Asthma in pregnancy

1. Senior Seminar II
Iae Ferreira, RN
Appendix B
ASTHMA IN PREGNANCY

2. INTRODUCTION
(Namazy& Schatz, 2011)
 Asthma currently affects
approximately 8% of pregnant
women
 It is one of the most common
potentially serious medical
conditions to complicate
pregnancy.
 Asthma ↑ the risk of adverse
outcomes: perinatal mortality,
preeclampsia, preterm birth
and low-birth weight infants.
 Asthma is a disease of the
airways by reversible airway
obstruction and hyper-
reactivity to a variety of stimuli.
 Although its cause is unknown
there are many triggering
agents that can be identified
such asviral infections,
allergens, exercise, sinusitis,
reflux, weather changes and
stress.

3. EVALUATION AND DIAGNOSIS
 Physical examination
 Subjective assessment
 Hx of symptoms,
temporal relationships,
triggers
 Pulmonary
impairment/asthma severity
classification
 Response to asthma therapy
 Pulmonary function tests
 Spirometry and forced
expiratory volume in the
first second of expiration
(FEV1)
 Peak expiratory flow rate
(PEFR)
 Fetal assessment during acute
asthma
(National Guideline Clearinghouse, 2012)

4. ASTHMA DIAGNOSIS DURING PREGNANCY
 Diagnosis of asthma is usually known before pregnancy;
however there are a further proportion of pregnant woman
who possibly have asthma
 Reduced forced expiratory volume in one second (FEV1) or
 Reduced ratio of FEV to forced vital capacity (FVC) and
 12% or greater improvement in FEV1 after inhalation of
rapid acting beta-agonist confirm diagnosis of
asthma(Ivancso, Bohacs, Eszes, Losonczy, &Tamasi, 2013).
 Diagnosis confirmation is made by reversible airway
obstruction after an inhaled short-acting bronchodilator
(Namazy& Schatz, 2011).

5. SHORTNESS OF BREATH AT REST OR WITH MILD EXERTION IS SO COMMONTHAT
IT IS OFTEN REFERREDTO AS “PHYSIOLOGIC DYSPNEA”
(MCCORMACK &WISE, 2009).
 It is important to be able to
differentiate normal
dyspnea of pregnancy from
disease pathology.
Shortness of breath may
occur in approximately 70%
of pregnant woman and
differs from asthma by its
lack of association with
cough, wheezing and airway
obstruction (Namazy& Schatz,
2011).
 Although dyspnea may be
physiological, tachypnea is
always abnormal and hence
should be sought in any
pregnant patient
complaining of
breathlessness (Bhatia & Bhatia,
2000).
 The ability of a patient to
complete sentences is a
useful bedside indicator of
the severity of the respiratory
insufficiency(Bhatia & Bhatia,

6. “IT CAN BE CHALLENGING FOR A PHYSICIANTO DIFFERENTIATE
NORMAL DYSPNEA OF PREGNANCY FROM DISEASE PATHOLOGY”.
(MCCORMACK &WISE, 2009).
 Asthma sign and symptoms
 Wheezing, chest tightness, cough and associated
shortness of breath(Namazy& Schatz, 2011).
 Respiratory rate greater than 20 per minute
 Arterial PCO2 less than 30 or greater than 35
 hypoxemia O2Sat <95% room air
 Abnormal measures on forced expiratory
spirometry, or cardiac echocardiography (McCormack
&Wise, 2009).

7. PHYSIOLOGIC CHANGES OF PREGNANCY
 Structural/Hormonal changes:
 ↑Progesterone (respiratory
stimulant) →Hyperventilation
→ overcompensation ↓ CO2
 ↑Estrogen→hyperemia-rhinitis
 ↑ Hypoxic ventilatory response
2x the normal level due to E&P
 Enlarged uterus ↑ abdominal
pressure ↓ chest wall
compliance 35-40% →
reduction functional residual
capacity (FRC)
 Elevation of diaphragm 4cm
 ↑ Relaxin → ribcage ligaments
relax ↑ circumference 5cm
 ↓ Expiratory muscle strength
 Circulatory changes:
 ↑ Cardiac output
 ↑ Pulmonary blood flow &
capillary blood volume
 ↑ Circulating blood volume
 ↓ Plasma oncotic pressure
→formation of edema in the
lungs.
 Increased metabolic rate with
low oxygen levels at end of
expiration make pregnant
woman particularly susceptible
to develop hypoxemia in the
presence of respiratory
problem
(McCormack &Wise, 2009).

