incidence and prevalence of asthma in pregnancy, guidelines for diagnosis and management of during pregnancy. drugs to be given and drugs to be avoided during pregnancy. pregnancy outcome in asthma patients.

1. ASTHMA AND
PREGNANCY

2. Dr S. RAGHU M.D.,
ASSOCIATE PROF
Department of TB & CD
Guntur medical college
&
Chest physician
Govt fever hospital
Guntur

3. Lungs in pregnancy
Lung volume changes associated with
pregnancy:
 Decreases : FRC(10-25%)
ERV(8-40%)
RV(7-22%)
 Increases : IC
 No change : TLC
VC

4.  Tidal volume increases considerably, i.e. 30 to
35%, as a result of increased ventilatory drive.
 Minute ventilation increases 20 to 50 percent
before the end of the first trimester due to an
increase in respiratory drive.
 Due to effect of increased serum progesterone-a
direct respiratory stimulant(from 25 ng/ml at 6
weeks to 150 ng/ml at 37 weeks)
 Therefore tachypnea during pregnancy is an
important abnormal finding that must be
investigated

6.  Increase in Minute ventilation causes
HYPERVENTILATORY PICTURE as a
normal state of affairs in the later half of
pregnancy.
1. chronic respiratory alkalosis
2. partial pressure of CO2 (PCO2)  ( 28-32 mmHg)
3. bicarbonate (HCO3-)  ( 18-21 mEq/L))
4. pH . ( 7.40-7.45)
5. PO2  > 100 mmHg
 A normal pCO2 in a pregnant patient may
signal impending respiratory failure.

7. Statistics of asthma in
pregnancy
 Prevalence of asthma in pregnancy: 4-8%
 52% of severe asthmatics prone to
Exacerbations during pregnancy
 55% of asthmatics have atleast One
exacerbation during pregnancy
 20% have a severe exacerbation during
pregnancy requiring medical intervention.
 5.8% of pregnant asthmatics are hospitalized for
a severe exacerbation.

8.  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

10.  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?

11. Effect of pregnancy on
asthma
 1/3 better (23%)
 1/3 no change
 1/3 worse (30%)
 Women with severe asthma tend to have
worsening of their asthma.
 Asthma exacerbations can occur at any time
during gestation but tend to cluster between 17 &
34 wk gestation.(mean 25 wk)
 Effect of pregnancy on asthma tends to be similar
in successive pregnancies

12.  Risk factors for asthma AE:
-respiratory viral infections
-discontinuation of treatment due fears about
their safety

13.  Hyperemia, friability, mucosal edema, and
hypersecretion of the airway mucosa occur
throughout pregnancy.
 These changes are most pronounced in the
upper airways, especially during the third
trimester.
 Hense the asthmatics are prone to RTIs during
pregnancy and also have an increased risk of
CAP.

14.  Asthmatic women who smoked
during pregnancy  multiple severe
exacerbations.
 Other factors that may worsen
asthma during pregnancy :
psychological stress, GERD, allergic
rhinitis.

15. Effect of asthma on
pregnancy
 Maternal health risks
Hyperemesis gravidarum
preeclampsia
gestational hypertension
uterine haemorrhage
placenta previa
maternal morbidity & mortality

16.  Fetal health risks
neonatal hypoxia
low birth weight
preterm birth
small for gestational age(IUGR)
congenital anomalies ( eg; cleft palate
especially with triamcinolone)
perinatal morbidity & mortality

17.  Poor controlled asthma has been
associated with 15 to 20 % increase in
both maternal & fetal risks
 These risks are increased 30 to 100 %
those with more severe asthma.
 Asthma is not associated with risk of
congenital malformations

18. D/D for acute respiratory distress in
pregnancy
 Venous thromboembolism
 Amniotic fluid embolism
 Pulmonary edema secondary to preeclampsia
 Tocolytic pulmonary edema
 Aspiration pneumonitis
 Peripartum cardiomyopathy
 Pneumomediastinum
 Air embolism
 Other: asthma, pneumonia, cardiac disease,
ARDS

