PB#90: Asthma in Pregnancy Flashcards
Trademark characteristics of asthma
Chronic airway inflammation w/ increased airway responsiveness to variety of stimuli, and airway obstruction that is partially/completely reversible
Is it safer for pregnant pts to be treated w/ asthma meds, or for them to have asthma sxs/exacerbations w/o meds?
Safer to be treated w/ asthma meds in pregnancy
General maternal/perinatal outcomes in pregnant pts w/ mild/well-controlled moderate asthma
Excellent outcomes
Maternal/Fetal risks associated w/ severe/poorly-controlled asthma in pregnancy
Prematurity, C/S, pre-E, FGR, perinatal complications, maternal M&M
Ultimate goal of asthma therapy in pregnancy
Maintaining adequate oxygenation of fetus by preventing hypoxic episodes in pt
Measures to optimally manage asthma during pregnancy (4)
Objective monitoring of lung function, avoiding/controlling asthma triggers, educating pts, individualizing pharmacologic tx to maintain normal pulm function
Long-term control meds used for maintenance therapy to prevent asthma manifestations (4)
Inhaled corticosteroids, cromolyn, LABAs, theophylline
Meds used for rescue therapy to provide immediate relief of sxs
SABAs
Meds that can be used either as rescue therapy or as long-term control therapy for pts w/ severe persistent asthma
PO corticosteroids
L&D meds that can trigger bronchospasm (4)
Nonselective β-blockers, carboprost, ergonovine, indomethacin (in pts who are sensitive to ASA)
L&D med that is a bronchodilator
Mag sulfate
Cervical ripening/abortion/PPH meds that are safe to use w/ asthma (2)
Misoprostol, cervidil
Most commonly used pulm function parameters (2)
PEFR, FEV1
Sx frequency, nighttime awakenings, interference w/ normal activity, and FEV1 measurements for intermittent (well-controlled) asthma
2 or fewer days/week, 2 or fewer times/month, no interference, >80% of personal best
Sx frequency, nighttime awakenings, interference w/ normal activity, and FEV1 measurements for mild persistent (not well controlled) asthma
> 2 days/week but not daily, >2 times/month, minor limitation, >80% of personal best
Sx frequency, nighttime awakenings, interference w/ normal activity, and FEV1 measurements for moderate persistent (not well controlled) asthma
Daily, >1x/week, some limitation, 60-80% of personal best
Sx frequency, nighttime awakenings, interference w/ normal activity, and FEV1 measurements for severe persistent (very poorly controlled) asthma
Throughout the day, at least 4x/week, extreme limitations, <60% of personal best
Asthma exacerbation rates, hospitalization rates of pregnant pts w/ mild asthma
12.6%, 2.3%
Asthma exacerbations rates, hospitalization rates of pregnant pts w/ moderate asthma
25.7%, 6.8%
Asthma exacerbation rates, hospitalization rates of pregnant pts w/ severe asthma
51.9%, 26.9%
Percentage of pts having improved asthma sxs during pregnancy, percentage of pts having worsened asthma sxs during pregnancy
23%, 30%
Increased fetal risks associated w/ decreasing FEV1 during pregnancy (2)
LBW, prematurity
Characteristic sxs of asthma (4)
Wheezing, chest cough, SOB, chest tightness
Temporal relationships classically associated w/ asthma (2)
Fluctuating intensity, worse at night)
Common asthma triggers (3)
Allergens, exercise, infections
Does absence of wheezing on exam exclude dx of asthma?