8. PREGNANCY HAS NO
SIGNIFICANT EFFECT ON FEV1
OR THE FEV1/FVC RATIO.
PEAK EXPIRATORY FLOW
RATES REMAIN CLOSE TO THE
NORMAL RANGE AND DO NOT
CHANGE DURING PREGNANCY.
THE SHAPE OF THE FLOW-
VOLUME CURVE AND
ABSOLUTE FLOW RATES AT
LOW LUNG VOLUMES ARE
NORMAL IN PREGNANT
WOMAN.
THUS IT IS POSSIBLE TO USE NON-PREGNANT
REFERENCES VALUES TO EVALUATE LUNG
FUNCTION IN PREGNANT WOMEN.
“A REDUCTION IN FEV1 OR FVC SHOULD NOT
BE ATTRIBUTED TO PREGNANCY ALONE.THIS IS
IMPORTANT FOR CLINICIANS TO UNDERSTAND,
PARTICULARLY AS THEY ARE FOLLOWING
PATIENTS WITH UNDERLYING LUNG DISEASES,
SUCH AS ASTHMA”.
(McCormack &Wise, 2009).

9. NORMAL RESPIRATORY PHYSIOLOGIC CHANGES IN PREGNANCY
ChestWall
Compliance
Decreased FEV1 Unchanged
Thoracic Diameter Increased FVC Unchanged
Diaphragm Elevated FEV1/FVC Unchanged
Lung Compliance Unchanged Minute ventilation Increased
Total Lung Capacity Unchanged/slightly
decreased
Tidal volume Increased
Vital Capacity Unchanged/slightly
decreased
Respiratory rate Unchanged
InspiratoryCapacity Slightly increased PH Normal
Functional Residual
Capacity
Decreased PaO2 Slightly elevated
(100-105 mmHg)
ResidualVolume Slightly decreased PaCO2 Slightly decreased
(32-34 mmHg)
Expiratory reserve
volume
Decreased Bicarbonate Slightly decreased
(15-20 meq/L)
(McCormack &Wise, 2009).

10. PREMATURITY, LOW BIRTH
WEIGHT AND PERINATAL
AND MATERNAL DEATH
WERE MORE LIKELY TO
OCCUR IN PREGNANCIES OF
ASTHMATIC WOMEN.
 Most pregnancies are
unaccompanied by
pulmonary complications,
however pulmonary
edema, pulmonary
thromboembolism,
pulmonary hypertension,
and acute respiratory
failure can occur during
pregnancy.These
conditions can lead to
mortality and hence they
should be sought and
treated appropriately.
(Bhatia & Bhatia, 2000).

11. ShortAsthma & PregnancyVideo by Asthma Australia
http://www.youtube.com/watch?v=dOiZhdMlT9k

12. COMORBIDITIES THAT MAY EXACERBATE ASTHMA
 Sinusitis and Reflux are relatively common comorbidities
during pregnancy that may exacerbate asthma.
 Pregnancy may be complicated by new-onset or preexisting
rhinitis, or asthma.
 Rhinitis is a very common problem that may occur during
pregnancy. In the past, rhinitis and asthma may have been
treated as separate disorders.
 The United Airway Disease Hypothesis proposes that upper
and lower airway disease are both manifestations of a single
inflammatory process.
(Namazy& Schatz, 2011) .

