"Simply put, when a pregnant patient has trouble breathing, her fetus also has trouble getting the oxygen it needs."

Updated guidelines emphasizing the optimal management of asthma in pregnant women are featured in a Quick Reference Guide in the January 2005 Journal of Allergy & Clinical Immunology (JACI). The JACI is the peer-reviewed scientific journal of the American Academy of Allergy, Asthma & Immunology (AAAAI).

Monthly Monitoring

Maternal asthma is associated with increased risk of infant death, preeclampsia (a serious condition marked by high blood pressure, which can cause seizures in the mother or fetus), premature birth, and low-birth weight. These risks are linked to asthma severity -- more severe asthma increases risk, while better controlled asthma is tied to decreased risks.

Asthma worsens in approximately 30 percent of women who have mild asthma at the beginning of their pregnancy, according to a recent study by the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network and cofunded by NHLBI. The study also found that, conversely, asthma improved in 23 percent of the women who initially had moderate or severe asthma.

"We cannot predict who will worsen during pregnancy, so the new guidelines recommend that pregnant patients with persistent asthma have their asthma checked at least monthly by a healthcare provider," explained Mitchell Dombrowski, M.D., chief of obstetrics and gynecology for St. John Hospital in Detroit, and a member of the NAEPP expert panel.

"Clinicians who provide obstetric care should be part of the patient's asthma management team, working with the patient and her asthma care provider to adjust her medications if needed to keep her asthma under control and to lower the risk of complications from asthma for her and her baby," Dr. Dombrowski recommends.

Stepwise Approach

A stepwise approach to asthma care similar to that used in the NAEPP general asthma treatment guidelines for children and nonpregnant adults is recommended. Under this approach, medication is stepped up in intensity if needed, and stepped down when possible, depending on asthma severity.

"The NAEPP expert panel's review of the evidence concludes that it is safer for pregnant women with asthma to be treated with asthma medications than for them to have asthma symptoms and exacerbations," stated NHLBI Acting Director Barbara Alving, M.D.

"Simply put, when a pregnant patient has trouble breathing, her fetus also has trouble getting the oxygen it needs," added William W. Busse, M.D., professor of medicine at the University of Wisconsin Medical School, and chair of the NAEPP multidisciplinary expert panel that developed the guidelines. "There are many ways we can help pregnant women control their asthma, and it is imperative that providers and their patients work together to do so."

Medication Guidelines

Key recommendations from the guidelines regarding medications:

• Albuterol, a short-acting inhaled beta2-agonist, should be used as a quick-relief medication to treat asthma symptoms. Pregnant women with asthma should have this medication available at all times.

• Women who have symptoms at least two days a week or two nights a month have persistent asthma and need daily medication for long-term care of their asthma and to prevent exacerbations. Inhaled corticosteroids are the preferred medication to control the underlying inflammation in pregnant women with persistent asthma.

  The guidelines note that there are more data on the safety of budesonide use during pregnancy than on other inhaled corticosteroids; however, there are no data indicating that other inhaled corticosteroids are unsafe during pregnancy, and other inhaled corticosteroids may be continued if they effectively control a patient's asthma. Alternative daily medications are leukotriene receptor antagonists, cromolyn, or theophylline.

• For patients whose persistent asthma is not well controlled on low doses of inhaled corticosteroids alone, the guidelines recommend either increasing the dose of inhaled corticosteroid or adding another medication -- a long-acting beta agonist. The expert panel concluded that data are insufficient to indicate a preference of one option over the other.

• Oral corticosteroids may be required for the treatment of severe asthma. The guidelines note that there are conflicting data regarding the safety of oral corticiosteroids during pregnancy; however, severe, uncontrolled asthma poses a definite risk to the mother and fetus; and use of oral corticosteroids may be warranted.

Avoiding Triggers

The guidelines highlight other important aspects of asthma management during pregnancy, such as identifying and limiting exposure to asthma triggers. Similarly, women with other conditions that can worsen asthma, such as allergic rhinitis, sinusitis and gastroesophageal reflux, should have those conditions treated as well. Such conditions often become more troublesome during pregnancy.

"As important as medications are for controlling asthma, a pregnant woman can reduce how much medication is needed by identifying and avoiding the factors that make her asthma worse, such as tobacco smoke or allergens like dust mites," added Dr. Schatz.