 48 Stunden zur Lungenreifeinduktion, der In-utero-Transfer in ein Perinatalzentrum und die Senkung der perinatalen/neonatalen Morbidität und Mortalität. In Deutschland zugelassen sind Betaagonisten, Magnesiumsulfat und Atosiban. Betaagonisten sind zwar effektiv, aber mit einem breiten Spektrum an mütterlichen Nebenwirkungen belastet. Magnesiumsulfat erwies sich in einer jüngsten Cochrane-Analyse als ineffektiv. Indomethacin ist nicht zur Tokolyse zugelassen, sollte nur über 48 Stunden gegeben werden und führt zu fetalen Nebenwirkungen. NO-Donatoren sind hinsichtlich ihrer tokolytischen Wirkung so effektiv wie Betaagonisten, allerdings ist die Datenlage bisher nicht ausreichend. Kalziumkanalblocker (Nifedipin) sind zur Tokolyse nicht zugelassen, weisen eine höhere tokolytische Wirksamkeit auf als Betaagonisten, es fehlen allerdings direkte Vergleichsuntersuchungen mit Atosiban. Der Oxytocinantagonist Atosiban hat die gleiche tokolytische Effizienz wie Betaagonisten, aber eine signifikant niedrigere Rate an maternalen Nebenwirkungen. Nachteil von Atosiban sind die hohen Kosten. Deshalb empfiehlt es sich, Atosiban in bestimmten geburtshilflichen Situationen einzusetzen. Derzeit werden Oxytocinantagonisten der zweiten Generation entwickelt, die auch zur Erhaltungstherapie geeignet sind.

Abstract

In spite of advances in obstetric care, the rate of prematurity has not decreased over the past decade. The leading symptom of prematurity is mostly preterm labour, which should only be treated if cervical changes are present. For 30 years preterm labour has been treated with tocolytic agents; however, the perfect tocolytic drug which is completely safe for both the mother and the fetus and will stop preterm labour in every case does not exist. The goals of tocolysis are prolongation of pregnancy for at least 48 hours to allow the in-utero-transfer to a perinatal center to induce lung maturation and the reduction of perinatal/neonatal morbidity and mortality. In Germany, beta agonists, magnesium sulfate and atosiban are licensed. Beta agonists are highly effective, but are associated with a broad spectrum of maternal side effects. A recent Cochrane analysis has shown that magnesium sulfate is ineffective in preventing birth. Indomethacin is not licensed for tocolytic therapy and should only be given for 48 hours because of constriction of the fetal ductus arteriosus; its administration is associated with severe neonatal complications. Nitric oxide donors are as effective as beta agonists regarding tocolytic efficacy, however these agents cannot be recommended for clinical practice until further data from large trials are available. Calcium channel blockers (nifedipine) are not licensed; their tocolytic efficacy is superior to that of beta agonists, however the ideal dosage and formulation are unclear. Comparative studies with atosiban are necessary. The oxytocin antagonist atosiban has been shown to have a similar tocolytic efficacy as beta agonists. The advantage of atosiban over beta agonists is the significantly lower rate of maternal side effects, the disadvantage is the high price. Therefore it is recommended to use atosiban in special obstetric conditions. At present a second generation of selective oxytocin antagonists are being developed, suitable for maintenance therapy.

Schlüsselwörter

Tokolyse - Betaagonisten - Magnesiumsulfat - Kalziumkanalblocker - Atosiban - mütterliche und kindliche Nebenwirkungen

Key words

Tocolysis - betaagonists - magnesium sulfate - calcium channel blockers - atosiban - maternal and fetal side effects

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