This document discusses female bronchial asthma, including its definition, pathophysiology, diagnosis, monitoring, treatment during pregnancy and effects of pregnancy on asthma. It is a reversible chronic obstructive lung disease characterized by recurrent wheezing and coughing alternating with normal breathing. Hormonal changes during the menstrual cycle, pregnancy, delivery and menopause can impact asthma symptoms. Treatment aims to prevent exacerbations and control symptoms using inhaled corticosteroids and bronchodilators. Close monitoring is important during pregnancy to balance controlling asthma and minimizing medication risks for the mother and baby.

1. Female Bronchial Asthma
• Dr Muhammad El Hennawy
• Ob/gyn Consultant
• Rass el barr central hospital and
dumyat specialised hospital
• Dumyatt – EGYPT
• www. mmhennawy.co.nr

2. Diseases of chest
• COLD----Chronic obstructive lung disease
reversible (bronchial asthma )
Irreversible (chronic bronchitis – chronic obstructive
emphysema)
Reversible and irreversible — asthmatic bronchitis
• SLD (supurative lung diseases)
Bilateral---bronchiectasis
--- infected systemic lung
Unilateral---lung abscess
--- empyema
• Syndrome of multiple negative – pleural thickning,
Pleural effusion ,lung fibrosis

3. Definition Of Asthma
• It is reversible chronic obstructive lung disease ,
characterized by recurrent episodes of wheezing,
chest tightness, and coughing alternating with
periods of relatively normal breathing.
. Asthma symptoms can occur spontaneously or may
be triggered by allergens, environmental factors,
exercise, cold air, infections, and stress.

4. there is strong evidence that estrogen and
progesterone may actually improve lung
function and asthma
• Progesterone has been shown to suppress
the immune system and so in that sense it's
protective or helpful. It may reduce the
increased inflammation that's occurring.
• both progesterone and estrogen have been
found to reduce constriction of the airways
and relax the bronchial smooth muscle in
the airways

5. Asthma
premenstrual
menestrual
OCPs
pregnancy
menopause HRT
delivery
Breast
feeding

6. • hormone levels are lower during the premenstrual and
menstrual phases--asthmatics have been found to experience
an increase
• Oral contraceptives, which really dampen and smooth out
these fluctuations in hormone levels, have been found to
improve pulmonary function in some women as well.
• women move through and into the menopausal period
because at this time estrogen, progesterone also rapidly
decrease -- experience an increase
• hormone replacement therapy in asthmatic menopausal
women have better pulmonary function and less pulmonary
obstruction but the increased risk of asthma to HRT on the
basis of an observational study in healthy menopausal
women

7. Menstruation and asthma
• Asthma is more common in boys than in girls before
puberty,
but then girls "catch up," suggesting a possible hormonal
influence initiating the onset of asthma at menarche
• asthma symptoms can begin to worsen from three to seven
days before the onset of menses(premenstrual asthma), and
can last until the bleeding ceases (menestrual asthma)
• half of cases the woman's attack struck within four days of
the start of her menstrual period.
• one-third of women think their symptoms are worse just
before or during menstruation.

8. Contraceptive pills and asthma
Oral contraceptives, which really dampen and
smooth out these fluctuations in hormone levels,
have been found to improve pulmonary function
in some women as well
• Some women who use birth control pills may
have greater difficulty controlling their asthma.
(pill asthma)

9. Menopause and asthma
• Variations in asthma presentation have been
observed during the time when serum estradiol
levels decreased sharply after a prolonged peak.
These findings suggest that these monthly variations
in this hormone may influence the severity of
asthma in women.
• The changing hormone levels of menopause may
cause some women to develop asthma for the first
time; others may experience worsening symptoms

10. Hormone replacement therapy (HRT) and asthma
• hormone replacement therapy in asthmatic
menopausal women have better pulmonary
function and less pulmonary obstruction
• but the increased risk of asthma to HRT on the
basis of an observational study in healthy
menopausal women

11. Ashtma with pregnancy,
delivery,postpartum and
breast feeding

12. Incidence
• 7 percent of women in their childbearing years
• 4 percent of all pregnancies .
• It can cause serious complications for both mother
and child if not controlled properly during
pregnancy.
• The good news is that asthma and allergies can be
controlled, and when they are, the risks to mother
and baby are extremely low.

