Asthma co-morbidities in pregnancy

Transcription

Head and Professor of
The Regional Center of Allergy and Clinical Immunology
University Hospital, "Dr. Jose Eleuterio Gonzalez"
Monterrey, N.L.Mexico
School of Medicine, U.A.N.L 1977- 1983. Monterrey, N.L.
Mexico
Internal Medicine Specialty, Universitary Hospital U.A.N.L.
1986 - 1988, Monterrey, N.L.
Fellowship Pediatric Allergy and Clinical Immunology,
U.C.S.D. 1987-1988, University of California, San Diego, USA
Allergy and Clinical Immunology Specialty, Universitary
Hospital U.A.N.L. 1988 - 1990, Monterrey, N. L.
Doctor´s Degree in Allergy and Clinical Immunology,
University Hospital U.A.N.L. 1991 – 1997, Monterrey, N.L.
Director of the Allergy and Clinical Immunology Training
Program, Centro Regional de Alergia e Inmunología Clínica,
Hospital Universitario de Monterrey, since 1990.
Professor, Centro Regional de Alergia e Inmunología Clínica,
Hospital Universitario de Monterrey, since 1990.
Head of Centro Regional de Alergia e Inmunología Clínica,
Hospital Universitario, Monterrey, N.L. since March 2000 – up to
date
Past President of the Mexican College of Clinical Immunology and
Allergy (CMICA) -2005-2007
Director of the Department of Funds Raising of the University
Hospital, January 2007 - up to date
President of UNASMA (International Asthma Foundation) 2007 –
2011
Director of the Institute of Clinical Immunology, Asthma and
Allergy A.C. (NPO)
President of the Latin-American Society of Asthma, Allergy and
Clinical Immunology (SLAAI) 2010-2012
Maintain adequate control of asthma
during pregnancy is important for the
health and welfare of mother and baby
NAEPP Expert Panel Report. Managing Asthma During Pregnancy: Recommendations for Pharmacologic
Treatment—2004 Update. J ALLERGY CLIN IMMUNOL JANUARY 2005
How pregnancy affects
asthma?
The diaphragm is
raised 4 cm
The diameter of the
rib cage increases 2
cm
The circumference
is increased 6 cm
Gluck MD. The Effect of Pregnancy on the Course of Asthma. Immunol Allergy Clin N Am 26 (2006) 63– 80
Changes in
pulmonary
physiology during
pregnancy
Increased
ventilation/minute
Increases in O2 consumption of 21-35%
Metabolism Increase 15%
Although…
VEF1 and peak expiratory flow, not as a
physiological change
Nelson, Piercy. Asthma in Pregnancy. Thorax 2001; 56
Asthma affects 3.7 to 8.4% of pregnant women
Young Women
White women
Obesity
Poor education
Poor income
Smoke during pregnancy
NationalCenter for Health Statistics and Behavioral Risk Factor Surveillance System
Louik Carol and cols. Asthma in pregnancy and its pharmacologic treatment. Annals of Allergy, Asthma &
Immunology. August 2010; 105: 110-117.
It is the most common medical issue
that can complicate pregnancy
Increased risk
Perinatal mortality
Pre eclampsia
Premature delivery
Low birth weight
NAEPP Expert Panel Report. Managing Asthma During Pregnancy: Recommendations for
Pharmacologic Treatment—2004 Update. J ALLERGY CLIN IMMUNOL JANUARY 2005
Several studies ...
Lao TT. Labour and delivey in
mothers with asthma. Eur J Obstet
Gynecol Reprod Biol. 1990; 35: 183190
Schatz M. The course of asthma
during pregnancy, post partum, and
with succesive pregnancies: a
prospective analysis. J Allergy Clin
Immunol. 1988; 81: 509-517
Murphy VE. Severe asthma
exacerbations during
pregnancy. Obstet Gynecol.
2005; 106: 1046-1054.
Schatz M. Asthma morbidity
during pregnancy can be
predicted by severity
classification. J Allergy Clin
Immunol. 2003; 112: 283-8.
