Erhöhtes Risiko für Totgeburt bei älteren Müttern – Rationale für Geburtseinleitung vor dem Termin?

Zusammenfassung

Das durchschnittliche mütterliche Alter bei der Geburt ist in Deutschland und anderen Industrieländern in den letzten 20 Jahren deutlich angestiegen. Neben der Zunahme an Schwangerschaftskomplikationen und mütterlichen Risikofaktoren wie Übergewicht, Diabetes und Hypertonie steigt bei Schwangeren≥35 Jahre auch das Gestationsalter-bezogene Risiko für Totgeburt im Vergleich zu jüngeren Schwangeren. Zusätzliche individuelle Risikofaktoren für Totgeburt sind vor allem Primiparität, Body-Maß-Index>30 und Rauchen. Nach Ausschluss von Risikofaktoren ist das absolute Risiko für Totgeburt bei Schwangeren>40 Jahre in der 39 (40.) SSW mit 1:503 doppelt so hoch wie bei unter 35-jährigen mit 1:1 020; es ist nach Ausschluss kongenitaler Ano­malien bei>40-jährigen in der 39. Woche vergleichbar hoch wie bei 25- bis 29-jährigen in der 42. SSW. Die zugrundeliegenden Ursachen für diesen Anstieg der Totgeburtenrate sind bisher nicht hinreichend geklärt. Unabhängig vom mütterlichen Alter erhöht sich die kumulative Wahrscheinlichkeit für perinatalen Tod von 1,8/1 000 Geburten in der 38. SSW auf 9,3/1 000 Geburten in der 42. SSW. Ob aufgrund dieser Datenlage älteren Schwangeren eine Geburtseinleitung in der 39. SSW zu empfehlen ist, war Gegenstand eines jüngsten Scientific Impact Papers des Royal College of Obstetricians and Gynaecologists. Dabei ist zu berücksichtigen, dass die Sectiorate bei Frauen≥40 Jahren in Deutschland bei 40% liegt und vor allem Nulliparae sich eher für eine Sectio als für eine elektive Geburtseinleitung entscheiden dürften. Jüngste Metaanalysen ergaben keine Erhöhung der Sectiorate durch die elektive Geburtseinleitung vor und nach dem Termin im Vergleich zu einem expektativen Vorgehen. Bisher liegen keine randomisierten kontrollierten Studien und dementsprechend auch keine aktuellen Leitlinienempfehlungen zur Geburtseinleitung bei Müttern fortgeschrittenen Alters vor. In jedem Fall ist ein sorgfältiges Aufklärungsgespräch und eine individuelle Risiko-Nutzenanalyse über das geburtshilfliche Vorgehen notwendig, die Entscheidung sollte im Konsens zwischen Schwangerer und Geburtshelfer getroffen werden. Zurzeit läuft eine randomisierte Multizenterstudie in England, die bei Nulliparae>35 Jahre die Geburtseinleitung in der 39. SSW mit einem expektativen Management im Hinblick auf die intrapartalen Komplikationen sowie die perinatale Morbidität und Mortalität vergleicht.

Abstract

The average age of childbearing has risen markedly in Germany and other high-income countries during the past 2 decades. Women aged 35 years or older have an increase in pregnancy complications and in preexisting medical conditions including obesity, diabetes and hypertension as well as a significant increase in the gestational age–related rate of stillbirth compared to younger mothers. Additional individual risk factors for stillbirth are primiparity, body mass index>30 and smoking. After exclusion of risk factors the absolute risk of stillbirth in women aged≥40 years old is 2-fold higher (1 in 503 maternities) at 39/40 weeks of gestation compared to women aged<35 years (1 in 1 020 maternities) at the same gestational age. Women aged 40 years or older have a similar stillbirth risk at 39 weeks of gestation to 25–29-year-olds at 41 weeks gestation. The underlying mechanism for the excess risk of stillbirth in women of advanced maternal age after exclusion of congenital anomalies is unknown. Independent of maternal age the cumulative probability of perinatal death increases from 1.8/1 000 deliveries at 38 weeks of gestation to 9.3/1 000 deliveries at 42 weeks of gestation. Whether on the basis of these data induction of labour at 39 weeks of gestation should be recommended in women of advanced maternal age has recently been discussed in a Scientific Impact Paper of the Royal College of Obstetricians and Gynaecologists. In this context it should be taken into account that the rate of Caesarean sections in women aged 40 years or over is 40%, and, in particular, older nulliparous may request elective Caesaran section rather than elective induction of labour. Recent metaanalyses have shown that elective induction of labour before or after term is not associated with an increase of the Caesarean section rate compared to expectant management. Up to now no randomised controlled trials exist and consequently no ­recommendations from current guidelines regarding induction of labour in women of advanced maternal age can be given. In any case, a careful consultation and an individual risk-benefit analysis regarding the obstetric management is mandatory, and the final decision should be made in agreement between the pregnant women and the obstetrician. Currently a randomised controlled trial in the U.K. comparing induction of labour at 39 weeks of gestation with expectant management in nulliparous women aged over 35 years is recruiting, with the aim to determine intrapartum complications and perinatal morbidity and mortality in both managements.

Schlüsselwörter

fortgeschrittenes mütterliches Alter - Schwangerschaftskomplikationen - Risiko für Totgeburt - Geburtseinleitung

Key words

advanced maternal age - obstetric complications - risk of stillbirth - induction of labour

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