What is the recommended management for asthma in pregnant women?

Management of Asthma During Pregnancy

Pregnant women with asthma should continue or initiate inhaled corticosteroids as the cornerstone of therapy, with budesonide as the preferred agent, and use albuterol as the preferred short-acting bronchodilator for rescue therapy. 1, 2

Core Management Principle

It is safer for pregnant women with asthma to be treated with asthma medications than to have asthma symptoms and exacerbations. 1, 2 Uncontrolled asthma poses greater risks to both mother and fetus—including perinatal mortality, pre-eclampsia, preterm birth, low birth weight, and small-for-gestational-age infants—than the medications used to treat it. 1, 3, 4, 5

Monitoring Throughout Pregnancy

• Perform monthly evaluations of asthma control and lung function during prenatal visits. 1, 2 Asthma improves in one-third of pregnant women, remains stable in one-third, and worsens in one-third during pregnancy. 1, 4

• Use spirometry as the preferred objective assessment tool for lung function in pregnant women with suspected or confirmed asthma. 4

• Consider serial ultrasound examinations starting at 32 weeks gestation for patients with moderate to severe or suboptimally controlled asthma. 2

Stepwise Pharmacologic Management

Quick-Relief Medications (All Patients)

• Albuterol is the preferred short-acting beta-agonist (SABA) because more safety data exist for albuterol during pregnancy than for other SABAs. 1, 2

• Dosing for symptom relief: 2-4 puffs as needed for symptoms. 1

• Warning sign: Use of SABA more than twice weekly in intermittent asthma (or daily/increasing use in persistent asthma) indicates need to initiate or increase long-term controller therapy. 1

Long-Term Controller Medications

• Inhaled corticosteroids (ICS) are the preferred long-term control medication for all levels of persistent asthma during pregnancy. 1, 2, 5, 6

• Budesonide is the preferred ICS because more safety data are available for budesonide in pregnant women than for other ICS preparations, and these data are reassuring. 1, 2, 7 However, no data indicate that other ICS preparations are unsafe during pregnancy. 1

• ICS dosing ranges (from low to high daily doses): 1

  • Budesonide DPI: 200-600 mcg (low), 600-1,200 mcg (medium), >1,200 mcg (high)
  • Beclomethasone HFA: 80-240 mcg (low), 240-480 mcg (medium), >480 mcg (high)
  • Fluticasone MDI: 88-264 mcg (low), 264-660 mcg (medium), >660 mcg (high)

• Recent evidence supports using ICS combined with long-acting bronchodilators as rescue therapy even for mild disease, as this dramatically reduces exacerbations in non-pregnant populations. 5 An ICS and rapid-onset bronchodilator combination inhaler should be used for as-needed use and for daily maintenance in those with more persistent symptoms. 5

• Leukotriene receptor antagonists have minimal human pregnancy data (only 9 patients in available studies), though animal data submitted to FDA are reassuring. 1 These should not be first-line agents given limited evidence.

Stepping Up and Down Therapy

• Review treatment every 3-6 months; gradual stepwise reduction may be possible if control is maintained. 1

• If control is not maintained: First review medication technique, adherence, and environmental triggers before stepping up. 1

• Gain control as quickly as possible (consider short course of systemic corticosteroids), then step down to the least medication necessary. 1, 3

Management of Acute Exacerbations

Home/Outpatient Treatment

• Administer albuterol immediately: 2-4 puffs every 20 minutes for up to 3 treatments, or single nebulizer treatment (2.5 mg). 1, 3, 2

• Add systemic corticosteroids when exacerbations are not quickly controlled with bronchodilators. 3, 2

• Outpatient systemic corticosteroid dosing: Prednisone 40-60 mg daily for 3-10 days. 3, 2

Severe Exacerbations

• 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. 3, 2

• Add ipratropium bromide for severe exacerbations: 0.25 mg every 20 minutes for 3 doses via nebulizer, or 4-8 puffs as needed via MDI. 2

• Consider arterial blood gas measurement in severe cases to assess maternal and fetal oxygenation. 2

• Involve the obstetrical care provider in assessment and monitoring of severe exacerbations. 2

Goals of Asthma Control

The treatment goal is to maintain optimal control defined as: 1

• Minimal or no chronic symptoms day or night
• Maintenance of (near) normal pulmonary function
• No limitations on activities
• Minimal or no exacerbations
• Minimal use of short-acting beta-agonist
• Minimal or no adverse effects from medications

Critical Pitfalls to Avoid

• Never discontinue or reduce asthma medications due to unfounded pregnancy safety concerns. 3, 2, 5 This is the most common and dangerous error, as uncontrolled asthma poses far greater risks than the medications. 1, 2

• Do not withhold systemic corticosteroids during exacerbations. While oral corticosteroids have been associated with slightly reduced birth weight and increased risk of oral clefts with first-trimester use, these risks are still less than the potential risks of severe uncontrolled asthma. 8

• Avoid oral decongestants in early pregnancy due to potential association with rare birth defects. 2

• Do not use approximately one canister of SABA per month as this indicates inadequate control and need to intensify long-term controller therapy. 1

Specialist Referral

Refer to an asthma specialist if there are difficulties controlling asthma or if Step 4 care is required. 1