Schwangerschaft und Stillzeit bei Morbus Crohn

Die Erstdiagnose einer chronisch entzündlichen Darmerkrankung (CED) erfolgt oft im jungen Erwachsenenalter. Für viele Patientinnen spielen daher Familienplanung und Schwangerschaft eine zentrale Rolle. Die European Crohn‘s and Colitis Organization (ECCO) hat 2022 eine neue Leitlinie zu Kinderwunsch, Schwangerschaft und Stillzeit herausgegeben [1]. In diesem Beitrag gehen wir auf die neuen Aspekte in Bezug auf Schwangerschaft bei Morbus Crohn ein.

Abstract

Inflammatory bowel disease (IBD) is often diagnosed in young adults. Starting a family is an important step in life and can be further complicated by Crohn’s disease. Therefore, family planning should be discussed with every patient early in the disease course. Counseling about the importance of disease remission and the safety of IBD medication during pregnancy can ameliorate the pregnancy outcome. Active disease during pregnancy can lead to adverse pregnancy outcomes such as preterm birth and low birthweight. To maintain disease remission most therapies should be continued despite the wish to have children. Only a few substances currently used to treat Crohn’s disease are contraindicated during pregnancy and should be stopped before conception. This includes Januskinase (JAK)-inhibitors and Methotrexate. Biologics including anti-TNF-therapy, anti-IL-12/anti-IL-23 and anti-integrin therapies should be continued during pregnancy.

Kernaussagen

• Eine frühzeitige und umfassende Beratung zu den Themen Familienplanung und Schwangerschaft beeinflusst den Schwangerschaftsausgang bei Patientinnen mit einem Morbus Crohn positiv.

• Die Remission der Erkrankung ist die wichtigste Voraussetzung, um unerwünschte Ereignisse in der Schwangerschaft zu verhindern.

• Während der Schwangerschaft sollte die Krankheitsaktivität regelmäßig durch Bestimmung von Calprotectin und CRP sowie – wenn verfügbar – mittels Darmsonografien überprüft werden.

• Eine Biologikatherapie sollte in der Schwangerschaft ab der 24. SSW nur bei stabiler Remission und auf ausdrücklichen Wunsch der Patientin pausiert werden.

• Die Wahl des Geburtsmodus sollte gemeinsam mit den Geburtshelfern und unter Einbezug des Patientinnenwunsches erfolgen. Nur bei ausgeprägtem perianalem Befall und rektovaginaler Fistel wird aus gastroenterologischer Sicht eine primäre Sectio empfohlen.

• Bei Biologikaexposition in utero muss im ersten Lebensjahr auf Lebendimpfungen verzichtet werden.

Schlüsselwörter

Familienplanung - Schwangerschaft - chronisch entzündliche Darmerkrankung - Morbus Crohn - Stillzeit

Keywords

family planning - pregnancy - inflammatory bowel disease - Crohn’s disease - breastfeeding

