Asthma Management Handbook

Giving preconception advice to women with asthma

Recommendations

Offer advice about healthy pregnancy to all women of reproductive age who have current asthma or a history of asthma. Explain that:

  • untreated asthma, poorly controlled asthma or flare-ups during pregnancy put mothers and babies at risk
  • it is especially important to maintain good asthma control during pregnancy.
How this recommendation was developed

Evidence-based recommendation (Grade A)

Based on systematic literature review.

Clinical question for literature search:

What are the effects of (1) asthma and (2) asthma treatment on pregnancy outcomes?

(e.g. Does effective asthma control improve pregnancy outcomes [maternal, foetal] in women with asthma? Does poorly controlled asthma [evidenced by exacerbations, acute asthma episodes, emergency visits)] affect pregnancy outcomes in women with asthma? Does asthma treatment affect pregnancy outcomes [maternal, foetal] in women with asthma?)

Key evidence considered:

  • Clifton et al. 20101
  • Moldenhauer et al. 20102
  • Murphy et al. 20063
  • Murphy et al. 20114
  • Namazy et al. 20125
  • Schatz et al. 19956
  • Schatz et al. 20017
  • Schatz et al. 20068

For women with current asthma or a history of asthma who intend to conceive, offer asthma review and advice about asthma control during pregnancy (in addition to standard preconception care and advice).

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Provide (or update) an individualised written asthma action plan.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Assess recent asthma symptom control and perform baseline spirometry.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If preventer therapy (e.g. low-dose inhaled corticosteroid) has been prescribed or is indicated, advise the woman to keep taking her preventer throughout pregnancy.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Lim et al. 20119
  • Murphy and Gibson, 201110
  • Murphy et al. 200511
  • Murphy et al. 20063
  • Murphy et al. 20114
  • Schatz et al. 200412

Advise that women with asthma have a slightly increased overall risk of having a baby with congenital abnormalities, compared with non-asthmatic women, but do not have a higher risk of having a baby with major congenital abnormalities or stillbirth than women without asthma.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Murphy et al. 201313

Advise quitting smoking and avoiding exposure to cigarette smoke.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • Zwar et al. 201114

Arrange vaccinations (influenza, pertussis) according to current national recommendations (refer to current Australian Immunisation Handbook).

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • Australian Technical Advisory Group on Immunisation and Department of Health and Ageing, 201315

Review all current medicines, including intranasal corticosteroids, complementary medicines and food supplements.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

For a woman planning pregnancy, consider replacing current preventer with a preventer rated category A for pregnancy (currently only budesonide), to see if asthma control remains stable. However, once a woman has become pregnant and her asthma is well controlled on combination inhaled corticosteroid/long-acting beta2 agonist, advise her to continue, and explain that stopping long-acting beta2 agonist often leads to loss of asthma control, which should not be risked during pregnancy.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Brozek et al. 201216

If the woman is anxious to stop taking long-acting beta2 agonist before pregnancy, discuss risks and benefits of a treatment trial of inhaled corticosteroid alone.

Explain that, if asthma control worsens (e.g. symptoms increase or a flare-up occurs) on inhaled corticosteroid alone, this indicates that she should go back to the previously effective regimen and continue taking it when she becomes pregnant.

Follow the steps for conducting a treatment trial.

Table. Steps for conducting a treatment trial

  1. Document baseline lung function.
  2. Document baseline asthma control using a validated standardised tool such as the Asthma Score.
  3. Discuss treatment goals and potential adverse effects with the person.
  4. Run treatment trial for agreed period (e.g. 4–8 weeks, depending on the treatment and clinical circumstances, including urgency).
  5. At an agreed interval, measure asthma control and lung function again and document any adverse effects.
  6. If asthma control has not improved despite correct inhaler technique and good adherence, resume previous treatment and consider referral for specialist consultation.

Asset ID: 36

Close
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Effects of asthma on pregnancy outcomes

Birth weight and related outcomes

Untreated asthma, poorly controlled asthma or asthma flare-ups during pregnancy put mothers and babies at risk:

  • Overall (not taking into account asthma severity or treatment), women with asthma have a higher risk of pre-eclampsia4 and preterm delivery,4 and their infants have a higher risk of low birth weight34 and of being small for gestational age,4 compared with non-asthmatic women.
  • Severe asthma flare-ups (symptoms requiring medical interventions such as hospitalisation, emergency department visits, other unscheduled urgent visits to the doctor, or the use of emergency treatment) during pregnancy increase the risk of low birth weight, compared with infants of women with asthma who do not have any flare-ups during pregnancy.35

Active management of asthma by a health professional reduces the risk of preterm delivery. Among women with asthma that is managed by a health professional, the risk of preterm labour and preterm delivery is not significantly higher than for non-asthmatic pregnant women.4

Inhaled corticosteroid use may reduce the risk of flare-ups during pregnancy.3 Inhaled corticosteroids generally have good safety profiles in pregnant women.17

Although treatment with oral corticosteroids for flare-ups has been associated with low birth weight5 and preterm delivery5 compared with no oral corticosteroid use, it is uncertain whether the effect is due to the treatment itself or to the acute flare-ups.

