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Pregnancy with bronchial asthma. Bronchial asthma during pregnancy - treatment

This is an atopic bronchospastic disease of the respiratory system that arose during gestation or pre-existing and can affect its course. It manifests itself as attacks of characteristic suffocation, unproductive cough, shortness of breath, noisy wheezing. It is diagnosed using physical examination methods, laboratory determination of markers of allergic reactions, spirography, peak flowmetry. For basic treatment, combinations of inhaled glucocorticoids, antileukotrienes, beta-agonists are used, and short-acting bronchodilators are used to relieve attacks.

ICD-10

O99.5 J45

General information

Diagnostics

The occurrence of repeated attacks of suffocation and sudden unproductive cough in a pregnant woman is sufficient grounds for a comprehensive examination to confirm or refute the diagnosis bronchial asthma. During the gestational period, there are certain restrictions on diagnostic tests. Due to the possible generalization of an allergic reaction, pregnant women are not prescribed provocative and scarification tests with probable allergens, provocative inhalations of histamine, methacholine, acetylcholine and other mediators. The most informative for diagnosing bronchial asthma during pregnancy are:

  • Percussion and auscultation of the lungs. During an attack, a box sound is noted over the lung fields. The lower borders of the lungs are shifted downwards, their excursion is practically not determined. Decreased breathing with scattered dry rales is heard. After coughing, wheezing intensifies mainly in the posterior lower parts of the lungs, which in some patients may persist between attacks.
  • Markers of allergic reactions. Bronchial asthma is characterized by increased levels of histamine, immunoglobulin E, and eosinophilic cationic protein (ECP). The content of histamine and IgE is usually increased both during exacerbation and between asthmatic attacks. An increase in ECP concentration indicates a specific immune response of eosinophils to the “allergen + immunoglobulin E” complex.
  • Spirography and peak flowmetry. A spirographic study allows, based on data on the second volume of forced expiration (FEF1), to confirm functional disorders of external respiration by obstructive or mixed type. During peak flowmetry, latent bronchospasm is detected, the degree of its severity and daily variability of peak expiratory flow (PEF) are determined.

Additional diagnostic criteria are an increase in the content of eosinophils in general analysis blood, detection of eosinophilic cells, Charcot-Leyden crystals and Courshman spirals in sputum analysis, the presence of sinus tachycardia and signs of overload of the right atrium and ventricle on the ECG. Differential diagnosis is carried out with chronic obstructive pulmonary diseases, cystic fibrosis, tracheobronchial dyskinesia, constrictive bronchiolitis, fibrosing and allergic alveolitis, tumors of the bronchi and lungs, occupational diseases of the respiratory organs, pathology of the cardiovascular system with heart failure. According to indications, the patient is consulted by a pulmonologist and an allergist.

Treatment of asthma during pregnancy

When managing patients with asthma, it is important to ensure high-quality monitoring of the condition of the pregnant woman and fetus and maintain normal level respiratory function. If the course of the disease is stable, the woman is examined by a pulmonologist three times during pregnancy - at 18-20, 28-30 weeks of gestation and before childbirth. Pulmonary function is monitored using peak flowmetry. Taking into account the high risk of fetoplacental insufficiency, fetometry and Dopplerography of placental blood flow are regularly performed. When choosing a pharmacotherapy regimen, the severity of bronchial asthma is taken into account:

  • With intermittent asthma the basic drug is not prescribed. Before possible contact with an allergen, when the first signs of bronchospasm appear and at the time of an attack, inhaled short-acting bronchodilators from the group of β2-agonists are used.
  • For persistent forms of asthma: basic therapy with inhaled glucocorticoids of category B is recommended, which, depending on the severity of asthma, are combined with antileukotrienes, short- or long-acting beta-agonists. The attack is controlled with inhaled bronchodilators.

The use of systemic glucocorticosteroids, which increase the risk of developing hyperglycemia, gestational diabetes, eclampsia, preeclampsia, and low birth weight birth, is justified only if basic pharmacotherapy is insufficiently effective. Triamcinolone, dexamethasone, and depot forms are not indicated. Prednisolone analogues are preferred. During an exacerbation, it is important to prevent or reduce possible fetal hypoxia. For this, inhalations with quaternary derivatives of atropine are additionally used, oxygen is used to maintain saturation, and in extreme cases, artificial ventilation is provided.

Although delivery by natural birth is recommended in cases of mild bronchial asthma, in 28% of cases, if there are obstetric indications, a cesarean section is performed. After the start labor activity the patient continues to take basic medications in the same dosages as during gestation. If necessary for stimulation uterine contractions Oxytocin is prescribed. The use of prostaglandins in such cases can provoke bronchospasm. During breastfeeding, it is necessary to take basic antiasthmatic drugs in doses that correspond to the clinical form of the disease.

Asthma occurs in 4-8% of pregnant women. When pregnancy occurs, approximately one third of patients experience improvement in symptoms, a third experience worsening (usually between 24 and 36 weeks), and another third experience no change in the severity of symptoms.

Asthma exacerbations during pregnancy significantly impair fetal oxygenation. Severe, uncontrolled asthma is associated with complications in both women (preeclampsia, vaginal bleeding, complicated labor) and newborns (increased perinatal mortality, intrauterine growth restriction, preterm birth, low birth weight of newborns, hypoxia in the neonatal period). In contrast, women with controlled asthma who receive adequate therapy have minimal risk of complications. First, in pregnant patients with asthma, it is important to assess the severity of symptoms.

Management of pregnant patients with bronchial asthma includes:

  • lung function monitoring;
  • limiting the factors that cause attacks;
  • patient education;
  • selection of individual pharmacotherapy.

In patients with a persistent form of bronchial asthma, indicators such as peak expiratory flow - PEF (must be at least 70% of the maximum), forced expiratory volume (FEV), and regular spirometry should be monitored.

Stepped therapy is selected taking into account the patient’s condition (the minimum effective dose of drugs is selected). In patients with severe asthma, in addition to the above measures, ultrasound should be constantly performed to monitor the child’s condition.

Regardless of the severity of symptoms, the most important principle in the management of pregnant patients with bronchial asthma is to limit exposure to factors that cause attacks; With this approach it is possible to reduce the need for drugs.

