How does pregnancy affect asthma symptoms. What are the potential complications of asthma during pregnancy. Are asthma medications safe for pregnant women. How can expectant mothers manage their asthma effectively.

Understanding Asthma Changes During Pregnancy

Pregnancy can have varying effects on asthma symptoms. Approximately one-third of pregnant women with asthma experience worsening symptoms, another third see no change, and the remaining third actually find their asthma improves. These changes typically revert to pre-pregnancy conditions within three months after giving birth.

Interestingly, the pattern of asthma changes during one pregnancy often repeats in subsequent pregnancies. However, predicting these changes remains challenging, emphasizing the importance of close monitoring and collaboration between expectant mothers and their healthcare team.

Why does asthma severity change during pregnancy?

The exact reasons for changes in asthma severity during pregnancy are not fully understood. Hormonal fluctuations, increased blood volume, and changes in lung function may all play a role. Some women may also experience increased sensitivity to asthma triggers during pregnancy.

Potential Complications of Asthma in Pregnancy

While asthma is a common medical concern during pregnancy, it can lead to potential complications if not properly managed. These may include:

• Slightly increased risk of preterm labor and delivery
• High blood pressure and pre-eclampsia
• Low birth weight (less than 5 pounds, 8 ounces)

It’s important to note that the direct causality between asthma and these complications is not firmly established. However, maintaining good asthma control during pregnancy may help reduce the risk of these issues.

How does uncontrolled asthma affect the fetus?

Uncontrolled asthma can reduce oxygen levels in the mother’s blood, consequently affecting the oxygen supply to the fetus. This oxygen deprivation may impair fetal growth and development. Research indicates that well-controlled asthma during pregnancy can reduce the risk of fetal or newborn death and improve intrauterine growth.

Strategies for Managing Asthma During Pregnancy

Effective asthma management during pregnancy is crucial for the health of both mother and baby. Here are some key strategies:

1. Avoid asthma triggers
2. Stay away from people with respiratory infections
3. Reduce exposure to allergens (dust mites, animal dander, pollen, mold, cockroaches)
4. Quit smoking and avoid secondhand smoke
5. Engage in regular, doctor-approved exercise
6. Use quick-relief medication before exercise if recommended

Is swimming beneficial for pregnant women with asthma?

Swimming is often considered an excellent exercise option for people with asthma, including pregnant women. The humid environment of indoor pools can help keep airways moist, potentially reducing asthma symptoms. However, it’s essential to consult with your healthcare provider before starting any new exercise regimen during pregnancy.

Safety of Asthma Medications During Pregnancy

Many asthma medications are considered safe for use during pregnancy. However, your doctor may adjust your treatment plan to ensure the best balance between managing your asthma and protecting your baby’s health.

Which asthma medications are generally considered safe during pregnancy?

While individual cases may vary, the following medications are often considered safe options for pregnant women with asthma:

• Short-acting inhaled bronchodilators
• Anti-leukotriene agents like montelukast (SINGULAIR速)
• Some inhaled corticosteroids, such as budesonide

Long-acting beta-agonists (like SEREVENT速, SYMBICORT速, and ADVAIR速) are not typically first-line treatments for pregnant women but may be considered if other medications fail to provide adequate control.

Are oral steroids safe during pregnancy?

In cases of severe asthma, oral steroids like prednisone may be necessary to ensure the health of both mother and baby. While doctors generally try to minimize the use of oral steroids during pregnancy, the benefits of well-controlled asthma often outweigh the potential risks of the medication.

Allergy Shots and Pregnancy: What You Need to Know

If you’re already receiving allergy shots (immunotherapy) before becoming pregnant, you can usually continue the treatment. However, your allergist may adjust the dosage to reduce the risk of severe allergic reactions.

Should allergy shot doses be increased during pregnancy?

As a precautionary measure, allergists typically avoid increasing allergy shot doses during pregnancy. The dose is usually maintained at the same level or slightly reduced to minimize the risk of adverse reactions. Starting new allergy shot regimens during pregnancy is generally not recommended.

The Importance of Asthma Action Plans During Pregnancy

An Asthma Action Plan is a crucial tool for managing asthma, especially during pregnancy when symptoms may change. This written plan, developed in collaboration with your healthcare provider, outlines daily management strategies and steps to take if asthma symptoms worsen.

How often should an Asthma Action Plan be updated during pregnancy?

It’s advisable to review and update your Asthma Action Plan at least once each trimester, or more frequently if your symptoms or medication needs change. Regular check-ins with your healthcare provider can ensure your plan remains effective throughout your pregnancy.

The Role of Diet in Managing Asthma During Pregnancy

While there’s no specific “asthma diet” for pregnant women, maintaining a healthy, balanced diet can support overall health and potentially help manage asthma symptoms. Some dietary considerations for pregnant women with asthma include:

• Consuming foods rich in vitamins C and E, which may have protective effects against asthma
• Ensuring adequate intake of omega-3 fatty acids, which may help reduce inflammation
• Staying hydrated to help keep airways moist
• Avoiding known food allergens that may trigger asthma symptoms

Can certain foods worsen asthma symptoms during pregnancy?

While individual responses can vary, some women may find that certain foods exacerbate their asthma symptoms. Common culprits include sulfites (found in dried fruits and wine), highly processed foods, and foods high in saturated fats. Keeping a food diary can help identify potential trigger foods.

Monitoring Fetal Health in Asthmatic Pregnancies

For pregnant women with asthma, especially those with more severe or poorly controlled asthma, additional fetal monitoring may be recommended. This can include:

1. More frequent ultrasounds to check fetal growth
2. Non-stress tests to monitor fetal heart rate and movement
3. Biophysical profiles to assess fetal well-being

How does maternal asthma affect fetal movement?

Severe or poorly controlled asthma that leads to reduced oxygen levels in the mother’s blood can potentially affect fetal movement. If you notice a significant decrease in fetal movement, especially during or after an asthma exacerbation, it’s important to contact your healthcare provider immediately.

Labor and Delivery Considerations for Women with Asthma

For most women with well-controlled asthma, labor and delivery proceed normally. However, it’s important to discuss your asthma management plan with your healthcare team in advance. Some considerations include:

• Continuing your regular asthma medications during labor
• Having quick-relief inhalers readily available
• Monitoring oxygen levels during labor
• Discussing pain management options that won’t interfere with asthma control

Can asthma medications affect the course of labor?

Most asthma medications do not interfere with labor or delivery. In fact, maintaining good asthma control can help ensure a smoother labor process. Some bronchodilators may even help relax uterine muscles, potentially easing labor in some cases.

Postpartum Asthma Management

After delivery, many women find that their asthma returns to its pre-pregnancy state within a few months. However, it’s crucial to continue monitoring and managing your asthma during the postpartum period. Some key points to remember include:

1. Continuing to take your asthma medications as prescribed
2. Scheduling a follow-up appointment with your asthma specialist
3. Being aware that stress and lack of sleep common in new motherhood can potentially exacerbate asthma symptoms
4. Discussing the safety of your asthma medications if you plan to breastfeed

Is it safe to breastfeed while taking asthma medications?

Most asthma medications are considered compatible with breastfeeding. The benefits of breastfeeding often outweigh any potential risks from asthma medications. However, it’s important to discuss your specific medication regimen with your healthcare provider to ensure it’s safe for your baby.

Emotional Well-being and Asthma During Pregnancy

Managing a chronic condition like asthma during pregnancy can be stressful. It’s important to address not only the physical aspects of asthma but also the emotional impact. Some strategies to support emotional well-being include:

• Practicing stress-reduction techniques like meditation or prenatal yoga
• Joining support groups for pregnant women with asthma
• Communicating openly with your partner and healthcare team about your concerns
• Seeking professional mental health support if you’re experiencing significant anxiety or depression

How can stress affect asthma during pregnancy?

Stress can potentially worsen asthma symptoms by triggering inflammation in the airways. Additionally, stress may lead to poor adherence to asthma management plans. Learning effective stress management techniques can be beneficial for both asthma control and overall well-being during pregnancy.

Planning for Future Pregnancies with Asthma

If you have asthma and are planning future pregnancies, it’s advisable to discuss your plans with your healthcare provider. Some considerations include:

1. Optimizing asthma control before conception
2. Reviewing your current medications for safety during pregnancy
3. Discussing any changes in asthma severity during previous pregnancies
4. Creating a management plan for the pregnancy and postpartum period

Should asthma medications be adjusted before trying to conceive?

In most cases, it’s recommended to maintain good asthma control with your current medication regimen when trying to conceive. However, your healthcare provider may want to review your medications to ensure they are the safest options for a potential pregnancy. Any necessary adjustments can be made before conception or early in pregnancy.

Managing asthma during pregnancy requires a collaborative effort between the expectant mother and her healthcare team. By maintaining good asthma control, avoiding triggers, and following medical advice, most women with asthma can navigate pregnancy successfully and deliver healthy babies. Remember, the key is to keep your asthma well-controlled, as the benefits of proper asthma management far outweigh the potential risks of medication use during pregnancy.

Asthma During Pregnancy | AAFA.org

Asthma During Pregnancy

Pregnancy is such an exciting and special time for parents-to-be. But women with asthma who are pregnant may worry about how their disease may affect their babies.

Changes in Asthma Severity

About one-third of pregnant women with asthma will see their asthma symptoms get worse. Another third will stay the same. The last third will see their asthma symptoms improve.

Most women with asthma whose symptoms changed in any way during pregnancy will return to their pre-pregnancy condition within three months after giving birth.

If your asthma symptoms increase or decrease during one pregnancy, you may be likely to experience the same thing in later pregnancies. It is difficult to predict how asthma will change during pregnancy.

Because of this uncertainty, work with your doctors to follow your asthma closely. This way, any change can be promptly matched with an appropriate change in treatment. This calls for good teamwork between you, your obstetrician, your primary care physician, and your asthma specialist.

Does Asthma Cause Complications During Pregnancy?

Potential Complications

Asthma is one of the most common medical concerns that occurs during pregnancy. Complications from asthma are possible and may include:

• A small increased risk of preterm (early) labor and delivery
• High blood pressure and a related condition known as pre-eclampsia
• Low birth weight (babies born weighing less than 5 pounds, 8 ounces)

It is not known if asthma is the direct cause of these problems or if other reasons are to blame. Keeping asthma well-controlled may help reduce the chance of complications.

How Does Uncontrolled Asthma Affect the Fetus? 

Uncontrolled asthma reduces the oxygen content of your blood. Since the fetus gets its oxygen from your blood, this can lead to decreased oxygen in the fetal blood. The result may impair fetal growth and survival. The fetus requires a constant supply of oxygen for normal growth and development.

There is evidence that keeping asthma well-controlled during pregnancy reduces the chances of fetal or newborn death. It also improves fetal growth inside the uterus. There are no indications that your asthma contributes to either spontaneous abortion or congenital malformation of the fetus.

What Should I Do to Avoid Asthma Attacks During Pregnancy?

Keep Your Asthma Well-Controlled

Avoiding asthma triggers is always important, but is even more important during pregnancy. Pregnant women with asthma should increase avoidance measures to gain greatest comfort with the least medicine.

• Stay away from people who are sick with respiratory infections.
• Reduce your exposure to allergens like dust mites, animal dander, pollen, mold, and cockroaches

Stop Smoking Cigarettes/Tobacco

Giving up cigarette smoking is important for any pregnant woman. Smoking may worsen asthma and harms the health of the growing fetus as well.

Exercise

Regular exercise is important to health. Talk to your doctor for the best advice about exercising during pregnancy. Swimming is a great exercise for people with asthma. Using quick-relief medicine 10 to 15 minutes before exercise may help you tolerate recommended exercise.

Are Asthma Medicines Safe to Use During Pregnancy?

Is It Safe to Use Asthma Inhalers or Corticosteroids While Pregnant?

During pregnancy, doctors may consider some asthma medicines to be safer than others, so your medicines may change. Work with your doctors to find the best

treatment for you. These include:

• Short-acting inhaled bronchodilators
• Anti-leukotriene agents like montelukast (SINGULAIR®)
• Some inhaled corticosteroids, like budesonide

Long-acting beta agonists (like SEREVENT®, SYMBICORT®, and ADVAIR®) are not considered first-line treatments for pregnant women with asthma. But doctors may consider them if your asthma is not well-controlled by the above medicines.

If your asthma is very severe, oral steroids, such as prednisone, may be necessary for the health of you and baby.

Asthma symptoms may get worse, stay the same, or get better during pregnancy. Talk to your health care provider to make sure the medicines you are taking are still the right choice. Update your Asthma Action Plan as needed.

Remember: It is better for you and your baby if you maintain asthma control (using any approved asthma medicines).

Are Allergy Shots Safe During Pregnancy?

If you are already receiving allergy shots (immunotherapy), you can usually continue if you are not having reactions.

As an extra precaution, though, your allergist may cut the dosage of the allergy extract to reduce the chance of a severe allergic reaction, or at a minimum keep the dose the same. But the dose should not be increased during pregnancy since that increases the chance of a reaction.

Are Flu Shots Safe to Receive During Pregnancy?

People with asthma should get flu (influenza) shots. Pregnancy does not change that recommendation. In fact, the flu may be particularly severe in pregnant women.

Asthma Attacks During Labor

When asthma is under control, asthma attacks almost never occur during labor and delivery. Also, most women with well-controlled asthma are able to perform breathing techniques during their labor without difficulty.

Is It Safe to Breastfeed?

Doctors do not believe asthma medicines are harmful to a nursing baby when used in usual amounts. The transfer of asthma medicines into breast milk has not been fully studied.

When breastfeeding, drinking extra liquids to avoid dehydration is also important (as it is for all people with asthma). Discuss this with your baby’s pediatrician.

Will I Pass On Asthma to My Baby?

Genetics plays a role in whether a baby will develop asthma. In other words, asthma tends to be more likely in a baby if their relatives have it. The environment also plays an important role.

Can I Do Anything to Prevent Asthma in My Baby?

One major prenatal risk factor for the development of asthma is maternal smoking. Giving up cigarette smoking is very important. Other prenatal factors that may influence the development of asthma are:

• Maternal stress
• Diet
• Vitamin D levels
• Antibiotic use
• Method of delivery

Talk to your doctors about identifying your risk factors and making safe changes in preparation for your new baby.

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Medical Review November 2016, update March 2021

References

Subbarao, P., Mandhane, P.J., Sears, M. R. (2009). “Asthma: epidemiology, etiology and risk factors.” CMAJ.  http://www.cmaj.ca/content/181/9/E181.full.pdf+html

Willemsen, G., van Beijsterveldt, T. C.; van Baal, C.G.; et al. (2008). “Heritability of self-reported asthma and allergy: a study in adult Dutch twins, siblings and parents.” Twin Research and Human Genetics. https://www.ncbi.nlm.nih.gov/pubmed/18361713

Holberg, C.J., Elston, R.C., Halonen, M., et al. (1996). “Segregation analysis of physician-diagnosed asthma in Hispanic and non-Hispanic white families. A recessive component?” American Journal of Respiratory and Critical Care Medicine. 1996;154:144–50. [PubMed]

Lawrence, S., Beasley, R., Doull, I., et al. (1994). “Genetic analysis of atopy and asthma as quantitative traits and ordered polychotomies.”  Annals of Human Genetics. 1994;58:359–68. [PubMed]

Fraga, M.F., Ballestar, E., Paz, M.F., et al. (2005). “Epigenetic differences arise during the lifetime of monozygotic twins.”  Proceedings of the National Academy of Sciences of the United States of America. [PMC free article]

Qiu, Jane. (2006). “Epigenetics: unfinished symphony.” Nature.

Camargo Jr, C.A., Rifas-Shiman, S.L., Litonjua, A.A., et al. (2007).  “Maternal intake of vitamin D during pregnancy and risk of recurrent wheeze in children at 3 y of age.” The American Journal of Clinical Nutrition. https://www.ncbi.nlm.nih.gov/pubmed/17344501

Managing asthma in pregnancy

Breathe (Sheff). 2015 Dec; 11(4): 258–267.

Centre for Asthma and Respiratory Disease, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia

Corresponding author.This article has been cited by other articles in PMC.

Abstract

Asthma is a common comorbidity during pregnancy and its prevalence is increasing in the community. Exacerbations are a major clinical problem during pregnancy with up to 45% of women needing to seek medical help, resulting in poor outcomes for mothers and their babies, including low birth weight and preterm delivery. The goals of effective asthma management in pregnancy are to maintain the best possible asthma control and prevent exacerbations. This is achieved by aiming to prevent day- and night-time symptoms, and maintain lung function and normal activity. In addition, maintaining fetal oxygenation is an important consideration in pregnancy. Guidelines recommend providing asthma advice and review prior to conception, and managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for other adults with asthma, and management of comorbid conditions such as rhinitis.

Improvements have been made in recent years in emergency department management of asthma in pregnancy, and multidisciplinary approaches are being proposed to optimise both asthma outcomes and perinatal outcomes. One strategy that has demonstrated success in reducing exacerbations in pregnancy is treatment adjustment using a marker of eosinophilic lung inflammation, the exhaled nitric oxide fraction (F_eNO). The use of an algorithm that adjusted inhaled corticosteroids (ICS) according to F_eNO and added long-acting β-agonists when symptoms remained uncontrolled resulted in fewer exacerbations, more women on ICS but at lower mean doses, and improved infant respiratory health at 12 months of age. Further evidence is needed to determine whether this strategy can also improve perinatal outcomes and be successfully translated into clinical practice.

Key points

• Asthma is the most common chronic disease to affect pregnant women.

• Exacerbations occur in up to 45% of pregnant women with asthma.

• Asthma should be managed during pregnancy as for other adults.

• Treatment adjustment using a marker of airway inflammation reduces the exacerbation rate in pregnancy.

Educational aims

• To identify the goals of and steps associated with effective asthma management in pregnancy.

• To understand the maternal and perinatal risks associated with asthma during pregnancy.

• To describe a management strategy that has been shown to reduce exacerbations in pregnant women with asthma.

Short abstract

Guidelines for the management of asthma during pregnancy exist but are too rarely used in clinical practice
http://ow.ly/U8Sq8

Introduction

Asthma is the most common chronic medical condition to be reported during pregnancy and its prevalence in the population has increased in recent decades. Kwon
et al. [1] reported an increase in the prevalence of asthma during pregnancy from 3.7% in 1997 to 8.4% in 2001. More recent reports from the USA found a prevalence of 5.5% in 2001, increasing to 7.8% in 2007 [2]. A prevalence of 9.3% has been reported in Ireland [3] and 12.7% in Australia [4]. Maternal asthma is associated with an increased risk of adverse perinatal outcomes, and changes in the course of the disease are to be expected and can be unpredictable during pregnancy. Optimising asthma management in pregnancy is paramount for protecting the health of both mother and baby.

Guidelines for the management of asthma during pregnancy

International guidelines are available that outline the goals of successful asthma management and recommendations for clinical management of asthma in pregnancy [5]. Goals include the prevention of chronic day and night symptoms, maintenance of optimal pulmonary function and normal activities, and prevention of exacerbations, using therapies with minimal or no adverse side-effects [5]. During pregnancy, there is the additional goal to maintain fetal oxygenation by preventing episodes of maternal hypoxia [5]. Achieving this requires regular monitoring of clinical symptoms, provision of self-management education and the correct use of pharmacotherapies. Multidisciplinary management by all health professionals involved in a woman’s care is encouraged [5].

A stepwise approach to asthma treatment is recommended during pregnancy as for other adults with asthma [5]. Guidelines recommend the use of short acting β-agonists (SABA) as reliever medication and the use of inhaled corticosteroids (ICS) for women with persistent asthma [5]. There is much reassuring data concerning the safety of ICS medication use in pregnancy, particularly for budesonide, which has the best safety rating during pregnancy. Guidelines recommend the continued use of ICS medication that has been effective in controlling asthma prior to pregnancy [5].

In 2014, the Australian National Asthma Council released updated guidelines for asthma management (www.asthmahandbook.org.au), including a section on pregnancy. These guidelines recommend managing asthma actively during pregnancy, as for asthma in other adults, including prescribing preventers if indicated, and stepping up the regimen as necessary with the goal to maintain the best possible asthma control and avoid exacerbations. Regular review of asthma every 4 weeks during pregnancy is recommended, with asthma control assessed each time. In addition, comorbidities such as rhinitis or gastro-oesophageal reflux, which can contribute to worsening asthma, should be identified and managed. In terms of exacerbations, the Australian guidelines recommend intervening early, providing a written action plan with a low threshold for seeking medical help and ensuring prompt treatment in emergency departments to minimise risks to the fetus. Preconception care is also suggested, with recommendations to offer advice that uncontrolled asthma or asthma exacerbations put both mothers and babies at risk, provide an asthma review prior to conception including performing baseline spirometry, offering a written action plan, smoking cessation advice and vaccinations as required, and discussing the need to continue taking preventer therapies (if prescribed) when pregnant.

Despite clear guidelines for the management of asthma during pregnancy, there is evidence of suboptimal management in primary care. An Australian survey of 174 general practitioners (GPs) found that there was a lack of knowledge and confidence in managing asthma during pregnancy, with 25.8% of respondents indicating that they would stop or decrease ICS doses even among pregnant women whose asthma was well controlled on current therapy [6]. 12% of GPs indicated that they did not know how to manage a deterioration of asthma during pregnancy and would refer the patient to another health professional, while 67% would increase her dose. Although ICS were perceived to be the safest and preferred preventer medication for use in the first trimester, there was considerable concern about the safety of leukotriene receptor antagonists (LTRA) in the first trimester, with 45% of GPs indicating that they did not consider them safe, while many GPs did not consider long acting β-agonists (LABA) or oral corticosteroids (OCS) to be safe in the first trimester [6]. Nearly half of the respondents reported having patients who were nonadherent during pregnancy; however, 82% were likely to reinforce the need for continuing preventer medication among women who reported stopping this when becoming pregnancy [6], which was an encouraging finding.

In Spain, a multiple-choice survey related to the use of asthma management guidelines for pregnant patients was completed in 2009 by 1000 healthcare professionals, including primary care physicians (46%), respiratory specialists (20%), allergy specialists (17%) and obstetricians (17%) [7]. While 96. 5% of respondents indicated that they found guidelines useful, 64% also indicated that they seldom or never followed guidelines. Asthma in pregnancy guidelines were more likely to be used by respiratory and allergy specialists (56.6% and 60.4% respectively) than by primary care physicians (25.3%) or obstetricians (16.3%). Just over half of physicians would maintain asthma therapy in patients who were clinically stable, while 25.5% would suggest medications be used “on demand”, 17.6% would send the patient to a specialist (47.7% of obstetricians answered this way) and 1% would withdraw all medication. 30% believed spirometry was not recommended in pregnant asthmatic patients, while 10% would use spirometry monthly and 37% only if symptomatic. Most allergists (83.7%) would continue with specific immunotherapy in pregnancy, while less than one-third of the other physicians would continue immunotherapy [7]. These data indicate a difference in the way asthma is managed in pregnancy depending on the healthcare specialist and reinforces the need for education for all of the multidisciplinary team managing a pregnant woman’s asthma.

Use of asthma medications in pregnancy

Recently published data indicates that undertreatment of asthma during pregnancy remains an issue. Among women reporting having asthma, asthma medications were used by 63% in an American study (2001–2007) [2] and 62.9% in an Irish study (2000–2007) [3]. In the American study, around a quarter of these women were using ICS and a further 4% an ICS/LABA combination [2]. In the Irish study, 23% were using ICS [3]. A Korean study analysing data from 2009 to 2013 found that ICS was used by 15% of pregnant women with asthma, and ICS/LABA by a further 10.5% [8]. In a 2009 Australian survey, 19% of women were using a preventer for asthma treatment in pregnancy, while 57% of women reported use of reliever medication only and 24.5% of women were not using any pharmacological treatments [4]. This study also reported pre-pregnancy medication use and found that this period was associated with greater use of medications, with only 7.8% of women not using medication for asthma prior to pregnancy [4]. These data demonstrate a disconnect between asthma medication use prior to pregnancy and once pregnant, potentially due to changes in prescribing habits, perceived risks held by women or health professionals, or a change in asthma disease severity or control with pregnancy.

Nonadherence to prescribed ICS medications has been outlined in many studies of pregnant women with asthma [9]. A small study of 32 Turkish pregnant women with asthma was recently published [10]. More than half of the women (56%) were “irregular” users of asthma medication during pregnancy, which was not significantly different from pre-pregnancy (68%). During pregnancy, 52% of women were using ICS, while 22% did not use any medication for their asthma while pregnant. Exacerbations among this study population were high, with 13% hospitalised, 22% receiving OCS and 47% having an emergency visit during pregnancy [10], and undertreatment was likely a contributing factor. Pregnant women themselves perceive there to be a risk of using asthma medications during pregnancy. Powell
et al. [11] found that women assigned minimal risk to SABA such as salbutamol (0.5 cm on a 10-cm visual analogue scale), with greater risks for ICS (1.2 cm) and OCS (4.5 cm). This translates to a decline in asthma medication use, particularly in early pregnancy, with one study of prescriptions reporting a 13% decline in SABA use, a 23% decline in ICS use and 54% decline in OCS use in the first trimester compared to the 20 weeks prior to pregnancy [12].

Data has recently been published from the Xolair Pregnancy Registry, a prospective study of outcomes among 160 infants whose mothers used the anti-IgE medication omalizumab during pregnancy [13]. Omalizumab is used in patients with moderate–severe asthma who are not adequately controlled with ICS. The majority of women monitored in this study were exposed to omalizumab during the first trimester, with a median total duration of exposure during pregnancy of 8.8 months. Infants were born at a mean gestational age of 38. 3 weeks and among singletons, the rates of prematurity (14.5%), small for gestational age (10.9%) and low birth weight (3.2%) were consistent with data from other studies of women with asthma. Congenital malformations were reported in 20 infants, of which seven were considered major malformations. This registry is ongoing and further data are expected to be reported once 250 women have been recruited [13].

Asthma exacerbations and healthcare utilisation during pregnancy

Asthma exacerbations are a significant clinical problem during pregnancy. Up to 45% of pregnant women with asthma have moderate–severe exacerbations requiring medical intervention during pregnancy [14]. In addition to the adverse effect on maternal health, exacerbations are a key contributor to adverse perinatal outcomes in asthma. Exacerbations, oral steroid use and severe asthma are associated with preterm delivery, possibly due to maternal hypoxia, the effects of maternal inflammation and/or changes in uterine smooth muscle function [15]. In addition, women with exacerbations of asthma are three times more likely to have a low birth weight baby compared to asthmatic women without exacerbations [16], suggesting that prevention of exacerbations during pregnancy may also lead to improvements in perinatal outcomes.

