HOW TO RELIEVE ASTHMA DURING PREGNANCY

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HOW TO RELIEVE ASTHMA DURING PREGNANCY. Sri Sulistyowati. FETOMATERNAL DIVISION OB/GYN DEPARTMENT SEBELAS MARET UNIVERSITY/DR. MOEWARDI HOSPITAL SOLO. INTRODUCTION. Is it really asthma? Why me? I had no family history. Does pregnancy cause my asthma to be exacerbated?
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HOW TO RELIEVE ASTHMA DURING PREGNANCY Sri Sulistyowati FETOMATERNAL DIVISION OB/GYN DEPARTMENT SEBELAS MARET UNIVERSITY/DR. MOEWARDI HOSPITAL SOLO INTRODUCTION
  • Is it really asthma?
  • Why me? I had no family history.
  • Does pregnancy cause my asthma to be exacerbated?
  • Can my asthma be cured?
  • Can Allergens affect to my asthma?
  • How does asthma affect to my fetus?
  • Is my child more prone to asthma?
  • What should I do in the case of asthma attack?
  • Can I do NVD or C- Section for termination of pregnancy?
  • IS IT REALLY ASTHMA?
  • Recurrentepisodes of wheezing
  • Troublesome cough at night
  • Cough or wheeze after exercise
  • Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants
  • Colds “go to the chest” or take more than 10 days to clear
  • Is it really asthma? Is it really asthma?
  • Pregnancy dyspnea
  • Increased tidal volume
  • Decreased ERV and RV and FRC
  • Intact FEV1
  • Less than normal PCo2
  • Above normal PO2
  • The presence of cough and wheezing suggests asthma
  • Clinical Presentation of Asthma
  • Wheezing
  • Dyspnea
  • Chest tightness
  • Use of accessory respiratory muscle
  • Central or peripheral cyanosis
  • Tachycardia
  • Prolonged expiration
  • WHY ME ? I HAD NO FAMILY HISTORY Asthma affects 4 to 8% of all pregnant women Prevalence of asthma appears to be increasing in pregnant women 0.2% of pregnancies will be complicated by status asthmaticus WHY ME ? I HAD NO FAMILY HISTORY
  • Asthma occurs more commonly in those with atopic history
  • In themselves or
  • Their’s family history
  • A person with allergic rhinitis has 5 times more chance of asthma
  • WHY ME ? I HAD NO FAMILY HISTORY
  • Asthma is a polygenic disease
  • Asthma occurs in a genetically susceptible person who exposed to specific etiologic factors
  • It occurs more common in identical twins
  • EFFECT OF PREGNANCY ON ASHTMA
  • No evidence to suggest that pregnancy has a predictable effect on underlying asthma
  • Pregnant women have different courses of their asthma
  • 1/3 aggravate
  • 1/3 improve
  • 1/3 does not change
  • EFFECT OF PREGNANCY ON ASHTMA
  • The most common cause of asthma exacerbation
  • Discontinuation of drugs
  • Viral infections
  • Well controlled asthma has favorable outcome in pregnancy
  • EFFECT OF ASHTMA ON PREGNANCY
  • Poor controlled asthma has been associated with 15 to 20 % increase in
  • Preterm delivery
  • Preeclampsia
  • Growth retardation
  • Need for C-Section
  • Maternal morbidity
  • Maternal mortality
  • EFFECT OF ASHTMA ON PREGNANCY
  • These risks are increased 30 to 100 % those with more severe asthma
  • Asthma is not associated with risk of congenital malformations
  • Antenatal Management
  • Asthma history
  • Severity of symptoms
  • Nocturnal symptoms
  • Pregnant patients with mild well controlled asthma may receive routine prenatal care
  • Moderate and Severe asthma will need more frequent visits and consider referral in severe cases
  • What is “well control”? No (or minimal) daytime symptoms No limitations of activity No nocturnal symptoms No (or minimal) need for rescue medication Normal lung function No exacerbations Referral Indication
  • To Asthma/ Allergy subspecialist
  • Diagnosis is severe, persistent asthma
  • Diagnosis is unclear
  • More complete allergy evaluation is desired
  • Asthma is not under control even after appropriate avoidance measures are taken and medications have been adjusted and redirected
  • Life threatening exacerbation
  • Management
  • Ultimate goal is prevention of hypoxic episodes to mother and fetus
  • Relies on four components
  • Objective measures for accurate monitoring
  • Minimizing asthma triggers
  • Patient education
  • Pharmacologic therapy
  • Management
  • In pregnant asthmatics you should confirm control by
  • Spirometry
  • Monthly
  • Peak flow metry
  • Twice daily
  • Upon awakening
  • After 12 hr
  • Objective Measures for Accurate Monitoring
  • FEV1 is best single measure of pulmonary function but requires a spirometer
  • PEFR correlates well with FEV1 and is inexpensive as it is measured by peak flow
  • Self-monitoring of PEFR aids in detecting early signs of deterioration in lung function
  • Objective Measures for Accurate Monitoring
  • FEV1 < 80% in pregnancy associated with poor pregnancy outcomes
  • Moderate to severe asthmatics
  • Serial ultrasound examination
  • Early in pregnancy
  • Regularly after 32 wk
  • After an asthma exacerbation
  • Minimizing Asthma Triggers
  • Use plastic mattress and pillow covers
  • Weekly washing of bedding in hot water
  • Animal dander control
  • Weekly bathing of the pet
  • Keeping pets out of the bedroom
  • Remove pet from the home
  • Cockroach control
  • Hardwood flooring
  • Avoid tobacco smoke
  • Inhibit mite and mold growth by reducing humidity
  • Do not be present when home is vacuumed
  • Patient Education
  • Understanding that asthma control is important to fetal well being
  • Reduction of triggers
  • Understanding of basic medical management including self monitoring
  • Can my asthma be cured?
