Asthma in pregnancy -mainder ahuja

ASTHMA IN PREGNANCYASTHMA IN PREGNANCY

Dr.Manider Ahuja Dr.Manider Ahuja Director Ahuja Hospital and Infertility CentreDirector Ahuja Hospital and Infertility Centre

VP FOGSI 2013-2014VP FOGSI 2013-2014President IMS 2014-2015President IMS 2014-2015

17/12/1717/12/17DR.MANINDER AHUJA VP FOGSI2013-DR.MANINDER AHUJA VP FOGSI2013-20142014 11


THANKS TO PATNA CHAPTER

I BRING GREETINGS FROM HARYANA

Dr.Maninder Ahuja PRESENT

DESIGNATION:

• DIRECTOR AHUJA HOSPITAL AND INFERTILITY CENTRE• 40 yrs work for women from ADOLESCENTS TO MENOPAUSE

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CO EDITOR OF JOURNAL OF MID LIFE HEALTH PRESIDENT INDIAN MENOPAUSE SOCIETY (2014-2015)Deputy SECRETARY GENERAL OF SOUTH ASIAN FEDERATION OF

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SEVERAL CHAPTERS IN MANY TEXT BOOKS MANY DVDS ON “ PRESCRIPTION OF EXERCISE”

BEST FOGSIAN AWARD 2008, BEST PRESENTATION AWARD, BEST ROTARIAN AWARD

Co editor for Jounrnal Of Midlife Health and peer reviewer for SAFOMS Journal

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DVDs ONEXERCISE

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ASTHMA IN PREGNANCY ASTHMA IN PREGNANCY Dr.Manider Ahuja Dr.Manider Ahuja

Director Ahuja Hospital and Infertility CentreDirector Ahuja Hospital and Infertility CentreVP FOGSI 2013-2014VP FOGSI 2013-2014

President IMS 2014-2015President IMS 2014-2015


DISCUSSION WOULD BE DISCUSSION WOULD BE ONON

Risk and Risk and PrevalencePrevalence

PathophysiologyPathophysiology

D/DD/D

Examination Examination findings findings

Etiology Etiology

InvestigationsInvestigations

Chest X-rayChest X-ray

PFT PFT

PharmacologyPharmacology

Hospital careHospital care

Admissions and Admissions and discharge discharge


introductionintroductionAsthma is result of Chronic inflammattion of air ways that Asthma is result of Chronic inflammattion of air ways that

results in air way obstruction anad can be triggered by various results in air way obstruction anad can be triggered by various stimulistimuli

Most common chronic condition of pregnancyMost common chronic condition of pregnancy

Episodic,For short periods a few min to hours Episodic,For short periods a few min to hours

Prevalence in general public is 4-5% in pregnancy .1-4%Prevalence in general public is 4-5% in pregnancy .1-4%

Mortality 2 persons per 100000Mortality 2 persons per 100000

Rey E, Boulet LP. Asthma in pregnancy. BMJ. 2007 Mar 17. 334(7593):582-5. [Medline]. [Full Text].

Sly RM, O'Donnell R. Stabilization of asthma mortality. Ann Allergy Asthma Immunol. 1997 Apr. 78(4):347-54. [Medline].


TRIGGERING factors in TRIGGERING factors in Asthma Asthma

Genetic and environmentalGenetic and environmental

Allergens, including pollens, house-dust mites, cockroach antigen, animal dander, molds, and Hymenoptera stings

Irritants, including cigarette smoke, wood smoke, air pollution, strong odors, occupational dust, and chemicals

Medical conditions, including viral upper respiratory tract infections, sinusitis, esophageal reflux, andAscaris infestations

Asthma is a disease of the airways by reversible airway obstruction and hyper- reactivity to a variety of stimuli.