If the course of asthma cannot be controlled by conservative methods, it is necessary to prescribe anti-asthmatic drugs. Table 2 provides information about their safety (FDA safety categories).

Short acting beta agonists

To stop attacks, it is preferable to use selective beta-agonists. Salbutamol, the most commonly used drug for these purposes, is classified as FDA category C.

In particular, salbutamol can cause tachycardia and hyperglycemia in the mother and fetus; hypotension, pulmonary edema, congestion of the systemic circulation in the mother. Use of this drug during pregnancy may also cause retinal circulatory problems and retinopathy in newborns.

Pregnant women with intermittent asthma who need to take short-acting beta-agonists more than twice a week may be prescribed long-term basal therapy. Similarly, disease-modifying medications may be prescribed to pregnant women with persistent asthma when short-acting beta-agonists are required 2 to 4 times per week.

Long acting beta agonists

For severe persistent asthma, the Asthma in Pregnancy Study Group ( Asthma and Pregnancy Working Group) recommends a combination of long-acting beta-agonists and inhaled glucocorticoids as the drugs of choice.

The use of the same therapy is possible in case of moderate persistent asthma. In this case, salmaterol is preferable to formoterol due to the longer experience with its use; this drug is the most studied among its analogues.

The FDA safety category for salmeterol and formoterol is C. The use of adrenaline and drugs containing alpha-adrenergic agonists (ephedrine, pseudoephedrine) to relieve attacks of bronchial asthma (ephedrine, pseudoephedrine) is contraindicated (especially in the first trimester), although all of them also belong to category C.

For example, the use of pseudoephedrine during pregnancy is associated with an increased risk of fetal gastroschisis.

Inhaled glucocorticoids

Inhaled glucocorticoids are the group of choice for pregnant women with asthma who require basic therapy. These drugs have been shown to improve lung function and reduce the risk of worsening symptoms. At the same time, the use of inhaled glucocorticoids is not associated with the occurrence of any congenital anomalies in newborns.

The drug of choice is budesonide - this is the only drug in this group that is classified as safety category B by the FDA, which is due to the fact that it (in the form of inhalation and nasal spray) has been studied in prospective studies.

An analysis of data from three registries, covering 99% of pregnancies in Sweden from 1995 to 2001, confirmed that the use of inhaled budesonide was not associated with the occurrence of any congenital anomalies. At the same time, the use of budesonide is associated with premature birth and low birth weight of newborns.

All other inhaled glucocorticoids used to treat asthma are category C. However, there is no evidence that they may be unsafe during pregnancy.

If asthma is successfully controlled with any inhaled glucocorticoid, changing therapy during pregnancy is not recommended.

Glucocorticosteroids for systemic use

All oral glucocorticoids are classified as FDA safety category C. The Asthma in Pregnancy Study Group recommends the addition of oral glucocorticoids to high-dose inhaled glucocorticoids in pregnant women with uncontrolled severe persistent asthma.

If it is necessary to use drugs of this group in pregnant women, triamcinolone should not be prescribed due to the high risk of developing myopathy in the fetus. Long-acting medications such as dexamethasone and betamethasone (both FDA Category C) are also not recommended. Preference should be given to prednisolone, the concentration of which decreases by more than 8 times when passing through the placenta.

A recent study showed that the use of oral glucocorticoids (especially in early stages pregnancy), regardless of the drug, slightly increases the risk of cleft palate in children (by 0.2-0.3%).

Other possible complications problems associated with taking glucocorticoids during pregnancy include preeclampsia, premature birth, and low birth weight of newborns.

Theophylline preparations

According to the recommendations of the Asthma in Pregnancy Study Group, theophylline at recommended doses (serum concentration 5-12 mcg/ml) is an alternative to inhaled glucocorticoids in pregnant patients with mild persistent asthma. It can also be added to glucocorticoids in the treatment of moderate to severe persistent asthma.

Taking into account the significant decrease in the clearance of theophylline in III trimester It is optimal to study the concentration of theophylline in the blood. It should also be taken into account that theophylline freely passes through the placenta, its concentration in the fetal blood is comparable to the maternal one, when used in high doses shortly before birth, a newborn may experience tachycardia, and with prolonged use, the development of withdrawal syndrome.

The use of theophylline during pregnancy has been suggested (but not proven) to be associated with preeclampsia and an increased risk of preterm birth.

Cromony

The safety of sodium cromoglycate preparations in the treatment of mild bronchial asthma was proven in two prospective cohort studies, the total number of patients receiving cromones was 318 out of 1917 pregnant women examined.

However, data on the safety of these drugs during pregnancy are limited. Both nedocromil and cromoglycate are classified as FDA safety category B. Cromones are not the group of choice in pregnant patients due to their lower effectiveness compared to inhaled glucocorticoids.

Leukotriene receptor blockers

Information on the safety of drugs in this group during pregnancy is limited. If a woman is able to control her asthma with zafirlukast or montelukast, the Asthma in Pregnancy Study Group does not recommend interrupting therapy with these drugs during pregnancy.

Both zafirlukast and montelukast are classified as safety category B by the FDA. When taken during pregnancy, no increase in the number of congenital anomalies was observed. Only hepatotoxic effects have been reported in pregnant women when using zafirluxt.

On the contrary, the lipoxygenase inhibitor zileuton in animal experiments (rabbits) increased the risk of cleft palate by 2.5% when used in doses similar to the maximum therapeutic one. Zileuton is classified as safety category C by the FDA.

The Asthma in Pregnancy Study Group allows the use of leukotriene receptor inhibitors (except zileuton) in minimal therapeutic doses in pregnant women with mild persistent asthma, and in the case of moderate persistent asthma, the use of drugs in this group (except zileuton) in combination with inhaled glucocorticoids.

Adequate asthma control is essential for the best pregnancy outcome (for both mother and baby). The attending physician should inform the patient about the possible risks associated with the use of drugs and the risks in the absence of pharmacotherapy.