In a Korean study of asthma during pregnancy, Kim
et al. [8] found that the rate of hospitalisation for asthma was higher among pregnant women (1.3%) than nonpregnant women (0.8%), after adjusting for age and exacerbation history; however, the length of hospital stay and number of hospitalisations per person was no different between these groups. Emergency department treatment for asthma occurred in 0.4% of pregnant women with asthma, while the number of outpatient visits was significantly lower than for their nonpregnant counterparts, with an increase observed after delivery. In addition, the use of medications was significantly lower in pregnancy for ICS/LABA combinations, LTRA, SABA, systemic steroids, xanthine derivatives and systemic LABA. Asthma exacerbations (measured by hospital admission) were 2.7 times more frequent in the subgroup of women with newly diagnosed asthma during pregnancy, and outpatient visits and prescriptions for asthma medications were also more frequent. Almost half of all women with newly diagnosed asthma were prescribed ICS or ICS/LABA combinations while only 14.6% of women with previously diagnosed asthma used these medications. However, the rate of hospitalisation and emergency department visits did not differ between these two groups. Overall, the proportion of women with hospitalisations (where OCS was prescribed for at least 3 days) increased from 0.2% in the first trimester to 0.5% in the second trimester and 0.7% in the third trimester. Severe exacerbations were experienced by 5.3% of participants [8], consistent with previous findings [17].

These studies demonstrate the potential for asthma status to markedly change during pregnancy and from trimester to trimester. Typically, approximately at least one-third of women with asthma report a worsening in their usual symptoms, one-third have no change and one-third have an improvement [18]. It is also recognised that women with mild disease are still at risk of severe exacerbations during pregnancy, and for this reason, regular monitoring of asthma during pregnancy is recommended [5].

Emergency department management of asthma exacerbations during pregnancy

Pregnant women with asthma exacerbations should be treated in the same way as nonpregnant adults with exacerbations. However, there is evidence from studies in emergency departments that this does not occur. A retrospective study from the USA compared OCS treatment during exacerbations among 123 pregnant and 123 nonpregnant women with asthma between 1996 and 2009 [19]. During the acute care visit, significantly more nonpregnant women were treated with OCS (72.4%) compared with pregnant women (50.8%), while 69% of nonpregnant women were prescribed OCS at discharge compared with 41% of pregnant women. The pregnant women were significantly more likely to return to the emergency department within 2 weeks of discharge (9. 7%) compared with the nonpregnant women (2.5%) [19]. These data were comparable to an earlier multicentre study from 36 emergency departments in the USA, where 51 pregnant women were compared with 500 nonpregnant women with similar peak expiratory flow rates and duration of asthma symptoms [20]. Here, 66% of nonpregnant women were treated with OCS, compared with only 44% of pregnant women. In addition, the pregnant women were 2.9 times more likely to report an ongoing exacerbation at the 2-week follow-up compared with the nonpregnant women [20]. A recent update from the same authors compared emergency department care of pregnant women with asthma from 1996–2001 to 2001–2012 [21]. They demonstrated that treatment with OCS increased from 51% to 78% and that the prescription of OCS at discharge rose from 42% to 63% over this time period, indicating a recent improvement in emergency department management of asthma exacerbations during pregnancy [21].

Recent data from a relatively small retrospective study of 39 women showed that pregnant women with asthma (n=28) were less likely to be prescribed OCS at the time of exacerbation (83%) than nonpregnant women with asthma (n=19, 100%) and where OCS were not prescribed at the first medical encounter, there was a delay in their prescription of 5.8 days [22]. OCS were prescribed during 87.5% of first-trimester exacerbations but only 70.6% of second-trimester and 66.7% of third-trimester exacerbations. While this may indicate an increasing reluctance to prescribe steroids as pregnancy progresses, it is possible that the severity of exacerbations in the third trimester was different from exacerbations earlier in pregnancy. This study also found that pregnant women were equally likely to fill their OCS prescription in the community after exacerbation (65%) as the nonpregnant women (67%), implying that the change in OCS use in pregnancy may be more related to prescribing habits than reduced use by pregnant women themselves, consistent with studies performed in the emergency department setting.

Intensive care management of status asthmaticus during pregnancy

There is limited literature available regarding the management of pregnant women with asthma in intensive care. A recent review suggests that multidisciplinary intensive care unit (ICU) care involving intensivists, asthma specialists, neonatologists and specialist high-risk obstetricians for pregnant women with status asthmaticus can result in good outcomes for both mother and baby, even when intubation is necessary [23]. Women whose asthma does not respond to or worsens despite maximal bronchodilator therapy in the emergency or hospital setting should be considered for ICU admission [23]. A series of five cases of status asthmaticus in pregnancy was reported from an inner city hospital in New York, NY, USA, in 2008 [24]. Three cases occurred early in pregnancy (6 weeks, 9 weeks and 14 weeks gestation), with the other two later in pregnancy (27 weeks and 28 weeks gestation). One case occurred in a woman with mild persistent asthma, highlighting the risk of severe exacerbations in pregnancy, even in those with previously mild disease. She developed severe respiratory distress and was placed on mechanical ventilation for 8 days. One woman had two admissions to the ICU, at 28 weeks and 34 weeks gestation. The second time, she was in respiratory distress and required continuous nebulised β-agonist, along with monitoring for potential respiratory failure. Her situation deteriorated on the fourth day, and a caesarean section was performed, with bronchospasm improving significantly after delivery. In all cases presented, there were no adverse perinatal outcomes (one pregnancy was terminated at 6 weeks). The importance of prevention of severe asthma exacerbations during pregnancy and slowing their progression to status asthmaticus is emphasised [23].

Multidisciplinary approaches to the management of asthma in pregnancy

A multi-disciplinary management approach is recommended during pregnancy [5]. There are several healthcare professionals that are well positioned to offer asthma self-management education and to co-ordinate management of asthma during pregnancy. These include nurses, asthma educators, pharmacists, midwives and primary care physicians. In addition, obstetricians and respiratory specialists may be involved in antenatal asthma management.

Nurse-led approaches

In 2005, data from Australia demonstrated the potential for nurses to improve health and self-management among pregnant women with asthma [9]. At their initial visit with an asthma nurse educator (at 20 weeks gestation), pregnant women with asthma had poor adherence (40% self-reported nonadherence with ICS), poor knowledge about asthma medications (42% were inadequate) and poor device technique (16% had inadequate inhaler technique). Following education, there were improvements in all aspects of asthma self-management, such that nonadherence fell to 21% and inadequate inhaler technique to 4%. In women classified as having severe asthma, night-time symptoms and reliever medication use were significantly reduced after education [9]. This study was not powered to investigate changes in exacerbations or perinatal outcomes; however, another Australian randomised controlled trial (RCT) is proposed that plans to test a similar approach in 378 women, involving a nurse-led intervention in the antenatal clinic setting with exacerbations as the primary outcome [25].

Pharmacist-led approaches

Lim
et al. [26] recently published a RCT testing a multidisciplinary asthma management strategy against usual care in 60 pregnant women with asthma, who were recruited prior to 20 weeks’ gestation. The monthly intervention involved visits to a pharmacist who provided education about self-management strategies, monitored asthma control and consulted with the woman’s GP when step-up of ICS therapy was required. The intervention group had a statistically and clinically significant improvement in asthma control after 6 months; however, this was potentially very late in pregnancy or post partum, and no changes in asthma control were observed between groups at the more clinically relevant time-point of 3 months post-randomisation [26].

Involvement of midwives in antenatal asthma management

While international guidelines suggest that management of asthma during pregnancy should be multidisciplinary, very few studies have investigated the role of the midwife in antenatal asthma management, despite their primary care role in many countries. A qualitative, descriptive study has been undertaken in Australia to explore midwives’ knowledge and understanding of asthma during pregnancy, and their perceived role in this area [27]. Data published to date indicate that midwives identify many barriers that prevent them from participating in antenatal asthma management, including lack of time, lack of knowledge about asthma during pregnancy, and lack of available equipment and referral pathways for women with asthma. Issues such as lack of time and knowledge are common barriers for midwives when faced with the implementation of additional education strategies for issues such as oral health, antenatal depression, genetic counselling and smoking cessation. Further research is needed to determine the importance pregnant women with asthma place on various caregivers during their pregnancy and who they would like to be providing asthma management. A study from the USA found that many women were likely to continue their ICS medication if advised to do so by their obstetrician [28], indicating the potential importance obstetric caregivers have in influencing women’s health behaviours surrounding asthma during pregnancy.

Dietary approaches

Grieger
et al. [29] have proposed that some of the poor perinatal outcomes associated with maternal asthma may be driven by increased oxidative stress as a result of both pregnancy and asthma. In nonpregnant adults, dietary intervention studies have demonstrated the protective effects of antioxidants in asthma; however, these approaches are yet to be tested in pregnancy. Observational data indicate that pregnant women with moderate or severe asthma have alterations in circulating antioxidants including α-tocopherol and total carotenoids, compared to women with mild or no asthma, and low concentrations were associated with reduced fetal growth [30]. Further work is required to determine whether dietary approaches can improve maternal and fetal outcomes in women with asthma.

Smoking cessation for pregnant women with asthma

Smoking is a critical issue for pregnant women with asthma, with data showing that women who smoke are more likely to have exacerbations during pregnancy and to have more severe symptoms during exacerbation [14]. Studies from around the world have suggested that pregnant women with asthma are more likely to smoke than pregnant women without asthma [15]. The 20–30% of women with asthma who continue to smoke during pregnancy are at increased risk of poor perinatal outcomes from the combined effects of smoking, asthma and severe asthma exacerbations. However, no studies have trialled smoking cessation strategies among this population of women.

A recent study from Denmark has identified the effects of both active smoking and passive smoking on asthma control [31]. Of the 500 women in this study, 6.4% were current smokers and 23% were ex-smokers, most of whom had quit smoking upon becoming pregnant. Of those who had never smoked, 18.4% reported passive smoking; that is, they lived with someone who smoked at home. Overall, those who had ever smoked had reduced lung function compared to never-smokers, while the effects of passive smoking among never-smokers showed similar patterns, with significantly reduced lung function, greater requirements for ICS and a higher likelihood of partly or uncontrolled asthma, compared to never-smokers without passive exposure [31]. These data suggest that passive smoking is potentially contributing to worse asthma control during pregnancy, which could have negative impacts on perinatal health.

Experiences of pregnant women in relation to asthma management in pregnancy

Two studies have examined the perspective of pregnant women in relation to their asthma and asthma care during pregnancy. Lim
et al. [32] conducted qualitative interviews with 23 pregnant women with asthma in Australia, at various stages of their pregnancy or up to 5 weeks post partum. Some women expressed the view that there were risks associated with asthma medication use during pregnancy, particularly related to steroid use, and they were therefore cautious about using ICS unless “desperate”. Their views about the safety of reliever medication such as salbutamol were quite different, however, with women preferring to use a lot of reliever therapy rather than preventers. There were also women who were more concerned about the possible risks of uncontrolled asthma and whether the baby was receiving enough oxygen. In terms of management by health professionals, the women noted that their GP was not concerned about their asthma and that other issues with the pregnancy often took priority. In addition, there was a view that there was a lack of information given about asthma during pregnancy, and that doctors and pharmacists were unclear about the safety of medication use in pregnancy, forcing some women to make a decision for themselves or consult “Dr Google”, where they obtained unreliable or inaccurate information [32].

A similar qualitative study was reported from the UK, in which seven women with asthma who had been pregnant within the previous 2 years were interviewed [33]. Four of these seven women reported a worsening of asthma symptoms during pregnancy, and these women expressed feelings of fear, panic and anxiety surrounding exacerbations, and a lack of understanding that some of their symptoms were due to asthma rather than the pregnancy itself. They expressed the need for more education and information so that they would have an awareness of the potential seriousness of asthma, and where to seek help. There was a lack of understanding about asthma medications and how they worked, as well as whether they were safe to use, by both women and their partners, which led to women “getting on with it” without support or assistance. This series of interviews conducted in 2012 identified that women generally did not have regular contact with GPs or practice nurses about their asthma and that management plans to monitor asthma during pregnancy were not in place, with one woman describing that her GP took her off her medication when she expressed concern about using it while pregnant. The perception was that midwives did not know much about asthma and concentrated more on issues surrounding the pregnancy. In addition, two women described delays in obtaining care when they had exacerbations of asthma requiring admission to hospital [33]. More work is needed to clarify the priorities of pregnant women themselves with regard to their asthma management in pregnancy.

The importance of active management for better maternal and fetal outcomes

The provision of optimal asthma management is essential for the health of both mother and baby. A recent systematic review and meta-analyses summarised the literature concerning the risks of adverse perinatal outcomes in women with asthma [34–36]. Compared to pregnant women without asthma, women with asthma are at risk of a range of adverse pregnancy outcomes affecting the mother, placenta and neonate, including preterm delivery, low birth weight, pre-eclampsia [34], gestational diabetes, caesarean section, placenta praevia [36], congenital malformations, neonatal hospitalisation and neonatal death [35]. Despite the fact that the majority of women included in the primary studies would be expected to have mild asthma, the effect of asthma on perinatal outcomes was still significant, suggesting that there may be a greater adverse effect among the subgroup with more severe disease [37]. Indeed, women with moderate or severe asthma were more likely to have small for gestational age babies than women with mild asthma [16]. Another interesting finding of this review was that active management of asthma during pregnancy may mitigate some of the increased perinatal risks. In the meta-analysis, when studies were grouped based on the provision of active asthma management, the risk associated with maternal asthma was reduced to nonsignificant for some perinatal outcomes. For example, women with asthma had a 50% increased risk for preterm delivery compared to women without asthma when no active management was given [34]. However, among five studies where active management was provided, the risk of preterm delivery was no longer increased or statistically significant, suggesting that active asthma management may be effective in reducing the risk of preterm delivery [34]. Similar results were observed for preterm labour [34] and neonatal hospitalisation [35]. The reduced risk of neonatal hospitalisation may be a consequence of improvements in gestational age and other birth outcomes. A reduction in preterm births with active asthma management is plausible, given that one of the benefits would be a reduction in the number of exacerbations and courses of oral steroids used, both of which have been implicated in larger studies as contributing to the risk of preterm delivery in asthmatic women.

Interventions for improving asthma management during pregnancy

There have been very few recent RCTs of interventions for managing asthma during pregnancy. A 2014 Cochrane review summarised eight RCTs involving 1181 women with asthma [38]. Five of the trials assessed pharmacological interventions and three assessed nonpharmacological interventions. The trials were of moderate quality overall and did not lead to any firm conclusions regarding optimal asthma management in pregnancy, due to a lack of clear benefits of pharmacological approaches over current practice and a lack of power in the nonpharmacological interventions to detect differences in perinatal outcomes [38].

Inflammation-based management of asthma during pregnancy

Only one study has successfully trialled a management approach that reduces exacerbations during pregnancy. The MAP (Managing Asthma in Pregnancy) Study from Australia was a double-blind, parallel-group RCT which tested the efficacy of an inflammation-based management strategy for reducing exacerbations in 220 nonsmoking pregnant women with asthma [39]. Women were randomised prior to 22 weeks gestation. The control group had treatment adjusted according to the results of the Asthma Control Questionnaire (ACQ), representing symptoms and lung function. The intervention group had treatment adjusted according to both the level of eosinophilic airway inflammation and the ACQ. Airway inflammation was measured by exhaled nitric oxide fraction (F_eNO), a steroid sensitive marker of eosinophilia, and used to adjust ICS. The ACQ was used to determine when symptoms remained uncontrolled, in which case a LABA was added. Both groups had stepwise ICS treatment adjustments (up or down) made monthly, and received free medications and self-management education. The primary study outcome was exacerbations requiring medical intervention, defined as hospitalisation, emergency department presentation, use of OCS or unscheduled doctor visit for asthma. There was a 50% reduction in exacerbations in the F_eNO group compared to the control group, along with alterations to the treatment profile, with more women from the F_eNO group being prescribed ICS (at a lower mean dose) and ICS/LABA combination therapy. In addition, there was a significant reduction in both OCS and SABA use, and a significantly higher quality of life in the F_eNO group compared to the control group [39]. The infants from this study were followed up at 12 months of age and those from mothers in the F_eNO group were significantly less likely to have recurrent bronchiolitis or recurrent croup reported by their parents [40], suggesting a potential long-term benefit to the health of the offspring. The F_eNO-based management approach has the potential to be widely used in clinical practice, as F_eNO is easily measured using a noninvasive breath test and gives an indication of the level of steroid-responsive eosinophilic airway inflammation, reducing exacerbations, a major clinical problem in pregnant women with asthma.

Conclusions

Asthma is a common comorbidity during pregnancy and exacerbations are a major clinical problem, with up to 45% of women requiring medical intervention for asthma during pregnancy, resulting in poor outcomes for mothers and their babies. Guidelines recommend managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for adults and management of comorbid conditions. Improvements have been made in recent years in emergency department management of asthma in pregnancy, and multidisciplinary approaches are being proposed to optimise both asthma outcomes and perinatal outcomes. One strategy that has been successful in reducing exacerbations in pregnancy is treatment adjustment using a marker of eosinophilic lung inflammation, F_eNO. Further evidence is needed to determine whether this strategy can also improve perinatal outcomes and be successfully translated into clinical practice.

Educational questions

1. Which of the following statements concerning guidelines for the management of asthma during pregnancy is/are correct?

   • a Inhaled corticosteroids should be used when women have persistent asthma

   • b Asthma should be managed as for other adults, with the exception of oral corticosteroid use during exacerbations

   • c Multidisciplinary management is recommended

   • d It is important to identify and manage comorbid conditions such as rhinitis or reflux

   • e Asthma should be reviewed every 4 weeks during pregnancy.

2. A woman presents to her general practitioner with asthma symptoms during pregnancy. She has previously admitted to nonadherence to her preventer medication and is concerned about whether this medication is harmful for her baby. Which is the most appropriate clinical decision?

   • a Withdraw all preventer medication and advise her to take more doses of her reliever

   • b Make a referral for her to see a respiratory specialist

   • c Advise her of the safety and importance of taking preventer medications in pregnancy, and advise her to continue her prescribed dose and return for review if symptoms continue to worsen

   • d Perform spirometry and provide a prescription for a different preventer medication

3. Which of the following statements is/are true concerning the risks of adverse perinatal outcomes in women with asthma?

   • a Women with asthma are not at risk of adverse perinatal outcomes compared to women without asthma

   • b Women with asthma are at increased risk of having a baby who dies or is hospitalised after birth

   • c Active management of asthma can reduce the risk of preterm labour and delivery

   • d Women who have exacerbations of asthma during pregnancy are at three times the risk of low birth weight compared with women without asthma exacerbations in pregnancy

4. Which of the following statements is/are true concerning inflammation-based management of asthma during pregnancy?

   • a Using a marker of airway inflammation to adjust treatment results in women taking higher doses of inhaled corticosteroids during pregnancy

   • b Using a marker of airway inflammation to adjust treatment reduces the exacerbation rate in pregnancy

   • c Exhaled nitric oxide fraction is a useful marker because it predicts the response to inhaled steroids

   • d Benefits to health in infancy have been described when inflammation-based management is used

   • e No studies have identified whether this approach improves perinatal outcomes.

Suggested Answers

1. a, c, d, e

2. c

3. b, c, d

4. b, c, d, e

Footnotes

Support statement Vanessa Murphy is supported by a Career Development Fellowship from the National Health and Medical Research Council of Australia.

Conflict of interest None declared.

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Managing asthma in pregnancy

Breathe (Sheff). 2015 Dec; 11(4): 258–267.

Centre for Asthma and Respiratory Disease, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia

Corresponding author.This article has been cited by other articles in PMC.

Abstract

Asthma is a common comorbidity during pregnancy and its prevalence is increasing in the community. Exacerbations are a major clinical problem during pregnancy with up to 45% of women needing to seek medical help, resulting in poor outcomes for mothers and their babies, including low birth weight and preterm delivery. The goals of effective asthma management in pregnancy are to maintain the best possible asthma control and prevent exacerbations. This is achieved by aiming to prevent day- and night-time symptoms, and maintain lung function and normal activity. In addition, maintaining fetal oxygenation is an important consideration in pregnancy. Guidelines recommend providing asthma advice and review prior to conception, and managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for other adults with asthma, and management of comorbid conditions such as rhinitis.

Improvements have been made in recent years in emergency department management of asthma in pregnancy, and multidisciplinary approaches are being proposed to optimise both asthma outcomes and perinatal outcomes. One strategy that has demonstrated success in reducing exacerbations in pregnancy is treatment adjustment using a marker of eosinophilic lung inflammation, the exhaled nitric oxide fraction (F_eNO). The use of an algorithm that adjusted inhaled corticosteroids (ICS) according to F_eNO and added long-acting β-agonists when symptoms remained uncontrolled resulted in fewer exacerbations, more women on ICS but at lower mean doses, and improved infant respiratory health at 12 months of age. Further evidence is needed to determine whether this strategy can also improve perinatal outcomes and be successfully translated into clinical practice.

Key points

• Asthma is the most common chronic disease to affect pregnant women.

• Exacerbations occur in up to 45% of pregnant women with asthma.

• Asthma should be managed during pregnancy as for other adults.

• Treatment adjustment using a marker of airway inflammation reduces the exacerbation rate in pregnancy.

Educational aims

• To identify the goals of and steps associated with effective asthma management in pregnancy.

• To understand the maternal and perinatal risks associated with asthma during pregnancy.

• To describe a management strategy that has been shown to reduce exacerbations in pregnant women with asthma.

Short abstract

Guidelines for the management of asthma during pregnancy exist but are too rarely used in clinical practice
http://ow.ly/U8Sq8

Introduction

Asthma is the most common chronic medical condition to be reported during pregnancy and its prevalence in the population has increased in recent decades. Kwon
et al. [1] reported an increase in the prevalence of asthma during pregnancy from 3.7% in 1997 to 8.4% in 2001. More recent reports from the USA found a prevalence of 5.5% in 2001, increasing to 7.8% in 2007 [2]. A prevalence of 9.3% has been reported in Ireland [3] and 12.7% in Australia [4]. Maternal asthma is associated with an increased risk of adverse perinatal outcomes, and changes in the course of the disease are to be expected and can be unpredictable during pregnancy. Optimising asthma management in pregnancy is paramount for protecting the health of both mother and baby.

Guidelines for the management of asthma during pregnancy

International guidelines are available that outline the goals of successful asthma management and recommendations for clinical management of asthma in pregnancy [5]. Goals include the prevention of chronic day and night symptoms, maintenance of optimal pulmonary function and normal activities, and prevention of exacerbations, using therapies with minimal or no adverse side-effects [5]. During pregnancy, there is the additional goal to maintain fetal oxygenation by preventing episodes of maternal hypoxia [5]. Achieving this requires regular monitoring of clinical symptoms, provision of self-management education and the correct use of pharmacotherapies. Multidisciplinary management by all health professionals involved in a woman’s care is encouraged [5].

A stepwise approach to asthma treatment is recommended during pregnancy as for other adults with asthma [5]. Guidelines recommend the use of short acting β-agonists (SABA) as reliever medication and the use of inhaled corticosteroids (ICS) for women with persistent asthma [5]. There is much reassuring data concerning the safety of ICS medication use in pregnancy, particularly for budesonide, which has the best safety rating during pregnancy. Guidelines recommend the continued use of ICS medication that has been effective in controlling asthma prior to pregnancy [5].

In 2014, the Australian National Asthma Council released updated guidelines for asthma management (www.asthmahandbook.org.au), including a section on pregnancy. These guidelines recommend managing asthma actively during pregnancy, as for asthma in other adults, including prescribing preventers if indicated, and stepping up the regimen as necessary with the goal to maintain the best possible asthma control and avoid exacerbations. Regular review of asthma every 4 weeks during pregnancy is recommended, with asthma control assessed each time. In addition, comorbidities such as rhinitis or gastro-oesophageal reflux, which can contribute to worsening asthma, should be identified and managed. In terms of exacerbations, the Australian guidelines recommend intervening early, providing a written action plan with a low threshold for seeking medical help and ensuring prompt treatment in emergency departments to minimise risks to the fetus. Preconception care is also suggested, with recommendations to offer advice that uncontrolled asthma or asthma exacerbations put both mothers and babies at risk, provide an asthma review prior to conception including performing baseline spirometry, offering a written action plan, smoking cessation advice and vaccinations as required, and discussing the need to continue taking preventer therapies (if prescribed) when pregnant.

Despite clear guidelines for the management of asthma during pregnancy, there is evidence of suboptimal management in primary care. An Australian survey of 174 general practitioners (GPs) found that there was a lack of knowledge and confidence in managing asthma during pregnancy, with 25.8% of respondents indicating that they would stop or decrease ICS doses even among pregnant women whose asthma was well controlled on current therapy [6]. 12% of GPs indicated that they did not know how to manage a deterioration of asthma during pregnancy and would refer the patient to another health professional, while 67% would increase her dose. Although ICS were perceived to be the safest and preferred preventer medication for use in the first trimester, there was considerable concern about the safety of leukotriene receptor antagonists (LTRA) in the first trimester, with 45% of GPs indicating that they did not consider them safe, while many GPs did not consider long acting β-agonists (LABA) or oral corticosteroids (OCS) to be safe in the first trimester [6]. Nearly half of the respondents reported having patients who were nonadherent during pregnancy; however, 82% were likely to reinforce the need for continuing preventer medication among women who reported stopping this when becoming pregnancy [6], which was an encouraging finding.

In Spain, a multiple-choice survey related to the use of asthma management guidelines for pregnant patients was completed in 2009 by 1000 healthcare professionals, including primary care physicians (46%), respiratory specialists (20%), allergy specialists (17%) and obstetricians (17%) [7]. While 96.5% of respondents indicated that they found guidelines useful, 64% also indicated that they seldom or never followed guidelines. Asthma in pregnancy guidelines were more likely to be used by respiratory and allergy specialists (56.6% and 60.4% respectively) than by primary care physicians (25.3%) or obstetricians (16.3%). Just over half of physicians would maintain asthma therapy in patients who were clinically stable, while 25.5% would suggest medications be used “on demand”, 17.6% would send the patient to a specialist (47.7% of obstetricians answered this way) and 1% would withdraw all medication. 30% believed spirometry was not recommended in pregnant asthmatic patients, while 10% would use spirometry monthly and 37% only if symptomatic. Most allergists (83.7%) would continue with specific immunotherapy in pregnancy, while less than one-third of the other physicians would continue immunotherapy [7]. These data indicate a difference in the way asthma is managed in pregnancy depending on the healthcare specialist and reinforces the need for education for all of the multidisciplinary team managing a pregnant woman’s asthma.

Use of asthma medications in pregnancy

Recently published data indicates that undertreatment of asthma during pregnancy remains an issue. Among women reporting having asthma, asthma medications were used by 63% in an American study (2001–2007) [2] and 62.9% in an Irish study (2000–2007) [3]. In the American study, around a quarter of these women were using ICS and a further 4% an ICS/LABA combination [2]. In the Irish study, 23% were using ICS [3]. A Korean study analysing data from 2009 to 2013 found that ICS was used by 15% of pregnant women with asthma, and ICS/LABA by a further 10.5% [8]. In a 2009 Australian survey, 19% of women were using a preventer for asthma treatment in pregnancy, while 57% of women reported use of reliever medication only and 24.5% of women were not using any pharmacological treatments [4]. This study also reported pre-pregnancy medication use and found that this period was associated with greater use of medications, with only 7.8% of women not using medication for asthma prior to pregnancy [4]. These data demonstrate a disconnect between asthma medication use prior to pregnancy and once pregnant, potentially due to changes in prescribing habits, perceived risks held by women or health professionals, or a change in asthma disease severity or control with pregnancy.

