Asthma and pregnancy

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Asthma and pregnancy

• aminim_at_mums.ac.ir

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Case history
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• A 20 yr old lady presented with
• Hx of cough and dyspnea for 6 months
• 2 weeks of drug discontinuation
• 1 week cough, sputum and dyspnea
• She is 3 mo pregnant
• She is concerned about her chest disease during
  pregnancy

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• Is it really asthma?
• Why me? I had no family history.
• Does pregnancy cause my asthma to be exacerbated?
• Can my asthma be cured?
• Can moisturizers help me to improve?
• How does asthma affect my fetus?
• Are asthma drugs risky for my fetus?
• Is my child more prone to asthma?
• Can heartburn cause my asthma?
• Should I get flu shot?
• What should I do in the case of asthma attack?
• Can I do NVD for termination of pregnancy?

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Is it really asthma?
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• Recurrent episodes of wheezing
• Troublesome cough at night
• Cough or wheeze after exercise
• Cough, wheeze or chest tightness after exposure
  to airborne allergens or pollutants
• Colds go to the chest or take more than 10 days
  to clear

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• Pregnancy dyspnea
• Increased tidal volume
• Decreased ERV and RV and FRC
• Intact FEV1
• Less than normal PCo2
• Above normal PO2
• The presence of cough and wheezing suggests
  asthma

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Why me?
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• Asthma is a common disease
• Even more than diabetes mellitus
• In some countries 1 out of every 4 children has
  asthma

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• Asthma affects 4 to 8 of all pregnant women

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I had no family history
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• Asthma occurs more commonly in those with atopic
  history
• In themselves or
• Their 1st degree relatives
• A person with allergic rhinitis has 5 times more
  chance of asthma

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• Asthma is a polygenic disease
• Asthma occurs in a genetically susceptible
  person,
• who exposed to specific etiologic factors
• It occurs more common in identical twins

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Does pregnancy cause my asthma to be exacerbated?
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• Pregnant women have different courses of their
  asthma
• 1/3 aggravate
• 1/3 improve
• 1/3 does not change

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• The most common cause of asthma exacerbation
• Discontinuation of drugs
• Viral infections
• Well controlled asthma has favorable outcome in
  pregnancy

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• Poor controlled asthma has been associated with
  15 to 20 increase in
• Preterm delivery
• Preeclampsia
• Growth retardation
• Need for C/S
• Maternal morbidity
• Maternal mortality

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• These risks are increased 30 to 100 those with
  more severe asthma
• Asthma is not associated with risk of congenital
  malformations

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What is well control?

• No (or minimal) daytime symptoms
• No limitations of activity
• No nocturnal symptoms
• No (or minimal) need for rescue medication
• Normal lung function
• No exacerbations

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• In pregnant asthmatics you should confirm control
  by
• Spirometry
• Monthly
• Peak flow metry
• Twice daily
• Upon awakening
• After 12 hr

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• FEV1 lt 80 in pregnancy associated with poor
  pregnancy outcomes
• moderate to severe asthmatics
• Serial ultrasound examination
• Early in pregnancy
• Regularly after 32 wk
• After an asthma exacerbation

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Can my asthma be cured?
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• Asthma is a chronic disease
• We have very few diseases with such a good
  response to therapy as asthma
• Quality of life improved markedly after treatment

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Are asthma drugs risky for my fetus?
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• As asthma is an inflammatory disease limited to
  lung airways
• Treatment of this disease in a topical form is
• More effective
• Less harmful

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• You can choose one of these categories for your
  asthmatic patient
• Relievers
• Controllers

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• If you choose the 1st one (reliever)
• You treat patient's symptom, but
• Relievers do not work on inflammation!
• Your patient is prone to
• Asthma attack
• Airway remodeling

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• If you choose the 2nd one (controllers)
• You treat your patient's disease, and
• You can control inflammation
• You reduce the risk of
• Asthma attack
• Airway remodeling in your patient

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• Relievers (No anti-inflammatory action)
• Salbutamol
• Atrovent
• Controllers (Mainly anti-inflammatory)
• Inhaled corticosteroids
• LABA
• cromolyn
• Theophylline
• Leukotrene antagonists

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• When should I start controllers?
• gt3 times/ wk day salbutamol need
• gt3 times/ mo night awakening
• gt3 times/ yr salbutamol prescription
• gt3 times/ yr exacerbation
• gt3 times/ yr short-term corticosteroid

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Safety profile of common anti-asthma drugs

• Drug

• Safety

• Safe, inhaler (labor)
• Category B, Budesonide
• Safe
• Safe (5-12 mcg/ml)
• ? clearance in 3rdtrimester
• Cord blood level the same
• Load 5-6 mg/kg
• Maintenance 0.5mg/kg/hr
• Delayed labor