Bronchial asthma is a chronic inflammatory disease of the airways in which many cells and cellular elements play a role. Chronic inflammation causes a concomitant increase in airway hyperresponsiveness, leading to repeated episodes of wheezing, shortness of breath, chest tightness and cough, especially at night or in the early morning. These episodes are usually associated with widespread but variable bronchial obstruction, which is often reversible either spontaneously or with treatment. Asthma is a treatable disease with the possibility of effective prevention.

ICD-10 code. 0.99 Other maternal diseases, classified elsewhere, but complicating pregnancy, childbirth and postpartum period. 0.99.5. Respiratory diseases complicating pregnancy, childbirth and the postpartum period. J.45. Asthma. J.45.0. Asthma with a predominance of the allergic component. J.45.1. Non-allergic asthma. J.45.8. Mixed asthma. J.45.9. Asthma, unspecified.

Classification of asthma severity according to clinical signs before treatment.

Stage 1: intermittent asthma
Symptoms less than once a week
Short exacerbations
Night attacks no more than 2 times a week
Variability in PEF or FEV 1< 20%

Stage 2: mild persistent asthma
Symptoms more often than once a week, but less than once a day
Night attacks more than 2 times a month
FEV 1 or PEF ≥ 80% of predicted values
Variability of PEF or FEV 1 = 20-30%

Stage 3: persistent moderate asthma:
Daily symptoms
Exacerbations may affect physical activity and sleep
Nighttime symptoms more than once a week
FEV 1 or PSV from 60 to 80% of the expected values
Variability of PEF or FEV 1 >30%

Stage 4: severe persistent asthma
Daily symptoms
Frequent exacerbations
Frequent night attacks
FEV 1 or PEF<60% от должных значений
Variability of PEF or FEV 1 >30%

Diagnostics.
Mandatory studies of a pregnant woman with asthma include:

A clinical blood test, in which eosinophilia of more than 0.40x10 9/l is diagnostically significant.
Examination of sputum, where microscopic examination reveals eosinophils, Charcot-Leyden crystals, and metachromatic cells.
- A pulmonary function test is performed to assess the degree of airway obstruction, quantify the effect of treatment, and also for the differential diagnosis of asthma. The most important indicators These studies in asthma are forced expiratory volume in the first minute (FEV 1) and the associated forced vital capacity (FVC), as well as peak expiratory flow (PEF). The diagnosis of asthma can be confirmed by spirometry when there is an increase in FEV1 of at least 12% after inhalation of a bronchodilator or in response to a trial of glucocorticosteroid therapy. Regular measurement of indicators at a certain interval, depending on the severity of the disease, helps monitor the progression of the disease and the long-term effects of treatment. Thus, it is advisable to measure PEF in the morning and evening before bedtime. A daily variation in PEF of more than 20% is considered a diagnostic sign of the disease, and the magnitude of the deviations is directly proportional to the severity of the disease.
- Measuring specific IgE in serum for diagnosing asthma in pregnant women is not very informative.
- X-ray of the lungs in pregnant women with asthma to clarify the diagnosis and carry out differential diagnosis is carried out according to strict indications.
- Skin tests with allergens are contraindicated during pregnancy.

Epidemiology.
According to epidemiological studies, the prevalence of asthma reaches 5% of the general population and there is a widespread trend towards a further increase in the number of patients; there is a steady trend towards an increase in the number of patients who are often hospitalized due to the severe course of the disease. The most common pathology of the bronchopulmonary system in pregnant women is asthma, accounting for 5%. Beginning with adolescence, the female part of the population suffers from asthma more often than the male part. At reproductive age, the ratio of women to men reaches 10:1. Aspirin-induced asthma is also more common in women.

Etiology.
In the etiology of asthma, both internal factors (or congenital characteristics of the body) play a role, which predispose a person to the development of asthma or protect against it, and external factors that cause the onset or development of asthma in predisposed people, leading to exacerbation of asthma and/or long-term persistence of symptoms of the disease.

Intrinsic factors include genetic predisposition to develop either asthma or atopy, airway hyperresponsiveness, gender, and race.

External factors include:

Factors (triggers) that cause exacerbation of asthma and/or contribute to the persistence of symptoms include: allergens, air pollutants, respiratory infections, physical exercise and hyperventilation, weather changes, sulfur dioxide, food, nutritional supplements and medications, emotional stress. Exacerbation of BA can be caused by pregnancy, menstruation, rhinitis, sinusitis, gastroesophageal reflux, polliposis, etc.

Pathogenesis.
The pathogenesis of asthma is based on a specific inflammatory process in the bronchial wall, leading to airway obstruction in response to various triggers. The main cause of obstruction is a decrease in bronchial smooth muscle tone caused by the action of agonists released from mast cells, local centripetal nerves and from postganglionic centrifugal nerves. Subsequently, contractions of the smooth muscles of the airways intensify due to thickening of the bronchial wall due to acute edema, cellular infiltration and remodeling of the airways - chronic hyperplasia of smooth muscles, blood vessels and secretory cells and matrix deposition in the bronchial wall. The obstruction is aggravated by a dense, viscous secretion produced by goblet cells and submucosal glands. In fact, all functional disorders in asthma are caused by obstruction, involving all parts of the bronchial tree, but most pronounced in small bronchi with a diameter of 2 to 5 mm.

Asthma is typically associated with a condition in which the airways narrow too easily and/or become very “overreactive” in response to triggers.

In patients with asthma, there is not just chronic hypersecretion of mucus. The secretion produced also differs in viscosity, elasticity and rheological properties. The pathological increase in viscosity and “rigidity” of such a secretion occurs due to increased production of mucin and accumulation of epithelial cells, albumin, basic proteins and DNA from decomposed inflammatory cells. In the sputum of patients with asthma, these changes appear in the form of mucous clots (Curshman spirals).

Signs of bronchial inflammation persist even during the asymptomatic period of the disease, and their severity correlates with symptoms that determine the severity of the disease.

Clinic.
During an exacerbation of asthma, the patient has symptoms of asthma: shortness of breath, flaring of the wings of the nose during inspiration, raised shoulders, tilting the body forward, participation of auxiliary respiratory muscles in breathing, orthopnea, difficulty speaking due to intermittent speech, constant or intermittent cough that disturbs sleep , tachycardia, cyanosis. On auscultation, dry wheezing is heard, increasing on exhalation. However, in some patients during an exacerbation of BA, wheezing may not be heard due to obstruction of the small bronchi. It is important to note that the onset of symptoms is provoked by allergens or nonspecific irritants, and the disappearance of symptoms occurs spontaneously or after the use of bronchodilators.