Nonadherence to prescribed ICS medications has been outlined in many studies of pregnant women with asthma [9]. A small study of 32 Turkish pregnant women with asthma was recently published [10]. More than half of the women (56%) were “irregular” users of asthma medication during pregnancy, which was not significantly different from pre-pregnancy (68%). During pregnancy, 52% of women were using ICS, while 22% did not use any medication for their asthma while pregnant. Exacerbations among this study population were high, with 13% hospitalised, 22% receiving OCS and 47% having an emergency visit during pregnancy [10], and undertreatment was likely a contributing factor. Pregnant women themselves perceive there to be a risk of using asthma medications during pregnancy. Powell
et al. [11] found that women assigned minimal risk to SABA such as salbutamol (0.5 cm on a 10-cm visual analogue scale), with greater risks for ICS (1.2 cm) and OCS (4.5 cm). This translates to a decline in asthma medication use, particularly in early pregnancy, with one study of prescriptions reporting a 13% decline in SABA use, a 23% decline in ICS use and 54% decline in OCS use in the first trimester compared to the 20 weeks prior to pregnancy [12].

Data has recently been published from the Xolair Pregnancy Registry, a prospective study of outcomes among 160 infants whose mothers used the anti-IgE medication omalizumab during pregnancy [13]. Omalizumab is used in patients with moderate–severe asthma who are not adequately controlled with ICS. The majority of women monitored in this study were exposed to omalizumab during the first trimester, with a median total duration of exposure during pregnancy of 8.8 months. Infants were born at a mean gestational age of 38.3 weeks and among singletons, the rates of prematurity (14.5%), small for gestational age (10.9%) and low birth weight (3.2%) were consistent with data from other studies of women with asthma. Congenital malformations were reported in 20 infants, of which seven were considered major malformations. This registry is ongoing and further data are expected to be reported once 250 women have been recruited [13].

Asthma exacerbations and healthcare utilisation during pregnancy

Asthma exacerbations are a significant clinical problem during pregnancy. Up to 45% of pregnant women with asthma have moderate–severe exacerbations requiring medical intervention during pregnancy [14]. In addition to the adverse effect on maternal health, exacerbations are a key contributor to adverse perinatal outcomes in asthma. Exacerbations, oral steroid use and severe asthma are associated with preterm delivery, possibly due to maternal hypoxia, the effects of maternal inflammation and/or changes in uterine smooth muscle function [15]. In addition, women with exacerbations of asthma are three times more likely to have a low birth weight baby compared to asthmatic women without exacerbations [16], suggesting that prevention of exacerbations during pregnancy may also lead to improvements in perinatal outcomes.

In a Korean study of asthma during pregnancy, Kim
et al. [8] found that the rate of hospitalisation for asthma was higher among pregnant women (1.3%) than nonpregnant women (0.8%), after adjusting for age and exacerbation history; however, the length of hospital stay and number of hospitalisations per person was no different between these groups. Emergency department treatment for asthma occurred in 0.4% of pregnant women with asthma, while the number of outpatient visits was significantly lower than for their nonpregnant counterparts, with an increase observed after delivery. In addition, the use of medications was significantly lower in pregnancy for ICS/LABA combinations, LTRA, SABA, systemic steroids, xanthine derivatives and systemic LABA. Asthma exacerbations (measured by hospital admission) were 2.7 times more frequent in the subgroup of women with newly diagnosed asthma during pregnancy, and outpatient visits and prescriptions for asthma medications were also more frequent. Almost half of all women with newly diagnosed asthma were prescribed ICS or ICS/LABA combinations while only 14.6% of women with previously diagnosed asthma used these medications. However, the rate of hospitalisation and emergency department visits did not differ between these two groups. Overall, the proportion of women with hospitalisations (where OCS was prescribed for at least 3 days) increased from 0.2% in the first trimester to 0.5% in the second trimester and 0.7% in the third trimester. Severe exacerbations were experienced by 5.3% of participants [8], consistent with previous findings [17].

These studies demonstrate the potential for asthma status to markedly change during pregnancy and from trimester to trimester. Typically, approximately at least one-third of women with asthma report a worsening in their usual symptoms, one-third have no change and one-third have an improvement [18]. It is also recognised that women with mild disease are still at risk of severe exacerbations during pregnancy, and for this reason, regular monitoring of asthma during pregnancy is recommended [5].

Emergency department management of asthma exacerbations during pregnancy

Pregnant women with asthma exacerbations should be treated in the same way as nonpregnant adults with exacerbations. However, there is evidence from studies in emergency departments that this does not occur. A retrospective study from the USA compared OCS treatment during exacerbations among 123 pregnant and 123 nonpregnant women with asthma between 1996 and 2009 [19]. During the acute care visit, significantly more nonpregnant women were treated with OCS (72.4%) compared with pregnant women (50.8%), while 69% of nonpregnant women were prescribed OCS at discharge compared with 41% of pregnant women. The pregnant women were significantly more likely to return to the emergency department within 2 weeks of discharge (9.7%) compared with the nonpregnant women (2.5%) [19]. These data were comparable to an earlier multicentre study from 36 emergency departments in the USA, where 51 pregnant women were compared with 500 nonpregnant women with similar peak expiratory flow rates and duration of asthma symptoms [20]. Here, 66% of nonpregnant women were treated with OCS, compared with only 44% of pregnant women. In addition, the pregnant women were 2.9 times more likely to report an ongoing exacerbation at the 2-week follow-up compared with the nonpregnant women [20]. A recent update from the same authors compared emergency department care of pregnant women with asthma from 1996–2001 to 2001–2012 [21]. They demonstrated that treatment with OCS increased from 51% to 78% and that the prescription of OCS at discharge rose from 42% to 63% over this time period, indicating a recent improvement in emergency department management of asthma exacerbations during pregnancy [21].

Recent data from a relatively small retrospective study of 39 women showed that pregnant women with asthma (n=28) were less likely to be prescribed OCS at the time of exacerbation (83%) than nonpregnant women with asthma (n=19, 100%) and where OCS were not prescribed at the first medical encounter, there was a delay in their prescription of 5.8 days [22]. OCS were prescribed during 87.5% of first-trimester exacerbations but only 70.6% of second-trimester and 66.7% of third-trimester exacerbations. While this may indicate an increasing reluctance to prescribe steroids as pregnancy progresses, it is possible that the severity of exacerbations in the third trimester was different from exacerbations earlier in pregnancy. This study also found that pregnant women were equally likely to fill their OCS prescription in the community after exacerbation (65%) as the nonpregnant women (67%), implying that the change in OCS use in pregnancy may be more related to prescribing habits than reduced use by pregnant women themselves, consistent with studies performed in the emergency department setting.

Intensive care management of status asthmaticus during pregnancy

There is limited literature available regarding the management of pregnant women with asthma in intensive care. A recent review suggests that multidisciplinary intensive care unit (ICU) care involving intensivists, asthma specialists, neonatologists and specialist high-risk obstetricians for pregnant women with status asthmaticus can result in good outcomes for both mother and baby, even when intubation is necessary [23]. Women whose asthma does not respond to or worsens despite maximal bronchodilator therapy in the emergency or hospital setting should be considered for ICU admission [23]. A series of five cases of status asthmaticus in pregnancy was reported from an inner city hospital in New York, NY, USA, in 2008 [24]. Three cases occurred early in pregnancy (6 weeks, 9 weeks and 14 weeks gestation), with the other two later in pregnancy (27 weeks and 28 weeks gestation). One case occurred in a woman with mild persistent asthma, highlighting the risk of severe exacerbations in pregnancy, even in those with previously mild disease. She developed severe respiratory distress and was placed on mechanical ventilation for 8 days. One woman had two admissions to the ICU, at 28 weeks and 34 weeks gestation. The second time, she was in respiratory distress and required continuous nebulised β-agonist, along with monitoring for potential respiratory failure. Her situation deteriorated on the fourth day, and a caesarean section was performed, with bronchospasm improving significantly after delivery. In all cases presented, there were no adverse perinatal outcomes (one pregnancy was terminated at 6 weeks). The importance of prevention of severe asthma exacerbations during pregnancy and slowing their progression to status asthmaticus is emphasised [23].

Multidisciplinary approaches to the management of asthma in pregnancy

A multi-disciplinary management approach is recommended during pregnancy [5]. There are several healthcare professionals that are well positioned to offer asthma self-management education and to co-ordinate management of asthma during pregnancy. These include nurses, asthma educators, pharmacists, midwives and primary care physicians. In addition, obstetricians and respiratory specialists may be involved in antenatal asthma management.

Nurse-led approaches

In 2005, data from Australia demonstrated the potential for nurses to improve health and self-management among pregnant women with asthma [9]. At their initial visit with an asthma nurse educator (at 20 weeks gestation), pregnant women with asthma had poor adherence (40% self-reported nonadherence with ICS), poor knowledge about asthma medications (42% were inadequate) and poor device technique (16% had inadequate inhaler technique). Following education, there were improvements in all aspects of asthma self-management, such that nonadherence fell to 21% and inadequate inhaler technique to 4%. In women classified as having severe asthma, night-time symptoms and reliever medication use were significantly reduced after education [9]. This study was not powered to investigate changes in exacerbations or perinatal outcomes; however, another Australian randomised controlled trial (RCT) is proposed that plans to test a similar approach in 378 women, involving a nurse-led intervention in the antenatal clinic setting with exacerbations as the primary outcome [25].

Pharmacist-led approaches

Lim
et al. [26] recently published a RCT testing a multidisciplinary asthma management strategy against usual care in 60 pregnant women with asthma, who were recruited prior to 20 weeks’ gestation. The monthly intervention involved visits to a pharmacist who provided education about self-management strategies, monitored asthma control and consulted with the woman’s GP when step-up of ICS therapy was required. The intervention group had a statistically and clinically significant improvement in asthma control after 6 months; however, this was potentially very late in pregnancy or post partum, and no changes in asthma control were observed between groups at the more clinically relevant time-point of 3 months post-randomisation [26].

Involvement of midwives in antenatal asthma management

While international guidelines suggest that management of asthma during pregnancy should be multidisciplinary, very few studies have investigated the role of the midwife in antenatal asthma management, despite their primary care role in many countries. A qualitative, descriptive study has been undertaken in Australia to explore midwives’ knowledge and understanding of asthma during pregnancy, and their perceived role in this area [27]. Data published to date indicate that midwives identify many barriers that prevent them from participating in antenatal asthma management, including lack of time, lack of knowledge about asthma during pregnancy, and lack of available equipment and referral pathways for women with asthma. Issues such as lack of time and knowledge are common barriers for midwives when faced with the implementation of additional education strategies for issues such as oral health, antenatal depression, genetic counselling and smoking cessation. Further research is needed to determine the importance pregnant women with asthma place on various caregivers during their pregnancy and who they would like to be providing asthma management. A study from the USA found that many women were likely to continue their ICS medication if advised to do so by their obstetrician [28], indicating the potential importance obstetric caregivers have in influencing women’s health behaviours surrounding asthma during pregnancy.

Dietary approaches

Grieger
et al. [29] have proposed that some of the poor perinatal outcomes associated with maternal asthma may be driven by increased oxidative stress as a result of both pregnancy and asthma. In nonpregnant adults, dietary intervention studies have demonstrated the protective effects of antioxidants in asthma; however, these approaches are yet to be tested in pregnancy. Observational data indicate that pregnant women with moderate or severe asthma have alterations in circulating antioxidants including α-tocopherol and total carotenoids, compared to women with mild or no asthma, and low concentrations were associated with reduced fetal growth [30]. Further work is required to determine whether dietary approaches can improve maternal and fetal outcomes in women with asthma.

Smoking cessation for pregnant women with asthma

Smoking is a critical issue for pregnant women with asthma, with data showing that women who smoke are more likely to have exacerbations during pregnancy and to have more severe symptoms during exacerbation [14]. Studies from around the world have suggested that pregnant women with asthma are more likely to smoke than pregnant women without asthma [15]. The 20–30% of women with asthma who continue to smoke during pregnancy are at increased risk of poor perinatal outcomes from the combined effects of smoking, asthma and severe asthma exacerbations. However, no studies have trialled smoking cessation strategies among this population of women.

A recent study from Denmark has identified the effects of both active smoking and passive smoking on asthma control [31]. Of the 500 women in this study, 6.4% were current smokers and 23% were ex-smokers, most of whom had quit smoking upon becoming pregnant. Of those who had never smoked, 18.4% reported passive smoking; that is, they lived with someone who smoked at home. Overall, those who had ever smoked had reduced lung function compared to never-smokers, while the effects of passive smoking among never-smokers showed similar patterns, with significantly reduced lung function, greater requirements for ICS and a higher likelihood of partly or uncontrolled asthma, compared to never-smokers without passive exposure [31]. These data suggest that passive smoking is potentially contributing to worse asthma control during pregnancy, which could have negative impacts on perinatal health.

Experiences of pregnant women in relation to asthma management in pregnancy

Two studies have examined the perspective of pregnant women in relation to their asthma and asthma care during pregnancy. Lim
et al. [32] conducted qualitative interviews with 23 pregnant women with asthma in Australia, at various stages of their pregnancy or up to 5 weeks post partum. Some women expressed the view that there were risks associated with asthma medication use during pregnancy, particularly related to steroid use, and they were therefore cautious about using ICS unless “desperate”. Their views about the safety of reliever medication such as salbutamol were quite different, however, with women preferring to use a lot of reliever therapy rather than preventers. There were also women who were more concerned about the possible risks of uncontrolled asthma and whether the baby was receiving enough oxygen. In terms of management by health professionals, the women noted that their GP was not concerned about their asthma and that other issues with the pregnancy often took priority. In addition, there was a view that there was a lack of information given about asthma during pregnancy, and that doctors and pharmacists were unclear about the safety of medication use in pregnancy, forcing some women to make a decision for themselves or consult “Dr Google”, where they obtained unreliable or inaccurate information [32].

A similar qualitative study was reported from the UK, in which seven women with asthma who had been pregnant within the previous 2 years were interviewed [33]. Four of these seven women reported a worsening of asthma symptoms during pregnancy, and these women expressed feelings of fear, panic and anxiety surrounding exacerbations, and a lack of understanding that some of their symptoms were due to asthma rather than the pregnancy itself. They expressed the need for more education and information so that they would have an awareness of the potential seriousness of asthma, and where to seek help. There was a lack of understanding about asthma medications and how they worked, as well as whether they were safe to use, by both women and their partners, which led to women “getting on with it” without support or assistance. This series of interviews conducted in 2012 identified that women generally did not have regular contact with GPs or practice nurses about their asthma and that management plans to monitor asthma during pregnancy were not in place, with one woman describing that her GP took her off her medication when she expressed concern about using it while pregnant. The perception was that midwives did not know much about asthma and concentrated more on issues surrounding the pregnancy. In addition, two women described delays in obtaining care when they had exacerbations of asthma requiring admission to hospital [33]. More work is needed to clarify the priorities of pregnant women themselves with regard to their asthma management in pregnancy.

The importance of active management for better maternal and fetal outcomes

The provision of optimal asthma management is essential for the health of both mother and baby. A recent systematic review and meta-analyses summarised the literature concerning the risks of adverse perinatal outcomes in women with asthma [34–36]. Compared to pregnant women without asthma, women with asthma are at risk of a range of adverse pregnancy outcomes affecting the mother, placenta and neonate, including preterm delivery, low birth weight, pre-eclampsia [34], gestational diabetes, caesarean section, placenta praevia [36], congenital malformations, neonatal hospitalisation and neonatal death [35]. Despite the fact that the majority of women included in the primary studies would be expected to have mild asthma, the effect of asthma on perinatal outcomes was still significant, suggesting that there may be a greater adverse effect among the subgroup with more severe disease [37]. Indeed, women with moderate or severe asthma were more likely to have small for gestational age babies than women with mild asthma [16]. Another interesting finding of this review was that active management of asthma during pregnancy may mitigate some of the increased perinatal risks. In the meta-analysis, when studies were grouped based on the provision of active asthma management, the risk associated with maternal asthma was reduced to nonsignificant for some perinatal outcomes. For example, women with asthma had a 50% increased risk for preterm delivery compared to women without asthma when no active management was given [34]. However, among five studies where active management was provided, the risk of preterm delivery was no longer increased or statistically significant, suggesting that active asthma management may be effective in reducing the risk of preterm delivery [34]. Similar results were observed for preterm labour [34] and neonatal hospitalisation [35]. The reduced risk of neonatal hospitalisation may be a consequence of improvements in gestational age and other birth outcomes. A reduction in preterm births with active asthma management is plausible, given that one of the benefits would be a reduction in the number of exacerbations and courses of oral steroids used, both of which have been implicated in larger studies as contributing to the risk of preterm delivery in asthmatic women.

Interventions for improving asthma management during pregnancy

There have been very few recent RCTs of interventions for managing asthma during pregnancy. A 2014 Cochrane review summarised eight RCTs involving 1181 women with asthma [38]. Five of the trials assessed pharmacological interventions and three assessed nonpharmacological interventions. The trials were of moderate quality overall and did not lead to any firm conclusions regarding optimal asthma management in pregnancy, due to a lack of clear benefits of pharmacological approaches over current practice and a lack of power in the nonpharmacological interventions to detect differences in perinatal outcomes [38].

Inflammation-based management of asthma during pregnancy

Only one study has successfully trialled a management approach that reduces exacerbations during pregnancy. The MAP (Managing Asthma in Pregnancy) Study from Australia was a double-blind, parallel-group RCT which tested the efficacy of an inflammation-based management strategy for reducing exacerbations in 220 nonsmoking pregnant women with asthma [39]. Women were randomised prior to 22 weeks gestation. The control group had treatment adjusted according to the results of the Asthma Control Questionnaire (ACQ), representing symptoms and lung function. The intervention group had treatment adjusted according to both the level of eosinophilic airway inflammation and the ACQ. Airway inflammation was measured by exhaled nitric oxide fraction (F_eNO), a steroid sensitive marker of eosinophilia, and used to adjust ICS. The ACQ was used to determine when symptoms remained uncontrolled, in which case a LABA was added. Both groups had stepwise ICS treatment adjustments (up or down) made monthly, and received free medications and self-management education. The primary study outcome was exacerbations requiring medical intervention, defined as hospitalisation, emergency department presentation, use of OCS or unscheduled doctor visit for asthma. There was a 50% reduction in exacerbations in the F_eNO group compared to the control group, along with alterations to the treatment profile, with more women from the F_eNO group being prescribed ICS (at a lower mean dose) and ICS/LABA combination therapy. In addition, there was a significant reduction in both OCS and SABA use, and a significantly higher quality of life in the F_eNO group compared to the control group [39]. The infants from this study were followed up at 12 months of age and those from mothers in the F_eNO group were significantly less likely to have recurrent bronchiolitis or recurrent croup reported by their parents [40], suggesting a potential long-term benefit to the health of the offspring. The F_eNO-based management approach has the potential to be widely used in clinical practice, as F_eNO is easily measured using a noninvasive breath test and gives an indication of the level of steroid-responsive eosinophilic airway inflammation, reducing exacerbations, a major clinical problem in pregnant women with asthma.

Conclusions

Asthma is a common comorbidity during pregnancy and exacerbations are a major clinical problem, with up to 45% of women requiring medical intervention for asthma during pregnancy, resulting in poor outcomes for mothers and their babies. Guidelines recommend managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for adults and management of comorbid conditions. Improvements have been made in recent years in emergency department management of asthma in pregnancy, and multidisciplinary approaches are being proposed to optimise both asthma outcomes and perinatal outcomes. One strategy that has been successful in reducing exacerbations in pregnancy is treatment adjustment using a marker of eosinophilic lung inflammation, F_eNO. Further evidence is needed to determine whether this strategy can also improve perinatal outcomes and be successfully translated into clinical practice.

Educational questions

1. Which of the following statements concerning guidelines for the management of asthma during pregnancy is/are correct?

   • a Inhaled corticosteroids should be used when women have persistent asthma

   • b Asthma should be managed as for other adults, with the exception of oral corticosteroid use during exacerbations

   • c Multidisciplinary management is recommended

   • d It is important to identify and manage comorbid conditions such as rhinitis or reflux

   • e Asthma should be reviewed every 4 weeks during pregnancy.

2. A woman presents to her general practitioner with asthma symptoms during pregnancy. She has previously admitted to nonadherence to her preventer medication and is concerned about whether this medication is harmful for her baby. Which is the most appropriate clinical decision?

   • a Withdraw all preventer medication and advise her to take more doses of her reliever

   • b Make a referral for her to see a respiratory specialist

   • c Advise her of the safety and importance of taking preventer medications in pregnancy, and advise her to continue her prescribed dose and return for review if symptoms continue to worsen

   • d Perform spirometry and provide a prescription for a different preventer medication

3. Which of the following statements is/are true concerning the risks of adverse perinatal outcomes in women with asthma?

   • a Women with asthma are not at risk of adverse perinatal outcomes compared to women without asthma

   • b Women with asthma are at increased risk of having a baby who dies or is hospitalised after birth

   • c Active management of asthma can reduce the risk of preterm labour and delivery

   • d Women who have exacerbations of asthma during pregnancy are at three times the risk of low birth weight compared with women without asthma exacerbations in pregnancy

4. Which of the following statements is/are true concerning inflammation-based management of asthma during pregnancy?

   • a Using a marker of airway inflammation to adjust treatment results in women taking higher doses of inhaled corticosteroids during pregnancy

   • b Using a marker of airway inflammation to adjust treatment reduces the exacerbation rate in pregnancy

   • c Exhaled nitric oxide fraction is a useful marker because it predicts the response to inhaled steroids

   • d Benefits to health in infancy have been described when inflammation-based management is used

   • e No studies have identified whether this approach improves perinatal outcomes.

Suggested Answers

1. a, c, d, e

2. c

3. b, c, d

4. b, c, d, e

Footnotes

Support statement Vanessa Murphy is supported by a Career Development Fellowship from the National Health and Medical Research Council of Australia.

Conflict of interest None declared.

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Managing asthma in pregnancy

Breathe (Sheff). 2015 Dec; 11(4): 258–267.

Centre for Asthma and Respiratory Disease, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia

Corresponding author.This article has been cited by other articles in PMC.

Abstract

Asthma is a common comorbidity during pregnancy and its prevalence is increasing in the community. Exacerbations are a major clinical problem during pregnancy with up to 45% of women needing to seek medical help, resulting in poor outcomes for mothers and their babies, including low birth weight and preterm delivery. The goals of effective asthma management in pregnancy are to maintain the best possible asthma control and prevent exacerbations. This is achieved by aiming to prevent day- and night-time symptoms, and maintain lung function and normal activity. In addition, maintaining fetal oxygenation is an important consideration in pregnancy. Guidelines recommend providing asthma advice and review prior to conception, and managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for other adults with asthma, and management of comorbid conditions such as rhinitis.

Improvements have been made in recent years in emergency department management of asthma in pregnancy, and multidisciplinary approaches are being proposed to optimise both asthma outcomes and perinatal outcomes. One strategy that has demonstrated success in reducing exacerbations in pregnancy is treatment adjustment using a marker of eosinophilic lung inflammation, the exhaled nitric oxide fraction (F_eNO). The use of an algorithm that adjusted inhaled corticosteroids (ICS) according to F_eNO and added long-acting β-agonists when symptoms remained uncontrolled resulted in fewer exacerbations, more women on ICS but at lower mean doses, and improved infant respiratory health at 12 months of age. Further evidence is needed to determine whether this strategy can also improve perinatal outcomes and be successfully translated into clinical practice.

Key points

• Asthma is the most common chronic disease to affect pregnant women.

• Exacerbations occur in up to 45% of pregnant women with asthma.

• Asthma should be managed during pregnancy as for other adults.

• Treatment adjustment using a marker of airway inflammation reduces the exacerbation rate in pregnancy.

Educational aims

• To identify the goals of and steps associated with effective asthma management in pregnancy.

• To understand the maternal and perinatal risks associated with asthma during pregnancy.

• To describe a management strategy that has been shown to reduce exacerbations in pregnant women with asthma.

Short abstract

Guidelines for the management of asthma during pregnancy exist but are too rarely used in clinical practice
http://ow.ly/U8Sq8

Introduction

Asthma is the most common chronic medical condition to be reported during pregnancy and its prevalence in the population has increased in recent decades. Kwon
et al. [1] reported an increase in the prevalence of asthma during pregnancy from 3.7% in 1997 to 8.4% in 2001. More recent reports from the USA found a prevalence of 5.5% in 2001, increasing to 7.8% in 2007 [2]. A prevalence of 9.3% has been reported in Ireland [3] and 12.7% in Australia [4]. Maternal asthma is associated with an increased risk of adverse perinatal outcomes, and changes in the course of the disease are to be expected and can be unpredictable during pregnancy. Optimising asthma management in pregnancy is paramount for protecting the health of both mother and baby.

Guidelines for the management of asthma during pregnancy

International guidelines are available that outline the goals of successful asthma management and recommendations for clinical management of asthma in pregnancy [5]. Goals include the prevention of chronic day and night symptoms, maintenance of optimal pulmonary function and normal activities, and prevention of exacerbations, using therapies with minimal or no adverse side-effects [5]. During pregnancy, there is the additional goal to maintain fetal oxygenation by preventing episodes of maternal hypoxia [5]. Achieving this requires regular monitoring of clinical symptoms, provision of self-management education and the correct use of pharmacotherapies. Multidisciplinary management by all health professionals involved in a woman’s care is encouraged [5].

A stepwise approach to asthma treatment is recommended during pregnancy as for other adults with asthma [5]. Guidelines recommend the use of short acting β-agonists (SABA) as reliever medication and the use of inhaled corticosteroids (ICS) for women with persistent asthma [5]. There is much reassuring data concerning the safety of ICS medication use in pregnancy, particularly for budesonide, which has the best safety rating during pregnancy. Guidelines recommend the continued use of ICS medication that has been effective in controlling asthma prior to pregnancy [5].

In 2014, the Australian National Asthma Council released updated guidelines for asthma management (www.asthmahandbook.org.au), including a section on pregnancy. These guidelines recommend managing asthma actively during pregnancy, as for asthma in other adults, including prescribing preventers if indicated, and stepping up the regimen as necessary with the goal to maintain the best possible asthma control and avoid exacerbations. Regular review of asthma every 4 weeks during pregnancy is recommended, with asthma control assessed each time. In addition, comorbidities such as rhinitis or gastro-oesophageal reflux, which can contribute to worsening asthma, should be identified and managed. In terms of exacerbations, the Australian guidelines recommend intervening early, providing a written action plan with a low threshold for seeking medical help and ensuring prompt treatment in emergency departments to minimise risks to the fetus. Preconception care is also suggested, with recommendations to offer advice that uncontrolled asthma or asthma exacerbations put both mothers and babies at risk, provide an asthma review prior to conception including performing baseline spirometry, offering a written action plan, smoking cessation advice and vaccinations as required, and discussing the need to continue taking preventer therapies (if prescribed) when pregnant.

