Managing Asthma in Expectant Mothers

Pregnancy does not appear to have a consistent effect on the frequency or severity of asthma. The most common cause of worsening asthma in pregnancy is likely to be noncompliance with medication. Emphasizing to the patient in advance that fetal well-being is dependent on maternal well-being may help prevent this.In general, well controlled asthma is not associated with a higher risk of adverse pregnancy outcomes. Essential to successful asthma management is patient education that helps to ensure effective medication use, avoidance of triggers, and prompt treatment. This education should include measurement of peak expiratory flow rate and a written asthma action plan. Most of the medications that are used to control asthma in the general population can be safely used in pregnant women. Inhaled beta-adrenoceptor agonists (beta-agonists), cromolyn sodium (sodium cromoglycate), and inhaled and systemic corticosteroids all appear to be very well tolerated by the fetus. Budesonide and beclomethasone should be considered as the preferred inhaled corticosteroids for the treatment of asthma in pregnancy. Use of the leukotriene receptor antagonists zafirlukast and montelukast in pregnancy is probably safe but should be limited to special circumstances, where they are viewed essential for asthma control. Zileuton should not be used in pregnancy.Acute asthma exacerbations in pregnant women should be treated in a similar manner to that in non-pregnant patients. Maternal blood glucose levels should be monitored periodically in pregnant women receiving systemic corticosteroids because of the deleterious effects of hyperglycemia upon embryos and fetuses. During pregnancy, maternal arterial oxygen saturations should be kept above 95% if possible for fetal well-being. Ambulatory oxygenation should be checked prior to discharge to ensure that women do not desaturate with their daily activities.Acute exacerbations of asthma during labor and delivery are rare. Dinoprost, ergometrine, and other ergot derivatives can cause severe bronchospasm, especially when used in combination with general anesthesia, and should be avoided in asthmatic patients. Pregnant women who have been treated with corticosteroids in the past year may require stress-dose corticosteroids during labor and delivery. Most asthma medications, including oral prednisone, are considered compatible with breast-feeding.     

Asthma in pregnancy.

Most gravidas with asthma can be managed with an inhaled beta-adrenergic agonist (terbutaline or epinephrine) and beclomethasone dipropionate. The administration of prednisone to control exacerbation of asthma is appropriate and should not be withheld if current medications are inadequate. The outcome of pregnancy in gravidas with asthma can approach that of the general population if asthma is controlled effectively. There may be an increased incidence of preterm deliveries or preeclampsia in women with asthma during pregnancy.     

妊娠期支气管哮喘治疗进展

临床研究已证明妊娠期重度及控制不佳的支气管哮喘(简称哮喘)与母亲及胎儿严重并发症相关.对于妊娠期哮喘患者,接受药物治疗比存在哮喘症状和哮喘发作更安全.所有程度的持续妊娠哮喘患者都应当应用吸入糖皮质激素作为控制药物,首选布地奈德.白三烯受体拮抗剂可以缓解支气管痉挛、减轻症状、改善肺功能.长效β2受体激动剂对于正在应用吸入糖皮质激素的患者可作为首选的添加药物.吸入短效β2受体激动剂可以作为缓解药物.对于正在接受维持量或接近维持量治疗,无不良反应、临床疗效好的妊娠哮喘患者可以继续进行变应原免疫治疗.     

The importance of control in asthma management: do leukotriene receptor antagonists meet patient and physician needs?

