aminim@mums.ac.

ir

ASTHMA AND PREGNANCY

CASE HISTORY
 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
 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?
IS IT REALLY ASTHMA?
 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
 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
WHY ME?
 Asthma is a common disease
 Even more than diabetes mellitus
 In some countries 1 out of every 4 children
has asthma
 Asthma affects 4 to 8% of all pregnant
women
I HAD NO FAMILY HISTORY
 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
 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
DOES PREGNANCY CAUSE MY
ASTHMA TO BE EXACERBATED?
 Pregnant women have different courses of
their asthma
 1/3 aggravate
 1/3 improve
 1/3 does not change
 The most common cause of asthma
exacerbation
 Discontinuation of drugs
 Viral infections
 Well controlled asthma has favorable
outcome in pregnancy
 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
 These risks are increased 30 to 100 % those
with more severe asthma
 Asthma is not associated with risk of
congenital malformations
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
 In pregnant asthmatics you should confirm
control by
 Spirometry
 Monthly
 Peak flow metry
 Twice daily
 Upon awakening
 After 12 hr
 FEV1 < 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
CAN MY ASTHMA BE CURED?
 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
ARE ASTHMA DRUGS RISKY FOR
MY FETUS?
 As asthma is an inflammatory disease limited
to lung airways
 Treatment of this disease in a topical form is
 More effective
 Less harmful
 You can choose one of these categories for
your asthmatic patient
 Relievers
 Controllers
 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
 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
 Relievers (No anti-inflammatory action)
 Salbutamol
 Atrovent
 Controllers (Mainly anti-inflammatory)
 Inhaled corticosteroids
 LABA
 cromolyn
 Theophylline
 Leukotrene antagonists
 When should I start controllers?
 >3 times/ wk day salbutamol need
 >3 times/ mo night awakening
 >3 times/ yr salbutamol prescription
 >3 times/ yr exacerbation
 >3 times/ yr short-term corticosteroid
Safety profile of common
anti-asthma drugs
Drug Safety
 Salbutamol  Safe, inhaler (labor)

 Inhaled corticosteroids  Category B, Budesonide

 Cromolyn  Safe
 Theophylline  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
Drug Safety
 LABA  Not reassuring
 Adrenaline  Not for asthma
 Systemic steroids  Pre-eclampsia, GDM
 Prematurity, LBW
 Atroent  Safe
 Leukotrene antagonists  Ziluten not assessed
 Zafirleukast, monteleukast
probably safe
 Mild intermittent  PRN Salbutamol

 Mild persistent  Inhaled corticoteroid

 Moderate persistent  Inhaled corticoteroid +

LABA
 Inhaled corticoteroid +
 Severe persistent
LABA
 Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
>5y Age <5y >5y Age <5y >5y Age <5y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400

Budesonide-Neb 250-500 >500-1000 >1000

Inhalation Suspension

Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250

Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500

Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400

Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200

 Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
>5y Age <5y >5y Age <5y >5y Age <5y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400

Budesonide-Neb 250-500 >500-1000 >1000

Inhalation Suspension

Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250

Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500

Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400

Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200

 Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
>5y Age <5y >5y Age <5y >5y Age <5y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400

Budesonide-Neb 250-500 >500-1000 >1000

Inhalation Suspension

Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250

Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500

Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400

Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200

 Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
>5y Age <5y >5y Age <5y >5y Age <5y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400

Budesonide-Neb 250-500 >500-1000 >1000

Inhalation Suspension

Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250

Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500

Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400

Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200

Choice of drug categories in
pregnancy
Category Drug of choice
 SABA  Salbutamol
 LABA  Salmetrol
 ICS  Budesonide
CAN MOISTURIZERS HELP ME TO
IMPROVE?
 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 > 50%
 speed up growth of mites and fungi
 Avoidance from
 allergens,
 irritants and
 air pollution
 Is necessary for any asthmatic pregnant
woman
 Allergen immunotherapy can be continued
during pregnancy
 But, should not be started for the 1st time in a
pregnant woman
IS MY CHILD MORE PRONE TO
ASTHMA?
 There is no association to mother asthma
during fetal period
 and development of asthma in childhood period.
 Albeit asthma is a genetic disease
CAN HEARTBURN CAUSE MY
ASTHMA?
 Comorbid conditions in asthma
 Gastro-esophageal reflux disease (GERD)
 Allergic rhinitis (AD)
 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
 Treatment of heartburn can improve asthma
symptoms
 Continue anti GERD drugs for at least 2-3
months
 Be suspicious to AD if
 Your asthmatic patient complains of
seasonal nose or sinus symptoms
 Treat AD with
 Intranasal corticosteroids
 Antihistamines (2nd generation in pregnancy)
 Allergen avoidance
SHOULD I GET FLU SHOT?
 Influenza vaccination is necessary for
 Pregnant women with 2nd and 3rd trimester
 In cold months
WHAT SHOULD I DO IN THE
CASE OF ASTHMA ATTACK?
 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 > 70
 Sat > 95
 Pco2 > 35 mmHg
 Po2 < 70 mm Hg
 Are abnormal during pregnancy
 IV fluid (dextrose) initially 100 ml/hour
 Seated position
 Fetal monitoring
 Dosage of glucocorticoids is not different
 IV aminophylline NOT generally
recommended
 IV Mg sulfate may be beneficial
 Concomitant hypertension
 Preterm contraction
 Respiratory infections in asthmatic patients
 Usually viral
 If indicated in a pregnant woman
 I V Ceftriaxone
 Erythromycin
LABOR: C/S OR NVD?
 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
 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
Summary
 Careful assessment and
monitoring
 Avoidance and controll of
triggers
 Maintenance rather than
symptomatic therapy
 Aggressive treatment of
exacerbations
THANK YOU