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aminim@mums.ac.

ir

A 20 yr old lady presented with


Hx of cough and dyspnea for 6

months
2 weeks of drug discontinuation
1 week cough, sputum and dyspnea
She is 3 mo pregnant
She is concerned about her chest
disease during pregnancy

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 moisturizers help me to improve?
How does asthma affect my fetus?
Are asthma drugs risky for my fetus?
Is my child more prone to asthma?
Can heartburn cause my asthma?
Should I get flu shot?
What should I do in the case of asthma
attack?
Can I do NVD for termination of

Recurrent episodes 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

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

Asthma is a common disease


Even more than diabetes mellitus

In some countries 1 out of every 4

children has asthma

Asthma affects 4 to 8% of all

pregnant women

Asthma occurs more commonly in

those with atopic history


In themselves or
Their 1st degree relatives

A person with allergic rhinitis has 5

times more chance of asthma

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

Pregnant women have different

courses of their asthma


1/3 aggravate
1/3 improve
1/3 does not change

The most common cause of asthma

exacerbation
Discontinuation of drugs
Viral infections

Well controlled asthma has favorable

outcome in pregnancy

Poor controlled asthma has been

associated with 15 to 20 % increase


in
Preterm delivery
Preeclampsia
Growth retardation
Need for C/S
Maternal morbidity
Maternal mortality

These risks are increased 30 to 100

% those with more severe asthma


Asthma is not associated with risk of
congenital malformations

?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

In pregnant asthmatics you should

confirm control by
Spirometry
Monthly
Peak flow metry
Twice daily
Upon awakening
After 12 hr

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

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

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

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

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

Relievers (No anti-inflammatory action)


Salbutamol
Atrovent

Controllers (Mainly anti-inflammatory)


Inhaled corticosteroids
LABA
cromolyn
Theophylline
Leukotrene antagonists

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

Safety profile of common


anti-asthma drugs
Drug

Safety

Salbutamol
Inhaled

Safe, inhaler (labor)

corticosteroids
Cromolyn
Theophylline

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

Drug

Safety

LABA
Adrenaline

Not reassuring
Not for asthma

Systemic steroids

Pre-eclampsia, GDM
Prematurity, LBW

Atroent
Leukotrene

Safe
Ziluten not assessed
Zafirleukast,

antagonists

monteleukast
probably safe

Mild intermittent

PRN Salbutamol

Mild persistent

Inhaled corticoteroid

Moderate persistent

Inhaled corticoteroid

Severe persistent

+ LABA
Inhaled corticoteroid
+ LABA

Drug
y

Age

Low Daily Dose (g)


<5y

Beclomethasone
Budesonide

Budesonide-Neb
Inhalation Suspension
Ciclesonide

>5y

Age

200-500

Medium Daily Dose (g)

<5y

100-200

200-600
100200

>5y

80 160

<5y5

>500-1000

>200-400

600-1000

>200-400

250500

Age

High Daily Dose (g)


<
>1000
>1000

>500-

>400
>400

>1000

1000
80-160

>160-320

>160-320

>320-1280

>750-1250

>2000

>1250

>200-500

>500

>500

Flunisolide

500-1000
750

500-

>1000-2000

Fluticasone

100-250
200

100-

>250-500

Mometasone furoate

200-400
200

100-

> 400-800

>200-400

>800-1200

Triamcinolone acetonide

400-1000
800

400-

>1000-2000

>800-1200

>2000

>320

>400
>1200

Drug
y

Age

Low Daily Dose (g)


<5y

Beclomethasone
Budesonide

Budesonide-Neb
Inhalation Suspension
Ciclesonide

>5y

Age

200-500

Medium Daily Dose (g)

<5y

100-200

200-600
100200

>5y

80 160

<5y5

>500-1000

>200-400

600-1000

>200-400

250500

Age

High Daily Dose (g)


<
>1000
>1000

>500-

>400
>400

>1000

1000
80-160

>160-320

>160-320

>320-1280

>750-1250

>2000

>1250

>200-500

>500

>500

Flunisolide

500-1000
750

500-

>1000-2000

Fluticasone

100-250
200

100-

>250-500

Mometasone furoate

200-400
200

100-

> 400-800

>200-400

>800-1200

Triamcinolone acetonide

400-1000
800

400-

>1000-2000

>800-1200

>2000

>320

>400
>1200

Drug
y

Age

Low Daily Dose (g)