Achieving control of asthma is a major goal of asthma management. Overreliance on high doses of a beta-agonist or a recent increase in beta-agonist requirement, increasing or wide variability in peak expiratory flow (PEF), and increased frequency of nocturnal symptoms are indicators of poor or declining asthma control, which should highlight the need to take action to avoid the risk of severe and potentially life-threatening asthma exacerbations. The prevention of exacerbations is important because these often require unscheduled physician visits and involve costly medical care. If control is not achieved, diagnosis, treatment, and compliance with therapy should be reviewed, stepping up to a more powerful treatment only if necessary to control symptoms. Many patients often receive inadequate treatment despite the best intentions of their physician. Incorrect inhaler technique and non-compliance with prescribed inhaled asthma therapy may contribute to treatment failure in 50% of patients and are recognized increasingly as reasons for poor response to treatment. Growing evidence indicates that leukotriene receptor antagonists (LTRAs) are useful as controller agents. As a simple tablet therapy, LTRAs should be considered as an alternative treatment option to inhaled corticosteroids in specific patient groups who are poorly compliant or reluctant to use inhaled corticosteroids. These agents reduce the risk of asthma exacerbations and are associated generally with improved compliance compared with inhaled corticosteroids or cromolyn sodium. Moreover, add-on therapy with LTRAs can provide additional benefits to patients whose asthma is not controlled adequately with existing doses of inhaled corticosteroids, and the complementary benefits obtained with these drugs facilitate the achievement of long-term control without the need for increasing the dose of corticosteroids.     

Treatment strategies in rhinoconjunctivitis and asthma during pregnancy

BackgroundThe incidence of asthma is high, especially in young people, a population group that in-cludes women of reproductive age. We reviewed recent publications on asthma control during pregnancy to avoid undesired effects on both the mother and fetus. The prevalence of rhinoconjunctivitis is also high, although this disease is often under-treated by physicians. The use of β₂-agonists, corticoids (systemic/inhaled/nebulized), epinephrine and specific allergen immunotherapy is discussed.MethodsWe reviewed recent publications on asthma during pregnancy as well as other articles of interest. Articles providing data on drug therapy, overall strategies and patient education were selected. Sufficient drugs are available for the management of this disease and under-treatment cannot be justifiedConclusionsPregnancy is not a disease, but constitutesa period when special care must be taken with underlying diseases. The aim of asthma treatment during pregnancy is to prevent fetal complications due to the effects of medication and asthma crises by keeping the mother symptom free and preventing possible exacerbations. Almost all authors agree that asthma crises in pregnant women should be treated no differently from those in non-pregnant women. Treatment of rhinoconjunctivitis should not be stopped during pregnancy since a wide variety of FDA category B drugs is available. Specific allergen immunotherapy should not be suspended during pregnancy as it is not contraindicated. However, this therapy should not be initiated during pregnancy.     

妊娠期支气管哮喘控制药物的应用

应积极控制妊娠期支气管哮喘(简称哮喘)确保母婴健康;对不同级别的持续性哮喘可应用不同剂量吸人性激素控制(推荐布地奈德),当病情不能得到很好控制时,可根据药物妊娠危险性的分类标准和2004年美国哮喘教育和预防项目(NAEPP)妊娠哮喘防治指南选择其他药物;哮喘控制药物妊娠期应用的安全性和有效性仍需进一步评价.     

Asthma and pregnancy

Asthma is the most frequent respiratory disorder complicating pregnancy. Diagnosis and evaluation of severity of asthma are unchanged by the presence of pregnancy, but the course of asthma varies: asthma may improve, remain stable, or worsen. Conversely, chronically poor control is associated with pregnancy-induced hypertension, preeclampsia, as well as greater rates of cesarian section, preterm delivery, intrauterine growth retardation, low birth weight, and congenital malformation. Highly-motivated women with well-controlled asthma during pregnancy, can achieve pregnancy outcome as good as their non-asthmatic conterparts. Inhalation therapies remain the cornerstone of treatment; most appear to be safe in pregnancy.     

Asthma in pregnancy

Although about 1% of pregnant women have asthma, it is often underrecognized and suboptimally treated. The course of asthma during pregnancy varies; it improves, remains stable, or worsens in similar proportions of women. The risk of an asthma exacerbation is high immediately postpartum, but the severity of asthma usually returns to the preconception level after delivery and often follows a similar course during subsequent pregnancies. Changes in beta(2)-adrenoceptor responsiveness and changes in airway inflammation induced by high levels of circulating progesterone have been proposed as possible explanations for the effects of pregnancy on asthma. Good control of asthma is essential for maternal and fetal well-being. Acute asthmatic attacks can result in dangerously low fetal oxygenation. Chronically poor control is associated with pregnancy-induced hypertension, preeclampsia, and uterine hemorrhage, as well as greater rates of cesarian section, preterm delivery, intrauterine growth retardation, low birth weight, and congenital malformation. Women with well-controlled asthma during pregnancy, however, have outcomes as good as those in their nonasthmatic counterparts. Inhaled therapies remain the cornerstone of treatment; most appear to be safe in pregnancy.     