  • Asthma is a chronic disease
  • We have very few diseases with such a good response to therapy as asthma
  • Quality of life improved markedly after treatment
  • Can Allergens affect to my asthma?
  • About 80 % of asthma patients have allergic (extrinsic) asthma
  • Allergens, especially indoor allergens
  • Mites
  • Fungi
  • Can cause asthma or allergic rhinitis to become worse
  • Room humidity of > 50%
  • speed up growth of mites and fungi
  • Can Allergens affect to my asthma?
  • Avoidance from
  • allergens,
  • irritants and
  • air pollution
  • Is necessary for any asthmatic pregnant woman
  • Can Allergens affect to my asthma?
  • AlergentImmunoteraphy can be continued during pregnancy
  • But should not be started for the first time in pregnant women
  • How about theraphy for asthma in pregnancy?
  • As asthma is an inflammatory disease limited to lung airways
  • Treatment of this disease in a topical form is
  • More effective
  • Less harmful
  • You can choose one of these categories for your asthmatic patient
  • Relievers
  • Controllers
  • How about theraphy for asthma in pregnancy?
  • If you choose the 1st one (reliever)
  • You treat patient's symptom, but
  • Relievers do not work on inflammation!
  • Your patient is prone to
  • Asthma attack
  • Airway remodeling
  • How about theraphy for asthma in pregnancy?
  • If you choose the 2nd one (controllers)
  • You treat your patient's disease, and
  • You can control inflammation
  • You reduce the risk of
  • Asthma attack
  • Airway remodeling in your patient
  • How about theraphy for asthma in pregnancy?
  • Relievers (No anti-inflammatory action)
  • Salbutamol
  • Atrovent
  • Controllers (Mainly anti-inflammatory)
  • Inhaled corticosteroids
  • LABA
  • cromolyn
  • Theophylline
  • Leukotrene antagonists
  • How about theraphy for asthma in pregnancy?
  • When should I start controllers?
  • >3 times/ wk day salbutamol need
  • >3 times/ mo night awakening
  • >3 times/ yr salbutamol prescription
  • >3 times/ yr exacerbation
  • >3 times/ yr short-term corticosteroid
  • Safety profile of common anti-asthma drugs Drug Safety
  • Salbutamol
  • Inhaled corticosteroids
  • Cromolyn
  • Theophylline
  • Safe, inhaler (labor)
  • Category B, Budesonide
  • Safe
  • Safe (5-12 mcg/ml)
  • ↓ clearance in 3rdtrimester
  • Cord blood level the same
  • Load 5-6 mg/kg
  • Maintenance 0.5mg/kg/hr
  • Delayed labor
  • Safety profile of common anti-asthma drugs Drug Safety
  • LABA
  • Adrenaline
  • Systemic steroids
  • Atroent
  • Leukotrene antagonists
  • Not reassuring
  • Not for asthma
  • Pre-eclampsia, GDM
  • Prematurity, LBW
  • Safe
  • Ziluten not assessed
  • Zafirleukast, monteleukast probably safe
  • Anti-asthma drugs Treatment Asthma Severity Treatment
  • Mild intermittent
  • Mild persistent
  • Moderate persistent
  • Severe persistent
  • PRN Salbutamol
  • Inhaled corticosteroid
  • Inhaled corticosteroid + LABA
  • Inhaled corticosteroid + LABA
  • Choice of drug categories in pregnancy Category Drug of choice
  • SABA (Short Acting β Agonist)
  • LABA (Long Acting β Agonist)
  • Inhaled Corticosteroid
  • Salbutamol
  • Salmetrol
  • Budesonide
  • Is my child more prone to asthma?
  • There is no association to mother asthma during fetal period
  • and development of asthma in childhood period.
  • Asthma is a genetic disease
  • What should I do in the case of asthma attack?
  • Treatment of asthma attack is the same as non-pregnant woman
  • Aggressive monitoring of mother and fetus
  • Oxygen 3-4 l/min by cannula
  • Goal of
  • Po2 > 70
  • Sat > 95
  • What should I do in the case of asthma attack?
  • Pco2 > 35 mmHg
  • fluid (dextrose) initially 100 ml/hour
  • Seated position
  • Fetal monitoring
  • What should I do in the case of asthma attack?
  • Dosage of glucocorticoids is not different
  • IV aminophylline NOT generally recommended
  • IV Mg sulfate may be beneficial
  • Concomitant hypertension
  • Preterm contraction
  • What should I do in the case of asthma attack?
  • Respiratory infections in asthmatic patients
  • Usually viral
  • If indicated in a pregnant woman
  • I V Ceftriaxone
  • Erythromycin
  • Labor: Sectio Caesarian or Vaginal Delivery?
  • No difference
  • PG F2 analogues should not be used in asthmatics for termination of pregnancy
  • Morphine and Eperidine should be avoidedFentanyl is an appropriate alternative
  • Labor: Sectio Caesarian or Vaginal Delivery?
  • In the case of emergency  cesarean section
  • Epidural anesthesia is the favoured anesthesia
  • Decreses O2 consumption and minute ventilation
  • If general anesthesia required
  • Ketamine is preferred
  • Ergot derivatives for peripartum bleeding, headache, should be avoided
  • Summary
  • Careful assessment and monitoring
  • Avoidance and controll of triggers
  • Maintenance rather than symptomatic therapy
  • Aggressive treatment of exacerbations
  • THANK YOU
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