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ASMA pada KEHAMILAN

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kehamilan
Penatalaksanaan yang tepat
menurunkan risiko terhadap ibu dan
anak
Kehamilan imunosupresi fisiologis
Perubahan keadaan imunologi saat hamil
pada penyandang asma berpengaruh
terhadap peningkatan risiko komplikasi
pada ibu dan janin

Asma
Penyempitan saluran napas
Ibu hamil bernapas untuk 2 orang
Oksigenisasi janin berkurang
komplikasi
Tidak terkontrol risiko meningkat

Komplikasi
Pada Janin
Kecacatan pada janin
Risiko kematian perinatal
meningkat
Retardasi pertumbuhan
intrauterin
Prematur
BBLR
Hipoksia neonatal

Pada Ibu
Preeklamsia
Hiperemesis gravidarum
Perdarahan pervaginam
Komplikasi kelahiran
lainnya

Komplikasi
KECACATAN PADA JANIN
Asthma exacerbations during the first
trimester of pregnancy were found to
significantly increase the risk of a
congenital malformation. (J Allergy Clin
Immunol 2008;121:1379-84.)

Jana et al. found that the mean birth


weight of neonates born to mothers
who were hospitalized for asthma
during pregnancy was about 400 g
lower than that of neonates born to
asthmatic mothers who were not
hospitalized (Respiratory Medicine
(2010) 104, 1278-1287)

Tujuan penatalaksanaan
Kontrol optimal gejala respirasi termasuk
serangan malam
Dapat mencapai atau mendekati fungsi
paru normal
Dapat beraktivitas sehari-hari
Menghindari atau meminimalisir
serangan asma
Menjaga dan menghindari efek samping
obat terhadap ibu dan janin

Manajemen asma
1. Menggunakan pengukuran objektif
untuk penilaian dan monitoring ibu
dan janin
2. Menghindari dan mengontrol
pencetus asma
3. Manajemen rencana pengobatan
dan mengatasi serangan
4. Edukasi
5. Dukungan Psikologi

Tujuan utama penatalaksanaan asma


selama kehamilan adalah untuk mengontrol
terjadinya serangan asma. Penyandang
asma harus tetap melanjutkan terapi
kontrol asma yg sudah didapatkan sebelum
kehamilan
Penilaian kontrol asma pada kehamilan
direkomendasikan dilakukan setiap bulan
termasuk juga penilaian keadaan janin
melalui USG

Terapi
Pelega (reliever)

Agonis beta 2
Antikolinergik
Kortikosteroid
Gol. Xantin

Pengontrol (controller)
Kortikosteroid
Sodium kromolin
Nedokromil
Teofilin SR
LABA
ketotifen

STEP 4: SEVERE PERSISTENT


CONTROLLER: daily multiple
medications
Inhaled steroid
Long-acting bronchodilator
Oral steroid

RELIEVER
Inhaled 2agonist p.r.n.

Step
down
when
controlled

Avoid or control triggers


STEP 3: MODERATE PERSISTENT
CONTROLLER: daily
medications
Inhaled steroid and long-acting
bronchodilator
Consider anti-leukotriene

RELIEVER
Inhaled 2agonist p.r.n.

Avoid or control triggers


STEP 2: MILD PERSISTENT
CONTROLLER: daily
medications
Inhaled steroid
Or possibly cromone, oral
theophylline or anti-leukotriene

RELIEVER
Inhaled 2agonist p.r.n.

Patient
education
essential at
every step
Reduce
therapy if
controlled for
at least
3 months
Continue
monitoring

Avoid or control triggers


STEP 1: INTERMITTENT
CONTROLLER: none

RELIEVER
Inhaled 2agonist p.r.n.

Avoid or control triggers


TREATMENT
GINA Guidelines 1998

Step up
if not controlled
(after check on
inhaler technique
and compliance)

Use of most common asthma and


allergy medications during
pregnancy was not associated with
increased perinatal risks. Maternal
use of oral corticosteroids was
independently associated with the
occurrence of preeclampsia
(J Allergy ClinImmunol1997;100:3016.)

