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Anästhesie und Schmerztherapie während der Schwangerschaft

Anesthesia and pain management during pregnancy

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Zusammenfassung

Im Rahmen der peri- und postoperativen Betreuung einer Schwangeren muss im besonderen Maß den veränderten physiologischen Bedingungen Rechnung getragen werden. Grundprinzipen der Versorgung sind die Aufrechterhaltung der maternalen und fetalen Homöostase sowie eine Vermeidung von für den Fetus schädlichen Substanzen. Bei der Planung eines Eingriffs müssen alle beteiligten Fachdisziplinen rechtzeitig involviert werden. Für die Durchführung einer Allgemeinanästhesie scheinen die modernen Anästhetika insgesamt gut geeignet zu sein. Es fehlen bisher sichere Hinweise auf human-teratogene Effekte einzelner Substanzen. Perioperativ ist auf die adäquate Überwachung und Beurteilung des Fetus zu achten.

Die Schmerztherapie während der Schwangerschaft orientiert sich prinzipiell am Stufenschema der World Health Organization (WHO). Jedoch dürfen nur Substanzen zum Einsatz kommen, die keinen embryo- oder fetotoxischen Effekt besitzen. Bei den Nichtopioidanalgetika kommt dem Paracetamol eine wesentliche Rolle zu. Innerhalb enger Grenzen kann auch der Einsatz von nichtsteroidalen Antirheumatika (NSAR) gerechtfertigt sein. Nach der 28. Schwangerschaftswoche sind sie kontraindiziert. Tramadol ist niedrig-potentes Opioid der 1. Wahl. Bei den hochpotenten Opioiden kann nach Risiko-Nutzen-Abwägung die Verabreichung von Morphin sinnvoll sein. Antikonvulsiva sollten nach Möglichkeit als Koanalgetikum vermieden werden. Im Bedarfsfall empfiehlt sich hier stattdessen die Gabe von besser untersuchten Antidepressiva. Neben der medikamentösen Schmerztherapie sollten auch nichtmedikamentöse konservative Therapieoptionen zur Behandlung von Schmerzen zum Einsatz kommen.

Abstract

During the perioperative and postoperative care of pregnant women it is prudent to pay close attention to the changed physiology of these patients. The main principles of care are the preservation of maternal and fetal homeostasis as well as avoidance of any substances with toxic effects on the fetus. In order to provide pregnant patients with good quality care, all relevant disciplines should be involved as early as possible. Modern anesthetic drugs can be used as they seem to be without teratogenic effects. Adequate perioperative surveillance and assessment of the fetus is also important.

The mainstay of pain management during pregnancy is the World Health Organization (WHO) pain ladder. It is of the utmost importance to use only substances without teratogenic or fetotoxic properties. Considering non-opioid drugs, the use of paracetamol is a viable option, whereas non-steroidal anti-inflammatory drugs (NSAID) should only be used with rigorous restrictions. Tramadol is a first-line drug when using opioids with low potency, whereas morphine can be used as an opioid with a higher potency after careful consideration of the risk-benefit ratio. If possible anticonvulsives should not be used as an adjunct in pain management during pregnancy. The use of thoroughly investigated antidepressants seems to be a better alternative. Apart from drug therapy it is important to use all available conservative pain treatment options.

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Authors and Affiliations

  1. Klinik für Anästhesiologie, Klinikum der Universität München (LMU), München, Deutschland

    T. Ninke &  S. Thoma-Jennerwein

  2. Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland

    J. Blunk &  T. Annecke

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  1. T. Ninke
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  4. T. Annecke
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Correspondence to T. Annecke.

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T. Ninke und S. Thoma-Jennerwein haben zu gleichen Teilen an der Entstehung dieses Beitrags beigetragen.

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Ninke, T., Thoma-Jennerwein, S., Blunk, J. et al. Anästhesie und Schmerztherapie während der Schwangerschaft. Anaesthesist 64, 347–356 (2015). https://doi.org/10.1007/s00101-015-0023-9

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