ASTHMA IN PREGNANCY OUTLINE - Introduction - Pathophysiology - Clinical Presentation - Diagnosis - Differential diagnosis - Management - Complications - Conclusion ASTHMA IN PREGNANCY Introduction: Asthma is a chronic inflammatory disease of the airways characterized by increase responsiveness of the tracheobronchial tree to multiple stimuli Episodic, characterized by acute exacerbations intermingled with symptom-free periods Most attacks are short-lived Though patients recover completely clinically, evidence suggests that patient with asthma developed chronic airflow limitations Introduction Prevalence of the disease: 4-5% in general population 1-4% in pregnancy Mortality and morbidity in pregnancy is comparable to those in the general population 1/3 aggravate 1/3 improve 1/3 does not change Most return to their prepregnancy baseline within 3 months postpartum PATHOPHYSIOLOGY Respiratory Physiologic changes in Pregnancy: - Respiratory rate and vital capacity, FEV1, FVC and FEV1/FVC ratio remain unchanged - Tidal volume, minute ventilation(40%), minute oxygen uptake(20%), airway conductance increased - Functional Residual volume, Residual Volume, and Expiratory reserve volume and total pulmonary resistance decreased PATHOPHYSIOLOGY The consequences of these changes: - Hyperventilation => decreased pCO2 => decreased HCO3 => increased pH - Chronic respiratory alkalosis Normal pCO2 in pregnant patient may signal impending respiratory failure Progesterone is a respiratory stimuli PATHOPHYSIOLOGY Asthma can occur spontaneously or in response to stimuli
Stimuli include allergens, medications, physical
exertion, emotions and stress
In response to contact with a triggering agents:
- Mast cells release vasoactive chemical mediators PATHOPHYSIOLOGY - The inflammation results in abnormal accumulation of mast cells, neutrophils, lymphocytes, macrophages, eosinophils, dendritic cells and myofibroblasts in bronchial tree Results in: - Bronchoconstriction, vascular congestion and increases in capillary and mucosal edema - Impaired mucociliary action and increased mucus production and airway resistance - Airway obstruction that is partially or completely reversible CLINICAL PRESENTATION History findings may include: - Cough, - Shortness of breath, - Chest tightness, - Noisy breathing, - Nocturnal awakenings, - Recurrent episodes of symptom complex, - Exacerbations possibly provoked by nonspecific stimuli, - Personal or family history of other atopic disease General physical examination findings may include: - Tachypnoea, - Retraction(sternomastoid, abdominal, pectoralis muscles) - Agitation- usually a sign of hypoxia or respiratory distress - Pulsus paradoxicus(>20mmHg) CLINICAL PRESENTATION Pulmonary findings: - Wheezes - Rhonchi - Bronchovesicular sounds - Expiratory phase of respiration equal to or more prominent than inspiratory phase CLINICAL PRESENTATION Signs of fatigue and near-respiratory arrest: - Alteration in level of consciousness(lethargy) - Abdominal breathing - Inability to speak in complete sentences Signs of complicated asthma: - Jugular venous distension(pneumothorax), - Hypotension and tachycardia(tension pneumothorax), - Fever(Respiratory Tract Infection) Amount of wheezes does not always correlate with the severity of the attack Categories of Asthma They present in one of the following categories
National Asthma Education and Prevention
Program(NAEPP) categorize asthma: - Mild intermittent - Mild persistent - Moderate persistent - Severe asthma Categories of Asthma Mild Intermittent Asthma - Symptoms twice per week or less - Nocturnal symptoms twice per month or less - PEFR or FEV1 80% of predicted or more Mild Persistent Asthma - Symptoms more than twice per week but not daily - Nocturnal symptoms more than twice per month - PEFR or FEV1 80% predicted or more Categories of Asthma Moderate Persistent Asthma - Daily symptoms - Nocturnal symptoms more than once per week - PEFR or EFV1 more than 60% to less than 80% predicted - Regular medications necessary to control sympoms Severe Asthma - Continuous symptoms and frequent exacerbations - Frequent nocturnal symptoms - PEFR or FEV1 60% predicted or less - Regular oral corticosteroids necessary to control symptoms DIAGNOSIS AND ASSESSMENT History- most of them the diagnosis is known before pregnancy Physical Examination Findings Pulmonary Function Testing Reversible airflow obstruction is central to the diagnosis and assessment of asthma Changes in Pulmonary function during acute asthma include: 1. Decreased PEFR and FEV1 2. Mild reduction in Forced vital Capacity 3. An increase Residual Volume, Functional Residual Capacity and Total Lung Capacity 4. Normal diffusing capacity DIAGNOSIS AND ASSESSMENT