Assessment of pulmonary function, particularly the reversibility of pulmonary function, provides the most accurate degree of airway obstruction.

Differential diagnosis
Despite the clear diagnostic signs of asthma, a number of difficulties arise when analyzing the course of the disease in pregnant women suffering from other pulmonary pathologies accompanied by bronchial obstruction: chronic obstructive pulmonary disease, cystic fibrosis, tumors of the respiratory system, lesions of the upper respiratory tract, tracheobronchial dyskinesia, pulmonary vasculitis, constrictive bronchiolitis, hyperventilation syndrome, acute and chronic left ventricular failure, sleep apnea-hypopnea syndrome, fungal infections of the lungs, etc. BA can occur in patients suffering from the above diseases, which also aggravates the course of the disease.

Treatment.
Before planning a pregnancy, patients with asthma should undergo training at the “School for Patients with Bronchial Asthma” to gain the most complete awareness of asthma and create sustainable motivation for self-control and treatment. Pregnancy should be planned after an allergological examination and achievement of maximum control over the course of asthma under the supervision of a pulmonologist. Pregnancy and the birth of a child should not be planned during the flowering period of plants to which the mother is sensitized.

A pregnant woman should adhere to a hypoallergenic diet, reduce contact with the allergen as much as possible, stop active smoking and eliminate passive smoking, and promptly sanitize foci of infection.

For severe and moderate-severe asthma to reduce the amount and dosage medicines Efferent treatment methods (plasmapheresis) should be used.

During pregnancy, the severity of asthma often changes, and patients may need more careful medical supervision and changes in treatment regimen. Retrospective studies have shown that during pregnancy, in about a third of women, the course of asthma worsens, in a third it becomes less severe, and in the remaining third it does not change. The overall perinatal prognosis for children born to mothers in whom asthma is well controlled is comparable to the prognosis for children born to mothers without asthma. Poorly controlled asthma leads to increased perinatal mortality, increased preterm births and births premature babies. For this reason, the use of drugs to achieve optimal control of asthma is justified even when their safety during pregnancy is not indisputable. Treatment with inhaled p2-agonists, theophylline, sodium cromoglycate, and inhaled glucocorticosteroids is not accompanied by an increase in the incidence of congenital malformations of the fetus.

Currently, a stepwise approach to the treatment of asthma has been adopted due to the fact that there is a significant diversity in the severity of asthma not only in different people, but also the same person at different times. The goal of this approach is to achieve asthma control using the smallest amount of drug. The amount and frequency of taking medications increases (step up) if the course of asthma worsens, and decreases (step down) if the course of asthma is well controlled.

Medicines for asthma are prescribed to eliminate and prevent symptoms and airway obstruction and include disease-controlling drugs and symptomatic drugs.

Disease control drugs - JIC, taken daily, long-term, to help achieve and maintain control of persistent asthma: anti-inflammatory drugs and long-acting bronchodilators. These include inhaled corticosteroids, systemic corticosteroids, sodium cromoclicate, nedocromil sodium, sustained-release theophyllines, long-acting inhaled P2-agonists, and systemic nonsteroidal therapy. Currently the most effective drugs Inhaled glucocorticosteroids are used to control asthma.

To symptomatic drugs (ambulance or emergency medicine, quick relief drugs) that eliminate bronchospasm and alleviate associated symptoms(wheezing, feeling of tightness in the chest, cough) include fast-acting inhaled P2-agonists, systemic glucocorticosteroids, inhaled anticholinergics, short-acting theophyllines, and short-acting oral P2-agonists.

Drugs for the treatment of asthma are administered in various ways, including inhalation, oral and parenteral. The main advantage of delivering JIC directly to the respiratory tract through inhalation is the more efficient creation of high concentrations of the drug in the respiratory tract and minimization of systemic adverse effects. When prescribing to pregnant women, preference should be given to inhalation forms of drug administration. Aerosol treatments are available in the form of metered dose aerosol inhalers, breath activated metered dose inhalers, dry powder metered dose inhalers, and “wet” aerosols delivered through a nebulizer. The use of a spacer (reservoir chamber) improves the delivery of the drug from an inhaler that dispenses an aerosol under pressure.

Stage 1. Intermittent asthma

Drug of choice (treatment regimen):
Basic drugs are not indicated.

To control asthma symptoms, but not more than once a week inhalation:
Terbutaline 100 mcg each (1-2 doses);
Fenoterol 100 mcg (1-2 doses) (use with caution in the first trimester of pregnancy).

Before anticipated physical activity or exposure to an allergen:
Salbutamol 100-200 mcg (1-2 doses);
Sodium cromoglycate 5 mg (1-2 doses) (contraindicated in the first trimester of pregnancy)

Stage 2. Mild persistent asthma

Drug of choice (treatment regimen):

Beclomethasone dipropionate 250 mcg, 1 dose 2 r. /day;
Budesonide 200 mcg, 1 dose 2 r. /day;
Flunisolide 250 mcg, 1 dose 2 r. /day;
Fluticasone propionate 50-125 mcg, 1 dose 2 r. /day
+ Iprathromium bromide 20 mcg, 2 doses 4 r. /day

Alternative drugs (treatment regimens):
Sodium cromoglicate 5 mg, 1-2 doses 4 r. /day;
Nedocromil 2 mg 1-2 doses 2 - 4 r. /day;
Theophylline 200-350 mg 1 capsule retard 2 r. /day

Stage 3. Persistent asthma medium degree gravity

Drug of choice (treatment regimen):
Salbutamol as needed (but not more than 3-4 times a day).

Daily long-term prophylactic intake:
Budesonide 200 mcg, 1 dose 2-4 r. /day;
Flunisolide 250 mcg, 2 doses 2 - 4 times. /day;
Fluticasone 125 mcg, 1 dose 2-4 r. /day (25,50,100,125, 250,500);
Salmeterol 25 mcg, 1-2 doses 2 r. /day;
Beclomethasone dipropionate 250 mcg, 1 dose 2 - 4 r. /day;
+ Theophylline 200-350 1 capsule retard 2 r. /day;
Beclomethasone dipropionate 250 mcg, 2 doses 4 r. /day

Stage 4. Severe persistent asthma

Drug of choice (treatment regimen):
Salbutamol as needed (but not more than 3-4 times a day).

