Zusammenfassung
Länger anhaltende Arrhythmien werden bei 1–2 % der Feten nachgewiesen. Differenziert werden fetale Arrhythmien mittels M‑mode- und Doppler-Echokardiographie. Überwachung und Therapie sind der vorliegenden Arrhythmie anzupassen. Bei Tachyarrhythmien werden transplazentar Digoxin, Flecainid, Sotalol und Amiodaron eingesetzt, wobei Flecainid bei atrioventrikulären Reentry-Tachykardien mehr und mehr primär eingesetzt wird. Beim inflammatorisch bedingten kompletten AV(atrioventrikulären)-Block (congenital complete heart block, CCHB) durch maternale Anti-SSA/Ro-Antikörper ist eine generelle transplazentare Behandlung mit hochdosierten fluorierten Kortikosteroiden zur Eindämmung einer begleitenden Myokarditis aufgrund des Nebenwirkungsprofils nicht indiziert; sie ist allenfalls bei Feten mit Zeichen kardialer Dysfunktion und kardialer Fibrose zu erwägen. Zur Prävention sollte im Hochrisikokollektiv (Wiederholungsrisiko bei vorherigem Kind mit CCHB 16–19 %) die tägliche Gabe von 400 mg Hydroxychloroquin (HCQ) bereits vor der 10. Schwangerschaftswoche (SSW) erfolgen, wodurch das Risiko halbiert werden kann. Derzeit nicht indiziert ist eine generelle HCQ bei allen Schwangeren mit nachweisbaren Anti-SSA/Ro-Antikörpern zwecks Prävention, da aufgrund des geringen Risikos von 1–2 % die „number needed to treat“ (NNT) 100+ beträgt und relevante kardiale Ereignisse aufgrund der HCQ-bedingten QT-Zeit-Verlängerung möglich erscheinen. Die lange Zeit empfohlene sehr aufwendige wöchentlich echokardiographische Messung der fetalen AV-Zeit mit dem Ziel, einen AV-Block I. Grades zu erkennen und durch Behandlung mit Dexamethason das Auftreten einer CCHB zu verhindern, hat sich mittlerweile als ineffektiv erweisen.
Abstract
Sustained fetal arrhythmias are detected in 1–2% of fetuses. Fetal arrhythmias are differentiated by M‑mode and Doppler echocardiography. Surveillance and treatment should be individually adapted to the arrhythmia. For tachyarrhythmias transplacental digoxin, flecainide, sotalol, and amiodarone are used, whereby flecainide is increasingly being used as first-line treatment for atrioventricular (AV) re-entry tachycardia. In cases of inflammation-related complete AV block (congenital complete hart block, CCHB) resulting from maternal anti-SSA/Ro antibodies, a general transplacental treatment with high-dose fluorinated corticosteroids to control concomitant myocarditis is not indicated because of the side effect profile; at most it should be considered for fetuses with signs of cardiac dysfunction and cardiac fibrosis. For prevention, daily administration of 400 mg hydroxychloroquine (HCQ) should already be given before the 10th week of gestation in the high-risk cohort (recurrence rate in previous child with CCHB 16–19%), which can halve the risk. Currently, a general HCQ is not indicated in all pregnant women with detectable anti-SSA/Ro antibodies for the purpose of prevention, as the number needed to treat (NNT) is 100+ due to the low risk of 1–2% for occurrence of CCHB and relevant cardiac events appear possible due to HCQ-related QT time prolongation. The very labor-intensive weekly echocardiographic measurement of the fetal AV interval, which was recommended for a long time, with the aim of detecting a first degree AV block and preventing the occurrence of CCHB by treatment with dexamethasone, has meanwhile proved to be ineffective.
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Ulrich Gembruch, Bonn
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Gembruch, U. Fetale Arrhythmien – ein Update. Gynäkologe 55, 39–50 (2022). https://doi.org/10.1007/s00129-021-04887-1
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DOI: https://doi.org/10.1007/s00129-021-04887-1