What is the recommended treatment for an acute exacerbation of bronchial asthma in a pregnant adult female?

Prednisolone in Acute Asthma Exacerbation During Pregnancy

Prednisolone 40-60 mg daily for 3-10 days should be initiated immediately for acute asthma exacerbations in pregnancy that do not respond quickly to bronchodilators, as the benefits of systemic corticosteroids far outweigh any theoretical risks, and uncontrolled asthma poses definite risks of perinatal mortality, preeclampsia, preterm birth, and low birth weight. 1, 2

Immediate Treatment Algorithm

First-Line Bronchodilator Therapy

• Administer albuterol 2.5-5 mg via nebulizer every 20 minutes for up to 3 doses as initial therapy 1
• For severe exacerbations, combine ipratropium 0.5 mg with albuterol 2.5 mg via nebulizer every 20 minutes for 3 doses, then every 2-4 hours as needed 1, 2
• Maintain maternal oxygen saturation >95% with supplemental oxygen to ensure adequate fetal oxygenation 1, 2

Systemic Corticosteroid Initiation

• If symptoms are not quickly controlled with bronchodilators alone, initiate oral prednisolone 40-60 mg daily (or prednisone 40-60 mg daily) for 3-10 days 1, 3
• The FDA label supports prednisolone dosing of 5-60 mg per day depending on disease severity, with the recommendation to continue "burst" therapy until symptoms resolve or peak expiratory flow reaches 80% of personal best, typically requiring 3-10 days 3
• Do not withhold systemic corticosteroids due to pregnancy concerns—the risk of uncontrolled asthma to mother and fetus is much greater than any medication risk 1, 2

Critical Safety Evidence

Maternal and Fetal Risks of Uncontrolled Asthma

• Uncontrolled asthma increases risks of perinatal mortality, preeclampsia, preterm birth, and low birth weight 1, 4, 5, 6
• Acute exacerbations during the first trimester are associated with increased risk of congenital malformations 6
• Asthma exacerbations have the potential to lead to severe problems for the fetus, requiring aggressive management 7

Corticosteroid Safety Profile

• Although data are uncertain about some risks of oral corticosteroids during pregnancy, severe uncontrolled asthma poses a definite risk to the mother and fetus 7
• The benefits of systemic corticosteroids in acute exacerbations far outweigh any risks 1, 2
• All asthma medications including prednisolone are compatible with breastfeeding 1, 2

Monitoring and Follow-Up

Immediate Monitoring

• Monitor peak expiratory flow (PEF) or spirometry to guide treatment intensity 1
• Monitor closely for 24-48 hours after the exacerbation as this is a high-risk period for cardiopulmonary complications 1, 2

Ongoing Pregnancy Management

• Perform monthly evaluations of asthma control and pulmonary function throughout pregnancy, as asthma improves in one-third and worsens in one-third of pregnant women 1, 4, 8, 6
• Involve the obstetrical care provider in assessment and monitoring at prenatal visits 1, 4

Long-Term Controller Adjustment

• After stabilizing the acute exacerbation, ensure the patient is on daily inhaled corticosteroids—budesonide is the preferred agent due to extensive pregnancy safety data 1, 5, 6
• Never discontinue or de-escalate asthma medications during pregnancy, as this is a critical pitfall that leads to poor outcomes 1
• If albuterol is needed more than twice weekly, this signals inadequate asthma control and requires initiation or escalation of controller therapy 4

Common Pitfalls to Avoid

• Do not delay systemic corticosteroids while waiting to see if bronchodilators alone will work in moderate-to-severe exacerbations—early corticosteroid administration is key to preventing progression 1, 9
• Do not taper corticosteroids after improvement in acute exacerbations, as there is no evidence that tapering prevents relapse 3
• Do not assume GERD medications will impair corticosteroid absorption unless there is documented severe gastrointestinal dysfunction 1
• Identify and control GERD as an asthma trigger, as this can reduce medication requirements and improve maternal well-being 1