19. Asthma & Pregnancy
management
Goals:
 Control symptoms, including nocturnal
symptoms
 Prevent acute exacerbations
 No limitations on activities
 Maintain (near) normal pulmonary
function
 Minimal use short-acting inhaled beta2-
agonists
 Protect the mother and fetus from

20. To achieve goals
 Maternal lung function monitoring
 Symptoms
 Spirometry
 Peak flows
 Fetal monitoring
 Ultrasound monitoring
 Elektronic fetal hearts

21. General Principles
 Preconception;
− Optimize asthma management.
− Few changes in treatment regimen are needed in
pregnancy especially if asthma is controlled.
 Avoid recently introduced medications whose
safety in pregnancy is not established.
 Use adequate doses of medications to control
symptoms and avoid hypoxia.
 It is essential to maintain adequate oxygenation
to the fetus.

22. Components of
Asthma Management
 Objective measures for assessment and
monitoring
 Patient education
 Avoidance of factors contributing to
asthma severity
 Pharmacologic therapy-
 Diagnose and treat rhinitis, sinusitis or
gastroesophageal reflux disease if present

23. Environmental Control in
Asthma
eliminate these “mobile allergen bearing units” & quit smoking

24. Drug treatment of asthma in
pregnancy

25.  As asthma is an inflammatory disease limited
to lung airways,
the drug treatment of asthma in pregnancy
is similar to the treatment of asthma in non-
pregnant women.
 Treatment of this disease in a topical form is
 More effective
 Less harmful

26. Medication safety in
pregnancy
 FDA Pregnancy Risk Classification for Drugs:
 Category A No risk demonstrated in 1st trimester
in controlled studies in women, no risk in later
trimesters
 Category B No risk in animal studies, but
controlled studies in women not done
 Category C Fetal harm in animals, no studies in
women (or studies in animals & women not
available)
 Category D Evidence of human fetal risk, but
benefits > risk in life-threatening situations
 Category X Contraindicated in pregnant women

27. drug FDA category
BUDESONIDE B
CROMOLYN B
NEDOCROMIL B
MONTELEUKAST B
ZAFIRLEUKAST B
TERBUTALINE B
IPRATROPIUM B
BECLOMETHASONE C
FLUTICASONE C
ALBUTEROL C
THEOPHYLLINE C
SALMETEROL C
FORMOTEROL C

28. Potential Adverse Effects of
Common
Asthma Drugs on the Fetus
Drug class Effect on fetus
Theophylline incresed HR, vomiting, jitteriness
(mother/fetus) when maternal levels
> 12 mcg/mL
Systemic b2 Agonists incresed fetal HR & neonatal HR,
tremor, Hypoglycemia
LT modifiers not known, animal data -
teratogenecity of zileuton
Decongestants Uterine vasoconstriction, fetal
gastroschisis
Corticosteroids preeclampsia, preterm and low birth
weight, cleft palate 1st trimester
(incidence 0.3%)

29. Medications to be Discouraged
in Pregnancy
 Frequent injections epinephrine (category C)
 Oral decongestants in the first trimester
 Iodine-containing cough medications
 Tetracycline (category D)
 Aspirin and NSAID (category D)
 Beta-blockers
 Prostaglandins

30. Stepwise Approach for the
Management of Asthma During
Pregnancy

31. Step 1 – Mild Intermittent
Asthma
Clinical Presentation
 Intermittent symptoms
 Brief exacerbations
 Normal between exacerbations
 Nighttime symptoms < 2/month
 PEF or FEV1 is: > 80% predicted
Controller : No daily medication
needed
Quick Relief : Inhaled b2 -agonist
(salbutamol)

32. Step 2 – Mild Persistent
Asthma
Clinical Presentation
 Symptoms > 2x/wk
 Nighttime symptoms > 2x/month
 PEF or FEV1 is:> 80% predicted
Controller : Low dose inhaled
steroid (Budesonide)
Cromolyn, leukotriene receptor
antagonist or theophylline
Quick Relief
Inhaled b2-agonist
(salbutamol)

33. Step 3 – Moderate Persistent
Asthma
Clinical Presentation
 Daily symptoms
 Daily use of b2-agonist
 Nighttime symptoms > 1x/wk
 PEF or FEV1 is: 60 – 80% predicted
Controller:
Inhaled steroid +
long-acting b2-agonist (or)
Increase dose inhaled steroid
Alt: ICS + Leukotriene receptor
antagonist or theophylline
Quick Relief:
Inhaled b2-agonist