13. causes
• allergen exposure --dust mites, cockroaches, and animal danders.
pollens, molds, pet dander, house dust mites and cockroaches
• Other non-allergic substances also may worsen your asthma and
allergies. These include tobacco smoke, paint and chemical fumes,
strong odors, environmental pollutants (including ozone and smog)
and drugs, such as aspirin or beta-blockers (used to treat high blood
pressure, migraine headaches and heart disorders).
• Chronic sinusitis ---the bacteria, toxins, and inflammatory mediators
contained in aspirated nasal secretions irritate the mucosa of the lower
airways of asthmatic patients, thereby worsening the control of their
reactive airway disease
• Gastroesophageal reflux disease (GERD) is commonly associated
with asthma. GERD can cause worsening of asthma by either a
vagally mediated mechanism or direct aspiration of acidic gastric
contents into the respiratory tree
• exacerbated by stress and anxiety
• Aspirin and nonsteroidal anti-inflammatory drugs can cause
bronchospasm in some patients with asthma
• . Hormonal factors (ie, menses, use of exogenous hormones by female

14. • The muscles of the bronchial tree become tight
• the lining of the air passages become swollen, reducing
airflow and producing the wheezing sound
• Mucus production is increased.
pathophysiology

15. Diagnosis and Monitoring
• objective measurements are important in evaluation of
difficult-to-manage cases
objective evidence of airflow obstruction (a tightness in
chest and wheezing, shortness of breath and/or coughing. )
that is reversible either spontaneously or through treatment
with a bronchodilator
• Because both patient and physician may have a poor
perception of the severity of the patient's asthma,
Spirometric measurement at each office visit or routine use
of a peak flow meter by the patient is needed to confirm the
effectiveness of the treatment strategy.

16. • A peak flow meter
• at home
• the convenience and ease of use
• measure the PEFR (peak expiratory
flow rate) by taking a deep breath and
then blowing into a tube on the meter
as hard and as fast as patient can.
• every day, sometimes several times a
day, and keep track of these rates over
time --are compared with charts that
list normal values for sex, race, and
height.
• A spirometer
• in a doctor's office
• gives a more accurate measure of lung
function
• diagnose asthma, classify its severity, and help
decide what is the best way to treat asthma
• done periodically
• The total volume patient exhale is called
"forced vital capacity," or FVC
• measures the volume of air patient exhale in
the first second. (This is referred to as "forced
expiratory volume in one second," or FEV1.)
• Patient will be given a bronchodilator and
repeat the measerment
•You would not consider managing hypertension without a sphygmomanometer,
or diabetes without a glucometer –
• accurate and objective assessmentand management of asthma is not possible
without a spirometer or peak flow meter

17. The effect of asthma on pregnancy
specially if untreated well
• MATERNAL
• Increase emergency department
visits,
• Increase hospitalizations,
• Increase Hyperemesis
• Increase vaginal hemorrhage
and accidental haemorrhage due
to severe coughing
• Increase CS
• Increase respiratory failure,
• Increase high blood pressure
and preeclampsia,
• Increase death..
• FETAL
• increased low birth weight,
• Increase premature delivery,
• Increase fetal demise
• NEONATAL
• Increase neonatal hypoxemia
• low newborn assessment
scores
• increased perinatal mortality

18. The effect of pregnancy on asthma
• Some patients experience an improvement of their symptoms
during pregnancy; The exact reason for this is unknown, but the
increase in the body's cortizone level during pregnancy may be an
important cause of the improvement which can occur. Many
women experience less asthma during the last four weeks of
pregnancy. This may be due, in part, to the increase of
prostaglandin E reported to occur during this time period of
pregnancy, or it may be that the "dropping" of the baby in the
final weeks of pregnancy takes pressure off the lungs, resulting in
easier breathing
• others have increased symptoms; . Some women experience
gastroesophageal reflux causing belching and heartburn. This
reflux, as well as sinus infections and increased stress, may
aggravate asthma. Asthma has a tendancy to worsen during
pregnancy in the late second and early third trimester.
• and some see no noticeable change in their asthma at all.