Enríquez R . Effect of maternal asthma and asthma control
on pregnancy and perinatal outcomes. Allergy Clin Immunol 2007;120:625-30. Nashville, Tenn
Uncontrolled asthma and exacerbations are
potentially dangerous to the fetus
Maternal
hypoxia
Respiratory
alkalosis
J Allergy Clin Immunol 2008;121:1379-84
Methods:
Cohort study
4344 pregnant
patients with
asthma
12.8% vs 8.9%
Conclusion: Asthma exacerbations during the first trimester of
pregnancy was found to significantly increase the risk of
congenital malformation
However…
Despite the increased symptoms of asthma
during pregnancy ...
And the potential risk to the fetus ...
Reported:
Low rates of asthma control medications...
◦ Leukotriene modifiers: 3.4%
◦ Inhaled Corticosteroids: 19-23%
◦ Short-acting B2 agonists:> 50%
Louik Carol and cols. Asthma in pregnancy and its pharmacologic treatment. Annals of Allergy, Asthma & Immunology.
August 2010; 105: 110-117.
Patients with uncontrolled asthma, 63% do not use
asthma medications during pregnancy
Louik Carol and cols. Asthma in pregnancy and its pharmacologic treatment. Annals of Allergy, Asthma &
Immunology. August 2010; 105: 110-117. Boston, Massachusetts.
Bronchodilators
6.667 pregnant women, of whom 1.929 had asthma and
B2 agonists had used drugs in1,599
Albuterol
Safety during
pregnancy
Formoterol
Salmeterol
Limited results
1-Bracken MB, Asthma symptoms, severity, and drug therapy: a prospective study of effects on 2205 pregnancies. Obstet
Gynecol 2003;102:739-52. 2-Rayburn WF. Short-term effects of inhaled albuterol on maternal and fetal circulations. Am J
Obstet Gynecol 1994;171:770-3. 3- Schatz M,. The safety of asthma and allergy medications during pregnancy. J Allergy
Clin Immunol 1997;100:301-6. 4- Wilton LV,. The outcomes of pregnancy in women exposed to newly marketed drugs in
general practice in England. Br J Obstet Gynaecol 1998;105:882-9. 5- Wilton LV, Shakir SA. A post-marketing surveillance
study of formoterol (Foradil): its use in general practice in England. Drug Saf 2002;25:213-23.
Theophylline
Studies and clinical experience
confirms
Safety of theophylline in
recommended doses during
pregnancy
Serum levels of 5-12mcg/mL
Dombrowski MP. Randomized trial of
inhaled beclomethasone dipropionate
versus theophylline for moderate asthma
during pregnancy. Am J Obstet Gynecol
2004;190:737-44.
57,163 pregnant women
and 3,616 had asthma
of which 660 had been medicated
theophylline
There was no difference in
exacerbations of asthma
and perinatal outcome
More adverse effects with
theophylline
So they had to stop the drug
NAEPP Expert Panel Report. Managing Asthma During Pregnancy:
Recommendations for Pharmacologic Treatment—2004 Update. J ALLERGY
CLIN IMMUNOL JANUARY 2005
Inhaled corticosteroids
Researchs in pregnant
women
5 cohort studies
1 controlled study
1.- The risk of asthma exacerbations associated with
pregnancy can be reduced and lung function (VEF1)
improved with the use of inhaled corticosteroid therapy
2 randomized controlled
2.- There are no studies to date of inhaled corticosteroid use
related to any increase in birth defects or other adverse
perinatal outcomes
21,072 pregnant women,
16.900 of whom had asthma
and 6.113 had been medicated
with inhaled corticosteroids
3.- Data on inhaled corticosteroids during pregnancy is
budesonide (there are few studies or no studies available
with the use of other formulations of inhaled corticosteroids
during pregnancy)
NAEPP Expert Panel Report. Managing Asthma During Pregnancy: Recommendations for
Pharmacologic Treatment—2004 Update. J ALLERGY CLIN IMMUNOL JANUARY 2005
Methods:
Cohort study of 13, 280
pregnancies in women with
asthma (1990-2002)
We compared patients who used ICS
(beclomethasone dipropionate
equivalent dose):
>1000mcg/d
> 0-1000mcg/d
0
Results:
ICS dose
1st Trimester
of pregnancy
Patients
Total
Malformation
Major
Malformation
>1000mcg/d
154
14.3
9.7%
>0-1000mcg/d
4392
9.0
5.7%
0
8734
9.6
5.9%
Conclusions:
It demonstrates the safety of using low-medium dose ICS
during the first trimester of pregnancy
Oral corticosteroid
Clinical studies and meta-analysis
(cohort, case-control)
51, 380 pregnant women, of
which 535 had been
medicated with oral
corticosteroids
4.321 pregnant, of whom
1.998 had asthma and
213 had been medicated
with oral corticosteroid
Uncontrolled
asthma
Oral steroid use during
the first trimester of
pregnancy:
Increased risk of cleft lip
with or without cleft palate
(Risk in general population is
0.1%, the risk in women with
oral corticosteroid was 0.3%)
Pre eclampsia
Prematurity
Low birth
weight
Park-Wyllie L, Birth defects after maternal exposure to corticosteroids: prospective cohort study and meta-analysis of epidemiological studies.
