Management léčby IBD v těhotenství vyžaduje multidisciplinární přístup

Download PDF English version

Authors: F. Marek ¹; Z. Kala ¹; R. Hrivnák ¹; I. Rovný ¹; P. Jabandžiev ^2,3; K. Poredská ⁴; Jiří Dolina ⁴; V. Procházka ¹; D. Ivanecká ¹; D. Bartušek ⁵; Vít Weinberger ⁶; Petr Janků ⁶; L. Kunovsky ^1,4
Authors‘ workplace: Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic ¹; Department of Pediatrics, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic ²; Central European Institute of Technology, Masaryk University, Brno, Czech Republic ³; Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic ⁴; Department of Radiology and Nuclear Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic ⁵; Department of Gynecology and Obstetrics, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic ⁶
Published in: Gastroent Hepatol 2021; 75(2): 149-158
Category:
doi: https://doi.org/10.48095/ccgh2021149

Overview

Crohnova nemoc a ulcerózní kolitida jsou chronická zánětlivá onemocnění střev (IBD – inflammatory bowel disease). V článku je shrnut přístup k léčbě gravidních pacientek s IBD od konzervativní terapie přes endoskopii, zobrazovací metody až po indikace k operačnímu řešení. Pacientky s IBD by měly těhotenství plánovat v době remise onemocnění. Pacientky v remisi mohou mít rovněž komplikace v těhotenství, ale riziko komplikací je nižší než u pacientek s aktivním onemocněním. Zavedená medikace (kromě teratogenního metotrexátu) by měla být ponechána. Dle dostupných dat samotné těhotenství nezhoršuje průběh IBD. Při těžkém relapsu či výskytu komplikací IBD je u těchto pacientek nutná multioborová spolupráce gastroenterologa, chirurga, radiologa a gynekologa. Operační řešení je nutné pouze při akutních komplikacích IBD (akutní těžká kolitida nereagující na medikamentózní terapii, perianální absces a komplikace IBD ve smyslu náhlých příhod břišních – perforace, ileózní stav při stenóze a masivním krvácení).

Konflikt zájmů: Autoři deklarují, že text článku odpovídá etickým standardům, byla dodržena anonymita pacientů a prohlašují, že v souvislosti s předmětem článku nemají finanční, poradenské ani jiné komerční zájmy.

Publikační etika: Příspěvek nebyl dosud publikován ani není v současnosti zaslán do jiného časopisu pro posouzení. Autoři souhlasí s uveřejněním svého jména a e-mailového kontaktu v publikovaném textu.

Dedikace: Tato práce byla podpořena projektem MZd ČR – koncepční vývoj výzkumné organizace (FNBr, 65269705).

Redakční rada potvrzuje, že rukopis práce splnil ICMJE kritéria pro publikace zasílané do biomedicínských časopisů.

Klíčová slova:

Crohnova nemoc – ulcerózní kolitida – idiopatické střevní záněty – gravidita – porod – relaps – endoskopie – chirurgie

