What is the recommended management for asthma during pregnancy?

Asthma Management During Pregnancy

Active asthma management during pregnancy is essential to reduce risks of adverse maternal and fetal outcomes, including monthly monitoring of symptoms by a multidisciplinary team of obstetric and respiratory providers. 1

Risks of Poorly Controlled Asthma During Pregnancy

Maternal asthma is associated with significant adverse outcomes that can be mitigated with proper management:

• Maternal risks: Increased exacerbations (particularly in second and third trimesters), pre-eclampsia, gestational diabetes, and cesarean section 1
• Fetal/neonatal risks: Pre-term birth, low birthweight (46% increased risk), small for gestational age, perinatal mortality, and neonatal hospitalization 1

Management Approach

Monitoring and Assessment

• Monthly monitoring of asthma symptoms throughout pregnancy 1, 2
• Initial assessment: Spirometry to establish baseline lung function 2
• Home monitoring: Peak flow monitoring for ongoing assessment 2
• Additional monitoring: Consider serial ultrasound examinations starting at 32 weeks for women with suboptimally controlled asthma 2

Pharmacological Management

1. Controller Medications:

   • Inhaled corticosteroids (ICS) are the preferred treatment for persistent asthma during pregnancy 1
   • Large studies demonstrate the relative safety of ICS use regarding congenital malformations 1
   • Budesonide has particularly extensive safety data in pregnancy 3

2. Rescue Medications:

   • Albuterol is the preferred short-acting beta-agonist (SABA) during pregnancy 2
   • Dosing options:
     • MDI with spacer: 2-4 puffs as needed for symptoms; 4-8 puffs every 20 minutes for 3 doses during exacerbations
     • Nebulizer: 2.5-5 mg every 20 minutes for 3 doses during exacerbations 2

3. Exacerbation Management:

   • Systemic corticosteroids (prednisone): 40-60 mg/day for outpatient treatment of moderate exacerbations
   • For severe exacerbations: 120-180 mg/day in 3-4 divided doses for 48 hours 2
   • Ipratropium bromide can be added for severe exacerbations 2

Non-Pharmacological Approaches

• Exercise: Regular moderate-intensity exercise with appropriate modifications as pregnancy progresses 1, 2
• Hydration and humidity: Increased fluid intake and humidifier use 2
• Trigger avoidance: Identify and minimize exposure to asthma triggers 1
• Vitamin D supplementation: Consider for pregnant women with asthma, as low levels are associated with adverse respiratory outcomes in infants 1

Special Considerations

Medication Safety

• The risk of uncontrolled asthma typically outweighs the potential risks of medication use during pregnancy 3, 4
• FDA data shows budesonide (inhaled) has not been associated with increased risk of congenital malformations 3
• For combination medications containing salmeterol, animal studies show potential risks at doses far exceeding human therapeutic doses, but clinical experience supports safety at recommended doses 4

Exacerbation Prevention

• Written asthma action plan specific for pregnancy 2
• FeNO-guided management (measuring exhaled nitric oxide) has been shown to reduce exacerbations, neonatal hospitalization, and later development of childhood asthma 1

Postpartum Considerations

• Breastfeeding is encouraged and may help prevent allergies in infants, particularly those at higher risk, when continued for at least 4 months 1
• Asthma medications should be continued during labor and breastfeeding 5

Red Flags for Referral or Hospitalization

• Cough with fever, dyspnea, hemoptysis, or significant chest pain 2
• Failure to respond to initial emergency treatment 2
• PEF or FEV1 <70% of predicted after initial treatment 2
• Persistent hypoxemia 2

Pitfalls to Avoid

• Discontinuing controller medications: This is a common but dangerous practice that can lead to exacerbations
• Inadequate monitoring: Monthly assessment is crucial due to the unpredictable course of asthma during pregnancy 1
• Delayed treatment of exacerbations: Aggressive management is essential to prevent maternal hypoxia and fetal compromise 6
• Overlooking comorbidities: Conditions such as rhinitis, GERD, and mental health issues can worsen asthma control and should be addressed 7