1. FETOMATERNAL DIVISION OB/GYN DEPARTMENT SEBELAS MARET UNIVERSITY/DR. MOEWARDI HOSPITAL SOLO

2.  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? INTRODUCTION

3.  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 IS IT REALLY ASTHMA?

4. Is it really asthma?

5.  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 Is it really asthma?

6.  Wheezing  Dyspnea  Chest tightness  Use of accessory respiratory muscle  Central or peripheral cyanosis  Tachycardia  Prolonged expiration Clinical Presentation of Asthma

7. 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

8.  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

9.  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 WHY ME ? I HAD NO FAMILY HISTORY

10.  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

11.  The most common cause of asthma exacerbation  Discontinuation of drugs  Viral infections  Well controlled asthma has favorable outcome in pregnancy EFFECT OF PREGNANCY ON ASHTMA

12.  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

13.  These risks are increased 30 to 100 % those with more severe asthma  Asthma is not associated with risk of congenital malformations EFFECT OF ASHTMA ON PREGNANCY

14.  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 Antenatal Management

15.  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”?

16.  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 Referral Indication

17.  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

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

19. 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

20.  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 Objective Measures for Accurate Monitoring

21. 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

22.  Understanding that asthma control is important to fetal well being  Reduction of triggers  Understanding of basic medical management including self monitoring Patient Education

23.  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 my asthma be cured?

24.  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?

25.  Avoidance from  allergens,  irritants and  air pollution  Is necessary for any asthmatic pregnant woman Can Allergens affect to my asthma?

26.  Alergent Immunoteraphy can be continued during pregnancy  But should not be started for the first time in pregnant women Can Allergens affect to my asthma?

27.  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?

28.  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 How about theraphy for asthma in pregnancy?

29.  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 How about theraphy for asthma in pregnancy?

30.  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?

31.  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 How about theraphy for asthma in pregnancy?

32. 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

33. 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 Safety profile of common anti- asthma drugs

34. Asthma SeverityTreatment  Mild intermittent  Mild persistent  Moderate persistent  Severe persistent  PRN Salbutamol  Inhaled corticosteroid  Inhaled corticosteroid + LABA Anti-asthma drugs Treatment

35. Choice of drug categories in pregnancy CategoryDrug of choice  SABA (Short Acting β Agonist)  LABA (Long Acting β Agonist)  Inhaled Corticosteroid  Salbutamol  Salmetrol  Budesonide

36.  There is no association to mother asthma during fetal period  and development of asthma in childhood period.  Asthma is a genetic disease Is my child more prone to asthma?

37.  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?

38.  Pco2 > 35 mmHg  fluid (dextrose) initially 100 ml/hour  Seated position  Fetal monitoring What should I do in the case of asthma attack?

39.  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?

40.  Respiratory infections in asthmatic patients  Usually viral  If indicated in a pregnant woman  I V Ceftriaxone  Erythromycin What should I do in the case of asthma attack?

41.  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?

42.  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 Labor: Sectio Caesarian or Vaginal Delivery?

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

44. THANK YOU