ALLERGENS ALLERGENS

Drugs and chemicals, including aspirin, nonsteroidal anti-inflammatory drugs, beta blockers, radiocontrast media, and sulfites

Exercise (see Exercise

Cold air,flu rhinitis

Menses

Emotional stress


Pregnancy out Pregnancy out comes in Asthma comes in Asthma


PregNANCY PregNANCY outcomes outcomes

Preeclampsia

PIH

Ut. hemorrhage

Preterm labor

Premature birth

Unplaned LSCS

Gestational Diabetes

Congenital anomalies

Fetal growth restriction

Low birth weight

Neonatal hypoglycemia, seizures, tachypnea, and neonatal intensive care unit (ICU) admission

These changes are seen only in historical studies and where corticosteroids were not used


PHYSIOLOGICAL CHANGES IN PHYSIOLOGICAL CHANGES IN RESP SYSTEM IN PREG RESP SYSTEM IN PREG

Resp rate and vital capacity no change Resp rate and vital capacity no change

Tidal volume, minute ventilation increased (40%),

Minute oxygen uptake (20%) increase,

With a resultant decrease in functional residual capacity and residual volume of air as a consequence of the elevated diaphragm.

In addition, airway conductance is increased

Total pulmonary resistance is reduced, possibly as a result of the influence of progesterone.

During pregnancy the severity of asthma remains stable in a third of women, worsens in another third, and improves in the remaining third.w7


changes IN changes IN RESPIRATORY SYSTEM IN RESPIRATORY SYSTEM IN

PREGNANCYPREGNANCYDecreased co2 pressureDecreased co2 pressure

Decreased bicarbonate Decreased bicarbonate

Increased phIncreased ph

Normal pco2 in pregnancy means respiratory failure Normal pco2 in pregnancy means respiratory failure

More effective gas exchageMore effective gas exchage

Respiratory alkalosis and hyperventilatory stage Respiratory alkalosis and hyperventilatory stage


PATHOPHYSIOLOGY Asthma PATHOPHYSIOLOGY Asthma

Inflammation of the airways, With an abnormal accumulation

of eosinophils, lymphocytes, mast cells, macrophages, dendritic cells, and myofibroblasts.

This leads to a reduction in airway diameter caused by smooth muscle contraction,

Vascular congestion, Bronchial wall edema, Thick secretions.


Asthma Asthma characteristicscharacteristics

Shortness of breath , wheezing and cough determine severity

Chest tightness

Nocturnal awakenings

Recurrent episodes of symptom complex


HISTORY AND HISTORY AND PHYSCIAL FINDINGSPHYSCIAL FINDINGS

Exacerbations possibly provoked by nonspecific stimuli

Personal or family history of other atopic disease (eg, hay fever, eczema)

Tachypnea

Retraction (sternomastoid, abdominal, pectoralis muscles)

Agitation, usually a sign of hypoxia or respiratory distress

Pulsus paradoxicus (>20 mm Hg)


PULMONARY FINDINGSPULMONARY FINDINGS

Diffuse wheezes - Long, high-pitched sounds on expiration and, occasionally, on inspiration)

Diffuse rhonchi - Short, high- or low-pitched squeaks or gurgles on inspiration and/or expiration

Bronchovesicular sounds

Expiratory phase of respiration equal to or more prominent than inspiratory phase


SIGNS OF RESP FAILURE SIGNS OF RESP FAILURE

Alteration in the level of consciousness, such as lethargy, which is a sign of respiratory acidosis and fatigue

Abdominal breathing

Inability to speak in complete sentences


Investigations Investigations

CBC-anemia, thrombocytopenia or infectionCBC-anemia, thrombocytopenia or infection

Blood gases ABG-to see oxygenation Blood gases ABG-to see oxygenation

ABG values: pH = 7.4-7.45, pO2= 95-105 mm Hg, pCO2 = 28-32 mm Hg, and bicarbonate = 18-31 mEq/L.

XRAY Chest XRAY Chest


Chest x-rayChest x-rayChest radiography is indicated

when the other coexistent conditions, such as pneumonia, barotrauma, CHF, or chronic obstructive pulmonary disease, are likely.

Chest radiographs (2 views) with a shielded maternal abdomen expose the fetus to approximately 0.00005 rad.

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SPIROMETRYSPIROMETRY

• TLC

• Total lung capacity: the volume in the lungs at maximal inflation, the sum of VC and RV.

