1. Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.

2. Asthma is chronic inflammatory disease of airway
characterized by episodic, reversible, bronchial constriction
due to hyperresponsiveness of tracheobronchial tree to a
multiple stimuli.
Clinically characterized by
paroxysms of dyspnea,
cough
wheezing

3. Manifested by
- obstruction of airflow
- damage to airway epithelium
- constriction of bronchioles

4. Asthma and pregnancy
It is the most common chronic condition in pregnancy
The prevalence of asthma in the general population is
4-5%. In pregnancy, the prevalence ranges from 1-4%.
Chromosome 5, 6, 11, 12, 14, 16 & 20
15 methyl PGF2 and methylergometrine should be
avoided if possible
Progesterone & estrogen: bronchodilators
Progesterone also suppresses immunity, so in that
sense it is protective or helpful

5. Pathogenesis & Pathophysiology
 Chronic inflammatory disorder of the airways with recurrent
exacerbations
Interaction among the residents and infiltrating inflammation cells
in the airway surface epithelium, inflamatory mediators and
cytokines

6. Allergens
Mast cell
histamine leukotrienes
cytokines
bronchospam
bronchospam
Mucus production
Vascular
permeabili
ty Muscle thickening
Muscle constriction
Deposition of collagen
&
Epithelial thickening

8. Stimuli of Asthma
Major categories of stimuli of asthma
1) Allegerns- depends on IgE response
 frequently seasonal , observed in childrens & adults
 Non seasonal form are allergy to feathers, animals danders,
dust mites, molds.
2) Pharmacologic stimuli  like asprin, coloring agents such as
tartrazine, ß-adrenergic antagonists, sulfiting agents , ACE
inhibitors

9. 3) Environmental and air pollution
It includes ozone, NO2, Sulfur dioxide.
4) Occupational factors
 high molecular weight compounds – immuniological mechanism
wood , vegetable dust, pharmaceutical agents, biological agents,
animals and insect dust
 low molecular weight compound – release bronchoconstrictor
substances
it includes metals salts like chromes, nickel, industrial and
chemical plastics,

10. 5) Infections
respiratory stmuli that evoke acute
exacerbation of asthma
In young children common is syncytial
virus and Parainfluenza virus
In older children and adults rhino virus
and influenza virus

11. 6) Exercise
exercise is very common precipitants of episodes of
asthma .
7) Emotional stress
Psychological factors can version asthma
8) others: some food additives like metabisulphite,
tartrazine.
9) Hormonal premenstrual worsening of asthma due to fall in
progesterone, hypo and hyperthyroididsm can both worsen
asthma
10) Gastroesopahgeal reflux

12. Warning Signs of an Asthma
Episode
Examination Findings
History findings in pregnant and nonpregnant patients
may include the following:
• 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 (eg, hay
fever, eczema)

13. General physical examination findings may include the
following:
Tachypnea
Retraction (sternomastoid, abdominal, pectoralis muscles)
Agitation, usually a sign of hypoxia or respiratory distress
Pulsus paradoxicus (>20 mm Hg)
.

14. Pulmonary findings are as follows:
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

15. Signs of fatigue and near-respiratory arrest are as
follows:
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

16. Signs of complicated asthma are as follows:
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

17. Outcomes and complications of asthma in
pregnancy
Preeclampsia
Pregnancy-induced hypertension
Uterine hemorrhage
Preterm labor
Premature birth
Congenital anomalies
Fetal growth restriction
Low birth weightNeonatal hypoglycemia, seizures, tachypnea,
and neonatal intensive care unit (ICU) admission

18. Fetal surveillance during pregnancy
primary affect on the fetus from asthma, or any other
pulmonary disease, is chronic hypoxia.
The impact of hypoxia can manifest in several ways, including
growth restriction or more significantly, fetal death.
Shortly after a woman with asthma becomes pregnant, she
should have an early ultrasound to confirm her pregnancy
dating.
Women should be instructed to monitor fetal activity during
the course of the pregnancy.
A third-trimester ultrasound can be considered in a woman
with well-controlled asthma who has appropriate growth in
the fundal height.

