Management of Asthma Exacerbation in Pregnancy
Asthma exacerbations during pregnancy should be managed aggressively with immediate administration of short-acting beta-agonists (preferably albuterol) as first-line treatment, followed by systemic corticosteroids when exacerbations are not quickly controlled with bronchodilators, as uncontrolled asthma poses greater risks to both mother and fetus than the medications used to treat it. 1, 2
Initial Assessment and Treatment
Administer short-acting beta-agonists (SABAs), preferably albuterol, immediately as first-line treatment: 2.5 mg every 20 minutes for 3 doses, then every 1-4 hours as needed via nebulizer solution, or 4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours as needed via MDI 1
Add ipratropium bromide for severe exacerbations: 0.25 mg every 20 minutes for 3 doses, then every 2-4 hours as needed via nebulizer solution, or 4-8 puffs as needed via MDI 1
Measure arterial blood gases in severe cases to assess maternal and fetal oxygenation 1
Involve the obstetrical care provider in assessment and monitoring 1
Systemic Corticosteroid Administration
Add systemic corticosteroids when exacerbations are not quickly controlled with bronchodilators 1, 2
For outpatient management: Prednisone 40-60 mg daily for 3-10 days 2
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 1, 2
The goal is to alleviate asthma symptoms and attain peak expiratory flow rate or forced expiratory volume in 1 second of 70% predicted or more 3
Hospital Management Considerations
Maintain adequate oxygenation of the fetus by prevention of hypoxic episodes in the mother 3
Continue asthma medications during labor 3
For severe persistent asthma requiring additional medication after Step 3 therapy, increase inhaled corticosteroid dose within the high-dose range, with budesonide being the preferred option 4
If high-dose inhaled corticosteroids are insufficient, addition of systemic corticosteroids is warranted despite some uncertainty about risks during pregnancy, as severe uncontrolled asthma poses definite risks to mother and fetus 4
Monitoring During and After Treatment
Schedule monthly evaluations of asthma history and pulmonary function throughout pregnancy 1, 2
After an exacerbation, step down to the least medication necessary to maintain control 1, 2
Consider serial ultrasounds starting at 32 weeks gestation for patients with moderate to severe asthma or suboptimally controlled asthma 1
Monitor for comorbid conditions that may exacerbate asthma, such as rhinitis, sinusitis, and gastroesophageal reflux 4
Long-term Management After Exacerbation
Inhaled corticosteroids are the preferred long-term control medication during pregnancy, with budesonide having the most safety data 1, 2
For allergic rhinitis management, which can exacerbate asthma, use intranasal corticosteroids as they have low risk of systemic effects at recommended doses 4
For antihistamine use, prefer loratadine or cetirizine 4
Evidence from randomized controlled trials shows that adding long-acting inhaled beta2-agonists to a low dose of inhaled corticosteroid provides greater asthma control than only increasing the dose of corticosteroid 4
Common Pitfalls to Avoid
Do not withhold or reduce asthma medications due to pregnancy concerns, as uncontrolled asthma poses greater risks to both mother and fetus than the medications used to treat it 1, 2
Avoid oral decongestants in early pregnancy due to potential association with rare birth defects 4, 1
Do not delay treatment of exacerbations, as asthma exacerbations during pregnancy have potential to lead to severe problems for the fetus 4
Recognize that uncontrolled asthma increases the risk of perinatal mortality, pre-eclampsia, preterm birth, and low birth weight infants 2, 5
Be aware that severe and poorly controlled asthma may be associated with increased prematurity, need for cesarean delivery, preeclampsia, growth restriction, and other perinatal complications 3