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BY

DR. FAUSTER K. KWAWUNUNU


ASTHMA IN PREGNANCY
 OUTLINE
- Introduction
- Pathophysiology
- Clinical Presentation
- Diagnosis
- Differential diagnosis
- Management
- Complications
- Conclusion
ASTHMA IN PREGNANCY
Introduction:
 Asthma is a chronic inflammatory disease of the airways
characterized by increase responsiveness of the
tracheobronchial tree to multiple stimuli
 Episodic, characterized by acute exacerbations
intermingled with symptom-free periods
 Most attacks are short-lived
 Though patients recover completely clinically, evidence
suggests that patient with asthma developed chronic
airflow limitations
Introduction
 Prevalence of the disease:
4-5% in general population
1-4% in pregnancy
 Mortality and morbidity in pregnancy is comparable to
those in the general population
 1/3 aggravate
 1/3 improve
 1/3 does not change
 Most return to their prepregnancy baseline within 3
months postpartum
PATHOPHYSIOLOGY
 Respiratory Physiologic changes in Pregnancy:
- Respiratory rate and vital capacity, FEV1, FVC
and FEV1/FVC ratio remain unchanged
- Tidal volume, minute ventilation(40%), minute
oxygen uptake(20%), airway conductance increased
- Functional Residual volume, Residual Volume,
and Expiratory reserve volume and total pulmonary
resistance decreased
PATHOPHYSIOLOGY
 The consequences of these changes:
- Hyperventilation => decreased pCO2 =>
decreased HCO3 => increased pH
- Chronic respiratory alkalosis
 Normal pCO2 in pregnant patient may signal
impending respiratory failure
 Progesterone is a respiratory stimuli
PATHOPHYSIOLOGY
 Asthma can occur spontaneously or in response to
stimuli

 Stimuli include allergens, medications, physical


exertion, emotions and stress

 In response to contact with a triggering agents:


- Mast cells release vasoactive chemical mediators
PATHOPHYSIOLOGY
- The inflammation results in abnormal
accumulation of mast cells, neutrophils, lymphocytes,
macrophages, eosinophils, dendritic cells and
myofibroblasts in bronchial tree
 Results in:
- Bronchoconstriction, vascular congestion and
increases in capillary and mucosal edema
- Impaired mucociliary action and increased
mucus production and airway resistance
- Airway obstruction that is partially or completely
reversible
CLINICAL PRESENTATION
 History findings may include:
- Cough,
- Shortness of breath,
- Chest tightness,
- Noisy breathing,
- Nocturnal awakenings,
- Recurrent episodes of symptom complex,
- Exacerbations possibly provoked by nonspecific stimuli,
- Personal or family history of other atopic disease
 General physical examination findings may include:
- Tachypnoea,
- Retraction(sternomastoid, abdominal, pectoralis muscles)
- Agitation- usually a sign of hypoxia or respiratory distress
- Pulsus paradoxicus(>20mmHg)
CLINICAL PRESENTATION
 Pulmonary findings:
- Wheezes
- Rhonchi
- Bronchovesicular sounds
- Expiratory phase of respiration equal to or more
prominent than inspiratory phase
CLINICAL PRESENTATION
 Signs of fatigue and near-respiratory arrest:
- Alteration in level of consciousness(lethargy)
- Abdominal breathing
- Inability to speak in complete sentences
 Signs of complicated asthma:
- Jugular venous distension(pneumothorax),
- Hypotension and tachycardia(tension
pneumothorax),
- Fever(Respiratory Tract Infection)
 Amount of wheezes does not always correlate with the
severity of the attack
Categories of Asthma
 They present in one of the following categories

