Asthma in Pregnancy
What is Asthma?
Asthma is a respiratory condition characterized by an airway that is hyper-reactive to triggers, and these triggers cause inflammation. The triggers can be varied, such as seasonal allergies, cockroaches, pet hair, weather changes, perfume, tobacco smoke, acid reflux, carpet fumes, food allergies…As we grow older, we may acquire new sensitivity to things. The symptoms include shortness of breath, wheezing, difficulty in breathing, daytime and nocturnal cough. The good news is that this condition is generally reversible with medication. The management of asthma revolves around eliminating environmental triggers, education and compliance with therapy.
Asthma in Pregnancy
Generally in pregnancy, 1/3 of patients with asthma get better, 1/3 have the same symptoms, and 1/3 get worse; if you have asthma, there is about a 70% chance your condition will improve or stay the same.
The management of asthma follows the same guidelines as if you weren’t pregnant; most asthma medications are safe for pregnancy, and should not be stopped when you find out you are pregnant! Talk to your obstetrician before you decide to stop any asthma medication.
If asthma is adequately treated, your outcome in pregnancy is good.
Asthma is divided into 3 basic categories, mild, moderate and severe. These are determined by your symptoms and your spirometer. If you have moderate to severe asthma you need a tool to determine how your asthma is. Your spirometer is a key tool that can tell how you are responding to treatment. You should know what your average peak flow rate is. To determine your peak flow take a deep breath and blow as hard as you can into your flow meter. The normal values for women run between 350-550. When you have an asthma attack, using your peak flow meter can give you a measure of how severe your asthma is. For instance, if your normal peak flow is 500, and during an attack, your peak flow is 350, then your Peak flow is (350/500 x 100=70%) 70% of normal. This would put you in the Moderate Asthma category.
Treatment
Asthma treatment during pregnancy is dependent upon your severity and you category. The treatment protocol is called step-wise therapy. Start with the minimum treatment necessary to control symptoms and add additional treatment in a step wise fashion to control more severe disease.
Mild asthma: occasional asthma (up to twice/week) with wheezing controlled with occasional use of an inhaler such as Albuterol or Ventolin. These medications are safe for use in pregnancy.
Moderate asthma: Daily frequent attacks, more than twice weekly nocturnal asthma attacks. PEF between 60-80% of normal. If you are in this category, you may need an inhaled steroid inhaler in addition to your albuterol/ventolin inhaler.
Severe asthma: Continuous daytime symptoms or PEF of 60% or less. This category is most concerning. In this category, you may need long acting albuterol, an inhaled steroid, and additional medications such as oral steroids, a nebulizer and/or other anti-inflammatory medications. People with asthma are at risk for a severe asthma attack called status asthmaticus which can be life threatening. If you have asthma that is not responsive to treatment and/or is getting worse, you need emergency treatment.
Uncontrolled asthma is associated with low birthweight, preterm delivery, low birth weight, perinatal mortality, preeclampsia and congenital anomalies. Well controlled asthma is associated with good outcomes.
The primary objective of asthma treatment is to decrease the number of asthmatic outbreaks. If you need to use your bronchodilator more than twice per week, you may benefit from inhaled corticosteroids. Talk to your doctor about your symptoms, and have your treatment individualized to meet your specific asthma needs in pregnancy.
In recent years, GERD, or acid reflux is known to be an important asthma trigger for nocturnal asthma. The addition of a proton pump inhibitor such as Nexium can alleviate this. Unfortunately TUMS, or Pepcid sometimes aren’t strong enough to completely eliminate the acid production, and stop the reactive asthma. This can be a very important treatment in the overall management of asthma that is resistant to traditional treatment.
For severe outbreaks oral steroids can be used for short durations with a nebulizer. Note, if these are used in the first trimester there is an increased risk of cleft lip and palate.
Well controlled asthma does not additional fetal testing for fetal surveillance. Labor and delivery is not associated with any worsening of asthma symptoms, however labor inducing medications such as prostaglandin F2alpha should be avoided as it is associated with bronchospasm, and may trigger a severe asthma attack.
The treatment of asthma in pregnancy involves both you and your doctor; together with good compliance, excellent outcomes in pregnancy can be achieved.
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