HOW TO RELIEVE ASTHMA DURING

PREGNANCYSRI SULISTYOWATI

FETOMATERNAL DIVISION OB/GYN DEPARTMENTSEBELAS MARET UNIVERSITY/DR. MOEWARDI HOSPITAL

SOLO

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 Allergens affect to my asthma? How does asthma affect to my fetus? Is my child more prone to asthma? What should I do in the case of asthma

attack? Can I do NVD or C- Section for termination

of pregnancy?

INTRODUCTION

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

IS IT REALLY ASTHMA?

Is it really asthma?

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

Is it really asthma?

WheezingDyspneaChest tightnessUse of accessory respiratory muscleCentral or peripheral cyanosisTachycardiaProlonged expiration

Clinical Presentation

of Asthma

Asthma affects 4 to 8% of all pregnant womenPrevalence of asthma appears to be increasing in pregnant women

0.2% of pregnancies will be complicated by status asthmaticus

WHY ME ? I HAD NO FAMILY HISTORY

Asthma occurs more commonly in those with atopic history In themselves or Their’s family history

A person with allergic rhinitis has 5 times more chance of asthma

WHY ME ? I HAD NO FAMILY HISTORY

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

WHY ME ? I HAD NO FAMILY HISTORY

No evidence to suggest that pregnancy has a predictable effect on underlying asthma

Pregnant women have different courses of their asthma 1/3 aggravate 1/3 improve 1/3 does not change

EFFECT OF PREGNANCY ON

ASHTMA

The most common cause of asthma exacerbation Discontinuation of drugs Viral infections

Well controlled asthma has favorable outcome in pregnancy

EFFECT OF PREGNANCY ON

ASHTMA

Poor controlled asthma has been associated with 15 to 20 % increase in Preterm delivery Preeclampsia Growth retardation Need for C-Section Maternal morbidity Maternal mortality

EFFECT OF ASHTMA ON PREGNANCY

These risks are increased 30 to 100 % those with more severe asthma

Asthma is not associated with risk of congenital malformations

EFFECT OF ASHTMA ON PREGNANCY

Asthma historySeverity of symptomsNocturnal symptoms

Pregnant patients with mild well controlled asthma may receive routine

prenatal careModerate and Severe asthma will need

more frequent visits and consider referral in severe cases

Antenatal Management

No (or minimal) daytime symptoms No limitations of activity No nocturnal symptoms No (or minimal) need for rescue

medication Normal lung function No exacerbations

What is “well control?”

To Asthma/ Allergy subspecialistDiagnosis is severe, persistent asthmaDiagnosis is unclearMore complete allergy evaluation is

desiredAsthma is not under control even after

appropriate avoidance measures are taken and medications have been

adjusted and redirectedLife threatening exacerbation

Referral Indication

Ultimate goal is prevention of hypoxic episodes to mother and fetus

Relies on four componentsObjective measures for accurate

monitoringMinimizing asthma triggersPatient educationPharmacologic therapy

Management

In pregnant asthmatics you should confirm control by Spirometry

Monthly Peak flow metry

Twice daily Upon awakening After 12 hr

Management

Objective Measures for Accurate Monitoring

FEV1 is best single measure of pulmonary function but requires a

spirometerPEFR correlates well with FEV1 and

is inexpensive as it is measured by peak flow

Self-monitoring of PEFR aids in detecting early signs of

deterioration in lung function

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

Objective Measures for Accurate Monitoring

Minimizing Asthma TriggersUse plastic mattress and pillow coversWeekly washing of bedding in hot waterAnimal dander control

Weekly bathing of the pet Keeping pets out of the bedroom Remove pet from the home

Cockroach controlHardwood flooring Avoid tobacco smokeInhibit mite and mold growth by reducing

humidityDo not be present when home is vacuumed

Understanding that asthma control is important to fetal well

beingReduction of triggersUnderstanding of basic medical

management including self monitoring

Patient Education

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

Can my asthma be cured?

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

Can Allergens affect to my

asthma?

Avoidance from allergens, irritants and air pollution

Is necessary for any asthmatic pregnant woman

Can Allergens affect to my

asthma?

Alergent Immunoteraphy can be continued during pregnancy

But should not be started for the first time in pregnant

women

Can Allergens affect to my

asthma?

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

How about theraphy for

asthma in pregnancy?

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

How about theraphy for

asthma in pregnancy?

If you choose the 2nd one (controllers) You treat your patient's disease, and

You can control inflammation You reduce the risk of Asthma attackAirway remodeling in your patient

How about theraphy for

asthma in pregnancy?

Relievers (No anti-inflammatory action) Salbutamol Atrovent

Controllers (Mainly anti-inflammatory) Inhaled corticosteroids LABA cromolyn Theophylline Leukotrene antagonists

How about theraphy for

asthma in pregnancy?

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

How about theraphy for

asthma in pregnancy?

Safety profile of common anti-asthma drugs

Drug Safety Salbutamol Inhaled

corticosteroids Cromolyn Theophylline

Safe, inhaler (labor) Category B, Budesonide Safe 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 Adrenaline Systemic steroids

Atroent Leukotrene

antagonists

Not reassuring Not for asthma Pre-eclampsia, GDM Prematurity, LBW Safe Ziluten not assessed Zafirleukast,

monteleukast probably safe

Safety profile of common anti-asthma drugs

Asthma Severity Treatment Mild intermittent

Mild persistent

Moderate persistent

Severe persistent

PRN Salbutamol

Inhaled corticosteroid

Inhaled corticosteroid + LABA

Inhaled corticosteroid + LABA

Anti-asthma drugs Treatment

Choice of drug categories in pregnancy

Category Drug of choice SABA (Short Acting β

Agonist)

LABA (Long Acting β Agonist)

Inhaled Corticosteroid

Salbutamol

Salmetrol

Budesonide

There is no association to mother asthma during fetal period and development of asthma in

childhood period. Asthma is a genetic disease

Is my child more prone to asthma?

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

What should I do in the case of asthma attack?

Pco2 > 35 mmHg fluid (dextrose) initially 100

ml/hour Seated position Fetal monitoring

What should I do in the case of asthma attack?

Dosage of glucocorticoids is not different

IV aminophylline NOT generally recommended

IV Mg sulfate may be beneficial Concomitant hypertension Preterm contraction

What should I do in the case of asthma attack?

Respiratory infections in asthmatic patients Usually viral

If indicated in a pregnant woman I V Ceftriaxone Erythromycin

What should I do in the case of asthma attack?

No difference PG F2 analogues should not be

used in asthmatics for termination of pregnancy

Morphine and Eperidine should be avoided Fentanyl is an appropriate alternative

Labor: Sectio Caesarian or Vaginal Delivery?

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 peripartum

bleeding, headache, should be avoided

Labor: Sectio Caesarian or Vaginal Delivery?

Summary Careful assessment and

monitoring Avoidance and controll

of triggers Maintenance rather

than symptomatic therapy

Aggressive treatment of exacerbations

THANK YOU