Skip to main content

State of the Art: Fertilität und Schwangerschaft bei rheumatischen Erkrankungen

State of the art: fertility and pregnancy in rheumatic diseases

Zusammenfassung

Entzündlich rheumatische Erkrankungen betreffen häufig Frauen im gebärfähigen Alter, für die eine Schwangerschaft nach wie vor mit erhöhten Risiken einhergeht. Gleichzeitig gewinnen wir immer mehr Einblick in Risikofaktoren und Präventionsmöglichkeiten, sodass für die meisten Frauen erfolgreiche und komplikationsarme Schwangerschaften möglich sind. Grundpfeiler sind eine Planung der Schwangerschaft unter guter Krankheitskontrolle und die Modifikation von behandelbaren Risikofaktoren. Dabei rückt erneut Hydroxychloroquin als Substanz mit vielfältigen positiven Wirkungen in den Fokus. Vom American College of Rheumatology (ACR) publizierte Empfehlungen geben einen praxisnahen Überblick zur Evidenzlage. Rheumatologen können, basierend auf dem aktuellen Wissensstand, nachhaltig zu einem positiven Schwangerschaftsverlauf für Mutter und Kind beitragen.

Abstract

Inflammatory rheumatic diseases often affect women of childbearing age, for whom pregnancy is still associated with increased risks. At the same time, we are gaining more and more insights into risk factors and preventive strategies, enabling almost all women to have successful pregnancies with few adverse outcomes. The cornerstones are planning of the pregnancy under effective disease control and the modification of individual risk factors. Hydroxychloroquine is once again coming into focus as a compound with multiple positive effects. Recommendations published by the American College of Rheumatology (ACR) provide a practical overview of the evidence. Based on the current state of knowledge, rheumatologists can make a lasting contribution to a positive pregnancy outcome for mother and child.

This is a preview of subscription content, access via your institution.

Literatur

  1. 1.

    (2020) Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstetrics and gynecology 135(6):e237–e260. https://doi.org/10.1097/AOG.0000000000003891

  2. 2.

    Alijotas-Reig J, Esteve-Valverde E, Ferrer-Oliveras R et al (2019) The European Registry on Obstetric Antiphospholipid Syndrome (EUROAPS): A survey of 1000 consecutive cases. Autoimmun Rev 18(4):406–414. https://doi.org/10.1016/j.autrev.2018.12.006

    Article  PubMed  Google Scholar 

  3. 3.

    Andreoli L, Bertsias GK, Agmon-Levin N et al (2017) EULAR recommendations for women’s health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome. Ann Rheum Dis 76(3):476–485. https://doi.org/10.1136/annrheumdis-2016-209770

    CAS  Article  Google Scholar 

  4. 4.

    Brito-Zerón P, Izmirly PM, Ramos-Casals M et al (2015) The clinical spectrum of autoimmune congenital heart block. Nat Rev Rheumatol 11(5):301–312. https://doi.org/10.1038/nrrheum.2015.29

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Brouwer J, Hazes JMW, Laven JSE et al (2015) Fertility in women with rheumatoid arthritis. Influence of disease activity and medication. Ann Rheum Dis 74(10):1836–1841. https://doi.org/10.1136/annrheumdis-2014-205383

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Buyon JP, Kim MY, Guerra MM et al (2015) Predictors of pregnancy outcomes in patients with lupus. A cohort study. Ann Intern Med 163(3):153–163. https://doi.org/10.7326/M14-2235

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Clowse MEB, Chakravarty E, Costenbader KH et al (2012) Effects of infertility, pregnancy loss, and patient concerns on family size of women with rheumatoid arthritis and systemic lupus erythematosus. Arthritis Care Res 64(5):668–674. https://doi.org/10.1002/acr.21593

    Article  Google Scholar 

  8. 8.

    Costedoat-Chalumeau N, Morel N, Fischer-Betz R et al (2019) Routine repeated echocardiographic monitoring of fetuses exposed to maternal anti-SSA antibodies: time to question the dogma. Lancet Rheumatol 1(3):e187–e193. https://doi.org/10.1016/S2665-9913(19)30069-4

    Article  Google Scholar 

  9. 9.

    https://www.fda.gov/drugs/drug-safety-and-availability/fda-recommends-avoiding-use-nsaids-pregnancy-20-weeks-or-later-because-they-can-result-low-amniotic. Zugegriffen: 9. Mai 2021

  10. 10.

    Friedman DM, Kim M, Costedoat-Chalumeau N et al (2020) Electrocardiographic QT intervals in infants exposed to hydroxychloroquine throughout gestation. Circ Arrhythm Electrophysiol 13(10):e8686. https://doi.org/10.1161/CIRCEP.120.008686

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Götestam Skorpen C, Lydersen S, Gilboe I‑M et al (2018) Women with systemic lupus erythematosus get pregnant more easily than women with rheumatoid arthritis. Rheumatology. https://doi.org/10.1093/rheumatology/key049

    Article  PubMed  Google Scholar 

  12. 12.

    Jethwa H, Lam S, Smith C et al (2019) Does rheumatoid arthritis really improve during pregnancy? A systematic review and metaanalysis. J Rheumatol 46(3):245–250. https://doi.org/10.3899/jrheum.180226

    Article  Google Scholar 

  13. 13.

    He WR, Wei H (2020) Maternal and fetal complications associated with systemic lupus erythematosus: an updated meta-analysis of the most recent studies (2017–2019). Medicine 99(16):e19797. https://doi.org/10.1097/MD.0000000000019797

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Ince-Askan H, Hazes JMW, Dolhain RJEM (2017) Identifying clinical factors associated with low disease activity and remission of rheumatoid arthritis during pregnancy. Arthritis Care Res 69(9):1297–1303. https://doi.org/10.1002/acr.23143

    CAS  Article  Google Scholar 

  15. 15.

