General Information
Pathogenesis of asthma
Chronic airway inflammation that is partially or completely reversible
Appropriate rescue therapy
Albuterol, up to 2 treatments at 20 minute intervals
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Differential for respiratory symptoms in pregnancy
Dyspnea in pregnancy
GERD
Postnasal drip
Bronchitis
Acute respiratory viral illness
Cardiac causes (peripartum cardiomyopathy)
Preeclampsia with severe features - pulmonary edema
When should patients seek care for exacerbation
If no response to rescue therapy or decrease in fetal activity
Adverse outcomes associated with severe asthma (name 2)
Increased prematurity
Cesarean delivery
preeclampsia
growth restriction
maternal morbidity/mortality
First-line controller therapy
Mild, persistent: low dose inhaled corticosteroids (ICS)
Moderate, persistent: Medium dose ICS or low dose + long-acting beta agonists (LABA)
Severe persistent: high dose ICS + LABA
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Asthma assessment in pregnancy
Spirometry preferred, but peak flow meter is sufficient
Severity is assessed with symptoms
Important to identify history of hospitalization, ED visits, or oral steroid use
Initial assessment
H&P, PEFR, O2 saturation
Fetal monitoring
Severity Level
Symptoms > 2 days per week, not daily
night time awakening > 2x/month
Peak Flow >80% of personal best
Mild persistent
Add-on controller options
theophylline
montelukast
LABA (preferred due to increased effectiveness)
Oral corticosteroids if persistently refractory
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Allergy shots in pregnancy - yay or nay
Generally nay
Can be considered in patients receiving a maintenance or near maintenance dose, but risk-benefit analysis doesn't favor beginning immunotherapy for allergies during pregnancy
When is hospitalization indicated after initial treatment?
If incomplete response to treatment (PEFR 50-70%)
OR poor response (50% or less)
If poor response + severe symptoms/drowsiness/confusion/hypercarbia, ICU recommended
Severity
symptoms throughout the day
night time awakening 4x+ per week
peak flow <60%
Severe persistent
Can someone on asthma medications breastfeed?
Yes!
Only small amounts of asthma medications cross the placenta.
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Fetal surveillance
Dating ultrasound (to facilitate evaluation of FGR)
serial growth + NST considered for poor control or moderate-to-severe asthma
Discharge meds after acute exacerbation
Albuterol 2-4 puffs every 3-4 hours
Oral corticosteroids 40-60mg in a single dose or 2 divided doses for 3-10 days
Continue ICS
Follow up in 5 days
Airway obstruction on spirometry that has a >12% increase in FEV1 after bronchodilator administration
Medications to avoid
nonselective beta blockers
hemabate
methergine
indocin (if patients are aspirin sensitive)
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Intrapartum concerns
- adequate analgesia to reduce risk of bronchospasm
- continue asthma meds
- stress dose steroids for people receiving oral steroids
- cesarean delivery rarely needed for acute exacerbation
- If high doses of albuterol in labor, glucose checks in baby for 24 hours
Appropriate medications in pregnancy for acute exacerbation
Same as non-pregnant adults!
Appropriate: SABA, ipratropium, steroids, IV magnesium sulfate
Intravenous aminophylline/theophylline is NOT generally recommended for use in the emergency management due to no additional benefit over SABA/steroids