Despite clear guidelines for the management of asthma during pregnancy, there is evidence of suboptimal management in primary care. An Australian survey of 174 general practitioners (GPs) found that there was a lack of knowledge and confidence in managing asthma during pregnancy, with 25.8% of respondents indicating that they would stop or decrease ICS doses even among pregnant women whose asthma was well controlled on current therapy [6]. 12% of GPs indicated that they did not know how to manage a deterioration of asthma during pregnancy and would refer the patient to another health professional, while 67% would increase her dose. Although ICS were perceived to be the safest and preferred preventer medication for use in the first trimester, there was considerable concern about the safety of leukotriene receptor antagonists (LTRA) in the first trimester, with 45% of GPs indicating that they did not consider them safe, while many GPs did not consider long acting β-agonists (LABA) or oral corticosteroids (OCS) to be safe in the first trimester [6]. Nearly half of the respondents reported having patients who were nonadherent during pregnancy; however, 82% were likely to reinforce the need for continuing preventer medication among women who reported stopping this when becoming pregnancy [6], which was an encouraging finding.

In Spain, a multiple-choice survey related to the use of asthma management guidelines for pregnant patients was completed in 2009 by 1000 healthcare professionals, including primary care physicians (46%), respiratory specialists (20%), allergy specialists (17%) and obstetricians (17%) [7]. While 96.5% of respondents indicated that they found guidelines useful, 64% also indicated that they seldom or never followed guidelines. Asthma in pregnancy guidelines were more likely to be used by respiratory and allergy specialists (56.6% and 60.4% respectively) than by primary care physicians (25.3%) or obstetricians (16.3%). Just over half of physicians would maintain asthma therapy in patients who were clinically stable, while 25.5% would suggest medications be used “on demand”, 17.6% would send the patient to a specialist (47.7% of obstetricians answered this way) and 1% would withdraw all medication. 30% believed spirometry was not recommended in pregnant asthmatic patients, while 10% would use spirometry monthly and 37% only if symptomatic. Most allergists (83.7%) would continue with specific immunotherapy in pregnancy, while less than one-third of the other physicians would continue immunotherapy [7]. These data indicate a difference in the way asthma is managed in pregnancy depending on the healthcare specialist and reinforces the need for education for all of the multidisciplinary team managing a pregnant woman’s asthma.

Use of asthma medications in pregnancy

Recently published data indicates that undertreatment of asthma during pregnancy remains an issue. Among women reporting having asthma, asthma medications were used by 63% in an American study (2001–2007) [2] and 62.9% in an Irish study (2000–2007) [3]. In the American study, around a quarter of these women were using ICS and a further 4% an ICS/LABA combination [2]. In the Irish study, 23% were using ICS [3]. A Korean study analysing data from 2009 to 2013 found that ICS was used by 15% of pregnant women with asthma, and ICS/LABA by a further 10.5% [8]. In a 2009 Australian survey, 19% of women were using a preventer for asthma treatment in pregnancy, while 57% of women reported use of reliever medication only and 24.5% of women were not using any pharmacological treatments [4]. This study also reported pre-pregnancy medication use and found that this period was associated with greater use of medications, with only 7.8% of women not using medication for asthma prior to pregnancy [4]. These data demonstrate a disconnect between asthma medication use prior to pregnancy and once pregnant, potentially due to changes in prescribing habits, perceived risks held by women or health professionals, or a change in asthma disease severity or control with pregnancy.

Nonadherence to prescribed ICS medications has been outlined in many studies of pregnant women with asthma [9]. A small study of 32 Turkish pregnant women with asthma was recently published [10]. More than half of the women (56%) were “irregular” users of asthma medication during pregnancy, which was not significantly different from pre-pregnancy (68%). During pregnancy, 52% of women were using ICS, while 22% did not use any medication for their asthma while pregnant. Exacerbations among this study population were high, with 13% hospitalised, 22% receiving OCS and 47% having an emergency visit during pregnancy [10], and undertreatment was likely a contributing factor. Pregnant women themselves perceive there to be a risk of using asthma medications during pregnancy. Powell
et al. [11] found that women assigned minimal risk to SABA such as salbutamol (0.5 cm on a 10-cm visual analogue scale), with greater risks for ICS (1.2 cm) and OCS (4.5 cm). This translates to a decline in asthma medication use, particularly in early pregnancy, with one study of prescriptions reporting a 13% decline in SABA use, a 23% decline in ICS use and 54% decline in OCS use in the first trimester compared to the 20 weeks prior to pregnancy [12].

Data has recently been published from the Xolair Pregnancy Registry, a prospective study of outcomes among 160 infants whose mothers used the anti-IgE medication omalizumab during pregnancy [13]. Omalizumab is used in patients with moderate–severe asthma who are not adequately controlled with ICS. The majority of women monitored in this study were exposed to omalizumab during the first trimester, with a median total duration of exposure during pregnancy of 8.8 months. Infants were born at a mean gestational age of 38.3 weeks and among singletons, the rates of prematurity (14.5%), small for gestational age (10.9%) and low birth weight (3.2%) were consistent with data from other studies of women with asthma. Congenital malformations were reported in 20 infants, of which seven were considered major malformations. This registry is ongoing and further data are expected to be reported once 250 women have been recruited [13].

Asthma exacerbations and healthcare utilisation during pregnancy

Asthma exacerbations are a significant clinical problem during pregnancy. Up to 45% of pregnant women with asthma have moderate–severe exacerbations requiring medical intervention during pregnancy [14]. In addition to the adverse effect on maternal health, exacerbations are a key contributor to adverse perinatal outcomes in asthma. Exacerbations, oral steroid use and severe asthma are associated with preterm delivery, possibly due to maternal hypoxia, the effects of maternal inflammation and/or changes in uterine smooth muscle function [15]. In addition, women with exacerbations of asthma are three times more likely to have a low birth weight baby compared to asthmatic women without exacerbations [16], suggesting that prevention of exacerbations during pregnancy may also lead to improvements in perinatal outcomes.

In a Korean study of asthma during pregnancy, Kim
et al. [8] found that the rate of hospitalisation for asthma was higher among pregnant women (1.3%) than nonpregnant women (0.8%), after adjusting for age and exacerbation history; however, the length of hospital stay and number of hospitalisations per person was no different between these groups. Emergency department treatment for asthma occurred in 0.4% of pregnant women with asthma, while the number of outpatient visits was significantly lower than for their nonpregnant counterparts, with an increase observed after delivery. In addition, the use of medications was significantly lower in pregnancy for ICS/LABA combinations, LTRA, SABA, systemic steroids, xanthine derivatives and systemic LABA. Asthma exacerbations (measured by hospital admission) were 2.7 times more frequent in the subgroup of women with newly diagnosed asthma during pregnancy, and outpatient visits and prescriptions for asthma medications were also more frequent. Almost half of all women with newly diagnosed asthma were prescribed ICS or ICS/LABA combinations while only 14.6% of women with previously diagnosed asthma used these medications. However, the rate of hospitalisation and emergency department visits did not differ between these two groups. Overall, the proportion of women with hospitalisations (where OCS was prescribed for at least 3 days) increased from 0.2% in the first trimester to 0.5% in the second trimester and 0.7% in the third trimester. Severe exacerbations were experienced by 5.3% of participants [8], consistent with previous findings [17].

These studies demonstrate the potential for asthma status to markedly change during pregnancy and from trimester to trimester. Typically, approximately at least one-third of women with asthma report a worsening in their usual symptoms, one-third have no change and one-third have an improvement [18]. It is also recognised that women with mild disease are still at risk of severe exacerbations during pregnancy, and for this reason, regular monitoring of asthma during pregnancy is recommended [5].

Emergency department management of asthma exacerbations during pregnancy

Pregnant women with asthma exacerbations should be treated in the same way as nonpregnant adults with exacerbations. However, there is evidence from studies in emergency departments that this does not occur. A retrospective study from the USA compared OCS treatment during exacerbations among 123 pregnant and 123 nonpregnant women with asthma between 1996 and 2009 [19]. During the acute care visit, significantly more nonpregnant women were treated with OCS (72.4%) compared with pregnant women (50.8%), while 69% of nonpregnant women were prescribed OCS at discharge compared with 41% of pregnant women. The pregnant women were significantly more likely to return to the emergency department within 2 weeks of discharge (9.7%) compared with the nonpregnant women (2.5%) [19]. These data were comparable to an earlier multicentre study from 36 emergency departments in the USA, where 51 pregnant women were compared with 500 nonpregnant women with similar peak expiratory flow rates and duration of asthma symptoms [20]. Here, 66% of nonpregnant women were treated with OCS, compared with only 44% of pregnant women. In addition, the pregnant women were 2.9 times more likely to report an ongoing exacerbation at the 2-week follow-up compared with the nonpregnant women [20]. A recent update from the same authors compared emergency department care of pregnant women with asthma from 1996–2001 to 2001–2012 [21]. They demonstrated that treatment with OCS increased from 51% to 78% and that the prescription of OCS at discharge rose from 42% to 63% over this time period, indicating a recent improvement in emergency department management of asthma exacerbations during pregnancy [21].

Recent data from a relatively small retrospective study of 39 women showed that pregnant women with asthma (n=28) were less likely to be prescribed OCS at the time of exacerbation (83%) than nonpregnant women with asthma (n=19, 100%) and where OCS were not prescribed at the first medical encounter, there was a delay in their prescription of 5.8 days [22]. OCS were prescribed during 87.5% of first-trimester exacerbations but only 70.6% of second-trimester and 66.7% of third-trimester exacerbations. While this may indicate an increasing reluctance to prescribe steroids as pregnancy progresses, it is possible that the severity of exacerbations in the third trimester was different from exacerbations earlier in pregnancy. This study also found that pregnant women were equally likely to fill their OCS prescription in the community after exacerbation (65%) as the nonpregnant women (67%), implying that the change in OCS use in pregnancy may be more related to prescribing habits than reduced use by pregnant women themselves, consistent with studies performed in the emergency department setting.

Intensive care management of status asthmaticus during pregnancy

There is limited literature available regarding the management of pregnant women with asthma in intensive care. A recent review suggests that multidisciplinary intensive care unit (ICU) care involving intensivists, asthma specialists, neonatologists and specialist high-risk obstetricians for pregnant women with status asthmaticus can result in good outcomes for both mother and baby, even when intubation is necessary [23]. Women whose asthma does not respond to or worsens despite maximal bronchodilator therapy in the emergency or hospital setting should be considered for ICU admission [23]. A series of five cases of status asthmaticus in pregnancy was reported from an inner city hospital in New York, NY, USA, in 2008 [24]. Three cases occurred early in pregnancy (6 weeks, 9 weeks and 14 weeks gestation), with the other two later in pregnancy (27 weeks and 28 weeks gestation). One case occurred in a woman with mild persistent asthma, highlighting the risk of severe exacerbations in pregnancy, even in those with previously mild disease. She developed severe respiratory distress and was placed on mechanical ventilation for 8 days. One woman had two admissions to the ICU, at 28 weeks and 34 weeks gestation. The second time, she was in respiratory distress and required continuous nebulised β-agonist, along with monitoring for potential respiratory failure. Her situation deteriorated on the fourth day, and a caesarean section was performed, with bronchospasm improving significantly after delivery. In all cases presented, there were no adverse perinatal outcomes (one pregnancy was terminated at 6 weeks). The importance of prevention of severe asthma exacerbations during pregnancy and slowing their progression to status asthmaticus is emphasised [23].

Multidisciplinary approaches to the management of asthma in pregnancy

A multi-disciplinary management approach is recommended during pregnancy [5]. There are several healthcare professionals that are well positioned to offer asthma self-management education and to co-ordinate management of asthma during pregnancy. These include nurses, asthma educators, pharmacists, midwives and primary care physicians. In addition, obstetricians and respiratory specialists may be involved in antenatal asthma management.

Nurse-led approaches

In 2005, data from Australia demonstrated the potential for nurses to improve health and self-management among pregnant women with asthma [9]. At their initial visit with an asthma nurse educator (at 20 weeks gestation), pregnant women with asthma had poor adherence (40% self-reported nonadherence with ICS), poor knowledge about asthma medications (42% were inadequate) and poor device technique (16% had inadequate inhaler technique). Following education, there were improvements in all aspects of asthma self-management, such that nonadherence fell to 21% and inadequate inhaler technique to 4%. In women classified as having severe asthma, night-time symptoms and reliever medication use were significantly reduced after education [9]. This study was not powered to investigate changes in exacerbations or perinatal outcomes; however, another Australian randomised controlled trial (RCT) is proposed that plans to test a similar approach in 378 women, involving a nurse-led intervention in the antenatal clinic setting with exacerbations as the primary outcome [25].

Pharmacist-led approaches

Lim
et al. [26] recently published a RCT testing a multidisciplinary asthma management strategy against usual care in 60 pregnant women with asthma, who were recruited prior to 20 weeks’ gestation. The monthly intervention involved visits to a pharmacist who provided education about self-management strategies, monitored asthma control and consulted with the woman’s GP when step-up of ICS therapy was required. The intervention group had a statistically and clinically significant improvement in asthma control after 6 months; however, this was potentially very late in pregnancy or post partum, and no changes in asthma control were observed between groups at the more clinically relevant time-point of 3 months post-randomisation [26].

Involvement of midwives in antenatal asthma management

While international guidelines suggest that management of asthma during pregnancy should be multidisciplinary, very few studies have investigated the role of the midwife in antenatal asthma management, despite their primary care role in many countries. A qualitative, descriptive study has been undertaken in Australia to explore midwives’ knowledge and understanding of asthma during pregnancy, and their perceived role in this area [27]. Data published to date indicate that midwives identify many barriers that prevent them from participating in antenatal asthma management, including lack of time, lack of knowledge about asthma during pregnancy, and lack of available equipment and referral pathways for women with asthma. Issues such as lack of time and knowledge are common barriers for midwives when faced with the implementation of additional education strategies for issues such as oral health, antenatal depression, genetic counselling and smoking cessation. Further research is needed to determine the importance pregnant women with asthma place on various caregivers during their pregnancy and who they would like to be providing asthma management. A study from the USA found that many women were likely to continue their ICS medication if advised to do so by their obstetrician [28], indicating the potential importance obstetric caregivers have in influencing women’s health behaviours surrounding asthma during pregnancy.

Dietary approaches

Grieger
et al. [29] have proposed that some of the poor perinatal outcomes associated with maternal asthma may be driven by increased oxidative stress as a result of both pregnancy and asthma. In nonpregnant adults, dietary intervention studies have demonstrated the protective effects of antioxidants in asthma; however, these approaches are yet to be tested in pregnancy. Observational data indicate that pregnant women with moderate or severe asthma have alterations in circulating antioxidants including α-tocopherol and total carotenoids, compared to women with mild or no asthma, and low concentrations were associated with reduced fetal growth [30]. Further work is required to determine whether dietary approaches can improve maternal and fetal outcomes in women with asthma.

Smoking cessation for pregnant women with asthma

Smoking is a critical issue for pregnant women with asthma, with data showing that women who smoke are more likely to have exacerbations during pregnancy and to have more severe symptoms during exacerbation [14]. Studies from around the world have suggested that pregnant women with asthma are more likely to smoke than pregnant women without asthma [15]. The 20–30% of women with asthma who continue to smoke during pregnancy are at increased risk of poor perinatal outcomes from the combined effects of smoking, asthma and severe asthma exacerbations. However, no studies have trialled smoking cessation strategies among this population of women.

A recent study from Denmark has identified the effects of both active smoking and passive smoking on asthma control [31]. Of the 500 women in this study, 6.4% were current smokers and 23% were ex-smokers, most of whom had quit smoking upon becoming pregnant. Of those who had never smoked, 18.4% reported passive smoking; that is, they lived with someone who smoked at home. Overall, those who had ever smoked had reduced lung function compared to never-smokers, while the effects of passive smoking among never-smokers showed similar patterns, with significantly reduced lung function, greater requirements for ICS and a higher likelihood of partly or uncontrolled asthma, compared to never-smokers without passive exposure [31]. These data suggest that passive smoking is potentially contributing to worse asthma control during pregnancy, which could have negative impacts on perinatal health.

Experiences of pregnant women in relation to asthma management in pregnancy

Two studies have examined the perspective of pregnant women in relation to their asthma and asthma care during pregnancy. Lim
et al. [32] conducted qualitative interviews with 23 pregnant women with asthma in Australia, at various stages of their pregnancy or up to 5 weeks post partum. Some women expressed the view that there were risks associated with asthma medication use during pregnancy, particularly related to steroid use, and they were therefore cautious about using ICS unless “desperate”. Their views about the safety of reliever medication such as salbutamol were quite different, however, with women preferring to use a lot of reliever therapy rather than preventers. There were also women who were more concerned about the possible risks of uncontrolled asthma and whether the baby was receiving enough oxygen. In terms of management by health professionals, the women noted that their GP was not concerned about their asthma and that other issues with the pregnancy often took priority. In addition, there was a view that there was a lack of information given about asthma during pregnancy, and that doctors and pharmacists were unclear about the safety of medication use in pregnancy, forcing some women to make a decision for themselves or consult “Dr Google”, where they obtained unreliable or inaccurate information [32].

A similar qualitative study was reported from the UK, in which seven women with asthma who had been pregnant within the previous 2 years were interviewed [33]. Four of these seven women reported a worsening of asthma symptoms during pregnancy, and these women expressed feelings of fear, panic and anxiety surrounding exacerbations, and a lack of understanding that some of their symptoms were due to asthma rather than the pregnancy itself. They expressed the need for more education and information so that they would have an awareness of the potential seriousness of asthma, and where to seek help. There was a lack of understanding about asthma medications and how they worked, as well as whether they were safe to use, by both women and their partners, which led to women “getting on with it” without support or assistance. This series of interviews conducted in 2012 identified that women generally did not have regular contact with GPs or practice nurses about their asthma and that management plans to monitor asthma during pregnancy were not in place, with one woman describing that her GP took her off her medication when she expressed concern about using it while pregnant. The perception was that midwives did not know much about asthma and concentrated more on issues surrounding the pregnancy. In addition, two women described delays in obtaining care when they had exacerbations of asthma requiring admission to hospital [33]. More work is needed to clarify the priorities of pregnant women themselves with regard to their asthma management in pregnancy.

The importance of active management for better maternal and fetal outcomes

The provision of optimal asthma management is essential for the health of both mother and baby. A recent systematic review and meta-analyses summarised the literature concerning the risks of adverse perinatal outcomes in women with asthma [34–36]. Compared to pregnant women without asthma, women with asthma are at risk of a range of adverse pregnancy outcomes affecting the mother, placenta and neonate, including preterm delivery, low birth weight, pre-eclampsia [34], gestational diabetes, caesarean section, placenta praevia [36], congenital malformations, neonatal hospitalisation and neonatal death [35]. Despite the fact that the majority of women included in the primary studies would be expected to have mild asthma, the effect of asthma on perinatal outcomes was still significant, suggesting that there may be a greater adverse effect among the subgroup with more severe disease [37]. Indeed, women with moderate or severe asthma were more likely to have small for gestational age babies than women with mild asthma [16]. Another interesting finding of this review was that active management of asthma during pregnancy may mitigate some of the increased perinatal risks. In the meta-analysis, when studies were grouped based on the provision of active asthma management, the risk associated with maternal asthma was reduced to nonsignificant for some perinatal outcomes. For example, women with asthma had a 50% increased risk for preterm delivery compared to women without asthma when no active management was given [34]. However, among five studies where active management was provided, the risk of preterm delivery was no longer increased or statistically significant, suggesting that active asthma management may be effective in reducing the risk of preterm delivery [34]. Similar results were observed for preterm labour [34] and neonatal hospitalisation [35]. The reduced risk of neonatal hospitalisation may be a consequence of improvements in gestational age and other birth outcomes. A reduction in preterm births with active asthma management is plausible, given that one of the benefits would be a reduction in the number of exacerbations and courses of oral steroids used, both of which have been implicated in larger studies as contributing to the risk of preterm delivery in asthmatic women.

Interventions for improving asthma management during pregnancy

There have been very few recent RCTs of interventions for managing asthma during pregnancy. A 2014 Cochrane review summarised eight RCTs involving 1181 women with asthma [38]. Five of the trials assessed pharmacological interventions and three assessed nonpharmacological interventions. The trials were of moderate quality overall and did not lead to any firm conclusions regarding optimal asthma management in pregnancy, due to a lack of clear benefits of pharmacological approaches over current practice and a lack of power in the nonpharmacological interventions to detect differences in perinatal outcomes [38].

Inflammation-based management of asthma during pregnancy

Only one study has successfully trialled a management approach that reduces exacerbations during pregnancy. The MAP (Managing Asthma in Pregnancy) Study from Australia was a double-blind, parallel-group RCT which tested the efficacy of an inflammation-based management strategy for reducing exacerbations in 220 nonsmoking pregnant women with asthma [39]. Women were randomised prior to 22 weeks gestation. The control group had treatment adjusted according to the results of the Asthma Control Questionnaire (ACQ), representing symptoms and lung function. The intervention group had treatment adjusted according to both the level of eosinophilic airway inflammation and the ACQ. Airway inflammation was measured by exhaled nitric oxide fraction (F_eNO), a steroid sensitive marker of eosinophilia, and used to adjust ICS. The ACQ was used to determine when symptoms remained uncontrolled, in which case a LABA was added. Both groups had stepwise ICS treatment adjustments (up or down) made monthly, and received free medications and self-management education. The primary study outcome was exacerbations requiring medical intervention, defined as hospitalisation, emergency department presentation, use of OCS or unscheduled doctor visit for asthma. There was a 50% reduction in exacerbations in the F_eNO group compared to the control group, along with alterations to the treatment profile, with more women from the F_eNO group being prescribed ICS (at a lower mean dose) and ICS/LABA combination therapy. In addition, there was a significant reduction in both OCS and SABA use, and a significantly higher quality of life in the F_eNO group compared to the control group [39]. The infants from this study were followed up at 12 months of age and those from mothers in the F_eNO group were significantly less likely to have recurrent bronchiolitis or recurrent croup reported by their parents [40], suggesting a potential long-term benefit to the health of the offspring. The F_eNO-based management approach has the potential to be widely used in clinical practice, as F_eNO is easily measured using a noninvasive breath test and gives an indication of the level of steroid-responsive eosinophilic airway inflammation, reducing exacerbations, a major clinical problem in pregnant women with asthma.

Conclusions

Asthma is a common comorbidity during pregnancy and exacerbations are a major clinical problem, with up to 45% of women requiring medical intervention for asthma during pregnancy, resulting in poor outcomes for mothers and their babies. Guidelines recommend managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for adults and management of comorbid conditions. Improvements have been made in recent years in emergency department management of asthma in pregnancy, and multidisciplinary approaches are being proposed to optimise both asthma outcomes and perinatal outcomes. One strategy that has been successful in reducing exacerbations in pregnancy is treatment adjustment using a marker of eosinophilic lung inflammation, F_eNO. Further evidence is needed to determine whether this strategy can also improve perinatal outcomes and be successfully translated into clinical practice.

Educational questions

1. Which of the following statements concerning guidelines for the management of asthma during pregnancy is/are correct?

   • a Inhaled corticosteroids should be used when women have persistent asthma

   • b Asthma should be managed as for other adults, with the exception of oral corticosteroid use during exacerbations

   • c Multidisciplinary management is recommended

   • d It is important to identify and manage comorbid conditions such as rhinitis or reflux

   • e Asthma should be reviewed every 4 weeks during pregnancy.

2. A woman presents to her general practitioner with asthma symptoms during pregnancy. She has previously admitted to nonadherence to her preventer medication and is concerned about whether this medication is harmful for her baby. Which is the most appropriate clinical decision?

   • a Withdraw all preventer medication and advise her to take more doses of her reliever

   • b Make a referral for her to see a respiratory specialist

   • c Advise her of the safety and importance of taking preventer medications in pregnancy, and advise her to continue her prescribed dose and return for review if symptoms continue to worsen

   • d Perform spirometry and provide a prescription for a different preventer medication

3. Which of the following statements is/are true concerning the risks of adverse perinatal outcomes in women with asthma?

   • a Women with asthma are not at risk of adverse perinatal outcomes compared to women without asthma

   • b Women with asthma are at increased risk of having a baby who dies or is hospitalised after birth

   • c Active management of asthma can reduce the risk of preterm labour and delivery

   • d Women who have exacerbations of asthma during pregnancy are at three times the risk of low birth weight compared with women without asthma exacerbations in pregnancy

4. Which of the following statements is/are true concerning inflammation-based management of asthma during pregnancy?

   • a Using a marker of airway inflammation to adjust treatment results in women taking higher doses of inhaled corticosteroids during pregnancy

   • b Using a marker of airway inflammation to adjust treatment reduces the exacerbation rate in pregnancy

   • c Exhaled nitric oxide fraction is a useful marker because it predicts the response to inhaled steroids

   • d Benefits to health in infancy have been described when inflammation-based management is used

   • e No studies have identified whether this approach improves perinatal outcomes.

Suggested Answers

1. a, c, d, e

2. c

3. b, c, d

4. b, c, d, e

Footnotes

Support statement Vanessa Murphy is supported by a Career Development Fellowship from the National Health and Medical Research Council of Australia.

Conflict of interest None declared.

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Managing asthma in pregnancy

Breathe (Sheff). 2015 Dec; 11(4): 258–267.

Centre for Asthma and Respiratory Disease, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia

Corresponding author.This article has been cited by other articles in PMC.

Abstract

Asthma is a common comorbidity during pregnancy and its prevalence is increasing in the community. Exacerbations are a major clinical problem during pregnancy with up to 45% of women needing to seek medical help, resulting in poor outcomes for mothers and their babies, including low birth weight and preterm delivery. The goals of effective asthma management in pregnancy are to maintain the best possible asthma control and prevent exacerbations. This is achieved by aiming to prevent day- and night-time symptoms, and maintain lung function and normal activity. In addition, maintaining fetal oxygenation is an important consideration in pregnancy. Guidelines recommend providing asthma advice and review prior to conception, and managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for other adults with asthma, and management of comorbid conditions such as rhinitis.

Improvements have been made in recent years in emergency department management of asthma in pregnancy, and multidisciplinary approaches are being proposed to optimise both asthma outcomes and perinatal outcomes. One strategy that has demonstrated success in reducing exacerbations in pregnancy is treatment adjustment using a marker of eosinophilic lung inflammation, the exhaled nitric oxide fraction (F_eNO). The use of an algorithm that adjusted inhaled corticosteroids (ICS) according to F_eNO and added long-acting β-agonists when symptoms remained uncontrolled resulted in fewer exacerbations, more women on ICS but at lower mean doses, and improved infant respiratory health at 12 months of age. Further evidence is needed to determine whether this strategy can also improve perinatal outcomes and be successfully translated into clinical practice.

Key points

• Asthma is the most common chronic disease to affect pregnant women.

• Exacerbations occur in up to 45% of pregnant women with asthma.

• Asthma should be managed during pregnancy as for other adults.

• Treatment adjustment using a marker of airway inflammation reduces the exacerbation rate in pregnancy.

Educational aims

• To identify the goals of and steps associated with effective asthma management in pregnancy.

• To understand the maternal and perinatal risks associated with asthma during pregnancy.

• To describe a management strategy that has been shown to reduce exacerbations in pregnant women with asthma.

