Management of asthma

during pregnancy

Dr. mbaluka
Lecture objectives

 Effects of pregnancy on asthma

 Effects of asthma on pregnancy
 Safety of specific asthmatic medications in pregnancy
 General care of a gravid asthmatic
 Management of Chronic asthma in pregnancy
 Management of Acute exacerbations
 Management Respiratory infections in gravid asthmatic
 Peripartum care of the asthmatic
Introduction
 Asthma is the most common pulmonary disease encountered during
pregnancy, occurring in 3 to 8 percent of pregnant women
 A review of maternal respiratory physiology during pregnancy:-
 Pregnancy is normally associated with a compensated respiratory
alkalosis.
 Minute ventilation increases during pregnancy, presumably due to
increased circulating levels of progesterone
 The increase in minute ventilation, which exceeds metabolic demands,
lowers alveolar and arterial PCO2 while simultaneously increasing
alveolar and arterial PO2 [over breathing=feeling of dyspnea]
 The resulting respiratory alkalosis induces secondary compensation
through renal loss of bicarbonate
 Thus, normal blood gases during pregnancy reveal a higher pO2 (100 to
106 mmHg) and a lower pCO2 (28 to 30 mmHg) than in the non-
pregnant state, typically accompanied by a slightly alkalotic pH
Introduction….
 Several lung volume changes occur during pregnancy
 Tidal volume increases, Residual volume decreases, Functional residual
capacity (FRC) decreases
 In spite of the reduced FRC during pregnancy, vital capacity and total
lung capacity are usually preserved during pregnancy due to increased
mobility and flaring of the ribs and unimpaired diaphragmatic excursion
 Airway mechanics do not change significantly during pregnancy.
 Thus, no changes in forced expiratory volume in one second (FEV1),
FEV1/FVC ratio, or maximum mid-expiratory flow rate (MMEF)
[FVC=forced vital capacity]
 The diagnosis of asthma during pregnancy is not different than in non-
pregnant patients
 Since airway mechanics do not change during pregnancy, the diagnosis
can be confirmed by demonstrating reversible airway obstruction as in
non-pregnant patients [methacholine testing]
 Since methacholine testing is not recommended during pregnancy,
therapeutic trials of asthma therapy should generally be used during
pregnancy in patients with possible but unconfirmed asthma
EFFECTS OF PREGNANCY ON
ASTHMA
 1/3 Worsen, 1/3 improve, 1/3 unchanged
 Asthma severity prior to pregnancy is related to asthma severity during
pregnancy
 Asthma is generally less severe during the last four weeks of pregnancy
 In women who improve, the improvement is gradual as pregnancy
progresses
 In women whose asthma worsen, the increase in symptoms is most
prominent between weeks 29 and 36 of gestation
 Substantial asthma symptoms are uncommon during labor and delivery
 The course of asthma in successive pregnancies in an individual patient
tends to be similar.
EFFECTS OF ASTHMA ON
PREGNANCY
Asthma may negatively impact various aspects of pregnancy, including
perinatal mortality and several common complications of pregnancy
 There Is increased risks of:-
 preeclampsia,
 hypertensive disorders,
 obstetric hemorrhage,
 hyperemesis,
 prematurity,
 low birthweight infants
 neonatal mortality,
 Three possible causes for these adverse pregnancy outcomes
 Hypoxia and other direct consequences of poorly controlled asthma
 Complications of asthma medications
 Factors related to both asthma and pregnancy — A factor associated with asthma that could
influence pregnancy would be polymorphisms of the beta-2 adrenergic receptor, as these
could contribute both to asthma and preterm labor .
 GENERAL CARE
 Requires team approach: chest physician and obstetrician
 The two primary goals of asthma management:-
1. Prevention of acute episodes:- should prevent potentially harmful acute
hypoxia, hypocapnia, alkalosis, and dehydration
2. Optimization of chronic maternal pulmonary function:- should reduce the
potential for chronic hypoxia, maternal symptoms, as well as the
likelihood of acute episodes.