Teratology 2000;62:385-92.
Perlow JH.. Severity of asthma and perinatal outcome.AmJObstetGynecol 1992;167(4 Pt 1):963-7.
Schatz M, The safety of asthma and allergy medications during pregnancy. J Allergy Clin Immunol 1997;100:301-6.
Cromoglycate
Safe use in pregnant
women
4.110 pregnant women, of
whom 1.917 had asthma and
318 had been medicated
with cromolyn
Bracken MB. Asthma symptoms, severity, and drug therapy: a prospective study of effects on 2205
pregnancies. Obstet Gynecol 2003;102:739-52.
Schatz M. The safety of asthma and allergy medications during pregnancy. J Allergy Clin Immunol
1997;100:301-6.
Leukotriene modifiers
Montelukast, Zafirlukast, Zileuton
Few studies are currently
available on the use of
leukotriene modifiers during
pregnancy
Bracken MB. Asthma symptoms, severity, and drug therapy: a prospective study of effects on 2205
pregnancies. Obstet Gynecol 2003;102:739-52
Methods:
Were compared
96 patients treated
with montelukast or
Zafirlukas
122 with exclusive
use of B2 agonists
and 346 women
without asthma
89% 1st
Trimester
Pregnancy
LTRAs
was not associated with
an increased risk of
miscarriage, gestational
diabetes, preeclampsia,
low maternal weight gain,
premature delivery and
low Apgar score, or
decreased birth length
and head circumference
infants
(P> 0.05)
Gluck. Asthma Controller therapy during Pregnancy. Am J Obstetrics & Ginecology. No 192 January 2005
Management of asthma in pregnancy
Asthma Control:
◦
◦
◦
◦
◦
◦
None or minimal symptoms during the day or night
Minimal or no exacerbations
No limitations in activities
Maintain normal lung function or close to normal
Minimal use of β-2 agonists inhaled short-acting
Minimal or no adverse effects of medication
Monitor and make necessary adjustments in
medication (antenatal care visits and medical
collaboration team)
Maintain lung function and ensure adequate
oxygenation in the fetus
Poor control of asthma is more risk to
the fetus than the use of asthma
medications during pregnancy
• Monthly assessment of asthma control
•Lung function: Spirometry, PEF
•Recognition of uterine activity
•Serial ultrasound after 32 weeks of
pregnancy (severe asthma or partially
controlled and even after an
exacerbation)
González-Díaz S. Asma"Situaciones Especiales", Editorial Médica
Internacional. Bogotá, Colombia. Septiembre 2004
•Identify, control or avoid allergens
and irritants
•Primarily cigarette smoke
González-Díaz S. Asma"Situaciones Especiales", Editorial Médica
Internacional. Bogotá, Colombia. Septiembre 2004
Management of asthma in
pregnancy
Reinforce self-monitoring of asthma
Correct use of inhalers
Plan long-term treatment
Early identification and management
of exacerbations
González-Díaz S. Asma"Situaciones Especiales", Editorial Médica Internacional. Bogotá, Colombia. Septiembre 2004
Achieve and maintain control
Dose, number of medications and
frequency increments based on the
severity and asthma control
Are reduced where possible
González –Díaz Sandra. Capítulo "Educación Del Paciente Con Asma", Asma. Editorial Médica Panamericana. Bogotá,
Colombia. Mayo 2005. Páginas 520-529.