    Izmirly P, Kim M, Friedman DM et al (2020) Hydroxychloroquine to prevent recurrent congenital heart block in fetuses of anti-SSA/Ro-positive mothers. J Am Coll Cardiol 76(3):292–302. https://doi.org/10.1016/j.jacc.2020.05.045

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Jakobsson GL, Stephansson O, Askling J et al (2016) Pregnancy outcomes in patients with ankylosing spondylitis. A nationwide register study. Ann Rheum Dis 75(10):1838–1842. https://doi.org/10.1136/annrheumdis-2015-207992

    Article  PubMed  Google Scholar 

  17. 17.

    Keeling SO, Bowker SL, Savu A et al (2020) A population-level analysis of the differing effects of rheumatoid arthritis and spondyloarthritis on peripartum outcomes. J Rheumatol 47(2):197–203. https://doi.org/10.3899/jrheum.181320

    Article  PubMed  Google Scholar 

  18. 18.

    Mehta B, Luo Y, Xu J et al (2019) Trends in maternal and fetal outcomes among pregnant women with systemic lupus erythematosus in the United States: a cross-sectional analysis. Ann Intern Med 171(3):164–171. https://doi.org/10.7326/M19-0120

    Article  PubMed  Google Scholar 

  19. 19.

    Nathan NO, Mørch LS, Wu CS et al (2020) Rheumatoid arthritis and risk of spontaneous abortion: a Danish nationwide cohort study. Rheumatology 59(8):1984–1991. https://doi.org/10.1093/rheumatology/kez565

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Rolnik DL, O’Gorman N, Roberge S et al (2017) Early screening and prevention of preterm pre-eclampsia with aspirin: time for clinical implementation. Ultrasound Obstet Gynecol 50(5):551–556. https://doi.org/10.1002/uog.18899

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Saavedra MÁ, Miranda-Hernández D, Lara-Mejía A et al (2020) Use of antimalarial drugs is associated with a lower risk of preeclampsia in lupus pregnancy: a prospective cohort study. Int J Rheum Dis 23(5):633–640. https://doi.org/10.1111/1756-185X.13830

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Sammaritano LR, Bermas BL, Chakravarty EE et al (2020) 2020 American college of rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases. Arthritis Rheumatol 72(4):529–556. https://doi.org/10.1002/art.41191

    Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Simard JF, Rossides M, Arkema EV et al (2021) Maternal hypertensive disorders in pregnant women with systemic lupus erythematosus and future cardiovascular outcomes. Arthritis Care Res 73(4):574–579. https://doi.org/10.1002/acr.24160

    Article  Google Scholar 

  24. 24.

    Smyth A, Oliveira GHM, Lahr BD et al (2010) A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis. Clin J Am Soc Nephrol 5(11):2060–2068. https://doi.org/10.2215/CJN.00240110

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Tani C, Zucchi D, Haase I et al (2021) Are remission and low disease activity state ideal targets for pregnancy planning in Systemic Lupus Erythematosus? A multicentre study. Rheumatology. https://doi.org/10.1093/rheumatology/keab155

    Article  PubMed  Google Scholar 

  26. 26.

    Tektonidou MG, Andreoli L, Limper M et al (2019) EULAR recommendations for the management of antiphospholipid syndrome in adults. Ann Rheum Dis 78(10):1296–1304. https://doi.org/10.1136/annrheumdis-2019-215213

    CAS  Article  Google Scholar 

  27. 27.

    Ursin K, Lydersen S, Skomsvoll JF et al (2018) Disease activity during and after pregnancy in women with axial spondyloarthritis. A prospective multicentre study. Rheumatology. https://doi.org/10.1093/rheumatology/key047

    Article  PubMed  Google Scholar 

  28. 28.

    Ursin K, Lydersen S, Skomsvoll JF et al (2020) Factors associated with time to pregnancy in women with axial spondyloarthritis: a registry-based multicenter study. Arthritis Care Res. https://doi.org/10.1002/acr.24233

    Article  Google Scholar 

  29. 29.

    van den Brandt S, Zbinden A, Baeten D et al (2017) Risk factors for flare and treatment of disease flares during pregnancy in rheumatoid arthritis and axial spondyloarthritis patients. Arthritis Res Ther 19(1):64. https://doi.org/10.1186/s13075-017-1269-1

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Zbinden A, van den Brandt S, Østensen M et al (2018) Risk for adverse pregnancy outcome in axial spondyloarthritis and rheumatoid arthritis: disease activity matters. Baillieres Clin Rheumatol 59:1241. https://doi.org/10.1093/rheumatology/key053

    Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Isabell Haase.

Ethics declarations

Interessenkonflikt

I. Haase und R. Fischer-Betz geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

Additional information

figureqr

QR-Code scannen & Beitrag online lesen

Redaktion

Rebecca Fischer-Betz, Düsseldorf

Frauke Förger, Bern

Anja Strangfeld, Berlin

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Haase, I., Fischer-Betz, R. State of the Art: Fertilität und Schwangerschaft bei rheumatischen Erkrankungen. Z Rheumatol 80, 699–706 (2021). https://doi.org/10.1007/s00393-021-01073-5

Download citation

Schlüsselwörter

  • Rheumatoide Arthritis
  • Systemischer Lupus erythematodes
  • Spondyloarthritis
  • Schwangerschaftskomplikationen
  • Schwangerschaftsplanung

Keywords

  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Spondylarthritis
  • Pregnancy complications
  • Pregnancy counselling