Daily long-term prophylactic intake
Beclomethasone dipropionate 250 mcg, 2 doses 4 r. /day;
Budesonide 200 mcg, 1 dose - 4 r. /day;
Flunisolide 250 mcg, 2 doses 4 times. /day;
Fluticasone 250 mcg, 1 dose 2-3 r. /day (25,50,100,125, 250,500);
+ Formoterol 12 mcg 1-2 doses 2 r. /day;
Salmeterol 25 mcg 1-2 doses 2 r. /day
+ Theophylline 200-300 mg, 1 capsule retard 2 r. /day
+ prednisolone 5 mg 1-6 1 r. /day;
+methylprednisolone 4 mg 5-10 1r. /day

Errors and unreasonable assignments
During exacerbation of asthma, the administration of parenteral theophylline is unjustified if the pregnant woman is already taking it orally. In aspirin-induced BA, the use of any systemic glucocorticosteroids other than dexamethasone is unjustified.

Drugs that are contraindicated during pregnancy due to embryotoxicity and teratogenicity: adrenaline, ephedrine, brompheniramine, triamcinolone, betamethalon.

Evaluation of treatment effectiveness
If asthma symptoms do not occur within 1 month of therapy, and pulmonary function (MSV and spirometry indicators) are within expected values, then therapy can be reduced (take a “step back”), achieving the minimum therapy necessary to control asthma, reduction side effects and unwanted effects from medicines for the mother and creating optimal conditions for the development of the fetus.

Severe attacks of asthma and the development of respiratory failure are indications for early termination of pregnancy or early delivery. It is not recommended to use prostaglandin F2-alpha to terminate pregnancy and induce labor, because it increases bronchospasm.

Delivery
It is preferable to give birth through the natural birth canal. Attacks of suffocation during childbirth are rare and can be stopped by inhalation of bronchodilators or intravenous administration of aminophylline. If a patient with asthma has previously taken corticosteroids orally, then on the day of delivery it is necessary to administer an additional 60-120 mg of prednisolone intravenously, with the dosage reduced by half over the next two days.

During labor, continuous fetal monitoring is performed. Severe respiratory and pulmonary heart failure are indications for surgical delivery by caesarean section under epidural anesthesia or fluorotane anesthesia. Promedol during childbirth and sedatives during surgery are used only in exceptional cases, as they depress the respiratory center and suppress the cough reflex.

In case of early delivery, in order to stimulate the maturation of the surfactant system of the lungs in the fetus, pregnant women are prescribed dexamethasone 16 tablets per day for 2 days.

In the early postpartum period Postpartum women may experience bleeding, as well as the development of purulent-septic complications and exacerbation of asthma.

In postpartum women with moderate to severe asthma, it is recommended to suppress lactation.

BIBLIOGRAPHY.

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For quotation: Ignatova G.L., Antonov V.N. Bronchial asthma in pregnant women // Breast cancer. Medical Review. 2015. No. 4. P. 224

The incidence of bronchial asthma (BA) in the world ranges from 4 to 10% of the population; V Russian Federation The prevalence among adults ranges from 2.2 to 5-7%; in the pediatric population this figure is about 10%. In pregnant women, asthma is the most common disease of the pulmonary system, the diagnosis rate of which in the world ranges from 1 to 4%, in Russia - from 0.4 to 1%. IN last years Standard international diagnostic criteria and pharmacotherapy methods have been developed to significantly increase the effectiveness of treatment for patients with asthma and improve their quality of life (Global Initiative for the Prevention and Treatment of Bronchial Asthma (GINA), 2014). However, modern pharmacotherapy and monitoring of asthma in pregnant women are more complex tasks, since they aim not only to preserve the health of the mother, but also to prevent the adverse effects of complications of the disease and side effects treatment for the fetus.

Pregnancy has different effects on the course of asthma. Changes in the course of the disease vary widely: improvement in 18–69% of women, deterioration in 22–44%, no effect of pregnancy on the course of asthma was detected in 27–43% of cases. This is explained, on the one hand, by multidirectional dynamics in patients with varying degrees severity of BA (with mild and moderate severity, worsening of BA is observed in 15–22%, improvement in 12–22%), on the other hand – insufficient diagnosis and not always correct therapy. In practice, asthma is often diagnosed only in the later stages of the disease. In addition, if its onset coincides with the gestational period, the disease may remain unrecognized, since the observed respiratory disorders are often attributed to changes caused by pregnancy.

At the same time, with adequate treatment of BA, the risk of unfavorable outcome of pregnancy and childbirth is no higher than in healthy women. In this regard, most authors do not consider asthma as a contraindication to pregnancy, and recommend monitoring its course using modern principles treatment

The combination of pregnancy and asthma requires close attention from doctors due to possible changes in the course of asthma during pregnancy, as well as the impact of the disease on the fetus. In this regard, the management of pregnancy and childbirth in a patient suffering from asthma requires careful monitoring and joint efforts of doctors of many specialties, in particular therapists, pulmonologists, obstetricians-gynecologists and neonatologists.

Changes in the respiratory system in asthma during pregnancy

During pregnancy, under the influence of hormonal and mechanical factors, the respiratory system undergoes significant changes: a restructuring of the mechanics of breathing occurs, ventilation-perfusion relationships change. In the first trimester of pregnancy, hyperventilation may develop due to hyperprogesteronemia, changes in blood gas composition - increased PaCO2 content. The appearance of shortness of breath later pregnancy is largely due to the development of a mechanical factor, which is a consequence of an increase in the volume of the uterus. As a result of these changes, disturbances in the function of external respiration are aggravated, vital capacity of the lungs, forced vital capacity of the lungs, and forced expiratory volume in 1 second (FEV1) are reduced. As the gestational age increases, vascular resistance in the pulmonary circulation increases, which also contributes to the development of shortness of breath. In this regard, shortness of breath causes certain difficulties when carrying out differential diagnosis between physiological changes in the function of external respiration during pregnancy and manifestations of broncho-obstruction.

