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ACOG Pub Review > PB#90: Asthma in Pregnancy > Flashcards

PB#90: Asthma in Pregnancy Flashcards

1
Q

Trademark characteristics of asthma

A

Chronic airway inflammation w/ increased airway responsiveness to variety of stimuli, and airway obstruction that is partially/completely reversible

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2
Q

Is it safer for pregnant pts to be treated w/ asthma meds, or for them to have asthma sxs/exacerbations w/o meds?

A

Safer to be treated w/ asthma meds in pregnancy

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3
Q

General maternal/perinatal outcomes in pregnant pts w/ mild/well-controlled moderate asthma

A

Excellent outcomes

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4
Q

Maternal/Fetal risks associated w/ severe/poorly-controlled asthma in pregnancy

A

Prematurity, C/S, pre-E, FGR, perinatal complications, maternal M&M

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5
Q

Ultimate goal of asthma therapy in pregnancy

A

Maintaining adequate oxygenation of fetus by preventing hypoxic episodes in pt

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6
Q

Measures to optimally manage asthma during pregnancy (4)

A

Objective monitoring of lung function, avoiding/controlling asthma triggers, educating pts, individualizing pharmacologic tx to maintain normal pulm function

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7
Q

Long-term control meds used for maintenance therapy to prevent asthma manifestations (4)

A

Inhaled corticosteroids, cromolyn, LABAs, theophylline

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8
Q

Meds used for rescue therapy to provide immediate relief of sxs

A

SABAs

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9
Q

Meds that can be used either as rescue therapy or as long-term control therapy for pts w/ severe persistent asthma

A

PO corticosteroids

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10
Q

L&D meds that can trigger bronchospasm (4)

A

Nonselective β-blockers, carboprost, ergonovine, indomethacin (in pts who are sensitive to ASA)

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11
Q

L&D med that is a bronchodilator

A

Mag sulfate

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12
Q

Cervical ripening/abortion/PPH meds that are safe to use w/ asthma (2)

A

Misoprostol, cervidil

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13
Q

Most commonly used pulm function parameters (2)

A

PEFR, FEV1

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14
Q

Sx frequency, nighttime awakenings, interference w/ normal activity, and FEV1 measurements for intermittent (well-controlled) asthma

A

2 or fewer days/week, 2 or fewer times/month, no interference, >80% of personal best

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15
Q

Sx frequency, nighttime awakenings, interference w/ normal activity, and FEV1 measurements for mild persistent (not well controlled) asthma

A

> 2 days/week but not daily, >2 times/month, minor limitation, >80% of personal best

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16
Q

Sx frequency, nighttime awakenings, interference w/ normal activity, and FEV1 measurements for moderate persistent (not well controlled) asthma

A

Daily, >1x/week, some limitation, 60-80% of personal best

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17
Q

Sx frequency, nighttime awakenings, interference w/ normal activity, and FEV1 measurements for severe persistent (very poorly controlled) asthma

A

Throughout the day, at least 4x/week, extreme limitations, <60% of personal best

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18
Q

Asthma exacerbation rates, hospitalization rates of pregnant pts w/ mild asthma

A

12.6%, 2.3%

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19
Q

Asthma exacerbations rates, hospitalization rates of pregnant pts w/ moderate asthma

A

25.7%, 6.8%

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20
Q

Asthma exacerbation rates, hospitalization rates of pregnant pts w/ severe asthma

A

51.9%, 26.9%

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21
Q

Percentage of pts having improved asthma sxs during pregnancy, percentage of pts having worsened asthma sxs during pregnancy

A

23%, 30%

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22
Q

Increased fetal risks associated w/ decreasing FEV1 during pregnancy (2)

A

LBW, prematurity

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23
Q

Characteristic sxs of asthma (4)

A

Wheezing, chest cough, SOB, chest tightness

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24
Q

Temporal relationships classically associated w/ asthma (2)

A

Fluctuating intensity, worse at night)

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25
Q

Common asthma triggers (3)

A

Allergens, exercise, infections

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26
Q

Does absence of wheezing on exam exclude dx of asthma?

