Outpatient Management Of Asthma in Pregnancy

Outpatient Management of Asthma in Pregnancy
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Pregnancy has no predictable effect on the course of asthma [1]. However, poorly controlled moderate or severe asthma increases the likelihood of intrauterine growth restriction independent of the effects of maternal smoking or medication use. Antepartum and postpartum hemorrhage are also increased independent of medication usage [2-4]. Oral corticosteroids appeared to increase the incidence of preeclampsia in one study[4].

ASSESSMENT [5-7]:

Asthma should be considered in any pregnant patient complaining of wheezing, cough, or dyspnea. The differential diagnosis includes:

Chronic obstructive pulmonary disease

Congestive heart failure

Pulmonary Embolism

Mechanical obstruction (benign or malignant tumors)

Pulmonary infiltration with eosinophilia

Cough secondary to drugs (ACE inhibitors)

Laryngeal dysfunction

The evaluation should include history, physical examination, peak flow measurement, and laboratory testing as indicated. Testing for inpatients might include pulse oximetry, arterial blood gas, chest roentgenogram, or other tests for complicating factors as indicated.

The evaluation should also classify asthma type and severity (duration, diurnal variation, seasonal) , and identify precipitating factors such as exercise , irritants (tobacco smoke) , sinusitis, gastroesophageal Reflux, and Influenza, Para-influenza

CONTROL

Remove or control potential precipitating factors such as:

Tobacco smoke
Animal allergens (dander, saliva)
House-dust Mites, indoor mold, cockroach allergens
Reduce indoor humidity, remove carpets from bathroom, wash bed sheets
and blankets in hot water (> 130 degrees F) weekly.
Outdoor allergens (pollen)
Patients who are sensitive to these allergens should attempt to stay
inside with the windows closed
NSAIDS
       Patients who have had episodes of bronchospasm associated with
       ingestion of aspirin or other NSAIDs should be warned about the
       dangers of a fatal exacerbation with use of these drugs.
Sulfite sensitivity
        Patients who have had asthma symptoms after drinking beer, wine,
        dried fruits, processed potatoes or shrimp may have sulfite sensitivity.
        Patients should be advised to avoid foods containing sulfites.
Allergic Rhinitis/Sinusitis
        Patients should be treated with intranasal corticosteroids.
        Antihistamines and decongestants may improve allergic rhinitis
        symptoms but will not improve asthma symptoms like a corticosteroid.
Occupational exposures :
       Patients with a history of asthma who report worsening of symptoms
       during the week and improvement during the weekends should be
       evaluated for an occupational exposure.

Patient Instructions

OUTPATIENT STEP THERAPY FOR CHRONIC ASTHMA DURING PREGNANCY[5-7]

1. Mild intermittent:

Symptoms: Daytime no more than twice a week; nocturnal symptoms less than twice per month

Treatment:

Albuterol up to q.i.d. as needed.

2. Mild persistent

Symptoms: Daytime symptoms more 3 to 6 times per week; nocturnal more than twice per month

Treatment:

Albuterol up to q.i.d. as needed AND inhaled Cromolyn 2 to 4 puffs t.i.d to q.i.d.
If no response then
Low-dose inhaled corticosteroid with Nebulizer or MDI with holding chamber
- Beclomethasone dipropionate (84 mcg/dose) 2 puffs b.i.d OR
- Budesonide Turbohaler (200 mcg/dose) 1 puff b.i.d.

3. Moderate persistent:

Symptoms: Daily daytime symptoms; nocturnal symptoms more than once per week

Treatment:

Albuterol up to q.i.d. as needed AND
Medium-dose inhaled corticosteroid
- Beclomethasone dipropionate (84 mcg/dose) 4 to 6 puffs b.i.d OR
- Budesonide Turbohaler (200 mcg/dose) 2 puffs b.i.d.
If no response then add
Salmeterol 2 puffs b.i.d. AND/OR
Theophylline 10 mg/kg per day up to 300 mg maximum dose to reach serum concentrations of 8-12 ug/mL.