 National Asthma Education and Prevention


Program(NAEPP) categorize asthma:
- Mild intermittent
- Mild persistent
- Moderate persistent
- Severe asthma
Categories of Asthma
 Mild Intermittent Asthma
- Symptoms twice per week or less
- Nocturnal symptoms twice per month or less
- PEFR or FEV1 80% of predicted or more
 Mild Persistent Asthma
- Symptoms more than twice per week but not daily
- Nocturnal symptoms more than twice per month
- PEFR or FEV1 80% predicted or more
Categories of Asthma
 Moderate Persistent Asthma
- Daily symptoms
- Nocturnal symptoms more than once per week
- PEFR or EFV1 more than 60% to less than 80%
predicted
- Regular medications necessary to control sympoms
 Severe Asthma
- Continuous symptoms and frequent exacerbations
- Frequent nocturnal symptoms
- PEFR or FEV1 60% predicted or less
- Regular oral corticosteroids necessary to control
symptoms
DIAGNOSIS AND ASSESSMENT
 History- most of them the diagnosis is known before pregnancy
 Physical Examination Findings
 Pulmonary Function Testing
 Reversible airflow obstruction is central to the diagnosis and
assessment of asthma
 Changes in Pulmonary function during acute asthma include:
1. Decreased PEFR and FEV1
2. Mild reduction in Forced vital Capacity
3. An increase Residual Volume, Functional Residual
Capacity and Total Lung Capacity
4. Normal diffusing capacity
DIAGNOSIS AND ASSESSMENT
 Patients with asthma demonstrate a greater than 15%
increase in FEV1, FVC and PEFR when treated with
bronchodilators
Differential Diagnosis
 Problems to consider that can mimic asthma in the
pregnant patients include the following:
- Airway obstruction
- Amniotic fluid embolism
- Acute congestive heart failure (CHF) secondary
to peripartum cardiomyopathy
- Physiological dyspnoea of pregnancy
ASTHMA IN PREGNANCY
MANAGEMENT
 Almost all antiasthma drugs are safe to use in pregnancy
and during breastfeeding
 Undertreatment of the pregnant patient is a frequent
occurrence because such patients are worried about
medication effect on the fetus
 Management Goal:
- Treat airway inflammation
- Decrease airway responsiveness
- Prevent asthma symptoms and exacerbations
- Maintain adequate oxygenation to the fetus by
preventing hypoxic episodes in the mother
ASTHMA IN PREGNANCY
MANAGEMENT
 Patient Education:
- Teach to identify and avoid triggers as much as possible
- Teach early recognition of signs and symptoms
- Improve compliance with medication
- Seek prompt treatment when necessary
- Prompt management of allergic rhinitis, sinusitis and
gastroesophageal reflux as these may exacerbate asthma symptoms
 Step wise management to therapy :
- Use least amount of drug to control a patient’s asthma
- Increases the number and frequency of medications with
increasing asthma severity
- Safer to be treated appropriately than have asthma symptoms
and exacerbations
- Treat exacerbations aggressively
MANAGEMENT- ANTIASTHMA
DRUGS

 Outpatient management of asthma is similar for the


pregnant patient as for the nonpregnant patient. Beta-
adrenergic agonists remain the mainstay of treating
exacerbations and handling mild forms of asthma
 For moderate-persistent asthma, beta-adrenergic
agonist combined with an inhaled anti-inflammatory
agent or inhaled corticosteroid is recommended for
treatment
 In severe asthma, oral corticosteroids and beta
agonists are recommended
ASTHMA IN PREGNANCY
MANAGEMENT- ANTIASTHMA
DRUGS
 A longer-acting beta2-adrenoceptor agonist(eg,
salmoterol), the bronchodilator effects of which last at
least 12 hours, is an effective treatment for nocturnal
asthma
 Historically, methylxanthines and oral beta agonists
have been used to treat asthma. Both are shown to be
safe but have fallen out of favour for newer medicines
and inhaled forms, respectively
ASTHMA IN PREGNANCY
MANAGEMENT- ANTIASTHMA
DRUGS
 Magnesium sulfate is another medication that is safe
to use in pregnancy. It works as a smooth-muscle
relaxant of the airway
 Epinephrine use should be avoided in the pregnant
patient. In general, epinephrine is used only in the
most severe asthma exacerbations. Its use can lead to
possible congenital malformations, fetal tachycardia,
and vasoconstriction of the uteroplacental circulation
ASTHMA IN PREGNANCY
MANAGEMENT- ANTIASTHMA
DRUGS
 Cromolyn sodium
- Is virtually devoid of significant side effects
- Blocks both the early and late phase pulmonary
response to allergen challenge
- Preventing the development of airway
hyperresponsiveness
- Alternative treatment for mild persistent asthma
- Does not have any intrinsic bronchodilator or
antihistaminic activity
ASTHMA IN PREGNANCY
MANAGEMENT- ANTIASTHMA
DRUGS
 Leukotriene modifiers
- Reduce bronchospasm and mucous secretion
- Increase vascular permeability
- Improve pulmonary function significantly
- An alternative treatment for mild persistent and
an adjunctive treatment for the management of
moderate and severe persistent asthma
Examples: Zafirlukast(Accolate),
Montelukast(Singlair)
- Category B drug
MANAGEMENT- HOSPITAL CARE
 Prehospital asthma treatment
- Address the patient’s airway status as needed
- Provide early institution of beta-agonist
inhalational therapy
- Provide supplemental oxygen
MANAGEMENT- HOSPITAL CARE
 Treatment in the emergency department
- Pregnant patients who present with typical mild
exacerbations of asthma may be treated in the same way
that a regular asthmatic patient with similar symptoms
would be, with bronchodilator therapy and steroids
- Special attention must be given to pregnant patients
who present with severe asthma exacerbations, because the
resulting maternal hypoxia can have devastating
consequences on the fetus
- Address ABCs, place patient on cardiac monitor and
pulse oximetry
- Low threshold for intubation to prevent/limit
hypoxic episodes to the fetus
MANAGEMENT- HOSPITAL CARE
 Intubate and mechanically ventilate patients who are
in or near respiratory arrest and patients who do not
respond to treatment as evidenced by the following:
- Hypoxaemia despite supplemental oxygen
- Increasing carbon dioxide retention
- Persistent/worsening level of consciousness
- Haemodynamic instability
MANAGEMENT- HOSPITAL CARE
 The key to treating asthma in the pregnant patient is
to frequently assess the patient, the severity of the
attack, and the response to treatment
 Hypoxia, acidosis, unequal breath sounds,
pneumothorax and atypiacal features serve as warning
signs of severe exacerbations
 Inhaled beta2-agonist are the mainstay of treatment.
The beta2-agonist, inhaled and/or subcutaneous, is
typically given in 3 doses over 60-90 minutes. Beta-
adrenergic blocking agents should be avoided owing to
bronchospastic effect
MANAGEMENT- HOSPITAL CARE
 The early use of systemic steroids has been shown to
reduce the length of stay in the ED and the admission
rate; the effect of the steroids is seen within 4-6 hours
of the institution of therapy
 Supply of supplemental oxygen to maintain oxygen
saturation higher than 95%. Intravenous fluids can
help to loosen and clear secretions
 Fetal monitoring becomes important after 28(32)
weeks of gestation in severe cases
MANAGEMENT- HOSPITAL CARE
 Avoid Tranquilizers and sedatives because of their
respiratory depressant effect