A

No, but presence of wheezing on exam helps support dx

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27
Q

Ideal method of diagnosing asthma

A

Confirmation of airway obstruction on spirometry that is partially reversible (>12% increase in FEV1 after bronchodilator therapy)

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28
Q

Alternative method of reasonably diagnosing asthma

A

Trial of asthma therapy w/ positive response (even w/o demonstrated reversible airway obstruction)

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29
Q

Most common item on ddx for new respiratory sxs in pregnancy

A

Dyspnea of pregnancy

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30
Q

Ways to differentiate dyspnea of pregnancy from asthma (4)

A

Lack of cough, lack of wheezing, lack of chest tightness, lack of airway obstruction

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31
Q

Common items on ddx for new respiratory sxs in pregnancy besides dyspnea of pregnancy and asthma (3)

A

GERD, chronic cough from postnatal drip, bronchitis

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32
Q

Recommended eval methods of pulm function in pregnant pts w/ asthma (2)

A

Spirometry (preferred), PEFR

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33
Q

When should pregnant pts w/ asthma be evaluated w/ PEFR and lung auscultation?

A

Whenever they have worsening sxs or report active acute exacerbation

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34
Q

Clinical methods to evaluate severity and control of asthma sxs (2)

A

Sx exacerbation, pulm impairment

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35
Q

Historical elements to obtain in pregnant pts w/ asthma (6)

A

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

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36
Q

Which pregnant pts w/ asthma should be considered to have persistent asthma?

A

Pts w/ 2+ episodes of sx exacerbation requiring use of PO corticosteroids in prior 12 months

37
Q

Allergen immunotherapy is effective in which subset of asthmatic pts?

A

Those w/ allergies

38
Q

Important risk associated w/ allergy shots (in pregnant and nonpregnant pts), and risk specifically to pregnant pts (2)

A

Anaphylaxis, maternal and/or fetal death

39
Q

Which pregnant pts w/ asthma may benefit from allergen immunotherapy? (3)

A

Pts receiving maintenance/near-maintenance dosing, not experiencing adverse reactions to injections, deriving clinical benefit

40
Q

Is it recommended to initiate allergen immunotherapy for asthmatic pts during pregnancy?

A

No

41
Q

Class of meds that is rescue therapy of choice for asthma in pregnancy, and specific med in this class that is first-choice option

A

SABAs, albuterol

42
Q

Recommended dose of albuterol for pregnant pts w/ mild-mod sxs

A

Up to 2 txs of inhaled albuterol (2-6 puffs) or nebulized albuterol at 20-min intervals

43
Q

At what time should rescue therapy be initiated, and why?

A

Initiate at home at time of sx exacerbation, in order to avoid maternal/fetal hypoxia

44
Q

What parameters should pt achieve in order to feel comfortable resuming normal daily activity during tx of asthma exacerbation? (2)

A

Reduction/Resolution of sxs w/ tx, PEFR reaches >80% of personal best

45
Q

Under what conditions should pt seek timely medical attention during tx of asthma exacerbation? (2)

A

Poor response to tx, DFM

46
Q

Recommended controller therapy for MI asthma

A

None indicated

47
Q

Class of meds that are first-line controller therapy for persistent asthma

A

Inhaled corticosteroids

48
Q

Ways to step up controller therapy if if MoP asthma or if sxs not controlled w/ low-dose inhaled corticosteroids (2)

A

Medium-dose inhaled corticosteroids, low-dose inhaled corticosteroids + LABAs

49
Q

Preferred inhaled corticosteroid in pregnancy, and dose per inhalation

A

Budesonide, 200mcg per inhalation

50
Q

Budesonide dosing for low dose, medium dose, and high dose regimen

A

1-3 puffs, 3-6 puffs, 6+ puffs

51
Q

Therapy for MI asthma (controller meds, rescue meds)

A

No daily/controller meds, albuterol PRN

52
Q

Preferred meds for MiP asthma

A

Low-dose inhaled corticosteroid

53
Q

Alternative meds for MiP asthma (3)

A

Cromolyn, leukotriene receptor antagonist, theophylline

54
Q

Preferred meds for MoP asthma (3)

A

Low-dose inhaled corticosteroid + salmeterol, medium-dose inhaled corticosteroid, (if needed) medium-dose inhaled corticosteroid + salmeterol

55
Q

Alternative med regimens for MoP asthma (2)

A

Low-dose or (if needed) medium-dose inhaled corticosteroid + either leukotriene receptor antagonist or theophylline

56
Q

Preferred meds for SP asthma

A

High-dose inhaled corticosteroid + salmeterol + (if needed) PO corticosteroid

57
Q

Alternative meds for SP asthma

A

High-dose inhaled corticosteroid + theophylline + PO corticosteroid (if needed)

58
Q

Preferred class of meds for add-on controller therapy, and when to add them on

A

LABAs, add when pt sxs are not controlled w/ use of medium-dose inhaled corticosteroids

59
Q

Alternative add-on therapies in pregnancy (2)

A

Theophylline, leukotriene receptor antagonists

60
Q

Commonly used leukotriene receptor antagonists (2)

A

Montelukast, zafirlukast

61
Q

Why are LABAs preferred over leukotriene receptor antagonists or theophylline in pregnant pts?