19. During delivery
• Only about 1 in 10 women with asthma have
symptoms during delivery.
• Most asthmatic women are even able to perform the
Lamaze breathing techniques during delivery
without difficulty.
• The increase in plasma epinephrine that occurs
during labor and delivery may contribute to the
absence of asthma symptoms during this critical
time period

20. postpartum and asthma
• If you've been pregnant before, you can
probably expect your asthma to behave the
same way in subsequent pregnancies.
Within three months of your baby's birth,
your asthma probably will return to the way
it was before you became pregnant.

21. Breastfeeding and asthma
• there is some evidence to suggest that
breastfeeding may reduce the risk of your baby
developing asthma
• child has a one in ten chance of inheriting the
condition from its mother, which rises to one in
three if both parents have asthma. But a recent
long-term study showed that breastfeeding for the
first six months of life significantly reduces the
risk of the child's developing allergic breathing
problems by age 17, compared to babies who are
breastfed for less than six months.

22. The goal of asthma therapy during
pregnancy
• It is virtually the same as in non-pregnant patients.
• The goal is ---to prevent hospitalization
----and emergency room visits
-----as well as lost time at work and chronic
disability.
Since the symptoms associated with asthma and allergies can
vary from day to day, month to month, or season to season,
regardless of pregnancy, treatment plan will be based on the
severity of disease and previous experience using specific
medications during pregnancy

23. Prevention
Decrease or control exposure to known allergens and
irritants by staying away from cigarette smoke,
exposure to pets
removing animals from bedrooms or entire houses,
and avoiding foods that cause symptoms.
Alcohol should be doubly avoided by the pregnant
woman with asthma, because it can harm the
developing fetus and because it can cause bronchial
constriction as it is exhaled through the lungs
Allergy desensitization is rarely successful in reducing
symptoms

24. If a patient tests allergic to a specific trigger,
allergists-immunologists recommend the
following avoidance steps
Remove allergy-causing pets from the house.
• Seal pillows, mattresses and box springs in special dust
mite-proof casings (your allergist should be able to give you
information regarding comfortable cases).
• Wash bedding weekly in 130 degrees F water (comforters
may be dry-cleaned periodically) to kill dust mites.* Keep
home humidity under 50 percent to control dust
mite and mold growth.
• Use filtering vacuums or "filter vacuum bags" to control
airborne dust when cleaning.
• Close windows, use air-conditioning and avoid outdoor
activity between 5 a.m. and 10 a.m., when pollen and
pollution are at their highest.

25. Monitoring
• The pregnant asthmatic should be monitored carefully and the
selection of medications should be reviewed by a specialist.
• Doctors are very cautious about the use of drugs during the first three
months of pregnancy
• even though most anti-asthmatic medications are considered safe
during pregnancy.
• The medications do not appear to be associated with increased
congenital malformations, nor is there is any evidence that anti-
asthmatic drugs (theophylline, beta agonists, cromolyn sodium, or
steroids) will adversely affect a nursing infant. the potential risks of
asthma medications are lower than the risks of uncontrolled asthma,
which can be harmful to mother and baby.
• As long as the asthma is controlled, the pregnancy and its outcome do
not appear to be adversely affected by the mother taking cortisone
(steroids) orally or by inhalation.
• Aerosols and sprays are preferable to oral medication
• Time-tested older medications are preferred