Congenital malformations

Maternal asthma is associated with increased risk of any congenital malformation, and increased risk of cleft lip with or without cleft palate, but not major congenital malformations or stillbirth.13

The use of bronchodilators and inhaled corticosteroids is not associated with increased risk of congenital malformations.13

Close
Effects of pregnancy on asthma control

In Australia the prevalence of asthma in pregnancy is approximately 12%.1819

Most women with asthma experience a change in asthma control while pregnant. Asthma control improves in approximately one in three, and worsens in at least one in three women.10 These changes are unpredictable from woman to woman and from pregnancy to pregnancy.10

During pregnancy, approximately 6% of women with asthma are hospitalised with a severe asthma flare-up.203 In a large Australian cohort of pregnant women, 36% of those with asthma experienced a severe flare-up that required medical intervention, and a further 19% experienced a milder flare-up.3

Although flare-ups occur at any time during gestation, they appear to be more common in the late second trimester.10

Risk factors for flare-ups during pregnancy include2010

  • ‘severe’ asthma (according to older classification based on pattern of symptoms when not treated)
  • nonadherence to preventer medicines
  • viral infections
  • a range of other factors such as obesity and gastro-oesophageal reflux.

In an Australian study, almost one third of women who experienced a severe asthma flare-up during pregnancy reported that they had not been taking their prescribed preventer before the flare-up.21

Close
Information for women about asthma and healthy pregnancy

Recommended reading for pregnant women with asthma and their partners includes material from the National Asthma Council Australia and Asthma Australia.

Close
Prenatal and childhood exposure to tobacco smoke

Tobacco smoking by pregnant women damages children’s respiratory health. It also increases the risk of stillbirth, spontaneous abortion, reduced foetal growth, preterm birth, low birth weight, placental abruption, sudden infant death, cleft palate, cleft lip and childhood cancers.14

Risk of developing asthma

Prenatal exposure to tobacco smoke and exposure during infancy increase the risk of wheezing during early childhood.22

Effects on children's asthma

Evidence from an Australian cohort study suggests that children with asthma whose mothers smoked during pregnancy benefit less from treatment with inhaled corticosteroids, and show less improvement in airway hyperresponsiveness over time, than those with asthma but no intrauterine exposure to smoke.23

Close
Safety of stepping down treatment during pregnancy

It may not be feasible to step down (e.g. reduce the inhaled corticosteroid dose or cease long-acting beta2 agonist) during pregnancy, because this is usually accomplished over several months while monitoring asthma control.

Several studies have reported deterioration in asthma control after ceasing long-acting beta2 agonist treatment in adults with asthma previously stabilised on inhaled corticosteroid/long-acting beta2 agonist combination.1624 If inhaled corticosteroid/long-acting beta2 agonist combination is replaced by inhaled corticosteroid only, patients should be advised to start taking their old combination inhaler again if asthma worsens within the first few days after switching.

In a woman planning a pregnancy, a failed treatment trial of inhaled corticosteroid alone may demonstrate that she needs to continue taking combination therapy during pregnancy in order to maintain asthma control. 

Close
Immunisation for pregnant women

The Australian Immunisation Handbook15 recommends influenza vaccination for pregnant women. Refer to the Australian Immunisation Handbook for up-to-date information on influenza, pneumococcal, pertussis and other vaccinations in pregnant women.