Often, pregnant women without somatic pathology develop swelling of the mucous membranes of the nasopharynx, trachea and large bronchi. These manifestations in pregnant women with asthma can also aggravate the symptoms of the disease.

Low compliance contributes to the worsening of asthma: many patients try to refuse to take inhaled glucocorticosteroids (ICS) due to fear of their possible side effect. In such cases, the doctor should explain to the woman the need for basic anti-inflammatory therapy due to the negative impact of uncontrolled asthma on the fetus. Asthma symptoms may first appear during pregnancy due to altered body reactivity and hypersensitivity to endogenous prostaglandin F2α (PGF2α). Attacks of suffocation that first occur during pregnancy may disappear after childbirth, but can also transform into true asthma. Among the factors contributing to the improvement of asthma during pregnancy, it should be noted a physiological increase in the concentration of progesterone, which has bronchodilation properties. An increase in the concentration of free cortisol, cyclic aminomonophosphate, and an increase in histaminase activity have a beneficial effect on the course of the disease. These effects are confirmed by an improvement in the course of asthma in the second half of pregnancy, when large quantities glucocorticoids of fetoplacental origin are supplied.

The course of pregnancy and fetal development in asthma

Current issues are the study of the effect of asthma on the course of pregnancy and the possibility of giving birth to healthy offspring in patients suffering from asthma.

Pregnant women with asthma have an increased risk of developing early toxicosis (37%), gestosis (43%), threatened miscarriage (26%), premature birth (19%), and fetoplacental insufficiency (29%). Obstetric complications, as a rule, occur in severe cases of the disease. Adequate drug control of asthma is of great importance. The lack of adequate treatment for the disease leads to the development of respiratory failure, arterial hypoxemia of the mother’s body, constriction of placental vessels, resulting in fetal hypoxia. A high incidence of fetoplacental insufficiency, as well as miscarriage, is observed against the background of damage to the vessels of the uteroplacental complex by circulating immune complexes and inhibition of the fibrinolysis system.

Women suffering from asthma are more likely to give birth to children with low body weight, neurological disorders, asphyxia, and congenital defects. In addition, the interaction of the fetus with maternal antigens through the placenta influences the formation of the child’s allergic reactivity. The risk of developing an allergic disease, including asthma, in a child is 45–58%. Such children more often suffer from respiratory viral diseases, bronchitis, and pneumonia. Low birth weight is observed in 35% of children born to mothers with asthma. The highest percentage of low birth weight babies is observed in women suffering from steroid-dependent asthma. The reasons for low birth weight of newborns are insufficient control of asthma, which contributes to the development of chronic hypoxia, as well as long-term use of systemic glucocorticoids. It has been proven that the development of severe exacerbations of asthma during pregnancy significantly increases the risk of having children with low body weight.

Management and treatment of pregnant women suffering from asthma

According to the provisions of GINA-2014, the main objectives of asthma control in pregnant women are:

  • clinical assessment of the condition of the mother and fetus;
  • elimination and control of trigger factors;
  • pharmacotherapy of asthma during pregnancy;
  • educational programs;
  • psychological support pregnant women.

Given the importance of achieving control over asthma symptoms, mandatory examinations by a pulmonologist are recommended between 18 and 20 weeks. gestation, 28–30 weeks. and before childbirth, in case of unstable asthma – as necessary. When managing pregnant women with asthma, one should strive to maintain lung function close to normal. Peak flowmetry is recommended to monitor respiratory function.

Due to the high risk of developing fetoplacental insufficiency, it is necessary to regularly assess the condition of the fetus and the uteroplacental complex using ultrasound fetometry, ultrasound Doppler ultrasound of the vessels of the uterus, placenta and umbilical cord. In order to increase the effectiveness of therapy, patients are recommended to take measures to limit contact with allergens, quit smoking, including passive smoking, strive to prevent ARVI, and avoid excessive physical activity. An important part of the treatment of asthma in pregnant women is the creation of educational programs that allow the patient to establish close contact with the doctor, increase the level of knowledge about her disease and minimize its impact on the course of pregnancy, and teach the patient self-control skills. The patient must be trained in peak flowmetry in order to monitor the effectiveness of treatment and recognize early symptoms of exacerbation of the disease. For patients with moderate and severe asthma, it is recommended to perform peak flow measurements in the morning and evening hours every day, calculate daily fluctuations in the peak volumetric expiratory flow rate and record the obtained indicators in the patient’s diary. According to the 2013 Federal Clinical Guidelines for the Diagnosis and Treatment of Bronchial Asthma, it is necessary to adhere to certain provisions (Table 1).

The principal approaches to pharmacotherapy of asthma in pregnant women are the same as in non-pregnant women (Table 2). For the basic therapy of mild BA, it is possible to use montelukast; for moderate and severe BA, it is preferable to use inhaled corticosteroids. Among the inhaled corticosteroids available today, only budesonide was classified as category B at the end of 2000. If it is necessary to use systemic corticosteroids (in extreme cases) in pregnant women, it is not recommended to prescribe triamcinolone preparations, as well as long-acting corticosteroids (dexamethasone). It is preferable to prescribe prednisolone.

Of the inhaled forms of bronchodilators, the use of fenoterol (group B) is preferable. It should be taken into account that β2-agonists are used in obstetrics to prevent premature birth; their uncontrolled use can cause an extension of the duration of labor. Prescribing depot forms of GCS drugs is strictly prohibited.

Exacerbation of asthma in pregnant women

Main activities (Table 3):

Assessment of condition: examination, measurement of peak expiratory flow (PEF), oxygen saturation, assessment of fetal condition.

Initial therapy:

  • β2-agonists, preferably fenoterol, salbutamol – 2.5 mg via nebulizer every 60–90 minutes;
  • oxygen to maintain saturation at 95%. If saturation<90%, ОФВ1 <1 л или ПСВ <100 л/мин, то:
  • Continue administering selective β2-agonists (fenoterol, salbutamol) via nebulizer every hour.