<5y

Beclomethasone
Budesonide

Budesonide-Neb
Inhalation Suspension
Ciclesonide

>5y

Age

200-500

Medium Daily Dose (g)

<5y

100-200

200-600
100200

>5y

80 160

<5y5

>500-1000

>200-400

600-1000

>200-400

250500

Age

High Daily Dose (g)


<
>1000
>1000

>500-

>400
>400

>1000

1000
80-160

>160-320

>160-320

>320-1280

>750-1250

>2000

>1250

>200-500

>500

>500

Flunisolide

500-1000
750

500-

>1000-2000

Fluticasone

100-250
200

100-

>250-500

Mometasone furoate

200-400
200

100-

> 400-800

>200-400

>800-1200

Triamcinolone acetonide

400-1000
800

400-

>1000-2000

>800-1200

>2000

>320

>400
>1200

Drug
y

Age

Low Daily Dose (g)


<5y

Beclomethasone
Budesonide

Budesonide-Neb
Inhalation Suspension
Ciclesonide

>5y

Age

200-500

Medium Daily Dose (g)

<5y

100-200

200-600
100200

>5y

80 160

<5y5

>500-1000

>200-400

600-1000

>200-400

250500

Age

High Daily Dose (g)


<
>1000
>1000

>500-

>400
>400

>1000

1000
80-160

>160-320

>160-320

>320-1280

>750-1250

>2000

>1250

>200-500

>500

>500

Flunisolide

500-1000
750

500-

>1000-2000

Fluticasone

100-250
200

100-

>250-500

Mometasone furoate

200-400
200

100-

> 400-800

>200-400

>800-1200

Triamcinolone acetonide

400-1000
800

400-

>1000-2000

>800-1200

>2000

>320

>400
>1200

Choice of drug
categories in pregnancy
Category

Drug of choice

SABA
LABA

Salbutamol
Salmetrol

ICS

Budesonide

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

Avoidance from
allergens,
irritants and
air pollution

Is necessary for any asthmatic

pregnant woman

Allergen immunotherapy can be

continued during pregnancy


But, should not be started for the 1st
time in a pregnant woman

There is no association to mother

asthma during fetal period


and development of asthma in childhood

period.

Albeit asthma is a genetic disease

Comorbid conditions in asthma


Gastro-esophageal reflux disease

(GERD)
Allergic rhinitis (AD)

Be suspicious to GERD if
Your asthmatic patient become poorly

controllable
Your asthmatic patient is worse at night
Your asthmatic patient has symptoms
when lies down
Patient complains of GERD symptoms

Treatment of heartburn can improve

asthma symptoms
Continue anti GERD drugs for at least
2-3 months

Be suspicious to AD if
Your asthmatic patient complains of

seasonal nose or sinus symptoms

Treat AD with
Intranasal corticosteroids
Antihistamines (2nd generation in

pregnancy)
Allergen avoidance

Influenza vaccination is necessary for


Pregnant women with 2nd and 3rd

trimester
In cold months

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

Pco2 > 35 mmHg


Po2 < 70 mm Hg
Are abnormal during pregnancy

IV fluid (dextrose) initially 100

ml/hour
Seated position
Fetal monitoring

Dosage of glucocorticoids is not

different
IV aminophylline NOT generally
recommended
IV Mg sulfate may be beneficial
Concomitant hypertension
Preterm contraction

Respiratory infections in asthmatic

patients
Usually viral

If indicated in a pregnant woman


I V Ceftriaxone
Erythromycin

No difference
PG F2 analogues should not be used

in asthmatics
for termination of pregnancy

Morphine and meperidine should be

avoided
Fentanyl is an appropriate alternative

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 pertiprtum

bleeding, headache, should be avoided

Summary
Careful assessment and

monitoring
Avoidance and controll
of triggers
Maintenance rather than
symptomatic therapy
Aggressive treatment of
exacerbations