Are oral corticosteroids (OCS) appropriate for managing asthma exacerbations in pregnancy?

Oral Corticosteroids for Asthma Exacerbations During Pregnancy

Oral corticosteroids are appropriate and necessary for managing asthma exacerbations during pregnancy, as it is safer for pregnant women to be treated with asthma medications than to have uncontrolled asthma symptoms and exacerbations that can lead to maternal hypoxia and adverse fetal outcomes. 1, 2

Benefits of Treating Asthma Exacerbations During Pregnancy

• Uncontrolled asthma increases the risk of perinatal mortality, pre-eclampsia, preterm birth, and low birth weight infants 1, 2
• Maintaining lung function is essential to ensure adequate oxygen supply to the fetus 1, 3
• Asthma exacerbations during pregnancy confer additional risk and must be promptly recognized and treated 3
• Up to 45% of pregnant women with asthma may experience exacerbations requiring medical intervention 4

Management Approach for Asthma Exacerbations in Pregnancy

First-Line Treatment

• Short-acting beta-agonists (preferably albuterol) should be used first: 2-4 puffs every 20 minutes for up to 3 doses or a single nebulizer treatment as needed 1
• Albuterol is the preferred SABA because more safety data are available during pregnancy 1

When to Add Oral Corticosteroids

• A course of systemic corticosteroids is indicated when exacerbations are not quickly controlled with bronchodilators 1
• Oral corticosteroids should be used when asthma symptoms are not controlled with other medications or during severe exacerbations 2, 5

Dosing of Oral Corticosteroids

• For outpatient management: Prednisone 40-60 mg daily for 3-10 days 1
• For more severe exacerbations: Prednisone 120-180 mg/day in 3-4 divided doses for 48 hours, then 60-80 mg/day until peak expiratory flow reaches 70% of predicted or personal best 1

Safety Considerations

• FDA classifies corticosteroids as Pregnancy Category C 6
• Animal studies have shown increased incidence of cleft palate in offspring, but the benefits of treating severe asthma exacerbations outweigh potential risks 6
• The major risk to the fetus in pregnant asthmatics is hypoxia from uncontrolled bronchospasm, not from medication therapy 7
• Use the lowest possible dose of systemic corticosteroids needed to control symptoms 7

Monitoring During and After Treatment

• After an exacerbation, step down to the least medication necessary to maintain control 1
• Regular monitoring of asthma symptoms and lung function is recommended throughout pregnancy 1, 2
• Monthly evaluations allow for therapy adjustments as needed, as asthma improves in 1/3 of women and worsens for 1/3 during pregnancy 1
• Consider ultrasound monitoring for fetal growth in pregnancies complicated by moderate or severe asthma 8

Common Pitfalls to Avoid

• Discontinuing asthma medications during pregnancy due to unfounded safety concerns, which can lead to poor asthma control 2, 9
• Not treating exacerbations aggressively enough, which can lead to maternal hypoxia and adverse fetal outcomes 2, 5
• Delaying treatment with oral corticosteroids when indicated, as prompt treatment is essential to prevent complications 3, 4

Long-term Management After Exacerbation

• After controlling the exacerbation, review medication technique, adherence, and environmental triggers 1
• Consider stepping up long-term controller therapy if exacerbations are frequent 1
• Inhaled corticosteroids are the preferred long-term control medication during pregnancy, with budesonide having the most safety data 1, 9

Remember that maintaining asthma control during pregnancy is critical for both maternal and fetal well-being, and oral corticosteroids play an important role in managing exacerbations when they occur.