Z Geburtshilfe Neonatol 2007; 211(6): 215-223
DOI: 10.1055/s-2007-981336
Übersicht

© Georg Thieme Verlag Stuttgart · New York

Management der gastroösophagealen Refluxkrankheit (GERD) in der Schwangerschaft

Handling of the Gastroesophageal Reflux Disease (GERD) during Pregnancy - A ReviewS. Fill1 , M. Malfertheiner2 , S.-D. Costa1 , K. Mönkemüller3
  • 1Klinik für Gynäkologie und Geburtshilfe, Otto-von-Guericke Universität, Magdeburg, Deutschland
  • 2Gastric Pathobiology Research Group, GI Surigical Division, Yale University, USA
  • 3Klinik für Gastroenterologie, Hepatologie und Infektiologie, Otto-von-Guericke Universität, Magdeburg, Deutschland
Further Information

Publication History

2007

2007

Publication Date:
02 January 2008 (online)

Zusammenfassung

Die gastroösophageale Refluxkrankheit (engl. gastroesophageal reflux disease, GERD) tritt in der Schwangerschaft bei mehr als 50 % der Frauen auf. Oftmals wird GERD als schwangerschaftsimmanente Erscheinung interpretiert. Inadäquat oder nicht behandelt kann GERD die Lebensqualität der Schwangeren erheblich beeinträchtigen. Hauptursache für GERD in der Schwangerschaft ist ein Abfall des unteren Ösophagussphinktertonus, hervorgerufen durch schwangerschaftsbedingte Veränderungen der Sexualhormone, insbesondere Progesteron. Das häufigste Symptom der GERD ist Sodbrennen. Schwere Komplikationen von GERD (z. B. erosive Ösophagitis) während der Schwangerschaft sind selten beschrieben. Symptomatische GERD in der Schwangerschaft sollte entsprechend einem „Step-up”-Algorithmus behandelt werden, beginnend mit spezifischen Verhaltensregeln und Veränderungen des Essverhaltens. Medikamente der ersten Wahl sind Antazida. Wenn die Symptome persistieren, stehen Histamin2-Rezeptorantagonisten zur Verfügung. Protonenpumpen-Inhibitoren (PPI) sind laut einem europäischen Konsensusmeeting 2003 in der Schwangerschaft nicht empfohlen. PPIs sollten daher nur Frauen mit persistierenden Symptomen und komplizierter GERD vorbehalten bleiben. Die GERD-Symptomatik bessert sich nach der Entbindung, über die Spätfolgen bzw. den Einfluss auf nachfolgende Schwangerschaften ist wenig bekannt. Daher wird zurzeit eine prospektive Studie (longitudinale Kohortenanalyse) durchgeführt.

Abstract

Gastroesophageal reflux disease (GERD) is common during pregnancy. The pathogenesis is a decrease in lower oesophageal sphincter pressure caused by female sex hormones, especially progesterone. The most common symptom of GERD is heartburn. Nevertheless, serious reflux complications during pregnancy are rare. In contrast to non-pregnant patients, GERD during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line on-demand drug therapy. If symptoms persist, any of the histamine-2-receptor antagonists can be used. Proton pump inhibitors are reserved for women with intractable symptoms or complicated reflux disease. Usually, heartburn during pregnancy resolves soon after delivery but little is known about the late sequelae or, respectively, an influence on subsequent pregnancies. Accordingly a prospective study (longitudinal cohort analysis) is currently underway.

