19-22: Asthma in Pregnancy

(See also Chapter 9.)

Asthma is one of the most common medical conditions encountered in pregnancy. Women with mild to moderate asthma can generally expect excellent pregnancy outcomes, but severe or poorly controlled asthma has been associated with several pregnancy complications, including preterm birth, small-for-gestational-age infants, and preeclampsia. The effects of pregnancy on asthma are likely minimal as asthma severity in the pregnancy has been reported to be similar to its severity during the year preceding the pregnancy. Strategies for treatment are similar to those in nonpregnant women. Patients should be educated about symptom management and avoidance of asthma triggers. Baseline pulmonary function tests can objectively assess lung function and may help the patient with self-monitoring of her asthma severity using a peak flow meter. As in nonpregnant women, treatment algorithms generally follow a stepwise approach, and commonly used medications, particularly those for mild to moderate asthma symptoms, are generally considered safe in pregnancy. Concerns about teratogenicity and medication effects on the fetus should be thoroughly discussed with the patient to decrease noncompliance rates. Inhaled beta-2-agonists are indicated for all asthma patients, and low to moderate dose inhaled corticosteroids are added for persistent symptoms when a rescue inhaler alone is inadequate. Systemic corticosteroid administration is reserved for severe exacerbations but should not be withheld, if indicated, irrespective of gestational age. Cromolyn, leukotriene receptor antagonists, and theophylline are appropriate alternative therapies if first-line management is ineffective. The primary goals of management in pregnancy include minimizing symptoms and avoiding hypoxic episodes to the fetus. Prostaglandin F2a and ergonovine—medications frequently used to treat postpartum uterine atony—should be avoided because they can precipitate bronchospasm in women with asthma.