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1. High lights on
Asthma in pregnancy
By
Dr. Ashraf El-Adawy
Consultant Chest Physcian
TB TEAM Expert – WHO
Mansoura - Egypt

2. Asthma in pregnancy: Reading between the lines
Asthma is probably the most common potentially serious medical
condition that can complicate pregnancy, and approximately 4% -
8% of pregnant women reported asthma in recent national surveys.
Effect of pregnancy on asthma
The effects of pregnancy on asthma are unpredictable.
The severity of asthma during pregnancy varies from one woman to
another. Unfortunately, it is difficult to predict the course that asthma
will follow in a woman's first pregnancy
During pregnancy, asthma worsens in about one-third of women,
improves in one-third, and remains stable in one-third.
 The factors that increase or decrease the risk of asthma attacks
during pregnancy are not entirely clear
 Women with severe asthma are more likely to worsen, while
those with mild asthma are more likely to improve or remain
unchanged.
Other patterns that have been observed include:
 Among women whose asthma worsens, an increase in
symptoms is often seen between weeks 24 and 36 of
pregnancy.
 Asthma is generally less severe during the last month of
pregnancy.
 Fortunately during labor and delivery, the majority of asthma
patients do well, with only occasional patients (10 percent or
fewer) becoming symptomatic during labor and delivery.
 Among women whose asthma improves, the improvement
typically progresses gradually throughout pregnancy.

3.  In an individual woman ,The severity of asthma symptoms
during the first pregnancy is often similar in subsequent
pregnancies.
 The changes in asthma noted during pregnancy usually return
to pre-pregnancy level of severity within three months post
partum.
 Asthma may occur for the first time during pregnancy .
Effect of asthma on pregnancy
 Pregnancy complicated by uncontrolled asthma should
be regarded as a high Risk pregnancy
 Uncontrolled asthma in pregnancy produce serious
maternal & fetal complications
Maternal complications
● Pre eclampsia
● Gestational hypertension
● Vaginal hemorrhage
● induced & complicated labors
● Premature delivery
● Placenta previa
● Increased frequencies of C.S among patients with moderate to
severe asthma.
Fetal complications
● Intra uterine growth retardation (IUGR)
● Low birth weight .
● Preterm birth .

4. ● Increased risk of perinatal mortality (death before, during or after
delivery).
● Neonatal hypoxia.
 But this does not mean that having asthma will make your
pregnancy more difficult or dangerous to you or your fetus.
 Pregnant women with well controlled asthma can expect to
have the same pregnancy outcomes as non asthmatic
women , with little or no increased risk to themselves or the
fetus
 During pregnancy, Good control of asthma is essential for
maternal & fetal well being as acute asthmatic attacks can
result in dangerously low fetal oxygenation.
 Underestimation of asthma severity & under treatment of
exacerbations are two common errors that may lead to
adverse maternal & fetal outcomes.
 Good asthma control is the key to successful pregnancy ,the
best way to have a healthy baby is to have a healthy mother.
Can asthma medications safely be used during pregnancy?
 Treatment recommendations for optimal asthma control
during pregnancy, it is safer for women with asthma to be
treated with asthma medications than to have asthma
symptoms and exacerbations.
 Overall, the risk of poorly controlled asthma is much greater
than the risk of taking medications to control asthma.
 For woman with asthma , a drug free pregnancy is not the
best option.
 Asthma should be as aggressively treated in pregnant
women just as it should be in non pregnant patients.

