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Pregnancy and Asthma

A. ı. l. l. l. a. e. r. D. j. i. k. m. i. l. H. i. B. a. s. r. t. l. a. k. a. ı. l. Prof.Dr.Zeynep MISIRLIGİL Ankara University School of Medicine Deparment of Pulmonary and Allergic Diseases. Pregnancy and Asthma. Prevalence of Asthma During Pregnancy. %3,7-8,4.

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Pregnancy and Asthma

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  1. A ı l l l a e r D j i k m i l H i B a s r t l a k a ı l Prof.Dr.Zeynep MISIRLIGİL Ankara University School of Medicine Deparment of Pulmonary and Allergic Diseases Pregnancy and Asthma

  2. Prevalence of Asthma During Pregnancy %3,7-8,4 Ann Epidemiol 2003;13:317

  3. Acute Asthma During Pregnancy • At least one emergency department visit • Pregnant women with acute severe asthma require hospitalization 18% 62 % Crit Care Med 2005;33:5321

  4. Effect of Pregnancy on Asthma • 1/3 better %36 • 1/3 same %41 • 1/3 worse %23 • Women with severe asthma tend to have worsening of their asthma Juniper EF, Newhouse MT. Asthma and Immunological Diseases in Pregnancy and Early Infancy. NY, MD, 1993: 401-427

  5. Asthma that is not adequately controlled during pregnancy can result in serious complications for both the mother and the fetus Maternal Complications Fetal Complications • Preeclampsia • Hypertension • Toxemia • Hyperemesis gravidorum • Perinatal mortality • Intrauterine growth • retardation • Premature birth • Low birth weight • Neonatal hypoxia Ann Allergy Asthma Immunol 2005;95;234-8

  6. Acute Asthma During Pregnancy • At least one emergency department visit • Pregnant women with acute severe asthma require hospitalization 18% 62 % Crit Care Med 2005;33:5321

  7. Maternal Asthma and Risk of Preterm Delivery • The study included women who delivered prior to the completion of 37 weeks gestation in a cohort population of 3253 pregnant women OR:2.03; 95% Cl 1.01-4.09 Serensen et a l(2003)

  8. Potential Mechanisms of Adverse Perinatal Outcomes in Asthma • Poor asthma control • Hypoxia • Reduced uteroplacental blood flow due to hypocapnia, alkalosis, dehydration, hypertension • Placental dysfanction • Asthma medications • Other factors

  9. Goals of Asthma Management in Pregnancy Mothers should have • Control of asthma symptoms • Normal lung function • Be able to go to work, school and exercise • Avoid medication side effects • Avoid attacks • Deliver a healthy infant

  10. To Achive Goals • Maternal lung function monitoring • Symptoms • Spirometry • Peak flows • Fetal monitoring • Ultrasound monitoring • Elektronic fetal hearts

  11. Management of Asthma During Pregnancy • Smoking • Allergen environmental control • Non-immunologic triggers

  12. Asthma and Pregnancy Choice of Medications • Human studies (when available) • Animal studies (when available and aplicable) • Drug efficacy • Route of administration • Duration of clinical exprience with the drug

  13. FDA Pregnancy Categories Category Animal Studies Human Studies Yarar/Risk A Negative Negative Yes B Negative Studies not doneYes B Pozitive Negative Yes C Pozitive Studies not doneYes C Not done Studies not doneYes D Irrelevant Studies and Rep.Yes Reports Pozitive X Irrelevant Studies and NO Reports Pozitive

  14. Recommendations for pharmacologic tratment in asthma during pregnancy DrugsFDA Category • Budesonide B • Cromolyn B • Nedocromil B • Montelukast B • Zafirlukast B • Terbutaline B • Ipratropium B • Beclamethasone C • Fluticasone C • Albuterol C • Theophylline C • Salmeterol C • Formoterol C

  15. Selected Studies of Preagnancy Outcomes Associated with Theophylline Use Investigators Desing No.of subjects Endpoints P value or OR ratio Stenius-Aarniala Retrospevtive 212 exposed Congenital anomalies NS Et al.(1995) Cohort asthmatics 292 nonexposed Low birht weight NS 237 nonasthmatics Perinatal death NS controls Preterm delivery NS Preeclamsia NS Shatz Et al 2123 asthmatics Congenital anomolies NS 2004 Cohort 273 exposed Low birht weight NS Preterm delivery NS Preeclamsia/PIH NS Perinatal project Cohort 55 000 Women Congenital anomolies NS 1977 117 exposed Immunol Allergy Clin N Am 2006;26:15

  16. Long acting β2 agonist medications and Pregnancy Investigators Desing No.of subject End Points % with event or p value Wilton et all Cohort 91 Salmetorol Congenital anomolies 2% 1995 65 exposed spontaneous abortion 8% 1.trimester preterm delivery 0% Wilton Shakir Cohort 31 Farmoterol Congenital anomalies 8% 2002 spontaneous abortion 10% preterm delivery 20% Brockenet al Cohort 2141 unexposed Low birth delivery NS 2005 112 exposed preterm delivery 20% Immunol Allergy Clin Am 2006:26;18

  17. Consensus Recommendations Regarding Leukotriene Antogonists During Pregnancy • Avoid Zileuton • Consider montelukast or Zafirlukast for patients with recalcitrant asthma who have shown a uniquely favorable response prior to pregnancy

  18. Consensus Recommendations Regarding Ipratropium During Pregnancy Consider use in pregnant women presenting with acute asthma who do not improve substanstially with the first inhaled beta agonist treatment