Publikationsverlauf

Artikel online veröffentlicht:
29. Dezember 2023

• Literatur

• 1 Torres J, Chaparro M, Julsgaard M. et al. European Crohn’s and Colitis Guidelines on Sexuality, Fertility, Pregnancy, and Lactation. J Crohns Colitis 2023; 17: 1-27 DOI: 10.1093/ecco-jcc/jjac115. (PMID: 36005814)
• 2 Walldorf J, Pijan E, Greinert R. et al. Family planning with inflammatory bowel disease: the challenge of childlessness and parent concerns. Z Gastroenterol 2021; 59: 841-850 DOI: 10.1055/a-1404-3610.
• 3 de Lima A, Zelinkova Z, Mulders AG. et al. Preconception care reduces relapse of inflammatory bowel disease during pregnancy. Clin Gastroenterol Hepatol 2016; 14: 1285-1292 e1281 DOI: 10.1016/j.cgh.2016.03.018.
• 4 Moller FT, Andersen V, Wohlfahrt J. et al. Familial risk of inflammatory bowel disease: a population-based cohort study 1977–2011. Am J Gastroenterol 2015; 110: 564-571 DOI: 10.1038/ajg.2015.50. (PMID: 25803400)
• 5 Laharie D, Debeugny S, Peeters M. et al. Inflammatory bowel disease in spouses and their offspring. Gastroenterology 2001; 120: 816-819 DOI: 10.1053/gast.2001.22574.
• 6 Duffy DL, Martin NG, Battistutta D. et al. Genetics of asthma and hay fever in Australian twins. Am Rev Respir Dis 1990; 142: 1351-1358 DOI: 10.1164/ajrccm/142.6_Pt_1.1351. (PMID: 2252253)
• 7 Ban L, Tata LJ, Humes DJ. et al. Decreased fertility rates in 9639 women diagnosed with inflammatory bowel disease: a United Kingdom population-based cohort study. Aliment Pharmacol Ther 2015; 42: 855-866 DOI: 10.1111/apt.13354.
• 8 Brondfield MN, Mahadevan U. Inflammatory bowel disease in pregnancy and breastfeeding. Nat Rev Gastroenterol Hepatol 2023; DOI: 10.1038/s41575-023-00758-3.. (PMID: 37002407)
• 9 Bublak R. Neue Leitlinie fürs hormonelle Verhüten. gynäkologie + geburtshilfe 2020; 25: 42-45 DOI: 10.1007/s15013-020-2981-5.
• 10 Abhyankar A, Ham M, Moss AC. Meta-analysis: the impact of disease activity at conception on disease activity during pregnancy in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2013; 38: 460-466 DOI: 10.1111/apt.12417. (PMID: 23855477)
• 11 Castiglione F, Testa A, Rea M. et al. Transmural healing evaluated by bowel sonography in patients with Crohn’s disease on maintenance treatment with biologics. Inflamm Bowel Dis 2013; 19: 1928-1934 DOI: 10.1097/MIB.0b013e31829053ce.
• 12 Calabrese E, Maaser C, Zorzi F. et al. Bowel ultrasonography in the management of Crohn’s disease. A review with recommendations of an international panel of experts. Inflamm Bowel Dis 2016; 22: 1168-1183 DOI: 10.1097/MIB.0000000000000706.
• 13 Bengtson MB, Martin CF, Aamodt G. et al. Inadequate gestational weight gain predicts adverse pregnancy outcomes in mothers with inflammatory bowel disease: Results from a prospective US pregnancy cohort. Dig Dis Sci 2017; 62: 2063-2069 DOI: 10.1007/s10620-017-4547-5.
• 14 Kozlowski RD, Steinbrunner JV, MacKenzie AH. et al. Outcome of first-trimester exposure to low-dose methotrexate in eight patients with rheumatic disease. Am J Med 1990; 88: 589-592 DOI: 10.1016/0002-9343(90)90522-f.
• 15 Embryotox. Methotrexat. 2023 Zugriff am 14. September 2023 unter: https://www.embryotox.de/arzneimittel/details/ansicht/medikament/methotrexat/
• 16 Kanis SL, Modderman S, Escher JC. et al. Health outcomes of 1000 children born to mothers with inflammatory bowel disease in their first 5 years of life. Gut 2021; 70: 1266-1274 DOI: 10.1136/gutjnl-2019-319129.
• 17 Shim L, Eslick GD, Simring AA. et al. The effects of azathioprine on birth outcomes in women with inflammatory bowel disease (IBD). J Crohns Colitis 2011; 5: 234-238 DOI: 10.1016/j.crohns.2011.01.009.