Serangan yang mengancam


jiwa:
Riwayat pemakaian ventilasi
mekanik
Berulang kali dirawat karena asma
yang berat
Terapi oral steroid jangka lama
Variasi diurnal besar
Tidak patuh
Perawatan tidak adekuat

PENATALAKSANAAN ASMA DI RUMAH

Persalinan
Selama proses persalinan obat-obat
asma tetap dapat diberikan
Penyandang asma yang mendapat
steroid sistemik selama kehamilan
dianjurkan untuk mendapat steroid IV
selama dan 24 jam setelah persalinan.

CHART 5. DURING DELIVERY


Assessment at Admission
Medical History
Physical examination
Expiratory flow measurement (PEFR or FEV1)
Oxygen saturation ( oxymeter or arterial blood gas)
Careful fetal monitoring

Well controlled mild, moderate, or severe asthma


(PEFR / FEV1 > 80% baseline, no / minimal
symptoms)
Continue routine inhaled asthma medications to IV
route
Administer hydrocortisone (100 mg every 8 hours
until postpartum ) if systemic steroids were taken within
4 weeks.
Analgesia
-Avoid morphine and meperidine
-Consider fentanyl
-Consider lumbal epidural with diluted concentrations
of local anesthetic and narcotics
Anesthesia, if necessary
-Pre-anesthetic atropine and glycopyrolate
-Low concentrations of halogenated anesthetics

Exacerbation of Asthma
(PEFR / FEV < 80% baseline
symptoms : wheeze, cough, breathlessness, or chest
tightness)
Treat exacerbation*
Inhaled beta2 agonist
IV corticostroids
Hydrocortisone (100 mg every 8 hours until postpartum
) if systemic steroids were taken within 4 weeks
Oxygen to maintain O2 saturation > 95 %
Continue efforts for vaginal delivery
Notify anesthesia consultant and paediatrician
Analgesia
-Consider fentanyl
-Consider epidural analgesia
Anesthetic, if necessary
-Pre-anesthetic atropine and glycopyrrolate
-Low concentrations of halogenated anesthetic

Continue assessment
PEFR /FEV1
Oxygen saturation
Intensive fetal monitoring (consider continuous electronic fetal
monitoring or intermittent auscultation)
Perform vaginal delivery, if possible

Respiratory failure
(PEFR /FEV < 25 % & CO2 > 35
mm Hg
Symptoms ; extreme distress,
confusion

Notify anesthesia consultationt and


paediatrician
Initiate mechanical ventilation
Perform vaginal delivery, if possible
Emergency cesarean section , if necessary

DURING DELIVERY
Assessment at Admission
Medical History
Physical examination
Expiratory flow measurement (PEFR or
Well controlled mild, moderate, or severe asthmaFEV1)
Exacerbation of Asthma
Respiratory failure
(PEFR / FEV1 > 80% baseline, no / minimal
(PEFR / FEV < 80% baseline
(PEFR /FEV < 25 % & CO2 > 35
Oxygensymptoms
saturation
( oxymeter
or arterialmm Hg
symptoms)
: wheeze, cough,
breathlessness, or chest
Continue routine inhaled asthma medications to IV
tightness)
Symptoms ; extreme distress,
blood gas)
route
Treat exacerbation*
confusion
Administer hydrocortisone (100 mg every 8 hours
Inhaled beta2 agonist
CarefulIVfetal
monitoring
until postpartum ) if systemic steroids were takenwithin
corticostroids
4 weeks.
Analgesia
-Avoid morphine and meperidine
-Consider fentanyl
-Consider lumbal epidural with diluted concentrations
of local anesthetic and narcotics
Anesthesia, if necessary
-Pre-anesthetic atropine and glycopyrolate
-Low concentrations of halogenated anesthetics