If there is no effect:

  • budesonide suspension – 1000 mcg via nebulizer;
  • add ipratropium bromide through a nebulizer - 10-15 drops, since it has category B.

If there is no further effect:

  • prednisolone – 60–90 mg IV (this drug has the lowest rate of passage through the placenta).

If the therapy is ineffective and long-acting theophyllines are not included in the treatment before the exacerbation of the disease:

  • administer theophylline intravenously in usual therapeutic dosages;
  • administer β2-agonists and budesonide suspension every 1–2 hours.

When choosing therapy, it is necessary to take into account the risk categories of prescribing medications for pregnant women, established by Physicians Desk Reference:

  • bronchodilators - all categories C, except ipratropium bromide, fenoterol, which belong to category B;
  • ICS – all categories C, except budesonide;
  • antileukotriene drugs – category B;
  • Cromony - category B.

Treatment of asthma during childbirth

Delivery of pregnant women with a controlled course of asthma and the absence of obstetric complications is carried out at full-term pregnancy. Preference should be given to vaginal delivery. Caesarean section is performed for appropriate obstetric indications. During labor, the woman should continue to take standard basic therapy (Table 4). If it is necessary to stimulate labor, preference should be given to oxytocin and avoid the use of PGF2α, which can stimulate bronchoconstriction.

Vaccinal prevention during pregnancy

When planning pregnancy, it is necessary to vaccinate against:

  • rubella, measles, mumps;
  • hepatitis B;
  • diphtheria, tetanus;
  • polio;
  • pathogens of respiratory infections;
  • influenza virus;
  • pneumococcus;
  • Haemophilus influenzae type b.

Timing for administering vaccines before pregnancy:

Viral vaccines:

  • rubella, measles, mumps - within 3 months. and more;
  • poliomyelitis, hepatitis B – for 1 month. and more;
  • influenza (subunit and split vaccines) – 2–4 weeks.

Toxoids and bacterial vaccines:

  • diphtheria, tetanus – 1 month. and more;
  • pneumococcal and hemophilic infections - for 1 month. and more.

Vaccination schedule before pregnancy:

Vaccination starts at least 3 months in advance. before conception.

Stage I – administration of vaccines against rubella, measles (for 3 months), mumps, hepatitis B (1st dose), Haemophilus influenzae type b.

Stage II – administration of vaccines against polio (2 months in advance, once), hepatitis B (2nd dose), pneumococcus.

Stage III – administration of vaccines against diphtheria, tetanus (for 1 month), hepatitis B (3rd dose), influenza (Table 5).

The combination of vaccines may vary depending on the woman's condition and the season.

When preparing for pregnancy, vaccination against pneumococcal, hemophilus influenza type b, and influenza is most important for women with children, since they are the main source of the spread of respiratory infections.

BA and pregnancy are mutually aggravating conditions, so management of pregnancy complicated by BA requires careful monitoring of the condition of the woman and the fetus. Achieving asthma control is an important factor contributing to the birth of a healthy child.

Literature

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Asthma is a chronic respiratory disease characterized by prolonged coughing and asthma attacks. Often the disease is hereditary, but can appear at any age, in both women and men. A woman often has bronchial asthma and pregnancy at the same time, in which case increased medical supervision is necessary.

Uncontrolled bronchial asthma during pregnancy can have a negative impact on both the health of the woman and the fetus. Despite all the difficulties, asthma and pregnancy are quite compatible concepts. The main thing is adequate treatment and constant monitoring by doctors.

It is impossible to predict in advance the course of the disease during pregnancy. It often happens that in pregnant women the condition improves or remains unchanged, but this applies to mild and moderate forms. And with severe asthma, attacks may become more frequent and their severity may increase. In this case, the woman should be under medical supervision throughout her pregnancy.

Medical statistics suggest that the disease is severe only in the first 12 weeks, and then the pregnant woman feels better. At the time of exacerbation of asthma, hospitalization is usually suggested.

In some cases, pregnancy can cause a complicated course of the disease in a woman:

  • increase in the number of attacks;
  • more severe attack;
  • the addition of a viral or bacterial infection;
  • giving birth before the due date;
  • risk of miscarriage;
  • complicated toxicosis.

Bronchial asthma during pregnancy can also affect the fetus. An asthma attack causes oxygen starvation of the placenta, which leads to fetal hypoxia and serious disturbances in the development of the child:

  • low fetal weight;
  • the baby’s development is delayed;
  • Pathologies of the cardiovascular system, neurological diseases may develop, and the development of muscle tissue may be disrupted;
  • when a child passes through the birth canal, difficulties may arise and result in birth injuries;
  • Due to oxygen deficiency, there are cases of fetal asphyxia (suffocation).

During a complicated pregnancy, the risk of having a child with a heart defect and a predisposition to respiratory diseases increases; such children may lag significantly behind normal development.

All these problems arise if the treatment is not carried out correctly and the woman’s condition is not controlled. If the pregnant woman is registered and adequate therapy is prescribed, the birth will go well and the baby will be born healthy. The risk for the child may be a tendency to allergic reactions and inheritance of bronchial asthma. For this reason, breastfeeding is indicated for the newborn, and a hypoallergenic diet is recommended for the mother.

Planning pregnancy with asthma

The condition of an asthmatic woman should be monitored not only during pregnancy, but also when planning it. Control of the disease should be established before pregnancy and must be maintained throughout the first trimester.

During this time, it is necessary to select adequate and safe therapy, as well as eliminate irritating factors in order to minimize the number of attacks. A woman should stop smoking if this addiction has taken place and avoid inhaling tobacco smoke if family members smoke.

Before pregnancy, the expectant mother should be vaccinated against pneumococcus, influenza, Haemophilus influenzae, hepatitis, measles, rubella, tetanus and diphtheria. All vaccinations are given three months before pregnancy under the supervision of a doctor.

How pregnancy affects the course of the disease


With the onset of pregnancy, a woman changes not only her hormonal levels, but also the functioning of her respiratory system. The composition of the blood changes, there is more progesterone and carbon dioxide, breathing becomes faster, ventilation of the lungs increases, and the woman may experience shortness of breath.

During advanced pregnancy, shortness of breath is associated with a change in the position of the diaphragm; the growing uterus raises it. The pressure in the pulmonary artery also changes and increases. This causes a decrease in lung volume and worsening spirometry readings in asthmatics.

