HOW TO RELIEVE ASTHMA DURING PREGNANCY SRI SULISTYOWATI FETOMATERNAL DIVISION OB/GYN DEPARTMENT SEBELAS MARET UNIVERSITY/DR. MOEWARDI HOSPITAL SOLO
Feb 23, 2016
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