Schwangerschaft und Autoimmunerkrankungen – Was gilt es zu beachten?

Frauen mit Autoimmunerkrankungen und Kinderwunsch sollten präkonzeptionell ausführlich über das spezifische Risiko für ihre Erkrankung und die Schwangerschaft beraten werden. Die Schwangerschaft sollte geplant werden und in der Remission sowie gegebenenfalls unter Anpassung der Medikation eintreten. In der Schwangerschaft sollten Ärzte ein sonografisches Organscreening sowie engmaschige Verlaufskontrollen bei Mutter und Kind durchführen. Dadurch können sie Komplikationen wie die Präeklampsie, vorzeitige Wehen oder eine intrauterine Wachstumsretardierung rechtzeitig erkennen und behandeln. Die Geburt bedarf in Einzelfällen besonderer Überwachungsmaßnahmen, eine primäre Sectio caesarea ist in den meisten Fällen jedoch nicht notwendig. Im Wochenbett sind Schübe nicht selten – eine prophylaktische medikamentöse Therapie oder die Wiederaufnahme der Medikation muss dann bei der Beratung für oder gegen das Stillen berücksichtigt werden.

Women with autoimmune disorders who plan to have children should be thoroughly counseled before conception about the specific risk for their disorder and the pregnancy. Pregnancy should be planned for the time of disease remission and optimized drug regime. During pregnancy, specialized antenatal ultrasound should be performed to exclude malformations. Frequent monitoring of mother and fetus are necessary for early diagnosis and treatment of pregnancy complications such as preeclampsia, preterm labor or intrauterine growth retardation. In special cases, maternal or fetal surveillance during parturition is needed, elective cesarean section is mostly not indicated. Post partum flares are frequent, a prophylactic treatment or the re–beginning of the treatment before pregnancy should be taken into consideration when discussing whether or not the patient is advised to breastfeed.

Key words

autoimmune disorders - pregnancy - systemic lupus erythematosus - antiphospholipid syndrome - myasthenia gravis - multiple sclerosis

