Progesteron zur Prävention der Frühgeburt – ein Update evidenzbasierter Indikationen

Zusammenfassung

Die Prävention und Behandlung der Frühgeburt stellt nach wie vor eine der größten Herausforderungen in der Geburtshilfe dar. Weltweit werden 11% aller Kinder zu früh geboren mit weitreichenden Konsequenzen für die betroffenen Kinder, ihre Familien und das Gesundheitssystem. Experimentelle Studien weisen darauf hin, dass Progesteron uterine Kontraktionen hemmt, die Cervix uteri stabilisiert und immunmodulatorisch wirksam ist. In den letzten Jahren ist eine Vielzahl von klinischen Studien, die Gestagene zur Prävention der Frühgeburt einsetzen, publiziert worden. Die Vergleichbarkeit dieser Studien untereinander ist durch unterschiedliche Einschlusskriterien, Anwendung verschiedener Gestagene sowie deren Applikationsmodi schwierig. Es wurde daher im Rahmen einer Literaturrecherche (1956 bis 09/2018) eine kritische Evaluation der Studienlage durchgeführt. Unter Berücksichtigung der neuesten randomisierten kontrollierten Studien ergeben sich folgende evidenzbasierte Empfehlungen: Bei asymptomatischen Frauen mit Einlingsschwangerschaften und sonografisch verkürzter Zervix ≤ 25 mm vor der 24. Schwangerschaftswoche (SSW) führt die tägliche Gabe von Progesteron vaginal (200 mg Kapsel oder 90 mg Gel) bis zur 36 + 6 SSW zu einer signifikanten Reduktion der Frühgeburtenrate und einer Verbesserung des neonatalen Outcomes. Neueste Daten weisen auch auf positive Effekte einer Behandlung mit Progesteron bei Geminischwangerschaften und einer sonografisch verkürzten Zervix ≤ 25 mm vor der 24. SSW hin. Dagegen ist die Studienlage für die Gabe von Progesteron bei Frauen mit Einlingsschwangerschaft mit vorausgegangener Frühgeburt deutlich uneinheitlicher geworden. Für diese Indikation kann derzeit keine generelle Empfehlung ausgesprochen werden, sie ist daher eine Einzelfallentscheidung. Auch wenn der Einsatz von Progesteron im Hinblick auf mögliche Langzeitfolgen als sicher gilt, sollte eine nicht indizierte Exposition vermieden werden. Entscheidend für den Therapieerfolg ist die präzise Selektion der Schwangeren.

Schlüsselwörter

Frühgeburt - Progesteron - 17-α-Hydroxyprogesteroncaproat - Zervixlänge

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