Sources

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(2): 107–124. doi: 10.1093/ ecco-jcc/ jju006.
Hashash JG, Kane S. Pregnancy and inflammatory bowel disease. Gastroenterol Hepatol (NY) 2015; 11(2): 96–102.
Oza SS, Pabby V, Dodge LE et al. In vitro fertilization in women with inflammatory bowel disease is as successful as in women from the general infertility population. Clin Gastroenterol Hepatol 2015; 13(9): 1641–1646. doi: 10.1016/ j.cgh.2015.03.016.
Pabby V, Oza SS, Dodge LE et al. In vitro fertilization is successful in women with ulcerative colitis and ileal pouch anal anastomosis. Am J Gastroenterol 2015; 110(6): 792–797. doi: 10.1038/ ajg.2014.400.
Shin T, Okada H. Infertility in men with inflammatory bowel disease. World J Gastrointest Pharmacol Ther 2016; 7(3): 361–369. doi: 10.4292/ wjgpt.v7.i3.361.
Ďuricová D. Plánování těhotenství a léčba v graviditě. In: Lukáš M et al (eds). Idiopatické střevní záněty – Nové trendy a mezioborové souvislosti. Praha: Grada Publishing 2020.
Cornish J, Tan E, Teare J et al. A meta-analysis on the inﬂuence of inﬂammatory bowel disease on pregnancy. Gut 2007; 56(8): 830–837. doi: 10.1136/ gut.2006.108324.
Bröms G, Granath F, Linder M et al. Complications from inﬂammatory bowel disease during pregnancy and delivery. Clin Gastroenterol Hepatol 2012; 10(11): 1246–1252. doi: 10.1016/ j.cgh.2012.08.018.
Ananthakrishnan AN, Zadvornova Y, Naik AS et al. Impact of pregnancy on health-related quality of life of patients with inflammatory bowel disease. J Dig Dis 2012; 13(9): 472–477. doi: 10.1111/ j.1751-2980.2012.00618.x.
Piccinni MP, Scaletti C, Maggi E et al. Role of hormone-controlled Th1-and Th2-type cytokines in successful pregnancy. J Neuroimmunol 2000; 109(1): 30–33. doi: 10.1016/ s01 65-5728(00)00299-x.
Pedersen N, Bortoli A, Duricova D et al. The course of inflammatory bowel disease during pregnancy and postpartum: a prospective European ECCO‐EpiCom Study of 209 pregnant women. Aliment Pharmacol Ther 2013; 38(5): 501–512. doi: 10.1111/ apt.12412.
de Lima-Karagiannis A, Zelinkova-Detkova Z, van der Woude CJ. The effects of active IBD during pregnancy in the era of novel IBD therapies. Am J Gastroenterol 2016; 111(9): 1305–1312. doi: 10.1038/ ajg.2016.254.
de Lima A, Zelinkova Z, Mulders AG et al. Preconception care reduces relapse of inflammatory bowel disease during pregnancy. Clin Gastroenterol Hepatol 2016; 14(9): 1285–1292. doi: 10.1016/ j.cgh.2016.03.018.
Nielsen OH, Maxwell C, Hendel J. IBD medications during pregnancy and lactation. Nat Rev Gastroenterol Hepatol 2014; 11(2): 116–127. doi: 10.1038/ nrgastro.2013.135.
Koss CA, Baras DC, Lane SD et al. Investigation of metronidazole use during pregnancy and adverse birth outcomes. Antimicrob Agents Chemother 2012; 56(9): 4800–4805. doi: 10.1128/ AAC.06477-11.
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(5): 1508–1524. doi: 10.1053/ j.gastro.2018.12.022.
Carmichael SL, Shaw GM, Ma C et al. Maternal corticosteroid use and orofacial clefts. Am J Obstet Gynecol 2007; 197(6): 683–684. doi: 10.1016/ j.ajog.2007.05.046.
Leung YP, Kaplan GG, Coward S et al. Intrapartum corticosteroid use significantly increases the risk of gestational diabetes in women with inflammatory bowel disease. J Crohns Colitis 2015; 9(3): 223–230. doi: 10.1093/ ecco-jcc/ jjv006.
Beaulieu DB, Ananthakrishnan AN, Issa M et al. Budesonide induction and maintenance therapy for Crohn’s disease during pregnancy. Inflamm Bowel Dis 2009; 15(1): 25–28. doi: 10.1002/ ibd.20640.
Jharap B, de Boer NK, Stokkers P et al. Intrauterine exposure and pharmacology of conventional thiopurine therapy in pregnant patients with inflammatory bowel disease. Gut 2014; 63(3): 451–457. doi: 10.1136/ gutjnl-2012-303615.
