The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of "Major Recommendations" field.
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- It is safer for pregnant women with asthma to be treated with asthma medications than it is for them to have asthma symptoms and exacerbations.
- Clinical evaluation of asthma includes subjective assessments and pulmonary function tests.
- The ultimate goal of asthma therapy in pregnancy is maintaining adequate oxygenation of the fetus by preventing hypoxic episodes in the mother.
- The step-care therapeutic approach (see box below) increases the number and dosage of medications with increasing asthma severity.
- Inhaled corticosteroids are first-line controller therapy for persistent asthma during pregnancy.
- Budesonide is the preferred inhaled corticosteroid for use during pregnancy.
- Inhaled albuterol is recommended rescue therapy for pregnant women with asthma.
- Identifying and controlling or avoiding factors such as allergens and irritants, particularly tobacco smoke, can lead to improved maternal well-being with less need for medication.
- Continuation of immunotherapy is recommended in patients who are at or near a maintenance dose, not experiencing adverse reactions to the injections, and apparently deriving clinical benefit.
- Use of prednisone, theophylline, antihistamines, inhaled corticosteroids, beta2-agonists, and cromolyn is not contraindicated for breastfeeding.
Step Therapy Medical Management of Asthma During Pregnancy
Mild Intermittent Asthma
- No daily medications, albuterol as needed
Mild Persistent Asthma
- Preferred – Low-dose inhaled corticosteroid
- Alternative – Cromolyn, leukotriene receptor antagonist, or theophylline (serum level 5 to 12 mcg/mL)
Moderate Persistent Asthma
- Preferred – Low-dose inhaled corticosteroid and salmeterol or medium-dose inhaled corticosteroid or (if needed) medium-dose inhaled corticosteroid and salmeterol
- Alternative – Low-dose or (if needed) medium-dose inhaled corticosteroid and either leukotriene receptor antagonist or theophylline (serum level 5 to 12 mcg/mL)
Severe Persistent Asthma
- Preferred – High-dose inhaled corticosteroid and salmeterol and (if needed) oral corticosteroid
- Alternative – High-dose inhaled corticosteroid and theophylline (serum level 5 to 12 mcg/mL) and oral corticosteroid if needed
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The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- Asthma self-management skills, including self-monitoring, correct use of inhalers, and following a plan for long-term management of asthma and promptly handling signs of worsening asthma, enhance asthma control.
- For pulmonary function assessment of patients during outpatient visits, spirometry is preferable, but peak expiratory flow measurement with a peak flow meter also is sufficient.
- Ultrasound examinations and antenatal fetal testing should be considered for women who have moderate or severe asthma during pregnancy.
- Pregnant patients with asthma, even those with mild or well-controlled disease, need to be monitored with peak expiratory flow rate (PEFR) and forced expiratory volume in the first second of expiration (FEV1) testing as well as by observing their symptoms during pregnancy.
- Routine evaluation of pulmonary function in pregnant women with persistent asthma is recommended.
- Because pulmonary function and asthma severity may change during the course of pregnancy, routine evaluation of pulmonary function in pregnant women with persistent asthma is recommended.
Definitions:
Grades of Evidence
I Evidence obtained from at least one properly designed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled trials without randomization.
II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.
II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.
III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Levels of Recommendation
Level A — Recommendations are based on good and consistent scientific evidence.
Level B — Recommendations are based on limited or inconsistent scientific evidence.
Level C — Recommendations are based primarily on consensus and expert opinion.