Short abstract

Guidelines for the management of asthma during pregnancy exist but are too rarely used in clinical practice
http://ow.ly/U8Sq8

Introduction

Asthma is the most common chronic medical condition to be reported during pregnancy and its prevalence in the population has increased in recent decades. Kwon
et al. [1] reported an increase in the prevalence of asthma during pregnancy from 3.7% in 1997 to 8.4% in 2001. More recent reports from the USA found a prevalence of 5.5% in 2001, increasing to 7.8% in 2007 [2]. A prevalence of 9.3% has been reported in Ireland [3] and 12.7% in Australia [4]. Maternal asthma is associated with an increased risk of adverse perinatal outcomes, and changes in the course of the disease are to be expected and can be unpredictable during pregnancy. Optimising asthma management in pregnancy is paramount for protecting the health of both mother and baby.

Guidelines for the management of asthma during pregnancy

International guidelines are available that outline the goals of successful asthma management and recommendations for clinical management of asthma in pregnancy [5]. Goals include the prevention of chronic day and night symptoms, maintenance of optimal pulmonary function and normal activities, and prevention of exacerbations, using therapies with minimal or no adverse side-effects [5]. During pregnancy, there is the additional goal to maintain fetal oxygenation by preventing episodes of maternal hypoxia [5]. Achieving this requires regular monitoring of clinical symptoms, provision of self-management education and the correct use of pharmacotherapies. Multidisciplinary management by all health professionals involved in a woman’s care is encouraged [5].

A stepwise approach to asthma treatment is recommended during pregnancy as for other adults with asthma [5]. Guidelines recommend the use of short acting β-agonists (SABA) as reliever medication and the use of inhaled corticosteroids (ICS) for women with persistent asthma [5]. There is much reassuring data concerning the safety of ICS medication use in pregnancy, particularly for budesonide, which has the best safety rating during pregnancy. Guidelines recommend the continued use of ICS medication that has been effective in controlling asthma prior to pregnancy [5].

In 2014, the Australian National Asthma Council released updated guidelines for asthma management (www.asthmahandbook.org.au), including a section on pregnancy. These guidelines recommend managing asthma actively during pregnancy, as for asthma in other adults, including prescribing preventers if indicated, and stepping up the regimen as necessary with the goal to maintain the best possible asthma control and avoid exacerbations. Regular review of asthma every 4 weeks during pregnancy is recommended, with asthma control assessed each time. In addition, comorbidities such as rhinitis or gastro-oesophageal reflux, which can contribute to worsening asthma, should be identified and managed. In terms of exacerbations, the Australian guidelines recommend intervening early, providing a written action plan with a low threshold for seeking medical help and ensuring prompt treatment in emergency departments to minimise risks to the fetus. Preconception care is also suggested, with recommendations to offer advice that uncontrolled asthma or asthma exacerbations put both mothers and babies at risk, provide an asthma review prior to conception including performing baseline spirometry, offering a written action plan, smoking cessation advice and vaccinations as required, and discussing the need to continue taking preventer therapies (if prescribed) when pregnant.

Despite clear guidelines for the management of asthma during pregnancy, there is evidence of suboptimal management in primary care. An Australian survey of 174 general practitioners (GPs) found that there was a lack of knowledge and confidence in managing asthma during pregnancy, with 25.8% of respondents indicating that they would stop or decrease ICS doses even among pregnant women whose asthma was well controlled on current therapy [6]. 12% of GPs indicated that they did not know how to manage a deterioration of asthma during pregnancy and would refer the patient to another health professional, while 67% would increase her dose. Although ICS were perceived to be the safest and preferred preventer medication for use in the first trimester, there was considerable concern about the safety of leukotriene receptor antagonists (LTRA) in the first trimester, with 45% of GPs indicating that they did not consider them safe, while many GPs did not consider long acting β-agonists (LABA) or oral corticosteroids (OCS) to be safe in the first trimester [6]. Nearly half of the respondents reported having patients who were nonadherent during pregnancy; however, 82% were likely to reinforce the need for continuing preventer medication among women who reported stopping this when becoming pregnancy [6], which was an encouraging finding.

In Spain, a multiple-choice survey related to the use of asthma management guidelines for pregnant patients was completed in 2009 by 1000 healthcare professionals, including primary care physicians (46%), respiratory specialists (20%), allergy specialists (17%) and obstetricians (17%) [7]. While 96.5% of respondents indicated that they found guidelines useful, 64% also indicated that they seldom or never followed guidelines. Asthma in pregnancy guidelines were more likely to be used by respiratory and allergy specialists (56.6% and 60.4% respectively) than by primary care physicians (25.3%) or obstetricians (16.3%). Just over half of physicians would maintain asthma therapy in patients who were clinically stable, while 25.5% would suggest medications be used “on demand”, 17.6% would send the patient to a specialist (47.7% of obstetricians answered this way) and 1% would withdraw all medication. 30% believed spirometry was not recommended in pregnant asthmatic patients, while 10% would use spirometry monthly and 37% only if symptomatic. Most allergists (83.7%) would continue with specific immunotherapy in pregnancy, while less than one-third of the other physicians would continue immunotherapy [7]. These data indicate a difference in the way asthma is managed in pregnancy depending on the healthcare specialist and reinforces the need for education for all of the multidisciplinary team managing a pregnant woman’s asthma.

Use of asthma medications in pregnancy

Recently published data indicates that undertreatment of asthma during pregnancy remains an issue. Among women reporting having asthma, asthma medications were used by 63% in an American study (2001–2007) [2] and 62.9% in an Irish study (2000–2007) [3]. In the American study, around a quarter of these women were using ICS and a further 4% an ICS/LABA combination [2]. In the Irish study, 23% were using ICS [3]. A Korean study analysing data from 2009 to 2013 found that ICS was used by 15% of pregnant women with asthma, and ICS/LABA by a further 10.5% [8]. In a 2009 Australian survey, 19% of women were using a preventer for asthma treatment in pregnancy, while 57% of women reported use of reliever medication only and 24.5% of women were not using any pharmacological treatments [4]. This study also reported pre-pregnancy medication use and found that this period was associated with greater use of medications, with only 7.8% of women not using medication for asthma prior to pregnancy [4]. These data demonstrate a disconnect between asthma medication use prior to pregnancy and once pregnant, potentially due to changes in prescribing habits, perceived risks held by women or health professionals, or a change in asthma disease severity or control with pregnancy.

Nonadherence to prescribed ICS medications has been outlined in many studies of pregnant women with asthma [9]. A small study of 32 Turkish pregnant women with asthma was recently published [10]. More than half of the women (56%) were “irregular” users of asthma medication during pregnancy, which was not significantly different from pre-pregnancy (68%). During pregnancy, 52% of women were using ICS, while 22% did not use any medication for their asthma while pregnant. Exacerbations among this study population were high, with 13% hospitalised, 22% receiving OCS and 47% having an emergency visit during pregnancy [10], and undertreatment was likely a contributing factor. Pregnant women themselves perceive there to be a risk of using asthma medications during pregnancy. Powell
et al. [11] found that women assigned minimal risk to SABA such as salbutamol (0.5 cm on a 10-cm visual analogue scale), with greater risks for ICS (1.2 cm) and OCS (4.5 cm). This translates to a decline in asthma medication use, particularly in early pregnancy, with one study of prescriptions reporting a 13% decline in SABA use, a 23% decline in ICS use and 54% decline in OCS use in the first trimester compared to the 20 weeks prior to pregnancy [12].

Data has recently been published from the Xolair Pregnancy Registry, a prospective study of outcomes among 160 infants whose mothers used the anti-IgE medication omalizumab during pregnancy [13]. Omalizumab is used in patients with moderate–severe asthma who are not adequately controlled with ICS. The majority of women monitored in this study were exposed to omalizumab during the first trimester, with a median total duration of exposure during pregnancy of 8.8 months. Infants were born at a mean gestational age of 38.3 weeks and among singletons, the rates of prematurity (14.5%), small for gestational age (10.9%) and low birth weight (3.2%) were consistent with data from other studies of women with asthma. Congenital malformations were reported in 20 infants, of which seven were considered major malformations. This registry is ongoing and further data are expected to be reported once 250 women have been recruited [13].

Asthma exacerbations and healthcare utilisation during pregnancy

Asthma exacerbations are a significant clinical problem during pregnancy. Up to 45% of pregnant women with asthma have moderate–severe exacerbations requiring medical intervention during pregnancy [14]. In addition to the adverse effect on maternal health, exacerbations are a key contributor to adverse perinatal outcomes in asthma. Exacerbations, oral steroid use and severe asthma are associated with preterm delivery, possibly due to maternal hypoxia, the effects of maternal inflammation and/or changes in uterine smooth muscle function [15]. In addition, women with exacerbations of asthma are three times more likely to have a low birth weight baby compared to asthmatic women without exacerbations [16], suggesting that prevention of exacerbations during pregnancy may also lead to improvements in perinatal outcomes.

In a Korean study of asthma during pregnancy, Kim
et al. [8] found that the rate of hospitalisation for asthma was higher among pregnant women (1.3%) than nonpregnant women (0.8%), after adjusting for age and exacerbation history; however, the length of hospital stay and number of hospitalisations per person was no different between these groups. Emergency department treatment for asthma occurred in 0.4% of pregnant women with asthma, while the number of outpatient visits was significantly lower than for their nonpregnant counterparts, with an increase observed after delivery. In addition, the use of medications was significantly lower in pregnancy for ICS/LABA combinations, LTRA, SABA, systemic steroids, xanthine derivatives and systemic LABA. Asthma exacerbations (measured by hospital admission) were 2.7 times more frequent in the subgroup of women with newly diagnosed asthma during pregnancy, and outpatient visits and prescriptions for asthma medications were also more frequent. Almost half of all women with newly diagnosed asthma were prescribed ICS or ICS/LABA combinations while only 14.6% of women with previously diagnosed asthma used these medications. However, the rate of hospitalisation and emergency department visits did not differ between these two groups. Overall, the proportion of women with hospitalisations (where OCS was prescribed for at least 3 days) increased from 0.2% in the first trimester to 0.5% in the second trimester and 0.7% in the third trimester. Severe exacerbations were experienced by 5.3% of participants [8], consistent with previous findings [17].

These studies demonstrate the potential for asthma status to markedly change during pregnancy and from trimester to trimester. Typically, approximately at least one-third of women with asthma report a worsening in their usual symptoms, one-third have no change and one-third have an improvement [18]. It is also recognised that women with mild disease are still at risk of severe exacerbations during pregnancy, and for this reason, regular monitoring of asthma during pregnancy is recommended [5].

Emergency department management of asthma exacerbations during pregnancy

Pregnant women with asthma exacerbations should be treated in the same way as nonpregnant adults with exacerbations. However, there is evidence from studies in emergency departments that this does not occur. A retrospective study from the USA compared OCS treatment during exacerbations among 123 pregnant and 123 nonpregnant women with asthma between 1996 and 2009 [19]. During the acute care visit, significantly more nonpregnant women were treated with OCS (72.4%) compared with pregnant women (50.8%), while 69% of nonpregnant women were prescribed OCS at discharge compared with 41% of pregnant women. The pregnant women were significantly more likely to return to the emergency department within 2 weeks of discharge (9.7%) compared with the nonpregnant women (2.5%) [19]. These data were comparable to an earlier multicentre study from 36 emergency departments in the USA, where 51 pregnant women were compared with 500 nonpregnant women with similar peak expiratory flow rates and duration of asthma symptoms [20]. Here, 66% of nonpregnant women were treated with OCS, compared with only 44% of pregnant women. In addition, the pregnant women were 2.9 times more likely to report an ongoing exacerbation at the 2-week follow-up compared with the nonpregnant women [20]. A recent update from the same authors compared emergency department care of pregnant women with asthma from 1996–2001 to 2001–2012 [21]. They demonstrated that treatment with OCS increased from 51% to 78% and that the prescription of OCS at discharge rose from 42% to 63% over this time period, indicating a recent improvement in emergency department management of asthma exacerbations during pregnancy [21].

Recent data from a relatively small retrospective study of 39 women showed that pregnant women with asthma (n=28) were less likely to be prescribed OCS at the time of exacerbation (83%) than nonpregnant women with asthma (n=19, 100%) and where OCS were not prescribed at the first medical encounter, there was a delay in their prescription of 5.8 days [22]. OCS were prescribed during 87.5% of first-trimester exacerbations but only 70.6% of second-trimester and 66.7% of third-trimester exacerbations. While this may indicate an increasing reluctance to prescribe steroids as pregnancy progresses, it is possible that the severity of exacerbations in the third trimester was different from exacerbations earlier in pregnancy. This study also found that pregnant women were equally likely to fill their OCS prescription in the community after exacerbation (65%) as the nonpregnant women (67%), implying that the change in OCS use in pregnancy may be more related to prescribing habits than reduced use by pregnant women themselves, consistent with studies performed in the emergency department setting.

Intensive care management of status asthmaticus during pregnancy

There is limited literature available regarding the management of pregnant women with asthma in intensive care. A recent review suggests that multidisciplinary intensive care unit (ICU) care involving intensivists, asthma specialists, neonatologists and specialist high-risk obstetricians for pregnant women with status asthmaticus can result in good outcomes for both mother and baby, even when intubation is necessary [23]. Women whose asthma does not respond to or worsens despite maximal bronchodilator therapy in the emergency or hospital setting should be considered for ICU admission [23]. A series of five cases of status asthmaticus in pregnancy was reported from an inner city hospital in New York, NY, USA, in 2008 [24]. Three cases occurred early in pregnancy (6 weeks, 9 weeks and 14 weeks gestation), with the other two later in pregnancy (27 weeks and 28 weeks gestation). One case occurred in a woman with mild persistent asthma, highlighting the risk of severe exacerbations in pregnancy, even in those with previously mild disease. She developed severe respiratory distress and was placed on mechanical ventilation for 8 days. One woman had two admissions to the ICU, at 28 weeks and 34 weeks gestation. The second time, she was in respiratory distress and required continuous nebulised β-agonist, along with monitoring for potential respiratory failure. Her situation deteriorated on the fourth day, and a caesarean section was performed, with bronchospasm improving significantly after delivery. In all cases presented, there were no adverse perinatal outcomes (one pregnancy was terminated at 6 weeks). The importance of prevention of severe asthma exacerbations during pregnancy and slowing their progression to status asthmaticus is emphasised [23].

Multidisciplinary approaches to the management of asthma in pregnancy

A multi-disciplinary management approach is recommended during pregnancy [5]. There are several healthcare professionals that are well positioned to offer asthma self-management education and to co-ordinate management of asthma during pregnancy. These include nurses, asthma educators, pharmacists, midwives and primary care physicians. In addition, obstetricians and respiratory specialists may be involved in antenatal asthma management.

Nurse-led approaches

In 2005, data from Australia demonstrated the potential for nurses to improve health and self-management among pregnant women with asthma [9]. At their initial visit with an asthma nurse educator (at 20 weeks gestation), pregnant women with asthma had poor adherence (40% self-reported nonadherence with ICS), poor knowledge about asthma medications (42% were inadequate) and poor device technique (16% had inadequate inhaler technique). Following education, there were improvements in all aspects of asthma self-management, such that nonadherence fell to 21% and inadequate inhaler technique to 4%. In women classified as having severe asthma, night-time symptoms and reliever medication use were significantly reduced after education [9]. This study was not powered to investigate changes in exacerbations or perinatal outcomes; however, another Australian randomised controlled trial (RCT) is proposed that plans to test a similar approach in 378 women, involving a nurse-led intervention in the antenatal clinic setting with exacerbations as the primary outcome [25].

Pharmacist-led approaches

Lim
et al. [26] recently published a RCT testing a multidisciplinary asthma management strategy against usual care in 60 pregnant women with asthma, who were recruited prior to 20 weeks’ gestation. The monthly intervention involved visits to a pharmacist who provided education about self-management strategies, monitored asthma control and consulted with the woman’s GP when step-up of ICS therapy was required. The intervention group had a statistically and clinically significant improvement in asthma control after 6 months; however, this was potentially very late in pregnancy or post partum, and no changes in asthma control were observed between groups at the more clinically relevant time-point of 3 months post-randomisation [26].

Involvement of midwives in antenatal asthma management

While international guidelines suggest that management of asthma during pregnancy should be multidisciplinary, very few studies have investigated the role of the midwife in antenatal asthma management, despite their primary care role in many countries. A qualitative, descriptive study has been undertaken in Australia to explore midwives’ knowledge and understanding of asthma during pregnancy, and their perceived role in this area [27]. Data published to date indicate that midwives identify many barriers that prevent them from participating in antenatal asthma management, including lack of time, lack of knowledge about asthma during pregnancy, and lack of available equipment and referral pathways for women with asthma. Issues such as lack of time and knowledge are common barriers for midwives when faced with the implementation of additional education strategies for issues such as oral health, antenatal depression, genetic counselling and smoking cessation. Further research is needed to determine the importance pregnant women with asthma place on various caregivers during their pregnancy and who they would like to be providing asthma management. A study from the USA found that many women were likely to continue their ICS medication if advised to do so by their obstetrician [28], indicating the potential importance obstetric caregivers have in influencing women’s health behaviours surrounding asthma during pregnancy.

Dietary approaches

Grieger
et al. [29] have proposed that some of the poor perinatal outcomes associated with maternal asthma may be driven by increased oxidative stress as a result of both pregnancy and asthma. In nonpregnant adults, dietary intervention studies have demonstrated the protective effects of antioxidants in asthma; however, these approaches are yet to be tested in pregnancy. Observational data indicate that pregnant women with moderate or severe asthma have alterations in circulating antioxidants including α-tocopherol and total carotenoids, compared to women with mild or no asthma, and low concentrations were associated with reduced fetal growth [30]. Further work is required to determine whether dietary approaches can improve maternal and fetal outcomes in women with asthma.

Smoking cessation for pregnant women with asthma

Smoking is a critical issue for pregnant women with asthma, with data showing that women who smoke are more likely to have exacerbations during pregnancy and to have more severe symptoms during exacerbation [14]. Studies from around the world have suggested that pregnant women with asthma are more likely to smoke than pregnant women without asthma [15]. The 20–30% of women with asthma who continue to smoke during pregnancy are at increased risk of poor perinatal outcomes from the combined effects of smoking, asthma and severe asthma exacerbations. However, no studies have trialled smoking cessation strategies among this population of women.

A recent study from Denmark has identified the effects of both active smoking and passive smoking on asthma control [31]. Of the 500 women in this study, 6.4% were current smokers and 23% were ex-smokers, most of whom had quit smoking upon becoming pregnant. Of those who had never smoked, 18.4% reported passive smoking; that is, they lived with someone who smoked at home. Overall, those who had ever smoked had reduced lung function compared to never-smokers, while the effects of passive smoking among never-smokers showed similar patterns, with significantly reduced lung function, greater requirements for ICS and a higher likelihood of partly or uncontrolled asthma, compared to never-smokers without passive exposure [31]. These data suggest that passive smoking is potentially contributing to worse asthma control during pregnancy, which could have negative impacts on perinatal health.

Experiences of pregnant women in relation to asthma management in pregnancy

Two studies have examined the perspective of pregnant women in relation to their asthma and asthma care during pregnancy. Lim
et al. [32] conducted qualitative interviews with 23 pregnant women with asthma in Australia, at various stages of their pregnancy or up to 5 weeks post partum. Some women expressed the view that there were risks associated with asthma medication use during pregnancy, particularly related to steroid use, and they were therefore cautious about using ICS unless “desperate”. Their views about the safety of reliever medication such as salbutamol were quite different, however, with women preferring to use a lot of reliever therapy rather than preventers. There were also women who were more concerned about the possible risks of uncontrolled asthma and whether the baby was receiving enough oxygen. In terms of management by health professionals, the women noted that their GP was not concerned about their asthma and that other issues with the pregnancy often took priority. In addition, there was a view that there was a lack of information given about asthma during pregnancy, and that doctors and pharmacists were unclear about the safety of medication use in pregnancy, forcing some women to make a decision for themselves or consult “Dr Google”, where they obtained unreliable or inaccurate information [32].

A similar qualitative study was reported from the UK, in which seven women with asthma who had been pregnant within the previous 2 years were interviewed [33]. Four of these seven women reported a worsening of asthma symptoms during pregnancy, and these women expressed feelings of fear, panic and anxiety surrounding exacerbations, and a lack of understanding that some of their symptoms were due to asthma rather than the pregnancy itself. They expressed the need for more education and information so that they would have an awareness of the potential seriousness of asthma, and where to seek help. There was a lack of understanding about asthma medications and how they worked, as well as whether they were safe to use, by both women and their partners, which led to women “getting on with it” without support or assistance. This series of interviews conducted in 2012 identified that women generally did not have regular contact with GPs or practice nurses about their asthma and that management plans to monitor asthma during pregnancy were not in place, with one woman describing that her GP took her off her medication when she expressed concern about using it while pregnant. The perception was that midwives did not know much about asthma and concentrated more on issues surrounding the pregnancy. In addition, two women described delays in obtaining care when they had exacerbations of asthma requiring admission to hospital [33]. More work is needed to clarify the priorities of pregnant women themselves with regard to their asthma management in pregnancy.

The importance of active management for better maternal and fetal outcomes

The provision of optimal asthma management is essential for the health of both mother and baby. A recent systematic review and meta-analyses summarised the literature concerning the risks of adverse perinatal outcomes in women with asthma [34–36]. Compared to pregnant women without asthma, women with asthma are at risk of a range of adverse pregnancy outcomes affecting the mother, placenta and neonate, including preterm delivery, low birth weight, pre-eclampsia [34], gestational diabetes, caesarean section, placenta praevia [36], congenital malformations, neonatal hospitalisation and neonatal death [35]. Despite the fact that the majority of women included in the primary studies would be expected to have mild asthma, the effect of asthma on perinatal outcomes was still significant, suggesting that there may be a greater adverse effect among the subgroup with more severe disease [37]. Indeed, women with moderate or severe asthma were more likely to have small for gestational age babies than women with mild asthma [16]. Another interesting finding of this review was that active management of asthma during pregnancy may mitigate some of the increased perinatal risks. In the meta-analysis, when studies were grouped based on the provision of active asthma management, the risk associated with maternal asthma was reduced to nonsignificant for some perinatal outcomes. For example, women with asthma had a 50% increased risk for preterm delivery compared to women without asthma when no active management was given [34]. However, among five studies where active management was provided, the risk of preterm delivery was no longer increased or statistically significant, suggesting that active asthma management may be effective in reducing the risk of preterm delivery [34]. Similar results were observed for preterm labour [34] and neonatal hospitalisation [35]. The reduced risk of neonatal hospitalisation may be a consequence of improvements in gestational age and other birth outcomes. A reduction in preterm births with active asthma management is plausible, given that one of the benefits would be a reduction in the number of exacerbations and courses of oral steroids used, both of which have been implicated in larger studies as contributing to the risk of preterm delivery in asthmatic women.

Interventions for improving asthma management during pregnancy

There have been very few recent RCTs of interventions for managing asthma during pregnancy. A 2014 Cochrane review summarised eight RCTs involving 1181 women with asthma [38]. Five of the trials assessed pharmacological interventions and three assessed nonpharmacological interventions. The trials were of moderate quality overall and did not lead to any firm conclusions regarding optimal asthma management in pregnancy, due to a lack of clear benefits of pharmacological approaches over current practice and a lack of power in the nonpharmacological interventions to detect differences in perinatal outcomes [38].

Inflammation-based management of asthma during pregnancy

Only one study has successfully trialled a management approach that reduces exacerbations during pregnancy. The MAP (Managing Asthma in Pregnancy) Study from Australia was a double-blind, parallel-group RCT which tested the efficacy of an inflammation-based management strategy for reducing exacerbations in 220 nonsmoking pregnant women with asthma [39]. Women were randomised prior to 22 weeks gestation. The control group had treatment adjusted according to the results of the Asthma Control Questionnaire (ACQ), representing symptoms and lung function. The intervention group had treatment adjusted according to both the level of eosinophilic airway inflammation and the ACQ. Airway inflammation was measured by exhaled nitric oxide fraction (F_eNO), a steroid sensitive marker of eosinophilia, and used to adjust ICS. The ACQ was used to determine when symptoms remained uncontrolled, in which case a LABA was added. Both groups had stepwise ICS treatment adjustments (up or down) made monthly, and received free medications and self-management education. The primary study outcome was exacerbations requiring medical intervention, defined as hospitalisation, emergency department presentation, use of OCS or unscheduled doctor visit for asthma. There was a 50% reduction in exacerbations in the F_eNO group compared to the control group, along with alterations to the treatment profile, with more women from the F_eNO group being prescribed ICS (at a lower mean dose) and ICS/LABA combination therapy. In addition, there was a significant reduction in both OCS and SABA use, and a significantly higher quality of life in the F_eNO group compared to the control group [39]. The infants from this study were followed up at 12 months of age and those from mothers in the F_eNO group were significantly less likely to have recurrent bronchiolitis or recurrent croup reported by their parents [40], suggesting a potential long-term benefit to the health of the offspring. The F_eNO-based management approach has the potential to be widely used in clinical practice, as F_eNO is easily measured using a noninvasive breath test and gives an indication of the level of steroid-responsive eosinophilic airway inflammation, reducing exacerbations, a major clinical problem in pregnant women with asthma.

Conclusions

Asthma is a common comorbidity during pregnancy and exacerbations are a major clinical problem, with up to 45% of women requiring medical intervention for asthma during pregnancy, resulting in poor outcomes for mothers and their babies. Guidelines recommend managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for adults and management of comorbid conditions. Improvements have been made in recent years in emergency department management of asthma in pregnancy, and multidisciplinary approaches are being proposed to optimise both asthma outcomes and perinatal outcomes. One strategy that has been successful in reducing exacerbations in pregnancy is treatment adjustment using a marker of eosinophilic lung inflammation, F_eNO. Further evidence is needed to determine whether this strategy can also improve perinatal outcomes and be successfully translated into clinical practice.

Educational questions

1. Which of the following statements concerning guidelines for the management of asthma during pregnancy is/are correct?

   • a Inhaled corticosteroids should be used when women have persistent asthma

   • b Asthma should be managed as for other adults, with the exception of oral corticosteroid use during exacerbations

   • c Multidisciplinary management is recommended

   • d It is important to identify and manage comorbid conditions such as rhinitis or reflux

   • e Asthma should be reviewed every 4 weeks during pregnancy.

2. A woman presents to her general practitioner with asthma symptoms during pregnancy. She has previously admitted to nonadherence to her preventer medication and is concerned about whether this medication is harmful for her baby. Which is the most appropriate clinical decision?

   • a Withdraw all preventer medication and advise her to take more doses of her reliever

   • b Make a referral for her to see a respiratory specialist

   • c Advise her of the safety and importance of taking preventer medications in pregnancy, and advise her to continue her prescribed dose and return for review if symptoms continue to worsen

   • d Perform spirometry and provide a prescription for a different preventer medication

3. Which of the following statements is/are true concerning the risks of adverse perinatal outcomes in women with asthma?

