Asthma control in pregnant patient
M.K., a 24-year-old woman diagnosed with moderate, persistent asthma, has attended your hospital's classes on asthma management. Her asthma has been adequately controlled with fluticasone (inhalation aerosol), 440 mcg twice daily, and use of an albuterol inhaler as needed. She is excited because the home pregnancy test she ran yesterday is positive. Her friends told her she should take no medicines during the first three months of her pregnancy, but before she discontinues her medication, she wanted to consult you. What do you tell her and why?
Maintaining control of asthma during pregnancy is essential for the well-being of the fetus. Increased perinatal mortality, prematurity, and low birth weight can result from poorly controlled asthma. Perinatal outcomes are similar between those with adequately controlled asthma and those who do not have asthma. Evidence exists suggesting that asthma symptoms during pregnancy improve in about a third of patients, remain the same in about a third of patients, and worsen in the remaining patients. There are no predictors to indicate into which category someone will fall.
Because adverse effects can result from inadequately controlled asthma, the use of asthma medications is justified. As this patient is well controlled on fluticasone, there is little reason to change her therapy. If an inhaled corticosteroid were to be initiated, budesonide should be considered. This recommendation is based on the recent FDA classification of pregnancy category B for budesonide. Little risk is associated with the use of short-acting beta-agonists.
For patients with moderate persistent asthma that is inadequately controlled on a medium dose of an inhaled corticosteroid, theophylline or salmeterol should be added. Careful monitoring of therapy needs to be conducted in patients with asthma. This can include monitoring short-acting, beta-agonist use as well as peak expiratory flow values.
First and foremost, do not stop the asthma medications. Asthma that is not well managed during pregnancy has been associated with respiratory symptoms, ER visits, hospitalizations, respiratory failure, and even death. Pregnant patients with uncontrolled severe asthma have an increased risk of perinatal mortality, intrauterine growth retardation, preterm birth, low birth weight, and neonatal hypoxia. However, women with well-controlled asthma during pregnancy can have outcomes similar to those of patients who do not have asthma.
A recent study suggests that controlling severe asthma in pregnancy with inhaled and oral corticosteroids improves maternal and fetal outcomes. Almost all drugs in widespread use to treat asthma are safe in pregnancy and during breast- feeding. And, corticosteroids, bronchodilators, cromolyn sodium, and immunotherapy have all been shown to have a positive effect on asthma control. It is always a good idea to check with your pharmacist or physician before starting or stopping medications while pregnant or breast-feeding.
Are you puzzled by a clinical situation that would make a good topic for this column? Or do you relish an opportunity to test your skill in resolving a clinical challenge? Please send us a clinical scenario or indicate your interest in providing us with a patient assessment by e-mailing us at firstname.lastname@example.org or fax us at (201) 722-2490.
Kathy Hitchens. Asthma control in pregnancy.