• TV

• Tidal volume: that volume of air moved into or out of the lungs during quiet breathing

• RV

• Residual volume: the volume of

air remaining in the lungs after a

maximal exhalation

• ERV

• Expiratory reserve volume: the

maximal volume of air that can

be exhaled from the end-

expiratory position


Changes in Pulmonary funCtion Changes in Pulmonary funCtion tests in Acute Asthma tests in Acute Asthma

Decreased peak expiratory flow rate (PEFR) and forced expiratory volume in 1 second (FEV 1)

Mild reduction in the forced vital capacity (FVC)

An increased residual volume (RV), functional residual capacity (FRC), and total lung capacity (TLC)

Normal diffusing capacity

PEFR N 380-550 L/Min


• Most pregnancies are Most pregnancies are unaccompanied by unaccompanied by pulmonary pulmonary complications, complications, however pulmonary however pulmonary edema, pulmonary edema, pulmonary thromboembolism, thromboembolism, pulmonary pulmonary hypertension, and hypertension, and acute respiratory acute respiratory failurefailure can occur can occur during pregnancy. during pregnancy. These conditions can These conditions can lead to mortality and lead to mortality and hence they should be hence they should be sought and treated sought and treated appropriately.appropriately.

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MANAGEMENT IN PREGMANAGEMENT IN PREG

• Lung function of women with persistent asthma should be monitored during pregnancy, using common pulmonary function parameters such as spirometry, the peak expiratory flow rate (PEFR), and forced expiratory volume in one second (FEV1).

• If possible, first-trimester ultrasound should also be performed to assess fetal growth restriction and risk of preterm birth. Starting at 32 weeks, ultrasound exams to monitor fetal activity and growth should be considered for women with poorly controlled asthma, moderate to severe asthma, or who are recovering from a severe asthma attack.


MANAGEMENT CONT-MANAGEMENT CONT-

• Outpatient management of asthma is similar for the pregnant patient as it is for the nonpregnant patient

• . Beta-adrenergic agonists remain the mainstay of treating exacerbations and handling mild forms of asthma.

• Management algorithm for asthma in pregnancy based on fraction of exhaled nitric oxide (FENO) and symptoms significantly reduces asthma exacerbations.

• For moderate-persistent asthma, a beta-adrenergic agonist combined with an inhaled anti-inflammatory agent or inhaled corticosteroid is recommended for treatment. In severe asthma, oral corticosteroids and beta agonists are recommended.


RECOMENDATIONSRECOMENDATIONS• Management geared Management geared

towards prevention of towards prevention of chronic symptomchronic symptom

• Pt should be educated Pt should be educated how to perform accurate how to perform accurate peakflowspeakflows

• + Action plan (Nelson, + Action plan (Nelson, Gossett, &Grobman, 2010)Gossett, &Grobman, 2010)

• + Monthly assessment in all + Monthly assessment in all asthmatic women with asthmatic women with evaluation of arterial sat >95% evaluation of arterial sat >95%

• ((Ivancso, Bohacs, Eszes, Losonczy, Ivancso, Bohacs, Eszes, Losonczy, &Tamasi, 2013)&Tamasi, 2013)


Assess oxygenation by measuring the Assess oxygenation by measuring the arterial oxygen saturation of Hgbarterial oxygen saturation of Hgb

+ The proper use of a pulse oximeter can + The proper use of a pulse oximeter can ensure earlier detection of hypoxiaensure earlier detection of hypoxia

+ A normal Spo2 range is 95% to 100%+ A normal Spo2 range is 95% to 100%

Spo2 is one patient- assessment tool Spo2 is one patient- assessment tool and should be interpreted along with and should be interpreted along with

other patient data includingother patient data including+ Vital signs+ Vital signs

+ Cardiac rhythm+ Cardiac rhythm+ Breath sounds+ Breath sounds(Paragas, 2008)(Paragas, 2008)

PULSE OXIMETER (SPO2)


Inhaler errors Inhaler errors

• Prior to adding therapy or increasing dosage, inhaler technique should be assessed and corrected. Up to one-third of dry powder inhaler users make insufficient inspiratory effort, and one-fourth of metered-dose inhaler users actuate before inhalation. These mistakes and others were associated with poor asthma control in the Critical Inhaler Mistakes and Asthma Control (CRITIKAL) study

•CRITIKAL study: type, frequency, and association with asthma outcomes. J Allergy Clin Immunol Pract. 2017;5(4):1071- 1081.e9


OTHER MEDICATIONSOTHER MEDICATIONS

• The leukotriene receptor antagonists montelukast and zafirlukast are considered safe medications due to reassuring animal data

• Theophylline can be continued in pregnancy, but its use carries the added burden of monitoring to ensure that serum concentrations remain between 5 and 12 mg/mL to avoid toxicity

• Omalizumab pregnancy registry data (The Xolair Pregnancy Registry [EXPECT]) indicate no increase in major congenital malformations, but omalizumab should not be started in pregnancy due to risk of anaphylaxis


Hospital managmentHospital managment

• Prehospial care Prehospial care

• Prior to arriving at the ED, address the patient’s airway status as needed. Provide early institution of beta-agonist inhalational therapy. Provide supplemental oxygen.


