Asthma Management Handbook

Advising pregnant women about good asthma control

Recommendations

Offer regular asthma review and advice about asthma control during pregnancy (in addition to standard prenatal care and advice).

How this recommendation was developed

Consensus

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

Arrange vaccinations (influenza, pertussis) according to current national recommendations for pregnant women (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, 20131

Advise women who smoke to quit, and offer support. Advise all pregnant women to avoid 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. 20112

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).

Advise pregnant women that:

  • asthma control and severity can change during pregnancy due to a range of factors (e.g. changes in the immune system, allergic rhinitis)
  • good asthma control during pregnancy is a high priority, to protect the foetus as well as the mother
  • treatment may need to change from time to time to maintain good asthma control throughout pregnancy, and therefore frequent planned asthma review is necessary.
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):

  • Ali and Ulrik, 20133
  • Clifton et al. 20094
  • Murphy and Gibson, 20115
  • Murphy et al. 20056
  • Murphy et al. 20067
  • Murphy et al. 20118
  • Namazy et al. 20129
  • Silverman et al. 200510

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. 201111
  • Murphy and Gibson, 20115
  • Murphy et al. 200512
  • Murphy et al. 20067
  • Murphy et al. 20118
  • Schatz et al. 200413

Explain that asthma medicines are used in pregnancy when the risks of poor asthma control outweigh the risks associated with medicines.

How this recommendation was developed

Consensus

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

Provide reliable information about asthma and health during pregnancy, and offer to discuss any information the woman may have read or be concerned about.

How this recommendation was developed

Consensus

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

Reassure women that acute asthma rarely occurs during labour and delivery, although some may experience asthma symptoms. Advise them to make sure that their midwife and obstetrician know they have asthma and that this is recorded in their birth plan.

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):

  • Murphy and Gibson, 20115

More information

Effects of pregnancy on asthma control

In Australia the prevalence of asthma in pregnancy is approximately 12%.414

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.5 These changes are unpredictable from woman to woman and from pregnancy to pregnancy.5

During pregnancy, approximately 6% of women with asthma are hospitalised with a severe asthma flare-up.37 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.7

Although flare-ups occur at any time during gestation, they appear to be more common in the late second trimester.5

Risk factors for flare-ups during pregnancy include35

  • ‘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.6

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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.

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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.2

Risk of developing asthma

Prenatal exposure to tobacco smoke and exposure during infancy increase the risk of wheezing during early childhood.15

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.16

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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-eclampsia8 and preterm delivery,8 and their infants have a higher risk of low birth weight78 and of being small for gestational age,8 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.79

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.8

Inhaled corticosteroid use may reduce the risk of flare-ups during pregnancy.7 Inhaled corticosteroids generally have good safety profiles in pregnant women.10

Although treatment with oral corticosteroids for flare-ups has been associated with low birth weight9 and preterm delivery9 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.17

The use of bronchodilators and inhaled corticosteroids is not associated with increased risk of congenital malformations.17

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Immunisation for pregnant women

The Australian Immunisation Handbook1 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.

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References

  1. 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
  2. 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/
  3. 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/
  4. 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
  5. Murphy VE, Gibson PG. Asthma in pregnancy. Clin Chest Med. 2011; 32: 93-110. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21277452
  6. 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
  7. 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/
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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
  17. 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