   • a Women with asthma are not at risk of adverse perinatal outcomes compared to women without asthma

   • b Women with asthma are at increased risk of having a baby who dies or is hospitalised after birth

   • c Active management of asthma can reduce the risk of preterm labour and delivery

   • d Women who have exacerbations of asthma during pregnancy are at three times the risk of low birth weight compared with women without asthma exacerbations in pregnancy

4. Which of the following statements is/are true concerning inflammation-based management of asthma during pregnancy?

   • a Using a marker of airway inflammation to adjust treatment results in women taking higher doses of inhaled corticosteroids during pregnancy

   • b Using a marker of airway inflammation to adjust treatment reduces the exacerbation rate in pregnancy

   • c Exhaled nitric oxide fraction is a useful marker because it predicts the response to inhaled steroids

   • d Benefits to health in infancy have been described when inflammation-based management is used

   • e No studies have identified whether this approach improves perinatal outcomes.

Suggested Answers

1. a, c, d, e

2. c

3. b, c, d

4. b, c, d, e

Footnotes

Support statement Vanessa Murphy is supported by a Career Development Fellowship from the National Health and Medical Research Council of Australia.

Conflict of interest None declared.

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Asthma and Pregnancy | AAAAI

If you’re pregnant or are thinking about becoming pregnant, it’s more important than ever to keep your asthma controlled. Avoiding triggers and taking your asthma medications as prescribed can all help ensure a healthy pregnancy for you and your baby-to-be.

A national expert panel* strongly encourages monthly monitoring of asthma during prenatal visits. This is because the course of asthma improves for about one-third of women and worsens for about one-third of women during pregnancy. A monthly evaluation gives your physician the opportunity to step down treatment (if possible) or increase treatment (if necessary).

Asthma attacks are most common during the later weeks of pregnancy, but are very rare during labor itself.

Asthma symptoms include:

•    Wheezing

•    Coughing

•    Chest tightness

•    Shortness of breath

Managing Your Asthma During Pregnancy

Good asthma control is crucial for a healthy pregnancy. An asthma flare-up causes decreased oxygen levels in the blood. This, in turn, can lead to less oxygen reaching the fetus. Low oxygen can impair healthy fetal growth and development.

To minimize risk, pregnant women should avoid allergens that trigger their symptoms. Also, women who smoke should quit prior to getting pregnant as smoking may trigger asthma and can interfere with fetal development.

If you were receiving allergy shots (immunotherapy) prior to becoming pregnant, you can continue this treatment during pregnancy. Just be sure to let your doctor know that you are pregnant. It is not recommended to start allergy shots during pregnancy.

What About Medications?

Continue to see your allergist / immunologist throughout your pregnancy and don’t stop taking your medications. Many mothers-to-be are concerned about taking medications during pregnancy. Yet the risks posed by uncontrolled asthma are much greater than those from asthma treatments.

Inhaled corticosteroids are often the treatment of choice for persistent asthma. Studies have shown them to be effective and low-risk for pregnant women. The National Asthma Education and Prevention Program (NAEPP) recommends two specific drugs: budesonide (inhaled corticosteroid) and albuterol (short-acting Beta 2-agonist) as having good safety profiles when used during pregnancy.

Oral corticosteroids are not preferred for regular asthma treatment during pregnancy. However they can be used to treat severe asthma attacks.

If you are pregnant and think you may have asthma, it’s important to have your condition diagnosed to reduce the risks to your baby. Studies have linked asthma attacks in early pregnancy to birth defects, so don’t wait to have your condition diagnosed.

If you are interested in helping researchers understand more about the effects of asthma and asthma medications on pregnancy, consider enrolling in the VAMPSS project.

*The NAEPP Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

Click here to find out additonal information about asthma.

Podcast EPsode: Challenges with Asthma Management During Pregnancy

Michael Schatz, MD, MS, FAAAAI, discusses the complicated issues surrounding how asthma can impact pregnancy. Listen now to learn all about medication safety, asthma monitoring and important research pertaining to pregnant women. (October 1, 2019)

Click here to listen to the podcast.
Read the transcript of the conversation.

This article has been reviewed by Andrew Moore, MD, FAAAAI

Reviewed: 9/28/20

Asthma & Pregnancy: Risks, Treatment & Prevention

What is asthma?

Asthma is a condition that causes your airways to tighten and narrow — called a bronchospasm — making it hard to breathe. It’s a chronic disease (long-lasting) that needs to be treated or controlled throughout your life. If you have asthma, you may experience symptoms like difficulty breathing, wheezing and coughing.

This is a common condition that affects millions of people in the United States. If you have a family history or allergies, you have a higher risk of developing asthma. Even though it doesn’t go away, asthma can be controlled.

What are the risks of having asthma during pregnancy?

Controlling any medical conditions you may have during pregnancy is important to both your health and the health of your baby. Uncontrolled asthma can increase the chance of complications for mother and baby. Low birth weight and premature delivery are just two examples of possible complications that can happen if you don’t control your asthma during pregnancy.

Uncontrolled asthma during pregnancy can cause a decrease in the amount of oxygen in your blood. This means that there’s also less oxygen available for your baby. Less oxygen could lead to impaired fetal growth and survival. Poor control of asthma is a greater risk to your baby than treating your asthma. With good asthma control, you should be able to expect a normal pregnancy.

The goals of asthma treatment during pregnancy are the same as treatment at any other time in your life. Asthma control means that you:

• Have minimal (or no) symptoms during the day.
• Sleep all night without asthma symptoms.
• Are able to perform normal activities.
• Rarely need to use your reliever inhaler (also called a rescue inhaler).
• Have normal or near normal lung function.

It’s safer for you to treat your asthma with asthma medications than to have an asthma episode.

How should I prepare before pregnancy if I have asthma?

Many healthcare providers recommend a preconception appointment before you start trying to get pregnant. This appointment is a chance to talk to your provider about any medical conditions you might have and your general health. Many people use this appointment to make a game plan for how they will want to treat their medical conditions — like asthma — during pregnancy. It’s a chance to prepare with your provider for the upcoming pregnancy. Remember, you shouldn’t stop taking any of your medications during pregnancy without first talking to your healthcare provider.

Should I stop treating my asthma when I’m pregnant?

You should never stop any medication without talking to your healthcare provider first. During pregnancy, it’s important to still treat any medical conditions you might have. Don’t stop taking your asthma medications during pregnancy without direction from your healthcare provider.

Is it safe to use an inhaler to control my asthma during pregnancy?

Using an inhaler to control asthma is one of the most common concerns. Most inhaled medicines are safe for use during pregnancy. Inhaled medicines are generally low doses that you breathe directly into your lungs. Very little, if any, of the medication from your inhaler is absorbed into your bloodstream. It’s important to make an appointment with the healthcare provider who helps you control your asthma before pregnancy to talk about the best ways to control your asthma and make sure you’re on the appropriate medications.

Oral medications (pills and liquids) can be used during pregnancy. Talk to your provider about the use of oral medications throughout your pregnancy to determine what’s best for you. Your provider will determine if this is necessary. In general, the same asthma treatment that’s appropriate when you are pregnant is also safe during labor and when you’re breastfeeding your baby.

What should I do to control my asthma when I am pregnant?

During your pregnancy, you should continue to follow your asthma control plan. You shouldn’t stop treating your asthma and need to talk to your healthcare provider before making any changes to your medications.

Some ways to keep your asthma in control during your pregnancy include avoiding your triggers and irritants. Triggers and irritants to avoid include:

Can I take allergy shots when I’m pregnancy?

Allergy shots are not started if a woman is pregnant. If you’re already receiving allergy shots, your healthcare provider may continue them. However, doses usually aren’t increased during pregnancy to help decrease the possibility of reactions. If you have moderate to severe asthma, a flu shot is generally a good idea. The flu shot is recommended in all trimesters of pregnancy. Talk to your healthcare provider about which shots are safe to get during pregnancy and when you should get them.

Can my asthma get worse during pregnancy?

Whether or not your asthma will get worse when you’re pregnant can be difficult to guess. For some women, asthma gets worse. For others, it can stay the same. There are also some women whose asthma actually improves. The simple way to think about it is like this — if you have severe asthma, the chances are that it might become a little worse during pregnancy. However, if you’ve had previous pregnancies and your asthma didn’t get worse, it’s reasonable to expect that your asthma won’t be much worse during your current pregnancy.

Should I avoid pregnancy if I have asthma?

Asthma is almost never a reason to not get pregnant. However, if you have severe asthma, it’s worth talking to your healthcare provider before getting pregnant. Make a plan with your provider about treatment for your asthma during your pregnancy. Remember, it’s important to treat your asthma during your pregnancy. You should never start or stop taking a medicine without consulting your healthcare provider first.

A note from Cleveland Clinic

Pregnancy can be an exciting time of life. It’s also a time to take care of yourself and make sure you’re managing all of your medical conditions. If you have asthma, it’s important to control this condition throughout your pregnancy. Talk to your healthcare provider about the best ways to have a healthy pregnancy with asthma.

90,000 Pregnancy and asthma.

01.06.2015

Not so long ago, 20-30 years ago, a pregnant woman with bronchial asthma often faced a negative attitude even among doctors: “What were you thinking about? What kind of children ?! You have asthma!” Thank God these times are long gone. Today, doctors all over the world are unanimous in their opinion: bronchial asthma is not a contraindication for pregnancy and in no case is it a reason for refusing to have children.

Nevertheless, a certain mystical halo around this disease persists, and this leads to an erroneous approach: some women are afraid of pregnancy and doubt their right to have children, others rely too much on nature and stop treatment during pregnancy, considering any drugs to be undoubtedly harmful in this period of life.Asthma treatment is surrounded by an incredible amount of myths and legends, rejection and misconceptions. For example, with an increase in blood pressure, a woman will not doubt that she can give birth to a child if she is properly treated. She will certainly take into account the doctor’s recommendations about the need to limit salt, about maintaining a healthy lifestyle, she knows that she must take medications to normalize blood pressure, that treatment cannot be abandoned. When planning a pregnancy, a woman will consult a doctor in advance on which medications can be taken during pregnancy and which cannot be taken, and she will acquire a tonometer to monitor her condition.And if the disease gets out of control, immediately seek medical help. Of course, you say, this is so natural. But as soon as it comes to asthma, doubts and hesitation appear.

Perhaps the whole point is that modern methods of treating asthma are still very young: they are a little over 12 years old. People still remember the times when asthma was a frightening and often disabling disease. More recently, treatment was reduced to endless droppers, theofedrine and hormones in tablets, and the inept and uncontrolled use of the first inhalers often ended in a very pitiable end.Now the state of affairs has changed, new ideas about the nature of the disease have led to the creation of new drugs and the development of methods for controlling the disease. But in order to achieve success in treatment, the joint efforts of doctors and the patients themselves are needed.

At the present stage of the development of medicine, there are no methods that can once and for all relieve a person from bronchial asthma. Asthma is a disease that cannot be cured yet, but can be learned to be well controlled. During pregnancy, the severity of bronchial asthma often changes.It is believed that in about a third of women, the course of asthma improves, in a third it worsens, and in a third it remains unchanged, while the course of the disease usually does not change in the first trimester. But rigorous scientific analysis is less optimistic: asthma improves in only 14% of cases. Therefore, you should not rely on this chance indefinitely in the hope that all problems will be resolved by themselves. The fate of a pregnant woman and her unborn child is in her own hands – and in the hands of her doctor.

As a matter of fact, asthma itself does not contribute to a complicated course of pregnancy and fetal developmental disorders (well, except that pregnant women with asthma are somewhat more likely to have toxicosis of pregnant women).All problems are connected not with the fact of the presence of bronchial asthma, but with its poor control. The greatest risk to the fetus is hypoxia (insufficient amount of oxygen in the blood), which occurs due to the uncontrolled course of bronchial asthma of bronchial asthma. If suffocation occurs, not only does the pregnant woman feel difficulty breathing, but the unborn child also suffers from a lack of oxygen (hypoxia). It is the lack of oxygen that can interfere with the normal development of the fetus, and in vulnerable periods even disrupt the normal laying of organs.To give birth to a healthy child, it is necessary to receive treatment appropriate to the severity of the disease in order to prevent an increase in the onset of symptoms and the development of hypoxia.

And the prognosis for children born to mothers with well-controlled asthma is comparable to that for children whose mothers do not have asthma. Therefore, it is necessary to treat asthma during pregnancy, avoiding symptoms of breathing difficulties, and even more exacerbations. A pregnant woman with asthma needs more careful medical supervision than before pregnancy.When assessing the degree of asthma control, not only clinical indicators are used, but also peak flowmetry data. This allows you to assess the respiratory function and the state of the disease and notice early signs of an impending exacerbation in time in order to take measures and prevent the development of a dangerous condition (the peak flow meter readings “react” before symptoms appear). We will return to this question later.

Treatment of a pregnant woman should be prescribed and monitored by a specialist doctor individually, and no medications, even vitamins, should be used without the consent of the doctor.Education of pregnant women with bronchial asthma plays an important role in treatment: asthma is one of those diseases that require the patient to understand the nature of the disease and the causes of exacerbation, awareness, the ability to use drugs correctly and certain skills of self-control.

A woman with bronchial asthma should prepare for pregnancy.

While asthma treatment can and should be continued during pregnancy, there are many issues that need to be addressed before it begins.The selection of drugs and the achievement of control of the disease take time, meanwhile, for the normal course of pregnancy, the most complete control of the disease is required. Asthma school attendance and education can be challenging for a pregnant woman. Thus, by the time of pregnancy, planned therapy should be selected that ensures good control of the disease (minimal symptoms, minimal need for drugs to relieve symptoms, no exacerbations and restrictions on activity, close to normal readings of respiratory function), the correct inhalation technique should be worked out, training in self-control using a peak flow meter was carried out, an individual Asthma Action Plan was developed.All these questions are within the competence of a pulmonologist (you will not always find this specialist in a district clinic, and in this case, you must contact the consultation and diagnostic center at your place of residence).

In cases where the selection of therapy, training in inhalation technique and self-control methods were not carried out before pregnancy, an appeal to a pulmonologist is all the more necessary.

But this is only one side of the problem directly related to the treatment of asthma.The other side is allergy issues. In young people, in most cases, bronchial asthma is atopic, that is, directly related to the presence of hypersensitivity to a number of allergens. Household, pollen, mold, epidermal allergens are the main provoking factors contributing to the exacerbation of the disease. Conversely, by eliminating or reducing contact with the most significant allergens, it is possible to improve the course of the disease and reduce the risk of exacerbations with the same or even less drug therapy, which is especially important during pregnancy.

But in order to apply the necessary measures, you need to know which allergens are causal in this particular case. At the same time, many methods of examination and treatment are difficult or even impossible to carry out when a woman is expecting a baby. Consequently, the allergological examination should be completed before the onset of pregnancy, after which recommendations on organizing a hypoallergenic life should be obtained from the allergist and implemented.

Thus, before the planned pregnancy, visit a pulmonologist and allergist, undergo the necessary examination, listen, if possible, to the Asthma School course, rebuild your life in accordance with the recommendations.The more you know about yourself and your disease, the less problems you will have during and after pregnancy.

Measures to limit contact with allergens.

In women of childbearing age, allergy plays a huge role in bronchial asthma. Contact with the “guilty” allergen provokes symptoms, leads to an exacerbation of the disease. On the other hand, if this contact can be excluded (or at least significantly limited), the disease recedes. Therefore, measures to limit contact with allergens are extremely important in bronchial asthma in general, and especially during pregnancy.For successful asthma therapy, this is a prerequisite, and the more complete elimination of allergens is achieved, the easier the disease progresses and the less drugs are needed to control it.

The individual spectrum of causally significant allergens is established by an allergological examination. But even if the test results are negative, a pregnant woman should also think about her unborn child: staying in a dusty, cluttered, moldy house is not good for his health and contributes to the formation of allergic diseases.Therefore, general measures to combat dust and mold can be recommended in any case.

Dust reduction. General measures to limit exposure to house dust allergens.

Modern dwellings tend to be overloaded with dust-collecting objects. A pile of upholstered furniture, carpets, lush curtains, stacks of books, old newspapers, scattered clothes serve as an endless reservoir of allergens. During the heating season, when the air humidity is sharply lowered, the smallest dust particles rise into the air and do not settle for hours.With each breath they enter our airways, causing irritation and – in sensitive people – an allergic reaction. The conclusion is simple: you should reduce the number of objects that collect dust.

Dust allergy

Fluffy woolen carpets, draperies and a four-poster bed are not for asthmatics. The decor should be spartan. The amount of upholstered furniture should be minimized. It is better to choose models without decorative details – buttons, folds, etc. or replace furniture with leather.Carpets and rugs are not recommended. Instead of curtains, it is better to use vertical blinds (dust also collects on horizontal surfaces). Books and knickknacks must be removed to the glazed shelves.

Optimal air humidity (40-50%) makes breathing easier and improves health, and most importantly, reduces the amount of suspended dust in the air. To determine the relative humidity of the air, special devices are used – hygrometers. If the humidity is low, you should consider a humidifier.But high humidity is also harmful: it contributes to the rapid growth of molds and the reproduction of house dust mites – the main allergens in rooms. If the humidity is high, consider using a dehumidifier.

There are devices specially designed to clean the air from dust and allergens, harmful gases and unpleasant odors. They are called that: air purifiers. Many models of such devices have been developed, but not every model is suitable for asthmatics, especially for a pregnant woman.It is recommended to use filter purifiers equipped with special filters to remove dust and allergens from the air and additional carbon filters to get rid of harmful gases. Allergens are inherently the smallest particles, and special fine filters have been created to capture them. The most common filters of the corresponding class are called HEPA (an English abbreviation that reads “hepa” and means “high efficiency filter for particle retention”).Various modifications of HEPA filters are also used: ProHEPA, ULPA, etc. Some models use highly efficient photocatalytic filters. But inexpensive electrostatic filters and filterless ionizers are not recommended: when operating such purifiers, ozone is released – a chemically active and toxic compound in high doses, which is dangerous for pulmonary diseases in general, and for pregnant women and young children in particular.

If the woman does the cleaning herself, it is recommended to wear a respirator that protects against dust and allergens.Currently, there are many disposable fine respirators. Special models with HEPA filters designed for reusable use have also been developed. After cleaning, you need to switch the air purifier to intensive cleaning mode for 45 minutes, or at least ventilate the room.

Daily wet cleaning has not lost its relevance, but you can’t do without a vacuum cleaner in a modern apartment. And if a woman has asthma, not every vacuum cleaner is suitable for her.The fact is that an ordinary vacuum cleaner retains only coarse dust, and the smallest particles and allergens “slip” through it and again fall into the air. After such cleaning, air pollution increases by 3 times or more. For the needs of allergy sufferers and asthmatics, special models of vacuum cleaners have been developed, equipped with filters similar to those used in air purifiers.

The bed, which serves as a resting place for a healthy person, turns into the main source of allergens for an allergic person.Dust accumulates in ordinary bedding, chitin of feather pillows and the wool of blankets serve as an excellent breeding ground for the development and reproduction of molds and house dust mites – the main sources of household allergens. It is necessary to replace bedding with special hypoallergenic ones – made of light and airy modern materials (polyester, hypoallergenic cellulose, etc.). The requirements for such materials are quite high: the fiber should not cause allergies, be environmentally friendly, odorless, have good antistatic properties (do not attract dust), good air and moisture permeability and thermoregulatory properties.Fillers in which glue or latex was used to hold the fibers together (for example, synthetic winterizer) are not recommended.

But just changing your pillow isn’t enough. New bedding requires proper care: regular whipping and airing, regular frequent washing at 60 ° C and above. Modern fillers are easily washed off and restore their shape after repeated washings, but the implementation of this recommendation is difficult for many.Well, you can wash less often and at the same time increase your allergen resistance by placing your pillow, mattress and blanket in anti-allergen protective covers. They are made of a dense weave fabric that allows air and water vapor to pass freely, but impervious even to small particles. Such covers reliably protect a sleeping person from sources of allergens lurking in bed. Well, everything that is not protected by covers (sheets, pillowcases, duvet covers) must be changed at least once a week and washed at a temperature of 60 ° C and above.In the summer it is useful to dry the bedding in direct sunlight, in the winter – to freeze it at a low temperature.

Special measures.

House dust is a complex of allergens. It contains textile fibers, particles of dead skin (peeled epidermis) of humans and pets, molds, allergens of cockroaches and tiny arachnids living in dust – house dust mites (these mites do not spread any diseases and do not “bite” them, but secretions and shell particles are the main source of allergens in indoor dust).

A detailed allergy examination carried out in our time allows not only to determine the presence of allergy to house dust, but also to establish which of its components is most significant for the patient. This is of great importance because allows you to apply additional measures: for a number of allergens, special products have been developed to help get rid of them.

Due to the huge role of house dust mites in the development of allergic diseases and bronchial asthma, scientists have created a large arsenal of tools both for the destruction of the mites themselves and for neutralizing their allergens.Means for killing ticks are called acaricides. Eliminate mite allergens will help the processing means – herbal preparations Easy Air: (read “easy air”).

Easy Air: (More …) are able to neutralize not only house dust mite allergens, but also allergenic components of animal origin (pet allergens). They are most effective in relation to the main cat allergens, which allows them to be used for treating premises after animals have lived there (reducing the concentration of allergens in a natural way is a long process).

All these measures applied in the complex allow creating a hypoallergenic environment: (More …) and to reduce the allergenic load on the body of a pregnant woman.

Unfortunately, no special means have been developed for the specific neutralization of pollen allergens. In this case, a complex of hygienic and behavioral measures is applied; air purifiers play an important role. Some models of purifiers have special modes for removing pollen.In addition, pollen allergy is one of the few types of respiratory allergy in which air conditioners (models equipped with HEPA filters) are effective. It is recommended to plan pregnancy so that its most vulnerable periods do not coincide with the active flowering of allergenic plants. Often, a temporary move to another climatic zone during the flowering period becomes the safest and most effective way to avoid contact with pollen and, thereby, exacerbation of bronchial asthma.

Animals in your house.

Fish food, bird feathers and excrement, dandruff, saliva and other excretions from domestic animals are a strong source of allergens. If you are allergic to any of these components, further contact with the “guilty” allergen is unacceptable. The danger threatens not only the woman herself. According to studies, having a cat in a house where the mother suffers from bronchial asthma increases the risk of developing allergic diseases 3 times. And although in recent years there have been reports that in some cases, early contact of babies with cats rather reduces the risk of developing allergies, one can argue as much theoretically as possible, how accurate and verified this information is, and in practice it should be remembered that in order to endure and give birth to a healthy child, a pregnant woman should take all measures to exclude contact with allergens.

Smoking – fight!

Pregnant women are absolutely not allowed to smoke! But giving up active smoking, this harmful habit, is not enough. Any contact with tobacco smoke must be carefully avoided. Staying in a smoky atmosphere, smoking in the house cause colossal harm to both the woman and her unborn child. Even if only the father smokes in the family, the likelihood of developing asthma in a predisposed child increases 3-4 times.

Infection.

Respiratory infections, which are dangerous for any pregnant woman, are many times more dangerous in bronchial asthma, since they carry the risk of exacerbation.Avoiding respiratory infections is, of course, necessary, but, of course, it is almost impossible to completely protect yourself from contact with them. Therefore, with a high risk of getting the flu, in cases where the flu has previously provoked severe exacerbations of asthma, it is recommended to vaccinate with an influenza vaccine (but not earlier than 3 months of pregnancy).

Note.

The US Vaccination Advisory Committee (ACIP) recommends seasonal influenza vaccination for all pregnant women 14 weeks or more and women at risk of influenza, regardless of gestational age.Studies have confirmed the effectiveness of vaccination of patients with pulmonary disease and patients receiving treatment with corticosteroids. Since an inactivated influenza vaccine is currently used, it does not have negative consequences for the fetus and is safe, which is confirmed by research. It is not dangerous for breastfeeding mothers either. Moreover, the antibodies produced by the mother in response to the vaccine pass through breast milk and provide additional protection for the baby.

For upper respiratory tract infections, rinse your nose regularly with warm saline. A similar effect can be achieved using a nebulizer, inhaling saline or Borjomi through a mask or nasal nozzle. In some nebulizers, it is possible to switch the level of drug delivery to the upper respiratory tract.

In some cases, it becomes necessary to prescribe antibiotics, but in no case should they be used without a doctor’s prescription.The use of streptomycin, tetracycline, aminoglycosides, sulfonamides (including biseptol), chloramphenicol, quinolones and fluoroquinolones is absolutely unacceptable. When choosing an antibiotic, the doctor each time weighs the risk / benefit ratio, and takes into account not only the fact of pregnancy and its timing, but also the nature of the disease that necessitated the use of antibiotics, the properties of the probable pathogen and, of course, the allergic history. For example, during pregnancy, penicillin antibiotics are quite safe, but they are often a source of allergic reactions.The appointment of benzylpenicillin, the ancestor of this group, is avoided even in cases where there is no indication of its intolerance. The necessity and possibility of using semisynthetic penicillins, erythromycin or cephalosporins is determined by a doctor according to strict indications. Prescribing antibiotics “for prophylactic purposes” is unacceptable.

Treatment of bronchial asthma during pregnancy.

Many pregnant women try, and justifiably, to avoid taking medications during pregnancy.But it is necessary to treat asthma: the harm caused by a severe uncontrolled disease and the resulting hypoxia (insufficient supply of oxygen to the fetus) is immeasurably higher than the possible side effects of drugs. Not to mention the fact that allowing asthma to worsen is a huge risk to the life of the woman herself. But the instructions for any medicinal products indicate contraindications, restrictions or special conditions for their use during pregnancy. How to be?

First of all, a doctor should prescribe treatment for a pregnant woman.Close contact with a specialist is a prerequisite for successful treatment: this is the only way to achieve maximum effect with minimal risk. All medicines are used on the principle: “only if the expected benefit outweighs the possible risk to the mother and fetus.” Particularly stringent requirements are imposed on the 1st trimester of pregnancy as the most vulnerable in terms of any impacts.

In the treatment of asthma, preference is given to topical (topically acting) inhalation drugs, since the concentration of the drug in the blood is minimal, and the local effect in the target zone, in the bronchi, is maximum.It is recommended to use freon-free inhalers. Metered-dose aerosol inhalers should be used with a spacer to reduce the risk of side effects. A prerequisite for successful treatment is correct inhalation (inhalation technique). A pulmonologist or instructor in the classroom at the Asthma School will help you master the necessary skills.

It has been established that bronchial asthma, regardless of the severity, is a chronic inflammatory disease.It is the constant presence of this particular chronic inflammation in the bronchi that causes the symptoms. If you only treat the symptoms (eliminate bronchospasm), but do not fight their cause, the disease will progress. Therefore, the treatment of bronchial asthma consists of basic therapy (drugs to control the disease), aimed at controlling inflammation, and drugs to relieve symptoms and treat exacerbations. The volume of basic therapy is determined by the doctor depending on the severity of the course of asthma.Adequate basic therapy significantly reduces the risk of exacerbations and minimizes the need for drugs to relieve symptoms.

On the safety of using drugs during pregnancy.