In the In the emergencydepartment emergencydepartment


Indications for Indications for admission admission

• As always in the ED, address the ABCs. The patient should be placed on a cardiac monitor and pulse oximetry. The threshold of intubation should be low to prevent/limit hypoxic episodes to the fetus. Intubate and mechanically ventilate patients who are in or near respiratory arrest and patients who do not respond to treatment


Indications for Indications for intubation intubation

• Hypoxemia despite supplemental oxygen

• Increasing carbon dioxide retention

• Persistent/worsening level of consciousness

• Hemodynamic instability

• The key to treating asthma in the pregnant patient is to frequently assess the patient, the severity of the attack, and the response to treatment.


Warning signs of severe Warning signs of severe exacerbationexacerbation

• Hypoxia, acidosis, unequal breath sounds, pneumothorax, and atypical features serve as warning signs of severe exacerbations.

• Inhaled beta2-agonists are the mainstay of treatment. The beta2-agonist, inhaled and/or subcutaneous, is typically given in 3 doses over 60-90 minutes.

• Beta-adrenergic blocking agents should be avoided owing to bronchospastic effect

• Tranquilizers and sedatives should be avoided because of their respiratory depressant effect. Antihistamines are not useful in the treatment of asthma. Mucolytic agents increase bronchospasm.


Ventilator damageVentilator damage

• Asthmatic patients have higher complication rates from mechanical ventilation. Increased airway resistance may result in extremely high peak airway pressures, barotraumas, and hemodynamic impairment. Mucous plugging is common, increasing airway resistance, atelectasis, and the incidence of secondary pneumonia. Paradoxical increases in bronchospasm may occur from aggravation by the endotracheal tube.


Criteria for hospital admissionCriteria for hospital admission

• Inadequate response to ED therapy

• pO 2 less than 70 mm Hg

• Signs of fetal distress (eg, decreased movement, abnormal cardio tocodynamometry, uterine contractions)

• Multiple medication use (ie, requiring 3 or more medications simultaneously)

• A protracted course with poor response to outpatient therapy thus far instituted or a history of severe asthma requiring intubation or ICU admission

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Criteria for icuCriteria for icu

• Altered level of consciousness

• Poor air flow

• Signs of fatigue, a downhill course, or a need for mechanical ventilation

• PEFR/FEV 1 less than 25% of predicted or pCO 2greater than 35 mm Hg


Criteria for discharge Criteria for discharge • Greatly improved symptoms and physical examination findings

• Ability of the patient to walk out of the ED without obvious distress

• PEFR/FEV 1 greater than 70% baseline

• No fetal distress

• Good follow-up and access to ED in case of relapse

• A follow-up appointment 2-4 days following the ED visit is recommended. Consider referral to an asthma specialist; in addition, involvement of a multidisciplinary team

• Guideline] American College of Obstetricians and Gynecologists (ACOG). Asthma in pregnancy. ACOG practice bulletin; no. 90. Washington (DC): American College of Obstetricians and Gynecologists (ACOG). 2008 Feb. [Full Text].


Ventilator settingsVentilator settings

• Decrease the ratio of the duration of inspiration to the duration of expiration (I:E ratio), and set a low respiratory rate to allow for adequate expiration.