Literatur

  • 1 El-Dika S, Guyatt G H, Armstrong D, Degl'innocenti A, Wiklund I, Fallone C A, Tanser L, Veldhuyzen van Zanten S, Heels-Ansdell D. The impact of illness in patients with moderate to severe gastroesophageal reflux disease.  BMC Gastroenterol. 2005;  10 23
  • 2 Bassey O O. Pregnancy heartburn in Nigerians and Caucasians with theories about aetiology based on manometric recordings from the oesophagus and stomach.  Br J Obstet Gynaecol. 1977;  84 439-443
  • 3 Marchand P. The gastroesophageal sphincter and the mechanism of regurgitation.  Br J Surg. 1955;  42 504-513
  • 4 Castro L de P. Reflux esophagitis as the cause of heartburn in pregnancy.  Am J Obstet Gynecol. 1967;  98 1-10
  • 5 Marrero J M, Goggin P M, de Caestecker J S, Pearce J M, Maxwell J D. Determinants of pregnancy heartburn.  Br J Obstet Gynaecol. 1992;  99 731-734
  • 6 Bainbridge E T, Temple J G, Nicholas S P, Newton J R, Boriah V. Symptomatic gastroesophageal reflux in pregnancy. A comparative study of white Europeans and Asians in Birmingham.  Br J Clin Pract. 1983;  37 53-57
  • 7 Vakil N, van Zanten S V, Kahrilas P, Dent J, Jones R. Global Consensus Group . The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus.  Am J Gastroenterol. 2006;  101 1900-1920
  • 8 Ronkainen J, Aro P, Storskrubb T, Johansson S E, Lind T, Bolling-Sternevald E, Graffner H, Vieth M, Stolte M, Engstrand L, Talley N J, Agreus L. High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population: a Kalixanda study report.  Scand J Gastroenterol. 2005;  40 275-285
  • 9 Fass R. Distinct phenotypic presentations of gastroesophageal reflux disease: a new view of the natural history.  Dig Dis. 2004;  22 100-107
  • 10 Poelmans J, Feenstra L, Demedts I, Rutgeerts P, Tack J. The yield of upper gastrointestinal endoscopy in patients with suspected reflux-related chronic ear, nose, and throat symptoms.  Am J Gastroenterol. 2004;  99 1419-1426
  • 11 Wong W M, Lai K C, Lam K F, Hui W M, Hu W H, Lam C L, Xia H H, Huang J Q, Chan C K, Lam S K, Wong B C. Prevalence, clinical spectrum and health care utilization of gastro-oesophageal reflux disease in a Chinese population: a population-based study.  Aliment Pharmacol Ther. 2003;  18 595-604
  • 12 Labenz J, Jaspersen D, Kullig M, Leodolter A, Lind T, Meyer-Sabelek W, Stolte M, Vieth M, Willich S, Malfertheiner P. Risk factors for erosive esophagitis: a multivariate analysis based on the ProGERD study initiative.  Am J Gastroenterol. 2004;  99 1652-1656
  • 13 Lundell L R, Dent J, Bennett J R, Blum A L, Armstrong D, Galmiche J P, Johnson F, Hongo M, Richter J E, Spechler S J, Tytgat G N, Wallin L. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification.  Gut. 1999;  45 172-180
  • 14 Richter J E. Dysphagia, Odynophagia, Heartburn, and other Esophageal Symptoms. In: Feldmann M, Scharschmidt BF, Sleisenger MH (eds). Sleisenger & Fordtrans Gastrointestinal and Liver Disease. 6th ed. Saunders, Philadelphia 1998; 97-105
  • 15 Kahrilas P J. Gastroesophageal Reflux Disease and its Complications. In: Feldmann M, Schaarschmidt BF, Sleisenger MH (eds). Sleisenger & Fordtrans Gastrointestinal and Liver Disease. 6th ed. Saunders, Philadelphia 1998; 498-517
  • 16 Revicki D A, Crawley J A, Zodet M W. et al . Complete resolution of heartburn symptoms and health-related quality of life in patients with gastro-esophageal reflux disease.  Alim Pharmacol Ther. 1999;  13 1621-1630
  • 17 Kulig M, Leodolter, Vieth M, Schulte E, Jaspersen D, Labenz J, Lind T, Meyer-Sabellek W, Malfertheiner P, Stolte M, Willich S N. Quality of life in relation to symptoms in patients with gastroesophageal relfux disease - an analyisis based on the ProGERD initiative.  Alim Pharmacol Ther. 2003;  18 767-776
