Uncontrolled asthma in the pregnant patient can lead to adverse outcomes for the mother or fetus.

2. Dr. Niranjan Chavan
MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson, FOGSI Oncology and TT Committee (2012-2014)
Treasurer, MOGS (2017- 2018)
Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016)
Chief Editor, AFG Times (2015-2017)
Editorial Board, European Journal of Gynecologic Oncology
Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters
Member, Managing Committee, IAGE (2013-2017)
Member , Oncology Committee, AOFOG (2013 -2015)
Recipient of 6 National & International Awards
Author of 15 Research Papers and 19 Scientific Chapters
Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of
Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. Asthma is one of the most common medical conditions
encountered during pregnancy, occurring in 3 - 8 % of pregnant
women.
Namazy JA, Schatz M. Pregnancy and asthma: recent developments. Curr Opin Pulm Med 2005; 11:56.
Liccardi G, Cazzola M, Canonica GW, et al. General strategy for the management of bronchial asthma in pregnancy. Resp
Tan KS, Thomson NC. Asthma in pregnancy. Am J Med 2000; 109:727.
Dombrowski MP, Schatz M, Wise R, et al. Asthma during pregnancy. Obstet Gynecol 2004; 103:5.

4. Allergens
Mast cell
histamine cytokines leukotrienes
bronchospam
Vascular
permeability
Deposition of collagen
&
Epithelial thickening
Muscle constriction
Muscle thickening
bronchospam
Mucus production
PATHOPHYSIOLOGY

6. TRIGGERS OF ASTHMA

8. Lung Volumes and Capacities
• Tidal volumes increases gradually(35-50%).
• Total lung capacity is reduced (4-5%) by the elevation of
the diaphragm.
• ERV ( Expiratory reserve volume , FRC (Functional
residual capacity) and RV (Residual volume) decrease by
about 20%.
• Increase in Inspiratory capacity

9. • 1/3 aggravate
• 1/3 improve
• 1/3 does not change
• Most return to their Pre-pregnancy baseline within 3 months postpartum
• Asthma symptoms peak in the late second or early third trimester
• (24-36 weeks)
• Most severe disease most likely to worsen during pregnancy
• The severity of symptoms in first pregnancy is similar in subsequent pregnancies.

10. MATERNAL
•↑ ED visits
•↑ Hospitalization
•↑ Hyperemesis
•↑ Accidental haemorrhage
•↑ Respiratory failure
•↑ PIH
•↑ Death
•↑ Preterm labor
•↑ Premature birth

11. FETAL
↑ OligohydroamniosOligohydroamnios
↑ LBW
↑ Premature delivery
↑ Fetal demise
↑Meconium staining
NEONATAL
↑ Neonatal hypoxemia
↑ Low newborn assessment scores
↑ Perinatal mortality

12. • Upper airways obstruction laryngeal edema
• Acute left ventricular failure
• Carciniod tumors
• Recurrent pulmonary emboli
• Endobronchial disease
• Airway obstruction
• Amniotic fluid embolism
• Acute congestive heart failure (CHF
• Physiologic dyspnea of pregnancy
• Eosinophilc pneumonias
““ALL THAT WHEEZES IS NOT ASTHMA””

13. 13
CLASSIFICATION OF SEVERITY
CLASSIFY SEVERITY
Clinical Features Before Treatment
SymptomsSymptoms NocturnalNocturnal
SymptomsSymptoms
FEVFEV11 or PEFor PEF
STEP 4STEP 4
SevereSevere
PersistentPersistent
STEP 3STEP 3
ModerateModerate
PersistentPersistent
STEP 2STEP 2
MildMild
PersistentPersistent
STEP 1STEP 1
IntermittentIntermittent
ContinuousContinuous
Limited physicalLimited physical
activityactivity
DailyDaily
Attacks affect activityAttacks affect activity
> 1 time a week> 1 time a week
but < 1 time abut < 1 time a
dayday
< 1 time a week< 1 time a week
AsymptomaticAsymptomatic
and normal PEFand normal PEF
between attacksbetween attacks
FrequentFrequent
> 1 time week> 1 time week
> 2 times a month> 2 times a month
≤ 2 times a2 times a
monthmonth
≤≤ 60% predicted60% predicted
Variability > 30%Variability > 30%
60 - 80% predicted60 - 80% predicted
Variability > 30%Variability > 30%
≥≥ 80% predicted80% predicted
Variability 20 - 30%Variability 20 - 30%
≥≥ 80% predicted80% predicted
Variability < 20%Variability < 20%
The presence of one feature of severity is sufficient to place patient in that category.

