Inhalers Are Safe During Pregnancy
Yes, inhalers are safe to use during pregnancy and should be continued—uncontrolled asthma poses far greater risks to both mother and fetus than the medications themselves. 1, 2, 3
Why Continuing Inhalers Is Critical
The risks of poorly controlled asthma during pregnancy substantially outweigh any theoretical medication risks. Uncontrolled asthma increases the risk of: 2, 3, 4
- Perinatal mortality
- Preeclampsia
- Preterm birth
- Low birth weight infants
- Small-for-gestational-age babies
In contrast, inhaled asthma medications have been used for many years without documentation of adverse fetal effects. 1
Preferred Short-Acting Bronchodilators (Rescue Inhalers)
Albuterol (salbutamol) is the preferred short-acting beta-agonist during pregnancy with the most extensive safety data available. 1, 2, 3
- Safety evidence includes data from 6,667 pregnant women, with no increased risk of structural anomalies compared to the general population 2, 3
- Has Australian TGA Category A classification, indicating compatibility during pregnancy 3
- Use 2-4 puffs via metered-dose inhaler as needed for acute symptoms 2, 3
Important monitoring point: If albuterol is needed more than twice weekly, this signals inadequate asthma control requiring initiation or escalation of inhaled corticosteroids. 2, 3
Preferred Long-Term Controller Medications
Inhaled corticosteroids are the preferred long-term control medication and should be continued throughout pregnancy. 1, 2, 4
Budesonide is the preferred inhaled corticosteroid because it has the most safety data during pregnancy and FDA pregnancy category B rating. 1, 2, 5
- Large Swedish registry data from 2,534 infants showed no increased rate of congenital malformations (3.6% vs. 3.5% in general population) 5
- No increased risk of orofacial clefts (4 observed vs. 3.3 expected) 5
However, if a woman was well-controlled on a different inhaled corticosteroid before pregnancy, it is acceptable to continue that medication rather than switching, as changing formulations may jeopardize asthma control. 1
Long-Acting Bronchodilators
Long-acting beta-agonists (LABAs) such as salmeterol and formoterol are probably safe during pregnancy, though they have less data than short-acting agents. 1
- Salmeterol is preferred over formoterol due to greater pregnancy experience 1
- If a woman was already controlling symptoms with formoterol pre-pregnancy, it is acceptable to continue 1
- Should be used in combination with inhaled corticosteroids, not as monotherapy 1
Treatment for Acute Exacerbations
For acute asthma exacerbations during pregnancy: 3, 6
- Initial treatment: Nebulized solution containing 0.5 mg ipratropium + 2.5 mg albuterol every 20 minutes for 3 doses 3, 6
- Maintenance: Every 2-4 hours as needed thereafter 6
- Alternative delivery: 4-8 puffs via MDI every 20 minutes for 3 doses, then every 1-4 hours as needed 6
For severe exacerbations not controlled with bronchodilators, systemic corticosteroids (such as prednisone) should be added, as the benefits of controlling severe asthma outweigh potential medication risks. 2
Essential Monitoring Throughout Pregnancy
Monthly evaluation of asthma control and lung function is recommended throughout pregnancy. 2, 3, 6
This is critical because asthma course changes in approximately two-thirds of pregnant women—improving in one-third and worsening in one-third. 2, 3
Common Pitfalls to Avoid
The most common cause of worsening asthma in pregnancy is medication non-compliance due to unfounded safety concerns. 7
- Never discontinue or reduce asthma medications due to pregnancy concerns 6, 4
- Actively discourage de-escalation of asthma therapies during pregnancy 4
- Emphasize to patients that fetal well-being depends on maternal well-being and adequate oxygenation 1, 6, 7
Maternal oxygen saturation should be kept above 95% for fetal well-being. 7
Medications During Labor and Breastfeeding
Usual respiratory medications, including bronchodilators and inhaled corticosteroids, should be continued during labor and delivery. 6
Most asthma medications, including oral prednisone, are compatible with breastfeeding. 7
Women who have received systemic corticosteroids in the past year may require stress-dose corticosteroids during labor and delivery. 7