What is the recommended treatment for asthma exacerbation in pregnancy?

Treatment of Asthma Exacerbation in Pregnancy

For asthma exacerbations during pregnancy, prompt treatment with albuterol (2-4 puffs as needed or via nebulizer) and systemic corticosteroids (40-60 mg/day prednisone for outpatient treatment) is strongly recommended to prevent adverse maternal and fetal outcomes. 1

Initial Assessment and Management

First-Line Treatment

• Short-Acting Beta-Agonists (SABA):

  • 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 1

• Systemic Corticosteroids:

  • Essential for moderate to severe exacerbations
  • Outpatient dosing: 40-60 mg/day prednisone
  • Severe exacerbation dosing: 120-180 mg/day in 3-4 divided doses for 48 hours 1
  • Do not withhold systemic corticosteroids due to pregnancy concerns, as uncontrolled asthma poses greater risks to both mother and fetus 2

• Adjunctive Treatment:

  • Ipratropium bromide for severe exacerbations:
    • 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 1

Monitoring During Exacerbation

• Assess response to initial treatment with objective measures (PEF or FEV1)
• Target PEF or FEV1 ≥70% of predicted 3
• Monitor oxygen saturation to maintain maternal SpO2 ≥95% to ensure adequate fetal oxygenation 4
• Arrange follow-up within 1-2 weeks after an exacerbation 1

Indications for Hospitalization

Consider hospitalization for any of the following:

• 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 1

Prevention of Future Exacerbations

• Provide a written asthma action plan specific for pregnancy 1
• Schedule monthly evaluation of asthma symptoms and pulmonary function during pregnancy 1
• Use inhaled corticosteroids as maintenance therapy for persistent asthma 2
• Do not discontinue or reduce asthma medications during pregnancy 2
• Consider using an inflammation-guided approach (FeNO monitoring) to adjust treatment 4, 5

Important Considerations

Maternal and Fetal Risks

• Uncontrolled asthma and exacerbations during pregnancy are associated with:
  • Preeclampsia
  • Preterm labor
  • Increased risk of cesarean delivery
  • Low birth weight and small-for-gestational-age infants
  • Neonatal respiratory distress 2, 3

Safety of Medications

• The risks of uncontrolled asthma far outweigh the potential risks of medication use 3
• Inhaled corticosteroids are considered safe in pregnancy 2
• Albuterol has reassuring safety data from large cohorts (adjusted OR 0.93,95% CI 0.80-1.08 for major congenital malformations) 1

Common Pitfalls to Avoid

1. Undertreating asthma exacerbations due to concerns about medication safety in pregnancy
2. Discontinuing controller medications during pregnancy, which increases exacerbation risk
3. Delaying systemic corticosteroid administration when indicated
4. Inadequate follow-up after an exacerbation
5. Failing to address comorbidities like rhinitis that can worsen asthma control 5

Multidisciplinary Approach

• Involve obstetricians, asthma specialists, and pediatricians in care planning 6
• Consider serial ultrasound examinations starting at 32 weeks for women with suboptimally controlled asthma 1
• Address comorbidities such as rhinitis, obesity, and mental health issues that may affect asthma control 5