In our time, medicine has become evidence-based, i.e. every recommendation, every concept, every drug, before being approved and approved for use, must be thoroughly tested according to certain scientific rules. A drug is considered completely safe only when its safety has been tested and proven in the course of so-called double-blind, randomized, placebo-controlled large-scale clinical trials in which the effects of this drug are compared with both known drugs and with no intervention.At the same time, the study is structured so that the beliefs or prejudices of the doctor or patient cannot influence the final conclusions. But conducting such research in pregnant women is almost impossible for ethical reasons. Safety has to be judged by animal data and long-term follow-up of pregnancy outcomes in humans. Therefore, none of the drugs used for bronchial asthma was assigned the highest safety level – category A (“safety at the placebo level”, indicating that taking the drug affects the safety indicators no more than if the drug was not used at all).

All drugs have been assigned a certain category of safety for use during pregnancy. Unfortunately, this is usually not indicated on the drug label. So, drugs in category A do not exist at the moment. The next safety category, category B, is assigned to drugs that have been shown to be safe in animal studies, or, even if animal studies have identified a side effect, it has been possible to confirm that the drug is safe for humans even during vulnerable periods of pregnancy.If the potential benefit of use outweighs the risk of complications, or there is simply not enough safety data, the drug receives category C. Category D includes drugs that have proven side effects, but the potential benefit may allow their use despite the risk. Category X – drugs with a teratogenic effect, the risk of their use exceeds the possible benefit, and they are not used during pregnancy.

Medicines for the relief of symptoms.

A pregnant woman should not endure or wait out attacks of suffocation, so that the lack of oxygen in the blood does not harm the development of the unborn child.Therefore, a drug is needed to relieve symptoms.

The drugs of choice are inhaled, rapid-onset beta2-agonists. They prefer selective drugs that selectively affect the bronchi with minimal effect on the cardiovascular system. The “gold standard” in Russia is salbutamol (Salbutamol, Ventolin, etc.), in the world – terbutaline (Bricanil Turbuhaler). Terbutaline is considered optimal (category B), but in our country it is much more expensive and less available than salbutamol preparations.The nebulizer form of terbutaline is not registered in our country, therefore, if necessary, only salbutamol is used in nebulizer therapy.

The use of these drugs during pregnancy requires caution and medical supervision. The limitations are primarily due to the fact that injectable forms of beta2-agonists are able to relax the muscles of the uterus, and therefore, with the threat of miscarriage in the 1st and 2nd trimester of pregnancy, premature placental abruption, bleeding and toxicosis in the 3rd trimester, there is a possibility of increased bleeding.In inhaled form and in recommended doses, the effect on the muscles of the uterus is very small, but this theoretical possibility is taken into account. Uncontrolled use of bronchodilators at the end of pregnancy can lengthen the duration of labor.

The use of fenoterol (Beroteka) and Berodual (a combination of fenoterol with an anticholinergic) in the first trimester of pregnancy is avoided, but allowed if the expected benefit outweighs the possible risk. The studies did not reveal a negative effect on the course of pregnancy, but the available data are insufficient to remove the restrictions.For inhaled anticholinergics (ipratropium – Atrovent), no negative effect on fetal development ( category B ) has been revealed, but this drug is usually not used to treat asthma (only in combinations), since its action develops more slowly.

During pregnancy, the use of any ephedrine preparations (theofedrine, Kogan powders, etc.) is absolutely contraindicated, since ephedrine causes a narrowing of the vessels of the uterus and aggravates fetal hypoxia. The use of adrenaline for exacerbations of bronchial asthma is not recommended (it is advisable to use injectable terbutaline).

The frequency of bronchodilator use is an important indicator of asthma control. With an increase in the need for their use, you should contact a pulmonologist to enhance the planned (basic) therapy to control the disease. Treatment with symptom relief drugs alone is only permissible in the mildest cases with rare mild symptoms and rare mild exacerbations. As their name suggests, these drugs are capable of relieving symptoms that have already arisen, but do not have anti-inflammatory activity and do not affect disease control.

Routine therapy (basic, therapy for disease control)

Planned (basic) therapy to control the disease must necessarily correspond to the severity of the disease, which is a necessary condition for reducing the need for drugs that expand the bronchi and preventing exacerbations. If the severity of asthma requires compulsory basic therapy, and the patient only relieves symptoms, asthma becomes uncontrollable, dangerous for the mother and harming the fetus.Prescribing routine therapy necessary to control asthma prevents attacks and exacerbations that cause fetal hypoxia, i.e. contributes not only to the normal course of pregnancy, but also to the normal development of the child.

Surrounded by a pregnant woman with bronchial asthma, there are always “well-wishers” (sometimes even doctors or – more often – former doctors) who are trying to infect a woman with fear of treatment and the drugs used. Always remember: you breathe for two, and unfounded fears are unacceptable.You shouldn’t listen to the highly experienced and illiterate “neighbor Baba Manya”. Use only information obtained from a qualified technician.

Drugs for disease control.

Cromones (Intal, Tiled) are used only for mild persistent asthma. If the drug is prescribed for the first time during pregnancy, sodium cromolyn is used (Intal). If the patient received nedocromil (Tylade) with a good effect before pregnancy, the therapy is continued. But if cromones do not provide adequate control of the disease, inhaled hormonal drugs should be prescribed.

Inhaled hormones are the basis of the basic therapy for persistent asthma in all but the mildest cases. Their appointment during pregnancy has its own characteristics. If the drug is to be prescribed for the first time, budesonide (Pulmicort) is preferred: an analysis of 2014 pregnancies conducted in 2000 did not reveal an increase in the risk to the fetus (the drug is included in category B). Beclomethasone, which is more available in our country, can also be prescribed. If asthma has been successfully controlled with another inhaled hormonal drug prior to pregnancy, this therapy may be continued.If medium doses are ineffective, the doctor may add theophylline preparations (with great care) or salmeterol. The use of theophylline (both aminophylline and prolonged-release drugs in tablets such as Teopek) during pregnancy is treated with greater caution, especially in the 3rd trimester, when the rate of excretion of theophylline from the body decreases: this drug freely penetrates the placenta and can cause tachycardia and disorders rhythm in the fetus and newborn.

Leukotriene antagonists can be used with caution and only under strict indications. Safety class – B .

The drugs are prescribed only individually, the more this rule should be observed during pregnancy. The amount of treatment required for a given degree of severity of bronchial asthma is determined by the doctor who is observing the patient, while focusing, in addition to the clinic of the disease, on the data of peak flowmetry.

Peak flowmetry and asthma action plan.

Bronchial asthma is one of those diseases that require the patient to be able to control their condition.Just as a blood pressure monitor is needed in hypertension, and a glucometer in the treatment of diabetes mellitus, a portable and easy-to-use device called a peak flow meter has been developed for self-monitoring in asthma.

The recorded indicator – peak expiratory flow rate, abbreviated as PSV – allows you to monitor the state of the disease at home.

The indications should be recorded 2 times a day, in the morning and in the evening, before the use of bronchodilators, as well as when symptoms appear.The data is recorded in the form of a graph, since it provides more information: not only the specific numbers matter, but also the shape of the resulting graph. One of the alarming symptoms is “morning dips”: periodically recorded low values ​​in the morning hours. Morning lapses are a sign of incomplete asthma control and an early symptom of impending exacerbation.

At the same time, tangible changes in well-being may still be absent, and timely measures taken will avoid the development of an exacerbation.Self-monitoring with a peak flow meter is a prerequisite for drawing up an Action Plan for Asthma: detailed doctor’s recommendations, which outline the basic therapy and the necessary actions in case of changes in the state.

Treatment of exacerbations.

The most important thing is to try to prevent exacerbations. Measures to limit exposure to allergens and properly selected routine therapy greatly reduce this risk. But exacerbations do occur, and the most common cause is ARVI.

Exacerbation of bronchial asthma, along with a danger to the mother, poses a serious threat to the fetus due to the development of hypoxia, therefore, a delay in treatment is unacceptable. Treatment of exacerbations requires the use of a nebulizer; salbutamol is the drug of choice in our country. The effect of treatment is assessed not only clinically, but also with the help of a peak flow meter: if, after the therapy, the indicators did not reach the level of 70% of normal (or the best for this patient), urgent hospitalization is required.If necessary, inhaled anticholinergics can be connected to nebulizer therapy; if the effect is insufficient, aminophylline is additionally prescribed intravenously. Oxygen therapy is used to combat fetal hypoxia. In severe exacerbations of bronchial asthma, the use of systemic hormonal drugs is required, including short-course hormone tablets; at the same time, drugs of trimcinolone (Polcortolone) are avoided due to the risk of affecting the muscular system of the mother and the fetus, as well as dexamethasone and betamethasone, and preference is given to drugs prednisolone or methylprednisolone.The harm caused to the child by hypoxia is many times higher than the possible side effects.

As already mentioned, during pregnancy, the use of any ephedrine preparations is absolutely contraindicated, since it aggravates fetal hypoxia. The use of adrenaline for exacerbations of bronchial asthma is not recommended.

Other questions of drug therapy.

Prescribing any medication during pregnancy should be handled with caution, including pain relievers and vitamins.Caution when taking non-steroidal analgesics (aspirin, analgin, etc.) is necessary for all patients with bronchial asthma, and with aspirin asthma, a complete and absolute exclusion of all drugs in this group is required.

Intolerance to any medications is not uncommon in bronchial asthma. You will be safer if you always have a passport filled out by an allergist with an allergic disease patient, which will list medications that have previously caused an allergic reaction or are contraindicated in asthma (for example, beta-blockers), as well as indicated related medications that may cause cross-allergy.Before using any medication, you must familiarize yourself with its composition and instructions for use, and discuss all questions with your doctor.

As already mentioned, during pregnancy, the use of any ephedrine preparations (including theofedrine) is absolutely contraindicated, since it causes a narrowing of the vessels of the uterus and aggravates fetal hypoxia. The use of adrenaline for exacerbations of bronchial asthma is not recommended (if necessary, use injectable terbutaline).

Deposited forms of long-acting systemic hormones – Kenalog, Diprospan – are categorically not used either for asthma or for allergies during pregnancy.

Sometimes special measures are required to combat heartburn in pregnant women. it can adversely affect the course of asthma, especially at night. It is very important to prescribe a diet with the exclusion of caffeine, chocolate and other products that provoke heartburn; in some cases, the appointment of drug treatment is required.

In the presence of concomitant diseases that require planned therapy (for example, hypertension), you should contact a specialist of the appropriate profile to correct therapy taking into account the planned pregnancy.

Of expectorant drugs, iodine preparations or iodine-containing substances (for example, potassium iodide) are contraindicated, since they can affect the function of the thyroid gland of the fetus.

Antihistamines familiar to allergy sufferers are not used to treat bronchial asthma in adults, but the need for them may be associated with the presence of other allergic diseases, for example, with concomitant allergic rhinitis.They have significant restrictions on their use during pregnancy, especially in the first trimester. Only a limited number of drugs are used under the strict supervision of a physician, in small doses and according to strict indications (for example, diphenhydramine – Diphenhydramine). Modern antihistamines are used during pregnancy as directed by a doctor only in cases of extreme necessity, when the expected benefit exceeds the potential risk to the fetus (experience of their use during pregnancy is still insufficient, experimental studies on animals have not revealed teratogenic effects, category B ): cetirizine ( Zyrtec), loratadine (Claritin).Fexofenadine is currently classified in category C (there is currently no data on its safety during pregnancy) and is usually not used. It is allowed to use mechitazin (Primalan) with extreme caution. The use of astemizole and terfenadine is unacceptable (arrhythmogenic effect, detection of embryotoxic effects on animals).

Antihistamines for pregnancy in the United States.

The FDA (Food and Drug Administration, USA) categorizes Chlorpheniramine (Chlor-Trimeton), dexchlorpheniramine (Polaramine), brompheniramine (Dimetapp), diphenhydramine (Benadryl, in Russia – Diphenhydramine), Cyproheptin, Peria , clemastine (Tavist, in Russia – Tavegil), cetirizine (Zyrtec), loratadine (Claritin), azatidine (Optimine).Acelastine (Astelin, in Russia – Allergodil), hydroxyzine (Atarax, in Russia – Atarax) and promethazine (Phenergan, in Russia – Pipolfen, Diprazin) are assigned to category C.

Pregnancy and Allergen-Specific Immunotherapy (ASIT, or SIT)

Although pregnancy is not a contraindication for ASIT, it is not recommended to start treatment during pregnancy. But if pregnancy occurs during ASIT, the treatment can be continued. One study showed that children born to mothers who received ASIT had a reduced risk of developing allergies.

Childbirth

A pregnant woman should know and take into account in her plans that with bronchial asthma, compared with healthy women, the risk of both premature birth and prolonged pregnancy is slightly increased, which requires careful observation of a gynecologist. To avoid exacerbation of asthma during labor, basic therapy is not discontinued during labor. Peak flowmetry should be assessed from the onset of labor and at least every 12 hours.If the pregnant woman has previously received systemic hormonal drugs, systemic hormones are prescribed during childbirth to avoid adrenal insufficiency. It is known that adequate pain relief during childbirth reduces the risk of exacerbation of bronchial asthma.

The course of childbirth in women with asthma has its own characteristics, according to statistics, more often than usual, there is a need to stimulate and conduct a caesarean section (in this case, epidural anesthesia is preferable). For stimulation, it is possible to use oxytocin, but preparations of prostaglandins and ergometrine are contraindicated.A number of drugs used in anesthesia and for pain relief (morphine, thiopental, etc.) are also contraindicated due to the possibility of oppression of the respiratory center or the ability to cause the release of histamine and provoke bronchospasm.

Risk of having a baby with asthma and allergies.

Any woman is worried about the health of her unborn child, and since the development of bronchial asthma, of course, involves inherited factors, this issue should be dwelled on.The most studied question is the inheritance of atopy (hereditary tendency of the body to respond to environmental influences by producing an excess amount of immunoglobulin E). It should be noted right away that we are not talking about the indispensable inheritance of bronchial asthma, but about the general risk of subsequently developing an allergic disease, namely about the risk, and not about fatal inevitability.

Atopic diseases include allergic rhinitis and conjunctivitis, atopic dermatitis, acute urticaria, and atopic bronchial asthma.Of course, the risk of atopy in a child from a family, all members of which suffer from atopic diseases from generation to generation, is higher than in families where these diseases have never occurred. The greatest risk is noted in families where heredity is burdened by this trait both on the mother’s side and on the father’s side. The risk of inheriting atopy on the maternal side is higher than on the father’s side, but an atopic child can also be born in a family with no previous allergies. Allergic diseases are not grounds for a ban on having children.

Allergies are widespread in the modern world, and up to 40% of people experience any of its symptoms at least once during their life. But in the development of allergic diseases, in addition to heredity, other factors play a role, including the microecology of the home, smoking parents, feeding the baby, etc. Active and passive smoking and environmental pollution are of no less importance than burdened heredity. The importance of dietary factors (both the nutrition of the woman herself during pregnancy and lactation, and the presence or absence of breastfeeding of the child), living conditions, even the number of children in the family, as well as exposure to allergens (external and indoor allergens – house dust mite, microscopic molds, pet allergens, rodents and cockroaches).The risk of developing hypersensitivity to allergens and the formation of an allergic disease should not be regarded as a sentence, but only as a basis for taking the necessary measures. But if the need to protect yourself, your home and your unborn child from exposure to tobacco smoke is beyond doubt, then in order to properly plan other measures, you need to know more about your body. Limiting exposure to allergens from birth is recommended in the case of burdened heredity, as well as with an increased content of total immunoglobulin E in blood taken from the umbilical cord during childbirth (such an analysis is performed with a burdened family history).Several studies have noted a decrease in the risk of developing allergic diseases with the early and prophylactic administration of probiotics containing certain types of lactobacilli.

Breastfeeding.

A lot of special and popular literature has been written about the benefits of breastfeeding, so we will not dwell on this in detail. Breastfeeding is recommended for at least 6 months, while the woman herself should follow a hypoallergenic diet.When introducing complementary foods, products with a low allergenic potential are selected.

Pregnant women with bronchial asthma should also consult a specialist for advice on the use of medications during breastfeeding. If it is necessary to take medications, they should be used no later than 4 hours before feeding: in this case, their concentration in milk is minimal. Most drugs pass into milk in one amount or another, and their possible effect cannot be ignored.For a range of drugs that can be prescribed to a breastfeeding woman, it is recommended that breastfeeding be stopped during treatment. At the same time, safety indicators during pregnancy and breastfeeding do not always coincide. For example, macrolide antibiotics (for example, Erythromycin), which may be prescribed during pregnancy, are not used during breastfeeding. their concentration in milk is 2-4 times higher than the concentration in blood plasma. Theophylline ingested with milk can cause toxic effects in a child, irritability, tachycardia and arrhythmia.All antihistamines in small doses pass into breast milk. It has not been established whether inhaled hormones are excreted in breast milk, although it can be assumed that inhaled topical drugs with a minimal systemic effect, when used in recommended doses, enter milk in insignificant quantities.

Preparations for the treatment of bronchial asthma during pregnancy

Asthma occurs in 4-8% of pregnant women. With the onset of pregnancy, about one third of patients experience an improvement in symptoms, a third have a worsening (more often between 24 and 36 weeks), and in another third, the severity of symptoms remains unchanged.

Exacerbations of asthma during pregnancy significantly impair fetal oxygenation. Severe, uncontrolled asthma is associated with complications both in women (preeclampsia, vaginal bleeding, complicated labor) and in newborns (increased perinatal mortality, intrauterine growth retardation, preterm birth, reduced birth weight, hypoxia in the neonatal period). In contrast, in women with controlled asthma who receive adequate therapy, the risk of complications is minimal.First of all, in pregnant women with asthma, it is important to assess the severity of symptoms.

Management of pregnant patients with bronchial asthma includes:

• monitoring of lung function;
• limitation of factors causing seizures;
• patient training;
• selection of individual pharmacotherapy.

In patients with persistent bronchial asthma, such parameters as peak expiratory flow rate – PSV (should be at least 70% of the maximum), forced expiratory volume (FEV), should be monitored, and spirometry should be performed regularly.

Step therapy is selected taking into account the patient’s condition (the minimum effective dose of drugs is selected). In patients with severe asthma, in addition to the above measures, an ultrasound scan should be carried out in order to monitor the child’s condition.

Regardless of the severity of symptoms, the most important principle of management of pregnant patients with bronchial asthma is to limit the impact of factors that cause attacks; with this approach, it is possible to reduce the need for drugs.

If the course of asthma cannot be controlled by conservative methods, it is necessary to prescribe anti-asthma drugs. Table 2 provides information on their safety (safety categories according to the FDA classification).

Short-acting beta-agonists

For the relief of seizures, it is preferable to use selective beta-adrenergic agonists. Salbutamol, the most commonly used for these purposes, is classified as Category C by the FDA.

In particular, salbutamol can cause tachycardia, hyperglycemia in the mother and the fetus; hypotension, pulmonary edema, stagnation in the systemic circulation in the mother. Use of this drug during pregnancy can also cause retinal circulatory disorders and retinopathy in newborns.

Pregnant women with intermittent asthma who need to take short-acting beta-agonists more than 2 times a week may be prescribed long-term basic therapy.Similarly, basic drugs can be prescribed to pregnant women with persistent asthma when the need for short-acting beta-agonists arises 2 to 4 times a week.

Long-acting beta-agonists

For severe persistent asthma, Asthma and Pregnancy Working Group recommends the combination of long-acting beta-agonists and inhaled glucocorticoids as the drug of choice.

Application of the same therapy is possible in the case of moderate persistent asthma. In this case, salmaterol is preferable to formoterol because of the longer experience with its use; this drug is the most studied among analogues.

The FDA safety category for salmeterol and formoterol is C. It is contraindicated (especially in the first trimester) to use adrenaline and preparations containing alpha-adrenergic agonists (ephedrine, pseudoephedrine) to relieve attacks of bronchial asthma, although they all also belong to category C.

For example, the use of pseudoephedrine during pregnancy is associated with an increased risk of gastroschisis in the fetus.

Inhaled glucocorticoids

Inhaled glucocorticoids are the group of choice for pregnant women with asthma who require basic therapy. These drugs have been shown to improve lung function and reduce the risk of worsening symptoms. At the same time, the use of inhaled glucocorticoids is not associated with the appearance of any congenital anomalies in newborns.

Budesonide is the drug of choice – it is the only drug in this group that belongs to the FDA safety category B, which is due to the fact that it (in the form of inhalation and nasal spray) has been studied in prospective studies.

An analysis of data from three registers covering 99% of pregnancies in Sweden from 1995 to 2001 confirmed that inhalation of budesonide was not associated with any congenital anomalies.At the same time, the use of budesonide is associated with preterm birth and reduced birth weight.

All other inhaled glucocorticoids used to treat asthma are Category C. However, there is no evidence that they may be unsafe during pregnancy.

If the course of bronchial asthma is successfully controlled with the help of any inhaled glucocorticoid, it is not recommended to change therapy during pregnancy.

Glucocorticosteroids for systemic use

All oral glucocorticoids are classified as Category C by the FDA. The Pregnancy Asthma Study Group recommends the addition of oral glucocorticoids to high-dose inhaled glucocorticoids in pregnant women with uncontrolled severe persistent asthma.

If it is necessary to use drugs of this group in pregnant women, triamcinolone should not be prescribed due to the high risk of developing myopathy in the fetus.Long-acting drugs such as dexamethasone and betamethasone (both FDA categories C) are also not recommended. Preference should be given to prednisolone, the concentration of which decreases by more than 8 times when passing through the placenta.

In a recent study, it was shown that the use of oral glucocorticoids (especially in early pregnancy), regardless of the drug, slightly increases the risk of cleft palate in children (by 0.2-0.3%).

Other possible complications associated with taking glucocorticoids during pregnancy include preeclampsia, premature birth, and low birth weight.

Theophylline preparations

According to the recommendations of the Asthma in Pregnancy Study Group, theophylline in recommended doses (serum concentration 5-12 μg / ml) is an alternative to inhaled glucocorticoids in pregnant patients with mild persistent asthma.It can also be added to glucocorticoids in the treatment of moderate to severe persistent asthma.

Taking into account a significant decrease in the clearance of theophylline in the third trimester, it is optimal to study the concentration of theophylline in the blood. It should also be borne in mind that theophylline freely passes through the placenta, its concentration in the fetal blood is comparable to that of the mother, when it is used in high doses shortly before childbirth, tachycardia is possible in a newborn, and with prolonged use, the development of a withdrawal syndrome.

It has been suggested (but not proven) that theophylline use during pregnancy is associated with preeclampsia and an increased risk of preterm birth.

Cromones

The safety of sodium cromoglycate preparations in the treatment of mild bronchial asthma has been proven in two prospective cohort studies, the total number of treated cromones in which was 318 out of 1917 examined pregnant women.

However, data on the safety of these drugs in pregnancy are limited.Both nedocromil and cromoglycate are classified as safety category B by the FDA. Cromones are not the group of choice in pregnant patients due to their lower efficacy compared to inhaled glucocorticoids.

Leukotriene receptor blockers

Information on the safety of drugs in this group during pregnancy is limited. In cases where a woman is able to control asthma with zafirlukast or montelukast, it is not recommended by the Asthma in Pregnancy Study Group to interrupt therapy with these drugs at the onset of pregnancy.

Both zafirlukast and montelukast are FDA Safety Category B. When taken during pregnancy, there was no increase in the number of congenital anomalies. Only reported hepatotoxic effects in pregnant women with the use of zafirlukst.

In contrast, the lipoxygenase inhibitor zileuton in animal experiments (rabbits) increased the risk of cleft palate by 2.5% when used in doses similar to the maximum therapeutic dose.Zileuton is classified as safety category C by the FDA.

The group for the study of asthma in pregnancy allows the use of inhibitors of leukotriene receptors (except for zileuton) in minimal therapeutic doses in pregnant women with mild persistent asthma, and in the case of moderate persistent asthma – the use of drugs of this group (except for zileuton) in combination with inhaled glucocorticoids.

Adequate asthma control is essential for the best pregnancy outcome (for both mother and baby).The attending physician should inform the patient about the possible risks associated with the use of drugs and the risks in the absence of pharmacotherapy.

O. L. Romanov

2011

90,000 Bronchial asthma during pregnancy – causes, symptoms, diagnosis and treatment

Bronchial asthma during pregnancy is an atopic bronchospastic disease of the respiratory system that occurred during gestation or pre-existing and can affect its course.It is manifested by attacks of characteristic suffocation, unproductive cough, shortness of breath, noisy wheezing. It is diagnosed using physical examination methods, laboratory determination of markers of allergic reactions, spirography, peak flowmetry. For basic treatment, combinations of inhaled glucocorticoids, antileukotrienes, beta-agonists are used, and short-acting bronchodilators are used to relieve seizures.

General information

Bronchial asthma (BA) is the most common pathology of the respiratory system during pregnancy; it occurs in 2-9% of patients.According to the observations of obstetricians-gynecologists and pulmonologists, the progression of the disease is observed in 33-69% of pregnant women. At the same time, in some women, the condition remains stable and even improves. Mild forms of asthma are diagnosed in 62% of women, moderate forms – in 30%, severe – in 8%. Although an exacerbation of the disease is possible at any stage of pregnancy, it most often occurs in the second trimester, and during the last 4 weeks, spontaneous improvement usually occurs due to an increase in the content of free cortisol. The relevance of timely diagnosis of asthma is associated with the almost complete absence of complications with proper drug control.

Bronchial asthma during pregnancy

Causes

The onset of the disease in a pregnant woman is provoked by the same factors as in non-pregnant patients. Atopy plays a significant role in the development of bronchial asthma – a hereditary predisposition to allergic diseases due to hypersensitization of the body with increased synthesis of immunoglobulin (IgE). The starting point for bronchospastic conditions in these cases is the action of external triggers – domestic allergens (dust, paint vapors, building materials), plant pollen, animal hair, food products, pharmaceuticals, tobacco smoke, occupational hazards, etc.The appearance of symptoms in predisposed pregnant women can be triggered by respiratory viral infections, chlamydia, mycobacterium tuberculosis, intestinal and other parasites.

The topic of the influence of changes during gestation on the onset and course of asthma is still considered insufficiently studied. According to various authors in the field of obstetrics, in some cases, the onset of the disease is associated with pregnancy, and its symptoms may persist or completely disappear after childbirth. A number of neuroendocrine, immune and mechanical factors have been identified that contribute to the development of bronchospasm during gestation.They also exacerbate the disease and aggravate its symptoms in pregnant women with bronchial asthma:

• Increased secretion of endogenous bronchoconstrictors . The maternal part of the placenta and uterine tissue synthesize prostaglandin F2α, which stimulates smooth muscle contraction. Its concentration rises towards the end of gestation, ensuring a timely onset of labor. The substance also provokes respiratory obstruction due to spasm of bronchial smooth muscle fibers.
• Increase in the concentration of immunoglobulin E .A high level of IgE is an important link in the pathogenesis of atopic reaction to the action of sensitizing factors. Immune reconstruction in response to constant exposure to fetal antigens leads to an increase in the content of this immunoglobulin in the blood of a pregnant woman and increases the likelihood of developing bronchospasm and asthma.
• Increase in the number of α-adrenergic receptors . Hormonal changes that occur towards the end of pregnancy are aimed at ensuring adequate labor.Stimulation of α-adrenergic receptors is accompanied by an increase in the contractile activity of the myometrium. The number of such receptors also increases in the bronchi, which facilitates and accelerates the onset of bronchospasm.
• Decreased sensitivity to cortisol . Glucocorticoids have a complex anti-asthma effect that affects different links in the pathogenesis of the disease. During pregnancy, because of competition with other hormones, the lung receptors become less sensitive to cortisol.As a result, the likelihood of bronchospasm increases.
• Change in breathing mechanics . The stimulating effect of progesterone contributes to the occurrence of hyperventilation and an increase in the partial pressure of carbon dioxide in the first trimester. The pressure of the growing uterus in the II-III trimesters and an increase in the resistance of the vessels of the pulmonary circulation potentiate the appearance of shortness of breath. In such conditions, bronchospasm develops more easily.