No, but presence of wheezing on exam helps support dx
Ideal method of diagnosing asthma
Confirmation of airway obstruction on spirometry that is partially reversible (>12% increase in FEV1 after bronchodilator therapy)
Alternative method of reasonably diagnosing asthma
Trial of asthma therapy w/ positive response (even w/o demonstrated reversible airway obstruction)
Most common item on ddx for new respiratory sxs in pregnancy
Dyspnea of pregnancy
Ways to differentiate dyspnea of pregnancy from asthma (4)
Lack of cough, lack of wheezing, lack of chest tightness, lack of airway obstruction
Common items on ddx for new respiratory sxs in pregnancy besides dyspnea of pregnancy and asthma (3)
GERD, chronic cough from postnatal drip, bronchitis
Recommended eval methods of pulm function in pregnant pts w/ asthma (2)
Spirometry (preferred), PEFR
When should pregnant pts w/ asthma be evaluated w/ PEFR and lung auscultation?
Whenever they have worsening sxs or report active acute exacerbation
Clinical methods to evaluate severity and control of asthma sxs (2)
Sx exacerbation, pulm impairment
Historical elements to obtain in pregnant pts w/ asthma (6)
Hx prior hospitalization, hx ICU admission, hx intubation, hx ED/unscheduled visits for asthma tx, need for PO corticosteroids, effect of prior pregnancies on asthma severity/control
Which pregnant pts w/ asthma should be considered to have persistent asthma?
Pts w/ 2+ episodes of sx exacerbation requiring use of PO corticosteroids in prior 12 months
Allergen immunotherapy is effective in which subset of asthmatic pts?
Those w/ allergies
Important risk associated w/ allergy shots (in pregnant and nonpregnant pts), and risk specifically to pregnant pts (2)
Anaphylaxis, maternal and/or fetal death
Which pregnant pts w/ asthma may benefit from allergen immunotherapy? (3)
Pts receiving maintenance/near-maintenance dosing, not experiencing adverse reactions to injections, deriving clinical benefit
Is it recommended to initiate allergen immunotherapy for asthmatic pts during pregnancy?
No
Class of meds that is rescue therapy of choice for asthma in pregnancy, and specific med in this class that is first-choice option
SABAs, albuterol
Recommended dose of albuterol for pregnant pts w/ mild-mod sxs
Up to 2 txs of inhaled albuterol (2-6 puffs) or nebulized albuterol at 20-min intervals
At what time should rescue therapy be initiated, and why?
Initiate at home at time of sx exacerbation, in order to avoid maternal/fetal hypoxia
What parameters should pt achieve in order to feel comfortable resuming normal daily activity during tx of asthma exacerbation? (2)
Reduction/Resolution of sxs w/ tx, PEFR reaches >80% of personal best
Under what conditions should pt seek timely medical attention during tx of asthma exacerbation? (2)
Poor response to tx, DFM
Recommended controller therapy for MI asthma
None indicated
Class of meds that are first-line controller therapy for persistent asthma
Inhaled corticosteroids
Ways to step up controller therapy if if MoP asthma or if sxs not controlled w/ low-dose inhaled corticosteroids (2)
Medium-dose inhaled corticosteroids, low-dose inhaled corticosteroids + LABAs
Preferred inhaled corticosteroid in pregnancy, and dose per inhalation
Budesonide, 200mcg per inhalation
Budesonide dosing for low dose, medium dose, and high dose regimen
1-3 puffs, 3-6 puffs, 6+ puffs
Therapy for MI asthma (controller meds, rescue meds)
No daily/controller meds, albuterol PRN
Preferred meds for MiP asthma
Low-dose inhaled corticosteroid
Alternative meds for MiP asthma (3)
Cromolyn, leukotriene receptor antagonist, theophylline
Preferred meds for MoP asthma (3)
Low-dose inhaled corticosteroid + salmeterol, medium-dose inhaled corticosteroid, (if needed) medium-dose inhaled corticosteroid + salmeterol
Alternative med regimens for MoP asthma (2)
Low-dose or (if needed) medium-dose inhaled corticosteroid + either leukotriene receptor antagonist or theophylline
Preferred meds for SP asthma
High-dose inhaled corticosteroid + salmeterol + (if needed) PO corticosteroid
Alternative meds for SP asthma
High-dose inhaled corticosteroid + theophylline + PO corticosteroid (if needed)
Preferred class of meds for add-on controller therapy, and when to add them on
LABAs, add when pt sxs are not controlled w/ use of medium-dose inhaled corticosteroids
Alternative add-on therapies in pregnancy (2)
Theophylline, leukotriene receptor antagonists
Commonly used leukotriene receptor antagonists (2)
Montelukast, zafirlukast
Why are LABAs preferred over leukotriene receptor antagonists or theophylline in pregnant pts?
