Präpartale Depression und Angst – Was ist relevant für den Geburtshelfer?

 

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Zusammenfassung

Fragestellung: Depressionen und Angststörungen stellen die häufigsten psychischen Erkrankungen dar und sind in unserer Gesellschaft weit verbreitet. Eine beachtliche Anzahl an Frauen leidet unter diesen psychischen Erkrankungen vor, während oder nach einer Schwangerschaft. Eine Schwangerschaft kann durch eine bereits vorbestehende oder neu auftretende Erkrankung erschwert werden. Im Gegensatz dazu haben sowohl die Angststörung als auch die Depression in ihrer klinischen Präsentation während der Schwangerschaft wenig Aufmerksamkeit erhalten. In diesem Artikel wird die aktuelle Literatur zu diesem Thema zusammengefasst mit dem Ziel, eine Übersicht über die Prävalenz und die klinische Präsentation depressiver Erkrankungen und Angststörungen im Prä- und Peripartalzeitraum zu geben. Klinische Implikationen werden diskutiert. Um in der Praxis ein besseres Verständnis dafür zu entwickeln, werden zuerst die Erkrankungen dargestellt, um dann auf die in der Literatur aufgeführten Schwangerschaftskomplikationen einzugehen. Im Vordergrund steht dabei die klinische Bedeutung dieser Erkrankungen. Des weiteren werden aktuelle Behandlungsoptionen und ein einfaches Screeninginstrument, an dem man sich im Alltag orientieren kann, vorgestellt. Methodik: Es wurde eine Datenrecherche in elektronischen Datenbasen (Medline, PubMed) in englischer Sprache anhand der Schlüsselwörter „Schwangerschaft“ und „Depression“ oder „Angststörung“ sowie „niedriges Geburtsgewicht“, „Wachstumsretardierung“, „Frühgeburt“ oder „Behandlung“ durchgeführt. Insgesamt 59 englischsprachige Artikel, publiziert innerhalb der Jahre 1986–2009 blieben nach Durchsicht übrig und wurden ausgewertet. Ergebnisse: Als Auswirkungen hoher Level an Depressivität und Angst auf die Schwangerschaft werden in aktuellen Studien besonders die intrauterine Wachstumsrestriktion sowie eine Frühgeburt herausgestellt. Eine Reihe von Autoren konnten hier Zusammenhänge demonstrieren. Über den Pathomechanismus herrscht Uneinigkeit. Am wahrscheinlichsten werden Regulationen über die Cortisolachse angenommen, was im Tierversuch demonstriert werden konnte. Die Diagnosestellung bedarf häufig der interdisziplinären Zusammenarbeit, um eine reaktive Symptomatik von tatsächlichen Psychopathologien zu unterscheiden. Behandlungsoptionen reichen von psychologischer Unterstützung bis hin zur Therapie mit Psychopharmaka. Schlussfolgerung: Angststörungen und depressive Erkrankungen zählen bei Frauen in den reproduktiven Jahren zu den häufigsten psychischen Störungen. Ihr Erscheinungsbild ist heterogen. Gerade das Erkennen dieser Erkrankungen in der Schwangerschaft und der Umgang mit ihnen ist erschwert. Unter der Annahme, dass sowohl die Erkrankung selbst durch Angst, Depression und Stress, jedoch auch eine psychotrope Medikation den Feten in seiner Entwicklung beeinflussen können, befindet sich der behandelnde Arzt in einem Dilemma. Sowohl die Behandlung als auch die Nichtbehandlung kann negative Konsequenzen nach sich ziehen. Eine frühzeitige Erkennung, Diagnosestellung und Zuführung zu Behandlungsangeboten stellt eine Möglichkeit dar, bereits präpartal entstehende Komplikationen zu mildern und postpartalen Störungen vorzubeugen.

Abstract

Purpose: Depression and anxiety disorders are the most common mental disorders and are widespread in our society. A considerable number of women suffer from these mental disorders either prior to, during or after pregnancy. They can cause severe complications during and after pregnancy. However, the prevalence and clinical presentation of depression and anxiety disorders during pregnancy have received little attention. In this article we review the medical literature as it relates to the prevalence and clinical presentation of depression and anxiety disorders during pregnancy. The aim of this study is to investigate the growing body of literature on maternal depression and anxiety during pregnancy. Its purpose is to present an overview of antenatal depression and anxiety and the clinical issues and implications involved. To develop a better understanding we describe the typical symptoms of these disorders and discuss the side effects on pregnant women and the developing fetus afterwards. The treatment options in clinical practice are explained, and the Edinburgh Postnatal Depression Scale (EPDS), which can be used as a simple screening instrument, is shown. Material and Methods: A search for empirical articles indexed in electronic databases (Medline, Pubmed) was conducted using combinations of the following search terms: pregnancy, childbirth, depression, postpartum, panic disorder, anxiety disorder, low birthweight, growth retardation, preterm birth or treatment. We included 59 articles published between 1986 and 2009. Results: A high level of depressive or anxiety symptoms during pregnancy were found in combination with fetal intrauterine growth retardation or preterm birth. A few studies were able to demonstrate an association. The pathomechanism remains partly unclear. Most likely those symptoms cause a change in the signalling pathway of cortisol, which has been demonstrated in animal research. It is not easy to establish a diagnosis during pregnancy. To differentiate between reactive symptoms and real psychopathology a psychiatrist or psychotherapist would often need to be involved. Treatment options range from supportive psychotherapy to treatment with antipsychotic drugs in severe cases. Conclusion: Depressive and anxiety disorders are the most common mental disorders in women during their reproductive years. The appearance of these disorders is heterogeneous. Making a diagnosis and treatment of the disorder is difficult during pregnancy. Given the growing evidence that depression, stress, anxiety and psychotropic medications all involve fetal exposure, pregnant women with depression or anxiety and their gynecologists face significant treatment dilemmas. Both treating and not treating the disorder can have negative side effects. Early detection of depression and anxiety disorders, confirmation of the diagnosis and early initiation of treatment options could limit prenatal complications and prevent their postpartum exacerbation.

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Dr. Stephanie Gawlik

Universitätsfrauenklinik Heidelberg

Voßstraße 9

69120 Heidelberg

Email: stephanie.gawlik@med.uni-heidelberg.de