34. Step 4 – Severe Persistent
Asthma
Clinical Presentation
 Daily symptoms
 Frequent nocturnal awakenings
 Frequent exacerbations
 PEF or FEV1 is: ≤ 60% predicted
Controller :
Inhaled steroid (high-dose)
Long acting b2-agonist and
if needed Oral steroids
Quick Reliever
Inhaled steroid (high-dose)
Long acting b2-agonist and if needed
Oral steroids
Short acting inhaled b2-agonists

35. Management of Acute Asthma
in Pregnant Women
 Oxygen supplementation
(SaO2>95% / Po2 >70)
 İntravenous fluid hydration (if necessary)
 Inhale salbutamol (every 20 mins up to three
doses in the first hour)
 Ipratropium bromide (500μg) (in severe
cases)
 Systemic corticostreoids either
intravenously or orally (in moderate/severe
cases)
 Dosage of glucocorticoids is not different
 IV aminophylline NOT generally
recommended
 IV Mg sulfate may be beneficial

36. 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

37.  In pregnant asthmatics you should
confirm control by
 Spirometry
 Monthly
 Peak flow metry
 Twice daily
Upon awakening &
After 12 hr

38.  FEV1 < 80% in pregnancy associated with poor
pregnancy outcomes
 Moderate to severe asthmatics
 Serial ultrasound examination of fetus
-Early in pregnancy
-Regularly after 32 wk
-After an asthma exacerbation

39. Immunotherapy
During Pregnancy
 No advers effects on pregnancy
outcomes
 Anapylaxix may a risk for mother and
baby
Recommendations
 Do not begin immunotherapy during
pregnancy
 Carefully continue ongoing effective
immunotherapy (avoid systemic reactions)

40. Flu shot
 Influenza vaccination is necessary for:
 Pregnant women with 2nd and 3rd trimester
 In cold months

41. Obstetrical Management of
Pregnants With Asthma
In case of cesarian section:
 Lumbar epidural analgesia (Decreses O2
consumption and minute ventilation)
 Fentanyl (as a narcotic analgesic)
 If general anesthesia required -Ketamine is
preferred
In case of labour:
 Oxytocin and prostaglandin E2 suppositories
(for labor induction)
 Pitocin, misoprostol (for postportum hemorrhage)

42. Obstetrical
management
Should be avoided
 Morphine
 Meperidine
 15-methylprostaglandin F2α
 Ergot alkaloides
 Whole delivery team should be made aware of
existing asthma, particularly anesthetist.

43. Asthma and Lactation
 There is no effect of lactation on maternal
asthma.
 Prednisone, theophylline, antihistamines,
ICS, SABAs, LABAs and cromolyn are not
contra-indicated.
 Theophylline may cause neonatal
irritability, feeding difficulties.

44. Allergic Rhinitis and Pregnacy
Intermitten rhinitis
(symtoms less than 4 days a week or for less
than 4 consecutive weeks )
− Mild:
• Loratadine or cetirizine as needed
− Modarate- severe
(İmpairmen of sleep, daily activities, school or work or
trouble some symptoms):
• Intermitten intrasal budesonide, supplemented
by loratadine or cetirizine as needed

45. Allergic Rhinitis & Pregnacy
Persistent Rhinitis
(symptoms more than 4 days per week
and for more than 4 consecutive weeks)
 Mild:
 Intranasal cromolyn supplemented by
loratadine or cetirizine as needed
 Moderate-Severe:
 Regular intranasal budesonide, supplemented
by loratadine or cetirizine as needed;
immunotherapy

46. Take home
 The biggest danger is poorly controlled or under-
treated asthma.
 Avoid exposure to tobacco smoke and other
irritants.
 The treatment is similar.
 Maintenance rather than symptomatic therapy
 No studies have related ICS to an increased risk
for the fetus.
 Preferred controller: Budesonide [Category B]
 Aggressive treatment of exacerbations
 It is unusual for asthma to cause problems in
labour.

47. Thank you..