Management of Acute Asthma Management of Acute Asthma in Pregnancy in Pregnancy

Intervene rapidly

Closely monitor the woman and assess fetal wellbeing continuously

Maintain oxygen saturation >95%

Avoid PaCO2 >40 mm Hg

Place woman in a left lateral position


ContinuedContinued

Provide ample hydration with intravenous fluid (isotonic saline 125 ml/h) if drinking is impossible

Avoid hypotension with adequate position, hydration, and treatment

Use adrenaline (epinephrine) only in the context of an anaphylactic reaction

Consider intubation earlier than usual and call an expert if intubation is required as it can be more difficult in pregnant women owing to the oedema of the oropharyngeal mucosa


Management of Management of acute exacerbationacute exacerbation

Beta2-agonist bronchodilation with one of the following:

• Albuterol MDI 4-8 puffs every 20 min up to 1 h, then every 1 to 4 hrs as needed

• Albuterol 0.083% 2.5-5 mg nebulized every 20 min for 3 doses, then every 1 to 4 h as needed

• Cont nebulization 10-15mg /hr

• Anticholinergics added to beta2-agonist therapy


Cont ---Cont ---

• Ipratropium bromide/Anticholinergic nebulized 0.5 mg every 20 minutes for 3 doses, then as needed, given simultaneously with albuterol

• Oxygen

• Fetal Monitoring

• Oral or I/V Hydrations


Cont –Cont –glucocorticoidsglucocorticoids

• Systemic Gluco corticosteroids if pt was already on CS

• Mild exacerbation that can be managed safely at home: oral prednisone 40 to 60 mg/d for 3 to 10 day

• Hospitalisation till PEF is 70% of predicted

• Critically ill: high-dose IV methylprednisolone 120-180 mg/d in three or four divided doses for 48 h, then 60-80 mg/d, tapered as patient improves


Cont –adjuNct Cont –adjuNct therapies therapies

• Adjunct therapies for patients poorly responsive to the above:

• Magnesium sulfate 2 g IV over 20 minutes. Assess baseline serum magnesium level if renal insufficiency present

• Terbutaline 0.25 mg subcutaneous every 20 min for up to three doses

• Plan early and expert intubation and mechanical ventilation for patients in severe distress poorly responsive to the above, or who exhibit arterial pH < 7.35, arterial PCO2 above the normal pregnancy range of 28-32 mm Hg, or arterial PO2 < 70


Cont -– monitor Cont -– monitor ventilation ventilation

• Titrate ventilation to achieve normal pH, normal pregnancy PCO2 of 28-32 mm Hg, and normal PO2. If hyperinflation does not permit titration to normal pregnancy PCO2, hypercapnia may be tolerated.

• For patients who fail the aforementioned ventilator strategies and maximum pharmacologic treatments, extracorporeal membrane oxygenation (ECMO) has been described in nonpregnant patients with asthma91 and in one case report of a pregnant woman with asthma.


ACOG Guidelines ACOG Guidelines -2008-2008

• Pregnant asthmatic women should continue to use their asthma medication in the lowest dose possible to manage symptoms during pregnancy, according to a new Practice Bulletin released by The American College of Obstetricians and Gynecologists (ACOG). Women with moderate or severe asthma should also be monitored throughout pregnancy for fetal growth restriction and signs of preterm birth.


Anti Asthma MedicationsAnti Asthma Medications

Almost all antiasthma drugs are safe to use in pregnancy and during breastfeeding.

In fact, undertreatment of the pregnant patient is a frequent occurrence, because such patients are worried about medication effects on the fetus.

Rey E, Boulet LP. Asthma in pregnancy. BMJ. 2007 Mar 17. 334(7593):582-5. [Medline]. [Full Text].

Powell H, Murphy VE, Taylor DR, et al. Management of asthma in pregnancy guided by measurement of fraction of exhaled nitric oxide: a double-blind, randomised controlled trial. Lancet. 2011 Sep 10. 378(9795):983-90. [Medline].


SYSTEMIC CORTICOSTEROIDSSYSTEMIC CORTICOSTEROIDS

• BECAUSE SEVERE, BECAUSE SEVERE, UNCONTROLLED ASTHMA UNCONTROLLED ASTHMA IS ASSOCIATED WITH IS ASSOCIATED WITH MATERNAL/FETAL DEATH, MATERNAL/FETAL DEATH, THE USE OF SYSTEMIC THE USE OF SYSTEMIC CORTICOSTEROIDS CORTICOSTEROIDS ALTHOUGH RISKY, IS ALTHOUGH RISKY, IS JUSTIFIED WHEN SEVERE JUSTIFIED WHEN SEVERE ASTHMA CANNOT BE ASTHMA CANNOT BE CONTROLLED BY OTHER CONTROLLED BY OTHER MEANSMEANS


