Asthma in Pregnancy

Timothy Hoskins, M.D. October 5, 2005

Objectives

Elicit pertinent history from asthma patient Perform targeted physical exam to detect findings associated with asthma Interpret Results of basic PFTs FEV1 Describe differential diagnosis of asthma Describe indications for referral of a patient with more severe asthma Review basic pathophysiology of asthma Review treatment of asthma in antepartum, chronic, and acute stages

Epidemiology of Asthma

15 million people in the U.S. have asthma 2003 estimated prevalence of asthma in pregnant women was 5%-9% According to the National Asthma Education Program an additional 10% of the population appears to have nonspecific airway hyper responsiveness Prevalence of asthma appears to be increasing in pregnant women 0.2% of pregnancies will be complicated by status asthmaticus

Pathophysiology of Asthma

Characterized by chronic airway inflammation with acute reversible airway obstruction to a variety of stimuli Obstruction component: bronchial smooth muscle hyper responsiveness to stimuli Inflammatory component: Divided into two separate responses

Early asthmatic response medicated by histamine occurs within minutes Late asthmatic response non histamine related occurs over hours

Pathophysiology of Asthma

Chronic Inflammatory Disorder Hallmarks reversible airway obstruction for bronchial smooth muscle contraction, mucous hypersecretion, and mucosal edema Mast cell activation by cytokines mediates bronchoconstriction by release of histamines, prostaglandin D2 and leukotrienes

Pathophysiology of Asthma

If left untreated chronic airway inflammation may lead to permanent airway changes

Airway thickening causes irreversible airflow limitation and shortened life expectancy

Common Asthma Triggers

URI Allergens Aerobic Exercise Irritants Air Pollution Strong emotions Medications Beta blockers

Clinical Presentation

Wheezing Dyspnea Chest tightness Use of accessory respiratory muscle Central or peripheral cyanosis Tachycardia Prolonged expiration Altered mental status

Differential Diagnosis of Asthma

Pulmonary COPD exacerbation Infection PE Obstruction Allergic anaphylaxis GERD Addisons disease Cardiac CHF Valvular heart disease Carcinoid tumor

Classification of Asthma by National Asthma Education Program (NAEP)

Based on symptoms (wheezing, coughing, dyspnea) and objective tests of PFTS FEV1

Volume of air forcibly exhaled during the first second of the forced expiratory manuever Assesses the degree of obstruction

Peak expiratory flow rate (PEFR) is most commonly used and correlates closely with FEV1

Modified NAEP Asthma Severity Classification

Mild Asthma

Brief (<1 h) symptomatic exacerbations < twice/week PEFR > 80% of personal best FEV1 > 80% of predicted when asymptomatic No nocturnal symptoms

Modified NAEP Asthma Severity Classification

Moderate Asthma

Symptomatic exacerbations > twice/week Exacerbations affect activity levels Exacerbations may last for days PEFR,FEV range from 60% to 80% of predicted Regular medications necessary to control symptoms

Modified NAEP Asthma Severity Classification

Severe Asthma

Continuous symptoms/frequent exacerbations limit activity levels PEFR,FEV <60% of expected, and are highly variable Regular oral corticosteroids necessary to control symptoms

Effects of Pregnancy on Asthma

No evidence to suggest that pregnancy has a predictable effect on underlying asthma Two prospective studies (1998) of more than 500 women found about equal thirds of the group either improved, remained unchanged or clearly worsened Again baseline asthma severity correlated with asthma morbidity during pregnancy

Mild asthma 13% had exacerbation Moderate 26 % had exacerbation Severe 50% had exacerbation

Effects of Asthma on Pregnancy

Controversial results in terms of preeclampsia, cesarean delivery, prematurity, IUGR, and perinatal mortality rate Generally unless there is severe disease, asthma has relatively minor effects on pregnancy outcome Most studies show slight increase of incidence of preeclampsia, pre-term labor, low birthweight infants and perinatal mortality

Effects of Asthma on Pregnancy

A prospective study by Dombrowski (2000), preterm delivery was not increased among pregnancies complicated by asthma compared to non-asthmatic controls. However, the majority of women in the study with severe asthma showed an increase of preterm labor by two fold. Status asthmaticus characterized by resp failure substantially increases maternal and perinatal mortality Bracken (2003) found preterm delivery only slightly increased with asthma while IUGR increased with severity of asthma

Antenatal Management

Asthma history

Severity of symptoms Nocturnal symptoms

Pregnant patients with mild well controlled asthma may receive routine prenatal care Moderate and Severe asthma will need more frequent visits and consider referral in severe cases

Referral Indications

To Asthma/Allergy subspecialist

Diagnosis is severe, persistent asthma Diagnosis is unclear More complete allergy evaluation is desired Asthma is not under control even after appropriate avoidance measures are taken and medications have been adjusted and redirected Life threatening exacerbation

Management

Ultimate goal is prevention of hypoxic episodes to mother and fetus Relies on four components

Objective measures for accurate monitoring Minimizing asthma triggers Patient education Pharmacologic therapy

Objective Measures for Accurate Monitoring

FEV1 is best single measure of pulmonary function but requires a spirometer PEFR correlates well with FEV1 and is inexpensive as it is measured by peak flow Self-monitoring of PEFR aids in detecting early signs of deterioration in lung function