Because they are more effective in nonpregnant pts
Goal serum therapeutic index for theophylline
5-12mcg/mL
Commonly used LABAs (2)
Salmeterol, formoterol
Practice that can lead to improved maternal well-being and less need for meds
Identifying/Controlling and/or avoiding instigating factors
Common instigating factors in asthma (2)
Allergens, irritants (especially tobacco smoke)
Measures to take if GERD is exacerbating asthma sxs (4)
Elevate head of bed, eat smaller meals, avoid eating within 2-3 hours of bedtime, avoid triggering foods
Does access to education about asthma improve asthma control?
Yes
Measures to promote animal dander control (2)
Removing animal from home, at minimum removing animal from pt bedroom
Next step in management if asthma sxs are not well-controlled w/ current med regimen
Step up to more intensive med therapy
Point at which step down in med therapy can be considered, and how it should be done (generally)
Once control is achieved and sustained for several months, cautiously and gradually
Criteria a pt should meet if discharged home following initial tx for acute asthma exacerbation (3)
FEV1 or PEFR >70% sustained for 60 mins after last tx, no distress, reassuring fetal status
Pts for whom dispo should be individualized (ie ED, discharge, admission) following initial tx for acute asthma exacerbation (2)
Incomplete response (FEV1 or PEFR 50-70%) to tx, mild-mod sxs
Pts for whom admission is indicated following initial tx for acute asthma exacerbation
Poor response (FEV1 or PEFR <50%) to tx
Pts for whom ICU admission +/- intubation should be considered in setting of acute asthma exacerbation (3)
Poor response (FEV1 or PEFR <50%) to tx, severe sxs/drowsiness/confusion, Pco2 >42
Recommended classes of meds to dc a pt home w/ following admission for acute asthma episode (3)
SABAs, PO corticosteroids, inhaled corticosteroids
SABA dosing after discharge following admission for acute asthma episode
2-4 puffs q3-4 hours PRN
PO corticosteroid dosing after discharge following admission for acute asthma episode
40-60mg daily (as single dose or two divided doses) x3-10 days
How long should inhaled corticosteroids be continued after discharge following admission for acute asthma episode?
Until outpatient f/u, within 5 days of acute episode
Which pregnant pts w/ asthma should get fetal surveillance? (2)
Pts w/ mod-severe asthma, pts recovering from severe asthma exacerbation
If a pregnant pt w/ asthma meets criteria for serial growth US, when should they start?
32wga
What outpatient prenatal counseling do you need to discuss w/ pts w/ asthma?
Close monitoring of fetal movements
Should asthma meds be continued intrapartum?
Yes
Intrapartum measures to decrease risk of bronchospasm (2)
Keep pt well-hydrated, provide appropriate analgesia
Risk of bronchospasm associated w/ regional anesthesia, and pathophysiology behind this
2%, because lumbar anesthesia can reduce oxygen consumption and minute ventilation during labor
What consideration must be kept in mind for pts actively/recently taking longterm systemic corticosteroids, and why?
Provision of IV stress dose steroids, in order to prevent adrenal crisis
Stress steroid dosing, and when to provide it
Hydrocortisone 100mg q8h, during labor and x24h PP
When would C/S be indicated in the context of asthma?
If pt has unstable asthma and mature fetus, and would benefit from improved respiratory status
Which asthma meds are NOT contraindicated w/ breastfeeding (6)
Prednisone, theophylline, antihistamines, inhaled corticosteroids, β2-agonists, cromolyn
