Zusammenfassung
Bei Schwangeren mit neurologischen Erkrankungen sind dringliche Operationen häufiger
als bei gesunden Schwangeren, die Rate an Schnittentbindungen ist aber nur leicht
erhöht. Während bei gesunden Schwangeren die Vermeidung einer Gefährdung des Fetus
im Vordergrund der Anästhesie steht, muss bei Schwangeren mit Begleiterkrankungen
das erhöhte mütterliche Risiko mit berücksichtigt werden. Die Krankheitsverläufe vorbestehender
neurologischer Schädigungen werden durch Schwangerschaft verändert, aber nicht einheitlich
verschlechtert. Von den gehäuft in der Schwangerschaft auftretenden Erkrankungen hat
die intrakranielle Blutung einen 65 %igen Anteil an der maternalen Sterblichkeit.
Schwangerschaftsinduzierte und für die Anästhesie relevante Erkrankungen sind außer
seltenen Geburtsverletzungen die Präeklamsie, Eklampsie und das HELLP–Syndrom. Die
anästhesiologische Betreuung aller neurologischen Erkrankungen ist gekennzeichnet
durch 1.) Kenntnis der Erkrankung und Risiken, 2.) sorgfältige, präoperative Erhebung
des neurologischen Status, 3.) sichere Auswahl des Verfahrens mit Bevorzugung der
Regionalanästhesie, 4.) Vermeidung von ungünstigen Medikamentenwirkungen auf die uteroplazentare
und zerebrale Funktion als auch auf den Feten und 5.) intraoperatives Monitoring der
neuronalen Funktion als auch der fetalen Herzfrequenz ab der 22. SSW.
Abstract
In the parturient as well as in the pregnant patient with neurological disease, surgery
is necessary more frequently than in healthy pregnants. Most pregnancies of these
patients will result in a slightly increased rate for cesarean section. The focus
of anesthesia care is mostly to avoid damage to the fetus, in some pathologies to
protect the mother. Pregnancy itself may change the course of pre–existent chronic
neurological diseases such as epileptic seizure, multiple sclerosis, or myasthenia
gravis. Other diseases will have their onset predominantly in pregnancy such as back
pain, nerve compression syndromes, some brain tumors or cerebrovascular events. Subarachnoidal
hemorrhage and intracranial bleeding contribute to 65 % of maternal mortality. Finally,
pregnancy induced conditions such as eclampsia and HELLP syndrome and its management
are reviewed where the concerns for the nervous system have high relevance for anesthesiological
management.
Anesthesia care for the pregnant and the parturient presenting with a neurological
disease requires 1.) expertise with neuroanesthesia and obstetric anesthesia care,
2.) accurate physical examination of the neurological system preoperatively, 3.) safe
choice and conductance of the anesthesia technique (mostly regional anesthesia) 4.)
avoidance of unfavorable drug effects for the fetus and the nervous system of the
mother and 5.) intraoperative neuromonitoring together with the control of the fetal
heart rate.
Schlüsselwörter
Epilepsie - Myasthenia gravis - Guillain–Barré–Syndrom - Migräne - Multiple Sklerose
- Subarachnoidalblutung - Sinusvenusthrombose
Keywords
Anesthesia - pregnancy - neurological diseases - management,
Kernaussagen
-
Regionalverfahren sind bei allen häufigen neurologischen Vorerkrankungen der Allgemeinanästhesie
vorzuziehen.
-
Bei einer Allgemeinanästhesie für schwangere Epileptikerinnen sind prokonvulsive Substanzen
und Muskelrelaxation zu vermeiden und/oder die elektrische Hirnaktivität zu überwachen.
-
Die Schwangere mit Multipler Sklerose profitiert am meisten von einer Periduralanästhesie.
Eine Hyperthermie muss perioperativ vermieden werden.
-
Auch bei der Myasthenia gravis sind Regionalverfahren zu bevorzugen; jedes 5. bis
10. Neugeborene hat eine postnatale, vorübergehende Myasthenie.
-
Die Anästhesieführung bei ZNS–Tumoren und Subarachnoidalblutungen vermeidet Hyperthermie,
Hypovolämie, zerebrale Hypoperfusion, Hirndruckerhöhung, Hyperventilation, Lachgas
und hohe Dosierungen von volatilen Anästhetika >0,5–1 MAC.
-
Bei Guillain–Barré–Syndrom erfolgt die Ileus–Einleitung – wenn möglich – ohneVerwendung
von depolarisierenden Muskelrelaxanzien.
-
Die Spinalanästhesie ist das bevorzugte Verfahren zur Entlastung von Bandscheibenvorfällen
in der Schwangerschaft.
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Dr. med. Annette Griebe
Dr. med. Luc Aniset
Dr. med. Csilla Jámbor
PD Dr. med. Thomas Frietsch
eMail: annette.griebe@anaes.ma.uni-heidelberg.de
eMail: luc.aniset@anaes.ma.uni-heidelberg.de
eMail: csilla.jambor@kssg.ch
eMail: thomas.frietsch@anaes.ma.uni-heidelberg.de