 Antihistamines are not useful in the treatment of asthma

 Mucolytic agents increase bronchospasm

 Beware of complications of mechanical ventilation-


Barotrauma, haemodymic impairment, mucous plugging,
atelectasis, secondary pneumonia and paradoxical increase
in bronchospasm
Asthma in Pregnancy
Admission and Discharge
 Criteria for hospital admission are as follows:
- Inadequate response to ED therapy
- pO2 less than 70 mmHg
- Signs of fetal distress
- Multiple medication use ( requiring 3 or more
medications simultaneosly)
- A protracted course with poor response to outpatient
therapy thus far instituted or a history of severe asthma
requiring intubation or ICU admission
- Inadequate home conditions and transport/access to
ED care
Asthma in Pregnancy
Admission and Discharge
 Criteria for ICU admission are as follows:
- Altered level of consciousness
- Poor air flow
- Signs of fatigue, a downhill course, or a need for
mechanical ventilation
- PEFR/EFV1 less than 25% of predicted or pCO2
greater than 35 mm Hg
Asthma in Pregnancy
Admission and Discharge
 Criteria for home discharge include the following:
- Greatly improved symptoms and physical examination findings
- Ability of the patient to walk out of the ED/ ward without
obvious distress
- PEFR/EFV1 greater than 70% baseline
- No fetal distress
- Good follow-up and access to ED in case of relapse

 A 2-4 days appointment following ED visit is recommended.


Consider/Involve asthma specialist
 Glucocorticoids at the time of discharge have proven to be useful and to
reduce the incidence of ED visits
Obstetrics Considerations in the
Management of Asthma
 Help patient to identify and avoid asthma triggers
during her booking visit
 Schedule her ANC visits based upon clinical severity
 Because asthma has been associated with IUGR and
preterm birth, it is useful to establish pregnancy
dating accurately by the first trimester
ultrasonography where possible
 Antepartum Surveillance for pregnancies complicated
by moderate or severe asthma: USG for fetal growth;
Antenatal assessment of fetal well-being at about 32
weeks
Intrapartum considerations related
to asthma
 Exacerbations of asthma are uncommon during labour
and birth Except in the most severe cases
 Asthma should not preclude a vaginal birth
 Occasionally, women with very severe asthma may be
advised to have an elective delivery( IOL or C/S) at a
time when their asthma is well controlled
 Plan after 37weeks + 6 days unless there are medical
complications requiring earlier intervention
 Avoid histamine releasing narcotics
Intrapartum considerations related
to asthma
 Symptoms of asthma during labour are generally controlled
with standard asthma therapy
 Inhaled beta-agonists do not impaired uterine contractions
or delay the onset of labour
 There is no evidence that oxytocin causes
bronchoconstriction
 Regional anaesthesia is preferred over general anaesthesia.
Intubation may trigger attack
 Ketamine for induction of anaesthesia is safer and prevent
bronchospasm
 Shortening of second stage of labour should be considered
Postpartum considerations related
to asthma
 Ergometrine has been reported to cause
bronchospasm
 Prostaglandin E1(misoprostol) is safe to use for
management of PPH
 Use of Prostaglandin F2a(diniprost) may trigger
bronchospasm
 Breastfeeding should be encouraged
COMPLICATIONS
 Uncontrolled or poorly controlled asthma during
pregnancy is associated with poor maternal and perinatal
outcomes
 Complications include:
- Increased prematurity
- Increased C/S rate
- Preeclampsia/Hypertension
- Growth restriction(SGA)
- Increased maternal morbidity/mortality
- NICU admission
- Congenital anomalies- cleft lips +/- cleft palate
CONCLUSION

Remember: if the mother can’t


breathe, neither can her
baby!
Thank you