Patients with asthma demonstrate a greater than 15% increase in FEV1, FVC and PEFR when treated with bronchodilators Differential Diagnosis Problems to consider that can mimic asthma in the pregnant patients include the following: - Airway obstruction - Amniotic fluid embolism - Acute congestive heart failure (CHF) secondary to peripartum cardiomyopathy - Physiological dyspnoea of pregnancy ASTHMA IN PREGNANCY MANAGEMENT Almost all antiasthma drugs are safe to use in pregnancy and during breastfeeding Undertreatment of the pregnant patient is a frequent occurrence because such patients are worried about medication effect on the fetus Management Goal: - Treat airway inflammation - Decrease airway responsiveness - Prevent asthma symptoms and exacerbations - Maintain adequate oxygenation to the fetus by preventing hypoxic episodes in the mother ASTHMA IN PREGNANCY MANAGEMENT Patient Education: - Teach to identify and avoid triggers as much as possible - Teach early recognition of signs and symptoms - Improve compliance with medication - Seek prompt treatment when necessary - Prompt management of allergic rhinitis, sinusitis and gastroesophageal reflux as these may exacerbate asthma symptoms Step wise management to therapy : - Use least amount of drug to control a patient’s asthma - Increases the number and frequency of medications with increasing asthma severity - Safer to be treated appropriately than have asthma symptoms and exacerbations - Treat exacerbations aggressively MANAGEMENT- ANTIASTHMA DRUGS
Outpatient management of asthma is similar for the
pregnant patient as for the nonpregnant patient. Beta- adrenergic agonists remain the mainstay of treating exacerbations and handling mild forms of asthma For moderate-persistent asthma, beta-adrenergic agonist combined with an inhaled anti-inflammatory agent or inhaled corticosteroid is recommended for treatment In severe asthma, oral corticosteroids and beta agonists are recommended ASTHMA IN PREGNANCY MANAGEMENT- ANTIASTHMA DRUGS A longer-acting beta2-adrenoceptor agonist(eg, salmoterol), the bronchodilator effects of which last at least 12 hours, is an effective treatment for nocturnal asthma Historically, methylxanthines and oral beta agonists have been used to treat asthma. Both are shown to be safe but have fallen out of favour for newer medicines and inhaled forms, respectively ASTHMA IN PREGNANCY MANAGEMENT- ANTIASTHMA DRUGS Magnesium sulfate is another medication that is safe to use in pregnancy. It works as a smooth-muscle relaxant of the airway Epinephrine use should be avoided in the pregnant patient. In general, epinephrine is used only in the most severe asthma exacerbations. Its use can lead to possible congenital malformations, fetal tachycardia, and vasoconstriction of the uteroplacental circulation ASTHMA IN PREGNANCY MANAGEMENT- ANTIASTHMA DRUGS Cromolyn sodium - Is virtually devoid of significant side effects - Blocks both the early and late phase pulmonary response to allergen challenge - Preventing the development of airway hyperresponsiveness - Alternative treatment for mild persistent asthma - Does not have any intrinsic bronchodilator or antihistaminic activity ASTHMA IN PREGNANCY MANAGEMENT- ANTIASTHMA DRUGS Leukotriene modifiers - Reduce bronchospasm and mucous secretion - Increase vascular permeability - Improve pulmonary function significantly - An alternative treatment for mild persistent and an adjunctive treatment for the management of moderate and severe persistent asthma Examples: Zafirlukast(Accolate), Montelukast(Singlair) - Category B drug MANAGEMENT- HOSPITAL CARE Prehospital asthma treatment - Address the patient’s airway status as needed - Provide early institution of beta-agonist inhalational therapy - Provide supplemental oxygen MANAGEMENT- HOSPITAL CARE Treatment in the emergency department - Pregnant patients who present with typical mild exacerbations of asthma may be treated in the same way that a regular asthmatic patient with similar symptoms would be, with bronchodilator therapy and steroids - Special attention must be given to pregnant patients who present with severe asthma exacerbations, because the resulting maternal hypoxia can have devastating consequences on the fetus - Address ABCs, place patient on cardiac monitor and pulse oximetry - Low threshold for intubation to prevent/limit hypoxic episodes to the fetus MANAGEMENT- HOSPITAL CARE Intubate and mechanically ventilate patients who are in or near respiratory arrest and patients who do not respond to treatment as evidenced by the following: - Hypoxaemia despite supplemental oxygen - Increasing carbon dioxide retention - Persistent/worsening level of consciousness - Haemodynamic instability MANAGEMENT- HOSPITAL