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

• Literatur

• 1 Aqua-Institut: Geburtshilfe. Qualitätsindikationen – Bundesauswertung zum Erfassungsjahr 2012. Göttingen 2013 16/1
• 2 Faktencheck Gesundheit. Kaiserschnittgeburten – Entwicklung und regionale Vorstellung. Bertelsmann-Stiftung 2012 http://faktencheck-gesundheit.de
• 3 Joseph KS, Allen AC, Dodds L et al. The perinatal effects of delayed childbearing. Obstet Gynecol 2005; 105: 1410-1418
• 4 O’Leary C, De Klerk N, Keogh J et al. Trends in mode of delivery during 1984–2003 – Can they be explained by pregnancy and delivery complications. BJOG 2007; 114: 855-864
• 5 Carolan M, Davey M-A, Biro M-A et al. Older maternal age and intervention in Labor: a population-based study comparing older and younger first-time mothers in Victoria, Australia. Birth 2011; 38: 24-29
• 6 Johnson J-A, Tough S. SOGC Committee Opinion: Delayed child-bearing. JOGC 2012; 271: 80-93
• 7 Canadian Institute of Health Information . In due time: why maternal age matter Sept 2011. Ottawa: Canadian Institute of Health Informa­tion; http://secure.chi.ca/chiweb/products/AIB-InDueTime-WhyMaternal Age Matters -E.pdf asserved October 6,   2011
• 8 Centre for Maternal and Child Enquiries (CMACE) . Perinatal mortality 2008-, United Kingdom. London: CMACE; 2010
• 9 Hilder L, Costeloe K, Thilaganathan B. Prolonged pregnancy evaluating gestation-specific risks of fetal and infant mortality. BJOG 1998; 105: 169-173
• 10 Smith GCS. Life-table analysis of the risk of perinatal death at term and post term in singleton pregnancies. AJOG 2001; 184: 489-496
• 11 Reddy UM, Ko CW, Willinger M. Maternal age and the risk of stillbirth throughout pregnancy on the United States. AJOG 2006; 195: 764-770
• 12 Fretts RC, Schmittdiel J, Frames H et al. Increased maternal age and the risk of fetal death. N Engl J Med 1995; 333: 953-957
• 13 Pasupathy D, Wood AM, Pell JP et al. Advanced maternal age and the risk of perinatal death due to intrapartum anoxia at term. J Edpidemiol Community Health 2011; 65: 241-245
• 14 Centre for Maternal and Child Enquiries (CMACE) . Saving Mother’s Lives: reviewing maternal deaths to make motherhood safer: 2000–2008. The Eights Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118 (Suppl1) 1-203
• 15 Huang L, Saeve R, Biskett N et al. Maternal age and risk of stillbirth: a systematic review. CMAJ 2008; 178: 165-172
• 16 Reddy UM, Langhorn SK, Sun L et al. Pregnancy risk factors for antepartum stillbirth in the United States. Obstet Gynecol 2010; 116: 1119-1126
• 17 Flenady V, Koopmans L, Middleton P et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet 2011; 377: 1331-1340
• 18 Wyatt PR, Owolabi T, Meier C et al. Age-specific risk of fetal loss observed in a second trimester serum screening population. AJOG 2005; 192: 240-246
• 19 Weiss E, Krombholz K, Eichner M. Fetal mortality at and beyond term in singleton pregnancies in Germany 2004–2009: Comparison with international studies. Arch Gynecol Obstet 2013;
• 20 Bahtiyar MO, Funai EF, Rosenberg V et al. Stillbirth at term in women of advanced maternal age in the United States: when could the antenatal testing be initiated?. Am J Perinatol 2008; 25: 301-304
• 21 Haavadsen C, Sarfraz AA, Samuelsen SO et al. The impact of maternal age on fetal death: does length of gestation matter?. AJOG 2010; 203: 554e1-554e8
• 22 Odibo AO, Nelson D, Stamilio DM et al. Advanced maternal age is an independent risk factor for intrauterine growth restriction. Am J Perinatol 2006; 23: 325-328
• 23 Froen JF, Gardosi JG, Thrumann A et al. Restricted fetal growth in sudden unexplained death. Arch Obstet Gynecol Scand 2004; 83: 801-807
• 24 Miller DA. Is advanced maternal age an independent risk factor for utero placental insufficiency?. AJOG 2005; 192: 1974-1980
• 25 Alfirevic Z, Stampalija T, Gyte GM. Fetal and umbilical Doppler ultrasound in normal pregnancy. Cochrane Database Syst Rev 2010; CD 001450
• 26 Walker KF, Bugg GJ, Macpherson M et al. Induction of labour at term for women over 35 years old: a survey of the views of women and obstetricians. Eur J Obstet Gynecol Reprod Biol 2012; 162: 144-148
• 27 Wang Y, Tenso T, Abyholm T et al. The impact of advanced maternal age and parity on obstetric and perinatal outcome in singleton gestations. Arch Gynecol Obstet 2011; 284: 31-37
• 28 Moore LE, Rayburn WF. Elective induction of labour. Clin Obstet Gynecol 2006; 49: 698-704
• 29 Ehrenthal DB, Jiang X, Strobino DM. Labor induction and the risk of a caesarean delivery among nulliparous women at term. Obstet Gynecol 2010; 116: 35-42
• 30 Caughey AB, Sundaram V, Kaimal AJ et al. Systematic review: elective induction of labour versus expectant margent of pregnancy. Ann Intern Med 2009; 151: 252-263
• 31 Jacquemyn Y, Michiels I, Martens G. Elective induction of labour increases caesarean section rate in low risk nulliparous women. J Obstet Gynaecol 2012; 32: 257-259
• 32 Guerra CV, Cecatti JG, Souza JP et al. Elective induction versus spontaneous labour in Latin America. Bull World Health Org 2011; 89: 657-665
• 33 Keirse MJN. Elective induction, selective deduction and cesarean section. Birth 2010; 37: 252-256
• 34 Stock SJ, Ferguson E, Duffy A et al. Outcomes of elective induction of labour at term compared with expectant management: population-based study. BMJ 2012; 344: e2838
• 35 Wood S, Cooper S, Ross S. Does induction of labour increase the risk of caesarean section? A systematic review and meta-analyses of trials in women with intact membranes. BJOG 2013;
• 36 Zeteroglu S, Sahin GH, Sahin HA. Induction of labour with misoprostol in pregnancies with advanced maternal age. Eur J Obstet Gynecol Reprod Biol 2006; 129: 140-144
• 37 Hospital Episode Statistics data online. http://www.hesonline-nhs.uk/Ease/servlet//ContentServer?site ID:1937category ID:1475
• 38 Leduc D, Biringer A, Lee L et al. SOGC Clinical Practice Guideline No. 296. Induction of labour. J Obstet Gynaecol Can 2013; 35: 840-857
• 39 ISRCTN Register. Induction of labour versus expectant management for women over 35 years. http://www.controlled-trials.com/ISRCTN11517275/J