Die Schwangere mit neurologischen Begleiterkrankungen – Implikationen für das peripartale Anästhesiemanagement – Teil I

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.

Epilepsie - Myasthenia gravis - Guillain–Barré–Syndrom - Migräne - Multiple Sklerose - Subarachnoidalblutung - Sinusvenusthrombose

Anesthesia - pregnancy - neurological diseases - management

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