CARE The key to treating asthma in the pregnant patient is to frequently assess the patient, the severity of the attack, and the response to treatment Hypoxia, acidosis, unequal breath sounds, pneumothorax and atypiacal features serve as warning signs of severe exacerbations Inhaled beta2-agonist are the mainstay of treatment. The beta2-agonist, inhaled and/or subcutaneous, is typically given in 3 doses over 60-90 minutes. Beta- adrenergic blocking agents should be avoided owing to bronchospastic effect MANAGEMENT- HOSPITAL CARE The early use of systemic steroids has been shown to reduce the length of stay in the ED and the admission rate; the effect of the steroids is seen within 4-6 hours of the institution of therapy Supply of supplemental oxygen to maintain oxygen saturation higher than 95%. Intravenous fluids can help to loosen and clear secretions Fetal monitoring becomes important after 28(32) weeks of gestation in severe cases MANAGEMENT- HOSPITAL CARE Avoid Tranquilizers and sedatives because of their respiratory depressant effect
Antihistamines are not useful in the treatment of asthma
Mucolytic agents increase bronchospasm
Beware of complications of mechanical ventilation-
Barotrauma, haemodymic impairment, mucous plugging, atelectasis, secondary pneumonia and paradoxical increase in bronchospasm Asthma in Pregnancy Admission and Discharge Criteria for hospital admission are as follows: - Inadequate response to ED therapy - pO2 less than 70 mmHg - Signs of fetal distress - Multiple medication use ( requiring 3 or more medications simultaneosly) - A protracted course with poor response to outpatient therapy thus far instituted or a history of severe asthma requiring intubation or ICU admission - Inadequate home conditions and transport/access to ED care Asthma in Pregnancy Admission and Discharge Criteria for ICU admission are as follows: - Altered level of consciousness - Poor air flow - Signs of fatigue, a downhill course, or a need for mechanical ventilation - PEFR/EFV1 less than 25% of predicted or pCO2 greater than 35 mm Hg Asthma in Pregnancy Admission and Discharge Criteria for home discharge include the following: - Greatly improved symptoms and physical examination findings - Ability of the patient to walk out of the ED/ ward without obvious distress - PEFR/EFV1 greater than 70% baseline - No fetal distress - Good follow-up and access to ED in case of relapse
A 2-4 days appointment following ED visit is recommended.
Consider/Involve asthma specialist Glucocorticoids at the time of discharge have proven to be useful and to reduce the incidence of ED visits Obstetrics Considerations in the Management of Asthma Help patient to identify and avoid asthma triggers during her booking visit Schedule her ANC visits based upon clinical severity Because asthma has been associated with IUGR and preterm birth, it is useful to establish pregnancy dating accurately by the first trimester ultrasonography where possible Antepartum Surveillance for pregnancies complicated by moderate or severe asthma: USG for fetal growth; Antenatal assessment of fetal well-being at about 32 weeks Intrapartum considerations related to asthma Exacerbations of asthma are uncommon during labour and birth Except in the most severe cases Asthma should not preclude a vaginal birth Occasionally, women with very severe asthma may be advised to have an elective delivery( IOL or C/S) at a time when their asthma is well controlled Plan after 37weeks + 6 days unless there are medical complications requiring earlier intervention Avoid histamine releasing narcotics Intrapartum considerations related to asthma Symptoms of asthma during labour are generally controlled with standard asthma therapy Inhaled beta-agonists do not impaired uterine contractions or delay the onset of labour There is no evidence that oxytocin causes bronchoconstriction Regional anaesthesia is preferred over general anaesthesia. Intubation may trigger attack Ketamine for induction of anaesthesia is safer and prevent bronchospasm Shortening of second stage of labour should be considered Postpartum considerations related to asthma Ergometrine has been reported to cause bronchospasm Prostaglandin E1(misoprostol) is safe to use for management of PPH Use of Prostaglandin F2a(diniprost) may trigger bronchospasm Breastfeeding should be encouraged COMPLICATIONS Uncontrolled or poorly controlled asthma during pregnancy is associated with poor maternal and perinatal outcomes Complications include: - Increased prematurity - Increased C/S rate - Preeclampsia/Hypertension - Growth restriction(SGA) - Increased maternal morbidity/mortality - NICU admission - Congenital anomalies- cleft lips +/- cleft palate CONCLUSION