Cleary BJ, Källén B. Early pregnancy azathioprine use and pregnancy outcomes. Birth Defects Res A Clin Mol Teratol 2009; 85(7): 647–654. doi: 10.1002/ bdra.20583.
Oz BB, Hackman R, Einarson T et al. Pregnancy outcome after cyclosporine therapy during pregnancy: a meta-analysis. Transplantation 2001; 71(8): 1051–1055. doi: 10.1097/ 00007890-20010427 0-00006.
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(6): 589–592. doi: 10.1016/ 0002-9343(90)90522-f.
Grosen A, Kelsen J, Hvas CL et al. The influence of methotrexate treatment on male fertility and pregnancy outcome after paternal exposure. Inflamm Bowel Dis 2017; 23(4): 561–569. doi: 10.1097/ MIB.0000000000001064.
Shannahan SE, Erlich JM, Peppercorn MA. Insights into the treatment of inflammatory bowel disease in pregnancy. Therap Adv Gastroenterol 2019; 12: 1756284819852231. doi: 10.1177/ 1756284819852231.
Schnitzler F, Fidder H, Ferrante M et al. Outcome of pregnancy in women with inflammatory bowel disease treated with antitumour necrosis factor therapy. Inflamm Bowel Dis 2011; 17(9): 1846–1854. doi: 10.1002/ ibd.21583.
Restellini S, Biedermann L, Hruz P et al. Update on the management of inflammatory bowel disease during pregnancy and breastfeeding. Digestion 2020; 101(Suppl 1): 27–42. doi: 10.1159/ 000502886.
Mahadevan U, Martin CF, Sandler RS, et al. PIANO: a 1000 patient prospective registry of pregnancy outcomes in women with ibd exposed to immunomodulators and biologic therapy. Gastroenterology 2012; 142(5): S-149. doi: 10.1016/ S0016-5085(12)60561-7.
Duricova D, Dvorakova E, Hradsky O et al. Safety of anti-TNF-alpha therapy during pregnancy on long-term outcome of exposed children: a controlled, multicenter observation. Inflamm Bowel Dis 2019; 25(4): 789–796. doi: 10.1093/ ibd/ izy294.
Zelinkova Z, van der Ent C, Bruin KF et al. Effects of discontinuing anti-tumour necrosis factor therapy during pregnancy on the course of inflammatory bowel disease and neonatal exposure. Clin Gastroenterol Hepatol 2013; 11(3): 318–321. doi: 10.1016/ j.cgh.2012.10.024.
Aratari A, Margagnoni G, Koch M et al. Intentional infliximab use during pregnancy for severe steroid-refractory ulcerative colitis. J Crohns Colitis 2011; 5(3): 262. doi: 10.1016/ j.crohns.2011.02.004.
AlAmeel T, Al Sulais E. Ustekinumab and pregnancy: continue or cease before you conceive? Gastroenterology 2019; 157(5): 1435. doi: 10.1053/ j.gastro.2019.05.077.
Geldhof A, Volger S, Lin CB et al. Pregnancy outcomes in women with psoriasis, psoriatic arthritis, Crohn’s disease and ulcerative colitis treated with ustekinumab. J Am Acad Dermatol 2020; 83(Suppl 6): AB74. doi: 10.1016/ j.jaad.2020.06.382.
Bar-Gil Shitrit A, YaʼAcov AB, Livovsky DM et al. Exposure to vedolizumab in IBD pregnant women appears of low risk for mother and neonate: a first prospective comparison study. Am J Gastroenterol 2019; 114(7): 1172–1175. doi: 10.14309/ ajg.0000000000000186.
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(1): 129–138. doi: 10.1111/ apt.15539.
SÚKL. Xeljanz. 2021 [online]. Available from: https:/ / www.sukl.cz/ modules/ medication/ detail.php?kod=0238764.
Magro F, Gionchetti P, Eliakim R et al. ECCO. Third European evidence-based consensus on diagnosis and management of ulcerative colitis. Part 1: definitions, diagnosis, extra-intestinal manifestations, pregnancy, cancer surveillance, surgery, and ileo-anal pouch disorders. J Crohns Colitis 2017; 11(6): 649–670. doi: 10.1093/ ecco-jcc/ jjx008.
Koželuhová J, Balihar K, Janská E et al. Terapie idiopatických střevních zánětů v graviditě. Interní Med 2015; 17(5): 218–222.
Maaser C, Sturm A, Vavricka RS et al. ECCO-ESGAR guideline for diagnostic assessment in IBD part 1: initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis 2019; 13(2): 144–164. doi: 10.1093/ ecco-jcc/ jjy113.