An additional factor that increases the likelihood of AD during gestation is progesterone-induced swelling of the mucous membranes, including those lining the airways.In addition, in connection with the relaxation of the smooth muscles of the esophageal-gastric sphincter in pregnant women, gastroesophageal reflux is more often formed, which serves as a trigger for the development of bronchospasm. An exacerbation of the disease in a patient with manifestations of bronchial asthma can also occur when refusing maintenance treatment with glucocorticoid drugs for fear of harming the child.

Pathogenesis

The key link in the development of asthma during pregnancy is an increase in the reactivity of the bronchial tree caused by specific changes on the part of the autonomic nervous system, inhibition of cyclic nucleotides (cAMP), degranulation of mast cells, the effect of histamine, leukotrienes, cytokines, chemo-tokines, and others.The action of trigger allergens triggers reversible bronchial obstruction with increased airway resistance, overstretching of alveolar tissue, and a mismatch between ventilation and perfusion. The final stage of respiratory failure is hypoxemia, hypoxia, metabolic disorders.

Classification

In the management of pregnant women suffering from bronchial asthma, a clinical systematization of the forms of the disease is used, taking into account the severity. The classification criteria for this approach are the frequency of occurrence of asthma attacks, their duration, changes in the parameters of external respiration.There are the following options for bronchial asthma during pregnancy:

• Episodic (intermittent) . Asthma attacks are observed no more than once a week, at night the patient is disturbed no more than 2 times a month. Periods of exacerbations last from several hours to several days. Outside of exacerbations, the functions of external respiration are not impaired.
• Light persistent . Typical symptoms occur several times during the week, but not more than once a day.With exacerbations, sleep disturbance and habitual activity may be disturbed. The peak expiratory flow rate and its second volume during forced breathing change by 20-30% during the day.
• Persistent moderate . There are daily attacks. Choking develops at night more often than once a week. Physical activity and sleep are altered. Characterized by a 20-40% decrease in the peak expiratory flow rate and its second volume when forcing with a daily variability of more than 30%.
• Severe persistent . The pregnant woman is worried about daily attacks with frequent exacerbations and appearance at night. There are restrictions on physical activity. The basic indicators of the assessment of the functions of external respiration are reduced by more than 40%, and their daily fluctuations exceed 30%.

Symptoms of asthma during pregnancy

The clinical picture of the disease is presented by attacks of suffocation with a short inhalation and a long obstructed exhalation.In some pregnant women, the classic symptoms are preceded by an aura – nasal congestion, sneezing, coughing, the appearance of a very itchy urticarial rash on the skin. To facilitate breathing, a woman takes a characteristic orthopnea posture: she sits down or stands, leaning forward and raising her shoulders. With an attack, interrupted speech is noted, an unproductive cough occurs with a small amount of vitreous sputum, wheezing rales are heard remotely, heart rate increases, cyanosis of the skin and visible mucous membranes is observed.

The auxiliary muscles are usually involved in breathing – the shoulder girdle, abdominal press. The intercostal spaces expand and retract, and the chest becomes cylindrical. On inhalation, the wings of the nose inflate. Choking is provoked by the action of a certain aeroallergen, a nonspecific irritant (tobacco smoke, gases, harsh perfumes), physical exertion. Periodically, symptoms develop at night, disrupting sleep. With a prolonged course, pain may appear in the lower parts of the chest, associated with overstrain of the diaphragm.The attack ends spontaneously or after the use of bronchodilators. In the interictal period, clinical manifestations are usually absent.

Complications

In the absence of proper drug control, a pregnant woman with signs of bronchial asthma develops respiratory failure, arterial hypoxemia, and peripheral microcirculation is impaired. As a result, 37% of patients have early toxicosis, 43% have gestosis, 26% have a threat of termination of pregnancy, and 14.2% have premature birth.The emergence of hypoxia at the time when the laying of the main organs and systems of the child occurs, leads to the formation of congenital developmental anomalies. According to the research results, heart defects, disorders of the development of the gastrointestinal tract, spine, and nervous system are observed in almost 13% of children born by women with exacerbations and attacks of suffocation in the 1st trimester.

Immune complexes circulating in the blood damage the endothelium of the uteroplacental vessels, which leads to placental insufficiency in 29% of pregnancy cases with BA.Fetal growth retardation is found in 27% of patients, malnutrition – in 28%, hypoxia and asphyxia of newborns – in 33%. Every third child born to a woman with a bronchial asthma clinic is underweight. This figure is even higher with a steroid-dependent form of the disease. Constant interaction with the mother’s antigens sensitizes the baby to allergens. In the future, 45-58% of children have an increased risk of developing allergic diseases, more often they get sick with ARVI, bronchitis, pneumonia.

Diagnostics

The appearance of recurrent attacks of suffocation and sudden unproductive cough in a pregnant woman is a sufficient basis for a comprehensive examination to confirm or deny the diagnosis of bronchial asthma.During the gestational period, there are certain restrictions on the performance of diagnostic tests. Due to the possible generalization of an allergic reaction, pregnant women are not prescribed provocative and scarification tests with probable allergens, provocative inhalations of histamine, methacholine, acetylcholine and other mediators. The most informative for the diagnosis of bronchial asthma during pregnancy are:

• Percussion and auscultation of the lungs . During an attack, a boxed sound is noted over the pulmonary fields.The lower boundaries of the lungs are displaced downward, their excursion is practically undefined. Weakened breathing with scattered dry wheezing is heard. After coughing, mainly in the posterior parts of the lungs, wheezing increases, which in some patients may persist between attacks.
• Markers of allergic reactions . Asthma is characterized by increased levels of histamine, immunoglobulin E, eosinophilic cationic protein (ECP). The content of histamine and IgE is usually increased both during an exacerbation and between asthmatic attacks.An increase in ECP concentration indicates a specific immune response of eosinophils to the “allergen + immunoglobulin E” complex.
• Spirography and peak flow measurement . Spirographic examination allows, on the basis of data on the forced expiratory volume (FE1), to confirm functional impairments of external respiration according to the obstructive or mixed type. During peak flowmetry, latent bronchospasm is detected, its severity and daily variability of peak expiratory flow (PSV) are determined.

Additional diagnostic criteria are an increase in the content of eosinophils in the general blood test, the identification of eosinophilic cells, Charcot-Leiden crystals and Kurshman’s coils in the analysis of sputum, the presence of sinus tachycardia and signs of overload of the right atrium and ventricle on the ECG. Differential diagnosis is carried out with chronic obstructive pulmonary diseases, cystic fibrosis, tracheobronchial dyskinesia, constrictive bronchiolitis, fibrosing and allergic alveolitis, bronchial and lung tumors, occupational diseases of the respiratory organs, pathology of the cardiovascular system with heart failure.According to the indications, the patient is consulted by a pulmonologist, an allergist.

Treatment of asthma during pregnancy

When managing patients with asthma, it is important to ensure high-quality monitoring of the state of the pregnant woman, the fetus and maintain respiratory function at a normal level. With a stable course of the disease, a woman is examined by a pulmonologist three times during pregnancy – at 18-20, 28-30 weeks of gestation and before childbirth. The external respiration function is monitored using peak flowmetry. Given the high risk of fetoplacental insufficiency, fetometry and Doppler ultrasonography of placental blood flow are regularly performed.When choosing a pharmacotherapy regimen, the severity of bronchial asthma is taken into account:

• With intermittent BA , the basic drug is not prescribed. Before probable contact with an allergen, when the first signs of bronchospasm appear and at the time of an attack, inhaled short-acting bronchodilators from the group of β2-agonists are used.
• In persistent forms of asthma : basic therapy with category B inhaled glucocorticoids is recommended, which, depending on the severity of asthma, are combined with antileukotrienes, short or long acting β-agonists.The attack is stopped with inhaled bronchodilators.

The use of systemic glucocorticosteroids, which increase the risk of hyperglycemia, gestational diabetes, eclampsia, preeclampsia, low birth weight, is justified only if basic pharmacotherapy is not effective enough. Triamcinolone, dexamethasone, depot forms are not shown. Prednisolone analogs are preferred. In case of exacerbation, it is important to prevent or reduce possible fetal hypoxia. For this, inhalations with quaternary atropine derivatives are additionally used, oxygen to maintain saturation, in extreme cases, artificial ventilation of the lungs is provided.

Although with a calm course of bronchial asthma, delivery by vaginal delivery is recommended, in 28% of cases with obstetric indications, a cesarean section is performed. After the onset of labor, the patient continues to take basic drugs in the same dosages as during gestation. If necessary, oxytocin is prescribed to stimulate uterine contractions. The use of prostaglandins in such cases can provoke bronchospasm. During the period of breastfeeding, it is necessary to take basic anti-asthma drugs in doses that correspond to the clinical form of the disease.

Forecast and prevention

Adequate therapy of bronchial asthma at the stage of pregnancy allows you to completely eliminate the danger to the fetus and minimize threats to the mother. Perinatal prognosis with controlled treatment does not differ from prognosis for children born by healthy women. For prophylactic purposes, patients from the risk group, prone to allergic reactions or suffering from atopic diseases, are recommended to quit smoking, limit contact with household, industrial, food, vegetable, animal exoallergens.To reduce the frequency of exacerbations, pregnant women with asthma are shown exercise therapy classes, therapeutic massage, special complexes of breathing exercises, speleotherapy.

90,000 ᐈ Why is bronchial asthma dangerous? ~ 【Treatment in Kiev】

Etiology

This multifactorial disease can be triggered by both external and internal circumstances. More often acquired than hereditary. The causes of bronchial asthma are individual for each case.

Unfavorable ecology.
It has been scientifically proven that polluted air has a detrimental effect on the body, several times more harmful than smoking. People living in close proximity to industrial areas, highways, and countries with humid climates are more at risk of asthma.

Work in hazardous industries.
Workers in the chemical industry, construction workers (especially painters, plasterers) and hairdressers are in direct contact with toxic volatile or bulk materials for most of the working day.Their systematic inhalation leads to the development of bronchial asthma. Employees of small and poorly ventilated premises are no exception.

Dust.
Common dust can act as a strong asthma trigger. Its accumulations contain dead skin particles, hair, dust mites and pollen, which, if inhaled, irritate the bronchi, causing an asthmatic cough.

Smoking.
Nicotine-addicted people are more at risk of developing bronchial asthma, since poisonous resins have a toxic effect not only on the respiratory system, but on the entire body as a whole.The addiction can also lead to the development of a chronic smoker’s cough or life-threatening diseases (such as cancer).

Long-term course of respiratory diseases.
Diseases of the respiratory organs (including those of an infectious nature) interfere with the functioning of the body. Inflammatory lesions destroy the mucous membranes of the trachea and bronchi, provoking complications and a chronic course of diseases such as tracheitis, bronchitis or pneumonia, which are exacerbated against the background of bronchial asthma.

Hereditary factor.
If one of the parents suffers from bronchial asthma, the risk of transmitting the disease to the child is about 30%. The probability increases to 70% if the disease is detected in both. Pathology does not necessarily appear immediately after birth, it can be in a dormant state for a long time.

Poor immunity and lack of vitamins B1 and D.
A reduced threshold of resistance to viruses of various natures can also cause bronchial asthma.Weakened immunity is more susceptible to infections and allergens from the outside.

Anti-inflammatory medicines.
Nonsteroidal anti-inflammatory drugs can also cause this disease. In particular, these include “Aspirin” and other medicines used for pain relief (“Ibuprofen”, “Ketanov”, etc.).

In addition to the listed factors, asthmatic manifestations can be caused by unhealthy unbalanced diet and regular stress.Timely diagnosis of bronchial asthma will help prevent the risk of developing irreversible pathologies of internal organs.

90,000 Asthma: risk factors

Bronchial asthma is the most common pathology of the respiratory system and one of the most common chronic diseases: asthma ranks fifth after heart disease, stroke, cancer and diabetes. According to the WHO, every 10th person on the planet has asthma. In the Rostov region, 28 thousand adults and over 6 thousand children and adolescents are under dynamic observation by doctors.Svetlana Vladimirovna Galkina, a physician-therapist of the highest category, a pulmonologist of GAU RO “OKDC”, spoke about when it is necessary to contact a narrow specialist – a pulmonologist and how to behave for patients with asthma during a pandemic.

– Svetlana Vladimirovna, what would you advise patients with asthma to do in these conditions, in addition to self-isolation?

– Patients with bronchial asthma, as well as with other respiratory diseases, are now at increased risk.For asthmatics, any infectious disease can have serious health consequences. By itself, the presence of a diagnosis of asthma does not increase the risk of infection with Covid-19, but if infected in patients with asthma, the course of the disease can pass with more severe symptoms, including an increase in the severity and number of potentially life-threatening attacks. Therefore, you should worry in advance about replenishing medications for stopping seizures, always have an inhaler with you and strictly observe the self-isolation regime.If you feel that you have an acute respiratory infection with an increase in temperature, do not postpone calling a doctor.

– How bright are the symptoms of bronchial asthma? Can an asthma attack be confused with something else?

– With a cough form of asthma, patients often delay contacting a pulmonologist, because except for coughing, nothing bothers them. But there are several alarming symptoms that will help you to be alert in time. With the cough form of asthma, the cough usually occurs at night or in the early morning hours.The cough is paroxysmal, usually unproductive, but sometimes ends in vitreous sputum. It can be triggered by strong odors or when you laugh. All this requires adequate treatment, and not the use of antitussives or mucolytic drugs. Bronchial asthma is diverse in its manifestations. We distinguish between allergic asthma, exercise-induced asthma (attacks of which occur after exercise), and the very dangerous form of aspirin, which occurs when using aspirin-containing drugs and products, as its name suggests.”Bright” symptoms in bronchial asthma – of course, asthma attacks, difficulty breathing (with limited exhalation) and a whistling sensation in the chest.

– Let’s talk about risk factors. The main one is genetic?

– Yes, the hereditary factor is very large. This is one of the main risk factors, most often in the atopic form of the disease (allergenic nature of occurrence). The most common triggers are indoor and outdoor allergens, such as house dust allergens, baptismus, plant pollen.Ignoring allergic diseases (in particular hay fever), lack of necessary therapy, can lead to bronchial asthma.

Now scientists have diagnosed more than 20 genes, a mutation in which leads to this pathology. But besides hereditary, there are many other risk factors. One of them, as I said, is infectious (after suffering from ARVI). The disease can be provoked by contacts with occupational hazards to which certain professions are exposed, nutritional disorders, which is associated with the introduction of various preservatives into the food industry, the use of which provokes the risk of developing diseases.

Smoking – not only active, but also passive – is also one of the risk factors. The pathogenic effects of irritating particles emitted with tobacco smoke irritate the mucous membrane, lead to mucus hypersecretion, thus becoming one of the triggers for both the occurrence of bronchial asthma and the unfavorable course of the disease. It has already been proven by medical science that a mother who smokes during pregnancy is more likely to expose her child to bronchial asthma.In addition, the disease in children with bronchial asthma has a more progressive unfavorable course in the family of smokers.

Clinical manifestations of the disease (i.e. patient complaints), as well as anamnestic data (frequency of episodes, association with provoking factors) are of decisive importance in making a diagnosis. Unfavorable climatic conditions also play a role in the development of the disease. It would seem that a large number of warm days should have a beneficial effect on the residents of the Rostov region.But our steppe area with its forbs is a rather powerful harmful risk factor for allergy sufferers during the polynation period. Therefore, patients with proven sensitization, i.e. sensitivity to weeds, should be notified of the need to refrain from going out into nature during the flowering period, and, if possible, even leave the region (but not currently due to the epidemiological situation).

– What are the features of the diagnosis and treatment of this pathology?

– Asthma is most often diagnosed in childhood, but asthma can be contracted at any age – all age groups are susceptible to the disease.In childhood, it is more often diagnosed in boys, and in adults – in women. This is due to hormonal changes in the body, most often during pregnancy, as another risk factor.

The diagnosis is made on the basis of the collection of anamnesis of the disease, the causal factors are established. The auxiliary methods include: x-ray of the chest organs, a study of the ventilation function of the lungs, which is carried out in our Department of Functional Diagnostics.

In addition to general clinical analyzes, the level of total immunoglobulin E is determined, and if atopy is suspected by an allergist, skin tests are performed.The goal of asthma treatment is to control symptoms, i.e. manifestations of the disease. The main drugs are inhalers containing bronchodilator and anti-inflammatory components, sometimes (much less often) – tablet drugs. Recent advances in pharmaceuticals enable us to treat severe bronchial asthma with genetically engineered drugs.

Treatment for patients is prescribed depending on the volume of symptoms – asthma attacks, a feeling of uncomfortable breathing. If we talk about the features of therapy, then you need to highlight the need to constantly monitor the symptoms, always “keep your finger on the pulse.”The latest advances in pharmaceuticals give us the opportunity to use both genetic engineering and the use of drugs that combine both emergency function and basic treatment at the same time.

– Can you tell us more about genetically engineered drugs?

– These drugs contain monochannel antibodies, the effect of such therapy is achieved due to the incorporation of the molecule into the pathogenetic mechanism of the development of the disease. This is an expensive treatment, but it is available for residents of the Rostov region in the presence of special indications and the ineffectiveness of the entire scope of the currently possible therapy.This type of therapy is carried out in the conditions of both day and round-the-clock hospital of the OKDC within the framework of the compulsory medical insurance system.

Drug treatment can control symptoms in patients with bronchial asthma, but does not affect the root cause of their occurrence. It is better to supplement therapy with diet, breathing exercises. When patients with asthma contact us, we teach the principles of self-help for stopping attacks, form an individual treatment plan. The doctor teaches the patient how to use the inhaler.But there are situations when the attack does not stop. The reason usually lies in the powerful influence of causal risk factors (contact with animals, stressful situations, etc.). In such cases, immediate assistance of the ambulance team is required.

– What complications can asthma cause?

– Ignoring the treatment of bronchial asthma can lead to a first aid situation (acute respiratory failure), in which help is even provided in the intensive care unit in some cases, and to a gradual disruption of bronchial patency and dyspnea during exercise, which limits the patient’s quality of life.It must be remembered that the peculiarity of this disease is that its mild course may not always mean the absence of dangerous seizures and even death in the future. Competent observance of the instructions given by the pulmonologist allows you to lead a fulfilling life and maintain your ability to work.

Recorded by Svetlana Chornovol

When should I see a therapist or pulmonologist?
– If you regularly suffer from a persistent cough with hard-to-separate phlegm.
– If you have shortness of breath, wheezing and wheezing when breathing.
In the event of a severe asthma attack, if it is not relieved by taking short-acting bronchodilators, you must urgently call an ambulance!

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90,000 Allergies and asthma complicate but do not prevent pregnancy

Allergies and asthma are some of the most common serious diseases that complicate pregnancy. The latter, according to various sources, affects 3-8% of pregnant women.

Other allergic diseases diagnosed in expectant mothers include urticaria, allergic rhinitis, atopic dermatitis or angioedema.

For life-threatening anaphylaxis, there is limited data on its prevalence in pregnant women. A UK study reports 1.6 to 3 cases per 100,000 pregnancies.

The general approach to the treatment of allergies during the period when a woman is expecting a child is to avoid its factors as much as possible in any form of allergic disease.

Ideally, women with allergic diseases should undergo all examinations and consultations with an allergist related to determining their health status before pregnancy.Then diagnostic methods will not affect the fetus and will allow doctors to better prepare a woman for bearing a child.

It should be remembered that the only method for diagnosing allergies allowed for pregnant women is the determination of specific immunoglobulins E to allergens in the blood.

Below we answer the most popular questions regarding the control of allergies and asthma during pregnancy

How does asthma affect the fetus?

Uncontrolled asthma symptoms can lead to a decrease in the amount of oxygen in the bloodstream of a pregnant woman, from whose blood the fetus receives oxygen.

For normal growth and development of the fetus, oxygen must be supplied to it constantly. To prevent the mom-to-be and her baby from experiencing hypoxia, it is very important to manage asthma symptoms.

Therefore, a woman during pregnancy should try to keep asthma under control, and, if necessary, take medications for it.

Is it safe to take asthma medications while pregnant?

The consequences of asthma exacerbations can be much more negative for the fetus than the risks of taking the necessary medications for it.

Studies show that most inhaled asthma medications are safe for pregnant women. However, oral medications (tablets) should be avoided unless absolutely necessary to control asthma symptoms.

Remember, the risk of inadequate oxygen supply to your baby is much greater than taking common asthma medications.

Will pregnancy affect my asthma symptoms?

Yes, pregnancy can affect the severity of asthma manifestations.According to one study, asthmatic symptoms worsened in 35% of pregnant women, improved in 28% and remained unchanged in 33% of women.

Asthma usually tends to get worse at the end of the second trimester and early in the third.

Is it safe for pregnant women to take allergy medications?

Certain antihistamines may be useful for women during pregnancy to treat:

And also – as an adjuvant for the treatment of serious allergic reactions, including anaphylaxis.With the exception of the latter, the benefits of drug use each time must be weighed against the likely risk to the fetus.

It is also worth remembering that allergy symptoms can have a serious impact on the mother-to-be’s diet, sleep, or emotional well-being. And, for example, uncontrolled rhinitis can develop into sinusitis or worsen asthma.

Can antigen specific immunotherapy (ASIT) and influenza vaccination be administered during pregnancy?

The ASIT course is not started if the patient is pregnant.But those who started the ASIT course before pregnancy can proceed with caution if this leads to relief of the condition and does not cause adverse reactions.

However, due to an increase in the dose of drugs used for antigen-specific immunotherapy, the risk of anaphylaxis increases. Given this, as well as the delayed effect of treatment, allergen-specific immunotherapy is usually not recommended for pregnant women.

The condition of patients receiving ASIT during pregnancy should be carefully assessed.It may be advisable to reduce the dosage of the drugs or stop the treatment altogether.

The influenza vaccine is recommended for all patients with moderate to severe asthma. Note: There is no evidence of a risk of vaccination to the mother or fetus.

What should a pregnant woman with allergies or asthma avoid?

Regardless of whether you are pregnant or not, you should avoid factors that cause symptoms of the disease.These include dust mites, animal dander, plant pollen and irritants such as cigarette smoke.

Can women with asthma do Lamaze breathing exercises?

Most women with asthma are able to perform the Lamaze breathing techniques without difficulty. Women whose asthma is under control during pregnancy rarely show symptoms during childbirth.

Can I breastfeed if the woman is taking asthma or allergy medication?

Breastfeeding is an effective way to increase the immunity of a child.Medicines recommended for use during pregnancy can be continued while breastfeeding, as the baby receives less maternal medication through breast milk than when in the womb.

Conclusions

Asthma and allergies cannot be ignored but controlled. These diseases should not become an obstacle to your motherhood:

• You can have a healthy pregnancy even if you have asthma or allergies.
• During pregnancy, it is necessary and very important to control the symptoms of the disease.
• Do not stop taking your medication because you are pregnant, but be sure to check the dosage and regimen with your allergist.

World Day Against Bronchial Asthma “KGBUZ” Taimyr MRB “

“Bronchial asthma is not scary!”

World Bronchial Asthma Day is held annually with the support of the World Health Organization on 11 December.
In Russia, 900 thousand patients with bronchial asthma were recorded, in the Krasnoyarsk Territory – more than 42.5 thousand patients.

The development of bronchial asthma is affected by air pollution with potential allergens, as well as smoking and consumption of unnatural food, which pose a great danger to the health of residents, especially large cities. According to the Federal Foundation for Social and Hygienic Monitoring, the city of Krasnoyarsk is a risk area for the development of bronchial asthma and COPD.

Asthma is a chronic illness characterized by recurrent attacks of breathlessness and wheezing, the severity and frequency of which varies from person to person. People with asthma may experience symptoms several times a day or week, and some people have attacks during physical activity or at night. During an asthma attack, the epithelial lining of the bronchioles swells, which narrows the airways and reduces airflow in and out of the lungs.Recurrent asthma attacks often lead to insomnia, daytime fatigue, decreased activity levels, and absenteeism from school and work. The mortality rate for asthma is relatively low compared to other chronic diseases.

What happens during an attack?
Bronchi (small branches of the respiratory tree) are narrowed due to a sharp contraction of muscle cells in their walls, inflammation, edema, mucus accumulation and the formation of “plugs”.Because of this, breathing becomes difficult, especially on exhalation, there is a feeling of congestion in the chest, shortness of breath, coughing, and in severe cases, even at a distance, wheezing is heard, resembling a whistle or buzzing. Such changes in the bronchi are reversible, sometimes the attack goes away without treatment, and sometimes special medications are needed to restore the normal functioning of the airways.

Causes
The underlying causes of asthma are not fully understood. The most significant risk factors for asthma are genetic predisposition in combination with inhaled substances and particles that are in the environment and can provoke allergic reactions or irritate the airways.These are substances and particles such as

• indoor allergens (house dust mites in bedding, carpets and upholstered furniture, air pollution and animal dander)
• outdoor allergens (pollen and mold)
• tobacco smoke
• chemical irritants in the workplace
• air pollution.

Other triggers include cold air, extreme emotional arousal such as anger or fear, and exercise.Certain medications such as aspirin and other non-steroidal anti-inflammatory drugs and beta-blockers (used to treat high blood pressure, heart disease, and migraines) can also trigger asthma.

Who is more susceptible to bronchial asthma?
Many factors have been identified that influence the development of bronchial asthma. In childhood, boys are more likely to suffer from asthma. After 20 years, the risk of developing the disease in men and women is equalized, but after 40 years, women are more susceptible to asthma.Many studies have noted that the likelihood of bronchial asthma in a child increases significantly if one or both parents suffered from this disease.
People with respiratory hypersensitivity are also at risk. The development of asthma is also associated with atopy (a genetic predisposition to allergies). So, about half of children who suffer from eczema or atopic dermatitis develop asthma. Allergy sufferers often have asthma. Sources of allergens can be house dust, food, animal dander, pollen, mold, etc.e. The development of asthma can lead to prolonged constant contact with harmful substances in the workplace or at home. Long-term inhalation of mineral dust, vapors of cleaning aerosols or detergents, tobacco smoke, smog, etc. can contribute to the appearance of the disease. A high risk of developing the disease is noted in people with overweight and obesity (body mass index over 25). The development of asthma in a child can be affected by the mother’s smoking during pregnancy. The likelihood of the onset of the disease is higher in premature babies.

Why is bronchial asthma dangerous?
If at the onset of an attack it is not possible to restore the normal functioning of the airways and to eliminate suffocation, then status asthmaticus may develop. Status asthma is a very serious complication of bronchial asthma, which can lead to death if the necessary medical care is not provided in time.