[email protected]. A 20 yr old lady presented with Hx of cough and dyspnea for 6 months 2 weeks...

[email protected]

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

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? Can I do NVD for termination of

pregnancy?

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

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

Asthma is a common disease Even more than diabetes mellitus

In some countries 1 out of every 4 children has asthma

Asthma affects 4 to 8% of all pregnant women

Asthma occurs more commonly in those with atopic history In themselves or Their 1st degree relatives

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

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

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

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

Well controlled asthma has favorable outcome in pregnancy

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

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

Asthma is not associated with risk of congenital malformations

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?”

In pregnant asthmatics you should confirm control by Spirometry

Monthly Peak flow metry

Twice daily Upon awakening After 12 hr

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

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

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

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

If you choose the 2nd one (controllers) You treat your patient's disease, and You can control inflammation You reduce the risk of

Asthma attack Airway remodeling in your patient

Relievers (No anti-inflammatory action) Salbutamol Atrovent Controllers (Mainly anti-inflammatory) Inhaled corticosteroids LABA cromolyn Theophylline Leukotrene antagonists

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

Safety profile of common anti-asthma drugsDrug 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

Mild intermittent

Mild persistent

Moderate persistent

Severe persistent

PRN Salbutamol

Inhaled corticoteroid

Inhaled corticoteroid + LABA

Inhaled corticoteroid + LABA

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

> 5 y Age< y < 5 y Age 5 < y < 5 y Age 5 <y 5

Drug ) Low Daily Dose) g) Medium Daily Dose) g) High Daily Dose(g

> 5 y Age < 5 y < 5 y Age < 5 y < 5 y Age < 5 y

Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide200-600 100-200

600-1000 >200-400 >1000 >400

Budesonide-Neb Inhalation Suspension

250-500

>500-1000

>1000

Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

Flunisolide500-1000 500-750

>1000-2000 >750-1250 >2000 >1250

Fluticasone100-250 100-200

>250-500 >200-500 >500 >500

Mometasone furoate200-400 100-200

> 400-800 >200-400>800-1200 >400

Triamcinolone acetonide400-1000 400-800

>1000-2000 >800-1200 >2000 >1200

Choice of drug categories in pregnancy Category Drug of choice

SABA LABA ICS

Salbutamol Salmetrol Budesonide

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

Avoidance from allergens, irritants and air pollution

Is necessary for any asthmatic pregnant woman

Allergen immunotherapy can be continued during pregnancy

But, should not be started for the 1st time in a pregnant woman

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

period. Albeit asthma is a genetic disease

Comorbid conditions in asthma Gastro-esophageal reflux disease

(GERD) Allergic rhinitis (AD)

Be suspicious to GERD if Your asthmatic patient become poorly

controllable Your asthmatic patient is worse at night Your asthmatic patient has symptoms

when lies down Patient complains of GERD symptoms

Treatment of heartburn can improve asthma symptoms

Continue anti GERD drugs for at least 2-3 months

Be suspicious to AD if Your asthmatic patient complains of

seasonal nose or sinus symptoms

Treat AD with Intranasal corticosteroids Antihistamines (2nd generation in

pregnancy) Allergen avoidance

Influenza vaccination is necessary for Pregnant women with 2nd and 3rd

trimester In cold months

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

Pco2 > 35 mmHg Po2 < 70 mm Hg

Are abnormal during pregnancy IV fluid (dextrose) initially 100

ml/hour Seated position Fetal monitoring

Dosage of glucocorticoids is not different

IV aminophylline NOT generally recommended

IV Mg sulfate may be beneficial Concomitant hypertension Preterm contraction

Respiratory infections in asthmatic patients Usually viral

If indicated in a pregnant woman I V Ceftriaxone Erythromycin

No difference PG F2 analogues should not be used

in asthmatics for termination of pregnancy

Morphine and meperidine should be avoided Fentanyl is an appropriate alternative

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 pertiprtum

bleeding, headache, should be avoided

Summary

Careful assessment and monitoring

Avoidance and controll of triggers

Maintenance rather than symptomatic therapy

Aggressive treatment of exacerbations

[email protected]. A 20 yr old lady presented with Hx of cough and dyspnea for 6 months 2 weeks...

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