5.  Most medications used to control asthma are not harmful to the
developing fetus & do not appear to contribute to either
spontaneous abortion or congenital birth defects.
 Although no medication can be proven entirely safe for use
during pregnancy , the potential benefits of asthma
medications out weight the potential risks of the all medications
& uncontrolled asthma.
 Asthma is almost never a reason to not pregnant.
In general, asthma medications used in pregnancy are chosen
based on the following criteria:
 With a few exceptions, the medications used to treat asthma
during pregnancy are similar to the medications used to treat
asthma at other times during a person's life.
 Inhaled medications are generally preferred because they
have a more localized effect with only small amounts entering
the bloodstream.
 When appropriate, time-tested older medications are preferred
since there is more experience with their use during pregnancy.
 Medication use is limited in the first trimester as much as
possible when the fetus is forming.
 Birth defects from medications are rare (no more than 1
percent of all birth defects are attributable to all medications)
 In general, the same medications used during pregnancy are
appropriate during labor and delivery and when nursing.
 Remember that the use of medications should not replace
avoidance of allergens or irritants, as avoidance will potentially
reduce medication needs.

6. FDA pregnancy risk categories for asthma medications
Agent Risk category
Albuterol (Ventolin)
Pirbuterol t(Maxair)
Levalbuterol (Xopenex)
Terbutaline (Bricanyl)
C
C
C
B
Salmeterol (Serevent)
Formoterol (Foradil & Oxis)
C
C
Ipratropium bromide (Atrovent) B
Cromolyn sodium (Intal)
Nedocromil sodium (Tilade)
B
B
Agent Risk category
Zafirlukast (Accolate)
Montelukast sodium (Singulair)
Zileuton (Zyflo)
B
B
C
Budesonide (pulmicort)
Beclomethasone dipropionate (Becotide)
Fluticasone propionate (Flixotide)
Triamcinolone acetate (Azmacort)
Flunisolide (AeroBid)
B
C
C
C
C
Oral Corticosteroids C
Theophylline C
Omalizumab (Xolair) B

7. Recommendations for step therapy medical management
of asthma during pregnancy are as follows:
1. Using the lowest amount of drug intervention necessary to
control a patient's severity of asthma."
2. Increasing both the number and dosage of medications as
asthma severity increases
Management of Asthma
 Medications for asthma are divided into long-term controller
medications (inhaled corticosteroids, long-acting β-agonists,
leukotriene modifiers, cromolyn, and theophylline) and
 Rescue medications that provides quick relief of symptoms
(primarily short-acting inhaled β-agonists).
Rescue medications "asthma relievers"
 Short-acting inhaled beta2-agonists (SABAs), are the preferred
rescue medications during pregnancy.
 Albuterol (Ventolin HFA) rather than terbutaline , is now is the
preferred short-acting inhaled beta2-agonist for use during
pregnancy since there are more available reassuring human
gestational safety data .
Short-acting inhaled beta2-agonists appear to be safe during
pregnancy. No significant association has been demonstrated
between major congenital malformations or other adverse perinatal
outcomes and exposure during the first trimester or at any time to
beta2-agonists.
SABA should be generally used on an as needed basis rather than
regularly.

8.  In persistent asthma in all steps in addition to regular daily
controller therapy, SABA should be taken as needed to relieve
symptoms but should not be taken more than 3 to 4 times a day.
 The use of short-acting inhaled beta2-agonists on a daily basis,
or increasing use, indicates the need for additional long term
control therapy.
 Inhaled B2 agonist in doses required for asthma control will not
interfere with labor.
 Ipratropium (Atrovent®), an anticholinergic bronchodilator
medication, It appears to be safe for use during pregnancy.
 First-line controller medications
Inhaled corticosteroids (ICSs) are the preferred long term
controller medications in pregnant women with persistent
asthma.
 Budesonide is the preferred inhaled corticosteroid for use
during pregnancy due to a large amount of reassuring human
gestational safety data.
 However, other inhaled corticosteroids have not been proven
to be unsafe during pregnancy and can be continued in
patients well-controlled by them prior to pregnan
 Inhaled Budesonide is the only ICS to be included in category B,
all other inhaled steroids are category C.
No significant association has been demonstrated between major
congenital malformations OR adverse perinatal outcome and
exposure to ICS during pregnancy.
Adherence to treatment with inhaled corticosteroids has been
reported to be poor in many studies due to the concern regarding
the safety of inhaled corticosteroids during pregnancy.
Despite the documented safety of ICS for asthma management
during pregnancy, a significant percentage of pregnant women do
not take their medication consistently also Physicians appear to be
reluctant to prescribe corticosteroids for pregnant women.