• 18 Mahadevan U, Long MD, Kane SV. et al. Pregnancy and neonatal outcomes after fetal exposure to biologics and thiopurines among women with inflammatory bowel disease. Gastroenterology 2021; 160: 1131-1139 DOI: 10.1053/j.gastro.2020.11.038.
• 19 Langagergaard V, Pedersen L, Gislum M. et al. Birth outcome in women treated with azathioprine or mercaptopurine during pregnancy: A Danish nationwide cohort study. Aliment Pharmacol Ther 2007; 25: 73-81 DOI: 10.1111/j.1365-2036.2006.03162.x. (PMID: 17229222)
• 20 Jolving LR, Anru PL, Nielsen J. et al. The risk of chronic diseases and congenital malformations during childhood and adolescence after in utero exposure to thiopurines. Aliment Pharmacol Ther 2021; 54: 1061-1069 DOI: 10.1111/apt.16578.
• 21 Moens A, van der Woude CJ, Julsgaard M. et al. Pregnancy outcomes in inflammatory bowel disease patients treated with vedolizumab, anti-TNF or conventional therapy: results of the European CONCEIVE study. Aliment Pharmacol Ther 2020; 51: 129-138 DOI: 10.1111/apt.15539. (PMID: 31692017)
• 22 Julsgaard M, Baumgart DC, Baunwall SMD. et al. Vedolizumab clearance in neonates, susceptibility to infections and developmental milestones: a prospective multicentre population-based cohort study. Aliment Pharmacol Ther 2021; 54: 1320-1329 DOI: 10.1111/apt.16593. (PMID: 34472644)
• 23 Avni-Biron I, Mishael T, Zittan E. et al. Ustekinumab during pregnancy in patients with inflammatory bowel disease: a prospective multicentre cohort study. Aliment Pharmacol Ther 2022; 56: 1361-1369 DOI: 10.1111/apt.17224.
• 24 Mahadevan U, Wolf DC, Dubinsky M. et al. Placental transfer of anti-tumor necrosis factor agents in pregnant patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2013; 11: 286-292 DOI: 10.1016/j.cgh.2012.11.011.
• 25 Mahadevan U, Robinson C, Bernasko N. et al. Inflammatory bowel disease in pregnancy clinical care pathway: a report from the American Gastroenterological Association IBD Parenthood Project Working Group. Gastroenterology 2019; 156: 1508-1524 DOI: 10.1053/j.gastro.2018.12.022.
• 26 Odufalu FD, Long M, Lin K. et al. Exposure to corticosteroids in pregnancy is associated with adverse perinatal outcomes among infants of mothers with inflammatory bowel disease: results from the PIANO registry. Gut 2022; 71: 1766-1772 DOI: 10.1136/gutjnl-2021-325317.
• 27 Beaulieu DB, Ananthakrishnan AN, Issa M. et al. Budesonide induction and maintenance therapy for Crohn’s disease during pregnancy. Inflamm Bowel Dis 2009; 15: 25-28 DOI: 10.1002/ibd.20640.
• 28 Monfared N, Gold M, Carbery I. et al. Reproductive Safety Issues of Novel Small Molecules for the Treatment of Inflammatory Bowel Disease: A Systematic Review. J Clin Med 2023; 13 (01) 34 DOI: 10.3390/jcm13010034.
• 29 Grosen A, Julsgaard M, Kelsen J. et al. Infliximab concentrations in the milk of nursing mothers with inflammatory bowel disease. J Crohns Colitis 2014; 8: 175-176 DOI: 10.1016/j.crohns.2013.09.003.
• 30 Matro R, Martin CF, Wolf D. et al. Exposure concentrations of infants breastfed by women receiving biologic therapies for inflammatory bowel diseases and effects of breastfeeding on infections and development. Gastroenterology 2018; 155: 696-704 DOI: 10.1053/j.gastro.2018.05.040. (PMID: 29857090)
• 31 Embryotox. Prednisolon. Stillzeit. 2022 https://www.embryotox.de/arzneimittel/details/ansicht/medikament/prednisolon/
• 32 Julsgaard M, Mahadevan U, Vestergaard T. et al. Tofacitinib concentrations in plasma and breastmilk of a lactating woman with ulcerative colitis. Lancet Gastroenterol Hepatol 2023; 8: 695-697 DOI: 10.1016/S2468-1253(23)00158-9.
• 33 van der Woude CJ, Ardizzone S, Bengtson MB. et al. The second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease. J Crohns Colitis 2015; 9: 107-124 DOI: 10.1093/ecco-jcc/jju006. (PMID: 25602023)