26. Self-management of asthma
outpatient management of asthma
• Teach the patient self-management (Level of Evidence=A;
• The patient should have good knowledge of self-management.
• The components of successful self-management are acceptance of
asthma and its treatment effective and compliant use of drugs
• a PEF meter and follow-up sheets at home
• written instructions for different problems
• As a part of controlled self-management the patient can be given
• a PEF follow-up sheet with individually determined alarm limits
and the following instructions (Level of Evidence=B;
• If the morning PEF values are 85% of the patient´s earlier
optimal value, the dose of the inhaled corticosteroid should be
doubled for two weeks.
• If the morning PEF values are below 50 - 70% of the optimal
value the patient can start a course of prednisolon 40 mg daily for
one week and contact the doctor by telephone.

27. Treatment Protocol
DIAGNOSIS BASED ON SYMPTOMS & OBJECTIVE ASSESSMENT
ASSESS SEVERITY
MILD MODERATE SEVERE
ENVIRONMENTAL CONTROL AND EDUCATION
ADDITIONAL THERAPY
INHALED CORTICOSTEROIDS
INHALED SHORT-ACTING BETA2-AGONIST PRN

28. New Asthma Treatment AlgorithmNew Asthma Treatment Algorithm

29. Categories of medication
• 1. "Relievers" (for intermittent symptoms)
-short-acting ß2-agonists
– -ipratropium (rarely)
• 2 ."Controllers" (maintenance therapy)
---anti-inflammatory medications
• -inhaled/oral glucocorticosteroids
• -leukotriene receptor antagonists
• -anti-allergic agents (cromoglycate, nedocromil)
----bronchodilators
• -long-acting inhaled ß2-agonists (salmeterol,formoterol)
• -theophylline
• -ipratropium

30. ..
Working Group Recommendations for the Pharmacological
Step Therapy of Chronic Asthma During Pregnancy
Category Frequency/Severity of
Symptoms (sx)
Pulmonar
y
Function*
(untreated)
Step Therapy
Mild intermittent Sx<=2 times per week
Nocturnal Sx <=2/month
Exacerbations brief (a few hours to
a few days)
Asymptomatic between episodes
=<80%
Normal
function
between
episodes
Inhaled beta2-agonists
as needed (for all
categories(
Mild persistent Sx > 2 times per week but not
daily.
Nocturnal Sx > 2/month
Exacerbations may affect activity
>=80% Inhaled cromolyn
Substitute inhaled
beclomethasone if not
adequate
Moderate
persistent
Daily Sx
Nocturnal Sx > 1/week.
Exacerbations affect activity
60-80% Inhaled
beclomethasone
Add oral theophylline
Severe persistent Continual Sx
Limited activity
Frequent nocturnal symptoms
Frequent acute exacerbations
<60% Above + oral
corticosteroid
(burst for active
symptoms, alternate
day or daily if

31. Inhaled Steroids
• The best option for initial anti-inflammatory treatment (Level I)
• initial daily dose: 400-1000 µg BDP or equivalent (Level III)
• initial daily dose in children: 200-1000 µg BDP or equivalent (Level IV)
• once best results are achieved, reduce dose to minimum required for control (Level
III)
• use a spacer with MDI delivery (Level I)
• Low to moderate doses provide the best risk-benefit profile (Level I)
• Adults using high doses should consider bone densitometry (Level III
• monitor IOP in glaucoma patients (Level V)
• avoid getting aerosolized steroids in the eye (Level V)
• regular users should rinse after use (Level I)
• patients requiring consistent high doses should be referred (Level IV)

32. Leukotriene receptor antagonists
• may be considered as an alternative to
increased doses of inhaled steroids as add-
on therapy to glucocorticosteroids (Level II)
• There is insufficient data to recommend
LTRAs for regular therapy in place of
inhaled glucocorticosteroids (Level IV)

33. Cromoglycate
• should not be added to an established regimen of
inhaled / systemic steroids (Level I)
• may be used as a less effective alternative to short-
acting ß2-agonists to prevent exercise-induced
symptoms (Level I)
• may be an alternative to low-dose IHS in children
with mild symptoms (Level I) unwilling to take
inhaled glucocorticosteroids
• may be used for short-term allergen exposure (Level
I)

