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Frühgeborene an der Grenze der Lebensfähigkeit

Periviable infants

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Zusammenfassung

Nach dem deutlichen Anstieg der Überlebensraten im Zusammenhang mit der Einführung antenataler Steroide, der Surfactant-Behandlung und Regionalisierung der Versorgung kleiner Frühgeborener vor etwa 30 Jahren sinkt die Mortalität seither eher zögerlich. Etwa alle 10 Jahre verringert sich das mit 50 %igem Überleben assoziierte Gestationsalter um eine Woche, während das Ausmaß kognitiver Einschränkungen bei überlebenden Kindern gleich zu bleiben scheint.

Im europäischen Vergleich zeigen sich bei nach Gestationsalter stratifizierter Betrachtung erhebliche Unterschiede. In Frankreich, den Niederlanden und der Schweiz überleben Frühgeborene unter 24 Wochen nur ausnahmsweise, während Österreich, Schweden und Deutschland Überlebensraten bei Frühgeborenen mit 23 Wochen von 40–60 % verzeichnen, bei 22 Wochen sind es in Deutschland 15 %, in Schweden 30 %. Diese Zahlen spiegeln unterschiedliche gesellschaftliche Einstellungen wider: Entsprechend den nationalen Empfehlungen ist die Grauzone mit optionaler kurativer Versorgung in Schweden bei 22 + 0 bis 22 + 6 Wochen, in Österreich bei 23 + 0 bis 23 + 6, in Deutschland und Großbritannien bei 22 + 0 bis 23 + 6, in der Schweiz bei 24 + 0 bis 24 + 6, in Frankreich und den Niederlanden bei 24 + 0 bis 25 + 6 Wochen angesiedelt.

Die unterschiedlichen Empfehlungen beruhen im Wesentlichen auf differierenden Bewertungen von v. a. unter 24 Wochen zu beobachtenden langfristigen Behinderungen, mit einem durchschnittlichen Defizit des Intelligenzquotienten (IQ) von 20 bis 25 Punkten. Bei rund einem Drittel der Kinder ist der IQ aber im Normalbereich.

Wesentlich mehr Neonatologinnen und Neonatologen sind bereit, ihr Handeln an den Wünschen der Eltern auszurichten, als dies vor 20 bis 30 Jahren der Fall war, und mehr sind auch zu einer Therapiezieländerung bei sich abzeichnender sehr schlechter Prognose bereit.

Abstract

The sharp increase in survival rates in preterm infants following the advent of antenatal steroids, surfactant replacement therapy, and regionalization of perinatal care about 30 years ago has been followed by slow progress in the reduction of mortality thereafter. The apparent decrement of the average gestational age associated with 50% survival is about 1 week over 10 years. The extent of neurodevelopmental impairment in surviving children, however, appears to have remained unchanged.

Survival of extremely preterm infants stratified by gestational age differs substantially between European countries. There are virtually no surviving preterm infants below 24 weeks in France, Switzerland and the Netherlands. Survival at 23 weeks exceeds 40–60% in Austria, Germany, and Sweden and for 22 weeks 15% and 30% survival has been reported in Germany and Sweden, respectively. This reflects the different societal attitudes as revealed by a comparison of the national guidelines. The grey zone where curative treatment is considered optional is 22 + 0 to 22 + 6 weeks in Sweden, 23 + 0 to 23 + 6 in Austria, 22 + 0 to 23 + 6 in Germany and the United Kingdom, 24 + 0 to 24 + 6 in Switzerland, and 24 + 0 to 25 + 6 weeks in France and the Netherlands.

The difference in recommendations is largely driven by differing views on neurodevelopmental impairment commonly observed in surviving infants below 24 weeks gestational age, with average intelligence quotients that are 20–25 points below the normal mean; however, approximately one third will display average intelligence.

Substantially more neonatologists are now more willing to accept parental choices than those working 20–30 years ago. Furthermore, more neonatologists consider and practice redirection of care in infants with poor prognosis.

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  1. Klinik für Neonatologie, Charité – Universitätsmedizin Berlin, 13344, Berlin, Deutschland

    Christoph Bührer

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Bührer, C. Frühgeborene an der Grenze der Lebensfähigkeit. Monatsschr Kinderheilkd 169, 1122–1132 (2021). https://doi.org/10.1007/s00112-021-01294-7

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