Case Discussion: Asthma in Pregnancy May 2014
Consider Jane… • Jane 23 yo child care worker • Presents 10/40 pregnant unplanned pregnancy • G1 P0 EDC 23 September • Smoker 25/day • Significantly cut back since becoming pregnant • Live in partner is smoker • Only PMH is asthma since childhood • Needs salbutamol script • Wants to do shared care
Asthma in Pregnancy… • Jane advises you that she usually only uses her salbutamol puffer occasionally and whilst she has had a preventer in the past, she stopped using it because she ran out and never got a new prescription • Started smoking “here and there” at age 15/16 but regularly by 18 • Currently Jane is not worried about her asthma control and thinks she only needs the ventolinoccasionally • On direct questioning… • Uses her puffer when she gets SOB running around at work 1-2 times/day most days • Will need it a couple of times on weekends when friends come over & everybody is smoking • Doesn’t really exercise so doesn’t know if she needs it with exercise • Needs it regularly (3-4 hrly) first couple of days when she has a cold
Examination findings… • Ht: 165 cm Wt: 71kg BMI: 26.1 • Afebrile • ENT: NAD • Chest: Clear good AE occasional expiratory wheeze bilaterally • Spirometry: • Pre-bronchodilator: • PEFR: 330 (exp 440) ie 75% expected • FEV1/FVC:82% (exp 85%) • Post-bronchodilator: • PEFR: 396 (exp 440) ie 90% expected • FEV1/FVC 84% (exp 85%)
Questions to consider: • What are the extra issues you need to consider in managing Jane during this pregnancy? • What do you advise Jane about her and her partner smoking in pregnancy? • What are Jane’s options to assist with stopping smoking in pregnancy? • What is the significance of contracting influenza in pregnancy? • What do you advise about immunisation against influenza during pregnancy? • Why is asthma control important in pregnancy? • How do you manage Jane’s asthma this pregnancy? • What non-pharmacological management could be offered? • What pharmacological management could be offered?
Take Home Messages… • Harmful effects of direct and passive smoking in pregnancy and on the health of babies and children have been well established • There is currently a lack of evidence on the safety of nicotine replacement therapy (NRT) in pregnancy but reports of expert committees have recommended its use in certain circumstances. NRT should be considered when a pregnant woman is otherwise unable to quit, and when the likelihood and benefits of cessation outweigh the risks of NRT and potential continued smoking • Pregnancy increases the risk of contracting influenza and developing serious complications from influenza • The vaccine is safe to give in all stages of pregnancy. • Maternal asthma has been shown to contribute to significant complications of pregnancy • These outcomes are likely to be reduced with well managed asthma; women with well managed asthma can expect the same outcomes as women without asthma • Short acting b 2 agonists and inhaled corticosteroidsare the mainstay of treatment for asthma and appear to be safe in pregnancy; most evidence for safety is for budesonide (ADEC category A)