19. If the growth is not appropriate or the woman has an acute
exacerbation, fetal testing should be started.
Testing may include umbilical artery Doppler flow velocity
studies, nonstress testing (NST) or biophysical profiles (BPP).
The frequency of such testing would depend on the severity of
the patient’s asthma or the degree of growth restriction .

20. Other differential diagnosis of asthma are:
Upper airways obstruction laryngeal edema
Acute left ventricular failure
Carciniod tumors
Recurrent pulmonary emboli
Endobronchial disease  foreign body aspiration, neoplasm & bronchial
stenosis
Eosinophilc pneumonias

21. Airway obstruction
Amniotic fluid embolism
Acute congestive heart failure (CHF), secondary to
peripartum cardiomyopathy
Physiologic dyspnea of pregnancy

22. Measures of Assessment
and Monitoring
Two aspects:
– Initial assessment and diagnosis of asthma
– Periodic assessment and monitoring

23. Initial Assessment and Diagnosis of
Asthma
Determine that:
 Patient has history or presence of episodic symptoms of airflow
obstruction
 Airflow obstruction is at least partially reversible
 Alternative diagnoses are excluded
Does patient have history or presence of episodic Symptoms of
airflow obstruction?
 Wheeze, shortness of breath, chest tightness, or cough
 Asthma symptoms vary throughout the day
 Absence of symptoms at the time of the examination does not
exclude the diagnosis of asthma

24. Is airflow obstruction at least partially reversible?
 Use spirometry to establish airflow obstruction:
– FEV1 < 80% predicted;
– FEV1/FVC <65% or below the lower limit of normal
 Use spirometry to establish reversibility:
– FEV1 increases >12% and at least 200 mL after using a short-
acting inhaled beta2-agonist
Are alternative diagnoses excluded?
 Vocal cord dysfunction, vascular rings, foreign bodies, other
pulmonary diseases

25. Additional Tests
Reasons for Additional Tests The
Tests
Patient has symptoms but spirometry is – Assess diurnal variation of peak flow
normal or near normal 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
– Chest x-ray
disease, or obstruction by foreign object
Suspect coexisting chronic obstructive pulmonary
– Additional pulmonary function studies
disease, restrictive defect, or central airway
obstruction – Diffusing capacity test
Suspect other factors contribute to asthma – Allergy tests—skin or in vitro
(These are not diagnostic tests for asthma.) – Nasal examination
– Gastroesophageal reflux assessment

26. Classification of Asthma Severity: Clinical
Features Before Treatment
Days With Nights With PEF or PEF
Symptoms Symptoms FEV1 Variability
Step 4 Continuous Frequent 60% >30%
Severe
Persistent
Step 3 Daily 5/month >60%-<80% >30%
Moderate
Persistent
Step 2 3-6/week 3-4/month 80% 20-30%
Mild
Persistent
Step 1 2/week 2/month 80%
<20%
Mild
Intermittent
Footnote: The patient’s step is determined by the most severe feature.

27. 1. Mild Intermittent Asthma
•Symptoms less than twice a week
•Symptoms at night less than twice a month
• No symptoms between episode
2. Mild Persistent
• Weekly, but not daily symptoms
• Episodes that may affect activity and sleep
• Symptoms at night more than twice a month

28. 3. Moderate Persistent
• Daily symptoms requiring bronchodialator inhaler use
• Episodes that affect activity and sleep
• Symptoms at night more than once a week
4. Severe Persistent
• Continuous symptoms
• Episodes that are frequent
• Symptoms at night all the time
• Activities are limited because of symptoms
• Symptoms occur while on maximal therapy

29. New strategy of asthma management are as below
GINA - 2006
Characteristic Controlled Partly controlled Uncontrolled
Day time symptoms None(twice or less/ More then
week) twice/week
Limitations of None Any
activities Three or more
features of partly
Nocturnal None Any controlled asthma
symptoms/awakeni present in any week
ng
Need for None(twice or less/ More than
reliever/rescue week) twice/week
treatment
Lungs function normal <80% predicted or
(PEF or FEV1 personal best (if
known
exacerbation none One or more /year One in any week