Close

References

  1. Clifton VL, Hodyl NA, Murphy VE, et al. Effect of maternal asthma, inhaled glucocorticoids and cigarette use during pregnancy on the newborn insulin-like growth factor axis. Growth Horm IGF Res. 2010; 20: 39-48. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19695914
  2. Moldenhauer JS, Lai Y, Schatz M, et al. Influence of maternal asthma and asthma severity on newborn morphometry. J Asthma. 2010; 47: 145-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20170320
  3. Murphy VE, Clifton VL, Gibson PG. Asthma exacerbations during pregnancy: incidence and association with adverse pregnancy outcomes. Thorax. 2006; 61: 169-76. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2104591/
  4. Murphy VE, Namazy JA, Powell H, et al. A meta-analysis of adverse perinatal outcomes in women with asthma. BJOG. 2011; 118: 1314-1323. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.03055.x/full
  5. Namazy JA, Murphy VE, Powell H, et al. Effects of asthma severity, exacerbations and oral corticosteroids on perinatal outcomes. Eur Respir J. 2012; 41: 1082-90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22903964
  6. Schatz M, Zeiger RS, Hoffman CP, et al. Perinatal outcomes in the pregnancies of asthmatic women: a prospective controlled analysis. Am J Respir Crit Care Med. 1995; 151: 1170-1174. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7697248
  7. Schatz M, Harden K, Kagnoff M, et al. Developmental follow-up in 15-month-old infants of asthmatic vs. control mothers. Pediatr Allergy Immunol. 2001; 12: 149-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11473679
  8. Schatz M, Dombrowski MP, Wise R, et al. Spirometry is related to perinatal outcomes in pregnant women with asthma. Am J Obstet Gynecol. 2006; 194: 120-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16389020
  9. Lim A, Stewart K, Konig K, George J. Systematic review of the safety of regular preventive asthma medications during pregnancy. Ann Pharmacother. 2011; 45: 931-945. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21712513
  10. Murphy VE, Gibson PG. Asthma in pregnancy. Clin Chest Med. 2011; 32: 93-110. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21277452
  11. Murphy VE, Gibson PG, Smith R, Clifton VL. Asthma during pregnancy: mechanisms and treatment implications. Eur Respir J. 2005; 25: 731-50. Available from: http://erj.ersjournals.com/content/25/4/731
  12. Schatz M, Dombrowski MP, Wise R, et al. The relationship of asthma medication use to perinatal outcomes. J Allergy Clin Immunol. 2004; 113: 1040-5. Available from: http://www.jacionline.org/article/S0091-6749(04)01149-2/fulltext
  13. Murphy VE, Wang G, Namazy JA, et al. The risk of congenital malformations, perinatal mortality and neonatal hospitalisation among pregnant women with asthma: a systematic review and meta-analysis. BJOG. 2013; 120: 812-22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23530780
  14. Zwar N, Richmond R, Borland R, et al. Supporting smoking cessation: a guide for health professionals. Updated 2012. The Royal Australian College of General Practitioners (RACGP), Melbourne, 2011. Available from: http://www.racgp.org.au/your-practice/guidelines/
  15. Australian Technical Advisory Group on Immunisation (ATAGI), Department of Health and Ageing. The Australian Immunisation Handbook. 10th Edition. Department of Health and Ageing, Canberra, 2013. Available from: http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
  16. Brozek JL, Kraft M, Krishnan JA, et al. Long-acting β2-agonist step-off in patients with controlled asthma: systematic review with meta-analysis. Arch Int Med. 2012; 172: 1365-75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22928176
  17. Silverman M, Sheffer A, Diaz PV, et al. Outcome of pregnancy in a randomized controlled study of patients with asthma exposed to budesonide. Ann Allergy Asthma Immunol. 2005; 95: 566-70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16400897
  18. Clifton VL, Engel P, Smith R, et al. Maternal and neonatal outcomes of pregnancies complicated by asthma in an Australian population. Aust N Z J Obstet Gynaecol. 2009; 49: 619-26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20070710
  19. Sawicki E, Stewart K, Wong S, et al. Management of asthma by pregnant women attending an Australian maternity hospital. Aust N Z J Obstet Gynaecol. 2012; 52: 183-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22141407
  20. Ali Z, Ulrik CS. Incidence and risk factors for exacerbations of asthma during pregnancy. J Asthma Allergy. 2013; 6: 53-60. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3650884/
  21. Murphy VE, Gibson P, Talbot PI, Clifton VL. Severe asthma exacerbations during pregnancy. Obstet Gynecol. 2005; 106: 1046-1054. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16260524
  22. Burke H, Leonardi-Bee J, Hashim A, et al. Prenatal and passive smoke exposure and incidence of asthma and wheeze: systematic review and meta-analysis. Pediatrics. 2012; 129: 735-744. Available from: http://pediatrics.aappublications.org/content/129/4/735.long
  23. Cohen RT, Raby BA, Van Steen K, et al. In utero smoke exposure and impaired response to inhaled corticosteroids in children with asthma. J Allergy Clin Immunol. 2010; 126: 491-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20673983
  24. Thomas A, Lemanske RF, Jackson DJ. Approaches to stepping up and stepping down care in asthmatic patients. J Allergy Clin Immunol. 2011; 128: 915-924. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3205296/