Minimizing Asthma Triggers

Use plastic mattress and pillow covers Weekly washing of bedding in hot water Animal dander control Weekly bathing of the pet Keeping pets out of the bedroom Remove pet from the home Cockroach control Hardwood flooring Avoid tobacco smoke Inhibit mite and mold growth by reducing humidity Do not be present when home is vacuumed

Patient Education

Understanding that asthma control is important to fetal well being Reduction of triggers Understanding of basic medical management including self monitoring

Pharmacologic Therapy

Goals

Relieve bronchospasms Protect airways from irritant stimuli Prevent pulmonary and inflammatory response to allergen exposure

Chronic Asthma Management

Beta agonists Inhaled Corticosteroids Cromolyn and Nedocromil Theophylline Leukotriene modifiers

Beta agonists

Mild asthma Acute exacerbations Rapid onset of action Can cause tremor, tachicardia, and palpitations

Inhaled Corticosteroids

Preferred for persistent asthma Goal is to reduce dependence on beta agonists for symptomatic relief Significantly reduce hospitalization in both pregnant and non pregnant women Side effects

Short term steroid use

Reversible increases in glucose, decreases potassium, fluid retention with weight gain, mood alterations including rare psychosis, hypertension, peptic ulcers, aseptic necrosis of the femur, and very rare allergic reactions Height and growth, immune suppression, hypertension, cataracts, and hirsutism

Long term steroid use

Cromolyn and Nedocromil

Inhibit mast cell degranulation Ineffective for acute asthma Not superior to inhaled corticosteriods

Theophylline

Bronchodilator with a possible anti-inflammatory component Used much less frequently now that inhaled steroids became available. No known teratogenic effects Long duration of action Used as additional therapy when beta agonists and anti-inflammatory agents do not adequately control symptoms

Leukotriene Modifiers

Category C

Little experience with use in pregnancy

Given orally for maintence not effective in acute setting Often used in conjunction with oral corticosteroids to obtain minimal steroid dose Ducharme in 2002 reviewed all randomized trials conducted through 2001

Concluded these agents only slightly improved control

Step Therapy

Least number of medications needed to control symptoms should be used Increase number and frequency of medications with increasing severity Systemic corticosteroids are indicated for exacerbations not responding to initial beta agonist therapy regardless of asthma severity

Home Management of Acute Asthma Exacerbations

Use inhaled albuterol two to four puffs and check PEFR in 20 minutes If PEFR <50% predicted or symptoms are severe: obtain emergency care If PEFR 50% to 70% predicted: Repeat albuterol treatment, check PEFR in 20 minutes If PEFR remains <70% predicted: Contact caregiver or go for emergency care If PEFR >70% predicted: Continue inhaled albuterol (two to four puffs q3 4h for 6-12h as needed) If decreased fetal movement: Contact caregiver or go for emergency care

Emergency Assessment and Management of Asthma Exacerbations

Initial Evaluation

History Examination PEFR Oximetry Fetal monitoring if potentially viable

Emergency Assessment and Management of Asthma Exacerbations

Initial treatment

Inhaled beta2 agonist (3 doses over 60-90 minutes) Oxygen to maintain saturation > 95% If no wheezing and PEFR or FEV1 > 70% baseline, discharge with follow up

Emergency Assessment and Management of Asthma Exacerbations

If oximetry <50% FEV1, <1.0 liter, or PEFR < 100 liters/min upon presentation Continue nebulized albuterol Start intravenous corticosteroids Obtain arterial blood gases Admit to intensive care unit Possible intubation

Emergency Assessment and Management of Asthma Exacerbations

If PEFR or FEV1 > 40% but <70% baseline after beta 2 agonist

Obtain arterial blood gases Continue inhaled beta 2 agonist every 1-4 hours Start intravenous corticosteroids in most cases Hospital admission in most cases

Labor and Delivery

Asthma usually quiesent thought to be due to increase in cortisol Continue regular asthma medications Adequate hydration and analgesia to reduce bronchospasm Stress doses of corticosteroids are indicated for patients given systemic steroids within preceding four weeks

Labor and Delivery (continued)

Establish baseline PEFR on admit and serially thereafter if symptoms develop Prostaglandin E1 and E2 may be used for cervical ripening, PPH Hemabate may cause bronchospasms and should be avoided

PROLOG Sample Question

A 22-year old, G2, P1, at 11 WGA has history of chronic asthma. Currently she has symptoms of wheezing and difficulty breathing 2 or 3 times per month and has never required hospitalization. She does not have nocturnal symptoms and is free of symptoms b/t exacerbations. To control her asthma, you prescribe: A) daily inhaled beta2 agonist B) inhaled beta2 agonist prn C) daily inhaled corticosteroid D) daily inhaled corticosteroid prn E) daily inhaled cromolyn sodium

Bibliography

Williams Obstetrics 22nd edition; pgs 1060-1064 Up to Date.com; Management of Asthma Marx: Rosens Emergency Medicine: Concepts and Clinical Practice 5th edition Maternal-Fetal Medicine: Principles and Practice 4th edition; pgs 962-967