Asthma Management Handbook

Managing flare-ups during pregnancy

Recommendations

Intervene early during flare-ups, to minimise risk to the foetus.

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):

  • Namazy et al. 20121

When preparing a written asthma action plan for a pregnant woman, consider specifying a lower threshold for getting medical help (e.g. advise her to see a doctor rather than self-manage when asthma symptoms are slightly worse than usual or needing reliever more often than usual).

How this recommendation was developed

Consensus

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

For a pregnant woman with asthma, prescribe oral corticosteroids if indicated, just as for other adults.

Note: Pregnancy is not a contraindication for oral corticosteroids. Oral prednisone or prednisolone is rated category A for 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):

  • Namazy et al. 20121

For pregnant women with asthma who live in rural or remote areas, consider providing an emergency pack containing a 5-day course of oral corticosteroids to start at home, advising them to contact their primary care doctor as soon as possible.

How this recommendation was developed

Consensus

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

In emergency departments, ensure that pregnant women who present with acute asthma receive treatment immediately to minimise risk to the foetus and to the woman.

How this recommendation was developed

Consensus

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

More information

Effects of pregnancy on asthma control

In Australia the prevalence of asthma in pregnancy is approximately 12%.23

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.4 These changes are unpredictable from woman to woman and from pregnancy to pregnancy.4

During pregnancy, approximately 6% of women with asthma are hospitalised with a severe asthma flare-up.56 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.6

Although flare-ups occur at any time during gestation, they appear to be more common in the late second trimester.4

Risk factors for flare-ups during pregnancy include54

  • ‘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.7

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Safety of asthma medicines in pregnancy

Published evidence for the safety of asthma medicines during pregnancy is limited mainly to prospective and retrospective cohort studies, and regional or national register databases. Many studies of the safety of asthma medicines in pregnancy have been underpowered.4

Therefore, it is not possible to precisely distinguish the effects on foetuses of asthma treatments from those of maternal asthma; any outcome statistically associated with the use of reliever medicines could be due to either to the medicines or to poor asthma control necessitating reliever use, while any outcome associated with the use of emergency asthma medicines could be due either to the medicines or to the effects of a severe flare-up.

Table. Pregnancy safety categories for asthma and allergic rhinitis medicines Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/44

Inhaled corticosteroids

A systematic review of evidence on the safety of regular preventer medicines during pregnancy did not find an association between the use of inhaled corticosteroids during pregnancy and any particular adverse event.8 This finding is consistent with earlier research.4

An adequately powered, large multicenter prospective cohort study found no significant relationships between inhaled corticosteroid use during pregnancy and adverse outcomes such as preterm birth at less than 32 weeks’ gestation, major malformations, low birth weight, and small-for-gestational age infants.9 By maintaining adequate asthma control, inhaled corticosteroid use may protect against low birth weight.410

Comparison of different formulations and doses

The majority of studies assessing the safety of inhaled corticosteroid use in pregnancy have involved women using budesonide.4  There is insufficient evidence to enable comparison between different inhaled corticosteroids,8 or to make conclusions about ciclesonide (a newer inhaled corticosteroid).8

There is little evidence about safety of different doses of inhaled corticosteroids.8 A study of pregnant women using beclometasone, budesonide or fluticasone propionate found that the rate of congenital malformations among those who used low-to-moderate doses in the first trimester was not higher than for those who did not use inhaled corticosteroids.11 The rate of congenital malformations (mainly musculoskeletal and cardiac malformations) was higher among those who used high doses than those who did not use inhaled corticosteroids.11 However, women who used higher doses of inhaled corticosteroid were older, more likely to have multiple foetuses, and more likely to have severe or uncontrolled asthma.8

The use of high doses of inhaled corticosteroids during pregnancy does not appear to affect foetal adrenal function.12

ICS/LABA combinations

There is insufficient evidence to make conclusions about the combination of inhaled corticosteroids and long-acting beta2 agonists during pregnancy.8

A systematic review of the safety of regular preventer medicines during pregnancy did not find an association between the use of long-acting beta2 agonists during pregnancy and any particular adverse event.8

In a retrospective cohort study of 7376 pregnancies, during which 8.8% women took long-acting beta2 agonists, long-acting beta2 agonist use was not associated with increased risk of low birth weight, preterm birth, or small for gestational age.13

Systemic corticosteroids

Associations have been reported between oral corticosteroid use during pregnancy and preeclampsia, preterm delivery, and reduced birth weight.4 However, it is difficult to separate the effects of the drug from the effects of the flare-up that necessitated its use.4

When systemic corticosteroids are required to manage severe acute asthma during pregnancy, the possible risks are less than the risks of severely uncontrolled asthma, which may result in maternal and/or foetal death.414

A meta-analysis of cohort studies found an association between the use of oral corticosteroid use and preterm delivery, low birth weight, and small-for-gestational age infants.15 However, use of oral corticosteroids was a marker of severe asthma.15

The use of oral corticosteroids during the first trimester may be associated with a small increase in the risk of oral cleft.16

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References

  1. 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
  2. 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
  3. 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
  4. Murphy VE, Gibson PG. Asthma in pregnancy. Clin Chest Med. 2011; 32: 93-110. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21277452
  5. 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/
  6. 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/
  7. 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
  8. 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
  9. 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
  10. 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
  11. Blais L, Beauchesne MF, Rey E, et al. Use of inhaled corticosteroids during the first trimester of pregnancy and the risk of congenital malformations among women with asthma. Thorax. 2007; 62: 320-328. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2092465/
  12. Ernst P, Suissa S. Systemic effects of inhaled corticosteroids. Curr Opin Pulm Med. 2012; 18: 85-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22112998
  13. Cossette B, Forget A, Beauchesne MF, et al. Impact of maternal use of asthma-controller therapy on perinatal outcomes. Thorax. 2013; 68: 724-30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23585516
  14. National Asthma Education and Prevention Program. Working Group Report on Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment. Update 2004. U.S. Department of of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute, Bethesda, 2005. Available from: http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg.htm
  15. Namazy JA, Murphy VE, Powell H, et al. Effects of asthma severity and medication use on prematurity and intrauterine growth: A meta analysis from published data. J Allergy Clin Immunol. 2011; 127: AB153. Available from: http://jacionline.org/article/S0091-6749(10)02550-9/fulltext
  16. Oren D, Nulman I, Makhija M, et al. Using corticosteroids during pregnancy. Are topical, inhaled, or systemic agents associated with risk?. Can Fam Physician. 2004; 50: 1083-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15455804