Pregnancy can cause swelling of the nasopharynx and respiratory tract even in a healthy woman, and in a patient with bronchial asthma it can cause an attack of suffocation. Every woman should remember that spontaneous withdrawal of certain drugs is as dangerous as self-medication. You should not stop taking steroids unless directed to do so by your doctor. Stopping the medication may cause a seizure, which will cause much more harm to the child than the effect of the drug.

There are cases that the first symptoms of asthma develop during pregnancy. After childbirth, they may disappear, or they may become a chronic form of the disease.


Usually the second half of pregnancy is easier for the patient, the reason lies in the increase in progesterone in the blood and dilation of the bronchi. In addition, the placenta is designed in such a way that it produces its own steroids to protect the fetus from inflammatory processes. According to statistics, a pregnant woman’s condition improves more often than it worsens.

If asthma appears only during pregnancy, it is rarely possible to diagnose it in the first months, therefore, in most cases, treatment is started in the later stages, which has a bad effect on the course of pregnancy and labor.

How does childbirth occur with asthma?


If the pregnancy is controlled throughout, then the woman is allowed to give birth independently. She is usually hospitalized at least two weeks before her due date and prepared for labor. All indicators of the mother and child are under strict control of doctors, and during labor, the woman is necessarily given medication to prevent an asthmatic attack. These drugs are absolutely safe for the baby, but have a positive effect on the condition of the mother in labor.

If asthma becomes more severe during pregnancy and asthmatic attacks become more frequent, then childbirth is carried out using a planned caesarean section at 38 weeks of pregnancy. By this time, the fetus is considered full-term, absolutely viable and formed for independent existence. Some women are prejudiced against surgical childbirth and refuse a cesarean section; in this case, complications during childbirth cannot be avoided, and besides, you can not only harm the child, but also lose him.

Common complications during childbirth:

  • premature discharge of amniotic fluid, before the onset of labor;
  • rapid labor, which negatively affects the child;
  • abnormal labor activity.

If labor begins spontaneously, but during the process an attack of suffocation and cardiopulmonary failure occurs, in addition to intensive therapy, surgical intervention is indicated, the patient is urgently given a cesarean section.

During delivery, an asthmatic attack occurs extremely rarely, provided that the patient takes all the necessary medications. Asthma as such is not considered an indication for caesarean section. If there are indications for surgery, it is better to use regional anesthesia rather than inhalation type.

If a pregnant woman has been treated with Prednisolone in a large dosage, she is prescribed Hydrocortisone injections during childbirth.

Bronchial asthma during pregnancy: treatment


If a woman has already been treated for asthma and becomes pregnant, the course of treatment and medications must be changed. Some medications are simply contraindicated during pregnancy, while others require dosage adjustments.

Throughout pregnancy, doctors should monitor the fetus using ultrasound; during exacerbations, oxygen therapy is very important to avoid oxygen starvation of the fetus. The condition of the pregnant woman is also monitored, special attention is paid to the condition of the vessels of the uterus and placenta.

The goal of treating bronchial asthma during pregnancy is to prevent an attack and provide safe therapy for both the fetus and the mother. The main task of doctors is to achieve the following results:

  • improve external respiration function;
  • prevent an asthmatic attack;
  • relieve side effects from medications;
  • disease control and timely relief of attacks.

To improve the condition and reduce the risk of developing an attack of suffocation, as well as other complications, a woman should strictly follow the following recommendations:

  1. exclude from your diet all foods that can cause an allergic reaction;
  2. wear underwear and clothes made from natural fabrics;
  3. for personal hygiene, use products with a hypoallergenic composition (creams, shower gels, soap, shampoo);
  4. eliminate external allergens from everyday life, to do this, avoid dusty places, polluted air, inhalation of various chemicals, and often carry out wet cleaning in the house;
  5. to maintain optimal humidity in your home, you should use special humidifiers, ionizers and air purifiers;
  6. avoid contact with animals and their fur;
  7. spend more time in the fresh air, take walks before bed;
  8. If a pregnant woman is professionally involved with chemicals or harmful fumes, she must be immediately transferred to a safe place of work.

During pregnancy, asthma is treated with bronchodilators and expectorants. In addition, breathing exercises, a rest regimen, and the elimination of physical and emotional stress are recommended.

The main medications for asthma during pregnancy remain inhalers, which are used to relieve (Salbutamol) and prevent (Beclamethasone) attacks. Other medications may be prescribed as prophylaxis; the doctor is guided by the degree of the disease.

In the later stages, drug therapy should be aimed not only at correcting the condition of the lungs, but also at optimizing intracellular processes that may be disrupted due to the disease. Maintenance therapy includes a set of drugs:

  • Tocopherol;
  • complex vitamins;
  • Interferon to strengthen the immune system;
  • Heparin to normalize blood clotting.

To track positive dynamics, it is necessary to monitor the level of hormones produced by the placenta and the fetal cardiovascular system.

Drugs contraindicated during pregnancy

Self-medication is not recommended for any disease, especially for asthma. A pregnant woman should take medications strictly as prescribed by the doctor and know that there are a number of drugs that are prescribed to patients with asthma, but are discontinued during pregnancy:

List of contraindicated drugs:

  • Adrenaline relieves asthma well, but is prohibited for use during pregnancy. Taking this drug can lead to fetal hypoxia; it causes vascular spasms of the uterus.
  • Terbutaline, Salbutamol, Fenoterol are prescribed to pregnant women, but under the strict supervision of a doctor. In the later stages they are usually not used, they can complicate and prolong labor; medications similar to these are used when there is a threat of miscarriage.
  • Theophylline is not used in the last three months of pregnancy; it enters the fetal bloodstream through the placenta and causes the baby's heart rate to increase.
  • Some glucocorticosteroids are contraindicated - Triamcinolone, Dexamethasone, Betamethasone, these drugs negatively affect the fetal muscular system.
  • Pregnant women should not use 2nd generation antihistamines; the side effects have a bad effect on the mother and child.

Bronchial asthma during pregnancy is not dangerous if the correct treatment is chosen and all recommendations are followed.