13. ASTHMA… ALMOST ALWAYS ASSOCIATED
WITH NASAL DISEASE.
 Treatment of the upper
airway should improve
asthma for a variety of
reasons
 Mechanisms linking the
development or
exacerbation of asthma in
individuals with upper
airway disease may be
multifactorial
 RELEASE OF SYSTEMIC IMMUNE
MEDIATORS FROMTHE UPPER
AIRWAY, DRAINAGE OF
INFLAMMATORY MEDIATORS FROM
THE UPPER AIRWAY INTOTHE
LOWER AIRWAY
 NEUROGENIC RESPONSES
RESULTING IN MORE GENERALIZED
AIRWAY INFLAMMATION OR
COMMON INHALANT MECHANISMS
WITH ALLERGENS CAUSING
INFLAMMATION INITIALLY INTHE
UPPER AIRWAY FOLLOWED BYTHE
LOWER AIRWAY INVOLVEMENT.
(Ledford &Lockey, 2013).

14. “PREGNANT WOMAN MAY OFTEN WORRY ABOUT EFFECTS OFTHEIR ASTHMA
MEDICATIONS, AND MAY DISCONTINUETHEM INAPPROPRIATELY…”
(NELSON,GOSSETT, &GROBMAN, 2010)
 Short-acting beta-agonists for
immediate relief of asthma
symptoms during pregnancy is
generally regarded as being
safe (Ulrik&Gregersen, 2013)
 Inhaled corticosteroids are the
mainstay of controller therapy
during pregnancy. Many
studies have shown no
increased perinatal risks
associated with ICS(Namazy&
Schatz, 2011)
 Most medications used for
asthma for asthma
treatment outside of
pregnancy are also not
contraindicated during
pregnancy(Nelson, Gossett,
&Grobman, 2010).
Budesonide is
considered the
preferred ICS for
asthma during
pregnancy

15. FDA - MEDICATION CLASSIFICATION FOR USE IN PREGNANCY
Risk category Animal Data Human Data Recommendation
A Negative Negative Use approved
B Negative None available Use approved
B Positive Negative Use approved
C Positive None available Use approved
C None available None available Use approved
D Positive/Negative Positive Use approved
X Positive Positive Contraindicated
(Nelson,Gossett, &Grobman, 2010).
 Ethical considerations have, for obvious reasons, limited the
types of studies that have been possible to conduct. Double-
blind, placebo-controlled studies are, in general unethical in
pregnant women, and this makes it difficult to control variables
and isolate specific therapeutic effects (Ulrik&Gregersen, 2013).

16. Beta-2 Agonists Binds to beta2 receptors leading to
bronchial relaxation. •short acting
•long acting
Human data scant, lacks
evidence of risk of
congenital malformation
Albuterol (C)
Salmeterol (C)
Inhaled
Corticosteroids
Counteract inflammatory response.
Maintenance therapy.
Not contraindicated in
pregnancy.
Beclomethasone (C)
Budesonide (B)
Fluticasone (C)
Flunisolide (C)
Systemic
corticosteroids*
Reverse inflammatory response of
asthma exacerbation/ short term
therapy for severe/persistent
asthma
Not clear to what extent.
Possible association (0.1-
0.3%) facial cleft lip during
first trimester
Predinisone (C)
Methylprednisone (C)
Dexamethasone (C)
Anticholinergics Bind to acetylcholine, resulting in
inhibition of secretions from
seromucous glands
Add on therapy for beta-
agonist. No association to
increased risk of
congenital
malformation/adverse
outcome
Ipatropium (B)
Methylxanthines Promote smooth muscle relaxation.
Suppress hypersensitivity reaction
of the airways to stimuli
Add on therapy. Not used
in pregnancy due to
multiple drug interactions,
need to monitor levels &
side effects
Not contraindicated during
pregnancy.
Theophylline (C)
Cromoglycates Inhibition of airway inflammatory
cells. Preventive therapy for
persistent asthma
Not associated with
increase risk of congenital
malformation/adverse
maternal outcome
Cromolyn Sodium (B)
Leukotriene
Inhibitors
Act to antagonize leukotriene
activity/inhibit bronchial smooth
Information during
pregnancy is
Zafirlukast (B)
Montelukast (B)
(Nelson,Gossett,&Grobman,2010).