Hydrocortisone (100 mg every 8 hours until postpartum


) if systemic steroids were taken within 4 weeks
Oxygen to maintain O2 saturation > 95 %
Continue efforts for vaginal delivery
Notify anesthesia consultant and paediatrician
Analgesia
-Consider fentanyl
-Consider epidural analgesia
Anesthetic, if necessary
-Pre-anesthetic atropine and glycopyrrolate
-Low concentrations of halogenated anesthetic

Continue assessment
PEFR /FEV1
Oxygen saturation
Intensive fetal monitoring (consider continuous electronic fetal
monitoring or intermittent auscultation)
Perform vaginal delivery, if possible

Notify anesthesia consultationt and


paediatrician
Initiate mechanical ventilation
Perform vaginal delivery, if possible
Emergency cesarean section , if necessary

CHART 5. DURING DELIVERY


Assessment at Admission

of Asthma
Well controlled mild, moderate,Exacerbation
or/ severe
asthma
(PEFR
FEV < 80% baseline
: wheeze, cough, breathlessness, or chest
(PEFR / FEV1 > 80% baseline, symptoms
no / minimal
symptoms)
tightness)
Treat exacerbation*
Continue routine inhaled asthma
to IV route
Inhaledmedications
beta2 agonist
IV corticostroids
Administer hydrocortisone (100
mg every
hours
until
Hydrocortisone
(100 mg 8
every
8 hours until
postpartum
) if systemic steroids were taken within 4 weeks
postpartum ) if systemic steroids
were
taken
within
Oxygen
to maintain
O2 saturation
> 95 % 4 weeks.
Continue efforts for vaginal delivery
Analgesia
Notify anesthesia consultant and paediatrician
Analgesia
-Avoid morphine and meperidine
-Consider fentanyl
-Consider epidural analgesia
-Consider fentanyl
Anesthetic, if necessary
atropine and glycopyrrolate
-Consider lumbal epidural with--Pre-anesthetic
diluted
concentrations
of
Low
concentrations
of halogenated anesthetic
local anesthetic and narcotics
Anesthesia, if necessary
-Pre-anesthetic atropine and
glycopyrolate
Continue
assessment
PEFR /FEV1
-Low concentrations of halogenated
Oxygen saturation anesthetics
Intensive fetal monitoring (consider continuous electronic fetal
monitoring or intermittent auscultation)
Perform vaginal delivery, if possible

Respiratory failure
(PEFR /FEV < 25 % & CO2 > 35
mm Hg
Symptoms ; extreme distress,
confusion

Notify anesthesia consultationt and


paediatrician
Initiate mechanical ventilation
Perform vaginal delivery, if possible
Emergency cesarean section , if necessary

CHART 5. DURING DELIVERY


Assessment at Admission
Exacerbation of Asthma
(PEFR / FEV1 < 80% baseline
symptoms
wheeze,
breathlessness, or chest tightness)
Well controlled mild, :
moderate,
or severe cough,
asthma
Respiratory failure
(PEFR / FEV1 > 80% baseline, no / minimal
(PEFR /FEV < 25 % & CO2 > 35
Treat
symptoms) exacerbation*
mm Hg
Continue routine inhaled asthma medications to IV
Symptoms ; extreme distress,
route
Inhaled beta2 agonist
confusion
Administer hydrocortisone (100 mg every 8 hours
untilIVpostpartum
corticostroids
) if systemic steroids were taken within
4 weeks.
Analgesia
Hydrocortisone (100 mg every 8 hours until postpartum ) if systemic steroids were
-Avoid morphine and meperidine
taken
within 4 weeks
-Consider fentanyl
-Consider lumbal epidural with diluted concentrations
of Oxygen
tonarcotics
maintain O2 saturation > 95 %
local anesthetic and
Anesthesia, if necessary
Continue
efforts
for vaginal delivery
-Pre-anesthetic atropine
and glycopyrolate
-Low concentrations of halogenated anesthetics
Notify anesthesia consultant and paediatrician
Analgesia
-Consider fentanyl
-Consider epidural analgesia
Notify anesthesia consultationt and
assessment
Anesthetic, if necessary Continue
PEFR /FEV1
paediatrician
Oxygen saturation
Initiate mechanical ventilation
-Pre-anesthetic atropine andIntensive
glycopyrrolate
Perform vaginal delivery, if possible
fetal monitoring (consider continuous electronic fetal
Emergency cesarean section , if necessary
monitoring or intermittent auscultation)
-Low concentrations of halogenated
anesthetic
Perform vaginal delivery,
if possible

