What is the recommended treatment for asthma exacerbation in pregnancy?

Treatment of Asthma Exacerbation in Pregnancy

For asthma exacerbations during pregnancy, the recommended first-line treatment includes oxygen therapy to maintain SpO2 >95%, albuterol (2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for 3 doses), ipratropium bromide for severe exacerbations, and systemic corticosteroids (40-60 mg/day prednisone) for moderate to severe exacerbations. 1

Initial Assessment and Management

Assessment Parameters:

• Respiratory rate
• Heart rate
• Oxygen saturation
• Peak expiratory flow (PEF) or FEV1

First-Line Treatment:

1. Oxygen therapy

   • Maintain SpO2 >95% to ensure adequate fetal oxygenation 1

2. Short-Acting Beta-Agonists (SABAs)

   • Albuterol is the preferred SABA during pregnancy 1
   • Dosing options:
     • Nebulizer: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed
     • MDI with spacer: 4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours as needed

3. Anticholinergics for Severe Exacerbations

   • Ipratropium bromide 1
   • Dosing options:
     • Nebulizer: 0.5 mg every 20 minutes for 3 doses, then as needed
     • MDI: 8 puffs every 20 minutes as needed up to 3 hours

4. Systemic Corticosteroids

   • For moderate to severe exacerbations 1
   • Prednisone 40-60 mg/day for outpatient treatment
   • 120-180 mg/day in 3-4 divided doses for 48 hours for severe exacerbations

Rationale and Evidence

It is safer for pregnant women to be treated with asthma medications than to experience asthma symptoms and exacerbations 2. Uncontrolled asthma poses greater risks to both mother and fetus than the potential risks of asthma medications, including:

• Perinatal mortality
• Pre-eclampsia
• Preterm birth
• Low birth weight infants
• Maternal hypoxia affecting fetal oxygenation 1

Asthma exacerbations during pregnancy confer additional risk and must be promptly recognized and treated with systemic corticosteroids and bronchodilators 3. The ultimate goal of asthma therapy during pregnancy is maintaining adequate oxygenation of the fetus by preventing hypoxic episodes in the mother 2.

Criteria for Hospitalization

Consider hospitalization for any of the following 1:

• Failure to respond to initial emergency treatment
• PEF or FEV1 <70% of predicted after initial treatment
• Persistent hypoxemia
• History of severe asthma requiring intubation
• Presence of high-risk comorbidities

Follow-up and Monitoring

• Arrange follow-up within 1-2 weeks after an exacerbation 1
• Provide a written asthma action plan specific for pregnancy 1
• Implement monthly evaluation of asthma symptoms and pulmonary function during pregnancy 1
• Consider serial ultrasound examinations starting at 32 weeks for women with suboptimally controlled asthma 1, 2
• Continue asthma medications during labor 2

Common Pitfalls to Avoid

1. Undertreating asthma during pregnancy

   • Evidence suggests that both chronic asthma and acute asthma exacerbations remain undertreated in pregnancy 3
   • Clinicians should actively discourage discontinuation or de-escalation of asthma therapies during pregnancy 3

2. Failing to educate patients

   • Educate women on the safety and importance of these medications for both themselves and their offspring 3
   • Patient's difficulty in complying with treatment often stems from an unjustified fear of teratogenicity 4

3. Lack of coordinated care

   • Coordination between healthcare professionals (general practitioner, respiratory specialist, and gynecologist) is essential throughout pregnancy 4

4. Inadequate monitoring

   • Failure to objectively monitor lung function can lead to poor outcomes 2
   • Use peak expiratory flow rate, spirometry to measure FEV1, or both for monitoring 2