17. SYSTEMIC
CORTICOSTEROIDS
BECAUSE SEVERE,
UNCONTROLLED
ASTHMA IS ASSOCIATED
W/ MATERNAL/FETAL
DEATH,THE USE OF
SYSTEMIC
CORTICOSTEROIDS
ALTHOUGH RISKY, IS
JUSTIFIEDWHEN SEVERE
ASTHMA CANNOT BE
CONTROLLED BY OTHER
MEANS
(Mennick, 2005)

18. MAJOR GOAL OF CHRONIC ASTHMA MANAGEMENT
ISTHE PREVENTION OF EXACERBATION…
 Pharmacologic approach:
 Inhaled Beta2-agonist (Albuterol)
 InhaledCorticosteroids (Budesonide)
 Alternative add-on medication (long-acting beta2-agonist, cromolyn,
leukotriene inhibitor, theophyline)
 Acute management
 Pharmacologic approach / step therapy
 Fetal monitoring / maternal monitoring.
 SupplementalO2 to maintain PO2 > 70 and O2 sat >95% by pulse
oximetry.
 IV fluids at rate of 100ml/hour with glucose if pt not hyperglycemic.
(Namazy& Schatz, 2011)
(National Guideline Clearinghouse, 2012)

19. RECOMMENDATIONS
 Management geared towards prevention of chronic
symptoms.
 Pt should be educated how to perform accurate
peakflows
 Action plan (Nelson, Gossett, &Grobman, 2010)
 Monthly assessment in all asthmatic women with
evaluation of arterial sat >95% (Ivancso, Bohacs,
Eszes, Losonczy, &Tamasi, 2013)

20. PULSE OXIMETER (SPO2)
 Assess oxygenation by
measuring the arterial
oxygen saturation of Hgb
 The proper use of a pulse
oximeter can ensure earlier
detection of hypoxia
 A normal Spo2 range is
95% to 100%
 Spo2 is one patient-
assessment tool and
should be interpreted
along with other patient
data including
 Vital signs
 Cardiac rhythm
 Breath sounds
(Paragas, 2008)

21. http://www.monaghanmed.com/products/consumer
/truzone-peak-flow-meter-pfm
EDUCATIONAL
PEAK FLOW VIDEO

22. References
Bhatia, P., & Bhatia, K. (2000). Pregnancy and the lungs. Post Graduate Medical
Journal, 76 (901), 683-689.
Ivancso, I., Bohacs, A., Eszes, N., Losonczy, G., &Tamasi, L. (2013, August 31). Asthma in
Pregnancy - European Medical Journal. Retrieved March 20, 2014, from European Medical
Journal: http://emjreviews.com/wp-content/uploads/Asthma-In-Pregnancy.pdf
Ledford, D. K., &Lockey, R. F. (2013). Asthma and Comorbidities:. Retrieved March 19,
2014, from Medscape: http://www.medscape.com/viewarticle/776917_1?src=emailthis
McCormack, M. C., &Wise, R. A. (2009). Respiratory Physiology in Pregnancy. In G.
Bourjeily, K. Rosene-Montella, & H. Press (Ed.), Pulmonary Problems in Pregnancy (pp. 16-26).
Springer Science and Business Medica, LLC.
Mennick, F. (2005, April).Treating Asthma in Pregnancy. American Journal of Nursing, 105 (4), p.
20.
Namazy, J. A., & Schatz, M. (2011). Asthma and Rhinitis During Pregnancy. Mount Sinai Journal
Of Medicine, 78 (5), 661-670.
National Guideline Clearinghouse. (2012). Asthma in Pregnancy. Retrieved April 1,
2014, fromAgency for Healthcare Research and Quality:
http://www.guideline.gov/content.aspx?id=12630
Nelson, L., Gossett, D. R., &Grobman,W. (2010, December 31). Search Results.
Retrieved March 10, 2014, fromThe Global Library ofWomen's Medicine:
http://www.glowm.com/pdf/section1_chapter4.pdf
Paragas, J. (2008, November). KeepingThe Beat With Pulse Oximetry. Nursing 2008 , pp. 56hn1-
56hn2.
Ulrik, C. S., &Gregersen,T. L. (2013). Safety of bronchodilators and corticosteroids for asthma
during pregnancy: what we know and what we need to do better. Journal of Asthma and Allergy,
6, 117-125.

23. TO ACCESS TO THIS POWER POINT
 http://www.slideshare.net/amariaela