Medications during Medications during LabourLabour

Continue medications and give short acting β2 agonists or corticosteroids, or both, if asthma is not well controlled

Provide ample hydration with intravenous fluid

Evaluate pulmonary status and oxygen saturation on admission, and later as needed


Management in Management in LabourLabour

Favour epidural to provide pain relief (which decreases bronchospasm) and to reduce oxygen consumption and minute ventilation

Stress dose of corticosteroids (such as 50-75 mg a day of hydrocortisone equivalent for one to two days if systemic corticosteroids have been taken within previous months

Avoid bronchoconstrictor agents for management of abortion or labour (such as prostaglandin F2 ) or for αpostpartum haemorrhage (such as ergonovine, methylergonovine (neither is licensed in the UK), and carboprost)


Asthma and Post PartumAsthma and Post Partum

The postpartum period is not associated with an increased rate of asthma exacerbations.

In women who experienced a change of severity during pregnancy, the severity reverts to pre-pregnancy level within three months after the birth

Irritability or sleepiness have been reported in the breastfed neonates of women taking theophylline and antihistamines.

Non-steroidal anti-inflammatory drugs should be avoided in women intolerant to aspirin.

Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. Seventh ed. Philadelphia: 2005.


ASTHMA… ALMOST ALWAYS ASSOCIATED WITH ASTHMA… ALMOST ALWAYS ASSOCIATED WITH NASAL DISEASE.NASAL DISEASE.

• Treatment of the upper airway should improve asthma for a variety of reasons

• Mechanisms linking the development or exacerbation of asthma in individuals with upper airway disease may be multifactorial

• (Ledford &Lockey, 2013).

RELEASE OF SYSTEMIC IMMUNE MEDIATORS FROM THE UPPER

• AIRWAY, DRAINAGE OF• INFLAMMATORY MEDIATORS FROM

THE UPPER AIRWAY INTOTHE LOWER AIRWAY

• + NEUROGENIC RESPONSES RESULTING IN MORE GENERALIZED

• AIRWAY INFLAMMATION OR• COMMON INHALANT MECHANISMS

WITH ALLERGENS CAUSING INFLAMMATION INITIALLY INTHE UPPER AIRWAY FOLLOWED BY THE LOWER AIRWAY INVOLVEMENT.


For rhinitis For rhinitis

• Leukotriene receptor antagonists such as montelukast are generally accepted as safe.

• Intranasal antihistamines or oral second-generation antihistamines, including cetirizine or loratadine, are also considered safe.61 Local vasoconstriction with oxymetazoline can be used, at usual dosing for # 3 days to avoid rebound rhinitis.

• However, oral decongestants such as pseudoephedrine and phenylephrine should be avoided, especially in early pregnancy, as their systemic vasoconstriction has teratogenic effects.


FACT SHEET FACT SHEET • Samita is a 36 years old woman currently in her 26th week of

pregnancy with a history of allergic rhinitis and seasonal allergies who appeared more tired for the past month and has shown progressive shortness of breath and wheezing for the past couple of weeks.

• During a recent doctors visit, her primary care physician prescribed an albuterol asthma pump which she didn’t use due to fear to harm the baby.

• A week later she returned to the same doctor who in turn prescribed an albuterol nebulizer treatment along with a nebulizer machine and some prednisone pills in case her shortness of breath got worst.

• Because of fear to harm the baby Jenny decided to use the nebulizer treatment and asthma pump and avoid the prednisone at all costs.


PREGNANT WOMAN MAY OFTEN WORRY ABOUT EFFECTS OF THEIR ASTHMA PREGNANT WOMAN MAY OFTEN WORRY ABOUT EFFECTS OF THEIR ASTHMA MEDICATIONS, AND MAY DISCONTINUE THEM INAPPROPRIATELY…MEDICATIONS, AND MAY DISCONTINUE THEM INAPPROPRIATELY…””

((NELSON, GOSSETT, &GROBMAN, NELSON, GOSSETT, &GROBMAN, 2010)2010)

• Short-acting beta-agonists for Short-acting beta-agonists for immediate relief of asthma immediate relief of asthma symptoms during pregnancy symptoms during pregnancy is generally regarded as is generally regarded as being safe being safe (Ulrik&Gregersen, 2013)(Ulrik&Gregersen, 2013)