34. Nedocromil
• is not recommended for first line therapy of asthma
• may be considered as a less effective alternative to
short-acting ß2-agonists to prevent exercise-induced
bronchospasm (Level I)
• may be a modestly effective alternative to low-dose
inhaled glucocorticosteroids in children with mild
symptoms (Level I)

35. Theophylline
• not recommended as 1st-line therapy (Level I)
• may be used as an alternative to increased doses of
inhaled glucocorticosteroids (Level II)
• dose must be titrated slowly (Level III) because of
the narrow therapeutic range and the potential for
severe side effects

36. Anticholinergic bronchodilators
• not recommended as 1st-line therapy except
in patients who cannot tolerate ß2-agonists
(Level III)

37. long-acting inhaled ß2-agonists
(salmeterol,formoterol(
• These work in the same way as the ordinary
relievers such as salbutamol and terbutaline, with
the difference that they stick to the cells in the body
on which they act, and so work for much longer.
The side-effects are the same, namely tremor,
increased pulse rate, and palpitations ,They have
been introduced much more recently, but no hazards
in pregnancy are known.

38. Other therapies
• in chronic severe asthma unresponsive to moderate doses of oral
glucocorticosteroids confounding factors should be assessed before
increasing therapy
• patients who need regular oral glucocorticosteroids should be referred
to a specialized centre (Level III) and should receive prophylactic
osteoporosis treatment (Level I)
• immunosuppressive agents should be reserved for patients dependent
on long-term high-dose glucocorticosteroids (Level III) followed in
specialized centres
• no apparent benefit for most unconventional therapies: acupuncture,
chiropractic, homeopathy, naturopathy, osteopathy, herbal remedies
(Level I to III, depending on the therapy)

39. Other treatments for asthma
• Antihistamins
Antihistamines have very limited effect in asthma (Level of
Evidence=B;
They can be used to alleviate other symptoms of allergy.
• Antibiotics
Only clear signs of bacterial infection are an indication for antibiotics.
Most infections causing exacerbations of asthma are of viral origin.
Remember sinusitis,
but avoid unnecessary antibiotics.
• Antitussives
Cough is usually a sign of poor control.
Increase the intensity of treatment,
or give a short course of oral corticosteroids.

40. Delivery devices
• inhaled drug delivery is recommended for ß2-agonists and
glucocorticosteroids (Level I)
• use the inhalation device that best fits the need of the individual
(Level III)
• health professionals must teach technique when devices are
dispensed (Level I)
• patients' technique must be reassessed and reinforced at each contact
(Level II)
• HFA-propellant devices are recommended over CFC devices (Level
IV)-- CFC-free inhalers use hydrofluoroalkanes (HFAs) as the
propellant. HFAs are less likely to affect the ozone layer.
• home wet nebulizers rarely indicated (Level III)
• in children, conversion from mask to mouthpiece is strongly
encouraged (Level II)
• spacers recommended in certain patients especially in those on high
dose IHS (Level I)
• MDIs with spacers for children <5 (Level II)-- Metered Dose
Inhalers
• dry-powder inhalers adequate for age 5+ (Level II) -- They are dry
powder devices and do not contain a propellant.

41. Related evidences

42. Levels of evidence (based on AHCPR 1992).
Ia Evidence obtained from a meta-analysis of RCTs
Ib Evidence obtained from at least one RCT
IIa Evidence obtained from at least one well-designed,
controlled study without randomisation
IIb Evidence obtained from at least one other type of well-
designed quasi-experimental study
III Evidence obtained from well-designed, non-
experimental, descriptive studies, such as comparative
studies, correlation studies and case-control studies
IV Evidence obtained from expert committee reports or
opinions and/or clinical experience of respected authorities.

