HAPPY MOTHER’S DAY!
Classic Mr. T video: “Treat Your Mother Right”
from the AAAAI 60th Annual Meeting: NAEPP Expert Panel Report:
Asthma reportedly affects about 7% of pregnant women, and some research has suggested that these women are at an increased risk of preeclampsia or having a child suffer perinatal mortality, preterm birth, or low birth weight.
However, by controlling asthma, those risks are thought to be decreased, noted Michael Schatz, MD, chief of the Allergy Department at Kaiser-Permanente Medical Center in San Diego, California, and coleader of the panel committee. “We can do something about what medicines we use,” Dr. Schatz said during his presentation. “How you control the asthma makes a difference.”
The new guidelines discuss the need to intensely monitor women with asthma once a month during pregnancy, reduce any triggers such as allergens and smoke, and educate patients on the importance of asthma control.
Caution must also be taken in step-down therapy, Dr. Nelson said, with more care taken than usual in preventing flare-ups, or even postponing step-down therapy until the pregnancy is completed.
The new recommendations primarily focus on the pharmacologic treatment of asthma. Researchers reviewed a total of 6,113 articles in the medical literature published between 1990 and May 2003, analyzing 44 in depth.
The new recommendations are as follows:
For mild intermittent asthma, pregnant women should be prescribed short-acting inhaled beta2-agonists, preferably albuterol.; Previously, the recommended drug was terbutaline.
For mild persistent asthma, pregnant women should be prescribed low-dose inhaled corticosteroids (ICS), preferably budesonide. Previously, cromolyn was the initial preferred treatment; now that is an alternative recommended treatment, as well as leukotriene receptor antagonists or theophylline.
“Budesonide is the preferred ICS because safety studies in pregnancy are available and reassuring,” Dr. Nelson said. “There are few or no data on other formulations during pregnancy, but no data indicate they are unsafe, and they may be continued in well-controlled patients.”
If a patient is doing well on a different ICS, the investigators advised against switching to budesonide. “If a person is controlled, that’s important,” Dr. Schatz said. “But for starting on a medication in pregnancy, or for women of childbearing age, you may use this data to make some choices.”
For moderate asthma, there are two equal recommendations: either a low dose of an ICS plus a long-acting inhaled beta2-agonist such as salmeterol, or a medium-dose ICS. Previous recommendations of cromolyn and oral beta2-agonists are no longer recommended.
For persistent severe asthma, pregnant women should be prescribed a high dose of an ICS, preferably budesonide, and oral prednisone as a last resort at a maximum of 60 mg. The risks of not treating severe asthma need to be weighed against the indication that oral corticosteroid use during the first trimester was associated with an increased risk in cleft palate and with preterm birth and low birth weight.
The researchers also made no recommendations regarding omalizumab, an asthma medication approved last June by the U.S. Food and Drug Administration, which has no published data regarding use among pregnant women. “This is the problem with a newer drug, it takes a while to get data,” Dr. Schatz said.
In the past, some physicians stopped asthma medications during pregnancy, but that’s not necessary, said William W. Busse, MD, a professor of medicine and allergy at the University of Wisconsin at Madison, who moderated the session. “There are good and safe treatments.”
from the AAAAI Tips to Remember:
During pregnancy, mothers-to-be may feel uneasy taking medications. However, if a pregnant woman has asthma, it is doubly important that her symptoms be well-managed to increase both her health and her baby’s health. Uncontrolled asthma can be a threat to maternal well-being and fetal growth and survival. The goals of asthma management and treatment during pregnancy are the same as for other patients-to prevent hospitalization, emergency room visits, work loss and chronic disability.
Pregnant women, like others with asthma, should avoid asthma triggers, including specific allergens such as house dust mites and animal dander, and irritants such as cigarette smoke. After discovering you are pregnant, see your allergist/immunologist soon after to discuss the best way to manage your asthma and what medications to take. He or she will be able to prescribe effective asthma and allergy medications that are appropriate to use during pregnancy, and will continue to work with you throughout your pregnancy to ensure your treatment is effective, without side effects.
If you are pregnant and have asthma, you may have questions regarding the best care for both your asthma symptoms and your baby. Following are some common questions and answers to assist you.