 Asthmatic women requiring regular medication should be evaluated at
least monthly
 All pregnant patients should have ready access to their clinician, should
their symptoms change or increase
 It is also important that effective communication exists among the
clinician managing the asthma, the patient, and the obstetrician.
GENERAL CARE …..
 four important components of effective therapy
1. Objective monitoring of maternal lung function and fetal well–being as a
guide to therapy
2. Proper control of environmental and other triggers for asthma
3. Patient education
4. Pharmacologic therapy
GENERAL CARE …..
 Monitoring lung function
 Asthmatic symptoms are often greatest at night (leading to nocturnal
awakening), or when waking up in the morning
 Functional assessment by the patient during times of worsening symptoms
may provide a more accurate reflection of the patient's condition than
spirometric measurements at the clinician's office
 Measurement of peak expiratory flow rate (PEFR), or forced expiratory
volume in one second (FEV1), by the pt, using a portable device offers the
advantages of less expense and greater ease of serial measurements at
home.
 Ideally, patients with asthma should measure their PEFR twice a day: upon
awakening and approximately 12 hours later
 An additional issue for pregnant women with asthma is the difficulty
differentiating an exacerbation of asthma symptoms from the normal
sensation of dyspnea experienced during pregnancy
 The presence of cough and wheezing suggests asthma.
 Objective information can also be obtained by measurement of the PEFR
or FEV1; reductions in either suggest an asthma exacerbation
GENERAL CARE …..
 Environmental control
 This includes avoiding exposure to allergens and to nonspecific airway
irritants, such as tobacco smoke, dust, and environmental pollutants
 Particular allergens of concern are dander from pets and antigens from
household dust mites
 Smoking cessation
 It is critical for the pregnant asthmatic woman to discontinue smoking
during pregnancy
 First, smoking may predispose the patient to asthma exacerbations,
bronchitis or sinusitis, and therefore necessitate an increased need for
medication
 Second, the increased perinatal morbidity attributed to smoking may be
additive to the baseline risk conferred by uncontrolled maternal asthma
 GENERAL CARE …..
 Patient education
 Includes early recognition of signs and symptoms of an asthma
exacerbation
 Avoidance of precipitating factors
 Correct use of medications
 Development of a treatment plan for acute exacerbations.
 Interrelationships between asthma and pregnancy and the safety of
asthma medications during pregnancy
 The clinician should clearly explain that it is safer for pregnant women
with asthma to take asthma medications than to have ongoing symptoms
or exacerbations of asthma
 It is important that anxiety regarding asthma and its impact on pregnancy
be reduced by giving women the opportunity to express their concerns
and then providing appropriate information
 Women should be reassured that safe and adequate asthma treatment is
possible during pregnancy and that good asthma control can help to
minimize the risk of complications
GENERAL CARE …..
 Pharmacologic therapy: safety of specific medications
 Experience with many of the medications used to treat asthma suggests
minimal or no known adverse effects for their use during pregnancy
 Most drugs used in the treatment of asthma fall into categories B or C
 Lack of adverse effects on human pregnancy outcomes with the following
drugs:
 Albuteral
 Metaproterenol
 Theophylline
 Cromolyn sodium
 Beclomethasone
 Budesonide
 For a number of asthma medications, there are minimal or no published
human data
 These include drugs with reassuring animal studies (formoterol, salmeterol,
ipratropium, nedocromil, zafirlukast, and montelukast)
 And those with non-reassuring animal studies (zileuton)
Classifying asthma severity and initiating treatment in youths greater than or equal to 12 years
of age and adults
Classification of asthma severity (≥12 years of age)

Components of severity Persistent

Intermittent
Mild Moderate Severe

Impairment Symptoms ≤2 days/week >2 days/week but Daily Throughout the day
Normal FEV1/FVC: not daily
8-19 yr 85 percent
20-39 yr 80 percent Nighttime ≤2x/month 3-4x/month >1x/week but not Often 7x/week
40-59 yr 75 percent awakenings nightly
60-80 yr 70 percent
Short-acting beta2- ≤2 days/week >2 days/week but Daily Several times per
agonist use for not daily, and not day
symptom control more than 1x on
(not prevention of any day
EIB)

Interference with None Minor limitation Some limitation Extremely limited

normal activity

Lung function • Normal FEV1 • FEV1 ≥80 percent • FEV1 >60 but <80 • FEV1 <60 percent
between predicted percent predicted predicted
exacerbations • FEV1/FVC normal • FEV1/FVC reduced • FEV1/FVC reduced
• FEV1 >80 percent 5 percent >5 percent
predicted
• FEV1/FVC normal

Risk Exacerbations 0-1/year (see ≥2/year (see footnote)

requiring oral footnote)
systemic
corticosteroids Consider severity and interval since last exacerbation

Frequency and severity may fluctuate over time for patients in any severity
category

Relative annual risk of exacerbations may be related to FEV 1

Recommended step for initiating treatment Step 1 Step 2 Step 3 Step 4 or 5

And consider short course of oral systemic

corticosteroids

In 2-6 weeks, evaluate level of asthma control that is achieved and adjust therapy
accordingly.
Assessing severity and initiating treatment for patients who
are not currently taking long-term control medications
 The stepwise approach is meant to assist, not replace, the clinical
decisionmaking required to meet individual patient needs.
 Level of severity is determined by assessment of both impairment and
risk. Assess impairment domain by patient's/caregiver's recall of previous
2-4 weeks and spirometry.
 Assign severity to the most severe category in which any feature occurs.
 At present, there are inadequate data to correspond frequencies of
exacerbations with different levels of asthma severity.
 In general, more frequent and intense exacerbations (eg, requiring
urgent, unscheduled care, hospitalization, or ICU admission) indicate
greater underlying disease severity.
 For treatment purposes, patients who had ≥2 exacerbations requiring
oral systemic corticosteroids in the past year may be considered the
same as patients who have persistent asthma, even in the absence of
impairment levels consistent with persistent asthma.
Assessing asthma control and adjusting therapy in youths greater than or equal to 12 years of
age and adults

Classification of asthma control (≥12 years of age)

Components of control
Well-controlled Not-well controlled Very poorly controlled

Impairment Symptoms ≤2 days/week >2 days/week Throughout the day

Nighttime awakenings ≤2x/month 1-3x/week ≥4x/week

Interference with normal None Some limitation Extremely limited

activity

Short-acting beta2-agonist ≤2 days/week >2 days/week Several times per day

use for symptom control (not
prevention of EIB)

FEV1 or peak flow >80 percent 60-80 percent <60 percent

predicted/personal best predicted/personal best predicted/personal best

Validated questionnaires

ATAQ 0 1-2 3-4

ACQ ≤0.75* ≥1.5 N/A

ACT ≥20 16-19 ≤15

Risk Exacerbations requiring 0-1/year ≥2/year (see footnote)

oral systemic
corticosteroids Consider severity and interval since last exacerbation

Progressive loss of lung Evaluation requires long-term followup care

function

Treatment-related adverse Medication side effects can vary in intensity from none to very troublesome and worrisome. The
effects level of intensity does not correlate to specific levels of control but should be considered in the
overall assessment of risk.

Recommended action for treatment • Maintain current step. • Step up 1 step and • Consider short course of
• Regular followups every 1-6 • Reevaluate in 2-6 weeks. oral systemic corticosteroids,
months to maintain control. • For side effects, consider • Step up 1-2 steps, and
• Consider step down if well alternative treatment • Reevaluate in 2 weeks.
controlled for at least 3 options. • For side effects, consider
months. alternative treatment
options.
Assessing asthma control and adjusting therapy in youths greater
than or equal to 12 years of age and adults
 The stepwise approach is meant to assist, not replace, the clinical
decisionmaking required to meet individual patient needs.
 The level of control is based on the most severe impairment or risk
category.
 Assess impairment domain by patient's recall of previous 2-4 weeks and
by spirometry/or peak flow measures.
 Symptom assessment for longer periods should reflect a global
assessment, such as inquiring whether the patient's asthma is better or
worse since the last visit.
 At present, there are inadequate data to correspond frequencies of
exacerbations with different levels of asthma control. In general, more
frequent and intense exacerbations (eg, requiring urgent, unscheduled
care, hospitalization, or ICU admission) indicate poorer disease control.
 For treatment purposes, patients who had ≥2 exacerbations requiring
oral systemic corticosteroids in the past year may be considered the
same as patients who have not-well-controlled asthma even in the
absence of impairment levels consistent with not-well-controlled asthma.
Validated Questionnaires for the impairment domain (the
Treatment of Chronic asthma
 Either medium dose inhaled glucocorticoids or combination low dose
inhaled glucocorticoids plus a long acting beta agonist (LABA) are
recommended for the initial management of moderate persistent
asthma; preference is for the former due to the greater experience with
inhaled glucocorticoids than with LABAs during pregnancy.
 Albuterol is recommended as the short-acting beta agonist of choice.
 Because there are more published gestational human data for
budesonide, it is the preferred inhaled glucocorticoid for use during
pregnancy. However, other inhaled glucocorticoids could be continued if
the patient was well-controlled on one of these medications prior to
pregnancy
 Salmeterol is recommended as the inhaled long-acting beta agonist of
choice in the United States due to the longer duration of clinical
experience with this agent compared with formoterol.
 Montelukast or zafirlukast could be considered as alternative but NOT
preferred therapy for mild persistent asthma or as add-on therapy to
inhaled glucocorticoids, especially for patients who have shown a
uniquely favorable response prior to pregnancy.
 Preferred pharmacologic step therapy of asthma during pregnancy

Category Step therapy

Mild intermittent Inhaled short-acting beta2 agonist* as needed (for all categories)