Asthma during Pregnancy: The Experiences,Concerns and Views of Pregnant Women with Asthma

Objective. To investigate how pregnant women manage their asthma during pregnancy and factors influencing their behavior. Methods. In-depth interviews (telephone or face-to-face) with a purposive sample of 23 asthmatic women at various stages of pregnancy and with varying severity of asthma. Results. Five major themes were discerned relating to health behavior of pregnant women with asthma. Many of the participants decreased or discontinued their asthma medications themselves and refrained from taking doses when necessary during pregnancy without consulting their doctors. Reasons behind their decisions revolved around lack of support and information about what to do, concerns about the safety of the medications, past experiences, and desire for an “all natural” pregnancy. Asthma monitoring during pregnancy was seen as a low priority for some women and their doctors. Communication between pregnant women and health professionals regarding asthma management was poor. The health behavior of pregnant women with asthma could be explained using the Health Beliefs Model. Conclusions. Pregnant women are not well supported in managing asthma during pregnancy, despite being concerned about outcomes. Interventions, education, and more support are warranted and wanted by pregnant women with asthma to optimize pregnancy and neonatal outcomes.     

Pregnancy and asthma: recent developments

PURPOSE OF REVIEW: Asthma is the most common potentially serious medical problem to complicate pregnancy. Asthmatic women have been shown to be at an increased risk of complications during pregnancy. Managing asthma during pregnancy is unique because the effects of both the illness and the treatment on the developing fetus and the patient must be considered. RECENT FINDINGS: This review summarizes the recent studies addressing the interrelationships between asthma and pregnancy and general aspects of pharmacologic therapy of gestational asthma. SUMMARY: The prevalence of asthma in pregnant women appears to be increasing. Recent evidence supports that pregnant asthmatic women with moderate to severe asthma may have an increased risk of adverse perinatal outcomes. The goal of asthma management during pregnancy is to optimize maternal and fetal health.     

Asthma und Schwangerschaft

Approximately 4-12 % of pregnant women suffer from asthma. The aims of asthma therapy in pregnant women are sufficient control of the asthma and oxygen supply to the fetus during pregnancy. Pharmacotherapy of pregnant women with asthma is no different from that in non-pregnant women. The possibility of severe side effects of medications can be disregarded when compared to the potential benefits for mother and fetus. The risk of congenital malformations is low but increases with the severity of the disease. Regular surveillance and control of asthmatics during pregnancy combined with a structured patient education contribute to a better control of asthma. In cases of asthma attacks, pregnant women should be treated in hospital and kept under close surveillance.     

Exercise-induced bronchoconstriction update: therapeutic management

Management of exercise-induced bronchoconstriction (EIB) should include both prevention and treatment directed toward the underlying asthma and bronchial hyperresponsiveness. Both nonpharmacologic and pharmacologic approaches should be followed. Preexercise warm-up, to take advantage of the refractory period that follows EIB, is an important preventive technique. Dietary interventions such as fish oil, vitamin D, and ascorbic acid have shown promising results. Beta 2-agonists are considered the most effective agents for EIB at this time but intermittent use is recommended to avoid tolerance or decreased effectiveness with daily regular use. Leukotriene inhibitors and mast cell stabilizing agents can be useful in EIB but are less effective than beta 2-agonists. Tolerance to beta 2-agonists is not prevented by concomitant use of inhaled corticosteroid but it is not known whether use of leukotriene inhibitors can affect tolerance. EIB in elite athletes with no underlying asthma may have a different pathogenesis.     