14. History findings
•Cough
•Shortness of breath
•Chest tightness
•Noisy breathing
•Nocturnal awakenings
•Recurrent episodes of symptom complex
•Exacerbations possibly provoked by nonspecific stimuli
•Personal or family history of other atopic disease
WARNING SIGNS OF AN ASTHMAWARNING SIGNS OF AN ASTHMA
EPISODEEPISODE

15. .
General physical examination
• Tachypnea
• Retraction (sternomastoid, abdominal, pectoralis muscles)
• Agitation, usually a sign of hypoxia or respiratory distress
• Pulsus paradoxicus (>20 mm Hg)

16. Pulmonary findings
• Diffuse wheezes - Long, high-pitched sounds on expiration and, occasionally, on
inspiration)
• Diffuse rhonchi - Short, high- or low-pitched squeaks or gurgles on inspiration and/or
expiration
• Bronchovesicular sounds
• Expiratory phase of respiration equal to or more prominent than inspiratory phase

17. Signs of Fatigue and Near-respiratory arrest
• Alteration in the level of consciousness, such as lethargy, which is a
sign of respiratory acidosis and fatigue
• Abdominal breathing
• Inability to speak in complete sentences

18. Signs of Complicated Asthma
• Equality of breath sounds: Check for equality of breath sounds
(pneumonia, mucous plugs, barotrauma).
• The amount of wheezing does not always correlate with the severity of the
attack. A silent chest in someone in distress is more worrisome.
• Jugular venous distension from increased intrathoracic pressure (from a
coexistent pneumothorax)
• Hypotension and tachycardia (think tension pneumothorax)
• Fever, a sign of upper or lower respiratory infections

19. Two aspects:
• Initial assessment and diagnosis of asthma
• Periodic assessment and monitoring
Once in Month History
Lung Auscultation
PFT

20.  SPIROMETRY: Decrease FVC , Decrease FEV1
INITIAL ASSESSMENT AND DIAGNOSIS OF ASTHMA

21. • The Peak flow or Peak Expiratory Flow or PEF indicates how
severe the asthma crisis is:
• PEF values to keep in mind :
• Normal for a woman : 450 l/min
Values depending on severity (in % of normal value):
Acute asthma Serious crisis Light/moderate
crisis
PEF impossible
or < 30%
(< 180 l/min)
PEF = 30 to 50%
(180 to 300 l/min)
PEF > 50%
(> 300 l/min)
PERIODIC ASSESSMENT AND MONITORING

22. ADDITIONAL TESTSADDITIONAL TESTS
Patient has symptoms but spirometry is
normal or near normal
Assess diurnal variation of peak flow
over 1 to 2 weeks
Refer to a specialist for bronchoprovocation
with methacholine histamine, or exercise;
Negative test may help rule out asthma
Suspect infection, large airway lesions,
heart disease, or obstruction by foreign
object
Chest x-ray
Suspect coexisting chronic obstructive
pulmonary disease, restrictive defect, or
central airway obstruction
Additional pulmonary function
studies – Diffusing capacity test
Suspect other factors contribute to
asthma
Allergy tests—skin or in vitro
Nasal examination
Gastroesophageal reflux assessment

23. The frequency of testing depends on the severity of
the patient’s asthma or the degree of growth
restriction :
Umbilical artery Doppler flow velocity
Non-stress testing (NST)
Biophysical profiles (BPP)
FETAL SURVEILLANCE

24. • Control symptoms, including nocturnal symptoms
• Prevent acute exacerbations
• No limitations on activities
• Maintain (near) normal pulmonary function
• Minimal use short-acting inhaled beta2- agonists
• Protect the mother and fetus from adverse effects

25. The Expert Panel Report of the Working Group on Asthma and Pregnancy stressed the
following four important components of effective therapy :
•Objective monitoring of maternal lung function and fetal well–being as a guide to
therapy
•Proper control of environmental and other triggers for asthma
•Patient education
•Pharmacologic therapy
NAEPP expert panel report. Managing asthma during pregnancy: recommendations for pharmacologic
treatment-2004 update.
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program Asthma and
Pregnancy Working Group
J Allergy Clin Immunol. 2005;115(1):34.

26. New strategy of Asthma Management in
Pregnancy
“GINA – 2007”

29. • Influenza vaccination is necessary for:
• Pregnant women with 2nd
and 3rd
trimester
• In cold months

30. • Oxygen therapy by tight fitting facemask (60%)
• Nebulised Salbutamol 2.5 +/- 0.5mg Ipratropium
• Start glucocorticoid therapy - Prednisolone 30-60mg p.o. or
Hydrocortisone 200mg i.v.
• Urgent chest X-ray to exclude pneumothorax
• Urgent blood gas

31. • Reassess in 15 min or if life-threatening features appear
• Consider i.v. aminophylline if life-threatening features or fails to improve after 15-30
minutes
• Ventilation needed if PEFR continues to fall despite medical therapy, patient
becoming drowsy/confused/exhausted or deteriorating blood gases
LATE MANAGEMENT :
• Step down initially by converting from nebulised to usual inhaled device (eg MDI)
checking that their technique is adequate.
• Patient is discharged only when PEFR normalized (80-90% of their best) without
dipping. They should also be discharged on high-dose inhaled glucocorticoid, which
should continue, until they are reviewed in clinic.