30. step 1 Step 2 Step 3 Step 4 Step 5
Asthma education and environmental control
As need rapid acting
β2 agonist As needed rapid acting β2 agonist
Select one Select one Add one or more Add one or both
Low dose ICS Low dose ICS + Medium or high-dose Oral glucocortico-
LABA ICS + LABA steroids (lowest dose)
Controller option Leukotriene modifier Medium or high dose Leukotriene modifier Anti IgE treatment
ICS
Low dose ICS + Sustained release
leukotriene modifier theophylline
Low dose ICS +
sustained release
theophylline

31. DRUGS USED IN ASTHMA
Bronchodilators Anti-inflammatory
Agents
Corticosteroids
Beta agonists Muscarinic Methyxanthines
antagonists Slow
Release Anti-inflammatory
inhibitors Drugs

32. Bronchodilators
(a) Beta agonists
• ß2 selective agonists e.g. albuterol given by inhalation via
aerosol
• stimulation of adenylyl cyclase - increases cAMP in bronchial
smooth muscle - increases bronchodilation
• extensively used and very effective in asthmatics
• Salbutamol--- 2-4mg oral, 0.5mg im /sc, 100-200mcg/puff
• Terbutaline----.25mg sc/inhalation,5mg oral.
• Long acting---- salmeterol/formoterol---(9-12 hrs)-
25mcg/puff, 2 puffs B D.

33. (b) Muscarinic antagonists
e.g. Ipratropium
Use:
• Ipratropium is available as pressurized aerosol
• not as useful as ß2 agonists in majority of asthmatics
• useful in chronic obstructive pulmonary disease

34. (c) Methyxanthines
e.g. theophylline .100-300mg tds
 major therapeutic preparation = aminophylline slow iv
250-500mg
Use:
•administered as theophylline salt orally
•diminishing use now because of more effective inhaled
bronchodilators
• used in patients who donít respond to anti- inflammatory
agents or ß2 agonists

35. Anti-inflammatory Agents
(a) Mast cell stabilisers---
e.g. Cromolym Na
 prophylactic drugs used as aerosol to inhibit antigen
and exercise induced asthma
 no effect on smooth muscle tone or bronchospasm
Use:
• inhaled cromolyn prevents allergen or exercise-induced
asthma
• 1mg/puff,2puff qid
• Nedocromil---4mg/2puff bd.

36. (b) Corticosteroids
e.g. lipid soluble corticosteroids
(beclomethazone, 100,200,250,mcg Budesonide 200-400mcg bd-qid
triamcinolone used in aerosols)
Use:
• used in asthma that is non-responsive to bronchodilator therapy
• high dose for several weeks followed by low dose, then given alternate days
C) leukotriene antagonist: --monteleukast 10 mg od zafirleukast—20 mg bd.
Md001921.jpg
d)Anti IgEm(Omalizumab) : s/c inj 2 to 4 weeks
e)Immunotherapy

37. When Having a Severe Asthma
Episode
 Go to the emergency room right away
 Signs of a severe episode
 Rescue or inhaler medicine doesn’t help within 15
minutes
 Person’s lips or fingernails are blue
 Person has trouble walking or talking due to
shortness of breath

38. Immediate management:
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
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

39. 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.
 The latter is important in preventing early relapse.

40. LABOUR & DELIVERY
Asthma exacerbations are rare in labor and delivery
due to the increase in serum cortisol
Asthma medications should not be discontinued through labor
and delivery.
Prostaglandin E2 is safe for cervical ripening, as is oxytocin.
The agent 15-methyl prostaglandin F2-alpha should be avoided
because it may cause severe bronchospasm.
methylergonovine may cause dyspnea, asthma is not an absolute
contraindication, and therefore it can be used when appropriate
in the management of postpartum hemorrhage.

41. Fentanyl is preferred to morphine and meperidine, which can
release histamine.
Epidural anesthesia is usually advised because it decreases
oxygen consumption and minute ventilation. Epidural
anesthesia also decreases the possibility of requiring general
anesthesia if an emergency cesarean becomes indicated during
labor

42. Postpartum period
During the postpartum period, women should initially
continue the same asthma medications they required during
pregnancy.
Close peak flow monitoring is indicated, particularly in those
with poorly controlled or moderate-to-severe asthma.

43. Thank you all…