43. Related evidence 1
• Antileukotienes alone are less effective than inhaled steroids for improving lung function and
quality of life (Level of Evidence=B;
• There is not enough evidence to evaluate the benefits of influenza vaccination in patients
with asthma (Level of Evidence=D;
• Physical training in patients with asthma improves cardiopulmonary fitness but does not
change lung function (Level of Evidence=B;
• There is limited evidence that breathing exercises may be of some benefit in asthma (Level
of Evidence=C;
• Methotrexate may have a small steroid sparing effect in adults with asthma who are
dependent on oral corticosteroids (Level of Evidence=B;
• Use of cyclosporin may reduce the need of oral steroids in asthma but side effects are
common (Level of Evidence=C;
• Gold may reduce the need of steroids in asthma, but given the side effects and necessity for
monitoring the treatment cannot be recommended (Level of Evidence=C;
• Use of limited asthma education as it has been practiced does not appear to improve health
outcomes (Level of Evidence=C;

44. Related evidence 2
• There is no overall improvement of asthma following treatment of gastro-
oesophageal reflux (Level of Evidence=C;
• There is insufficient evidence to assess the benefits of different ways to organise
asthma care(Level of Evidence=D;
• Inhaled corticosteroids are as effective as a daily dose of 7.5 to 10 mg or
prednisolone, probably with fewer adverse effects (Level of Evidence=B;
• Inhaled beclomethasone has a small dose-response effect (Level of Evidence=B;
• There is no conclusive evidence of differences in relative efficacy between
beclomethasone and budesonide, although there is some data to suggest that
BUD via Turbohaler is moreeffective than BDP via either Rotahaler of
metered dose device (Level of Evidence=B;
• Doses of fluticasone in the range of 100 µg to 1000 µg are more effective than
placebo in the treatment of asthma, low doses being almost as effective as high
doses in mild-moderate asthma (Level of Evidence=A;

45. Related evidence 3
• Higher potency compounds such as fluticasone may be more effective, but
there is an excess of systemic activity with fluticasone propionate compared
with other inhaled corticosteroids when therapeutically effective doses are
compared (Level of Evidence=A;
• Nedochromil sodium is as effective as cromoglycate for exercise-induced
asthma (Level of Evidence=B;
• There is insufficient evidence to compare the effectiveness of holding
chambers versus nebulisers in chronic asthma (Level of Evidence=D;
• There are no significant differences for any important outcomes between
standard CFC containing pMDI and other devices in the delivery of beta-2
agonist for non-acute asthma (Level of Evidence=A;
• In patients under 60 years of age there is no evidence of an effect of inhaled
corticosteroids at conventional doses given for two or three years on BMD or
vertebral fractures (Level of Evidence=B;
• There is some evidence that macrolides may be beneficial in some subgroups of
asthmatic patients, but further studies are needed (Level of Evidence=D;
• There is no evidence to support the use of dehumidification for asthma
patients (Level of Evidence=D;
• lBreathing techniques including slow deep breathing, physiotherapy,
respiratory muscle strengthening, and yoga breathing exercises, are not proven
to be effective for asthma (Level of Evidence=C;

46. Follow-up
• Because asthma is a common disease it should be
mainly treated and followed up by a general
practitioner.
• A patient on medication should meet his own
doctor regularly.
• In mild cases one follow-up appointment yearly is
sufficient.
• A two-week measuring of PEF values at home is
usually sufficient as follow-up
examination,eventually complemented by a simple
spirometer examination.

47. Expectations (prognosis(
• Asthma is a disease that has no cure.
• With proper self management and medical
treatment, most people with asthma can
lead normal lives.

48. “Dyspnea of pregnancy"
• The important physiologic changes that happen
during pregnancy include some changes in the
cardiopulmonary system. Beginning in the first
trimester and continuing throughout pregnancy,
mothers experience some "dyspnea of pregnancy"
whether or not they have asthma; elevated
progesterone levels stimulate increased breathing
depth and relative hyperventilation. Additionally,
oxygen consumption is increased during
pregnancy