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05/19/2024
Asthma • Asthma is the commonest chronic medical illness • Affecting up to 7% of women of childbearing age • It is often undiagnosed and when recognized, may be undertreated.
05/19/2024 Signs • Signs are often absent unless seen during an acute attack. Increased respiratory rate Inability to complete sentences Wheeze Use of accessory muscles Tachycardia
05/19/2024 05/19/2024 Pathogenesis
• Reversible bronchoconstriction is caused by the following:
Smooth muscle spasm in the airway walls
Inflammation with swelling and excessive production of mucus
05/19/2024 05/19/2024 05/19/2024 Diagnosis
•A hallmark of asthma is variability and reversibility of the
bronchoconstriction.
• The degree of bronchoconstriction is measured with PEFR or more
preferably spirometry to measure FEV1 and forced vital capacity(FVC).
• A typical feature is morning ‘dipping; in the peak flow.a > 20% diurnal variation in PEFR for 3 or more days a week during 2 week PEFR diary is diagnostic. 05/19/2024 Other diagnostic features
• Greater than 15% improvement in FEV1 following inhalation of beta-
sympathomimetic bronchodilator.
• A greater than 15% fall in FEV 1 following 6 minutes of exercise
• Fractional concentration of expired nitric oxide is raised in
allergic/eosinophilia asthma.
05/19/2024 Effect of pregnancy on asthma • Asthma may improve, deteriorate or remain unchanged during pregnancy. • Women with only mild disease are unlikely to experience problems • Severe asthma are at a greater risk of deterioration, particularly late in pregnancy.
05/19/2024 Effect of pregnancy on asthma
• Acute asthma in labour is unlikely because of increased endogenous
steroids at this time.
• Deterioration in disease control is commonly caused by reduction or
even complete cerssation of medications due to fear about its safety.
05/19/2024 Effect of asthma on pregnancy
• There are no adverse effects on pregnancy outcome.
• Poorly controlled asthma, associated with chronic or intermittent
maternal hypoxiaemia, may adversely effect the fetus.
05/19/2024 Effect of asthma on pregnancy • Some associations exit between maternal asthma and the followings; Pregnancy induced hypertension/ pre-eclampsia Preterm birth and preterm labour Low birth weight infants Fetal growth restrictions(FGR) Neonatal morbidity, for example: o Transient tachypnoea of newborn o Neonatal hypoglycemia o Neonatal seizures o Admission to the neonatal intensive care unit
05/19/2024 05/19/2024 Management • Women should be advised that their asthma is unlikely to adversely affect their pregnancy. • Emphasis in the management of asthma is the prevention, rather than treatment. • Complete control is defined as the absence of daytime symptoms, night time awakening due to asthma, need for rescue medication, exercebations and limitations on activity including exercise, and normal FFEV1 or PEFR > 80% predicted.
05/19/2024 Management • Mild intermittent asthma is managed with inhaled short-acting “reliever” (β2-agonist) medication as required ( step 1). • If usage of a ‘reliever’ (β2-agonist) inhaler exceeds three times per week, regular inhaled anti-inflammatory medication with a steroid ‘preventer’ (e.g. beclomethasone) inhaler [400 µg/day] should be commenced (step 2). • The next step in therapy is either the addition of a long-acting ‘reliever’ β2-agonist (LABA) e.g. salmeterol, or an increase in the dose of inhaled steroid (800 µg/ day) (step 3)
05/19/2024 Management • Further steps involve a trial of additional therapies e.g. leukotriene receptor antagonist (see later), slow-release oral theophylline or oral β2-agonist. Alternatively, the dose of inhaled steroid can be increased to 2000 µg/day (step 4). • If these measures fail to achieve adequate control, then continuous or frequent use of oral steroids becomes necessary. The lowest dose providing adequate control should be used, if necessary with steroid sparing agents (step 5).
05/19/2024 Management • Educate women with asthma – Women should be advised to stop smoking. – Explanation and reassurance regarding the importance and safety of regular medication in pregnancy is essential to ensure compliance. – Women with asthma should be encouraged to avoid known trigger factors. – Home peak flow monitoring and written personalized self-management plans should be encouraged. – Use of a large volume spacer may improve drug delivery and is recommended with high doses of inhaled steroid. – Women should be counselled about indications for an increase in inhaled steroid dosage and if appropriate given an ‘emergency’ supply of oral steroids.
05/19/2024 Management
• The treatment of asthma in pregnancy is essentially no different from
the treatment of asthma in non-pregnant women. All the drugs in widespread use to treat asthma, including systemic steroids, are safe in pregnancy and during lactation
05/19/2024 Medication β2-Agonists
• β2-Agonists from the systemic circulation cross the placenta rapidly,
but very little of a given inhaled dose reaches the lungs and only a minute fraction of this reaches the systemic circulation.
05/19/2024 Medication
• Studies show no difference in perinatal mortality, congenital
malformations, birthweight, Apgar scores or delivery complications when pregnant women with asthma treated with inhaled β2-agonists are compared with women with asthma not using β2-agonists and non- asthmatic controls
• LABA e.g. salmeterol (Serevent®), are also safe in pregnancy.
