HOW TO RELIEVE ASTHMA DURING PREGNANCY

1. HOW TO RELIEVE ASTHMA DURING PREGNANCY Sri Sulistyowati FETOMATERNAL DIVISION OB/GYN DEPARTMENT SEBELAS MARET UNIVERSITY/DR. MOEWARDI HOSPITAL SOLO

2. INTRODUCTION • 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?

3. IS IT REALLY ASTHMA? • Recurrentepisodes 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

4. Is it really asthma?

5. 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

6. Clinical Presentation of Asthma • Wheezing • Dyspnea • Chest tightness • Use of accessory respiratory muscle • Central or peripheral cyanosis • Tachycardia • Prolonged expiration

7. WHY ME ? I HAD NO FAMILY HISTORY Asthma affects 4 to 8% of all pregnant women Prevalence of asthma appears to be increasing in pregnant women 0.2% of pregnancies will be complicated by status asthmaticus

8. 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

9. 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

10. EFFECT OF PREGNANCY ON ASHTMA • 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

11. 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

12. EFFECT OF ASHTMA ON PREGNANCY • 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

13. 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

14. Antenatal Management • Asthma history • Severity of symptoms • Nocturnal symptoms • Pregnant patients with mild well controlled asthma may receive routine prenatal care • Moderate and Severe asthma will need more frequent visits and consider referral in severe cases

15. What is “well control”? No (or minimal) daytime symptoms No limitations of activity No nocturnal symptoms No (or minimal) need for rescue medication Normal lung function No exacerbations

16. Referral Indication • To Asthma/ Allergy subspecialist • Diagnosis is severe, persistent asthma • Diagnosis is unclear • More complete allergy evaluation is desired • Asthma is not under control even after appropriate avoidance measures are taken and medications have been adjusted and redirected • Life threatening exacerbation

17. Management • Ultimate goal is prevention of hypoxic episodes to mother and fetus • Relies on four components • Objective measures for accurate monitoring • Minimizing asthma triggers • Patient education • Pharmacologic therapy

18. Management • In pregnant asthmatics you should confirm control by • Spirometry • Monthly • Peak flow metry • Twice daily • Upon awakening • After 12 hr

19. Objective Measures for Accurate Monitoring • FEV1 is best single measure of pulmonary function but requires a spirometer • PEFR 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

20. Objective Measures for Accurate Monitoring • 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

21. Minimizing Asthma Triggers • Use plastic mattress and pillow covers • Weekly washing of bedding in hot water • Animal dander control • Weekly bathing of the pet • Keeping pets out of the bedroom • Remove pet from the home • Cockroach control • Hardwood flooring • Avoid tobacco smoke • Inhibit mite and mold growth by reducing humidity • Do not be present when home is vacuumed

22. Patient Education • Understanding that asthma control is important to fetal well being • Reduction of triggers • Understanding of basic medical management including self monitoring

23. Can my asthma be cured? • 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

24. Can Allergens affect to my asthma? • 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

25. Can Allergens affect to my asthma? • Avoidance from • allergens, • irritants and • air pollution • Is necessary for any asthmatic pregnant woman

26. Can Allergens affect to my asthma? • AlergentImmunoteraphy can be continued during pregnancy • But should not be started for the first time in pregnant women

27. How about theraphy for asthma in pregnancy? • 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

28. 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

29. 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 attack • Airway remodeling in your patient

30. 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

31. 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

32. 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

33. Safety profile of common anti-asthma drugs 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

34. Anti-asthma drugs Treatment Asthma Severity Treatment • Mild intermittent • Mild persistent • Moderate persistent • Severe persistent • PRN Salbutamol • Inhaled corticosteroid • Inhaled corticosteroid + LABA • Inhaled corticosteroid + LABA

35. 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

36. Is my child more prone to asthma? • There is no association to mother asthma during fetal period • and development of asthma in childhood period. • Asthma is a genetic disease

37. What should I do in the case of asthma attack? • 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

38. What should I do in the case of asthma attack? • Pco2 > 35 mmHg • fluid (dextrose) initially 100 ml/hour • Seated position • Fetal monitoring

39. 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

40. 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

41. Labor: Sectio Caesarian or Vaginal Delivery? • 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

42. 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

43. Summary • Careful assessment and monitoring • Avoidance and controll of triggers • Maintenance rather than symptomatic therapy • Aggressive treatment of exacerbations

44. THANK YOU