Asthma In Pregnancy


Article Author:
Eman Shebl


Article Editor:
Rebanta Chakraborty


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/18/2019 12:32:55 PM

Introduction

Bronchial asthma (BA) is considered the most common chronic disease in pregnancy, complicating 4% to 8% of pregnancies. Bronchial asthma exacerbation in pregnancy represents a major clinical problem that can lead to maternal and fetal morbidity and mortality in pregnant patients with asthma. The percentage of women hospitalized for asthma exacerbation during pregnancy was 5.8% in a previous study.[1]

Etiology

The mechanisms, predictors, and outcome of asthma exacerbations during pregnancy are not well understood. Many previous studies have shown that the bronchial asthma exacerbation rate in pregnancy is related to increasing asthma severity. Other studies considered nonadherence with bronchial asthma controller medication due to concern about its teratogenic effect during pregnancy to be an important risk factor for asthma exacerbations during pregnancy. Respiratory viral infections are also risk factors that trigger bronchial asthma exacerbations in pregnancy.[1][2]

Epidemiology

The prevalence of bronchial asthma during preg­nancy in the United States is between 8.4% and 8.8%. In other countries, the prevalence of bronchial asthma may be higher or lower, so further data is needed for demonstrating international trends. Bronchial asthma diagnosis may be different according to population characteristics.[1]

Pathophysiology

Many physiologic changes take place during pregnancy that can affect the bronchial asthma course including:

  • A metabolic rate increase of the pregnant women by about 15%, with a resultant 20% increase in oxygen consumption with a subsequent increase in minute ventilation (mainly by tidal volume increase) by 30% to 40%.This hyperventilation is mediated by respiratory center stimulation by progesterone hormone. The hyperventilation leads to respiratory alkalosis during pregnancy, in which there is decreased the arterial partial pressure of carbon dioxide, decreased bicarbonate, and increased pH.[3]
  • Uterine size increase with its upward push on the diaphragm and a subsequent decrease of the functional residual capacity.[3]
  • The changes of maternal immunity as pregnancy are proposed to be associated with a shift from T-helper 1-type cytokine production and towards Th2-type immune responses, which is mandatory for the fetus to survive. The Th2 up-regulation and other immunity changes may lead to bronchial asthma exacerbation during pregnancy.[4]
  • Mucosal and laryngeal edema which may be mediated by the estrogen hormones leading to rhino sinusitis in about 20% of pregnant women.[5]

History and Physical

Approximately one-third of pregnant women suffer from a worsening of their bronchial asthma during pregnancy; in another one-third, asthma severity remains without change; while in the remaining third, their bronchial asthma shows improvement from the basal condition. The explanation of this variability still unexplained.[2]

Symptoms of asthma peak in the late second or early third trimester, but exacerbations are rare during labor and the peripartum period.[6]

Symptoms of bronchial asthma may include chest wheeze, shortness of breath, and cough. These symptoms characterized by the following:

  • Variability over time and in intensity
  • Often are worse at night or in the early morning
  • Symptoms are triggered by viral infections (colds), exercise, allergen exposure, changes in weather, laughter, or other irritants

Physical examination in people with bronchial asthma may be normal, but the most frequent physical sign is wheezing on auscultation. Wheezing may be absent in cases of severe bronchial asthma exacerbations as a result of severe reduction of airflow (silent chest).[6]

Evaluation

Like bronchial asthma in the general population, spirometry can help in bronchial asthma diagnosis in pregnancy by detecting reversible airway obstructive pattern and helping to monitor response to asthma treatment.

A methacholine challenge test is contraindicated during pregnancy as it may lead to acute bronchospasm.[7]

An asthma control test (ACT) can be used to assess bronchial asthma control during pregnancy. The ACT is five items, with a 4-week recall of symptoms and daily functioning (self-administered questionnaire). The scores range from 5, indicating poor asthma control, to 25 for complete control. A score of less than 20 on the ACT is defined as uncontrolled asthma.[8]

Bronchial asthma patients are considered to have bronchial asthma exacerbation if they have a change of the basal condition which leads any of the following:

  • Adding oral corticosteroids for BA treatment
  • Unscheduled outpatient visits
  • Admission to the emergency room or the need for hospitalization[7]

Treatment / Management

The goals of bronchial asthma treatment in pregnancy are to control asthma symptoms, maintain optimal lung function, and avoid bronchial asthma exacerbation in addition to maintaining fetal oxygenation by avoiding attacks of maternal hypoxia.

The National Asthma Education and Prevention Program recommends treating and managing bronchial asthma in pregnant women the same as in non-pregnant patients (Evidence B).

Salbutamol is the preferred reliever due to its high safety profile. Inhaled corticosteroids (ICS) are the preferred controller medications. It is safe to use ICS, theophylline, and montelukast during pregnancy. Prolonged use of systemic steroids has been associated with pregnancy-related complications, especially in the first trimester. But systemic steroids if indicated they should be used the same as in non-pregnancy (Evidence C). If anesthesia is indicated during labor, regional anesthesia is preferred.[9][7]

Differential Diagnosis

The following should be considered in the differential diagnosis of bronchial asthma during pregnancy:

  • Gastroesophageal reflux disease
  • Postnasal drip
  • Vocal cord dysfunction
  • Hyperventilation syndrome
  • Pulmonary embolism[10]

Complications

The complications of bronchial asthma in pregnancy are related to severity and the intensity of treatment of bronchial asthma. Bronchial asthma exacerbations are considered the most important factor leading to maternal and fetal morbidity and mortality in pregnancies related to bronchial asthma.