  • 18 Van Thiel D H, Wald A. Evidence refuting a role for increased abdominal pressure in the pathogenesis of the heartburn associated with pregnancy.  Am J Obstet Gynecol. 1981;  140 420-422
  • 19 Richter J E. Gastroesophageal reflux disease during pregnancy.  Gastroenterol Clin North Am. 2003;  32 135-161
  • 20 Fisher R S, Robert G S, Grabowski C J. et al . Altered lower esophageal sphinkter function during early pregnancy.  Gastroenterology. 1978;  74 1233-1237
  • 21 Van Thiel D H, Gavaler J S, Joshi S N. et al . Heartburn of pregnancy.  Gastroenterology. 1977;  72 668-678
  • 22 Nagler R, Spiro H M. Heartburn in the late pregnancy: manometric studies of esophageal motor function.  J Clin Invest. 1961;  40 945-970
  • 23 Al-Amri S M. Twenty-four hour pH monitoring during pregnancy and at postpartum.  Eur J Obstet Gynecol Reprod Biol. 2002;  102 127-130
  • 24 Fisher R S, Roberts G S, Grabowski C J, Cohen S. Inhibition of lower esophageal sphincter circular muscle by female sex hormones.  Am J Physiol. 1978;  234 E243-E247
  • 25 Van Thiel D H, Gavaler J S, Stremple J. Lower esophageal sphincter pressure in women using sequential oral contraceptives.  Gastroenterology. 1976;  71 232-234
  • 26 Schulze K, Christensen J. Lower sphincter of the opossum esophagus in pseudopregnancy.  Gastroenterology. 1977;  73 1082-1085
  • 27 Alvarez-Sanches A, Rey E, Achem S R, Diaz Rubio M. Does progesterone fluctuation across the menstrual cycle predispose to gastrooesophageal reflux?.  Am J Gastroenterol. 1999;  94 1468-1471
  • 28 Mohiuddin M A, Pursnani K G, Katzka D A, Castell J A, Castell D O. Effect of cyclic hormonal changes during normal menstrual cycle on esophageal motility.  Dig Dis Sci. 1999;  44 1368-1375
  • 29 Fillipone M, Malmud L, Kryston L, Antonucci J, Bottger J, Fisher R S. Esophageal and LES pressure in male transsexuals treated with female sex hormons.  Clin Res. 1983;  3 282A
  • 30 Lind J F, Smith A M, McKiver D K. et al . Heartburn in pregnancy - a manometry study.  CMAJ. 1968;  98 571-574
  • 31 Baron T H, Richter J E. Gastroesophageal Reflux Disease in Pregnancy.  Gastroenterol Clin North Am. 1992;  21 777-791
  • 32 Torbey C F, Richter J E. Esophageal Disorders During Pregnancy.  Pract Gastroenterol. 1995;  19 22-36
  • 33 Olans L B, Wolf J L. Gastroesophageal Reflux in Pregnancy.  Gastrointest Endosc Clin North Am. 1994;  4 699-712
  • 34 Dollinger H C. Sodbrennen in der Schwangerschaft.  Apotheken Journal. 1994;  16 25-28
  • 35 Miller P L. General Practitioner Management of Gastroenterological Problems in Pregnancy.  J Int Med Res. 1978;  6 6-10
  • 36 Leite L P, Johnston B T, Garrett J. et al . Nonspecific esophageal motility disorder is primarily ineffective esophageal motility: is it associated with abnormal recumbent acid exposure?.  Dig Dis Sci. 1997;  42 1859-1865
  • 37 Ulmsten U, Sundstrom G. Esophageal manometry in pregnant and nonpregnant women.  Am J Obstet Gynecol. 1978;  132 260-264
  • 38 Schade R R, Pelekans M J, Tauxe W N. et al . Gastric emptying during pregnancy.  Gastroenterology. 1984;  86 1234A
  • 39 Müller-Lissner S, Karbach U. Gastroenterologische Erkrankungen und Schwangerschaft.  Internist. 1992;  33 472-479
  • 40 Feeney J G. Heartburn in Pregnancy.  BMJ. 1982;  284 1138-1139
  • 41 Vanner R G, Goodman N W. Gastro-Oesophageal reflux in pregnancy at term and after delivery.  Anaesthesia. 1989;  44 808-811
  • 42 Knudsen A, Lebech M, Hansen M. Upper gastrointestinal symptoms in the third trimester of the normal pregnancy.  Eur J Obstet Gynecol Reprod Biol. 1995;  60 29-33
