Clinical Review

Safe, efficient management of acute asthma

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Fear that drugs will harm the fetus is the biggest barrier to control, but uncontrolled asthma is more dangerous


 

References

CASE Could fetal loss have been prevented?

“L.S.” is a 23-year-old gravida at 16 weeks’ gestation who is experiencing severe asthma. Prior to pregnancy, her asthma was moderate and persistent, but was well-controlled on a low-dose inhaled corticosteroid accompanied by monthly use of a short-acting beta-2 adrenergic inhaler and weekly allergy injections. When she learned she was pregnant, L.S. stopped all treatment except for the beta-2 adrenergic inhaler, which she now uses daily.

After stopping treatment, she remained stable until a viral infection developed, causing shortness of breath and wheezing that are affecting her sleep and daytime activity.

A physical examination reveals audible wheezing with nasal flaring and some retraction at the sternal notch. L.S. is treated with nebulized albuterol and ipratropium in the office, but refuses an injection of corticosteroid.

She is told to start oral steroids and advised that failure to do so will put her at increased risk for pregnancy complications, including fetal loss.

She calls later the same day from the hospital to report vaginal bleeding and continued wheezing. She is admitted and treated with intravenous steroids, nebulized beta-2 adrenergics, and oxygen, but suffers spontaneous abortion.

Many women assume “less is more” when it comes to asthma medications in pregnancy. When L.S. stopped her inhaled corticosteroid therapy, she mistakenly believed she was protecting her fetus. In actuality, it destabilized her condition and led to the pregnancy loss.

With few exceptions, the medications needed to control asthma will diminish maternal and fetal complications, and are safer—for both mother and fetus—than uncontrolled asthma.

The biggest barrier to good control of asthma during pregnancy is the fear—on the part of both physician and patient—that asthma medication may harm the fetus.1,2

This article reviews current understanding of:

  • Asthma control before and during gestation
  • How to prevent acute asthma in the first place
  • Safe treatment of acute asthma in pregnancy

Asthma is the most common chronic disease in pregnancy

Asthma in pregnancy is not an isolated occurrence but the most common chronic disease in pregnancy. It affects almost 7% of women. About one third of gravidas with asthma experience an exacerbation during pregnancy.

If the asthma is well controlled, however, it need not increase pregnancy risks. Asthma control means:

  • Minimal or no chronic symptoms day or night
  • Minimal or no exacerbations
  • No limitations on activities
  • Maintenance of near-normal pulmonary function
  • Minimal use of short-acting inhaled beta-2 agonist
  • Minimal or no adverse drug effects

For best results, continue asthma treatment throughout pregnancy, and closely monitor women with severe asthma, especially around 26 weeks’ gestation, as they are more likely to experience disease exacerbation. Treatment for acute asthma is similar to therapy in nonpregnant women.

Manage asthma exacerbations aggressively. When exacerbations do occur during pregnancy despite our best efforts, aggressive management—whether at home or in the hospital—is recommended by the National Asthma Education and Prevention Program (TABLE 1).

TABLE 1

What to do if asthma worsens

OUTPATIENT MANAGEMENT
Assess severity
  • Measure PEF (<50% personal best means severe exacerbation)
  • Use of accessory muscles and suprasternal retraction correlates with severity
  • Note fetal activity by change in fetal kick count
Treatment
  • Short-acting beta-2 agonist metered-dose inhaler: 2–4 puffs every 20 minutes, up to 3 times
  • Oral corticosteroid: 40–60 mg/day for 3–10 days
  • Ipratropium metered-dose inhaler: 4–8 puffs as needed
  • If severe distress or poor response to treatment: prompt emergency assessment
EMERGENCY DEPARTMENT AND INPATIENT MANAGEMENT
Initial assessment
  • History and physical
  • PEF or FEV1
  • Oxygen saturation
  • Fetal assessment (consider continuous electronic fetal monitoring and/or biophysical profile if fetus is viable)
Treatment
  • Nebulized albuterol: 2.5–5.0 mg every 20 minutes for 3 doses, then 2.5–10 mg every 1–4 hours as needed
  • Nebulized ipratropium: 0.5 mg every 30 minutes for 3 doses, then every 2–4 hours as needed
  • Oxygen
  • Systemic corticosteroids: 120–180 mg/day in 3 or 4 divided doses for 48 hours, then 60–80 mg/day until PEF=70%
  • Consider intravenous aminophylline: 6 mg/kg loading dose, 0.5 mg/kg per hour initial maintenance; keep theophylline level between 8 and 12 μg/mL
  • Consider 0.25 mg subcutaneous terbutaline or magnesium sulfate if no response to therapy
FEV1=forced expiratory volume in the first second of pulmonary function test, PEF=peak expiratory flow.
SOURCE: Modified from National Heart, Lung, and Blood Institute15

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