9. Nonadherence to treatment with inhaled corticosteroids during
pregnancy was associated with an increased frequency of asthma
exacerbations.
Other controller medications
 Alternative therapy may include use of mast cell stabilizers
(Intal), leukotriene receptor antagonists LTRAs e.g (Singulair), or
theophylline.
 However, mast cell stabilizers and LTRAs provide inferior control
of asthma symptoms when compared with ICS.
 Theophylline is safe for use in pregnancy when dosed within the
recommended therapeutic serum concentrations ( 5-12 µcg /
ml ).
When compared with ICS, theophylline has has been associated with
more adverse reactions, higher discontinuation rates, and lower FEV1
than ICS.
Additionally, drug clearance may be reduced during the third
trimester, necessitating frequent monitoring of serum theophylline
levels and adjustment of drug dosage.
Appropriate add-on controller therapy
Long-acting beta2-agonists (LABAs) in combination with ICS (Seretide,
Symbicort) is the recommended add-on therapy for patients not
controlled on a medium-dose ICS alone.
Theophylline and LTRA are considered alternative add-on therapies.
However, LABAs provide better asthma control than either of these
agents and have fewer adverse reactions than theophylline.
If asthma symptoms are not controlled on medium-dose ICS and
LABA (or alternatives), then therapy should be advanced to high-
dose ICS and LABA.

10. Those with severe asthma not controlled on high-dose ICS and LABA
may require daily oral corticosteroids.
LABAs (salmeterol (Serevent Diskus ®), formoterol (Foradil®), are
recommended as add-on therapy in those uncontrolled on a
moderate dose of ICS, but they should never be used as
monotherapy in asthma
To ensure the safe use of LABAs in the treatment of asthma: 2010 FDA
 Single-ingredient LABAs should only be used in combination
with an asthma controller medication such as an inhaled
corticosteroid ,they should not be used alone.
 Long-Acting Beta Agonists (LABAs) do not relieve sudden-onset
asthma symptoms. Patients should always have a rescue
inhaler, such as an albuterol inhaler, to treat sudden onset
asthma symptoms.
 Long-Acting Beta Agonists (LABAs) should not be started in
patients with acutely deteriorating asthma
 Pediatric and adolescent patients who require the addition of a
LABA to an inhaled corticosteroid for better control of their
asthma should use a combination product containing both an
inhaled corticosteroid and a LABA, to ensure compliance with
both medications.
There are limited data on the use of LABAs in pregnancy, but LABAs
are believed to have a safety profile similar to a SABA.
Oral corticosteroids in pregnancy
In some cases oral or injectable corticosteroids, may be necessary
for a few days in patients with severe asthma exacerbations or
throughout pregnancy in women with severe asthma.

11. Adverse associations with oral steroids during pregnancy:
 Some studies have demonstrated a slight increase in the
incidence of cleft lip or cleft palate in the babies of mothers
who took oral glucocorticoid medications during the first
trimester of pregnancy and pre-eclampsia, premature
deliveries or low-birth-weight infants with chronic use of oral
corticosteroids
 The available data make it difficult to separate the adverse
effects of oral steroids on maternal & fetal outcomes from the
effects of severe or uncontrolled asthma
However, all of the above risks are probably smaller than the risk of
not treating severe asthma, which could be life-threatening for the
mother, and the baby
The risk-benefit considerations favor the use of oral corticosteroid
medication when indicated in the long-term management of severe
persistent asthma & acute exacerbations during pregnancy. . .
their significant benefit usually far exceeds their minimal risk.
Steroid tablets should never be withheld because of pregnancy
Derivatives of cortisone & prednisone are recommended since they
are inactivated by the placenta as opposed to dexamethasone
which are not.