Literatur

• 1 Abramsky O.. Pregnancy and multiple sclerosis.  Ann Neurol. 1994;  36 38-41
• 2 Batocchi AP, Majolini L, Evoli A. et al. . Course and treatment of myasthenia gravis during pregnancy.  Neurology. 1999;  52 447-452
• 3 Bauersachs RM, Dudenhausen J, Faridi A. et al. . EThIG Investigators. Risk stratification and heparin prophylaxis to prevent venous thromboembolism in pregnant women.  Thromb Haemost. 2007;  98 1237-1245
• 4 Branch DW, Scott JR, Kochenour NK, Hershgold E.. Obstetric complications associated with the lupus anticoagulant.  N Engl J Med. 1985;  313 1322-1326
• 5 Brucato A, Frassi M, Franceschini F. et al. . Risk of congenital complete heart block in newborns of mothers with anti–Ro/SSA antibodies detected by counterimmunoelectrophoresis: a prospective study of 100 women.  Arthritis Rheum. 2001;  44 1832-1835
• 6 Costedoat–Chalumeau N, Amoura Z, Huong DL. et al. . Safety of hydroxychloroquine in pregnant patients with connective tissue diseases. Review of the literature.  Autoimmun Rev. 2005;  4 111-115
• 7 Djelms J, Sostarko M, Mayer D, Ivanisevic M.. Myasthenia gravis in pregnancy: a report on 69 cases.  Eur J Obstet Gynecol Repro Biol. 2002;  104 21-25
• 8 Empson M, Lassere M, Craig J, Scott J.. Prevention of recurrent miscarriage for women with antiphospholipid antibody or lupus anticoagulant.  Cochrane Database Syst Rev. 2005;  18
• 9 Ferrero S, Esposito F, Pretta S, Ragni N.. Fetal risks related to the treatment of multiple sclerosis during pregnancy and breastfeeding.  Expert Rev Neurother. 2006;  6 1823-1831
• 10 Galie N, Manes A, Farahani KV. et al. . Pulmonary arterial hypertension associated to connective tissue diseases.  Lupus. 2005;  14 713-717
• 11 Goldstein LH, Dolinsky G, Greenberg R. et al. . Pregnancy outcome of women exposed to azathioprine during pregnancy.  Birth Defects Res A Clin Mol Teratol. 2007;  79 696-701
• 12 Gordon P, Khamashta MA, Rosenthal E. et al. . Anti–52 kDa Ro, anti–60 kDa Ro, and anti–La antibody profiles in neonatal lupus.  J Rheumatol. 2004;  31 2480-2487
• 13 Gordon PA.. Congenital heart block: clinical features and therapeutic approaches.  Lupus. 2007;  16 642-646
• 14 Haas J, Hommes OR.. A dose comparison study of IVIG in postpartum relapsing–remitting multiple sclerosis.  Mult Scler. 2007;  13 900-908
• 15 Jain AB, Shapiro R, Scantlebury VP. et al. . Pregnancy after kidney and kidney–pancreas transplantation under tacrolimus: a single center's experience.  Transplantation. 2004;  77 897-902
• 16 Jungers P, Dougados M, Pélissier C. et al. . Influence of oral contraceptive therapy on the activity of systemic lupus erythematosus.  Arthritis Rheum. 1982;  25 618-623
• 17 Khamashta MA, Ruiz–Irastorza G, Hughes GR.. Systemic lupus erythematosus flares during pregnancy.  Rheum Dis Clin North Am. 1997;  23 15-30
• 18 Kuczkowski KM.. Labor analgesia for the parturient with neurological disease: what does an obstetrician need to know?.  Arch Gynecol Obstet. 2006;  274 41-46
• 19 Lahita RG, Bradlow HL, Kunkel HG, Fishman J.. Alterations of estrogen metabolism in systemic lupus erythematosus.  Arthritis Rheum. 1979;  22 1195-1198
• 20 Ostensen M, Villiger PM.. The remission of rheumatoid arthritis during pregnancy.  Semin Immunopathol. 2007;  29 185-191
• 21 Palmer BF.. Sexual dysfunction in men and women with chronic kidney disease and end–stage kidney disease.  Adv Ren Replace Ther. 2003;  10 48-60
• 22 Park–Wyllie L, Mazzotta P, Pastuszak A. et al. . Birth defects after maternal exposure to corticosteroids: prospective cohort study and meta–analysis of epidemiological studies.  Teratology. 2000;  62 385-392
• 23 Pierangeli SS, Girardi G, Vega–Ostertag M. et al. . Requirement of activation of complement C3 and C5 for antiphospholipid antibody–mediated thrombophilia.  Arthritis Rheum. 2005;  52 2120-2124
• 24 Ruiz–Irastorza G, Khamashta MA.. Antiphospholipid syndrome in pregnancy.  Rheum Dis Clin North Am. 2007;  33 287-297
• 25 Schaefer C, Spielmann H, Vetter K.. Arzneiverordnung in Schwangerschaft und Stillzeit. München, Jena: Urban & Fischer 2006
• 26 Schmidt RJ, Holley JL.. Fertility and contraception in end–stage renal disease.  Adv Ren Replace Ther. 1989;  5 38-44
• 27 Stafford IP, Dildy GA.. Myasthenia gravis and pregnancy.  Clin Obstet Gynecol. 2005;  48 48-56
• 28 Stone S, Khamashta MA, Poston L.. Placentation, antiphospholipid syndrome and pregnancy outcome.  Lupus. 2001;  10 67-74
• 29 Warren JB, Silver RM.. Autoimmune disease in pregnancy: systemic lupus erythematosus and antiphospholipid syndrome.  Obstet Gynecol Clin North Am. 2004;  34 345-372
• 30 Zenclussen AC, Gerlof K, Zenclussen ML. et al. . Regulatory T cells induce a privileged tolerant microenvironment at the fetal–maternal interface.  Eur J Immunol. 2006;  36 82-94
• 31 Zenclussen ML, Anegon I, Bertoja AZ. et al. . Over–expression of heme oxygenase–1 by adenoviral gene transfer improves pregnancy outcome in a murine model of abortion.  J Reprod Immunol. 2006;  69 35-52

Korrespondenz