Uffmann M, Schaefer-Prokop C. Digital radiography: the balance between image quality and required radiation dose. Eur J Radiol 2009; 72(2): 202–208. doi: 10.1016/ j.ejrad.2009.05.060.
Válek V, Zbořil V, Hep A et al. Tenké střevo – radiologická diagnostika patologických stavů. 1. vyd. Brno: NCONZO 2003: 61–68.
Jaffe TA, Miller CM, Merkle EM. Practice patterns in imaging of the pregnant patient with abdominal pain: a survey of academic centers. AJR Am J Roentgenol 2007; 189(5): 1128–1134. doi: 10.2214/ AJR.07.2277.
Patenaude Y, Pugash D, Lim K et al. Diagnostic Imaging Committee. Society of Obstetricians and Gynaecologists of Canada. The use of magnetic resonance imaging in the obstetric patient. J Obstet Gynaecol Can 2014; 36(4): 349–363. doi: 10.1016/ s1701-2163(15)30612-5.
Ray JG, Vermeulen MJ, Bharatha A et al. Association between MRI exposure during pregnancy and fetal and childhood outcomes. JAMA 2016; 316(9): 952–961. doi: 10.1001/ jama.2016.12126.
Ilnyckyji A, Blanchard JF, Rawsthorne P et al. Perianal Crohn’s disease and pregnancy: role of the mode of delivery. Am J Gastroenterol 1999; 94(11): 3274–3278. doi: 10.1111/ j.1572-0241.1999.01537.x.
Brandt LJ, Estabrook SG, Reinus JF. Results of a survey to evaluate whether vaginal delivery and episiotomy lead to perineal involvement in women with Crohn’s disease. Am J Gastroenterol 1995; 90(11): 1918–1922.
Beniada A, Benoist G, Maurel J et al. Inflammatory bowel disease and pregnancy: report of 76 cases and review of the literature. J Gynecol Obstet Biol Reprod (Paris) 2005; 34(6): 581–588. doi: 10.1016/ s0368-2315(05)82883-2.
van Assche G, Dignass A, Reinisch W et al. The second European evidence-based consensus on the diagnosis and management of Crohn’s disease: special situations. J Crohns Colitis 2010; 4(1): 63–101. doi: 10.1016/ j.crohns.2009.09.009.
Kitayama T, Funayama Y, Fukushima K et al. Anal function during pregnancy and postpartum after ileal pouch anal anastomosis for ulcerative colitis. Surg Today 2005; 35(3): 211–215. doi: 10.1007/ s00595-004-2926-y.
Remzi FH, Gorgun E, Bast J et al. Vaginal delivery after ileal pouch-anal anastomosis: a word of caution. Dis Colon Rectum 2005; 48(9): 1691–1699. doi: 10.1007/ s10350-005-0124-7.
Hahnloser D, Pemberton JH, Wolff BG et al.Pregnancy and delivery before and after ileal pouch-anal anastomosis for inflammatory bowel disease: immediate and long-term consequences and outcomes. Dis Colon Rectum 2004; 47(7): 1127–1135. doi: 10.1007/ s10350-004-0569-0.
Lepistö A, Sarna S, Tiitinen A et al. Female fertility and childbirth after ileal pouch-anal anastomosis for ulcerative colitis. Br J Surg 2007; 94(4): 478–482. doi: 10.1002/ bjs.5509.
Hill J, Clark A, Scott NA. Surgical treatment of acute manifestations of Crohn’s disease during pregnancy. J R Soc Med 1997; 90(2): 64–66. doi: 10.1177/ 014107689709000203.
Adamina M, Bonovas S, Raine T et al. ECCO guidelines on therapeutics in Crohn’s disease: surgical treatment. J Crohns Colitis 2020; 14(2): 155–168. doi: 10.1093/ ecco-jcc/ jjz187.
Kizer NT, Powell MA. Surgery in the pregnant patient. Clin Obstet Gynecol 2011; 54(4): 633–641. doi: 10.1097/ GRF.0b013e318236eb0d.
Germain A, Brunaud L. Visceral surgery and pregnancy. J Visc Surg 2010; 147(3): e129–e135. doi: 10.1016/ j.jviscsurg.2010.07.005.
Pearl J, Price R, Richardson W et al. Society of American Gastrointestinal Endoscopic Surgeons. Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc 2011; 25(11): 3479–3492. doi: 10.1007/ s00464-011-1927-3.
Yakasai IA, Bappa LA. Diagnosis and management of adnexal masses in pregnancy. J Surg Tech Case Rep 2012; 4(2): 79–85. doi: 10.4103/ 2006-8808.110249.
Kunovsky L, Kala Z, Mitas L et al. Rare cases imitating acute appendicitis: three case reports and a review of literature. Rozhl Chir 2017; 96(2): 82–87.