  • 43 Klauser A G, Schindlbeck N E, Müller-Lissner S A. Symptoms in gastroesophageal reflux desease.  Lancet. 1990;  335 265-268
  • 44 Capell M S. The safety and efficacy of gastrointestinal endoscopy during pregnancy.  Gastroenterol Clin North Am. 1998;  27 37-71
  • 45 Rustgi V K, Cooper J N, Colcher H. Endoscopy in the pregnant patient. In: Rustgi VK, Cooper JN (eds). Gastrointestinal and hepatic complications of pregnancy. Churchill Livingstone, New York 1986; 104-123
  • 46 Bainbridge E T, Nicholas S D, Newton J R, Temple J G. Gastro-oesophageal reflux in pregnancy. Altered function of the barrier to reflux in asymptomatic women during early pregnancy.  Scand J Gastroenterol. 1984;  19 85-89
  • 47 Hey W M, Cowley D J, Ganguli P C, Skinner L D, Ostick D G, Sharp D S. Gastro-oesophageal reflux in late pregnancy.  Anaesthesia. 1977;  32 372-377
  • 48 Hart D M. Heartburn in Pregnancy.  J Int Med Res. 1978;  1 1-5
  • 49 Broussard S N, Richter J E. Treating gastro-esophageal reflux disease during pregnancy and lactation. What are the saftest therapie options?.  Drug Saf. 1998;  4 325-327
  • 50 Lewis J H, Weingold A B. The committee on FDA-related matters for the American college of Gastroenterology . The use of gastrointestinal drugs during pregnancy and lactation.  Am J Gastroenterol. 1985;  80 912-923
  • 51 Niebly J R. Terontology and drug use during pregnancy and lactation. In: Scott JR, Isaia PD, Hammond C et al. (eds). Dansforth's obstetrics and gynecology. 7th edition. Saunders, Philadelphia 1994; 225-244
  • 52 Witten F P, King T M, Blake O. The effects of chronic gastrointestinal medication on the fetus and neonate.  Obstet Gynecol. 1981;  58 79S-84S
  • 53 Ching C, Lam S. Antacids: indications and limitations.  Drugs. 1994;  47 305-317
  • 54 Tytgat G N, Heading R C, Muller-Lissner S, Kamm M A, Scholmerich J, Berstad A, Fried M, Chaussade S, Jewell D, Briggs A. Contemporary understanding and management of reflux and constipation in the general population and pregnancy: a consensus meeting.  Aliment Pharmacol Ther. 2003;  18 291-301
  • 55 Lindow S W, Regnell P, Sykes J, Little S. An open-label, multicentre study to assess the safety and efficacy of a novel reflux suppressant (Gaviscon Advance) in the treatment of heartburn during pregnancy.  Int J Clin Pract. 2003;  57 175-179
  • 56 Ranchet G, Gangemi O, Petrone M. Sucralfat in the treatment of gravid pyrosis.  G Ital Obstet Ginecol. 1990;  12 1-16
  • 57 Briggs G G, Freeman R Y, Yaffe S J. Drugs in Pregnancy and Lactation: A Reference Guid to Fetal and Neonatal Risk. William and Wilkins, Baltimore, USA 2002
  • 58 Yokal R A, McNamara P J. Aluminium bioavailability ans disposition adults and immature rabbits.  Toxicol Appl Pharmacol. 1985;  77 344-352
  • 59 Greenberger N J, Arvanitakis C, Hurwitz A. Drug treatment of gastrointestinal disorders. Chapter 1: Antacids and gastric antisecretory drugs. Churchill Livingstone, New York, Edinburgh, London 1978; 1-41
  • 60 Berkovich M, Elbirt D, Addis A. et al . Fetal affects of metoclopramide therapy for nausea and vomiting of pregnancy.  N Engl J Med. 2000;  343 445-446
  • 61 Larson J D, Patatanian E, Miner P B. et al . Double-blind, placebo-controlled study af ranitidine for gastroesophageal reflux symptoms during pregnancy.  Obstet Gynecol. 1997;  90 83-87
  • 62 Finkelstein W, Isselbacker K J. Cimetidine.  N Engl J Med. 1978;  229 992-996
  • 63 Parker S, Schade R R. et al . Prenatal and neonatal exposure of male rat pups to cimetidine but not ranitidine adversely affects subsequent adult sexual functioning.  Gastroenterology. 1984;  86 675-680
