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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