33. • Acute asthma is rare in labour.
• Continue usual asthma medications.
• Avoid prostaglandin F2α ( Dinoprost for induction ) and
Ergometrine
• Women receiving steroid tablets at a dose exceeding
Prednisolone 7.5mg per day for more than 2 weeks prior to
delivery should receive parenteral hydrocortisone 100mg 6-8
hourly during labour.
• Pitocin, misoprostol (for postportum haemorrhage)

34. •Lumbar epidural analgesia (Decreases O2
consumption and minute ventilation)
•Fentanyl (as a narcotic analgesic)
• General anesthesia (SOS)

35. • Whenever possible if RA can do, it is preferred to General
• Avoid GA as possible in patients at risk of aspiration of gastric contents:
 Emergency surgery in non fasting patient
 Gastroesophageal reflux
 Marked obesity
 Bowel obstruction
 Gastroparesis (trauma or diabetes)
If General anesthesia is needed:
 Pretreatment with Atropine may provide a bronchodilating effect.
 Ketamine is the agent of choice for anesthesia induction

36. • There is no effect of lactation on maternal asthma.
• Prednisone, theophylline, antihistamines, ICS,
SABAs, LABAs and cromolyn are not contra-
indicated.
• Theophylline may cause neonatal irritability, feeding
difficulties.

37. Study type and author yr
[ref]
Population study years Sample Size Method for assessing
asthma changes
Asthma worse Asthma unchanged Asthma improved
Changes in asthma
symptoms during
pregnancy
Williams, 1967 8 UK 210 (asthma) Examination of hospital
records
24% 34% 42%
Gluck and Gluck, 1976
96
USA 47 (asthma) Symptoms (wheeze)
and/or medication
requirements
43% 43% 14%
Gibbs et al., 1984 98 England 67 (asthma) Self-report of overall
changes
14% 30% 33%
Schatz et al., 1988 97 USA 1978–1984 336 (asthma) Daily symptom diaries and
subjective classification of
overall changes
35% 33% 28%
Lao and Huengsburg,
1990 11
Hong Kong 1984–1997 87 (asthma) Frequency and severity of
symptoms/attacks and
third trimester PEF
30% 39% 31%
Beecroft et al., 1998 99 England 34 (asthma) Questionnaire on
symptoms and treatment
41% 32% 27%
Kurinczuk et al., 1999 6 Australia 1995–1997 79 (asthma) Self-report of overall
changes in breathing
35% 35% 16%
Kircher et al., 2002 100 USA 1978–1984 671 (asthma) Daily symptom diaries and
subjective classification of
overall changes
36% 26% 34%
Beckmann, 2002 101 Internet survey 166 (asthma) Self-report of overall
changes
41% 14% 35%
STUDIES

38. Changes in asthma
treatment during
pregnancy
Fein and Kamin, 1964 102 USA 50 (atopy) 23 (asthma) Overall change in treatment 21% 67% 12%
Murphy et al., 2003 30 Australia 1998–2002 71 (asthma) Change in ICS use from first to
third trimester
ICS increased with female
foetus
Dodds et al., 1999 103 Canada 1991–1993 817 (asthma) Use of β2-agonists and
steroids
Steroid use greater with
female foetus
Changes in lung function
or airway
hyperresponsiveness
Sims et al., 1976 104 England 1973–1974 12 (control) 27 (asthma) Serial spirometry (FEV1 and
FVC)
No changes with pregnancy
Juniper et al., 1989 105 Canada 16 (asthma) Airway hyperresponsiveness
to methacholine and
spirometry and medications
use
Overall no alteration Overall PC20improved in
second trimester
White et al., 1989 106 England 31 (asthma) Questionnaire (perception of
symptoms), daily
bronchodilator use and peak
flow
6% (subjective) 23% (subjective) 71% (subjective) 34% (peak
flow)
Asthma exacerbations
during pregnancy
Stenius-Aarniala et al., 1996
23
Finland 1982–1992 504 (asthma) Acute attack of asthma not
controlled by normal rescue
medications
9.3%
Henderson et al., 2000 107 USA 1960–1965 1564 (asthma) Exacerbation and
hospitalisation or acute
asthma without hospitalisation
2% hospitalised 15% acute
asthma
Schatz et al., 2003 66 USA 1994–2000 1739 (sub-divided into mild,
moderate and severe asthma)
Exacerbations (emergency
department visits,
unscheduled doctor visits, oral
steroids or hospitalisation)
12% (mild), 26% (moderate),
52% (severe

39. • Uncontrolled asthma in the pregnant patient can lead to adverse outcomes for the mother
or fetus.
• With appropriate care, however, normal outcomes usually can be achieved. This care
includes development of a patient-physician relationship involving patient education, early
symptom recognition, self-management strategies, patient self-restraint regarding
unauthorized medication use, and compliance with appointments and medications.
• Physicians can take advantage of the growing body of literature regarding asthma and
pregnancy to help guide their management of disease in this setting.
• Helping patients avoid asthma exacerbations, emergency department visits, and
hospitalizations can reduce the risk of maternal/fetal morbidity and mortality.