Geschlechtspezifische Differenzen bei Lungenerkrankungen

Gender differences can be observed not only in cardiac diseases but also in asthma, chronic obstructive pulmonary disease (COPD), lung cancer and mycobacterial diseases. A special case of a sex-related disease is lymphangioleiomyomatosis, a rare interstitial lung disease mostly observed in younger women. Clinical problems during pregnancy are of special interest. Although life expectation is higher in women throughout the world, there are a number of differences between men and women that should be carefully considered when making treatment decisions.     

Management of asthma and chronic airflow limitation: Are methylxanthines obsolete?

The widespread popularity of methylxanthine derivatives should be reassessed in light of current evidence. These drugs are relatively weak bronchodilators, respiratory muscle stimulants and inotropic agents and adverse effects, sometimes life threatening, occur fairly frequently. In contrast, beta-2 adrenergic and anticholinergic bronchodilator aerosols used in asthma or chronic obstructive lung disease, and the prophylactic anti-inflammatory aerosols of corticosteroids and cromolyn provide a spectrum of therapeutic choices which address both the inflammatory and bronchoconstrictor components of acute and chronic airflow limitation. Aerosol bronchodilators, in general, are more potent, are virtually free of important side effects, and do not require costly serum level monitoring. Adrenoceptor agonists, together with inhaled steroids, should be considered first-line drugs of choice in managing patients with reversible airflow obstruction associated with asthma or COPD, while methylxanthines should be relegated to the position of third or fourth line drugs, if they are to be used at all. If they are, they should be used with great caution and close patient supervision and, even then, only if benefit, over and above the aerosol bronchodilators and inhaled anti-inflammatory agents can be demonstrated objectively.     

Trends in asthma self-management skills and inhaled corticosteroid use during pregnancy and postpartum from 2004 to 2017

Objective: Asthma exacerbations and medication non-adherence are significant clinical problems during pregnancy. While asthma self-management education is effective, the number of education sessions required to maximise asthma management knowledge and inhaler technique and whether improvements persist postpartum, are unknown. This paper describes how asthma knowledge, skills, and inhaled corticosteroid (ICS) use have changed over time. Methods: Data were obtained from 3 cohorts of pregnant women with asthma recruited in Newcastle, Australia between 2004 and 2017 (N = 895). Medication use, adherence, knowledge, and inhaler technique were compared between cohorts. Changes in self-management knowledge/skills and women's perception of medication risk to the fetus were assessed in 685 women with 5 assessments during pregnancy, and 95 women who had a postpartum assessment. Results: At study entry, 41%, 29%, and 38% of participants used ICS in the 2004, 2007, and 2013 cohorts, respectively (p = 0.017), with 40% non-adherence in each cohort. Self-management skills of pregnant women with asthma did not improve between 2004 and 2017 and possession of a written action plan remained low. Maximum improvements were reached by 3 sessions for medications knowledge and one session for inhaler technique, and were maintained postpartum. ICS adherence was maximally improved after one session, but not maintained postpartum. Perceived risk of asthma medications on the fetus was highest for corticosteroid-containing medication; and was significantly reduced following education. Conclusions: There was a high prevalence of non-adherence and poor self-management skills in all cohorts. More awareness of the importance of optimal asthma management during pregnancy is warranted, since no improvements were observed over the past decade.     

Inhaled corticosteroids (budesonide): the cornerstone of asthma therapy--what are the options?

The clinical value of corticosteroids in treating asthma has long been recognised. Major advances in the use of these drugs came with the introduction of inhaled corticosteroids (ICS) and the recognition that even mild asthma has an inflammatory component. ICS are now considered as first-line therapy in all asthma treatment guidelines. Over the past decade there has been clarification of the dose-response relationship with ICS and confirmation of the general long-term efficacy and safety of these drugs in both adults and children. Recent work has focused on simplifying dosing regimens and investigating flexibility of dosing. Moreover, ICS can be used in combination with other agents such as long-acting inhaled beta(2)-agonists to provide effective asthma control in patients with persistent asthma not adequately controlled on ICS alone. Thus, ICS remain the cornerstone of modern asthma therapy.