  19. Inhaled Corticosteroids During Pregnancy(3 animal and 10 human studies included) • ICS associated with decreased exacerbation risk and increased FEV1 • ICS no associated with congenital anomolies or perinatal outcomes • Budesonide is preferred although no data indicate others are unsafe that other formulations may be continued in those who were well maintained on these agents prior to pregnancy. RG Maureen, AAAAI, 2005

  20. “START” study support the finding that treatment with low dose budesonide (400mcg) during the full course of pregnancy in individuals with mild to moderate persistent asthma had no adverse effects on the fetus or newborn Outcomes of the 313 pregnancies Analyzed Budesonide Placebo n:196 n:117 Healthy children %81 %77 Adverse outcomes %19 %23 Ann Allergy Asthma Immunol 2005;95:566-70

  21. Adverse Associations with Oral Corticosteroids During Pregnancy • Oral Clefts(3-6 fold Increased risk) • Lower infant birth weight(10 mg dally throughout pregnancy) • Preeclampsia

  22. The Use Of Oral Corticosteroids During Pregnancy • İdeally, asthma would be controlled without oral corticosteroids • When indicated for the management of severe asthma, risks of treatment are less than the potantial risks of severe uncontrolled asthma • Maternal death • Fetal death

  23. Immunotherapy During Pregnancy • No advers effects on pregnancy outcomes • Anapylaxix may a risk for mother and baby Recommendations • Do not begin immunotherapy during pregnancy • Carefully continue ongoing effective immunotherapy (avoid sistemic reactions)

  24. Stepwise Approach for the Management of Chronic Asthma During Pregnancy (National Asthma Education Program report of the working group on asthma during pregnancy update 2004) Category Step Therapy • Mild intermitant Inhaled β2 agonist as needed • Mild persistant Low dose inhaled corticosteroid • Alternative: Cromolyn, leukotriene receptor antogonist or theophylline

  25. Moderate Persistent: • Low dose inhaled Corticosteroid and long acting β agonist • Medium dose inhaled corticosteroid or (if neeeded) medium dose long acting β agonist Alternative: Low dose or (if needed) medium dose inhaled corticosteroid and either theophylline or leukotriene receptor antagonist • Severe Persistent: • High dose inhaled corticosteroid and long acting β agonist and if needed oral corticosteroid and theophylline Alternative:High dose inhaled corticosteroid and theophylline

  26. Management of Acute Asthma in a Pregnant Women • Oxygen supplementation(SaO2>95%) • İntravenous fluid hydration(if necessary) • Inhale albuterol(every 20 mins up to three doses in the first hour) • Ipratropium bromide (500μg)(in severe cases) • Systemic corticostreoids either intravenously or orally(in moderate/severe cases)

  27. Obstetrical Management of Pregnant Patients With Asthma Excellent Choice During Labor • Lumbar epidural analgesia • Fentonyl (as a narcotic analgesic) • Oxytocin and prostaglandin E2 supposituars (for labor induction) • Pitocin, misoprostol and methylergonovine (for postportum hemorrhage) Should be avoided • Morphine • Meperidine • 15-methylprostaglandin F2α

  28. Asthma and Lactation • There is no effect of lactation on maternal asthma • Prednisone, theophylline, antihistamines, ICS, SABAs, LABAs and cromolyn are not contrendicated. • Theophylline may cause neonatal irritability, feeding difficulties.

  29. Allergic Diseases Morbidity During Pregnancy • Allergic diseases effect 20 % of women in childbearing years • Nasal symptoms occur in at least 20-30 % of pregnant women.

  30. Pregnancy Rhinitis During Pregnancy • Allergic Rhinitis* • Infectious Sinusitis • Rhinitis medicamentosa • Pregnancy rhinitis • Eosinophilic nonallergic* rhinitis • Nasal polyps* • Structural nasal obstruction *History of some often precedes pregnancy

  31. Allergic Rhinitis During Pregnancy 15 % better 34 % worse 45 % same 6 % unknown There was a sixfold increased risk of bacterial rhinosinusitis during pregnancy

  32. Antihistamines Oral and Intranasal • Tripelennamine B • Chlorpheniramine B • Loratadine B • Cetirisine B • Fexofenadine C • Azelastine C • Desloratadine C Ophtalmic Antihistamines • Antezoline C • Azelastine C • Ketotifen C • Levocobastine C • Olopatodine C • Pheniramine C

  33. Medications to Treat Rhinitis During Pregnancy Topical and oral decongestants • Phenylephrine C • Naphazoline C • Tetraphydrozolin C • Oxymetazoline C • Xylometazoline C • Pseudoephedrine C

  34. Nasal Corticosteroids During Pregnancy • Budesonide B • Beklamatazon C • Flutikazon C • Mometazon C

  35. Treatment of Allergic Rhinoconjunktivitis in Pregnancy • Allergen avoidance : All patients • Conjuntivitis: Optalmic cromolyn, supplemented by loratadine or cetirizine as needed

  36. Allergic Rhinitis and Pregnacy • Intermitten rhinitis • (symtoms less than 4 days a week or for less than 4 weeks per year) • Mild: • Loratadine or cetirizine as needed • Modarate- severe (İmpairmen of sleep, daily activities, school or work or trouble some symptoms): • Intermitten intrasal budesonide, supplemented by loratadine or cetirizine as needed

  37. Allergic Rhinitis and Pregnacy Persistent Rhinitis (symptoms more than 4 days per week and more than 4 weeks per year) • Mild: • Intranasal cromolyn supplemented by loratadine or cetirizine as needed • Moderate-Severe: • Regular intranasal budesonide, supplemented bye loratadine or cetirizine as needed; immunotherapy

  38. Thank you.. Prof.Dr.Zeynep MISIRLIGİL

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