Uncontrolled asthma in pregnancy has been linked with a higher incidence of low fetal birth weight and preterm birth.[11]

Deterrence and Patient Education

All patients who are asthmatic and pregnant should receive asthma health education on adherence to medications, proper usage of an inhaler device, a written asthma action plan, asthma trigger avoidance and smoking cessation counseling when appropriate, and a monthly revision and adjustment of their asthma medications according to its control together with treatment of bronchial asthma exacerbation when present.

Pearls and Other Issues

Patients who are pregnant and diagnosed with bronchial asthma should receive adequate asthma assessment and treatment. Bronchial asthma should be treated and managed in pregnant women the same as in nonpregnant patients. (Level II).

Enhancing Healthcare Team Outcomes

As pregnancy is an important risk factor for poor asthma outcomes, all pregnant women with bronchial asthma should be considered at high risk for exacerbations that can lead to maternal and fetal complications. All high-risk women who are pregnant and asthmatic should be managed by pulmonologists and obstetricians in an interprofessional fashion to protect the mother and fetus (Evidence A). For pregnant women who remain compliant with their medications, the prognosis is good. (Level V)


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Asthma In Pregnancy - Questions

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A 25- year-old female patient, pregnant in the second trimester, complains of recurrent shortness of breath, cough and wheezy chest more at night, and more in exposure to dust or fumes. The patient gives a history of receiving asthma medications at childhood. On chest examination, there are generalized expiratory wheezes. Which of the following is the primary controller medication for her?



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Which is true in a 27-year-old pregnant patient with asthma?



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A female who is in her second trimester of pregnancy presents for pulmonary functioning testing to compare with her results prior to pregnancy. What would be found on pulmonary function testing and arterial blood gas measurement?



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A 25-year-old female patient presents to a clinic for medical advice as she is pregnant with four weeks of gestation. She reports that she has bronchial asthma and allergic rhinitis. She is taking regular mild dose inhaled steroids, short-acting inhaled bronchodilator per need, and immunotherapy, which she started before pregnancy. On examination, her heart rate is 88/min, respiratory rate is 19/min, the temperature is 37.2 C, blood pressure is 110/70 mmHg, and arterial oxygen saturation is 97% at room air. A review of her systemic examination is insignificant. Her asthma control test score is 23. What advice should the health care provider give her?



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Which of the following is not true about bronchial asthma exacerbation during pregnancy?



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Which of the following is true about bronchial asthma during pregnancy?



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Which of the following physiologic changes take place during pregnancy and may affect bronchial asthma course?



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A 25-year-old pregnant female presents to a clinic with complaints of recurrent shortness of breath with dry cough and chest wheeze, which occurs on exposure to dust and fumes. The patient has a history of allergic rhinitis, and she also has a family history of bronchial asthma. On examination, her oxygen saturation taken by pulse oximeter at room air is 97%. No chest abnormality can be detected on a chest exam. Which of the following investigation is contraindicated in this case?



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A pregnant patient admitted to the intensive care unit due to acute severe bronchial asthma. Which of the following is not true about her management?



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Asthma In Pregnancy - References

References

Kwon HL,Triche EW,Belanger K,Bracken MB, The epidemiology of asthma during pregnancy: prevalence, diagnosis, and symptoms. Immunology and allergy clinics of North America. 2006 Feb     [PubMed]
Gluck JC,Gluck PA, The effect of pregnancy on the course of asthma. Immunology and allergy clinics of North America. 2006 Feb     [PubMed]
Contreras G,Gutiérrez M,Beroíza T,Fantín A,Oddó H,Villarroel L,Cruz E,Lisboa C, Ventilatory drive and respiratory muscle function in pregnancy. The American review of respiratory disease. 1991 Oct     [PubMed]
Chaouat G,Ledee-Bataille N,Dubanchet S,Zourbas S,Sandra O,Martal J, Reproductive immunology 2003: reassessing the Th1/Th2 paradigm? Immunology letters. 2004 Apr 15     [PubMed]
Ellegård EK, Clinical and pathogenetic characteristics of pregnancy rhinitis. Clinical reviews in allergy     [PubMed]
Belanger K,Hellenbrand ME,Holford TR,Bracken M, Effect of pregnancy on maternal asthma symptoms and medication use. Obstetrics and gynecology. 2010 Mar     [PubMed]
Reddel HK,Bateman ED,Becker A,Boulet LP,Cruz AA,Drazen JM,Haahtela T,Hurd SS,Inoue H,de Jongste JC,Lemanske RF Jr,Levy ML,O'Byrne PM,Paggiaro P,Pedersen SE,Pizzichini E,Soto-Quiroz M,Szefler SJ,Wong GW,FitzGerald JM, A summary of the new GINA strategy: a roadmap to asthma control. The European respiratory journal. 2015 Sep     [PubMed]
Maselli DJ,Adams SG,Peters JI,Levine SM, Management of asthma during pregnancy. Therapeutic advances in respiratory disease. 2013 Apr     [PubMed]
Nathan RA,Sorkness CA,Kosinski M,Schatz M,Li JT,Marcus P,Murray JJ,Pendergraft TB, Development of the asthma control test: a survey for assessing asthma control. The Journal of allergy and clinical immunology. 2004 Jan     [PubMed]
Elsayegh D,Shapiro JM, Management of the obstetric patient with status asthmaticus. Journal of intensive care medicine. 2008 Nov-Dec     [PubMed]
Schatz M, Asthma during pregnancy: interrelationships and management. Annals of allergy. 1992 Feb     [PubMed]

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