Lungenreifeinduktion mit Glukokortikoiden - einmalige oder wiederholte Applikation?[*]

Zusammenfassung

Die Unsicherheit über die Wirkungsdauer einer antenatalen Glukokortikoidtherapie (ANC) zur Lungenreifung veranlasst einen großen Teil der Geburtshelfer zu wiederholten Applikationen. Tierversuche, aber auch Untersuchungen aus dem Bereich der Humanmedizin, lassen es möglich erscheinen, dass die Morbidität der Neonaten durch die wiederholte Kortisongabe zunimmt: Erhöhte neonatale Mortalität, ein geringeres Geburtsgewicht, Beeinträchtigung der mentalen und psychomotorischen Entwicklung, Anstieg der Infektmorbidität von Mutter und Kind, Beeinflussung der intrauterinen Programmierung durch Modifikation der hypothalamo-pituitär-adrenalen Achse mit Manifestation von Diabetes und Bluthochdruck im späteren Leben des Kindes. Bei Auswertung der aktuellen Literatur können diese diskutierten Komplikationen einer wiederholten ANC-Gabe jedoch keinesfalls als bewiesen gelten. Da andererseits die wiederholte ANC-Applikation lediglich mit einer unterschiedlich ausgeprägten Verminderung des Atemnotsyndroms korreliert, gibt es auch für die routinemäßige multiple Wiederholung der Steroidgabe keine wissenschaftliche Begründung. Bis die Ergebnisse größerer prospektiver, randomisierter Studien vorliegen, sollte jeder Schwangeren mit signifikanten Frühgeburtsbestrebungen zwischen der 24. und der 34. Schwangerschaftswoche (SSW) ein Zyklus z. B. Betamethason (2 × 12 mg im Abstand von 24 Stunden) appliziert werden. Aufgrund bisheriger Daten kann allenfalls die einmalige Wiederholung der Prophylaxe als sinnvoll und unbedenklich angesehen werden.

Abstract

The discussion on the application of multiple versus single courses of antenatal corticosteroids (ANC) for the prevention of respiratory distress syndrome (RDS) in newborns is still controversial. Since the benefits of ANC have been shown to be most significant within 7 to 10 days after treatment, many obstetricians tend to treat women with repeated courses of ANC if the risk of premature delivery persists. However, data from animal as well as from clinical studies suggest detrimental effects of multiple courses of ANC: an increase of neonatal mortality, low birth weight, retardation of mental, and psychomotoric development, an increase in infectious morbidity of the mother and the newborn, alterations of intra-uterine programming by modification of the hypothalamic-pituitary-adrenal axis with the consequence of an increased rate of diabetes and hypertension in later life. However, a detailed review of the literature fails to prove a causal relationship between multiple courses of ANC and the complications mentioned above. Conversely, only gradual decreases in the severity of RDS do not justify routine application of repeated courses of ANC. Until publication of the results of larger prospective randomised controlled trials, each pregnant woman at significant risk for premature delivery (24 - 34 weeks of gestation) should receive a single course of ANC (e.g. betamethasone, 2 × 12 mg in a 24-hour interval). Based on the data published, a second course of ANC can be considered as efficient and harmless.

Frühgeburt - Lungenreifeinduktion - antenatale Glukokortikoide - Atemnotsyndrom

Premature delivery - preterm labour - antenatal corticosteroids - respiratory distress syndrome

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1 Herrn Prof. em. Dr. med. Dr. med. h. c. J. Schneider zum 75. Geburtstag gewidmet