Mitchell P. Dombrowski CLINICAL MANAGEMENT GUIDELINES FOR OBSTETRICIAN–GYNECOLOGISTS OBSTETRICS &
GYNECOLOGY NUMBER 90, FEBRUARY 2008
Inhaled corticosteroids
Step 1. Mild intermittent asthma
Short-acting β2 agonists
Rapid symptom relief
Albuterol/ salbutamol
Extensive experience in pregnant women
Breastfeeding
Step 2. Mild persistent asthma
Low-dose inhaled corticosteroids daily
Efficacy and safety in pregnant women
No increase in perinatal risk
Budesonide
Continue inhaled steroid prior to pregnancy if you have had a
good control or if there is a risk when removing
Other: Cromolyn, leukotriene antagonists and theophylline
Less effective than inhaled steroids
Potential toxicity at high doses and interaction with other drugs
Step 3. Moderate persistent asthma
Option 1: Combination of low dose inhaled steroid + LABA
Option 2: Increase half-dose inhaled steroid alone or add LABA
Salmeterol and formoterol
Pharmacological and toxicological profile similar albuterol
Step 4. Severe persistent asthma
Evaluate the technique and adherence to treatment of step 3
Increased high-dose inhaled steroid + LABA
Budesonide is preferred
Add oral steroids if it fails to control symptoms
Severe uncontrolled asthma is a real risk to mother and
fetus
2008 British Guideline on the Management of Asthma - updated June 2009
Management of asthma
exacerbations during pregnancy
Initial assessment
◦
◦
◦
◦
◦
◦
◦
◦
Medical history
Physical examination:
Respiratory rate
Heart rate
Auscultation
Use of accessory muscles
PEF or VEF1
Oxygen saturation
Fetal assessment
◦ Continuous fetal monitoring
◦ Biophysical profile
Initial assessment results
Short-acting B2
agonist MDI or
nebulized
3 doses in 1 hour
Oxygen
Maintain saturation
≥ 95%
Oral CS
Re-evaluate
•
High dose Short-acting
B2
• Nebulized every 20
minutes or continuously
for 1 hour +
ipratropium bromide
• Oxygen
Maintain saturation
≥ 95%
Oral CS
Re-evaluate
• Intubation and
VMC with 100%
Oxygen
• Nebulization with
short-acting B2
agonists +
ipratropium
bromide
•
IV corticosteroid
ICU
Re-evaluate
Categorize
Act
Symptoms, physical examination, PEF,
O2 saturation, fetal monitoring
Severe
exacerbation
Moderate
Exacerbation
VEF 1 or PEF 50-80%
VEF1 or PEF <50%
Moderate symptoms
severe symptoms
Short-acting B2 agonists
every 60 min
Systemic steroids
Oxygen saturation> 95%
Continue treatment for 1-3
hours
B2 agonistas de acción corta
continuous + bromuro de
ipratropio inhalado
Oxígeno
Esteroides sistémicos
Go home
Continue short-acting B2 agonists
Continue oral steroid
Continue or start inhaled steroid
Patient Education
Admission to hospital
Short-acting B2 agonists + ipratropium
bromide
Oxygen
FEV1 or PEF monitoring, oxygen saturation
and pulse
Continue fetal assessment
ICU admission
Rate intubation and mechanical ventilation
Short-acting B2 agonists + ipratropium
bromide continuous
Intravenous corticosteroid
Oxygen
Continue monitoring fetal
Management of comorbidities
Allergic rhinitis
Sinusitis
Viral or bacterial respiratory infections
Gastroesophageal Reflux
Asthma symptoms can be treated and in
most cases prevented during pregnancy

Asthma co-morbidities in pregnancy

Transcription

Similar documents