asthma during pregnancy
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Epidemiology
- 6% of pregnant women
Diagnostic procedures
- methacholine challenge test contraindicated during pregnancy[1]
Complications
- increase in perinatal mortality
- neonatal sepsis more common
- low birth weight
- prematurity
- NOT associated with preterm delivery unless severe[4]
- adverse perinatal outcomes with poor asthma control[6]
- pre-eclampsia
- chronic gestational hypertension
- Cesarean section more common[4]
Risk factors for adverse outcomes:
Management
- management of GERD
- antireflux measures
- antacids, prokinetic agents, H2-blockers especially for nocturnal symptoms
- treat acute exacerbations of asthma aggressively to avoid fetal hypoxia:
- early addition of corticosteroids for rapid reversal of airway obstruction during exacerbations
- risks of adverse pregnancy outcomes exceed risks of asthma medications[1]
- also see stepwise management based on classification as for asthma in non-pregnant patients
- pharmaceutical agents
- bronchodilators
- inhaled beta-2 adrenergic agonists
- short-acting 0K: albuterol MDI
- long-acting OK: salmeterol (Serevent) or formoterol for persistent asthma[5]
- theophylline associated with adverse outcomes[3]
- inhaled beta-2 adrenergic agonists
- glucocorticoids ok[1]
- inhaled beclomethasone or budesonide safe[1]
- low-dose for mild asthma
- prednisone as needed for severe exacerbations
- oral steroids associated with adverse outcomes[3]
- inhaled beclomethasone or budesonide safe[1]
- risk greatest in 1st trimester[5]
- preterm delivery[4][5], cleft palate[5]
- cromolyn (inhaled) <inhaled steroid preferred>[5]
- nedocromil (Tilade) may be continued in women doing well on it prior to pregnancy
- amoxicillin clavulanate (Augmentin) for sinusitis
- decongestants
- pseudoephedrine AVOID, especially during 1st trimester
- oxymetazoline (inhaled)
- antihistamines
- chlorpheniramine
- tripelennamine
- loratadine (Claritin)
- cetirizine (Zyrtec)
- fexofenadine (Allegra) -> NOT enough data to recommend
- leukotriene modifiers ok[1]
- do NOT use zileuton (Zyflo)
- zafirlukast (Accolate) -> use only when needed
- montelukast (Singulair) -> use only when needed
- guaifenesin as expectorant
- AVOID epinephrine
- teratogenic
- reduces uteroplacental bloodflow
- bronchodilators
- management of status asthmaticus
- methylprednisolone 1 mg/kg IV every 6-8 hours; taper with improvement
- oxygen 1-3 L/min by nasal cannula to keep O2 sat > 90%
- albuterol nebulizer 2.5 mg in 2.5 mL normal saline every 20 minutes x 3 if no response
- terbutaline 0.25 mg SC up to 3 doses given every 20 min PRN
- aminophylline
- 5 mg/kg IV loading dose over 30 min (if not receiving theophylline)
- infusion 0.4 mg/kg/hour
- therapeutic monitoring: 8-12 ug/mL
- magnesium sulfate: 1-2 g IV over 20 min
More general terms
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Prescriber's Letter 7(7):39 2000
- ↑ 3.0 3.1 3.2 Journal Watch 23(24):192, 2003 Bracken MB et al Asthma symptoms, severity, and drug therapy: a prospective study of effects on 2205 pregnancies. Obstet Gynecol 102:739, 2003 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14551004
- ↑ 4.0 4.1 4.2 4.3 Journal Watch 24(4):33, 2004 Dombrowski MP et al, Obstet Gynecol 103:5, 2004 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14704237
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Prescriber's Letter 12(2): 2005 Treatment of Chronic Asthma in Pregnancy Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=210203&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 6.0 6.1 Schatz M, Dombrowski MP, Wise R, Momirova V, Landon M, Mabie W, Newman RB, Rouse DJ, Lindheimer M, Miodovnik M, Caritis SN, Leveno KJ, Meis P, Wapner RJ, Paul RH, O'Sullivan MJ, Varner MW, Thurnau GR, Conway DL; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network; National Heart, Lung, and Blood Institute. Spirometry is related to perinatal outcomes in pregnant women with asthma. Am J Obstet Gynecol. 2006 Jan;194(1):120-6. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16389020
- ↑ Schatz M, Dombrowski MP. Clinical practice. Asthma in pregnancy. N Engl J Med. 2009 Apr 30;360(18):1862-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19403904
- ↑ Bonham CA, Patterson KC, Strek ME. Asthma Outcomes and Management During Pregnancy. Chest. 2018 Feb;153(2):515-527. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28867295 Free PMC Article
- ↑ NEJM Knowledge+