A

Because they are more effective in nonpregnant pts

62
Q

Goal serum therapeutic index for theophylline

A

5-12mcg/mL

63
Q

Commonly used LABAs (2)

A

Salmeterol, formoterol

64
Q

Practice that can lead to improved maternal well-being and less need for meds

A

Identifying/Controlling and/or avoiding instigating factors

65
Q

Common instigating factors in asthma (2)

A

Allergens, irritants (especially tobacco smoke)

66
Q

Measures to take if GERD is exacerbating asthma sxs (4)

A

Elevate head of bed, eat smaller meals, avoid eating within 2-3 hours of bedtime, avoid triggering foods

67
Q

Does access to education about asthma improve asthma control?

A

Yes

68
Q

Measures to promote animal dander control (2)

A

Removing animal from home, at minimum removing animal from pt bedroom

69
Q

Next step in management if asthma sxs are not well-controlled w/ current med regimen

A

Step up to more intensive med therapy

70
Q

Point at which step down in med therapy can be considered, and how it should be done (generally)

A

Once control is achieved and sustained for several months, cautiously and gradually

71
Q

Criteria a pt should meet if discharged home following initial tx for acute asthma exacerbation (3)

A

FEV1 or PEFR >70% sustained for 60 mins after last tx, no distress, reassuring fetal status

72
Q

Pts for whom dispo should be individualized (ie ED, discharge, admission) following initial tx for acute asthma exacerbation (2)

A

Incomplete response (FEV1 or PEFR 50-70%) to tx, mild-mod sxs

73
Q

Pts for whom admission is indicated following initial tx for acute asthma exacerbation

A

Poor response (FEV1 or PEFR <50%) to tx

74
Q

Pts for whom ICU admission +/- intubation should be considered in setting of acute asthma exacerbation (3)

A

Poor response (FEV1 or PEFR <50%) to tx, severe sxs/drowsiness/confusion, Pco2 >42

75
Q

Recommended classes of meds to dc a pt home w/ following admission for acute asthma episode (3)

A

SABAs, PO corticosteroids, inhaled corticosteroids

76
Q

SABA dosing after discharge following admission for acute asthma episode

A

2-4 puffs q3-4 hours PRN

77
Q

PO corticosteroid dosing after discharge following admission for acute asthma episode

A

40-60mg daily (as single dose or two divided doses) x3-10 days

78
Q

How long should inhaled corticosteroids be continued after discharge following admission for acute asthma episode?

A

Until outpatient f/u, within 5 days of acute episode

79
Q

Which pregnant pts w/ asthma should get fetal surveillance? (2)

A

Pts w/ mod-severe asthma, pts recovering from severe asthma exacerbation

80
Q

If a pregnant pt w/ asthma meets criteria for serial growth US, when should they start?

A

32wga

81
Q

What outpatient prenatal counseling do you need to discuss w/ pts w/ asthma?

A

Close monitoring of fetal movements

82
Q

Should asthma meds be continued intrapartum?

A

Yes

83
Q

Intrapartum measures to decrease risk of bronchospasm (2)

A

Keep pt well-hydrated, provide appropriate analgesia

84
Q

Risk of bronchospasm associated w/ regional anesthesia, and pathophysiology behind this

A

2%, because lumbar anesthesia can reduce oxygen consumption and minute ventilation during labor

85
Q

What consideration must be kept in mind for pts actively/recently taking longterm systemic corticosteroids, and why?

A

Provision of IV stress dose steroids, in order to prevent adrenal crisis

86
Q

Stress steroid dosing, and when to provide it

A

Hydrocortisone 100mg q8h, during labor and x24h PP

87
Q

When would C/S be indicated in the context of asthma?

A

If pt has unstable asthma and mature fetus, and would benefit from improved respiratory status

88
Q

Which asthma meds are NOT contraindicated w/ breastfeeding (6)

A

Prednisone, theophylline, antihistamines, inhaled corticosteroids, β2-agonists, cromolyn

ACOG Pub Review (6 decks)

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