Mild persistent Low dose inhaled glucocorticoid•

Moderate persistent Medium dose inhaled glucocorticoid•

OR

Low dose inhaled glucocorticoid• plus long-acting beta agonistΔ

OR

Medium dose inhaled glucocorticoid• plus long-acting beta agonistΔ, if needed

Severe persistent High dose inhaled glucocorticoid• plus long-acting beta agonistΔ

Prednisone if needed
 Pharmacologic management of acute asthma during
pregnancy
1. Beta2-agonist bronchodilator (nebulized or metered-dose inhaler)

Albuterol by MDI 4 to 8 puffs every 20 minutes up to 4 hours, then every 1 to 4 hours, as needed

Albuterol by nebulizer 0.083 percent (2.5 mg/3 mL), 2.5 to 5 mg every 20 minutes for 3 doses and then 2.5 to 5 mg every 1 to 4 hours, as needed

Albuterol by continuous nebulization, administering 10 to 15 mg per hour

2. Ipratropium

By nebulizer, 500 mcg every 20 minutes for 3 doses, then as needed. Can be given simultaneously with beta 2-agonist.

By MDI, 4 to 8 inhalations every 20 minutes for 3 doses, then as needed

3. Systemic glucocorticoids (for those with a poor response to treatment after one hour, or with initial therapy for patients on chronic oral glucocorticoids)

For patients who can be managed at home: prednisone 40 to 60 mg per day in a single or divided dose

For patients who require hospitalization: prednisone 40 to 80 mg daily in a single or divided dose (or the equivalent dose of methylprednisolone* intravenously) until
peak flow reaches 70 percent of predicted or personal best, and then taper as patient improves

For patients who have a life-threatening exacerbation, a higher initial dose of methylprednisolone*, 60 to 80 mg every 6 to 12 hours, may be given intravenously, and
then tapered as the patient improves, as above

4. For patients not responding to above therapies, consider adjunct therapies

Intravenous magnesium sulfate 2 g infused over 20 minutes, in absence of renal insufficiency•

Subcutaneous terbutaline 0.25 mg every 20 minutes for up to 3 doses

Acute asthma….
 Supportive care
 Supplemental oxygen (initially 3 to 4 L/min by nasal cannula) should be administered
 Adjusting the fraction of inspired oxygen (FiO2) to maintain an arterial oxygen tension
(PaO2) of at least 70 mmHg and/or oxygen saturation by pulse oximetry of 95 percent
or greater
 Intravenous fluids (containing glucose if the patient is not hyperglycemic) are
administered, if needed to ensure adequate hydration.
 Pregnant patients with acute asthma should rest in a seated, rather than supine,
position
 Dosages of systemic glucocorticoids for acute asthma exacerbations in pregnancy are
not different than those recommended for non-pregnant patients
 Intravenous aminophylline/theophylline is NOT generally recommended for use in the
emergency management of acute gestational asthma because it has been
demonstrated that aminophylline/theophylline provides no additional benefit to optimal
inhaled beta agonist and intravenous glucocorticoid therapy
 when used in combination with intensive inhaled beta-agonist therapy, intravenous
aminophylline causes increased adverse side effects
 Intravenous magnesium sulfate may be beneficial in acute severe asthma as an adjunct
to inhaled beta agonists and intravenous glucocorticoids, especially in patients with
coexistent hypertension or preterm uterine contractions
Respiratory infections

 Most respiratory infections that trigger an exacerbation of asthma are

viral rather than bacterial and do not require antibiotic therapy
 Peripartum care
 Oxytocin is the drug of choice for induction of labor and control of postpartum
hemorrhage
 Analogs of prostaglandin F2–alpha can cause bronchoconstriction and should
not be used for termination of pregnancy, cervical ripening, induction of labor,
or control of uterine hemorrhage
 Prostaglandin E2 (in gel or suppository form) and prostaglandin E1 (misoprostol)
have not been reported to cause bronchoconstriction and are safer analogs if
prostaglandin treatment is required
 For peripartum pain control, morphine and meperidine should be avoided, if
possible, since they can induce histamine release
 Butorphanol or fentanyl may be appropriate alternatives.
 Epidural anesthesia is preferred for the asthmatic patient who opts for pain
control during labor because it reduces oxygen consumption and minute
ventilation in the first and second stage of labor and usually can provide
adequate anesthesia if cesarean delivery becomes necessary
 If general anesthesia is required, ketamine and halogenated anesthetics are
preferred, because they may have a bronchodilatory effect
 Use of ergot derivatives for postpartum bleeding or headache should be
avoided because of their potential to cause bronchoconstriction
END