  • 64 Magee L A, Inocencian G, Kamboijt R. et al . Safety of first trimester exposure to histamine H2blockers. A prospective cohort study.  Dig Dis Sci. 1996;  41 1145-1149
  • 65 Smallwood R A. et al . Safety of acid-suppressing drugs.  Dig Dis Sci. 1995;  40 (Suppl) 63S-80S
  • 66 Savarino V, Giasti M, Scalabrini P. et al . Famotidine has no significant affect an gonadal function in men.  Gastroenterol Clin Biol. 1988;  12 19-22
  • 67 Morton D M. Pharmacology and toxicity of nizatidine.  Scand J Gastroenterol. 1987;  22 (Suppl. 136) 1-8
  • 68 Neubauer B L, Goode R L, Bert K K. et al . Endocrine affects af a new histamine H2 receptor antagonist, nizatidine in the male rat.  Toxicol Appl Pharmacol. 1990;  102 219-232
  • 69 Tytgat G N, Heading R C, Müller-Lissner S. et al . Contemporary understanding and management of reflux and constipation in the general population and pregnancy: a consensus meeting.  Aliment Pharmacol Ther. 2003;  18 291-301
  • 70 Richter J E. Gastroesophageal reflux disease during pregnancy.  Gastroenterol Clin North Am. 2003;  32 135-161
  • 71 Anonymous .Prilosec (product information). Astra-Zeneca, Wilmington, DE, USA 2004
  • 72 Harper M A, McVeigh J E, Thompson W. et al . Successful pregnancy in association with Zollinger-Ellison Syndrome.  Am J Obstet Gynecol. 1995;  173 863-864
  • 73 Brunner G, Meyerr H, Athmann C. Omeprazole for peptic ulcer disease in pregnancy.  Digestion. 1998;  59 651-654
  • 74 Wilton L V, Pearce G L, Martin R M. et al . The outcomes of pregnancy in women exposed to newly marketed drugs in general practice in England.  Br J Obstet Gynaecol. 1998;  105 882-889
  • 75 Nikfar S, Abdollahi M. et al . Use of proton pump inhibitors during pregnancy and rates of major malformations. A meta-analysis.  Dig Dis Sci. 2002;  47 1526-1529
  • 76 Nielson G L, Sorensen H T. et al . The safety of proton pump inhibitors in pregnancy.  Aliment Pharmacol Ther. 1999;  13 1085-1089
  • 77 Larkin A, Loebstein R. et al . The safety of omeprazole during pregnancy: a multicenter prospective controlled study.  Am J Obstet Gynecol. 1998;  179 727-730
  • 78 Kalle B. Delivery outcome after the use of acid-suppressing drugs in early pregnancy with special reference to omeprazole.  Br J Obstet Gynaecol. 1998;  105 877-881
  • 79 Ruigomez A, Rodriguez L AG. et al . Use of cimetidine, omeprazole, and ranitidine in pregnant women and pregnancy outcomes.  Am J Epidemiol. 1999;  150 476-481
  • 80 Anonymous .Prevacid (product information). TAP Pharmaceutical, Lake Forest, IL, USA 2005
  • 81 Somogyi A, Gugler R. Cimetidine excretion in breast milk.  Br J Clin Pharmacol. 1979;  7 627-629
  • 82 Courtney T P, Shaw R W, Cedar E. et al . Excretion of famotidine in breast milk.  Br J Clin Pharmacol. 1988;  26 639
  • 83 Obermeyer B D, Bergstrom P F, Callagher J T. et al . Secretion of nizatidine into human breast milk after single and multiple doses.  Clin Pharmacol Ther. 1990;  47 724-730
  • 84 Physician Desk Reference. 58th edn. Medical Economics, Montvale, NJ, USA 2002
  • 85 Committee on Drugs. American Academy of Pediatrics . The transfer of drugs and other chemicals into human milk.  Pediatrics. 1994;  93 137-150
  • 86 Marshall J K, Thompson A BR, Armstrong D. Omeprazole for refractory gastroesophageal reflux disease during pregnancy and lactation.  Can J Gastroenterol. 1998;  12 225-227
  • 87 Anonymous .Rabeprazole (product information). Eisai, Teaneck, NJ, USA 2004

Dr. med. univ. S. Fill

Otto-von-Guericke-Universität · Klinik für Gynäkologie und Geburtshilfe

Gerhart-Hauptmann-Str. 35

39108 Magdeburg

Phone: 03 91 / 6 71 73 10

Fax: 03 91 / 6 71 73 11

Email: sara.fill@medizin.uni-magdeburg.de

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