Consider referral to allergy or pulmonary specialist.

4. Severe persistent:

Symptoms: Throughout the day with limited activity; frequent nocturnal symptoms

Treatment:

Albuterol up to q.i.d. as needed AND
High-dose inhaled corticosteroid
- Beclomethasone dipropionate (84 mcg/dose) 4 to 6 puffs b.i.d OR
- Budesonide Turbohaler (200 mcg/dose) 2 puffs b.i.d.
If no response then add
Salmeterol 2 puffs b.i.d. AND/OR
Theophylline 10 mg/kg per day up to 300 mg maximum dose to reach serum concentrations of 8-12 ug/mL.
AND IF NEEDED
Corticosteroid tablet 1mg/kg/day generally not to exceed 60 mg per day.
- Prednisone 40 to 60 mg per day as single or divided dose for 3 to 10 days.

Referral to allergy or pulmonary specialist recommended.

Monitoring Treatment of Asthma [7]:

With each follow-up visit asthma patients should have the efficacy of their treatment reassessed.

Ask about daytime and nocturnal symptoms, quality of life (missed work, decreased activity, or sleep disturbances) and any exacerbations which may have occurred

Patients with moderate to severe persistent asthma should also learn how to monitor their peak expiratory flow rate.

This should be done every morning after awakening prior to use of a beta2-agonist.

They should also be given a written action plan and be instructed how to use it.

FETAL MONITORING [2-4]

Patients with moderate or severe asthma should have serial evaluation of fetal growth and antenatal testing after 34 weeks unless it is clinically indicated to begin such testing earlier.

INDICATIONS FOR HOSPITALIZATION

Post therapy PEFR less than 300 L/min

Initial respiratory failure (even with improvement)

The presence of complications such as:
     1. pneumonia
     2. pneumothorax
     3. cardiac arrhythmias

Repeat emergency room visit within 72 hours.

Admission Orders

REFERENCES:
1. Schatz M, Harden K, Forsythe A, et al: The course of asthma during pregnancy, postpartum and with successive pregnancies: A prospective analysis. J Allergy Clin Immunol 81:509-517, 1988
2. Schatz M, Zeiger RS, Hoffman CP, and the Kaiser-Permanente Asthma and Pregnancy Study Group: Intrauterine growth is related to gestational pulmonary function in pregnant asthmatic women. Chest 98:389-392,1990
3. Alexander S, Dodds L, Armson A Perinatal outcomes in women with asthma during pregnancy Obstet Gynecol 1998;92:435-440.
4.Schatz M Interrelationships between asthma and pregnancy: A literature review. J Allergy Clin Immunol. 1999 Feb;103(2 Pt 2):330-336. PMID: 9949333.
5. National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics--2002.
J Allergy Clin Immunol. 2002 ;110:S141-219. PMID: 12542074
6. Position statement: The use of newer asthma and allergy medications during pregnancy. Ann Allergy Asthma Immunol. 2000;84:475-480.
7. National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma NIH Publication No. 97-4051
8. Brancazio LR, Laifer SA, Schwartz T. Peak expiratory flow rate in normal pregnancy.Obstet Gynecol 1997 Mar;89(3):383-6
9. Wendel PJ, Ramin SM, Barnett-Hamm C, Rowe TF, Cunningham FG. Asthma treatment in pregnancy: A randomized controlled study Am J Obstet Gynecol 1996;175:150-4.
10. National Asthma Education Program. Report of the Working Group on Asthma and Pregnancy: executive summary. Management of asthma during pregnancy. Bethesda (MD): National Institutes of Health, National Heart, Lung, and Blood Institute; 1993 March.
11. Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment--Update 2004

Created: 4/1/2003 Mark Curran, M.D.
Updated: 9/1/2006 Mark Curran, M.D.

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