CHART 5. DURING DELIVERY


Assessment at Admission

Well controlled mild, moderate, or severe asthma


(PEFR / FEV1 > 80% baseline, no / minimal
symptoms)
Continue routine inhaled asthma medications to IV
route
Administer hydrocortisone (100 mg every 8 hours
until postpartum ) if systemic steroids were taken within
4 weeks.
Analgesia
-Avoid morphine and meperidine
-Consider fentanyl
-Consider lumbal epidural with diluted concentrations
of local anesthetic and narcotics
Anesthesia, if necessary
-Pre-anesthetic atropine and glycopyrolate
-Low concentrations of halogenated anesthetics

Exacerbation of Asthma

Respiratory failure
(PEFR /FEV < 25 % & CO2 > 35
mm Hg
Symptoms ; extreme distress,
confusion

Continue assessment
PEFR /FEV1
Oxygen saturation
anesthesia consultationt and
Intensive fetal monitoring (consider continuous electronicNotify
fetal
paediatrician
Initiate mechanical ventilation
monitoring or intermittent auscultation)
Perform vaginal delivery, if possible
Emergency cesarean section , if necessary
Perform vaginal delivery, if possible

CHART 5. DURING DELIVERY


Assessment at Admission
Medical History
Physical examination
Expiratory flow measurement (PEFR or FEV1)
Oxygen saturation ( oxymeter or arterial blood gas)
Careful fetal monitoring

Well controlled mild, moderate, or severe asthma


(PEFR / FEV1 > 80% baseline, no / minimal
symptoms)
Continue routine inhaled asthma medications to IV
route
Administer hydrocortisone (100 mg every 8 hours
until postpartum ) if systemic steroids were taken within
4 weeks.
Analgesia
-Avoid morphine and meperidine
-Consider fentanyl
-Consider lumbal epidural with diluted concentrations
of local anesthetic and narcotics
Anesthesia, if necessary
-Pre-anesthetic atropine and glycopyrolate
-Low concentrations of halogenated anesthetics

Exacerbation of Asthma
(PEFR / FEV < 80% baseline
symptoms : wheeze, cough, breathlessness, or chest
tightness)
Treat exacerbation*
Inhaled beta2 agonist
IV corticostroids
Hydrocortisone (100 mg every 8 hours until postpartum
) if systemic steroids were taken within 4 weeks
Oxygen to maintain O2 saturation > 95 %
Continue efforts for vaginal delivery
Notify anesthesia consultant and paediatrician
Analgesia
-Consider fentanyl
-Consider epidural analgesia
Anesthetic, if necessary
-Pre-anesthetic atropine and glycopyrrolate
-Low concentrations of halogenated anesthetic

Respiratory failure
(PEFR /FEV1 < 25 % & PCO2
> 35 mm Hg
Symptoms ; extreme distress,
confusion

Notify anesthesia consultation and


paediatrician
Initiate mechanical ventilation
Continue assessment
Perform vaginal delivery, if possible
PEFR /FEV1
Oxygen saturation
Emergency cesarean section , if
Intensive fetal monitoring (consider continuous electronic fetal
monitoring or intermittent auscultation)
necessary
Perform
vaginal delivery, if possible

Health professionals should encourage


pregnant asthmatic women to continue
their controller therapy to control their
asthma symptoms, avoid
exacerbations, and reduce the risk of
congenital malformations

TERIMA KASIH
THANK YOU
ARIGATO
DANKWELL
MATURNUWUN