Clinical Review

Safe, efficient management of acute asthma

OBG Manag. 2006 April;18(4):30-44

References

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2. Otsuka H, Narushima M, Suzuki H. Assessment of inhaled corticosteroid therapy for asthma treatment during pregnancy. Allergology Int. 2005;54:381-386.

3. Gluck JC, Gluck PA. The effects of pregnancy on asthma: a prospective study. Ann Allergy. 1976;37:164-168.

4. Schatz M, Harden K, Forsythe A, et al. The course of asthma during pregnancy, post partum, and with successive pregnancies: a prospective analysis. J Allergy Clin Immunol. 1988;81:509-517.

5. Mabie WC, Barton JR, Wasserstrum N, et al. Clinical observations on asthma in pregnancy. J Matern Fetal Med. 1992;1:45-50.

6. Beck SA. Asthma in the female: hormonal effect and pregnancy. Allergy Asthma Proc. 2001;22:1-4.

7. Lehrer S, Stone J, Lapinski R, et al. Association between pregnancy-induced hypertension and asthma during pregnancy. Am J Obstet Gynecol. 1993;168:1463-1466.

8. Alexander S, Dodds L, Armson BA. Perinatal outcomes in women with asthma during pregnancy. Obstet Gynecol. 1998;92:435-440.

9. Schatz M, Dombrowski M, Wise R, et al, for the Maternal-Fetal Medicine Units Network, The National Institute of Child Health and Development; The National Heart, Lung and Blood Institute. The relationship of asthma medication use to perinatal outcomes. J Allergy Clin Immunol. 2004;113:1040-1045.

10. Ericson A, Kallen B. Use of drugs during pregnancy-unique Swedish registration method that can be improved. Swedish Medical Products Agency. 1999;1:8-11.

11. Dombrowski MP, Schatz M, Wise R, et al, for the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network and the National Heart, Lung and Blood Institute. Asthma during pregnancy. Obstet Gynecol. 2004;103:5-12.

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15. National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program Asthma and Pregnancy Working Group. NAEPP expert panel report. Managing asthma during pregnancy: recommendations for pharmacologic treatment-2004 update [published correction appears in J Allergy Clin Immunol. 2005;115:477]. J Allergy Clin Immunol. 2005;115:34-46.

16. American College of Obstetricians and Gynecologists (ACOG) and The American College of Allergy, Asthma and Immunology (ACAAI). Position statement: The use of newer asthma and allergy medications during pregnancy. Ann Allergy Asthma Immunol. 2000;84:475-480.

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Both authors receive grant/research support from Astra Zeneca. In addition, Dr. Joan Gluck receives grant/research support from Sepracor.

Back off as asthma is controlled

Review treatment every 1 to 3 months; gradual stepwise reduction in treatment may be possible. The goal is to use the least medication necessary to maintain good control of symptoms.

General principles

Maintain pulmonary function to adequately oxygenate the fetus.
Prevent acute exacerbation.
Intervene promptly when treating acute exacerbation and associated conditions such as rhinitis, sinusitis, and gastroesophageal reflux (TABLE 1).
Prescribe daily anti-inflammatory therapy for persistent asthma.

Recommendations from ACOG and ACAAI

The American College of Obstetricians and Gynecologists and the American College of Allergy, Asthma, and Immunology also offer specific recommendations,¹⁶ which include:

Avoid zileuton (Zyflo), which causes adverse fetal effects in animals and lacks human data
Give the leukotriene modifiers montelukast (Singulair) or zafirlukast (Accolate) if the patient had a good pre-pregnancy response to these drugs
Budesonide (Rhinocort) is a good choice for high-dose inhaled corticosteroid and is now classified as a category B drug
Drugs to be avoided: alpha-adrenergic medications (except pseudoephedrine), iodides, tetracyclines, sulfonamides, and epinephrine (except for a life-threatening event)

In addition, we make sure:

Every woman with asthma of any severity has a beta-adrenergic short-acting (bronchodilator) inhaler as a “rescue” treatment and knows when and how to use it.
Women with persistent asthma have an action plan, and, in some cases, a peak-flow meter at home.
Every patient with asthma has oral prednisone at home, with instructions to start it immediately in the event of an exacerbation unresponsive to bronchodilators and other measures in the action plan.
Finally, we reassure gravidas that their asthma drugs will provide more benefit than harm to the fetus, compared with uncontrolled asthma.

Overcoming reluctance to treat

The reluctance to treat gravidas with asthma can be difficult to overcome, even with the proper assurance and education. Effective management requires a team effort, with communication between the allergist, obstetrician, and patient. Compliance will improve if women of childbearing age are treated with asthma drugs that can be safely continued during pregnancy.

At the first prenatal visit, reassure the patient that, in most cases, it is safer for her and her baby to control the asthma than to discontinue therapy. Every visit should include assessment of maternal asthma, and there should be a consultation with the allergist/pulmonologist whenever needed. Overall, helping a pregnant woman maintain control of her asthma and improve obstetric outcomes is easy—a matter of paying attention to the right details.