• Inhaled corticosteroids are Inhaled corticosteroids are the mainstay of controller the mainstay of controller therapy during pregnancy. therapy during pregnancy. ICS(Namazy&ICS(Namazy&

• Schatz, 2011)Schatz, 2011)

• Budesonide is Budesonide is considered the considered the preferred ICS for preferred ICS for asthma during asthma during pregnancypregnancy

• Most medications used Most medications used for asthma for asthma for asthma for asthma treatment outside of treatment outside of pregnancy are also not pregnancy are also not contraindicated during contraindicated during pregnancypregnancy (Nelson, Gossett, (Nelson, Gossett, &Grobman, 2010&Grobman, 2010


Co morbidities aggaravating Co morbidities aggaravating asthmaasthma

• Sinusitis and Reflux are relatively common Sinusitis and Reflux are relatively common comorbiditiescomorbidities during pregnancy that may during pregnancy that may exacerbate asthma.exacerbate asthma.

• Pregnancy may be complicated by new-onset Pregnancy may be complicated by new-onset or preexisting rhinitis, or asthma.or preexisting rhinitis, or asthma.

• + + Rhinitis is a very common problem that may Rhinitis is a very common problem that may occur during pregnancy. In the past, rhinitis occur during pregnancy. In the past, rhinitis and asthma may have been treated as and asthma may have been treated as separate disorders.separate disorders.

• + + The United Airway Disease Hypothesis proposes that upper and lower The United Airway Disease Hypothesis proposes that upper and lower airway disease are both manifestations of a single inflammatory process.airway disease are both manifestations of a single inflammatory process.

• (Namazy& Schatz, 2011(Namazy& Schatz, 2011


MMAJOR GOAL OF CHRONIC ASTHMA MANAGEMENT IS AJOR GOAL OF CHRONIC ASTHMA MANAGEMENT IS THE PREVENTION OF EXACERBATIONTHE PREVENTION OF EXACERBATION

• Pharmacologic approach:Pharmacologic approach:• + + Inhaled Beta2-agonist (Albuterol)Inhaled Beta2-agonist (Albuterol)• + + Inhaled Corticosteroids (Budesonide)Inhaled Corticosteroids (Budesonide)• + + Alternative add-on medication (long-acting beta2-Alternative add-on medication (long-acting beta2-

agonist, cromolyn,agonist, cromolyn,

• leukotriene inhibitor, theophyline)leukotriene inhibitor, theophyline)• (National Guideline Clearinghouse, 2012)(National Guideline Clearinghouse, 2012)• + + Acute managementAcute management• + + Pharmacologic approach / step therapyPharmacologic approach / step therapy• + + Fetal monitoring / maternal monitoring.Fetal monitoring / maternal monitoring.• + + Supplemental O2 to maintain PO2 > 70 and O2 sat Supplemental O2 to maintain PO2 > 70 and O2 sat

>95% by pulseoximetry.>95% by pulseoximetry.• + + IV fluids at rate of 100ml/hour with glucose if pt not IV fluids at rate of 100ml/hour with glucose if pt not

hyperglycemic.hyperglycemic. 17/12/1717/12/17DR.MANINDER AHUJA VP FOGSI2013-DR.MANINDER AHUJA VP FOGSI2013-20142014 6363

Special considerations in Special considerations in Preg with Asthma Preg with Asthma

• Ensure optimal asthma control

• Manage asthma exacerbations aggressively

• Avoid delay in diagnosis and treatment

• Assess medication needs and response to therapy frequently

• Ensure adequate patient education and acquisition of self management skills

• Treat rhinitis, gastric reflux, and other comorbidities adequately

Encourage smoking cessation

Assess pulmonary function (expiratory flow) with spirometry at least monthly

Offer a multidisciplinary team approach

Do not give flu vaccination until after 12 weeks of pregnancy

Be aware of the risk of pre-eclampsia and intrauterine growth retardation


Conclusions Conclusions

Asthma may be influenced by pregnancy, but the outcome and prognosis of most asthmatic mothers and their newborn infants are usually favourable, particularly if the women's asthma is well controlled in pregnancy.

Exacerbations should be prevented by optimal asthma management,

Treatment should be started before pregnancy to educate and prevent exacerbation in preg so that asthma does not become transgeneration


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Asthma in pregnancy -mainder ahuja

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