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Asthma and Pregnancy
Pregnant women with asthma are not necessarily ‘high risk’ patients. In
fact, asthma can follow a curious pattern in
pregnant patients. One third of women experience no change in their asthma
during pregnancy, one third actually notice an improvement when they are
pregnant, and one third may experience a flare-up of their asthma during this
time. Since there is no index to predict which way a patient will react, it is
necessary to closely follow every pregnant asthma patient.
Most people are well aware of the myriad changes a body goes through during
pregnancy – even the lungs go through interesting and intelligent alterations to
adapt to the developing baby. In fact, one of the most confounding aspects of
taking care of a pregnant patient is that it is normal for her to be short of
breath. This makes it difficult to discern a ‘normal’ breathlessness from a
problem that requires medication.
The Pregnant Body
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woman’s body adjusts gradually as the pregnancy develops. Since a pregnant
patient is carrying more weight, the lungs need to accommodate to the additional
work of breathing caused by the weight gain. A pregnant woman breathes a little
faster than normal, which is perfectly healthy. The body is raising what is
called the minute ventilation.
 As
the belly grows, it alters the shape of the bottom part of the chest. The chest
is separated from the belly by a swathe of muscle called the diaphragm, which is
a vital muscle that helps you to breathe. As the belly gains in girth, it pushes
upwards against the diaphragm, preventing deep breaths and consequently
increasing the respiratory rate. To make the chest a little bigger, the ribs
splay outwards like bucket handles, letting the patient breathe a little deeper.
Remember, just because you have asthma does not mean that your
baby will too – in fact, it’s more likely that he will not. You
should be able to use your usual medications now that the baby is
born, but always check with your doctor. Not only is it safe for the
baby to breast-feed, breast-feeding is also beneficial to your
newborn baby’s immune system. As your body recovers from the
pregnancy and all the changes that happened in the lungs and chest
normalize, your breathing will return to normal.
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Can pregnancy ever trigger asthma for the first time?
Some women develop asthma for the first time during pregnancy. In some of the
women who appear to have asthma for the first time, if you go into some detail
in the medical history, you find that they probably had some previous asthma, it
just was very mild or very intermittent, so it wasn't noticed until now because
the pregnancy seemed to make it worse.
Also, about a third of people with asthma may get worse during pregnancy and
anywhere from a quarter to a third may find their asthma gets better during
pregnancy. These changes that occur during pregnancy revert most of the time
after delivery, or at least within the three months postpartum. So it does
appear that it was really the pregnancy that did it.
Warning Symptoms
Asthma warning symptoms are the same when you are pregnant as when you are
not. If you notice any of the following, visit your doctor immediately:
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You are finding your usual tasks increasingly difficult because of your
breathing.
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You find yourself reaching for your inhaler more than you are used to.
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You are awakened by coughing at night.
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You hear yourself wheeze on the telephone.
The main message here is – do not ignore symptoms, and talk with your doctor
about any changes in your breathing. Your doctor may recommend a peak flow
meter. This simple device measures airflow when you blow into it, and can be an
important tool for monitoring asthma. Talk to your doctor about whether it is
right for you.
Women with poorly treated asthma who are pregnant are at
increased risk of suffering from uterine hemorrhage and vaginal
bleeding. But the most frequent complication for the mother is a
condition that can lead to premature delivery, or the need to induce
delivery, sometimes before the fetus is viable.
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Risks to the mother or poorly-treated asthma during pregnancy
The risks include :
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pre-eclampsia - which is a condition of rapidly progressing high blood
pressure, and swelling from the retention of fluid.
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Also, women with asthma can have severe asthma attacks during pregnancy,
which can result in adverse outcomes for the baby. Complications for the
baby may include an increased risk of premature birth, low birth weight, and
stillbirth
Guidelines For Prescribing Newer Asthma Drugs During Pregnancy
A joint committee of the American College of Obstetricians and Gynecologists (ACOG)
and the American College of Allergy, Asthma and Immunology (ACAAI) convened to
provide guidance for physicians on asthma management in pregnant patients,
particularly with regard to the use of newer asthma and allergy medications. The
committee's recommendations include:
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A stepped approach, beginning with inhaled ß 2-agonists for mild,
intermittent asthma and including inhaled cromolyn for mild persistent
asthma; inhaled corticosteroids for moderate persistent asthma; and inhaled
plus oral corticosteroids for severe persistent asthma (Table 1).
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Use of either beclomethasone or budesonide if inhaled corticosteroids
are initiated during pregnancy.
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Consideration of inhaled salmeterol instead of, or in addition to,
theophylline for asthma that is not controlled by inhaled corticosteroids.
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Avoidance of oral decongestants during the first trimester.
In general, the committee preferred inhaled medications (because they have
fewer systemic effects) and time-tested drugs (because of greater experience
with their use during pregnancy). Physicians are advised to limit medication use
as much as possible during the first trimester, although birth defects related
to most asthma drugs are uncommon.
Step Therapy for Chronic Asthma During Pregnancy
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Category
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Frequency/severity of symptoms
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Pulmonary function (untreated)
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Step therapy
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Mild intermittent
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Symptoms no more than twice a week; nocturnal symptoms less than
twice per month; brief exacerbations (a few hours to a few
days);asymptomatic between episodes.
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as much as or more than 80%; normal
pulmonary function between episodes
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Inhaled ß 2-agonists as needed.
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Mild persistent
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Symptoms more than twice a week but persistent not daily;
nocturnal symptoms more than twice per month; exacerbations affect
activity.
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as much as or more than 80%
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Inhaled cromolyn; continue inhaled nedocromil in patients who
had a good may response prior to pregnancy; substitute inhaled
beclomethasone or budesonide if not adequate.
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Moderate persistent
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Daily symptoms; nocturnal symptoms more than once per week;
exacerbations affect activity.
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60%-- 80%
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Inhaled corticosteroids; if inhaled corticosteroids are
initiated during pregnancy, use beclomethasone or budesonide;
continue inhaled salmeterol in patients with a good response prior
to pregnancy; add oral theophylline and/or inhaled salmeterol for
patients inadequately controlled by medium-dose inhaled
corticosteroids.
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Severe persistent
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Continual symptoms; limited activity; frequent nocturnal
symptoms; frequent acute exacerbations.
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less than 60%
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Treatment as described above, plus oral corticosteroids (burst
for active symptoms; alternate day or daily, if necessary).
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Adapted from Position statement: The use of newer asthma and
allergy medications during pregnancy. 2000. [1]
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Managing Asthma during pregnancy
There are two basic approaches that are both important in optimizing the
mother's health. First identify and avoid
triggering factors that can worsen
asthma; particularly dust mites, animal dander or mold. And then, since, most
patients with persistent asthma can't avoid enough of the triggering factors to
have that suffice, to be on appropriate therapy. This is important because of
their health and because there are risks from uncontrolled asthma to the baby's
health. Our study adds strength to the safety profile of the inhaled steroids,
which are clearly the most effective preventative medicine relative to asthma.
Related Links
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