• Salbutamol
• Inhaled corticosteroids
• Cromolyn
• Theophylline

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• Drug

• Safety

• LABA
• Adrenaline
• Systemic steroids
• Atroent
• Leukotrene antagonists

• Not reassuring
• Not for asthma
• Pre-eclampsia, GDM
• Prematurity, LBW
• Safe
• Ziluten not assessed
• Zafirleukast, monteleukast probably safe

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• Mild intermittent
• Mild persistent
• Moderate persistent
• Severe persistent

• PRN Salbutamol
• Inhaled corticoteroid
• Inhaled corticoteroid LABA
• Inhaled corticoteroid LABA

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Drug Low Daily
Dose (?g) Medium Daily Dose (?g) High
Daily Dose (?g)
gt 5 y Age lt 5 y gt 5 y Age
lt 5 y gt 5 y Age lt 5 y
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Drug Low Daily
Dose (?g) Medium Daily Dose (?g) High
Daily Dose (?g)
gt 5 y Age lt 5 y gt 5 y Age
lt 5 y gt 5 y Age lt 5 y
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Drug Low Daily
Dose (?g) Medium Daily Dose (?g) High
Daily Dose (?g)
gt 5 y Age lt 5 y gt 5 y Age
lt 5 y gt 5 y Age lt 5 y
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Drug Low Daily
Dose (?g) Medium Daily Dose (?g) High
Daily Dose (?g)
gt 5 y Age lt 5 y gt 5 y Age
lt 5 y gt 5 y Age lt 5 y
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Choice of drug categories in pregnancy

• Category

• Drug of choice

• SABA
• LABA
• ICS

• Salbutamol
• Salmetrol
• Budesonide

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Can moisturizers help me to improve?
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• About 80 of asthma patients have allergic
  (extrinsic) asthma
• Allergens, especially indoor allergens
• Mites
• Fungi
• Can cause asthma or allergic rhinitis to become
  worse
• Room humidity of gt 50
• speed up growth of mites and fungi

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• Avoidance from
• allergens,
• irritants and
• air pollution
• Is necessary for any asthmatic pregnant woman

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• Allergen immunotherapy can be continued during
  pregnancy
• But, should not be started for the 1st time in a
  pregnant woman

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Is my child more prone to asthma?
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• There is no association to mother asthma during
  fetal period
• and development of asthma in childhood period.
• Albeit asthma is a genetic disease

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Can heartburn cause my asthma?
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• Comorbid conditions in asthma
• Gastro-esophageal reflux disease (GERD)
• Allergic rhinitis (AD)

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• Be suspicious to GERD if
• Your asthmatic patient become poorly controllable
• Your asthmatic patient is worse at night
• Your asthmatic patient has symptoms when lies
  down
• Patient complains of GERD symptoms

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• Treatment of heartburn can improve asthma
  symptoms
• Continue anti GERD drugs for at least 2-3 months

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• Be suspicious to AD if
• Your asthmatic patient complains of seasonal
  nose or sinus symptoms

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• Treat AD with
• Intranasal corticosteroids
• Antihistamines (2nd generation in pregnancy)
• Allergen avoidance

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Should I get flu shot?
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• Influenza vaccination is necessary for
• Pregnant women with 2nd and 3rd trimester
• In cold months

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What should I do in the case of asthma attack?
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• Treatment of asthma attack is the same as
  non-pregnant woman
• Aggressive monitoring of mother and fetus
• Oxygen 3-4 l/min by cannula
• Goal of
• Po2 gt 70
• Sat gt 95

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• Pco2 gt 35 mmHg
• Po2 lt 70 mm Hg
• Are abnormal during pregnancy
• IV fluid (dextrose) initially 100 ml/hour
• Seated position
• Fetal monitoring

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• Dosage of glucocorticoids is not different
• IV aminophylline NOT generally recommended
• IV Mg sulfate may be beneficial
• Concomitant hypertension
• Preterm contraction

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• Respiratory infections in asthmatic patients
• Usually viral
• If indicated in a pregnant woman
• I V Ceftriaxone
• Erythromycin

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Labor C/s or nvd?
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• No difference
• PG F2 analogues should not be used in asthmatics
• for termination of pregnancy
• Morphine and meperidine should be avoided
• Fentanyl is an appropriate alternative

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• In the case of emergency cesarean section
• Epidural anesthesia is the favoured anesthesia
• Decreses O2 consumption and minute ventilation
• If general anesthesia required
• Ketamine is preferred
• Ergot derivatives for pertiprtum bleeding,
  headache, should be avoided

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Summary

• Careful assessment and monitoring
• Avoidance and controll of triggers
• Maintenance rather than symptomatic therapy
• Aggressive treatment of exacerbations

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Thank you