Kirshtein B, Perry ZH, Avinoach E et al. Safety of laparoscopic appendectomy during pregnancy. World J Surg 2009; 33(3): 475–480. doi: 10.1007/ s00268-008-9890-4.
Corneille MG, Gallup TM, Bening T et al. The use of laparoscopic surgery in pregnancy: evaluation of safety and efficacy. Am J Surg 2010; 200(3): 363–367. doi: 10.1016/ j.amjsurg.2009.09.022.
Sadot E, Telem DA, Arora M et al. Laparoscopy: a safe approach to appendicitis during pregnancy. Surg Endosc 2010; 24(2): 383–389. doi: 10.1007/ s00464-009-0571-7.
Walker HG, Al Samaraee A, Mills SJ et al. Laparoscopic appendicectomy in pregnancy: a systematic review of the published evidence. Int J Surg 2014; 12(11): 1235–1241. doi: 10.1016/ j.ijsu.2014.08.406.
Toiyama Y, Araki T, Yoshiyama S et al. Fulminant ulcerative colitis during pregnancy successfully treated by three-stage operation. J Gastroenterol 2004; 39(3): 300–301. doi: 10.1007/ s00535-003-1295-4.
Quddus A, Martin-Perez B, Schoonyoung H et al. Toxic megacolon during pregnancy in ulcerative colitis: a case report. Int J Surg Case Rep 2015; 11: 83–86. doi: 10.1016/ j.ijscr.2015.04.033.
Germain A, Chateau T, Beyer-Berjot L et al. Surgery for Crohn΄s disease in pregnancy: a nationwide survey. United European Gastroenterol J 2020; 8(6):736–740. doi: 10.1177/ 2050 640620921060.
Selinger CP, Leong RW, Lal S. Pregnancy related issues in inflammatory bowel disease: evidence base and patients’ perspective. World J Gastroenterol 2012; 18(21): 2600–2608. doi: 10.3748/ wjg.v18.i21.2600.
Biedermann L, Rogler G, Vavricka SR et al. Pregnancy and breastfeeding in inflammatory bowel disease. Digestion 2012; 86(Suppl 1): 45–54. doi: 10.1159/ 000341941.
Šerclová Z, Ryska O, Bortlík M et al. Doporučené postupy chirurgické léčby pacientů s idiopatickými střevními záněty – 2. část: Crohnova nemoc. Gastroent Hepatol. 2015; 69(3): 223–238. doi: 10.14735/ amgh2015223.
Kunovsky L, Marek F, Kala Z et al. Possibilities of minimally invasive surgery in patients with Crohn’s disease and ulcerative colitis. Gastroent Hepatol 2017; 71(1): 29–35. doi: 10.14735/ amgh201729.
Marek F, Kunovsky L, Grolich T et al. Acute abdomen in patients with Crohn’s disease case reports. Rozhl Chir 2019; 98(1): 31–34.
Visser BC, Glasgow RE, Mulvihill KK et al. Safety and timing of nonobstetric abdominal surgery in pregnancy. Dig Surg 2001; 18(5): 409–417. doi: 10.1159/ 000050183.
Kunovsky L, Hemmelova B, Kala Z et al. Crohn disease and pregnancy: a case report of an acute abdomen. Int J Colorectal Dis 2016; 31(8): 1493–1494. doi: 10.1007/ s00384-016-2554-1.
Porter H, Seeho S. Obstructed ileostomy in the third trimester of pregnancy due to compression from the gravid uterus: diagnosis and management. BMJ Case Rep 2014; 2014: bcr2014205884. doi: 10.1136/ bcr-2014-205884.
Spring A, Lee M, Patchett S et al. Ileostomy obstruction in the third trimester of pregnancy. Colorectal Dis 2012; 14(9): e631–e632. doi: 10.1111/ j.1463-1318.2012.02972.x.
Bemelman WA, Warusavitarne J, Sampietro GM et al. ECCO-ESCP consensus on surgery for Crohn΄s disease. J Crohns Colitis 2018; 12(1): 1–16. doi: 10.1093/ ecco-jcc/ jjx061.
Rogler G. Chronic ulcerative colitis and colorectal cancer. Cancer Lett 2014; 345(2): 235–241. doi: 10.1016/ j.canlet.2013.07.032.
Ross H, Steele SR, Varma M et al. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum 2014; 57(1): 5–22. doi: 10.1097/ DCR.0000000000000030.
Šerclová Z, Ryska O, Bortlík M et al. Doporučené postupy chirurgické léčby pacientů s idiopatickými střevními záněty – 3. část: ulcerózní kolitida. Gastroent Hepatol 2016; 70(3): 252–261. doi: 10.14735/ amgh2015252.
Teeuwen PH, Stommel MW, Bremers AJ et al. Colectomy in patients with acute colitis: a systematic review. J Gastrointest Surg 2009; 13(4): 676–686. doi: 10.1007/ s11605-008-0792-4.