12. The American College of Obstetricians and Gynecologists
(ACOG) 2008 Recommendations for step therapy medical
management of asthma during pregnancy :
1. For mild intermittent asthma, albuterol should be given as
needed, with no regular daily medications.
2. For mild persistent asthma, the preferred regimen is a low-dose
inhaled corticosteroid, budesonide is the preferred ICS.
(with alternative treatments being cromolyn, a leukotriene
receptor antagonist, or theophylline to a target serum level of 5
to 12 µg/mL).
3. For moderate persistent asthma the preferred treatment is a
low-dose ICS and LABA or medium-dose ICS or medium-dose
ICS and LABA if needed.
(An alternative regimen is a low-dose or medium-dose (if
needed) ICS with either a leukotriene receptor antagonist or
theophylline to a target serum level of 5 to 12 µg/mL).
4. For severe persistent asthma, preferred treatment is a high-dose
ICS and, LABA plus oral corticosteroid if needed.
(An alternative regimen is a high-dose ICS and theophylline to
a target serum level of 5 to 12 µg/mL, plus an oral corticosteroid
if needed)

13. Management of Asthma During Labor and Delivery
 Asthma medications should be continued during labor and
delivery
 It is commonly recommended that for women who have
been used systemic corticosteroids in the previous 4 weeks,
or who have received several short courses of systemic
corticosteroids during pregnancy , a stress-dose steroid (e.g.
hydrocortisone 100 mg every 8 hours, intravenously) should
be administered during labor and for 24 hours after delivery
in order to prevent adrenal crisis.

Prostaglandin E1 or E2 can be used for cervical ripening,
management of spontaneous or induced abortions, or
postpartum hemorrhage,

14. 
In contrast, carboprost (15-methyl prostaglandin F2 ) and
ergonovine may trigger bronchospasm and should be avoided,
if possible.
 If tocolysis is required, magnesium sulfate and terbutaline are
preferable because they are bronchodilators
 Indomethacin can induce bronchospasm in a patient with
aspirin-sensitive asthma
 Women with asthma can be treated with the drug oxytocin
(Pitocin®) to induce labor and to control bleeding after delivery.
 During labor and delivery, epidural anesthesia is preferred over
general anesthesia for women with asthma because epidural
anesthesia can reduce oxygen consumption and minute
ventilation during labor.
Rarely, if ever, is it necessary to deliver a fetus via cesarean due to
an acute exacerbation of asthma. Usually, maternal and fetal
hypoxia can be managed by optimal medical management.
Occasionally, delivery may improve the respiratory status of a
patient who has unstable asthma and is near term.
Breastfeeding considerations
 In general, only small amounts of asthma medications enter
breast milk. During breast-feeding, use of prednisone,
theophylline, antihistamines, inhaled corticosteroids, beta2-
agonists, and cromolyn is not contraindicated
 Some infants can have irritability and insomnia if exposed to
higher doses of theophylline.

15.  Leukotriene modifiers are Not recommended for breast feeding
mothers due to lack of data regarding safety
 Breastfeeding appears to lower the risk that an infant will have
recurrent episodes of wheezing during the first two years of life.
This is probably due to the fact that infants who breastfeed
have a reduced number of respiratory infections during this
period. Respiratory infections are a common cause of
wheezing in infants.
Immunotherapy (allergy shots)
 Women who are not using immunotherapy at the time they
become pregnant generally should not start immunotherapy
until after delivery.
 Continuation of immunotherapy is recommended in patients
who are at or near a maintenance dose, not experiencing
adverse reactions to the injections, and apparently deriving
clinical benefit.
 Starting immunotherapy or advancing the dose is not
recommended during pregnancy due to the risk of anaphylaxis.
Seasonal Influenza (flu) vaccine
Immunization with the inactivated seasonal Influenza vaccines
is recommended if the pregnancy occurs during influenza
season.. for all patients with moderate and severe asthma
There is no evidence of associated risk to the mother or fetus.

16.  Pregnant women should not smoke or permit smoking
in their home.

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