May 2014

Case Discussion: Asthma in Pregnancy

Consider Jane…

• Jane 23 yo child care worker

• Presents 10/40 pregnant unplanned pregnancy

• G1 P0 EDC 23 September

• Smoker 25/day • Significantly cut back since becoming pregnant• Live in partner is smoker

• Only PMH is asthma since childhood• Needs salbutamol script• Wants to do shared care

Asthma in Pregnancy…

• Jane advises you that she usually only uses her salbutamol puffer occasionally and whilst she has had a preventer in the past, she stopped using it because she ran out and never got a new prescription

• Started smoking “here and there” at age 15/16 but regularly by 18

• Currently Jane is not worried about her asthma control and thinks she only needs the ventolin occasionally

• On direct questioning…• Uses her puffer when she gets SOB running around at work 1-2 times/day most

days• Will need it a couple of times on weekends when friends come over & everybody

is smoking• Doesn’t really exercise so doesn’t know if she needs it with exercise• Needs it regularly (3-4 hrly) first couple of days when she has a cold

Examination findings…

• Ht: 165 cm Wt: 71kg BMI: 26.1

• Afebrile

• ENT: NAD

• Chest: Clear good AE occasional expiratory wheeze bilaterally

• Spirometry:Pre-bronchodilator:PEFR: 330 (exp 440) ie 75% expectedFEV1/FVC: 82% (exp 85%)

Post-bronchodilator:PEFR: 396 (exp 440) ie 90% expectedFEV1/FVC 84% (exp 85%)

Questions to consider:

• What are the extra issues you need to consider in managing Jane during this pregnancy?

• What do you advise Jane about her and her partner smoking in pregnancy?

• What are Jane’s options to assist with stopping smoking in pregnancy?

• What is the significance of contracting influenza in pregnancy?

• What do you advise about immunisation against influenza during pregnancy?

• Why is asthma control important in pregnancy?

• How do you manage Jane’s asthma this pregnancy?

• What non-pharmacological management could be offered?

• What pharmacological management could be offered?

• Harmful effects of direct and passive smoking in pregnancy and on the health of babies and children have been well established

• There is currently a lack of evidence on the safety of nicotine replacement therapy (NRT) in pregnancy but reports of expert committees have recommended its use in certain circumstances. NRT should be considered when a pregnant woman is otherwise unable to quit, and when the likelihood and benefits of cessation outweigh the risks of NRT and potential continued smoking

• Pregnancy increases the risk of contracting influenza and developing serious complications from influenza

• The vaccine is safe to give in all stages of pregnancy.

• Maternal asthma has been shown to contribute to significant complications of pregnancy

• These outcomes are likely to be reduced with well managed asthma; women with well managed asthma can expect the same outcomes as women without asthma

• Short acting b 2 agonists and inhaled corticosteroids are the mainstay of treatment for asthma and appear to be safe in pregnancy; most evidence for safety is for budesonide (ADEC category A)

Take Home Messages…