Management of asthma during pregnancy
- Michael Schatz, MD, MS
Michael Schatz, MD, MS
- Clinical Professor, Department of Medicine
- University of California San Diego School of Medicine
- Steven E Weinberger, MD
Steven E Weinberger, MD
- Adjunct Professor of Medicine
- University of Pennsylvania School of Medicine
- Executive Vice President and CEO
- American College of Physicians
- Section Editors
- Bruce S Bochner, MD
Bruce S Bochner, MD
- Editor-in-Chief — Allergy and Immunology
- Section Editor — Adult Allergy; Asthma
- Samuel M Feinberg Professor of Medicine
- Northwestern University Feinberg School of Medicine
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Asthma is one of the most common medical conditions encountered during pregnancy, occurring in 3 to 8 percent of pregnant women [1-3]. Pregnancy may be associated with changes in the course of asthma, and asthma may affect the outcome of pregnancy. When considering the use of asthma medications in a pregnant woman, the potential risk of a drug must be balanced against the effects of untreated asthma.
The management of asthma in pregnancy, including the safety data for specific asthma medications, general management, and recommended pharmacotherapy for acute and chronic asthma in pregnancy, is reviewed here. An overview of asthma management and the physiology and clinical course of asthma in pregnancy are discussed separately. (See "An overview of asthma management" and "Physiology and clinical course of asthma in pregnancy".)
ASSESSING DRUG SAFETY IN PREGNANCY
Information about potential adverse effects must be interpreted with an understanding that the baseline frequency of complications in pregnancy is relatively high, even in the absence of asthma or other disorders. In the United States, major congenital anomalies occur in 2 to 4 percent of live-born infants. An overview of congenital malformations and a discussion of genetic and environmental causes are provided separately. (See "Approach to congenital malformations".)
There is a small but significant increase in complications of pregnancy in asthmatic women . A large representative study suggests that asthmatic patients, on average, have a 15 to 20 percent increased risk of perinatal mortality, preeclampsia, preterm delivery, or low birth weight infants compared with non-asthmatic women, and that patients with more severe asthma have a 30 to 100 percent increased risk (table 1) .
For many years, the US Food and Drug Administration (FDA) has used five categories (A, B, C, D, and X) to describe a drug's potential for causing adverse effects during pregnancy (table 2) . The categories are based upon the results of animal studies, human data, and consideration of whether the benefit of the drug's use during pregnancy outweighs the risk. The FDA has begun the phase-out of pregnancy risk categories from prescription drug labeling and now requires information from available human and animal studies about (1) known or potential maternal or fetal risks, (2) dose adjustments needed during pregnancy and the postpartum period, and (3) benefit/risk considerations . While new medications include this information, the process of updating existing medications will likely take several years. In the interim, it is useful to have an understanding of the various categories.
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- ASSESSING DRUG SAFETY IN PREGNANCY
- MAINTAINING ASTHMA CONTROL
- Adjustments to pharmacologic therapy in pregnancy
- Safety of specific medications
- - Inhaled beta-adrenergic agonists
- - Oral/Systemic glucocorticoids
- - Inhaled glucocorticoids
- - Anticholinergic agents
- - Leukotriene modifiers
- - Immunotherapy for allergic asthma
- - Anti-immunoglobulin E
- - Rarely used medications
- Nonpharmacologic treatments
- ACUTE EXACERBATIONS
- Maternal and fetal monitoring
- Supportive care
- Supplemental oxygen
- Respiratory infections
- PERIPARTUM CARE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS