Chapter 19

Pregnancy and Asthma

In This Chapter

Controlling asthma while pregnant

Maintaining healthy lung functions for you and your baby

I f you have asthma and you’re pregnant or considering pregnancy, I have some good news for you: With appropriate care, the vast majority of women with asthma have uncomplicated pregnancies.

Although treatment issues related to asthma affect approximately 4 percent of all pregnancies in the United States, very few of these cases involve situations that imperil either the mother or the child she carries. However, the potential for serious asthma-related complications exists if you don’t control your asthma during pregnancy.

Therefore, continuing treatment for your disease — under your doctor’s supervision — with an appropriate and effective asthma management plan is vital to

Avert sudden aggravations of your asthma symptoms, thus minimizing the need for emergency care and hospitalizations

Maintain as close to normal lung functions as possible

Prevent chronic and troublesome symptoms of asthma, such as coughing, shortness of breath, wheezing — especially upon awakening in the morning, and episodes that disturb your sleep at night

Provide the most effective medication therapy that results in minimal or no adverse side effects

Sustain near-to-normal levels of exercise and other physical activities

Give birth to a healthy, beautiful baby

In spite of what some people may think, most asthmatics go through pregnancy and labor well. Although I’m sure it has happened somewhere, in my more than 25 years practicing as an allergist, I’ve never seen labor or delivery set off a severe asthma attack.

Identifying Special Issues with Asthma during Pregnancy

Although one-third of pregnant women don’t experience any change in asthma severity levels during pregnancy, another third of expectant mothers suffer from more severe asthma. For the remaining third, their condition may actually improve. In most cases, asthma severity returns to pre-pregnancy levels by the third month after delivery. Your asthma’s severity can vary from one pregnancy to another, and neither you nor your doctor can predict how pregnancy may affect your condition.

Your hormones and your asthma

For some women, pregnancy seems to trigger asthma symptoms. In fact, you may not realize that you have asthma until it shows up during your pregnancy, because the significant hormonal changes your body experiences during pregnancy may cause increased airway congestion. Your body’s hormonal changes can also induce or aggravate allergic and nonallergic rhinitis and sinusitis during pregnancy. These conditions can, in turn, increase your asthma’s severity.

Therefore, you also need to address allergies and related conditions when you’re expecting a child. If you have allergic rhinitis (hay fever) or allergic conjunctivitis (red, itchy eyes), both of which affect many people with aller-gic asthma, work with your doctor to control those symptoms while you’re pregnant.

The basics of managing asthma while pregnant

The first step in avoiding asthma-related complications during your pregnancy is to make sure that your doctor properly diagnoses your respiratory symptoms. (See Chapter 2 for more information.)

If the diagnosis reveals that you have asthma, your doctor should help you develop an effective asthma management plan. This plan should consist of specific avoidance strategies, medications, monitoring, and assessment measures. Your management plan should also provide you with steps to take in case your asthma symptoms suddenly worsen.

Make sure that you (and your doctors) integrate your asthma management plan and any treatment that you may receive from an asthma specialist (such as an allergist or pulmonologist) with obstetric care from your obstetrician, family doctor, and/or primary care physician. A team approach by your physicians helps eliminate the risk of different doctors prescribing different treatments that can, in combination, produce adverse side effects for you and your baby. Integrated treatment can also ensure more effective control of any other condition or complications, besides asthma and related disorders that you may experience during pregnancy.

Breathing for Two

During your pregnancy, you’re not only eating for two but also breathing for two — yourself and your baby. Contrary to what some people believe, the greatest danger to your unborn child isn’t the preventive (or controller) medication your doctor prescribes to help manage your asthma, but rather the adverse effects that oxygen deprivation can have on your baby if you suffer severe or repeated asthma episodes during pregnancy.

In order to avoid adverse effects during your pregnancy, your asthma management plan needs to

Assess your condition with appropriate pulmonary function tests. With these tests, you can establish benchmark results against which your doctor can compare later tests to determine your condition’s severity.

Avoid or at least minimize exposure to allergens or irritants that may cause asthma flare-ups. In many cases, effective avoidance measures can reduce the possibility of asthma episodes that require you to take additional medications, especially the frequent need for rescue (or quick-relief) drugs.

Treat your condition with appropriate preventive medications to ensure that you adequately maintain your lung functions and that your baby receives a sufficient supply of oxygen. Preventive medications can also minimize the possibility of asthma episodes that may require emergency treatment or drugs.

Mother Nature’s milk

Breastfeeding provides nutritional, immunologic, and psychological benefits for your newborn child. Breast milk, in contrast to cow’s milk in infant formulas, may decrease the potential for allergic sensitization by reducing your baby’s exposure to ingested food allergens. In addition, breast milk may reduce the incidence of bronchiolitis (see Chapter 18) and infection-induced asthma during infancy, because the baby receives antibodies against viral infections through the mother’s breast milk.

Avoiding asthma triggers, allergens, and irritants during pregnancy

During your pregnancy, avoid precipitating factors that may trigger asthma episodes. See Chapter 5 for extensive details on asthma triggers and precipitating factors.

If you suffer from allergic asthma, implement (under your doctor’s supervision) an avoidance and allergy-proofing plan that limits your exposure to inhalant allergens as well as airborne irritants, especially tobacco smoke. Furthermore, a comprehensive avoidance strategy can help to alleviate symptoms of allergic rhinitis and/or allergic conjunctivitis. Effective allergy-proofing focuses on your home in general and your bedroom in particular. I provide extensive information and tips on allergy-proofing in Chapter 10.

Undergoing allergy testing and immunotherapy during pregnancy

If you’re already receiving immunotherapy (allergy shots) when you become pregnant, your doctor may advise you to continue with the treatment because, in many cases, it can help prevent allergy attacks that may make your asthma worse. Stopping immunotherapy may result in your symptoms worsening, thus requiring additional medication therapy. Frequently, your doctor may advise reduced doses of immunotherapy to minimize potential risks of allergy-shot reactions.

If you’re already pregnant and are considering having allergy testing to determine which allergens trigger your symptoms, or if you’re thinking about starting immunotherapy, your doctor will probably advise you to wait until after your baby is born.

Managing nasal conditions associated with pregnancy

Expectant women often experience worsening of their pre-existing rhinitis or develop certain nasal and upper respiratory symptoms for the first time. As with the changes in asthma severity levels that I explain in “Your hormones and your asthma,” earlier in this chapter, in many cases these increased or newly acquired nasal symptoms result from hormonal changes that occur only during pregnancy.

Poorly managing these nasal conditions can complicate your asthma and, in severe cases, interfere with sleeping, eating, your emotional well-being, and your overall quality of life. Contending with the unpleasantness of impaired sleep, sneezing, runny nose, itchy eyes, inflamed sinuses, ear infections, and sinus headaches while pregnant is a challenge that you (and your family) want to avoid.

The following sections provide information and tips for managing the most common nasal conditions associated with pregnancy.

Allergic rhinitis (Hay fever)

If avoidance and allergy-proofing don’t provide sufficient control of your hay fever symptoms, your doctor may advise using nasal cromolyn spray. However, avoid using oral decongestants during the first trimester of your pregnancy. Sometime after the first trimester, your doctor may consider prescribing antihistamines, such as chlorpheniramine (Chlor-Trimeton) and tripelennamine, as well as decongestants such as pseudoephedrine (Sudafed), depending on your condition, the development of your baby, and the severity of your allergy symptoms.

Many people treat hay fever symptoms with over-the-counter (OTC) decongestants and antihistamines. But during your pregnancy, check with your doctor before taking any medications, including OTC products. In many cases, particularly with antihistamines, second-generation products, such as Claritin (now available OTC) and Zyrtec (available by prescription), are actually safer and cause less drowsiness than many of the first-generation antihistamines. In addition, OTC Nasalcrom is considered the safest nasal spray for treating allergic rhinitis during pregnancy.

Vasomotor rhinitis of pregnancy

Vasomotor rhinitis of pregnancy is a nonallergic upper respiratory syndrome that usually only develops during pregnancy, mostly from the second month to term. The associated symptoms of nasal congestion, nasal dryness, and nosebleeds usually disappear after delivery.

Buffered saline nose sprays can provide effective relief for vasomotor rhinitis of pregnancy. Exercise can sometimes help relieve this condition. If nasal congestion persists, however, your doctor may advise using pseudoephedrine (Sudafed) as a decongestant.

Sinusitis

The incidence of sinusitis in pregnant women is six times higher than in the rest of the population. These often-painful sinus infections can develop as complications of rhinitis and viral upper respiratory infections, such as the common cold. Sinusitis can trigger asthma symptoms and, in some cases, may complicate your asthma to the point that it doesn’t respond to treatment. Poorly managed sinusitis can also worsen to the point where sinus surgery becomes necessary.

To reduce the risk of sinus infections, your doctor may advise using a nasal douche cup, nasal bulb syringe, or other type of nasal wash device at home to irrigate your nostrils with warm saline solution, thus relieving pressure and congestion in your nasal passages. Ask your doctor for specific instructions on using these devices.

If your doctor prescribes medication to clear a sinus infection, amoxicillin is probably her first choice, unless you’re allergic to penicillin. If you’re allergic to penicillin, your doctor may prescribe some type of erythromycin-based medication.

Exercising with asthma during pregnancy

Most asthmatics experience some degree of exercise-induced asthma (EIA), particularly as a result of activities that involve breathing cold, dry air (such as running outdoors). Consult with your doctor to evaluate what level and type of exercise benefits you most during your pregnancy.

Activities that allow you to breathe warmer, humidified air (such as swimming in a heated pool) may be less likely to trigger EIA symptoms. In order to lessen the occurrence of EIA episodes, ask your doctor about medications that can help control airway inflammation when you exercise and prevent symptoms of this condition. (See Chapters 15 and 16 for information on these products.)

With proper treatment and management, asthma doesn’t have to keep you from your regular physical activities during pregnancy.

Assessing your asthma during pregnancy

In addition to closely monitoring your lung functions through office spirometry (see Chapter 2 for an explanation of this process), your doctor may also advise measuring your airflow at home using a portable peak-flow meter to assess your peak expiratory flow rate (PEFR).

Although PEFR measurements generally don’t provide complete information by themselves to fully evaluate your asthma’s severity, they certainly can provide a valuable insight into the daily course of your asthma. (I provide detailed instructions on using peak-flow meters in Chapter 4.)

Monitoring your baby’s condition

During the beginning of your second trimester, your doctor may use an ultrasound to establish a benchmark for assessing your baby’s growth. If your asthma is moderate or severe, your doctor may advise further ultrasound scans during your third trimester.

During the third trimester, your doctor should assess your baby weekly. However, if your doctor suspects problems, she may need to check the baby’s well-being more often. Your doctor should encourage you to record the baby’s activity, or kick counts, on a daily basis.

During labor, your doctor needs to closely monitor the baby. In most cases, doctors follow the baby’s progress through close electronic monitoring. Also, make sure that the staff measures your PEFR when you’re first admitted to the hospital for labor and again every 12 hours thereafter until you deliver.

In rare cases, mothers who enter labor with severe or uncontrolled asthma may require more intensive monitoring, either by continuous, electronic monitoring of the baby’s heart rate or relatively frequent auscultation (listening through a stethoscope to the baby’s heart rate).

Taking asthma medications while pregnant

In general, continue your course of asthma medications through your pregnancy, labor, and delivery. The specific medication plan that your doctor prescribes depends on your asthma’s severity.

The primary goal of pharmacological asthma management during pregnancy is to use the minimum level of medication necessary — with minimal risk of adverse side effects — to control the underlying airway inflammation.

The preferred medications for treatment of asthma while pregnant are

Inhaled products that deliver the drug directly to your airway in higher, and thus more effective, concentrations than oral medications. Inhaled drugs also reduce the risk of systemic side effects. To find out more about asthma medications, their use, and their side effects, turn to Chapters 15 and 16.

Drugs, such as cromolyn (Intal), that have a long history of safe use in pregnant women and have been studied extensively in published clinical trials. Budesonide (Pulmicort) is also considered a safe inhaled medication for treatment of asthma during pregnancy.

The drugs your doctor prescribes in order to safely control your asthma during pregnancy may include the following:

An inhaled beta ₂ -adrenergic (beta ₂ -agonist) bronchodilator to use in case your asthma symptoms suddenly worsen, or preventively as needed prior to exercise.

For mild asthma, occasionally using inhaled beta ₂ -adrenergics usually suffices for asthma control. In some cases, your doctor may also recommend regularly using inhaled cromolyn sodium (Intal).

Sustained-release theophylline or a long-acting oral or inhaled beta ₂ -adrenergic if your asthma symptoms primarily show up at night.

A regimen of constant preventive doses of inhaled corticosteroids, sometimes in combination with a long-acting bronchodilator.

In milder cases, your doctor may prescribe theophylline, as well as cromolyn sodium, as alternate choices. However, in more severe cases, you may require short bursts of oral prednisone if a combination of bronchodilators, inhaled corticosteroids, and cromolyn sodium fails to keep your asthma symptoms under control.

Managing severe persistent asthma may require higher doses of inhaled corticosteroids, often in combination with long-acting bronchodilators. Maintaining this aggressive regimen usually allows your doctor to minimize your use of oral corticosteroids.

In rare cases of uncontrolled asthma during pregnancy, you may require an alternate-day or single-daily morning dose of oral corticosteroids to re-establish control of your symptoms. Make sure that an asthma specialist, in consultation with an obstetrician who specializes in high-risk pregnancies, monitors this course of medication. As soon as your symptoms are under control, your doctors should taper off the dosage of oral corticosteroids and gradually replace them with the regular use of inhaled corticosteroids to reduce the risk of adverse side effects to you or your baby.

Handling asthma emergencies while pregnant

Your doctor should instruct you how to recognize the signs of worsening asthma and how to treat these episodes early with appropriate medications. Also, make sure that you can tell when a deteriorating situation may require emergency medical attention, and know what you need to do if that happens. (Chapter 4 provides details on the emergency management of asthma.)

The most important points to keep in mind when dealing with an asthma emergency during pregnancy are

If you’re exposed to any allergens or irritants (especially tobacco smoke), get away from those allergy triggers as quickly as possible. Otherwise, your condition may deteriorate.

Even if you have days when you’re feeling better, don’t stop taking your preventive medications during your pregnancy, unless your doctor instructs otherwise.

If your symptoms worsen, don’t resort to frequently overusing your beta ₂ -adrenergic (beta ₂ -agonist) inhaler. Doing so probably won’t improve your condition and may even make matters worse.

If your condition doesn’t improve rapidly after one or two doses of your beta ₂ -adrenergic inhaler or if your condition continues to deteriorate, seek appropriate medical care, as detailed in your asthma management plan.