Can women with asthma have safe, full-term pregnancies?
Studies show maternal asthma that is well-managed during pregnancy does not increase the risk of maternal or infant complications. With appropriate asthma management, you can have a healthy baby. Conversely, there is a direct relationship between lower birth weight and uncontrolled asthma. So, it benefits you and your baby to control asthma symptoms.
Why would uncontrolled asthma affect the fetus?
Uncontrolled asthma causes a decrease in the amount of oxygen in the mother’s blood. Since the fetus receives its oxygen from the mother’s blood, decreased oxygen in her blood can lead to decreased oxygen in the fetal blood. This, in turn, can lead to impaired fetal growth and survival, since a fetus requires a constant supply of oxygen for normal growth and development.
How do asthma medications affect the fetus?
Studies and observations of hundreds of pregnant women with asthma have demonstrated that most inhaled asthma medications are appropriate for patients to use while pregnant. The risks of uncontrolled asthma appear to be greater than the risks of necessary asthma medications. However, oral medications (pills) should be avoided unless necessary to control symptoms.
What effect does pregnancy have on asthma?
Pregnancy may affect the severity of asthma. One study showed that asthma symptoms worsened in 35% of pregnant women, improved in 28% and remained the same in 33% of the pregnant women. These changes in severity are another reason to stay in close contact with your allergist/immunologist so he or she can monitor your condition and alter your medications or dosages if necessary.
During what part of pregnancy will asthma change?
Asthma has a tendency to worsen during pregnancy in the late second and early third trimesters; however, women may experience fewer symptoms during the last four weeks of pregnancy. Troublesome asthma during labor and delivery is extremely rare in women whose asthma has been adequately controlled during pregnancy.
Why does asthma improve for some women during pregnancy?
The exact reason is unknown. Higher levels of cortisone in the body during pregnancy may be an important cause of this improvement.
Why does asthma worsen for some women during pregnancy?
Again, the exact reasons are not known. Because the stomach area is compacted during pregnancy, some women may experience gastroesophageal reflux, a condition that causes heartburn and other symptoms. This reflux can worsen asthma symptoms. Other conditions, such as sinus infections, viral respiratory infections and increased stress, may also aggravate asthma during pregnancy.
Can I continue to receive allergy shots during pregnancy?
Immunotherapy or “allergy shots,” do not have an adverse effect on pregnancy, so they can be continued. As always, your allergist/immunologist will monitor your dose to reduce the risk of an allergic reaction to the shots. These reactions are rare; however, such a reaction could be harmful to the fetus. And, allergy shot treatments should not be started for the first time during pregnancy.
Can women with asthma perform Lamaze?
Most women with asthma are able to perform Lamaze breathing techniques without difficulty.
Can I breast feed if I have asthma?
Breast feeding is a good way to increase your child’s immunity, and is encouraged. The transfer of most drugs into breast milk has not been precisely evaluated; however, there appears to be no evidence that asthma medications adversely affect nursing infants. (However, some infants may become irritable from theophylline transferred by breast milk.) Also, if you have allergy symptoms while nursing, it is appropriate to treat these as well. Again, make sure to see your allergist/immunologist for the best treatment of allergies and asthma while nursing.
Although these are common questions during pregnancy, each patient’s individual treatment varies. Managing asthma and avoiding asthma flare-ups during pregnancy is important to the health of the mother and fetus. It is best if women see their allergist/immunologist regularly during pregnancy so that any worsening of asthma can be countered by appropriate changes in the management program. Make sure to discuss any specific concerns with your doctor to ensure the healthiest pregnancy-for your well-being and that of your baby.
When to see an allergy/asthma specialist
The AAAAI’s How the Allergist/Immunologist Can Help: Consultation and Referral Guidelines Citing the Evidence provide information to assist patients and health care professionals in determining when a patient may need consultation or ongoing specialty care by the allergist/immunologist. Patients should see an allergist/immunologist if they:
Have a family history of allergies and are interested in identifying prevention strategies for their infant.
Have moderate-severe or uncontrolled asthma.
Your allergist/immunologist can provide you with more information on asthma and pregnancy.
Tips to Remember are created by the Public Education Committee of the American Academy of Allergy, Asthma and Immunology.