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Asthma and pregnancy

aminim@mums.ac.ir. Asthma and pregnancy. Case history. 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.

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Asthma and pregnancy

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  1. aminim@mums.ac.ir Asthma and pregnancy

  2. Case history

  3. 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

  4. 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 pregnancy?

  5. Is it really asthma?

  6. 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

  7. 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

  8. Why me?

  9. Asthma is a common disease • Even more than diabetes mellitus • In some countries 1 out of every 4 children has asthma

  10. Asthma affects 4 to 8% of all pregnant women

  11. I had no family history

  12. 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

  13. 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

  14. Does pregnancy cause my asthma to be exacerbated?

  15. Pregnant women have different courses of their asthma • 1/3 aggravate • 1/3 improve • 1/3 does not change

  16. The most common cause of asthma exacerbation • Discontinuation of drugs • Viral infections • Well controlled asthma has favorable outcome in pregnancy

  17. 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

  18. These risks are increased 30 to 100 % those with more severe asthma • Asthma is not associated with risk of congenital malformations

  19. 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

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

  21. 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

  22. Can my asthma be cured?

  23. 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. Are asthma drugs risky for my fetus?

  25. As asthma is an inflammatory disease limited to lung airways • Treatment of this disease in a topical form is • More effective • Less harmful

  26. You can choose one of these categories for your asthmatic patient • Relievers • Controllers

  27. 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

  28. 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

  29. Relievers (No anti-inflammatory action) • Salbutamol • Atrovent • Controllers (Mainly anti-inflammatory) • Inhaled corticosteroids • LABA • cromolyn • Theophylline • Leukotrene antagonists

  30. 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

  31. 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

  32. 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

  33. Mild intermittent • Mild persistent • Moderate persistent • Severe persistent • PRN Salbutamol • Inhaled corticoteroid • Inhaled corticoteroid + LABA • Inhaled corticoteroid + LABA

  34. Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g) > 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

  35. Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g) > 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

  36. Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g) > 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

  37. Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g) > 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

  38. Choice of drug categories in pregnancy Category Drug of choice • SABA • LABA • ICS • Salbutamol • Salmetrol • Budesonide

  39. Can moisturizers help me to improve?

  40. 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

  41. Avoidance from • allergens, • irritants and • air pollution • Is necessary for any asthmatic pregnant woman

  42. Allergen immunotherapy can be continued during pregnancy • But, should not be started for the 1st time in a pregnant woman

  43. Is my child more prone to asthma?

  44. There is no association to mother asthma during fetal period • and development of asthma in childhood period. • Albeit asthma is a genetic disease

  45. Can heartburn cause my asthma?

  46. Comorbid conditions in asthma • Gastro-esophageal reflux disease (GERD) • Allergic rhinitis (AD)

  47. 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

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