New Treatment Guidelines For Pregnant Women
With Asthma -- Monitoring And Managing Asthma
Important for Healthy Mother and Baby
The National Asthma Education and Prevention Program
(NAEPP) is issuing the first new guidelines in more
than a decade for managing asthma during pregnancy.
The report reflects new medications that have emerged
and updates treatment recommendations for pregnant
women with asthma based on a systematic review of
data on the safety of asthma medications during pregnancy.
An executive summary ("Quick Reference")
of the guidelines is published in the January issue
of the Journal of Allergy & Clinical Immunology.
Poorly controlled asthma can lead to serious medical
problems for pregnant women and their fetuses. The
guidelines emphasize that controlling asthma during
pregnancy is important for the health and well-being
of the mother as well as for the healthy development
of the fetus. A stepwise approach to asthma care similar
to that used in the NAEPP general asthma treatment
guidelines for children and nonpregnant adults is
recommended. Under this approach, medication is stepped
up in intensity if needed, and stepped down when possible,
depending on asthma severity. Because asthma severity
changes during pregnancy for most women, the guidelines
also recommend that clinicians who provide obstetric
care monitor asthma severity during prenatal visits
of their patients who have asthma.
“The guidelines review the evidence on asthma
medications used by pregnant patients,” said
Barbara Alving, M.D., acting director of the National
Heart, Lung, and Blood Institute (NHLBI), which administers
the NAEPP. “The evidence is reassuring, and
suggests that it is safer to take medications than
to have asthma exacerbations. The guidelines should
be a useful tool for physicians to develop optimal
asthma management plans for pregnant women.”
"Simply put, when a pregnant patient has trouble
breathing, her fetus also has trouble getting the
oxygen it needs," added William W. Busse, M.D.,
professor of medicine at the University of Wisconsin
Medical School, and chair of the NAEPP multidisciplinary
expert panel that developed the guidelines. "There
are many ways we can help pregnant women control their
asthma, and it is imperative that providers and their
patients work together to do so."
Asthma affects over 20 million Americans and is one
of the most common potentially serious medical conditions
to complicate pregnancy. Maternal asthma is associated
with increased risk of infant death, preeclampsia
(a serious condition marked by high blood pressure,
which can cause seizures in the mother or fetus),
premature birth, and low-birth weight. These risks
are linked to asthma severity – more severe
asthma increases risk, while better controlled asthma
is tied to decreased risks.
Asthma worsens in approximately 30 percent of women
who have mild asthma at the beginning of their pregnancy,
according to a recent study by the National Institute
of Child Health and Human Development Maternal-Fetal
Medicine Units Network and cofunded by NHLBI. The
study also found that, conversely, asthma improved
in 23 percent of the women who initially had moderate
or severe asthma.
“We cannot predict who will worsen during pregnancy,
so the new guidelines recommend that pregnant patients
with persistent asthma have their asthma checked at
least monthly by a healthcare provider,” explained
Mitchell Dombrowski, M.D., chief of obstetrics and
gynecology for St. John Hospital in Detroit, and a
member of the NAEPP expert panel. “Clinicians
who provide obstetric care should be part of the patient’s
asthma management team, working with the patient and
her asthma care provider to adjust her medications
if needed to keep her asthma under control and to
lower the risk of complications from asthma for her
and her baby.”
Key recommendations from the guidelines regarding medications
include:
- Albuterol, a short-acting inhaled beta2-agonist,
should be used as a quick-relief medication to
treat asthma symptoms. Pregnant women with asthma
should have this medication available at all times.
- Women who have symptoms at least two days a week
or two nights a month have persistent asthma and
need daily medication for long-term care of their
asthma and to prevent exacerbations. Inhaled corticosteroids
are the preferred medication to control the underlying
inflammation in pregnant women with persistent
asthma. The guidelines note that there are more
data on the safety of budesonide use during pregnancy
than on other inhaled corticosteroids; however,
there are no data indicating that other inhaled
corticosteroids are unsafe during pregnancy, and
other inhaled corticosteroids may be continued
if they effectively control a patient’s
asthma. Alternative daily medications are leukotriene
receptor antagonists, cromolyn, or theophylline.
- For patients whose persistent asthma is not well
controlled on low doses of inhaled corticosteroids
alone, the guidelines recommend either increasing
the dose of inhaled corticosteroid or adding another
medication -- a long-acting beta agonist. The
expert panel concluded that data are insufficient
to indicate a preference of one option over the
other.
- & Oral corticosteroids may be required for the
treatment of severe asthma. The guidelines note
that there are conflicting data regarding the
safety of oral corticiosteroids during pregnancy;
however, severe, uncontrolled asthma poses a definite
risk to the mother and fetus; and use of oral
corticosteroids may be warranted.
“Several studies have shown that taking inhaled
corticosteroids improves lung function during pregnancy
and reduces asthma exacerbations—and other large,
prospective studies found no relation between taking
inhaled corticosteroids and congenital abnormalities
or other adverse pregnancy outcomes,” said Michael
Schatz, M.D., M.S., chief of the Department of Allergy
for Kaiser Permanente San Diego Medical Center. Schatz
is also a member of the NAEPP expert panel on asthma
during pregnancy and author of an editorial accompanying
the guidelines report.
The guidelines highlight other important aspects of
asthma management during pregnancy, such as identifying
and limiting exposure to asthma triggers. Similarly,
women with other conditions that can worsen asthma,
such as allergic rhinitis, sinusitis, and gastroesophageal
reflux, should have those conditions treated as well.
Such conditions often become more troublesome during
pregnancy.
“As important as medications are for controlling
asthma, a pregnant woman can reduce how much medication
is needed by identifying and avoiding the factors
that make her asthma worse, such as tobacco smoke
or allergens like dust mites,” added Dr. Schatz.
The NAEPP was established in March 1989 to reduce asthma-related
illness and death and to enhance the quality of life
of people with asthma. Today, 40 organizations, including
major medical associations, voluntary health organizations,
and numerous federal agencies, comprise the NAEPP
Coordinating Committee. The NAEPP also coordinates
federal asthma-related activities, as designated by
Congress through the Children's Health Act of 2000.
NAEPP convenes expert panels as needed to ensure that
the latest scientific evidence is translated into
clinical recommendations to help clinicians provide
the best possible asthma care.
To interview an NHLBI expert, please contact the NHLBI
Communications Office at (301) 496-4236. To interview
Dr. Busse, please contact Reitha Johnson at (608)
263-6174. To interview Dr. Dombrowski, please contact
Heather Hall at St. John Hospital at (313) 343-7458.
To interview Dr. Schatz, please contact Mike Byrne
at Kaiser Permanente at (626) 405-5528, or Sylvia
Wallace, Media Relations Manager, Kaiser Permanente
at (619) 528-7675.
For more information on the new guidelines, NAEPP,
and asthma care:
NHLBI is part of the National Institutes of Health
(NIH), the Federal Government's primary agency for
biomedical and behavioral research. NIH is a component
of the U.S. Department of Health and Human Services.
Additional information about asthma and other NHLBI-supported
research and educational programs are available online
at the NHLBI website, www.nhlbi.nih.gov.
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