Management of Acute Asthma Exacerbation in Pregnancy
Treating asthma exacerbations aggressively during pregnancy is essential as inadequate control poses a greater risk to both mother and fetus than the medications used to treat it. 1
Initial Assessment and Treatment
First-line treatment: Short-acting beta-agonists (SABAs), preferably albuterol, should be administered immediately 2, 3
Add ipratropium bromide for severe exacerbations 1:
- Nebulizer solution: 0.25 mg every 20 minutes for 3 doses, then every 2-4 hours as needed
- MDI: 4-8 puffs as needed
Systemic Corticosteroids
- Add systemic corticosteroids when exacerbations are not quickly controlled with bronchodilators 2
- Dosing recommendations 1, 2:
- For outpatient management: Prednisone 40-60 mg daily for 3-10 days
- For 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
Hospital Management Considerations
- Continuous pulse oximetry monitoring to ensure maternal oxygen saturation ≥95% 4
- Consider arterial blood gas measurement in severe cases to assess maternal and fetal oxygenation 1
- Maintain aggressive hydration to prevent mucus plugging 5
- For severe, unresponsive cases, consider intravenous magnesium sulfate as adjunct therapy 6
Monitoring During and After Treatment
- Monthly evaluations of asthma history and pulmonary function are recommended throughout pregnancy 1, 2
- After an exacerbation, step down to the least medication necessary to maintain control 2
- Consider using fraction of exhaled nitric oxide (FeNO) measurements to guide therapy adjustments, as this approach has been shown to reduce exacerbations during pregnancy 7
Special Considerations
- Involve the obstetrical care provider in assessment and monitoring 1
- Consider serial ultrasounds starting at 32 weeks gestation for patients with moderate to severe asthma or suboptimally controlled asthma 8, 5
- Maintain asthma medications during labor 5
Common Pitfalls to Avoid
- Do not withhold or reduce asthma medications due to pregnancy concerns - uncontrolled asthma poses greater risks to both mother and fetus than the medications used to treat it 1, 2, 6
- Do not delay corticosteroid administration when indicated, as untreated exacerbations can lead to maternal hypoxia and adverse fetal outcomes 2, 9
- Do not use oral decongestants in early pregnancy due to potential association with rare birth defects 1
Long-term Management After Exacerbation
- Review medication technique, adherence, and environmental triggers 2
- Consider stepping up long-term controller therapy if exacerbations are frequent 2
- Inhaled corticosteroids are the preferred long-term control medication during pregnancy, with budesonide having the most safety data 2, 8
Remember that maintaining adequate oxygenation for the fetus by preventing hypoxic episodes in the mother is the ultimate goal of asthma therapy during pregnancy 5.