05/19/2024 Corticosteroids • Use of both inhaled and oral steroids is safe in pregnancy. • Fluticasone propionate (Flixotide®) is a longer acting inhaled corticosteroid that may be used for those requiring high doses of inhaled steroids. • Combination inhalers of corticosteroids plus LABA, for example, budesonide/ formoterol (Symbicort®) and fluticasone/salmeterol (Seretide®), are widely available and may aid compliance.
05/19/2024 Corticosteroids
• Prednisolone is metabolized by the placenta, and very little (10%)
active drug reaches the fetus.
• There is no evidence of an increased risk of miscarriage, stillbirth,
other congenital malformations or neonatal death attributable to maternal steroid therapy.
05/19/2024 Corticosteroids
• Long-term, high-dose steroids may increase the risk of preterm rupture
of the membranes.
• Oral steroids will increase the risk of infection, gestational diabetes
and cause deterioration in blood glucose control in women with established diabetes in pregnancy. Blood glucose should be checked regularly.
05/19/2024 Corticosteroids
• The development of hyperglycaemia is not an indication to
discontinue or decrease the dose of oral steroids.
• Oral steroids for medical disorders in the mother should not be
withheld because of pregnancy.
05/19/2024 Leukotriene receptor antagonists
• These agents (e.g. montelukast and zafirlukast) block the effects of
cysteinyl leukotrienes in the airways.
• Studies do not suggest any increased risk of congenital malformations
or other adverse outcomes with their use in pregnancy.
05/19/2024 05/19/2024 Acute severe asthma
• Acute severe attacks of asthma are dangerous and should be
vigorously managed in hospital.
• The treatment is no different from the emergency management of
acute severe asthma in the non-pregnant patient.
05/19/2024 Acute severe asthma
• The features of acute severe asthma are:
– PEFR 33%–50% best/predicted
– Respiratory rate >25/min – Heart rate >110/min – Inability to complete sentences in one breath
05/19/2024 Management • – High flow oxygen. • – β2-agonists (e.g. salbutamol 5 mg) administered via a nebulizer driven by oxygen. • β2-agonists can be administered by repeated activations of a metered dose inhaler via an appropriate large-volume spacer. • Repeated doses or continuous nebulization (salbutamol 5–10 mg/h) may be indicated for those with a poor response.
05/19/2024 Management • – Nebulized ipratropium bromide (0.5 mg 4–6 hourly) should be added for severe or poorly responding asthma. • – Corticosteroids (intravenous [i.v.] [hydrocortisone 100 mg] and/or oral [40– 50 mg prednisolone for at least 5 days]). • – IV rehydration is often appropriate. • – Chest x-ray (CXR) should be performed if there is any clinical suspicion of pneumonia or pneumothorax, or if the woman fails to improve.
• Management of life-threatening or acute severe asthma that fails to
respond should involve consultation with the critical care team and consideration should be given to • – i.v. β2-agonists • – i.v. magnesium sulphate 1.2–2 g infusion over 20 minutes.
05/19/2024 Intrapartum management
• Asthma attacks in labour are exceedingly rare because of endogenous
steroid production.
• Women receiving oral steroids (prednisolone >5 mg/day for >3 weeks prior to delivery) should receive parenteral hydrocortisone (50–100 mg three or four times/day) to cover the stress of labour, and until oral medication is restarted.
05/19/2024 Intrapartum management
• Prostaglandin E2, used to induce labour, to ripen the cervix, and
prostaglandin E1 (misoprostol) for termination of pregnancy or for treatment or prevention of postpartum haemorrhage, are bronchodilators and are safe to use.
• The use of prostaglandin F2α to treat life-threatening postpartum
haemorrhage may be unavoidable, but it can cause bronchospasm and should be used with caution in women with asthma. 05/19/2024 Intrapartum management
• All forms of pain relief in labour, including epidural analgesia and
Entonox can be used safely by women with asthma, although in the unlikely event of an acute severe asthmatic attack, opiates for pain relief should only be used with extreme caution. Regional, rather than general anaesthesia, is preferable because of the decreased risk of chest infection and atelectasis.
• Ergometrine has been reported to cause bronchospasm.
05/19/2024 Conclusion
• Pregnancy itself does not usually influence the severity of asthma. ]
• For the majority of women, asthma has no adverse effect on
pregnancy outcome, and women should be reassured accordingly.
• Poorly controlled severe asthma presents more of a risk to the
pregnancy than the medication used to prevent or treat it. This small risk is minimized with good control. 05/19/2024 Conclusion
• Education and reassurance, ideally prior to pregnancy, concerning the safety of
asthma medications during pregnancy are integral parts of management.
• Decreasing or stopping inhaled anti-inflammatory therapy during pregnancy is
a frequent cause of potentially dangerous deterioration in disease control.
• Inhaled, oral and i.v. steroids and inhaled, nebulized and i.v. β2-agonists are safe to use in pregnancy and while breastfeeding.
05/19/2024 Conclusion
• Treatment of asthma in pregnancy differs little from the management
in the non-pregnant patient. Effective control of the disease process and its accompanying symptoms is a priority.
• An increase in the dose or frequency of inhaled steroids should be the
first step if symptoms are not optimally controlled on the current dose of inhaled steroids and the inhaler technique is good.
