 A 20 yr old lady presented with  Hx of cough and dyspnea for 6 months  2 weeks of drug discontinuation  1 week cough, sputum.

aminim@mums.ac.ir

 A 20 yr old lady presented with  Hx of cough and dyspnea for 6 months  2 weeks of drug discontinuation  1 week cough, sputum and dyspnea  She is 3 mo pregnant  She is concerned about her chest disease during pregnancy

 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 moisturizers help me to improve?  How does asthma affect my fetus?  Are asthma drugs risky for my fetus?  Is my child more prone to asthma?  Can heartburn cause my asthma?  Should I get flu shot?  What should I do in the case of asthma attack?  Can I do NVD for termination of pregnancy?

 Recurrent episodes 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

 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

 Asthma is a common disease  Even more than diabetes mellitus  In some countries 1 out of every 4 children has asthma

 Asthma affects 4 to 8% of all pregnant women

 Asthma occurs more commonly in those with atopic history  In themselves or  Their 1 st degree relatives  A person with allergic rhinitis has 5 times more chance of asthma

 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

 Pregnant women have different courses of their asthma  1/3 aggravate  1/3 improve  1/3 does not change

 The most common cause of asthma exacerbation  Discontinuation of drugs  Viral infections  Well controlled asthma has favorable outcome in pregnancy

 Poor controlled asthma has been associated with 15 to 20 % increase in  Preterm delivery  Preeclampsia  Growth retardation  Need for C/S  Maternal morbidity  Maternal mortality

 These risks are increased 30 to 100 % those with more severe asthma  Asthma is not associated with risk of congenital malformations

 No (or minimal) daytime symptoms  No limitations of activity  No nocturnal symptoms  No (or minimal) need for rescue medication  Normal lung function  No exacerbations What is “well control”?

 In pregnant asthmatics you should confirm control by  Spirometry  Monthly  Peak flow metry  Twice daily  Upon awakening  After 12 hr

 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

 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

 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

 If you choose the 1 st one (reliever)  You treat patient ' s symptom, but  Relievers do not work on inflammation !  Your patient is prone to  Asthma attack  Airway remodeling

 If you choose the 2 nd 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

 Relievers (No anti-inflammatory action)  Salbutamol  Atrovent  Controllers (Mainly anti-inflammatory)  Inhaled corticosteroids  LABA  cromolyn  Theophylline  Leukotrene antagonists

 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 DrugSafety  Salbutamol  Inhaled corticosteroids  Cromolyn  Theophylline  Safe, inhaler (labor)  Category B, Budesonide  Safe  Safe (5-12 mcg/ml)  ↓ clearance in 3 rd trimester  Cord blood level the same  Load 5-6 mg/kg  Maintenance 0.5mg/kg/hr  Delayed labor

DrugSafety  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

 Mild intermittent  Mild persistent  Moderate persistent  Severe persistent  PRN Salbutamol  Inhaled corticoteroid  Inhaled corticoteroid + LABA

Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) > 5 y Age 5 y Age 5 y Age < 5 y Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) > 5 y Age 5 y Age 5 y Age < 5 y Beclomethasone200-500 100-200 >500-1000 >200-400 >1000 >400 Budesonide200-600 100-200 600-1000 >200-400>1000 >400 Budesonide-Neb Inhalation Suspension 250-500 >500-1000 >1000 Ciclesonide 80 – 160 80-160 >160-320 >160-320>320-1280 >320 Flunisolide500-1000 500-750>1000-2000 >750-1250 >2000 >1250 Fluticasone100-250 100-200 >250-500 >200-500 >500 >500 Mometasone furoate200-400 100-200 > 400-800 >200-400>800-1200 >400 Triamcinolone acetonide400-1000 400-800>1000-2000 >800-1200>2000 >1200

Choice of drug categories in pregnancy CategoryDrug of choice  SABA  LABA  ICS  Salbutamol  Salmetrol  Budesonide

 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

 Avoidance from  allergens,  irritants and  air pollution  Is necessary for any asthmatic pregnant woman

 Allergen immunotherapy can be continued during pregnancy  But, should not be started for the 1 st time in a pregnant woman

 There is no association to mother asthma during fetal period  and development of asthma in childhood period.  Albeit asthma is a genetic disease

 Comorbid conditions in asthma  Gastro-esophageal reflux disease (GERD)  Allergic rhinitis (AD)

 Be suspicious to GERD if  Your asthmatic patient become poorly controllable  Your asthmatic patient is worse at night  Your asthmatic patient has symptoms when lies down  Patient complains of GERD symptoms

 Treatment of heartburn can improve asthma symptoms  Continue anti GERD drugs for at least 2-3 months

 Be suspicious to AD if  Your asthmatic patient complains of seasonal nose or sinus symptoms

 Treat AD with  Intranasal corticosteroids  Antihistamines (2 nd generation in pregnancy)  Allergen avoidance

 Influenza vaccination is necessary for  Pregnant women with 2 nd and 3 rd trimester  In cold months

 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

 Pco2 > 35 mmHg  Po2 < 70 mm Hg  Are abnormal during pregnancy  IV fluid (dextrose) initially 100 ml/hour  Seated position  Fetal monitoring

 Dosage of glucocorticoids is not different  IV aminophylline NOT generally recommended  IV Mg sulfate may be beneficial  Concomitant hypertension  Preterm contraction

 Respiratory infections in asthmatic patients  Usually viral  If indicated in a pregnant woman  I V Ceftriaxone  Erythromycin

 No difference  PG F2 analogues should not be used in asthmatics  for termination of pregnancy  Morphine and meperidine should be avoided  Fentanyl is an appropriate alternative

 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 pertiprtum bleeding, headache, should be avoided

Summary  Careful assessment and monitoring  Avoidance and controll of triggers  Maintenance rather than symptomatic therapy  Aggressive treatment of exacerbations

 A 20 yr old lady presented with  Hx of cough and dyspnea for 6 months  2 weeks of drug discontinuation  1 week cough, sputum.

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 A 20 yr old lady presented with  Hx of cough and dyspnea for 6 months  2 weeks of drug discontinuation  1 week cough, sputum.

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Presentation on theme: " A 20 yr old lady presented with  Hx of cough and dyspnea for 6 months  2 weeks of drug discontinuation  1 week cough, sputum."— Presentation transcript:

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